preferred prescriptions member guide meipg_v4(w).pdf · preferred prescriptions® is a formulary...

Preferred Prescriptions®Member GuidePlease bring this guide with you on your next doctor visit.

Medco and Preferred Prescriptions are registered trademarks of Medco Health Solutions, Inc.

© 2007 Medco Health Solutions, Inc. All rights reserved.Medco is a registered trademark of Medco Health Solutions, Inc.

If you have questions about your prescription drug benefit, visit www.medco.com or call Member Services using the toll-free number on the back of your prescription drug ID card.

Medco manages your prescription drug benefit for your health plan.

MG920297 MEIPG(Ed. 10/07 - reflects 1/1/08formulary changes)

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Preferred Prescriptions® is a formulary list of medications that may be covered under yourprescription drug plan. This list was reviewed by an independent group of practicing doctors andpharmacists, and it contains medications made by most pharmaceutical manufacturers. It includesmedications for many covered conditions.

SAVING MONEY ON PRESCRIPTIONSYour plan may prefer some medications over others. These are called preferred drugs.

You may pay:• Lowest co-payment for generic drugs• Higher co-payment for preferred brand-name drugs• Highest co-payment for nonpreferred brand-name drugs

Your doctor may be able to help you save money by prescribing generic and preferredbrand-name drugs if appropriate. So be sure to bring this guide with you on every visit toyour doctor. Some commonly prescribed nonpreferred drugs are also listed in this guidefor your reference.

Please note: This guide does not contain a complete list of preferred and nonpreferred drugs. It onlylists the most commonly prescribed drugs. For an updated and complete listing of your prescriptionbenefit, you can visit the “Benefit Highlights” section of our website—www.medco.com—and clickon the View your preferred drug list link.

FINDING MEDICATIONS WITH LOWER CO-PAYMENTSThis guide lists medications two ways to help you find some generic, preferred, and nonpreferred brand-name drugs.

SECTION I - ALPHABETICALLY BY DRUG CATEGORY (SUCH AS RESPIRATORY)Within each category, medications are listed in alphabetical order, with generic, preferred brand-name,and nonpreferred brand-name drugs sorted separately:

G Means a preferred generic medicationP Means a preferred brand-name medicationNP Means a nonpreferred brand-name medication

SECTION II - ALPHABETICALLY BY BRAND NAMEAfter each nonpreferred brand-name drug, you will find possible generic and preferred brand-namealternatives.

SAFETY CONSIDERATION SYMBOLSHere is a quick guide for you and your doctor, which explains our safety symbols. These symbolsappear next to certain medications.

Means weigh risk of birth defects or other adverse outcomes.

Means do not use in pregnancy.

The information in this guide was in effect at the time of printing and may be subject to change.

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Oral PenicillinsG amoxicillin trihydrateG amoxicillin trihydrate/

potassium clavulanateG ampicillin trihydrateG dicloxacillin sodiumG penicillin v potassiumP Augmentin Chewable Tablet

125 - 31.25mg,250 - 62.5mg

P Augmentin Suspension 125 - 31.25mg/5,250 - 62.5mg/5

P Augmentin Tablet 250-125mgP Augmentin XRNP Augmentin Chewable Tablet

200 - 28.5mg,400 - 57mg

NP Augmentin ESNP Augmentin Suspension

200 - 28.5mg/5,400 - 57mg/5

NP Augmentin Tablet 500 - 125mg,875 - 125mg

NP DispermoxNP GeocillinOral TetracyclinesG doxycycline hyclate capsuleG doxycycline hyclate tabletG doxycycline monohydrateG minocycline HClG tetracycline HClP AdoxaP Vibramycin SuspensionNP DoryxNP DynacinNP MinocinNP MonodoxNP OraceaNP PeriostatNP SolodynNP Vibramycin SyrupOral CephalosporinsG cefaclorG cefadroxil hydrateG cefdinirG cefpodoxime proxetilG cefprozilG cefuroxime axetilG cephalexin monohydrateG cephradineP Ceftin SuspensionP Ceftin Tablet 125mgNP Ceclor CDNP CedaxNP Ceftin Tablet 250mg, 500mgNP CefzilNP Duricef

NP KeflexNP KeftabNP OmnicefNP SpectracefNP SupraxNP VantinNP VelosefOral ErythromycinsG azithromycinG clarithromycinG erythromycin base tablet,

enteric coatedG erythromycin ethylsuccinateG erythromycin ethylsuccinate/

sulfisoxazole acetylG erythromycin stearateP Biaxin XLNP BiaxinNP EryPedNP PCENP ZithromaxNP ZmaxOral QuinolonesG ciprofloxacin HCl tabletG ofloxacinP AveloxP Cipro SuspensionP Cipro Tablet 100mg P LevaquinP NoroxinNP Cipro Tablet 250mg, 500mg,

750mgNP Cipro XRNP FactiveNP FloxinNP MaxaquinNP Proquin XRNP TequinOral SulfasG erythromycin ethylsuccinate/

sulfisoxazole acetylG sulfadiazineG sulfamethoxazole/

trimethoprimG sulfisoxazoleNP Bactrim DSNP GantrisinNP Septra DSOral Urinary Tract AgentsG methenamine hippurateG methenamine mandelateG nitrofurantoin macrocrystalG nitrofurantoin/nitrofurantoin

macrocrystalG phenazopyridine HClG trimethoprimP FuradantinNP Hiprex

NP MacrobidNP MacrodantinNP MonurolNP NeggramNP PrimsolOral Antifungal AgentsG clotrimazoleG fluconazoleG griseofulvin ultramicrosizeG itraconazoleG ketoconazoleG nystatinG terbinafine HClP AncobonP NoxafilP Sporanox Oral SolutionP Vfend Tablet NP DiflucanNP Fulvicin U/FNP FungizoneNP Grifulvin VNP Gris-PegNP Lamisil TabletNP MycostatinNP Mycelex Troche NP NizoralNP Sporanox CapsuleNP Vfend SuspensionOral Miscellaneous AgentsG clindamycin HClG neomycin sulfateP DapsoneP Tobi Ampul for

NebulizationP ZyvoxNP Cleocin HClNP KetekNP XifaxanVaginal AntifungalsG fluconazoleG miconazole nitrate vaginal

suppositoryG nystatinG terconazole vaginal creamG terconazole vaginal

suppositoryP Gynazole-1NP Terazol Suppository,VaginalNP Terazol Vaginal Cream with

Applicator

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ANTI-INFECTIVES (Antibiotics/Antifungals)

SECTION I: THERAPEUTIC DRUG CATEGORIES

= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.

Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.


Hypnotic AgentsG chloral hydrateG estazolamG flurazepam HClG temazepamG triazolamG zolpidem tartrateP Ambien CRP Restoril 7.5mg, 22.5mgP SonataNP AmbienNP DalmaneNP DoralNP HalcionNP LunestaNP ProSomNP Restoril 15mg, 30mgNP RozeremTricyclic AntidepressantsG amitriptyline HClG amoxapineG clomipramine HClG desipramine HClG doxepin HClG imipramine HClG nortriptyline HClP SurmontilP Tofranil-PMP VivactilNP AnafranilNP AsendinNP Aventyl HClNP ElavilNP NorpraminNP PamelorNP SinequanNP TofranilMiscellaneous AntidepressantsG bupropion HCl tabletG bupropion HCl tablet,

sustained actionG maprotiline HClG mirtazapine tabletG mirtazapine tablet, rapid

dissolve

G trazodone HClG venlafaxine HClP CymbaltaP Wellbutrin XL 150mgNP DesyrelNP EffexorNP Effexor XRNP LudiomilNP Remeron SolTabNP Remeron TabletNP SerzoneNP WellbutrinNP Wellbutrin SRNP Wellbutrin XL 300mgAntipsychoticsG chlorpromazine HClG clozapineG fluphenazine HClG haloperidolG haloperidol lactate

concentrate, oralG loxapine succinateG perphenazineG thiothixeneG trifluoperazine HClP ClozarilP GeodonP MobanP OrapP RisperdalP Risperdal M-TabP SerentilP SeroquelP Seroquel XRP ZyprexaP Zyprexa ZydisNP AbilifyNP InvegaNP SymbyaxAnxiolyticsG alprazolamG alprazolam XRG buspirone HClG chlordiazepoxide HClG clorazepate dipotassium

G diazepamG lorazepamG oxazepamNP AtivanNP BusparNP LibriumNP NiravamNP PaxipamNP SeraxNP Tranxene SDNP Tranxene T-TabNP ValiumNP XanaxNP Xanax XRMAOI AntidepressantsG tranylcypromine sulfateP NardilNP EmsamNP ParnateSSRI AntidepressantsG citalopram HBrG fluoxetine HClG fluvoxamine maleateG paroxetine HClG sertraline HClP Paxil CRNP CelexaNP LexaproNP LuvoxNP PaxilNP PexevaNP ProzacNP Prozac WeeklyNP SarafemNP Zoloft

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PSYCHOTHERAPEUTICS (Anxiety/Depression)




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Beta BlockersG acebutolol HClG atenololG betaxolol HClG bisoprolol fumarateG carvedilolG labetalol HClG metoprolol succinateG metoprolol tartrateG nadololG pindololG propranolol HClG propranolol HCl capsule,

sustained action 24 hrG timolol maleateP Coreg CRNP CoregNP CorgardNP InderalNP Inderal LANP Innopran XLNP KerloneNP LevatolNP LopressorNP NormodyneNP SectralNP TenorminNP Toprol XLNP TrandateNP ZebetaCalcium BlockersG diltiazem HClG diltiazem HCl capsule,

sustained actionG diltiazem HCl capsule,

sustained release 12 hrG diltiazem HCl capsule,

sustained release 24 hrG nimodipineG verapamil HClG verapamil HCl tablet, sustained

actionP Cardizem LAP Covera-HSNP Calan SRNP CardizemNP Cardizem CDNP Cardizem SRNP Isoptin S.R.NP NimotopNP TiazacNP VerelanNP Verelan PMDihydropyridinesG amlodipine besylateG isradipineG felodipine ERG nifedipineG nifedipine tablet, sustained

actionG nifedipine tablet, sustained

release osmotic pushP SularNP Adalat CCNP Cardene SRNP DynaCirc

NP DynaCirc CRNP NorvascNP PlendilNP Procardia XLNitroglycerin PatchesG nitroglycerin patchP Minitran PatchNP Nitro-Dur PatchAdrenergic Antagonists & RelatedDrugsG clonidine HClG doxazosin mesylateG guanfacine HClG methyldopaG prazosin HClG reserpineG terazosin HClP Catapres-TTS PatchNP CarduraNP Cardura XLNP CatapresNP HytrinNP MinipressNP TenexAngiotensin II Blockers & ReninInhibitorsP AtacandP Atacand HCTP BenicarP Benicar HCTP CozaarP DiovanP Diovan HCTP HyzaarP MicardisP Micardis HCTNP AvalideNP AvaproNP TekturnaNP TevetenNP Teveten HCTAntilipidemicsG cholestyramine/aspartameG cholestyramine/sucroseG colestipol HClG fenofibrate, micronizedG gemfibrozilG lovastatinG niacinG pravastatinG simvastatinP AdvicorP AltoprevP CrestorP LipitorP LovazaP NiaspanP TricorP TriglideP VytorinP WelcholP ZetiaNP AntaraNP CaduetNP Colestid

NP LescolNP Lescol XLNP LofibraNP LopidNP MevacorNP PravacholNP QuestranNP Questran LightNP ZocorACE InhibitorsG benazepril HClG captoprilG enalapril maleateG fosinopril sodiumG lisinoprilG quinaprilG trandolaprilP AceonP AltaceNP AccuprilNP CapotenNP LotensinNP MavikNP MonoprilNP PrinivilNP UnivascNP VasotecNP ZestrilCombination AntihypertensivesG amlodipine besylate/benazeprilG atenolol/chlorthalidoneG benazepril HCl/

hydrochlorothiazideG bisoprolol fumarate/

hydrochlorothiazideG captopril/hydrochlorothiazideG enalapril maleate/

hydrochlorothiazideG fosinopril/hydrochlorothiazideG hydralazine HCl/

hydrochlorothiazideG lisinopril/hydrochlorothiazideG methyldopa/

hydrochlorothiazideG metoprolol/hydrochlorothiazideG moexipril/hydrochlorothiazideG propranolol HCl/

hydrochlorothiazideG quinapril/hydrochlorothiazideP LotrelNP AccureticNP CapozideNP ClorpresNP CorzideNP ExforgeNP LexxelNP Lopressor HCTNP Lotensin HCTNP Monopril HCTNP PrinzideNP TarkaNP TenoreticNP UnireticNP VasereticNP ZestoreticNP Ziac

CARDIOVASCULAR (Blood Pressure/Heart/Cholesterol)




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Insulin TherapyP ApidraP HumalogP Humalog Mix 50/50P Humalog Mix 75/25P HumulinP LantusP Lantus SoloStarP LevemirP NovoLogP NovoLog Mix 70/30NP ExuberaNP NovolinNon-Insulin Hypoglycemic AgentsG acetohexamideG chlorpropamideG glimepirideG glipizideG glipizide/metformin HClG glipizide tablet, sustained

release osmotic pushG glyburideG glyburide/metformin HClG glyburide, micronizedG metformin HClG metformin HCl tablet,

sustained release 24 hrG tolazamideG tolbutamideP Actoplus MetP ActosP AvandametP AvandarylP AvandiaP ByettaP DuetactP JanumetP JanuviaP PrandinP PrecoseP StarlixP SymlinNP AmarylNP DiaBetaNP GlucophageNP Glucophage XRNP GlucotrolNP Glucotrol XLNP GlucovanceNP GlynaseNP GlysetNP MetaglipNP Micronase

Blood Glucose Test StripsG alcohol antiseptic padsP Accu-Chek Active Test StripsP Accu-Chek Aviva Test StripsP Accu-Chek Comfort Curve

Test StripsP Accu-Chek Compact Test

StripsP Fast Take Test StripsP One Touch Test StripsP One Touch Ultra Test Strips P Surestep Pro Test StripsP Surestep Test StripsP Tracer BG Test StripsContraceptive AgentsG desogestrel-ethinyl

estradiolG desogestrel-ethinyl

estradiol/ethinyl estradiolG ethynodiol d-ethinyl

estradiolG levonorgestrel-ethinyl

estradiolG norethindroneG norethindrone a-e

estradiolG norethindrone a-e

estradiol/ferrous fumarateG norethindrone-ethinyl

estradiolG norethindrone-mestranolG norgestimate-ethinyl

estradiolG norgestrel-ethinyl estradiolP CyclessaP NuvaRingP Ortho Tri-Cyclen LoP OvretteP Plan BP SeasoniqueP YasminP YazNP AlesseNP BreviconNP DemulenNP DesogenNP Estrostep FeNP LevlenNP LevliteNP LoestrinNP Loestrin FeNP Loestrin 24 FeNP Lo/Ovral

NP LybrelNP MircetteNP ModiconNP NordetteNP NorinylNP Ortho-CeptNP Ortho-CyclenNP Ortho EvraNP Ortho MicronorNP Ortho-NovumNP Ortho Tri-CyclenNP SeasonaleNP Tri-LevlenNP Tri-NorinylNP TriphasilEstrogens/EstrogenCombinationsG estradiol patch,

transdermal weeklyG estradiol tabletG estropipateG methyltestosterone/

estrogens, esterifiedP ActivellaP CenestinP Climara PatchP CombipatchP EnjuviaP Estraderm PatchP EstratestP Estratest H.S.P Estring Vaginal RingP Premarin Tablet P Premarin Vaginal CreamP PremphaseP PremproP VagifemP Vivelle PatchNP AloraNP AngeliqNP Climara Pro PatchNP ElestrinNP Esclim PatchNP EstraceNP EstrasorbNP FemhrtNP FemringNP FemtraceNP MenestNP OgenNP Ortho-Prefest

ENDOCRINE (Diabetes/Hormones/Contraceptives)




NSAIDsG etodolacG etodolac tablet, sustained

release 24 hrG flurbiprofenG ibuprofenG indomethacinG indomethacin capsule,

sustained actionG ketoprofenG ketoprofen capsule, 24 hr

sustained release pelletsG meclofenamate sodium

G meloxicamG nabumetoneG naproxenG naproxen sodiumG naproxen sodium tablet,

sustained actionG oxaprozinG piroxicamG sulindacG tolmetin sodiumNP ClinorilNP DayproNP diclofenac potassiumNP diclofenac sodium

NP IndocinNP LodineNP Lodine XLNP MobicNP MotrinNP NaprelanNP OruvailNP RelafenNP VoltarenNSAID COX-2 InhibitorsP Celebrex

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NSAIDS (Pain Relievers)

Ulcer DrugsG cimetidine HCl liquidG cimetidine tabletG famotidineG misoprostolG nizatidineG omeprazoleG ranitidine HClP Axid Oral Solution

P Nexium CapsuleP Nexium SuspensionNP AciphexNP Axid CapsuleNP CytotecNP PepcidNP PrevacidNP Prilosec RxNP Protonix

NP TagametNP Zantac Rx Syrup NP Zantac Rx TabletNP ZegeridOther G I DrugsG sucralfate tabletP Carafate Suspension NP Carafate Tablet

G I (Ulcer)

G acetaminophen/butalbitalG acetaminophen/caffeine/

butalbital G aspirin/caffeine/butalbitalG ergotamine/caffeine tabletG ergotamine

tartrate/caffeinesuppository, rectal

G dihydroergotaminemesylate

G isometheptene mucate/acetaminophen/dichloralphenazone

P AmergeP ErgomarP FrovaP Imitrex InjectionP Imitrex Nasal SprayP Imitrex TabletP Maxalt

P Maxalt MLTP PhrenilinP Phrenilin ForteP RelpaxP Zomig Nasal SprayP Zomig TabletP Zomig ZMTNP AxertNP Cafergot tabletNP MidrinNP Migranal

MIGRAINE/HEADACHE THERAPY

P AriceptP Aricept ODTP Exelon

P RazadyneP Razadyne ERNP Cognex

NP Namenda

DRUGS TO TREAT ALZHEIMER’S DISEASE

G flavoxateG oxybutynin chloride P Detrol

P Detrol LAP EnablexP Oxytrol

P VesicareNP Ditropan XLNP Sanctura

DRUGS TO TREAT OVERACTIVE BLADDER




P BonivaP EvistaP ForteoP Fosamax Plus D

P Fosamax SolutionP Fosamax TabletP Miacalcin Nasal SprayNP Actonel 5mg

NP Actonel 35mgNP Actonel 75mgNP Actonel with Calcium

OSTEOPOROSIS/PAGET’S DISEASE

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Beta Agonists OralG albuterol sulfateG albuterol sulfate SRG metaproterenol sulfateG terbutaline sulfateNP AlupentNP BrethineNP VentolinNP VolmaxBeta Agonist InhalersG albuterol aerosolG albuterol sulfate solutionG isoetharine HCl solutionG metaproterenol sulfate

solutionP AccunebP ForadilP Maxair AutohalerP Proventil HFAP Serevent DiskusP XopenexP Xopenex HFANP AlupentNP BrovanaNP PerforomistNP Proair HFANP Proventil Inhalation SolutionNP Proventil InhalerNP Ventolin HFANP Ventolin InhalerInhaled SteroidsP AsmanexP Flovent DiskusP Flovent HFAP Flovent InhalerP Flovent RotadiskP Pulmicort FlexhalerP Pulmicort InhalerP Pulmicort RespulesP QVARNP AerobidNP Aerobid-MNP AzmacortNasal CorticosteroidsG flunisolideG fluticasone propionateP Nasacort AQP NasonexP Rhinocort AquaP VeramystNP Beconase AQNP FlonaseNP Nasacort

NP NasalideNP NasarelNP Rhinocort NP VancenaseMiscellaneous Pulmonary AgentsG acetylcysteine vialG cromolyn sodium ampul for

nebulizationG ipratropium bromide

solutionP AccolateP Advair DiskusP Advair HFAP Atrovent HFAP Atrovent InhalerP Combivent InhalerP DuonebP Intal InhalerP LetairisP PulmozymeP RevatioP SingulairP SpirivaP SymbicortP Tilade InhalerP TracleerP VentavisNP Atrovent Inhalation SolutionNP XolairNP ZyfloAntihistamine/DecongestantCombinationsG carbetapentane tannate/

chlorpheniramine tannateG carbetapentane tannate/

ephedrine tannate/phenylephrine/chlorpheniramine suspension

G carbetapentane tannate/phenylephrine tannate/chlorpheniramine suspension

G phenylephrine HCl/phenyltoloxamine citrate/chlorpheniramine

G phenylephrine HCl/promethazine HCl

G phenylephrine tannate/chlorpheniramine tannate

G phenylephrine tannate/diphenhydramine tannatesuspension

G phenylephrine tannate/pyrilamine tannate/chlorpheniramine tablet

G pseudoephedrine HCl/

brompheniramine maleateG pseudoephedrine HCl/

brompheniramine maleatecapsule, sustained release 12hr

G pseudoephedrine HCl/chlorpheniramine maleate

G pseudoephedrine HCl/chlorpheniramine maleatecapsule, sustained release 12hr

G pseudoephedrine tannate/chlorpheniramine tannate

G pseudoephedrine tannate/dexchlorpheniramine tannate

P Allegra-DP Deconamine Chewable

TabletP Deconamine SRP Deconamine SyrupP Histex LiquidP Histex SRP Respi-TannP Zyrtec-DNP Clarinex-D 12 hrNP Clarinex-D 24 hrNP Deconamine TabletNP RynatanNP RynatussNP Semprex-DAntihistaminesG clemastine fumarateG cyproheptadine HClG dexchlorpheniramine

maleate syrupG diphenhydramine HClG fexofenadine HClG hydroxyzine HClG hydroxyzine pamoateP Allegra Oral SuspensionP Astelin Nasal SprayP Clarinex RediTabsP Clarinex Tablet P Zyrtec Chewable Tablet P Zyrtec SyrupP Zyrtec TabletNP Allegra TabletNP AtaraxNP Clarinex SyrupNP Histex IENP Vistaril

RESPIRATORY (Allergy/Asthma)




Abilify® clozapine (generic), Geodon® (Pfizer), Risperdal® (Janssen Pharmaceutical), Seroquel® (AstraZeneca),Zyprexa® (Eli Lilly)

Accupril® quinapril (generic)Accuretic® quinaretic (generic)Aciphex® omeprazole (generic), Nexium® (AstraZeneca)Actonel 5mg® Boniva® (Roche), Fosamax 5mg® (Merck), Fosamax 10mg® (Merck)Actonel 35mg® Boniva® (Roche), Fosamax 35mg® (Merck), Fosamax 70mg® (Merck)Actonel® with Calcium Boniva® (Roche), Fosamax® (Merck)Adalat CC® nifedipine ER tablet, sustained action (generic), amlodipine besylate (generic), Sular® (First-Horizon)Aerobid® Asmanex® (Schering), Flovent Inhaler® (GlaxoSmithKline), Pulmicort Inhaler® (AstraZeneca), QVAR® (Ivax)Aerobid-M® Asmanex® (Schering), Flovent Inhaler® (GlaxoSmithKline), Pulmicort Inhaler® (AstraZeneca), QVAR® (Ivax)Allegra® Tablet fexofenadine HCl (generic), Clarinex® (Schering), Zyrtec® (Pfizer)Alesse® Aviane® (Barr-branded generic*), Lessina® (Barr-branded generic*), Lutera® (Watson-branded generic*)Alora® estradiol patch (generic), Climara® (Berlex), Estraderm® (Novartis),Vivelle® (Novartis)Alupent® albuterol (generic), Maxair Autohaler® (3M)Amaryl® glimepiride (generic)Ambien® zolpidem tartrate (generic)Amoxil® amoxicillin trihydrate (generic)Anafranil® clomipramine HCl (generic)Anaprox DS® naproxen sodium (generic)Angeliq® Activella® (Novo Nordisk), Premphase® (Wyeth), Prempro® (Wyeth)Ansaid® flurbiprofen (generic)Antara® fenofibrate (generic), gemfibrozil (generic),Tricor® (Abbott),Triglide® (First Horizon)Arthrotec® Celebrex® (Pfizer)Asendin® 50mg, 100mg amoxapine (generic)Atarax® hydroxyzine HCl (generic)Ativan® lorazepam (generic)Atrovent® solution, non-oral ipratropium bromide (generic)Augmentin® chewable tablet 200-28.5mg, 400-57mg amoxicillin trihydrate/potassium clavulanate (generic)Augmentin® suspension 200-28.5mg/5, 400-57mg/5 amoxicillin trihydrate/potassium clavulanate (generic)Augmentin® tablet 500-125mg, 875-125mg amoxicillin trihydrate/potassium clavulanate (generic)Augmentin ES® amoxicillin trihydrate/potassium clavulanate (generic)Avalide® Atacand HCT® (AstraZeneca), Benicar HCT® (Sankyo), Diovan HCT® (Novartis), Hyzaar® (Merck),

Micardis HCT® (BIPI)Avapro® Atacand® (AstraZeneca), Benicar® (Sankyo), Cozaar® (Merck), Diovan® (Novartis), Micardis® (BIPI)Aventyl HCl® nortriptyline HCl (generic)Axert® Amerge® (GlaxoSmithKline), Frova® (Endo), Imitrex® (GlaxoSmithKline), Maxalt® (Merck), Relpax® (Pfizer),

Zomig® (AstraZeneca)Axid® Capsule nizatidine (generic)Azmacort® Asmanex® (Schering), Flovent Inhaler® (GlaxoSmithKline), Pulmicort Inhaler® (AstraZeneca), QVAR® (Ivax)Bactrim DS® sulfamethoxazole/trimethoprim (generic)Beconase AQ® flunisolide (generic), fluticasone propionate (generic), Nasacort AQ® (Aventis), Nasonex® (Schering),

Rhinocort Aqua® (AstraZeneca)Biaxin® clarithromycin (generic)Biohist-LA® pseudoephedrine HCl/chlorpheniramine maleate (generic)Brethine® terbutaline sulfate (generic)Brevicon® Necon® (Watson-branded generic*), Nortrel® (Barr-branded generic*)Brovana® albuterol sulfate (generic), Foradil® (Schering), Serevent Diskus® (GlaxoSmithKline)

Buspar® buspirone HCl (generic)Butisol Sodium® chloral hydrate (generic), temazepam (generic), triazolam (generic)Caduet® amlodipine besylate (generic), Lipitor® (Pfizer)Calan SR® verapamil HCl tablet, sustained action (generic)Capoten® captopril (generic)Capozide® captopril/hydrochlorothiazide (generic)Carafate Tablet® sucralfate (generic)Cardene SR® amlodipine besylate (generic), nifedipine ER tablet, sustained release osmotic push (generic),

Sular® (First-Horizon)Cardizem® diltiazem HCl (generic)Cardizem CD® diltiazem HCl capsule, sustained release 24 hr (generic)Cardizem SR® diltiazem HCl capsule, sustained release 12 hr (generic)Cardura® doxazosin mesylate (generic)Cataflam® etodolac (generic), ibuprofen (generic), naproxen (generic)

Nonpreferred Product Possible Preferred Products

8

SECTION II: NONPREFERRED DRUGS AND THEIR POSSIBLE PREFERRED ALTERNATIVES

*Branded generics have the same co-payment as regular generics.


Catapres® clonidine HCl (generic)Ceclor CD® cefaclor (generic), cefuroxime axetil (generic), Omnicef® (Abbott)Cedax® cefaclor (generic), cefuroxime axetil (generic), Omnicef® (Abbott)Ceftin Tablet® 250mg, 500mg cefuroxime axetil (generic)Cefzil® cefaclor (generic), cefuroxime axetil (generic), Omnicef® (Abbott)Celexa® citalopram (generic)Cipro Tablet® 250mg, 500mg, 750mg ciprofloxacin HCl tablet (generic)Clarinex-D 12 Hour® Allegra-D® (Aventis), Zyrtec-D® (Pfizer)Clarinex-D 24 Hour® Allegra-D® (Aventis), Zyrtec-D® (Pfizer)Clarinex Syrup® Zyrtec Syrup® (Pfizer)Cleocin HCl® clindamycin HCl (generic)Climara Pro® Combipatch® (Novartis)Clinoril® sulindac (generic)Clorpres® clonidine HCl (generic), chlorthalidone (generic)Cognex® Aricept® (Eisai), Exelon® (Novartis), Razadyne® (Janssen Pharmaceuticals)Colestid® cholestyramine/sucrose (generic),Welchol® (Sankyo)Coreg® carvedilol (generic)

Corgard® nadolol (generic)Corzide® bisoprolol fumarate/hydrochlorothiazide (generic), metoprolol/hydrochlorothiazide (generic), propranolol

HCl/hydrochlorothiazide (generic)Cytotec® misoprostol (generic)Dallergy® syrup pseudoephedrine HCl/brompheniramine maleate (generic)Dalmane® flurazepam HCl (generic)Daypro® oxaprozin (generic)Deconamine® tablet pseudoephedrine w/chlorpheniramine (generic)Demulen® Zovia® (Watson-branded generic*)Desogen® Apri® (Barr-branded generic*), Solia® (Prasco Labs-branded generic*)Desyrel® trazodone HCl (generic)DiaBeta® glyburide (generic)Diclofenac Potassium etodolac (generic), ibuprofen (generic), naproxen (generic)Diclofenac Sodium etodolac (generic), ibuprofen (generic), naproxen (generic)Diflucan® fluconazole (generic)Dilacor XR® diltiazem XR (generic)Dispermox® amoxicillin trihydrate suspension (generic), amoxicillin trihydrate chewable tablet (generic)Ditropan XL® oxybutynin chloride ER (generic)

Doral® temazepam (generic), triazolam (generic), zolpidem tartrate (generic), Restoril® (Mallinckrodt),Sonata® (Wyeth)

Doryx® doxycycline hyclate (generic)Duricef® cefadroxil hydrate (generic)Dynacin® minocycline HCl (generic), myrac (generic)DynaCirc® isradipine (generic), amlodipine besylate (generic), nifedipine ER tablet, sustained release osmotic push

(generic), Sular® (First-Horizon)DynaCirc CR® amlodipine besylate (generic), nifedipine ER tablet, sustained release osmotic push (generic),

Sular® (First-Horizon)EC-Naprosyn® naproxen (generic)Effexor® venlafaxine HCl (generic)Effexor XR® venlafaxine HCl (generic), citalopram (generic), fluoxetine HCl (generic), paroxetine HCl (generic), sertraline

HCl (generic), Cymbalta® (Eli Lilly)Elavil® amitriptyline HCl (generic)Elestrin® estradiol patch (generic), Climara® (Berlex), Estraderm® (Novartis),Vivelle® (Novogyne)

Emsam® tranylcypromine sulfate (generic), Nardil® (Parke-Davis)Enduronyl® hydrochlorothiazide (generic), methyldopa/HCTZ (generic)Enduronyl Forte® hydrochlorothiazide (generic), methyldopa/HCTZ (generic)EryPed Chewable Tablet® 200mg erythromycin ethylsuccinate (generic)EryPed Suspension® 400mg/5ml erythromycin ethylsuccinate (generic)Esclim® estradiol (generic)Estrace Tablet® estradiol (generic)Estrace Vaginal Cream® Premarin Vaginal Cream® (Wyeth)Estrasorb® estradiol patch (generic)Estrogel® estradiol patch (generic), Climara Patch® (Berlex), Estraderm Patch® (Novartis),Vivelle Patch® (Novartis)Estrostep Fe® Apri® (Barr-branded generic*), Kariva® (Barr-branded generic*), Microgestin Fe® (Watson-branded generic*),

Cyclessa® (Organon)Exubera® Humalog® (Eli Lilly), Novolog® (Novo Nordisk)Factive® ciprofloxacin (generic), Avelox® (Schering), Levaquin® (J&J)


9



Feldene® piroxicam (generic)Femhrt® Activella® (Novo Nordisk), Premphase® (Wyeth), Prempro® (Wyeth)Femring® Estring® (Pfizer), Premarin Vaginal Cream® (Wyeth)Femtrace® estradiol (generic)Flonase® fluticasone propionate (generic)Floxin® ofloxacin (generic)Fortamet® tablet, SR osmotic push 24 hr metformin HCl ER tablet, sustained release 24 hr (generic), metformin HCl tablet (generic)Fulvicin U/F® griseofulvin ultramicrosize (generic), itraconazole (generic), ketoconazole (generic), terbinafine HCl

(generic)Gantrisin® sulfisoxazole (generic)Geocillin® ciprofloxacin HCl (generic)Glucophage® metformin HCl (generic)Glucophage XR® metformin HCl ER tablet, sustained release 24 hr (generic), metformin HCl tablet (generic)Glucotrol® glipizide (generic)Glucotrol XL® glipizide ER (generic)Glucovance® glyburide/metformin HCl (generic)Glynase® glyburide, micronized (generic)Glyset® Precose® (Bayer)Grifulvin V® griseofulvin ultramicrosize (generic), itraconazole (generic), ketoconazole (generic), terbinafine HCl

(generic)Gris-Peg® griseofulvin ultramicrosize (generic), itraconazole (generic), ketoconazole (generic), terbinafine HCl

(generic)Guanabenz Acetate® clonidine HCl (generic), methyldopa (generic)Halcion® triazolam (generic)Hiprex® methenamine hippurate (generic)Hytrin® terazosin (generic)Inderal® propranolol HCl (generic)Inderal LA® propranolol capsule, sustained action (generic)Indocin® indomethacin (generic)Innopran XL® propranolol capsule, sustained action (generic)Invega® Geodon® (Pfizer), Risperdal® (Janssen Pharmaceutical), Seroquel® (AstraZeneca), Zyprexa® (Eli Lilly)

Isoptin S.R.® verapamil HCl tablet, sustained action (generic)Keflex® cephalexin monohydrate (generic)Keftab® cephalexin monohydrate (generic)Kerlone® betaxolol HCl (generic)Ketek® amoxicillin trihydrate/potassium clavulanate (generic), azithromycin (generic), Avelox® (Schering),

Levaquin® (J&J)Lamisil® terbinafine HCl (generic)

Lescol® lovastatin (generic), simvastatin (generic), Altoprev® (Andrx), Crestor® (AstraZeneca), Lipitor® (Pfizer),VytorinTM (Merck/Schering)

Lescol XL® lovastatin (generic), simvastatin (generic), Altoprev® (Andrx), Crestor® (AstraZeneca), Lipitor® (Pfizer),VytorinTM (Merck/Schering)

Levatol® acebutolol HCl (generic), atenolol (generic), metoprolol tartrate (generic)Levlen® Levora® (Watson-branded generic*), Portia® (Barr-branded generic*)Levlite® Aviane® (Barr-branded generic*), Lessina® (Barr-branded generic*) Lexapro® citalopram (generic), fluoxetine HCl (generic), paroxetine HCl (generic), sertraline HCl (generic), Paxil CR®

(GlaxoSmithKline)Lexapro Solution® citalopram solution (generic), fluoxetine HCl solution (generic), paroxetine HCl suspension (generic)Lexxel® Lotrel® (Novartis)Librium® chlordiazepoxide HCl (generic)Lodine® etodolac (generic)Lodine XL® etodolac (generic)Loestrin® Junel® (Barr-branded generic*), Microgestin® (Watson-branded generic*)Loestrin Fe® Junel Fe® (Barr-branded generic*), Microgestin Fe® (Watson-branded generic*)Loestrin 24 Fe® Junel Fe® (Barr-branded generic*), Microgestin Fe® (Watson-branded generic*)Lofibra® fenofibrate (generic),Tricor® (Abbott),Triglide® (First Horizon)Lo/Ovral® Low-Ogestrel® (Watson-branded generic*)Lopid® gemfibrozil (generic)Lopressor® metoprolol tartrate (generic)Lopressor HCT® metoprolol/hydrochlorothiazide (generic)Lotensin® benazepril HCl (generic)Lotensin HCT® benazepril HCl/hydrochlorothiazide (generic)Ludiomil® maprotiline HCl (generic)Lunesta® temazepam (generic), zolpidem tartrate (generic), Ambien CR® (Sanofi-Aventis)Luvox® fluvoxamine maleate (generic)


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Macrobid® nitrofurantoin monohyd macro (generic)Macrodantin® nitrofurantoin macrocrystal (generic)Mandelamine® methenamine mandelate (generic)Mandelamine Hafgrams® methenamine mandelate (generic)Mavik® trandolapril HCl (generic), benazepril HCl (generic), enalapril maleate (generic), lisinopril (generic), quinapril

(generic), Aceon® (Solvay Pharmaceuticals), Altace® (Monarch)Maxaquin® ciprofloxacin HCl (generic), Avelox® (Schering), Levaquin® (J&J)Mellaril® chlorpromazine HCl (generic), haloperidol (generic), Risperdal® (Janssen), Seroquel® (AstraZeneca)Menest® estradiol (generic), estropipate (generic), Cenestin® (Duramed/Barr), Enjuvia® (Duramed/Barr),

Premarin® (Wyeth)Menostar Patch® Climara Patch® (Berlex),Vivelle Patch® (Novartis)Mescolor® Deconamine SR® (Bradley)Metaglip® glipizide/metformin (generic)Mevacor® lovastatin (generic)Micronase® glyburide (generic)Midrin® isometheptene/apap/dichloralphenazone (generic)Migranal® Imitrex® Nasal Spray (GlaxoSmithKline), Zomig® Nasal Spray (AstraZeneca), Amerge® (GlaxoSmithKline),

Frova® (Endo), Maxalt® (Merck), Relpax® (Pfizer)Minipress® prazosin HCl (generic)Minocin® minocycline HCl (generic)Mircette® Kariva® (Barr-branded generic*)Mobic® meloxicam (generic)Modicon® Necon® (Watson-branded generic*), Nortrel® (Barr-branded generic*)Monistat 3 Vaginal Suppository® miconazole 3 vaginal suppository (generic)Monodox® doxycycline monohydrate (generic)Monopril® fosinopril sodium (generic)Monopril HCT® fosinopril/hydrochlorothiazide (generic)Monurol® ciprofloxacin HCl (generic), sulfamethoxazole/trimethoprim (generic), trimethoprim (generic),

Noroxin® (Merck)Motrin® ibuprofen (generic)Nalex-A® rhinacon-A (generic)Nalfon® etodolac (generic), ibuprofen (generic), indomethacin (generic), meclofenamate sodium (generic),

naproxen (generic), sulindac (generic)Namenda Dose Pack® Aricept® (Eisai), Exelon® (Novartis), Razadyne® (Janssen Pharmaceuticals)Namenda Oral Solution® Exelon Oral Solution® (Novartis), Razadyne Oral Solution® (Janssen Pharmaceuticals)Namenda Tablet® Aricept® (Eisai), Exelon® (Novartis), Razadyne® (Janssen Pharmaceuticals)Naprelan® naproxen sodium (generic)Naprosyn® naproxen (generic)Nasacort® Nasacort AQ® (Aventis)Nasalide® flunisolide (generic)Nasarel® flunisolide (generic), fluticasone propionate (generic), Nasacort AQ® (Aventis), Nasonex® (Schering), Rhinocort

Aqua® (AstraZeneca)Neggram® ciprofloxacin HCl (generic), sulfamethoxazole/trimethoprim (generic), trimethoprim (generic),

Noroxin® (Merck)Nembutal Sodium® chloral hydrate (generic), temazepam (generic), triazolam (generic)Nimotop® nimodipine (generic)Niravam® alprazolam (generic)Nitro-Dur® nitroglycerin patch (generic), Minitran® (3M)Nizoral® ketoconazole (generic)Nordette® Levora® (Watson-branded generic*), Portia® (Barr-branded generic*)Norinyl® Necon® (Watson-branded generic*), Nortrel® (Barr-branded generic*)Normodyne® labetalol HCl (generic)Norpramin® desipramine HCl (generic)Norvasc® amlodipine besylate (generic)Novolin® Humulin® (Eli Lilly)Ogen® estropipate (generic)Omnicef® cefdinir (generic)Oracea® doxycycline monohydrate (generic)Orinase® tolbutamide (generic)Ortho-Cept® Apri®(Barr-branded generic*), Solia® (Prasco Labs-branded generic*)Ortho-Cyclen® MonoNessa® (Watson-branded generic*), Previfem® (Teva-branded generic*), Sprintec® (Barr-branded

generic*)Ortho Evra® MonoNessa® (Watson-branded generic*),TriNessa® (Watson-branded generic*)Ortho Micronor® norethindrone acetate (generic)


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Ortho-Novum® 1/35, 7/7/7 Necon® (Watson-branded generic*), Nortrel® (Barr-branded generic*)Ortho-Novum® 1/50 Necon® (Watson-branded generic*)Ortho-Prefest® Activella® (Novo Nordisk), Premphase® (Wyeth), Prempro® (Wyeth)Ortho Tri-Cyclen® TriNessa® (Watson-branded generic*),Tri-Previfem® (Teva-branded generic*),Tri-Sprintec® (Barr-branded

generic*)Oruvail® ketoprofen (generic)Ovcon® Necon® (Watson-branded generic*)Ovral® Ogestrel® (Watson-branded generic*)Pamelor® nortriptyline HCl (generic)Paxil® paroxetine HCl (generic)Paxipam® clorazepate dipotassium (generic), diazepam (generic), lorazepam (generic), oxazepam (generic)PCE® erythromycin base (generic)Pepcid® famotidine (generic)Perforomist® albuterol sulfate (generic), Foradil® (Schering), Serevent Diskus® (GlaxoSmithKline)

Periostat® doxycycline hyclate (generic)Pexeva® paroxetine HCl (generic)Phenergan® promethazine HCl (generic)Plendil® felodipine ER (generic), amlodipine besylate (generic), nifedipine ER tablet, sustained release osmotic push

(generic), Sular® (First-Horizon)Ponstel® etodolac (generic), ibuprofen (generic), indomethacin (generic), meclofenamate sodium (generic),

naproxen (generic), sulindac (generic)Pravachol® pravastatin (generic)Prevacid® omeprazole (generic), Nexium® (AstraZeneca)Prevacid Suspension® omeprazole (generic), Nexium® (AstraZeneca)Prilosec Rx® omeprazole (generic), Nexium® (AstraZeneca)Primsol® trimethoprim (generic)Prinivil® lisinopril (generic)Prinzide® lisinopril/hydrochlorothiazide (generic)Proair HFA® albuterol inhaler (generic), Proventil HFA® (Schering), Xopenex HFA® (Sepracor)Procardia XL® nifedipine ER tablet, sustained release osmotic push (generic)Proquin XR® ciprofloxacin HCl (generic)ProSom® estazolam (generic)Protonix® omeprazole (generic), Nexium® (AstraZeneca)Proventil® albuterol (generic)Proventil Multiphasic Release Tablet® albuterol sulfate (generic)Prozac® fluoxetine HCl (generic)Prozac Weekly® fluoxetine HCl (generic)Questran® cholestyramine/sucrose (generic)Questran Light® cholestyramine/aspartame (generic)Raniclor® tablet, chewable cefaclor suspension (generic), cefaclor capsule (generic)Relafen® nabumetone (generic)Remeron® mirtazapine soltabs (generic), mirtazapine tabs (generic)Restoril® 15mg, 30mg temazepam (generic)Rhinocort® Rhinocort AQ® (AstraZeneca)Riomet Solution® metformin HCl (generic)Rozerem® estazolam (generic), temazepam (generic), triazolam (generic), zolpidem tartrate (generic)Rynatan® phenclor tannate pediatric (generic), brompheniramine/pseudoephedrine (generic), pseudoephedrine

HCl/chlorpheniramine maleate (generic)Rynatuss® tablet Deconamine SR® (Bradley)Sanctura® oxybutynin chloride (generic), Detrol® (Pharmacia/Upjohn), Detrol LA® (Pharmacia/Upjohn), Enablex®

(Novartis),Vesicare® (GlaxoSmithKline)Sarafem® fluoxetine HCl (generic)Seasonale® Jolessa® (Barr-branded generic*), Quasense® (Watson-branded generic*), Seasonique® (Duramed/Barr),Seconal Sodium® chloral hydrate (generic), temazepam (generic), triazolam (generic)Sectral® acebutolol HCl (generic)Semprex-D® pseudoephedrine HCl/brompheniramine (generic), pseudoephedrine HCl/chlorpheniramine (generic)Septra DS® sulfamethoxazole/trimethoprim (generic)Serax® oxazepam (generic)Serzone® fluoxetine HCl (generic), paroxetine HCl (generic)Sinequan® doxepin HCl (generic)Solodyn® minocycline HCl (generic), doxycycline monohydrate (generic)Spectracef® cefaclor (generic), cefuroxime axetil (generic), Omnicef® (Abbott)Sporanox® capsule itraconazole (generic)Suprax® cefuroxime axetil (generic), Omnicef® (Abbott)


12



Symbyax® fluoxetine HCl (generic), Risperdal Tablet® (Janssen), Seroquel® (AstraZeneca), Zyprexa® (Eli Lilly)Tagamet® cimetidine (generic)Tarka® Lotrel® (Novartis)Tenex® guanfacine HCl (generic)Tenoretic® atenolol/chlorthalidone (generic)Tenormin® atenolol (generic)Tequin® Avelox® (Schering), Levaquin® (J&J)Terazol® terconazole (generic)Teveten® Atacand® (AstraZeneca), Benicar® (Sankyo), Cozaar® (Merck), Diovan® (Novartis), Micardis® (BIPI)Teveten HCT® Atacand HCT® (AstraZeneca), Benicar HCT® (Sankyo), Diovan HCT® (Novartis), Hyzaar® (Merck),

Micardis HCT® (BIPI)Thioridazine HCl® chlorpromazine HCl (generic), haloperidol (generic), Risperdal® (Janssen), Seroquel® (AstraZeneca)Tiazac® 120mg, 180mg, 240mg, 300mg, 360mg diltiazem HCl capsule, sustained release 24 hr (generic)Tiazac® 420mg Cardizem LA® (Biovail)Tofranil® imipramine HCl (generic)Toprol XL® metoprolol succinate (generic)Toradol® etodolac (generic), ibuprofen (generic), indomethacin (generic), meclofenamate sodium (generic),

naproxen (generic), sulindac (generic)Trandate® labetalol HCl (generic)Tranxene SD® clorazepate dipotassium (generic)Tranxene T-Tab® clorazepate dipotassium (generic)Tri-Levlen® Enpresse® (Barr-branded generic*),Trivora® (Watson-branded generic*)Tri-Norinyl® Necon® (Watson-branded generic*), Nortrel® (Barr-branded generic*)Triphasil® Enpresse® (Barr-branded generic*),Trivora® (Watson-branded generic*)Uniretic® moexipril/hydrochlorothiazide (generic), benazepril HCl/hydrochlorothiazide (generic), enalapril

maleate/hydrochlorothiazide (generic), lisinopril/hydrochlorothiazide (generic)Univasc® benazepril (generic), enalapril maleate (generic), lisinopril (generic), Aceon® (Solvay Pharmaceuticals),

Altace® (Monarch)Valium® diazepam (generic)Vancenase® Nasonex® (Schering), Rhinocort AQ® (AstraZeneca)Vantin Suspension® cefaclor suspension (generic), Omnicef Suspension® (Abbott)Vantin Tablet® cefpodoxime proxetil tablet (generic)Vaseretic® enalapril maleate/hydrochlorothiazide (generic)Vasotec® enalapril maleate (generic)Velosef® cephradine (generic)Ventolin® albuterol (generic)Ventolin HFA® albuterol (generic), Proventil HFA® (Schering)Verelan® verapamil ER (generic)Verelan PM® verapamil ER PM (generic)Vfend Suspension® Vfend Tablet® (Pfizer)Vibramycin Syrup® Vibramycin Suspension® (Pfizer)Vistaril® hydroxyzine pamoate (generic)Volmax® albuterol sulfate (generic)Voltaren® etodolac (generic), ibuprofen (generic), naproxen (generic)Voltaren-XR® etodolac (generic), ibuprofen (generic), naproxen (generic)Wellbutrin® bupropion HCl (generic)Wellbutrin SR® bupropion HCl tablet, sustained release (generic)Wellbutrin XL® 300mg bupropion tablet, sustained release (generic)Wytensin® clonidine HCl (generic), methyldopa (generic)Xanax® alprazolam (generic)Xanax XR® alprazolam XR (generic)Xifaxan® ciprofloxacin HCl (generic), azithromycin (generic)Xolair® Asmanex® (Schering), Flovent HFA® (GlaxoSmithKline), Pulmicort® (AstraZeneca), QVAR® (Ivax)Zantac Rx Syrup® ranitidine HCl tablet (generic), Axid Oral Solution® (Braintree)Zantac Rx Tablet® ranitidine HCl tablet (generic)Zebeta® bisoprolol fumarate (generic)Zegerid® omeprazole (generic), Nexium® (AstraZeneca)Zestoretic® lisinopril/hydrochlorothiazide (generic)Zestril® lisinopril (generic)Ziac® bisoprolol fumarate/hydrochlorothiazide (generic)Zithromax® azithromycin (generic)Zmax® azithromycin (generic)Zocor® simvastatin (generic)Zoloft® sertraline HCl (generic)Zyflo® Accolate® (AstraZeneca), Singulair® (Merck)


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