United Healthcare Drug Formulary
ACE INHIBITORS	COST CODE		cefadroxil tablet, capsule	$$$
captopril	$		Cefzil suspension	$$$
Accupril	$$		Zithromax capsule	$$$
Altace	$$		Augmentin tablet	$$$$
Prinivil   bb	$$$		Cefzil tablet	$$$$
			Cipro	$$$$
ANTIDEPRESSANTS	COST CODE		Floxin	$$$$
amitriptyline	$		Levaquin	$$$$
desipramine	$		Biaxin suspension	$$$$
doexpin	$		Biaxin tablet	$$$$
imipramine	$
nortriptyline	$		ANTILIPIDEMICS	COST CODE
trazodone	$		gemfibrozil	$$
amoxapine	$$$		cholestyramine / aspartame	$$$
Celexa	$$$		cholestyramine / sucrose	$$
Paxil	$$$		Colestid	$$$$
Serzone	$$$		Niaspan	$$$
Wellbutrin/SR   pa	$$$		Lipitor	$$$$
Effexor/XR	$$$$		Pravachol	$$$$
Prozac	$$$$$		Zocor	$$$$$
Zoloft	$$$$
ANTIHISTIMINES	COST CODE		ANTIULCER DRUGS	COST CODE
cyproheptadine	$		H2 ANTAGONISTS
hydroxyzine hcl	$		cimetidine	$
pamoate	$		ranitidine	$$
Ploy-Histine elixir	$$		OTHER ANTIULCER DRUGS
promethazine	$$		Cytotec	$$$
Allegra	$$$		Propulsid	$$$
Polaramine (repetab only)	$$$		sucralfate	$$$
PBZ	$$$$		PROTON PUMP INHIBITORS
PBZ-SR	$$$$		Prevacid	$$$$
Claritin	$$$$$		HELICOBACTER PYLORI
			Helidac	$$$
			PrevPac	!!!!!
ANTIHIST / DECONGEST
COMBO - GROUP II	COST CODE
Allegra-D tablet	$$$$		CALCIUM CHANNEL BOCKERS	COST CODE
Kronofed-A  JR  (60/4 capsule)	$$$		verapamil SR	$$
Rondec  (60/4 tablet)	$$$		Adalat CC	$$$$
Claritin-D  (120/5 tablet)	$$$$$		Dilacor XR	$$$$
			diltiazem SR	$$
			Plendil	$$$
ANTI-INFECTIVES	COST CODE		Cardizem CD	$$$$
amoxicillin	$		Norvasc	$$$$
cephalexin	$		Nimotop	!!!!!
cephradine	$
erythromycin base	$
penicillin VK	$		COST CODE KEY
sulfamethoxazole/trimethoprim	$
cefadroxil suspension	$$		Relative cost to health plan sponsor	$  -  !
Zithromax suspension	$$		Generic available	bold
Augmentin suspension	$$		Brand interchange product	bb
cefaclor	$$		Prior authorization required	pa
COMBO ANTIHYPERTENSIVES	COST CODE		ORAL HYPOGLYCEMIC DRUGS	COST CODE
hydralazine / HCTZ	$		Amaryl	$
methyldopa / HCTZ	$		glipizide	$
propranolo / HCTZ	$		Glucotrol XL	$
captopril / HCTZ	$$		glyburide	$
Diovan HCT    pa	$$$		Precose	$$$
Prinzide    bb	$$$		Glucophage	$$$
Ziac	$$$		micronized glyburide	$
clonidine / chlorthalidone	$$$$		Prandin	$$$$
Hyzaar    pa	$$$$		Glyset	$$
NASAL DRUGS	COST CODE		INSULINS	COST CODE
Rhinocort	$$		Novolin	$
Beconase / AQ	$$$		Humulin	$$
Flonase / AQ	$$$		Humalog	$$$
NSAIDS	COST CODE		INSULIN SENSITIZERS	COST CODE
ibuprofen	$		Avandia	$$$$
indomethacin	$
meclofenamate	$
naproxen	$		PULMONARY ANTI-INFLAMMATORY	COST CODE
naproxen enteric coated	$		Vanceril / DS     bb	$$$
naproxen sodium	$		Azmacort	$$$$
piroxicam	$		Flovent	$$$$$
sulindac	$		Flovent Rotadisk	$$$$$
etodolac	$$
flurbiprofen	$$
tolmetin	$$
diclofenac sodium (XR not included)	$$$
ketoprofen	$$$		COST CODE KEY
ORAL CONTRACEPTIVES	COST CODE		Relative cost to health plan sponsor	$  -  !
For patients with OC coverage, the following are			Generic available	bold
included in the Preferred Drug List:			Brand interchange product	bb
Alesse	$$$		Prior authorization required	pa
Estrostep Fe, Loestrin/ Fe	$$$
Modicon    bb	$$
Nordette    bb	$$$
Ortho-Cept    bb	$$
Ortho-Cyclen	$$
Ortho Novum  10/11     bb	$$
Ortho Novum  1/35       bb	$$
Ortho Novum  1/50       bb	$$
Ortho Novum  7/7/7	$$
Ortho Tri-Cyclen	$$
Triphasil     bb	$$$
Lo / Ovral	$$$$
Zovia	$$$$
Micronor    bb	$$$$$
			updated 2/14/00