Respiratory Agents
Antitussives

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Hycodan generic.gif (400 bytes)
hydrocodone-homatropine		 5-1.5 mg tablet   approved.gif (510 bytes)  

$$
Hycodan generic.gif (400 bytes)
hydrocodone-homatropine		 5-1.5 mg/5 mL Syrup   approved.gif (510 bytes)  

$$
Respi-Tann
pseudoeph-carbetapent tannates		 Suspension   nonform.gif (625 bytes)  

Not Applicable
Respi-Tann
pseudoeph-carbetapent tannates		 tablet, chewable   nonform.gif (625 bytes)  

Not Applicable
Tessalon Perles generic.gif (400 bytes)
benzonatate		 100 mg capsule   approved.gif (510 bytes)  

$$$$
Zonatuss generic.gif (400 bytes)
benzonatate		 capsule   notreimb.gif (545 bytes)  

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)

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