$

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.

Table of Contents     Index     Policy Information


 

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)

 

 

 

ASACOL HD (mesalamine)

 

 

 

balsalazide disodium (balsalazide disodium)

 

 

 

CORTENEMA (hydrocortisone)

 

 

 

gavilyte-c (electrolyte solution/peg's)

 

 

 

gavilyte-g (electrolyte solution/peg's)

 

 

 

gavilyte-n (electrolyte solution/peg's)

 

 

 

hydrocortisone (hydrocortisone)

 

 

 

hydrocortisone acetate (hydrocortisone acetate)

25 mg rectal

 

 

hydrocortisone-pramoxine (pramoxine/hydrocortisone)

 

 

 

pancrelipase ec (amylase/lipase/protease)

 

 

 

peg 3350-electrolyte (electrolyte solution/peg's)

 

 

 

peg-3350 and electrolytes (electrolyte solution/peg's)

 

 

 

peg-3350 with flavor packs (electrolyte solution/peg's)

 

 

 

SFROWASA (mesalamine)

 

 

 

ursodiol (ursodiol)

tab

$

 

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)

 

$$$

 

PROCTOFOAM-HC (pramoxine/hc acetate)

 

$$$

 

sulfasalazine dr (sulfasalazine)

 

$$$$

 

ACTIGALL (ursodiol)

 

$$$$

 

PROCTOCORT (hydrocortisone)

cream

$$$$

 

ursodiol (ursodiol)

cap

$$$$$

 

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)

 

$$$$$

 

mesalamine (mesalamine)

rectal

$$$$$

 

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)

 

$$$$$

 

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

 

ANALPRAM E

 

Non-Formulary

 

ANAMANTLE HC

 

Non-Formulary

 

APRISO

 

Non-Formulary

 

COLAZAL

 

Non-Formulary

 

CREON

 

Non-Formulary

 

DIPENTUM

 

Non-Formulary

 

ENTEREG

 

Non-Formulary

 

HALFLYTELY-BISACODYL

 

Non-Formulary

 

HEMRIL

 

Non-Formulary

 

HYDROCORTISONE ACETATE

 

Non-Formulary

 

LIALDA

 

Non-Formulary

 

LIDOCAINE-HYDROCORTISONE

 

Non-Formulary

 

LIDOCORT

 

Non-Formulary

 

MESALAMINE

 

Non-Formulary

 

MOVIPREP

 

Non-Formulary

 

PERANEX HC

 

Non-Formulary

 

PROCTOCORT

 

Non-Formulary

 

RECTAGEL HC

 

Non-Formulary

 

ROWASA

 

Non-Formulary

 

ZYPRAM

 


Return to Top
 

Formulary Date: 10/21/2009    Update Date: 10/26/2009    V1.3.0