$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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THERAPEUTIC VITAMINS & MINERALS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
CALCIJEX (calcitriol) |
|
|
|
calcium acetate (calcium acetate) |
|
|
|
CARNITOR (levocarnitine) |
soln |
|
|
CARNITOR SF (levocarnitine) |
|
|
|
cyanocobalamin (cyanocobalamin) |
|
|
|
hydroxocobalamin (hydroxocobalamin) |
|
|
|
levocarnitine (levocarnitine) |
soln |
|
|
nervidox (cyanocobalamin/thiamine) |
|
|
|
neurin-12 (cyanocobalamin) |
|
|
|
TIA DOCE (cyanocobalamin/thiamine) |
|
|
|
VITAJECT (cyanocobalamin/vit bcomp&c) |
|
$ |
|
DRISDOL (ergocalciferol) |
|
$ |
|
folic acid (folic acid) |
|
$ |
|
MARTINIC (vitamin b12-intrinsic factor) |
|
$ |
|
vitamin d (ergocalciferol) |
|
$$$$ |
|
calcitriol (calcitriol) |
|
$$$$$ |
|
HECTOROL (doxercalciferol) |
inj |
$$$$$ |
|
ROCALTROL (calcitriol) |
|
Non-Formulary |
|
CALOMIST |
|
Non-Formulary |
|
CARNITOR |
|
Non-Formulary |
|
DEPLIN |
|
Non-Formulary |
|
ELIPHOS |
|
Non-Formulary |
|
GALZIN |
|
Non-Formulary |
|
HECTOROL |
|
Non-Formulary |
|
LEVOCARNITINE |
|
Non-Formulary |
|
NASCOBAL |
|
Non-Formulary |
|
PHOSLO |
|
Non-Formulary |
|
ZEMPLAR |
|
Non-Formulary |
|
ZERVALX |
|
Formulary Date: 10/21/2009 Update Date: 10/26/2009 V1.3.0