Comprehensive Dual Eligible Preferred Drug List (List of Covered Drugs)

Transcription

1 2014 Comprehensive Dual Eligible referred Drug List (List of Covered Drugs) Ohana Health lan 00 9 lease read: This document contains information about the drugs we cover in this plan. Last updated (01/01/2014)

2 Ohana Dual Eligible Cough & Cold Drug List Non-referred Drugs ANTITUSSIVES,NON-NARCOTIC Benzonatate TESSALON 200 CASULE BENZONATATE 100 CASULE BENZONATATE 200 CASULE Dextromethorphan olistirex DELSYM 30 /5 ML EXTENDED-RELEASE SUSENSION Dextromethorphan HBr ROBITUSSIN EDIATRIC COUGH SY Dextromethorphan HBr/Menthol DELSYM COUGH RELIEF LUS LOZENGE NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST Brompheniramine/Dextromethorphan HBr/seudoephedrine HCl ALLANHIST DX DROS BROMHIST DX DROS BROTA DM LIQUID Q-TA DM ELIXIR BROMFED DM SYRU ENDACOF-D DROS Brophenaramine/Dextromethorphan HBr/henylephrine HCl COLD/COUGH CHILDRENS ELIXIR RYNEX DM DIMAHEN DM ELIXIR Chlorpheniramine/Dextromethorphan HBr/henylephrine HCl C-HEN DM RONDEX-DM SYRU DE-CHLOR DM LIQUID NOHIST-DM D-COF SYRU SILDEC E-DM SYRU CORFEN DM TRI-DEX E Chlorpheniramine/Dextromethorphan HBr/seudoephedrine HCl EDIATRIC COUGH-COLD LIQUID MESEHIST DM KIDKARE COUGH/COLD Dexchlorpheniramine/seudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID Chlorpheniramine/Dextromethorphan HBr DIMETA LONG-ACTING COUGH LIQ ROBITUSSIN LONG ACTING LIQUID romethazine HCl/Dextromethorphan HBr ROMETHAZINE-DM SYRU NON-NARC ANTITUSS-1ST GEN. ANTIHIST-ANALGESIC COMBINATION Dextromethorphan HBr/Acetaminophen/Doxylamine DELSYM NIGHTTIME MULTI-SYMTOM EXECTORANTS DECONGESTANT-EXECTORANT COMBINATIONS referred Drugs Guaifenesin/henylephrine HCl DONATUSSIN DROS E-GUAI DROS DESEC LIQUID RESCON-GG LIQUID Last updated 01/01/14 age 1 of 2

3 Ohana Dual Eligible Cough & Cold Drug List Non-referred Drugs referred Drugs NON-NARCOTIC DECONGESTANT-EXECTORANT-ANTITUSSIVE Guaifenesin/Dextromethorphan HBr/henylephreine ROBAFEN CF SYRU Dextromethorphan HBr/Guaifenesin DURATUSS DM ELIXIR SU-TUSS DM ELIXIR MUCUS RELIEF COUGH LIQUID DIABETIC TUSSIN DM LIQUID SIMUC-DM ELIXIR GUAIFENESIN DM SYRU Q-TUSSIN-DM SYRU EXTRA ACTION COUGH SILTUSSIN DM COUGH SYRU REFENESEN DM SILTUSSIN DM DAS COUGH SYRU MUCOSA DM ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID Chlorpheniramine/Hydrocodone olistirex TUSSIONEX ENNKINETIC SUS TUSSICAS (min. age 6 years old) HYDROCODONE-CHLORHENIRAMINE SUSENSION (min. age 6 years old) Codeine hosphate/romethazine HCl ROMETHAZINE-CODEINE SYRU (min. age 6 years old) Dexbrompheniramine/Hydrocodone Bit/henylephrine HCl Codeine/henylephrine HCl/romethazine CYTUSS-HC NR SYRU HC/E/DBROM SYRU ROMETH VC W/COD SYRU ROMETHAZINE VC/COD SYRU HC 2.5-E 5-DBROM 1 SYRU seudoephedrine HCl/Codeine/Chlorpheniramine HYDROMET SYRU NON-NARCOTIC ANTITUSSIVE AND EXECTORANT COMB. NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT HENYLHISTINE DH NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATION Hydrocodone Bit/Homatropine HYDROCODONE-HOMATROINE NARCOTIC ANTITUSSIVE-EXECTORANT COMBINATION Guaifenesin/Hydrocodone Bit Codeine hosphate/guaifenesin HYDROCODONE-GUAIFENESIN SYRU CHERATUSSIN AC SYRU NARCOF SYRU TUSSICLEAR DH SYRU GUAIFENESIN-CODEINE SYRU IOHEN C-NR NARCOTIC ANTITUSSIVE-DECONGESTANT-EXECTORANT COMBINATIONS Codeine hosphate/guaifenesin/seudoephedrine HCl CHERATUSSIN DAC SYRU Last updated 01/01/14 age 2 of 2

4 UERCASE = Brand name drugs italics = Generic drugs reference Details = referred Dagger ( ) = N/A Asterisk (*) = N/A Asterisk (**) = N/A Asterisk (***) = N/A XX = N/A Coverage Details A = rior Authorization ST = Step Therapy QL = Quantity Limit AL = Age Limit = - Covered w/rx Drug Name reference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts* *Anti-Obesity Agents** *Lipase Inhibitors*** XENICAL ORAL CASULE 120 A *Alternative Medicines* *Alternative Medicine - C's** *Alternative Medicine - Ch's*** Charcoal ORAL CASULE 200 *Alternative Medicine - M's** *Alternative Medicine - Me's*** Melatonin Maximum Strength ORAL TABLET 5 *Analgesics - Anti-Inflammatory* *Nonsteroidal Anti-Inflammatory Agents (Nsaids)** *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** Ibuprofen ORAL SUSENSION 100 /5ML Ibuprofen ORAL TABLET 200 1

5 Drug Name reference Details Coverage Details Ibuprofen Junior Strength ORAL TABLET CHEWABLE 100 *Analgesics - Nonnarcotic* *Analgesics Other** *Analgesics Other*** ACEHEN RE SUOSITORY 120, 325, 650 Acetaminophen ORAL SOLUTION 160 /5ML Acetaminophen ORAL TABLET 325 ; QL (279 EA per 31 day(s)) Acetaminophen ORAL TABLET 500 ; QL (186 EA per 31 day(s)) Acetaminophen ORAL TABLET CHEWABLE 80 AA ORAL TABLET 325 ; QL (279 EA per 31 day(s)) AA Extra Strength ORAL TABLET 500 Childrens Non-ASA ain Relief ORAL TABLET CHEWABLE 80 Childrens Non-Aspirin ORAL TABLET CHEWABLE 80 Childrens Non-Aspirin ain ORAL TABLET CHEWABLE 80 Childrens ain Reliever ORAL TABLET CHEWABLE 80 Childrens Silapap ORAL LIQUID 160 /5ML Childrens Tactinal ORAL TABLET CHEWABLE 80 ; QL (186 EA per 31 day(s)) Ed-AA ORAL LIQUID 160 /5ML Mapap ORAL CASULE 500 ; QL (186 EA per 31 day(s)) Mapap ORAL TABLET 325 ; QL (279 EA per 31 day(s)) Mapap ORAL TABLET 500 ; QL (186 EA per 31 day(s)) Mapap ORAL TABLET CHEWABLE 80 Mapap Arthritis ain ORAL TABLET EXTENDEDRELEASE* 650 Maxapap Maximum Strength ORAL TABLET 500 Maxapap Regular Strength ORAL TABLET 325 ; QL (93 EA per 31 day(s)) ; QL (186 EA per 31 day(s)) ; QL (279 EA per 31 day(s)) 2

6 Drug Name reference Details Coverage Details Non-Aspirin ORAL TABLET 325 ; QL (279 EA per 31 day(s)) Non-Aspirin Extra Strength ORAL TABLET 500 Non-Aspirin ain Relief ORAL TABLET 325 Nortemp Infants ORAL SUSENSION 80 /0.8ML ain & Fever Childrens ORAL SOLUTION 160 /5ML ; QL (186 EA per 31 day(s)) ; QL (279 EA per 31 day(s)) ain Relief ORAL TABLET 500 ; QL (186 EA per 31 day(s)) ain Relief Extra Strength ORAL TABLET 500 ; QL (186 EA per 31 day(s)) HARBETOL ORAL TABLET 325 ; QL (279 EA per 31 day(s)) HARBETOL EXTRA STRENGTH ORAL TABLET 500 ; QL (186 EA per 31 day(s)) Q-A ORAL TABLET 325 ; QL (279 EA per 31 day(s)) Tactinal ORAL TABLET 325 ; QL (279 EA per 31 day(s)) Tactinal Extra Strength ORAL TABLET 500 *Salicylates** *Salicylate Combinations*** Tri-Buffered Aspirin ORAL TABLET 325 *Salicylates*** Aspirin ORAL TABLET 325, 81 Aspirin ORAL TABLET CHEWABLE 81 Aspirin ORAL TABLET DELAYED RELEASE 81 Aspirin Childrens ORAL TABLET CHEWABLE 81 Aspirin EC ORAL TABLET DELAYED RELEASE 325, 81 Aspirin EC Low Dose ORAL TABLET DELAYED RELEASE 81 ; QL (186 EA per 31 day(s)) Aspirin Low Dose ORAL TABLET 81 ECIRIN ORAL TABLET DELAYED RELEASE 325 *Anorectal Agents* *Rectal Combinations** 3

7 Drug Name reference Details Coverage Details *Rectal Combinations - Misc.*** FORMULATION R RE OINTMENT % Hem-rep RE SUOSITORY % *Antacids* *Antacid Combinations** *Antacid & Simethicone*** Alamag lus ORAL TABLET CHEWABLE ALMACONE ORAL SUSENSION /5ML Antacid ORAL SUSENSION /5ML Antacid Anti-Gas ORAL SUSENSION /5ML Antacid Anti-Gas Max Strength ORAL SUSENSION /5ML Antacid Extra Strength ORAL SUSENSION /5ML Antacid I ORAL SUSENSION /5ML Antacid III ORAL SUSENSION /5ML Geri-Lanta ORAL SUSENSION /5ML MAALOX ADVANCED ORAL SUSENSION /5ML MAALOX ADVANCED MAX ST ORAL SUSENSION /5ML MAALOX MAX ORAL SUSENSION /5ML MAALOX MULTI SYMTOM MAX ST ORAL SUSENSION /5ML MAALOX REGULAR STRENGTH ORAL SUSENSION /5ML Milantex ORAL SUSENSION /5ML Milantex Extra Strength ORAL SUSENSION /5ML 4

8 Drug Name reference Details Coverage Details MINTOX LUS ORAL TABLET CHEWABLE *Antacid Combinations*** ACID GONE ORAL TABLET CHEWABLE , MI-ACID ORAL TABLET CHEWABLE *Antacids - Aluminum Salts** *Antacids - Aluminum Salts*** Aluminum Hydroxide Gel ORAL SUSENSION 320 /5ML *Antacids - Bicarbonate** *Antacids - Bicarbonate*** Sodium Bicarbonate ORAL TABLET 325, 650 *Antacids - Calcium Salts** *Antacids - Calcium Salts*** Alcalak ORAL TABLET CHEWABLE 420 Antacid ORAL TABLET CHEWABLE 420, 500 CAL-GEST ANTACID ORAL TABLET CHEWABLE 500 Calcium Antacid ORAL TABLET CHEWABLE 500 Calcium Antacid Extra Strength ORAL TABLET CHEWABLE 750 Calcium Carbonate Antacid ORAL TABLET 648 Calcium Carbonate Antacid ORAL TABLET CHEWABLE 500 MAALOX ORAL TABLET CHEWABLE 600 TITRALAC ORAL TABLET CHEWABLE 420 *Antidiabetics* *Diabetic Other** *Diabetic Other*** 5

9 Drug Name reference Details Coverage Details BD GLUCOSE ORAL TABLET CHEWABLE 5 GM Glucose ORAL TABLET CHEWABLE 4 GM Ultilet Glucose ORAL TABLET CHEWABLE 4 GM *Antidiarrheals* *Antidiarrheal Agents - Misc.** *Antidiarrheal Agents - Misc.*** Bismatrol ORAL SUSENSION 262 /15ML Bismatrol ORAL TABLET CHEWABLE 262 Bismuth ORAL TABLET CHEWABLE 262 Diotame ORAL TABLET CHEWABLE 262 Kao-Tin ORAL SUSENSION 262 /15ML KAOECTATE ORAL SUSENSION 262 /15ML KAOECTATE EXTRA STRENGTH ORAL SUSENSION 525 /15ML ink Bismuth ORAL SUSENSION 262 /15ML ink Bismuth ORAL TABLET CHEWABLE 262 Stomach Relief ORAL SUSENSION 262 /15ML, 527 /30ML Stomach Relief ORAL TABLET CHEWABLE 262 Stomach Relief lus ORAL SUSENSION 525 /15ML *Antiperistaltic Agents** *Antiperistaltic Agents*** Anti-Diarrheal ORAL LIQUID 1 /5ML LOERAMIDE A-D ORAL TABLET 2 Loperamide HCl ORAL LIQUID 1 /5ML *Antidotes* *Antidotes** *Antidotes*** 6

10 Drug Name reference Details Coverage Details Actidose-Aqua ORAL LIQUID 15 GM/72ML, 25 GM/120ML, 50 GM/240ML Actidose/Sorbitol ORAL LIQUID 25 GM/120ML, 50 GM/240ML Charcoal ORAL CASULE 260 Charcoal Activated ORAL TABLET 250 CHARCOCAS ORAL CASULE 260 Ipecac ORAL SYRU KERR INSTA-CHAR ORAL LIQUID 25 GM/120ML, 50 GM/240ML KERR INSTA-CHAR IN SORBITOL ORAL LIQUID 25 GM/120ML, 50 GM/240ML LITTLE REMEDIES OISON TREAT ORAL SUSENSION RECONSTITUTED 15 GM/120ML *Antiemetics* *Antiemetics - Anticholinergic** *Antiemetics - Anticholinergic*** Meclizine HCl ORAL TABLET 12.5, 25 *Antihistamines* *Antihistamines - Alkylamines** *Antihistamines - Alkylamines*** Aller-Chlor ORAL SYRU 2 /5ML Aller-Chlor ORAL TABLET 4 Allergy ORAL TABLET 4 Allergy Relief ORAL TABLET 4 ChlorHist ORAL TABLET 4 Chlorphen ORAL TABLET 4 DIABETIC TUSSIN ALLERGY ORAL SYRU 2 /5ML *Antihistamines - Ethanolamines** *Antihistamines - Ethanolamines*** Aler-Cap ORAL CASULE 25 Aler-Dryl ORAL TABLET 50 AlerTab ORAL TABLET 25 Allergy Relief Childrens ORAL LIQUID 12.5 /5ML 7

11 Drug Name reference Details Coverage Details Altaryl ORAL ELIXIR 12.5 /5ML Altaryl ORAL SYRU 12.5 /5ML Anti-Hist ORAL CASULE 25 Anti-Hist Allergy ORAL TABLET 25 BANOHEN ORAL CASULE 25 BANOHEN ORAL LIQUID 12.5 /5ML BANOHEN ORAL TABLET 25 BENADRYL ALLERGY CHILDRENS ORAL LIQUID 12.5 /5ML Complete Allergy Medication ORAL TABLET 25 Complete Allergy Relief ORAL TABLET 25 Diphenhist ORAL CASULE 25 Diphenhist ORAL LIQUID 12.5 /5ML Diphenhist ORAL TABLET 25 DiphenhydrAMINE HCl ORAL CASULE 25, 50 DiphenhydrAMINE HCl ORAL TABLET 25 DORMIN ORAL CASULE 25 Genahist ORAL CASULE 25 harbedryl ORAL CASULE 25, 50 Q-Dryl ORAL CASULE 25 Q-Dryl ORAL LIQUID 12.5 /5ML Quenalin ORAL SYRU 12.5 /5ML SCOT-TUSSIN ALLERGY RELIEF ORAL LIQUID 12.5 /5ML Siladryl Allergy ORAL LIQUID 12.5 /5ML Silphen Cough ORAL SYRU 12.5 /5ML SIMLY ALLERGY ORAL TABLET 25 Total Allergy ORAL TABLET 25 TOTAL ALLERGY MEDICINE ORAL LIQUID 12.5 /5ML *Antihistamines - Non-Sedating** 8

12 Drug Name reference Details Coverage Details *Antihistamines - Non-Sedating*** Cetirizine HCl ORAL TABLET 10, 5 Cetirizine HCl Childrens ORAL SOLUTION 1 /ML Cetirizine HCl Childrens Alrgy ORAL SYRU 1 /ML Loratadine ORAL TABLET 10 Loratadine Hives Relief ORAL SOLUTION 5 /5ML *Antiseptics & Disinfectants* *Iodine Antiseptics** *Iodine Antiseptics*** OERAND OVIDONE-IODINE EXTERNAL SOLUTION 10 % ovidone-iodine EXTERNAL OINTMENT 10 % ovidone-iodine EXTERNAL SOLUTION 10 % ovidone-iodine EXTERNAL SWAB 10 %, 7.5 % *Assorted Classes* *Assorted Classes** *Assorted Classes*** ; QL (300 ML per 31 day(s)) Gelatin ORAL CASULE 650 *Cough/Cold/Allergy* *Cough/Cold/Allergy Combinations** *Decongestant & Antihistamine*** ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* BROTA ORAL LIQUID 1-15 /5ML Q-TA ORAL ELIXIR 1-15 /5ML *Expectorants** *Expectorants*** Mucus Relief ORAL TABLET 400 Refenesen ORAL TABLET 200 Refenesen 400 ORAL TABLET 400 Robafen ORAL SYRU 100 /5ML 9

13 Drug Name reference Details Coverage Details *Misc. Respiratory Inhalants** *Misc. Respiratory Inhalants*** Sodium Chloride INHALATION NEBULIZATION SOLUTION 0.9 % *Dermatologicals* *Acne roducts** *Acne roducts*** Acne Medication EXTERNAL LOTION 10 % Acne Medication 10 EXTERNAL GEL 10 % Acne-Clear EXTERNAL GEL 10 % Benzoyl eroxide EXTERNAL GEL 10 %, 5 % CLEAN & CLEAR ERSA-GEL EX ST EXTERNAL GEL 5 % CLEAN & CLEAR ERSA-GEL MAX ST EXTERNAL GEL 10 % CLEARLEX V EXTERNAL GEL 5 % CLEARSKIN EXTERNAL CREAM 10 % NEUTROGENA ON-THE-SOT EXTERNAL CREAM 2.5 % ANOXYL WASH EXTERNAL LIQUID 10 % *Antibiotics - Topical** *Antibiotic Mixtures Topical*** Bacitracin-Neomycin-olymyxin EXTERNAL OINTMENT Double Antibiotic EXTERNAL OINTMENT UNIT/GM Triple Antibiotic EXTERNAL OINTMENT , *Antibiotics - Topical*** Bacitracin EXTERNAL OINTMENT 500 UNIT/GM Bacitracin Zinc EXTERNAL OINTMENT 500 UNIT/GM *Antifungals - Topical** *Antifungals - Topical*** Anti-Fungal EXTERNAL OWDER 1 % Terbinafine HCl EXTERNAL CREAM 1 % 10

14 Drug Name reference Details Coverage Details Tolnaftate EXTERNAL CREAM 1 % Tolnaftate EXTERNAL SOLUTION 1 % Tolnaftate Antifungal EXTERNAL CREAM 1 % *Imidazole-Related Antifungals - Topical*** Clotrimazole EXTERNAL CREAM 1 % Clotrimazole EXTERNAL SOLUTION 1 % Clotrimazole Anti-Fungal EXTERNAL CREAM 1 % *Antihistamines-Topical** *Antihistamines - Topical*** Allergy EXTERNAL CREAM 2 % Anti-Itch Maximum Strength EXTERNAL CREAM 2 % BENADRYL ITCH STOING EXTERNAL GEL 2 % Itch Relief EXTERNAL CREAM 2 % *Corticosteroids - Topical** *Corticosteroids - Topical*** Hydrocortisone EXTERNAL CREAM 0.5 % Hydrocortisone EXTERNAL OINTMENT 0.5 %, 1 % Hydrocortisone Max St EXTERNAL CREAM 1 % Hydrocortisone Max St/12 Moist EXTERNAL CREAM 1 % HYDROSKIN EXTERNAL CREAM 1 % REARATION H HYDROCORTISONE EXTERNAL CREAM 1 % *Topical Steroid Combinations*** Hydrocortisone-Aloe EXTERNAL CREAM 1 % *Misc. Topical** *Misc. Topical*** REARATION H EXTERNAL AD 50 % *Scabicides & ediculicides** *Scabicides & ediculicides*** A-200 XX AEROSOL 0.5 % 11

15 Drug Name reference Details Coverage Details ermethrin EXTERNAL LOTION 1 % ; QL (60 ML per 31 day(s)) *Sunscreens** *Sunscreens*** COERTONE SUNBLOCK SF15 EXTERNAL LOTION NEUTROGENA MOISTURE SF15 EXTERNAL LOTION *Tar roducts** *Tar roducts*** BETA CARE BETATAR GEL EXTERNAL SHAMOO 2.5 % ELTA TAR EXTERNAL CREAM 2 % IONIL-T EXTERNAL SHAMOO 1 % 217 MEDICATED TAR EXTERNAL SHAMOO 15 % NEUTROGENA T/GEL EX ST EXTERNAL SHAMOO 1 % C-Tar EXTERNAL SHAMOO 1 % TERA-GEL TAR EXTERNAL SHAMOO 0.5 % *Gastrointestinal Agents - Misc.* *Antiflatulents** *Antiflatulents*** Mi-Acid Gas Relief ORAL TABLET CHEWABLE 80 Mytab Gas ORAL TABLET CHEWABLE 80 Simethicone ORAL SUSENSION 40 /0.6ML Simethicone ORAL TABLET CHEWABLE 80 *Genitourinary Agents - Miscellaneous* *Urinary Analgesics** *Urinary Analgesics*** henazopyridine HCl ORAL TABLET 95 *Hematopoietic Agents* *Cobalamins** *Cobalamins*** 12

16 Drug Name reference Details Coverage Details Cyanocobalamin INJECTION SOLUTION 1000 MCG/ML Vitamin B-12 ORAL TABLET 1000 MCG, 250 MCG, 500 MCG Vitamin B-12 SUBLINGUAL TABLET SUBLINGUAL 1000 MCG Vitamin B-12 ER ORAL TABLET EXTENDEDRELEASE* 1000 MCG *Folic Acid/Folates** *Folic Acid/Folates*** Folic Acid ORAL TABLET 1 *Iron** *Iron*** Ferro-Bob ORAL TABLET 325 (65 Fe) Ferrous Sulfate ORAL ELIXIR 220 (44 Fe) /5ML Ferrous Sulfate ORAL SOLUTION 75 (15 Fe) /ML Ferrous Sulfate ORAL TABLET 325 (65 Fe) Ferrous Sulfate ORAL TABLET DELAYED RELEASE 324 (65 Fe), 325 (65 Fe) FerrouSul ORAL TABLET 325 (65 Fe) Iron ORAL TABLET 325 (65 Fe), 90 (18 Fe) *Hypnotics* *Antihistamine Hypnotics** *Antihistamine Hypnotic Combinations*** Acetaminophen M ORAL TABLET ; QL (62 EA per 31 Day(s)) Headache M ORAL TABLET ; QL (62 EA per 31 day(s)) Mapap M ORAL TABLET ; QL (62 EA per 31 day(s)) ain Relief M Extra Strength ORAL TABLET ; QL (62 EA per 31 day(s)) ain Reliever M ORAL TABLET ; QL (62 EA per 31 day(s)) *Antihistamine Hypnotics*** Compoz ORAL CASULE 50 Compoz ORAL TABLET 50 13

17 Drug Name reference Details Coverage Details NYTOL ORAL TABLET 25 SIMLY SLEE ORAL TABLET 25 Sleep Tabs ORAL TABLET 25 Sleep-Tabs ORAL TABLET 25 SOMINEX ORAL TABLET 25 SOMINEX MAXIMUM STRENGTH ORAL TABLET 50 Tetra-Formula Nighttime Sleep ORAL TABLET 50 *Laxatives* *Bulk Laxatives** *Bulk Laxatives*** Fiber ORAL TABLET 625 Fiber Laxative ORAL TABLET 625 Fiber Therapy ORAL OWDER 58.6 % Fiber-Lax ORAL TABLET 625 FIBERGEN ORAL TABLET 625 KONSYL ORAL ACKET 100 % KONSYL FIBER ORAL TABLET 625 METAMUCIL ORAL OWDER 30.9 % METAMUCIL MULTIHEALTH FIBER ORAL OWDER 58.6 % METAMUCIL SMOOTH TEXTURE ORAL ACKET 28 % METAMUCIL SMOOTH TEXTURE ORAL OWDER 28.3 %, 58.6 % Natural Fiber Therapy ORAL OWDER 30.9 %, % Natural Vegetable Fiber ORAL OWDER % REGULOID ORAL CASULE 0.52 GM *Laxative Combinations** *Laxatives & Dss*** DOC-Q-LAX ORAL TABLET ERI-COLACE ORAL TABLET Senna lus ORAL TABLET Senna S ORAL TABLET

18 Drug Name reference Details Coverage Details Senna-Docusate Sodium ORAL TABLET Senna-S ORAL TABLET Senna-Time S ORAL TABLET SENNALAX-S ORAL TABLET Sennosides-Docusate Sodium ORAL TABLET *Laxatives - Miscellaneous** *Laxatives - Miscellaneous*** Sorbitol ORAL SOLUTION 70 % *Saline Laxatives** *Saline Laxative Mixtures*** Enema RE ENEMA 7-19 GM/118ML SM Oral Saline Laxative ORAL SOLUTION GM/5ML *Saline Laxatives*** Citrate of Magnesia ORAL SOLUTION GM/30ML CITROMA ORAL SOLUTION GM/30ML DULCOLAX MILK OF MAGNESIA ORAL SUSENSION 400 /5ML Magnesium Citrate ORAL SOLUTION GM/30ML Milk of Magnesia ORAL SUSENSION 400 /5ML, 7.75 % *Stimulant Laxatives** *Stimulant Laxatives*** BISAC-EVAC ORAL TABLET DELAYED RELEASE 5 BISAC-EVAC RE SUOSITORY 10 Biscolax RE SUOSITORY 10 CARTERS LITTLE ILLS ORAL TABLET DELAYED RELEASE 5 Correct ORAL TABLET DELAYED RELEASE 5 CORRECTOL ORAL TABLET DELAYED RELEASE 5 15

19 Drug Name reference Details Coverage Details Ducodyl ORAL TABLET DELAYED RELEASE 5 EX-LAX ORAL TABLET CHEWABLE 15 EX-LAX ULTRA ORAL TABLET DELAYED RELEASE 5 FEENAMINT ORAL TABLET DELAYED RELEASE 5 FLEET LAXATIVE ORAL TABLET DELAYED RELEASE 5 Gentle Laxative ORAL TABLET DELAYED RELEASE 5 Laxative RE SUOSITORY 10 Magic Bullets RE SUOSITORY 10 Natural Senna Laxative ORAL TABLET Senexon ORAL LIQUID 8.8 /5ML Senexon ORAL TABLET 8.6 Senna ORAL SYRU 8.8 /5ML Senna ORAL TABLET 15, 8.6 Senna Lax ORAL TABLET 8.6 Senna Laxative ORAL TABLET 8.6 Senna Maximum Strength ORAL TABLET 25 SENNA SMOOTH ORAL TABLET 15 Senna-Lax ORAL TABLET 8.6 Senna-Tabs ORAL TABLET 8.6 Senna-Time ORAL TABLET 8.6 SENNACON ORAL TABLET 8.6 SENNO ORAL TABLET 8.6 Stimulant Laxative ORAL TABLET DELAYED RELEASE 5 Womens Laxative ORAL TABLET DELAYED RELEASE 5 *Surfactant Laxatives** *Surfactant Laxatives*** CORRECTOL EXTRA GENTLE ORAL CASULE

20 Drug Name reference Details Coverage Details D.O.S. ORAL CASULE 250 Diocto ORAL LIQUID 50 /5ML Diocto ORAL SYRU 60 /15ML DocQLace ORAL CASULE 100 Docu Soft ORAL CASULE 100 Docusate Sodium ORAL TABLET 100 DOCUSIL ORAL CASULE 100 DOK ORAL CASULE 100, 250 DOK ORAL TABLET 100 DSS ORAL CASULE 100, 250 DULCOLAX STOOL SOFTENER ORAL CASULE 100 ENEMEEZ MINI RE ENEMA 283 Kao-Tin ORAL CASULE 240 Laxa Basic ORAL CASULE 100, 250 Silace ORAL LIQUID 150 /15ML Silace ORAL SYRU 60 /15ML SOF-LAX ORAL CASULE 100 Stool Softener ORAL CASULE 100, 250 Stool Softener Laxative DC ORAL CASULE 240 Sur-Q-Lax ORAL CASULE 240 SURFAK ORAL CASULE 240 *Medical Devices* *Respiratory Therapy Supplies** *Respiratory Therapy Supplies*** ACE AEROSOL CLOUD ENHANCER XX MISC IN-CHECK DIAL FLOW TRAINER XX DEVICE QL (2 EA per 365 day(s)) QL (2 EA per 365 day(s)) Inhaler Companions XX MISC ; QL (2 EA per 365 day(s)) FLEX XX MISC QL (2 EA per 365 day(s)) THRESHOLD IMT XX MISC QL (2 EA per 365 day(s)) THRESHOLD E XX DEVICE QL (2 EA per 365 day(s)) WINDMILL TRAINER XX MISC QL (2 EA per 365 day(s)) 17

21 Drug Name reference Details Coverage Details *Spacer/Aerosol-Holding Chambers & Supplies*** AEROCHAMBER MV XX MISC QL (2 EA per 365 day(s)) AEROCHAMBER LUS FLO-VU XX MISC AEROCHAMBER LUS FLO-VU LARGE XX MISC AEROCHAMBER LUS FLO-VU SMALL XX MISC AEROCHAMBER LUS FLO-VU W/MASK XX MISC AEROCHAMBER W/FLOWSIGNAL XX MISC QL (2 EA per 365 day(s)) QL (2 EA per 365 day(s)) QL (2 EA per 365 day(s)) QL (2 EA per 365 day(s)) QL (2 EA per 365 day(s)) AEROCHAMBER Z-STAT LUS XX MISC QL (2 EA per 365 day(s)) AEROCHAMBER Z-STAT LUS CHAMBR XX MISC QL (2 EA per 365 day(s)) EASIVENT XX MISC QL (2 EA per 365 day(s)) MICROCHAMBER XX MISC QL (2 EA per 365 day(s)) MICROSACER XX MISC QL (2 EA per 365 day(s)) OTICHAMBER ADVANTAGE XX MISC QL (2 EA per 365 day(s)) OTIHALER XX DEVICE QL (2 EA per 365 day(s)) OTIHALER XX MISC QL (2 EA per 365 day(s)) OCKET CHAMBER XX DEVICE QL (2 EA per 365 day(s)) OCKET SACER XX DEVICE QL (2 EA per 365 day(s)) WATCHHALER XX DEVICE QL (2 EA per 365 day(s)) *Minerals & Electrolytes* *Calcium** *Calcium Combinations*** Calcium ORAL TABLET UNIT Calcium + D3 ORAL TABLET UNIT Calcium 600-D ORAL TABLET UNIT Calcium Carbonate-Vitamin D ORAL TABLET UNIT, UNIT Calcium High otency/vitamin D ORAL TABLET UNIT 18

22 Drug Name reference Details Coverage Details Calcium-Carb D ORAL TABLET UNIT Calcium-Vitamin D ORAL TABLET UNIT, UNIT, UNIT CALTRATE 600+D ORAL TABLET UNIT Liquid Calcium/Vitamin D ORAL CASULE UNIT OS-CAL D ORAL TABLET UNIT OYSCO 500+D ORAL TABLET UNIT OYSCO D ORAL TABLET UNIT Oyst-Cal D ORAL TABLET UNIT Oyster Calcium + D ORAL TABLET UNIT Oyster Shell Calcium + D ORAL TABLET UNIT Oyster Shell Calcium D ORAL TABLET UNIT Oyster Shell Calcium/D ORAL TABLET UNIT, UNIT Oyster Shell Calcium/Vitamin D ORAL TABLET UNIT Oyster Shell/Vitamin D ORAL TABLET UNIT *Calcium*** CAL-CARB FORTE ORAL TABLET 1250 Calcarb 600 ORAL TABLET 1500 CALCI-CHEW ORAL TABLET CHEWABLE 1250 Calcium 600 ORAL TABLET 600 Calcium Carbonate ORAL SUSENSION 1250 /5ML Calcium Carbonate ORAL TABLET 1250, 1500,

23 Drug Name reference Details Coverage Details Calcium High otency ORAL TABLET 600 Calcium Oyster Shell ORAL TABLET 1250 Calcium-Carb 600 ORAL TABLET 600 CALTRATE 600 ORAL TABLET 1500 OS-CAL ORAL TABLET CHEWABLE 1250 OYSCO 500 ORAL TABLET 500 OYSTERCAL ORAL TABLET 500 *Electrolyte Mixtures** *Electrolytes Oral*** ORALYTE FREEZER OS ORAL SOLUTION REHYDRALYTE ORAL SOLUTION ReVital Freezer ops ORAL SOLUTION ReVital Liquid Squeezers ORAL SOLUTION *Magnesium** *Magnesium*** Mag-Delay ORAL TABLET EXTENDEDRELEASE* 535 (64 Mg) Mag-SR ORAL TABLET EXTENDEDRELEASE* 535 (64 Mg) MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 (7MEQ) MAG64 ORAL TABLET EXTENDEDRELEASE* 535 (64 ) ; QL (4000 ML per 31 day(s)) ; QL (4000 ML per 31 day(s)) ; QL (4000 ML per 31 day(s)) ; QL (4000 ML per 31 day(s)) Magnacaps ORAL CASULE 100 Magnesium ORAL TABLET 250 Magnesium Oxide ORAL TABLET 400 (240 Mg) MAGNESIUM-OXIDE ORAL TABLET 400 (241.3 ) *Sodium** *Sodium*** Sodium Chloride ORAL TABLET 1 GM 20

24 Drug Name reference Details Coverage Details *Zinc** *Zinc*** ORAZINC ORAL CASULE 220 Zinc ORAL TABLET 25, 50 Zinc Gluconate ORAL TABLET 100, 30, 50 Zinc Methionate ORAL CASULE 50 Zinc icolinate ORAL TABLET 25 Zinc Sulfate ORAL CASULE 220 Zinc Sulfate ORAL TABLET 220 (50 Zn) Zinc-220 ORAL CASULE 220 *Multivitamins* *B-Complex W/ Folic Acid** *B-Complex W/ C & Folic Acid*** NEHRONEX ORAL TABLET Rena-Vite Rx ORAL TABLET 1 RENAL ORAL CASULE 1 Reno Caps ORAL CASULE 1 *Multiple Vitamins W/ Minerals** *Multiple Vitamins W/ Minerals*** Centamin ORAL LIQUID CentaVite ORAL LIQUID Centavite A-Z Complete-Mineral ORAL TABLET CEROVITE ADVANCED FORMULA ORAL TABLET CERTAVITE/ANTIOXIDANTS ORAL LIQUID Formula Twenty-One ORAL TABLET Gerivite Complete ORAL TABLET Golden Age Vitamin/Minerals ORAL LIQUID Multivitamin & Mineral ORAL LIQUID SUER NU-THERA ORAL TABLET Thera Vital M ORAL TABLET Therabasic-M ORAL TABLET 21

25 Drug Name reference Details Coverage Details Therapeutic Liquid ORAL SOLUTION Therapeutic-M ORAL TABLET TOTAL FORMULA 3 ORAL TABLET *Multivitamins** *Multivitamins*** Daily Multiple Vitamins ORAL TABLET Daily Vite ORAL TABLET Daily Vites ORAL TABLET Multi-Day ORAL TABLET Multi-Vitamin ORAL TABLET Multi-Vitamins ORAL TABLET Once Daily ORAL TABLET One-Daily Multi Vitamins ORAL TABLET THERA ORAL TABLET Thera-Tabs ORAL TABLET THERA/BETA-CAROTENE ORAL TABLET Therapeutic ORAL TABLET *ed Mv W/ Fluoride** *ed Mv W/ Fluoride*** Multi-Vit/Fluoride ORAL SOLUTION 0.25 /ML, 0.5 /ML Multi-Vitamin/Fluoride ORAL TABLET CHEWABLE 0.25, 0.5, 1 Multivitamin/Fluoride ORAL TABLET CHEWABLE 0.25, 0.5, 1 Multivitamins/Fluoride ORAL TABLET CHEWABLE 0.25 *Specialty Vitamins roducts** *Specialty Vitamins roducts*** Vitamins for Hair ORAL TABLET *Nasal Agents - Systemic And Topical* *Nasal Agents - Misc.** *Nasal Agents - Misc.*** Altamist Spray NASAL SOLUTION 0.65 % AYR NASAL SOLUTION 0.65 % 22

26 Drug Name reference Details Coverage Details Deep Sea Nasal Spray NASAL SOLUTION 0.65 % HUMIST NASAL SOLUTION 0.65 % LITTLE NOSES SALINE NASAL SOLUTION 0.65 % Na-Zone NASAL SOLUTION 0.65 % NASAL MOIST NASAL SOLUTION 0.65 % OCEAN FOR KIDS NASAL SOLUTION 0.65 % Saline Mist Spray NASAL SOLUTION 0.65 % Saline Nasal Spray NASAL SOLUTION 0.65 % Sea Soft Nasal Mist NASAL SOLUTION 0.65 % *Nasal Antiallergy** *Nasal Mast Cell Stabilizers*** Cromolyn Sodium NASAL AEROSOL, SOLUTION 5.2 /ACT *Sympathomimetic Decongestants** *Systemic Decongestants*** Nasal Decongestant ORAL SYRU 30 /5ML seudoephedrine HCl ORAL TABLET 30, 60 SUDAFED 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HR* 120 *Ophthalmic Agents* *Artificial Tears And Lubricants** *Artificial Tear And Lubricant Combinations*** Artificial Tears OHTHALMIC OINTMENT % HYOTEARS OHTHALMIC SOLUTION 1-1 % *Artificial Tear Ointments*** Tears Again OHTHALMIC OINTMENT ULTRA FRESH M OHTHALMIC OINTMENT *Artificial Tear Solutions*** 23

27 Drug Name reference Details Coverage Details Tears Again OHTHALMIC SOLUTION *Artificial Tears And Lubricants*** Artificial Tears OHTHALMIC SOLUTION 1.4 % ; QL (15 ML per 31 day(s)) Liquitears OHTHALMIC SOLUTION 1.4 % ; QL (15 ML per 31 Day(s)) olyvinyl Alcohol OHTHALMIC SOLUTION 1.4 % *Ophthalmics - Misc.** *Ophthalmic Antiallergic*** ALAWAY OHTHALMIC SOLUTION % Ketotifen Fumarate OHTHALMIC SOLUTION % *Otic Agents* *Otic Agents - Miscellaneous** *Otic Agents - Miscellaneous*** ; QL (15 ML per 31 Day(s)) Auraphene-B OTIC SOLUTION 6.5 % AURO EARDROS OTIC SOLUTION 6.5 % E-R-O EAR DROS OTIC SOLUTION 6.5 % E-R-O EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % Ear Drops Earwax Aid OTIC SOLUTION 6.5 % Earwax Treatment Drops OTIC SOLUTION 6.5 % MURINE EAR OTIC SOLUTION 6.5 % MURINE EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % OTIX OTIC SOLUTION 6.5 % Thera-Ear OTIC SOLUTION 6.5 % *sychotherapeutic And Neurological Agents - Misc.* *Smoking Deterrents** *Smoking Deterrents*** Nicotine TRANSDERMAL ATCH 24 HR 14 /24HR, 21 /24HR, 7 /24HR ; QL (70 EA per 365 day(s)) 24

28 Drug Name reference Details Coverage Details Nicotine olacrilex MOUTH/THROAT GUM 2, 4 *Ulcer Drugs* *H-2 Antagonists** *H-2 Antagonists*** Acid Reducer ORAL TABLET 75 Cimetidine ORAL TABLET 200 Cimetidine Acid Reducer ORAL TABLET 200 ; QL (2016 EA per 365 day(s)) Famotidine ORAL TABLET 10 Heartburn Relief ORAL TABLET 10, 200 Heartburn Relief Max St ORAL TABLET 20 Ranitidine Acid Reducer ORAL TABLET 75 *roton ump Inhibitors** *roton ump Inhibitors*** Omeprazole ORAL TABLET DELAYED RELEASE 20 *Vaginal roducts* *Spermicides** *Spermicides*** ENCARE VAGINAL SUOSITORY 100 OTIONS CONCETROL VAGINAL GEL 4 % VCF VAGINAL CONTRACETIVE VAGINAL FOAM 12.5 % *Vaginal Anti-Infectives** *Imidazole-Related Antifungals*** Miconazole 3 Combo ack VAGINAL KIT % (9GM) Miconazole 7 VAGINAL CREAM 2 % Miconazole 7 VAGINAL SUOSITORY 100 Miconazole Nitrate VAGINAL CREAM 2 % 25

29 Drug Name reference Details Coverage Details Miconazole Nitrate VAGINAL SUOSITORY 100 *Vitamins* *Oil Soluble Vitamins** *Vitamin D*** CALCIFEROL ORAL SOLUTION 8000 UNIT/ML Vitamin D ORAL TABLET 400 UNIT Vitamin D (Ergocalciferol) ORAL CASULE UNIT Vitamin D-400 ORAL TABLET 400 UNIT Vitamin D3 ORAL CASULE 2000 UNIT Vitamin D3 ORAL TABLET 1000 UNIT, 400 UNIT *Vitamin K*** MEHYTON ORAL TABLET 5 *Water Soluble Vitamins** *Vitamin B-3*** ENDUR-ACIN ORAL TABLET EXTENDEDRELEASE* 250, 500 Niacin ORAL TABLET 100, 250, 50, 500 Niacin ER ORAL CASULE EXTENDED RELEASE* 250, 500 Niacin ER ORAL TABLET EXTENDEDRELEASE* 250, 500, 750 QL (4 EA per 31 day(s)) Niacin-50 ORAL TABLET 50 SLO-NIACIN ORAL TABLET EXTENDEDRELEASE* 250 *Vitamin C*** Ascorbic Acid ORAL TABLET 1000, 250, 500 Ascorbic Acid ORAL TABLET CHEWABLE 250 C-500 ORAL TABLET CHEWABLE 500 Vitamin C ORAL SYRU 500 /5ML Vitamin C ORAL TABLET 100, 1000, 250,

30 Drug Name reference Details Coverage Details Vitamin C ORAL TABLET CHEWABLE 100,

31 28

32 Index A-200 XX AEROSOL 0.5 % ACE AEROSOL CLOUD ENHANCER XX MISC ACEHEN RE SUOSITORY 120, 325, Acetaminophen ORAL SOLUTION 160 /5ML... 2 Acetaminophen ORAL TABLET Acetaminophen ORAL TABLET Acetaminophen ORAL TABLET CHEWABLE Acetaminophen M ORAL TABLET ACID GONE ORAL TABLET CHEWABLE , Acid Reducer ORAL TABLET Acne Medication 10 EXTERNAL GEL 10 % Acne Medication EXTERNAL LOTION 10 % Acne-Clear EXTERNAL GEL 10 % Actidose/Sorbitol ORAL LIQUID 25 GM/120ML, 50 GM/240ML... 7 Actidose-Aqua ORAL LIQUID 15 GM/72ML, 25 GM/120ML, 50 GM/240ML... 7 AEROCHAMBER MV XX MISC AEROCHAMBER LUS FLO-VU LARGE XX MISC AEROCHAMBER LUS FLO-VU SMALL XX MISC AEROCHAMBER LUS FLO-VU W/MASK XX MISC AEROCHAMBER LUS FLO-VU XX MISC AEROCHAMBER W/FLOWSIGNAL XX MISC AEROCHAMBER Z-STAT LUS CHAMBR XX MISC AEROCHAMBER Z-STAT LUS XX MISC Alamag lus ORAL TABLET CHEWABLE ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* ALAWAY OHTHALMIC SOLUTION % Alcalak ORAL TABLET CHEWABLE Aler-Cap ORAL CASULE Aler-Dryl ORAL TABLET AlerTab ORAL TABLET Aller-Chlor ORAL SYRU 2 /5ML... 7 Aller-Chlor ORAL TABLET Allergy EXTERNAL CREAM 2 % Allergy ORAL TABLET Allergy Relief Childrens ORAL LIQUID 12.5 /5ML... 7 Allergy Relief ORAL TABLET ALMACONE ORAL SUSENSION /5ML... 4 Altamist Spray NASAL SOLUTION 0.65 % Altaryl ORAL ELIXIR 12.5 /5ML... 8 Altaryl ORAL SYRU 12.5 /5ML... 8 Aluminum Hydroxide Gel ORAL SUSENSION 320 /5ML... 5 Antacid Anti-Gas Max Strength ORAL SUSENSION /5ML... 4 Antacid Anti-Gas ORAL SUSENSION /5ML... 4 Antacid Extra Strength ORAL SUSENSION /5ML... 4 Antacid I ORAL SUSENSION /5ML... 4 Antacid III ORAL SUSENSION /5ML... 4 Antacid ORAL SUSENSION /5ML... 4 Antacid ORAL TABLET CHEWABLE 420, Anti-Diarrheal ORAL LIQUID 1 /5ML... 6 Anti-Fungal EXTERNAL OWDER 1 % Anti-Hist Allergy ORAL TABLET Anti-Hist ORAL CASULE Anti-Itch Maximum Strength EXTERNAL CREAM 2 % AA Extra Strength ORAL TABLET AA ORAL TABLET Artificial Tears OHTHALMIC OINTMENT % Artificial Tears OHTHALMIC SOLUTION 1.4 % Ascorbic Acid ORAL TABLET 1000, 250, Ascorbic Acid ORAL TABLET CHEWABLE Aspirin Childrens ORAL TABLET CHEWABLE Aspirin EC Low Dose ORAL TABLET DELAYED RELEASE Aspirin EC ORAL TABLET DELAYED RELEASE 325, Aspirin Low Dose ORAL TABLET Aspirin ORAL TABLET 325, Aspirin ORAL TABLET CHEWABLE

33 Aspirin ORAL TABLET DELAYED RELEASE Auraphene-B OTIC SOLUTION 6.5 % AURO EARDROS OTIC SOLUTION 6.5 % AYR NASAL SOLUTION 0.65 % Bacitracin EXTERNAL OINTMENT 500 UNIT/GM Bacitracin Zinc EXTERNAL OINTMENT 500 UNIT/GM Bacitracin-Neomycin-olymyxin EXTERNAL OINTMENT BANOHEN ORAL CASULE BANOHEN ORAL LIQUID 12.5 /5ML... 8 BANOHEN ORAL TABLET BD GLUCOSE ORAL TABLET CHEWABLE 5 GM... 6 BENADRYL ALLERGY CHILDRENS ORAL LIQUID 12.5 /5ML... 8 BENADRYL ITCH STOING EXTERNAL GEL 2 % Benzoyl eroxide EXTERNAL GEL 10 %, 5 % BETA CARE BETATAR GEL EXTERNAL SHAMOO 2.5 % BISAC-EVAC ORAL TABLET DELAYED RELEASE BISAC-EVAC RE SUOSITORY Biscolax RE SUOSITORY Bismatrol ORAL SUSENSION 262 /15ML... 6 Bismatrol ORAL TABLET CHEWABLE Bismuth ORAL TABLET CHEWABLE BROTA ORAL LIQUID 1-15 /5ML... 9 C-500 ORAL TABLET CHEWABLE Calcarb 600 ORAL TABLET CAL-CARB FORTE ORAL TABLET CALCI-CHEW ORAL TABLET CHEWABLE CALCIFEROL ORAL SOLUTION 8000 UNIT/ML Calcium + D3 ORAL TABLET UNIT Calcium 600 ORAL TABLET Calcium 600-D ORAL TABLET UNIT Calcium Antacid Extra Strength ORAL TABLET CHEWABLE Calcium Antacid ORAL TABLET CHEWABLE Calcium Carbonate Antacid ORAL TABLET Calcium Carbonate Antacid ORAL TABLET CHEWABLE Calcium Carbonate ORAL SUSENSION 1250 /5ML Calcium Carbonate ORAL TABLET 1250, 1500, Calcium Carbonate-Vitamin D ORAL TABLET UNIT, UNIT Calcium High otency ORAL TABLET Calcium High otency/vitamin D ORAL TABLET UNIT Calcium ORAL TABLET UNIT Calcium Oyster Shell ORAL TABLET Calcium-Carb D ORAL TABLET UNIT Calcium-Carb 600 ORAL TABLET Calcium-Vitamin D ORAL TABLET UNIT, UNIT, UNIT CAL-GEST ANTACID ORAL TABLET CHEWABLE CALTRATE 600 ORAL TABLET CALTRATE 600+D ORAL TABLET UNIT CARTERS LITTLE ILLS ORAL TABLET DELAYED RELEASE Centamin ORAL LIQUID Centavite A-Z Complete-Mineral ORAL TABLET CentaVite ORAL LIQUID CEROVITE ADVANCED FORMULA ORAL TABLET CERTAVITE/ANTIOXIDANT S ORAL LIQUID Cetirizine HCl Childrens Alrgy ORAL SYRU 1 /ML... 9 Cetirizine HCl Childrens ORAL SOLUTION 1 /ML... 9 Cetirizine HCl ORAL TABLET 10, Charcoal Activated ORAL TABLET Charcoal ORAL CASULE Charcoal ORAL CASULE CHARCOCAS ORAL CASULE Childrens Non-ASA ain Relief ORAL TABLET CHEWABLE Childrens Non-Aspirin ORAL TABLET CHEWABLE Childrens Non-Aspirin ain ORAL TABLET CHEWABLE Childrens ain Reliever ORAL TABLET CHEWABLE Childrens Silapap ORAL LIQUID 160 /5ML... 2 Childrens Tactinal ORAL TABLET CHEWABLE

34 ChlorHist ORAL TABLET Chlorphen ORAL TABLET Cimetidine Acid Reducer ORAL TABLET Cimetidine ORAL TABLET Citrate of Magnesia ORAL SOLUTION GM/30ML CITROMA ORAL SOLUTION GM/30ML CLEAN & CLEAR ERSA-GEL EX ST EXTERNAL GEL 5 % CLEAN & CLEAR ERSA-GEL MAX ST EXTERNAL GEL 10 % CLEARLEX V EXTERNAL GEL 5 % CLEARSKIN EXTERNAL CREAM 10 % Clotrimazole Anti-Fungal EXTERNAL CREAM 1 % Clotrimazole EXTERNAL CREAM 1 % Clotrimazole EXTERNAL SOLUTION 1 % Complete Allergy Medication ORAL TABLET Complete Allergy Relief ORAL TABLET Compoz ORAL CASULE Compoz ORAL TABLET COERTONE SUNBLOCK SF15 EXTERNAL LOTION Correct ORAL TABLET DELAYED RELEASE CORRECTOL EXTRA GENTLE ORAL CASULE CORRECTOL ORAL TABLET DELAYED RELEASE Cromolyn Sodium NASAL AEROSOL, SOLUTION 5.2 /ACT Cyanocobalamin INJECTION SOLUTION 1000 MCG/ML D.O.S. ORAL CASULE Daily Multiple Vitamins ORAL TABLET Daily Vite ORAL TABLET Daily Vites ORAL TABLET Deep Sea Nasal Spray NASAL SOLUTION 0.65 % DIABETIC TUSSIN ALLERGY ORAL SYRU 2 /5ML... 7 Diocto ORAL LIQUID 50 /5ML Diocto ORAL SYRU 60 /15ML Diotame ORAL TABLET CHEWABLE Diphenhist ORAL CASULE Diphenhist ORAL LIQUID 12.5 /5ML... 8 Diphenhist ORAL TABLET DiphenhydrAMINE HCl ORAL CASULE 25, DiphenhydrAMINE HCl ORAL TABLET DocQLace ORAL CASULE DOC-Q-LAX ORAL TABLET Docu Soft ORAL CASULE Docusate Sodium ORAL TABLET DOCUSIL ORAL CASULE DOK ORAL CASULE 100, DOK ORAL TABLET DORMIN ORAL CASULE Double Antibiotic EXTERNAL OINTMENT UNIT/GM DSS ORAL CASULE 100, Ducodyl ORAL TABLET DELAYED RELEASE DULCOLAX MILK OF MAGNESIA ORAL SUSENSION 400 /5ML DULCOLAX STOOL SOFTENER ORAL CASULE Ear Drops Earwax Aid OTIC SOLUTION 6.5 % Earwax Treatment Drops OTIC SOLUTION 6.5 % EASIVENT XX MISC ECIRIN ORAL TABLET DELAYED RELEASE Ed-AA ORAL LIQUID 160 /5ML... 2 ELTA TAR EXTERNAL CREAM 2 % ENCARE VAGINAL SUOSITORY ENDUR-ACIN ORAL TABLET EXTENDEDRELEASE* 250, Enema RE ENEMA 7-19 GM/118ML ENEMEEZ MINI RE ENEMA E-R-O EAR DROS OTIC SOLUTION 6.5 % E-R-O EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % EX-LAX ORAL TABLET CHEWABLE EX-LAX ULTRA ORAL TABLET DELAYED RELEASE Famotidine ORAL TABLET FEENAMINT ORAL TABLET DELAYED RELEASE Ferro-Bob ORAL TABLET 325 (65 Fe) Ferrous Sulfate ORAL ELIXIR 220 (44 Fe) /5ML Ferrous Sulfate ORAL SOLUTION 75 (15 Fe) /ML

35 Ferrous Sulfate ORAL TABLET 325 (65 Fe) Ferrous Sulfate ORAL TABLET DELAYED RELEASE 324 (65 Fe), 325 (65 Fe) FerrouSul ORAL TABLET 325 (65 Fe) Fiber Laxative ORAL TABLET Fiber ORAL TABLET Fiber Therapy ORAL OWDER 58.6 % FIBERGEN ORAL TABLET Fiber-Lax ORAL TABLET FLEET LAXATIVE ORAL TABLET DELAYED RELEASE Folic Acid ORAL TABLET Formula Twenty-One ORAL TABLET FORMULATION R RE OINTMENT %... 4 Gelatin ORAL CASULE Genahist ORAL CASULE Gentle Laxative ORAL TABLET DELAYED RELEASE Geri-Lanta ORAL SUSENSION /5ML... 4 Gerivite Complete ORAL TABLET Glucose ORAL TABLET CHEWABLE 4 GM... 6 Golden Age Vitamin/Minerals ORAL LIQUID Headache M ORAL TABLET Heartburn Relief Max St ORAL TABLET Heartburn Relief ORAL TABLET 10, Hem-rep RE SUOSITORY %... 4 HUMIST NASAL SOLUTION 0.65 % Hydrocortisone EXTERNAL CREAM 0.5 % Hydrocortisone EXTERNAL OINTMENT 0.5 %, 1 % Hydrocortisone Max St EXTERNAL CREAM 1 % Hydrocortisone Max St/12 Moist EXTERNAL CREAM 1 % Hydrocortisone-Aloe EXTERNAL CREAM 1 % HYDROSKIN EXTERNAL CREAM 1 % HYOTEARS OHTHALMIC SOLUTION 1-1 % Ibuprofen Junior Strength ORAL TABLET CHEWABLE Ibuprofen ORAL SUSENSION 100 /5ML... 1 Ibuprofen ORAL TABLET IN-CHECK DIAL FLOW TRAINER XX DEVICE Inhaler Companions XX MISC IONIL-T EXTERNAL SHAMOO 1 % Ipecac ORAL SYRU... 7 Iron ORAL TABLET 325 (65 Fe), 90 (18 Fe) Itch Relief EXTERNAL CREAM 2 % KAOECTATE EXTRA STRENGTH ORAL SUSENSION 525 /15ML... 6 KAOECTATE ORAL SUSENSION 262 /15ML... 6 Kao-Tin ORAL CASULE Kao-Tin ORAL SUSENSION 262 /15ML... 6 KERR INSTA-CHAR IN SORBITOL ORAL LIQUID 25 GM/120ML, 50 GM/240ML... 7 KERR INSTA-CHAR ORAL LIQUID 25 GM/120ML, 50 GM/240ML... 7 Ketotifen Fumarate OHTHALMIC SOLUTION % KONSYL FIBER ORAL TABLET KONSYL ORAL ACKET 100 % Laxa Basic ORAL CASULE 100, Laxative RE SUOSITORY Liquid Calcium/Vitamin D ORAL CASULE UNIT Liquitears OHTHALMIC SOLUTION 1.4 % LITTLE NOSES SALINE NASAL SOLUTION 0.65 % LITTLE REMEDIES OISON TREAT ORAL SUSENSION RECONSTITUTED 15 GM/120ML... 7 LOERAMIDE A-D ORAL TABLET Loperamide HCl ORAL LIQUID 1 /5ML... 6 Loratadine Hives Relief ORAL SOLUTION 5 /5ML... 9 Loratadine ORAL TABLET MAALOX ADVANCED MAX ST ORAL SUSENSION /5ML... 4 MAALOX ADVANCED ORAL SUSENSION /5ML... 4 MAALOX MAX ORAL SUSENSION /5ML... 4 MAALOX MULTI SYMTOM MAX ST ORAL SUSENSION /5ML... 4 MAALOX ORAL TABLET CHEWABLE MAALOX REGULAR STRENGTH ORAL SUSENSION /5ML... 4 MAG64 ORAL TABLET EXTENDEDRELEASE* 535 (64 ) Mag-Delay ORAL TABLET EXTENDEDRELEASE* 535 (64 Mg) Magic Bullets RE SUOSITORY

36 Magnacaps ORAL CASULE Magnesium Citrate ORAL SOLUTION GM/30ML Magnesium ORAL TABLET Magnesium Oxide ORAL TABLET 400 (240 Mg) MAGNESIUM-OXIDE ORAL TABLET 400 (241.3 ) Mag-SR ORAL TABLET EXTENDEDRELEASE* 535 (64 Mg) MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 (7MEQ) Mapap Arthritis ain ORAL TABLET EXTENDEDRELEASE* Mapap ORAL CASULE Mapap ORAL TABLET Mapap ORAL TABLET Mapap ORAL TABLET CHEWABLE Mapap M ORAL TABLET Maxapap Maximum Strength ORAL TABLET Maxapap Regular Strength ORAL TABLET Meclizine HCl ORAL TABLET 12.5, Melatonin Maximum Strength ORAL TABLET MEHYTON ORAL TABLET METAMUCIL MULTIHEALTH FIBER ORAL OWDER 58.6 % METAMUCIL ORAL OWDER 30.9 % METAMUCIL SMOOTH TEXTURE ORAL ACKET 28 % METAMUCIL SMOOTH TEXTURE ORAL OWDER 28.3 %, 58.6 % MEDICATED TAR EXTERNAL SHAMOO 15 % Mi-Acid Gas Relief ORAL TABLET CHEWABLE MI-ACID ORAL TABLET CHEWABLE Miconazole 3 Combo ack VAGINAL KIT % (9GM) Miconazole 7 VAGINAL CREAM 2 % Miconazole 7 VAGINAL SUOSITORY Miconazole Nitrate VAGINAL CREAM 2 % Miconazole Nitrate VAGINAL SUOSITORY MICROCHAMBER XX MISC MICROSACER XX MISC Milantex Extra Strength ORAL SUSENSION /5ML... 4 Milantex ORAL SUSENSION /5ML... 4 Milk of Magnesia ORAL SUSENSION 400 /5ML, 7.75 % MINTOX LUS ORAL TABLET CHEWABLE Mucus Relief ORAL TABLET Multi-Day ORAL TABLET Multi-Vit/Fluoride ORAL SOLUTION 0.25 /ML, 0.5 /ML Multivitamin & Mineral ORAL LIQUID Multi-Vitamin ORAL TABLET Multivitamin/Fluoride ORAL TABLET CHEWABLE 0.25, 0.5, Multi-Vitamin/Fluoride ORAL TABLET CHEWABLE 0.25, 0.5, Multi-Vitamins ORAL TABLET Multivitamins/Fluoride ORAL TABLET CHEWABLE MURINE EAR OTIC SOLUTION 6.5 % MURINE EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % Mytab Gas ORAL TABLET CHEWABLE Nasal Decongestant ORAL SYRU 30 /5ML NASAL MOIST NASAL SOLUTION 0.65 % Natural Fiber Therapy ORAL OWDER 30.9 %, % Natural Senna Laxative ORAL TABLET Natural Vegetable Fiber ORAL OWDER % Na-Zone NASAL SOLUTION 0.65 % NEHRONEX ORAL TABLET NEUTROGENA MOISTURE SF15 EXTERNAL LOTION NEUTROGENA ON-THE-SOT EXTERNAL CREAM 2.5 % NEUTROGENA T/GEL EX ST EXTERNAL SHAMOO 1 % Niacin ER ORAL CASULE EXTENDED RELEASE* 250, Niacin ER ORAL TABLET EXTENDEDRELEASE* 250, 500, Niacin ORAL TABLET 100, 250, 50, Niacin-50 ORAL TABLET Nicotine olacrilex MOUTH/THROAT GUM 2, Nicotine TRANSDERMAL ATCH 24 HR 14 /24HR, 21 /24HR, 7 /24HR Non-Aspirin Extra Strength ORAL TABLET Non-Aspirin ORAL TABLET

37 Non-Aspirin ain Relief ORAL TABLET Nortemp Infants ORAL SUSENSION 80 /0.8ML... 3 NYTOL ORAL TABLET OCEAN FOR KIDS NASAL SOLUTION 0.65 % Omeprazole ORAL TABLET DELAYED RELEASE Once Daily ORAL TABLET One-Daily Multi Vitamins ORAL TABLET OERAND OVIDONE-IODINE EXTERNAL SOLUTION 10 %... 9 OTICHAMBER ADVANTAGE XX MISC OTIHALER XX DEVICE OTIHALER XX MISC OTIONS CONCETROL VAGINAL GEL 4 % ORALYTE FREEZER OS ORAL SOLUTION ORAZINC ORAL CASULE OS-CAL D ORAL TABLET UNIT OS-CAL ORAL TABLET CHEWABLE OTIX OTIC SOLUTION 6.5 % OYSCO 500 ORAL TABLET OYSCO 500+D ORAL TABLET UNIT OYSCO D ORAL TABLET UNIT Oyst-Cal D ORAL TABLET UNIT Oyster Calcium + D ORAL TABLET UNIT Oyster Shell Calcium + D ORAL TABLET UNIT Oyster Shell Calcium D ORAL TABLET UNIT Oyster Shell Calcium/D ORAL TABLET UNIT, UNIT Oyster Shell Calcium/Vitamin D ORAL TABLET UNIT Oyster Shell/Vitamin D ORAL TABLET UNIT OYSTERCAL ORAL TABLET ain & Fever Childrens ORAL SOLUTION 160 /5ML... 3 ain Relief Extra Strength ORAL TABLET ain Relief ORAL TABLET ain Relief M Extra Strength ORAL TABLET ain Reliever M ORAL TABLET ANOXYL WASH EXTERNAL LIQUID 10 % C-Tar EXTERNAL SHAMOO 1 % ERI-COLACE ORAL TABLET ermethrin EXTERNAL LOTION 1 % FLEX XX MISC harbedryl ORAL CASULE 25, HARBETOL EXTRA STRENGTH ORAL TABLET HARBETOL ORAL TABLET henazopyridine HCl ORAL TABLET ink Bismuth ORAL SUSENSION 262 /15ML... 6 ink Bismuth ORAL TABLET CHEWABLE OCKET CHAMBER XX DEVICE OCKET SACER XX DEVICE olyvinyl Alcohol OHTHALMIC SOLUTION 1.4 % ovidone-iodine EXTERNAL OINTMENT 10 %... 9 ovidone-iodine EXTERNAL SOLUTION 10 %... 9 ovidone-iodine EXTERNAL SWAB 10 %, 7.5 %... 9 REARATION H EXTERNAL AD 50 % REARATION H HYDROCORTISONE EXTERNAL CREAM 1 % seudoephedrine HCl ORAL TABLET 30, Q-Dryl ORAL CASULE Q-Dryl ORAL LIQUID 12.5 /5ML... 8 Q-A ORAL TABLET Q-TA ORAL ELIXIR 1-15 /5ML... 9 Quenalin ORAL SYRU 12.5 /5ML... 8 Ranitidine Acid Reducer ORAL TABLET Refenesen 400 ORAL TABLET Refenesen ORAL TABLET REGULOID ORAL CASULE 0.52 GM REHYDRALYTE ORAL SOLUTION RENAL ORAL CASULE Rena-Vite Rx ORAL TABLET Reno Caps ORAL CASULE ReVital Freezer ops ORAL SOLUTION ReVital Liquid Squeezers ORAL SOLUTION Robafen ORAL SYRU 100 /5ML... 9 Saline Mist Spray NASAL SOLUTION 0.65 % Saline Nasal Spray NASAL SOLUTION 0.65 %

38 SCOT-TUSSIN ALLERGY RELIEF ORAL LIQUID 12.5 /5ML... 8 Sea Soft Nasal Mist NASAL SOLUTION 0.65 % Senexon ORAL LIQUID 8.8 /5ML Senexon ORAL TABLET Senna Lax ORAL TABLET Senna Laxative ORAL TABLET Senna Maximum Strength ORAL TABLET Senna ORAL SYRU 8.8 /5ML Senna ORAL TABLET 15, Senna lus ORAL TABLET Senna S ORAL TABLET SENNA SMOOTH ORAL TABLET SENNACON ORAL TABLET Senna-Docusate Sodium ORAL TABLET Senna-Lax ORAL TABLET SENNALAX-S ORAL TABLET Senna-S ORAL TABLET Senna-Tabs ORAL TABLET Senna-Time ORAL TABLET Senna-Time S ORAL TABLET SENNO ORAL TABLET Sennosides-Docusate Sodium ORAL TABLET Silace ORAL LIQUID 150 /15ML Silace ORAL SYRU 60 /15ML Siladryl Allergy ORAL LIQUID 12.5 /5ML... 8 Silphen Cough ORAL SYRU 12.5 /5ML... 8 Simethicone ORAL SUSENSION 40 /0.6ML Simethicone ORAL TABLET CHEWABLE SIMLY ALLERGY ORAL TABLET SIMLY SLEE ORAL TABLET Sleep Tabs ORAL TABLET Sleep-Tabs ORAL TABLET SLO-NIACIN ORAL TABLET EXTENDEDRELEASE* SM Oral Saline Laxative ORAL SOLUTION GM/5ML Sodium Bicarbonate ORAL TABLET 325, Sodium Chloride INHALATION NEBULIZATION SOLUTION 0.9 % Sodium Chloride ORAL TABLET 1 GM SOF-LAX ORAL CASULE SOMINEX MAXIMUM STRENGTH ORAL TABLET SOMINEX ORAL TABLET Sorbitol ORAL SOLUTION 70 % Stimulant Laxative ORAL TABLET DELAYED RELEASE Stomach Relief ORAL SUSENSION 262 /15ML, 527 /30ML... 6 Stomach Relief ORAL TABLET CHEWABLE Stomach Relief lus ORAL SUSENSION 525 /15ML... 6 Stool Softener Laxative DC ORAL CASULE Stool Softener ORAL CASULE 100, SUDAFED 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HR* SUER NU-THERA ORAL TABLET SURFAK ORAL CASULE Sur-Q-Lax ORAL CASULE Tactinal Extra Strength ORAL TABLET Tactinal ORAL TABLET Tears Again OHTHALMIC OINTMENT Tears Again OHTHALMIC SOLUTION TERA-GEL TAR EXTERNAL SHAMOO 0.5 % Terbinafine HCl EXTERNAL CREAM 1 % Tetra-Formula Nighttime Sleep ORAL TABLET THERA ORAL TABLET Thera Vital M ORAL TABLET THERA/BETA-CAROTENE ORAL TABLET Therabasic-M ORAL TABLET Thera-Ear OTIC SOLUTION 6.5 % Therapeutic Liquid ORAL SOLUTION Therapeutic ORAL TABLET Therapeutic-M ORAL TABLET Thera-Tabs ORAL TABLET THRESHOLD IMT XX MISC THRESHOLD E XX DEVICE TITRALAC ORAL TABLET CHEWABLE Tolnaftate Antifungal EXTERNAL CREAM 1 % Tolnaftate EXTERNAL CREAM 1 % Tolnaftate EXTERNAL SOLUTION 1 %

39 TOTAL ALLERGY MEDICINE ORAL LIQUID 12.5 /5ML... 8 Total Allergy ORAL TABLET TOTAL FORMULA 3 ORAL TABLET Tri-Buffered Aspirin ORAL TABLET Triple Antibiotic EXTERNAL OINTMENT , Ultilet Glucose ORAL TABLET CHEWABLE 4 GM... 6 ULTRA FRESH M OHTHALMIC OINTMENT VCF VAGINAL CONTRACETIVE VAGINAL FOAM 12.5 % Vitamin B-12 ER ORAL TABLET EXTENDEDRELEASE* 1000 MCG Vitamin B-12 ORAL TABLET 1000 MCG, 250 MCG, 500 MCG Vitamin B-12 SUBLINGUAL TABLET SUBLINGUAL 1000 MCG Vitamin C ORAL SYRU 500 /5ML Vitamin C ORAL TABLET 100, 1000, 250, Vitamin C ORAL TABLET CHEWABLE 100, Vitamin D (Ergocalciferol) ORAL CASULE UNIT Vitamin D ORAL TABLET 400 UNIT Vitamin D3 ORAL CASULE 2000 UNIT Vitamin D3 ORAL TABLET 1000 UNIT, 400 UNIT Vitamin D-400 ORAL TABLET 400 UNIT Vitamins for Hair ORAL TABLET WATCHHALER XX DEVICE WINDMILL TRAINER XX MISC Womens Laxative ORAL TABLET DELAYED RELEASE XENICAL ORAL CASULE Zinc Gluconate ORAL TABLET 100, 30, Zinc Methionate ORAL CASULE Zinc ORAL TABLET 25, Zinc icolinate ORAL TABLET Zinc Sulfate ORAL CASULE Zinc Sulfate ORAL TABLET 220 (50 Zn) Zinc-220 ORAL CASULE