San Francisco Health Plan CWRAP Formulary Restrictions AS OF

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San Francisco Health Plan CWRAP Formulary Restrictions AS OF OCTOBER 2014 Trade Name Ingredient Dosage Dosage Age Limit Gender Quantity Max Quantity Coverage Message Form Limit Days PRENATAL ASCORBIC ACID; ASCORBYL PALMITATE; 100MG; 0; 0; TABS None None 30 30 BETA CAROTENE; CALCIUM; 263MG; CHOLECALCIFEROL; CYANOCOBALAMIN; 400UNIT; FERROUS FUMARATE; FOLIC ACID; 4MCG; NIACINAMIDE; PYRIDOXINE 27MG; HYDROCHLORIDE; RIBOFLAVIN; THIAMINE 0.8MG; MONONITRATE; TOCOPHERYL ACET,DL- 18MG; ALPHA; VITAMIN A ACETATE (RETINYL 2.6MG; ACETATE); ZINC OXIDE 1.7MG; 1.5MG; 11UNIT; 4000UNIT; THERANATAL COMPLETE ASCORBIC ACID; BETA CAROTENE; BIOTIN; 100MG;25MG MISC None None 30 30 CALCIUM CARBONATE; CALCIUM 3000UNIT; PANTOTHENATE; CHOLECALCIFEROL; 30MCG; CHOLINE BITARTRATE; CHROMIUM AMINO 140MG; ACID CHELATE; CUPRIC OXIDE; 6MG; CYANOCOBALAMIN; D-ALPHA-TOCOPHERYL 3000UNIT; ACID SUCCINATE; DOCOSAHEXAENOIC 200MG; ACID (DHA); FERROUS FUMARATE; FOLIC 30MCG; ACID; MAGNESIUM OXIDE; NIACINAMIDE; 2MG; POTASSIUM IODIDE; PYRIDOXINE 12MCG; HYDROCHLORIDE; RIBOFLAVIN; SELENIUM 30UNIT; AMINO ACID CHELATE; SODIUM 300MG; MOLYBDATE; THIAMINE MONONITRATE; 27MG; 1MG; ZINC GLUCONATE 50MG; 20MG; 220MCG; 30MG; 1.7MG; 70MCG; 50MCG; 1.5MG; 15MG

Page 1 of 13 San Francisco Health Plan CWRAP Formulary Restrictions AS OF OCTOBER 2014 Trade Name Ingredient Dosage Dosage Age Limit Gender Quantity Max Quantity Coverage Message Form Limit Days THERANATAL CORE ASCORBIC ACID; BETA CAROTENE; BIOTIN; 100MG; TABS None None 30 30 NUTRITION CALCIUM CARBONATE; CALCIUM 3000UNIT; PANTOTHENATE; CHOLECALCIFEROL; 30MCG; CHOLINE BITARTRATE; CHROMIUM AMINO 140MG; ACID CHELATE; CUPRIC OXIDE; 6MG; CYANOCOBALAMIN; D-ALPHA-TOCOPHERYL 2000UNIT; ACID SUCCINATE; FERROUS FUMARATE; 50MG; FOLIC ACID; MAGNESIUM OXIDE; 30MCG; NIACINAMIDE; POTASSIUM IODIDE; 2MG; PYRIDOXINE HYDROCHLORIDE; 12MCG; RIBOFLAVIN; SELENIUM AMINO ACID 30UNIT; CHELATE; SODIUM MOLYBDATE; THIAMINE 27MG; 1MG; MONONITRATE; ZINC GLUCONATE 50MG; 20MG; 220MCG; 12MG; 1.7MG; 70MCG; 50MCG; 1.5MG; 15MG

Page 2 of 13 San Francisco Health Plan CWRAP Formulary Restrictions AS OF OCTOBER 2014 Trade Name Ingredient Dosage Dosage Age Limit Gender Quantity Max Quantity Coverage Message Form Limit Days CENTRUM SPECIALIST ASCORBIC ACID; BETA CAROTENE; BIOTIN; 90MG; 0; MISC None None 60 30 PRENATAL CALCIUM; CALCIUM PANTOTHENATE; 30MCG; CHLORIDE ION; CHOLECALCIFEROL; 250MG; CHROMIC CHLORIDE; CUPRIC SULFATE 6MG; 72MG; ANHYDROUS; CYANOCOBALAMIN; 400UNIT; DOCOSAHEXAENOIC ACID (DHA); 30MCG; EICOSAPENTAENOIC ACID (EPA); FERROUS 0.9MG; FUMARATE; FISH OIL; FOLIC ACID; 2.6MCG; MAGNESIUM; MANGANESE SULFATE; 200MG; NIACINAMIDE; PHOSPHORUS; 15MG; PHYTONADIONE; POTASSIUM; POTASSIUM 27MG; 0; IODIDE; PYRIDOXINE HYDROCHLORIDE; 800MCG; RIBOFLAVIN; SODIUM MOLYBDATE; 50MG; 2MG; SODIUM SELENATE; THIAMINE 18MG; MONONITRATE; TOCOPHERYL ACET,DL- 20MG; ALPHA; VITAMIN A ACETATE (RETINYL 30MCG; ACETATE); ZINC OXIDE 80MG; 220MCG; 1.9MG; 1.4MG; 50MCG; 30MCG; 1.4MG; 35UNIT; 2500UNIT; 11MG

Page 3 of 13 San Francisco Health Plan CWRAP Formulary Restrictions AS OF OCTOBER 2014 Trade Name Ingredient Dosage Dosage Age Limit Gender Quantity Max Quantity Coverage Message Form Limit Days ONE-A-DAY WOMENS ASCORBIC ACID; BETA CAROTENE; BIOTIN; 60MG; 0; MISC None None 60 30 PRENATAL CALCIUM; CALCIUM PANTOTHENATE; 300MCG; CHOLECALCIFEROL; CUPRIC OXIDE; 300MG; CYANOCOBALAMIN; DOCOSAHEXAENOIC 10MG; ACID (DHA); EICOSAPENTAENOIC ACID 400UNIT; (EPA); FERROUS FUMARATE; FOLIC ACID; 2MG; 8MCG; MAGNESIUM OXIDE; NIACINAMIDE; OMEGA- 200MG; 3 FATTY ACIDS; POTASSIUM IODIDE; 240MG; PYRIDOXINE HYDROCHLORIDE; 28MG; RIBOFLAVIN; THIAMINE MONONITRATE; 800MCG; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A 50MG; ACETATE (RETINYL ACETATE); ZINC OXIDE 20MG; 440MG; 150MCG; 2.5MG; 2MG; 1.7MG; 30UNIT; 4000UNIT; 15MG

CENTRUM KIDS COMPLETE ASCORBIC ACID; BETA CAROTENE; BIOTIN; 60MG; 0; CHEW Max Age: 12Y None CALCIUM; CALCIUM PANTOTHENATE; 45MCG; CHROMIC CHLORIDE; CUPRIC OXIDE; 108MG; CYANOCOBALAMIN; ERGOCALCIFEROL; 10MG; FOLIC ACID; IRON CARBONYL; 20MCG; MAGNESIUM; MANGANESE SULFATE; 2MG; 6MCG; NIACINAMIDE; PHOSPHORUS; 400UNIT; PHYTONADIONE; POTASSIUM IODIDE; 400MCG; PYRIDOXINE HYDROCHLORIDE; 18MG; RIBOFLAVIN; SODIUM MOLYBDATE; 40MG; 1MG; THIAMINE MONONITRATE; TOCOPHERYL 20MG; ACET,DL-ALPHA; VITAMIN A ACETATE 50MG; (RETINYL ACETATE); ZINC OXIDE 10MCG; 150MCG; 2MG; 1.7MG; 20MCG; 1.5MG; 30UNIT; 3500UNIT; 15MG

Page 4 of 13 San Francisco Health Plan CWRAP Formulary Restrictions AS OF OCTOBER 2014 Trade Name Ingredient Dosage Dosage Age Limit Gender Quantity Max Quantity Coverage Message Form Limit Days NUTRICION PORVIDA ASCORBIC ACID; BETA CAROTENE; BIOTIN; 40MG; TABS None None 30 30 CALCIUM; CYANOCOBALAMIN; FOLIC ACID; 3000UNIT; IRON; MAGNESIUM OXIDE; NIACINAMIDE; 100MCG; PANTOTHENIC ACID; POTASSIUM IODIDE; 300MG; PYRIDOXINE HYDROCHLORIDE; 2MCG; RIBOFLAVIN; THIAMINE MONONITRATE; 250MCG; VITAMIN E; VITAMIN K 14MG; 150MG; 6MG; 3MG; 50MCG; 3MG; 3MG; 3MG; 5UNIT; 30MCG PERRY PRENATAL ASCORBIC ACID; BETA CAROTENE; 50MG; 0; CAPS None None 30 30 CALCIUM CARBONATE; CALCIUM 100MG; PANTOTHENATE; CHOLECALCIFEROL; 5MG; CUPRIC OXIDE; CYANOCOBALAMIN; 200UNIT; FERROUS FUMARATE; FOLIC ACID; 1MG; 4MCG; MAGNESIUM OXIDE; NIACINAMIDE; 13.5MG; POTASSIUM IODIDE; PYRIDOXINE 400MCG; HYDROCHLORIDE; RIBOFLAVIN; THIAMINE 50MG; MONONITRATE; TOCOPHERYL ACET,DL- 10MG; ALPHA; VITAMIN A ACETATE (RETINYL 75MCG; ACETATE); ZINC CITRATE 2MG; 1MG; 1.5MG; 15UNIT; 3000UNIT; 7.5MG PRENATAL 19 ASCORBIC ACID; BETA CAROTENE; 100MG; CHEW None Female 30 30 CALCIUM CARBONATE; CALCIUM 1000UNIT; PANTOTHENATE; CYANOCOBALAMIN; 200MG; DOCUSATE SODIUM; FERROUS FUMARATE; 7MG; FOLIC ACID; NIACINAMIDE; PYRIDOXINE 12MCG; HYDROCHLORIDE; RIBOFLAVIN; THIAMINE 25MG; MONONITRATE; VITAMIN D; VITAMIN E 29MG; 1MG; ACETATE (D-ALPHA); ZINC OXIDE 6MG; 20MG; 3MG; 3MG; 400UNIT; 30UNIT; 20MG

Page 5 of 13 San Francisco Health Plan CWRAP Formulary Restrictions AS OF OCTOBER 2014 Trade Name Ingredient Dosage Dosage Age Limit Gender Quantity Max Quantity Coverage Message Form Limit Days PRENATAL MULTIVITAMIN ASCORBIC ACID; BETA CAROTENE; 120MG; 0; MISC None Female 30 30 + DHA CALCIUM CARBONATE; CHOLECALCIFEROL; 200MG; CYANOCOBALAMIN; DOCOSAHEXAENOIC 400UNIT; ACID (DHA) (MICROALGAE); FERROUS 8MCG; FUMARATE; FOLIC ACID; NIACINAMIDE; 200MG; PYRIDOXINE HYDROCHLORIDE; 28MG; RIBOFLAVIN; THIAMINE MONONITRATE; 800MCG; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A; 20MG; ZINC OXIDE 2.6MG; 1.7MG; 1.8MG; 30UNIT; 4000UNIT; STUART PRENATAL + DHA ASCORBIC ACID; BETA CAROTENE; 120MG;25MG 0; MISC None None 60 30 CALCIUM CARBONATE; CHOLECALCIFEROL; 200MG; CYANOCOBALAMIN; DOCOSAHEXAENOIC 400UNIT; ACID (DHA); EICOSAPENTAENOIC ACID 8MCG; (EPA); FERROUS FUMARATE; FOLIC ACID; 262MG; NIACINAMIDE; OMEGA-3 FATTY ACIDS; 98MG; PYRIDOXINE HYDROCHLORIDE; 28MG; RIBOFLAVIN; THIAMINE MONONITRATE; 800MCG; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A; 20MG; ZINC OXIDE 656MG; 2.6MG; 1.7MG; 1.8MG; 30UNIT; 4000UNIT; 25MG

Page 6 of 13 San Francisco Health Plan CWRAP Formulary Restrictions AS OF OCTOBER 2014 Trade Name Ingredient Dosage Dosage Age Limit Gender Quantity Max Quantity Coverage Message Form Limit Days PRENATAL MULTI +DHA ASCORBIC ACID; BETA CAROTENE; 100MG; 0; CAPS None None 60 30 CALCIUM CARBONATE; CHOLECALCIFEROL; 150MG; CYANOCOBALAMIN; DOCOSAHEXAENOIC 400UNIT; ACID (DHA); EICOSAPENTAENOIC ACID 4MCG; (EPA); FERROUS FUMARATE; FOLIC ACID; 200MG; NIACINAMIDE; OMEGA-3 FATTY ACIDS; 28MG; PYRIDOXINE HYDROCHLORIDE; 27MG; RIBOFLAVIN; THIAMINE MONONITRATE; 800MCG; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A; 18MG; ZINC OXIDE 228MG; 2.6MG; 1.7MG; 1.5MG; 11UNIT; 4000UNIT; PRENATAL ASCORBIC ACID; BETA CAROTENE; 120MG;25MG TABS None None 30 30 CALCIUM CARBONATE; CHOLECALCIFEROL; 4000UNIT; CYANOCOBALAMIN; FERROUS FUMARATE; 200MG; FOLIC ACID; NIACINAMIDE; PYRIDOXINE 400UNIT; HYDROCHLORIDE; RIBOFLAVIN; THIAMINE 8MCG; MONONITRATE; TOCOPHERYL ACET,DL- 28MG; ALPHA; ZINC OXIDE 800MCG; 20MG; 2.6MG; 1.7MG; 1.8MG; 30UNIT; 25MG

Page 7 of 13 San Francisco Health Plan CWRAP Formulary Restrictions AS OF OCTOBER 2014 Trade Name Ingredient Dosage Dosage Age Limit Gender Quantity Max Quantity Coverage Message Form Limit Days OBTREX DHA ASCORBIC ACID; BETA CAROTENE; 120MG; MISC None None 60 30 CHOLECALCIFEROL; CYANOCOBALAMIN; 2700UNIT; DOCOSAHEXAENOIC ACID (DHA); 400UNIT; DOCUSATE SODIUM; EICOSAPENTAENOIC 12MCG; ACID (EPA); FOLIC ACID; IRON CARBONYL; 250MG; MAGNESIUM OXIDE; NIACINAMIDE; 50MG; PYRIDOXINE HYDROCHLORIDE; 100MG; RIBOFLAVIN; SODIUM SELENATE; 1MG; 29MG; THIAMINE HYDROCHLORIDE; TOCOPHERYL 30MG; ACET,DL-ALPHA; ZINC OXIDE 20MG; 40MG; 3.4MG; 65MCG; 3MG; 18UNIT; 25MG PRENATAL FORMULA A- ASCORBIC ACID; BIOFLAVONOIDS (VITAMIN 33.333MG; TABS None None 30 30 FREE P SUBSTANCES); BIOTIN; CALCIUM 0; 10MCG; 0; ASCORBATE ANHYDROUS; CALCIUM 333.333MG; CARBONATE; CALCIUM PANTOTHENATE; 5MG; 0.1MG; COPPER GLUCONATE; CYANOCOBALAMIN; 2MCG; ERGOCALCIFEROL; FERROUS FUMARATE; 133.333UNIT FOLIC ACID; HESPERIDIN; MAGNESIUM ; 9MG; OXIDE; MANGANESE GLUCONATE; 266.667MCG; NIACINAMIDE; PYRIDOXINE 0; HYDROCHLORIDE; RIBOFLAVIN; THIAMINE 33.333MG; HYDROCHLORIDE; TOCOPHERYL ACID 0.1MG; SUCCINATE,DL-ALPHA; ZINC CITRATE 10MG; 1MG; 2MG; 2MG; 10UNIT; 7.5MG

Page 8 of 13 San Francisco Health Plan CWRAP Formulary Restrictions AS OF OCTOBER 2014 Trade Name Ingredient Dosage Dosage Age Limit Gender Quantity Max Quantity Coverage Message Form Limit Days PRENATAL 1 ASCORBIC ACID; BIOTIN; CALCIUM 60MG; CAPS None None 30 30 PANTOTHENATE; CHOLECALCIFEROL; 300MCG; CYANOCOBALAMIN; FERROUS FUMARATE; 10MG; FOLIC ACID; IRON; NIACINAMIDE; 400UNIT; PYRIDOXINE HYDROCHLORIDE; 8MCG; 0; RIBOFLAVIN; THIAMINE MONONITRATE; 975MCG; VITAMIN E ACETATE (D-ALPHA); ZINC 30MG; OXIDE 20MG; 25MG; 1.7MG; 1.5MG; 21UNIT; EZFE FORTE ASCORBIC ACID; BIOTIN; CALCIUM 45MG;7.5MG CAPS None None 30 30 PANTOTHENATE; CYANOCOBALAMIN; FOLIC 150MCG; ACID; NIACINAMIDE; POLYSACCHARIDE 10MG; IRON COMPLEX; PYRIDOXINE 1000MCG; HYDROCHLORIDE; RIBOFLAVIN; THIAMINE 1000MCG; MONONITRATE 20MG; 155MG; 25MG; 1.7MG; 1.5MG RIGHT STEP PRENATAL ASCORBIC ACID; CALCIUM SULFATE; 50MG; TABS None None 30 30 CHOLECALCIFEROL; CUPRIC SULFATE 250MG; ANHYDROUS; CYANOCOBALAMIN; FERROUS 400UNIT; FUMARATE; FOLIC ACID; IODINE; 0.15MG; MAGNESIUM OXIDE; MANGANESE SULFATE; 2MCG; NIACINAMIDE; POTASSIUM SULFATE; 27MG; PYRIDOXINE HYDROCHLORIDE; 0.8MG; RIBOFLAVIN; THIAMINE MONONITRATE; 0.01MG; VITAMIN A PALMITATE (RETINYL 0.15MG; PALMITATE); ZINC 0.05MG; 10MG; 0.835MG; 1MG; 2MG; 3MG; 4000UNIT; 0.085MG

Page 9 of 13 San Francisco Health Plan CWRAP Formulary Restrictions AS OF OCTOBER 2014 Trade Name Ingredient Dosage Dosage Age Limit Gender Quantity Max Quantity Coverage Message Form Limit Days CLASSIC PRENATAL ASCORBIC ACID; CALCIUM SULFATE; 60MG; TABS None None 30 30 CHOLECALCIFEROL; CYANOCOBALAMIN; 200MG; FERROUS FUMARATE; FOLIC ACID; 400UNIT; MAGNESIUM OXIDE; NIACINAMIDE; 8MCG; POTASSIUM IODIDE; PYRIDOXINE 28MG; HYDROCHLORIDE; RIBOFLAVIN; THIAMINE 800MCG; MONONITRATE; TOCOPHERYL ACET,DL- 100MG; ALPHA; VITAMIN A ACETATE (RETINYL 20MG; ACETATE) 150MCG; 4MG; 2MG; 1.7MG; 30UNIT; PRENATAL ASCORBIC ACID; CALCIUM SULFATE; 100MG;8000UNIT TABS None None 30 30 CHOLECALCIFEROL; CYANOCOBALAMIN; 200MG; FOLIC ACID; IRON; NIACINAMIDE; 400UNIT; PYRIDOXINE HYDROCHLORIDE; 4MCG; RIBOFLAVIN; THIAMINE MONONITRATE; 0.8MG; TOCOPHERYL ACET,DL-ALPHA; VITAMIN A; 27MG; ZINC OXIDE 18MG; 2.6MG; 1.7MG; 1.84MG; 11UNIT; 4000UNIT; POLY-VI-SOL ASCORBIC ACID; CYANOCOBALAMIN; 35MG/ML;25MG SOLN Max Age: 12Y None NIACINAMIDE; PYRIDOXINE 2MCG/ML; HYDROCHLORIDE; RIBOFLAVIN; THIAMINE 8MG/ML; HYDROCHLORIDE; VITAMIN A 0.4MG/ML; (SYNTHETIC); VITAMIN D; VITAMIN E 0.6MG/ML; 0.5MG/ML; 1500UNIT/M L; 400UNIT/ML; 5UNIT/ML BENZOYL PEROXIDE BENZOYL PEROXIDE 10% GEL None None 60 30 BENZOYL PEROXIDE BENZOYL PEROXIDE 2.5% GEL None None 60 30

Page 10 of 13 San Francisco Health Plan CWRAP Formulary Restrictions AS OF OCTOBER 2014 Trade Name Ingredient Dosage Dosage Age Limit Gender Quantity Max Quantity Coverage Message Form Limit Days KPN PRENATAL BIOFLAVONOIDS (VITAMIN P SUBSTANCES); 21.67MG; TABS None None 30 30 CALCIUM; CALCIUM ASCORBATE 333.33MG; ANHYDROUS; CALCIUM PANTOTHENATE; 33.33MG; CHOLECALCIFEROL; COPPER GLUCONATE; 3.33MG; CYANOCOBALAMIN; FERROUS FUMARATE; 133.33UNIT; FOLIC ACID; MAGNESIUM OXIDE; 0.03MG; MANGANESE GLUCONATE; NIACIN; 2MCG; POTASSIUM GLUCONATE; POTASSIUM 33.33MG; IODIDE; PYRIDOXINE HYDROCHLORIDE; 0.13MG; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; 33.33MG; VITAMIN A; VITAMIN E; ZINC GLUCONATE 0.03MG; 10MG; 2MG; 0.01MG; 0.83MG; 2MG; 2MG; 2666.67UNIT ; 10UNIT; 0.03MG PRENATAL BIOTIN; CALCIUM; CALCIUM ASCORBATE 25MCG; TABS None None 30 30 ANHYDROUS; CALCIUM PANTOTHENATE; 50MG; COPPER GLUCONATE; CYANOCOBALAMIN; 25MG; ERGOCALCIFEROL; FERROUS FUMARATE; 2.5MG; FOLIC ACID; MAGNESIUM OXIDE; 0.5MG; MANGANESE GLUCONATE; NIACINAMIDE; 2.5MCG; PYRIDOXINE HYDROCHLORIDE; 100UNIT; RIBOFLAVIN; THIAMINE HYDROCHLORIDE; 6.75MG; TOCOPHERYL ACID SUCCINATE,DL-ALPHA; 200MCG; VITAMIN A PALMITATE (RETINYL 15MG; PALMITATE); ZINC CITRATE 0.5MG; 5MG; 0.75MG; 0.75MG; 0.5MG; 3.75UNIT; 500UNIT; 3.75MG SALONPAS CAMPHOR; MENTHOL; METHYL SALICYLATE 1.2%; 5.7%; PTCH Min Age: 18Y None 40 30 6.3%

CAPSAICIN HP CAPSAICIN 0.1% CREA None None 42.5 30 PROMETHAZINE/CODEINE CODEINE PHOSPHATE; PROMETHAZINE 10MG/5ML; SYRP Min Age: 2Y None HYDROCHLORIDE 6.25MG/5ML

CROMOLYN SODIUM CROMOLYN SODIUM 5.2MG/ACT AERS Min Age: 2Y None

Page 11 of 13 San Francisco Health Plan CWRAP Formulary Restrictions AS OF OCTOBER 2014 Trade Name Ingredient Dosage Dosage Age Limit Gender Quantity Max Quantity Coverage Message Form Limit Days VITAMIN B-12 CYANOCOBALAMIN 100MCG TABS None None 100 30 PROMETHAZINE-DM DEXTROMETHORPHAN HYDROBROMIDE; 15MG/5ML; SYRP Min Age: 2Y None PROMETHAZINE HYDROCHLORIDE 6.25MG/5ML

FISH OIL DOCOSAHEXAENOIC ACID (DHA); 0; 0; CAPS None None 120 30 EICOSAPENTAENOIC ACID (EPA); FISH OIL; 1000MG; OMEGA-3 FATTY ACIDS; VITAMIN E 300MG; 1UNIT ABREVA DOCOSANOL (N-DOCOSANOL) 10% CREA None None 2 30 ALLEGRA ALLERGY FEXOFENADINE HYDROCHLORIDE 30MG TABS None None 60 30 CHILDRENS FISH OIL FISH OIL 1000MG CAPS None None 120 30 HYDROCORTISONE HYDROCORTISONE 1% LOTN None None 240 30 HYDROCORTISONE HYDROCORTISONE 1% CREA None None 240 30 Only the OTC products will pay at point of sale. The RX/legend version is not a covered benefit. HYDROCORTISONE HYDROCORTISONE 1% OINT None None 240 30 Only OTC version is on the formulary. The RX version is not covered should be billed to Medicare Part D

HYDROCORTISONE HYDROCORTISONE 1% CREA None None 240 30 MAGNESIUM OXIDE MAGNESIUM OXIDE 400MG TABS None None 60 30 NICOTINE NICOTINE 7MG/24HR PT24 None None 30 30 Member allowed 6 fills per year NICOTINE NICOTINE 14MG/24HR PT24 None None 30 30 Member allowed 6 fills per year NICOTINE NICOTINE 21MG/24HR PT24 None None 30 30 Member allowed 6 fills per year NICOTINE POLACRILEX NICOTINE POLACRILEX 2MG GUM None None 360 30 NICOTINE POLACRILEX NICOTINE POLACRILEX 4MG GUM None None 360 30 Member allowed 6 fills per year PROMETHAZINE VC PHENYLEPHRINE HYDROCHLORIDE; 5MG/5ML; SYRP Min Age: 2Y None PROMETHAZINE HYDROCHLORIDE 6.25MG/5ML

POLYETHYLENE GLYCOL POLYETHYLENE GLYCOL 0 PACK None None 527 30 OTC version is on the 3350 formulary. RX version is not covered and should be billed to Medicare Part D or B

Page 12 of 13 San Francisco Health Plan CWRAP Formulary Restrictions AS OF OCTOBER 2014 Trade Name Ingredient Dosage Dosage Age Limit Gender Quantity Max Quantity Coverage Message Form Limit Days PEG 3350 POLYETHYLENE GLYCOL 0 POWD None None 527 30 OTC version is on the formulary. RX version is not covered and should be billed to Medicare Part D or B PROMETHAZINE HCL PROMETHAZINE HYDROCHLORIDE 25MG SUPP Min Age: 2Y None PROMETHAZINE HCL PROMETHAZINE HYDROCHLORIDE 12.5MG SUPP Min Age: 2Y None PROMETHAZINE HCL PROMETHAZINE HYDROCHLORIDE 6.25MG/5ML SYRP Min Age: 2Y None

PROMETHAZINE HCL PROMETHAZINE HYDROCHLORIDE 12.5MG TABS Min Age: 2Y None PROMETHAZINE HCL PROMETHAZINE HYDROCHLORIDE 25MG TABS Min Age: 2Y None PROMETHAZINE HCL PROMETHAZINE HYDROCHLORIDE 50MG TABS Min Age: 2Y None SALICYLIC ACID SALICYLIC ACID 17% SOLN None None 15 30 RA WART REMOVER SALICYLIC ACID 17% SOLN None None 14.8 30 DEEP SEA NASAL SPRAY SODIUM CHLORIDE 0.65% SOLN None None 90 30 NASACORT ALLERGY 24HR TRIAMCINOLONE ACETONIDE 55MCG/ACT AERO None None 16.9 30

UREA UREA (CARBAMIDE) 20% CREA None None 85 30

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