MORPHINE SUPPOSITORIES (RECTAL) DIVALPROEX SPRINKLE (ORAL) KETOCONAZOLE CREAM, SHAMPOO (TOPICAL) appropriate

Transcription

1 CONNECTICUT MEDICAID Acne Agents, Topical Antibiotics, GI Antidepressants, Other (cont.) AZELEX (TOPICAL) METRONIDAZOLE TABLET (ORAL) MARPLAN (ORAL) BENZACLIN (TOPICAL) NEOMYCIN (ORAL) MIRTAZAPINE TABLET, ODT (ORAL) BENZACLIN W/PUMP (TOPICAL) VANCOMYCIN (ORAL) PARNATE (ORAL) CLINDAMYCIN PHOSPHATE GEL, LOTION, SOLUTION (TOPICAL) Antibiotics, Inhaled PHENELZINE (ORAL) DIFFERIN CREAM, GEL, LOTION (TOPICAL) BETHKIS (INHALATION) PRISTIQ (ORAL) DUAC (TOPICAL) CAYSTON (INHALATION) TRAZODONE (ORAL) EPIDUO (TOPICAL) KITABIS PAK (INHALATION)* VENLAFAXINE ER CASPULES (ORAL) ERYTHROMYCIN GEL, SOLUTION (TOPICAL) TOBI PODHALER (INHALATION) VIIBRYD, VIIBRYD DS PK (ORAL) TRETINOIN CREAM, GEL (TOPICAL) Antibiotics, Topical Antidepressants, SSRI Alzheimer's Agents BACTROBAN CREAM*, OINTMENT (TOPICAL) CITALOPRAM TABLET, SOLUTION (ORAL) DONEPEZIL TABLET, ODT (ORAL) GENTAMICIN CREAM, OINTMENT (TOPICAL) ESCITALOPRAM TABLET (ORAL) EXELON (TRANSDERMAL) NEOMYCIN / POLYMYXIN / PRAMOXINE (TOPICAL) FLUOXETINE CAPSULE, SOLUTION, TABLET (ORAL) GALANTAMINE ER (ORAL) Antibiotics, Vaginal FLUVOXAMINE (ORAL) NAMENDA SOLUTION, TABLET DS PAK, TABLET (ORAL) CLEOCIN OVULES (VAGINAL) LEXAPRO SOLUTION (ORAL) RIVASTIGMINE CAPSULES (ORAL) METROGEL-VAGINAL (VAGINAL) PAROXETINE TABLET (ORAL) Analgesics, Narcotic Long Anticoagulants, Injectable SERTRALINE CONC, TABLET (ORAL) FENTANYL (TRANSDERM) FRAGMIN DISP SYRIN, VIAL (SUBCUTANE.) Antiemetics KADIAN (ORAL) LOVENOX SYRINGE, VIAL (SUBCUTANE.) EMEND, EMEND PACK (ORAL) METHADONE CONC, SOL TABLET, SOLUTION, TABLET (ORAL) Anticoagulants, Oral DICLEGIS (ORAL)* MORPHINE ER (ORAL) ELIQUIS (ORAL) DRONABINOL (ORAL) TRAMADOL ER (ORAL) PRADAXA (ORAL) ONDANSETRON ODT, SOL, TAB (ORAL) Analgesics, Narcotic Short WARFARIN (ORAL) Antifungals, Oral APAP / CODEINE ELIXIR, TABLET (ORAL) XARELTO (ORAL) CLOTRIMAZOLE (MUCOUS MEM) BUTALBITAL / CAFFEINE / APAP W/CODEINE (ORAL) Anticonvulsants FLUCONAZOLE SUSPENSION, TABLET (ORAL) BUTALBITAL COMPOUND W/CODEINE (ORAL) CARBAMAZEPINE SUSPENSION, TAB CHEW, TABLET (ORAL) GRISEOFULVIN SUSPENSION (ORAL) 7/1/2015 * New Drug added to the PDL effective 7/1/2015 BUTORPHANOL TARTRATE (NASAL) CARBAMAZEPINE ER (GENERIC CARBATROL) (ORAL) GRISEOFULVIN ULTRAMICROSIZE (ORAL)* CODEINE (ORAL) CARBAMAZEPINE XR (ORAL) NYSTATIN SUSPENSION (ORAL) DIHYDROCODEINE / APAP / CAFFEINE (ORAL) CARBATROL (ORAL) TERBINAFINE (ORAL) PA Requirements HYDROCODONE / APAP CAPSULE, SOLUTION, TABLET (ORAL) CELONTIN (ORAL) Antifungals, Topical Intolerance of the preferred agents HYDROCODONE / IBUPROFEN (ORAL) CLONAZEPAM (ORAL) CLOTRIMAZOLE CREAM RX, SOLUTION RX (TOPICAL) Adverse reaction to the preferred agents HYDROMORPHONE TABLET (ORAL) DIASTAT, DIASTAT ACUDIAL (RECTAL) CLOTRIMAZOLE CREAM OTC, SOLUTION OTC (TOPICAL) Inadequate response from the preferred agents MORPHINE CONC, SOLUTION, MORPHINE IR TABLET (ORAL) DILANTIN INFATAB (ORAL) CLOTRIMAZOLE-BETAMETHASONE CREAM (TOPICAL) Determined medically necessary and medically MORPHINE SUPPOSITORIES (RECTAL) DIVALPROEX SPRINKLE (ORAL) KETOCONAZOLE CREAM, SHAMPOO (TOPICAL) appropriate OXYCODONE / APAP CAPSULE, TABLET (ORAL) DIVALPROEX TABLET, DIVALPROEX ER (ORAL) LOTRIMIN AF OTC (TOPICAL) Absence of appropriate formulation of the preferred OXYCODONE / ASA (ORAL) ETHOSUXIMIDE SYRUP (ORAL) MICONAZOLE CREAM OTC, OINT OTC, POWDER OTC (TOPICAL) agents OXYCODONE / IBUPROFEN (ORAL) FELBAMATE SUSPENSION (ORAL) NYSTATIN CREAM, OINT, POWDER (TOPICAL) OXYCODONE CAPSULE, SOLUTION, TABLET (ORAL) GABITRIL (ORAL) NYSTATIN-TRIAMCINOLONE CREAM, OINT (TOPICAL) PENTAZOCINE / APAP (ORAL) LAMOTRIGINE, LAMOTRIGINE TAB DS PK (ORAL) Antihistamines, Minimally Sedating Important Connecticut Medicaid ROXICET SOLUTION (ORAL) LEVETIRACETAM SOLUTION, TABLETS (ORAL) CETIRIZINE SOLUTION, CETIRIZINE SOLUTION OTC, Phone Numbers TRAMADOL, TRAMADOL / APAP (ORAL) OXCARBAZEPINE SUSPENSION, TABLET (ORAL) CETIRIZINE-D OTC (ORAL) Preferred Drug List The Connecticut Medicaid Preferred Drug List (PDL) is a listing of prescription products selected by the Pharmaceutical and Therapeutics Committee as efficacious, safe and cost effective choices when prescribing for Medicaid patients Preferred or Non-preferred status only applies to those medications that fall within the drug classes listed on this PDL HIV medications are excluded from the PDL and do not require prior authorization All strengths and dosage forms of preferred agents are covered, unless otherwise stated The brand-name of a generically available medication will not be covered without a PA, unless the brand is listed on the PDL Preferred brand-name medications with non-preferred generic equivalents are listed in bold Any OTC product included on the PDL with the exception of insulin will be covered for clients under the age of 21 only. ** New Therapeutic Class added to PDL effective HP Pharmacy Prior Authorization Center Androgenic Agents PEGANONE (ORAL) FEXOFENADINE-D 12-HOUR OTC (ORAL) p (toll-free) ANDROGEL GEL PACKET, PUMP (TRANSDERM.) PHENOBARBITAL ELIXIR, TABLET (ORAL) LORATADINE ODT, SOLUTION, TABLET, LORATADINE-D OTC (ORAL) f (toll-free) Angiotensin Modulators PHENYTOIN CAPSULE, SUSPENSION (ORAL) Antihypertensives, Sympatholytics PA forms are only available on our website: Navigate to: Pharmacy Information or: information > publications > forms CAPTOPRIL, CAPTOPRIL HCTZ (ORAL) PHENYTOIN EXT CAPSULE (GENERIC PHENYTEK) (ORAL) CATAPRES-TTS (TRANSDERM) DIOVAN, DIOVAN HCT (ORAL) PRIMIDONE (ORAL) CLONIDINE (ORAL) ENALAPRIL, ENALAPRIL HCTZ (ORAL) TOPIRAMATE SPRINKLE, TABLET (ORAL) GUANFACINE (ORAL) EPANED (ORAL)* VALPROATE SYRUP (ORAL) METHYLDOPA, METHYLDOPA HCTZ (ORAL) LISINOPRIL, LISINOPRIL HCTZ (ORAL) VALPROIC ACID (ORAL) Antihyperuricemics HP Provider Assistance Center LOSARTAN, LOSARTAN HCTZ (ORAL) VIMPAT SOLUTION, TABLET (ORAL) ALLOPURINOL (ORAL) QUINAPRIL, QUINIPRIL HCTZ (ORAL) ZONISAMIDE (ORAL) PROBENECID (ORAL) Angiotensin Modulators/CCB Comb. Antidepressants, Other PROBENECID / COLCHICINE (ORAL) Dept of Social Services Rx Consultant AMLODIPINE / BENAZEPRIL (ORAL) BRINTELLIX (ORAL) Antimigraine Agents (860) AZOR (ORAL) BUPROPION, BUPROPION SR, BUPROPION XL (ORAL) IMITREX (NASAL) EXFORGE, EXFORGE HCT (ORAL) FETZIMA (ORAL) IMITREX KIT, VIAL (SUBCUTANE.)

2 Antimigraine Agents (cont.) Antipsychotics (cont.) BPH Agents (cont.) Contraceptives, Oral (cont.) RELPAX (ORAL) PERPHENAZINE (ORAL) DOXAZOSIN (ORAL) LEVORA (ORAL) SUMATRIPTAN (ORAL) QUETIAPINE TABLET (ORAL) FINASTERIDE (ORAL) LOESTRIN, LOESTRIN FE (ORAL) Antiparasitics, Topical RISPERDAL CONSTA (INTRAMUSC.) TAMSULOSIN (ORAL) LORYNA (ORAL) NATROBA (TOPICAL) RISPERDAL ODT, SOLUTION, TABLET (ORAL) TERAZOSIN (ORAL) LOSEASONIQUE (ORAL) PERMETHRIN, PERMETHRIN OTC (TOPICAL) RISPERIDONE TABLET, ODT, SOLUTION(ORAL) Bronchodilators, Beta-Agonists LOW-OGESTREL (ORAL) PIPERONYL BUTOXIDE/PYRETHRINS SHAMPOO OTC (TOPICAL) SAPHRIS (SUBLINGUAL) ALBUTEROL NEB SOLN 100 MG/20 ML (INHALATION) LUTERA (ORAL) SKLICE (TOPICAL) SEROQUEL (ORAL) ALBUTEROL NEB SOLN 2.5 MG/3 ML (INHALATION) MICROGESTIN FE (ORAL) ULESFIA (TOPICAL) SEROQUEL XR (ORAL) ALBUTEROL NEB SOLN 0.63, 1.25 MG (INHALATION) MIRCETTE (ORAL) Antiparkinson's Agents SYMBYAX (ORAL) ALBUTEROL SYRUP, TABLET (ORAL) MYZILRA (ORAL) AMANTADINE CAPSULE, SYRUP (ORAL) THIORIDAZINE (ORAL) PROAIR HFA (INHALATION) NORDETTE-28 (ORAL) BENZTROPINE (ORAL) THIOTHIXENE (ORAL) PROVENTIL HFA (INHALATION) NORETHINDRONE-ETHIN ESTRADIOL FE (ORAL) BROMOCRIPTINE (ORAL) TRIFLUOPERAZINE (ORAL) STRIVERDI RESPIMAT (INHALATION) NORETHINDRONE-ETHIN ESTRADIOL (ORAL) CARBIDOPA / LEVODOPA TABLET, ODT, CARBIDOPA / VERSACLOZ (ORAL) TERBUTALINE (ORAL) NORINYL 1+50 (ORAL) LEVODOPA ER (ORAL) ZIPRASIDONE CAPSULE (ORAL) Calcium Channel Blockers NOR-Q-D (ORAL) CARBIDOPA / LEVODOPA / ENTACAPONE (ORAL) ZYPREXA (INTRAMUSC) AMLODIPINE (ORAL) NORTREL (ORAL) PRAMIPEXOLE (ORAL) ZYPREXA (ORAL) DILTIAZEM TABLET, DILTIAZEM CAPSULE ER (ORAL) ORSYTHIA (ORAL) ROPINIROLE (ORAL) ZYPREXA RELPREVV (INTRAMUSC) NICARDIPINE (ORAL) ORTHO TRI-CYCLEN LO (ORAL) SELEGILINE CAPSULE, TABLET (ORAL) ZYPREXA ZYDIS (ORAL) NIFEDIPINE ER, NIFEDIPINE IR (ORAL) ORTHO-NOVUM MONOPHASIC (ORAL) TRIHEXYPHENIDYL ELIXIR, TABLET (ORAL) Antivirals VERAPAMIL CAPSULE, TABLET, VERAPAMIL TABLET ER OVCON-35 (ORAL) Antipsoriatics, Oral ACYCLOVIR CAPSULE, SUSPENSION, TABLET (ORAL) VERAPAMIL ER PM (ORAL) PHILITH (ORAL) OXSORALEN-ULTRA (ORAL) RELENZA (INHALATION) Cephalosporins & Related Agents PORTIA (ORAL) SORIATANE (ORAL) RIMANTADINE (ORAL) AMOXICILLIN/CLAV CHEW TAB, SUSPENSION, TABLET (ORAL) SEASONIQUE (ORAL) Antipsoriatics, Topical TAMIFLU CAPSULE, SUSPENSION (ORAL) CEFACLOR CAPSULE, SUSPENSION (ORAL) SRONYX (ORAL) CALCIPOTRIENE CREAM, OINTMENT, SOLUTION (TOPICAL) VALACYCLOVIR (ORAL) CEFADROXIL CAPSULE, SUSPENSION, TABLET (ORAL) SYEDA (ORAL) CALCITRIOL OINTMENT (TOPICAL) Antivirals, Topical CEFDINIR CAPSULE, SUSPENSION (ORAL) TRI-LINYAH (ORAL) Antipsychotics DENAVIR (TOPICAL) CEFPODOXIME SUSPENSION, TABLET (ORAL) TRI-NORINYL (ORAL) ABILIFY (INTRAMUSC) ZOVIRAX OINTMENT (TOPICAL) CEFPROZIL SUSPENSION, TABLET (ORAL) TRI-PREVIFEM (ORAL) ABILIFY DISCMELT, SOLUTION, TABLET (ORAL) Anxiolytics CEFTIN SUSPENSION (ORAL)* TRI-SPRINTEC (ORAL) ABILIFY MAINTENA (INTRAMUSC.) ALPRAZOLAM TABLET (ORAL) CEFUROXIME TABLET (ORAL) TRIVORA-28 (ORAL) ADASUVE (INHALATION) BUSPIRONE (ORAL) CEPHALEXIN CAPSULE, SUSPENSION, TABLET (ORAL) VESTURA (ORAL) AMITRIPTYLINE / PERPHENAZINE (ORAL) CHLORDIAZEPOXIDE (ORAL) SUPRAX CAPSULE, SUSPENSION, TAB CHEW (ORAL) WERA (ORAL) ARIPIPRAZOLE (ORAL) CLORAZEPATE (ORAL) Colony Stimulating Factors YASMIN 28 (ORAL) CHLORPROMAZINE (ORAL) DIAZEPAM SOLUTION, TABLET (ORAL) GRANIX (INJECTION) YAZ (ORAL) CLOZAPINE, CLOZAPINE ODT (ORAL) LORAZEPAM INTENSOL (ORAL) NEULASTA SYRINGE (INJECTION) ZARAH (ORAL) CLOZARIL (ORAL) LORAZEPAM TABLET (ORAL) NEUPOGEN DISP SYRIN, VIAL (INJECTION) ZENCHENT FE (ORAL) FANAPT TABLET, TITRATION PACK (ORAL) Beta Blockers Contraceptives, Oral COPD Agents FAZACLO (ORAL) ATENOLOL, ATENOLOL / CHLORTHALIDONE (ORAL) ALYACEN (ORAL) ALBUTEROL SULFATE / IPRATROPIUM INHALATION SOLUTION FLUPHENAZINE DECANOATE (INJECTION) CARVEDILOL (ORAL) AVIANE (ORAL) ANORO ELLIPTA (INHALATION) FLUPHENAZINE ELIXER/SOLN, TABLET (ORAL) LABETALOL (ORAL) BREVICON (ORAL) ATROVENT HFA (INHALATION) GEODON (INTRAMUSC) METOPROLOL (ORAL) CHATEAL (ORAL) COMBIVENT RESPIMAT (INHALATION) GEODON (ORAL) METOPROLOL ER (ORAL)* CRYSELLE (ORAL) DALIRESP (ORAL) HALDOL (INJECTION) PROPRANOLOL SOLUTION, TABLET, PROPRANOLOL ER (ORAL) CYCLAFEM (ORAL) IPRATROPIUM NEBULIZER (INHALATION) HALDOL DECANOATE (INTRAMUSC) Bile Salts, Oral DASETTA (ORAL) SPIRIVA (INHALATION) HALOPERIDOL (ORAL) URSODIOL TABLET (ORAL) DESOGEN (ORAL) Cytokine & CAM Antagonists HALOPERIDOL DECANOATE (INJECTION) Bladder Relaxants ELINEST (ORAL) ENBREL DISP SYRINGE, KIT, PEN (INJECTION) HALOPERIDOL LACTATE (INJECTION) OXYBUTYNIN SYRUP, TABLET, OXYBUTYNIN ER (ORAL) ENPRESSE (ORAL) HUMIRA KIT, PEN INJ KIT (INJECTION) HALOPERIDOL LACTATE CONC (ORAL) TOVIAZ (ORAL) ESTROSTEP FE (ORAL) Emollients, Topical INVEGA (ORAL) VESICARE (ORAL) FALMINA (ORAL) AMMONIUM LACTATE CREAM/LOTION (TOPICAL) INVEGA SUSTENNA, INVEGA TRINZIA (INTRAMUSC) Bone Resorption Inhibitors FEMCON FE (ORAL) LACTIC ACID CREAM/LOTION (TOPICAL) LATUDA (ORAL) ALENDRONATE TABLETS (ORAL) GILDESS FE (ORAL) Epinephrine, Self-Injected LOXAPINE (ORAL) FORTICAL (NASAL) JUNEL FE (ORAL) EPI-PEN, EPI-PEN JR. (INJECTION) OLANZAPINE (INTRAMUSC) Botulinum Toxins, Injectable LARIN FE (ORAL) Erythropoiesis Stimulating Proteins OLANZAPINE TABLET, ODT (ORAL) BOTOX (INTRAMUSC) LESSINA (ORAL) ARANESP DISP SYRIN, VIAL (INJECTION) OLANZAPINE/FLUOXETINE (ORAL) BPH Agents LEVONEST (ORAL) PROCRIT (INJECTION) ORAP (ORAL) ALFUZOSIN (ORAL) LEVONORGESTREL/ETHINYL ESTRADIOL MONOPHASIC (LUPIN)(ORAL)(28)

3 Fluoroquinolones, Oral Hypoglycemics, Alpha Glucosidase Inhibitors Intranasal Rhinitis Agents (cont.) Irritable Bowel Syndrome CIPRO SUSPENSION (ORAL) ACARBOSE (ORAL) IPRATROPIUM (NASAL) AMITIZA (ORAL) CIPROFLOXACIN TABLET (ORAL) GLYSET (ORAL) NASONEX (NASAL) LINZESS (ORAL) LEVOFLOXACIN TABLET (ORAL) Hypoglycemics, Incretin Mimetics/Enhancers PATANASE (NASAL) MOVANTIK (ORAL)* Glucocorticoids, Inhaled BYDUREON (SUBCUTANE.) Iron, Oral ACCOLATE (ORAL) ADVAIR DISKUS (INHALATION) BYDUREON PENS (SUBCUTANE.)* CENTRATEX (ORAL) MONTELUKAST SOD TABLET, TAB CHEW (ORAL) ASMANEX (INHALATION) BYETTA PENS (SUBCUTANE.) FE C OTC (ORAL) Lipotropics, Other DULERA (INHALATION) JANUMET, JANUMET XR (ORAL) FE FUMARATE/VIT C/B12-IF/FA (ORAL) CHOLESTYRAMINE/ASPARTAME (ORAL) FLOVENT DISKUS, FLOVENT HFA (INHALATION) JANUVIA (ORAL) FEOSOL OTC (ORAL) CHOLESTYRAMINE/SUCROSE (ORAL) PULMICORT 0.25, 0.5 MG RESPULES (INHALATION) JENTADUETO (ORAL) FERATE OTC (ORAL) COLESTIPOL TABLET (ORAL) PULMICORT FLEXHALER (INHALATION) TANZEUM (SUBCUTANE.)* FERRALET 90 DUAL-IRON (ORAL) GEMFIBROZIL (ORAL) QVAR (INHALATION) TRADJENTA (ORAL) FERRAPLUS 90 (ORAL) NIASPAN (ORAL) SYMBICORT (INHALATION) VICTOZA (SUBCUTANE.) FERRIMIN 150 OTC (ORAL) TRICOR (ORAL)* Glucocorticoids, Oral Hypoglycemics, Insulin & Related FERROCITE PLUS (ORAL) TRILIPIX (ORAL)* DEXAMETHASONE SOLUTION, TABLET (ORAL) HUMALOG CARTRIDGE, PEN, VIAL (SUBCUTANE.) FERROUS FUMARATE/ASCORBIC ACID/B12-IF/FA Lipotropics, Statins ENTOCORT EC (ORAL) HUMALOG MIX PEN, VIAL (SUBCUTANE.) CAPSULE (ORAL) ATORVASTATIN (ORAL) HYDROCORTISONE (ORAL) HUMULIN 500 U/M VIAL (SUBCUTANE.) FERROUS FUMARATE/FA/MULTIVITAMIN & MINERALS CRESTOR (ORAL) METHYLPREDNISOLONE TAB DS PK (ORAL) HUMULIN 70/30 PEN OTC, VIAL OTC (SUBCUTANE.) CAPSULE (ORAL) LOVASTATIN (ORAL) METHYLPREDNISOLONE TABLET (ORAL) HUMULIN PEN OTC, VIAL OTC (SUBCUTANE.) FERROUS FUMARATE/IRON POLYSACCHARIDES/FA/ PRAVASTATIN (ORAL) ORAPRED, ORAPRED ODT (ORAL) LANTUS CARTRIDGE, VIAL (SUBCUTANE.) MULTIVITAMIN CAPSULE (ORAL) SIMVASTATIN (ORAL) PREDNISOLONE SODIUM PHOSPHATE (ORAL) LANTUS SOLOSTAR PEN (SUBCUTANE.) FERROUS GLUCONATE OTC (ORAL) Macrolides & Ketolides PREDNISOLONE SOLUTION (ORAL) LEVEMIR PENS, VIAL (SUBCUTANE.) FERROUS SULFATE 65 MG TABLET OTC (ORAL) AZITHROMYCIN PACKET, SUSPENSION, TABLET (ORAL) PREDNISONE SOLUTION, TABLET (ORAL) NOVOLIN 70/30 VIAL OTC (SUBCUTANE.) FERROUS SULFATE OTC (ORAL) CLARITHROMYCIN TABLET (ORAL) VERIPRED 20 (ORAL) NOVOLOG CARTRIDGE, PEN, VIAL (SUBCUTANE.) FERROUS SULFATE SOLUTION OTC (ORAL) E.E.S. 400 TABLET (ORAL) Growth Factors NOVOLOG MIX 70/30 PEN, VIAL (SUBCUTANE.) FERROUS SULFATE TABLET ER OTC (ORAL) ERY-TAB (ORAL) EGRIFTA (SUB-Q) Hypoglycemics, Meglitinides FERROUS SULFATE, DRIED TABLET ER OTC (ORAL) ERYTHROCIN (ORAL) INCRELEX (SUB-Q) NATEGLINIDE (ORAL) FERROUS SULFATE/ASCORBIC ACID/FA TABLET ER OTC (ORAL) ERYTHROMYCIN BASE TABLET (ORAL) Growth Hormones PRANDIN (ORAL) FOLITAB 500 OTC (ORAL) Multiple Sclerosis Agents NORDITROPIN PEN (INJECTION) Hypoglycemics, Metformins FOLIVANE-F (ORAL) AVONEX, AVONEX PEN (INTRAMUSC.) NUTROPIN VIAL, NUTROPIN AQ CARTRIDGE, VIAL (INJECTION) GLIPIZIDE-METFORMIN (ORAL) FOLIVANE-PLUS (ORAL) BETASERON KIT (SUBCUTANE.)* H. Pylori Agents METFORMIN (ORAL) HEMATOGEN (ORAL) COPAXONE 20MG (SUBCUTANE.) HELIDAC (ORAL) METFORMIN ER (GLUCOPHAGE XR) (ORAL) HEMATOGEN FA (ORAL) GILENYA (ORAL)* LANSOPRAZOLE/AMOXICILN/CLARITH (ORAL) Hypoglycemics, SGLT2** HEMOCYTE PLUS (ORAL) REBIF, REBIF REBIDOSE PEN INJCTR (SUBCUTANE.) PYLERA (ORAL) INVOKANA (ORAL)* HEMOCYTE-F (ORAL) Neuropathic Pain Hepatitis C Agents FARXIGA (ORAL)* IFEREX 150 FORTE (ORAL) DULOXETINE (ORAL) DAKLINZA (ORAL) Hypoglycemics, TZDs INTEGRA F (ORAL) GABAPENTIN CAPSULE (ORAL) HARVONI (ORAL)* PIOGLITAZONE (ORAL) INTEGRA OTC (ORAL) LIDODERM (TOPICAL) INCIVEK (ORAL) Immunomodulators, Topical INTEGRA PLUS (ORAL) LYRICA (ORAL) OLYSIO (ORAL) ALDARA (TOPICAL) IRON 45 MG TABLET OTC (ORAL) Non-Steroidal Anti-Inflammatory PEGASYS KIT, PROCLICK, SYRINGE, VIAL (SUBCUTANE.) Immunomodulators, Atopic Dermatitis IRON POLYSACCHARIDES COMPLEX OTC (ORAL) ETODOLAC ER (ORAL) PEG-INTRON (SUBCUTANE.)* ELIDEL (TOPICAL) IRON PS CMPLX/VIT B12/FA (ORAL) FLECTOR (TOPICAL) RIBAVIRIN TABLET (ORAL) Immunosuppressives, Oral IRON,CARBONYL/ASCORBIC ACID OTC (ORAL) FLURBIPROFEN (ORAL) SOVALDI (ORAL) AZATHIOPRINE (ORAL) MV COMB18/FEFM-FEPOL CB1/FA (ORAL) IBUPROFEN SUSPENSION, TABLET (ORAL) TECHNIVIE DOSE PACK (ORAL) CYCLOSPORINE CAPSULE, SOFTGEL (ORAL) NEPHRON FA (ORAL) INDOCIN SUSPENSION (ORAL) VICTRELIS (ORAL) CYCLOSPORINE MODIFIED CAPSULE, MODIFIED SOLUTION (ORAL) NOVAFERRUM 50 CAPSULE OTC (ORAL) INDOMETHACIN (ORAL/RECTAL) VIEKIRA PAK (ORAL)* MYCOPHENOLATE MOFETIL CAPSULE, TABLET (ORAL) NOVAFERRUM DROPS OTC (ORAL) INDOMETHACIN CAPSULE (ORAL) Histamine II Receptor Blockers NEORAL CAPSULE (ORAL) NU-IRON 150 CAPSULE OTC (ORAL) KETOPROFEN (ORAL) CIMETIDINE TABLET (ORAL) PROGRAF (ORAL) SE-TAN PLUS (ORAL) KETOROLAC (ORAL) CIMETIDINE TABLET OTC (ORAL) RAPAMUNE SOLUTION (ORAL) SLOW RELEASE IRON (ORAL) MELOXICAM TABLET, SUSPENSION (ORAL) FAMOTIDINE TABLET (ORAL) SANDIMMUNE CAPSULE, SOLUTION (ORAL) TANDEM DUAL ACTION OTC (ORAL) MOBIC SUSPENSION (ORAL) FAMOTIDINE TABLET OTC (ORAL) SIROLIMUS (AG), SIROLIMUS (ORAL) TANDEM PLUS (ORAL) NABUMETONE (ORAL) PEPCID SUSPENSION (ORAL) Intranasal Rhinitis Agents TARON FORTE (ORAL) NAPROXEN TABLET, SUSPENSION (ORAL) RANITIDINE SYRUP, TABLET (ORAL) ASTEPRO (NASAL) TL-FOL 500 (ORAL) NAPROXEN SODIUM (ORAL) RANITIDINE TABLET OTC (ORAL) FLUNISOLIDE (NASAL) TL-HEM 150 (ORAL) PIROXICAM (ORAL) FLUTICASONE (NASAL) VITRON-C OTC (ORAL) SULINDAC (ORAL) VOLTAREN (TOPICAL)

4 Oncology Agents, Breast Cancer Ophthalmics, Antibiotics Otic, Antibiotics Prenatal Vitamins (cont.) ARIMIDEX (ORAL) BACITRACIN / POLYMYXIN B SULFATE OINT. (OPTHALMIC) CIPRODEX (OTIC) PRENATA (ORAL) EXEMESTANE (ORAL) BLEPHAMIDE, BLEPHAMIDE S.O.P. (OPHTHALMIC) CORTISPORIN SOLUTION (OTIC) PRENATAL COMPLETE OTC (ORAL)* LETROZOLE (ORAL) ERYTHROMYCIN (OPHTHALMIC) NEOMYCIN/POLYMYXIN/HC SOLUTION, SUSPENSION (OTIC) PRENATAL DHA+COMPLETE PRENATAL OTC (ORAL)* TAMOXIFEN CITRATE (ORAL) GENTAMICIN DROPS, OINTMENT (OPHTHALMIC) OFLOXACIN (OTIC) PRENATAL RX (ORAL) Oncology Agents, Oral MOXEZA (OPHTHALMIC) Otic, Anti-Infectives & Anesthetics PRENATAL VIT 15/IRON CB/FA/DSS (ORAL) AFINITOR (ORAL) NEOMYCIN/BACITRACIN/POLY/HC (OPHTHALMIC) ACETIC ACID (OTIC) PRENATAL VIT 18/IRON CB/FA/DSS (ORAL) AFINITOR DISPERZ (ORAL) NEOMYCIN/POLYMYXIN/DEXAMETHASONE (OPHTH.) ANTIPYRINE / BENZOCAINE (OTIC) PRENATAL VIT 86/IRON BISGLY/FA (ORAL) ALKERAN (ORAL) NEOMYCIN-POLYMYXIN-GRAMICIDIN (OPTHALMIC) PAH Agents, Oral & Inhaled PRENATAL VIT/FE FUMARATE/FA OTC (ORAL) BICALUTAMIDE (ORAL) OFLOXACIN (OPHTHALMIC) LETAIRIS (ORAL) PRENATAL VIT27&CALCIUM/IRON/FA (ORAL) BOSULIF (ORAL) POLYMYXIN/TRIMETHOPRIM (OPHTHALMIC) SILDENAFIL (ORAL) PRENATAL VITAMIN + DHA OTC (ORAL) CAPRELSA (ORAL) PRED-G DROPS SUSP, OINTMENT (OPHTHALMIC) TRACLEER (ORAL) PRENATAL VITAMINS OTC (ORAL) CASODEX (ORAL) SULFACETAMIDE / PREDNISOLONE (OPHTHALMIC) VENTAVIS (INHALATION) PRENATAL VITS W-CA,FE,FA(LT1MG) OTC (ORAL) COMETRIQ (ORAL) SULFACETAMIDE SOLUTION (OPHTHALMIC) Pancreatic Enzymes PRENEXA (ORAL) ERIVEDGE (ORAL) TOBRADEX OINTMENT, SUSPENSION (OPHTHALMIC) CREON (ORAL) SELECT-OB (ORAL) FARYDAK (ORAL) TOBRAMYCIN (OPHTHALMIC) PANCRELIPASE (ORAL) SE-NATAL 19 TAB CHEW, TABLET (ORAL) FLUTAMIDE (ORAL) TOBREX OINTMENT (OPHTHALMIC) ZENPEP (ORAL) TARON-BC, TARON-C DHA (ORAL) GILOTRIF (ORAL) VIGAMOX (OPHTHALMIC) Phosphate Binders TRIVEEN-U (ORAL) GLEEVEC (ORAL) Ophthalmic Anti-Inflammatories CALCIUM ACETATE CAPSULE, TABLET (ORAL) TRUST NATAL DHA (ORAL) HYDREA (ORAL) DEXAMETHASONE (OPHTHALMIC) PHOSLYRA (ORAL) VINATE AZ, VINATE CALCIUM, VINATE GT, VINATE IC, HYDROXYUREA (ORAL) DICLOFENAC (OPHTHALMIC) RENAGEL (ORAL) VINATE II (ORAL) IBRANCE (ORAL) DUREZOL (OPHTHALMIC) RENVELA TABLET (ORAL)* VITAFOL-OB, VITAFOL-ONE (ORAL) ICLUSIG (ORAL) FLAREX (OPHTHALMIC) Pituitary Suppressive Agents, LNRH VOL-NATE (ORAL) IMBRUVICA (ORAL) FLUOROMETHOLONE (OPHTHALMIC) ELIGARD (SUB-Q)* VOL-TAB RX (ORAL) INLYTA (ORAL) FLURBIPROFEN (OPHTHALMIC) LEUPROLIDE ACETATE (SUB-Q) VP-CH-PNV (ORAL) JAKAFI (ORAL) FML FORTE, FML S.O.P. (OPHTHALMIC) LUPRON DEPOT, KIT (INTRAMUSC) VP-GGR-B6 (ORAL) LENVIMA (ORAL) ILEVRO (OPHTHALMIC) LUPRON DEPOT-PED, KIT (INJECTION) WOMEN'S PRENATAL + DHA OTC (ORAL)* LYNPARZA (ORAL) KETOROLAC (OPHTHALMIC) SYNAREL (NASAL)* Proton Pump Inhibitors MEKINIST (ORAL) KETOROLAC LS (OPHTHALMIC) Platelet Aggregation Inhibitors NEXIUM (ORAL) MERCAPTOPURINE (ORAL) LOTEMAX DROPS (OPHTHALMIC) AGGRENOX (ORAL) NEXIUM SUSPENSION (ORAL) NEXAVAR (ORAL) MAXIDEX (OPHTHALMIC) BRILINTA (ORAL) PANTOPRAZOLE (ORAL) NILANDRON (ORAL) PRED MILD (OPHTHALMIC) CLOPIDOGREL (ORAL) PREVACID SOLUTAB (ORAL) PURIXAN (ORAL) PREDNISOLONE ACETATE (OPHTHALMIC) DIPYRIDAMOLE (ORAL) PRILOSEC OTC (ORAL) SPRYCEL (ORAL) PREDNISOLONE SOD PHOSPHATE (OPHTHALMIC) EFFIENT (ORAL)* PROTONIX SUSPENSION (ORAL) STIVARGA (ORAL) Ophthalmics, Glaucoma Agents Prenatal Vitamins Sedative Hypnotics SUTENT (ORAL) ALPHAGAN P 0.15% (OPHTHALMIC) CITRANATAL HARMONY (ORAL) FLURAZEPAM (ORAL) TAFINLAR (ORAL) AZOPT (OPHTHALMIC) COMPLETENATE (ORAL) TEMAZEPAM 15MG, 30MG (ORAL) TARCEVA (ORAL) BETAXOLOL (OPHTHALMIC) CONCEPT DHA (ORAL) ZOLPIDEM TARTRATE (NOT ER) (ORAL) TASIGNA (ORAL) BETIMOL (OPHTHALMIC) DAILY PRENATAL (ORAL) Skeletal Muscle Relaxants TEMODAR (ORAL) BETOPTIC S (OPHTHALMIC) FE C (ORAL) BACLOFEN (ORAL) TEMOZOLOMIDE (AG) (ORAL) BRIMONIDINE (OPHTHALMIC) FOLIVANE-OB (ORAL) CHLORZOXAZONE (ORAL) TEMOZOLOMIDE (ORAL) CARTEOLOL (OPHTHALMIC) NATAFORT (ORAL) CYCLOBENZAPRINE (ORAL) TYKERB (ORAL) DORZOLAMIDE (OPHTHALMIC) NATALVIRT 90 DHA (ORAL) METHOCARBAMOL (ORAL) VOTRIENT (ORAL) DORZOLAMIDE / TIMOLOL (OPHTHALMIC) NATELLE-EZ OTC (ORAL) Smoking Cessations XALKORI (ORAL) ISTALOL (OPHTHALMIC) NESTABS (ORAL) BUPROPION SR (ORAL) XELODA (ORAL) LATANOPROST 2.5 ML (OPHTHALMIC) OB COMPLETE WITH DHA (ORAL) CHANTIX TAB DS PK, TABLET (ORAL) XTANDI (ORAL) LEVOBUNOLOL (OPHTHALMIC) ONE-A-DAY WOMEN'S PRENATAL DHA OTC (ORAL) NICOTINE GUM OTC (BUCCAL) ZELBORAF (ORAL) METIPRANOLOL (OPHTHALMIC) PNV 87/IRON BISGLY/FA/DHA (ORAL) NICOTINE LOZENGE OTC (MUCOUS MEM) ZOLINZA (ORAL) PILOCARPINE (OPHTHALMIC) PNV WITH CA,NO.71/IRON/FA (ORAL) NICOTINE PATCH OTC (TRANSDERMAL) ZYDELIG (ORAL) SIMBRINZA (OPHTHALMIC) PNV WITH CA,NO.72/IRON/FA (ORAL) Steroids, Topical-High Potency ZYKADIA (ORAL) TIMOLOL (OPHTHALMIC) PNV WITH CA,NO.74/IRON/FA BRAND (ORAL) BETAMETHASONE DIPROPIONATE CREAM, LOTION (TOPICAL) ZYTIGA (ORAL) TRAVATAN / TRAVATAN Z 2.5 ML, 5 ML (OPHTHALMIC) PNV66/IRON FUMARATE/FA/DSS/DHA (ORAL) BETAMETHASONE VALERATE CREAM, LOTION, OINT (TOPICAL) Ophthalmics, Allergic Conjunctivitis Opiate Dependence Treatments PNV80/IRON FUMARATE/FA/DSS/DHA (ORAL) FLUOCINONIDE CREAM, EMOLLIENT, GEL, SOLUTION (TOPICAL) ALREX (OPHTHALMIC) NALOXONE SYRINGE, VIAL (INJECTION)* PR NATAL 400 (ORAL) TRIAMCINOLONE ACETONIDE CREAM, OINT (TOPICAL) CROMOLYN SODIUM (OPHTHALMIC) NALTREXONE (ORAL) PREFERA OB ONE (ORAL) Steroids, Topical-Low Potency PATADAY (OPHTHALMIC) SUBOXONE FILM (SUBLINGUAL) PRENAISSANCE BALANCE, PRENAISSANCE NEXT (ORAL) CAPEX SHAMPOO (TOPICAL)

5 Steroids, Topical-Low Potency (cont.) DESONIDE CREAM, LOTION, OINTMENT (TOPICAL) DESOWEN LOTION (TOPICAL) FLUOCINOLONE 0.01% OIL (TOPICAL) HYDROCORTISONE / MIN OIL / PET OINT. (TOPICAL) HYDROCORTISONE CREAM, GEL, OINT. (TOPICAL) Steroids, Topical-Medium Potency HYDROCORTISONE BUTYRATE CREAM, SOLUTION (TOPICAL) HYDROCORTISONE BUTYRATE BRAND CREAM, OINT, SOLUTION (TOPICAL) HYDROCORTISONE VALERATE CREAM, OINT (TOPICAL) MOMETASONE FUROATE CREAM, OINT, SOLUTION (TOPICAL) Steroids, Topical-Very High Potency CLOBETASOL EMOLLIENT (TOPICAL) CLOBETASOL PROPIONATE CREAM, GEL, OINT, SOLUTION (TOPICAL) CLOBEX SHAMPOO (TOPICAL) HALOBETASOL PROPIONATE CREAM, OINT (TOPICAL) Stimulants & Related Agents ADDERALL XR (ORAL) AMPHETAMINE SALT COMBO (ORAL) DAYTRANA (TRANSDERMAL) DEXMETHYLPHENIDATE (ORAL) DEXTROAMPHETAMINE TABLET (ORAL) FOCALIN, FOCALIN XR (ORAL) INTUNIV (ORAL) METADATE CD (ORAL) METHYLIN CHEWABLE TABLETS (ORAL) METHYLPHENIDATE ER (CONCERTA) (AG) (ORAL) METHYLPHENIDATE ER (CONCERTA) (ORAL) METHYLPHENIDATE SOLUTION (ORAL) METHYLPHENIDATE, METHYLPHENIDATE ER (METHLYN ) (ORAL) PROCENTRA (ORAL) PROVIGIL (ORAL) QUILLIVANT XR (ORAL) RITALIN LA (ORAL) RITALIN LA 10 MG CAPSULE (ORAL) STRATTERA (ORAL) VYVANSE (ORAL) Tetracyclines, Oral DOXYCYCLINE HYCLATE CAPSULE, TABLET (ORAL) DOXYCYCLINE MONOHYDRATE 100 MG & 50 MG CAPSULE (ORAL) MINOCYCLINE CAPSULES (ORAL) TETRACYCLINE (ORAL) Ulcerative Colitis Agents ASACOL (ORAL) APRISO (ORAL) CANASA (RECTAL) LIALDA (ORAL) PENTASA (ORAL) SULFASALAZINE (ORAL) SULFASALAZINE DR (ORAL) Vasodilators, Coronary ISOSORBIDE DINITRATE (ORAL) ISOSORBIDE DINITRATE (SUBLINGUAL) ISOSORBIDE MONONITRATE (ORAL) ISOSORBIDE MONONITRATE SR (ORAL) NITRO-BID OINT. (TRANSDERM) Vasodilators, Coronary (cont.) NITROGLYCERIN (SUBLINGUAL) NITROGLYCERIN (TRANSDERM) NITROGLYCERIN ER (ORAL) NITROLINGUAL SPRAY (TRANSLINGUAL) NITROSTAT (SUBLINGUAL)