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

ANTIHISTAMINE/DECONGESTANT COMBINATIONS

Relative Cost	MAC	Drug Name (Generic Name) Drug and/or Generic Comments	Strength and/or Dosage Strength and/or Dosage Comments
		BROFED (pse/bpm)
		duradryl sr (pe/cpm/scop)
		gripex pe (gua/pe)
		NUMONYL PEDIATRIC (gua/pe)
		relcof pe (pe/cpm/scop)
$		andehist (pse/bpm)
$		HISTADE (pse/cpm)
$		prehist d (pe/cpm/scop)
$		promethazine vc (pe/pro)
$		pse bpm (pse/bpm)
$		sildec (pse/bpm)
$$		respahist (pse/bpm)
$$		ULTRABROM (pse/bpm)
$$		ultrabrom pd (pse/bpm)
Non-Formulary		ACCUHIST
Non-Formulary		AEROHIST PLUS
Non-Formulary		AEROKID
Non-Formulary		AH-CHEW
Non-Formulary		AH-CHEW II
Non-Formulary		AH-CHEW ULTRA
Non-Formulary		AH-CHEW ULTRA
Non-Formulary		ALA-HIST D
Non-Formulary		ALAHIST LQ
Non-Formulary		ALDEX D
Non-Formulary		ALDEX-CT
Non-Formulary		ALERSULE
Non-Formulary		ALLANTAN
Non-Formulary		ALLANVAN-S
Non-Formulary		ALLEGRA-D 12 HOUR
Non-Formulary		ALLEGRA-D 24 HOUR
Non-Formulary		ALLERGY DN PE
Non-Formulary		ALLERX
Non-Formulary		ALLERX 10
Non-Formulary		ALLERX 30
Non-Formulary		ALLERX PE
Non-Formulary		BLANEX-A
Non-Formulary		BPM PE
Non-Formulary		BPM PSEUDO
Non-Formulary		BROMFED
Non-Formulary		BROMFED-PD
Non-Formulary		BROMHIST
Non-Formulary		BROMHIST-NR
Non-Formulary		BROMPHENIRAMINE-PHENYLEPHRINE
Non-Formulary		BROMPHENIRAMINE-PSEUDOEPHEDR
Non-Formulary		BROMPHENIRAMINE-PSEUDOEPHEDRIN
Non-Formulary		BROVEX ADT
Non-Formulary		BROVEX PD
Non-Formulary		BROVEX PEB
Non-Formulary		BROVEX PSB
Non-Formulary		BROVEX PSE
Non-Formulary		BROVEX SR
Non-Formulary		BROVEX-D
Non-Formulary		C-PHEN DROPS
Non-Formulary		C-TAN D
Non-Formulary		C-TAN D PLUS
Non-Formulary		CHLOR-MES D
Non-Formulary		CLARINEX-D 12 HOUR
Non-Formulary		CLARINEX-D 24 HOUR
Non-Formulary		CORYZA-D
Non-Formulary		CPM 8-PE 20-MSC 1.25
Non-Formulary		DALLERGY
Non-Formulary		DALLERGY
Non-Formulary		DALLERGY PE
Non-Formulary		DALLERGY PSE
Non-Formulary		DALLERGY-JR
Non-Formulary		DECONSAL CT
Non-Formulary		DEHISTINE
Non-Formulary		DEXPHEN M
Non-Formulary		DICEL
Non-Formulary		DIPHENMAX D
Non-Formulary		DRYSEC
Non-Formulary		DURADRYL
Non-Formulary		DURADRYL
Non-Formulary		DYTAN-D
Non-Formulary		ED A-HIST
Non-Formulary		ED CHLORPED D
Non-Formulary		HISTEX
Non-Formulary		HISTEX SR
Non-Formulary		J-TAN D
Non-Formulary		J-TAN D
Non-Formulary		J-TAN D PD
Non-Formulary		K-TAN
Non-Formulary		LODRANE
Non-Formulary		LODRANE 24D
Non-Formulary		LODRANE D
Non-Formulary		LOHIST 12D
Non-Formulary		LOHIST-D
Non-Formulary		LOHIST-PD
Non-Formulary		MAXICHLOR PEH
Non-Formulary		MAXICHLOR PSE
Non-Formulary		MYHIST-PD
Non-Formulary		NALDEX
Non-Formulary		NALEX A 12
Non-Formulary		NALEX-A
Non-Formulary		NARIZ
Non-Formulary		NASOHIST
Non-Formulary		NEUTRAHIST
Non-Formulary		NOHIST
Non-Formulary		NOHIST-PE
Non-Formulary		NOHIST-PLUS
Non-Formulary		NOHIST-PLUS JR
Non-Formulary		NOREL SR
Non-Formulary		NUMONYL
Non-Formulary		NY-TANNIC
Non-Formulary		OMNIHIST II LA
Non-Formulary		OMNIHIST L.A.
Non-Formulary		PCM LA
Non-Formulary		PEDIATEX TD
Non-Formulary		PHENA-PLUS
Non-Formulary		PHENA-S
Non-Formulary		PHENA-S 12
Non-Formulary		PHENABID
Non-Formulary		PHENYL CHLOR-TAN
Non-Formulary		PHENYLEPH-CHLORPHEN
Non-Formulary		PHENYLEPHRINE-BROMPHENIRAMIN
Non-Formulary		PHENYLTOLOXAMINE PE CPM
Non-Formulary		POLY HIST FORTE
Non-Formulary		POLY HIST PD
Non-Formulary		POLY TAN D
Non-Formulary		PREHIST
Non-Formulary		PSEUDOEPHEDRINE-CHLORPHENIRAMI
Non-Formulary		R-TANNA
Non-Formulary		RE-DRYLEX
Non-Formulary		RE2+30
Non-Formulary		RELCOF DN PE
Non-Formulary		RELCOF DN PSE
Non-Formulary		RELCOF PSE
Non-Formulary		RESCON
Non-Formulary		RESCON-JR
Non-Formulary		RESCON-MX
Non-Formulary		RESPA A.R.
Non-Formulary		RESPA C&C
Non-Formulary		RESPAHIST-II
Non-Formulary		RHINACON A
Non-Formulary		RU-HIST FORTE
Non-Formulary		RU-TUSS
Non-Formulary		RY-T-12
Non-Formulary		RYNA-12
Non-Formulary		RYNA-12 S
Non-Formulary		RYNATAN
Non-Formulary		RYNATAN PEDIATRIC
Non-Formulary		RYNATAN PEDIATRIC
Non-Formulary		SCOPOHIST
Non-Formulary		SCOPOHIST
Non-Formulary		SCOPOHIST-PE
Non-Formulary		SEMPREX-D
Non-Formulary		SERADEX-LA
Non-Formulary		SILDEC-PE
Non-Formulary		SITREX PD
Non-Formulary		SONAHIST
Non-Formulary		STAHIST
Non-Formulary		SUCLOR
Non-Formulary		SUDAHIST
Non-Formulary		SUDAL 12
Non-Formulary		SUDAL-12
Non-Formulary		SYMPAK
Non-Formulary		SYMPAK PDX
Non-Formulary		TANABID DA
Non-Formulary		TANAHIST D
Non-Formulary		TANNATE
Non-Formulary		TIME-HIST QD
Non-Formulary		TRI-HIST
Non-Formulary		TRIALL
Non-Formulary		TRIPOHIST D
Non-Formulary		TRITAL SR
Non-Formulary		VAZOBID
Non-Formulary		VAZOTAB
Non-Formulary		VIRAVAN-P
Non-Formulary		WE ALLERGY
Non-Formulary		ZOTEX-PE
Non-Formulary		ZYMINE DXR
Non-Formulary		ZYMINE-D

Return to Top

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