Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

CellCept mycophenolate mofetil 200 mg/mL Suspension for Reconstitution   Not Applicable CellCept mycophenolate mofetil 250 mg capsule   Not Applicable CellCept mycophenolate mofetil 500 mg tablet   Not Applicable Gengraf cyclosporine modified 25 mg capsule; 100 mg capsule   Not Applicable Hecoria tacrolimus 0.5 mg capsule; 1 mg capsule; 5 mg capsule   Not Applicable Imuran azathioprine 50 mg tablet   $$ Myfortic mycophenolate sodium 180 mg tablet,delayed release (DR/EC); 360 mg tablet,delayed release (DR/EC)   Not Applicable Neoral cyclosporine modified 100 mg capsule; 25 mg capsule   Not Applicable Neoral cyclosporine modified 100 mg/mL Solution   Not Applicable Prograf tacrolimus 0.5 mg capsule; 1 mg capsule; 5 mg capsule   Not Applicable Prograf tacrolimus 5 mg/mL Solution   Not Applicable Rapamune sirolimus 0.5 mg tablet; 2 mg tablet; 1 mg tablet   Not Applicable Rapamune sirolimus 1 mg/mL Solution   Not Applicable Sandimmune cyclosporine 25 mg capsule; 100 mg capsule   Not Applicable Sandimmune cyclosporine 250 mg/5 mL Solution; 100 mg/mL Solution   Not Applicable Zortress everolimus 0.25 mg tablet; 0.5 mg tablet; 0.75 mg tablet   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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