$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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CLASS III NARCOTICS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
aspirin with codeine (codeine phosphate/aspirin) |
|
|
|
hydrogesic (hydrocodone bitartrate/apap) |
|
|
|
LIQUICET (hydrocodone bitartrate/apap) |
|
|
|
LORCET 10-650 (hydrocodone bitartrate/apap) |
|
|
|
POLYGESIC (hydrocodone bitartrate/apap) |
|
$ |
|
acetaminophen-codeine (codeine phosphate/apap) |
|
$ |
|
co-gesic (hydrocodone bitartrate/apap) |
|
$ |
|
hydrocodone-acetaminophen (hydrocodone bitartrate/apap) |
|
$ |
|
LORCET PLUS (hydrocodone bitartrate/apap) |
|
$ |
|
margesic h (hydrocodone bitartrate/apap) |
|
$ |
|
stagesic (hydrocodone bitartrate/apap) |
|
$ |
|
TYLENOL-CODEINE NO.3 (codeine phosphate/apap) |
|
$ |
|
VICODIN (hydrocodone bitartrate/apap) |
|
$ |
|
VICODIN ES (hydrocodone bitartrate/apap) |
|
$ |
|
VICODIN HP (hydrocodone bitartrate/apap) |
|
$$ |
|
CAPITAL W-CODEINE (codeine phosphate/apap) |
|
$$ |
|
DOLOREX FORTE (hydrocodone bitartrate/apap) |
|
$$ |
|
LORTAB (hydrocodone bitartrate/apap) |
|
$$ |
|
NORCO (hydrocodone bitartrate/apap) |
|
$$$ |
|
HYCET (hydrocodone bitartrate/apap) |
|
$$$ |
|
MAXIDONE (hydrocodone bitartrate/apap) |
|
$$$ |
|
TYLENOL-CODEINE NO.4 (codeine phosphate/apap) |
|
$$$ |
|
ZYDONE (hydrocodone bitartrate/apap) |
|
Non-Formulary |
|
APAP-CAFFEINE-DIHYDROCODEINE |
|
Non-Formulary |
|
HYDROCODONE BIT-IBUPROFEN |
|
Non-Formulary |
|
IBUDONE |
|
Non-Formulary |
|
PANLOR DC |
|
Non-Formulary |
|
PANLOR SS |
|
Non-Formulary |
|
REPREXAIN |
|
Non-Formulary |
|
REPREXAIN |
|
Non-Formulary |
|
SUBOXONE |
|
Non-Formulary |
|
SUBUTEX |
|
Non-Formulary |
|
SYNALGOS-DC |
|
Non-Formulary |
|
TREZIX |
|
Non-Formulary |
|
VICOPROFEN |
|
Non-Formulary |
|
VOPAC |
|
Non-Formulary |
|
XODOL 10-300 |
|
Non-Formulary |
|
XODOL 5-300 |
|
Non-Formulary |
|
XODOL 7.5-300 |
|
Non-Formulary |
|
ZAMICET |
|
Non-Formulary |
|
ZERLOR |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0