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Rx Selections™
Member Guide
Please bring this guide
with you to your next
doctor visit.
Medco Health Solutions, Inc., is a subsidiary of Merck & Co., Inc.
Rx Selections and Live life well are
trademarks of Medco Health Solutions, Inc.
2003 Medco Health Solutions, Inc. All rights reserved.
If you have questions about your prescription drug benefit,
visit www.medcohealth.com or call Member Services.
Medco Health is your pharmacy benefit manager at the request of your plan sponsor.
THE BENEFITS OF RX SELECTIONSTM
Rx Selections is a list of medications that may be covered under your prescription drug plan.
This list was reviewed by an independent group of practicing doctors and pharmacists, and it contains
medications made by most pharmaceutical manufacturers. It includes medications for many covered
conditions.
SAVING MONEY ON PRESCRIPTIONS
Your plan may prefer some medications over others. These are called plan-preferred drugs, and their
co-payment is lower. The amount of your co-payment depends on which drug your doctor prescribes
for you.
Higher co-payment for plan-preferred, brand-name drugs Highest co-payment for nonpreferred, brand-name drugs Your doctor may be able to help you save money by prescribing generic and
plan-preferred drugs. So be sure to bring this guide with you on every visit to your doctor.
This guide lists only the most common drugs. For an updated and complete listing of plan-preferred
drugs, you can visit the “My Benefits” section of our website — www.medcohealth.com and click
the Learn about formularies link.
FINDING LOWER CO-PAYMENT VERSIONS
This guide lists medications two ways to help you find some generic and plan-preferred
brand-name drugs.
ALPHABETICALLY BY DRUG CATEGORY (SUCH AS RESPIRATORY)
Within each category, medications are listed in order of their cost to your plan sponsor, from lowest to
highest. The $ and ! symbols next to each medication show the cost of that medication compared with
others in the same category:
ALPHABETICALLY BY BRAND NAMEAfter each nonpreferred brand-name drug, you will find possible generic and plan-preferred brand-name versions.
GENERIC COVERAGE
When a generic version of a brand-name drug is available, it will have one of the following symbols:
Means only the generic version is plan-preferred; the brand-name product has the highest co-payment. Means both brand-name and generic versions are plan-preferred, but the generic version has alower co-payment.
SAFETY CONSIDERATION SYMBOLS
Here is a quick guide for you and your doctor, which explains our safety symbols. These symbols
appear next to certain medications.
Means that a dose lower than the manufacturer’s guidelines is often recommended for people 65and older. Means that use by people 65 and older is associated with increased risk; safer alternatives may beavailable. If used, dosage should generally be lowered.
Weigh risk of birth defects or other adverse outcomes.
This information is in effect at the time of printing, and may be subject to change.
SECTION I: THERAPEUTIC DRUG CATEGORIES
ANTI-INFECTIVES (Antibiotics/Antifungals)
Oral Penicillins
+ erythromycin
+ amoxicillin trihydrate
+ nitrofurantoin macrocrystal
+ ampicillin trihydrate
+ erythromycin
Oral Antifungal Agents
+ dicloxacillin sodium
+ griseofulvin ultramicrosize
+ penicillin v potassium
+ ketoconazole
+ erythromycin stearate
+ nystatin
Oral Quinolones
Oral Tetracyclines
+ doxycycline hyclate
+ tetracycline HCl
+ minocycline HCl
Oral Miscellaneous Agents
+ doxycycline monohydrate
+ clindamycin HCl
Oral Cephalosporins
+ neomycin sulfate
Oral Sulfas
+ cefaclor
+ cephalexin monohydrate
+ erythromycin
Vaginal Antifungals
+ nystatin tablet
+ sulfamethoxazole/
+ cefuroxime axetil tablet
+ sulfisoxazole
+ sulfadiazine
Oral Erythromycins
Oral Urinary Tract Agents
+ erythromycin base tablet,
+ trimethoprim
PSYCHOTHERAPEUTICS (Anxiety/Depression)
Hypnotic Agents
+ chloral hydrate
+ temazepam
▲+triazolam
Tricyclic Antidepressants
▲+fluoxetine HCl
▲+amitriptyline HCl
▲+doxepin HCl
Anxiolytics
▲+imipramine HCl
▲+nortriptyline HCl
▲+alprazolam
Antipsychotics
▲+clomipramine HCl
▲+chlordiazepoxide HCl
▲+desipramine HCl
▲+chlorpromazine HCl
▲+diazepam
+ fluphenazine HCl
+ lorazepam
▲+haloperidol
+ buspirone HCl
▲+perphenazine
▲+clorazepate
Miscellaneous Antidepressants
▲+thioridazine HCl
▲+trazodone HCl
▲+thiothixene
▲+oxazepam
▲+bupropion HCl
▲+thiothixene HCl
▲+maprotiline HCl
+ mirtazapine tablet
+ trifluoperazine HCl
▲+haloperidol lactate
▲+loxapine succinate
= Lowest relative cost to plan sponsor.
= Means that a dose lower than the manufacturer’s guidelines is often recommended for people 65 and older.
! ! ! ! ! = Highest relative cost to plan sponsor.
= Means only the generic version is plan-preferred; ▲ = Means that use by people 65 and older is associated with increased risk; safer alternatives may be available. If used, dosage should generally be lowered.
the brand-name product has the highest co-payment.
= Means both brand-name and generic versions are plan- = Weigh risk of birth defects or other adverse outcomes.
preferred, but the generic version has a lower co-payment.
CARDIOVASCULAR (Blood Pressure/Heart/Cholesterol)
Beta Blockers
▲+methyldopa/
Antilipidemics
▲+atenolol
▲+gemfibrozil
▲+metoprolol tartrate
▲+propranolol HCl/
+ cholestyramine/aspartame
▲+pindolol
+ cholestyramine/sucrose
▲+propranolol HCl
+ reserpine/
+ lovastatin
▲+timolol maleate
▲+acebutolol HCl
+ clonidine HCl/
▲+labetalol HCl
▲+nadolol
+ enalapril maleate
▲+lisinopril
▲+lisinopril/
Calcium Blockers
▲+verapamil HCl
▲+verapamil HCl tablet,
+ diltiazem HCl
+ diltiazem HCl capsule,
Adrenergic Antagonists &
+ diltiazem HCl capsule,
Related Drugs
+ clonidine HCl
▲+doxazosin mesylate
+ guanfacine HCl
Dihydropyridines
▲+methyldopa
+ nifedipine
▲+prazosin HCl
+ nifedipine ER tablet,
+ reserpine
▲+terazosin HCl
Nitroglycerin Patches
Angiotensin II Blockers
+ nitroglycerin patch,
ACE Inhibitors/Combinations
▲+captopril
+ hydralazine HCl/
ENDOCRINE (Diabetes/Hormones/Contraceptives)
Insulin Therapy
Estrogens/Combinations
+ estradiol
+ estropipate
Oral Hypoglycemics
▲+glipizide
+ glyburide
+ glyburide, micronized
+ metformin HCl
Blood Glucose Test Strips
+ norgestrel-ethinyl
Oral Contraceptives
G. I. (Ulcer)
Ulcer Drugs
+ misoprostol
Other G.I. Drugs
+ cimetidine HCl liquid (ml)
+ sucralfate tablet
+ cimetidine tablet
+ famotidine
+ ranitidine HCl
NSAIDS (Pain Relievers)
▲+piroxicam
▲+tolmetin sodium
▲+diclofenac sodium
▲+sulindac
▲+etodolac tablet,
▲+ibuprofen
▲+etodolac
▲+indomethacin
▲+oxaprozin
▲+nabumetone
▲+indomethacin capsule,
▲+ketoprofen capsule,
NSAID COX II Inhibitors
▲+ketoprofen
▲+naproxen
▲+naproxen sodium
▲+naproxen sodium
RESPIRATORY (Allergy/Asthma)
Antihistamines/Combinations
▲+pseudoephedrine HCl/
Inhaled Steroids
▲+clemastine fumarate
+ cyproheptadine HCl
▲+diphenhydramine HCl
▲+pseudoephedrine HCl/
▲+hydroxyzine pamoate
▲+pseudoephedrine HCl/
Nasal Corticosteroids
▲+pseudoephedrine HCl/
+ flunisolide
Beta Agonists Oral
▲+pseudoephedrine HCl/
+ albuterol sulfate
+ metaproterenol sulfate
▲+pseudoephedrine HCl/
+ terbutaline sulfate
Miscellaneous Pulmonary Agents
Beta Agonist Inhalers
+ cromolyn sodium ampul
▲+hydroxyzine HCl
+ promethazine HCl
+ albuterol aerosol
+ albuterol sulfate solution,
▲+pseudoephedrine HCl/
+ metaproterenol sulfate
+ acetylcysteine
+ ipratropium bromide
+ isoetharine HCl solution,
MISCELLANEOUS
SECTION II: NONPREFERRED DRUGS AND THEIR POSSIBLE PLAN-PREFERRED ALTERNATIVES
Nonpreferred Product
Possible Plan-preferred Products
Nonpreferred Product
Possible Plan-preferred Products
acebutolol HCl (generic), atenolol tablet albuterol sulfate solution, non-oral (generic) (generic), metoprolol tartrate tablet(generic), propranolol HCl tablet (generic), propranolol HCl capsule, sustained action (generic), timolol maleate tablet (generic) cefaclor capsule (hard, soft, etc.) (generic), nifedipine ER (generic), Norvasc® (Pfizer) lovastatin (generic), Lipitor® (Pfizer), cefaclor capsule (hard, soft, etc.) (generic),cefuroxime axetil (generic), Augmentin® (generic), Augmentin® (GlaxoSmithKline), Noroxin® (Merck & Co.), Cipro® (Bayer), cholestyramine/sucrose (generic),Welchol®(Sankyo) Benicar® (Sankyo), Cozaar® (Merck & Co.), (generic), pseudoephedrine HCl/chlorpheniramine maleate (generic) clemastine fumarate (generic), hydroxyzineHCl (generic), Allegra® (Aventis), Clarinex® clemastine fumarate (generic), hydroxyzine Benicar® (Sankyo), Cozaar® (Merck & Co.), HCl (generic), Allegra® (Aventis), Clarinex® cimetidine (generic), famotidine (generic), nifedipine ER (generic), Norvasc® (Pfizer) nifedipine ER (generic), Norvasc® (Pfizer) erythromycin ethylsuccinate suspension, oral albuterol (generic), Alupent® (Boehringer estradiol (generic), estropipate (generic), estradiol (generic), estropipate (generic), nifedipine ER (generic), Norvasc® (Pfizer) diltiazem HCl capsule, sustained release Nonpreferred Product
Possible Plan-preferred Products
Nonpreferred Product
Possible Plan-preferred Products
nitroglycerin patch, transdermal 24 hours (generic), Lotensin® (Novartis), Accupril® (Pfizer), Altace® (Monarch Pharmaceutical) Noroxin® (Merck & Co.), Cipro® (Bayer) triazolam (generic), temazepam (generic), Sporanox® (Janssen), Lamisil® (Novartis) sulindac (generic), indomethacin (generic), clonidine HCl tablet (generic), methyldopa Noroxin® (Merck & Co.), Cipro® (Bayer), (generic), pseudoephedrineHCl/chlorpheniramine maleate (generic) chloral hydrate (generic), temazepam(generic), triazolam (generic) methyldopa (generic), clonidine HCl(generic) nitroglycerin patch, transdermal 24 hours lovastatin (generic), Lipitor® (Pfizer),Zocor® (Merck & Co.) lovastatin (generic), Lipitor® (Pfizer), Humalog Mix 75/25® (Eli Lilly and Company) clemastine fumarate (generic), hydroxyzine HCl (generic), Allegra® (Aventis), Clarinex® (generic), Lotensin® (Novartis), Accupril®(Pfizer), Altace® (Monarch Pharmaceutical) pseudoephedrine HCl/brompheniraminemaleate (generic) albuterol aerosol (gm) (generic), ProventilHFA® (Schering), Xopenex® (Sepracor) oxazepam (generic), diazepam (generic),lorazepam (generic), clorazepate albuterol aerosol (gm) (generic), Proventil Avelox® (Bayer), Cipro® (Bayer), Levaquin® (Ortho Pharmaceutical),Tequin® (Bristol-Myers Squibb) sulfamethoxazole/trimethoprim (generic),Macrobid® (Procter & Gamble Pharmaceuticals), Noroxin® (Merck & Co.), sustained release 12 hr (generic),pseudoephedrine HCl/brompheniramine maleate (generic), Carbodec TR® (Various) Nonpreferred Product
Possible Plan-preferred Products
Nonpreferred Product
Possible Plan-preferred Products
maleate capsule, sustained action (generic), nortriptyline HCl (generic), trazodone HCl (generic), Effexor XR® (Wyeth),Wellbutrin nifedipine ER (generic), Norvasc® (Pfizer) clemastine fumarate (generic), hydroxyzine Omnicef® (Abbott Laboratories), Suprax® HCl (generic), Allegra® (Aventis), Clarinex® clemastine fumarate (generic), hydroxyzineHCl (generic), Allegra® (Aventis), Clarinex® nifedipine ER (generic), Norvasc® (Pfizer) lovastatin (generic), Lipitor® (Pfizer), sulfamethoxazole/trimethoprim suspension, maleate capsule, sustained release 12 hr(generic), pseudoephedrine HCl/ pseudoephedrine HCl/chlorpheniraminemaleate capsule, sustained release 12 hr (generic), pseudoephedrine HCl/chlorpheniramine maleate (generic) Benicar® (Sankyo), Cozaar® (Merck & Co.), diltiazem HCl capsule, sustained release diltiazem HCl capsule, sustained release diltiazem HCl capsule, sustained release diltiazem HCl capsule, sustained release diltiazem HCl capsule, sustained release pseudoephedrine HCl/chlorpheniraminemaleate capsule, sustained release 12 hr indomethacin (generic), sulindac (generic), albuterol aerosol (gm) (generic), Proventil chlorpheniramine maleate (generic),pseudoephedrine HCl/brompheniramine maleate (generic), Carbodec TR® (Various) Nonpreferred Product
Possible Plan-preferred Products
Nonpreferred Product
Possible Plan-preferred Products
(generic), Lotensin® (Novartis), Accupril® (Pfizer), Altace® (Monarch Pharmaceutical) Premarin® (Wyeth), Estring® (Pharmacia) pseudoephedrine HCl/chlorpheniraminemaleate capsule, sustained release 12 hr (generic), Augmentin® (GlaxoSmithKline), lisinopril/hydrochlorothiazide (generic), maleate capsule, sustained release 12 hr(generic), pseudoephedrine HCl/ clonidine HCl tablet (generic), methyldopa maleate capsule, sustained release 12 hr(generic), pseudoephedrine HCl/ pseudoephedrine HCl/chlorpheniraminemaleate capsule, sustained release 12 hr (generic), pseudoephedrine HCl/chlorpheniramine maleate (generic) lisinopril/hydrochlorothiazide (generic),

Source: http://www.kvri.com/RxGuide.pdf