$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
|
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OTHER GENITOURINARY PRODUCTS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
PROSED-DS (meth/meth blue/ba/salicy/hyos) |
|
|
|
TRICITRATES (citric acid/k-na citrates) |
syrup |
$ |
|
cytra-3 (citric acid/k-na citrates) |
|
$ |
|
K-PHOS M.F. (pot acid phos/sod acid phos) |
|
$ |
|
K-PHOS NO.2 (pot acid phos/sod acid phos) |
|
$ |
|
K-PHOS ORIGINAL (potassium acid phosphate) |
|
$ |
|
potassium citrate-citric acid (citric acid/potassium citrate) |
|
$ |
|
urin d.s. (meth/me blue/ba/salol/atp/hyos) |
|
$$ |
|
cytra-k (citric acid/potassium citrate) |
|
$$ |
|
tricitrates (citric acid/k-na citrates) |
soln |
$$$ |
|
LEVITRA (vardenafil) |
|
$$$ |
|
POLYCITRA-K (citric acid/potassium citrate) |
|
$$$ |
|
RENACIDIN (gluconic acid/citric acid) |
|
$$$ |
|
UROXATRAL (alfuzosin hcl) |
|
$$$$ |
|
finasteride (finasteride) |
|
$$$$ |
|
PROSCAR (finasteride) |
|
$$$$ |
|
PROSCAR (PAR) (finasteride) |
|
$$$$$ |
|
CAVERJECT (PAR) (alprostadil) |
|
$$$$$ |
|
CYSTADANE (betaine hcl) |
|
$$$$$ |
|
ELMIRON (pentosan polysulfate sodium) |
|
$$$$$ |
|
MUSE (PAR) (alprostadil) |
|
Non-Formulary |
|
ACETIC ACID |
|
Non-Formulary |
|
ACETIC ACID |
|
Non-Formulary |
|
AVODART |
|
Non-Formulary |
|
CIALIS |
|
Non-Formulary |
|
DAYTO-HIMBIN |
|
Non-Formulary |
|
DIMETHYL SULFOXIDE |
|
Non-Formulary |
|
EDEX (PAR) |
|
Non-Formulary |
|
FLOMAX |
|
Non-Formulary |
|
GLYCINE |
|
Non-Formulary |
|
LITHOSTAT |
|
Non-Formulary |
|
NEOSPORIN G.U. IRRIGANT |
|
Non-Formulary |
|
PHENAZOPYRIDINE PLUS |
|
Non-Formulary |
|
POTASSIUM CITRATE |
|
Non-Formulary |
|
PYRELLE HB |
|
Non-Formulary |
|
PYRIDIUM PLUS |
|
Non-Formulary |
|
RIMSO-50 |
|
Non-Formulary |
|
URELLE |
|
Non-Formulary |
|
UROCIT-K |
|
Non-Formulary |
|
UROLENE BLUE |
|
Non-Formulary |
|
UROSEX |
|
Non-Formulary |
|
UTA |
|
Non-Formulary |
|
VIAGRA (PAR) |
|
Non-Formulary |
|
YOHIMBINE HCL |
|
Non-Formulary |
|
YOHIMEX |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0