Quick viewing(Text Mode)

FORMULARY - Listed Alphabetically by BRAND Name Rev

FORMULARY - Listed Alphabetically by BRAND Name Rev

HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - Page 1 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 95 aripiprazole Abilify O O X 194 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 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 195 flunisolide, inhaler Aerobid P P X 195 flunisolide, inhaler Aerobid M P P X 197 spacer Aerochamber P 3 P 3 X 20 amprenavir Agenerase P O X 34 aspirin/ dipyridamole Aggrenox P P X 34 anagrelide Agrylin O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - Page 2 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 209 phenylephrine/ chlorpheniramine/ AH-chew G G X methscopolamine 199 phenylephrine AH-Chew D G G X 197 peak flow meter Air Zone P 3 P 3 X 229 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 / hctz Aldactazide O O 39 spironolactone Aldactone O O 261 imiquimod Aldara P O X 52 methyldopa/ chlorothiazide Aldoclor O O 52 methyldopa Aldomet O O 52 methyldopa/ hctz Aldoril O O 123 ethinyl estradiol/ levonorgestrel Alesse P 3 P 3 X X X 26 melphalan Alkeran P O X 205 fexofenadine Allegra P P X 205 fexofenadine/ pseudoephedrine Allegra D P P X 225 nedocromil Alocril P O X 225 lodoxamide Alomide O O 119 estradiol, transdermal Alora O O 217 brimonidine, 0.15% Alphagan P O O X 229 loteprednol etabonate Alrex O O 56 ramipril Altace P P X 60 lovastatin, extended release Altocor O 21 O 21 188 metaproterenol sulfate Alupent O O 189 metaproterenol sulfate, inhalation Alupent O O 189 metaproterenol sulfate, metered dose Alupent MDI P O X inhaler HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - Page 3 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 144 glimepiride Amaryl O O 99 zolpidem tartrate Ambien P O 121 medroxyprogesterone acetate Amen O O 70 naratriptan Amerge P 23 O 23 X 23 239 benzethonium chloride/ glycerin/ Americaine O O benzocaine 11 sodium propionate/ amino acid/ urea Amino-Cerv O O 132 oxymetholone Anadrol O O 78 clomipramine Anafranil O O 191 epinephrine/ chlorpheniramine Anakit P O X 139 hydrocortisone acetate/ pramoxine Analpram HC O O X 68 naproxen sodium Anaprox O O 130 testosterone, transdermal Androderm P O X 130 testosterone, gel Androgel O O 129 methyltestosterone Android P O X 63 hydrocodone/ apap Anexsia O O 68 flurbiprofen Ansaid O O 113 disulfiram Antabuse P O X X 242 anthralin Anthra-Derm O O 73 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 phosphate Aralen P O X 16 chloroquine phosphate Aralen P O X 269 leflunomide Arava O O 97 donepezil Aricept P O X 28 anastrazole Arimidex P O X 138 triamcinolone Aristocort O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - Page 4 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 149 thyroid, desiccated Armour Thyroid P O 110 trihexyphenidyl Artane O O 68 diclofenac/ misoprostol Arthrotec O O 162 diclofenac/ misoprostol Arthrotec O O 173 mesalamine, delayed release Asacol P O X 79 amoxapine Asendin O O 204 azelastine Astelin P O X 57 candesartan Atacand O O 57 candesartan/ hctz Atacand HCT O O 77 hydroxyzine hcl Atarax O O 206 hydroxyzine hcl Atarax O O 76 lorazepam Ativan O O 61 clofibrate Atromid S O O 192 ipratropium, inhalation Atrovent O O 201 ipratropium, nasal Atrovent O O 192 ipratropium, inhalation Atrovent MDI P O X 240 ATS O O 249 erythromycin, topical ATS O O 2 amoxicillin/ k clavulanate Augmentin O O 2 amoxicillin/ k clavulanate, extra strength Augmentin ES O O

2 amoxicillin/ k clavulanate, extended Augmentin XR O O release 239 antipyrine/ benzocaine Auralgan O O 57 irbesartan/ hctz Avalide P P X 146 rosiglitazone/ metformin Avandamet P O X 146 rosiglitazone Avandia P O X 57 irbesartan Avapro P P X 11 sulfanilamide AVC O O 4 moxifloxacin Avelox P O X 1 79 nortriptyline Aventyl O O 240 tretinoin Avita O 10 O 10 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - Page 5 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 70 almotriptan Axert O 25 O 25 161 nizatidine Axid O O 121 norethindrone acetate Aygestin O O 240 azelaic acid Azelex O O 195 triamcinolone, inhaler Azmacort O O 222 brinzolamide Azopt O O 173 sulfasalazine Azulfidine O O 173 sulfasalazine, enteric coated Azulfidine EN-tabs O O 269 sulfasalazine, enteric coated Azulfidine EN-tabs O O 63 belladonna/ opium B&O suppositories O O 10 sulfamethoxazole/ trimethoprim Bactrim O O 241 sulfamethoxazole/ trimethoprim Bactrim O O 249 mupirocin Bactroban O O 158 methantheline bromide Banthine O O 202 beclomethasone Beconase AQ O O 157 belladona tincture Belladonna Tincture O O 157 l-alkaloids of belladonna/ / Bellergal-S O O ergotamine 73 diphenhydramine Benadryl O O 110 diphenhydramine Benadryl O O 206 diphenhydramine Benadryl O O 57 olmesartan Benicar O O 159 dicyclomine, tablets and capsules Bentyl O O 159 dicyclomine, syrup Bentyl Syrup P O X 240 benzoyl peroxide Benzac O O 240 erythromycin/ benzoyl peroxide Benzamycin O O 181 iron/ multivit/ mineral, prescription Berocca Plus O 2 O 2 219 levobunolol Betagan O O 49 sotalol Betapace O O 44 sotalol Betapace AF P P X 49 sotalol Betapace AF P P X 219 betaxolol Betoptic O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - Page 6 Ther. Generic Brand Select Select Choice Choice QUEST QUEST- CCS Child- Categ. Net ren's Code Code Footnote Code Footnote G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text. 219 betaxolol Betoptic S O O 69 valdecoxib Bextra O 22 O 6 clarithromycin Biaxin P O X 29 6 clarithromycin, extended release Biaxin XL P O X 29 185 sodium citrate/ citric acid Bicitra P O X 262 sodium citrate/ citric acid Bicitra P O X 24 praziquantel Biltricide O O 233 sulfacetamide/ prednisolone acetate Blephamide P O X 49 timolol maleate Blocadren O O 189 terbutaline sulfate Brethaire P O X 188 terbutaline sulfate Brethine P O X 188 terbutaline sulfate Bricanyl O O X 207 pseudoephedrine/ brompheniramine Bromfed O O 193 theophylline, capsules Bronkodyl O O 38 bumetanide Bumex O O 77 buspirone Buspar O O 157 belladonna extract/ butabarbital sodium Butibel O O

101 butabarbital sodium Butisol Sodium O O 71 ergotamine tartrate/ caffeine Cafergot O O 47 verapamil Calan O O 47 verapamil, sustained release Calan SR O O 178 cellulose sodium phosphate Calcibind P O X 158 mepenzolate bromide Cantil O O 246 chloroxine Capitrol O O 56 captopril Capoten O O 56 captopril/ hctz Capozide O O 156 sucralfate Carafate O O 220 carbachol Carbastat O O 107 , extended release Carbatrol O O 213 dextromethorphan/ pseudoephedrine/ Cardec DM Drops G G carbinoxamine HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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 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. 3/1/04 - 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 205 desloratadine Clarinex O O 8 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

122 estradiol/ norethindrone acetate, Combipatch O O transdermal HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 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 249 neomycin/ poly+D2035myxin B/ Cortisporin Cream P O X hydrocortiso+D2042ne, topical HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 , vaginal 8% Crinone 8% O 2 O 2 20 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 Cytoxan P O X 209 phenylephrine/ chlorpheniramine/ D.A chew O O methscopolamine 98 flurazepam Dalmane O O 135 danazol Danocrine P O X 109 dantrolene Dantrium O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 255 desonide 0.05%, cream/ ointment Desowen O O 255 desonide 0.05%, lotion Desowen O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 173 olsalazine sodium Dipentum O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 / 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 , transdermal Duragesic P O X 208 pseudoephedrine/ chlorpheniramine Dura-Tap/PD O O 214 guaifenesin Duratuss GO O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 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 256 lidocaine/ prilocaine EMLA O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 96 lithium carbonate, controlled release Eskalith CR P O X X

118 ethinyl estradiol Estinyl O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 122 ethinyl estradiol/ norethindrone acetate Femhrt O O

119 estradiol, transdermal FemPatch O O 67 butalbital/ apap/ caffeine Fioricet O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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/ 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 microsize Fulvicin-U/F O O 244 nitrofurazone Furacin O O 25 nitrofurantoin Furadantin O O 25 furazolidone Furoxone O O 107 tiagabine Gabatril P O X 10 sulfamethoxazole Gantanol O O 10 sulfisoxazole Gantrisin P O X 233 sulfisoxazole diolamine, ophthalmic Gantrisin O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 235 idoxuridine Herplex P O X 24 diethylcarbamazine citrate Hetrazan O O 30 altretamine Hexalen P O X 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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/ Kaletra P O X 9 kanamycin sulfate Kantrex O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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 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 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 / 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 Lipitor 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 / 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 , inhaler Nicotrol inhaler O O 116 nicotine, nasal spray Nicotrol NS O O 28 nilutamide Nilandron O O 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 43 nitroglycerin, sublingual Nitrostat G G X 12 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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 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

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 prednisone Orasone G G X 214 guaifenesin Organidin NRO O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 144 tolbutamide Orinase O O 119 dienestrol, vaginal Ortho Dienestrol O O 118 estropipate Ortho-EST G G X 128 ethinyl estradiol/ 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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 prednisolone sodium phosphate, oral Pediapred P O X

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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 P X 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 P 6 P 6 X 6 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 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 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 Prograf P O X 88 fluphenazine Prolixin O O 121 progesterone, micronized Prometrium P O X 44 procainamide Pronestyl O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 Rapamune O O 22 ribavirin Rebetol P O X 72 metoclopramide Reglan O O 165 metoclopramide Reglan O O HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 261 becaplermin Regranex O O 54 reserpine/ chlorthalidone Regroton O O 68 nabumetone Relafen O O 21 zanamivir Relenza O O 80 mirtazapine Remeron G G X X 80 mirtazapine Remeron Soltab G G X X 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 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 Risperdal-M P O X X 62 methylphenidate Ritalin O 8 O 8 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 Sustiva P O X 21 amantadine Symmetrel O O 111 amantadine Symmetrel O O 255 fluocinolone acetonide 0.01% Synalar O O 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 21 oseltamivir Tamiflu O O 6 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 Terazol 3 O O 13 terconazole Terazol 7 O O 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 193 theophylline, liquid Theolair O O 193 theophylline, tablets Theolair O O 27 thioguanine Thioguanine P O X 267 tiopronin Thiola O O 72 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 Vexol O O 133 sildenafil Viagra O 2 O 2 5 doxycycline hyclate Vibramycin O O 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 166 pancrelipase Viokase/Cotazym P O X 69 rofecoxib Vioxx P 22 O X 22 235 vidarabine Vira-A P O X HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 20 nelfinavir mesylate Viracept P O X 18 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 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 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 56 lisinopril Zestril O O 50 bisoprolol/ hctz Ziac O O 17 abacavir sulfate Ziagen P O X 6 azithromycin Zithromax O O X 16 60 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 HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 3/1/04 - 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. 22 acyclovir Zovirax O O 248 acyclovir ointment Zovirax P O X 116 bupropion, extended release Zyban P O X X 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

Top View