Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Flumadine rimantadine 100 mg tablet   $$ Flumadine rimantadine 50 mg/5 mL Syrup   $$ Relenza Diskhaler zanamivir 5 mg/actuation Disk with Device   Not Applicable Tamiflu oseltamivir 12 mg/mL Suspension for Reconstitution; 6 mg/mL Suspension for Reconstitution   Not Applicable Tamiflu oseltamivir 75 mg capsule; 30 mg capsule; 45 mg capsule   Not Applicable

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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