Cardiovascular Agents
Diuretics, Thiazides

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Diuril generic.gif (400 bytes)
chlorothiazide		 250 mg/5 mL Suspension   approved.gif (510 bytes)  

$
Enduron
methyclothiazide		 tablet   nonform.gif (625 bytes)  

Not Applicable
HydroDiuril generic.gif (400 bytes)
Hydrochlorothiazide		   approved.gif (510 bytes)  

$
Hygroton generic.gif (400 bytes)
chlorthalidone		 50 mg tablet; 25 mg tablet   approved.gif (510 bytes)  

$
Lozol generic.gif (400 bytes)
indapamide		 1.25 mg tablet; 2.5 mg tablet   approved.gif (510 bytes)  

$$
Microzide generic.gif (400 bytes)
hydrochlorothiazide		 12.5 mg capsule   approved.gif (510 bytes)  

$$
Zaroxolyn generic.gif (400 bytes)
metolazone		 2.5 mg tablet; 5 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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