Clickable Table

Generic Name Brand Name Strength Dosing 90 Day Cost Coverage Comments Category 1 Category 2
Lansoprazole Prevacid 30 mg QD $35 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for PPIs paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost of rabeprazole 10mg for lansoprazole 15mg, omeprazole 10mg and rabeprazole 10mg, or the cost of pantoprazole magnesium 40mg for all other covered PPIs. The patient will have to pay out of pocket for any difference between that price and the price of the prescribed PPI.

Gastrointestinal Proton Pump Inhibitors (PPIs)
Pantoprazole Magnesium Tecta 40 mg QD $35 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for PPIs paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost of rabeprazole 10mg for lansoprazole 15mg, omeprazole 10mg and rabeprazole 10mg, or the cost of pantoprazole magnesium 40mg for all other covered PPIs. The patient will have to pay out of pocket for any difference between that price and the price of the prescribed PPI.

Gastrointestinal Proton Pump Inhibitors (PPIs)
Dexlansoprazole Dexilant 30 mg QD $245 BC / IA - NC

Maximum Allowable Cost (MAC) pricing exists for PPIs paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost of rabeprazole 10mg for lansoprazole 15mg, omeprazole 10mg and rabeprazole 10mg, or the cost of pantoprazole magnesium 40mg for all other covered PPIs. The patient will have to pay out of pocket for any difference between that price and the price of the prescribed PPI.

Gastrointestinal Proton Pump Inhibitors (PPIs)
Omeprazole Losec 20 mg QD $35 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for PPIs paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost of rabeprazole 10mg for lansoprazole 15mg, omeprazole 10mg and rabeprazole 10mg, or the cost of pantoprazole magnesium 40mg for all other covered PPIs. The patient will have to pay out of pocket for any difference between that price and the price of the prescribed PPI.

Gastrointestinal Proton Pump Inhibitors (PPIs)
Esomeprazole Nexium 40 mg QD $210 BC / IA - NC

Maximum Allowable Cost (MAC) pricing exists for PPIs paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost of rabeprazole 10mg for lansoprazole 15mg, omeprazole 10mg and rabeprazole 10mg, or the cost of pantoprazole magnesium 40mg for all other covered PPIs. The patient will have to pay out of pocket for any difference between that price and the price of the prescribed PPI.

Gastrointestinal Proton Pump Inhibitors (PPIs)
Rabeprazole Pariet 10 mg QD $20 BC / IA - Covered

Maximum Allowable Cost (MAC) pricing exists for PPIs paid for by Alberta government sponsored drug programs. The drug plan will only pay the cost of rabeprazole 10mg for lansoprazole 15mg, omeprazole 10mg and rabeprazole 10mg, or the cost of pantoprazole magnesium 40mg for all other covered PPIs. The patient will have to pay out of pocket for any difference between that price and the price of the prescribed PPI.

Gastrointestinal Proton Pump Inhibitors (PPIs)
Doxylamine/Pyridoxine Diclectin 10 mg/10 mg PRN $35 BC / IA - Covered Gastrointestinal Antiemetics
Dimenhydrinate Gravol 50 mg PRN $15 BC / IA - Covered Gastrointestinal Antiemetics
Metoclopramide Maxeran 2x5 mg PRN $20 BC / IA - Covered Gastrointestinal Antiemetics
Ondansetron Zofran 8 mg PRN $180 BC / IA - Covered Gastrointestinal Antiemetics
Pyridoxine Pyridoxine 25 mg PRN $5 BC - NC; IA - Covered

30 tablets

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

As 4 separate generic
prescriptions

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

As 4 separate generic
prescriptions

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

As 4 separate generic
prescriptions

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

As 4 separate generic
prescriptions

Gastrointestinal Helicobacter Pylori Eradication (CLAMET Quadruple Regimen)
Ranitidine Zantac 150 mg BID $40 BC / IA - Covered Gastrointestinal Histamine-2 Receptor Antagonists (H2RAs)
Lactulose Lactulose 1 tbsp QD $35 BC / IA - Covered Gastrointestinal Laxatives
PEG3350 Restoralax/Lax-A-Day 17 g QD $55 BC - NC; IA - Covered Gastrointestinal Laxatives
Legend:
BC = Alberta Blue Cross, IA = Indian Affairs, NC = Not covered, SA = special authorization, SR = sustained release, OTC = over the counter, SQ = subcutaneous injection, SS=Social Services