CAREMARK SELF DIRCTED HEALTH PLAN (SDHP) AND HEALTH SAVINGS ACCOUNT (HSA) PREVENTIVE PRESCRIPTION DRUG LIST FOR CITGO PETROLEUM CORPORATION
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1 CAREMARK SELF DIRCTED HEALTH PLAN (SDHP) AND HEALTH SAVINGS ACCOUNT (HSA) PREVENTIVE PRESCRIPTION DRUG LIST FOR CITGO PETROLEUM CORPORATION THIS LIST REPRESENTS PREVENTIVE PRESCRIPTION DRUGS FOR THE CITGO PETROLEUM SELF DIRECTED HEALTH PLAN (SDHP). GENERIC PRODUCTS ARE LISTED IN LOWER CASE ITALIC LETTERS BRANDED GENERIC PRODUCTS ARE LISTED IN A COMBINATION OF LOWER AND UPPER CASE ITALIC LETTERS BRAND PRODUCTS ARE LISTED IN ALL CAPITAL LETTERS Some strengths or dosage forms may not be available. 1
2 CARDIOVASCULAR - OTHER ANTIARRHYTHMIC propafenone ext-rel MULTAQ RYTHMOL SR ORAL ANTIANGINAL isosorbide dinitrate isosorbide mononitrate nitroglycerin Isochron Nitrocot SA Nitroglyn Nitro-Par Nitro-Time CR DILATRATE-SR IMDUR ISMO ISORDIL ISOTRATE ER MONOKET NITRO-BID SORBITRATE SL and chewable formulations are not included on this list. TRANSDERMAL/TOPICAL ANTIANGINAL nitroglycerin transdermal Minitran DEPONIT NITRO-BID NITRODISC NITRO-DUR NITROL CORONARY ARTERY DISEASE ANTIHYPERLIPIDEMICS cholestyramine colestipol fenofibrate fenofibric acid gemfibrozil lovastatin pravastatin simvastatin Prevalite ALTOPREV ANTARA COLESTID CRESTOR FENOGLIDE FIBRICOR LESCOL LESCOL XL LIPITOR LIPOFEN LIVALO LOCHOLEST/LOCHOLEST LIGHT LOFIBRA LOPID LOVAZA MEVACOR NIASPAN OMACOR PRAVACHOL QUESTRAN/QUESTRAN LIGHT TRICOR TRIGLIDE TRILIPIX WELCHOL ZETIA ZOCOR COMBINATION ANTIHYPERLIPIDEMICS ADVICOR CADUET SIMCOR VYTORIN DIABETES DIAGNOSTIC BLOOD GLUCOSE MONITORS - ALL BLOOD GLUCOSE STRIPS - ALL CONTROL SOLUTIONS KETONE BLOOD TEST STRIPS - ALL LANCETS, LANCET DEVICES URINE TESTING STRIPS - ALL INJECTABLE DIABETES APIDRA BYETTA HUMALOG HUMULIN LANTUS LEVEMIR NOVOLIN NOVOLOG SYMLIN VICTOZA ORAL DIABETES acarbose acetohexamide chlorpropamide glimepiride glipizide glipizide ext-rel glipizide/metformin glyburide glyburide, micronized glyburide/metformin metformin metformin ext-rel nateglinide tolbutamide Glycron ACTOPLUS MET ACTOS 2
3 AMARYL DIABETA DIABINESE DUETACT DYMELOR FORTAMET GLUCOPHAGE GLUCOPHAGE XR GLUCOTROL GLUCOTROL XL GLUCOVANCE GLUMETZA GLYNASE GLYSET JANUMET JANUVIA METAGLIP ONGLYZA ORINASE PRANDIMET PRANDIN PRECOSE RIOMET STARLIX TRADJENTA HEMATOLOGIC ADVATE ALPHANATE ALPHANINE SD BEBULIN BENEFIX CORIFACT FEIBA GENARC HELIXATE HELIXATE FS HEMOFIL M HUMATE-P KOATE-DVI KOATE-HP KOGENATE KOGENATE FS MONARC-M MONOCLATE-P MONONINE PROFILNINE SD RECOMBINATE REFACTO WILATE XYNTHA HYPERTENSION ACE INHIBITORS/ ANGIOTENSIN II RECEPTOR ANTAGONISTS benazepril benazepril/hydrochlorothiazide captopril captopril/hydrochlorothiazide enalapril enalapril/hydrochlorothiazide fosinopril fosinopril/hydrochlorothiazide lisinopril lisinopril/hydrochlorothiazide losartan losartan/hydrochlorothiazide moexipril moexipril/hydrochlorothiazide perindopril quinapril quinapril/hydrochlorothiazide ramipril trandolapril Quinaretic ACCUPRIL ACCURETIC ACEON ALTACE ATACAND ATACAND HCT AVALIDE AVAPRO BENICAR BENICAR HCT CAPOTEN CAPOZIDE COZAAR DIOVAN DIOVAN HCT EDARBI HYZAAR LOTENSIN LOTENSIN HCT MAVIK MICARDIS MICARDIS HCT MONOPRIL MONOPRIL-HCT PRINIVIL PRINZIDE TEVETEN TEVETEN HCT UNIRETIC UNIVASC VASERETIC VASOTEC ZESTORETIC ZESTRIL ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril trandolapril/verapamil ext-rel LEXXEL LOTREL TARKA BETA-BLOCKERS acebutolol atenolol atenolol/chlorthalidone betaxolol bisoprolol bisoprolol/hydrochlorothiazide carvedilol labetalol metoprolol metoprolol succinate ext-rel metoprolol/hydrochlorothiazide nadolol nadolol/bendroflumethiazide pindolol propranolol propranolol ext-rel propranolol/hydrochlorothiazide timolol maleate BETACHRON 3
4 BYSTOLIC COREG COREG CR CORGARD CORZIDE INDERAL LA INDERIDE INDERIDE LA KERLONE LEVATOL LOPRESSOR LOPRESSOR HCT NORMODYNE SECTRAL TENORETIC TENORMIN TIMOLIDE TOPROL-XL TRANDATE VISKEN ZEBETA ZIAC CALCIUM CHANNEL BLOCKERS amlodipine diltiazem diltiazem ext-rel diltiazem XR felodipine ext-rel nicardipine nifedipine nifedipine ext-rel nisoldipine ext-rel verapamil verapamil ext-rel Afeditab CR Cartia XT Dilt-CD Diltia XT Dilt-XR Nifediac CC Nifedical XL Taztia XT ADALAT ADALAT CC CALAN CALAN SR CARDENE SR CARDIZEM CARDIZEM CD CARDIZEM LA CARDIZEM SR COVERA-HS DILACOR XR DYNACIRC DYNACIRC CR ISOPTIN SR NORVASC PROCARDIA PROCARDIA XL SULAR TIAZAC VASCOR VERELAN VERELAN PM DIURETICS amiloride/hydrochlorothiazide chlorothiazide chlorthalidone hydrochlorothiazide indapamide methyclothiazide spironolactone/hydrochlorothiazide triamterene/hydrochlorothiazide Carozide Ezide ALDACTAZIDE DIUCARDIN DIURIL DYAZIDE ENDURON ESIDRIX HYDRODIURIL HYGROTON MAXZIDE MICROZIDE ORETIC SALURON THALITONE OTHER ANTIHYPERTENSIVE clonidine clonidine transdermal clonidine/chlorthalidone guanabenz guanfacine hydralazine hydrochlorothiazide/reserpine hydrochlorothiazide/reserpine/ hydralazine methyldopa methyldopa/ hydrochlorothiazide minoxidil reserpine Cam-Ap-Es Marpres Ser-A-Gen Serpazide Tri-Hydroserpine Uni-Serp ALDOCLOR ALDOMET ALDORIL AMTURNIDE APRESAZIDE APRESOLINE AZOR CATAPRES CATAPRES-TTS CLORPRES COMBIPRES ENDURONYL FORTE ESIMIL EXFORGE EXFORGE HCT INVERSINE LONITEN MINIZIDE NEXICLON XR SER-AP-ES TEKAMLO TEKTURNA TEKTURNA HCT TENEX TRIBENZOR TWYNSTA 4
5 VALTURNA WYTENSIN IMMUNIZING ZOSTAVAX MENTAL HEALTH ANTIDEPRESSANTS amitriptyline amoxapine bupropion bupropion ext-rel citalopram clomipramine desipramine doxepin fluoxetine fluoxetine delayed-rel fluvoxamine imipramine HCl imipramine pamoate maprotiline mirtazapine nortriptyline paroxetine HCl paroxetine HCl ext-rel phenelzine protriptyline sertraline tranylcypromine trazodone trimipramine venlafaxine venlafaxine ext-rel Budeprion SR Budeprion XL Vanatrip ADAPIN ANAFRANIL APLENZIN ASENDIN AVENTYL CELEXA CYMBALTA EFFEXOR EFFEXOR XR ELAVIL EMSAM ENDEP LEXAPRO LUDIOMIL LUVOX MARPLAN NARDIL NORPRAMIN OLEPTRO PAMELOR PARNATE PAXIL PAXIL CR PEXEVA PRISTIQ PROZAC PROZAC WEEKLY RAPIFLUX REMERON SURMONTIL TOFRANIL TOFRANIL-PM VIVACTIL WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL ZOLOFT ANTIPSYCHOTICS chlorpromazine clozapine fluphenazine fluphenazine decanoate haloperidol loxapine perphenazine risperidone thioridazine thiothixene trifluoperazine ABILIFY CLOZARIL EQUETRO FAZACLO GEODON HALDOL HALDOL DECANOATE INVEGA INVEGA SUSTENNA LOXITANE MELLARIL MOBAN NAVANE PERMITIL PROLIXIN RISPERDAL RISPERDAL CONSTA SAPHRIS SEROQUEL SEROQUEL XR THORAZINE TRILAFON ZYPREXA ZYPREXA ZYDIS OSTEOPOROSIS alendronate calcitonin calcitonin-salmon Fortical ACTONEL ATELVIA BONIVA EVISTA FOSAMAX FOSAMAX PLUS D MIACALCIN NASAL SPRAY PROLIA PRENATAL VITAMINS PRESCRIPTIN PRENATAL VITAMINS - ALL 5
6 RESPIRATORY budesonide suspension cromolyn sodium zafirlukast ACCOLATE ADVAIR ADVAIR HFA AEROBID AEROBID-M ALVESCO ASMANEX AZMACORT BECLOVENT BROVANA DALIRESP DULERA FLOVENT HFA FORADIL INTAL PERFOROMIST PULMICORT QVAR SEREVENT SINGULAIR SYMBICORT SYNAGIS XOLAIR ZYFLO CR STROKE ANTICOAGULANTS warfarin Jantoven COUMADIN COUMADIN INJECTION PRADAXA XARELT ANTICOAGULANTS/PLATELET AGGREGATION INHIBITORS dipyridamole ticlopidine Dipradam AGGRENOX ARIXTRA BRILINTA EFFIENT FRAGMIN INNOHEP IPRIVASK LOVENOX PERSANTINE PLAVIX TICLID VARIOUS ANTI-MALARIAL chloroquine mefloquine ARALEN LARIAM MALARONE PRIMAQUINE PRENATAL VITAMINS PRENATAL VITAMINS - ALL PRESCRIPTION ANTICONVULSANTS carbamazepine carbamazepine ext-rel clonazepam divalproex sodium delayed-rel divalproex sodium ext-rel ethosuximide lamotrigine levetiracetam oxcarbazepine phenobarbital phenytoin phenytoin sodium extended primidone topiramate valproic acid zonisamide Atretol Ceberclon Di-Phen Epitol BANZEL CARBATROL CELONTIN DEPAKENE DEPAKOTE DEPAKOTE ER DILANTIN FELBATOL GABITRIL KEPPRA KEPPRA XR KLONOPIN LAMICTAL LAMICTAL XR LAMICTAL XR KIT MYSOLINE PEGANONE PHENYTEK SABRIL STAVZOR TEGRETOL TEGRETOL-XR TOPAMAX TRILEPTAL VIMPAT ZARONTIN ZONEGRAN 6
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