ANALGESIC AGENTS
ANALGESICS, NARCOTIC
** Ingredient Cost Per Therapy
Click on notes for additional information
|
|
| Brand/Generic Name |
Dosage/Strength |
Status |
Notes |
Ingredient Cost |
OxyCONTIN
OxyCODONE HCl
|
|
 |
 |
$450-$500 |
Oxyfast
OxyCODONE HCl
|
Conc - 20 mg/ml
|
|
|
$30-$40 |
OxyIR
OxyCODONE HCl
|
|
|
|
$20-$30 |
Roxicodone
OxyCODONE HCl
|
Conc - 20 mg/ml
|
|
|
$10-$20 |
Roxicodone
OxyCODONE HCl
|
Solution - 5 mg/5ml
|
|
|
$10-$20 |
Roxicodone
OxyCODONE HCl
|
Tab - 5 mg
|
|
|
$10-$20 |
Roxicodone
OxyCODONE HCl
|
Tab - 15 mg
|
 |
|
Unknown |
Roxicodone
OxyCODONE HCl
|
Tab - 30 mg
|
|
|
Unknown |
Key for Product(s) Listed Above
(click on symbol for full definition) |
Formulary
(Brand non-formulary if Generic available) |
Prior Authorization Required
(Once approved Brand and Generic, if available, are formulary) |
Non-Formulary
(Brand and Generic, if available, are non-formulary) |
 Not Reimbursed |
Generic Available |
 Notes or Restrictions |
| |
 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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