Cardiovascular Agents
Antihypertensive, Antihypertensive Combinations

Brand/Generic Name
(Generics in italics)		 Dosage/Strength Status Restrictions Notes Copayment
Tier
Accuretic generic.gif (400 bytes)
Quinapril-Hydrochlorothiazide		   nonform.gif (510 bytes)   NOTES.gif (377 bytes) N/A
Atacand HCT
Candesartan Cilexetil-HCTZ		   approved.gif (510 bytes)     Tier 3
Atacand HCT
Candesartan Cilexetil-HCTZ		 Tab - 16-12.5 mg   approved.gif (510 bytes)   NOTES.gif (377 bytes) Tier 3
Atacand HCT
Candesartan Cilexetil-HCTZ		 Tab - 32-12.5 mg   approved.gif (510 bytes)   NOTES.gif (377 bytes) Tier 3
Avalide
Irbesartan-Hydrochlorothiazide		   approved.gif (510 bytes)     Tier 3
Avalide
Irbesartan-Hydrochlorothiazide		 Tab - 150-12.5 mg   approved.gif (510 bytes)   NOTES.gif (377 bytes) Tier 3
Avalide
Irbesartan-Hydrochlorothiazide		 Tab - 300-12.5 mg   approved.gif (510 bytes)   NOTES.gif (377 bytes) Tier 3
Azor
Amlodipine-Olmesartan		   approved.gif (510 bytes)     Tier 3
Benazepril-Hydrochlorothiazide generic.gif (400 bytes)
Benazepril-Hydrochlorothiazide		   approved.gif (510 bytes)     Tier 1
Benicar HCT
Olmesartan Medoxomil-HCTZ		   approved.gif (510 bytes)   NOTES.gif (377 bytes) Tier 3
Bisoprolol-Hydrochlorothiazide generic.gif (400 bytes)
Bisoprolol-Hydrochlorothiazide		   approved.gif (510 bytes)     Tier 1
Capozide generic.gif (400 bytes)
Captopril-Hydrochlorothiazide		   nonform.gif (510 bytes)   NOTES.gif (377 bytes) N/A
Captopril-Hydrochlorothiazide generic.gif (400 bytes)
Captopril-Hydrochlorothiazide		   approved.gif (510 bytes)     Tier 1
Corzide generic.gif (400 bytes)
Nadolol-Bendroflumethiazide		   nonform.gif (510 bytes)   NOTES.gif (377 bytes) N/A
Diovan HCT
Valsartan-Hydrochlorothiazide		   approved.gif (510 bytes)     Tier 2
Diovan HCT
Valsartan-Hydrochlorothiazide		 Tab - 160-12.5 mg   approved.gif (510 bytes)   NOTES.gif (377 bytes) Tier 2
Diovan HCT
Valsartan-Hydrochlorothiazide		 Tab - 160-25 mg   approved.gif (510 bytes)   NOTES.gif (377 bytes) Tier 2
Diovan HCT
Valsartan-Hydrochlorothiazide		 Tab - 80-12.5 mg   approved.gif (510 bytes)   NOTES.gif (377 bytes) Tier 2
Exforge
Amlodipine Besylate-Valsartan		   approved.gif (510 bytes)     Tier 2
Exforge HCT
Amlodipine-Valsartan-HCTZ		   approved.gif (510 bytes)     Tier 2
Fosinopril Sodium-HCTZ generic.gif (400 bytes)
Fosinopril Sodium-HCTZ		   approved.gif (510 bytes)     Tier 1
Hyzaar generic.gif (400 bytes)
Losartan Potassium-HCTZ		   nonform.gif (510 bytes)   NOTES.gif (377 bytes) N/A
Inderide generic.gif (400 bytes)
Propranolol-HCTZ		   nonform.gif (510 bytes)   NOTES.gif (377 bytes) N/A
InnoPran XL
Propranolol HCl SR Beads		   approved.gif (510 bytes)   NOTES.gif (377 bytes) Tier 3
Lexxel
Enalapril Maleate-Felodipine		   approved.gif (510 bytes)   NOTES.gif (377 bytes) Tier 3
Lisinopril-Hydrochlorothiazide generic.gif (400 bytes)
Lisinopril-Hydrochlorothiazide		   approved.gif (510 bytes)     Tier 1
Lopressor HCT generic.gif (400 bytes)
Metoprolol-Hydrochlorothiazide		   nonform.gif (510 bytes)   NOTES.gif (377 bytes) N/A
Losartan Potassium-HCTZ generic.gif (400 bytes)
Losartan Potassium-HCTZ		   approved.gif (510 bytes)     Tier 1
Lotensin HCT generic.gif (400 bytes)
Benazepril-Hydrochlorothiazide		   nonform.gif (510 bytes)   NOTES.gif (377 bytes) N/A
Lotrel generic.gif (400 bytes)
Amlodipine Besy-Benazepril HCl		   nonform.gif (510 bytes)   NOTES.gif (377 bytes) N/A
Metoprolol-Hydrochlorothiazide generic.gif (400 bytes)
Metoprolol-Hydrochlorothiazide		   approved.gif (510 bytes)     Tier 1
Micardis HCT
Telmisartan-HCTZ		   approved.gif (510 bytes)     Tier 2
Micardis HCT
Telmisartan-HCTZ		 Tab - 40-12.5 mg   approved.gif (510 bytes)   NOTES.gif (377 bytes) Tier 2
Micardis HCT
Telmisartan-HCTZ		 Tab - 80-12.5 mg   approved.gif (510 bytes)   NOTES.gif (377 bytes) Tier 2
Micardis HCT
Telmisartan-HCTZ		 Tab - 80-25 mg   approved.gif (510 bytes)   NOTES.gif (377 bytes) Tier 2
Moexipril-Hydrochlorothiazide generic.gif (400 bytes)
Moexipril-Hydrochlorothiazide		   approved.gif (510 bytes)     Tier 1
Monopril HCT generic.gif (400 bytes)
Fosinopril Sodium-HCTZ		   nonform.gif (510 bytes)   NOTES.gif (377 bytes) N/A
Nadolol-Bendroflumethiazide generic.gif (400 bytes)
Nadolol-Bendroflumethiazide		   approved.gif (510 bytes)     Tier 1
Prinzide generic.gif (400 bytes)
Lisinopril-Hydrochlorothiazide		   nonform.gif (510 bytes)   NOTES.gif (377 bytes) N/A
Propranolol-HCTZ generic.gif (400 bytes)
Propranolol-HCTZ		   approved.gif (510 bytes)     Tier 1
Quinapril-Hydrochlorothiazide generic.gif (400 bytes)
Quinapril-Hydrochlorothiazide		   approved.gif (510 bytes)     Tier 1
Tarka generic.gif (400 bytes)
Trandolapril-Verapamil HCl		   approved.gif (510 bytes)     Tier 3
Teveten HCT
Eprosartan Mesylate-HCTZ		   approved.gif (510 bytes)   NOTES.gif (377 bytes) Tier 3
Timolide
Timolol-Hydrochlorothiazide		   approved.gif (510 bytes)     Tier 3
Twynsta
Telmisartan-Amlodipine		 Tab   approved.gif (510 bytes)     Tier 2
Uniretic generic.gif (400 bytes)
Moexipril-Hydrochlorothiazide		   nonform.gif (510 bytes)   NOTES.gif (377 bytes) N/A
Valturna
Aliskiren-Valsartan		 Tab   approved.gif (510 bytes)

sl.gif

  Tier 2
Zestoretic generic.gif (400 bytes)
Lisinopril-Hydrochlorothiazide		   nonform.gif (510 bytes)   NOTES.gif (377 bytes) N/A
Ziac generic.gif (400 bytes)
Bisoprolol-Hydrochlorothiazide		   nonform.gif (510 bytes)   NOTES.gif (377 bytes) N/A

Key for Product(s) Listed Above
Formulary
Non-Covered Medications that have Covered Alternatives
Prior Authorization
 Not Covered
Quantity Limit
Generic is Formulary, Brand is Non-Formulary
 Step Therapy Notes
Specialty Medications
Tier 1Generic Drugs
Tier 2Preferred Brand Name Drugs
Tier 3Non-Preferred Brand-Name Drugs
Tier 4Specialty Drugs - Tier 3 Copay
      

© 2006 MediMedia USA, Inc. All Rights Reserved.   Last Updated: 07/12/2010