$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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LOCAL ANESTHETICS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
bupivacaine hcl-epinephrine (bupivacaine hydrochloride/epi) |
|
|
|
CARBOCAINE (mepivacaine) |
|
|
|
chloroprocaine hcl (chloroprocaine) |
|
|
|
droperidol (droperidol) |
|
|
|
inapsine (droperidol) |
|
|
|
lidocaine hcl (lidocaine) |
inj |
|
|
lidocaine hcl-epinephrine (lidocaine hydrochloride/epi) |
|
|
|
MARCAINE WITH EPINEPHRINE (bupivacaine hydrochloride/epi) |
|
|
|
MARCAINE-EPINEPHRINE (bupivacaine hydrochloride/epi) |
|
|
|
midazolam hcl (midazolam hcl) |
1 mg/ml inj |
|
|
MIDAZOLAM HCL (midazolam hcl) |
1 mg/ml inj |
|
|
NESACAINE (chloroprocaine) |
|
|
|
NESACAINE-MPF (chloroprocaine) |
|
|
|
POLOCAINE (mepivacaine) |
|
|
|
SENSORCAINE WITH EPINEPHRINE (bupivacaine hydrochloride/epi) |
|
|
|
VERSED (midazolam hcl) |
|
|
|
XYLOCAINE (lidocaine) |
|
|
|
XYLOCAINE WITH EPINEPHRINE (lidocaine hydrochloride/epi) |
|
$ |
|
propofol (propofol) |
|
$ |
|
SENSORCAINE (bupivacaine) |
|
$ |
|
XYLOCAINE-MPF (lidocaine) |
|
$$ |
|
bupivacaine hcl (bupivacaine) |
|
$$ |
|
MARCAINE (bupivacaine) |
|
$$$$ |
|
DIPRIVAN (propofol) |
|
$$$$$ |
|
KETALAR (ketamine) |
|
$$$$$ |
|
ketamine hcl (ketamine) |
|
$$$$$ |
|
NOVOCAIN (procaine) |
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0