$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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PHARMACEUTICAL NECESSITIES
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
GRAPE CONCENTRATE (flavoring agent) |
|
|
|
PHENOL (phenol) |
|
|
|
PHOSPHORIC ACID (phosphoric acid, diluted) |
|
|
|
VEHICLE-N (water/alc/isopropanol/prop gly) |
|
|
|
VEHICLE-N MILD (water/alc/isopropanol/prop gly) |
|
$$ |
|
PROPYLENE GLYCOL (propylene glycol) |
|
Non-Formulary |
|
DIBUTYL SQUARATE |
|
Non-Formulary |
|
DICHLOROACETIC ACID |
|
Non-Formulary |
|
ETHYL ACETATE |
|
Non-Formulary |
|
GLUTATHIONE-L |
|
Non-Formulary |
|
GLYCOLIC ACID |
|
Non-Formulary |
|
HRT CREAM BASE WOMEN |
|
Non-Formulary |
|
HYDROCHLORIC ACID |
|
Non-Formulary |
|
ISOPROPYL PALMITATE |
|
Non-Formulary |
|
ORA PLUS |
|
Non-Formulary |
|
ORA SWEET |
|
Non-Formulary |
|
PCCA COSMETIC HRT BASE |
|
Non-Formulary |
|
PCCA LIPODERM BASE |
|
Non-Formulary |
|
PERMETHRIN |
|
Non-Formulary |
|
SIMETHICONE |
|
Non-Formulary |
|
TROCHE BASE |
|
Non-Formulary |
|
UNDECYLENIC ACID |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0