$ |
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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ANTISPASMODICS/DRUGS AFFECT GI MOTILITY
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
chlordiazepoxide-clidinium (clidinium/chlordiazepoxide) |
|
|
|
DONNAMAR (hyoscyamine sulfate) |
|
|
|
hyomax-ft (hyoscyamine sulfate) |
|
|
|
hyomax-sl (hyoscyamine sulfate) |
|
|
|
hyomax-sr (hyoscyamine sulfate) |
|
|
|
ILOPAN INJECTION (dexpanthenol) |
|
|
|
LEVSIN-SL (hyoscyamine sulfate) |
|
$ |
|
ANASPAZ (hyoscyamine sulfate) |
|
$ |
|
belladonna-phenobarbital (belladonna alkaloids/phenobarb) |
|
$ |
|
BENTYL (dicyclomine) |
|
$ |
|
colidrops (belladonna alkaloids/phenobarb) |
|
$ |
|
colidrops (hyoscyamine sulfate) |
|
$ |
|
COLYTROL (hyoscyamine sulfate) |
oral drops |
$ |
|
dexpanthenol (dexpanthenol) |
|
$ |
|
dicyclomine hcl (dicyclomine) |
|
$ |
|
hyoscyamine (hyoscyamine) |
|
$ |
|
hyoscyamine sulfate (hyoscyamine sulfate) |
elix |
$ |
|
hyoscyamine sulfate (hyoscyamine sulfate) |
oral drops |
$ |
|
hyoscyamine sulfate (hyoscyamine sulfate) |
0.125 mg tab |
$ |
|
hyoscyamine sulfate (hyoscyamine sulfate) |
tab |
$ |
|
hyoscyamine sulfate (hyoscyamine sulfate) |
sl |
$ |
|
hyosyne (hyoscyamine sulfate) |
|
$ |
|
metoclopramide hcl (metoclopramide) |
|
$ |
|
REGLAN (metoclopramide) |
|
$ |
|
SCOPOLAMINE HYDROBROMIDE (scopolamine) |
|
$ |
|
symax (hyoscyamine sulfate) |
|
$ |
|
symax-sl (hyoscyamine sulfate) |
|
$$ |
|
DONNATAL (belladonna alkaloids/phenobarb) |
elix |
$$ |
|
DONNATAL (belladonna alkaloids/phenobarb) |
tab |
$$ |
|
IB-STAT (hyoscyamine sulfate) |
|
$$ |
|
propantheline bromide (propantheline) |
|
$$$ |
|
glycopyrrolate (glycopyrrolate) |
inj |
$$$ |
|
LEVSIN (hyoscyamine sulfate) |
|
$$$ |
|
ROBINUL (glycopyrrolate) |
inj |
$$$$ |
|
LEVBID (hyoscyamine sulfate) |
|
$$$$$ |
|
LIBRAX (clidinium/chlordiazepoxide) |
|
Non-Formulary |
|
BELLADONNA |
|
Non-Formulary |
|
CANTIL |
|
Non-Formulary |
|
COLYTROL |
|
Non-Formulary |
|
COLYTROL |
|
Non-Formulary |
|
DIGEX NF |
|
Non-Formulary |
|
DONNATAL |
|
Non-Formulary |
|
GLYCOPYRROLATE |
|
Non-Formulary |
|
HYOMAX-DT |
|
Non-Formulary |
|
HYOSCYAMINE SULFATE |
|
Non-Formulary |
|
MAR-SPAS |
|
Non-Formulary |
|
METHSCOPOLAMINE BROMIDE |
|
Non-Formulary |
|
PAMINE |
|
Non-Formulary |
|
PAMINE FORTE |
|
Non-Formulary |
|
PAMINE FQ |
|
Non-Formulary |
|
PRO-HYO |
|
Non-Formulary |
|
ROBINUL |
|
Non-Formulary |
|
ROBINUL FORTE |
|
Non-Formulary |
|
SAL-TROPINE |
|
Non-Formulary |
|
SCOPACE |
|
Non-Formulary |
|
SERVIRA |
|
Non-Formulary |
|
SYMAX DUOTAB |
|
Non-Formulary |
|
SYMAX-SR |
|
Formulary Date: 05/13/2009 Update Date: 05/15/2009 V1.3.0