Analgesics, Narcotic
Brand/Generic Name
(Generics in italics) |
Dosage/Strength |
Status |
Restrictions |
Notes |
Copayment
Tier |
Darvocet-N 100
Propoxyphene N-APAP |
|
 |
|
 |
N/A |
Darvocet-N 50
Propoxyphene N-APAP |
|
|
|
|
N/A |
Propoxyphene N-APAP
Propoxyphene N-APAP |
|
 |
|
|
Tier 1 |
|
| Key for Product(s) Listed Above |
| Formulary |
| Non-Covered Medications that have Covered Alternatives |
|
 | Prior Authorization |
|
 Not Covered |
 Quantity Limit |
| Generic is Formulary, Brand is Non-Formulary |
|
 Step Therapy |
 Notes |
 | Specialty Medications |
|
|
| Tier 2 | Preferred Brand Name Drugs |
|
| Tier 3 | Non-Preferred Brand-Name Drugs |
|
| Tier 4 | Specialty Drugs - Tier 3 Copay |
|
|
|
|
|
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