$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
ANTIVERTIGO AND ANTIEMETIC DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
granisetron hcl (granisetron) |
|
|
|
granisol (granisetron) |
|
|
|
promethazine hcl (promethazine) |
|
|
|
trimethobenzamide hcl (trimethobenzamide) |
|
$ |
|
ANTIVERT (meclizine hcl) |
tab |
$ |
|
COMPAZINE (prochlorperazine edisylate) |
|
$ |
|
compro (prochlorperazine maleate) |
|
$ |
|
MECLIZINE HCL (50mg Only) (meclizine hcl) |
|
$ |
|
ondansetron hcl (ondansetron) |
|
$ |
|
ondansetron odt (ondansetron) |
|
$ |
|
phenadoz (promethazine) |
|
$ |
|
prochlorperazine edisylate (prochlorperazine edisylate) |
|
$ |
|
prochlorperazine maleate (prochlorperazine maleate) |
|
$ |
|
promethegan (promethazine) |
|
$ |
|
TIGAN (trimethobenzamide) |
|
$ |
|
VERTIN-32 (meclizine hcl) |
|
$$$$ |
|
EMEND (aprepitant) |
|
$$$$$ |
|
KYTRIL (PAR) (granisetron) |
|
$$$$$ |
|
ondansetron hcl in dextrose (dextrose 5%-water/ondansetron) |
|
$$$$$ |
|
ZOFRAN (Q) (PAR) (ondansetron) |
|
$$$$$ |
|
ZOFRAN IN DEXTROSE (dextrose 5%-water/ondansetron) |
|
$$$$$ |
|
ZOFRAN ODT (Q) (ondansetron) |
|
Non-Formulary |
|
ANTIVERT |
|
Non-Formulary |
|
ANZEMET (Q) (PA) |
|
Non-Formulary |
|
CESAMET |
|
Non-Formulary |
|
DRONABINOL |
|
Non-Formulary |
|
EMEND (prescribing limited to oncology) |
|
Non-Formulary |
|
MARINOL |
|
Non-Formulary |
|
TRANSDERM-SCOP |
|
Formulary Date: 07/08/2008 Update Date: 07/09/2008 V1.3.0