$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
NON-STEROIDAL ANTIINFLAMMATORY AGENTS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
INDOCIN I.V. (indomethacin sodium trihydrate) |
|
|
|
TORADOL (ketorolac) |
|
|
|
VOLTAREN (requires trial of 2 first line NSAIDs) (diclofenac sodium) |
|
$ |
|
FELDENE (requires trial of OTC NSAID) (piroxicam) |
|
$ |
|
FLURBIPROFEN (requires trial of OTC NSAID) (flurbiprofen) |
|
$ |
|
ketorolac tromethamine (ketorolac) |
inj |
$ |
|
piroxicam (piroxicam) |
|
$ |
|
PIROXICAM (Requires trial of OTC NSAID) (piroxicam) |
|
$$ |
|
ANSAID (requires trial of OTC NSAID) (flurbiprofen) |
|
$$ |
|
DAYPRO (requires trial of OTC NSAID) (oxaprozin) |
|
$$ |
|
diclofenac sodium (diclofenac sodium) |
|
$$ |
|
etodolac (etodolac) |
|
$$ |
|
ETODOLAC (requires trial of OTC NSAID) (etodolac) |
|
$$ |
|
FENOPROFEN CALCIUM (requires trial of OTC NSAID) (fenoprofen) |
|
$$ |
|
indomethacin (indomethacin) |
|
$$ |
|
INDOMETHACIN (Requires trial of OTC NSAID) (indomethacin) |
|
$$ |
|
oxaprozin (oxaprozin) |
|
$$ |
|
OXAPROZIN (Requires trial of OTC NSAID) (oxaprozin) |
|
$$ |
|
SULINDAC (requires trial of OTC NSAID) (sulindac) |
|
$$$ |
|
CLINORIL (requires trial of OTC NSAID) (sulindac) |
|
$$$ |
|
DICLOFENAC POTASSIUM (requires trial of OTC NSAID) (diclofenac potassium) |
|
$$$ |
|
INDOCIN (indomethacin) |
oral susp |
$$$ |
|
nabumetone (nabumetone) |
|
$$$ |
|
NABUMETONE (Requires trial of 2 first line NSAIDs within 6 months) (nabumetone) |
|
$$$ |
|
NALFON (Requires trial of OTC NSAID) (fenoprofen) |
|
$$$$ |
|
CATAFLAM (requires trial of OTC NSAID) (diclofenac potassium) |
|
$$$$ |
|
MECLOFENAMATE SODIUM (Requires trial of OTC NSAID) (meclofenamate) |
|
$$$$$ |
|
ARTHROTEC 50 (requires trial of OTC NSAID) (diclofenac sodium/misoprostol) |
|
$$$$$ |
|
ARTHROTEC 75 (requires trial of OTC NSAID) (diclofenac sodium/misoprostol) |
|
$$$$$ |
|
CELEBREX (requires trial of 2 first line NSAIDs) (celecoxib) |
|
$$$$$ |
|
PONSTEL (mefenamic acid) |
|
$$$$$ |
|
PONSTEL (requires trial of 2 first line NSAIDs within 6 months) (mefenamic acid) |
|
$$$$$ |
|
TOLMETIN SODIUM (requires trial of OTC NSAID) (tolmetin) |
|
Non-Formulary |
|
ANAPROX DS (requires trial of OTC NSAID) |
|
Non-Formulary |
|
DICLOFENAC SODIUM (requires trial of OTC NSAID) |
|
Non-Formulary |
|
EC-NAPROSYN |
|
Non-Formulary |
|
IBUPROFEN |
|
Non-Formulary |
|
IBUPROFEN (requires trial of OTC NSAID) |
|
Non-Formulary |
|
IC400 |
|
Non-Formulary |
|
IC800 |
|
Non-Formulary |
|
INDOCIN |
|
Non-Formulary |
|
KETOPROFEN (Requires trial of OTC NSAID) |
|
Non-Formulary |
|
KETOROLAC TROMETHAMINE |
|
Non-Formulary |
|
MELOXICAM |
|
Non-Formulary |
|
MOBIC (Requires trial of 2 first line NSAIDs) |
|
Non-Formulary |
|
NAPRELAN |
|
Non-Formulary |
|
NAPRELAN |
|
Non-Formulary |
|
NAPROSYN (Requires trial of OTC NSAID) |
|
Non-Formulary |
|
NAPROXEN |
|
Non-Formulary |
|
NAPROXEN (Requires trial of OTC NSAID) |
|
Non-Formulary |
|
NAPROXEN SODIUM |
|
Non-Formulary |
|
NAPROXEN SODIUM (Requires trial of OTC NSAID) |
|
Non-Formulary |
|
VOLTAREN-XR |
|
Non-Formulary |
|
ZIPSOR |
|
Formulary Date: 10/21/2009 Update Date: 10/26/2009 V1.3.0