$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
|
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| Prev. Page | Prev. Class | Next Class | Next Page |
ANTIACNE DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
CLINDAMAX (clindamycin phosphate) |
lotion |
|
|
clindamycin phosphate (clindamycin phosphate) |
gel |
|
|
clindamycin phosphate (clindamycin phosphate) |
lotion |
|
|
clindamycin phosphate (clindamycin phosphate) |
soln |
|
|
clindamycin phosphate (clindamycin phosphate) |
top |
|
|
clindamycin-benzoyl peroxide (clindamycin phos/benz per) |
|
|
|
DEL-MYCIN (erythromycin base) |
|
|
|
erythromycin (erythromycin base) |
|
|
|
metronidazole (metronidazole) |
cream |
|
|
metronidazole (metronidazole) |
gel |
|
|
metronidazole (metronidazole) |
lotion |
|
|
tretinoin (tretinoin) |
0.025 % cream |
|
|
tretinoin (tretinoin) |
0.05 % cream |
|
|
tretinoin (tretinoin) |
0.1 % cream |
|
|
tretinoin (tretinoin) |
gel |
$$ |
|
benzoyl peroxide (benzoyl peroxide) |
5 % gel |
$$ |
|
benzoyl peroxide (benzoyl peroxide) |
10 % gel |
$$ |
|
benzoyl peroxide (benzoyl peroxide) |
soln |
$$ |
|
benzoyl peroxide (benzoyl peroxide) |
10 % top |
$$ |
|
CLEOCIN T (clindamycin phosphate) |
gel |
$$ |
|
CLEOCIN T (clindamycin phosphate) |
lotion |
$$ |
|
CLEOCIN T (clindamycin phosphate) |
soln |
$$ |
|
CLEOCIN T (clindamycin phosphate) |
top |
$$ |
|
clinda-derm (clindamycin phosphate) |
|
$$ |
|
EMGEL (erythromycin base) |
|
$$ |
|
NUOX (benzoyl peroxide/sulfur) |
|
$$ |
|
ZETACET (sulfacetamide/sulfur) |
suspensions |
$$ |
|
ZETACET (sulfacetamide/sulfur) |
not oral |
$$$ |
|
ery (erythromycin base) |
|
$$$ |
|
METROCREAM (metronidazole) |
|
$$$$ |
|
AKNE-MYCIN (erythromycin base) |
|
$$$$ |
|
BENZAMYCIN (erythromycin base/benz per) |
|
$$$$ |
|
erythromycin-benzoyl peroxide (erythromycin base/benz per) |
|
$$$$ |
|
FINACEA (azelaic acid) |
|
$$$$ |
|
METROLOTION (metronidazole) |
|
$$$$ |
|
RETIN-A (PAR age > 29) (tretinoin) |
|
$$$$ |
|
sodium sulfacetamide-sulfur (sulfacetamide/sulfur) |
lotion |
$$$$ |
|
sulfatol (sulfacetamide sod/sulfur/ure) |
lotion |
$$$$$ |
|
BENZACLIN (clindamycin phos/benz per) |
gel |
$$$$$ |
|
BENZAMYCINPAK (erythromycin base/benz per) |
|
$$$$$ |
|
CLINDAGEL (clindamycin phosphate) |
|
$$$$$ |
|
DIFFERIN (PAR age > 29) (adapalene) |
|
$$$$$ |
|
NORITATE (metronidazole) |
|
$$$$$ |
|
RETIN-A MICRO (PAR age > 29) (tretinoin) |
|
$$$$$ |
|
RETIN-A MICRO PUMP (tretinoin) |
|
$$$$$ |
|
ROSULA (sulfacetamide sod/sulfur/ure) |
lotion |
Non-Formulary |
|
ACANYA |
|
Non-Formulary |
|
ACZONE |
|
Non-Formulary |
|
ATRALIN |
|
Non-Formulary |
|
AVAR |
|
Non-Formulary |
|
AVAR |
|
Non-Formulary |
|
AVAR-E |
|
Non-Formulary |
|
AVAR-E GREEN |
|
Non-Formulary |
|
AVITA |
|
Non-Formulary |
|
AZELEX |
|
Non-Formulary |
|
BENZACLIN |
|
Non-Formulary |
|
BENZEFOAM |
|
Non-Formulary |
|
BENZIQ |
|
Non-Formulary |
|
BENZOYL PEROXIDE |
|
Non-Formulary |
|
BENZOYL PEROXIDE |
|
Non-Formulary |
|
BENZOYL PEROXIDE |
|
Non-Formulary |
|
BP |
|
Non-Formulary |
|
BP 10-1 |
|
Non-Formulary |
|
BPO |
|
Non-Formulary |
|
CLARIFOAM EF |
|
Non-Formulary |
|
CLARIS |
|
Non-Formulary |
|
CLEANSING WASH |
|
Non-Formulary |
|
CLENIA |
|
Non-Formulary |
|
CLENIA |
|
Non-Formulary |
|
CLEOCIN T |
|
Non-Formulary |
|
CLINDAMAX |
|
Non-Formulary |
|
CLINDAMYCIN PHOSPHATE |
|
Non-Formulary |
|
CLINDAREACH |
|
Non-Formulary |
|
CLINDETS |
|
Non-Formulary |
|
DUAC CS |
|
Non-Formulary |
|
EPIDUO |
|
Non-Formulary |
|
EVOCLIN |
|
Non-Formulary |
|
FINACEA PLUS |
|
Non-Formulary |
|
INOVA |
|
Non-Formulary |
|
INOVA 4-1 |
|
Non-Formulary |
|
INOVA 8-2 |
|
Non-Formulary |
|
LAVOCLEN-4 |
|
Non-Formulary |
|
LAVOCLEN-4 |
|
Non-Formulary |
|
LAVOCLEN-8 |
|
Non-Formulary |
|
LAVOCLEN-8 |
|
Non-Formulary |
|
METROGEL |
|
Non-Formulary |
|
METROGEL |
|
Non-Formulary |
|
NEOBENZ MICRO |
|
Non-Formulary |
|
NEOBENZ MICRO |
|
Non-Formulary |
|
NEOBENZ MICRO SD |
|
Non-Formulary |
|
NYDAMAX |
|
Non-Formulary |
|
OSCION |
|
Non-Formulary |
|
PACNEX |
|
Non-Formulary |
|
PLEXION |
|
Non-Formulary |
|
PLEXION SCT |
|
Non-Formulary |
|
PRASCION |
|
Non-Formulary |
|
PRASCION FC |
|
Non-Formulary |
|
PRASCION RA |
|
Non-Formulary |
|
PRASCION TS |
|
Non-Formulary |
|
ROSAC |
|
Non-Formulary |
|
ROSAC |
|
Non-Formulary |
|
ROSADERM |
|
Non-Formulary |
|
ROSADERM |
|
Non-Formulary |
|
ROSANIL |
|
Non-Formulary |
|
ROSULA |
|
Non-Formulary |
|
ROSULA CLK |
|
Non-Formulary |
|
ROSULA NS |
|
Non-Formulary |
|
SOD SULFACETAMIDE-SULFUR WASH |
|
Non-Formulary |
|
SODIUM SULFA-SULFUR-MERATAN |
|
Non-Formulary |
|
SODIUM SULFACETAMIDE |
|
Non-Formulary |
|
SODIUM SULFACETAMIDE-SULFUR |
|
Non-Formulary |
|
SODIUM SULFACETAMIDE-SULFUR |
|
Non-Formulary |
|
SULFATOL |
|
Non-Formulary |
|
SULFATOL C |
|
Non-Formulary |
|
SULFATOL SS |
|
Non-Formulary |
|
SULZEE |
|
Non-Formulary |
|
SUMAXIN |
|
Non-Formulary |
|
SUPHERA |
|
Non-Formulary |
|
TOPISULF |
|
Non-Formulary |
|
TRETIN-X |
|
Non-Formulary |
|
TRETIN-X |
|
Non-Formulary |
|
TRIAZ |
|
Non-Formulary |
|
ZACARE |
|
Non-Formulary |
|
ZACLIR |
|
Non-Formulary |
|
ZETACET |
|
Non-Formulary |
|
ZIANA |
|
Non-Formulary |
|
ZODERM |
|
Non-Formulary |
|
ZODERM |
|
Formulary Date: 10/21/2009 Update Date: 10/26/2009 V1.3.0