HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - 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. 17 abacavir sulfate Ziagen P O X 17 abacavir/ lamivudine/ zidovudine Trizivir P O X 141 acarbose Precose P P X 50 acebutolol -- G G 50 acebutolol Sectral O O 65 acetaminophen -- X 40 acetazolamide -- G G X 40 acetazolamide Diamox O O 107 acetazolamide -- G G X 107 acetazolamide Diamox O O 40 acetazolamide, extended release Diamox Sequels P O X 239 acetic acid in aluminum acetate -- G G X 239 acetic acid in aluminum acetate Domeboro Otic O O 238 acetic acid, otic -- G G X 238 acetic acid, otic VoSol O O 238 acetic acid/ hydrocortisone, otic -- G G X 238 acetic acid/ hydrocortisone, otic VosSol HC O O 144 acetohexamide -- G G X 144 acetohexamide Dymelor O O 267 acetohydroxamic acid Lithostat O O 99 acetylcarbromal Paxarel O O 198 acetylcysteine -- G G X 198 acetylcysteine Mucomyst O O 243 acitretin Soriatane P O X 255 aclometasone dipropionate 0.05%, cream/ ointment Aclovate O O 173 activated charcoal -- X 22 acyclovir -- G G X 22 acyclovir Zovirax O O 248 acyclovir ointment Zovirax P O X 240 adapalene Differin P 10 O 10 X 10 24 albendazole Albenza O O 188 albuterol -- G G X 188 albuterol Proventil O O 188 albuterol Ventolin O O 189 albuterol -- G G X 189 albuterol Proventil P O X 189 albuterol Proventil HFA O O 189 albuterol Ventolin P O X 189 albuterol Ventolin HFA O O 188 albuterol, extended release -- G G X 188 albuterol, extended release Volmax O O 189 albuterol/ ipratropium Combivent P O X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - 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. 192 albuterol/ ipratropium Combivent P O X 152 alendronate Fosamax P O X 261 alitretinoin Panretin O O 153 allopurinol -- G G X 153 allopurinol Zyloprim O O 70 almotriptan Axert O 25 O 25 76 alprazolam -- G G X 19 X 76 alprazolam Xanax O O 133 alprostadil Caverject O O 133 alprostadil Muse O O 30 altretamine Hexalen P O X 260 aluminum acetate -- X 240 aluminum chloride hexahydrate Xerac AC O O 261 aluminum chloride hexahydrate Drysol O O 155 aluminum hydroxide/ magnesium hydroxide -- X 155 aluminum hydroxide/ magnesium hydroxide/ simethicone -- X

21 amantadine -- G G X X 21 amantadine Symmetrel O O 111 amantadine -- G G X X 111 amantadine Symmetrel O O 112 ambenonium chloride Mytelase O O 253 amcinonide -- G G 253 amcinonide Cyclocort O O 39 amiloride hcl -- G G 39 amiloride hcl Midamor O O 41 amiloride/ hctz -- G G 41 amiloride/ hctz Moduretic O O 35 aminocaproic acid -- G G 140 aminoglutethimide Cytadren P O X 193 aminophylline -- G G 15 aminosalicylic acid Paser O O 44 amiodarone -- G G X 44 amiodarone Cordarone P O X 78 amitriptyline -- G G X X 78 amitriptyline Elavil O O 78 amitriptyline/ perphenazine -- G G X X 78 amitriptyline/ perphenazine Etrafon O O 78 amitriptyline/ perphenazine Triavil O O 88 amitriptyline/ perphenazine -- G G X X 88 amitriptyline/ perphenazine Etrafon O O 88 amitriptyline/ perphenazine Triavil O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - 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. 172 amlexanox Aphthasol O O 46 amlodipine Norvasc O O 46 amlodipine/ benazepril Lotrel P O X 242 ammoniated mercury Emersal O O 79 amoxapine -- G G X X 79 amoxapine Asendin O O 1 amoxicillin trihydrate -- G G X X X 2 amoxicillin/ k clavulanate -- G G X 1 2 amoxicillin/ k clavulanate Augmentin O O 2 amoxicillin/ k clavulanate, extended release Augmentin XR P O X 1 2 amoxicillin/ k clavulanate, extra strength Augmentin ES P O X 1 62 amphetamine mixture -- G 8 G 8 X 8 X 8 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 1 ampicillin -- G G X X X 1 ampicillin Omnipen O O 20 amprenavir Agenerase P O X 34 anagrelide Agrylin P O X 28 anastrazole Arimidex P O X 35 anisindione Miradon O O 242 anthralin Anthra-Derm O O 242 anthralin Drithocreme P O X 242 anthralin Drithocreme HP P O X 242 anthralin Dritho-Scalp P O X 239 antipyrine/ benzocaine -- G G X 239 antipyrine/ benzocaine Auralgan O O 95 aripiprazole Abilify P O X X 236 artificial tears -- X 34 aspirin -- X 66 aspirin -- X 66 aspirin, controlled release ZORprin O O 66 aspirin, enteric coated Easprin O O 34 aspirin/ dipyridamole Aggrenox P P X 20 atazanavir Reyataz P O X 50 atenolol -- G G 50 atenolol Tenormin O O 50 atenolol/ chlorthalidone -- G G 50 atenolol/ chlorthalidone Tenoretic O O 117 atomoxetine Strattera O O X 60 atorvastatin, 10mg, 20mg & 40mg Lipitor, 10mg, 20mg & 40mg O 21 O 21

60 atorvastatin, 80 mg Lipitor, 80 mg P 21 P 21 X 21 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - 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. 25 atovaquone Mepron O O 227 atropine -- G G X 227 atropine Isopto Atropine O O 157 atropine sulfate Sal-Tropine O O 169 attapulgite -- X 253 augmented betamethasone dipropionate 0.05%, cream Diprolene AF O O 252 augmented betamethasone dipropionate 0.05%, ointment/ -- G G gel 252 augmented betamethasone dipropionate 0.05%, ointment/ Diprolene O O gel 269 auranofin Ridaura P O X 206 azatadine Optimine O O 268 azathioprine -- G G X 268 azathioprine Imuran O O 269 azathioprine -- G G X 269 azathioprine Imuran O O 240 azelaic acid Azelex O O 204 azelastine Astelin P O X 225 azelastine Optivar O O 6 azithromycin Zithromax O O X 16 230 bacitracin -- G G X X X 230 bacitracin AK-Tracin O O 249 bacitracin -- X 231 bacitracin/ neomycin/ polymyxin B, ointment -- G G X X X 231 bacitracin/ neomycin/ polymyxin B, ointment Neosporin ointment O O 232 bacitracin/ neomycin/ polymyxin B/ hydrocortisone, ointment -- G G X X X

232 bacitracin/ neomycin/ polymyxin B/ hydrocortisone, ointment Cortisporin O O

249 bacitracin/ polymyxin B -- X 231 bacitracin/ polymyxin B, ointment -- G G X 231 bacitracin/ polymyxin B, ointment Polysporin O O 249 bacitracin/ polymyxin B/ neomycin -- X 108 baclofen -- G G X 108 baclofen Lioresal O O 261 becaplermin Regranex O O 202 beclomethasone Beconase AQ O O 195 beclomethasone, inhaler QVAR O O 157 belladona tincture Belladonna Tincture O O 157 belladonna alkaloids/ phenobarbital -- G G 157 belladonna alkaloids/ phenobarbital Donnatal O O 157 belladonna extract/ butabarbital sodium Butibel O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - 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. 63 belladonna/ opium B&O suppositories O O 56 benazepril -- G G 56 benazepril Lotensin O O 56 benazepril/ amlodipine Lotrel P O X 56 benazepril/ hctz -- G G 56 benazepril/ hctz Lotensin HCT O O 37 bendroflumethiazide Naturetin O O 239 benzethonium chloride/ glycerin/ benzocaine Americaine O O 212 benzonatate -- G G X 212 benzonatate Tessalon Perles O O 240 benzoyl peroxide -- G G X 240 benzoyl peroxide Benzac O O 240 benzoyl peroxide Desquam O O 240 benzoyl peroxide Triaz O O 110 benztropine -- G G X X 110 benztropine Cogentin O O 48 bepridil Vascor O O 138 betamethasone Celestone O O 253 betamethasone dipropionate 0.05%, cream/ ointment -- G G 253 betamethasone dipropionate 0.05%, cream/ ointment Diprosone O O 253 betamethasone dipropionate 0.05%, cream/ ointment Maxivate O O 254 betamethasone dipropionate 0.05%, lotion -- G G 254 betamethasone dipropionate 0.05%, lotion Diprosone O O 254 betamethasone dipropionate 0.05%, lotion Maxivate O O 254 betamethasone valerate 0.1%, cream/ lotion -- G G X 254 betamethasone valerate 0.1%, cream/ lotion Valisone O O 253 betamethasone valerate 0.1%, ointment -- G G X 253 betamethasone valerate 0.1%, ointment Valisone O O 50 betaxolol Kerlone O O 219 betaxolol Betoptic O O 219 betaxolol Betoptic S O O 265 bethanechol -- G G X 265 bethanechol Urecholine O O 30 bexarotene Targretin P P X 28 bicalutamide Casodex P O X 223 bimatoprost Lumigan P O X 110 biperiden Akineton O O 168 bisacodyl -- X 169 bismuth subsalicylate -- X 160 bismuth subsalicylate/ metronidazole/ tetracycline Helidac P O X 50 bisoprolol -- G G X 50 bisoprolol Zebeta O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - 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. 50 bisoprolol/ hctz -- G G X 50 bisoprolol/ hctz Ziac O O 189 bitolterol mesylate Tornalate O O 55 bosentan Tracleer P O X 217 brimonidine, 0.15% Alphagan P P O X 217 brimonidine, 0.2% -- G G X 222 brinzolamide Azopt O O 111 bromocriptine Parlodel P O X 138 budesonide Entocort EC O O 202 budesonide Rhinocort AQ P O X 195 budesonide, inhaler Pulmicort P O X 195 budesonide, respules Pulmicort respules P P X 38 bumetanide -- G G 38 bumetanide Bumex O O 116 bupropion, extended release -- G G X X 116 bupropion, extended release Zyban O O 82 buproprion -- G G X X 82 buproprion Wellbutrin O O 82 buproprion, extended release Wellbutrin XL P P X X 82 buproprion, sustained release Wellbutrin SR P P X X 77 buspirone -- G G X X 77 buspirone Buspar O O 26 busulfan Myleran P O X 101 butabarbital sodium Butisol Sodium O O 67 butalbital/ apap Phrenilin O O 67 butalbital/ apap Phrenilin Forte O O 67 butalbital/ apap/ caffeine -- G G X 67 butalbital/ apap/ caffeine Esgic O O 67 butalbital/ apap/ caffeine Esgic Plus O O 67 butalbital/ apap/ caffeine Fioricet O O 67 butalbital/ asa/ caffeine -- G G X 67 butalbital/ asa/ caffeine Fiorinal O O 250 butenafine Mentax O O 64 butorphanol -- G G 64 butorphanol Stadol NS O O 154 cabergoline Dostinex P O X 242 calcipotriene Dovonex P O X 151 calcitonin-salmon, nasal Miacalcin O O 175 calcitriol -- G G X 175 calcitriol Rocaltrol O O 182 calcium acetate Phoslo P 12 O 12 X 12 155 calcium carbonate -- X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 7 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. 182 calcium carbonate -- X 57 candesartan Atacand O O 57 candesartan/ hctz Atacand HCT O O 27 capecitabine Xeloda P O X 56 captopril -- G G X 56 captopril Capoten O O 56 captopril/ hctz -- G G X 56 captopril/ hctz Capozide O O 220 carbachol Carbastat O O 220 carbachol Isopto Carbachol P O X 107 carbamazepine -- G G X X 107 carbamazepine Tegretol P O X X 107 carbamazepine, extended release Carbatrol O O 107 carbamazepine, extended release Tegretol XR P O X X 239 carbamide peroxide -- X 111 carbidopa Lodosyn O O 108 carisoprodol -- G G X 108 carisoprodol Soma O O 108 carisoprodol/ asa -- G G 108 carisoprodol/ asa Soma Compound O O 108 carisoprodol/ asa/ codeine -- G G 108 carisoprodol/ asa/ codeine Soma Compound OO w/Codeine 136 carteolol Cartrol O O 219 carteolol -- G G 219 carteolol Ocupress O O 51 carvedilol Coreg P P X 3 cefaclor -- G G 3 cefaclor Ceclor O O 3 cefaclor, extended release -- G G 3 cefaclor, extended release Ceclor CD O O 3 cefadroxil -- G G 3 cefadroxil Duricef O O 3 cefdinir Omnicef O O 3 cefpodoxime proxetil -- G G 3 cefpodoxime proxetil Vantin O O 3 cefprozil Cefzil O O 3 ceftibuten Cedax O O 3 cefuroxime -- G G X 1 3 cefuroxime Ceftin O O 69 celecoxib Celebrex P 22 O X 22 178 cellulose sodium phosphate Calcibind P O X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 8 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. 3 cephalexin -- G G X X X 3 cephalexin Keflex O O 3 cephalexin monohydrate Keftab O O 3 cephradine -- G G 3 cephradine Velosef O O 205 cetirizine, syrup Zyrtec syrup P P X 205 cetirizine, tablets Zyrtec tablet O O 205 cetirizine/ pseudoephedrine Zyrtec D O O 171 cevimeline Evoxac O O 77 chloral hydrate -- G G X 5 99 chloral hydrate -- G G X 5 26 chlorambucil Leukeran P O X 230 chloramphenicol, ophthalmic -- G G X X X 230 chloramphenicol, ophthalmic Chloroptic O O 238 chloramphenicol, otic Chloromycetin Otic O O 106 chlorazepate dipotassium -- G G X 19 106 chlorazepate dipotassium Tranxene O O 76 chlordiazepoxide -- G G X 19 76 chlordiazepoxide Librium O O 76 chlordiazepoxide/ amitriptyline -- G G 76 chlordiazepoxide/ amitriptyline Limbitrol DS O O 78 chlordiazepoxide/ amitriptyline -- G G 78 chlordiazepoxide/ amitriptyline Limbitrol DS O O 170 chlorhexidine gluconate -- G G X 170 chlorhexidine gluconate Peridex O O 14 chloroquine phosphate -- G G X 14 chloroquine phosphate Aralen O O 16 chloroquine phosphate -- G G X 16 chloroquine phosphate Aralen O O 37 chlorothiazide -- G G 37 chlorothiazide Diuril O O 246 chloroxine Capitrol O O 108 chlorphenesin carbamate Maolate O O 206 chlorpheniramine -- X 72 chlorpromazine -- G G X X 72 chlorpromazine Thorazine O O 87 chlorpromazine -- G G X X 87 chlorpromazine Thorazine O O 144 chlorpropamide -- G G X 144 chlorpropamide Diabinese O O 37 chlorthalidone -- G G 37 chlorthalidone Thalitone O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 9 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. 108 chlorzoxazone -- G G X 108 chlorzoxazone Parafon Forte DSC O O 59 cholestyramine/ aspartame LoCHOLEST Light O O 59 cholestyramine/ aspartame Prevalite O O 59 cholestyramine/ aspartame -- G G 59 cholestyramine/ aspartame Questran Light O O 59 cholestyramine/ sucrose -- G G 59 cholestyramine/ sucrose LoCHOLEST O O 59 cholestyramine/ sucrose Questran O O 66 choline salicyclate/ magnesium salicylate Trilisate O O 250 ciclopirox Loprox P O X 250 ciclopirox Penlac O O 34 cilostazol Pletal O O 161 cimetidine -- G G X 161 cimetidine Tagamet O O 25 cinoxacin Cinobac O O 4 ciprofloxacin -- G G X 1 4 ciprofloxacin Cipro O O 238 ciprofloxacin hcl/ dexamethasone, otic Ciprodex O O 230 ciprofloxacin, ointment Ciloxan Ointment P P X 230 ciprofloxacin, solution -- G G 230 ciprofloxacin, solution Ciloxan Solution O O 238 ciprofloxacin/ hydrocortisone, otic Cipro HC Otic O O 85 citalopram Celexa P P X X 6 clarithromycin Biaxin P O X 29 6 clarithromycin, extended release Biaxin XL P O X 29 206 clemastine -- G G X 206 clemastine Tavist O O 157 clidinium bromide Quarzan O O 157 clidinium/ chlordiazepoxide -- G G 157 clidinium/ chlordiazepoxide Librax O O 8 clindamycin -- G G X 8 clindamycin Cleocin O O 11 clindamycin Cleocin Vaginal P O X 241 clindamycin -- G G X 241 clindamycin Cleocin O O 8 clindamycin palmitate, suspension Cleocin Suspension P O X 240 clindamycin phoshpate/ benzoyl peroxide Benzaclin O O 240 clindamycin phosphate, topical -- G G X 240 clindamycin phosphate, topical Cleocin T O O 249 clindamycin phosphate, topical -- G G X 249 clindamycin phosphate, topical Cleocin T O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 10 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. 252 clobetasol 0.05% -- G G X 252 clobetasol 0.05% Cormax G G X 252 clobetasol 0.05% Temovate O O 252 clobetasol 0.05% Temovate E O O 254 clocortolone pivalate 0.1%, cream Cloderm O O 23 clofazimine Lamprene O O 61 clofibrate Atromid S O O 133 clomiphene -- G 2 G 2 133 clomiphene Serophene O 2 O 2 133 clomiphene Clomid O 2 O 2 78 clomipramine -- G G X X 78 clomipramine Anafranil O O 106 clonazepam -- G G X 19 X 106 clonazepam Klonopin P O X 19 X 52 clonidine, oral -- G G X X 52 clonidine, oral Catapres O O 52 clonidine, transdermal Catapres-TTS O O X 52 clonidine/ chlorthalidone -- G G 52 clonidine/ chlorthalidone Combipres O O 34 clopidogrel Plavix P P X 76 clorazepate dipotassium -- G G X 19 76 clorazepate dipotassium Tranxene O O 13 clotrimazole -- X 170 clotrimazole Mycelex Troches P O X 250 clotrimazole -- X 2 cloxacillin sodium -- G G X 95 clozapine -- G G 95 clozapine Clozaril P O X 246 coal tar -- X 63 codeine sulfate -- G G X 63 codeine/ apap -- G G X 63 codeine/ apap Tylenol w/Codeine O O 63 codeine/ apap/ caffeine/ butalbital Fioricet w/Codeine O O 63 codeine/ asa -- G G X 63 codeine/ asa Empirin w/Codeine O O 63 codeine/ asa/ caffeine/ butalbital Fiorinal w/Codeine O O 210 codeine/ phenylephrine/ promethazine -- O O 210 codeine/ phenylephrine/ promethazine Phenergan VC w/codeine O O 210 codeine/ promethazine -- G G X 210 codeine/ promethazine Phenergan w/codeine O O 210 codeine/ pseudoephedrine Nucofed O O 210 codeine/ pseudoephedrine/ chlorpheniramine -- G G X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 11 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. 211 codeine/ pseudoephedrine/ chlorpheniramine -- G G X 153 colchicine 0.5mg -- O O 153 colchicine 0.6mg -- G G X 153 colchicine/ probenecid -- G G X 59 colesevelam Welchol O O 59 colestipol, granules Colestid P O X 59 colestipol, tablets Colestid P O 259 collagenase Santyl O O 270 condoms -- X 118 conjugated estrogens Premarin P O X 119 conjugated estrogens, vaginal Premarin P O X 122 conjugated estrogens/ medroxyprogesterone Premphase P O X 122 conjugated estrogens/ medroxyprogesterone Prempro P O X 122 conjugated estrogens/ medroxyprogesterone Prempro Low Dose P O X 138 cortisone acetate Cortisone O O X 225 cromolyn -- G G X 225 cromolyn Opticrom O O 225 cromolyn Crolom O O 203 cromolyn sodium Nasalcrom X 196 cromolyn sodium, inhalation -- G G X 196 cromolyn sodium, inhalation Intal O O 196 cromolyn sodium, metered dose inhaler Intal MDI P O X 251 crotamiton Eurax O O 32 cyanocobalamin, nasal Nascobal P 11 O 11 X 11 174 cyanocobalamin, nasal Nascobal P 11 O 11 X 11 108 cyclobenzaprine -- G G X 108 cyclobenzaprine Flexeril O O 26 cyclophosphamide -- G G X 26 cyclophosphamide Cytoxan P O X 15 cycloserine Seromycin O O 268 cyclosporine Sandimmune P O X 268 cyclosporine, microemulsion -- G G X 268 cyclosporine, microemulsion Neoral P O X 206 cyproheptadine -- G G X 206 cyproheptadine Periactin O O 267 cysteamine bitartrate Cystagon O O 135 danazol -- G G X 135 danazol Danocrine O O 109 dantrolene Dantrium O O 23 dapsone Dapsone O O 18 delavirdine mesylate Rescriptor P O X 5 demeclocycline Declomycin O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 12 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. 54 deserpidine/ methyclothiazide Enduronyl O O 54 deserpidine/ methyclothiazide Enduronyl Forte O O 79 desipramine -- G G X X 79 desipramine Norpramin O O 205 desloratadine Clarinex O O 136 desmopressin, nasal Stimate P O X 136 desmopressin, nasal DDAVP P O X 136 desmopressin, oral DDAVP P O X 255 desonide 0.05%, cream/ ointment -- G G X 255 desonide 0.05%, cream/ ointment Desowen O O 255 desonide 0.05%, lotion Desowen O O 254 desoximetasone 0.05%, cream -- G G 254 desoximetasone 0.05%, cream Topicort LP O O 253 desoximetasone 0.05%, gel -- G G 253 desoximetasone 0.05%, gel Topicort O O 253 desoximetasone 0.25%, cream/ ointment -- G G 253 desoximetasone 0.25%, cream/ ointment Topicort O O 138 dexamethasone -- G G X 138 dexamethasone Decadron O O 255 dexamethasone 0.04%, aerosol Decaspray O O 255 dexamethasone sodium phosphate 0.1%, cream Decadron O O 229 dexamethasone sodium phosphate, ophthalmic -- G G X 229 dexamethasone sodium phosphate, ophthalmic Decadron O O 206 dexchlorpheniramine Polaramine O O 62 dextroamphetamine sulfate -- G 8 G 8 X 8 X 8 62 dextroamphetamine sulfate Dexedrine P 8 O 8 X 8 X 8 62 dextroamphetamine sulfate, sustained release -- G 7 G 7 X 7 X 7 62 dextroamphetamine sulfate, sustained release Dexedrine Spansules O 7 O 7 X 7 212 dextromethorphan/ guaifenesin/ phenylephrine Sinutuss DM G G 212 dextromethorphan/ promethazine -- G G X 212 dextromethorphan/ promethazine Phenergan DM O O 212 dextromethorphan/ pseudoephedrine/ brompheniramine -- G G X 212 dextromethorphan/ pseudoephedrine/ brompheniramine Dimetane DX O O 212 dextromethorphan/ pseudoephedrine/ brompheniramine Rondec DM O O 213 dextromethorphan/ pseudoephedrine/ brompheniramine Rondec DM syrup O O 212 dextromethorphan/ pseudoephedrine/ carbinoxamine -- G G X 213 dextromethorphan/ pseudoephedrine/ carbinoxamine Cardec DM Drops G G 213 dextromethorphan/ pseudoephedrine/ carbinoxamine Cardec DM Pediatric G G 213 dextromethorphan/ pseudoephedrine/ carbinoxamine Rondec DM Drops O O 270 diaphragms -- O 3 O 3 X X X 76 diazepam -- G G X 19 76 diazepam Valium O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 13 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. 106 diazepam -- G G X 19 106 diazepam Valium O O 108 diazepam -- G G X 19 108 diazepam Valium O O 106 diazepam, rectal Diastat P O X 40 dichlorphenamide Daranide O O 68 diclofenac potasium -- G G 68 diclofenac potasium Cataflam O O 68 diclofenac sodium, delayed release, oral -- G G 68 diclofenac sodium, delayed release, oral Voltaren O O 68 diclofenac sodium, extended release, oral Voltaren XR O O 228 diclofenac sodium, ophthalmic Voltaren P O X 68 diclofenac/ misoprostol Arthrotec O O 162 diclofenac/ misoprostol Arthrotec O O 2 dicloxacillin sodium -- G G X 2 dicloxacillin sodium Dynapen O O 2 dicloxacillin sodium, suspension Dynapen Suspension P O X 35 dicumarol Dicumarol O O 159 dicyclomine -- G G X 159 dicyclomine, syrup Bentyl Syrup P O X 159 dicyclomine, tablets and capsules Bentyl O O 17 didanosine Videx P O X 17 didanosine, enteric coated Videx EC P O X 119 dienestrol, vaginal Ortho Dienestrol O O 24 diethylcarbamazine citrate Hetrazan O O 28 diethylstilbestrol Stilphostrol O O 253 diflorasone 0.05% cream/ ointment -- G G 253 diflorasone 0.05%, cream Psorcon O O 253 diflorasone 0.05%, cream/ ointment Florone O O 253 diflorasone 0.05%, cream/ ointment Maxiflor O O 252 diflorasone 0.05%, ointment Psorcon B O O 66 diflunisal -- G G 66 diflunisal Dolobid O O 42 digitoxin Crystodigin O O 42 digoxin -- G G X 42 digoxin Lanoxicaps O O 42 digoxin Lanoxin G G X 71 dihydroergotamine mesylate Migranal O 20 O 20 45 diltiazem -- G G X 45 diltiazem Cardizem O O 45 diltiazem, sustained release -- G G X 45 diltiazem, sustained release Cardizem CD O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 14 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. 45 diltiazem, sustained release Cardizem SR O O 45 diltiazem, sustained release Dilacor XR O O 45 diltiazem, sustained release Tiazac P P X 73 diphenhydramine -- G G X X 73 diphenhydramine Benadryl O O 110 diphenhydramine -- G G X X 110 diphenhydramine Benadryl O O 206 diphenhydramine -- G G X X 206 diphenhydramine Benadryl O O 247 diphenhydramine, topical -- X 169 diphenoxylate/ atropine sulfate -- G G 169 diphenoxylate/ atropine sulfate Lomotil O O 218 dipivefrin -- G G X 218 dipivefrin Propine O O 218 dipivefrin AKPro O O 34 dipyridamole -- G G X 34 dipyridamole Persantine O O 6 dirithromycin Dynabac O O 44 disopyramide -- G G X 44 disopyramide Norpace P O X 44 disopyramide, sustained release -- G G X 44 disopyramide, sustained release Norpace CR P O X 113 disulfiram Antabuse P O X X 107 divalproex sodium Depakote P O X X 107 divalproex sodium, extended release Depakote ER P O X X 168 docusate sodium -- X 168 docusate sodium/ casanthranol -- X 44 dofetilide Tikosyn O O 75 dolasetron mesylate Anzemet O O 97 donepezil Aricept P O X 198 dornase alfa Pulmozyme O O 222 dorzolamide Trusopt P O X 222 dorzolamide/ timolol Cosopt P O X 53 doxazosin -- G G 53 doxazosin mesylate Cardura O O 77 doxepin -- G G X X 77 doxepin Sinequan O O 78 doxepin -- G G X X 78 doxepin Sinequan O O 247 doxepin Zonalon O O 5 doxycycline hyclate -- G G X X X 5 doxycycline hyclate Doryx O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 15 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. 5 doxycycline hyclate Periostat O O 5 doxycycline hyclate Vibramycin O O 14 doxycycline hyclate -- G G X X X 14 doxycycline hyclate Vibramycin O O 170 doxycycline hyclate Periostat O O 241 doxycycline hyclate -- G G X X X 241 doxycycline hyclate Doryx O O 241 doxycycline hyclate Vibramycin O O 5 doxycycline monohydrate -- G G 5 doxycycline monohydrate Monodox O O 241 doxycycline monohydrate -- G G 241 doxycycline monohydrate Monodox O O 74 dronabinol Marinol O O 221 echothiophate iodide Phospholine Iodide P O X 250 econazole -- G G X 250 econazole Spectazole O O 18 efavirenz Sustiva P O X 225 emedastine Emadine O O 17 emtricitabine Emtriva P O X 56 enalapril -- G G X 56 enalapril Vasotec O O 56 enalapril/ hctz -- G G X 56 enalapril/ hctz Vaseretic O O 4 enoxacin Penetrex O O 111 entacapone Comtan O O 218 epinephrine Epifrin P O X 191 epinephrine, injectable Epi-pen P O X 191 epinephrine, injectable Epi-pen JR P O X 218 epinephrine/ pilocarpine E-Pilo P O X 218 epinephryl borate Epinal P O X 57 eprosartan Teveten O O 57 eprosartan/ hctz Teveten HCT O O 117 ergoloid mesylates Hydergine O O 117 ergoloid mesylates Hydergine LC O O 117 ergoloid mesylates, sublingual -- G G 117 ergoloid mesylates, sublingual Hydergine O O 71 ergotamine tartrate Ergomar P O X 71 ergotamine tartrate/ caffeine -- G G X 71 ergotamine tartrate/ caffeine Cafergot O O 71 ergotamine tartrate/ caffeine/ tartaric acid Wigraine suppositories O O 230 erythromycin -- G G X X X 230 erythromycin Ilotycin O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 16 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. 240 erythromycin -- G G X 240 erythromycin ATS O O 240 erythromycin Emgel O O 240 erythromycin Erygel O O 240 erythromycin T-Stat G G 6 erythromycin base -- G G X X X 6 erythromycin base Eryc O O 6 erythromycin base Ery-Tab G G X X X 6 erythromycin base PCE O O 241 erythromycin base -- G G X X X 241 erythromycin base Eryc O O 241 erythromycin base Ery-Tab G G X X X 241 erythromycin base PCE O O 6 erythromycin estolate -- G G X X X 6 erythromycin estolate Ilosone O O 6 erythromycin ethylsuccinate -- G G X X X 6 erythromycin ethylsuccinate EryPed O O 6 erythromycin stearate -- G G X X X 249 erythromycin, topical -- G G X 249 erythromycin, topical ATS O O 249 erythromycin, topical Emgel O O 249 erythromycin, topical Erygel O O 249 erythromycin, topical T-Stat O O 240 erythromycin/ benzoyl peroxide -- G G 240 erythromycin/ benzoyl peroxide Benzamycin O O 6 erythromycin/ sufisoxazole -- G G X 6 erythromycin/ sufisoxazole Pediazole O O 10 erythromycin/ sufisoxazole -- G G X 10 erythromycin/ sufisoxazole Pediazole O O 85 escitalopram Lexapro P P X X 98 estazolam -- G G 98 estazolam Prosom O O 118 esterified estrogens Menest O O 118 esterified estrogens/ methyltestosterone Estratest P O X 118 esterified estrogens/ methyltestosterone Estratest HS P O X 129 esterified estrogens/ methyltestosterone Estratest HS P O X 129 esterified estrogens/ methyltestosterone Estratest P O X 118 estradiol -- G G X 118 estradiol Estrace O O 119 estradiol hemihydrate Vagifem O O 119 estradiol, transdermal -- G G X 119 estradiol, transdermal Alora O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 17 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. 119 estradiol, transdermal Climara O O 119 estradiol, transdermal Esclim O O 119 estradiol, transdermal Estraderm O O 119 estradiol, transdermal FemPatch O O 119 estradiol, transdermal Vivelle O O 119 estradiol, vaginal Estrace P O X 119 estradiol, vaginal Estring O O 122 estradiol/ norethindrone acetate Activella O O 122 estradiol/ norethindrone acetate, transdermal Combipatch O O 28 estramustine Emcyt P O X 118 estropipate -- G G X 118 estropipate Ogen O O 118 estropipate Ortho-EST G G X 119 estropipate, vaginal Ogen O O 38 ethacrynic acid Edecrin O O 15 ethambutol -- G G X 18 15 ethambutol Myambutol O O 99 ethchlorvynol Placidyl O O 118 ethinyl estradiol Estinyl O O 123 ethinyl estradiol/ desogestrel Desogen P 3 P 3 X X X 124 ethinyl estradiol/ desogestrel Mircette P 3 P 3 X X X 123 ethinyl estradiol/ drospirenone Yasmin P 3 P 3 X X X 123 ethinyl estradiol/ levonorgestrel Alesse P 3 P 3 X X X 125 ethinyl estradiol/ levonorgestrel Tri-Levlen P 3 P 3 X X X 127 ethinyl estradiol/ levonorgestrel Preven O X 128 ethinyl estradiol/ levonorgestrel Nuvaring O O X 128 ethinyl estradiol/ norelgestromin OrthoEvra O O X 122 ethinyl estradiol/ norethindrone acetate Femhrt O O 15 ethionamide Trecator-SC O O 104 ethosuximide Zarontin P O X 103 ethotoin Peganone O O 152 etidronate -- G G 152 etidronate Didronel O O 68 etodolac -- G G 68 etodolac Lodine O O 68 etodolac, extended release -- G G 68 etodolac, extended release Lodine XL O O 29 etoposide -- G G X 29 etoposide VePesid O O 61 ezetimibe Zetia O O 22 famciclovir Famvir P O X 161 famotidine -- G G HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 18 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. 161 famotidine Pepcid O O 107 felbamate Felbatol P O X 46 felodipine Plendil P P X 46 felodipine/ enalapril Lexxel O O 56 felodipine/ enalapril Lexxel O O 61 fenofibrate -- O O 61 fenofibrate Tricor O O 68 fenoprofen calcium -- G G 68 fenoprofen calcium Nalfon O O 63 fentanyl, transdermal Duragesic P 31 O 31 X 31 181 ferrous sulfate -- X 205 fexofenadine Allegra P P X 205 fexofenadine/ pseudoephedrine Allegra D P P X 259 fibrinolysin/ desoxyribonuclease Elase O O 131 finasteride Proscar P O X 264 flavoxate Urispas O O 44 flecainide -- G G X 44 flecainide Tambocor P O X 12 fluconazole Diflucan P O X 137 fludrocortisone -- G G X 137 fludrocortisone Florinef O O 195 flunisolide, inhaler Aerobid P P X 195 flunisolide, inhaler Aerobid M P P X 202 flunisolide, nasal -- P O X 255 fluocinolone acetonide 0.01% -- G G X 255 fluocinolone acetonide 0.01% Synalar O O 254 fluocinolone acetonide 0.025%, cream/ ointment -- G G X 254 fluocinolone acetonide 0.025%, cream/ ointment Synalar O O 253 fluocinolone acetonide 0.2%, cream Synalar HP O O 253 fluocinonide 0.05% -- G G 253 fluocinonide 0.05% Lidex O O 229 fluoromethalone -- G G X 229 fluoromethalone Flarex O O 229 fluoromethalone FML O O 229 fluoromethalone FML Forte O O 229 fluoromethalone FML SOP O O 261 fluorouracil Efudex O O 261 fluorouracil Fluoroplex O O 85 fluoxetine -- G G X X 85 fluoxetine Prozac O O 129 fluoxymesterone Halotestin P O X 88 fluphenazine -- G G X X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 19 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. 88 fluphenazine Prolixin O O 88 fluphenazine deconoate, injectable -- XX 254 flurandrenolide Cordran P O X 254 flurandrenolide Cordran SP P O X 254 flurandrenolide 4mcg/ cm2, tape Cordran tape P O X 98 flurazepam -- G G 98 flurazepam Dalmane O O 68 flurbiprofen -- G G 68 flurbiprofen Ansaid O O 228 flurbiprofen sodium, ophthalmic -- G G 228 flurbiprofen sodium, ophthalmic Ocufen O O 28 flutamide -- G G X 28 flutamide Eulexin O O 202 fluticasone Flonase P O X 254 fluticasone propionate 0.05%, cream/ ointment Cutivate O O 195 fluticasone, inhaler Flovent P O X 60 fluvastatin Lescol O 21 O 21 60 fluvastatin, extended release Lescol XL O 21 O 21 85 fluvoxamine maleate -- G G X 31 folic acid -- G G X 190 formoterol Foradil O O 25 fosfomycin tromethamine Monurol O O 56 fosinopril -- G G 56 fosinopril Monopril O O 56 fosinopril/ hctz Monopril HCT O O 70 frovatriptan Frova O 25 O 25 25 furazolidone Furoxone O O 38 furosemide -- G G X 38 furosemide Lasix O O 107 gabapentin Neurontin P O X X 97 galantamine Reminyl O O 22 ganciclovir -- G G X 22 ganciclovir Cytovene O O 4 gatifloxacin Tequin O O 61 gemfibrozil -- G G X 61 gemfibrozil Lopid O O 230 gentamicin -- G G X 230 gentamicin Garamycin O O 249 gentamicin sulfate, topical -- G G X 249 gentamicin sulfate, topical Garamycin O O 11 glacial acetic acid Aci-jel O O 144 glimepiride Amaryl O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 20 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 glipizide -- G G X 144 glipizide Glucotrol O O 144 glipizide, extended release -- G G X 144 glipizide, extended release Glucotrol XL O O 148 glucagon Glucagon Emergency Kit P O X 144 glyburide -- G G X 144 glyburide Diabeta O O 144 glyburide Micronase O O 144 glyburide, micronized -- G G X 144 glyburide, micronized Glynase O O 144 glyburide/ metformin -- G G X 144 glyburide/ metformin Glucovance O O 168 glycerin -- X 158 glycopyrrolate Robinul O O 158 glycopyrrolate Robinul Forte O O 231 gramicidin/ neomycin/ polymyxin B, solution -- G G X X X 231 gramicidin/ neomycin/ polymyxin B, solution Neosporin solution O O 75 granisetron Kytril P O X 12 griseofulvin microsize -- G G 12 griseofulvin microsize Fulvicin-U/F O O 12 griseofulvin microsize Grifulvin V O O 12 griseofulvin ultramicrosize -- G G X 12 griseofulvin ultramicrosize Gris-Peg P O X 214 guaifenesin Duratuss G O O 214 guaifenesin Organidin NR O O 214 guaifenesin (generic Robitussin) -- X 214 guaifenesin, sustained release -- G G 214 guaifenesin, sustained release Humibid LA O O 215 guaifenesin/ codeine -- G G X 215 guaifenesin/ codeine Robitussin AC O O 214 guaifenesin/ dextromethorphan (generic Robitussin DM) -- X 215 guaifenesin/ hydrocodone -- G G 215 guaifenesin/ hydrocodone Vicodin Tuss O O 214 guaifenesin/ phenylephrine Sinuvent PE G G 214 guaifenesin/ phenylephrine Entex LA O O 214 guaifenesin/ pseudoephedrine -- G G X 214 guaifenesin/ pseudoephedrine Robitussin PE O O 214 guaifenesin/ pseudoephedrine Entex PSE O O 215 guaifenesin/ pseudoephedrine/ codeine -- G G X 215 guaifenesin/ pseudoephedrine/ codeine Nucofed Expectorant O O 216 guaifenesin/ pseudoephedrine/ codeine -- G G HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 21 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. 216 guaifenesin/ pseudoephedrine/ codeine Nucofed Pediatric OO Expectorant 52 guanabenz -- G G 52 guanabenz Wytensin O O 54 guanadrel Hylorel O O 54 guanethidine Ismelin O O 52 guanfacine -- G G X 52 guanfacine Tenex O O 112 guanidine hcl Guanidine O O 76 halazepam Paxipam O O 253 halcinonide 0.1%, cream/ ointment Halog O O 253 halcinonide 0.1%, cream/ ointment Halog E O O 252 halobetasol propionate 0.05%, cream/ ointment Ultravate P O X 14 halofantrine hcl Halfan O O 91 haloperidol -- G G X X 91 haloperidol Haldol O O 91 haloperidol decanoate, injectable -- XX 261 hexachlorophene pHisoHex O O 227 homatropine HBr Isopto Homatropine P O X 143 human 50/ 50 insulin Humulin 50/50 G G X 143 human 70/ 30 insulin Humulin 70/30 G G X 143 human 70/ 30 insulin Novolin 70/30 G G X 143 human 70/ 30 insulin Novolin 70/30 Penfill G G X 143 human 70/ 30 insulin Novolin 70/30 Prefilled G G X 143 human insulin Novolog mix G G X 143 human insulin aspart Novolog G G X 143 human insulin lispro Humalog G G X 143 human insulin lispro Humalog 50/50 G G X 143 human insulin lispro Humalog 75/25 G G X 143 human lente insulin Humulin L G G X 143 human NPH insulin Humulin N G G X 143 human NPH insulin Novolin N G G X 143 human NPH insulin Novolin N Penfill G G X 143 human NPH insulin Novolin N Prefilled G G X 143 human regular insulin Humulin R G G X 143 human regular insulin Novolin R G G X 143 human regular insulin Novolin R Penfill G G X 143 human regular insulin Novolin R Prefilled G G X 143 human regular insulin Velosulin Human BR G G X 143 human ultralente insulin Humulin U Ultralente G G X 55 hydralazine -- G G X 55 hydralazine Apresoline O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 22 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. 55 hydralazine/ hctz -- G G 55 hydralazine/ hctz Apresazide O O 37 hydrochlorothiazide -- G G X 37 hydrochlorothiazide HydroDIURIL O O 37 hydrochlorothiazide Microzide O O 63 hydrocodone/ apap -- G G X 63 hydrocodone/ apap Anexsia O O 63 hydrocodone/ apap Lorcet O O 63 hydrocodone/ apap Lortab O O 63 hydrocodone/ apap Norco O O 63 hydrocodone/ apap Vicodin O O 63 hydrocodone/ apap Vicodin HP O O 63 hydrocodone/ asa Lortab ASA O O 210 hydrocodone/ chlorpheniramine Tussionex O O 211 hydrocodone/ homatopine Hycodan O O 210 hydrocodone/ homatropine -- G G 210 hydrocodone/ homatropine Hycodan O O 211 hydrocodone/ homatropine -- G G 63 hydrocodone/ ibuprofen -- G G 63 hydrocodone/ ibuprofen Vicoprofen O O 210 hydrocodone/ pseudoephedrine -- G G 138 hydrocortisone -- G G X 138 hydrocortisone Cortef O O 139 hydrocortisone Cortenema P O X 139 hydrocortisone Proctocort O O X 255 hydrocortisone 0.25%, lotion -- G G X 255 hydrocortisone 0.25%, lotion Cetacort O O 255 hydrocortisone 0.5% -- G G X 255 hydrocortisone 0.5% Hytone O O 255 hydrocortisone 1% -- G G X 255 hydrocortisone 1% Hytone O O 255 hydrocortisone 2.5% -- G G X 255 hydrocortisone 2.5% Hytone O O 139 hydrocortisone acetate -- G G X 14 139 hydrocortisone acetate Anusol HC O O 139 hydrocortisone acetate Cortifoam O O 139 hydrocortisone acetate/ pramoxine Analpram HC O O X 139 hydrocortisone acetate/ pramoxine Proctocream-HC O O X 139 hydrocortisone acetate/ pramoxine Proctofoam-HC O O X 254 hydrocortisone butyrate 0.1% Locoid O O 254 hydrocortisone valerate 0.2%, cream/ ointment -- G G X 254 hydrocortisone valerate 0.2%, cream/ ointment Westcort O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 23 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. 63 hydromorphone -- G G X 63 hydromorphone Dilaudid O O 14 hydroxychloroquine sulfate -- G G X 14 hydroxychloroquine sulfate Plaquenil O O 269 hydroxychloroquine sulfate -- G G X 269 hydroxychloroquine sulfate Plaquenil O O 236 hydroxypropyl cellulose Lacrisert O O 30 hydroxyurea -- G G X 30 hydroxyurea Hydrea O O 77 hydroxyzine hcl -- G G X X 77 hydroxyzine hcl Atarax O O 206 hydroxyzine hcl -- G G X X 206 hydroxyzine hcl Atarax O O 77 hydroxyzine pamoate, capsules -- G G X X 77 hydroxyzine pamoate, capsules Vistaril O O 206 hydroxyzine pamoate, capsules -- G G X X 206 hydroxyzine pamoate, capsules Vistaril O O 77 hydroxyzine pamoate, suspension Vistaril Suspension P O X X 206 hydroxyzine pamoate, suspension Vistaril suspension P O X X 68 ibuprofen -- G G X 68 ibuprofen Motrin O O 235 idoxuridine Herplex P O X 78 imipramine -- G G X X 78 imipramine Tofranil O O 78 imipramine pamoate Tofranil PM P O X X 261 imiquimod Aldara P O X 37 indapamide -- G G X 37 indapamide Lozol O O 20 indinavir sulfate Crixivan P O X 68 indomethacin -- G G X 68 indomethacin Indocin O O 68 indomethacin, sustained release -- G G X 68 indomethacin, sustained release Indocin SR O O 143 insulin glargine Lantus G G X 147 insulin injector Novopen G G X 147 insulin needles B-D G G X 147 insulin needles Novofine G G X 147 insulin needles Novofine 30 G G X 16 iodoquinol Yodoxin P O X 173 ipecac syrup -- X 192 ipratropium, inhalation -- G G X 192 ipratropium, inhalation Atrovent O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 24 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. 192 ipratropium, inhalation Atrovent MDI P O X 201 ipratropium, nasal -- G G X 201 ipratropium, nasal Atrovent O O 57 irbesartan Avapro P P X 57 irbesartan/ hctz Avalide P P X 181 iron/ multivit/ mineral, prescription -- G 2 G 2 181 iron/ multivit/ mineral, prescription Berocca Plus O 2 O 2 181 iron/ vit c/ vit b12/ intrinsic factor/ folate Trinsicon O 2 O 2 86 isocarboxazid Marplan O O 189 isoetharine -- O O 71 isometheptene/ dichloralphenazone/ apap -- G G 71 isometheptene/ dichloralphenazone/ apap Midrin O O 15 isoniazid -- G G X 4 15 isoniazid/ rifampin Rifamate O O 15 isoniazid/ rifampin/ pyrazinamide Rifater O O 189 isoproterenol Isuprel O O 43 isosorbide dinitrate, chewable Sorbitrate O O 43 isosorbide dinitrate, oral -- G G X 43 isosorbide dinitrate, oral Isordil Titradose O O 43 isosorbide dinitrate, oral, sustained release -- G G X 43 isosorbide dinitrate, oral, sustained release Dilatrate-SR O O 43 isosorbide dinitrate, oral, sustained release Isordil Tembids O O 43 isosorbide dinitrate, sublingual -- G G X 43 isosorbide dinitrate, sublingual Isordil O O 43 isosorbide mononitrate -- G G 43 isosorbide mononitrate ISMO O O 43 isosorbide mononitrate Monoket O O 43 isosorbide mononitrate, extended release -- G G X 43 isosorbide mononitrate, extended release Imdur O O 241 isotretinoin -- G G 241 isotretinoin Accutane O O 46 isradipine DynaCirc O O 12 itraconazole Sporanox P O X 24 ivermectin Stromectol O O 9 kanamycin sulfate Kantrex O O 169 kaolin/ pectin -- X 12 ketoconazole -- G G X 12 ketoconazole Nizoral O O 246 ketoconazole, cream -- G G X 246 ketoconazole, cream Nizoral O O X 250 ketoconazole, cream -- G G X 250 ketoconazole, cream Nizoral O O X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 25 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. 250 ketoconazole, shampoo -- G G X 250 ketoconazole, shampoo Nizoral O O 68 ketoprofen -- G G 68 ketoprofen Orudis O O 68 ketoprofen, extended release -- G G 68 ketoprofen, extended release Oruvail O O 228 ketorolac tromethamine, ophthalmic Acular P O X 228 ketorolac tromethamine, ophthalmic Acular PF P O X 68 ketorolac, oral -- G G 68 ketorolac, oral Toradol O O 225 ketotifen Zaditor P P X 51 labetolol -- G G X 51 labetolol Normodyne O O 51 labetolol Trandate O O 168 lactulose -- G G X 168 lactulose Cephulac O O 168 lactulose Chronulac O O 157 l-alkaloids of belladonna/ phenobarbital/ ergotamine -- G G 157 l-alkaloids of belladonna/ phenobarbital/ ergotamine Bellergal-S O O 17 lamivudine Epivir P O X 17 lamivudine Epivir-HBV P O X 17 lamivudine/ zidovudine Combivir P O X 107 lamotrigine Lamictal P O X X 163 lansoprazole Prevacid O O 163 lansoprazole Prevacid Granules O O 160 lansoprazole/ amoxicillin/ clarithromycin Prevpac P O X 223 latanoprost Xalatan P O X 269 leflunomide Arava O O 28 letrozole Femara O O 31 leucovorin calcium -- G G X 31 leucovorin calcium Wellcovorin O O 189 levalbuterol Xopenex O O 30 levamisole Ergamisol P O X 107 levetiracetam Keppra P O X X 219 levobunolol -- G G X 219 levobunolol Betagan O O 225 levocabastine Livostin O O 186 levocarnitine Carnitor P 13 O 13 X 13 111 levodopa Larodopa O O 111 levodopa Dopar O O 111 levodopa/ carbidopa -- G G X 111 levodopa/ carbidopa Sinemet O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 26 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. 111 levodopa/ carbidopa, sustained release -- G G X 111 levodopa/ carbidopa, sustained release Sinemet CR O O 4 levofloxacin Levaquin O O 230 levofloxacin Quixin O O 127 levonorgestrel Plan B P X 63 levorphanol Levo-Dromoran P O X 149 levothyroxine sodium -- G G X 149 levothyroxine sodium Levothroid P O X 149 levothyroxine sodium Synthroid P O X 157 l-hyoscyamine sulfate -- G G 157 l-hyoscyamine sulfate Levsin O O 157 l-hyoscyamine sulfate, extended release Levbid O O 157 l-hyoscyamine sulfate, sublingual Levsin/SL O O 157 l-hyoscyamine sulfate, timed release Levsinex Timecaps O O 256 lidocaine -- G G X 256 lidocaine Xylocaine O O 172 lidocaine, viscous -- G G X 172 lidocaine, viscous Xylocaine O O 257 lidocaine, viscous -- G G X 257 lidocaine, viscous Xylocaine Viscous O O 256 lidocaine/ prilocaine -- G G 256 lidocaine/ prilocaine EMLA O O 251 lindane -- G G X 149 liothyronine sodium Cytomel P O X 149 liothyronine sodium/ levothyroxine Thyrolar P O X 56 lisinopril -- G G X 56 lisinopril Prinivil O O 56 lisinopril Zestril O O 56 lisinopril/ hctz -- G G X 56 lisinopril/ hctz Prinzide O O 56 lisinopril/ hctz Zestoretic O O 96 lithium carbonate -- G G X X 96 lithium carbonate Eskalith O O 96 lithium carbonate Lithotabs O O 96 lithium carbonate, controlled release Eskalith CR P O X X 96 lithium carbonate, slow release -- G G X X 96 lithium carbonate, slow release Lithobid P O X X 96 lithium citrate -- G G X X 225 lodoxamide Alomide O O 4 lomefloxacin Maxaquin O O 26 lomustine CeeNu P O X 169 loperamide -- G G X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 27 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. 169 loperamide Imodium O O 20 lopinavir/ ritonavir Kaletra P O X 3 loracarbef Lorabid O O 205 loratadine -- X 76 lorazepam -- G G X 19 X 76 lorazepam Ativan O O 57 losartan Cozaar P P X 57 losartan/ hctz Hyzaar P P X 229 loteprednol etabonate Alrex O O 229 loteprednol etabonate Lotemax P P X 60 lovastatin -- G G X 60 lovastatin Mevacor O O 60 lovastatin, extended release Altocor G 21 G 21 X 21 60 lovastatin, extended release Altoprev G 21 G 21 X 21 94 loxapine -- G G 94 loxapine Loxitane O O 94 loxapine solution Loxitane C O O 244 mafenide Sulfamylon O O 168 magnesium citrate -- X 155 magnesium hydroxide -- X 168 magnesium hydroxide -- X 66 magnesium salicylate Magan O O 66 magnesium salicylate Mobidin O O 251 malathion Ovide O O 80 maprotiline -- G G X X 80 maprotiline Ludiomil O O 261 masoprocol Actinex O O 24 mebendazole -- G G X 24 mebendazole Vermox O O 73 meclizine -- G G X 73 meclizine Antivert O O 240 meclocycline sulfosalicylate Meclan O O 68 meclofenamate sodium -- G G 121 medroxyprogesterone acetate -- G G X 121 medroxyprogesterone acetate Amen O O 121 medroxyprogesterone acetate Curretab O O 121 medroxyprogesterone acetate Provera O O 128 medroxyprogesterone acetate, injectable Depo-Provera X X 68 mefenamic acid Ponstel O O 14 mefloquine hcl Larium O O 28 megestrol -- G G X 28 megestrol Megace O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 28 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. 26 melphalan Alkeran P O X 158 mepenzolate bromide Cantil O O 63 meperidine -- G G X 63 meperidine Demerol O O 103 mephenytoin Mesantoin O O 100 mephobarbital Mebaral P O X 26 77 meprobamate -- G G 77 meprobamate Equanil O O 77 meprobamate Miltown O O 27 mercaptopurine -- G G X 27 mercaptopurine Purinethol O O 173 mesalamine, controlled release Pentasa O O 173 mesalamine, delayed release Asacol P O X 173 mesalamine, rectal Rowasa P O X 89 mesoridazine Serentil O O 188 metaproterenol sulfate -- G G X 188 metaproterenol sulfate Alupent O O 189 metaproterenol sulfate, inhalation -- G G X 189 metaproterenol sulfate, inhalation Alupent O O 189 metaproterenol sulfate, metered dose inhaler Alupent MDI P O X 108 metaxalone Skelaxin O O 145 metformin -- G G X 145 metformin Glucophage O O 145 metformin, extended release -- G G X 145 metformin, extended release Glucophage XR O O 63 methadone -- G G X X 63 methadone Dolophine O O X 114 methadone -- G G X X 114 methadone Dolophine O O 62 methamphetamine Desoxyn O 7 O 7 158 methantheline bromide Banthine O O 40 methazolamide -- G G X 40 methazolamide Neptazane O O 25 methenamine hippurate -- G G 25 methenamine hippurate Hiprex O O 25 methenamine hippurate Urex O O 25 methenamine mandelate -- G G X 25 methenamine mandelate Mandelamine O O 150 methimazole -- G G X 150 methimazole Tapazole O O 245 methionine Pedameth O O 108 methocarbamol -- G G X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 29 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. 108 methocarbamol Robaxin O O 108 methocarbamol/ asa -- G G 108 methocarbamol/ asa Robaxisal O O 27 methotrexate -- G G X 27 methotrexate Rheumatrex O O 243 methotrexate -- G G X 243 methotrexate Rheumatrex O O 269 methotrexate -- G G X 269 methotrexate Rheumatrex O O 243 methoxasalen Oxsoralen-Ultra P O X 157 methscopolamine bromide Pamine O O 104 methsuximide Celontin Kapseals P O X 37 methyclothiazide -- G G 37 methyclothiazide Enduron O O 52 methyldopa -- G G X 52 methyldopa Aldomet O O 52 methyldopa/ chlorothiazide Aldoclor O O 52 methyldopa/ hctz -- G G 52 methyldopa/ hctz Aldoril O O 25 methylene blue Urolene Blue O O 62 methylphenidate -- G 8 G 8 X 8 X 8 62 methylphenidate Ritalin O 8 O 8 62 methylphenidate, extended release Ritalin LA P 7 O 7 X 7 X 7 62 methylphenidate, extended release Concerta P 7 O 7 X 7 X 7 62 methylphenidate, extended release Metadate CD P 7 O 7 X 7 X 7 62 methylphenidate, extended release Metadate ER P 7 O 7 X 7 X 7 62 methylphenidate, sustained release -- G 8 G 8 X 8 X 8 62 methylphenidate, sustained release Ritalin SR O 8 O 8 138 methylprednisolone -- G G 138 methylprednisolone Medrol O O 129 methyltestosterone Android P O X 129 methyltestosterone Testred O O 219 metipranolol -- G G 219 metipranolol OptiPranolol O O 72 metoclopramide -- G G X 72 metoclopramide Reglan O O 165 metoclopramide -- G G X 165 metoclopramide Reglan O O 37 metolazone Mykrox O O 37 metolazone -- G G X 37 metolazone Zaroxolyn O O 50 metoprolol -- G G X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 30 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. 50 metoprolol Lopressor O O 50 metoprolol, extended release Toprol XL P P X 50 metoprolol/ hctz Lopressor HCT O O 11 metronidazole Metro-Gel Vaginal P O X 16 metronidazole -- G G X 16 metronidazole Flagyl O O 240 metronidazole, topical -- G G X 240 metronidazole, topical MetroCream O O 240 metronidazole, topical MetroGel P O X 240 metronidazole, topical MetroLotion P O X 240 metronidazole, topical Noritate O O 249 metronidazole, topical -- G G X 249 metronidazole, topical MetroCream O O 249 metronidazole, topical MetroGel P O X 249 metronidazole, topical MetroLotion P O X 249 metronidazole, topical Noritate O O 58 metyrosine Demser O O 44 mexiletine -- G G X 44 mexiletine Mexitil P O X 13 miconazole -- X 250 miconazole -- X 141 miglitol Glyset P P X 5 minocycline -- G G X 5 minocycline Minocin O O 241 minocycline hcl -- G G X 241 minocycline hcl Minocin O O 55 minoxidil -- G G X 55 minoxidil Loniten O O 80 mirtazapine -- G G X X 80 mirtazapine Remeron O O 80 mirtazapine -- G G X X 80 mirtazapine Remeron Soltab O O 162 misoprostol -- G G X 162 misoprostol Cytotec O O 30 mitotane Lysodren O O 62 modafinil Provigil O 9 O 9 X9 56 moexipril -- G G 56 moexipril Univasc O O 56 moexipril/ hctz Uniretic O O 93 molindone Moban O O 202 mometasone Nasonex P O X 254 mometasone furoate 0.1% Elocon O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 31 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. 194 montelukast sodium Singulair P 30 O X 30 44 moricizine Ethmozine P O X 63 morphine sulfate -- G G X 63 morphine sulfate MSIR O O 63 morphine sulfate, controlled release -- G G X 63 morphine sulfate, controlled release Kadian O O 63 morphine sulfate, controlled release MS Contin O O 4 moxifloxacin Avelox P O X 1 232 moxifloxacin Vigamox O O 177 multivitamins -- X 6 179 multivitamins with fluoride -- G 2 G 2 X 6 179 multivitamins with fluoride Poly-Vi-Flor O 2 O 2 179 multivitamins with fluoride, prescription Tri-Vi-Flor O 2 O 2 177 multivitamins/ minerals -- X 6 249 mupirocin Bactroban O O 268 mycophenolate mofetil CellCept P O X 68 nabumetone -- G G 68 nabumetone Relafen O O 49 nadolol -- G G 49 nadolol Corgard O O 49 nadolol/ bendroflumethiazide Corzide O O 134 nafarelin Synarel P O X 250 naftifine Naftin O O 25 nalidixic acid NegGram O O 115 naltrexone Depade O O 115 naltrexone ReVia P O X X 224 naphazoline -- G G X 224 naphazoline Albalon O O 224 naphazoline Vasocon O O 226 naphazoline/ antazoline Vasocon-A O O 68 naproxen -- G G X 68 naproxen Naprosyn O O 68 naproxen sodium -- G G X 68 naproxen sodium Anaprox O O 68 naproxen sodium, controlled release Naprelan O O 70 naratriptan Amerge P 23 O 23 X 23 234 natamycin Natacyn O O 141 nateglinide Starlix P O X 225 nedocromil Alocril P O X 196 nedocromil, inhaler Tilade O O 84 nefazodone -- G G X 84 nefazodone Serzone O O X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 32 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. 20 nelfinavir mesylate Viracept P O X 9 neomycin -- G G X 238 neomycin/ colistin/ hydrocortisone, otic Cortisporin TC Otic O O 232 neomycin/ dexamethasone, ointment NeoDecadron ointment O O 232 neomycin/ dexamethasone, solution -- G G X X 232 neomycin/ dexamethasone, solution NeoDecadron solution O O 238 neomycin/ hydrocortisone, otic Coly-Mycin S Otic O O 232 neomycin/ polymyxin B/ dexamethasone -- G G X 232 neomycin/ polymyxin B/ dexamethasone Maxitrol O O 238 neomycin/ polymyxin B/ hydrocortisone, otic -- G G X X X 238 neomycin/ polymyxin B/ hydrocortisone, otic Cortisporin Otic O O 232 neomycin/ polymyxin B/ hydrocortisone, suspension -- G G X X X 232 neomycin/ polymyxin B/ hydrocortisone, suspension Cortisporin O O 249 neomycin/ polymyxin B/ hydrocortisone, topical Cortisporin Cream P O X 112 neostigmine Prostigmin O O 265 neostigmine Prostigmin O O 18 nevirapine Viramune P O X 46 nicardipine -- G G 46 nicardipine Cardene O O 46 nicardipine, sustained release Cardene SR O O 116 nicotine, inhaler Nicotrol inhaler O O 116 nicotine, nasal spray Nicotrol NS O O 116 nicotine, transdermal -- G 2 G 2 X X 61 nicotinic acid, extended release Niaspan P P X 61 nicotinic acid, extended release/ lovastatin Advicor P P X 46 nifedipine -- G G 46 nifedipine Adalat O O 46 nifedipine Procardia O O 46 nifedipine, sustained release -- G G X 46 nifedipine, sustained release Adalat CC O O 46 nifedipine, sustained release Procardia XL O O 28 nilutamide Nilandron O O 46 nimodipine Nimotop P O X 46 nisoldipine Sular P P X 25 nitrofurantoin Furadantin O O 25 nitrofurantoin macrocrystals -- G G X 25 nitrofurantoin macrocrystals Macrobid O O 25 nitrofurantoin macrocrystals Macrodantin O O 244 nitrofurazone Furacin O O 43 nitroglycerin, sublingual Nitrostat G G X 43 nitroglycerin, sustained release, oral -- G G 43 nitroglycerin, sustained release, oral Nitroglyn O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 33 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. 43 nitroglycerin, sustained release, oral Nitrong O O 43 nitroglycerin, topical -- G G 43 nitroglycerin, topical Nitro-Bid O O 43 nitroglycerin, topical Nitrol O O 43 nitroglycerin, transdermal -- G G X 43 nitroglycerin, transdermal Minitran O O 43 nitroglycerin, transdermal Nitrodisc O O 43 nitroglycerin, transdermal Nitro-Dur P O X 43 nitroglycerin, transdermal Transderm-Nitro O O 43 nitroglycerin, translingual Nitrolingual P O X 43 nitroglycerin, transmucosal Nitrogard O O 161 nizatidine -- G G 161 nizatidine Axid O O 126 norethindrone Nor-QD P 3 P 3 X X X 121 norethindrone acetate -- G G 121 norethindrone acetate Aygestin O O 4 norfloxacin Noroxin O O 230 norfloxacin Chibroxin O O 79 nortriptyline -- G G X X 79 nortriptyline Aventyl O O 79 nortriptyline Pamelor O O 12 nystatin -- G G X 12 nystatin Mycostatin O O 13 nystatin -- G G X 13 nystatin Mycostatin O O 170 nystatin -- G G X 170 nystatin Mycostatin O O 250 nystatin -- G G X 250 nystatin Mycostatin O O 250 nystatin/ triamcinolone -- G G X 236 ocular lubricants -- X 4 ofloxacin -- G G 4 ofloxacin Floxin O O 230 ofloxacin Ocuflox P O X 238 ofloxacin, otic Floxin Otic P P X 95 olanzapine Zyprexa P O X X 95 olanzapine Zyprexa Zydis O O X 57 olmesartan Benicar O O 225 olopatadine Patanol O O 173 olsalazine sodium Dipentum O O 163 omeprazole -- G G 163 omeprazole Prilosec O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 34 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. 75 ondansetron Zofran P O X 75 ondansetron Zofran ODT P O X 63 opium tincture, deodorized -- G G 108 orphenadrine citrate -- G G 108 orphenadrine citrate Norflex O O 108 orphenadrine/ asa/ caffeine Norgesic Forte O O 108 orphenadrine/ asa/ caffeine Norgesic O O 21 oseltamivir Tamiflu O O 2 oxacillin sodium -- G G X 24 oxamniquine Vansil O O 132 oxandrolone Oxandrin P O X 68 oxaprozin -- G G 68 oxaprozin Daypro O O 76 oxazepam -- G G 76 oxazepam Serax O O 107 oxcarbazepine Trileptal P O X X 250 oxiconazole Oxistat O O 193 oxtriphylline Choledyl O O 264 oxybutynin -- G G X 264 oxybutynin Ditropan O O 264 oxybutynin, extended release Ditropan XL P O X 63 oxycodone -- G G X 63 oxycodone OxyIR O O 63 oxycodone, controlled release Oxycontin P 32 O 32 63 oxycodone, controlled release, 80mg -- G 32 G 32 63 oxycodone, controlled release, 80mg Oxycontin, 80mg O 32 O 32 63 oxycodone/ apap -- G G X 63 oxycodone/ apap Percocet O O 63 oxycodone/ apap Tylox O O 63 oxycodone/ asa -- G G X 63 oxycodone/ asa Percodan O O 200 oxymetazoline -- X 132 oxymetholone Anadrol O O 166 pancreatin Creon O O 166 pancrelipase Pancrease O O 166 pancrelipase Pancrease MT O O 166 pancrelipase Ultrase MT O O 166 pancrelipase Viokase/Cotazym P O X 163 pantoprazole Protonix P P X 15 63 paregoric -- G G 169 paregoric -- G G 8 paromomycin -- G G HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 35 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. 8 paromomycin Humatin O O 16 paromomycin -- G G 16 paromomycin Humatin O O 85 paroxetine -- G G X X 85 paroxetine Paxil O O 85 paroxetine, controlled release Paxil CR P P X X 197 peak flow meter Air Zone P 3 P 3 X 187 pediatric electrolyte replacement solution -- X 62 pemoline -- G 7 G 7 X 7 62 pemoline Cylert O 7 O 7 X 7 49 penbutolol Levatol O O 248 penciclovir Denavir O O 269 penicillamine Cuprimine P O X 269 penicillamine Depen O O 1 penicillin V potassium -- G G X X X 1 penicillin V potassium V-Cillin K O O 25 pentamidine isethionate, inhalation NebuPent P O X 198 pentamidine, inhalation Nebupent P O X 64 pentazocine/ apap Talacen O O 64 pentazocine/ asa Talwin Compound O O 64 pentazocine/ naloxone -- G G 64 pentazocine/ naloxone Talwin NX O O 102 pentobarbital Nembutal O O 266 pentosan polysulfate sodium Elmiron O O 36 pentoxifylline -- G G X 36 pentoxifylline Trental O O 111 pergolide -- G G X 111 pergolide Permax O O 56 perindopril Aceon O O 251 permethrin -- G G X 251 permethrin Elimite O O 225 permivolast Alamast O O 72 perphenazine -- G G X X 72 perphenazine Trilafon O O 88 perphenazine -- G G X 88 perphenazine Trilafon O O 266 phenazopyridine -- G G X 266 phenazopyridine Pyridium O O 86 phenelzine sulfate Nardil P O X X 100 phenobarbital -- G G X 26 58 phenoxybenzamine Dibenzyline O O 199 phenylephrine AH-Chew D G G X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 36 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. 200 phenylephrine -- X 224 phenylephrine -- G G X 224 phenylephrine Neo-Synephrine O O 207 phenylephrine/ chlorpheniramine/ methscopolamine -- G G 207 phenylephrine/ chlorpheniramine/ methscopolamine Dura-Vent/DA O O 207 phenylephrine/ chlorpheniramine/ methscopolamine OMNIhist LA G G 209 phenylephrine/ chlorpheniramine/ methscopolamine -- G G X 209 phenylephrine/ chlorpheniramine/ methscopolamine AH-chew G G X 209 phenylephrine/ chlorpheniramine/ methscopolamine D.A chew O O 209 phenylephrine/ chlorpheniramine/ pyrilamine, suspension -- G G X

209 phenylephrine/ chlorpheniramine/ pyrilamine, suspension Rynatan Pediatric OO Suspension 207 phenylephrine/ chlorpheniramine/ pyrilamine, tablets -- G G X 207 phenylephrine/ chlorpheniramine/ pyrilamine, tablets Rynatan O O 208 phenylephrine/ promethazine -- G G X 208 phenylephrine/ promethazine Phenergan VC O O 103 phenytoin -- G G X 103 phenytoin Dilantin Infatab P O X 103 phenytoin Dilantin 125 P O X 103 phenytoin sodium, extended release -- G G X 103 phenytoin sodium, extended release Dilantin Kapseals P O X 221 physostigmine Eserine sulfate O O 33 phytonadione Mephyton P O X 176 phytonadione Mephyton P O X 220 pilocarpine -- G G X 220 pilocarpine Isopto Carpine O O 220 pilocarpine Pilocar O O 220 pilocarpine Pilopine HS P O X 220 pilocarpine Pilostat O O 220 pilocarpine nitrate Pilagan P O X 191 epinephrine/ chlorpheniramine Anakit P O X 220 pilocarpine ocular therapeutic system Ocusert Pilo O O 171 pilocarpine, oral Salagen O O 220 pilocarpine/ epinephrine E-Pilo P O X 261 pimecrolimus Elidel P O X 92 pimozide Orap O O 49 pindolol -- G G 49 pindolol Visken O O 146 pioglitazone Actos P O X 189 pirbuterol acetate Maxair P O X 189 pirbuterol acetate Maxair Auto P O X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 37 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. 68 piroxicam -- G G 68 piroxicam Feldene O O 261 podofilox Condylox P O X 168 polyethylene glycol-electrolyte solution -- G G X 168 polyethylene glycol-electrolyte solution CoLyte O O 168 polyethylene glycol-electrolyte solution GoLYTELY O O 238 polymyxin B/ hydrocortisone, otic Otobiotic P O X 37 polythiazide Renese O O 183 potassium bicarb/ citrate -- G G 183 potassium bicarb/ citrate K Lyte DS O O 183 potassium bicarb/ citrate K Lyte O O 183 potassium chloride -- G G X 183 potassium chloride K-Dur O O 183 potassium chloride K-Lor O O 183 potassium chloride K-Tab O O 183 potassium chloride Micro K O O 183 potassium chloride/ potassium bicarb/ citrate -- G G 183 potassium chloride/ potassium bicarb/ citrate K Lyte Cl O O 262 potassium citrate Urocit-K O O 185 potassium citrate/ citric acid Polycitra K P O X 262 potassium citrate/ citric acid Polycitra K P O X 185 potassium citrate/ sodium citrate/ citric acid Polycitra P O X 185 potassium citrate/ sodium citrate/ citric acid Polycitra LC O O 262 potassium citrate/ sodium citrate/ citric acid Polycitra P O X 262 potassium citrate/ sodium citrate/ citric acid Polycitra LC O O 183 potassium gluconate -- G G 183 potassium gluconate Kaon O O 214 potassium iodide Pima O O 214 potassium iodide SSKI O O 263 potassium/ sodium acid phosphate K-Phos Neutral O O 111 pramipexole Mirapex P O X 60 pravastatin Pravachol P 21 P 21 X 21 60 pravastatin/ aspirin Pravigard P 21 P 21 X 21 76 prazepam -- G G 24 praziquantel Biltricide O O 53 prazosin -- G G X 53 prazosin Minipress O O 53 prazosin/ polythiazide Minizide O O 138 prednisolone -- G G X 138 prednisolone Prelone O O 229 prednisolone acetate, ophthalmic -- G G X 229 prednisolone acetate, ophthalmic Econopred O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 38 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. 229 prednisolone acetate, ophthalmic Econopred Plus O O 229 prednisolone acetate, ophthalmic Pred Forte P O X 229 prednisolone acetate, ophthalmic Pred Mild O O 229 prednisolone sodium phosphate -- G G X 229 prednisolone sodium phosphate AK Pred O O 229 prednisolone sodium phosphate Inflamase Forte O O 229 prednisolone sodium phosphate Inflamase Mild O O 138 prednisolone sodium phosphate, oral Orapred P O X 138 prednisolone sodium phosphate, oral Pediapred O O 138 prednisone -- G G X 138 prednisone Liquid Pred P O X 138 prednisone Orasone G G X 177 prenatal vitamins -- G 2 G 2 X 28 177 prenatal vitamins Materna O 2 O 2 177 prenatal vitamins Stuartnatal Plus O 2 O 2 14 primaquine phosphate Primaquine O O 107 primidone -- G G X 107 primidone Mysoline P O X 153 probenecid -- G G X 44 procainamide -- G G X 44 procainamide Pronestyl O O 44 procainamide, sustained release -- G G X 44 procainamide, sustained release Procan SR O O 44 procainamide, sustained release Procanbid P O X 30 procarbazine Matulane P O X 72 prochlorperazine edisylate, syrup Compazine Syrup P O X X 88 prochlorperazine edisylate, syrup Compazine Syrup P O X X 72 prochlorperazine maleate, sustained release Compazine Spansules O O 88 prochlorperazine maleate, sustained release Compazine Spansules O O 72 prochlorperazine maleate, tablets -- G G X X 72 prochlorperazine maleate, tablets Compazine O O 88 prochlorperazine maleate, tablets -- G G X X 88 prochlorperazine maleate, tablets Compazine O O 110 procyclidine Kemadrin O O X 121 progesterone, micronized Prometrium P O X 133 progesterone, vaginal 8% Crinone 8% O 2 O 2 87 promazine Sparine O O 206 promethazine -- G G X 206 promethazine Phenergan O O 72 promethazine, suppositories Phenergan Suppositories P O X 72 promethazine, tablets and liquid -- G G X X 72 promethazine, tablets and liquid Phenergan O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 39 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. 44 propafenone -- G G X 44 propafenone Rythmol P O X 158 propantheline bromide -- G G 158 propantheline bromide Pro-Banthine O O 63 propoxyphene -- G G 63 propoxyphene Darvon O O 63 propoxyphene napsylate Darvon N O O 63 propoxyphene napsylate/ apap -- G G 63 propoxyphene napsylate/ apap Darvocet N O O 63 propoxyphene/ apap Wygesic O O 63 propoxyphene/ asa/ caffeine -- G G 63 propoxyphene/ asa/ caffeine Darvon Compound O O 49 propranolol -- G G X X 49 propranolol Inderal O O 49 propranolol, sustained release -- G G X X 49 propranolol, sustained release Inderal LA P O X X 49 propranolol/ hctz -- G G X 49 propranolol/ hctz Inderide O O 150 propylthiouracil -- G G X 79 protriptyline -- G G X X 79 protriptyline Vivactil O O 199 pseudoephedrine -- X 207 pseudoephedrine/ azatadine Trinalin O O 207 pseudoephedrine/ brompheniramine -- G G 207 pseudoephedrine/ brompheniramine Bromfed O O 207 pseudoephedrine/ brompheniramine Ultrabrom G G 209 pseudoephedrine/ brompheniramine Ultrabrom PD G G 209 pseudoephedrine/ brompheniramine, capsules (generic -- X Bromfed) 209 pseudoephedrine/ brompheniramine, liquid (generic -- X Dimetapp) 208 pseudoephedrine/ carbinoxamine -- G G X 208 pseudoephedrine/ carbinoxamine Rondec O O 207 pseudoephedrine/ chlorpheniramine Deconamine SR O O 208 pseudoephedrine/ chlorpheniramine Dura-Tap/PD O O 208 pseudoephedrine/ chlorpheniramine (generic Chlor-Trimeton -- X Allergy D) 208 pseudoephedrine/ triprolidine (generic Actifed) -- X 168 psyllium -- X 15 pyrazinamide -- G G 112 pyridostigmine bromide Mestinon P O X 14 pyrimethamine Daraprim O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 40 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. 14 pyrimethamine/ sulfadoxine Fansidar O O 98 quazepam Doral O O 95 quetiapine fumarate Seroquel P O X X 56 quinapril -- G G 56 quinapril Accupril O O 56 quinapril/ hctz -- G G 56 quinapril/ hctz Accuretic O O 44 quinidine gluconate -- G G X 44 quinidine gluconate Quinaglute Dura-Tabs P O X 44 quinidine polygalacturonate Cardioquin P O X 44 quinidine sulfate -- G G X 44 quinidine sulfate Quinora O O 44 quinidine sulfate, extended release -- G G X 44 quinidine sulfate, extended release Quinidex Extentabs P O X 14 quinine sulfate -- G G X 163 rabeprazole sodium Aciphex P P X 15 120 raloxifene Evista P O X 56 ramipril Altace P P X 161 ranitidine -- G G X 161 ranitidine syrup Zantac Syrup P O X 161 ranitidine, tablets and capsules Zantac O O 142 repaglinide Prandin P O X 54 reserpine -- G G 54 reserpine/ chlorothiazide -- G G 54 reserpine/ chlorothiazide Diupres O O 54 reserpine/ chlorthalidone Regroton O O 54 reserpine/ hctz -- G G 54 reserpine/ hctz Hydropres O O 54 reserpine/ hctz Hydro-Serp O O 54 reserpine/ hydroflumethiazide Salutensin O O 54 reserpine/ methyclothiazide Diutensen-R O O 54 reserpine/ polythiazide Renese-R O O 54 reserpine/ trichlormethiazide Metatensin O O 22 ribavirin -- G G X 22 ribavirin Copegus P O X 22 ribavirin Rebetol O O 15 rifabutin Mycobutin P O X 18 15 rifampin -- G G X 18 15 rifampin Rifadin O O 15 rifapentine Priftin O O 117 riluzole -- G G X 117 riluzole Rilutek P O X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 41 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. 21 rimantadine -- G G X 21 rimantadine Flumadine O O 229 rimexolone Vexol O O 152 risedronate Actonel P O X 95 risperidone Risperdal P O X X 95 risperidone Risperdal-M P O X X 95 risperidone injection Risperdal Consta X 20 ritonavir Norvir P O X 97 rivastigmine Exelon O O 70 rizatriptan Maxalt O 25 O 25 70 rizatriptan Maxalt-MLT O 25 O 25 69 rofecoxib Vioxx P 22 O X 22 111 ropinirole Requip P O X 146 rosiglitazone Avandia P O X 146 rosiglitazone/ metformin Avandamet P O X 240 salicylic acid -- X 246 salicylic acid -- X 258 salicylic acid -- X 190 salmeterol Serevent P O X 190 salmeterol/ fluticasone Advair P O X 195 salmeterol/ fluticasone Advair P O X 66 salsalate -- G G 66 salsalate Disalcid O O 66 salsalate Marthritic O O 20 saquinavir Fortovase P O X 227 scopolamine HBr Isopto Hyoscine P O X 73 scopolamine, trandsdermal Transderm-Scop O O 102 secobarbital sodium Seconal O O 111 selegiline -- G G X 111 selegiline Eldepryl O O 246 selenium sulfide -- G G X 246 selenium sulfide Selsun O O 168 senna -- X 85 sertraline Zoloft P P X X 182 sevelamer Renagel P O X 133 sildenafil Viagra O 2 O 2 244 silver sulfadiazine -- G G X 244 silver sulfadiazine Silvadene O O 164 simethicone -- X 60 simvastatin Zocor O 21 O 21 268 sirolimus Rapamune O O 147 SMBG test strips Fast Take test strips G G X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 42 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. 147 SMBG test strips One Touch test strips G G X 147 SMBG test strips One Touch Ultra test strips G G X

147 SMBG test strips Surestep test strips G G X 155 sodium bicarbonate -- X 185 sodium bicarbonate -- X 237 sodium chloride, hypertonic Muro 128 X 198 sodium chloride, inhalation -- G G X 185 sodium citrate/ citric acid Bicitra P O X 185 sodium citrate/ citric acid Oracit O O 262 sodium citrate/ citric acid Bicitra P O X 262 sodium citrate/ citric acid Oracit O O 179 sodium fluoride -- G G X 5 179 sodium fluoride Luride O O 179 sodium fluoride Prevident O O 168 sodium phosphate, enema -- X 168 Sodium phosphate, oral solution Fleets Phospho - Soda X 184 sodium polystyrene sulfonate -- G G X 184 sodium polystyrene sulfonate Kayexalate O O 11 sodium propionate/ amino acid/ urea Amino-Cerv O O 44 sotalol Betapace AF P P X 49 sotalol -- G G X 49 sotalol Betapace O O 49 sotalol Betapace AF P P X 197 spacer Aerochamber P 3 P 3 X 197 spacer E-Z Spacer P 3 P 3 X 197 spacer Vortex P 3 P 3 X 270 spermicides -- X 39 spironolactone -- G G X 39 spironolactone Aldactone O O 41 spironolactone/ hctz -- G G X 41 spironolactone/ hctz Aldactazide O O 132 stanozolol Winstrol P O X 17 stavudine Zerit P O X 180 succimer Chemet P O X 156 sucralfate -- G G X 156 sucralfate Carafate O O 250 sulconazole Exelderm O O 233 sulfacetamide -- G G X X X 233 sulfacetamide Sodium Sulamyd O O 240 sulfacetamide sodium Klaron O O 246 sulfacetamide sodium, shampoo Sebizon O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 43 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. 233 sulfacetamide/ fluorometholone FML-S O O 233 sulfacetamide/ phenylephrine Vasosulf O O 233 sulfacetamide/ prednisolone acetate Blephamide P O X 233 sulfacetamide/ prednisolone acetate Cetapred O O 233 sulfacetamide/ prednisolone sodium phosphate -- G G X 233 sulfacetamide/ prednisolone sodium phosphate Vasocidin O O 10 sulfadiazine -- G G X 10 sulfamethoxazole Gantanol O O 10 sulfamethoxazole/ trimethoprim -- G G X X X 10 sulfamethoxazole/ trimethoprim Bactrim O O 10 sulfamethoxazole/ trimethoprim Septra O O 241 sulfamethoxazole/ trimethoprim -- G G X X X 241 sulfamethoxazole/ trimethoprim Bactrim O O 241 sulfamethoxazole/ trimethoprim Septra O O 11 sulfanilamide -- G G X 11 sulfanilamide AVC O O 173 sulfasalazine -- G G X 173 sulfasalazine Azulfidine O O 173 sulfasalazine, enteric coated -- G G 173 sulfasalazine, enteric coated Azulfidine EN-tabs O O 269 sulfasalazine, enteric coated -- G G 269 sulfasalazine, enteric coated Azulfidine EN-tabs O O 153 sulfinpyrazone -- G G 153 sulfinpyrazone Anturane O O 10 sulfisoxazole -- G G X 10 sulfisoxazole Gantrisin P O X 233 sulfisoxazole diolamine, ophthalmic Gantrisin O O 240 sulfur/ sulfacetamide Novacet O O 240 sulfur/ sulfacetamide Sulfacet-R O O 68 sulindac -- G G 68 sulindac Clinoril O O 70 sumatriptan Imitrex P 24 O 24 X 24 259 sutilains Travase O O 118 synthetic conjugated estrogens Cenestin O O 97 tacrine Cognex O O 261 tacrolimus Protopic P O X 268 tacrolimus Prograf P O X 28 tamoxifen -- G G X 28 tamoxifen Nolvadex O O 53 tamsulosin Flomax P O X 240 tazarotene Tazorac O O 242 tazarotene Tazorac O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 44 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. 57 telmisartan Micardis O O 57 telmisartan/ hctz Micardis HCT O O 98 temazepam -- G G 98 temazepam Restoril O O 30 temozolomide Temodar P O X 19 tenofovir Viread P O X 53 terazosin -- G G X 53 terazosin Hytrin O O 12 terbinafine Lamisil P O X 188 terbutaline sulfate Brethine P O X 188 terbutaline sulfate Bricanyl O O X 189 terbutaline sulfate Brethaire P O X 13 terconazole Terazol 3 O O 13 terconazole Terazol 7 O O 28 testolactone Teslac O O 130 testosterone, gel Androgel O O 130 testosterone, transdermal Androderm P O X 130 testosterone, transdermal Testoderm O O 5 tetracycline -- G G X X X 240 tetracycline Topicycline O O 241 tetracycline -- G G X X X 23 thalidomide Thalomid O O 193 theophylline, capsules Bronkodyl O O 193 theophylline, capsules Elixophyllin O O 193 theophylline, liquid -- G G X 193 theophylline, liquid Elixophyllin O O 193 theophylline, liquid Slo-Phyllin O O 193 theophylline, liquid Theolair O O 193 theophylline, tablets -- G G X 193 theophylline, tablets Quibron-T O O 193 theophylline, tablets Slo-Phyllin O O 193 theophylline, tablets Theolair O O 193 theophylline, timed release capsules -- G G X 193 theophylline, timed release capsules Elixophyllin SR O O 193 theophylline, timed release capsules Slo-Bid O O 193 theophylline, timed release capsules Slo-Bid 50mg and 75mg P O X 193 theophylline, timed release capsules Slo-Phyllin Gyrocaps O O 193 theophylline, timed release capsules Theo-24 P O X 193 theophylline, timed release capsules Theo-Dur Sprinkle O O 193 theophylline, timed release tablets -- G G 193 theophylline, timed release tablets Theochron G G X 193 theophylline, timed release tablets T-Phyl O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 45 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. 193 theophylline, timed release tablets Unidur O O 193 theophylline, timed release tablets Uniphyl O O 193 theophylline/ ephedrine/ hydroxyzine hcl Marax O O 24 thiabendazole Mintezol O O 174 thiamine -- X 27 X 27 72 thiethylperazine maleate Torecan O O 27 thioguanine Thioguanine P O X 89 thioridazine -- G G X X 89 thioridazine Mellaril O O 90 thiothixene -- G G X X 90 thiothixene Navane O O 149 thyroid, desiccated -- G G X 149 thyroid, desiccated Armour Thyroid P O 107 tiagabine Gabitril P O X X 34 ticlopidine -- G G X 34 ticlopidine Ticlid O O 152 tiludronate Skelid O O 219 timolol -- G G X 219 timolol Timoptic O O 219 timolol XE Timoptic XE O O 49 timolol maleate -- G G 49 timolol maleate Blocadren O O 49 timolol maleate/ hctz Timolide O O 219 timolol XE -- G G X 219 timolol/ dorzolamide Cosopt P O X 267 tiopronin Thiola O O 192 tiotropium Spiriva P O X 108 tizanidine -- G G 108 tizanidine Zanaflex O O 25 tobramycin, inhalation TOBI P O X 198 tobramycin, inhalation TOBI P O X 230 tobramycin, ointment Tobrex ointment P O X 230 tobramycin, solution -- G G X 230 tobramycin, solution Tobrex solution O O 232 tobramycin/ dexamethasone TobraDex P O X 144 tolazamide -- G G X 144 tolazamide Tolinase O O 144 tolbutamide -- G G X 144 tolbutamide Orinase O O 111 tolcapone Tasmar O O 68 tolmetin sodium -- G G 68 tolmetin sodium Tolectin O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 46 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. 264 tolterodine Detrol P O X 264 tolterodine, long-acting Detrol LA P O X 107 topiramate Topamax P O X X 28 toremifene Fareston O O 38 torsemide -- G G 38 torsemide Demadex O O 65 tramadol -- G G 65 tramadol Ultram O O 65 tramadol/ apap Ultracet O O 56 trandolapril Mavik O O 86 tranylcypromine sulfate Parnate O O 223 travoprost Travatan O O 81 trazodone -- G G X X 81 trazodone Desyrel O O 240 tretinoin -- G 10 G 10 X 10 240 tretinoin Avita O 10 O 10 240 tretinoin Retin-A O 10 O 10 240 tretinoin Retin-A Micro O 10 O 10 30 tretinoin, oral Vesanoid O O 138 triamcinolone Aristocort O O 202 triamcinolone Nasacort P O X 202 triamcinolone Nasacort AQ P O X 254 triamcinolone acetonide 0.025% -- G G X 254 triamcinolone acetonide 0.025% Kenalog O O 254 triamcinolone acetonide 0.1% -- G G X 254 triamcinolone acetonide 0.1% Kenalog O O 253 triamcinolone acetonide 0.5%, cream/ ointment -- G G X 253 triamcinolone acetonide 0.5%, cream/ ointment Kenalog O O 254 triamcinolone acetonide, aerosol Kenalog aerosol P O X 172 triamcinolone paste -- G G X 172 triamcinolone paste Kenalog in Orabase O O 195 triamcinolone, inhaler Azmacort O O 39 triamterene Dyrenium O O 41 triamterene/ hctz -- G G X 41 triamterene/ hctz Dyazide O O 41 triamterene/ hctz Maxzide O O 98 triazolam -- G G 98 triazolam Halcion O O 37 trichlormethiazide -- G G 37 trichlormethiazide Naqua O O 181 trientine Syprine O 2 O 2 239 triethanolamine Cerumenex O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 47 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. 88 trifluoperazine -- G G 88 trifluoperazine Stelazine O O 235 trifluridine -- G G X 235 trifluridine Viroptic O O 110 trihexyphenidyl -- G G X X 110 trihexyphenidyl Artane O O 105 trimethadione Tridione P O X 73 trimethobenzamide -- G G 73 trimethobenzamide Tigan O O 25 trimethoprim -- G G X 25 trimethoprim Trimpex O O 231 trimethoprim/ polymyxin B -- G G X 231 trimethoprim/ polymyxin B Polytrim O O 78 trimipramine maleate Surmontil P O X X 206 tripelennamine -- G G 206 tripelennamine PBZ O O 11 triple sulfa -- G G X 6 troleandomycin Tao O O 223 unoprostone Rescula O O 167 ursodiol -- G G X 167 ursodiol Actigall O O 22 valacyclovir Valtrex P O X 69 valdecoxib Bextra O O 107 valproic acid -- G G X X 107 valproic acid Depakene P O X X 57 valsartan Diovan O O 57 valsartan/ hctz Diovan HCT O O 7 vancomycin Vancocin O O 83 venlafaxine Effexor O O X 83 venlafaxine, extended release Effexor XR P P X X 47 verapamil -- G G X 47 verapamil Calan O O 47 verapamil Isoptin O O 47 verapamil ER/ trandolapril Tarka O O 56 verapamil ER/ trandolapril Tarka O O 47 verapamil, sustained release -- G G X 47 verapamil, sustained release Calan SR O O 47 verapamil, sustained release Covera HS O O 47 verapamil, sustained release Isoptin SR O O 47 verapamil, sustained release Verelan O O 235 vidarabine Vira-A P O X 174 vitamin B complex -- X 27 X 27 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 10/1/04 - Page 48 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. 177 vitamin B complex/ vit C/ vit E/ folate Renal Tabs P 12 O 12 X 12 35 warfarin -- G G X 35 warfarin Coumadin P O X 133 yohimbine -- G 2 G 2 133 yohimbine Yocon O 2 O 2 194 zafirlukast Accolate P 30 O X 30 17 zalcitabine Hivid P O X 99 zaleplon Sonata O O 21 zanamivir Relenza O O 17 zidovudine Retrovir P O X 194 zileuton Zyflo P 30 O X 30 95 ziprasidone Geodon P O X X 70 zolmitriptan Zomig O 25 O 25 99 zolpidem tartrate Ambien P O 107 zonisamide Zonegran P O X