$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
ANTIGLAUCOMA DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
acetazolamide (acetazolamide) |
cap sa |
|
|
betaxolol hcl (betaxolol) |
ophth drops |
|
|
COMBIGAN (PA REQUIRED) (brimonidine tartrate/timolol) |
|
|
|
dorzolamide hcl (dorzolamide) |
|
|
|
dorzolamide-timolol (dorzolamide/timolol) |
|
|
|
pilocarpine hcl (pilocarpine hcl) |
|
|
|
timolol maleate (timolol) |
|
$ |
|
acetazolamide (acetazolamide) |
tab |
$ |
|
ISOPTO CARPINE (pilocarpine hcl) |
|
$ |
|
levobunolol hcl (levobunolol) |
|
$ |
|
methazolamide (methazolamide) |
|
$ |
|
PROPINE (dipivefrin) |
|
$$ |
|
BETAGAN (levobunolol) |
|
$$ |
|
TIMOPTIC-XE (timolol) |
|
$$$ |
|
brimonidine tartrate (brimonidine tartrate) |
|
$$$ |
|
ISOPTO CARBACHOL (carbachol) |
|
$$$ |
|
PILOPINE HS (pilocarpine hcl) |
|
$$$ |
|
TIMOPTIC (timolol) |
|
$$$ |
|
TRUSOPT (dorzolamide) |
|
$$$$ |
|
ALPHAGAN P (brimonidine tartrate) |
|
$$$$ |
|
PHOSPHOLINE IODIDE (echothiophate iodide) |
|
$$$$ |
|
XALATAN (latanoprost) |
|
$$$$$ |
|
COSOPT (dorzolamide/timolol) |
|
$$$$$ |
|
DIAMOX SEQUELS (acetazolamide) |
|
$$$$$ |
|
LUMIGAN (bimatoprost) |
|
Non-Formulary |
|
AZOPT |
|
Non-Formulary |
|
BETIMOL |
|
Non-Formulary |
|
BETOPTIC S |
|
Non-Formulary |
|
CARTEOLOL HCL |
|
Non-Formulary |
|
IOPIDINE |
|
Non-Formulary |
|
ISTALOL |
|
Non-Formulary |
|
METIPRANOLOL |
|
Non-Formulary |
|
OPTIPRANOLOL |
|
Non-Formulary |
|
TRAVATAN |
|
Non-Formulary |
|
TRAVATAN Z |
|
Formulary Date: 05/13/2009 Update Date: 05/15/2009 V1.3.0