$ |
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 |
MEDICAL (MISCELLANEOUS) SUPPLIES
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
AEROCHAMBER MV (nebulizer/supplies) |
|
|
|
AEROCHAMBER WITH FLOWSIGNAL (nebulizer/supplies) |
|
|
|
AEROTRACH PLUS (nebulizer/supplies) |
|
|
|
ALLERGIST TRAY (allergy syringes) |
|
|
|
BABY CONVERSION KIT (nebulizer/supplies) |
|
|
|
BABY CONVERSION PACK 1 (nebulizer/supplies) |
|
|
|
BABY CONVERSION PACK 2 (nebulizer/supplies) |
|
|
|
BABY NEBULIZER (nebulizer/supplies) |
|
|
|
COMFORT (misc supplies) |
|
|
|
COMFORT SHORT (misc supplies) |
ea |
|
|
DEVILBISS TRAVELER (nebulizer/supplies) |
|
|
|
FLUTTER (nebulizer/supplies) |
|
|
|
INSPIRATION (nebulizer/supplies) |
|
|
|
INSPIRATION ELITE (nebulizer/supplies) |
ea |
|
|
LEVER LOCK CANNULA (non insulin syringes/needles) |
|
|
|
MASK SET (nebulizer/supplies) |
|
|
|
MASK SET WITH Y-PIECE (nebulizer/supplies) |
|
|
|
MASK, PEDIATRIC (nebulizer/supplies) |
|
|
|
MICROCHAMBER (nebulizer/supplies) |
|
|
|
MISTERNEB COMPRESSOR (nebulizer/supplies) |
|
|
|
MONOJECT LUER LOCK TB SYRINGE (tuberculin syringes) |
|
|
|
MONOJECT TB (tuberculin syringes) |
|
|
|
OPTIHALER (nebulizer/supplies) |
|
|
|
PARADIGM SILHOUETTE (misc supplies) |
|
|
|
PRONEB ULTRA II (nebulizer/supplies) |
|
|
|
PULMO-AIDE (nebulizer/supplies) |
|
|
|
SAFETYGLIDE ALLERGY SYRINGE (allergy syringes) |
|
|
|
SIDESTREAM (nebulizer/supplies) |
|
|
|
SPECTRAGEL (misc supp (dress,tape,gauze)) |
|
|
|
SURE-T (misc supplies) |
|
|
|
T.E.D. ANTI-EMBOLISM STOCKING (anti-embolism stockings) |
|
|
|
TOUCH-TROL (misc supplies) |
|
|
|
VENTSTREAM NEBULIZER (nebulizer/supplies) |
|
|
|
VORTEX (nebulizer/supplies) |
|
|
|
XEROFORM PETROLATUM DRESSING (misc supp (dress,tape,gauze)) |
|
|
|
ZOEY (nebulizer/supplies) |
|
$ |
|
AEROCHAMBER MAX (nebulizer/supplies) |
|
$ |
|
AEROCHAMBER Z-STAT PLUS (nebulizer/supplies) |
|
$ |
|
ALLERGIST SYRINGE (allergy syringes) |
|
$ |
|
BUBBLES THE FISH (nebulizer/supplies) |
|
$ |
|
E-Z SPACER MASK (nebulizer/supplies) |
|
$ |
|
EASIVENT (nebulizer/supplies) |
|
$ |
|
LC PLUS (nebulizer/supplies) |
|
$ |
|
MONOJECT SYRINGE (non insulin syringes/needles) |
disposable syringes |
$$ |
|
E-Z SPACER & MASK (nebulizer/supplies) |
|
$$ |
|
OPTICHAMBER (nebulizer/supplies) |
|
$$$ |
|
AEROCHAMBER (nebulizer/supplies) |
|
$$$ |
|
MINIMED RESERVOIR (non insulin syringes/needles) |
|
$$$$ |
|
ACTIS (misc supplies) |
|
$$$$ |
|
THINSET (non insulin syringes/needles) |
|
$$$$$ |
|
DEVILBISS PULMO-AIDE (nebulizer/supplies) |
|
$$$$$ |
|
INFUSION (misc supplies) |
|
$$$$$ |
|
INFUSION SET (misc supplies) |
|
$$$$$ |
|
MINIMED (misc supplies) |
|
$$$$$ |
|
PARADIGM (non insulin syringes/needles) |
|
$$$$$ |
|
PARADIGM INFUSION (misc supplies) |
|
$$$$$ |
|
POLYFIN (misc supplies) |
|
$$$$$ |
|
POLYFIN QR (misc supplies) |
|
$$$$$ |
|
PRONEB ULTRA (nebulizer/supplies) |
|
$$$$$ |
|
QUICK RELEASE SOFT TEFLON (misc supplies) |
|
$$$$$ |
|
RELIEFBAND (misc supplies) |
|
$$$$$ |
|
SILHOUETTE (misc supplies) |
|
$$$$$ |
|
SOF-SET (misc supplies) |
|
$$$$$ |
|
SOF-SET MICRO (misc supplies) |
|
Non-Formulary |
|
ACAPELLA |
|
Non-Formulary |
|
APLIGRAF |
|
Non-Formulary |
|
CARTICEL |
|
Non-Formulary |
|
CATHETER |
|
Non-Formulary |
|
COMFORT SHORT |
|
Non-Formulary |
|
CONCEIVEX CONCEPTION |
|
Non-Formulary |
|
CURITY IODOFORM |
|
Non-Formulary |
|
DERMAGRAFT |
|
Non-Formulary |
|
E-Z SPACER PEDSPAK |
|
Non-Formulary |
|
EAR POPPER |
|
Non-Formulary |
|
FEMALE SELF CATHETER |
|
Non-Formulary |
|
HYPODERMIC NEEDLE |
|
Non-Formulary |
|
I-PORT |
|
Non-Formulary |
|
INSET 30 TUBING |
|
Non-Formulary |
|
INSPIRATION ELITE |
|
Non-Formulary |
|
MICRO ELITE |
|
Non-Formulary |
|
MINIELITE |
|
Non-Formulary |
|
MONOJECT |
|
Non-Formulary |
|
MONOJECT MAGELLAN |
|
Non-Formulary |
|
MONOJECT SAFETY SYRINGE |
|
Non-Formulary |
|
MONOJECT SYRINGE |
|
Non-Formulary |
|
MONOJECT SYRINGE |
|
Non-Formulary |
|
OMNITROPE PEN 5 |
|
Non-Formulary |
|
PARAGARD T 380-A |
|
Non-Formulary |
|
PROVENT |
|
Non-Formulary |
|
PUDENDAL & PARASYMPATHETIC |
|
Non-Formulary |
|
RITEFLO |
|
Non-Formulary |
|
SECURITY BEAD NEEDLE, LOCAL |
|
Non-Formulary |
|
SINUSTAR |
|
Non-Formulary |
|
SUNRISE COMPRESSOR-NEBULIZER |
|
Non-Formulary |
|
TENS 502 |
|
Non-Formulary |
|
TENS 504 |
|
Non-Formulary |
|
TERUMO SURGUARD2 |
|
Non-Formulary |
|
TERUMO SURGUARD2 |
|
Non-Formulary |
|
TOUCH II |
|
Non-Formulary |
|
TREK S COMBO PACK |
|
Non-Formulary |
|
WHITACRE SPINAL NEEDLE |
|
Formulary Date: 10/21/2009 Update Date: 10/26/2009 V1.3.0