$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
ANTIHISTAMINES
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
cetirizine hcl (cetirizine) |
|
|
|
promethazine hcl (promethazine) |
|
|
|
PROMETHAZINE HCL (SUPP) (promethazine) |
|
$ |
|
chlorpheniramine maleate (chlorpheniramine) |
12 mg cap sa |
$ |
|
clemastine fumarate (clemastine fumarate) |
syrup |
$ |
|
complete allergy medicine (diphenhydramine) |
|
$ |
|
dexchlorpheniramine maleate (dexchlorpheniramine maleate) |
tab sa |
$ |
|
diphenhydramine hcl (diphenhydramine) |
|
$ |
|
dytuss (diphenhydramine) |
|
$$ |
|
cyproheptadine hcl (cyproheptadine) |
|
$$$$ |
|
PHENERGAN (promethazine) |
|
Non-Formulary |
|
AEROHIST |
|
Non-Formulary |
|
AHIST |
|
Non-Formulary |
|
ALA-HIST |
|
Non-Formulary |
|
ALDEX AN |
|
Non-Formulary |
|
ALDEX AN |
|
Non-Formulary |
|
ALLEGRA |
|
Non-Formulary |
|
ALLEGRA ODT |
|
Non-Formulary |
|
ALLERX DF |
|
Non-Formulary |
|
ALLERX DF 30 |
|
Non-Formulary |
|
B-VEX |
|
Non-Formulary |
|
BEN-TANN |
|
Non-Formulary |
|
BIDHIST |
|
Non-Formulary |
|
BPM |
|
Non-Formulary |
|
BROMPHENIRAMINE TANNATE |
|
Non-Formulary |
|
BROVEX |
|
Non-Formulary |
|
BROVEX CT |
|
Non-Formulary |
|
CARBINOXAMINE MALEATE |
|
Non-Formulary |
|
CHLORPHENIRAMINE MALEATE |
|
Non-Formulary |
|
CHLORTAN |
|
Non-Formulary |
|
CLARINEX |
|
Non-Formulary |
|
CLEMASTINE FUMARATE |
|
Non-Formulary |
|
CONEX |
|
Non-Formulary |
|
CPM 12 |
|
Non-Formulary |
|
DEXCHLORPHENIRAMINE MALEATE |
|
Non-Formulary |
|
DEXODRYL |
|
Non-Formulary |
|
DIPHENMAX |
|
Non-Formulary |
|
DYTAN |
|
Non-Formulary |
|
ED CHLORPED |
|
Non-Formulary |
|
ED-CHLOR-TAN |
|
Non-Formulary |
|
FEXOFENADINE HCL (Not covered for MAHP members) |
|
Non-Formulary |
|
J-TAN |
|
Non-Formulary |
|
J-TAN PD |
|
Non-Formulary |
|
LODRANE 24 |
|
Non-Formulary |
|
LOHIST 12HR |
|
Non-Formulary |
|
NOHIST-EXT |
|
Non-Formulary |
|
P-TEX |
|
Non-Formulary |
|
PALGIC |
|
Non-Formulary |
|
PALGIC |
|
Non-Formulary |
|
PEDIAPHYL |
|
Non-Formulary |
|
PEDIATAN |
|
Non-Formulary |
|
PEDIOX-S |
|
Non-Formulary |
|
POLY TAN |
|
Non-Formulary |
|
PYRLEX |
|
Non-Formulary |
|
RESPA-BR |
|
Non-Formulary |
|
RESPIVENT DF |
|
Non-Formulary |
|
RESPIVENT DF 30 |
|
Non-Formulary |
|
RICOBID-H |
|
Non-Formulary |
|
TANACOF XR |
|
Non-Formulary |
|
TANAHIST-PD |
|
Non-Formulary |
|
TRIPOHIST |
|
Non-Formulary |
|
TRIPROLIDINE HCL |
|
Non-Formulary |
|
VAZOL |
|
Non-Formulary |
|
VISRX |
|
Non-Formulary |
|
XYZAL |
|
Non-Formulary |
|
XYZAL |
|
Non-Formulary |
|
ZYMINE |
|
Non-Formulary |
|
ZYMINE XR |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0