$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
OTHER OPHTHALMIC DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
altafrin (phenylephrine hcl) |
|
|
|
AMVISC (sodium hyaluronate) |
|
|
|
AMVISC PLUS (sodium hyaluronate) |
|
|
|
BOTOX (botulinum toxin a) |
|
|
|
cromolyn sodium (cromolyn) |
|
|
|
FLUCAINE (proparacaine/fluorescein) |
|
|
|
PROVISC (sodium hyaluronate) |
|
|
|
VOLTAREN (diclofenac sodium) |
ophth drops |
$ |
|
ak-dilate (phenylephrine hcl) |
|
$ |
|
ak-pentolate (cyclopentolate) |
|
$ |
|
atropine care (atropine sulfate) |
|
$ |
|
atropine sulfate (atropine sulfate) |
|
$ |
|
CROLOM (cromolyn) |
|
$ |
|
cyclopentolate hcl (cyclopentolate) |
|
$ |
|
flurbiprofen sodium (flurbiprofen) |
|
$ |
|
homatropaire (homatropine hbr) |
|
$ |
|
MYDRIACYL (tropicamide) |
|
$ |
|
OCUFEN (flurbiprofen) |
|
$ |
|
phenylephrine hcl (phenylephrine hcl) |
|
$ |
|
tropicacyl (tropicamide) |
|
$ |
|
tropicamide (tropicamide) |
|
$$ |
|
CYCLOGYL (cyclopentolate) |
|
$$ |
|
diclofenac sodium (diclofenac sodium) |
|
$$ |
|
ISOPTO ATROPINE (atropine sulfate) |
|
$$ |
|
ISOPTO HOMATROPINE (homatropine hbr) |
|
$$ |
|
ISOPTO HYOSCINE (scopolamine) |
|
$$ |
|
MYDFRIN (phenylephrine hcl) |
|
$$$$ |
|
ACULAR (ketorolac) |
|
$$$$ |
|
ACULAR LS (ketorolac) |
|
$$$$ |
|
ALOMIDE (lodoxamide) |
|
$$$$ |
|
PATADAY (olopatadine hcl) |
|
$$$$ |
|
PATANOL (olopatadine hcl) |
|
$$$$$ |
|
ALOCRIL (nedocromil) |
|
$$$$$ |
|
RESTASIS (cyclosporine) |
|
Non-Formulary |
|
ACUVAIL |
|
Non-Formulary |
|
AK-CON |
|
Non-Formulary |
|
AKORN BALANCED SALT |
|
Non-Formulary |
|
AKTEN |
|
Non-Formulary |
|
ALAMAST |
|
Non-Formulary |
|
ALCAINE |
|
Non-Formulary |
|
ALTAFLUOR |
|
Non-Formulary |
|
BEPREVE |
|
Non-Formulary |
|
BETADINE |
|
Non-Formulary |
|
BSS |
|
Non-Formulary |
|
BSS PLUS |
|
Non-Formulary |
|
CYCLOMYDRIL |
|
Non-Formulary |
|
ELESTAT |
|
Non-Formulary |
|
EMADINE |
|
Non-Formulary |
|
FLUORESCEIN-BENOXINATE |
|
Non-Formulary |
|
FLUORESCEIN-PROPARACAINE HCL |
|
Non-Formulary |
|
FLURATE |
|
Non-Formulary |
|
FLURESS |
|
Non-Formulary |
|
FRESHKOTE |
|
Non-Formulary |
|
LACRISERT |
|
Non-Formulary |
|
MUROCOLL-2 |
|
Non-Formulary |
|
NATACYN |
|
Non-Formulary |
|
NEVANAC |
|
Non-Formulary |
|
OPTIVAR |
|
Non-Formulary |
|
PROPARACAINE HCL |
|
Non-Formulary |
|
VITRASERT |
|
Non-Formulary |
|
XIBROM |
|
Formulary Date: 10/21/2009 Update Date: 10/26/2009 V1.3.0