$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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| Prev. Page | Prev. Class | Next Class | Next Page |
ANTIHISTAMINES
QLL= 30
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
promethazine (promethazine) |
|
$ |
|
complete allergy medicine (diphenhydramine) |
|
$ |
|
diphenhydramine hcl (diphenhydramine) |
|
$ |
|
dytuss (diphenhydramine) |
|
$ |
|
hydroxyzine pamoate (hydroxyzine pamoate) |
|
$ |
|
promethazine hcl (promethazine) |
|
$ |
|
VISTARIL - generic (hydroxyzine pamoate) |
|
$$ |
|
clemastine fumarate (clemastine fumarate) |
|
$$ |
|
cyproheptadine hcl (cyproheptadine) |
|
$$ |
|
dexchlorpheniramine maleate (dexchlorpheniramine maleate) |
|
$$ |
|
hydroxyzine hcl (hydroxyzine hcl) |
|
$$$$ |
|
ALLEGRA - generic (fexofenadine) |
|
$$$$ |
|
fexofenadine hcl (fexofenadine) |
|
$$$$ |
|
ZYRTEC (cetirizine) |
|
Non-Formulary |
|
AHIST |
|
Non-Formulary |
|
ALLERGY DN |
|
Non-Formulary |
|
ALLERX |
|
Non-Formulary |
|
ALLERX DF |
|
Non-Formulary |
|
B-VEX |
|
Non-Formulary |
|
BEN-TANN |
|
Non-Formulary |
|
BIDHIST |
|
Non-Formulary |
|
BPM |
|
Non-Formulary |
|
brompheniramine |
|
Non-Formulary |
|
BROMPHENIRAMINE TANNATE |
|
Non-Formulary |
|
BROVEX |
|
Non-Formulary |
|
BROVEX CT |
|
Non-Formulary |
|
carbinoxamine maleate |
|
Non-Formulary |
|
chlor-mal/scop me-nitrate |
|
Non-Formulary |
|
CHLORPHENIRAMINE MALEATE |
|
Non-Formulary |
|
chlorpheniramine tannate |
|
Non-Formulary |
|
CHLORPHENIRAMINE TR |
|
Non-Formulary |
|
CHLORTAN |
|
Non-Formulary |
|
CLARINEX |
|
Non-Formulary |
|
CLEMASTINE FUMARATE |
|
Non-Formulary |
|
CONEX |
|
Non-Formulary |
|
CPM 12 |
|
Non-Formulary |
|
desloratadine |
|
Non-Formulary |
|
DEXCHLORPHENIRAMINE MALEATE |
|
Non-Formulary |
|
diphenhydramine tannate |
|
Non-Formulary |
|
DIPHENMAX |
|
Non-Formulary |
|
DYTAN |
|
Non-Formulary |
|
ED CHLORPED |
|
Non-Formulary |
|
ED-CHLOR-TAN |
|
Non-Formulary |
|
J-TAN |
|
Non-Formulary |
|
LODRANE |
|
Non-Formulary |
|
LODRANE 24 |
|
Non-Formulary |
|
LODRANE XR |
|
Non-Formulary |
|
LOHIST 12HR |
|
Non-Formulary |
|
NOHIST-EXT |
|
Non-Formulary |
|
P-TANN |
|
Non-Formulary |
|
P-TEX |
|
Non-Formulary |
|
PALGIC |
|
Non-Formulary |
|
PEDIAPHYL |
|
Non-Formulary |
|
PEDIATAN |
|
Non-Formulary |
|
PEDIOX-S |
|
Non-Formulary |
|
QDALL AR |
|
Non-Formulary |
|
RICOBID-H |
|
Non-Formulary |
|
RYNEZE |
|
Non-Formulary |
|
TANACOF XR |
|
Non-Formulary |
|
triprolidine hcl |
|
Non-Formulary |
|
VAZOL |
|
Non-Formulary |
|
ZYMINE |
|
Formulary Date: 06/01/2007 Update Date: 07/13/2007 V1.3.0