Anti-Infectives
Antimycobacterial

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
isoniazid generic.gif (400 bytes)
isoniazid		 300 mg tablet; 100 mg tablet   approved.gif (510 bytes)

mo.gif

$
isoniazid generic.gif (400 bytes)
isoniazid		 50 mg/5 mL Syrup   approved.gif (510 bytes)

mo.gif

$
Myambutol generic.gif (400 bytes)
ethambutol		 100 mg tablet; 400 mg tablet   approved.gif (510 bytes)

mo.gif

$
Mycobutin
rifabutin		 150 mg capsule   approved.gif (510 bytes)

mo.gif

$$$$$
pyrazinamide generic.gif (400 bytes)
pyrazinamide		 500 mg tablet   approved.gif (510 bytes)

mo.gif

$
Rifadin generic.gif (400 bytes)
rifampin		 150 mg capsule; 300 mg capsule   approved.gif (510 bytes)

mo.gif

$$$$$
Rifadin generic.gif (400 bytes)
rifampin		 600 mg Recon Soln   approved.gif (510 bytes)

mo.gif

$$$$$

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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