$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
|
|
|
|
|
| Prev. Page | Prev. Class | Next Class | Next Page |
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
paroxetine hcl (paroxetine) |
tab sa |
$$ |
|
citalopram hbr (citalopram) |
|
$$ |
|
fluoxetine hcl (fluoxetine) |
|
$$ |
|
fluvoxamine maleate (fluvoxamine) |
|
$$ |
|
paroxetine hcl (paroxetine) |
oral susp |
$$ |
|
paroxetine hcl (paroxetine) |
tab |
$$ |
|
PAXIL (Requires trial of generic fluoxetine) (10mg not covered) (paroxetine) |
|
$$ |
|
PROZAC (fluoxetine) |
|
$$ |
|
sertraline hcl (sertraline) |
|
$$ |
|
ZOLOFT (requires trial of generic fluoxetine) (50mg not covered) (sertraline) |
|
$$$ |
|
LEXAPRO (escitalopram oxalate) |
|
$$$ |
|
LEXAPRO (requires trial of generic fluoxetine) (escitalopram oxalate) |
|
$$$$ |
|
citalopram (citalopram) |
|
$$$$ |
|
PAXIL CR (paroxetine) |
|
Non-Formulary |
|
CELEXA (requires trial of generic fluoxetine) |
|
Non-Formulary |
|
LUVOX CR |
|
Non-Formulary |
|
PEXEVA |
|
Non-Formulary |
|
PROZAC WEEKLY (Requires trial of generic fluoxetine) |
|
Non-Formulary |
|
SARAFEM |
|
Non-Formulary |
|
SELFEMRA |
|
Formulary Date: 07/08/2008 Update Date: 07/09/2008 V1.3.0