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February __, 2004 March 4, 2004 MEMORANDUM TO: Participating Pharmacists FROM: John Berthiaume, M.D. Assistant Vice President, Medical Director Care Management SUBJECT: Corrected formulary Enclosed is the HMSA Formulary listing by brand name reflecting changes and additions as of January 1, 2004. Please discard the previously disseminated brand section, which is outdated. All other formulary sections include the January 1 changes. If you have any questions, please call a Provider Teleservice Representative at 948-6330 on Oahu or 1 (800) 790-4672 from the Neighbor Islands for Select plans, or 948-6321 on Oahu and 1 (800) 771-0677 from the Neighbor Islands for The HMSA Plan for QUEST Members. For clinical questions, an HMSA staff pharmacist or physician will return your call. PM04-007 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - Page 1 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 95 aripiprazole Abilify O O X 194 zafirlukast Accolate P 30 O X 30 56 quinapril Accupril O O 56 quinapril/ hctz Accuretic O O 241 isotretinoin Accutane O O 56 perindopril Aceon O O 11 glacial acetic acid Aci-jel O O 163 rabeprazole sodium Aciphex P P X 15 255 aclometasone dipropionate 0.05%, Aclovate O O cream/ ointment 167 ursodiol Actigall O O 261 masoprocol Actinex O O 122 estradiol/ norethindrone acetate Activella O O 152 risedronate Actonel P O X 146 pioglitazone Actos P O X 228 ketorolac tromethamine, ophthalmic Acular P O X 228 ketorolac tromethamine, ophthalmic Acular PF P O X 46 nifedipine Adalat O O 46 nifedipine, sustained release Adalat CC O O 62 amphetamine mixture Adderall P 8 O 8 X 8 X 8 62 amphetamine mixture, extended release Adderall XR P 7 O 7 X 7 X 7 190 salmeterol/ fluticasone Advair P O X 195 salmeterol/ fluticasone Advair P O X 61 nicotinic acid, extended release/ Advicor P P X lovastatin 195 flunisolide, inhaler Aerobid P P X 195 flunisolide, inhaler Aerobid M P P X 197 spacer Aerochamber P 3 P 3 X 20 amprenavir Agenerase P O X 34 aspirin/ dipyridamole Aggrenox P P X 34 anagrelide Agrylin O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - Page 2 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 209 phenylephrine/ chlorpheniramine/ AH-chew G G X methscopolamine 199 phenylephrine AH-Chew D G G X 197 peak flow meter Air Zone P 3 P 3 X 229 prednisolone sodium phosphate AK Pred O O 110 biperiden Akineton O O 218 dipivefrin AKPro O O 230 bacitracin AK-Tracin O O 225 permivolast Alamast O O 224 naphazoline Albalon O O 24 albendazole Albenza O O 41 spironolactone/ hctz Aldactazide O O 39 spironolactone Aldactone O O 261 imiquimod Aldara P O X 52 methyldopa/ chlorothiazide Aldoclor O O 52 methyldopa Aldomet O O 52 methyldopa/ hctz Aldoril O O 123 ethinyl estradiol/ levonorgestrel Alesse P 3 P 3 X X X 26 melphalan Alkeran P O X 205 fexofenadine Allegra P P X 205 fexofenadine/ pseudoephedrine Allegra D P P X 225 nedocromil Alocril P O X 225 lodoxamide Alomide O O 119 estradiol, transdermal Alora O O 217 brimonidine, 0.15% Alphagan P O O X 229 loteprednol etabonate Alrex O O 56 ramipril Altace P P X 60 lovastatin, extended release Altocor O 21 O 21 188 metaproterenol sulfate Alupent O O 189 metaproterenol sulfate, inhalation Alupent O O 189 metaproterenol sulfate, metered dose Alupent MDI P O X inhaler HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - Page 3 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 144 glimepiride Amaryl O O 99 zolpidem tartrate Ambien P O 121 medroxyprogesterone acetate Amen O O 70 naratriptan Amerge P 23 O 23 X 23 239 benzethonium chloride/ glycerin/ Americaine O O benzocaine 11 sodium propionate/ amino acid/ urea Amino-Cerv O O 132 oxymetholone Anadrol O O 78 clomipramine Anafranil O O 191 epinephrine/ chlorpheniramine Anakit P O X 139 hydrocortisone acetate/ pramoxine Analpram HC O O X 68 naproxen sodium Anaprox O O 130 testosterone, transdermal Androderm P O X 130 testosterone, gel Androgel O O 129 methyltestosterone Android P O X 63 hydrocodone/ apap Anexsia O O 68 flurbiprofen Ansaid O O 113 disulfiram Antabuse P O X X 242 anthralin Anthra-Derm O O 73 meclizine Antivert O O 153 sulfinpyrazone Anturane O O 139 hydrocortisone acetate Anusol HC O O 75 dolasetron mesylate Anzemet O O 172 amlexanox Aphthasol O O 55 hydralazine/ hctz Apresazide O O 55 hydralazine Apresoline O O 14 chloroquine phosphate Aralen P O X 16 chloroquine phosphate Aralen P O X 269 leflunomide Arava O O 97 donepezil Aricept P O X 28 anastrazole Arimidex P O X 138 triamcinolone Aristocort O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - Page 4 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 149 thyroid, desiccated Armour Thyroid P O 110 trihexyphenidyl Artane O O 68 diclofenac/ misoprostol Arthrotec O O 162 diclofenac/ misoprostol Arthrotec O O 173 mesalamine, delayed release Asacol P O X 79 amoxapine Asendin O O 204 azelastine Astelin P O X 57 candesartan Atacand O O 57 candesartan/ hctz Atacand HCT O O 77 hydroxyzine hcl Atarax O O 206 hydroxyzine hcl Atarax O O 76 lorazepam Ativan O O 61 clofibrate Atromid S O O 192 ipratropium, inhalation Atrovent O O 201 ipratropium, nasal Atrovent O O 192 ipratropium, inhalation Atrovent MDI P O X 240 erythromycin ATS O O 249 erythromycin, topical ATS O O 2 amoxicillin/ k clavulanate Augmentin O O 2 amoxicillin/ k clavulanate, extra strength Augmentin ES O O 2 amoxicillin/ k clavulanate, extended Augmentin XR O O release 239 antipyrine/ benzocaine Auralgan O O 57 irbesartan/ hctz Avalide P P X 146 rosiglitazone/ metformin Avandamet P O X 146 rosiglitazone Avandia P O X 57 irbesartan Avapro P P X 11 sulfanilamide AVC O O 4 moxifloxacin Avelox P O X 1 79 nortriptyline Aventyl O O 240 tretinoin Avita O 10 O 10 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - Page 5 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 70 almotriptan Axert O 25 O 25 161 nizatidine Axid O O 121 norethindrone acetate Aygestin O O 240 azelaic acid Azelex O O 195 triamcinolone, inhaler Azmacort O O 222 brinzolamide Azopt O O 173 sulfasalazine Azulfidine O O 173 sulfasalazine, enteric coated Azulfidine EN-tabs O O 269 sulfasalazine, enteric coated Azulfidine EN-tabs O O 63 belladonna/ opium B&O suppositories O O 10 sulfamethoxazole/ trimethoprim Bactrim O O 241 sulfamethoxazole/ trimethoprim Bactrim O O 249 mupirocin Bactroban O O 158 methantheline bromide Banthine O O 202 beclomethasone Beconase AQ O O 157 belladona tincture Belladonna Tincture O O 157 l-alkaloids of belladonna/ phenobarbital/ Bellergal-S O O ergotamine 73 diphenhydramine Benadryl O O 110 diphenhydramine Benadryl O O 206 diphenhydramine Benadryl O O 57 olmesartan Benicar O O 159 dicyclomine, tablets and capsules Bentyl O O 159 dicyclomine, syrup Bentyl Syrup P O X 240 benzoyl peroxide Benzac O O 240 erythromycin/ benzoyl peroxide Benzamycin O O 181 iron/ multivit/ mineral, prescription Berocca Plus O 2 O 2 219 levobunolol Betagan O O 49 sotalol Betapace O O 44 sotalol Betapace AF P P X 49 sotalol Betapace AF P P X 219 betaxolol Betoptic O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - Page 6 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 219 betaxolol Betoptic S O O 69 valdecoxib Bextra O 22 O 6 clarithromycin Biaxin P O X 29 6 clarithromycin, extended release Biaxin XL P O X 29 185 sodium citrate/ citric acid Bicitra P O X 262 sodium citrate/ citric acid Bicitra P O X 24 praziquantel Biltricide O O 233 sulfacetamide/ prednisolone acetate Blephamide P O X 49 timolol maleate Blocadren O O 189 terbutaline sulfate Brethaire P O X 188 terbutaline sulfate Brethine P O X 188 terbutaline sulfate Bricanyl O O X 207 pseudoephedrine/ brompheniramine Bromfed O O 193 theophylline, capsules Bronkodyl O O 38 bumetanide Bumex O O 77 buspirone Buspar O O 157 belladonna extract/ butabarbital sodium Butibel O O 101 butabarbital sodium Butisol Sodium O O 71 ergotamine tartrate/ caffeine Cafergot O O 47 verapamil Calan O O 47 verapamil, sustained release Calan SR O O 178 cellulose sodium phosphate Calcibind P O X 158 mepenzolate bromide Cantil O O 246 chloroxine Capitrol O O 56 captopril Capoten O O 56 captopril/ hctz Capozide O O 156 sucralfate Carafate O O 220 carbachol Carbastat O O 107 carbamazepine, extended release Carbatrol O O 213 dextromethorphan/ pseudoephedrine/ Cardec DM Drops G G carbinoxamine HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev.
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