$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
ANTIPSYCHOTIC DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
risperidone (risperidone) |
|
$ |
|
CLOZARIL (PAR-Coverd if prescribed by psychiatrist) (clozapine) |
|
$ |
|
fluphenazine decanoate (fluphenazine decanoate) |
|
$ |
|
fluphenazine hcl (fluphenazine hcl) |
|
$ |
|
HALDOL (haloperidol) |
|
$ |
|
HALDOL DECANOATE 100 (haloperidol decanoate) |
|
$ |
|
HALDOL DECANOATE 50 (haloperidol decanoate) |
|
$ |
|
haloperidol (haloperidol) |
|
$ |
|
haloperidol decanoate (haloperidol) |
|
$ |
|
haloperidol decanoate (haloperidol decanoate) |
|
$ |
|
haloperidol lactate (haloperidol) |
|
$ |
|
loxapine (loxapine succinate) |
|
$ |
|
LOXITANE (loxapine succinate) |
|
$ |
|
NAVANE (thiothixene) |
|
$ |
|
ORAP (pimozide) |
|
$ |
|
perphenazine (perphenazine) |
|
$ |
|
thioridazine hcl (thioridazine) |
|
$ |
|
thiothixene (thiothixene) |
|
$ |
|
trifluoperazine hcl (trifluoperazine) |
|
$$ |
|
MOBAN (molindone) |
|
$$ |
|
RISPERDAL (risperidone) |
|
$$ |
|
SEROQUEL (PAR covered if prescribed by psychiatrist) (quetiapine fumarate) |
|
$$$ |
|
GEODON (PAR-Covered if prescribed by psychiatrist) (ziprasidone) |
|
$$$ |
|
SEROQUEL XR (PAR covered if prescribed by psychiatrist) (quetiapine fumarate) |
|
$$$$$ |
|
RISPERDAL CONSTA (risperidone) |
|
Non-Formulary |
|
ABILIFY |
|
Non-Formulary |
|
ABILIFY DISCMELT |
|
Non-Formulary |
|
CLOZAPINE (PAR- Covered if prescribed by psychiatrist; 200mg NF) |
|
Non-Formulary |
|
FAZACLO |
|
Non-Formulary |
|
INVEGA |
|
Non-Formulary |
|
RISPERDAL M |
|
Non-Formulary |
|
ZYPREXA (PAR-Coverd if prescribed by psychiatrist) |
|
Non-Formulary |
|
ZYPREXA ZYDIS |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0