$ |
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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DRUGS TO PREVENT AND TREAT HEADACHES
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
ascomp with codeine (codeine/asa/caffeine/butalb) |
|
|
|
butalbital-aspirin-caffeine (aspirin/caffeine/butalbital) |
tab |
|
|
diacetazone (apap/isometheptene/dichlphen) |
|
|
|
FIORICET WITH CODEINE (codeine/apap/caffeine/butalb) |
|
|
|
FIORINAL WITH CODEINE #3 (codeine/asa/caffeine/butalb) |
|
|
|
isometh-d-chloralphenaz-apap (apap/isometheptene/dichlphen) |
|
|
|
isomethept-caffeine-apap (acetaminophen/caffeine/isometh) |
|
|
|
PHRENILIN-CAFFEINE-CODEINE (codeine/apap/caffeine/butalb) |
|
$ |
|
acetaminophen-butalbital (acetaminophen/butalbital) |
|
$ |
|
bupap (acetaminophen/butalbital) |
|
$ |
|
butalbital compound (aspirin/caffeine/butalbital) |
|
$ |
|
butalbital-apap-caffeine (acetaminophen/caffeine/butalb) |
tab |
$ |
|
butorphanol tartrate (butorphanol) |
|
$ |
|
cephadyn (acetaminophen/butalbital) |
|
$ |
|
DOLGIC LQ (acetaminophen/caffeine/butalb) |
|
$ |
|
epidrin (apap/isometheptene/dichlphen) |
|
$ |
|
ESGIC (acetaminophen/caffeine/butalb) |
tab |
$ |
|
farbital (aspirin/caffeine/butalbital) |
|
$ |
|
marten-tab (acetaminophen/butalbital) |
|
$ |
|
MIDRIN (apap/isometheptene/dichlphen) |
|
$ |
|
MIGRATEN (acetaminophen/caffeine/isometh) |
|
$ |
|
PHRENILIN (acetaminophen/butalbital) |
|
$ |
|
promacet (acetaminophen/butalbital) |
|
$ |
|
tencon (acetaminophen/butalbital) |
|
$$ |
|
butalbital-aspirin-caffeine (aspirin/caffeine/butalbital) |
cap |
$$ |
|
butalbital-caff-apap-codeine (codeine/apap/caffeine/butalb) |
|
$$ |
|
CAFERGOT (ergotamine tartrate/caffeine) |
|
$$ |
|
DOLGIC PLUS (acetaminophen/caffeine/butalb) |
|
$$ |
|
ergotamine-caffeine (ergotamine tartrate/caffeine) |
|
$$ |
|
ESGIC-PLUS (acetaminophen/caffeine/butalb) |
|
$$ |
|
FIORICET (acetaminophen/caffeine/butalb) |
|
$$ |
|
FIORINAL (aspirin/caffeine/butalbital) |
|
$$ |
|
PHRENILIN FORTE (acetaminophen/butalbital) |
|
$$ |
|
repan (acetaminophen/caffeine/butalb) |
|
$$ |
|
sedapap (acetaminophen/butalbital) |
|
$$$ |
|
butalbital compound-codeine (codeine/asa/caffeine/butalb) |
|
$$$ |
|
ERGOMAR (ergotamine) |
|
$$$ |
|
migergot (ergotamine tartrate/caffeine) |
|
$$$ |
|
ZEBUTAL (acetaminophen/caffeine/butalb) |
|
$$$$ |
|
ZOMIG (QL= 6x2.5mg; 3x5mg) (zolmitriptan) |
|
$$$$ |
|
ZOMIG ZMT (QL=6 tabs/Rx; 18 tabs/Month) (zolmitriptan) |
|
$$$$$ |
|
D.H.E.45 (dihydroergotamine) |
|
$$$$$ |
|
dihydroergotamine mesylate (dihydroergotamine) |
|
$$$$$ |
|
MAXALT (QLL = 6 tabs/Rx) (rizatriptan benzoate) |
|
$$$$$ |
|
MAXALT MLT (rizatriptan benzoate) |
|
$$$$$ |
|
MAXALT MLT (QLL = 6 tabs/Rx) (rizatriptan benzoate) |
|
$$$$$ |
|
MIGRALAM (acetaminophen/caffeine/isometh) |
|
$$$$$ |
|
MIGRANAL (dihydroergotamine) |
|
Non-Formulary |
|
ALAGESIC |
|
Non-Formulary |
|
AMERGE (QL=9 tabs/Rx) |
|
Non-Formulary |
|
ANOLOR-300 |
|
Non-Formulary |
|
AXERT |
|
Non-Formulary |
|
BUTALBITAL-APAP-CAFFEINE |
|
Non-Formulary |
|
EQUAGESIC |
|
Non-Formulary |
|
ESGIC |
|
Non-Formulary |
|
FROVA |
|
Non-Formulary |
|
GEONE |
|
Non-Formulary |
|
IMITREX (Oral: QL=9 tabs/Rx; Nasal Spray: QL=6 devices/Rx; Injectable: QL= 1 kit/Rx) |
|
Non-Formulary |
|
MARGESIC |
|
Non-Formulary |
|
RELPAX |
|
Non-Formulary |
|
TREXIMET |
|
Non-Formulary |
|
TRIAD |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0