$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
OTHER ANTIPARKINSON DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
APOKYN (apomorphine hcl) |
|
|
|
ropinirole hcl (ropinirole) |
|
|
|
SINEMET 10-100 (carbidopa/levodopa) |
|
|
|
SINEMET 25-100 (carbidopa/levodopa) |
|
|
|
SINEMET 25-250 (carbidopa/levodopa) |
|
|
|
STALEVO 125 (carbidopa/levodopa/entacap) |
|
|
|
STALEVO 200 (carbidopa/levodopa/entacap) |
|
|
|
STALEVO 75 (carbidopa/levodopa/entacap) |
|
$$ |
|
selegiline hcl (selegiline) |
|
$$$ |
|
carbidopa-levodopa (carbidopa/levodopa) |
10 mg tab |
$$$ |
|
carbidopa-levodopa (carbidopa/levodopa) |
25 mg tab |
$$$ |
|
carbidopa-levodopa (carbidopa/levodopa) |
250 mg tab |
$$$ |
|
carbidopa-levodopa (carbidopa/levodopa) |
tab sa |
$$$ |
|
LODOSYN (carbidopa) |
|
$$$$ |
|
bromocriptine mesylate (bromocriptine mesylate) |
|
$$$$ |
|
MIRAPEX (pramipexole) |
|
$$$$ |
|
REQUIP (ropinirole) |
|
$$$$ |
|
SINEMET CR (carbidopa/levodopa) |
|
$$$$$ |
|
COMTAN (entacapone) |
|
$$$$$ |
|
ELDEPRYL (selegiline) |
|
$$$$$ |
|
PARLODEL (bromocriptine mesylate) |
|
$$$$$ |
|
STALEVO 100 (carbidopa/levodopa/entacap) |
|
$$$$$ |
|
STALEVO 150 (carbidopa/levodopa/entacap) |
|
$$$$$ |
|
STALEVO 50 (carbidopa/levodopa/entacap) |
|
$$$$$ |
|
TASMAR (tolcapone) |
|
Non-Formulary |
|
AZILECT |
|
Non-Formulary |
|
CARBIDOPA-LEVODOPA |
|
Non-Formulary |
|
PARCOPA |
|
Non-Formulary |
|
REQUIP XL |
|
Non-Formulary |
|
ZELAPAR |
|
Formulary Date: 05/13/2009 Update Date: 05/15/2009 V1.3.0