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FORMULARY - Listed Alphabetically by BRAND Name Rev

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