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Molina Healthcare of New Mexico Formulary for Centennial Care As of January 2014

Brand Name Generic Name AMOXIL, TRIMOX amoxicillin insulin syringes, disposable lancets ANAFRANIL clomipramine pediatric multivitamins ANAPROX naproxen sodium sodium chloride 0.9% sterile ANSAID flurbiprofen tablets spacer for inhalers *ANTABUSE disulfiram A/T/S erythromycin topical solution and gel ANUCORT-HC (rectal) *ABILIFY aripiprazole ANUSOL-HC hydrocortisone suppositories ABREVA docosanol APIDRA insulin glulisine ACCUPRIL quinapril APRESOLINE hydralazine ACCURETIC quinapril/hydrochlorothiazide APRISO mesalamine ACEON perindopril APTIVUS tipranavir ACLOVATE dipropionate ARALEN chloroquine phosphate 500mg tablets ACTIGALL ursodiol capsules *ARICEPT donepezil ACTIVELLA estradiol/norethindrone tablets ARIMIDEX anastrozole *ACTONEL risedronate ARMOUR THYROID thyroid ACTOPLUS MET metformin/pioglitazone AROMASIN exemestane ACTOS pioglitazone ARTANE trihexyphenidyl ACULAR ketorolac ophthalmic solution ASACOL HD mesalamine ADALAT nifedipine ASENDIN amoxapine ADDERALL amphetamine mixed salts ASPIRIN aspirin ADDERALL XR amphetamine mixed salts extended release ASTELIN azelastine 0.1% nasal spray ADEKs multivitamin/zinc gluconate ATARAX hydroxyzine *ADVAIR /salmeterol inhaler ATIVAN lorazepam AK-POLY-BAC bacitracin/polymyxin b ophthalmic ointment ATRIPLA efavirenz/emtricitabine/tenofovir ALA-CORT hydrocortisone (topical) ATROVENT HFA ipratropium inhaler ALDACTAZIDE spironolactone & hydrochlorothiazide ATROVENT NASAL SPRAY ipratropium nasal spray ALDACTONE spironolactone ATROVENT Nebs ipratropium solution-nebs *ALDARA imiquimod AUGMENTIN amoxicillin/clavulanate (not XR 1000mg tabs) ALDOMET methyldopa AURODEX benzocaine/antipyrine otic ALESSE levonorgestrel 0.1mg/estradiol 20mcg *AVONEX interferon beta-1a ALKERAN melphalan AYGESTIN norethindrone acetate *ALLEGRA fexofenadine AZOPT brinzolamide ophthalmic solution ALPHAGAN, ALPHAGAN-P brimonidine ophthalmic solution AZULFIDINE sulfasalazine AMARYL glimepiride BACITRACIN bacitracin ophthalmic AMBIEN zolpidem BACTRIM, SEPTRA sulfamethoxazole/trimethoprim AMERGE naratriptan BACTROBAN mupirocin topical ointment AMICAR aminocaproic acid BARACLUDE entecavir AMLACTIN ammonium lactate cream, lotion BENADRYL diphenhydramine

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Molina Healthcare of New Mexico Formulary for Centennial Care As of January 2014

BENEMID probenecid CIPRO ciprofloxacin tablets, oral suspension BENTYL dicyclomine CIPRODEX ciprofloxacin/ BETAGAN levobunolol ophthalmic solution CLARITIN loratadine BETAPACE sotalol CLEOCIN clindamycin capsules BETOPTIC, BETOPTIC-S betaxolol ophthalmic solution CLEOCIN T clindamycin topical solution and gel BIAXIN clarithromycin CLEOCIN VAGINAL clindamycin vaginal cream CYTRA sodium citrate/citric acid CLINORIL sulindac BLEPH-10, SULAMYD sulfacetamide ophthalmic CLOBEX solution, cream, gel, ointment BLEPHAMIDE sulfacetamide/ ophthalmic CLOTRIMAZOLE VAGINAL clotrimazole vaginal BRETHINE terbutaline tablets CLOZARIL clozapine BUMEX bumetanide CODEINE codeine tablets BUPROPION, BUDEPRION bupropion COGENTIN benztropine mesylate BUSPAR buspirone (not 7.5mg and 30mg) COLCRYS colchicine CAFERGOT ergotamine/caffeine COLESTID colestipol CAFFEINE CITRATE caffeine citrate oral solution COLY-MYCIN OTIC hydrocortisone/neomycin/colistin otic CALAN, CALAN SR verapamil COMBIVENT, COMBIVENT RESPIMAT ipratropium/albuterol inhaler VITAMIN D ergocalciferol capsules 50,000 units COMBIVIR lamivudine/zidovudine *CAMPRAL acamprosate COMBUNOX oxycodone/ibuprofen CAPOTEN captopril *COMMIT nicotine lozenge CARAFATE sucralfate COMPAZINE prochlorperazine tabs, suppositories TEGRETOL XR carbamazepine ER cap, tab, suspension COMPLERA emtricitabine/rilpivirine/tenofovir CARDEC chlorpheniramine/phenylephrine COMTAN entacapone CARDEC-DM chlorpheniramine/phenylephrine/dm CONCERTA methylphenidate extended release tablets CARDENE nicardipine CONDYLOX podofilox solution 0.5% CARDIZEM diltiazem CONSTULOSE lactulose oral solution CARDURA doxazosin *COPAXONE glatiramer acetate CASODEX bicalutamide CORDARONE amiodarone 200mg CATAPRES clonidine COREG carvedilol tablets CECLOR cefaclor capsules and suspension CORGARD nadolol (not 160mg) CEENU lomustine CORTEF hydrocortisone tablets CEFTIN cefuroxime tablets and suspension CORTENEMA hydrocortisone enema CEFZIL cefprozil tablets and suspension CORTISPORIN bacitracin/poly/neomycin/hydrocortisone *CELEBREX celecoxib CORTISPORIN OPHTH neomycin/polymyxin/hc ophthalmic CELEXA citalopram tablets and suspension CORTISPORIN OTIC hydrocortisone/neomycin/polymyxin otic CELLCEPT mycophenolate tab, cap, and suspension CORTISPORIN –TC OTIC neomycin/colistin/hc/thonzonium otic COSOPT dorzolamide/timolol (not PF) *CHANTIX varenicline CHEMSTRIP K acetone urine test kit COUMADIN warfarin CHLOR-TRIMETON chlorpheniramine maleate COZAAR losartan CILOXAN ciprofloxacin ophthalmic COZAAR/HCT losartan/hydrochlorothiazide *CRESTOR rosuvastatin Page 2

Molina Healthcare of New Mexico Formulary for Centennial Care As of January 2014

CRIXIVAN indinavir DILAUDID hydromorphone CUPRIMINE penicillamine capsules DIPROLENE AF dipropionate augmented CUTIVATE cream and ointment DIPROLENE, DIPROSONE betamethasone dipropionate topical CYCLOCORT DISALCID salsalate CYCLOGEL cyclopentolate ophthalmic DITROPAN, DITROPAN ER oxybutynin tablets, syrup CYCRIN medroxyprogesterone COLACE docusate sodium CYTOTEC misoprostol DOLOBID diflunisal *CYTOVENE ganciclovir capsules *DOLOPHINE methadone CYTOXAN cyclophosphamide tablets DALMANE flurazepam DOMEBORO aluminum acetate DANOCRINE DOSTINEX cabergoline DANTRIUM dantrolene *DOVONEX calcipotriene DAPSONE dapsone tablets DUETACT glimepiride/pioglitazone DAYPRO oxaprozin DULERA /formoterol inhaler DDAVP NASAL SPRAY desmopressin acetate nasal spray *DURAGESIC PATCHES fentanyl patches DECADRON dexamethasone tablets DURICEF cefadroxil DECADRON dexamethasone ophthalmic DYAZIDE, MAXZIDE triamterene/hydrochlorothiazide tabs and caps DECLOMYCIN demeclocycline DYNAPEN dicloxacillin DESONATE DYRENIUM triamterene DELTASONE tablets EDECRIN ethacrynic acid DEMADEX torsemide DEMEROL meperidine EDURANT rilpivirine DEMULEN 1/35E, 1/50E ethynodiol/estradiol EES, ERYPED erythromycin ethylsuccinate *DENAVIR penciclovir EFFEXOR, EFFEXOR XR venlafaxine IR tablets and ER capsules DEPAKENE valproic acid capsules EFUDEX fluorouracil cream 5% DEPAKOTE, DEPAKOTE ER divalproex sodium ELAVIL amitriptyline DEPO-PROVERA medroxyprogesterone injection ELDEPRYL selegiline 5mg DERMATOP *ELIDEL pimecrolimus cream ELIMITE permethrin DESYREL trazodone ELLA ulipristal DETROL tolterodine ELOCON mometasone furoate DEXEDRINE dextroamphetamine ELIXOPHYLLIN theophylline elixir DHE-45 dihydorergotamine mesylate injection EMLA lidocaine/prilocaine cream DIABETA, MICRONASE glyburide EMPIRIN #3, #4 asa/codeine DIABINESE chlorpropamide EMTRIVA emtricitabine DIAMOX acetazolamide *ENBREL etanercept *DIASTAT diazepam gel EPIPEN, EPIPEN JR epinephrine self-injection device *DIFFERIN adapalene topical cream and gel DIFLUCAN fluconazole tablets, oral suspension EPIVIR, EPIVIR HBV lamivudine DILACOR XR diltiazem sustained release EPZICOM abacavir/lamivudine DILANTIN, DILANTIN ER phenytoin *EQUETRO carbamazepine SR capsules Page 3

Molina Healthcare of New Mexico Formulary for Centennial Care As of January 2014

ERY-TAB erythromycin base GENOPTIC gentamycin ophthalmic GEODON ziprasidone ERYTHROCIN erythromycin stearate *GLEEVEC imatinib ESKALITH, ESKALITH CR lithium carbonate GLUCAGON glucagon ESTRACE estradiol tablets GLUCOPHAGE, ESTRADERM estradiol patch, biweekly GLUCOPHAGE XR metformin EULEXIN flutamide GLUCOTROL, GLUCOTROL XL glipizide EVISTA raloxifene GLUCOVANCE glyburide/metformin *EXTAVIA interferon beta-1b GLYCOLAX polyethylene glycol 3350 FELDENE piroxicam *GRANISOL granisetron tablets *FANAPT iloperidone GRISEOFULVIN V griseofulvin microsize FEMARA letrozole GRIS-PEG griseofulvin ultramicrosize FEMHRT estradiol/norethindrone tablets HALCION triazolam FERGON ferrous gluconate HALDOL haloperidol FERROUS SULFATE ferrous sulfate ANDROXY FIORICET butalbital/apap/caffeine HEPARIN heparin sodium injection FIORICET W/CODEINE butalbital/apap/codeine HEPSERA adefovir dipivoxil FIORINAL butalbital/asa/caffeine HUMALOG insulin lispro vials FIORINAL W/CODEINE butalbital/asa/codeine *HUMIRA adalimumab HYCODAN hydrocodone/homatropine syrup FLAGYL metronidazole HYDERGINE ergoloid mesylates FLEXERIL cyclobenzaprine HYDREA hydroxyurea capsules 500mg FLOMAX tamsulosin HYPERCARE aluminum chloride FLONASE fluticasone HYTRIN terazosin FLORINEF acetate ILOTYCIN erythromycin ophthalmic ointment FLOXIN OTIC ofloxacin IMDUR isosorbide mononitrate FLOVENT HFA fluticasone inhaler IMITREX sumatriptan tablets *FLUVOX fluvoxamine tablets IMODIUM loperamide FML, FML-FORTE ophthalmic suspension IMURAN azathioprine FOLIC ACID folic acid INDERAL propranolol FORADIL formoterol fumarate aerolizer INDOCIN indomethacin INVIRASE saquinavir INFLAMASE prednisolone phosphate ophthalmic FOSAMAX alendronate INTAL cromolyn sodium inhaler and nebs FURADANTIN nitrofurantoin suspension *INVEGA paliperidone GANTRISIN PEDIATRIC sulfisoxazole suspension ISOPTO ATROPINE atropine sulfate ophthalmic solution GARAMYCIN TOPICAL gentamycin ISOPTO CARPINE pilocarpine ophthalmic GAVILYTE-G, GAVILYTE-C peg 3350/kcl/sod bicarb/nacl/sod sulfate ISOPTO HOMATROPINE homatropine ophthalmic GAVILTYE-N, TRILYTE peg 3350/kcl/sod bicarb/nacl ISOPTO HYOSCINE scopolamine ophthalmic Page 4

Molina Healthcare of New Mexico Formulary for Centennial Care As of January 2014

ISORDIL isosorbide dinitrate LODINE etodolac ISORDIL TEMBIDS isosorbide dinitrate sustained release LOESTRIN/ LOESTRIN FE norethindrone/estradiol *JANUMET, *JANUMET XR sitagliptin/metformin LOFIBRA fenofibrate tablets 54mg, 160mg *JANUVIA sitagliptin LOMOTIL diphenoxylate/atropine *JENTADUETO linagliptin /metformin *LONITEN minoxidil JOLESSA, QUASENSE levonorgestrel/ethinyl estradiol (91-day) LOPID gemfibrozil KALETRA lopinavir/ritonavir LOPRESSOR metoprolol KARIGEL fluoride 1.1% LOPROX ciclopirox 8% soln, gel, shampoo, cream K-DUR potassium cl controlled release 20meq LOTEMAX loteprednol ophthalmic suspension 0.5% KEFLEX cephalexin capsules LOTENSIN, LOTENSIN HCT benazepril KENALOG topical LOTREL benazepril/amlodipine KENALOG IN ORABASE triamcinolone oral gel *LOVENOX enoxaparin *KEPPRA/KEPPRA XR levetiracetam LOXITANE loxapine LOZOL indapamide KETO-DIASTIX glucose and ketone urine test strips LUDIOMIL maprotiline KETOSTIX urine acetone test strips LURIDE fluoride tablets KLONOPIN clonazepam LYSODREN KLOR-CON potassium chloride tab, cap, powder MACROBID nitrofurantoin macrocrystals KOVIA papain/urea topical MACRODANTIN nitrofurantoin K-PHOS potassium phosphate monobasic tablets MATULANE procarbazine LAMISIL terbinafine tablets, oral granules MAVIK trandolapril LANOXIN digoxin MAXITROL dexamethasone/neomycin/polymyxin b ophth LANTUS VIALS Insulin glargine LASIX furosemide MCT OIL medium chain triglycerides *LATUDA lurasidone MEBARAL mephobarbital LEUKERAN chlorambucil MEDROL LEVAQUIN levofloxacin tablets, oral solution MEGACE ES LEVBID, LEVSIN hyosycamine MELLARIL thioridazine *LEVEMIR Insulin detemir MENEST esterified estrogens LEVOTHROID, SYNTHROID levothyroxine MEPHYTON phytonadione LEXIVA fosamprenavir MESTINON pyridostigmine LIBRIUM chlordiazepoxide METADATE CD methylphenidate extended release capsules METHERGINE methylergonovine maleate LIDEX, LIDEX-E topical METHITEST methyltestosterone LIDOCAINE lidocaine 5% oint, lotion, 2% gel, 3% cream METROCREAM, GEL metronidazole topical cream, gel 0.75% LIORESAL baclofen METROGEL VAGINAL metronidazole vaginal *LIPITOR atorvastatin MEXITIL mexiletine LITHIUM CITRATE lithium citrate syrup *MIACALCIN calcitonin salmon LO/OVRAL norgestrel/estradiol Page 5

Molina Healthcare of New Mexico Formulary for Centennial Care As of January 2014

MIDAMOR amiloride NITRO-BID nitroglycerin ointment MILTOWN meprobamate NITROSTAT nitroglycerin sublingual MINIPRES prazosin NIZORAL tablets MINOCIN minocycline MIRALAX polyethylene glycol 3350 NIZORAL ketoconazole topical cream, shampoo 2% MIRAPEX pramipexole NOCTEC chloral hydrate MIRCETTE /ethinyl estradiol biphasic NOLVADEX tamoxifen citrate MOBAN molindone NORDETTE, LEVLEN levonorgestrel/estradiol MOBIC meloxicam NORMODYNE, TRANDATE labetolol MODICON norethindrone/estradiol NORPACE disopyramide MODURETIC amiloride/hydrochlorothiazide MONODOX doxycycline monohydrate capsules NORPRAMIN desipramine MONOPRIL fosinopril NOR-QD norethindrone 0.35mg MORPHINE morphine sulfate tablets NORVASC amlodipine MOTRIN ibuprofen NORVIR ritonavir capsules, oral solution MS CONTIN morphine sulfate sustained release NOVAHISTINE DH phenylephrine/cpm/dihydrocodeine liquid MYAMBUTOL ethambutol MYCOSTATIN nystatin NOVOLOG insulin aspart vial, flexpen MYDRIACYL tropicamide ophthalmic NOVOLIN, HUMULIN insulin NPHs MYLERAN busulfan NYSTATIN nystatin tablets MYSOLINE primidone OCUFLOX ofloxacin ophthalmic NAPHCON naphazoline OCUPRESS carteolol ophthalmic NAPROSYN naproxen OGEN estropipate NARDIL phenelzine NASALIDE nasal spray OMNICEF cefdinir *NASONEX mometasone nasal spray ORETIC hydrochlorothiazide NAVANE thiothixene ORTHO-CEPT, DESOGEN desogestrel/estradiol 3 NEOMYCIN neomycin tablets ORTHO-CYCLEN norgestimate/estradiol NEORAL cyclosporine microemulsion ORTHO-NOVUM 1/35 norethindrone/estradiol NEPTAZANE methazolamide NEURONTIN gabapentin capsules, 600mg & 800mg tabs ORTHO-NOVUM 1/50 norethindrone/mestranol NEUTRA-PHOS potassium phosphate k powder, solution ORTHO-NOVUM 10/11 norethindrone biphasic/estradiol NIASPAN SR niacin sustained release ORTHO-NOVUM 7/7/7 norethindrone triphasic/estradiol NIAZID isoniazid ORTHO-TRI-CYCLEN norgestimate triphasic/estradiol NICOTINE POLACRILEX nicotine gum ORTHO-TRI-CYCLEN LO norgestimate triphasic/estradiol *NICOTINE TRANSDERMAL nicotine patch ORUDIS ketoprofen *NICOTROL NS nicotine nasal spray *OVIDE malathion *NICOTINE INHALATION nicotine inhaler OVRAL norgestrel/estradiol Page 6

Molina Healthcare of New Mexico Formulary for Centennial Care As of January 2014

OXSORALEN methoxsalen lotion PLETAL cilostazol PAMELOR nortriptyline POLYTRIM polymyxin b/ trimethoprim ophthalmic solution POLY-VI-FLOR fluoride/multivitamins PANAFIL papain/urea/chlorophyllin PANCREAZE, ZENPEP, PRAVACHOL pravastatin ULTRESA, CREON, pancrelipase PRECOSE acarbose PARAFON chlorzoxazone 500mg tablets PRED-FORTE, PRED MILD ophthalmic PARLODEL bromocriptine PREMARIN conjugated estrogens PARNATE tranylcypromine PREMPHASE, PREMPRO conjugated estrogens/medroxyprogesterone *PATANOL olopatadine ophthalmic PREMPRO LOW DOSE conjugated estrogens/medroxyprogesterone PAXIL paroxetine PRENATAL VITAMINS prenatal vitamins PEDIAPRED, PRELONE prednisolone PREVACID lansoprazole capsules PEDIAZOLE erythromycin/sulfisoxazole PRILOSEC omeprazole 10mg, 20mg capsules & tablets *PEGASYS peginterferon alfa-2a PRIMAQUIN primaquine *PEG-INTRON interferon alfa-2b PRINCIPEN ampicillin PENTAM pentamidine PROAIR HFA albuterol *PENTASA mesalamine PRO-BANTHINE propantheline PEN-VEE K penicillin v potassium PROCAN SR procainamide sustained release PEPCID famotidine PROCARDIA XL nifedipine sustained release PERCOCET oxycodone/apap PERCODAN oxycodone/asa PROCTOCREAM-HC hydrocortisone/pramoxine PERIACTIN cyproheptadine PROCTOFOAM-HC pramoxine/hydrocortisone foam PERIDEX chlorhexidine PROGRAF tacrolimus PERMAX pergolide PROLIXIN fluphenazine PERSANTINE dipyridamole PROLOPRIM, TRIMPEX trimethoprim PHENERGAN promethazine PRONESTYL procainamide PHENERGAN DM promethazine dm PROPECIA finasteride PHENERGAN VC phenylephrine/promethazine/codeine liquid PROPINE dipivefrin PHENERGAN W/CODEINE promethazine/codeine liquid PROPYLTHIOURACIL propylthiouracil PHENOBARBITAL phenobarbital PROSCAR finasteride PHOS-LO calcium acetate PROTONIX pantoprazole PHOSPHOLINE IODIDE echothiophate iodide ophthalmic soln *PROTOPIC tacrolimus ointment

PROZAC fluoxetine PLAN B levonorgestrel 0.75mg *PULMICORT RESPULES for inhalation PLAN-B ONE-STEP levonorgestrel 1.5mg PULMICORT FLEXHALER budesonide dry powder inhaler PLAQUENIL hydroxychloroquine *PULMOZYME dornase alpha PLAVIX clopidogrel PURINETHOL mercaptopurine *PLENDIL felodipine Page 7

Molina Healthcare of New Mexico Formulary for Centennial Care As of January 2014

PYRAZINAMIDE pyrazinamide ROWASA mesalamine enema PYRIDIUM phenazopyridine RYNATAN perphenazine/chlorpheniramine pediatric

QUASENSE levonorgestrel/ethinyl estradiol SANDIMMUNE cyclosporine QUESTRAN,QUESTRAN SALAGEN pilocarpine tablets LITE cholestyramine *SAPHRIS asenapine QUINAGULTE quinidine gluconate SECTROL acebutolol QUINAGLUTE DURA-TAB quinidine gluconate sustained release SELENOS selenium/pyrithione/urea shampoo 2.25% QUINARETIC quinapril/hydrochlorothiazide SELSUN selenium sulfide lotion 1%, 2.5% QUINIDINE SULFATE quinidine sulfate SENNA TABLETS senna QVAR beclomethasone inhaler SERAX oxazepam *REBETOL ribavirin SEREVENT DISKUS salmeterol *REBIF interferon beta-1a SEROMYCIN cycloserine REGLAN metoclopramide RELAFEN nabumetone SEROQUEL quetiapine *RELENZA zanamivir *SEROQUEL-XR quetiapine REMERON mirtazapine SERZONE nefazodone RENAGEL sevelamer SILVADENE silver sulfadiazine topical REQUIP ropinirole SINEMET, SINEMET CR levodopa/carbidopa RESCRIPTOR delavirdine SINEQUAN doxepin RESTORIL temazepam SINGULAIR montelukast RETIN-A 0.025% cream tretinoin 0.025% cream tretinoin topical products other than 0.025 % SLOBID theophylline time release 12 hour *RETIN-A cream SLOW-K potassium cl controlled release 8meq RETROVIR zidovudine SOMA carisoprodol *REVIA naltrexone SOMA COMPOUND carisoprodol/asa REYATAZ atazanavir SOMA COMPOUND RHEUMATREX methotrexate W/CODEINE carisoprodol/asa/codeine RIDAURA auranofin *SONATA zaleplon SPECTAZOLE econazole RIFADIN rifampin capsules STELAZINE trifluoperazine RISPERDAL risperidone STRATTERA atomoxetine RITALIN methylphenidate *STRIBILD elvitegravir/cobicistat/emtricitabine/tenofovir RITALIN SR methylphenidate extended release SUBOXONE buprenorphine/naloxone ROBAXIN methocarbamol SUBUTEX buprenorphine ROBITUSSIN-AC codeine/guaifenesin syrup SUDAFED pseudoephedrine ROBITUSSIN-DAC pseudoephedrine/codeine/guaifenesin SULAR nisoldipine ROCALTROL calcitriol Page 8

Molina Healthcare of New Mexico Formulary for Centennial Care As of January 2014

*SULFATOL-M sulfacetamide/sulfur topical TOPROL XL metoprolol sustained release SULTRIN triple sulfa vaginal TORADOL ketorolac tablets SUMYCIN tetracycline *TRADJENTA linagliptin SUSTIVA efavirenz TRANXENE clorazepate dipotassium SYMBICORT budesonide/formoterol TRENTAL pentoxifylline SYMMETREL amantadine TRIAVIL amitriptyline/perphenazine SYNALAR acetonide topical soln, crm, oint TRIAZ benzoyl peroxide 5%, 10% TAGAMET cimetidine TRILAFON perphenazine TAMBOCOR flecainide TRILEPTAL oxcarbazepine TAMIFLU oseltamivir TRI-LEVLEN, TRIPHASIL levonorgestrel /estradiol TAPAZOLE methimazole TRIZIVIR abacavir/zidovudine/lamivudine TAVIST clemastine fumarate TRUE TEST glucose blood test strips TEGRETOL carbamazepine TRUSOPT DROPS dorzolamide ophthalmic *TEGRETOL XR carbamazepine extended release tab TRUVADA emtricitabine/tenofovir *TEMODAR temozolomide TUSSI-ORGANIDIN-DM dextromethorphan/guaifenesin TEMOVATE clobetasol topical cream, soln, gel, ointment TYLENOL acetaminophen TEN-K potassium cl controlled release 10meq TYLENOL #3, TYLENOL #4 acetaminophen /codeine TENEX guanfacine TYMPAGESIC benzocaine-phenylephrine-antipyrine TENORMIN atenolol *TRIANEX triamcinolone 0.5% ointment TENORETIC atenolol/chlorthalidone TYZEKA telbivudine TERAZOL 3 terconazole vaginal ULTRACET tramadol/acetaminophen TESSALON PERLES benzonatate ULTRAM tramadol *TEV-TROPIN somatropin ULTRAVATE halobetasol propionate THALITONE chlorthalidone UNIPHYL theophylline time release 24 hour THIOGUANINE thioguanine URECHOLINE bethanechol THORAZINE chlorpromazine URISED methenamine/belladonna TICLID ticlopidine URISPAS flavoxate TIGAN trimethobenzamide UROCIT-K potassium citrate TILTERMAZENE silver sulfadiazine VAGIFEM estradiol vaginal tablet 10mcg TIMOPTIC timolol ophthalmic VALCYTE valganciclovir tablets *TOBI tobramycin VALISONE topical TOBRADEX tobramycin/dexamethasone VALIUM diazepam TOBREX tobramycin ophthalmic VANTIN cefpodoxime *VALTREX valacyclovir TOFRANIL imipramine VASERETIC enalapril/hydrochlorothiazide TOLINASE tolazamide VASOTEC enalapril TOPAMAX topiramate tablets VENTOLIN HFA albuterol inhaler TOPICORT Page 9

Molina Healthcare of New Mexico Formulary for Centennial Care As of January 2014

VIBRAMYCIN doxycycline 25mg/5ml suspension YASMIN drospirenone/ethinyl estradiol VICODIN hydrocodone/apap (not all strengths covered) ZANAFLEX tizanidine tablets *VICTRELIS boceprevir ZANTAC ranitidine VIDEX didanosine ZARONTIN ethosuximide VIRACEPT nelfinavir ZAROXOLYN metolazone VIRAMUNE, VIRAMUNE XR nevirapine ZAZOLE terconazole vaginal VIREAD tenofovir 300mg tablet ZEBETA bisoprolol VIROPTIC trifluridine ophthalmic solution ZERIT stavudine VISTARIL hydroxyzine pamoate ZESTORETIC lisinopril/hydrochlorothiazide VITAMIN D ergocholecalciferol capsules 50,000 units ZESTRIL lisinopril *VIVELLE-DOT estradiol biweekly transdermal patch *ZETIA ezetimibe VOLTAREN diclofenac tablets ZIAC bisoprolol/hydrochlorothiazide VOLTAREN diclofenac ophthalmic solution ZIAGEN abacavir VOLTAREN TOPICAL diclofenac sodium gel 1% ZITHROMAX azithromycin VOSOL acetic acid ZOCOR simvastatin VOSOL HC OTIC acetic acid/hydrocortisone otic ZOFRAN ondansetron *VYTORIN ezetimibe/simvastatin ZOLOFT sertraline VYVANSE lisdexamfetamine ZONEGRAN zonisamide WELCHOL colesevelam tablets ZOVIRAX acyclovir tablets, capsules WELLBUTRIN bupropion *ZOVIRAX acyclovir topical ointment WELLBUTRIN SR bupropion sustained release ZYBAN bupropion sr WELLCOVORIN leucovorin tablets ZYLOPRIM allopurinol XALATAN latanoprost ophthalmic solution ZYPREXA olanzapine XANAX alprazolam ZYRTEC cetirizine XYLOCAINE VISCOUS lidocaine viscous

*Please refer to Prescription Drug Prior Authorization Criteria on our website www.Molinhealhcare.com Whenever a brand name drug has an available generic equivalent, only the generic product is covered. This Drug Formulary is current as of December 1dicloxacilli, 2013. Since updates and changes may be made by the P&T Committee on a monthly basis, please visit our website for the most current version: www.Molinahealthcare.com or contact Provider Services at 828-9594 in Albuquerque or 1-800-377-9594.

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