$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
ANTIRETROVIRALS & PROTEASE INH
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
FUZEON (enfuvirtide) |
|
$$ |
|
zidovudine (zidovudine) |
|
$$$$ |
|
RETROVIR (zidovudine) |
|
$$$$$ |
|
APTIVUS (tipranavir) |
|
$$$$$ |
|
COMBIVIR (lamivudine/zidovudine) |
|
$$$$$ |
|
CRIXIVAN (indinavir) |
|
$$$$$ |
|
didanosine (didanosine) |
|
$$$$$ |
|
EMTRIVA (emtricitabine) |
|
$$$$$ |
|
EPIVIR (lamivudine) |
|
$$$$$ |
|
INVIRASE (saquinavir mesylate) |
|
$$$$$ |
|
KALETRA (ritonavir/lopinavir) |
|
$$$$$ |
|
LEXIVA (fosamprenavir calcium) |
|
$$$$$ |
|
NORVIR (ritonavir) |
|
$$$$$ |
|
PREZISTA (darunavir ethanolate) |
|
$$$$$ |
|
RESCRIPTOR (delavirdine mesylate) |
|
$$$$$ |
|
REYATAZ (atazanavir sulfate) |
|
$$$$$ |
|
SUSTIVA (efavirenz) |
|
$$$$$ |
|
TRIZIVIR (zidovudine/lamivudine/abacavir) |
|
$$$$$ |
|
TRUVADA (emtricitabine/tenofovir) |
|
$$$$$ |
|
VIDEX (didanosine) |
|
$$$$$ |
|
VIDEX EC (didanosine) |
|
$$$$$ |
|
VIRACEPT (nelfinavir mesylate) |
|
$$$$$ |
|
VIRAMUNE (nevirapine) |
tab |
$$$$$ |
|
VIREAD (tenofovir disproxil fumarate) |
|
$$$$$ |
|
ZERIT (stavudine) |
|
$$$$$ |
|
ZIAGEN (abacavir sulfate) |
|
Non-Formulary |
|
ATRIPLA |
|
Non-Formulary |
|
EPZICOM |
|
Non-Formulary |
|
INTELENCE |
|
Non-Formulary |
|
ISENTRESS |
|
Non-Formulary |
|
SELZENTRY |
|
Non-Formulary |
|
VIRAMUNE |
|
Formulary Date: 07/08/2008 Update Date: 07/09/2008 V1.3.0