$ |
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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IMMUNOLOGICALS AND VACCINES
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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ACTHIB (haemophilus b-tet toxoid) |
|
|
|
AFLURIA (influenza virus trivalent) |
|
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|
APLISOL (tuberculin,ppd) |
|
|
|
ATGAM (lymphocyte immune globulin) |
|
|
|
ATTENUVAX VACCINE WITH DILUENT (measles vaccine,atten) |
|
|
|
candin (mold extracts) |
|
|
|
CROFAB (antivenin, crotalidae) |
|
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|
CYTOGAM (cytomegalovirus immune glob) |
|
|
|
ENGERIX-B (hepatitis b virus vaccine) |
|
|
|
FLUARIX (influenza virus trivalent) |
|
|
|
FLULAVAL (influenza virus trivalent) |
|
|
|
FLUVIRIN (influenza virus trivalent) |
|
|
|
FLUZONE (influenza virus trivalent) |
|
|
|
GAMASTAN S-D (immune globulin - im) |
|
|
|
GAMMAGARD S-D (immune globulin - iv) |
|
|
|
HAVRIX (hepatatis a virus vaccine) |
|
|
|
HIBTITER (haemophilus b vaccine) |
|
|
|
HONEY BEE VENOM TREATMENT KIT (hymenoptera allergenic extract) |
|
|
|
HYPERHEP B S-D (hepatitis b immune globulin) |
inj |
|
|
HYPERRAB S-D (rabies immune globulin) |
|
|
|
HYPERRHO S-D (rho(d) immune globulin) |
|
|
|
HYPERTET S-D (tetanus immune globulin) |
|
|
|
IMOGAM RABIES-HT (rabies immune globulin) |
|
|
|
IMOVAX RABIES VACCINE (rabies vaccine,human diploid) |
|
|
|
INFANRIX (diphther,pertuss,tetanus vac) |
|
|
|
IPOL (poliomyelitis vac,killed) |
|
|
|
JE-VAX (japanese encephalitis vaccine) |
|
|
|
M-M-R II VACCINE (measles,mumps&rubella vaccine) |
|
|
|
MENOMUNE-A-C-Y-W-135 (meningococcal vac a,c,y,w-135) |
|
|
|
MERUVAX II VACCINE W-DILUENT (rubella vaccine) |
|
|
|
MIXED VESPID VENOM PROTEIN (hymenoptera allergenic extract) |
|
|
|
MUMPSVAX VACCINE W-DILUENT (mumps vaccine,live) |
|
|
|
PEDVAXHIB (haemophilus b vaccine) |
|
|
|
PNEUMOVAX 23 (pneumococcal vaccine) |
|
|
|
RABAVERT (rabies vac,pf chick-emb cell) |
|
|
|
RECOMBIVAX HB (hepatitis b virus vaccine) |
|
|
|
RHOGAM PLUS (rho(d) immune globulin) |
|
|
|
SYNAGIS (palivizumab) |
|
|
|
TE ANATOXAL BERNA (tetanus toxoid,adsorbed) |
|
|
|
tetanus toxoid adsorbed (tetanus toxoid,adsorbed) |
|
|
|
THYMOGLOBULIN (lymphocyte immune globulin) |
|
|
|
TICE BCG (bcg vaccine) |
|
|
|
TUBERSOL (tuberculin,ppd) |
|
|
|
TYPHIM VI (typhoid vaccine) |
|
|
|
VARIVAX VACCINE (varicella virus vaccine live) |
|
|
|
WASP VENOM PROTEIN (hymenoptera allergenic extract) |
|
|
|
YELLOW JACKET VENOM PROTEIN (hymenoptera allergenic extract) |
|
|
|
YF-VAX (yellow fever vaccine) |
|
$ |
|
MICRHOGAM (rho(d) immune globulin) |
|
$ |
|
RHOGAM (rho(d) immune globulin) |
|
$ |
|
VIVOTIF BERNA (typhoid vaccine) |
|
$$ |
|
NABI-HB (hepatitis b immune globulin) |
|
$$$$ |
|
WINRHO SDF (rho(d) immune globulin) |
|
$$$$$ |
|
CARIMUNE NF NANOFILTERED (immune globulin - iv) |
6000 mg inj |
Non-Formulary |
|
CARIMUNE NF NANOFILTERED |
|
Non-Formulary |
|
FLEBOGAMMA |
|
Non-Formulary |
|
FLUMIST |
|
Non-Formulary |
|
GAMUNEX |
|
Non-Formulary |
|
HYPERHEP B S-D |
|
Non-Formulary |
|
PRIVIGEN |
|
Non-Formulary |
|
RHOPHYLAC |
|
Non-Formulary |
|
ROTARIX |
|
Non-Formulary |
|
ROTATEQ |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0