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
		hydrocodone-homatropine (hyd/ht)
		tusnel c (gua/pse/cod)
$		BROMFED-DM (dm/pse/bpm)
$		corfen-dm-[PAR], [QLL] (dm/pe/cpm)
$		gani-tuss nr (gua/cod)
$		gani-tuss-dm nr (gua/dm)
$		guaifenesin dm nr (gua/dm)
$		guaifenesin-codeine (gua/cod)
$		hydromet (hyd/ht)
$		iophen dm (gua/dm)
$		iophen-c nr (gua/cod)
$		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		10PEH-400GFN
Non-Formulary		10PEH-400GFN-20DM
Non-Formulary		40PSE-400GFN
Non-Formulary		60PSE-400GFN-20DM
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 NN
Non-Formulary		ALBATUSSIN PEDIATRIC
Non-Formulary		ALBATUSSIN SR
Non-Formulary		ALDEX DM
Non-Formulary		ALLANHIST PDX
Non-Formulary		ALLANHIST PDX
Non-Formulary		ALLFEN CD
Non-Formulary		ALLFEN CDX
Non-Formulary		ALLRES G
Non-Formulary		ALLRES PD
Non-Formulary		AMBIFED
Non-Formulary		ANAPLEX DMX
Non-Formulary		ANDEHIST-DM
Non-Formulary		AQUATAB C
Non-Formulary		ATUSS DS
Non-Formulary		BALACALL DM
Non-Formulary		BALTUSSIN
Non-Formulary		BENZONATATE
Non-Formulary		BIOTUSS
Non-Formulary		BP 8
Non-Formulary		BPM PE DM
Non-Formulary		BROMDEX D
Non-Formulary		BROMHIST PDX
Non-Formulary		BROMHIST-DM
Non-Formulary		BROMHIST-DM
Non-Formulary		BROMHIST-PDX
Non-Formulary		BROMPLEX DM
Non-Formulary		BRONTEX
Non-Formulary		BRONTUSS SF
Non-Formulary		BROVEX PEB DM
Non-Formulary		BROVEX PSB DM
Non-Formulary		BROVEX PSE DM
Non-Formulary		C-PHEN DM
Non-Formulary		C-TANNA 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		CARBOFED DM
Non-Formulary		CERON-DM
Non-Formulary		CHLORDEX GP
Non-Formulary		CODEINE-GUAIFENESIN
Non-Formulary		COLDCOUGH
Non-Formulary		COLDCOUGH PD
Non-Formulary		CORYZA-DM
Non-Formulary		CORZALL
Non-Formulary		CORZALL PLUS
Non-Formulary		COTAB AX
Non-Formulary		COTABFLU
Non-Formulary		CP DEC-DM
Non-Formulary		DACEX-DM
Non-Formulary		DALLERGY DM
Non-Formulary		DCP
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-EXP
Non-Formulary		DESPEC-PD
Non-Formulary		DEX PC
Non-Formulary		DEX-TUSS
Non-Formulary		DICEL DM
Non-Formulary		DIHYDRO-CP
Non-Formulary		DIHYDRO-GP
Non-Formulary		DIHYDRO-PE
Non-Formulary		DM-CHLORPHEN-METHSCOP
Non-Formulary		DM-PE-DEXCHLORPHEN TANN
Non-Formulary		DM-PE-PYRILAMINE TANN
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		DURATUSS AC 12
Non-Formulary		DURATUSS DM
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 AC
Non-Formulary		ENDACOF-C
Non-Formulary		ENDACOF-PD
Non-Formulary		ENDAL CD
Non-Formulary		EXALL
Non-Formulary		EXECLEAR-C
Non-Formulary		EXECLEAR-DM
Non-Formulary		EXPECTUSS
Non-Formulary		FLUTABS
Non-Formulary		GANIDIN NR
Non-Formulary		GENTEX 30
Non-Formulary		GG 200 NR
Non-Formulary		GILTUSS
Non-Formulary		GILTUSS HC
Non-Formulary		GILTUSS PED-C
Non-Formulary		GILTUSS PEDIATRIC
Non-Formulary		GILTUSS TR
Non-Formulary		GUAIFENESIN
Non-Formulary		GUAIFENESIN-PHENYLEPHRINE
Non-Formulary		GUIADEX DM
Non-Formulary		GUIADRINE DX
Non-Formulary		GUIATEX PE
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		LEXUSS 210
Non-Formulary		LIVETAN DM
Non-Formulary		LOHIST-DM
Non-Formulary		LUSONAL
Non-Formulary		M-CLEAR WC
Non-Formulary		M-END DM
Non-Formulary		M-END PE
Non-Formulary		M-END WC
Non-Formulary		MAR-COF CG
Non-Formulary		MAXICHLOR DM
Non-Formulary		MAXICHLOR PEH DM
Non-Formulary		MAXICHLOR PSE DM
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		MAXIFED-G CDX
Non-Formulary		MAXIFLU CD
Non-Formulary		MAXIFLU DM
Non-Formulary		MAXIPHEN
Non-Formulary		MAXIPHEN CD
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		NOHIST DMX
Non-Formulary		NOHIST-PDX
Non-Formulary		NORTUSS-EX
Non-Formulary		NOTUSS AC
Non-Formulary		NOTUSS DC
Non-Formulary		NOTUSS-PE
Non-Formulary		NOVAHISTINE DH
Non-Formulary		NUMONYL DX
Non-Formulary		ORATUSS
Non-Formulary		ORGAN-I NR
Non-Formulary		ORGANIDIN NR
Non-Formulary		P CHLOR
Non-Formulary		PANATUSS DXP
Non-Formulary		PBM ALLERGY
Non-Formulary		PDM GG
Non-Formulary		PE-HIST DM
Non-Formulary		PEDIAHIST DM
Non-Formulary		PEDIAHIST DM
Non-Formulary		PHENABID DM
Non-Formulary		PHENCARB GG
Non-Formulary		PHENFLU DM
Non-Formulary		PHENYLEPHRINE-GUAIFENESIN
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		PRO-CLEAR AC
Non-Formulary		PRO-RED AC
Non-Formulary		PROLEX DM
Non-Formulary		PSE BROM
Non-Formulary		PSEUDO COUGH
Non-Formulary		PSEUDO DM GG
Non-Formulary		PSEUDOEPHEDRINE GG
Non-Formulary		PULMARI-GP
Non-Formulary		QUAD-TUSS TANNATE
Non-Formulary		QUARTUSS
Non-Formulary		QUARTUSS DM
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		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		SU-TUSS DM
Non-Formulary		SUDAL
Non-Formulary		SUDATEX G
Non-Formulary		SUTAN-DM
Non-Formulary		SUTTAR-2
Non-Formulary		SUTTAR-SF
Non-Formulary		SYMPAK DM
Non-Formulary		TANAFED DMX
Non-Formulary		TANNATE 12 S
Non-Formulary		TANNATE DMP-DEX
Non-Formulary		TANNATE PD-DM
Non-Formulary		TANNATE-V-DM
Non-Formulary		TENAR DM
Non-Formulary		TENAR PSE
Non-Formulary		TESSALON
Non-Formulary		TESSALON PERLE
Non-Formulary		TRIPLEX DM
Non-Formulary		TRISPEC DMX
Non-Formulary		TRISPEC PSE
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-PRES
Non-Formulary		TUSSI-PRES PEDIATRIC
Non-Formulary		TUSSICAPS
Non-Formulary		TUSSIGON
Non-Formulary		TUSSO-C
Non-Formulary		TUSSO-DMR
Non-Formulary		TUSSO-XR
Non-Formulary		TUSSO-ZMR
Non-Formulary		TUSSO-ZR
Non-Formulary		TUSTAN 12S
Non-Formulary		VANACOF
Non-Formulary		VANACOF CD
Non-Formulary		VANACOF DX
Non-Formulary		VAZOTAN
Non-Formulary		VIRAVAN-PDM
Non-Formulary		VITA-NUMONYL EX
Non-Formulary		XIRATUSS
Non-Formulary		Y-COF DM
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 AC
Non-Formulary		Z-TUSS DM
Non-Formulary		ZOTEX
Non-Formulary		ZOTEX 12
Non-Formulary		ZOTEX-12D
Non-Formulary		ZOTEX-C
Non-Formulary		ZOTEX-D
Non-Formulary		ZOTEX-GP

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