Clickable Table
| Generic Name | Brand Name | Strength | Dosing | 90 Day Cost | Coverage | Comments | Category 1 | Category 2 |
|---|---|---|---|---|---|---|---|---|
| Itraconazole | Sporanox | 2x100 mg QD x 12 weeks | $795 | BC / NIHB - Covered |
Onychomycosis dosing |
O Miscellaneous | Antifungals | |
| 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 | ||
| Risedronate | Actonel | 35 mg once weekly | $35 | BC / NIHB - Covered | O Miscellaneous | Osteoporosis | ||
| Teriparatide | Forteo | 20 mcg SQ | QD | $1935 | BC / NIHB - NC | O Miscellaneous | Osteoporosis | |
| Alendronate | Fosamax | 70 mg once weekly | $40 | BC / NIHB - Covered | O Miscellaneous | Osteoporosis | ||
| Denosumab | Prolia | 60 mg SQ every 6 months | $245 | BC / NIHB - SA | O Miscellaneous | Osteoporosis | ||
| Moxifloxacin | Avelox | 400 mg QD x 7 days | $25 | BC - SA / 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 (uncomplicated UTI) | $30 | BC / NIHB - Covered | O Miscellaneous | Antibiotics | ||
| Azithromycin | Zithromax | 250 mg x 4 days | $20 | BC / NIHB - Covered | O Miscellaneous | Antibiotics | ||
| Fluconazole | Diflucan | 150 mg once weekly x 12 weeks | $65 | BC / NIHB - Covered |
Onychomycosis dosing |
O Miscellaneous | Antifungals | |
| Efinaconazole | Jublia | Nail lacquer; price for 8ml | $125 | 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 | |
| Cicloporox | Penlac | Nail lacquer; price for 6 g | $70 | BC / NIHB - NC |
Onychomycosis dosing |
O Miscellaneous | Antifungals | |
| Amoxicillin | Amoxil | 500 mg TID x 7 days | $15 | BC / NIHB - Covered | O Miscellaneous | Antibiotics |