$ |
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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KEY:
ANTIHISTAMINES
AZA = azatadine
BPM = brompheniramine
BDPH = bromodiphenhydramine
CBX = carbinoxamine
CLE = clemestine
CPM = chlorpheniramine
CPMT = chlorpheniramine tannate
DBM = dexbrompheniramine
DCPM = dexchlorpheniramine
DOX = doxylamine
DPH = diphenhydramine
LOR = loratadine
PHE = pheniramine
PND = phenindamine
PRO = promethazine
PTX = phenyltoloxamine
PYR = pyrilamine
TER = terfenadine
TRI = tripolidine
OTHER
APAP = acetaminophen
ASA = aspirin
DYP = dyphylline
HAS = hyoscyamine/atropine/scopolamine
HT = homatropine
METH = methscopolamine
SAL = sodium salicylate
SCIT = sodium citrate
DECONGESTANTS
EPH = ephedrine
PE = phenylephrine
PET = phenylephrine tannate
PPM = phenylpropanolamine
PSE = pseudoephedrine
ANTITUSSIVES
CAR = caramiphen
CARB = carbapentane
COD = codeine
DM = dextromethorphan
HYD = hydrocodone
HYM = hydromorphone
EXPECTORANTS
AMCL = ammonium chloride
CAI = calcium iodide
GUA = guaifenesin
IPEC = ipecac
KGUA = potassium guaiacolate
KI = potassium iodide
Formulary Date: 06/01/2007 Update Date: 07/13/2007 V1.3.0