$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
DIAGNOSTIC PRODUCTS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
ASTHMAPACK II (breathing devices-peak meters) |
|
|
|
BAL IN OIL (dimercaprol) |
|
|
|
CALCIUM DISODIUM VERSENATE (edetate, calcium disodium) |
|
|
|
CYANIDE ANTIDOTE PACKAGE (na thiosul/sod nit/amyl nit) |
|
|
|
deferoxamine mesylate (deferoxamine) |
|
|
|
DESFERAL (deferoxamine) |
|
|
|
DESFERAL MESYLATE (deferoxamine) |
|
|
|
HISTATROL INTRADERMAL (histamine phosphate) |
|
|
|
ipecac (ipecac) |
|
|
|
ISOVUE-300 (iopamidol) |
|
|
|
ISOVUE-M 300 (iopamidol) |
|
|
|
KINEVAC (sincalide) |
|
|
|
methylene blue (methylene blue) |
|
|
|
OMNIPAQUE (iohexol) |
|
|
|
PROVOCHOLINE (methacholine) |
|
|
|
sodium thiosulfate (sodium thiosulfate) |
|
|
|
THYROGEN (thyrotropin) |
|
|
|
TRUZONE PEAK FLOW METER (breathing devices-peak meters) |
|
$ |
|
CEBOCAP #1 (lactose) |
|
$ |
|
CEBOCAP #3 (lactose) |
|
$ |
|
GASTROGRAFIN (diatr meglu/diatrizoate sodium) |
|
$ |
|
HYPAQUE SODIUM (diatrizoate sodium) |
|
$$$ |
|
dipyridamole (dipyridamole) |
|
$$$$$ |
|
PRECISION XTRA (ketone testing products) |
|
Non-Formulary |
|
CHEMET |
|
Non-Formulary |
|
COAGUCHEK |
|
Non-Formulary |
|
CONTINUOUS GLUCOSE SENSOR |
|
Non-Formulary |
|
E-Z-CAT |
|
Non-Formulary |
|
E-Z-PAQUE |
|
Non-Formulary |
|
EXJADE |
|
Non-Formulary |
|
FLUORETS |
|
Non-Formulary |
|
GASTROMARK |
|
Non-Formulary |
|
GUARDIAN TEST PLUG |
|
Non-Formulary |
|
MINILINK REAL-TIME TRANSMITTER |
|
Non-Formulary |
|
PARADIGM REAL-TIME |
|
Non-Formulary |
|
READI-CAT |
|
Non-Formulary |
|
READI-CAT 2 |
|
Non-Formulary |
|
SOF-SENSOR |
|
Non-Formulary |
|
TAGITOL |
|
Non-Formulary |
|
THIOLA |
|
Non-Formulary |
|
VOLUMEN |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0