2004 Prescription Drug Guide for Members with a Three-Tier Pharmacy Benefit

2004 Prescription Drug Guide For Members with a three-tier pharmacy benefit

If you have questions about your prescription drug benefit, please call Pharmacy Customer Service at 800-905-0201

Medco Health is your pharmacy benefit manager, at the request of Oxford Health Plans. Live life well is a trademark of Medco Health Solutions, Inc. ©2004 Medco Health Solutions, Inc. All Rights Reserved.

MS-04-153 MG903337 6922 Dear Member: Your healthcare coverage through Oxford Health Plans includes prescription drug benefits that are administered by Medco Health. Your prescription drug benefit includes a formulary. The formulary represents outpatient prescription drugs that may be covered for Members under their Oxford Health Plans’ prescription drug benefit. The formulary is developed by Oxford Health Plans Pharmacy and Therapeutics Committee (P&T Committee), which reviews each medication on the list for Food and Drug Administration (FDA) approval for safety and efficacy. Oxford's P&T Committee will regularly review new and existing medications so that the formulary remains responsive to the needs of our Members and providers. Section I of this guide lists formulary drugs within the most commonly prescribed therapeutic drug categories. A three-tier prescription drug benefit provides Members with the option of paying a lower copayment (cost share) for preferred drugs and a higher copayment (cost share) for non-preferred drugs. Section II of this guide lists commonly prescribed non-preferred drugs with possible preferred alternatives. Section III is an alphabetical listing of generic and preferred brand drugs. Section IV lists medications that generally require precertification (also known as prior authorization) depending on your prescription drug plan. In some cases your plan may specify other limits or exclusions to coverage of certain medications from your prescription drug benefit. You can refer to your Prescription Drug Rider and your Summary of Benefits for specific plan information. Please discuss any questions or concerns about your drug therapy with your physician or pharmacist. Please share this guide with your physician before filling your next prescription.

Dear Physician: Please refer to this guide when prescribing for this patient. This guide does not contain a complete list of medications covered by the plan. Section I lists formulary drugs within the most commonly prescribed therapeutic categories. Section II lists commonly prescribed non-preferred drugs with possible preferred alternatives. Section III is an alphabetical listing of generic and preferred brand drugs. Section IV lists medications that generally require precertification (also known as prior authorization) depending on the Member’s prescription drug plan. Please keep in mind, your patient’s plan may require a higher copayment (cost share) for a prescription written for a medication not on Oxford’s preferred drug list. We realize that prescribing for patients over 65 may involve special considerations. To help address this, we are providing information based on guidelines proposed by geriatric medical experts. When a symbol precedes a medication, caution should be used in prescribing for patients over 65; safer choices may be available. Medications preceded by a symbol may require dosage reductions below manufacturer guidelines. When medications are preceded by symbols, caution should be used in prescribing these medications for pregnant patients. We also realize that a preferred drug may not always be right for your patient. Prescribing with cost and coverage in mind, you can help to ensure that your patient has access to affordable prescription coverage. Use of preferred products may result in a lower copayment (cost share) for participants; non-preferred drugs may be available at a higher copayment (cost share). Please consider prescribing preferred drugs for your patients when appropriate. This guide and its recommendations are not intended to be a substitute for your professional judgment. Rather, we offer them as a tool to help you maximize efficacy while taking into account drug therapy problems and costs. We hope that you will use it as a guide to prescribe preferred drugs and to check on drug selection and dosing. As always, only you can make appropriate prescribing decisions for your patient’s medical treatment. Please note: The contents of this guide represent outpatient prescription drugs that may be covered for Members under Oxford Health Plans' Drug Benefit. The listing of a drug product does not guarantee coverage as certain products are excluded due to benefit plan design limitations that are specific to Members' individual or group benefits. • Based on plan design, selected high-risk or high-cost medications may require precertification by Oxford to be eligible for coverage. • For certain medications, a limitation on the quantity covered at one time is in place, often reflecting the maximum FDA-recommended dosage for a medication or use of the most efficient dosage strength for the fully prescribed daily dose. • Diabetes supplies that are available through the Member’s base medical benefit will be subject to the applicable copayment (cost share) noted on the Member’s Summary of Benefits. The information contained herein is in effect at the time of printing and may be subject to change. 2 SECTION I: FORMULARY DRUGS IN MOST COMMONLY PRESCRIBED THERAPEUTIC DRUG CATEGORIES

ANTI-INFECTIVES (Antibiotics/Antifungals)

Oral Antifungals Oral Sulfas $$ Eryped drops, $ +griseofulvin $ +smz/tmp suspension ultramicrosize $ +sulfisoxazole $$ Zithromax* $ +nystatin $ +sulfisoxazole/ Oral Quinolones $$$$ Diflucan* erythromycin $$$ Tequin $$$$ +ketoconazole !!!!! +sulfadiazine $$$$ Avelox Oral Cephalosporins Oral Tetracyclines $$$$ Cipro* $ +cephalexin $ +doxycycline $$$$ Levaquin $$ +cefaclor hyclate $$$$ +ofloxacin $$$$ Ceftin suspension $ +tetracycline Oral Urinary Tract Agents $$$$ +cefuroxime $$$ +minocycline $ +trimethoprim $$$$ Omnicef Oral Erythromycins $$ Monurol* Oral Penicillins $ +erythromycin base, $$ +nitrofurantoin $ +amoxicillin delayed release caps Oral Misc.Agents $ +ampicillin $ +erythromycin base $$ +clindamycin $ +dicloxacillin film & enteric $$ Dapsone $ +penicillin VK coated tabs $$ +neomycin $$ Dynapen suspension $ +erythromycin $$$ +amoxicillin/ ethylsuccinate Vaginal Antifungals potassium $ +erythromycin $$$ Diflucan 150mg clavulanate stearate 250 mg. (single dose)* $$$ Augmentin ES and 500 mg. only $ +erythromycin w/sulfisoxazole

CARDIOVASCULAR (Blood Pressure/Heart/Cholesterol)

ACE Inhibitors/ Angiotensin II Blockers $$ +verapamil Combination Agents $$$ Benicar long acting $ +captopril $$$ Benicar HCT $$$ +diltiazem SR $ +moexipril $$$$ Cozaar Dihydropyridines $$ Accuretic $$$$ Hyzaar $ +nifedipine $$ +benazepril/ Beta Blockers $$$ Norvasc hydrochlorothiazide $$ +enalapril $ +atenolol Nitroglycerin Patches $$ +lisinopril $ +metoprolol $$$ +nitroglycerin $$$ Accupril $ +pindolol transdermal $ +timolol $$$$ Nitro Dur $$$ +benazepril $ +propranolol $$$ +fosinopril $$ +acebutolol Adrenergic Antagonists $$$ +lisinopril/ $$ +nadolol & Related Drugs hydrochlorothiazide $$ Toprol XL $ +clonidine Antilipidemics $$$ Inderal LA $ +doxazosin $$ +gemfibrozil $$$ +labetalol $ +methyldopa $$ +lovastatin* $$$ +propranolol LA $ +prazosin $$$ +cholestyramine $$$$$ Coreg $ +reserpine $$ +guanfacine $$$ +cholestyramine Calcium Blockers light $$$ +terazosin $ +diltiazem $$$$ Catapres-TTS* $$$ Lipitor* $$$$ Zocor* $$ +verapamil

For symbol meanings, please refer to the KEY located at the bottom of Page 5. 3 ENDOCRINE (Diabetes/Hormones/Contraceptives)

Insulin Therapy $$ +metformin, Contraceptives $$ ‡Humulin® (Lilly) extended-release $$ Alesse (all forms) $$ Precose $$ Estrostep FE $$ Novolin vials $$$ Glucovance $$ Loestrin (Novo Nordisk) $$$ Metaglip $$ Loestrin FE $$$ Lantus $$$$ Avandia* $$ Lo/Ovral $$$ Novolin InnoLet $$$$ Prandin $$ Micronor $$$$ Humalog $$$$ Starlix $$ Modicon $$$$ Humalog Pen $$$$$ Actos* $$ Ortho Evra $$$$ Humulin Pen $$$$$ Avandamet* $$ Ortho Tri-Cyclen $$$$ Iletin® (Lilly) Estrogens/Combinations $$ Ortho Tri-Cyclen Lo $$$$$ Novolin pens/ $ ‡Premarin $$ Ortho-Cept cartridges $ +estropipate $$ Ortho-Cyclen (Novo Nordisk) $ +micronized $$ Ortho-Novum $$$$$ NovoLog vials estradiol $$ Ovrette !!! NovoLog pens and $ Premphase, $$ Triphasil cartridges Prempro $$ Yasmin Oral Hypoglycemics $$ Climara* Blood Glucose Test Strips $ Amaryl $$ +estradiol patch* $$$ Accu-Chek® $ +glipizide $$ Femhrt $$$ Chemstrip® $ +glipizide, $$ +methyltestos- $$$ Fast Take® extended-release terone/estrogens $$$ One Touch® $ +glyburide esterified $$$ One Touch Ultra® $$ +metformin $$ Vivelle*,Vivelle DOT* $$$ Surestep® $$$ Estring* $$$ Tracer® BG

G. I. (Ulcer)

Ulcer Drugs $$ +misoprostil Other G.I. Drugs $ +cimetidine $$$ +nizatidine $ +metoclopramide $ +famotidine $$$ Protonix § (PAR)* $$ +sucralfate $ +ranitidine $$$$ Nexium § (PAR)* !!!!! PrevPac* $$$$ +omeprazole (PAR)*

PSYCHOTHERAPEUTICS (Anxiety/Depression)

Tricyclic Antidepressants $$$$ +paroxetine* $ +lithium carbonate $ +amitriptyline $$$$ Zoloft* $ +perphenazine $ +desipramine MAOI $ +thioridazine $ +doxepin $ +thiothixene $$ Nardil $ +imipramine $$$ Parnate $ +trifluoperazine $ +nortriptyline $$ +chlorpromazine $$ +clomipramine Anxiolytics $$ Orap $$ +protriptyline $ +alprazolam $$$ +loxapine $ +chlordiazepoxide $$$$ Moban Misc. Antidepressants $ +diazepam $$$$$ Risperdal $ +trazodone $$ +lorazepam !!!!! Zyprexa $$ +mirtazapine $$ +oxazepam $$ +nefazodone Hypnotic Agents $$$ +bupropion $$$ +clorazepate $ +chloral hydrate $$$ Effexor $$$$ +buspirone $ +temazepam $$$$ Effexor XR Antipsychotics $ +triazolam $$$$ Wellbutrin SR $ Eskalith CR $$$ Sonata* SSRI $ +fluphenazine $$$ +fluoxetine* $ +haloperidol

For symbol meanings, please refer to the KEY located at the bottom of Page 5. 4 NSAIDS (Pain Relievers)

NSAIDs $ +sulindac NSAID COX II Inhibitors $ +ibuprofen $$ +diclofenac sodium $$$$ Bextra § (PAR)* $ +indomethacin $$ +etodolac $$$$ Celebrex § (PAR)* $ +naproxen $$$ +oxaprozin $$$$ Vioxx § (PAR)* $ +naproxen sodium $$$ +ketoprofen $ +indomethacin SR $$$ +nabumetone $ +piroxicam $$$ +tolmetin

RESPIRATORY (Allergy/Asthma)

Nasal Corticosteroids Beta Agonists Inhaled Steroids $$$ Flonase* $ +albuterol inhaler* $$$ Flovent Rotadisk* $$$ +flunisolide* $ +albuterol tablets, $$$$ Flovent* $$$$ Rhinocort Aqua* syrup !!!!! Pulmicort Respules* $$$ Maxair*, Misc. Pulmonary Agents Antihistamines Maxair Autohaler* $ +cyproheptadine $$$ Atrovent MDI $$$$ +albuterol soln $ +diphenhydramine $$$ +cromolyn sodium $$$$ +isoetharine soln $ +hydroxyzine neb. soln $$$$ +metaproterenol $ +promethazine $$$ Singulair (PAR) tablets, syrup, $ +tripelennamine $$$ Tilade inhaler* inhalation $$ +clemastine $$$$$ Advair* solution $$$ Zyrtec § * !!!!! ‡Mucomyst $$$$ Serevent Diskus* $$$ Zyrtec-D § *

MISCELLANEOUS

$$$ Actonel 35 mg* $$$ Fosamax* $$$$ Evista*

Key: Cost Scale Lowest relative cost Highest relative cost to plan sponsor to plan sponsor $ $$ $$$ $$$$ $$$$$ !!! !!!! !!!!!

+ = Use generic (brand non-preferred). ‡ = Brand preference exists. Use designated brand. = The recommended dose for people 65 and older is often lower than the usual dosing guidelines. = Use by people 65 and older is generally not recommended. The side effects may not be obvious, but may be serious. Safer medications may be available. If used, lower dosages are recommended. Bold = Denotes a formulary drug with a preferred copayment (cost share). § = Denotes a formulary drug with a higher copayment (cost share). * = Denotes medications affected by quantity limits. (PAR) = Precertification required (also known as prior authorization). To obtain precertification, please call Medco Health directly at 1-800-753-2851, Monday through Friday from 8:00 AM to 9:00 PM (eastern standard time). = Do not use while pregnant. = Weigh risk of birth defects or other adverse outcomes. 5 SECTION II: USING PREFERRED ALTERNATIVES Below is a list of the most commonly prescribed non-preferred drugs along with possible preferred alternatives, which may be appropriate for treatment. Only you and your doctor can make appropriate prescribing decisions for your medical treatment. If your doctor decides that you need to continue taking a non-preferred brand drug, you have the option to do so. Please be aware, however, that your copayment (cost share) may be higher. We encourage you, and your doctor, when medically appropriate, to consider generic or preferred brand alternatives that can help keep your out-of-pocket expenses lower.

Non-preferred Drug Preferred Alternatives Accolate® Singulair® (Merck & Co.) Accutane® isotretinoin (generic) Aceon® enalapril (generic), captopril (generic), fosinopril (generic), lisinopril (generic), Accupril® (Pfizer, Inc.) Aciphex® omeprazole (generic) Aclovate® hydrocortisone cream, ointment 2.5 % (generic), fluocinolone acetonide cream .01% (generic), desonide cream .05% (generic) Activella® Premphase® (Wyeth-Ayerst), Prempro® (Wyeth-Ayerst) Adalat CC® nifedipine [extended-release] (generic) Adderall® amphetamine/dextroamphetamine (generic) Adderall XR® amphetamine/dextroamphetamine (generic) Advicor® lovastatin (generic), Lipitor® (Pfizer Inc.), Zocor® (Merck & Co.) Aerobid® Flovent® (GlaxoSmithKline) Aerobid-M® Flovent® (GlaxoSmithKline) Alocril® Acular® (Allergan),Acular PF® (Allergan), Livostin® (Novartis) Altace® enalapril (generic), captopril (generic), fosinopril (generic), lisinopril (generic), Accupril® (Pfizer, Inc.) Ambien® triazolam (generic), temazepam (generic), Sonata® (Elan) Anzemet® Kytril® (Roche), Zofran® (GlaxoSmithKline) Aristocort A® triamcinolone acetonide cream, ointment .1% (generic) Atacand® Benicar® (Sankyo Pharma), Cozaar® (Merck & Co.) Atacand HCT® Benicar HCT® (Sankyo Pharma), Hyzaar® (Merck & Co.) Ativan® lorazepam (generic) Augmentin® amoxicillin/potassium clavulanate (generic) Avalide® Benicar HCT® (Sankyo Pharma), Hyzaar® (Merck & Co.) Avapro® Benicar® (Sankyo Pharma), Cozaar® (Merck & Co.) Axid® nizatidine (generic) Azelex® azelaic acid (generic) Azmacort® Flovent® (GlaxoSmithKline) Bactroban® ointment mupirocin ointment (generic) Benzac® benzoyl peroxide (generic) Benzaclin® benzoyl peroxide (generic), clindamycin phosphate (generic) Benzamycin® erythromycin topical (generic), benzoyl peroxide (generic) Betapace® sotalol (generic) Betimol® timolol maleate (generic) Biaxin® erythromycin (generic), Zithromax® (Pfizer, Inc.) Biaxin XL® erythromycin (generic), Zithromax® (Pfizer, Inc.) Brethine® terbutaline (generic) Brevicon® norethindrone-ethinyl estradiol (generic) Brevoxyl® benzoyl peroxide (generic) Buspar® buspirone (generic) Capoten® enalapril (generic), captopril (generic), fosinopril (generic), lisinopril (generic), Accupril® (Pfizer, Inc.)

6 SECTION II: USING PREFERRED ALTERNATIVES (CONTINUED)

Non-preferred Drug Preferred Alternatives Capozide® captopril/hydrochlorothiazide (generic), lisinopril/hydrochlorothiazide (generic), Accuretic® (Pfizer, Inc.) Cardene® nicardipine HCl (generic) Cardene SR® nicardipine HCl (generic), Norvasc® (Pfizer, Inc.) Cardizem CD® diltiazem HCl [extended-release] (generic) Cartrol® atenolol (generic), metoprolol (generic),Toprol XL® (AstraZeneca), Inderal LA® (Wyeth-Ayerst) Ceclor CD® cefaclor (generic), cefuroxime (generic), Omnicef® (Abbott Labs) Cedax® cefaclor (generic), cefuroxime (generic), Omnicef® (Abbott Labs) Ceftin® tablets cefuroxime (generic) Cefzil® cefaclor (generic), cefuroxime (generic), Omnicef® (Abbott Labs) Celexa® fluoxetine (generic), paroxetine (generic), Zoloft® (Pfizer, Inc.) Cenestin® estradiol (generic), Premarin® (Wyeth-Ayerst) Ciloxan® Ocuflox® (Allergan) Cipro HC® neomycin sulfate/polymyxin B/hydrocortisone otic solution (generic), Floxin Otic® (Daiichi) Cleocin T® solution clindamycin topical solution (generic) Clindagel® erythromycin (generic), clindamycin phosphate (generic) Cloderm® fluocinolone acetonide cream .025% (generic), desoximetasone cream .05% (generic), betamethasone valerate cream .1% (generic), Cordran SP® (Watson), Pandel® (Savage Labs) Cognex® Aricept® (Pfizer, Inc.) Colazal® sulfasalazine (generic),Asacol® (P&G), Pentasa® (Shire) Colestid® cholestyramine (generic) Coly-Mycin S Otic® neomycin sulfate/polymyxin B/hydrocortisone otic solution (generic), Floxin Otic® (Daiichi) Combipatch® Premphase® (Wyeth-Ayerst), Prempro® (Wyeth-Ayerst) Concerta® methylphenidate sustained release (generic), methylphenidate immediate release (generic) Cortisporin-TC Otic® neomycin sulfate/polymyxin B/hydrocortisone otic solution (generic), Floxin Otic® (Daiichi) Covera HS® verapamil HCl [extended-release] (generic) Cutivate® betamethasone valerate cream, lotion .1% (generic), fluocinolone acetonide cream, ointment .025% (generic), hydrocortisone valerate cream, ointment .2% (generic), Pandel® cream .1% (Savage Labs) Cyclocort® desoximetasone cream, ointment .25% (generic), betamethasone dipropionate cream, ointment .05% (generic), fluocinonide cream, ointment .05% (generic), Halog® (Westwood-Squibb), Halog-E® (Westwood-Squibb) Cylert® pemoline (generic) Cytotec® misoprostol (generic) Dalmane® flurazepam (generic) Darvocet-N® propoxyphene napsylate/acetaminophen (generic) Daypro® oxaprozin (generic), ibuprofen (generic), naproxen (generic), nabumetone (generic) Demadex® bumetanide (generic), furosemide (generic) Dermatop® fluocinolone acetonide cream .025% (generic), desoximetasone cream .05% (generic), betamethasone valerate cream .1% (generic), Cordran SP® (Watson), Pandel® (Savage Labs) Desogen® desogestrel-ethinyl estradiol (generic) DesOwen® desonide (generic) Desquam® benzoyl peroxide (generic) Detrol LA® oxybutynin (generic)

7 SECTION II: USING PREFERRED ALTERNATIVES (CONTINUED)

Non-preferred Drug Preferred Alternatives Diamox Sequels® acetazolamide (generic) Differin® tretinoin (generic) Dilaudid® hydromorphone (generic) Diovan® Benicar® (Sankyo Pharma), Cozaar® (Merck & Co.) Diovan HCT® Benicar HCT® (Sankyo Pharma), Hyzaar® (Merck & Co.) Dipentum® sulfasalazine (generic),Asacol® (P&G), Pentasa® (Shire) Diprolene AF® desoximetasone cream .25% (generic), betamethasone dipropionate cream .05% (generic), fluocinonide cream .05% (generic), Halog® (Westwood-Squibb), Halog-E® (Westwood-Squibb) Ditropan XL® oxybutynin (generic) Doral® triazolam (generic), temazepam (generic), Sonata® (Elan) Doryx® doxycycline (generic) Dostinex® bromocriptine (generic) Duricef® cefadroxil (generic), cefuroxime (generic), cephalexin (generic) Dyazide® triamterene/hydrochlorothiazide (generic) Dynabac® erythromycin (generic), Zithromax® (Pfizer, Inc.) Dynacin® minocycline (generic) Dynacirc® nifedipine (generic), Norvasc® (Pfizer, Inc.) Dynacirc CR® nifedipine [extended-release] (generic), Norvasc® (Pfizer, Inc.) EC-Naprosyn® naproxen [delayed-release] (generic) Elocon® betamethasone valerate cream, lotion .1% (generic), fluocinolone acetonide cream, ointment .025% (generic), hydrocortisone valerate cream, ointment .2% (generic), Cordran® (Watson), Cordran SP® (Watson) Emadine® Acular® (Allergan),Acular PF® (Allergan), Livostin® (Novartis) Estinyl® estradiol (generic), estropipate (generic), Premarin® (Wyeth-Ayerst) Estratab® estradiol (generic), estropipate (generic), Premarin® (Wyeth-Ayerst) Estrace® estradiol (generic) Estrace® cream Premarin® vaginal cream (Wyeth-Ayerst) Exelderm® econazole (generic), ketoconazole (generic) Exelon® Aricept® (Pfizer, Inc.) Flagyl ER® metronidazole [sustained action] (generic) Florinef® fludrocortisone acetate (generic) Floxin® ofloxacin (generic) Flumadine® amantadine HCl (generic) Focalin® methylphenidate sustained release (generic), methylphenidate immediate release (generic) Foradil® Serevent® (GlaxoSmithKline) Geodon® Risperdal® (Janssen), Zyprexa® (Eli Lilly) Glucophage® metformin (generic) Glucophage XR® metformin [extended-release] (generic) Glucotrol® glipizide (generic) Glucotrol XL® glipizide [extended-release] (generic) Grifulvin V® griseofulvin ultramicrosize (generic) Gris-Peg® griseofulvin ultramicrosize (generic) Grisactin® griseofulvin ultramicrosize (generic) Hycotuss® guaifenesin/hydrocodone bitartrate (generic) Hylorel® clonidine (generic), methyldopa (generic) Hytrin® terazosin (generic) K-Dur® potassium chloride tablet [controlled-release] (generic)

8 SECTION II: USING PREFERRED ALTERNATIVES (CONTINUED)

Non-preferred Drug Preferred Alternatives Keftab® cephalexin (generic) Kerlone® betaxolol (generic) Klonopin® clonazepam (generic) Ku-Zyme® Pancrease® (McNeil), Pancrease MT® (McNeil), Ultrase® (Scandipharm), Ultrase MT® (Scandipharm) Kutrase® Pancrease® (McNeil), Pancrease MT® (McNeil), Ultrase® (Scandipharm), Ultrase MT® (Scandipharm) Lac-Hydrin® ammonium lactate (generic) Lanoxicaps® Lanoxin® (GlaxoSmithKline) Lariam® mefloquine (generic) Lasix® furosemide (generic) Lescol® lovastatin (generic), Lipitor® (Pfizer, Inc.), Zocor® (Merck & Co.) Lescol XL® lovastatin (generic), Lipitor® (Pfizer, Inc.), Zocor® (Merck & Co.) Levatol® atenolol (generic), metoprolol (generic),Toprol XL® (AstraZeneca), Inderal LA® (Wyeth-Ayerst) Levlite® levonorgestrel-ethinyl estradiol (generic) Lexapro® fluoxetine (generic), paroxetine (generic), Zoloft® (Pfizer, Inc.) Lithobid® lithium carbonate (generic) Locoid® triamcinolone acetonide cream, lotion, ointment .1% (generic), fluocinolone acetonide cream, ointment .025% (generic), betamethasone dipropionate lotion .05% (generic), Cordran® (Watson), Cordran SP® (Watson), Pandel® (Savage Labs) Lodine® etodolac (generic) Lodine XL® etodolac [extended-release] (generic) Loprox® econazole (generic), ketoconazole (generic) Lorabid® cefaclor (generic), cefuroxime (generic), Omnicef® (Abbott Labs) Lotensin® enalapril (generic), captopril (generic), fosinopril (generic), lisinopril (generic), Accupril® (Pfizer, Inc.) Lotrisone® cream clotrimazole/betamethasone dipropionate (generic) Luvox® fluvoxamine (generic) Luxiq® betamethasone valerate lotion .1% (generic) Macrobid® nitrofurantoin (generic) Mavik® enalapril (generic), captopril (generic), fosinopril (generic), lisinopril (generic), Accupril® (Pfizer, Inc.) Maxaquin® ofloxacin (generic),Avelox® (Bayer), Cipro® (Bayer), Levaquin® (Ortho Pharma), Tequin® (BMS Primarycare) Medrol® methylprednisolone (generic) Mentax® econazole (generic), ketoconazole (generic) Metadate CD® methylphenidate sustained release (generic), methylphenidate immediate release (generic) Mevacor® lovastatin (generic) Microzide® hydrochlorothiazide (generic) Minitran® nitroglycerin transdermal (generic), Nitro-Dur® (Schering-Plough) Mobic® flurbiprofen (generic), ibuprofen (generic), naproxen (generic) Monopril® enalapril (generic), captopril (generic), fosinopril (generic), lisinopril (generic), Accupril® (Pfizer, Inc.) Monopril HCT® lisinopril/hydrochlorothiazide (generic), enalapril/hydrochlorothiazide (generic), Accuretic® (Pfizer, Inc.) MS Contin® morphine sulfate (generic) Naftin® econazole (generic), ketoconazole (generic) Naprelan® naproxen sodium (generic) 9 SECTION II: USING PREFERRED ALTERNATIVES (CONTINUED)

Non-preferred Drug Preferred Alternatives Nasacort AQ® Flonase® (GlaxoSmithKline), Rhinocort AQ® (AstraZeneca) Nasalide® flunisolide (generic) Nasarel® flunisolide (generic) Nasonex® Flonase® (GlaxoSmithKline), Rhinocort AQ® (AstraZeneca) Nitrodisc® nitroglycerin transdermal (generic), Nitro-Dur® (Schering-Plough) Nizoral® cream ketoconazole (generic) Norflex® chlorzoxazone (generic), cyclobenzaprine HCl (generic), methocarbamol (generic), orphenadrine citrate (generic) Norgesic® carisoprodol compound (generic) Norgesic Forte® carisoprodol compound (generic) Norinyl® norethindrone-mestranol (generic), norethindrone-ethinyl estradiol (generic) Noritate® Metrocream® (Galderma) Nulytely® polyethylene glycol-electrolyte solution (generic) Ocupress® carteolol (generic), Betoptic S® (Alcon) Optivar® Acular® (Allergan),Acular PF® (Allergan), Livostin® (Novartis) Orapred® prednisolone sodium phosphate (generic) Ortho-Dienestrol® Premarin® vaginal cream (Wyeth-Ayerst) Ortho-Prefest® Premphase® (Wyeth-Ayerst), Prempro® (Wyeth-Ayerst) Oruvail® ketoprofen [extended-release] (generic) Ovcon-35® norethindrone-ethinyl estradiol (generic), Modicon® (Ortho-McNeil) Ovral® norgestrel-ethinyl estradiol (generic) Oxistat® econazole (generic), ketoconazole (generic) Patanol® Acular® (Allergan),Acular PF® (Allergan), Livostin® (Novartis) Paxil® paroxetine (generic) Paxil CR® paroxetine (generic) PCE® erythromycin base (generic), Zithromax® (Pfizer, Inc.) Pediapred® prednisolone sodium phosphate (generic) Pediotic® neomycin sulfate/polymyxin B/hydrocortisone otic solution (generic), Floxin Otic® (Daiichi) Pepcid® famotidine (generic), ranitidine (generic), cimetidine (generic) Percocet® oxycodone/acetaminophen (generic) Permax® pergolide mesylate (generic) Phenergan® promethazine HCl (generic) Plendil® nifedipine (generic), Norvasc® (Pfizer, Inc.) Plexion® sulfacetamide sodium/sulfur (generic) Pravachol® lovastatin (generic), Lipitor® (Pfizer, Inc.), Zocor® (Merck & Co.) Pred Forte® prednisolone acetate (generic) Prevacid® omeprazole (generic) Prilosec® omeprazole (generic) Prinivil® lisinopril (generic), captopril (generic), enalapril (generic), fosinopril (generic), Accupril® (Pfizer, Inc.) Prinzide® lisinopril/hydrochlorothiazide (generic),Accuretic® (Pfizer, Inc.) Procardia XL® nifedipine [extended-release] (generic) Prometrium® medroxyprogesterone acetate (generic) Prosom® estazolam (generic) Provera® medroxyprogesterone acetate (generic) Provigil® methylphenidate (generic), dextroamphetamine (generic), amphetamine/ dextroamphetamine (generic) Prozac® fluoxetine (generic) 10 SECTION II: USING PREFERRED ALTERNATIVES (CONTINUED)

Non-preferred Drug Preferred Alternatives Pulmicort Turbuhaler® Flovent® (GlaxoSmithKline) Questran® cholestyramine/sucrose (generic) Questran Light® cholestyramine/aspartame (generic) Quixin® Ocuflox® (Allergan) QVAR® Flovent® (GlaxoSmithKline) Relafen® nabumetone (generic), oxaprozin (generic), ibuprofen (generic), naproxen (generic) Remeron® mirtazapine (generic) Reminyl® Aricept® (Pfizer, Inc.) Rescula® Xalatan® (Pharmacia) Restoril® temazepam (generic) Retin-A Micro® tretinoin (generic) Ritalin® methylphenidate HCl (generic) Ritalin SR® methylphenidate HCl [extended-release] (generic) Rocaltrol® calcitriol (generic) Rondec-DM® dextromethorphan HBr/brompheniramine maleate/pseudoephedrine HCl (generic) Rythmol® propafenone HCl (generic) Sarafem® fluoxetine (generic) Seroquel® Risperdal® (Janssen), Zyprexa® (Eli Lilly) Serzone® nefazodone (generic) Sinemet CR® carbidopa/levodopa [sustained release] (generic) Skelaxin® carisoprodol (generic), cyclobenzaprine HCl (generic), tizanidine HCl (generic) Spectazole® econazole (generic) Stadol NS® butorphanol tartrate nasal spray (generic) Sular® nifedipine [extended-release] (generic), Norvasc® (Pfizer, Inc.) Suprax® cefaclor (generic), cefuroxime (generic), Omnicef® (Abbott Labs) T-Stat® erythromycin base/ethyl alcohol (generic) Tambocor® flecainide acetate (generic) Tarka® Lotrel® (Novartis) Tenormin® atenolol (generic) Testoderm® Androderm® (Watson),Androgel® (Solvay) Testoderm TTS® Androderm® (Watson),Androgel® (Solvay) Teveten® Benicar® (Sankyo Pharma), Cozaar® (Merck & Co.) Theo-24® theophylline [timed release] (generic) Theolair-SR® theophylline [timed release] (generic) Tiazac® diltiazem HCl [sustained action] (generic) Timoptic XE® timolol gel-forming solution (generic) Tobradex® Poly-Pred® (Allergan), Pred-G® (Allergan) Tofranil-PM® imipramine HCl (generic) Tolinase® glipizide (generic), glyburide (generic), tolazamide (generic) Toradol® ketorolac tromethamine (generic) Tornalate® albuterol MDI (generic) Transderm-Nitro® nitroglycerin transdermal (generic), Nitro-Dur® (Schering-Plough) Travatan® Xalatan® (Pharmacia) Tri-Levlen® levonorgestrel-ethinyl estradiol (generic) Tri-Norinyl® Triphasil® (Wyeth-Ayerst) Triaz® benzoyl peroxide (generic) Trileptal® carbamazepine (generic),Tegretol® (Novartis),Tegretol XR® (Novartis) Tussionex® guaifenesin/codeine phosphate (generic) 11 SECTION II: USING PREFERRED ALTERNATIVES (CONTINUED)

Non-preferred Drug Preferred Alternatives Tylenol w/Codeine® acetaminophen w/codeine (generic) Ultracet® tramadol HCl (generic), acetaminophen (generic) Ultram® tramadol HCl (generic) Ultravate® clobetasol propionate cream, ointment .05% (generic), diflorasone diacetate ointment .05% (generic), augmented betamethasone dipropionate ointment .05% (generic) Uniretic® lisinopril/hydrochlorothiazide (generic), enalapril/hydrochlorothiazide (generic), Accuretic® (Pfizer, Inc.) Univasc® moexipril (generic) Vagifem® Estring® (Pharmacia), Premarin® vaginal cream (Wyeth-Ayerst) Valium® diazepam (generic) Vantin® cefaclor (generic), cefuroxime (generic), Omnicef® (Abbott Labs) Vaseretic® lisinopril/hydrochlorothiazide (generic), enalapril/hydrochlorothiazide (generic), Accuretic® (Pfizer, Inc.) Vasotec® enalapril (generic), captopril (generic), fosinopril (generic), lisinopril (generic), Accupril® (Pfizer, Inc.) Velosef® cephradine (generic) Vexol® dexamethasone sodium phosphate (generic), fluorometholone (generic), prednisolone acetate (generic), prednisolone sodium phosphate (generic), Pred Mild® (Allergan) Vicodin® acetaminophen/hydrocodone (generic) Vicodin ES® acetaminophen/hydrocodone (generic) Vicodin Tuss® guaifenesin/hydrocodone (generic) Vicoprofen® ibuprofen/hydrocodone (generic) Voltaren-XR® diclofenac sodium [extended-release] (generic) Wellbutrin® bupropion (generic) Westcort® hydrocortisone valerate cream, ointment .2% (generic) Xanax® alprazolam (generic) Xopenex® albuterol inhalation solution (generic), metaproterenol inhalation solution (generic) Zaditor® Acular® (Allergan),Acular PF® (Allergan), Livostin® (Novartis) Zagam® ofloxacin (generic),Avelox® (Bayer), Cipro® (Bayer), Levaquin® (Ortho Pharma), Tequin® (BMS Primarycare) Zanaflex® tizanidine HCl (generic) Zantac® ranitidine (generic), famotidine (generic), cimetidine (generic) Zaroxolyn® metolazone (generic) Zebeta® bisoprolol (generic) Zestoretic® lisinopril/hydrochlorothiazide (generic), enalapril/hydrochlorothiazide (generic), Accuretic® (Pfizer, Inc.) Zestril® lisinopril (generic), captopril (generic), enalapril (generic), fosinopril (generic), Accupril® (Pfizer, Inc.) Ziac® bisoprolol/hydrochlorothiazide (generic) Zomig® Amerge® (GlaxoSmithKline), Imitrex® (GlaxoSmithKline), Maxalt® (Merck & Co.) Zovirax® acyclovir (generic) Zyflo® Singulair® (Merck & Co.)

This list is subject to change without notice. For the most up-to-date information, please call Pharmacy Customer Service at 1-800-905-0201. 12 SECTION III: PREFERRED DRUG LIST

The following is an alphabetical listing of generic and preferred brand drugs that you may obtain through your Oxford three-tier pharmacy benefit. Please note: Drugs listed in lowercase are generic drugs and are subject to the lowest drug copayment (cost share). Drugs listed in uppercase are preferred brand drugs and are subject to a higher drug copayment (cost share). All other drugs that are covered under your pharmacy benefit that are not on the list are non-preferred brand drugs and are subject to the highest drug copayment (cost share). The listing of a drug product does not guarantee coverage, as certain products are excluded due to benefit plan limitations that are specific to Members' individual or group benefits. This list of drugs is subject to change from time to time during the calendar year. For the most up-to-date information, please call Pharmacy Customer Service at 1-800-905-0201.

A amiloride/HCTZ azelaic acid ACCUPRIL aminocaproic acid AZOPT ACCURETIC aminophylline acebutolol amiodarone B acetaminophen/butalbital amitriptyline bacitracin/polymyxin B acetaminophen/caffeine/butalb amitriptyline HCl/perphenazine ophthalmic acetazolamide amitriptyline/chlordiazepoxide baclofen acetic acid ammonium lactate BACTROBAN CREAM acetic acid/aluminum acetate amoxapine belladonna alkaloids/ acetic acid/hydrocortisone amoxicillin acetohexamide amoxicillin/potassium phenobarb ACETOHEXAMIDE clavulanate benazepril acetylcysteine amphetamine/ benazepril/HCTZ *ACTONEL 35 MG dextroamphetamine (PAR) BENICAR *ACTOS ampicillin BENICAR HCT ACULAR/PF *ANA-KIT benzoyl peroxide acyclovir ANDRODERM (PAR) benztropine *ADVAIR ANDROGEL (PAR) betamethasone dipropionate AGENERASE antipyrine/benzocaine betamethasone valerate AGRYLIN ARICEPT *BETASERON ALBENZA ARIMIDEX betaxolol *albuterol inhaler AROMASIN bethanechol albuterol (tablet, solution) ASACOL BETOPTIC S ALDARA aspirin/caffeine/butalbital BILTRICIDE ALESSE atenolol bisoprolol ALKERAN atropine sulfate bisoprolol fumarate/HCTZ allopurinol ATROVENT inh ALPHAGAN P AUGMENTIN ES BLEPHAMIDE alprazolam *AVANDAMET brimonidine tartrate aluminum chloride *AVANDIA bromocriptine mesylate amantadine AVC bumetanide AMARYL AVELOX bupropion immediate release *AMERGE *AVONEX buspirone amiloride azathioprine *butorphanol NS

Legend: * = Denotes drugs affected by quantity limits (PAR) = Precertification required 13 SECTION III: PREFERRED DRUG LIST (CONTINUED)

C CLEOCIN VAGINAL DEPAKENE CAFERGOT clidinium/chlordiazepoxide DEPAKOTE calciferol (PAR) *CLIMARA DEPEN TITRATABS calcitriol (PAR) clindamycin *DEPO-PROVERA 150 MG CANASA clobetasol propionate DERMA-SMOOTHE/FS 0.01% CAPITROL SHAMPOO clomiphene citrate desipramine captopril clomipramine desmopressin acetate solution captopril/HCTZ clonazepam desmopressin acetate spray carbamazepine clonidine HCl desogestrel/ethinyl estradiol CARBATROL clonidine HCl/chlorthalidone desonide carbidopa/levodopa clorazepate desoximetasone carbidopa/levodopa clotrimazole/betamethasone dexamethasone (extended-release) dipropionate dexamethasone sod phosphate carisoprodol clozapine dexchlorpheniramine maleate CARNITOR codeine sulfate (extended-release) carteolol colchicine dextroamphetamine (PAR) CASODEX COMBIVIR dextromethorphan/ *CATAPRES TTS COMTAN pseudoephedrine HCl/ CEENU CONDYLOX carbinoxamine cefaclor *COPAXONE *DIASTAT COPEGUS cefadroxil diazepam CORDRAN/SP CEFTIN (susp only) DIBENZYLINE COREG cefuroxime diclofenac potassium CORTIFOAM CELLCEPT diclofenac sodium cortisone acetate CELONTIN dicloxacillin COTAZYM cephalexin dicyclomine COUMADIN cephradine diethylpropion HCl COZAAR CERUMENEX CREON diflorasone CHEMET CRIXIVAN DIFLUCAN chloral hydrate cromolyn nebulizer solution *DIFLUCAN 150MG TAB chlordiazepoxide HCl CUPRIMINE diflunisal chlorhexidine gluconate cyclobenzaprine digoxin chloroquine phosphate cyclopentolate DILANTIN chlorothiazide cyclosporine diltiazem chlorpromazine cyproheptadine diltiazem, sustained release chlorpropamide CYTADREN diphenhydramine chlorthalidone CYTOVENE diphenoxylate/atropine sulfate chlorthalidone/atenolol CYTOXAN dipivefrin chlorzoxazone DIPROSONE 0.1% top spray chol sal/magnesium salicylate D dipyridamole cholestyramine danazol disopyramide cholestyramine/aspartame DANTRIUM disulfiram cholestyramine/sucrose DAPSONE DOVONEX *chorionic gonadotropin DARAPRIM doxazosin cimetidine DDAVP Tablets doxepin *CIPRO deltasone doxycycline hyclate clemastine fumarate . DENAVIR doxycycline monohydrate

Legend: * = Denotes drugs affected by quantity limits (PAR) = Precertification required 14 SECTION III: PREFERRED DRUG LIST (CONTINUED)

DRITHOCREME/HP F GONAL F DRITHO-SCALP famotidine griseofulvin ultramicrosize DURAGESIC FANSIDAR guaifenesin (extended-release) DYNAPEN (susp only) FARESTON guaifenesin/codeine phosphate FELBATOL guaifenesin/dextromethorphan E FEMARA (extended-release) econazole nitrate FEMHRT guaifenesin/pseudoephedrine EFFEXOR fenofibrate HCl (extended-release) EFFEXOR XR fenoprofen guaifenesin/pseudoephedrine EFUDEX FIORICET WITH CODEINE #3 HCl/codeine phosphate ELMIRON flecainide guaifenesin/pseudoephedrine ELOXATIN *FLONASE HCl/hydrocodone bitartrate EMCYT *FLOVENT guanabenz *EMEND *FLOVENT ROTADISK guanfacine EMTRIVA FLOXIN OTIC enalapril fludrocortisone H *ENBREL (PAR) *flunisolide nasal solution HALOG/E ENTOCORT EC fluocinolone haloperidol EPIFRIN fluocinonide HALOTESTIN (PAR) *EPI E-Z PEN/JR fluorometholone heparin *EPIPEN/JR FLUOROPLEX HEXALEN EPIVIR *fluoxetine HIVID EPIVIR HBV fluoxymesterone (PAR) homatropine hydrobromide ergoloid mesylates fluphenazine HCl HUMALOG ERGOMAR flurazepam HUMALOG MIX ERYPED SUSPENSION flurbiprofen *HUMIRA (PAR) erythromycin base flutamide HUMULIN 50/50 erythromycin base/ethanol *fluvoxamine erythromycin ethylsuccinate FML-S HUMULIN 70/30 erythromycin stearate folic acid HUMULIN L erythromycin/sulfisoxazole FORTOVASE HUMULIN N ESKALITH CR *FOSAMAX HUMULIN R estazolam fosinopril HUMULIN U *estradiol patch furosemide hydralazine estradiol tablet FUROXONE hydralazine/HCTZ *ESTRING *FUZEON hydrochlorothiazide estropipate hydrocodone bitartrate/apap ESTROSTEP FE G hydrocortisone ethambutol GABITRIL hydrocortisone acetate ETHMOZINE gemfibrozil hydrocortisone valerate ethosuximide gentamicin sulfate hydromorphone ethynodiol diacetate/ethinyl GLEEVEC hydroquinone estradiol glipizide hydroquinone/ferric oxide etodolac glipizide (extended-release) hydroxychloroquine etoposide GLUCAGON hydroxyurea EULEXIN GLUCOVANCE hydroxyzine HCl EURAX glyburide hydroxyzine pamoate *EVISTA glyburide micronized hyoscyamine

Legend: * = Denotes drugs affected by quantity limits (PAR) = Precertification required 15 SECTION III: PREFERRED DRUG LIST (CONTINUED) hyoscyamine sulfate LANOXIN MESTINON TIMESPAN hyoscyamine LANTUS METAGLIP sulfate/phenobarb LARODOPA metaproterenol HYZAAR LEUCOVORIN metformin leucovorin calcium metformin (extended-release) I LEUKERAN methadone ibuprofen leuprolide acetate injection methazolamide ibuprofen/hydrocodone (PAR) ILETIN II REGULAR(PORK) LEVAQUIN methenamine mandelate ILETIN INSULIN levobunolol METHERGINE ILETIN LENTE PORK ZINC levonorgestrel/ethinyl estradiol methimazole ILETIN NPH PORK ZINC levothyroxine methocarbamol ILETIN REGULAR PORK LEXIVA methocarbamol/aspirin ZINC lidocaine viscous solution methotrexate imipramine HCl *LIPITOR methyclothiazide *IMITREX lisinopril methyldopa indapamide lisinopril/HCTZ methyldopa/HCTZ INDERAL LA lithium carbonate methylphenidate indomethacin lithium citrate INVIRASE LIVOSTIN methylphenidate HCI ipratropium nebulizer solution LOESTRIN/FE (extended-release) isoetharine HCl solution for LO/OVRAL methylprednisolone inhalation lorazepam methyltestosterone/estrogens, isometheptene/ LOTEMAX esterified dichloralphenazone/apap LOTREL metoclopramide isoniazid LOTRISONE LOTION metolazone ISOPTO CARBACHOL *lovastatin metoprolol tartrate isosorbide dinitrate loxapine METROCREAM isosorbide mononitrate LYSODREN METROGEL isotretinoin METROGEL-VAGINAL isoxsuprine M maprotiline METROLOTION K MATULANE metronidazole KALETRA *MAXAIR metronidazole, sustained ketoconazole *MAXAIR AUTOHALER action ketoprofen *MAXALT mexiletine *ketorolac tablet *MAXALT MLT MICRONOR KLARON MEBARAL minocycline K-LYTE/CL mebendazole minoxidil tabs *KYTRIL meclizine HCl MINTEZOL *KYTRIL ORAL SOLUTION meclofenamate MIRALAX medroxyprogesterone L *mefloquine MIRAPEX labetalol megestrol mirtazapine lactulose meperidine misoprostol LAMICTAL meprobamate MOBAN LAMPRENE MEPRON MODICON

Legend: * = Denotes drugs affected by quantity limits (PAR) = Precertification required 16 SECTION III: PREFERRED DRUG LIST (CONTINUED) moexipril norethindrone/ethinyl estradiol *paroxetine mometasone furoate norethindrone/mestranol PASER *MONUROL norgestimate/ethinyl estradiol PEGANONE morphine sulfate suppository norgestrel/ethinyl estradiol PEGASYS morphine sulfate tablet,solution nortriptyline pemoline morphine sulfate NORVASC penicillin v potassium (extended-release) NORVIR PENTASA MUCOMYST NOVOLIN pentazocine HCI/ mupirocin ointment NOVOLIN INNOLET acetaminophen MYCOBUTIN NOVOLOG pentazocine HCI/naloxone MYLERAN nystatin pentoxifylline MYSOLINE nystatin/triamcinolone pergolide mesylate permethrin N O perphenazine nabumetone OCUFLOX phenazopyridine nadolol *omeprazole (PAR) phendimetrazine naphazoline HCI OMNICEF phenobarbital naproxen ORAP phentermine naproxen sodium orphenadrine phenylephrine HCl NARDIL orphenadrine/aspirin/caffeine PHENYTEK *NEBUPENT ORTHO NOVUM 1/35 phenytoin nefazodone ORTHO NOVUM 1/50 PHOSPHOLINE IODIDE neomycin sulfate ORTHO NOVUM 10/11 pilocarpine HCl neomycin sulfate/bacitracin/ ORTHO NOVUM 7/7/7 PILOPINE H.S. polymyxin B ointment ORTHO TRI-CYCLEN pindolol neomycin ORTHO TRI-CYCLEN LO piroxicam sulfate/dexamethasone ORTHO-CEPT PLAVIX sodium phosphate ORTHO-CYCLEN polymyxin b sulfate/tmp neomycin sulfate/gramicidin D/ ORTHO-EVRA POLY-PRED polymyxin B drops OSMOGLYN potassium bicarbonate/citric neomycin sulfate/polymyxin B OVRETTE acid sulfate/dexamethasone oxaprozin potassium chloride capsule neomycin sulfate/polymyxin B oxazepam (extended-release) sulfate/ hydrocortisone OXSORALEN-ULTRA potassium chloride liquid 10% NEORAL oxybutynin potassium chloride powder NEURONTIN oxycodone potassium chloride tablet nicotine patch oxycodone/acetaminophen (extended-release) nifedipine oxycodone/aspirin potassium chloride (extended- NILANDRON OXYCONTIN release) NIMOTOP potassium chloride/potassium NITRO-DUR P bicarbonate/citric acid nitrofurantoin PANCREASE /MT potassium iodide nitroglycerin (topical,SR PANCRECARB MS-8 pramoxine/hc acetate capsules, SL, patch) PANDEL PRANDIN nizatidine paregoric prazosin NOLVADEX PARNATE PRECOSE norethindrone paromomycin PRED MILD

Legend: * = Denotes drugs affected by quantity limits (PAR) = Precertification required 17 SECTION III: PREFERRED DRUG LIST (CONTINUED)

PRED-G Q sodium sulfacetamide/ prednisolone quinidine gluconate prednisolone sodium prednisolone acetate quinidine sulfate phosphate prednisolone sodium quinine sulfate sodium sulfacetamide/sulfur phosphate sodium sulfate/sodium/sodium prednisone R bicarbonate/potassium PREDNISONE (1 MG) ranitidine chloride/PEG 3350 PREMARIN RAPAMUNE *SONATA PREMARIN VAGINAL *REBIF SORIATANE PREMPHASE REPRONEX sotalol PREMPRO spironolactone REQUIP *PREVPAC spironolactone/HCTZ RESCRIPTOR PRIFTIN STARLIX reserpine PRIMAQUINE PHOSPHATE sucralfate primidone reserpine/hydrochlorothiazide sulfacetamide sodium PROAMATINE RETROVIR sulfadiazine probenecid REYATAZ sulfamethoxazole/trimethoprim procainamide RHEUMATREX sulfanilamide cream PROCANBID *RHINOCORT AQ sulfasalazine prochlorperazine RIDAURA sulfathiaz/sulfacet/sulfabenz PROCTOFOAM-HC RIFAMATE sulfinpyrazone PROGRAF rifampin sulfisoxazole promethazine RIFATER sulindac propafenone HCl RILUTEK SUSTIVA propoxyphene HCl SYNALAR HP propoxyphene HCl/ RISPERDAL SYNTHROID acetaminophen ROWASA propoxyphene HCl/asa/caffeine ROXICODONE propoxyphene napsylate T propoxyphene napsylate/apap S tamoxifen propranolol SALAGEN TARGRETIN propranolol/HCTZ salsalate TASMAR propylthiouracil SANDIMMUNE TAZORAC TEGRETOL pseudoephedrine HCl/ selegiline TEGRETOL XR brompheniramine maleate selenium sulfide temazepam pseudoephedrine HCl/ *SEREVENT DISKUS TEMODAR brompheniramine/ SEROMYCIN dextromethorphan TEQUIN silver sulfadiazine pseudoephedrine HCl/ terazosin SINGULAIR (PAR) carbinoxamine maleate terbutaline pseudoephedrine HCl/ sodium citrate/citric acid TESLAC chlorpheniramine maleate sodium fluoride testosterone (PAR) PSORCON E sodium polystyrene sulfonate tetracycline *PULMICORT RESPULES sodium sulfacetamide/ theophylline PURINETHOL fluorometholone THIOGUANINE pyrazinamide sodium sulfacetamide/ thioridazine pyridostigmine bromide prednisolone acetate thiothixene

Legend: * = Denotes drugs affected by quantity limits (PAR) = Precertification required 18 SECTION III: PREFERRED DRUG LIST (CONTINUED) ticlopidine TRIZIVIR VIROPTIC *TILADE tropicamide *VIVELLE timolol *VIVELLE-DOT tizanidine U tobramycin ULTRASE/MT W tolazamide UNIPHYL warfarin sodium tolbutamide URISED WELLBUTRIN SR tolmetin URISPAS TONOCARD UROCIT-K X TOPAMAX ursodiol XALATAN TOPROL XL XELODA TRACLEER V XYLOCAINE ORAL SPRAY tramadol VALCYTE trazodone valproate sodium Y TRECATOR-SC valproic acid YASMIN tretinoin (PAR) *VALTREX YODOXIN TREXALL VANCOCIN yohimbine triamcinolone VELOSULIN triamterene/HCTZ VEPESID Z triazolam verapamil *ZELNORM (PAR) trifluoperazine verapamil, sustained action ZERIT trifluridine VESANOID ZIAGEN trihexyphenidyl VIDEX/EC *ZITHROMAX TRI-K VIOKASE *ZOCOR trimethobenzamide VIRA-A *ZOFRAN (capsule,suppository) VIRACEPT *ZOFRAN ODT trimethoprim VIRAMUNE *ZOLOFT TRIPHASIL VIREAD ZYPREXA

This list is subject to change without notice. For the most up-to-date information, please call Pharmacy Customer Service at 1-800-905-0201.

Legend: * = Denotes drugs affected by quantity limits (PAR) = Precertification required 19 SECTION IV: MEDICATIONS REQUIRING PRECERTIFICATION Oxford Health Plans has a mission to help its Members maintain and improve their overall health through the appropriate use of drug therapy. In order promote this, Oxford and our pharmacy benefits manager, Medco Health Solutions, Inc. (Medco Health), have established programs to encourage drug therapy that is appropriate and economical for our Members. For most Members with pharmacy benefit coverage through Oxford, the medications on the following list (including their generic equivalent, if available) generally require precertification through Medco Health, based on Oxford’s coverage criteria. Precertification, also known as prior authorization, requires that your physician formally submit a request to and receive approval from Medco Health in order to receive coverage for a prescription for certain medications. If you have any questions regarding the medications on this list or any additional medication, please call our Pharmacy Customer Service line at 1-800-905-0201. Anabolic steroids*/ Proton Pump Inhibitors* Specialized OB/GYN drugs Androgens* • Aciphex • Lupron (3.75 mg & 11.25 mg) • Anadrol – 50 • Nexium • Androderm Patches • Prevacid Misc. drugs • Androgel • Prilosec • Forteo • Android • Protonix • Nutritional Therapies3 • Deca Durabolin • Serostim • Delatestryl Misc. Gastrointestinal • Singulair4* • Depo Testosterone drugs* • Strattera • Halotestin • Lotronex • Vitamin D Preparations • Methyltestosterone • Zelnorm (i.e. Hectorol, Rocaltrol, etc.) • Oxandrin • Striant Erectile Dysfunction 1 Applies only to Members • Testim drugs** 19 years of age or older. 2 • Testoderm • Caverject Applies only to Members • Testosterone • Cialis 40 years of age or older. 3 For coverage information, • Testred • Edex Members should contact Oxford • Winstrol • Levitra Customer Service at the number • Muse on the back of their ID card. CNS stimulants • Viagra 4 Applies only to Members • Adderall1 12 years of age or older • Concerta1 Arthritis drugs • Desoxyn1 • Bextra* Please note: Precertification • Dexedrine1 • Celebrex* requirements may vary, depending • Dextrostat1 • Enbrel on the Member’s benefit. • Provigil • Humira *Precertification is not required • Kineret for Oxford Medicare AdvantageSM Acne drugs • Vioxx* Members. • Avita2 • Differin2 **Medication is not covered • Retin A2 for Oxford Medicare AdvantageSM Members.

To obtain precertification, please call Medco Health directly at 1-800-753-2851, Monday through Friday from 8:00 AM to 9:00 PM (eastern standard time). This list is subject to change without notice. For the most up-to-date information, please call Pharmacy Customer Service at 1-800-905-0201.