$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
CONTRACEPTIVES
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
kelnor 1-35 (ethynodiol diace-eth estradiol) |
|
|
|
ocella (eth estradiol/drospirenone) |
|
|
|
zovia 1-35e (ethynodiol diace-eth estradiol) |
|
|
|
zovia 1-50e (ethynodiol diace-eth estradiol) |
|
$$ |
|
apri (desogestrel-ethinyl estradiol) |
|
$$ |
|
aranelle (norethindrone-ethin estradiol) |
|
$$ |
|
aviane (levonorgestrel-ethin estradiol) |
|
$$ |
|
BREVICON (norethindrone-ethin estradiol) |
|
$$ |
|
cesia (desogestrel-ethinyl estradiol) |
|
$$ |
|
cryselle (norgestrel-ethinyl estradiol) |
|
$$ |
|
enpresse (levonorgestrel-ethin estradiol) |
|
$$ |
|
junel (norethindrone a-e estradiol) |
|
$$ |
|
junel fe (noreth a-et estra/fe fumarate) |
|
$$ |
|
lessina (levonorgestrel-ethin estradiol) |
|
$$ |
|
LEVLEN 28 (levonorgestrel-ethin estradiol) |
|
$$ |
|
levora-28 (levonorgestrel-ethin estradiol) |
|
$$ |
|
low-ogestrel (norgestrel-ethinyl estradiol) |
|
$$ |
|
lutera (levonorgestrel-ethin estradiol) |
|
$$ |
|
microgestin (norethindrone a-e estradiol) |
|
$$ |
|
microgestin fe (noreth a-et estra/fe fumarate) |
|
$$ |
|
MODICON (norethindrone-ethin estradiol) |
|
$$ |
|
mononessa (norgestimate-ethinyl estradiol) |
|
$$ |
|
necon (norethindrone-ethin estradiol) |
|
$$ |
|
necon (norethindrone-mestranol) |
|
$$ |
|
nortrel (norethindrone-ethin estradiol) |
|
$$ |
|
ORTHO TRI-CYCLEN (norgestimate-ethinyl estradiol) |
|
$$ |
|
ORTHO-CEPT (desogestrel-ethinyl estradiol) |
|
$$ |
|
ORTHO-CYCLEN (norgestimate-ethinyl estradiol) |
|
$$ |
|
ORTHO-NOVUM (norethindrone-ethin estradiol) |
|
$$ |
|
ORTHO-NOVUM (norethindrone-mestranol) |
|
$$ |
|
portia (levonorgestrel-ethin estradiol) |
|
$$ |
|
previfem (norgestimate-ethinyl estradiol) |
|
$$ |
|
reclipsen (desogestrel-ethinyl estradiol) |
|
$$ |
|
solia (desogestrel-ethinyl estradiol) |
|
$$ |
|
sprintec (norgestimate-ethinyl estradiol) |
|
$$ |
|
tri-previfem (norgestimate-ethinyl estradiol) |
|
$$ |
|
tri-sprintec (norgestimate-ethinyl estradiol) |
|
$$ |
|
trinessa (norgestimate-ethinyl estradiol) |
|
$$ |
|
trivora-28 (levonorgestrel-ethin estradiol) |
|
$$ |
|
velivet (desogestrel-ethinyl estradiol) |
|
$$$ |
|
kariva (desog-et estra/ethin estra) |
|
$$$ |
|
MIRCETTE (desog-et estra/ethin estra) |
|
$$$ |
|
ogestrel (norgestrel-ethinyl estradiol) |
|
$$$ |
|
ORTHO TRI-CYCLEN LO (norgestimate-ethinyl estradiol) |
|
$$$ |
|
YASMIN 28 (eth estradiol/drospirenone) |
|
$$$ |
|
YAZ (eth estradiol/drospirenone) |
|
Non-Formulary |
|
BALZIVA |
|
Non-Formulary |
|
CYCLESSA |
|
Non-Formulary |
|
DEMULEN 1-50-21 |
|
Non-Formulary |
|
DESOGEN |
|
Non-Formulary |
|
ESTROSTEP FE |
|
Non-Formulary |
|
FEMCON FE |
|
Non-Formulary |
|
JOLESSA |
|
Non-Formulary |
|
LEENA |
|
Non-Formulary |
|
LO-OVRAL-28 |
|
Non-Formulary |
|
LOESTRIN |
|
Non-Formulary |
|
LOESTRIN 24 FE |
|
Non-Formulary |
|
LOESTRIN FE |
|
Non-Formulary |
|
LYBREL |
|
Non-Formulary |
|
NORDETTE-28 |
|
Non-Formulary |
|
NORINYL 1+35 |
|
Non-Formulary |
|
NORINYL 1+50 |
|
Non-Formulary |
|
NUVARING |
|
Non-Formulary |
|
ORTHO EVRA |
|
Non-Formulary |
|
OVCON-35 |
|
Non-Formulary |
|
OVCON-50 |
|
Non-Formulary |
|
PLAN B |
|
Non-Formulary |
|
QUASENSE |
|
Non-Formulary |
|
SEASONALE |
|
Non-Formulary |
|
SEASONIQUE |
|
Non-Formulary |
|
SRONYX |
|
Non-Formulary |
|
TILIA FE |
|
Non-Formulary |
|
TRI-LEGEST FE |
|
Non-Formulary |
|
TRI-NORINYL |
|
Non-Formulary |
|
ZENCHENT |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0