Clickable Table
| Generic Name | Brand Name | Strength | Dosing | 90 Day Cost | Coverage | Comments | Category 1 | Category 2 |
|---|---|---|---|---|---|---|---|---|
| Doxylamine/Pyridoxine | Diclectin | 10 mg/10 mg | PRN | $35 | BC / NIHB - Covered | F Gastrointestinal | Antiemetics | |
| Dimenhydrinate | Gravol | 50 mg | PRN | $15 | BC / NIHB - Covered | F Gastrointestinal | Antiemetics | |
| Metoclopramide | Maxeran | 2x5 mg | PRN | $20 | BC / NIHB - Covered | F Gastrointestinal | Antiemetics | |
| Ondansetron | Zofran | 8mg | PRN | $145 | BC / NIHB - Covered | F Gastrointestinal | Antiemetics | |
| Pyridoxine | Pyridoxine | 25 mg | PRN | $5 | BC - NC/ NIHB - Covered |
30 tablets |
F Gastrointestinal | Antiemetics |
| Amoxicillin | Amoxil | 1 g | BID x 14d | $95 | BC / NIHB - Covered |
As 4 separate generic |
F Gastrointestinal | Helicobacter Pylori Eradication (CLAMET Quadruple Regimen) |
| Clarithromycin | Biaxin | 2x250 mg | BID x 14d | BC / NIHB - Covered |
As 4 separate generic |
F Gastrointestinal | Helicobacter Pylori Eradication (CLAMET Quadruple Regimen) | |
| Metronidazole | Flagyl | 500 mg | BID x 14d | BC / NIHB - Covered |
As 4 separate generic |
F Gastrointestinal | Helicobacter Pylori Eradication (CLAMET Quadruple Regimen) | |
| Pantoprazole Magnesium | Tecta | 40 mg | BID x 14d | BC / NIHB - Covered |
As 4 separate generic |
F Gastrointestinal | Helicobacter Pylori Eradication (CLAMET Quadruple Regimen) | |
| Ranitidine | Zantac | 150 mg | BID | $40 | BC / NIHB - Covered | F Gastrointestinal | Histamine-2 Receptor Antagonists (H2RAs) | |
| Lactulose | Lactulose | 1 tbsp | QD | $35 | BC / NIHB - Covered | F Gastrointestinal | Laxatives | |
| PEG3350 | Restoralax/Lax-A-Day | 17 g | QD | $55 | BC - NC/ NIHB - Covered | F Gastrointestinal | Laxatives | |
| Dexlansoprazole | Dexilant | 30 mg | QD | $225 | BC / NIHB - NC |
Maximum Allowable Cost (MAC) pricing exists for Proton Pump Inhibitors. See https://www.ab.bluecross.ca/pdfs/MAC-pricing-categories.pdf. |
F Gastrointestinal | Proton Pump Inhibitors (PPIs) |
| 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) |
| 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) |
| 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) |
| 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) |
| 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) |