$ |
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 |
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
amifostine (amifostine) |
|
|
|
BLENOXANE (bleomycin sulfate) |
|
|
|
BUSULFEX (busulfan) |
|
|
|
cerubidine (daunorubicin hcl) |
|
|
|
cladribine (cladribine) |
|
|
|
COSMEGEN (dactinomycin) |
|
|
|
daunorubicin hcl (daunorubicin hcl) |
|
|
|
DAUNOXOME (daunorubicin liposome) |
|
|
|
dexrazoxane (dexrazoxane) |
|
|
|
DOXIL (doxorubicin hcl liposome) |
|
|
|
doxorubicin hcl (doxorubicin hcl) |
|
|
|
DTIC-DOME IV (dacarbazine) |
|
|
|
ELSPAR (asparaginase) |
|
|
|
FLUDARA (fludarabine phosphate) |
|
|
|
FLUDARABINE PHOSPHATE (fludarabine phosphate) |
|
|
|
fluorouracil (fluorouracil) |
|
|
|
fudr (floxuridine) |
|
|
|
IFEX (ifosfamide) |
|
|
|
IFEX-MESNEX (ifosfamide/mesna) |
|
|
|
ifosfamide (ifosfamide) |
|
|
|
ifosfamide-mesna (ifosfamide/mesna) |
|
|
|
LEUSTATIN (cladribine) |
|
|
|
NAVELBINE (vinorelbine) |
|
|
|
NIPENT (pentostatin) |
|
|
|
ONCASPAR (pegaspargase) |
|
|
|
ONTAK (denileukin diftitox) |
|
|
|
onxol (paclitaxel) |
|
|
|
PARAPLATIN (carboplatin) |
|
|
|
pentostatin (pentostatin) |
|
|
|
TAXOL (paclitaxel) |
|
|
|
toposar (etoposide) |
|
|
|
tretinoin (tretinoin) |
cap |
|
|
VUMON (teniposide) |
|
|
|
ZANOSAR (streptozocin) |
|
|
|
ZINECARD (dexrazoxane) |
|
$ |
|
adrucil (fluorouracil) |
|
$ |
|
AGRYLIN (anagrelide) |
|
$ |
|
anagrelide hcl (anagrelide) |
|
$ |
|
azathioprine (azathioprine) |
|
$ |
|
CEENU (lomustine) |
|
$ |
|
cisplatin (cisplatin) |
|
$ |
|
cytarabine (cytarabine) |
|
$ |
|
dacarbazine (dacarbazine) |
|
$ |
|
DROXIA (hydroxyurea) |
|
$ |
|
HYDREA (hydroxyurea) |
|
$ |
|
hydroxyurea (hydroxyurea) |
|
$ |
|
IMURAN (azathioprine) |
|
$ |
|
leflunomide (leflunomide) |
|
$ |
|
leucovorin calcium (leucovorin) |
|
$ |
|
MEGACE (megestrol) |
|
$ |
|
megestrol acetate (megestrol) |
|
$ |
|
methotrexate (methotrexate) |
|
$ |
|
methotrexate (methotrexate sodium) |
|
$ |
|
MYLERAN (busulfan) |
|
$ |
|
tamoxifen citrate (tamoxifen) |
|
$ |
|
vinblastine sulfate (vinblastine) |
|
$ |
|
vincristine sulfate (vincristine) |
|
$$ |
|
ALKERAN (melphalan) |
|
$$ |
|
ARAVA (covered only if prescribed by rheumatologist) (leflunomide) |
|
$$ |
|
cyclophosphamide (cyclophosphamide) |
|
$$ |
|
CYTOXAN (cyclophosphamide) |
|
$$ |
|
FARESTON (toremifene) |
|
$$ |
|
flutamide (flutamide) |
|
$$ |
|
LEUKERAN (chlorambucil) |
|
$$ |
|
mercaptopurine (mercaptopurine) |
|
$$ |
|
PURINETHOL (mercaptopurine) |
|
$$ |
|
RHEUMATREX (methotrexate) |
|
$$ |
|
TESLAC (testolactone) |
|
$$ |
|
TREXALL (methotrexate sodium) |
|
$$$ |
|
adriamycin (doxorubicin hcl) |
|
$$$ |
|
bleomycin sulfate (bleomycin sulfate) |
|
$$$ |
|
cyclosporine (cyclosporine) |
|
$$$ |
|
DEPO-PROVERA (medroxyprogesterone) |
|
$$$ |
|
gengraf (cyclosporine) |
|
$$$ |
|
MESNA (mesna) |
|
$$$ |
|
NEORAL (PAR) (cyclosporine) |
|
$$$ |
|
THIOGUANINE (thioguanine) |
|
$$$$ |
|
ARIMIDEX (anastrozole) |
|
$$$$ |
|
AROMASIN (exemestane) |
|
$$$$ |
|
BICNU (carmustine) |
|
$$$$ |
|
EMCYT (estramustine phosphate sodium) |
|
$$$$ |
|
FEMARA (letrozole) |
|
$$$$ |
|
SANDIMMUNE (PAR) (cyclosporine) |
|
$$$$$ |
|
carboplatin (carboplatin) |
|
$$$$$ |
|
CASODEX (bicalutamide) |
|
$$$$$ |
|
CELLCEPT (PA) (mycophenolate mofetil) |
|
$$$$$ |
|
ELIGARD (leuprolide) |
|
$$$$$ |
|
ENBREL (PAR) (covered only if prescribed by rheumatologist) (etanercept) |
|
$$$$$ |
|
ETHYOL (amifostine) |
|
$$$$$ |
|
etoposide (etoposide) |
|
$$$$$ |
|
GLEEVEC (imatinib mesylate) |
|
$$$$$ |
|
HERCEPTIN (trastuzumab) |
|
$$$$$ |
|
HEXALEN (altretamine) |
|
$$$$$ |
|
HUMIRA (adalimumab) |
|
$$$$$ |
|
HUMIRA (PAR) (adalimumab) |
|
$$$$$ |
|
IRESSA (gefitinib) |
|
$$$$$ |
|
LYSODREN (mitotane) |
|
$$$$$ |
|
MATULANE (procarbazine) |
|
$$$$$ |
|
MESNEX (mesna) |
|
$$$$$ |
|
mitomycin (mitomycin) |
|
$$$$$ |
|
mitoxantrone hcl (mitoxantrone) |
|
$$$$$ |
|
MUSTARGEN (mechlorethamine) |
|
$$$$$ |
|
MYFORTIC (mycophenolate sodium) |
|
$$$$$ |
|
NILANDRON (nilutamide) |
|
$$$$$ |
|
NOVANTRONE (mitoxantrone) |
|
$$$$$ |
|
octreotide acetate (octreotide) |
|
$$$$$ |
|
ORENCIA (Restricted to rheumatology) (abatacept/maltose) |
|
$$$$$ |
|
paclitaxel (paclitaxel) |
|
$$$$$ |
|
PROGRAF (PAR) (tacrolimus) |
|
$$$$$ |
|
RAPAMUNE (sirolimus) |
|
$$$$$ |
|
REMICADE (PAR) (infliximab) |
|
$$$$$ |
|
RITUXAN (Restricted to rheumatology and oncology) (rituximab) |
|
$$$$$ |
|
SANDOSTATIN (octreotide) |
|
$$$$$ |
|
SANDOSTATIN LAR (octreotide) |
|
$$$$$ |
|
TARCEVA (erlotinib hcl) |
|
$$$$$ |
|
TARGRETIN (bexarotene) |
|
$$$$$ |
|
TEMODAR (temozolomide) |
|
$$$$$ |
|
THERACYS (bcg vaccine) |
|
$$$$$ |
|
thiotepa (thiotepa) |
|
$$$$$ |
|
VESANOID (tretinoin) |
|
$$$$$ |
|
vinorelbine tartrate (vinorelbine) |
|
$$$$$ |
|
XELODA (capecitabine) |
|
$$$$$ |
|
ZOLADEX (goserelin acetate) |
3.6 mg inj |
Non-Formulary |
|
AZASAN (use generic Azathioprine) |
|
Non-Formulary |
|
HYCAMTIN |
|
Non-Formulary |
|
MEGACE ES |
|
Non-Formulary |
|
NEXAVAR |
|
Non-Formulary |
|
REVLIMID |
|
Non-Formulary |
|
SPRYCEL |
|
Non-Formulary |
|
SUTENT |
|
Non-Formulary |
|
TASIGNA |
|
Non-Formulary |
|
TRELSTAR LA |
|
Non-Formulary |
|
TYKERB |
|
Non-Formulary |
|
VIADUR |
|
Non-Formulary |
|
ZOLADEX |
|
Non-Formulary |
|
ZOLINZA |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0