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BCBSMN GenRx
Alphabetical Drug List
April 2009

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Category
acarbose (Precose - brand is NF)
acebutolol (Sectral – brand is NF)
acetaminophen/codeine (Tylenol w/Codeine – brand is NF)
acetaminophen/isometheptene/dichloralphenazone (Midrin – brand is NF)
acetazolamide
acetazolamide ext-release (Diamox Sequels – brand is NF)
acetic acid ear soln
acetylcysteine
ACTOS – ST
acyclovir (Zovirax – brand is NF)
ADVAIR DISKUS 250/50 – QL
ADVATE – PA
albuterol sulfate inhal soln
albuterol sulfate syrup, tabs
alclometasone (Aclovate – brand is NF)
alendronate tabs (Fosamax – brand is NF) – QL
allopurinol
ALPHANATE – PA
ALPHANINE SD – PA
alprazolam (Xanax – brand is NF)
aluminum chloride soln (Drysol – brand is NF)
amantadine caps, syrup
amiloride/hydrochlorothiazide
aminocaproic acid inj (Amicar – brand is NF)
aminocaproic acid syrup, tabs (Amicar – brand is NF)
amiodarone
amitriptyline
amlodipine (Norvasc – brand is NF)
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS amlodipine/benazepril (Lotrel – brand is NF)
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS amoxicillin
amoxicillin/potassium clavulanate (Augmentin – brand is NF)
amphetamine/dextroamphetamine mixed salts (Adderall – brand is NF)
ampicillin caps
anagrelide (Agrylin – brand is NF)
GenRx Drug Alphabetical Drug List, April 2009 1
Category
anthralin (Dritho-Creme HP – brand is NF)
ASCENSIA AUTODISC – QL
ASCENSIA BREEZE/BREEZE 2 – QL
ASCENSIA CONTOUR – QL
ASCENSIA ELITE/ELITE XL – QL
ASMANEX – QL
atenolol (Tenormin – brand is NF)
atenolol/chlorthalidone (Tenoretic – brand is NF)
atropine sulfate oint, soln (Isopto Atropine – brand is NF)
azathioprine (Imuran – brand is NF)
azithromycin (Zithromax – brand is NF)
bacitracin oint
bacitracin/polymyxin B oint
baclofen
balsalazide (Colazal - brand is NF)
BEBULIN VH – PA
benazepril (Lotensin – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS benazepril/hydrochlorothiazide (Lotensin HCT – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS BENEFIX – PA
benzocaine/antipyrine
benzonatate (Tessalon – brand is NF)
benztropine
betamethasone dipropionate
betamethasone dipropionate, augmented (Diprolene – brand is NF)
betamethasone valerate
bethanechol (Urecholine – brand is NF)
bisoprolol (Zebeta – brand is NF)
bisoprolol/hydrochlorothiazide (Ziac – brand is NF)
brimonidine soln, 0.2%
bromocriptine (Parlodel – brand is NF)
brompheniramine/pseudoephedrine ext-release caps, 6/60
bumetanide (Bumex – brand is NF)
bupropion (Wellbutrin – brand is NF)
bupropion ext-release 12 hr (Wellbutrin SR – brand is NF)
bupropion ext-release 24 hr (Wellbutrin XL – brand is NF)
GenRx Drug Alphabetical Drug List, April 2009 2
Category
bupropion ext-release (Zyban)
buspirone (Buspar – brand is NF)
butalbital/acetaminophen tabs, 50/325 (Phrenilin – brand is NF)
butalbital/acetaminophen tabs, 50/650 (Sedapap – brand is NF)
butalbital/acetaminophen/caffeine caps, 50/325/40 (Esgic – brand is NF)
butalbital/acetaminophen/caffeine tabs, 50/325/40 (Fioricet – brand is NF)
butalbital/acetaminophen/caffeine tabs, 50/500/40 (Esgic Plus – brand is NF)
butalbital/aspirin/caffeine caps, 50/325/40 (Fiorinal – brand is NF)
butalbital/aspirin/caffeine tabs, 50/325/40
butalbital/aspirin/caffeine/codeine caps (Fiorinal w/Codeine – brand is NF)
cabergoline
calcipotriene soln (Dovonex – brand is NF)
calcitonin-salmon nasal includes Fortical
calcitriol (Rocaltrol – brand is NF)
calcium acetate (Phoslo)
captopril (Capoten – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS captopril/hydrochlorothiazide
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS carbamazepine (Tegretol – brand is NF)
carbidopa/levodopa (Sinemet – brand is NF)
carbidopa/levodopa ext-release (Sinemet CR – brand is NF)
carbidopa/levodopa ODT (Parcopa – brand is NF)
carteolol soln
carvedilol (Coreg – brand is NF)
cefadroxil
cefdinir (Omnicef – brand is NF)
cefpodoxime (Vantin – brand is NF)
cefprozil
ceftriaxone (Rocephin – brand is NF)
cefuroxime (Ceftin – brand is NF)
cephalexin (Keflex – brand is NF)
CHANTIX – QL
chloral hydrate syrup
chlorhexidine oral rinse (Peridex – brand is NF)
chloroquine phosphate (Aralen – brand is NF)
chlorothiazide
chlorpromazine
chlorpropamide
chlorthalidone 25 mg, 50 mg
chlorzoxazone
cholestyramine (Questran, Questran Light – brands are NF)
chorionic gonadotropin
GenRx Drug Alphabetical Drug List, April 2009 3
Category
ciclopirox (Loprox – brand is NF)
cilostazol (Pletal – brand is NF)
cimetidine
ciprofloxacin ext-release (Cipro XR – brand is NF)
ciprofloxacin soln (Ciloxan – brand is NF)
ciprofloxacin tabs (Cipro – brand is NF)
citalopram (Celexa – brand is NF)
clarithromycin (Biaxin – brand is NF)
clarithromycin ext-release (Biaxin XL – brand is NF)
clindamycin (Cleocin – brand is NF)
clindamycin (Cleocin T – brand is NF)
clindamycin crm (Cleocin – brand is NF)
clobetasol (Olux – brand is NF)
clobetasol (Temovate – brand is NF)
clomiphene (Clomid – brand is NF)
clomipramine (Anafranil – brand is NF)
clonazepam (Klonopin – brand is NF)
clonidine (Catapres – brand is NF)
clotrimazole troche (Mycelex – brand is NF)
clotrimazole/betamethasone (Lotrisone – brand is NF)
clozapine 25 mg, 50 mg, 100 mg (Clozaril – brand is NF) – QL
codeine sulfate 30 mg, 60 mg
codeine/guaifenesin soln, 10/100 per 5 mL
colchicine
colestipol tabs (Colestid – brand is NF)
cortisone acetate
COZAAR – ST
CRESTOR 40 mg – ST
cromolyn sodium inhal soln
cromolyn sodium soln (Crolom – brand is NF)
cyanocobalamin inj
cyclobenzaprine (Flexeril – brand is NF)
cyclopentolate soln (Cyclogyl – brand is NF)
cyclosporine (Sandimmune – brand is NF)
cyclosporine modified caps, 25 mg, 100 mg; soln (Neoral – brand is NF)
cyproheptadine
GenRx Drug Alphabetical Drug List, April 2009 4
Category
dantrolene (Dantrium – brand is NF)
demeclocycline (Declomycin – brand is NF)
desipramine (Norpramin – brand is NF)
desmopressin inj (DDAVP – brand is NF)
desmopressin nasal (DDAVP – brand is NF)
desmopressin tabs (DDAVP – brand is NF)
desogestrel/ethinyl estradiol (Cyclessa – brand is NF)
desogestrel/ethinyl estradiol (Mircette – brand is NF)
desogestrel/ethinyl estradiol (Ortho-Cept – brand is NF)
desonide (Desowen – brand is NF)
desoximetasone (Topicort – brand is NF)
DEXAMETHASONE elixir, soln; tabs, 1 mg, 2 mg dexamethasone sodium phosphate soln
EYE, Steroids and Steroid Combination Products dexamethasone tabs, 0.5 mg, 0.75 mg, 1.5 mg, 4 mg, 6 mg
dextroamphetamine ext-release (Dexedrine Spansule – brand is NF)
dextroamphetamine tabs, 5 mg
diazepam tabs (Valium – brand is NF)
diclofenac sodium delayed-release (Voltaren – brand is NF)
diclofenac sodium ext-release (Voltaren XR – brand is NF)
diclofenac soln (Voltaren – brand is NF)
dicloxacillin
dicyclomine (Bentyl – brand is NF)
didanosine delayed-release (Videx EC – brand is NF)
diflorasone
digoxin tabs (Lanoxin – brand is NF)
diltiazem (Cardizem – brand is NF)
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS diltiazem ext-release 12 hr
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS diltiazem ext-release (Cardizem CD – brand is NF)
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS diltiazem ext-release (Dilacor XR – brand is NF)
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS diltiazem ext-release (Tiazac – brand is NF)
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS diphenoxylate/atropine (Lomotil – brand is NF)
dipivefrin soln (Propine – brand is NF)
disopyramide (Norpace – brand is NF)
disopyramide ext-release 150 mg (Norpace CR – brand is NF)
divalproex delayed-release (Depakote - brand is NF)
divalproex delayed-release (Depakote Sprinkles - brand is NF)
divalproex ext-release (Depakote ER – brand is NF)
dorzolamide (Trusopt – brand is NF)
dorzolamide/timolol maleate (Cosopt – brand is NF)
GenRx Drug Alphabetical Drug List, April 2009 5
Category
doxazosin (Cardura – brand is NF)
doxepin caps, soln
doxepin crm (Zonalon – brand is NF)
doxycycline hyclate
doxycycline monohydrate caps, tabs (Monodox, Adoxa – brands are NF)
dronabinol (Marinol – brand is NF)
drospirenone/ethinyl estradiol (Yasmin – brand is NF)
econazole
ELIDEL – ST
enalapril (Vasotec – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS enalapril/hydrochlorothiazide (Vaseretic – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS ENBREL – ST
epoprostenol (Flolan – brand is NF)
ergocalciferol caps (Drisdol – brand is NF)
ergotamine/caffeine tabs (Cafergot – brand is NF) – QL
erythromycin ethylsuccinate
erythromycin gel
erythromycin oint
erythromycin pads, soln, 2%
erythromycin/benzoyl peroxide (Benzamycin – brand is NF)
erythromycin/sulfisoxazole (Pediazole – brand is NF)
estazolam
estradiol patches (Climara – brand is NF)
estradiol tabs (Estrace – brand is NF)
estradiol/norethindrone acetate 1/0.5 mg (Activella – brand is NF)
estropipate (Ogen – brand is NF)
ethambutol (Myambutol – brand is NF)
ethosuximide (Zarontin – brand is NF)
ethynodiol/ethinyl estradiol (Demulen – brand is NF)
etodolac
etoposide
famciclovir (Famvir – brand is NF)
famotidine (Pepcid – brand is NF)
GenRx Drug Alphabetical Drug List, April 2009 6
Category
FEIBA VH – PA
felodipine ext-release
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS fenofibrate micronized, caps, 67 mg, 134 mg, 200 mg (Lofibra – brand is NF)
fenofibrate tabs, 54 mg, 160 mg (Lofibra – brand is NF)
fentanyl patches (Duragesic – brand is NF)
fexofenadine (Allegra – brand is NF)
finasteride (Proscar – brand is NF)
flecainide (Tambocor – brand is NF)
fluconazole (Diflucan – brand is NF)
fludrocortisone
flunisolide (Nasarel – brand is NF)
flunisolide 25 mcg/spray
fluocinonide
fluorometholone susp (FML – brand is NF)
EYE, Steroids and Steroid Combination Products fluorouracil crm, soln, 5% (Efudex – brand is NF )
fluoxetine (Prozac – brand is NF)
fluphenazine decanoate
fluphenazine hcl tabs
flurbiprofen soln (Ocufen – brand is NF)
flutamide
fluticasone (Flonase – brand is NF)
fluticasone propionate (Cutivate – brand is NF)
folic acid inj
folic acid tabs, 1 mg
FOLLISTIM AQ – PA – Benefit Exclusions May Apply
FORADIL AEROLIZER – QL
fosinopril (Monopril – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS fosinopril/hydrochlorothiazide (Monopril HCT – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS furosemide soln, 10 mg/mL; tabs (Lasix – brand is NF)
gabapentin caps, tabs (Neurontin – brand is NF)
gemfibrozil (Lopid – brand is NF)
gentamicin crm, oint
gentamicin oint, soln
glimepiride (Amaryl – brand is NF)
glipizide (Glucotrol – brand is NF)
glipizide ext-release (Glucotrol XL – brand is NF)
glipizide/metformin (Metaglip – brand is NF)
glyburide (Micronase – brand is NF)
glyburide micronized (Glynase – brand is NF)
glyburide/metformin (Glucovance – brand is NF)
GenRx Drug Alphabetical Drug List, April 2009 7
Category
glycopyrrolate (Robinul – brand is NF)
granisetron tabs (Kytril – brand is NF)
griseofulvin microsize susp (Grifulvin V – brand is NF)
guanfacine (Tenex – brand is NF)
halobetasol (Ultravate – brand is NF)
haloperidol decanoate (Haldol – brand is NF)
haloperidol lactate oral soln
haloperidol tabs
HELIXATE FS – PA
HEMOFIL M – PA
heparin sodium inj
heparin sodium lock flush
homatropine soln (Isopto Homatropine – brand is NF)
HUMATE-P – PA
hydralazine
hydrochlorothiazide caps (Microzide – brand is NF)
hydrochlorothiazide tabs, 25 mg, 50 mg
hydrocodone/acetaminophen caps, 5/500
hydrocodone/acetaminophen soln, 7.5/500 per 15 mL (Lortab – brand is NF)
hydrocodone/acetaminophen tabs, 10/750 (Maxidone – brand is NF)
hydrocodone/acetaminophen tabs, 2.5/500, 5/500, 7.5/500, 10/500
hydrocodone/acetaminophen tabs, 5/325, 7.5/325, 10/325
hydrocodone/acetaminophen tabs, 5/500, 7.5/750, 10/660
(Vicodin, Vicodin ES, Vicodin HP – brands are NF) hydrocodone/acetaminophen tabs, 7.5/650, 10/650
hydrocodone/ibuprofen tabs, 5/200 (Reprexain – brand is NF)
hydrocodone/ibuprofen tabs, 7.5/200 (Vicoprofen – brand is NF)
hydrocodone/ibuprofen tabs, 10/200 (Ibudone – brand is NF)
hydrocortisone (Cortef – brand is NF)
hydrocortisone 2.5%
hydrocortisone acetate supp, 25 mg (Anusol-HC – brand is NF)
hydrocortisone butyrate (Locoid – brand is NF)
hydrocortisone crm, 2.5% (Anusol-HC – brand is NF)
hydrocortisone enema
hydrocortisone valerate (Westcort – brand is NF)
hydrocortisone/acetic acid
hydromorphone tabs (Dilaudid – brand is NF)
hydroxychloroquine (Plaquenil – brand is NF)
hydroxyurea (Hydrea – brand is NF)
hydroxyzine hcl
hydroxyzine pamoate (Vistaril – brand is NF)
GenRx Drug Alphabetical Drug List, April 2009 8
Category
hyoscyamine (Cystospaz – brand is NF)
hyoscyamine (Levsin – brand is NF)
hyoscyamine ext-release tabs (Levbid – brand is NF)
hyoscyamine ODT
HYZAAR – ST
ibuprofen
imipramine hcl (Tofranil – brand is NF)
IMITREX inj – QL
IMITREX nasal – QL
IMITREX tabs – QL
INCRELEX – PA
indapamide
indomethacin
indomethacin ext-release (Indocin SR – brand is NF)
ipratropium inhal soln
ipratropium spray (Atrovent – brand is NF)
ipratropium/albuterol sulfate (Duoneb – brand is NF)
isoniazid tabs
isoniazid/rifampin (Rifamate – brand is NF)
isosorbide dinitrate oral tabs (Isordil – brand is NF)
isosorbide mononitrate (Monoket – brand is NF)
isosorbide mononitrate ext-release
isotretinoin caps (Accutane – brand is NF)
itraconazole caps (Sporanox – brand is NF)
KEPPRA soln; tabs, 1000 mg – ST
ketoconazole crm
ketoconazole shampoo, 2% (Nizoral – brand is NF)
ketoconazole tabs
ketoprofen
ketorolac QL
KOATE-DVI – PA
KOGENATE FS – PA
labetalol (Trandate – brand is NF)
lactulose
lamotrigine (Lamictal – brand is NF)
GenRx Drug Alphabetical Drug List, April 2009 9
Category
leflunomide (Arava – brand is NF)
leucovorin calcium tabs, 5 mg, 25 mg
leuprolide (Lupron – brand is NF)
CANCER DRUGS, OTHER HORMONES AND RELATED DRUGS levetiracetam (Keppra – brand is NF)
levobunolol soln (Betagan – brand is NF)
levonorgestrel/ethinyl estradiol, 0.1/20
levonorgestrel/ethinyl estradiol (Nordette – brand is NF)
levonorgestrel/ethinyl estradiol (Seasonale – brand is NF)
levonorgestrel/ethinyl estradiol (Triphasil – brand is NF)
levothyroxine includes Levoxyl (Synthroid – brand is NF)
lidocaine jelly, 2%; oint, 5%; soln, 4% (Xylocaine – brand is NF)
lidocaine viscous
lidocaine/prilocaine crm (Emla – brand is NF)
lindane lotn
lisinopril (Prinivil – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS lisinopril/hydrochlorothiazide (Prinzide – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS lithium carbonate caps
lithium carbonate ext-release 300 mg (Lithobid – brand is NF)
lithium carbonate ext-release 450 mg
lithium citrate
lorazepam (Ativan – brand is NF)
lovastatin (Mevacor – brand is NF)
loxapine
CANCER DRUGS, OTHER HORMONES AND RELATED DRUGS mebendazole
meclizine (Antivert – brand is NF)
meclizine tabs, 32 mg
medroxyprogesterone acetate (Provera – brand is NF)
medroxyprogesterone inj, 150 mg/mL (Depo-Provera – brand is NF)
mefloquine (Lariam – brand is NF)
megestrol (Megace – brand is NF)
meloxicam tabs (Mobic – brand is NF)
mercaptopurine (Purinethol – brand is NF)
GenRx Drug Alphabetical Drug List, April 2009 10
Category
mesalamine enema
metformin (Glucophage – brand is NF)
metformin ext-release (Glucophage XR – brand is NF)
methadone conc, tabs
methazolamide
methenamine hippurate (Hiprex, Urex – brands are NF)
methenamine mandelate/sodium biphosphate
methimazole (Tapazole – brand is NF)
methocarbamol (Robaxin – brand is NF)
methotrexate inj
CANCER DRUGS, RHEUMATOID AND OSTEOARTHRITIS methotrexate tabs 2.5 mg
CANCER DRUGS, RHEUMATOID AND OSTEOARTHRITIS methscopolamine (Pamine – brand is NF)
methyldopa
methylphenidate (Ritalin – brand is NF)
methylphenidate ext-release (Metadate ER – brand is NF)
methylphenidate ext-release (Ritalin SR – brand is NF)
methylprednisolone (Medrol – brand is NF)
metipranolol soln (Optipranolol – brand is NF)
metoclopramide (Reglan – brand is NF)
metolazone (Zaroxolyn – brand is NF)
metoprolol succinate ext-release (Toprol XL – brand is NF)
metoprolol tartrate (Lopressor – brand is NF)
metoprolol tartrate/hydrochlorothiazide 50/25 mg, 100/25 mg
metronidazole (Flagyl – brand is NF)
metronidazole (MetroGel-Vaginal – brand is NF)
metronidazole (Metrolotion – brand is NF)
metronidazole 0.75% (Metrocream – brand is NF)
metronidazole gel, 0.75%
midodrine (Proamatine – brand is NF)
minocycline caps, tabs (Minocin, Dynacin – brands are NF)
minoxidil
mirtazapine (Remeron – brand is NF)
mirtazapine ODT (Remeron Soltab – brand is NF)
misoprostol (Cytotec – brand is NF)
moexipril (Univasc – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS moexipril/hydrochlorothiazide (Uniretic – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS mometasone (Elocon – brand is NF)
MONARC-M – PA
MONOCLATE-P – PA
MONONINE – PA
morphine sulfate conc, soln, tabs
GenRx Drug Alphabetical Drug List, April 2009 11
Category
morphine sulfate ext-release (MS Contin – brand is NF)
morphine sulfate supp, 5 mg, 10 mg, 20 mg
mupirocin oint (Bactroban – brand is NF)
nabumetone
nadolol 20 mg, 40 mg, 80 mg (Corgard – brand is NF)
naltrexone (ReVia – brand is NF)
naproxen (Naprosyn – brand is NF)
naproxen sodium (Anaprox – brand is NF)
neomycin sulfate
neomycin/polymyxin B/bacitracin oint
neomycin/polymyxin B/bacitracin/hydrocortisone oint
EYE, Steroids and Steroid Combination Products neomycin/polymyxin B/dexamethasone oint, susp (Maxitrol – brand is NF)
EYE, Steroids and Steroid Combination Products neomycin/polymyxin B/gramicidin soln (Neosporin – brand is NF)
neomycin/polymyxin B/hydrocortisone soln, susp (Cortisporin – brand is NF)
nicotine gum (Nicorette) – OTC, QL
nicotine lozenges (Commit) – OTC, QL
nicotine patches (Nicoderm CQ) – OTC, QL
NICOTROL INHALER – QL
NICOTROL NS – QL
nifedipine ext-release (Adalat CC – brand is NF)
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS nifedipine ext-release (Procardia XL – brand is NF)
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS nitrofurantoin macrocrystals (Macrodantin – brand is NF)
nitrofurantoin monohydrate/macrocrystals (Macrobid – brand is NF)
nitroglycerin patches (Nitro-Dur – brand is NF)
nitroglycerin sublingual tabs (Nitrostat – brand is NF)
nizatidine (Axid – brand is NF)
norethindrone (Nor-QD – brand is NF)
norethindrone (Ortho Micronor – brand is NF)
norethindrone acetate (Aygestin – brand is NF)
norethindrone acetate/ethinyl estradiol (Loestrin – brand is NF)
norethindrone acetate/ethinyl estradiol/Fe (Loestrin Fe – brand is NF)
norethindrone/ethinyl estradiol (Modicon – brand is NF)
norethindrone/ethinyl estradiol (Ortho-Novum 1/35 – brand is NF)
norethindrone/ethinyl estradiol (Ortho-Novum 7/7/7 – brand is NF)
norethindrone/ethinyl estradiol (Ovcon 35 – brand is NF)
norethindrone/ethinyl estradiol (Tri-Norinyl – brand is NF)
norethindrone/mestranol (Ortho-Novum 1/50 – brand is NF)
norgestimate/ethinyl estradiol (Ortho Tri-Cyclen – brand is NF)
GenRx Drug Alphabetical Drug List, April 2009 12
Category
norgestimate/ethinyl estradiol (Ortho-Cyclen – brand is NF)
norgestrel/ethinyl estradiol (Lo/Ovral – brand is NF)
nortriptyline (Pamelor – brand is NF)
NOVOSEVEN – PA
NOVOSEVEN RT – PA
nystatin (Mycostatin – brand is NF)
nystatin oral powder
nystatin oral tabs
nystatin susp
nystatin/triamcinolone
octreotide (Sandostatin – brand is NF)
ofloxacin (Floxin Otic – brand is NF)
ofloxacin soln (Ocuflox – brand is NF)
ofloxacin tabs
omeprazole delayed-release (Prilosec – brand is NF) – QL
OMNITROPE – PA
ondansetron inj (Zofran – brand is NF)
ondansetron ODT (Zofran ODT – brand is NF)
ondansetron oral soln, tabs (Zofran – brand is NF)
orphenadrine citrate ext-release
orphenadrine/aspirin/caffeine 25/385/30
OVIDREL – PA – Benefit Exclusions May Apply
oxcarbazepine tabs (Trileptal – brand is NF)
oxybutynin QL
oxybutynin ext-release (Ditropan XL – brand is NF) – QL
oxycodone caps (OxyIR – brand is NF)
oxycodone conc, soln, tabs (Roxicodone – brand is NF)
oxycodone ext-release (OxyContin) – ST, QL
oxycodone/acetaminophen caps, 5/500 (Tylox – brand is NF)
oxycodone/acetaminophen tabs, 5/325, 7.5/325, 7.5/500, 10/325, 10/650
oxycodone/aspirin tabs, 5/325 (Percodan – brand is NF)
OXYCONTIN – QL, ST
pantoprazole delayed-release tabs (Protonix – brand is NF) – QL, ST
paregoric
paromomycin
paroxetine hcl (Paxil – brand is NF)
paroxetine hcl ext-release, 12.5 mg, 25 mg (Paxil CR – brand is NF)
pediatric multivitamins/fluoride
pediatric multivitamins/fluoride/iron
GenRx Drug Alphabetical Drug List, April 2009 13
Category
pediatric vitamins ADC/fluoride
pediatric vitamins ADC/fluoride/iron
PEG-electrolytes for soln (Colyte – brand is NF)
PEG-electrolytes for soln (Nulytely – brand is NF)
penicillin v potassium
pentoxifylline ext-release (Trental – brand is NF)
permethrin crm, 5% (Elimite – brand is NF)
perphenazine
phenazopyridine (Pyridium – brand is NF)
phenobarbital elixer; tabs, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 100 mg
phenytoin sodium extended (Dilantin – brand is NF)
phenytoin susp (Dilantin – brand is NF)
phytonadione inj, 1 mg/0.5 mL
pilocarpine soln (Isopto Carpine – brand is NF)
pilocarpine tabs (Salagen – brand is NF)
piroxicam (Feldene – brand is NF)
podofilox soln (Condylox – brand is NF)
polymyxin B/trimethoprim soln (Polytrim – brand is NF)
potassium bicarbonate/chloride effervescent tabs, 25 mEq
potassium chloride ext-release caps, 10 mEq (Micro-K 10 – brand is NF)
potassium chloride ext-release tabs, 8 mEq
potassium chloride ext-release tabs, 10 mEq (K-Tabs – brand is NF)
potassium chloride ext-release tabs, 10 mEq, 20 mEq
potassium chloride liq 10%, 20%
potassium chloride packets, 20 mEq (K-Lor – brand is NF)
potassium citrate ext-release (Urocit-K – brand is NF)
potassium citrate/citric acid powder, soln (Polycitra-K – brand is NF)
potassium phosphate/sodium phosphates (K-Phos Neutral – brand is NF)
pravastatin (Pravachol – brand is NF)
prazosin (Minipress – brand is NF)
prednisolone acetate susp (Pred Forte – brand is NF)
EYE, Steroids and Steroid Combination Products prednisolone sodium phosphate soln (Orapred, Pediapred – brands are NF)
prednisolone syrup (Prelone – brand is NF)
prednisone
prenatal multivitamins/folic acid 1 mg
primidone (Mysoline – brand is NF)
PROAIR HFA – QL
probenecid
GenRx Drug Alphabetical Drug List, April 2009 14
Category
probenecid/colchicine
prochlorperazine supp
prochlorperazine tabs
PROFILNINE – PA
promethazine supp
promethazine syrup, tabs
propafenone (Rythmol – brand is NF)
propoxyphene hcl/acetaminophen tabs, 65/650
propoxyphene napsylate/acetaminophen tabs, 50/325, 100/650
propranolol ext-release (Inderal LA – brand is NF)
propranolol tabs
propranolol/hydrochlorothiazide 40/25
propylthiouracil
pyrazinamide
pyridostigmine tabs (Mestinon – brand is NF)
quinapril (Accupril – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS quinapril/hydrochlorothiazide (Accuretic – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS quinidine gluconate ext-release
quinidine sulfate
ramipril caps (Altace – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS ranitidine (Zantac – brand is NF)
RECOMBINATE – PA
REFACTO – PA
REVATIO – PA
ribavirin caps (Rebetol – brand is NF)
ribavirin tabs (Copegus – brand is NF)
ribavirin tabs, 400 mg, 600 mg
rifampin (Rifadin – brand is NF)
RISPERDAL M-TAB – QL, ST
RISPERDAL soln – QL, ST
risperidone ODT, 0.5 mg, 2 mg (Risperdal M-Tab) – QL
risperidone soln, tabs (Risperdal - brand is NF) – QL
ropinirole (Requip – brand is NF)
salsalate
scopolamine (Scopace – brand is NF)
selegiline caps (Eldepryl – brand is NF)
GenRx Drug Alphabetical Drug List, April 2009 15
Category
selenium sulfide 2.5% (Selsun – brand is NF)
SEROQUEL – QL, ST
SEROQUEL XR – QL, ST
sertraline (Zoloft – brand is NF)
silver sulfadiazine (Silvadene – brand is NF)
simvastatin (Zocor – brand is NF)
SINGULAIR – ST
sodium citrate/citric acid (Bicitra – brand is NF)
sodium fluoride chew tabs, drops; tabs, 2.2 mg
sodium fluoride crm, gel (Prevident – brand is NF)
SODIUM FLUORIDE soln, 0.55 mg/drop; tabs, 1.1 mg sodium polystyrene sulfonate
sotalol (Betapace – brand is NF)
sotalol (Betapace AF – brand is NF)
SPACER DEVICES, for inhalers – AEROCHAMBER SPIRIVA HANDIHALER – QL
spironolactone (Aldactone – brand is NF)
spironolactone/hydrochlorothiazide tabs, 25/25 (Aldactazide – brand is NF)
stavudine caps (Zerit – brand is NF)
sucralfate tabs (Carafate – brand is NF)
sulfacetamide sodium lotn (Klaron – brand is NF)
sulfacetamide sodium soln (Bleph-10 – brand is NF)
sulfacetamide sodium/prednisolone soln
EYE, Steroids and Steroid Combination Products sulfacetamide sodium/sulfur crm, emulsion (Plexion – brand is NF)
sulfacetamide sodium/sulfur lotn
sulfamethoxazole/trimethoprim (Bactrim, Septra – brands are NF)
sulfasalazine (Azulfidine – brand is NF)
sulindac (Clinoril – brand is NF)
sumatriptan tabs (Imitrex) – QL
sumatriptan vials, 6 mg (Imitrex) – QL
SYMBICORT – QL
SYNAGIS – PA
tamoxifen
GenRx Drug Alphabetical Drug List, April 2009 16
Category
temazepam (Restoril – brand is NF)
terazosin
terbinafine tabs (Lamisil – brand is NF)
terbutaline (Brethine – brand is NF)
terconazole (Terazol – brand is NF)
testosterone cypionate (Depo-Testosterone – brand is NF)
testosterone enanthate (Delatestryl – brand is NF)
tetracycline
theophylline ext-release tabs 12 hr Theochron
theophylline ext-release tabs 24 hr (Uniphyl – brand is NF)
thiothixene (Navane – brand is NF)
THROMBATE III – PA
timolol maleate gel-forming soln (Timoptic-XE – brand is NF)
timolol maleate soln (Timoptic – brand is NF)
tizanidine tabs (Zanaflex – brand is NF)
tobramycin soln (Tobrex – brand is NF)
tobramycin/dexamethasone susp (Tobradex – brand is NF)
TOPAMAX – ST
TOPAMAX SPRINKLES – ST
torsemide (Demadex – brand is NF)
tramadol (Ultram – brand is NF)
tramadol/acetaminophen (Ultracet – brand is NF)
trandolapril (Mavik – brand is NF)
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS tranylcypromine (Parnate – brand is NF)
trazodone
tretinoin (Retin-A – brand is NF)
tretinoin (Vesanoid – brand is NF)
triamcinolone
triamcinolone paste
triamterene/hydrochlorothiazide caps, 37.5/25 (Dyazide – brand is NF)
triamterene/hydrochlorothiazide caps, 50/25
triamterene/hydrochlorothiazide tabs, 37.5/25 (Maxzide-25 – brand is NF)
triamterene/hydrochlorothiazide tabs, 75/50 (Maxzide – brand is NF)
trifluoperazine
trifluridine soln (Viroptic – brand is NF)
trihexyphenidyl
trimethobenzamide caps (Tigan – brand is NF)
trimethoprim
GenRx Drug Alphabetical Drug List, April 2009 17
Category
ursodiol (Actigall – brand is NF)
valproic acid (Depakene – brand is NF)
venlafaxine (Effexor – brand is NF) – ST
verapamil (Calan – brand is NF)
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS verapamil ext-release (Calan SR – brand is NF)
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS verapamil ext-release (Verelan – brand is NF)
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS verapamil ext-release (Verelan PM – brand is NF)
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS VIAGRA – QL – Benefit Exclusions May Apply
warfarin (Coumadin – brand is NF)
XALATAN – QL
XYNTHA – PA
zaleplon (Sonata – brand is NF)
zidovudine (Retrovir – brand is NF)
zolpidem (Ambien – brand is NF)
ZOMIG nasal – QL
ZOMIG tabs – QL
ZOMIG ZMT – QL
zonisamide (Zonegran – brand is NF)
GenRx Drug Alphabetical Drug List, April 2009 18

Source: http://forums.e-democracy.org/groups/cc/files/f/801-2009-06-10T184646Z/BCBS%20MN%20GenRx%20formulary%202009.pdf

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