Formulary Detail

$	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

ANTITUSSIVE AND EXPECTORANT DRUGS

Relative Cost	MAC	Drug Name (Generic Name) Drug and/or Generic Comments	Strength and/or Dosage Strength and/or Dosage Comments
		benzonatate (benzonatate)	100 mg cap
		dextromethorphan-pe-cpm (dm/pe/cpm)	soln
		hydrocodone-homatropine (hyd/ht)
		tusnel c (gua/pse/cod)
$		BROMFED-DM (dm/pse/bpm)
$		corfen-dm-[PAR], [QLL] (dm/pe/cpm)
$		DESPEC (gua/pe)	soln
$		gani-tuss nr (gua/cod)
$		gani-tuss-dm nr (gua/dm)
$		guaifenesin dm nr (gua/dm)
$		guaifenesin-codeine (gua/cod)	10 mg/5ml syrup
$		guaifenesin-codeine (gua/cod)	tab
$		gual-co (gua/cod)
$		gual-dex (gua/dm)
$		hydromet (hyd/ht)
$		iophen dm (gua/dm)
$		iophen-c nr (gua/cod)
$		norel dm (dm/pe/cpm)
$		promethazine-codeine (cod/pro)
$		promethazine-dm (dm/pro)
$		robafen ac (gua/cod)
$		SSKI (potassium iodide)
$		trital dm (dm/pe/cpm)
$		TUSNEL-DM (gua/dm/pse)
$$		crantex (gua/pe)
$$		guaifenesin nr (guaifenesin)
$$		promethazine vc-codeine (pe/cod/pro)
$$$$$		TUSSIONEX (hydp/cpmp)
Non-Formulary		A-TAN 12X
Non-Formulary		ACCUHIST DM
Non-Formulary		ACCUHIST PDX
Non-Formulary		AH-CHEW D
Non-Formulary		ALA-HIST AC
Non-Formulary		ALA-HIST DM
Non-Formulary		ALACOL DM
Non-Formulary		ALAHIST DHC
Non-Formulary		ALBATUSSIN CF
Non-Formulary		ALBATUSSIN CF
Non-Formulary		ALBATUSSIN DM
Non-Formulary		ALBATUSSIN NN
Non-Formulary		ALBATUSSIN PEDIATRIC
Non-Formulary		ALBATUSSIN SR
Non-Formulary		ALBATUSSIN SR
Non-Formulary		ALBATUSSIN SR F
Non-Formulary		ALBATUSSIN SR SENIOR
Non-Formulary		ALDEX DM
Non-Formulary		ALLANHIST PDX
Non-Formulary		ALLANHIST PDX
Non-Formulary		ALLANVAN-DM
Non-Formulary		ALLERDUR
Non-Formulary		ALLFEN CD
Non-Formulary		ALLFEN CDX
Non-Formulary		ALLFEN DM
Non-Formulary		ALLRES D
Non-Formulary		ALLRES G
Non-Formulary		ALLRES PD
Non-Formulary		ANAPLEX DM
Non-Formulary		ANAPLEX DMX
Non-Formulary		ANDEHIST-DM
Non-Formulary		ATUSS DS
Non-Formulary		BALACALL DM
Non-Formulary		BALTUSSIN
Non-Formulary		BENZONATATE
Non-Formulary		BIOTUSS
Non-Formulary		BROM-PE-DM
Non-Formulary		BROMATAN PLUS
Non-Formulary		BROMATAN-DM
Non-Formulary		BROMHIST PDX
Non-Formulary		BROMHIST-DM
Non-Formulary		BROMHIST-DM
Non-Formulary		BROMHIST-PDX
Non-Formulary		BROMPHENEX DM
Non-Formulary		BROMPLEX DM
Non-Formulary		BRONTEX
Non-Formulary		BRONTUSS SF
Non-Formulary		BROVEX PEB DM
Non-Formulary		BROVEX PSB DM
Non-Formulary		C-PHEN DM
Non-Formulary		C-TANNA 12
Non-Formulary		CAR-B-PEN TAN-CHLOR-TAN
Non-Formulary		CARB-PHENYL-12
Non-Formulary		CARBA-XP
Non-Formulary		CARBAPHEN 12
Non-Formulary		CARBAPHEN 12 PED
Non-Formulary		CARBATUSS
Non-Formulary		CARBATUSS-12
Non-Formulary		CARBATUSS-CL
Non-Formulary		CARBETAPENTANE-PE-GUAIFENESIN
Non-Formulary		CARBETAPLEX
Non-Formulary		CARBODEX DM
Non-Formulary		CARBOFED DM
Non-Formulary		CARDEC DM
Non-Formulary		CERON-DM
Non-Formulary		CHLORDEX GP
Non-Formulary		COLDCOUGH
Non-Formulary		COLDCOUGH PD
Non-Formulary		CONPEC
Non-Formulary		CORYZA-DM
Non-Formulary		COTABFLU
Non-Formulary		CP DEC-DM
Non-Formulary		D-TANN AT
Non-Formulary		D-TANN CD
Non-Formulary		D-TANN CT
Non-Formulary		D-TANN DM
Non-Formulary		DACEX-DM
Non-Formulary		DALLERGY DM
Non-Formulary		DE-CHLOR DM
Non-Formulary		DE-CHLOR DR
Non-Formulary		DECON-G
Non-Formulary		DECONSAL DM
Non-Formulary		DELTUSS DMX
Non-Formulary		DESPEC
Non-Formulary		DESPEC DM
Non-Formulary		DESPEC-EXP
Non-Formulary		DESPEC-PD
Non-Formulary		DEX PC
Non-Formulary		DEX-TUSS
Non-Formulary		DEX-TUSS DM
Non-Formulary		DEXALL
Non-Formulary		DEXTROMETHORPHAN-PE-CPM
Non-Formulary		DICEL DM
Non-Formulary		DIHYDRO-CP
Non-Formulary		DIHYDRO-GP
Non-Formulary		DIHYDRO-PE
Non-Formulary		DM TANN-PE TANN-BROM TANN
Non-Formulary		DM-GUAI
Non-Formulary		DONATUSSIN
Non-Formulary		DONATUSSIN
Non-Formulary		DONATUSSIN DM
Non-Formulary		DONATUSSIN DM
Non-Formulary		DONATUSSIN DM
Non-Formulary		DUOHIST DH
Non-Formulary		DURAFLU
Non-Formulary		DURATAN FORTE
Non-Formulary		DURATUSS AC 12
Non-Formulary		DURATUSS DM
Non-Formulary		DURATUSS DM 12
Non-Formulary		DYNATUSS-EX
Non-Formulary		DYNEX 12
Non-Formulary		DYNEX LA
Non-Formulary		DYNEX VR
Non-Formulary		DYTAN CD
Non-Formulary		DYTAN-AT
Non-Formulary		DYTAN-CS
Non-Formulary		DYTAN-DM
Non-Formulary		ED-A-HIST DM
Non-Formulary		ENDACOF-DM
Non-Formulary		ENDACOF-PD
Non-Formulary		ENDAL CD
Non-Formulary		EXPECTUSS
Non-Formulary		EXTENDRYL DM
Non-Formulary		EXTENDRYL GCP
Non-Formulary		FLUTABS
Non-Formulary		GANIDIN NR
Non-Formulary		GENTEX 30
Non-Formulary		GG 200 NR
Non-Formulary		GILTUSS
Non-Formulary		GILTUSS PED-C
Non-Formulary		GILTUSS PEDIATRIC
Non-Formulary		GUAIFENESIN
Non-Formulary		GUAIFENESIN-CODEINE
Non-Formulary		GUIADEX DM
Non-Formulary		HDC DM
Non-Formulary		HISTACOL DM
Non-Formulary		HT-TUSS DM
Non-Formulary		HYCODAN (syrup only)
Non-Formulary		INDAMIX DM
Non-Formulary		IOPHEN NR
Non-Formulary		J-COF DHC
Non-Formulary		J-MAX
Non-Formulary		J-MAX DHC
Non-Formulary		L-ALL 12 NF
Non-Formulary		LEVALL
Non-Formulary		LEVALL-12
Non-Formulary		LIQUIBID
Non-Formulary		LIQUICOUGH DM
Non-Formulary		LIVETAN DM
Non-Formulary		LOHIST-DM
Non-Formulary		LUSONAL
Non-Formulary		M-END DM
Non-Formulary		M-END WC
Non-Formulary		MAXIFED
Non-Formulary		MAXIFED CD
Non-Formulary		MAXIFED DM
Non-Formulary		MAXIFED DMX
Non-Formulary		MAXIFED-G
Non-Formulary		MAXIFED-G CD
Non-Formulary		MAXIFLU CD
Non-Formulary		MAXIFLU DM
Non-Formulary		MAXIPHEN
Non-Formulary		MAXIPHEN DM
Non-Formulary		MINTUSS DR
Non-Formulary		MYHIST-DM
Non-Formulary		NALEX AC
Non-Formulary		NASOHIST DM
Non-Formulary		NASOP
Non-Formulary		NASOP 12
Non-Formulary		NEO DM
Non-Formulary		NEO DM
Non-Formulary		NEO DM
Non-Formulary		NEOTUSS-D
Non-Formulary		NEUTRAHIST PDX
Non-Formulary		NEW ALLERGY DM
Non-Formulary		NOHIST DMX
Non-Formulary		NORTUSS-EX
Non-Formulary		NOTUSS AC
Non-Formulary		NOTUSS DC
Non-Formulary		NUCOFED
Non-Formulary		NUMONYL DX
Non-Formulary		ORATUSS
Non-Formulary		ORGAN-I NR
Non-Formulary		ORGANIDIN NR
Non-Formulary		P CHLOR
Non-Formulary		P-HIST
Non-Formulary		P-HIST DM
Non-Formulary		PANATUSS DXP
Non-Formulary		PANCOF PD
Non-Formulary		PBM ALLERGY
Non-Formulary		PD-COF
Non-Formulary		PDM GG
Non-Formulary		PE-HIST DM
Non-Formulary		PEDIAHIST DM
Non-Formulary		PEDIAHIST DM
Non-Formulary		PENTUSS
Non-Formulary		PHENABID DM
Non-Formulary		PHENCARB GG
Non-Formulary		PHENYL-T
Non-Formulary		POLY HIST DM
Non-Formulary		POLY TAN DM
Non-Formulary		POLY-TUSSIN AC
Non-Formulary		POLY-TUSSIN DHC
Non-Formulary		POLY-TUSSIN DM
Non-Formulary		PROHIST
Non-Formulary		PROHIST DM
Non-Formulary		PROLEX DM
Non-Formulary		PSE BROM
Non-Formulary		PSEUDACARB
Non-Formulary		PSEUDO COUGH
Non-Formulary		PSEUDO DM GG
Non-Formulary		PSEUDOEPHEDRINE GG
Non-Formulary		PULMARI-GP
Non-Formulary		PYRLEX CB
Non-Formulary		QUAD TANN
Non-Formulary		QUAD TANN PEDIATRIC
Non-Formulary		QUAD-TUSS TANNATE
Non-Formulary		QUAL-TUSSIN
Non-Formulary		QUARTUSS
Non-Formulary		QUARTUSS DM
Non-Formulary		RE ALL 12
Non-Formulary		REME HIST DM
Non-Formulary		REME TUSSIN DM
Non-Formulary		RESPAIRE-30
Non-Formulary		RESPERAL
Non-Formulary		RESPERAL-DM
Non-Formulary		RESPI-TANN
Non-Formulary		RESPI-TANN PD
Non-Formulary		RICOBID
Non-Formulary		RICOTUSS
Non-Formulary		RICOTUSS
Non-Formulary		RONDEC-DM
Non-Formulary		RU-TUSS DM
Non-Formulary		RYNA-12X
Non-Formulary		RYNATUSS
Non-Formulary		SERADEX
Non-Formulary		SILDEC PE-DM
Non-Formulary		SILDEC-DM
Non-Formulary		SIMUC-DM
Non-Formulary		SINA-12X
Non-Formulary		SINUTUSS DM
Non-Formulary		SINUVENT PE
Non-Formulary		SOLOTUSS
Non-Formulary		SONAHIST DM
Non-Formulary		SORBUTUSS
Non-Formulary		SU-TUSS DM
Non-Formulary		SUDAL
Non-Formulary		SUTAN
Non-Formulary		SUTAN-DM
Non-Formulary		SUTTAR-2
Non-Formulary		SUTTAR-SF
Non-Formulary		SYMPAK DM
Non-Formulary		TANAFED DMX
Non-Formulary		TANDUR DM
Non-Formulary		TANNATE 12 S
Non-Formulary		TANNATE DMP-DEX
Non-Formulary		TANNATE PD-DM
Non-Formulary		TANNATE-V-DM
Non-Formulary		TANNIC-12
Non-Formulary		TANNIC-12 S
Non-Formulary		TESSALON
Non-Formulary		TESSALON PERLE
Non-Formulary		TRIPLEX DM
Non-Formulary		TRISPEC DMX
Non-Formulary		TRISPEC PSE
Non-Formulary		TRISPEC SFX
Non-Formulary		TRITUSS
Non-Formulary		TUSDEC-DM
Non-Formulary		TUSNEL
Non-Formulary		TUSNEL PED-C
Non-Formulary		TUSNEL PEDIATRIC
Non-Formulary		TUSNEL PEDIATRIC
Non-Formulary		TUSSAFED EX
Non-Formulary		TUSSALL
Non-Formulary		TUSSALL-ER
Non-Formulary		TUSSI-12
Non-Formulary		TUSSI-12 S
Non-Formulary		TUSSI-12D
Non-Formulary		TUSSI-12D S
Non-Formulary		TUSSI-ORGANIDIN DM NR
Non-Formulary		TUSSI-ORGANIDIN DM-S NR
Non-Formulary		TUSSI-ORGANIDIN NR
Non-Formulary		TUSSI-ORGANIDIN-S NR
Non-Formulary		TUSSI-PRES
Non-Formulary		TUSSI-PRES PEDIATRIC
Non-Formulary		TUSSICAPS
Non-Formulary		TUSSIDEN DM
Non-Formulary		TUSSIGON
Non-Formulary		TUSSIZONE-12 RF
Non-Formulary		TUSSO-C
Non-Formulary		TUSSO-DMR
Non-Formulary		TUSSO-XR
Non-Formulary		TUSTAN 12S
Non-Formulary		VANACOF
Non-Formulary		VANACOF CD
Non-Formulary		VANACOF DX
Non-Formulary		VAZOTAN
Non-Formulary		VIRATAN-DM
Non-Formulary		VIRAVAN-PDM
Non-Formulary		VITA-NUMONYL
Non-Formulary		VITA-NUMONYL EX
Non-Formulary		WELLTUSS EXP
Non-Formulary		XIRATUSS
Non-Formulary		Y-COF DM
Non-Formulary		YODEFAN
Non-Formulary		YODEFAN-NF
Non-Formulary		Z-COF 12DM
Non-Formulary		Z-COF 8 DM
Non-Formulary		Z-DEX
Non-Formulary		Z-DEX SYRUP
Non-Formulary		Z-TUSS DM
Non-Formulary		ZINX
Non-Formulary		ZINX
Non-Formulary		ZOTEX
Non-Formulary		ZOTEX 12
Non-Formulary		ZOTEX-12D
Non-Formulary		ZOTEX-G
Non-Formulary		ZOTEX-GP

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Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0