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Preferred Prescriptions®
Member GuidePlease bring this guide with you on your next doctor visit.
Medco manages your prescription drug benefit for your health plan.
PMS 2728C Black
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
NOTES
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Preferred Prescriptions® is a formulary list of medications that may be covered under your prescription drug plan. This list wasreviewed by an independent group of practicing doctors and pharmacists, and it contains medications made by most pharma-ceutical manufacturers. It includes medications for many coveredconditions.
BE SURE TO BRING THIS GUIDE WITH YOU ON EVERY VISITTO YOUR DOCTORPlease note: This guide does not contain a complete list of formulary and nonformulary drugs. It only lists the most commonly prescribed drugs. Visit www.medco.com anytime tocheck the price and coverage of medications under your plan.Simply select “Price a medication” from the left hand menu andsearch for your medication to see pricing. Click “View coveragenotes” on the pricing results page to see any coverage details. Ifyou are a first-time visitor to medco.com, please take a momentto register. (Be sure to have your member ID number and arecent prescription number handy.) Not all medications listedhere are covered by every prescription drug plan.
KEEPING COSTS DOWN SO YOUR COVERAGE CONTINUESOften, your doctor can choose among several drugs to treat a condition, and your plan may prefer some medications over others.These are called preferred drugs, and using them helps keep costsdown for your plan sponsor. This in turn helps ensure that yourplan will provide coverage for the medications you need in theyears ahead.
In many cases, using these preferred drugs can also save youmoney now. For example, brand-name drugs may have generic versions that may have a lower co-payment/co-insurance.
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MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
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FINDING MEDICATIONS WITH LOWERCO-PAYMENTS/CO-INSURANCEThis guide lists medications two ways to help you find somegeneric, preferred, and nonpreferred brand-name drugs.
SECTION I - ALPHABETICALLY BY DRUG CATEGORY (SUCH AS RESPIRATORY)Within each category, medications are listed in alphabetical order, with generic, preferred brand-name, and nonpreferredbrand-name drugs sorted separately:
G Means a preferred generic medicationP Means a preferred brand-name medicationNP Means a nonpreferred brand-name medication
SECTION II - ALPHABETICALLY BY BRAND NAMEAfter each nonpreferred brand-name drug, you will find possiblegeneric and preferred brand-name alternatives.
SAFETY CONSIDERATION SYMBOLSHere is a quick guide for you and your doctor.
Means weigh risk of birth defects or other adverse outcomes.
Means do not use in pregnancy.
The information in this guide was in effect at the time of printing and maybe subject to change.
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
3
SECTION I: THERAPEUTIC DRUG CATEGORIES
Oral PenicillinsG amoxicillin trihydrateG amoxicillin trihydrate/
potassium clavulanateG ampicillin trihydrateG dicloxacillin sodiumG penicillin v
potassiumP Augmentin Chewable
Tablet 250 - 62.5mgP Augmentin
Suspension 125 - 31.25mg/5
NP AmoxilNP Augmentin Chewable
Tablet 200 - 28.5mg,400 - 57mg
NP Augmentin ESNP Augmentin
Suspension 200 - 28.5mg/5, 250 - 62.5mg/5,400 - 57mg/5
NP Augmentin TabletNP Augmentin XRNP Moxatag
Oral TetracyclinesG doxycycline hyclateG doxycycline
monohydrateG minocycline HClG tetracycline HCl
P OraceaNP AdoxaNP Adoxa PakNP DoryxNP DynacinNP MinocinNP MonodoxNP PeriostatNP SolodynNP Vibramycin
Oral CephalosporinsG cefaclorG cefadroxil hydrateG cefdinirG cefpodoxime proxetilG cefprozilG cefuroxime axetilG cephalexin
monohydrateNP Ceclor CDNP CedaxNP CeftinNP CefzilNP DuricefNP KeflexNP OmnicefNP RaniclorNP SpectracefNP SupraxNP Vantin
ANTI-INFECTIVES (Antibiotics/Antifungals)
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
4
Oral ErythromycinsG azithromycinG clarithromycinG clarithromycin ERG erythromycin baseG erythromycin
ethylsuccinateG erythromycin
ethylsuccinate/sulfisoxazole acetyl
G erythromycin stearateP DificidNP BiaxinNP Biaxin XLNP EryPedNP PCENP ZithromaxNP Zmax
Oral QuinolonesG ciprofloxacin HClG levofloxacinG ofloxacinP AveloxP Cipro SuspensionP NoroxinNP Cipro TabletNP Cipro XRNP FactiveNP FloxinNP LevaquinNP Proquin XR
Oral SulfasG erythromycin
ethylsuccinate/sulfisoxazole acetyl
G sulfadiazine
G sulfamethoxazole/trimethoprim
G sulfisoxazoleNP Bactrim DSNP GantrisinNP Septra DS
Oral Urinary TractAgentsG methenamine
hippurateG methenamine
mandelateG nitrofurantoinG nitrofurantoin
macrocrystalG phenazopyridine HClG trimethoprimNP FuradantinNP HiprexNP MacrobidNP MacrodantinNP MonurolNP Primsol
Oral AntifungalAgentsG clotrimazoleG fluconazoleG flucytosineG griseofulvin G griseofulvin
ultramicrosizeG itraconazoleG ketoconazoleG nystatinG terbinafine HClG voriconazoleP Lamisil Oral Granules
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Hypnotic AgentsG chloral hydrateG estazolamG flurazepam HClG temazepamG triazolamG zaleplonG zolpidem tartrateP SilenorNP AmbienNP Ambien CRNP DoralNP EdluarNP HalcionNP IntermezzoNP LunestaNP ProSomNP Restoril NP Rozerem
NP SonataNP Zolpimist
TricyclicAntidepressantsG amitriptyline HClG amoxapineG clomipramine HClG desipramine HClG doxepin HClG imipramine HClG imipramine
pamoate G nortriptyline HClG protriptyline HClG trimipramine maleateP Surmontil 100mgNP AnafranilNP NorpraminNP Pamelor
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
5
P NoxafilP Sporanox Oral
SolutionNP AncobonNP DiflucanNP Grifulvin VNP Gris-PegNP Lamisil TabletNP MycostatinNP Mycelex Troche NP NizoralNP OravigNP Sporanox Capsule
NP Vfend
PSYCHOTHERAPEUTICS (Anxiety/Depression)
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
6
NP Surmontil 25mg,50mg
NP TofranilNP Tofranil-PMNP Vivactil
MiscellaneousAntidepressantsG bupropion HCl G maprotiline HClG mirtazapineG trazodone HClG venlafaxine HClP CymbaltaP PristiqNP DesyrelNP EffexorNP Effexor XRNP Oleptro ERNP RemeronNP WellbutrinNP Wellbutrin SRNP Wellbutrin XL
AntipsychoticsG chlorpromazine HClG clozapineG fluphenazine HClG haloperidolG haloperidol lactate
concentrate, oralG loxapine succinateG olanzapineG perphenazineG quetiapine fumarateG risperidoneG thiothixeneG trifluoperazine HClG ziprasidone HCl
P ClozarilP LatudaP MobanP OrapP Seroquel XRNP AbilifyNP FanaptNP GeodonNP InvegaNP RisperdalNP SaphrisNP SeroquelNP SymbyaxNP ZyprexaNP Zyprexa Zydis
AnxiolyticsG alprazolamG alprazolam XRG buspirone HClG chlordiazepoxide
HClG clorazepate
dipotassiumG diazepamG lorazepamG oxazepamNP AtivanNP BusparNP LibriumNP NiravamNP Tranxene SDNP Tranxene T-TabNP ValiumNP XanaxNP Xanax XR
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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MAOIAntidepressantsG phenelzine sulfateG tranylcypromine
sulfateNP EmsamNP NardilNP Parnate
SSRI AntidepressantsG citalopram HBrG escitalopram oxalateG fluoxetine HClG fluvoxamine maleateG paroxetine HClG sertraline HClP ViibrydNP CelexaNP LexaproNP Luvox CRNP PaxilNP Paxil CRNP PexevaNP ProzacNP Prozac WeeklyNP SarafemNP Zoloft
MiscellaneousPsychotherapeuticAgentsG amphetamine
aspartate/amphetamine sulfate/dextroamphetamine
G dextroamphetaminesulfate
G lithium carbonate
G lithium citrateG methamphetamine
HClG methylphenidate HClG modafinilP DaytranaP IntunivP Metadate CDP Metadate ER 20mgP StratteraP Vyvanse P XyremNP AdderallNP Adderall XRNP ConcertaNP DesoxynNP DexedrineNP FocalinNP Focalin XRNP KapvayNP LiquaddNP LithobidNP Metadate ER 10mgNP Methylin Oral
SolutionNP Methylin Chewable
TabletNP NuvigilNP ProvigilNP RitalinNP Ritalin LANP Ritalin SR
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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Beta BlockersG acebutolol HClG atenololG betaxolol HClG bisoprolol fumarateG carvedilolG labetalol HClG metoprolol succinateG metoprolol tartrateG nadololG pindololG propranolol HClG timolol maleateP BystolicP Coreg CRNP CoregNP CorgardNP InderalNP Inderal LANP Innopran XLNP KerloneNP LevatolNP LopressorNP SectralNP TenorminNP Toprol XLNP TrandateNP Zebeta
Calcium BlockersG diltiazem HClG nimodipineG verapamil HClP Cardizem LA 120mg
NP Calan SRNP CardizemNP Cardizem CDNP Cardizem LA 180mg,
240mg, 300mg,360mg, 420mg
NP Cardizem SRNP Covera-HSNP Dilacor XRNP Isoptin S.R.NP NimotopNP TiazacNP VerelanNP Verelan PM
DihydropyridinesG amlodipine besylateG felodipineG isradipineG nifedipineG nisoldipineNP Adalat CCNP Cardene SRNP DynaCirc CRNP NorvascNP PlendilNP Procardia XLNP Sular
Nitroglycerin PatchesG nitroglycerin patchP Nitro-Dur PatchNP Minitran Patch
CARDIOVASCULAR(Blood Pressure/Heart/Cholesterol)
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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AdrenergicAntagonists &Related DrugsG clonidine HClG doxazosin mesylateG guanfacine HClG methyldopaG prazosin HClG reserpineG terazosin HClNP CarduraNP Cardura XLNP CatapresNP Catapres-TTSNP HytrinNP MinipressNP Nexiclon XRNP Tenex
Angiotensin IIBlockers & ReninInhibitorsG eprosartan
mesylateG irbesartanG irbesartan/
hydrochlorothiazideG losartan potassiumG losartan/
hydrochlorothiazideP AmturnideP AtacandP Atacand HCTP BenicarP Benicar HCTP DiovanP Diovan HCTP MicardisP Micardis HCTP Tekamlo
P TekturnaP Tekturna HCTP ValturnaNP AvalideNP AvaproNP CozaarNP EdarbiNP HyzaarNP TevetenNP Teveten HCT
AntilipidemicsG atorvastatin calciumG cholestyramine/
aspartameG cholestyramine/
sucroseG colestipol HClG fenofibrate,
micronizedG gemfibrozilG lovastatinG pravastatinG simvastatinP AltoprevP AntaraP CrestorP FenoglideP LipofenP LovazaP NiaspanP SimcorP TricorP TriglideP TrilipixP VytorinP WelcholP ZetiaNP AdvicorNP CaduetNP Colestid
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
10
NP FibricorNP LescolNP Lescol XLNP LipitorNP LivaloNP LofibraNP LopidNP MevacorNP PravacholNP QuestranNP Questran LightNP Zocor
ACE InhibitorsG benazepril HClG captoprilG enalapril maleateG fosinopril sodiumG lisinoprilG moexiprilG perindopril erbumineG quinaprilG ramiprilG trandolaprilNP AccuprilNP AceonNP AltaceNP CapotenNP LotensinNP MavikNP MonoprilNP PrinivilNP UnivascNP VasotecNP Zestril
CombinationAntihypertensivesG amlodipine
besylate/benazepril
G atenolol/chlorthalidone
G benazepril HCl/hydrochlorothiazide
G bisoprolol fumarate/hydrochlorothiazide
G captopril/hydrochlorothiazide
G enalapril maleate/hydrochlorothiazide
G fosinopril/hydrochlorothiazide
G hydralazine HCl/hydrochlorothiazide
G lisinopril/hydrochlorothiazide
G methyldopa/hydrochlorothiazide
G metoprolol/hydrochlorothiazide
G moexipril/hydrochlorothiazide
G propranolol HCl/hydrochlorothiazide
G quinapril/hydrochlorothiazide
G trandolapril/verapamil
P AzorP ExforgeP Exforge HCTP TarkaP TribenzorP TwynstaNP AccureticNP ClorpresNP CorzideNP DutoprolNP Lopressor HCTNP Lotensin HCT
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
11
Insulin TherapyP ApidraP Apidra SolostarP HumalogP Humalog Mix 50/50P Humalog Mix 75/25P HumulinP LantusP Lantus SoloStarP LevemirP NovoLogP NovoLog Mix 70/30NP Novolin
Non-InsulinHypoglycemic AgentsG acarboseG chlorpropamideG glimepirideG glipizideG glipizide/
metformin HClG glyburideG glyburide/
metformin HClG glyburide, micronized
G metformin HClG nateglinideG tolazamideG tolbutamideP Actoplus MetP ActosP AvandametP AvandarylP AvandiaP ByettaP DuetactP JanumetP JanuviaP Kombiglyze XRP OnglyzaP PrandinP RiometP SymlinP TradjentaNP Actoplus Met XRNP AmarylNP CyclosetNP DiaBetaNP FortametNP GlucophageNP Glucophage XRNP Glucotrol
ENDOCRINE (Diabetes/Hormones/Contraceptives)
NP LotrelNP PrinzideNP TenoreticNP UnireticNP VasereticNP Zestoretic
NP Ziac
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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NP Glucotrol XLNP GlucovanceNP GlumetzaNP GlynaseNP GlysetNP JuvisyncNP MetaglipNP PrandimetNP PrecoseNP StarlixNP Victoza
Blood Glucose TestStripsG alcohol antiseptic
padsP Accu-Chek Active Test
StripsP Accu-Chek Aviva Plus
Test StripsP Accu-Chek Aviva Test
StripsP Accu-Chek Comfort
Curve Test StripsP Accu-Chek Compact
Test StripsP Fast Take Test StripsP One Touch Test StripsP One Touch Ultra Test
Strips P One Touch Verio Test
Strips P Surestep Pro Test
StripsP Surestep Test Strips
Contraceptive AgentsG desogestrel-ethinyl
estradiol
G desogestrel-ethinylestradiol/ethinylestradiol
G ethinyl estradiol/drospirenone
G ethynodiol d-ethinylestradiol
G levonorgestrelG levonorgestrel-
ethinyl estradiolG levonorgestrel-
ethinyl estradiol/ethinyl estradiol
G norethindroneG norethindrone a-e
estradiolG norethindrone a-e
estradiol/ferrousfumarate
G norethindrone-ethinyl estradiol
G norethindrone-ethinyl estradiol/ferrous fumarate
G norethindrone-mestranol
G norgestimate-ethinyl estradiol
G norgestrel-ethinylestradiol
P BeyazP EllaP Loestrin 24 FeP Lo Loestrin FeP NataziaP NuvaRingP Plan B One-StepP SafyralP YazNP Alesse
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
13
NP BreviconNP CyclessaNP DemulenNP DesogenNP Estrostep FeNP Femcon FeNP LevliteNP LoestrinNP Loestrin FeNP Lo/OvralNP LoSeasoniqueNP LybrelNP MircetteNP ModiconNP NordetteNP NorinylNP Ortho-CeptNP Ortho-CyclenNP Ortho EvraNP Ortho MicronorNP Ortho-NovumNP Ortho Tri-CyclenNP Ortho Tri-Cyclen LoNP OvconNP OvralNP SeasonaleNP SeasoniqueNP Tri-NorinylNP Yasmin
Estrogens/EstrogenCombinationsG estradiolG estradiol/
norethindroneacetate
G estropipateG methyl-
testosterone/estrogens, esterified
G norethindrone/ethinyl estradiol
P CenestinP ClimaraP CombipatchP DivigelP EnjuviaP Estrace Vaginal
CreamP EstradermP EstringP EvamistP Premarin Tablet P PremphaseP PremproP VagifemP VivelleP Vivelle-DotNP ActivellaNP AloraNP AngeliqNP Climara ProNP ElestrinNP Estrace TabletNP EstrasorbNP EstratestNP Estratest H.S.NP EstrogelNP FemhrtNP FemringNP FemtraceNP MenestNP MenostarNP OgenNP Ortho-PrefestNP PrefestNP Premarin Vaginal
Cream
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
14
NSAIDsG etodolacG flurbiprofenG ibuprofenG indomethacinG ketoprofenG meclofenamate
sodiumG meloxicamG nabumetoneG naproxenG naproxen sodiumG oxaprozinG piroxicamG sulindacG tolmetin sodiumP Vimovo
NP Anaprox DSNP AnsaidNP ArthrotecNP CambiaNP CataflamNP ClinorilNP DayproNP diclofenac
potassiumNP diclofenac sodiumNP DuexisNP EC-NaprosynNP FeldeneNP FlectorNP IndocinNP LodineNP MobicNP Motrin
NSAIDS (Pain Relievers)
Ulcer DrugsG cimetidine HCl liquidG cimetidine tabletG famotidineG lansoprazoleG misoprostolG nizatidineG omeprazoleG omeprazole/sodium
bicarbonateG pantoprazole sodiumG ranitidine HCl
P Axid Oral SolutionP Nexium NP AciphexNP Axid CapsuleNP CytotecNP DexilantNP PepcidNP PrevacidNP Prilosec RxNP ProtonixNP TagametNP Zantac RxNP Zegerid Rx
G I (Ulcer)
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
15
NP NalfonNP NaprelanNP NaprosynNP PennsaidNP RelafenNP SprixNP Toradol
NP VoltarenNP Voltaren-XR
NSAID COX-2InhibitorsP Celebrex
G flavoxateG oxybutynin chloride G trospium chlorideP DetrolP Detrol LAP EnablexP GelniqueP Oxytrol
P Sanctura XRP ToviazP VesicareNP Ditropan XLNP Sanctura
DRUGS TO TREAT OVERACTIVE BLADDER
Beta Agonists OralG albuterol sulfateG metaproterenol
sulfateG terbutaline sulfateNP AlupentNP Proventil
Beta Agonist InhalersG albuterolG albuterol sulfateG levalbuterol HClG metaproterenol
sulfate
P ForadilP PerforomistP Proair HFAP Serevent DiskusP Xopenex 0.31mg/3mL,
0.63mg/3mL,1.25mg/3mL
P Xopenex HFANP AccunebNP Arcapta NeohalerNP BrovanaNP Maxair AutohalerNP Proventil HFANP Ventolin HFANP Xopenex 1.25mg/0.5
RESPIRATORY (Allergy/Asthma)
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
16
Inhaled SteroidsG budesonideP AlvescoP AsmanexP Flovent DiskusP Flovent HFAP Pulmicort FlexhalerP Pulmicort 1mg/2mL
RespulesP QVARNP AerobidNP Aerobid-MNP AzmacortNP Pulmicort 0.25mg/2mLNP Pulmicort 0.5mg/2mL
Nasal CorticosteroidsG flunisolideG fluticasone propionateG triamcinolone
acetonide P NasonexP Rhinocort AquaP VeramystNP Beconase AQNP FlonaseNP Nasacort AQNP NasarelNP Omnaris
MiscellaneousPulmonary AgentsG acetylcysteineG cromolyn sodium
ampul for nebulization
G ipratropium/albuterolsulfate
G ipratropium bromidesolution
G zafirlukastP Advair DiskusP Advair HFAP Atrovent HFAP BerinertP CinryzeP CombiventP DuleraP Intal InhalerP LetairisP PulmozymeP RevatioP SingulairP SpirivaP SymbicortP TracleerP TyvasoP VentavisNP AccolateNP AdcircaNP DalirespNP DuonebNP FirazyrNP KalbitorNP XolairNP ZyfloNP Zyflo CR
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
17
G alendronate sodiumG calcitonin, salmon,
syntheticG ibandronate sodiumP Actonel 30mgP Boniva 2.5mgP EvistaP ForteoP Fosamax SolutionNP Actonel 5mg
NP Actonel 35mgNP Actonel 75mgNP Actonel 150mgNP Actonel with CalciumNP AtelviaNP Boniva 150mgNP Fosamax Plus DNP Fosamax TabletNP Miacalcin Nasal SprayNP Prolia
OSTEOPOROSIS/PAGET’S DISEASE
Anticonvulsants/Anti-SeizureG carbamazepineG clonazepamG diazepamG divalproex sodiumG ethosuximideG felbamateG gabapentinG lamotrigineG levetiracetamG mephobarbitalG oxcarbazepineG phenobarbitalG phenytoinG phenytoin sodium
extendedG primidoneG topiramateG valproic acid
P Banzel TabletP CelontinP DiastatP Dilantin Chewable
TabletP Dilantin 30mgP GabitrilP Lamictal ODTP Lamictal XRP LyricaP PeganoneP Tegretol XR 100mgP VimpatNP Banzel SuspensionNP CarbatrolNP DepakoteNP Depakote ERNP Depakote SprinkleNP Dilantin 100mg
Capsule
NEUROLOGICALS
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
18
NP Dilantin OralSuspension
NP EquetroNP Felbatol NP GraliseNP KeppraNP Keppra XRNP KlonopinNP LamictalNP MebaralNP MysolineNP NeurontinNP PhenytekNP SabrilNP TegretolNP Tegretol XR 200mg,
400mgNP TopamaxNP TrileptalNP ZarontinNP Zonegran
Migraine/HeadacheTherapyG acetaminophen/
butalbitalG acetaminophen/
caffeine/butalbital G aspirin/caffeine/
butalbitalG dihydroergotamine
mesylateG ergotamine/caffeineG isometheptene
mucate/acetaminophen/dichloralphenazone
G naratriptan HClG sumatriptan succinateP Ergomar
P FrovaP MaxaltP Maxalt MLTP RelpaxP TreximetP ZomigP Zomig ZMTNP AlsumaNP AmergeNP AxertNP Cafergot tabletNP ImitrexNP MidrinNP MigranalNP PhrenilinNP Phrenilin ForteNP Sumavel
Drugs to treatAlzheimers DiseaseG donepezil HClG galantamine HBrG rivastigmine tartrateP Aricept 23mgP Exelon PatchP Exelon SolutionP NamendaNP Aricept 5mg, 10mgNP Aricept ODTNP CognexNP Exelon CapsulesNP RazadyneNP Razadyne ER
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Nonpreferred Possible Preferred ProductsProduct
19
SECTION II: NONPREFERRED DRUGS AND THEIR POSSIBLE PREFERRED
ALTERNATIVES
Abilify® clozapine (generic), olanzapine (generic), quetiapinefumarate (generic), risperidone (generic), ziprasidoneHCl (generic), Seroquel XR® (AstraZeneca)
Accolate® zafirlukast (various)
Accuneb® albuterol sulfate (generic)
Accupril® quinapril (generic)Accuretic® quinapril/hydrochlorothiazide (generic)Aceon® perindopril erbumine (generic)Aciphex® omeprazole (generic), Nexium® (AstraZeneca)Activella® estradiol/norethindrone acetate (generic)Actonel® 5mg alendronate sodium 5mg (generic), alendronate
sodium 10mg (generic), ibandronate sodium (generic)Actonel® 35mg alendronate sodium 35mg (generic), alendronate
75mg, 150mg sodium 70mg (generic), ibandronate sodium (generic)Actonel® alendronate sodium (generic), ibandronate sodium
with Calcium (generic)Actoplus Met XR® metformin HCl ER (generic), Actos® (Takeda)Adalat CC® nifedipine ER (generic), amlodipine besylate (generic),
nisoldipine (generic)Adcirca® Revatio® (Pfizer)Adderall® amphetamine salt combo (generic)Adderall XR® dextroamphetamine-amphetamine ER (generic)Adoxa® doxycycline monohydrate (generic)Adoxa Pak® doxycycline monohydrate (generic)Advicor® atorvastatin calcium (generic), lovastatin (generic),
pravastatin (generic), simvastatin (generic), Crestor®
(AstraZeneca), Niaspan® (Abbott), VytorinTM
(Merck/Schering)Aerobid® Asmanex® (Schering), Flovent HFA® (GlaxoSmithKline),
Pulmicort Flexhaler® (AstraZeneca), QVAR® (Ivax)Aerobid-M® Asmanex® (Schering), Flovent HFA® (GlaxoSmithKline),
Pulmicort Flexhaler® (AstraZeneca), QVAR® (Ivax)Alesse® Aviane® (Barr-branded generic*), Lessina® (Barr-
branded generic*), Lutera® (Watson-branded generic*),Lybrel® (Wyeth)
*Branded generics have the same co-payment as regular generics.
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
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20*Branded generics have the same co-payment as regular generics.
Alora® estradiol patch (generic), Climara® (Berlex), Estraderm®
(Novartis), Vivelle® (Novartis)Alsuma® sumatriptan succinate (generic)Altace® ramipril (generic)Amaryl® glimepiride (generic)Ambien® zolpidem tartrate (generic)Ambien CR® zolpidem tartrate ER (generic)Amerge® naratriptan HCl (generic)Amoxil® amoxicillin trihydrate (generic)Anafranil® clomipramine HCl (generic)Anaprox DS® naproxen sodium (generic)Ancobon® flucytosine (generic)Angeliq® estradiol/norethindrone acetate (generic),
Premphase® (Wyeth), Prempro® (Wyeth)Ansaid® flurbiprofen (generic)Arcapta Neohaler® Foradil® (Schering), Serevent Diskus® (GlaxoSmithKline)Aricept® 5mg,10mg donepezil HCl (generic)Aricept ODT® donepezil HCl (generic)Arthrotec® ibuprofen (generic), naproxen (generic), Celebrex®
(Pfizer)Atelvia® alendronate sodium (generic), ibandronate sodium
(generic)Ativan® lorazepam (generic)Augmentin® amoxicillin trihydrate/potassium clavulanate (generic)chewable tablet200-28.5mg,400-57mg
Augmentin® amoxicillin trihydrate/potassium clavulanate (generic)suspension200-28.5mg/5, 250-62.5mg/5,400-57mg/5
Augmentin® amoxicillin trihydrate/potassium clavulanate (generic)tablet
Augmentin ES® amoxicillin trihydrate/potassium clavulanate (generic)Augmentin XR® amoxicillin trihydrate/potassium clavulanate (generic)Avalide® irbesartan/hydrochlorothiazide (generic)Avapro® irbesartan (generic)Axert® naratriptan HCl (generic), sumatriptan succinate
(generic), Frova® (Endo), Maxalt® (Merck), Relpax® (Pfizer),Zomig® (AstraZeneca)
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
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21
Axid® Capsule nizatidine (generic)Azmacort® Asmanex® (Schering), Flovent HFA® (GlaxoSmithKline),
Pulmicort Flexhaler® (AstraZeneca), QVAR® (Ivax)Bactrim DS® sulfamethoxazole/trimethoprim (generic)Banzel® Banzel® Tablet (Eisai)Oral Suspension
Beconase AQ® flunisolide (generic), fluticasone propionate (generic),triamcinolone acetonide (generic), Nasonex®
(Schering), Rhinocort Aqua® (AstraZeneca), Veramyst®
(GlaxoSmithKline)Biaxin® clarithromycin (generic)Biaxin XL® clarithromycin ER (generic)Boniva® ibandronate sodium (generic)Brevicon® Necon® (Watson-branded generic*), Nortrel®
(Barr-branded generic*)Brovana® Foradil® (Schering), Perforomist® (Dey Labs), Proair HFA®
(Teva), Serevent Diskus® (GlaxoSmithKline)Buspar® buspirone HCl (generic)Butisol Sodium® chloral hydrate (generic), temazepam (generic),
triazolam (generic)Caduet® amlodipine besylate (generic), atorvastatin calcium
(generic)Calan SR® verapamil HCl tablet, sustained action (generic)Cambia® etodolac (generic), ibuprofen (generic), naproxen
(generic)Capoten® captopril (generic)Carbatrol® carbamazepine (generic)Cardene SR® amlodipine besylate (generic), nifedipine ER (generic)Cardizem® diltiazem HCl (generic)Cardizem CD® diltiazem HCl capsule, sustained release 24 hr
(generic)Cardizem LA® diltiazem ER (generic)180mg, 240mg,300mg, 360mg, 420mg
Cardizem SR® diltiazem HCl capsule, sustained release 12 hr (generic)
Cardura® doxazosin mesylate (generic)Cataflam® etodolac (generic), ibuprofen (generic), naproxen
(generic)Catapres® clonidine HCl tablet (generic)Catapres-TTS® clonidine HCl patch (generic)
*Branded generics have the same co-payment as regular generics.
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22
Ceclor CD® cefaclor (generic), cefdinir (generic), cefuroxime axetil (generic)
Cedax® cefaclor (generic), cefdinir (generic), cefuroxime axetil (generic)
Ceftin® cefuroxime axetil (generic)Cefzil® cefaclor (generic), cefdinir (generic),
cefuroxime axetil (generic)Celexa® citalopram (generic)Cipro Tablet® ciprofloxacin HCl tablet (generic)Climara Pro® Combipatch® (Novartis)Clinoril® sulindac (generic)Clorpres® chlorthalidone (generic), clonidine HCl (generic)Cognex® donepezil HCl (generic), galantamine (generic),
rivastigmine tartrate (generic)Colestid® cholestyramine (generic), Welchol® (Sankyo)Coreg® carvedilol (generic)Corgard® nadolol (generic)Corzide® bisoprolol fumarate/hydrochlorothiazide (generic),
metoprolol/hydrochlorothiazide (generic), propranololHCl/hydrochlorothiazide (generic)
Covera-HS® verapamil HCl capsule, 24 hr sustained release (generic)Cozaar® losartan potassium (generic)Cyclessa® Caziant® (Watson-branded generic*), Cesia® (Prasco
Labs-branded generic*), Velivet® (Barr-branded generic*)Cycloset® metformin HCl (generic), Byetta® (Amylin Pharma),
Janumet® (Merck), Januvia® (Merck), Onglyza®
(Bristol-Myers Squibb)Cytotec® misoprostol (generic)Daliresp® Advair Diskus® (GlaxoSmithKline), Combivent®
(Boehringer), Foradil® (Schering), Pulmicort Flexhaler®
(AstraZeneca), Serevent Diskus® (GlaxoSmithKline),Spiriva® (Boehringer), Symbicort® (AstraZeneca)
Daypro® oxaprozin (generic)Demulen® Zovia® (Watson-branded generic*)Depakote® divalproex sodium (generic)Depakote ER® divalproex sodium ER (generic)Depakote® Sprinkle divalproex sodium (generic)Desogen® Apri® (Barr-branded generic*),
Solia® (Prasco Labs-branded generic*)Desoxyn® methamphetamine HCl (generic)Desyrel® trazodone HCl (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
Nonpreferred Possible Preferred ProductsProduct
23
Dexedrine® dextroamphetamine sulfate (generic)Dexilant® omeprazole (generic), Nexium® (AstraZeneca)DiaBeta® glyburide (generic)Diclofenac etodolac (generic), ibuprofen (generic), naproxen
Potassium (generic)Diclofenac etodolac (generic), ibuprofen (generic), naproxen
Sodium (generic)Diflucan® fluconazole (generic)Dilacor XR® diltiazem XR (generic)Dilantin® phenytoin sodium capsule (generic)
100mg CapsuleDilantin® Oral phenytoin (generic)
SuspensionDitropan XL® oxybutynin chloride ER (generic)
Doral® temazepam (generic), triazolam (generic), zaleplon(generic), zolpidem tartrate (generic)
Doryx® doxycycline hyclate (generic)Duexis® famotidine (generic), ibuprofen (generic), naproxen
(generic), omeprazole (generic)Duoneb® ipratropium/albuterol sulfate (generic)Duricef® cefadroxil hydrate (generic)Dutoprol® hydrochlorothiazide (generic), metoprolol succinate
(generic)Dynacin® minocycline HCl (generic)DynaCirc CR® amlodipine besylate (generic), nifedipine ER (generic),
nisoldipine (generic)EC-Naprosyn® naproxen (generic)Edarbi® losartan potassium (generic), Atacand® (AstraZeneca),
Benicar® (Daiichi Sankyo), Diovan® (Novartis), Micardis®
(BIPI)Edluar® zolpidem tartrate (generic)Effexor® venlafaxine HCl (generic)Effexor XR® venlafaxine HCl (generic)Elestrin® estradiol patch (generic), Climara® (Berlex), Divigel®
(Upsher Smith), Estraderm® (Novartis), Vivelle®
(Novogyne)
Emsam® phenelzine sulfate (generic), tranylcypromine sulfate(generic)
Equetro® carbamazepine (generic), divalproex sodium (generic),lithium carbonate (generic)
*Branded generics have the same co-payment as regular generics.
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
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EryPed erythromycin ethylsuccinate (generic)Suspension®
400mg/5mlEstrace® Tablet estradiol (generic)Estrasorb® estradiol patch (generic), Divigel® (Upsher Smith)Estratest® estrogen/methyltestosterone(generic)Estratest H.S.® estrogen/methyltestosterone(generic)Estrogel® estradiol patch (generic), Climara® (Berlex), Divigel®
(Upsher Smith), Estraderm® (Novartis), Vivelle®
(Novartis)Estrostep Fe® Apri® (Barr-branded generic*), Kariva® (Barr-branded
generic*), Microgestin Fe® (Watson-branded generic*)Exelon® Capsules rivastigmine tartrate (generic)Factive® ciprofloxacin (generic), levofloxacin (generic)Fanapt® clozapine (generic), olanzapine (generic), quetiapine
fumarate (generic), risperidone (generic), ziprasidoneHCl (generic), Seroquel XR® (AstraZeneca)
Felbatol® felbamate (generic)Feldene® piroxicam (generic)Femhrt® Jinteli® (Teva-branded generic*)Femcon Fe® Zeosa® (Teva-branded generic*)Femring® Estrace Vaginal Cream® (Warner Chilcott), Estring®
(Pfizer)Femtrace® estradiol (generic)Fibricor® fenofibrate (generic), Tricor® (Abbott), Triglide® (Sciele),
Trilipix® (Abbott)Firazyr® Berinert® (CSL Behring), Cinryze® (Viropharma)Flonase® fluticasone propionate (generic)Floxin® ofloxacin (generic)Focalin® dexmethylphenidate HCl (generic)Focalin XR® dextroamphetamine-amphetamine ER (generic),
methylphenidate ER (generic), Daytrana® (Shire US Inc.),Metadate CD® (Celltech Pharm), Methylin ER®
(Mallinckrodt Pharmaceuticals)Fortamet® metformin HCl ER (generic), metformin HCl tablet
(generic)Fosamax® Tablets alendronate sodium (generic)Fosamax Plus D® alendronate sodium (generic), ibandronate sodium
(generic)Furadantin® nitrofurantoin (generic)Gantrisin® sulfisoxazole (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
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25
Geodon® ziprasidone HCl (generic)Glucophage® metformin HCl (generic)Glucophage XR® metformin HCl ER (generic), metformin HCl tablet
(generic)Glucotrol® glipizide (generic)Glucotrol XL® glipizide ER (generic)Glucovance® glyburide/metformin HCl (generic)Glynase® glyburide, micronized (generic)Glyset® acarbose (generic)Gralise® gabapentin (generic)Grifulvin V® griseofulvin ultramicrosize (generic), itraconazole
(generic), ketoconazole (generic), terbinafine HCl(generic)
Gris-Peg® griseofulvin ultramicrosize (generic), itraconazole(generic), ketoconazole (generic), terbinafine HCl(generic)
Guanabenz clonidine HCl (generic), methyldopa (generic)Acetate®
Halcion® triazolam (generic)Hiprex® methenamine hippurate (generic)Hytrin® terazosin (generic)Hyzaar® losartan/hydrochlorothiazide (generic)Imitrex® sumatriptan succinate (generic)Inderal® propranolol HCl (generic)Inderal LA® propranolol capsule, sustained action (generic)Indocin® indomethacin (generic)Innopran XL® propranolol capsule, sustained action (generic)Intermezzo® zaleplon (generic)Invega® olanzapine (generic), quetiapine fumarate (generic),
risperidone (generic), ziprasidone HCl (generic),Seroquel XR® (AstraZeneca)
Isoptin S.R.® verapamil HCl tablet, sustained action (generic)Juvisync® simvastatin (generic), Januvia® (Merck)Kalbitor® Berinert® (CSL Behring)Kapvay® clonidine HCl (generic), Intuniv® (Shire US Inc.)Keflex® cephalexin monohydrate (generic)Keppra® levetiracetam (generic)Keppra XR® levetiracetam (generic)Kerlone® betaxolol HCl (generic)Klonopin® clonazepam (generic)
*Branded generics have the same co-payment as regular generics.
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Lamictal® lamotrigine (generic)Lamisil® tablet terbinafine HCl (generic)Lescol® atorvastatin calcium (generic), lovastatin (generic),
simvastatin (generic), Altoprev® (Andrx), Crestor®
(AstraZeneca), VytorinTM (Merck/Schering)Lescol XL® atorvastatin calcium (generic), lovastatin (generic),
simvastatin (generic), Altoprev® (Andrx), Crestor®
(AstraZeneca), VytorinTM (Merck/Schering)Levaquin® levofloxacin (generic)Levatol® acebutolol HCl (generic), atenolol (generic),
metoprolol tartrate (generic)Levlite® Aviane® (Barr-branded generic*), Lessina®
(Barr-branded generic*), Lybrel® (Wyeth) Lexapro® escitalopram oxalate (generic)Librium® chlordiazepoxide HCl (generic)Lipitor® atorvastatin calcium (generic)Liquadd® dextroamphetamine sulfate (generic)Lithobid® lithium carbonate tablet, sustained action (generic)Livalo® atorvastatin calcium (generic), lovastatin (generic),
pravastatin (generic), simvastatin (generic), Crestor®
(AstraZeneca)Lodine® etodolac (generic)Loestrin® Junel® (Barr-branded generic*), Microgestin®
(Watson-branded generic*)Loestrin Fe® Junel Fe® (Barr-branded generic*), Microgestin Fe®
(Watson-branded generic*)Lofibra® fenofibrate (generic), Tricor® (Abbott), Triglide® (First
Horizon), Trilipix® (Abbott)Lo/Ovral® Low-Ogestrel® (Watson-branded generic*)Lopid® gemfibrozil (generic)Lopressor® metoprolol tartrate (generic)Lopressor HCT® metoprolol/hydrochlorothiazide (generic)LoSeasonique® Amethia Lo® (Watson-branded generic*), Camrese Lo®
(Teva-branded generic*)Lotensin® benazepril HCl (generic)Lotensin HCT® benazepril HCl/hydrochlorothiazide (generic)Lotrel® amlodipine besylate/benazepril (generic)Lunesta® temazepam (generic), zolpidem tartrate (generic)Luvox CR® fluvoxamine maleate (generic)Lybrel® Amethyst® (Watson-branded generic*)Macrobid® nitrofurantoin macrocrystal (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -
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27
Macrodantin® nitrofurantoin (generic)Mavik® trandolapril HCl (generic)Maxair Autohaler® Proair HFA® (Teva), Xopenex HFA® (Sepracor)Mebaral® mephobarbital (generic)Menest® estradiol (generic), estropipate (generic), Cenestin®
(Duramed/Barr), Enjuvia® (Duramed/Barr),Premarin® (Wyeth)
Menostar Patch® Climara Patch® (Berlex), Vivelle Patch® (Novartis)Metadate ER® methylphenidate ER (generic)
10mgMetaglip® glipizide/metformin (generic)Methylin® methylphenidate HCl (generic)
Oral SolutionMethylin® methylphenidate HCl (generic)
Chewable TabletMevacor® lovastatin (generic)Miacalcin® calcitonin-salmon (generic)Midrin® isometheptene/apap/dichloralphenazone (generic)Migranal® naratriptan HCl (generic), sumatriptan nasal spray
(generic), Frova® (Endo), Maxalt® (Merck), Relpax® (Pfizer),Zomig® Nasal Spray (AstraZeneca)
Minipress® prazosin HCl (generic)Minitran® nitroglycerin patch (generic), Nitro-Dur® (Schering)Minocin® minocycline HCl (generic)Mircette® Kariva® (Barr-branded generic*)Mobic® meloxicam (generic)Modicon® Necon® (Watson-branded generic*), Nortrel®
(Barr-branded generic*)Monistat 3 Vaginal miconazole 3 vaginal suppository (generic)
Suppository®
Monodox® doxycycline monohydrate (generic)Monopril® fosinopril sodium (generic)Monurol® ciprofloxacin HCl (generic), sulfamethoxazole/
trimethoprim (generic), trimethoprim (generic),Noroxin® (Merck)
Motrin® ibuprofen (generic)Moxatag® amoxicillin (generic)Mysoline® primidone (generic)Nalfon® etodolac (generic), ibuprofen (generic), indomethacin
(generic), meclofenamate sodium (generic), naproxen (generic), sulindac (generic)
*Branded generics have the same co-payment as regular generics.
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28
Naprelan® naproxen sodium (generic)Naprosyn® naproxen (generic)Nardil® phenelzine sulfate (generic)Nasacort AQ® triamcinolone acetonide (generic)Nasarel® flunisolide (generic)Nembutal chloral hydrate (generic), temazepam (generic),
Sodium® triazolam (generic)Neurontin® gabapentin (generic)Nexiclon XR® clonidine HCl (generic)Nimotop® nimodipine (generic)Niravam® alprazolam (generic)Nizoral® ketoconazole (generic)Nordette® Levora® (Watson-branded generic*), Portia®
(Barr-branded generic*)Norinyl® Necon® (Watson-branded generic*), Nortrel®
(Barr-branded generic*)Norpramin® desipramine HCl (generic)Norvasc® amlodipine besylate (generic)Novolin® Humulin® (Eli Lilly)Nuvigil® modafinil (generic)Ogen® estropipate (generic)Oleptro ER® trazodone HCl (generic)Omnaris® flunisolide (generic), fluticasone propionate (generic),
triamcinolone acetonide (generic), Nasonex®
(Schering), Rhinocort Aqua® (AstraZeneca), Veramyst®
(GlaxoSmithKline)Omnicef® cefdinir (generic)Oravig® clotrimazole (generic), fluconazole (generic), nystatin
suspension (generic)Ortho-Cept® Apri®(Barr-branded generic*), Solia®
(Prasco Labs-branded generic*)Ortho-Cyclen® MonoNessa® (Watson-branded generic*), Previfem®
(Teva-branded generic*), Sprintec® (Barr-branded generic*)
Ortho Evra® MonoNessa® (Watson-branded generic*), TriNessa®
(Watson-branded generic*)Ortho Micronor® norethindrone acetate (generic)Ortho-Novum® Necon® (Watson-branded generic*), Nortrel®
1/35, 7/7/7 (Barr-branded generic*)Ortho-Novum® Necon® (Watson-branded generic*)
1/50
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
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29
Ortho-Prefest® estradiol/norethindrone acetate (generic), Premphase® (Wyeth), Prempro® (Wyeth)
Ortho Tri-Cyclen® TriNessa® (Watson-branded generic*), Tri-Previfem®
(Teva-branded generic*), Tri-Sprintec® (Barr-brandedgeneric*)
Ortho Tri-Cyclen TriNessa® (Watson-branded generic*), Tri-Previfem®
Lo® (Teva-branded generic*), Tri-Sprintec® (Barr-brandedgeneric*)
Ovcon® Necon® (Watson-branded generic*)Ovral® Ogestrel® (Watson-branded generic*)Pamelor® nortriptyline HCl (generic)Parnate® tranylcypromine sulfate (generic)Paxil® paroxetine HCl (generic)Paxil CR® paroxetine HCl sustained release tab (generic)PCE® erythromycin (generic)Pennsaid® etodolac (generic), ibuprofen (generic), naproxen
(generic)Pepcid® famotidine (generic), cimetidine HCl liquid (generic),
Suspension Axid Oral Solution® (Braintree)Pepcid® Tablet famotidine (generic)Periostat® doxycycline hyclate (generic)Pexeva® paroxetine HCl (generic)Phenytek® phenytoin sodium (generic)Phrenilin® acetaminophen/butalbital (generic)Plendil® felodipine ER (generic)Ponstel® etodolac (generic), ibuprofen (generic), indomethacin
(generic), meclofenamate sodium (generic), naproxen (generic), sulindac (generic)
Prandimet® metformin HCl (generic), Prandin® (Novo Nordisk)Pravachol® pravastatin (generic)Precose® acarbose (generic)Prefest® estradiol/norethindrone acetate (generic),
Premphase® (Wyeth), Prempro® (Wyeth)Premarin® Estrace® Vaginal Cream (Warner Chilcott)Vaginal Cream
Prevacid® lansoprazole (generic), omeprazole (generic), Nexium®
(AstraZeneca)Prilosec Rx® omeprazole (generic), Nexium® (AstraZeneca)Primsol® trimethoprim (generic)Prinivil® lisinopril (generic)Prinzide® lisinopril/hydrochlorothiazide (generic)
*Branded generics have the same co-payment as regular generics.
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Procardia XL® nifedipine ER (generic)Prolia® alendronate sodium (generic), ibandronate sodium
(generic), Evista® (Eli Lilly), Forteo® (Eli Lilly)Proquin XR® ciprofloxacin HCl (generic)ProSom® estazolam (generic)Protonix® Nexium® Suspension (AstraZeneca)
SuspensionProtonix® Tablet pantoprazole sodium (generic), omeprazole (generic),
Nexium® (AstraZeneca)Proventil HFA® Proair HFA® (Teva), Xopenex HFA® (Sepracor)Provigil® modafinil (generic)Prozac® fluoxetine HCl (generic)Prozac Weekly® fluoxetine HCl (generic)Pulmicort® budesonide (generic)0.25mg/2mL,0.5mg/2mL
Questran® cholestyramine (generic), prevalite (generic)Questran Light® cholestyramine/aspartame (generic), prevalite (generic)Raniclor® cefaclor suspension (generic), cefaclor capsule
(generic)Razadyne® galantamine (generic)Razadyne ER® galantamine ER (generic)Relafen® nabumetone (generic)Remeron® mirtazapine soltabs (generic), mirtazapine tabs
(generic)Restoril® temazepam (generic)Risperdal® risperidone (generic)
Oral SolutionRisperdal® Tablet risperidone (generic)Ritalin® methylphenidate HCl (generic)Ritalin LA® methylphenidate ER (generic), dextroamphetamine
sulfate (generic), dextroamphetamine-amphetamineER (generic), Daytrana® (Shire US Inc.), Metadate CD®
(Celltech Pharm)Ritalin SR® methylphenidate ER (generic)Rozerem® estazolam (generic), temazepam (generic), triazolam
(generic), zolpidem tartrate (generic)Sabril® divalproex sodium (generic), lamotrigine (generic),
levetiracetam (generic), topiramate (generic), Gabitril®
(Cephalon)Sanctura® trospium chloride (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
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31
Saphris® clozapine (generic), olanzapine (generic), quetiapinefumarate (generic), risperidone (generic), ziprasidoneHCl (generic), Seroquel XR® (AstraZeneca)
Sarafem® fluoxetine HCl (generic)Seasonale® Amethyst® (Watson-branded generic*), Jolessa®
(Barr-branded generic*), Quasense® (Watson-brandedgeneric*),
Seasonique® Amethia® (Watson-branded generic*), Camrese®
(Teva-branded generic*)Seconal Sodium® chloral hydrate (generic), temazepam (generic),
triazolam (generic)Sectral® acebutolol HCl (generic)Septra DS® sulfamethoxazole/trimethoprim (generic)Seroquel® quetiapine fumarate (generic)Solodyn® minocycline HCl (generic), doxycycline monohydrate
(generic)Sonata® zaleplon (generic)Spectracef® cefaclor (generic), cefdinir (generic), cefuroxime axetil
(generic)Sporanox® itraconazole (generic)
CapsuleSprix® etodolac (generic), ibuprofen (generic), naproxen
(generic)Starlix® nateglinide (generic)Sular® nisoldipine (generic), amlodipine besylate (generic),
isradipine (generic), nifedipine ER (generic)Suprax® cefdinir (generic), cefuroxime axetil (generic)Surmontil® trimipramine maleate (generic)
25mg, 50mgSymbyax® fluoxetine HCl (generic), olanzapine (generic),
quetiapine fumarate (generic), risperidone (generic),Seroquel XR® (AstraZeneca)
Tagamet® cimetidine (generic)Tegretol® carbamazepine (generic)Tegretol XR® carbamazepine XR (generic)
200mg, 400mgTenex® guanfacine HCl (generic)Tenoretic® atenolol/chlorthalidone (generic)Tenormin® atenolol (generic)Teveten® eprosartan mesylate (generic), losartan potassium
(generic), Atacand® (AstraZeneca), Benicar® (DaiichiSankyo), Diovan® (Novartis), Micardis® (BIPI)
*Branded generics have the same co-payment as regular generics.
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Teveten HCT® losartan/hydrochlorothiazide (generic), Atacand HCT®
(AstraZeneca), Benicar HCT® (Daiichi Sankyo), DiovanHCT® (Novartis), Micardis HCT® (BIPI)
Thioridazine HCl® chlorpromazine HCl (generic), haloperidol (generic),quetiapine fumarate (generic), risperidone (generic)
Tiazac® diltiazem HCl capsule, sustained release 24 hr (generic)Tofranil® imipramine HCl (generic)Tofranil-PM® imipramine pamoate (generic)Topamax® topiramate (generic)Toprol XL® metoprolol succinate (generic)Toradol® etodolac (generic), ibuprofen (generic), indomethacin
(generic), meclofenamate sodium (generic), naproxen (generic), sulindac (generic)
Trandate® labetalol HCl (generic)Tranxene SD® clorazepate dipotassium (generic)Tranxene T-Tab® clorazepate dipotassium (generic)Trileptal® carbamazepine (generic)Tri-Norinyl® Necon® (Watson-branded generic*), Nortrel®
(Barr-branded generic*)Uniretic® moexipril/hydrochlorothiazide (generic)Univasc® moexipril HCl (generic)Valium® diazepam (generic)Vantin® cefpodoxime proxetil (generic)Vaseretic® enalapril maleate/hydrochlorothiazide (generic)Vasotec® enalapril maleate (generic)Ventolin HFA® Proair HFA® (Teva), Xopenex HFA® (Sepracor)Verelan® verapamil ER (generic)Verelan PM® verapamil ER PM (generic)Vfend® voriconazole (generic)Vibramycin Syrup® doxycycline monohydrate suspension (generic)Victoza® metformin HCl (generic), Actos® (Takeda), Byetta®
(Amylin), Januvia® (Merck), Onglyza® (Bristol-MyersSquibb)
Vivactil® protriptyline HCl (generic)Voltaren® etodolac (generic), ibuprofen (generic), naproxen
(generic)Voltaren-XR® etodolac (generic), ibuprofen (generic), naproxen
(generic)Wellbutrin® bupropion HCl (generic)Wellbutrin SR® bupropion HCl tablet, sustained release (generic)Wellbutrin XL® bupropion HCl tablet, extended release (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
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Wytensin® clonidine HCl (generic), methyldopa (generic)Xanax® alprazolam (generic)Xanax XR® alprazolam XR (generic)Xolair® Asmanex® (Schering), Flovent HFA® (GlaxoSmithKline),
Pulmicort Flexhaler® (AstraZeneca), QVAR® (Ivax)Xopenex® levalbuterol HCl (generic)
1.25mg/0.5Yasmin® Ocella® (Barr-branded generic*)Zantac Rx Syrup® ranitidine HCl tablet (generic), Axid Oral Solution®
(Braintree)Zantac Rx Tablet® ranitidine HCl tablet (generic)Zarontin® ethosuximide (generic)Zebeta® bisoprolol fumarate (generic)Zegerid Rx® omeprazole/sodium bicarbonate (generic), omeprazole
(generic), Nexium® (AstraZeneca)Zestoretic® lisinopril/hydrochlorothiazide (generic)Zestril® lisinopril (generic)Ziac® bisoprolol fumarate/hydrochlorothiazide (generic)Zithromax® azithromycin (generic)Zmax® azithromycin (generic)Zocor® simvastatin (generic)Zoloft® sertraline HCl (generic)Zolpimist® zolpidem tartrate (generic)Zonegran® carbamazepine (generic), clonazepam (generic)
ethosuximide (generic,) phenobarbital (generic), phenytoin sodium (generic), Lyrica® (Pfizer)
Zyflo® Singulair® (Merck)Zyflo CR® Singulair® (Merck)Zyprexa® olanzapine (generic)Zyprexa Zydis® olanzapine ODT (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
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This guide does not contain a complete list of formulary and nonformulary drugs. It only liststhe most commonly prescribed drugs. Visitwww.medco.com anytime to check the price andcoverage of medications under your plan. Simplyselect “Price a medication” from the left handmenu and search for your medication to see pricing. Click “View coverage notes” on the pricingresults page to see any coverage details. If you area first-time visitor to medco.com, please take amoment to register. (Be sure to have your memberID number and a recent prescription numberhandy.) Or, for an updated and complete listing of your prescription benefit, call customer serviceat the phone number on the back of your prescription card.
www.medco.com
Medco and Preferred Prescriptions are trademarks of Medco Health Solutions, Inc.© 2012 Medco Health Solutions, Inc. All rights reserved.MG42790K MEDPG (Ed. 4/12)
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