$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
INJECTABLE VITAMINS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
ALBAFORT (iron/vit b comp/liver extract) |
inj |
|
|
ALBAFORT S (ferrous gluconate/vit b comp) |
|
|
|
ascor l 500 (ascorbic acid) |
|
|
|
ascorbic acid (ascorbic acid) |
inj |
|
|
CENOLATE (ascorbic acid) |
|
|
|
M.V.I. PEDIATRIC (multivitamins) |
|
|
|
M.V.I.-12 (multivitamins) |
|
|
|
mega c-a plus (ascorbic acid) |
|
|
|
NERVIDOX 6 (vitamin b comp w-c) |
|
|
|
neurin bc (vitamin b comp w-c) |
|
|
|
NEURO B12 FORTE (vitamin b comp w-c) |
|
|
|
nutriject (vitamin b comp w-c) |
|
|
|
OCTRON (ferrous gluconate/vit b comp) |
|
|
|
vi-cert c500 (ascorbic acid) |
|
|
|
VITA-NUMONYL (vit a palm/vitamin d/eucalyp) |
inj |
|
|
vitamin b complex (vitamin b complex) |
|
$$ |
|
b-complex (vitamin b complex) |
|
$$ |
|
thiamine hcl (thiamine) |
|
$$$ |
|
SIDEROL (fe/vit b comp/vit b12/liver) |
inj |
$$$$$ |
|
dexferrum (iron dextran complex) |
|
$$$$$ |
|
infed (iron dextran complex) |
|
$$$$$ |
|
pyridoxine hcl (pyridoxine) |
|
$$$$$ |
|
VENOFER (iron sucrose complex) |
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0