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ANALGESIC AGENTS
ANALGESICS, MISCELLANEOUS
** Ingredient Cost Per Therapy

 Click on notes for additional information
Brand/Generic Name Dosage/Strength Status Notes Ingredient Cost
Darvocet-N 100 generic.gif (400 bytes)
Propoxyphene N-APAP 		  approved.gif (510 bytes)   $10-$20
Darvocet-N 50 generic.gif (400 bytes)
Propoxyphene N-APAP 		  approved.gif (510 bytes)   $10-$20
Darvon generic.gif (400 bytes)
Propoxyphene HCl 		  approved.gif (510 bytes)   $20-$30
Darvon Compound
Propoxyphene Compound 		  nonform.gif (625 bytes)   Unknown
Stadol NS
Butorphanol Tartrate 		  nonform.gif (625 bytes)

NOTES.gif (377 bytes)

 Unknown
Talacen
Pentazocine-APAP 		  nonform.gif (625 bytes)   Unknown
Talwin NX
Pentazocine-Naloxone 		  nonform.gif (625 bytes)   Unknown
Tramadol ER
Tramadol HCl Extended Release 		  nonform.gif (625 bytes)   Unknown
Ultracet
Tramadol-Acetaminophen 		  nonform.gif (625 bytes)   Unknown
Ultram generic.gif (400 bytes)
TraMADol HCl 		  approved.gif (510 bytes)   $10-$20
Ultram ODT
Tramadol HCl 		  nonform.gif (625 bytes)   Unknown
Wygesic generic.gif (400 bytes)
Propoxyphene-APAP 		  approved.gif (510 bytes)   $10-$20

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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