$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
OTHER DRUGS FOR ASTHMA
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
ADRENALIN CHLORIDE (epinephrine hcl) |
|
|
|
budesonide (budesonide) |
|
|
|
cromolyn sodium (cromolyn) |
|
|
|
ipratropium bromide (ipratropium) |
|
|
|
sodium chloride (sodium chloride) |
0.9 % nebs |
$ |
|
epinephrine (epinephrine hcl) |
|
$$ |
|
QVAR (beclomethasone) |
|
$$$ |
|
FLOVENT DISKUS (fluticasone propionate) |
|
$$$$ |
|
acetylcysteine (acetylcysteine) |
|
$$$$ |
|
ASMANEX (mometasone) |
|
$$$$ |
|
FLOVENT HFA (fluticasone propionate) |
|
$$$$$ |
|
ADVAIR DISKUS (salmeterol/fluticasone) |
|
$$$$$ |
|
ADVAIR HFA (salmeterol/fluticasone) |
|
$$$$$ |
|
ATROVENT HFA (ipratropium) |
|
$$$$$ |
|
COMBIVENT (albuterol sulfate/ipratropium) |
|
$$$$$ |
|
DUONEB (albuterol sulfate/ipratropium) |
|
$$$$$ |
|
EPIPEN (epinephrine hcl) |
|
$$$$$ |
|
EPIPEN JR (epinephrine hcl) |
|
$$$$$ |
|
INTAL (cromolyn) |
|
$$$$$ |
|
ipratropium-albuterol (albuterol sulfate/ipratropium) |
|
$$$$$ |
|
SPIRIVA (tiotropium bromide) |
|
$$$$$ |
|
SYMBICORT (budesonide/formoterol fum) |
|
Non-Formulary |
|
AEROBID |
|
Non-Formulary |
|
AEROBID-M |
|
Non-Formulary |
|
ALVESCO |
|
Non-Formulary |
|
AZMACORT |
|
Non-Formulary |
|
GASTROCROM |
|
Non-Formulary |
|
HYPER-SAL |
|
Non-Formulary |
|
PULMICORT (PAR age < 4) |
|
Non-Formulary |
|
PULMICORT FLEXHALER |
|
Non-Formulary |
|
SENOPHYLLINE |
|
Non-Formulary |
|
SODIUM CHLORIDE |
|
Non-Formulary |
|
TWINJECT |
|
Formulary Date: 10/21/2009 Update Date: 10/26/2009 V1.3.0