Miscellaneous Gastrointestinal Drugs
| Brand/Generic Name |
Dosage/Strength |
Status |
Restrictions |
Notes |
Relative Cost |
Apriso
mesalamine |
capsule,extended release 24hr |
 |
|
|
$$$$ |
Asacol
mesalamine |
tablet,delayed release (DR/EC) |
|
|
|
$$$$ |
Asacol HD
mesalamine |
800 mg tablet,delayed release (DR/EC) |
|
|
|
$$$$ |
Canasa
mesalamine |
Suppository |
|
|
|
$$$$$ |
Delzicol
mesalamine |
400 mg capsule |
|
|
|
Not Applicable |
Lialda
mesalamine |
1.2 g tablet,delayed release (DR/EC) |
 |
|
|
Not Applicable |
Pentasa
mesalamine |
capsule, extended release |
|
|
|
Not Applicable |
Rowasa
mesalamine |
Enema |
|
|
|
$$$$$ |
|
| 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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