' Hydrocodone-Acetaminophen
Analgesics
Analgesics, Narcotic

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Lortab generic.gif (400 bytes)
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   approved.gif (510 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$
Vicodin generic.gif (400 bytes)
hydrocodone-acetaminophen		 5-500 mg tablet   approved.gif (510 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$
Vicodin ES generic.gif (400 bytes)
hydrocodone-acetaminophen		 7.5-300 mg tablet; 7.5-750 mg tablet   approved.gif (510 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$$
Vicodin HP generic.gif (400 bytes)
hydrocodone-acetaminophen		 10-300 mg tablet; 10-660 mg tablet   nonform.gif (625 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$$
Xodol 10/300 generic.gif (400 bytes)
hydrocodone-acetaminophen		 10-300 mg tablet   nonform.gif (625 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$$
Xodol 5/300 generic.gif (400 bytes)
hydrocodone-acetaminophen		 5-300 mg tablet   nonform.gif (625 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$
Xodol 7.5/300 generic.gif (400 bytes)
hydrocodone-acetaminophen		 7.5-300 mg tablet   nonform.gif (625 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$$
Zamicet generic.gif (400 bytes)
hydrocodone-acetaminophen		 Solution   nonform.gif (625 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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