BCBSM Maintenance Drug Program
This program covers maintenance drugs, which are prescription drugs taken for extended periods for
chronic or recurring conditions such as high blood pressure, heart conditions, diabetes or arthritis. In
selecting drugs for the program, BCBSM follows these guidelines:
•
The drug must have been on the market for at least one year.
•
The drug must be commonly prescribed.
•
The drug must have a large therapeutic window.
•
The drug must not be likely to cause severe side effects.
•
The drug must not have a complex and variable dosing schedule.
•
The drug must not require close patient monitoring (frequent lab tests, for example) during
long-term therapy.
Some types of medications are not covered by the Maintenance Drug Program, including topical
products, injectable drugs, suppositories and inhalers.
BCBSM Maintenance Drug List
Drugs That Can Be Dispensed in 100-Unit Quantities or a 30-Day Supply,
Whichever is Greater
GCN
Brand Name
Generic Name
18690
ACCOLATE
ZAFIRLUKAST
52271
ACCOLATE
ZAFIRLUKAST
48691
ACCUPRIL
QUINAPRIL HCL
48692
ACCUPRIL
QUINAPRIL HCL
48693
ACCUPRIL
QUINAPRIL HCL
48694
ACCUPRIL
QUINAPRIL HCL
02226
ADALAT CC
NIFEDIPINE
02227
ADALAT CC
NIFEDIPINE
02228
ADALAT CC
NIFEDIPINE
02350
ADALAT CC
NIFEDIPINE
02351
ADALAT CC
NIFEDIPINE
82330
ALDACTAZIDE
SPIRONOLACTONE/HCTZ
82331
ALDACTAZIDE
SPIRONOLACTONE/HCTZ
27690
ALDACTONE
SPIRONOLACTONE
27691
ALDACTONE
SPIRONOLACTONE
27692
ALDACTONE
SPIRONOLACTONE
01420
ALDOMET
METHYLDOPA
01430
ALDOMET
METHYLDOPA
01431
ALDOMET
METHYLDOPA
01432
ALDOMET
METHYLDOPA
48541
ALTACE
RAMIPRIL
48542
ALTACE
RAMIPRIL
48543
ALTACE
RAMIPRIL
48544
ALTACE
RAMIPRIL
19720
ALUPENT
METAPROTERENOL SULFATE
19730
ALUPENT
METAPROTERENOL SULFATE
19731
ALUPENT
METAPROTERENOL SULFATE
05830
AMARYL
GLIMEPIRIDE
05832
AMARYL
GLIMEPIRIDE
05833
AMARYL
GLIMEPIRIDE
47130
ANAPROX
NAPROXEN SODIUM
47131
ANAPROX
NAPROXEN SODIUM
35710
ANSAID
FLURBIPROFEN
35711
ANSAID
FLURBIPROFEN
01241
APRESOLINE
HYDRALAZINE HCL
01242
APRESOLINE
HYDRALAZINE HCL
01243
APRESOLINE
HYDRALAZINE HCL
01244
APRESOLINE
HYDRALAZINE HCL
17540
ARTANE
TRIHEXYPHENIDYL HCL
17550
ARTANE
TRIHEXYPHENIDYL HCL
17561
ARTANE
TRIHEXYPHENIDYL HCL
17563
ARTANE
TRIHEXYPHENIDYL HCL
02341
ARTANE
TRIHEXYPHENIDYL HCL
02342
ARTANE
TRIHEXYPHENIDYL HCL
03001
ARTANE
TRIHEXYPHENIDYL HCL
03002
ARTANE
TRIHEXYPHENIDYL HCL
35072
BENEMID
PROBENECID
20670
BLOCADREN
TIMOLOL MALEATE
20671
BLOCADREN
TIMOLOL MALEATE
20672
BLOCADREN
TIMOLOL MALEATE
20071
BRETHINE
TERBUTALINE SULFATE
20072
BRETHINE
TERBUTALINE SULFATE
35020
BUMEX
BUMETANIDE
35021
BUMEX
BUMETANIDE
35022
BUMEX
BUMETANIDE
03003
CALAN / ISOPTIN / VERELAN
VERAPAMIL HCL
32470
CALAN / ISOPTIN / VERELAN
VERAPAMIL HCL
32471
CALAN / ISOPTIN / VERELAN
VERAPAMIL HCL
32472
CALAN / ISOPTIN / VERELAN
VERAPAMIL HCL
47110
CALAN / ISOPTIN / VERELAN
VERAPAMIL HCL
01480
CAPOTEN
CAPTOPRIL
01481
CAPOTEN
CAPTOPRIL
01482
CAPOTEN
CAPTOPRIL
01483
CAPOTEN
CAPTOPRIL
54940
CAPOZIDE
CAPTOPRIL/HCTZ
54941
CAPOZIDE
CAPTOPRIL/HCTZ
54942
CAPOZIDE
CAPTOPRIL/HCTZ
54943
CAPOZIDE
CAPTOPRIL/HCTZ
01881
CARDENE
NICARDIPINE HCL
01882
CARDENE
NICARDIPINE HCL
01883
CARDENE
NICARDIPINE HCL
02390
CARDENE
NICARDIPINE HCL
02391
CARDENE
NICARDIPINE HCL
02320
CARDIZEM
DILTIAZEM HYDROCHLORIDE
02321
CARDIZEM
DILTIAZEM HYDROCHLORIDE
02322
CARDIZEM
DILTIAZEM HYDROCHLORIDE
02323
CARDIZEM
DILTIAZEM HYDROCHLORIDE
02324
CARDIZEM
DILTIAZEM HYDROCHLORIDE
02325
CARDIZEM
DILTIAZEM HYDROCHLORIDE
02326
CARDIZEM
DILTIAZEM HYDROCHLORIDE
07460
CARDIZEM
DILTIAZEM HYDROCHLORIDE
02360
CARDIZEM
DILTIAZEM HYDROCHLORIDE
02361
CARDIZEM
DILTIAZEM HYDROCHLORIDE
02362
CARDIZEM
DILTIAZEM HYDROCHLORIDE
02363
CARDIZEM
DILTIAZEM HYDROCHLORIDE
07461
CARDIZEM
DILTIAZEM HYDROCHLORIDE
07462
CARDIZEM
DILTIAZEM HYDROCHLORIDE
07463
CARDIZEM
DILTIAZEM HYDROCHLORIDE
33431
CARDURA
DOXAZOSIN MESYLATE
33432
CARDURA
DOXAZOSIN MESYLATE
33433
CARDURA
DOXAZOSIN MESYLATE
33434
CARDURA
DOXAZOSIN MESYLATE
01390
CATAPRES
CLONIDINE HCL
01391
CATAPRES
CLONIDINE HCL
01392
CATAPRES
CLONIDINE HCL
35800
CLINORIL
SULINDAC
35801
CLINORIL
SULINDAC
17620
COGENTIN
BENZTROPINE MESYLATE
17621
COGENTIN
BENZTROPINE MESYLATE
17622
COGENTIN
BENZTROPINE MESYLATE
51940
COMBIPRES
CLONIDONE/CHLORTHALIDONE
51941
COMBIPRES
CLONIDONE/CHLORTHALIDONE
51942
COMBIPRES
CLONIDONE/CHLORTHALIDONE
20650
CORGARD
NADOLOL
20651
CORGARD
NADOLOL
20652
CORGARD
NADOLOL
20653
CORGARD
NADOLOL
20654
CORGARD
NADOLOL
14850
COZAAR
LOSARTAN POTASSIUM
14851
COZAAR
LOSARTAN POTASSIUM
14853
COZAAR
LOSARTAN POTASSIUM
00073
CRYSTODIGIN
DIGITOXIN
05731
DIABINESE
CHLORPROPAMIDE
05732
DIABINESE
CHLORPROPAMIDE
34700
DIAMOX
ACETAZOLAMIDE
34721
DIAMOX
ACETAZOLAMIDE
34722
DIAMOX
ACETAZOLAMIDE
13838
DIOVAN
VALSARTAN
13844
DIOVAN
VALSARTAN
13846
DIOVAN
VALSARTAN
15902
DIOVAN
VALSARTAN
15903
DIOVAN
VALSARTAN
34790
DIURIL
CHLOROTHIAZIDE
34802
DIURIL
CHLOROTHIAZIDE
34803
DIURIL
CHLOROTHIAZIDE
88730
DYAZIDE / MAXZIDE
HCTZ/TRIAMTERENE
88731
DYAZIDE / MAXZIDE
HCTZ/TRIAMTERENE
88740
DYAZIDE / MAXZIDE
HCTZ/TRIAMTERENE
88741
DYAZIDE / MAXZIDE
HCTZ/TRIAMTERENE
05690
DEMEROL
ACETOHEXAMIDE
05691
DEMEROL
ACETOHEXAMIDE
02611
DYNACIRC
ISRADIPINE
02612
DYNACIRC
ISRADIPINE
35040
DYRENIUM
TRIAMTERENE
35041
DYRENIUM
TRIAMTERENE
61850
EC-NAPROSYN
NAPROXEN EC
61851
EC-NAPROSYN
NAPROXEN EC
15600
ELDEPRYL
SELEGILINE HCL
15603
ELDEPRYL
SELEGILINE HCL
34871
ENDURON
METHYCLOTHIAZIDE
34872
ENDURON
METHYCLOTHIAZIDE
10772
ESTRACE
ESTRADIOL
10770
ESTRACE
ESTRADIOL
10771
ESTRACE
ESTRADIOL
68031
ESTRATEST
METHYLTEST.;ESTROG., ESTD.
68030
ESTRATEST H.S.
METHYLTEST.;ESTROG., ESTD.
26361
EUTHROID / THYROLAR
LIOTRIX
26362
EUTHROID / THYROLAR
LIOTRIX
26363
EUTHROID / THYROLAR
LIOTRIX
26364
EUTHROID / THYROLAR
LIOTRIX
26366
EUTHROID / THYROLAR
LIOTRIX
34852
EXNA
BENZTHIAZIDE
10810
GLUCOPHAGE
METFORMIN HYDROCHLORIDE
10811
GLUCOPHAGE
METFORMIN HYDROCHLORIDE
10857
GLUCOPHAGE
METFORMIN HYDROCHLORIDE
10840
GLUCOTROL
GLIPIZIDE
10841
GLUCOTROL
GLIPIZIDE
10844
GLUCOTROL XL
GLIPIZIDE
50638
GLUCOTROL XL
GLIPIZIDE
05713
GLYNASE
GLYBURIDE (MICRONIZED)
05714
GLYNASE
GLYBURIDE (MICRONIZED)
05715
GLYNASE
GLYBURIDE (MICRONIZED)
10270
HYDRODIURIL
HYDROCHLOROTHIAZIDE
10271
HYDRODIURIL
HYDROCHLOROTHIAZIDE
34821
HYDRODIURIL
HYDROCHLOROTHIAZIDE
34824
HYDRODIURIL
HYDROCHLOROTHIAZIDE
34825
HYDRODIURIL
HYDROCHLOROTHIAZIDE
34981
HYGROTON
CHLORTHALIDONE
34982
HYGROTON
CHLORTHALIDONE
34984
HYGROTON
CHLORTHALIDONE
34985
HYGROTON
CHLORTHALIDONE
47120
HYTRIN
TERAZOSIN HCL
47121
HYTRIN
TERAZOSIN HCL
47122
HYTRIN
TERAZOSIN HCL
47123
HYTRIN
TERAZOSIN HCL
47124
HYTRIN
TERAZOSIN HCL
47125
HYTRIN
TERAZOSIN HCL
47126
HYTRIN
TERAZOSIN HCL
47127
HYTRIN
TERAZOSIN HCL
03230
INDERAL
PROPRANOLOL HCL
03231
INDERAL
PROPRANOLOL HCL
03232
INDERAL
PROPRANOLOL HCL
03233
INDERAL
PROPRANOLOL HCL
20630
INDERAL
PROPRANOLOL HCL
20631
INDERAL
PROPRANOLOL HCL
20632
INDERAL
PROPRANOLOL HCL
20633
INDERAL
PROPRANOLOL HCL
20634
INDERAL
PROPRANOLOL HCL
20635
INDERAL
PROPRANOLOL HCL
45160
INDERAL
PROPRANOLOL HCL
45260
INDERAL
PROPRANOLOL HCL
45261
INDERAL
PROPRANOLOL HCL
52030
INDERIDE
PROPRANOLOL/HCTZ
52031
INDERIDE
PROPRANOLOL/HCTZ
53130
INDERIDE
PROPRANOLOL/HCTZ
53131
INDERIDE
PROPRANOLOL/HCTZ
53132
INDERIDE
PROPRANOLOL/HCTZ
20240
INDOCIN
INDOMETHACIN
35680
INDOCIN
INDOMETHACIN
35681
INDOCIN
INDOMETHACIN
35690
INDOCIN
INDOMETHACIN
36490
INDOCIN
INDOMETHACIN
01910
ISORDIL / SORBITRATE
ISOSORBIDE DINITRATE
01942
ISORDIL / SORBITRATE
ISOSORBIDE DINITRATE
01944
ISORDIL / SORBITRATE
ISOSORBIDE DINITRATE
01945
ISORDIL / SORBITRATE
ISOSORBIDE DINITRATE
01946
ISORDIL / SORBITRATE
ISOSORBIDE DINITRATE
01947
ISORDIL / SORBITRATE
ISOSORBIDE DINITRATE
01950
ISORDIL / SORBITRATE
ISOSORBIDE DINITRATE
01951
ISORDIL / SORBITRATE
ISOSORBIDE DINITRATE
01960
ISORDIL / SORBITRATE
ISOSORBIDE DINITRATE
01971
ISORDIL / SORBITRATE
ISOSORBIDE DINITRATE
01975
ISORDIL / SORBITRATE
ISOSORBIDE DINITRATE
01976
ISORDIL / SORBITRATE
ISOSORBIDE DINITRATE
03523
KAON
POTASSIUM GLUCONATE
03550
KAON
POTASSIUM GLUCONATE
03554
KAON
POTASSIUM GLUCONATE
03320
KAY CIEL / SLOW K / K DUR
POTASSIUM CHLORIDE
03321
KAY CIEL / SLOW K / K DUR
POTASSIUM CHLORIDE
03405
KAY CIEL / SLOW K / K DUR
POTASSIUM CHLORIDE
03442
KAY CIEL / SLOW K / K DUR
POTASSIUM CHLORIDE
03443
KAY CIEL / SLOW K / K DUR
POTASSIUM CHLORIDE
03447
KAY CIEL / SLOW K / K DUR
POTASSIUM CHLORIDE
03510
KAY CIEL / SLOW K / K DUR
POTASSIUM CHLORIDE
03512
K-DUR
POTASSIUM CHLORIDE
03513
K-DUR
POTASSIUM CHLORIDE
03514
K-DUR
POTASSIUM CHLORIDE
12791
KERLONE
BETAXOLOL HYDROCHLORIDE
12792
KERLONE
BETAXOLOL HYDROCHLORIDE
00080
LANOXIN
DIGOXIN
00081
LANOXIN
DIGOXIN
00082
LANOXIN
DIGOXIN
00120
LANOXIN
DIGOXIN
00132
LANOXIN
DIGOXIN
00133
LANOXIN
DIGOXIN
00134
LANOXIN
DIGOXIN
34950
LASIX
FUROSEMIDE
34951
LASIX
FUROSEMIDE
34961
LASIX
FUROSEMIDE
34962
LASIX
FUROSEMIDE
34963
LASIX
FUROSEMIDE
00030
LESCOL
FLUVASTATIN SODIUM
00031
LESCOL
FLUVASTATIN SODIUM
48580
LESCOL
FLUVASTATIN SODIUM
43720
LIPITOR
ATORVASTATIN CALCIUM
43721
LIPITOR
ATORVASTATIN CALCIUM
43722
LIPITOR
ATORVASTATIN CALCIUM
43723
LIPITOR
ATORVASTATIN CALCIUM
33870
LODINE
ETODOLAC
33871
LODINE
ETODOLAC
61761
LODINE
ETODOLAC
61766
LODINE
ETODOLAC
01290
LONITEN
MINOXIDIL
01291
LONITEN
MINOXIDIL
25540
LOPID
GEMFIBROZIL
20641
LOPRESSOR
METOPROLOL TARTRATE
20642
LOPRESSOR
METOPROLOL TARTRATE
48611
LOTENSIN
BENAZAPRIL HYDROCHLORIDE
48612
LOTENSIN
BENAZAPRIL HYDROCHLORIDE
48613
LOTENSIN
BENAZAPRIL HYDROCHLORIDE
48614
LOTENSIN
BENAZAPRIL HYDROCHLORIDE
07310
LOZOL
INDAPAMIDE
07311
LOZOL
INDAPAMIDE
32191
MAVIK
TRANDOLAPRIL
32192
MAVIK
TRANDOLAPRIL
32193
MAVIK
TRANDOLAPRIL
47040
MEVACOR
LOVASTATIN
47041
MEVACOR
LOVASTATIN
47042
MEVACOR
LOVASTATIN
05710
MICRONASE / DIABETA
GLYBURIDE
05711
MICRONASE / DIABETA
GLYBURIDE
05712
MICRONASE / DIABETA
GLYBURIDE
27700
MIDAMOR
AMILORIDE HYDROCHLORIDE
01250
MINIPRESS
PRAZOSIN HCL
01251
MINIPRESS
PRAZOSIN HCL
01252
MINIPRESS
PRAZOSIN HCL
82341
MODURETIC
AMILORIDE/HCTZ
48581
MONOPRIL
FOSINOPRIL SODIUM
48582
MONOPRIL
FOSINOPRIL SODIUM
35740
MOTRIN
IBUPROFEN
35741
MOTRIN
IBUPROFEN
35742
MOTRIN
IBUPROFEN
35744
MOTRIN
IBUPROFEN
33812
NAPRELAN
NAPROXEN SODIUM
33813
NAPRELAN
NAPROXEN SODIUM
35790
NAPROSYN
NAPROXEN
35792
NAPROSYN
NAPROXEN
35793
NAPROSYN
NAPROXEN
41670
NAPROSYN
NAPROXEN
34861
NAQUA
TRICHLORMETHIAZIDE
34862
NAQUA
TRICHLORMETHIAZIDE
34840
NATURETIN
BENDROFLUMETHIAZIDE
34842
NATURETIN
BENDROFLUMETHIAZIDE
34740
NEPTAZANE
METHAZOLAMIDE
34741
NEPTAZANE
METHAZOLAMIDE
01681
NITROBID / NITROSTAT
NITROGLYCERIN
01682
NITROBID / NITROSTAT
NITROGLYCERIN
01684
NITROBID / NITROSTAT
NITROGLYCERIN
01771
NITROBID / NITROSTAT
NITROGLYCERIN
01772
NITROBID / NITROSTAT
NITROGLYCERIN
01773
NITROBID / NITROSTAT
NITROGLYCERIN
28831
NITROBID / NITROSTAT
NITROGLYCERIN
28832
NITROBID / NITROSTAT
NITROGLYCERIN
10340
NORMODYNE / TRANDATE
LABETALOL HYDROCHLORIDE
10341
NORMODYNE / TRANDATE
LABETALOL HYDROCHLORIDE
10342
NORMODYNE / TRANDATE
LABETALOL HYDROCHLORIDE
01130
NORPACE
DISOPYRAMIDE PHOSPHATE
01131
NORPACE
DISOPYRAMIDE PHOSPHATE
01140
NORPACE
DISOPYRAMIDE PHOSPHATE
01141
NORPACE
DISOPYRAMIDE PHOSPHATE
02681
NORVASC
AMOLDIPINE BESYLATE
02682
NORVASC
AMOLDIPINE BESYLATE
02683
NORVASC
AMOLDIPINE BESYLATE
11080
OGEN / ORTHO-EST
ESTROPIPATE
11084
OGEN / ORTHO-EST
ESTROPIPATE
11085
OGEN / ORTHO-EST
ESTROPIPATE
05724
ORINASE
TOLBUTAMIDE
02082
PAVABID
PAPAVERINE HYDROCHLORIDE
02125
PAVABID
PAPAVERINE HYDROCHLORIDE
02021
PERSANTINE
DIPYRIDAMOLE
02022
PERSANTINE
DIPYRIDAMOLE
02023
PERSANTINE
DIPYRIDAMOLE
02620
PLENDIL
FELODIPINE
02621
PLENDIL
FELODIPINE
02622
PLENDIL
FELODIPINE
15412
PRAVACHOL
PRAVASTATIN SODIUM
48671
PRAVACHOL
PRAVASTATIN SODIUM
48672
PRAVACHOL
PRAVASTATIN SODIUM
48673
PRAVACHOL
PRAVASTATIN SODIUM
10942
PREMARIN / ESTRATAB
ESTROGENS (CONJ. OR ESTD.)
10943
PREMARIN / ESTRATAB
ESTROGENS (CONJ. OR ESTD.)
10944
PREMARIN / ESTRATAB
ESTROGENS (CONJ. OR ESTD.)
10945
PREMARIN / ESTRATAB
ESTROGENS (CONJ. OR ESTD.)
10947
PREMARIN / ESTRATAB
ESTROGENS (CONJ. OR ESTD.)
11050
PREMARIN / ESTRATAB
ESTROGENS (CONJ. OR ESTD.)
11051
PREMARIN / ESTRATAB
ESTROGENS (CONJ. OR ESTD.)
11052
PREMARIN / ESTRATAB
ESTROGENS (CONJ. OR ESTD.)
11053
PREMARIN / ESTRATAB
ESTROGENS (CONJ. OR ESTD.)
55730
PREMPHASE
ESTROGEN, CON/M-PROGEST ACET
55733
PREMPHASE
ESTROGEN, CON/M-PROGEST ACET
20769
PREMPRO
ESTROGEN, CON/M-PROGEST ACET
55731
PREMPRO
ESTROGEN, CON/M-PROGEST ACET
19739
PREMPRO LOW DOSE
ESTROGEN, CON/M-PROGEST ACET
19975
PREMPRO LOW DOSE
ESTROGEN, CON/M-PROGEST ACET
01092
PROCAN / PRONESTYL
PROCAINAMIDE HCL
01093
PROCAN / PRONESTYL
PROCAINAMIDE HCL
01094
PROCAN / PRONESTYL
PROCAINAMIDE HCL
01110
PROCAN / PRONESTYL
PROCAINAMIDE HCL
01111
PROCAN / PRONESTYL
PROCAINAMIDE HCL
01112
PROCAN / PRONESTYL
PROCAINAMIDE HCL
01120
PROCAN / PRONESTYL
PROCAINAMIDE HCL
01121
PROCAN / PRONESTYL
PROCAINAMIDE HCL
01122
PROCAN / PRONESTYL
PROCAINAMIDE HCL
01123
PROCAN / PRONESTYL
PROCAINAMIDE HCL
02221
PROCARDIA / PROCARDIA XL
NIFEDIPINE
02222
PROCARDIA / PROCARDIA XL
NIFEDIPINE
02223
PROCARDIA / PROCARDIA XL
NIFEDIPINE
20100
PROVENTIL / VENTOLIN
ALBUTEROL SULFATE
20101
PROVENTIL / VENTOLIN
ALBUTEROL SULFATE
22780
PROVENTIL / VENTOLIN
ALBUTEROL SULFATE
45730
PROVENTIL / VENTOLIN
ALBUTEROL SULFATE
11260
PROVERA
MEDROXYPROGEST. ACETATE
11261
PROVERA
MEDROXYPROGEST. ACETATE
11262
PROVERA
MEDROXYPROGEST. ACETATE
01011
QUINAGLUTE
QUINIDINE GLUCONATE
01053
QUINIDEX
QUINIDINE SULFATE
01055
QUINIDEX
QUINIDINE SULFATE
01060
QUINIDEX
QUINIDINE SULFATE
32692
RELAFEN
NABUMETONE
32961
RELAFEN
NABUMETONE
34880
RENESE
POLYTHIAZIDE
34881
RENESE
POLYTHIAZIDE
34882
RENESE
POLYTHIAZIDE
26460
SECTRAL
ACEBUTOLOL HYDROCHLORIDE
26461
SECTRAL
ACEBUTOLOL HYDROCHLORIDE
51690
SER-AP-ES
HCTZ/HYDRALAZINE/RESERPINE
01351
SERPASIL
RESERPINE
01354
SERPASIL
RESERPINE
62552
SINEMET
CARBIDOPA/LEVODOPA
62591
SINEMET
CARBIDOPA/LEVODOPA
62740
SINEMET
CARBIDOPA/LEVODOPA
62741
SINEMET
CARBIDOPA/LEVODOPA
62742
SINEMET
CARBIDOPA/LEVODOPA
42373
SINGULAIR
MONTELUKAST SODIUM
94440
SINGULAIR
MONTELUKAST SODIUM
94444
SINGULAIR
MONTELUKAST SODIUM
14701
SULAR
NISOLDIPINE
14702
SULAR
NISOLDIPINE
14703
SULAR
NISOLDIPINE
14704
SULAR
NISOLDIPINE
32480
TENEX
GUANFACINE HCL
32481
TENEX
GUANFACINE HCL
66990
TENORETIC
ATENOLOL/CHLORTHALIDONE
66991
TENORETIC
ATENOLOL/CHLORTHALIDONE
20660
TENORMIN
ATENOLOL
20661
TENORMIN
ATENOLOL
20662
TENORMIN
ATENOLOL
00324
THEO-24
THEOPHYLLINE ANHYDROUS
00325
THEO-24
THEOPHYLLINE ANHYDROUS
00326
THEO-24
THEOPHYLLINE ANHYDROUS
00352
THEO-24
THEOPHYLLINE ANHYDROUS
00361
THEO-24
THEOPHYLLINE ANHYDROUS
00371
THEO-24
THEOPHYLLINE ANHYDROUS
00410
THEO-24
THEOPHYLLINE ANHYDROUS
00411
THEO-24
THEOPHYLLINE ANHYDROUS
00412
THEO-24
THEOPHYLLINE ANHYDROUS
00413
THEO-24
THEOPHYLLINE ANHYDROUS
00414
THEO-24
THEOPHYLLINE ANHYDROUS
00415
THEO-24
THEOPHYLLINE ANHYDROUS
00416
THEO-24
THEOPHYLLINE ANHYDROUS
00417
THEO-24
THEOPHYLLINE ANHYDROUS
00230
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00231
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00232
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00233
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00260
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00261
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00262
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00263
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00265
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00301
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00302
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00310
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00311
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00312
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00313
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00314
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00315
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00316
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00317
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00318
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00319
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00320
THEODUR / SLOPHYLLIN
THEOPHYLLINE ANHYDROUS
00323
THEODUR / SLOPHYLLIN
DILTIAZEM HYDROCHLORIDE
02328
TIAZAC
DILTIAZEM HYDROCHLORIDE
02329
TIAZAC
DILTIAZEM HYDROCHLORIDE
02330
TIAZAC
DILTIAZEM HYDROCHLORIDE
02332
TIAZAC
DILTIAZEM HYDROCHLORIDE
02333
TIAZAC
DILTIAZEM HYDROCHLORIDE
94691
TIAZAC
DILTIAZEM HYDROCHLORIDE
32820
TIMOPTIC
TIMOLOL MALEATE
32821
TIMOPTIC
TIMOLOL MALEATE
05740
TOLINASE
TOLAZAMIDE
05741
TOLINASE
TOLAZAMIDE
12947
TOPROL XL
METOPROLOL SUCCINATE
20741
TOPROL XL
METOPROLOL SUCCINATE
20742
TOPROL XL
METOPROLOL SUCCINATE
20743
TOPROL XL
METOPROLOL SUCCINATE
48561
UNIVASC
MOEXIPRIL HYDROCHLORIDE
48562
UNIVASC
MOEXIPRIL HYDROCHLORIDE
54860
VASORETIC
ENALAPRIL MALEATE/HCTZ
00960
VASOTEC
ENALAPRIL MALEATE
00961
VASOTEC
ENALAPRIL MALEATE
00962
VASOTEC
ENALAPRIL MALEATE
00963
VASOTEC
ENALAPRIL MALEATE
54862
VASOTEC
ENALAPRIL MALEATE
20680
VISKEN
PINDOLOL
20681
VISKEN
PINDOLOL
35850
VOLTAREN
DICLOFENAC SODIUM
35851
VOLTAREN
DICLOFENAC SODIUM
35852
VOLTAREN
DICLOFENAC SODIUM
34990
ZAROXOLYN
METOLAZONE
34991
ZAROXOLYN
METOLAZONE
34992
ZAROXOLYN
METOLAZONE
34993
ZAROXOLYN
METOLAZONE
63820
ZEBETA
BISOPROLOL FUMARATE
63821
ZEBETA
BISOPROLOL FUMARATE
88002
ZESTORETIC / PRINZIDE
LISINOPRIL/HCTZ
88000
ZESTORETIC / PRINZIDE
LISINOPRIL/HCTZ
88001
ZESTORETIC / PRINZIDE
LISINOPRIL/HCTZ
47264
ZESTRIL / PRINIVIL
LISINOPRIL
47260
ZESTRIL / PRINIVIL
LISINOPRIL
47261
ZESTRIL / PRINIVIL
LISINOPRIL
47262
ZESTRIL / PRINIVIL
LISINOPRIL
47265
ZESTRIL / PRINIVIL
LISINOPRIL
47263
ZESTRIL / PRINIVIL
LISINOPRIL
26531
ZOCOR
SIMVASTATIN
26532
ZOCOR
SIMVASTATIN
26533
ZOCOR
SIMVASTATIN
26534
ZOCOR
SIMVASTATIN
26535
ZOCOR
SIMVASTATIN
07070
ZYLOPRIM
ALLOPURINOL
07071
ZYLOPRIM
ALLOPURINOL
Drugs That Can Be Dispensed in 200-Unit Quantities or a 30-Day Supply,
Whichever is Greater
GCN
Brand Name
Generic Name
26250
ARMOUR THYROID
THYROID
26252
ARMOUR THYROID
THYROID
26255
ARMOUR THYROID
THYROID
26281
ARMOUR THYROID
THYROID
26282
ARMOUR THYROID
THYROID
26283
ARMOUR THYROID
THYROID
26284
ARMOUR THYROID
THYROID
26285
ARMOUR THYROID
THYROID
26287
ARMOUR THYROID
THYROID
26288
ARMOUR THYROID
THYROID
26289
ARMOUR THYROID
THYROID
26240
ARMOUR THYROID
THYROID
26241
ARMOUR THYROID
THYROID
26340
CYTOMEL
LIOTHYRONINE SODIUM
26341
CYTOMEL
LIOTHYRONINE SODIUM
26342
CYTOMEL
LIOTHYRONINE SODIUM
17161
DILANTIN
PHENYTOIN SODIUM
17700
DILANTIN
PHENYTOIN SODIUM
17701
DILANTIN
PHENYTOIN SODIUM
17241
DILANTIN
PHENYTOIN SODIUM
17250
DILANTIN
PHENYTOIN SODIUM
41741
INH
ISONIAZID
41742
INH
ISONIAZID
26320
LEVOTHROID/SYNTHROID
LEVOTHYROXINE SODIUM
26321
LEVOTHROID/SYNTHROID
LEVOTHYROXINE SODIUM
26322
LEVOTHROID/SYNTHROID
LEVOTHYROXINE SODIUM
26323
LEVOTHROID/SYNTHROID
LEVOTHYROXINE SODIUM
26324
LEVOTHROID/SYNTHROID
LEVOTHYROXINE SODIUM
26325
LEVOTHROID/SYNTHROID
LEVOTHYROXINE SODIUM
26326
LEVOTHROID/SYNTHROID
LEVOTHYROXINE SODIUM
26327
LEVOTHROID/SYNTHROID
LEVOTHYROXINE SODIUM
26328
LEVOTHROID/SYNTHROID
LEVOTHYROXINE SODIUM
26329
LEVOTHROID/SYNTHROID
LEVOTHYROXINE SODIUM
47631
LEVOTHROID/SYNTHROID
LEVOTHYROXINE SODIUM
47632
LEVOTHROID/SYNTHROID
LEVOTHYROXINE SODIUM
17310
MYSOLINE
PRIMIDONE
17321
MYSOLINE
PRIMIDONE
17322
MYSOLINE
PRIMIDONE
41762
PAS
PARA-AMINOSALICYLIC ACID
26391
PTU
PROPYLTHIOURACIL