$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
SEDATIVE/HYPNOTIC DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
AMYTAL SODIUM (amobarbital) |
|
|
|
NEMBUTAL SODIUM (pentobarbital sodium) |
|
|
|
zaleplon (zaleplon) |
|
$ |
|
DALMANE (flurazepam) |
|
$ |
|
flurazepam hcl (flurazepam) |
|
$ |
|
HALCION (triazolam) |
|
$ |
|
temazepam (temazepam) |
cap |
$ |
|
TEMAZEPAM (temazepam) |
7.5 mg cap |
$ |
|
triazolam (triazolam) |
|
$ |
|
zolpidem tartrate (zolpidem) |
|
$$ |
|
AMBIEN (For members under the age of 60 requires trail of generic benzodiazepine) (zolpidem) |
|
$$$$ |
|
RESTORIL (temazepam) |
cap |
$$$$ |
|
SONATA (For members under the age of 60 requires trial of generic benzodiazepine) (zaleplon) |
|
Non-Formulary |
|
AMBIEN CR |
|
Non-Formulary |
|
BUTISOL SODIUM |
|
Non-Formulary |
|
CHLORAL HYDRATE |
|
Non-Formulary |
|
CHLORAL HYDRATE |
|
Non-Formulary |
|
DORAL |
|
Non-Formulary |
|
ESTAZOLAM |
|
Non-Formulary |
|
LUNESTA |
|
Non-Formulary |
|
MIDAZOLAM HCL |
|
Non-Formulary |
|
PARALDEHYDE |
|
Non-Formulary |
|
RESTORIL |
|
Non-Formulary |
|
ROZEREM |
|
Non-Formulary |
|
SECONAL SODIUM |
|
Non-Formulary |
|
SOMNOTE |
|
Non-Formulary |
|
TEMAZEPAM |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0