2017 Drug Formulary. Care with a Conscience. Questions? Contact Health Choice Integrated Care Member Services at

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1 2017 Drug Formulary Care with a Conscience Updated January 1, 2017 Questions? Contact Health Choice Integrated Care Member Services at

2 HEALTH CHOICE INTERATED CARE FORMULARY DRU LIST 01/01/2017 Health Choice Integrated Care Health Choice Integrated Care is a health plan contract with the Arizona Health Care Cost Containment System (AHCCCS) to provide medically necessary, cost-effective pharmacy benefits and services to members who are eligible for Arizona Medicaid-funded medical and behavioral health services. Health Choice Integrated Care Formulary Health Choice Integrated Care (HCIC) uses a Formulary Drug List to guide the health providers in their use of medications for our members. The Formulary Drug list is developed under the guidance of AHCCCS. The Formulary is consistent with the AHCCCS Minimum Required Prescription Drug List (MRPDL). The Formulary Drug List begins on page H-1. It provides information about the drugs covered by Health Choice Integrated Care. The list is divided into two major therapeutic category sections, behavioral health and acute care for easy use. Non-integrated members have access to the behavioral health formulary and integrated members have access to both formularies through HCIC. Products that are approved for more than one therapeutic indication may be included on both lists. Drugs are listed by generic names with brand names provided for reference. The fourth column "Requirements, Limits" lists any requirements for the drug such as prior authorization (PA), quantity limits (QL) and step therapy (ST). Prior authorization criteria may be based on multiple factors including age limits, concomitant therapy, and drug interactions. Formulary Drug List The Formulary drugs listed are intended to provide clinically appropriate, evidenced-based, cost-effective medication options, for all eligible recipients receiving services through Health Choice Integrated Care. The drugs listed on the Formulary Drug List have been reviewed and approved by our Pharmacy and Therapeutics (P&T) Committees. The Formulary Drug List is not intended as a comprehensive listing of all drugs that may be covered by HCIC. If a drug is not listed on the Formulary Drug List and is determined to be medically necessary for a behavioral health or acute care diagnosis, it may be requested through our Prior Authorization process. Providers and recipients may contact the HCIC to request more information about the process for medications not listed on the Formulary Drug List. HCIC Director of Pharmacy HCIC Pharmacy Department 1300 South Yale Street Flagstaff, Arizona Phone; (877) , Fax; (855) The HCIC Formulary may change during the year; drugs may be added or removed. To get the latest information about covered drugs, go to our website at or call the Pharmacy Help Desk at (928) or 1 (877) , Option #2.

3 Pharmacy and Therapeutics (P&T) Committees The P&T Committees that develop and maintain the HCIC Formulary Drug List are composed of clinical staff from ADHS/DHS, AHCCCS and each of its Health Contractors (health plans) as well as doctors and community pharmacist servicing ours member. The committees meet at least quarterly to discuss a variety of clinical issues, which pertain to drug selections, including additions, deletions and changes as well as pharmacy program management. The P&T Committees evaluate clinical information for newly marketed drugs within 180 days of market launch. When a new drug is considered for formulary inclusion, an attempt will be made to examine the drug relative to similar drugs currently on formulary. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in deletion of one or more drugs in a particular therapeutic class in an effort to continually promote the most clinically useful and cost-effective agents. Additionally, the current Formulary Drug List medications are reviewed and approved on an annual basis. All decisions for Formulary Drug List placement are based on scientific evidence and standards of practice that include peer-reviewed medical literature, outcomes research data, official compendia, or published practice guidelines developed by an evidence-based process. Key considerations: Clinical safety and efficacy as well as therapeutic advantages outweighing cost in all decisions. Market share shifts, price increases, generic availability and varied dosage regimens may affect the actual cost of therapy and drug coverage Patient administration and compliance are evaluated Products with less expensive formulary alternatives that meet the health care needs of the members we serve, will not be added. Health Choice Integrated Care providers may formally request the Health Choice Pharmacy & Therapeutics Committee consider a medication be considered for addition to the formulary. The instructions and required submission form(s) which indicate how to submit a formulary medication consideration request are detailed in the Health Choice Provider Manual. The instructions and materials are also available on the Health Choice website. Drug Exclusions Health Choice will not cover drugs that have been excluded from coverage under Medicaid and AHCCCS. Examples of excluded drugs are noted in the list of categories below and include drugs designated as DESI and drug products that have not been appropriately approved by the FDA (e.g. bulk powders). The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the formulary. Anti-obesity agents Experimental / research drugs Cosmetic drugs Cosmetic drugs for hair growth Nutritional / diet supplements lood and blood plasma products Products to promote fertility Erectile dysfunction drugs Drugs from manufacturers that do not participate in the FFS Medicaid Drug Rebate Program

4 Diagnostic products Intrauterine devices Medical supplies except: o Syringes o Needles o Lancets o Alcohol o Swabs o Spacers o lood glucose meters and test strips Drug Efficacy Study Implementation Drugs (DESI). Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval. eginning in 1962, all new drugs were required to be both safe and effective before they could be marketed. This legislation also applied retroactively to all drugs approved as safe from The Drug Efficacy Study Implementation (DESI) program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products remain classified as "less than fully effective" while awaiting final administrative disposition. Also, classified as DESI are many products listed as identical, similar, or related to actual DESI products. Pharmacy enefit Manager (PM) Health Choice integrated Care uses EnvisionRx Options to process our prescription drug claims. Formulary changes are implemented via our PM. The formulary is distributed to the provider network on an annual basis, and when changes have occurred as appropriate. The formulary, with updates as needed, is also available on the Health Choice Integrated Care website: or by request to the Health Choice Integrated Care Pharmacy Department at 1(877) ehavioral Health Drug list Section The Formulary Drug List is organized by therapeutic sections. Each section includes therapeutic groups identified by drug class. Products are listed in alphabetical order by generic name. enerics drugs are to be considered as the first line of prescribing. Use of the most cost-effective (least costly) clinically appropriate pharmaceutical treatment is required. Drug Table Key: Drug are listed by alphabetically by class. Drug names in the Product column are preferred. rand Drugs listed in CAPITAL LETTERS indicate the medication is only available or only covered as a brand name product. rand/ eneric indicates covered product. "" is brand drug covered, "" is generic drug covered designates drug is covered Requirements/ Limits defines requirements and restrictions for coverage. PA means prior authorization is required; multiple PA requirements may exist for a specific drug. QL means a quantity limit exists. Age edits may be represented as PA for use < specific age or limit that drug can only be used for ages > 18.

5 Index of Drugs: Due to volume of drugs, the ehavioral Health Drug List contains an index to assist with quick access to drugs covered within the ehavioral Health Formulary drug list section. Index starts on page H-20. Requirement/ limit PA REQ FOR <6 ANTIPSYCHOTICS PA REQ FOR <6 ADHD Concomitant Antipsychotics Concomitant Antidepressants RAND DRU Quantity Limit For 18 and over only uprenorphine Description Prior Authorization required for ages < 6 years old Prior Authorization required for ages < 6 years old Prior Authorization required for concomitant antipsychotic treatment Prior Authorization required for concomitant antidepressant treatment Prior Authorization required for RAND DRU Prior Authorization required for all meds prescribed for more the #240 capsules/tablets, unless otherwise specified Use only allowed for 18 and older Prior Authorization required for buprenorphine Acute Care Formulary Drug list Section The Formulary Drug List is organized by therapeutic sections. Each section includes therapeutic groups identified by drug class. Products are listed in alphabetical order by covered drug name; generic drugs are in lower case and RAND drugs in upper case. Drug Table Key: Drug are listed by covered drug product name. eneric drugs in lower case and RAND drugs are in upper case. designates only drug is covered rand/ eneric indicates covered product. "" is brand drug covered, "" is generic drug covered Reference RAND name is provided for generic products Requirements / Limits defines requirements and limitations for coverage. PA means prior authorization is required. QL means a quantity limit exists. ST means step therapy protocol exists. Other AHCCCS required notes may also exist. Index of Drugs: Due to volume of drugs, the Acute Care Drug List contains an index to assist with quick access to drugs covered within the Acute Care Formulary drug list section. Index starts on page 61.

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7 Health Choice Integrated Care ehavioral Health Formulary Effective January 1, 2017 Product Reference rand- eneric *Adhd/Anti-Narcolepsy/Anti-Obesity/A norexiants* ADDERALL XR amphetamine-dextroamphetamine Adderall DAYTRANA PA Req for<6 ADHD; QL (60 EA per 30 PA Req for<6 ADHD; QL (120 EA per 30 PA Req for<6 ADHD; QL (60 EA per 30 dextroamphetamine sulfate er Dexedrine QL (60 EA per 30 dextroamphetamine sulfate oral tablet Zenzedi FOCALIN FOCALIN XR guanfacine hcl er Intuniv KAPVAY ORAL TALET EXTENDED RELEASE 12 HR* METADATE CD METHYLIN ORAL SOLUTION METHYLIN ORAL TALET CHEWALE methylphenidate hcl er (la) Ritalin LA methylphenidate hcl er oral tablet extended release 24 hr* methylphenidate hcl er oral tablet extendedrelease* 18 mg, 27 mg, 36 mg, 54 mg Concerta methylphenidate hcl oral tablet Ritalin QUILLICHEW ER QUILLIVANT XR RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 M 1 PA Req for<6 ADHD; QL (120 EA per 30 PA Req for<6 ADHD; QL (120 EA per 30 PA Req for<6 ADHD; QL (60 EA per 30 PA Req for<6 ADHD; QL (60 EA per 30 PA Req for<6 ADHD; QL (120 EA per 30 PA Req for<6 ADHD; QL (60 EA per 30 PA Req for<6 ADHD; QL (300 ML per 30 PA Req for<6 ADHD; QL (120 EA per 30 PA Req for<6 ADHD; QL (60 EA per 30 PA Req for<6 ADHD; QL (120 EA per 30 PA Req for<6 ADHD; QL (120 EA per 30 PA Req for<6 ADHD; QL (120 EA per 30 PA Req for<6 ADHD; QL (60 EA per 30 PA Req for<6 ADHD; QL (150 ML per 30 ; Min 6 Years PA Req for<6 ADHD; QL (60 EA per 30

8 Product Reference rand- eneric STRATTERA VYVANSE *Analgesics - Opioid* buprenorphine hcl sublingual tablet sublingual 2 mg buprenorphine hcl sublingual tablet sublingual 8 mg buprenorphine hcl-naloxone hcl Suboxone PA Req for<6 ADHD; QL (60 EA per 30 PA Req for<6 ADHD; QL (60 EA per 30 PA QL ( EA per 30 PA req prefer brand Suboxone Film; QL (240 EA per 30 SUOXONE SULINUAL FILM QL (240 EA per 30 *Antianxiety Agents* alprazolam er Xanax XR QL ALPRAZOLAM INTENSOL alprazolam oral Xanax buspirone hcl oral chlordiazepoxide hcl oral capsule 10 mg, 25 mg clorazepate dipotassium Tranxene-T diazepam injection diazepam oral solution 1 mg/ml QL ( EA per 30 diazepam oral tablet Valium QL ( EA per 30 hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet hydroxyzine pamoate oral LORAZEPAM INTENSOL lorazepam oral tablet Ativan meprobamate oxazepam *Anticonvulsants* carbamazepine er oral capsule extended release 12 hour carbamazepine er oral tablet extended release 12 hr* 200 mg, 400 mg QL (240 EA per 30 QL ( EA per 30 Carbatrol QL (240 EA per 30 TEretol XR QL (240 EA per 30 carbamazepine oral suspension TEretol carbamazepine oral tablet TEretol carbamazepine oral tablet chewable clonazepam oral tablet KlonoPIN clonazepam oral tablet dispersible mg, 0.25 mg, 2 mg QL (240 EA per 30 QL (240 EA per 30 QL ( EA per 30 days ) clonazepam oral tablet dispersible 0.5 mg, 1 mg QL (120 EA per 30 2

9 Product Reference rand- eneric divalproex sodium er oral tablet extended release 24 hr* Depakote ER QL (240 EA per 30 divalproex sodium oral Depakote Sprinkles QL (240 EA per 30 divalproex sodium oral tablet delayed release Depakote QL (240 EA per 30 gabapentin oral capsule Neurontin QL (240 EA per 30 gabapentin oral solution 250 mg/5ml Neurontin gabapentin oral tablet Neurontin QL (240 EA per 30 LAMICTAL ORAL TALET CHEWALE 2 M QL (240 EA per 30 lamotrigine er LaMICtal XR QL (240 EA per 30 lamotrigine oral tablet LaMICtal QL (240 EA per 30 lamotrigine oral tablet chewable LaMICtal QL (240 EA per 30 lamotrigine oral tablet dispersible LaMICtal ODT QL (240 EA per 30 oxcarbazepine oral suspension Trileptal oxcarbazepine oral tablet Trileptal QL (240 EA per 30 TERETOL-XR ORAL TALET EXTENDED RELEASE 12 HR* 100 M QL (240 EA per 30 topiramate er Qudexy XR QL (240 EA per 30 topiramate oral Topiragen QL (240 EA per 30 valproate sodium intravenous* solution 500 mg/5ml Depacon QL (240 ML per 30 valproic acid oral capsule Depakene QL (240 EA per 30 valproic acid oral syrup Depakene *Antidepressants* amitriptyline hcl oral amoxapine APLENZIN bupropion hcl er (sr) oral tablet extended release 12 hr* 100 mg, 150 mg bupropion hcl er (sr) oral tablet extended release 12 hr* 200 mg udeprion SR Wellbutrin SR bupropion hcl er (xl) Wellbutrin XL bupropion hcl oral Wellbutrin Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 rand Drugs/CYP 450; QL (240 EA per 30 rand Drugs/CYP 450 rand Drugs/CYP 450; QL (240 EA per 30 rand Drugs/CYP 450 rand Drugs/CYP 450; QL (240 EA per 30 3

10 Product Reference rand- eneric citalopram hydrobromide oral solution citalopram hydrobromide oral tablet CeleXA clomipramine hcl oral Anafranil desipramine hcl oral Norpramin desvenlafaxine er Khedezla doxepin hcl oral capsule doxepin hcl oral concentrate duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg duloxetine hcl oral capsule delayed release particles 40 mg EMSAM Cymbalta Irenka escitalopram oxalate oral solution Lexapro escitalopram oxalate oral tablet Lexapro Concomitant Antidepressant Treatment Concomitant Antidepressant Treatment; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 RAND DRU / Concomitant Antidepressant Treatment; QL (240 EA per 30 Concomitant Antidepressant Treatment Concomitant Antidepressant Treatment; QL (240 EA per 30 4

11 Product Reference rand- eneric fluoxetine hcl oral capsule PROzac fluoxetine hcl oral capsule delayed release PROzac Weekly fluoxetine hcl oral solution fluoxetine hcl oral tablet 10 mg, 20 mg fluoxetine hcl oral tablet 60 mg fluvoxamine maleate fluvoxamine maleate er Luvox CR FORFIVO XL imipramine hcl oral Tofranil imipramine pamoate Tofranil-PM KHEDEZLA ORAL TALET EXTENDED RELEASE 24 HR* 50 M maprotiline hcl Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 PA required CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment; QL (240 EA per 30 Concomitant Antidepressant Treatment; QL (240 EA per 30 5

12 Product Reference rand- eneric MARPLAN Concomitant Antidepressant Treatment; QL (240 EA per 30 mirtazapine oral Remeron SolTab QL (240 EA per 30 nefazodone hcl nortriptyline hcl oral capsule Pamelor nortriptyline hcl oral solution paroxetine hcl er Paxil CR paroxetine hcl oral tablet 10 mg Paxil PAXIL ORAL SUSPENSION PEXEVA phenelzine sulfate oral Nardil PRISTIQ protriptyline hcl Vivactil sertraline hcl oral concentrate Zoloft Concomitant Antidepressant Treatment; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 RAND DRU / Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment; QL (240 EA per 30 RAND DRU / Concomitant Antidepressant Treatment; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450 6

13 Product Reference rand- eneric sertraline hcl oral tablet Zoloft Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 tranylcypromine sulfate Parnate QL (240 EA per 30 trazodone hcl oral trimipramine maleate oral Surmontil venlafaxine hcl venlafaxine hcl er Effexor XR VIIRYD ORAL TALET *Antidotes* Concomitant Antidepressant Treatment; QL (240 EA per 30 Concomitant Antidepressant Treatment / CYP 450; QL (240 EA per 30 Concomitant Antidepressant Treatment; QL (240 EA per 30 Concomitant Antidepressant Treatment; QL (240 EA per 30 RAND DRU / Concomitant Antidepressant Treatment; QL (240 EA per 30 naltrexone hcl oral Depade QL (240 EA per 30 VIVITROL QL (240 EA per 30 *Antihistamines* aler-dryl allergy relief childrens oral liquid Total Allergy Medicine allergy relief oral capsule enadryl allergy relief oral tablet 25 mg Alka-Seltzer Plus Allergy cyproheptadine hcl oral tablet QL (240 EA per 30 diphenhydramine hcl injection QL (240 ML per 30 diphenhydramine hcl oral capsule 50 mg anophen diphenhydramine hcl oral elixir Medi-Phedryl quenalin *Antihyperlipidemics* omega-3-acid ethyl esters Lovaza QL (240 EA per 30 *Antihypertensives* clonidine hcl oral Catapres QL (240 EA per 30 clonidine hcl transdermal Catapres-TTS-1 QL (240 EA per 30 7

14 Product Reference rand- eneric guanfacine hcl oral Tenex QL (240 EA per 30 prazosin hcl oral Minipress QL (240 EA per 30 *Antiparkinson Agents* amantadine hcl oral capsule QL (240 EA per 30 amantadine hcl oral syrup amantadine hcl oral tablet QL (240 EA per 30 benztropine mesylate injection Cogentin QL (240 ML per 30 benztropine mesylate oral QL (240 EA per 30 bromocriptine mesylate oral Parlodel QL (240 EA per 30 selegiline hcl oral capsule Eldepryl QL (240 EA per 30 trihexyphenidyl hcl oral tablet QL (240 EA per 30 *Antipsychotics/Antimanic Agents* AILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 300 M, 400 M AILIFY ORAL TALET ARISTADA INTRAMUSCULAR* 441 M/1.6ML ARISTADA INTRAMUSCULAR* 662 M/2.4ML ARISTADA INTRAMUSCULAR* 882 M/3.2ML chlorpromazine hcl oral clozapine FazaClo FANAPT FANAPT TITRATION PACK FAZACLO ORAL TALET DISPERSILE 150 M, 200 M 8 Concomitant Antipsychotic Treatment; QL (1 EA per 28 ; Min 18 Years Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years Concomitant Antipsychotic Treatment; QL (1.6 ML per 28 ; Min 18 Years Concomitant Antipsychotic Treatment; QL (2.4 ML per 28 ; Min 18 Years Concomitant Antipsychotic Treatment; QL (3.2 ML per 28 ; Min 18 Years Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years RAND DRU / Concomitant Antipsychotic Treatment; QL (240 EA per 30 RAND DRU / Concomitant Antipsychotic Treatment; QL (240 EA per 30 Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years

15 Product Reference rand- eneric fluphenazine decanoate injection fluphenazine hcl oral concentrate fluphenazine hcl oral elixir fluphenazine hcl oral tablet Concomitant Antipsychotic Treatment; QL (240 ML per 30 ; Min 18 Years Concomitant Antipsychotic Treatment; Min 6 Years Concomitant Antipsychotic Treatment; Min 6 Years Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years EODON INTRAMUSCULAR* QL (240 EA per 30 haloperidol decanoate intramuscular* Haldol Decanoate haloperidol lactate injection Haldol haloperidol lactate oral haloperidol oral INVEA SUSTENNA INTRAMUSCULAR* SUSPENSION 117 M/0.75ML INVEA SUSTENNA INTRAMUSCULAR* SUSPENSION 156 M/ML INVEA SUSTENNA INTRAMUSCULAR* SUSPENSION 234 M/1.5ML INVEA SUSTENNA INTRAMUSCULAR* SUSPENSION 39 M/0.25ML INVEA SUSTENNA INTRAMUSCULAR* SUSPENSION 78 M/0.5ML Concomitant Antipsychotic Treatment; QL (240 ML per 30 ; Min 18 Years Concomitant Antipsychotic Treatment; QL (240 ML per 30 ; Min 6 Years Concomitant Antipsychotic Treatment; Min 6 Years Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years Concomitant Antipsychotic Treatment; QL (0.75 ML per 28 ; Min 18 Years Concomitant Antipsychotic Treatment; QL (1 ML per 28 ; Min 18 Years Concomitant Antipsychotic Treatment; QL (1.5 ML per 28 ; Min 18 Years Concomitant Antipsychotic Treatment; QL (0.25 ML per 28 ; Min 18 Years Concomitant Antipsychotic Treatment; QL (0.5 ML per 28 ; Min 18 Years 9

16 Product Reference rand- eneric INVEA TRINZA INTRAMUSCULAR* SUSPENSION 273 M/0.875ML INVEA TRINZA INTRAMUSCULAR* SUSPENSION 410 M/1.315ML INVEA TRINZA INTRAMUSCULAR* SUSPENSION 546 M/1.75ML INVEA TRINZA INTRAMUSCULAR* SUSPENSION 819 M/2.625ML LATUDA lithium Concomitant Antipsychotic Treatment; QL (0.88 ML per 28 ; Min 18 Years Concomitant Antipsychotic Treatment; QL (1.31 ML per 28 ; Min 18 Years Concomitant Antipsychotic Treatment; QL (1.75 ML per 28 ; Min 18 Years Concomitant Antipsychotic Treatment; QL (2.63 ML per 28 ; Min 18 Years Concomitant Antipsychotic Treatment; QL (240 EA per 30 lithium carbonate er Lithobid QL (240 EA per 30 lithium carbonate oral QL (240 EA per 30 loxapine succinate oral Loxitane olanzapine ZyPREXA paliperidone er Invega perphenazine oral quetiapine fumarate SEROquel RISPERDAL CONSTA risperidone oral solution RisperDAL Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years Concomitant Antipsychotic Treatment; QL (240 EA per 30 Concomitant Antipsychotic Treatment; QL (240 EA per 30 Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years Concomitant Antipsychotic Treatment; QL (1 EA per 28 ; Min 18 Years Concomitant Antipsychotic Treatment; Min 6 Years 10

17 Product Reference rand- eneric risperidone oral tablet RisperDAL risperidone oral tablet dispersible RisperiDONE M-TA SAPHRIS SULINUAL TALET SULINUAL 10 M, 5 M SAPHRIS SULINUAL TALET SULINUAL 2.5 M SEROQUEL XR thioridazine hcl oral thiothixene oral trifluoperazine hcl oral ziprasidone hcl eodon ZYPREXA RELPREVV *eta lockers* Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years PA required Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years RAND DRU / Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years PA Req for LA INJ Antipsychotics / Concomitant Antipsychotic Treatment; QL (1 EA per 28 ; Min 18 Years nadolol oral tablet 20 mg, 40 mg, 80 mg Corgard QL (240 EA per 30 propranolol hcl er Inderal LA QL (240 EA per 30 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80 mg *Cough/Cold/Allergy* WAL-DRYL-D QL (240 EA per 30 11

18 Product Reference rand- eneric *Hematopoietic Agents* b-12 oral tablet 2000 mcg b-12 oral tablet 2500 mcg cyanocobalamin injection QL (240 ML per 30 FA-8 ORAL CAPSULE folic acid oral capsule folic acid oral tablet 1 mg, 400 mcg folic acid oral tablet 800 mcg FA-8 vitamin b-12 oral tablet *Hypnotics* chloral hydrate oral diphenhydramine hcl (sleep) oral tablet 50 mg Sominex Maximum Strength EDLUAR rand Drug; QL (240 EA per 30 estazolam QL ( EA per 30 eszopiclone Lunesta QL ( EA per 30 flurazepam hcl INTERMEZZO nighttime sleep aid oral tablet 25 mg Restfully Sleep phenobarbital oral tablet 100 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg QL ( EA per 30 days ) rand Drug; QL (240 EA per 30 QL (240 EA per 30 phenobarbital oral tablet 15 mg QL (240 EA per 30 ra sleep aid oral liquid ZzzQuil ra sleep-aid nighttime ZzzQuil ROZEREM QL (240 EA per 30 SILENOR sleep-aid maximum strength Unisom Sleepgels RAND DRU / Concomitant Antidepressant Treatment; QL (240 EA per 30 SOMNOTE QL (30 EA per 30 temazepam Restoril triazolam QL ( EA per 30 12

19 Product Reference rand- eneric WAL-SLEEP Z ORAL TALET DISPERSILE zaleplon Sonata zolpidem tartrate er Ambien CR zolpidem tartrate oral tablet 10 mg Ambien QL ( EA per 30 QL ( EA per 30 QL ( EA per 30 zolpidem tartrate oral tablet 5 mg Ambien QL (60 EA per 30 ZOLPIMIST *Laxatives* bisacodyl ec Carters Little Pills bisacodyl laxative isac-evac chocolated laxative Ex-Lax CVS NATURAL FIER SUPPLEMENT ORAL PACKET cvs senna-extra Senokot XTRA docusate calcium Surfak docusate sodium oral capsule 250 mg DOK docusate sodium oral liquid 50 mg/5ml docusate sodium oral syrup Colace DOK ORAL TALET Promolaxin enema enema 7-19 gm/118ml Fleet Pediatric ENEMEEZ MINI epsom salt oral HYDROCIL ORAL PACKET KONSYL ORAL PACKET 100 %, 28.3 %, 60.3 % KONSYL ORAL POWDER 28.3 % KONSYL ORAL POWDER 30.9 % KONSYL ORAL POWDER 60.3 %, % KONSYL-D ORAL POWDER laxative pills Ex-Lax Maximum Strength magnesium citrate oral solution gm/30ml Citroma METAMUCIL MULTIHEALTH FIER ORAL PACKET rand Drug; QL ( ML per ; QL (240 M per 30 ; QL (240 M per 30 ; QL (240 M per 30 ; QL (240 M per 30

20 Product Reference rand- eneric METAMUCIL MULTIHEALTH FIER ORAL POWDER %, 63 % METAMUCIL ORAL WAFER METAMUCIL SMOOTH TEXTURE ORAL PACKET milk of magnesia oral suspension 400 mg/5ml Phillips Milk of Magnesia natural fiber oral capsule Wal-Mucil natural fiber oral powder 58.6 % Metamucil MultiHealth Fiber natural fiber therapy oral powder 30 % natural senna laxative oral tablet mg phosphate laxative oral solution gm/5ml qc natural vegetable Hydrocil ra col-rite oral capsule 50 mg Colace sb fib lax orange oral powder 33 % sb natural fiber laxative senna laxative oral tablet 8.6 mg Evac-U-en senna oral capsule senna oral syrup 8.8 mg/5ml senna s Peri-Colace stool softener oral capsule 100 mg Colace WAL-MUCIL ORAL POWDER % *Minerals & Electrolytes* calcium + d3 calcium d3 Os-Cal D calcium 500/d oral tablet Os-Cal D calcium minerals calcium 600 oral tablet 600 mg High Potency Calcium calcium 600+d oral tablet mg-unit Caltrate 600+D ; QL (240 M per 30 ; QL (240 ML per 30 ; QL (240 M per 30 ; QL (240 M per 30 ; QL (240 M per 30 ; QL (240 M per 30 14

21 Product Reference rand- eneric calcium 600+d plus minerals oral tablet Caltrate 600+D Plus 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-Carb Forte calcium carbonate-vitamin d3 calcium oral tablet 500 mg, 600 mg calcium oral tablet chewable 500 mg calcium plus vitamin d3 oral tablet Caltrate 600+D calcium-vitamin d oral tablet mg-unit, mg-unit calcium-vitamin d oral tablet mg-unit Oystercal-D CALTRATE 600 elite calcium liquid calcium/vitamin d 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 MagOx 400 OS-CAL CALCIUM + D3 oyster shell calcium plus d oral tablet mg-unit oyster shell calcium/vitamin d oral tablet mg-unit *Mouth/Throat/Dental Agents* Oysco D LISTERINE ANTISEPTIC ORAL RELIEF SPRAY *Multivitamins* iotene Oralalance Dry Mouth adult one daily gummies One-A-Day VitaCraves Sour ; QL (240 ML per 30 15

22 Product Reference rand- eneric ANTIOXIDANT FORMULA S antioxidant oral capsule Ocuvite Adult 50+ b complex 50 oral tablet extendedrelease* b complex oral tablet b complex vitamins oral balanced b complex cr b-complex balanced Milco--Forte b-complex/b-12 sublingual centavite Apatate Forte cvs prenatal gummy multiple vitamin-folic acid Thera multi-vitamin/minerals Prosight ONE-A-DAY WOMENS PRENATAL ORAL & 440 M prenatal complete prenatal multi +dha oral capsule mg PRENATAL MULTIVITAMIN + DHA prenatal oral tablet mg Stuart Prenatal prenatal plus/iron M-Vit QL (240 EA per 30 prenatal+dha oral & 200 mg rena-vite Vitaline iotin Forte RIHT STEP PRENATAL SIMILAC PRENATAL EARLY SHIELD stress formula/zinc superior 35 Ultra Mega Two ULTRA MEA OLD vitamin c-electrolytes Maximin Pack 16

23 Product Reference rand- eneric vitamin e/folic acid/b-6/b-12 Ze-Plus vita-rx diabetic vitamin Carozyme QL (240 EA per 30 *Nasal Agents - Systemic And Topical* nasal moisturizing spray aby Ayr Saline *Nutrients* fish oil extra strength oral capsule 435 mg fish oil oral capsule 645 mg OMEA omega-3 fish oil Tyler Eskimo-3 *Ophthalmic Agents* artificial tears ophthalmic solution 1.4 % Akwa Tears ENTEAL MILD ONIOVISC OPHTHALMIC SOLUTION 2 % ISOPTO TEARS lubricant eye drops ophthalmic solution 0.5 % Refresh Plus natures tears ophthalmic solution 0.4 % NUTRATEAR PURE & ENTLE LURICANT OPHTHALMIC SOLUTION 3 M/ML REFRESH CELLUVISC SYSTANE CONTACTS THERATEARS OPHTHALMIC SOLUTION *Orexin Receptor Antagonists*** ELSOMRA ORAL TALET 10 M *Prenatal Mv & Minerals W/ Fa-Omega Fatty Acids W/O Iron*** cvs prenatal gummy *Psychotherapeutic And Neurological Agents - Misc.* ; QL (240 ML per 30 ; QL (240 ML per 30 ; QL (240 ML per 30 ; QL (240 ML per 30 ; QL (240 ML per 30 ; QL (240 ML per 30 ; QL (240 ML per 30 rand Drug; QL (240 EA per 30 acamprosate calcium Campral QL (240 EA per 30 17

24 Product Reference rand- eneric bupropion hcl er (smoking det) uproban QL (240 EA per 30 disulfiram oral Antabuse QL (240 EA per 30 RALISE RALISE STARTER HORIZANT ORAL TALET EXTENDEDRELEASE* olanzapine-fluoxetine hcl Symbyax ORAP perphenazine-amitriptyline pimozide Orap *Serotonin Modulators*** rand Drug; QL (240 EA per 30 rand Drug; QL (240 EA per 30 rand Drug; QL (240 EA per 30 Concomitant Antidepressant Treatment / Concomitant Antipsychotic Treatment / CYP 450; QL (240 EA per 30 ; Min 6 Years RAND DRU / Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years Concomitant Antidepressant Treatment / Concomitant Antipsychotic Treatment / CYP 450; QL (240 EA per 30 Concomitant Antipsychotic Treatment; QL (240 EA per 30 ; Min 6 Years nefazodone hcl oral tablet 250 mg, 50 mg QL (240 EA per 30 trazodone hcl oral QL (240 EA per 30 VIIRYD ORAL TALET QL (240 EA per 30 *Thyroid Agents* levothyroxine sodium oral Unithroid QL (240 EA per 30 liothyronine sodium oral Cytomel QL (240 EA per 30 SYNTHROID QL (240 EA per 30 *Vitamins* ascorbic acid oral tablet 500 mg PureWay-C b1 natural b-1 oral tablet 500 mg benfotiamine oral 18

25 Product Reference rand- eneric -NATAL NEURO-K-250 T.D. pyridoxine hcl ; QL (240 M per 30 pyridoxine hcl injection QL (240 ML per 30 sm vitamin d3 oral capsule 4000 unit thiamine thiamine hcl injection QL (240 ML per 30 vitamin b1 vitamin b-1 vitamin b-6 vitamin b-6 er vitamin b6 oral tablet 200 mg vitamin d (ergocalciferol) Drisdol QL (240 EA per 30 vitamin d oral tablet 1000 unit Vitamin D-1000 Max St vitamin d oral tablet 2000 unit Thera-D 2000 vitamin d3 oral capsule Dialyvite Vitamin D 5000 vitamin d3 oral liquid 400 unit/ml D-Vi-Sol vitamin d3 oral liquid 5000 unit/ml vitamin d3 oral tablet 400 unit, 5000 unit vitamin e oral capsule vitamin e oral tablet 100 unit, 200 unit vitamin e oral tablet 400 unit E-Pherol 19

26 Index Index AILIFY... 8 AILIFY MAINTENA... 8 acamprosate calcium ADDERALL XR... 1 adult one daily gummies aler-dryl... 7 allergy relief... 7 allergy relief childrens... 7 alprazolam... 2 alprazolam er... 2 ALPRAZOLAM INTENSOL... 2 amantadine hcl... 8 amitriptyline hcl... 3 amoxapine... 3 amphetamine-dextroamphetamine... 1 antioxidant ANTIOXIDANT FORMULA S APLENZIN... 3 ARISTADA... 8 artificial tears ascorbic acid b complex b complex b complex vitamins b b1 natural b balanced b complex cr b-complex balanced b-complex/b ELSOMRA benfotiamine benztropine mesylate... 8 bisacodyl ec bisacodyl laxative NATAL bromocriptine mesylate... 8 buprenorphine hcl... 2 buprenorphine hcl-naloxone hcl... 2 bupropion hcl... 3 bupropion hcl er (smoking det) bupropion hcl er (sr)... 3 bupropion hcl er (xl)... 3 buspirone hcl... 2 calcium calcium + d calcium d calcium 500/d calcium calcium minerals calcium 600+d calcium 600+d plus minerals calcium 600+d3 plus minerals calcium carbonate calcium carbonate-vitamin d calcium plus vitamin d calcium-vitamin d CALTRATE carbamazepine... 2 carbamazepine er... 2 centavite chloral hydrate chlordiazepoxide hcl... 2 Index chlorpromazine hcl... 8 chocolated laxative citalopram hydrobromide... 4 clomipramine hcl... 4 clonazepam... 2 clonidine hcl... 7 clorazepate dipotassium... 2 clozapine... 8 CVS NATURAL FIER SUPPLEMENT cvs prenatal gummy... 16, 17 cvs senna-extra cyanocobalamin cyproheptadine hcl... 7 DAYTRANA... 1 desipramine hcl... 4 desvenlafaxine er... 4 dextroamphetamine sulfate... 1 dextroamphetamine sulfate er... 1 diazepam... 2 diphenhydramine hcl... 7 diphenhydramine hcl (sleep) disulfiram divalproex sodium... 3 divalproex sodium er... 3 docusate calcium docusate sodium DOK doxepin hcl... 4 duloxetine hcl... 4 EDLUAR elite calcium EMSAM... 4 enema ENEMEEZ MINI epsom salt escitalopram oxalate... 4 estazolam eszopiclone FA FANAPT... 8 FANAPT TITRATION PACK... 8 FAZACLO... 8 fish oil fish oil extra strength fluoxetine hcl... 5 fluphenazine decanoate... 9 fluphenazine hcl... 9 flurazepam hcl fluvoxamine maleate... 5 fluvoxamine maleate er... 5 FOCALIN... 1 FOCALIN XR... 1 folic acid FORFIVO XL... 5 gabapentin... 3 ENTEAL MILD EODON... 9 ONIOVISC RALISE RALISE STARTER guanfacine hcl... 8 guanfacine hcl er... 1 Index haloperidol... 9 haloperidol decanoate... 9 haloperidol lactate... 9 HORIZANT HYDROCIL hydroxyzine hcl... 2 hydroxyzine pamoate... 2 imipramine hcl... 5 imipramine pamoate... 5 INTERMEZZO INVEA SUSTENNA... 9 INVEA TRINZA ISOPTO TEARS KAPVAY... 1 KHEDEZLA... 5 KONSYL KONSYL-D LAMICTAL... 3 lamotrigine... 3 lamotrigine er... 3 LATUDA laxative pills levothyroxine sodium liothyronine sodium liquid calcium/vitamin d LISTERINE ANTISEPTIC lithium lithium carbonate lithium carbonate er lorazepam... 2 LORAZEPAM INTENSOL... 2 loxapine succinate lubricant eye drops MA magnesium magnesium citrate magnesium oxide magnesium oxide -mg supplement maprotiline hcl... 5 MARPLAN... 6 meprobamate... 2 METADATE CD... 1 METAMUCIL METAMUCIL MULTIHEALTH FIER... 13, 14 METAMUCIL SMOOTH TEXTURE METHYLIN... 1 methylphenidate hcl... 1 methylphenidate hcl er... 1 methylphenidate hcl er (la)... 1 milk of magnesia mirtazapine... 6 multiple vitamin-folic acid multi-vitamin/minerals nadolol naltrexone hcl... 7 nasal moisturizing spray natural fiber natural fiber therapy natural senna laxative natures tears nefazodone hcl... 6, 18

27 Index NEURO-K-250 T.D nighttime sleep aid nortriptyline hcl... 6 NUTRATEAR olanzapine olanzapine-fluoxetine hcl OMEA omega-3 fish oil omega-3-acid ethyl esters... 7 ONE-A-DAY WOMENS PRENATAL ORAL RELIEF SPRAY ORAP OS-CAL CALCIUM + D oxazepam... 2 oxcarbazepine... 3 oyster shell calcium plus d oyster shell calcium/vitamin d paliperidone er paroxetine hcl... 6 paroxetine hcl er... 6 PAXIL... 6 perphenazine perphenazine-amitriptyline PEXEVA... 6 phenelzine sulfate... 6 phenobarbital phosphate laxative pimozide prazosin hcl... 8 prenatal prenatal complete prenatal multi +dha PRENATAL MULTIVITAMIN + DHA prenatal plus/iron prenatal+dha PRISTIQ... 6 propranolol hcl propranolol hcl er protriptyline hcl... 6 PURE & ENTLE LURICANT pyridoxine hcl qc natural vegetable quenalin... 7 quetiapine fumarate QUILLICHEW ER... 1 QUILLIVANT XR... 1 ra col-rite ra sleep aid ra sleep-aid nighttime REFRESH CELLUVISC rena-vite RIHT STEP PRENATAL RISPERDAL CONSTA risperidone... 10, 11 RITALIN LA... 1 ROZEREM SAPHRIS sb fib lax orange sb natural fiber laxative selegiline hcl... 8 senna senna laxative senna s SEROQUEL XR Index sertraline hcl... 6, 7 SILENOR SIMILAC PRENATAL EARLY SHIELD sleep-aid maximum strength sm vitamin d SOMNOTE stool softener STRATTERA... 2 stress formula/zinc SUOXONE... 2 superior SYNTHROID SYSTANE CONTACTS TERETOL-XR... 3 temazepam THERATEARS thiamine thiamine hcl thioridazine hcl thiothixene topiramate... 3 topiramate er... 3 tranylcypromine sulfate... 7 trazodone hcl... 7, 18 triazolam trifluoperazine hcl trihexyphenidyl hcl... 8 trimipramine maleate... 7 ULTRA MEA OLD valproate sodium... 3 valproic acid... 3 venlafaxine hcl... 7 venlafaxine hcl er... 7 VIIRYD... 7, 18 vitamin b vitamin b vitamin b vitamin b vitamin b vitamin b-6 er vitamin c-electrolytes vitamin d vitamin d (ergocalciferol) vitamin d vitamin e vitamin e/folic acid/b-6/b vita-rx diabetic vitamin VIVITROL... 7 VYVANSE... 2 WAL-DRYL-D WAL-MUCIL WAL-SLEEP Z zaleplon ziprasidone hcl zolpidem tartrate zolpidem tartrate er ZOLPIMIST ZYPREXA RELPREVV... 11

28 '()*'+)',-)'-'"*-./(-!-/,( )0/)'-' 01/01/ ! "#$%& January 1, 2017

29 Health Choice Integrated Care Formulary Effective January 1, 2017 Product Reference rand- eneric *Adhd/Anti-Narcolepsy/Anti-Obesity /Anorexiants* ADDERALL XR amphetamine-dextroamphetamine Adderall DAYTRANA dextroamphetamine sulfate er Dexedrine dextroamphetamine sulfate oral tablet Zenzedi FOCALIN FOCALIN XR guanfacine hcl er Intuniv KAPVAY ORAL TALET EXTENDED RELEASE 12 HR* METADATE CD METHYLIN ORAL SOLUTION METHYLIN ORAL TALET CHEWALE old; QL (30 EA per 30 old; QL (60 EA per 30 old; QL (30 EA per 30 old; QL (60 EA per 30 old; QL (60 EA per 30 old; QL (60 EA per 30 old; QL (60 EA per 30 old; QL (30 EA per 30 old; QL (120 EA per 30 old; QL (30 EA per 30 old; QL (300 ML per 30 old; QL (90 EA per 30 1

30 Product Reference rand- eneric methylphenidate hcl er (la) Ritalin LA old; QL (30 EA per 30 methylphenidate hcl er oral tablet extended release 24 hr* METHYLPHENIDATE HCL ER ORAL TALET EXTENDEDRELEASE* 18 M, 27 M, 36 M, 54 M Concerta methylphenidate hcl oral tablet Ritalin modafinil Provigil PA QUILLICHEW ER QUILLIVANT XR RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 M STRATTERA VYVANSE *Aminoglycosides* ETHKIS PA KITAIS PAK PA; SP old; QL (60 EA per 30 old; QL (60 EA per 30 old; QL (90 EA per 30 old; QL (30 EA per 30 old; QL (150 ML per 30 old; QL (30 EA per 30 old; QL (30 EA per 30 old; QL (30 EA per 30 neomycin sulfate oral paromomycin sulfate oral *Analgesics - Anti-Inflammatory* celecoxib oral CeleREX PA childrens ibuprofen 100 Childrens Advil diclofenac potassium Cataflam diclofenac sodium er Voltaren-XR diclofenac sodium oral ENREL SUCUTANEOUS* 25 M/0.5ML ENREL SUCUTANEOUS* 50 M/ML ENREL SUCUTANEOUS* SOLUTION RECONSTITUTED ENREL SURECLICK SUCUTANEOUS* 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 2

31 Product Reference rand- eneric etodolac er etodolac oral fenoprofen calcium oral tablet flurbiprofen oral HUMIRA PEN SUCUTANEOUS* HUMIRA SUCUTANEOUS* ibuprofen junior strength oral tablet chewable Motrin Junior Strength ibuprofen oral capsule Midol ibuprofen oral tablet 200 mg Motrin I ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN INDOCIN ORAL indomethacin er indomethacin oral infants ibuprofen Infants Advil ketoprofen oral PA; SP; QL (2 EA per 30 PA; SP; QL (2 EA per 30 ketorolac tromethamine oral QL (20 EA per 30 leflunomide oral Arava meloxicam oral tablet Mobic nabumetone oral naproxen dr EC-Naprosyn naproxen oral Naprosyn naproxen sodium oral tablet 220 mg Pamprin All Day Relief Max St naproxen sodium oral tablet 275 mg Anaprox naproxen sodium oral tablet 550 mg Anaprox DS oxaprozin Daypro piroxicam oral Feldene RIDAURA sm ibuprofen jr Motrin Junior Strength sulindac oral *Analgesics - Nonnarcotic* 8 hour pain relief Tylenol Arthritis Pain acetaminophen extra strength Medi-Tabs Extra Strength acetaminophen junior strength Tylenol Jr Meltaways acetaminophen oral elixir Medi-Tabs Childrens acetaminophen oral liquid Little Remedies for Fever acetaminophen oral solution 160 mg/5ml Little Fevers Fever-Pain Rel acetaminophen oral suspension 160 mg/5ml Tylenol Childrens acetaminophen oral tablet 325 mg Tylenol 3

32 Product Reference rand- eneric acetaminophen suppository 120 mg Feverall aspirin adult low strength oral tablet delayed release ayer Low Dose aspirin ec oral tablet delayed release 325 mg ayer Aspirin Regimen aspirin low strength ayer Low Dose aspirin oral tablet 325 mg ayer Aspirin aspirin suppository 300 mg, 600 mg buffered aspirin ufferin butalbital-acetaminophen Tencon butalbital-apap-caffeine oral capsule Orbivan butalbital-apap-caffeine oral tablet mg Fioricet butalbital-aspirin-caffeine oral capsule Fiorinal childrens acetaminophen oral tablet dispersible Tylenol Childrens Meltaways childrens non-aspirin oral tablet chewable Childrens Medi-Tabs choline & mag trisalicylate oral tablet 1000 mg choline-mag trisalicylate diflunisal oral extra strength acetaminophen feverall junior strength infants pain reliever Triaminic Infants migraine formula Pamprin Max non-aspirin jr strength oral tablet chewable Medi-Tabs Junior Strength pain relief 8 hour Tylenol Arthritis Pain q-pap infants ra aspirin oral tablet 500 mg ayer Advanced Aspirin Ex St salsalate oral Disalcid *Analgesics - Opioid* acetaminophen-codeine #2 QL (180 EA per 30 acetaminophen-codeine #3 Tylenol with Codeine #3 QL (180 EA per 30 acetaminophen-codeine #4 Tylenol with Codeine #4 QL (180 EA per 30 acetaminophen-codeine oral solution butalbital-apap-caff-cod Fioricet/Codeine QL (180 EA per 30 UTRANS PA; QL codeine sulfate oral tablet 30 mg, 60 mg QL (180 EA per 30 EMEDA PA; QL fentanyl transdermal patch 72 hr 100 mcg/hr Duragesic-100 PA; QL fentanyl transdermal patch 72 hr 12 mcg/hr Duragesic-12 PA; QL fentanyl transdermal patch 72 hr 25 mcg/hr Duragesic-25 PA; QL fentanyl transdermal patch 72 hr 50 mcg/hr Duragesic-50 PA; QL 4

33 Product Reference rand- eneric fentanyl transdermal patch 72 hr 75 mcg/hr Duragesic-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 hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg Zamicet Hycet Vicodin HP QL (180 EA per 30 Norco QL (180 EA per 30 Verdrocet QL (180 EA per 30 Vicodin QL (180 EA per 30 Xodol QL (180 EA per 30 hydrocodone-ibuprofen oral tablet mg Ibudone QL (180 EA per 30 hydrocodone-ibuprofen oral tablet mg Reprexain QL (180 EA per 30 hydrocodone-ibuprofen oral tablet mg Vicoprofen QL (180 EA per 30 hydromorphone hcl oral tablet Dilaudid QL (180 EA per 30 HYSINLA ER PA; QL meperidine hcl oral tablet Demerol QL (180 EA per 30 morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate er oral tablet extendedrelease* morphine sulfate oral solution MS Contin PA; QL morphine sulfate oral tablet QL (180 EA per 30 MORPHINE SULFATE SUPPOSITORY 10 M, 20 M, 5 M morphine sulfate suppository 30 mg oxycodone hcl oral capsule QL (180 EA per 30 oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution oxycodone hcl oral tablet QL (180 EA per 30 oxycodone-acetaminophen oral solution Roxicet oxycodone-acetaminophen oral tablet mg oxycodone-acetaminophen oral tablet mg, mg, mg Endocet QL (180 EA per 30 Percocet QL (180 EA per 30 oxycodone-aspirin oral tablet mg Percodan QL (180 EA per 30 OXYCONTIN ORAL PA; QL oxymorphone hcl Opana QL (180 EA per 30 tramadol hcl oral Ultram QL (180 EA per 30 tramadol-acetaminophen Ultracet 5

34 Product Reference rand- eneric *Androgens-Anabolic* ANDRODERM TRANSDERMAL PATCH 24 HR 2 M/24HR, 4 M/24HR 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 (1.62%) ANDROEL TRANSDERMAL EL 50 M/5M (1%) PA PA PA PA PA ANDROXY PA danazol oral FORTESTA PA testosterone cypionate intramuscular* solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular* solution Depo-Testosterone PA testosterone transdermal gel 10 mg/act (2%) Fortesta PA testosterone transdermal gel 12.5 mg/act (1%) Androel Pump PA testosterone transdermal gel 25 mg/2.5gm (1%) PA Androel PA testosterone transdermal gel 50 mg/5gm (1%) Testim PA VOELXO PUMP PA *Anorectal Agents* CORTIFOAM hydrocortisone ace-pramoxine cream 1-1 % Analpram-HC hydrocortisone enema Cortenema lidocaine-hydrocortisone ace cream LidaZone HC lidocaine-hydrocortisone ace kit Ana-Lex pramoxine hcl foam Proctofoam PROCORT PROCTOFOAM HC procto-med hc procto-pak *Antacids* acid gone oral suspension almacone oral tablet chewable mg aluminum hydroxide gel oral suspension 320 mg/5ml antacid & antigas oral suspension mg/5ml Mylanta Double-Strength 6

35 Product Reference rand- eneric antacid extra strength oral tablet chewable mg ANTACID ORAL TALET CHEWALE 1177 M Rolaids Extra Strength Rolaids Extra Strength antacid oral tablet chewable 420 mg Titralac antacid oral tablet chewable mg Rolaids calcium antacid Tums calcium antacid extra strength Tums E-X 750 calcium antacid ultra max st Tums Ultra 1000 childrens pepto Childrens Soothe geri-lanta supreme Mylanta Supreme heartburn antacid ex st aviscon Extra Strength magnesium oxide oral tablet 250 mg magnesium oxide oral tablet 400 mg Mag-Oxide magnesium oxide oral tablet 420 mg Maox mi-acid oral tablet chewable sm foaming antacid Acid one sodium bicarbonate oral tablet 325 mg, 650 mg *Anthelmintics* ALENZA ILTRICIDE ivermectin oral Stromectol pin-x oral suspension *Antianginal Agents* isosorbide dinitrate er isosorbide dinitrate oral isosorbide mononitrate isosorbide mononitrate er Imdur NITRO-ID nitroglycerin transdermal patch 24 hr Nitro-Dur nitroglycerin translingual Nitrolingual NITROSTAT RANEXA PA *Antianxiety Agents* alprazolam er Xanax XR QL (30 EA per 30 ALPRAZOLAM INTENSOL QL (60 ML per 15 alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg Xanax QL (120 EA per 30 alprazolam oral tablet 2 mg Xanax QL (60 EA per 30 alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg Niravam QL (120 EA per 30 alprazolam oral tablet dispersible 2 mg Niravam QL (60 EA per 30 7

36 Product Reference rand- eneric buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg QL (120 EA per 30 buspirone hcl oral tablet 30 mg QL (60 EA per 30 chlordiazepoxide hcl QL (60 EA per 30 clorazepate dipotassium oral tablet 15 mg Tranxene-T QL (60 EA per 30 clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg Tranxene-T QL (120 EA per 30 diazepam intensol QL (60 ML per 30 diazepam oral solution 1 mg/ml QL (300 ML per 30 diazepam oral tablet Valium QL (90 EA per 30 hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet hydroxyzine pamoate oral lorazepam intensol QL (60 ML per 30 lorazepam oral tablet 0.5 mg, 1 mg Ativan QL (120 EA per 30 lorazepam oral tablet 2 mg Ativan QL (60 EA per 30 oxazepam QL (60 EA per 30 *Antiarrhythmics* amiodarone hcl oral Cordarone disopyramide phosphate oral Norpace dofetilide Tikosyn flecainide acetate Tambocor mexiletine hcl oral MULTAQ NORPACE CR pacerone oral tablet 100 mg, 200 mg, 400 mg propafenone hcl Rythmol 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 ATROVENT HFA QL (26 M per 30 COMIVENT RESPIMAT 8