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
		co-natal fa (prenatal vitamins (< 1mg fa))
		folbecal (prenatal vitamins (< 1mg fa))
		folinatal plus b (prenatal vitamins (< 1mg fa))
		multinatal plus (prenatal vitamins (< 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))
		prenacare (prenatal vit( = or > 1mg fa))
		prenaplus (prenatal vitamins (< 1mg fa))
		prenatal multivitamin w-iron (prenatal vitamins (< 1mg fa))
		previte rx (prenatal vitamins (< 1mg fa))
		re-nata 29 ob (prenatal vit( = or > 1mg fa))
		se-care (prenatal vitamins (< 1mg fa))
		se-care conceive (prenatal vitamins (< 1mg fa))
		se-natal 90 (prenatal vitamins (< 1mg fa))
		se-natal one (prenatal vitamins (< 1mg fa))
		triadvance (prenatal vitamins (< 1mg fa))
		trimesis rx (prenatal vitamins (< 1mg fa))
		vinate c (prenatal vitamins (< 1mg fa))
		vinate care (prenatal vitamins (< 1mg fa))
		vinate one (prenatal vitamins (< 1mg fa))
		vynatal-fa (prenatal vit( = or > 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))
$		O-CAL FA (prenatal vit( = or > 1mg fa))
$		prenatabs fa (prenatal vitamins (< 1mg fa))
$		prenatabs rx (prenatal vit( = or > 1mg fa))
$		prenatal low iron (prenatal vitamins (< 1mg fa))
$		prenatal plus (prenatal vitamins (< 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))
$$		vitafol-pn (prenatal vit( = or > 1mg fa))
$$$		PRECARE CONCEIVE (prenatal vitamins (< 1mg fa))
Non-Formulary		ADVANCED CARE PLUS
Non-Formulary		ATABEX
Non-Formulary		ATABEX EC
Non-Formulary		CITRANATAL 90 DHA
Non-Formulary		CITRANATAL ASSURE
Non-Formulary		CITRANATAL DHA
Non-Formulary		CITRANATAL RX
Non-Formulary		COMPLETE NATAL DHA
Non-Formulary		COMPLETE-RF PRENATAL
Non-Formulary		COMPLETENATE
Non-Formulary		CONCEPT DHA
Non-Formulary		CONCEPT OB
Non-Formulary		DOCOSAVIT
Non-Formulary		DUALVIT OB
Non-Formulary		DUET DHA WITH FERRAZONE
Non-Formulary		EDGE OB
Non-Formulary		ELITE OB DHA
Non-Formulary		ELITE-OB
Non-Formulary		FOLCAPS CARE ONE
Non-Formulary		FOLTABS
Non-Formulary		FOLTABS 90 PLUS DHA
Non-Formulary		FOLTABS PRENATAL PLUS DHA
Non-Formulary		GENTEX ADE
Non-Formulary		GESTICARE
Non-Formulary		GESTICARE DHA
Non-Formulary		M-VIT
Non-Formulary		MARNATAL-F PLUS
Non-Formulary		MAXINATE
Non-Formulary		NATALVIT
Non-Formulary		NATELLE C
Non-Formulary		NATELLE PLUS
Non-Formulary		NATELLE PREFER
Non-Formulary		NATELLE-EZ
Non-Formulary		NEEVO
Non-Formulary		NEEVO DHA
Non-Formulary		NOVANATAL
Non-Formulary		O-CAL PRENATAL
Non-Formulary		OB + DHA
Non-Formulary		OB 90 + DHA
Non-Formulary		OB COMPLETE
Non-Formulary		OB COMPLETE 400
Non-Formulary		OB COMPLETE DHA
Non-Formulary		OB-NATAL ONE
Non-Formulary		OBSTETRIX DHA
Non-Formulary		OBSTETRIX EC
Non-Formulary		OBTREX
Non-Formulary		OBTREX DHA
Non-Formulary		POLY IRON PN FORTE
Non-Formulary		PRECARE PREMIER
Non-Formulary		PREFERA-OB
Non-Formulary		PREFERA-OB PLUS DHA
Non-Formulary		PRENAFIRST
Non-Formulary		PRENATAL 19
Non-Formulary		PRENATAL AD
Non-Formulary		PRENATAL-U
Non-Formulary		PRENATE DHA
Non-Formulary		PRENATE ELITE
Non-Formulary		PRENEXA
Non-Formulary		PREVIT+DHA
Non-Formulary		PRUET DHA
Non-Formulary		PRUET DHA EC
Non-Formulary		RE-NATA 29
Non-Formulary		RENATE
Non-Formulary		RENATE DHA
Non-Formulary		RENATE DHA EXTRA
Non-Formulary		SE-CARE GESTURE
Non-Formulary		SE-NATAL 19
Non-Formulary		SE-PLETE DHA
Non-Formulary		SELECT-OB
Non-Formulary		SELECT-OB + DHA
Non-Formulary		SETONET
Non-Formulary		SETONET-EC
Non-Formulary		TANDEM DHA
Non-Formulary		TANDEM OB
Non-Formulary		TARON A PRENATAL
Non-Formulary		TARON EC CALCIUM
Non-Formulary		TARON-PREX PRENATAL
Non-Formulary		TRI RX
Non-Formulary		TRICARE DHA
Non-Formulary		TRINATAL RX 1
Non-Formulary		TRINATE
Non-Formulary		TRUST NATAL DHA
Non-Formulary		ULTIMATECARE ADVANTAGE
Non-Formulary		ULTIMATECARE COMBO
Non-Formulary		ULTIMATECARE ONE
Non-Formulary		ULTIMATECARE ONE NF
Non-Formulary		VINATE AZ
Non-Formulary		VINATE AZ EXTRA
Non-Formulary		VINATE CALCIUM
Non-Formulary		VINATE IC
Non-Formulary		VINATE II
Non-Formulary		VINATE III
Non-Formulary		VINATE PN CARE
Non-Formulary		VITAFOL-OB+DHA
Non-Formulary		VITAPHIL
Non-Formulary		VITAPHIL + DHA
Non-Formulary		VITAPHIL + DHA 90
Non-Formulary		VITAPHIL AIDE
Non-Formulary		VITASPIRE
Non-Formulary		VIVA DHA

Return to Top

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