® Registered Marks Blue Cross and Blue Shield Association Drug formulary for Blue Cross and Blue Shield of Oklahoma and BlueLincs HMO - Effective July 1, 2005

The Formulary is a list of preferred medications, and all plans may not provide coverage for all medications listed. Coverage of prescription drugs and supplies listed on the drug list/formulary is subject to your benefit plan's design and coverage provisions. If there are any differences between the information contained herein and a specific plan document, the plan document will govern. For additional questions about benefits or coverage, call the customer service phone number printed on your Blue Cross and Blue Shield ID card.

1.1 - Penicillins Amoxicillin AUGMENTIN - 8 hr dosing Amoxicillin/potassium clavulanate - 12 hr dosing Ampicillin AUGMENTIN XR Dicloxacillin Penicillin v potassium (All other Generics)

1.2 - Cephalosporins Cefadroxil OMNICEF VANTIN Cefuroxime axetil Cephalexin (All other Generics)

1.3 - Macrolide antibiotics Erythromycin delayed-rel caps ERY-TAB BIAXIN Erythromycin ethylsuccinate ZITHROMAX BIAXIN XL Erythromycin stearate

Page 1 of 25 (All other Generics)

1.4 - Tetracyclines Demeclocycline Doxycycline hyclate Minocycline Tetracycline (All other Generics)

1.5 - Fluoroquinolones Ciprofloxacin tabs LEVAQUIN AVELOX (All other Generics)

1.6 - Aminoglycosides Neomycin sulfate tabs TOBI NEB SOLUTION (All other Generics)

1.7 - Sulfonamides (All other Generics)

1.8 - Antimycobacterial agents Ethambutol MYCOBUTIN Isoniazid tabs Pyrazinamide Rifampin (All other Generics)

1.9 - Antifungals Fluconazole GRIFULVIN V tabs MYCELEX TROCHES Griseofulvin microsize susp Ketoconazole

Page 2 of 25 Itraconazole (All other Generics)

1.10 - Antiviral ALL BRANDS FOR HIV Acyclovir FLUMADINE syrup INFERGEN Didanosine delayed-rel HEPSERA INTRON A Ganciclovir VALTREX PEG-INTRON Ribavirin caps REBETRON Rimantadine tabs ROFERON A (All other Generics)

1.11 - Antimalarial Chloroquine phosphate 500 mg FANSIDAR Hydroxychloroquine MALARONE Mefloquine PRIMAQUINE (All other Generics)

1.12 - Amebicides (All other Generics)

1.13 - Anthelmintic Mebendazole MINTEZOL (All other Generics)

1.14 - Misc. anti-infectives Clindamycin CLEOCIN PEDIATRIC soln Erythromycin/sulfisoxazole KETEK Metronidazole tabs Sulfamethoxazole/trimethoprim Trimethoprim (All other Generics)

Page 3 of 25 CHAPTER 2 BIOLOGICALS

CHAPTER 3 ANTINEOPLASTICS AGENTS 3.1 - Antineoplastics Cyclophosphamide ALKERAN HYDREA Etoposide AROMASIN IMURAN Flutamide CASODEX NEORAL Hydroxyurea CEENU SANDIMMUNE Leucovorin calcium LEUKERAN Megestrol MATULANE Mercaptopurine TARGRETIN caps Methotrexate TEMODAR Tamoxifen (All other Generics)

CHAPTER 4 ENDOCRINE AND METABOLIC DRUGS 4.1 - Corticosteroids Cortisone acetate Dexamethasone Fludrocortisone Hydrocortisone tabs, 20 mg Methylprednisolone Prednisolone sodium phosphate soln Prednisolone syrup, tabs Prednisone (All other Generics)

4.2 - Androgen-anabolic

Page 4 of 25 (All other Generics) ANDROID TESTIM topical gel

4.3 - Estrogens Esterified estrogens/methyltestosterone ACTIVELLA Estradiol patches, tabs ESTRADERM Estropipate ESTROGEL (All other Generics) PREMARIN tabs PREMPHASE PREMPRO VIVELLE VIVELLE-DOT

4.4 - Contraceptives Desogestrel/ethinyl estradiol, biphasic - Kariva NUVARING TRI-NORINYL Desogestrel/ethinyl estradiol, 0.15/30 - Apri, Solia ORTHO EVRA Ethynodiol/ethinyl estradiol - Zovia 1/35, 1/50 ORTHO TRI-CYCLEN LO Levonorgestrel/ethinyl estradiol, 0.1/20 - Aviane, Lutera YASMIN Levonorgestrel/ethinyl estradiol, triphasic - Enpresse, Trivora Levonorgestrel/ethinyl estradiol, 0.15/30 - Levora, Portia Norethindrone/mestranol - Necon 1/50 Norethindrone - Camila, Errin, Jolivette, Nora-Be Norethindrone acetate/ethinyl estradiol, 1/20, 1.5/30 - Junel, Microgestin Norethindrone acetate/ethinyl estradiol/Fe, 1/20, 1.5/30 - Junel Fe, Microgestin Fe Norethindrone/ethinyl estradiol, 0.5/35, 1/35 - Necon, Nortrel Norethindrone/ethinyl estradiol, biphasic - Necon 10/11 Norethindrone/ethinyl estradiol, triphasic, 7/7/7 - Necon, Nortrel Norgestimate/ethinyl estradiol, 0.25/35 - Mononessa, Previfem, Sprintec Norgestimate/ethinyl estradiol, triphasic - Trinessa, Tri-Previfem, Tri-Sprintec

Page 5 of 25 Norgestrel/ethinyl estradiol, 0.3/30 - Cryselle, Low-Ogestrel; 0.5/50 - Ogestrel (All other Generics)

4.5 - Progestins Medroxyprogesterone acetate PROMETRIUM Norethindrone acetate (All other Generics)

4.6 - Antidiabetic Glipizide immed-rel, ext-rel ACTOS GLUCAGON EMERGEN KIT Glyburide AMARYL Metformin immed-rel, ext-rel AVANDAMET (All other Generics) AVANDIA STARLIX Rapid-Acting Insulins HUMALOG NOVOLOG Short-Acting Insulins HUMULIN R NOVOLIN R Intermediate-Acting Insulins HUMULIN L HUMULIN N NOVOLIN N HUMULIN 50/50 HUMULIN 70/30 NOVOLIN 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 Long-Acting Insulins HUMULIN U

Page 6 of 25 Basal Insulins LANTUS

4.7 - Thyroid Levothyroxine - includes Levoxyl THYROLAR Methimazole SYNTHROID Propylthiouracil Thyroid (All other Generics)

4.8 - Oxytocics (All other Generics) METHERGINE

4.9 - Misc. endocrine Clomiphene ACTONEL SANDOSTATIN Desmopressin nasal soln, spray DDAVP tabs DOSTINEX (All other Generics) FOSAMAX HECTOROL MIACALCIN nasal SENSIPAR STIMATE nasal

CHAPTER 5 CARDIOVASCULAR 5.1 - Cardiotonics Digoxin LANOXIN PEDIATRIC ELIXIR (All other Generics)

5.2 - Antianginal agents

Page 7 of 25 Isosorbide dinitrate NITROLINGUAL Isosorbide mononitrate immed-rel, ext-rel Nitroglycerin patches, sublingual tabs (All other Generics)

5.3 - Beta blockers Acebutolol COREG Atenolol TOPROL XL Labetalol Metoprolol Nadolol Pindolol Propranolol Sotalol Sotalol AF Timolol (All other Generics)

5.4 - Calcium blockers Diltiazem immed-rel, ext-rel - 24 hr dosing NORVASC Nifedipine ext-rel Verapamil immed-rel, ext-rel (All other Generics)

5.5 - Antiarrhythmic Amiodarone PACERONE 100, 300, 400 mg Disopyramide immed-rel, ext-rel Flecainide Mexiletine Propafenone Quinidine gluconate ext-rel

Page 8 of 25 Quinidine sulfate (All other Generics)

5.6 - Antihypertensive Atenolol/chlorthalidone ALTACE ACCUPRIL Benazepril COZAAR TARKA Benazepril/hydrochlorothiazide DIBENZYLINE Bisoprolol/hydrochlorothiazide DIOVAN Captopril DIOVAN HCT Captopril/hydrochlorothiazide HYZAAR Clonidine LOTREL Doxazosin Enalapril Enalapril/hydrochlorothiazide Guanfacine Hydralazine Lisinopril Lisinopril/hydrochlorothiazide Methyldopa Minoxidil Prazosin Propranolol/hydrochlorothiazide Quinapril Quinapril/hydrochlorothiazide Terazosin (All other Generics)

5.7 - Diuretics Acetazolamide DIAMOX SEQUELS Amiloride Amiloride/hydrochlorothiazide

Page 9 of 25 Bumetanide Chlorothiazide Chlorthalidone 25, 50 mg furosemide soln, 10 mg/mL; tabs Hydrochlorothiazide Indapamide Methazolamide Metolazone Spironolactone Spironolactone/hydrochlorothiazide Triamterene/hydrochlorothiazide (All other Generics)

5.8 - Pressors Midodrine (All other Generics)

5.9 - Antihyperlipidemic Cholestyramine COLESTID LESCOL Gemfibrozil LIPITOR PRAVACHOL Lovastatin NIASPAN ADVICOR (All other Generics) TRICOR VYTORIN ZETIA ZOCOR

5.10 - Misc. cardiovascular (All other Generics) CADUET PROAMATINE TRACLEER EPIPEN

Page 10 of 25 CHAPTER 6 RESPIRATORY AGENTS 6.1 - Antihistamines Cyproheptadine tabs ALLEGRA CLARINEX SYRUP Promethazine supp, syrup, tabs ZYRTEC OPTIMINE (All other Generics)

6.2 - Systemic and topical nasal products Flunisolide 0.025mg/spray ASTELIN Ipratropium bromide BACTROBAN nasal BACTROBAN OINT (All other Generics) FLONASE BECONASE NASACORT AQ BECONASE AQ NASONEX RHINOCORT AQUA

6.3 - Cough/cold/allergy Acetylcysteine ALLEGRA-D TRINALIN Brompheniramine/pseudoephedrine ext-rel caps, 6/60, 10/120, 12ZYRTEC-D TUSSIONEX Carbinoxamine/pseudoephedrine soln, 1-15/mL; syrup, 2-25/5 mL; tabs, 4/60; ext-rel tabs, 8/120 Chlorpheniramine/pseudoephedrine/codeine soln, 2-30-10/5 mL Codeine/guaifenesin soln, syrup, 10-100/5 mL; tabs, 10/300 Hydrocodone/guaifenesin syrup, 2.5-200/5 mL, 5-100/5 mL Pseudoephedrine/guaifenesin ext-rel caps 60/300; ext-rel tabs 45/600, 60/600, 120/600 (All other Generics)

6.4 - Antiasthmatic Albuterol inhaler ACCOLATE QVAR

Page 11 of 25 Albuterol sulfate neb soln, syrup, tabs ADVAIR DISKUS MAXAIR AEROSOL Cromolyn sodium neb soln ATROVENT INHALER PULMOZYME Ipratropium bromide neb soln COMBIVENT Terbutaline FLOVENT Theophylline ext-rel FLOVENT HFA (All other Generics) FORADIL AEROLIZER PULMICORT RESPULES PULMICORT TURBUHALER SEREVENT DISKUS SINGULAIR SPIRIVA HANDIHALER TILADE

CHAPTER 7 GASTROINTESTINAL AGENTS 7.1 - Laxatives Lactulose PEG-electrolytes for soln Polyethylene glycol 3350 (All other Generics)

7.4 - Ulcer drugs Cimetidine ACIPHEX CYTOTEC Dicyclomine PROTONIX Famotidine Hyoscyamine immed-rel, ext-rel Omeprazole delayed-rel Ranitidine Sucralfate (All other Generics)

Page 12 of 25 7.5 - Antiemetics Trimethobenzamide ZOFRAN ANZEMET Trimethobenzamide/benzocaine ZOFRAN ODT TORECAN (All other Generics) TRANSDERM-SCOP

7.6 - Digestive aids (All other Generics) CREON PANCREASE LIPRAM/CR/PN/UL PANCREASE MT PANCREASE/MT PANCRELIPASE IR caps, 20-4-25 PANCRELIPASE IR tabs, 30-8-30 - various tradenames PANOKASE-16 ULTRASE/MT VIOKASE 16 VIOKASE powder

7.7 - Misc. gi Lactulose - encephalopathy ASACOL ENTOCORT EC Mesalamine enema CANASA ZELNORM Metoclopramide PHOSLO Sulfasalazine Ursodiol (All other Generics)

CHAPTER 8 GENITOURINARY PRODUCTS 8.1 - Urinary anti-infectives Nitrofurantoin macrocrystals HIPREX Nitrofurantoin monohydrate/macrocrystals (All other Generics)

Page 13 of 25 8.2 - Urinary antispasmodics Oxybutynin DETROL (All other Generics) DETROL LA

8.3 - Vaginal products Acetic acid vaginal gel CLEOCIN vaginal supp Amino acid/urea cervical crm ESTRACE vaginal crm Clindamycin vaginal crm METROGEL VAGINAL (All other Generics) PREMARIN vaginal crm TERAZOL 3 vaginal supp

8.4 - Misc. genitourinary products Potassium citrate/citric acid AVODART Tricitrates soln FLOMAX Sodium citrate/citric acid PROSCAR (All other Generics)

CHAPTER 9 CENTRAL NERVOUS SYSTEM AGENT 9.1 - Antianxiety agents Alprazolam Buspirone Diazepam Hydroxyzine hcl Hydroxyzine pamoate Lorazepam (All other Generics)

9.2 - Antidepressants

Page 14 of 25 Amitriptyline EFFEXOR CYMBALTA Bupropion immed-rel, ext-rel EFFEXOR XR NARDIL Clomipramine PAXIL CR PARNATE Citalopram PAXIL susp VIVACTIL Desipramine WELLBUTRIN XL Doxepin ZOLOFT Fluoxetine Imipramine hcl Mirtazapine Nortriptyline Paroxetine hcl Trazodone (All other Generics)

9.3 - Antipsychotics Chlorpromazine hcl MOBAN Clozapine 25, 100 mg RISPERDAL Fluphenazine hcl RISPERDAL M-TAB Haloperidol 0.5, 1, 2, 5 mg SEROQUEL Haloperidol lactate conc Lithium carbonate immed-rel, ext-rel Lithium citrate syrup Loxapine Perphenazine Prochlorperazine supp, 25 mg Prochlorperazine tabs Thioridazine conc; tabs, 10, 25, 50, 100 mg Thiothixene Trifluoperazine (All other Generics)

Page 15 of 25 9.4 - Hypnotics Chloral hydrate syrup AMBIEN Estazolam Phenobarbital Temazepam (All other Generics)

9.5 - Adhd/anti-narcolepsy/anti-obesity/anorexiants Amphetamine/dextroamphetamine mixed salts ADDERALL XR Dextroamphetamine immed-rel, ext-rel CONCERTA Methylphenidate immed-rel, ext-rel RITALIN LA (All other Generics)

9.6 - Misc. psychotherapeutic and neurological agents Bupropion ext-rel - smoking deterrent ORAP ARICEPT (All other Generics) AVONEX BETASERON COPAXONE EXELON NAMENDA

CHAPTER 10 ANALGESIC AGENTS 10.1 - Analgesics - nonnarcotic Butalbital/acetaminophen Butalbital/acetaminophen/caffeine Butalbital/aspirin/caffeine Salsalate (All other Generics)

10.2 - Analgesics - narcotic

Page 16 of 25 Acetaminophen/codeine OXYCONTIN (all except 80 mg) Aspirin/codeine Butalbital/aspirin/caffeine/codeine Fentanyl patches Hydrocodone/acetaminophen Hydromorphone Methadone conc, tabs Morphine sulfate soln, tabs, ext-rel tabs, supp Oxycodone immed-rel, conc includes Oxyfast; ext-rel 80 mg Oxycodone/acetaminophen Oxycodone/aspirin Pentazocine/naloxone Propoxyphene hcl Propoxyphene hcl/acetaminophen Propoxyphene napsylate/acetaminophen 50/325, 100 (All other Generics)

10.3 - Analgesics - anti-inflammatory Diclofenac sodium delayed-rel, ext-rel RIDAURA Etodolac ENBREL Ibuprofen Indomethacin Ketoprofen Nabumetone Naproxen Naproxen sodium Piroxicam Sulindac (All other Generics)

10.4 - Migraine products

Page 17 of 25 Acetaminophen/isometheptene/dichloralphenazone DEPAKOTE ER AXERT (All other Generics) IMITREX nasal spray IMITREX injectable IMITREX tabs MIGRANAL ZOMIG ZOMIG nasal spray ZOMIG ZMT

10.5 - Gout Allopurinol Colchicine Probenecid (All other Generics)

CHAPTER 11 NEUROMUSCULAR AGENTS 11.1 - Anticonvulsant Carbamazepine CELONTIN KEPPRA Clonazepam DEPAKOTE LAMICTAL Ethosuximide DIASTAT NEURONTIN Gabapentin DILANTIN INFATABS Phenytoin sodium extended DILANTIN susp Phenytoin susp Primidone Valproic acid (All other Generics)

11.2 - Antiparkinsonian Amantadine MIRAPEX COMTAN Benztropine PARCOPA Bromocriptine REQUIP

Page 18 of 25 Carbidopa/levodopa immed-rel, ext-rel Pergolide Selegiline Trihexyphenidyl (All other Generics)

11.3 - Neuromuscular agents (All other Generics) RILUTEK

11.4 - Musculoskeletal therapy agents Baclofen SKELAXIN Cyclobenzaprine Dantrolene Methocarbamol Orphenadrine ext-rel Orphenadrine/aspirin/caffeine Tizanidine (All other Generics)

11.5 - Antimyasthenic agents Pyridostigmine MESTINON SYRUP (All other Generics)

CHAPTER 12 NUTRITIONAL PRODUCTS 12.1 - Vitamins Calcitriol MEPHYTON Ergocalciferol (All other Generics)

12.2 - Multivitamins

Page 19 of 25 Pediatric multivitamins/fluoride Pediatric multivitamins/fluoride/iron Pediatric vitamins ADC/fluoride Pediatric vitamins ADC/fluoride/iron Prenatal multivitamins/1 mg folic acid (All other Generics)

12.3 - Minerals and electrolytes Potassium bicarbonate/chloride effervescent 25 mEq Potassium chloride soln, ext-rel Potassium phosphate/sodium phosphates Sodium fluoride (All other Generics)

CHAPTER 13 HEMATOLOGICAL AGENTS 13.1 - Hematopoietic agents Folic acid 1mg EPOGEN (All other Generics) LEUKINE LOVENOX NEUMEGA NEUPOGEN PROCRIT

13.2 - Anticoagulants Warfarin COUMADIN (All other Generics)

13.4 - Misc. hematological Anagrelide PLAVIX PLAVIX

Page 20 of 25 Pentoxifylline ext-rel PLETAL Cilostazol (All other Generics)

CHAPTER 14 TOPICAL PRODUCTS 14.1 - Ophthalmic Atropine sulfate oint, soln ACULAR CYCLOGYL Bacitracin/polymyxin B oint ACULAR LS LACRISERT Brimonidine 0.2% soln ACULAR PF Carbachol soln ALPHAGAN P Carteolol soln ALREX Ciprofloxacin soln AZOPT Cromolyn sodium soln BETIMOL Cyclopentolate soln BETOPTIC-S Dexamethasone sodium phosphate soln BLEPHAMIDE Erythromycin oint BLEPHAMIDE S.O.P. Fluorometholone susp CILOXAN oint Gentamicin oint, soln COSOPT Homatropine soln LOTEMAX Levobunolol soln LUMIGAN Metipranolol soln OPTIVAR Neomycin/polymyxin B/bacitracin oint PATANOL Neomycin/polymyxin B/bacitracin/hydrocortisone oint TOBRADEX Neomycin/polymyxin B/dexamethasone oint, susp TRUSOPT Neomycin/polymyxin B/gramicidin soln VIGAMOX Ofloxacin soln VOLTAREN eye soln Pilocarpine soln XALATAN Polymyxin B/trimethoprim soln ZADITOR Prednisolone acetate susp Prednisolone sodium phosphate 1% soln Sulfacetamide sodium soln

Page 21 of 25 Sulfacetamide sodium/prednisolone soln Timolol maleate soln, gel-forming soln Tobramycin soln Trifluridine soln (All other Generics)

14.2 - Otic Acetic acid Benzocaine/antipyrine CIPRO HC Hydrocortisone/acetic acid CIPRODEX Neomycin/polymyxin B/hydrocortisone FLOXIN OTIC (All other Generics)

14.3 - Mouth and throat (local) Chlorhexidine MYCELEX TROCHE Lidocaine viscous SALAGEN Nystatin susp Pilocarpine hcl tabs, 5 mg Sodium fluoride dental crm, gel Triamcinolone acetonide dental paste (All other Generics)

14.4 - Anorectal Hydrocortisone acetate supp, 25 mg Hydrocortisone rectal crm, 2.5% Hydrocortisone enema (All other Generics)

14.5 - Dermatological Aluminum chloride DOVONEX ACLOVATE Anthralin ELIDEL BACTROBAN

Page 22 of 25 Betamethasone dipropionate FINACEA CARAC Betamethasone dipropionate, augmented crm, gel, oint METROGEL CONDYLOX Betamethasone valerate METROLOTION OXISTAT Ciclopirox crm, lotn OVIDE ZOVIRAX Clindamycin OXSORALEN Clobetasol OXSORALEN ULTRA Desonide PROTOPIC Desoximetasone TARGRETIN gel Diflorasone Doxepin Econazole Erythromycin Erythromycin/benzoyl peroxide Fluocinolone acetonide Fluocinonide Fluorouracil soln, 2%, 5% Gentamicin Hydrocortisone 2.5% Hydrocortisone acetate 2.5%/pramoxine 1% crm Hydrocortisone valerate Isotretinoin caps Ketoconazole crm Lidocaine crm, 3%; jelly, 2%; lotn, 3%; soln, 4% Lidocaine/prilocaine Lindane shampoo Metronidazole crm, 0.75% Mometasone crm, oint Mupirocin oint Nystatin crm, oint Nystatin/triamcinolone Permethrin crm, 5%

Page 23 of 25 Podofilox soln Selenium sulfide 2.5% Silver sulfadiazine Sulfacetamide sodium/sulfur lotn Tretinoin Triamcinolone acetonide (All other Generics)

CHAPTER 15 MISCELLANEOUS PRODUCTS 15.3 - Diagnostic products (All other Generics) ONE TOUCH FASTTAKE TEST STRIPS DEPEN ONE TOUCH II/BASIC/PROFILE TEST STRIPS ONE TOUCH SURESTEP TEST STRIPS ONE TOUCH ULTRA TEST STRIPS

15.6 - Medical devices (All other Generics) B-D INSULIN SYRINGES B-D LANCETS LIFESCAN LANCETS

15.8 - Assorted classes Azathioprine CELLCEPT Cyclosporine IMURAN Cyclosporine modified MYFORTIC Sodium polystyrene sulfonate PROGRAF (All other Generics) RAPAMUNE SANDIMMUNE Bupropion EFFEXOR Maprotiline HCl EFFEXOR XR

Page 24 of 25 Mirtazapine WELLBUTRIN SR (all except 100 mg) (All other Generics) WELLBUTRIN XL

Page 25 of 25