Learn About Your Formulary Your list, also called a formulary, is the list of covered by St. Louis County Department of Health. Your plan with the St. Louis County Department of Health has specific guidelines you must follow to get prescription drug coverage.

You must choose generic medications when they are Many drug companies offer programs to help people available. Generic medications have the same ingredients afford their drugs. We encourage you to ask your doctor as brand drugs, at lower prices. about manufacturer assistance programs.

You must fill your prescription at participating pharmacies Drugs are listed on the formulary in alphabetical order by within the St. Louis area: name in the appropriate therapeutic category and class. > CVS > The Medicine Shoppe > Walmart > Schnucks Medications on the High Priority Drug List are covered for > Sam's Club > Beverly Hills Pharmacy ONLY two 30-day fills per year. > Dierbergs > If you are prescribed a High Priority Drug, contact the drug maker to request assistance in getting your medication at reduced or no cost. You must get your prescriptions from Department of > If you do not take this step, you will pay 100% of the Health Physicians discounted drug cost after getting two 30-day fills. > If a medication is prescribed by a non-panel doctor, a > The High Priority Drug List includes: special review is required and can be requested at the • Diabetes drugs: Lantus, Novolog and Novolin

number below. • Asthma Inhalers: Atrovent, Spiriva, Ventolin, Proair, Respiclick, Symbicort, Advair, Flovent and Proventil

Online Tools Who can I call if I have a question? Our Customer Service Center is available 24 hours a day, 7 Access your pharmacy beneft information through our days a week, 365 days a year to help answer any questions or portal, Members.EnvolveRx.com, and mobile app, concerns you have about your pharmacy benefit. Please call EnvolveRx. Our digital tools allow you to: us at 844.985.11188. > Access your digital ID cards on the EnvolveRx app > Compare prices for retail, mail, brand and generic medications How do I know if a drug is covered? > Find a pharmacy near you Review your formulary, below, or contact Envolve Pharmacy > Find generic alternatives to expensive brand name drugs Solutions’ Customer Service Center at 844.985.11188. > Check to see if a specifc drug is covered on your drug list > Review your claims history or print an Explanation of Benefts

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© 2020 Envolve. All rights reserved. 02-20 844.985.11118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- diclofenac sodium tb24 F OBESITY/ANOREXIANTS - Drugs to Treat ADHD, Sleep and Eating Disorders diclofenac sodium tbec F Amphetamines ibuprofen susp 100 mg/5ml F RX/OTC amphetamine- F QL(2 ea daily) dextroamphetamine cp24 ibuprofen tabs 400 mg, 600 F MP mg, 800 mg amphetamine- F QL(2 ea daily) dextroamphetamine tabs INDOCIN SUPP F dextroamphetamine sulfate F QL(2 ea daily) cp24 5 mg, 10 mg, 15 mg INDOCIN SUSP F dextroamphetamine sulfate F QL(60 ml daily) soln 5 mg/5ml indomethacin caps F dextroamphetamine sulfate F QL(2 ea daily) tabs 10 mg indomethacin cpcr F dextroamphetamine sulfate F ketorolac tromethamine F QL(20 ea per tabs 5 mg tabs 30 days retail) Stimulants - Misc. meloxicam tabs F MP methylphenidate hcl chew F 5 mg, 10 mg, 2.5 mg nabumetone tabs F methylphenidate hcl cp24 F QL(2 ea daily) 10 mg, 20 mg, 30 mg naproxen sodium tabs F MP methylphenidate hcl cp24 F QL(1 ea daily) 40 mg naproxen tabs F MP methylphenidate hcl cpcr MP 10 mg, 40 mg, 50 mg, 60 F naproxen tbec F mg sulindac tabs F methylphenidate hcl cpcr F QL(2 ea daily) 20 mg, 30 mg ANALGESICS - NonNarcotic - Drugs to Treat methylphenidate hcl tabs 5 F QL(2 ea daily) Pain, Muscle and Joint Conditions mg, 10 mg, 20 mg methylphenidate hcl tbcr 10 QL(1 ea daily) Salicylates mg, 18 mg, 20 mg, 27 mg, F aspirin chew F MP 54 mg MP methylphenidate hcl tbcr 36 F QL(2 ea daily) aspirin tabs F mg MP AMINOGLYCOSIDES - Drugs to Treat Bacterial aspirin tbec F Infections ANALGESICS - OPIOID - Drugs to Treat Pain, Aminoglycosides Muscle and Joint Conditions neomycin sulfate tabs F Opioid Agonists ANALGESICS - ANTI-INFLAMMATORY - Drugs hydromorphone hcl tabs F to Treat Pain, Swelling, Muscle and Joint morphine sulfate tabs 15 F Conditions mg, 30 mg Nonsteroidal Anti-inflammatory Agents (NSAIDs) hcl tabs F QL(8 ea daily)

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Opioid Combinations sulfamethoxazole- F trimethoprim susp acetaminophen w/ codeine F soln sulfamethoxazole- F trimethoprim tabs acetaminophen w/ codeine F tabs Lincosamides hydrocodone- clindamycin hcl caps F acetaminophen tabs 2.5 F mg-325 mg ANTIANGINAL AGENTS - Drugs to Treat Chest hydrocodone- QL(240 ea per Pain acetaminophen tabs 5 mg- F fill retail) 325 mg, 10 mg-325 mg, Nitrates 7.5 mg-325 mg ISOSORBIDE DINITRATE F MP ER TBCR hydrocodone-ibuprofen F tabs isosorbide dinitrate tabs F MP oxycodone w/ F acetaminophen tabs isosorbide mononitrate tabs F MP tramadol-acetaminophen F isosorbide mononitrate F MP tabs tb24 Opioid Partial Agonists nitroglycerin cpcr F buprenorphine hcl subl F nitroglycerin subl F buprenorphine hcl- PA Required naloxone hcl dihydrate film F after 30 days 8 mg-2 mg, 2 mg-0.5 mg ANTIANXIETY AGENTS - Drugs to Treat Anxiety buprenorphine hcl- Antianxiety Agents - Misc. naloxone hcl dihydrate subl F MP 8 mg-2 mg, 2 mg-0.5 mg buspirone hcl tabs F ANORECTAL AGENTS - Rectal Drugs to Treat hydroxyzine hcl tabs 10 mg F Pain, Swelling and Itching hydroxyzine hcl tabs 25 F MP Rectal Steroids mg, 50 mg hydrocortisone (rectal) crea F HYDROXYZINE F PAMOATE CAPS 100 MG hydrocortisone acetate F (rectal) supp hydroxyzine pamoate caps F 25 mg ANTI-INFECTIVE AGENTS - MISC. - Drugs to hydroxyzine pamoate caps F MP Treat Bacterial Infections 50 mg Anti-infective Agents - Misc. Benzodiazepines metronidazole caps F alprazolam tabs F metronidazole tabs F hcl caps F trimethoprim tabs F diazepam tabs F Anti-infective Misc. - Combinations lorazepam tabs F

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIARRHYTHMICS - Drugs to treat abnormal ADVAIR HFA AERO 21 QL(0.4 gm heart rhythms MCG/ACT-45 MCG/ACT, F daily)2 rtl MAX 21 MCG/ACT-115 fill,365 rtl Antiarrhythmics Type III MCG/ACT day(s) supply, amiodarone hcl tabs F MP QL(1.2 gm albuterol sulfate aers 108 F daily)2 rtl MAX ANTIASTHMATIC AND BRONCHODILATOR mcg/act fill,365 rtl AGENTS - Drugs to Treat Lung Conditions day(s) supply, Bronchodilators - QL(1.2 gm ALBUTEROL SULFATE F daily)2 rtl MAX QL(0.86 gm HFA AERS fill,365 rtl ATROVENT HFA AERS F daily)2 rtl MAX day(s) supply, fill,365 rtl day(s) supply, albuterol sulfate nebu 0.63 2 rtl MAX mg/3ml, 0.083 %, 0.5 %, F fill,365 rtl 2 rtl MAX 1.25 mg/3ml, 2.5 mg/0.5ml day(s) supply, F fill,365 rtl soln day(s) supply,; QL(0.34 gm BUDESONIDE/FORMOTE daily)2 rtl MAX MP ROL FUMARATE F DIHYDRATE AERO fill,365 rtl QL(1 ea daily)2 day(s) supply, SPIRIVA HANDIHALER F rtl MAX fill,365 CAPS rtl day(s) QL(0.2 gm supply, COMBIVENT RESPIMAT F daily)2 rtl MAX AERS fill,365 rtl Steroid Inhalants day(s) supply, QL(20 ea QL(2 ea daily)2 FLOVENT DISKUS AEPB daily)2 rtl MAX F F rtl MAX fill,365 100 MCG/BLIST fill,365 rtl fluticasone-salmeterol aepb rtl day(s) day(s) supply, supply, QL(8 ea daily)2 QL(0.07 ea FLOVENT DISKUS AEPB rtl MAX fill,365 F PROAIR RESPICLICK F daily)2 rtl MAX 250 MCG/BLIST rtl day(s) AEPB fill,365 rtl supply, day(s) supply, QL(40 ea QL(1.2 gm FLOVENT DISKUS AEPB daily)2 rtl MAX F PROVENTIL HFA AERS F daily)2 rtl MAX 50 MCG/BLIST fill,365 rtl fill,365 rtl day(s) supply, day(s) supply, QL(0.8 gm QL(0.34 gm FLOVENT HFA AERO 110 daily)2 rtl MAX F SYMBICORT AERO F daily)2 rtl MAX MCG/ACT, 220 MCG/ACT fill,365 rtl fill,365 rtl day(s) supply, day(s) supply, QL(0.36 gm QL(1.2 gm FLOVENT HFA AERO 44 daily)2 rtl MAX F VENTOLIN HFA AERS F daily)2 rtl MAX MCG/ACT fill,365 rtl fill,365 rtl day(s) supply, day(s) supply, Sympathomimetics Xanthines 2 rtl MAX ADVAIR HFA AERO 21 F THEO-24 CP24 F MCG/ACT-230 MCG/ACT fill,365 rtl day(s) supply, THEOPHYLLINE ER TB12 F

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits theophylline tb12 F Hydantoins DILANTIN CAPS 30 MG F theophylline tb24 F phenytoin chew F ANTICOAGULANTS - Blood Thinners phenytoin sodium extended F Coumarin Anticoagulants caps MP warfarin sodium tabs F phenytoin susp F Heparins And Heparinoid-Like Agents Succinimides 1 rtl MAX enoxaparin sodium soln F fill,365 rtl ethosuximide caps F day(s) supply, ethosuximide soln F ANTICONVULSANTS - Drugs to Treat Seizures Valproic Acid Anticonvulsants - Benzodiazepines divalproex sodium tb24 F MP clonazepam tabs F divalproex sodium tbec F MP Anticonvulsants - Misc. valproic acid caps F MP carbamazepine chew 100 F MP mg ANTIDEPRESSANTS - Drugs to Treat carbamazepine cp12 100 F MP mg, 200 mg, 300 mg Depression Alpha-2 Receptor Antagonists (Tetracyclics) carbamazepine susp 100 F mg/5ml tabs F MP carbamazepine tabs 200 F MP mg mirtazapine tbdp F MP carbamazepine tb12 100 F MP mg, 200 mg, 400 mg Antidepressants - Misc. gabapentin caps F MP bupropion hcl tabs 75 mg, F MP 100 mg MP gabapentin tabs F bupropion hcl tb12 100 mg, F MP 150 mg, 200 mg lamotrigine chew 5 mg, 25 F bupropion hcl tb24 150 mg, F QL(1 ea daily); mg 300 mg MP lamotrigine kit 25 mg, F BUPROPION QL(1 ea daily); HYDROCHLORIDE ER F MP lamotrigine tabs 25 mg, F MP (XL) TB24 100 mg, 150 mg, 200 mg QL(1 ea daily); FORFIVO XL TB24 F levetiracetam tabs F MP MP Monoamine Oxidase Inhibitors (MAOIs) levetiracetam tb24 F MP tranylcypromine sulfate F tabs primidone tabs F MP Selective Serotonin Reuptake Inhibitors (SSRIs) topiramate tabs F MP

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits citalopram hydrobromide F QL(4 ea daily); hcl caps 10 mg, 25 F MP tabs 10 mg MP mg, 50 mg, 75 mg, 100 mg citalopram hydrobromide F QL(2 ea daily); DOXEPIN HCL CAPS 150 F MP tabs 20 mg MP MG citalopram hydrobromide F QL(1 ea daily); doxepin hcl conc 10 mg/ml F tabs 40 mg MP MP escitalopram oxalate tabs F MP hcl tabs F MP fluoxetine hcl caps 10 mg, F MP hcl caps F 20 mg, 40 mg ANTIDIABETICS - Drugs to Regulate Blood fluoxetine hcl soln 20 F mg/5ml Sugar fluoxetine hcl tabs 20 mg F MP Alpha-Glucosidase Inhibitors MP QL(1 ea daily); acarbose tabs F fluoxetine hcl tabs 60 mg F MP Antidiabetic Combinations hcl tabs F MP glyburide-metformin tabs F MP MP paroxetine hcl tb24 F Biguanides sertraline hcl conc 20 F metformin hcl tabs F MP mg/ml MP sertraline hcl tabs 25 mg, F MP metformin hcl tb24 F 50 mg, 100 mg Serotonin Modulators Insulin Sensitizing Agents MP trazodone hcl tabs F MP pioglitazone hcl tabs F Serotonin-Norepinephrine Reuptake Inhibitors Insulin QL(2 ea daily); 2 rtl MAX duloxetine hcl cpep F BASAGLAR KWIKPEN F MP SOPN fill,365 rtl day(s) supply, venlafaxine hcl cp24 75 F QL(2 ea daily); mg, 150 mg, 37.5 mg MP QL(1.34 ml daily)2 rtl MAX HUMULIN 70/30 SUSP F venlafaxine hcl tabs 25 mg, fill,365 rtl 50 mg, 75 mg, 100 mg, F day(s) supply, 37.5 mg QL(1.34 ml venlafaxine hcl tb24 150 QL(1 ea daily); F HUMULIN N SUSP F daily)2 rtl MAX mg MP fill,365 rtl venlafaxine hcl tb24 75 mg, F QL(2 ea daily); day(s) supply, 37.5 mg MP QL(1.34 ml daily)2 rtl MAX Tricyclic Agents HUMULIN R SOLN F MP fill,365 rtl hcl tabs F day(s) supply, QL(1.34 ml hcl caps F daily)2 rtl MAX INSULIN ASPART SOLN F MP fill,365 rtl hcl tabs F day(s) supply,

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1.5 ml TOLBUTAMIDE TABS F daily)2 rtl MAX LANTUS SOLN F fill,365 rtl ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs day(s) supply, to Treat Diarrhea 2 rtl MAX LANTUS SOLOSTAR F fill,365 rtl Antiperistaltic Agents SOPN day(s) supply, diphenoxylate w/ F QL(1.34 ml tabs DIPHENOXYLATE/ATROP NOVOLIN 70/30 RELION F daily)2 rtl MAX F SUSP fill,365 rtl INE LIQD day(s) supply, loperamide hcl caps F RX/OTC QL(1.34 ml NOVOLIN 70/30 SUSP F daily)2 rtl MAX ANTIDOTES AND SPECIFIC ANTAGONISTS fill,365 rtl day(s) supply, Opioid Antagonists QL(1.34 ml naltrexone hcl tabs F MP NOVOLIN N RELION F daily)2 rtl MAX SUSP fill,365 rtl day(s) supply, ANTIEMETICS - Drugs to Treat Nausea and Vomiting QL(1.34 ml daily)2 rtl MAX 5-HT3 Receptor Antagonists NOVOLIN N SUSP F fill,365 rtl QL(30 ea per ondansetron hcl tabs F day(s) supply, fill retail) QL(1.34 ml Antiemetics - NOVOLIN R RELION F daily)2 rtl MAX SOLN fill,365 rtl hcl tabs F RX/OTC day(s) supply, trimethobenzamide hcl F QL(1.34 ml caps daily)2 rtl MAX NOVOLIN R SOLN F fill,365 rtl ANTIFUNGALS - Drugs to Treat Fungal Infections day(s) supply, QL(1.34 ml Antifungals NOVOLOG SOLN F daily)2 rtl MAX griseofulvin microsize tabs F fill,365 rtl day(s) supply, griseofulvin ultramicrosize F Sulfonylureas tabs nystatin tabs F CHLORPROPAMIDE F TABS terbinafine hcl tabs F glimepiride tabs F MP Imidazole-Related Antifungals glipizide tabs F MP fluconazole tabs F glipizide tb24 F MP ketoconazole tabs F glyburide tabs F MP ANTIHISTAMINES - Drugs to Treat Allergies TOLAZAMIDE TABS F Antihistamines - Alkylamines

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); chlorpheniramine maleate F rosuvastatin calcium tabs F tabs MP QL(1 ea daily); Antihistamines - Ethanolamines simvastatin tabs F MP ALER-DRYL TABS F Nicotinic Acid Derivatives hcl caps F NIACIN TABS 500 MG F diphenhydramine hcl tabs F ANTIHYPERTENSIVES - Drugs to Treat High Blood Pressure ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol ACE Inhibitors MP Antihyperlipidemics - Combinations benazepril hcl tabs F QL(1 ea daily); ezetimibe-simvastatin tabs F MP captopril tabs F Bile Acid Sequestrants enalapril maleate tabs F MP cholestyramine light pack F lisinopril tabs F MP cholestyramine light powd F quinapril hcl tabs F MP cholestyramine pack F Angiotensin II Receptor Antagonists cholestyramine powd F losartan potassium tabs F MP Fibric Acid Derivatives Antiadrenergic Antihypertensives fenofibrate micronized caps F clonidine hcl tabs F MP fenofibrate tabs 160 mg F doxazosin mesylate tabs F MP

FENOFIBRATE TABS 160 1 methyldopa tabs F MG fenofibrate tabs 40 mg, 48 MP prazosin hcl caps F MP mg, 54 mg, 120 mg, 145 F mg terazosin hcl caps F MP gemfibrozil tabs F MP Antihypertensive Combinations HMG CoA Reductase Inhibitors amlodipine besylate- F MP benazepril hcl caps ADVICOR TB24 F CAPTOPRIL/HYDROCHL F QL(1 ea daily); OROTHIAZIDE TABS atorvastatin calcium tabs F MP lisinopril & F MP hydrochlorothiazide tabs lovastatin tabs F MP losartan potassium & F MP pravastatin sodium tabs 10 F QL(1 ea daily); hydrochlorothiazide tabs mg, 20 mg, 80 mg MP quinapril- F pravastatin sodium tabs 40 F QL(2 ea daily); hydrochlorothiazide tabs mg MP Vasodilators Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydralazine hcl tabs F MP amantadine hcl tabs 100 F mg ANTIMALARIALS - Drugs to Treat Malaria bromocriptine mesylate F (Parasitic Infections) caps Antimalarials bromocriptine mesylate F tabs hydroxychloroquine sulfate F tabs carbidopa-levodopa tabs F MP

ANTIMYASTHENIC/ AGENTS carbidopa-levodopa tbcr F MP Antimyasthenic/Cholinergic Agents carbidopa-levodopa tbdp F MP pyridostigmine bromide F tabs ropinirole hydrochloride F MP ANTINEOPLASTICS AND ADJUNCTIVE tabs THERAPIES - Drugs to Treat Cancer Antiparkinson Monoamine Oxidase Inhibitors Antimetabolites selegiline hcl caps F methotrexate sodium tabs F MP SELEGILINE HCL TABS F Antineoplastic - Hormonal and Related Agents selegiline hcl tabs F megestrol acetate susp F ANTIPSYCHOTICS/ANTIMANIC AGENTS - megestrol acetate tabs F Drugs to Treat Mood Disorders Antimanic Agents tamoxifen citrate tabs F lithium carbonate caps 150 F MP Antineoplastics Misc. mg, 300 mg, 600 mg lithium carbonate tabs 300 F MP hydroxyurea caps F mg Chemotherapy Rescue/Antidote Agents lithium carbonate tbcr 300 F MP mg, 450 mg LEUCOVORIN CALCIUM F TABS 10 MG, 15 MG Antipsychotics - Misc. MP leucovorin calcium tabs 5 F ziprasidone hcl caps F mg, 25 mg ANTIPARKINSON AND RELATED THERAPY Benzisoxazoles AGENTS - Drugs to Treat Parkinson's Disease risperidone soln 1 mg/ml F Antiparkinson Anticholinergics risperidone tabs 0.25 mg, MP benztropine mesylate tabs F 0.5 mg, 1 mg, 2 mg, 3 mg, F 4 mg hcl tabs F Butyrophenones Antiparkinson Dopaminergics haloperidol tabs F MP amantadine hcl caps 100 F MP mg Dibenzapines MP amantadine hcl syrp 50 F succinate caps F mg/5ml

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tabs F MP carvedilol tabs F MP olanzapine tbdp F MP labetalol hcl tabs F MP fumarate tabs F MP Beta Blockers Cardio-Selective MP atenolol tabs F hcl tabs F metoprolol succinate tb24 F MP

FLUPHENAZINE HCL metoprolol tartrate tabs F MP TABS 1 MG, 5 MG, 10 MG, F 2.5 MG Beta Blockers Non-Selective fluphenazine hcl tabs 1 mg, F MP 5 mg, 10 mg, 2.5 mg nadolol tabs F perphenazine tabs F propranolol hcl cp24 60 MP mg, 80 mg, 120 mg, 160 F prochlorperazine maleate F mg tabs PROPRANOLOL HCL prochlorperazine supp F SOLN 20 MG/5ML, 40 F MG/5ML trifluoperazine hcl tabs F propranolol hcl tabs 10 mg, MP 20 mg, 40 mg, 60 mg, 80 F Quinolinone Derivatives mg aripiprazole soln 1 mg/ml F CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure aripiprazole tabs 2 mg, 5 MP mg, 10 mg, 15 mg, 20 mg, F Calcium Channel Blockers 30 mg amlodipine besylate tabs F MP ANTIVIRALS - Drugs to Treat Viral Infections CARDIZEM LA TB24 120 F MP MG Herpes Agents diltiazem hcl coated beads F MP acyclovir caps 200 mg F MP cp24 diltiazem hcl coated beads F MP acyclovir susp 200 mg/5ml F tb24 diltiazem hcl cp12 60 mg, MP acyclovir tabs 400 mg, 800 F MP F mg 90 mg, 120 mg diltiazem hcl cp24 120 mg, F Influenza Agents 180 mg, 240 mg oseltamivir phosphate caps QL(10 ea per F diltiazem hcl extended MP 30 mg, 45 mg fill retail) F release beads cp24 oseltamivir phosphate caps QL(120 ea per F diltiazem hcl tabs 30 mg, MP 75 mg fill retail) F 60 mg, 90 mg, 120 mg BETA BLOCKERS - Drugs to Treat High Blood nifedipine caps 10 mg, 20 F Pressure mg Alpha-Beta Blockers nifedipine tb24 30 mg, 60 F MP mg, 90 mg

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits verapamil hcl cp24 100 mg, F CEFTIN SUSR F 200 mg, 300 mg verapamil hcl cp24 120 mg, F MP cefuroxime axetil tabs F 180 mg, 240 mg Cephalosporins - 3rd Generation VERAPAMIL HCL ER 1 CP24 cefpodoxime proxetil susr F VERAPAMIL HCL SR 1 CP24 cefpodoxime proxetil tabs F verapamil hcl tabs 40 mg, F 80 mg, 120 mg CORTICOSTEROIDS - Steroid Hormone Drugs to Treat Systemic Swelling Conditions verapamil hcl tbcr 120 mg, F 180 mg, 240 mg Glucocorticosteroids VERAPAMIL dexamethasone elix 0.5 F HYDROCHLORIDE ER 1 mg/5ml CP24 DEXAMETHASONE F CARDIOTONICS - Drugs to Treat Heart Failure INTENSOL CONC and Abnormal Heart Rhythm DEXAMETHASONE SOLN F Cardiac Glycosides 0.5 MG/5ML dexamethasone tabs 0.75 digoxin soln 0.05 mg/ml F mg, 0.5 mg, 4 mg, 6 mg, F digoxin tabs 0.125 mg, MP 1.5 mg 0.25 mg, 125 mcg, 250 F DEXAMETHASONE TABS F mcg 1 MG, 2 MG CEPHALOSPORINS - Drugs to Treat Bacterial hydrocortisone tabs F Infections Cephalosporins - 1st Generation MEDROL TABS 2 MG F cefadroxil caps F methylprednisolone tabs F cefadroxil susr F PREDNISONE INTENSOL F CONC cefadroxil tabs F PREDNISONE SOLN 5 F MG/5ML cephalexin caps 250 mg, F prednisone tabs 1 mg, 5 500 mg, 750 mg mg, 10 mg, 20 mg, 50 mg, F cephalexin susr 125 F 2.5 mg mg/5ml, 250 mg/5ml COUGH/COLD/ALLERGY - Drugs to Treat CEPHALEXIN TABS 250 F Cough, Cold and Allergy Symptoms MG, 500 MG Antitussives Cephalosporins - 2nd Generation benzonatate caps F cefaclor caps 250 mg, 500 F mg Cough/Cold/Allergy Combinations CEFACLOR SUSR 125 MG/5ML, 250 MG/5ML, F BIOSPEC DMX LIQD F 375 MG/5ML dextromethorphan- F guaifenesin liqd Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dextromethorphan- F clotrimazole (topical) soln F RX/OTC guaifenesin syrp dextromethorphan- F ketoconazole (topical) crea F guaifenesin tabs ketoconazole (topical) dextromethorphan- F F guaifenesin tb12 sham guaifenesin-codeine liqd F nystatin (topical) crea F guaifenesin-codeine soln F nystatin (topical) oint F guaifenesin-codeine syrp F nystatin-triamcinolone crea F

NORTUSS-EX LIQD F nystatin-triamcinolone oint F Expectorants Antineoplastic or Premalignant Lesion Agents - guaifenesin tabs F fluorouracil (topical) crea F DERMATOLOGICALS - Drugs to Treat Skin FLUOROURACIL SOLN F Conditions Antivirals - Topical Acne Products QL(0.17 gm acyclovir topical crea F clindamycin phosphate F daily) (topical) gel 1 % acyclovir topical oint F QL(1 gm daily) clindamycin phosphate F (topical) lotn 1 % Burn Products clindamycin phosphate F (topical) soln 1 % silver sulfadiazine crea F clindamycin phosphate F (topical) swab 1 % Corticosteroids - Topical AUGMENTED erythromycin (acne aid) F soln BETAMETHASONE F DIPROPIONATE GEL sulfacetamide sodium F (acne) lotn betamethasone F dipropionate (topical) crea Antibiotics - Topical betamethasone F CORTISPORIN CREA F dipropionate (topical) lotn betamethasone F CORTISPORIN OINT F dipropionate (topical) oint betamethasone mupirocin calcium (topical) F dipropionate augmented F crea crea MUPIROCIN CREA F betamethasone dipropionate augmented F mupirocin oint F gel betamethasone Antifungals - Topical dipropionate augmented F clotrimazole (topical) crea F RX/OTC lotn

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits betamethasone metronidazole (topical) gel F dipropionate augmented F oint Scabicides & Pediculicides DESOXIMETASONE F CREA 0.05 % LINDANE SHAM F desoximetasone crea 0.05 F %, 0.25 % permethrin crea F desoximetasone oint 0.25 F DIGESTIVE AIDS - Drugs to Treat Low Digestive % Enzymes fluocinonide crea F Digestive Enzymes fluocinonide gel F CREON CPEP F fluocinonide oint F PANCREAZE CPEP F DIURETICS - Drugs to Treat Heart, Circulation fluocinonide soln F Conditions and Blood Pressure hydrocortisone (topical) F RX/OTC Carbonic Anhydrase Inhibitors crea 1 % acetazolamide tabs F MP hydrocortisone (topical) F crea 2.5 % methazolamide tabs F hydrocortisone (topical) F lotn 1 %, 2.5 % Diuretic Combinations hydrocortisone (topical) RX/OTC F spironolactone & F MP oint 1 % hydrochlorothiazide tabs hydrocortisone (topical) F triamterene & F MP oint 2.5 % hydrochlorothiazide caps mometasone furoate crea F triamterene & F MP hydrochlorothiazide tabs mometasone furoate oint F Loop Diuretics triamcinolone acetonide bumetanide tabs F (topical) crea 0.025 %, 0.1 F %, 0.5 % furosemide tabs F MP triamcinolone acetonide (topical) lotn 0.025 %, 0.1 F torsemide tabs F MP % triamcinolone acetonide Potassium Sparing Diuretics (topical) oint 0.025 %, 0.1 F MP %, 0.5 % spironolactone tabs F triamcinolone acetonide F QL(2 gm daily) Thiazides and Thiazide-Like Diuretics (topical) oint 0.05 % chlorthalidone tabs F MP TRIANEX OINT F QL(2 gm daily) hydrochlorothiazide caps F MP Rosacea Agents MP metronidazole (topical) F hydrochlorothiazide tabs F crea

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits indapamide tabs F CIPROFLOXACIN HCL F TABS 100 MG MP metolazone tabs F ciprofloxacin hcl tabs 250 F mg, 500 mg, 750 mg ENDOCRINE AND METABOLIC AGENTS - MISC. - Drugs to Treat Bone Disease and levofloxacin soln F Regulate Hormones levofloxacin tabs F Bone Density Regulators GASTROINTESTINAL AGENTS - MISC. - alendronate sodium tabs F QL(0.15 ea 35 mg, 70 mg daily); MP Miscellaneous Gastrointestinal Drugs ALENDRONATE SODIUM F MP Gastrointestinal Stimulants TABS 40 MG metoclopramide hcl soln F MP ALENDRONATE SODIUM F QL(1 ea daily); TABS 5 MG MP metoclopramide hcl tabs F MP alendronate sodium tabs 5 F QL(1 ea daily); mg, 10 mg MP Inflammatory Bowel Agents ETIDRONATE DISODIUM F TABS mesalamine supp F Metabolic Modifiers mesalamine tbec F calcitriol caps F MP PENTASA CPCR F ESTROGENS - Hormone Replacement/Modifying MP Drugs sulfasalazine tabs F Estrogens sulfasalazine tbec F MP DIVIGEL GEL F Intestinal Acidifiers ELESTRIN GEL F lactulose (encephalopathy) F soln estradiol ptwk td 0.025 QL(0.15 ea GENITOURINARY AGENTS - MISCELLANEOUS mg/24hr, 0.05 mg/24hr, F daily) 0.06 mg/24hr, 0.1 mg/24hr, - Miscellaneous Drugs to Treat Reproductive 37.5 mcg/24hr Organs and Urinary System Prostatic Hypertrophy Agents estradiol ptwk td 0.075 F mg/24hr QL(1 ea daily); finasteride tabs F MP estradiol tabs or 0.5 mg, 1 F mg, 2 mg tamsulosin hcl caps F MP QL(1.67 gm ESTROGEL GEL F daily) Urinary Analgesics MENOSTAR PTWK F QL(0.15 ea phenazopyridine hcl tabs F daily) PREMARIN TABS F GOUT AGENTS - Drugs to Treat Gout FLUOROQUINOLONES - Drugs to Treat Bacterial Gout Agents Infections allopurinol tabs F MP Fluoroquinolones

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits colchicine tabs F Azithromycin AZITHROMYCIN PACK 1 F COLCHICINE TABS F GM azithromycin susr 100 F COLCRYS TABS F mg/5ml, 200 mg/5ml QL(6 ea per fill Uricosurics azithromycin tabs 250 mg F retail) probenecid tabs F azithromycin tabs 500 mg F HEMATOLOGICAL AGENTS - MISC. - Drugs to QL(10 ea per azithromycin tabs 600 mg F Treat Blood Disorders fill retail) Hematorheologic Agents Clarithromycin MP pentoxifylline tbcr F CLARITHROMYCIN SUSR F 125 MG/5ML, 250 MG/5ML Platelet Aggregation Inhibitors clarithromycin tabs 250 mg, F clopidogrel bisulfate tabs F MP 500 mg Erythromycins dipyridamole tabs F erythromycin base tabs F HEMATOPOIETIC AGENTS - Drugs to Treat ERYTHROMYCIN F Blood Disorders ETHYLSUCCINATE TABS Folic Acid/Folates MIGRAINE PRODUCTS - Drugs to Treat Migraine folic acid tabs 1 mg F RX/OTC; MP Headaches Migraine Combinations folic acid tabs 400 mcg, F MP 800 mcg isometheptene- dichloralphenazone- F Iron acetaminophen caps ferrous sulfate tabs F MP ISOMETHEPTENE/DICHL ORALPHENAZONE/ACET F HYPNOTICS/SEDATIVES/SLEEP DISORDER AMINOPHEN CAPS AGENTS Serotonin Agonists Non-Barbiturate Hypnotics QL(0.6 ea rizatriptan benzoate tabs F temazepam caps F QL(1 ea daily) daily) QL(0.3 ea sumatriptan succinate tabs F triazolam tabs F QL(1 ea daily) daily) MINERALS & ELECTROLYTES LAXATIVES - Bowel Treatment Drugs Potassium Laxative Combinations peg 3350-kcl-sod bicarb- QL(4000 ml per K-BICARB CAPS F sod chloride-sod sulfate F fill retail) solr K-TAB TBCR 8 MEQ F MP MACROLIDES - Drugs to Treat Bacterial potassium chloride cpcr F MP Infections

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POTASSIUM CHLORIDE F MP Nasal Anti-infectives ER TBCR BACTROBAN NASAL F potassium chloride MP OINT microencapsulated crystals F er tbcr Nasal Anticholinergics 2 rtl MAX potassium chloride soln F MP ipratropium bromide (nasal) F fill,365 rtl MP soln day(s) supply,; potassium chloride tbcr F MP MISCELLANEOUS THERAPEUTIC CLASSES Nasal Steroids fluticasone propionate F RX/OTC; MP Immunosuppressive Agents (nasal) susp MP azathioprine tabs F triamcinolone acetonide F RX/OTC (nasal) aero 55 mcg/act MOUTH/THROAT/DENTAL AGENTS OPHTHALMIC AGENTS - Drugs to Treat the Eye Anti-infectives - Throat Beta-blockers - Ophthalmic clotrimazole lozg F dorzolamide hcl-timolol F maleate soln clotrimazole troc F DORZOLAMIDE HCL/TIMOLOL MALEATE F nystatin (mouth-throat) F SOLN susp LEVOBUNOLOL HCL F Antiseptics - Mouth/Throat SOLN chlorhexidine gluconate F levobunolol hcl soln F (mouth-throat) soln Steroids - Mouth/Throat/Dental timolol maleate (ophth) soln F 0.25 % triamcinolone acetonide F (mouth) pste timolol maleate (ophth) soln F MP 0.5 % MUSCULOSKELETAL THERAPY AGENTS - Drugs to Treat Spasms Cycloplegic Mydriatics ATROPINE SULFATE F Central Muscle Relaxants OINT baclofen tabs 10 mg, 20 MP F ATROPINE SULFATE F mg SOLN MP BACLOFEN TABS 5 MG F hcl soln F carisoprodol tabs F hbr soln F chlorzoxazone tabs F ISOPTO ATROPINE SOLN F MP hcl tabs F Miotics methocarbamol tabs F hcl soln F NASAL AGENTS - SYSTEMIC AND TOPICAL - Ophthalmic Adrenergic Agents Drugs to treat the Nose or Sinus Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALPHAGAN P SOLN 0.1 % F SULFACETAMIDE SODIUM/PREDNISOLONE F brimonidine tartrate soln F SODIUM PHOSPHATE SOLN Ophthalmic Anti-infectives tobramycin- F QL(5 ml per fill dexamethasone susp retail) CILOXAN OINT F Ophthalmics - Misc. ciprofloxacin hcl (ophth) F diclofenac sodium (ophth) F soln soln erythromycin (ophth) oint F dorzolamide hcl soln F

GENTAK OINT F DORZOLAMIDE HCL F SOLN gentamicin sulfate (ophth) F soln flurbiprofen sodium soln F levofloxacin (ophth) soln F FLURBIPROFEN SODIUM F SOLN QL(5 ml per fill ofloxacin (ophth) soln F ketorolac tromethamine F retail) (ophth) soln polymyxin b-trimethoprim F soln Prostaglandins - Ophthalmic QL(0.09 ml sulfacetamide sodium F latanoprost soln F (ophth) soln daily) LATANOPROST SOLN F QL(0.09 ml tobramycin (ophth) soln F daily) QL(0.09 ml F travoprost soln F TRIFLURIDINE SOLN daily) Ophthalmic Steroids OTIC AGENTS - Drugs to Treat the Ear fluorometholone (ophth) F susp Otic Agents - Miscellaneous FML FORTE SUSP F acetic acid (otic) soln F

FML OINT F Otic Combinations neomycin-polymyxin-hc F neomycin-polymy- F (otic) soln dexameth oint neomycin-polymyxin-hc F neomycin-polymy- F (otic) susp dexameth susp Otic Steroids PREDNISOLONE 1 ACETATE P-F SUSP hydrocortisone w/acetic F QL(10 ml per acid soln fill retail) PREDNISOLONE 1 ACETATE SUSP PENICILLINS - Drugs to Treat Bacterial Infections sulfacetamide sod- F prednisolone soln Aminopenicillins amoxicillin caps 250 mg, F 500 mg

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMOXICILLIN CHEW 125 F galantamine hydrobromide F QL(1 ea daily) MG, 250 MG cp24 8 mg, 16 mg, 24 mg amoxicillin susr 125 GALANTAMINE mg/5ml, 200 mg/5ml, 250 F HYDROBROMIDE SOLN 4 F mg/5ml, 400 mg/5ml MG/ML amoxicillin tabs 500 mg, F galantamine hydrobromide F 875 mg tabs 4 mg, 8 mg, 12 mg AMPICILLIN CAPS F rivastigmine tartrate caps F Natural Penicillins TETRACYCLINES - Drugs to Treat Bacterial Infections penicillin v potassium tabs F Tetracyclines Penicillin Combinations doxycycline hyclate caps F amoxicillin & pot F clavulanate susr doxycycline hyclate tabs F amoxicillin & pot F clavulanate tabs minocycline hcl caps F amoxicillin & pot F clavulanate tb12 minocycline hcl tabs F AMOXICILLIN/CLAVULAN F ATE POTASSIUM CHEW tetracycline hcl caps F AMOXICILLIN/CLAVULAN ATE POTASSIUM ER F THYROID AGENTS - Drugs to Regulate Thyroid TB12 Hormones Antithyroid Agents AUGMENTIN SUSR 125 F MG/5ML-31.25 MG/5ML methimazole tabs F MP Penicillinase-Resistant Penicillins propylthiouracil tabs F MP dicloxacillin sodium caps F Thyroid Hormones PROGESTINS - Hormone Replacement/Modifying Drugs levothyroxine sodium tabs F MP Progestins ULCER DRUGS - Drugs to Treat Bowel, Intestine medroxyprogesterone F and Stomach Conditions acetate tabs progesterone micronized F caps chlordiazepoxide hcl- F clidinium bromide caps PSYCHOTHERAPEUTIC AND NEUROLOGICAL dicyclomine hcl caps or 10 F MP AGENTS - MISC. - Drugs to Treat Mental and mg Emotional Conditions dicyclomine hcl soln im 10 F Agents for Chemical Dependency mg/ml acamprosate calcium tbec F dicyclomine hcl soln or 10 F mg/5ml Antidementia Agents dicyclomine hcl tabs or 20 F MP mg

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sulfate subl F MP nitrofurantoin macrocrystal F caps MP hyoscyamine sulfate tabs F nitrofurantoin monohyd F macro caps MP hyoscyamine sulfate tb12 F URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms hyoscyamine sulfate tbdp F MP Urinary - Antimuscarinics H-2 Antagonists chloride tabs F MP cimetidine tabs 200 mg F RX/OTC oxybutynin chloride tb24 F MP cimetidine tabs 300 mg, F 400 mg, 800 mg Urinary Antispasmodics - Direct Muscle Relaxants famotidine tabs 20 mg F RX/OTC; MP hcl tabs F MP famotidine tabs 40 mg F VAGINAL AND RELATED PRODUCTS ranitidine hcl caps 150 mg, F MP Vaginal Anti-infectives 300 mg CLEOCIN SUPP VA 100 F ranitidine hcl tabs 150 mg F RX/OTC; MP MG clindamycin phosphate F ranitidine hcl tabs 75 mg, F MP vaginal crea 300 mg Misc. Anti-Ulcer metronidazole vaginal gel F sucralfate susp 1 gm/10ml F TERCONAZOLE CREA F sucralfate tabs 1 gm F MP terconazole vaginal crea F

Proton Pump Inhibitors terconazole vaginal supp F omeprazole cpdr 10 mg, 40 F MP mg Vaginal Estrogens omeprazole cpdr 20 mg F RX/OTC; MP estradiol vaginal crea F omeprazole tbec 20 mg F MP PREMARIN CREA F

OMEPRAZOLE TBEC 20 F MP VITAMINS MG pantoprazole sodium tbec F MP Oil Soluble Vitamins cholecalciferol caps F MP Ulcer Drugs - Prostaglandins MP misoprostol tabs F cholecalciferol tabs F MP URINARY ANTI-INFECTIVES - Drugs to Treat ergocalciferol caps F Bladder/Kidney Infections phytonadione tabs F Urinary Anti-infectives Water Soluble Vitamins

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

18 Drug Requirements/ Drug Name Tier Limits niacin tabs 50 mg, 100 mg, F MP 250 mg, 500 mg

Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product

19 Index acamprosate calcium 17 baclofen 15 chlorzoxazone 15 acarbose 5 BACLOFEN 15 cholecalciferol 18 acetaminophen w/ codeine 2 BACTROBAN NASAL 15 cholestyramine 7 acetazolamide 12 BASAGLAR KWIKPEN 5 cholestyramine light 7 acetic acid (otic) 16 benazepril hcl 7 CILOXAN 16 acyclovir 9 benzonatate 10 cimetidine 18 acyclovir topical 11 benztropine mesylate 8 CIPROFLOXACIN HCL 13 ADVAIR HFA 3 betamethasone dipropionate ciprofloxacin hcl 13 ADVICOR 7 (topical) 11 ciprofloxacin hcl (ophth) 16 betamethasone dipropionate albuterol sulfate 3 augmented 11 citalopram hydrobromide 5 ALBUTEROL SULFATE HFA 3 BIOSPEC DMX 10 CLARITHROMYCIN 14 alendronate sodium 13 brimonidine tartrate 16 clarithromycin 14 ALENDRONATE SODIUM 13 bromocriptine mesylate 8 CLEOCIN 18 alendronate sodium 13 BUDESONIDE/FORMOTEROL clindamycin hcl 2 ALER-DRYL 7 FUMARATE DIHYDRATE 3 clindamycin phosphate allopurinol 13 bumetanide 12 (topical) 11 clindamycin phosphate ALPHAGAN P 16 buprenorphine hcl 2 buprenorphine hcl-naloxone hcl vaginal 18 alprazolam 2 dihydrate 2 clomipramine hcl 5 amantadine hcl 8 bupropion hcl 4 clonazepam 4 amiodarone hcl 3 BUPROPION clonidine hcl 7 amitriptyline hcl 5 HYDROCHLORIDE ER (XL)4 clopidogrel bisulfate 14 amlodipine besylate 9 buspirone hcl 2 clotrimazole 15 amlodipine besylate-benazepril calcitriol 13 clotrimazole (topical) 11 hcl 7 captopril 7 colchicine 14 amoxicillin 16 CAPTOPRIL/HYDROCHLORO COLCHICINE 14 AMOXICILLIN 17 THIAZIDE 7 COLCRYS 14 amoxicillin 17 carbamazepine 4 COMBIVENT RESPIMAT 3 amoxicillin & pot clavulanate 17 carbidopa-levodopa 8 AMOXICILLIN/CLAVULANATE CARDIZEM LA 9 CORTISPORIN 11 POTASSIUM 17 carisoprodol 15 CREON 12 AMOXICILLIN/CLAVULANATE carvedilol 9 cyclobenzaprine hcl 15 POTASSIUM ER 17 cyclopentolate hcl 15 amphetamine- cefaclor 10 dextroamphetamine 1 CEFACLOR 10 desipramine hcl 5 AMPICILLIN 17 cefadroxil 10 DESOXIMETASONE 12 aripiprazole 9 cefpodoxime proxetil 10 desoximetasone 12 aspirin 1 CEFTIN 10 dexamethasone 10 atenolol 9 cefuroxime axetil 10 DEXAMETHASONE 10 atorvastatin calcium 7 cephalexin 10 dexamethasone 10 ATROPINE SULFATE 15 CEPHALEXIN 10 DEXAMETHASONE 10 ATROVENT HFA 3 chlordiazepoxide hcl 2 DEXAMETHASONE INTENSOL 10 AUGMENTED chlordiazepoxide hcl-clidinium BETAMETHASONE bromide 17 dextroamphetamine sulfate 1 DIPROPIONATE 11 chlorhexidine gluconate dextromethorphan-guaifenesin AUGMENTIN 17 (mouth-throat) 15 10 azathioprine 15 chlorpheniramine maleate 7 diazepam 2 AZITHROMYCIN 14 chlorpromazine hcl 9 diclofenac sodium 1 azithromycin 14 CHLORPROPAMIDE 6 diclofenac sodium (ophth) 16 chlorthalidone 12 dicloxacillin sodium 17

Index 1 dicyclomine hcl 17 finasteride 13 hydrocodone-ibuprofen 2 digoxin 10 flavoxate hcl 18 hydrocortisone 10 DILANTIN 4 FLOVENT DISKUS 3 hydrocortisone (rectal) 2 diltiazem hcl 9 FLOVENT HFA 3 hydrocortisone (topical) 12 diltiazem hcl coated beads 9 fluconazole 6 hydrocortisone acetate diltiazem hcl extended release fluocinonide 12 (rectal) 2 hydrocortisone w/acetic acid 16 beads 9 fluorometholone (ophth) 16 diphenhydramine hcl 7 hydromorphone hcl 1 FLUOROURACIL 11 diphenoxylate w/ atropine 6 hydroxychloroquine sulfate 8 fluorouracil (topical) 11 DIPHENOXYLATE/ATROPINE hydroxyurea 8 fluoxetine hcl 5 6 hydroxyzine hcl 2 dipyridamole 14 FLUPHENAZINE HCL 9 HYDROXYZINE PAMOATE 2 divalproex sodium 4 fluphenazine hcl 9 hydroxyzine pamoate 2 DIVIGEL 13 flurbiprofen sodium 16 hyoscyamine sulfate 18 dorzolamide hcl 16 FLURBIPROFEN SODIUM16 ibuprofen 1 DORZOLAMIDE HCL 16 fluticasone propionate imipramine hcl 5 dorzolamide hcl-timolol (nasal) 15 maleate 15 fluticasone-salmeterol 3 indapamide 13 DORZOLAMIDE HCL/TIMOLOL FML 16 INDOCIN 1 MALEATE 15 FML FORTE 16 indomethacin 1 doxazosin mesylate 7 folic acid 14 INSULIN ASPART 5 doxepin hcl 5 FORFIVO XL 4 ipratropium bromide 3 DOXEPIN HCL 5 furosemide 12 ipratropium bromide (nasal) 15 doxepin hcl 5 gabapentin 4 isometheptene- doxycycline hyclate 17 galantamine hydrobromide 17 dichloralphenazone- duloxetine hcl 5 acetaminophen 14 GALANTAMINE ISOMETHEPTENE/DICHLORAL ELESTRIN 13 HYDROBROMIDE 17 PHENAZONE/ACETAMINOPHE enalapril maleate 7 galantamine hydrobromide 17 N 14 enoxaparin sodium 4 gemfibrozil 7 ISOPTO ATROPINE 15 ergocalciferol 18 GENTAK 16 isosorbide dinitrate 2 erythromycin (acne aid) 11 gentamicin sulfate (ophth) 16 ISOSORBIDE DINITRATE ER2 erythromycin (ophth) 16 glimepiride 6 isosorbide mononitrate 2 erythromycin base 14 glipizide 6 K-BICARB 14 ERYTHROMYCIN glyburide 6 K-TAB 14 ETHYLSUCCINATE 14 glyburide-metformin 5 ketoconazole 6 escitalopram oxalate 5 griseofulvin microsize 6 ketoconazole (topical) 11 estradiol 13 griseofulvin ultramicrosize 6 ketorolac tromethamine 1 estradiol vaginal 18 guaifenesin 11 ketorolac tromethamine ESTROGEL 13 guaifenesin-codeine 11 (ophth) 16 ethosuximide 4 haloperidol 8 labetalol hcl 9 ETIDRONATE DISODIUM 13 homatropine hbr 15 lactulose (encephalopathy) 13 ezetimibe-simvastatin 7 HUMULIN 70/30 5 lamotrigine 4 famotidine 18 HUMULIN N 5 LANTUS 6 fenofibrate 7 HUMULIN R 5 LANTUS SOLOSTAR 6 FENOFIBRATE 7 hydralazine hcl 8 latanoprost 16 fenofibrate 7 hydrochlorothiazide 12 LATANOPROST 16 fenofibrate micronized 7 hydrocodone- LEUCOVORIN CALCIUM 8 ferrous sulfate 14 acetaminophen 2 leucovorin calcium 8

Index 2 levetiracetam 4 mupirocin 11 pentoxifylline 14 LEVOBUNOLOL HCL 15 mupirocin calcium (topical) 11 permethrin 12 levobunolol hcl 15 nabumetone 1 perphenazine 9 levofloxacin 13 nadolol 9 phenazopyridine hcl 13 levofloxacin (ophth) 16 naltrexone hcl 6 phenytoin 4 levothyroxine sodium 17 naproxen 1 phenytoin sodium extended 4 LINDANE 12 naproxen sodium 1 phytonadione 18 lisinopril 7 neomycin sulfate 1 pilocarpine hcl 15 lisinopril & neomycin-polymy- pioglitazone hcl 5 hydrochlorothiazide 7 dexameth 16 polymyxin b-trimethoprim 16 lithium carbonate 8 neomycin-polymyxin-hc potassium chloride 14 loperamide hcl 6 (otic) 16 NIACIN 7 POTASSIUM CHLORIDE lorazepam 2 ER 15 niacin 19 losartan potassium 7 potassium chloride losartan potassium & nifedipine 9 microencapsulated crystals hydrochlorothiazide 7 nitrofurantoin macrocrystal 18 er 15 lovastatin 7 nitrofurantoin monohyd pravastatin sodium 7 loxapine succinate 8 macro 18 prazosin hcl 7 nitroglycerin 2 meclizine hcl 6 PREDNISOLONE ACETATE16 nortriptyline hcl 5 MEDROL 10 PREDNISOLONE ACETATE P- F 16 medroxyprogesterone NORTUSS-EX 11 acetate 17 NOVOLIN 70/30 6 PREDNISONE 10 megestrol acetate 8 NOVOLIN 70/30 RELION 6 prednisone 10 meloxicam 1 NOVOLIN N 6 PREDNISONE INTENSOL 10 MENOSTAR 13 NOVOLIN N RELION 6 PREMARIN 13 mesalamine 13 NOVOLIN R 6 primidone 4 metformin hcl 5 NOVOLIN R RELION 6 PROAIR RESPICLICK 3 methazolamide 12 NOVOLOG 6 probenecid 14 methimazole 17 nystatin 6 prochlorperazine 9 methocarbamol 15 nystatin (mouth-throat) 15 prochlorperazine maleate 9 methotrexate sodium 8 nystatin (topical) 11 progesterone micronized 17 methyldopa 7 nystatin-triamcinolone 11 propranolol hcl 9 methylphenidate hcl 1 ofloxacin (ophth) 16 PROPRANOLOL HCL 9 methylprednisolone 10 olanzapine 9 propranolol hcl 9 metoclopramide hcl 13 omeprazole 18 propylthiouracil 17 metolazone 13 OMEPRAZOLE 18 PROVENTIL HFA 3 metoprolol succinate 9 ondansetron hcl 6 pyridostigmine bromide 8 metoprolol tartrate 9 oseltamivir phosphate 9 quetiapine fumarate 9 metronidazole 2 oxybutynin chloride 18 quinapril hcl 7 metronidazole (topical) 12 oxycodone w/ quinapril-hydrochlorothiazide 7 metronidazole vaginal 18 acetaminophen 2 ranitidine hcl 18 PANCREAZE 12 minocycline hcl 17 risperidone 8 pantoprazole sodium 18 mirtazapine 4 rivastigmine tartrate 17 paroxetine hcl 5 misoprostol 18 rizatriptan benzoate 14 peg 3350-kcl-sod bicarb-sod ropinirole hydrochloride 8 mometasone furoate 12 chloride-sod sulfate 14 morphine sulfate 1 penicillin v potassium 17 rosuvastatin calcium 7 MUPIROCIN 11 PENTASA 13 selegiline hcl 8 SELEGILINE HCL 8

Index 3 sertraline hcl 5 triamcinolone acetonide silver sulfadiazine 11 (topical) 12 triamterene & simvastatin 7 hydrochlorothiazide 12 SPIRIVA HANDIHALER 3 TRIANEX 12 spironolactone 12 triazolam 14 spironolactone & trifluoperazine hcl 9 hydrochlorothiazide 12 TRIFLURIDINE 16 sucralfate 18 sulfacetamide sod- trihexyphenidyl hcl 8 prednisolone 16 trimethobenzamide hcl 6 sulfacetamide sodium (acne)11 trimethoprim 2 sulfacetamide sodium valproic acid 4 (ophth) 16 venlafaxine hcl 5 SULFACETAMIDE SODIUM/PREDNISOLONE VENTOLIN HFA 3 SODIUM PHOSPHATE 16 verapamil hcl 10 sulfamethoxazole- VERAPAMIL HCL ER 10 trimethoprim 2 VERAPAMIL HCL SR 10 sulfasalazine 13 VERAPAMIL sulindac 1 HYDROCHLORIDE ER 10 sumatriptan succinate 14 warfarin sodium 4 SYMBICORT 3 ziprasidone hcl 8 tamoxifen citrate 8 tamsulosin hcl 13 temazepam 14 terazosin hcl 7 terbinafine hcl 6 TERCONAZOLE 18 terconazole vaginal 18 tetracycline hcl 17 THEO-24 3 theophylline 4 THEOPHYLLINE ER 3 timolol maleate (ophth) 15 tobramycin (ophth) 16 tobramycin-dexamethasone 16 TOLAZAMIDE 6 TOLBUTAMIDE 6 topiramate 4 torsemide 12 tramadol hcl 1 tramadol-acetaminophen 2 tranylcypromine sulfate 4 travoprost 16 trazodone hcl 5 triamcinolone acetonide (mouth) 15 triamcinolone acetonide (nasal) 15

Index 4