Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Achromycin V tetracycline 250 mg capsule; 500 mg capsule   $ Adoxa doxycycline monohydrate 150 mg capsule   Not Applicable Adoxa doxycycline monohydrate 75 mg tablet; 100 mg tablet; 50 mg tablet   Not Applicable Avidoxy doxycycline monohydrate 100 mg tablet     Not Applicable Cleeravue-M minocycline 50 mg tablet     Not Applicable Cleeravue-M Convenience Kit minocycline-eyelid cleanser #1 Kit     Not Applicable Declomycin demeclocycline 300 mg tablet; 150 mg tablet   Not Applicable Doryx doxycycline hyclate 100 mg tablet,delayed release (DR/EC); 75 mg tablet,delayed release (DR/EC); 150 mg tablet,delayed release (DR/EC)   Not Applicable Dynacin Dynacin   $$ Dynacin minocycline 100 mg capsule; 50 mg capsule; 75 mg capsule; 75 mg capsule; 100 mg capsule   $$ Dynacin minocycline 75 mg tablet; 75 mg tablet; 100 mg tablet; 100 mg tablet; 50 mg tablet   Not Applicable Minocin minocycline 50 mg capsule; 100 mg capsule   $$ Monodox doxycycline monohydrate 100 mg capsule   $$ Monodox doxycycline monohydrate 50 mg capsule   $$ Monodox doxycycline monohydrate 75 mg capsule   Not Applicable Oracea doxycycline monohydrate 40 mg capsule, ER multiphase 24 hr   Not Applicable Oraxyl doxycycline hyclate capsule     Not Applicable Periostat doxycycline hyclate 20 mg tablet; 20 mg tablet   $ Periostat doxycycline hyclate 20 mg tablet; 20 mg tablet   Not Applicable Solodyn minocycline 45 mg tablet extended release 24 hr; 90 mg tablet extended release 24 hr; 135 mg tablet extended release 24 hr; 65 mg tablet extended release 24 hr; 115 mg tablet extended release 24 hr; 55 mg tablet extended release 24 hr; 80 mg tablet extended release 24 hr; 105 mg tablet extended release 24 hr   Not Applicable Tetracycline HCl Tetracycline HCl Tab   Not Applicable Vibra-Tabs doxycycline hyclate 100 mg tablet   $ Vibramycin doxycycline hyclate 100 mg capsule; 50 mg capsule   $ Vibramycin doxycycline monohydrate 25 mg/5 mL Suspension for Reconstitution   $ Vibramycin doxycycline calcium 50 mg/5 mL Syrup   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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