2018 HEALTH CHOICE ARIZONA FORMULARIO

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1 2018 HEALTH CHOICE ARIZONA FORMULARIO ARIZONA Preguntas? Póngase en contacto con los Servicios a Farmacias de Health Choice Arizona al Welcome to Our Family! ienvenidos a Nuestra Familia!

2 Qué es el formulario/listado de medicamentos de preferidos (PDL, por sus siglas en inglés) de Health Choice Arizona? Un formulario/listado de medicamentos preferidos (PDL) es una lista de medicamentos elegidos por Health Choice Arizona y un equipo de médicos y farmacéuticos. Health Choice cubrirá los medicamentos enumerados en nuestra PDL siempre que sean necesarios y adecuados desde el punto de vista médico. Todos los medicamentos recetados de miembros de Health Choice deben ser obtenidos en farmacias de la red de Health Choice y deben cumplirse otras reglas del plan. Qué pasa si un medicamento no está en el formulario/pdl? Si el medicamento que desea recetar a su paciente no está en este formulario/pdl, el médico podrá: Recetar un medicamento similar incluido en el formulario/pdl o Solicitar a Health Choice una excepción y cubrir el medicamento necesario desde el punto de vista médico, no incluido en el formulario, mediante un proceso de autorización previa. Puede cambiar el formulario/pdl? Sí, Health Choice podría agregar o quitar medicamentos durante el año. Para obtener la información más reciente sobre medicamentos cubiertos, visite nuestro sitio Web o llame a Servicios para afiliados de Health Choice al o (fuera del condado de Maricopa). Criterios de selección de productos El Comité de farmacia y terapéutica de Health Choice evaluará y hará recomendaciones a Health Choice sobre medicamentos nuevos en el mercado y revisará y evaluará continuamente los medicamentos existentes en el mercado para su inclusión en el formulario/pdl. La evaluación del comité incluye la revisión de la bibliografía actual. También podrá obtenerse la opinión de expertos externos. Se preparan revisiones formales, que generalmente incluyen la siguiente información: Seguridad Eficacia Estudios de comparación Indicaciones aprobadas Efectos adversos Contraindicaciones, advertencias y precauciones Farmacocinética Relación costo-beneficio Administración a pacientes y consideraciones de cumplimiento Cuando se considere un nuevo medicamento para su inclusión en el formulario, se hará el intento de examinar el medicamento en relación con otros medicamentos similares ya incluidos en el formulario. Además periódicamente se revisan clases terapéuticas completas. El proceso de revisión de clase podría generar la eliminación de uno o más medicamentos de una clase terapéutica en particular para continuar promoviendo los agentes más útiles y con mejor relación costo-beneficio. El formulario/pdl completo es revisado y aprobado cada año. Se requiere autorización previa (PA) para dos grupos de medicamentos y para dos condiciones de anulación de formulario/pdl: i

3 rupos de medicamentos Medicamentos con la anotación PA en el formulario/pdl. Todos los medicamentos que no figuran en la lista Condiciones clínicas de anulación Para anular una modificación de terapia escalonada (ST) Para anular una modificación de límite de cantidad (QL) Health Choice anticipa que las solicitudes de medicamentos no incluidos en la lista serán poco frecuentes y los proveedores podrán recetar los medicamentos del formulario/pdl para la amplia mayoría de las necesidades terapéuticas. Se anima a los proveedores a utilizar este formulario/pdl al recetar medicamentos a miembros de Health Choice para evitar retrasos innecesarios en el tratamiento. La lista de mínimo de medicamentos de venta con receta requeridos por AHCCCS se incluye en el formulario de Health Choice Arizona. Podrán autorizarse medicamentos para usos diferentes a los indicados en su etiqueta cuando se haya demostrado que son el estándar en la comunidad. Health Choice Arizona emplea un proceso de anulación de 4 (las cuatro) días para asegurarse de que los miembros puedan acceder de inmediato a los medicamentos necesarios que no están incluidos en el formulario o para los que se requiera autorización previa. La farmacia de la red de Health Choice puede cancelar un requisito de autorización previa para ofrecer al miembro el medicamento necesario de inmediato, como por ejemplo, un antibiótico o u otro medicamento de emergencia. Los proveedores de Health Choice pueden solicitar formalmente al Comité de Farmacia y Terapéutica de Health Choice que consideren un medicamento para su inclusión en el formulario/pdl. Las instrucciones y formularios de presentación necesarios, que indican cómo presentar una solicitud de consideración de medicamento para el formulario/pdl se detallan en el manual de proveedores de Health Choice. Las instrucciones y materiales están además disponibles en el sitio Web de Health Choice. Toda la información sobre el formulario de Health Choice se proporciona como referencia para la selección de tratamientos farmacológicos. La elección de los medicamentos específicos para cada paciente es exclusivamente de quien los recete. Descripciones de productos del formulario Para colaborar con la comprensión de las concentraciones y formas de dosificación de los medicamentos del formulario, se incluyen ejemplos a continuación. Los principios generales presentados en los ejemplos pueden aplicarse en general a otras entradas del libro. Las excepciones se incluyen en la lista de medicamentos. También podría haber una declaración vinculada a una lista de medicamentos que aporte información adicional sobre los productos y formas de dosificación incluidos en el formulario. Los medicamentos genéricos están identificados con minúsculas, en tanto los medicamentos de marca se identifican mediante el uso de mayúsculas. alopurinol es un medicamento genérico ULORIC es un medicamento de marca ii

4 Los productos de marca que se muestran son únicamente para referencia; podría dispensarse una marca diferente o una versión genérica. simvastatina ZOCOR Los productos de liberación prolongada y de liberación retardada requieren su propia entrada. Identificados a continuación, propranolol y propranolol SR están incluidos en el formulario. propranolol propranolol SR INDERAL INDERAL LA Las formas de dosificación del formulario deberán coincidir con la categoría y uso enumerados. Identificados a continuación del grupo ótico, la solución ótica y ungüento oftálmico están incluidos en el formulario y los productos oftálmicos y crema tópica no se puede asumir que lo estén a menos que estén incluidos en las secciones de OFTALMOLOÍA y DERMATOLOÍA del formulario. neomicina / polimixina / hidrocortisona CORTISPORIN Sustitución por genérico Los planes de salud de AHCCCS están obligados a aplicar una política de sustitución por medicamentos genéricos obligatoria. La sustitución por genéricos es una acción de la farmacia por la cual se dispensa una versión genérica de un medicamento, en lugar del producto de nombre recetado. Una importante consideración de la sustitución genérica es el conocimiento de que todas las aprobaciones de medicamentos genéricos por parte de la FDA desde 1984, y muchas aprobaciones de genéricos antes de esa fecha, han demostrado bioequivalencia entre las versiones genéricas y el producto de marca de referencia. Para obtener la aprobación de la FDA: 1. El medicamento genérico debe contener los mismos ingredientes activos, la misma concentración y la misma dosificación que el producto de marca. 2. La FDA ha dado al genérico una calificación de A en comparación con el producto de marca que indica bioequivalencia y ha determinado que el genérico es equivalente desde el punto de vista terapéutico al producto de marca de referencia. Las calificaciones de los medicamentos genéricos están disponibles consultando la referencia de la FDA, Approved Drug Products with Therapeutic Equivalence Evaluations (productos farmacológicos aprobados con evaluaciones de equivalencia terapéutica) (Orange ook). Cuando se cumplen los dos criterios anteriores, el genérico se puede sustituir con la total expectativa de que el producto sustituto produzca el mismo efecto clínico y tenga el mismo perfil de seguridad que el producto recetado. Los productos farmacológicos con índice terapéutico estrecho (NTI, por sus siglas en inglés) también pueden guiarse por estos principios. No es necesario que el médico trate a ninguna de las clases terapéuticas de productos farmacológicos (como por ejemplo medicamentos NTI) de forma diferente a los de ninguna otra clase, cuando se ha determinado la equivalencia terapéutica por parte de la FDA para los productos farmacológicos en consideración. Tampoco es necesario que el médico lleve a cabo pruebas o exámenes clínicos adicionales al sustituir un producto farmacológico genérico de equivalencia terapéutica en lugar del producto de marca. Se recomienda que el farmacéutico no lleve a cabo la sustitución genérica con productos de orígenes múltiples que figuren en el Orange ook y tengan una calificación de ", indicando que estos iii

5 productos no se pueden considerar equivalentes terapéuticos a otros productos en el grupo. También se recomienda que la sustitución por genéricos no sea utilizada para ningún producto de fuentes múltiples sin calificación que se pueda considerar como de índice terapéutico estrecho o medicamentos de mantenimiento cuando se sepa que los productos no calificados de diferentes productores no son bioequivalentes. Las leyes y reglamentaciones estatales podrían indicar la capacidad para poner en práctica una sustitución por genéricos para productos o categorías de productos farmacológicos seleccionados. Medicamentos de implementación de estudios de eficacia de medicamentos Los medicamentos lanzados al mercado entre 1938 y 1962 fueron aprobados como seguros pero no se requirió prueba de su eficacia para la aprobación por parte de la FDA. Desde 1962, todos los medicamentos nuevos deben ser tanto seguros como eficaces para poder ser lanzados al mercado. Esta legislación se aplicó además en forma retroactiva a todos los medicamentos aprobados como seguros entre 1938 y El programa de Implementación de estudios de eficacia de los medicamentos (DESI, por sus siglas en inglés) fue establecido por la FDA para revisar la eficacia de estos medicamentos anteriores a 1962 para su uso indicado y para la mayoría de estos productos se estableció su eficacia total y siguen en el mercado. Algunos productos DESI siguen clasificados como menos que totalmente eficaces a la espera de una disposición administrativa final. Además, están clasificados como DESI muchos productos listados como idénticos, similares o relacionados a productos DESI. AHCCCS y Health Choice no pagan por productos farmacológicos de clasificación DESI menos que totalmente eficaces. Exclusiones del plan Las siguientes categorías de medicamentos están excluidas de la cobertura del beneficio de farmacia para pacientes ambulatorios y no forman parte del formulario /PDL Agentes antiobesidad Medicamentos experimentales/de investigación Medicamentos cosméticos Medicamentos cosméticos para el crecimiento capilar Complementos nutricionales/dietarios Productos sanguíneos y productos de plasma sanguíneo Productos para promover la fertilidad Medicamentos para la disfunción eréctil Medicamentos de fabricantes que no participen en el programa de reembolso de medicamentos FFS de Medicaid Productos de diagnóstico Suministros médicos excepto: o Jeringas o Agujas o Lancetas o Hisopos con alcohol o Espaciadores o Medidores de glucosa en sangre y tiras de prueba Dispositivos intrauterinos iv

6 Administrador de beneficios de farmacia (PM) Health Choice Arizona utiliza a Optum Rx para procesar nuestros reclamos de medicamentos recetados REFERENCIA Negrita PA QL ST Indica disponibilidad genérica De venta libre Se requiere autorización previa Limitaciones de nivel de cantidad Se requiere tratamiento escalonado con el medicamento requerido previamente Editor Animamos que nos haga comentarios y sugerencias sobre el formulario de Health Choice. Sus aportes son fundamentales para la continuidad del éxito del formulario clínico. Todas las respuestas serán evaluadas y tenidas en cuenta. Envíe sus comentarios a: Pharmacy Services Department (Departamento de servicios farmacológicos) Health Choice Arizona 410 N 44 th Street, Suite 405 Phoenix, AZ Aviso La información contenida en este documento es confidencial. No está permitido copiar toda o parte de la información sin el consentimiento previo por escrito de Health Choice Arizona. Copyright Todos los derechos reservados. Los nombres de medicamentos enumerados aquí son marcas comerciales registradas o no registradas de compañías farmacéuticas independientes, sin relación o afiliación a Health Choice. Estas marcas se incluyen únicamente con fines informativos y no se pretende implicar ni sugerir una afiliación entre Health Choice y dichas compañías farmacéuticas. v

7 Health Choice Arizona 2018 Formulary Therapeutic Category eginning On Page *ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants* 3 *Aminoglycosides* 4 *Analgesics - Anti-Inflammatory* 4 *Analgesics - Nonnarcotic* 6 *Analgesics - Opioid* 7 *Androgens-Anabolic* 9 *Anorectal Agents* 9 *Antacids* 10 *Anthelmintics* 10 *Antianginal Agents* 11 *Antianxiety Agents* 11 *Antiarrhythmics* 12 *Antiasthmatic And ronchodilator Agents* 13 *Anticoagulants* 14 *Anticonvulsants* 14 *Antidepressants* 15 *Antidiabetics* 19 *Antidiarrheals* 20 *Antidotes* 21 *Antiemetics* 21 *Antifungals* 21 *Antihistamines* 21 *Antihyperlipidemics* 22 *Antihypertensives* 23 *Anti-Infective Agents - Misc.* 24 *Antimalarials* 24 *Antimyasthenic Agents* 24 *Antimyasthenic/Cholinergic Agents* 24 *Antimycobacterial Agents* 24 *Antineoplastics And Adjunctive Therapies*- ONCOLOY 25 *Antiparkinson Agents* 26 *Antipsychotics/Antimanic Agents* 27 *Antiretrovirals Adjuvants*** 27 *Antivirals* 27 *Assorted Classes* 29 *eta lockers* 29 *Calcium Channel lockers* 30 *Cardiotonics* 30 *Cardiovascular Agents - Misc.* 30 *Cephalosporins* 31 *Contraceptives* 31 *Corticosteroids* 35 *Cough/Cold/Allergy* 35 *Cystic Fibrosis Agent - Combinations*** 37 *Dermatologicals* 37 *Diagnostic Products* 43 *Digestive Aids* 44 *Direct-Acting P2y12 Inhibitors*** 44 *Diuretics* 44 *Endocrine And Metabolic Agents - Misc.* 45 *Estrogens* 45 *Fluoroquinolones* 46 *astrointestinal Agents - Misc.* 46 1

8 *enitourinary Agents - Miscellaneous* 46 *out Agents* 47 *Hematological Agents - Misc.* 47 *Hematopoietic Agents* 47 *Hemostatics* 48 *Hepatitis C Agent Combinations*** 48 *Hypnotics* 48 *Laxatives* 49 *Leptin Analogues*** 50 *Macrolides* 50 *Medical Devices* 51 *Migraine Products* 52 *Minerals & Electrolytes* 52 *Mouth/Throat/Dental Agents* 54 *Multivitamins* 54 *Musculoskeletal Therapy Agents* 56 *Nasal Agents - Systemic And Topical* 56 *Neprilysin Inhib (ARNI)-Angiotensin II Recept Antag Comb*** 57 *Neurogenic Orthostatic Hypotension (NOH) - Agents*** 57 *Neuromuscular Agents* 57 *Nutrients* 57 *Ophthalmic Agents* 57 *Otic Agents* 59 *Oxytocics* 60 *Penicillins* 60 *Potassium Removing Agents*** 60 *Prenatal Mv & Minerals W/ Fa-Omega Fatty Acids W/O Iron*** 60 *Progestins* 60 *Psychotherapeutic And Neurological Agents - Misc.* 60 *Pulmonary Fibrosis Agents*** 61 *Respiratory Agents - Misc.* 62 *Serotonin Modulators*** 62 *Sodium-lucose Co-Transporter 2 Inhibitor-iguanide Comb*** 62 *Sulfonamides* 62 *Tetracyclines* 62 *Thyroid Agents* 62 *Toxoids* 62 *Ulcer Drugs* 63 *Urinary Anti-Infectives* 63 *Urinary Antispasmodics* 64 *Vaccines* 64 *Vaginal Products* 65 *Vasopressors* 66 *Vitamins* 66 2

9 Health Choice Arizona Formulary Effective April 1, 2018 Product Reference rand- eneric *ADHD/Anti-Narcolepsy/Anti- Obesity/Anorexiants* ADDERALL XR amphetamine-dextroamphetamine ADDERALL PA Required for <6 years old; QL (30 EA per 30 rand Only PA Required for <6 years old; QL (60 EA per 30 APTENSIO XR PA Required for <6 years old; QL (30 EA per 30 rand Only clonidine hcl CATAPRES PA Required for <6 years old clonidine hcl transdermal patch CATAPRES PATCH PA Required for <6 years old; QL (4 EA per 28 DAYTRANA dextroamphetamine sulfate er capsule DEXEDRINE dextroamphetamine sulfate oral tablet DEXEDRINE FOCALIN FOCALIN XR guanfacine hcl TENEX PA Required for <6 years old; QL (30 EA per 30 rand Only PA Required for <6 years old; QL (60 EA per 30 PA Required for <6 years old; QL (60 EA per 30 PA Required for <6 years old; QL (60 EA per 30 rand Only PA Required for <6 years old; QL (60 EA per 30 rand Only PA Required for <6 years old guanfacine hcl er INTUNIV KAPVAY ORAL TALET EXTENDED RELEASE 12 HOUR PA Required for <6 years old; QL (30 EA per 30 PA Required for <6 years old; QL (120 EA per 30 rand Only 3

10 Product Reference rand- eneric METHYLIN ORAL SOLUTION METHYLIN ORAL TALET CHEWALE PA Required for <6 years old; QL (300 ML per 30 rand Only PA Required for <6 years old; QL (90 EA per 30 methylphenidate hcl er (CD) oral capsule extended release 24 hour methylphenidate hcl er (LA) oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg METADATE CD PA Required for <6 years old; QL (30 EA per 30 RITALIN LA methylphenidate hcl ER oral tablet extended release 18 mg, 27 mg, 36 mg, 54 mg CONCERTA PA Required for <6 years old; QL (30 EA per 30 PA Required for <6 years old; QL (60 EA per 30 methylphenidate hcl oral tablet RITALIN PA Required for <6 years old; QL (90 EA per 30 modafinil PROVIIL PA QUILLICHEW ER QUILLIVANT XR RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 M STRATTERA VYVANSE ORAL CAPSULE *Aminoglycosides* PA Required for <6 years old; QL (30 EA per 30 rand Only PA Required for <6 years old; QL (150 ML per 30 rand Only PA Required for <6 years old; QL (30 EA per 30 PA Required for <6 years old; QL (30 EA per 30 rand Only PA Required for <6 years old; QL (30 EA per 30 rand Only ETHKIS PA KITAIS PAK PA; SP neomycin sulfate oral paromomycin sulfate oral *Analgesics - Anti-Inflammatory* celecoxib oral CELEREX PA childrens ibuprofen 100 CHILDRENS ADVIL 4

11 Product Reference rand- eneric diclofenac potassium diclofenac sodium er diclofenac sodium oral ENREL SUCUTANEOUS SOLUTION PREFILLED SYRINE 25 M/0.5ML ENREL SUCUTANEOUS SOLUTION PREFILLED SYRINE 50 M/ML ENREL SUCUTANEOUS SOLUTION RECONSTITUTED ENREL SURECLICK SUCUTANEOUS SOLUTION AUTO-INJECTOR ENREL MINI CARTRIDE SUCUTANEOUS SOLUTION 50 M/ML etodolac er etodolac oral fenoprofen calcium oral tablet flurbiprofen oral 5 PA; SP; QL (4.08 ML per 28 PA; SP; QL (3.92 ML per 28 PA; SP; QL (8 EA per 28 PA; SP; QL (3.92 ML per 28 PA; SP; QL (3.92 ML per 28 HUMIRA PEN SUCUTANEOUS PEN- PA; SP; QL (2 EA per 30 INJECTOR KIT HUMIRA SUCUTANEOUS PREFILLED PA; SP; QL (2 EA per 30 SYRINE KIT ibuprofen junior strength oral tablet chewable ADVIL JUNIOR STRENTH ibuprofen oral capsule MIDOL ibuprofen oral tablet 200 mg PROVIL ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN ORAL SUSPENSION INDOCIN RECTAL indomethacin er indomethacin oral infants ibuprofen MEDI-PROFEN ketoprofen oral ketorolac tromethamine oral QL (20 EA per 30 leflunomide oral ARAVA meloxicam oral tablet MOIC nabumetone oral naproxen dr EC-NAPROSYN naproxen oral NAPROSYN naproxen sodium oral tablet 220 mg ALEVE naproxen sodium oral tablet 275 mg naproxen sodium oral tablet 550 mg ANAPROX DS oxaprozin DAYPRO piroxicam oral FELDENE RIDAURA

12 Product Reference rand- eneric ibuprofen jr ADVIL JUNIOR STRENTH sulindac oral *Analgesics - Nonnarcotic* 8 hour pain relief TYLENOL 8 HOUR acetaminophen extra strength oral liquid CHLORASEPTIC SORE THROAT acetaminophen extra strength oral tablet MEDI-TAS EXTRA STRENTH acetaminophen junior strength JUNIOR MAPAP acetaminophen oral elixir MEDI-TAS CHILDREN acetaminophen oral liquid LITTLE REMIDIES FOR FEVER acetaminophen oral solution 160 mg/5ml acetaminophen oral suspension 160 mg/5ml MAPAP CHILDRENS acetaminophen oral tablet 325 mg TYLENOL acetaminophen rectal suppository 120 mg FEVERALL CHILDRENS aspirin adult low strength oral tablet delayed release ASPIR-LOW aspirin ec oral tablet delayed release 325 mg ECOTRIN aspirin low strength AYER LOW DOSE aspirin oral tablet 325 mg NORWICH ASPIRIN aspirin rectal suppository 300 mg, 600 mg buffered aspirin UFFERIN butalbital-acetaminophen oral tablet mg TENCON butalbital-apap-caffeine oral capsule FIORICET butalbital-apap-caffeine oral tablet mg ESIC butalbital-aspirin-caffeine oral capsule FIORINAL childrens acetaminophen oral tablet dispersible MAPAP CHILDRENS childrens non-aspirin oral tablet chewable CHILDRENS MEDI-TAS choline & mag trisalicylate oral tablet 1000 mg choline-mag trisalicylate diflunisal oral extra strength acetaminophen feverall junior strength acetaminophen infants pain reliever migraine formula PAMPRIN MAX non-aspirin jr strength oral tablet chewable MEDI-TAS JUNIOR STRENTH pain relief 8 hour TYLENOL 8 HOUR aspirin oral tablet 500 mg AYER ASPIRIN EXTRA STRENTH salsalate oral DISALCID 6

13 Product Reference rand- eneric *Analgesics - Opioid* acetaminophen-codeine #2 acetaminophen-codeine #3 acetaminophen-codeine #4 acetaminophen-codeine oral solution TYLENOL WITH CODEINE #3 TYLENOL WITH CODEINE #4 butalbital-apap-caff-cod FIORICET/CODEINE PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5 PA Required for Day Supply reater than 5; QL (180 EA per 30 UTRANS PA; QL codeine sulfate oral tablet 30 mg, 60 mg EMEDA PA; QL PA Required for Day Supply reater than 5; QL (180 EA per 30 fentanyl transdermal patch 72 hour 100 mcg/hr DURAESIC-100 PA; QL fentanyl transdermal patch 72 hour 12 mcg/hr DURAESIC-12 PA; QL fentanyl transdermal patch 72 hour 25 mcg/hr DURAESIC-25 PA; QL fentanyl transdermal patch 72 hour 50 mcg/hr DURAESIC-50 PA; QL fentanyl transdermal patch 72 hour 75 mcg/hr DURAESIC-75 PA; QL hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg ZAMICET HYCET VICODIN HP LORTA VERDROCET PA Required for Day hydrocodone-acetaminophen oral tablet mg VICODIN Supply reater than 5; QL (180 EA per 30 7 PA Required for Day Supply reater than 5 PA Required for Day Supply reater than 5 PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5; QL (180 EA per 30

14 Product Reference rand- eneric hydrocodone-acetaminophen oral tablet mg XODOL hydrocodone-ibuprofen oral tablet mg XYLON hydrocodone-ibuprofen oral tablet mg REPREXAIN hydrocodone-ibuprofen oral tablet mg hydromorphone hcl oral tablet DILAUDID meperidine hcl oral tablet DEMEROL morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate er oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg morphine sulfate er oral tablet extended release 200 mg morphine sulfate oral solution morphine sulfate oral tablet MORPHINE SULFATE RECTAL SUPPOSITORY 10 M, 20 M, 5 M morphine sulfate rectal suppository 30 mg oxycodone hcl oral capsule oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution oxycodone hcl oral tablet oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet mg, mg, mg 8 PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5 MS CONTIN PA; QL (90 EA per 30 MS CONTIN PA; QL ENDOCET PA Required for Day Supply reater than 5 PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5 PA Required for Day Supply reater than 5 PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5 PA Required for Day Supply reater than 5 PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5 PA Required for Day Supply reater than 5; QL (180 EA per 30

15 Product Reference rand- eneric oxycodone-acetaminophen oral tablet mg PERCOCET PA Required for Day Supply reater than 5; QL (180 EA per 30 oxycodone-aspirin oral tablet mg PA Required for Day Supply reater than 5; QL (180 EA per 30 XTAMPZA ER PA oxymorphone hcl OPANA tramadol hcl oral ULTRAM tramadol-acetaminophen ULTRACET tramadol HCl tab ER 24 hr ULTRAM ER PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5; QL (180 EA per 30 PA Required for Day Supply reater than 5 PA *Androgens-Anabolic* ANDRODERM TRANSDERMAL PATCH 24 HOUR ANDROEL PUMP TRANSDERMAL EL 12.5 M/ACT (1%) ANDROEL PUMP TRANSDERMAL EL M/ACT (1.62%) ANDROEL TRANSDERMAL EL M/1.25M (1.62%), 40.5 M/2.5M PA (1.62%) ANDROXY PA danazol oral FORTESTA PA testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml DEPO-TESTOSTERONE PA testosterone enanthate intramuscular solution PA testosterone transdermal gel 10 mg/act (2%) FORTESTA PA testosterone transdermal solution 30 mg/act AXIRON PA testosterone transdermal gel 12.5 mg/act (1%) VOELXO Pump PA testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) 9 PA PA PA ANDROEL PA VOELXO PUMP PA *Anorectal Agents* CORTIFOAM hydrocortisone ace-pramoxine rectal cream 1-1 % ANALPRAM-HC hydrocortisone rectal enema COLOCORT

16 Product Reference rand- eneric lidocaine-hydrocortisone ace rectal cream LIDAZONE HC lidocaine-hydrocortisone ace rectal kit 2-2 % ANA-LEX pramoxine hcl rectal PROCTOFOAM PROCORT PROCTOFOAM HC procto-med hc procto-pak *Antacids* aluminum hydroxide magnesium carbonate oral suspension aluminum & mag hydroxide - simethicone oral tablet chewable mg aluminum hydroxide gel oral suspension 320 mg/5ml antacid & antigas oral suspension mg/5ml antacid extra strength oral tablet chewable mg ACID ONE ALMACONE MAALOX MAX ANTACID ORAL TALET CHEWALE 1177 TUMS CHEWY M DELIHTS antacid oral tablet chewable 420 mg TITRALAC antacid oral tablet chewable mg ROLAIDS calcium antacid CAL-EST ANTACID calcium antacid extra strength calcium antacid ultra max st TUMS ULTRA 1000 childrens pepto CHILDRENS SOOTHE geri-lanta (calcium carbonate mag hydroxide) supreme heartburn antacid ex st ACID ONE magnesium oxide oral tablet 250 mg, 400 mg magnesium oxide oral tablet 420 mg MAOX calcium carbonate-mag hydroxide chew tab mg oral tablet chewable aluminum hydroxide magnesium trisilicate foaming antacid sodium bicarbonate oral tablet 325 mg, 650 mg *Anthelmintics* ALENZA ILTRICIDE MI ACID ivermectin oral STROMECTOL pyrantel pamoate oral suspension PIN-X 10

17 Product Reference rand- eneric *Antianginal Agents* isosorbide dinitrate er isosorbide dinitrate oral isosorbide mononitrate isosorbide mononitrate er NITRO-ID nitroglycerin transdermal patch 24 hour NITRO-DUR nitroglycerin sublingual NITROSTAT RANEXA PA *Antianxiety Agents* alprazolam er XANAX XR QL (30 EA per 30 ALPRAZOLAM INTENSOL PA Required for < 6 years of old; QL (60 ML per 15 alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg XANAX PA Required for < 6 years of old; QL (120 EA per 30 alprazolam oral tablet 2 mg XANAX PA Required for < 6 years of old; QL (60 EA per 30 alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg PA Required for < 6 years of old; QL (120 EA per 30 alprazolam oral tablet dispersible 2 mg PA Required for < 6 years of old; QL (60 EA per 30 alprazolam oral tablet 24hr 1 mg, 2 mg, 3 mg buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg PA Required for < 6 years of old; QL (30 EA per 30 PA Required for <6 years old; QL (120 EA per 30 buspirone hcl oral tablet 30 mg PA Required for < 6 years old; QL (60 EA per 30 chlordiazepoxide hcl PA Required for < 6 years old; QL (60 EA per 30 clonazepam oral tablet 0.5 mg, 1.0 mg KLONOPIN PA Required for <6 years old; QL (120 EA per 30 clonazepam oral tablet 2 mg KLONOPIN PA Required for < 6 years old; QL (60 EA per 30 11

18 Product Reference rand- eneric clonazepam oral tablet dispersible mg, 0.25 mg, 0.5 mg, 1 mg PA Required for <6 years old; QL (120 EA per 30 clonazepam oral table dispersible 2 mg PA Required for < 6 years old; QL (60 EA per 30 clorazepate dipotassium oral tablet 15 mg PA Required for < 6 years old; QL (60 EA per 30 clorazepate dipotassium oral tablet 3.75 mg PA Required for < 6 years old; QL (120 EA per 30 clorazepate dipotassium oral tablet 7.5 mg TRANXENE-T PA Required for < 6 years old; QL (120 EA per 30 diazepam intensol PA Required for < 6 years old; QL (60 ML per 30 diazepam oral solution 1 mg/ml PA Required for < 6 years old; QL (300 ML per 30 diazepam oral tablet VALIUM PA Required for < 6 years old; QL (120 EA per 30 hydroxyzine hcl oral syrup QL (300ml per 30 hydroxyzine hcl oral tablet QL (240 EA per 30 hydroxyzine pamoate oral VISTARIL QL (120 EA per 30 lorazepam intensol PA Required for < 6 years old; QL (60 ML per 30 lorazepam oral tablet 0.5 mg, 1 mg ATIVAN PA Required for < 6 years old; QL (120 EA per 30 lorazepam oral tablet 2 mg ATIVAN PA Required for < 6 years old; QL (60 EA per 30 oxazepam PA Required for < 6 years old; QL (60 EA per 30 *Antiarrhythmics* amiodarone hcl oral tablet 100 mg, 200 mg PACERONE disopyramide phosphate oral NORPACE dofetilide TIKOSYN flecainide acetate mexiletine hcl oral MULTAQ 12

19 Product Reference rand- eneric NORPACE CR pacerone oral tablet 100 mg, 200 mg propafenone hcl propafenone hcl er RYTHMOL SR quinidine gluconate er quinidine sulfate oral *Antiasthmatic And ronchodilator Agents* ADVAIR DISKUS ST albuterol sulfate er VOSPIRE ER albuterol sulfate inhalation albuterol sulfate oral ASMANEX 120 METERED DOSES ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER REATH ACTIVATED 110 MC/INH 13 ATROVENT HFA QL (26 M per 30 COMIVENT RESPIMAT cromolyn sodium inhalation DULERA ST FLOVENT HFA ipratropium bromide inhalation ipratropium-albuterol metaproterenol sulfate oral montelukast sodium oral packet SINULAIR montelukast sodium oral tablet SINULAIR QL (30 EA per 30 montelukast sodium oral tablet chewable SINULAIR QL (30 EA per 30 PROAIR HFA PULMICORT FLEXHALER PULMICORT RESPULES PA _ rand Only for > 4 years old; QL QVAR INHALATION AEROSOL SOLUTION SEREVENT DISKUS PA SPIRIVA HANDIHALER SYMICORT ST terbutaline sulfate oral theophylline er THEOCRON theophylline oral solution VENTOLIN HFA XOPENEX HFA zafirlukast ACCOLATE

20 Product Reference rand- eneric *Anticoagulants* ELIQUIS QL (60 EA per 30 enoxaparin sodium injection LOVENOX QL (60 EA per 30 heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) intravenous solution SP heparin sodium (porcine) pf SP PRADAXA QL (60 EA per 30 warfarin sodium oral COUMADIN XARELTO QL (60 EA per 30 XARELTO DOSE PACK QL (51 EA per 30 *Anticonvulsants* ANZEL carbamazepine er CARATROL carbamazepine oral clonazepam oral tablet 0.5 mg, 1 mg KLONOPIN PA Required for < 6 years old; QL (120 EA per 30 clonazepam oral tablet 2 mg KLONOPIN PA Required for < 6 years old; QL (60 EA per 30 clonazepam oral tablet dispersible mg, 0.25 mg, 0.5 mg, 1 mg SP PA Required for < 6 years old; QL (120 EA per 30 clonazepam oral tablet dispersible 2 mg PA Required for < 6 years old; QL (60 EA per 30 DIASTAT ACUDIAL RECTAL EL 10 M QL 2/Fill DIASTAT PEDIATRIC QL 2/Fill diazepam rectal DIASTAT ACUDIAL QL 2/Fill divalproex sodium er oral tablet extended release 24 hour divalproex sodium oral capsule delayed release sprinkle DEPAKOTE ER DEPAKOTE SPRINKLES divalproex sodium oral tablet delayed release DEPAKOTE ethosuximide oral ZARONTIN felbamate FELATOL gabapentin oral capsule NEURONTIN 14

21 Product Reference rand- eneric gabapentin oral solution 250 mg/5ml NEURONTIN gabapentin oral tablet NEURONTIN RALISE PA HORIZANT PA lamotrigine er LAMICTAL XR lamotrigine oral tablet LAMICTAL lamotrigine oral tablet chewable LAMICTAL levetiracetam er KEPPRA XR levetiracetam oral KEPPRA LYRICA ORAL CAPSULE 100 M, 150 M, 200 M, 25 M, 50 M, 75 M LYRICA ORAL CAPSULE 225 M, 300 M LYRICA ORAL SOLUTION PA ONFI ORAL SUSPENSION PA ONFI ORAL TALET 10 M, 20 M PA oxcarbazepine TRILEPTAL OXTELLAR XR phenytoin infatabs phenytoin oral suspension 125 mg/5ml DILANTIN phenytoin sodium extended DILANTIN primidone oral MYSOLINE tiagabine hcl AITRIL topiramate oral TOPAMAX SPRINKLE valproic acid oral capsule DEPAKENE VIMPAT ORAL zonisamide oral ZONERAN *Antidepressants* amitriptyline hcl oral amoxapine oral tablet 100 mg, 150 mg, 25 mg bupropion hcl er (sr) WELLUTRIN SR bupropion hcl er (xl) WEILLUTRIN XL bupropion hcl oral CELEXA PA Required for<6 years citalopram hydrobromide solution old; QL (600 ml per PA; QL (90 EA per 30 PA; QL (60 EA per 30 PA Required for<6 years old PA Required for<6 years old; PA Required for<6 years old; QL (60 EA for 30 PA Required for<6 years old; QL (30 EA for 30 PA Required for<6 years old; QL (120 EA for 30

22 Product Reference rand- eneric citalopram hydrobromide tablet 10 mg CELEXA PA Required for<6 years old; QL (60 EA per 30 citalopram hydrobromide tablet 20 mg, 40 mg CELEXA PA Required for<6 years old; QL (30 EA per 30 clomipramine hcl oral ANAFRANIL desipramine hcl oral NORPRAMIN PA Required for<6 years old PA Required for<6 years old desvenlafaxine succinate er PRISTIQ PA Required for <6 years old; QL (120 EA per 30 doxepin hcl oral capsule PA Required for<6 years old; QL (90 EA per 30 doxepin hcl oral concentrate PA R ) equired for<6 years old; QL (180 ML per 30 duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg CYMALTA duloxetine hcl oral capsule delayed release particles 60 mg CYMALTA EMSAM PA PA R ) equired for<6 years old; QL (120 EA per 30 PA Required for<6 years old; QL (60 EA per 30 escitalopram oxalate solution LEXAPRO PA Required for<6 years old; QL (600 ml per 30 escitalopram oxalate tablets 5mg LEXAPRO PA Required for<6 years old; QL (60 EA per 30 escitalopram oxalate tablets 10 mg, 20mg LEXAPRO PA Required for<6 years old; QL (30 EA per 30 fluoxetine hcl oral capsule 20 mg fluoxetine hcl oral capsule 10 mg, 40 mg fluoxetine hcl oral capsule delayed release PROZAC PROZAC PROZAC WEEKLY PA Required for<6 years old; QL (120 EA per 30 PA Required for<6 years old; QL (60 EA per 30 PA fluoxetine hcl oral solution fluvoxamine maleate 25 mg PROZAC LUVOX PA Required for<6 years old; QL (600 ml per 30 PA Required for<6 years old; QL (60 EA per 30 16

23 Product Reference rand- eneric fluvoxamine maleate 50 mg LUVOX PA Required for<6 years old; QL (180 EA per 30 fluvoxamine maleate 100 mg LUVOX PA Required for<6 years old; QL (90 EA per 30 LUVOX CR PA Required for<6 years fluvoxamine maleate er 100 mg old; QL (90 EA per 30 fluvoxamine maleate er 150 mg LUVOX CR PA Required for<6 years old; QL (60 EA per 30 UPROPION HCL TA ER 24HR 450 M FORFIVO XL imipramine hcl oral imipramine pamoate maprotiline hcl MARPLAN TOFRANIL paroxetine hcl oral tablet 40 mg PAXIL PA Required for<6 years old; QL (45 EA per PA Required for<6 years old PA Required for<6 years old PA Required for<6 years old PA Required for<6 years old mirtazapine oral REMERON PA Required for<6 years old; QL (30 EA for 30 mirtazapine orally disintegrating tablets REMERON SOLTA PA Required for<6 years old; QL (30 EA for 30 nefazodone hcl 50 mg, 100 mg, 250 mg PA Required for<6 years old; QL (60 EA per 30 nefazodone hcl 150 mg PA Required for<6 years old; QL (120 EA per 30 nefazodone hcl 200 mg PA Required for<6 years old; QL (90 EA per 30 nortriptyline hcl oral capsule NORTRIPTYLINE HCL ORAL SOLUTION paroxetine hcl er paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg PAMELOR PAXIL CR PAXIL PA Required for<6 years old PA Required for<6 years old PA Required for<6 years old; QL (90 EA per 30 PA Required for<6 years old; QL (30 EA per 30

24 Product Reference rand- eneric PAXIL ORAL SUSPENSION PA Required for<6 years old; QL (900 ML per 30 PEXEVA PA phenelzine NARDIL PA required for <6years protriptyline hcl PA Required for<6 years old ZOLOFT PA Required for<6 years sertraline hcl oral concentrate old; QL (300 ML per 30 sertraline hcl oral tablet 25 mg ZOLOFT PA Required for<6 years old; QL (90 EA per 30 sertraline hcl oral tablet 50 mg PA Required for<6 years ZOLOFT old; QL (120 EA per 30 sertraline hcl oral tablet 100 mg tranylcypromine sulfate trazodone hcl oral 50 mg ZOLFOT PARNATE PA Required for<6 years old; QL (60 EA per 30 PA Required for<6 years old PA Required for<6 years old; QL (90 EA per 30 trazodone hcl oral 100 mg PA Required for<6 years old; QL (120 EA per 30 trazodone hcl oral 150 mg PA Required for<6 years old; QL (60 EA per 30 trazodone hcl oral 300 mg PA Required for<6 years old; QL (30 EA per 30 PA Required for<6 years trimipramine maleate oral SURMONTIL old venlafaxine hcl tablet 25 mg venlafaxine hcl tablet 37.5mg, 50 mg, 100 mg venlafaxine hcl tablet 75 mg venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg EFFEXOR XR PA Required for<6 years old; QL (120 EA per 30 PA Required for<6 years old; QL (90 EA per 30 PA Required for<6 years old; QL (150 EA per 30 PA Required for<6 years old; QL (90 EA per 30 18

25 Product Reference rand- eneric venlafaxine hcl er oral capsule extended release 24 hour 150 mg VIIRYD ORAL TALET VIIRYD STARTER PACK *Antidiabetics* EFFEXOR XR acarbose PRECOSE ACTOPLUS MET XR AVANDIA ORAL TALET 2 M, 4 M YETTA 5MC, 10MC PEN SUCUTANEOUS SOL PENINJECTOR PA Required for<6 years old; QL (30 EA per 30 PA PA PA YDUREON PEN, VIAL PA chlorpropamide glimepiride AMARYL glipizide er LUCOTROL XL glipizide oral LUCOTROL glipizide-metformin hcl LUCAON EMERENCY glyburide micronized LYNASE glyburide oral glyburide-metformin HUMALO KWIKPEN SUCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML QL (60 ML per 30 HUMALO MIX 50/50 QL (60 ML per 30 HUMALO MIX 50/50 KWIKPEN SUCUTANEOUS SUSPENSION PEN- QL (60 ML per 30 INJECTOR HUMALO MIX 75/25 QL (60 ML per 30 HUMALO MIX 75/25 KWIKPEN SUCUTANEOUS SUSPENSION PEN- QL (60 ML per 30 INJECTOR HUMALO SUCUTANEOUS SOLUTION QL (60 ML per 30 HUMULIN 70/30 19 ; QL (60 ML per 30 HUMULIN N ; QL (60 ML per 30 HUMULIN R ; QL (60 ML per 30 HUMULIN R U-500 (CONCENTRATED) PA; QL (60 ML per 30 INVOKANA JANUMET / JANUMET XR PA JENTADUETO PA KOMILYZE XR PA

26 Product Reference rand- eneric JANUVIA PA NOVOLO INJECTION QL (60 ML per 30 NOVOLO INJECTION FLEXPEN QL (60 ML per 30 NOVOLO INJECTION PENFILL QL (60 ML per 30 NOVOLO MIX 70/30 QL (60 ML per 30 NOVOLO MIX 70/30 FLEXPEN QL (60 ML per 30 ONLYZA PA LANTUS QL (60 ML per 30 LANTUS SOLOSTAR SUCUTANEOUS SOLUTION PEN-INJECTOR QL (60 ML per 30 LEVEMIR QL (60 ML per 30 LEVEMIR FLEXTOUCH QL (60 ML per 30 metformin hcl er LUCOPHAE XR metformin hcl oral LUCOPHAE nateglinide STARLIX pioglitazone hcl ACTOS pioglitazone hcl-glimepiride DUETACT pioglitazone hcl-metformin hcl ACTOPLUS MET repaglinide SYMLINPEN 120 SUCUTANEOUS SOLUTION PEN-INJECTOR SYMLINPEN 60 SUCUTANEOUS SOLUTION PEN-INJECTOR tolazamide tolbutamide TRADJENTA PA VICTOZA SUCUTANEOUS SOLUTION PEN- PA INJECTOR *Antidiarrheals* bismuth subsalicylate oral tablet chewable PEPTO-ISMOL 262 mg INSTACOOL diphenoxylate-atropine FULYZAQ PA; QL (60 EA per 30 IMODIUM A-D ORAL TALET CHEWALE loperamide hcl oral capsule IMODIUM A-D loperamide hcl oral liquid loperamide hcl oral suspension IMODIUM A-D loperamide hcl oral tablet LOPERAMIDE A-D MYTESI PA; QL (60 EA per 30 pink bismuth maximum strength PEPTO-ISMOL MAX STRENTH pink bismuth oral suspension 262 mg/15ml PEPTO-ISMOL pink bismuth oral tablet KAOPECTATE 20 PA PA

27 Product Reference rand- eneric *Antidotes* naloxone hcl injection solution 0.4 mg/ml NALOXONE HCL INJECTION SOLUTION 1 M/ML NARCAN *Antiemetics* ANZEMET ORAL PA aprepitant oral capsule 125 mg, 80 & 125 mg EMEND 21 aprepitant oral capsule 40 mg, 80 mg EMEND QL (6 EA per 30 dimenhydrinate oral granisetron hcl oral meclizine hcl oral tablet meclizine hcl oral tablet chewable MOTION SICKNESS RELIEF dimenhydrinate MOTION SICKNESS ondansetron ZOFRAN ODT QL (30 EA per 30 ondansetron hcl oral solution ZOFRAN ondansetron hcl oral tablet QL (30 EA per 30 trimethobenzamide hcl oral TIAN *Antifungals* fluconazole oral DIFLUCAN flucytosine oral ANCOON griseofulvin microsize oral griseofulvin ultramicrosize RIS-PE itraconazole oral SPORANOX PA ketoconazole oral NOXAFIL ORAL SUSPENSION PA nystatin oral tablet SPORANOX ORAL SOLUTION PA terbinafine hcl oral LAMISIL QL (90 EA per 365 voriconazole oral tablet VFEND *Antihistamines* all day allergy oral capsule ZYRTEC ALLERY ALLERA ALLERY CHILDRENS ORAL TALET ALLERA ALLERY CHILDRENS ORAL TALET DISPERSILE carbinoxamine maleate oral solution carbinoxamine maleate oral tablet cetirizine hcl oral syrup 5 mg/5ml ZYRTEC CHILDRENS ALLERY cetirizine hcl oral tablet cetirizine hcl oral tablet chewable ZYRTEC CHILDRENS

28 Product Reference rand- eneric chlorpheniramine maleate er CHLOR-TRIMETON ALLERY chlorpheniramine maleate oral clemastine fumarate oral tablet 2.68 mg allergy childrens oral tablet chewable cyproheptadine hcl oral ENADRYL ALLERY CHILDRENS clemastine fumarate oral tablet 1.34 mg DAYIST ALLERY 12 HOUR RELIEF diphenhydramine hcl oral capsule ANOPHEN diphenhydramine hcl oral elixir diphenhydramine hcl oral liquid diphenhydramine hcl oral tablet 25 mg ANOPHEN diphenhydramine oral tablet chewable 12.5 mg ENADRYL ALLERY CHILDRENS doxylamine succinate tablets ed chlorped jr DIAETIC TUSSIN ALLERY ED CHLORPED (chlorpheniramine maleate) ORAL LIQUID fexofenadine hcl childrens ALLERA ALLERY CHILDRENS fexofenadine hcl oral tablet 180 mg ALLERA fexofenadine hcl oral tablet 60 mg ALLERA ALLERY levocetirizine dihydrochloride oral XYZAL loratadine allergy relief oral tablet dispersible CLARITIN loratadine childrens oral solution CLARITIN loratadine oral tablet CLARITINE promethazine hcl injection PHENERAN promethazine hcl oral syrup promethazine hcl oral tablet promethazine hcl rectal PHENADOZ *Antihyperlipidemics* atorvastatin calcium oral LIPITOR QL (30 EA per 30 cholestyramine light PREVALITE cholestyramine oral QUESTRAN colestipol hcl COLESTID FLAVORED ezetimibe ZETIA fenofibrate micronized oral capsule 134 mg, LOFIRA 200 mg, 67 mg fenofibrate oral tablet 145 mg, 48 mg TRICOR fenofibrate oral tablet 160 mg, 54 mg LOFIRA fenofibric acid TRILIPIX fluvastatin sodium LESCOL gemfibrozil oral LOPID 22

29 Product Reference rand- eneric JUXTAPID PA; QL (30 EA per 30 lovastatin QL (30 EA per 30 omega-3-acid ethyl esters LOVAZA QL (30 EA per 30 pravastatin sodium QL (30 EA per 30 simvastatin oral ZOCOR QL (30 EA per 30 *Antihypertensives* amlodipine besy-benazepril hcl LOTREL atenolol-chlorthalidone TENORETIC 100 benazepril hcl oral LOTENSIN bisoprolol-hydrochlorothiazide ZIAC captopril oral captopril-hydrochlorothiazide clonidine hcl oral CATAPRES clonidine hcl transdermal CATAPRES-TTS-1 PA Required for <6 years old; QL (4 EA per 28 doxazosin mesylate CARDURA enalapril maleate oral VASOTEC enalapril-hydrochlorothiazide VASERETIC eplerenone INSPRA eprosartan mesylate fosinopril sodium fosinopril sodium-hctz guanfacine hcl oral hydralazine hcl oral Irbesartan AVAPRO irbesartan-hydrochlorothiazide AVALIDE lisinopril oral ZESTRIL lisinopril-hydrochlorothiazide ZESTORETIC losartan potassium COZAAR losartan potassium-hctz HYZAAR methyldopa oral metoprolol-hydrochlorothiazide minoxidil oral moexipril hcl moexipril-hydrochlorothiazide nadolol-bendroflumethiazide CORZIDE perindopril erbumine prazosin hcl oral MINIPRESS propranolol-hctz quinapril hcl ACCUPRIL 23

30 Product Reference rand- eneric quinapril-hydrochlorothiazide ACCURETIC ramipril ALTACE terazosin hcl oral trandolapril MAVIK valsartan DIOVAN valsartan-hydrochlorothiazide DIOVAN HCT *Anti-Infective Agents - Misc.* atovaquone oral MEPRON clindamycin hcl oral CLEOCIN clindamycin palmitate hcl CLEOCIN dapsone oral linezolid oral suspension reconstituted ZYVOX PA linezolid oral tablet ZYVOX PA metronidazole oral FLAYL PRIMSOL SIVEXTRO ORAL PA; SP sulfamethoxazole-trimethoprim oral SULFATRIM PEDIATRIC suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet ACTRIM DS tinidazole oral trimethoprim oral vancomycin hcl oral capsules VANCOCIN HCL XIFAXAN PA *Antimalarials* atovaquone-proguanil hcl MALARONE chloroquine phosphate oral COARTEM hydroxychloroquine sulfate oral PLAQUENIL mefloquine hcl quinine sulfate oral QUALAQUIN *Antimyasthenic Agents* pyridostigmine bromide er MESTINON pyridostigmine bromide oral MESTINON *Antimyasthenic/Cholinergic Agents* pyridostigmine bromide er MESTINON pyridostigmine bromide oral MESTINON *Antimycobacterial Agents* ethambutol hcl oral MYAMUTOL isoniazid oral pyrazinamide oral 24

31 Product Reference rand- eneric rifamate rifampin oral RIFADIN SIRTURO *Antineoplastics And Adjunctive Therapies*- ONCOLOY -FEDERALLY REIMURSALE ANTINEOPLASTIC AENTS,NOT LISTED ELOW, ARE AVAILALE THROUH PRIOR AUTHORIZATION ACTIMMUNE PA; SP AFINITOR PA AFINITOR DISPERZ PA ALKERAN ORAL SP anastrozole oral ARIMIDEX PA bexarotene TARRETIN SP bicalutamide CASODEX CAPRELSA PA; SP cyclophosphamide oral capsule CYTOXAN PA ELIARD PA; SP ETOPOPHOS PA; SP etoposide oral SP exemestane AROMASIN PA FARESTON PA flutamide LEOSTINE ORAL CAPSULE 10 M, 100 M, 40 M PA; SP HEXALEN PA; SP hydroxyurea oral HYDREA ICLUSI PA; SP; QL (60 EA per 30 imatinib mesylate LEEVEC PA; SP IMRUVICA PA; SP INLYTA PA; SP INTRON A PA; SP IRESSA PA; SP JAKAFI PA letrozole oral FEMARA leucovorin calcium oral PA LEUKERAN leuprolide acetate injection SP LUPRON DEPOT PA; SP 25

32 Product Reference rand- eneric LYSODREN MATULANE PA; SP megestrol acetate oral suspension 40 mg/ml MEACE ORAL megestrol acetate oral tablet mercaptopurine oral methotrexate oral methotrexate sodium (pf) injection solution 50 mg/2ml methotrexate sodium injection solution 50 mg/2ml methotrexate sodium injection solution reconstituted MYLERAN NEXAVAR PA SUTENT PA TALOID tamoxifen citrate oral TARCEVA PA; SP TARRETIN ORAL PA TASINA PA; SP TYKER PA; SP VOTRIENT PA; SP XALKORI PA; SP ZELORAF PA ZOLINZA PA *Antiparkinson Agents* amantadine hcl oral benztropine mesylate oral bromocriptine mesylate oral PARLODEL carbidopa-levodopa SINEMET carbidopa-levodopa er oral tablet extended release mg, mg carbidopa-levodopa-entacapone STLEVO 50 entacapone COMTAN pramipexole dihydrochloride MIRAPEX ropinirole hcl REQUIP selegiline hcl oral ELDEPRYL trihexyphenidyl hcl 26

33 Product Reference rand- eneric *Antipsychotics/Antimanic Agents* prochlorperazine COMPRO prochlorperazine maleate oral *Antiretrovirals Adjuvants*** TYOST *Antivirals* abacavir sulfate ZIAEN SP abacavir sulfate-lamivudine EPZICOM abacavir-lamivudine-zidovudine TRIZIVIR SP acyclovir oral ZOVIRAX adefovir dipivoxil HEPSERA PA; SP APTIVUS SP ATRIPLA SP ARACLUDE ORAL SOLUTION PA; SP COMPLERA SP CRIXIVAN ORAL CAPSULE 200 M, 400 M DESCOVY SP didanosine VIDEX EC SP EDURANT SP EMTRIVA SP Entecavir ARACLUDE PA; SP EPIVIR HV ORAL SOLUTION SP EVOTAZ SP famciclovir oral FUZEON SUCUTANEOUS SOLUTION RECONSTITUTED ENVOYA SP INTELENCE SP INVIRASE SP ISENTRESS ORAL TALET SP ISENTRESS ORAL TALET CHEWALE SP KALETRA ORAL TALET SP lamivudine EPIVIR SP lamivudine-zidovudine COMIVIR SP LEXIVA SP lopinavir-ritonavir solution KALETRA 27 SP PA; SP moderiba oral tablet 200 mg PA; SP nevirapine tablets, oral suspension VIRAMUNE SP nevirapine er VIRAMUNE XR SP

34 Product Reference rand- eneric ritonavir tablet 100 M NORVIR SP NORVIR capsule, oral solution SP ODEFSEY SP oseltamivir phosphate TAMIFLU QL (10 EA per 365 oseltamivir oral suspension reconstituted 6 M/ML PEASYS PROCLICK SUCUTANEOUS SOLUTION 135 MC/0.5ML PEASYS PROCLICK SUCUTANEOUS SOLUTION 180 MC/0.5ML PE-INTRON SUCUTANEOUS KIT 120 MC/0.5ML PE-INTRON SUCUTANEOUS KIT 150 MC/0.5ML, 50 MC/0.5ML, 80 MC/0.5ML PREZCOIX PREZISTA ORAL TALET 150 M, 600 M, 75 M, 800 M TAMIFLU QL (60 ML per 365 PA; SP PA PA; SP RELENZA DISKHALER QL (10 EA per 365 RESCRIPTOR SP atazanavir oral capsule 150 M, 200 M, 300 M REYATAZ ribavirin oral capsule REETOL PA; SP ribavirin oral tablet 200 mg MODERIA PA; SP rimantadine hcl FLUMADINE SELZENTRY ORAL TALET 150 M, 300 M PA; SP stavudine ZERIT SP STRIILD SP efavirenz tab 600 M SUSTIVA SP TIVICAY ORAL TALET 50 M SP TRIUMEQ SP TRUVADA PA; SP TYZEKA PA; SP valacyclovir hcl oral VALTREX valganciclovir hcl VALCYTE VIDEX SP VIRACEPT ORAL TALET SP VIREAD ORAL TALET SP VITEKTA SP ZIAEN ORAL SOLUTION SP zidovudine RETROVIR SP PA SP SP 28

35 Product Reference rand- eneric *Assorted Classes* AZASAN azathioprine oral IMURAN CUPRIMINE ORAL CAPSULE 250 M cyclosporine modified ENRAF cyclosporine oral capsule SANDIMMUNE ENRAF ORAL CAPSULE 100 M, 25 M, 50 M ENRAF ORAL SOLUTION mycophenolate mofetil oral capsule CELLCEPT mycophenolate mofetil oral tablet CELLCEPT mycophenolate sodium oral tablet MYFORTIC RAPAMUNE ORAL SOLUTION REVLIMID PA; SP sirolimus oral RAPAMUNE sodium polystyrene sulfonate oral suspension KIONEX sodium polystyrene sulfonate rectal suspension 30 gm/120ml tacrolimus oral PRORAF THALOMID PA; SP ZORTRESS PA; SP *eta lockers* acebutolol hcl oral atenolol oral TENORMIN betaxolol hcl oral bisoprolol fumarate ZEETA carvedilol CORE labetalol hcl oral metoprolol succinate er TOPROL XL metoprolol tartrate oral tablet 100 mg, 50 mg LOPRESSOR metoprolol tartrate oral tablet 25 mg nadolol oral tablet 20 mg, 40 mg, 80 mg CORARD pindolol propranolol hcl er INDERAL LA propranolol hcl oral solution propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80 mg sotalol hcl (af) ETAPACE AF sotalol hcl oral SORINE timolol maleate oral 29

36 Product Reference rand- eneric *Calcium Channel lockers* amlodipine besylate oral NORVASC QL (30 EA per 30 CARDIZEM LA ORAL TALET EXTENDED RELEASE 24 HOUR 120 M QL (30 EA per 30 diltiazem hcl er beads TAZTIA XT QL (30 EA per 30 diltiazem hcl er coated beads CARTIA XT QL (30 EA per 30 diltiazem hcl er oral capsule extended release 12 hour diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg diltiazem hcl oral CARDIZEM felodipine er isradipine nicardipine hcl oral nifedipine er ADALAT CC nifedipine er osmotic release PROCARDIA XL nifedipine oral PROCARDIA nimodipine oral nisoldipine er SULAR verapamil hcl er oral capsule extended release 24 hour verapamil hcl er oral tablet extended release 120 mg, 180 mg verapamil hcl er oral tablet extended release 240 mg verapamil hcl oral *Cardiotonics* digoxin oral LANOXIN ORAL TALET MC, 62.5 MC *Cardiovascular Agents - Misc.* VERALAN PM CALAN SR ISOPTIN SR ADCIRCA PA; SP amlodipine-atorvastatin CADUET LETAIRIS PA; SP sildenafil citrate oral REVATIO PA TRACLEER PA; SP TYVASO PA; SP TYVASO REFILL PA; SP TYVASO STARTER PA; SP VENTAVIS PA; SP QL (30 EA per 30 QL (60 EA per 30 QL (60 EA per 30 30

37 Product Reference rand- eneric *Cephalosporins* cefaclor er cefaclor oral capsule cefadroxil cefdinir cefditoren pivoxil cefixime SUPRAX cefpodoxime proxetil cefprozil CEFTIN ORAL SUSPENSION RECONSTITUTED cefuroxime axetil oral tablet CEFTIN cephalexin KEFLEX SUPRAX ORAL SUSPENSION RECONSTITUTED 500 M/5ML *Contraceptives* altavera alyacen 1/35 DASETTA 1/35 alyacen 7/7/7 CYCLAFEM 7/7/7 amethia amethia lo amethyst apri aranelle ashlyna aubra aviane azurette ALZIVA bekyree blisovi fe 1.5/30 blisovi fe 1/20 briellyn ILDAIA camila 31 camrese QL (91 EA per 91 camrese lo QL (91 EA per 91 caziant cesia chateal cryselle-28 cyclafem 1/35

38 Product Reference rand- eneric cyclafem 7/7/7 cyred dasetta 1/35 dasetta 7/7/7 daysee deblitane delyla DEPO-SUQ PROVERA 104 SUCUTANEOUS SUSPENSION desogestrel-ethinyl estradiol ENSKYCE drospirenone-ethinyl estradiol LORYNA elinest emoquette enpresse-28 enskyce errin estarylla falmina gianvi gildagia gildess 1.5/30 gildess 1/20 gildess fe 1.5/30 gildess fe 1/20 heather introvale jencycla 32 QL (1 ML per 90 jolessa QL (91 EA per 91 jolivette juleber junel 1.5/30 junel 1/20 junel fe 1.5/30 junel fe 1/20 junel fe 24 kaitlib fe kariva kelnor 1/35 kimidess kurvelo

39 Product Reference rand- eneric larin 1.5/30 larin 1/20 larin 24 fe larin fe 1.5/30 larin fe 1/20 layolis fe leena lessina levonest levonorgest-eth estrad 91-day LOSEASONIQUE levonorgestrel oral tablet 1.5 mg FALLACK SOLO, AFTERA, ECONTRA EZ, OPCICON ONE-STEP, REACT, TAKE ACTION levonorgestrel-ethinyl estrad FALMINA levonorg-eth estrad triphasic MYZILRA levora 0.15/30 (28) LO LOESTRIN FE lomedia 24 fe loryna low-ogestrel lutera lyza marlissa CHATEAL medroxyprogesterone acetate intramuscular DEPO-PROVERA suspension microgestin 1.5/30 microgestin 1/20 microgestin 24 fe microgestin fe 1.5/30 microgestin fe 1/20 mono-linyah mononessa my way myzilra NATAZIA necon 0.5/35 (28) necon 1/35 (28) NECON 1/50 (28) necon 10/11 (28) necon 7/7/7 next choice one dose nikki 33 QL (1 ML per 90

40 Product Reference rand- eneric nora-be norethin ace-eth estrad-fe oral tablet LISOVI FE 1/20 norethindrone acet-ethinyl est LARIN 1/20 norethindrone oral JENCYCLA norethin-eth estradiol-fe oral tablet chewable LAYOLIS FE mg-mcg norgestimate-eth estradiol oral tablet mg- MONONESSA mcg norgestim-eth estrad triphasic oral tablet ORTHO TRI-CYCLEN LO 0.18/0.215/0.25 mg-25 mcg norlyroc nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 NUVARIN ocella OESTREL orsythia philith pimtrea pirmella 1/35 pirmella 7/7/7 portia-28 previfem quasense reclipsen setlakin sharobel solia sprintec 28 sronyx syeda tarina fe 1/20 tilia fe tri-estarylla tri-legest fe tri-linyah tri-lo-estarylla tri-lo-marzia tri-lo-sprintec trinessa (28) 34

41 Product Reference rand- eneric trinessa lo tri-previfem tri-sprintec trivora (28) velivet vestura vienva viorele PIMTREA vyfemla wera wymzya fe XULANE zarah zenchent zenchent fe zovia 1/35e (28) *Corticosteroids* budesonide oral ENTOCORT EC dexamethasone oral fludrocortisone acetate oral hydrocortisone oral CORTEF methylprednisolone oral MEDROL prednisolone oral solution prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml prednisone oral solution prednisone oral tablet PEDIAPRED prednisone oral tablet therapy pack 10 mg (21), 5 mg (21) *Cough/Cold/Allergy* phenylephrine-dexbrompheniramine-dm oral liquid ALAHIST DM phenylephrine w/ dm-gg tab mg TUSICOF benzonatate oral capsule 100 mg TESSALON PERLES benzonatate oral capsule 200 mg phenylephrine w/ dm-gg liqd mg/5ml TUSSI-PRES PEDIATRIC broncho saline broncotron ped brontuss sf nr ROTAPP brotapp dm 35

42 Product Reference rand- eneric cetirizine-pseudoephedrine er ZYRTEC-D ALLERY & CONESTION coricidin hbp congestion/cough cough dm childrens oral suspension extended release ROITUSSIN 12 HOUR COUH despec dm oral syrup mg/5ml despec eda NORTUSS DE diabetic tussin dm dometuss-dmx double-tussin dm phenylephrine w/ dm-gg liqd mg/5ml fexofenadine-pseudoephed er giltuss pediatric oral liquid ALLERA D 12 HOUR, ALLERA D 24 HOUR VICKS DAYQUIL MUCUS dextromethorphan-guaifenesin liquid mg/15 CONTROL DM ml guaifenesin dac guaifenesin dm TA TUSSIN DM guaifenesin oral solution 300 mg/15ml DIAETIC TUSSIN guaifenesin-codeine oral solution guaifenesin-dm oral syrup hydrocodone-homatropine HYPERSAL INHALATION NEULIZATION SOLUTION 3.5 % phenylephrine-guaifenesin syrup mg/5ml J MAX guaifenesin liquid 200 mg/5ml LIQUITUSS lohist-d loratadine-d 12hr CLARITIN D-12HR loratadine-d 24hr CLARITIN-D 24 Hour medi-tussin dm double strength mucus d oral tablet extended release 12 hour mg mucus relief d oral tablet extended release 12 hour mg mucus relief dm max oral liquid mg/20ml mucus relief er oral tablet extended release 12 hour 600 mg mucus relief multi symptom MUCINEX D MUCINEX D MUCINEX FAST-MAX DM MAX MUCINEX MUCINEX FAST-MAX CONEST COUH 36

43 Product Reference rand- eneric mucus-dm MUCINEX DM mucus-dm max NEUSAL INHALATION NEULIZATION SOLUTION 6 % nohist-dm MUCINEX DM MAXIMUM STRENTH pedia relief cough/cold promethazine vc promethazine vc/codeine promethazine-codeine promethazine-dm pseudoeph-bromphen-dm oral syrup ROMFED DM pseudoephedrine-dm-gg oral liquid pseudoephedine-dm-gg tab mg NIVANEX DMX relcof c sodium chloride inhalation nebulization solution 0.9 %, 10 % sodium chloride inhalation nebulization solution 3 % sodium chloride inhalation nebulization solution 7 % NEUSAL PULMOSAL sudogest sinus/allergy TRIOFEN DM trymine cg MAR-COF C EXPECTORANT tussin cf max multi-symptom tussin chest congestion DIAETIC TUSSIN EX tussin dm max adult DIAETIC TUSSIN MAX ST tussin dm oral syrup tusslin pediatric *Cystic Fibrosis Agent Combinations*** ORKAMI ORAL TALET M PA; SP *Dermatologicals* AREVA absorica oral capsule 10 mg, 20 mg, 30 mg, 40 mg acne maximum strength external pad STRI-DEX MAXIMUM STRENTH acne treatment external bar acyclovir ointment 5% external ZOVIRAX QL (15 M per 30 adapalene external cream DIFFERIN adapalene external gel DIFFERIN alclometasone dipropionate ACLOVATE 37

44 Product Reference rand- eneric amcinonide ammonium lactate external ERI-HYDROLAC 12 antibiotic plus pain relief anti-dandruff NEOSPORIN PLUS PAIN RELIEF MS SELSUN LUE MOISTURIZIN aqua care external lotion athletes foot external powder 2 % LOTRIMIN AF athletes foot spray external aerosol TINACTIN bacitracin external ACIUENT bacitracin zinc external bedding spray lice treatment (permethrin aerosol LICIDE 0.5%) benzoyl peroxide cleanser external lotion 6 % OSCION CLEANSER benzoyl peroxide external foam ENZEPRO benzoyl peroxide external gel 10 % CLEAN & CLEAR PPERSA-EL MAX ST benzoyl peroxide external gel 5 % CLEARPLEX V benzoyl peroxide wash external liquid 10 % PANOXYL WASH benzoyl peroxide wash external liquid 5 % ENZAC AC WASH benzoyl peroxide-erythromycin ENZAMYCIN beta care betamide coal tar shampoo 2.5% ETARTAR EL 38 betamethasone dipropionate aug external cream DIPROLENE AF betamethasone dipropionate aug external gel QL (50 M per 30 betamethasone dipropionate aug external lotion betamethasone dipropionate aug external ointment betamethasone dipropionate external betamethasone valerate external cream betamethasone valerate external lotion betamethasone valerate external ointment DIPROLENE DIPROLENE bp 10-1 CERISA WASH bp cleansing wash bp wash external liquid 2.5 % PANOXYL bp wash external liquid 7 % PR ENZOYL PEROXIDE WASH bpo creamy wash bpo external gel 4 % bpo foaming cloths external 6 % ENZEPRO FOAMIN CLOTHS calcipotriene external DOVONEX calcitriol external VECTICAL QL (50 M per 30

45 Product Reference rand- eneric CENTANY AT ciclopirox external solution CICLODAN ciclopirox olamine external CICLODAN clean & clear advantage acne external lotion CLEAN & CLEAR LACKHEAD ERASER EXTERNAL CREAM CLEAN & CLEAR OIL ASORIN EXTERNAL CREAM clindamycin phosphate external CLEOCIN-T clobetasol propionate e TEMOVATE E clobetasol propionate emulsion OLUX-E fluocinolone acetonide body DERMA-SMOOTHE/FS ODY 39 clobetasol propionate external cream TEMOVATE QL (60 M per 30 clobetasol propionate external foam OLUX QL (100 ML per 30 clobetasol propionate external gel TEMOVATE QL (60 M per 30 clobetasol propionate external lotion CLOEX QL (118 ML per 30 clobetasol propionate external ointment TEMOVATE QL (60 M per 30 clobetasol propionate external shampoo CLODAN clobetasol propionate external solution CORMAX SCALP APPLICATION clotrimazole af DESENEX clotrimazole external solution FUNICURE INTENSIVE/NAILUARD clotrimazole-betamethasone LOTRISONE CNL8 NAIL complete lice treatment RID COMPLETE LICE ELIMINATION corn remover one-step COMPOUND W ONE STEP INVISILE corn/callus remover external solution 12.6 % hydrocortisone external gel 1% CORTICOOL benzoyl peroxide cream 2.5% NEUTROENA ON-THE- SPOT desenex spray external aerosol desonide external DESOWEN diclofenac sodium transdermal gel 1 % VOLTAREN PA double antibiotic POLYSPORIN DRYSOL ELIDEL PA; QL (30 M per 30 elta tar external cream erythromycin external ERYEL EURAX PA first aid antibiotic external ointment 4 % PROCOMYCIN

46 Product Reference rand- eneric fluocinolone acetonide external fluocinolone acetonide scalp DERMA-SMOOTHE/FS SCALP fluocinonide external cream 40 fluocinonide external gel QL (60 M per 30 fluocinonide external ointment QL (60 M per 30 fluocinonide external solution fluocinonide-e FLUOROPLEX fluorouracil external cream 5 % EFUDEX fluorouracil external solution fluticasone propionate external CUTIVATE gentamicin sulfate external lactic acid (ammonium lactate) lotion zinc oxide cream HALAC COTTONTAILS DIAPER RASH CREAMY halobetasol propionate ULTRAVATE hydrocortisone acetate external cream LANACORT 10 hydrocortisone butyrate external LOCOID hydrocortisone external cream 0.5 % hydrocortisone external cream 1 % hydrocortisone external cream 2.5 % AVEENO ANTI-ITCH MAX ST hydrocortisone external lotion 1 % HYDROSKIN hydrocortisone external lotion 2.5 % hydrocortisone external ointment 0.5 % hydrocortisone external ointment 1 % CORTIZONE-10 hydrocortisone external ointment 2.5 % hydrocortisone valerate hydrocortisone-iodoquinol external cream 1-1 % DERMAZENE hydrophor AQUAPHOR imiquimod external ALDARA invisible acne max st CLEARSKIN KERALYT EXTERNAL EL 3 %, 5 % KERALYT 5 SHAMPOO 5 % KERALYT SCALP ketoconazole external cream ketoconazole external shampoo NIZORAL lactic acid external lotion LATRIX XM lice treatment external lotion

47 Product Reference rand- eneric lidocaine external cream LIDOCREAM lidocaine external ointment 41 PA; QL (50 M per 30 lidocaine external patch 5 % LIDODERM QL (60 EA per 30 lidocaine hcl external gel 2 % REENECARE HA lidocaine hcl external solution XYLOCAINE lidocaine-prilocaine external cream lindane external shampoo liquid corn & callus remover ETS-IT CORN/CALLUS REMOVER malathion external OVIDE metronidazole external cream ROSADAN metronidazole external gel 0.75 % ROSADAN metronidazole external lotion METROLOTION M217 PSORIASIS MULTI-SYMPTOM EXTERNAL CREAM M217 PSORIASIS MULTI-SYMPTOM EXTERNAL OINTMENT 2 % miconazole nitrate external CRUEX PRESCRIPTION STRENTH mometasone furoate external ELOCON mupirocin calcium ACTROAN mupirocin external CENTANY myorisan neutrogena clear pore external liquid nit remover gel LICEOUT nystatin external OC8 EXTERNAL EL 7 % coal tar shampoo 1% IONIL-T permethrin external cream ELIMITE permethrin crème rinse 1% NIX CREAM RINSE permethrin spray & pyrethins-piperonyl butoxide shampoo kit podofilox external CONDYLOX PRAMOSONE EXTERNAL CREAM 1-1 % prednicarbate DERMATOP pyrethrins-piperonyl butoxide liq % LICIDE acne cleanser oil-free NEUTROENA OIL-FREE ACNE WASH scalp itch/dandruff relief SCALPICIN RID ESSENTIAL LICE ELIMINATION salactic film solution 17% salicylic acid pad 40% MEDIPLAST salicylic acid external cream SALACYN

48 Product Reference rand- eneric salicylic acid external foam SALVAX salicylic acid gel 2% salicylic acid external gel KERALYT salicylic acid external liquid 26 % salicylic acid external lotion SALACYN salicylic acid external shampoo SALEX salicylic acid wart remover VIRASAL salicylic acid-cleanser SALEX scalacort ALA SCALP scalp relief maximum strength NOLE FORMULA HC selenium sulfide external lotion selenium sulf-pyrithione-urea silver sulfadiazine external SILVADENE SKLICE PA spinosad NATROA sss 10-5 external foam sulfacetamide sodium (acne) KLARON sulfacetamide sodium external liquid OVACE PLUS WASH sulfacetamide sodium-sulfur external cream 10-2 % sulfacetamide sodium-sulfur external cream 10-5 % AVAR-E LS AVAR-E EMOLLIENT sulfacetamide sodium-sulfur external emulsion AVAR CLEANSER sulfacetamide sodium-sulfur external liquid 10-2 % sulfacetamide sodium-sulfur external liquid 9-4 % sulfacetamide sodium-sulfur external liquid % sulfacetamide sodium-sulfur external lotion 10-5 % sulfacetamide sodium-sulfur external pad 10-4% sulfacetamide sodium-sulfur external suspension 8-4 % sulfacetamide-sulfur in urea external emulsion SULFACETAMIDE-SULFUR IN UREA EXTERNAL EL tacrolimus external TAZORAC gel, 0.05% cream AVAR LS CLEANSER SUMAXIN WASH SUMADAN WASH SUMAXIN SULFACLEANSE 8/4 PROTOPIC tetterine therapeutic external DHS TAR EL tolnaftate external LIS-TO-SOL tretinoin external RETIN-A 42 PA; QL (30 M per 30

49 Product Reference rand- eneric triamcinolone acetonide external cream triamcinolone acetonide external lotion triamcinolone acetonide external ointment triple antibiotic external ointment LANAIOTIC triple antibiotic plus umecta mousse urea external cream 10 % urea external cream 20 % NEOSPORIN + PAIN RELIEF MAX ST ATRAC-TAIN CARMOL ; QL (85 M per 30 ; QL (85 M per 30 urea external cream 45 % URAMAXIN QL (85 M per 30 urea external cream 50 % urea external emulsion REMEVEN urea external gel CEROVEL urea external lotion 40 % CEROVEL urea external lotion 45 % URAMAXIN urea external suspension 50 % LATRIX urea nail external gel 45 % URAMAXIN urea nail film UMECTA NAIL FILM wart remover maximum strength external gel *Diagnostic Products* ACCU-CHEK TEST ACTIVE ACCU-CHEK TEST AVIVA, AVIVA PLUS ACCU-CHEK TEST UIDE ACCU-CHEK TEST SMART FREESTYLE LITE TEST COMPOUND W MAXIMUM STRENTH QL (142 M per 30 QL (#500/90 days for members on insulin; #200/90 days for members not on insulin); QL (#500/90 days for members on insulin; #200/90 days for members not on insulin); QL (#500/90 days for members on insulin; #200/90 days for members not on insulin); QL (#500/90 days for members on insulin; #200/90 days for members not on insulin); QL (#500/90 days for members on insulin; #200/90 days for members not on insulin);

50 Product Reference rand- eneric 44 FREESTYLE TEST QL (#500/90 days for members on insulin; #200/90 days for members not on insulin); KETO-DIASTIX KETONE TEST CHEK-STIX CONTROL PRECISION XTRA LOOD LUCOSE QL (#500/90 days for members on insulin; #200/90 days for members not on insulin); *Digestive Aids* CREON rand Only PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 2600 UNIT rand Only pancrelipase (lip-prot-amyl) ZENPEP SUCRAID ZENPEP ORAL CAPSULE DELAYED rand Only RELEASE PARTICLES UNIT, UNIT, UNIT, UNIT, 3000 UNIT, UNIT ZENPEP CAPSULE DR 5000 UNIT *Direct-Acting P2y12 Inhibitors*** RILINTA ORAL TALET 60 M RILINTA ORAL TALET 90M *Diuretics* acetazolamide er DIAMOX SEQULES acetazolamide oral amiloride hcl oral amiloride-hydrochlorothiazide bumetanide oral UMEX chlorothiazide oral chlorthalidone oral tablet 25 mg, 50 mg furosemide oral solution 10 mg/ml, 8 mg/ml furosemide oral tablet LASIX hydrochlorothiazide oral tablet 25 mg, 50 mg indapamide oral methazolamide oral NEPTAZANE methyclothiazide oral metolazone spironolactone oral ALDACTONE spironolactone-hctz ALDACTAZIDE torsemide oral DEMADEX triamterene-hctz oral capsule mg DYAZIDE triamterene-hctz oral tablet MAXZIDE-25 QL 60mg & 90mg 60 per 30 days; 90mg 365 day MAX

51 Product Reference rand- eneric *Endocrine And Metabolic Agents Misc.* alendronate sodium oral tablet 10 mg, 40 mg, 5 mg 45 QL (30 EA per 30 alendronate sodium oral tablet 35 mg QL (4 EA per 28 alendronate sodium oral tablet 70 mg FOSAMAX QL (4 EA per 28 cabergoline calcitonin (salmon) MIACALCIN calcitriol oral capsule ROCALTROL QL (30 EA per 30 calcitriol oral solution ROCALTROL desmopressin ace rhinal tube DDAVP RHINAL TUE PA desmopressin ace spray refrig PA desmopressin acetate oral DDAVP desmopressin acetate spray DDAVP PA doxercalciferol oral HECTOROL FORTEO SUCUTANEOUS SOLUTION 600 MC/2.4ML PA; SP ENOTROPIN PA; SP ENOTROPIN MINIQUICK PA; SP ibandronate sodium oral ONIVA INCRELEX PA levocarnitine oral solution CARNITOR SF levocarnitine oral tablet CARNITOR LUPRON DEPOT-PED PA; SP MIACALCIN INJECTION NORDITROPIN FLEXPRO PA; SP raloxifene hcl EVISTA SENSIPAR PA; SP SINIFOR *Estrogens* CLIMARA PRO estradiol oral ESTRACE estradiol transdermal VIVELLE-DOT estradiol-norethindrone acet MIMVEY LO estropipate oral MENEST MINIVELLE norethindrone-eth estradiol FEMHRT LOW DOSE PREFEST PREMARIN ORAL PREMPRO PA; SP; QL (60 ML per 30

52 Product Reference rand- eneric *Fluoroquinolones* ciprofloxacin hcl oral levofloxacin oral ofloxacin oral tablet 400 mg *astrointestinal Agents - Misc.* AMITIZA PA APRISO ASACOL HD balsalazide disodium COLAZAL calcium acetate (phos binder) ELIPHOS CANASA cromolyn sodium oral ASTROCROM DELZICOL DIPENTUM lanthanum carbonate oral tablet chewable 1000 M, 500 M, 750 M FOSRENOL FOSRENOL POWDER 750 M, 1000 M PA PA gas relief oral liquid AS-X INFANT DROPS infants simethicone oral suspension 20 mg/0.3ml lactulose encephalopathy MYLICON INFANTS AS RELIEF LINZESS ORAL CAPSULE 145 MC, 290 MC mesalamine oral ASACOL HD, LIALDA mesalamine rectal metoclopramide hcl oral solution 5 mg/5ml metoclopramide hcl oral tablet RELAN PENTASA RENAEL sevelamer carbonate RENVELA simethicone oral capsule AS-X EXTRA STRENTH simethicone oral tablet chewable AS-X sulfasalazine oral AZULFADINE EN-TAS ursodiol oral ACTIALL *enitourinary Agents Miscellaneous* citric acid-sodium citrate SHOHLS MODIFIED dutasteride AVODART PA ELMIRON finasteride oral tablet 5 mg PROSCAR phenazopyridine hcl oral tablet 100 mg, 200 PYRIDIUM mg 46 PA

53 Product Reference rand- eneric phenazopyridine hcl oral tablet 95 mg AZO URINARY PAIN RELIEF potassium citrate er UROCIT-K 10 tamsulosin hcl FLOMAX urinary pain relief max st 97.5 mg AZO URINARY PAIN RELIEF *out Agents* allopurinol oral ZYLOPRIM colchicine oral tablet, capsule COLCRYS, MITIARE colchicine-probenecid probenecid oral ULORIC *Hematological Agents - Misc.* anagrelide hcl ARYLIN RILINTA ORAL TALET 90 M cilostazol clopidogrel bisulfate oral PLAVIX dipyridamole oral pentoxifylline er *Hematopoietic Agents* ARANESP (ALUMIN FREE) INJECTION SOLUTION 10 MC/0.4ML, 100 MC/ML, 200 MC/ML, 25 MC/ML, 300 MC/ML, 40 PA; SP MC/ML, 60 MC/ML ARANESP (ALUMIN FREE) INJECTION SOLUTION PREFILLED SYRINE 100 MC/0.5ML, 150 MC/0.3ML, 200 MC/0.4ML, 25 MC/0.42ML, 300 PA; SP MC/0.6ML, 40 MC/0.4ML, 500 MC/ML, 60 MC/0.3ML b-12 oral tablet 2000 mcg, 2500 mcg cyanocobalamin injection FA-8 ORAL CAPSULE fa-vitamin b-6-vitamin b-12 ferrogels forte ferrous gluconate oral tablet 240 (27 fe) mg FERON ferrous gluconate oral tablet 324 (37.5 fe) mg, 325 (36 fe) mg ferrous sulfate granules ferrous sulfate oral elixir FEROSUL ferrous sulfate oral tablet 27 mg, 325 (65 fe) mg ferrous sulfate oral tablet delayed release 325 (65 fe) mg FOLIC ACID ORAL CAPSULE 20 M, 5 M folic acid oral tablet 1 mg folic acid oral tablet 400 mcg 47

54 Product Reference rand- eneric folic acid oral tablet 800 mcg FA-8 folitab 500 FOLTAS 800 iron oral tablet 200 (65 fe) mg FEOSUL high potency iron oral tablet iron 100 plus ICAR-C PLUS iron oral tablet extended release 142 (45 fe) SLOW FE mg iron supplement childrens FER-IN-SOL K-TAN PLUS LEUKINE INTRAVENOUS PA; SP NEULASTA ONPRO PA; SP NEULASTA SUCUTANEOUS SOLUTION PREFILLED SYRINE PA; SP NEUPOEN INJECTION SOLUTION 300 MC/ML, 480 MC/1.6ML PA; SP, rand Only NEUPOEN INJECTION SOLUTION PREFILLED SYRINE PA; SP, rand Only poly-iron 150 forte IFEREX 150 FORTE EPOETIN ALFA SOLUTION EPOEN/PROCRIT PA; SP PROMACTA PA; SP slow release iron oral tablet extended release 45, 47.5 mg, 50 mg VIRT-ARD virt-vite NUFOL vitamin b-12 oral tablet *Hemostatics* AMICAR ORAL TALET tranexamic acid oral LYSTEDA *Hepatitis C Agent Combinations*** MAVYRET PA; SP *Hypnotics* diphenhydramine hcl (sleep) oral tablet 50 mg NYTOL MAXIMUM STRENTH diphenhydramine hcl (sleep) oral cap 25 mg diphenhydramine hcl (sleep) oral liquid 50 mg/30 ml EDLUAR (zolpidem) PA estazolam PA Required for <6years of age; QL (30 EA per 30 eszopiclone LUNESTA PA Required for <6 years of age; QL (30 EA per 30 flurazepam hcl PA Required for <6 years of age; QL (30 EA per 30 INTERMEZZO SL PA phenobarbital oral 48

55 Product Reference rand- eneric meprobamate PA Required for <6 years of age; QL (30 per 30 sleep aid oral liquid ZZZQUIL ROZEREM PA SILENOR PA sleep aid (diphenhydramine) NYTOL sleep-aid maximum strength UNISON SLEEPELS temazepam oral capsule 15 mg, 30 mg RESTORIL PA Required for <6 years of age; QL (30 EA per 30 triazolam oral tablet HALCION PA Required for <6 years of age; QL (30 EA for 30 zaleplon SONATA PA Required for <6years of age; QL (30 EA per 30 zolpidem tartrate oral tablet 5mg, 10 mg AMIEN PA Required for <6 years of age; QL (5mg= 60 per 60 days, 10mg = 30 EA per 30 zolpidem SL INTERMEZZO SL PA Required for <6years of age; zolpidem tartrate er AMIEN CR PA ZOLPIMIST PA *Laxatives* bisacodyl ec FLEET LAXATIVE bisacodyl rectal THE MAIC ULLET chocolated laxative EX-LAX cvs natural fiber supplement oral packet diocto oral syrup docusate calcium SURFAK docusate sodium oral capsule PHILLIPS STOOL SOFTENER docusate sodium oral liquid 50 mg/5ml docusate sodium oral tablet DOK docusol mini enema rectal enema 7-19 gm/118ml FLEET PEDIATRIC epsom salt oral fiber laxative oral capsule MEDI-MUCIL gavilyte-c gavilyte-g gavilyte-n with flavor pack geri-mucil REULOID HYDROCIL ORAL PACKET KONSYL ORAL PACKET 100 %, 60.3 % 49

56 Product Reference rand- eneric KONSYL ORAL POWDER 60.3 %, % psyllium powder 28.3%, 30.9% lactulose oral solution 10 gm/15ml laxative pills oral tablet 15 mg EX-LAX magnesium citrate oral solution gm/30ml CITROMA METAMUCIL MULTIHEALTH FIER ORAL PACKET METAMUCIL MULTIHEALTH FIER ORAL POWDER % METAMUCIL ORAL WAFER milk of magnesia oral suspension 400 mg/5ml PHILLIPS MILKE OF MANESIA natural fiber laxative oral powder 28.3 % REULOID natural fiber laxative oral powder 30.9 % KONSYL natural fiber laxative oral powder % METAMUCIL natural fiber oral powder 58.6 % METAMUCIL SMOOTH TEXTURE natural psyllium seed KONSYL natural senna laxative oral tablet mg OSMOPREP peg 3350/electrolytes COLYTE WITH FLAVOR PACKS peg 3350-kcl-na bicarb-nacl NULYTELY WITH FLAVOR PACKS peg-3350/electrolytes OLYTELY phosphate laxative oral solution gm/5ml polyethylene glycol 3350 oral LYCOLAX qc natural vegetable HYDROCIL sennosides 17.2 mg tab SENOKOT EXTRA STRENTH psyllium powder 49% senna laxative SENOKOT senna oral capsule senna oral syrup 8.8 mg/5ml senna s SENOKOT S trilyte *Leptin Analogues*** MYALEPT PA *Macrolides* azithromycin oral packet ZITHROMAX azithromycin oral suspension reconstituted ZITHROMAX azithromycin oral tablet 250 mg, 500 mg, 600 mg ZITHROMAX clarithromycin er IAXIN XL PAC clarithromycin oral 50

57 Product Reference rand- eneric DIFICID PA erythromycin ethylsuccinate for suspension ERYPED *Medical Devices* ALCOHOL PREP PAD 70 % RELION ALCOHOL SWAS D AUTOSHIELD DUO D INSULIN SYRINE 25 X 1" 1 ML, 25 X 5/8" 1 ML, 26 X 1/2" 1 ML D INSULIN SYRINE 27 X 1/2" 1 ML D INSULIN SYRINE MICROFINE 27 X 5/8" 1 ML, 28 X 1/2" 0.3 ML D INSULIN SYRINE MICROFINE 28 X 1/2" 1 ML D INSULIN SYRINE ULTRAFINE 29 X 1/2" 1 ML D INSULIN SYRINE ULTRAFINE 31 X 15/64" 0.3 ML, 31 X 15/64" 0.5 ML, 31 X 15/64" 1 ML CAYA CONDOMS LIFESTYLES RIED E-Z SPACER FC2 FEMALE CONDOM FREESTYLE CONTROL SOLUTION FREESTYLE FREEDOM FREESTYLE FREEDOM LITE FREESTYLE INSULINX SYSTEM FREESTYLE LITE FREESTYLE SYSTEM INSULIN SYRINE 29 X 1/2" 0.3 ML SURE-JECT INSULIN SYRINE INSULIN SYRINE 29 X 1/2" 0.5 ML, 29 X D INSULIN SYRINE 1/2" 1 ML ULTRAFINE INSULIN SYRINE 30 X 1/2" 0.5 ML D INSULIN SYRINE INSULIN SYRINE 30 X 5/16" 0.3 ML, 30 X 5/16" 0.5 ML INSULIN SYRINE 30 X 5/16" 1 ML INSULIN SYRINE 31 X 5/16" 0.3 ML INSULIN SYRINE 31 X 5/16" 0.5 ML INSULIN SYRINE 31 X 5/16" 1 ML INSULIN SYRINE/NEEDLE 27 X 1/2" 0.5 ML INSULIN SYRINE/NEEDLE 28 X 1/2" 0.5 ML LANCETS MONOJECT INSULIN SYRINE COMFORT ASSIST INSULIN SYRINE LITETOUCH INSULIN SYRINE FIFTY50 SUPERIOR COMFORT SYR ULTILET INSULIN SYRINE SHORT EASY TOUCH INSULIN SYRINE ULTICARE INSULIN SYRINE EZ SMART LOOD LUCOSE LANCETS 51

58 Product Reference rand- eneric OMNIFLEX DIAPHRAM ORTHO DIAPHRAM COIL ORTHO DIAPHRAM FLAT PRECISION LUCOSE CONTROL PRECISION QID MONITOR PRECISION SURE-DOSE SYRINE 30 X 3/8" 0.5 ML PRECISION XTRA KIT REALITY LATEX/ULTRA THIN RELI-ON INSULIN SYRINE ML, ML relion insulin syringe 29g x 1/2" 1 ml relion insulin syringe 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 1 ml SURE COMFORT INSULIN SYRINE 30 X 1/2" 0.3 ML TRUEPLUS INSULIN SYRINE 30 X 5/16" 0.5 ML LUCOPRO INSULIN SYRINE TRUSTEX RIA NON-LURICATED ULTICARE INSULIN SYRINE 30 X 1/2" 1 ML WIDE-SEAL DIAPHRAM *Migraine Products* ALSUMA SUCUTANEOUS SOLUTION AUTO-INJECTOR 52 QL (2 ML per 30 CAFEROT MIEROT rizatriptan benzoate MAXALT QL (9 EA per 30 sumatriptan nasal IMITRAX QL (6 EA per 30 sumatriptan succinate oral IMITRAX QL (9 EA per 30 sumatriptan succinate refill subcutaneous solution cartridge sumatriptan succinate subcutaneous solution 6 mg/0.5ml sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml IMITREX STATDOSE REFILL IMITREX IMITREX STATDOSE SYSTEM *Minerals & Electrolytes* calcium d3 oral tablet OS-CAL EXTRA D3 calcium minerals calcium 600 oral tablet 600 mg HIH POTENCY CALCIUM calcium 600+d high potency calcium 600+d plus minerals oral tablet QL (2 ML per 30 QL (2 ML per 30 QL (2 ML per 30 QL (1 ML per 30

59 Product Reference rand- eneric calcium 600+d3 oral tablet mg-unit calcium 600+d3 plus minerals oral tablet CALTRATE 600+D PLUS MINERALS calcium carbonate oral suspension calcium carbonate oral tablet 1250 (500 ca) mg CAL-CAR FORTE calcium carbonate oral tablet 1500 (600 ca) mg CALTRATE 600 calcium carbonate oral tablet 600 mg HIH POTENSY CALCIUM calcium carbonate-vitamin d oral capsule calcium carbonate-cholecalciferol tab calcium carbonate-vitamin d3 calcium oral tablet 600 mg calcium oral tablet chewable 500 mg calcium oyster shell oral tablet 1250 (500 ca) mg calcium plus vitamin d3 oral tablet calcium-vitamin d oral tablet mg-unit, mg-unit effervescent pot chloride CAL-CAR FORTE PRONUTRIENTS CALCIUM+D3 ELITE CALCIUM fluor-a-day oral solution KLOR-CON ORAL PACKET 25 MEQ k-tab oral tablet extended release 20 meq MA-200 magnesium oral capsule 500 mg magnesium oxide -mg supplement oral tablet magnesium oxide oral tablet 400 (240 mg) mg, 500 mg magnesium oxide oral tablet 400 (241.3 mg) mg MANESIUM-OXIDE oyster shell calcium + d3 OYSTERCAL-D oyster shell calcium 250+d oyster shell calcium plus d oral tablet mg-unit oyster shell calcium plus d oral tablet mg-unit 53 OYSCO 500+D oyster-cal 500 pediatric electrolyte oral solution PEDIALYTE FREEZER POPS potassium bicarbonate oral KLOR-CON/EF potassium chloride crys er KLOR-CON M10 potassium chloride er KLOR-CON SPRINKLE potassium chloride oral packet KLOR-CON

60 Product Reference rand- eneric potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) sodium fluoride oral solution LURIDE sodium fluoride oral tablet chewable LUDENT *Mouth/Throat/Dental Agents* IOTENE MOISTURIZIN MOUTH cevimeline hcl EVOXAC chlorhexidine gluconate mouth/throat PAROEX clinpro 5000 clotrimazole mouth/throat troche sodium fluoride cream 1.1% DENTA 5000 PLUS sodium fluoride gel 1.1% (0.5% f) DENTAEL fluoride mouth rinse LISTERINE RESTORIN stannous fluoride gel 0.4% EL-TIN LIDOCAINE HCL MOUTH/THROAT lidocaine viscous neutral sodium fluoride PREVIDENT nystatin mouth/throat stannous fluoride conc 0.63% PERIOMED pilocarpine hcl oral SALAEN carbamide peroxide CANKAID sodium fluoride rinse FLUORIARD triamcinolone acetonide mouth/throat ORALONE *Multivitamins* adult one daily gummies MVW COMPLETE FORMULATION ANTIOXIDANT FORMULA S b complex vitamins oral b-complex high potency oral tablet extended release b-complex/b-12 sublingual b-complex w/ C & folic acid cap 1 mg RENO CAP centavite FORTAVIT CENTRUM SPECIALIST PRENATAL childrens chewable multi vits ONE-A-DAY VITACRAVES+OMEA-3 childrens multivitamin oral tablet chewable 60 FLINSTONES COMPLETE mg childrens multivitamin/iron FLINSTONES PLUS IRON corvita daily multiple vitamins THERA/ETA-CAROTENE mens 50+ advanced ANTIOXIN 4000 multi vitamin/fluoride oral tablet chewable 0.25 mg MVC-FLUORIDE 54

61 Product Reference rand- eneric multi-delyn PediaVit multiple vitamins/fluoride MVC-FLUORIDE multi-vit/fluoride oral solution 0.5 mg/ml QUFLORA PEDIATRIC multivitamin gummies childrens FLINSTONES UMMIES PLUS multi-vitamin/fluoride oral solution 0.25 mg/ml QUFLORA PEDIATRIC multi-vitamin/fluoride/iron multi-vitamin/minerals YELETS TEENAE FORMULA multivitamins pediatric VITAMAX PEDIATRIC multivitamins plus zinc ANTIOXIN 4000 mult-vitamin/fluoride MVC-FLUORIDE MYNATAL-Z VITAFOL-O O-CAL PRENATAL PNV TAS 29-1 PRENATAS RX poly-vita POLY-VI-SOL polyvitamin/fluoride oral solution 0.25 mg/ml QUFLORA PEDIATRIC poly-vitamin/fluoride oral solution 0.5 mg/ml QUFLORA PEDIATRIC poly-vitamin/iron PRENATA PROTECTED PEDIA POLY- VITE/FE PRENATAS FA ORAL TALET CO-NATAL FA PRENATAL 19 ORAL TALET 29-1 M PRENATAL 19 ORAL TALET CHEWALE 29-1 M PRENATAL COMPLETE PRENATAL LOW IRON ORAL TALET M PRENATAL MULTI +DHA ORAL CAPSULE M RIHT STEP PRENATAL PRENATAL MULTIVITAMIN + DHA PRENATAL ORAL TALET M PRENATAL PLUS IRON PRENATAS RX PRENATAL PLUS/IRON M-VIT PRENATAL+DHA ORAL & 200 M PRENATAL-U PREQUE 10 ORAL TALET M PRETA CO-NATAL FA rena-vite RENAL MULTIVITAMIN FORMULA rena-vite rx DIALYVITE SIMILAC PRENATAL EARLY SHIELD 55

62 Product Reference rand- eneric SM ONE DAILY PRENATAL ONE-A-DAY WOMENS PRENATAL stress formula/zinc super b-complex/vit c/fa MILCO--FORTE superior 35 ULTRA MEA TRIADVANCE INATAL T TRINATE tri-vit/fluoride tri-vit/fluoride/iron tri-vitamin TRI-VITA ultra-mega ULTRA MEA VIRT NATE TRINATE VIRT-ADVANCE INATAL T VIRT-C DHA TARON-C DHA virt-caps RENAL virt-vite plus vitamin b complex oral tablet vitamin c-electrolytes MAXIMIN PAC vitamin e/folic acid/b-6/b-12 ZE-PLUS vita-rx diabetic vitamin CAROZYME *Musculoskeletal Therapy Agents* baclofen oral chlorzoxazone oral tablet 500 mg PARAFON FORTE DSC cyclobenzaprine hcl oral tablet 10 mg, 5 mg dantrolene sodium oral methocarbamol oral ROAXIN tizanidine hcl oral tablet *Nasal Agents - Systemic And Topical* azelastine hcl nasal solution 0.1 % QL (30 ML per 30 budesonide nasal RHINOCORT AQUA QL (9 M per 30 pseudoephedrine hcl liquid SUDAFED CHILDRENS NASALCROM ; QL (13 ML per 30 cromolyn sodium nasal flunisolide nasal solution 25 mcg/act (0.025%) QL (50 ML per 30 fluticasone propionate nasal FLONASE ALLERY QL (16 M per 30 RELIEF ipratropium bromide nasal NASACORT ALLERY 24HR ; QL (17 ML per 30 nasal allergy 24 hour NASACORT ALLERY 24HR nasal decongestant spray AFRIN NODRIP ORIINAL nexafed oral tablet abuse-deterrent 56

63 Product Reference rand- eneric pseudoephedrine hcl er SUDAFED pseudoephedrine hcl oral tablet SUDAFED 57 saline mist spray HUMIST triamcinolone acetonide nasal aerosol NASACORT ALLERY 24HR QL (17 M per 30 *Neprilysin Inhib (ARNI)-Angiotensin II Recept Antag Comb*** ENTRESTO PA *Neurogenic Orthostatic Hypotension (NOH) - Agents*** NORTHERA PA; SP *Neuromuscular Agents* riluzole RILUTEK *Nutrients* fish oil extra strength oral capsule 435 mg fish oil oral capsule 645 mg omega-3 fish oil oral capsule 1200 mg THERARAN-M FISH OIL CONC omega-3 fish oil oral capsule 300 mg FISH OIL PEARLS omega-3 fish oil oral capsule 500 mg SUPER OMEA 3 *Ophthalmic Agents* ALPHAAN P OPHTHALMIC SOLUTION 0.1 % apraclonidine hcl IOPIDINE TEARS AAIN ADVANCED artificial tears ophthalmic solution % EYELID artificial tears ophthalmic solution % VISINE TEARS artificial tears ophthalmic solution 1.4 % artificial tears ophthalmic solution % MOISTURE EYES artificial tears ophthalmic solution 5-6 mg/ml MURINE TEARS FOR DRY EYES atropine sulfate ophthalmic azelastine hcl ophthalmic AZOPT PA bacitracin ophthalmic QL (3.5 M per 7 bacitracin-polymyxin b ophthalmic ointment unit/gm POLYCIN bacitra-neomycin-polymyxin-hc NEO-POLYCIN HC betaxolol hcl ophthalmic ETOPTIC-S LEPHAMIDE LEPHAMIDE S.O.P. brimonidine tartrate ophthalmic ALPHAAN P carteolol hcl

64 Product Reference rand- eneric ciprofloxacin hcl ophthalmic CILOXAN COSOPT PF PA cromolyn sodium ophthalmic lubricant drops ophthalmic gel ENTEAL cyclopentolate hcl ophthalmic CYCLOYL dexamethasone sodium phosphate ophthalmic diclofenac sodium ophthalmic dorzolamide hcl TRUSOPT dorzolamide hcl-timolol mal COSOPT epinastine hcl ELESTAT erythromycin ophthalmic eye allergy relief NAPHCON-A fluorometholone ophthalmic FML LIQUIFILM flurbiprofen sodium OCUFEN gentamicin sulfate ophthalmic ENTEAL MILD ONIOVISC OPHTHALMIC SOLUTION 2 % homatropine hbr ophthalmic HOMTROPAIRE ISOPTO TEARS ketorolac tromethamine ophthalmic ketotifen fumarate ophthalmic ALAWAY latanoprost ophthalmic XALATAN levobunolol hcl ophthalmic solution 0.5 % ETAAN levofloxacin ophthalmic lubricant eye HYPOTEARS lubricant eye drops SYSTANE lubricant eye fast acting RETAINE PM lubricating eye drops ophthalmic solution % metipranolol REFRESH OPTIVE NATACYN neomycin-bacitracin zn-polymyx NEO-POLYCIN neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension 0.1 % neomycin-polymyxin-gramicidin ophthalmic solution neomycin-polymyxin-hc ophthalmic suspension NEVANAC MAXITROL MAXITROL NEOSPORIN 58 PA; QL (3 ML per 30

65 Product Reference rand- eneric NUTRATEAR ofloxacin ophthalmic OCUFLOX phenylephrine hcl ophthalmic solution 10 %, 2.5 % pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % ALTAFRN ISOPTO CARPINE polymyxin b-trimethoprim POLYTRIM PRED- PRED- S.O.P. prednisolone acetate ophthalmic OMNIPRED prednisolone sodium phosphate ophthalmic proparacaine hcl ophthalmic ALCAINE pure & gentle lubricant ophthalmic solution 3 mg/ml REFRESH LIQUIEL RESTASIS PA glycerin-hypromellose-pe 400 ophth soln % SOOTHE OPHTHALMIC SOLUTION % 59 VISINE TEARS STERILE LURICANT sulfacetamide sodium ophthalmic solution LEPH-10 sulfacetamide-prednisolone ophthalmic solution SYSTANE OPHTHALMIC EL tetracaine hcl ophthalmic TETCAINE propylene glycol-glycerin ophth soln 1-0.3% THERATEARS OPHTHALMIC SOLUTION timolol maleate ophthalmic TIMOPTIC-XE TORADEX OPHTHALMIC OINTMENT QL (3.5 M per 7 tobramycin ophthalmic TOREX tobramycin-dexamethasone TORADEX TRAVATAN Z PA travoprost PA trifluridine ophthalmic VIROPTIC tropicamide ophthalmic VEXOL VIAMOX PA ZIOPTAN PA *Otic Agents* acetic acid otic acetic acid-aluminum acetate

66 Product Reference rand- eneric antipyrine-benzocaine otic solution mg/ml CIPRODEX ciprofloxacin hcl otic CETRAXAL ear wax removal drops DEROX fluocinolone acetonide otic DERMOTIC hydrocortisone-acetic acid ACETASOL HC neomycin-polymyxin-hc otic solution 1 % CORTISPORIN neomycin-polymyxin-hc otic suspension ofloxacin otic FLOXIN OTIC *Oxytocics* methylergonovine maleate oral METHERINE *Penicillins* amoxicillin oral capsule amoxicillin oral suspension reconstituted amoxicillin oral tablet amoxicillin oral tablet chewable 125 mg, 250 mg amoxicillin-pot clavulanate er AUMENTIN XR amoxicillin-pot clavulanate oral ampicillin AUMENTIN ORAL SUSPENSION RECONSTITUTED M/5ML dicloxacillin sodium penicillin v potassium *Potassium Removing Agents*** sodium polystyrene sulfonate oral suspension KIONEX sodium polystyrene sulfonate rectal suspension 30 gm/120ml *Prenatal Mv & Minerals W/ Fa-Omega Fatty Acids W/O Iron* prenatal gummy *Progestins* MAKENA PA medroxyprogesterone acetate oral PROVERA norethindrone acetate oral AYESTIN progesterone micronized oral PROMETRIUM *Psychotherapeutic And Neurological Agents - Misc.* AVONEX PA; SP AVONEX PEN INTRAMUSCULAR AUTO- INJECTOR KIT PA; SP 60

67 Product Reference rand- eneric AVONEX PREFILLED INTRAMUSCULAR PA; SP PREFILLED SYRINE KIT AUAIO PA; SP ETASERON SUCUTANEOUS KIT PA; SP 61 bupropion hcl er (smoking det) ZYAN QL (84 days per 180 CHANTIX QL (84 days per 180 CHANTIX CONTINUIN MONTH PAK QL (84 days per 180 CHANTIX STARTIN MONTH PAK d ) QL (84 days per 180 COPAXONE SUCUTANEOUS SOLUTION PREFILLED SYRINE PA; SP_rand Only donepezil hcl ARICEPT ergoloid mesylates oral galantamine hydrobromide er RAZADYNE ER ALANTAMINE HYDROROMIDE ORAL SOLUTION galantamine hydrobromide oral tablet RAZADYNE ILENYA PA; SP MEMANTINE HCL ORAL SOLUTION NAMENDA PA memantine hcl oral tablet NAMENDA PA memantine HC capsule ER NAMENDA XR PA NAMENDA XR TITRATION PACK PA nicotine polacrilex mouth/throat NICORETTE ; QL (84 days per 180 nicotine transdermal patch 24 hour NICODERM CQ QL (84 days per 180 NICOTROL QL (84 days per 180 NICOTROL NS QL (84 days per 180 PLERIDY STARTER PACK SUCUTANEOUS SOLUTION PREFILLED SYRINE PLERIDY SUCUTANEOUS SOLUTION PREFILLED SYRINE REIF REIDOSE SUCUTANEOUS SOLUTION AUTO-INJECTOR rivastigmine EXELON rivastigmine tartrate PA; SP PA; SP PA; SP SAVELLA QL (60 EA per 30 SAVELLA TITRATION PACK TECFIDERA PA; SP *Pulmonary Fibrosis Agents*** ESRIET PA; SP

68 Product Reference rand- eneric *Respiratory Agents - Misc.* PULMOZYME PA; SP *Serotonin Modulators*** trazodone hcl oral *Sodium-lucose Co-Transporter 2 Inhibitor-iguanide Comb* INVOKAMET *Sulfonamides* sulfadiazine oral *Tetracyclines* demeclocycline hcl oral doxycycline hyclate oral capsule VIRAMYCIN doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg MONODOX doxycycline monohydrate oral capsule 150 mg ADOXA doxycycline monohydrate oral capsule 50 mg MONDOXYNE XL doxycycline monohydrate oral suspension reconstituted VIRAMYCIN doxycycline monohydrate oral tablet 100 mg ADOXA minocycline hcl oral capsule MINOCIN *Thyroid Agents* ARMOUR THYROID ORAL TALET 120 M, 180 M, 240 M, 300 M levothyroxine sodium oral LEVOXYL liothyronine sodium oral CYTOMEL methimazole oral TAPZOLE NATURE-THROID ORAL TALET M, M, 260 M, 325 M np thyroid ARMOUR THYROID propylthiouracil oral WESTHROID ORAL TALET 195 M, 32.5 M, 97.5 M WESTHROID ORAL TALET 65 M WP THYROID ORAL TALET M, 130 M, M, M, M *Toxoids* 62 ADACEL Min 19 Years OOSTRIX INTRAMUSCULAR SUSPENSION Min 19 Years DAPTACEL Min 19 Years DIPHTHERIA-TETANUS TOXOIDS INTRAMUSCULAR INJECTALE 2-5 LFU Min 19 Years tetanus-diphtheria toxoids td Min 19 Years

69 Product Reference rand- eneric *Ulcer Drugs* acid reducer maximum strength oral tablet 150 mg ZANTAC CARAFATE ORAL SUSPENSION cimetidine acid reducer TAAMET H cimetidine hcl oral cimetidine oral tablet 300 mg, 400 mg, 800 mg dicyclomine hcl oral ENTYL famotidine oral suspension reconstituted PEPCID famotidine oral tablet 10 mg PEPCID AC famotidine oral tablet 20 mg PEPCID AC MAXIMUM STRENTH famotidine oral tablet 40 mg PEPCID FIRST-LANSOPRAZOLE FIRST-OMEPRAZOLE glycopyrrolate oral ROINUL hyoscyamine sulfate er oral tablet extended SYMAX-XR release 12 hour hyoscyamine sulfate oral LEVSIN hyoscyamine sulfate sublingual SYMAX-SL lansoprazole oral capsule delayed release PREVACID methscopolamine bromide oral PAMINE misoprostol oral CYTOTEC NEXIUM 24HR Cap 20mg omeprazole magnesium omeprazole oral capsule delayed release omeprazole oral tablet delayed release 63 pantoprazole sodium oral PROTONIX QL (30 EA per 30 propantheline bromide oral ranitidine acid reducer ranitidine hcl oral capsule ranitidine hcl oral syrup 15 mg/ml ranitidine hcl oral tablet 300 mg ZANTAC sucralfate oral tablet CARAFATE *Urinary Anti-Infectives* methenamine hippurate HIPREX methenamine mandelate oral tablet 1 gm nitrofurantoin macrocrystal oral capsule 100 MACRODANTIN mg, 50 mg nitrofurantoin monohyd macro MACROID nitrofurantoin oral suspension FURADANTIN ur n-c UTRONA-C ustell

70 Product Reference rand- eneric *Urinary Antispasmodics* bethanechol chloride oral URECHOLINE MYRETRIQ ST oxybutynin chloride er DITROPAN XL oxybutynin chloride oral tolterodine tartrate DETROL ST tolterodine tartrate er DETROL LA ST trospium chloride *Vaccines* AFLURIA AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINE CERVARIX ENERIX- INJECTION SUSPENSION 20 MC/ML ENERIX- INTRAMUSCULAR INJECTALE 20 MC/ML FLUARIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINE FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINE FLULOK FLUCELVAX INTRAMUSCULAR SUSPENSION PREFILLED SYRINE FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINE FLUMIST QUADRIVALENT FLUVIRIN INTRAMUSCULAR SUSPENSION FLUVIRIN INTRAMUSCULAR SUSPENSION PREFILLED SYRINE FLUVIRIN PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINE FLUZONE HIH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINE FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION, 0.5 ML FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINE 64 Min 19 Years and Max 26 Years Min 19 Years Min 19 Years

71 Product Reference rand- eneric ARDASIL 9 ARDASIL INTRAMUSCULAR SUSPENSION MEDICAL PROVIDER EZ FLU PF INTRAMUSCULAR PREFILLED SYRINE KIT MEDICAL PROVIDER EZ FLUVIRIN 65 Min 19 Years and Max 26 Years Min 19 Years and Max 26 Years M-M-R II Min 19 Years PNEUMOVAX 23 Min 19 Years PREVNAR 13 Min 19 Years RECOMIVAX H INJECTION SUSPENSION 40 MC/ML ZOSTAVAX SUCUTANEOUS SOLUTION RECONSTITUTED *Vaginal Products* AVC VAINAL clindamycin phosphate vaginal CLEOCIN clotrimazole 3 YNE-LOTRIMIN 3 clotrimazole vaginal cream 1 % YNE-LOTRIMIN estradiol vaginal cream ESTRACE VAINAL ESTRIN Min 19 Years Min 60 Years FEMRIN PA; QL (1 EA per 90 FIRST-PROESTERONE VS 100 FIRST-PROESTERONE VS 200 FIRST-PROESTERONE VS 400 FIRST-PROESTERONE VS 50 metronidazole vaginal VANDAZOLE miconazole 1 miconazole 3 combo pack MONISTAT 1 COMO PACK MONISTAT 3 COMINATION PACK miconazole 3 vaginal cream MONISTAT 3 miconazole 3 vaginal suppository miconazole 7 MONISTAT 7 SIMPLY CURE OPTIONS YNOL II CONTRACEPTIVE PREMARIN VAINAL terconazole TERAZOL 7 VCF VAINAL CONTRACEPTIVE VAINAL FILM VCF VAINAL CONTRACEPTIVE VAINAL EL YUVAFEM

72 Product Reference rand- eneric *Vasopressors* epinephrine injection solution auto-injector EPIPEN, EPIPEN JR QL (2 EA per 30 midodrine hcl *Vitamins* 1 NATURAL -NATAL d3-50 DECARA ORAL CAPSULE UNIT liqui-e NEURO-K-250 T.D. niacin er oral capsule extended release NIACIN ER ORAL TALET EXTENDED RELEASE 1000 M niacin er oral tablet extended release 250 mg ENDUR-ACIN niacin er oral tablet extended release 500 mg, 750 mg SLO-NIACIN niacin oral tablet VITAMIN D3 ORAL CAPSULE 4000 UNIT THIAMINE vitamin b1 vitamin b-1 pyridoxine (vitamin b-6) vitamin b-6 er vitamin b6 oral tablet 200 mg vitamin d (ergocalciferol) DRISDOL vitamin d oral tablet 1000 unit VITAMIN D-1000 MAX ST vitamin d oral tablet 2000 unit THERA-D RAPID REPLETION vitamin d-3 oral capsule PRONUTRIENTS VITAMIN D3 vitamin d3 oral capsule unit MAXIMUM D3 vitamin d3 oral capsule 2000 unit, 400 unit vitamin d3 oral capsule 5000 unit DIALYVITE VITAMIN D 5000 vitamin d3 oral liquid 400 unit/ml PROTECTED PEDIA D- VITE vitamin d3 oral liquid 5000 unit/ml vitamin d3 oral tablet 400 unit, 5000 unit vitamin e oral capsule 100 unit, 1000 unit, 600 unit vitamin e oral oil vitamin e oral solution VITAMIN E ORAL TALET 200 UNIT vitamin e oral tablet 400 unit E-PHEROL vitamin e-200 vitamin e-400 FORMULA E

73 PHARMACY Medication Prior Authorization / Exception Request Form FAX: (877) Phone: (800) To ensure a timely response, please fill out the form completely and legibly. Standard (Up to 14 Calendar Days) Expedited* (Up to 72 hours) Member Name Last, First) Member ID# DO Date Requesting Provider Name NPI: PCP ( if different) Office Contact Person Direct Phone # Fax # Diagnosis 1 (include ICD-9) Diagnosis 2 Diagnosis 3 Please send all pertinent clinical documentation with this fax. Use of pharmaceutical samples cannot be accepted as justification. Name of Medication Dosage Quantity/ Amount Refills (<12) Sig/Instructions Allergies List Formulary Medications Tried include length of treatment and response with dates List Formulary Medications Contraindicated / Reason This is a reauthorization of current medication. Recent clinical documentation is required. Please provide. CONFIDENTIALITY NOTICE: This fax transmission, including any attachments, contains confidential information that may be privileged. The information is intended only for the use of the individual(s) or entity to which it is addressed. If you are not the intended recipient, any disclosure, distribution or the taking of any action in reliance upon this fax transmission is prohibited and may be unlawful. If you have received this fax in error, please notify the sender immediately via telephone at the above phone number and destroy the original documents. Thank you. 74

74 ARIZONA Servicios al Miembro 410 N. 44th Street, Suite 900 Phoenix, Arizona Teléfono: Llamadas gratuitas: TTY/TDD: 711 Servicios al Miembro: De lunes a viernes, 6 a.m. - 6 p.m. HealthChoiceAZ.com ienvenidos a Nuestra Familia!

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