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You searched for Donnatal Oral Elixir.

Donnatal At a Glance
Covered:	No
Your Cost*:	$$$$
Notices?:	No
* Your cost reflects copayment amount for drug. Individuals with high deductible plans may pay full cost of drug until deductible is met.

Strength:

Donnatal 16.2 mg-0.1037 mg-0.0194 mg/5 mL oral elixir

Donnatal is not included in this formulary. Member pays full cost.

A generic drug may be available.

A drug with the same active ingredients is covered. Your pharmacist may automatically substitute your prescription for Donnatal with the drug listed below. Talk with your pharmacist.

Generic Drug	Drug Form	Covered	Type	Your Cost*	Notices?
Phenobarb-Hyoscy-Atropine-Scop	Phenobarb-Hyoscyamn-Atropine-Scop Oral Elixir	Yes	Generic	$$$$	No

Drug Name	Drug Form	Covered	Type	Your Cost*	Notices?
Atropine	Atropine Injection Syringe	Yes	Generic	$$$$	No
Hyoscyamine Sulfate	Hyoscyamine Disintegrating Tablet	Yes	Generic	$$$$	No
Hyoscyamine Sulfate	Hyoscyamine ER Tablet,Extended Release	Yes	Generic	$$$$	No
Hyoscyamine Sulfate	Hyoscyamine Sulfate Tablet	Yes	Generic	$$$$	No
Oscimin	Oscimin Disintegrating Tablet	Yes	Brand	$$$$	No
Ed-Spaz	Ed-Spaz Disintegrating Tablet	Yes	Brand	$$$$	No
Hyoscyamine Sulfate	Hyoscyamine Sublingual Tablet	Yes	Generic	$$$$	No
Hyoscyamine Sulfate	Hyoscyamine Oral Elixir	Yes	Generic	$$$$	No
Hyosyne	Hyosyne Oral Elixir	Yes	Brand	$$$$	No
Oscimin	Oscimin Tablet	Yes	Brand	$$$$	No
Oscimin SL	Oscimin SL Sublingual Tablet	Yes	Brand	$$$$	No
Symax Fastabs	Symax Fastabs Disintegrating Tablet	Yes	Brand	$$$$	No
Symax-SL	Symax-SL Sublingual Tablet	Yes	Brand	$$$$	No
Hyoscyamine Sulfate	Hyoscyamine Oral Drops	Yes	Generic	$$$$	No
Hyoscyamine Sulfate	Hyoscyamine ER Tablet,Extended Release,12 Hr	Yes	Generic	$$$$	No
Oscimin SR	Oscimin SR Tablet,Extended Release	Yes	Brand	$$$$	No
Phenobarb-Hyoscy-Atropine-Scop	Phenobarb-Hyoscyamn-Atropine-Scop Oral Elixir	Yes	Generic	$$$$	No
Scopolamine Hbr	Scopolamine Injection Solution	Yes	Generic	$$$$	No
Symax-SR	Symax-SR Tablet,Extended Release	Yes	Brand	$$$$	No
Hyosyne	Hyosyne Oral Drops	Yes	Brand	$$$$	No
Methscopolamine	Methscopolamine Tablet	Yes	Generic	$$$$	No
Phenohytro	Phenohytro Oral Elixir	Yes	Brand	$$$$	No

Drug Name	Drug Form	Covered	Type	Your Cost*	Notices?
Atropine In 0.9 % Sod Chloride	Atropine In 0.9 % Sodium Chloride Intravenous Syringe	No	Generic	$$$$	No
Atropine	Atropine Intravenous Syringe	No	Generic	$$$$	No
Atropine	Atropine Injection Solution	No	Generic	$$$$	No
Atropine	Atropine Intravenous Solution	No	Generic	$$$$	No
B-Donna	B-Donna Tablet	No	Brand	$$$$	No
Donnatal	Donnatal Tablet	No	Brand	$$$$	No
Donnatal	Donnatal Oral Elixir	No	Brand	$$$$	No
Hyoscyamine Sulfate	Hyoscyamine Injection Solution	No	Generic	$$$$	No
Levbid	Levbid Tablet,Extended Release	No	Brand	$$$$	No
Levsin	Levsin Injection Solution	No	Brand	$$$$	No
Me-PB-Hyos	Me-PB-Hyos Tablet	No	Brand	$$$$	No
Me-PB-Hyos	Me-PB-Hyos Oral Elixir	No	Brand	$$$$	No
Nulev	Nulev Disintegrating Tablet	No	Brand	$$$$	No
Pamine	Pamine Tablet	No	Brand	$$$$	No
Pamine Forte	Pamine Forte Tablet	No	Brand	$$$$	No
Phenobarb-Hyoscy-Atropine-Scop	Phenobarb-Hyoscyamn-Atropine-Scop Tablet	No	Generic	$$$$	No
Phenohytro	Phenohytro Tablet	No	Brand	$$$$	No
Symax Duotab	Symax Duotab Tablet,Extended Release	No	Brand	$$$$	No

Alternative Drug Information

The value of choosing UPMC Health Plan

At UPMC Health Plan, we support our members in focusing on their total well-being. We want to make sure our members have everything you need to be as healthy and happy as possible. We do this by:

Providing access to care to help keep you healthy.

	$0 preventive care that covers many health services for adults and children at 100 percent.¹
	Coverage for high-value generic and no-cost preventive medications.²
	Access to top-ranked doctors and hospitals and an extended network.³

Taking care of your mental and physical health.

	Six free counseling sessions through LifeSolutions®.⁴
	Free health coaching to help you make healthy changes in your life.
	The RxWell® app provides virtual support for your total well-being.

Supporting you when you need it.

	24/7 virtual urgent care and connections to pharmacists, health coaches, and behavioral health concierges. Designed to fit your schedule, it's covered at 100 percent by most plans.⁵
	The UPMC Health Plan app for easy access to your health insurance information.
	Our exceptional Health Care Concierge team for help navigating your benefits with a quick online chat or phone call.

¹Preventive care will be covered at 100 percent only when it is received from a participating provider and it is billed as preventive. A separate cost share may apply if additional medical services are received during the same visit or if your preventive care appointment becomes diagnostic in nature.

²Preventive medications on UPMC Health Plan’s Advantage Choice formulary will be covered with no cost share for members who meet certain criteria in accordance with the Patient Protection and Affordable Care Act of 2010.

³Go to www.upmchealthplan.com/BEST for award information.

⁴Only the virtual visit with the provider will be covered at 100 percent. Prescription drug and other costs related to the visit or recommended by the provider will not be included in the virtual visit coverage and will be your responsibility. If you are enrolled in the UPMC Advantage Silver HSA $4,000/$0, UPMC Advantage Gold HSA $2,500/10%, or UPMC Advantage Catastrophic $9,200/$0 plan, UPMC AnywhereCare virtual visits will be covered at 100 percent after you meet your deductible. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply.

⁵UPMC Health Plan members who are in Pennsylvania at the time of a virtual visit may select a UPMC-employed provider, subject to availability and discretion of the provider. Members located outside of Pennsylvania at the time of service or those who select Talk Therapy or Psychiatry services will receive care from a provider employed or contracted by Online Care Network II PC (OCN), also known as Amwell Medical Group. OCN is not an affiliate of UPMC. Limitations may apply for members of ASO plans that have opted out of coverage. Providers are not available to treat members who are in Puerto Rico.

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You searched for Donnatal Oral Elixir.

A generic drug may be available.

Alternative drugs to Donnatal may be available. Review this list with your doctor.

These alternative drugs are not covered.