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RESPIRATORY, ALLERGY, COUGH & COLD THERAPY
ANTITUSSIVE COMBINATIONS
** Ingredient Cost Per Therapy

 Click on notes for additional information

Brand/Generic Name Dosage/Strength Status Notes Ingredient Cost
Phenergan VC/Codeine generic.gif (400 bytes)
Phenyleph-Promethazine-Cod 		  approved.gif (510 bytes) NOTES.gif (377 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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