$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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TETRACYCLINES
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
ALA-TET (tetracycline) |
|
|
|
doxy-lemmon (doxycycline hyclate) |
|
|
|
TERRAMYCIN (oxytetracycline) |
|
|
|
TERRAMYCIN IM (oxytetracycline) |
|
$ |
|
doxycycline hyclate (doxycycline hyclate) |
cap |
$ |
|
doxycycline hyclate (doxycycline hyclate) |
inj |
$ |
|
doxycycline hyclate (doxycycline hyclate) |
100 mg tab |
$ |
|
tetracycline hcl (tetracycline) |
|
$ |
|
VIBRA-TABS (doxycycline hyclate) |
|
$$ |
|
minocycline hcl (minocycline) |
cap |
$$$ |
|
VIBRAMYCIN (doxycycline hyclate) |
cap |
$$$$$ |
|
MINOCIN (minocycline) |
cap |
Non-Formulary |
|
ADOXA |
|
Non-Formulary |
|
ADOXA CK |
|
Non-Formulary |
|
ADOXA PAK |
|
Non-Formulary |
|
ADOXA TT |
|
Non-Formulary |
|
ALODOX |
|
Non-Formulary |
|
CLEERAVUE-M |
|
Non-Formulary |
|
DECLOMYCIN |
|
Non-Formulary |
|
DEMECLOCYCLINE HCL |
|
Non-Formulary |
|
DORYX |
|
Non-Formulary |
|
DORYX |
|
Non-Formulary |
|
DOXYCYCLINE |
|
Non-Formulary |
|
DOXYCYCLINE |
|
Non-Formulary |
|
DOXYCYCLINE HYCLATE |
|
Non-Formulary |
|
DOXYCYCLINE MONOHYDRATE |
|
Non-Formulary |
|
DYNACIN |
|
Non-Formulary |
|
MINOCIN |
|
Non-Formulary |
|
MINOCYCLINE HCL |
|
Non-Formulary |
|
MONODOX |
|
Non-Formulary |
|
MYRAC |
|
Non-Formulary |
|
ORACEA |
|
Non-Formulary |
|
SOLODYN |
|
Non-Formulary |
|
VIBRAMYCIN |
|
Non-Formulary |
|
VIBRAMYCIN |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0