Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Ancobon flucytosine 250 mg capsule; 500 mg capsule   Not Applicable Diflucan fluconazole 150 mg tablet   $$ Diflucan fluconazole 200 mg tablet; 50 mg tablet; 100 mg tablet   $$ Diflucan fluconazole 40 mg/mL Suspension for Reconstitution; 10 mg/mL Suspension for Reconstitution   $$ Fulvicin P/G Griseofulvin Ultramicrosize   $$ Fulvicin U/F griseofulvin microsize 125 mg/5 mL Suspension   $$ Gris-PEG griseofulvin ultramicrosize 125 mg tablet; 250 mg tablet   $$ Grisactin Ultra Griseofulvin Ultramicrosize   $$ Lamisil terbinafine 250 mg tablet   $$ Lamisil terbinafine 125 mg Granules in Packet; 187.5 mg Granules in Packet   Not Applicable Mycostatin nystatin 100,000 unit/mL Suspension   $ Mycostatin nystatin 500,000 unit tablet   $ Noxafil posaconazole 200 mg/5 mL (40 mg/mL) Suspension   Not Applicable Onmel itraconazole 200 mg tablet   Not Applicable Oravig miconazole 50 mg muco-adhesive buccal tablet   Not Applicable Sporanox itraconazole 10 mg/mL Solution   $$$$$ Sporanox itraconazole 100 mg capsule   $$$$$ Terbinex terbinafine-hydroxy chitosan 250-1 mg-% Kit     Not Applicable Vfend voriconazole 200 mg/5 mL (40 mg/mL) Suspension for Reconstitution   $$$$$+ Vfend voriconazole 50 mg tablet; 200 mg tablet   $$$$$+

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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