$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
CNS STIMULANT DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
caffeine and sodium benzoate (caff/sod benzoate) |
|
|
|
dextroamphetamine-amphetamine (amphetamine/dextroamphetamine) |
|
|
|
methylphenidate sr (methylphenidate) |
|
$$ |
|
dexmethylphenidate hcl (dexmethylphenidate) |
|
$$ |
|
dextroamphetamine sulfate (d-amphetamine) |
|
$$ |
|
METHYLIN (methylphenidate) |
soln |
$$ |
|
METHYLIN (methylphenidate) |
2.5 mg tab |
$$ |
|
METHYLIN (methylphenidate) |
5 mg tab |
$$ |
|
METHYLIN (methylphenidate) |
10 mg tab |
$$ |
|
methylin (methylphenidate) |
tab |
$$ |
|
methylin er (methylphenidate) |
|
$$ |
|
methylphenidate er (methylphenidate) |
|
$$ |
|
methylphenidate hcl (methylphenidate) |
|
$$ |
|
RITALIN (methylphenidate) |
|
$$$ |
|
ADDERALL (PAR) (amphetamine/dextroamphetamine) |
|
$$$ |
|
amphetamine salt combo (amphetamine/dextroamphetamine) |
|
$$$ |
|
DEXEDRINE (d-amphetamine) |
|
$$$ |
|
DEXEDRINE (PAR) (d-amphetamine) |
|
$$$ |
|
METADATE ER (PAR) (methylphenidate) |
|
$$$ |
|
RITALIN-SR (methylphenidate) |
|
$$$$ |
|
FOCALIN XR (dexmethylphenidate) |
|
$$$$ |
|
METADATE CD (methylphenidate) |
|
$$$$$ |
|
ADDERALL XR (amphetamine/dextroamphetamine) |
|
$$$$$ |
|
CAFCIT (caffeine citrated) |
|
$$$$$ |
|
caffeine citrate (caffeine citrated) |
|
$$$$$ |
|
DESOXYN (PAR) (methamphetamine) |
|
$$$$$ |
|
PROVIGIL (PAR) (modafinil) |
|
Non-Formulary |
|
CONCERTA |
|
Non-Formulary |
|
DAYTRANA |
|
Non-Formulary |
|
FOCALIN |
|
Non-Formulary |
|
LIQUADD |
|
Non-Formulary |
|
NUVIGIL |
|
Non-Formulary |
|
PROCENTRA |
|
Non-Formulary |
|
RITALIN LA |
|
Non-Formulary |
|
VYVANSE |
|
Formulary Date: 05/13/2009 Update Date: 05/15/2009 V1.3.0