$ |
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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ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
ACD-A (citrate dextrose solution) |
|
|
|
ALBUMINAR-25 (albumin human) |
|
|
|
alburx (albumin human) |
|
|
|
albutein (albumin human) |
|
|
|
AMINOSYN II (amino acids) |
|
|
|
AMINOSYN-PF (amino acids) |
|
|
|
AMMONIUM CHLORIDE (ammonium chloride) |
|
|
|
BUMINATE (albumin human) |
|
|
|
calcium chloride (calcium chloride) |
|
|
|
copper chloride (cupric chloride) |
|
|
|
dextrose 5%-1/3ns-kcl (dextrose/nacl/kcl) |
|
|
|
dextrose 5%-1/4ns-kcl (dextrose/nacl/kcl) |
|
|
|
dextrose 5%-electrolyte #48 (dextrose/electrolytes) |
|
|
|
dextrose 5%-electrolyte #75 (dextrose/electrolytes) |
|
|
|
dextrose 5%-ns-kcl (dextrose/nacl/kcl) |
|
|
|
dextrose 5%-potassium chloride (potassium chloride/d5w) |
|
|
|
dextrose in ringers injection (dextrose/lactated ringers) |
|
|
|
DIANEAL PD-2 W-1.5% DEXTROSE (dextrose/lactated ringers) |
|
|
|
DIANEAL PD-2 W-2.5% DEXTROSE (dextrose/lactated ringers) |
|
|
|
DIANEAL PD-2 W-4.25% DEXTROSE (dextrose/lactated ringers) |
|
|
|
FREAMINE III (amino acids) |
|
|
|
HEPATAMINE (amino acids) |
|
|
|
ISOLYTE H WITH DEXTROSE (dextrose/electrolytes) |
|
|
|
ISOLYTE M WITH DEXTROSE (dextrose/electrolytes) |
|
|
|
ISOLYTE P WITH DEXTROSE (dextrose/electrolytes) |
|
|
|
ISOLYTE S (electrolyte solutions) |
|
|
|
ISOLYTE S WITH DEXTROSE (dextrose/electrolytes) |
|
|
|
l-cysteine (cysteine hcl) |
|
|
|
MONOJECT PREFILL ADVANCED (normal saline) |
0.9 % inj |
|
|
MULTITRACE-5 (trace metals) |
|
|
|
NORMOSOL-M AND DEXTROSE (dextrose/electrolytes) |
|
|
|
OSMITROL (mannitol) |
|
|
|
PLASBUMIN-25 (albumin human) |
|
|
|
PLASMA-LYTE 56 IN DEXTROSE (d5w/electrolyte-56 solution) |
|
|
|
posiflush saline (sodium chloride) |
|
|
|
potassium chl-normal saline (pot chloride/na chlor) |
|
|
|
potassium chloride in d5lr (dextrose/nacl/kcl) |
|
|
|
PREMASOL (amino acids) |
|
|
|
PROCALAMINE (aa 3%/electrolyte-tpn/glycerin) |
|
|
|
RESECTISOL (mannitol) |
|
|
|
ringers injection (ringers solution) |
|
|
|
sodium acetate (sodium acetate) |
|
|
|
sodium chloride (sodium chloride) |
inj |
|
|
sodium chloride (sodium chloride) |
soln |
|
|
TRACE ELEMENTS (trace metals) |
|
|
|
TRACE ELEMENTS-4 (trace metals) |
|
|
|
TRACE METALS (trace metals) |
|
|
|
TRAVASOL (amino acids) |
|
|
|
TRAVASOL WITH DEXTROSE (amino acids) |
|
|
|
TROPHAMINE (amino acids) |
|
|
|
zinc chloride (zinc chloride) |
|
$ |
|
CITRATE PHOSPHATE DEXTROSE (citrate dextrose solution) |
|
$ |
|
dextrose in lactated ringers (dextrose/lactated ringers) |
|
$ |
|
dextrose in water (dextrose/water) |
|
$ |
|
magnesium sulfate (magnesium sulfate) |
|
$ |
|
mannitol (mannitol) |
|
$ |
|
MONOJECT PREFILL (sodium chloride) |
|
$ |
|
potassium phosphate (potassium phosphate) |
|
$ |
|
selenium (selenium) |
|
$ |
|
sodium bicarbonate (sodium bicarbonate) |
|
$ |
|
sodium phosphate (sodium biphosphate) |
|
$ |
|
zinc sulfate (zinc sulfate) |
inj |
$$ |
|
AMINOSYN (amino acids) |
|
$$ |
|
calcium gluconate (calcium gluconate) |
|
$$ |
|
dextrose with sodium chloride (dextrose/sodium chloride) |
|
$$ |
|
lactated ringers (ringers solution,lactated) |
|
$$ |
|
ringers irrigation (ringers solution) |
|
$$ |
|
tis-u-sol (ringers solution) |
soln |
$$ |
|
water (water) |
|
$$$ |
|
saline flush (sodium chloride) |
|
$$$$$ |
|
dextrose 5%-1/2ns-kcl (dextrose/nacl/kcl) |
|
$$$$$ |
|
magnesium chloride (magnesium chloride) |
|
$$$$$ |
|
normal saline flush (sodium chloride) |
|
$$$$$ |
|
syrex (sodium chloride) |
|
Non-Formulary |
|
CYSTAGON |
|
Non-Formulary |
|
PHYSIOLYTE |
|
Non-Formulary |
|
PHYSIOSOL |
|
Non-Formulary |
|
TIS-U-SOL |
|
Non-Formulary |
|
ZINC SULFATE |
|
Non-Formulary |
|
ZINCATE |
|
Formulary Date: 10/21/2009 Update Date: 10/26/2009 V1.3.0