formulary - aetna what pharmacy benefit plan do i have? you are enrolled in an aetna u.s. healthcare...

Aetna U.S. Healthcare® Preferred Drug List

Golden Medicare PlanTM

January 2002

Formulary

05.05.304.1-9/01 7A-10902[US] ©2001 Aetna U.S. Healthcare Inc.

Have questions or need more information? Call the Member Services number on your member ID card.

Important Note

Receipt of this booklet is not a guarantee of coverage under apharmacy benefits plan. Please refer to your 2002 Summary ofBenefits to determine whether prescription drug coverage willbe available to you in 2002 or whether you have made anelection for a Plan that makes available prescription drugcoverage. If you will be enrolled in a Plan that has the ReducedRate Pharmacy Discount Program for 2002, the information inthis booklet will not apply. If you have any questions, pleasecall the Member Services number on your ID card.If you need this material translated into another language,please call Member Services at 1-800-282-5366. Si ustednecesita este material en otro lenguaje, por favor llame aServicios al Miembro al 1-800-533-6615.

Dear Member:If you’re like many Aetna U.S. Healthcare members, thebenefit you use most frequently is your prescription drugcoverage. For that reason, we’re pleased to provide youwith your copy of the January 2002 formulary for theGolden Medicare Plan. It’s a useful reference that will helpyou understand how using drugs on the formulary (our listof preferred drugs) affects your pharmacy benefit. And, itwill help you determine your copayment level for manyprescription drugs. We encourage you to take this with youto your doctor appointments.

Please remember that this is not a complete list of the drugs covered under your benefit plan. Because there arethousands of drugs available for your physician to prescribethat are covered under your pharmacy benefit, we couldn’tlist them all here.

If you have questions about your medications, pleasediscuss them with your doctor or pharmacist. If you havequestions about your prescription drug benefit, please referto your plan documents or call the Member Servicesnumber on your ID card.

Thank you for choosing Aetna U.S. Healthcare.

Table of Contents

What Pharmacy Benefit Plan Do I Have? .............................1

What Is a Formulary? ..........................................................2

What Are Generic Drugs? ...................................................2

Who Reviews Drugs for the Formulary? ..............................3

How Are Drugs Selected for the Formulary? .......................3

Does the Formulary Ever Change? ......................................4

Why Do Some Drugs Require Precertification (Prior Approval)? ............................................................4

Why Do Some Drugs Have Quantity Limits? .......................5

How Is the Annual Maximum Calculated? ..........................6

Aetna U.S. Healthcare Formulary (Preferred Drug List) ........7

1

What Pharmacy Benefit Plan Do I Have?You are enrolled in an Aetna U.S. Healthcare three-tiercopay/open formulary pharmacy benefit plan.

■ Open formulary means your pharmacy benefit coversdrugs that are on the formulary (our preferred drug list) aswell as many that are not on the formulary.

■ Three-tier means there are three different copay levels forcovered prescription drugs. – Your copay will be determined by whether the drug is a

brand-name or generic medication and whether it is aformulary or nonformulary medication (a medicationthat is not on our preferred drug list).

The three copay levels in your plan are:

Please refer to your Summary of Benefits or call MemberServices at the number on your member ID card for yourspecific copay amounts for each level.

Copay Level Symbol Type of Drug

Lowest Copay ●

Middle Copay ▲

Highest Copay ■

Covered generic drugs

Covered brand-namedrugs on the formulary

Covered brand-namedrugs not on the formulary

What Is a Formulary?■ A formulary is a list of preferred drugs.

■ Medications on our formulary have been shown to besafe, effective and affordable.

■ Our formulary includes brand-name and generic drugsthat have been approved by the Food and DrugAdministration (FDA).

■ Many drugs on the formulary are subject to manufacturerrebate arrangements between Aetna U.S. Healthcare andthe manufacturer of those drugs for the benefit of AetnaU.S. Healthcare.

Your pharmacy benefit also covers drugs that are not on ourpreferred list.

What Are Generic Drugs?■ Generic drugs have been approved by the FDA as safe and

effective.

■ Generic drugs contain the same active ingredients in thesame amounts as the brand-name products, althoughgenerics may differ in color, shape or size from the brand-name product.

■ When rated by the FDA as equivalent and where permittedby law, a generic drug can be substituted for a brand-namedrug.

We encourage you to ask your doctor if a generic medicationwould be appropriate for you.

2

Who Reviews Drugs for the Formulary?■ Aetna U.S. Healthcare’s Pharmacy Quality Advisory

Committee (PQAC) and Pharmacy and Therapeutics(P&T) Committee review drugs that have been approvedby the FDA.

■ The PQAC includes pharmacists and physicians whoparticipate in Aetna U.S. Healthcare’s networks.

How Are Drugs Selected for the Formulary?■ The PQAC reviews clinical information on the drugs being

considered for the formulary.

■ The PQAC provides its clinical comments to the P&TCommittee.

■ The P&T Committee reviews information from differentsources as it evaluates each drug. Each drug is categorizedaccording to whether it has advantages or disadvantagesover other drugs within the same therapeutic class. Category 1: The drug represents an important therapeutic

advance. Drugs in this category are alwaysincluded on the formulary.

Category 2: The drug is clinically and therapeuticallysimilar to other available products. Aetna U.S. Healthcare conducts additional reviewsof drugs in this category for overall value,including cost and manufacturer rebatearrangements, before a decision on whetherto include them on the formulary is made.

Category 3: The drug has significant disadvantages insafety or effectiveness when compared withother similar products. Drugs in this categoryare always excluded from the formulary.

3

Does the Formulary Ever Change?■ The formulary may change because the FDA approves

many new drugs throughout the year and because wereview existing drugs to make sure they still meet thecriteria for safety, effectiveness and overall value.

■ As new FDA-approved drugs become available, they aregenerally covered immediately under your plan.– You may pay a higher copayment and the drug also may

be subject to precertification requirements.

■ As brand-name drugs lose their patents and new genericsbecome available on the market, the brand-name drugmay be removed from the formulary.

Visit our website at www.aetnaushc.com or contactMember Services at the number on your ID card for currentformulary information.

Why Do Some Drugs Require Precertification (Prior Approval)?■ Some drugs are more likely than others to be taken

incorrectly. Sometimes they may be prescribed forinappropriate reasons or used in amounts that exceedrecommendations for dosage or length of treatment.

■ Some drugs are more expensive than other drugs thathave been shown to be clinically or therapeutically similar.

■ Precertification helps encourage the appropriate and cost-effective use of drugs by allowing coverage only whencertain conditions are met.

4

■ The precertification program is based upon currentmedical findings, manufacturer labeling information, FDAguidelines, and cost and manufacturer rebatearrangements.

■ These drugs are identified in this booklet by thedesignation “PR,” and must be preauthorized beforethey will be covered under your pharmacy benefit.

■ Your doctor can request prior authorization for a drug. Ifthe request is approved, the drug will be covered.

For information on whether precertification applies to yourplan, please refer to your plan documents or call theMember Services number on your ID card.

The drugs requiring precertification are subject to change.Visit our website at www.aetnaushc.com, or call MemberServices for the current pharmacy Precertification List andfor the Pharmacy Coverage Policy Bulletins. These bulletinsdescribe the coverage criteria for drugs subject toprecertification.

Why Do Some Drugs Have Quantity Limits?Quantity limits are designed to help promote appropriatemedication use and enhance patient safety. Dispensinglimits are based on generally accepted pharmaceuticalguidelines and FDA-approved manufacturer labeling.

5

How Is the Annual Maximum Calculated?If you are a Golden Medicare plan member with aprescription drug benefit with an annual limit on brand-name drugs, the annual brand maximum is based upon theAetna U.S. Healthcare contracted price with theparticipating pharmacy. This price does not reflect anyrebates Aetna U.S. Healthcare receives from manufacturers.The copayment you pay to the pharmacy does not applytowards the annual brand maximum. For example:

Aetna U.S. Healthcare Covered Brand-Name Prescription (contracted price) $50

Brand Drug Copayment –$15Amount Applied Towards the Annual Brand Maximum $35

In addition, outpatient prescription drugs covered byOriginal Medicare are a medical benefit and do not applytoward your annual maximum amount. Some plans have anunlimited annual benefit for covered generic medications.These generic medications do not apply towards yourannual brand maximum.

6

Aetna U.S. Healthcare Formulary (Preferred Drug List)

AAccolate ■ SingulairAccupril ▲

Accuretic ▲

Accutane PR ▲

acebutolol ●

Aceon ■ captopril, enalapril,Accupril, Altace, Prinivil

acetaminophen/caffeine/ ●

butalbital acetaminophen/codeine ●

acetaminophen/ ●

dichloralphenazone/isometheptene

7

Copay SuggestedDrug Name Level Alternative(s)

Copay Levels: ● = Lowest ▲ = Middle ■ = HighestUpper case = Brand-name drug PR = Precertification may applylower case italics = Generic drug QL = Quantity limits may apply* = Generic drug of the listed brand-name drugNot every form or strength of a drug is on our formulary. Yourpharmacy benefit plan may not cover certain drugs, even thoughthey are listed in this booklet. Some of these drugs include birthcontrol pills, infertility medications and diabetic supplies. Pleasesee your plan documents or call the Member Services number onyour ID card for more information.

acetazolamide tab ●

acetic acid soln 2% ●

acetic acid/aluminum acetate ●

acetic acid/hydrocortisone ●

acetohexamide ●

AcipHex ▲

Aclovate ▲

Actigall ■ ursodiol*Actinex ▲

Actiq ■ any generic NSAID ornarcotic analgesic

Activella ■ Premphase, PremproActonel ▲

Actos ▲

Acular ▲

8


Aetna U.S. Healthcare Formulary


acyclovir ●

Adalat ■ nifedipine* Adalat CC ■ nifedipine CR*Adderall ▲

Advair Diskus ▲

Aerobid ■ Azmacort, Flovent, Flovent Rotadisk, Pulmicort Respules,Vanceril, Vanceril DS

Aerobid M ■ Azmacort, Flovent, Flovent Rotadisk, Pulmicort Respules,Vanceril, Vanceril DS

Agenerase ▲

Aggrenox ▲

Agrylin ▲

Akne-mycin ▲

Alamast ■ cromolyn, Alocril, Livostin,Patanol, Zaditor, Optivar,Alomide

albuterol inhaler/tab ●

Aldactazide ■ spironolactone/hctz*Aldactone ■ spironolactone* Aldara ▲

Aldomet ■ methyldopa* Alesse ■ aviane*

9


Alkeran ▲

Allegra ■ Claritin, ZyrtecAllegra D ■ Claritin D, Zyrtecallopurinol ●

Alocril ▲

Alomide ▲

Alora ■ Estraderm, Vivelle, Vivelle DOT

Alphagan ▲

alprazolam ●

Alrex ▲

Altace ▲

Alupent ■ albuterol, Proventil HFA,Combivent, Maxair

amantadine ●

10




Amaryl ▲

Ambenyl ■ codeine/bromodiphenhydramine*

Ambien ■ lorazepam, temazepam,triazolam, estazolam,Sonata

Amerge QL ▲

(Total quantity any strength = 9 tablets/30-day supply increments)amiloride ●

aminophylline ●

amiodarone ●

amitriptyline ●

amitriptyline/perphenazine ●

amoxapine ●

amoxicillin ●

Amoxil ■ amoxicillin* Amoxil BID ■ amoxicillinampicillin ●

Anafranil ■ clomipramine*Anaprox ■ naproxen sodium*Ancobon ▲

Androderm ▲

Androgel ■ Androderm, Testoderm,Testoderm TTS

11


Ansaid ■ flurbiprofen*Anturane ■ sulfinpyrazone* apri ■ Ortho-CeptAquasol A ▲

Aralen ■ chloroquine* Arava ▲

Aricept ▲

Arimidex ▲

Aristocort ■ triamcinolone* Armour Thyroid ▲

Aromasin ▲

Artane ■ trihexyphenidyl* Arthrotec ▲

Asacol ▲

Ascendin ■ amoxapine*

12




aspirin/butalbital/caffeine ●

Astelin ▲

Atacand ■ Cozaar, DiovanAtacand HCT ■ Hyzaar, Diovan HCTAtarax ■ hydralazine*atenolol ●

Ativan ■ lorazepam*Atrohist Plus ▲

Atromid-S ■ gemfibrozil, Tricoratropine/scopolamine/ ●

hyoscyamine/PbAtrovent inhaler ▲

Atrovent nasal ▲

Augmentin ▲

Auralgan ■ benzocaine/antipyrine* Avalide ■ Diovan HCT, HyzaarAvandia ▲

Avapro ■ Cozaar, DiovanAvelox PR < 10 yr old ▲

Aventyl ■ nortriptyline* aviane ●

Avita PR > 36 yr old ■ tretinoin* PR > 36 yr old Avonex ▲

(Note: Some plans may cover injectable medications through the medical benefit.)

13


Axert QL (All strengths = ■ Imitrex QL, Amerge QL,6 tablets/30-day supply Maxalt QL,increments) Maxalt MLT QLAxid ■ cimetidine, ranitidine,

famotidineAygestin ▲

azathioprine ●

Azelex ▲

Azmacort ▲

Azopt ▲

Azulfidine ■ sulfasalazine*Azulfidine Entab ▲

BBaciguent ■ bacitracin*

14




bacitracin ●

baclofen ●

Bactrim DS ■ sulfamethoxazole/trimethoprim*

Bactroban ▲

BD insulin syringes ▲

BD lancets ▲

Beclovent ■ VancerilBeconase ■ VancenaseBeconase AQ ■ Vancenase AQbelladonna/phenobarbital/ ●

ergotamineBentyl ■ dicyclomine*Benzac ■ benzoyl peroxide gel* Benzaclin ▲

Benzagel ■ benzoyl peroxide gel* Benzamycin ▲

benzocaine ●

benzocaine/antipyrine ●

benzoyl peroxide gel ●

benztropine ●

Betagan ■ levobunolol* betamethasone dipropionate ●

crm/lot/oint

15


betamethasone valerate ●

crm/lot/oint Betapace ■ sotalol*Betapace AF ▲

bethanechol ●

Betimol ▲

Betoptic-S ▲

Biaxin ▲

Biaxin XL ▲

Bicitra ▲

bisoprolol ●

bisoprolol/hctz ●

Blephamide ▲

Blocadren ■ timolol*Brethine ▲

16




Brevicon ■ Modicon, Ortho-CyclenBromfed cap ■ brompheniramine/

pseudoephedrine SR* Bromfed PD ■ brompheniramine/

pseudoephedrine SR* brompheniramine/ ●

pseudoephedrine SRBrontex ■ codeine/guaifenesin* bumetanide ●

Bumex ■ bumetanide*bupropion ●

Buspar ■ buspirone*buspirone ●

butalbital/caffeine/codeine/ASA ●

CCafergot ■ ergotamine/caffeine* Cafergot suppository ▲

Calan ■ verapamil*Calan SR ■ verapamil SR*Calciferol ▲

Calderol ▲

Capitrol ▲

Capoten ■ captopril* Capozide ■ captopril/hctz*captopril ●

17


captopril/hctz ●

Carafate susp ▲

Carafate tabs ■ sucralfate tabs* carbamazepine ●

carbidopa/levodopa ●

Cardene ■ nicardipine*Cardene SR ■ nifedipine, nifedipine CR,

felodipine, nicardipine,Norvasc

Cardizem CD ■ diltiazem CR*Cardizem SR ■ diltiazem SR*Cardura ■ doxazosin*carisoprodol ●

carisoprodol/aspirin ●

carisoprodol/aspirin/codeine ●

18




carteolol ●

Cartrol ■ atenolol, metoprolol,nadolol, propranolol,bisoprolol, pindolol, timolol,acebutolol

Casodex ▲

Cataflam ■ diclofenac potassium*Catapress ■ clonidine* Ceclor ■ cefaclor*Ceclor CD ▲

Cedax ▲

CeeNu ▲

cefaclor ●

Ceftin ▲

Cefzil ■ cefaclor, Ceclor CD, Ceftin,Lorabid

Celebrex PR, QL (100 mg = ▲

60 capsules/30-day supply increments; 200 mg = 30 capsules/30-day supply increments)Celestone ▲

Celexa ■ fluoxetine, Paxil, ZoloftCellcept ▲

Celontin ▲

19


Cenestin ■ Premarincephalexin ●

cephradine ●

Cerumenex ▲

Chemet ▲

Chibroxin ▲

chloral hydrate ●

chloramphenicol ●

chlordiazepoxide ●

Chloromycetin Otic ▲

Chloroptic ■ chloramphenicol*chloroquine ●

chlorothiazide ●

chlorpromazine ●

chlorpropamide ●

20




chlorthalidone ●

cholestyramine ●

choline Mg trisalicylate ●

Chronulac ■ lactulose*Ciloxan ▲

cimetidine ●

Cipro HC Otic ▲

Cipro PR < 10 yr old ▲

citrate/citric acid ●

Claritin ▲

Claritin D ▲

Cleocin ■ clindamycin* Cleocin vaginal crm/suppos ▲

clidinium/chlordiazepoxide ●

Climara ■ Estraderm, Vivelle, Vivelle DOT

clindamycin ●

Clinoril ■ sulindac*clobetasol crm/oint/gel/emoll ●

Cloderm ▲

Clomid ■ clomiphene citrate* (Note: Some plans may not cover infertility medications. If plan covers, they may be covered through the medical benefit.)

21


clomiphene citrate ●

(Note: Some plans may not cover infertility medications. If plan covers, they may be covered through the medical benefit.)clomipramine ●

clonazepam ●

clonidine ●

clorazepate ●

clotrimazole/betamethasone crm ●

cloxacillin ●

Cloxapen ■ cloxacillin* clozapine ●

Clozaril ■ clozapine*codeine/bromodiphenhydramine ●

22




codeine/guaifenesin ●

codeine/promethazine ●

codeine/promethazine/phenylephrine ●

codeine/pseudoephedrine/ ●

chlorpheniraminecodeine/pseudoephedrine/ ●

guaifenesincodeine/triprolidine/ ●

pseudoephedrineCogentin ■ benztropine* Cognex ■ Aricept, ReminylColazal ■ Asacol, Rowasacolchicine ●

Colymycin-S ▲

Colyte ■ lactulose, Golytely,Nulytely

Combipatch ■ Estraderm, Vivelle, Vivelle DOT

Combivent inhaler ▲

Combivir ▲

Compazine ■ prochlorperazine* COMTan ▲

23


Concerta ■ methylphenidate,methylphenidate SR, methylin ER, Dexedrine,Adderall, Metadate CD,Metadate ER

Condylox ▲

Cordarone ■ amiodarone* Cordran lot/tape ▲

Coreg ▲

Corgard ■ nadolol*Cortic ▲

Cortifoam ▲

Cortisporin ■ polymyxin/neomycin/hydrocortisone*

24




Corzide ■ nadolol and hctz,bisoprolol/hctz

Cosopt ▲

Cotazym-S ■ Creon, Ku-Zyme, Ku-Zyme HP, Ultrase,Viokase

Coumadin ▲

Covera HS ■ verapamil SRCozaar ▲

Creon ▲

Crixivan ▲

cromolyn sodium ●

Cuprimine ▲

Cutivate ▲

cyanocobalamin injection ●

Cyclessa ■ Ortho-Novum 7/7/7, Ortho-Tri-Cyclen

cyclobenzaprine ●

cyclosporine ●

Cylert ■ pemoline*cyproheptadine ●

Cytotec ▲

Cytovene ▲

Cytoxan ▲

25


DD.A. Chewable ▲

Dalmane ■ flurazepam* danazol ●

Danocrine ■ danazol*Dantrium ▲

Dapsone ▲

Daranide ▲

Daraprim ▲

Darvon ■ propoxyphene*Darvon CPD ■ propoxyphene/

ASA/caffeine* Darvon-N ■ propoxyphene napsylate/

acetaminophen* Daypro ■ oxaprozin*

26




DDAVP ▲

Decadron ■ dexamethasone*Declomycin PR ≤ 8 yr old ■ tetracyline PR ≤ 8 yr oldDemadex ▲

Demulen 1/35 ■ zovia 1/35*Demulen 1/50 ■ zovia 1/50*Denavir ▲

Depakene ■ valproic acid*Depakote ▲

Depakote ER ▲

desipramine ●

Desogen ■ Ortho-Ceptdesonide crm/oint ●

Desowen Lotion ▲

desoximetasone crm ●

Desoxyn ▲

Desquam ■ benzoyl peroxide gel* Desyrel ■ trazodone* Detrol ▲

Detrol LA ▲

dexamethasone ●

Dexedrine ▲

dextromethorphan/promethazine ●

DHC Plus ▲

27


DHE-45 ▲

Diabeta ■ glyburide*diabetic test strips — all brands, ■ Precision Q-I-D, except Precision Q-I-D, Precision Precision Xtra, Sof-TacXtra and Sof-Tac test stripsDiabinese ■ chlorpropamide* Diamox ■ acetazolamide tab*Diamox Sequels ▲

Diastat ▲

diazepam ●

Dibenzyline ▲

diclofenac potassium ●

diclofenac sodium ●

diclofenac sodium XR ●

dicloxacillin ●

28




dicyclomine ●

Didronel ▲

Differin ▲

diflorasone oint/crm ●

Diflucan PR, QL 150 mg only ▲

(2 doses/30-day supply increments)diflunisal ●

digoxin ●

Dilacor ■ diltiazem*Dilacor XR ■ diltiazem CR*Dilantin ▲

Dilatrate SR ▲

diltiazem ●

diltiazem SR/ER/CR/XT ●

Diovan ▲

Diovan HCT ▲

Dipentum ■ Asacoldiphenoxylate/atropine ●

dipivefrin ●

Diprolene gel/lot ▲

Diprolene oint ■ betamethasonedipropionate oint*

Diprolene AF crm ▲

dipyridamole ●

29


Disalcid ■ salsalate* disopyramide ●

Ditropan ■ oxybutynin* Ditropan XL ▲

Diuril ■ chlorothiazide*Dolobid ■ diflunisal*Domeboro otic ■ acetic acid/hydrocortisone*Donnatal ■ atropine/scopolamine/

hyoscyamine/Pb*Donnazyme ■ Creon, Ku-Zyme,

Ku-Zyme HP, Ultrase,Viokase

Doral ■ flurazepam, temazepamDovonex ▲

doxazosin ●

30




doxepin ●

doxycycline PR ≤ 8 yr old ●

Drysol ▲

Duofilm ▲

Duragesic ▲

Dura-Tap PD ▲

Duratuss DM ▲

Duratuss G ▲

Duratuss GP ▲

Duratuss HD elixir ▲

Dura-Vent DA ▲

Duricef ■ cephalexin, cephradineDyazide ■ triamterene/hctz* Dymelor ■ acetohexamide* Dynabac ■ erythromycin, Biaxin,

Biaxin XL, ZithromaxDynacin PR ≤ 8 yr old ■ minocycline*

PR ≤ 8 yr oldDynacirc ■ nifedipine, nifedipine CR,


Dynacirc CR ■ nifedipine, nifedipine CR,felodipine, nicardipine,Norvasc

Dynapen ■ dicloxacillin*

31


EEC Naprosyn ■ naproxen EC*Econopred ▲

Econopred Plus ▲

Edecrin ▲

Effexor ▲

Effexor XR ▲

Efudex ▲

Elavil ■ amitriptyline* Eldepryl ■ selegiline*Eldopaque Forte ▲

Eldoquin Forte ▲

Elimite ■ permethrin* Elmiron ▲

Elocon ▲

32




Emadine ■ cromolyn, Alocril, Livostin,Patanol, Zaditor, Optivar,Alomide

Emcyt ▲

Emla ▲

E-Mycin ■ erythromycin* enalapril ●

endafed cap ●

Enduron ■ methyclothiazide*Epifrin ▲

Epipen ▲

Epipen Jr ▲

Epivir ▲

Epivir HBV ▲

Equagesic ▲

Ergamisol ▲

ergotamine/caffeine ●

Ery-Tab ■ erythromycin* erythromycin ●

Esclim ■ Estraderm, Vivelle, Vivelle DOT

estazolam ●

Estrace ■ estradiol tabs*Estraderm ▲

estradiol tabs ●

33


Estratab ▲

Estratest ▲

Estratest HS ▲

Estring ▲

estropipate tabs ●

Estrostep ■ Ortho-Novum 7/7/7, Ortho-Tri-Cyclen

Estrostep Fe ■ Ortho-Novum 7/7/7, Ortho-Tri-Cyclen

Ethmozine ▲

etodolac ●

etodolac XL ●

Eulexin ▲

Eurax ■ lindane, permethrinEvista ▲

34




Evoxac ▲

Exelderm ▲

Exelon ■ Aricept, Reminyl

Ffamotidine ●

Famvir ■ acyclovir, ValtrexFansidar ▲

Fareston ▲

Felbatol ▲

Feldene ■ piroxicam* felodipine ●

Femara ▲

Femhrt ■ Premphase, Premprofenoprofen ●

Fertinex ▲

(Note: Some plans may not cover infertility medications. If plan covers, they may be coveredthrough the medical benefit.) Fiorinal ■ aspirin/butalbital/caffeine* Fiorinal w/codeine ■ butalbital/caffeine/

codeine/asa*Fiorocet ■ acetaminophen/

caffeine/butalbital* Flagyl ■ metronidazole tab*

35


Flexeril ■ cyclobenzaprine* Flomax ▲

Flonase ▲

Florinef ▲

Flovent ▲

Flovent Rotadisk ▲

Floxin oral PR < 10 yr old ■ Avelox, Cipro, LevaquinAll PR < 10 yr old

Floxin Otic ▲

Flumadine ▲

fluocinolone acetonide ●

crm/lot/oint/solnfluocinonide crm/oint/gel/soln ●

fluorometholone ●

fluoxetine ●

36




fluphenazine ●

flurazepam ●

flurbiprofen ●

fluvoxamine ●

FML Forte ■ fluorometholone* FML Liquifilm ■ fluorometholone* FML-S ▲

Follistim ▲

(Note: Some plans may not cover infertility medications. If plan covers, they may be coveredthrough the medical benefit.) Foradil ▲

Fortovase ▲

Fosamax ▲

Fulvicin ■ griseofulvin*furosemide ●

GGabitril ▲

Gantanol ▲

Gantrisin ■ sulfisoxazole* Garamycin ophthalmic ■ gentamicin* gemfibrozil ●

37


Genotropin PR ■

(Note: Some plans may cover injectable medications through the medical benefit.) gentamicin ●

Geocillin ■ amoxicillin, ampicillinGeodon ▲

Gleevec PR ▲

glipizide ●

Glucophage ■ metformin*Glucophage XR ▲

Glucotrol ■ glipizide* Glucotrol XL ▲

Glucovance ▲

glyburide ●

38




Golytely ▲

Gonal-F ▲

(Note: Some plans may not cover infertility medications. If plan covers, they may be coveredthrough the medical benefit.) griseofulvin ●

Gris-Peg ■ griseofulvin*Guaifed ■ pseudoephedrine/

guaifenesin SR caps*Guaifed PD ■ pseudoephedrine/

guaifenesin SR caps*guaifenesin tab/cap ●

guanabenz ●

guanfacine ●

Gynazole-1 ▲

HHalcion ■ triazolam* Haldol ■ haloperidol* Halog ■ betamethasone,

fluocinonide, triamcinolonehaloperidol ●

Halotestin ▲

Helidac ▲

Hexalen ▲

39


Hivid ▲

HMS Liquifilm ▲

Humalog ▲

Humalog 75/25 ▲

Humatrope PR ■

(Note: Some plans may cover injectable medications through the medical benefit.)Humegon ▲

(Note: Some plans may not cover infertility medications. If plan covers, they may be coveredthrough the medical benefit.) Humulin 50/50 ▲

Humulin 70/30 ▲

40




Humulin L ▲

Humulin N ▲

Humulin R ▲

Humulin U Ultralente ▲

Hycodan ■ hydrocodone/homatropine* Hycomine ■ hydrocodone/

phenylpropanolamine* hydralazine ●

Hydrea ■ hydroxyurea* hydrochlorothiazide ●

hydrocodone/acetaminophen ●

hydrocodone/ASA ●

hydrocodone/homatropine ●

hydrocodone/phenylpropanolamine ●

hydrocortisone ●

hydrocortisone 1%/pramoxine 1% ●

Hydrodiuril ■ hydrochlorothiazide*hydroxychloroquine ●

hydroxyurea ●

hydroxyzine ●

Hygroton ■ chlorthalidone* hyoscyamine ●

Hytakerol ▲

Hytone ■ hydrocortisone*

41


Hytrin ■ terazosin*Hyzaar ▲

Iibuprofen (strengths > 200 mg) ●

Iletin I Lente ▲

Iletin I NPH ▲

Iletin I Regular ▲

Iletin II Lente ▲

Iletin II NPH ▲

Iletin II Regular ▲

Imdur ▲

imipramine ●

42




Imitrex QL ▲

(Nasal = 6 sprays/30-day supply increments; Injection = 4 kits/30-day supply increments or 8 vials/30-day supply increments; Tablet [all strengths] = 18 tablets/30-day supply increments)Imodium ■ loperamide cap*Imuran ■ azathioprine* indapamide ●

Inderal ■ propranolol*Inderal SR ■ propranolol SR*Indocin ■ indomethacin*Indocin SR ■ indomethacin SR* indomethacin ●

indomethacin SR ●

insulin syringes — ■ BD insulin syringesall brands, except BDIntal ▲

Intron-A ▲

Invirase ▲

Iopidine ▲

ipratropium inhalation soln 0.02% ●

Ismo ■ isosorbide mononitrate*

43


isoniazid ●

Isoptin ■ verapamil*Isoptin SR ■ verapamil SR*Isopto Carbachol ▲

Isopto Carpine ■ pilocarpine hcl* Isordil ■ isosorbide dinitrate SR*isosorbide dinitrate ●

isosorbide mononitrate ●

isoxsuprine ●

IV Immune Globulin (IVIG) PR ■

(Note: Some plans may cover injectable medications through the medical benefit.)

44




JJenest ■ Ortho-Novum 10/11

KKadian CR ▲

Kaletra ▲

K-Dur ■ potassium chloride* K-Dur 20 mEq ▲

Keflex ■ cephalexin* Kenalog ■ triamcinolone* Keppra ▲

Kerlone ■ atenolol, metoprolol,nadolol, propranolol,bisoprolol, pindolol, timolol,acebutolol

ketoconazole ●

ketoprofen ●

ketorolac QL ●

(20 tablets/30-day supply increments)Klaron ▲

Klonopin ■ clonazepam* Kristalose ▲

Ku-Zyme ▲

45


Ku-Zyme HP ▲

Kytril ▲

Llabetalol ●

Lac-Hydrin ▲

lactulose ●

Lamictal ▲

Lamisil tab PR ▲

lancets — all brands, except BD ■ BD lancetsLanoxin ▲ digoxin*Lantus ▲

Lasix ■ furosemide* Lescol ▲

Lescol XL ▲

46




Leucovorin ▲

Leukeran ▲

Levaquin PR < 10 yr old ▲

Levatol ■ atenolol, metoprolol,nadolol, propranolol,bisoprolol, pindolol, timolol,acebutolol

Levlen ■ NordetteLevlite ■ aviane*levobunolol ●

levora ●

levothroid ■ levoxyl, Synthroid,Unithroid

levoxyl ●

Levsinex ■ hyoscyamine*Lexxel ■ LotrelLibrax ■ clidinium/chlordiazepoxide* Librium ■ chlordiazepoxide* Lidex ■ fluocinonide* lidocaine ●

Lidoderm ▲

lindane ●

Lioresal ■ baclofen* Lipitor ■ Lescol, Lescol XL, Zocorlithium carbonate ●

47


Lithobid ▲

Livostin ▲

Lodine ■ etodolac*Lodine XL ■ etodolac XL*Loestrin 1.5/30 ■ microgestin*Loestrin 1/20 ■ microgestin*Loestrin FE 1.5/30 ■ microgestin Fe*Loestrin FE 1/20 ■ microgestin Fe*Lomotil ■ diphenoxylate/atropine*Loniten ■ minoxidil*Lo-Ovral ■ low-ogestrel* loperamide cap ●

Lopid ■ gemfibrozil* Lopressor ■ metoprolol*

48




Lopressor HCT ■ metoprolol and hctz,bisoprolol/hctz

Loprox crm/lot/gel ▲

Lorabid ▲

lorazepam ●

Lorcet ■ hydrocodone/acetaminophen*

Lortab ■ hydrocodone/acetaminophen*

Lortab ASA ■ hydrocodone/ASA* Lotemax ▲

Lotensin ■ captopril, enalapril,Accupril, Altace, Prinivil

Lotensin HCT ■ captopril/hctz, Accuretic,Prinzide

Lotrel ▲

Lotrisone cream ■ clotrimazole/betamethasone crm*

Lotrisone lotion ▲

low-ogestrel ●

loxapine ●

Loxitane ■ loxapine*Lozol ■ indapamide*Ludiomil ■ maprotiline* Lumigan ■ Travatan, Xalatan

49


Lupron ▲

(Note: Some plans may cover injectable medications through the medical benefit.) Luride ▲

Lustra ▲

Lustra AF ▲

Luvox ■ fluvoxamine*Luxiq ▲

MMacrobid ▲

Malarone ▲

Mandelamine ■ methenamine*maprotiline ●

50




Matulane ▲

Mavik ■ captopril, enalapril,Accupril, Altace, Prinivil

Maxair Autohaler ▲

Maxalt QL ▲

(Total quantity any strength = 12 tablets/30-day supply increments)Maxalt MLT QL ▲

(Total quantity any strength = 12 tablets/30-day supply increments)Maxaquin PR < 10 yr old ■ Avelox, Cipro, Levaquin

All PR < 10 yr oldMaxidone ▲

Mebaral ■ mephobarbital* mebendazole ●

meclofenamate ●

Meclomen ■ meclofenamate* Medrol ■ methylprednisolone* medroxyprogesterone ●

Megace ■ megestrol*megestrol ●

Mellaril ■ thioridazine*Mentax ▲

51


mephobarbital ●

Mephyton ▲

Mepron ▲

Mestinon ▲

Metadate CD ▲

Metadate ER ▲

metaproterenol ■ albuterol, Proventil HFA,Combivent, Maxair

metformin ●

methazolamide tab ●

methenamine ●

methocarbamol ●

methocarbamol/aspirin ●

methotrexate ●

methyclothiazide ●

52




methyldopa ●

methylin ER ●

methylphenidate ●

methylphenidate SR ●

methylprednisolone ●

metoclopramide ●

metoprolol ●

Metrocream ▲

Metrodin ■

(Note: Some plans may not coverinfertility medications. If plan covers, they may be covered through the medical benefit.)Metrogel ▲

Metrolotion ▲

metronidazole tab ●

Mevacor ■ Lescol, Lescol XL, Zocormexiletine ●

Mexitil ■ mexiletine* Miacalcin nasal ▲

Micardis ■ Cozaar, DiovanMicardis HCT ■ Hyzaar, Diovan HCTMicifradin ■ neomycin tab* microgestin ●

53


microgestin Fe ●

Micro-K ■ potassium chloride* Micronase ■ glyburide*Micronor ▲

Midamor ■ amiloride*Midrin ■ acetaminophen/

dichloralphenazone/isometheptene*

Migranal ▲

Minipress ■ prazosin*Minocin PR ≤ 8 yr old ■ minocycline*

PR ≤ 8 yr oldminocycline PR ≤ 8 yr old ●

minoxidil ●

Mintezol ▲

54




Miralax ▲

Mirapex ▲

Mircette ▲

Mobic ■ any generic NSAIDModicon ●

Monodox PR ≤ 8 yr old ▲

Monoket ■ isosorbide mononitrate*Monopril ■ captopril, enalapril,

Accupril, Altace, PrinivilMonopril HCT ■ captopril/hctz, Accuretic,

PrinzideMonurol ■ ampicillin, amoxicillin,

sulfamethoxazole/trimethoprim

Motrin ■ ibuprofen* (strengths > 200 mg)

MS Contin ▲

MSIR ▲

multivitamins w/fluoride ●

Myambutol ▲

Mycelex ▲

Mycifradin ■ neomycin*Mycobutin ▲

Mycolog II ■ nystatin/triamcinolone* Mycostatin ■ nystatin*

55


Myleran ▲

Mysoline ■ primidone* Mytelase ▲

Nnadolol ●

Nalfon ■ fenoprofen* Naprelan ■ naproxen*Naprosyn ■ naproxen*naproxen ●

naproxen EC ●

naproxen sodium ●

Nardil ▲

Nasacort ▲

Nasacort AQ ▲

56




Nasalide ■ Flonase, Nasacort, Nasacort AQ, Nasonex,Vancenase, Vancenase AQ,Vancenase AQ-DS

Nasarel ■ Flonase, Nasacort, Nasacort AQ, Nasonex,Vancenase, Vancenase AQ,Vancenase AQ-DS

Nasonex ▲

Navane ■ thiothixene* Nebupent ▲

necon .5/35 ■ Modicon, Ortho-Cyclennecon 1/35 ■ Ortho-Novum 1/35necon 1/50 ■ Ortho-Novum 1/50necon 10/11 ■ Ortho-Novum 10/11nelova .5/35E ■ Modicon, Ortho-Cyclennelova 1/35E ■ Ortho-Novum 1/35nelova 1/50M ■ Ortho-Novum 1/50nelova 10/11 ■ Ortho-Novum 10/11Nembutal ▲

neomycin tab ●

neomycin/polymyxin/bacitracin/ ●

hydrocortisoneneomycin/polymyxin/gramicidin ●

Neoral ■ cyclosporine*

57


Neosporin ophthalmic ■ neomycin/polymyxin/gramicidin*

Neptazane ■ methazolamide tab*Nestabs CBF ▲

Nestabs FA ▲

Neurontin ▲

Neutrexin ▲

Nexium ■ AcipHex, PrevacidNiaspan ER ▲

nicardipine ●

nifedipine ●

nifedipine CR ●

Nilandron ▲

Nimotop ▲

Nitro-Bid oint ▲

58




Nitro-Dur ▲

nitroglycerin cap SR ●

Nitrol oint ▲

Nitrolingual ▲

Nitrostat SL ▲

Nizoral crm, shampoo ▲

Nizoral oral ■ ketoconazole* Nolvadex ▲

Norco ■ hydrocodone/acetaminophen*

Nordette ■ levora*Norditropin PR ■

(Note: Some plans may cover injectable medications through the medical benefit.) norethin 1/35 ■ Ortho-Novum 1/35norethin 1/50M ■ Ortho-Novum 1/50Norgesic Forte ■ orphenadrine/

aspirin/caffeine* Norinyl 1/35 ■ Ortho-Novum 1/35Norinyl 1/50 ■ Ortho-Novum 1/50Noritate ▲

Normodyne ■ labetalol*Noroxin PR < 10 yr old ■ Avelox, Cipro, Levaquin

All PR < 10 yr old

59


Norpace ■ disopyramide* Norpace CR ▲

Norpramin ■ desipramine* Nor-QD ■ Micronornortriptyline ●

Norvasc ▲

Norvir ▲

Novahistine ■ codeine/pseudoephedrine/guaifenesin*

Novahistine DH ■ codeine/pseudoephedrine/chlorpheniramine*

Novolin 70/30 ■ Humulin 70/30Novolin L ■ Humulin L Novolin N ■ Humulin N Novolin R ■ Humulin R

60




Nucofed Expect ■ codeine/pseudoephedrine/guaifenesin*

Nucofed Ped ■ codeine/pseudoephedrine/guaifenesin*

Nulytely ▲

Nutropin PR ■

(Note: Some plans may cover injectable medications through the medical benefit.)Nutropin AQ PR ■

(Note: Some plans may cover injectable medications through the medical benefit.)nystatin ●

nystatin/triamcinolone ●

OOcufen ■ flurbiprofen*Ocuflox ▲

Ocupress ■ carteolol*Ogen ■ estropipate tabs*Ogen crm ▲

ogestrel ●

Olux ▲

Omnicef ▲

Omnipen ■ ampicillin*

61


Opticrom ■ cromolyn sodium* Optimine ▲

Optipranolol ■ carteolol, levobunolol,timolol, timolol gfs, Betimol

Optivar ▲

Orabase HCA ▲

orphenadrine/aspirin/caffeine ●

Ortho-Cept ●

Ortho-Cyclen ▲

Ortho-Novum 1/35 ●



Ortho-Novum 7/7/7 ▲

Ortho-Prefest ■ Premphase, PremproOrtho-Tri-Cyclen ▲

62




Orudis ■ ketoprofen*Oruvail ■ ketoprofen*Otobiotic ▲

Ovcon-35 ■ Modicon, Ortho-CyclenOvcon-50 ■ ogestrelOvral ■ ogestrel*Ovrette ■ Micronoroxaprozin ●

oxazepam ●

Oxistat ▲

oxybutynin ●

oxycodone/acetaminophen ●

oxycodone/ASA ●

Oxycontin CR ▲

Oxyfast ▲

Oxy-IR ▲

Pp1e1, p2e1, etc. ●

(pilocarpine/epinephrine)Pamelor ■ nortriptyline* Pamine ▲

Panretin gel ▲

papaverine hcl ●

paraldehyde ●

63


paregoric liquid ●

Parlodel ▲

Parnate ▲

Patanol ▲

Paxil ▲

PCE ▲

Pediapred ▲

Pediazole ■ sulfisoxazole/erythromycin pemoline ●

Penetrex PR < 10 yr old ■ Avelox, Cipro, LevaquinAll PR < 10 yr old

penicillin VK ●

Penlac ■ Lamisil tab PRPentasa ■ Asacolpentazocine/naloxone/propoxyphene ●

64




pentoxifylline ●

Pepcid ■ famotidine*Percocet ■ oxycodone/acetaminophen* Percodan ■ oxycodone/ASA* Pergonal ▲

(Note: Some plans may not cover infertility medications. If plan covers, they may be covered through the medical benefit.)Periactin ■ cyproheptadine* Permax ▲

permethrin ●

perphenazine ●

Persantine ■ dipyridamole* phenazopyridine ●

Phenergan ■ promethazine*Phenergan DM ■ dextromethorphan/

promethazine*Phenergan w/codeine ■ codeine/promethazine* Phenergan VC w/codeine ■ codeine/promethazine/

phenylephrine* phenobarbital ●

phenylephrine/chlorpheniramine/ ●

hydrocodone liqPhisohex ▲

65


PhosLo ▲

Phospholine ▲

Pilagan ▲

pilocarpine hcl ●

Pilopine HS ▲

pindolol ●

piroxicam ●

Placidyl ■ lorazepam, temazepam,triazolam, estazolam,Sonata

Plan B ▲

Plaquenil ■ hydroxychloroquine*Plavix ▲

Plendil ■ felodipine*Pletal ▲

66




Plexion ▲

Plexion TS ▲

Polaramine ▲

Poly-Citra ■ citrate/citric acid*polymyxin/neomycin/hydrocortisone ●

polymyxin/trimethoprim ●

Polypred ▲

Polytrim ■ polymyxin/trimethoprim* Poly-Vi-Flor ■ multivitamins w/fluoride*Ponstel ■ any generic NSAIDpotassium chloride ●

Prandin ▲

Pravachol ■ Lescol, Lescol XL, Zocorprazosin ●

Precare ■ Nestabs FA, Nestabs CBF,Prenate Advance, Prenate Ultra, Vitafol PN

Precision Ketone test strips ▲

Precision Q-I-D test strips ▲

Precision Xtra test strips ▲

Precose ▲

Pred G ▲

Pred SOP ▲

prednisolone ●

67


prednisolone phosphate/ ●

sulfacetamideprednisone ●

Premarin ▲

Premphase ▲

Prempro ▲

Prenate Advance ▲

Prenate Ultra ▲

Prevacid ▲

Prevpac ▲

Prilosec ■ AcipHex, Prevacidprimaquine ●

primidone ●

Principen ■ ampicillin* Prinivil ▲

68




Prinzide ▲

ProAmatine ▲

probenecid ●

procainamide SR ●

Procanbid ■ procainamide SR* Procardia ■ nifedipine*Procardia XL ■ nifedipine CR*prochlorperazine ●

Procrit ▲

(Note: Some plans may cover injectable medications through the medical benefit.)Proctofoam ■ hydrocortisone 1%/

pramoxine 1%*Prograf ▲

Prolixin ■ fluphenazine* promethazine ●

Prometrium ▲

Propine ■ dipivefrin* propoxyphene napsylate/

acetaminophen ●

propoxyphene/ASA/caffeine ●

propranolol/SR ●

propylthiouracil ●

Proscar ▲

69


Prosom ■ estazolam*Prostigmin ▲

Protonix ■ AcipHex, PrevacidProtopic ▲

protriptyline ●

Protropin PR ■

(Note: Some plans may cover injectable medications through the medical benefit.)Proventil ■ albuterol*Proventil HFA ▲

Proventil Repetabs ■ albuterol, VolmaxProvera ■ medroxyprogesterone

70




Provigil ■ methylphenidate,methylphenidate SR, methylin ER, Dexedrine,Adderall, Metadate CD,Metadate ER

Prozac (brand only) ■ fluoxetine*Prozac weekly ■ fluoxetinepseudoephedrine/carbinoxamine/ ●

dextromethorphan pseudoephedrine/guaifenesin ●

pseudoephedrine/guaifenesin SR caps ●

Psorcon ■ diflorasone*Psorcon E ■ diflorasone*Pulmicort Respules ▲

Pulmicort Turbuhaler ■ Azmacort, Flovent, Pulmicort Respules,Vanceril, Vanceril DS

Pulmozyme ▲

Purinethol ▲

pyrazinamide ●

Pyridium ■ phenazopyridine*

QQuestran ■ cholestyramine* Questran Light ■ cholestyramine*Quinidex ■ quinidine SR*

71


quinidine ●

quinidine SR ●

Quixin ■ Ciloxan, OcufloxQvar ■ Azmacort, Flovent,

Flovent Rotadisk,Pulmicort Respules,Vanceril, Vanceril DS

Rranitidine ●

Rapamune ▲

Reglan ■ metoclopramide* Relafen ■ any generic NSAIDRelenza QL ■ amantadine, Flumadine(2 treatments [units]/year)

72




Remeron ▲

Remeron Sol tab ▲

Reminyl ▲

Renagel ▲

Renax ▲

Repan CF ▲

Requip ▲

Rescriptor ▲

Rescula ■ Travatan, XalatanRestoril ■ temazepam* Retin-A PR > 36 yr old ■ tretinoin* PR > 36 yr oldRetin-A gel 0.01% PR > 36 yr old ▲

Retin-A micro PR > 36 yr old ▲

Retrovir ▲

Rheumatrex ■ methotrexate* Rhinocort ■ Flonase, Nasacort,

Nasacort AQ, Nasonex,Vancenase, Vancenase AQ,Vancenase AQ-DS

Rhinocort Aqua ■ Flonase, Nasacort, Nasacort AQ, Nasonex,Vancenase, Vancenase AQ,Vancenase AQ-DS

Ridaura ▲

Rifadin ■ rifampin*

73


rifampin ●

Risperdal ▲

Ritalin ■ methylphenidate*Ritalin SR ■ methylphenidate SR*Robaxin ■ methocarbamol*Robaxisal ■ methocarbamol/aspirin*Robinul ▲

Robitussin AC SF syp ■ codeine/guaifenesin* Robitussin DAC ■ codeine/pseudoephedrine/

guaifenesin*Rocaltrol ▲

Roferon-A ▲

Rondec DM ■ pseudoephedrine/carbinoxamine/dextromethorphan*

74




Rowasa ▲

Roxicet ■ oxycodone/acetaminophen*Rynatan Ped susp ▲

Rynatan-S susp ▲

Rythmol ▲

SSaizen PR ■

(Note: Some plans may cover injectable medications through the medical benefit.)Salagen ▲

salsalate ●

Sandimmune ▲

Sansert ▲

Sarafem ■ fluoxetineSebizon ■ Plexion, Plexion TS,

Sulfacet-RSectral ■ acebutolol*selegiline ●

selenium sulfide shampoo ●

Selsun ■ selenium sulfide shampoo*Semprex-D ▲

Septra DS ■ sulfamethoxazole/trimethoprim*

Serax ■ oxazepam*

75


Serentil ▲

Serevent ▲

Serevent Diskus ▲

Seromycin ▲

Serostim PR ■

(Note: Some plans may cover injectable medications through the medical benefit.)Serzone ▲

Silvadene ■ silver sulfadiazine crm* silver sulfadiazine crm ●

Sinemet ■ carbidopa/levodopa* Sinequan ■ doxepin* Singulair ▲

Skelaxin ▲

76




Skelid ▲

Slo-phyllin ▲ theophylline CR* Sof-Tac test strips ▲

Solaquin Forte ▲

Soma ■ carisoprodol* Soma CPD ■ carisoprodol/aspirin* Soma CPD w/codeine ■ carisoprodol/aspirin/

codeine*Sonata ▲

sotalol ●

Spectazole ▲

Spectrobid ■ amoxicillin, ampicillinspironolactone ●

spironolactone/hctz ●

Sporanox PR ■ Lamisil PR, Diflucan PRSSKI ▲

Stadol NS QL ■ any generic NSAID or (2 vials/30-day supply increments) narcotic analgesicStarlix ▲

Stelazine ■ trifluoperazine* Strovite tab/syr ▲

Strovite Advance cap ▲

Strovite Forte tab/syr ▲

Strovite Plus tab/syr ▲

sucralfate tabs ●

77


Sulamyd ■ sulfacetamide*Sular ■ nifedipine, nifedipine CR,


sulfacetamide ●

Sulfacet-R ▲

sulfamethoxazole/trimethoprim ●

sulfasalazine ●

sulfinpyrazone ●

sulfisoxazole ●

sulfisoxazole/erythromycin ●

Sulfoxyl ▲

sulindac ●

Sumycin PR ≤ 8 yr old ■ tetracycline*PR ≤ 8 yr old

78




Suprax ▲

Surmontil ▲

Sustiva ▲

Symax SL ■ hyoscyamine*Symax SR ■ hyoscyamine*Symmetrel ■ amantadine* Synalar ■ fluocinolone acetonide*Synarel ▲

Syn-RX/DM ▲

Synthroid ▲

TTagamet ■ cimetidine* Talwin NX ■ pentazocine/naloxone/

propoxyphene* Tambocor ▲

Tamiflu QL ■ amantadine, Flumadine(2 treatments [20 capsules]/year)Tamoxifen ▲

Tao ■ erythromycin, Biaxin, Biaxin XL, Zithromax

Tapazole ▲

Targretin ▲

Tarka ■ Lotrel

79


Tasmar ■ carbidopa/levodopa,COMTan, Mirapex,Requip

Tazorac ▲

Teczem ■ LotrelTegretol ■ carbamazepine*Tegretol XR ▲

temazepam ●

Temodar ▲

Temovate ■ clobetasol*Tenex ■ guanfacine* Tenormin ■ atenolol*Tequin PR < 10 yr old ■ Avelox, Cipro, Levaquin

All PR < 10 yr old

80




Terazol ■ Diflucan 150 mg QL,Gynazole-1

terazosin ●

Teslac ▲

Testoderm ▲

Testoderm TTS ▲

tetracycline PR ≤ 8 yr old ●

Teveten ■ Cozaar, DiovanTheo-24 ▲

theophylline CR ●

thioguanine ●

thioridazine ●

thiothixene ●

Thorazine ■ chlorpromazine* Thyrolar ▲

Tiamate ■ diltiazem CRTiazac ■ diltiazem CRTiclid ■ ticlopidine*ticlopidine ●

Tigan ■ trimethobenzamide*Tilade ▲

Timolide ■ timolol and hctz,bisoprolol/hctz

timolol ●

timolol gfs ●

81


Timoptic ■ timolol*Timoptic XE ■ timolol gfs*Tobradex ▲

tobramycin ●

Tobrex ■ tobramycin* Tofranil ■ imipramine* tolazamide ●

tolbutamide ●

Tolectin ■ tolmetin* Tolinase ■ tolazamide* tolmetin ●

Tonocard ▲

Topamax ▲

Topicort ■ desoximetasone*

82




Toprol XL ■ atenolol, metoprolol,nadolol, propranolol,bisoprolol, pindolol, timolol,acebutolol, Coreg

Toradol QL ■ ketorolac* QL(20 tablets/30-day supply increments)Tornalate ■ albuterol, Proventil HFA,

Combivent, Maxairtramadol ●

Trandate ■ labetalol*Transderm Nitro ■ Nitro-DurTransderm Scop ▲

Tranxene ■ clorazepate* Travatan ▲

trazodone ●

Trental ■ pentoxifylline*tretinoin PR > 36 yr old ●

Trexall ▲

triamcinolone ●

triamterene/hctz ●

Triavil ■ amitriptyline/perphenazine* Triaz 6% ■ benzoyl peroxidetriazolam ●

Tricor ▲

83


trifluoperazine ●

trihexyphenidyl ●

Trilafon ■ perphenazine* Trileptal ▲

Tri-Levlen ■ trivora*Trilisate ■ choline Mg trisalicylate* trimethobenzamide ●

trimethoprim ●

Trimox ■ amoxicillin* Trimpex ■ trimethoprim* Trinalin ▲

Tri-Nasal ■ Flonase, Nasacort, Nasacort AQ, Nasonex,Vancenase, Vancenase AQ,Vancenase AQ-DS

84




Tri-Norinyl ■ Ortho-Novum 7/7/7, Ortho-Tri-Cyclen

Trinsicon ▲

Triphasil ■ trivora*triple sulfa vaginal crm ●

Tritec ▲

Tri-Vi-Flor ■ vit ADC/fluoride*trivora ●

Trizivir ▲

Trusopt ▲

Tuinal ■ pentobarbital,phenobarbital, temazepam,triazolam*

Tusnel Ped-C ■ codeine/pseudoephedrine/guaifenesin*

Tussafed EX ▲

Tussafed HC ▲

Tussafed LA ▲

Tussionex susp ▲

Tylenol w/codeine ■ acetaminophen/codeine* Tylox ■ oxycodone/acetaminophen*

UUltram ■ tramadol* Ultrase ▲

85


Ultravate ■ clobetasol, Diprolene,Diprolene AF

Uniphyl ▲

Uniretic ■ captopril/hctz, Accuretic,Prinzide

Unithroid ▲

Univasc ■ captopril, enalapril,Accupril, Altace, Prinivil

Urecholine ■ bethanechol* Urex ▲

Urispas ▲

Urso ▲

ursodiol ●

86




VVagifem ■ Estring, Ogen crm,

Premarin crmValcyte ▲

Valisone ■ betamethasone*Valium ■ diazepam*valproic acid ●

Valtrex ▲

Vancenase ▲

Vancenase AQ ▲

Vancenase AQ-DS ▲

Vanceril ▲

Vanceril DS ▲

Vantin ■ Suprax, Cedax, OmnicefVascor ■ verapamil SR*Vaseretic ■ enalapril and hctzVasocidin ■ prednisolone phosphate/

sulfacetamide* Vasodilan ■ isoxsuprine*Vasotec ■ enalapril*Velosef ■ cephradine* Ventolin ■ albuterol*Ventolin Rotacaps ▲

Vepesid ▲

verapamil ●

87


verapamil SR ●

Verelan ■ verapamil* Verelan SR ■ verapamil SR*Vermox ■ mebendazole* Vesanoid ▲

Vexol ▲

Vibramycin PR ≤ 8 yr old ■ doxycycline*PR ≤ 8 yr old

Vicon Forte ▲

Vicoprofen ■ any generic NSAID ornarcotic analgesic

Videx ▲

Videx EC ▲

Viokase ▲

88




Vioxx PR, QL ▲

(All strengths = 30 tablets/30-day supply increments)Vira-A ▲

Viracept ▲

Viramune ▲

Viroptic ▲

Visken ■ pindolol*vit ADC/fluoride ●

Vitafol tab/syr ▲

Vitafol-PN ▲

Vitamin B12 ■ cyanocobalamin injection* Vivactil ■ protriptyline* Vivelle ▲

Vivelle DOT ▲

Volmax ▲

Voltaren soln ▲

Voltaren tab ■ diclofenac sodium*Voltaren XR ■ diclofenac sodium XR*Vosol ■ acetic acid soln 2%*Vosol HC otic ■ acetic acid/aluminum

acetate*

Wwarfarin sodium ●

Welchol ▲

89


Wellbutrin ■ bupropion*Wellbutrin SR ▲

Wytensin ■ guanabenz*

XXalatan ▲

Xanax ■ alprazolam* Xeloda ▲

Xopenex ■ albuterol, Proventil HFA,Combivent, Maxair

Xylocaine ■ lidocaine*

ZZaditor ▲

Zagam PR < 10 yr old ■ Avelox, Cipro, LevaquinAll PR < 10 yr old

90




Zanaflex ▲

Zantac ■ ranitidine*Zantac syrup ▲

Zarontin ▲

Zaroxolyn ▲

Zebeta ■ bisoprolol*Zenate ■ Nestabs FA, Nestabs CBF,

Prenate Advance, Prenate Ultra, Vitafol PN

Zephrex LA ■ pseudoephedrine/guaifenesin*

Zerit ▲

Zestoretic ■ captopril/hctz, Accuretic,Prinzide

Zestril ■ PrinivilZiac ■ bisoprolol/hctz*Ziagen ▲

Zithromax ▲

Zocor ▲

Zofran ▲

Zofran ODT ▲

Zoloft ▲

91


Zomig QL ■ Imitrex QL, Amerge QL,(2.5 mg = 12 tablets/ Maxalt QL, 30-day supply increments; Maxalt MLT QL5 mg = 6 tablets/30-day increments)Zomig ZMT QL ■ Imitrex QL, Amerge QL,(2.5 mg = 12 tablets/ Maxalt QL, 30-day supply increments; Maxalt MLT QL5 mg = 6 tablets/30-day increments)Zonegran ▲

zovia 1/35 ●

zovia 1/50 ●

Zovirax oint ▲

Zovirax tab ■ acyclovir*

92




Zydone ■ any generic NSAID or narcotic analgesic

Zyflo ■ SingulairZyloprim ■ allopurinol* Zymase ■ Creon, Ku-Zyme,

Ku-Zyme HP, Ultrase,Viokase

Zyprexa ▲

Zyprexa Zydis ▲

Zyrtec ▲

Zyvox PR ▲

93


Aetna U.S. Healthcare is a for-profit HMO.This material is for informational purposes only and is neitheran offer of coverage nor medical advice. It contains only apartial, general description of plan or program benefits anddoes not constitute a contract. Consult your plan documents(Schedule of Benefits, Evidence of Coverage) to determinegoverning contractual provisions, including procedures,exclusions and limitations relating to your plan. All the termsand conditions of your plan or program are subject toapplicable laws, regulations and policies. The availability of aplan or program may vary by geographic service area. Allbenefits are subject to coordination of benefits. Aetna U.S. Healthcare does not provide health care services and,therefore, cannot guarantee any results or outcomes.Participating providers and vendors are independentcontractors in private practice and are neither employees noragents of Aetna U.S. Healthcare or its affiliates. The availabilityof any particular provider cannot be guaranteed and providernetwork composition is subject to change. Notice of changewill be provided in accordance with state law. You must be entitled to Medicare Part A and continue to payyour Part B premium and Part A if applicable. You must usenetwork providers except in an emergency or for urgent careor renal dialysis services received out of the service area.Coverage is provided through a Medicare approved HMO inan approved service area. As with other Medicare HMO plans,benefits, limitations, service areas and premiums are subject tochange on January 1 of each year.

www.aetnaushc.com

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