March 23, 2004

MEMORANDUM

TO: Participating Pharmacies

FROM: John T. Berthiaume, M.D. Medical Director, Pharmacy Management

SUBJECT: Updated HMSA Drug Formulary

Enclosed is the comprehensive updated formulary, effective April 1. This copy incorporates the changes listed in the Formulary Update sent to you in February. Please replace the current formulary sections in your pharmacy handbook with the enclosed version.

If you have any questions, please call an HMSA Provider Teleservice Representative at 948- 6330 on Oahu or 1 (800) 790-4672 from the Neighbor Islands.

PM04-010

HMSA DRUG FORMULARY 4/1/04 - Page 1 Code THERAPEUTIC CATEGORY LISTING 1 I. Anti-infectives A. Antibiotics 1. Penicillins - non-penicillinase resistant 2 I. Anti-infectives A. Antibiotics 2. Penicillins - penicillinase resistant 3 I. Anti-infectives A. Antibiotics 3. Cephalosporins 4 I. Anti-infectives A. Antibiotics 4. Fluoroquinolones 5 I. Anti-infectives A. Antibiotics 5. Tetracyclines 6 I. Anti-infectives A. Antibiotics 6. Macrolides 7 I. Anti-infectives A. Antibiotics 7. Vancomycin 8 I. Anti-infectives A. Antibiotics 8. Lincosamides 9 I. Anti-infectives A. Antibiotics 9. Aminoglycoside 10 I. Anti-infectives A. Antibiotics 10. Sulfonamides 11 I. Anti-Infectives A. Antibiotics 11. Vaginal preparations 12 I. Anti-infectives B. Antifungal agents 1. Oral 13 I. Anti-Infectives B. Antifungal agents 2. Vaginal preparations OTC considerations: clotrimazole (Gyne-Lotrimin 3, Mycelex-7), miconazole (Monistat 7), tioconazole (Vagistat-1), butoconazole (Femstat 3) 14 I. Anti-infectives C. Antimalarial 15 I. Anti-infectives D. Antituberculous 16 I. Anti-infectives E. Amebicides 17 I. Anti-infectives F. Antiviral agents 1. Nucleoside Reverse-transcriptase Inhibitors (NRTI) 18 I. Anti-infectives F. Antiviral agents 2. Non-Nucleotide Reverse-transcriptase Inhibitors (NNRTI) 19 I. Anti-infectives F. Antiviral agents 3. Nucleotide Reverse transcriptase inhibitor 20 I. Anti-infectives F. Antiviral agents 3. Protease Inhibitors 21 I. Anti-infectives F. Antiviral agents 4. Agents for influenza 22 I. Anti-infectives F. Antiviral agents 5. Other 23 I. Anti-infectives G. Leprostatics 24 I. Anti-infectives H. Antihelmintics 25 I. Anti-infectives I. Other 26 II. Anti-neoplastics A. Alkylating Agents 27 II. Anti-neoplastics B. Antimetabolites 28 II. Anti-neoplastics C. Hormones 29 II. Anti-neoplastics D. Mitotic Inhibitors 30 II. Anti-neoplastics E. Other HMSA DRUG FORMULARY 4/1/04 - Page 2 31 III. Blood Modifiers A. Folic acid derivatives 32 III. Blood Modifiers B. Vitamin B 33 III. Blood Modifiers C. Vitamin K 34 III. Blood Modifiers D. Antiplatelet agents OTC consideration: apsirin 35 III. Blood Modifiers E. Anticoagulants 36 III. Blood Modifiers F. Hemorrheologic agent 37 IV. Cardiovasculars A. Diuretics 1. Thiazide and related diuretics 38 IV. Cardiovasculars A. Diuretics 2. Loop diuretics 39 IV. Cardiovasculars A. Diuretics 3. Potassium-Sparing diuretics 40 IV. Cardiovasculars A. Diuretics 4. Carbonic anhydrase inhibitors 41 IV. Cardiovasculars A. Diuretics 5. Diuretic combinations 42 IV. Cardiovasculars B. Cardiac Glycosides 43 IV. Cardiovasculars C. Nitrates 44 IV. Cardiovasculars D. Anti-arrhythmic agents 45 IV. Cardiovasculars E. Calcium channel blocking agents 1. Benzothiazepine 46 IV. Cardiovasculars E. Calcium channel blocking agents 2. Dihydropyridine 47 IV. Cardiovasculars E. Calcium channel blocking agents 3. Diphenylalkylamine 48 IV. Cardiovasculars E. Calcium channel blocking agents 4. Other 49 IV. Cardiovasculars F. Beta-adrenergic blocking agents 1. Non-selective agents 50 IV. Cardiovasculars F. Beta-adrenergic blocking agents 2. Beta-1 selective agents Inhibits beta-2 receptors (bronchial and vascular) at higher doses. 51 IV. Cardiovasculars G. Alpha/beta-adrenergic blocking agents 52 IV. Cardiovasculars H. Anti-adrenergic agents-centrally located 53 IV. Cardiovasculars I. Anti-adrenergic agents-peripherally located 1. Alpha-1 adrenergic block 54 IV. Cardiovasculars I. Anti-adrenergic agents-peripherally located 2. Other 55 IV. Cardiovasculars J. Vasodilators 56 IV. Cardiovasculars K. Angiotensin converting enzyme inhibitors 57 IV. Cardiovasculars L. Angiotensin II Receptor Antagonists 58 IV. Cardiovasculars M. Agents for Pheochromocytoma 59 IV. Cardiovasculars N. Antihyperlipidemic Agents 1. Bile Acid Sequestrants 60 IV. Cardiovasculars N. Antihyperlipidemic Agents 2. HMG-CoA Reductase Inhibitors 61 IV. Cardiovasculars N. Antihyperlipidemic Agents 3. Other HMSA DRUG FORMULARY 4/1/04 - Page 3 62 V. Central Nervous System Agents A. CNS Stimulants 63 V. Central Nervous System Agents B. Analgesics 1. Narcotic Agonist Analgesics 64 V. Central Nervous System Agents B. Analgesics 2. Narcotic Agonist-Antagonist Analgesics 65 V. Central Nervous System Agents B. Analgesics 3. Central Analgesics 66 V. Central Nervous System Agents B. Analgesics 4. Salicylates OTC considerations: aspirin, sodium salicylate, choline salicylate (Arthropan), magnesium salicylate (Doan's) 67 V. Central Nervous System Agents B. Analgesics 5. Non-Narcotic Analgesic Combinations 68 V. Central Nervous System Agents B. Analgesics 6. Non-Steroidal Anti-inflammatory Agents (NSAIDs) a. Non-selective NSAIDs OTC considerations: ibuprofen (Advil, Motrin), ketoprofen (Orudis KT), naproxen sodium (Aleve) 69 V. Central Nervous System Agents B. Analgesics 6. Non-Steroidal Anti-inflammatory Agents (NSAIDs) b. COX-2 selective

70 V. Central Nervous System Agents C. Abortive Agents for Migraine 1. 5HT-1 Receptor Agonists 71 V. Central Nervous System Agents C. Abortive Agents for Migraine 2. Other 72 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 1. Anti-dopaminergics 73 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 2. Anti-cholinergics OTC considerations: cyclizine (Marezine), meclizine (Bonine), diphenhydramine (Benadryl), dimenhydrinate (Dramamine) 74 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 3. Other OTC consideration: phosphorated carohydrate solution (Emetrol) 75 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 4. 5HT-3 Receptor Antagonists 76 V. Central Nervous System Agents E. Anti-Anxiety 1. Benzodiazepines 77 V. Central Nervous System Agents E. Anti-Anxiety 2. Other 78 V. Central Nervous System Agents F. Anti-depressants 1. Tricyclic compounds-Tertiary amines 79 V. Central Nervous System Agents F. Anti-depressants 2. Tricyclic compounds - Secondary amines 80 V. Central Nervous System Agents F. Anti-depressants 3. Tetracyclics 81 V. Central Nervous System Agents F. Anti-depressants 4. Triazolopyridine 82 V. Central Nervous System Agents F. Anti-depressants 5. Aminoketone 83 V. Central Nervous System Agents F. Anti-depressants 6. Phenethylamine 84 V. Central Nervous System Agents F. Anti-depressants 7. Phenylpiperazine 85 V. Central Nervous System Agents F. Anti-depressants 8. Selective serotonin reuptake inhibitors 86 V. Central Nervous System Agents F. Anti-depressants 9. Monoamine oxidase inhibitors 87 V. Central Nervous System Agents G. Anti-psychotic 1. Phenothiazines - aliphatic 88 V. Central Nervous System Agents G. Anti-psychotic 2. Phenothiazines - piperazine HMSA DRUG FORMULARY 4/1/04 - Page 4 89 V. Central Nervous System Agents G. Anti-psychotic 3. Phenothiazines - piperidine 90 V. Central Nervous System Agents G. Anti-psychotic 4. Thioxanthenes 91 V. Central Nervous System Agents G. Anti-psychotic 5. Butyrophenone 92 V. Central Nervous System Agents G. Anti-psychotic 6. Diphenylbutylpiperadine 93 V. Central Nervous System Agents G. Anti-psychotic 7. Dihydroindolones 94 V. Central Nervous System Agents G. Anti-psychotic 8. Dibenzepine 95 V. Central Nervous System Agents G. Anti-psychotic 9. Atypicals 96 V. Central Nervous System Agents G. Anti-psychotic 10. Anti-manic agents 97 V. Central Nervous System Agents H. Cholinesterase inhibitors 98 V. Central Nervous System Agents I. Sedatives and hypnotics, non-barbiturates 1. Benzodiazepines 99 V. Central Nervous System Agents I. Sedatives and hypnotics, non-barbiturates 2. Other OTC considerations: doxylamine succinate (Unisom), diphenhydramine (Nytol, Sominex) 100 V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 1. Long-acting 101 V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 2. Intermediate-acting 102 V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 3. Short-acting 103 V. Central Nervous System Agents K. Anticonvulsants 1. Hydantoins 104 V. Central Nervous System Agents K. Anticonvulsants 2. Succinimides 105 V. Central Nervous System Agents K. Anticonvulsants 3. Oxazolidinediones 106 V. Central Nervous System Agents K. Anticonvulsants 4. Benzodiazepines 107 V. Central Nervous System Agents K. Anticonvulsants 5. Other 108 V. Central Nervous System Agents L. Skeletal muscle relaxants 1. Centrally acting 109 V. Central Nervous System Agents L. Skeletal muscle relaxants 2. Direct acting 110 V. Central Nervous System Agents M. Antiparkinson agents 1. Anti-cholinergics 111 V. Central Nervous System Agents M. Antiparkinson agents 2. Other 112 V. Central Nervous System Agents N. Cholinergic muscle stimulants 113 V. Central Nervous System Agents O. Agents for dependency and withdrawal 1. Alcohol 114 V. Central Nervous System Agents O. Agents for dependency and withdrawal 2. Narcotic agonists 115 V. Central Nervous System Agents O. Agents for dependency and withdrawal 3. Narcotic antagonists 116 V. Central Nervous System Agents O. Agents for dependency and withdrawal 4. Nicotine OTC considerations: nicotine, transdermal (Nicotrol, Nicoderm CQ), nicotine, polacrilex (Nicorette, Nicorette DS) 117 V. Central Nervous System Agents P. Other 118 VI. Endocrine/Metabolic A. Sex Hormones 1. Estrogens a. Oral HMSA DRUG FORMULARY 4/1/04 - Page 5 119 VI. Endocrine/Metabolic A. Sex Hormones 1. Estrogens b. Other 120 VI. Endocrine/Metabolic A. Sex Hormones 2. Selective Estrogen Receptor Modulator (SERM) 121 VI. Endocrine/Metabolic A. Sex Hormones 3. Progestins a. Oral 122 VI. Endocrine/Metabolic A. Sex Hormones 4. Estrogen/progestin combination 123 VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives a. Monophasic 124 VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives b. Biphasic 125 VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives c. Triphasic 126 VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives d. Progetin-only 127 VI. Endocrine/Metabolic A. Sex Hormones 6. Emergency Contraceptives 128 VI. Endocrine/Metabolic A. Sex Hormones 7. Other contraceptives 129 VI. Endocrine/Metabolic A. Sex Hormones 8. Androgens a. Oral 130 VI. Endocrine/Metabolic A. Sex Hormones 8. Androgens b. Other 131 VI. Endocrine/Metabolic A. Sex Hormones 9. Androgen hormone inhibitor 132 VI. Endocrine/Metabolic B. Anabolic steroids 133 VI. Endocrine/Metabolic C. Agents for infertility/impotence 134 VI. Endocrine/Metabolic D. Gonadotropin releasing hormone 135 VI. Endocrine/Metabolic E. Danazol 136 VI. Endocrine/Metabolic F. Posterior pituitary hormones 137 VI. Endocrine/Metabolic G. Adrenal cortical steroids 1. Mineralocorticoids 138 VI. Endocrine/Metabolic G. Adrenal cortical steroids 2. Glucocorticoids a. Oral 139 VI. Endocrine/Metabolic G. Adrenal cortical steroids 2. Glucocorticoids b. Rectal 140 VI. Endocrine/Metabolic H. Adrenal steroid inhibitor 141 VI. Endocrine/Metabolic I. Antidiabetic agents 1. Alpha-glucoside inhibitor 142 VI. Endocrine/Metabolic I. Antidiabetic agents 2. Meglitinides 143 VI. Endocrine/Metabolic I. Antidiabetic agents 3. Human Insulin 144 VI. Endocrine/Metabolic I. Antidiabetic agents 4. Sulfonylureas 145 VI. Endocrine/Metabolic I. Antidiabetic agents 5. Biguanides 146 VI. Endocrine/Metabolic I. Antidiabetic agents 6. Thiazolidinediones 147 VI. Endocrine/Metabolic I. Antidiabetic agents 7. Other 148 VI. Endocrine/Metabolic J. Glucose elevating agents 149 VI. Endocrine/Metabolic K. Thyroid drugs 1. Thyroid hormones 150 VI. Endocrine/Metabolic K. Thyroid drugs 2. Antithyroid agents HMSA DRUG FORMULARY 4/1/04 - Page 6 151 VI. Endocrine/Metabolic L. Calcitonin-salmon 152 VI. Endocrine/Metabolic M. Bisphosphonates 153 VI. Endocrine/Metabolic N. Agents for Gout 154 VI. Endocrine/Metabolic O. Other 155 VII. Gastrointestinals A. Antacids OTC considerations: aluminum hydroxide gel (Amphojel), calcium carbonate (Tums), magaldrate (Riopan), magnesium hydroxide (Milk of Magnesia), magnesium oxide (Mag-Ox), sodium bicarbonate 156 VII. Gastrointestinals B. Sucralfate 157 VII. Gastrointestinals C. Anticholinergics/antispasmodics 1. Belladonna alkaloids 158 VII. Gastrointestinals C. Anticholinergics/antispasmodics 2. Anticholinergics 159 VII. Gastrointestinals C. Anticholinergics/antispasmodics 3. Anti-spasmodics 160 VII. Gastrointestinals D. Combination Helicobacter Pylori agents 161 VII. Gastrointestinals E. Histamine (H2) antagonists OTC considerations: cimetidine (Tagamet HB), ranitidine (Zantac 75), famotidine (Pepcid AC), nizatidine (Axid AR) 162 VII. Gastrointestinals F. Prostaglandins 163 VII. Gastrointestinals G. Proton pump inhibitors 164 VII. Gastrointestinals H. Antiflatulents OTC consideration: simethicone 165 VII. Gastrointestinals I. GI stimulants 166 VII. Gastrointestinals J. Digestive enzymes 167 VII. Gastrointestinals K. Gallstone solubilizing agents 168 VII. Gastrointestinals L. Laxatives OTC considerations: magnesium hydroxide (Milk of Magnesia), magnesium citrate, monobasic sodium phosphate/dibasic sodium phosphate (Fleets Enema, Fleets Phospho Soda), cascara, sennosides (Senokot), bisacodyl (Dulcolax), psyllium (Metamucil), polycarbophil (Fiber Con), methylcellulose (Citrucel), mineral oil, docusate sodium (Colace), docusate calcium (Surfak), glycerin, castor oil, docusate sodium/casanthranol (Peri-Colace)

169 VII. Gastrointestinals M. Antidiarrheals OTC consideraitons: loperamide (Imodium AD), bismuth subsalicylate (Pepto-Bismol), kaolin/pectin (Kaopectate), attapulgite (Donnagel) 170 VII. Gastrointestinals N. Mouth and throat products 1. Antimicrobial 171 VII. Gastrointestinal N. Mouth and throat products 2. Saliva substitutes 172 X. Gastrointestinal N. Mouth and throat products 3. Other 173 VII. Gastrointestinals O. Other 174 VIII. Nutritionals A. Vitamins 1. Vitamin B 175 VIII. Nutritionals A. Vitamins 2. Vitamin D HMSA DRUG FORMULARY 4/1/04 - Page 7 176 VIII. Nutritionals A. Vitamins 3. Vitamin K 177 VIII. Nutritionals A. Vitamins 4. Multivitamins 178 VIII. Nutritionals B. Minerals and electrolytes 1. Calcium-removing resins 179 VIII. Nutritionals B. Minerals and electrolytes 2. Fluoride 180 VIII. Nutritionals B. Minerals and electrolytes 3. Chelating Agents 181 VIII. Nutritionals B. Minerals and electrolytes 4. Iron preparations OTC considerations: ferrous sulfate, ferrous gluconate, ferrous sulfate/vit c/folate (Fero-Folic 500), ferrous sulfate/vit b/vit c/folate (Iberet-Folic 500), ferrous sulfate/multivit/mineral (Advanced Formula Centrum) 182 VIII. Nutritionals B. Minerals and electrolytes 5. Phosphorus-reducing agents OTC consideration: calcium carbonate 183 VIII. Nutritionals B. Minerals and electrolytes 6. Potassium replacement 184 VIII. Nutritionals B. Minerals and electrolytes 7. Potassium-removing resin 185 VIII. Nutritionals C. Systemic alkalinizers OTC consideration: sodium bicarbonate 186 VIII. Nutritionals D. Levocarnitine 187 VIII. Nutritionals E. Electrolyte replacement 188 IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics a. Oral 189 IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics b. Inhalation-short-acting 190 IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics c. Inhalation-long-acting 191 IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics d. Injection 192 IX. Respiratory Drugs A. Bronchodilators 2. Anticholinergics 193 IX. Respiratory Drugs B. Xanthine derivatives 194 IX. Respiratory Drugs C. Leukotriene receptor antagonists 195 IX. Respiratory Drugs D. Anti-inflammatory agents 1. Corticosteroids 196 IX. Respiratory Drugs D. Anti-inflammatory agents 2. Non-steroidal 197 IX. Respiratory Drugs E. Devices 198 IX. Respiratory Drugs F. Other inhalation drugs 199 IX. Respiratory Drugs G. Decongestants 1. Oral OTC considerations: pseudoephedrine (Sudafed) 200 IX. Respiratory Drugs G. Decongestants 2. Intranasol OTC considerations: phenylephrine hcl (Neo-Synephrine), oxymetazoline hcl (Afrin), tetrahydrozoline hcl (Tyzine) 201 IX. Respiratory Drugs H. Intranasal anticholinergic agents 202 IX. Respiratory Drugs I. Intranasal anti-inflammatory agents 1. Corticosteroids 203 IX. Respiratory Drugs I. Intranasal anti-inflammatory agents 2. Non-steroidal OTC consideration: cromolyn sodium (Nasalcrom) HMSA DRUG FORMULARY 4/1/04 - Page 8 204 IX. Respiratory Drugs J. Intranasal antihistamine 205 IX. Respiratory Drugs K. Antihistamines 1. Non-Sedating/Low-Sedating Antihistamines OTC consideration: loratadine (Alavert, Claritin) 206 IX. Respiratory Drugs K. Antihistamines 2. Sedating Antihistamines OTC considerations: diphenhydramine (Benadryl), clemastine (Tavist 1), chlorpheniramine (Chlor-Trimeton) 207 IX. Respiratory Drugs L. Decongestant and antihistamine combinations 1. Adult formulations-solid dosage forms OTC considerations: pseudoephedrine/diphenhydramine (Benadryl Allergy Decongestant), pseudoephedrine/loratadine (Claritin-D), pseudoephedrine/chlorpheniramine (Chlor-Trimeton), pseudoephedrine/triprolidine (Actifed), pseudoephedrine/dexbrompheniramine (Drixoral Cold & Allergy) 208 IX. Respiratory Drugs L. Decongestant and antihistamine combinations 2. Adult formulations-liquid dosage forms OTC considerations: pseudoephedrine/brompheniramine (Dimetapp), pseudoephedrine/triprolidine (Actifed), pseudoephedrine/chlorpheniramine (Chlor-Trimeton Allergy D) 209 IX. Respiratory Drugs L. Decongestant and antihistamine combinations 3. Pediatric formulations OTC considerations: pseudoephedrine/brompheniramine (Dimetapp), pseudoephedrine/ diphenhydramine (Benadryl Children's Allergy & Sinus)

210 IX. Respiratory Drugs M. Narcotic antitussives and combinations 1. Adult formulations 211 IX. Respiratory Drugs M. Narcotic antitussives and combinations 2. Pediatric formulations 212 IX. Respiratory Drugs N. Non-narcotic antitussives and combinations 1. Adult Formulations OTC considerations: dextromethorphan (Delsym, Benylin), pseudoephedrine/dextromethorphan (Robitussin Maximum Strength Cough & Cold), (guaifenesin/dextromethorphan (Robitussin DM) 213 IX. Respiratory Drugs N. Non-narcotic antitussives and combinations 2. Pediatric formulations OTC considerations: dextromethorphan/pseudoephedrine (Robitussin Pediatric Cough & Cold), dextromethorphan/pseudoephedrine/chorpheniramine (Pediacare Cough & Cold), dextromethorphan (Benylin), dextromethorphan/pseudoephedrine/brompheniramine (Dimetapp DM), diphenhydramine (Benadryl) 214 IX. Respiratory Drugs O. Expectorants 1. Adult formulations-solid dosage forms 215 IX. Respiratory Drugs O. Expectorants 2. Adult formulations-liquid dosage forms OTC considerations: guaifenesin (Robitussin), guaifenesin/pseudoephedrine (Robitussin PE), guaifenesin/ephedrine (Primatene) 216 IX. Respiratory Drugs O. Expectorants 3. Pediatric formulations OTC consideration: guaifenesin/pseudoephedrine (Thera-Hist Expectorant Chest Congestion Liquid or Triaminic Chest Congestion Liquid) 217 X. Ophthalmics A. Agents for glaucoma 1. Alpha-2 adrenergic agonist 218 X. Ophthalmics A. Agents for glaucoma 2. Sympathomimetics 219 X. Ophthalmics A. Agents for glaucoma 3. Beta-adrenergic blocking agents HMSA DRUG FORMULARY 4/1/04 - Page 9 220 X. Ophthalmics A. Agents for glaucoma 4. Miotics, direct-acting 221 X. Ophthalmics A. Agents for glaucoma 5. Miotics, cholinesterase inhibitors 222 X. Ophthalmics A. Agents for glaucoma 6. Carbonic anhydrase inhibitors 223 X. Ophthalmics A. Agents for glaucoma 7. Prostaglandin agonist 224 X. Ophthalmics B. Vasoconstrictors/mydriatics OTC considerations: tetrahydrozoline hcl (Generic, Collyrium Fresh, Visine), phenylephrine hcl (Relief), oxymetazoline (OcuClear, Visine LR), naphazoline hcl (Allerest, Clear Eyes, Naphcon)

225 X. Ophthalmics C. Anti-allergy agents 226 X. Ophthalmics D. Decongestant/antihistamine combinations OTC considerations: naphazoline/pheniramine (generic, Naphcon-A, Opcon-A), naphazoline/antazoline (generic) 227 X. Ophthalmics E. Cycloplegic mydriatics 228 X. Ophthalmics F. Nonsteroidal Anti-inflammatory Agents (NSAIDS) 229 X. Ophthalmics G. Corticosteroids 230 X. Ophthalmics H. Antibiotics 1. Single agent 231 X. Ophthalmics H. Antibiotics 2. Combination antibiotic products 232 X. Ophthalmics H. Antibiotics 3. Steroid and antibiotic combinations 233 X. Ophthalmics I. Sulfonamides 234 X. Ophthalmics J. Antifungal agent 235 X. Ophthalmics K. Antiviral agent 236 X. Ophthalmics L. Ocular lubricants OTC consideration: artificial tears 237 X. Ophthalmics M. Hyperosmolar preparations OTC considerations: sodium chloride, hypertonic (Muro 128) 238 XI. Otic preparations A. Antibiotics 239 XI. Otic preparations B. Other OTC considerations: boric acid/isopropyl alcohol (Ear-Dry), glycerin/isopropyl alcohol (Swim-Ear), carbamide peroxide (Debrox, Murine Ear, Auro Ear Drops) 240 XII. Dermatological Agents A. Acne products 1. Topical OTC considerations: benzoyl peroxide, sulfur, salicylic acid Note: Because tretinoin (Renova) is indicated only for cosmetic purposes, it is not a benefit. 241 XII. Dermatological Agents A. Acne products 2. Systemic 242 XII. Dermatological Agents B. Antipsoriatics 1. Topical 243 XII. Dermatological Agents B. Antipsoriatics 2. Systemic 244 XII. Dermatological Agents C. Burn preparations 245 XII. Dermatological Agents D. Diaper rash products OTC consideration: zinc oxide (Desitin) HMSA DRUG FORMULARY 4/1/04 - Page 10 246 XII. Dermatological Agents E. Antiseborrheic products OTC considerations: selenium sulfide (Selsun Blue), coal tar (Neutrogena T/Gel, Pentrax), pyrithione zinc (Head & Shoulders, Sebulon), povidone-iodine (Betadine shampoo), sulfur-salicylic acid (Sebulex), phenol (P&S) 247 XII. Dermatological Agents F. Topical antihistamines OTC considerations: diphenhydramine (Benadryl), diphenhydramine/calamine (Caladryl), diphenhydramine/benzocaine (Sting-Eze) 248 XII. Dermatological Agents G. Topical anti-infectives 1. Antiviral agents 249 XII. Dermatological Agents G. Topical anti-infectives 2. Antibiotics OTC considerations: bacitracin, bacitracin/polymyxin B (Polysporin), bacitracin/polymyxin B/Neomycin (Neosporin) 250 XII. Dermatological Agents G. Topical anti-infectives 3. Antifungal OTC considerations: miconazole (Micatin), clotrimazole (Lotrimin AF), terbinafine (Lamisil AT), tolnaftate (Tinactin) 251 XII. Dermatological Agents H. Scabicides/pediculicides OTC considerations: permethrin (Nix), pyrethrins, piperonyl butoxide technical (End Lice, A-2000, RID) 252 XII. Dermatological Agents I. Corticosteroids, topical 1. Very high potency 253 XII. Dermatological Agents I. Corticosteroids, topical 2. High potency 254 XII. Dermatological Agents I. Corticosteroids, topical 3. Medium potency 255 XII. Dermatological Agents I. Corticosteroids, topical 4. Low potency OTC considerations: hydrocortisone cream, ointment 0.5% and 1%, hydrocortisone acetate cream, ointment 0.5% and 1% 256 XII. Dermatological Agents J. Local anesthetics, topical 1. Topical anesthetics for skin disorders OTC considerations: benzocaine (Solarcaine, Lanacane), dibucaine (Nupercainal), lidocaine (Xylocaine, ELA-Max, Solarcaine Extra Burn Relief), tetracaine (Pontocaine), pramoxine (Prax) 257 XII. Dermatological Agents J. Local anesthetics, topical 2. Topical anesthetics for mucous membranes OTC consideration: benzocaine (Hurricane, Orajel) 258 XII. Dermatological Agents K . Keratolytics OTC considerations: salicylic acid (Occlusal HP, Compound W, Duofilm) 259 XII. Dermatological Agents L. Topical enzyme preparations 260 XII. Dermatological Agents M. Emollients OTC considerations: lactic acid (Lac-Hydrin, Amlactin), urea (Carmol 20, Aquacare), mineral oil/petrolatum/lanolin (Lubriderm), glycerin/petrolatum (Curell), mineral oil (Eucerin, Keri) 261 XII. Dermatological Agents N. Other 262 XIII. Urinary tract products A. Alkalinizers OTC consideration: sodium bicarbonate 263 XIII. Urinary tract products B. Acidifiers OTC considerations: ammonium chloride, ascorbic acid 264 XIII. Urinary tract products C. Antispasmodics 265 XIII. Urinary tract products D. Cholinergic stimulants 266 XIII. Urinary tract products E. Analgesics OTC consideration: phenazopyridine (Azo-Standard, Prodium) HMSA DRUG FORMULARY 4/1/04 - Page 11 267 XIII. Urinary tract products F. Other 268 XIV. Immunologic Agents A. Immunosuppressive agents 269 XIV. Immunologic Agents B. Disease Modifying Antirheumatic Drugs (DMARD) 270 XV. Miscellaneous A. Contraceptive barriers HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 1 I. Anti-infectives A. Antibiotics 1. Penicillins - non-penicillinase resistant 1 amoxicillin trihydrate -- G G X X X 1 ampicillin -- G G X X X 1 ampicillin Omnipen O O 1 penicillin V potassium -- G G X X X 1 penicillin V potassium V-Cillin K O O 2 I. Anti-infectives A. Antibiotics 2. Penicillins - penicillinase resistant 2 amoxicillin/ k clavulanate -- G G X 1 2 amoxicillin/ k clavulanate Augmentin O O 2 amoxicillin/ k clavulanate, extra Augmentin ES P O X 1 strength 2 amoxicillin/ k clavulanate, extended Augmentin XR P O X 1 release 2 cloxacillin sodium -- G G X 2 dicloxacillin sodium -- G G X 2 dicloxacillin sodium Dynapen O O 2 dicloxacillin sodium, suspension Dynapen Suspension P O X 2 oxacillin sodium -- G G X 3 I. Anti-infectives A. Antibiotics 3. Cephalosporins 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 HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 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 3 loracarbef Lorabid O O 4 I. Anti-infectives A. Antibiotics 4. Fluoroquinolones 4 ciprofloxacin -- O O 4 ciprofloxacin Cipro P O X 1 4 enoxacin Penetrex O O 4 levofloxacin Levaquin O O 4 gatifloxacin Tequin O O 4 lomefloxacin Maxaquin O O 4 moxifloxacin Avelox P O X 1 4 norfloxacin Noroxin O O 4 ofloxacin Floxin O O 5 I. Anti-infectives A. Antibiotics 5. Tetracyclines 5 demeclocycline Declomycin O O 5 doxycycline hyclate -- G G X X X 5 doxycycline hyclate Doryx O O 5 doxycycline hyclate Periostat O O 5 doxycycline hyclate Vibramycin O O 5 doxycycline monohydrate -- G G 5 doxycycline monohydrate Monodox O O 5 minocycline -- G G X 5 minocycline Minocin O O 5 tetracycline -- G G X X X 6 I. Anti-infectives A. Antibiotics 6. Macrolides 6 azithromycin Zithromax O O X 16 6 clarithromycin Biaxin P O X 29 6 clarithromycin, extended release Biaxin XL P O X 29 6 dirithromycin Dynabac O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 6erythromycin 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 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 6 erythromycin/ sufisoxazole -- G G X 6 erythromycin/ sufisoxazole Pediazole O O 6 troleandomycin Tao O O 7 I. Anti-infectives A. Antibiotics 7. Vancomycin 7 vancomycin Vancocin O O 8 I. Anti-infectives A. Antibiotics 8. Lincosamides 8 clindamycin -- G G X 8 clindamycin Cleocin O O 8 clindamycin palmitate, suspension Cleocin Suspension P O X 8 paromomycin -- G G 8 paromomycin Humatin O O 9 I. Anti-infectives A. Antibiotics 9. Aminoglycoside 9 kanamycin sulfate Kantrex O O 9 neomycin -- G G X 10 I. Anti-infectives A. Antibiotics 10. Sulfonamides 10 erythromycin/ sufisoxazole -- G G X 10 erythromycin/ sufisoxazole Pediazole 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 10 sulfisoxazole -- G G X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 10 sulfisoxazole Gantrisin P O X 11 I. Anti-Infectives A. Antibiotics 11. Vaginal preparations 11 clindamycin Cleocin Vaginal P O X 11 glacial acetic acid Aci-jel O O 11 metronidazole Metro-Gel Vaginal P O X 11 sodium propionate/ amino acid/ urea Amino-Cerv O O

11 sulfanilamide -- G G X 11 sulfanilamide AVC O O 11 triple sulfa -- G G X 12 I. Anti-infectives B. Antifungal agents 1. Oral 12 fluconazole Diflucan 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 12 itraconazole Sporanox P O X 12 ketoconazole -- G G X 12 ketoconazole Nizoral O O 12 nystatin -- G G X 12 nystatin Mycostatin O O 12 terbinafine Lamisil P O X 13 I. Anti-Infectives B. Antifungal agents 2. Vaginal preparations OTC considerations: clotrimazole (Gyne-Lotrimin 3, Mycelex- 7), miconazole (Monistat 7), tioconazole (Vagistat-1), butoconazole (Femstat 3) 13 clotrimazole -- X 13 miconazole -- X 13 nystatin -- G G X 13 nystatin Mycostatin O O 13 terconazole Terazol 3 O O 13 terconazole Terazol 7 O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 14 I. Anti-infectives C. Antimalarial 14 chloroquine phosphate Aralen P O X 14 doxycycline hyclate -- G G X X X 14 doxycycline hyclate Vibramycin O O 14 halofantrine hcl Halfan O O 14 hydroxychloroquine sulfate -- G G X 14 hydroxychloroquine sulfate Plaquenil O O 14 mefloquine hcl Larium O O 14 primaquine phosphate Primaquine O O 14 pyrimethamine Daraprim O O 14 pyrimethamine/ sulfadoxine Fansidar O O 14 quinine sulfate -- G G X 15 I. Anti-infectives D. Antituberculous 15 aminosalicylic acid Paser O O 15 cycloserine Seromycin O O 15 ethionamide Trecator-SC O O 15 ethambutol -- G G X 18 15 ethambutol Myambutol O O 15 isoniazid -- G G X 4 15 isoniazid/ rifampin Rifamate O O 15 isoniazid/ rifampin/ pyrazinamide Rifater O O 15 pyrazinamide -- G G 15 rifabutin Mycobutin P O X 18 15 rifampin -- G G X 18 15 rifampin Rifadin O O 15 rifapentine Priftin O O 16 I. Anti-infectives E. Amebicides 16 chloroquine phosphate Aralen P O X 16 iodoquinol Yodoxin P O X 16 metronidazole -- G G X 16 metronidazole Flagyl O O 16 paromomycin -- G G HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 16 paromomycin Humatin O O 17 I. Anti-infectives F. Antiviral agents 1. Nucleoside Reverse-transcriptase Inhibitors (NRTI) 17 abacavir sulfate Ziagen P O X 17 abacavir/ lamivudine/ zidovudine Trizivir P O X 17 didanosine Videx P O X 17 didanosine, enteric coated Videx EC P O X 17 lamivudine Epivir P O X 17 lamivudine Epivir-HBV P O X 17 lamivudine/ zidovudine Combivir P O X 17 stavudine Zerit P O X 17 zalcitabine Hivid P O X 17 zidovudine Retrovir P O X 18 I. Anti-infectives F. Antiviral agents 2. Non-Nucleotide Reverse-transcriptase Inhibitors (NNRTI) 18 delavirdine mesylate Rescriptor P O X 18 efavirenz Sustiva P O X 18 nevirapine Viramune P O X 19 I. Anti-infectives F. Antiviral agents 3. Nucleotide Reverse-transcriptase inhibitor 19 tenofovir Viread P O X 20 I. Anti-infectives F. Antiviral agents 3. Protease Inhibitors 20 amprenavir Agenerase P O X 20 lopinavir/ ritonavir Kaletra P O X 20 indinavir sulfate Crixivan P O X 20 nelfinavir mesylate Viracept P O X 20 ritonavir Norvir P O X 20 saquinavir Fortovase P O X 21 I. Anti-infectives F. Antiviral agents 4. Agents for influenza 21 amantadine -- G G X X 21 amantadine Symmetrel O O 21 oseltamivir Tamiflu O O 21 rimantadine -- G G X 21 rimantadine Flumadine O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 21 zanamivir Relenza O O 22 I. Anti-infectives F. Antiviral agents 5. Other 22 acyclovir -- G G X 22 acyclovir Zovirax O O 22 famciclovir Famvir P O X 22 ganciclovir -- G G X 22 ganciclovir Cytovene O O 22 ribavirin Rebetol P O X 22 valacyclovir Valtrex P O X 23 I. Anti-infectives G. Leprostatics 23 clofazimine Lamprene O O 23 dapsone Dapsone O O 23 thalidomide Thalomid O O 24 I. Anti-infectives H. Antihelmintics 24 albendazole Albenza O O 24 diethylcarbamazine citrate Hetrazan O O 24 ivermectin Stromectol O O 24 mebendazole -- G G X 24 mebendazole Vermox O O 24 oxamniquine Vansil O O 24 praziquantel Biltricide O O 24 thiabendazole Mintezol O O 25 I. Anti-infectives I. Other 25 atovaquone Mepron O O 25 cinoxacin Cinobac O O 25 fosfomycin tromethamine Monurol O O 25 furazolidone Furoxone O O 25 methenamine hippurate Hiprex O O 25 methenamine hippurate Urex O O 25 methenamine mandelate -- G G X 25 methenamine mandelate Mandelamine O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 25 methylene blue Urolene Blue O O 25 nalidixic acid NegGram O O 25 nitrofurantoin Furadantin O O 25 nitrofurantoin macrocrystals -- G G X 25 nitrofurantoin macrocrystals Macrobid P O X 25 nitrofurantoin macrocrystals Macrodantin O O 25 pentamidine isethionate, inhalation NebuPent P O X 25 tobramycin, inhalation TOBI P O X 25 trimethoprim -- G G X 25 trimethoprim Trimpex O O 26 II. Anti-neoplastics A. Alkylating Agents 26 busulfan Myleran P O X 26 chlorambucil Leukeran P O X 26 cyclophosphamide -- G G X 26 cyclophosphamide Cytoxan P O X 26 lomustine CeeNu P O X 26 melphalan Alkeran P O X 27 II. Anti-neoplastics B. Antimetabolites 27 capecitabine Xeloda P O X 27 mercaptopurine Purinethol P O X 27 methotrexate -- G G X 27 methotrexate Rheumatrex O O 27 thioguanine Thioguanine P O X 28 II. Anti-neoplastics C. Hormones 28 anastrazole Arimidex P O X 28 bicalutamide Casodex P O X 28 diethylstilbestrol Stilphostrol O O 28 estramustine Emcyt P O X 28 flutamide -- G G X 28 flutamide Eulexin O O 28 letrozole Femara O O 28 megestrol -- G G X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 28 megestrol Megace O O 28 nilutamide Nilandron O O 28 tamoxifen -- G G X 28 tamoxifen Nolvadex O O 28 testolactone Teslac O O 28 toremifene Fareston O O 29 II. Anti-neoplastics D. Mitotic Inhibitors 29 etoposide VePesid P O X 30 II. Anti-neoplastics E. Other 30 altretamine Hexalen P O X 30 bexarotene Targretin P P X 30 hydroxyurea -- G G X 30 hydroxyurea Hydrea P O X 30 levamisole Ergamisol P O X 30 mitotane Lysodren O O 30 procarbazine Matulane P O X 30 temozolomide Temodar P O X 30 tretinoin, oral Vesanoid O O 31 III. Blood Modifiers A. Folic acid derivatives 31 folic acid -- G G X 31 leucovorin calcium -- G G X 31 leucovorin calcium Wellcovorin O O 32 III. Blood Modifiers B. Vitamin B 32 cyanocobalamin, nasal Nascobal P 11 O 11 X 11 33 III. Blood Modifiers C. Vitamin K 33 phytonadione Mephyton P O X 34 III. Blood Modifiers D. Antiplatelet agents OTC consideration: apsirin 34 aspirin -- X 34 aspirin/ dipyridamole Aggrenox P P X 34 anagrelide Agrylin O O 34 cilostazol Pletal O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 34 clopidogrel Plavix P P X 34 dipyridamole -- G G X 34 dipyridamole Persantine O O 34 ticlopidine -- G G X 34 ticlopidine Ticlid O O 35 III. Blood Modifiers E. Anticoagulants 35 anisindione Miradon O O 35 dicumarol Dicumarol O O 35 warfarin -- G G X 35 warfarin Coumadin P O X 36 III. Blood Modifiers F. Hemorrheologic agent 36 pentoxifylline -- G G X 36 pentoxifylline Trental O O 37 IV. Cardiovasculars A. Diuretics 1. Thiazide and related diuretics 37 bendroflumethiazide Naturetin O O 37 chlorothiazide -- G G 37 chlorothiazide Diuril O O 37 chlorthalidone -- G G 37 chlorthalidone Thalitone O O 37 furosemide -- G G X 37 furosemide Lasix O O 37 hydrochlorothiazide -- G G X 37 hydrochlorothiazide HydroDIURIL O O 37 hydrochlorothiazide Microzide O O 37 indapamide -- G G X 37 indapamide Lozol O O 37 methyclothiazide -- G G 37 methyclothiazide Enduron O O 37 metolazone Mykrox O O 37 metolazone Zaroxolyn P O X 37 polythiazide Renese O O 37 trichlormethiazide -- G G HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 37 trichlormethiazide Naqua O O 38 IV. Cardiovasculars A. Diuretics 2. Loop diuretics 38 bumetanide -- G G 38 bumetanide Bumex O O 38 ethacrynic acid Edecrin O O 38 torsemide -- G G 38 torsemide Demadex O O 39 IV. Cardiovasculars A. Diuretics 3. Potassium-Sparing diuretics 39 amiloride hcl -- G G 39 amiloride hcl Midamor O O 39 spironolactone -- G G X 39 spironolactone Aldactone O O 39 triamterene Dyrenium O O 40 IV. Cardiovasculars A. Diuretics 4. Carbonic anhydrase inhibitors 40 acetazolamide -- G G X 40 acetazolamide Diamox O O 40 acetazolamide, extended release Diamox Sequels P O X 40 dichlorphenamide Daranide O O 40 methazolamide -- G G X 40 methazolamide Neptazane O O 41 IV. Cardiovasculars A. Diuretics 5. Diuretic combinations 41 amiloride/ hctz -- G G 41 amiloride/ hctz Moduretic O O 41 spironolactone/ hctz -- G G X 41 spironolactone/ hctz Aldactazide O O 41 triamterene/ hctz -- G G X 41 triamterene/ hctz Dyazide O O 41 triamterene/ hctz Maxzide O O 42 IV. Cardiovasculars B. Cardiac Glycosides 42 digitoxin Crystodigin O O 42 digoxin -- G G X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 42 digoxin Lanoxicaps O O 42 digoxin Lanoxin G G X 43 IV. Cardiovasculars C. Nitrates 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 -- G G X release 43 isosorbide dinitrate, oral, sustained Dilatrate-SR O O release 43 isosorbide dinitrate, oral, sustained Isordil Tembids O O release 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 -- G G X release 43 isosorbide mononitrate, extended Imdur O O release 43 nitroglycerin, sublingual Nitrostat G G X 43 nitroglycerin, sustained release, oral -- G G

43 nitroglycerin, sustained release, oral Nitroglyn O O

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 HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 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 44 IV. Cardiovasculars D. Anti-arrhythmic agents 44 amiodarone -- G G X 44 amiodarone Cordarone P O X 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 44 dofetilide Tikosyn O O 44 flecainide -- G G X 44 flecainide Tambocor P O X 44 mexiletine -- G G X 44 mexiletine Mexitil P O X 44 moricizine Ethmozine P O 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 44 propafenone -- G G X 44 propafenone Rythmol P O X 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 HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 44 quinidine sulfate, extended release Quinidex Extentabs P O X 44 sotalol Betapace AF P P X 45 IV. Cardiovasculars E. Calcium channel blocking agents 1. Benzothiazepine 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 45 diltiazem, sustained release Cardizem SR O O 45 diltiazem, sustained release Dilacor XR O O 45 diltiazem, sustained release Tiazac P P X 46 IV. Cardiovasculars E. Calcium channel blocking agents 2. Dihydropyridine 46 amlodipine Norvasc O O 46 amlodipine/ benazepril Lotrel P O X 46 felodipine Plendil P P X 46 felodipine/enalapril Lexxel OO 46 isradipine DynaCirc O O 46 nicardipine -- G G 46 nicardipine Cardene O O 46 nicardipine, sustained release Cardene SR O O 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 46 nimodipine Nimotop P O X 46 nisoldipine Sular P P X 47 IV. Cardiovasculars E. Calcium channel blocking agents 3. Diphenylalkylamine 47 verapamil -- G G X 47 verapamil Calan O O 47 verapamil Isoptin O O 47 verapamil, sustained release -- G G X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 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 47 verapamil ER/ trandolapril Tarka O O 48 IV. Cardiovasculars E. Calcium channel blocking agents 4. Other 48 bepridil Vascor O O 49 IV. Cardiovasculars F. Beta-adrenergic blocking agents 1. Non-selective agents 49 nadolol -- G G 49 nadolol Corgard O O 49 nadolol/ bendroflumethiazide Corzide O O 49 penbutolol Levatol O O 49 pindolol -- G G 49 pindolol Visken 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 49 sotalol -- G G X 49 sotalol Betapace O O 49 sotalol Betapace AF P P X 49 timolol maleate -- G G 49 timolol maleate Blocadren O O 49 timolol maleate/ hctz Timolide O O 50 IV. Cardiovasculars F. Beta-adrenergic blocking agents 2. Beta-1 selective agents Inhibits beta-2 receptors (bronchial and vascular) at higher doses. 50 acebutolol -- G G 50 acebutolol Sectral O O 50 atenolol -- G G HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 50 atenolol Tenormin O O 50 atenolol/ chlorthalidone -- G G 50 atenolol/ chlorthalidone Tenoretic O O 50 betaxolol Kerlone O O 50 bisoprolol -- G G X 50 bisoprolol Zebeta O O 50 bisoprolol/ hctz -- G G X 50 bisoprolol/ hctz Ziac O O 50 metoprolol -- G G X 50 metoprolol Lopressor O O 50 metoprolol, extended release Toprol XL P P X 50 metoprolol/ hctz Lopressor HCT O O 51 IV. Cardiovasculars G. Alpha/beta-adrenergic blocking agents 51 carvedilol Coreg P P X 51 labetolol -- G G X 51 labetolol Normodyne O O 51 labetolol Trandate O O 52 IV. Cardiovasculars H. Anti-adrenergic agents-centrally located 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 52 guanabenz -- G G 52 guanabenz Wytensin O O 52 guanfacine -- G G X 52 guanfacine Tenex 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 HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 53 IV. Cardiovasculars I. Anti-adrenergic agents-peripherally located 1. Alpha-1 adrenergic block 53 doxazosin -- G G 53 doxazosin mesylate Cardura O O 53 prazosin -- G G X 53 prazosin Minipress O O 53 prazosin/ polythiazide Minizide O O 53 tamsulosin Flomax P O X 53 terazosin -- G G X 53 terazosin Hytrin O O 54 IV. Cardiovasculars I. Anti-adrenergic agents-peripherally located 2. Other 54 deserpidine/ methyclothiazide Enduronyl O O 54 deserpidine/ methyclothiazide Enduronyl Forte O O 54 guanadrel Hylorel O O 54 guanethidine Ismelin O O 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 55 IV. Cardiovasculars J. Vasodilators 55 hydralazine -- G G X 55 hydralazine Apresoline O O 55 hydralazine/ hctz -- G G 55 hydralazine/ hctz Apresazide O O 55 minoxidil -- G G X 55 minoxidil Loniten O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 56 IV. Cardiovasculars K. Angiotensin converting enzyme inhibitors 56 benazepril Lotensin O O 56 benazepril/ hctz Lotensin HCT O O 56 benazepril/ amlodipine Lotrel 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 56 enalapril -- G G X 56 enalapril Vasotec O O 56 enalapril/ hctz -- G G X 56 enalapril/ hctz Vaseretic O O 56 felodipine/ enalapril Lexxel O O X 56 fosinopril -- G G 56 fosinopril Monopril O O 56 fosinopril/hctz Monopril HCT O O 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 56 moexipril -- G G 56 moexipril Univasc O O 56 moexipril/ hctz Uniretic O O 56 perindopril Aceon O O 56 quinapril -- G G 56 quinapril Accupril O O 56 quinapril/ hctz Accuretic O O 56 ramipril Altace P P X 56 trandolapril Mavik O O 56 verapamil ER/ trandolapril Tarka O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 57 IV. Cardiovasculars L. Angiotensin II Receptor Antagonists 57 candesartan Atacand O O 57 candesartan/ hctz Atacand HCT O O 57 eprosartan Teveten O O 57 eprosartan/ hctz Teveten HCT O O 57 irbesartan Avapro P P X 57 irbesartan/ hctz Avalide P P X 57 losartan Cozaar P P X 57 losartan/ hctz Hyzaar P P X 57 olmesartan Benicar O O 57 telmisartan Micardis O O 57 telmisartan/ hctz Micardis HCT O O 57 valsartan Diovan O O 57 valsartan/ hctz Diovan HCT O O 58 IV. Cardiovasculars M. Agents for Pheochromocytoma 58 metyrosine Demser O O 58 phenoxybenzamine Dibenzyline O O 59 IV. Cardiovasculars N. Antihyperlipidemic Agents 1. Bile Acid Sequestrants 59 colesevelam Welchol O O 59 cholestyramine/ aspartame LoCHOLEST Light O O 59 cholestyramine/ aspartame Prevalite O O 59 cholestyramine/ sucrose -- G G 59 cholestyramine/ sucrose LoCHOLEST O O 59 cholestyramine/ sucrose Questran O O 59 cholestyramine/ aspartame -- G G 59 cholestyramine/ aspartame Questran Light O O 59 colestipol, granules Colestid P O X 59 colestipol, tablets Colestid P O 60 IV. Cardiovasculars N. Antihyperlipidemic Agents 2. HMG-CoA Reductase Inhibitors 60 atorvastatin, 10mg, 20mg & 40mg Lipitor, 10mg, 20mg & O21O 21 40mg HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 60 atorvastatin, 80 mg Lipitor, 80 mg P 21 P 21 X 21 60 fluvastatin Lescol O 21 O 21 60 fluvastatin, extended release Lescol XL O 21 O 21 60 lovastatin -- G G X 60 lovastatin Mevacor O O 60 lovastatin, extended release Altocor O 21 O 21 60 pravastatin Pravachol P 21 P 21 X 21 60 pravastatin/ aspirin Pravigard P 21 P 21 X 21 60 simvastatin Zocor O 21 O 21 61 IV. Cardiovasculars N. Antihyperlipidemic Agents 3. Other 61 clofibrate Atromid S O O 61 ezetimibe Zetia O O 61 fenofibrate -- O O 61 fenofibrate Tricor O O 61 gemfibrozil -- G G X 61 gemfibrozil Lopid O O 61 nicotinic acid, extended release Niaspan P P X 61 nicotinic acid, extended release/ Advicor PPX 62 V. Central Nervous System Agents A. CNS Stimulants 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

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 -- G 7 G 7 X 7 X 7 release 62 dextroamphetamine sulfate, sustained Dexedrine Spansules O 7 O 7 X 7 release 62 methamphetamine Desoxyn O 7 O 7 HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 62 methylphenidate -- G 8 G 8 X 8 X 8 62 methylphenidate Ritalin O 8 O 8 62 methylphenidate, extended release Concerta O 7 O 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 62 modafinil Provigil O 9 O 9 62 pemoline -- G 7 G 7 X 7 62 pemoline Cylert O 7 O 7 X 7 63 V. Central Nervous System Agents B. Analgesics 1. Narcotic Agonist Analgesics 63 belladonna/ opium B&O suppositories O O 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 63 fentanyl, transdermal Duragesic P O X 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 63 hydrocodone/ ibuprofen -- G G 63 hydrocodone/ ibuprofen Vicoprofen O O 63 hydromorphone -- G G X 63 hydromorphone Dilaudid O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 63 levorphanol Levo-Dromoran P O X 63 meperidine -- G G X 63 meperidine Demerol O O 63 methadone -- G G X X 63 methadone Dolophine O 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 63 opium tincture, deodorized -- G G 63 oxycodone -- G G X 63 oxycodone OxyIR O O 63 oxycodone, controlled release Oxycontin P O 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 63 paregoric -- G G 63 propoxyphene -- G G 63 propoxyphene Darvon O O 63 propoxyphene/ apap Wygesic O O 63 propoxyphene/ asa/ caffeine -- G G 63 propoxyphene/ asa/ caffeine Darvon Compound O O 63 propoxyphene napsylate Darvon N O O 63 propoxyphene napsylate/ apap -- G G 63 propoxyphene napsylate/ apap Darvocet N O O 64 V. Central Nervous System Agents B. Analgesics 2. Narcotic Agonist-Antagonist Analgesics 64 butorphanol -- G G 64 butorphanol Stadol NS O O 64 pentazocine/ apap Talacen O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 64 pentazocine/ asa Talwin Compound O O 64 pentazocine/ naloxone -- G G 64 pentazocine/ naloxone Talwin NX O O 65 V. Central Nervous System Agents B. Analgesics 3. Central Analgesics 65 acetaminophen -- X

65 tramadol -- G G 65 tramadol Ultram O O 65 tramadol/ apap Ultracet O O 66 V. Central Nervous System Agents B. Analgesics 4. Salicylates OTC considerations: aspirin, sodium salicylate, choline 66 aspirin -- X 66 aspirin, controlled release ZORprin O O 66 aspirin, enteric coated Easprin O O 66 choline salicyclate/ magnesium Trilisate O O salicylate 66 diflunisal -- G G 66 diflunisal Dolobid O O 66 magnesium salicylate Magan O O 66 magnesium salicylate Mobidin O O 66 salsalate -- G G 66 salsalate Disalcid O O 66 salsalate Marthritic O O 67 V. Central Nervous System Agents B. Analgesics 5. Non-Narcotic Analgesic Combinations 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 HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 67 butalbital/ apap/ caffeine Fioricet O O 67 butalbital/ asa/ caffeine -- G G X 67 butalbital/ asa/ caffeine Fiorinal O O 68 V. Central Nervous System Agents B. Analgesics 6. Non-Steroidal Anti-inflammatory Agents (NSAIDs) a. Non-selective 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, Voltaren XR O O oral 68 diclofenac/ misoprostol Arthrotec 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 68 fenoprofen calcium -- G G 68 fenoprofen calcium Nalfon O O 68 flurbiprofen -- G G 68 flurbiprofen Ansaid O O 68 ibuprofen -- G G X 68 ibuprofen Motrin O O 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 68 ketoprofen -- G G 68 ketoprofen Orudis O O 68 ketoprofen, extended release -- G G 68 ketoprofen, extended release Oruvail O O 68 ketorolac, oral -- G G HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 68 ketorolac, oral Toradol O O 68 meclofenamate sodium -- G G 68 mefenamic acid Ponstel O O 68 nabumetone -- G G 68 nabumetone Relafen 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

68 oxaprozin -- G G 68 oxaprozin Daypro O O 68 piroxicam -- G G 68 piroxicam Feldene O O 68 sulindac -- G G

68 sulindac Clinoril O O 68 tolmetin sodium -- G G 68 tolmetin sodium Tolectin O O 69 V. Central Nervous System Agents B. Analgesics 6. Non-Steroidal Anti-inflammatory Agents (NSAIDs) b. COX-2 selective 69 celecoxib Celebrex P 22 O X 22 69 rofecoxib Vioxx P 22 O X 22 69 valdecoxib Bextra O 22 O 70 V. Central Nervous System Agents C. Abortive Agents for Migraine 1. 5HT-1 Receptor Agonists 70 almotriptan Axert O 25 O 25 70 frovatriptan Frova O 25 O 25 70 naratriptan Amerge P 23 O 23 X 23 70 rizatriptan Maxalt O 25 O 25 70 rizatriptan Maxalt-MLT O 25 O 25 70 sumatriptan Imitrex P 24 O 24 X 24 HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 70 zolmitriptan Zomig O 25 O 25 71 V. Central Nervous System Agents C. Abortive Agents for Migraine 2. Other 71 dihydroergotamine mesylate Migranal O 20 O 20 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 Wigraine suppositories O O 71 isometheptene/ dichloralphenazone/ -- G G apap 71 isometheptene/ dichloralphenazone/ Midrin O O apap 72 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 1. Anti-dopaminergics 72 chlorpromazine -- G G X X 72 chlorpromazine Thorazine O O 72 metoclopramide -- G G X 72 metoclopramide Reglan O O 72 perphenazine -- G G X X 72 perphenazine Trilafon O O 72 prochlorperazine edisylate, syrup Compazine Syrup P O X X 72 prochlorperazine maleate, sustained Compazine Spansules O O 72 prochlorperazine maleate, tablets -- G G X X 72 prochlorperazine maleate, tablets Compazine O O 72 promethazine, tablets and liquid -- G G X X

72 promethazine, suppositories Phenergan Suppositories P O X 72 promethazine, tablets and liquid Phenergan O O 72 thiethylperazine maleate Torecan O O 73 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 2. Anti-cholinergics OTC considerations: cyclizine 73 diphenhydramine -- G G X X 73 diphenhydramine Benadryl O O 73 meclizine -- G G X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 73 meclizine Antivert O O

73 scopolamine, trandsdermal Transderm-Scop O O 73 trimethobenzamide -- G G 73 trimethobenzamide Tigan O O 74 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 3. Other OTC consideration: phosphorated 74 dronabinol Marinol O O 75 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 4. 5HT-3 Receptor Antagonists 75 dolasetron mesylate Anzemet O O 75 granisetron Kytril P O X 75 ondansetron Zofran P O X 75 ondansetron Zofran ODT P O X 76 V. Central Nervous System Agents E. Anti-Anxiety 1. Benzodiazepines 76 alprazolam -- G G X 19 X 76 alprazolam Xanax O O 76 clorazepate dipotassium -- G G X 19 76 clorazepate 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 76 diazepam -- G G X 19 76 diazepam Valium O O 76 halazepam Paxipam O O 76 lorazepam -- G G X 19 X 76 lorazepam Ativan O O 76 oxazepam -- G G 76 oxazepam Serax O O 76 prazepam -- G G 77 V. Central Nervous System Agents E. Anti-Anxiety 2. Other 77 buspirone -- G G X X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 77 buspirone Buspar O O 77 chloral hydrate -- G G X 5 77 doxepin -- G G X X 77 doxepin Sinequan O O 77 hydroxyzine hcl -- G G X X 77 hydroxyzine hcl Atarax O O 77 hydroxyzine pamoate, capsules -- G G X X 77 hydroxyzine pamoate, capsules Vistaril O O 77 hydroxyzine pamoate, suspension Vistaril Suspension P O X X 77 meprobamate -- G G 77 meprobamate Equanil O O 77 meprobamate Miltown O O 78 V. Central Nervous System Agents F. Anti-depressants 1. Tricyclic compounds-Tertiary amines 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 78 chlordiazepoxide/ amitriptyline -- G G 78 chlordiazepoxide/ amitriptyline Limbitrol DS O O 78 clomipramine -- G G X X 78 clomipramine Anafranil O O 78 doxepin -- G G X X 78 doxepin Sinequan O O 78 imipramine -- G G X X 78 imipramine Tofranil O O 78 imipramine pamoate Tofranil PM P O X X 78 trimipramine maleate Surmontil P O X X 79 V. Central Nervous System Agents F. Anti-depressants 2. Tricyclic compounds - Secondary amines 79 amoxapine -- G G X X 79 amoxapine Asendin O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 79 desipramine -- G G X X 79 desipramine Norpramin O O 79 nortriptyline -- G G X X 79 nortriptyline Aventyl O O 79 nortriptyline Pamelor O O 79 protriptyline -- G G X X 79 protriptyline Vivactil O O 80 V. Central Nervous System Agents F. Anti-depressants 3. Tetracyclics 80 maprotiline -- G G X X 80 maprotiline Ludiomil 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 81 V. Central Nervous System Agents F. Anti-depressants 4. Triazolopyridine 81 trazodone -- G G X X 81 trazodone Desyrel O O 82 V. Central Nervous System Agents F. Anti-depressants 5. Aminoketone 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 83 V. Central Nervous System Agents F. Anti-depressants 6. Phenethylamine 83 venlafaxine Effexor O O X 83 venlafaxine, extended release Effexor XR P P X X 84 V. Central Nervous System Agents F. Anti-depressants 7. Phenylpiperazine 84 nefazodone -- G G X 84 nefazodone Serzone O O X 85 V. Central Nervous System Agents F. Anti-depressants 8. Selective serotonin reuptake inhibitors 85 citalopram Celexa P P X X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 85 escitalopram Lexapro O O X 85 fluoxetine -- G G X X 85 fluoxetine Prozac O O 85 fluvoxamine maleate -- G G X 85 paroxetine Paxil P P X X 85 paroxetine, controlled release Paxil CR P P X X 85 sertraline Zoloft P P X X 86 V. Central Nervous System Agents F. Anti-depressants 9. Monoamine oxidase inhibitors 86 isocarboxazid Marplan O O 86 phenelzine sulfate Nardil P O X X 86 tranylcypromine sulfate Parnate O O 87 V. Central Nervous System Agents G. Anti-psychotic 1. Phenothiazines - aliphatic 87 promazine Sparine O O 87 chlorpromazine -- G G X X 87 chlorpromazine Thorazine O O 88 V. Central Nervous System Agents G. Anti-psychotic 2. Phenothiazines - piperazine 88 amitriptyline/ perphenazine -- G G X X 88 amitriptyline/ perphenazine Etrafon O O 88 amitriptyline/ perphenazine Triavil O O 88 fluphenazine -- G G X X 88 fluphenazine Prolixin O O 88 fluphenazine deconoate, injectable -- X X 88 perphenazine -- G G X 88 perphenazine Trilafon O O 88 prochlorperazine edisylate, syrup Compazine Syrup P O X X 88 prochlorperazine maleate, sustained Compazine Spansules O O release 88 prochlorperazine maleate, tablets -- G G X X 88 prochlorperazine maleate, tablets Compazine O O 88 trifluoperazine -- G G 88 trifluoperazine Stelazine O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 89 V. Central Nervous System Agents G. Anti-psychotic 3. Phenothiazines - piperidine 89 mesoridazine Serentil O O 89 thioridazine -- G G X X 89 thioridazine Mellaril O O 90 V. Central Nervous System Agents G. Anti-psychotic 4. Thioxanthenes 90 thiothixene -- G G X X 90 thiothixene Navane O O 91 V. Central Nervous System Agents G. Anti-psychotic 5. Butyrophenone 91 haloperidol -- G G X X 91 haloperidol Haldol O O 91 haloperidol decanoate, injectable -- X X 92 V. Central Nervous System Agents G. Anti-psychotic 6. Diphenylbutylpiperadine 92 pimozide Orap O O 93 V. Central Nervous System Agents G. Anti-psychotic 7. Dihydroindolones 93 molindone Moban O O 94 V. Central Nervous System Agents G. Anti-psychotic 8. Dibenzepine 94 loxapine -- G G 94 loxapine Loxitane O O 94 loxapine solution Loxitane C O O 95 V. Central Nervous System Agents G. Anti-psychotic 9. Atypicals 95 aripiprazole Abilify P O X X 95 clozapine -- G G 95 clozapine Clozaril P O X 95 olanzapine Zyprexa P O X X 95 olanzapine Zyprexa Zydis O O X 95 quetiapine fumarate Seroquel P O X X 95 risperidone Risperdal P O X X 95 risperidone Risperdal-M P O X X 95 risperidone injection Risperdal Consta X 95 ziprasidone Geodon P O X X 96 V. Central Nervous System Agents G. Anti-psychotic 10. Anti-manic agents HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 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 97 V. Central Nervous System Agents H. Cholinesterase inhibitors 97 donepezil Aricept P O X 97 galantamine Reminyl O O 97 rivastigmine Exelon O O 97 tacrine Cognex O O 98 V. Central Nervous System Agents I. Sedatives and hypnotics, non-barbiturates 1. Benzodiazepines 98 estazolam -- G G

98 estazolam Prosom O O 98 flurazepam -- G G 98 flurazepam Dalmane O O 98 quazepam Doral O O 98 temazepam -- G G 98 temazepam Restoril O O 98 triazolam -- G G 98 triazolam Halcion O O 99 V. Central Nervous System Agents I. Sedatives and hypnotics, non-barbiturates 2. Other OTC considerations: doxylamine 99 acetylcarbromal Paxarel O O 99 chloral hydrate -- G G X 5 99 ethchlorvynol Placidyl O O 99 zaleplon Sonata O O 99 zolpidem tartrate Ambien P O 100 V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 1. Long-acting HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 100 mephobarbital Mebaral P O X 26 100 phenobarbital -- G G X 26 101 V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 2. Intermediate-acting 101 butabarbital sodium Butisol Sodium O O 102 V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 3. Short-acting 102 pentobarbital Nembutal O O 102 secobarbital sodium Seconal O O 103 V. Central Nervous System Agents K. Anticonvulsants 1. Hydantoins 103 ethotoin Peganone O O 103 mephenytoin Mesantoin 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 104 V. Central Nervous System Agents K. Anticonvulsants 2. Succinimides 104 ethosuximide Zarontin P O X 104 methsuximide Celontin Kapseals P O X 105 V. Central Nervous System Agents K. Anticonvulsants 3. Oxazolidinediones 105 trimethadione Tridione P O X 106 V. Central Nervous System Agents K. Anticonvulsants 4. Benzodiazepines 106 chlorazepate dipotassium -- G G X 19 106 chlorazepate dipotassium Tranxene O O 106 clonazepam -- G G X 19 X 106 clonazepam Klonopin P O X 19 X 106 diazepam -- G G X 19 106 diazepam Valium O O 106 diazepam, rectal Diastat P O X 107 V. Central Nervous System Agents K. Anticonvulsants 5. Other 107 acetazolamide -- G G X 107 acetazolamide Diamox O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 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 107 divalproex sodium Depakote P O X X 107 divalproex sodium, extended release Depakote ER P O X X 107 felbamate Felbatol P O X 107 gabapentin Neurontin P O X X 107 lamotrigine Lamictal P O X X 107 levetiracetam Keppra P O X X 107 primidone -- G G X 107 primidone Mysoline P O X 107 tiagabine Gabatril P O X 107 topiramate Topamax P O X X 107 oxcarbazepine Trileptal P O X X 107 valproic acid -- G G X X 107 valproic acid Depakene P O X X 107 zonisamide Zonegran P O X 108 V. Central Nervous System Agents L. Skeletal muscle relaxants 1. Centrally acting 108 baclofen -- G G X 108 baclofen Lioresal 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 w/ OO Codeine 108 chlorphenesin carbamate Maolate O O 108 chlorzoxazone -- G G X 108 chlorzoxazone Parafon Forte DSC O O 108 cyclobenzaprine -- G G X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 108 cyclobenzaprine Flexeril O O 108 diazepam -- G G X 19 108 diazepam Valium O O 108 metaxalone Skelaxin O O 108 methocarbamol -- G G X 108 methocarbamol Robaxin O O 108 methocarbamol/ asa -- G G 108 methocarbamol/ asa Robaxisal O O 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 108 tizanidine -- G G 108 tizanidine Zanaflex O O 109 V. Central Nervous System Agents L. Skeletal muscle relaxants 2. Direct acting 109 dantrolene Dantrium O O 110 V. Central Nervous System Agents M. Antiparkinson agents 1. Anti-cholinergics 110 benztropine -- G G X X 110 benztropine Cogentin O O 110 biperiden Akineton O O 110 diphenhydramine -- G G X X 110 diphenhydramine Benadryl O O 110 procyclidine Kemadrin O O X 110 trihexyphenidyl -- G G X X 110 trihexyphenidyl Artane O O 111 V. Central Nervous System Agents M. Antiparkinson agents 2. Other 111 amantadine -- G G X X 111 amantadine Symmetrel O O 111 bromocriptine Parlodel P O X 111 carbidopa Lodosyn O O 111 entacapone Comtan O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 111 levodopa Larodopa O O 111 levodopa Dopar O O 111 levodopa/ carbidopa -- G G X 111 levodopa/ carbidopa Sinemet O O 111 levodopa/ carbidopa, sustained release -- G G X

111 levodopa/ carbidopa, sustained release Sinemet CR O O

111 pergolide -- G G X 111 pergolide Permax O O 111 pramipexole Mirapex P O X 111 ropinirole Requip P O X 111 selegiline -- G G X 111 selegiline Eldepryl O O 111 tolcapone Tasmar O O 112 V. Central Nervous System Agents N. Cholinergic muscle stimulants 112 ambenonium chloride Mytelase O O 112 guanidine hcl Guanidine O O 112 neostigmine Prostigmin O O 112 pyridostigmine bromide Mestinon P O X 113 V. Central Nervous System Agents O. Agents for dependency and withdrawal 1. Alcohol

113 disulfiram Antabuse P O X X 114 V. Central Nervous System Agents O. Agents for dependency and withdrawal 2. Narcotic agonists 114 methadone -- G G X X 114 methadone Dolophine O O 115 V. Central Nervous System Agents O. Agents for dependency and withdrawal 3. Narcotic antagonists 115 naltrexone Depade O O 115 naltrexone ReVia P O X X 116 V. Central Nervous System Agents O. Agents for dependency and withdrawal 4. Nicotine OTC considerations: nicotine, 116 bupropion, extended release Zyban P O X X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 116 nicotine, inhaler Nicotrol inhaler O O 116 nicotine, nasal spray Nicotrol NS O O 116 nicotine, transdermal -- G 2 G 2 X X 117 V. Central Nervous System Agents P. Other 117 atomoxetine Strattera O O X 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 117 riluzole -- G G X 117 riluzole Rilutek P O X 118 VI. Endocrine/Metabolic A. Sex Hormones 1. Estrogens a. Oral 118 conjugated estrogens Premarin P O X 118 esterified estrogens Menest O O 118 esterified estrogens/ methyltestosterone Estratest P O X

118 esterified estrogens/ methyltestosterone Estratest HS P O X

118 estradiol -- G G X 118 estradiol Estrace O O 118 estropipate -- G G X 118 estropipate Ogen O O 118 estropipate Ortho-EST G G X 118 ethinyl estradiol Estinyl O O 118 synthetic conjugated estrogens Cenestin O O 119 VI. Endocrine/Metabolic A. Sex Hormones 1. Estrogens b. Other 119 conjugated estrogens, vaginal Premarin P O X 119 dienestrol, vaginal Ortho Dienestrol O O 119 estradiol hemihydrate Vagifem O O 119 estradiol, transdermal -- G G X 119 estradiol, transdermal Alora O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 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 119 estropipate, vaginal Ogen O O 120 VI. Endocrine/Metabolic A. Sex Hormones 2. Selective Estrogen Receptor Modulator (SERM) 120 raloxifene Evista P O X 121 VI. Endocrine/Metabolic A. Sex Hormones 3. Progestins a. Oral 121 medroxyprogesterone acetate -- G G X 121 medroxyprogesterone acetate Amen O O 121 medroxyprogesterone acetate Curretab O O 121 medroxyprogesterone acetate Provera O O 121 norethindrone acetate -- G G 121 norethindrone acetate Aygestin O O 121 progesterone, micronized Prometrium P O X 122 VI. Endocrine/Metabolic A. Sex Hormones 4. Estrogen/progestin combination 122 conjugated estrogens/ Premphase P O X medroxyprogesterone 122 conjugated estrogens/ Prempro P O X 122 conjugated estrogens/ Prempro Low Dose P O X medroxyprogesterone 122 estradiol/ norethindrone acetate Activella O O 122 estradiol/ norethindrone acetate, Combipatch O O transdermal 122 ethinyl estradiol/ norethindrone acetate Femhrt O O 123 VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives a. Monophasic 123 ethinyl estradiol/ levonorgestrel Alesse P 3 P 3 X X X 123 ethinyl estradiol/ desogestrel Desogen P 3 P 3 X X X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 123 ethinyl estradiol/ drospirenone Yasmin P 3 P 3 X X X 124 VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives b. Biphasic 124 ethinyl estradiol/ desogestrel Mircette P 3 P 3 X X X 125 VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives c. Triphasic 125 ethinyl estradiol/ levonorgestrel Tri-Levlen P 3 P 3 X X X 126 VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives d. Progetin-only 126 norethindrone Nor-QD P 3 P 3 X X X 127 VI. Endocrine/Metabolic A. Sex Hormones 6. Emergency Contraceptives 127 levonorgestrel Plan B P X 127 ethinyl estradiol/ levonorgestrel Preven O X 128 VI. Endocrine/Metabolic A. Sex Hormones 7. Other contraceptives 128 ethinyl estradiol/ levonorgestrel Nuvaring O O X 128 ethinyl estradiol/ norelgestromin OrthoEvra O O X 128 medroxyprogesterone acetate, injectable Depo-Provera X X

129 VI. Endocrine/Metabolic A. Sex Hormones 8. Androgens a. Oral 129 esterified estrogens/ methyltestosterone Estratest HS P O X 129 esterified estrogens/ methyltestosterone Estratest P O X

129 fluoxymesterone Halotestin P O X 129 methyltestosterone Android P O X 129 methyltestosterone Testred O O 130 VI. Endocrine/Metabolic A. Sex Hormones 8. Androgens b. Other 130 testosterone, gel Androgel O O 130 testosterone, transdermal Androderm P O X 130 testosterone, transdermal Testoderm O O 131 VI. Endocrine/Metabolic A. Sex Hormones 9. Androgen hormone inhibitor 131 finasteride Proscar P O X 132 VI. Endocrine/Metabolic B. Anabolic steroids 132 oxandrolone Oxandrin P O X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 132 oxymetholone Anadrol O O 132 stanozolol Winstrol P O X 133 VI. Endocrine/Metabolic C. Agents for infertility/impotence 133 alprostadil Caverject O O 133 alprostadil Muse O O 133 clomiphene -- G 2 G 2 133 clomiphene Serophene O 2 O 2 133 clomiphene Clomid O 2 O 2 133 progesterone, vaginal 8% Crinone 8% O 2 O 2 133 sildenafil Viagra O 2 O 2 133 yohimbine -- G 2 G 2 133 yohimbine Yocon O 2 O 2 134 VI. Endocrine/Metabolic D. Gonadotropin releasing hormone 134 nafarelin Synarel P O X 135 VI. Endocrine/Metabolic E. Danazol 135 danazol -- G G X 135 danazol Danocrine P O X 136 VI. Endocrine/Metabolic F. Posterior pituitary hormones 136 carteolol Cartrol O O 136 desmopressin, nasal Stimate P O X 136 desmopressin, nasal DDAVP P O X 136 desmopressin, oral DDAVP P O X 137 VI. Endocrine/Metabolic G. Adrenal cortical steroids 1. Mineralocorticoids 137 fludrocortisone -- G G X 137 fludrocortisone Florinef O O 138 VI. Endocrine/Metabolic G. Adrenal cortical steroids 2. Glucocorticoids a. Oral 138 betamethasone Celestone O O 138 budesonide Entocort EC O O 138 cortisone acetate Cortisone O O X 138 dexamethasone -- G G X 138 dexamethasone Decadron O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 138 hydrocortisone -- G G X 138 hydrocortisone Cortef O O 138 methylprednisolone -- G G 138 methylprednisolone Medrol O O 138 prednisolone -- G G X 138 prednisolone Prelone 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 138 triamcinolone Aristocort O O 139 VI. Endocrine/Metabolic G. Adrenal cortical steroids 2. Glucocorticoids b. Rectal 139 hydrocortisone Cortenema P O X 139 hydrocortisone Proctocort O O X 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 140 VI. Endocrine/Metabolic H. Adrenal steroid inhibitor 140 aminoglutethimide Cytadren P O X 141 VI. Endocrine/Metabolic I. Antidiabetic agents 1. Alpha-glucoside inhibitor 141 acarbose Precose P P X 141 miglitol Glyset P P X 141 nateglinide Starlix P O X 142 VI. Endocrine/Metabolic I. Antidiabetic agents 2. Meglitinides 142 repaglinide Prandin P O X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 143 VI. Endocrine/Metabolic I. Antidiabetic agents 3. Human Insulin 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 50/ 50 insulin Humulin 50/50 G G X 143 human 70/ 30 insulin Humulin 70/30 G G X 143 human lente insulin Humulin L G G X 143 human NPH insulin Humulin N G G X 143 human regular insulin Humulin R G G X 143 human ultralente insulin Humulin U Ultralente G G X 143 insulin glargine Lantus 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 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 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 insulin aspart Novolog G G X 143 human insulin Novolog mix G G X 143 human regular insulin Velosulin Human BR G G X 144 VI. Endocrine/Metabolic I. Antidiabetic agents 4. Sulfonylureas 144 acetohexamide -- G G X 144 acetohexamide Dymelor O O 144 chlorpropamide -- G G X 144 chlorpropamide Diabinese O O 144 glimepiride Amaryl O O 144 glipizide -- G G X 144 glipizide Glucotrol O O 144 glipizide, extended release -- G G X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 144 glipizide, extended release Glucotrol XL O O 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 Glucovance P O X 144 tolazamide -- G G X 144 tolazamide Tolinase O O 144 tolbutamide -- G G X 144 tolbutamide Orinase O O 145 VI. Endocrine/Metabolic I. Antidiabetic agents 5. Biguanides 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 146 VI. Endocrine/Metabolic I. Antidiabetic agents 6. Thiazolidinediones 146 pioglitazone Actos P O X 146 rosiglitazone Avandia P O X 146 rosiglitazone/ metformin Avandamet P O X 147 VI. Endocrine/Metabolic I. Antidiabetic agents 7. Other 147 insulin injector Novopen G G X 147 insulin needles Novofine G G X 147 insulin needles Novofine 30 G G X 147 SMBG test strips Fast Take test strips G G X 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 148 VI. Endocrine/Metabolic J. Glucose elevating agents 148 glucagon Glucagon Emergency Kit P O X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 149 VI. Endocrine/Metabolic K. Thyroid drugs 1. Thyroid hormones 149 levothyroxine sodium -- G G X 149 levothyroxine sodium Levothroid P O X 149 levothyroxine sodium Synthroid P O X 149 liothyronine sodium Cytomel P O X 149 liothyronine sodium/ levothyroxine Thyrolar P O X 149 thyroid, desiccated -- G G X 149 thyroid, desiccated Armour Thyroid P O 150 VI. Endocrine/Metabolic K. Thyroid drugs 2. Antithyroid agents 150 methimazole -- G G X 150 methimazole Tapazole O O 150 propylthiouracil -- G G X 151 VI. Endocrine/Metabolic L. Calcitonin-salmon 151 calcitonin-salmon, nasal Miacalcin O O 152 VI. Endocrine/Metabolic M. Bisphosphonates 152 alendronate Fosamax P O X 152 etidronate -- G G 152 etidronate Didronel O O 152 risedronate Actonel P O X 152 tiludronate Skelid O O

153 VI. Endocrine/Metabolic N. Agents for Gout 153 allopurinol -- G G X 153 allopurinol Zyloprim O O 153 colchicine 0.5mg -- O O 153 colchicine 0.6mg -- G G X 153 colchicine/ probenecid -- G G X 153 probenecid -- G G X 153 sulfinpyrazone -- G G 153 sulfinpyrazone Anturane O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 154 VI. Endocrine/Metabolic O. Other 154 cabergoline Dostinex P O X 155 VII. Gastrointestinals A. Antacids OTC considerations: aluminum hydroxide gel (Amphojel), calcium carbonate (Tums), 155 aluminum hydroxide/ magnesium -- X hydroxide 155 aluminum hydroxide/ magnesium -- X hydroxide/ simethicone 155 calcium carbonate -- X 155 magnesium hydroxide -- X 155 sodium bicarbonate -- X 156 VII. Gastrointestinals B. Sucralfate 156 sucralfate -- G G X 156 sucralfate Carafate O O 157 VII. Gastrointestinals C. Anticholinergics/antispasmodics 1. Belladonna alkaloids 157 atropine sulfate Sal-Tropine 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

157 clidinium bromide Quarzan O O 157 clidinium/ chlordiazepoxide -- G G 157 clidinium/ chlordiazepoxide Librax O O 157 l-alkaloids of belladonna/ phenobarbital/ -- G G ergotamine 157 l-alkaloids of belladonna/ phenobarbital/ Bellergal-S O O ergotamine 157 l-hyoscyamine sulfate -- G G 157 l-hyoscyamine sulfate Levsin O O 157 l-hyoscyamine sulfate, extended release Levbid O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 157 l-hyoscyamine sulfate, sublingual Levsin/SL O O 157 l-hyoscyamine sulfate, timed release Levsinex Timecaps O O 157 methscopolamine bromide Pamine O O 158 VII. Gastrointestinals C. Anticholinergics/antispasmodics 2. Anticholinergics 158 glycopyrrolate Robinul O O 158 glycopyrrolate Robinul Forte O O

158 mepenzolate bromide Cantil O O 158 methantheline bromide Banthine O O 158 propantheline bromide -- G G 158 propantheline bromide Pro-Banthine O O 159 VII. Gastrointestinals C. Anticholinergics/antispasmodics 3. Anti-spasmodics 159 dicyclomine -- G G X 159 dicyclomine, syrup Bentyl Syrup P O X 159 dicyclomine, tablets and capsules Bentyl O O 160 VII. Gastrointestinals D. Combination Helicobacter Pylori agents 160 bismuth subsalicylate/ metronidazole/ Helidac P O X tetracycline 160 lansoprazole/ amoxicillin/ Prevpac P O X clarithromycin 161 VII. Gastrointestinals E. Histamine (H2) antagonists OTC considerations: cimetidine (Tagamet HB), ranitidine (Zantac 75), 161 famotidine -- G G 161 famotidine Pepcid O O 161 ranitidine -- G G X 161 ranitidine, tablets and capsules Zantac O O 161 ranitidine syrup Zantac Syrup P O X 161 cimetidine -- G G X 161 cimetidine Tagamet O O 161 nizatidine -- G G 161 nizatidine Axid O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 162 VII. Gastrointestinals F. Prostaglandins 162 diclofenac/ misoprostol Arthrotec O O 162 misoprostol -- G G X 162 misoprostol Cytotec O O 163 VII. Gastrointestinals G. Proton pump inhibitors 163 lansoprazole Prevacid O O 163 lansoprazole Prevacid Granules O O 163 omeprazole -- G G 163 omeprazole Prilosec O O 163 pantoprazole Protonix P P X 15 163 rabeprazole sodium Aciphex P P X 15 164 VII. Gastrointestinals H. Antiflatulents OTC consideration: simethicone 164 simethicone -- X

165 VII. Gastrointestinals I. GI stimulants 165 metoclopramide -- G G X 165 metoclopramide Reglan O O 166 VII. Gastrointestinals J. Digestive enzymes 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 167 VII. Gastrointestinals K. Gallstone solubilizing agents 167 ursodiol -- G G X 167 ursodiol Actigall O O 168 VII. Gastrointestinals L. Laxatives OTC considerations: magnesium hydroxide (Milk of Magnesia), magnesium citrate, 168 bisacodyl -- X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - 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. 168 docusate sodium -- X 168 docusate sodium/ casanthranol -- X 168 glycerin -- X

168 magnesium citrate -- X 168 magnesium hydroxide -- X 168 psyllium -- X 168 senna -- X 168 sodium phosphate, enema -- X 168 Sodium phosphate, oral solution Fleets Phospho - Soda X 168 lactulose -- G G X 168 lactulose Cephulac O O 168 lactulose Chronulac O O 168 polyethylene glycol-electrolyte solution -- G G X

168 polyethylene glycol-electrolyte solution CoLyte O O

168 polyethylene glycol-electrolyte solution GoLYTELY O O

169 VII. Gastrointestinals M. Antidiarrheals OTC consideraitons: loperamide (Imodium AD), bismuth subsalicylate (Pepto-Bismol), 169 attapulgite -- X 169 bismuth subsalicylate -- X 169 diphenoxylate/ atropine sulfate -- G G 169 diphenoxylate/ atropine sulfate Lomotil O O 169 kaolin/ pectin -- X 169 loperamide -- G G X 169 loperamide Imodium O O 169 paregoric -- G G 170 VII. Gastrointestinals N. Mouth and throat products 1. Antimicrobial 170 chlorhexidine gluconate -- G G X 170 chlorhexidine gluconate Peridex O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 49 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. 170 clotrimazole Mycelex Troches P O X 170 doxycycline hyclate Periostat O O 170 nystatin -- G G X 170 nystatin Mycostatin O O 171 VII. Gastrointestinal N. Mouth and throat products 2. Saliva substitutes 171 pilocarpine, oral Salagen O O 172 X. Gastrointestinal N. Mouth and throat products 3. Other 172 amlexanox Aphthasol O O 172 lidocaine, viscous -- G G X 172 lidocaine, viscous Xylocaine O O 172 triamcinolone paste -- G G X 172 triamcinolone paste Kenalog in Orabase O O 173 VII. Gastrointestinals O. Other 173 activated charcoal -- X 173 ipecac syrup -- X 173 mesalamine, controlled release Pentasa O O 173 mesalamine, delayed release Asacol P O X 173 mesalamine, rectal Rowasa P O X 173 olsalazine sodium Dipentum 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 174 VIII. Nutritionals A. Vitamins 1. Vitamin B 174 thiamine -- X 27 X 27 174 cyanocobalamin, nasal Nascobal P 11 O 11 X 11 174 vitamin B complex -- X 27 X 27 175 VIII. Nutritionals A. Vitamins 2. Vitamin D 175 calcitriol -- G G X 175 calcitriol Rocaltrol O O 176 VIII. Nutritionals A. Vitamins 3. Vitamin K HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 50 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. 176 phytonadione Mephyton P O X 177 VIII. Nutritionals A. Vitamins 4. Multivitamins 177 multivitamins -- X 6 177 multivitamins/ minerals -- G 7 G 7 X 6 177 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

177 vitamin B complex/ vit C/ vit E/ folate Renal Tabs P 12 O 12 X 12

178 VIII. Nutritionals B. Minerals and electrolytes 1. Calcium-removing resins 178 cellulose sodium phosphate Calcibind P O X 179 VIII. Nutritionals B. Minerals and electrolytes 2. Fluoride 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, Tri-Vi-Flor O 2 O 2 prescription 179 sodium fluoride -- G G X 5 179 sodium fluoride Luride O O 179 sodium fluoride Prevident O O 180 VIII. Nutritionals B. Minerals and electrolytes 3. Chelating Agents 180 succimer Chemet P O X 181 VIII. Nutritionals B. Minerals and electrolytes 4. Iron preparations OTC considerations: ferrous sulfate, ferrous 181 trientine Syprine O 2 O 2 181 ferrous sulfate -- X 181 iron/ multivit/ mineral, prescription -- G 2 G 2 181 iron/ multivit/ mineral, prescription Berocca Plus O 2 O 2 HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 51 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. 181 iron/ vit c/ vit b12/ intrinsic factor/ Trinsicon O 2 O 2 folate 182 VIII. Nutritionals B. Minerals and electrolytes 5. Phosphorus-reducing agents OTC consideration: calcium carbonate 182 calcium acetate Phoslo P 12 O 12 X 12 182 calcium carbonate -- X 182 sevelamer Renagel P O X 183 VIII. Nutritionals B. Minerals and electrolytes 6. Potassium replacement 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/ -- G G citrate 183 potassium chloride/ potassium bicarb/ K Lyte Cl O O citrate 183 potassium gluconate -- G G 183 potassium gluconate Kaon O O 184 VIII. Nutritionals B. Minerals and electrolytes 7. Potassium-removing resin 184 sodium polystyrene sulfonate -- G G X 184 sodium polystyrene sulfonate Kayexalate O O 185 VIII. Nutritionals C. Systemic alkalinizers OTC consideration: sodium bicarbonate 185 potassium citrate/ citric acid Polycitra K P O X 185 potassium citrate/ sodium citrate/ citric Polycitra P O X 185 potassium citrate/ sodium citrate/ citric Polycitra LC O O acid 185 sodium bicarbonate -- X 185 sodium citrate/ citric acid Bicitra P O X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 52 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. 185 sodium citrate/ citric acid Oracit O O 186 VIII. Nutritionals D. Levocarnitine 186 levocarnitine Carnitor P 13 O 13 X 13 187 VIII. Nutritionals E. Electrolyte replacement 187 pediatric electrolyte replacement -- X solution 188 IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics a. Oral 188 albuterol -- G G X 188 albuterol Proventil O O 188 albuterol Ventolin O O 188 albuterol, extended release -- G G X 188 albuterol, extended release Volmax O O 188 metaproterenol sulfate -- G G X 188 metaproterenol sulfate Alupent O O 188 terbutaline sulfate Brethine P O X 188 terbutaline sulfate Bricanyl O O X 189 IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics b. Inhalation-short-acting 189 albuterol -- G G X 189 albuterol Proventil O O 189 albuterol Proventil HFA O O 189 albuterol Ventolin O O 189 albuterol Ventolin HFA O O 189 albuterol/ ipratropium Combivent P O X 189 bitolterol mesylate Tornalate O O 189 isoetharine -- O O 189 isoproterenol Isuprel O O 189 levalbuterol Xopenex O O 189 metaproterenol sulfate, inhalation -- G G X 189 metaproterenol sulfate, inhalation Alupent O O 189 metaproterenol sulfate, metered dose Alupent MDI P O X inhaler HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 53 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. 189 pirbuterol acetate Maxair P O X 189 pirbuterol acetate Maxair Auto P O X 189 terbutaline sulfate Brethaire P O X 190 IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics c. Inhalation-long-acting 190 formoterol Foradil OO 190 salmeterol/ fluticasone Advair P O X 190 salmeterol Serevent P O X 191 IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics d. Injection 191 epinephrine, injectable Epi-pen P O X 191 epinephrine, injectable Epi-pen JR P O X 191 epinephrine/ chlorpheniramine Anakit P O X 192 IX. Respiratory Drugs A. Bronchodilators 2. Anticholinergics 192 albuterol/ ipratropium Combivent P O X 192 ipratropium, inhalation -- G G X 192 ipratropium, inhalation Atrovent O O 192 ipratropium, inhalation Atrovent MDI P O X 193 IX. Respiratory Drugs B. Xanthine derivatives 193 aminophylline -- G G 193 oxtriphylline Choledyl 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 HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 54 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 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 193 theophylline, timed release tablets Unidur O O 193 theophylline, timed release tablets Uniphyl O O 193 theophylline/ ephedrine/ hydroxyzine Marax O O hcl 194 IX. Respiratory Drugs C. Leukotriene receptor antagonists 194 montelukast sodium Singulair P 30 O X 30 194 zafirlukast Accolate P 30 O X 30 194 zileuton Zyflo P 30 O X 30 195 IX. Respiratory Drugs D. Anti-inflammatory agents 1. Corticosteroids 195 beclomethasone, inhaler QVAR OO 195 budesonide, inhaler Pulmicort P O X 195 budesonide, respules Pulmicort respules P P X 195 flunisolide, inhaler Aerobid P P X 195 flunisolide, inhaler Aerobid M P P X 195 fluticasone, inhaler Flovent P O X 195 triamcinolone, inhaler Azmacort O O 195 salmeterol/ fluticasone Advair P O X 196 IX. Respiratory Drugs D. Anti-inflammatory agents 2. Non-steroidal 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

196 nedocromil, inhaler Tilade O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 55 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. 197 IX. Respiratory Drugs E. Devices 197 peak flow meter Air Zone P 3 P 3 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 198 IX. Respiratory Drugs F. Other inhalation drugs 198 acetylcysteine -- G G X 198 acetylcysteine Mucomyst O O 198 dornase alfa Pulmozyme O O 198 pentamidine, inhalation Nebupent P O X 198 sodium chloride, inhalation -- G G X 198 tobramycin, inhalation TOBI P O X 199 IX. Respiratory Drugs G. Decongestants 1. Oral OTC considerations: pseudoephedrine (Sudafed) 199 pseudoephedrine -- X 199 phenylephrine AH-Chew D G G X 200 IX. Respiratory Drugs G. Decongestants 2. Intranasol OTC considerations: phenylephrine hcl (Neo-Synephrine), 200 phenylephrine -- X 200 oxymetazoline -- X

201 IX. Respiratory Drugs H. Intranasal anticholinergic agents 201 ipratropium, nasal -- G G X 201 ipratropium, nasal Atrovent O O 202 IX. Respiratory Drugs I. Intranasal anti-inflammatory agents 1. Corticosteroids

202 beclomethasone Beconase AQ O O 202 budesonide Rhinocort AQ P O X 202 flunisolide, nasal -- P O X 202 fluticasone Flonase P O X 202 mometasone Nasonex P O X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 56 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. 202 triamcinolone Nasacort P O X 202 triamcinolone Nasacort AQ P O X 203 IX. Respiratory Drugs I. Intranasal anti-inflammatory agents 2. Non-steroidal OTC consideration: cromolyn sodium (Nasalcrom) 203 cromolyn sodium Nasalcrom X 204 IX. Respiratory Drugs J. Intranasal antihistamine 204 azelastine Astelin P O X 205 IX. Respiratory Drugs K. Antihistamines 1. Non-Sedating/Low-Sedating Antihistamines OTC consideration: loratadine 205 cetirizine, syrup Zyrtec syrup P P X 205 cetirizine, tablets Zyrtec tablet O O 205 cetirizine/ pseudoephedrine Zyrtec D O O 205 desloratadine Clarinex O O 205 fexofenadine Allegra P P X 205 fexofenadine/ pseudoephedrine Allegra D P P X 205 loratadine -- X 206 IX. Respiratory Drugs K. Antihistamines 2. Sedating Antihistamines OTC considerations: diphenhydramine (Benadryl), 206 azatadine Optimine O O 206 chlorpheniramine -- X 206 clemastine -- G G X 206 clemastine Tavist O O 206 cyproheptadine -- G G X 206 cyproheptadine Periactin O O 206 dexchlorpheniramine Polaramine O O

206 diphenhydramine -- G G X X 206 diphenhydramine Benadryl O O 206 hydroxyzine hcl -- G G X X 206 hydroxyzine hcl Atarax O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 57 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. 206 hydroxyzine pamoate, capsules -- G G X X 206 hydroxyzine pamoate, capsules Vistaril O O 206 hydroxyzine pamoate, suspension Vistaril suspension P O X X 206 promethazine -- G G X 206 promethazine Phenergan O O 206 tripelennamine -- G G 206 tripelennamine PBZ O O

207 IX. Respiratory Drugs L. Decongestant and antihistamine combinations 1. Adult formulations-solid dosage forms OTC 207 phenylephrine/ chlorpheniramine/ -- G G methscopolamine 207 phenylephrine/ chlorpheniramine/ Dura-Vent/DA O O 207 phenylephrine/ chlorpheniramine/ OMNIhist LA G G methscopolamine 207 phenylephrine/ chlorpheniramine/ -- G G X pyrilamine, tablets 207 phenylephrine/ chlorpheniramine/ Rynatan O O pyrilamine, tablets 207 pseudoephedrine/ azatadine Trinalin O O 207 pseudoephedrine/ brompheniramine -- G G

207 pseudoephedrine/ brompheniramine Bromfed O O 207 pseudoephedrine/ brompheniramine Ultrabrom G G 207 pseudoephedrine/ chlorpheniramine Deconamine SR O O 208 IX. Respiratory Drugs L. Decongestant and antihistamine combinations 2. Adult formulations-liquid dosage forms OTC 208 phenylephrine/ promethazine -- G G X 208 phenylephrine/ promethazine Phenergan VC O O 208 pseudoephedrine/ carbinoxamine -- G G X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 58 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. 208 pseudoephedrine/ carbinoxamine Rondec O O 208 pseudoephedrine/ chlorpheniramine Dura-Tap/PD O O 208 pseudoephedrine/ chlorpheniramine -- X (generic Chlor-Trimeton Allergy D) 208 pseudoephedrine/ triprolidine (generic -- X Actifed) 209 IX. Respiratory Drugs L. Decongestant and antihistamine combinations 3. Pediatric formulations OTC considerations: 209 phenylephrine/ chlorpheniramine/ -- G G X methscopolamine 209 phenylephrine/ chlorpheniramine/ AH-chew G G X methscopolamine 209 phenylephrine/ chlorpheniramine/ D.A chew O O methscopolamine 209 phenylephrine/ chlorpheniramine/ -- G G X pyrilamine, suspension 209 phenylephrine/ chlorpheniramine/ Rynatan Pediatric OO pyrilamine, suspension Suspension 209 pseudoephedrine/ brompheniramine Ultrabrom PD G G 209 pseudoephedrine/ brompheniramine, -- X capsules (generic Bromfed)

209 pseudoephedrine/ brompheniramine, -- X liquid (generic Dimetapp)

210 IX. Respiratory Drugs M. Narcotic antitussives and combinations 1. Adult formulations 210 codeine/ phenylephrine/ promethazine -- O O

210 codeine/ phenylephrine/ promethazine Phenergan VC w/codeine O O 210 codeine/ promethazine -- G G X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 59 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. 210 codeine/ promethazine Phenergan w/codeine O O 210 codeine/ pseudoephedrine Nucofed O O 210 codeine/ pseudoephedrine/ -- G G X 210 hydrocodone/ chlorpheniramine Tussionex O O 210 hydrocodone/ homatropine -- G G 210 hydrocodone/ homatropine Hycodan O O 210 hydrocodone/ pseudoephedrine -- G G 211 IX. Respiratory Drugs M. Narcotic antitussives and combinations 2. Pediatric formulations 211 codeine/ pseudoephedrine/ -- G G X chlorpheniramine 211 hydrocodone/ homatropine -- G G

211 hydrocodone/ homatopine Hycodan O O 212 IX. Respiratory Drugs N. Non-narcotic antitussives and combinations 1. Adult Formulations OTC considerations: 212 benzonatate -- G G X 212 benzonatate Tessalon Perles O O 212 dextromethorphan/ guaifenesin/ Sinutuss DM G G phenylephrine 212 dextromethorphan/ promethazine -- G G X 212 dextromethorphan/ promethazine Phenergan DM O O 212 dextromethorphan/ pseudoephedrine/ -- G G X 212 dextromethorphan/ pseudoephedrine/ Dimetane DX O O brompheniramine 212 dextromethorphan/ pseudoephedrine/ -- G G X carbinoxamine 212 dextromethorphan/ pseudoephedrine/ Rondec DM O O brompheniramine 213 IX. Respiratory Drugs N. Non-narcotic antitussives and combinations 2. Pediatric formulations OTC considerations: HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 60 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. 213 dextromethorphan/ pseudoephedrine/ Cardec DM Drops G G carbinoxamine 213 dextromethorphan/ pseudoephedrine/ Cardec DM Pediatric G G carbinoxamine 213 dextromethorphan/ pseudoephedrine/ Rondec DM Drops O O carbinoxamine 213 dextromethorphan/ pseudoephedrine/ Rondec DM syrup O O brompheniramine 214 IX. Respiratory Drugs O. Expectorants 1. Adult formulations-solid dosage forms 214 guaifenesin Duratuss GO O 214 guaifenesin Organidin NRO O

214 guaifenesin (generic Robitussin) -- X 214 guaifenesin, sustained release -- G G 214 guaifenesin, sustained release Humibid LA O O 214 guaifenesin/ dextromethorphan (generic -- X Robitussin DM) 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 214 potassium iodide Pima O O 214 potassium iodide SSKI O O 215 IX. Respiratory Drugs O. Expectorants 2. Adult formulations-liquid dosage forms OTC considerations: guaifenesin 215 guaifenesin/ codeine -- G G X 215 guaifenesin/ codeine Robitussin AC O O 215 guaifenesin/ hydrocodone -- G G 215 guaifenesin/ hydrocodone Vicodin Tuss O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 61 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. 215 guaifenesin/ pseudoephedrine/ codeine -- G G X

215 guaifenesin/ pseudoephedrine/ codeine Nucofed Expectorant O O

216 IX. Respiratory Drugs O. Expectorants 3. Pediatric formulations OTC consideration: guaifenesin/pseudoephedrine (Thera- 216 guaifenesin/ pseudoephedrine/ codeine -- G G

216 guaifenesin/ pseudoephedrine/ codeine Nucofed Pediatric OO Expectorant 217 X. Ophthalmics A. Agents for glaucoma 1. Alpha-2 adrenergic agonist 217 brimonidine, 0.15% Alphagan P P O X 217 brimonidine, 0.2% -- G G X 218 X. Ophthalmics A. Agents for glaucoma 2. Sympathomimetics 218 dipivefrin -- G G X 218 dipivefrin Propine O O 218 dipivefrin AKPro O O 218 epinephrine Epifrin P O X 218 epinephrine/ pilocarpine E-Pilo P O X 218 epinephryl borate Epinal P O X 219 X. Ophthalmics A. Agents for glaucoma 3. Beta-adrenergic blocking agents 219 betaxolol Betoptic O O 219 betaxolol Betoptic S O O 219 carteolol -- G G 219 carteolol Ocupress O O 219 levobunolol -- G G X 219 levobunolol Betagan O O 219 metipranolol -- G G 219 metipranolol OptiPranolol O O 219 timolol XE -- G G X 219 timolol XE Timoptic XE O O 219 timolol -- G G X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 62 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 219 timolol Timoptic O O 219 timolol/ dorzolamide Cosopt P O X 220 X. Ophthalmics A. Agents for glaucoma 4. Miotics, direct-acting 220 carbachol Carbastat O O 220 carbachol Isopto CarbacholP O X 220 pilocarpine/ epinephrine E-Pilo 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 220 pilocarpine ocular therapeutic system Ocusert Pilo O O

221 X. Ophthalmics A. Agents for glaucoma 5. Miotics, cholinesterase inhibitors 221 echothiophate iodide Phospholine Iodide P O X 221 physostigmine Eserine sulfateO O 222 X. Ophthalmics A. Agents for glaucoma 6. Carbonic anhydrase inhibitors 222 brinzolamide Azopt O O 222 dorzolamide Trusopt P O X 222 dorzolamide/ timolol Cosopt P O X 223 X. Ophthalmics A. Agents for glaucoma 7. Prostaglandin agonist 223 bimatoprost Lumigan P O X 223 latanoprost Xalatan P O X 223 travoprost Travatan O O 223 unoprostone Rescula O O 224 X. Ophthalmics B. Vasoconstrictors/mydriatics OTC considerations: tetrahydrozoline hcl (Generic, Collyrium Fresh, Visine), 224 naphazoline -- G G X 224 naphazoline Albalon O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 63 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. 224 naphazoline Vasocon O O 224 phenylephrine -- G G X 224 phenylephrine Neo-Synephrine O O

225 X. Ophthalmics C. Anti-allergy agents 225 azelastine Optivar O O 225 cromolyn -- G G X 225 cromolyn Opticrom O O 225 cromolyn Crolom O O 225 emedastine Emadine O O 225 ketotifen Zaditor P P X 225 levocabastine Livostin O O 225 lodoxamide Alomide O O 225 nedocromil Alocril P O X 225 olopatadine Patanol O O 225 permivolast Alamast O O 226 X. Ophthalmics D. Decongestant/antihistamine combinations OTC considerations: naphazoline/pheniramine (generic, Naphcon- 226 naphazoline/ antazoline Vasocon-A O O 227 X. Ophthalmics E. Cycloplegic mydriatics 227 atropine -- G G X 227 atropine Isopto Atropine O O 227 homatropine HBr Isopto Homatropine P O X 227 scopolamine HBr Isopto Hyoscine P O X 228 X. Ophthalmics F. Nonsteroidal Anti-inflammatory Agents (NSAIDS) 228 diclofenac sodium, ophthalmic Voltaren P O X 228 flurbiprofen sodium, ophthalmic -- G G 228 flurbiprofen sodium, ophthalmic Ocufen O O 228 ketorolac tromethamine, ophthalmic Acular P O X

228 ketorolac tromethamine, ophthalmic Acular PF P O X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 64 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 X. Ophthalmics G. Corticosteroids 229 dexamethasone sodium phosphate, -- G G X ophthalmic 229 dexamethasone sodium phosphate, Decadron O O ophthalmic 229 prednisolone acetate, ophthalmic -- G G X 229 prednisolone acetate, ophthalmic Econopred O O 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 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 229 loteprednol etabonate Alrex O O 229 loteprednol etabonate Lotemax P P X 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 229 rimexolone Vexol O O 230 X. Ophthalmics H. Antibiotics 1. Single agent 230 bacitracin -- G G X X X 230 bacitracin AK-Tracin O O 230 chloramphenicol, ophthalmic -- G G X X X 230 chloramphenicol, ophthalmic Chloroptic O O 230 ciprofloxacin, ointment Ciloxan Ointment P P X 230 ciprofloxacin, solution Ciloxan Solution O O 230 erythromycin -- G G X X X 230 erythromycin Ilotycin O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 65 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. 230 gentamicin -- G G X 230 gentamicin Garamycin O O 230 levofloxacin Quixin O O 230 norfloxacin Chibroxin O O 230 ofloxacin Ocuflox P O X 230 tobramycin, solution -- G G X 230 tobramycin, solution Tobrex solution O O 230 tobramycin, ointment Tobrex ointment P O X 231 X. Ophthalmics H. Antibiotics 2. Combination antibiotic products 231 bacitracin/ neomycin/ polymyxin B, -- G G X X X ointment 231 bacitracin/ neomycin/ polymyxin B, Neosporin ointment O O ointment 231 bacitracin/ polymyxin B, ointment -- G G X 231 bacitracin/ polymyxin B, ointment Polysporin O O 231 gramicidin/ neomycin/ polymyxin B, -- G G X X X solution 231 gramicidin/ neomycin/ polymyxin B, Neosporin solution O O solution 231 trimethoprim/ polymyxin B -- G G X 231 trimethoprim/ polymyxin B Polytrim O O 232 X. Ophthalmics H. Antibiotics 3. Steroid and antibiotic combinations 232 bacitracin/ neomycin/ polymyxin B/ -- G G X X X hydrocortisone, ointment 232 bacitracin/ neomycin/ polymyxin B/ Cortisporin O O 232 moxifloxacin Vigamox O O 232 neomycin/ dexamethasone, solution -- G G X X 232 neomycin/ dexamethasone, solution NeoDecadron solution O O 232 neomycin/ dexamethasone, ointment NeoDecadron ointment O O

232 neomycin/ polymyxin B/ -- G G X dexamethasone HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 66 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. 232 neomycin/ polymyxin B/ Maxitrol O O dexamethasone 232 neomycin/ polymyxin B/ -- G G X X X hydrocortisone, suspension 232 neomycin/ polymyxin B/ Cortisporin O O hydrocortisone, suspension 232 tobramycin/ dexamethasone TobraDex P O X 233 X. Ophthalmics I. Sulfonamides 233 sulfacetamide -- G G X X X 233 sulfacetamide Sodium Sulamyd O O 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 -- G G X phosphate 233 sulfacetamide/ prednisolone sodium Vasocidin O O phosphate 233 sulfisoxazole diolamine, ophthalmic Gantrisin O O 234 X. Ophthalmics J. Antifungal agent 234 natamycin Natacyn O O 235 X. Ophthalmics K. Antiviral agent 235 idoxuridine Herplex P O X 235 trifluridine Viroptic P O X 235 vidarabine Vira-A P O X 236 X. Ophthalmics L. Ocular lubricants OTC consideration: artificial tears 236 artificial tears -- X 236 hydroxypropyl cellulose Lacrisert O O 236 ocular lubricants -- X 237 X. Ophthalmics M. Hyperosmolar preparations OTC considerations: sodium chloride, hypertonic (Muro 128) HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 67 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. 237 sodium chloride, hypertonic Muro 128 X

238 XI. Otic preparations A. Antibiotics 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 238 chloramphenicol, otic Chloromycetin Otic O O 238 ciprofloxacin hcl/ dexamethasone, otic Ciprodex O O

238 ciprofloxacin/ hydrocortisone, otic Cipro HC Otic O O

238 neomycin/ colistin/ hydrocortisone, otic Cortisporin TC Otic O O

238 neomycin/ hydrocortisone, otic Coly-Mycin S Otic O O 238 neomycin/ polymyxin B/ -- G G X X X hydrocortisone, otic 238 neomycin/ polymyxin B/ Cortisporin Otic O O 238 ofloxacin, otic Floxin Otic P P X 238 polymyxin B/ hydrocortisone, otic Otobiotic P O X 239 XI. Otic preparations B. Other OTC considerations: boric acid/isopropyl alcohol (Ear-Dry), glycerin/isopropyl alcohol (Swim- 239 acetic acid in aluminum acetate -- G G X 239 acetic acid in aluminum acetate Domeboro Otic O O 239 antipyrine/ benzocaine -- G G X 239 antipyrine/ benzocaine Auralgan O O 239 benzethonium chloride/ glycerin/ Americaine O O benzocaine 239 carbamide peroxide -- X 239 triethanolamine Cerumenex O O 240 XII. Dermatological Agents A. Acne products 1. Topical OTC considerations: benzoyl peroxide, sulfur, salicylic acid Note: 240 adapalene Differin P 10 O 10 X 10 HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 68 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 aluminum chloride hexahydrate Xerac AC O O 240 azelaic acid Azelex 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 240 clindamycin phosphate, topical -- G G X 240 clindamycin phosphate, topical Cleocin T O O 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 240 erythromycin/ benzoyl peroxide -- G G 240 erythromycin/ benzoyl peroxide Benzamycin O O 240 meclocycline sulfosalicylate Meclan O O 240 metronidazole, topical MetroCream P O X 240 metronidazole, topical MetroGel P O X 240 metronidazole, topical MetroLotion P O X 240 metronidazole, topical Noritate O O 240 salicylic acid -- X 240 sulfacetamide sodium Klaron O O 240 sulfur/ sulfacetamide Novacet O O 240 sulfur/ sulfacetamide Sulfacet-R O O 240 tazarotene Tazorac O O 240 tetracycline Topicycline 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 10 241 XII. Dermatological Agents A. Acne products 2. Systemic 241 clindamycin -- G G X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 69 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. 241 clindamycin Cleocin O O 241 doxycycline hyclate -- G G X X X 241 doxycycline hyclate Doryx O O 241 doxycycline hyclate Vibramycin O O 241 doxycycline monohydrate -- G G 241 doxycycline monohydrate Monodox 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 241 isotretinoin -- G G 241 isotretinoin Accutane O O 241 minocycline hcl -- G G X 241 minocycline hcl Minocin O O 241 sulfamethoxazole/ trimethoprim -- G G X X X 241 sulfamethoxazole/ trimethoprim Bactrim O O 241 sulfamethoxazole/ trimethoprim Septra O O 241 tetracycline -- G G X X X 242 XII. Dermatological Agents B. Antipsoriatics 1. Topical 242 ammoniated mercury Emersal 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

242 calcipotriene Dovonex P O X 242 tazarotene Tazorac O O 243 XII. Dermatological Agents B. Antipsoriatics 2. Systemic 243 acitretin Soriatane P O X 243 methotrexate -- G G X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 70 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. 243 methotrexate Rheumatrex O O 243 methoxasalen Oxsoralen-Ultra P O X 244 XII. Dermatological Agents C. Burn preparations 244 mafenide Sulfamylon O O

244 nitrofurazone Furacin O O 244 silver sulfadiazine -- G G X 244 silver sulfadiazine Silvadene O O 245 XII. Dermatological Agents D. Diaper rash products OTC consideration: zinc oxide (Desitin) 245 methionine Pedameth O O 246 XII. Dermatological Agents E. Antiseborrheic products OTC considerations: selenium sulfide (Selsun Blue), coal tar (Neutrogena T/Gel, Pentrax), pyrithione zinc (Head & Shoulders, Sebulon), povidone-iodine (Betadine shampoo), sulfur-salicylic acid 246 chloroxine Capitrol O O 246 coal tar -- X 246 ketoconazole, cream -- G G X 246 ketoconazole, cream Nizoral O O X 246 salicylic acid -- X 246 selenium sulfide -- G G X 246 selenium sulfide Selsun O O 246 sulfacetamide sodium, shampoo Sebizon O O 247 XII. Dermatological Agents F. Topical antihistamines OTC considerations: diphenhydramine (Benadryl), 247 diphenhydramine, topical -- X 247 doxepin Zonalon O O 248 XII. Dermatological Agents G. Topical anti-infectives 1. Antiviral agents 248 acyclovir ointment Zovirax P O X 248 penciclovir Denavir O O 249 XII. Dermatological Agents G. Topical anti-infectives 2. Antibiotics OTC considerations: bacitracin, bacitracin/polymyxin B 249 bacitracin -- X 249 bacitracin/ polymyxin B -- X 249 bacitracin/ polymyxin B/ neomycin -- X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 71 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. 249 clindamycin phosphate, topical -- G G X

249 clindamycin phosphate, topical Cleocin T O O 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 249 gentamicin sulfate, topical -- G G X 249 gentamicin sulfate, topical Garamycin O O 249 metronidazole, topical MetroCream P O X 249 metronidazole, topical MetroGel P O X 249 metronidazole, topical MetroLotion P O X 249 metronidazole, topical Noritate O O 249 mupirocin Bactroban O O 249 neomycin/ poly+D2035myxin B/ Cortisporin Cream P O X hydrocortiso+D2042ne, topical 250 XII. Dermatological Agents G. Topical anti-infectives 3. Antifungal OTC considerations: miconazole (Micatin), clotrimazole 250 butenafine Mentax O O

250 ciclopirox Loprox P O X 250 clotrimazole -- X 250 econazole -- G G X 250 econazole Spectazole O O 250 ketoconazole, cream -- G G X 250 ketoconazole, cream Nizoral O O X 250 ketoconazole, shampoo Nizoral P O X 250 miconazole -- X 250 naftifine Naftin O O 250 nystatin -- G G X 250 nystatin Mycostatin O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 72 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 nystatin/ triamcinolone -- G G X 250 oxiconazole Oxistat O O 250 sulconazole Exelderm O O 251 XII. Dermatological Agents H. Scabicides/pediculicides OTC considerations: permethrin (Nix), pyrethrins, piperonyl butoxide 251 crotamiton Eurax O O 251 lindane -- G G X 251 malathion Ovide O O 251 permethrin -- G G X 251 permethrin Elimite O O 252 XII. Dermatological Agents I. Corticosteroids, topical 1. Very high potency 252 augmented betamethasone dipropionate -- G G 0.05%, ointment/gel 252 augmented betamethasone dipropionate Diprolene O O 0.05%, ointment/gel 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 252 diflorasone 0.05%, ointment Psorcon B O O 252 halobetasol propionate 0.05%, cream/ Ultravate P O X ointment 253 XII. Dermatological Agents I. Corticosteroids, topical 2. High potency 253 amcinonide -- G G 253 amcinonide Cyclocort O O 253 augmented betamethasone dipropionate Diprolene AF O O 0.05%, cream 253 betamethasone dipropionate 0.05%, -- G G cream/ ointment 253 betamethasone dipropionate 0.05%, Diprosone O O cream/ ointment HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 73 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. 253 betamethasone dipropionate 0.05%, Maxivate O O cream/ ointment 253 betamethasone valerate 0.1%, ointment -- G G X

253 betamethasone valerate 0.1%, ointment Valisone 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

253 diflorasone 0.05% cream/ ointment -- G G 253 diflorasone 0.05%, cream/ ointment Florone O O 253 diflorasone 0.05%, cream/ ointment Maxiflor O O 253 diflorasone 0.05%, cream Psorcon 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 253 halcinonide 0.1%, cream/ ointment Halog O O 253 halcinonide 0.1%, cream/ ointment Halog E O O 253 triamcinolone acetonide 0.5%, cream/ -- G G X ointment 253 triamcinolone acetonide 0.5%, cream/ Kenalog O O ointment 254 XII. Dermatological Agents I. Corticosteroids, topical 3. Medium potency 254 betamethasone dipropionate 0.05%, -- GG lotion 254 betamethasone dipropionate 0.05%, Diprosone O O lotion HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 74 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. 254 betamethasone dipropionate 0.05%, Maxivate O O lotion 254 betamethasone valerate 0.1%, cream/ -- G G X lotion 254 betamethasone valerate 0.1%, cream/ Valisone O O lotion 254 clocortolone pivalate 0.1%, cream Cloderm O O 254 desoximetasone 0.05%, cream -- G G 254 desoximetasone 0.05%, cream Topicort LP O O 254 fluocinolone acetonide 0.025%, cream/ -- G G X ointment 254 fluocinolone acetonide 0.025%, cream/ Synalar O O ointment 254 flurandrenolide Cordran P O X 254 flurandrenolide Cordran SP P O X 254 flurandrenolide 4mcg/ cm2, tape Cordran tape P O X 254 fluticasone propionate 0.05%, cream/ Cutivate O O ointment 254 hydrocortisone butyrate 0.1% Locoid O O 254 hydrocortisone valerate 0.2%, cream/ -- G G X ointment 254 hydrocortisone valerate 0.2%, cream/ Westcort O O ointment 254 mometasone furoate 0.1% Elocon O O 254 triamcinolone acetonide, aerosol Kenalog aerosol 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 255 XII. Dermatological Agents I. Corticosteroids, topical 4. Low potency OTC considerations: hydrocortisone cream, ointment HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 75 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. 255 aclometasone dipropionate 0.05%, Aclovate O O cream/ ointment 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 255 dexamethasone 0.04%, aerosol Decaspray O O 255 dexamethasone sodium phosphate 0.1%, Decadron O O cream 255 fluocinolone acetonide 0.01% -- G G X 255 fluocinolone acetonide 0.01% Synalar O O 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 256 XII. Dermatological Agents J. Local anesthetics, topical 1. Topical anesthetics for skin disorders OTC considerations: 256 lidocaine -- G G X 256 lidocaine Xylocaine O O 256 lidocaine/ prilocaine EMLA O O 257 XII. Dermatological Agents J. Local anesthetics, topical 2. Topical anesthetics for mucous membranes OTC consideration: 257 lidocaine, viscous -- G G X 257 lidocaine, viscous Xylocaine Viscous O O 258 XII. Dermatological Agents K . Keratolytics OTC considerations: salicylic acid (Occlusal HP, Compound W, Duofilm) HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 76 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. 258 salicylic acid -- X 259 XII. Dermatological Agents L. Topical enzyme preparations 259 collagenase Santyl O O 259 fibrinolysin/ desoxyribonuclease Elase O O 259 sutilains Travase O O 260 XII. Dermatological Agents M. Emollients OTC considerations: lactic acid (Lac-Hydrin, Amlactin), urea (Carmol 20, 260 aluminum acetate -- X 261 XII. Dermatological Agents N. Other 261 alitretinoin Panretin O O 261 aluminum chloride hexahydrate Drysol O O 261 becaplermin Regranex O O 261 fluorouracil Efudex O O 261 fluorouracil Fluoroplex O O 261 hexachlorophene pHisoHex O O 261 imiquimod Aldara P O X 261 masoprocol Actinex O O 261 podofilox Condylox P O X 262 XIII. Urinary tract products A. Alkalinizers OTC consideration: sodium bicarbonate 262 potassium citrate Urocit-K O O 262 potassium citrate/ citric acid Polycitra K P O X 262 potassium citrate/ sodium citrate/ citric Polycitra P O X acid 262 potassium citrate/ sodium citrate/ citric Polycitra LC O O acid 262 sodium citrate/ citric acid Bicitra P O X 262 sodium citrate/ citric acid Oracit O O 263 XIII. Urinary tract products B. Acidifiers OTC considerations: ammonium chloride, ascorbic acid 263 potassium/ sodium acid phosphate K-Phos Neutral O O 264 XIII. Urinary tract products C. Antispasmodics 264 flavoxate Urispas O O HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 77 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 oxybutynin -- G G X 264 oxybutynin Ditropan O O 264 oxybutynin, extended release Ditropan XL P O X 264 tolterodine Detrol P O X 264 tolterodine, long-acting Detrol LA P O X 265 XIII. Urinary tract products D. Cholinergic stimulants 265 bethanechol -- G G X 265 bethanechol Urecholine O O 265 neostigmine Prostigmin O O 266 XIII. Urinary tract products E. Analgesics OTC consideration: phenazopyridine (Azo-Standard, Prodium) 266 pentosan polysulfate sodium Elmiron O O 266 phenazopyridine -- G G X 266 phenazopyridine Pyridium O O 267 XIII. Urinary tract products F. Other 267 acetohydroxamic acid Lithostat O O 267 cysteamine bitartrate Cystagon O O 267 tiopronin Thiola O O 268 XIV. Immunologic Agents A. Immunosuppressive agents 268 azathioprine -- G G X 268 azathioprine Imuran O O 268 cyclosporine Sandimmune P O X 268 cyclosporine, microemulsion -- G G X 268 cyclosporine, microemulsion Neoral P O X 268 mycophenolate mofetil CellCept P O X 268 sirolimus Rapamune O O 268 tacrolimus Prograf P O X 269 XIV. Immunologic Agents B. Disease Modifying Antirheumatic Drugs (DMARD) 269 auranofin Ridaura P O X 269 azathioprine -- G G X 269 azathioprine Imuran O O 269 hydroxychloroquine sulfate -- G G X HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 78 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. 269 hydroxychloroquine sulfate Plaquenil O O 269 leflunomide Arava O O 269 methotrexate -- G G X 269 methotrexate Rheumatrex O O 269 penicillamine Cuprimine P O X 269 penicillamine Depen O O 269 sulfasalazine, enteric coated -- G G 269 sulfasalazine, enteric coated Azulfidine EN-tabs O O 270 XV. Miscellaneous A. Contraceptive barriers 270 condoms -- X 270 diaphragms -- O 3 O 3 X X X 270 spermicides -- X HMSA DRUG FORMULARY 4/1/04 FOOTNOTES 1 Second line protocol. 2 Coverage is subject to member's plan benefits. 3 Special member rates apply. Check plan benefits. 4 Benefit for TB prophylaxis age 21 or younger. Benefit for MAC, MAI, MK only. 5 Benefit only for children age 18 or younger. 6 Benefit only for children age 12 or younger. 7 Benefit only when prescribed to treat ADD/ADHD. 8 Benefit only when prescribed to treat ADD/ADHD or narcolepsy. 9 Benefit only when prescribed to treat narcolepsy. 10 Benefit only when prescribed to treat acne vulgaris. 11 Benefit only when prescribed to treat pernicious anemia. 12 Benefit only when prescribed to treat ESRD. 13 Benefit only when prescribed to treat carnitine deficiency. 14 Non-DESI products only. 15 Benefit only when prescribed to treat H. Pylori or GERD. 16 Benefit only when prescribed to treat STD. 17 Benefit for TB prophylaxis age 21 or younger. 18 Benefit for MAC, MAI, MK only. 19 Restricted to treatment of seizures, panic disorder, generalized anxiety, OCD, alcohol withdrawal, and bipolar agitation. Pre- certification required for insomnia and other diagnoses. 20 4 x 1ml ampules per 30 days 21 DACON criteria apply. 22 COX-2 criteria apply. 23 9 tablets per 30 days. 24 9 tablets, 6 nasal sprays, and/or 4 injections per 30 days 25 6 tablets per 30 days. 26 Benefit only when prescribed to treat seizures. 27 Benefit only when prescribed to treat Wernicke Korsakoff Syndrome. 28 Benefit only when prescribed to pregnancy or lactation. 29 Second line protocol. Benefit only when prescribed to treat H. Pylori or GERD. 30 Therapeutic protocol. HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - Page 1 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 95 aripiprazole Abilify P O X X 194 zafirlukast Accolate P 30 O X 30 56 quinapril Accupril O O 56 quinapril/ hctz Accuretic O O 241 isotretinoin Accutane O O 56 perindopril Aceon O O 11 glacial acetic acid Aci-jel O O 163 rabeprazole sodium Aciphex P P X 15 255 aclometasone dipropionate 0.05%, Aclovate O O cream/ ointment 167 ursodiol Actigall O O 261 masoprocol Actinex O O 122 estradiol/ norethindrone acetate Activella O O 152 risedronate Actonel P O X 146 pioglitazone Actos P O X 228 ketorolac tromethamine, ophthalmic Acular P O X 228 ketorolac tromethamine, ophthalmic Acular PF P O X 46 nifedipine Adalat O O 46 nifedipine, sustained release Adalat CC O O 62 amphetamine mixture Adderall P 8 O 8 X 8 X 8 62 amphetamine mixture, extended release Adderall XR P 7 O 7 X 7 X 7

190 salmeterol/ fluticasone Advair P O X 195 salmeterol/ fluticasone Advair P O X 61 nicotinic acid, extended release/ Advicor P P X lovastatin 195 flunisolide, inhaler Aerobid P P X 195 flunisolide, inhaler Aerobid M P P X 197 spacer Aerochamber P 3 P 3 X 20 amprenavir Agenerase P O X 34 aspirin/ dipyridamole Aggrenox P P X 34 anagrelide Agrylin O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - Page 2 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 209 phenylephrine/ chlorpheniramine/ AH-chew G G X methscopolamine 199 phenylephrine AH-Chew D G G X 197 peak flow meter Air Zone P 3 P 3 X 229 prednisolone sodium phosphate AK Pred O O 110 biperiden Akineton O O 218 dipivefrin AKPro O O 230 bacitracin AK-Tracin O O 225 permivolast Alamast O O 224 naphazoline Albalon O O 24 albendazole Albenza O O 41 spironolactone/ hctz Aldactazide O O 39 spironolactone Aldactone O O 261 imiquimod Aldara P O X 52 methyldopa/ chlorothiazide Aldoclor O O 52 methyldopa Aldomet O O 52 methyldopa/ hctz Aldoril O O 123 ethinyl estradiol/ levonorgestrel Alesse P 3 P 3 X X X 26 melphalan Alkeran P O X 205 fexofenadine Allegra P P X 205 fexofenadine/ pseudoephedrine Allegra D P P X 225 nedocromil Alocril P O X 225 lodoxamide Alomide O O 119 estradiol, transdermal Alora O O 217 brimonidine, 0.15% Alphagan P P O X 229 loteprednol etabonate Alrex O O 56 ramipril Altace P P X 60 lovastatin, extended release Altocor O 21 O 21 188 metaproterenol sulfate Alupent O O 189 metaproterenol sulfate, inhalation Alupent O O 189 metaproterenol sulfate, metered dose Alupent MDI P O X inhaler HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - Page 3 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 144 glimepiride Amaryl O O 99 zolpidem tartrate Ambien P O 121 medroxyprogesterone acetate Amen O O 70 naratriptan Amerge P 23 O 23 X 23 239 benzethonium chloride/ glycerin/ Americaine O O benzocaine 11 sodium propionate/ amino acid/ urea Amino-Cerv O O 132 oxymetholone Anadrol O O 78 clomipramine Anafranil O O 191 epinephrine/ chlorpheniramine Anakit P O X 139 hydrocortisone acetate/ pramoxine Analpram HC O O X 68 naproxen sodium Anaprox O O 130 testosterone, transdermal Androderm P O X 130 testosterone, gel Androgel O O 129 methyltestosterone Android P O X 63 hydrocodone/ apap Anexsia O O 68 flurbiprofen Ansaid O O 113 disulfiram Antabuse P O X X 242 anthralin Anthra-Derm O O 73 meclizine Antivert O O 153 sulfinpyrazone Anturane O O 139 hydrocortisone acetate Anusol HC O O 75 dolasetron mesylate Anzemet O O 172 amlexanox Aphthasol O O 55 hydralazine/ hctz Apresazide O O 55 hydralazine Apresoline O O 14 chloroquine phosphate Aralen P O X 16 chloroquine phosphate Aralen P O X 269 leflunomide Arava O O 97 donepezil Aricept P O X 28 anastrazole Arimidex P O X 138 triamcinolone Aristocort O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - Page 4 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 149 thyroid, desiccated Armour Thyroid P O 110 trihexyphenidyl Artane O O 68 diclofenac/ misoprostol Arthrotec O O 162 diclofenac/ misoprostol Arthrotec O O 173 mesalamine, delayed release Asacol P O X 79 amoxapine Asendin O O 204 azelastine Astelin P O X 57 candesartan Atacand O O 57 candesartan/ hctz Atacand HCT O O 77 hydroxyzine hcl Atarax O O 206 hydroxyzine hcl Atarax O O 76 lorazepam Ativan O O 61 clofibrate Atromid S O O 192 ipratropium, inhalation Atrovent O O 201 ipratropium, nasal Atrovent O O 192 ipratropium, inhalation Atrovent MDI P O X 240 erythromycin ATS O O 249 erythromycin, topical ATS O O 2 amoxicillin/ k clavulanate Augmentin O O 2 amoxicillin/ k clavulanate, extra strength Augmentin ES P O X 1

2 amoxicillin/ k clavulanate, extended Augmentin XR P O X 1 release 239 antipyrine/ benzocaine Auralgan O O 57 irbesartan/ hctz Avalide P P X 146 rosiglitazone/ metformin Avandamet P O X 146 rosiglitazone Avandia P O X 57 irbesartan Avapro P P X 11 sulfanilamide AVC O O 4 moxifloxacin Avelox P O X 1 79 nortriptyline Aventyl O O 240 tretinoin Avita O 10 O 10 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - Page 5 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 70 almotriptan Axert O 25 O 25 161 nizatidine Axid O O 121 norethindrone acetate Aygestin O O 240 azelaic acid Azelex O O 195 triamcinolone, inhaler Azmacort O O 222 brinzolamide Azopt O O 173 sulfasalazine Azulfidine O O 173 sulfasalazine, enteric coated Azulfidine EN-tabs O O 269 sulfasalazine, enteric coated Azulfidine EN-tabs O O 63 belladonna/ opium B&O suppositories O O 10 sulfamethoxazole/ trimethoprim Bactrim O O 241 sulfamethoxazole/ trimethoprim Bactrim O O 249 mupirocin Bactroban O O 158 methantheline bromide Banthine O O 202 beclomethasone Beconase AQ O O 157 belladona tincture Belladonna Tincture O O 157 l-alkaloids of belladonna/ phenobarbital/ Bellergal-S O O ergotamine 73 diphenhydramine Benadryl O O 110 diphenhydramine Benadryl O O 206 diphenhydramine Benadryl O O 57 olmesartan Benicar O O 159 dicyclomine, tablets and capsules Bentyl O O 159 dicyclomine, syrup Bentyl Syrup P O X 240 benzoyl peroxide Benzac O O 240 erythromycin/ benzoyl peroxide Benzamycin O O 181 iron/ multivit/ mineral, prescription Berocca Plus O 2 O 2 219 levobunolol Betagan O O 49 sotalol Betapace O O 44 sotalol Betapace AF P P X 49 sotalol Betapace AF P P X 219 betaxolol Betoptic O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - Page 6 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 219 betaxolol Betoptic S O O 69 valdecoxib Bextra O 22 O 6 clarithromycin Biaxin P O X 29 6 clarithromycin, extended release Biaxin XL P O X 29 185 sodium citrate/ citric acid Bicitra P O X 262 sodium citrate/ citric acid Bicitra P O X 24 praziquantel Biltricide O O 233 sulfacetamide/ prednisolone acetate Blephamide P O X 49 timolol maleate Blocadren O O 189 terbutaline sulfate Brethaire P O X 188 terbutaline sulfate Brethine P O X 188 terbutaline sulfate Bricanyl O O X 207 pseudoephedrine/ brompheniramine Bromfed O O 193 theophylline, capsules Bronkodyl O O 38 bumetanide Bumex O O 77 buspirone Buspar O O 157 belladonna extract/ butabarbital sodium Butibel O O

101 butabarbital sodium Butisol Sodium O O 71 ergotamine tartrate/ caffeine Cafergot O O 47 verapamil Calan O O 47 verapamil, sustained release Calan SR O O 178 cellulose sodium phosphate Calcibind P O X 158 mepenzolate bromide Cantil O O 246 chloroxine Capitrol O O 56 captopril Capoten O O 56 captopril/ hctz Capozide O O 156 sucralfate Carafate O O 220 carbachol Carbastat O O 107 carbamazepine, extended release Carbatrol O O 213 dextromethorphan/ pseudoephedrine/ Cardec DM Drops G G carbinoxamine HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 213 dextromethorphan/ pseudoephedrine/ Cardec DM Pediatric G G carbinoxamine 46 nicardipine Cardene O O 46 nicardipine, sustained release Cardene SR O O 44 quinidine polygalacturonate Cardioquin P O X 45 diltiazem Cardizem O O 45 diltiazem, sustained release Cardizem CD O O 45 diltiazem, sustained release Cardizem SR O O 53 doxazosin mesylate Cardura O O 186 levocarnitine Carnitor P 13 O 13 X 13 136 carteolol Cartrol O O 28 bicalutamide Casodex P O X 68 diclofenac potasium Cataflam O O 52 clonidine, oral Catapres O O 52 clonidine, transdermal Catapres-TTS O O X 133 alprostadil Caverject O O 3 cefaclor Ceclor O O 3 cefaclor, extended release Ceclor CD O O 3 ceftibuten Cedax O O 26 lomustine CeeNu P O X 3 cefuroxime Ceftin O O 3 cefprozil Cefzil O O 69 celecoxib Celebrex P 22 O X 22 138 betamethasone Celestone O O 85 citalopram Celexa P P X X 268 mycophenolate mofetil CellCept P O X 104 methsuximide Celontin Kapseals P O X 118 synthetic conjugated estrogens Cenestin O O 168 lactulose Cephulac O O 239 triethanolamine Cerumenex O O 255 hydrocortisone 0.25%, lotion Cetacort O O 233 sulfacetamide/ prednisolone acetate Cetapred O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 180 succimer Chemet P O X 230 norfloxacin Chibroxin O O 238 chloramphenicol, otic Chloromycetin Otic O O 230 chloramphenicol, ophthalmic Chloroptic O O 193 oxtriphylline Choledyl O O 168 lactulose Chronulac O O 230 ciprofloxacin, ointment Ciloxan Ointment P P X 230 ciprofloxacin, solution Ciloxan Solution O O 25 cinoxacin Cinobac O O 4 ciprofloxacin Cipro P O X 1 238 ciprofloxacin/ hydrocortisone, otic Cipro HC Otic O O 238 ciprofloxacin hcl/ dexamethasone, otic Ciprodex O O

205 desloratadine Clarinex O O 8 clindamycin Cleocin O O 241 clindamycin Cleocin O O 8 clindamycin palmitate, suspension Cleocin Suspension P O X 240 clindamycin phosphate, topical Cleocin T O O 249 clindamycin phosphate, topical Cleocin T O O 11 clindamycin Cleocin Vaginal P O X 119 estradiol, transdermal Climara O O 68 sulindac Clinoril O O 254 clocortolone pivalate 0.1%, cream Cloderm O O 133 clomiphene Clomid O 2 O 2 95 clozapine Clozaril P O X 110 benztropine Cogentin O O 97 tacrine Cognex O O 59 colestipol, granules Colestid P O X 59 colestipol, tablets Colestid P O 238 neomycin/ hydrocortisone, otic Coly-Mycin S Otic O O 168 polyethylene glycol-electrolyte solution CoLyte O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 122 estradiol/ norethindrone acetate, Combipatch O O transdermal 52 clonidine/ chlorthalidone Combipres O O 189 albuterol/ ipratropium Combivent P O X 192 albuterol/ ipratropium Combivent P O X 17 lamivudine/ zidovudine Combivir P O X 72 prochlorperazine maleate, tablets Compazine O O 88 prochlorperazine maleate, tablets Compazine O O 72 prochlorperazine maleate, sustained Compazine Spansules O O release 88 prochlorperazine maleate, sustained Compazine Spansules O O release 72 prochlorperazine edisylate, syrup Compazine Syrup P O X X 88 prochlorperazine edisylate, syrup Compazine Syrup P O X X 111 entacapone Comtan O O 62 methylphenidate, extended release Concerta O 7 O 7 261 podofilox Condylox P O X 44 amiodarone Cordarone P O X 254 flurandrenolide Cordran P O X 254 flurandrenolide Cordran SP P O X 254 flurandrenolide 4mcg/ cm2, tape Cordran tape P O X 51 carvedilol Coreg P P X 49 nadolol Corgard O O 252 clobetasol 0.05% Cormax G G X 138 hydrocortisone Cortef O O 139 hydrocortisone Cortenema P O X 139 hydrocortisone acetate Cortifoam O O 138 cortisone acetate Cortisone O O X 232 bacitracin/ neomycin/ polymyxin B/ Cortisporin O O hydrocortisone, ointment 232 neomycin/ polymyxin B/ Cortisporin O O hydrocortisone, suspension HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 249 neomycin/ poly+D2035myxin B/ Cortisporin Cream P O X hydrocortiso+D2042ne, topical 238 neomycin/ polymyxin B/ Cortisporin Otic O O hydrocortisone, otic 238 neomycin/ colistin/ hydrocortisone, otic Cortisporin TC Otic O O

49 nadolol/ bendroflumethiazide Corzide O O 222 dorzolamide/ timolol Cosopt P O X 219 timolol/ dorzolamide Cosopt P O X 35 warfarin Coumadin P O X 47 verapamil, sustained release Covera HS O O 57 losartan Cozaar P P X 166 pancreatin Creon O O 133 progesterone, vaginal 8% Crinone 8% O 2 O 2 20 indinavir sulfate Crixivan P O X 225 cromolyn Crolom O O 42 digitoxin Crystodigin O O 269 penicillamine Cuprimine P O X 121 medroxyprogesterone acetate Curretab O O 254 fluticasone propionate 0.05%, cream/ Cutivate O O ointment 253 amcinonide Cyclocort O O 62 pemoline Cylert O 7 O 7 X 7 267 cysteamine bitartrate Cystagon O O 140 aminoglutethimide Cytadren P O X 149 liothyronine sodium Cytomel P O X 162 misoprostol Cytotec O O 22 ganciclovir Cytovene O O 26 cyclophosphamide Cytoxan P O X 209 phenylephrine/ chlorpheniramine/ D.A chew O O methscopolamine 98 flurazepam Dalmane O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 135 danazol Danocrine P O X 109 dantrolene Dantrium O O 23 dapsone Dapsone O O 40 dichlorphenamide Daranide O O 14 pyrimethamine Daraprim O O 63 propoxyphene napsylate/ apap Darvocet N O O 63 propoxyphene Darvon O O 63 propoxyphene/ asa/ caffeine Darvon Compound O O 63 propoxyphene napsylate Darvon N O O 68 oxaprozin Daypro O O 136 desmopressin, nasal DDAVP P O X 136 desmopressin, oral DDAVP P O X 138 dexamethasone Decadron O O 255 dexamethasone sodium phosphate 0.1%, Decadron O O cream 229 dexamethasone sodium phosphate, Decadron O O ophthalmic 255 dexamethasone 0.04%, aerosol Decaspray O O 5 demeclocycline Declomycin O O 207 pseudoephedrine/ chlorpheniramine Deconamine SR O O 38 torsemide Demadex O O 63 meperidine Demerol O O 58 metyrosine Demser O O 248 penciclovir Denavir O O 115 naltrexone Depade O O 107 valproic acid Depakene P O X X 107 divalproex sodium Depakote P O X X 107 divalproex sodium, extended release Depakote ER P O X X 269 penicillamine Depen O O 128 medroxyprogesterone acetate, injectable Depo-Provera X X

123 ethinyl estradiol/ desogestrel Desogen P 3 P 3 X X X HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 255 desonide 0.05%, cream/ ointment Desowen O O 255 desonide 0.05%, lotion Desowen O O 62 methamphetamine Desoxyn O 7 O 7 240 benzoyl peroxide Desquam O O 81 trazodone Desyrel O O 264 tolterodine Detrol P O X 264 tolterodine, long-acting Detrol LA P O X 62 dextroamphetamine sulfate Dexedrine P 8 O 8 X 8 X 8 62 dextroamphetamine sulfate, sustained Dexedrine Spansules O 7 O 7 X 7 release 144 glyburide Diabeta O O 144 chlorpropamide Diabinese O O 40 acetazolamide Diamox O O 107 acetazolamide Diamox O O 40 acetazolamide, extended release Diamox Sequels P O X 106 diazepam, rectal Diastat P O X 58 phenoxybenzamine Dibenzyline O O 35 dicumarol Dicumarol O O 152 etidronate Didronel O O 240 adapalene Differin P 10 O 10 X 10 12 fluconazole Diflucan P O X 45 diltiazem, sustained release Dilacor XR O O 103 phenytoin Dilantin 125 P O X 103 phenytoin Dilantin Infatab P O X 103 phenytoin sodium, extended release Dilantin Kapseals P O X 43 isosorbide dinitrate, oral, sustained Dilatrate-SR O O release 63 hydromorphone Dilaudid O O 212 dextromethorphan/ pseudoephedrine/ Dimetane DX O O brompheniramine 57 valsartan Diovan O O 57 valsartan/ hctz Diovan HCT O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 173 olsalazine sodium Dipentum O O 252 augmented betamethasone dipropionate Diprolene O O 0.05%, ointment/gel 253 augmented betamethasone dipropionate Diprolene AF O O 0.05%, cream 253 betamethasone dipropionate 0.05%, Diprosone O O cream/ ointment 254 betamethasone dipropionate 0.05%, Diprosone O O lotion 66 salsalate Disalcid O O 264 oxybutynin Ditropan O O 264 oxybutynin, extended release Ditropan XL P O X 54 reserpine/ chlorothiazide Diupres O O 37 chlorothiazide Diuril O O 54 reserpine/ methyclothiazide Diutensen-R O O 66 diflunisal Dolobid O O 63 methadone Dolophine O O X 114 methadone Dolophine O O 239 acetic acid in aluminum acetate Domeboro Otic O O 157 belladonna alkaloids/ phenobarbital Donnatal O O 111 levodopa Dopar O O 98 quazepam Doral O O 5 doxycycline hyclate Doryx O O 241 doxycycline hyclate Doryx O O 154 cabergoline Dostinex P O X 242 calcipotriene Dovonex P O X 242 anthralin Drithocreme P O X 242 anthralin Drithocreme HP P O X 242 anthralin Dritho-Scalp P O X 261 aluminum chloride hexahydrate Drysol O O 63 fentanyl, transdermal Duragesic P O X 208 pseudoephedrine/ chlorpheniramine Dura-Tap/PD O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 214 guaifenesin Duratuss GO O 207 phenylephrine/ chlorpheniramine/ Dura-Vent/DA O O methscopolamine 3 cefadroxil Duricef O O 41 triamterene/ hctz Dyazide O O 144 acetohexamide Dymelor O O 6 dirithromycin Dynabac O O 46 isradipine DynaCirc O O 2 dicloxacillin sodium Dynapen O O 2 dicloxacillin sodium, suspension Dynapen Suspension P O X 39 triamterene Dyrenium O O 66 aspirin, enteric coated Easprin O O 229 prednisolone acetate, ophthalmic Econopred O O 229 prednisolone acetate, ophthalmic Econopred Plus O O 38 ethacrynic acid Edecrin O O 83 venlafaxine Effexor O O X 83 venlafaxine, extended release Effexor XR P P X X 261 fluorouracil Efudex O O 259 fibrinolysin/ desoxyribonuclease Elase O O 78 amitriptyline Elavil O O 111 selegiline Eldepryl O O 251 permethrin Elimite O O 193 theophylline, capsules Elixophyllin O O 193 theophylline, liquid Elixophyllin O O 193 theophylline, timed release capsules Elixophyllin SR O O 266 pentosan polysulfate sodium Elmiron O O 254 mometasone furoate 0.1% Elocon O O 225 emedastine Emadine O O 28 estramustine Emcyt P O X 242 ammoniated mercury Emersal O O 240 erythromycin Emgel O O 249 erythromycin, topical Emgel O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 256 lidocaine/ prilocaine EMLA O O 63 codeine/ asa Empirin w/ Codeine O O 37 methyclothiazide Enduron O O 54 deserpidine/ methyclothiazide Enduronyl O O 54 deserpidine/ methyclothiazide Enduronyl Forte O O 214 guaifenesin/ phenylephrine Entex LA O O 214 guaifenesin/ pseudoephedrine Entex PSE O O 138 budesonide Entocort EC O O 218 epinephrine Epifrin P O X 218 epinephrine/ pilocarpine E-Pilo P O X 220 pilocarpine/ epinephrine E-Pilo P O X 218 epinephryl borate Epinal P O X 191 epinephrine, injectable Epi-pen P O X 191 epinephrine, injectable Epi-pen JR P O X 17 lamivudine Epivir P O X 17 lamivudine Epivir-HBV P O X 77 meprobamate Equanil O O 30 levamisole Ergamisol P O X 71 ergotamine tartrate Ergomar P O X 6 erythromycin base Eryc O O 241 erythromycin base Eryc O O 240 erythromycin Erygel O O 249 erythromycin, topical Erygel O O 6 erythromycin ethylsuccinate EryPed O O 6 erythromycin base Ery-Tab G G X X X 241 erythromycin base Ery-Tab G G X X X 119 estradiol, transdermal Esclim O O 221 physostigmine Eserine sulfateO O 67 butalbital/ apap/ caffeine Esgic O O 67 butalbital/ apap/ caffeine Esgic Plus O O 96 lithium carbonate Eskalith O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 96 lithium carbonate, controlled release Eskalith CR P O X X

118 ethinyl estradiol Estinyl O O 118 estradiol Estrace O O 119 estradiol, vaginal Estrace P O X 119 estradiol, transdermal Estraderm O O 118 esterified estrogens/ methyltestosterone Estratest P O X

129 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

119 estradiol, vaginal Estring O O 44 moricizine Ethmozine P O X 78 amitriptyline/ perphenazine Etrafon O O 88 amitriptyline/ perphenazine Etrafon O O 28 flutamide Eulexin O O 251 crotamiton Eurax O O 120 raloxifene Evista P O X 250 sulconazole Exelderm O O 97 rivastigmine Exelon O O 197 spacer E-Z Spacer P 3 P 3 X 22 famciclovir Famvir P O X 14 pyrimethamine/ sulfadoxine Fansidar O O 28 toremifene Fareston O O 147 SMBG test strips Fast Take test strips G G X 107 felbamate Felbatol P O X 68 piroxicam Feldene O O 28 letrozole Femara O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 122 ethinyl estradiol/ norethindrone acetate Femhrt O O

119 estradiol, transdermal FemPatch O O 67 butalbital/ apap/ caffeine Fioricet O O 63 codeine/ apap/ caffeine/ butalbital Fioricet w/ Codeine O O 67 butalbital/ asa/ caffeine Fiorinal O O 63 codeine/ asa/ caffeine/ butalbital Fiorinal w/ Codeine O O 16 metronidazole Flagyl O O 229 fluoromethalone Flarex O O 168 Sodium phosphate, oral solution Fleets Phospho - Soda X 108 cyclobenzaprine Flexeril O O 53 tamsulosin Flomax P O X 202 fluticasone Flonase P O X 137 fludrocortisone Florinef O O 253 diflorasone 0.05%, cream/ ointment Florone O O 195 fluticasone, inhaler Flovent P O X 4 ofloxacin Floxin O O 238 ofloxacin, otic Floxin Otic P P X 21 rimantadine Flumadine O O 261 fluorouracil Fluoroplex O O 229 fluoromethalone FML O O 229 fluoromethalone FML Forte O O 229 fluoromethalone FML SOP O O 233 sulfacetamide/ fluorometholone FML-S O O 190 formoterol Foradil OO 20 saquinavir Fortovase P O X 152 alendronate Fosamax P O X 70 frovatriptan Frova O 25 O 25 12 griseofulvin microsize Fulvicin-U/F O O 244 nitrofurazone Furacin O O 25 nitrofurantoin Furadantin O O 25 furazolidone Furoxone O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 107 tiagabine Gabatril P O X 10 sulfamethoxazole Gantanol O O 10 sulfisoxazole Gantrisin P O X 233 sulfisoxazole diolamine, ophthalmic Gantrisin O O 230 gentamicin Garamycin O O 249 gentamicin sulfate, topical Garamycin O O 95 ziprasidone Geodon P O X X 148 glucagon Glucagon Emergency Kit P O X

145 metformin Glucophage O O 145 metformin, extended release Glucophage XR O O 144 glipizide Glucotrol O O 144 glipizide, extended release Glucotrol XL O O 144 glyburide/ metformin Glucovance P O X 144 glyburide, micronized Glynase O O 141 miglitol Glyset P P X 168 polyethylene glycol-electrolyte solution GoLYTELY O O

12 griseofulvin microsize Grifulvin V O O 12 griseofulvin ultramicrosize Gris-Peg P O X 112 guanidine hcl Guanidine O O 98 triazolam Halcion O O 91 haloperidol Haldol O O 14 halofantrine hcl Halfan O O 253 halcinonide 0.1%, cream/ ointment Halog O O 253 halcinonide 0.1%, cream/ ointment Halog E O O 129 fluoxymesterone Halotestin P O X 160 bismuth subsalicylate/ metronidazole/ Helidac P O X tetracycline 235 idoxuridine Herplex P O X 24 diethylcarbamazine citrate Hetrazan O O 30 altretamine Hexalen P O X HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 25 methenamine hippurate Hiprex O O 17 zalcitabine Hivid P O 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 8 paromomycin Humatin O O 16 paromomycin Humatin O O 214 guaifenesin, sustained release Humibid LA O O 143 human 50/ 50 insulin Humulin 50/50 G G X 143 human 70/ 30 insulin Humulin 70/30 G G X 143 human lente insulin Humulin L G G X 143 human NPH insulin Humulin N G G X 143 human regular insulin Humulin R G G X 143 human ultralente insulin Humulin U Ultralente G G X 211 hydrocodone/ homatopine Hycodan O O 210 hydrocodone/ homatropine Hycodan O O 117 ergoloid mesylates Hydergine O O 117 ergoloid mesylates, sublingual Hydergine O O 117 ergoloid mesylates Hydergine LC O O 30 hydroxyurea Hydrea P O X 37 hydrochlorothiazide HydroDIURIL O O 54 reserpine/ hctz Hydropres O O 54 reserpine/ hctz Hydro-Serp O O 54 guanadrel Hylorel O O 255 hydrocortisone 0.5% Hytone O O 255 hydrocortisone 1% Hytone O O 255 hydrocortisone 2.5% Hytone O O 53 terazosin Hytrin O O 57 losartan/ hctz Hyzaar P P X 6 erythromycin estolate Ilosone O O 230 erythromycin Ilotycin O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 43 isosorbide mononitrate, extended release Imdur O O

70 sumatriptan Imitrex P 24 O 24 X 24 169 loperamide Imodium O O 268 azathioprine Imuran O O 269 azathioprine Imuran O O 49 propranolol Inderal O O 49 propranolol, sustained release Inderal LA P O X X 49 propranolol/ hctz Inderide O O 68 indomethacin Indocin O O 68 indomethacin, sustained release Indocin SR O O 229 prednisolone sodium phosphate Inflamase Forte O O 229 prednisolone sodium phosphate Inflamase Mild O O 196 cromolyn sodium, inhalation Intal O O 196 cromolyn sodium, metered dose inhaler Intal MDI P O X

54 guanethidine Ismelin O O 43 isosorbide mononitrate ISMO O O 47 verapamil Isoptin O O 47 verapamil, sustained release Isoptin SR O O 227 atropine Isopto Atropine O O 220 carbachol Isopto CarbacholP O X 220 pilocarpine Isopto Carpine O O 227 homatropine HBr Isopto Homatropine P O X 227 scopolamine HBr Isopto Hyoscine P O X 43 isosorbide dinitrate, sublingual Isordil O O 43 isosorbide dinitrate, oral, sustained Isordil Tembids O O release 43 isosorbide dinitrate, oral Isordil Titradose O O 189 isoproterenol Isuprel O O 183 potassium bicarb/ citrate K Lyte O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 183 potassium chloride/ potassium bicarb/ K Lyte Cl O O citrate 183 potassium bicarb/ citrate K Lyte DS O O 63 morphine sulfate, controlled release Kadian O O 20 lopinavir/ ritonavir Kaletra P O X 9 kanamycin sulfate Kantrex O O 183 potassium gluconate Kaon O O 184 sodium polystyrene sulfonate Kayexalate O O 183 potassium chloride K-Dur O O 3 cephalexin Keflex O O 3 cephalexin monohydrate Keftab O O 110 procyclidine Kemadrin O O X 254 triamcinolone acetonide 0.025% Kenalog O O 254 triamcinolone acetonide 0.1% Kenalog O O 253 triamcinolone acetonide 0.5%, cream/ Kenalog O O ointment 254 triamcinolone acetonide, aerosol Kenalog aerosol P O X 172 triamcinolone paste Kenalog in Orabase O O 107 levetiracetam Keppra P O X X 50 betaxolol Kerlone O O 240 sulfacetamide sodium Klaron O O 106 clonazepam Klonopin P O X 19 X 183 potassium chloride K-Lor O O 263 potassium/ sodium acid phosphate K-Phos Neutral O O 183 potassium chloride K-Tab O O 75 granisetron Kytril P O X 236 hydroxypropyl cellulose Lacrisert O O 107 lamotrigine Lamictal P O X X 12 terbinafine Lamisil P O X 23 clofazimine Lamprene O O 42 digoxin Lanoxicaps O O 42 digoxin Lanoxin G G X HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 143 insulin glargine Lantus G G X 14 mefloquine hcl Larium O O 111 levodopa Larodopa O O 37 furosemide Lasix O O 60 fluvastatin Lescol O 21 O 21 60 fluvastatin, extended release Lescol XL O 21 O 21 26 chlorambucil Leukeran P O X 4 levofloxacin Levaquin O O 49 penbutolol Levatol O O 157 l-hyoscyamine sulfate, extended release Levbid O O

63 levorphanol Levo-Dromoran P O X 149 levothyroxine sodium Levothroid P O X 157 l-hyoscyamine sulfate Levsin O O 157 l-hyoscyamine sulfate, sublingual Levsin/SL O O 157 l-hyoscyamine sulfate, timed release Levsinex Timecaps O O

85 escitalopram Lexapro O O X 56 felodipine/ enalapril Lexxel O O X 46 felodipine/enalapril Lexxel O O 157 clidinium/ chlordiazepoxide Librax O O 76 chlordiazepoxide Librium O O 253 fluocinonide 0.05% Lidex O O 76 chlordiazepoxide/ amitriptyline Limbitrol DS O O 78 chlordiazepoxide/ amitriptyline Limbitrol DS O O 108 baclofen Lioresal O O 60 atorvastatin, 10mg, 20mg & 40mg Lipitor, 10mg, 20mg & O21O 21 40mg 60 atorvastatin, 80 mg Lipitor, 80 mg P 21 P 21 X 21 138 prednisone Liquid Pred P O X 96 lithium carbonate, slow release Lithobid P O X X 267 acetohydroxamic acid Lithostat O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 96 lithium carbonate Lithotabs O O 225 levocabastine Livostin O O 59 cholestyramine/ sucrose LoCHOLEST O O 59 cholestyramine/ aspartame LoCHOLEST Light O O 254 hydrocortisone butyrate 0.1% Locoid O O 68 etodolac Lodine O O 68 etodolac, extended release Lodine XL O O 111 carbidopa Lodosyn O O 169 diphenoxylate/ atropine sulfate Lomotil O O 55 minoxidil Loniten O O 61 gemfibrozil Lopid O O 50 metoprolol Lopressor O O 50 metoprolol/ hctz Lopressor HCT O O 250 ciclopirox Loprox P O X 3 loracarbef Lorabid O O 63 hydrocodone/ apap Lorcet O O 63 hydrocodone/ apap Lortab O O 63 hydrocodone/ asa Lortab ASA O O 229 loteprednol etabonate Lotemax P P X 56 benazepril Lotensin O O 56 benazepril/ hctz Lotensin HCT O O 46 amlodipine/ benazepril Lotrel P O X 56 benazepril/ amlodipine Lotrel P O X 94 loxapine Loxitane O O 94 loxapine solution Loxitane C O O 37 indapamide Lozol O O 80 maprotiline Ludiomil O O 223 bimatoprost Lumigan P O X 179 sodium fluoride Luride O O 30 mitotane Lysodren O O 25 nitrofurantoin macrocrystals Macrobid P O X 25 nitrofurantoin macrocrystals Macrodantin O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 66 magnesium salicylate Magan O O 25 methenamine mandelate Mandelamine O O 108 chlorphenesin carbamate Maolate O O 193 theophylline/ ephedrine/ hydroxyzine Marax O O hcl 74 dronabinol Marinol O O 86 isocarboxazid Marplan O O 66 salsalate Marthritic O O 177 prenatal vitamins Materna O 2 O 2 30 procarbazine Matulane P O X 56 trandolapril Mavik O O 189 pirbuterol acetate Maxair P O X 189 pirbuterol acetate Maxair Auto P O X 70 rizatriptan Maxalt O 25 O 25 70 rizatriptan Maxalt-MLT O 25 O 25 4 lomefloxacin Maxaquin O O 253 diflorasone 0.05%, cream/ ointment Maxiflor O O 232 neomycin/ polymyxin B/ Maxitrol O O dexamethasone 253 betamethasone dipropionate 0.05%, Maxivate O O cream/ ointment 254 betamethasone dipropionate 0.05%, Maxivate O O lotion 41 triamterene/ hctz Maxzide O O 100 mephobarbital Mebaral P O X 26 240 meclocycline sulfosalicylate Meclan O O 138 methylprednisolone Medrol O O 28 megestrol Megace O O 89 thioridazine Mellaril O O 118 esterified estrogens Menest O O 250 butenafine Mentax O O 33 phytonadione Mephyton P O X HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 176 phytonadione Mephyton P O X 25 atovaquone Mepron O O 103 mephenytoin Mesantoin O O 112 pyridostigmine bromide Mestinon P O X 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 54 reserpine/ trichlormethiazide Metatensin O O 240 metronidazole, topical MetroCream P O X 249 metronidazole, topical MetroCream P O X 240 metronidazole, topical MetroGel P O X 249 metronidazole, topical MetroGel P O X 11 metronidazole Metro-Gel Vaginal P O X 240 metronidazole, topical MetroLotion P O X 249 metronidazole, topical MetroLotion P O X 60 lovastatin Mevacor O O 44 mexiletine Mexitil P O X 151 calcitonin-salmon, nasal Miacalcin O O 57 telmisartan Micardis O O 57 telmisartan/ hctz Micardis HCT O O 183 potassium chloride Micro K O O 144 glyburide Micronase O O 37 hydrochlorothiazide Microzide O O 39 amiloride hcl Midamor O O 71 isometheptene/ dichloralphenazone/ Midrin O O apap 71 dihydroergotamine mesylate Migranal O 20 O 20 77 meprobamate Miltown O O 53 prazosin Minipress O O 43 nitroglycerin, transdermal Minitran O O 53 prazosin/ polythiazide Minizide O O 5 minocycline Minocin O O 241 minocycline hcl Minocin O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 24 thiabendazole Mintezol O O 35 anisindione Miradon O O 111 pramipexole Mirapex P O X 124 ethinyl estradiol/ desogestrel Mircette P 3 P 3 X X X 93 molindone Moban O O 66 magnesium salicylate Mobidin O O 41 amiloride/ hctz Moduretic O O 5 doxycycline monohydrate Monodox O O 241 doxycycline monohydrate Monodox O O 43 isosorbide mononitrate Monoket O O 56 fosinopril Monopril O O 56 fosinopril/hctz Monopril HCT O O 25 fosfomycin tromethamine Monurol O O 68 ibuprofen Motrin O O 63 morphine sulfate, controlled release MS Contin O O 63 morphine sulfate MSIR O O 198 acetylcysteine Mucomyst O O 237 sodium chloride, hypertonic Muro 128 X 133 alprostadil Muse O O 15 ethambutol Myambutol O O 170 clotrimazole Mycelex Troches P O X 15 rifabutin Mycobutin P O X 18 12 nystatin Mycostatin O O 13 nystatin Mycostatin O O 170 nystatin Mycostatin O O 250 nystatin Mycostatin O O 37 metolazone Mykrox O O 26 busulfan Myleran P O X 107 primidone Mysoline P O X 112 ambenonium chloride Mytelase O O 250 naftifine Naftin O O 68 fenoprofen calcium Nalfon O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 68 naproxen sodium, controlled release Naprelan O O 68 naproxen Naprosyn O O 37 trichlormethiazide Naqua O O 86 phenelzine sulfate Nardil P O X X 202 triamcinolone Nasacort P O X 202 triamcinolone Nasacort AQ P O X 203 cromolyn sodium Nasalcrom X 32 cyanocobalamin, nasal Nascobal P 11 O 11 X 11 174 cyanocobalamin, nasal Nascobal P 11 O 11 X 11 202 mometasone Nasonex P O X 234 natamycin Natacyn O O 37 bendroflumethiazide Naturetin O O 90 thiothixene Navane O O 25 pentamidine isethionate, inhalation NebuPent P O X 198 pentamidine, inhalation Nebupent P O X 25 nalidixic acid NegGram O O 102 pentobarbital Nembutal O O 232 neomycin/ dexamethasone, ointment NeoDecadron ointment O O

232 neomycin/ dexamethasone, solution NeoDecadron solution O O 268 cyclosporine, microemulsion Neoral P O X 231 bacitracin/ neomycin/ polymyxin B, Neosporin ointment O O ointment 231 gramicidin/ neomycin/ polymyxin B, Neosporin solution O O solution 224 phenylephrine Neo-Synephrine O O 40 methazolamide Neptazane O O 107 gabapentin Neurontin P O X X 61 nicotinic acid, extended release Niaspan P P X 116 nicotine, inhaler Nicotrol inhaler O O 116 nicotine, nasal spray Nicotrol NS O O 28 nilutamide Nilandron O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 46 nimodipine Nimotop P O X 43 nitroglycerin, topical Nitro-Bid O O 43 nitroglycerin, transdermal Nitrodisc O O 43 nitroglycerin, transdermal Nitro-Dur P O X 43 nitroglycerin, transmucosal Nitrogard O O 43 nitroglycerin, sustained release, oral Nitroglyn O O 43 nitroglycerin, topical Nitrol O O 43 nitroglycerin, translingual Nitrolingual P O X 43 nitroglycerin, sustained release, oral Nitrong O O 43 nitroglycerin, sublingual Nitrostat G G X 12 ketoconazole Nizoral O O 246 ketoconazole, cream Nizoral O O X 250 ketoconazole, cream Nizoral O O X 250 ketoconazole, shampoo Nizoral P O X 28 tamoxifen Nolvadex O O 63 hydrocodone/ apap Norco O O 108 orphenadrine citrate Norflex O O 108 orphenadrine/ asa/ caffeine Norgesic O O 108 orphenadrine/ asa/ caffeine Norgesic Forte O O 240 metronidazole, topical Noritate O O 249 metronidazole, topical Noritate O O 51 labetolol Normodyne O O 4 norfloxacin Noroxin O O 44 disopyramide Norpace P O X 44 disopyramide, sustained release Norpace CR P O X 79 desipramine Norpramin O O 126 norethindrone Nor-QD P 3 P 3 X X X 46 amlodipine Norvasc O O 20 ritonavir Norvir P O X 240 sulfur/ sulfacetamide Novacet O O 147 insulin needles Novofine G G X 147 insulin needles Novofine 30 G G X HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 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 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 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 insulin aspart Novolog G G X 143 human insulin Novolog mix G G X 147 insulin injector Novopen G G X 210 codeine/ pseudoephedrine Nucofed O O 215 guaifenesin/ pseudoephedrine/ codeine Nucofed Expectorant O O

216 guaifenesin/ pseudoephedrine/ codeine Nucofed Pediatric OO Expectorant 128 ethinyl estradiol/ levonorgestrel Nuvaring O O X 228 flurbiprofen sodium, ophthalmic Ocufen O O 230 ofloxacin Ocuflox P O X 219 carteolol Ocupress O O 220 pilocarpine ocular therapeutic system Ocusert Pilo O O

118 estropipate Ogen O O 119 estropipate, vaginal Ogen O O 3 cefdinir Omnicef O O 207 phenylephrine/ chlorpheniramine/ OMNIhist LA G G methscopolamine 1 ampicillin Omnipen O O 147 SMBG test strips One Touch test strips G G X 147 SMBG test strips One Touch Ultra test strips G G X HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 225 cromolyn Opticrom O O 206 azatadine Optimine O O 219 metipranolol OptiPranolol O O 225 azelastine Optivar O O 185 sodium citrate/ citric acid Oracit O O 262 sodium citrate/ citric acid Oracit O O 92 pimozide Orap O O 138 prednisolone sodium phosphate, oral Orapred P O X

138 prednisone Orasone G G X 214 guaifenesin Organidin NRO O 144 tolbutamide Orinase O O 119 dienestrol, vaginal Ortho Dienestrol O O 118 estropipate Ortho-EST G G X 128 ethinyl estradiol/ norelgestromin OrthoEvra O O X 68 ketoprofen Orudis O O 68 ketoprofen, extended release Oruvail O O 238 polymyxin B/ hydrocortisone, otic Otobiotic P O X 251 malathion Ovide O O 132 oxandrolone Oxandrin P O X 250 oxiconazole Oxistat O O 243 methoxasalen Oxsoralen-Ultra P O X 63 oxycodone, controlled release Oxycontin P O 63 oxycodone OxyIR O O 79 nortriptyline Pamelor O O 157 methscopolamine bromide Pamine O O 166 pancrelipase Pancrease O O 166 pancrelipase Pancrease MT O O 261 alitretinoin Panretin O O 108 chlorzoxazone Parafon Forte DSC O O 111 bromocriptine Parlodel P O X 86 tranylcypromine sulfate Parnate O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 15 aminosalicylic acid Paser O O 225 olopatadine Patanol O O 99 acetylcarbromal Paxarel O O 85 paroxetine Paxil P P X X 85 paroxetine, controlled release Paxil CR P P X X 76 halazepam Paxipam O O 206 tripelennamine PBZ O O 6 erythromycin base PCE O O 241 erythromycin base PCE O O 245 methionine Pedameth O O 138 prednisolone sodium phosphate, oral Pediapred O O

6 erythromycin/ sufisoxazole Pediazole O O 10 erythromycin/ sufisoxazole Pediazole O O 103 ethotoin Peganone O O 4 enoxacin Penetrex O O 173 mesalamine, controlled release Pentasa O O 161 famotidine Pepcid O O 63 oxycodone/ apap Percocet O O 63 oxycodone/ asa Percodan O O 206 cyproheptadine Periactin O O 170 chlorhexidine gluconate Peridex O O 5 doxycycline hyclate Periostat O O 170 doxycycline hyclate Periostat O O 111 pergolide Permax O O 34 dipyridamole Persantine O O 206 promethazine Phenergan O O 72 promethazine, tablets and liquid Phenergan O O 212 dextromethorphan/ promethazine Phenergan DM O O 72 promethazine, suppositories Phenergan Suppositories P O X

208 phenylephrine/ promethazine Phenergan VC O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 210 codeine/ phenylephrine/ promethazine Phenergan VC w/codeine O O

210 codeine/ promethazine Phenergan w/codeine O O 261 hexachlorophene pHisoHex O O 182 calcium acetate Phoslo P 12 O 12 X 12 221 echothiophate iodide Phospholine Iodide P O X 67 butalbital/ apap Phrenilin O O 67 butalbital/ apap Phrenilin Forte O O 220 pilocarpine nitrate Pilagan P O X 220 pilocarpine Pilocar O O 220 pilocarpine Pilopine HS P O X 220 pilocarpine Pilostat O O 214 potassium iodide Pima O O 99 ethchlorvynol Placidyl O O 127 levonorgestrel Plan B P X 14 hydroxychloroquine sulfate Plaquenil O O 269 hydroxychloroquine sulfate Plaquenil O O 34 clopidogrel Plavix P P X 46 felodipine Plendil P P X 34 cilostazol Pletal O O 206 dexchlorpheniramine Polaramine O O 185 potassium citrate/ sodium citrate/ citric Polycitra P O X acid 262 potassium citrate/ sodium citrate/ citric Polycitra P O X acid 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 Polycitra LC O O acid 262 potassium citrate/ sodium citrate/ citric Polycitra LC O O acid 231 bacitracin/ polymyxin B, ointment Polysporin O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 231 trimethoprim/ polymyxin B Polytrim O O 179 multivitamins with fluoride Poly-Vi-Flor O 2 O 2 68 mefenamic acid Ponstel O O 142 repaglinide Prandin P O X 60 pravastatin Pravachol P 21 P 21 X 21 60 pravastatin/ aspirin Pravigard P 21 P 21 X 21 141 acarbose Precose P P X 229 prednisolone acetate, ophthalmic Pred Forte P O X 229 prednisolone acetate, ophthalmic Pred Mild O O 138 prednisolone Prelone O O 118 conjugated estrogens Premarin P O X 119 conjugated estrogens, vaginal Premarin P O X 122 conjugated estrogens/ Premphase P O X medroxyprogesterone 122 conjugated estrogens/ Prempro P O X medroxyprogesterone 122 conjugated estrogens/ Prempro Low Dose P O X medroxyprogesterone 163 lansoprazole Prevacid O O 163 lansoprazole Prevacid Granules O O 59 cholestyramine/ aspartame Prevalite O O 127 ethinyl estradiol/ levonorgestrel Preven O X 179 sodium fluoride Prevident O O 160 lansoprazole/ amoxicillin/ Prevpac P O X clarithromycin 15 rifapentine Priftin O O 163 omeprazole Prilosec O O 14 primaquine phosphate Primaquine O O 56 lisinopril Prinivil O O 56 lisinopril/ hctz Prinzide O O 158 propantheline bromide Pro-Banthine O O 44 procainamide, sustained release Procan SR O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 44 procainamide, sustained release Procanbid P O X 46 nifedipine Procardia O O 46 nifedipine, sustained release Procardia XL O O 139 hydrocortisone Proctocort O O X 139 hydrocortisone acetate/ pramoxine Proctocream-HC O O X 139 hydrocortisone acetate/ pramoxine Proctofoam-HC O O X 268 tacrolimus Prograf P O X 88 fluphenazine Prolixin O O 121 progesterone, micronized Prometrium P O X 44 procainamide Pronestyl O O 218 dipivefrin Propine O O 131 finasteride Proscar P O X 98 estazolam Prosom O O 112 neostigmine Prostigmin O O 265 neostigmine Prostigmin O O 163 pantoprazole Protonix P P X 15 188 albuterol Proventil O O 189 albuterol Proventil O O 189 albuterol Proventil HFA O O 121 medroxyprogesterone acetate Provera O O 62 modafinil Provigil O 9 O 9 85 fluoxetine Prozac O O 253 diflorasone 0.05%, cream Psorcon O O 252 diflorasone 0.05%, ointment Psorcon B O O 195 budesonide, inhaler Pulmicort P O X 195 budesonide, respules Pulmicort respules P P X 198 dornase alfa Pulmozyme O O 27 mercaptopurine Purinethol P O X 266 phenazopyridine Pyridium O O 157 clidinium bromide Quarzan O O 59 cholestyramine/ sucrose Questran O O 59 cholestyramine/ aspartame Questran Light O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 193 theophylline, tablets Quibron-T O O 44 quinidine gluconate Quinaglute Dura-Tabs P O X 44 quinidine sulfate, extended release Quinidex Extentabs P O X 44 quinidine sulfate Quinora O O 230 levofloxacin Quixin O O 195 beclomethasone, inhaler QVAR OO 268 sirolimus Rapamune O O 22 ribavirin Rebetol P O X 72 metoclopramide Reglan O O 165 metoclopramide Reglan O O 261 becaplermin Regranex O O 54 reserpine/ chlorthalidone Regroton O O 68 nabumetone Relafen O O 21 zanamivir Relenza O O 80 mirtazapine Remeron O O 80 mirtazapine Remeron Soltab O O 97 galantamine Reminyl O O 182 sevelamer Renagel P O X 177 vitamin B complex/ vit C/ vit E/ folate Renal Tabs P 12 O 12 X 12

37 polythiazide Renese O O 54 reserpine/ polythiazide Renese-R O O 111 ropinirole Requip P O X 18 delavirdine mesylate Rescriptor P O X 223 unoprostone Rescula O O 98 temazepam Restoril O O 240 tretinoin Retin-A O 10 O 10 240 tretinoin Retin-A Micro O 10 O 10 17 zidovudine Retrovir P O X 115 naltrexone ReVia P O X X 27 methotrexate Rheumatrex O O 243 methotrexate Rheumatrex O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 269 methotrexate Rheumatrex O O 202 budesonide Rhinocort AQ P O X 269 auranofin Ridaura P O X 15 rifampin Rifadin O O 15 isoniazid/ rifampin Rifamate O O 15 isoniazid/ rifampin/ pyrazinamide Rifater O O 117 riluzole Rilutek P O X 95 risperidone Risperdal P O X X 95 risperidone injection Risperdal Consta X 95 risperidone Risperdal-M P O X X 62 methylphenidate Ritalin O 8 O 8 62 methylphenidate, sustained release Ritalin SR O 8 O 8 108 methocarbamol Robaxin O O 108 methocarbamol/ asa Robaxisal O O 158 glycopyrrolate Robinul O O 158 glycopyrrolate Robinul Forte O O 215 guaifenesin/ codeine Robitussin AC O O 214 guaifenesin/ pseudoephedrine Robitussin PE O O 175 calcitriol Rocaltrol O O 208 pseudoephedrine/ carbinoxamine Rondec O O 212 dextromethorphan/ pseudoephedrine/ Rondec DM O O brompheniramine 213 dextromethorphan/ pseudoephedrine/ Rondec DM Drops O O carbinoxamine 213 dextromethorphan/ pseudoephedrine/ Rondec DM syrup O O brompheniramine 173 mesalamine, rectal Rowasa P O X 207 phenylephrine/ chlorpheniramine/ Rynatan O O pyrilamine, tablets 209 phenylephrine/ chlorpheniramine/ Rynatan Pediatric OO pyrilamine, suspension Suspension 44 propafenone Rythmol P O X HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 171 pilocarpine, oral Salagen O O 157 atropine sulfate Sal-Tropine O O 54 reserpine/ hydroflumethiazide Salutensin O O 268 cyclosporine Sandimmune P O X 259 collagenase Santyl O O 246 sulfacetamide sodium, shampoo Sebizon O O 102 secobarbital sodium Seconal O O 50 acebutolol Sectral O O 246 selenium sulfide Selsun O O 10 sulfamethoxazole/ trimethoprim Septra O O 241 sulfamethoxazole/ trimethoprim Septra O O 76 oxazepam Serax O O 89 mesoridazine Serentil O O 190 salmeterol Serevent P O X 15 cycloserine Seromycin O O 133 clomiphene Serophene O 2 O 2 95 quetiapine fumarate Seroquel P O X X 84 nefazodone Serzone O O X 244 silver sulfadiazine Silvadene O O 111 levodopa/ carbidopa Sinemet O O 111 levodopa/ carbidopa, sustained release Sinemet CR O O

77 doxepin Sinequan O O 78 doxepin Sinequan O O 194 montelukast sodium Singulair P 30 O X 30 212 dextromethorphan/ guaifenesin/ Sinutuss DM G G phenylephrine 214 guaifenesin/ phenylephrine Sinuvent PE G G 108 metaxalone Skelaxin O O 152 tiludronate Skelid O O 193 theophylline, timed release capsules Slo-Bid O O 193 theophylline, timed release capsules Slo-Bid 50mg and 75mg P O X HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 193 theophylline, liquid Slo-Phyllin O O 193 theophylline, tablets Slo-Phyllin O O 193 theophylline, timed release capsules Slo-Phyllin Gyrocaps O O 233 sulfacetamide Sodium Sulamyd O O 108 carisoprodol Soma O O 108 carisoprodol/ asa Soma Compound O O 108 carisoprodol/ asa/ codeine Soma Compound w/ OO Codeine 99 zaleplon Sonata O O 43 isosorbide dinitrate, chewable Sorbitrate O O 243 acitretin Soriatane P O X 87 promazine Sparine O O 250 econazole Spectazole O O 12 itraconazole Sporanox P O X 214 potassium iodide SSKI O O 64 butorphanol Stadol NS O O 141 nateglinide Starlix P O X 88 trifluoperazine Stelazine O O 28 diethylstilbestrol Stilphostrol O O 136 desmopressin, nasal Stimate P O X 117 atomoxetine Strattera O O X 24 ivermectin Stromectol O O 177 prenatal vitamins Stuartnatal Plus O 2 O 2 46 nisoldipine Sular P P X 240 sulfur/ sulfacetamide Sulfacet-R O O 244 mafenide Sulfamylon O O 147 SMBG test strips Surestep test strips G G X 78 trimipramine maleate Surmontil P O X X 18 efavirenz Sustiva P O X 21 amantadine Symmetrel O O 111 amantadine Symmetrel O O 255 fluocinolone acetonide 0.01% Synalar O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 254 fluocinolone acetonide 0.025%, cream/ Synalar O O ointment 253 fluocinolone acetonide 0.2%, cream Synalar HP O O 134 nafarelin Synarel P O X 149 levothyroxine sodium Synthroid P O X 181 trientine Syprine O 2 O 2 161 cimetidine Tagamet O O 64 pentazocine/ apap Talacen O O 64 pentazocine/ asa Talwin Compound O O 64 pentazocine/ naloxone Talwin NX O O 44 flecainide Tambocor P O X 21 oseltamivir Tamiflu O O 6 troleandomycin Tao O O 150 methimazole Tapazole O O 30 bexarotene Targretin P P X 47 verapamil ER/ trandolapril Tarka O O 56 verapamil ER/ trandolapril Tarka O O 111 tolcapone Tasmar O O 206 clemastine Tavist O O 240 tazarotene Tazorac O O 242 tazarotene Tazorac O O 107 carbamazepine Tegretol P O X X 107 carbamazepine, extended release Tegretol XR P O X X 30 temozolomide Temodar P O X 252 clobetasol 0.05% Temovate O O 252 clobetasol 0.05% Temovate E O O 52 guanfacine Tenex O O 50 atenolol/ chlorthalidone Tenoretic O O 50 atenolol Tenormin O O 4 gatifloxacin Tequin O O 13 terconazole Terazol 3 O O 13 terconazole Terazol 7 O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 28 testolactone Teslac O O 212 benzonatate Tessalon Perles O O 130 testosterone, transdermal Testoderm O O 129 methyltestosterone Testred O O 57 eprosartan Teveten O O 57 eprosartan/ hctz Teveten HCT O O 37 chlorthalidone Thalitone O O 23 thalidomide Thalomid O O 193 theophylline, timed release capsules Theo-24 P O X 193 theophylline, timed release tablets Theochron G G X 193 theophylline, timed release capsules Theo-Dur Sprinkle O O 193 theophylline, liquid Theolair O O 193 theophylline, tablets Theolair O O 27 thioguanine Thioguanine P O X 267 tiopronin Thiola O O 72 chlorpromazine Thorazine O O 87 chlorpromazine Thorazine O O 149 liothyronine sodium/ levothyroxine Thyrolar P O X 45 diltiazem, sustained release Tiazac P P X 34 ticlopidine Ticlid O O 73 trimethobenzamide Tigan O O 44 dofetilide Tikosyn O O 196 nedocromil, inhaler Tilade O O 49 timolol maleate/ hctz Timolide O O 219 timolol Timoptic O O 219 timolol XE Timoptic XE O O 25 tobramycin, inhalation TOBI P O X 198 tobramycin, inhalation TOBI P O X 232 tobramycin/ dexamethasone TobraDex P O X 230 tobramycin, ointment Tobrex ointment P O X 230 tobramycin, solution Tobrex solution O O 78 imipramine Tofranil O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 78 imipramine pamoate Tofranil PM P O X X 68 tolmetin sodium Tolectin O O 144 tolazamide Tolinase O O 107 topiramate Topamax P O X X 253 desoximetasone 0.05%, gel Topicort O O 253 desoximetasone 0.25%, cream/ ointment Topicort O O

254 desoximetasone 0.05%, cream Topicort LP O O 240 tetracycline Topicycline O O 50 metoprolol, extended release Toprol XL P P X 68 ketorolac, oral Toradol O O 72 thiethylperazine maleate Torecan O O 189 bitolterol mesylate Tornalate O O 193 theophylline, timed release tablets T-Phyl O O 51 labetolol Trandate O O 43 nitroglycerin, transdermal Transderm-Nitro O O 73 scopolamine, trandsdermal Transderm-Scop O O 106 chlorazepate dipotassium Tranxene O O 76 clorazepate dipotassium Tranxene O O 259 sutilains Travase O O 223 travoprost Travatan O O 15 ethionamide Trecator-SC O O 36 pentoxifylline Trental O O 78 amitriptyline/ perphenazine Triavil O O 88 amitriptyline/ perphenazine Triavil O O 240 benzoyl peroxide Triaz O O 61 fenofibrate Tricor O O 105 trimethadione Tridione P O X 72 perphenazine Trilafon O O 88 perphenazine Trilafon O O 107 oxcarbazepine Trileptal P O X X 125 ethinyl estradiol/ levonorgestrel Tri-Levlen P 3 P 3 X X X HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 66 choline salicyclate/ magnesium Trilisate O O salicylate 25 trimethoprim Trimpex O O 207 pseudoephedrine/ azatadine Trinalin O O 181 iron/ vit c/ vit b12/ intrinsic factor/ Trinsicon O 2 O 2 folate 179 multivitamins with fluoride, prescription Tri-Vi-Flor O 2 O 2

17 abacavir/ lamivudine/ zidovudine Trizivir P O X 222 dorzolamide Trusopt P O X 240 erythromycin T-Stat G G 249 erythromycin, topical T-Stat O O 210 hydrocodone/ chlorpheniramine Tussionex O O 63 codeine/ apap Tylenol w/ Codeine O O 63 oxycodone/ apap Tylox O O 207 pseudoephedrine/ brompheniramine Ultrabrom G G 209 pseudoephedrine/ brompheniramine Ultrabrom PD G G 65 tramadol/ apap Ultracet O O 65 tramadol Ultram O O 166 pancrelipase Ultrase MT O O 252 halobetasol propionate 0.05%, cream/ Ultravate P O X ointment 193 theophylline, timed release tablets Unidur O O 193 theophylline, timed release tablets Uniphyl O O 56 moexipril/ hctz Uniretic O O 56 moexipril Univasc O O 265 bethanechol Urecholine O O 25 methenamine hippurate Urex O O 264 flavoxate Urispas O O 262 potassium citrate Urocit-K O O 25 methylene blue Urolene Blue O O 119 estradiol hemihydrate Vagifem O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 254 betamethasone valerate 0.1%, cream/ Valisone O O lotion 253 betamethasone valerate 0.1%, ointment Valisone O O

76 diazepam Valium O O 106 diazepam Valium O O 108 diazepam Valium O O 22 valacyclovir Valtrex P O X 7 vancomycin Vancocin O O 24 oxamniquine Vansil O O 3 cefpodoxime proxetil Vantin O O 48 bepridil Vascor O O 56 enalapril/ hctz Vaseretic O O 233 sulfacetamide/ prednisolone sodium Vasocidin O O phosphate 224 naphazoline Vasocon O O 226 naphazoline/ antazoline Vasocon-A O O 233 sulfacetamide/ phenylephrine Vasosulf O O 56 enalapril Vasotec O O 1 penicillin V potassium V-Cillin K O O 3 cephradine Velosef O O 143 human regular insulin Velosulin Human BR G G X 188 albuterol Ventolin O O 189 albuterol Ventolin O O 189 albuterol Ventolin HFA O O 29 etoposide VePesid P O X 47 verapamil, sustained release Verelan O O 24 mebendazole Vermox O O 30 tretinoin, oral Vesanoid O O 229 rimexolone Vexol O O 133 sildenafil Viagra O 2 O 2 5 doxycycline hyclate Vibramycin O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 14 doxycycline hyclate Vibramycin O O 241 doxycycline hyclate Vibramycin O O 63 hydrocodone/ apap Vicodin O O 63 hydrocodone/ apap Vicodin HP O O 215 guaifenesin/ hydrocodone Vicodin Tuss O O 63 hydrocodone/ ibuprofen Vicoprofen O O 17 didanosine Videx P O X 17 didanosine, enteric coated Videx EC P O X 232 moxifloxacin Vigamox O O 166 pancrelipase Viokase/Cotazym P O X 69 rofecoxib Vioxx P 22 O X 22 235 vidarabine Vira-A P O X 20 nelfinavir mesylate Viracept P O X 18 nevirapine Viramune P O X 19 tenofovir Viread P O X 235 trifluridine Viroptic P O X 49 pindolol Visken O O 77 hydroxyzine pamoate, capsules Vistaril O O 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 79 protriptyline Vivactil O O 119 estradiol, transdermal Vivelle O O 188 albuterol, extended release Volmax O O 68 diclofenac sodium, delayed release, oral Voltaren O O

228 diclofenac sodium, ophthalmic Voltaren P O X 68 diclofenac sodium, extended release, Voltaren XR O O oral 197 spacer Vortex P 3 P 3 X 238 acetic acid, otic VoSol O O 238 acetic acid/ hydrocortisone, otic VosSol HC O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 59 colesevelam Welchol O O 82 buproprion Wellbutrin O O 82 buproprion, sustained release Wellbutrin SR P P X X 82 buproprion, extended release Wellbutrin XL P P X X 31 leucovorin calcium Wellcovorin O O 254 hydrocortisone valerate 0.2%, cream/ Westcort O O ointment 71 ergotamine tartrate/ caffeine/ tartaric Wigraine suppositories O O acid 132 stanozolol Winstrol P O X 63 propoxyphene/ apap Wygesic O O 52 guanabenz Wytensin O O 223 latanoprost Xalatan P O X 76 alprazolam Xanax O O 27 capecitabine Xeloda P O X 240 aluminum chloride hexahydrate Xerac AC O O 189 levalbuterol Xopenex O O 256 lidocaine Xylocaine O O 172 lidocaine, viscous Xylocaine O O 257 lidocaine, viscous Xylocaine Viscous O O 123 ethinyl estradiol/ drospirenone Yasmin P 3 P 3 X X X 133 yohimbine Yocon O 2 O 2 16 iodoquinol Yodoxin P O X 225 ketotifen Zaditor P P X 108 tizanidine Zanaflex O O 161 ranitidine, tablets and capsules Zantac O O 161 ranitidine syrup Zantac Syrup P O X 104 ethosuximide Zarontin P O X 37 metolazone Zaroxolyn P O X 50 bisoprolol Zebeta O O 17 stavudine Zerit P O X 56 lisinopril/ hctz Zestoretic O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - 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. 56 lisinopril Zestril O O 61 ezetimibe Zetia O O 50 bisoprolol/ hctz Ziac O O 17 abacavir sulfate Ziagen P O X 6 azithromycin Zithromax O O X 16 60 simvastatin Zocor O 21 O 21 75 ondansetron Zofran P O X 75 ondansetron Zofran ODT P O X 85 sertraline Zoloft P P X X 70 zolmitriptan Zomig O 25 O 25 247 doxepin Zonalon O O 107 zonisamide Zonegran P O X 66 aspirin, controlled release ZORprin O O 22 acyclovir Zovirax O O 248 acyclovir ointment Zovirax P O X 116 bupropion, extended release Zyban P O X X 194 zileuton Zyflo P 30 O X 30 153 allopurinol Zyloprim O O 95 olanzapine Zyprexa P O X X 95 olanzapine Zyprexa Zydis O O X 205 cetirizine/ pseudoephedrine Zyrtec D O O 205 cetirizine, syrup Zyrtec syrup P P X 205 cetirizine, tablets Zyrtec tablet O O HMSA DRUG FORMULARY 4/1/04 FOOTNOTES 1 Second line protocol. 2 Coverage is subject to member's plan benefits. 3 Special member rates apply. Check plan benefits. 4 Benefit for TB prophylaxis age 21 or younger. Benefit for MAC, MAI, MK only. 5 Benefit only for children age 18 or younger. 6 Benefit only for children age 12 or younger. 7 Benefit only when prescribed to treat ADD/ADHD. 8 Benefit only when prescribed to treat ADD/ADHD or narcolepsy. 9 Benefit only when prescribed to treat narcolepsy. 10 Benefit only when prescribed to treat acne vulgaris. 11 Benefit only when prescribed to treat pernicious anemia. 12 Benefit only when prescribed to treat ESRD. 13 Benefit only when prescribed to treat carnitine deficiency. 14 Non-DESI products only. 15 Benefit only when prescribed to treat H. Pylori or GERD. 16 Benefit only when prescribed to treat STD. 17 Benefit for TB prophylaxis age 21 or younger. 18 Benefit for MAC, MAI, MK only. 19 Restricted to treatment of seizures, panic disorder, generalized anxiety, OCD, alcohol withdrawal, and bipolar agitation. Pre- certification required for insomnia and other diagnoses. 20 4 x 1ml ampules per 30 days 21 DACON criteria apply. 22 COX-2 criteria apply. 23 9 tablets per 30 days. 24 9 tablets, 6 nasal sprays, and/or 4 injections per 30 days 25 6 tablets per 30 days. 26 Benefit only when prescribed to treat seizures. 27 Benefit only when prescribed to treat Wernicke Korsakoff Syndrome. 28 Benefit only when prescribed to pregnancy or lactation. 29 Second line protocol. Benefit only when prescribed to treat H. Pylori or GERD. 30 Therapeutic protocol. HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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%, Aclovate O O cream/ ointment 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 188 albuterol -- G G X 188 albuterol Proventil O O 188 albuterol Ventolin O O 189 albuterol -- G G X 189 albuterol Proventil O O 189 albuterol Proventil HFA O O 189 albuterol Ventolin O O 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 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 -- X hydroxide 155 aluminum hydroxide/ magnesium -- X hydroxide/ simethicone 21 amantadine -- G G X X 21 amantadine Symmetrel O O 111 amantadine -- G G X X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 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 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 Augmentin XR P O X 1 release HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 O O 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 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 & O21O 21 40mg HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 60 atorvastatin, 80 mg Lipitor, 80 mg P 21 P21X 21 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 Diprolene AF O O 0.05%, cream 252 augmented betamethasone dipropionate -- G G 0.05%, ointment/gel 252 augmented betamethasone dipropionate Diprolene O O 0.05%, ointment/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, -- G G X X X ointment 231 bacitracin/ neomycin/ polymyxin B, Neosporin ointment O O ointment 232 bacitracin/ neomycin/ polymyxin B/ -- G G X X X hydrocortisone, ointment HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 232 bacitracin/ neomycin/ polymyxin B/ Cortisporin O O hydrocortisone, ointment 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 OO 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

63 belladonna/ opium B&O suppositories O O 56 benazepril Lotensin O O 56 benazepril/ amlodipine Lotrel P O X 56 benazepril/ hctz Lotensin HCT O O 37 bendroflumethiazide Naturetin O O 239 benzethonium chloride/ glycerin/ Americaine O O benzocaine 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 138 betamethasone Celestone O O 253 betamethasone dipropionate 0.05%, -- G G cream/ ointment 253 betamethasone dipropionate 0.05%, Diprosone O O cream/ ointment 253 betamethasone dipropionate 0.05%, Maxivate O O cream/ ointment 254 betamethasone dipropionate 0.05%, -- GG lotion 254 betamethasone dipropionate 0.05%, Diprosone O O lotion 254 betamethasone dipropionate 0.05%, Maxivate O O lotion 254 betamethasone valerate 0.1%, cream/ -- G G X lotion 254 betamethasone valerate 0.1%, cream/ Valisone O O lotion 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 160 bismuth subsalicylate/ metronidazole/ Helidac P O X tetracycline 50 bisoprolol -- G G X 50 bisoprolol Zebeta O O 50 bisoprolol/ hctz -- G G X 50 bisoprolol/ hctz Ziac O O 189 bitolterol mesylate Tornalate O O 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 Zyban P O X X 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 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 CarbacholP 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 108 carisoprodol/ asa/ codeine -- G G 108 carisoprodol/ asa/ codeine Soma Compound w/ OO 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 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 77 chloral hydrate -- G G X 5 99 chloral hydrate -- G G X 5 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 Aralen P O X 16 chloroquine phosphate Aralen P O X 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 108 chlorzoxazone -- G G X 108 chlorzoxazone Parafon Forte DSC O O 59 cholestyramine/ aspartame LoCHOLEST Light O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 Trilisate O O salicylate 250 ciclopirox Loprox P O X 34 cilostazol Pletal O O 161 cimetidine -- G G X 161 cimetidine Tagamet O O 25 cinoxacin Cinobac O O 4 ciprofloxacin -- O O 4 ciprofloxacin Cipro P O X 1 238 ciprofloxacin hcl/ dexamethasone, otic Ciprodex O O

230 ciprofloxacin, ointment Ciloxan Ointment P P X 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 241 clindamycin Cleocin O O 8 clindamycin palmitate, suspension Cleocin Suspension P O X 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 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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/ -- G G X chlorpheniramine 211 codeine/ pseudoephedrine/ -- G G X chlorpheniramine 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 122 conjugated estrogens/ Premphase P O X medroxyprogesterone 122 conjugated estrogens/ Prempro P O X medroxyprogesterone 122 conjugated estrogens/ Prempro Low Dose P O X medroxyprogesterone 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 P O X 109 dantrolene Dantrium O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 23 dapsone Dapsone O O 18 delavirdine mesylate Rescriptor P O X 5 demeclocycline Declomycin O O 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%, Decadron O O cream 229 dexamethasone sodium phosphate, -- G G X ophthalmic 229 dexamethasone sodium phosphate, Decadron O O ophthalmic 206 dexchlorpheniramine Polaramine O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 -- G 7 G 7 X 7 X 7 release 62 dextroamphetamine sulfate, sustained Dexedrine Spansules O 7 O 7 X 7 release 212 dextromethorphan/ guaifenesin/ Sinutuss DM G G phenylephrine 212 dextromethorphan/ promethazine -- G G X 212 dextromethorphan/ promethazine Phenergan DM O O 212 dextromethorphan/ pseudoephedrine/ -- G G X brompheniramine 212 dextromethorphan/ pseudoephedrine/ Dimetane DX O O brompheniramine 212 dextromethorphan/ pseudoephedrine/ Rondec DM O O brompheniramine 213 dextromethorphan/ pseudoephedrine/ Rondec DM syrup O O brompheniramine 212 dextromethorphan/ pseudoephedrine/ -- G G X carbinoxamine 213 dextromethorphan/ pseudoephedrine/ Cardec DM Drops G G carbinoxamine 213 dextromethorphan/ pseudoephedrine/ Cardec DM Pediatric G G carbinoxamine 213 dextromethorphan/ pseudoephedrine/ Rondec DM Drops O O carbinoxamine 270 diaphragms -- O 3 O 3 X X X 76 diazepam -- G G X 19 76 diazepam Valium O O 106 diazepam -- G G X 19 106 diazepam Valium O O 108 diazepam -- G G X 19 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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, Voltaren XR O O oral 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 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 191 epinephrine/ chlorpheniramine Anakit 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 Wigraine suppositories O O acid 230 erythromycin -- G G X X X 230 erythromycin Ilotycin O O 240 erythromycin -- G G X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 Benzamycin O O 240 erythromycin/ benzoyl peroxide -- G G 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 O O X 98 estazolam -- G G 98 estazolam Prosom O O 118 esterified estrogens Menest O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 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, Combipatch O O transdermal 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 VePesid P O X 61 ezetimibe Zetia O O 22 famciclovir Famvir P O X 161 famotidine -- G G 161 famotidine Pepcid O O 107 felbamate Felbatol P O X 46 felodipine Plendil P P X 56 felodipine/ enalapril Lexxel O O X 46 felodipine/enalapril Lexxel O O 61 fenofibrate -- O O 61 fenofibrate Tricor O O 68 fenoprofen calcium -- G G HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 68 fenoprofen calcium Nalfon O O 63 fentanyl, transdermal Duragesic P O X 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/ -- G G X ointment 254 fluocinolone acetonide 0.025%, cream/ Synalar O O ointment 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 88 fluphenazine Prolixin O O 88 fluphenazine deconoate, injectable -- X X 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/ Cutivate O O ointment 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 OO 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 25 furazolidone Furoxone O O 37 furosemide -- G G X 37 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 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 Glucovance P O X 168 glycerin -- X 158 glycopyrrolate Robinul O O 158 glycopyrrolate Robinul Forte O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 231 gramicidin/ neomycin/ polymyxin B, -- G G X X X solution 231 gramicidin/ neomycin/ polymyxin B, Neosporin solution O O solution 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 GO O 214 guaifenesin Organidin NRO 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 -- X Robitussin DM) 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. 4/1/04 - 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. 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/ Ultravate P O X ointment 14 halofantrine hcl Halfan O O 91 haloperidol -- G G X X 91 haloperidol Haldol O O 91 haloperidol decanoate, injectable -- X X 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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/ -- G G X ointment 254 hydrocortisone valerate 0.2%, cream/ Westcort O O ointment 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 P O X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 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. 4/1/04 - 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. 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/ Trinsicon O 2 O 2 folate 86 isocarboxazid Marplan O O 189 isoetharine -- O O 71 isometheptene/ dichloralphenazone/ -- G G apap 71 isometheptene/ dichloralphenazone/ Midrin O O apap 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 -- G G X release 43 isosorbide dinitrate, oral, sustained Dilatrate-SR O O release 43 isosorbide dinitrate, oral, sustained Isordil Tembids O O release 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 250 ketoconazole, shampoo Nizoral P O X 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 168 lactulose Cephulac O O 168 lactulose Chronulac O O 157 l-alkaloids of belladonna/ phenobarbital/ -- G G ergotamine 157 l-alkaloids of belladonna/ phenobarbital/ Bellergal-S O O ergotamine 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/ Prevpac P O X clarithromycin 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 111 levodopa/ carbidopa, sustained release -- G G X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 111 levodopa/ carbidopa, sustained release Sinemet CR O O

230 levofloxacin Quixin O O 4 levofloxacin Levaquin 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 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 Lithobid P O X X 96 lithium carbonate, slow release -- G G 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 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 O 21 O 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 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 Purinethol P O X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 Alupent MDI P O X inhaler 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 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 108 methocarbamol Robaxin O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 Concerta O 7 O 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 Zaroxolyn P O X 50 metoprolol -- G G X 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 MetroCream P O X 240 metronidazole, topical MetroGel P O X 240 metronidazole, topical MetroLotion P O X 240 metronidazole, topical Noritate O O 249 metronidazole, topical MetroCream P O X 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 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 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 -- G 7 G 7 X 6 249 mupirocin Bactroban O O 268 mycophenolate mofetil CellCept P O X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 249 neomycin/ poly+D2035myxin B/ Cortisporin Cream P O X hydrocortiso+D2042ne, topical 232 neomycin/ polymyxin B/ -- G G X dexamethasone 232 neomycin/ polymyxin B/ Maxitrol O O dexamethasone 238 neomycin/ polymyxin B/ -- G G X X X hydrocortisone, otic 238 neomycin/ polymyxin B/ Cortisporin Otic O O hydrocortisone, otic 232 neomycin/ polymyxin B/ -- G G X X X hydrocortisone, suspension 232 neomycin/ polymyxin B/ Cortisporin O O hydrocortisone, suspension 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/ Advicor P P X lovastatin 46 nifedipine -- G G 46 nifedipine Adalat O O 46 nifedipine Procardia O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 P O X 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 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 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 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 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 O 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 8 paromomycin Humatin O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - 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. 16 paromomycin -- G G 16 paromomycin Humatin O O 85 paroxetine Paxil P P X X 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 -- X solution 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 49 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. 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 200 phenylephrine -- X 224 phenylephrine -- G G X 224 phenylephrine Neo-Synephrine O O 207 phenylephrine/ chlorpheniramine/ -- G G methscopolamine 207 phenylephrine/ chlorpheniramine/ Dura-Vent/DA O O methscopolamine 207 phenylephrine/ chlorpheniramine/ OMNIhist LA G G methscopolamine 209 phenylephrine/ chlorpheniramine/ -- G G X methscopolamine 209 phenylephrine/ chlorpheniramine/ AH-chew G G X methscopolamine 209 phenylephrine/ chlorpheniramine/ D.A chew O O methscopolamine 209 phenylephrine/ chlorpheniramine/ -- G G X pyrilamine, suspension 209 phenylephrine/ chlorpheniramine/ Rynatan Pediatric OO pyrilamine, suspension Suspension 207 phenylephrine/ chlorpheniramine/ -- G G X pyrilamine, tablets 207 phenylephrine/ chlorpheniramine/ Rynatan O O pyrilamine, tablets HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 50 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. 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 sulfateO 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 220 pilocarpine ocular therapeutic system Ocusert Pilo O O

171 pilocarpine, oral Salagen O O 220 pilocarpine/ epinephrine E-Pilo 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 68 piroxicam -- G G 68 piroxicam Feldene O O 261 podofilox Condylox P O X 168 polyethylene glycol-electrolyte solution -- G G X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 51 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. 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/ -- G G citrate 183 potassium chloride/ potassium bicarb/ K Lyte Cl O O citrate 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 Polycitra P O X acid 185 potassium citrate/ sodium citrate/ citric Polycitra LC O O acid 262 potassium citrate/ sodium citrate/ citric Polycitra P O X acid 262 potassium citrate/ sodium citrate/ citric Polycitra LC O O acid 183 potassium gluconate -- G G 183 potassium gluconate Kaon O O 214 potassium iodide Pima O O HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 52 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. 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 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 53 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. 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 Compazine Spansules O O release 88 prochlorperazine maleate, sustained Compazine Spansules O O release 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 44 propafenone -- G G X 44 propafenone Rythmol P O X 158 propantheline bromide -- G G HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 54 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. 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, -- X capsules (generic Bromfed) 209 pseudoephedrine/ brompheniramine, -- X liquid (generic 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 55 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. 208 pseudoephedrine/ chlorpheniramine -- X (generic Chlor-Trimeton Allergy D) 208 pseudoephedrine/ triprolidine (generic -- X Actifed) 168 psyllium -- X 15 pyrazinamide -- G G 112 pyridostigmine bromide Mestinon P O X 14 pyrimethamine Daraprim O O 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 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 56 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 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 Rebetol P O X 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 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 57 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. 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 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 58 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. 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 59 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 Sodium Sulamyd O O 240 sulfacetamide sodium Klaron O O 246 sulfacetamide sodium, shampoo Sebizon O O 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 -- G G X phosphate 233 sulfacetamide/ prednisolone sodium Vasocidin O O phosphate 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 60 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 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 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 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 61 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 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 193 theophylline, timed release tablets Unidur O O 193 theophylline, timed release tablets Uniphyl O O 193 theophylline/ ephedrine/ hydroxyzine Marax O O hcl 24 thiabendazole Mintezol O O 174 thiamine -- X 27 X 27 72 thiethylperazine maleate Torecan O O 27 thioguanine Thioguanine P O X HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 62 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. 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 Gabatril P O 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 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 63 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 tolmetin sodium -- G G 68 tolmetin sodium Tolectin O O 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/ -- G G X ointment 253 triamcinolone acetonide 0.5%, cream/ Kenalog O O ointment HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 64 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. 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 88 trifluoperazine -- G G 88 trifluoperazine Stelazine O O 235 trifluridine Viroptic P O X 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 65 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. 167 ursodiol -- G G X 167 ursodiol Actigall O O 22 valacyclovir Valtrex P O X 69 valdecoxib Bextra O 22 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 27 177 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 HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 66 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 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 HMSA DRUG FORMULARY 4/1/04 FOOTNOTES 1 Second line protocol. 2 Coverage is subject to member's plan benefits. 3 Special member rates apply. Check plan benefits. 4 Benefit for TB prophylaxis age 21 or younger. Benefit for MAC, MAI, MK only. 5 Benefit only for children age 18 or younger. 6 Benefit only for children age 12 or younger. 7 Benefit only when prescribed to treat ADD/ADHD. 8 Benefit only when prescribed to treat ADD/ADHD or narcolepsy. 9 Benefit only when prescribed to treat narcolepsy. 10 Benefit only when prescribed to treat acne vulgaris. 11 Benefit only when prescribed to treat pernicious anemia. 12 Benefit only when prescribed to treat ESRD. 13 Benefit only when prescribed to treat carnitine deficiency. 14 Non-DESI products only. 15 Benefit only when prescribed to treat H. Pylori or GERD. 16 Benefit only when prescribed to treat STD. 17 Benefit for TB prophylaxis age 21 or younger. 18 Benefit for MAC, MAI, MK only. 19 Restricted to treatment of seizures, panic disorder, generalized anxiety, OCD, alcohol withdrawal, and bipolar agitation. Pre- certification required for insomnia and other diagnoses. 20 4 x 1ml ampules per 30 days 21 DACON criteria apply. 22 COX-2 criteria apply. 23 9 tablets per 30 days. 24 9 tablets, 6 nasal sprays, and/or 4 injections per 30 days 25 6 tablets per 30 days. 26 Benefit only when prescribed to treat seizures. 27 Benefit only when prescribed to treat Wernicke Korsakoff Syndrome. 28 Benefit only when prescribed to pregnancy or lactation. 29 Second line protocol. Benefit only when prescribed to treat H. Pylori or GERD. 30 Therapeutic protocol.