Preferred Prescriptions RX Selections™ Member...
Transcript of Preferred Prescriptions RX Selections™ Member...
Preferred Prescriptions®/RX Selections™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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Preferred Prescriptions®/RX Selections™ is a formulary list of medications that may be covered under your prescription drugplan.This list was reviewed by an independent group of practicingdoctors and pharmacists, and it contains medications made bymost pharmaceutical manufacturers. It includes medications formany covered conditions.
SAVING MONEY ON PRESCRIPTIONSYour plan may prefer some medications over others. These arecalled preferred drugs.
You may pay:• Lowest co-payment/co-insurance for generic drugs• Higher co-payment/co-insurance for preferred brand-name
drugs• Highest co-payment/co-insurance for nonpreferred
brand-name drugs
Your doctor may be able to help you save money by prescribinggeneric and preferred brand-name drugs if appropriate. So be sureto bring this guide with you on every visit to your doctor. Somecommonly prescribed nonpreferred drugs are also listed in thisguide for your reference.
Please note: This guide does not contain a complete list of preferred and nonpreferred drugs. It only lists the mostcommonly prescribed drugs. For an updated and complete listing of your prescription benefit, you can visit the “BenefitHighlights” section of our website—www.medco.com—andclick on the View your preferred drug list link. Not all medica-tions listed here are covered by every prescription drug plan.
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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 possible generic and preferred brand-name alternatives.
SAFETY CONSIDERATION SYMBOLSHere is a quick guide for you and your doctor, which explains our safety symbols. These symbols appear next to certain medications.
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.
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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 125 - 31.25mg,250 - 62.5mg
P AugmentinSuspension 125 - 31.25mg/5
P Augmentin XRNP 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 DispermoxNP GeocillinNP Moxatag
Oral TetracyclinesG doxycycline hyclate
capsuleG doxycycline hyclate
tabletG doxycycline
monohydrateG minocycline HClG tetracycline HClP AdoxaP Adoxa PakP OraceaNP DoryxNP DynacinNP MinocinNP MonodoxNP PeriostatNP SolodynNP Vibramycin
Oral CephalosporinsG cefaclorG cefadroxil hydrateG cefdinirG cefpodoxime proxetilG cefprozilG cefuroxime axetilG cephalexin
monohydrateG cephradineNP Ceclor CDNP CedaxNP Ceftin
ANTI-INFECTIVES (Antibiotics/Antifungals)
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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 CefzilNP DuricefNP KeflexNP OmnicefNP RaniclorNP SpectracefNP SupraxNP Vantin
Oral ErythromycinsG azithromycinG clarithromycinG clarithromycin ERG erythromycin baseG erythromycin
ethylsuccinateG erythromycin
ethylsuccinate/sulfisoxazole acetyl
G erythromycin stearateNP BiaxinNP Biaxin XLNP EryPedNP PCENP ZithromaxNP Zmax
Oral QuinolonesG ciprofloxacin HClG ofloxacinP Cipro SuspensionP LevaquinP NoroxinNP AveloxNP Cipro TabletNP Cipro XRNP FactiveNP FloxinNP Proquin XR
Oral SulfasG erythromycin
ethylsuccinate/sulfisoxazole acetyl
G sulfadiazineG sulfamethoxazole/
trimethoprimG sulfisoxazoleNP Bactrim DSNP GantrisinNP Septra DS
Oral Urinary TractAgentsG methenamine
hippurateG methenamine
mandelateG nitrofurantoinG nitrofurantoin
macrocrystalG phenazopyridine HClG trimethoprimP FuradantinNP HiprexNP MacrobidNP MacrodantinNP MonurolNP Primsol
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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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Oral AntifungalAgentsG clotrimazoleG fluconazoleG griseofulvin G griseofulvin
ultramicrosizeG itraconazoleG ketoconazoleG nystatinG terbinafine HClP AncobonP Lamisil Oral GranulesP NoxafilP Sporanox Oral
SolutionP Vfend TabletNP DiflucanNP Grifulvin VNP Gris-PegNP Lamisil TabletNP MycostatinNP Mycelex Troche NP NizoralNP Sporanox CapsuleNP Vfend Suspension
Oral MiscellaneousAgentsG clindamycin HClG neomycin sulfateP DapsoneP Tobi Ampul for
NebulizationP ZyvoxNP Cleocin HClNP KetekNP Xifaxan
Vaginal AntifungalsG fluconazoleG miconazole nitrate
vaginal suppositoryG nystatinG terconazoleP Gynazole-1NP Terazol
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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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Hypnotic AgentsG chloral hydrateG estazolamG flurazepam HClG temazepamG triazolamG zaleplonG zolpidem tartrateP Restoril 7.5mg,
22.5mgNP AmbienNP Ambien CRNP DalmaneNP DoralNP EdluarNP HalcionNP LunestaNP ProSomNP Restoril 15mg, 30mgNP RozeremNP Sonata
TricyclicAntidepressantsG amitriptyline HClG amoxapineG clomipramine HClG desipramine HClG doxepin HClG imipramine HClG imipramine
pamoate G nortriptyline HClG protriptyline HClG trimipramine maleate
P SurmontilP Tofranil-PMNP AnafranilNP AsendinNP Aventyl HClNP ElavilNP NorpraminNP PamelorNP SinequanNP TofranilNP Vivactil
MiscellaneousAntidepressantsG bupropion HCl tabletG bupropion HCl tablet,
sustained actionG maprotiline HClG mirtazapineG trazodone HClG venlafaxine HClP CymbaltaP Effexor XRP PristiqNP DesyrelNP EffexorNP LudiomilNP RemeronNP SerzoneNP WellbutrinNP Wellbutrin SRNP Wellbutrin XL
AntipsychoticsG chlorpromazine HClG clozapineG fluphenazine HCl
PSYCHOTHERAPEUTICS (Anxiety/Depression)
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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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G haloperidolG haloperidol lactate
concentrate, oralG loxapine succinateG perphenazineG risperidoneG thiothixeneG trifluoperazine HClP ClozarilP GeodonP MobanP OrapP SeroquelP Seroquel XRP ZyprexaP Zyprexa ZydisNP AbilifyNP FanaptNP InvegaNP RisperdalNP SaphrisNP Symbyax
AnxiolyticsG alprazolamG alprazolam XRG buspirone HClG chlordiazepoxide
HClG clorazepate
dipotassiumG diazepamG lorazepamG oxazepamNP AtivanNP BusparNP LibriumNP NiravamNP Serax
NP Tranxene SDNP Tranxene T-TabNP ValiumNP XanaxNP Xanax XR
MAOIAntidepressantsG tranylcypromine
sulfateP NardilNP EmsamNP Parnate
SSRI AntidepressantsG citalopram HBrG fluoxetine HClG fluvoxamine maleateG paroxetine HClG sertraline HClNP CelexaNP LexaproNP LuvoxNP Luvox CRNP PaxilNP Paxil CRNP PexevaNP ProzacNP Prozac WeeklyNP SarafemNP Zoloft
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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 propranolol HCl
capsule, sustainedaction 24 hr
G timolol maleateP Coreg CRNP BystolicNP CoregNP CorgardNP InderalNP Inderal LANP Innopran XLNP KerloneNP LevatolNP LopressorNP NormodyneNP SectralNP TenorminNP Toprol XLNP TrandateNP ZebetaCalcium BlockersG diltiazem HClG diltiazem HCl capsule,
sustained release 12 hr
G diltiazem HCl capsule,sustained release 24 hr
G diltiazem HCl tablet,sustained release
G nimodipineG verapamil HClG verapamil HCl
capsule, 24 hr sustained release
G verapamil HCl tablet,sustained action
P Cardizem LA 120mgNP Calan SRNP CardizemNP Cardizem CDNP Cardizem LA 180mg,
240mg, 300mg,360mg, 420mg
NP Cardizem SRNP Covera-HSNP Isoptin S.R.NP NimotopNP TiazacNP VerelanNP Verelan PM
DihydropyridinesG amlodipine besylateG felodipineG isradipineG nifedipineG nifedipine tablet,
sustained releaseG nisoldipineP SularNP Adalat CCNP Cardene SR
CARDIOVASCULAR(Blood Pressure/Heart/Cholesterol)
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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 DynaCircNP DynaCirc CRNP NorvascNP PlendilNP Procardia XL
Nitroglycerin PatchesG nitroglycerin patchP Minitran PatchNP Nitro-Dur Patch
AdrenergicAntagonists &Related DrugsG clonidine HClG doxazosin mesylateG guanfacine HClG methyldopaG prazosin HClG reserpineG terazosin HClNP CarduraNP Cardura XLNP CatapresNP Catapres-TTSNP HytrinNP MinipressNP Tenex
Angiotensin IIBlockers & ReninInhibitorsG losartan potassiumG losartan/
hydrochlorothiazideP AtacandP Atacand HCTP BenicarP Benicar HCTP Diovan
P Diovan HCTP MicardisP Micardis HCTP TekturnaP Tekturna HCTP ValturnaNP AvalideNP AvaproNP CozaarNP HyzaarNP TevetenNP Teveten HCT
AntilipidemicsG cholestyramine/
aspartameG cholestyramine/
sucroseG colestipol HClG fenofibrate,
micronizedG gemfibrozilG lovastatinG pravastatinG simvastatinP AdvicorP AltoprevP CrestorP FenoglideP LipitorP LovazaP NiaspanP SimcorP TricorP TriglideP TrilipixP VytorinP WelcholP ZetiaNP AntaraNP Caduet
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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 ColestidNP FibricorNP LescolNP Lescol XLNP 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/benazeprilG 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
P ExforgeP Exforge HCTP Lotrel 5-40mg,
10-40mgNP AccureticNP AzorNP CapozideNP ClorpresNP CorzideNP LexxelNP Lopressor HCTNP Lotensin HCTNP Lotrel 2.5-10mg,
5-10mg, 5-20mg,10-20mg
NP Monopril HCT
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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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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, micronizedG metformin HClG metformin HCl tablet,
sustained release 24 hr
G nateglinideG tolazamideG tolbutamideP Actoplus MetP ActosP AvandametP AvandarylP AvandiaP ByettaP DuetactP JanumetP JanuviaP OnglyzaP PrandinP SymlinNP AmarylNP DiabineseNP DiaBetaNP FortametNP GlucophageNP Glucophage XRNP GlucotrolNP Glucotrol XLNP GlucovanceNP GlumetzaNP GlynaseNP GlysetNP MetaglipNP MicronaseNP OrinaseNP Prandimet
ENDOCRINE (Diabetes/Hormones/Contraceptives)
NP PrinzideNP TarkaNP TenoreticNP Twynsta
NP UnireticNP VasereticNP ZestoreticNP Ziac
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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 PrecoseNP RiometNP StarlixNP Tolinase
Blood Glucose TestStripsG alcohol antiseptic
padsP Accu-Chek Active 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 Surestep Pro Test
StripsP Surestep Test Strips
Contraceptive AgentsG desogestrel-ethinyl
estradiolG desogestrel-ethinyl
estradiol/ethinylestradiol
G ethinyl estradiol/drospirenone
G ethynodiol d-ethinylestradiol
G levonorgestrelG levonorgestrel-
ethinyl estradiolG norethindroneG norethindrone a-e
estradiol
G norethindrone a-eestradiol/ferrousfumarate
G norethindrone-ethinyl estradiol
G norethindrone-mestranol
G norgestimate-ethinyl estradiol
G norgestrel-ethinylestradiol
P CyclessaP LybrelP NuvaRingP Plan B One-StepP SeasoniqueP YazNP AlesseNP BreviconNP DemulenNP DesogenNP Estrostep FeNP LevlenNP LevliteNP LoestrinNP Loestrin FeNP Loestrin 24 FeNP Lo/OvralNP LoSeasoniqueNP MircetteNP ModiconNP NordetteNP NorinylNP Ortho-CeptNP Ortho-CyclenNP Ortho EvraNP Ortho MicronorNP Ortho-NovumNP Ortho Tri-CyclenNP Ortho Tri-Cyclen Lo
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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 OvconNP OvralNP SeasonaleNP Tri-LevlenNP Tri-NorinylNP TriphasilNP Yasmin
Estrogens/EstrogenCombinationsG estradiol patchG estradiol tabletG estradiol/
norethindroneacetate
G estropipateG methyl-
testosterone/estrogens, esterified
P CenestinP ClimaraP CombipatchP DivigelP EnjuviaP EstradermP Estratest
P Estratest H.S.P EstringP EvamistP Premarin TabletP Premarin Vaginal
CreamP PremphaseP PremproP VagifemP VivelleP Vivelle-DotNP ActivellaNP AloraNP AngeliqNP Climara ProNP ElestrinNP EstraceNP EstrasorbNP EstrogelNP FemhrtNP FemringNP FemtraceNP MenestNP MenostarNP OgenNP Ortho-Prefest
Ulcer DrugsG cimetidine HCl liquidG cimetidine tabletG famotidineG lansoprazoleG misoprostolG nizatidine
G omeprazoleG pantoprazole sodiumG ranitidine HClP Axid Oral SolutionP Nexium NP AciphexNP Axid CapsuleNP Cytotec
G I (Ulcer)
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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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NSAIDsG etodolacG flurbiprofenG ibuprofenG indomethacinG ketoprofenG meclofenamate
sodiumG meloxicamG nabumetoneG naproxenG naproxen sodiumG oxaprozinG piroxicamG sulindacG tolmetin sodiumNP Anaprox DSNP AnsaidNP ArthrotecNP ClinorilNP DayproNP diclofenac
potassiumNP diclofenac sodiumNP EC-Naprosyn
NP FeldeneNP FlectorNP IndocinNP LodineNP Lodine XLNP MobicNP MotrinNP NaprelanNP NaprosynNP OruvailNP PennsaidNP RelafenNP ToradolNP VoltarenNP Voltaren-XR
NSAID COX-2InhibitorsP Celebrex
NSAIDS (Pain Relievers)
NP KapidexNP PepcidNP PrevacidNP Prilosec RxNP ProtonixNP TagametNP Zantac RxNP Zegerid
Other G I DrugsG sucralfate tabletP Carafate Suspension P PyleraNP Carafate Tablet
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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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G acetaminophen/butalbital
G acetaminophen/caffeine/butalbital
G aspirin/caffeine/butalbital
G dihydroergotaminemesylate
G ergotamine/caffeineG isometheptene
mucate/acetaminophen/dichloralphenazone
G sumatriptan succinateP Amerge
P ErgomarP FrovaP MaxaltP Maxalt MLTP PhrenilinP Phrenilin ForteP RelpaxP TreximetP ZomigP Zomig ZMTNP AxertNP Cafergot tabletNP ImitrexNP MidrinNP Migranal
MIGRAINE/HEADACHE THERAPY
G galantamine HBrP AriceptP Aricept ODTP ExelonNP Cognex
NP NamendaNP RazadyneNP Razadyne ER
DRUGS TO TREAT ALZHEIMER’S DISEASE
G flavoxateG oxybutynin chloride P DetrolP Detrol LAP EnablexP GelniqueP Oxytrol
P Sanctura XRP VesicareNP DitropanNP Ditropan XLNP SancturaNP Toviaz
DRUGS TO TREAT OVERACTIVE BLADDER
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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 Agonists OralG albuterol sulfateG metaproterenol
sulfateG terbutaline sulfateNP AlupentNP BrethineNP ProventilNP Ventolin
Beta Agonist InhalersG albuterolG albuterol sulfateG isoetharine HCl
solutionG levalbuterol HClG metaproterenol
sulfateP ForadilP Maxair AutohalerP PerforomistP Proair HFAP Serevent DiskusP Xopenex 0.31mg/3mL,
0.63mg/3mL,1.25mg/3mL
P Xopenex HFANP AccunebNP AlupentNP BrovanaNP ProventilNP Proventil HFANP Xopenex 1.25mg/0.5NP Ventolin NP Ventolin HFA
Inhaled SteroidsG budesonideP AsmanexP Flovent DiskusP Flovent HFAP Pulmicort FlexhalerP Pulmicort 1mg/2mL
RespulesP QVARNP AerobidNP Aerobid-MNP AlvescoNP AzmacortNP Pulmicort 0.25mg/2mLNP Pulmicort 0.5mg/2mL
Nasal CorticosteroidsG flunisolideG fluticasone propionateP Nasacort AQP NasonexP Rhinocort AquaP VeramystNP Beconase AQNP FlonaseNP NasacortNP NasalideNP NasarelNP Omnaris
MiscellaneousPulmonary AgentsG acetylcysteineG cromolyn sodium
ampul for nebulization
RESPIRATORY (Allergy/Asthma)
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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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G ipratropium/albuterolsulfate
G ipratropium bromidesolution
P Advair DiskusP Advair HFAP Atrovent HFAP BerinertP CinryzeP CombiventP Intal InhalerP LetairisP PulmozymeP RevatioP SingulairP SpirivaP SymbicortP TiladeP TracleerP VentavisNP AccolateNP AdcircaNP Atrovent Inhalation
SolutionNP DuonebNP TyvasoNP XolairNP ZyfloNP Zyflo CR
Antihistamine/DecongestantCombinationsG pseudoephedrine HCl/
brompheniraminemaleate
G pseudoephedrine HCl/brompheniraminemaleate capsule,sustained release 12 hr
G pseudoephedrine HCl/chlorpheniraminemaleate
G pseudoephedrine HCl/chlorpheniraminemaleate capsule,sustained release 12 hr
G pseudoephedrine tannate/chlorpheniramine tannate
P Allegra-D 24 HourP Clarinex-D 12 hrP Clarinex-D 24 hrP Deconamine LiquidP Deconamine SRNP Allegra-D 12 HourNP Deconamine TabletNP HistexNP Histex SRNP RynatanNP RynatussNP Semprex-D
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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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AntihistaminesG clemastine fumarateG cyproheptadine HClG diphenhydramine HClG fexofenadine HClG hydroxyzine HClG hydroxyzine pamoateG promethazine HClP Allegra Oral
Suspension
P ClarinexNP AllegraNP Allegra ODTNP AtaraxNP PhenerganNP VistarilNP Xyzal
G alendronate sodiumG calcitonin, salmon,
syntheticP Actonel 30mgP BonivaP EvistaP ForteoP Fosamax Plus DP Fosamax SolutionNP Actonel 5mgNP Actonel 35mgNP Actonel 75mgNP Actonel 150mgNP Actonel with CalciumNP Fosamax TabletNP Miacalcin Nasal Spray
OSTEOPOROSIS/PAGET’S DISEASE
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Nonpreferred Possible Preferred ProductsProduct
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SECTION II:NONPREFERRED DRUGS AND THEIR POSSIBLE PREFERRED
ALTERNATIVES
Abilify® clozapine (generic), risperidone (generic), Geodon®
(Pfizer), Seroquel® (AstraZeneca), Seroquel XR®
(AstraZeneca), Zyprexa® (Eli Lilly)Accolate® Singulair® (Merck)
Accuneb® albuterol sulfate (generic)
Accupril® quinapril (generic)Accuretic® quinapril/hydrochlorothiazide (generic)Aceon® perindopril erbumine (generic)Aciphex® omeprazole (generic), Nexium® (AstraZeneca)Activella® 1-0.5mg estradiol/norethindrone acetate (generic)Activella® estradiol/norethindrone acetate (generic), Premphase®
0.5-0.1mg (Wyeth), Prempro® (Wyeth)Actonel® 5mg alendronate sodium 5mg (generic), alendronate
sodium 10mg (generic), Boniva® (Roche)Actonel® 35mg alendronate sodium 35mg (generic), alendronate
75mg, 150mg sodium 70mg (generic), Boniva® (Roche)Actonel® alendronate sodium (generic), Boniva® (Roche)
with CalciumAdalat CC® nifedipine ER (generic), amlodipine besylate (generic),
Sular® (First-Horizon)Adcirca® Revatio® (Pfizer)Aerobid® Asmanex® (Schering), Flovent HFA® (GlaxoSmithKline),
Pulmicort Inhaler® (AstraZeneca), QVAR® (Ivax)Aerobid-M® Asmanex® (Schering), Flovent HFA® (GlaxoSmithKline),
Pulmicort Inhaler® (AstraZeneca), QVAR® (Ivax)Alesse® Aviane® (Barr-branded generic*), Lessina® (Barr-
branded generic*), Lutera® (Watson-branded generic*),Lybrel® (Wyeth)
Allegra® ODT fexofenadine HCl (generic)Allegra® Tablet fexofenadine HCl (generic), Clarinex® (Schering)Allegra-D® 12 Hour pseudoephedrine HCl/fexofenadine HCl (generic)Alora® estradiol patch (generic), Climara® (Berlex), Estraderm®
(Novartis), Vivelle® (Novartis)Altace® ramipril (generic)
*Branded generics have the same co-payment as regular generics.
MG40113M PPF_RXS INCENTIVE_MEIPG_v3.qxd 5/26/10 2:57 PM
Nonpreferred Possible Preferred ProductsProduct
20*Branded generics have the same co-payment as regular generics.
Alupent® metaproterenol sulfate (generic), Maxair Autohaler®
(Graceway), Proair HFA® (Teva), Xopenex HFA® (Sepracor)Alvesco® Asmanex® (Schering), Flovent HFA® (GlaxoSmithKline),
Pulmicort Flexhaler® (AstraZeneca)Amaryl® glimepiride (generic)Ambien® zolpidem tartrate (generic)Ambien CR® zolpidem tartrate (generic)Amoxil® amoxicillin trihydrate (generic)Anafranil® clomipramine HCl (generic)Anaprox DS® naproxen sodium (generic)Angeliq® estradiol/norethindrone acetate (generic),
Premphase® (Wyeth), Prempro® (Wyeth)Ansaid® flurbiprofen (generic)Antara® fenofibrate (generic), gemfibrozil (generic), Tricor®
(Abbott), Triglide® (Sciele), Trilipix® (Abbott)Arthrotec® ibuprofen (generic), naproxen (generic), Celebrex®
(Pfizer)Asendin® amoxapine (generic)Atarax® hydroxyzine HCl (generic)Ativan® lorazepam (generic)Atrovent® ipratropium bromide (generic)
solutionAugmentin® 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)Avalide® losartan/hydrochlorothiazide (generic), Atacand HCT®
(AstraZeneca), Benicar HCT® (Daiichi Sankyo), DiovanHCT® (Novartis), Micardis HCT® (BIPI)
Avapro® losartan potassium (generic), Atacand® (AstraZeneca),Benicar® (Daiichi Sankyo), Diovan® (Novartis),Micardis® (BIPI)
Avelox® Levaquin® (J&J)
MG40113M PPF_RXS INCENTIVE_MEIPG_v3.qxd 5/26/10 2:57 PM
Nonpreferred Possible Preferred ProductsProduct
21
Aventyl HCl® nortriptyline HCl (generic)Axert® sumatriptan succinate (generic), Amerge®
(GlaxoSmithKline), Frova® (Endo), Maxalt® (Merck),Relpax® (Pfizer), Zomig® (AstraZeneca)
Axid® Capsule nizatidine (generic)Azmacort® Asmanex® (Schering), Flovent HFA® (GlaxoSmithKline),
Pulmicort Inhaler® (AstraZeneca), QVAR® (Ivax)Azor® amlodipine besylate (generic), amlodipine
besylate/benazepril (generic), Benicar® (DaiichiSankyo), Exforge® (Novartis)
Bactrim DS® sulfamethoxazole/trimethoprim (generic)Beconase AQ® flunisolide (generic), fluticasone propionate (generic),
Nasacort AQ® (Aventis), Nasonex® (Schering), RhinocortAqua® (AstraZeneca), Veramyst® (GlaxoSmithKline)
Biaxin® clarithromycin (generic)Biaxin XL® clarithromycin ER (generic)Brethine® terbutaline sulfate (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)Bystolic® atenolol (generic), metoprolol tartrate (generic)Caduet® amlodipine besylate (generic), Lipitor® (Pfizer)Calan SR® verapamil HCl tablet, sustained action (generic)Capoten® captopril (generic)Capozide® captopril/hydrochlorothiazide (generic)Carafate Tablet® sucralfate (generic)Cardene SR® amlodipine besylate (generic), nifedipine ER (generic),
Sular® (First-Horizon)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)
*Branded generics have the same co-payment as regular generics.
MG40113M PPF_RXS INCENTIVE_MEIPG_v3.qxd 5/26/10 2:57 PM
22
Cardura® doxazosin mesylate (generic)Cataflam® etodolac (generic), ibuprofen (generic), naproxen
(generic)Catapres® clonidine HCl tablet (generic)Catapres-TTS® clonidine HCl patch (generic)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)Cleocin HCl® clindamycin HCl (generic)Climara Pro® Combipatch® (Novartis)Clinoril® sulindac (generic)Clorpres® chlorthalidone (generic), clonidine HCl (generic)Cognex® galantamine (generic), Aricept® (Eisai), Exelon®
(Novartis)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)Cytotec® misoprostol (generic)Dallergy® syrup pseudoephedrine HCl/brompheniramine maleate
(generic)Dalmane® flurazepam HCl (generic)Daypro® oxaprozin (generic)Deconamine® pseudoephedrine w/chlorpheniramine (generic)
tabletDemulen® Zovia® (Watson-branded generic*)Desogen® Apri® (Barr-branded generic*),
Solia® (Prasco Labs-branded generic*)Desyrel® trazodone HCl (generic)DiaBeta® glyburide (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
MG40113M PPF_RXS INCENTIVE_MEIPG_v3.qxd 5/26/10 2:57 PM
Nonpreferred Possible Preferred ProductsProduct
23
Diclofenac etodolac (generic), ibuprofen (generic), naproxen Potassium (generic)
Diclofenac etodolac (generic), ibuprofen (generic), naproxen Sodium (generic)
Diflucan® fluconazole (generic)Dilacor XR® diltiazem XR (generic)Dispermox® amoxicillin trihydrate suspension (generic),
amoxicillin trihydrate chewable tablet (generic)Ditropan® oxybutynin chloride (generic)Ditropan XL® oxybutynin chloride ER (generic)Doral® temazepam (generic), triazolam (generic), zaleplon
(generic), zolpidem tartrate (generic), Restoril®
(Mallinckrodt)Doryx® doxycycline hyclate (generic)Duoneb® ipratropium/albuterol sulfate (generic)Duricef® cefadroxil hydrate (generic)Dynacin® minocycline HCl (generic)DynaCirc® isradipine (generic), amlodipine besylate (generic),
nifedipine ER (generic), Sular® (First-Horizon)DynaCirc CR® amlodipine besylate (generic), nifedipine ER (generic),
Sular® (First-Horizon)EC-Naprosyn® naproxen (generic)Edluar® zolpidem tartrate (generic)Effexor® venlafaxine HCl (generic)Elavil® amitriptyline HCl (generic)Elestrin® estradiol patch (generic), Climara® (Berlex), Divigel®
(Upsher Smith), Estraderm® (Novartis), Vivelle®
(Novogyne)Emsam® tranylcypromine sulfate (generic), Nardil® (Parke-Davis)EryPed Chewable erythromycin ethylsuccinate (generic)Tablet® 200mg
EryPed erythromycin ethylsuccinate (generic)Suspension®
400mg/5mlEstrace Tablet® estradiol (generic)Estrace Vaginal Premarin Vaginal Cream® (Wyeth)
Cream®
Estrasorb® estradiol patch (generic), Divigel® (Upsher Smith)Estrogel® estradiol patch (generic), Climara® (Berlex), Divigel®
(Upsher Smith), Estraderm® (Novartis), Vivelle®
(Novartis)
*Branded generics have the same co-payment as regular generics.
MG40113M PPF_RXS INCENTIVE_MEIPG_v3.qxd 5/26/10 2:57 PM
24
Estrostep Fe® Apri® (Barr-branded generic*), Kariva® (Barr-brandedgeneric*), Microgestin Fe® (Watson-branded generic*),Cyclessa® (Organon)
Factive® ciprofloxacin (generic), Levaquin® (J&J)Fanapt® clozapine (generic), risperidone (generic), Geodon®
(Pfizer), Seroquel® (AstraZeneca), Seroquel XR®
(AstraZeneca), Zyprexa® (Eli Lilly)Feldene® piroxicam (generic)Femhrt® estradiol/norethindrone acetate (generic),
Premphase® (Wyeth), Prempro® (Wyeth)Femring® Estring® (Pfizer), Premarin Vaginal Cream® (Wyeth)Femtrace® estradiol (generic)Fibricor® fenofibrate (generic), Fenoglide® (Shionogi Pharma),
Tricor® (Abbott), Triglide® (Sciele), Trilipix® (Abbott)Flonase® fluticasone propionate (generic)Floxin® ofloxacin (generic)Fortamet® metformin HCl ER (generic), metformin HCl tablet
(generic)Fosamax® Tablets alendronate sodium (generic)Gantrisin® sulfisoxazole (generic)Geocillin® ciprofloxacin 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)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)Histex® pseudoephedrine w/chlorpheniramine (generic)Histex SR® pseudoephedrine w/chlorpheniramine (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
MG40113M PPF_RXS INCENTIVE_MEIPG_v3.qxd 5/26/10 2:57 PM
Nonpreferred Possible Preferred ProductsProduct
25
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)Invega® risperidone (generic), Geodon® (Pfizer), Seroquel®
(AstraZeneca), Seroquel XR® (AstraZeneca),Zyprexa® (Eli Lilly)
Isoptin S.R.® verapamil HCl tablet, sustained action (generic)Kapidex® omeprazole (generic), Nexium® (AstraZeneca)Keflex® cephalexin monohydrate (generic)Kerlone® betaxolol HCl (generic)Ketek® amoxicillin trihydrate/potassium clavulanate (generic),
azithromycin (generic), Levaquin® (J&J)Lamisil® tablet terbinafine HCl (generic)Lescol® lovastatin (generic), simvastatin (generic), Altoprev®
(Andrx), Crestor® (AstraZeneca), Lipitor® (Pfizer),VytorinTM (Merck/Schering)
Lescol XL® lovastatin (generic), simvastatin (generic), Altoprev®
(Andrx), Crestor® (AstraZeneca), Lipitor® (Pfizer),VytorinTM (Merck/Schering)
Levatol® acebutolol HCl (generic), atenolol (generic),metoprolol tartrate (generic)
Levlen® Levora® (Watson-branded generic*), Portia®
(Barr-branded generic*)Levlite® Aviane® (Barr-branded generic*), Lessina®
(Barr-branded generic*), Lybrel® (Wyeth) Lexapro® citalopram (generic), fluoxetine HCl (generic),
paroxetine HCl (generic), sertraline HCl (generic),Cymbalta® (Eli Lilly), Effexor XR® (Wyeth), Pristiq® (Wyeth)
Lexapro Solution® citalopram solution (generic), fluoxetine HCl solution(generic), paroxetine HCl suspension (generic)
Lexxel® amlodipine besylate/benazepril (generic)Librium® chlordiazepoxide HCl (generic)Lodine® etodolac (generic)Lodine XL® etodolac (generic)Loestrin® Junel® (Barr-branded generic*), Microgestin®
(Watson-branded generic*)
*Branded generics have the same co-payment as regular generics.
MG40113M PPF_RXS INCENTIVE_MEIPG_v3.qxd 5/26/10 2:57 PM
26
Loestrin Fe® Junel Fe® (Barr-branded generic*), Microgestin Fe®
(Watson-branded generic*)Loestrin 24 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® Aviane® (Barr-branded generic*), Lutera® (Watson-
branded generic*)Lotensin® benazepril HCl (generic)Lotensin HCT® benazepril HCl/hydrochlorothiazide (generic)Lotrel® 2.5-10mg, amlodipine besylate/benazepril (generic)5-10mg, 5-20mg,10-20mg
Ludiomil® maprotiline HCl (generic)Lunesta® temazepam (generic), zolpidem tartrate (generic)Luvox® fluvoxamine maleate (generic)Luvox CR® fluvoxamine maleate (generic)Macrobid® nitrofurantoin macrocrystal (generic)Macrodantin® nitrofurantoin (generic)Mandelamine® methenamine mandelate (generic)Mavik® trandolapril HCl (generic)Menest® estradiol (generic), estropipate (generic), Cenestin®
(Duramed/Barr), Enjuvia® (Duramed/Barr),Premarin® (Wyeth)
Menostar Patch® Climara Patch® (Berlex), Vivelle Patch® (Novartis)Metaglip® glipizide/metformin (generic)Mevacor® lovastatin (generic)Miacalcin® calcitonin-salmon (generic)Micronase® glyburide (generic)Midrin® isometheptene/apap/dichloralphenazone (generic)Migranal® sumatriptan nasal spray (generic), Zomig® Nasal Spray
(AstraZeneca), Amerge® (GlaxoSmithKline), Frova®
(Endo), Maxalt® (Merck), Relpax® (Pfizer)Minipress® prazosin HCl (generic)Minocin® minocycline HCl (generic)Mircette® Kariva® (Barr-branded generic*)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
MG40113M PPF_RXS INCENTIVE_MEIPG_v3.qxd 5/26/10 2:57 PM
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27
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)Monopril HCT® fosinopril/hydrochlorothiazide (generic)Monurol® ciprofloxacin HCl (generic), sulfamethoxazole/
trimethoprim (generic), trimethoprim (generic),Noroxin® (Merck)
Motrin® ibuprofen (generic)Moxatag® amoxicillin (generic)Nalfon® etodolac (generic), ibuprofen (generic), indomethacin
(generic), meclofenamate sodium (generic),naproxen (generic), sulindac (generic)
Namenda galantamine (generic), Aricept® (Eisai), Exelon®
Dose Pack® (Novartis)Namenda Oral galantamine oral solution (generic), Exelon Oral
Solution® Solution® (Novartis)Namenda Tablet® galantamine (generic), Aricept® (Eisai), Exelon®
(Novartis)Naprelan® naproxen sodium (generic)Naprosyn® naproxen (generic)Nasacort® Nasacort AQ® (Aventis), Veramyst® (GlaxoSmithKline)Nasalide® flunisolide (generic)Nasarel® flunisolide (generic)Nembutal chloral hydrate (generic), temazepam (generic),
Sodium® triazolam (generic)Nimotop® nimodipine (generic)Niravam® alprazolam (generic)Nitro-Dur® nitroglycerin patch (generic), Minitran® (3M)Nizoral® ketoconazole (generic)Nordette® Levora® (Watson-branded generic*), Portia®
(Barr-branded generic*)Norinyl® Necon® (Watson-branded generic*), Nortrel®
(Barr-branded generic*)Normodyne® labetalol HCl (generic)Norpramin® desipramine HCl (generic)Norvasc® amlodipine besylate (generic)
*Branded generics have the same co-payment as regular generics.
MG40113M PPF_RXS INCENTIVE_MEIPG_v3.qxd 5/26/10 2:57 PM
28
Novolin® Humulin® (Eli Lilly)Ogen® estropipate (generic)Omnaris® flunisolide (generic), fluticasone propionate (generic),
Nasacort AQ® (Aventis), Nasonex® (Schering), RhinocortAqua® (AstraZeneca), Veramyst® (GlaxoSmithKline)
Omnicef® cefdinir (generic)Orinase® tolbutamide (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*)
1/50Ortho-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*)
Oruvail® ketoprofen (generic)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)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
MG40113M PPF_RXS INCENTIVE_MEIPG_v3.qxd 5/26/10 2:57 PM
Nonpreferred Possible Preferred ProductsProduct
29
Pexeva® paroxetine HCl (generic)Phenergan® promethazine HCl (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)Prevacid® lansoprazole (generic), omeprazole (generic), Nexium®
(AstraZeneca)Prilosec Rx® omeprazole (generic), Nexium® (AstraZeneca)Primsol® trimethoprim (generic)Prinivil® lisinopril (generic)Prinzide® lisinopril/hydrochlorothiazide (generic)Procardia XL® nifedipine ER tablet, sustained release osmotic push
(generic)Proquin XR® ciprofloxacin HCl (generic)ProSom® estazolam (generic)Protonix® Nexium® Suspension (AstraZeneca)
SuspensionProtonix® Tablet pantoprazole sodium (generic), omeprazole (generic),
Nexium® (AstraZeneca)Proventil® albuterol (generic)Proventil HFA® Proair HFA® (Teva), Xopenex HFA® (Sepracor)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)
*Branded generics have the same co-payment as regular generics.
MG40113M PPF_RXS INCENTIVE_MEIPG_v3.qxd 5/26/10 2:57 PM
30
Restoril® temazepam (generic)15mg, 30mg
Riomet Solution® metformin HCl (generic)Risperdal risperidone (generic)
Oral Solution®
Risperdal Tablet® risperidone (generic)Rozerem® estazolam (generic), temazepam (generic), triazolam
(generic), zolpidem tartrate (generic)Rynatan® phenclor tannate pediatric (generic),
brompheniramine/pseudoephedrine (generic),pseudoephedrine HCl/chlorpheniramine maleate(generic)
Rynatuss® carbetapentane/ephed/phenyleph/CP (generic)Sanctura® oxybutynin chloride (generic), oxybutynin chloride ER
(generic), Detrol® (Pharmacia/Upjohn), Detrol LA®
(Pharmacia/Upjohn), Enablex® (Novartis), Gelnique®
(Watson), Vesicare® (GlaxoSmithKline)Saphris® clozapine (generic), risperidone (generic), Geodon®
(Pfizer), Seroquel® (AstraZeneca), Seroquel XR®
(AstraZeneca), Zyprexa® (Eli Lilly)Sarafem® fluoxetine HCl (generic)Seasonale® Jolessa® (Barr-branded generic*), Quasense®
(Watson-branded generic*), Lybrel® (Wyeth),Seasonique® (Duramed/Barr)
Seconal Sodium® chloral hydrate (generic), temazepam (generic),triazolam (generic)
Sectral® acebutolol HCl (generic)Semprex-D® pseudoephedrine HCl/brompheniramine (generic),
pseudoephedrine HCl/chlorpheniramine (generic)Septra DS® sulfamethoxazole/trimethoprim (generic)Serax® oxazepam (generic)Serzone® fluoxetine HCl (generic), paroxetine HCl (generic)Sinequan® doxepin HCl (generic)Solodyn® minocycline HCl (generic), doxycycline monohydrate
(generic)Sonata® zaleplon (generic)Spectracef® cefaclor (generic), cefdinir (generic), cefuroxime axetil
(generic)Sporanox® itraconazole (generic)
capsuleStarlix® nateglinide (generic)Suprax® cefdinir (generic), cefuroxime axetil (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
MG40113M PPF_RXS INCENTIVE_MEIPG_v3.qxd 5/26/10 2:57 PM
Nonpreferred Possible Preferred ProductsProduct
31
Symbyax® fluoxetine HCl (generic), risperidone (generic),Seroquel® (AstraZeneca), Seroquel XR® (AstraZeneca),Zyprexa® (Eli Lilly)
Tagamet® cimetidine (generic)Tarka® amlodipine besylate/benazepril (generic)Tenex® guanfacine HCl (generic)Tenoretic® atenolol/chlorthalidone (generic)Tenormin® atenolol (generic)Terazol® terconazole (generic)Teveten® losartan potassium (generic), Atacand® (AstraZeneca),
Benicar® (Daiichi Sankyo), Diovan® (Novartis), Micardis®
(BIPI)Teveten HCT® losartan/hydrochlorothiazide (generic), Atacand HCT®
(AstraZeneca), Benicar HCT® (Daiichi Sankyo), DiovanHCT® (Novartis), Micardis HCT® (BIPI)
Thioridazine HCl® chlorpromazine HCl (generic), haloperidol (generic),risperidone (generic), Seroquel® (AstraZeneca)
Tiazac® diltiazem HCl capsule, sustained release 24 hr (generic)Tofranil® imipramine HCl (generic)Toprol XL® metoprolol succinate (generic)Toradol® etodolac (generic), ibuprofen (generic), indomethacin
(generic), meclofenamate sodium (generic),naproxen (generic), sulindac (generic)
Toviaz® oxybutynin chloride ER (generic), Detrol®
(Pharmacia/Upjohn), Detrol LA® (Pharmacia/Upjohn),Enablex® (Novartis), Gelnique® (Watson), Vesicare®
(GlaxoSmithKline)Trandate® labetalol HCl (generic)Tranxene SD® clorazepate dipotassium (generic)Tranxene T-Tab® clorazepate dipotassium (generic)Tri-Levlen® Enpresse® (Barr-branded generic*), Trivora®
(Watson-branded generic*)Tri-Norinyl® Necon® (Watson-branded generic*), Nortrel®
(Barr-branded generic*)Triphasil® Enpresse® (Barr-branded generic*), Trivora®
(Watson-branded generic*)Twynsta® amlodipine besylate (generic), Micardis ® (Boehringer
Ingelheim)Tyvaso® Ventavis® (Actelion)Uniretic® moexipril/hydrochlorothiazide (generic)Univasc® moexipril HCl (generic)Valium® diazepam (generic)
*Branded generics have the same co-payment as regular generics.
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Vantin® cefpodoxime proxetil (generic)Vaseretic® enalapril maleate/hydrochlorothiazide (generic)Vasotec® enalapril maleate (generic)Ventolin® Proair HFA® (Teva), Xopenex HFA® (Sepracor)Ventolin HFA® Proair HFA® (Teva), Xopenex HFA® (Sepracor)Verelan® verapamil ER (generic)Verelan PM® verapamil ER PM (generic)Vfend Suspension® Vfend Tablet® (Pfizer)Vibramycin Syrup® doxycycline monohydrate suspension (generic)Vistaril® hydroxyzine pamoate (generic)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 tablet, sustained release (generic)Wytensin® clonidine HCl (generic), methyldopa (generic)Xanax® alprazolam (generic)Xanax XR® alprazolam XR (generic)Xifaxan® azithromycin (generic), ciprofloxacin HCl (generic)Xolair® Asmanex® (Schering), Flovent HFA® (GlaxoSmithKline),
Pulmicort® (AstraZeneca), QVAR® (Ivax)Xopenex® levalbuterol HCl (generic)
1.25mg/0.5Xyzal Solution® fexofenadine HCl (generic), Allegra Suspension®
(Aventis), Clarinex® Rapid Dissolve Tabs (Schering)Xyzal Tablet® fexofenadine HCl (generic), Clarinex® Tablet (Schering)Yasmin® Ocella® (Barr-branded generic*)Zantac Rx Syrup® ranitidine HCl tablet (generic), Axid Oral Solution®
(Braintree)Zantac Rx Tablet® ranitidine HCl tablet (generic)Zebeta® bisoprolol fumarate (generic)Zegerid® omeprazole (generic), Nexium® (AstraZeneca)Zestoretic® lisinopril/hydrochlorothiazide (generic)Zestril® lisinopril (generic)Ziac® bisoprolol fumarate/hydrochlorothiazide (generic)Zithromax® azithromycin (generic)Zmax® azithromycin (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
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Zocor® simvastatin (generic)Zoloft® sertraline HCl (generic)Zyflo® Singulair® (Merck)Zyflo CR® Singulair® (Merck)
*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. For anupdated and complete listing of your prescriptionbenefit, you can visit the “Benefit highlights”section of our website, www.medco.com, and click on “Learn about formularies” or by callingcustomer service at the phone number on theback of your prescription card.
www.medco.com
Medco, Preferred Prescriptions and Rx Selections are trademarks of Medco Health Solutions, Inc.© 2010 Medco Health Solutions, Inc.All rights reserved.MG40113M MEIPG (Ed. 5/10)
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