$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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CALCIUM ANTAGONISTS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
CARDENE I.V. (nicardipine) |
|
$ |
|
CALAN (verapamil) |
|
$ |
|
diltiazem hcl (diltiazem) |
|
$ |
|
nicardipine hcl (nicardipine) |
|
$$ |
|
afeditab cr (nifedipine) |
|
$$ |
|
amlodipine besylate (amlodipine) |
|
$$ |
|
CALAN SR (verapamil) |
|
$$ |
|
CARDIZEM (diltiazem) |
|
$$ |
|
cartia xt (diltiazem) |
|
$$ |
|
DILACOR XR (diltiazem) |
|
$$ |
|
dilt-xr (diltiazem) |
|
$$ |
|
diltia xt (diltiazem) |
|
$$ |
|
diltiazem er (diltiazem) |
|
$$ |
|
ISOPTIN SR (verapamil) |
|
$$ |
|
nifediac cc (nifedipine) |
|
$$ |
|
nifedical xl (nifedipine) |
|
$$ |
|
NORVASC (amlodipine) |
|
$$ |
|
taztia xt (diltiazem) |
|
$$ |
|
verapamil hcl (verapamil) |
|
$$$ |
|
ADALAT CC (nifedipine) |
|
$$$ |
|
dilt-cd (diltiazem) |
|
$$$ |
|
felodipine er (felodipine) |
|
$$$ |
|
nifedipine (nifedipine) |
|
$$$ |
|
nifedipine er (nifedipine) |
|
$$$ |
|
PLENDIL (felodipine) |
|
$$$ |
|
PROCARDIA (nifedipine) |
|
$$$ |
|
PROCARDIA XL (nifedipine) |
|
$$$ |
|
TIAZAC (diltiazem) |
|
$$$$$ |
|
nimodipine (nimodipine) |
|
$$$$$ |
|
NIMOTOP (PAR) (nimodipine) |
|
Non-Formulary |
|
CARDENE SR |
|
Non-Formulary |
|
CARDIZEM CD |
|
Non-Formulary |
|
CARDIZEM LA |
|
Non-Formulary |
|
COVERA-HS |
|
Non-Formulary |
|
DYNACIRC CR |
|
Non-Formulary |
|
ISRADIPINE |
|
Non-Formulary |
|
NISOLDIPINE |
|
Non-Formulary |
|
SULAR |
|
Non-Formulary |
|
VERAPAMIL ER |
|
Non-Formulary |
|
VERELAN |
|
Non-Formulary |
|
VERELAN PM |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0