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3 Tier Copay 23 Therapeutic Categories Note: Non-Preferred Drugs Include All Forms of the Drugs

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3 Tier Copay 23 Therapeutic Categories Note: Non-Preferred Drugs Include All Forms of the Drugs 3 Tier Copay 23 Therapeutic Categories Note: Non-preferred drugs include all forms of the drugs Therapeutic Categories Preferred drugs Non-Preferred Drugs Cholesterol Lowering Agents Lipitor (atorvastatin) Zocor (simvastatin) (HMG-CoA ) Pravachol (pravastatin) Mevacor* (lovastatin) Lescol (fluvastatin) Antidepressants – Celexa (citalopram) Remeron (mirtazapine) Selective Serotonin Reuptake Effexor (venlafaxine) Serzone (nefazodone) Inhibitors Effexor XR (venlafaxine) (SSRI) and newer non-SSRI Paxil (paroxetine) Wellbutrin* (bupropion) Wellbutrin SR (bupropion) Zoloft (sertraline) Prozac* (fluoxetine) Luvox (fluvoxamine) High Blood Pressure Agents – Accupril (quinapril) Aceon (perindopril erbumine ) Angiotension Converting Capoten* (captopril) Monopril (fosinopril) Enzyme Inhibitors (ACEI) Altace (ramipril) Lotensin (benazepril) Zestril (lisinopril) Mavik (trandolapril) Vasotec (enalapril) Prinivil (lisinopril) Univasc (moexipril) High Blood Pressure Agents – Cozaar (losartan) Atacand (candesartan) Angiotensin Receptor Hyzaar(losartan/hctz) Micardis (telmisartan) Blockers (ARB) Diovan (valsartan) Teveten (eprosartan mesylate) Diovan HCT (valsartan/hctz) Avapro (irbesartan) Avalide (irbesartan/hctz) Benicar (olmesartan) Pain Agents – Cataflam* (diclofenac) Bextra (valdecoxib) Non- Steroidal Anti- Daypro (oxaprozin) Vioxx (rofecoxib) inflammatory Drugs and Lodine XL* (etodolac) COX-2s Relafen (nabumetone) Celebrex (celecoxib) Toradol *(ketorolac) Voltaren *(diclofenac) Lodine *(etodolac) Ansaid *(flurbiprofen) Indocin* (indomethacin) Nalfon* (fenoprofen) Ponstel (mefenamic acid) Mobic (meloxicam) Feldene* (piroxicam) Clinoril *(sulindac) Tolectin DS* (tolmetin) *This drug has a generic equivalent. This list is updated every quarter. Every effort has been made to show these listings accurately, but additions, deletions and changes will occur. Through the 2003 plan year there may be changes to the Therapeutic Categories List, however we do not anticipate significant changes. Blue Cross and Blue Shield of Texas, a Division of Health care Service Corporation, a Mutual Legal Reserve CompanyH 4Q 2002 Southwest Texas HMO, Inc.H d/b/a HMO Blue® Texas 8709.455-0203 HIndependent Licensees of the Blue Cross and Blue Shield Association Therapeutic Categories Preferred drugs Non-Preferred Drugs Heartburn Agents – Aciphex (rabeprazole) Prevacid (lansoprazole) Proton Pump Inhibitors (PPI) Prilosec (omeprazole) Protonix (pantoprazole) Nexium (esomeprazole) Anti-Migraines Imitrex (sumatriptan) Axert (almotriptan) Zomig (zolmitriptan) Maxalt (rizatriptan) Maxalt MLT (rizatriptan) Frova (frovatriptan) Amerge (naratriptan) Asthma Agents – Beclovent (beclomethasone dipropionate) Aerobid (flunisolide) Inhalers - Steroid and Flovent (fluticasone propionate) Azmacort (triamcinolone acetonide) Beta Agonist Maxair Autoinhaler (short acting) Tornalate (bitolterol mesylate) Nasonex (mometasone furoate monohydrate) Vancenase (beclomethasone dipropionate) Pulmicort (budesonide) Vancenase AQ (beclomethasone dipropionate) Serevent (salmeterol) Vanceril (beclomethasone dipropionate) Flonase (fluticasone) Foradil (formoterol) Rhinocort (budesonide) Nasacort (triamcinolone) Nasacort AQ (triamcinolone) Beconase (beclomethasone) Beconase AQ (beclomethasone) Nasalide (flunisolide) Nasarel (flunisolide) High Blood Pressure Agents – Adalat CC* (nifedipine SR) Dilacor XR (diltiazem) Calcium Channel Calan SR* (verapamil SR) Plendil (felodipine) Blockers (CCB) Cardizem CD* (diltiazem SR) Procardia XL(nifedipine SR) Norvasc (amlodipine) Sular (nisoldipine) Cardene* (nicardipine) Vascor (bepridil) Tiazac (diltiazem) Verelan(verapamil SR) Nimotop (nimodipine) Dynacirc CR (isradipine) Antifungals Lamisil tablets (terbinafine) Sporanox (itraconazole) Allergy Agents – Clarinex (desloratadine) Zyrtec (cetirizine) Non-Sedating Antihistamine Allegra (fexofenadine) Hormone Replacement Premarin (conjugated estrogens) Cenestin (synthetic conjugated estrogen) Therapy CombiPatch (estradiol/norethindrone) FemHRT (ethinyl estradiol/norethindrone) OrthoPrefest (estradiol/norgestimate) Activella (estradiol/norethindrone) Prempro (conjugated Premphase ( conjugated estrogen/medroxyprogesterone) estrogen/medroxyprogesterone) Estrace (estradiol) Estratab (esterified estrogen) Climara (estradiol transdermal) Menest (esterified estrogen) *This drug has a generic equivalent This list is updated every quarter. Every effort has been made to show these listings accurately, but additions, deletions and changes will occur. Through the 2003 plan year there may be changes to the Therapeutic Categories List, however we do not anticipate significang changes. 2 Therapeutic Categories Preferred drugs Non-Preferred Drugs Topical Antifungals Mycostatin* (nystatin) Mentax (butenafine) Monistat-Derm (miconazole) Oxistat (oxiconazole) Fungoid (triacetin) Loprox (ciclopirox) Naftin (naftifine) Spectazole (econazole) Nizoral (ketoconazole) Versiclear (sodium thiosulfate) Tinver (sodium thioosulfate) Exelderm (sulconazole) High Blood Pressure Agents – Lexxel (enalapril /felodipine) Tarka (trandolapril/verapamil) Angiotensin Converting Teczem (enalapril /diltiazem ) Enzyme Inhibitors/ Calcium Lotrel (benazepril/amlodipine) Channel Blockers (ACEI/CCB) Oral Diabetic Actos (rosiglitazone) (Thiazolidinediones) Avandia (pioglitazone) Antivirals - Zovirax(acyclovir) Valtrex (valcyclovir) Anti-Herpes Famvir (famciclovir) Influenza Flumadine* (rimantadine) Tamiflu (oseltamivir) Relenza (zanamivir) Bone Loss Slowing Agents– Actonel (risedronate) Skelid (tiludronate) Oral Bisphosphonates Didronel (etidronate) Fosamax (alendronate) Tranquilizer/Sleeping Agents - Halcion* (triazolam) Ambien (zolpidem tartrate) Sedative Hypnotics- ProSom* (estazolam) Sonata (zaleplon) Nonbarbiturate Restoril* (temazepam) Placidyl (ethchlorvynol) Somnote* (chloral hydrate) Doral (quazepam) Dalmane* (flurazepam) Asthma Agents – Singulair (montelukast sodium) Accolate (zafirlukast) Leukotriene Receptor Zyflo (zileuton) Antagonists *This drug has a generic equivalent This list is updated every quarter. Every effort has been made to show these listings accurately, but additions, deletions and changes will occur. Through the 2003 plan year there may be changes to the Therapeutic Categories List, however we do not anticipate significang changes. 3 Therapeutic Categories Preferred drugs Non-Preferred Drugs Inflammation Reducing Low Potency: Low potency: Agents– Capex ( formally FS Shampoo) (fluocinolone Aclovate (alclometasone 0.05%) Topical Corticorsteroids acetonide) DesOwen (desonide) Synalar (fluocinolone 0.01%) Kenalog* (triamcinolone 0.025%) Medium potency: Westcort (hydrocortisone valerate Cutivate (fluticasone) Cordran (flurandrenolide) Medium Potency: Locoid (hydrocortisone butyprate) Elocon (mometasone) Cloderm (clocortolone) Pandel (hydrocortisone propionate 0.1%) Valisone* (betamethasone 0.1%) Luxiq (betmethasone 0.1%) Synalar* (fluocinolone 0.025%) Kenalog* (triamcinolone 0.1%) High Potency: Halog, Halog E (halcinonide 0.1%) Cyclocort (amcinonide 0.1%) Kenalog* (triamcinolone 0.5%) Lidex* (fluocinonide 0.05%) Diprosone (betamethasone 0.05%) Maxivate (betamethasone 0.05%) Very High: Ultravate (halobetasol) Olux (clobetasol propionate 0.05%) Diprolene (augmented betamethasone dipropionate) Diprolene AF (augmented betametasone dipropionate) Temovate* (clobetasol propionate) Antibiotics – Levaquin (levofloxacin) Avelox (moxifloxacin) Quinolones Avelox ABC Pack (moxifloxacin) Floxin (ofloxacin) Cipro (ciprofloxacin) Maxaquin (lomefloxacin) Noroxin (norfloxacin) Tequin (gatifloxacin) Antibiotics – Zithromax (azithromycin) Biaxin (clarithromycin) Macrolides Biaxin XL (clarithromycin) (2nd generation) Dynabac (dirithromycin) *This drug has a generic equivalent This list is updated every quarter. Every effort has been made to show these listings accurately, but additions, deletions and changes will occur. Through the 2003 plan year there may be changes to the Therapeutic Categories List, however we do not anticipate significang changes. 4 Therapeutic Categories Preferred drugs Non-Preferred Drugs Oral Contraceptives Monophasic Ortho-Cyclen (ethinyl estradiol/ norgestimate) Yasmin (ethinyl estradiol/ drospirenone) Nordette (ethinyl estradiol/ levonorgestrel) Ovcon 35 (ethinyl estradiol/ norethindrone) Alesse (ethinyl estradiol/ levonorgestrel) Ovcon 50 (ethinyl estradiol/ norethindrone) Lo/Ovral* (ethinyl estradiol/ norgestrel) Ortho-Cept* (ethinyl estradiol/ desogestrel) Ortho-Novum 1/35* (ethinyl estradiol/ norethindrone) Ortho-Novum 1/50* (ethinyl estradiol/ norethindrone) Ovral (ethinyl estradiol/ norgestrel) Demulen 1/50* (ethinyl estradiol/ ethynodiol) Demulen 1/35* (ethinyl estradiol/ ethynodiol) Norinyl 1/35* (mestranol/ norenthindrone) Norinyl 1/50* (mestranol/ norenthindrone) Loestrin (Fe) 1/20* (ethinyl estradiol/ norethindrone) Loestrin (Fe) 1.5/30* (ethinyl estradiol/ norethindrone acetate) Levlen (ethinyl estradiol/ norgestrel) Desogen* (ethinyl estradiol/ desogestrel) Modicon* (ethinyl estradiol/ norethindrone) Levlite (ethinyl estradiol/ levonorgestrel) Biphasic Ortho-Novum 10/11* (ethinyl estradiol/ norethindrone) Mircette (ethinyl estradiol/ desogestrel) Jenest (ethinyl estradiol/ norethindrone) Triphasic Ortho-TriCyclen (ethinyl estradiol/ norgestimate) Cyclessa (ethinyl estradiol/ desogestrel) Ortho-TriCyclen Lo (ethinyl estradiol/ Estrostep (Fe) (ethinyl estradiol/ norethindrone norgestimate) acetate) Ortho-Novum 7/7/7 (ethinyl estradiol/ Tri-Norinyl (ethinyl estradiol/ norethindrone) norethindrone) Triphasil* (ethinyl estradiol/ levonorgestrel) Trilevlen (ethinyl estradiol/ levonorgestrel) Progestin Only Micronor (norethindrone) Ovrette (norgestrel) Miscellaneous products Ortho –Evra (norelgestromin/ethinyl estradiol transdermal system) NuvaRing (etonogestrel/ethinyl estradiol) *This drug has a generic equivalent This list is updated every quarter. Every effort has been made to show these listings accurately, but additions, deletions and changes will occur. Through the 2003 plan year there may be changes to the Therapeutic Categories List, however we do not anticipate significang changes. 5 .
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