march 23, 2004 memorandum96 v. central nervous system agents g. anti-psychotic 10. anti-manic agents...

PM04-010

March 23, 2004 MEMORANDUM TO: Participating Pharmacies FROM: John T. Berthiaume, M.D. Medical Director, Pharmacy Management SUBJECT: Updated HMSA Drug Formulary Enclosed is the comprehensive updated formulary, effective April 1. This copy incorporates the changes listed in the Formulary Update sent to you in February. Please replace the current formulary sections in your pharmacy handbook with the enclosed version. If you have any questions, please call an HMSA Provider Teleservice Representative at 948-6330 on Oahu or 1 (800) 790-4672 from the Neighbor Islands.

HMSA DRUG FORMULARY 4/1/04 - Page 1Code THERAPEUTIC CATEGORY LISTING

1 I. Anti-infectives A. Antibiotics 1. Penicillins - non-penicillinase resistant2 I. Anti-infectives A. Antibiotics 2. Penicillins - penicillinase resistant 3 I. Anti-infectives A. Antibiotics 3. Cephalosporins4 I. Anti-infectives A. Antibiotics 4. Fluoroquinolones5 I. Anti-infectives A. Antibiotics 5. Tetracyclines 6 I. Anti-infectives A. Antibiotics 6. Macrolides7 I. Anti-infectives A. Antibiotics 7. Vancomycin8 I. Anti-infectives A. Antibiotics 8. Lincosamides 9 I. Anti-infectives A. Antibiotics 9. Aminoglycoside 10 I. Anti-infectives A. Antibiotics 10. Sulfonamides 11 I. Anti-Infectives A. Antibiotics 11. Vaginal preparations12 I. Anti-infectives B. Antifungal agents 1. Oral 13 I. Anti-Infectives B. Antifungal agents 2. Vaginal preparations OTC considerations: clotrimazole (Gyne-Lotrimin 3, Mycelex-7),

miconazole (Monistat 7), tioconazole (Vagistat-1), butoconazole (Femstat 3)14 I. Anti-infectives C. Antimalarial15 I. Anti-infectives D. Antituberculous16 I. Anti-infectives E. Amebicides17 I. Anti-infectives F. Antiviral agents 1. Nucleoside Reverse-transcriptase Inhibitors (NRTI)18 I. Anti-infectives F. Antiviral agents 2. Non-Nucleotide Reverse-transcriptase Inhibitors (NNRTI)19 I. Anti-infectives F. Antiviral agents 3. Nucleotide Reverse transcriptase inhibitor20 I. Anti-infectives F. Antiviral agents 3. Protease Inhibitors21 I. Anti-infectives F. Antiviral agents 4. Agents for influenza22 I. Anti-infectives F. Antiviral agents 5. Other23 I. Anti-infectives G. Leprostatics24 I. Anti-infectives H. Antihelmintics25 I. Anti-infectives I. Other26 II. Anti-neoplastics A. Alkylating Agents27 II. Anti-neoplastics B. Antimetabolites28 II. Anti-neoplastics C. Hormones29 II. Anti-neoplastics D. Mitotic Inhibitors30 II. Anti-neoplastics E. Other

HMSA DRUG FORMULARY 4/1/04 - Page 231 III. Blood Modifiers A. Folic acid derivatives 32 III. Blood Modifiers B. Vitamin B33 III. Blood Modifiers C. Vitamin K34 III. Blood Modifiers D. Antiplatelet agents OTC consideration: apsirin35 III. Blood Modifiers E. Anticoagulants36 III. Blood Modifiers F. Hemorrheologic agent37 IV. Cardiovasculars A. Diuretics 1. Thiazide and related diuretics38 IV. Cardiovasculars A. Diuretics 2. Loop diuretics39 IV. Cardiovasculars A. Diuretics 3. Potassium-Sparing diuretics40 IV. Cardiovasculars A. Diuretics 4. Carbonic anhydrase inhibitors41 IV. Cardiovasculars A. Diuretics 5. Diuretic combinations42 IV. Cardiovasculars B. Cardiac Glycosides43 IV. Cardiovasculars C. Nitrates44 IV. Cardiovasculars D. Anti-arrhythmic agents45 IV. Cardiovasculars E. Calcium channel blocking agents 1. Benzothiazepine46 IV. Cardiovasculars E. Calcium channel blocking agents 2. Dihydropyridine47 IV. Cardiovasculars E. Calcium channel blocking agents 3. Diphenylalkylamine48 IV. Cardiovasculars E. Calcium channel blocking agents 4. Other 49 IV. Cardiovasculars F. Beta-adrenergic blocking agents 1. Non-selective agents50 IV. Cardiovasculars F. Beta-adrenergic blocking agents 2. Beta-1 selective agents Inhibits beta-2 receptors (bronchial and

vascular) at higher doses.51 IV. Cardiovasculars G. Alpha/beta-adrenergic blocking agents52 IV. Cardiovasculars H. Anti-adrenergic agents-centrally located53 IV. Cardiovasculars I. Anti-adrenergic agents-peripherally located 1. Alpha-1 adrenergic block54 IV. Cardiovasculars I. Anti-adrenergic agents-peripherally located 2. Other55 IV. Cardiovasculars J. Vasodilators56 IV. Cardiovasculars K. Angiotensin converting enzyme inhibitors57 IV. Cardiovasculars L. Angiotensin II Receptor Antagonists58 IV. Cardiovasculars M. Agents for Pheochromocytoma59 IV. Cardiovasculars N. Antihyperlipidemic Agents 1. Bile Acid Sequestrants60 IV. Cardiovasculars N. Antihyperlipidemic Agents 2. HMG-CoA Reductase Inhibitors 61 IV. Cardiovasculars N. Antihyperlipidemic Agents 3. Other

HMSA DRUG FORMULARY 4/1/04 - Page 362 V. Central Nervous System Agents A. CNS Stimulants63 V. Central Nervous System Agents B. Analgesics 1. Narcotic Agonist Analgesics64 V. Central Nervous System Agents B. Analgesics 2. Narcotic Agonist-Antagonist Analgesics65 V. Central Nervous System Agents B. Analgesics 3. Central Analgesics66 V. Central Nervous System Agents B. Analgesics 4. Salicylates OTC considerations: aspirin, sodium salicylate, choline salicylate

(Arthropan), magnesium salicylate (Doan's)67 V. Central Nervous System Agents B. Analgesics 5. Non-Narcotic Analgesic Combinations68 V. Central Nervous System Agents B. Analgesics 6. Non-Steroidal Anti-inflammatory Agents (NSAIDs) a. Non-selective

NSAIDs OTC considerations: ibuprofen (Advil, Motrin), ketoprofen (Orudis KT), naproxen sodium (Aleve)69 V. Central Nervous System Agents B. Analgesics 6. Non-Steroidal Anti-inflammatory Agents (NSAIDs) b. COX-2 selective

70 V. Central Nervous System Agents C. Abortive Agents for Migraine 1. 5HT-1 Receptor Agonists71 V. Central Nervous System Agents C. Abortive Agents for Migraine 2. Other72 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 1. Anti-dopaminergics73 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 2. Anti-cholinergics OTC considerations: cyclizine

(Marezine), meclizine (Bonine), diphenhydramine (Benadryl), dimenhydrinate (Dramamine)74 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 3. Other OTC consideration: phosphorated carohydrate

solution (Emetrol)75 V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 4. 5HT-3 Receptor Antagonists76 V. Central Nervous System Agents E. Anti-Anxiety 1. Benzodiazepines77 V. Central Nervous System Agents E. Anti-Anxiety 2. Other78 V. Central Nervous System Agents F. Anti-depressants 1. Tricyclic compounds-Tertiary amines79 V. Central Nervous System Agents F. Anti-depressants 2. Tricyclic compounds - Secondary amines80 V. Central Nervous System Agents F. Anti-depressants 3. Tetracyclics81 V. Central Nervous System Agents F. Anti-depressants 4. Triazolopyridine82 V. Central Nervous System Agents F. Anti-depressants 5. Aminoketone83 V. Central Nervous System Agents F. Anti-depressants 6. Phenethylamine84 V. Central Nervous System Agents F. Anti-depressants 7. Phenylpiperazine85 V. Central Nervous System Agents F. Anti-depressants 8. Selective serotonin reuptake inhibitors86 V. Central Nervous System Agents F. Anti-depressants 9. Monoamine oxidase inhibitors87 V. Central Nervous System Agents G. Anti-psychotic 1. Phenothiazines - aliphatic88 V. Central Nervous System Agents G. Anti-psychotic 2. Phenothiazines - piperazine

HMSA DRUG FORMULARY 4/1/04 - Page 489 V. Central Nervous System Agents G. Anti-psychotic 3. Phenothiazines - piperidine90 V. Central Nervous System Agents G. Anti-psychotic 4. Thioxanthenes91 V. Central Nervous System Agents G. Anti-psychotic 5. Butyrophenone92 V. Central Nervous System Agents G. Anti-psychotic 6. Diphenylbutylpiperadine93 V. Central Nervous System Agents G. Anti-psychotic 7. Dihydroindolones94 V. Central Nervous System Agents G. Anti-psychotic 8. Dibenzepine95 V. Central Nervous System Agents G. Anti-psychotic 9. Atypicals96 V. Central Nervous System Agents G. Anti-psychotic 10. Anti-manic agents97 V. Central Nervous System Agents H. Cholinesterase inhibitors98 V. Central Nervous System Agents I. Sedatives and hypnotics, non-barbiturates 1. Benzodiazepines99 V. Central Nervous System Agents I. Sedatives and hypnotics, non-barbiturates 2. Other OTC considerations: doxylamine

succinate (Unisom), diphenhydramine (Nytol, Sominex)100 V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 1. Long-acting101 V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 2. Intermediate-acting102 V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 3. Short-acting103 V. Central Nervous System Agents K. Anticonvulsants 1. Hydantoins104 V. Central Nervous System Agents K. Anticonvulsants 2. Succinimides105 V. Central Nervous System Agents K. Anticonvulsants 3. Oxazolidinediones106 V. Central Nervous System Agents K. Anticonvulsants 4. Benzodiazepines107 V. Central Nervous System Agents K. Anticonvulsants 5. Other108 V. Central Nervous System Agents L. Skeletal muscle relaxants 1. Centrally acting109 V. Central Nervous System Agents L. Skeletal muscle relaxants 2. Direct acting110 V. Central Nervous System Agents M. Antiparkinson agents 1. Anti-cholinergics111 V. Central Nervous System Agents M. Antiparkinson agents 2. Other112 V. Central Nervous System Agents N. Cholinergic muscle stimulants113 V. Central Nervous System Agents O. Agents for dependency and withdrawal 1. Alcohol114 V. Central Nervous System Agents O. Agents for dependency and withdrawal 2. Narcotic agonists115 V. Central Nervous System Agents O. Agents for dependency and withdrawal 3. Narcotic antagonists116 V. Central Nervous System Agents O. Agents for dependency and withdrawal 4. Nicotine OTC considerations: nicotine,

transdermal (Nicotrol, Nicoderm CQ), nicotine, polacrilex (Nicorette, Nicorette DS)117 V. Central Nervous System Agents P. Other118 VI. Endocrine/Metabolic A. Sex Hormones 1. Estrogens a. Oral

HMSA DRUG FORMULARY 4/1/04 - Page 5119 VI. Endocrine/Metabolic A. Sex Hormones 1. Estrogens b. Other120 VI. Endocrine/Metabolic A. Sex Hormones 2. Selective Estrogen Receptor Modulator (SERM)121 VI. Endocrine/Metabolic A. Sex Hormones 3. Progestins a. Oral122 VI. Endocrine/Metabolic A. Sex Hormones 4. Estrogen/progestin combination123 VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives a. Monophasic124 VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives b. Biphasic125 VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives c. Triphasic126 VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives d. Progetin-only127 VI. Endocrine/Metabolic A. Sex Hormones 6. Emergency Contraceptives128 VI. Endocrine/Metabolic A. Sex Hormones 7. Other contraceptives129 VI. Endocrine/Metabolic A. Sex Hormones 8. Androgens a. Oral130 VI. Endocrine/Metabolic A. Sex Hormones 8. Androgens b. Other131 VI. Endocrine/Metabolic A. Sex Hormones 9. Androgen hormone inhibitor132 VI. Endocrine/Metabolic B. Anabolic steroids133 VI. Endocrine/Metabolic C. Agents for infertility/impotence134 VI. Endocrine/Metabolic D. Gonadotropin releasing hormone135 VI. Endocrine/Metabolic E. Danazol136 VI. Endocrine/Metabolic F. Posterior pituitary hormones137 VI. Endocrine/Metabolic G. Adrenal cortical steroids 1. Mineralocorticoids138 VI. Endocrine/Metabolic G. Adrenal cortical steroids 2. Glucocorticoids a. Oral139 VI. Endocrine/Metabolic G. Adrenal cortical steroids 2. Glucocorticoids b. Rectal140 VI. Endocrine/Metabolic H. Adrenal steroid inhibitor141 VI. Endocrine/Metabolic I. Antidiabetic agents 1. Alpha-glucoside inhibitor142 VI. Endocrine/Metabolic I. Antidiabetic agents 2. Meglitinides143 VI. Endocrine/Metabolic I. Antidiabetic agents 3. Human Insulin144 VI. Endocrine/Metabolic I. Antidiabetic agents 4. Sulfonylureas145 VI. Endocrine/Metabolic I. Antidiabetic agents 5. Biguanides146 VI. Endocrine/Metabolic I. Antidiabetic agents 6. Thiazolidinediones147 VI. Endocrine/Metabolic I. Antidiabetic agents 7. Other148 VI. Endocrine/Metabolic J. Glucose elevating agents149 VI. Endocrine/Metabolic K. Thyroid drugs 1. Thyroid hormones150 VI. Endocrine/Metabolic K. Thyroid drugs 2. Antithyroid agents

HMSA DRUG FORMULARY 4/1/04 - Page 6151 VI. Endocrine/Metabolic L. Calcitonin-salmon152 VI. Endocrine/Metabolic M. Bisphosphonates153 VI. Endocrine/Metabolic N. Agents for Gout154 VI. Endocrine/Metabolic O. Other155 VII. Gastrointestinals A. Antacids OTC considerations: aluminum hydroxide gel (Amphojel), calcium carbonate (Tums),

magaldrate (Riopan), magnesium hydroxide (Milk of Magnesia), magnesium oxide (Mag-Ox), sodium bicarbonate156 VII. Gastrointestinals B. Sucralfate157 VII. Gastrointestinals C. Anticholinergics/antispasmodics 1. Belladonna alkaloids158 VII. Gastrointestinals C. Anticholinergics/antispasmodics 2. Anticholinergics159 VII. Gastrointestinals C. Anticholinergics/antispasmodics 3. Anti-spasmodics160 VII. Gastrointestinals D. Combination Helicobacter Pylori agents161 VII. Gastrointestinals E. Histamine (H2) antagonists OTC considerations: cimetidine (Tagamet HB), ranitidine (Zantac 75),

famotidine (Pepcid AC), nizatidine (Axid AR)162 VII. Gastrointestinals F. Prostaglandins163 VII. Gastrointestinals G. Proton pump inhibitors164 VII. Gastrointestinals H. Antiflatulents OTC consideration: simethicone165 VII. Gastrointestinals I. GI stimulants166 VII. Gastrointestinals J. Digestive enzymes167 VII. Gastrointestinals K. Gallstone solubilizing agents168 VII. Gastrointestinals L. Laxatives OTC considerations: magnesium hydroxide (Milk of Magnesia), magnesium citrate, monobasic

sodium phosphate/dibasic sodium phosphate (Fleets Enema, Fleets Phospho Soda), cascara, sennosides (Senokot), bisacodyl (Dulcolax), psyllium (Metamucil), polycarbophil (Fiber Con), methylcellulose (Citrucel), mineral oil, docusate sodium (Colace), docusate calcium (Surfak), glycerin, castor oil, docusate sodium/casanthranol (Peri-Colace)

169 VII. Gastrointestinals M. Antidiarrheals OTC consideraitons: loperamide (Imodium AD), bismuth subsalicylate (Pepto-Bismol), kaolin/pectin (Kaopectate), attapulgite (Donnagel)

170 VII. Gastrointestinals N. Mouth and throat products 1. Antimicrobial171 VII. Gastrointestinal N. Mouth and throat products 2. Saliva substitutes172 X. Gastrointestinal N. Mouth and throat products 3. Other173 VII. Gastrointestinals O. Other174 VIII. Nutritionals A. Vitamins 1. Vitamin B175 VIII. Nutritionals A. Vitamins 2. Vitamin D

HMSA DRUG FORMULARY 4/1/04 - Page 7176 VIII. Nutritionals A. Vitamins 3. Vitamin K177 VIII. Nutritionals A. Vitamins 4. Multivitamins178 VIII. Nutritionals B. Minerals and electrolytes 1. Calcium-removing resins179 VIII. Nutritionals B. Minerals and electrolytes 2. Fluoride180 VIII. Nutritionals B. Minerals and electrolytes 3. Chelating Agents181 VIII. Nutritionals B. Minerals and electrolytes 4. Iron preparations OTC considerations: ferrous sulfate, ferrous gluconate,

ferrous sulfate/vit c/folate (Fero-Folic 500), ferrous sulfate/vit b/vit c/folate (Iberet-Folic 500), ferrous sulfate/multivit/mineral (Advanced Formula Centrum)

182 VIII. Nutritionals B. Minerals and electrolytes 5. Phosphorus-reducing agents OTC consideration: calcium carbonate183 VIII. Nutritionals B. Minerals and electrolytes 6. Potassium replacement184 VIII. Nutritionals B. Minerals and electrolytes 7. Potassium-removing resin185 VIII. Nutritionals C. Systemic alkalinizers OTC consideration: sodium bicarbonate186 VIII. Nutritionals D. Levocarnitine187 VIII. Nutritionals E. Electrolyte replacement188 IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics a. Oral189 IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics b. Inhalation-short-acting190 IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics c. Inhalation-long-acting191 IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics d. Injection192 IX. Respiratory Drugs A. Bronchodilators 2. Anticholinergics193 IX. Respiratory Drugs B. Xanthine derivatives194 IX. Respiratory Drugs C. Leukotriene receptor antagonists195 IX. Respiratory Drugs D. Anti-inflammatory agents 1. Corticosteroids196 IX. Respiratory Drugs D. Anti-inflammatory agents 2. Non-steroidal197 IX. Respiratory Drugs E. Devices198 IX. Respiratory Drugs F. Other inhalation drugs199 IX. Respiratory Drugs G. Decongestants 1. Oral OTC considerations: pseudoephedrine (Sudafed)200 IX. Respiratory Drugs G. Decongestants 2. Intranasol OTC considerations: phenylephrine hcl (Neo-Synephrine), oxymetazoline

hcl (Afrin), tetrahydrozoline hcl (Tyzine)201 IX. Respiratory Drugs H. Intranasal anticholinergic agents202 IX. Respiratory Drugs I. Intranasal anti-inflammatory agents 1. Corticosteroids203 IX. Respiratory Drugs I. Intranasal anti-inflammatory agents 2. Non-steroidal OTC consideration: cromolyn sodium (Nasalcrom)

HMSA DRUG FORMULARY 4/1/04 - Page 8204 IX. Respiratory Drugs J. Intranasal antihistamine205 IX. Respiratory Drugs K. Antihistamines 1. Non-Sedating/Low-Sedating Antihistamines OTC consideration: loratadine (Alavert,

Claritin)206 IX. Respiratory Drugs K. Antihistamines 2. Sedating Antihistamines OTC considerations: diphenhydramine (Benadryl),

clemastine (Tavist 1), chlorpheniramine (Chlor-Trimeton)207 IX. Respiratory Drugs L. Decongestant and antihistamine combinations 1. Adult formulations-solid dosage forms OTC

considerations: pseudoephedrine/diphenhydramine (Benadryl Allergy Decongestant), pseudoephedrine/loratadine (Claritin-D), pseudoephedrine/chlorpheniramine (Chlor-Trimeton), pseudoephedrine/triprolidine (Actifed), pseudoephedrine/dexbrompheniramine (Drixoral Cold & Allergy)

208 IX. Respiratory Drugs L. Decongestant and antihistamine combinations 2. Adult formulations-liquid dosage forms OTC considerations: pseudoephedrine/brompheniramine (Dimetapp), pseudoephedrine/triprolidine (Actifed), pseudoephedrine/chlorpheniramine (Chlor-Trimeton Allergy D)

209 IX. Respiratory Drugs L. Decongestant and antihistamine combinations 3. Pediatric formulations OTC considerations: pseudoephedrine/brompheniramine (Dimetapp), pseudoephedrine/ diphenhydramine (Benadryl Children's Allergy & Sinus)

210 IX. Respiratory Drugs M. Narcotic antitussives and combinations 1. Adult formulations211 IX. Respiratory Drugs M. Narcotic antitussives and combinations 2. Pediatric formulations 212 IX. Respiratory Drugs N. Non-narcotic antitussives and combinations 1. Adult Formulations OTC considerations:

dextromethorphan (Delsym, Benylin), pseudoephedrine/dextromethorphan (Robitussin Maximum Strength Cough & Cold), (guaifenesin/dextromethorphan (Robitussin DM)

213 IX. Respiratory Drugs N. Non-narcotic antitussives and combinations 2. Pediatric formulations OTC considerations: dextromethorphan/pseudoephedrine (Robitussin Pediatric Cough & Cold), dextromethorphan/pseudoephedrine/chorpheniramine (Pediacare Cough & Cold), dextromethorphan (Benylin), dextromethorphan/pseudoephedrine/brompheniramine (Dimetapp DM), diphenhydramine (Benadryl)

214 IX. Respiratory Drugs O. Expectorants 1. Adult formulations-solid dosage forms215 IX. Respiratory Drugs O. Expectorants 2. Adult formulations-liquid dosage forms OTC considerations: guaifenesin (Robitussin),

guaifenesin/pseudoephedrine (Robitussin PE), guaifenesin/ephedrine (Primatene)216 IX. Respiratory Drugs O. Expectorants 3. Pediatric formulations OTC consideration: guaifenesin/pseudoephedrine (Thera-Hist

Expectorant Chest Congestion Liquid or Triaminic Chest Congestion Liquid)217 X. Ophthalmics A. Agents for glaucoma 1. Alpha-2 adrenergic agonist218 X. Ophthalmics A. Agents for glaucoma 2. Sympathomimetics219 X. Ophthalmics A. Agents for glaucoma 3. Beta-adrenergic blocking agents

HMSA DRUG FORMULARY 4/1/04 - Page 9220 X. Ophthalmics A. Agents for glaucoma 4. Miotics, direct-acting221 X. Ophthalmics A. Agents for glaucoma 5. Miotics, cholinesterase inhibitors222 X. Ophthalmics A. Agents for glaucoma 6. Carbonic anhydrase inhibitors223 X. Ophthalmics A. Agents for glaucoma 7. Prostaglandin agonist224 X. Ophthalmics B. Vasoconstrictors/mydriatics OTC considerations: tetrahydrozoline hcl (Generic, Collyrium Fresh, Visine),

phenylephrine hcl (Relief), oxymetazoline (OcuClear, Visine LR), naphazoline hcl (Allerest, Clear Eyes, Naphcon)

225 X. Ophthalmics C. Anti-allergy agents226 X. Ophthalmics D. Decongestant/antihistamine combinations OTC considerations: naphazoline/pheniramine (generic, Naphcon-A,

Opcon-A), naphazoline/antazoline (generic)227 X. Ophthalmics E. Cycloplegic mydriatics228 X. Ophthalmics F. Nonsteroidal Anti-inflammatory Agents (NSAIDS)229 X. Ophthalmics G. Corticosteroids230 X. Ophthalmics H. Antibiotics 1. Single agent231 X. Ophthalmics H. Antibiotics 2. Combination antibiotic products232 X. Ophthalmics H. Antibiotics 3. Steroid and antibiotic combinations233 X. Ophthalmics I. Sulfonamides234 X. Ophthalmics J. Antifungal agent235 X. Ophthalmics K. Antiviral agent236 X. Ophthalmics L. Ocular lubricants OTC consideration: artificial tears237 X. Ophthalmics M. Hyperosmolar preparations OTC considerations: sodium chloride, hypertonic (Muro 128)238 XI. Otic preparations A. Antibiotics239 XI. Otic preparations B. Other OTC considerations: boric acid/isopropyl alcohol (Ear-Dry), glycerin/isopropyl alcohol (Swim-Ear),

carbamide peroxide (Debrox, Murine Ear, Auro Ear Drops)240 XII. Dermatological Agents A. Acne products 1. Topical OTC considerations: benzoyl peroxide, sulfur, salicylic acid Note:

Because tretinoin (Renova) is indicated only for cosmetic purposes, it is not a benefit.241 XII. Dermatological Agents A. Acne products 2. Systemic242 XII. Dermatological Agents B. Antipsoriatics 1. Topical243 XII. Dermatological Agents B. Antipsoriatics 2. Systemic244 XII. Dermatological Agents C. Burn preparations245 XII. Dermatological Agents D. Diaper rash products OTC consideration: zinc oxide (Desitin)

HMSA DRUG FORMULARY 4/1/04 - Page 10246 XII. Dermatological Agents E. Antiseborrheic products OTC considerations: selenium sulfide (Selsun Blue), coal tar (Neutrogena

T/Gel, Pentrax), pyrithione zinc (Head & Shoulders, Sebulon), povidone-iodine (Betadine shampoo), sulfur-salicylic acid (Sebulex), phenol (P&S)

247 XII. Dermatological Agents F. Topical antihistamines OTC considerations: diphenhydramine (Benadryl), diphenhydramine/calamine (Caladryl), diphenhydramine/benzocaine (Sting-Eze)

248 XII. Dermatological Agents G. Topical anti-infectives 1. Antiviral agents249 XII. Dermatological Agents G. Topical anti-infectives 2. Antibiotics OTC considerations: bacitracin, bacitracin/polymyxin B

(Polysporin), bacitracin/polymyxin B/Neomycin (Neosporin)250 XII. Dermatological Agents G. Topical anti-infectives 3. Antifungal OTC considerations: miconazole (Micatin), clotrimazole

(Lotrimin AF), terbinafine (Lamisil AT), tolnaftate (Tinactin)251 XII. Dermatological Agents H. Scabicides/pediculicides OTC considerations: permethrin (Nix), pyrethrins, piperonyl butoxide

technical (End Lice, A-2000, RID)252 XII. Dermatological Agents I. Corticosteroids, topical 1. Very high potency253 XII. Dermatological Agents I. Corticosteroids, topical 2. High potency254 XII. Dermatological Agents I. Corticosteroids, topical 3. Medium potency255 XII. Dermatological Agents I. Corticosteroids, topical 4. Low potency OTC considerations: hydrocortisone cream, ointment 0.5%

and 1%, hydrocortisone acetate cream, ointment 0.5% and 1%256 XII. Dermatological Agents J. Local anesthetics, topical 1. Topical anesthetics for skin disorders OTC considerations: benzocaine

(Solarcaine, Lanacane), dibucaine (Nupercainal), lidocaine (Xylocaine, ELA-Max, Solarcaine Extra Burn Relief), tetracaine (Pontocaine), pramoxine (Prax)

257 XII. Dermatological Agents J. Local anesthetics, topical 2. Topical anesthetics for mucous membranes OTC consideration: benzocaine (Hurricane, Orajel)

258 XII. Dermatological Agents K . Keratolytics OTC considerations: salicylic acid (Occlusal HP, Compound W, Duofilm)259 XII. Dermatological Agents L. Topical enzyme preparations260 XII. Dermatological Agents M. Emollients OTC considerations: lactic acid (Lac-Hydrin, Amlactin), urea (Carmol 20, Aquacare),

mineral oil/petrolatum/lanolin (Lubriderm), glycerin/petrolatum (Curell), mineral oil (Eucerin, Keri)261 XII. Dermatological Agents N. Other262 XIII. Urinary tract products A. Alkalinizers OTC consideration: sodium bicarbonate263 XIII. Urinary tract products B. Acidifiers OTC considerations: ammonium chloride, ascorbic acid264 XIII. Urinary tract products C. Antispasmodics265 XIII. Urinary tract products D. Cholinergic stimulants266 XIII. Urinary tract products E. Analgesics OTC consideration: phenazopyridine (Azo-Standard, Prodium)

HMSA DRUG FORMULARY 4/1/04 - Page 11267 XIII. Urinary tract products F. Other268 XIV. Immunologic Agents A. Immunosuppressive agents269 XIV. Immunologic Agents B. Disease Modifying Antirheumatic Drugs (DMARD)270 XV. Miscellaneous A. Contraceptive barriers

HMSA DRUG FORMULARY - MASTER list (Therapeutic Category order) Rev. 4/1/04 - Page 1

Ther. Categ. Code

Generic Brand Select

Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

11 amoxicillin trihydrate -- G G X X X1 ampicillin -- G G X X X1 ampicillin Omnipen O O1 penicillin V potassium -- G G X X X1 penicillin V potassium V-Cillin K O O22 amoxicillin/ k clavulanate -- G G X 12 amoxicillin/ k clavulanate Augmentin O O2 amoxicillin/ k clavulanate, extra

strengthAugmentin ES P O X 1

2 amoxicillin/ k clavulanate, extended release

Augmentin XR P O X 1

2 cloxacillin sodium -- G G X2 dicloxacillin sodium -- G G X2 dicloxacillin sodium Dynapen O O2 dicloxacillin sodium, suspension Dynapen Suspension P O X2 oxacillin sodium -- G G X33 cefaclor -- G G3 cefaclor Ceclor O O3 cefaclor, extended release -- G G3 cefaclor, extended release Ceclor CD O O3 cefadroxil -- G G3 cefadroxil Duricef O O3 cefdinir Omnicef O O3 cefpodoxime proxetil -- G G3 cefpodoxime proxetil Vantin O O3 cefprozil Cefzil O O3 ceftibuten Cedax O O3 cefuroxime -- G G X 13 cefuroxime Ceftin O O

I. Anti-infectives A. Antibiotics 1. Penicillins - non-penicillinase resistant

I. Anti-infectives A. Antibiotics 2. Penicillins - penicillinase resistant

I. Anti-infectives A. Antibiotics 3. Cephalosporins

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.3 cephalexin -- G G X X X3 cephalexin Keflex O O3 cephalexin monohydrate Keftab O O3 cephradine -- G G3 cephradine Velosef O O3 loracarbef Lorabid O O44 ciprofloxacin -- O O4 ciprofloxacin Cipro P O X 14 enoxacin Penetrex O O4 levofloxacin Levaquin O O4 gatifloxacin Tequin O O4 lomefloxacin Maxaquin O O4 moxifloxacin Avelox P O X 14 norfloxacin Noroxin O O4 ofloxacin Floxin O O55 demeclocycline Declomycin O O5 doxycycline hyclate -- G G X X X5 doxycycline hyclate Doryx O O5 doxycycline hyclate Periostat O O5 doxycycline hyclate Vibramycin O O5 doxycycline monohydrate -- G G5 doxycycline monohydrate Monodox O O5 minocycline -- G G X5 minocycline Minocin O O5 tetracycline -- G G X X X66 azithromycin Zithromax O O X 166 clarithromycin Biaxin P O X 296 clarithromycin, extended release Biaxin XL P O X 296 dirithromycin Dynabac O O

I. Anti-infectives A. Antibiotics 4. Fluoroquinolones

I. Anti-infectives A. Antibiotics 5. Tetracyclines

I. Anti-infectives A. Antibiotics 6. Macrolides


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.6 erythromycin base -- G G X X X6 erythromycin base Eryc O O6 erythromycin base Ery-Tab G G X X X6 erythromycin base PCE O O6 erythromycin estolate -- G G X X X6 erythromycin estolate Ilosone O O6 erythromycin ethylsuccinate -- G G X X X6 erythromycin ethylsuccinate EryPed O O6 erythromycin stearate -- G G X X X6 erythromycin/ sufisoxazole -- G G X6 erythromycin/ sufisoxazole Pediazole O O6 troleandomycin Tao O O77 vancomycin Vancocin O O88 clindamycin -- G G X8 clindamycin Cleocin O O8 clindamycin palmitate, suspension Cleocin Suspension P O X8 paromomycin -- G G8 paromomycin Humatin O O99 kanamycin sulfate Kantrex O O9 neomycin -- G G X1010 erythromycin/ sufisoxazole -- G G X10 erythromycin/ sufisoxazole Pediazole O O10 sulfadiazine -- G G X10 sulfamethoxazole Gantanol O O10 sulfamethoxazole/ trimethoprim -- G G X X X10 sulfamethoxazole/ trimethoprim Bactrim O O10 sulfamethoxazole/ trimethoprim Septra O O10 sulfisoxazole -- G G X

I. Anti-infectives A. Antibiotics 7. Vancomycin

I. Anti-infectives A. Antibiotics 8. Lincosamides

I. Anti-infectives A. Antibiotics 9. Aminoglycoside

I. Anti-infectives A. Antibiotics 10. Sulfonamides


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.10 sulfisoxazole Gantrisin P O X1111 clindamycin Cleocin Vaginal P O X11 glacial acetic acid Aci-jel O O11 metronidazole Metro-Gel Vaginal P O X11 sodium propionate/ amino acid/ urea Amino-Cerv O O

11 sulfanilamide -- G G X11 sulfanilamide AVC O O11 triple sulfa -- G G X1212 fluconazole Diflucan P O X12 griseofulvin microsize -- G G12 griseofulvin microsize Fulvicin-U/F O O12 griseofulvin microsize Grifulvin V O O12 griseofulvin ultramicrosize -- G G X12 griseofulvin ultramicrosize Gris-Peg P O X12 itraconazole Sporanox P O X12 ketoconazole -- G G X12 ketoconazole Nizoral O O12 nystatin -- G G X12 nystatin Mycostatin O O12 terbinafine Lamisil P O X13

13 clotrimazole -- X13 miconazole -- X13 nystatin -- G G X13 nystatin Mycostatin O O13 terconazole Terazol 3 O O13 terconazole Terazol 7 O O

I. Anti-infectives B. Antifungal agents 1. Oral

I. Anti-Infectives A. Antibiotics 11. Vaginal preparations

I. Anti-Infectives B. Antifungal agents 2. Vaginal preparations OTC considerations: clotrimazole (Gyne-Lotrimin 3, Mycelex-7), miconazole (Monistat 7), tioconazole (Vagistat-1), butoconazole (Femstat 3)


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.1414 chloroquine phosphate Aralen P O X14 doxycycline hyclate -- G G X X X14 doxycycline hyclate Vibramycin O O14 halofantrine hcl Halfan O O14 hydroxychloroquine sulfate -- G G X14 hydroxychloroquine sulfate Plaquenil O O14 mefloquine hcl Larium O O14 primaquine phosphate Primaquine O O14 pyrimethamine Daraprim O O14 pyrimethamine/ sulfadoxine Fansidar O O14 quinine sulfate -- G G X1515 aminosalicylic acid Paser O O15 cycloserine Seromycin O O15 ethionamide Trecator-SC O O15 ethambutol -- G G X 1815 ethambutol Myambutol O O15 isoniazid -- G G X 415 isoniazid/ rifampin Rifamate O O15 isoniazid/ rifampin/ pyrazinamide Rifater O O15 pyrazinamide -- G G15 rifabutin Mycobutin P O X 1815 rifampin -- G G X 1815 rifampin Rifadin O O15 rifapentine Priftin O O1616 chloroquine phosphate Aralen P O X16 iodoquinol Yodoxin P O X16 metronidazole -- G G X16 metronidazole Flagyl O O16 paromomycin -- G G

I. Anti-infectives E. Amebicides

I. Anti-infectives C. Antimalarial

I. Anti-infectives D. Antituberculous


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.16 paromomycin Humatin O O1717 abacavir sulfate Ziagen P O X17 abacavir/ lamivudine/ zidovudine Trizivir P O X17 didanosine Videx P O X17 didanosine, enteric coated Videx EC P O X17 lamivudine Epivir P O X17 lamivudine Epivir-HBV P O X17 lamivudine/ zidovudine Combivir P O X17 stavudine Zerit P O X17 zalcitabine Hivid P O X17 zidovudine Retrovir P O X1818 delavirdine mesylate Rescriptor P O X18 efavirenz Sustiva P O X18 nevirapine Viramune P O X1919 tenofovir Viread P O X2020 amprenavir Agenerase P O X20 lopinavir/ ritonavir Kaletra P O X20 indinavir sulfate Crixivan P O X20 nelfinavir mesylate Viracept P O X20 ritonavir Norvir P O X20 saquinavir Fortovase P O X2121 amantadine -- G G X X21 amantadine Symmetrel O O21 oseltamivir Tamiflu O O21 rimantadine -- G G X21 rimantadine Flumadine O O

I. Anti-infectives F. Antiviral agents 4. Agents for influenza

I. Anti-infectives F. Antiviral agents 1. Nucleoside Reverse-transcriptase Inhibitors (NRTI)

I. Anti-infectives F. Antiviral agents 2. Non-Nucleotide Reverse-transcriptase Inhibitors (NNRTI)

I. Anti-infectives F. Antiviral agents 3. Nucleotide Reverse-transcriptase inhibitor

I. Anti-infectives F. Antiviral agents 3. Protease Inhibitors


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.21 zanamivir Relenza O O2222 acyclovir -- G G X22 acyclovir Zovirax O O22 famciclovir Famvir P O X22 ganciclovir -- G G X22 ganciclovir Cytovene O O22 ribavirin Rebetol P O X22 valacyclovir Valtrex P O X2323 clofazimine Lamprene O O23 dapsone Dapsone O O23 thalidomide Thalomid O O2424 albendazole Albenza O O24 diethylcarbamazine citrate Hetrazan O O24 ivermectin Stromectol O O24 mebendazole -- G G X24 mebendazole Vermox O O24 oxamniquine Vansil O O24 praziquantel Biltricide O O24 thiabendazole Mintezol O O2525 atovaquone Mepron O O25 cinoxacin Cinobac O O25 fosfomycin tromethamine Monurol O O25 furazolidone Furoxone O O25 methenamine hippurate Hiprex O O25 methenamine hippurate Urex O O25 methenamine mandelate -- G G X25 methenamine mandelate Mandelamine O O

I. Anti-infectives G. Leprostatics

I. Anti-infectives F. Antiviral agents 5. Other

I. Anti-infectives H. Antihelmintics

I. Anti-infectives I. Other


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.25 methylene blue Urolene Blue O O25 nalidixic acid NegGram O O25 nitrofurantoin Furadantin O O25 nitrofurantoin macrocrystals -- G G X25 nitrofurantoin macrocrystals Macrobid P O X25 nitrofurantoin macrocrystals Macrodantin O O25 pentamidine isethionate, inhalation NebuPent P O X25 tobramycin, inhalation TOBI P O X25 trimethoprim -- G G X25 trimethoprim Trimpex O O2626 busulfan Myleran P O X26 chlorambucil Leukeran P O X26 cyclophosphamide -- G G X26 cyclophosphamide Cytoxan P O X26 lomustine CeeNu P O X26 melphalan Alkeran P O X2727 capecitabine Xeloda P O X27 mercaptopurine Purinethol P O X27 methotrexate -- G G X27 methotrexate Rheumatrex O O27 thioguanine Thioguanine P O X2828 anastrazole Arimidex P O X28 bicalutamide Casodex P O X28 diethylstilbestrol Stilphostrol O O28 estramustine Emcyt P O X28 flutamide -- G G X28 flutamide Eulexin O O28 letrozole Femara O O28 megestrol -- G G X

II. Anti-neoplastics A. Alkylating Agents

II. Anti-neoplastics B. Antimetabolites

II. Anti-neoplastics C. Hormones


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.28 megestrol Megace O O28 nilutamide Nilandron O O28 tamoxifen -- G G X28 tamoxifen Nolvadex O O28 testolactone Teslac O O28 toremifene Fareston O O2929 etoposide VePesid P O X3030 altretamine Hexalen P O X30 bexarotene Targretin P P X30 hydroxyurea -- G G X30 hydroxyurea Hydrea P O X30 levamisole Ergamisol P O X30 mitotane Lysodren O O30 procarbazine Matulane P O X30 temozolomide Temodar P O X30 tretinoin, oral Vesanoid O O3131 folic acid -- G G X31 leucovorin calcium -- G G X31 leucovorin calcium Wellcovorin O O3232 cyanocobalamin, nasal Nascobal P 11 O 11 X 113333 phytonadione Mephyton P O X3434 aspirin -- X34 aspirin/ dipyridamole Aggrenox P P X34 anagrelide Agrylin O O34 cilostazol Pletal O O

III. Blood Modifiers B. Vitamin B

III. Blood Modifiers C. Vitamin K

II. Anti-neoplastics E. Other

III. Blood Modifiers A. Folic acid derivatives

III. Blood Modifiers D. Antiplatelet agents OTC consideration: apsirin

II. Anti-neoplastics D. Mitotic Inhibitors


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.34 clopidogrel Plavix P P X34 dipyridamole -- G G X34 dipyridamole Persantine O O34 ticlopidine -- G G X34 ticlopidine Ticlid O O3535 anisindione Miradon O O35 dicumarol Dicumarol O O35 warfarin -- G G X35 warfarin Coumadin P O X3636 pentoxifylline -- G G X36 pentoxifylline Trental O O3737 bendroflumethiazide Naturetin O O37 chlorothiazide -- G G37 chlorothiazide Diuril O O37 chlorthalidone -- G G37 chlorthalidone Thalitone O O37 furosemide -- G G X37 furosemide Lasix O O37 hydrochlorothiazide -- G G X37 hydrochlorothiazide HydroDIURIL O O37 hydrochlorothiazide Microzide O O37 indapamide -- G G X37 indapamide Lozol O O37 methyclothiazide -- G G37 methyclothiazide Enduron O O37 metolazone Mykrox O O37 metolazone Zaroxolyn P O X37 polythiazide Renese O O37 trichlormethiazide -- G G

IV. Cardiovasculars A. Diuretics 1. Thiazide and related diuretics

III. Blood Modifiers E. Anticoagulants

III. Blood Modifiers F. Hemorrheologic agent


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.37 trichlormethiazide Naqua O O3838 bumetanide -- G G38 bumetanide Bumex O O38 ethacrynic acid Edecrin O O38 torsemide -- G G38 torsemide Demadex O O3939 amiloride hcl -- G G39 amiloride hcl Midamor O O39 spironolactone -- G G X39 spironolactone Aldactone O O39 triamterene Dyrenium O O4040 acetazolamide -- G G X40 acetazolamide Diamox O O40 acetazolamide, extended release Diamox Sequels P O X40 dichlorphenamide Daranide O O40 methazolamide -- G G X40 methazolamide Neptazane O O4141 amiloride/ hctz -- G G41 amiloride/ hctz Moduretic O O41 spironolactone/ hctz -- G G X41 spironolactone/ hctz Aldactazide O O41 triamterene/ hctz -- G G X41 triamterene/ hctz Dyazide O O41 triamterene/ hctz Maxzide O O4242 digitoxin Crystodigin O O42 digoxin -- G G X

IV. Cardiovasculars A. Diuretics 2. Loop diuretics

IV. Cardiovasculars A. Diuretics 5. Diuretic combinations

IV. Cardiovasculars B. Cardiac Glycosides

IV. Cardiovasculars A. Diuretics 3. Potassium-Sparing diuretics

IV. Cardiovasculars A. Diuretics 4. Carbonic anhydrase inhibitors


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.42 digoxin Lanoxicaps O O42 digoxin Lanoxin G G X4343 isosorbide dinitrate, chewable Sorbitrate O O43 isosorbide dinitrate, oral -- G G X43 isosorbide dinitrate, oral Isordil Titradose O O43 isosorbide dinitrate, oral, sustained

release-- G G X

43 isosorbide dinitrate, oral, sustained release

Dilatrate-SR O O


Isordil Tembids O O

43 isosorbide dinitrate, sublingual -- G G X43 isosorbide dinitrate, sublingual Isordil O O43 isosorbide mononitrate -- G G43 isosorbide mononitrate ISMO O O43 isosorbide mononitrate Monoket O O43 isosorbide mononitrate, extended

release-- G G X

43 isosorbide mononitrate, extended release

Imdur O O

43 nitroglycerin, sublingual Nitrostat G G X43 nitroglycerin, sustained release, oral -- G G

43 nitroglycerin, sustained release, oral Nitroglyn O O

43 nitroglycerin, sustained release, oral Nitrong O O

43 nitroglycerin, topical -- G G43 nitroglycerin, topical Nitro-Bid O O43 nitroglycerin, topical Nitrol O O43 nitroglycerin, transdermal -- G G X

IV. Cardiovasculars C. Nitrates


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.43 nitroglycerin, transdermal Minitran O O43 nitroglycerin, transdermal Nitrodisc O O43 nitroglycerin, transdermal Nitro-Dur P O X43 nitroglycerin, transdermal Transderm-Nitro O O43 nitroglycerin, translingual Nitrolingual P O X43 nitroglycerin, transmucosal Nitrogard O O4444 amiodarone -- G G X44 amiodarone Cordarone P O X44 disopyramide -- G G X44 disopyramide Norpace P O X44 disopyramide, sustained release -- G G X44 disopyramide, sustained release Norpace CR P O X44 dofetilide Tikosyn O O44 flecainide -- G G X44 flecainide Tambocor P O X44 mexiletine -- G G X44 mexiletine Mexitil P O X44 moricizine Ethmozine P O X44 procainamide -- G G X44 procainamide Pronestyl O O44 procainamide, sustained release -- G G X44 procainamide, sustained release Procan SR O O44 procainamide, sustained release Procanbid P O X44 propafenone -- G G X44 propafenone Rythmol P O X44 quinidine gluconate -- G G X44 quinidine gluconate Quinaglute Dura-Tabs P O X44 quinidine polygalacturonate Cardioquin P O X44 quinidine sulfate -- G G X44 quinidine sulfate Quinora O O44 quinidine sulfate, extended release -- G G X

IV. Cardiovasculars D. Anti-arrhythmic agents


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.44 quinidine sulfate, extended release Quinidex Extentabs P O X44 sotalol Betapace AF P P X4545 diltiazem -- G G X45 diltiazem Cardizem O O45 diltiazem, sustained release -- G G X45 diltiazem, sustained release Cardizem CD O O45 diltiazem, sustained release Cardizem SR O O45 diltiazem, sustained release Dilacor XR O O45 diltiazem, sustained release Tiazac P P X4646 amlodipine Norvasc O O46 amlodipine/ benazepril Lotrel P O X46 felodipine Plendil P P X46 felodipine/enalapril Lexxel O O46 isradipine DynaCirc O O46 nicardipine -- G G46 nicardipine Cardene O O46 nicardipine, sustained release Cardene SR O O46 nifedipine -- G G46 nifedipine Adalat O O46 nifedipine Procardia O O46 nifedipine, sustained release -- G G X46 nifedipine, sustained release Adalat CC O O46 nifedipine, sustained release Procardia XL O O46 nimodipine Nimotop P O X46 nisoldipine Sular P P X4747 verapamil -- G G X47 verapamil Calan O O47 verapamil Isoptin O O47 verapamil, sustained release -- G G X

IV. Cardiovasculars E. Calcium channel blocking agents 2. Dihydropyridine

IV. Cardiovasculars E. Calcium channel blocking agents 3. Diphenylalkylamine

IV. Cardiovasculars E. Calcium channel blocking agents 1. Benzothiazepine


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.47 verapamil, sustained release Calan SR O O47 verapamil, sustained release Covera HS O O47 verapamil, sustained release Isoptin SR O O47 verapamil, sustained release Verelan O O47 verapamil ER/ trandolapril Tarka O O4848 bepridil Vascor O O4949 nadolol -- G G49 nadolol Corgard O O49 nadolol/ bendroflumethiazide Corzide O O49 penbutolol Levatol O O49 pindolol -- G G49 pindolol Visken O O49 propranolol -- G G X X49 propranolol Inderal O O49 propranolol, sustained release -- G G X X49 propranolol, sustained release Inderal LA P O X X49 propranolol/ hctz -- G G X49 propranolol/ hctz Inderide O O49 sotalol -- G G X49 sotalol Betapace O O49 sotalol Betapace AF P P X49 timolol maleate -- G G49 timolol maleate Blocadren O O49 timolol maleate/ hctz Timolide O O50

50 acebutolol -- G G50 acebutolol Sectral O O50 atenolol -- G G

IV. Cardiovasculars E. Calcium channel blocking agents 4. Other

IV. Cardiovasculars F. Beta-adrenergic blocking agents 1. Non-selective agents

IV. Cardiovasculars F. Beta-adrenergic blocking agents 2. Beta-1 selective agents Inhibits beta-2 receptors (bronchial and vascular) at higher doses.


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.50 atenolol Tenormin O O50 atenolol/ chlorthalidone -- G G50 atenolol/ chlorthalidone Tenoretic O O50 betaxolol Kerlone O O50 bisoprolol -- G G X50 bisoprolol Zebeta O O50 bisoprolol/ hctz -- G G X50 bisoprolol/ hctz Ziac O O50 metoprolol -- G G X50 metoprolol Lopressor O O50 metoprolol, extended release Toprol XL P P X50 metoprolol/ hctz Lopressor HCT O O5151 carvedilol Coreg P P X51 labetolol -- G G X51 labetolol Normodyne O O51 labetolol Trandate O O5252 clonidine, oral -- G G X X52 clonidine, oral Catapres O O52 clonidine, transdermal Catapres-TTS O O X52 clonidine/ chlorthalidone -- G G52 clonidine/ chlorthalidone Combipres O O52 guanabenz -- G G52 guanabenz Wytensin O O52 guanfacine -- G G X52 guanfacine Tenex O O52 methyldopa -- G G X52 methyldopa Aldomet O O52 methyldopa/ chlorothiazide Aldoclor O O52 methyldopa/ hctz -- G G52 methyldopa/ hctz Aldoril O O

IV. Cardiovasculars G. Alpha/beta-adrenergic blocking agents

IV. Cardiovasculars H. Anti-adrenergic agents-centrally located


Ther. Categ. Code


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.5353 doxazosin -- G G53 doxazosin mesylate Cardura O O53 prazosin -- G G X53 prazosin Minipress O O53 prazosin/ polythiazide Minizide O O53 tamsulosin Flomax P O X53 terazosin -- G G X53 terazosin Hytrin O O5454 deserpidine/ methyclothiazide Enduronyl O O54 deserpidine/ methyclothiazide Enduronyl Forte O O54 guanadrel Hylorel O O54 guanethidine Ismelin O O54 reserpine -- G G54 reserpine/ chlorothiazide -- G G54 reserpine/ chlorothiazide Diupres O O54 reserpine/ chlorthalidone Regroton O O54 reserpine/ hctz -- G G54 reserpine/ hctz Hydropres O O54 reserpine/ hctz Hydro-Serp O O54 reserpine/ hydroflumethiazide Salutensin O O54 reserpine/ methyclothiazide Diutensen-R O O54 reserpine/ polythiazide Renese-R O O54 reserpine/ trichlormethiazide Metatensin O O5555 hydralazine -- G G X55 hydralazine Apresoline O O55 hydralazine/ hctz -- G G55 hydralazine/ hctz Apresazide O O55 minoxidil -- G G X55 minoxidil Loniten O O

IV. Cardiovasculars I. Anti-adrenergic agents-peripherally located 1. Alpha-1 adrenergic block

IV. Cardiovasculars I. Anti-adrenergic agents-peripherally located 2. Other

IV. Cardiovasculars J. Vasodilators


Ther. Categ. Code


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.5656 benazepril Lotensin O O56 benazepril/ hctz Lotensin HCT O O56 benazepril/ amlodipine Lotrel P O X56 captopril -- G G X56 captopril Capoten O O56 captopril/ hctz -- G G X56 captopril/ hctz Capozide O O56 enalapril -- G G X56 enalapril Vasotec O O56 enalapril/ hctz -- G G X56 enalapril/ hctz Vaseretic O O56 felodipine/ enalapril Lexxel O O X56 fosinopril -- G G56 fosinopril Monopril O O56 fosinopril/hctz Monopril HCT O O56 lisinopril -- G G X56 lisinopril Prinivil O O56 lisinopril Zestril O O56 lisinopril/ hctz -- G G X56 lisinopril/ hctz Prinzide O O56 lisinopril/ hctz Zestoretic O O56 moexipril -- G G56 moexipril Univasc O O56 moexipril/ hctz Uniretic O O56 perindopril Aceon O O56 quinapril -- G G56 quinapril Accupril O O56 quinapril/ hctz Accuretic O O56 ramipril Altace P P X56 trandolapril Mavik O O56 verapamil ER/ trandolapril Tarka O O

IV. Cardiovasculars K. Angiotensin converting enzyme inhibitors


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.5757 candesartan Atacand O O57 candesartan/ hctz Atacand HCT O O57 eprosartan Teveten O O57 eprosartan/ hctz Teveten HCT O O57 irbesartan Avapro P P X57 irbesartan/ hctz Avalide P P X57 losartan Cozaar P P X57 losartan/ hctz Hyzaar P P X57 olmesartan Benicar O O57 telmisartan Micardis O O57 telmisartan/ hctz Micardis HCT O O57 valsartan Diovan O O57 valsartan/ hctz Diovan HCT O O5858 metyrosine Demser O O58 phenoxybenzamine Dibenzyline O O5959 colesevelam Welchol O O59 cholestyramine/ aspartame LoCHOLEST Light O O59 cholestyramine/ aspartame Prevalite O O59 cholestyramine/ sucrose -- G G59 cholestyramine/ sucrose LoCHOLEST O O59 cholestyramine/ sucrose Questran O O59 cholestyramine/ aspartame -- G G59 cholestyramine/ aspartame Questran Light O O59 colestipol, granules Colestid P O X59 colestipol, tablets Colestid P O6060 atorvastatin, 10mg, 20mg & 40mg Lipitor, 10mg, 20mg &

40mgO 21 O 21

IV. Cardiovasculars M. Agents for Pheochromocytoma

IV. Cardiovasculars N. Antihyperlipidemic Agents 1. Bile Acid Sequestrants

IV. Cardiovasculars N. Antihyperlipidemic Agents 2. HMG-CoA Reductase Inhibitors

IV. Cardiovasculars L. Angiotensin II Receptor Antagonists


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.60 atorvastatin, 80 mg Lipitor, 80 mg P 21 P 21 X 2160 fluvastatin Lescol O 21 O 2160 fluvastatin, extended release Lescol XL O 21 O 2160 lovastatin -- G G X60 lovastatin Mevacor O O60 lovastatin, extended release Altocor O 21 O 2160 pravastatin Pravachol P 21 P 21 X 2160 pravastatin/ aspirin Pravigard P 21 P 21 X 2160 simvastatin Zocor O 21 O 216161 clofibrate Atromid S O O61 ezetimibe Zetia O O61 fenofibrate -- O O61 fenofibrate Tricor O O61 gemfibrozil -- G G X61 gemfibrozil Lopid O O61 nicotinic acid, extended release Niaspan P P X61 nicotinic acid, extended release/ Advicor P P X6262 amphetamine mixture -- G 8 G 8 X 8 X 862 amphetamine mixture Adderall P 8 O 8 X 8 X 8

62 amphetamine mixture, extended release Adderall XR P 7 O 7 X 7 X 7

62 dextroamphetamine sulfate -- G 8 G 8 X 8 X 862 dextroamphetamine sulfate Dexedrine P 8 O 8 X 8 X 862 dextroamphetamine sulfate, sustained

release-- G 7 G 7 X 7 X 7

62 dextroamphetamine sulfate, sustained release

Dexedrine Spansules O 7 O 7 X 7

62 methamphetamine Desoxyn O 7 O 7

V. Central Nervous System Agents A. CNS Stimulants

IV. Cardiovasculars N. Antihyperlipidemic Agents 3. Other


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.62 methylphenidate -- G 8 G 8 X 8 X 862 methylphenidate Ritalin O 8 O 862 methylphenidate, extended release Concerta O 7 O 762 methylphenidate, extended release Metadate CD P 7 O 7 X 7 X 762 methylphenidate, extended release Metadate ER P 7 O 7 X 7 X 762 methylphenidate, sustained release -- G 8 G 8 X 8 X 862 methylphenidate, sustained release Ritalin SR O 8 O 862 modafinil Provigil O 9 O 962 pemoline -- G 7 G 7 X 762 pemoline Cylert O 7 O 7 X 76363 belladonna/ opium B&O suppositories O O63 codeine sulfate -- G G X63 codeine/ apap -- G G X63 codeine/ apap Tylenol w/ Codeine O O63 codeine/ apap/ caffeine/ butalbital Fioricet w/ Codeine O O63 codeine/ asa -- G G X63 codeine/ asa Empirin w/ Codeine O O63 codeine/ asa/ caffeine/ butalbital Fiorinal w/ Codeine O O63 fentanyl, transdermal Duragesic P O X63 hydrocodone/ apap -- G G X63 hydrocodone/ apap Anexsia O O63 hydrocodone/ apap Lorcet O O63 hydrocodone/ apap Lortab O O63 hydrocodone/ apap Norco O O63 hydrocodone/ apap Vicodin O O63 hydrocodone/ apap Vicodin HP O O63 hydrocodone/ asa Lortab ASA O O63 hydrocodone/ ibuprofen -- G G63 hydrocodone/ ibuprofen Vicoprofen O O63 hydromorphone -- G G X63 hydromorphone Dilaudid O O

V. Central Nervous System Agents B. Analgesics 1. Narcotic Agonist Analgesics


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.63 levorphanol Levo-Dromoran P O X63 meperidine -- G G X63 meperidine Demerol O O63 methadone -- G G X X63 methadone Dolophine O O X63 morphine sulfate -- G G X63 morphine sulfate MSIR O O63 morphine sulfate, controlled release -- G G X63 morphine sulfate, controlled release Kadian O O63 morphine sulfate, controlled release MS Contin O O63 opium tincture, deodorized -- G G63 oxycodone -- G G X63 oxycodone OxyIR O O63 oxycodone, controlled release Oxycontin P O63 oxycodone/ apap -- G G X63 oxycodone/ apap Percocet O O63 oxycodone/ apap Tylox O O63 oxycodone/ asa -- G G X63 oxycodone/ asa Percodan O O63 paregoric -- G G63 propoxyphene -- G G63 propoxyphene Darvon O O63 propoxyphene/ apap Wygesic O O63 propoxyphene/ asa/ caffeine -- G G63 propoxyphene/ asa/ caffeine Darvon Compound O O63 propoxyphene napsylate Darvon N O O63 propoxyphene napsylate/ apap -- G G63 propoxyphene napsylate/ apap Darvocet N O O6464 butorphanol -- G G64 butorphanol Stadol NS O O64 pentazocine/ apap Talacen O O

V. Central Nervous System Agents B. Analgesics 2. Narcotic Agonist-Antagonist Analgesics


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.64 pentazocine/ asa Talwin Compound O O64 pentazocine/ naloxone -- G G64 pentazocine/ naloxone Talwin NX O O6565 acetaminophen -- X

65 tramadol -- G G65 tramadol Ultram O O65 tramadol/ apap Ultracet O O6666 aspirin -- X66 aspirin, controlled release ZORprin O O66 aspirin, enteric coated Easprin O O66 choline salicyclate/ magnesium

salicylateTrilisate O O

66 diflunisal -- G G66 diflunisal Dolobid O O66 magnesium salicylate Magan O O66 magnesium salicylate Mobidin O O66 salsalate -- G G66 salsalate Disalcid O O66 salsalate Marthritic O O6767 butalbital/ apap Phrenilin O O67 butalbital/ apap Phrenilin Forte O O67 butalbital/ apap/ caffeine -- G G X67 butalbital/ apap/ caffeine Esgic O O67 butalbital/ apap/ caffeine Esgic Plus O O

V. Central Nervous System Agents B. Analgesics 4. Salicylates OTC considerations: aspirin, sodium salicylate, choline

V. Central Nervous System Agents B. Analgesics 5. Non-Narcotic Analgesic Combinations

V. Central Nervous System Agents B. Analgesics 3. Central Analgesics


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.67 butalbital/ apap/ caffeine Fioricet O O67 butalbital/ asa/ caffeine -- G G X67 butalbital/ asa/ caffeine Fiorinal O O6868 diclofenac potasium -- G G68 diclofenac potasium Cataflam O O68 diclofenac sodium, delayed release, oral -- G G

68 diclofenac sodium, delayed release, oral Voltaren O O

68 diclofenac sodium, extended release, oral

Voltaren XR O O

68 diclofenac/ misoprostol Arthrotec O O68 etodolac -- G G68 etodolac Lodine O O68 etodolac, extended release -- G G68 etodolac, extended release Lodine XL O O68 fenoprofen calcium -- G G68 fenoprofen calcium Nalfon O O68 flurbiprofen -- G G68 flurbiprofen Ansaid O O68 ibuprofen -- G G X68 ibuprofen Motrin O O68 indomethacin -- G G X68 indomethacin Indocin O O68 indomethacin, sustained release -- G G X68 indomethacin, sustained release Indocin SR O O68 ketoprofen -- G G68 ketoprofen Orudis O O68 ketoprofen, extended release -- G G68 ketoprofen, extended release Oruvail O O68 ketorolac, oral -- G G

V. Central Nervous System Agents B. Analgesics 6. Non-Steroidal Anti-inflammatory Agents (NSAIDs) a. Non-selective


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.68 ketorolac, oral Toradol O O68 meclofenamate sodium -- G G68 mefenamic acid Ponstel O O68 nabumetone -- G G68 nabumetone Relafen O O68 naproxen -- G G X68 naproxen Naprosyn O O68 naproxen sodium -- G G X68 naproxen sodium Anaprox O O68 naproxen sodium, controlled release Naprelan O O

68 oxaprozin -- G G68 oxaprozin Daypro O O68 piroxicam -- G G68 piroxicam Feldene O O68 sulindac -- G G

68 sulindac Clinoril O O68 tolmetin sodium -- G G68 tolmetin sodium Tolectin O O6969 celecoxib Celebrex P 22 O X 2269 rofecoxib Vioxx P 22 O X 2269 valdecoxib Bextra O 22 O7070 almotriptan Axert O 25 O 2570 frovatriptan Frova O 25 O 2570 naratriptan Amerge P 23 O 23 X 2370 rizatriptan Maxalt O 25 O 2570 rizatriptan Maxalt-MLT O 25 O 2570 sumatriptan Imitrex P 24 O 24 X 24

V. Central Nervous System Agents B. Analgesics 6. Non-Steroidal Anti-inflammatory Agents (NSAIDs) b. COX-2 selective

V. Central Nervous System Agents C. Abortive Agents for Migraine 1. 5HT-1 Receptor Agonists


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.70 zolmitriptan Zomig O 25 O 257171 dihydroergotamine mesylate Migranal O 20 O 2071 ergotamine tartrate Ergomar P O X71 ergotamine tartrate/ caffeine -- G G X71 ergotamine tartrate/ caffeine Cafergot O O71 ergotamine tartrate/ caffeine/ tartaric Wigraine suppositories O O71 isometheptene/ dichloralphenazone/

apap-- G G

71 isometheptene/ dichloralphenazone/ apap

Midrin O O

7272 chlorpromazine -- G G X X72 chlorpromazine Thorazine O O72 metoclopramide -- G G X72 metoclopramide Reglan O O72 perphenazine -- G G X X72 perphenazine Trilafon O O72 prochlorperazine edisylate, syrup Compazine Syrup P O X X72 prochlorperazine maleate, sustained Compazine Spansules O O72 prochlorperazine maleate, tablets -- G G X X72 prochlorperazine maleate, tablets Compazine O O72 promethazine, tablets and liquid -- G G X X

72 promethazine, suppositories Phenergan Suppositories P O X72 promethazine, tablets and liquid Phenergan O O72 thiethylperazine maleate Torecan O O7373 diphenhydramine -- G G X X73 diphenhydramine Benadryl O O73 meclizine -- G G X

V. Central Nervous System Agents C. Abortive Agents for Migraine 2. Other

V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 1. Anti-dopaminergics

V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 2. Anti-cholinergics OTC considerations: cyclizine


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.73 meclizine Antivert O O

73 scopolamine, trandsdermal Transderm-Scop O O73 trimethobenzamide -- G G73 trimethobenzamide Tigan O O7474 dronabinol Marinol O O7575 dolasetron mesylate Anzemet O O75 granisetron Kytril P O X75 ondansetron Zofran P O X75 ondansetron Zofran ODT P O X7676 alprazolam -- G G X 19 X76 alprazolam Xanax O O76 clorazepate dipotassium -- G G X 1976 clorazepate dipotassium Tranxene O O76 chlordiazepoxide -- G G X 1976 chlordiazepoxide Librium O O76 chlordiazepoxide/ amitriptyline -- G G76 chlordiazepoxide/ amitriptyline Limbitrol DS O O76 diazepam -- G G X 1976 diazepam Valium O O76 halazepam Paxipam O O76 lorazepam -- G G X 19 X76 lorazepam Ativan O O76 oxazepam -- G G76 oxazepam Serax O O76 prazepam -- G G7777 buspirone -- G G X X

V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 3. Other OTC consideration: phosphorated

V. Central Nervous System Agents D. Antiemetic/ Antivertigo agents 4. 5HT-3 Receptor Antagonists

V. Central Nervous System Agents E. Anti-Anxiety 1. Benzodiazepines

V. Central Nervous System Agents E. Anti-Anxiety 2. Other


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.77 buspirone Buspar O O77 chloral hydrate -- G G X 577 doxepin -- G G X X77 doxepin Sinequan O O77 hydroxyzine hcl -- G G X X77 hydroxyzine hcl Atarax O O77 hydroxyzine pamoate, capsules -- G G X X77 hydroxyzine pamoate, capsules Vistaril O O77 hydroxyzine pamoate, suspension Vistaril Suspension P O X X77 meprobamate -- G G77 meprobamate Equanil O O77 meprobamate Miltown O O7878 amitriptyline -- G G X X78 amitriptyline Elavil O O78 amitriptyline/ perphenazine -- G G X X78 amitriptyline/ perphenazine Etrafon O O78 amitriptyline/ perphenazine Triavil O O78 chlordiazepoxide/ amitriptyline -- G G78 chlordiazepoxide/ amitriptyline Limbitrol DS O O78 clomipramine -- G G X X78 clomipramine Anafranil O O78 doxepin -- G G X X78 doxepin Sinequan O O78 imipramine -- G G X X78 imipramine Tofranil O O78 imipramine pamoate Tofranil PM P O X X78 trimipramine maleate Surmontil P O X X7979 amoxapine -- G G X X79 amoxapine Asendin O O

V. Central Nervous System Agents F. Anti-depressants 1. Tricyclic compounds-Tertiary amines

V. Central Nervous System Agents F. Anti-depressants 2. Tricyclic compounds - Secondary amines


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.79 desipramine -- G G X X79 desipramine Norpramin O O79 nortriptyline -- G G X X79 nortriptyline Aventyl O O79 nortriptyline Pamelor O O79 protriptyline -- G G X X79 protriptyline Vivactil O O8080 maprotiline -- G G X X80 maprotiline Ludiomil O O80 mirtazapine -- G G X X80 mirtazapine Remeron O O80 mirtazapine -- G G X X80 mirtazapine Remeron Soltab O O8181 trazodone -- G G X X81 trazodone Desyrel O O8282 buproprion -- G G X X82 buproprion Wellbutrin O O82 buproprion, extended release Wellbutrin XL P P X X82 buproprion, sustained release Wellbutrin SR P P X X8383 venlafaxine Effexor O O X83 venlafaxine, extended release Effexor XR P P X X8484 nefazodone -- G G X84 nefazodone Serzone O O X8585 citalopram Celexa P P X X

V. Central Nervous System Agents F. Anti-depressants 3. Tetracyclics

V. Central Nervous System Agents F. Anti-depressants 7. Phenylpiperazine

V. Central Nervous System Agents F. Anti-depressants 4. Triazolopyridine

V. Central Nervous System Agents F. Anti-depressants 5. Aminoketone

V. Central Nervous System Agents F. Anti-depressants 6. Phenethylamine

V. Central Nervous System Agents F. Anti-depressants 8. Selective serotonin reuptake inhibitors


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.85 escitalopram Lexapro O O X85 fluoxetine -- G G X X85 fluoxetine Prozac O O85 fluvoxamine maleate -- G G X85 paroxetine Paxil P P X X85 paroxetine, controlled release Paxil CR P P X X85 sertraline Zoloft P P X X8686 isocarboxazid Marplan O O86 phenelzine sulfate Nardil P O X X86 tranylcypromine sulfate Parnate O O8787 promazine Sparine O O87 chlorpromazine -- G G X X87 chlorpromazine Thorazine O O8888 amitriptyline/ perphenazine -- G G X X88 amitriptyline/ perphenazine Etrafon O O88 amitriptyline/ perphenazine Triavil O O88 fluphenazine -- G G X X88 fluphenazine Prolixin O O88 fluphenazine deconoate, injectable -- X X88 perphenazine -- G G X88 perphenazine Trilafon O O88 prochlorperazine edisylate, syrup Compazine Syrup P O X X88 prochlorperazine maleate, sustained

releaseCompazine Spansules O O

88 prochlorperazine maleate, tablets -- G G X X88 prochlorperazine maleate, tablets Compazine O O88 trifluoperazine -- G G88 trifluoperazine Stelazine O O

V. Central Nervous System Agents F. Anti-depressants 9. Monoamine oxidase inhibitors

V. Central Nervous System Agents G. Anti-psychotic 1. Phenothiazines - aliphatic

V. Central Nervous System Agents G. Anti-psychotic 2. Phenothiazines - piperazine


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.8989 mesoridazine Serentil O O89 thioridazine -- G G X X89 thioridazine Mellaril O O9090 thiothixene -- G G X X90 thiothixene Navane O O9191 haloperidol -- G G X X91 haloperidol Haldol O O91 haloperidol decanoate, injectable -- X X9292 pimozide Orap O O9393 molindone Moban O O9494 loxapine -- G G94 loxapine Loxitane O O94 loxapine solution Loxitane C O O9595 aripiprazole Abilify P O X X95 clozapine -- G G95 clozapine Clozaril P O X95 olanzapine Zyprexa P O X X95 olanzapine Zyprexa Zydis O O X95 quetiapine fumarate Seroquel P O X X95 risperidone Risperdal P O X X95 risperidone Risperdal-M P O X X95 risperidone injection Risperdal Consta X95 ziprasidone Geodon P O X X96

V. Central Nervous System Agents G. Anti-psychotic 6. Diphenylbutylpiperadine

V. Central Nervous System Agents G. Anti-psychotic 8. Dibenzepine

V. Central Nervous System Agents G. Anti-psychotic 7. Dihydroindolones

V. Central Nervous System Agents G. Anti-psychotic 9. Atypicals

V. Central Nervous System Agents G. Anti-psychotic 10. Anti-manic agents

V. Central Nervous System Agents G. Anti-psychotic 5. Butyrophenone

V. Central Nervous System Agents G. Anti-psychotic 4. Thioxanthenes

V. Central Nervous System Agents G. Anti-psychotic 3. Phenothiazines - piperidine


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.96 lithium carbonate -- G G X X96 lithium carbonate Eskalith O O96 lithium carbonate Lithotabs O O96 lithium carbonate, controlled release Eskalith CR P O X X

96 lithium carbonate, slow release -- G G X X96 lithium carbonate, slow release Lithobid P O X X96 lithium citrate -- G G X X9797 donepezil Aricept P O X97 galantamine Reminyl O O97 rivastigmine Exelon O O97 tacrine Cognex O O9898 estazolam -- G G

98 estazolam Prosom O O98 flurazepam -- G G98 flurazepam Dalmane O O98 quazepam Doral O O98 temazepam -- G G98 temazepam Restoril O O98 triazolam -- G G98 triazolam Halcion O O9999 acetylcarbromal Paxarel O O99 chloral hydrate -- G G X 599 ethchlorvynol Placidyl O O99 zaleplon Sonata O O99 zolpidem tartrate Ambien P O

100

V. Central Nervous System Agents H. Cholinesterase inhibitors

V. Central Nervous System Agents I. Sedatives and hypnotics, non-barbiturates 1. Benzodiazepines

V. Central Nervous System Agents I. Sedatives and hypnotics, non-barbiturates 2. Other OTC considerations: doxylamine

V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 1. Long-acting


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.100 mephobarbital Mebaral P O X 26100 phenobarbital -- G G X 26101101 butabarbital sodium Butisol Sodium O O102102 pentobarbital Nembutal O O102 secobarbital sodium Seconal O O103103 ethotoin Peganone O O103 mephenytoin Mesantoin O O103 phenytoin -- G G X103 phenytoin Dilantin Infatab P O X103 phenytoin Dilantin 125 P O X103 phenytoin sodium, extended release -- G G X103 phenytoin sodium, extended release Dilantin Kapseals P O X104104 ethosuximide Zarontin P O X104 methsuximide Celontin Kapseals P O X105105 trimethadione Tridione P O X106106 chlorazepate dipotassium -- G G X 19106 chlorazepate dipotassium Tranxene O O106 clonazepam -- G G X 19 X106 clonazepam Klonopin P O X 19 X106 diazepam -- G G X 19106 diazepam Valium O O106 diazepam, rectal Diastat P O X107107 acetazolamide -- G G X107 acetazolamide Diamox O O

V. Central Nervous System Agents K. Anticonvulsants 5. Other

V. Central Nervous System Agents K. Anticonvulsants 2. Succinimides

V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 3. Short-acting

V. Central Nervous System Agents K. Anticonvulsants 1. Hydantoins

V. Central Nervous System Agents K. Anticonvulsants 3. Oxazolidinediones

V. Central Nervous System Agents K. Anticonvulsants 4. Benzodiazepines

V. Central Nervous System Agents J. Sedatives and hypnotics, barbiturates 2. Intermediate-acting


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.107 carbamazepine -- G G X X107 carbamazepine Tegretol P O X X107 carbamazepine, extended release Carbatrol O O107 carbamazepine, extended release Tegretol XR P O X X107 divalproex sodium Depakote P O X X107 divalproex sodium, extended release Depakote ER P O X X107 felbamate Felbatol P O X107 gabapentin Neurontin P O X X107 lamotrigine Lamictal P O X X107 levetiracetam Keppra P O X X107 primidone -- G G X107 primidone Mysoline P O X107 tiagabine Gabatril P O X107 topiramate Topamax P O X X107 oxcarbazepine Trileptal P O X X107 valproic acid -- G G X X107 valproic acid Depakene P O X X107 zonisamide Zonegran P O X108108 baclofen -- G G X108 baclofen Lioresal O O108 carisoprodol -- G G X108 carisoprodol Soma O O108 carisoprodol/ asa -- G G108 carisoprodol/ asa Soma Compound O O108 carisoprodol/ asa/ codeine -- G G108 carisoprodol/ asa/ codeine Soma Compound w/

CodeineO O

108 chlorphenesin carbamate Maolate O O108 chlorzoxazone -- G G X108 chlorzoxazone Parafon Forte DSC O O108 cyclobenzaprine -- G G X

V. Central Nervous System Agents L. Skeletal muscle relaxants 1. Centrally acting


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.108 cyclobenzaprine Flexeril O O108 diazepam -- G G X 19108 diazepam Valium O O108 metaxalone Skelaxin O O108 methocarbamol -- G G X108 methocarbamol Robaxin O O108 methocarbamol/ asa -- G G108 methocarbamol/ asa Robaxisal O O108 orphenadrine citrate -- G G108 orphenadrine citrate Norflex O O108 orphenadrine/ asa/ caffeine Norgesic Forte O O108 orphenadrine/ asa/ caffeine Norgesic O O108 tizanidine -- G G108 tizanidine Zanaflex O O109109 dantrolene Dantrium O O110110 benztropine -- G G X X110 benztropine Cogentin O O110 biperiden Akineton O O110 diphenhydramine -- G G X X110 diphenhydramine Benadryl O O110 procyclidine Kemadrin O O X110 trihexyphenidyl -- G G X X110 trihexyphenidyl Artane O O111111 amantadine -- G G X X111 amantadine Symmetrel O O111 bromocriptine Parlodel P O X111 carbidopa Lodosyn O O111 entacapone Comtan O O

V. Central Nervous System Agents L. Skeletal muscle relaxants 2. Direct acting

V. Central Nervous System Agents M. Antiparkinson agents 1. Anti-cholinergics

V. Central Nervous System Agents M. Antiparkinson agents 2. Other


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.111 levodopa Larodopa O O111 levodopa Dopar O O111 levodopa/ carbidopa -- G G X111 levodopa/ carbidopa Sinemet O O111 levodopa/ carbidopa, sustained release -- G G X

111 levodopa/ carbidopa, sustained release Sinemet CR O O

111 pergolide -- G G X111 pergolide Permax O O111 pramipexole Mirapex P O X111 ropinirole Requip P O X111 selegiline -- G G X111 selegiline Eldepryl O O111 tolcapone Tasmar O O112112 ambenonium chloride Mytelase O O112 guanidine hcl Guanidine O O112 neostigmine Prostigmin O O112 pyridostigmine bromide Mestinon P O X113

113 disulfiram Antabuse P O X X114114 methadone -- G G X X114 methadone Dolophine O O115115 naltrexone Depade O O115 naltrexone ReVia P O X X116116 bupropion, extended release Zyban P O X X

V. Central Nervous System Agents O. Agents for dependency and withdrawal 4. Nicotine OTC considerations: nicotine,

V. Central Nervous System Agents O. Agents for dependency and withdrawal 2. Narcotic agonists

V. Central Nervous System Agents O. Agents for dependency and withdrawal 3. Narcotic antagonists

V. Central Nervous System Agents N. Cholinergic muscle stimulants

V. Central Nervous System Agents O. Agents for dependency and withdrawal 1. Alcohol


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.116 nicotine, inhaler Nicotrol inhaler O O116 nicotine, nasal spray Nicotrol NS O O116 nicotine, transdermal -- G 2 G 2 X X117117 atomoxetine Strattera O O X117 ergoloid mesylates Hydergine O O117 ergoloid mesylates Hydergine LC O O117 ergoloid mesylates, sublingual -- G G117 ergoloid mesylates, sublingual Hydergine O O117 riluzole -- G G X117 riluzole Rilutek P O X118118 conjugated estrogens Premarin P O X118 esterified estrogens Menest O O118 esterified estrogens/ methyltestosterone Estratest P O X

118 esterified estrogens/ methyltestosterone Estratest HS P O X

118 estradiol -- G G X118 estradiol Estrace O O118 estropipate -- G G X118 estropipate Ogen O O118 estropipate Ortho-EST G G X118 ethinyl estradiol Estinyl O O118 synthetic conjugated estrogens Cenestin O O119119 conjugated estrogens, vaginal Premarin P O X119 dienestrol, vaginal Ortho Dienestrol O O119 estradiol hemihydrate Vagifem O O119 estradiol, transdermal -- G G X119 estradiol, transdermal Alora O O

VI. Endocrine/Metabolic A. Sex Hormones 1. Estrogens a. Oral

VI. Endocrine/Metabolic A. Sex Hormones 1. Estrogens b. Other

V. Central Nervous System Agents P. Other


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.119 estradiol, transdermal Climara O O119 estradiol, transdermal Esclim O O119 estradiol, transdermal Estraderm O O119 estradiol, transdermal FemPatch O O119 estradiol, transdermal Vivelle O O119 estradiol, vaginal Estrace P O X119 estradiol, vaginal Estring O O119 estropipate, vaginal Ogen O O120120 raloxifene Evista P O X121121 medroxyprogesterone acetate -- G G X121 medroxyprogesterone acetate Amen O O121 medroxyprogesterone acetate Curretab O O121 medroxyprogesterone acetate Provera O O121 norethindrone acetate -- G G121 norethindrone acetate Aygestin O O121 progesterone, micronized Prometrium P O X122122 conjugated estrogens/

medroxyprogesteronePremphase P O X

122 conjugated estrogens/ Prempro P O X122 conjugated estrogens/

medroxyprogesteronePrempro Low Dose P O X

122 estradiol/ norethindrone acetate Activella O O122 estradiol/ norethindrone acetate,

transdermalCombipatch O O

122 ethinyl estradiol/ norethindrone acetate Femhrt O O123123 ethinyl estradiol/ levonorgestrel Alesse P 3 P 3 X X X123 ethinyl estradiol/ desogestrel Desogen P 3 P 3 X X X

VI. Endocrine/Metabolic A. Sex Hormones 2. Selective Estrogen Receptor Modulator (SERM)

VI. Endocrine/Metabolic A. Sex Hormones 3. Progestins a. Oral

VI. Endocrine/Metabolic A. Sex Hormones 4. Estrogen/progestin combination

VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives a. Monophasic


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.123 ethinyl estradiol/ drospirenone Yasmin P 3 P 3 X X X124124 ethinyl estradiol/ desogestrel Mircette P 3 P 3 X X X125125 ethinyl estradiol/ levonorgestrel Tri-Levlen P 3 P 3 X X X126126 norethindrone Nor-QD P 3 P 3 X X X127127 levonorgestrel Plan B P X127 ethinyl estradiol/ levonorgestrel Preven O X128128 ethinyl estradiol/ levonorgestrel Nuvaring O O X128 ethinyl estradiol/ norelgestromin OrthoEvra O O X128 medroxyprogesterone acetate, injectable Depo-Provera X X

129129 esterified estrogens/ methyltestosterone Estratest HS P O X129 esterified estrogens/ methyltestosterone Estratest P O X

129 fluoxymesterone Halotestin P O X129 methyltestosterone Android P O X129 methyltestosterone Testred O O130130 testosterone, gel Androgel O O130 testosterone, transdermal Androderm P O X130 testosterone, transdermal Testoderm O O131131 finasteride Proscar P O X132132 oxandrolone Oxandrin P O X

VI. Endocrine/Metabolic A. Sex Hormones 8. Androgens b. Other

VI. Endocrine/Metabolic A. Sex Hormones 9. Androgen hormone inhibitor

VI. Endocrine/Metabolic B. Anabolic steroids

VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives b. Biphasic

VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives c. Triphasic

VI. Endocrine/Metabolic A. Sex Hormones 7. Other contraceptives

VI. Endocrine/Metabolic A. Sex Hormones 8. Androgens a. Oral

VI. Endocrine/Metabolic A. Sex Hormones 5. Oral Contraceptives d. Progetin-only

VI. Endocrine/Metabolic A. Sex Hormones 6. Emergency Contraceptives


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.132 oxymetholone Anadrol O O132 stanozolol Winstrol P O X133133 alprostadil Caverject O O133 alprostadil Muse O O133 clomiphene -- G 2 G 2133 clomiphene Serophene O 2 O 2133 clomiphene Clomid O 2 O 2133 progesterone, vaginal 8% Crinone 8% O 2 O 2133 sildenafil Viagra O 2 O 2133 yohimbine -- G 2 G 2133 yohimbine Yocon O 2 O 2134134 nafarelin Synarel P O X135135 danazol -- G G X135 danazol Danocrine P O X136136 carteolol Cartrol O O136 desmopressin, nasal Stimate P O X136 desmopressin, nasal DDAVP P O X136 desmopressin, oral DDAVP P O X137137 fludrocortisone -- G G X137 fludrocortisone Florinef O O138138 betamethasone Celestone O O138 budesonide Entocort EC O O138 cortisone acetate Cortisone O O X138 dexamethasone -- G G X138 dexamethasone Decadron O O

VI. Endocrine/Metabolic E. Danazol

VI. Endocrine/Metabolic G. Adrenal cortical steroids 1. Mineralocorticoids

VI. Endocrine/Metabolic G. Adrenal cortical steroids 2. Glucocorticoids a. Oral

VI. Endocrine/Metabolic C. Agents for infertility/impotence

VI. Endocrine/Metabolic D. Gonadotropin releasing hormone

VI. Endocrine/Metabolic F. Posterior pituitary hormones


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.138 hydrocortisone -- G G X138 hydrocortisone Cortef O O138 methylprednisolone -- G G138 methylprednisolone Medrol O O138 prednisolone -- G G X138 prednisolone Prelone O O138 prednisolone sodium phosphate, oral Orapred P O X

138 prednisolone sodium phosphate, oral Pediapred O O

138 prednisone -- G G X138 prednisone Liquid Pred P O X138 prednisone Orasone G G X138 triamcinolone Aristocort O O139139 hydrocortisone Cortenema P O X139 hydrocortisone Proctocort O O X139 hydrocortisone acetate -- G G X 14139 hydrocortisone acetate Anusol HC O O139 hydrocortisone acetate Cortifoam O O139 hydrocortisone acetate/ pramoxine Analpram HC O O X139 hydrocortisone acetate/ pramoxine Proctocream-HC O O X139 hydrocortisone acetate/ pramoxine Proctofoam-HC O O X140140 aminoglutethimide Cytadren P O X141141 acarbose Precose P P X141 miglitol Glyset P P X141 nateglinide Starlix P O X142142 repaglinide Prandin P O X

VI. Endocrine/Metabolic H. Adrenal steroid inhibitor

VI. Endocrine/Metabolic I. Antidiabetic agents 1. Alpha-glucoside inhibitor

VI. Endocrine/Metabolic G. Adrenal cortical steroids 2. Glucocorticoids b. Rectal

VI. Endocrine/Metabolic I. Antidiabetic agents 2. Meglitinides


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.143143 human insulin lispro Humalog G G X143 human insulin lispro Humalog 50/50 G G X143 human insulin lispro Humalog 75/25 G G X143 human 50/ 50 insulin Humulin 50/50 G G X143 human 70/ 30 insulin Humulin 70/30 G G X143 human lente insulin Humulin L G G X143 human NPH insulin Humulin N G G X143 human regular insulin Humulin R G G X143 human ultralente insulin Humulin U Ultralente G G X143 insulin glargine Lantus G G X143 human 70/ 30 insulin Novolin 70/30 G G X143 human 70/ 30 insulin Novolin 70/30 Penfill G G X143 human 70/ 30 insulin Novolin 70/30 Prefilled G G X143 human NPH insulin Novolin N G G X143 human NPH insulin Novolin N Penfill G G X143 human NPH insulin Novolin N Prefilled G G X143 human regular insulin Novolin R G G X143 human regular insulin Novolin R Penfill G G X143 human regular insulin Novolin R Prefilled G G X143 human insulin aspart Novolog G G X143 human insulin Novolog mix G G X143 human regular insulin Velosulin Human BR G G X144144 acetohexamide -- G G X144 acetohexamide Dymelor O O144 chlorpropamide -- G G X144 chlorpropamide Diabinese O O144 glimepiride Amaryl O O144 glipizide -- G G X144 glipizide Glucotrol O O144 glipizide, extended release -- G G X

VI. Endocrine/Metabolic I. Antidiabetic agents 3. Human Insulin

VI. Endocrine/Metabolic I. Antidiabetic agents 4. Sulfonylureas


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.144 glipizide, extended release Glucotrol XL O O144 glyburide -- G G X144 glyburide Diabeta O O144 glyburide Micronase O O144 glyburide, micronized -- G G X144 glyburide, micronized Glynase O O144 glyburide/ metformin Glucovance P O X144 tolazamide -- G G X144 tolazamide Tolinase O O144 tolbutamide -- G G X144 tolbutamide Orinase O O145145 metformin -- G G X145 metformin Glucophage O O145 metformin, extended release -- G G X145 metformin, extended release Glucophage XR O O146146 pioglitazone Actos P O X146 rosiglitazone Avandia P O X146 rosiglitazone/ metformin Avandamet P O X147147 insulin injector Novopen G G X147 insulin needles Novofine G G X147 insulin needles Novofine 30 G G X147 SMBG test strips Fast Take test strips G G X147 SMBG test strips One Touch test strips G G X147 SMBG test strips One Touch Ultra test strips G G X

147 SMBG test strips Surestep test strips G G X148148 glucagon Glucagon Emergency Kit P O X

VI. Endocrine/Metabolic I. Antidiabetic agents 7. Other

VI. Endocrine/Metabolic J. Glucose elevating agents

VI. Endocrine/Metabolic I. Antidiabetic agents 6. Thiazolidinediones

VI. Endocrine/Metabolic I. Antidiabetic agents 5. Biguanides


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.149149 levothyroxine sodium -- G G X149 levothyroxine sodium Levothroid P O X149 levothyroxine sodium Synthroid P O X149 liothyronine sodium Cytomel P O X149 liothyronine sodium/ levothyroxine Thyrolar P O X149 thyroid, desiccated -- G G X149 thyroid, desiccated Armour Thyroid P O150150 methimazole -- G G X150 methimazole Tapazole O O150 propylthiouracil -- G G X151151 calcitonin-salmon, nasal Miacalcin O O152152 alendronate Fosamax P O X152 etidronate -- G G152 etidronate Didronel O O152 risedronate Actonel P O X152 tiludronate Skelid O O

153153 allopurinol -- G G X153 allopurinol Zyloprim O O153 colchicine 0.5mg -- O O153 colchicine 0.6mg -- G G X153 colchicine/ probenecid -- G G X153 probenecid -- G G X153 sulfinpyrazone -- G G153 sulfinpyrazone Anturane O O

VI. Endocrine/Metabolic K. Thyroid drugs 1. Thyroid hormones

VI. Endocrine/Metabolic K. Thyroid drugs 2. Antithyroid agents

VI. Endocrine/Metabolic L. Calcitonin-salmon

VI. Endocrine/Metabolic M. Bisphosphonates

VI. Endocrine/Metabolic N. Agents for Gout


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.154154 cabergoline Dostinex P O X155155 aluminum hydroxide/ magnesium

hydroxide-- X

155 aluminum hydroxide/ magnesium hydroxide/ simethicone

-- X

155 calcium carbonate -- X155 magnesium hydroxide -- X155 sodium bicarbonate -- X156156 sucralfate -- G G X156 sucralfate Carafate O O157157 atropine sulfate Sal-Tropine O O157 belladona tincture Belladonna Tincture O O157 belladonna alkaloids/ phenobarbital -- G G157 belladonna alkaloids/ phenobarbital Donnatal O O157 belladonna extract/ butabarbital sodium Butibel O O

157 clidinium bromide Quarzan O O157 clidinium/ chlordiazepoxide -- G G157 clidinium/ chlordiazepoxide Librax O O157 l-alkaloids of belladonna/ phenobarbital/

ergotamine-- G G

157 l-alkaloids of belladonna/ phenobarbital/ ergotamine

Bellergal-S O O

157 l-hyoscyamine sulfate -- G G157 l-hyoscyamine sulfate Levsin O O157 l-hyoscyamine sulfate, extended release Levbid O O

VII. Gastrointestinals B. Sucralfate

VII. Gastrointestinals C. Anticholinergics/antispasmodics 1. Belladonna alkaloids

VII. Gastrointestinals A. Antacids OTC considerations: aluminum hydroxide gel (Amphojel), calcium carbonate (Tums),

VI. Endocrine/Metabolic O. Other


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.157 l-hyoscyamine sulfate, sublingual Levsin/SL O O157 l-hyoscyamine sulfate, timed release Levsinex Timecaps O O157 methscopolamine bromide Pamine O O158158 glycopyrrolate Robinul O O158 glycopyrrolate Robinul Forte O O

158 mepenzolate bromide Cantil O O158 methantheline bromide Banthine O O158 propantheline bromide -- G G158 propantheline bromide Pro-Banthine O O159159 dicyclomine -- G G X159 dicyclomine, syrup Bentyl Syrup P O X159 dicyclomine, tablets and capsules Bentyl O O160160 bismuth subsalicylate/ metronidazole/

tetracyclineHelidac P O X

160 lansoprazole/ amoxicillin/ clarithromycin

Prevpac P O X

161161 famotidine -- G G161 famotidine Pepcid O O161 ranitidine -- G G X161 ranitidine, tablets and capsules Zantac O O161 ranitidine syrup Zantac Syrup P O X161 cimetidine -- G G X161 cimetidine Tagamet O O161 nizatidine -- G G161 nizatidine Axid O O

VII. Gastrointestinals C. Anticholinergics/antispasmodics 2. Anticholinergics

VII. Gastrointestinals C. Anticholinergics/antispasmodics 3. Anti-spasmodics

VII. Gastrointestinals D. Combination Helicobacter Pylori agents

VII. Gastrointestinals E. Histamine (H2) antagonists OTC considerations: cimetidine (Tagamet HB), ranitidine (Zantac 75),


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.162162 diclofenac/ misoprostol Arthrotec O O162 misoprostol -- G G X162 misoprostol Cytotec O O163163 lansoprazole Prevacid O O163 lansoprazole Prevacid Granules O O163 omeprazole -- G G163 omeprazole Prilosec O O163 pantoprazole Protonix P P X 15163 rabeprazole sodium Aciphex P P X 15164164 simethicone -- X

165165 metoclopramide -- G G X165 metoclopramide Reglan O O166166 pancreatin Creon O O166 pancrelipase Pancrease O O166 pancrelipase Pancrease MT O O166 pancrelipase Ultrase MT O O166 pancrelipase Viokase/Cotazym P O X167167 ursodiol -- G G X167 ursodiol Actigall O O168168 bisacodyl -- X

VII. Gastrointestinals F. Prostaglandins

VII. Gastrointestinals H. Antiflatulents OTC consideration: simethicone

VII. Gastrointestinals K. Gallstone solubilizing agents

VII. Gastrointestinals L. Laxatives OTC considerations: magnesium hydroxide (Milk of Magnesia), magnesium citrate,

VII. Gastrointestinals G. Proton pump inhibitors

VII. Gastrointestinals I. GI stimulants

VII. Gastrointestinals J. Digestive enzymes


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.168 docusate sodium -- X168 docusate sodium/ casanthranol -- X168 glycerin -- X

168 magnesium citrate -- X168 magnesium hydroxide -- X168 psyllium -- X168 senna -- X168 sodium phosphate, enema -- X168 Sodium phosphate, oral solution Fleets Phospho - Soda X168 lactulose -- G G X168 lactulose Cephulac O O168 lactulose Chronulac O O168 polyethylene glycol-electrolyte solution -- G G X

168 polyethylene glycol-electrolyte solution CoLyte O O

168 polyethylene glycol-electrolyte solution GoLYTELY O O

169169 attapulgite -- X169 bismuth subsalicylate -- X169 diphenoxylate/ atropine sulfate -- G G169 diphenoxylate/ atropine sulfate Lomotil O O169 kaolin/ pectin -- X169 loperamide -- G G X169 loperamide Imodium O O169 paregoric -- G G170170 chlorhexidine gluconate -- G G X170 chlorhexidine gluconate Peridex O O

VII. Gastrointestinals M. Antidiarrheals OTC consideraitons: loperamide (Imodium AD), bismuth subsalicylate (Pepto-Bismol),

VII. Gastrointestinals N. Mouth and throat products 1. Antimicrobial


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.170 clotrimazole Mycelex Troches P O X170 doxycycline hyclate Periostat O O170 nystatin -- G G X170 nystatin Mycostatin O O171171 pilocarpine, oral Salagen O O172172 amlexanox Aphthasol O O172 lidocaine, viscous -- G G X172 lidocaine, viscous Xylocaine O O172 triamcinolone paste -- G G X172 triamcinolone paste Kenalog in Orabase O O173173 activated charcoal -- X173 ipecac syrup -- X173 mesalamine, controlled release Pentasa O O173 mesalamine, delayed release Asacol P O X173 mesalamine, rectal Rowasa P O X173 olsalazine sodium Dipentum O O173 sulfasalazine -- G G X173 sulfasalazine Azulfidine O O173 sulfasalazine, enteric coated -- G G173 sulfasalazine, enteric coated Azulfidine EN-tabs O O174174 thiamine -- X 27 X 27174 cyanocobalamin, nasal Nascobal P 11 O 11 X 11174 vitamin B complex -- X 27 X 27175175 calcitriol -- G G X175 calcitriol Rocaltrol O O176

VIII. Nutritionals A. Vitamins 1. Vitamin B

VIII. Nutritionals A. Vitamins 3. Vitamin K

VIII. Nutritionals A. Vitamins 2. Vitamin D

VII. Gastrointestinals O. Other

VII. Gastrointestinal N. Mouth and throat products 2. Saliva substitutes

X. Gastrointestinal N. Mouth and throat products 3. Other


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.176 phytonadione Mephyton P O X177177 multivitamins -- X 6177 multivitamins/ minerals -- G 7 G 7 X 6177 prenatal vitamins -- G 2 G 2 X 28177 prenatal vitamins Materna O 2 O 2177 prenatal vitamins Stuartnatal Plus O 2 O 2

177 vitamin B complex/ vit C/ vit E/ folate Renal Tabs P 12 O 12 X 12

178178 cellulose sodium phosphate Calcibind P O X179179 multivitamins with fluoride -- G 2 G 2 X 6179 multivitamins with fluoride Poly-Vi-Flor O 2 O 2

179 multivitamins with fluoride, prescription

Tri-Vi-Flor O 2 O 2

179 sodium fluoride -- G G X 5179 sodium fluoride Luride O O179 sodium fluoride Prevident O O180180 succimer Chemet P O X181181 trientine Syprine O 2 O 2181 ferrous sulfate -- X181 iron/ multivit/ mineral, prescription -- G 2 G 2181 iron/ multivit/ mineral, prescription Berocca Plus O 2 O 2

VIII. Nutritionals B. Minerals and electrolytes 2. Fluoride

VIII. Nutritionals B. Minerals and electrolytes 3. Chelating Agents

VIII. Nutritionals B. Minerals and electrolytes 4. Iron preparations OTC considerations: ferrous sulfate, ferrous

VIII. Nutritionals A. Vitamins 4. Multivitamins

VIII. Nutritionals B. Minerals and electrolytes 1. Calcium-removing resins


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.181 iron/ vit c/ vit b12/ intrinsic factor/

folateTrinsicon O 2 O 2

182182 calcium acetate Phoslo P 12 O 12 X 12182 calcium carbonate -- X182 sevelamer Renagel P O X183183 potassium bicarb/ citrate -- G G183 potassium bicarb/ citrate K Lyte DS O O183 potassium bicarb/ citrate K Lyte O O183 potassium chloride -- G G X183 potassium chloride K-Dur O O183 potassium chloride K-Lor O O183 potassium chloride K-Tab O O183 potassium chloride Micro K O O183 potassium chloride/ potassium bicarb/

citrate-- G G

183 potassium chloride/ potassium bicarb/ citrate

K Lyte Cl O O

183 potassium gluconate -- G G183 potassium gluconate Kaon O O184184 sodium polystyrene sulfonate -- G G X184 sodium polystyrene sulfonate Kayexalate O O185185 potassium citrate/ citric acid Polycitra K P O X185 potassium citrate/ sodium citrate/ citric Polycitra P O X185 potassium citrate/ sodium citrate/ citric

acidPolycitra LC O O

185 sodium bicarbonate -- X185 sodium citrate/ citric acid Bicitra P O X

VIII. Nutritionals C. Systemic alkalinizers OTC consideration: sodium bicarbonate

VIII. Nutritionals B. Minerals and electrolytes 5. Phosphorus-reducing agents OTC consideration: calcium carbonate

VIII. Nutritionals B. Minerals and electrolytes 6. Potassium replacement

VIII. Nutritionals B. Minerals and electrolytes 7. Potassium-removing resin


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.185 sodium citrate/ citric acid Oracit O O186186 levocarnitine Carnitor P 13 O 13 X 13187187 pediatric electrolyte replacement

solution-- X

188188 albuterol -- G G X188 albuterol Proventil O O188 albuterol Ventolin O O188 albuterol, extended release -- G G X188 albuterol, extended release Volmax O O188 metaproterenol sulfate -- G G X188 metaproterenol sulfate Alupent O O188 terbutaline sulfate Brethine P O X188 terbutaline sulfate Bricanyl O O X189189 albuterol -- G G X189 albuterol Proventil O O189 albuterol Proventil HFA O O189 albuterol Ventolin O O189 albuterol Ventolin HFA O O189 albuterol/ ipratropium Combivent P O X189 bitolterol mesylate Tornalate O O189 isoetharine -- O O189 isoproterenol Isuprel O O189 levalbuterol Xopenex O O189 metaproterenol sulfate, inhalation -- G G X189 metaproterenol sulfate, inhalation Alupent O O189 metaproterenol sulfate, metered dose

inhalerAlupent MDI P O X

IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics b. Inhalation-short-acting

VIII. Nutritionals D. Levocarnitine

VIII. Nutritionals E. Electrolyte replacement

IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics a. Oral


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.189 pirbuterol acetate Maxair P O X189 pirbuterol acetate Maxair Auto P O X189 terbutaline sulfate Brethaire P O X190190 formoterol Foradil O O190 salmeterol/ fluticasone Advair P O X190 salmeterol Serevent P O X191191 epinephrine, injectable Epi-pen P O X191 epinephrine, injectable Epi-pen JR P O X191 epinephrine/ chlorpheniramine Anakit P O X192192 albuterol/ ipratropium Combivent P O X192 ipratropium, inhalation -- G G X192 ipratropium, inhalation Atrovent O O192 ipratropium, inhalation Atrovent MDI P O X193193 aminophylline -- G G 193 oxtriphylline Choledyl O O193 theophylline, capsules Bronkodyl O O193 theophylline, capsules Elixophyllin O O193 theophylline, liquid -- G G X193 theophylline, liquid Elixophyllin O O193 theophylline, liquid Slo-Phyllin O O193 theophylline, liquid Theolair O O193 theophylline, tablets -- G G X193 theophylline, tablets Quibron-T O O193 theophylline, tablets Slo-Phyllin O O193 theophylline, tablets Theolair O O193 theophylline, timed release capsules -- G G X193 theophylline, timed release capsules Elixophyllin SR O O

IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics c. Inhalation-long-acting

IX. Respiratory Drugs A. Bronchodilators 2. Anticholinergics

IX. Respiratory Drugs B. Xanthine derivatives

IX. Respiratory Drugs A. Bronchodilators 1. Sympathomimetics d. Injection


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.193 theophylline, timed release capsules Slo-Bid O O193 theophylline, timed release capsules Slo-Bid 50mg and 75mg P O X193 theophylline, timed release capsules Slo-Phyllin Gyrocaps O O193 theophylline, timed release capsules Theo-24 P O X193 theophylline, timed release capsules Theo-Dur Sprinkle O O193 theophylline, timed release tablets -- G G193 theophylline, timed release tablets Theochron G G X193 theophylline, timed release tablets T-Phyl O O193 theophylline, timed release tablets Unidur O O193 theophylline, timed release tablets Uniphyl O O193 theophylline/ ephedrine/ hydroxyzine

hclMarax O O

194194 montelukast sodium Singulair P 30 O X 30194 zafirlukast Accolate P 30 O X 30194 zileuton Zyflo P 30 O X 30195195 beclomethasone, inhaler QVAR O O195 budesonide, inhaler Pulmicort P O X195 budesonide, respules Pulmicort respules P P X195 flunisolide, inhaler Aerobid P P X195 flunisolide, inhaler Aerobid M P P X195 fluticasone, inhaler Flovent P O X195 triamcinolone, inhaler Azmacort O O195 salmeterol/ fluticasone Advair P O X196196 cromolyn sodium, inhalation -- G G X196 cromolyn sodium, inhalation Intal O O196 cromolyn sodium, metered dose inhaler Intal MDI P O X

196 nedocromil, inhaler Tilade O O

IX. Respiratory Drugs D. Anti-inflammatory agents 1. Corticosteroids

IX. Respiratory Drugs C. Leukotriene receptor antagonists

IX. Respiratory Drugs D. Anti-inflammatory agents 2. Non-steroidal


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.197197 peak flow meter Air Zone P 3 P 3 X197 spacer Aerochamber P 3 P 3 X

197 spacer E-Z Spacer P 3 P 3 X197 spacer Vortex P 3 P 3 X198198 acetylcysteine -- G G X198 acetylcysteine Mucomyst O O198 dornase alfa Pulmozyme O O198 pentamidine, inhalation Nebupent P O X198 sodium chloride, inhalation -- G G X198 tobramycin, inhalation TOBI P O X199199 pseudoephedrine -- X199 phenylephrine AH-Chew D G G X200200 phenylephrine -- X200 oxymetazoline -- X

201201 ipratropium, nasal -- G G X201 ipratropium, nasal Atrovent O O202

202 beclomethasone Beconase AQ O O202 budesonide Rhinocort AQ P O X202 flunisolide, nasal -- P O X202 fluticasone Flonase P O X202 mometasone Nasonex P O X

IX. Respiratory Drugs G. Decongestants 2. Intranasol OTC considerations: phenylephrine hcl (Neo-Synephrine),

IX. Respiratory Drugs H. Intranasal anticholinergic agents

IX. Respiratory Drugs I. Intranasal anti-inflammatory agents 1. Corticosteroids

IX. Respiratory Drugs G. Decongestants 1. Oral OTC considerations: pseudoephedrine (Sudafed)

IX. Respiratory Drugs E. Devices

IX. Respiratory Drugs F. Other inhalation drugs


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.202 triamcinolone Nasacort P O X202 triamcinolone Nasacort AQ P O X203

203 cromolyn sodium Nasalcrom X204204 azelastine Astelin P O X205205 cetirizine, syrup Zyrtec syrup P P X205 cetirizine, tablets Zyrtec tablet O O205 cetirizine/ pseudoephedrine Zyrtec D O O205 desloratadine Clarinex O O205 fexofenadine Allegra P P X205 fexofenadine/ pseudoephedrine Allegra D P P X205 loratadine -- X206206 azatadine Optimine O O206 chlorpheniramine -- X206 clemastine -- G G X206 clemastine Tavist O O206 cyproheptadine -- G G X206 cyproheptadine Periactin O O206 dexchlorpheniramine Polaramine O O

206 diphenhydramine -- G G X X206 diphenhydramine Benadryl O O206 hydroxyzine hcl -- G G X X206 hydroxyzine hcl Atarax O O

IX. Respiratory Drugs K. Antihistamines 2. Sedating Antihistamines OTC considerations: diphenhydramine (Benadryl),

IX. Respiratory Drugs J. Intranasal antihistamine

IX. Respiratory Drugs I. Intranasal anti-inflammatory agents 2. Non-steroidal OTC consideration: cromolyn sodium (Nasalcrom)

IX. Respiratory Drugs K. Antihistamines 1. Non-Sedating/Low-Sedating Antihistamines OTC consideration: loratadine


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.206 hydroxyzine pamoate, capsules -- G G X X206 hydroxyzine pamoate, capsules Vistaril O O206 hydroxyzine pamoate, suspension Vistaril suspension P O X X206 promethazine -- G G X206 promethazine Phenergan O O206 tripelennamine -- G G206 tripelennamine PBZ O O

207207 phenylephrine/ chlorpheniramine/

methscopolamine-- G G

207 phenylephrine/ chlorpheniramine/ Dura-Vent/DA O O207 phenylephrine/ chlorpheniramine/

methscopolamineOMNIhist LA G G

207 phenylephrine/ chlorpheniramine/ pyrilamine, tablets

-- G G X


Rynatan O O

207 pseudoephedrine/ azatadine Trinalin O O207 pseudoephedrine/ brompheniramine -- G G

207 pseudoephedrine/ brompheniramine Bromfed O O207 pseudoephedrine/ brompheniramine Ultrabrom G G207 pseudoephedrine/ chlorpheniramine Deconamine SR O O208208 phenylephrine/ promethazine -- G G X208 phenylephrine/ promethazine Phenergan VC O O208 pseudoephedrine/ carbinoxamine -- G G X

IX. Respiratory Drugs L. Decongestant and antihistamine combinations 1. Adult formulations-solid dosage forms OTC

IX. Respiratory Drugs L. Decongestant and antihistamine combinations 2. Adult formulations-liquid dosage forms OTC


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.208 pseudoephedrine/ carbinoxamine Rondec O O208 pseudoephedrine/ chlorpheniramine Dura-Tap/PD O O208 pseudoephedrine/ chlorpheniramine

(generic Chlor-Trimeton Allergy D)-- X

208 pseudoephedrine/ triprolidine (generic Actifed)

-- X

209209 phenylephrine/ chlorpheniramine/

methscopolamine-- G G X

209 phenylephrine/ chlorpheniramine/ methscopolamine

AH-chew G G X


D.A chew O O

209 phenylephrine/ chlorpheniramine/ pyrilamine, suspension

-- G G X


Rynatan Pediatric Suspension

O O

209 pseudoephedrine/ brompheniramine Ultrabrom PD G G209 pseudoephedrine/ brompheniramine,

capsules (generic Bromfed)-- X

209 pseudoephedrine/ brompheniramine, liquid (generic Dimetapp)

-- X

210210 codeine/ phenylephrine/ promethazine -- O O

210 codeine/ phenylephrine/ promethazine Phenergan VC w/codeine O O210 codeine/ promethazine -- G G X

IX. Respiratory Drugs M. Narcotic antitussives and combinations 1. Adult formulations

IX. Respiratory Drugs L. Decongestant and antihistamine combinations 3. Pediatric formulations OTC considerations:


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.210 codeine/ promethazine Phenergan w/codeine O O210 codeine/ pseudoephedrine Nucofed O O210 codeine/ pseudoephedrine/ -- G G X210 hydrocodone/ chlorpheniramine Tussionex O O210 hydrocodone/ homatropine -- G G210 hydrocodone/ homatropine Hycodan O O210 hydrocodone/ pseudoephedrine -- G G211211 codeine/ pseudoephedrine/

chlorpheniramine-- G G X

211 hydrocodone/ homatropine -- G G

211 hydrocodone/ homatopine Hycodan O O212212 benzonatate -- G G X212 benzonatate Tessalon Perles O O212 dextromethorphan/ guaifenesin/

phenylephrineSinutuss DM G G

212 dextromethorphan/ promethazine -- G G X212 dextromethorphan/ promethazine Phenergan DM O O212 dextromethorphan/ pseudoephedrine/ -- G G X212 dextromethorphan/ pseudoephedrine/

brompheniramineDimetane DX O O

212 dextromethorphan/ pseudoephedrine/ carbinoxamine

-- G G X

212 dextromethorphan/ pseudoephedrine/ brompheniramine

Rondec DM O O

213

IX. Respiratory Drugs M. Narcotic antitussives and combinations 2. Pediatric formulations

IX. Respiratory Drugs N. Non-narcotic antitussives and combinations 1. Adult Formulations OTC considerations:

IX. Respiratory Drugs N. Non-narcotic antitussives and combinations 2. Pediatric formulations OTC considerations:


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.213 dextromethorphan/ pseudoephedrine/

carbinoxamineCardec DM Drops G G


Cardec DM Pediatric G G


Rondec DM Drops O O


Rondec DM syrup O O

214214 guaifenesin Duratuss G O O214 guaifenesin Organidin NR O O

214 guaifenesin (generic Robitussin) -- X214 guaifenesin, sustained release -- G G214 guaifenesin, sustained release Humibid LA O O214 guaifenesin/ dextromethorphan (generic

Robitussin DM)-- X

214 guaifenesin/ phenylephrine Sinuvent PE G G214 guaifenesin/ phenylephrine Entex LA O O214 guaifenesin/ pseudoephedrine -- G G X

214 guaifenesin/ pseudoephedrine Robitussin PE O O214 guaifenesin/ pseudoephedrine Entex PSE O O214 potassium iodide Pima O O214 potassium iodide SSKI O O215215 guaifenesin/ codeine -- G G X215 guaifenesin/ codeine Robitussin AC O O215 guaifenesin/ hydrocodone -- G G215 guaifenesin/ hydrocodone Vicodin Tuss O O

IX. Respiratory Drugs O. Expectorants 2. Adult formulations-liquid dosage forms OTC considerations: guaifenesin

IX. Respiratory Drugs O. Expectorants 1. Adult formulations-solid dosage forms


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.215 guaifenesin/ pseudoephedrine/ codeine -- G G X

215 guaifenesin/ pseudoephedrine/ codeine Nucofed Expectorant O O

216216 guaifenesin/ pseudoephedrine/ codeine -- G G

216 guaifenesin/ pseudoephedrine/ codeine Nucofed Pediatric Expectorant

O O

217217 brimonidine, 0.15% Alphagan P P O X217 brimonidine, 0.2% -- G G X218218 dipivefrin -- G G X218 dipivefrin Propine O O218 dipivefrin AKPro O O218 epinephrine Epifrin P O X218 epinephrine/ pilocarpine E-Pilo P O X218 epinephryl borate Epinal P O X219219 betaxolol Betoptic O O219 betaxolol Betoptic S O O219 carteolol -- G G219 carteolol Ocupress O O219 levobunolol -- G G X219 levobunolol Betagan O O219 metipranolol -- G G219 metipranolol OptiPranolol O O219 timolol XE -- G G X219 timolol XE Timoptic XE O O219 timolol -- G G X

X. Ophthalmics A. Agents for glaucoma 3. Beta-adrenergic blocking agents

IX. Respiratory Drugs O. Expectorants 3. Pediatric formulations OTC consideration: guaifenesin/pseudoephedrine (Thera-

X. Ophthalmics A. Agents for glaucoma 1. Alpha-2 adrenergic agonist

X. Ophthalmics A. Agents for glaucoma 2. Sympathomimetics


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.219 timolol Timoptic O O219 timolol/ dorzolamide Cosopt P O X220220 carbachol Carbastat O O220 carbachol Isopto Carbachol P O X220 pilocarpine/ epinephrine E-Pilo P O X220 pilocarpine -- G G X220 pilocarpine Isopto Carpine O O220 pilocarpine Pilocar O O220 pilocarpine Pilopine HS P O X220 pilocarpine Pilostat O O220 pilocarpine nitrate Pilagan P O X220 pilocarpine ocular therapeutic system Ocusert Pilo O O

221221 echothiophate iodide Phospholine Iodide P O X221 physostigmine Eserine sulfate O O222222 brinzolamide Azopt O O222 dorzolamide Trusopt P O X222 dorzolamide/ timolol Cosopt P O X223223 bimatoprost Lumigan P O X223 latanoprost Xalatan P O X223 travoprost Travatan O O223 unoprostone Rescula O O224224 naphazoline -- G G X224 naphazoline Albalon O O

X. Ophthalmics A. Agents for glaucoma 4. Miotics, direct-acting

X. Ophthalmics A. Agents for glaucoma 5. Miotics, cholinesterase inhibitors

X. Ophthalmics A. Agents for glaucoma 6. Carbonic anhydrase inhibitors

X. Ophthalmics A. Agents for glaucoma 7. Prostaglandin agonist

X. Ophthalmics B. Vasoconstrictors/mydriatics OTC considerations: tetrahydrozoline hcl (Generic, Collyrium Fresh, Visine),


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.224 naphazoline Vasocon O O224 phenylephrine -- G G X224 phenylephrine Neo-Synephrine O O

225225 azelastine Optivar O O225 cromolyn -- G G X225 cromolyn Opticrom O O225 cromolyn Crolom O O225 emedastine Emadine O O225 ketotifen Zaditor P P X225 levocabastine Livostin O O225 lodoxamide Alomide O O225 nedocromil Alocril P O X225 olopatadine Patanol O O225 permivolast Alamast O O226226 naphazoline/ antazoline Vasocon-A O O227227 atropine -- G G X227 atropine Isopto Atropine O O227 homatropine HBr Isopto Homatropine P O X227 scopolamine HBr Isopto Hyoscine P O X228228 diclofenac sodium, ophthalmic Voltaren P O X228 flurbiprofen sodium, ophthalmic -- G G228 flurbiprofen sodium, ophthalmic Ocufen O O228 ketorolac tromethamine, ophthalmic Acular P O X

228 ketorolac tromethamine, ophthalmic Acular PF P O X

X. Ophthalmics E. Cycloplegic mydriatics

X. Ophthalmics F. Nonsteroidal Anti-inflammatory Agents (NSAIDS)

X. Ophthalmics D. Decongestant/antihistamine combinations OTC considerations: naphazoline/pheniramine (generic, Naphcon-

X. Ophthalmics C. Anti-allergy agents


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.229229 dexamethasone sodium phosphate,

ophthalmic-- G G X

229 dexamethasone sodium phosphate, ophthalmic

Decadron O O

229 prednisolone acetate, ophthalmic -- G G X229 prednisolone acetate, ophthalmic Econopred O O229 prednisolone acetate, ophthalmic Econopred Plus O O229 prednisolone acetate, ophthalmic Pred Forte P O X229 prednisolone acetate, ophthalmic Pred Mild O O229 fluoromethalone -- G G X229 fluoromethalone Flarex O O229 fluoromethalone FML O O229 fluoromethalone FML Forte O O229 fluoromethalone FML SOP O O229 loteprednol etabonate Alrex O O229 loteprednol etabonate Lotemax P P X229 prednisolone sodium phosphate -- G G X229 prednisolone sodium phosphate AK Pred O O229 prednisolone sodium phosphate Inflamase Forte O O229 prednisolone sodium phosphate Inflamase Mild O O229 rimexolone Vexol O O230230 bacitracin -- G G X X X230 bacitracin AK-Tracin O O230 chloramphenicol, ophthalmic -- G G X X X230 chloramphenicol, ophthalmic Chloroptic O O230 ciprofloxacin, ointment Ciloxan Ointment P P X230 ciprofloxacin, solution Ciloxan Solution O O230 erythromycin -- G G X X X230 erythromycin Ilotycin O O

X. Ophthalmics G. Corticosteroids

X. Ophthalmics H. Antibiotics 1. Single agent


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.230 gentamicin -- G G X230 gentamicin Garamycin O O230 levofloxacin Quixin O O230 norfloxacin Chibroxin O O230 ofloxacin Ocuflox P O X230 tobramycin, solution -- G G X230 tobramycin, solution Tobrex solution O O230 tobramycin, ointment Tobrex ointment P O X231231 bacitracin/ neomycin/ polymyxin B,

ointment-- G G X X X

231 bacitracin/ neomycin/ polymyxin B, ointment

Neosporin ointment O O

231 bacitracin/ polymyxin B, ointment -- G G X231 bacitracin/ polymyxin B, ointment Polysporin O O231 gramicidin/ neomycin/ polymyxin B,

solution-- G G X X X

231 gramicidin/ neomycin/ polymyxin B, solution

Neosporin solution O O

231 trimethoprim/ polymyxin B -- G G X231 trimethoprim/ polymyxin B Polytrim O O232232 bacitracin/ neomycin/ polymyxin B/

hydrocortisone, ointment-- G G X X X

232 bacitracin/ neomycin/ polymyxin B/ Cortisporin O O232 moxifloxacin Vigamox O O232 neomycin/ dexamethasone, solution -- G G X X232 neomycin/ dexamethasone, solution NeoDecadron solution O O232 neomycin/ dexamethasone, ointment NeoDecadron ointment O O

232 neomycin/ polymyxin B/ dexamethasone

-- G G X

X. Ophthalmics H. Antibiotics 3. Steroid and antibiotic combinations

X. Ophthalmics H. Antibiotics 2. Combination antibiotic products


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.232 neomycin/ polymyxin B/

dexamethasoneMaxitrol O O

232 neomycin/ polymyxin B/ hydrocortisone, suspension

-- G G X X X


Cortisporin O O

232 tobramycin/ dexamethasone TobraDex P O X233233 sulfacetamide -- G G X X X233 sulfacetamide Sodium Sulamyd O O233 sulfacetamide/ fluorometholone FML-S O O233 sulfacetamide/ phenylephrine Vasosulf O O233 sulfacetamide/ prednisolone acetate Blephamide P O X233 sulfacetamide/ prednisolone acetate Cetapred O O233 sulfacetamide/ prednisolone sodium

phosphate-- G G X

233 sulfacetamide/ prednisolone sodium phosphate

Vasocidin O O

233 sulfisoxazole diolamine, ophthalmic Gantrisin O O234234 natamycin Natacyn O O235235 idoxuridine Herplex P O X235 trifluridine Viroptic P O X235 vidarabine Vira-A P O X236236 artificial tears -- X236 hydroxypropyl cellulose Lacrisert O O236 ocular lubricants -- X237

X. Ophthalmics I. Sulfonamides

X. Ophthalmics J. Antifungal agent

X. Ophthalmics K. Antiviral agent

X. Ophthalmics L. Ocular lubricants OTC consideration: artificial tears

X. Ophthalmics M. Hyperosmolar preparations OTC considerations: sodium chloride, hypertonic (Muro 128)


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.237 sodium chloride, hypertonic Muro 128 X

238238 acetic acid, otic -- G G X238 acetic acid, otic VoSol O O238 acetic acid/ hydrocortisone, otic -- G G X238 acetic acid/ hydrocortisone, otic VosSol HC O O238 chloramphenicol, otic Chloromycetin Otic O O238 ciprofloxacin hcl/ dexamethasone, otic Ciprodex O O

238 ciprofloxacin/ hydrocortisone, otic Cipro HC Otic O O

238 neomycin/ colistin/ hydrocortisone, otic Cortisporin TC Otic O O

238 neomycin/ hydrocortisone, otic Coly-Mycin S Otic O O238 neomycin/ polymyxin B/

hydrocortisone, otic-- G G X X X

238 neomycin/ polymyxin B/ Cortisporin Otic O O238 ofloxacin, otic Floxin Otic P P X238 polymyxin B/ hydrocortisone, otic Otobiotic P O X239239 acetic acid in aluminum acetate -- G G X239 acetic acid in aluminum acetate Domeboro Otic O O239 antipyrine/ benzocaine -- G G X239 antipyrine/ benzocaine Auralgan O O239 benzethonium chloride/ glycerin/

benzocaineAmericaine O O

239 carbamide peroxide -- X239 triethanolamine Cerumenex O O240240 adapalene Differin P 10 O 10 X 10

XI. Otic preparations A. Antibiotics

XI. Otic preparations B. Other OTC considerations: boric acid/isopropyl alcohol (Ear-Dry), glycerin/isopropyl alcohol (Swim-

XII. Dermatological Agents A. Acne products 1. Topical OTC considerations: benzoyl peroxide, sulfur, salicylic acid Note:


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.240 aluminum chloride hexahydrate Xerac AC O O240 azelaic acid Azelex O O240 benzoyl peroxide -- G G X240 benzoyl peroxide Benzac O O240 benzoyl peroxide Desquam O O240 benzoyl peroxide Triaz O O240 clindamycin phosphate, topical -- G G X240 clindamycin phosphate, topical Cleocin T O O240 erythromycin -- G G X240 erythromycin ATS O O240 erythromycin Emgel O O240 erythromycin Erygel O O240 erythromycin T-Stat G G240 erythromycin/ benzoyl peroxide -- G G240 erythromycin/ benzoyl peroxide Benzamycin O O240 meclocycline sulfosalicylate Meclan O O240 metronidazole, topical MetroCream P O X240 metronidazole, topical MetroGel P O X240 metronidazole, topical MetroLotion P O X240 metronidazole, topical Noritate O O240 salicylic acid -- X240 sulfacetamide sodium Klaron O O240 sulfur/ sulfacetamide Novacet O O240 sulfur/ sulfacetamide Sulfacet-R O O240 tazarotene Tazorac O O240 tetracycline Topicycline O O240 tretinoin -- G 10 G 10 X 10240 tretinoin Avita O 10 O 10240 tretinoin Retin-A O 10 O 10240 tretinoin Retin-A Micro O 10 O 10241241 clindamycin -- G G X

XII. Dermatological Agents A. Acne products 2. Systemic


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.241 clindamycin Cleocin O O241 doxycycline hyclate -- G G X X X241 doxycycline hyclate Doryx O O241 doxycycline hyclate Vibramycin O O241 doxycycline monohydrate -- G G241 doxycycline monohydrate Monodox O O241 erythromycin base -- G G X X X241 erythromycin base Eryc O O241 erythromycin base Ery-Tab G G X X X241 erythromycin base PCE O O241 isotretinoin -- G G241 isotretinoin Accutane O O241 minocycline hcl -- G G X241 minocycline hcl Minocin O O241 sulfamethoxazole/ trimethoprim -- G G X X X241 sulfamethoxazole/ trimethoprim Bactrim O O241 sulfamethoxazole/ trimethoprim Septra O O241 tetracycline -- G G X X X242242 ammoniated mercury Emersal O O242 anthralin Anthra-Derm O O242 anthralin Drithocreme P O X242 anthralin Drithocreme HP P O X242 anthralin Dritho-Scalp P O X

242 calcipotriene Dovonex P O X242 tazarotene Tazorac O O243243 acitretin Soriatane P O X243 methotrexate -- G G X

XII. Dermatological Agents B. Antipsoriatics 1. Topical

XII. Dermatological Agents B. Antipsoriatics 2. Systemic


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.243 methotrexate Rheumatrex O O243 methoxasalen Oxsoralen-Ultra P O X244244 mafenide Sulfamylon O O

244 nitrofurazone Furacin O O244 silver sulfadiazine -- G G X244 silver sulfadiazine Silvadene O O245245 methionine Pedameth O O246

246 chloroxine Capitrol O O246 coal tar -- X246 ketoconazole, cream -- G G X246 ketoconazole, cream Nizoral O O X246 salicylic acid -- X246 selenium sulfide -- G G X246 selenium sulfide Selsun O O246 sulfacetamide sodium, shampoo Sebizon O O247247 diphenhydramine, topical -- X247 doxepin Zonalon O O248248 acyclovir ointment Zovirax P O X248 penciclovir Denavir O O249249 bacitracin -- X249 bacitracin/ polymyxin B -- X249 bacitracin/ polymyxin B/ neomycin -- X

XII. Dermatological Agents E. Antiseborrheic products OTC considerations: selenium sulfide (Selsun Blue), coal tar (Neutrogena T/Gel, Pentrax), pyrithione zinc (Head & Shoulders, Sebulon), povidone-iodine (Betadine shampoo), sulfur-salicylic acid

XII. Dermatological Agents F. Topical antihistamines OTC considerations: diphenhydramine (Benadryl),

XII. Dermatological Agents G. Topical anti-infectives 1. Antiviral agents

XII. Dermatological Agents G. Topical anti-infectives 2. Antibiotics OTC considerations: bacitracin, bacitracin/polymyxin B

XII. Dermatological Agents C. Burn preparations

XII. Dermatological Agents D. Diaper rash products OTC consideration: zinc oxide (Desitin)


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.249 clindamycin phosphate, topical -- G G X

249 clindamycin phosphate, topical Cleocin T O O249 erythromycin, topical -- G G X249 erythromycin, topical ATS O O249 erythromycin, topical Emgel O O249 erythromycin, topical Erygel O O249 erythromycin, topical T-Stat O O249 gentamicin sulfate, topical -- G G X249 gentamicin sulfate, topical Garamycin O O249 metronidazole, topical MetroCream P O X249 metronidazole, topical MetroGel P O X249 metronidazole, topical MetroLotion P O X249 metronidazole, topical Noritate O O249 mupirocin Bactroban O O249 neomycin/ poly+D2035myxin B/

hydrocortiso+D2042ne, topicalCortisporin Cream P O X

250250 butenafine Mentax O O

250 ciclopirox Loprox P O X250 clotrimazole -- X250 econazole -- G G X250 econazole Spectazole O O250 ketoconazole, cream -- G G X250 ketoconazole, cream Nizoral O O X250 ketoconazole, shampoo Nizoral P O X250 miconazole -- X250 naftifine Naftin O O250 nystatin -- G G X250 nystatin Mycostatin O O

XII. Dermatological Agents G. Topical anti-infectives 3. Antifungal OTC considerations: miconazole (Micatin), clotrimazole


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.250 nystatin/ triamcinolone -- G G X250 oxiconazole Oxistat O O250 sulconazole Exelderm O O251251 crotamiton Eurax O O251 lindane -- G G X251 malathion Ovide O O251 permethrin -- G G X251 permethrin Elimite O O252252 augmented betamethasone dipropionate

0.05%, ointment/gel-- G G

252 augmented betamethasone dipropionate 0.05%, ointment/gel

Diprolene O O

252 clobetasol 0.05% -- G G X252 clobetasol 0.05% Cormax G G X252 clobetasol 0.05% Temovate O O252 clobetasol 0.05% Temovate E O O252 diflorasone 0.05%, ointment Psorcon B O O252 halobetasol propionate 0.05%, cream/

ointmentUltravate P O X

253253 amcinonide -- G G253 amcinonide Cyclocort O O253 augmented betamethasone dipropionate

0.05%, creamDiprolene AF O O

253 betamethasone dipropionate 0.05%, cream/ ointment

-- G G


Diprosone O O

XII. Dermatological Agents I. Corticosteroids, topical 2. High potency

XII. Dermatological Agents H. Scabicides/pediculicides OTC considerations: permethrin (Nix), pyrethrins, piperonyl butoxide

XII. Dermatological Agents I. Corticosteroids, topical 1. Very high potency


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.253 betamethasone dipropionate 0.05%,

cream/ ointmentMaxivate O O

253 betamethasone valerate 0.1%, ointment -- G G X

253 betamethasone valerate 0.1%, ointment Valisone O O

253 desoximetasone 0.05%, gel -- G G253 desoximetasone 0.05%, gel Topicort O O253 desoximetasone 0.25%, cream/ ointment -- G G

253 desoximetasone 0.25%, cream/ ointment Topicort O O

253 diflorasone 0.05% cream/ ointment -- G G253 diflorasone 0.05%, cream/ ointment Florone O O253 diflorasone 0.05%, cream/ ointment Maxiflor O O253 diflorasone 0.05%, cream Psorcon O O253 fluocinolone acetonide 0.2%, cream Synalar HP O O

253 fluocinonide 0.05% -- G G253 fluocinonide 0.05% Lidex O O253 halcinonide 0.1%, cream/ ointment Halog O O253 halcinonide 0.1%, cream/ ointment Halog E O O253 triamcinolone acetonide 0.5%, cream/

ointment-- G G X

253 triamcinolone acetonide 0.5%, cream/ ointment

Kenalog O O

254254 betamethasone dipropionate 0.05%,

lotion-- G G

254 betamethasone dipropionate 0.05%, lotion

Diprosone O O

XII. Dermatological Agents I. Corticosteroids, topical 3. Medium potency


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.254 betamethasone dipropionate 0.05%,

lotionMaxivate O O

254 betamethasone valerate 0.1%, cream/ lotion

-- G G X


Valisone O O

254 clocortolone pivalate 0.1%, cream Cloderm O O254 desoximetasone 0.05%, cream -- G G254 desoximetasone 0.05%, cream Topicort LP O O254 fluocinolone acetonide 0.025%, cream/

ointment-- G G X

254 fluocinolone acetonide 0.025%, cream/ ointment

Synalar O O

254 flurandrenolide Cordran P O X254 flurandrenolide Cordran SP P O X254 flurandrenolide 4mcg/ cm2, tape Cordran tape P O X254 fluticasone propionate 0.05%, cream/

ointmentCutivate O O

254 hydrocortisone butyrate 0.1% Locoid O O254 hydrocortisone valerate 0.2%, cream/

ointment-- G G X

254 hydrocortisone valerate 0.2%, cream/ ointment

Westcort O O

254 mometasone furoate 0.1% Elocon O O254 triamcinolone acetonide, aerosol Kenalog aerosol P O X254 triamcinolone acetonide 0.025% -- G G X254 triamcinolone acetonide 0.025% Kenalog O O254 triamcinolone acetonide 0.1% -- G G X254 triamcinolone acetonide 0.1% Kenalog O O255 XII. Dermatological Agents I. Corticosteroids, topical 4. Low potency OTC considerations: hydrocortisone cream, ointment


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.255 aclometasone dipropionate 0.05%,

cream/ ointmentAclovate O O

255 desonide 0.05%, cream/ ointment -- G G X

255 desonide 0.05%, cream/ ointment Desowen O O255 desonide 0.05%, lotion Desowen O O255 dexamethasone 0.04%, aerosol Decaspray O O255 dexamethasone sodium phosphate 0.1%,

creamDecadron O O

255 fluocinolone acetonide 0.01% -- G G X255 fluocinolone acetonide 0.01% Synalar O O255 hydrocortisone 0.25%, lotion -- G G X

255 hydrocortisone 0.25%, lotion Cetacort O O255 hydrocortisone 0.5% -- G G X255 hydrocortisone 0.5% Hytone O O255 hydrocortisone 1% -- G G X255 hydrocortisone 1% Hytone O O255 hydrocortisone 2.5% -- G G X

255 hydrocortisone 2.5% Hytone O O256256 lidocaine -- G G X256 lidocaine Xylocaine O O256 lidocaine/ prilocaine EMLA O O257257 lidocaine, viscous -- G G X257 lidocaine, viscous Xylocaine Viscous O O258

XII. Dermatological Agents J. Local anesthetics, topical 1. Topical anesthetics for skin disorders OTC considerations:

XII. Dermatological Agents J. Local anesthetics, topical 2. Topical anesthetics for mucous membranes OTC consideration:

XII. Dermatological Agents K . Keratolytics OTC considerations: salicylic acid (Occlusal HP, Compound W, Duofilm)


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Code

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.258 salicylic acid -- X259259 collagenase Santyl O O259 fibrinolysin/ desoxyribonuclease Elase O O259 sutilains Travase O O260260 aluminum acetate -- X261261 alitretinoin Panretin O O261 aluminum chloride hexahydrate Drysol O O261 becaplermin Regranex O O261 fluorouracil Efudex O O261 fluorouracil Fluoroplex O O261 hexachlorophene pHisoHex O O261 imiquimod Aldara P O X261 masoprocol Actinex O O261 podofilox Condylox P O X262262 potassium citrate Urocit-K O O262 potassium citrate/ citric acid Polycitra K P O X262 potassium citrate/ sodium citrate/ citric

acidPolycitra P O X

262 potassium citrate/ sodium citrate/ citric acid

Polycitra LC O O

262 sodium citrate/ citric acid Bicitra P O X262 sodium citrate/ citric acid Oracit O O263263 potassium/ sodium acid phosphate K-Phos Neutral O O264264 flavoxate Urispas O O

XIII. Urinary tract products B. Acidifiers OTC considerations: ammonium chloride, ascorbic acid

XIII. Urinary tract products C. Antispasmodics

XII. Dermatological Agents L. Topical enzyme preparations

XII. Dermatological Agents M. Emollients OTC considerations: lactic acid (Lac-Hydrin, Amlactin), urea (Carmol 20,

XII. Dermatological Agents N. Other

XIII. Urinary tract products A. Alkalinizers OTC consideration: sodium bicarbonate


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.264 oxybutynin -- G G X264 oxybutynin Ditropan O O264 oxybutynin, extended release Ditropan XL P O X264 tolterodine Detrol P O X264 tolterodine, long-acting Detrol LA P O X265265 bethanechol -- G G X265 bethanechol Urecholine O O265 neostigmine Prostigmin O O266266 pentosan polysulfate sodium Elmiron O O266 phenazopyridine -- G G X266 phenazopyridine Pyridium O O267267 acetohydroxamic acid Lithostat O O267 cysteamine bitartrate Cystagon O O267 tiopronin Thiola O O268268 azathioprine -- G G X268 azathioprine Imuran O O268 cyclosporine Sandimmune P O X268 cyclosporine, microemulsion -- G G X268 cyclosporine, microemulsion Neoral P O X268 mycophenolate mofetil CellCept P O X268 sirolimus Rapamune O O268 tacrolimus Prograf P O X269269 auranofin Ridaura P O X269 azathioprine -- G G X269 azathioprine Imuran O O269 hydroxychloroquine sulfate -- G G X

XIV. Immunologic Agents A. Immunosuppressive agents

XIV. Immunologic Agents B. Disease Modifying Antirheumatic Drugs (DMARD)

XIII. Urinary tract products D. Cholinergic stimulants

XIII. Urinary tract products E. Analgesics OTC consideration: phenazopyridine (Azo-Standard, Prodium)

XIII. Urinary tract products F. Other


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.269 hydroxychloroquine sulfate Plaquenil O O269 leflunomide Arava O O269 methotrexate -- G G X269 methotrexate Rheumatrex O O269 penicillamine Cuprimine P O X269 penicillamine Depen O O269 sulfasalazine, enteric coated -- G G269 sulfasalazine, enteric coated Azulfidine EN-tabs O O270270 condoms -- X270 diaphragms -- O 3 O 3 X X X270 spermicides -- X

XV. Miscellaneous A. Contraceptive barriers

HMSA DRUG FORMULARY 4/1/04

FOOTNOTES 1 Second line protocol.2 Coverage is subject to member's plan benefits.3 Special member rates apply. Check plan benefits.4 Benefit for TB prophylaxis age 21 or younger. Benefit for MAC, MAI, MK only.5 Benefit only for children age 18 or younger.6 Benefit only for children age 12 or younger.7 Benefit only when prescribed to treat ADD/ADHD.8 Benefit only when prescribed to treat ADD/ADHD or narcolepsy.9 Benefit only when prescribed to treat narcolepsy.10 Benefit only when prescribed to treat acne vulgaris.11 Benefit only when prescribed to treat pernicious anemia.12 Benefit only when prescribed to treat ESRD.13 Benefit only when prescribed to treat carnitine deficiency.14 Non-DESI products only.15 Benefit only when prescribed to treat H. Pylori or GERD.16 Benefit only when prescribed to treat STD.17 Benefit for TB prophylaxis age 21 or younger.18 Benefit for MAC, MAI, MK only.19 Restricted to treatment of seizures, panic disorder, generalized anxiety, OCD, alcohol withdrawal, and bipolar agitation. Pre-

certification required for insomnia and other diagnoses.20 4 x 1ml ampules per 30 days21 DACON criteria apply.22 COX-2 criteria apply.23 9 tablets per 30 days.24 9 tablets, 6 nasal sprays, and/or 4 injections per 30 days25 6 tablets per 30 days.26 Benefit only when prescribed to treat seizures.27 Benefit only when prescribed to treat Wernicke Korsakoff Syndrome.28 Benefit only when prescribed to pregnancy or lactation.29 Second line protocol. Benefit only when prescribed to treat H. Pylori or GERD.30 Therapeutic protocol.

HMSA DRUG FORMULARY - Listed alphabetically by BRAND name Rev. 4/1/04 - Page 1

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QUEST QUEST-Net

CCS Child-ren's

95 aripiprazole Abilify P O X X194 zafirlukast Accolate P 30 O X 3056 quinapril Accupril O O56 quinapril/ hctz Accuretic O O

241 isotretinoin Accutane O O56 perindopril Aceon O O11 glacial acetic acid Aci-jel O O

163 rabeprazole sodium Aciphex P P X 15255 aclometasone dipropionate 0.05%,


167 ursodiol Actigall O O261 masoprocol Actinex O O122 estradiol/ norethindrone acetate Activella O O152 risedronate Actonel P O X146 pioglitazone Actos P O X228 ketorolac tromethamine, ophthalmic Acular P O X228 ketorolac tromethamine, ophthalmic Acular PF P O X46 nifedipine Adalat O O46 nifedipine, sustained release Adalat CC O O62 amphetamine mixture Adderall P 8 O 8 X 8 X 862 amphetamine mixture, extended release Adderall XR P 7 O 7 X 7 X 7

190 salmeterol/ fluticasone Advair P O X195 salmeterol/ fluticasone Advair P O X61 nicotinic acid, extended release/

lovastatinAdvicor P P X

195 flunisolide, inhaler Aerobid P P X195 flunisolide, inhaler Aerobid M P P X197 spacer Aerochamber P 3 P 3 X20 amprenavir Agenerase P O X34 aspirin/ dipyridamole Aggrenox P P X34 anagrelide Agrylin O O



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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.209 phenylephrine/ chlorpheniramine/

methscopolamineAH-chew G G X

199 phenylephrine AH-Chew D G G X197 peak flow meter Air Zone P 3 P 3 X229 prednisolone sodium phosphate AK Pred O O110 biperiden Akineton O O218 dipivefrin AKPro O O230 bacitracin AK-Tracin O O225 permivolast Alamast O O224 naphazoline Albalon O O24 albendazole Albenza O O41 spironolactone/ hctz Aldactazide O O39 spironolactone Aldactone O O

261 imiquimod Aldara P O X52 methyldopa/ chlorothiazide Aldoclor O O52 methyldopa Aldomet O O52 methyldopa/ hctz Aldoril O O

123 ethinyl estradiol/ levonorgestrel Alesse P 3 P 3 X X X26 melphalan Alkeran P O X

205 fexofenadine Allegra P P X205 fexofenadine/ pseudoephedrine Allegra D P P X225 nedocromil Alocril P O X225 lodoxamide Alomide O O119 estradiol, transdermal Alora O O217 brimonidine, 0.15% Alphagan P P O X229 loteprednol etabonate Alrex O O56 ramipril Altace P P X60 lovastatin, extended release Altocor O 21 O 21

188 metaproterenol sulfate Alupent O O189 metaproterenol sulfate, inhalation Alupent O O189 metaproterenol sulfate, metered dose



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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.144 glimepiride Amaryl O O99 zolpidem tartrate Ambien P O

121 medroxyprogesterone acetate Amen O O70 naratriptan Amerge P 23 O 23 X 23

239 benzethonium chloride/ glycerin/ benzocaine

Americaine O O

11 sodium propionate/ amino acid/ urea Amino-Cerv O O132 oxymetholone Anadrol O O78 clomipramine Anafranil O O

191 epinephrine/ chlorpheniramine Anakit P O X139 hydrocortisone acetate/ pramoxine Analpram HC O O X68 naproxen sodium Anaprox O O

130 testosterone, transdermal Androderm P O X130 testosterone, gel Androgel O O129 methyltestosterone Android P O X63 hydrocodone/ apap Anexsia O O68 flurbiprofen Ansaid O O

113 disulfiram Antabuse P O X X242 anthralin Anthra-Derm O O73 meclizine Antivert O O

153 sulfinpyrazone Anturane O O139 hydrocortisone acetate Anusol HC O O75 dolasetron mesylate Anzemet O O

172 amlexanox Aphthasol O O55 hydralazine/ hctz Apresazide O O55 hydralazine Apresoline O O14 chloroquine phosphate Aralen P O X16 chloroquine phosphate Aralen P O X

269 leflunomide Arava O O97 donepezil Aricept P O X28 anastrazole Arimidex P O X

138 triamcinolone Aristocort O O


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.149 thyroid, desiccated Armour Thyroid P O110 trihexyphenidyl Artane O O68 diclofenac/ misoprostol Arthrotec O O

162 diclofenac/ misoprostol Arthrotec O O173 mesalamine, delayed release Asacol P O X79 amoxapine Asendin O O

204 azelastine Astelin P O X57 candesartan Atacand O O57 candesartan/ hctz Atacand HCT O O77 hydroxyzine hcl Atarax O O

206 hydroxyzine hcl Atarax O O76 lorazepam Ativan O O61 clofibrate Atromid S O O

192 ipratropium, inhalation Atrovent O O201 ipratropium, nasal Atrovent O O192 ipratropium, inhalation Atrovent MDI P O X240 erythromycin ATS O O249 erythromycin, topical ATS O O

2 amoxicillin/ k clavulanate Augmentin O O2 amoxicillin/ k clavulanate, extra strength Augmentin ES P O X 1

2 amoxicillin/ k clavulanate, extended release

Augmentin XR P O X 1

239 antipyrine/ benzocaine Auralgan O O57 irbesartan/ hctz Avalide P P X

146 rosiglitazone/ metformin Avandamet P O X146 rosiglitazone Avandia P O X57 irbesartan Avapro P P X11 sulfanilamide AVC O O4 moxifloxacin Avelox P O X 179 nortriptyline Aventyl O O

240 tretinoin Avita O 10 O 10


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Code

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.70 almotriptan Axert O 25 O 25

161 nizatidine Axid O O121 norethindrone acetate Aygestin O O240 azelaic acid Azelex O O195 triamcinolone, inhaler Azmacort O O222 brinzolamide Azopt O O173 sulfasalazine Azulfidine O O173 sulfasalazine, enteric coated Azulfidine EN-tabs O O269 sulfasalazine, enteric coated Azulfidine EN-tabs O O63 belladonna/ opium B&O suppositories O O10 sulfamethoxazole/ trimethoprim Bactrim O O

241 sulfamethoxazole/ trimethoprim Bactrim O O249 mupirocin Bactroban O O158 methantheline bromide Banthine O O202 beclomethasone Beconase AQ O O157 belladona tincture Belladonna Tincture O O157 l-alkaloids of belladonna/ phenobarbital/

ergotamineBellergal-S O O

73 diphenhydramine Benadryl O O110 diphenhydramine Benadryl O O206 diphenhydramine Benadryl O O57 olmesartan Benicar O O

159 dicyclomine, tablets and capsules Bentyl O O159 dicyclomine, syrup Bentyl Syrup P O X240 benzoyl peroxide Benzac O O240 erythromycin/ benzoyl peroxide Benzamycin O O181 iron/ multivit/ mineral, prescription Berocca Plus O 2 O 2219 levobunolol Betagan O O49 sotalol Betapace O O44 sotalol Betapace AF P P X49 sotalol Betapace AF P P X

219 betaxolol Betoptic O O


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.219 betaxolol Betoptic S O O69 valdecoxib Bextra O 22 O6 clarithromycin Biaxin P O X 296 clarithromycin, extended release Biaxin XL P O X 29

185 sodium citrate/ citric acid Bicitra P O X262 sodium citrate/ citric acid Bicitra P O X24 praziquantel Biltricide O O

233 sulfacetamide/ prednisolone acetate Blephamide P O X49 timolol maleate Blocadren O O

189 terbutaline sulfate Brethaire P O X188 terbutaline sulfate Brethine P O X188 terbutaline sulfate Bricanyl O O X207 pseudoephedrine/ brompheniramine Bromfed O O193 theophylline, capsules Bronkodyl O O38 bumetanide Bumex O O77 buspirone Buspar O O

157 belladonna extract/ butabarbital sodium Butibel O O

101 butabarbital sodium Butisol Sodium O O71 ergotamine tartrate/ caffeine Cafergot O O47 verapamil Calan O O47 verapamil, sustained release Calan SR O O

178 cellulose sodium phosphate Calcibind P O X158 mepenzolate bromide Cantil O O246 chloroxine Capitrol O O56 captopril Capoten O O56 captopril/ hctz Capozide O O

156 sucralfate Carafate O O220 carbachol Carbastat O O107 carbamazepine, extended release Carbatrol O O213 dextromethorphan/ pseudoephedrine/

carbinoxamineCardec DM Drops G G


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Code

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Code

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.213 dextromethorphan/ pseudoephedrine/

carbinoxamineCardec DM Pediatric G G

46 nicardipine Cardene O O46 nicardipine, sustained release Cardene SR O O44 quinidine polygalacturonate Cardioquin P O X45 diltiazem Cardizem O O45 diltiazem, sustained release Cardizem CD O O45 diltiazem, sustained release Cardizem SR O O53 doxazosin mesylate Cardura O O

186 levocarnitine Carnitor P 13 O 13 X 13136 carteolol Cartrol O O28 bicalutamide Casodex P O X68 diclofenac potasium Cataflam O O52 clonidine, oral Catapres O O52 clonidine, transdermal Catapres-TTS O O X

133 alprostadil Caverject O O3 cefaclor Ceclor O O3 cefaclor, extended release Ceclor CD O O3 ceftibuten Cedax O O26 lomustine CeeNu P O X3 cefuroxime Ceftin O O3 cefprozil Cefzil O O69 celecoxib Celebrex P 22 O X 22

138 betamethasone Celestone O O85 citalopram Celexa P P X X

268 mycophenolate mofetil CellCept P O X104 methsuximide Celontin Kapseals P O X118 synthetic conjugated estrogens Cenestin O O168 lactulose Cephulac O O239 triethanolamine Cerumenex O O255 hydrocortisone 0.25%, lotion Cetacort O O233 sulfacetamide/ prednisolone acetate Cetapred O O


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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.180 succimer Chemet P O X230 norfloxacin Chibroxin O O238 chloramphenicol, otic Chloromycetin Otic O O230 chloramphenicol, ophthalmic Chloroptic O O193 oxtriphylline Choledyl O O168 lactulose Chronulac O O230 ciprofloxacin, ointment Ciloxan Ointment P P X230 ciprofloxacin, solution Ciloxan Solution O O25 cinoxacin Cinobac O O4 ciprofloxacin Cipro P O X 1

238 ciprofloxacin/ hydrocortisone, otic Cipro HC Otic O O238 ciprofloxacin hcl/ dexamethasone, otic Ciprodex O O

205 desloratadine Clarinex O O8 clindamycin Cleocin O O

241 clindamycin Cleocin O O8 clindamycin palmitate, suspension Cleocin Suspension P O X

240 clindamycin phosphate, topical Cleocin T O O249 clindamycin phosphate, topical Cleocin T O O11 clindamycin Cleocin Vaginal P O X

119 estradiol, transdermal Climara O O68 sulindac Clinoril O O

254 clocortolone pivalate 0.1%, cream Cloderm O O133 clomiphene Clomid O 2 O 295 clozapine Clozaril P O X

110 benztropine Cogentin O O97 tacrine Cognex O O59 colestipol, granules Colestid P O X59 colestipol, tablets Colestid P O

238 neomycin/ hydrocortisone, otic Coly-Mycin S Otic O O168 polyethylene glycol-electrolyte solution CoLyte O O


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Code

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.122 estradiol/ norethindrone acetate,


52 clonidine/ chlorthalidone Combipres O O189 albuterol/ ipratropium Combivent P O X192 albuterol/ ipratropium Combivent P O X17 lamivudine/ zidovudine Combivir P O X72 prochlorperazine maleate, tablets Compazine O O88 prochlorperazine maleate, tablets Compazine O O72 prochlorperazine maleate, sustained


88 prochlorperazine maleate, sustained release

Compazine Spansules O O

72 prochlorperazine edisylate, syrup Compazine Syrup P O X X88 prochlorperazine edisylate, syrup Compazine Syrup P O X X

111 entacapone Comtan O O62 methylphenidate, extended release Concerta O 7 O 7

261 podofilox Condylox P O X44 amiodarone Cordarone P O X

254 flurandrenolide Cordran P O X254 flurandrenolide Cordran SP P O X254 flurandrenolide 4mcg/ cm2, tape Cordran tape P O X51 carvedilol Coreg P P X49 nadolol Corgard O O

252 clobetasol 0.05% Cormax G G X138 hydrocortisone Cortef O O139 hydrocortisone Cortenema P O X139 hydrocortisone acetate Cortifoam O O138 cortisone acetate Cortisone O O X232 bacitracin/ neomycin/ polymyxin B/

hydrocortisone, ointmentCortisporin O O


Cortisporin O O


Ther. Categ. Code


Code

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Choice

Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.249 neomycin/ poly+D2035myxin B/


238 neomycin/ polymyxin B/ hydrocortisone, otic

Cortisporin Otic O O


49 nadolol/ bendroflumethiazide Corzide O O222 dorzolamide/ timolol Cosopt P O X219 timolol/ dorzolamide Cosopt P O X35 warfarin Coumadin P O X47 verapamil, sustained release Covera HS O O57 losartan Cozaar P P X

166 pancreatin Creon O O133 progesterone, vaginal 8% Crinone 8% O 2 O 220 indinavir sulfate Crixivan P O X

225 cromolyn Crolom O O42 digitoxin Crystodigin O O

269 penicillamine Cuprimine P O X121 medroxyprogesterone acetate Curretab O O254 fluticasone propionate 0.05%, cream/


253 amcinonide Cyclocort O O62 pemoline Cylert O 7 O 7 X 7

267 cysteamine bitartrate Cystagon O O140 aminoglutethimide Cytadren P O X149 liothyronine sodium Cytomel P O X162 misoprostol Cytotec O O22 ganciclovir Cytovene O O26 cyclophosphamide Cytoxan P O X


D.A chew O O

98 flurazepam Dalmane O O


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Choice

Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.135 danazol Danocrine P O X109 dantrolene Dantrium O O23 dapsone Dapsone O O40 dichlorphenamide Daranide O O14 pyrimethamine Daraprim O O63 propoxyphene napsylate/ apap Darvocet N O O63 propoxyphene Darvon O O63 propoxyphene/ asa/ caffeine Darvon Compound O O63 propoxyphene napsylate Darvon N O O68 oxaprozin Daypro O O

136 desmopressin, nasal DDAVP P O X136 desmopressin, oral DDAVP P O X138 dexamethasone Decadron O O255 dexamethasone sodium phosphate 0.1%,

creamDecadron O O


Decadron O O

255 dexamethasone 0.04%, aerosol Decaspray O O5 demeclocycline Declomycin O O

207 pseudoephedrine/ chlorpheniramine Deconamine SR O O38 torsemide Demadex O O63 meperidine Demerol O O58 metyrosine Demser O O

248 penciclovir Denavir O O115 naltrexone Depade O O107 valproic acid Depakene P O X X107 divalproex sodium Depakote P O X X107 divalproex sodium, extended release Depakote ER P O X X269 penicillamine Depen O O128 medroxyprogesterone acetate, injectable Depo-Provera X X

123 ethinyl estradiol/ desogestrel Desogen P 3 P 3 X X X


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.255 desonide 0.05%, cream/ ointment Desowen O O255 desonide 0.05%, lotion Desowen O O62 methamphetamine Desoxyn O 7 O 7

240 benzoyl peroxide Desquam O O81 trazodone Desyrel O O

264 tolterodine Detrol P O X264 tolterodine, long-acting Detrol LA P O X62 dextroamphetamine sulfate Dexedrine P 8 O 8 X 8 X 862 dextroamphetamine sulfate, sustained

releaseDexedrine Spansules O 7 O 7 X 7

144 glyburide Diabeta O O144 chlorpropamide Diabinese O O40 acetazolamide Diamox O O

107 acetazolamide Diamox O O40 acetazolamide, extended release Diamox Sequels P O X

106 diazepam, rectal Diastat P O X58 phenoxybenzamine Dibenzyline O O35 dicumarol Dicumarol O O

152 etidronate Didronel O O240 adapalene Differin P 10 O 10 X 1012 fluconazole Diflucan P O X45 diltiazem, sustained release Dilacor XR O O

103 phenytoin Dilantin 125 P O X103 phenytoin Dilantin Infatab P O X103 phenytoin sodium, extended release Dilantin Kapseals P O X43 isosorbide dinitrate, oral, sustained

releaseDilatrate-SR O O

63 hydromorphone Dilaudid O O212 dextromethorphan/ pseudoephedrine/

brompheniramineDimetane DX O O

57 valsartan Diovan O O57 valsartan/ hctz Diovan HCT O O


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.173 olsalazine sodium Dipentum O O252 augmented betamethasone dipropionate

0.05%, ointment/gelDiprolene O O

253 augmented betamethasone dipropionate 0.05%, cream

Diprolene AF O O


Diprosone O O


Diprosone O O

66 salsalate Disalcid O O264 oxybutynin Ditropan O O264 oxybutynin, extended release Ditropan XL P O X54 reserpine/ chlorothiazide Diupres O O37 chlorothiazide Diuril O O54 reserpine/ methyclothiazide Diutensen-R O O66 diflunisal Dolobid O O63 methadone Dolophine O O X

114 methadone Dolophine O O239 acetic acid in aluminum acetate Domeboro Otic O O157 belladonna alkaloids/ phenobarbital Donnatal O O111 levodopa Dopar O O98 quazepam Doral O O5 doxycycline hyclate Doryx O O

241 doxycycline hyclate Doryx O O154 cabergoline Dostinex P O X242 calcipotriene Dovonex P O X242 anthralin Drithocreme P O X242 anthralin Drithocreme HP P O X242 anthralin Dritho-Scalp P O X261 aluminum chloride hexahydrate Drysol O O63 fentanyl, transdermal Duragesic P O X

208 pseudoephedrine/ chlorpheniramine Dura-Tap/PD O O


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.214 guaifenesin Duratuss G O O207 phenylephrine/ chlorpheniramine/

methscopolamineDura-Vent/DA O O

3 cefadroxil Duricef O O41 triamterene/ hctz Dyazide O O

144 acetohexamide Dymelor O O6 dirithromycin Dynabac O O46 isradipine DynaCirc O O2 dicloxacillin sodium Dynapen O O2 dicloxacillin sodium, suspension Dynapen Suspension P O X39 triamterene Dyrenium O O66 aspirin, enteric coated Easprin O O

229 prednisolone acetate, ophthalmic Econopred O O229 prednisolone acetate, ophthalmic Econopred Plus O O38 ethacrynic acid Edecrin O O83 venlafaxine Effexor O O X83 venlafaxine, extended release Effexor XR P P X X

261 fluorouracil Efudex O O259 fibrinolysin/ desoxyribonuclease Elase O O78 amitriptyline Elavil O O

111 selegiline Eldepryl O O251 permethrin Elimite O O193 theophylline, capsules Elixophyllin O O193 theophylline, liquid Elixophyllin O O193 theophylline, timed release capsules Elixophyllin SR O O266 pentosan polysulfate sodium Elmiron O O254 mometasone furoate 0.1% Elocon O O225 emedastine Emadine O O28 estramustine Emcyt P O X

242 ammoniated mercury Emersal O O240 erythromycin Emgel O O249 erythromycin, topical Emgel O O


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.256 lidocaine/ prilocaine EMLA O O63 codeine/ asa Empirin w/ Codeine O O37 methyclothiazide Enduron O O54 deserpidine/ methyclothiazide Enduronyl O O54 deserpidine/ methyclothiazide Enduronyl Forte O O

214 guaifenesin/ phenylephrine Entex LA O O214 guaifenesin/ pseudoephedrine Entex PSE O O138 budesonide Entocort EC O O218 epinephrine Epifrin P O X218 epinephrine/ pilocarpine E-Pilo P O X220 pilocarpine/ epinephrine E-Pilo P O X218 epinephryl borate Epinal P O X191 epinephrine, injectable Epi-pen P O X191 epinephrine, injectable Epi-pen JR P O X17 lamivudine Epivir P O X17 lamivudine Epivir-HBV P O X77 meprobamate Equanil O O30 levamisole Ergamisol P O X71 ergotamine tartrate Ergomar P O X6 erythromycin base Eryc O O

241 erythromycin base Eryc O O240 erythromycin Erygel O O249 erythromycin, topical Erygel O O

6 erythromycin ethylsuccinate EryPed O O6 erythromycin base Ery-Tab G G X X X

241 erythromycin base Ery-Tab G G X X X119 estradiol, transdermal Esclim O O221 physostigmine Eserine sulfate O O67 butalbital/ apap/ caffeine Esgic O O67 butalbital/ apap/ caffeine Esgic Plus O O96 lithium carbonate Eskalith O O


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.96 lithium carbonate, controlled release Eskalith CR P O X X

118 ethinyl estradiol Estinyl O O118 estradiol Estrace O O119 estradiol, vaginal Estrace P O X119 estradiol, transdermal Estraderm O O118 esterified estrogens/ methyltestosterone Estratest P O X

129 esterified estrogens/ methyltestosterone Estratest P O X



119 estradiol, vaginal Estring O O44 moricizine Ethmozine P O X78 amitriptyline/ perphenazine Etrafon O O88 amitriptyline/ perphenazine Etrafon O O28 flutamide Eulexin O O

251 crotamiton Eurax O O120 raloxifene Evista P O X250 sulconazole Exelderm O O97 rivastigmine Exelon O O

197 spacer E-Z Spacer P 3 P 3 X22 famciclovir Famvir P O X14 pyrimethamine/ sulfadoxine Fansidar O O28 toremifene Fareston O O

147 SMBG test strips Fast Take test strips G G X107 felbamate Felbatol P O X68 piroxicam Feldene O O28 letrozole Femara O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.122 ethinyl estradiol/ norethindrone acetate Femhrt O O

119 estradiol, transdermal FemPatch O O67 butalbital/ apap/ caffeine Fioricet O O63 codeine/ apap/ caffeine/ butalbital Fioricet w/ Codeine O O67 butalbital/ asa/ caffeine Fiorinal O O63 codeine/ asa/ caffeine/ butalbital Fiorinal w/ Codeine O O16 metronidazole Flagyl O O

229 fluoromethalone Flarex O O168 Sodium phosphate, oral solution Fleets Phospho - Soda X108 cyclobenzaprine Flexeril O O53 tamsulosin Flomax P O X

202 fluticasone Flonase P O X137 fludrocortisone Florinef O O253 diflorasone 0.05%, cream/ ointment Florone O O195 fluticasone, inhaler Flovent P O X

4 ofloxacin Floxin O O238 ofloxacin, otic Floxin Otic P P X21 rimantadine Flumadine O O

261 fluorouracil Fluoroplex O O229 fluoromethalone FML O O229 fluoromethalone FML Forte O O229 fluoromethalone FML SOP O O233 sulfacetamide/ fluorometholone FML-S O O190 formoterol Foradil O O20 saquinavir Fortovase P O X

152 alendronate Fosamax P O X70 frovatriptan Frova O 25 O 2512 griseofulvin microsize Fulvicin-U/F O O

244 nitrofurazone Furacin O O25 nitrofurantoin Furadantin O O25 furazolidone Furoxone O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.107 tiagabine Gabatril P O X10 sulfamethoxazole Gantanol O O10 sulfisoxazole Gantrisin P O X

233 sulfisoxazole diolamine, ophthalmic Gantrisin O O230 gentamicin Garamycin O O249 gentamicin sulfate, topical Garamycin O O95 ziprasidone Geodon P O X X

148 glucagon Glucagon Emergency Kit P O X

145 metformin Glucophage O O145 metformin, extended release Glucophage XR O O144 glipizide Glucotrol O O144 glipizide, extended release Glucotrol XL O O144 glyburide/ metformin Glucovance P O X144 glyburide, micronized Glynase O O141 miglitol Glyset P P X168 polyethylene glycol-electrolyte solution GoLYTELY O O

12 griseofulvin microsize Grifulvin V O O12 griseofulvin ultramicrosize Gris-Peg P O X

112 guanidine hcl Guanidine O O98 triazolam Halcion O O91 haloperidol Haldol O O14 halofantrine hcl Halfan O O

253 halcinonide 0.1%, cream/ ointment Halog O O253 halcinonide 0.1%, cream/ ointment Halog E O O129 fluoxymesterone Halotestin P O X160 bismuth subsalicylate/ metronidazole/


235 idoxuridine Herplex P O X24 diethylcarbamazine citrate Hetrazan O O30 altretamine Hexalen P O X


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.25 methenamine hippurate Hiprex O O17 zalcitabine Hivid P O X

143 human insulin lispro Humalog G G X143 human insulin lispro Humalog 50/50 G G X143 human insulin lispro Humalog 75/25 G G X8 paromomycin Humatin O O16 paromomycin Humatin O O

214 guaifenesin, sustained release Humibid LA O O143 human 50/ 50 insulin Humulin 50/50 G G X143 human 70/ 30 insulin Humulin 70/30 G G X143 human lente insulin Humulin L G G X143 human NPH insulin Humulin N G G X143 human regular insulin Humulin R G G X143 human ultralente insulin Humulin U Ultralente G G X211 hydrocodone/ homatopine Hycodan O O210 hydrocodone/ homatropine Hycodan O O117 ergoloid mesylates Hydergine O O117 ergoloid mesylates, sublingual Hydergine O O117 ergoloid mesylates Hydergine LC O O30 hydroxyurea Hydrea P O X37 hydrochlorothiazide HydroDIURIL O O54 reserpine/ hctz Hydropres O O54 reserpine/ hctz Hydro-Serp O O54 guanadrel Hylorel O O

255 hydrocortisone 0.5% Hytone O O255 hydrocortisone 1% Hytone O O255 hydrocortisone 2.5% Hytone O O53 terazosin Hytrin O O57 losartan/ hctz Hyzaar P P X6 erythromycin estolate Ilosone O O

230 erythromycin Ilotycin O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.43 isosorbide mononitrate, extended release Imdur O O

70 sumatriptan Imitrex P 24 O 24 X 24169 loperamide Imodium O O268 azathioprine Imuran O O269 azathioprine Imuran O O49 propranolol Inderal O O49 propranolol, sustained release Inderal LA P O X X49 propranolol/ hctz Inderide O O68 indomethacin Indocin O O68 indomethacin, sustained release Indocin SR O O

229 prednisolone sodium phosphate Inflamase Forte O O229 prednisolone sodium phosphate Inflamase Mild O O196 cromolyn sodium, inhalation Intal O O196 cromolyn sodium, metered dose inhaler Intal MDI P O X

54 guanethidine Ismelin O O43 isosorbide mononitrate ISMO O O47 verapamil Isoptin O O47 verapamil, sustained release Isoptin SR O O

227 atropine Isopto Atropine O O220 carbachol Isopto Carbachol P O X220 pilocarpine Isopto Carpine O O227 homatropine HBr Isopto Homatropine P O X227 scopolamine HBr Isopto Hyoscine P O X43 isosorbide dinitrate, sublingual Isordil O O43 isosorbide dinitrate, oral, sustained

releaseIsordil Tembids O O

43 isosorbide dinitrate, oral Isordil Titradose O O189 isoproterenol Isuprel O O183 potassium bicarb/ citrate K Lyte O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.183 potassium chloride/ potassium bicarb/

citrateK Lyte Cl O O

183 potassium bicarb/ citrate K Lyte DS O O63 morphine sulfate, controlled release Kadian O O20 lopinavir/ ritonavir Kaletra P O X9 kanamycin sulfate Kantrex O O

183 potassium gluconate Kaon O O184 sodium polystyrene sulfonate Kayexalate O O183 potassium chloride K-Dur O O

3 cephalexin Keflex O O3 cephalexin monohydrate Keftab O O

110 procyclidine Kemadrin O O X254 triamcinolone acetonide 0.025% Kenalog O O254 triamcinolone acetonide 0.1% Kenalog O O253 triamcinolone acetonide 0.5%, cream/

ointmentKenalog O O

254 triamcinolone acetonide, aerosol Kenalog aerosol P O X172 triamcinolone paste Kenalog in Orabase O O107 levetiracetam Keppra P O X X50 betaxolol Kerlone O O

240 sulfacetamide sodium Klaron O O106 clonazepam Klonopin P O X 19 X183 potassium chloride K-Lor O O263 potassium/ sodium acid phosphate K-Phos Neutral O O183 potassium chloride K-Tab O O75 granisetron Kytril P O X

236 hydroxypropyl cellulose Lacrisert O O107 lamotrigine Lamictal P O X X12 terbinafine Lamisil P O X23 clofazimine Lamprene O O42 digoxin Lanoxicaps O O42 digoxin Lanoxin G G X


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.143 insulin glargine Lantus G G X14 mefloquine hcl Larium O O

111 levodopa Larodopa O O37 furosemide Lasix O O60 fluvastatin Lescol O 21 O 2160 fluvastatin, extended release Lescol XL O 21 O 2126 chlorambucil Leukeran P O X4 levofloxacin Levaquin O O49 penbutolol Levatol O O

157 l-hyoscyamine sulfate, extended release Levbid O O

63 levorphanol Levo-Dromoran P O X149 levothyroxine sodium Levothroid P O X157 l-hyoscyamine sulfate Levsin O O157 l-hyoscyamine sulfate, sublingual Levsin/SL O O157 l-hyoscyamine sulfate, timed release Levsinex Timecaps O O

85 escitalopram Lexapro O O X56 felodipine/ enalapril Lexxel O O X46 felodipine/enalapril Lexxel O O

157 clidinium/ chlordiazepoxide Librax O O76 chlordiazepoxide Librium O O

253 fluocinonide 0.05% Lidex O O76 chlordiazepoxide/ amitriptyline Limbitrol DS O O78 chlordiazepoxide/ amitriptyline Limbitrol DS O O

108 baclofen Lioresal O O60 atorvastatin, 10mg, 20mg & 40mg Lipitor, 10mg, 20mg &

40mgO 21 O 21

60 atorvastatin, 80 mg Lipitor, 80 mg P 21 P 21 X 21138 prednisone Liquid Pred P O X96 lithium carbonate, slow release Lithobid P O X X

267 acetohydroxamic acid Lithostat O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.96 lithium carbonate Lithotabs O O

225 levocabastine Livostin O O59 cholestyramine/ sucrose LoCHOLEST O O59 cholestyramine/ aspartame LoCHOLEST Light O O

254 hydrocortisone butyrate 0.1% Locoid O O68 etodolac Lodine O O68 etodolac, extended release Lodine XL O O

111 carbidopa Lodosyn O O169 diphenoxylate/ atropine sulfate Lomotil O O55 minoxidil Loniten O O61 gemfibrozil Lopid O O50 metoprolol Lopressor O O50 metoprolol/ hctz Lopressor HCT O O

250 ciclopirox Loprox P O X3 loracarbef Lorabid O O63 hydrocodone/ apap Lorcet O O63 hydrocodone/ apap Lortab O O63 hydrocodone/ asa Lortab ASA O O

229 loteprednol etabonate Lotemax P P X56 benazepril Lotensin O O56 benazepril/ hctz Lotensin HCT O O46 amlodipine/ benazepril Lotrel P O X56 benazepril/ amlodipine Lotrel P O X94 loxapine Loxitane O O94 loxapine solution Loxitane C O O37 indapamide Lozol O O80 maprotiline Ludiomil O O

223 bimatoprost Lumigan P O X179 sodium fluoride Luride O O30 mitotane Lysodren O O25 nitrofurantoin macrocrystals Macrobid P O X25 nitrofurantoin macrocrystals Macrodantin O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.66 magnesium salicylate Magan O O25 methenamine mandelate Mandelamine O O

108 chlorphenesin carbamate Maolate O O193 theophylline/ ephedrine/ hydroxyzine

hclMarax O O

74 dronabinol Marinol O O86 isocarboxazid Marplan O O66 salsalate Marthritic O O

177 prenatal vitamins Materna O 2 O 230 procarbazine Matulane P O X56 trandolapril Mavik O O

189 pirbuterol acetate Maxair P O X189 pirbuterol acetate Maxair Auto P O X70 rizatriptan Maxalt O 25 O 2570 rizatriptan Maxalt-MLT O 25 O 254 lomefloxacin Maxaquin O O

253 diflorasone 0.05%, cream/ ointment Maxiflor O O232 neomycin/ polymyxin B/

dexamethasoneMaxitrol O O


Maxivate O O


Maxivate O O

41 triamterene/ hctz Maxzide O O100 mephobarbital Mebaral P O X 26240 meclocycline sulfosalicylate Meclan O O138 methylprednisolone Medrol O O28 megestrol Megace O O89 thioridazine Mellaril O O

118 esterified estrogens Menest O O250 butenafine Mentax O O33 phytonadione Mephyton P O X


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.176 phytonadione Mephyton P O X25 atovaquone Mepron O O

103 mephenytoin Mesantoin O O112 pyridostigmine bromide Mestinon P O X62 methylphenidate, extended release Metadate CD P 7 O 7 X 7 X 762 methylphenidate, extended release Metadate ER P 7 O 7 X 7 X 754 reserpine/ trichlormethiazide Metatensin O O

240 metronidazole, topical MetroCream P O X249 metronidazole, topical MetroCream P O X240 metronidazole, topical MetroGel P O X249 metronidazole, topical MetroGel P O X11 metronidazole Metro-Gel Vaginal P O X

240 metronidazole, topical MetroLotion P O X249 metronidazole, topical MetroLotion P O X60 lovastatin Mevacor O O44 mexiletine Mexitil P O X

151 calcitonin-salmon, nasal Miacalcin O O57 telmisartan Micardis O O57 telmisartan/ hctz Micardis HCT O O

183 potassium chloride Micro K O O144 glyburide Micronase O O37 hydrochlorothiazide Microzide O O39 amiloride hcl Midamor O O71 isometheptene/ dichloralphenazone/

apapMidrin O O

71 dihydroergotamine mesylate Migranal O 20 O 2077 meprobamate Miltown O O53 prazosin Minipress O O43 nitroglycerin, transdermal Minitran O O53 prazosin/ polythiazide Minizide O O5 minocycline Minocin O O

241 minocycline hcl Minocin O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.24 thiabendazole Mintezol O O35 anisindione Miradon O O

111 pramipexole Mirapex P O X124 ethinyl estradiol/ desogestrel Mircette P 3 P 3 X X X93 molindone Moban O O66 magnesium salicylate Mobidin O O41 amiloride/ hctz Moduretic O O5 doxycycline monohydrate Monodox O O

241 doxycycline monohydrate Monodox O O43 isosorbide mononitrate Monoket O O56 fosinopril Monopril O O56 fosinopril/hctz Monopril HCT O O25 fosfomycin tromethamine Monurol O O68 ibuprofen Motrin O O63 morphine sulfate, controlled release MS Contin O O63 morphine sulfate MSIR O O

198 acetylcysteine Mucomyst O O237 sodium chloride, hypertonic Muro 128 X133 alprostadil Muse O O15 ethambutol Myambutol O O

170 clotrimazole Mycelex Troches P O X15 rifabutin Mycobutin P O X 1812 nystatin Mycostatin O O13 nystatin Mycostatin O O

170 nystatin Mycostatin O O250 nystatin Mycostatin O O37 metolazone Mykrox O O26 busulfan Myleran P O X

107 primidone Mysoline P O X112 ambenonium chloride Mytelase O O250 naftifine Naftin O O68 fenoprofen calcium Nalfon O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.68 naproxen sodium, controlled release Naprelan O O68 naproxen Naprosyn O O37 trichlormethiazide Naqua O O86 phenelzine sulfate Nardil P O X X

202 triamcinolone Nasacort P O X202 triamcinolone Nasacort AQ P O X203 cromolyn sodium Nasalcrom X32 cyanocobalamin, nasal Nascobal P 11 O 11 X 11

174 cyanocobalamin, nasal Nascobal P 11 O 11 X 11202 mometasone Nasonex P O X234 natamycin Natacyn O O37 bendroflumethiazide Naturetin O O90 thiothixene Navane O O25 pentamidine isethionate, inhalation NebuPent P O X

198 pentamidine, inhalation Nebupent P O X25 nalidixic acid NegGram O O

102 pentobarbital Nembutal O O232 neomycin/ dexamethasone, ointment NeoDecadron ointment O O

232 neomycin/ dexamethasone, solution NeoDecadron solution O O268 cyclosporine, microemulsion Neoral P O X231 bacitracin/ neomycin/ polymyxin B,

ointmentNeosporin ointment O O



224 phenylephrine Neo-Synephrine O O40 methazolamide Neptazane O O

107 gabapentin Neurontin P O X X61 nicotinic acid, extended release Niaspan P P X

116 nicotine, inhaler Nicotrol inhaler O O116 nicotine, nasal spray Nicotrol NS O O28 nilutamide Nilandron O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.46 nimodipine Nimotop P O X43 nitroglycerin, topical Nitro-Bid O O43 nitroglycerin, transdermal Nitrodisc O O43 nitroglycerin, transdermal Nitro-Dur P O X43 nitroglycerin, transmucosal Nitrogard O O43 nitroglycerin, sustained release, oral Nitroglyn O O43 nitroglycerin, topical Nitrol O O43 nitroglycerin, translingual Nitrolingual P O X43 nitroglycerin, sustained release, oral Nitrong O O43 nitroglycerin, sublingual Nitrostat G G X12 ketoconazole Nizoral O O

246 ketoconazole, cream Nizoral O O X250 ketoconazole, cream Nizoral O O X250 ketoconazole, shampoo Nizoral P O X28 tamoxifen Nolvadex O O63 hydrocodone/ apap Norco O O

108 orphenadrine citrate Norflex O O108 orphenadrine/ asa/ caffeine Norgesic O O108 orphenadrine/ asa/ caffeine Norgesic Forte O O240 metronidazole, topical Noritate O O249 metronidazole, topical Noritate O O51 labetolol Normodyne O O4 norfloxacin Noroxin O O44 disopyramide Norpace P O X44 disopyramide, sustained release Norpace CR P O X79 desipramine Norpramin O O

126 norethindrone Nor-QD P 3 P 3 X X X46 amlodipine Norvasc O O20 ritonavir Norvir P O X

240 sulfur/ sulfacetamide Novacet O O147 insulin needles Novofine G G X147 insulin needles Novofine 30 G G X


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Code

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Choice

Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.143 human 70/ 30 insulin Novolin 70/30 G G X143 human 70/ 30 insulin Novolin 70/30 Penfill G G X143 human 70/ 30 insulin Novolin 70/30 Prefilled G G X143 human NPH insulin Novolin N G G X143 human NPH insulin Novolin N Penfill G G X143 human NPH insulin Novolin N Prefilled G G X143 human regular insulin Novolin R G G X143 human regular insulin Novolin R Penfill G G X143 human regular insulin Novolin R Prefilled G G X143 human insulin aspart Novolog G G X143 human insulin Novolog mix G G X147 insulin injector Novopen G G X210 codeine/ pseudoephedrine Nucofed O O215 guaifenesin/ pseudoephedrine/ codeine Nucofed Expectorant O O

216 guaifenesin/ pseudoephedrine/ codeine Nucofed Pediatric Expectorant

O O

128 ethinyl estradiol/ levonorgestrel Nuvaring O O X228 flurbiprofen sodium, ophthalmic Ocufen O O230 ofloxacin Ocuflox P O X219 carteolol Ocupress O O220 pilocarpine ocular therapeutic system Ocusert Pilo O O

118 estropipate Ogen O O119 estropipate, vaginal Ogen O O

3 cefdinir Omnicef O O207 phenylephrine/ chlorpheniramine/

methscopolamineOMNIhist LA G G

1 ampicillin Omnipen O O147 SMBG test strips One Touch test strips G G X147 SMBG test strips One Touch Ultra test strips G G X


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Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.225 cromolyn Opticrom O O206 azatadine Optimine O O219 metipranolol OptiPranolol O O225 azelastine Optivar O O185 sodium citrate/ citric acid Oracit O O262 sodium citrate/ citric acid Oracit O O92 pimozide Orap O O

138 prednisolone sodium phosphate, oral Orapred P O X

138 prednisone Orasone G G X214 guaifenesin Organidin NR O O144 tolbutamide Orinase O O119 dienestrol, vaginal Ortho Dienestrol O O118 estropipate Ortho-EST G G X128 ethinyl estradiol/ norelgestromin OrthoEvra O O X68 ketoprofen Orudis O O68 ketoprofen, extended release Oruvail O O

238 polymyxin B/ hydrocortisone, otic Otobiotic P O X251 malathion Ovide O O132 oxandrolone Oxandrin P O X250 oxiconazole Oxistat O O243 methoxasalen Oxsoralen-Ultra P O X63 oxycodone, controlled release Oxycontin P O63 oxycodone OxyIR O O79 nortriptyline Pamelor O O

157 methscopolamine bromide Pamine O O166 pancrelipase Pancrease O O166 pancrelipase Pancrease MT O O261 alitretinoin Panretin O O108 chlorzoxazone Parafon Forte DSC O O111 bromocriptine Parlodel P O X86 tranylcypromine sulfate Parnate O O


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Code

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Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.15 aminosalicylic acid Paser O O

225 olopatadine Patanol O O99 acetylcarbromal Paxarel O O85 paroxetine Paxil P P X X85 paroxetine, controlled release Paxil CR P P X X76 halazepam Paxipam O O

206 tripelennamine PBZ O O6 erythromycin base PCE O O

241 erythromycin base PCE O O245 methionine Pedameth O O138 prednisolone sodium phosphate, oral Pediapred O O

6 erythromycin/ sufisoxazole Pediazole O O10 erythromycin/ sufisoxazole Pediazole O O

103 ethotoin Peganone O O4 enoxacin Penetrex O O

173 mesalamine, controlled release Pentasa O O161 famotidine Pepcid O O63 oxycodone/ apap Percocet O O63 oxycodone/ asa Percodan O O

206 cyproheptadine Periactin O O170 chlorhexidine gluconate Peridex O O

5 doxycycline hyclate Periostat O O170 doxycycline hyclate Periostat O O111 pergolide Permax O O34 dipyridamole Persantine O O

206 promethazine Phenergan O O72 promethazine, tablets and liquid Phenergan O O

212 dextromethorphan/ promethazine Phenergan DM O O72 promethazine, suppositories Phenergan Suppositories P O X

208 phenylephrine/ promethazine Phenergan VC O O


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Code

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Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.210 codeine/ phenylephrine/ promethazine Phenergan VC w/codeine O O

210 codeine/ promethazine Phenergan w/codeine O O261 hexachlorophene pHisoHex O O182 calcium acetate Phoslo P 12 O 12 X 12221 echothiophate iodide Phospholine Iodide P O X67 butalbital/ apap Phrenilin O O67 butalbital/ apap Phrenilin Forte O O

220 pilocarpine nitrate Pilagan P O X220 pilocarpine Pilocar O O220 pilocarpine Pilopine HS P O X220 pilocarpine Pilostat O O214 potassium iodide Pima O O99 ethchlorvynol Placidyl O O

127 levonorgestrel Plan B P X14 hydroxychloroquine sulfate Plaquenil O O

269 hydroxychloroquine sulfate Plaquenil O O34 clopidogrel Plavix P P X46 felodipine Plendil P P X34 cilostazol Pletal O O

206 dexchlorpheniramine Polaramine O O185 potassium citrate/ sodium citrate/ citric

acidPolycitra P O X


Polycitra P O X

185 potassium citrate/ citric acid Polycitra K P O X262 potassium citrate/ citric acid Polycitra K P O X185 potassium citrate/ sodium citrate/ citric

acidPolycitra LC O O


Polycitra LC O O

231 bacitracin/ polymyxin B, ointment Polysporin O O


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.231 trimethoprim/ polymyxin B Polytrim O O179 multivitamins with fluoride Poly-Vi-Flor O 2 O 268 mefenamic acid Ponstel O O

142 repaglinide Prandin P O X60 pravastatin Pravachol P 21 P 21 X 2160 pravastatin/ aspirin Pravigard P 21 P 21 X 21

141 acarbose Precose P P X229 prednisolone acetate, ophthalmic Pred Forte P O X229 prednisolone acetate, ophthalmic Pred Mild O O138 prednisolone Prelone O O118 conjugated estrogens Premarin P O X119 conjugated estrogens, vaginal Premarin P O X122 conjugated estrogens/


122 conjugated estrogens/ medroxyprogesterone

Prempro P O X


Prempro Low Dose P O X

163 lansoprazole Prevacid O O163 lansoprazole Prevacid Granules O O59 cholestyramine/ aspartame Prevalite O O

127 ethinyl estradiol/ levonorgestrel Preven O X179 sodium fluoride Prevident O O160 lansoprazole/ amoxicillin/

clarithromycinPrevpac P O X

15 rifapentine Priftin O O163 omeprazole Prilosec O O14 primaquine phosphate Primaquine O O56 lisinopril Prinivil O O56 lisinopril/ hctz Prinzide O O

158 propantheline bromide Pro-Banthine O O44 procainamide, sustained release Procan SR O O


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Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.44 procainamide, sustained release Procanbid P O X46 nifedipine Procardia O O46 nifedipine, sustained release Procardia XL O O

139 hydrocortisone Proctocort O O X139 hydrocortisone acetate/ pramoxine Proctocream-HC O O X139 hydrocortisone acetate/ pramoxine Proctofoam-HC O O X268 tacrolimus Prograf P O X88 fluphenazine Prolixin O O

121 progesterone, micronized Prometrium P O X44 procainamide Pronestyl O O

218 dipivefrin Propine O O131 finasteride Proscar P O X98 estazolam Prosom O O

112 neostigmine Prostigmin O O265 neostigmine Prostigmin O O163 pantoprazole Protonix P P X 15188 albuterol Proventil O O189 albuterol Proventil O O189 albuterol Proventil HFA O O121 medroxyprogesterone acetate Provera O O62 modafinil Provigil O 9 O 985 fluoxetine Prozac O O

253 diflorasone 0.05%, cream Psorcon O O252 diflorasone 0.05%, ointment Psorcon B O O195 budesonide, inhaler Pulmicort P O X195 budesonide, respules Pulmicort respules P P X198 dornase alfa Pulmozyme O O27 mercaptopurine Purinethol P O X

266 phenazopyridine Pyridium O O157 clidinium bromide Quarzan O O59 cholestyramine/ sucrose Questran O O59 cholestyramine/ aspartame Questran Light O O


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Code

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Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.193 theophylline, tablets Quibron-T O O44 quinidine gluconate Quinaglute Dura-Tabs P O X44 quinidine sulfate, extended release Quinidex Extentabs P O X44 quinidine sulfate Quinora O O

230 levofloxacin Quixin O O195 beclomethasone, inhaler QVAR O O268 sirolimus Rapamune O O22 ribavirin Rebetol P O X72 metoclopramide Reglan O O

165 metoclopramide Reglan O O261 becaplermin Regranex O O54 reserpine/ chlorthalidone Regroton O O68 nabumetone Relafen O O21 zanamivir Relenza O O80 mirtazapine Remeron O O80 mirtazapine Remeron Soltab O O97 galantamine Reminyl O O

182 sevelamer Renagel P O X177 vitamin B complex/ vit C/ vit E/ folate Renal Tabs P 12 O 12 X 12

37 polythiazide Renese O O54 reserpine/ polythiazide Renese-R O O

111 ropinirole Requip P O X18 delavirdine mesylate Rescriptor P O X

223 unoprostone Rescula O O98 temazepam Restoril O O

240 tretinoin Retin-A O 10 O 10240 tretinoin Retin-A Micro O 10 O 1017 zidovudine Retrovir P O X

115 naltrexone ReVia P O X X27 methotrexate Rheumatrex O O

243 methotrexate Rheumatrex O O


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Code

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Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.269 methotrexate Rheumatrex O O202 budesonide Rhinocort AQ P O X269 auranofin Ridaura P O X15 rifampin Rifadin O O15 isoniazid/ rifampin Rifamate O O15 isoniazid/ rifampin/ pyrazinamide Rifater O O

117 riluzole Rilutek P O X95 risperidone Risperdal P O X X95 risperidone injection Risperdal Consta X95 risperidone Risperdal-M P O X X62 methylphenidate Ritalin O 8 O 862 methylphenidate, sustained release Ritalin SR O 8 O 8

108 methocarbamol Robaxin O O108 methocarbamol/ asa Robaxisal O O158 glycopyrrolate Robinul O O158 glycopyrrolate Robinul Forte O O215 guaifenesin/ codeine Robitussin AC O O214 guaifenesin/ pseudoephedrine Robitussin PE O O175 calcitriol Rocaltrol O O208 pseudoephedrine/ carbinoxamine Rondec O O212 dextromethorphan/ pseudoephedrine/

brompheniramineRondec DM O O


Rondec DM Drops O O


Rondec DM syrup O O

173 mesalamine, rectal Rowasa P O X207 phenylephrine/ chlorpheniramine/

pyrilamine, tabletsRynatan O O



O O

44 propafenone Rythmol P O X


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.171 pilocarpine, oral Salagen O O157 atropine sulfate Sal-Tropine O O54 reserpine/ hydroflumethiazide Salutensin O O

268 cyclosporine Sandimmune P O X259 collagenase Santyl O O246 sulfacetamide sodium, shampoo Sebizon O O102 secobarbital sodium Seconal O O50 acebutolol Sectral O O

246 selenium sulfide Selsun O O10 sulfamethoxazole/ trimethoprim Septra O O

241 sulfamethoxazole/ trimethoprim Septra O O76 oxazepam Serax O O89 mesoridazine Serentil O O

190 salmeterol Serevent P O X15 cycloserine Seromycin O O

133 clomiphene Serophene O 2 O 295 quetiapine fumarate Seroquel P O X X84 nefazodone Serzone O O X

244 silver sulfadiazine Silvadene O O111 levodopa/ carbidopa Sinemet O O111 levodopa/ carbidopa, sustained release Sinemet CR O O

77 doxepin Sinequan O O78 doxepin Sinequan O O

194 montelukast sodium Singulair P 30 O X 30212 dextromethorphan/ guaifenesin/

phenylephrineSinutuss DM G G

214 guaifenesin/ phenylephrine Sinuvent PE G G108 metaxalone Skelaxin O O152 tiludronate Skelid O O193 theophylline, timed release capsules Slo-Bid O O193 theophylline, timed release capsules Slo-Bid 50mg and 75mg P O X


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.193 theophylline, liquid Slo-Phyllin O O193 theophylline, tablets Slo-Phyllin O O193 theophylline, timed release capsules Slo-Phyllin Gyrocaps O O233 sulfacetamide Sodium Sulamyd O O108 carisoprodol Soma O O108 carisoprodol/ asa Soma Compound O O108 carisoprodol/ asa/ codeine Soma Compound w/

CodeineO O

99 zaleplon Sonata O O43 isosorbide dinitrate, chewable Sorbitrate O O

243 acitretin Soriatane P O X87 promazine Sparine O O

250 econazole Spectazole O O12 itraconazole Sporanox P O X

214 potassium iodide SSKI O O64 butorphanol Stadol NS O O

141 nateglinide Starlix P O X88 trifluoperazine Stelazine O O28 diethylstilbestrol Stilphostrol O O

136 desmopressin, nasal Stimate P O X117 atomoxetine Strattera O O X24 ivermectin Stromectol O O

177 prenatal vitamins Stuartnatal Plus O 2 O 246 nisoldipine Sular P P X

240 sulfur/ sulfacetamide Sulfacet-R O O244 mafenide Sulfamylon O O147 SMBG test strips Surestep test strips G G X78 trimipramine maleate Surmontil P O X X18 efavirenz Sustiva P O X21 amantadine Symmetrel O O

111 amantadine Symmetrel O O255 fluocinolone acetonide 0.01% Synalar O O


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.254 fluocinolone acetonide 0.025%, cream/

ointmentSynalar O O

253 fluocinolone acetonide 0.2%, cream Synalar HP O O134 nafarelin Synarel P O X149 levothyroxine sodium Synthroid P O X181 trientine Syprine O 2 O 2161 cimetidine Tagamet O O64 pentazocine/ apap Talacen O O64 pentazocine/ asa Talwin Compound O O64 pentazocine/ naloxone Talwin NX O O44 flecainide Tambocor P O X21 oseltamivir Tamiflu O O6 troleandomycin Tao O O

150 methimazole Tapazole O O30 bexarotene Targretin P P X47 verapamil ER/ trandolapril Tarka O O56 verapamil ER/ trandolapril Tarka O O

111 tolcapone Tasmar O O206 clemastine Tavist O O240 tazarotene Tazorac O O242 tazarotene Tazorac O O107 carbamazepine Tegretol P O X X107 carbamazepine, extended release Tegretol XR P O X X30 temozolomide Temodar P O X

252 clobetasol 0.05% Temovate O O252 clobetasol 0.05% Temovate E O O52 guanfacine Tenex O O50 atenolol/ chlorthalidone Tenoretic O O50 atenolol Tenormin O O4 gatifloxacin Tequin O O13 terconazole Terazol 3 O O13 terconazole Terazol 7 O O


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.28 testolactone Teslac O O

212 benzonatate Tessalon Perles O O130 testosterone, transdermal Testoderm O O129 methyltestosterone Testred O O57 eprosartan Teveten O O57 eprosartan/ hctz Teveten HCT O O37 chlorthalidone Thalitone O O23 thalidomide Thalomid O O

193 theophylline, timed release capsules Theo-24 P O X193 theophylline, timed release tablets Theochron G G X193 theophylline, timed release capsules Theo-Dur Sprinkle O O193 theophylline, liquid Theolair O O193 theophylline, tablets Theolair O O27 thioguanine Thioguanine P O X

267 tiopronin Thiola O O72 chlorpromazine Thorazine O O87 chlorpromazine Thorazine O O

149 liothyronine sodium/ levothyroxine Thyrolar P O X45 diltiazem, sustained release Tiazac P P X34 ticlopidine Ticlid O O73 trimethobenzamide Tigan O O44 dofetilide Tikosyn O O

196 nedocromil, inhaler Tilade O O49 timolol maleate/ hctz Timolide O O

219 timolol Timoptic O O219 timolol XE Timoptic XE O O25 tobramycin, inhalation TOBI P O X

198 tobramycin, inhalation TOBI P O X232 tobramycin/ dexamethasone TobraDex P O X230 tobramycin, ointment Tobrex ointment P O X230 tobramycin, solution Tobrex solution O O78 imipramine Tofranil O O


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.78 imipramine pamoate Tofranil PM P O X X68 tolmetin sodium Tolectin O O

144 tolazamide Tolinase O O107 topiramate Topamax P O X X253 desoximetasone 0.05%, gel Topicort O O253 desoximetasone 0.25%, cream/ ointment Topicort O O

254 desoximetasone 0.05%, cream Topicort LP O O240 tetracycline Topicycline O O50 metoprolol, extended release Toprol XL P P X68 ketorolac, oral Toradol O O72 thiethylperazine maleate Torecan O O

189 bitolterol mesylate Tornalate O O193 theophylline, timed release tablets T-Phyl O O51 labetolol Trandate O O43 nitroglycerin, transdermal Transderm-Nitro O O73 scopolamine, trandsdermal Transderm-Scop O O

106 chlorazepate dipotassium Tranxene O O76 clorazepate dipotassium Tranxene O O

259 sutilains Travase O O223 travoprost Travatan O O15 ethionamide Trecator-SC O O36 pentoxifylline Trental O O78 amitriptyline/ perphenazine Triavil O O88 amitriptyline/ perphenazine Triavil O O

240 benzoyl peroxide Triaz O O61 fenofibrate Tricor O O

105 trimethadione Tridione P O X72 perphenazine Trilafon O O88 perphenazine Trilafon O O

107 oxcarbazepine Trileptal P O X X125 ethinyl estradiol/ levonorgestrel Tri-Levlen P 3 P 3 X X X


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.66 choline salicyclate/ magnesium


25 trimethoprim Trimpex O O207 pseudoephedrine/ azatadine Trinalin O O181 iron/ vit c/ vit b12/ intrinsic factor/


179 multivitamins with fluoride, prescription Tri-Vi-Flor O 2 O 2

17 abacavir/ lamivudine/ zidovudine Trizivir P O X222 dorzolamide Trusopt P O X240 erythromycin T-Stat G G249 erythromycin, topical T-Stat O O210 hydrocodone/ chlorpheniramine Tussionex O O63 codeine/ apap Tylenol w/ Codeine O O63 oxycodone/ apap Tylox O O

207 pseudoephedrine/ brompheniramine Ultrabrom G G209 pseudoephedrine/ brompheniramine Ultrabrom PD G G65 tramadol/ apap Ultracet O O65 tramadol Ultram O O

166 pancrelipase Ultrase MT O O252 halobetasol propionate 0.05%, cream/


193 theophylline, timed release tablets Unidur O O193 theophylline, timed release tablets Uniphyl O O56 moexipril/ hctz Uniretic O O56 moexipril Univasc O O

265 bethanechol Urecholine O O25 methenamine hippurate Urex O O

264 flavoxate Urispas O O262 potassium citrate Urocit-K O O25 methylene blue Urolene Blue O O

119 estradiol hemihydrate Vagifem O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.254 betamethasone valerate 0.1%, cream/

lotionValisone O O


76 diazepam Valium O O106 diazepam Valium O O108 diazepam Valium O O22 valacyclovir Valtrex P O X7 vancomycin Vancocin O O24 oxamniquine Vansil O O3 cefpodoxime proxetil Vantin O O48 bepridil Vascor O O56 enalapril/ hctz Vaseretic O O


Vasocidin O O

224 naphazoline Vasocon O O226 naphazoline/ antazoline Vasocon-A O O233 sulfacetamide/ phenylephrine Vasosulf O O56 enalapril Vasotec O O1 penicillin V potassium V-Cillin K O O3 cephradine Velosef O O

143 human regular insulin Velosulin Human BR G G X188 albuterol Ventolin O O189 albuterol Ventolin O O189 albuterol Ventolin HFA O O29 etoposide VePesid P O X47 verapamil, sustained release Verelan O O24 mebendazole Vermox O O30 tretinoin, oral Vesanoid O O

229 rimexolone Vexol O O133 sildenafil Viagra O 2 O 2

5 doxycycline hyclate Vibramycin O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.14 doxycycline hyclate Vibramycin O O

241 doxycycline hyclate Vibramycin O O63 hydrocodone/ apap Vicodin O O63 hydrocodone/ apap Vicodin HP O O

215 guaifenesin/ hydrocodone Vicodin Tuss O O63 hydrocodone/ ibuprofen Vicoprofen O O17 didanosine Videx P O X17 didanosine, enteric coated Videx EC P O X

232 moxifloxacin Vigamox O O166 pancrelipase Viokase/Cotazym P O X69 rofecoxib Vioxx P 22 O X 22

235 vidarabine Vira-A P O X20 nelfinavir mesylate Viracept P O X18 nevirapine Viramune P O X19 tenofovir Viread P O X

235 trifluridine Viroptic P O X49 pindolol Visken O O77 hydroxyzine pamoate, capsules Vistaril O O

206 hydroxyzine pamoate, capsules Vistaril O O77 hydroxyzine pamoate, suspension Vistaril Suspension P O X X

206 hydroxyzine pamoate, suspension Vistaril suspension P O X X79 protriptyline Vivactil O O

119 estradiol, transdermal Vivelle O O188 albuterol, extended release Volmax O O68 diclofenac sodium, delayed release, oral Voltaren O O

228 diclofenac sodium, ophthalmic Voltaren P O X68 diclofenac sodium, extended release,

oralVoltaren XR O O

197 spacer Vortex P 3 P 3 X238 acetic acid, otic VoSol O O238 acetic acid/ hydrocortisone, otic VosSol HC O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.59 colesevelam Welchol O O82 buproprion Wellbutrin O O82 buproprion, sustained release Wellbutrin SR P P X X82 buproprion, extended release Wellbutrin XL P P X X31 leucovorin calcium Wellcovorin O O


Westcort O O

71 ergotamine tartrate/ caffeine/ tartaric acid

Wigraine suppositories O O

132 stanozolol Winstrol P O X63 propoxyphene/ apap Wygesic O O52 guanabenz Wytensin O O

223 latanoprost Xalatan P O X76 alprazolam Xanax O O27 capecitabine Xeloda P O X

240 aluminum chloride hexahydrate Xerac AC O O189 levalbuterol Xopenex O O256 lidocaine Xylocaine O O172 lidocaine, viscous Xylocaine O O257 lidocaine, viscous Xylocaine Viscous O O123 ethinyl estradiol/ drospirenone Yasmin P 3 P 3 X X X133 yohimbine Yocon O 2 O 216 iodoquinol Yodoxin P O X

225 ketotifen Zaditor P P X108 tizanidine Zanaflex O O161 ranitidine, tablets and capsules Zantac O O161 ranitidine syrup Zantac Syrup P O X104 ethosuximide Zarontin P O X37 metolazone Zaroxolyn P O X50 bisoprolol Zebeta O O17 stavudine Zerit P O X56 lisinopril/ hctz Zestoretic O O


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Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.56 lisinopril Zestril O O61 ezetimibe Zetia O O50 bisoprolol/ hctz Ziac O O17 abacavir sulfate Ziagen P O X6 azithromycin Zithromax O O X 1660 simvastatin Zocor O 21 O 2175 ondansetron Zofran P O X75 ondansetron Zofran ODT P O X85 sertraline Zoloft P P X X70 zolmitriptan Zomig O 25 O 25

247 doxepin Zonalon O O107 zonisamide Zonegran P O X66 aspirin, controlled release ZORprin O O22 acyclovir Zovirax O O

248 acyclovir ointment Zovirax P O X116 bupropion, extended release Zyban P O X X194 zileuton Zyflo P 30 O X 30153 allopurinol Zyloprim O O95 olanzapine Zyprexa P O X X95 olanzapine Zyprexa Zydis O O X

205 cetirizine/ pseudoephedrine Zyrtec D O O205 cetirizine, syrup Zyrtec syrup P P X205 cetirizine, tablets Zyrtec tablet O O

HMSA DRUG FORMULARY - Listed alphabetically by GENERIC name Rev. 4/1/04 - Page 1

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Code

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Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

17 abacavir sulfate Ziagen P O X17 abacavir/ lamivudine/ zidovudine Trizivir P O X141 acarbose Precose P P X50 acebutolol -- G G50 acebutolol Sectral O O65 acetaminophen -- X40 acetazolamide -- G G X40 acetazolamide Diamox O O107 acetazolamide -- G G X107 acetazolamide Diamox O O40 acetazolamide, extended release Diamox Sequels P O X239 acetic acid in aluminum acetate -- G G X239 acetic acid in aluminum acetate Domeboro Otic O O238 acetic acid, otic -- G G X238 acetic acid, otic VoSol O O238 acetic acid/ hydrocortisone, otic -- G G X238 acetic acid/ hydrocortisone, otic VosSol HC O O144 acetohexamide -- G G X144 acetohexamide Dymelor O O267 acetohydroxamic acid Lithostat O O99 acetylcarbromal Paxarel O O198 acetylcysteine -- G G X198 acetylcysteine Mucomyst O O243 acitretin Soriatane P O X255 aclometasone dipropionate 0.05%,


173 activated charcoal -- X22 acyclovir -- G G X22 acyclovir Zovirax O O248 acyclovir ointment Zovirax P O X240 adapalene Differin P 10 O 10 X 1024 albendazole Albenza O O



Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.188 albuterol -- G G X188 albuterol Proventil O O188 albuterol Ventolin O O189 albuterol -- G G X189 albuterol Proventil O O189 albuterol Proventil HFA O O189 albuterol Ventolin O O189 albuterol Ventolin HFA O O188 albuterol, extended release -- G G X188 albuterol, extended release Volmax O O189 albuterol/ ipratropium Combivent P O X192 albuterol/ ipratropium Combivent P O X152 alendronate Fosamax P O X261 alitretinoin Panretin O O153 allopurinol -- G G X153 allopurinol Zyloprim O O70 almotriptan Axert O 25 O 2576 alprazolam -- G G X 19 X76 alprazolam Xanax O O133 alprostadil Caverject O O133 alprostadil Muse O O30 altretamine Hexalen P O X260 aluminum acetate -- X240 aluminum chloride hexahydrate Xerac AC O O261 aluminum chloride hexahydrate Drysol O O155 aluminum hydroxide/ magnesium

hydroxide-- X

155 aluminum hydroxide/ magnesium hydroxide/ simethicone

-- X

21 amantadine -- G G X X21 amantadine Symmetrel O O111 amantadine -- G G X X


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.111 amantadine Symmetrel O O112 ambenonium chloride Mytelase O O253 amcinonide -- G G253 amcinonide Cyclocort O O39 amiloride hcl -- G G39 amiloride hcl Midamor O O41 amiloride/ hctz -- G G41 amiloride/ hctz Moduretic O O140 aminoglutethimide Cytadren P O X193 aminophylline -- G G 15 aminosalicylic acid Paser O O44 amiodarone -- G G X44 amiodarone Cordarone P O X78 amitriptyline -- G G X X78 amitriptyline Elavil O O78 amitriptyline/ perphenazine -- G G X X78 amitriptyline/ perphenazine Etrafon O O78 amitriptyline/ perphenazine Triavil O O88 amitriptyline/ perphenazine -- G G X X88 amitriptyline/ perphenazine Etrafon O O88 amitriptyline/ perphenazine Triavil O O172 amlexanox Aphthasol O O46 amlodipine Norvasc O O46 amlodipine/ benazepril Lotrel P O X242 ammoniated mercury Emersal O O79 amoxapine -- G G X X79 amoxapine Asendin O O1 amoxicillin trihydrate -- G G X X X2 amoxicillin/ k clavulanate -- G G X 12 amoxicillin/ k clavulanate Augmentin O O2 amoxicillin/ k clavulanate, extended

releaseAugmentin XR P O X 1


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.2 amoxicillin/ k clavulanate, extra strength Augmentin ES P O X 1

62 amphetamine mixture -- G 8 G 8 X 8 X 862 amphetamine mixture Adderall P 8 O 8 X 8 X 862 amphetamine mixture, extended release Adderall XR P 7 O 7 X 7 X 7

1 ampicillin -- G G X X X1 ampicillin Omnipen O O

20 amprenavir Agenerase P O X34 anagrelide Agrylin O O28 anastrazole Arimidex P O X35 anisindione Miradon O O242 anthralin Anthra-Derm O O242 anthralin Drithocreme P O X242 anthralin Drithocreme HP P O X242 anthralin Dritho-Scalp P O X239 antipyrine/ benzocaine -- G G X239 antipyrine/ benzocaine Auralgan O O95 aripiprazole Abilify P O X X236 artificial tears -- X34 aspirin -- X66 aspirin -- X66 aspirin, controlled release ZORprin O O66 aspirin, enteric coated Easprin O O34 aspirin/ dipyridamole Aggrenox P P X50 atenolol -- G G50 atenolol Tenormin O O50 atenolol/ chlorthalidone -- G G50 atenolol/ chlorthalidone Tenoretic O O117 atomoxetine Strattera O O X60 atorvastatin, 10mg, 20mg & 40mg Lipitor, 10mg, 20mg &

40mgO 21 O 21


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.60 atorvastatin, 80 mg Lipitor, 80 mg P 21 P 21 X 2125 atovaquone Mepron O O227 atropine -- G G X227 atropine Isopto Atropine O O157 atropine sulfate Sal-Tropine O O169 attapulgite -- X253 augmented betamethasone dipropionate

0.05%, creamDiprolene AF O O


-- G G


Diprolene O O

269 auranofin Ridaura P O X206 azatadine Optimine O O268 azathioprine -- G G X268 azathioprine Imuran O O269 azathioprine -- G G X269 azathioprine Imuran O O240 azelaic acid Azelex O O204 azelastine Astelin P O X225 azelastine Optivar O O

6 azithromycin Zithromax O O X 16230 bacitracin -- G G X X X230 bacitracin AK-Tracin O O249 bacitracin -- X231 bacitracin/ neomycin/ polymyxin B,

ointment-- G G X X X

231 bacitracin/ neomycin/ polymyxin B, ointment

Neosporin ointment O O

232 bacitracin/ neomycin/ polymyxin B/ hydrocortisone, ointment

-- G G X X X


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.232 bacitracin/ neomycin/ polymyxin B/

hydrocortisone, ointmentCortisporin O O

249 bacitracin/ polymyxin B -- X231 bacitracin/ polymyxin B, ointment -- G G X231 bacitracin/ polymyxin B, ointment Polysporin O O249 bacitracin/ polymyxin B/ neomycin -- X108 baclofen -- G G X108 baclofen Lioresal O O261 becaplermin Regranex O O202 beclomethasone Beconase AQ O O195 beclomethasone, inhaler QVAR O O157 belladona tincture Belladonna Tincture O O157 belladonna alkaloids/ phenobarbital -- G G157 belladonna alkaloids/ phenobarbital Donnatal O O157 belladonna extract/ butabarbital sodium Butibel O O

63 belladonna/ opium B&O suppositories O O56 benazepril Lotensin O O56 benazepril/ amlodipine Lotrel P O X56 benazepril/ hctz Lotensin HCT O O37 bendroflumethiazide Naturetin O O239 benzethonium chloride/ glycerin/

benzocaineAmericaine O O

212 benzonatate -- G G X212 benzonatate Tessalon Perles O O240 benzoyl peroxide -- G G X240 benzoyl peroxide Benzac O O240 benzoyl peroxide Desquam O O240 benzoyl peroxide Triaz O O110 benztropine -- G G X X110 benztropine Cogentin O O48 bepridil Vascor O O


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.138 betamethasone Celestone O O253 betamethasone dipropionate 0.05%,

cream/ ointment-- G G


Diprosone O O


Maxivate O O


-- G G


Diprosone O O


Maxivate O O


-- G G X


Valisone O O

253 betamethasone valerate 0.1%, ointment -- G G X


50 betaxolol Kerlone O O219 betaxolol Betoptic O O219 betaxolol Betoptic S O O265 bethanechol -- G G X265 bethanechol Urecholine O O30 bexarotene Targretin P P X28 bicalutamide Casodex P O X223 bimatoprost Lumigan P O X110 biperiden Akineton O O168 bisacodyl -- X169 bismuth subsalicylate -- X


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.160 bismuth subsalicylate/ metronidazole/


50 bisoprolol -- G G X50 bisoprolol Zebeta O O50 bisoprolol/ hctz -- G G X50 bisoprolol/ hctz Ziac O O189 bitolterol mesylate Tornalate O O217 brimonidine, 0.15% Alphagan P P O X217 brimonidine, 0.2% -- G G X222 brinzolamide Azopt O O111 bromocriptine Parlodel P O X138 budesonide Entocort EC O O202 budesonide Rhinocort AQ P O X195 budesonide, inhaler Pulmicort P O X195 budesonide, respules Pulmicort respules P P X38 bumetanide -- G G38 bumetanide Bumex O O116 bupropion, extended release Zyban P O X X82 buproprion -- G G X X82 buproprion Wellbutrin O O82 buproprion, extended release Wellbutrin XL P P X X82 buproprion, sustained release Wellbutrin SR P P X X77 buspirone -- G G X X77 buspirone Buspar O O26 busulfan Myleran P O X101 butabarbital sodium Butisol Sodium O O67 butalbital/ apap Phrenilin O O67 butalbital/ apap Phrenilin Forte O O67 butalbital/ apap/ caffeine -- G G X67 butalbital/ apap/ caffeine Esgic O O67 butalbital/ apap/ caffeine Esgic Plus O O67 butalbital/ apap/ caffeine Fioricet O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.67 butalbital/ asa/ caffeine -- G G X67 butalbital/ asa/ caffeine Fiorinal O O250 butenafine Mentax O O64 butorphanol -- G G64 butorphanol Stadol NS O O154 cabergoline Dostinex P O X242 calcipotriene Dovonex P O X151 calcitonin-salmon, nasal Miacalcin O O175 calcitriol -- G G X175 calcitriol Rocaltrol O O182 calcium acetate Phoslo P 12 O 12 X 12155 calcium carbonate -- X182 calcium carbonate -- X57 candesartan Atacand O O57 candesartan/ hctz Atacand HCT O O27 capecitabine Xeloda P O X56 captopril -- G G X56 captopril Capoten O O56 captopril/ hctz -- G G X56 captopril/ hctz Capozide O O220 carbachol Carbastat O O220 carbachol Isopto Carbachol P O X107 carbamazepine -- G G X X107 carbamazepine Tegretol P O X X107 carbamazepine, extended release Carbatrol O O107 carbamazepine, extended release Tegretol XR P O X X239 carbamide peroxide -- X111 carbidopa Lodosyn O O108 carisoprodol -- G G X108 carisoprodol Soma O O108 carisoprodol/ asa -- G G108 carisoprodol/ asa Soma Compound O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.108 carisoprodol/ asa/ codeine -- G G108 carisoprodol/ asa/ codeine Soma Compound w/

CodeineO O

136 carteolol Cartrol O O219 carteolol -- G G219 carteolol Ocupress O O51 carvedilol Coreg P P X3 cefaclor -- G G3 cefaclor Ceclor O O3 cefaclor, extended release -- G G3 cefaclor, extended release Ceclor CD O O3 cefadroxil -- G G3 cefadroxil Duricef O O3 cefdinir Omnicef O O3 cefpodoxime proxetil -- G G3 cefpodoxime proxetil Vantin O O3 cefprozil Cefzil O O3 ceftibuten Cedax O O3 cefuroxime -- G G X 13 cefuroxime Ceftin O O

69 celecoxib Celebrex P 22 O X 22178 cellulose sodium phosphate Calcibind P O X

3 cephalexin -- G G X X X3 cephalexin Keflex O O3 cephalexin monohydrate Keftab O O3 cephradine -- G G3 cephradine Velosef O O

205 cetirizine, syrup Zyrtec syrup P P X205 cetirizine, tablets Zyrtec tablet O O205 cetirizine/ pseudoephedrine Zyrtec D O O77 chloral hydrate -- G G X 599 chloral hydrate -- G G X 5


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.26 chlorambucil Leukeran P O X230 chloramphenicol, ophthalmic -- G G X X X230 chloramphenicol, ophthalmic Chloroptic O O238 chloramphenicol, otic Chloromycetin Otic O O106 chlorazepate dipotassium -- G G X 19106 chlorazepate dipotassium Tranxene O O76 chlordiazepoxide -- G G X 1976 chlordiazepoxide Librium O O76 chlordiazepoxide/ amitriptyline -- G G76 chlordiazepoxide/ amitriptyline Limbitrol DS O O78 chlordiazepoxide/ amitriptyline -- G G78 chlordiazepoxide/ amitriptyline Limbitrol DS O O170 chlorhexidine gluconate -- G G X170 chlorhexidine gluconate Peridex O O14 chloroquine phosphate Aralen P O X16 chloroquine phosphate Aralen P O X37 chlorothiazide -- G G37 chlorothiazide Diuril O O246 chloroxine Capitrol O O108 chlorphenesin carbamate Maolate O O206 chlorpheniramine -- X72 chlorpromazine -- G G X X72 chlorpromazine Thorazine O O87 chlorpromazine -- G G X X87 chlorpromazine Thorazine O O144 chlorpropamide -- G G X144 chlorpropamide Diabinese O O37 chlorthalidone -- G G37 chlorthalidone Thalitone O O108 chlorzoxazone -- G G X108 chlorzoxazone Parafon Forte DSC O O59 cholestyramine/ aspartame LoCHOLEST Light O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.59 cholestyramine/ aspartame Prevalite O O59 cholestyramine/ aspartame -- G G59 cholestyramine/ aspartame Questran Light O O59 cholestyramine/ sucrose -- G G59 cholestyramine/ sucrose LoCHOLEST O O59 cholestyramine/ sucrose Questran O O66 choline salicyclate/ magnesium


250 ciclopirox Loprox P O X34 cilostazol Pletal O O161 cimetidine -- G G X161 cimetidine Tagamet O O25 cinoxacin Cinobac O O4 ciprofloxacin -- O O4 ciprofloxacin Cipro P O X 1

238 ciprofloxacin hcl/ dexamethasone, otic Ciprodex O O

230 ciprofloxacin, ointment Ciloxan Ointment P P X230 ciprofloxacin, solution Ciloxan Solution O O238 ciprofloxacin/ hydrocortisone, otic Cipro HC Otic O O85 citalopram Celexa P P X X6 clarithromycin Biaxin P O X 296 clarithromycin, extended release Biaxin XL P O X 29

206 clemastine -- G G X206 clemastine Tavist O O157 clidinium bromide Quarzan O O157 clidinium/ chlordiazepoxide -- G G157 clidinium/ chlordiazepoxide Librax O O

8 clindamycin -- G G X8 clindamycin Cleocin O O

11 clindamycin Cleocin Vaginal P O X241 clindamycin -- G G X


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.241 clindamycin Cleocin O O8 clindamycin palmitate, suspension Cleocin Suspension P O X

240 clindamycin phosphate, topical -- G G X240 clindamycin phosphate, topical Cleocin T O O249 clindamycin phosphate, topical -- G G X249 clindamycin phosphate, topical Cleocin T O O252 clobetasol 0.05% -- G G X252 clobetasol 0.05% Cormax G G X252 clobetasol 0.05% Temovate O O252 clobetasol 0.05% Temovate E O O254 clocortolone pivalate 0.1%, cream Cloderm O O23 clofazimine Lamprene O O61 clofibrate Atromid S O O133 clomiphene -- G 2 G 2133 clomiphene Serophene O 2 O 2133 clomiphene Clomid O 2 O 278 clomipramine -- G G X X78 clomipramine Anafranil O O106 clonazepam -- G G X 19 X106 clonazepam Klonopin P O X 19 X52 clonidine, oral -- G G X X52 clonidine, oral Catapres O O52 clonidine, transdermal Catapres-TTS O O X52 clonidine/ chlorthalidone -- G G52 clonidine/ chlorthalidone Combipres O O34 clopidogrel Plavix P P X76 clorazepate dipotassium -- G G X 1976 clorazepate dipotassium Tranxene O O13 clotrimazole -- X170 clotrimazole Mycelex Troches P O X250 clotrimazole -- X

2 cloxacillin sodium -- G G X


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.95 clozapine -- G G95 clozapine Clozaril P O X246 coal tar -- X63 codeine sulfate -- G G X63 codeine/ apap -- G G X63 codeine/ apap Tylenol w/ Codeine O O63 codeine/ apap/ caffeine/ butalbital Fioricet w/ Codeine O O63 codeine/ asa -- G G X63 codeine/ asa Empirin w/ Codeine O O63 codeine/ asa/ caffeine/ butalbital Fiorinal w/ Codeine O O210 codeine/ phenylephrine/ promethazine -- O O

210 codeine/ phenylephrine/ promethazine Phenergan VC w/codeine O O

210 codeine/ promethazine -- G G X210 codeine/ promethazine Phenergan w/codeine O O210 codeine/ pseudoephedrine Nucofed O O210 codeine/ pseudoephedrine/

chlorpheniramine-- G G X

211 codeine/ pseudoephedrine/ chlorpheniramine

-- G G X

153 colchicine 0.5mg -- O O153 colchicine 0.6mg -- G G X153 colchicine/ probenecid -- G G X59 colesevelam Welchol O O59 colestipol, granules Colestid P O X59 colestipol, tablets Colestid P O259 collagenase Santyl O O270 condoms -- X118 conjugated estrogens Premarin P O X119 conjugated estrogens, vaginal Premarin P O X


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.122 conjugated estrogens/



Prempro P O X


Prempro Low Dose P O X

138 cortisone acetate Cortisone O O X225 cromolyn -- G G X225 cromolyn Opticrom O O225 cromolyn Crolom O O203 cromolyn sodium Nasalcrom X196 cromolyn sodium, inhalation -- G G X196 cromolyn sodium, inhalation Intal O O196 cromolyn sodium, metered dose inhaler Intal MDI P O X

251 crotamiton Eurax O O32 cyanocobalamin, nasal Nascobal P 11 O 11 X 11174 cyanocobalamin, nasal Nascobal P 11 O 11 X 11108 cyclobenzaprine -- G G X108 cyclobenzaprine Flexeril O O26 cyclophosphamide -- G G X26 cyclophosphamide Cytoxan P O X15 cycloserine Seromycin O O268 cyclosporine Sandimmune P O X268 cyclosporine, microemulsion -- G G X268 cyclosporine, microemulsion Neoral P O X206 cyproheptadine -- G G X206 cyproheptadine Periactin O O267 cysteamine bitartrate Cystagon O O135 danazol -- G G X135 danazol Danocrine P O X109 dantrolene Dantrium O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.23 dapsone Dapsone O O18 delavirdine mesylate Rescriptor P O X5 demeclocycline Declomycin O O

54 deserpidine/ methyclothiazide Enduronyl O O54 deserpidine/ methyclothiazide Enduronyl Forte O O79 desipramine -- G G X X79 desipramine Norpramin O O205 desloratadine Clarinex O O136 desmopressin, nasal Stimate P O X136 desmopressin, nasal DDAVP P O X136 desmopressin, oral DDAVP P O X255 desonide 0.05%, cream/ ointment -- G G X255 desonide 0.05%, cream/ ointment Desowen O O255 desonide 0.05%, lotion Desowen O O254 desoximetasone 0.05%, cream -- G G254 desoximetasone 0.05%, cream Topicort LP O O253 desoximetasone 0.05%, gel -- G G253 desoximetasone 0.05%, gel Topicort O O253 desoximetasone 0.25%, cream/ ointment -- G G

253 desoximetasone 0.25%, cream/ ointment Topicort O O

138 dexamethasone -- G G X138 dexamethasone Decadron O O255 dexamethasone 0.04%, aerosol Decaspray O O255 dexamethasone sodium phosphate 0.1%,

creamDecadron O O


-- G G X


Decadron O O

206 dexchlorpheniramine Polaramine O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.62 dextroamphetamine sulfate -- G 8 G 8 X 8 X 862 dextroamphetamine sulfate Dexedrine P 8 O 8 X 8 X 862 dextroamphetamine sulfate, sustained

release-- G 7 G 7 X 7 X 7

62 dextroamphetamine sulfate, sustained release

Dexedrine Spansules O 7 O 7 X 7

212 dextromethorphan/ guaifenesin/ phenylephrine

Sinutuss DM G G

212 dextromethorphan/ promethazine -- G G X212 dextromethorphan/ promethazine Phenergan DM O O212 dextromethorphan/ pseudoephedrine/

brompheniramine-- G G X


Dimetane DX O O


Rondec DM O O


Rondec DM syrup O O


-- G G X


Cardec DM Drops G G


Cardec DM Pediatric G G


Rondec DM Drops O O

270 diaphragms -- O 3 O 3 X X X76 diazepam -- G G X 1976 diazepam Valium O O106 diazepam -- G G X 19106 diazepam Valium O O108 diazepam -- G G X 19


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.108 diazepam Valium O O106 diazepam, rectal Diastat P O X40 dichlorphenamide Daranide O O68 diclofenac potasium -- G G68 diclofenac potasium Cataflam O O68 diclofenac sodium, delayed release, oral -- G G

68 diclofenac sodium, delayed release, oral Voltaren O O

68 diclofenac sodium, extended release, oral

Voltaren XR O O

228 diclofenac sodium, ophthalmic Voltaren P O X68 diclofenac/ misoprostol Arthrotec O O162 diclofenac/ misoprostol Arthrotec O O

2 dicloxacillin sodium -- G G X2 dicloxacillin sodium Dynapen O O2 dicloxacillin sodium, suspension Dynapen Suspension P O X

35 dicumarol Dicumarol O O159 dicyclomine -- G G X159 dicyclomine, syrup Bentyl Syrup P O X159 dicyclomine, tablets and capsules Bentyl O O17 didanosine Videx P O X17 didanosine, enteric coated Videx EC P O X119 dienestrol, vaginal Ortho Dienestrol O O24 diethylcarbamazine citrate Hetrazan O O28 diethylstilbestrol Stilphostrol O O253 diflorasone 0.05% cream/ ointment -- G G253 diflorasone 0.05%, cream Psorcon O O253 diflorasone 0.05%, cream/ ointment Florone O O253 diflorasone 0.05%, cream/ ointment Maxiflor O O252 diflorasone 0.05%, ointment Psorcon B O O66 diflunisal -- G G


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Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.66 diflunisal Dolobid O O42 digitoxin Crystodigin O O42 digoxin -- G G X42 digoxin Lanoxicaps O O42 digoxin Lanoxin G G X71 dihydroergotamine mesylate Migranal O 20 O 2045 diltiazem -- G G X45 diltiazem Cardizem O O45 diltiazem, sustained release -- G G X45 diltiazem, sustained release Cardizem CD O O45 diltiazem, sustained release Cardizem SR O O45 diltiazem, sustained release Dilacor XR O O45 diltiazem, sustained release Tiazac P P X73 diphenhydramine -- G G X X73 diphenhydramine Benadryl O O110 diphenhydramine -- G G X X110 diphenhydramine Benadryl O O206 diphenhydramine -- G G X X206 diphenhydramine Benadryl O O247 diphenhydramine, topical -- X169 diphenoxylate/ atropine sulfate -- G G169 diphenoxylate/ atropine sulfate Lomotil O O218 dipivefrin -- G G X218 dipivefrin Propine O O218 dipivefrin AKPro O O34 dipyridamole -- G G X34 dipyridamole Persantine O O6 dirithromycin Dynabac O O

44 disopyramide -- G G X44 disopyramide Norpace P O X44 disopyramide, sustained release -- G G X44 disopyramide, sustained release Norpace CR P O X


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Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.113 disulfiram Antabuse P O X X107 divalproex sodium Depakote P O X X107 divalproex sodium, extended release Depakote ER P O X X168 docusate sodium -- X168 docusate sodium/ casanthranol -- X44 dofetilide Tikosyn O O75 dolasetron mesylate Anzemet O O97 donepezil Aricept P O X198 dornase alfa Pulmozyme O O222 dorzolamide Trusopt P O X222 dorzolamide/ timolol Cosopt P O X53 doxazosin -- G G53 doxazosin mesylate Cardura O O77 doxepin -- G G X X77 doxepin Sinequan O O78 doxepin -- G G X X78 doxepin Sinequan O O247 doxepin Zonalon O O5 doxycycline hyclate -- G G X X X5 doxycycline hyclate Doryx O O5 doxycycline hyclate Periostat O O5 doxycycline hyclate Vibramycin O O

14 doxycycline hyclate -- G G X X X14 doxycycline hyclate Vibramycin O O170 doxycycline hyclate Periostat O O241 doxycycline hyclate -- G G X X X241 doxycycline hyclate Doryx O O241 doxycycline hyclate Vibramycin O O5 doxycycline monohydrate -- G G5 doxycycline monohydrate Monodox O O

241 doxycycline monohydrate -- G G241 doxycycline monohydrate Monodox O O


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Code

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Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.74 dronabinol Marinol O O221 echothiophate iodide Phospholine Iodide P O X250 econazole -- G G X250 econazole Spectazole O O18 efavirenz Sustiva P O X225 emedastine Emadine O O56 enalapril -- G G X56 enalapril Vasotec O O56 enalapril/ hctz -- G G X56 enalapril/ hctz Vaseretic O O4 enoxacin Penetrex O O

111 entacapone Comtan O O218 epinephrine Epifrin P O X191 epinephrine, injectable Epi-pen P O X191 epinephrine, injectable Epi-pen JR P O X191 epinephrine/ chlorpheniramine Anakit P O X218 epinephrine/ pilocarpine E-Pilo P O X218 epinephryl borate Epinal P O X57 eprosartan Teveten O O57 eprosartan/ hctz Teveten HCT O O117 ergoloid mesylates Hydergine O O117 ergoloid mesylates Hydergine LC O O117 ergoloid mesylates, sublingual -- G G117 ergoloid mesylates, sublingual Hydergine O O71 ergotamine tartrate Ergomar P O X71 ergotamine tartrate/ caffeine -- G G X71 ergotamine tartrate/ caffeine Cafergot O O71 ergotamine tartrate/ caffeine/ tartaric

acidWigraine suppositories O O

230 erythromycin -- G G X X X230 erythromycin Ilotycin O O240 erythromycin -- G G X


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Code

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Choice

Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.240 erythromycin ATS O O240 erythromycin Emgel O O240 erythromycin Erygel O O240 erythromycin T-Stat G G6 erythromycin base -- G G X X X6 erythromycin base Eryc O O6 erythromycin base Ery-Tab G G X X X6 erythromycin base PCE O O

241 erythromycin base -- G G X X X241 erythromycin base Eryc O O241 erythromycin base Ery-Tab G G X X X241 erythromycin base PCE O O

6 erythromycin estolate -- G G X X X6 erythromycin estolate Ilosone O O6 erythromycin ethylsuccinate -- G G X X X6 erythromycin ethylsuccinate EryPed O O6 erythromycin stearate -- G G X X X

249 erythromycin, topical -- G G X249 erythromycin, topical ATS O O249 erythromycin, topical Emgel O O249 erythromycin, topical Erygel O O249 erythromycin, topical T-Stat O O240 erythromycin/ benzoyl peroxide Benzamycin O O240 erythromycin/ benzoyl peroxide -- G G

6 erythromycin/ sufisoxazole -- G G X6 erythromycin/ sufisoxazole Pediazole O O

10 erythromycin/ sufisoxazole -- G G X10 erythromycin/ sufisoxazole Pediazole O O85 escitalopram Lexapro O O X98 estazolam -- G G98 estazolam Prosom O O118 esterified estrogens Menest O O


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Code

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Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.118 esterified estrogens/ methyltestosterone Estratest P O X



129 esterified estrogens/ methyltestosterone Estratest P O X

118 estradiol -- G G X118 estradiol Estrace O O119 estradiol hemihydrate Vagifem O O119 estradiol, transdermal -- G G X119 estradiol, transdermal Alora O O119 estradiol, transdermal Climara O O119 estradiol, transdermal Esclim O O119 estradiol, transdermal Estraderm O O119 estradiol, transdermal FemPatch O O119 estradiol, transdermal Vivelle O O119 estradiol, vaginal Estrace P O X119 estradiol, vaginal Estring O O122 estradiol/ norethindrone acetate Activella O O122 estradiol/ norethindrone acetate,


28 estramustine Emcyt P O X118 estropipate -- G G X118 estropipate Ogen O O118 estropipate Ortho-EST G G X119 estropipate, vaginal Ogen O O38 ethacrynic acid Edecrin O O15 ethambutol -- G G X 1815 ethambutol Myambutol O O99 ethchlorvynol Placidyl O O


Ther. Categ. Code


Code

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Choice

Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.118 ethinyl estradiol Estinyl O O123 ethinyl estradiol/ desogestrel Desogen P 3 P 3 X X X124 ethinyl estradiol/ desogestrel Mircette P 3 P 3 X X X123 ethinyl estradiol/ drospirenone Yasmin P 3 P 3 X X X123 ethinyl estradiol/ levonorgestrel Alesse P 3 P 3 X X X125 ethinyl estradiol/ levonorgestrel Tri-Levlen P 3 P 3 X X X127 ethinyl estradiol/ levonorgestrel Preven O X128 ethinyl estradiol/ levonorgestrel Nuvaring O O X128 ethinyl estradiol/ norelgestromin OrthoEvra O O X122 ethinyl estradiol/ norethindrone acetate Femhrt O O

15 ethionamide Trecator-SC O O104 ethosuximide Zarontin P O X103 ethotoin Peganone O O152 etidronate -- G G152 etidronate Didronel O O68 etodolac -- G G68 etodolac Lodine O O68 etodolac, extended release -- G G68 etodolac, extended release Lodine XL O O29 etoposide VePesid P O X61 ezetimibe Zetia O O22 famciclovir Famvir P O X161 famotidine -- G G161 famotidine Pepcid O O107 felbamate Felbatol P O X46 felodipine Plendil P P X56 felodipine/ enalapril Lexxel O O X46 felodipine/enalapril Lexxel O O61 fenofibrate -- O O61 fenofibrate Tricor O O68 fenoprofen calcium -- G G


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.68 fenoprofen calcium Nalfon O O63 fentanyl, transdermal Duragesic P O X181 ferrous sulfate -- X205 fexofenadine Allegra P P X205 fexofenadine/ pseudoephedrine Allegra D P P X259 fibrinolysin/ desoxyribonuclease Elase O O131 finasteride Proscar P O X264 flavoxate Urispas O O44 flecainide -- G G X44 flecainide Tambocor P O X12 fluconazole Diflucan P O X137 fludrocortisone -- G G X137 fludrocortisone Florinef O O195 flunisolide, inhaler Aerobid P P X195 flunisolide, inhaler Aerobid M P P X202 flunisolide, nasal -- P O X

255 fluocinolone acetonide 0.01% -- G G X255 fluocinolone acetonide 0.01% Synalar O O254 fluocinolone acetonide 0.025%, cream/

ointment-- G G X

254 fluocinolone acetonide 0.025%, cream/ ointment

Synalar O O

253 fluocinolone acetonide 0.2%, cream Synalar HP O O253 fluocinonide 0.05% -- G G253 fluocinonide 0.05% Lidex O O229 fluoromethalone -- G G X229 fluoromethalone Flarex O O229 fluoromethalone FML O O229 fluoromethalone FML Forte O O229 fluoromethalone FML SOP O O261 fluorouracil Efudex O O


Ther. Categ. Code


Code

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Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.261 fluorouracil Fluoroplex O O85 fluoxetine -- G G X X85 fluoxetine Prozac O O129 fluoxymesterone Halotestin P O X88 fluphenazine -- G G X X88 fluphenazine Prolixin O O88 fluphenazine deconoate, injectable -- X X254 flurandrenolide Cordran P O X254 flurandrenolide Cordran SP P O X254 flurandrenolide 4mcg/ cm2, tape Cordran tape P O X98 flurazepam -- G G98 flurazepam Dalmane O O68 flurbiprofen -- G G68 flurbiprofen Ansaid O O228 flurbiprofen sodium, ophthalmic -- G G228 flurbiprofen sodium, ophthalmic Ocufen O O28 flutamide -- G G X28 flutamide Eulexin O O202 fluticasone Flonase P O X254 fluticasone propionate 0.05%, cream/


195 fluticasone, inhaler Flovent P O X60 fluvastatin Lescol O 21 O 2160 fluvastatin, extended release Lescol XL O 21 O 2185 fluvoxamine maleate -- G G X31 folic acid -- G G X190 formoterol Foradil O O25 fosfomycin tromethamine Monurol O O56 fosinopril -- G G56 fosinopril Monopril O O56 fosinopril/hctz Monopril HCT O O70 frovatriptan Frova O 25 O 25


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.25 furazolidone Furoxone O O37 furosemide -- G G X37 furosemide Lasix O O107 gabapentin Neurontin P O X X97 galantamine Reminyl O O22 ganciclovir -- G G X22 ganciclovir Cytovene O O4 gatifloxacin Tequin O O

61 gemfibrozil -- G G X61 gemfibrozil Lopid O O230 gentamicin -- G G X230 gentamicin Garamycin O O249 gentamicin sulfate, topical -- G G X249 gentamicin sulfate, topical Garamycin O O11 glacial acetic acid Aci-jel O O144 glimepiride Amaryl O O144 glipizide -- G G X144 glipizide Glucotrol O O144 glipizide, extended release -- G G X144 glipizide, extended release Glucotrol XL O O148 glucagon Glucagon Emergency Kit P O X

144 glyburide -- G G X144 glyburide Diabeta O O144 glyburide Micronase O O144 glyburide, micronized -- G G X144 glyburide, micronized Glynase O O144 glyburide/ metformin Glucovance P O X168 glycerin -- X158 glycopyrrolate Robinul O O158 glycopyrrolate Robinul Forte O O


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.231 gramicidin/ neomycin/ polymyxin B,

solution-- G G X X X



75 granisetron Kytril P O X12 griseofulvin microsize -- G G12 griseofulvin microsize Fulvicin-U/F O O12 griseofulvin microsize Grifulvin V O O12 griseofulvin ultramicrosize -- G G X12 griseofulvin ultramicrosize Gris-Peg P O X214 guaifenesin Duratuss G O O214 guaifenesin Organidin NR O O214 guaifenesin (generic Robitussin) -- X214 guaifenesin, sustained release -- G G214 guaifenesin, sustained release Humibid LA O O215 guaifenesin/ codeine -- G G X215 guaifenesin/ codeine Robitussin AC O O214 guaifenesin/ dextromethorphan (generic

Robitussin DM)-- X

215 guaifenesin/ hydrocodone -- G G215 guaifenesin/ hydrocodone Vicodin Tuss O O214 guaifenesin/ phenylephrine Sinuvent PE G G214 guaifenesin/ phenylephrine Entex LA O O214 guaifenesin/ pseudoephedrine -- G G X214 guaifenesin/ pseudoephedrine Robitussin PE O O214 guaifenesin/ pseudoephedrine Entex PSE O O215 guaifenesin/ pseudoephedrine/ codeine -- G G X

215 guaifenesin/ pseudoephedrine/ codeine Nucofed Expectorant O O

216 guaifenesin/ pseudoephedrine/ codeine -- G G


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.216 guaifenesin/ pseudoephedrine/ codeine Nucofed Pediatric

ExpectorantO O

52 guanabenz -- G G52 guanabenz Wytensin O O54 guanadrel Hylorel O O54 guanethidine Ismelin O O52 guanfacine -- G G X52 guanfacine Tenex O O112 guanidine hcl Guanidine O O76 halazepam Paxipam O O253 halcinonide 0.1%, cream/ ointment Halog O O253 halcinonide 0.1%, cream/ ointment Halog E O O252 halobetasol propionate 0.05%, cream/


14 halofantrine hcl Halfan O O91 haloperidol -- G G X X91 haloperidol Haldol O O91 haloperidol decanoate, injectable -- X X261 hexachlorophene pHisoHex O O227 homatropine HBr Isopto Homatropine P O X143 human 50/ 50 insulin Humulin 50/50 G G X143 human 70/ 30 insulin Humulin 70/30 G G X143 human 70/ 30 insulin Novolin 70/30 G G X143 human 70/ 30 insulin Novolin 70/30 Penfill G G X143 human 70/ 30 insulin Novolin 70/30 Prefilled G G X143 human insulin Novolog mix G G X143 human insulin aspart Novolog G G X143 human insulin lispro Humalog G G X143 human insulin lispro Humalog 50/50 G G X143 human insulin lispro Humalog 75/25 G G X143 human lente insulin Humulin L G G X143 human NPH insulin Humulin N G G X


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.143 human NPH insulin Novolin N G G X143 human NPH insulin Novolin N Penfill G G X143 human NPH insulin Novolin N Prefilled G G X143 human regular insulin Humulin R G G X143 human regular insulin Novolin R G G X143 human regular insulin Novolin R Penfill G G X143 human regular insulin Novolin R Prefilled G G X143 human regular insulin Velosulin Human BR G G X143 human ultralente insulin Humulin U Ultralente G G X55 hydralazine -- G G X55 hydralazine Apresoline O O55 hydralazine/ hctz -- G G55 hydralazine/ hctz Apresazide O O37 hydrochlorothiazide -- G G X37 hydrochlorothiazide HydroDIURIL O O37 hydrochlorothiazide Microzide O O63 hydrocodone/ apap -- G G X63 hydrocodone/ apap Anexsia O O63 hydrocodone/ apap Lorcet O O63 hydrocodone/ apap Lortab O O63 hydrocodone/ apap Norco O O63 hydrocodone/ apap Vicodin O O63 hydrocodone/ apap Vicodin HP O O63 hydrocodone/ asa Lortab ASA O O210 hydrocodone/ chlorpheniramine Tussionex O O211 hydrocodone/ homatopine Hycodan O O210 hydrocodone/ homatropine -- G G210 hydrocodone/ homatropine Hycodan O O211 hydrocodone/ homatropine -- G G63 hydrocodone/ ibuprofen -- G G63 hydrocodone/ ibuprofen Vicoprofen O O210 hydrocodone/ pseudoephedrine -- G G


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.138 hydrocortisone -- G G X138 hydrocortisone Cortef O O139 hydrocortisone Cortenema P O X139 hydrocortisone Proctocort O O X255 hydrocortisone 0.25%, lotion -- G G X255 hydrocortisone 0.25%, lotion Cetacort O O255 hydrocortisone 0.5% -- G G X255 hydrocortisone 0.5% Hytone O O255 hydrocortisone 1% -- G G X255 hydrocortisone 1% Hytone O O255 hydrocortisone 2.5% -- G G X255 hydrocortisone 2.5% Hytone O O139 hydrocortisone acetate -- G G X 14139 hydrocortisone acetate Anusol HC O O139 hydrocortisone acetate Cortifoam O O139 hydrocortisone acetate/ pramoxine Analpram HC O O X139 hydrocortisone acetate/ pramoxine Proctocream-HC O O X139 hydrocortisone acetate/ pramoxine Proctofoam-HC O O X254 hydrocortisone butyrate 0.1% Locoid O O254 hydrocortisone valerate 0.2%, cream/

ointment-- G G X


Westcort O O

63 hydromorphone -- G G X63 hydromorphone Dilaudid O O14 hydroxychloroquine sulfate -- G G X14 hydroxychloroquine sulfate Plaquenil O O269 hydroxychloroquine sulfate -- G G X269 hydroxychloroquine sulfate Plaquenil O O236 hydroxypropyl cellulose Lacrisert O O30 hydroxyurea -- G G X30 hydroxyurea Hydrea P O X


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.77 hydroxyzine hcl -- G G X X77 hydroxyzine hcl Atarax O O206 hydroxyzine hcl -- G G X X206 hydroxyzine hcl Atarax O O77 hydroxyzine pamoate, capsules -- G G X X77 hydroxyzine pamoate, capsules Vistaril O O206 hydroxyzine pamoate, capsules -- G G X X206 hydroxyzine pamoate, capsules Vistaril O O77 hydroxyzine pamoate, suspension Vistaril Suspension P O X X206 hydroxyzine pamoate, suspension Vistaril suspension P O X X68 ibuprofen -- G G X68 ibuprofen Motrin O O235 idoxuridine Herplex P O X78 imipramine -- G G X X78 imipramine Tofranil O O78 imipramine pamoate Tofranil PM P O X X261 imiquimod Aldara P O X37 indapamide -- G G X37 indapamide Lozol O O20 indinavir sulfate Crixivan P O X68 indomethacin -- G G X68 indomethacin Indocin O O68 indomethacin, sustained release -- G G X68 indomethacin, sustained release Indocin SR O O143 insulin glargine Lantus G G X147 insulin injector Novopen G G X147 insulin needles Novofine G G X147 insulin needles Novofine 30 G G X16 iodoquinol Yodoxin P O X173 ipecac syrup -- X192 ipratropium, inhalation -- G G X192 ipratropium, inhalation Atrovent O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.192 ipratropium, inhalation Atrovent MDI P O X201 ipratropium, nasal -- G G X201 ipratropium, nasal Atrovent O O57 irbesartan Avapro P P X57 irbesartan/ hctz Avalide P P X181 iron/ multivit/ mineral, prescription -- G 2 G 2181 iron/ multivit/ mineral, prescription Berocca Plus O 2 O 2181 iron/ vit c/ vit b12/ intrinsic factor/


86 isocarboxazid Marplan O O189 isoetharine -- O O71 isometheptene/ dichloralphenazone/

apap-- G G

71 isometheptene/ dichloralphenazone/ apap

Midrin O O

15 isoniazid -- G G X 415 isoniazid/ rifampin Rifamate O O15 isoniazid/ rifampin/ pyrazinamide Rifater O O189 isoproterenol Isuprel O O43 isosorbide dinitrate, chewable Sorbitrate O O43 isosorbide dinitrate, oral -- G G X43 isosorbide dinitrate, oral Isordil Titradose O O43 isosorbide dinitrate, oral, sustained

release-- G G X


Dilatrate-SR O O


Isordil Tembids O O

43 isosorbide dinitrate, sublingual -- G G X43 isosorbide dinitrate, sublingual Isordil O O43 isosorbide mononitrate -- G G43 isosorbide mononitrate ISMO O O


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.43 isosorbide mononitrate Monoket O O43 isosorbide mononitrate, extended release -- G G X

43 isosorbide mononitrate, extended release Imdur O O

241 isotretinoin -- G G241 isotretinoin Accutane O O46 isradipine DynaCirc O O12 itraconazole Sporanox P O X24 ivermectin Stromectol O O9 kanamycin sulfate Kantrex O O

169 kaolin/ pectin -- X12 ketoconazole -- G G X12 ketoconazole Nizoral O O246 ketoconazole, cream -- G G X246 ketoconazole, cream Nizoral O O X250 ketoconazole, cream -- G G X250 ketoconazole, cream Nizoral O O X250 ketoconazole, shampoo Nizoral P O X68 ketoprofen -- G G68 ketoprofen Orudis O O68 ketoprofen, extended release -- G G68 ketoprofen, extended release Oruvail O O228 ketorolac tromethamine, ophthalmic Acular P O X228 ketorolac tromethamine, ophthalmic Acular PF P O X68 ketorolac, oral -- G G68 ketorolac, oral Toradol O O225 ketotifen Zaditor P P X51 labetolol -- G G X51 labetolol Normodyne O O51 labetolol Trandate O O168 lactulose -- G G X


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.168 lactulose Cephulac O O168 lactulose Chronulac O O157 l-alkaloids of belladonna/ phenobarbital/

ergotamine-- G G

157 l-alkaloids of belladonna/ phenobarbital/ ergotamine

Bellergal-S O O

17 lamivudine Epivir P O X17 lamivudine Epivir-HBV P O X17 lamivudine/ zidovudine Combivir P O X107 lamotrigine Lamictal P O X X163 lansoprazole Prevacid O O163 lansoprazole Prevacid Granules O O160 lansoprazole/ amoxicillin/

clarithromycinPrevpac P O X

223 latanoprost Xalatan P O X269 leflunomide Arava O O28 letrozole Femara O O31 leucovorin calcium -- G G X31 leucovorin calcium Wellcovorin O O189 levalbuterol Xopenex O O30 levamisole Ergamisol P O X107 levetiracetam Keppra P O X X219 levobunolol -- G G X219 levobunolol Betagan O O225 levocabastine Livostin O O186 levocarnitine Carnitor P 13 O 13 X 13111 levodopa Larodopa O O111 levodopa Dopar O O111 levodopa/ carbidopa -- G G X111 levodopa/ carbidopa Sinemet O O111 levodopa/ carbidopa, sustained release -- G G X


Ther. Categ. Code


Code

Select

Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.111 levodopa/ carbidopa, sustained release Sinemet CR O O

230 levofloxacin Quixin O O4 levofloxacin Levaquin O O

127 levonorgestrel Plan B P X63 levorphanol Levo-Dromoran P O X149 levothyroxine sodium -- G G X149 levothyroxine sodium Levothroid P O X149 levothyroxine sodium Synthroid P O X157 l-hyoscyamine sulfate -- G G157 l-hyoscyamine sulfate Levsin O O157 l-hyoscyamine sulfate, extended release Levbid O O

157 l-hyoscyamine sulfate, sublingual Levsin/SL O O157 l-hyoscyamine sulfate, timed release Levsinex Timecaps O O

256 lidocaine -- G G X256 lidocaine Xylocaine O O172 lidocaine, viscous -- G G X172 lidocaine, viscous Xylocaine O O257 lidocaine, viscous -- G G X257 lidocaine, viscous Xylocaine Viscous O O256 lidocaine/ prilocaine EMLA O O251 lindane -- G G X149 liothyronine sodium Cytomel P O X149 liothyronine sodium/ levothyroxine Thyrolar P O X56 lisinopril -- G G X56 lisinopril Prinivil O O56 lisinopril Zestril O O56 lisinopril/ hctz -- G G X56 lisinopril/ hctz Prinzide O O56 lisinopril/ hctz Zestoretic O O


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Code

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.96 lithium carbonate -- G G X X96 lithium carbonate Eskalith O O96 lithium carbonate Lithotabs O O96 lithium carbonate, controlled release Eskalith CR P O X X

96 lithium carbonate, slow release Lithobid P O X X96 lithium carbonate, slow release -- G G X X96 lithium citrate -- G G X X225 lodoxamide Alomide O O

4 lomefloxacin Maxaquin O O26 lomustine CeeNu P O X169 loperamide -- G G X169 loperamide Imodium O O20 lopinavir/ ritonavir Kaletra P O X3 loracarbef Lorabid O O

205 loratadine -- X76 lorazepam -- G G X 19 X76 lorazepam Ativan O O57 losartan Cozaar P P X57 losartan/ hctz Hyzaar P P X229 loteprednol etabonate Alrex O O229 loteprednol etabonate Lotemax P P X60 lovastatin -- G G X60 lovastatin Mevacor O O60 lovastatin, extended release Altocor O 21 O 2194 loxapine -- G G94 loxapine Loxitane O O94 loxapine solution Loxitane C O O244 mafenide Sulfamylon O O168 magnesium citrate -- X155 magnesium hydroxide -- X168 magnesium hydroxide -- X


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Code

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Choice

Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.66 magnesium salicylate Magan O O66 magnesium salicylate Mobidin O O251 malathion Ovide O O80 maprotiline -- G G X X80 maprotiline Ludiomil O O261 masoprocol Actinex O O24 mebendazole -- G G X24 mebendazole Vermox O O73 meclizine -- G G X73 meclizine Antivert O O240 meclocycline sulfosalicylate Meclan O O68 meclofenamate sodium -- G G121 medroxyprogesterone acetate -- G G X121 medroxyprogesterone acetate Amen O O121 medroxyprogesterone acetate Curretab O O121 medroxyprogesterone acetate Provera O O128 medroxyprogesterone acetate, injectable Depo-Provera X X

68 mefenamic acid Ponstel O O14 mefloquine hcl Larium O O28 megestrol -- G G X28 megestrol Megace O O26 melphalan Alkeran P O X158 mepenzolate bromide Cantil O O63 meperidine -- G G X63 meperidine Demerol O O103 mephenytoin Mesantoin O O100 mephobarbital Mebaral P O X 2677 meprobamate -- G G77 meprobamate Equanil O O77 meprobamate Miltown O O27 mercaptopurine Purinethol P O X


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Code

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Code

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.173 mesalamine, controlled release Pentasa O O173 mesalamine, delayed release Asacol P O X173 mesalamine, rectal Rowasa P O X89 mesoridazine Serentil O O188 metaproterenol sulfate -- G G X188 metaproterenol sulfate Alupent O O189 metaproterenol sulfate, inhalation -- G G X189 metaproterenol sulfate, inhalation Alupent O O189 metaproterenol sulfate, metered dose


108 metaxalone Skelaxin O O145 metformin -- G G X145 metformin Glucophage O O145 metformin, extended release -- G G X145 metformin, extended release Glucophage XR O O63 methadone -- G G X X63 methadone Dolophine O O X114 methadone -- G G X X114 methadone Dolophine O O62 methamphetamine Desoxyn O 7 O 7158 methantheline bromide Banthine O O40 methazolamide -- G G X40 methazolamide Neptazane O O25 methenamine hippurate Hiprex O O25 methenamine hippurate Urex O O25 methenamine mandelate -- G G X25 methenamine mandelate Mandelamine O O150 methimazole -- G G X150 methimazole Tapazole O O245 methionine Pedameth O O108 methocarbamol -- G G X108 methocarbamol Robaxin O O


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Code

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Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.108 methocarbamol/ asa -- G G108 methocarbamol/ asa Robaxisal O O27 methotrexate -- G G X27 methotrexate Rheumatrex O O243 methotrexate -- G G X243 methotrexate Rheumatrex O O269 methotrexate -- G G X269 methotrexate Rheumatrex O O243 methoxasalen Oxsoralen-Ultra P O X157 methscopolamine bromide Pamine O O104 methsuximide Celontin Kapseals P O X37 methyclothiazide -- G G37 methyclothiazide Enduron O O52 methyldopa -- G G X52 methyldopa Aldomet O O52 methyldopa/ chlorothiazide Aldoclor O O52 methyldopa/ hctz -- G G52 methyldopa/ hctz Aldoril O O25 methylene blue Urolene Blue O O62 methylphenidate -- G 8 G 8 X 8 X 862 methylphenidate Ritalin O 8 O 862 methylphenidate, extended release Concerta O 7 O 762 methylphenidate, extended release Metadate CD P 7 O 7 X 7 X 762 methylphenidate, extended release Metadate ER P 7 O 7 X 7 X 762 methylphenidate, sustained release -- G 8 G 8 X 8 X 862 methylphenidate, sustained release Ritalin SR O 8 O 8138 methylprednisolone -- G G138 methylprednisolone Medrol O O129 methyltestosterone Android P O X129 methyltestosterone Testred O O219 metipranolol -- G G219 metipranolol OptiPranolol O O


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Choice

Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.72 metoclopramide -- G G X72 metoclopramide Reglan O O165 metoclopramide -- G G X165 metoclopramide Reglan O O37 metolazone Mykrox O O37 metolazone Zaroxolyn P O X50 metoprolol -- G G X50 metoprolol Lopressor O O50 metoprolol, extended release Toprol XL P P X50 metoprolol/ hctz Lopressor HCT O O11 metronidazole Metro-Gel Vaginal P O X16 metronidazole -- G G X16 metronidazole Flagyl O O240 metronidazole, topical MetroCream P O X240 metronidazole, topical MetroGel P O X240 metronidazole, topical MetroLotion P O X240 metronidazole, topical Noritate O O249 metronidazole, topical MetroCream P O X249 metronidazole, topical MetroGel P O X249 metronidazole, topical MetroLotion P O X249 metronidazole, topical Noritate O O58 metyrosine Demser O O44 mexiletine -- G G X44 mexiletine Mexitil P O X13 miconazole -- X250 miconazole -- X141 miglitol Glyset P P X

5 minocycline -- G G X5 minocycline Minocin O O

241 minocycline hcl -- G G X241 minocycline hcl Minocin O O55 minoxidil -- G G X


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Code

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Choice

Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.55 minoxidil Loniten O O80 mirtazapine -- G G X X80 mirtazapine Remeron O O80 mirtazapine -- G G X X80 mirtazapine Remeron Soltab O O162 misoprostol -- G G X162 misoprostol Cytotec O O30 mitotane Lysodren O O62 modafinil Provigil O 9 O 956 moexipril -- G G56 moexipril Univasc O O56 moexipril/ hctz Uniretic O O93 molindone Moban O O202 mometasone Nasonex P O X254 mometasone furoate 0.1% Elocon O O194 montelukast sodium Singulair P 30 O X 3044 moricizine Ethmozine P O X63 morphine sulfate -- G G X63 morphine sulfate MSIR O O63 morphine sulfate, controlled release -- G G X63 morphine sulfate, controlled release Kadian O O63 morphine sulfate, controlled release MS Contin O O4 moxifloxacin Avelox P O X 1

232 moxifloxacin Vigamox O O177 multivitamins -- X 6179 multivitamins with fluoride -- G 2 G 2 X 6179 multivitamins with fluoride Poly-Vi-Flor O 2 O 2179 multivitamins with fluoride, prescription Tri-Vi-Flor O 2 O 2

177 multivitamins/ minerals -- G 7 G 7 X 6249 mupirocin Bactroban O O268 mycophenolate mofetil CellCept P O X


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Code

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Choice

Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.68 nabumetone -- G G68 nabumetone Relafen O O49 nadolol -- G G49 nadolol Corgard O O49 nadolol/ bendroflumethiazide Corzide O O134 nafarelin Synarel P O X250 naftifine Naftin O O25 nalidixic acid NegGram O O115 naltrexone Depade O O115 naltrexone ReVia P O X X224 naphazoline -- G G X224 naphazoline Albalon O O224 naphazoline Vasocon O O226 naphazoline/ antazoline Vasocon-A O O68 naproxen -- G G X68 naproxen Naprosyn O O68 naproxen sodium -- G G X68 naproxen sodium Anaprox O O68 naproxen sodium, controlled release Naprelan O O70 naratriptan Amerge P 23 O 23 X 23234 natamycin Natacyn O O141 nateglinide Starlix P O X225 nedocromil Alocril P O X196 nedocromil, inhaler Tilade O O84 nefazodone -- G G X84 nefazodone Serzone O O X20 nelfinavir mesylate Viracept P O X9 neomycin -- G G X


232 neomycin/ dexamethasone, ointment NeoDecadron ointment O O


Ther. Categ. Code


Code

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Choice

Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.232 neomycin/ dexamethasone, solution -- G G X X232 neomycin/ dexamethasone, solution NeoDecadron solution O O238 neomycin/ hydrocortisone, otic Coly-Mycin S Otic O O249 neomycin/ poly+D2035myxin B/



-- G G X


Maxitrol O O


-- G G X X X


Cortisporin Otic O O


-- G G X X X


Cortisporin O O

112 neostigmine Prostigmin O O265 neostigmine Prostigmin O O18 nevirapine Viramune P O X46 nicardipine -- G G46 nicardipine Cardene O O46 nicardipine, sustained release Cardene SR O O116 nicotine, inhaler Nicotrol inhaler O O116 nicotine, nasal spray Nicotrol NS O O116 nicotine, transdermal -- G 2 G 2 X X61 nicotinic acid, extended release Niaspan P P X61 nicotinic acid, extended release/

lovastatinAdvicor P P X

46 nifedipine -- G G46 nifedipine Adalat O O46 nifedipine Procardia O O


Ther. Categ. Code


Code

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Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.46 nifedipine, sustained release -- G G X46 nifedipine, sustained release Adalat CC O O46 nifedipine, sustained release Procardia XL O O28 nilutamide Nilandron O O46 nimodipine Nimotop P O X46 nisoldipine Sular P P X25 nitrofurantoin Furadantin O O25 nitrofurantoin macrocrystals -- G G X25 nitrofurantoin macrocrystals Macrobid P O X25 nitrofurantoin macrocrystals Macrodantin O O244 nitrofurazone Furacin O O43 nitroglycerin, sublingual Nitrostat G G X43 nitroglycerin, sustained release, oral -- G G43 nitroglycerin, sustained release, oral Nitroglyn O O43 nitroglycerin, sustained release, oral Nitrong O O43 nitroglycerin, topical -- G G43 nitroglycerin, topical Nitro-Bid O O43 nitroglycerin, topical Nitrol O O43 nitroglycerin, transdermal -- G G X43 nitroglycerin, transdermal Minitran O O43 nitroglycerin, transdermal Nitrodisc O O43 nitroglycerin, transdermal Nitro-Dur P O X43 nitroglycerin, transdermal Transderm-Nitro O O43 nitroglycerin, translingual Nitrolingual P O X43 nitroglycerin, transmucosal Nitrogard O O161 nizatidine -- G G161 nizatidine Axid O O126 norethindrone Nor-QD P 3 P 3 X X X121 norethindrone acetate -- G G121 norethindrone acetate Aygestin O O

4 norfloxacin Noroxin O O230 norfloxacin Chibroxin O O


Ther. Categ. Code


Code

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Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.79 nortriptyline -- G G X X79 nortriptyline Aventyl O O79 nortriptyline Pamelor O O12 nystatin -- G G X12 nystatin Mycostatin O O13 nystatin -- G G X13 nystatin Mycostatin O O170 nystatin -- G G X170 nystatin Mycostatin O O250 nystatin -- G G X250 nystatin Mycostatin O O250 nystatin/ triamcinolone -- G G X236 ocular lubricants -- X

4 ofloxacin Floxin O O230 ofloxacin Ocuflox P O X238 ofloxacin, otic Floxin Otic P P X95 olanzapine Zyprexa P O X X95 olanzapine Zyprexa Zydis O O X57 olmesartan Benicar O O225 olopatadine Patanol O O173 olsalazine sodium Dipentum O O163 omeprazole -- G G163 omeprazole Prilosec O O75 ondansetron Zofran P O X75 ondansetron Zofran ODT P O X63 opium tincture, deodorized -- G G108 orphenadrine citrate -- G G108 orphenadrine citrate Norflex O O108 orphenadrine/ asa/ caffeine Norgesic Forte O O108 orphenadrine/ asa/ caffeine Norgesic O O21 oseltamivir Tamiflu O O2 oxacillin sodium -- G G X


Ther. Categ. Code


Code

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Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.24 oxamniquine Vansil O O132 oxandrolone Oxandrin P O X68 oxaprozin -- G G68 oxaprozin Daypro O O76 oxazepam -- G G76 oxazepam Serax O O107 oxcarbazepine Trileptal P O X X250 oxiconazole Oxistat O O193 oxtriphylline Choledyl O O264 oxybutynin -- G G X264 oxybutynin Ditropan O O264 oxybutynin, extended release Ditropan XL P O X63 oxycodone -- G G X63 oxycodone OxyIR O O63 oxycodone, controlled release Oxycontin P O63 oxycodone/ apap -- G G X63 oxycodone/ apap Percocet O O63 oxycodone/ apap Tylox O O63 oxycodone/ asa -- G G X63 oxycodone/ asa Percodan O O200 oxymetazoline -- X132 oxymetholone Anadrol O O166 pancreatin Creon O O166 pancrelipase Pancrease O O166 pancrelipase Pancrease MT O O166 pancrelipase Ultrase MT O O166 pancrelipase Viokase/Cotazym P O X163 pantoprazole Protonix P P X 1563 paregoric -- G G169 paregoric -- G G

8 paromomycin -- G G8 paromomycin Humatin O O


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.16 paromomycin -- G G16 paromomycin Humatin O O85 paroxetine Paxil P P X X85 paroxetine, controlled release Paxil CR P P X X197 peak flow meter Air Zone P 3 P 3 X187 pediatric electrolyte replacement

solution-- X

62 pemoline -- G 7 G 7 X 762 pemoline Cylert O 7 O 7 X 749 penbutolol Levatol O O248 penciclovir Denavir O O269 penicillamine Cuprimine P O X269 penicillamine Depen O O

1 penicillin V potassium -- G G X X X1 penicillin V potassium V-Cillin K O O

25 pentamidine isethionate, inhalation NebuPent P O X198 pentamidine, inhalation Nebupent P O X64 pentazocine/ apap Talacen O O64 pentazocine/ asa Talwin Compound O O64 pentazocine/ naloxone -- G G64 pentazocine/ naloxone Talwin NX O O102 pentobarbital Nembutal O O266 pentosan polysulfate sodium Elmiron O O36 pentoxifylline -- G G X36 pentoxifylline Trental O O111 pergolide -- G G X111 pergolide Permax O O56 perindopril Aceon O O251 permethrin -- G G X251 permethrin Elimite O O225 permivolast Alamast O O72 perphenazine -- G G X X


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.72 perphenazine Trilafon O O88 perphenazine -- G G X88 perphenazine Trilafon O O266 phenazopyridine -- G G X266 phenazopyridine Pyridium O O86 phenelzine sulfate Nardil P O X X100 phenobarbital -- G G X 2658 phenoxybenzamine Dibenzyline O O199 phenylephrine AH-Chew D G G X200 phenylephrine -- X224 phenylephrine -- G G X224 phenylephrine Neo-Synephrine O O207 phenylephrine/ chlorpheniramine/

methscopolamine-- G G


Dura-Vent/DA O O


OMNIhist LA G G


-- G G X


AH-chew G G X


D.A chew O O


-- G G X



O O


-- G G X


Rynatan O O


Ther. Categ. Code


Code

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Choice

Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.208 phenylephrine/ promethazine -- G G X208 phenylephrine/ promethazine Phenergan VC O O103 phenytoin -- G G X103 phenytoin Dilantin Infatab P O X103 phenytoin Dilantin 125 P O X103 phenytoin sodium, extended release -- G G X103 phenytoin sodium, extended release Dilantin Kapseals P O X221 physostigmine Eserine sulfate O O33 phytonadione Mephyton P O X176 phytonadione Mephyton P O X220 pilocarpine -- G G X220 pilocarpine Isopto Carpine O O220 pilocarpine Pilocar O O220 pilocarpine Pilopine HS P O X220 pilocarpine Pilostat O O220 pilocarpine nitrate Pilagan P O X220 pilocarpine ocular therapeutic system Ocusert Pilo O O

171 pilocarpine, oral Salagen O O220 pilocarpine/ epinephrine E-Pilo P O X92 pimozide Orap O O49 pindolol -- G G49 pindolol Visken O O146 pioglitazone Actos P O X189 pirbuterol acetate Maxair P O X189 pirbuterol acetate Maxair Auto P O X68 piroxicam -- G G68 piroxicam Feldene O O261 podofilox Condylox P O X168 polyethylene glycol-electrolyte solution -- G G X


Ther. Categ. Code


Code

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Choice

Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.168 polyethylene glycol-electrolyte solution CoLyte O O

168 polyethylene glycol-electrolyte solution GoLYTELY O O

238 polymyxin B/ hydrocortisone, otic Otobiotic P O X37 polythiazide Renese O O183 potassium bicarb/ citrate -- G G183 potassium bicarb/ citrate K Lyte DS O O183 potassium bicarb/ citrate K Lyte O O183 potassium chloride -- G G X183 potassium chloride K-Dur O O183 potassium chloride K-Lor O O183 potassium chloride K-Tab O O183 potassium chloride Micro K O O183 potassium chloride/ potassium bicarb/

citrate-- G G

183 potassium chloride/ potassium bicarb/ citrate

K Lyte Cl O O

262 potassium citrate Urocit-K O O185 potassium citrate/ citric acid Polycitra K P O X262 potassium citrate/ citric acid Polycitra K P O X185 potassium citrate/ sodium citrate/ citric

acidPolycitra P O X


Polycitra LC O O


Polycitra P O X


Polycitra LC O O

183 potassium gluconate -- G G183 potassium gluconate Kaon O O214 potassium iodide Pima O O


Ther. Categ. Code


Code

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Choice

Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.214 potassium iodide SSKI O O263 potassium/ sodium acid phosphate K-Phos Neutral O O111 pramipexole Mirapex P O X60 pravastatin Pravachol P 21 P 21 X 2160 pravastatin/ aspirin Pravigard P 21 P 21 X 2176 prazepam -- G G24 praziquantel Biltricide O O53 prazosin -- G G X53 prazosin Minipress O O53 prazosin/ polythiazide Minizide O O138 prednisolone -- G G X138 prednisolone Prelone O O229 prednisolone acetate, ophthalmic -- G G X229 prednisolone acetate, ophthalmic Econopred O O229 prednisolone acetate, ophthalmic Econopred Plus O O229 prednisolone acetate, ophthalmic Pred Forte P O X229 prednisolone acetate, ophthalmic Pred Mild O O229 prednisolone sodium phosphate -- G G X229 prednisolone sodium phosphate AK Pred O O229 prednisolone sodium phosphate Inflamase Forte O O229 prednisolone sodium phosphate Inflamase Mild O O138 prednisolone sodium phosphate, oral Orapred P O X

138 prednisolone sodium phosphate, oral Pediapred O O

138 prednisone -- G G X138 prednisone Liquid Pred P O X138 prednisone Orasone G G X177 prenatal vitamins -- G 2 G 2 X 28177 prenatal vitamins Materna O 2 O 2177 prenatal vitamins Stuartnatal Plus O 2 O 214 primaquine phosphate Primaquine O O


Ther. Categ. Code


Code

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Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.107 primidone -- G G X107 primidone Mysoline P O X153 probenecid -- G G X44 procainamide -- G G X44 procainamide Pronestyl O O44 procainamide, sustained release -- G G X44 procainamide, sustained release Procan SR O O44 procainamide, sustained release Procanbid P O X30 procarbazine Matulane P O X72 prochlorperazine edisylate, syrup Compazine Syrup P O X X88 prochlorperazine edisylate, syrup Compazine Syrup P O X X72 prochlorperazine maleate, sustained


88 prochlorperazine maleate, sustained release

Compazine Spansules O O

72 prochlorperazine maleate, tablets -- G G X X72 prochlorperazine maleate, tablets Compazine O O88 prochlorperazine maleate, tablets -- G G X X88 prochlorperazine maleate, tablets Compazine O O110 procyclidine Kemadrin O O X121 progesterone, micronized Prometrium P O X133 progesterone, vaginal 8% Crinone 8% O 2 O 287 promazine Sparine O O206 promethazine -- G G X206 promethazine Phenergan O O72 promethazine, suppositories Phenergan Suppositories P O X

72 promethazine, tablets and liquid -- G G X X72 promethazine, tablets and liquid Phenergan O O44 propafenone -- G G X44 propafenone Rythmol P O X158 propantheline bromide -- G G


Ther. Categ. Code


Code

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Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.158 propantheline bromide Pro-Banthine O O63 propoxyphene -- G G63 propoxyphene Darvon O O63 propoxyphene napsylate Darvon N O O63 propoxyphene napsylate/ apap -- G G63 propoxyphene napsylate/ apap Darvocet N O O63 propoxyphene/ apap Wygesic O O63 propoxyphene/ asa/ caffeine -- G G63 propoxyphene/ asa/ caffeine Darvon Compound O O49 propranolol -- G G X X49 propranolol Inderal O O49 propranolol, sustained release -- G G X X49 propranolol, sustained release Inderal LA P O X X49 propranolol/ hctz -- G G X49 propranolol/ hctz Inderide O O150 propylthiouracil -- G G X79 protriptyline -- G G X X79 protriptyline Vivactil O O199 pseudoephedrine -- X207 pseudoephedrine/ azatadine Trinalin O O207 pseudoephedrine/ brompheniramine -- G G207 pseudoephedrine/ brompheniramine Bromfed O O207 pseudoephedrine/ brompheniramine Ultrabrom G G209 pseudoephedrine/ brompheniramine Ultrabrom PD G G209 pseudoephedrine/ brompheniramine,

capsules (generic Bromfed)-- X

209 pseudoephedrine/ brompheniramine, liquid (generic Dimetapp)

-- X

208 pseudoephedrine/ carbinoxamine -- G G X208 pseudoephedrine/ carbinoxamine Rondec O O207 pseudoephedrine/ chlorpheniramine Deconamine SR O O208 pseudoephedrine/ chlorpheniramine Dura-Tap/PD O O


Ther. Categ. Code


Code

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Footnote

Choice

Code

Choice

Footnote

QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.208 pseudoephedrine/ chlorpheniramine

(generic Chlor-Trimeton Allergy D)-- X

208 pseudoephedrine/ triprolidine (generic Actifed)

-- X

168 psyllium -- X15 pyrazinamide -- G G112 pyridostigmine bromide Mestinon P O X14 pyrimethamine Daraprim O O14 pyrimethamine/ sulfadoxine Fansidar O O98 quazepam Doral O O95 quetiapine fumarate Seroquel P O X X56 quinapril -- G G56 quinapril Accupril O O56 quinapril/ hctz Accuretic O O44 quinidine gluconate -- G G X44 quinidine gluconate Quinaglute Dura-Tabs P O X44 quinidine polygalacturonate Cardioquin P O X44 quinidine sulfate -- G G X44 quinidine sulfate Quinora O O44 quinidine sulfate, extended release -- G G X44 quinidine sulfate, extended release Quinidex Extentabs P O X14 quinine sulfate -- G G X163 rabeprazole sodium Aciphex P P X 15120 raloxifene Evista P O X56 ramipril Altace P P X161 ranitidine -- G G X161 ranitidine syrup Zantac Syrup P O X161 ranitidine, tablets and capsules Zantac O O142 repaglinide Prandin P O X54 reserpine -- G G54 reserpine/ chlorothiazide -- G G54 reserpine/ chlorothiazide Diupres O O


Ther. Categ. Code


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Choice

Code

Choice

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QUEST QUEST-Net

CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.54 reserpine/ chlorthalidone Regroton O O54 reserpine/ hctz -- G G54 reserpine/ hctz Hydropres O O54 reserpine/ hctz Hydro-Serp O O54 reserpine/ hydroflumethiazide Salutensin O O54 reserpine/ methyclothiazide Diutensen-R O O54 reserpine/ polythiazide Renese-R O O54 reserpine/ trichlormethiazide Metatensin O O22 ribavirin Rebetol P O X15 rifabutin Mycobutin P O X 1815 rifampin -- G G X 1815 rifampin Rifadin O O15 rifapentine Priftin O O117 riluzole -- G G X117 riluzole Rilutek P O X21 rimantadine -- G G X21 rimantadine Flumadine O O229 rimexolone Vexol O O152 risedronate Actonel P O X95 risperidone Risperdal P O X X95 risperidone Risperdal-M P O X X95 risperidone injection Risperdal Consta X20 ritonavir Norvir P O X97 rivastigmine Exelon O O70 rizatriptan Maxalt O 25 O 2570 rizatriptan Maxalt-MLT O 25 O 2569 rofecoxib Vioxx P 22 O X 22111 ropinirole Requip P O X146 rosiglitazone Avandia P O X146 rosiglitazone/ metformin Avandamet P O X240 salicylic acid -- X246 salicylic acid -- X


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.258 salicylic acid -- X190 salmeterol Serevent P O X190 salmeterol/ fluticasone Advair P O X195 salmeterol/ fluticasone Advair P O X66 salsalate -- G G66 salsalate Disalcid O O66 salsalate Marthritic O O20 saquinavir Fortovase P O X227 scopolamine HBr Isopto Hyoscine P O X73 scopolamine, trandsdermal Transderm-Scop O O102 secobarbital sodium Seconal O O111 selegiline -- G G X111 selegiline Eldepryl O O246 selenium sulfide -- G G X246 selenium sulfide Selsun O O168 senna -- X85 sertraline Zoloft P P X X182 sevelamer Renagel P O X133 sildenafil Viagra O 2 O 2244 silver sulfadiazine -- G G X244 silver sulfadiazine Silvadene O O164 simethicone -- X60 simvastatin Zocor O 21 O 21268 sirolimus Rapamune O O147 SMBG test strips Fast Take test strips G G X147 SMBG test strips One Touch test strips G G X147 SMBG test strips One Touch Ultra test strips G G X

147 SMBG test strips Surestep test strips G G X155 sodium bicarbonate -- X185 sodium bicarbonate -- X237 sodium chloride, hypertonic Muro 128 X


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.198 sodium chloride, inhalation -- G G X185 sodium citrate/ citric acid Bicitra P O X185 sodium citrate/ citric acid Oracit O O262 sodium citrate/ citric acid Bicitra P O X262 sodium citrate/ citric acid Oracit O O179 sodium fluoride -- G G X 5179 sodium fluoride Luride O O179 sodium fluoride Prevident O O168 sodium phosphate, enema -- X168 Sodium phosphate, oral solution Fleets Phospho - Soda X184 sodium polystyrene sulfonate -- G G X184 sodium polystyrene sulfonate Kayexalate O O11 sodium propionate/ amino acid/ urea Amino-Cerv O O44 sotalol Betapace AF P P X49 sotalol -- G G X49 sotalol Betapace O O49 sotalol Betapace AF P P X197 spacer Aerochamber P 3 P 3 X197 spacer E-Z Spacer P 3 P 3 X197 spacer Vortex P 3 P 3 X270 spermicides -- X39 spironolactone -- G G X39 spironolactone Aldactone O O41 spironolactone/ hctz -- G G X41 spironolactone/ hctz Aldactazide O O132 stanozolol Winstrol P O X17 stavudine Zerit P O X180 succimer Chemet P O X156 sucralfate -- G G X156 sucralfate Carafate O O250 sulconazole Exelderm O O233 sulfacetamide -- G G X X X


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.233 sulfacetamide Sodium Sulamyd O O240 sulfacetamide sodium Klaron O O246 sulfacetamide sodium, shampoo Sebizon O O233 sulfacetamide/ fluorometholone FML-S O O233 sulfacetamide/ phenylephrine Vasosulf O O233 sulfacetamide/ prednisolone acetate Blephamide P O X233 sulfacetamide/ prednisolone acetate Cetapred O O233 sulfacetamide/ prednisolone sodium

phosphate-- G G X


Vasocidin O O

10 sulfadiazine -- G G X10 sulfamethoxazole Gantanol O O10 sulfamethoxazole/ trimethoprim -- G G X X X10 sulfamethoxazole/ trimethoprim Bactrim O O10 sulfamethoxazole/ trimethoprim Septra O O241 sulfamethoxazole/ trimethoprim -- G G X X X241 sulfamethoxazole/ trimethoprim Bactrim O O241 sulfamethoxazole/ trimethoprim Septra O O11 sulfanilamide -- G G X11 sulfanilamide AVC O O173 sulfasalazine -- G G X173 sulfasalazine Azulfidine O O173 sulfasalazine, enteric coated -- G G173 sulfasalazine, enteric coated Azulfidine EN-tabs O O269 sulfasalazine, enteric coated -- G G269 sulfasalazine, enteric coated Azulfidine EN-tabs O O153 sulfinpyrazone -- G G153 sulfinpyrazone Anturane O O10 sulfisoxazole -- G G X10 sulfisoxazole Gantrisin P O X233 sulfisoxazole diolamine, ophthalmic Gantrisin O O


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G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.240 sulfur/ sulfacetamide Novacet O O240 sulfur/ sulfacetamide Sulfacet-R O O68 sulindac -- G G68 sulindac Clinoril O O70 sumatriptan Imitrex P 24 O 24 X 24259 sutilains Travase O O118 synthetic conjugated estrogens Cenestin O O97 tacrine Cognex O O268 tacrolimus Prograf P O X28 tamoxifen -- G G X28 tamoxifen Nolvadex O O53 tamsulosin Flomax P O X240 tazarotene Tazorac O O242 tazarotene Tazorac O O57 telmisartan Micardis O O57 telmisartan/ hctz Micardis HCT O O98 temazepam -- G G98 temazepam Restoril O O30 temozolomide Temodar P O X19 tenofovir Viread P O X53 terazosin -- G G X53 terazosin Hytrin O O12 terbinafine Lamisil P O X188 terbutaline sulfate Brethine P O X188 terbutaline sulfate Bricanyl O O X189 terbutaline sulfate Brethaire P O X13 terconazole Terazol 3 O O13 terconazole Terazol 7 O O28 testolactone Teslac O O130 testosterone, gel Androgel O O130 testosterone, transdermal Androderm P O X130 testosterone, transdermal Testoderm O O


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.5 tetracycline -- G G X X X

240 tetracycline Topicycline O O241 tetracycline -- G G X X X23 thalidomide Thalomid O O193 theophylline, capsules Bronkodyl O O193 theophylline, capsules Elixophyllin O O193 theophylline, liquid -- G G X193 theophylline, liquid Elixophyllin O O193 theophylline, liquid Slo-Phyllin O O193 theophylline, liquid Theolair O O193 theophylline, tablets -- G G X193 theophylline, tablets Quibron-T O O193 theophylline, tablets Slo-Phyllin O O193 theophylline, tablets Theolair O O193 theophylline, timed release capsules -- G G X193 theophylline, timed release capsules Elixophyllin SR O O193 theophylline, timed release capsules Slo-Bid O O193 theophylline, timed release capsules Slo-Bid 50mg and 75mg P O X193 theophylline, timed release capsules Slo-Phyllin Gyrocaps O O193 theophylline, timed release capsules Theo-24 P O X193 theophylline, timed release capsules Theo-Dur Sprinkle O O193 theophylline, timed release tablets -- G G193 theophylline, timed release tablets Theochron G G X193 theophylline, timed release tablets T-Phyl O O193 theophylline, timed release tablets Unidur O O193 theophylline, timed release tablets Uniphyl O O193 theophylline/ ephedrine/ hydroxyzine

hclMarax O O

24 thiabendazole Mintezol O O174 thiamine -- X 27 X 2772 thiethylperazine maleate Torecan O O27 thioguanine Thioguanine P O X


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.89 thioridazine -- G G X X89 thioridazine Mellaril O O90 thiothixene -- G G X X90 thiothixene Navane O O149 thyroid, desiccated -- G G X149 thyroid, desiccated Armour Thyroid P O107 tiagabine Gabatril P O X34 ticlopidine -- G G X34 ticlopidine Ticlid O O152 tiludronate Skelid O O219 timolol -- G G X219 timolol Timoptic O O219 timolol XE Timoptic XE O O49 timolol maleate -- G G49 timolol maleate Blocadren O O49 timolol maleate/ hctz Timolide O O219 timolol XE -- G G X219 timolol/ dorzolamide Cosopt P O X267 tiopronin Thiola O O108 tizanidine -- G G108 tizanidine Zanaflex O O25 tobramycin, inhalation TOBI P O X198 tobramycin, inhalation TOBI P O X230 tobramycin, ointment Tobrex ointment P O X230 tobramycin, solution -- G G X230 tobramycin, solution Tobrex solution O O232 tobramycin/ dexamethasone TobraDex P O X144 tolazamide -- G G X144 tolazamide Tolinase O O144 tolbutamide -- G G X144 tolbutamide Orinase O O111 tolcapone Tasmar O O


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CCS Child-ren's

G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.68 tolmetin sodium -- G G68 tolmetin sodium Tolectin O O264 tolterodine Detrol P O X264 tolterodine, long-acting Detrol LA P O X107 topiramate Topamax P O X X28 toremifene Fareston O O38 torsemide -- G G38 torsemide Demadex O O65 tramadol -- G G65 tramadol Ultram O O65 tramadol/ apap Ultracet O O56 trandolapril Mavik O O86 tranylcypromine sulfate Parnate O O223 travoprost Travatan O O81 trazodone -- G G X X81 trazodone Desyrel O O240 tretinoin -- G 10 G 10 X 10240 tretinoin Avita O 10 O 10240 tretinoin Retin-A O 10 O 10240 tretinoin Retin-A Micro O 10 O 1030 tretinoin, oral Vesanoid O O138 triamcinolone Aristocort O O202 triamcinolone Nasacort P O X202 triamcinolone Nasacort AQ P O X254 triamcinolone acetonide 0.025% -- G G X254 triamcinolone acetonide 0.025% Kenalog O O254 triamcinolone acetonide 0.1% -- G G X254 triamcinolone acetonide 0.1% Kenalog O O253 triamcinolone acetonide 0.5%, cream/

ointment-- G G X

253 triamcinolone acetonide 0.5%, cream/ ointment

Kenalog O O


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G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.254 triamcinolone acetonide, aerosol Kenalog aerosol P O X172 triamcinolone paste -- G G X172 triamcinolone paste Kenalog in Orabase O O195 triamcinolone, inhaler Azmacort O O39 triamterene Dyrenium O O41 triamterene/ hctz -- G G X41 triamterene/ hctz Dyazide O O41 triamterene/ hctz Maxzide O O98 triazolam -- G G98 triazolam Halcion O O37 trichlormethiazide -- G G37 trichlormethiazide Naqua O O181 trientine Syprine O 2 O 2239 triethanolamine Cerumenex O O88 trifluoperazine -- G G88 trifluoperazine Stelazine O O235 trifluridine Viroptic P O X110 trihexyphenidyl -- G G X X110 trihexyphenidyl Artane O O105 trimethadione Tridione P O X73 trimethobenzamide -- G G73 trimethobenzamide Tigan O O25 trimethoprim -- G G X25 trimethoprim Trimpex O O231 trimethoprim/ polymyxin B -- G G X231 trimethoprim/ polymyxin B Polytrim O O78 trimipramine maleate Surmontil P O X X206 tripelennamine -- G G206 tripelennamine PBZ O O11 triple sulfa -- G G X6 troleandomycin Tao O O

223 unoprostone Rescula O O


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G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.167 ursodiol -- G G X167 ursodiol Actigall O O22 valacyclovir Valtrex P O X69 valdecoxib Bextra O 22 O107 valproic acid -- G G X X107 valproic acid Depakene P O X X57 valsartan Diovan O O57 valsartan/ hctz Diovan HCT O O7 vancomycin Vancocin O O

83 venlafaxine Effexor O O X83 venlafaxine, extended release Effexor XR P P X X47 verapamil -- G G X47 verapamil Calan O O47 verapamil Isoptin O O47 verapamil ER/ trandolapril Tarka O O56 verapamil ER/ trandolapril Tarka O O47 verapamil, sustained release -- G G X47 verapamil, sustained release Calan SR O O47 verapamil, sustained release Covera HS O O47 verapamil, sustained release Isoptin SR O O47 verapamil, sustained release Verelan O O235 vidarabine Vira-A P O X174 vitamin B complex -- X 27 X 27177 vitamin B complex/ vit C/ vit E/ folate Renal Tabs P 12 O 12 X 12

35 warfarin -- G G X35 warfarin Coumadin P O X133 yohimbine -- G 2 G 2133 yohimbine Yocon O 2 O 2194 zafirlukast Accolate P 30 O X 3017 zalcitabine Hivid P O X99 zaleplon Sonata O O


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G = Generic. P = Preferred. O = Other brand. X = Covered. If a number appears next to alpha code, see last page for footnote text.21 zanamivir Relenza O O17 zidovudine Retrovir P O X194 zileuton Zyflo P 30 O X 3095 ziprasidone Geodon P O X X70 zolmitriptan Zomig O 25 O 2599 zolpidem tartrate Ambien P O107 zonisamide Zonegran P O X

march 23, 2004 memorandum96 v. central nervous system agents g. anti-psychotic 10. anti-manic agents...

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