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County of San Diego

County Medical Services (CMS) Program

DRUG FORMULARY

June 2015

This document has been prepared by AmeriChoice for the County of San Diego and is updated at least quarterly throughout the year. Please be sure to confer with the website at http://www.sdcounty.ca.gov/hhsa/programs/ssp/county_medical_services/index.html to ensure this is the most recent version.

June 2015 Page 1 of 42 San Diego County CMS Drug Formulary The County of San Diego has contracted with AmeriChoice as their Administrative Services Organization (ASO) for the County Medical Services (CMS) Program. In turn, AmeriChoice has contracted with Catamran® to act as the Pharmacy Benefits Manager (PBM).

The CMS Pharmacy and Therapeutics (P&T) Committee determines the content of this formulary. Additions to this formulary are recommended by the P&T Committee and must be approved by the County. To request the review of a new product, complete the “Request for Formulary Change” form located at the end of this document and fax to the Medical Management Services Manager at AmeriChoice at (855) 394-7927.

FORMULARY FORMAT

Generic Products 1. The Formulary is generic based. 2. When a brand name drug is ordered and a generic equivalent is available, the generic will be dispensed by the pharmacy. The prescriber must justify any exception and the “Drug Prior Authorization” form must be completed and faxed to Catamran® at (866) 511-2202. The Drug Prior Authorization Form is also located at the end of the formulary.

Maximum Allowable Limits Except as otherwise noted below, enrollees can receive a 30-day supply of prescribed . Exceptions: . Certain classes of medications used to treat chronic diseases, such as asthma controller medications, statins, blood thinners, ACE-I and ARBs, Insulins, and Beta blockers, may be filled for a 90 day supply if the prescription is written for a 90 day supply. MEDICATIONS WITH A 90 DAY FILL ARE NOTED WITH AN ASTERICK IN THE FORMULARY. . Refills are allowed after 23 days. . One vacation supply is allowed every 12 months, to a max of one 60 day supply per per 12 months. . One "lost prescription" supply is allowed every 12 months, to a max of a 30 day supply for one lost prescription per medication per 12 months. . Quantity limits of drugs are noted as applicable. Products containing aspirin have a quantity limit of 4 grams per day. Products containing acetaminophen have a quantity limit of 3 grams per day.

Code 1 Restrictions Products with this notation are limited to prescriber’s specialty, to a restricted amount, to specific diagnoses, or to step therapy.

Formulary Exclusions . Medication prescribed for cosmetic purposes . Medications prescribed for the treatment of mental health conditions . All OTC products not included in this listing . Oral birth control and birth control devices for non-pathological reasons . and smoking cessation products . Experimental drugs, drugs used in an experimental manner, and all drugs without FDA approval . Medications for the treatment of drug and abuse . Medications for the treatment of erectile dysfunction . Medications related to transgender care . Drug and alcohol abuse treatment . Compounded medications

Authorization Policy Every provider has the right to request coverage of a non-formulary medication. However, medical justification for using a non-formulary medication is required. First, please review any notations found under the “Utilization Management” column in the drug category type of the non-formulary medication. Second, complete the “Drug Prior Authorization” form found at the end of this document and fax to Catamaran® at (866) 511-2202. Additionally, you may contact Catamaran ® Customer Service by phone (800-626-0072) which is available 24 hours a day, every day, to assist with any formulary questions

June 2015 Page 2 of 42

Denials and Appeals When a product is excluded or is not medically justified, Catamaran® will issue a provisional denial to the pharmacy and/or the prescriber. As the CMS Medical Director completes the denial, the prescriber and the enrollee are issued written notification. Appeals may be made directly to CMS, and instructions for submitting an appeal are incorporated in the denial notice.

Formulary Updates This formulary is published on the Web and is updated on a quarterly basis. The most recent document is located at: www2.sdcounty.ca.gov/hhsa/documents/Formulary.pdf

June 2015 Page 3 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

INFECTIOUS DISEASE AGENTS Penicillins Amoxicillin Oral Trimox Amoxicillin & Potassium Augmentin,

Clavulanate Oral Augmentin XR Ampicillin Oral Ampicillin Dicloxacillin Sodium Oral Dicloxacillin Sodium 1.2 MU per syringe (2ml) and 2.4 MU per Penicillin G Benzathine Bicillin LA syringe (4ml) only. Penicillin V Potassium Oral Pen-VK, Veetids

Cephalosporins Cefixime Tab 400mg Oral Suprax Cephalexin Monohydrate Keflex Cefdinir Oral Omnicef Cefpodoxime Proxetil Oral Vantin

Fluroquinolones HCl 250mg, Cipro Limited to 28/14 days. 500mg, 750mg Tab Oral Code 1 Restriction: For diagnosis of Tab Oral Levaquin Pneumonia. Limited to 10 tablets/10 days.

Macrolides Limited to 6 tablets/fill and 2 fills/month for Azithromycin 250mg, 500mg Zithromax 250mg; 3 tablets/fill and 2 fills/month for Tab Oral 500mg. Code 1 Restriction: For diagnosis of Azithromycin Susp Oral Zithromax community-acquired pneumonia only. Clarithromycin 250mg, 500mg Limited to 28 tablets/14 days. Biaxin Tab Oral Erythromycin Base Oral Erythromycin Erythromycin Delayed E-Mycin, Eryc, Ery-

Release Oral Tab Erythromycin w/EC Particles PCE Oral Erythromycin Ethylsuccinate E.E.S. Oral Erythromycin Stearate Oral Erythrocin

Misc. Anti-Infectives Atovaquone Mepron Clindamycin HCL Cap Oral Cleocin Oral Dapsone Tab Oral Flagyl Pentamidine Nebupent, Pentam Inhaled or injection forms only. Trimpex, Proloprim Oral form only. Trimethoprim/ Bactrim, Bactrim DS Oral

June 2015 Page 4 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Sulfonamides Lantrisul Oral form only. Sulfisoxazole Powder Sulfisoxazole Sulfisoxazole Acetyl Oral Gantrisin

Tetracyclines Doxycycline Hyclate Cap Vibramycin, 50mg & 100mg, Tab 100mg Vibratab Oral HCl Oral Sumycin

Amebicides Iodoquinol Oral Yodoxin Paromomycin Paromycin

Aminoglycosides Sulfate, Neomycin Sulfate Oral Neo-Fradin

Antihelmintics Mebendazole Oral Vermox Pamoate Oral Pin-X, Antiminth Thiabendazole Oral Mintezol

Antifungals Limited to 1 tablet/fill, 2 fills/month. Fluconazole Tab 50mg, Diflucan Code 1 – 100mg approved with the 100mg, 150mg Oral diagnosis of oral thrush. Flucytosine Ancobon Itraconazole Caps Sporanox Ketoconazole Tab Oral Nizoral Nystatin Mycostatin Terbinafine Lamisil

Antimalarials Chloroquine Phosphate Tab Aralen Oral Hydroxychloroquine Sulfate Plaquenil Oral Primaquine Primaquine Phosphate Oral phosphate Pyrimethamine Oral Daraprim Quinine Sulfate Tab 324mg Qualaquin Oral

Antimycobacterial Agents Isoniazid Oral Nydrazid Rifampin Oral Rifadin Prior Authorization required for Tuberculosis.

June 2015 Page 5 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Antivirals Acyclovir Oral Zovirax Oseltamivir Tamiflu

ANTINEOPLASTIC AGENTS Oral agents are covered up to $1500. Prior Antineoplastic Agents Authorization required for agents greater than $1500.

ENDOCRINE_AND METABOLIC DRUGS Glucocorticosteroids Cortisone Acetate Oral Cortisone Oral Decadron, Dexone Hydrocortisone Tab Oral Cortef Prelone Prednisolone Sodium Phosphate Powder Prednisolone Prednisolone Sodium Phosphate Oral Meticorten, Prednisone Oral Deltasone, Liquid Pred

Mineralocorticoids Fludrocortisone Acetate Oral Florinef

DIABETIC AGENTS *Insulins may be filled for a 90 day supply if the prescription is written as such. Human Insulin Limited to vials only. *Insulin Aspart Inj 100 U/mL Novolog Limited to 2 vials/month *Insulin Aspart Prot & Aspart Novolog Mix Inj 100 U/mL *Insulin Detemir Inj U/mL Levemir Limited to 4 vials/month *Insulin Glargine Inj 100 U/mL Lantus (vials only) Limited to 4 vials/month *Insulin Lispro Inj 100 U/mL Humalog *Insulin Lispro Prot & Lispro Inj Humalog Mix 75/25 100 U/mL (75-25) *Insulin Regular Inj 100 U/mL Humulin R, Novolin R Limited to 2 vials/month *Insulin Regular Inj 500 U/mL Humulin R Limited to 2 vials/month *Insulin Isophane Inj 100 U/mL Humulin N, Novolin N Limited to 2 vials/month *Insulin Regular & Isophane Inj Humulin 70/30 100 U/mL Novolin 70/30 Limited to 2 vials/month *Insulin Regular & Isophane Inj Humulin 50/50 100 U/mL (50) Limited to 2 vials/month *Insulin Zinc Inj 100 U/mL Humulin L, Novolin L Limited to 2 vials/month

June 2015 Page 6 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Sulfonylureas Oral Amaryl Limited to 1/tablet/day for 1mg & 2mg and 2 tablets/day for 4mg Tab Oral Glucotrol Glyburide Oral Diabeta Micronase Limited to 120/30 days Glyburide Micronized Glynase Limited to 120/30 days

Biguanides–Metformin Metformin HCL Oral Glucophage Limited to 2500 mg/day Glyburide/Metformin Tab Glucovance

Other Antidiabetics Acarbose Tab Oral Precose Glucagon Kit Injection Glucagon Kit Glucose Chew Tab Oral BD – Glucose Chw

Thiazolidinediones Contingent Therapy: To be used in Pioglitazone Oral Actos conjunction with Sulfonylureas, Biguanides or Alpha-Glucosidase Inhibitors Pioglitazone/Metformin Actoplus Met

Thyroid Hormones Synthroid, L- Thyroxine, Levothyroxine Sodium Oral Available as “Do Not Substitute” Levothroid, Levoxyl, Euthyrox Liothyronine Sodium Oral Cytomel

Antithyroid Agents Methimazole Oral Tapazole Propylthiouracil Oral Propylthiouracil (PTU)

Vasopressin Cabergoline Oral Dostinex Desmopressin Acetate Oral, DDAVP Nasal Spray

CARDIOVASCULAR AGENTS Anti-Arrhythmia Disopyramide Phosphate Norpace CR Oral Oral Tikosyn Flecainide Acetate Oral Tambocor Mexiletine HCL Mexiletine Moricizine HCL Oral Ethmozine Procainamide HCL Oral Pronestyl Propafenone HCL Oral Rythmol Gluconate CR Oral Quinidine June 2015 Page 7 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Quinidine Sulfate Tab Oral Quinidex

ACE Inhibitors *ACE Inhibitors may be filled for a 90 day supply if the prescription is written as such. *Benazepril HCL Oral Lotensin *Captopril Oral Capoten *Enalapril Oral Vasotec *Lisinopril Oral Prinivil, Zestril

Adrenolytics-Central Avoid in elderly enrollees Clonidine HCL Oral Catapres Methyldopa Oral Aldomet

Alpha-Blockers Doxazosin Mesylate Oral Cardura Prazosin HCL Oral Minipress Terazosin Oral Hytrin Finasteride Proscar Contingent therapy: For enrollee failing therapy with Terazosin.

Angiotensin II Inhibitors *Angiotensin II Inhibitors may be filled for a 90 day supply if the prescription is written as such. *Olmesartan Tabs Benicar Code 1 Restriction: For enrollee failing *Losartan Oral Cozaar therapy with or intolerant to ACE Inhibitors.

Angiotensin II Inhibitor Combinations *Angiotensin II Inhibitor Combniations may be filled for a 90 day supply if the prescription is written as such. Code 1 Restriction: For enrollee failing *Losartan-HCTZ Oral Hyzaar therapy with or intolerant to ACE Inhibitors. Limited to 1/day

Anti-Anginals, Other Dipyridamole Oral Persantine

Beta-Blockers Non-Selective *Beta-Blockers Non-Selective may be filled for a 90 day supply if the prescription is written as such. *Propranolol HCL Oral Inderal, Inderal LA Betapace, * HCl Oral Betapace AF

Beta-Blockers Cardio-Selective *Beta-Blockers Cardio-Selective may be filled for a 90 day supply if the prescription is written as such. *Atenolol Oral Tenormin *Metoprolol Succinate SR Code 1 Restriction: For Heart Failure. Toprol XL Oral Limited to 1 tablet/day *Metoprolol Tartrate Oral Lopressor

June 2015 Page 8 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Alpha-Beta Blockers *Alpha-Beta Blockers may be filled for a 90 day supply if the prescription is written as such. *Carvedilol Tab Oral Coreg Code 1 Restriction: For Heart Failure, MI or Diabetes. Limited to 2 tablets/day Trandate, *Labetalol HCL Oral Normodyne

Calcium Blockers Amlodipine Besylate Oral Norvasc Limited to 1 tablet/day Cardizem SR, Diltiazem HCL CR Oral Diltiazem ER Diltiazem HCL Oral Cardizem Diltiazem HCL SR/24hr Oral Dilacor XR Nimodipine Cap Oral Nimotop Verapamil HCL Tab Oral Calan, Isoptin

Digitalis Digoxin Oral Lanoxin

Nitrates Isordil, Sorbitrate Isosorbide Dinitrate Isosorbide Dinitrate Oral Oral Tabs & Chew Tabs Isosorbide Dinitrate SL Oral Isordil Monoket, ISMO Isosorbide Mononitrate Oral Imdur Nitroglycerin Buccal Oral Nitrogard Nitroglycerin SL Tab & Aer Nitrostat, Nitrotab, Oral Nitroquick Nitroglycerin Intravenous Soln Nitroglycerin Nitroglycerin CR Oral Nitro-Time, Nitroglyn Nitroglycerin Oint 2% Nitrobid Nitrol Transdermal Nitro-Dur, Minitran, Nitroglycerin TD Transdermal Transderm-Nitro, Deponit, Nitrodisc

Carbonic Anhydrase Inhibitors Oral Acetazolamide Oral Neptazane

Loop Oral Lasix

Potassium Sparing Diuretics Oral 25mg, Aldactone 50mg, 100mg

June 2015 Page 9 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Thiazides Chlorthalidone 25mg, 50mg, Hygroton Limited to 1 tablet per day 100mg tablet Oral Hydrochlorthiazide (HCTZ) Hydrodiuril, Oretic, Oral Esidrix, Microzide Oral Lozol Oral Zaroxolyn Code 1: For Impaired Renal Function or CHF

Combination Diuretics Spironolaone & HCTZ Oral Aldactazide & HCTZ Oral Dyazide, Maxzide

Vasodilators Hydralazine HCL Oral Apresoline Minoxidil Oral Loniten

Anaphylaxis Therapy Agents Epinephrine HCl Injection Code 1 for Epipen Jr. : Approve for Epipen, Epipen Jr. (Anaphylaxis) enrollees <30kg Epinephrine- Ana-Kit Chlorpheniramine

Bile Sequestrants Cholestyramine Powder Can Oral Cholestyramine Powder Questran/Lite & Packets Oral

Antihyperlipidemics: Fenamates Gemfibrozil Oral Lopid Available as the following strengths; 48mg, Fenofibrate Tabs Oral Lofibra 54mg, 145mg, and 160mg tablets.

Available as the following strengths: 67mg, Fenofibrate Micronized Caps Tricor 130mg, 134mg, 200mg capsules Oral

Antihyperlipidemics: HMG-CoA Reduase Inhibitor *Antihyperlipidemics: HMG-CoA Reduase Inhibitors may be filled for a 90 day supply if the prescription is written as such. *Atorvastatin Oral 40mg, Lipitor Contingent Therapy: For enrollee failing 80mg therapy with or intolerant to Simvastatin. Limited to 1 tablet/day *Lovastatin Oral Mevacor *Simvastatin Oral Zocor *Pravastatin Oral Pravachol

June 2015 Page 10 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Nicotinic Acid Derivatives Niacin Vitamin B-3 Contingent Therapy: For enrollee failing Niacin Tab CR Niaspan therapy with or intolerant to niacin. Limited to 1 tablet/day

RESPIRATORY AGENTS -Alkylamines HCL Oral Periactin HCL Benadryl, Diphedryl capsule, tablet Oral Phenergan, HCL Oral Phenergan Forte Promethazine HCL Suppos Phenergan Rectal

Antihistamines-Non-Sedating 10mg Tab Oral Claritin Limited to 1 tablet/day (OTC)

Nasal Steroids Code 1 Restriction: For diagnosis of nasal 0.025% Nasal Nasalide polyps, chronic sinusitis, or asthma. Limited to 1 unit/month Propionate Nasal Flonase Limited to 1 unit/month

Expectorants Organidin NR, Diabetic Tus, Guaifenesin Oral Robitussin Cold/Cough, Naldecon Sr

Miscellaneous Respiratory Sodium Chloride Soln Nebu Broncho 0.9%

Decongestant or Combinations -GG Oral Rescon-GG Promethazine & Phenylephrine Syrup 6.25- Phenergan VC 5mg/5mL Oral HCL Oral Sudafed Pseudoephedrine w/DM-GG Robitussin Cod/Cgh, Cap 30-10-200mg Oral Novahistine-DMX Humibid, Guaifed, Pseudoephedrine-GG/CR Robitussin PE, Oral Guaifed-PD

June 2015 Page 11 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Triprolidine & Actifed Pseudoephedrine Oral

Antitussive- Narcotic Tussi-Organi, Codine-GG Oral Robitussin A-C Phenergan Limited to 240 mL/fill, maximum of 3 Narcotic (codeine cough syr) w/Codeine, etc. fills/month.

Antitussive Non-Narcotic Chlorpheniramine-DM Syrup Scot-Tussin DM SF Oral -GG Robitussin DM, Liquid 10-100mg/5mL Oral Diabetic Tus DM Phenylephrine-Chlorphen-DM Cerose-DM Oral Phenylephrine-Pyrilamine-DM Codimal DM, Oral Codituss DM Promethazine-DM Syrup Oral Phenergan DM Pseudoephed-Bromphen-DM Dimetane-DX, Oral Bromatane DX Pseudoephed- -DM Liquid Rondec DM Oral Sudafed Plus, Chlor- Chlorpheniramine & Trimeton, Histex, Pseudoephedrine Oral Deconamine & Sudex Pseudoephedrine Oral Phenylephrine w/DM-GG Tussex Oral

Anticholinergics

Ipratropium Atrovent HFA Inhalation Ipratripium Sol Inh Atrovent Tiotropium Step Therapy: Trial and failure of Atrovent or Spiriva Handihaler Combivent.

Mast Cell Stabilizers *Mast Cell Stabilizers may be filled for a 90 day supply if the prescription is written as such. *Cromolyn Sodium Solution Intal Limited to 30/month for aerosol solution

Beta Adrenergics *Beta Adrenergics noted with an asterisk may be filled for a 90 day supply if the prescription is written as such.

June 2015 Page 12 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Albuterol Sulfate Aero Ventolin HFA Inhalation Albuterol Sulfate Soln Nebu Ventolin, Accuneb Inhalation */Formoterol Symbicort Ipratropium/Albuterol Sol Duoneb furoate/ Dulera Aer Formoterol fumarate dehydrate Arcapta Neohaler Indacateriol Oral Inh. Cap Limited to 1 unit/month Salmeterol Xinafoate Powder Serevent Diskus Contingent Therapy: For diagnosis of Disks Inhalation asthma only. Use with steroid. Terbutaline Sulfate Oral Brethine

Adrenergic Combinations Albuterol-Ipratropium Aerosol Combivent

Inhalation Respimat

Xanthines (Theophylline) *Xanthines (Theophylline) may be filled for a 90 day supply if the prescription is written as such. *Theophylline Tab ER Oral Theochron ER *Theophylline Tab CR Oral Theo-24

Steroid Inhalants *Steroid Inhalants may be filled for a 90 day supply if the prescription is written as such. *Beclomethasone QVAR Dipropionate Inhal Aero *Fluticasone Flovent Diskus

Leukotriene Receptor Inhibitors *Leukotriene Receptor Inhibitors may be filled for a 90 day supply if the prescription is written as such. *Montelukast Sodium TAB Singulair Oral

GASTROINTESTINAL AGENTS Antiperistaltic Agents Diphenoxylate w/ Limited to 50 tabs or 500ml’s/ month Lomotil, Lonox Oral Imodium, Imodium Loperamide HCL Oral A-D

Belladonna Alkaloids

June 2015 Page 13 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Levsinex, Cystospaz- M, Levsin, Levsin SL, Sulfate Oral Anaspaz, Levbid, Colytrol

Antispasmodics Dicyclomine HCL Oral Bentyl

Anticholinergic Combinations Belladonna Alkaloids- Donnatal Tab, Tab & Elixir Donnatal Elixir

H-2 Antagonists Tablet 10mg, Pepcid 20mg, 40mg Oral HCL Tabs 75mg, Zantac Rx 150mg, 300mg

Anti-Ulcers: (Proton-Pump Inhibitors)

Limited to 2 tablets/day, quantity limit of Omeprazole Magnesium Tab Prilosec (OTC) 180 days or 6 months with look back of 365 days

Miscellaneous Anti-Ulcer Sucralfate Oral Carafate

Anti-Emetics- Oral Antivert Promethazine HCL Oral Phenergan, Phenergan Forte Maleate Compazine Oral Prochlorperazine Maleate Cap CR & Tab Oral Prochlorperazine Edisylate Compazine Oral Metoclopramide HCL Oral Reglan

Gallstone Solubilizing Agents Ursodiol Capsule 300mg Oral Actigall

GI Stimulants Metoclopramide HCL Oral Reglan

Intestinal Acidifiers

June 2015 Page 14 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Cephulac, Enulose Lactulose Syr 10gm/15mL Calulose, Cholac, Code 1 for Encephalopathy Oral Generlac

Laxatives Clearlax Polyethylene Glycol Miralax 3350 SM Powder

Misc. GI Asacol, Asacol HD, Mesalamine Enema Rectal, Canasa, Rowasa, Limited to 2520mL/6 months for enema Suppos Rectal, Oral Pentasa Tab & EC Oral Azulfidine

ESTROGENS/PROGESTINS **Coverage may depend on patient gender Estrogen Estrogen Vaginal Cream Estrace Estradiol Vaginal Cream Estrogel Estradiol Femtrace, Estrace Estropipate Orth-est/Ogen

Progestins Medroxyprogesterone Provera Acetate

GENITOURINARY PRODUCTS Calcium Acetate (Phosphate Binder) Calcium Acetate (Phosphate PhosLo, Biphos Binder) Cap 667mg Oral

Urinary Anti-Infectives Susp Oral Furadantin Nitrofurantoin Macrodantin Macrocrystalline Oral Nitrofurantoin Monohydrate Macrobid Macrocrystalline Oral

Urinary Antispasmodics Chloride Oral Urecholine Hyoscyamine Tab 0.15 mg Cystospaz Oral Chloride Tab & Ditropan Syr Oral

Vaginal Anti-Infectives Clindamycin Phosphate CR Cleocin Vaginal Vaginal

June 2015 Page 15 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Metronidazole Gel 0.75% Metrogel Vag Gel, Vaginal Vandazole

Vaginal Antifungals Nystatin Tab 100000 U Nystatin Vaginal Tab Vaginal Clotrimazole Vaginal Clotrimazole Gyne-Lotrimin Clotrimazole Tab Cream 1%, Kit Vaginal Miconazole Nitrate Vagina Miconazole Nitrate Vagina Kit, Monistat Miconazole Nitrate Cream, Suppos VaginalTerconazole Vaginal

Urinary Analgesics Azo-gesic, Pyridium, Phenazopyridine HCL Tab Urogesic, Uro Oral, Kit Femme Kit

Misc. Genitourinary Agents Pentosan Polysulfate Sodium Elmiron Oral Potassium & Sodium Citrates Cytra K, Polycitra, w/Citric Acid Oral Tricitrates

Genitourinary Irrigants Sodium Chloride Irrigation Sodium Chloride

Soln Irrigation Soln PSYCHOTHERAPEUTIC AGENTS Tab Oral Klonopin Code 1 Restriction: For seizure Tab Oral Valium

Miscellaneous Antihistamine Agents HCL Oral Atarax Hydroxyzine Pamoate Oral Vistaril

Code 1 Restriction: For diagnosis of Agents neuropathy or as an adjunct to pain management. HCL Oral Elavil Oral Ascendin HCL Oral Anafranil HCL Oral Norpramin HCL Oral Sinequan

June 2015 Page 16 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Imipramine HCL Oral Tofranil HCL Oral Pamelor HCL Oral Vivactil Maleate Oral Surmontil

Barbiturate Hypnotics Phenobarbital Oral Phenobarbital PA required for FDA indications only

ANALGESICS AND ANESTHETICS Salicylates Maximum acetaminophen daily dose = 3gm/day Maximum aspirin daily dose = 4gm/day *Salicylates may be filled for a 90 day supply if the prescription is written as such. Bayer ASA, Empirin, Ascriptin, ASA Low Does not include single source branded *Aspirin Oral Dose, Ecotrin, products Genacote Does not include single source branded *Aspirin Suppos Rectal Aspirin Supp products Salflex, Disalcid, *Salsalate Oral Amigesic

Salicylate Combinations Maximum acetaminophen daily dose = 3gm/day Maximum aspirin daily dose = 4gm/day *Salicylate Combinations may be filled for a 90 day supply if the prescription is written as such. *Aspirin Buffered (mg Aspirin Buffered, Carbonate-Al Glycinate) Gennin –FC 325mg Tab Oral *Aspirin Buffered 325mg Tab Buffaprin, Buffered

Oral ASA

Analgesics Other Acetaminophen Oral Tylenol Acetaminophen Suppos Feverall, Acephen Rectal

Narcotic Agonist Code 1 for pain. Use for substance abuse is HCL Oral not a covered benefit. Morphine Sulfate Tab Oral MSIR Limited to 12 tablets/day MS Contin, Limited to 4 tablets/day Morphine Sulfate Tab CR Oral Oramorph SR HCL Tab Ultram Limited to 8 tablets/day

Narcotic Combinations Maximum acetaminophen daily dose = 3gm/day Maximum aspirin daily dose = 4gm/day Oxycodone w/ Acetaminophen 5-325mg & Roxicet 7.5-325mg Tab Oral

June 2015 Page 17 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Codeine Combinations Maximum acetaminophen daily dose = 3gm/day Maximum aspirin daily dose = 4gm/day Acetaminophen w/ Codeine Tylenol/Codeine #2, 300-15mg, 300-30mg, 300- Limited to 60 tablets/month #3, #4, Vopac 60mg, 650-30 mg Tab Oral Acetaminophen w/ Codeine Tylenol/Codeine Limited to 500mL/month Oral Soln Aspirin w/ Codeine 325- Empirin/Codeine #2, 15mg, 325-30mg, & 325-60mg Limited to 60 tablets/month #3, #4 Tab Oral

Hydrocodone Combinations Maximum acetaminophen daily dose = 3gm/day Maximum aspirin daily dose = 4gm/day Acetaminophen w/ Lortab 5mg, Norco 5-500mg, 7.5- 10-325mg, Vicodin, 750mg, 10-325mg Tab Oral Vicodin ES Acetaminophen w/ Hydrocodone 7.5- Lortab Elixer Limited to 500mL/month 500mg/15mL Soln Oral

Nonsteroidal Anti-Inflammatory Agents Diclofenac Potassium Oral Cataflam Limited to 4 tablets/day Diclofenac Sodium EC Oral Voltaren Limited to 4 tablets/day Limited to 3 capsules/day for 200mg & Etodolac Cap & Tab Oral Lodine 300mg capsules; 3 tablets/day for 400mg tablet and 2 tablets/day for 500mg tablet Fenoprofen Calcium Oral Nalfon Limited to 16 tablets/day Ibuprofen Oral Motrin Limited to FDA approved limit Indomethacin Oral, Suppos Indocin Rectal Meloxicam Tab Oral Mobic Limited to 1 tablet/day Naproxen Oral Naprosyn Naproxen DR Oral EC-Naprosyn Code 1: Failure of naproxen or GI disease Oxaprozin Oral Daypro Limited to 2 tablets/day Limited to 2 capsules/day for 10mg and 1 Piroxicam Oral Feldene capsule/day for 20mg Sulindac Oral Clinoril Limited to 2 tablets/day

ANTI-RHEUMATIC AND ANTI-PSORIATIC AGENTS Folic Acid Antagonist Methotrexate Oral 2.5mg

MIGRAINE AGENTS Migraine Products Maximum acetaminophen daily dose = 3gm/day Maximum aspirin daily dose = 4gm/day APAP-Isometheptane- Dichloral Cap 325-65-100mg Midrin Oral

June 2015 Page 18 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Opioid Combinations Maximum acetaminophen daily dose = 3gm/day Maximum aspirin daily dose = 4gm/day Butalbital-Acetaminophen- Caff w/ Cod 50-325-40-30mg Phrenilin w/ Codeine Cap Oral Butalbital-Acetaminophen 50-650mg Cap, 50-325 mg & Phrenilin, Sedapop 50-650mg Tab Oral Butalbital-Aspirin-Caff w/ Codeine 50-325-40-30mg Fiorinal w/ Codeine Limited to 60 capsules/month Cap Oral Fiorinal, Fiortal, Aspirin-Caffeine-Butalbital Butalbital CPD, 325-40-50mg Tab & Cap Oral Fortabs Acetaminophen-Caffeine- Esgic, Esgic Plus, Butalbital 325-40-50mg Tab & Fioricet Cap Oral

Serotonin Agonist Contingent Therapy: For enrollee failing therapy with or intolerant to Cafergot, Spray Nasal Imitrex NS Midrin, Fioricet, or Fiorinal. Limited to 6 units/month Contingent Therapy: For enrollee failing Sumatriptan Succinate Imitrex therapy with or intolerant to Cafergot, Injection Midrin, Fioricet, or Fiorinal. Limited to 4 packages (8 injections)/month Contingent therapy: For enrollee failing therapy with or intolerant to Cafergot, Sumatriptan Succinate Tab Imitrex Midrin, Fioricet, or Fiorinal. Limited to 18 Oral tablets/month for 25mg & 50mg and 9 tablets/month for 100mg For trial and failure of Sumitriptan tabs or Amerge Naratriptan Tab Ornaratriptan tabs with 120 day look back. Limited to 9 tabs/month. For trial and failure of Sumitriptan tabs with Rizatriptan Maxalt-MLT 120 day look back. Limited to 9 tabs/month.

Ergot Combinations Ergotamine w/ Caffeine 1- Wigraine, Ercaf 100mg Tab Oral

GOUT AGENTS Gout Allopurinol Tab Oral Zyloprim

June 2015 Page 19 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Uricosurics Oral Probenecid Benemid Tab 500 mg Sulfinpyrazone Oral Anturane

Combination Gout Drugs Colchicine w/Probenecid Proben-C Tab 0.5-500 mg Oral

NEUROMUSCULAR AGENTS Sod. Susp Dilantin Phenytoin Inj. Dilantin Phenytoin Sod. Extended Dilantin Caps

Valproic Acid Divalproex Sodium EC Cap Depakote Sprinkle Oral Divalproex Sodium EC Tab Delayed Release 125mg, Depakote EC 250mg, 500mg Divalproex Sodium SR 24 Hr Depakote ER Tab Oral Valproic Acid Cap 250mg Depakene Oral Sodium Syrup Depakene Valproate Acid Soln Depakene

Miscellaneous Limited to enrollee intolerant to or failing Tab SR Oral Tegretol XR therapy with carbamazepine tablets Carbamazepine Chew Tab Tegretol, Epitol Oral Carbamazepine Susp Oral Tegretol Limited to 6 capsules/day for 400mg 400mg Cap, capsules, 6 tablets/day for 400mg tablets, 5 400mg, 600mg, & 800mg Neurontin tablets/day for 600mg tablets, and 4 Tablet Oral tablets/day for 800mg tablets Tablet Oral Mysoline Limited to 120 tablets/30 days for 5mg 5mg, 25mg, tablet, 25mg tablet, 25mg chew & 200mg 100mg, 150mg& 200mg Tabs, Lamictal tablet, 60 tablets/30 days for 100mg tablet, 25mg chew 150 tablets/30 days for 150mg tablets Caps Zarontin Approved as Adjunct Therapy for Seizure Capsule Oral Zonegran Disorder Tabs Keppra

June 2015 Page 20 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Oxcarbazepine Tabs Trileptal Tabs Topamax Topiragen Tabs

Antiparkinsonian Agents Generic agents in this class are covered (i.e. carbidopa, levodopa, benztropine, etc.)

Central Muscle Relaxants Baclofen Tab Oral Lioresal, Lioresal DS Limited to 4 tablets/day HCL 10mg Flexeril Limited to 3 tablets/day Tab Oral Methocarbamol Oral Robaxin Limited to 6 tablets/day

Antimyasthenic Agents Neostigmine Bromide Tab Prostigmin 15mg Oral Pyridostigmine Bromide Oral Mestinon

NUTRITIONAL PRODUCTS Vitamin B-3 Niacin Oral Niacin

Vitamin B-6 HCL Cap, HLC Cap CR, Tab Vitamin B-6 Code 1 Restriction: For use with INH only Oral

Vitamin K Phytonadione Tab 5mg Oral Mephyton

Potassium Potassium Chloride Cap CR Micro-K 8mEq & 10mEq Oral Potassium Chloride Tab CR Slow-K, Klor-Con, K- 8mEq, 10mEq, 15mEq & Tabs, K-Dur, Klortrix, 20mEq Oral Kaon-CL Potassium Chloride Oral Liq Klorvess, Kaochlor, 10% & 20% Oral Kay Ciel KCL, Kaon- CL SF Potassium & Sodium Phosphates for Soln 278-164- 250mg/75mL, Powder 278- Neutraphos 164-250mg & 280-160-250mg Oral

Potassium Removing Resin Sodium Polystyrene Sulfonate SPS Susp 15gm/60mL Oral/Rectal

June 2015 Page 21 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Sodium Polystyrene Sulfonate Kayexalate Powder Oral

Sodium Sodium Chloride Injection Normal Saline (IV)

HEMATOLOGICAL AGENTS Folic Acid Folic Acid Oral Folic Acid

Iron Ferrous Fumarate Oral Feostat Ferrous Gluconate Oral Ferrous Gluconate Iron, Slow-Fe, Feosol, Ferrous Sulfate Oral Fer-In-Sol, Feratab

Coumarin Anticoagulants *Coumarin Anticoagulants may be filled for a 90 day supply if the prescription is written as such. *Warfarin Sodium Tab Oral Coumadin

Platelet Aggregation Inhibitors *Platelet Aggregation Inhibitors may be filled for a 90 day supply if the prescription is written as such. *Cilostazol Pletal *Dipyridamole Tab Oral Persantine *Clopidogrel Bisulfate Tab Plavix Oral

Heparins and Heparinoid-Like Agents *Heparins and Heoarinoid-Like Agents may be filled for a 90 day supply if the prescription is written as such. *Enoxaparin Sodium Injection Lovenox Limited to 10 vials per month.

OPHTHALMIC AND OTIC AGENTS Ophthalmic Ciprofloxacin HCL Soln 0.3% Ciloxan Ophthalmic Erythromycin Oint 5mg/gm Llotycin Ophthalmic Sulfate Soln & Garamycin, Oint 0.3% Ophthalmic Genoptic Ophth Soln 0.3% Ocuflox Ophthalmic Sodium 10% Bleph-10, Sod Ophthalmic Sulamyd

Ophthalmic Beta-Blockers Betaxolol HCL Soln -.5% & 1% Betoptic, Betoptic-S

June 2015 Page 22 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name and Susp 0.25% Ophthalmic Carteolol HCL Soln 1% Ocupress Ophthalmic Metipranolol HCL Soln 0.3% Optipranolol Ophthalmic Levobunolol HCL Soln 0.25% Betagan & 0.5% Ophthalimc Timolol Maleate Soln 0.25% & Timoptic 0.5% Ophthalmic Timolol Maleate Soln (Gel Forming) 0.25% & 0.5% Timoptic XE ophthalmic

Ophthalmic Carbonic Anhydrase Inhibitors Susp 1% Azopt Ophthalmic

Ophthalmic Carbonic Anhydrase Inhibitors – Beta-Blocker Combination -Timolol Soln 2- Cosopt 0.5% Ophthalmic

Ophthalmic Steroids Dexamethasone Susp 0.1% Maxidex Ophthalmic Dexamethasone Sodium Decadron, Dexa-sol Phosphate Soln Ophthalmic Fluorometholone Susp FML Liquifilm, FML

Ophthalmic Forte Fluorometholone Oint 0.1% FML S.O.P. Ophthalmic Fluorometholone Acetate Flarex, Eflone Susp 0.1% Ophthalmic Econopred Plus, Prednisolone Acetate Susp Omnipred Pred 1% Ophthalmic Forte Prednisolone Sodium Phosphate Soln 1% Inflamase Forte Ophthalmic

Ophthalmic Steroid Combinations Loteprednol etabonate- Tobramycin Susp 0.5-0.3% Zylet Ophthalmic Sulfacetamide Sodium- Prednisolone Susp10-0.2% Blephamide Ophthalmic Sulfacetamide Sodium- Blephamide S.O.P. Prednisolone Oint 10-0.2%

June 2015 Page 23 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Ophthalmic Tobramycin-Dexamethasone Susp & Oint 0.3-0.1% Tobradex Ophthalmic Neomycin-Polymyxin- Dexamethasone Susp & Oint Maxitrol, Dexacidin 0.1% Ophthalmic Neomycin-Polymyxin-HC Susp Cortisporin Ophthalmic -Polymyxin- Cortisporin, AK- Neomycin-HC Ophthalmic Spore HC, Triple Oint 1%

Ophthalmics- Alpha 2 Adrenergic Agonists Brimonidine Soln 0.1% Alphagan/

Ophthalmic Alphagan-P

Prostaglandin Agonists Ophthalmic Latanoprost Soln 0.005% Xalatan Ophthalmic

Cycloplegics Atropine Sulfate Soln 1% Iso Atropine Ophthalmic Atropine Sulfate Oint 1% Ocu-tropine Ophthalmic HCL Soln Cyclogyl 0.5%, 1%, 2% Ophthalmic HBr Soln 2%, 5% Iso Homatropine Ophthalmic HBr Soln 0.25% Iso Hyoscine Ophthalmic Soln 0.5%, 1% Mydriacyl, Infi-Cyle Ophthalmic

Cycloplegics Mydriatic Combinations Cyclopentolate w/ Phenylephrine Soln 0.2-1% Cyclomydri Ophthalmic Scopolamine w/ Phenylephrine Soln 0.3-10% Murocoll-2 Ophthalmic

Ophthalmic Decongestant Combinations w/ Vasocon-A Soln 0.05-0.5% Ophthalmic Naphazoline w/ Naphcon-A Soln 0.025-0.3% Ophthalmic

June 2015 Page 24 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Ophthalmics – Direct Acting HCL Soln 0.5%, Iso Carpine, Pilocar 1%, 2%, 4%, 6% Ophthalmic Pilocarpine HCL Gel 4% Pilopine HS

Ophthalmic

Adrenergic Mydriatics Dipivefrin Soln 0.1% Propine-C

Ophthalmic

Ophthalmic Anti-Allergic Contingent Therapy: For enrollee failing HCL Soln Patanol therapy with or intolerant to Naphcon-A or Ophthalmic Vasacon-A

Ophthalmic Non-Steroidal Anti-Inflammatory Agents Diclofenac Sodium Soln 0.1% Code 1 Restriction: For Ophthalmologist Voltaren Ophthalmic Limited to #2.5mL/30 days Flurbiprofen Soln 0.03% Ocufen Ophthalmic Ketorolac Tromethamine Soln Code 1 Restriction: For Ophthalmologist Acular LS, Acular 0.4%, 0.5% Ophthalmic Limited to #2.5mL/30 days Nepafenac Susp 0.1% Nevanac Code 1 Restriction: For Ophthalmologist Ophthalmic Limited to #3mL/30 days Bromfenac Sodium Soln Code 1 Restriction: For Ophthalmologist Xibrom 0.09% Ophthalmic Limited to #2.5mL/30 days

Otic Steroids Hydrocortisone W/ Acetic Vosol-HC Acid 1-2% Soln Otic

Otic Miscellaneous Acetic Acid 2% Soln Otic Vosol Carbamide Peroxide 6.5% Debrox Soln Otic

Otic Steroid Antibiotic Combinations Benzocaine-Antipyrine 1.4- Auralgan 5.4% Soln Otic Neomycin-Polymyxin-HC Susp 3.5mg/mL-10000 U/mL-1% Cortisporin Otic Otic Neomycin-Polymyxin-HC Soln Cortisporin Otic 1% Otic Ciprofloxacin-Hydrocortisone Code 1 Restriction: Must be written by ENT Cipro HC Otic Otic Susp 0.2-1% or Emergency Department Physician.

June 2015 Page 25 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

MOUTH & THROAT AGENTS Mouth & Throat (Local) Lidocaine HCL in Viscous Soln Lidocaine Viscous 2% (Mouth-Throat) Nystatin Susp 100000 U/mL Mycostatin, Bio- (Mouth/Throat) Statin Pilocarpine HCL 5mg Tab Salagen Oral Acetonide in Kenalog Orabase 0.1% (Mouth)

DERMATOLOGICAL PRODUCTS Antibiotics – Topical 2% Oint External Bactroban Limited to 60gm/month

Antifungals – Topical Crotamiton External Eurax Mycostatin, Nystop, Nystatin External Pedi-Dri Tolnaftate Power External Tinactin Desenex, Lotrimin, Clotrimazole External Lotrimin AF Ketoconazole Cream 2% Nizoral External Ketoconazole Shampoo 2% Nizoral Limited to 120mL/month External Miconazole Nitrate Cream Micatin, Monistat 2% External

Antifungals – Topical Combinations Clotrimazole w/ Cream, Lotrisone External Nystatin-Triamcinolone Mycolog II Cream & Oint External

Burn Products Cream 1% Silvadene External

Tar Products Allantoin-Coal Tar and Tegrin Medicated Combinations Shampoo Shampoo 7% External Fototar, G-Tar, Coal Tar External Tegrin, Medotar

June 2015 Page 26 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Corticosteroids – Topical Betamethasone Limited to 90gm/mo for cream, & ointment, Diprosone, Maxivate Dipropionate Cream External and 120ml/mo for lotion. Fluocinolone Acetonide Limited to 120 gm/mo for cream, & Synalar, Fluorosyn, Cream, Soln External ointment, and 120ml/mo for solution. Fluocinonide Cream, Limited to 120 gm/mo for cream, gel & Emusified Cream, Gel, Soln, Lidex, Lidex-E ointment, and 120ml/mo for solution. Oint 0.05% External Corticreme, Genasone, Dermacort, Cortaid, Hytone, Dermatex HC, Nutracort, Limited to 120gm/mo for cream & ointment, Hydrocortisone External Hydrocort, Cortaid, and 120mL/mo for lotion. Nercainal, Lanacort HC, AC/Aloe, Anusol HC, Hydrocort/ AN, Cotacort Aristocort A, Limited to 80gm/mo for 0.025%, 0.1% and Cream, Ointment External Kenalog 45gm/mo for 0.5%

Anorectal Products Hydrocortisone w/ Pramoxine Proctofoam-HC Foam 1-1% Rectal Phenylephrine in Hard Fat Rectacaine Suppos 0.25% Rectal Pramoxine Hcl Oint 1% Rectal Tucks Analpram-HC, Pramoxine-HC External Epifoam, Pramosone Pramoxine w/ Zinc Oxide in Mineral Oil Oint 1-12.5% Tucks, Anusol Rectal Starch Suppositories 51% Tucks Rectal

Enzymes Papain- Ointment Accuzyme,

External Ethezyme Papain & Urea-Chlorophyllin Panafil Ointment External Trypsin w/ Castor Oil & Peruvian Balsam Ointment Xenaderm External

Keratolytics Podofilox Soln & Gel 0.5% Condylox External

June 2015 Page 27 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Local Anesthetics – Topical Lidocaine HCL Gel 2% Xylocaine External Lidocaine HCL Viscous Soln Xylocaine 2% Mouth/Throat

Scabicides & Pediculocides Crotamiton Cream & Lotion Eurax 10% External Malathion 0.5% Lotion Ovide External Permethrin Cream Rinse 1% Nix Cream Rinse External Permethrin Cream 5% Elimite, Acticin External Pyrethrins-Piperonyl Butoxide Rid, A-200, Pronto External

Miscellaneous Topical Calcipotriene Soln External Dovonex Coal Tar (Crude) Solution Coal Tar External

DIAGNOSTIC PRODUCTS Diagnostic Reagents Acetone Test Acetest, Ketostix Glucose Urine Test-(Glucose Diastix, Clinistix Oxidase) Glucose Urine Test-(Copper Sulfate) Clinitest

Limited to 50 per 30 days if not on insulin. If on insulin, allow limit 100 per 30 days. Ascencia Contour Glucose Blood Test Strips Limited to Bayer Ascencia Ascencia Breeze 2 Contour,Ascencia Breeze 2, and Contour Next only. Multiple Urine Test Strips Limited to 51/month. Maximum of 3 Chemstrips fills/prescription Urine Glucose-Ketones Test Strips Chemstrips

Diabetic Supplies Glucose Blood Calibration Control Solutions Soln Glucose Blood Monitoring Kit Ascencia Contour Limited to 1 fill per year. Maximum of $60 Ascencia Breeze 2 per fill. Limited to Ascencia Contour, Breeze Contour Next 2, and Contour Next products. Limited to 100/month. Maximum of 3 Insulin Syringes B-D Insulin Syringes fills/prescription

June 2015 Page 28 of 42 San Diego County Drug Formulary

Representative Generic Name Utilization Management Brand Name

Limited to 51/month. Maximum of 3 Lancets Lancets fills/prescription Limited to 2 fills/year, maximum Lancets Devices Lancets $25/prescription

Transplant Medications Prior Authorization Required

June 2015 Page 29 of 42

Ana-Kit, 10 A ANALGESICS AND ANESTHETICS, 17 Analgesics Other, 17 A-200, 28 Analpram-HC, 27 AC/Aloe, 27 Anaphylaxis Therapy Agents, 10 Acarbose Tab Oral, 7 Anaspaz, 14 Accuneb, 13 Ancobon, 5 Accuzyme, 27 Angiotensin II Inhibitor Combinations, 8 ACE Inhibitors, 8 Angiotensin II Inhibitors, 8 Acephen, 17 Anorectal Products, 27 Acetaminophen Oral, 17 AntfFungals, 5 Acetaminophen Suppos Rectal, 17 Anti-Anginals, Other, 8 Acetaminophen w/ Codeine, 18 Anti-Arrhythmia, 7 Acetaminophen w/ Codeine Oral Soln, 18 Antibiotics, 4 Acetaminophen w/ Hydrocodone 5-500mg, 7.5-750mg, Antibiotics – Topical, 26 10-325mg Tab Oral, 18 Anticholinergic Combinations, 14 Acetaminophen w/ Hydrocodone 7.5-500mg/15mL , 12 Soln, 18 Anti-Emetics-Anticholinergic, 14 Acetaminophen w/ Hydrocodone Cap, Tab Oral, 18 Antifungals – Topical, 26 Acetaminophen-Caffeine-Butalbital, 19 Antifungals – Topical Combinations, 26 Acetazolamide, 9 Antihelmintics, 5 Acetazolamide Oral, 9 Antihistamines-Alkylamines, 11 Acetest, 28 Antihistamines-Non-Sedating, 11 Acetic Acid 2% Soln Otic, 25 Antihyperlipidemics: Fenamates, 10; HMG-CoA Reduase Acetone Test, 28 Inhibitor, 10 Acticin, 28 Antimalarials, 5 Actifed, 12 Antiminth, 5 Actigall, 14 Antimyasthenic Agents, 21 Actoplus Met, 7 Antimycobacterial Agents, 5 Actos, 7 Antineoplastic Agents, 6 Acular, 25 ANTINEOPLASTIC AGENTS, 6 Acular LS, 25 Antiparkinsonian Agents, 21 Acyclovir Oral, 6 Antiperistaltic Agents, 13 Adrenergic Combinations, 13 ANTI-RHEUMATIC AND ANTI-PSORIATIC AGENTS, 18 Adrenergic Mydriatics, 25 Antispasmodics, 14 Adrenolytics-Central, 8 Antithyroid Agents, 7 AK-Spore HC, 24 Antitussive Non-Narcotic, 12 Albuterol Sulfate Aero Inhalation, 13 Antitussive-Antihistamine Narcotic, 12 Albuterol Sulfate Soln Nebu Inhalation, 13 Anti-Ulcers: Imidazoles (Proton-Pump Inhibitors), 14 Albuterol-Ipratropium Aerosol Inhalation, 13 Antivert, 14 Aldactazide, 10 Antivirals, 6 Aldactone, 9 Anturane, 20 Aldomet, 8 Anusol, 27 Allantoin-Coal Tar and Combinations Shampoo Externa, Anusol HC, 27 26 APAP-Isometheptane-Dichloral Cap 325-65-100mg Oral, Allopurinol Tab Oral, 19 18 Alpha-Beta Blockers, 9 Apresoline, 10 Alpha-Blockers, 8 Aralen, 5 Alphagan/ Alphagan-P, 24 Arcapta Neohaler Cap, 13 Amaryl, 7 Aristocort A, 27 Amebicides, 5 ASA Low Dose, 17 Amerge, 19 Asacol, 15 Amigesic, 17 Ascencia Breeze 2, 28 , 5 Ascencia Contour, 28 Amitriptyline HCL Oral, 16 Ascendin, 16 Amlodipine Besylate Oral, 9 Ascriptin, 17 Amoxapine Oral, 16 Aspirin Buffered, 17 Amoxicillin & Potassium Clavulanate Oral, 4 Aspirin Buffered (mg Carbonate-Al Glycinate) 325mg Amoxicillin Oral, 4 Tab Oral, 17 Ampicillin, 4 Aspirin Buffered 325mg Tab Oral, 17 Ampicillin Oral, 4 Aspirin Oral, 17 Anafranil, 16 Aspirin Supp, 17

June 2015 Page 30 of 42

Aspirin Suppos Rectal, 17 Blephamide, 23 Aspirin w/ Codeine 325-15mg, 325-30mg, & 325-60mg Blephamide S.O.P., 23 Tab Oral, 18 Brethine, 13 Aspirin-Caffeine-Butalbital 325-40-50mg Tab & Cap Oral, Brinzolamide Susp 1% Ophthalmic, 23 19 Bromatane DX, 12 Atarax, 16 Bromfenac Sodium Soln 0.09% Ophthalmic, 25 Atenolol Oral, 8 Broncho Saline, 11 Atorvastatin Oral, 10 Budesonide/Formoterol, 13 Atovaquone, 4 Buffaprin, 17 Atropine Sulfate Oint 1% Ophthalmic, 24 Buffered ASA, 17 Atropine Sulfate Soln 1% Ophthalmic, 24 Burn Products, 26 Atrovent, 12 Butalbital CPD, 19 Atrovent HFA, 12 Butalbital-Acetaminophen, 19 Augmentin, 4 Butalbital-Acetaminophen-Caff w/ Cod 50-325-40-30mg Augmentin XR, 4 Cap Oral, 19 Auralgan, 25 Butalbital-Aspirin-Caff w/ Codeine 50-325-40-30mg Cap Azithromycin Susp Oral, 4 Oral, 19 Azithromycin Tab Oral, 4 Azo-gesic, 16 C Azopt, 23 Azulfidine, 15 Cabergoline Oral, 7 Calan, 9 B Calcipotriene Soln External, 28 Calcium Acetate, 15 Bacitracin-Polymyxin-Neomycin-HC Ophthalmic Oint Calcium Acetate (Phosphate Binder), 15 1%, 24 Calcium Blockers, 9 Baclofen Tab Oral, 21 Calulose, 15 Bactrim, 4 Canasa, 15 Bactrim DS, 4 Capoten, 8 Bactroban, 26 Captopril Oral, 8 Hypnotics, 17 Carafate, 14 Bayer ASA, 17 Carbamazepine Chew Tab Oral, 20 BD – Glucose Chw, 7 Carbamazepine Susp Oral, 20 B-D Insulin Syringes, 28 Carbamazepine Tab SR Oral, 20 Beclomethasone Dipropionate Inhal Aero, 13 Carbamide Peroxide 6.5% Soln Otic, 25 Belladonna Alkaloids, 14 Carbonic Anhydrase Inhibitors, 9 Belladonna Alkaloids- Phenobarbital Tab & Elixir, 14 CARDIOVASCULAR AGENTS, 7 Benadryl, 11 Cardizem, 9 Benazepril HCL Oral, 8 Cardizem SR, 9 Benemid, 20 Cardura, 8 Benicar, 8 Carteolol HCL Soln 1% Ophthalmic, 23 Bentyl, 14 Carvedilol Tab Oral, 9 Benzocaine-Antipyrine 1.4-5.4% Soln Otic, 25 Cataflam, 18 Benzodiazepines, 16 Catapres, 8 Beta Adrenergics, 13 Cefdinir Oral, 4 BetaBlockers Cardio-Selective, 8 Cefixime Tab 400mg Oral, 4 Beta-Blockers Non-Selective, 8 Cefpodoxime Proxetil Oral, 4 Betagan, 23 Central Muscle Relaxants, 21 Betamethasone Dipropionate Cream External, 27 Cephalexin Monohydrate, 4 Betapace, 8 Cephalosporins, 4 Betapace AF, 8 Cephulac, 15 Betaxolol HCL Soln -.5% & 1% and Susp 0.25% Cerose-DM, 12 Ophthalmic, 22 Chemstrips, 28 Bethanechol Chloride Oral, 15 Chloroquine Phosphate Tab Oral, 5 Betoptic, 22 Chlorpheniramine & Pseudoephedrine Oral, 12 Betoptic-S, 22 Chlorpheniramine-DM Syrup Oral, 12 Biaxin, 4 Chlorthalidone Oral, 10 Bicillin LA, 4 Chlor-Trimeton, 12 Biguanides –Metformin, 7 Cholac, 15 Bile Sequestrants, 10 Cholestyramine Powder & Packets Oral, 10 Bio-Statin, 26 Cholestyramine Powder Can Oral, 10 Biphos, 15 Cilostazol, 22 Bleph-10, 22 Ciloxan, 22

June 2015 Page 31 of 42

Cipro, 4 Cycloplegics Mydriatic Combinations, 24 Cipro HC Otic, 25 Cyproheptadine HCL Oral, 11 Ciprofloxacin HCl 250mg, 500mg, 750mg Tab Oral, 4 Cystospaz, 15 Ciprofloxacin HCL Oint & Soln 0.3% Ophthalmic, 22 Cystospaz-M, 14 Ciprofloxacin-Hydrocortisone Otic Susp 0.2-1%, 25 Cytomel, 7 Clarithromycin 250mg, 500mg Tab Oral, 4 Cytra K, 16 Claritin, 11 Clearlax Polyethylene Glycol 3350 SM Powder, 15 D Cleocin, 4 Cleocin Vaginal, 15 Dapsone, 4 Clindamycin HCL Cap Oral, 4 Dapsone Oral, 4 Clindamycin Phosphate CR Vaginal, 15 Daraprim, 5 Clinistix, 28 Daypro, 18 Clinoril, 18 DDAVP, 7 Clomipramine HCL Oral, 16 Debrox, 25 Clonazepam Tab Oral, 16 Decadron, 6, 23 Clonidine HCL Oral, 8 Deconamine, 12 Clopidogrel Bisulfate Tab Oral, 22 Decongestant or Decongestant Combinations, 11 Clotrimazole, 16 Depakene, 20 Clotrimazole External, 26 Depakote EC, 20 Clotrimazole Tab, 16 Depakote ER, 20 Clotrimazole Vaginal, 16 Depakote Sprinkle, 20 Clotrimazole w/ Betamethasone Cream, External, 26 Deponit, 9 Coal Tar, 28 Dermacort, 27 Coal Tar (Crude) Solution External, 28 Dermatex HC, 27 Coal Tar External, 26 DERMATOLOGICAL PRODUCTS, 26 Codeine Combinations, 18 Desenex,, 26 Codimal DM, 12 Desipramine HCL Oral, 16 Codine-GG Oral, 12 Desmopressin Acetate Oral, Nasal Spray, 7 Codituss DM, 12 Dexacidin, 24 Colchicine w/Probenecid, 20 Dexamethasone Oral, 6 Colytrol, 14 Dexamethasone Sodium Phosphate Soln Ophthalmic, Combination Diuretics, 10 23 Combination Gout Drugs, 20 Dexamethasone Susp 0.1% Ophthalmic, 23 Combivent Respimat, 13 Dexa-sol, 23 Compazine, 14 Dexbrompheniramine & Pseudoephedrine Oral, 12 Condylox, 27 Dexone, 6 Control Solutions, 28 Dextromethorphan-GG Liquid 10-100mg/5mL Oral, 12 Coreg, 9 Diabeta Micronase, 7 Cortaid, 27 DIABETIC AGENTS, 6, 8, 9, 10, 12, 13, 17, 22 Cortef, 6 Diabetic Supplies, 28 – Topical, 27 Diabetic Tus, 11 Corticreme, 27 Diabetic Tus DM, 12 Cortisone, 6 DIAGNOSTIC PRODUCTS, 28 Cortisone Acetate Oral, 6 Diagnostic Reagents, 28 Cortisporin, 24 Diastix, 28 Cortisporin Otic, 25 Diazepam Tab Oral, 16 Cosopt, 23 Diclofenac, 25 Cotacort, 27 Diclofenac Potassium Oral, 18 Coumadin, 22 Diclofenac Sodium EC Oral, 18 Coumarin Anticoagulant, 22 Diclofenac Sodium Soln 0.1% Ophthalmic, 25 Cozaar, 8 Dicloxacillin Sodium, 4 Cream 1%, Kit Vaginal, 16 Dicloxacillin Sodium Oral, 4 Cromolyn Sodium Solution, 12 Dicyclomine HCL Oral, 14 Crotamiton Cream & Lotion 10% External, 28 Diflucan, 5 Crotamiton External, 26 Digitalis, 9 Cyclobenzaprine HCL 10mg Tab Oral, 21 Digoxin Oral, 9 Cyclogyl, 24 Dilacor XR, 9 Cyclomydri, 24 Dilantin, 20 Cyclopentolate HCL Soln 0.5%, 1%, 2% Ophthalmic, 24 Diltiazem ER, 9 Cyclopentolate w/ Phenylephrine Soln 0.2-1% Diltiazem HCL CR Oral, 9 Ophthalmic, 24 Diltiazem HCL Oral, 9 Cycloplegics, 24 Diltiazem HCL SR/24hr Oral, 9

June 2015 Page 32 of 42

Dimetane-DX, 12 Erythromycin w/EC Particles Oral, 4 Diphedryl, 11 Esgic, 19 Diphenhydramine HCL Oral, 11 Esgic Plus, 19 Diphenoxylate w/ Atropine Oral, 13 Esidrix, 10 Dipivefrin Soln 0.1% Ophthalmic, 24, 25 Estrace, 15 Diprosone, 27 Estradiol, 15 Dipyridamole Oral, 8 Estradiol Vaginal Cream, 15 Dipyridamole Tab Oral, 22 Estrogel, 15 Disalcid, 17 Estrogen, 15 Disopyramide Phosphate Oral, 7 ESTROGENS, 15 Ditropan, 15 Estropipate, 15 Divalproex Sodium EC Cap Oral, 20 Ethezyme, 27 Divalproex Sodium EC Tab Oral, 20 Ethmozine, 7 Divalproex Sodium SR 24 Hr Tab Oral, 20 Ethosuximide Caps, 20 Dofetilide Ora, 7 Etodolac Cap & Tab Oral, 18 Donnatal, 14 Eurax, 26, 28 Donnatal Elixir, 14 Euthyrox, 7 Dorzolamide-Timolol Soln 2-0.5% Ophthalmic, 23 Expectorants, 11 Dostinex, 7 Dovonex, 28 F Doxazosin Mesylate Oral, 8 Doxepin HCL Oral, 16 Famotidine Tablet 40mg Oral, 14 Doxycycline Hyclate Cap, 5 Feldene, 18 Dulera Aer, 13 Femtrace, 15 Duoneb, 13 Fenofibrate Micronized Caps Oral, 10 Dyazide, 10 Fenofibrate Oral, 10 Fenoprofen Calcium Oral, 18 E Feosol, 22 Feostat, 22 E.E.S., 4 Feratab, 22 EC-Naprosyn, 18 Fer-In-Sol, 22 Econopred Plus, 23 Ferrous Fumarate Oral, 22 Ecotrin, 17 Ferrous Gluconate, 22 Eflone, 23 Ferrous Gluconate Oral, 22 Elavil, 16 Ferrous Sulfate Oral, 22 Elimite, 28 Feverall, 17 Elixer, 18 Finasteride, 8 Elmiron, 16 Fioricet, 19 Empirin, 17 Fiorinal, 19 Empirin/Codeine #2, #3, #4, 18 Fiorinal w/ Codeine, 19 E-Mycin, 4 Fiortal, 19 Enalapril Oral, 8 Flagyl, 4 ENDOCRINE_AND METABOLIC DRUGS, 6 Flarex, 23 Enoxaparin Sodium Injection, 22 Flecainide Acetate Oral, 7 Enulose, 15 Flexeril, 21 Enzymes, 27 Flonase, 11 Epifoam, 27 Florinef, 6 Epinephrine HCl Injection (Anaphylaxis), 10 Flovent Disku, 13 Epinephrine-Chlorpheniramine, 10 Fluconazole Tab 50mg, 100mg, 150mg Oral, 5 Epipen, 10 Flucytosine, 5 Epipen Jr, 10 Fludrocortisone Acetate Oral, 6 Ercaf, 19 Flunisolide 0.025% Nasal, 11 Ergot Combinations, 19 Fluocinolone Acetonide Cream, Oil, Soln External, 27 Ergotamine w/ Caffeine 1-100mg Tab Oral, 19 Fluocinonide Cream, Emusified Cream, Gel, Soln, Oint Eryc, 4 0.05% External, 27 Ery-Tab, 4 Fluorometholone Acetate Susp 0.1% Ophthalmic, 23 Erythrocin, 4 Fluorometholone Oint 0.1% Ophthalmic, 23 Erythromycin, 4 Fluorometholone Susp Ophthalmic, 23 Erythromycin Base Oral, 4 Fluorosyn, 27 Erythromycin Delayed Release Oral, 4 Flurbiprofen Soln 0.03% Ophthalmic, 25 Erythromycin Ethylsuccinate Oral, 4 Fluroquinolones, 4 Erythromycin Oint 5mg/gm Ophthalmic, 22 Fluticasone, 13 Erythromycin Stearate Oral, 4 Nasal, 11

June 2015 Page 33 of 42

FML Forte, 23 Humalog, 6 FML Liquifilm, 23 Humalog Mix 75/25, 6 FML S.O.P., 23 Human Insulin, 6 Folic Acid, 22 Humibid, 12 Folic Acid Antagonist, 18 Humulin 50/50, 6 Folic Acid Oral, 22 Humulin 70/30, 6 Fortabs, 19 Humulin L, 6 Fototar,, 26 Humulin N, 6 Furadantin, 15 Humulin R, 6 Furosemide Oral, 9 Hydantoins, 20 Hydralazine HCL Oral, 10 G Hydrochlorthiazide (HCTZ) Oral, 10 Hydrocodone Combinations, 18 Gabapentin 400mg Cap, 400mg, 600mg, & 800mg Hydrocort, 27 Tablet Oral, 20 Hydrocort/AN, 27 Gallstone Solubilizing Agents, 14 Hydrocortisone External, 27 Gantrisin, 5 Hydrocortisone Tab Oral, 6 Garamycin, 22 Hydrocortisone W/ Acetic Acid 1-2% Soln Otic, 25 GASTROINTESTINAL AGENTS, 13 Hydrocortisone w/ Pramoxine Foam 1-1% Rectal, 27 Gemfibrozil Oral, 10 Hydrodiuril, 10 Genacote, 17 Hydroxychloroquine Sulfate Oral, 5 Genasone, 27 Hydroxyzine HCL Oral, 16 Generlac, 15 Hydroxyzine Pamoate Oral, 16 Genitourinary Irrigants, 16 Hygroton, 10 GENITOURINARY PRODUCTS, 15 Hyoscyamine Sulfate Oral, 14 Gennin –FC, 17 Hyoscyamine Tab 0.15 mg Oral, 15 Genoptic, 22 Hytone, 27 Gentamicin Sulfate Soln & Oint 0.3% Ophthalmic, 22 Hytrin, 8 GI Stimulants, 14 Hyzaar, 8 Glimepiride Oral, 7 Glipizide Tab Oral, 7 I Glucagon Kit, 7 Glucagon Kit Injection, 7 Ibuprofen Oral, 18 Glucocorticosteroids, 6 Imdur, 9 Glucophage, 7 HCL Oral, 17 Glucose Blood Monitoring Kit, 28 Imitrex, 19 Glucose Blood Test Strips, 28 Imitrex NS, 19 Glucose Chew Tab Oral, 7 Imodium, 13 Glucose Urine Test-(Copper Sulfate), 28 Imodium A-D, 13 Glucose Urine Test-(Glucose Oxidase), 28 Indacateriol Oral Inh., 13 GlucoseBloodCalibrationSoln, 28 Indapamide Oral, 10 Glucotrol, 7 Inderal, 8 Glucovance, 7 Inderal LA, 8 Glyburide Micronized, 7 Indocin, 18 Glyburide Oral, 7 Indomethacin Oral, Suppos Rectal, 18 Glyburide/Metformin Tab, 7 INFECTIOUS DISEASE AGENTS, 4 Glynase, 7 Infi-Cyle, 24 Gout, 19 Inflamase Forte, 23 GOUT AGENTS, 19 Insulin Aspart Inj 100 U/mL, 6 G-Tar, 26 Insulin Aspart Prot & Aspart Inj 100 U/mL (70-, 6 Guaifed, 12 Insulin Detemir Inj U/mL, 6 Guaifed-PD, 12 Insulin Glargine Inj 100 U/mL, 6 Guaifenesin Oral, 11 Insulin Isophane Inj 100 U/mL, 6 Gyne-Lotrimin, 16 Insulin Lispro inj100 U/mL, 6 Insulin Lispro Prot & Lispro Inj 100 U/mL (75-25), 6 H Insulin Regular & Isophane Inj 100 U/mL, 6 Insulin Regular & Isophane Inj 100 U/mL (50), 6 H-2 Antagonists, 14 Insulin Regular Inj 100 U/mL, 6 HCL Cap, HLC Cap CR, Tab Oral, 21 Insulin Regular Inj 500 U/mL, 6 HEMATOLOGICAL AGENTS, 22 Insulin Syringes, 28 Heparins And Heparinoid-Like Agents, 22 Insulin Zinc Inj 100 U/mL, 6 Histex, 12 Intal, 12 Homatropine HBr Soln 2%, 5% Ophthalmic, 24 Intestinal Acidifiers, 15

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Iodoquinol Oral, 5 Levetiracetam Tabs, 20 Ipratripium Sol Inh, 12 Levobunolol HCL Soln 0.25% & 0.5% Ophthalimc, 23 Inhalation, 12 Levofloxacin Tab Oral, 4 Ipratropium/Albuterol Sol, 13 Levothroid, 7 Iron, 22 Levothyroxine Sodium Oral, 7 Irrigation Soln, 16 Levoxyl, 7 ISMO, 9 Levsin, 14 Iso Atropine, 24 Levsin SL, 14 Iso Carpine, Pilocar, 25 Levsinex, 14 Iso Homatropine, 24 Lidex, 27 Iso Hyoscine, 24 Lidex-E, 27 Isoniazid Oral, 5 Lidocaine HCL Gel 2% External, 28 Isoptin, 9 Lidocaine HCL in Viscous Soln 2% (Mouth-Throat), 26 Isordil, 9 Lidocaine HCL Viscous Soln 2% Mouth/Throat, 28 Isosorbide Dinitrate Oral, 9 Lidocaine Viscous, 26 Isosorbide Dinitrate Oral Tabs & Chew Tabs, 9 Lioresal, 21 Isosorbide Dinitrate SL Oral, 9 Lioresal DS, 21 Isosorbide Mononitrate Oral, 9 Liothyronine Sodium Oral, 7 Itraconazole Caps, 5 Lipitor, 10 Liquid Pred, 6 K Lisinopril Oral, 8 Llotycin, 22 Kaochlor, 21 Local Anesthetics – Topical, 28 Kaon-CL, 21 Lodine, 18 Kaon-CL SF, 21 Lofibra, 10 Kay Ciel KCL, 21 Lomotil, 13 Kayexalate, 22 Loniten, 10 K-Dur, 21 Lonox, 13 Keflex, 4 Loop Diuretics, 9 Kenalog, 26, 27 Loperamide HCL Oral, 13 Keppra, 20 Lopid, 10 Keratolytics, 27 Lopressor, 8 Ketoconazole Cream 2% External, 26 Loratadine 10mg Tab Oral (OTC), 11 Ketoconazole Shampoo 2% External, 26 Lortab, 18 Ketoconazole Tab Oral, 5 Lotensin, 8 Ketorolac, 25 Loteprednol etabonate-Tobramycin Susp 0.5-0.3% Ketorolac Tromethamine Soln 0.4%, 0.5% Ophthalmic, 25 Ophthalmic, 23 Ketostix, 28 Lotrimin, 26 Klonopin, 16 Lotrimin AF, 26 Klor-Con, 21 Lotrisone, 26 Klortrix, 21 Lovastatin Oral, 10 Klorvess, 21 Lovenox, 22 K-Tabs,, 21 Lozol, 10

L M Labetalol HCL Oral, 9 Macrobid, 15 Lactulose Syr, 15 Macrodantin, 15 Lamictal, 20 Macrolides, 4 Lamisil, 5 Malathion 0.5% Lotion External, 28 Lamotrigine Tabs, 20 Mast Cell Stabilizers, 12 Lanacort HC, 27 Maxalt-MLT, 19 Lancets, 29 Maxidex, 23 Lancets Devices, 29 Maxitrol, 24 Lanoxin, 9 Maxivate, 27 Lantrisul, 5 Maxzide, 10 Lantus, 6 Mebendaxole Oral, 5 Lasix, 9 Meclizine Oral, 14 Latanoprost Soln 0.005% Ophthalmic, 24 Medotar, 26 Leukotriene Receptor Inhibitor, 13 Medroxyprogesterone Acetate, 15 Levaquin, 4 Meloxicam, 18 Levbid, 14 Mephyton, 21 Levemir, 6 Mepron, 4

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Mesalamine Enema Rectal, Suppos Rectal, Oral, 15 Mydriacyl, 24 Mestinon, 21 Mysoline, 20 Metformin HCL Oral, 7 Methadone HCL Oral, 17 N Methazolamide Oral, 9 Methimazole Oral, 7 Naldecon Sr, 11 Methocarbamol Oral, 21 Nalfon, 18 Methotrexate Oral, 18 Naphazoline w/ Pheniramine Soln 0.025-0.3% Methyldopa Oral, 8 Ophthalmic, 24 Meticorten, Deltasone, 6 Naprosyn, 18 Metipranolol HCL Soln 0.3% Ophthalmic, 23 Naproxen DR Oral, 18 Metoclopramide HCL Oral, 14 Naproxen Oral, 18 Metolazone Oral, 10 Naratriptan Tab, 19 Metoprolol Succinate SR Oral, 8 Narcotic (codeine cough syr), 12 Metoprolol Tartrate Oral, 8 Narcotic Agonist, 17 Metrogel Vag Gel, 16 Narcotic Combinations, 17 Metronidazole Gel 0.75% Vaginal, 16 Nasal Steroids, 11 Metronidazole Tab Oral, 4 Nasalide, 11 Mevacor, 10 Nebupent, 4 Mexiletine, 7 Neo-Fradin, 5 Mexiletine HCI, 7 Neomycin Sulfate, 5 Micatin, 26 Neomycin Sulfate Oral, 5 Miconazole Nitrate Cream 2% External, 26 Neomycin-Polymyxin-Dexamethasone Susp & Oint 0.1% Miconazole Nitrate Cream, Suppos Vaginal, 16 Ophthalmic, 24 Miconazole Nitrate Vagina, 16 Neomycin-Polymyxin-HC Soln 1% Otic, 25 Miconazole Nitrate Vagina Kit, 16 Neomycin-Polymyxin-HC Susp 3.5mg/mL-10000 U/mL-1% Micro-K, 21 Otic, 25 Microzide, 10 Neomycin-Polymyxin-HC Susp Ophthalmic, 24 Midrin, 18 Neostigmine Bromide Tab 15mg Oral, 21 MIGRAINE AGENTS, 18 Nepafenac Susp 0.1% Ophthalmic, 25 Migraine Products, 18 Neptazane, 9 Mineralocorticoids, 6 Nercainal, 27 Minipress, 8 NEUROMUSCULAR AGENTS, 20 Minitran, 9 Neurontin, 20 Minoxidil Oral, 10 Neutraphos, 21 Mintezol, 5 Nevanac, 25 Miralax, 15 Niacin, 11, 21 Misc. Anti-Infectives, 4 Niacin Oral, 21 Misc. Genitourinary Agents, 16 Niacin Tab CR, 11 Misc. GI, 15 Niaspan, 11 Miscellaneous Anticonvulsants, 20 Nicotinic Acid Derivatives, 11 Miscellaneous Antihistamine Agents, 16 Nilstat, 26 Miscellaneous Anti-Ulcer, 14 Nimodipine Cap Oral, 9 Miscellaneous Respiratory, 11 Nimotop, 9 Miscellaneous Topical, 28 Nitrates, 9 Mobic, 18 Nitro, 9 Mometasone furoate/ Formoterol fumarate dehydrate, Nitrobid, 9 13 Nitrodisc, 9 Monistat, 16, 26 Nitro-Dur, 9 Monoket, 9 Nitrofurantoin, 15 Montelukast Sodium Oral, 13 Nitrofurantoin Macrocrystalline Oral, 15 Moricizine HCI Oral, 7 Nitrofurantoin Monohydrate Macrocrystalline Oral, 15 Morphine Sulfate Tab CR Oral, 17 Nitrofurantoin Susp Oral, 15 Morphine Sulfate Tab Oral, 17 Nitrogard, 9 Motrin, 18 Nitroglycerin, 9 Mouth & Throat (Local), 26 Nitroglycerin Buccal Oral, 9 MS Contin, 17 Nitroglycerin CR Oral, 9 MSIR, 17 Nitroglycerin Intravenous Soln, 9 Multiple Urine Test Strips, 28 Nitroglycerin Oint 2% Transdermal, 9 Mupirocin 2% Oint External, 26 Nitroglycerin SL Tab & Aer Oral, 9 Murocoll-2, 24 Nitroglycerin TD Transdermal, 9 Mycolog II, 26 Nitroglyn, 9 Mycostatin, 5, 26 Nitroquick, 9

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Nitrostat,, 9 Oseltamivir, 6 Nitrotab, 9 Other Antidiabetics, 7 Nitro-Time, 9 Otic Miscellaneous, 25 Nix Cream Rinse, 28 Otic Steroid Antibiotic Combinations, 25 Nizoral, 5, 26 Otic Steroids, 25 Anti-Inflammatory Agents, 18 Ovide, 28 Norco, 18 Oxaprozin Oral, 18 Normal Saline (IV), 22 Tabs, 21 Normodyne, 9 Oxybutynin Chloride Tab & Syr Oral, 15 Norpace CR, 7 Oxycodone w/ Acetaminophen 5-325mg, 7.5-325mg, & Norpramin, 16 10-325mg Tab Oral, 17 Nortriptyline HCL Oral, 17 Norvasc, 9 P Novahistine-DM, 11 Novolin 70/30, 6 Pamelor, 17 Novolin L, 6 Panafil, 27 Novolin N, 6 Papain & Urea-Chlorophyllin Ointment External, 27 Novolin R, 6 Papain-Urea Ointment External, 27 Novolog, 6 Paromomycin, 5 Novolog Mix, 6 Paromycin, 5 Nutracort, 27 Patanol, 25 NUTRITIONAL PRODUCTS, 21 PCE, 4 Nydrazid, 5 Pedi-Dri, 26 Nystatin, 5 Penicillin G Benzathine, 4 Nystatin External, 26 Penicillin V Potassium Oral, 4 Nystatin Susp 100000 U/mL (Mouth/Throat), 26 Pentam, 4 Nystatin Tab 100000 U Vaginal, 16 Pentamidine, 4 Nystatin Vaginal Tab, 16 Pentasa, 15 Nystatin-Triamcinolone Cream & Oint External, 26 Pentosan Polysulfate Sodium Oral, 16 Nystop, 26 Pen-VK, Veetids, 4 Pepcid, 14 O Periactin, 11 Permethrin Cream 5% External, 28 Ocufen, 25 Permethrin Cream Rinse 1% External, 28 Ocuflox, 22 Persantine, 8, 22 Ocupress, 23 Phenazopyridine HCL Tab Oral, Kit, 16 Ocu-tropine, 24 Phenergan, 11, 14 Ofloxacin Ophth Soln 0.3% Ophthalmic, 22 Phenergan DM, 12 Olmesartan Oral, 8 Phenergan Forte, 11, 14 Olmesartan Tabs, 8 Phenergan VC, 11 Olmesartan-HCTZ Oral, 8 Phenergan w/Codeine, 12 Olopatadine HCL Soln Ophthalmic, 25 Phenobarbital, 17 Omeprazole Magnesium Tab, 14 Phenobarbital Oral, 17 Omnicef, 4 Phenylephrine in Hard Fat Suppos 0.25% Recta, 27 Omnipred,, 23 Phenylephrine w/DM-GG Oral, 12 Ophthalmic Anti-Allergic, 25 Phenylephrine-Chlorphen-DM Oral, 12 Ophthalmic Antibiotics, 22 Phenylephrine-GG Oral, 11 Ophthalmic Beta-Blockers, 22 Phenylephrine-Pyrilamine-DM Oral, 12 Ophthalmic Carbonic Anhydrase Inhibitors, 23 Phenytoin Inj., 20 Ophthalmic Carbonic Anhydrase Inhibitors – Beta- Phenytoin Sod. Extended Caps, 20 Blocker Combination, 23 Phenytoin Sod. Susp and Inj., 20 Ophthalmic Decongestant Combinations, 24 PhosLo, 15 Ophthalmic Non-Steroidal Anti-Inflammatory Agents, 25 Phrenilin, 19 Ophthalmic Steroid, 23 Phrenilin w/ Codeine, 19 Ophthalmic Steroid Combinations, 23 Phytonadione Tab 5mg Oral, 21 Ophthalmics – Direct Acting, 25 Pilocarpine HCL 5mg Tab Oral, 26 Ophthalmics- Alpha 2 Adrenergic Agonists, 24 Pilocarpine HCL Gel 4% Ophthalmic, 25 Opioid Combinations, 19 Pilocarpine HCL Soln 0.5%, 1%, 2%, 4%, 6% Ophthalmic, Optipranolol, 23 25 Oramorph SR, 17 Pilopine HS, 25 Oretic, 10 Pin-X, 5 Organidin NR, 11 Pioglitazone Oral, 7 Orth-est/Ogen, 15 Pioglitazone/Metformin, 7

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Piroxicam, 18 Prostaglandin Agonists Ophthalmi, 24 Piroxicam Ora, 18 Prostigmin, 21 Plaquenil, 5 Protonix, 14 Platelet Aggregation Inhibitors, 22 Protriptyline HCL Oral, 17 Plavix, 22 Provera, 15 Pletal, 22 Pseudoephed-Bromphen-DM Oral, 12 Podofilox Soln & Gel 0.5% External, 27 Pseudoephed-Carbinoxamine-DM Liquid Oral, 12 Polycitra, 16 Pseudoephedrine HCL Oral, 11 Potassium, 21 Pseudoephedrine w/DM-GG Cap 30-10-200mg Oral, 11 Potassium & Sodium Citrates w/Citric Acid Oral, 16 Pseudoephedrine-GG/CR Oral, 12 Potassium & Sodium Phosphates for Soln 278-164- PSYCHOTHERAPEUTIC AGENTS, 16 250mg/75mL, Powder 278-164-250mg & 280-160- Pyrantel Pamoate Ora, 5 250mg Oral, 21 Pyrethrins-Piperonyl Butoxide External, 28 Potassium Chloride Cap CR 8mEq & 10mEq Oral, 21 Pyridium, 16 Potassium Chloride Oral Liq 10% & 20% Oral, 21 Pyridostigmine Bromide Oral, 21 Potassium Chloride Tab CR 8mEq, 10mEq, 15mEq & Pyrimethamine Oral, 5 20mEq Oral, 21 Potassium Removing Resin, 21 Q Potassium Sparing Diuretics, 9 Pramosone, 27 Qualaquin, 5 Pramoxine Hcl Oint 1% Rectal, 27 Questran/Lite, 10 Pramoxine w/ Zinc Oxide in Mineral Oil Oint 1-12.5% Quinidex, 8 Rectal, 27 Quinidine, 7 Pramoxine-HC External, 27 Quinidine Gluconate CR Oral, 7 Pravachol, 10 Quinidine Sulfate Tab Oral, 8 Pravastatin Oral, 10 QUININE SULFATE, 6 Prazosin HCL Oral, 8 Quinine Sulfate Tab, 5 Precose, 7 QVAR, 13 Pred Forte, 23 Prednisolone, 6 R Prednisolone Sodium Phosphate Powder, 6 Prednisolone Acetate Susp 1% Ophthalmic, 23 Ranitidine HCL Tabs 75mg, 150mg, 300mg, 14 Prednisolone Sodium Phosphate Oral, 6 Rectacaine, 27 Prednisolone Sodium Phosphate Soln 1% Ophthalmic, 23 Reglan, 14 Prednisone Oral, 6 Rescon-GG, 11 Prelone, 6 RESPIRATORY AGENTS, 11 Prilosec (OTC), 14 Rid, 28 Primaquine phosphate, 5 Rifadin, 5 Primaquine Phosphate Oral, 5 Rifampin Oral, 5 Primidone Tablet Oral, 20 Rizatriptan, 19 Prinivil, Zestril, 8 Robaxin, 21 Proben-C, 20 Robitussin, 11 Probenecid Oral Probenecid Tab 500 mg, 20 Robitussin A-C, 12 Procainamide HCI Oral, 7 Robitussin Cod/Cgh, 11 Prochlorperazine Edisylate Oral, 14 Robitussin DM, 12 Prochlorperazine Maleate Cap CR & Tab Oral, 14 Robitussin PE, 12 Prochlorperazine Maleate Oral, 14 Rondec DM, 12 Proctofoam-HC, 27 Rowasa, 15 Progestins, 15 Roxicet, 17 Proloprim, 4 Rythmal, 7 Promethazine & Phenylephrine Syrup 6.25-5mg/5mL Oral, 11 S Promethazine HCL Oral, 11, 14 Promethazine HCL Suppos Rectal, 11 Salagen, 26 Promethazine-DM Syrup Oral, 12 Salflex, 17 Pronestyl, 7 Salicylate Combinations, 17 Pronto, 28 Salicylates, 17 Propafenone HCI Oral, 7 Salmeterol Xinafoate Powder Disks Inhalation, 13 Propine-C, 25 Salsalate Oral, 17 Propranolol HCL Oral, 8 Scabicides & Pediculocides, 28 Propylthiouracil (PTU), 7 Scopolamine HBr Soln 0.25% Ophthalmic, 24 Propylthiouracil Oral, 7 Scopolamine w/ Phenylephrine Soln 0.3-10% Proscar, 8 Ophthalmic, 24

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Scot-Tussin DM SF, 12 Tegretol, 20 Sedapop, 19 Tegretol XR, 20 Serevent Diskus, 13 Tegrin, 26 Serotonin Agonist, 19 Tegrin Medicated Shampoo 7%, 26 Silvadene, 26 Tenormin, 8 Silver Sulfadiazine Cream 1% External, 26 Terazosin Oral, 8 Simvastatin Oral, 10 Terbinafine, 5 Sinequan, 16 Terbutaline Sulfate Oral, 13 Singulair, 13 Terconazole Vaginal, 16 Slow-Fe, 22 Tetracycline HCl Oral, 5 Slow-K, 21 , 5 Sod Sulamyd, 22 Theo-24, 13 Sodium, 22 Theochron, 13 Sodium Chloride, 16 Theophylline Tab CR Oral, 13 Sodium Chloride Injection, 22 Theophylline Tab Oral, 13 Sodium Chloride Irrigation Soln, 16 Thiabendaxole Oral, 5 Sodium Chloride Soln Nebu 0.9%, 11 , 10 Sodium Polystyrene Sulfonate Powder Oral, 22 Thiazolidinediones, 7 Sodium Polystyrene Sulfonate Susp 15gm/60mL Thyroid Hormones, 7 Oral/Rectal, 21 Thyroxine, 7 Sodium Sulfacetamide 10% Ophthalmic, 22 Tikosyn, 7 Sorbitrate, 9 Timolol Maleate Soln (Gel Forming) 0.25% & 0.5% Sotalol HCl Oral, 8 ophthalmic, 23 Spiriva Handihaler, 12 Timolol Maleate Soln 0.25% & 0.5% Ophthalmic, 23 Spironolactone Oral, 9 Timoptic, 23 Spironolaone & HCTZ Oral, 10 Timoptic XE, 23 Sporanox, 5 Tinactin, 26 SPS, 21 Tiotropium, 12 Starch Suppositories 51% Recta, 27 Tobradex, 24 Steroid Inhalants, 13 Tobramycin-Dexamethasone Susp & Oint 0.3-0.1% Sucralfate Oral, 14 Ophthalmic, 24 Sudafed, 11 Tofranil, 17 Sudafed Plus, 12 Tolnaftate Power External, 26 Sudex, 12 Topamax, 21 Sulfacetamide Sodium-Prednisolone Oint 10-0.2% Topiragen Tabs, 21 Ophthalmic, 23 Topiramate Tabs, 21 Sulfacetamide Sodium-Prednisolone Susp 10- Toprol XL, 8 0.2%Ophthalmic, 23 Tramadol HCL Tab 50mg Oral, 17 Sulfadiazine, 5, 26 Trandate, 9 Sulfasalazine Tab & EC Oral, 15 Transderm-Nitro, 9 Sulfinpyrazone Oral, 20 Transplant Medications, 29 Sulfisoxazole, 5 Triamcinolone Acetonide External, 27 Sulfisoxazole Acetyl Oral, 5 Triamcinolone Acetonide in Orabase 0.1% (Mouth), 26 Sulfisoxazole Powder, 5 Triamterene & HCTZ Oral, 10 Sulfonamides, 5 Tricitrates, 16 Sulfonylureas, 7 Tricor, 10 Sulindac Oral, 18 Tricyclic Agents, 16 Sumatriptan Spray Nasal, 19 Trileptal, 21 Sumatriptan Succinate Injection, 19 Trimethoprim, 4 Sumatriptan Succinate Tab Oral, 19 Trimethoprim/Sulfamethoxazole Oral, 4 Sumycin, 5 Trimipramine Maleate Oral, 17 Suprax, 4 Trimox, 4 Surmontil, 17 Trimpex, 4 Symbicort, 13 Triple Antibiotic, 24 Synalar, 27 & Pseudoephedrine Oral, 12 Synthroid, L, 7 Tropicamide Soln 0.5%, 1% Ophthalmic, 24 Trypsin w/ Castor Oil & Peruvian Balsam Ointment T External, 27 Tucks, 27 Tambocor, 7 Tussex, 12 Tamiflu, 6 Tussi-Organi, 12 Tapazole, 7 Tylenol, 17 Tar Products, 26 Tylenol/Codeine, 18

June 2015 Page 39 of 42

Tylenol/Codeine #2, #3, #4, 18 Vitamin B-3, 11 Vitamin B-6, 21 U Vitamin K, 21 Vivactil, 17 Ultram, 17 Voltaren, 18, 25 Urecholine, 15 Vopac, 18 , 20 Vosol, 25 Urinary Analgesics, 16 Vosol-HC, 25 Urinary Anti-infectives, 15 Urinary Antispasmodics, 15 W Urine Glucose-Ketones Test Strips, 28 Uro Femme Kit, 16 Warfarin Sodium Tab Oral, 22 Urogesic, 16 Wigraine, 19 Ursodiol Capsule, 14 X V Xalatan, 24 Vaginal Antifungals, 16 Xanthines (Theophylline), 13 Vaginal Anti-Infectives, 15 Xenaderm, 27 Valium, 16 Xibrom, 25 Valproate Acid Caps Soln, 20 Xylocaine, 28 Valproate Sodium Syrup, 20 Valproic Acid, 20 Y Valproic Acid Cap 250mg Oral, 20 Vandazole, 16 Yodoxin, 5 Vantin, 4 Vasocon-A, 24 Z Vasodilators, 10 Vasopressin, 7 Zantac Rx, 14 Vasotec, 8 Zarontin, 20 Ventolin, 13 Zaroxolyn, 10 Ventolin HFA, 13 Zithromax, 4 Verapamil HCL Tab Oral, 9 Zocor, 10 Vermox, 5 Zonegran, 20 Vibramycin, 5 Zonisamide Capsule Oral, 20 Vibratab, 5 Zovirax, 6 Vicodin, 18 Zylet, 23 Vicodin ES, 18 Zyloprim, 19 Vistaril, 16 Vitamin B-, 21

June 2015 Page 40 of 42

SAN DIEGO COUNTY CMS REQUEST FOR FORMULARY CHANGE FORM Fax Completed Form to (855) 394-7927 Attention: Medical Management Services, Manager

DATE FORM COMPLETED: ______

REQUESTED BY: ______

CLINIC ______SPECIALTY ______

PHONE NUMBER: ______FAX NUMBER: ______EMAIL: ______

COMPARABLE DRUG(S) ON FORMULARY:

1) ______

2) ______

DRUG INFORMATION

GENERIC NAME ______BRAND NAME ______

MANUFACTURER ______DOSAGE: ______

MEDICAL INDICATIONS: ______

______

PRECAUTIONS/ALERTS: ______

______

ADVANTAGES AND DISADVANTAGES: (YOU MAY ATTACH REFERENCES OR PUBLICATIONS THAT SUPPORT THE

EFFICACY OF THIS DRUG) ______

______

------

FOR CMS PROGRAM USE ONLY

COMMITTEE COMMENTS: ______

______

DRUG COST PER MONTH______POTENTIAL OVERALL COST ______

ADVANTAGE/DISADVANTAGE ______

ACCEPTED: ______REJECTED: ______DATE: ______

DATE ADDED TO FORMULARY ______FORM 7/01/11

June 2015 Page 41 of 42

San Diego CMS Phone: 800-626-0072 Fax: 866-511-2202

June 2015 Page 42 of 42