$ |
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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PENICILLINS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
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ampicillin sodium (ampicillin sodium) |
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ampicillin-sulbactam (ampicillin sodium/sulbactam na) |
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BICILLIN C-R (pen g procaine/pen g benz) |
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BICILLIN L-A (penicillin g benzathine) |
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NAFCILL IN DEXTROSE (nafcillin) |
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nafcillin (nafcillin) |
|
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nafcillin sodium (nafcillin) |
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NALLPEN (nafcillin) |
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NALLPEN IN DEXTROSE (nafcillin) |
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NALLPEN-ISO-OSMOTIC DEXTROSE (nafcillin) |
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oxacillin (oxacillin) |
|
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oxacillin sodium (oxacillin) |
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penicillin g potassium (penicillin g potassium) |
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PENICILLIN G POTASSIUM IN D5W (pen g pot/dextrose-water) |
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PENICILLIN G POTASSIUM IN D5W (penicillin g potassium) |
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penicillin g procaine (penicillin g procaine) |
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penicillin g sodium (penicillin g sodium) |
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PENICILLIN GK-ISO-OSM DEXTROSE (pen g pot/dextrose-water) |
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PFIZERPEN (penicillin g potassium) |
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piperacillin-tazobactam (piperacillin/tazobactam sodium) |
|
|
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PIPRACIL IN DEXTROSE (piperacillin) |
|
|
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TICAR IN DEXTROSE (ticarcillin) |
|
|
|
TIMENTIN (ticarcillin/k clavulanate) |
|
|
|
TOTACILLIN-N (ampicillin sodium) |
|
|
|
UNASYN (ampicillin sodium/sulbactam na) |
|
|
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ZOSYN (piperacillin/tazobactam na/d5w) |
|
|
|
ZOSYN (piperacillin/tazobactam sodium) |
|
$ |
|
amoxicillin (amoxicillin) |
cap |
$ |
|
amoxicillin (amoxicillin) |
125 mg chew tab |
$ |
|
amoxicillin (amoxicillin) |
250 mg chew tab |
$ |
|
amoxicillin (amoxicillin) |
125 mg/5ml susp |
$ |
|
amoxicillin (amoxicillin) |
250 mg/5ml susp |
$ |
|
amoxicillin (amoxicillin) |
400 mg/5ml susp |
$ |
|
amoxicillin (amoxicillin) |
875 mg tab |
$ |
|
AMOXIL (amoxicillin) |
|
$ |
|
ampicillin trihydrate (ampicillin trihydrate) |
|
$ |
|
penicillin v potassium (penicillin v potassium) |
|
$$ |
|
amoclan (amoxicillin clavulanate) |
|
$$ |
|
amox tr-potassium clavulanate (amoxicillin clavulanate) |
|
$$ |
|
AUGMENTIN ES-600 (amoxicillin clavulanate) |
|
$$ |
|
dicloxacillin sodium (dicloxacillin) |
|
$$$ |
|
AUGMENTIN (amoxicillin clavulanate) |
|
Non-Formulary |
|
AMOXICILLIN |
|
Non-Formulary |
|
AUGMENTIN XR |
|
Non-Formulary |
|
BACTOCILL |
|
Non-Formulary |
|
MOXATAG |
|
Formulary Date: 10/21/2009 Update Date: 10/26/2009 V1.3.0