$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
DIABETIC SUPPLIES
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
ACCU-CHEK ADVANTAGE (glucose monitors) |
|
|
|
CARTRIDGE PUMP (misc supplies) |
|
|
|
INSUFLON (misc supplies) |
|
|
|
NORDIPEN 15 (insulin syringes/needles) |
|
|
|
NORDIPEN 5 (insulin syringes/needles) |
|
|
|
NOVOFINE (insulin syringes/needles) |
|
|
|
NOVOFINE 32 (insulin syringes/needles) |
|
|
|
PRECISION (insulin syringes/needles) |
|
|
|
SAFETY SYRINGE WITH SHIELD (insulin syringes/needles) |
|
$ |
|
MONOJECT INSULIN SYRINGE (insulin syringes/needles) |
|
$ |
|
NORM-JECT (insulin syringes/needles) |
|
$$ |
|
BD SAFETYGLIDE (insulin syringes/needles) |
|
$$ |
|
MONOJECT (insulin syringes/needles) |
|
$$$ |
|
ACCU-CHEK (glucose control solutions) |
combo packs |
$$$ |
|
ACCU-CHEK (glucose monitors) |
ea |
$$$ |
|
ACCU-CHEK (glucose monitors) |
kit |
$$$ |
|
ACCU-CHEK (glucose testing (blood)) |
strip |
$$$ |
|
ACCU-CHEK III (glucose monitors) |
|
$$$ |
|
FAST TAKE (glucose testing (blood)) |
|
$$$ |
|
NOVOFINE AUTOCOVER (insulin syringes/needles) |
|
$$$ |
|
ONE TOUCH BASIC SYSTEM (glucose monitors) |
|
$$$ |
|
ONE TOUCH TEST STRIPS (glucose testing (blood)) |
|
$$$ |
|
ONE TOUCH ULTRA 2 (glucose monitors) |
|
$$$ |
|
ONE TOUCH ULTRA SMART (glucose monitors) |
|
$$$ |
|
ONE TOUCH ULTRA SYSTEM (glucose monitors) |
|
$$$ |
|
ONE TOUCH ULTRA TEST STRIPS (glucose testing (blood)) |
|
$$$ |
|
ONE TOUCH ULTRAMINI (glucose monitors) |
|
$$$ |
|
SURESTEP (glucose monitors) |
|
$$$ |
|
SURESTEP (glucose testing (blood)) |
|
$$$$$ |
|
PRECISION XTRA (glucose monitors) |
|
$$$$$ |
|
PRECISION XTRA (glucose testing (blood)) |
|
Non-Formulary |
|
ACCU-CHEK |
|
Non-Formulary |
|
ACCU-CHEK SPIRIT |
|
Non-Formulary |
|
ACCU-CHEK TENDER |
|
Non-Formulary |
|
ACCU-CHEK ULTRAFLEX |
|
Non-Formulary |
|
ASCENSIA AUTODISC |
|
Non-Formulary |
|
ASCENSIA AUTODISC |
|
Non-Formulary |
|
ASCENSIA BREEZE 2 |
|
Non-Formulary |
|
ASCENSIA BREEZE 2 |
|
Non-Formulary |
|
ASCENSIA BREEZE 2 |
|
Non-Formulary |
|
ASCENSIA CONTOUR |
|
Non-Formulary |
|
ASCENSIA CONTOUR |
|
Non-Formulary |
|
ASCENSIA CONTOUR |
|
Non-Formulary |
|
ASCENSIA ELITE |
|
Non-Formulary |
|
ASCENSIA ELITE |
|
Non-Formulary |
|
DELTEC COZMO |
|
Non-Formulary |
|
DELTEC COZMO CLEO INFUSION SET |
|
Non-Formulary |
|
FREESTYLE FLASH SYSTEM |
|
Non-Formulary |
|
FREESTYLE FREEDOM |
|
Non-Formulary |
|
FREESTYLE FREEDOM LITE |
|
Non-Formulary |
|
FREESTYLE LITE METER |
|
Non-Formulary |
|
FREESTYLE LITE STRIPS |
|
Non-Formulary |
|
FREESTYLE SIDEKICK II |
|
Non-Formulary |
|
FREESTYLE SYSTEM |
|
Non-Formulary |
|
FREESTYLE TEST STRIPS |
|
Non-Formulary |
|
GLUCOMETER DEX |
|
Non-Formulary |
|
GUARDIAN RT STARTER KIT |
|
Non-Formulary |
|
HUMAPEN LUXURA HD |
|
Non-Formulary |
|
HUMAPEN MEMOIR |
|
Non-Formulary |
|
INSULIN PUMP |
|
Non-Formulary |
|
MINIMED INFUSION |
|
Non-Formulary |
|
PARADIGM INSULIN PUMP |
|
Non-Formulary |
|
PRECISION PCX |
|
Non-Formulary |
|
PRECISION PCX PLUS |
|
Non-Formulary |
|
PRECISION Q-I-D |
|
Non-Formulary |
|
PRECISION Q-I-D |
|
Non-Formulary |
|
PRECISION SOF-TACT |
|
Non-Formulary |
|
PRESTIGE |
|
Non-Formulary |
|
PRESTIGE METER |
|
Non-Formulary |
|
PRESTIGE SMART SYSTEM |
|
Non-Formulary |
|
PRESTIGE SMART SYSTEM |
|
Non-Formulary |
|
PRESTIGE SMART SYSTEM IQ |
|
Non-Formulary |
|
PRESTIGE TEST STRIPS |
|
Non-Formulary |
|
REAL-TIME STARTER KIT |
|
Non-Formulary |
|
SOF-TACT |
|
Non-Formulary |
|
TRUETRACK SMART SYSTEM |
|
Non-Formulary |
|
TRUETRACK TEST STRIP |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0