Clickable Table
Generic Name | Brand Name | Strength | Dosing | 90 Day Cost | Coverage | Comments | Category 1 | Category 2 |
---|---|---|---|---|---|---|---|---|
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.
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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 | |||
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 | |||
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 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 | |||
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 &"System Font,Regular"
&K000000https://tinyurl.com/5fdxy8km
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Opioid Dependency | |
Buprenorphine Extended Release | Sublocade | 100 mg, 300 mg | Monthly | $1810 | BC / NIHB - Covered |
P
Opioid Agonist Therapy &"System Font,Regular"
&K000000https://tinyurl.com/5fdxy8km
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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 &"System Font,Regular"
&K000000https://tinyurl.com/5fdxy8km
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Opioid Dependency |
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 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 | |||
Betamethasone Dipropionate Glycol | Diprolene | 0.05% | As dir | $30 | 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.
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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.
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Tacrolimus | Protopic (30g tube) | 0.03% | As dir | $100 | BC - SA / NIHB - Covered | L Topicals | Miscellaneous Topicals | |
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.
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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.
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Amcinonide | Cyclocort | 0.10% | As dir | $30 | 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.
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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.
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Dimethicone | Nyda | 50% | As dir | $40 | BC / NIHB - Covered | L Topicals | Lice | |
Pyrethrins/Piperonyl Butoxide | R&C | 0.33%/3% | As dir | $25 | BC / NIHB - Covered | L Topicals | Lice | |
Isopropyl Myristate | Resultz | 50% | As dir | $35 | BC / NIHB - Covered | L Topicals | Lice | |
Imiquimod | Aldara (24x250mg) | 5% | As dir | $300 | 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 | |
Risedronate | Actonel | 35 mg once weekly | $35 | BC / NIHB - Covered | O Miscellaneous | Osteoporosis | ||
Teriparatide | Forteo | 20 mcg SQ | QD | $1935 | BC - NC / NIHB - SA | O Miscellaneous | Osteoporosis | |
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
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Efinaconazole | Jublia | Nail lacquer; price for 8ml | $130 | BC / NIHB - NC | O Miscellaneous |
Antifungals
Onychomycosis dosing, recommended duration: 6 weeks for fingernails, 12 weeks for toenails
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Terbinafine | Lamisil | 250 mg QD | $85 | BC / NIHB - Covered | O Miscellaneous |
Antifungals
Onychomycosis dosing, recommended duration: 6 weeks for fingernails, 12 weeks for toenails
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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
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Itraconazole | Sporanox | 2x100 mg QD | $795 | BC / NIHB - Covered | O Miscellaneous |
Antifungals
Onychomycosis dosing, recommended duration: 6 weeks for fingernails, 12 weeks for toenails
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Donepezil | Aricept | 5 mg | QD | $60 | BC / NIHB - SA | O Miscellaneous | Dementia | |
Memantine | Ebixa | 10 mg | QD | $185 | BC - NC / NIHB - SA | O Miscellaneous | Dementia | |
Rivastigmine | Exelon | 3 mg | BID | $145 | BC / NIHB - SA | O Miscellaneous | Dementia | |
Galantamine ER | Reminyl ER | 16 mg | QD | $140 | BC / NIHB - SA | O Miscellaneous | Dementia | |
Zoledronic Acid | Aclasta | 5 mg yearly | $110 | BC / NIHB - SA | O Miscellaneous | Osteoporosis | ||
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 |
P
Contraceptives &"System Font,Regular"
&K000000Max 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.
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Intrauterine Devices (IUDs) |
Norelgestromin | Evra | Patch | As dir | $105 | BC - NC / NIHB - Covered |
P
Contraceptives &"System Font,Regular"
&K000000Max 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.
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Transdermal / Vaginal | |
Etonogestrel | Nuvaring | Vaginal ring | As dir | $65 | BC - NC / NIHB - Covered |
P
Contraceptives &"System Font,Regular"
&K000000Max 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.
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Transdermal / Vaginal | |
Etonogestrel implant | Nexplanon | Hormonal implant | One time insertion | $20 | BC / NIHB - Covered |
Upfront cost is $346 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $17 every 90 days |
P
Contraceptives &"System Font,Regular"
&K000000Max 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.
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Hormonal implant |
Medroxyprogesterone | Depo-Provera | Intramuscular | Q 3 months | $50 | BC / NIHB - Covered |
P
Contraceptives &"System Font,Regular"
&K000000Max 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.
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Injectable | |
Estradiol-17β | Estrace | 1 mg | QD | $35 | BC / NIHB - Covered | I Hormone Replacement Therapy | Oral | |
Conjugated Estrogens | Premarin | 0.3 mg, 0.625 mg | QD | $55 | BC / NIHB - Covered | I Hormone Replacement Therapy | Oral | |
Micronized Progesterone | Prometrium | 100 mg | HS | $50 | BC / NIHB - Covered | I Hormone Replacement Therapy | Oral | |
Medroxyprogesterone | Provera | 5 mg | QD | $40 | BC / NIHB - Covered | I Hormone Replacement Therapy | Oral | |
Estradiol-17β Patch | Estradot/Oesclim | 50 mcg | Twice weekly | $85 | BC / NIHB - Covered | I Hormone Replacement Therapy | Transdermal | |
Estradiol-17β Gel | Estrogel | 2.5 g gel = 1.5 mg estradiol | QD | $105 | BC / NIHB - Covered | I Hormone Replacement Therapy | Transdermal | |
Conjugated Estrogens | Premarin Vaginal Cr | 0.625 mg | QD | $100 | BC / NIHB - Covered | I Hormone Replacement Therapy | Vaginal | |
Estradiol-17β Vaginal Tablet | Vagifem-10 | 10 mcg | Twice weekly | $140 | BC / NIHB - Covered | I Hormone Replacement Therapy | Vaginal | |
Dutasteride | Avodart | 0.5 mg | QD | $40 | 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) | |
Terazosin | Hytrin | 2 mg | QD | $65 | BC / NIHB - Covered | J Urology | Benign Prostatic Hyperplasia (BPH) | |
Finasteride | Proscar | 5 mg | QD | $50 | BC / NIHB - Covered | J Urology | Benign Prostatic Hyperplasia (BPH) | |
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
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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
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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
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Testosterone Undecanoate | Andriol | 40 mg | BID | $105 | BC - SA / NIHB - Covered | J Urology | Testosterone Replacement | |
Testosterone Gel | Androgel | 5 g | QD | $470 | BC - NC / NIHB - SA | J Urology | Testosterone Replacement | |
Testosterone Enanthate | Delatestryl | 200 mg/mL | 400 mg Q30D | $60 | BC / NIHB - Covered | J Urology | Testosterone Replacement | |
Testosterone Cypionate | Depo-Testosterone | 100 mg/mL | 200 mg Q2W | $60 | BC / NIHB - Covered | J Urology | Testosterone Replacement | |
Sumatriptan | Imitrex | 100 mg | PRN | $35 | BC / NIHB - Covered |
12 Tablets / 30 Days |
K Analgesics | Anti-Migraine |
Topiramate | Topamax | 100 mg | QD | $60 | BC / NIHB - Covered | K Analgesics | Anti-Migraine | |
Zolmitriptan | Zomig | 2.5 mg | PRN | $40 | BC / NIHB - Covered |
12 Tablets / 30 Days |
K Analgesics | Anti-Migraine |
Colchicine | Colchicine | 0.6 mg | QD | $40 | BC / NIHB - Covered | K Analgesics | Gout | |
Allopurinol | Zyloprim | 200 mg | QD | $25 | BC / NIHB - Covered | K Analgesics | Gout | |
Tramadol/Acetaminophen | Tramacet | 37.5 mg/325 mg | PRN | $80 | BC - NC / NIHB - SA |
90 tablets |
K Analgesics | Miscellaneous Analgesics |
Amitriptyline | Elavil | 10 mg, 25 mg | HS | $20 | BC / NIHB - Covered | K Analgesics | Neuropathic or Chronic Pain | |
Pregabalin | Lyrica | 50 mg | HS | $35 | BC / NIHB - Covered | K Analgesics | Neuropathic or Chronic Pain | |
Gabapentin | Neurontin | 300 mg | TID | $45 | BC / NIHB - Covered | K Analgesics | Neuropathic or Chronic Pain | |
Duloxetine | Cymbalta | 30 mg, 60 mg | QD | $85 | BC / NIHB - Covered | K Analgesics | Neuropathic or Chronic Pain | |
Diclofenac/Misoprostol | Arthrotec | 75 mg/200 mcg | BID | $100 | 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) | |
Naproxen | Naproxen | 500 mg | BID | $55 | BC / NIHB - Covered | K Analgesics | Non-Steroidal Antiinflammatory Drugs (NSAIDs) | |
Ketorolac | Toradol | 10 mg | BID | $50 | 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) | |
Diclofenac | Voltaren SR | 75 mg | BID | $105 | BC / NIHB - Covered | K Analgesics | Non-Steroidal Antiinflammatory Drugs (NSAIDs) | |
Amoxicillin | Amoxil | 500 mg TID x 7 days | $15 | BC / NIHB - Covered | O Miscellaneous | Antibiotics | ||
Clarithromycin | Biaxin | 2x250 mg BID x 5 days | $25 | BC / NIHB - Covered | O Miscellaneous | Antibiotics | ||
Ciprofloxacin | Cipro | 500 mg BID x 5 days | $20 | BC - SA / NIHB - Covered | O Miscellaneous | Antibiotics | ||
Amoxicillin/Clavulanate | Clavulin | 500 mg TID x 7 days | $25 | BC / NIHB - Covered | O Miscellaneous | Antibiotics | ||
Doxycycline | Doxycycline | 100 mg QD x 7 days | $20 | BC / NIHB - Covered | O Miscellaneous | Antibiotics | ||
Cephalexin | Keflex | 500 mg QID x 7 days | $20 | BC / NIHB - Covered | O Miscellaneous | Antibiotics | ||
Nitrofurantoin | Macrobid | 100 mg BID x 3 days | $15 | BC / NIHB - Covered | O Miscellaneous | Antibiotics | ||
Fosfomycin | Monurol | 3 g as a single dose | $30 | BC / NIHB - Covered | O Miscellaneous | Antibiotics | ||
Azithromycin | Zithromax | 250 mg x 4 days | $20 | BC / NIHB - Covered | O Miscellaneous | Antibiotics | ||
Alendronate | Fosamax | 70 mg once weekly | $40 | BC / NIHB - Covered | O Miscellaneous | Osteoporosis | ||
Denosumab | Prolia | 60 mg SQ every 6 months | $255 | BC / NIHB - SA | O Miscellaneous | Osteoporosis | ||
Isotretinoin | Accutane | 40 mg | QD x 90 days | $205 | BC / 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 | |
Adapalene | Differin (60g tube) | 0.10% | As dir | $215 | BC - NC / 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 | |
Permethrin | Nix | 1% | As dir | $25 | BC / NIHB - Covered | L Topicals | Lice | |
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.
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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.
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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.
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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.
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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.
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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.
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Fluticasone/Salmeterol | Advair Diskus (60) | 250/50 mcg | 1 pf bid | $180 | BC / NIHB - SA | E Respiratory | Long-acting beta-agonist/Corticosteroid Combos | |
Fluticasone/Salmeterol | Advair MDI (120) | 250/25 mcg | 1 pf bid | $285 | BC / NIHB - SA | E Respiratory | Long-acting beta-agonist/Corticosteroid Combos | |
Fluticasone/Vilanterol | Breo Ellipta (30) | 100/25 mcg | 1 pf qd | $335 | BC / NIHB - SA | E Respiratory | Long-acting beta-agonist/Corticosteroid Combos | |
Budesonide/Formoterol | Symbicort (120) | 200/6 mcg | 1 pf qd | $180 | BC / NIHB - SA | E Respiratory | Long-acting beta-agonist/Corticosteroid Combos | |
Montelukast | Singulair | 10 mg | QD | $55 | BC - Restricted / NIHB - Covered | E Respiratory | Leukotriene Receptor Antagonist | |
Fluticasone furoate/Umeclidinium/Vilanterol | Trelegy Ellipta (30) | 100/62.5/25 mcg | 1 pf qd | $470 | BC / NIHB - SA | E Respiratory | Long-acting beta-agonist/long acting muscarinic antagonist/Corticosteroid Combos | |
Doxylamine/Pyridoxine | Diclectin | 10 mg/10 mg | PRN | $35 | BC / NIHB - Covered | P &K000000Gastrointestinal |
Antiemetics
30 tablets
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Dimenhydrinate | Gravol | 50 mg | PRN | $15 | BC / NIHB - Covered | P &K000000Gastrointestinal |
Antiemetics
30 tablets
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Metoclopramide | Maxeran | 2x5 mg | PRN | $15 | BC / NIHB - Covered | P &K000000Gastrointestinal |
Antiemetics
30 tablets
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Ondansetron | Zofran | 8mg | PRN | $145 | BC / NIHB - Covered | P &K000000Gastrointestinal |
Antiemetics
30 tablets
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Pyridoxine (Vitamin B6) | Pyridoxine | 25 mg | PRN | $5 | BC - NC/ NIHB - Covered | P &K000000Gastrointestinal |
Antiemetics
30 tablets
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Amoxicillin | Amoxil | 1 g | BID x 14d | $95 | BC / NIHB - Covered | P &K000000Gastrointestinal |
Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
All HP regimens covered
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Clarithromycin | Biaxin | 2x250 mg | BID x 14d | BC / NIHB - Covered | P &K000000Gastrointestinal |
Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
All HP regimens covered
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Metronidazole | Flagyl | 500 mg | BID x 14d | BC / NIHB - Covered | P &K000000Gastrointestinal |
Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
All HP regimens covered
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Pantoprazole Magnesium | Tecta | 40 mg | BID x 14d | BC / NIHB - Covered | P &K000000Gastrointestinal |
Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
All HP regimens covered
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Ranitidine | Zantac | 150 mg | BID | $40 | BC / NIHB - Covered | P &K000000Gastrointestinal | Histamine-2 Receptor Antagonists (H2RAs) | |
Lactulose | Lactulose | 1 tbsp | QD | $35 | BC / NIHB - Covered | P &K000000Gastrointestinal | Laxatives | |
PEG3350 | Restoralax/Lax-A-Day | 17 g | QD | $55 | BC - NC/ NIHB - Covered | P &K000000Gastrointestinal | Laxatives | |
Dexlansoprazole | Dexilant | 30 mg | QD | $225 | BC / NIHB - NC | P &K000000Gastrointestinal |
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.
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Omeprazole | Losec | 20 mg | QD | $35 | BC / NIHB - Covered | P &K000000Gastrointestinal |
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.
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Esomeprazole | Nexium | 40 mg | QD | $210 | BC - NC / NIHB - SA | P &K000000Gastrointestinal |
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.
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Rabeprazole | Pariet | 10 mg, 20 mg | QD | $20 | BC / NIHB - Covered | P &K000000Gastrointestinal |
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.
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Lansoprazole | Prevacid | 30 mg | QD | $65 | BC / NIHB - Covered | P &K000000Gastrointestinal |
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.
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Pantoprazole Magnesium | Tecta | 40 mg | QD | $35 | BC / NIHB - Covered | P &K000000Gastrointestinal |
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.
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Citalopram | Celexa | 20 mg | QD | $25 | BC / NIHB - Covered | P &K000000Psychiatry | Antidepressants | |
Escitalopram | Cipralex | 10 mg | QD | $45 | BC / NIHB - Covered | P &K000000Psychiatry | Antidepressants | |
Duloxetine | Cymbalta | 30 mg | QD | $50 | BC / NIHB - Covered | P &K000000Psychiatry | Antidepressants | |
Venlafaxine | Effexor XR | 75 mg | QD | $30 | BC / NIHB - Covered | P &K000000Psychiatry | Antidepressants | |
Paroxetine | Paxil | 20 mg | QD | $45 | BC / NIHB - Covered | P &K000000Psychiatry | Antidepressants | |
Desvenlafaxine | Pristiq | 50 mg | QD | $255 | BC - NC / NIHB - SA | P &K000000Psychiatry | Antidepressants | |
Fluoxetine | Prozac | 20 mg | QD | $45 | BC / NIHB - Covered | P &K000000Psychiatry | Antidepressants | |
Mirtazapine | Remeron | 30 mg | HS | $35 | BC / NIHB - Covered | P &K000000Psychiatry | Antidepressants | |
Vortioxetine | Trintellix | 20 mg | QD | $260 | BC / NIHB - Covered | P &K000000Psychiatry | Antidepressants | |
Bupropion | Wellbutrin XL | 150 mg | QD | $45 | BC / NIHB - Covered | P &K000000Psychiatry | Antidepressants | |
Sertraline | Zoloft | 50 mg | QD | $45 | BC / NIHB - Covered | P &K000000Psychiatry | Antidepressants | |
Aripiprazole | Abilify | 15 mg | QD | $140 | BC - Restricted / NIHB - Covered | P &K000000Psychiatry | Antipsychotics | |
Risperidone | Risperdal | 1 mg | QD | $35 | BC / NIHB - Covered | P &K000000Psychiatry | Antipsychotics | |
Quetiapine | Seroquel | 25 mg | HS | $20 | BC / NIHB - Covered | P &K000000Psychiatry | Antipsychotics | |
Quetiapine | Seroquel XR | 300 mg | QD | $110 | BC / NIHB - Covered | P &K000000Psychiatry | Antipsychotics | |
Olanzapine | Zyprexa | 5 mg, 10 mg | QD | $85 | BC / NIHB - Covered | P &K000000Psychiatry | Antipsychotics | |
Lorazepam | Ativan | 1 mg | PRN | $20 | BC / NIHB - Covered |
90 tablets |
P &K000000Psychiatry | Anxiolytic Sedative |
Trazodone | Desyrel | 50 mg | PRN | $20 | BC / NIHB - Covered |
90 tablets |
P &K000000Psychiatry | Anxiolytic Sedative |
Zopiclone | Imovane | 7.5 mg | PRN | $25 | BC - Covered / NIHB - NC |
90 tablets |
P &K000000Psychiatry | Anxiolytic Sedative |
Temazepam | Restoril | 30 mg | PRN | $45 | BC / NIHB - Covered |
90 tablets |
P &K000000Psychiatry | Anxiolytic Sedative |
Lemborexant | Dayvigo | 5 mg, 10 mg | HS | $195 | BC / NIHB - NC | P &K000000Psychiatry | Anxiolytic Sedative | |
Amphetamines, Mixed Salts | Adderall XR | 10 mg | QD | $75 | BC - Restricted / NIHB - Covered | P &K000000Psychiatry | Stimulants (ADHD) | |
Methylphenidate | Concerta | 36 mg | QD | $150 | BC - Restricted / NIHB - Covered | P &K000000Psychiatry | Stimulants (ADHD) | |
Methylphenidate | Ritalin | 10 mg | BID | $60 | BC / NIHB - Covered | P &K000000Psychiatry | Stimulants (ADHD) | |
Methylphenidate | Biphentin | 10 mg | QD | $65 | BC - Restricted / NIHB - NC | P &K000000Psychiatry | Stimulants (ADHD) | |
Lisdexamfetamine | Vyvanse | 20 mg | QD | $85 | BC - Restricted / NIHB - Covered | P &K000000Psychiatry | Stimulants (ADHD) | |
Norethindrone Acetate | Lolo | QD | $85 | BC - NC / NIHB - Covered |
P
Contraceptives &"System Font,Regular"
&K000000Max 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 |
P
Contraceptives &"System Font,Regular"
&K000000Max 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 |
P
Contraceptives &"System Font,Regular"
&K000000Max 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 |
P
Contraceptives &"System Font,Regular"
&K000000Max 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 |
P
Contraceptives &"System Font,Regular"
&K000000Max 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 |
P
Contraceptives &"System Font,Regular"
&K000000Max 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 | ||
Desogestrel | Marvelon | QD | $40 | BC / NIHB - Covered |
P
Contraceptives &"System Font,Regular"
&K000000Max 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 |
P
Contraceptives &"System Font,Regular"
&K000000Max 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 |
P
Contraceptives &"System Font,Regular"
&K000000Max 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 |
P
Contraceptives &"System Font,Regular"
&K000000Max 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 |
P
Contraceptives &"System Font,Regular"
&K000000Max 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) |
Telmisartan | Micardis | 80 mg | QD | $35 | BC / NIHB - Covered | P &K000000Cardiovascular | Angiotensin Receptor Blockers | |
Warfarin | Coumadin | 5 mg | QD | $20 | BC / NIHB - Covered | P &K000000Cardiovascular | Anti-Coagulant | |
Apixaban | Eliquis | 5 mg | BID | $95 | BC / NIHB - Covered | P &K000000Cardiovascular | Anti-Coagulant | |
Edoxaban | Lixiana | 60 mg | QD | $305 | BC - SA / NIHB - Covered | P &K000000Cardiovascular | Anti-Coagulant | |
Dabigatran | Pradaxa | 110 mg, 150 mg | BID | $265 | BC - SA / NIHB - Covered | P &K000000Cardiovascular | Anti-Coagulant | |
Rivaroxaban | Xarelto | 15 mg, 20 mg | QD | $85 | BC / NIHB - Covered | P &K000000Cardiovascular | Anti-Coagulant | |
Rivaroxaban | Xarelto | 2.5 mg | BID | $85 | BC - Covered / NIHB - SA | P &K000000Cardiovascular | Anti-Coagulant | |
Ticagrelor | Brilinta | 90 mg | BID | $95 | BC - Restricted / NIHB - Covered | P &K000000Cardiovascular | Anti-Platelet | |
Clopidogrel | Plavix | 75 mg | QD | $40 | BC / NIHB - Covered | P &K000000Cardiovascular | Anti-Platelet | |
Metoprolol | Lopresor | 25 mg, 50 mg | BID | $25 | BC / NIHB - Covered | P &K000000Cardiovascular | Beta Blockers | |
Metoprolol-SR | Lopresor SR | 100 mg, 200 mg | QD | $50 | BC / NIHB - Covered | P &K000000Cardiovascular | Beta Blockers | |
Bisoprolol | Monocor | 10 mg | QD | $25 | BC / NIHB - Covered | P &K000000Cardiovascular | Beta Blockers | |
Atenolol | Tenormin | 50 mg | QD | $25 | BC / NIHB - Covered | P &K000000Cardiovascular | Beta Blockers | |
Nifedipine | Adalat XL | 30 mg | QD | $75 | BC / NIHB - Covered | P &K000000Cardiovascular |
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 | P &K000000Cardiovascular |
Calcium Channel Blockers
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 | P &K000000Cardiovascular |
Calcium Channel Blockers
Maximum Allowable Cost (MAC) pricing exists for Calcium Channel Blockers. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
|
|
Spironolactone | Aldactone | 25 mg, 100 mg | QD | $25 | BC / NIHB - Covered | P &K000000Cardiovascular | Diuretics | |
Hydrochlorothiazide | Hydrodiuril | 12.5 mg, 25 mg | QD | $15 | BC / NIHB - Covered | P &K000000Cardiovascular | Diuretics | |
Chlorthalidone | Hygroton | 12.5 mg, 25 mg, 50 mg | QD | $25 | BC / NIHB - Covered | P &K000000Cardiovascular | Diuretics | |
Furosemide | Lasix | 20 mg, 40 mg | QD | $15 | BC / NIHB - Covered | P &K000000Cardiovascular | Diuretics | |
Indapamide | Lozide | 2.5 mg | QD | $40 | BC / NIHB - Covered | P &K000000Cardiovascular | Diuretics | |
Rosuvastatin | Crestor | 10 mg, 20 mg | QD | $30 | BC / NIHB - Covered | P &K000000Cardiovascular |
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 | P &K000000Cardiovascular |
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 | P &K000000Cardiovascular |
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 | P &K000000Cardiovascular |
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 | P &K000000Cardiovascular |
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 | $1885 | BC / NIHB - SA | P &K000000Cardiovascular |
Lipid Lowering Agents
Maximum Allowable Cost (MAC) pricing exists for statins. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
|
|
Evolocumab | Repatha | 140 mg SQ | Q2W | $1920 | BC / NIHB - SA | P &K000000Cardiovascular |
Lipid Lowering Agents
Maximum Allowable Cost (MAC) pricing exists for statins. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf.
|
|
Sacubitril/Valsartan | Entresto | 97 mg/103 mg | BID | $750 | BC / NIHB - SA | P &K000000Cardiovascular | Neprilysin Inhibitor / ARB Combos | |
Metformin | Glucophage | 500 mg | 2 BID | $25 | BC / NIHB - Covered | P &K000000Hypoglycemic Agents | Biguanides | |
Metformin SR | Glumetza SR | 1000 mg | 2 QD | $290 | BC - NC / NIHB - SA | P &K000000Hypoglycemic Agents | Biguanides | |
Linagliptin | Trajenta | 5 mg | QD | $280 | BC - SA / NIHB - Covered | P &K000000Hypoglycemic Agents | Dipeptidylpeptidase-4 Inhibitors (DPP-4) | |
Sitagliptin | Januvia | 100 mg | QD | $95 | BC / NIHB - SA | P &K000000Hypoglycemic Agents | Dipeptidylpeptidase-4 Inhibitors (DPP-4) | |
Semaglutide | Ozempic | 1 mg SQ | Once weekly | $540 | BC / NIHB - SA | P &K000000Hypoglycemic Agents | Glucagon-like Peptide 1 Agonist (GLP-1) | |
Liraglutide | Victoza | 1.2 mg SQ | QD | $745 | BC / NIHB - NC | P &K000000Hypoglycemic Agents | Glucagon-like Peptide 1 Agonist (GLP-1) | |
Liraglutide | Victoza | 1.8 mg SQ | QD | $1115 | BC / NIHB - NC | P &K000000Hypoglycemic Agents | Glucagon-like Peptide 1 Agonist (GLP-1) | |
Basal insulin (Degludec) | Tresiba | 100 U/ml | As dir | $140 | BC / NIHB - Covered | P &K000000Hypoglycemic 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 | P &K000000Hypoglycemic 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 | P &K000000Hypoglycemic 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 | P &K000000Hypoglycemic 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 | P &K000000Hypoglycemic 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 | P &K000000Hypoglycemic 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 | P &K000000Hypoglycemic 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 | P &K000000Hypoglycemic 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 | P &K000000Hypoglycemic 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 | P &K000000Hypoglycemic Agents | Meglitinides | |
Canagliflozin | Invokana | 100 mg | QD | $295 | BC / NIHB - SA | P &K000000Hypoglycemic Agents | Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors | |
Dapagliflozin Propanediol Monohydrate | Forxiga | 10 mg | QD | $80 | BC / NIHB - Covered | P &K000000Hypoglycemic Agents | Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors | |
Empagliflozin | Jardiance | 10 mg, 25 mg | QD | $290 | BC - SA / NIHB - Covered | P &K000000Hypoglycemic Agents | Sodium Glucose Cotransporter 2 (SGLT2) Inhibitors | |
Gliclazide | Diamicron | 80 mg | BID | $35 | BC / NIHB - Covered | P &K000000Hypoglycemic Agents | Sulfonylureas | |
Gliclazide MR | Diamicron MR | 30 mg MR | 2 QD | $35 | BC / NIHB - Covered | P &K000000Hypoglycemic Agents | Sulfonylureas | |
Glyburide | Diabeta | 5 mg | BID | $25 | BC / NIHB - Covered | P &K000000Hypoglycemic Agents | Sulfonylureas | |
Liraglutide | Saxenda | 3 mg SQ | QD | $1485 | BC / NIHB - NC | C Obesity | Obesity | |
Orlistat | Xenical | 120 mg | TID | $610 | BC / NIHB - NC | C Obesity | Obesity | |
Semaglutide | Ozempic | 2.4 mg SQ | Once weekly | $1270 | NC for weight management |
Must titrate to 2.4 mg dose |
C Obesity | Obesity |
Semaglutide | Rybelsus | 14 mg | Once daily | $780 | BC - NC / NIHB - SA | C Obesity | Obesity | |
Semaglutide | Wegovy | 2.4 mg SQ | Once weekly | $1485 | BC / NIHB - NC | C Obesity | Obesity | |
Naltrexone | Contrave | 16 mg/180 mg | BID | $990 | BC / NIHB - NC | C 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 |
Lifetime $ limit |
P
&K000000Smoking Cessation &"System Font,Regular"
&K000000Cost quoted for 12 weeks of stated dosing frequency
|
Nicotine Replacement Therapy | |
Nicotine Gum | Nicorette | 2 mg, 4 mg | 12 pcs/d | $400 | BC - Restricted / NIHB - Covered |
Lifetime $ limit |
P
&K000000Smoking Cessation &"System Font,Regular"
&K000000Cost quoted for 12 weeks of stated dosing frequency
|
Nicotine Replacement Therapy |
Nicotine Inhaler | Nicorette | Cartridges | 6 ctgs/d | $500 | BC - Restricted / NIHB - Covered |
Lifetime $ limit |
P
&K000000Smoking Cessation &"System Font,Regular"
&K000000Cost quoted for 12 weeks of stated dosing frequency
|
Nicotine Replacement Therapy |
Nortriptyline | Aventyl | 25 mg | 3 HS | $210 | BC / NIHB - Covered |
P
&K000000Smoking Cessation &"System Font,Regular"
&K000000Cost 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 |
P
&K000000Smoking Cessation &"System Font,Regular"
&K000000Cost quoted for 12 weeks of stated dosing frequency
|
Smoking Cessation | |
Bupropion | Wellbutrin SR | 150 mg | BID | $195 | BC / NIHB - Covered |
P
&K000000Smoking Cessation &"System Font,Regular"
&K000000Cost quoted for 12 weeks of stated dosing frequency
|
Smoking Cessation | |
Bupropion | Zyban | 150 mg | BID | $245 | BC / NIHB - Covered |
P
&K000000Smoking Cessation &"System Font,Regular"
&K000000Cost quoted for 12 weeks of stated dosing frequency
|
Smoking Cessation | |
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.
|
|
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.
|
|
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.
|
|
Ramipril | Altace | 5 mg, 10 mg | QD | $25 | BC / NIHB - Covered | P &K000000Cardiovascular |
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 | P &K000000Cardiovascular |
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 | P &K000000Cardiovascular |
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 | P &K000000Cardiovascular |
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 | P &K000000Cardiovascular |
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 | P &K000000Cardiovascular | Angiotensin Receptor Blockers | |
Losartan | Cozaar | 50 mg | QD | $30 | BC / NIHB - Covered | P &K000000Cardiovascular | Angiotensin Receptor Blockers | |
Valsartan | Diovan | 80 mg, 160 mg | QD | $35 | BC / NIHB - Covered | P &K000000Cardiovascular | Angiotensin Receptor Blockers |