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): $20	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 - NC / NIHB - Covered	Total Dose (mg/tab or 5mL): 150 Elemental Iron (mg/tab or 5mL): 30 90 Day Cost (100 mg elemental iron/day): $30	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	$90	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	$30	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 / NIHB - NC		L Topicals	Acne Treatments
Adapalene	Differin (60g tube)	0.10%	As dir	$185	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		$230	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 - NC / NIHB - Covered		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		$120	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		$20	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	$60	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 - Covered / NIHB - SA		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 - Covered / NIHB - SA		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	$85	BC / NIHB - Covered		J Urology	Testosterone Replacement
Testosterone Gel	Androgel	5 g	QD	$455	BC - NC / NIHB - SA		J Urology	Testosterone Replacement
Testosterone Patch	Androderm	5 mg/day	QD	$455	BC / 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	$35	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	$130	BC / NIHB - Covered		I Hormone Replacement Therapy	Vaginal
Conjugated Estrogens	Premarin Vaginal Cr	0.625 mg	QD	$90	BC / NIHB - Covered		I Hormone Replacement Therapy	Vaginal
Estradiol-17β Gel	Estrogel	2.5 g gel = 1.5 mg estradiol	QD	$100	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	$50	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	$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.	Transdermal / Vaginal
Levonorgestrel	Mirena	IUD	As dir	$20	BC / NIHB - Covered	Upfront cost is $396 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $20 every 90 days	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 $371 but the IUD lasts 5 years, so cost spread out over 5 years is roughly $18 every 90 days	H Contraceptives Max allowable price for 12 week supply unless otherwise stated, and 21 or 28 tab products costs are equivalent. All except IUDs contain Ethinyl Estradiol plus the listed progesterone.	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	$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.	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	$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
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	$80	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	$290	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	$400	BC - NC / NIHB - Covered		G Psychiatry	Stimulants (ADHD)
Amphetamines, Mixed Salts	Adderall XR	10 mg	QD	$265	BC / NIHB - NC		G Psychiatry	Stimulants (ADHD)
Temazepam	Restoril	30 mg	PRN	$40	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	$30	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 / NIHB - NC		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	$250	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 prescriptions	F Gastrointestinal	Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
Metronidazole	Flagyl	500 mg	BID x 14d		BC / NIHB - Covered	As 4 separate generic prescriptions	F Gastrointestinal	Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
Clarithromycin	Biaxin	2x250 mg	BID x 14d		BC / NIHB - Covered	As 4 separate generic prescriptions	F Gastrointestinal	Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
Amoxicillin	Amoxil	1 g	BID x 14d	$95	BC / NIHB - Covered	As 4 separate generic prescriptions	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	$160	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	$310	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	$265	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 / 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	Leukotriene Receptor Antagonist
Beclomethasone	Qvar (200)	100 mcg	1 pf bid	$80	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	$80	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	$70	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	$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
Glycopyrronium	Seebri (30)	50 mcg	1 pf qd	$190	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	$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	Bronchodilators / Anti-cholingergics
Bupropion	Zyban	150 mg	BID	$225	BC / NIHB - Covered		D Smoking Cessation Cost quoted for 12 weeks of stated dosing frequency	Smoking Cessation
Bupropion	Wellbutrin SR	150 mg	BID	$120	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		$190	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	$185	BC / NIHB - Covered		D Smoking Cessation Cost quoted for 12 weeks of stated dosing frequency	Smoking Cessation
Nicotine Inhaler	Nicorette	Cartridges	6 ctgs/d	$470	BC - Restricted / NIHB - Covered	Lifetime $ limit	D Smoking Cessation Cost quoted for 12 weeks of stated dosing frequency	Nicotine Replacement Therapy
Nicotine Gum	Nicorette	4 mg	12 pcs/d	$380	BC - Restricted / NIHB - Covered	Lifetime $ limit	D Smoking Cessation Cost quoted for 12 weeks of stated dosing frequency	Nicotine Replacement Therapy
Nicotine Gum	Nicorette	2 mg	12 pcs/d	$380	BC - Restricted / NIHB - Covered	Lifetime $ limit	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	$3340	NC for weight management	Must titrate to 2.4 mg dose	C Obesity	Obesity
Orlistat	Xenical	120 mg	TID	$535	BC / NIHB - NC		C Obesity	Obesity
Liraglutide	Saxenda	3 mg SQ	QD	$1360	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	$285	BC - SA / 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	$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	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	$90	BC - NC / NIHB - SA	Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively).	B Hypoglycemic Agents	Insulin
Long-acting insulin	Novolin NPH/Humulin N	100 U/ml	As dir	$65	BC / NIHB - Covered	Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively).	B Hypoglycemic Agents	Insulin
Basal insulin biosimilar (Glargine)	Basaglar	100 U/ml	As dir	$90	BC / NIHB - Covered	Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively).	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 - 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 (Detemir)	Levemir	100 U/ml	As dir	$135	BC / NIHB - Covered	Prices may vary between pharmacies, relative differences likely consistent. Max allowable price for 1500 Units of penfill insulin. Lantus, Novorapid, and Humalog part of Blue Cross biosimilar initiative so only biosimilar alternatives are covered (Basaglar, Trurapi, and Admelog, respectively).	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	$1020	BC / NIHB - NC		B Hypoglycemic Agents	Glucagon-like Peptide 1 Agonist (GLP-1)
Liraglutide	Victoza	1.2 mg SQ	QD	$685	BC / NIHB - NC		B Hypoglycemic Agents	Glucagon-like Peptide 1 Agonist (GLP-1)
Semaglutide	Ozempic	0.5 mg SQ	Once weekly	$680	BC - SA / NIHB - Covered		B Hypoglycemic Agents	Glucagon-like Peptide 1 Agonist (GLP-1)
Lixisenatide	Adlyxine	0.02 mg SQ	QD	$390	BC - SA / NIHB - Covered		B Hypoglycemic Agents	Glucagon-like Peptide 1 Agonist (GLP-1)
Sitagliptin	Januvia	100 mg	QD	$335	BC / NIHB - SA		B Hypoglycemic Agents	Dipeptidylpeptidase-4 Inhibitors (DPP-4)
Saxagliptin	Onglyza	5 mg	QD	$310	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	$225	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	$1735	BC / NIHB - SA		A Cardiovascular	Lipid Lowering Agents
Alirocumab	Praluent	75 mg x Q2W SQ	Q2W	$1830	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
Spironolactone	Aldactone	25 mg, 100 mg	QD	$35	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	$250	BC - SA / NIHB - Covered		A Cardiovascular	Anti-Platelet
Rivaroxaban	Xarelto	2.5 mg	BID	$295	BC / NIHB - SA		A Cardiovascular	Anti-Coagulant
Rivaroxaban	Xarelto	15 mg, 20 mg	QD	$300	BC - SA / 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	$340	BC - SA / 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

Legend:

BC = Alberta Blue Cross, NIHB = Non-Insured Health Benefits for First Nations and Inuit, NC = Not covered, SA = special authorization, SR = sustained release, OTC = over the counter, SQ = subcutaneous injection, SS=Social Services