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 Gastrointestinal Antiemetics
Dimenhydrinate Gravol 50 mg PRN $15 BC / NIHB - Covered Gastrointestinal Antiemetics
Metoclopramide Maxeran 2x5 mg PRN $20 BC / NIHB - Covered Gastrointestinal Antiemetics
Ondansetron Zofran 8mg PRN $145 BC / NIHB - Covered Gastrointestinal Antiemetics
Pyridoxine Pyridoxine 25 mg PRN $5 BC - NC/ NIHB - Covered

30 tablets

Gastrointestinal Antiemetics
Amoxicillin Amoxil 1 g BID x 14d $95 BC / NIHB - Covered

As 4 separate generic
prescriptions

Gastrointestinal Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
Clarithromycin Biaxin 2x250 mg BID x 14d BC / NIHB - Covered

As 4 separate generic
prescriptions

Gastrointestinal Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
Metronidazole Flagyl 500 mg BID x 14d BC / NIHB - Covered

As 4 separate generic
prescriptions

Gastrointestinal Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
Pantoprazole Magnesium Tecta 40 mg BID x 14d BC / NIHB - Covered

As 4 separate generic
prescriptions

Gastrointestinal Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
Ranitidine Zantac 150 mg BID $40 BC / NIHB - Covered Gastrointestinal Histamine-2 Receptor Antagonists (H2RAs)
Lactulose Lactulose 1 tbsp QD $35 BC / NIHB - Covered Gastrointestinal Laxatives
PEG3350 Restoralax/Lax-A-Day 17 g QD $55 BC - NC/ NIHB - Covered Gastrointestinal Laxatives
Dexlansoprazole Dexilant 30 mg QD $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.

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.

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.

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.

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.

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.

Gastrointestinal Proton Pump Inhibitors (PPIs)
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