$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
INSULIN
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
HUMALOG MIX 50-50 (insulin npl/insulin lispro) |
|
|
|
HUMALOG MIX 75-25 (insulin npl/insulin lispro) |
|
|
|
HUMULIN 50-50 (insulin human regular/nph) |
|
|
|
HUMULIN 70-30 (insulin human regular/nph) |
|
|
|
NOVOLOG MIX 70-30 (insulin asp prt/insulin aspart) |
|
$$$ |
|
HUMULIN N (insulin, nph) |
|
$$$ |
|
HUMULIN R (insulin, regular) |
|
$$$$ |
|
LEVEMIR (insulin detemir) |
|
$$$$$ |
|
HUMALOG (insulin lispro) |
|
$$$$$ |
|
LANTUS (QLL = 5 cartridges) (insulin glargine,hum.rec.anlo) |
|
$$$$$ |
|
LANTUS SOLOSTAR (insulin glargine,hum.rec.anlo) |
|
$$$$$ |
|
NOVOLOG (insulin aspart) |
|
Non-Formulary |
|
APIDRA |
|
Non-Formulary |
|
NOVOLIN 70-30 |
|
Non-Formulary |
|
NOVOLIN 70-30 INNOLET |
|
Non-Formulary |
|
NOVOLIN N |
|
Non-Formulary |
|
NOVOLIN N INNOLET |
|
Non-Formulary |
|
NOVOLIN R |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0