$

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.

Table of Contents     Index     Policy Information


 

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

 


Return to Top
 

Formulary Date: 10/21/2009    Update Date: 10/26/2009    V1.3.0