PG902988.

1REV 8/19/04 10:02 AM Page 1

SECTION I: SELECTED THERAPEUTIC DRUG CATEGORIES

The Formulary Pocket Guide is not meant to be a complete list of drugs covered under your plan.
Since prescription drug benefits vary by client, the inclusion of a drug in this formulary does not imply drug coverage.
The cost ranges are based on actual claims utilization data as of March 31, 2004 and are subject to change.
ANTI-INFECTIVES Beta Blockers Oral Contraceptives $40-$50 ▲SerentiI
(Antibiotics/Antifungals) <$10 +atenolol $20-$30 Plan B $50-$60 Orap
(INGREDIENT COST PER THERAPY) <$10 +metoprolol tartrate $30-$40 ⊕Alesse $60-$70
+loxapine succinate
<$10 +propranolol HCl $30-$40 ⊕Demulen $90-$100
Moban
Oral Cephalosporins $125-$150
Seroquel
$10-$20 +nadolol $30-$40 ⊕Loestrin Fe
$10-$20 +cefaclor $150-$175
Risperdal
$10-$20 +cephalexin monohydrate
$10-$20 +pindolol $30-$40 ⊕Lo/Ovral $200-$250
+clozapine
$30-$40 +cefadroxil hydrate
$10-$20 +timolol maleate $30-$40 ⊕Mircette $200-$250 Zyprexa
$20-$30 +acebutolol HCl $30-$40 ⊕Nordette
$60-$70 +cefuroxime $20-$30 +labetalol HCl
$70-$80 Suprax $30-$40 +bisoprolol fumarate
$30-$40 Ovrette NSAIDS (Pain Relievers)
$90-$100 ⊕Vantin $40-$50 ⊕Inderal LA $30-$40 ⊕Triphasil (INGREDIENT COST PER THERAPY)
$30-$40 Yasmin
Oral Penicillins Calcium Blockers $40-$50 Estrostep Fe NSAIDs
<$10 +amoxicillin <$10 +diltiazem HCl $40-$50 ⊕Micronor <$10 +ibuprofen
<$10 +ampicillin <$10
+verapamil HCl $40-$50 ⊕Modicon <$10 +piroxicam
$10-$20 ⊕penicillin V potassium $10-$20
+verapamil HCl tablet, sustained $40-$50 ⊕Ortho-Cept $10-$20 ▲+indomethacin
$20-$30 +dicloxacillin sodium action $40-$50 ⊕Ortho-Cyclen $10-$20 +ketoprofen
$50-$60 +amoxicillin/clavulanate susp $20-$30 +diltiazem HCl capsule, sustained $40-$50 ⊕Ortho-Novum $10-$20 +naproxen
$70-$80 Augmentin ES release 12 hr $40-$50 Ortho-Novum 7/7/7 $10-$20 +naproxen sodium
$70-$80 +amoxicillin/clavulanate tab $20-$30 +diltiazem HCl capsule, sustained $40-$50 ⊕Ortho-TriCyclen $10-$20 +sulindac
Oral Sulfas release 24 hr $40-$50 Ortho-TriCyclen Lo $20-$30 +diclofenac sodium
Dihydropyridines $20-$30 +flurbiprofen
<$10 +sulfamethoxazole $50-$60 +Ovral $30-$40 +etodolac
<$10 +sulfamethoxazole/trimethoprim $40-$50 +nifedipine tablet, extended Other Contraceptives $30-$40 ▲+indomethacin sustained
<$10 +sulfisoxazole release release
$10-$20 +erythromycin ethylsuccinate/ $40-$50
Plendil $30-$40 Nuvaring
sulfisoxazole $50-$60 +nifedipine tablet, osmotic $30-$40 Ortho Evra NSAID COX-2 Inhibitors
$100-$125 +sulfadiazine laser-drilled formulation G.I. (Ulcer) $80-$90 Vioxx
Oral Tetracyclines $50-$60 Norvasc $90-$100 Celebrex
(INGREDIENT COST PER THERAPY)
<$10 +doxycycline hyclate Nitroglycerin Patches RESPIRATORY (Allergy/Asthma)
<$10 +tetracycline HCl $30-$40 ⊕Transderm Nitro H2 Antagonists (INGREDIENT COST PER THERAPY)
$50-$60 +minocycline HCl $60-$70 Nitro-Dur $10-$20 +cimetidine HCI
$350-$400 Declomycin Adrenergic Antagonists & Related Drugs $10-$20 +famotidine Antihistamines/Combinations
$10-$20 +ranitidine HCl <$10 ▲+diphenhydramine HCl
Oral Erythromycins <$10 +clonidine HCl $50-$60 +nizatidine
$10-$20
+doxazosin mesylate
(Rx Only)
<$10 +erythromycin base $70-$80 Zantac syrup <$10 ▲+hydroxyzine pamoate
<$10 +erythromycin base tablet, enteric $10-$20 ▲+methyldopa
Proton Pump Inhibitors $10-$20 ▲+clemastine fumarate
coated $10-$20 +reserpine $10-$20 +cyproheptadine HCl
<$10 +erythromycin ethylsuccinate $10-$20
+terazosin HCl $90-$100 (generic)
$150-$175 (brand) } ⊕Prilosec
$10-$20 ▲+dexchlorpheniramine
<$10 +erythromycin stearate $20-$30 +guanfacine HCl
$20-$30
+prazosin HCl
$10-$20 +promethazine HCl
$10-$20 +erythromycin estolate $100-$125 Protonix $20-$30 ▲+hydroxyzine HCl
$30-$40 Biaxin XL $30-$40 Ismelin $125-$150 Nexium
$90-$100 Catapres-TTS $50-$60 Astelin
$40-$50 Biaxin Other G.I. Drugs $50-$60 Zyrtec
$40-$50 Zithromax $50-$60 Zyrtec D
ENDOCRINE $20-$30 +sucralfate
Oral Quinolones (Diabetes/Hormones/Contraceptives) $150-$175 Helidac $60-$70 Allegra
$10-$20 (INGREDIENT COST PER THERAPY) $70-$80 Allegra D
(generic)
} ⊕Cipro $250-$300 Prevpac
$90-$100 (brand)
Insulin Therapy Beta Agonists
$40-$50 Noroxin PSYCHOTHERAPEUTICS $10-$20
$80-$90 Avelox $40-$50
$50-$60
Novolin
Humulin (Anxiety/Depression) $40-$50 } ⊕Proventil
(generic)
(brand)

$50-$60 InnoLet (INGREDIENT COST PER THERAPY) $10-$20 +albuterol sulfate (oral)
CARDIOVASCULAR $80-$90 Lantus $30-$40 Alupent Inhaler
(Blood Pressure/Heart/Cholesterol) Tricyclic Antidepressants $30-$40 +metaproterenol sulfate
$90-$100 Iletin II
(INGREDIENT COST PER THERAPY) <$10 ▲+amitriptyline HCl $30-$40 Ventolin Rotacaps
$100-$125 Humulin Cartridge
ACE Inhibitors $125-$150 Humalog <$10 ▲+doxepin HCl $40-$50 +albuterol sulfate solution
<$10
+captopril $125-$150 Novolin Cartridge <$10
+nortriptyline HCl $40-$50 Proventil, HFA
$10-$20
+benazepril $150-$175 Humalog Pen $20-$30 ▲+clomipramine HCl $70-$80 Foradil
$10-$20
+benazepril/HCTZ $150-$175 NovoLog $20-$30
+desipramine HCl $70-$80 Maxair Autohaler
$10-$20 +captopril/HCTZ $150-$175 NovoLog Pen $20-$30 ▲+imipramine HCl $70-$80 Serevent Diskus
$10-$20 +enalapril maleate $30-$40 ▲+amoxapine $70-$80 Volmax
Blood Glucose Test Strips $70-$80 ▲Surmontil
$10-$20
+lisinopril $70-$80 One Touch Inhaled Steroids
$10-$20 +lisinopril/HCTZ $90-$100 ▲Vivactil $50-$60 Flovent Rotadisk
$70-$80 One Touch Surestep
$20-$30 Aceon $80-$90 One Touch Fast Take Misc. Antidepressants $70-$80 Azmacort
$20-$30 +enalapril/HCTZ $90-$100 One Touch Ultra $70-$80 Flovent
$30-$40
Accupril <$10
+trazodone HCl
Oral Hypoglycemics $20-$30
+maprotiline HCl $100-$125 Pulmicort
$30-$40
$40-$50
(generic)
(brand) }
⊕Accuretic <$10
+glipizide $30-$40 +mirtazapine $175-$200 Pulmicort Respules
$10-$20 +glyburide $30-$40 +nefazodone HCl Nasal Corticosteroids
Angiotensin II Blockers $10-$20 +glyburide, micronized $40-$50
+bupropion HCl $40-$50 Tri-Nasal
$30-$40 Avapro $20-$30 +glipizide, extended release $80-$90
Effexor $50-$60 Flonase
$30-$40 Benicar $20-$30 +metformin $80-$90 (generic) $50-$60 Nasonex
$30-$40 Benicar HCT $50-$60 (generic) $100-$125 (brand) }
⊕Wellbutrin SR $60-$70 Rhinocort Aqua
$40-$50 Avalide $70-$80 (brand) } ⊕Glucovance $100-$125
Effexor XR
$40-$50 Diovan $50-$60 Glyset
$40-$50 Diovan HCT $50-$60 Precose SSRI
Other Antihypertensive Combinations $60-$70 Metaglip $20-$30
+fluoxetine HCl KEY
<$10 +atenolol/chlorthalidone $100-$125 Actos $60-$70 Lexapro
<$10 +propranolol HCl/HCTZ tablet $100-$125 Avandamet $60-$70
+paroxetine The cost ranges are based on actual claims utilization
$100-$125 Avandia $70-$80 Celexa data as of March 31, 2004. Ingredient costs are the
$10-$20 +bisoprolol fumarate/HCTZ $100-$125
Prandin Average Wholesale Price for brand medications and the
$10-$20 +hydralazine HCl/HCTZ $80-$90 Zoloft
maximum allowable cost for most generic medications
$10-$20 ▲+methyldopa/HCTZ Estrogens/Combinations $90-$100 +fluvoxamine maleate less the average pharmacy discounts and may include
$20-$30 Timolide <$10 +estradiol Anxiolytics other discounts earned.These ranges are meant to
$40-$50 Lopressor HCT $10-$20 +estropipate <$10
+alprazolam provide a relative cost difference between drugs used to
$50-$60 Clorpres $10-$20 Menest treat similar conditions.
<$10 ▲+chlordiazepoxide HCl
$60-$70 Lotrel $20-$30 (generic) + = Means only the generic drug is formulary; the
Antilipidemics $30-$40 (brand) } ⊕Climara <$10 ▲+diazepam brand-name drug has the highest co-payment.
$20-$30 $20-$30
+lorazepam ⊕ = Means both brand-name and generic drugs
$10-$20
+gemfibrozil $40-$50
(generic)
(brand) }
⊕Estratest H.S. $30-$40 +buspirone HCl are formulary, but the generic alternative has
$30-$40 +lovastatin $20-$30 Premarin $30-$40 ▲+clorazepate a lower co-payment.
$50-$60 +cholestyramine light $30-$40 Combipatch $40-$50
+oxazepam
= Means that a dose lower than the
$50-$60 +cholestyramine/sucrose $30-$40 Estraderm manufacturer’s guidelines is recommended.
$50-$60 Colestid Antipsychotics ▲
$30-$40 Femhrt = Means that use by people 65 and older is
$60-$70 Niaspan $30-$40 Ortho-Dienestrol $10-$20 +fluphenazine HCI associated with increased risk; safer versions
$60-$70 Zetia $30-$40 Premphase $10-$20
+haloperidol may be available. If used, dosage should
$70-$80 Advicor $30-$40 Prempro $10-$20 ▲+thioridazine HCI generally be lowered.
$70-$80 Lipitor $30-$40 Vivelle $10-$20
+thiothixene = Means use by pregnant women is associated
$70-$80 Tricor $40-$50 $20-$30
+chlorpromazine HCI with increased risks. The risk to the baby
$80-$90 Zocor $50-$60
(generic)
(brand) } ⊕Estratest $20-$30
+perphenazine outweighs the benefit of the medication.
$90-$100 Pravachol $100-$125 Estring $20-$30 +trifluoperazine HCI = Means do not use in pregnancy.

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SECTION II: NONFORMULARY MEDICATIONS AND THEIR POSSIBLE FORMULARY ALTERNATIVES

Nonformulary Possible Formulary
Products
Aciphex® omeprazole (generic),
Protonix® (Wyeth),
Nexium® (AstraZeneca),
Prilosec® (AstraZeneca)
Aerobid® Azmacort® (Rhone-Poulenc
Rorer),
Flovent® (GlaxoSmithKline),
Flovent Rotadisk®
(GlaxoSmithKline)
Altace
®
benazepril (generic),
enalapril maleate (generic),
lisinopril (generic),
Aceon® (Solvay),
Accupril® (Pfizer)
Amaryl ®
glipizide (generic),
glipizide ER (generic),
glyburide (generic)
Bextra® Vioxx® (Merck & Co.),
Celebrex® (Pfizer)
Brevicon® Modicon® (Ortho Pharmaceutical)
Cardene® Plendil® (AstraZeneca),
Norvasc® (Pfizer),
nifedipine ER (generic)
Cardene SR® Plendil® (AstraZeneca),
Norvasc® (Pfizer),
nifedipine ER (generic)
Cozaar® Benicar® (Sankyo),
Avapro® (Bristol-Myers Squibb),
Diovan® (Novartis)
Crestor® lovastatin (generic),
Lipitor® (Pfizer),
Zocor® (Merck & Co.),
Pravachol® (Bristol-Myers Squibb)
Daypro® ibuprofen (generic),
naproxen (generic),
piroxicam (generic)
Nonformulary Possible Formulary
Products
Desogen® Ortho-Cept® (Ortho
Pharmaceutical)
Esclim® Climara® (Berlex Laboratories),
Estraderm® (Novartis),
Vivelle® (Novartis)
Estinyl® estradiol (generic),
estropipate (generic),
Menest® (Monarch),
Premarin® (Wyeth)
Estrace® Ogen® (Pharmacia/Upjohn),
cream with applicator Premarin® (Wyeth)
Glucophage XR® metformin (generic)
Hyzaar® Benicar HCT® (Sankyo),
Avalide® (Bristol-Myers Squibb),
Diovan HCT® (Novartis)
Lescol® lovastatin (generic),
Lipitor® (Pfizer),
Zocor® (Merck & Co.),
Pravachol® (Bristol-Myers Squibb) Nasarel®
Levlen®
levonorgestrel/ethinyl
estradiol (generic),
Nordette® (Monarch
Pharmaceutical)
Loestrin® levonorgestrel/ethinyl
estradiol (generic),
Lo/Ovral® (Wyeth),
Nordette® (Monarch
Pharmaceutical)
Loestrin Fe® (Pfizer)
Mavik® benazepril (generic),
enalapril maleate (generic),
lisinopril (generic),
Aceon® (Solvay),
Accupril® (Pfizer)
Maxair® Maxair Autohaler® (3M
Pharmaceuticals)
Nonformulary Possible Formulary Nonformulary Possible Formulary
Products Products
Micardis® Benicar® (Sankyo), Prozac® fluoxetine (generic)
Avapro® (Bristol-Myers Squibb),
Diovan® (Novartis)
Micardis HCT® Benicar HCT® (Sankyo), Questran® cholestyramine/sucrose
(generic)
Avalide® (Bristol-Myers Squibb),
Diovan HCT® (Novartis)
Mobic® ibuprofen (generic),
Questran Light® cholestyramine light
naproxen (generic), (generic)
diclofenac (generic)
Monopril® benazepril (generic),
Toprol XL® atenolol (generic),
enalapril maleate (generic),
bisoprolol fumarate (generic),
lisinopril (generic),
metoprolol tartrate (generic)
Aceon® (Solvay),
Accupril® (Pfizer)
Nasalide® Flonase® (GlaxoSmithKline), Tri-Levlen® levonorgestrel/ethinyl
Nasonex® (Schering Corporation), estradiol (generic),
Tri-Nasal® (Muro Triphasil® (Wyeth)
Pharmaceuticals),
Rhinocort Aqua® (AstraZeneca)
Rhinocort Aqua® (AstraZeneca), Tri-Norinyl® levonorgestrel/ethinyl
Flonase® (GlaxoSmithKline), estradiol (generic),
Nasonex® (Schering Corporation), Triphasil® (Wyeth)
Tri-Nasal® (Muro
Pharmaceuticals)
Ultracet® tramadol (generic)
Norinyl® Ortho-Novum® (Ortho
Pharmaceutical)
Ortho-Est® estropipate (generic) Ultram® tramadol (generic)
Ovcon® Lo/Ovral® (Wyeth),
Nordette® (Monarch
Pharmaceutical) Univasc® benazepril (generic),
enalapril maleate (generic),
lisinopril (generic),
Paxil CR® paroxetine (generic) Aceon® (Solvay),
Accupril® (Pfizer)
Prevacid® omeprazole (generic),
Protonix® (Wyeth),
Nexium® (AstraZeneca),
Prilosec® (AstraZeneca) Welchol® cholestyramine (generic)

F O R M U L A RY http://mydrug.formularies.com
Dear Physician: Please visit our website at:
Please refer to this pocket guide when prescribing medications for this patient. Section I
lists commonly prescribed formulary medications by therapeutic category. Due to appointment.
space limitations, not all categories are included; however, a complete formulary is available family member has an
upon request. The formulary can also be found at: http://mydrug.formularies.com.
Section II lists commonly prescribed nonformulary medications and their possible you or another covered
therapeutic alternatives. Please prescribe formulary medications for this patient if to your doctor when
appropriate. Please bring this guide
Because of the special considerations involved in prescribing for patients over 65,
additional information is provided based on guidelines proposed by medical experts in
geriatric pharmacology. Medications preceded by a ▲ symbol should be used with caution
in patients over 65;safer alternatives may be available. Medications preceded by a

symbol may require dosage reduction below manufacturer guidelines in patients over 65.
Please understand that this pocket guide, including the accompanying recommendations,
is not intended as a substitute for your professional judgment. Rather, it is offered as a tool
to help you maximize therapeutic efficacy while taking into account both drug therapy 2005
problems and costs. We hope that you will use it as a guide to the prescribing of
formulary drugs and as a safety check on drug selection and dosing. Pocket Guide

Dear Participant: If you have questions regarding your prescription drug benefit,
In an effort to continue providing quality care and to help contain the increasing call Member Services. If you have questions regarding your drug
cost of prescription drug coverage, a formulary feature is included in your therapy, please contact your doctor or pharmacist.
prescription drug benefit. A formulary is a select list of FDA-approved
prescription drugs reviewed by our Pharmacy and Therapeutics Committee, an
independent network of physicians and pharmacists. The formulary can assist in
maintaining quality care while meeting your plan’s cost containment objectives.
Please note: This formulary, which represents a listing of the most
frequently prescribed drugs, is current as of September 1, 2004 and is
updated from time to time. Please consult your health care provider
to check if any drugs have been removed from or new drugs added to Medco Health administers the prescription
the list. A complete listing of all formulary drugs is available at: drug benefit.
http://mydrug.formularies.com. Since prescription drug benefit © 2004 Medco Health Solutions, Inc.
programs vary by client, the inclusion of a drug in this formulary does All rights reserved.
NOT imply drug coverage.

FORM PG902988 HMK 22621

(Ed. 8/04)

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