$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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PROTON PUMP INHIBITORS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
pantoprazole sodium (pantoprazole) |
|
|
|
PANTOPRAZOLE SODIUM (Requires trial of H2 and OTC omeprazole) (pantoprazole) |
|
$$$ |
|
PROTONIX (Requires trial of H2 and OTC omeprazole) (pantoprazole) |
|
$$$$ |
|
PREVACID (lansoprazole) |
tab |
$$$$$ |
|
PRILOSEC (Requires trial of H2 and OTC Omeprazole) (omeprazole) |
|
Non-Formulary |
|
ACIPHEX (Requires trial of H2 and OTC omeprazole) |
|
Non-Formulary |
|
KAPIDEX |
|
Non-Formulary |
|
KAPIDEX (Requires trial of H2 and OTC Omeprazole) |
|
Non-Formulary |
|
NEXIUM (Requires trial of H2 and OTC omeprazole) |
|
Non-Formulary |
|
OMEPRAZOLE |
|
Non-Formulary |
|
OMEPRAZOLE (Requires trial of H2 and OTC omeprazole) |
|
Non-Formulary |
|
PREVACID |
|
Non-Formulary |
|
PRILOSEC (Requires trial of H2 and OTC Omeprazole) |
|
Non-Formulary |
|
PROTONIX Inj & Susp |
|
Non-Formulary |
|
ZEGERID |
|
Formulary Date: 10/21/2009 Update Date: 10/26/2009 V1.3.0