Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Abstral fentanyl citrate 100 mcg tablet, sublingual; 200 mcg tablet, sublingual; 300 mcg tablet, sublingual; 400 mcg tablet, sublingual; 600 mcg tablet, sublingual; 800 mcg tablet, sublingual   Not Applicable acetaminophen-codeine acetaminophen-codeine 300-15 mg tablet   $ Actiq fentanyl citrate 400 mcg Lozenge on a Handle; 200 mcg Lozenge on a Handle; 1,200 mcg Lozenge on a Handle; 1,600 mcg Lozenge on a Handle; 600 mcg Lozenge on a Handle; 800 mcg Lozenge on a Handle   $$$$$+ Avinza morphine 45 mg capsule, ER multiphase 24 hr; 75 mg capsule, ER multiphase 24 hr; 30 mg capsule, ER multiphase 24 hr; 60 mg capsule, ER multiphase 24 hr; 90 mg capsule, ER multiphase 24 hr; 120 mg capsule, ER multiphase 24 hr   Not Applicable B & O 15-A Supprette belladonna alkaloids-opium 16.2-30 mg Suppository   Not Applicable B & O 16-A Supprette belladonna alkaloids-opium 16.2-60 mg Suppository   Not Applicable Butrans buprenorphine 5 mcg/hour Patch Weekly; 10 mcg/hour Patch Weekly; 20 mcg/hour Patch Weekly   $$$$$ codeine sulfate codeine sulfate 30 mg tablet; 60 mg tablet; 15 mg tablet   $$ codeine sulfate codeine sulfate 30 mg/5 mL Solution   $$ Combunox ibuprofen-oxycodone 400-5 mg tablet   Not Applicable ConZip tramadol 100 mg capsule, ER mphase 24 hr 25-75   Not Applicable Dazidox oxycodone 10 mg tablet; 20 mg tablet   Not Applicable Demerol meperidine 100 mg tablet; 50 mg tablet   $$$$ Demerol meperidine 50 mg/5 mL Solution; 50 mg/mL Solution; 100 mg/mL Solution   $$$$ Dilaudid hydromorphone 2 mg tablet; 8 mg tablet; 4 mg tablet   $$$$ Dilaudid hydromorphone 2 mg/mL Solution   $$$$ Dilaudid hydromorphone 3 mg Suppository   $$$$ Dilaudid-5 hydromorphone 1 mg/mL Liquid   Not Applicable Dolophine methadone 5 mg tablet; 10 mg tablet   $ Duragesic fentanyl 12 mcg/hr Patch 72 hr; 25 mcg/hr Patch 72 hr; 100 mcg/hr Patch 72 hr; 50 mcg/hr Patch 72 hr; 75 mcg/hr Patch 72 hr   $$$$$ Embeda morphine-naltrexone 20-0.8 mg capsule,extend.release pellets; 30-1.2 mg capsule,extend.release pellets; 50-2 mg capsule,extend.release pellets; 60-2.4 mg capsule,extend.release pellets; 80-3.2 mg capsule,extend.release pellets; 100-4 mg capsule,extend.release pellets   Not Applicable Equagesic meprobamate-aspirin 200-325 mg tablet   Not Applicable Exalgo ER hydromorphone 32 mg tablet extended release 24hr; 8 mg tablet extended release 24hr; 12 mg tablet extended release 24hr; 16 mg tablet extended release 24hr   Not Applicable Fentora fentanyl citrate 300 mcg tablet, effervescent; 800 mcg tablet, effervescent; 600 mcg tablet, effervescent; 400 mcg tablet, effervescent; 200 mcg tablet, effervescent; 100 mcg tablet, effervescent   Not Applicable Fiorinal-Codeine #3 codeine-butalbital-ASA-caff 30-50-325-40 mg capsule   $$ Kadian morphine 10 mg capsule,extend.release pellets; 200 mg capsule,extend.release pellets; 80 mg capsule,extend.release pellets; 30 mg capsule,extend.release pellets; 20 mg capsule,extend.release pellets; 50 mg capsule,extend.release pellets; 100 mg capsule,extend.release pellets; 60 mg capsule,extend.release pellets   $$$ Lazanda fentanyl citrate 100 mcg/spray Spray, Non-Aerosol; 400 mcg/spray Spray, Non-Aerosol   Not Applicable Levo-Dromoran levorphanol tartrate 2 mg tablet   Not Applicable Lortab hydrocodone-acetaminophen 7.5-500 mg tablet; 2.5-500 mg tablet; 5-500 mg tablet; 10-500 mg tablet; 7.5-500 mg tablet   $ meperidine-promethazine meperidine-promethazine 50-25 mg capsule   Not Applicable Meprozine meperidine-promethazine capsule     Not Applicable MS Contin morphine 100 mg tablet extended release; 30 mg tablet extended release; 60 mg tablet extended release; 200 mg tablet extended release; 15 mg tablet extended release   $$$$ MSIR morphine 15 mg tablet   $ MSIR morphine 10 mg/5 mL Solution   $$ Nucynta tapentadol 50 mg tablet; 75 mg tablet; 100 mg tablet   Not Applicable Nucynta ER tapentadol 50 mg tablet extended release 12 hr; 100 mg tablet extended release 12 hr; 150 mg tablet extended release 12 hr; 200 mg tablet extended release 12 hr; 250 mg tablet extended release 12 hr   Not Applicable Onsolis fentanyl citrate 200 mcg Film; 400 mcg Film; 600 mcg Film; 800 mcg Film; 1,200 mcg Film   Not Applicable Opana oxymorphone 5 mg tablet; 10 mg tablet   Not Applicable Opana ER oxymorphone 7.5 mg tablet extended release 12 hr; 15 mg tablet extended release 12 hr; 30 mg tablet extended release 12 hr; 20 mg tablet extended release 12 hr; 10 mg tablet extended release 12 hr; 40 mg tablet extended release 12 hr; 5 mg tablet extended release 12 hr   $$$ Oramorph SR morphine 100 mg tablet extended release; 15 mg tablet extended release; 60 mg tablet extended release; 30 mg tablet extended release   $$$$ Oxecta oxycodone 5 mg tablet, oral only; 7.5 mg tablet, oral only   $$$$ OxyContin oxycodone 15 mg tablet extended release 12 hr; 30 mg tablet extended release 12 hr; 60 mg tablet extended release 12 hr; 10 mg tablet extended release 12 hr; 80 mg tablet extended release 12 hr; 160 mg tablet extended release 12 hr; 40 mg tablet extended release 12 hr; 20 mg tablet extended release 12 hr   $$$$$+ Oxyfast oxycodone 20 mg/mL Concentrate   $$$$$ OxyIR oxycodone 5 mg capsule   $$$$ Panlor DC dihydrocode-acetaminophen-caff 16-356.4-30 mg capsule   Not Applicable Panlor SS dihydrocode-acetaminophen-caff 32-712.8-60 mg tablet   Not Applicable paregoric paregoric 2 mg/5 mL Liquid   Not Applicable Percocet oxycodone-acetaminophen 2.5-325 mg tablet; 7.5-500 mg tablet; 7.5-325 mg tablet; 10-650 mg tablet; 5-325 mg tablet; 10-325 mg tablet   $$ Percodan oxycodone HCl-oxycodone-ASA 4.5-0.38-325 mg tablet; 4.8355-325 mg tablet   $$ Percodan oxycodone-aspirin 4.5-0.38-325 mg tablet; 4.8355-325 mg tablet   $$ Primalev oxycodone-acetaminophen tablet     Not Applicable Primlev oxycodone-acetaminophen 7.5-300 mg tablet; 5-300 mg tablet; 10-300 mg tablet     Not Applicable RMS morphine 30 mg Suppository; 20 mg Suppository; 5 mg Suppository; 10 mg Suppository   $$$$$ Rybix ODT tramadol tablet,disintegrating     Not Applicable Stadol NS butorphanol tartrate 10 mg/mL Spray, Non-Aerosol   Not Applicable Suboxone buprenorphine-naloxone 2-0.5 mg Film   Not Applicable Suboxone buprenorphine-naloxone 8-2 mg Film   Not Applicable Suboxone buprenorphine-naloxone 2-0.5 mg tablet, sublingual; 8-2 mg tablet, sublingual   Not Applicable Subsys fentanyl 1,200 mcg (600 mcg/spray X 2) Spray, Non-Aerosol; 1,600 mcg (800 mcg/spray X 2) Spray, Non-Aerosol; 100 mcg/spray Spray, Non-Aerosol; 200 mcg/spray Spray, Non-Aerosol; 400 mcg/spray Spray, Non-Aerosol; 600 mcg/spray Spray, Non-Aerosol; 800 mcg/spray Spray, Non-Aerosol   $$$$$+ Subutex buprenorphine 2 mg tablet, sublingual; 8 mg tablet, sublingual   Not Applicable Synalgos-DC dihydrocodeine-aspirin-caff 16-356.4-30 mg capsule   Not Applicable Talwin NX pentazocine-naloxone 50-0.5 mg tablet   Not Applicable TraMADol HCl TraMADol HCl Capsule SR 24 HR - 150mg   Not Applicable Tylenol-Codeine #3 acetaminophen-codeine 300-30 mg tablet   $ Tylenol-Codeine #4 acetaminophen-codeine 300-60 mg tablet   $ Tylox oxycodone-acetaminophen 5-500 mg capsule   $$ Ultracet tramadol-acetaminophen 37.5-325 mg tablet   $$ Ultram tramadol 50 mg tablet     $$ Ultram ER tramadol 100 mg tablet extended release 24 hr; 200 mg tablet extended release 24 hr; 300 mg tablet extended release 24 hr   Not Applicable Vicodin hydrocodone-acetaminophen 5-500 mg tablet   $ Vicodin ES hydrocodone-acetaminophen 7.5-300 mg tablet; 7.5-750 mg tablet   $$ Vicodin HP hydrocodone-acetaminophen 10-300 mg tablet; 10-660 mg tablet   $$ Vicoprofen hydrocodone-ibuprofen 7.5-200 mg tablet   Not Applicable Xodol 10/300 hydrocodone-acetaminophen 10-300 mg tablet   $$ Xodol 5/300 hydrocodone-acetaminophen 5-300 mg tablet   $ Xodol 7.5/300 hydrocodone-acetaminophen 7.5-300 mg tablet   $$ Zamicet hydrocodone-acetaminophen Solution     Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

© 2002 Managed Markets Insight and Technology, LLC. All Rights Reserved