$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
bacitracin (bacitracin) |
|
|
|
ciprofloxacin hcl (ciprofloxacin) |
ophth drops |
|
|
erythromycin (erythromycin base) |
|
|
|
gentamicin sulfate (gentamicin) |
|
|
|
gentasol (gentamicin) |
|
|
|
ofloxacin (ofloxacin) |
|
|
|
polycin-b (bacitracin/polymyxin b sulfate) |
|
|
|
romycin (erythromycin base) |
|
|
|
sulfacetamide sodium (sulfacetamide sodium) |
|
$ |
|
ak-poly-bac (bacitracin/polymyxin b sulfate) |
|
$ |
|
aktob (tobramycin) |
|
$ |
|
bacitracin-polymyxin (bacitracin/polymyxin b sulfate) |
|
$ |
|
BLEPH-10 (sulfacetamide sodium) |
|
$ |
|
gentak (gentamicin) |
|
$ |
|
neomycin-bacitracin-polymyxin (neomycin/bacitracin/polymyxin) |
|
$ |
|
polymyxin b sul-trimethoprim (polymyxin b sulfate/tmp) |
|
$ |
|
POLYTRIM (polymyxin b sulfate/tmp) |
|
$ |
|
sulfac (sulfacetamide sodium) |
|
$ |
|
sulfamide (sulfacetamide sodium) |
|
$ |
|
tobramycin sulfate (tobramycin) |
|
$ |
|
tobrasol (tobramycin) |
|
$$ |
|
neocidin (neomycin/gramicidin/polymyxin) |
|
$$ |
|
neomycin-polymyxin-gramicidin (neomycin/gramicidin/polymyxin) |
|
$$ |
|
NEOSPORIN (neomycin/gramicidin/polymyxin) |
|
$$ |
|
OCUFLOX (ofloxacin) |
|
$$$ |
|
TOBREX (tobramycin) |
|
$$$ |
|
VIGAMOX (moxifloxacin) |
|
$$$ |
|
ZYMAR (gatifloxacin) |
|
$$$$ |
|
CILOXAN (ciprofloxacin) |
|
Non-Formulary |
|
AZASITE |
|
Non-Formulary |
|
IQUIX |
|
Non-Formulary |
|
QUIXIN |
|
Non-Formulary |
|
TERRAMYCIN WITH POLYMYXIN |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0