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ANALGESIC AGENTS
ANALGESIC AND NARCOTIC COMBINATIONS
** Ingredient Cost Per Therapy

 Click on notes for additional information
Brand/Generic Name Dosage/Strength Status Notes Ingredient Cost
Aspirin-Codeine generic.gif (400 bytes)
Aspirin-Codeine 		  approved.gif (510 bytes)

NOTES.gif (377 bytes)

 $20-$30
Combunox generic.gif (400 bytes)
Oxycodone-Ibuprofen 		  nonform.gif (625 bytes)   Unknown
Esgic
Butalbital-APAP-Caffeine 		  nonform.gif (625 bytes)   Unknown
Fioricet generic.gif (400 bytes)
Butalbital-APAP-Caffeine 		  approved.gif (510 bytes)   $30-$40
Fiorinal generic.gif (400 bytes)
Butalbital-Aspirin-Caffeine 		  approved.gif (510 bytes)   $30-$40
Fiorinal/Codeine #3
Butalbital-ASA-Caff-Codeine 		  nonform.gif (625 bytes)   Unknown
Hycet
Hydrocodone-Acetaminophen 		  nonform.gif (625 bytes)   Unknown
Norco generic.gif (400 bytes)
Hydrocodone-Acetaminophen 		  approved.gif (510 bytes)   $30-$40
Percocet generic.gif (400 bytes)
Oxycodone-Acetaminophen 		Tab - 5-325 mg   approved.gif (510 bytes)   $10-$20
Percocet generic.gif (400 bytes)
Oxycodone-Acetaminophen 		Tab - 10-650 mg   nonform.gif (625 bytes)   Unknown
Percocet generic.gif (400 bytes)
Oxycodone-Acetaminophen 		Tab - 2.5-325 mg   nonform.gif (625 bytes)   Unknown
Percocet generic.gif (400 bytes)
Oxycodone-Acetaminophen 		Tab - 7.5-500 mg   nonform.gif (625 bytes)   Unknown
Percodan generic.gif (400 bytes)
Oxycodone-Aspirin 		  approved.gif (510 bytes)   $20-$30
Phrenilin generic.gif (400 bytes)
Butalbital-Acetaminophen 		  approved.gif (510 bytes)   $10-$20
Phrenilin Forte generic.gif (400 bytes)
Butalbital-Acetaminophen 		  approved.gif (510 bytes)   $10-$20
Roxicet generic.gif (400 bytes)
Oxycodone-Acetaminophen 		Tab - 5-325 mg   approved.gif (510 bytes)   $10-$20
Synalgos-DC
Dihydrocodeine Compound 		  nonform.gif (625 bytes)   Unknown
Tylenol with Codeine #3 generic.gif (400 bytes)
Acetaminophen-Codeine 		  approved.gif (510 bytes)

NOTES.gif (377 bytes)

 $20-$30
Tylenol with Codeine #4 generic.gif (400 bytes)
Acetaminophen-Codeine 		  approved.gif (510 bytes)

NOTES.gif (377 bytes)

 $20-$30
Tylenol/Codeine
Acetaminophen-Codeine 		Elixir   approved.gif (510 bytes)

NOTES.gif (377 bytes)

 Unknown
Tylenol/Codeine #2 generic.gif (400 bytes)
Acetaminophen-Codeine 		  approved.gif (510 bytes)

NOTES.gif (377 bytes)

 $20-$30
Tylox generic.gif (400 bytes)
Oxycodone-Acetaminophen 		  approved.gif (510 bytes)   $30-$40
Vicodin generic.gif (400 bytes)
Hydrocodone-Acetaminophen 		  approved.gif (510 bytes)   $10-$20
Vicoprofen
Hydrocodone-Ibuprofen 		  nonform.gif (625 bytes)   Unknown

Key for Product(s) Listed Above
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Formulary

(Brand non-formulary if Generic available)		 Click here for an explanation of these icons. 
Prior Authorization Required

(Once approved Brand and Generic, if available, are formulary)		 Click here for an explanation of these icons.
Non-Formulary

(Brand and Generic, if available, are non-formulary)
Click here for an explanation of these icons. Not Reimbursed Click here for an explanation of these icons. Generic Available Additional notes exist for this drug.Additional restrictions exist for this drug.Notes or Restrictions
  Click here for an explanation of these icons. Brand and Generic are Formulary  

Disclaimer: This is not a comprehensive list of all products covered on the formulary. Formulary status, ingredient cost, and/or copay may vary subject to availability of newly approved dosage forms and/or strengths.
If you have additional questions regarding your prescription drug benefit, please contact Member Services.

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