Note:  The Formulary copay applies only to the generics listed in the Formulary.  Brand Names are listed for reference only.  Please note the specific form and strength combinations that qualify a Generic Drug to be listed in this Formulary.  Generic Drugs with form and strength combinations other than those in this formulary, as well as other Generic Drugs not listed in this Formulary, are discounted approximately 40% to 50%.

           
** This formulary is effective March 1, 2003 and is subject to change without notice.

Generic Name

Brand Name

ACETAMINOPHEN W/ CODEINE TAB 300-15MG APAP/CODEINE
ACETAMINOPHEN W/ CODEINE TAB 300-30MG APAP/CODEINE
ACETAMINOPHEN W/ CODEINE TAB 300-60MG APAP/CODEINE
ACETAMINOPHEN W/ HYDROCODONE CAP 500-5MG HYDROCODONE/APAP
ACETAMINOPHEN W/ HYDROCODONE ELIXIR 167-2.5MG/5ML HYDROCODONE/APAP
ACETAMINOPHEN W/ HYDROCODONE TAB 500-5MG HYDROCODONE/APAP
ACETAMINOPHEN W/ HYDROCODONE TAB 500-7.5MG HYDROCODONE/APAP
ACETAMINOPHEN W/ HYDROCODONE TAB 650-7.5MG HYDROCODONE/APAP
ACETAMINOPHEN W/ HYDROCODONE TAB 650-10MG HYDROCODONE/APAP
ACETAMINOPHEN W/ HYDROCODONE TAB 750-7.5MG HYDROCODONE/APAP
ACETAZOLAMIDE TAB 250MG ACETAZOLAMIDE
ALBUTEROL SULFATE SOLN NEBU 0.083% ALBUTEROL
ALLOPURINOL TAB 100MG ALLOPURINOL
ALLOPURINOL TAB 300MG ALLOPURINOL
ALPRAZOLAM TAB 0.25MG ALPRAZOLAM
ALPRAZOLAM TAB 0.5MG ALPRAZOLAM
ALPRAZOLAM TAB 1MG ALPRAZOLAM
ALPRAZOLAM TAB 2MG ALPRAZOLAM
AMANTADINE HCL SYRUP 50MG/5ML AMANTADINE 
AMILORIDE & HYDROCHLOROTHIAZIDE TAB 5-50MG AMILORIDE/HCTZ
AMINOPHYLLINE TAB 100MG AMINOPHYLLINE
AMINOPHYLLINE TAB 200MG AMINOPHYLLINE
AMITRIPTYLINE HCL TAB 10MG AMITRIPTYLINE
AMITRIPTYLINE HCL TAB 25MG AMITRIPTYLINE
AMITRIPTYLINE HCL TAB 50MG AMITRIPTYLINE
AMITRIPTYLINE HCL TAB 75MG AMITRIPTYLINE
AMITRIPTYLINE HCL TAB 100MG AMITRIPTYLINE
AMITRIPTYLINE HCL TAB 150MG AMITRIPTYLINE
AMOXICILLIN (TRIHYDRATE) CAP 250MG AMOXICILLIN
AMOXICILLIN (TRIHYDRATE) CAP 500MG AMOXICILLIN
AMOXICILLIN (TRIHYDRATE) CHEW TAB 250MG AMOXICILLIN
AMOXICILLIN (TRIHYDRATE) FOR SUSP 125MG/5ML AMOXICILLIN
ATENOLOL TAB 25MG ATENOLOL
ATENOLOL TAB 50MG ATENOLOL
ATENOLOL TAB 100MG ATENOLOL
ATENOLOL & CHLORTHALIDONE TAB 50-25MG ATENOLOL/CHLORTHALIDONE
ATENOLOL & CHLORTHALIDONE TAB 100-25MG ATENOLOL/CHLORTHALIDONE
BENZTROPINE MESYLATE TAB 0.5MG BENZTROPINE
BENZTROPINE MESYLATE TAB 1MG BENZTROPINE
BENZTROPINE MESYLATE TAB 2MG BENZTROPINE
BETAMETHASONE DIPROPIONATE CREAM 0.05% ALPHATREX
BETAMETHASONE VALERATE CREAM 0.1% BETAMETHASONE VALERATE
BETAMETHASONE VALERATE LOTION 0.1% BETAMETHASONE VALERATE
BUMETANIDE TAB 0.5MG BUMETANIDE
BUMETANIDE TAB 1MG BUMETANIDE
BUSPIRONE HCL TAB 5MG BUSPIRONE
CAPTOPRIL TAB 12.5MG CAPTOPRIL
CAPTOPRIL TAB 25MG CAPTOPRIL
CAPTOPRIL TAB 50MG CAPTOPRIL
CAPTOPRIL TAB 100MG CAPTOPRIL
CAPTOPRIL & HYDROCHLOROTHIAZIDE TAB 25-15MG CAPTOPRIL/HCTZ
CARBAMAZEPINE TAB 200MG CARBAMAZEPINE
CEFACLOR FOR SUSP 125MG/5ML CEFACLOR
CEFACLOR FOR SUSP 187MG/5ML CEFACLOR
CEFACLOR FOR SUSP 250MG/5ML CEFACLOR
CEPHALEXIN CAP 250MG CEPHALEXIN
CHLORDIAZEPOXIDE HCL CAP 5MG CHLORDIAZEPOXIDE
CHLORDIAZEPOXIDE HCL CAP 10MG CHLORDIAZEPOXIDE
CHLORHEXIDINE GLUCONATE SOLN 0.12% PERIOGARD
CHLORPHENIRAMINE MALEATE TAB 4MG ALLER-CHLOR
CHLORPROPAMIDE TAB 100MG CHLORPROPAMIDE
CHLORTHALIDONE TAB 25MG CHLORTHALIDONE
CHLORTHALIDONE TAB 50MG CHLORTHALIDONE
CHLORZOXAZONE TAB 500MG CHLORZOXAZONE
CIMETIDINE SOLN 300MG/5ML CIMETIDINE
CIMETIDINE TAB 200MG CIMETIDINE
CIMETIDINE TAB 300MG CIMETIDINE
CIMETIDINE TAB 400MG CIMETIDINE
CIMETIDINE TAB 800MG CIMETIDINE
CLINDAMYCIN PHOSPHATE SOLN 1% CLINDA-DERM
CLONAZEPAM TAB 0.5MG CLONAZEPAM
CLONAZEPAM TAB 1MG CLONAZEPAM
CLONIDINE HCL TAB 0.1MG CLONIDINE
CLONIDINE HCL TAB 0.2MG CLONIDINE
CLONIDINE HCL TAB 0.3MG CLONIDINE
CYCLOBENZAPRINE HCL TAB 10MG CYCLOBENZAPRINE
DEXAMETHASONE ELIXIR 0.5MG/5ML DEXAMETHASONE
DIAZEPAM TAB 2MG DIAZEPAM
DIAZEPAM TAB 5MG DIAZEPAM
DIAZEPAM TAB 10MG DIAZEPAM
DICYCLOMINE HCL CAP 10MG DICYCLOMINE
DICYCLOMINE HCL TAB 20MG DICYCLOMINE
DILTIAZEM HCL TAB 30MG DILTIAZEM
DILTIAZEM HCL TAB 60MG DILTIAZEM
DILTIAZEM HCL TAB 90MG DILTIAZEM
DILTIAZEM HCL TAB 120MG DILTIAZEM
DIPHENHYDRAMINE HCL ELIXIR 12.5MG/5ML BANOPHEN
DIPHENHYDRAMINE HCL LIQUID 12.5MG/5ML BANOPHEN
DIPHENHYDRAMINE HCL SYRUP 6.25MG/5ML BANOPHEN
DOXEPIN HCL CAP 10MG DOXEPIN HCL
DOXEPIN HCL CAP 25MG DOXEPIN HCL
DOXEPIN HCL CAP 50MG DOXEPIN HCL
DOXEPIN HCL CAP 75MG DOXEPIN HCL
DOXEPIN HCL CONC 10MG/ML DOXEPIN HCL
DOXYCYCLINE HYCLATE CAP 50MG DOXYCYCLINE HYCLATE
DOXYCYCLINE HYCLATE CAP 100MG DOXYCYCLINE HYCLATE
DOXYCYCLINE HYCLATE TAB 100MG DOXYCYCLINE HYCLATE
ERYTHROMYCIN W/ DELAYED RELEASE PARTICLES CAP 250MG ERYTHROMYCIN
ERYTHROMYCIN SOLN 2% A/T/S
ESTRADIOL TAB 0.5MG ESTRADIOL
ESTRADIOL TAB 1MG ESTRADIOL
ESTROPIPATE TAB 0.75MG ORTHO-EST
FENOPROFEN CALCIUM TAB 600MG FENOPROFEN 
FLUOCINOLONE ACETONIDE SOLN 0.01% FLUOCINOLONE ACETONIDE
FLUOCINONIDE CREAM 0.05% FLUOCINONIDE
FLUOCINONIDE SOLN 0.05% FLUOCINONIDE
FLUPHENAZINE HCL TAB 1MG FLUPHENAZINE
FLUPHENAZINE HCL TAB 2.5MG FLUPHENAZINE
FLURAZEPAM HCL CAP 15MG FLURAZEPAM
FLURAZEPAM HCL CAP 30MG FLURAZEPAM
FOLIC ACID TAB 1MG FOLIC ACID
FUROSEMIDE ORAL SOLN 10MG/ML FUROSEMIDE
FUROSEMIDE TAB 20MG FUROSEMIDE
FUROSEMIDE TAB 40MG FUROSEMIDE
FUROSEMIDE TAB 80MG FUROSEMIDE
GEMFIBROZIL TAB 600MG GEMFIBROZIL
GLIPIZIDE TAB 5MG GLIPIZIDE
GLIPIZIDE TAB 10MG GLIPIZIDE
GLYBURIDE MICRONIZED TAB 1.5MG GLYBURIDE MICRONIZED
HALOPERIDOL LACTATE ORAL CONC 2MG/ML HALOPERIDOL
HYDRALAZINE HCL TAB 10MG HYDRALAZINE 
HYDRALAZINE HCL TAB 25MG HYDRALAZINE 
HYDROCODONE W/ HOMATROPINE SYRUP 5-1.5MG/5ML HYDROMET
HYDROCORTISONE CREAM 0.5% HYDROCORTISONE
HYDROCORTISONE CREAM 1% HYDROCORTISONE
HYDROCORTISONE CREAM 2.5% HYDROCORTISONE
HYDROCORTISONE LOTION 1% HYDROCORTISONE
HYDROCORTISONE OINT 1% HYDROCORTISONE
HYDROCORTISONE-ALOE VERA CREAM 1% CORTAID
HYDROXYZINE HCL SYRUP 10MG/5ML HYDROXYZINE
HYDROXYZINE PAMOATE CAP 25MG HYDROXYZINE
HYDROXYZINE PAMOATE CAP 50MG HYDROXYZINE
IBUPROFEN TAB 400MG IBUPROFEN
IBUPROFEN TAB 600MG IBUPROFEN
IBUPROFEN TAB 800MG IBUPROFEN
IMIPRAMINE HCL TAB 10MG IMIPRAMINE HCL 
IMIPRAMINE HCL TAB 25MG IMIPRAMINE HCL 
IMIPRAMINE HCL TAB 50MG IMIPRAMINE HCL 
INDAPAMIDE TAB 1.25MG INDAPAMIDE
INDAPAMIDE TAB 2.5MG INDAPAMIDE
ISONIAZID TAB 300MG ISONIAZID
ISOSORBIDE DINITRATE SL TAB 2.5MG ISOSORBIDE DINITRATE
ISOSORBIDE DINITRATE TAB 5MG ISOSORBIDE DINITRATE
ISOSORBIDE DINITRATE TAB 10MG ISOSORBIDE DINITRATE
ISOSORBIDE DINITRATE TAB 20MG ISOSORBIDE DINITRATE
LACTULOSE (ENCEPHALOPATHY) SYRUP 10GM/15ML LACTULOSE
LACTULOSE SYRUP 10GM/15ML DUPHALAC
LIDOCAINE HCL VISCOUS SOLN 2% LIDOCAINE
MECLIZINE HCL TAB 12.5MG MECLIZINE
MECLIZINE HCL TAB 25MG MECLIZINE
MEDROXYPROGESTERONE ACETATE TAB 2.5MG MEDROXYPROGESTERONE ACETATE
MEDROXYPROGESTERONE ACETATE TAB 10MG MEDROXYPROGESTERONE ACETATE
METHENAMINE MANDELATE TAB 1GM METHENAMINE MANDELATE
METHOCARBAMOL TAB 500MG METHOCARBAMOL
METOCLOPRAMIDE HCL SYRUP 5MG/5ML METOCLOPRAMIDE 
METOCLOPRAMIDE HCL TAB 5MG METOCLOPRAMIDE
METOCLOPRAMIDE HCL TAB 10MG METOCLOPRAMIDE
METOPROLOL TARTRATE TAB 50MG METOPROLOL
METOPROLOL TARTRATE TAB 100MG METOPROLOL
METRONIDAZOLE TAB 250MG METRONIDAZOLE
METRONIDAZOLE TAB 500MG METRONIDAZOLE
NAPROXEN TAB 250MG NAPROXEN
NAPROXEN TAB 375MG NAPROXEN
NAPROXEN TAB 500MG NAPROXEN
NIACIN TAB 500MG NIACIN
NIFEDIPINE CAP 10MG NIFEDIPINE
NORTRIPTYLINE HCL CAP 10MG NORTRIPTYLINE
NORTRIPTYLINE HCL CAP 25MG NORTRIPTYLINE
NORTRIPTYLINE HCL CAP 50MG NORTRIPTYLINE
NORTRIPTYLINE HCL CAP 75MG NORTRIPTYLINE
NYSTATIN CREAM 100000 U/GM NYSTATIN
NYSTATIN OINT 100000 U/GM NYSTATIN
NYSTATIN SUSP 100000 U/ML NYSTATIN
NYSTATIN-TRIAMCINOLONE CREAM 100000-0.1 U/GM-% MYCOGEN II
NYSTATIN-TRIAMCINOLONE OINT 100000-0.1 U/GM-% MYCOGEN II
OXYBUTYNIN CHLORIDE TAB 5MG OXYBUTYNIN
OXYCODONE W/ ACETAMINOPHEN CAP 5-500MG OXYCODONE/APAP
OXYCODONE W/ ACETAMINOPHEN TAB 5-325MG OXYCODONE/APAP
PENICILLIN V POTASSIUM FOR SOLN 250MG/5ML VEETIDS
PERPHENAZINE TAB 2MG PERPHENAZINE
PERPHENAZINE W/ AMITRIPTYLINE TAB 2-10MG DUO-VIL
PERPHENAZINE W/ AMITRIPTYLINE TAB 2-25MG DUO-VIL
PINDOLOL TAB 5MG PINDOLOL
PINDOLOL TAB 10MG PINDOLOL
PIROXICAM CAP 10MG PIROXICAM
PIROXICAM CAP 20MG PIROXICAM
POTASSIUM CHLORIDE TAB CR 8MEQ KLOR-CON 8
PREDNISOLONE SYRUP 15MG/5ML PREDNISOLONE
PREDNISONE TAB 5MG DOSE PACK PREDNISONE
PREDNISONE TAB 10MG DOSE PACK PREDNISONE
PREDNISONE TAB 5MG DELTASONE
PREDNISONE TAB 10MG DELTASONE
PREDNISONE TAB 20MG DELTASONE
PROMETHAZINE HCL SYRUP 6.25MG/5ML PROMETHAZINE 
PROPOXYPHENE HCL W/ APAP TAB 65-650MG PROPOXYPHENE/APAP
PROPOXYPHENE-N W/ APAP TAB 100-650MG PROPOXYPHENE-N/APAP
PROPRANOLOL & HYDROCHLOROTHIAZIDE TAB 40-25MG PROPRANOLOL/HCTZ
PROPRANOLOL & HYDROCHLOROTHIAZIDE TAB 80-25MG PROPRANOLOL/HCTZ
PROPRANOLOL HCL TAB 10MG PROPRANOLOL
PROPRANOLOL HCL TAB 20MG PROPRANOLOL
PROPRANOLOL HCL TAB 40MG PROPRANOLOL
PROPRANOLOL HCL TAB 80MG PROPRANOLOL
SELENIUM SULFIDE SHAMPOO 2.5% SELENIUM SULFIDE
SULFACETAMIDE SODIUM OPHTH SOLN 10% BLEPH-10
SULFASALAZINE TAB 500MG SULFASALAZINE
SULINDAC TAB 150MG SULINDAC
TEMAZEPAM CAP 15MG TEMAZEPAM
TEMAZEPAM CAP 30MG TEMAZEPAM
TETRACYCLINE HCL CAP 500MG SUMYCIN
THEOPHYLLINE TAB SR 12HR 100MG THEOCHRON
THEOPHYLLINE TAB SR 12HR 200MG THEOCHRON
THEOPHYLLINE TAB SR 12HR 300MG THEOCHRON
THIORIDAZINE HCL TAB 10MG THIORIDAZINE
THIORIDAZINE HCL TAB 25MG THIORIDAZINE
THIOTHIXENE CAP 1MG THIOTHIXENE
THIOTHIXENE CAP 2MG THIOTHIXENE
THIOTHIXENE CAP 5MG THIOTHIXENE
TOLAZAMIDE TAB 250MG TOLAZAMIDE
TRAZODONE HCL TAB 50MG TRAZODONE
TRAZODONE HCL TAB 100MG TRAZODONE
TRIAMCINOLONE ACETONIDE CREAM 0.025% TRIAMCINOLONE 
TRIAMCINOLONE ACETONIDE CREAM 0.1% TRIAMCINOLONE
TRIAMCINOLONE ACETONIDE CREAM 0.5% TRIAMCINOLONE
TRIAMCINOLONE ACETONIDE LOTION 0.1% TRIAMCINOLONE 
TRIAMCINOLONE ACETONIDE OINT 0.1% TRIAMCINOLONE
TRIAMTERENE & HYDROCHLOROTHIAZIDE TAB 75-50MG TRIAMTERENE/HCTZ
TRIFLUOPERAZINE HCL TAB 1MG TRIFLUOPERAZINE
TRIHEXYPHENIDYL HCL TAB 2MG TRIHEXYPHENIDYL
TRIHEXYPHENIDYL HCL TAB 5MG TRIHEXYPHENIDYL
TRIMETHOPRIM-SULFAMETHOXAZOLE TAB 80-400MG SMZ/TMP-SMZ/TMP DS
TRIMETHOPRIM-SULFAMETHOXAZOLE TAB 160-800MG SMZ/TMP-SMZ/TMP DS
TRIPROLIDINE & PSEUDOEPHEDRINE TAB 2.5-60MG ALLERFRIM
VALPROATE SODIUM SYRUP 250MG/5ML VALPROIC ACID
VALPROIC ACID CAP 250MG VALPROIC ACID
VERAPAMIL HCL TAB 40MG VERAPAMIL
VERAPAMIL HCL TAB 80MG VERAPAMIL
VERAPAMIL HCL TAB 120MG VERAPAMIL

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