Formulary Detail

$	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

PRENATAL VITAMINS

Relative Cost	MAC	Drug Name (Generic Name) Drug and/or Generic Comments	Strength and/or Dosage Strength and/or Dosage Comments
		aminate with 90mg iron (prenatal vit( = or > 1mg fa))
		co-natal fa (prenatal vitamins (< 1mg fa))
		multifol plus (prenatal vit( = or > 1mg fa))
		mynatal plus (prenatal vit( = or > 1mg fa))
		mynatal-z (prenatal vit( = or > 1mg fa))
		mynate 90 plus (prenatal vitamins (< 1mg fa))
		poly iron pn (prenatal vitamins (< 1mg fa))
		prenatal 1-1 (prenatal vit( = or > 1mg fa))
		verotin-by (prenatal vit( = or > 1mg fa))
		vynatal-fa (prenatal vit( = or > 1mg fa))
$		advanced natalcare (prenatal vitamins (< 1mg fa))
$		advanced-rf natalcare (prenatal vitamins (< 1mg fa))
$		fe c (iron,carbonyl/vit c/vit b12/fa)
$		inatal advance (prenatal vitamins (< 1mg fa))
$		inatal gt (prenatal vit( = or > 1mg fa))
$		inatal ultra (prenatal vit( = or > 1mg fa))
$		LACTOCAL-F (prenatal vit( = or > 1mg fa))
$		maternity (prenatal vitamins (< 1mg fa))
$		mynatal (prenatal vit( = or > 1mg fa))
$		mynatal advance (prenatal vit( = or > 1mg fa))
$		natalcare pic (prenatal vitamins (< 1mg fa))
$		natalcare pic forte (prenatal vitamins (< 1mg fa))
$		natalcare plus (prenatal vitamins (< 1mg fa))
$		NATALCARE RX (prenatal vitamins (< 1mg fa))
$		natalcare three (prenatal vit( = or > 1mg fa))
$		natatab (prenatal vit( = or > 1mg fa))
$		natatab fa (prenatal vitamins (< 1mg fa))
$		nutrinate (prenatal vitamins (< 1mg fa))
$		O-CAL FA (prenatal vit( = or > 1mg fa))
$		OBSTETRIX-100 (prenatal vitamins (< 1mg fa))
$		prenatabs fa (prenatal vitamins (< 1mg fa))
$		prenatabs rx (prenatal vit( = or > 1mg fa))
$		prenatal formula (prenatal vitamins (< 1mg fa))
$		prenatal low iron (prenatal vitamins (< 1mg fa))
$		prenatal mr 90 fe (prenatal vitamins (< 1mg fa))
$		PRENATAL MTR (prenatal vitamins (< 1mg fa))
$		prenatal plus (prenatal vitamins (< 1mg fa))
$		prenatal rx (prenatal vitamins (< 1mg fa))
$		prenatal rx 1 (prenatal vit( = or > 1mg fa))
$		prenatal rx 1 (prenatal vitamins (< 1mg fa))
$		prenatal z (prenatal vitamins (< 1mg fa))
$		ultra natalcare (prenatal vit( = or > 1mg fa))
$		vinate gt (prenatal vit( = or > 1mg fa))
$		vinate ultra (prenatal vit( = or > 1mg fa))
$		vinate-m (prenatal vitamins (< 1mg fa))
$		vitafol-ob (prenatal vit( = or > 1mg fa))
$$		ICAR-C PLUS (iron,carbonyl/vit c/vit b12/fa)
$$		NATACHEW (prenatal vitamins (< 1mg fa))
$$		NATAFORT (prenatal vitamins (< 1mg fa))
$$		PRECARE (prenatal vitamins (< 1mg fa))
$$		PREMESIS RX (prenatal vitamins (< 1mg fa))
$$		TRICARE (prenatal vit( = or > 1mg fa))
$$		vinatal forte (prenatal vitamins (< 1mg fa))
$$		vitafol-pn (prenatal vit( = or > 1mg fa))
$$$		PRECARE CONCEIVE (prenatal vitamins (< 1mg fa))
Non-Formulary		ATABEX
Non-Formulary		CAL-NATE
Non-Formulary		CAL-NATE
Non-Formulary		CARENATAL DHA
Non-Formulary		CENOGEN ULTRA
Non-Formulary		CITRANATAL 90 DHA
Non-Formulary		CITRANATAL DHA
Non-Formulary		CITRANATAL RX
Non-Formulary		DUET DHA EC STUARTNATAL
Non-Formulary		DUET DHA STUARTNATAL
Non-Formulary		DUET STUARTNATAL
Non-Formulary		ELITE OB
Non-Formulary		ELITE-OB
Non-Formulary		FOLTABS
Non-Formulary		ICAR PRENATAL
Non-Formulary		M-VIT
Non-Formulary		MARNATAL-F PLUS
Non-Formulary		MAXINATE
Non-Formulary		MULTIVITAMIN WITH MINERALS
Non-Formulary		NATACAPS
Non-Formulary		NATALCARE
Non-Formulary		NATALVIT
Non-Formulary		NATELLE
Non-Formulary		NATELLE C
Non-Formulary		NATELLE PLUS
Non-Formulary		NATELLE PREFER
Non-Formulary		NATELLE-EZ
Non-Formulary		NEEVO
Non-Formulary		NOVANATAL
Non-Formulary		NOVASTART
Non-Formulary		NUTRACARE
Non-Formulary		NUTRISPIRE
Non-Formulary		O-CAL PRENATAL
Non-Formulary		OB COMPLETE
Non-Formulary		OB COMPLETE DHA
Non-Formulary		OBSTETRIX EC
Non-Formulary		OBTREX
Non-Formulary		OPTINATE
Non-Formulary		PERRY PRENATAL TABLET
Non-Formulary		POLY IRON PN FORTE
Non-Formulary		PRECARE PREMIER
Non-Formulary		PREFERA-OB
Non-Formulary		PRENAFIRST
Non-Formulary		PRENATAL 19
Non-Formulary		PRENATAL AD
Non-Formulary		PRENATAL-H
Non-Formulary		PRENATAL-U
Non-Formulary		PRENATE DHA
Non-Formulary		PRENATE ELITE
Non-Formulary		PRIMACARE
Non-Formulary		PRIMACARE ADVANTAGE
Non-Formulary		PRIMACARE ONE
Non-Formulary		RE DUALVIT OB
Non-Formulary		SELECT-OB
Non-Formulary		STRONGSTART
Non-Formulary		TANDEM DHA
Non-Formulary		TANDEM OB
Non-Formulary		TRINATE
Non-Formulary		VINATE AZ
Non-Formulary		VINATE AZ EXTRA
Non-Formulary		VINATE CALCIUM
Non-Formulary		VINATE II
Non-Formulary		VITAFOL-OB+DHA
Non-Formulary		VITAPHIL

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Formulary Date: 07/08/2008 Update Date: 07/09/2008 V1.3.0