$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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ORAL ANTIFUNGAL DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
$ |
|
DIFLUCAN (PAR) (QL = 1) (fluconazole) |
|
$ |
|
fluconazole (fluconazole) |
|
$ |
|
ketoconazole (ketoconazole) |
|
$ |
|
nystatin (nystatin) |
oral susp |
$ |
|
nystatin (nystatin) |
tab |
$$ |
|
clotrimazole (clotrimazole) |
|
$$ |
|
terbinafine hcl (terbinafine) |
|
$$$ |
|
GRIFULVIN V (griseofulvin microsize) |
|
$$$ |
|
griseofulvin (griseofulvin microsize) |
|
$$$$ |
|
GRIS-PEG (griseofulvin ultramicrosize) |
|
$$$$$ |
|
itraconazole (itraconazole) |
|
$$$$$ |
|
VFEND (PAR) (voriconazole) |
|
Non-Formulary |
|
ANCOBON |
|
Non-Formulary |
|
LAMISIL |
|
Non-Formulary |
|
NOXAFIL |
|
Non-Formulary |
|
NYSTATIN |
|
Non-Formulary |
|
SPORANOX (PAR) |
|
Non-Formulary |
|
TERBINEX |
|
Formulary Date: 10/21/2009 Update Date: 10/26/2009 V1.3.0