$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
OTHER GI DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
anudil hc (hydrocortisone acetate) |
|
|
|
balsalazide disodium (balsalazide disodium) |
|
|
|
CORTENEMA (hydrocortisone) |
|
|
|
DIGESPLEN PLUS (enzymes/simethicone/whole bile) |
|
|
|
hydrocortisone (hydrocortisone) |
|
|
|
hydrocortisone acetate (hydrocortisone acetate) |
25 mg rectal |
|
|
pancrelipase ec (amylase/lipase/protease) |
|
|
|
peg 3350-electrolyte (electrolyte solution/peg's) |
|
$ |
|
anucort-hc (hydrocortisone acetate) |
|
$ |
|
anumed-hc (hydrocortisone acetate) |
|
$ |
|
COLYTE WITH FLAVOR PACKETS (electrolyte solution/peg's) |
|
$ |
|
GOLYTELY (electrolyte solution/peg's) |
|
$ |
|
hemorrhoidal hc (hydrocortisone acetate) |
|
$ |
|
NULYTELY WITH FLAVOR PACKS (electrolyte solution/peg's) |
|
$ |
|
OCL (electrolyte solution/peg's) |
|
$ |
|
PROCTOCREAM-HC (hydrocortisone) |
|
$ |
|
PROCTOSOL-HC (hydrocortisone acetate) |
|
$ |
|
proctozone-hc (hydrocortisone acetate) |
|
$ |
|
sulfasalazine (sulfasalazine) |
|
$ |
|
TRILYTE WITH FLAVOR PACKETS (electrolyte solution/peg's) |
|
$$ |
|
ANALPRAM HC (pramoxine/hc acetate) |
|
$$ |
|
ANALPRAM HC (pramoxine/hydrocortisone) |
|
$$ |
|
AZULFIDINE (sulfasalazine) |
|
$$ |
|
procto-kit (hydrocortisone) |
1 % cream |
$$ |
|
PROCTO-KIT (hydrocortisone) |
2.5 % cream |
$$ |
|
procto-pak (hydrocortisone) |
|
$$ |
|
sulfazine (sulfasalazine) |
|
$$ |
|
sulfazine ec (sulfasalazine) |
|
$$$ |
|
ANUSOL-HC (hydrocortisone) |
|
$$$ |
|
ANUSOL-HC (hydrocortisone acetate) |
|
$$$ |
|
dygase (amylase/lipase/protease) |
|
$$$ |
|
lapase (amylase/lipase/protease) |
|
$$$ |
|
pancrelipase (amylase/lipase/protease) |
|
$$$ |
|
pangestyme cn 10 (amylase/lipase/protease) |
|
$$$ |
|
pangestyme ec (amylase/lipase/protease) |
|
$$$ |
|
plaretase 8000 (amylase/lipase/protease) |
|
$$$ |
|
PROCTOFOAM-HC (pramoxine/hc acetate) |
|
$$$ |
|
sulfasalazine dr (sulfasalazine) |
|
$$$$ |
|
ACTIGALL (ursodiol) |
|
$$$$ |
|
pangestyme ul 12 (amylase/lipase/protease) |
|
$$$$ |
|
PROCTOCORT (hydrocortisone) |
cream |
$$$$ |
|
ursodiol (ursodiol) |
|
$$$$$ |
|
ASACOL (mesalamine) |
|
$$$$$ |
|
CANASA (mesalamine) |
|
$$$$$ |
|
COLOCORT (hydrocortisone) |
|
$$$$$ |
|
CORTIFOAM (hydrocortisone acetate) |
|
$$$$$ |
|
CREON 10 (amylase/lipase/protease) |
|
$$$$$ |
|
CREON 20 (amylase/lipase/protease) |
|
$$$$$ |
|
CREON 5 (amylase/lipase/protease) |
|
$$$$$ |
|
ENTOCORT EC (budesonide) |
|
$$$$$ |
|
lipram-ul12 (amylase/lipase/protease) |
|
$$$$$ |
|
lipram-ul18 (amylase/lipase/protease) |
|
$$$$$ |
|
lipram-ul20 (amylase/lipase/protease) |
|
$$$$$ |
|
mesalamine (mesalamine) |
|
$$$$$ |
|
PANCREASE MT 10 (amylase/lipase/protease) |
|
$$$$$ |
|
PANCREASE MT 16 (amylase/lipase/protease) |
|
$$$$$ |
|
PANCREASE MT 20 (amylase/lipase/protease) |
|
$$$$$ |
|
PANCREASE MT 4 (amylase/lipase/protease) |
|
$$$$$ |
|
PANCRECARB MS-16 (amylase/lipase/protease) |
|
$$$$$ |
|
PANCRECARB MS-4 (amylase/lipase/protease) |
|
$$$$$ |
|
PANCRECARB MS-8 (amylase/lipase/protease) |
|
$$$$$ |
|
pangestyme cn 20 (amylase/lipase/protease) |
|
$$$$$ |
|
pangestyme mt 16 (amylase/lipase/protease) |
|
$$$$$ |
|
pangestyme ul 18 (amylase/lipase/protease) |
|
$$$$$ |
|
pangestyme ul 20 (amylase/lipase/protease) |
|
$$$$$ |
|
PENTASA (mesalamine) |
|
$$$$$ |
|
SUCRAID (sacrosidase) |
|
$$$$$ |
|
ULTRASE (amylase/lipase/protease) |
|
$$$$$ |
|
ULTRASE MT 12 (amylase/lipase/protease) |
|
$$$$$ |
|
ULTRASE MT 18 (amylase/lipase/protease) |
|
$$$$$ |
|
ULTRASE MT 20 (amylase/lipase/protease) |
|
$$$$$ |
|
URSO (ursodiol) |
|
$$$$$ |
|
URSO FORTE (ursodiol) |
|
$$$$$ |
|
VIOKASE (amylase/lipase/protease) |
|
Non-Formulary |
|
ANA-LEX HC |
|
Non-Formulary |
|
ANAMANTLE HC |
|
Non-Formulary |
|
BAROS GRANULES |
|
Non-Formulary |
|
COLAZAL |
|
Non-Formulary |
|
DIGEX |
|
Non-Formulary |
|
DIPENTUM |
|
Non-Formulary |
|
ENZYMAX |
|
Non-Formulary |
|
GASTRINEX |
|
Non-Formulary |
|
HALFLYTELY-BISACODYL |
|
Non-Formulary |
|
HEMRIL |
|
Non-Formulary |
|
HYDROCORTISONE ACETATE |
|
Non-Formulary |
|
LIALDA |
|
Non-Formulary |
|
LIDOCAINE-HYDROCORTISONE |
|
Non-Formulary |
|
MOVIPREP |
|
Non-Formulary |
|
PERANEX HC |
|
Non-Formulary |
|
PROCTOCORT |
|
Non-Formulary |
|
PROCTOSERT HC |
|
Non-Formulary |
|
RECTAGEL HC |
|
Non-Formulary |
|
ROWASA |
|
Non-Formulary |
|
XYRALID RC |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0