$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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BETA-2 ADRENERGIC DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
ACE AEROSOL CLOUD ENHANCER (breathing supplies) |
|
|
|
AIRET (albuterol) |
|
|
|
E-Z SPACER (breathing supplies) |
|
|
|
ephedrine sulfate (ephedrine sulfate) |
|
|
|
INSPIREASE (breathing supplies) |
|
|
|
MICROSPACER (breathing supplies) |
|
$$ |
|
PROAIR HFA (albuterol) |
|
$$ |
|
terbutaline sulfate (terbutaline sulfate) |
|
$$$ |
|
albuterol sulfate (albuterol) |
0.83 mg/ml nebs |
$$$ |
|
albuterol sulfate (albuterol) |
5 mg nebs |
$$$ |
|
albuterol sulfate (albuterol) |
syrup |
$$$ |
|
albuterol sulfate (albuterol) |
tab |
$$$ |
|
albuterol sulfate (albuterol) |
tab sa |
$$$ |
|
VENTOLIN HFA (albuterol) |
|
$$$$ |
|
metaproterenol sulfate (metaproterenol) |
|
$$$$$ |
|
BROVANA (arformoterol tartrate) |
|
$$$$$ |
|
FORADIL (formoterol fumarate) |
|
$$$$$ |
|
SEREVENT DISKUS (salmeterol) |
|
$$$$$ |
|
VOSPIRE ER (albuterol) |
|
Non-Formulary |
|
ACCUNEB |
|
Non-Formulary |
|
ALBUTEROL SULFATE |
|
Non-Formulary |
|
MAXAIR AUTOHALER |
|
Non-Formulary |
|
PERFOROMIST |
|
Non-Formulary |
|
PROVENTIL HFA |
|
Non-Formulary |
|
XOPENEX |
|
Non-Formulary |
|
XOPENEX HFA |
|
Formulary Date: 05/13/2009 Update Date: 05/15/2009 V1.3.0