Blood Modifiers and Electrolytes
Miscellaneous Blood Modifiers

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Anemagen generic.gif (400 bytes)
Iron Combinations		   notreimb.gif (545 bytes)  

Not Applicable
folic acid generic.gif (400 bytes)
folic acid		 1 mg tablet; 400 mcg tablet   approved.gif (510 bytes)  

$
folic acid generic.gif (400 bytes)
folic acid		 20 mg capsule   approved.gif (510 bytes)  

$
Orfadin
nitisinone		 10 mg capsule   nonform.gif (625 bytes)

mo.gif sp.gif (377 bytes)

NOTES_restrict.gif (377 bytes)

Not Applicable
Orfadin
nitisinone		 2 mg capsule   nonform.gif (625 bytes)

mo.gif sp.gif (377 bytes)

NOTES_restrict.gif (377 bytes)

Not Applicable
Orfadin
nitisinone		 5 mg capsule   nonform.gif (625 bytes)

mo.gif sp.gif (377 bytes)

NOTES_restrict.gif (377 bytes)

Not Applicable
Trental generic.gif (400 bytes)
pentoxifylline		 400 mg tablet extended release   approved.gif (510 bytes)  

$$$
ZAVESCA
miglustat		 100 mg capsule   nonform.gif (625 bytes)

priorauth.gif (377 bytes) ql.gif mo.gif sp.gif (377 bytes)

NOTES_restrict.gif (377 bytes)

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)

© 2002 Managed Markets Insight and Technology, LLC. All Rights Reserved