Antidiabetic Agents
Sulfonylureas

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Amaryl generic.gif (400 bytes)
glimepiride		 4 mg tablet; 1 mg tablet; 2 mg tablet   approved.gif (510 bytes)  

$$
Diabeta generic.gif (400 bytes)
glyburide		 5 mg tablet; 2.5 mg tablet; 1.25 mg tablet   approved.gif (510 bytes)  

$$
Diabinese generic.gif (400 bytes)
chlorpropamide		 100 mg tablet; 250 mg tablet   approved.gif (510 bytes)  

$
Glucotrol generic.gif (400 bytes)
glipizide		 10 mg tablet; 5 mg tablet   approved.gif (510 bytes)  

$
Glucotrol XL generic.gif (400 bytes)
glipizide		 2.5 mg tablet extended release 24hr; 5 mg tablet extended release 24hr; 10 mg tablet extended release 24hr   approved.gif (510 bytes)  

$$
Glynase generic.gif (400 bytes)
glyburide micronized		 1.5 mg tablet; 6 mg tablet; 3 mg tablet   approved.gif (510 bytes)  

$$
Micronase generic.gif (400 bytes)
glyburide		 5 mg tablet; 2.5 mg tablet; 1.25 mg tablet   approved.gif (510 bytes)  

$$
Orinase generic.gif (400 bytes)
tolbutamide		 500 mg tablet   approved.gif (510 bytes)  

$
Tolinase generic.gif (400 bytes)
tolazamide		 500 mg tablet; 250 mg tablet   approved.gif (510 bytes)  

$

Key for Product(s) Listed Above
Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary
(Third tier coverage applies for selected plans)		 Not Reimbursed
Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans.
Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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