ANTIBIOTICS AKNE-MYCIN (erythromycin) CLEOCIN-T (clindamycin) CLINDAREACH (clindamycin) EVOCLIN (clindamycin) RETINOIDS

Transcription

1 ACNE AGENTS, TOPICAL CLINDAGEL (clindamycin) clindamycin erythromycin ANTIBIOTICS AKNE-MYCIN (erythromycin) CLEOCIN-T (clindamycin) CLINDAREACH (clindamycin) EVOCLIN (clindamycin) RETINOIDS DIFFERIN (adapalene) RETIN-A MICRO (tretinoin) tretinoin adapalene ATRALIN (tretinoin) TAZORAC (tazarotene) OTHERS ACZONE (dapsone) AZELEX (azelaic acid) BENZACLIN (benzoyl peroxide/ clindamycin) benzoyl peroxide benzoyl peroxide/sulfur CLARIFOAM EF (sodium sulfacetamide/sulfur) CLINAC BPO (benzoyl peroxide) EPIDUO (benzoyl peroxide/adapalene) NUOX (benzoyl peroxide/sulfur) ACANYA (benzoyl peroxide/clindamycin) AVAR-E (sodium sulfacetamide/sulfur) BENZAMYCIN (benzoyl peroxide/erythromycin) BREVOXYL (benzoyl peroxide) DELOS (benzoyl peroxide) DUAC (benzoyl peroxide/clindamycin) erythromycin/benzoyl peroxide INOVA (benzoyl peroxide) INOVA 4/1 (benzoyl peroxide/salicylic acid) KLARON (sodium sulfacetamide) LAVOCLEN (benzoyl peroxide) NEOBENZ MICRO (benzoyl peroxide) SE BPO (benzoyl peroxide) sodium sulfacetamide sodium sulfacetamide/sulfur sodium sulfacetamide/sulfur/meratan VELTIN (clindamycin/tretinoin) TRIAZ (benzoyl peroxide) ZIANA (clindamycin/tretinoin) ZODERM (benzoyl peroxide) 1

2 ALZHEIMER S AGENTS ARICEPT (donepezil) ARICEPT ODT (donepezil) EXELON (rivastigmine) CHOLINESTERASE INHIBITORS donepezil donepezil ODT galantamine galantamine ER RAZADYNE (galantamine) RAZADYNE ER (galantamine) NMDA RECEPTOR ANTAGONIST NAMENDA (memantine) ANALGESICS, NARCOTIC LONG ACTING EMBEDA (morphine/naltrexone) fentanyl patch PPG KADIAN (morphine) morphine PPG OPANA ER (oxymorphone) AVINZA (morphine) BUTRANS (buprenorphine) DURAGESIC (fentanyl) EXALGO (hydromorphone) MS CONTIN (morphine) oxycodone ER OXYCONTIN (oxycodone) oxymorphone ER RYZOLT (tramadol) tramadol ER ULTRAM ER (tramadol) 2

3 ANALGESICS, NARCOTIC SHORT ACTING (Non-parenteral) APAP/codeine PPG ASA/codeine butalbital/apap/caffeine/codeine butalbital/asa/caffeine/codeine codeine dihydrocodeine/apap/caffeine hydrocodone/apap PPG hydrocodone/ibuprofen hydromorphone PPG morphine PPG oxycodone PPG pentazocine/apap pentazocine/naloxone tramadol tramadol/apap ABSTRAL (fentanyl) ACTIQ (fentanyl) DEMEROL (meperidine) DILAUDID (hydromorphone) fentanyl FENTORA (fentanyl) FIORICET W/CODEINE (butalbital/apap/caffeine/codeine) FIORINAL W/CODEINE (butalbital/asa/caffeine/codeine) IBUDONE (hydrocodone/ibuprofen) levorphanol LORCET (hydrocodone/apap) LORTAB (hydrocodone/apap) meperidine NORCO (hydrocodone/apap) NUCYNTA (tapentadol) ONSOLIS (fentanyl) OPANA (oxymorphone) oxycodone/apap oxycodone/asa oxycodone/ibuprofen OXYFAST (oxycodone) PERCOCET (oxycodone/apap) propoxyphene propoxyphene/apap REPREXAIN (hydrocodone/ibuprofen) RYBIX ODT (tramadol) SYNALGOS-DC (dihydrocodeine/asa/caffeine) TALACEN (pentazocine/apap) TALWIN NX (pentazocine/naloxone) TYLENOL W/CODEINE (APAP/codeine) ULTRACET (tramadol/apap) ULTRAM (tramadol) VICODIN (hydrocodone/apap) VICOPROFEN (hydrocodone/ibuprofen) XODOL (hydrocodone/apap) Unless otherwise specified, the listing of a particular brand or generic name includes al l ZAMICET dosage forms (hydrocodone/apap) of that drug. 7/25/11 ZOLVIT (hydrocodone/apap) 3

4 ANALGESICS/ANESTHETICS, TOPICAL capsaicin OTC LIDODERM (lidocaine) PENNSAID (diclofenac) VOLTAREN (diclofenac) FLECTOR (diclofenac) QUTENZA (capsacin).. ANDROGENIC AGENTS, TOPICAL ANDRODERM (testosterone) ANDROGEL (testosterone) TESTIM (testosterone) FORTESTA (testosterone) ANGIOTENSIN MODULATORS benazepril captopril enalapril fosinopril lisinopril quinapril ramipril ACE INHIBITORS ACCUPRIL (quinapril) ACEON (perindopril) ALTACE (ramipril) CAPOTEN (captopril) LOTENSIN (benazepril) MAVIK (trandolapril) moexepril MONOPRIL (fosinopril) perindopril PRINIVIL (lisinopril) trandolapril UNIVASC (moexepril) VASOTEC (enalapril) ZESTRIL (lisinopril) ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hctz captopril/hctz enalapril/hctz fosinopril/hctz lisinopril/hctz quinapril/hctz ACCURETIC (quinapril/hctz) CAPOZIDE (captopril/hctz) LOTENSIN HCT (benazepril/hctz) moxepril/hctz MONOPRIL HCT (fosinopril/hctz) PRINZIDE (lisinopril/hctz) UNIRETIC (moexepril/hctz) VASERETIC (enalapril/hctz) ZESTORETIC (lisinopril/hctz) 4

5 ANGIOTENSIN MODULATORS (cont) BENICAR (olmesartan) DIOVAN (valsartan) losartan MICARDIS (telmisartan) ANGIOTENSIN II RECEPTOR BLOCKERS (ARBs) ATACAND (candesartan) AVAPRO (irbesartan) COZAAR (losartan) EDARBI (azilsartan) TEVETEN (eprosartan) ARB/DIURETIC COMBINATIONS BENICAR-HCT (olmesartan/hctz) DIOVAN-HCT (valsartan/hctz) losartan/hctz MICARDIS-HCT (telmisartan/hctz) ATACAND-HCT (candesartan/hctz) AVALIDE (irbesartan/hctz) HYZAAR (losartan/hctz) TEVETEN-HCT (eprosartan/hctz) DIRECT RENIN INHIBITORS TEKTURNA (aliskerin) DIRECT RENIN INHIBITOR/DIURETIC COMBINATIONS TEKTURNA HCT (aliskerin/hctz) ANGIOTENSIN MODULATOR COMBINATIONS AZOR (olmesartan/amlodipine) EXFORGE (valsartan/amlodipine) EXFORGE HCT (valsartan/amlodipine/hctz) LOTREL (benazepril/amlodipine) TRIBENZOR (olmesartan/amlodipine/hctz) TWYNSTA (telmisartan/amlodipine) benazepril/amlodipine TARKA (trandolapril/verapamil) TEKAMLO (aliskerin/amlodipine) trandolapril/verapamil VALTURNA (valsartan/aliskerin) ANTIBIOTICS, TOPICAL bacitracin gentamicin mupirocin ALTABAX (retapamulin) BACTROBAN (mupirocin) CENTANY (mupirocin) ANTIBIOTICS, VAGINAL clindamycin METROGEL (metronidazole) metronidazole CLEOCIN (clindamycin) CLINDAMAX (clindamycin) CLINDESSE (clindamycin) VANDAZOLE (metronidazole) 5

6 ANTICOAGULANTS ARIXTRA (fondaparinux) LOVENOX (enoxaparin) PRADAXA (dabigatran) for patients meeting clinical criteria warfarin COUMADIN (warfarin) fondaparinux FRAGMIN (dalteparin) ANTIDEPRESSANTS, OTHER bupropion CYMBALTA (duloxetine) MARPLAN (isocarboxazid) mirtazapine NARDIL (phenelzine) PRISTIQ (desvenlafaxine) trazodone venlafaxine ER tablets PPG Venlafaxine ER tablets APLENZIN (bupropion) DESYREL (trazodone) EFFEXOR (venlafaxine) EFFEXOR XR (venlafaxine) EMSAM (selegiline) nefazodone OLEPTRO ER (trazodone) phenelzine REMERON (mirtazapine) tranylcypromine venlafaxine IR venlafaxine ER capsules WELLBUTRIN (bupropion) Patients on a non-preferred product will be authorized to continue on that product. ANTIDEPRESSANTS, SSRIs citalopram fluoxetine fluvoxamine LEXAPRO (escitalopram) paroxetine sertraline CELEXA (citalopram) LUVOX CR (fluvoxamine) paroxetine CR PAXIL (paroxetine) PAXIL CR (paroxetine) PEXEVA (paroxetine) PROZAC (fluoxetine) SARAFEM (fluoxetine) ZOLOFT (sertraline) 6

7 ANTIEMETIC-ANTIVERTIGO AGENTS (excludes injectables) ANTICHOLINERGICS, ANTIHISTAMINES, DOPAMINE ANTAGONISTS dimenhydrinate meclizine metoclopramide prochlorperazine promethazine SCOPACE (scopolamine) trimethobenzamide TRANSDERM-SCOP (scopolamine) METOZOLV ODT (metoclopramide) CANNABINOIDS CESAMET (nabilone) dronabinol MARINOL (dronabinol) 5-HT3 RECEPTOR ANTAGONISTS product product product ondansetron SANCUSO (granisetron) ANZEMET (dolasetron) granisetron KYTRIL (granisetron) ZOFRAN (ondansetron) ZUPLENZ (ondansetron) SUBSTANCE P ANTAGONISTS EMEND (aprepitant) ANTIFUNGALS, ORAL clotrimazole fluconazole griseofulvin GRIS-PEG (griseofulvin) ketoconazole nystatin terbinafine ANCOBON (flucytosine) DIFLUCAN (fluconazole) GRIFULVIN V (griseofulvin) itraconazole LAMISIL (terbinafine) MYCELEX (clotrimazole) MYCOSTATIN (nystatin) NIZORAL (ketoconazole) NOXAFIL (posaconazole) SPORANOX (itraconazole) TERBINEX (terbinafine) VFEND (voriconazole) voriconazole 7

8 ANTIFUNGALS, TOPICAL NAFTIN (naftifine) OXISTAT (oxiconazole) ciclopirox solution clotrimazole ketoconazole miconazole nystatin terbinafine tolnaftate ANTIFUNGALS BENSAL HP (benzoic acid/salicylic acid) ciclopirox cream/gel/shampoo/suspension CNL 8 (ciclopirox) econazole ERTACZO (sertaconazole) EXELDERM (sulconazole) EXTINA (ketoconazole) LAMISIL (terbinafine) LOPROX (ciclopirox) LOTRIMIN (clotrimazole) MENTAX (butenafine) MONISTAT (miconazole) MYCELEX (clotrimazole) MYCOSTATIN (nystatin) NIZORAL (ketoconazole) PENLAC (ciclopirox) TINACTIN (tolnaftate) VUSION (miconazole/zinc/petrolatum) XOLEGEL (miconazole) ANTIFUNGAL/STEROID COMBINATIONS nystatin/triamcinolone clotrimazole/betamethasone LOTRISONE (clotrimazole/betamethasone) ANTIHISTAMINES, MINIMALLY SEDATING cetirizine syrup, tablets loratadine ANTIHISTAMINES ALLEGRA (fexofenadine) cetirizine chewable CLARINEX (desloratadine) CLARITIN (loratadine) fexofenadine levocetirizine XYZAL (levocetirizine) Treatment failure after no less than a 30-day trial of preferred product product product 8

9 ANTIHISTAMINES, MINIMALLY SEDATING (continued) cetirizine/pseudoephedrine loratadine/pseudoephedrine ANTIHISTAMINE/DECONGESTANT COMBINATIONS ALLEGRA-D (fexofenadine/pseudoephedrine) CLARINEX-D (desloratadine/pseudoephedrine) CLARITIN-D (loratadine/pseudoephedrine) fexofenadine/pseudoephedrine SEMPREX-D (acrivastine/pseudoephedrine) ANTIHYPERURICEMICS allopurinol probenecid probenecid/colchicine COLCRYS (colchicine) ULORIC (febuxostat) ZYLOPRIM (allopurinol) ANTIMIGRAINE AGENTS IMITREX injection, nasal (sumatriptan) RELPAX (eletriptan) TREXIMET (sumatriptan/naproxen) AMERGE (naratriptan) AXERT (almotriptan) CAMBIA (diclofenac) FROVA (frovatriptan) IMITREX tablets (sumatriptan) MAXALT (rizatriptan) sumatriptan ZOMIG (zolmitriptan) ANTIPARASITICS, TOPICAL EURAX (cromtamiton) permethrin ULESFIA (benzyl alcohol) ACTICIN (permethrin) ELIMITE (permethrin) lindane malathion OVIDE (malathion). ANTIPARKINSON S AGENTS (Oral) benztropine trihexyphenidyl ANTICHOLINERGICS COMT INHIBITORS COMTAN (entacapone) TASMAR (tolcapone) 9

10 ANTIPARKINSON S AGENTS (continued) bromocriptine REQUIP XL (ropinirole) ropinirole DOPAMINE AGONISTS MIRAPEX (pramipexole) MIRAPEX ER (pramipexole) PARLODEL (bromocriptine) pramipexole REQUIP (ropinirole) MAO-B INHIBITORS selegiline AZILECT (rasagiline) ELDEPRYL (selegiline) ZELAPAR (selegiline) OTHERS levodopa/carbidopa STALEVO (levodopa/carbidopa/entacapone) PARCOPA (levodopa/carbidopa) SINEMET (levodopa/carbidopa) ANTIPSYCHOTICS (Oral) ABILIFY (aripiprazole) chlorpromazine FANAPT (iloperidone) fluphenazine GEODON (ziprasidone) haloperidol INVEGA (paliperidone) perphenazine risperidone SAPHRIS (asenapine) SEROQUEL (quetiapine) SEROQUEL XR (quetiapine) thiothixene trifluoperazine ZYPREXA (olanzapine) ANTIPSYCHOTICS clozapine CLOZARIL (clozapine) FAZACLO (clozapine) LATUDA (lurasidone) MOBAN (molindone) NAVANE (thiothixene) ORAP (pimozide) RISPERDAL (risperidone) thioridazine perphenazine/amitriptyline SYMBYAX (olanzapine/fluoxetine) ANTIPSYCHOTIC/SSRI COMBINATIONS 10

11 ANTIVIRALS, ANTIHERPETIC (Oral) acyclovir VALTREX (valacyclovir) FAMVIR (famciclovir) valacyclovir ZOVIRAX (acyclovir) ANTIVIRALS, TOPICAL ABREVA (docosanol) DENAVIR (penciclovir) ZOVIRAX OINTMENT (acyclovir) XERESE (acyclovir/hydrocortisone) ZOVIRAX CREAM (acyclovir) BETA BLOCKERS (Oral) acebutolol atenolol betaxolol bisoprolol BYSTOLIC (nebivolol) INNOPRAN XL (propranolol) LEVATOL (penbutolol) metoprolol IR nadolol pindolol propranolol IR sotalol timolol TOPROL XL (metoprolol) BETA BLOCKERS BETAPACE (sotalol) CORGARD (nadolol) INDERAL (propranolol) KERLONE (betaxolol) LOPRESSOR (metoprolol) metoprolol XL propranolol ER SECTRAL (acebutolol) TENORMIN (atenolol) ZEBETA (bisoprolol) BETA BLOCKER COMBINATIONS atenolol/chlorthalidone bisoprolol/hctz metoprolol/hctz nadolol/bendroflumethiazide propranolol/hctz CORZIDE (nadolol/bendroflumethiazide) INDERIDE (propranolol/hctz) LOPRESSOR HCT (metoprolol/hctz) TENORETIC (atenolol/hctz) ZIAC (bisoprolol/hctz) 11

12 BETA BLOCKERS (continued) carvedilol labetalol BETA- AND ALPHA- BLOCKERS COREG (carvedilol) COREG CR (carvedilol) TRANDATE (labetalol) BILE SALTS ursodiol ACTIGALL (ursodiol) CHENODAL (chenodiol) URSO (ursodiol) URSO FORTE (urosodiol) BLADDER RELAXANT PREPARATIONS ENABLEX (darifenacin) oxybutynin IR VESICARE (solifenacin) DETROL (tolterodine) DETROL LA (tolterodine) DITROPAN (oxybutynin) DITROPAN XL (oxybutynin) GELNIQUE (oxybutynin) oxybutynin ER (oxybutynin) OXYTROL (oxybutynin) SANCTURA (trospium) SANCTURA XR (trospium) TOVIAZ (fesoterodine) BONE RESORPTION SUPPRESSION AND RELATED AGENTS alendronate PPG BISPHOSPHONATES ACTONEL (risedronate) ACTONEL W/ CALCIUM (risedronate/calcium) ATELVIA (risedronate) BONIVA (ibandronate) DIDRONEL (etidronate) etidronate FOSAMAX (alendronate) FOSAMAX PLUS D (alendronate/vitamin D) OTHER BONE RESORPTION SUPPRESSION AND RELATED AGENTS MIACALCIN (calcitonin) calcitonin nasal EVISTA (raloxifene) FORTEO (teriparatide) FORTICAL (calcitonin) 12

13 BPH AGENTS doxazosin FLOMAX (tamsulosin) terazosin UROXATRAL (alfuzosin) ALPHA BLOCKERS alfuzosin CARDURA (doxazosin) CARDURA XL (doxazosin) HYTRIN (terazosin) tamsulosin product product product 5-ALPHA-REDUCTASE (5AR) INHIBITORS finasteride AVODART (dutasteride) PROSCAR (finasteride) ALPHA BLOCKER/5AR INHIBITOR COMBINATIONS JALYN (dutasteride/tamsulosin) BRONCHODILATORS, BETA AGONIST PROVENTIL HFA (albuterol) XOPENEX HFA (levalbuterol) INHALERS, SHORT-ACTING MAXAIR (pirbuterol) PROAIR HFA (albuterol) VENTOLIN HFA (albuterol) INHALERS, LONG-ACTING FORADIL (formoterol) SEREVENT (salmeterol) History of intolerable side effects to preferred product INHALATION SOLUTION XOPENEX (levalbuterol) albuterol ACCUNEB (albuterol) BROVANA (arformoterol) levalbuterol PERFOROMIST (formoterol) ORAL albuterol terbutaline BRETHINE (terbutaline) metaproterenol VOSPIRE ER (albuterol) 13

14 CALCIUM CHANNEL BLOCKERS (Oral) diltiazem ER nifedipine verapamil SHORT-ACTING CALAN (verapamil) CARDENE (nicardipine) CARDIZEM (diltiazem) diltiazem LA DYNACIRC (isradipine) isradipine nicardipine nimodipine NIMOTOP (nimodipine) PROCARDIA (nifedipine) VERELAN (verapamil) LONG-ACTING amlodipine diltiazem felodipine nifedipine verapamil ER ADALAT CC (nifedipine) CALAN SR (verapamil) CARDENE SR (nicardipine) CARDIZEM CD (diltiazem) CARDIZEM LA (diltiazem) COVERA-HS (verapamil) DILACOR XR (diltiazem) DYNACIRC CR (isradipine) ISOPTIN SR (verapamil) nisoldipine NORVASC (amlodipine) PLENDIL (felodipine) PROCARDIA XL (nifedipine) SULAR (nisoldipine) TIAZAC (diltiazem) verapamil ER PM VERELAN PM (verapamil) 14

15 CEPHALOSPORINS AND RELATED ANTIBIOTICS (Oral) BETA LACTAM/BETA-LACTAMASE INHIBITOR COMBINATIONS amoxicillin/clavulanate IR AUGMENTIN 125 and 250 suspension only (amoxicillin/clavulanate) AUGMENTIN XR (amoxicillin/clavulanate) amoxicillin/clavulanate XR AUGMENTIN (amoxicillin/clavulanate) except 125 and 250 suspension CEPHALOSPORINS First Generation cefadroxil cephalexin KEFLEX (cephalexin) PANIXINE (cephalexin) CEPHALOSPORINS Second Generation cefaclor cefprozil cefuroxime CEFTIN (cefuroxime) CEPHALOSPORINS Third Generation CEDAX (ceftibuten) cefdinir cefpodoxime SUPRAX (cefixime) cefditoren OMNICEF (cefdinir) SPECTRACEF (cefditoren) VANTIN (cefpodoxime) COLONY STIMULATING FACTORS COPD AGENTS LEUKINE (sargramostim, GM-CSF) NEULASTA (pegfilgrastim) NEUPOGEN (filgrastim, G-CSF) ATROVENT HFA (ipratropium) ipratropium inhalation solution SPIRIVA (tiotropium) COMBIVENT (albuterol/ipratropium) ANTICHOLINERGICS ANTICHOLINERGIC-BETA AGONIST COMBINATIONS albuterol/ipratropium DUONEB (albuterol/ipratropium) COUGH AND COLD AGENTS See Separate Preferred Cough and Cold Agent Listing 15

16 CYTOKINE AND CAM ANTAGONISTS CIMZIA (certolizumab) ENBREL (etanercept) HUMIRA (adalimumab) KINERET (anakinra) SIMPONI (golimumab) ERYTHROPOIESIS STIMULATING PROTEINS EPOGEN (RhUEPO) PROCRIT (RhUEPO) ARANESP (darbepoetin) FIBROMYALGIA AGENTS CYMBALTA (duloxetine) LYRICA (pregabalin) SAVELLA (milnacipran) FLUROQUINOLONES, ORAL AVELOX (moxifloxacin) ciprofloxacin IR LEVAQUIN (levofloxacin) levofloxacin CIPRO (ciprofloxacin) ciprofloxacin ER FACTIVE (gemifloxacin) NOROXIN (norfloxacin) ofloxacin PROQUIN XR (ciprofloxacin) Cipro Suspension will be authorized for patients 10 years of age and under. GLUCOCORTICOIDS, INHALED ASMANEX (mometasone) budesonide FLOVENT (fluticasone) QVAR (beclomethasone) GLUCOCORTICOIDS AEROBID (flunisolide) AEROBID-M (flunisolide) ALVESCO (ciclesonide) AZMACORT (triamcinolone) PULMICORT (budesonide) GLUCOCORTICOID/BRONCHODILATOR COMBINATIONS ADVAIR (fluticasone/salmeterol) SYMBICORT (budesonide/formoterol) DULERA (mometasone/formoterol) Pulmicort Respules will be authorized for patients 8 years of age and under. GROWTH HORMONE GENOTROPIN (somatropin) NORDITROPIN (somatropin) NUTROPIN AQ (somatropin) HUMATROPE (somatropin) NUTROPIN (somatropin) OMNITROPE (somatropin) SAIZEN (somatropin) SEROSTIM (somatropin) TEV-TROPIN (somatropin) ZORBTIVE (somatropin) 16

17 HEPATITIS C AGENTS PEGASYS (pegylated IFN alfa-2a) PEG-INTRON (pegylated IFN alfa-2b) INFERGEN (consensus IFN) product of same type product of same type product of same type HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS SYMLIN (pramlintide) AMYLIN ANALOGS Patient must meet all of the following criteria: o Diagnosis of diabetes mellitus o Age >18 years o HbA1 C in past 6 months o No history of gastroparesis, neurologic manifestations of diabetes or recent treatment of hypoglycemia JANUMET (sitagliptin/metformin) JANUVIA (sitagliptin) KOMBIGLYZE XR (saxagliptin/metformin) ONGLYZA (saxagliptin) INCRETIN ENHANCERS BYETTA (exenatide) INCRETIN MIMETICS VICTOZA (liraglutide) HYPOGLYCEMICS, INSULIN HUMALOG Vials (insulin lispro) LANTUS (insulin glargine) NOVOLIN (insulin) NOVOLOG (insulin aspart) NOVOLOG MIX (insulin aspart/aspart protamine) APIDRA (insulin glulisine) HUMALOG Pens (insulin lispro/lispro protamine) HUMALOG MIX (insulin lispro/lispro protamine) HUMULIN (insulin) LEVEMIR (insulin detemir) HYPOGLYCEMICS, MEGLITINIDES nateglinide PRANDIN (repaglinide) PRANDIMET (repaglinide/metformin) STARLIX (nateglinide) Separate prescriptions for the individual components should be used instead of the combination product. 17

18 HYPOGLYCEMICS, TZD ACTOS (pioglitazone) AVANDIA (rosiglitazone) THIAZOLINEDIONES Separate prescriptions for the individual components should be used instead of the combination product. TZD COMBINATIONS ACTOPLUS MET (pioglitazone/metformin) AVANDAMET (rosiglitazone/metformin) AVANDARYL (rosiglitazone/glimepiride) DUETACT (pioglitazone/glimepiride) IMMUNOMODULATORS, ATOPIC DERMATITIS ELIDEL (pimecrolimus) PROTOPIC (tacrolimus) INTRANASAL RHINITIS AGENTS BECONASE AQ (beclomethasone) NASONEX (mometasone) GLUCOCORTICOIDS FLONASE (fluticasone propionate) flunisolide fluticasone NASACORT AQ (triamcinolone) NASAREL (flunisolide) OMNARIS (ciclesonide) RHINOCORT AQUA (budesonide) triamcinolone VERAMYST (fluticasone furoate) OTHERS ASTEPRO (azelastine) PATANASE (olopatadine) ASTELIN (azelastine) ATROVENT nasal spray (ipratropium) ipratropium nasal spray IRON, ORAL See Separate Listing Of Preferred Oral Iron Products LEUKOTRIENE MODIFIERS ACCOLATE (zafirlukast) SINGULAIR (montelukast) zafirlukast ZYFLO CR (zileuton) product product product 18

19 LIPOTROPICS, OTHER cholestyramine COLESTID (colestipol) BILE ACID SEQUESTRANTS colestipol QUESTRAN (cholestyramine) WELCHOL (colesevalam) CHOLESTEROL ABSORPTION INHIBITORS ZETIA (ezetimibe) FIBRIC ACID DERIVATIVES gemfibrozil TRICOR (fenofibrate) TRILIPIX (fenofibric acid) ANTARA (fenofibrate) fenofibrate fenofibric acid FENOGLIDE (fenofibrate) FIBRICOR (fenofibric acid) LIPOFEN (fenofibrate) LOFIBRA (fenofibrate) LOPID (gemfibrozil) TRIGLIDE (fenofibrate) NIACIN niacin NIACOR (niacin) NIASPAN (niacin) OMEGA-3 FATTY ACIDS LOVAZA (omega-3 fatty acids) LIPOTROPICS, STATINS CRESTOR (rosuvastatin) LESCOL (fluvastatin) LESCOL XL (fluvastatin) LIPITOR (atorvastatin) pravastatin simvastatin STATINS ALTOPREV (lovastatin) LIVALO (pitavastatin) lovastatin MEVACOR (lovastatin) PRAVACHOL (pravastatin) ZOCOR (simvastatin) Treatment failure with at least two preferred accounting for no less than 120 days of therapy combined STATIN COMBINATIONS SIMCOR (simvastatin/niacin) ADVICOR (lovastatin/niacin) CADUET (atorvastatin/amlodipine) VYTORIN (simvastatin/ezetimibe) 19

20 MACROLIDES/KETOLIDES (Oral) azithromycin clarithromycin IR EES (erythromycin) ERYTHROCIN (erythromycin) ERY-TAB (erythromycin) ERYPED (erythromycin) erythromycin PCE (erythromycin) Z-MAX (azithromycin) KETOLIDES KETEK (telithromycin) MACROLIDES BIAXIN (clarithromycin) BIAXIN XL (clarithromycin) clarithromycin ER ZITHROMAX (azithromycin) NSAIDS diclofenac etodolac fenoprofen flurbiprofen ibuprofen (except Rx suspension) INDOCIN suspension (indomethacin) indomethacin ketoprofen ketorolac meclofenamate nabumetone naproxen oxaprozin piroxicam sulindac NONSPECIFIC ANAPROX (naproxen) ANSAID (flurbiprofen) CATAFLAM (diclofenac) CLINORIL (sulindac) DAYPRO (oxaprozin) FELDENE (piroxicam) ibuprofen Rx suspension INDOCIN (indomethacin) (excluding suspension) mefenamic acid MOTRIN (ibuprofen) NALFON (fenoprofen) NAPRELAN (naproxen) NAPROSYN (naproxen) PONSTEL (meclofenamate) tolmetin VOLTAREN (diclofenac) ZIPSOR (diclofenac) NSAID/GI PROTECTANT COMBINATIONS VIMOVO (naproxen/ esomeprazole) ARTHROTEC (diclofenac/misoprostol) 20

21 NSAIDs COX-II SELECTIVE continued meloxicam CELEBREX (celecoxib) MOBIC (meloxicam) OPHTHALMICS, ANTIBIOTIC STEROID COMBINATIONS neomycin/polymyxin/dexamethasone sulfacetamide/prednisolone TOBRADEX (tobramycin/dexamethasone) ZYLET (tobramycin/loteprednol) BLEPHAMIDE (sulfacetamide/prednisolone) CORTISPORIN Ointment (neomycin/bacitracin/polymyxin/hydrocortisone CORTISPORIN Suspension (neomycin/polymyxin/hydrocortisone) MAXITROL (neomycin/polymyxin/dexamethasone) neomycin/bacitracin/polymyxin/hydrocortisone neomycin/polymyxin/hydrocortisone POLY-PRED (neomycin/polymyxin/prednisolone) PRED-G (gentamicin/prednisolone) TOBRADEX ST (tobramycin/dexamethasone) tobramycin/dexamethasone OPHTHALMICS FOR ALLERGIC CONJUNCTIVITIS ALREX (loteprednol) BEPREVE (bepotastine) cromolyn ketotifen OPTIVAR (azelastine) PATADAY (olopatadine) PATANOL (olopatadine) ALAMAST (pemirolast) ALOCRIL (nedocromil) ALOMIDE (lodoxamide) azelastine CROLOM (cromolyn) ELESTAT (epinastine) EMADINE (emedastine) epinastine LASTACAFT (alcaftadine) VOLTAREN (ketotifen) ZADITOR (ketotifen) OPHTHALMIC ANTIBIOTICS gentamicin tobramycin TOBREX Ointment AMINOGLYCOSIDES 21

22 OPHTHALMIC ANTIBIOTICS continued BESIVANCE (besifloxacin) MOXEZA (moxifloxacin) ofloxacin VIGAMOX (moxifloxacin) QUINOLONES CILOXAN (ciprofloxacin) ciprofloxacin IQUIX (levofloxacin) levofloxacin OCUFLOX (ofloxacin) QUIXIN (levofloxacin) ZYMAXID (gatifloxacin) ZYMAR (gatifloxacin) MACROLIDES erythromycin AZASITE (azithromycin) OTHER bacitracin/polymyxin neomycin/polymyxin/gramicidin polymyxin/trimethoprim sulfacetamide bacitracin bacitracin/neomycin/polymyxin NATACYN (natamycin) OPHTHALMICS, GLAUCOMA AGENTS ALPHAGAN P (brimonidine) brimonidine dipivefrin pilocarpine SYMPATHOMIMETICS ISOPTO CARPINE (pilocarpine) PROPINE (dipivefrin) BETA BLOCKERS betaxolol BETIMOL (timolol) BETOPTIC S (betaxolol) carteolol ISTALOL (timolol) levobunolol metipranolol timolol BETAGAN (levobunolol) OPTIPRANOLOL (metipranolol) TIMOPTIC (timolol) CARBONIC ANHYDRASE INHIBITORS AZOPT (brinzolamide) dorzolamide TRUSOPT (dorzolamide) 22

23 OPHTHALMICS, GLAUCOMA AGENTS continued TRAVATAN-Z (travoprost) XALATAN (latanoprost) PROSTAGLANDIN ANALOGS latanoprost LUMIGAN (bimatoprost) COMBINATION AGENTS COMBIGAN (brimonidine/timolol) dorzolamide/timolol COSOPT (dorzolamide/timolol) OPHTHALMICS, ANTI- INFLAMMATORIES flurbiprofen NEVANAC (nepafenac) NSAIDS ACULAR (ketorolac) ACULAR LS (ketorolac) ACULAR PF (ketorolac) ACUVAIL (ketorolac) bromfenac diclofenac ketorolac OCUFEN (flurbiprofen) VOLTAREN (diclofenac) XIBROM (bromfenac) STEROIDS dexamethasone FLAREX (fluorometholone) fluorometholone FML FORTE (fluorometholone) FML S.O.P. (fluorometholone) LOTEMAX (loteprednol) MAXIDEX (dexamethasone) PRED MILD (prednisolone) prednisolone DUREZOL (difluprednate) VEXOL (rimexolone) OTIC ANTIBIOTICS CIPRODEX (ciprofloxacin/dexamethasone) neomycin/polymyxin/hydrocortisone ofloxacin CETRAXAL (ciprofloxacin) CIPRO HC (ciprofloxacin/hydrocortisone) COLY-MYCIN S (colistin/neomycin/thonzonium/hydrocortisone) CORTISPORIN-TC (colistin/neomycin/thonzonium/hydrocortisone) FLOXIN (ofloxacin) 23

24 PAH AGENTS (Oral, Inhalation) ADCIRCA (tadalafil) LETAIRIS (ambrisentan) REVATIO (sildenafil) TRACLEER (bosentan) PANCREATIC ENZYMES CREON (pancrelipase) PANCREAZE (pancrelipase) pancrelipase ZENPEP (pancrelipase) PHOSPHATE BINDERS FOSRENOL (lanthanum) PHOSLO (calcium acetate) RENAGEL (sevelamer HCl) calcium acetate ELIPHOS (calcium acetate) RENVELA (sevelamer carbonate) Diagnosis of ESRD and hyperphosphatemia despite dietary phosphorous restrictions and at least one of the following: hypercalcemia (corrected serum calcium >10.2 mg/dl) plasma PTH levels <150 pg/ml on two consecutive measurements dialysis patients with severe vascular and/or soft tissue calcifications allergic reaction to preferred product treatment failure with preferred product PLATELET AGGREGATION INHIBITORS AGGRENOX (dipyridamole/aspirin) PLAVIX (clopidogrel) dipyridamole EFFIENT (prasugrel) PERSANTINE (dipyridamole) ticlopidine product. product. product. PRENATAL VITAMINS See Separate Preferred Prenatal Vitamin Listing Prenatal vitamins are covered only for females less than 50 years of age. 24

25 PROTON PUMP INHIBITORS (Oral) ACIPHEX (rabeprazole) NEXIUM (esomeprazole) DEXILANT (dexlansoprazole) lansoprazole omeprazole pantoprazole PREVACID (lansoprazole) PRILOSEC (omeprazole) PROTONIX (pantoprazole) ZEGERID OTC (omeprazole/sodium bicarbonate) Treatment failure after no less than a 30 day trial of each preferred product Prevacid Solutabs will be approved for children 10 years of age and under SEDATIVE HYPNOTICS flurazepam temazepam 15, 30 mg PPG triazolam BENZODIAZEPINES DORAL (quazepam) estazolam HALCION (triazolam) PROSOM (estazolam) RESTORIL (temazepam) temazepam 7.5, 22.5 mg OTHERS chloral hydrate LUNESTA (eszopiclone) zaleplon zolpidem AMBIEN (zolpidem) AMBIEN CR (zolpidem) EDLUAR (zolpidem) ROZEREM (ramelteon) SILENOR (doxepin) SONATA (zaleplon) ZOLPIMIST (zolpidem) SKELETAL MUSCLE RELAXANTS baclofen carisoprodol carisoprodol/asa chlorzoxazone cyclobenzaprine methocarbamol orphenadrine orphenadrine compound tizanidine AMRIX (cyclobenzaprine ER) cyclobenzaprine ER dantrolene FEXMID (cyclobenzaprine) FLEXERIL (cyclobenzaprine) metaxolone NORFLEX (orphenadrine) PARAFON FORTE (chlorzoxazone) ROBAXIN (methocarbamol) SKELAXIN (metaxolone) SOMA (carisoprodol) ZANAFLEX (tizanidine) 25

26 STEROIDS, TOPICAL alclometasone DERMA-SMOOTHE/FS (fluocinolone) desonide hydrocortisone LOW POTENCY DESONATE (desonide) DESOWEN (desonide) PEDIADERM HC (hydrocortisone) VERDESO (desonide) MEDIUM POTENCY hydrocortisone valerate mometasone CLODERM (clocortolone) CORDRAN (flurandrenolide) CUTIVATE (fluticasone) fluticasone propionate hydrocortisone butyrate LUXIQ (betamethasone) MOMEXIN (mometasone) PANDEL (hydrocortisone probutate) prednicarbate HIGH POTENCY betamethasone valerate fluocinolone fluocinonide triamcinolone amcinonide betamethasone dipropionate CAPEX (fluocinolone) desoximetasone diflorasone HALOG (halcinonide) KENALOG aerosol (triamcinolone) VANOS (fluocinonide) VERY HIGH POTENCY clobetasol halobetasol CLOBEX (clobetasol) HALONATE (halobetasol) OLUX (clobetasol) ULTRAVATE (halobetasol) 26

27 STIMULANTS AND RELATED AGENTS ADDERALL XR (amphetamine salt combination) amphetamine salt combination IR CONCERTA (methylphenidate) DAYTRANA (methylphenidate) dexmethylphenidate dextroamphetamine FOCALIN XR (dexmethylphenidate) METHYLIN (methylphenidate) methylphenidate PPG VYVANSE (lisdexamfetamine) STIMULANTS ADDERALL (amphetamine salt combination) amphetamine salt combination ER DEXEDRINE (dextroamphetamine) DEXEDRINE SPANSULES (dextroamphetamine) FOCALIN (dexmethylphenidate) METADATE CD (methylphenidate) METHYLIN (methylphenidate) chewable tablets methylphenidate SA (equivalent to Concerta) NUVIGIL (armodafinil) PROCENTRA (dextroamphetamine) PROVIGIL (modafinil) RITALIN (methylphenidate) NON-STIMULANTS INTUNIV (guanfacine ER) KAPVAY (clonidine ER) STRATTERA (atomoxetine) TETRACYCLINES doxycycline hyclate minocycline capsules tetracycline VIBRAMYCIN suspension (doxycycline) ADOXA CK (doxycycline) ADOXA TT (doxycycline) demeclocycline doxycycline hyclate DR doxycycline monohydrate DYNABAC (dirithromycin) minocycline ER minocycline tablets NUTRIDOX (doxycycline) ORACEA (doxycycline) SOLODYN (minocycline) ULCERATIVE COLITIS ASACOL (mesalamine) COLAZAL (balsalazide) LIALDA (mesalamine) PENTASA (mesalamine) sulfasalazine ORAL APRISO (mesalamine) ASACOL HD (mesalamine) AZULFIDINE (sulfasalazine) balsalazide DIPENTUM (olsalazine of same route of same route of same route 27

28 ULCERATIVE COLITIS (continued) CANASA (mesalamine) SFROWASA (mesalamine) mesalamine ROWASA (mesalamine) RECTAL 28

29 PREMIUM PREFERRED GENERIC () MANUFACTURERS: These manufacturers have offered Supplemental Rebates to the state for their PDL dispensed to Medicaid recipients. Pharmacists will receive an additional $0.50 dispensing fee when they dispense the PDL of these manufacturers. Generic Manufacturer Mallinckrodt Sun Pharma Glob Labeler Code(s) 29

30 PRENATAL VITAMINS January 20, 2011 PREFERRED DRUGS NON-PREFERRED DRUGS CAVAN-ALPHA KIT ADVANCED CARE PLUS CAVAN-EC SOD DHA CAVAN ONE OMEGA CITRANATAL 90 DHA CITRANATAL HARMONY CITRANATAL ASSURE CONCEPT DHA CITRANATAL B-CALM CONCEPT OB CITRANATAL DHA DOCOSAVIT CITRANATAL RX DUET DHA COMPLETE NATAL DHA DUET DHA COMPLETE COMPLETENATE DUET DHA EC COMPLETE-RF PRENATAL DUET DHA WITH FERRAZONE DUALVIT OB DUET STUARTNATAL ED CYTE F EDGE OB FE C ELITE OB DHA FEMECAL OB ELITE-OB FOLBECAL FOLCAL DHA FOLTABS FOLCAPS CARE ONE FOLTABS 90 PLUS DHA FOLINATAL PLUS B FOLTABS PRENATAL PLUS DHA FOLIVANE-EC CALCIUM DHA NF ICAR-C PLUS FOLIVANE-OB ICAR-C PLUS SR FOLIVANE-PRX DHA NF INATAL ADVANCE GESTICARE INATAL GT GESTICARE DHA INATAL ULTRA MULTINATAL PLUS LACTOCAL-F NATACHEW MARNATAL-F NATELLE MARNATAL-F PLUS NATELLE ONE MATERNITY NATELLE PLUS MAXINATE NATELLE PREFER MISSION PRENATAL FA OTC NATELLE-EZ MISSION PRENATAL HP OTC NEEVO MISSION PRENATAL OTC NEEVO DHA MULTIFOL PLUS OB COMPLETE MULTI-NATE 30 OB COMPLETE 400 MULTI-NATE 30 DHA OB COMPLETE DHA MULTI-NATE DHA EXTRA OB-NATAL ONE M-VIT PNV-DHA NATACAPS PNV-DHA + DOCUSATE NATAFORT PNV-SELECT NATALCARE PLUS PRECARE CONCEIVE NATALVIT PRECARE PREMIER NUTRISPIRE PREFERA-OB ONE OB + DHA PRENATE DHA OB 90 + DHA PRENATE DHA 1 of 3

31 PRENATAL VITAMINS January 20, 2011 PREFERRED DRUGS NON-PREFERRED DRUGS O-CAL FA PRENATE ELITE O-CAL PRENATAL PRENATE ESSENTIAL POLY IRON PN PRENATE PLUS POLY IRON PN FORTE PRENEXA PR NATAL 400 PREQUE 10 PR NATAL 400 EC PRIMACARE ONE PR NATAL 430 RENATE DHA EXTRA PR NATAL 430 EC ROVIN-NV PR NATAL 440 EC ROVIN-NV DHA PREFERA OB SE-CARE PREFERA-OB PLUS DHA SE-CARE CONCEIVE PRENACARE SE-CARE GESTURE PRENAFIRST SE-PLETE DHA PRENAPLUS TANDEM DHA PRENATABS FA TANDEM OB PRENATABS RX TARON EC CALCIUM PRENATAL 1-1 TARON-C DHA PRENATAL 19 TARON-EC CAL PRENATAL AD TARON-PREX PRENATAL PRENATAL LOW IRON TRICARE DHA PRENATAL MR 90 FE TRIMESIS RX PRENATAL MULTIVITAMIN W-IRON TRIVEEN-ONE PRENATAL PLUS TRIVEEN-PRX RNF PRENATAL VITAMINS OTC ULTIMATECARE ADVANTAGE PRENATAL Z ULTIMATECARE COMBO PRENATAL-U ULTIMATECARE ONE PRENAVITE OTC ULTIMATECARE ONE NF PREVITE RX VINACAL PRUET DHA VIVA DHA PRUET DHA EC ZATEAN-PN RE-NATA 29 ZATEAN-PN DHA RE-NATA 29 OB ZATEAN-PN PLUS SELECT-OB SELECT-OB + DHA SE-NATAL 19 SE-NATAL 90 SE-NATAL ONE SE-TAN DHA SETONET SETONET-EC STUART PRENATAL OTC TRI RX TRIADVANCE 2 of 3

32 PRENATAL VITAMINS January 20, 2011 PREFERRED DRUGS TRICARE TRINATAL RX 1 TRINATE VINATE AZ VINATE AZ EXTRA VINATE C VINATE CALCIUM VINATE CARE VINATE GT VINATE IC VINATE II VINATE III VINATE ONE VINATE PN CARE VINATE ULTRA VINATE-M VITAFOL-OB VITAFOL-OB+DHA VITAFOL-PN VITAPHIL VITAPHIL + DHA VITASPIRE NON-PREFERRED DRUGS 3 of 3

33 IRON AGENTS, ORAL PREFERRED DRUGS NON-PREFERRED DRUGS BIFERA RX CORVITA 150 CENTRATEX CORVITE 150 DUALVIT F CORVITE FE DUALVIT PLUS FERRALET 90 FEROCON FERREX 150 FORTE PLUS FEROTRINSIC MAXARON FORTE FERRALET 90 DUAL-IRON MULTIGEN FERRAPLUS 90 MULTIGEN FOLIC FERREX 28 MULTIGEN PLUS FERROCITE PLUS NIFEREX-150 FORTE FERROGELS FORTE PRUVATE 21-7 FETRIN TL ICON FOLITAB 500 VITAFOL FOLIVANE-F FOLIVANE-PLUS FOLTRIN FUMATINIC HEMATINIC PLUS HEMATINIC WITH FOLIC ACID HEMATOGEN HEMATOGEN FA HEMATOGEN FORTE HEMOCYTE PLUS HEMOCYTE-F IFEREX 150 FORTE INTEGRA F INTEGRA PLUS IRON MYKIDZ IRON 10 NEPHRON FA NOVAFERRUM POLY-IRON 150 FORTE POLYSACCHARIDE IRON FORTE REOCYTE PLUS SE-TAN PLUS SE-VATE 21-7 TANDEM F TANDEM PLUS TARON FORTE TRICON TRIGELS-F FORTE

34 COUGH AND COLD, NON-ANTITUSSIVE PREFERRED DRUGS ALAHIST LQ (ORAL) ALA-HIST PE OTC (ORAL) ALLANTAN (ORAL) ALLERFRIM OTC (ORAL) ALLERGY & SINUS HEADACHE OTC (ORAL) ALLERGY & SINUS OTC (ORAL) ALLERGY MULTI-SYMPTOM (ORAL) ALLERGY MULTI-SYMPTOM OTC (ORAL) ALLERGY RELIEF OTC (ORAL) APRODINE OTC (ORAL) BPM PE (ORAL) BROMALINE OTC (ORAL) BROTAPP OTC (ORAL) CERON (ORAL) CHEST CONGESTION & SINUS OTC (ORAL) CHEST CONGESTION RELIEF D OTC (ORAL) CHEST CONGESTION RELIEF OTC (ORAL) CHEST CONGESTION RELIEF PE OTC (ORAL) CHEST-SINUS CONGESTION RELIEF OTC (ORAL) CHILDREN'S COLD & ALLERGY (ORAL) CHILDREN'S COLD & ALLERGY OTC (ORAL) CHILDREN'S MUCUS RELIEF (ORAL) CHILDREN'S MUCUS RELIEF OTC (ORAL) CHILDRENS TYLENOL PLUS COLD OTC (ORAL) CHILD'S MUCINEX OTC (ORAL) CHILDS PLUS COLD & ALLERGY OTC (ORAL) CHILDS TRIACTING COLD & COUGH (ORAL) CHILDS TRIACTING COLD & COUGH OTC (ORAL) COLD & ALLERGY (ORAL) COLD & ALLERGY OTC (ORAL) COLD & ALLERGY PE OTC (ORAL) COLD RELIEF PLUS OTC (ORAL) COLD, ALLERGY & SINUS OTC (ORAL) COMPLETE SINUS RELIEF OTC (ORAL) NON-PREFERRED DRUGS 10PEH-4CPM OTC (ORAL) 60PSE-400GFN OTC (ORAL) 60PSE-4CPM OTC (ORAL) ACCUHIST (ORAL) ALDEX-CT (ORAL) ALERSULE (ORAL) ALLFEN OTC (ORAL) BIDEX OTC (ORAL) BROMAX D (ORAL) BROMHIST (ORAL) BROMHIST-NR (ORAL) BROVEX PSE (ORAL) CENHIST (ORAL) COUGH AND COLD, COLD FDA LIST CPM-PE (ORAL) CPM-PSE (ORAL) CPM-PYR-PE (ORAL) CRANTEX (ORAL) DICEL (ORAL) DONATUSSIN (ORAL) DRYMAX (ORAL) ED BRON GP (ORAL) ED CHLORPED D (ORAL) ENTEX LQ (ORAL) ENTRE-B (ORAL) FLU & SEVERE COLD OTC (ORAL) FLU & SORE THROAT (ORAL) FLU-SEVERE COLD & COUGH (ORAL) HISTEX SR (ORAL) HIST-PSE (ORAL) J-TAN D PD (ORAL) LIQUIBID D-R OTC (ORAL) LIQUIBID OTC (ORAL) LIQUIBID PD-R OTC (ORAL) 1 of 5

35 COUGH AND COLD, NON-ANTITUSSIVE PREFERRED DRUGS COMTREX FLU THERAPY OTC (ORAL) COMTREX SEVERE COLD & SINUS OTC (ORAL) CONEX OTC (ORAL) CONGESTAC OTC (ORAL) CONGEST-EZE OTC (ORAL) CONGEST-EZE PE OTC (ORAL) CONTAC OTC (ORAL) COUGH CONTROL OTC (ORAL) COUGHTAB 400 OTC (ORAL) COUGHTAB OTC (ORAL) DALLERGY (ORAL) DALLERGY-JR (ORAL) DECONEX IR OTC (ORAL) DECONEX OTC (ORAL) DELSYM COUGH & COLD (ORAL) DIABETIC TUSSIN EX OTC (ORAL) DIABETIC TUSSIN MUCUS RELIEF OTC (ORAL) DIMAPHEN OTC (ORAL) DIMETAPP COLD & CONGESTION OTC (ORAL) DIMETAPP OTC (ORAL) DRISTAN COLD OTC (ORAL) DRIXORAL OTC (ORAL) EFFERVESCENT COLD RELIEF OTC (ORAL) EXPECTORANT OTC (ORAL) FLU RELIEF THERAPY (ORAL) FLU RELIEF THERAPY NIGHTTIME (ORAL) FLU RELIEF THERAPY OTC (ORAL) GENAC OTC (ORAL) GENAPHED PLUS OTC (ORAL) G-FENESIN OTC (ORAL) GUAIFENESIN OTC (ORAL) GUAIFENESIN/PHENYLEPHRINE HCL OTC (ORAL) HISTAFED OTC (ORAL) INTENSE COLD & FLU OTC (ORAL) NON-PREFERRED DRUGS LORTUSS LQ (ORAL) MAXICHLOR PEH (ORAL) MAXICHLOR PSE (ORAL) MEDENT-PEI OTC (ORAL) MYCI CHLORPED D (ORAL) NASOHIST (ORAL) NEUTRAHIST (ORAL) NOREL SR (ORAL) NY-TANNIC (ORAL) PE-CPM-MSN (ORAL) PEDIATEX PS (ORAL) PEDIATEX TD (ORAL) PHENA-PLUS (ORAL) PHENA-S (ORAL) PHENYLEPHRINE/CHLOR-TAN (ORAL) POLY HIST FORTE (ORAL) POLY HIST PD (ORAL) PYRICHLOR PE (ORAL) PYRIL D (ORAL) PYRIL-CHLOR-PHEN (ORAL) RELHIST (ORAL) RESPA A.R. (ORAL) RESPAHIST (ORAL) R-TANNA (ORAL) R-TANNA PEDIATRIC (ORAL) RU-HIST FORTE (ORAL) RU-HIST-D OTC (ORAL) RU-TUSS (ORAL) RYDEX G (ORAL) RYNATAN (ORAL) RYNATAN PEDIATRIC (ORAL) SINA-12X (ORAL) SONAHIST (ORAL) TEKRAL (ORAL) 2 of 5

36 COUGH AND COLD, NON-ANTITUSSIVE PREFERRED DRUGS IOPHEN NR (ORAL) LOHIST-D (ORAL) LUSAIR (ORAL) MEDIFIN EXPECTORANT OTC (ORAL) MEDI-TUSSIN OTC (ORAL) MUCINEX COLD OTC (ORAL) MUCINEX D MAXIMUM STRENGTH OTC (ORAL) MUCINEX D OTC (ORAL) MUCINEX OTC (ORAL) MUCOSA OTC (ORAL) MUCUS ER (ORAL) MUCUS RELIEF OTC (ORAL) MUCUS RELIEF SINUS OTC (ORAL) MYHIST-PD (ORAL) NASOPEN (ORAL) NIGHTTIME SINUS OTC (ORAL) ORGAN-I NR (ORAL) PAIN RELIEF ALLERGY OTC (ORAL) PE HCL-CPM-MSN (ORAL) PHENYLEPHRINE HCL/PROMETH HCL (ORAL) PHENYLTOLOXAMINE PE CPM (ORAL) POLY-VENT IR OTC (ORAL) PRIMATENE ASTHMA OTC (ORAL) PROHIST LQ (ORAL) PSEUDO PLUS COLD & ALLERGY OTC (ORAL) Q-TAPP OTC (ORAL) Q-TUSSIN OTC (ORAL) RESCON (ORAL) RESCON-GG OTC (ORAL) RESCON-JR. (ORAL) RHINACON A (ORAL) ROBAFEN OTC (ORAL) ROBITUSSIN COUGH & COLD OTC (ORAL) ROBITUSSIN OTC (ORAL) NON-PREFERRED DRUGS THERAFLU COLD-SORE THROAT OTC (ORAL) THERAFLU OTC (ORAL) THERAFLU SINUS & COLD (ORAL) TIBAMINE LA (ORAL) TRIP-PSE (ORAL) TRYMINE D (ORAL) VAZOTAB (ORAL) V-HIST (ORAL) ZOTEX-PE (ORAL) 3 of 5

37 COUGH AND COLD, NON-ANTITUSSIVE PREFERRED DRUGS RYMED OTC (ORAL) RYNEX PSE (ORAL) SILAFED OTC (ORAL) SILDEC (ORAL) SILTUSSIN DAS OTC (ORAL) SILTUSSIN SA OTC (ORAL) SINUS & ALLERGY OTC (ORAL) SINUS & ALLERGY PE (ORAL) SINUS & ALLERGY PE OTC (ORAL) SINUS CONGESTION & PAIN (ORAL) SINUS CONGESTION & PAIN OTC (ORAL) SINUS NIGHTTIME OTC (ORAL) SINUTROL PE OTC (ORAL) SUDOGEST COLD & ALLERGY OTC (ORAL) SUDOGEST SINUS & ALLERGY (ORAL) TRIACTIN OTC (ORAL) TRIACTING COLD AND ALLERGY OTC (ORAL) TRIAMINIC CHEST NASAL CONGESTION OTC (ORAL) TRIAMINIC COLD & ALLERGY OTC (ORAL) TRIAMINIC COLD & COUGH OTC (ORAL) TRIAMINIC COLD-ALLERGY PE OTC (ORAL) TRIAMINIC SOFTCHEWS OTC (ORAL) TRIAMINICIN OTC (ORAL) TRIGOFEN (ORAL) TRIPOHIST D (ORAL) TRIPTIFED OTC (ORAL) TUSSANIL (ORAL) TUSSIN COLD SEVERE CONGESTION OTC (ORAL) TUSSIN HONEY OTC (ORAL) TUSSIN OTC (ORAL) TUSSIN PE OTC (ORAL) TYLENOL ALLERGY COMPLETE OTC (ORAL) TYLENOL ALLERGY M-S NIGHTTIME OTC (ORAL) TYLENOL ALLERGY MULTI-SYMPTOM OTC (ORAL) NON-PREFERRED DRUGS 4 of 5

38 COUGH AND COLD, NON-ANTITUSSIVE PREFERRED DRUGS TYLENOL SINUS NIGHTTIME OTC (ORAL) VALU-TAPP OTC (ORAL) ZODEN PD (ORAL) NON-PREFERRED DRUGS 5 of 5

39 COUGH AND COLD, NARCOTIC ANTITUSSIVES PREFERRED DRUGS NON-PREFERRED DRUGS ALA-HIST AC (ORAL) AIRACOF (ORAL) ALAHIST DHC (ORAL) ALLFEN CD (ORAL) BALTUSSIN (ORAL) ALLFEN CDX (ORAL) CAPCOF (ORAL) AMBIFED CD (ORAL) CHERATUSSIN AC OTC (ORAL) AMBIFED CDX (ORAL) CHERATUSSIN DAC OTC (ORAL) AMBIFED-G CD (ORAL) CODAL-DH (ORAL) AMBIFED-G CDX (ORAL) CODEINE/PROMETHAZINE HCL (ORAL) BROMPHENIRAM/PE/DIHYDROCODEINE (ORAL) COLDCOUGH PD (ORAL) BRONTEX (ORAL) CYTUSS HC (ORAL) CENTUSSIN DHC (ORAL) EXECLEAR-C (ORAL) CHLORPHENIRAMINE/CODEINE PHOS (ORAL) GANI-TUSS NR (ORAL) CODEINE-GUAIFENESIN (ORAL) GUAIFENESIN/CODEINE PHOS (ORAL) COTAB A (ORAL) HYCODAN (ORAL) COTAB AX (ORAL) HYPHED (ORAL) COTABFLU (ORAL) IOPHEN-C NR (ORAL) COUGH AND COLD, NARCOTIC FDA LIST M-CLEAR (ORAL) DEXPHEN W-C (ORAL) M-CLEAR WC (ORAL) DEX-TUSS (ORAL) MYTUSSIN AC OTC (ORAL) DIHYDROCODEINE-BPM-PE (ORAL) MYTUSSIN DAC OTC (ORAL) DIHYDRO-CP (ORAL) PHENYLEPHRINE HCL/COD/PROMETH (ORAL) DIHYDRO-GP (ORAL) PHENYLHISTINE DH OTC (ORAL) DIHYDRO-PE (ORAL) POLY-TUSSIN AC (ORAL) DONATUSS DC (ORAL) POLY-TUSSIN DHC (ORAL) DUOHIST DH (ORAL) POLY-TUSSIN EX (ORAL) ENDACOF AC (ORAL) PRO-CLEAR AC (ORAL) ENDACOF-C (ORAL) PRO-CLEAR CAPS (ORAL) ENDACOF-DC (ORAL) PRO-RED AC (ORAL) ENDAL CD (ORAL) PSEUDOEPHEDRINE HCL/CODEINE (ORAL) HYDROCODONE/HOMATROPINE (ORAL) ROBAFEN AC (ORAL) HYDROCODONE-CHLORPHENIRAMINE (ORAL) SU-TUSS HD (ORAL) HYDROMET (ORAL) TUSNEL C (ORAL) J-COF DHC (ORAL) TUSNEL PED-C (ORAL) J-MAX DHC (ORAL) TUSSIONEX (ORAL) LEXUSS 210 (ORAL) 1 of 3

40 COUGH AND COLD, NARCOTIC ANTITUSSIVES PREFERRED DRUGS NON-PREFERRED DRUGS LORTUSS EX (ORAL) MAR-COF BP (ORAL) MAR-COF CG (ORAL) MAXIFED CD (ORAL) MAXIFED CDX (ORAL) MAXIFED-G CD (ORAL) MAXIFED-G CDX (ORAL) MAXIFLU CD (ORAL) MAXIFLU CDX (ORAL) MAXIPHEN CD (ORAL) MAXIPHEN CDX (ORAL) M-END PE (ORAL) M-END WC (ORAL) MESEHIST WC (ORAL) MYCI-GC (ORAL) NASOTUSS (ORAL) NEO AC (ORAL) NOTUSS AC (ORAL) NOTUSS DC (ORAL) NOTUSS-NX (ORAL) NOTUSS-NXD (ORAL) NOTUSS-PE (ORAL) PHENFLU CD (ORAL) PHENFLU CDX (ORAL) POLY HIST DHC (ORAL) POLY HIST NC (ORAL) RYDEX (ORAL) TL-HIST CD (ORAL) TL-HIST CM (ORAL) TUSSCOUGH DHC (ORAL) TUSSICAPS (ORAL) TUSSIGON (ORAL) TUSSO-C (ORAL) ZODRYL AC 25 OTC (ORAL) 2 of 3

41 COUGH AND COLD, NARCOTIC ANTITUSSIVES PREFERRED DRUGS NON-PREFERRED DRUGS ZODRYL AC 30 OTC (ORAL) ZODRYL AC 35 OTC (ORAL) ZODRYL AC 40 OTC (ORAL) ZODRYL AC 50 OTC (ORAL) ZODRYL AC 60 OTC (ORAL) ZODRYL AC 80 OTC (ORAL) ZODRYL DAC 25 OTC (ORAL) ZODRYL DAC 30 OTC (ORAL) ZODRYL DAC 35 OTC (ORAL) ZODRYL DAC 40 OTC (ORAL) ZODRYL DAC 50 OTC (ORAL) ZODRYL DAC 60 OTC (ORAL) ZODRYL DAC 80 OTC (ORAL) ZODRYL DEC 25 OTC (ORAL) ZODRYL DEC 30 OTC (ORAL) ZODRYL DEC 35 OTC (ORAL) ZODRYL DEC 40 OTC (ORAL) ZODRYL DEC 50 OTC (ORAL) ZODRYL DEC 60 OTC (ORAL) ZODRYL DEC 80 OTC (ORAL) ZOTEX-C (ORAL) Z-TUSS AC (ORAL) 3 of 3

42 COUGH AND COLD, NON-NARCOTIC ANTITUSSIVES PREFERRED DRUGS NON-PREFERRED DRUGS ADULT ROBITUSSIN COUGH-COLD D OTC (ORAL) 10PEH-4CPM-20DM OTC (ORAL) ADULT ROBITUSSIN OTC (ORAL) 20DM-4CPM OTC (ORAL) ALA-HIST DM (ORAL) 40PSE-400GFN-20DM OTC (ORAL) ALLANHIST PDX (ORAL) 60PSE-4CPM-20DM OTC (ORAL) ALLANVAN-DM (ORAL) ALLRES PD (ORAL) ANAPLEX DMX (ORAL) ATUSS DS (ORAL) BENZONATATE (ORAL) BROMFED DM (ORAL) BROMALINE DM OTC (ORAL) BROMFED-DM (ORAL) BROMDEX D (ORAL) BROMHIST PDX (ORAL) BROMPHENEX DM OTC (ORAL) BROMPHENIRAMIN/PE/DEXTROMETHOR (ORAL) BROMPLEX DM (ORAL) CARBATUSS-12 (ORAL) BROTAPP DM OTC (ORAL) CENTUSS DM (ORAL) CAPMIST DM OTC (ORAL) CLOFERA (ORAL) CHERACOL D OTC (ORAL) CLOFERA OTC (ORAL) CHEST CONGESTION RELIEF DM OTC (ORAL) CORZALL PLUS (ORAL) CHEST CONGESTION-COUGH RELIEF OTC (ORAL) COUGH AND COLD, NON-NARCOTIC FDA LIST CHILD MUCINEX MULTI-SYMPTOM (ORAL) CPM-PSE DM (ORAL) CHILD MUCUS RELIEF COUGH (ORAL) DECONSAL DM (ORAL) CHILD MUCUS RELIEF COUGH OTC (ORAL) DICEL CD (ORAL) CHILD TRIACTING COLD-COUGH (ORAL) DICEL DM (ORAL) CHILD TRIAMINIC-D MT-SYM COLD OTC (ORAL) D-METHORPHAN HB/P-EPD HCL/BPM (ORAL) CHILDREN'S COLD & COUGH (ORAL) D-METHORPHAN HB/P-EPHED HCL/CP (ORAL) CHILDREN'S COLD & COUGH DM OTC (ORAL) DONATUSSIN DM (ORAL) CHILDREN'S COLD & COUGH OTC (ORAL) ENDACOF-PD (ORAL) CHILDREN'S MUCINEX COUGH OTC (ORAL) ENDACON OTC (ORAL) CHLO TUSS OTC (ORAL) ENTRE-S (ORAL) CODAL-DM OTC (ORAL) FLU-SEVERE COLD-COUGH (ORAL) CODITUSS DM OTC (ORAL) FLUTABS (ORAL) COLD & COUGH DM OTC (ORAL) INDAMIX DM (ORAL) COLD & COUGH OTC (ORAL) LIVETAN DM (ORAL) COLD HEAD CONGESTION (ORAL) LORTUSS DM (ORAL) COLD HEAD CONGESTION OTC (ORAL) MAXIFED DM OTC (ORAL) COLD MULTI-SYMPTOM (ORAL) MAXIPHEN DMX (ORAL) COLD MULTI-SYMPTOM DAYTIME (ORAL) M-END DM (ORAL) COLD MULTI-SYMPTOM SEVERE (ORAL) NASOHIST DM (ORAL) 1 of 5

43 COUGH AND COLD, NON-NARCOTIC ANTITUSSIVES PREFERRED DRUGS NON-PREFERRED DRUGS COLD SEVERE CONGESTION OTC (ORAL) NEO DM (ORAL) COMTREX COLD & COUGH OTC (ORAL) NEUTRAHIST PDX (ORAL) CORFEN-DM (ORAL) PEDIAHIST DM (ORAL) CORICIDIN HBP OTC (ORAL) PHENYLEPHRINE COMPLEX (ORAL) COUGH & COLD OTC (ORAL) POLY HIST CB (ORAL) COUGH & RUNNY NOSE OTC (ORAL) PYRIL DM (ORAL) COUGH & SORE THROAT OTC (ORAL) PYRILAMINE/PE/DEXTROMETHORPHAN (ORAL) COUGH CONTROL DM (ORAL) RE DCP (ORAL) COUGH CONTROL DM MAX (ORAL) RESPERAL-DM (ORAL) COUGH CONTROL DM OTC (ORAL) RYDEX DM (ORAL) COUGH RELIEF (ORAL) RYNATUSS (ORAL) COUGH RELIEF OTC (ORAL) SIMUC-DM (ORAL) COUGH SUPPRESSANT OTC (ORAL) TANAFED DMX (ORAL) DALLERGY DM (ORAL) THERAFLU COLD & COUGH OTC (ORAL) DAY TIME COUGH (ORAL) THERAFLU MAX-D SEVERE COLD-FLU (ORAL) DAYTIME (ORAL) THERAFLU NIGHTTIME OTC (ORAL) DAYTIME COLD & FLU RELIEF (ORAL) TL-HIST DM (ORAL) DAYTIME COLD-FLU RELIEF (ORAL) TREXBROM (ORAL) DAYTIME COUGH (ORAL) TRYMINE CD (ORAL) DAYTIME MUCUS RELIEF DM (ORAL) TUSDEC-DM (ORAL) DECONEX DM OTC (ORAL) TUSSALL (ORAL) DECONEX DMX OTC (ORAL) TUSSALL-ER (ORAL) DELSYM MULTI-SYMPTOM (ORAL) TUSSI-12 S (ORAL) DELSYM OTC (ORAL) TUSSO-XR (ORAL) DIABETIC TUSSIN DM OTC (ORAL) VANACOF DX OTC (ORAL) DIABETIC TUSSIN MAX-STRENGTH OTC (ORAL) VANACOF G (ORAL) DIMAPHEN DM OTC (ORAL) VANACOF OTC (ORAL) DIMETAPP DM OTC (ORAL) VANATAB DX OTC (ORAL) DIMETAPP LONG-ACTING OTC (ORAL) VAZOTAN (ORAL) D-METHORPHAN HB/PROMETH HCL (ORAL) V-COF (ORAL) DURAFLU (ORAL) Z-COF 12DM (ORAL) EXECLEAR-DM (ORAL) Z-DEX (ORAL) EXPECTORANT DM (ORAL) ZONATUSS (ORAL) EXPECTORANT DM OTC (ORAL) ZOTEX-D (ORAL) FLU RELIEF THERAPY DAYTIME OTC (ORAL) ZOTEX-EX (ORAL) 2 of 5

44 COUGH AND COLD, NON-NARCOTIC ANTITUSSIVES PREFERRED DRUGS G-FENESIN DM OTC (ORAL) GUAIFENESIN DM (ORAL) GUAIFENESIN/D-METHORPHAN HB OTC (ORAL) HOLD OTC (ORAL) INTENSE COUGH OTC (ORAL) INTENSE COUGH RELIEVER OTC (ORAL) IOPHEN DM (ORAL) KIDCARE OTC (ORAL) MEDI-TUSSIN DM DIABETIC OTC (ORAL) MEDI-TUSSIN DM OTC (ORAL) MUCINEX COUGH OTC (ORAL) MUCINEX DM OTC (ORAL) MUCOSA DM OTC (ORAL) MUCUS RELIEF COUGH OTC (ORAL) MUCUS RELIEF DM OTC (ORAL) MULTI-SYMPTOM COLD OTC (ORAL) NIGHT TIME COUGH OTC (ORAL) NIGHTTIME COUGH OTC (ORAL) NITE TIME COUGH (ORAL) NITE TIME COUGH OTC (ORAL) NOHIST-PDX (ORAL) NON-ASPIRIN SEVERE CONGESTION OTC (ORAL) PAIN RELIEF COLD OTC (ORAL) PBM ALLERGY (ORAL) PEDIA RELIEF COUGH-COLD OTC (ORAL) PEDIATRIC COUGH-COLD OTC (ORAL) POLY-VENT DM OTC (ORAL) PSE BROM (ORAL) Q-TAPP DM OTC (ORAL) Q-TUSSIN DM OTC (ORAL) RESCON-DM OTC (ORAL) ROBAFEN CF OTC (ORAL) ROBAFEN COUGH OTC (ORAL) ROBAFEN DM MAX (ORAL) ROBAFEN-DM CLEAR OTC (ORAL) NON-PREFERRED DRUGS 3 of 5

45 COUGH AND COLD, NON-NARCOTIC ANTITUSSIVES PREFERRED DRUGS ROBAFEN-DM OTC (ORAL) ROBITUSSIN COUGH & COLD CF OTC (ORAL) ROBITUSSIN COUGH-COLD OTC (ORAL) ROBITUSSIN COUGHGELS OTC (ORAL) ROBITUSSIN DM MAX OTC (ORAL) ROBITUSSIN DM TO GO (ORAL) ROBITUSSIN LONG-ACTING OTC (ORAL) ROBITUSSIN PEDIATRIC COUGH OTC (ORAL) ROBITUSSIN-COUGH-CHEST-CONG OTC (ORAL) ROBITUSSIN-DM COUGH OTC (ORAL) RYNEX DM (ORAL) SILDEC-DM (ORAL) SILPHEN DM OTC (ORAL) SILTUSSIN DM DAS COUGH FORMULA OTC (ORAL) SILTUSSIN DM OTC (ORAL) SIMPLY COUGH OTC (ORAL) SUPER TROCHE DM OTC (ORAL) TESSALON (ORAL) TESSALON PERLE (ORAL) TRIACTING COLD & COUGH (ORAL) TRIACTING OTC (ORAL) TRIAMINIC COLD & COUGH LIQUID OTC (ORAL) TRIAMINIC NIGHT TIME OTC (ORAL) TRIAMINIC OTC (ORAL) TUSNEL DIABETIC OTC (ORAL) TUSNEL-A OTC (ORAL) TUSSIN CF (ORAL) TUSSIN CF OTC (ORAL) TUSSIN COLD-CONGESTION OTC (ORAL) TUSSIN COUGH (ORAL) TUSSIN COUGH OTC (ORAL) TUSSIN DM (ORAL) TUSSIN DM CLEAR OTC (ORAL) TUSSIN DM MAX (ORAL) TUSSIN DM MAX OTC (ORAL) NON-PREFERRED DRUGS 4 of 5

46 COUGH AND COLD, NON-NARCOTIC ANTITUSSIVES PREFERRED DRUGS TUSSIN DM OTC (ORAL) TYLENOL COLD M-S SEVERE DAY OTC (ORAL) TYLENOL COLD SEVERE CONGESTION OTC (ORAL) ULTRA DM FREE & CLEAR OTC (ORAL) VICKS 44 OTC (ORAL) VICKS 44D COUGH & HEAD OTC (ORAL) VICKS 44E COUGH & CHEST OTC (ORAL) VICKS CHILDREN'S NYQUIL OTC (ORAL) VICKS DAYQUIL COUGH OTC (ORAL) VICKS DAYQUIL OTC (ORAL) VICKS FORMULA 44 D OTC (ORAL) VICKS PEDIATRIC 44E OTC (ORAL) VICKS PEDIATRIC 44M OTC (ORAL) Y-COF DM (ORAL) NON-PREFERRED DRUGS 5 of 5