$

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


 

VITAMINS & MINERALS & RELATED PRODUCTS

Relative Cost

MAC

Drug Name (Generic Name)

Drug and/or Generic Comments

Strength and/or Dosage

Strength and/or Dosage Comments

 

 

FERRLECIT (sod ferric gluc complex/sucr)

 

 

 

INTRALIPID (fat emulsions)

 

 

 

LIPOSYN II (fat emulsions)

 

 

 

liposyn iii (fat emulsions)

 

 

 

multi vitamins with fluoride (multivitamins w/fluoride)

 

 

 

multivit-fluoride (multivitamins w/fluoride)

 

 

 

multivitamin-fluoride (multivitamins w/fluoride)

 

 

 

multivitamins with fluoride (multivitamins w/fluoride)

 

 

 

MVC-FLUORIDE (multivitamins w/fluoride)

 

 

 

polyvitamins-fluoride (multivitamins w/fluoride)

 

 

 

tri-vit with fluoride-iron (triple vits w/fluor & iron)

 

 

 

tri-vitamin with fluoride (triple vitamins w/fluoride)

 

 

 

tri-vitamin with iron-fluoride (triple vits w/fluor & iron)

 

 

 

tri-vitamins with fluoride (triple vitamins w/fluoride)

 

 

 

VITAMAX (multivitamins)

 

$

 

fa-cyanocobalamine-pyridoxine (cyanocobalamin/fa/pyridoxine)

 

$

 

FLUORABON BASIC (triple vitamins w/fluoride)

 

$

 

folbee (cyanocobalamin/fa/pyridoxine)

 

$

 

folcaps (cyanocobalamin/fa/pyridoxine)

 

$

 

folplex 2.2 (cyanocobalamin/fa/pyridoxine)

 

$

 

nufol (cyanocobalamin/fa/pyridoxine)

 

$

 

PROTECT PLUS (amino acids/mv,fe,other min)

 

$

 

THEROBEC (vitamin b comp w-c)

 

$

 

tri-vitamin-fluoride (triple vitamins w/fluoride)

 

$

 

vitalize plus (multivitamins w-iron, hematini)

 

$$

 

allanfol rx (cyanocobalamin/fa/pyridoxine)

 

$$

 

allantex (cyanocobalamin/fa/pyridoxine)

 

$$

 

folbalin plus (cyanocobalamin/fa/pyridoxine)

 

$$

 

folbic (cyanocobalamin/fa/pyridoxine)

 

$$

 

FOLGARD RX (cyanocobalamin/fa/pyridoxine)

 

$$

 

FOLTX (cyanocobalamin/fa/pyridoxine)

 

$$

 

VITAFOL (multivits w fe,ca,fa,minerals)

tab

Non-Formulary

 

ADVANCED AM/PM

 

Non-Formulary

 

ALBALYBE

 

Non-Formulary

 

AMINOBENZOATE POTASSIUM

 

Non-Formulary

 

ANIMI-3

 

Non-Formulary

 

ASCORBIC ACID

 

Non-Formulary

 

B-PLEX

 

Non-Formulary

 

B-PLEX PLUS

 

Non-Formulary

 

BACMIN

 

Non-Formulary

 

CALAFOL RX

 

Non-Formulary

 

CALCIFOL

 

Non-Formulary

 

CALCIFOLIC-D

 

Non-Formulary

 

CALCIUM-FOLIC ACID PLUS D

 

Non-Formulary

 

CARDIOTEK-RX

 

Non-Formulary

 

CARDIOVID PLUS

 

Non-Formulary

 

CEREFOLIN

 

Non-Formulary

 

CEREFOLIN NAC

 

Non-Formulary

 

CHROMAGEN

 

Non-Formulary

 

CHROMAGEN FA

 

Non-Formulary

 

CHROMAGEN FORTE

 

Non-Formulary

 

CORVITA

 

Non-Formulary

 

CORVITA 150

 

Non-Formulary

 

CORVITE

 

Non-Formulary

 

CORVITE 150

 

Non-Formulary

 

CORVITE FREE

 

Non-Formulary

 

DIALYVITE

 

Non-Formulary

 

DIALYVITE 3000

 

Non-Formulary

 

DIALYVITE 800 WITH IRON

 

Non-Formulary

 

DIALYVITE ZINC

 

Non-Formulary

 

DIATX ZN

 

Non-Formulary

 

DUALVIT F

 

Non-Formulary

 

DUALVIT PLUS

 

Non-Formulary

 

ED CYTE F

 

Non-Formulary

 

ELDERCAPS

 

Non-Formulary

 

ENCORA

 

Non-Formulary

 

FABB

 

Non-Formulary

 

FAC-X

 

Non-Formulary

 

FEMTABS

 

Non-Formulary

 

FEROCON

 

Non-Formulary

 

FEROTRIN

 

Non-Formulary

 

FEROTRINSIC

 

Non-Formulary

 

FERRALET 90

 

Non-Formulary

 

FERRAPLUS 90

 

Non-Formulary

 

FERREX 150 FORTE

 

Non-Formulary

 

FERREX 150 FORTE PLUS

 

Non-Formulary

 

FERREX 28

 

Non-Formulary

 

FERRO-PLEX HEMATINIC

 

Non-Formulary

 

FERROCITE PLUS

 

Non-Formulary

 

FERROCITE PLUS

 

Non-Formulary

 

FERROFLEX 150 FORTE

 

Non-Formulary

 

FERROGELS FORTE

 

Non-Formulary

 

FERROVITE

 

Non-Formulary

 

FERROVITE FA

 

Non-Formulary

 

FERROVITE FORTE

 

Non-Formulary

 

FOLBEE PLUS

 

Non-Formulary

 

FOLBEE PLUS CZ

 

Non-Formulary

 

FOLGARD OS

 

Non-Formulary

 

FOLITAB 500

 

Non-Formulary

 

FOLPACE RX

 

Non-Formulary

 

FOLPLEX

 

Non-Formulary

 

FOLTRATE

 

Non-Formulary

 

FOLTRIN

 

Non-Formulary

 

FORMULA B PLUS

 

Non-Formulary

 

FORTAVIT

 

Non-Formulary

 

FUMATINIC

 

Non-Formulary

 

GLUTOFAC-MX

 

Non-Formulary

 

GLUTOFAC-ZX

 

Non-Formulary

 

HEMATINIC PLUS

 

Non-Formulary

 

HEMATINIC WITH FOLIC ACID

 

Non-Formulary

 

HEMATOGEN

 

Non-Formulary

 

HEMATOGEN FA

 

Non-Formulary

 

HEMATOGEN FORTE

 

Non-Formulary

 

HEMATRON

 

Non-Formulary

 

HEMATRON

 

Non-Formulary

 

HEMATRON-AF

 

Non-Formulary

 

HEMAX

 

Non-Formulary

 

HEMOCYTE PLUS

 

Non-Formulary

 

HEMOCYTE-F

 

Non-Formulary

 

HEMOCYTE-F

 

Non-Formulary

 

ICAR-C PLUS SR

 

Non-Formulary

 

IFEREX 150 FORTE

 

Non-Formulary

 

INTEGRA F

 

Non-Formulary

 

INTEGRA PLUS

 

Non-Formulary

 

IRCON-FA

 

Non-Formulary

 

IRON

 

Non-Formulary

 

IVITES RX

 

Non-Formulary

 

LIPOCHOL PLUS

 

Non-Formulary

 

LYSIPLEX

 

Non-Formulary

 

MAXARON FORTE

 

Non-Formulary

 

MEGAVITE RX

 

Non-Formulary

 

METANX

 

Non-Formulary

 

MI-OMEGA NF

 

Non-Formulary

 

MULTICHEW

 

Non-Formulary

 

MULTIGEN

 

Non-Formulary

 

MULTIGEN FOLIC

 

Non-Formulary

 

MULTIGEN PLUS

 

Non-Formulary

 

MULTIVITAMINS W-FLUORIDE-IRON

 

Non-Formulary

 

MYFERON-150 FORTE

 

Non-Formulary

 

MYKIDZ IRON FL

 

Non-Formulary

 

NEPHPLEX RX

 

Non-Formulary

 

NEPHRO-VITE RX

 

Non-Formulary

 

NEPHROCAPS

 

Non-Formulary

 

NEPHRON FA

 

Non-Formulary

 

NEURIN-SL

 

Non-Formulary

 

NICOTINAMIDE

 

Non-Formulary

 

NIFEREX GOLD

 

Non-Formulary

 

NIFEREX-150 FORTE

 

Non-Formulary

 

NUTRESTORE

 

Non-Formulary

 

NUTRICAP

 

Non-Formulary

 

OSTIVA

 

Non-Formulary

 

POLY-IRON 150 FORTE

 

Non-Formulary

 

POLYSACCHARIDE IRON FORTE

 

Non-Formulary

 

POLYVITAMIN WITH IRON-FLUORIDE

 

Non-Formulary

 

POTABA

 

Non-Formulary

 

PROFERRIN-FORTE

 

Non-Formulary

 

PROMAR

 

Non-Formulary

 

PROTECT PLUS NR

 

Non-Formulary

 

PRUVATE 21-7

 

Non-Formulary

 

RECAL D

 

Non-Formulary

 

RENA-VITE RX

 

Non-Formulary

 

RENAL CAPS

 

Non-Formulary

 

RENATABS

 

Non-Formulary

 

RENATABS WITH IRON

 

Non-Formulary

 

RENAX

 

Non-Formulary

 

RENO CAPS

 

Non-Formulary

 

REOCYTE PLUS

 

Non-Formulary

 

REQ49+

 

Non-Formulary

 

SIDEROL

 

Non-Formulary

 

SIDEROL

 

Non-Formulary

 

STROVITE

 

Non-Formulary

 

STROVITE ADVANCE

 

Non-Formulary

 

STROVITE ADVANCE + D

 

Non-Formulary

 

STROVITE FORTE

 

Non-Formulary

 

STROVITE ONE

 

Non-Formulary

 

STROVITE PLUS

 

Non-Formulary

 

SUPERVITE

 

Non-Formulary

 

SUPPORT-500

 

Non-Formulary

 

TANDEM F

 

Non-Formulary

 

TANDEM PLUS

 

Non-Formulary

 

TARON FORTE

 

Non-Formulary

 

THERAPEUTIC HEMATINIC

 

Non-Formulary

 

THERAPEUTIC VITAMIN W-MINERALS

 

Non-Formulary

 

THEROBEC PLUS

 

Non-Formulary

 

TL GARD RX

 

Non-Formulary

 

TL ICON

 

Non-Formulary

 

TRICON

 

Non-Formulary

 

TRIFEREX 150 FORTE

 

Non-Formulary

 

TRIMAGEN

 

Non-Formulary

 

TRIMAGEN FA

 

Non-Formulary

 

TRIMAGEN FORTE

 

Non-Formulary

 

TRINSICON

 

Non-Formulary

 

TRIPHROCAPS

 

Non-Formulary

 

UDAMIN

 

Non-Formulary

 

UDAMIN SP

 

Non-Formulary

 

V-C FORTE

 

Non-Formulary

 

VICA-FORTE

 

Non-Formulary

 

VICAP FORTE

 

Non-Formulary

 

VIT 3

 

Non-Formulary

 

VITA S FORTE

 

Non-Formulary

 

VITA-RESPA

 

Non-Formulary

 

VITACEL

 

Non-Formulary

 

VITAFOL

 

Non-Formulary

 

VITAL-D RX

 

Non-Formulary

 

VITATAB MV

 


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