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*Notes
GC - Generic Covered	PA - Prior Authorization
ST - Step Therapy	QL - Quantity Limited
GA - Generic Available	SPN - Specialty Pharmacy
Last updated: 7/27/2010

Generic Name: Valsartan	Brand Name: Diovan
Therapeutic Category: CARDIOVASCULAR	Therapeutic Class: ANTIHYPERTENSIVES
Notes: ST QL
Effective Date: 6/1/2010
Reason: Formulary deletion.

Generic Name: Valsartan/Hydrochlorothiazide	Brand Name: Diovan HCT
Therapeutic Category: CARDIOVASCULAR	Therapeutic Class: ANTIHYPERTENSIVES
Notes: ST QL
Effective Date: 6/1/2010
Reason: Formulary deletion.

Generic Name: Dalteparin Sodium,Porcine	Brand Name: Fragmin
Therapeutic Category: CARDIOVASCULAR	Therapeutic Class: CIRCULATION/COAGULATION
Notes: QL
Effective Date: 6/1/2010
Reason: QL applies

Generic Name: Enoxaparin Sodium	Brand Name: Lovenox
Therapeutic Category: CARDIOVASCULAR	Therapeutic Class: CIRCULATION/COAGULATION
Notes: QL
Effective Date: 6/1/2010
Reason: QL applies

Generic Name: Fondaparinux	Brand Name: Arixtra
Therapeutic Category: CARDIOVASCULAR	Therapeutic Class: CIRCULATION/COAGULATION
Notes: QL
Effective Date: 6/1/2010
Reason: QL applies

Generic Name: Amlodipine / Valsartan	Brand Name: Exforge
Therapeutic Category: CARDIOVASCULAR	Therapeutic Class: ANTIHYPERTENSIVES
Notes: ST QL
Effective Date: 6/1/2010
Reason: Formulary deletion.

Generic Name: amlodipine/valsartan/HCTZ	Brand Name: Exforge HCT
Therapeutic Category: CARDIOVASCULAR	Therapeutic Class: ANTIHYPERTENSIVES
Notes: ST QL
Effective Date: 6/1/2010
Reason: Formulary deletion.

Generic Name: Amlodipine/Olmesartan	Brand Name: Azor
Therapeutic Category: CARDIOVASCULAR	Therapeutic Class: ANTIHYPERTENSIVES
Notes: ST QL
Effective Date: 1/1/2010
Reason: Formulary addition

Generic Name: Losartan potassium	Brand Name: Cozaar
Therapeutic Category: CARDIOVASCULAR	Therapeutic Class: ANTIHYPERTENSIVES
Notes: GC ST QL
Effective Date: 5/1/2010
Reason: Formulary addition.

Generic Name: Losartan/Hydrochlorothiazide	Brand Name: Hyzaar
Therapeutic Category: CARDIOVASCULAR	Therapeutic Class: ANTIHYPERTENSIVES
Notes: GC ST QL
Effective Date: 5/1/2010
Reason: Formulary addition.

Generic Name: Buprenorphine/Naloxone	Brand Name: Suboxone
Therapeutic Category: PAIN/INFLAMMATION	Therapeutic Class: MISC
Notes: PA QL
Effective Date: 4/1/2010
Reason: Prior authorization required.

Generic Name: Buprenorphine	Brand Name: Subutex
Therapeutic Category: PAIN/INFLAMMATION	Therapeutic Class: MISC
Notes: GC PA QL
Effective Date: 4/1/2010
Reason: Prior authorization required.

Generic Name: Oxycodone HCl	Brand Name: Roxicodone
Therapeutic Category: PAIN/INFLAMMATION	Therapeutic Class: NARCOTIC ANALGESICS
Notes: GC QL
Effective Date: 6/1/2010
Reason: QL applies

Generic Name: Darifenacin	Brand Name: Enablex
Therapeutic Category: UROLOGY	Therapeutic Class: ANTISPASMODIC/ ANTI-INCONTINENCE
Notes: QL
Effective Date: 6/1/2010
Reason: Formulary deletion.