$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
CNS MUSCLE RELAXANTS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
NORFLEX (orphenadrine) |
|
$$ |
|
carisoprodol (carisoprodol) |
|
$$ |
|
chlorzoxazone (chlorzoxazone) |
|
$$ |
|
cyclobenzaprine hcl (cyclobenzaprine) |
|
$$ |
|
FLEXERIL (cyclobenzaprine) |
|
$$ |
|
methocarbamol (methocarbamol) |
|
$$ |
|
orphenadrine compound (orphenadrine/aspirin/caffeine) |
|
$$ |
|
PARAFON FORTE DSC (chlorzoxazone) |
|
$$ |
|
ROBAXIN (methocarbamol) |
|
$$$ |
|
carisoprodol compound (carisoprodol/aspirin) |
|
$$$ |
|
orphenadrine citrate (orphenadrine) |
|
$$$ |
|
orphenadrine compound forte (orphenadrine/aspirin/caffeine) |
|
$$$ |
|
ROBAXIN-750 (methocarbamol) |
|
$$$$$ |
|
FEXMID (cyclobenzaprine) |
|
Non-Formulary |
|
AMRIX |
|
Non-Formulary |
|
ANABAR |
|
Non-Formulary |
|
ASP |
|
Non-Formulary |
|
BE-FLEX PLUS |
|
Non-Formulary |
|
BY-ACHE |
|
Non-Formulary |
|
CAFGESIC |
|
Non-Formulary |
|
CAFGESIC FORTE |
|
Non-Formulary |
|
CARISOPRODOL COMPOUND-CODEINE |
|
Non-Formulary |
|
COMBIFLEX |
|
Non-Formulary |
|
COMBIFLEX ES |
|
Non-Formulary |
|
DOLOREX |
|
Non-Formulary |
|
DOLOREX |
|
Non-Formulary |
|
DURABAC |
|
Non-Formulary |
|
DURABAC FORTE |
|
Non-Formulary |
|
DURAXIN |
|
Non-Formulary |
|
ED-FLEX |
|
Non-Formulary |
|
SKELAXIN |
|
Non-Formulary |
|
SOMA 350mg Only (250mg not covered) |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0