$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
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CLASS II NARCOTICS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
ASTRAMORPH-PF (morphine) |
|
|
|
DILAUDID-HP (hydromorphone) |
|
|
|
DURAMORPH (morphine) |
|
|
|
fentanyl with droperidol (fentanyl citrate/droperidol) |
|
|
|
INFUMORPH (morphine) |
|
|
|
LEVO-DROMORAN (levorphanol) |
inj |
|
|
sublimaze (fentanyl citrate) |
|
$ |
|
DOLOPHINE HCL (methadone) |
|
$ |
|
meperidine hcl (meperidine) |
|
$ |
|
methadone hcl (methadone) |
inj |
$ |
|
methadone hcl (methadone) |
soln |
$ |
|
methadone hcl (methadone) |
5 mg tab |
$ |
|
methadone hcl (methadone) |
10 mg tab |
$ |
|
methadose (methadone) |
soln |
$ |
|
methadose (methadone) |
5 mg tab |
$ |
|
methadose (methadone) |
10 mg tab |
$ |
|
oxycodone-acetaminophen (oxycodone/acetaminophen) |
cap |
$ |
|
oxycodone-acetaminophen (oxycodone/acetaminophen) |
5 mg tab |
$ |
|
ROXICET (oxycodone/acetaminophen) |
soln |
$ |
|
ROXICET (oxycodone/acetaminophen) |
500 mg tab |
$ |
|
roxicet (oxycodone/acetaminophen) |
5 mg tab |
$$ |
|
codeine sulfate (codeine sulfate) |
|
$$ |
|
DEMEROL (meperidine) |
|
$$ |
|
endocet (oxycodone/acetaminophen) |
5 mg tab |
$$ |
|
hydromorphone hcl (hydromorphone) |
|
$$ |
|
meperitab (meperidine) |
|
$$ |
|
morphine sulfate (morphine) |
inj |
$$ |
|
morphine sulfate (morphine) |
rectal |
$$ |
|
morphine sulfate (morphine) |
soln |
$$ |
|
morphine sulfate (morphine) |
tab |
$$ |
|
morphine sulfate (morphine) |
15 mg tab sa |
$$ |
|
morphine sulfate (morphine) |
30 mg tab sa |
$$ |
|
morphine sulfate (morphine) |
60 mg tab sa |
$$ |
|
morphine sulfate (morphine) |
100 mg tab sa |
$$ |
|
morphine sulfate (morphine) |
200 mg tab sa |
$$ |
|
morphine sulfate (morphine) |
tab |
$$ |
|
morphine sulfate (morphine) |
soluble |
$$ |
|
PERCOCET (oxycodone/acetaminophen) |
5 mg tab |
$$ |
|
TYLOX (oxycodone/acetaminophen) |
|
$$$ |
|
codeine phosphate (codeine phosphate) |
|
$$$ |
|
DILAUDID-5 (hydromorphone) |
|
$$$ |
|
endodan (oxycodone/aspirin) |
|
$$$ |
|
methadone intensol (methadone) |
|
$$$ |
|
oxycodone-aspirin (oxycodone/aspirin) |
|
$$$ |
|
ROXANOL (morphine) |
|
$$$$ |
|
DILAUDID (hydromorphone) |
|
$$$$ |
|
eth-oxydose (oxycodone) |
|
$$$$ |
|
MS CONTIN (morphine) |
|
$$$$ |
|
OPIUM (opium) |
|
$$$$ |
|
PERCODAN (oxycodone/aspirin) |
|
$$$$ |
|
ROXICODONE (oxycodone) |
|
$$$$$ |
|
ACTIQ (fentanyl citrate) |
|
$$$$$ |
|
DURAGESIC (fentanyl) |
adh. patch |
$$$$$ |
|
fentanyl (fentanyl) |
|
$$$$$ |
|
fentanyl citrate (fentanyl citrate) |
|
$$$$$ |
|
MAGNACET (oxycodone/acetaminophen) |
5 mg tab |
$$$$$ |
|
oxycodone hcl (oxycodone) |
cap |
$$$$$ |
|
oxycodone hcl (oxycodone) |
soln |
$$$$$ |
|
oxycodone hcl (oxycodone) |
5 mg tab |
$$$$$ |
|
oxycodone hcl (oxycodone) |
15 mg tab |
$$$$$ |
|
oxycodone hcl (oxycodone) |
30 mg tab |
$$$$$ |
|
oxycodone hcl (oxycodone) |
tab sa |
$$$$$ |
|
OXYCONTIN (oxycodone) |
|
$$$$$ |
|
ROXICODONE INTENSOL (oxycodone) |
|
Non-Formulary |
|
ALCET |
|
Non-Formulary |
|
AVINZA |
|
Non-Formulary |
|
B & O SUPPRETTES NO.15-A |
|
Non-Formulary |
|
B & O SUPPRETTES NO.16-A |
|
Non-Formulary |
|
BELLADONNA-OPIUM |
|
Non-Formulary |
|
COMBUNOX |
|
Non-Formulary |
|
DAZIDOX |
|
Non-Formulary |
|
DURAGESIC |
|
Non-Formulary |
|
ENDOCET |
|
Non-Formulary |
|
FENTORA |
|
Non-Formulary |
|
KADIAN |
|
Non-Formulary |
|
LEVO-DROMORAN |
|
Non-Formulary |
|
LEVORPHANOL TARTRATE |
|
Non-Formulary |
|
MAGNACET |
|
Non-Formulary |
|
MEPROZINE |
|
Non-Formulary |
|
METHADONE HCL |
|
Non-Formulary |
|
METHADOSE |
|
Non-Formulary |
|
MORPHINE SULFATE |
|
Non-Formulary |
|
OPANA |
|
Non-Formulary |
|
OPANA ER |
|
Non-Formulary |
|
ORAMORPH SR |
|
Non-Formulary |
|
OXYCODONE HCL |
|
Non-Formulary |
|
OXYCODONE HCL-ACETAMINOPHEN |
|
Non-Formulary |
|
OXYCODONE HCL-IBUPROFEN |
|
Non-Formulary |
|
OXYCODONE-ACETAMINOPHEN |
|
Non-Formulary |
|
OXYIR |
|
Non-Formulary |
|
PERCOCET |
|
Non-Formulary |
|
PRIMALEV |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0