Preferred Prescriptions Member Guide - Delaware · Member Guide Please bring this ... For example,...

Preferred Prescriptions®

Member GuidePlease bring this guide with you on your next doctor visit.

Medco manages your prescription drug benefit for your health plan.

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MG42790K - 1Q12 PPF OPEN - MEDPG_v2_MG42790K - 1Q12 PPF OPEN -

NOTES


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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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.


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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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)




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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


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



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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)




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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




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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




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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)




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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




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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




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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




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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




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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




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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)




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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)




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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




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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




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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


Nonpreferred Possible Preferred ProductsProduct

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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.



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)



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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)



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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)





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)



24

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)





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)



26

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)





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)



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





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


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)



30

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)





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)



32

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


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)




33

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)




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.

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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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