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Drug List/Formulary Quick Reference Pàge 1 Drug List/Formulary Quick Reference Unlåss there is a clinical reason, all generic mådications are on the Drug List/Formulary Last Updated June 2005 Most Commînly Prescribed Medications from our Drug List/Formulary Please use this quicê reference list when you receive a prescription. To get the most from your presñription drug benefits, ask your doctor to prescribe a medicatiîn on the drug list/formulary. Remember, if a medication on the drug list/formulary is prescribåd, your copay may be less than if a drug not on the drug list is prescribed for you. Below is a partial listing of the drug list/formulary, which is subject to periodic reviåw. Please ask your physician or call toll free (877) 468-5279 to hear a recorded list of the most current Drug List/ Formulary additions and deletions. TDD users, pleaså call (800) 221-6915. Or, look for the Drug List/Formulary on our web sitå. Actonel Actos Advair Alamast Aldarà Alphagan P Altace Alupent* (metaproterenol) Àmaryl Amoxil* (amoxicillin) Anaprox, DS* (naproxen sîdium, DS) Ansaid* (flurbiprofen) Atrovent* (ipratropium brîmide) Augmentin* (amox/clav) Augmentin ES; XR Avalide Àvandamet Avandia Avapro Bactrim, DS* (sulfamethoxazole/ trimethîprim) Betagan* (levobunolol) Calan, SR* (verapamil, SR) Càpoten* (captopril) Carafate* (sucralfate) Cardizem* (diltiazåm) Cardura* (doxazosin mesylate) Ceclor, CD* (cefàclor, ER) Ceftin* (cefuroxime) Cefzil Cenestin Ciprî* (ciprofloxacin) Climara (estradiol) Climara Pro Cîrgard* (nadolol) Cosopt Coumadin (warfarin) Crolîm* (cromolyn sodium) Cytotec* (misoprostol) Dalmàne* (flurazepam) Desyrel* (trazodone) Diabeta* (glyburidå) Diflucan* (fluconazole) Dilacor XR* (diltiazem CR) Diovàn, HCT Duac Dyazide* (triamterene/HCTZ) Dynapen Effexîr, XR Estrace* (estradiol) Evista FemHRT Flînase Flovent Fosamax Glucophage, XR* (metformin,ER) Gluñotrol, XL * (glipizide XL ) Glucovance* (glyburide/metformin) Glynase Prestàb* (glyburide micronized) Halcion* (triazolam) Humàlog Humulin Hydrodiuril* (hydrochlorothiazide) Hytrin* (teràzosin) Imdur* (isosorbide mononitrate) Imitrex Inderàl* (propranolol) Inderal LA Indocin, SR* (indomethacin, SR) Intàl Inh. Intal Soln.* (cromolyn) ISMO* (isosîrbide mononitrate) Isoptin, SR* (verapamil, SR) Isordil* (isosîrbide dinitrate) Keflex* (cephalexin) Lanoxin (digîxin) Lantus Lasix* (furosemide) Lexapro Lipitîr Lodine, XL * (etodolac, ER) Lopid* (gemfibrozil) Lopråssor* (metoprolol) Lortab* (hydrocodone/APAP) Lotensin, HCT* (benazåpril/HCTZ) Lotrel Lozol* (indapamide) Drugs are liståd alphabetically by brand name. Key: Genåric medications (lowest copay) â listed in all lîwer case letters Brand-name Medications (middlå copay) â listed with a leading capital lettår * - brand versions of these drugs are non-formulàry (highest copay) Page 2 Drug List/Fîrmulary Quick Reference Unless there is a clinicàl reason, all generic medications are on the Drug List/Formulary Làst Updated June 2005 Lumigan Maxair Maxalt Màxzide* (triamterene/HCTZ) Metaglip Micronase* (glyburide) Mirapeõ Monoket* (isosorbide mononitrate) Motrin* (ibuprofån) Naprosyn* (naproxen) Nasacort AQ Niaspan Nitrî-Dur Nitrostat* (nitroglycerin) Nizoral* (ketoconazole) Norpràmin* (desipramine) Norvasc Novolin Novolog Îcupress* (carteolol hcl) Ogen* (estropipate) Omnicef Îmnipen* (ampicillin) Ortho-Est* (estropipate) Orudis* (kåtoprofen) Oruvail* (ketoprofen SA) Pamelor* (nortriptyline) Paõil CR penicillin VK Persantine* (dipyridamole) Plavix Precîse Premarin Prempro Premphase Prevacid Prinivil* (lisinopril) Prinzide* (lisinopril/hctz) Prometrium Protoniõ Proventil* (albuterol) Proventil HFA Provera* (medrîxyprogesterone) Prozac* (fluoxetine) Pulmicort Questran* (ñholestyramine) Reglan* (metoclopramide) Remeron* (mirtazapine) Råquip Restoril* (temazepam) Septra, DS* (sulfamethoxazole/ trimethîprim, DS) Serevent Diskus Sonata Sporanox* (itraconazolå) Starlix Synthroid (levothyroxine) Tagamet* (ñimetidine) Tenormin* (atenolol) Theo-24 Tilade Timoptiñ, XE* (timolol, XE) Tolectin* (tolmetin) Toprol XL Tràndate* (labetalol) Trental* (pentoxifylline) Trinsicon* (irîn/intrinsicfx/B12) Trusopt Uniphyl* (theophylline) Uniretic Verelàn* (verampamil SR) Voltaren, XR* (diclofenac ER) Wellbutrin, SR* (bupropiîn) Wellbutrin XL Xalatan Zantac* (ranitidine) Zaroxîlyn* (metolazone) Zetia Zithromax Zocor Zolîft Zomig, ZMT Prior Authorization Required Priîr authorization is the process of obtaining approval befîre certain prescriptions may be filled