Therapeutic Drug Class Brand Name (Route) State Final Decisions ALZHEIMER'S AGENTS

Transcription

1 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug Therapeutic Drug Class Brand Name (Route) State Final Decisions ALZHEIMER'S AGENTS ARICEPT (ORAL) ARICEPT 23 MG (ORAL) ARICEPT ODT (ORAL) DONEPEZIL 23 MG (ORAL) DONEPEZIL ODT (ORAL) DONEPEZIL TABLET (ORAL) EXELON (TRANSDERM.) EXELON CAPSULES (ORAL) GALANTAMINE ER (ORAL) GALANTAMINE SOLUTION (ORAL) GALANTAMINE TABLET (ORAL) NAMENDA SOLUTION (ORAL) NAMENDA TABLET (ORAL) NAMENDA TABLET DOSE PACK (ORAL) NAMENDA XR (ORAL) RIVASTIGMINE CAPSULES (ORAL) ANTI-ALLERGENS, ORAL GRASTEK (SUBLINGUAL) RAGWITEK (SUBLINGUAL) ANTICONVULSANTS APTIOM (ORAL) BANZEL SUSPENSION (ORAL) BANZEL TABLET (ORAL) CARBAMAZEPINE CHEWABLE TABLET (ORAL) CARBAMAZEPINE ER (GENERIC CARBATROL) (ORAL) CARBAMAZEPINE SUSPENSION (ORAL) CARBAMAZEPINE TABLET (ORAL) CARBAMAZEPINE XR (ORAL) CARBATROL (ORAL) CELONTIN (ORAL) CLONAZEPAM (ORAL) CLONAZEPAM ODT (ORAL) DEPAKENE CAPSULE (ORAL) DEPAKENE SYRUP (ORAL) DEPAKOTE (ORAL) DEPAKOTE ER (ORAL)

2 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug DEPAKOTE SPRINKLE (ORAL) DIASTAT (RECTAL) DIASTAT ACUDIAL (RECTAL) DIAZEPAM (RECTAL) DIAZEPAM DEVICE (RECTAL) DILANTIN (ORAL) DILANTIN 30 MG CAPSULE (ORAL) DILANTIN INFATAB (ORAL) DILANTIN SUSPENSION (ORAL) DIVALPROEX ER (ORAL) DIVALPROEX SPRINKLE (ORAL) DIVALPROEX TABLET (ORAL) EQUETRO (ORAL) ETHOSUXIMIDE CAPSULE (ORAL) ETHOSUXIMIDE SYRUP (ORAL) FELBAMATE SUSPENSION (ORAL) FELBAMATE TABLET (ORAL) FELBATOL SUSPENSION (ORAL) FELBATOL TABLET (ORAL) FYCOMPA (ORAL) GABITRIL (ORAL) KEPPRA SOLUTION (ORAL) KEPPRA TABLETS (ORAL) KEPPRA XR (ORAL) KLONOPIN TABLET (ORAL) LAMICTAL ODT (ORAL) LAMICTAL ODT DOSE PACK (ORAL) LAMICTAL TABLET (ORAL) LAMICTAL TABLET DOSE PACK (ORAL) LAMICTAL XR (ORAL) LAMICTAL XR DOSE PACK (ORAL) LAMOTRIGINE TABLET (ORAL) LAMOTRIGINE TABLET DOSE PACK (ORAL) LAMOTRIGINE XR (ORAL) LEVETIRACETAM ER (ORAL) LEVETIRACETAM SOLUTION (ORAL) LEVETIRACETAM TABLETS (ORAL) MYSOLINE (ORAL)

3 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug ONFI SUSPENSION (ORAL) ONFI TABLET (ORAL) OXCARBAZEPINE SUSPENSION (ORAL) OXCARBAZEPINE TABLETS (ORAL) OXTELLAR XR (ORAL) PEGANONE (ORAL) PHENOBARBITAL ELIXIR (ORAL) PHENOBARBITAL TABLET (ORAL) PHENYTEK (ORAL) PHENYTOIN CAPSULE (ORAL) PHENYTOIN CHEWABLE TABLET (ORAL) PHENYTOIN EXT CAPSULE (GENERIC PHENYTEK) (ORAL) PHENYTOIN SUSPENSION (ORAL) POTIGA (ORAL) PRIMIDONE (ORAL) QUDEXY XR (ORAL) SABRIL POWDER PACK (ORAL) SABRIL TABLET (ORAL) STAVZOR (ORAL) TEGRETOL SUSPENSION (ORAL) TEGRETOL TABLET (ORAL) TEGRETOL XR (ORAL) TIAGABINE (ORAL) TOPAMAX SPRINKLE (ORAL) TOPAMAX TABLETS (ORAL) TOPIRAMATE ER (AG) (ORAL) TOPIRAMATE SPRINKLE (ORAL) TOPIRAMATE TABLETS (ORAL) TRILEPTAL SUSPENSION (ORAL) TRILEPTAL TABLETS (ORAL) TROKENDI XR (ORAL) VALPROATE SYRUP (ORAL) VALPROIC ACID (ORAL) VIMPAT SOLUTION (ORAL) VIMPAT TABLET (ORAL) ZARONTIN CAPSULE (ORAL) ZARONTIN SYRUP (ORAL) ZONEGRAN (ORAL)

4 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug ZONISAMIDE (ORAL) ANTIDEPRESSANTS, OTHER APLENZIN (ORAL) BRINTELLIX (ORAL) BUPROPION (ORAL) BUPROPION SR (ORAL) BUPROPION XL (ORAL) DESVENLAFAXINE ER (KHEDEZLA) (AG) (ORAL) DESVENLAFAXINE ER (ORAL) DESVENLAFAXINE FUMARATE ER (ORAL) EFFEXOR XR (ORAL) EMSAM (TRANSDERMAL) FETZIMA (ORAL) FORFIVO XL (ORAL) KHEDEZLA (ORAL) MARPLAN (ORAL) MIRTAZAPINE ODT (ORAL) MIRTAZAPINE TABLET (ORAL) NARDIL (ORAL) NEFAZODONE (ORAL) OLEPTRO ER (ORAL) PARNATE (ORAL) PHENELZINE (ORAL) PRISTIQ (ORAL) REMERON ODT (ORAL) REMERON TABLET (ORAL) TRANYLCYPROMINE SULFATE (ORAL) TRAZODONE (ORAL) VENLAFAXINE (ORAL) VENLAFAXINE ER CAPSULES (ORAL) VENLAFAXINE ER TABLETS (GENERIC) (ORAL) VENLAFAXINE ER TABLETS (SCHWARZ) (AG) (ORAL) VENLAFAXINE ER TABLETS (UPSTATE) (AG) (ORAL) VIIBRYD (ORAL) VIIBRYD DOSE PACK (ORAL) WELLBUTRIN (ORAL) WELLBUTRIN SR (ORAL) WELLBUTRIN XL (ORAL)

5 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug ANTIDEPRESSANTS, SSRIs BRISDELLE (ORAL) CELEXA TABLET (ORAL) CITALOPRAM SOLUTION (ORAL) CITALOPRAM TABLET (ORAL) ESCITALOPRAM SOLUTION (ORAL) ESCITALOPRAM TABLET (ORAL) FLUOXETINE 60 MG (ORAL) FLUOXETINE CAPSULE (ORAL) FLUOXETINE CAPSULE DR (ORAL) FLUOXETINE SOLUTION (ORAL) FLUOXETINE TABLET (ORAL) FLUVOXAMINE (ORAL) FLUVOXAMINE ER (ORAL) LEXAPRO SOLUTION (ORAL) LEXAPRO TABLET (ORAL) PAROXETINE CR (ORAL) PAROXETINE TABLET (ORAL) PAXIL (ORAL) PAXIL CR (ORAL) PAXIL SUSPENSION (ORAL) PEXEVA (ORAL) PROZAC CAPSULE (ORAL) PROZAC WEEKLY (ORAL) SARAFEM (ORAL) SERTRALINE CONC (ORAL) SERTRALINE TABLET (ORAL) ZOLOFT CONC (ORAL) ZOLOFT TABLET (ORAL) ANTIHISTAMINES, MINIMALLY SEDATING ALLEGRA-D 12 HOUR OTC (ORAL) CETIRIZINE CAPSULE OTC (ORAL) CETIRIZINE CHEWABLE OTC (ORAL) CETIRIZINE SOLUTION (ORAL) CETIRIZINE SOLUTION 5MG/5ML OTC (ORAL) CETIRIZINE SOLUTION OTC (ORAL) CETIRIZINE TABLETS OTC (ORAL) CETIRIZINE-D OTC (ORAL)

6 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug CLARINEX SYRUP (ORAL) CLARINEX TABLET (ORAL) CLARINEX-D 12 HOUR (ORAL) CLARITIN CAPSULE OTC (ORAL) CLARITIN CHEW OTC (ORAL) CLARITIN ODT OTC (ORAL) CLARITIN SOLUTION OTC (ORAL) CLARITIN TABLET OTC (ORAL) CLARITIN-D 12 HOUR OTC (ORAL) CLARITIN-D 24 HOUR OTC (ORAL) DESLORATADINE (ORAL) DESLORATADINE ODT (ORAL) FEXOFENADINE 60, 180 MG (ORAL) FEXOFENADINE 60, 180 MG OTC (ORAL) LEVOCETIRIZINE SOLUTION (ORAL) LEVOCETIRIZINE TABLETS (ORAL) LORATADINE ODT OTC (ORAL) LORATADINE SOLUTION OTC (ORAL) LORATADINE TABLETS OTC (ORAL) LORATADINE-D OTC (ORAL) SEMPREX-D (ORAL) XYZAL SOLUTION (ORAL) XYZAL TABLET (ORAL) ANTIHYPERTENSIVES, SYMPATHOLYTICS CATAPRES (ORAL) CATAPRES-TTS (TRANSDERM) CLONIDINE (ORAL) CLONIDINE (TRANSDERM) CLORPRES (ORAL) GUANFACINE (ORAL) METHYLDOPA (ORAL) METHYLDOPA/HYDROCHLOROTHIAZIDE (ORAL) RESERPINE (ORAL) TENEX (ORAL) ANTIHYPERURICEMICS ALLOPURINOL (ORAL) COLCRYS (ORAL) KRYSTEXXA (INTRAVEN)

7 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug PROBENECID (ORAL) PROBENECID / COLCHICINE (ORAL) ULORIC (ORAL) ZYLOPRIM (ORAL) ANTIPARKINSON'S AGENTS AZILECT (ORAL) BENZTROPINE (ORAL) BROMOCRIPTINE (ORAL) CARBIDOPA (ORAL) CARBIDOPA / LEVODOPA (ORAL) CARBIDOPA / LEVODOPA ER (ORAL) CARBIDOPA / LEVODOPA ODT (ORAL) CARBIDOPA/LEVODOPA/ENTACAPONE (ORAL) COMTAN (ORAL) ENTACAPONE (ORAL) LODOSYN (ORAL) MIRAPEX (ORAL) MIRAPEX ER (ORAL) NEUPRO (TRANSDERM) PRAMIPEXOLE (ORAL) REQUIP (ORAL) REQUIP XL (ORAL) ROPINIROLE (ORAL) ROPINIROLE ER (ORAL) SELEGILINE CAPSULE (ORAL) SELEGILINE TABLET (ORAL) SINEMET (ORAL) SINEMET CR (ORAL) STALEVO (ORAL) TASMAR (ORAL) TRIHEXYPHENIDYL ELIXIR (ORAL) TRIHEXYPHENIDYL TABLET (ORAL) ZELAPAR (ORAL) ANTIPSORIATICS, ORAL 8-MOP (ORAL) ACITRETIN (AG) (ORAL) ACITRETIN (ORAL) METHOXSALEN RAPID (ORAL)

8 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug OXSORALEN-ULTRA (ORAL) SORIATANE (ORAL) ANTIPSORIATICS, TOPICAL CALCIPOTRIENE CREAM (TOPICAL) CALCIPOTRIENE OINTMENT (TOPICAL) CALCIPOTRIENE SOLUTION (TOPICAL) CALCIPOTRIENE/BETAMETHASONE OINTMENT (AG) (TOPICAL) CALCIPOTRIENE/BETAMETHASONE OINTMENT (TOPICAL) CALCITRENE (TOPICAL) CALCITRIOL OINTMENT (TOPICAL) DOVONEX CREAM (TOPICAL) SORILUX (TOPICAL) TACLONEX OINTMENT (TOPICAL) TACLONEX SCALP (TOPICAL) VECTICAL (TOPICAL) ANTIPSYCHOTICS ABILIFY (INTRAMUSC) ABILIFY DISCMELT (ORAL) ABILIFY MAINTENA (INTRAMUSC.) ABILIFY SOLUTION (ORAL) ABILIFY TABLET (ORAL) ADASUVE (INHALATION) AMITRIPTYLINE / PERPHENAZINE (ORAL) CHLORPROMAZINE (ORAL) CLOZAPINE (ORAL) CLOZAPINE ODT (ORAL) CLOZARIL (ORAL) FANAPT TABLET (ORAL) FANAPT TITRATION PACK (ORAL) FAZACLO (ORAL) FLUPHENAZINE DECANOATE (INJECTION) FLUPHENAZINE ELIXIR/SOLN (ORAL) FLUPHENAZINE TABLET (ORAL) GEODON (INTRAMUSC) GEODON (ORAL) HALDOL (INJECTION) HALDOL DECANOATE (INTRAMUSC) HALOPERIDOL (ORAL)

9 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug HALOPERIDOL DECANOATE (INJECTION) HALOPERIDOL LACTATE (INJECTION) HALOPERIDOL LACTATE CONC (ORAL) INVEGA (ORAL) INVEGA SUSTENNA (INTRAMUSC) LATUDA (ORAL) LOXAPINE (ORAL) OLANZAPINE (INTRAMUSC) OLANZAPINE ODT (ORAL) OLANZAPINE TABLET (ORAL) OLANZAPINE/FLUOXETINE (ORAL) ORAP (ORAL) PERPHENAZINE (ORAL) QUETIAPINE TABLETS (ORAL) RISPERDAL CONSTA (INTRAMUSC.) RISPERDAL ODT (ORAL) RISPERDAL SOLUTION (ORAL) RISPERDAL TABLET (ORAL) RISPERIDONE ODT (ORAL) RISPERIDONE SOLUTION (ORAL) RISPERIDONE TABLET (ORAL) SAPHRIS (SUBLINGUAL) SEROQUEL (ORAL) SEROQUEL XR (ORAL) SYMBYAX (ORAL) THIORIDAZINE (ORAL) THIOTHIXENE (ORAL) TRIFLUOPERAZINE (ORAL) VERSACLOZ (ORAL) ZIPRASIDONE CAPSULE (ORAL) ZYPREXA (INTRAMUSC) ZYPREXA (ORAL) ZYPREXA RELPREVV (INTRAMUSC) ZYPREXA ZYDIS (ORAL) ANXIOLYTICS ALPRAZOLAM ER (ORAL) ALPRAZOLAM INTENSOL (ORAL) ALPRAZOLAM ODT (ORAL)

10 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug ALPRAZOLAM TABLET (ORAL) ATIVAN TABLET (ORAL) BUSPIRONE (ORAL) CHLORDIAZEPOXIDE (ORAL) CLORAZEPATE (ORAL) DIAZEPAM INTENSOL (ORAL) DIAZEPAM SOLUTION (ORAL) DIAZEPAM SYRINGE (INJECTION) DIAZEPAM TABLET (ORAL) DIAZEPAM VIAL (INJECTION) LORAZEPAM INTENSOL (ORAL) LORAZEPAM TABLET (ORAL) MEPROBAMATE (ORAL) OXAZEPAM (ORAL) TRANXENE T-TAB (ORAL) VALIUM TABLET (ORAL) XANAX TABLET (ORAL) XANAX XR (ORAL) BILE SALTS ACTIGALL (ORAL) CHENODAL (ORAL) URSO/URSO FORTE TABLET (ORAL) URSODIOL 300 MG CAPSULE (ORAL) URSODIOL TABLET (ORAL) BOTULINUM TOXINS BOTOX (INTRAMUSC) DYSPORT (INTRAMUSC) MYOBLOC (INTRAMUSC) XEOMIN (INTRAMUSC) BRONCHODILATORS, BETA AGONIST ALBUTEROL ER (ORAL) ALBUTEROL NEB SOLN 0.63, 1.25 MG (INHALATION) ALBUTEROL NEB SOLN 100 MG/20 ML (INHALATION) ALBUTEROL NEB SOLN 2.5 MG/0.5 ML (INHALATION) ALBUTEROL NEB SOLN 2.5 MG/3 ML (INHALATION) ALBUTEROL SYRUP (ORAL) ALBUTEROL TABLET (ORAL) ARCAPTA NEOHALER (INHALATION)

11 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug BROVANA (INHALATION) FORADIL (INHALATION) LEVALBUTEROL NEB SOLN (INHALATION) LEVALBUTEROL NEB SOLN CONC (INHALATION) METAPROTERENOL SYRUP (ORAL) METAPROTERENOL TABLET (ORAL) PERFOROMIST (INHALATION) PROAIR HFA (INHALATION) PROVENTIL HFA (INHALATION) SEREVENT (INHALATION) STRIVERDI RESPIMAT (INHALATION) TERBUTALINE (ORAL) VENTOLIN HFA (INHALATION) XOPENEX HFA (INHALATION) XOPENEX NEB SOLN (INHALATION) XOPENEX NEB SOLN CONC (INHALATION) COPD AGENTS ANORO ELLIPTA (INHALATION) ATROVENT HFA (INHALATION) COMBIVENT RESPIMAT (INHALATION) DALIRESP (ORAL) IPRATROPIUM / ALBUTEROL (INHALATION) IPRATROPIUM NEBULIZER (INHALATION) SPIRIVA (INHALATION) TUDORZA PRESSAIR (INHALATION) CYTOKINE AND CAM ANTAGONISTS ACTEMRA SYRINGE (SUBCUTANE.) ACTEMRA VIAL (INJECTION) ARCALYST (SUBCUTANE.) CIMZIA KIT (INJECTION) CIMZIA SYRINGE KIT (INJECTION) ENBREL KIT (INJECTION) ENBREL PEN (INJECTION) ENBREL SYRINGE (INJECTION) ENTYVIO (INJECTION) HUMIRA KIT (INJECTION) HUMIRA PEN KIT (INJECTION) ILARIS (SUBCUTANE.)

12 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug KINERET (INJECTION) ORENCIA SYRINGE (SUBCUTANE.) ORENCIA VIAL (INJECTION) OTEZLA (ORAL) REMICADE (INJECTION) SIMPONI ARIA VIAL (INTRAVEN.) SIMPONI PEN INJECTER (INJECTION) SIMPONI SYRINGE (INJECTION) STELARA SYRINGE (INJECTION) XELJANZ (ORAL) DIABETES METERS ACCU-CHEK AVIVA PLUS ACCU-CHEK NANO SMARTVIEW BLOOD GLUCOSE MONITORING BREEZE 2 CLEVER CHOICE MICRO CONTOUR CONTOUR NEXT CONTOUR NEXT EZ CONTOUR NEXT USB CONTOUR USB FORA V30A FREESTYLE FREEDOM LITE FREESTYLE INSULINX FREESTYLE LITE METER ONE TOUCH ULTRA 2 ONE TOUCH ULTRA SMART ONE TOUCH ULTRA SYSTEM ONE TOUCH ULTRAMINI ONE TOUCH ULTRAMINI ONE TOUCH VERIO IQ PRECISION XTRA PREMIUM BLOOD GLUCOSE PRODIGY PRODIGY POCKET TRUERESULT BLOOD GLUCOSE SYSTM TRUETRACK SMART SYSTEM WAVESENSE PRESTO

13 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug DIABETES TEST STRIPS ACCU-CHEK ACTIVE ACCU-CHEK AVIVA ACCU-CHEK AVIVA PLUS ACCU-CHEK AVIVA PLUS ACCU-CHEK COMFORT CURVE ACCU-CHEK COMPACT ACCU-CHEK COMPACT ACCU-CHEK COMPACT PLUS ACCU-CHEK SMARTVIEW ACCU-CHEK SMARTVIEW ADVOCATE TEST STRIP BLOOD GLUCOSE TEST BREEZE 2 CLEVER CHOICE MICRO TEST STRIP CONTOUR CONTOUR CONTOUR NEXT CONTOUR NEXT EASYGLUCO EMBRACE FORA TEST STRIP FORA V30A FREESTYLE INSULINX FREESTYLE INSULINX FREESTYLE INSULINX TEST STRIPS FREESTYLE LITE STRIPS FREESTYLE LITE STRIPS FREESTYLE TEST STRIPS FREESTYLE TEST STRIPS GLUCOCARD 01 SENSOR GLUCOCARD EXPRESSION GLUCOCARD VITAL SENSOR NOVA MAX GLUCOSE TEST STRIPS ONE TOUCH ULTRA TEST STRIPS ONE TOUCH VERIO PRECISION XTRA PREMIUM BLOOD GLUCOSE TEST

14 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug PRODIGY NO CODING TRUETEST TEST STRIPS TRUETEST TEST STRIPS TRUETRACK TEST STRIP TRUETRACK TEST STRIP WAVESENSE PRESTO EMOLLIENTS ALOE VERA OTC (TOPICAL) AMLACTIN ULTRA OTC (TOPICAL) AMMONIUM LACTATE CREAM/LOTION (TOPICAL) AMMONIUM LACTATE CREAM/LOTION OTC (TOPICAL) ATOPICLAIR (TOPICAL) AVEENO BABY OTC (TOPICAL) AVEENO BATH OTC (TOPICAL) BIAFINE (TOPICAL) CERAVE MOISTURIZING LOTION OTC (TOPICAL) CERAVE PM OTC (TOPICAL) CETAPHIL RESTORADERM OTC (TOPICAL) COCOA BUTTER LOTION OTC (TOPICAL) COCOA BUTTER OINT. OTC (TOPICAL) COLLOIDAL OATMEAL OTC (TOPICAL) ELETONE (TOPICAL) EMOLLIENT COMBINATION NO.10 (TOPICAL) EMOLLIENT COMBINATION NO.32 (TOPICAL) EMOLLIENT COMBO 35 CREAM (TOPICAL) EMOLLIENT FOAM (TOPICAL) EMOLLIENT FOAM PLUS (TOPICAL) EPICERAM (TOPICAL) HPA LANOLIN OTC (TOPICAL) HPR PLUS (TOPICAL) HPR PLUS-MB HYROGEL (TOPICAL) HYLATOPIC PLUS (TOPICAL) KERADAN OTC (TOPICAL) LACTIC ACID CREAM/LOTION (TOPICAL) LANTISEPTIC OTC (TOPICAL) LUBRIDERM ADVANCED THERAPY OTC (TOPICAL) LUBRIDERM DAILY MOISTURE OTC (TOPICAL) MB HYDROGEL (TOPICAL)

15 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug MOISTUREL OTC (TOPICAL) NIVATOPIC PLUS (TOPICAL) PROMISEB (TOPICAL) PRUCLAIR (TOPICAL) REMEDY CLEAR-AID OTC (TOPICAL) TL TRISEB (TOPICAL) TROPAZONE LOTION (TOPICAL) ENZYME REPLACEMENT, GAUCHERS DISEASE CEREZYME 400 UNITS (INTRAVEN) ELELYSO (INTRAVEN) VPRIV 400 UNITS (INTRAVEN) ZAVESCA (ORAL) EPINEPHRINE, SELF-INJECTED AUVI-Q (INTRAMUSC) EPINEPHRINE (AG) (INJECTION) EPIPEN (INTRAMUSC) EPIPEN JR (INTRAMUSC) GLUCOCORTICOIDS, INHALED ADVAIR DISKUS (INHALATION) ADVAIR HFA (INHALATION) AEROSPAN (INHALATION) ALVESCO (INHALATION) ASMANEX (INHALATION) BREO ELLIPTA (INHALATION) BUDESONIDE 0.25, 0.5 MG RESPULES (INHALATION) DULERA (INHALATION) FLOVENT DISKUS (INHALATION) FLOVENT HFA (INHALATION) PULMICORT 0.25, 0.5 MG RESPULES (INHALATION) PULMICORT 1 MG RESPULES (INHALATION) PULMICORT FLEXHALER (INHALATION) QVAR (INHALATION) SYMBICORT (INHALATION) GLUCOCORTICOIDS, ORAL BUDESONIDE EC (ORAL) CORTEF (ORAL) CORTISONE (ORAL) DEXAMETHASONE ELIXIR (ORAL)

16 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug DEXAMETHASONE INTENSOL (ORAL) DEXAMETHASONE SOLUTION (ORAL) DEXAMETHASONE TABLET (ORAL) DEXPAK (ORAL) ENTOCORT EC (ORAL) FLO-PRED (ORAL) HYDROCORTISONE (ORAL) MEDROL TAB DS PK (ORAL) MEDROL TABLET (ORAL) METHYLPREDNISOLONE 16 MG TABLET (ORAL) METHYLPREDNISOLONE 32 MG TABLET (ORAL) METHYLPREDNISOLONE 8 MG TABLET (ORAL) METHYLPREDNISOLONE TAB DS PK (ORAL) METHYLPREDNISOLONE TABLET (ORAL) MILLIPRED DP TAB DS PK (ORAL) MILLIPRED SOLUTION (ORAL) MILLIPRED TABLET (ORAL) ORAPRED ODT (ORAL) PEDIAPRED (ORAL) PREDNISOLONE SODIUM PHOSPHATE (ORAL) PREDNISOLONE SOLUTION (ORAL) PREDNISONE INTENSOL (ORAL) PREDNISONE SOLUTION (ORAL) PREDNISONE TAB DS PK (ORAL) PREDNISONE TABLET (ORAL) RAYOS TABLET DR (ORAL) VERIPRED 20 (ORAL) HISTAMINE II RECEPTOR BLOCKER CIMETIDINE SOLUTION (ORAL) CIMETIDINE TABLET (ORAL) CIMETIDINE TABLET OTC (ORAL) FAMOTIDINE PIGGYBACK (INJECTION) FAMOTIDINE SUSPENSION (ORAL) FAMOTIDINE TABLET (ORAL) FAMOTIDINE TABLET OTC (ORAL) FAMOTIDINE VIAL (INJECTION) FAMOTIDINE/CALCIUM CARBONATE/MAGNESIUM HYDROXIDE TAB CH NIZATIDINE CAPSULE (ORAL)

17 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug NIZATIDINE SOLUTION (ORAL) PEPCID AC TABLET OTC (ORAL) PEPCID COMPLETE TAB CHEW OTC (ORAL) PEPCID SUSPENSION (ORAL) PEPCID TABLET (ORAL) RANITIDINE (INJECTION) RANITIDINE CAPSULE (ORAL) RANITIDINE SYRUP (ORAL) RANITIDINE TABLET (ORAL) RANITIDINE TABLET OTC (ORAL) ZANTAC (INJECTION) ZANTAC 25 (ORAL) ZANTAC 75 TABLET OTC (ORAL) ZANTAC TABLET (ORAL) ZANTAC TABLET OTC (ORAL) IMMUNOMODULATORS, ATOPIC DERMATITIS ELIDEL (TOPICAL) PROTOPIC (TOPICAL) IMMUNOMODULATORS, TOPICAL ALDARA (TOPICAL) IMIQUIMOD (TOPICAL) ZYCLARA (TOPICAL) INTRANASAL RHINITIS AGENTS ASTEPRO (NASAL) ATROVENT (NASAL) AZELASTINE (ASTELIN) (NASAL) AZELASTINE (ASTEPRO) (NASAL) BECONASE AQ (NASAL) BUDESONIDE (AG) (NASAL) BUDESONIDE (NASAL) DYMISTA (NASAL) FLONASE (NASAL) FLUNISOLIDE (NASAL) FLUTICASONE (NASAL) IPRATROPIUM (NASAL) NASACORT OTC (NASAL) NASONEX (NASAL) OMNARIS (NASAL)

18 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug PATANASE (NASAL) QNASL (NASAL) RHINOCORT AQUA (NASAL) TRIAMCINOLONE (NASAL) VERAMYST (NASAL) ZETONNA (NASAL) IRON, ORAL ACTIVE FE TABLET (ORAL) BIFERA RX TABLET (ORAL) CORVITA 150 TABLET (ORAL) CORVITE 150 TABLET (ORAL) CORVITE FE TABLET (ORAL) DUOFER TABLET OTC (ORAL) EZFE 200 CAPSULE OTC (ORAL) FEOSOL TABLET OTC (ORAL) FERATE TABLET OTC (ORAL) FERGON (ORAL) FERIVA CAP MPHASE (ORAL) FERIVAFA CAPSULE (ORAL) FERRALET 90 DUAL-IRON TABLET (ORAL) FERRAPLUS 90 TABLET (ORAL) FERREX 150 FORTE PLUS CAPSULE (ORAL) FERREX 150 PLUS CAPSULE OTC (ORAL) FERREX 28 TABLET (ORAL) FERRIMIN 150 TABLET OTC (ORAL) FERROCITE PLUS TABLET (ORAL) FERROUS ASPARTO GLYCINATE/IRON POLYSACCHARIDES/ASCORBIC AC FERROUS FUMARATE TABLET OTC (ORAL) FERROUS FUMARATE/ASCORBIC ACID/B12/FA CAPSULE (ORAL) FERROUS FUMARATE/ASCORBIC ACID/B12-IF/FA CAPSULE (ORAL) FERROUS FUMARATE/FA/MULTIVITAMIN & MINERALS CAPSULE (ORAL) FERROUS FUMARATE/IRON POLYSACCHARIDES/FA/MULTIVITAMIN CAP FERROUS GLUCONATE TABLET OTC (ORAL) FERROUS SULFATE SOLUTION OTC (ORAL) FERROUS SULFATE TABLET ER OTC (ORAL) FERROUS SULFATE TABLET OTC (ORAL) FERROUS SULFATE, DRIED TABLET ER OTC (ORAL) FERROUS SULFATE/ASCORBIC ACID/FA TABLET ER OTC (ORAL)

19 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug FOLIVANE-F CAPSULE (ORAL) FOLIVANE-PLUS CAPSULE (ORAL) FUSION PLUS CAPSULE (ORAL) HEMATOGEN CAPSULE (ORAL) HEMATOGEN FA CAPSULE (ORAL) HEMOCYTE PLUS CAPSULE (ORAL) HEMOCYTE TABLET OTC (ORAL) HEMOCYTE-F TABLET (ORAL) ICAR SUSPENSION OTC (ORAL) ICAR TABLET CHEWABLE OTC (ORAL) ICAR-C TABLET OTC (ORAL) INTEGRA CAPSULE OTC (ORAL) INTEGRA F CAPSULE (ORAL) INTEGRA PLUS CAPSULE (ORAL) IRON CARBONYL SUSPENSION OTC (ORAL) IRON CARBONYL TABLET CHEWABLE OTC (ORAL) IRON CARBONYL/ASCORBIC ACID TABLET OTC (ORAL) IRON CARBONYL/DOCUSATE/B12-IF/FA/MULTIVITAMIN & MINERAL TA IRON CARBONYL/IRON GLUCONATE/FA/B12/ASCORBIC ACID/DOCUSAT IRON POLYSACCHARIDES CAPSULE OTC (ORAL) IRON POLYSACCHARIDES/B12/FA CAPSULE (ORAL) IRON POLYSACCHARIDES/HEME IRON POLYPEPTIDE/FA/B12 TABLET (OR IROSPAN TABLET (ORAL) MAXARON FORTE TABLET (ORAL) MULTIGEN FOLIC TABLET (ORAL) MULTIGEN PLUS TABLET (ORAL) MULTIGEN TABLET (ORAL) MV-IRON FUM-ASP-ASC-B12-FA-SUC (ORAL) MV-IRON-ASC-B12-THRE-SUC-STOM (ORAL) NEPHRON FA TABLET (ORAL) NOVAFERRUM 125 LIQUID OTC (ORAL) NOVAFERRUM 50 CAPSULE OTC (ORAL) NOVAFERRUM DROPS OTC (ORAL) NOVAFERRUM SOLN RECON (ORAL) NU-IRON 150 CAPSULE OTC (ORAL) TANDEM DUAL ACTION CAPSULE OTC (ORAL) TANDEM PLUS CAPSULE (ORAL) TARON FORTE CAPSULE (ORAL)

20 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug TL-HEM 150 TABLET ER 24H (ORAL) VITAFOL TABLET (ORAL) VITRON-C TABLET DR OTC (ORAL) IRON, PARENTERAL DEXFERRUM (INJECTION) FERAHEME (INJECTION) FERRLECIT (INJECTION) INFED (INJECTION) INJECTAFER (INTRAVENOUS) SOD FERRIC GLUC COMPLEX/SUC (INTRAVENOUS) VENOFER (INJECTION) LEUKOTRIENE MODIFIERS ACCOLATE (ORAL) MONTELUKAST CHEWABLE TABLET (ORAL) MONTELUKAST GRANULES (ORAL) MONTELUKAST TABLET (ORAL) SINGULAIR CHEWABLE TABLET (ORAL) SINGULAIR GRANULES (ORAL) SINGULAIR TABLET (ORAL) ZAFIRLUKAST (ORAL) ZYFLO (ORAL) ZYFLO CR (ORAL) NEUROPATHIC PAIN CAPSAICIN OTC (TOPICAL) CYMBALTA (ORAL) DULOXETINE (AG) (ORAL) DULOXETINE (ORAL) GABAPENTIN CAPSULE (ORAL) GABAPENTIN SOLUTION (ORAL) GABAPENTIN TABLET (ORAL) GRALISE (ORAL) HORIZANT (ORAL) LIDOCAINE (AG) (TOPICAL) LIDOCAINE (TOPICAL) LIDODERM (TOPICAL) LYRICA CAPSULE (ORAL) LYRICA SOLUTION (ORAL) NEURONTIN CAPSULE (ORAL)

21 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug NEURONTIN SOLUTION (ORAL) NEURONTIN TABLET (ORAL) QUTENZA KIT (TOPICAL) SAVELLA (ORAL) SAVELLA DOSE PACK (ORAL) ZOSTRIX OTC (TOPICAL) NSAIDS ADVIL MIGRAINE CAPSULE OTC (ORAL) ADVIL OTC (ORAL) ADVIL TAB CHEW OTC (ORAL) ALEVE CAPSULE OTC (ORAL) ALEVE TABLET OTC (ORAL) ANAPROX (ORAL) ARTHROTEC (ORAL) CATAFLAM TABLET (ORAL) CELEBREX (ORAL) CHILDREN'S MOTRIN ORAL SUSP OTC (ORAL) DAYPRO (ORAL) DICLOFENAC POTASSIUM (ORAL) DICLOFENAC SODIUM (ORAL) DICLOFENAC SODIUM/MISOPROSTOL (ORAL) DICLOFENAC SOLUTION (TOPICAL) DICLOFENAC SR (ORAL) DIFLUNISAL (ORAL) DUEXIS (ORAL) ETODOLAC (ORAL) ETODOLAC TAB SR (ORAL) FENOPROFEN (ORAL) FLECTOR (TOPICAL) FLURBIPROFEN (ORAL) IBUPROFEN CAPSULE OTC (ORAL) IBUPROFEN DROPS SUSPENSION OTC (ORAL) IBUPROFEN SUSPENSION (ORAL) IBUPROFEN SUSPENSION OTC (ORAL) IBUPROFEN TAB CHEW OTC (ORAL) IBUPROFEN TABLET (ORAL) IBUPROFEN TABLET OTC (ORAL) INDOCIN (RECTAL)

22 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug INDOCIN SUSPENSION (ORAL) INDOMETHACIN CAPSULE (ORAL) INDOMETHACIN CAPSULE ER (ORAL) INFANT'S MOTRIN DROPS SUSP OTC (ORAL) KETOPROFEN (ORAL) KETOPROFEN ER (ORAL) KETOROLAC (ORAL) MECLOFENAMATE (ORAL) MEFENAMIC ACID (ORAL) MELOXICAM SUSPENSION (ORAL) MELOXICAM TABLET (ORAL) MIDOL TABLET OTC (ORAL) MOBIC SUSPENSION (ORAL) MOBIC TABLET (ORAL) NABUMETONE (ORAL) NALFON (ORAL) NAPRELAN (ORAL) NAPROSYN EC (ORAL) NAPROSYN TABLET (ORAL) NAPROXEN EC (ORAL) NAPROXEN SODIUM (ORAL) NAPROXEN SODIUM OTC (ORAL) NAPROXEN SUSPENSION (ORAL) NAPROXEN TABLET (ORAL) OXAPROZIN (ORAL) PENNSAID PUMP (TOPICAL) PENNSAID SOLUTION (TOPICAL) PIROXICAM (ORAL) PONSTEL (ORAL) SPRIX (NASAL) SULINDAC (ORAL) TOLMETIN SODIUM CAPSULE (ORAL) TOLMETIN SODIUM TABLET (ORAL) VIMOVO (ORAL) VOLTAREN (TOPICAL) VOLTAREN / XR (ORAL) ZIPSOR (ORAL) ZORVOLEX (ORAL)

23 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug ONCOLOGY AGENTS, BREAST CANCER ANASTROZOLE (ORAL) ARIMIDEX (ORAL) AROMASIN (ORAL) EXEMESTANE (ORAL) FARESTON (ORAL) FEMARA (ORAL) LETROZOLE (ORAL) TAMOXIFEN CITRATE (ORAL) ONCOLOGY AGENTS, ORAL AFINITOR (ORAL) AFINITOR DISPERZ (ORAL) BOSULIF (ORAL) CAPECITABINE (ORAL) CAPRELSA (ORAL) CASODEX (ORAL) COMETRIQ (ORAL) ERIVEDGE (ORAL) GILOTRIF (ORAL) GLEEVEC (ORAL) ICLUSIG (ORAL) IMBRUVICA (ORAL) INLYTA (ORAL) JAKAFI (ORAL) MEKINIST (ORAL) NEXAVAR (ORAL) PURIXAN (ORAL) SPRYCEL (ORAL) STIVARGA (ORAL) SUTENT (ORAL) TAFINLAR (ORAL) TARCEVA (ORAL) TASIGNA (ORAL) TEMODAR (ORAL) TEMOZOLOMIDE (AG) (ORAL) TEMOZOLOMIDE (ORAL) TYKERB (ORAL) VOTRIENT (ORAL)

24 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug XALKORI (ORAL) XELODA (ORAL) XTANDI (ORAL) ZELBORAF (ORAL) ZOLINZA (ORAL) ZYDELIG (ORAL) ZYKADIA (ORAL) ZYTIGA (ORAL) OPHTHALMIC ANTIBIOTICS AZASITE (OPHTHALMIC) BACITRACIN (OPHTHALMIC) BACITRACIN/POLYMYXIN B SULFATE OINT. (OPHTHALMIC) BESIVANCE (OPHTHALMIC) BLEPH-10 (OPHTHALMIC) CILOXAN DROPS (OPHTHALMIC) CILOXAN OINTMENT (OPHTHALMIC) CIPROFLOXACIN SOLUTION (OPHTHALMIC) ERYTHROMYCIN (OPHTHALMIC) GARAMYCIN OINT. (OPHTHALMIC) GATIFLOXACIN (OPHTHALMIC) GENTAMICIN DROPS (OPHTHALMIC) GENTAMICIN OINT. (OPHTHALMIC) LEVOFLOXACIN (OPHTHALMIC) MOXEZA (OPHTHALMIC) NATACYN (OPHTHALMIC) NEOMYCIN/BACITRACIN/POLYMYXIN OINT (OPHTHALMIC) NEOMYCIN-POLYMYXIN-GRAMICIDIN (OPHTHALMIC) OCUFLOX (OPHTHALMIC) OFLOXACIN (OPHTHALMIC) POLYMYXIN/TRIMETHOPRIM (OPHTHALMIC) POLYTRIM (OPHTHALMIC) SULFACETAMIDE OINTMENT (OPHTHALMIC) SULFACETAMIDE SOLUTION (OPHTHALMIC) TOBRAMYCIN (OPHTHALMIC) TOBREX OINTMENT (OPHTHALMIC) VIGAMOX (OPHTHALMIC) ZYMAXID (OPHTHALMIC)

25 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug OPHTHALMIC ANTIBIOTIC-STEROID COMBINATIONS BLEPHAMIDE (OPHTHALMIC) BLEPHAMIDE S.O.P. (OPHTHALMIC) MAXITROL DROPS SUSP (OPHTHALMIC) MAXITROL OINT. (OPHTHALMIC) NEOMYCIN/BACITRACIN/POLY/HC (OPHTHALMIC) NEOMYCIN/POLYMYXIN/DEXAMETHASONE (OPHTHALMIC) NEOMYCIN/POLYMYXIN/HC (OPHTHALMIC) PRED-G DROPS SUSP (OPHTHALMIC) PRED-G OINT. (OPHTHALMIC) SULFACETAMIDE / PREDNISOLONE (OPHTHALMIC) TOBRADEX OINTMENT (OPHTHALMIC) TOBRADEX ST (OPHTHALMIC) TOBRADEX SUSPENSION (OPHTHALMIC) TOBRAMYCIN / DEXAMETHASONE SUSPENSION (OPHTHALMIC) ZYLET (OPHTHALMIC) OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS ALOCRIL (OPHTHALMIC) ALOMIDE (OPHTHALMIC) ALREX (OPHTHALMIC) AZELASTINE (OPHTHALMIC) BEPREVE (OPHTHALMIC) CROMOLYN SODIUM (OPHTHALMIC) ELESTAT (OPHTHALMIC) EMADINE (OPHTHALMIC) EPINASTINE (OPHTHALMIC) KETOTIFEN OTC (OPHTHALMIC) LASTACAFT (OPHTHALMIC) PATADAY (OPHTHALMIC) PATANOL (OPHTHALMIC) ZADITOR OTC (OPHTHALMIC) OPHTHALMICS, ANTI-INFLAMMATORIES ACULAR (OPHTHALMIC) ACULAR LS (OPHTHALMIC) ACUVAIL (OPHTHALMIC) BROMFENAC (OPHTHALMIC) DEXAMETHASONE (OPHTHALMIC) DICLOFENAC (OPHTHALMIC) DUREZOL (OPHTHALMIC)

26 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug FLAREX (OPHTHALMIC) FLUOROMETHOLONE (OPHTHALMIC) FLURBIPROFEN (OPHTHALMIC) FML (OPHTHALMIC) FML FORTE (OPHTHALMIC) FML S.O.P. (OPHTHALMIC) ILEVRO (OPHTHALMIC) KETOROLAC (OPHTHALMIC) KETOROLAC LS (OPHTHALMIC) LOTEMAX DROPS (OPHTHALMIC) LOTEMAX GEL (OPHTHALMIC) LOTEMAX OINTMENT (OPHTHALMIC) MAXIDEX (OPHTHALMIC) NEVANAC (OPHTHALMIC) OCUFEN (OPHTHALMIC) OMNIPRED (OPHTHALMIC) PRED FORTE (OPHTHALMIC) PRED MILD (OPHTHALMIC) PREDNISOLONE ACETATE (OPHTHALMIC) PREDNISOLONE SOD PHOSPHATE (OPHTHALMIC) PROLENSA (OPHTHALMIC) RETISERT (INTRAOCULR) TRIESENCE (INTRAOCULR) VEXOL (OPHTHALMIC) OPHTHALMICS, ANTI-INFLAMMATORIES- IMMUNOMODULTORS RESTASIS (OPHTHALMIC) OPHTHALMICS, GLAUCOMA AGENTS ALPHAGAN P 0.1% (OPHTHALMIC) ALPHAGAN P 0.15% (OPHTHALMIC) APRACLONIDINE (OPHTHALMIC) AZOPT (OPHTHALMIC) BETAGAN (OPHTHALMIC) BETAXOLOL (OPHTHALMIC) BETOPTIC S (OPHTHALMIC) BRIMONIDINE (OPHTHALMIC) BRIMONIDINE P 0.15% (OPHTHALMIC) CARTEOLOL (OPHTHALMIC) COMBIGAN (OPHTHALMIC)

27 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug COSOPT (OPHTHALMIC) COSOPT PF (OPHTHALMIC) DORZOLAMIDE (OPHTHALMIC) DORZOLAMIDE / TIMOLOL (OPHTHALMIC) IOPIDINE (OPHTHALMIC) ISTALOL (OPHTHALMIC) LATANOPROST 2.5 ML (OPHTHALMIC) LEVOBUNOLOL (OPHTHALMIC) LUMIGAN 2.5ML (OPHTHALMIC) LUMIGAN 5ML (OPHTHALMIC) LUMIGAN 7.5ML (OPHTHALMIC) METIPRANOLOL (OPHTHALMIC) PILOCARPINE (OPHTHALMIC) RESCULA (OPHTHALMIC) SIMBRINZA (OPHTHALMIC) TIMOLOL (OPHTHALMIC) TIMOPTIC (OPHTHALMIC) TIMOPTIC OCUDOSE (OPHTHALMIC) TIMOPTIC-XE (OPHTHALMIC) TRAVATAN Z 2.5 ML (OPHTHALMIC) TRAVATAN Z 5 ML (OPHTHALMIC) TRAVOPROST 2.5 ML (OPHTHALMIC) TRAVOPROST 5 ML (OPHTHALMIC) TRUSOPT (OPHTHALMIC) XALATAN 2.5 ML (OPHTHALMIC) ZIOPTAN (OPHTHALMIC) OTIC ANTIBIOTICS CIPRO HC (OTIC) CIPRODEX (OTIC) CIPROFLOXACIN (OTIC) COLY-MYCIN S (OTIC) CORTISPORIN SOLUTION (OTIC) CORTISPORIN-TC (OTIC) NEOMYCIN/POLYMYXIN/HC SOLN/SUSP (OTIC) OFLOXACIN (OTIC) OTIC ANTI-INFECTIVES & ANESTHETICS ACETIC ACID (OTIC) ACETIC ACID HC (OTIC)

28 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug ACETIC ACID/ALUMINUM (OTIC) ANTIPYRINE / BENZOCAINE (OTIC) OTO-END 10 (OTIC) OTOZIN (OTIC) PINNACAINE (OTIC) VOSOL HC (OTIC) PROGESTATIONAL AGENTS AYGESTIN (ORAL) CRINONE (VAGINAL) DEPO-PROVERA 400 MG/ML (INJECTION) MAKENA (INTRAMUSC) MEDROXYPROGESTERONE ACETATE (ORAL) NORETHINDRONE ACETATE (ORAL) PROGESTERONE (INTRAMUSC) PROGESTERONE CAPSULE (ORAL) PROMETRIUM (ORAL) PROVERA (ORAL) SEDATIVE HYPNOTICS AMBIEN (ORAL) AMBIEN CR (ORAL) EDLUAR (SUBLINGUAL) ESTAZOLAM (ORAL) ESZOPICLONE (ORAL) FLURAZEPAM (ORAL) HALCION (ORAL) HETLIOZ (ORAL) INTERMEZZO (SUBLINGUAL) LUNESTA (ORAL) RESTORIL (ORAL) RESTORIL 7.5 MG (ORAL) ROZEREM (ORAL) SILENOR (ORAL) SONATA (ORAL) TEMAZEPAM (ORAL) TEMAZEPAM 22.5 MG (ORAL) TEMAZEPAM 7.5 MG (ORAL) TRIAZOLAM (ORAL) ZALEPLON (ORAL)

29 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug ZOLPIDEM (ORAL) ZOLPIDEM ER (ORAL) ZOLPIMIST (ORAL) SMOKING CESSATION BUPROPION SR (ORAL) CHANTIX (ORAL) CHANTIX DOSE PACK (ORAL) NICODERM CQ (TRANSDERMAL) NICORETTE GUM OTC (BUCCAL) NICORETTE LOZENGE OTC (BUCCAL) NICOTINE GUM OTC (BUCCAL) NICOTINE LOZENGE OTC (BUCCAL) NICOTINE LOZENGE OTC (MUCOUS MEM.) NICOTINE PATCH OTC (TRANSDERMAL) NICOTROL (INHALATION) NICOTROL NS (NASAL) ZYBAN (ORAL) STEROIDS, TOPICAL HIGH AMCINONIDE CREAM (TOPICAL) AMCINONIDE LOTION (TOPICAL) AMCINONIDE OINTMENT (TOPICAL) BETAMET DIPROP / PROP GLY CREAM (TOPICAL) BETAMET DIPROP / PROP GLY LOTION (TOPICAL) BETAMET DIPROP / PROP GLY OINTMENT (TOPICAL) BETAMETHASONE DIPROPIONATE CREAM (TOPICAL) BETAMETHASONE DIPROPIONATE GEL (TOPICAL) BETAMETHASONE DIPROPIONATE LOTION (TOPICAL) BETAMETHASONE DIPROPIONATE OINTMENT (TOPICAL) BETAMETHASONE VALERATE CREAM (TOPICAL) BETAMETHASONE VALERATE LOTION (TOPICAL) BETAMETHASONE VALERATE OINTMENT (TOPICAL) DESOXIMETASONE CREAM (TOPICAL) DESOXIMETASONE GEL (TOPICAL) DESOXIMETASONE OINTMENT (TOPICAL) DIFLORASONE DIACETATE CREAM (TOPICAL) DIFLORASONE DIACETATE OINTMENT (TOPICAL) DIPROLENE LOTION (TOPICAL) DIPROLENE OINTMENT (TOPICAL)

30 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug FLUOCINONIDE CREAM (TOPICAL) FLUOCINONIDE EMOLLIENT (TOPICAL) FLUOCINONIDE GEL (TOPICAL) FLUOCINONIDE OINTMENT (TOPICAL) FLUOCINONIDE SOLUTION (TOPICAL) HALOG CREAM (TOPICAL) HALOG OINTMENT (TOPICAL) KENALOG AEROSOL (TOPICAL) TOPICORT CREAM (TOPICAL) TOPICORT LP CREAM (TOPICAL) TOPICORT OINTMENT (TOPICAL) TOPICORT SPRAY (TOPICAL) TRIAMCINOLONE ACETONIDE CREAM (TOPICAL) TRIAMCINOLONE ACETONIDE LOTION (TOPICAL) TRIAMCINOLONE ACETONIDE OINTMENT (TOPICAL) TRIANEX OINTMENT (TOPICAL) VANOS (TOPICAL) STEROIDS, TOPICAL LOW ALCLOMETASONE DIPROPIONATE CREAM (TOPICAL) ALCLOMETASONE DIPROPIONATE OINTMENT (TOPICAL) AQUA GLYCOLIC HC (TOPICAL) CAPEX SHAMPOO (TOPICAL) DERMA-SMOOTHE-FS (TOPICAL) DESONATE GEL (TOPICAL) DESONIDE CREAM (TOPICAL) DESONIDE LOTION (TOPICAL) DESONIDE OINTMENT (TOPICAL) DESOWEN LOTION (TOPICAL) FLUOCINOLONE 0.01% OIL (TOPICAL) HYDROCORTISONE / MIN OIL / PET OINTMENT (TOPICAL) HYDROCORTISONE ACETATE / UREA (TOPICAL) HYDROCORTISONE ACETATE CREAM OTC (TOPICAL) HYDROCORTISONE ACETATE OINTMENT OTC (TOPICAL) HYDROCORTISONE CREAM (TOPICAL) HYDROCORTISONE CREAM OTC (TOPICAL) HYDROCORTISONE GEL (TOPICAL) HYDROCORTISONE LOTION (TOPICAL) HYDROCORTISONE LOTION OTC (TOPICAL)

31 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug HYDROCORTISONE OINTMENT (TOPICAL) HYDROCORTISONE OINTMENT OTC (TOPICAL) HYDROCORTISONE SOLUTION OTC (TOPICAL) HYDROCORTISONE/ALOE CREAM OTC (TOPICAL) HYDROCORTISONE/ALOE GEL (TOPICAL) HYDROCORTISONE-ALOE CREAM OTC (TOPICAL) HYDROCORTISONE-ALOE OINTMENT OTC (TOPICAL) NEOSPORIN OTC (TOPICAL) PEDIADERM HC (TOPICAL) PEDIADERM TA (TOPICAL) SCALPICIN OTC (TOPICAL) TEXACORT (TOPICAL) VERDESO (TOPICAL) STEROIDS, TOPICAL MEDIUM BETAMETHASONE VALERATE FOAM (TOPICAL) CLOCORTOLONE CREAM (AG) (TOPICAL) CLODERM (TOPICAL) CORDRAN TAPE (TOPICAL) CUTIVATE LOTION (TOPICAL) DERMATOP CREAM (TOPICAL) DERMATOP OINTMENT (TOPICAL) ELOCON CREAM (TOPICAL) ELOCON OINTMENT (TOPICAL) ELOCON SOLUTION (TOPICAL) FLUOCINOLONE ACETONIDE CREAM (TOPICAL) FLUOCINOLONE ACETONIDE OINTMENT (TOPICAL) FLUOCINOLONE ACETONIDE SOLUTION (TOPICAL) FLUTICASONE PROPIONATE CREAM (TOPICAL) FLUTICASONE PROPIONATE LOTION (TOPICAL) FLUTICASONE PROPIONATE OINTMENT (TOPICAL) HYDROCORTISONE BUTYRATE CREAM (TOPICAL) HYDROCORTISONE BUTYRATE CREAM BRAND (TOPICAL) HYDROCORTISONE BUTYRATE OINTMENT (TOPICAL) HYDROCORTISONE BUTYRATE OINTMENT BRAND (TOPICAL) HYDROCORTISONE BUTYRATE SOLUTION BRAND (TOPICAL) HYDROCORTISONE BUTYRATE/EMOLLIENT (AG) (TOPICAL) HYDROCORTISONE BUTYRATE/EMOLLIENT (TOPICAL) HYDROCORTISONE VALERATE CREAM (TOPICAL)

32 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug HYDROCORTISONE VALERATE OINTMENT (TOPICAL) LUXIQ (TOPICAL) MOMETASONE FUROATE CREAM (TOPICAL) MOMETASONE FUROATE OINTMENT (TOPICAL) MOMETASONE FUROATE SOLUTION (TOPICAL) MOMEXIN (TOPICAL) PANDEL (TOPICAL) PREDNICARBATE CREAM (TOPICAL) PREDNICARBATE OINTMENT (TOPICAL) SYNALAR CREAM (TOPICAL) SYNALAR CREAM KIT (TOPICAL) SYNALAR OINTMENT KIT (TOPICAL) SYNALAR SOLUTION (TOPICAL) SYNALAR TS KIT (TOPICAL) STEROIDS, TOPICAL VERY HIGH APEXICON E (TOPICAL) CLOBETASOL EMOLLIENT (TOPICAL) CLOBETASOL LOTION (TOPICAL) CLOBETASOL PROPIONATE CREAM (TOPICAL) CLOBETASOL PROPIONATE FOAM (TOPICAL) CLOBETASOL PROPIONATE GEL (TOPICAL) CLOBETASOL PROPIONATE OINTMENT (TOPICAL) CLOBETASOL PROPIONATE SOLUTION (TOPICAL) CLOBETASOL SHAMPOO (TOPICAL) CLOBEX LOTION (TOPICAL) CLOBEX SHAMPOO (TOPICAL) CLOBEX SPRAY (TOPICAL) CLODAN KIT (TOPICAL) HALOBETASOL PROPIONATE CREAM (TOPICAL) HALOBETASOL PROPIONATE OINTMENT (TOPICAL) HALONATE (TOPICAL) OLUX (TOPICAL) OLUX-E (TOPICAL) TEMOVATE OINTMENT (TOPICAL) ULTRAVATE OINTMENT (TOPICAL) ULTRAVATE X PAC CREAM (TOPICAL) ULTRAVATE X PAC OINTMENT (TOPICAL)

33 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug STIMULANTS AND RELATED AGENTS ADDERALL XR (ORAL) AMPHETAMINE SALT COMBO (ORAL) AMPHETAMINE SALT COMBO ER (AG) (ORAL) AMPHETAMINE SALT COMBO ER (ORAL) CLONIDINE ER (ORAL) CONCERTA (ORAL) DAYTRANA (TRANSDERMAL) DESOXYN (ORAL) DEXEDRINE SPANSULE (ORAL) DEXMETHYLPHENIDATE (ORAL) DEXMETHYLPHENIDATE XR (AG) (ORAL) DEXMETHYLPHENIDATE XR (ORAL) DEXTROAMPHETAMINE CAPSULE ER (ORAL) DEXTROAMPHETAMINE SOLUTION (ORAL) DEXTROAMPHETAMINE TABLET (ORAL) FOCALIN (ORAL) FOCALIN XR (ORAL) INTUNIV (ORAL) KAPVAY (ORAL) METADATE CD (ORAL) METHAMPHETAMINE (ORAL) METHYLIN CHEWABLE TABLETS (ORAL) METHYLIN SOLUTION (ORAL) METHYLPHENIDATE (ORAL) METHYLPHENIDATE CD (AG) (ORAL) METHYLPHENIDATE CD (ORAL) METHYLPHENIDATE ER (CONCERTA) (AG) (ORAL) METHYLPHENIDATE ER (CONCERTA) (ORAL) METHYLPHENIDATE ER (GEN RITALIN LA) (ORAL) METHYLPHENIDATE ER (ORAL) METHYLPHENIDATE SOLUTION (AG) (ORAL) METHYLPHENIDATE SOLUTION (ORAL) MODAFINIL (ORAL) NUVIGIL (ORAL) PROCENTRA (ORAL) PROVIGIL (ORAL) QUILLIVANT XR (ORAL) RITALIN (ORAL)

34 Pennsylvania November 2014 Pharmacy and Therapeutics Final Status Decision: = Preferred Agent on Preferred Drug List; = Non-Preferred Drug RITALIN LA (ORAL) RITALIN LA 10 MG CAPSULE (ORAL) RITALIN SR (ORAL) STRATTERA (ORAL) VYVANSE (ORAL) ZENZEDI (ORAL) THALIDOMIDE & DERIVATIVES POMALYST (ORAL) REVLIMID (ORAL) THALOMID (ORAL)