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Healthy Louisiana Common Preferred List (PDL) Effective October 1, 2015 Modified Date: 10/1/2017 Aetna Better Health of Louisiana LA Healthcare Connections Phone: 1-855-242-0802 Fax: 1-844-699-2889 Phone: 1-888-929-3790 Fax: 1-866-399-0929 www.aetnabetterhealth.com/louisiana/providers/pharmacy www.louisianahealthconnect.com/for-members/pharmacy-services/

Healthy Blue UnitedHealthcare Phone: 1-844-521-6942 Fax: 1-844-864-7865 Phone: 1-800-310-6826 Fax: 1-866-940-7328 https://providers.healthybluela.com www.uhccommunityplan.com/health-professionals/la/pharmacy.html

AmeriHealth Caritas Louisiana Phone: 1-800-684-5502 Fax: 1-855-452-9131 www.amerihealthcaritasla.com/pharmacy/index.aspx

The Common PDL was a collaboration between the five Bayou Health Plans. listed on the Common PDL will not require prior authorization or step-therapy by any of the Managed Care plans listed above. Safety edits at Point of Sale (POS) such as dosage limits, age limits, therapeutic duplication, quantity limits, early refill, etc. should still apply. *ADHD may have safety edits for recipients 6 years old and younger.

Therapeutic Class Generic Name Brand Name (for reference) Strength Route 1ST GEN & COMBINATIONS HCL/PROMETH HCL PHENERGAN VC 5-6.25MG/5 SYRUP ORAL 2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS / CLARITIN-D 24 HOUR 10MG-240MG TAB ER 24H ORAL 2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS LORATADINE/PSEUDOEPHEDRINE CLARITIN-D 12 HOUR 5 MG-120MG TAB ER 12H ORAL ANTIHISTAMINES - 1ST GENERATION CHLORPHENIRAMINE MALEATE ALLER-CHLOR, CHLOR-TRIMETON 2 MG/5 ML SYRUP ORAL ANTIHISTAMINES - 1ST GENERATION FUMARATE TAVIST-1 1.34 MG TABLET ORAL ANTIHISTAMINES - 1ST GENERATION HCL PERIACTIN 4 MG TABLET ORAL ANTIHISTAMINES - 1ST GENERATION CYPROHEPTADINE HCL PERIACTIN 2 MG/5 ML SYRUP ORAL ANTIHISTAMINES - 1ST GENERATION HCL 12.5MG/5ML LIQUID ORAL ANTIHISTAMINES - 1ST GENERATION DIPHENHYDRAMINE HCL BENADRYL 25, 50MG CAPSULE ORAL ANTIHISTAMINES - 1ST GENERATION DIPHENHYDRAMINE HCL BENADRYL ALLERGY 25 MG TABLET ORAL ANTIHISTAMINES - 1ST GENERATION DIPHENHYDRAMINE HCL BENADRYL 12.5MG/5ML SYRUP ORAL ANTIHISTAMINES - 1ST GENERATION HCL ATARAX 10, 25, 50MG TABLET ORAL ANTIHISTAMINES - 1ST GENERATION HYDROXYZINE HCL ATARAX 10 MG/5 ML SYRUP ORAL ANTIHISTAMINES - 1ST GENERATION HYDROXYZINE PAMOATE VISTARIL 25, 50, 100MG CAPSULE ORAL ANTIHISTAMINES - 1ST GENERATION HCL PHENERGAN 6.25MG/5ML SYRUP ORAL ANTIHISTAMINES - 2ND GENERATION LORATADINE CLARITIN 5 MG/5 ML SOLUTION ORAL ANTIHISTAMINES - 2ND GENERATION LORATADINE CLARITIN 10 MG TAB, TAB RAPDIS ORAL CARDIOVASCULAR ACE INHIBITOR/CALCIUM COMBINATION AMLODIPINE BESYLATE/BENAZEPRIL LOTREL 2.5-10, 5-10, 5-20, 10-20MG CAPSULE ORAL ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC BENAZEPRIL/HYDROCHLOROTHIAZIDE LOTENSIN HCT 5-6.25, 10-12.5, 20-12.5, 20- TABLET ORAL 25MG ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPOZIDE 25-15, 25-25, 50-15, 50-25MG TABLET ORAL ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC ENALAPRIL/HYDROCHLOROTHIAZIDE VASERETIC 5-12.5, 10MG-25MG TABLET ORAL ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC FOSINOPRIL/HYDROCHLOROTHIAZIDE MONOPRIL HCT 10-12.5, 20-12.5MG TABLET ORAL ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC LISINOPRIL/HYDROCHLOROTHIAZIDE ZESTORETIC 10-12.5, 20-12.5, 20-25MG TABLET ORAL VASOPRESSOR AGENTS HCL PROAMATINE 2.5, 5, 10MG TABLET ORAL ALPHA/BETA-ADRENERGIC BLOCKING AGENTS COREG 3.125, 6.25, 12.5, 25MG TABLET ORAL ALPHA/BETA-ADRENERGIC BLOCKING AGENTS HCL TRANDATE 100, 200, 300MG TABLET ORAL ALPHA-ADRENERGIC BLOCKING AGENTS MESYLATE CARDURA 1, 2, 4, 8MG TABLET ORAL ALPHA-ADRENERGIC BLOCKING AGENTS HCL MINIPRESS 1, 2, 5MG CAPSULE ORAL ALPHA-ADRENERGIC BLOCKING AGENTS HCL HYTRIN 1, 2, 5, 10MG CAPSULE ORAL ANGIOTENSIN ANTAG./THIAZIDE DIURETIC COMB LOSARTAN/HYDROCHLOROTHIAZIDE HYZAAR 50-12.5, 100-12.5, 100-25MG TABLET ORAL ANTIARRHYTHMICS HCL CORDARONE, PACERONE 200 MG TABLET ORAL ANTIARRHYTHMICS DISOPYRAMIDE PHOSPHATE NORPACE 150 MG CAPSULE ORAL ANTIARRHYTHMICS FLECAINIDE ACETATE TAMBOCOR 50, 100, 150MG TABLET ORAL ANTIARRHYTHMICS MEXILETINE HCL MEXITIL 150, 200, 250MG CAPSULE ORAL ANTIARRHYTHMICS HCL RYTHMOL 150, 225, 300MG TABLET ORAL ANTIARRHYTHMICS GLUCONATE QUINAGLUTE 324 MG TABLET ER ORAL ANTIARRHYTHMICS QUINIDINE SULFATE QUINIDINE SULFATE 200, 300MG TABLET ORAL

Page 1 of 9 Therapeutic Class Generic Name Brand Name (for reference) Strength Dosage Form Route CARDIOVASCULAR (Cont.) ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS ATORVASTATIN CALCIUM LIPITOR 40, 80MG TABLET ORAL ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS LOVASTATIN MEVACOR 10, 20, 40MG TABLET ORAL ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS PRAVASTATIN SODIUM PRAVACHOL 10, 20, 40, 80MG TABLET ORAL ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS SIMVASTATIN ZOCOR 5, 10, 20, 40MG TABLET ORAL ANTIHYPERTENSIVES, ACE INHIBITORS BENAZEPRIL HCL LOTENSIN 5, 10, 20, 40 MG TABLET ORAL ANTIHYPERTENSIVES, ACE INHIBITORS CAPTOPRIL CAPOTEN 12.5, 25, 50, 100 MG TABLET ORAL ANTIHYPERTENSIVES, ACE INHIBITORS ENALAPRIL MALEATE VASOTEC 2.5, 5, 10, 20MG TABLET ORAL ANTIHYPERTENSIVES, ACE INHIBITORS FOSINOPRIL SODIUM MONOPRIL 10, 20, 40MG TABLET ORAL ANTIHYPERTENSIVES, ACE INHIBITORS LISINOPRIL ZESTRIL, PRINIVIL 2.5, 5, 10, 20, 30, 40 MG TABLET ORAL ANTIHYPERTENSIVES, ACE INHIBITORS QUINAPRIL HCL ACCUPRIL 5, 10, 20, 40MG TABLET ORAL ANTIHYPERTENSIVES, ACE INHIBITORS RAMIPRIL ALTACE 1.25, 2.5, 5, 10MG CAPSULE ORAL ANTIHYPERTENSIVES, ACE INHIBITORS TRANDOLAPRIL MAVIK 1, 2, 4MG TABLET ORAL ANTIHYPERTENSIVES, ANGIOTENSIN IRBESARTAN AVAPRO 75, 150, 300MG TABLET ORAL ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST LOSARTAN POTASSIUM COZAAR 25, 50, 100 MG TABLET ORAL ANTIHYPERTENSIVES, HCL CATAPRES 0.1, 0.2, 0.3MG TABLET ORAL ANTIHYPERTENSIVES, SYMPATHOLYTIC HCL TENEX 1, 2MG TABLET ORAL ANTIHYPERTENSIVES, SYMPATHOLYTIC ALDOMET 250 , 500MG TABLET ORAL ANTIHYPERTENSIVES, SYMPATHOLYTIC RESERPINE 0.1 , 0.25MG TABLET ORAL ANTIHYPERTENSIVES, VASODILATORS HYDRALAZINE HCL APRESOLINE 10, 25, 50, 100MG TABLET ORAL ANTIHYPERTENSIVES, VASODILATORS LONITEN 2.5, 10 MG TABLET ORAL BETA-ADRENERGIC BLOCKING AGENTS HCL SECTRAL 200, 400MG CAPSULE ORAL BETA-ADRENERGIC BLOCKING AGENTS TENORMIN 25, 50, 100 MG TABLET ORAL BETA-ADRENERGIC BLOCKING AGENTS FUMARATE ZEBETA 5, 10 MG TABLET ORAL BETA-ADRENERGIC BLOCKING AGENTS SUCCINATE TOPROL XL 25, 50, 100, 200MG TAB ER 24H ORAL BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL TARTRATE LOPRESSOR 25, 50, 100 MG TABLET ORAL BETA-ADRENERGIC BLOCKING AGENTS PINDOLOL 5, 10MG TABLET ORAL BETA-ADRENERGIC BLOCKING AGENTS HCL INDERAL 10, 20, 40, 60, 80MG TABLET ORAL BETA-ADRENERGIC BLOCKING AGENTS PROPRANOLOL HCL INDERAL 20 MG/5 ML, 40 MG/5 ML SOLUTION ORAL BETA-ADRENERGIC BLOCKING AGENTS HCL BETAPACE AF 80, 120, 160, 240MG TABLET ORAL BETA-ADRENERGIC BLOCKING AGENTS MALEATE TIMOLOL MALEATE 5, 10, 20MG TABLET ORAL BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & RELATED ATENOLOL/CHLORTHALIDONE TENORETIC 50 50-25, 100-25MG TABLET ORAL BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & RELATED BISOPROLOL FUMARATE/HCTZ ZIAC 5-6.25, 10-6.25MG TABLET ORAL BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & RELATED METOPROLOL/HYDROCHLOROTHIAZIDE LOPRESSOR HCT 50-25, 100-25MG TABLET ORAL BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & RELATED PROPRANOLOL/HYDROCHLOROTHIAZID INDERIDE 40-25, 80-25MG TABLET ORAL CALCIUM CHANNEL BLOCKING AGENTS AMLODIPINE BESYLATE NORVASC 2.5, 5, 10MG TABLET ORAL CALCIUM CHANNEL BLOCKING AGENTS DILTIAZEM HCL CARDIZEM 30, 60, 90, 120MG TABLET ORAL CALCIUM CHANNEL BLOCKING AGENTS DILTIAZEM HCL CARDIZEM CD 120, 180, 240MG CAP ER DEG ORAL CALCIUM CHANNEL BLOCKING AGENTS DILTIAZEM HCL CARDIZEM LA, CARTIA XT 120, 180, 240, 300MG CAP ER 24H ORAL CALCIUM CHANNEL BLOCKING AGENTS DILTIAZEM HCL CARDIZEM SR 12 HR 60, 90, 120MG CAP ER 12H ORAL CALCIUM CHANNEL BLOCKING AGENTS DILTIAZEM HCL TAZTIA XT, TIAZAC 120, 180, 240, 300, 360, 420MG CAPSULE ER ORAL

CALCIUM CHANNEL BLOCKING AGENTS FELODIPINE FELODIPINE ER 2.5, 5, 10MG TAB ER 24H ORAL CALCIUM CHANNEL BLOCKING AGENTS NICARDIPINE HCL CARDENE 20, 30MG CAPSULE ORAL CALCIUM CHANNEL BLOCKING AGENTS NIFEDIPINE PROCARDIA 10, 20MG CAPSULE ORAL CALCIUM CHANNEL BLOCKING AGENTS NIFEDIPINE XL NIFEDICAL XL, PROCARDIA XL, ADALAT CC 30, 60, 90MG TABLET ER ORAL

CALCIUM CHANNEL BLOCKING AGENTS VERAPAMIL HCL CALAN 40, 80, 120MG TABLET ORAL CALCIUM CHANNEL BLOCKING AGENTS VERAPAMIL HCL CALAN SR 120, 180, 240MG TABLET ER ORAL CALCIUM CHANNEL BLOCKING AGENTS VERAPAMIL HCL VERELAN 120, 180, 240, 360MG CAP24H PEL ORAL DIGITALIS GLYCOSIDES DIGOXIN LANOXIN 125, 250MCG TABLET ORAL DIGITALIS GLYCOSIDES DIGOXIN DIGOXIN 0.25MG/5ML SOLUTION ORAL LIPOTROPICS FENOFIBRATE LOFIBRA 54, 160 MG TABLET ORAL LIPOTROPICS FENOFIBRATE,MICRONIZED LOFIBRA 67, 134, 200MG CAPSULE ORAL LIPOTROPICS GEMFIBROZIL LOPID 600 MG TABLET ORAL

Page 2 of 9 Therapeutic Class Generic Name Brand Name (for reference) Strength Dosage Form Route CARDIOVASCULAR (Cont.) LOOP DIURETICS BUMETANIDE BUMEX 0.5, 1, 2MG TABLET ORAL LOOP DIURETICS FUROSEMIDE LASIX 20, 40, 80MG TABLET ORAL LOOP DIURETICS FUROSEMIDE LASIX 10 MG/1 ML, 40 MG/5 ML SOLUTION ORAL LOOP DIURETICS TORSEMIDE DEMADEX 5, 10, 20, 100MG TABLET ORAL POTASSIUM REPLACEMENT POTASSIUM BICARBONATE/CIT AC K-LYTE 25 MEQ TABLET EFF ORAL POTASSIUM REPLACEMENT POTASSIUM CHLORIDE KLOR-CON 8, 10MEQ TABLET ER ORAL POTASSIUM REPLACEMENT POTASSIUM CHLORIDE K-SOL 20MEQ/15ML, 40MEQ/15ML LIQUID ORAL POTASSIUM REPLACEMENT POTASSIUM CHLORIDE K-LOR 20, 25MEQ PACKET ORAL POTASSIUM REPLACEMENT POTASSIUM CHLORIDE MICRO-K 10 MEQ CAPSULE ER ORAL POTASSIUM REPLACEMENT POTASSIUM CHLORIDE K-DUR 10, 20MEQ TAB ER PRT ORAL POTASSIUM SPARING DIURETICS AMILORIDE HCL MIDAMOR 5 MG TABLET ORAL POTASSIUM SPARING DIURETICS ALDACTONE 25, 50, 100MG TABLET ORAL POTASSIUM SPARING DIURETICS IN COMBINATION AMILORIDE/HYDROCHLOROTHIAZIDE MODURETIC 5MG-50MG TABLET ORAL POTASSIUM SPARING DIURETICS IN COMBINATION SPIRONOLACT/HYDROCHLOROTHIAZID ALDACTAZIDE 25 MG-25MG TABLET ORAL POTASSIUM SPARING DIURETICS IN COMBINATION TRIAMTERENE/HYDROCHLOROTHIAZID TRIAMTERENE/HYDROCHLOROTHIAZID 37.5-25, 50-25MG CAPSULE ORAL POTASSIUM SPARING DIURETICS IN COMBINATION TRIAMTERENE/HYDROCHLOROTHIAZID MAXZIDE-25 MG 37.5-25, 75-50MG TABLET ORAL THIAZIDE AND RELATED DIURETICS CHLOROTHIAZIDE DIURIL 250, 500MG TABLET ORAL THIAZIDE AND RELATED DIURETICS CHLORTHALIDONE CHLORTHALIDONE 25, 50MG TABLET ORAL THIAZIDE AND RELATED DIURETICS HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE ORAL THIAZIDE AND RELATED DIURETICS HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 25, 50MG TABLET ORAL THIAZIDE AND RELATED DIURETICS INDAPAMIDE LOZOL 1.25, 2.5MG TABLET ORAL THIAZIDE AND RELATED DIURETICS METOLAZONE ZAROXOLYN 2.5, 5, 10MG TABLET ORAL VASODILATORS,CORONARY ISOSORBIDE DINITRATE ISORDIL 5, 10, 20, 30MG TABLET ORAL VASODILATORS,CORONARY ISOSORBIDE DINITRATE ISORDIL 40 MG TABLET ER ORAL VASODILATORS,CORONARY ISOSORBIDE MONONITRATE ISMO 10, 20 MG TABLET ORAL VASODILATORS,CORONARY ISOSORBIDE MONONITRATE IMDUR 30, 60, 120MG TAB ER 24H ORAL VASODILATORS,CORONARY NITROGLYCERIN NITROGLYCERIN PATCH 0.1, 0.2, 0.4, 0.6MG/HR PATCH TD24 TRANSDERM. VASODILATORS,CORONARY NITROGLYCERIN NITRO-BID 2% OINT. (G) TRANSDERM. VASODILATORS,CORONARY NITROGLYCERIN NITROSTAT 0.3, 0.4, 0.6MG TAB SUBL SUBLINGUAL BEHAVIORAL HEALTH , AROMATIC, NON-CATECHOLAMINE DEXTROAMPHETAMINE SULFATE DEXEDRINE 5, 10, 15MG CAPSULE ER ORAL ADRENERGICS, AROMATIC, NON-CATECHOLAMINE *DEXTROAMPHETAMINE/ ADDERALL 5, 7.5, 10, 12.5, 15, 20, 30 MG TABLET ORAL

ADRENERGICS, AROMATIC, NON-CATECHOLAMINE *DEXTROAMPHETAMINE/AMPHETAMINE ADDERALL XR 5, 10, 15, 20, 25, 30MG CAP ER 24H ORAL

ALPHA-2 RECEPTOR ANTAGONIST REMERON 7.5, 15, 30, 45MG TABLET ORAL ANTI- DRUGS XANAX 0.25, 0.5, 1, 2MG TABLET ORAL ANTI-ANXIETY DRUGS HCL BUSPAR 5, 7.5, 10, 15, 30MG TABLET ORAL ANTI-ANXIETY DRUGS HCL LIBRIUM 5, 10, 25MG CAPSULE ORAL ANTI-ANXIETY DRUGS DIPOTASSIUM TRANXENE 3.75, 7.5, 15MG TABLET ORAL ANTI-ANXIETY DRUGS VALIUM 2, 5, 10 MG TABLET ORAL ANTI-ANXIETY DRUGS DIAZEPAM DIAZEPAM 5 MG/5 ML SOLUTION ORAL ANTI-ANXIETY DRUGS ATIVAN 0.5, 1, 2MG TABLET ORAL ANTI-ANXIETY DRUGS SERAX 10, 15, 30MG CAPSULE ORAL , & ANTAGONISTS SUCCINATE LOXITANE 5, 10, 25, 50MG CAPSULE ORAL ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG CLOZARIL 25, 50, 100, 200MG TABLET ORAL ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG ZYPREXA 2.5, 5, 7.5, 10, 15, 20MG TABLET ORAL ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG FUMARATE SEROQUEL 25, 50, 100, 200, 300, 400MG TABLET ORAL ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG RISPERDAL 0.25, 0.5, 1, 2, 3, 4MG TABLET ORAL ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG RISPERIDONE RISPERDAL 1 MG/ML SOLUTION ORAL ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG HCL GEODON 20, 40, 60, 80MG CAPSULE ORAL ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOTHIXENE NAVANE 1, 2, 5, 10MG CAPSULE ORAL ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES HALDOL 0.5, 1, 2, 5, 10, 20MG TABLET ORAL ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES HALOPERIDOL DECANOATE 50, 100 MG/ML VIAL INTRAMUSC. ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES HALOPERIDOL LACTATE HALDOL 2 MG/ML ORAL CONC ORAL

Page 3 of 9 Therapeutic Class Generic Name Brand Name (for reference) Strength Dosage Form Route BEHAVIORAL HEALTH (Cont.) ANTI-PSYCHOTICS, HCL THORAZINE 10, 25, 50, 100, 200MG TABLET ORAL ANTI-PSYCHOTICS,PHENOTHIAZINES DECANOATE FLUPHENAZINE DECANOATE 25 MG/ML VIAL INJECTION ANTI-PSYCHOTICS,PHENOTHIAZINES FLUPHENAZINE HCL PROLIXIN 1, 2.5, 5, 10 MG TABLET ORAL ANTI-PSYCHOTICS,PHENOTHIAZINES TRILAFON 2, 4, 8, 16MG TABLET ORAL ANTI-PSYCHOTICS,PHENOTHIAZINES HCL MELLARIL 10, 25, 50, 100MG TABLET ORAL ANTI-PSYCHOTICS,PHENOTHIAZINES HCL STELAZINE 1, 2, 5, 10MG TABLET ORAL BIPOLAR DISORDER DRUGS CARBONATE ESKALITH 150, 300, 600MG CAPSULE ORAL BIPOLAR DISORDER DRUGS LITHIUM CARBONATE LITHOBID 300 MG TABLET ORAL BIPOLAR DISORDER DRUGS LITHIUM CARBONATE ESKALITH CR 300, 450MG TABLET ER ORAL MAOIS - NON-SELECTIVE & IRREVERSIBLE SULFATE NARDIL 15 MG TABLET ORAL MAOIS - NON-SELECTIVE & IRREVERSIBLE TRANYLCYPROMINE SULFATE PARNATE 10 MG TABLET ORAL SELECTIVE SEROTONIN INHIBITOR (SSRIS) HYDROBROMIDE CELEXA 10, 20, 40MG TABLET ORAL SELECTIVE SEROTONIN (SSRIS) CITALOPRAM HYDROBROMIDE CELEXA 10 MG/5 ML SOLUTION ORAL SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) HCL PROZAC 20 MG/5 ML SOLUTION ORAL SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) FLUOXETINE HCL PROZAC 10, 20, 40MG CAPSULE ORAL SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) MALEATE LUVOX 25, 50, 100MG TABLET ORAL SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) HCL PAXIL 10, 20, 30, 40MG TABLET ORAL SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) HCL ZOLOFT 20 MG/ML ORAL CONC ORAL SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) SERTRALINE HCL ZOLOFT 25, 50, 100MG TABLET ORAL SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) HCL DESYREL 50, 100, 150, 300MG TABLET ORAL SEROTONIN- REUPTAKE-INHIB (SNRIS) HCL EFFEXOR XR 37.5, 75, 150MG CAP ER 24H ORAL SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) VENLAFAXINE HCL EFFEXOR 25, 37.5, 50, 75, 100MG TABLET ORAL / COMBINATNS PERPHENAZINE/ HCL ETRAFON, TRIAVIL 2-10, 2-25, 4-10, 4-25, 4-50MG TABLET ORAL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB AMITRIPTYLINE HCL ELAVIL 10, 25, 50, 75, 100, 150MG TABLET ORAL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB AMOXAPINE 25, 50, 100, 150MG TABLET ORAL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB HCL NORPRAMIN 10, 25, 50, 75, 100, 150MG TABLET ORAL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB HCL SINEQUAN 10, 25, 50, 75, 100, 150MG CAPSULE ORAL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB DOXEPIN HCL DOXEPIN HCL 10 MG/ML ORAL CONC ORAL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB HCL TOFRANIL 10, 25, 50MG TABLET ORAL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB HCL MAPROTILINE HCL 25, 50, 75MG TABLET ORAL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB HCL PAMELOR 10, 25, 50, 75MG CAPSULE ORAL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB NORTRIPTYLINE HCL NORTRIPTYLINE HCL 10 MG/5 ML SOLUTION ORAL TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY * HCL RITALIN 5, 10, 20MG TABLET ORAL TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY *METHYLPHENIDATE HCL CONCERTA 18, 27, 36, 54MG TAB ER 24 ORAL TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY *METHYLPHENIDATE HCL RITALIN-SR 10, 20MG TABLET ER ORAL MISCELLANEOUS BEHAVIORAL HEALTH MISCELLANEOUS (ANTICONVULSANT) KLONOPIN 0.5, 1, 2MG TABLET ORAL MISCELLANEOUS (ANTICONVULSANT) DIVALPROEX SODIUM DEPAKOTE 125, 250, 500MG TABLET DR ORAL MISCELLANEOUS (ANTICONVULSANT) DIVALPROEX SODIUM DEPAKOTE SPRINKLE 125 MG CAP SPRINK ORAL MISCELLANEOUS (ANTICONVULSANT) NEURONTIN 100, 300, 400MG CAPSULE ORAL MISCELLANEOUS (ANTICONVULSANT) GABAPENTIN NEURONTIN 250 MG/5ML SOLUTION ORAL MISCELLANEOUS (ANTICONVULSANT) LAMOTRIGINE LAMICTAL 25, 100, 150, 200MG TABLET ORAL MISCELLANEOUS (ANTICONVULSANT) LAMOTRIGINE LAMICTAL 5, 25MG TB CHW DSP ORAL MISCELLANEOUS (ANTICONVULSANT) TRILEPTAL 300 MG/5ML ORAL SUSP ORAL MISCELLANEOUS (ANTICONVULSANT) OXCARBAZEPINE TRILEPTAL 150, 300, 600MG TABLET ORAL MISCELLANEOUS (ANTICONVULSANT) VALPROIC ACID DEPAKENE 250 MG CAPSULE ORAL MISCELLANEOUS (ANTICONVULSANT) VALPROIC ACID DEPAKENE 250 MG/5ML SOLUTION ORAL MISCELLANEOUS (ANTIPARKINSON DRUGS, ) BENZTROPINE MESYLATE COGENTIN 0.5, 1, 2MG TABLET ORAL MISCELLANEOUS (ANTIPARKINSON DRUGS, OTHER HCL SYMMETREL 100 MG CAPSULE ORAL MISCELLANEOUS (ANTIPARKINSON DRUGS, OTHER AMANTADINE HCL AMANTADINE 50 MG/5 ML SOLUTION ORAL OTIC PREPARATIONS NEOMYCIN/POLYMYXIN/HYDROCORTISONE OTIC SOLUTION NEO/POLY/HC SOLN CORTISPORIN 3.5/10,000/10 SOLUTION OTIC NEOMYCIN/POLYMYXIN/HYDROCORTISONE OTIC SUSPENSION NEO/POLY/HC SUSP CORTISPORIN 3.5/10,000/10 SUSPENSION OTIC

Page 4 of 9 Therapeutic Class Generic Name Brand Name (for reference) Strength Dosage Form Route , NON-SALICYLATE & COMB. /ACETAMINOPHEN PHRENILIN 50 MG-325 MG TABLET ORAL ANALGESIC, SALICYLATE, BARBITURATE,& XANTHINE CMB BUTALBITAL/ASPIRIN/CAFFEINE FIORINAL 50-325-40 CAPSULE ORAL ANALGESIC,NON-SALICYLATE,BARBITURATE,&XANTHINE CMB BUTALB/ACETAMINOPHEN/CAFFEINE FIORICET 50-325-40 TABLET ORAL ANALGESIC/ANTIPYRETICS, SALICYLATES ASPIRIN ASPIRIN 300, 600MG SUPP.RECT RECTAL ANALGESIC/ANTIPYRETICS, SALICYLATES ASPIRIN ASPIRIN 325 MG TABLET ORAL ANALGESIC/ANTIPYRETICS, SALICYLATES ASPIRIN ST. JOSEPH ASPIRIN 81 MG TAB CHEW ORAL ANALGESIC/ANTIPYRETICS, SALICYLATES ASPIRIN ECOTRIN 325, 500MG TABLET DR ORAL ANALGESIC/ANTIPYRETICS, SALICYLATES ASPIRIN ADULT LOW STRENGTH ASPIRIN 81 MG TABLET DR ORAL ANALGESIC/ANTIPYRETICS, SALICYLATES SALSALATE DISALCID 500, 750MG TABLET ORAL ANALGESIC/ANTIPYRETICS,NON-SALICYLATE ACETAMINOPHEN TYLENOL 160 MG TAB CHEW ORAL ANALGESIC/ANTIPYRETICS,NON-SALICYLATE ACETAMINOPHEN FEVERALL 120, 325, 650MG SUPP.RECT RECTAL ANALGESIC/ANTIPYRETICS,NON-SALICYLATE ACETAMINOPHEN TYLENOL 160 MG/5ML ,LIQUID, ORAL ORAL SUSP ANALGESIC/ANTIPYRETICS,NON-SALICYLATE ACETAMINOPHEN TYLENOL 500 MG TABLET ORAL ANALGESIC/ANTIPYRETICS,NON-SALICYLATE ACETAMINOPHEN TYLENOL 100 MG/ML DROPS ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE DICLOFENAC POTASSIUM CATAFLAM 50 MG TABLET ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE DICLOFENAC SODIUM VOLTAREN 25, 50, 75MG TABLET DR ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE DICLOFENAC SODIUM VOLTAREN-XR 100 MG TAB ER 24H ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ETODOLAC LODINE 200, 300MG CAPSULE ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ETODOLAC LODINE 400, 500MG TABLET ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE IBUPROFEN CHILDREN'S MOTRIN 100 MG/5ML ORAL SUSP ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE IBUPROFEN MOTRIN 200, 400, 600, 800MG TABLET ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE IBUPROFEN MOTRIN 50 MG/1.25 DROPS SUSP ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE IBUPROFEN MOTRIN 100 MG TAB CHEW ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE INDOMETHACIN INDOCIN 25, 50MG CAPSULE ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE KETOPROFEN ORUDIS 50, 75MG CAPSULE ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE KETOROLAC TROMETHAMINE TORADOL 10 MG TABLET ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE MELOXICAM MOBIC 7.5, 15MG TABLET ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE NABUMETONE RELAFEN 500, 750MG TABLET ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE NAPROXEN NAPROSYN 125 MG/5ML ORAL SUSP ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE NAPROXEN NAPROSYN 220, 250, 375, 500MG TABLET ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE NAPROXEN EC-NAPROSYN 375, 500MG TABLET DR ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE OXAPROZIN DAYPRO 600 MG TABLET ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE PIROXICAM FELDENE 10, 20MG CAPSULE ORAL NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE SULINDAC CLINORIL 150, 200MG TABLET ORAL

Page 5 of 9 Therapeutic Class Generic Name Brand Name (for reference) Strength Dosage Form Route DIABETES ANTIHYPERGLYCEMIC, BIGUANIDE TYPE METFORMIN HCL GLUCOPHAGE 500, 850, 1000MG TABLET ORAL ANTIHYPERGLYCEMIC, BIGUANIDE TYPE METFORMIN HCL GLUCOPHAGE XR 500, 750MG TAB ER 24H ORAL ANTIHYPERGLYCEMIC, INCRETIN MIMETIC LIRAGLUTIDE VICTOZA 2-PAK, 3-PAK PEN INJ SUB-Q ANTIHYPERGLYCEMIC, INSULIN-RELEASE TYPE GLIMEPIRIDE AMARYL 1, 2, 4MG TABLET ORAL ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE GLIPIZIDE GLUCOTROL 5, 10MG TABLET ORAL ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE GLIPIZIDE GLUCOTROL XL 2.5, 5, 10MG TAB ER 24 ORAL ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE GLYBURIDE DIABETA 1.25, 2.5, 5MG TABLET ORAL ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE GLYBURIDE,MICRONIZED GLYNASE 1.5, 3, 6MG TABLET ORAL ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE NATEGLINIDE STARLIX 60, 120MG TABLET ORAL ANTIHYPERGLYCEMIC,INSULIN-REL STIM.& BIGUANIDE CMB GLIPIZIDE/METFORMIN HCL METAGLIP 2.5-250, 2.5-500, 5-500MG TABLET ORAL ANTIHYPERGLYCEMIC,INSULIN-REL STIM.& BIGUANIDE CMB GLYBURIDE/METFORMIN HCL GLUCOVANCE 1.25-250, 2.5-500, 5-500MG TABLET ORAL ANTIHYPERGLYCEMIC,THIAZOLIDINEDIONE & BIGUANIDE PIOGLITAZONE HCL/METFORMIN HCL ACTOPLUS MET 15-500, 15-850MG TABLET ORAL INSULINS INSULIN ASPART PROTAM & ASPART NOVOLOG MIX 70-30 70-30/ML VIAL SUB-Q INSULINS INSULIN GLARGINE,HUM.REC.ANLOG LANTUS OR BASAGLAR 100/ML VIAL SUB-Q INSULINS INSULIN NPH HUMAN ISOPHANE HUMULIN N 100/ML VIAL SUB-Q INSULINS INSULIN NPH HUMAN ISOPHANE NOVOLIN N 100/ML VIAL SUB-Q INSULINS INSULIN NPL/INSULIN LISPRO HUMALOG MIX 50-50 50-50/ML VIAL SUB-Q INSULINS INSULIN NPL/INSULIN LISPRO HUMALOG MIX 75-25 75-25/ML VIAL SUB-Q INSULINS INSULIN NPL/INSULIN LISPRO HUMALOG MIX 50-50 50-50/ML INSULN PEN SUB-Q INSULINS INSULIN NPL/INSULIN LISPRO HUMALOG MIX 75-25 75-25/ML INSULN PEN SUB-Q INSULINS INSULIN REGULAR, HUMAN HUMULIN R 100/ML VIAL INJECTION INSULINS INSULIN REGULAR, HUMAN NOVOLIN R 100/ML VIAL INJECTION INSULINS INSULIN REGULAR, HUMAN HUMULIN R U-500 500/ML VIAL SUB-Q COPD/ BETA-ADRENERGIC AGENTS ALBUTEROL SULFATE ACCUNEB 0.63MG/3ML, 1.25MG/3ML, VIAL-NEB INHALATION 2.5MG/3ML BETA-ADRENERGIC AGENTS ALBUTEROL SULFATE VENTOLIN 5 MG/ML SOLUTION ORAL BETA-ADRENERGIC AGENTS ALBUTEROL SULFATE ALBUTEROL SULFATE 2 MG/5 ML SYRUP ORAL BETA-ADRENERGIC AGENTS ALBUTEROL SULFATE PROVENTIL HFA 90 MCG HFA AER AD INHALATION BETA-ADRENERGIC AGENTS ALBUTEROL SULFATE VENTOLIN, PROVENTIL 2, 4MG TABLET ORAL BETA-ADRENERGIC AGENTS METAPROTERENOL SULFATE METAPROTERENOL SULFATE 10 MG/5 ML SYRUP ORAL BETA-ADRENERGIC AGENTS XINAFOATE SEREVENT DISKUS 50 MCG BLST W/DEV INHALATION BETA-ADRENERGIC AGENTS SULFATE BRETHINE 2.5, 5MG TABLET ORAL BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS IPRATROPIUM/ALBUTEROL SULFATE COMBIVENT RESPIMAT 20-100 MCG MIST INHAL INHALATION BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS IPRATROPIUM/ALBUTEROL SULFATE DUONEB 0.5-3MG/3 AMPUL-NEB INHALATION GENERAL BRONCHODILATOR AGENTS IPRATROPIUM ATROVENT HFA 17MCG HFA AER AD INHALATION GENERAL BRONCHODILATOR AGENTS IPRATROPIUM BROMIDE 0.2 MG/ML SOLUTION INHALATION GLUCOCORTICOIDS, ORALLY INHALED PULMICORT 0.25MG/2ML, 0.5MG/2ML, AMPUL-NEB INHALATION 1MG/2ML GLUCOCORTICOIDS, ORALLY INHALED BUDESONIDE PULMICORT FLEXHALER 90, 180MCG AER POW BA INHALATION GLUCOCORTICOIDS, ORALLY INHALED PROPIONATE FLOVENT DISKUS 50, 100, 250MCG BLST W/DEV INHALATION GLUCOCORTICOIDS, ORALLY INHALED FLOVENT HFA 44, 110, 220MCG AER W/ADAP INHALATION LEUKOTRIENE RECEPTOR ANTAGONISTS MONTELUKAST SODIUM SINGULAIR 4 MG GRAN PACK ORAL LEUKOTRIENE RECEPTOR ANTAGONISTS MONTELUKAST SODIUM SINGULAIR 10 MG TABLET ORAL LEUKOTRIENE RECEPTOR ANTAGONISTS MONTELUKAST SODIUM SINGULAIR 4, 5MG TAB CHEW ORAL XANTHINES CAFFEINE CITRATED CAFCIT 60 MG/3 ML SOLUTION ORAL XANTHINES THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 100, 200, 300MG TAB ER 12H ORAL XANTHINES THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 400, 450, 600MG TABLET SA ORAL XANTHINES THEOPHYLLINE ANHYDROUS THEO-24 100, 200, 300, 400MG CAP ER 24H ORAL

Page 6 of 9 Therapeutic Class Generic Name Brand Name (for reference) Strength Dosage Form Route ANTIBIOTICS ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS SULFAMETHOXAZOLE-TMP DS BACTRIM DS TAB 800-160 800-160 MG TABLET ORAL ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS SULFAMETHOXAZOLE-TMP SS TABLET BACTRIM TAB 400-80MG 400-80 MG TABLET ORAL ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS SULFAMETHOXAZOLE-TMP SUSP SMZ-TMP SUS 200-40/5 200-40 MG/5ML SUSPENSION ORAL ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS SULFASALAZINE AZULFIDINE 500 MG TABLET ORAL ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS SULFASALAZINE DR AZULFIDINE 500 MG TABLET DR ORAL CEPHALOSPORINS - 1ST GENERATION CEFADROXIL DURICEF 1 G TABLET ORAL CEPHALOSPORINS - 1ST GENERATION CEFADROXIL CEFADROXIL 250 MG/5ML, 500MG/5ML SUSP RECON ORAL CEPHALOSPORINS - 1ST GENERATION CEFADROXIL DURICEF 500 MG CAPSULE ORAL CEPHALOSPORINS - 1ST GENERATION CEPHALEXIN CEPHALEXIN 125MG/5ML, 250MG/5ML SUSP RECON ORAL CEPHALOSPORINS - 1ST GENERATION CEPHALEXIN KEFLEX 250, 500MG CAPSULE ORAL CEPHALOSPORINS - 2ND GENERATION CEFACLOR CECLOR 250, 500MG CAPSULE ORAL CEPHALOSPORINS - 2ND GENERATION CEFPROZIL CEFZIL 125MG/5ML, 250MG/5ML SUSP RECON ORAL CEPHALOSPORINS - 2ND GENERATION CEFPROZIL CEFZIL 250, 500MG TABLET ORAL CEPHALOSPORINS - 2ND GENERATION CEFUROXIME AXETIL CEFTIN 125MG/5ML, 250MG/5ML SUSP RECON ORAL CEPHALOSPORINS - 2ND GENERATION CEFUROXIME AXETIL CEFTIN 250, 500MG TABLET ORAL CEPHALOSPORINS - 3RD GENERATION CEFDINIR OMNICEF 125MG/5ML, 250MG/5ML SUSP RECON ORAL CEPHALOSPORINS - 3RD GENERATION CEFDINIR OMNICEF 300 MG CAPSULE ORAL LINCOSAMIDES CLINDAMYCIN HCL CLEOCIN 150, 300MG CAPSULE ORAL LINCOSAMIDES CLINDAMYCIN PALMITATE HCL CLEOCIN PALMITATE 75 MG/5 ML SOLN RECON ORAL MACROLIDES AZITHROMYCIN ZITHROMAX 100MG/5ML, 200MG/5ML SUSP RECON ORAL MACROLIDES AZITHROMYCIN ZITHROMAX 250, 500, 600MG TABLET ORAL MACROLIDES CLARITHROMYCIN BIAXIN 125MG/5ML, 250MG/5ML SUSP RECON ORAL MACROLIDES CLARITHROMYCIN BIAXIN 250, 500MG TABLET ORAL MACROLIDES CLARITHROMYCIN BIAXIN XL 500 MG TAB ER 24H ORAL MACROLIDES ERYTHROMYCIN BASE ERY-TAB 250, 333, 500MG TABLET DR ORAL MACROLIDES ERYTHROMYCIN BASE ERYTHROMYCIN 250, 500MG TABLET ORAL MACROLIDES ERYTHROMYCIN BASE ERYTHROMYCIN 250 MG CAPSULE DR ORAL MACROLIDES ERYTHROMYCIN STEARATE ERYTHROCIN STEARATE 250 MG TABLET ORAL NITROFURAN DERIVATIVES NITROFURANTOIN FURADANTIN 25 MG/5 ML ORAL SUSP ORAL NITROFURAN DERIVATIVES NITROFURANTOIN MACROCRYSTAL MACRODANTIN 50, 100MG CAPSULE ORAL NITROFURAN DERIVATIVES NITROFURANTOIN MONOHYD/M-CRYST MACROBID 100 MG CAPSULE ORAL PENICILLINS AMOXICILLIN AMOXICILLIN 125, 250MG TAB CHEW ORAL PENICILLINS AMOXICILLIN AMOXIL 125/5, 200/5, 250/5, 400MG/5ML SUSP RECON ORAL

PENICILLINS AMOXICILLIN AMOXICILLIN 250, 500MG CAPSULE ORAL PENICILLINS AMOXICILLIN AMOXIL 875 MG TABLET ORAL PENICILLINS AMOXICILLIN/POTASSIUM CLAV AUGMENTIN 200-28.5, 400-57MG TAB CHEW ORAL PENICILLINS AMOXICILLIN/POTASSIUM CLAV AUGMENTIN 200-28.5/5, 250-62.5/5, 400- SUSP RECON ORAL 75/5, 600-42.9/5 PENICILLINS AMOXICILLIN/POTASSIUM CLAV AUGMENTIN 250-125, 500-125, 875-125MG TABLET ORAL PENICILLINS AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE 250, 500MG CAPSULE ORAL PENICILLINS DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM 250, 500MG CAPSULE ORAL PENICILLINS PENICILLIN V POTASSIUM VEETIDS 125 125MG/5ML, 250MG/5ML SOLN RECON ORAL PENICILLINS PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 250, 500MG TABLET ORAL QUINOLONES HCL CIPRO 100, 250, 500, 750MG TABLET ORAL QUINOLONES LEVOFLOXACIN LEVAQUIN 250, 500, 750MG TABLET ORAL QUINOLONES OFLOXACIN FLOXIN 400 MG TABLET ORAL TETRACYCLINES MINOCYCLINE HCL MINOCIN 50, 100MG CAPSULE ORAL TETRACYCLINES TETRACYCLINE HCL TETRACYCLINE HCL 250, 500MG CAPSULE ORAL

Page 7 of 9 Therapeutic Class Generic Name Brand Name (for reference) Strength Dosage Form Route WOMEN'S HEALTH CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC ETONOGESTREL/ETHINYL ESTRADIOL NUVARING 0.12-0.015 VAG RING VAGINAL CONTRACEPTIVES, NON-SYTEMIC LEVONORGESTREL SKYLA 14 MCG/24HR IUD VAGINAL CONTRACEPTIVES, NON-SYTEMIC LEVONORGESTREL MIRENA 20 MCG/24HR IUD VAGINAL CONTRACEPTIVES, NON-SYTEMIC LEVONORGESTREL LILETTA 18.6 MCG/24HR IUD VAGINAL CONTRACEPTIVES,IMPLANTABLE ETONOGESTREL NEXPLANON 68 MG IMPLANT SUB-Q CONTRACEPTIVES,INJECTABLE MEDROXYPROGESTERONE ACETATE DEPO-PROVERA 150 MG/ML SYRINGE INTRAMUSC. CONTRACEPTIVES,INTRAVAGINAL NONOXYNOL 9 VCF 12.50% FOAM/APPL VAGINAL CONTRACEPTIVES,ORAL DESOG-E.ESTRADIOL/E.ESTRADIOL MIRCETTE 21-5 TABLET ORAL CONTRACEPTIVES,ORAL DESOGESTREL-ETHINYL ESTRADIOL APRI 0.15-0.03 TABLET ORAL CONTRACEPTIVES,ORAL DESOGESTREL-ETHINYL ESTRADIOL VELIVET 7 DAYS X 3 TABLET ORAL CONTRACEPTIVES,ORAL ETHYNODIOL D-ETHINYL ESTRADIOL ZOVIA 1-35E 1 MG-35MCG TABLET ORAL CONTRACEPTIVES,ORAL ETHYNODIOL D-ETHINYL ESTRADIOL ZOVIA 1-50E 1 MG-50MCG TABLET ORAL CONTRACEPTIVES,ORAL LEVONORGESTREL PLAN B ONE-STEP 1.5 MG TABLET ORAL CONTRACEPTIVES,ORAL LEVONORGESTREL PLAN B 0.75 MG TABLET ORAL CONTRACEPTIVES,ORAL LEVONORGESTREL-ETH ESTRADIOL ALESSE 0.1-0.02 TABLET ORAL CONTRACEPTIVES,ORAL LEVONORGESTREL-ETHIN ESTRADIOL TRIPHASIL 6-5-10 TABLET ORAL CONTRACEPTIVES,ORAL LEVONORGESTREL-ETHIN ESTRADIOL NORDETTE 0.15-0.03 TABLET ORAL CONTRACEPTIVES,ORAL LEVONORGESTREL-ETHIN ESTRADIOL SEASONALE 0.15-0.03 TBDSPK 3MO ORAL CONTRACEPTIVES,ORAL NORETHINDRONE CAMILA 0.35 MG TABLET ORAL CONTRACEPTIVES,ORAL NORETHINDRONE AC-ETH ESTRADIOL LOESTRIN 1MG-20MCG TABLET ORAL CONTRACEPTIVES,ORAL NORETHINDRONE AC-ETH ESTRADIOL LOESTRIN 1.5-0.03MG TABLET ORAL CONTRACEPTIVES,ORAL NORETHINDRONE-E.ESTRADIOL-IRON LOESTRIN FE 1MG-20(21), 1.5-30(21) TABLET ORAL CONTRACEPTIVES,ORAL NORETHINDRONE-ETHINYL ESTRAD NORINYL 1+35 1 MG-35MCG TABLET ORAL CONTRACEPTIVES,ORAL NORETHINDRONE-ETHINYL ESTRAD ORTHO-NOVUM 7 DAYS X 3 TABLET ORAL CONTRACEPTIVES,ORAL NORETHINDRONE-ETHINYL ESTRAD OVCON-35 0.4-0.035 TABLET ORAL CONTRACEPTIVES,ORAL NORETHINDRONE-ETHINYL ESTRAD BREVICON 0.5-0.035 TABLET ORAL CONTRACEPTIVES,ORAL NORETHINDRONE-ETHINYL ESTRAD ORTHO-NOVUM 10/11 TABLET ORAL CONTRACEPTIVES,ORAL NORETHINDRONE-ETHINYL ESTRAD TRI-NORINYL 0.5/1/0.5MG-35MCG TABLET ORAL CONTRACEPTIVES,ORAL NORETHINDRONE-MESTRANOL ORTHO-NOVUM 1 MG-50MCG TABLET ORAL CONTRACEPTIVES,ORAL NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN 7DAYSX3 28 TABLET ORAL CONTRACEPTIVES,ORAL NORGESTIMATE-ETHINYL ESTRADIOL MONONESSA 0.25-0.035 TABLET ORAL CONTRACEPTIVES,ORAL NORGESTREL-ETHINYL ESTRADIOL LO-OVRAL 0.3-0.03MG TABLET ORAL CONTRACEPTIVES,ORAL NORGESTREL-ETHINYL ESTRADIOL OVRAL 0.5-0.05MG TABLET ORAL CONTRACEPTIVES,TRANSDERMAL NORELGESTROMIN/ETHIN.ESTRADIOL ORTHO EVRA 150-35/24H PATCH TDWK TRANSDERM. ESTROGENIC AGENTS ESTRADIOL ESTRACE 0.5, 1, 2MG TABLET ORAL ESTROGENIC AGENTS ESTROGEN,CON/M-PROGEST ACET PREMPHASE 0.625 (14) TABLET ORAL ESTROGENIC AGENTS ESTROGEN,CON/M-PROGEST ACET PREMPRO 0.3-1.5, 0.45-1.5, 0.625-2.5. 0.625- TABLET ORAL 5MG ESTROGENIC AGENTS ESTROGENS, CONJUGATED PREMARIN 0.3, 0.45, 0.625, 0.9, 1.25MG TABLET ORAL ESTROGENIC AGENTS ESTROPIPATE ESTROPIPATE 0.75, 1.5, 3MG TABLET ORAL PREGNANCY FACILITATING/MAINTAINING AGENT,HORMONAL FIRST-PROGESTERONE 25, 50, 100, 200, 400MG SUPP VAGINAL PROGESTATIONAL AGENTS HYDROXYPROGESTERONE CAPROATE 17-P COMPOUNDED VIAL INTRAMUSC. PROGESTATIONAL AGENTS MEDROXYPROGESTERONE ACETATE PROVERA 2.5, 5, 10MG TABLET ORAL PROGESTATIONAL AGENTS NORETHINDRONE ACETATE AYGESTIN 5 MG TABLET ORAL PROGESTATIONAL AGENTS PROGESTERONE,MICRONIZED PROMETRIUM 100, 200MG CAPSULE ORAL MULTIVITAMINS MULTIVITAMIN PREPARATIONS FOLIC ACID/MULTIVIT-MINERALS ONE DAILY ESSENTIAL 0.4 MG TABLET ORAL MULTIVITAMIN PREPARATIONS MULTIVITAMIN/IRON/FOLIC ACID A THRU Z ADVANCED FORMULA 18MG-0.4MG TABLET ORAL NIACIN PREPARATIONS NIACIN SLO-NIACIN 250, 500, 750MG TABLET ER ORAL NIACIN PREPARATIONS NIACIN NIACIN 500 MG TABLET ORAL NIACIN PREPARATIONS NIACIN NICOBID 250 MG CAPSULE SA ORAL

Page 8 of 9 Therapeutic Class Generic Name Brand Name (for reference) Strength Dosage Form Route MULTIVITAMINS (Cont.) PEDIATRIC VITAMIN PREPARATIONS FLUORIDE/IRON/VIT A,C&D TRI-VIT WITH FLUORIDE-IRON 0.25 MG/ML DROPS ORAL PEDIATRIC VITAMIN PREPARATIONS MULTI-VITAMINS + IRON VI-DAYLIN + IRON DROPS ORAL PEDIATRIC VITAMIN PREPARATIONS PED MV A,C,D3 #21 W-FLUORIDE TRI-VITAMIN WITH FLUORIDE 0.25MG/ML, 0.5MG/ML DROPS ORAL PEDIATRIC VITAMIN PREPARATIONS PEDI M.VIT NO.17 WITH FLUORIDE MULTI-VITAMIN WITH FLUORIDE 0.5 MG TAB CHEW ORAL PEDIATRIC VITAMIN PREPARATIONS PEDI M.VIT NO.17 WITH FLUORIDE MULTIVITAMINS WITH FLUORIDE 0.25, 1MG TAB CHEW ORAL PEDIATRIC VITAMIN PREPARATIONS PEDI MULTIVIT NO.2 W-FLUORIDE MULTI-VITAMIN W-FLUORIDE 0.25 MG/ML DROPS ORAL PEDIATRIC VITAMIN PREPARATIONS PEDI MULTIVIT NO.2 W-FLUORIDE MULTIVITAMIN AND FLUORIDE 0.5 MG/ML DROPS ORAL PEDIATRIC VITAMIN PREPARATIONS PEDI MV #45/FLUORIDE/IRON MULTI-VITAMIN W-FLUORIDE-IRON 0.25-10/ML DROPS ORAL PEDIATRIC VITAMIN PREPARATIONS PEDIATRIC MULTIVIT COMB #25/FA CHILDREN'S CHEWABLE MULTIVITMN 300 MCG TAB CHEW ORAL PEDIATRIC VITAMIN PREPARATIONS PEDIATRIC MULTIVIT COMB NO.20 POLY-VITAMIN 1500-400/1 DROPS ORAL PRENATAL VITAMIN PREPARATIONS PNV NO.118/IRON FUMARATE/FA PRENATAL 19 29 MG-1 MG TAB CHEW ORAL PRENATAL VITAMIN PREPARATIONS PNV NO.4/IRON CBN&GLUC/FA/DOSS VINATE CALCIUM 27-1-50 MG TABLET ORAL PRENATAL VITAMIN PREPARATIONS PNV WITH CA,NO.72/IRON/FA PRENATAL PLUS 27 MG-1 MG TABLET ORAL PRENATAL VITAMIN PREPARATIONS PNV/FERROUS FUMARATE/DOSS/FA MYNATE 90 PLUS 90-50-1MG TABLET ER ORAL PRENATAL VITAMIN PREPARATIONS PNV115/IRON FUMARATE/FA/DSS PRENATAL 19 29-1-25 MG TABLET ORAL PRENATAL VITAMIN PREPARATIONS PRENATAL VIT #76/IRON,CARB/FA PRENATABS RX 29 MG-1 MG TABLET ORAL PRENATAL VITAMIN PREPARATIONS PRENATAL VIT 15/IRON CB/FA/DSS ADVANCED NATALCARE 90-1-50 MG TABLET ORAL PRENATAL VITAMIN PREPARATIONS PRENATAL VIT NO.78/IRON/FA PRENATABS FA 29 MG-1 MG TABLET ORAL PRENATAL VITAMIN PREPARATIONS PRENATAL VIT/FE FUMARATE/FA/SE MATERNA 27 MG-1 MG TABLET ORAL PRENATAL VITAMIN PREPARATIONS PRENATAL VIT/IRON FUMARATE/FA PRENATAL Z 65 MG-1 MG TABLET ORAL PRENATAL VITAMIN PREPARATIONS PRENATAL VIT27&CALCIUM/IRON/FA VINATE ONE 60 MG-1 MG TABLET ORAL VITAMIN B12 PREPARATIONS CYANOCOBALAMIN (VITAMIN B-12) CYANOCOBALAMIN INJECTION 1000MCG/ML VIAL INJECTION VITAMIN B6 PREPARATIONS PYRIDOXINE HCL VITAMIN B-6 25, 50, 100MG TABLET ORAL VITAMIN D PREPARATIONS CALCITRIOL ROCALTROL 0.25. 0.5MCG CAPSULE ORAL VITAMIN D PREPARATIONS ERGOCALCIFEROL (VITAMIN D2) DRISDOL 50000 UNIT CAPSULE ORAL VITAMIN K PREPARATIONS PHYTONADIONE MEPHYTON 5 MG TABLET ORAL GASTROINTESTINAL ANTI-ULCER PREPARATIONS MISOPROSTOL CYTOTEC 100, 200MCG TABLET ORAL ANTI-ULCER PREPARATIONS SUCRALFATE CARAFATE 1 GM TABLET ORAL ANTI-ULCER PREPARATIONS SUCRALFATE CARAFATE 1 GM/10ML SUSPENSION ORAL H2-RECEPTOR INHIBITORS PEPCID 10, 20, 40MG TABLET ORAL HISTAMINE H2-RECEPTOR INHIBITORS AXID 75 MG TABLET ORAL HISTAMINE H2-RECEPTOR INHIBITORS ZANTAC 15 MG/ML SYRUP ORAL HISTAMINE H2-RECEPTOR INHIBITORS RANITIDINE ZANTAC 75, 150, 300MG TABLET ORAL PROTON-PUMP INHIBITORS PANTOPRAZOLE PROTONIX 20, 40MG DR TABLET ORAL ANTIMIGRAINE PREPARATIONS ANTIMIGRAINE PREPARATIONS TARTRATE/CAFFEINE CAFERGOT 1 MG-100 MG TABLET ORAL ANTIMIGRAINE PREPARATIONS AMERGE 1, 2.5MG TABLET ORAL ANTIMIGRAINE PREPARATIONS IMITREX 5, 20MG SPRAY NASAL ANTIMIGRAINE PREPARATIONS SUMATRIPTAN IMITREX 6 MG/0.5ML PEN INJ INJECTABLE ANTIMIGRAINE PREPARATIONS SUMATRIPTAN IMITREX 6 MG/0.5ML SYRINGE INJECTABLE ANTIMIGRAINE PREPARATIONS SUMATRIPTAN IMITREX 6 MG/0.5ML VIAL INJECTABLE ANTIMIGRAINE PREPARATIONS SUMATRIPTAN IMITREX TAB 100MG 25, 50, 100MG TABLET ORAL ANTICOAGULANTS ANTICOAGULANTS,COUMARIN TYPE WARFARIN SODIUM COUMADIN 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10MG TABLET ORAL HEMORRHEOLOGIC AGENTS PENTOXIFYLLINE ER PENTOXIFYLLIN 400 MG TABLET ER ORAL HEPARIN AND RELATED PREPARATIONS HEPARIN SOD LIQUAEMIN 1MU/ML VIAL INJECTABLE HEPARIN AND RELATED PREPARATIONS HEPARIN SOD HEPARIN SOD 10000/ML VIAL INJECTABLE HEPARIN AND RELATED PREPARATIONS HEPARIN SOD LIQUAEMIN 20MU/ML VIAL INJECTABLE HEPARIN AND RELATED PREPARATIONS HEPARIN SOD HEPARIN SOD 5000/0.5ML VIAL INJECTABLE HEPARIN AND RELATED PREPARATIONS HEPARIN SOD LIQUAEMIN 5MU/ML VIAL INJECTABLE PLATELET AGGREGATION INHIBITORS CILOSTAZOL PLETAL 50, 100MG TABLET ORAL PLATELET AGGREGATION INHIBITORS CLOPIDOGREL PLAVIX 75 MG TABLET ORAL PLATELET AGGREGATION INHIBITORS DIPYRIDAMOLE PERSANTINE 25, 50, 75MG TABLET ORAL URINARY TRACT /ANTI-INCONTINENCE URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT FLAVOXATE HCL FLAVOXATE HCL 100 MG TABLET ORAL URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT DITROPAN 5 MG TABLET ORAL URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT OXYBUTYNIN OXYBUTYNIN 5 MG/5ML SYRUP ORAL URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT OXYBUTYNIN CL ER DITROPAN XL 5, 10, 15MG TAB ER 24HR ORAL

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