$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
HEMOSTATICS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
CYKLOKAPRON (tranexamic acid) |
|
|
|
NOVOSEVEN (factor viia, recomb (bhk cells) |
|
$$$$$ |
|
ALPHANATE (factor viii (antihemophl fctr)) |
|
$$$$$ |
|
ALPHANINE SD (factor ix complex (human)) |
|
$$$$$ |
|
AMICAR (aminocaproic acid) |
|
$$$$$ |
|
aminocaproic acid (aminocaproic acid) |
|
$$$$$ |
|
BEBULIN VH IMMUNO (factor ix complex (human)) |
|
$$$$$ |
|
BENEFIX (factor viii (antihemophl fctr)) |
|
$$$$$ |
|
FEIBA VH IMMUNO (anti-inhibitor coagulant comp.) |
|
$$$$$ |
|
HELIXATE FS (factor viii (antihemophl fctr)) |
|
$$$$$ |
|
HEMOFIL M (factor viii (antihemophl fctr)) |
inj |
$$$$$ |
|
HUMATE-P (factor viii (antihemophl fctr)) |
|
$$$$$ |
|
KOATE-DVI (factor viii (antihemophl fctr)) |
|
$$$$$ |
|
KOGENATE FS (factor viii (antihemophl fctr)) |
|
$$$$$ |
|
MONARC-M (factor viii (antihemophl fctr)) |
|
$$$$$ |
|
MONOCLATE-P (factor viii (antihemophl fctr)) |
250 units inj |
$$$$$ |
|
MONOCLATE-P (factor viii (antihemophl fctr)) |
500 units inj |
$$$$$ |
|
MONOCLATE-P (factor viii (antihemophl fctr)) |
1000 units inj |
$$$$$ |
|
MONONINE (factor ix complex (human)) |
|
$$$$$ |
|
PROFILNINE SD (factor ix complex (human)) |
|
$$$$$ |
|
RECOMBINATE (factor viii (antihemophl fctr)) |
|
$$$$$ |
|
REFACTO (factor viii (antihemophl fctr)) |
250 ahfu inj |
$$$$$ |
|
REFACTO (factor viii (antihemophl fctr)) |
500 iu inj |
$$$$$ |
|
REFACTO (factor viii (antihemophl fctr)) |
1000 iu inj |
Non-Formulary |
|
ADVATE |
|
Non-Formulary |
|
ADVATE H |
|
Non-Formulary |
|
ADVATE L |
|
Non-Formulary |
|
ADVATE M |
|
Non-Formulary |
|
ADVATE SH |
|
Non-Formulary |
|
ADVATE UH |
|
Non-Formulary |
|
ASTRINGYN |
|
Non-Formulary |
|
AVITENE |
|
Non-Formulary |
|
ENDO-AVITENE |
|
Non-Formulary |
|
GELFILM |
|
Non-Formulary |
|
GELFOAM |
|
Non-Formulary |
|
GELFOAM COMPRESSED |
|
Non-Formulary |
|
GELFOAM PACKS |
|
Non-Formulary |
|
HELISTAT |
|
Non-Formulary |
|
HELITENE |
|
Non-Formulary |
|
HEMOFIL M |
|
Non-Formulary |
|
INSTAT MCH |
|
Non-Formulary |
|
MONOCLATE-P |
|
Non-Formulary |
|
OXYCEL |
|
Non-Formulary |
|
REFACTO |
|
Non-Formulary |
|
SURGICEL |
|
Non-Formulary |
|
SURGIFOAM |
|
Non-Formulary |
|
THROMBOGEN |
|
Non-Formulary |
|
XYNTHA |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0