$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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ANDROGEN DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
DELATESTRYL (testosterone enanthate) |
|
|
|
DEPO-TESTOSTERONE (testosterone cypionate) |
|
|
|
testosterone cypionate (testosterone cypionate) |
|
|
|
testosterone enanthate (testosterone enanthate) |
|
$$$$ |
|
ANDRODERM (testosterone) |
|
$$$$$ |
|
ANDROGEL (testosterone) |
|
$$$$$ |
|
ANDROID (methyltestosterone) |
|
$$$$$ |
|
ANDROXY (fluoxymesterone) |
|
$$$$$ |
|
danazol (danazol) |
|
$$$$$ |
|
METHITEST (methyltestosterone) |
|
$$$$$ |
|
TESTIM (testosterone) |
|
$$$$$ |
|
TESTRED (methyltestosterone) |
|
Non-Formulary |
|
ANADROL-50 |
|
Non-Formulary |
|
FIRST-TESTOSTERONE |
|
Non-Formulary |
|
FIRST-TESTOSTERONE MC |
|
Non-Formulary |
|
OXANDRIN |
|
Non-Formulary |
|
OXANDROLONE |
|
Non-Formulary |
|
STRIANT |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0