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HMSA DRUG FORMULARY - Listed Alphabetically by GENERIC Name Rev

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HMSA DRUG FORMULARY - Listed Alphabetically by GENERIC Name Rev 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.
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