Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- Attention-Deficit/Hyperactivity Disorder (ADHD) OBESITY/ANOREXIANTS - to Treat QL(2 ea daily); ADHD, Sleep and Eating Disorders hcl caps 10 F mg AL(At least 6 yrs old) TABS QL(2 ea daily); atomoxetine hcl caps 18 QL(1 ea daily); (- F AL(At least 6 mg, 25 mg, 40 mg, 60 mg, F AL(At least 6 ) yrs old) 80 mg, 100 mg yrs old) ADDERALL XR CP24 QL(1 ea daily); QL(1 ea daily); 2.5MG-2.5MG-2.5MG- AL(At least 6 hcl (adhd) tb24 F AL(At least 6 2.5MG, 7.5MG-7.5MG- yrs old) yrs old) 7.5MG-7.5MG, 1.25MG- QL(1 ea daily); 1.25MG-1.25MG-1.25MG, INTUNIV TB24 NF F )) AL(At least 6 3.75MG-3.75MG-3.75MG- (Guanfacine HCl (ADHD yrs old) 3.75MG, 6.25MG-6.25MG- QL(4 ea daily); 6.25MG-6.25MG KAPVAY TB12 0.1 MG F )) AL(At least 6 (Amphetamine- ( HCl (ADHD yrs old) Dextroamphetamine) QL(2 ea daily); ADDERALL XR CP24 QL(2 ea daily); STRATTERA CAPS 10 MG NF (Atomoxetine HCl) AL(At least 6 5MG-5MG-5MG-5MG F AL(At least 6 yrs old) (Amphetamine- yrs old) Dextroamphetamine) STRATTERA CAPS 18 QL(1 ea daily); MG, 25 MG, 40 MG, 60 NF AL(At least 6 amphetamine- QL(2 ea daily); MG, 80 MG, 100 MG yrs old) dextroamphetamine tabs AL(At least 6 (Atomoxetine HCl) 5mg-5mg-5mg-5mg, yrs old) 2.5mg-2.5mg-2.5mg- - Misc. 2.5mg, 7.5mg-7.5mg- QL(1 ea daily); 7.5mg-7.5mg, 1.25mg- APTENSIO XR CP24 F AL(At least 6 1.25mg-1.25mg-1.25mg, F yrs old) 3.75mg-3.75mg-3.75mg- QL(2 ea daily); 3.75mg, 1.875mg- CONCERTA TBCR NF ) AL(At least 6 1.875mg-1.875mg- ( HCl yrs old) 1.875mg, 3.125mg- 3.125mg-3.125mg- QL(1 ea daily); 3.125mg DAYTRANA PTCH F AL(At least 6 yrs old) DEXEDRINE CP24 QL(2 ea daily); (Dextroamphetamine NF AL(At least 6 QL(2 ea daily); FOCALIN TABS F Sulfate) yrs old) ) AL(At least 6 ( HCl yrs old) QL(2 ea daily); dextroamphetamine sulfate F AL(At least 6 QL(2 ea daily); cp24 5 mg, 10 mg, 15 mg FOCALIN XR CP24 F yrs old) ) AL(At least 6 (Dexmethylphenidate HCl yrs old) QL(2 ea daily); dextroamphetamine sulfate F AL(At least 6 QL(1 ea daily); tabs 5 mg, 10 mg METADATE CD CPCR NF yrs old) ) AL(At least 6 (Methylphenidate HCl yrs old) QL(1 ea daily); VYVANSE CAPS F AL(At least 6 METHYLIN CHEW 5 MG, AL(At least 6 yrs old) 10 MG, 2.5 MG NF yrs old) (Methylphenidate HCl) QL(1 ea daily); VYVANSE CHEW F AL(At least 6 yrs old) Arizona Complete Health-Complete Care Plan Effective October 1, 2018

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METHYLIN SOLN 5 QL(10 ml TOBI NEBU (Tobramycin) NF MG/5ML, 10 MG/5ML F daily); AL(At (Methylphenidate HCl) least 6 yrs old) - ANTI-INFLAMMATORY - Drugs methylphenidate hcl chew F AL(At least 6 to Treat Pain, Swelling, Muscle and Joint or 5 mg, 10 mg, 2.5 mg yrs old) Conditions methylphenidate hcl cp24 QL(2 ea daily); Anti-TNF-alpha - Monoclonal Antibodies or 10 mg, 20 mg, 30 mg, F AL(At least 6 40 mg yrs old) HUMIRA PEDIATRIC PA; SP CROHNS DISEASE F methylphenidate hcl cpcr or QL(1 ea daily); STARTER PACK PSKT 10 mg, 20 mg, 30 mg, 40 F AL(At least 6 mg, 50 mg, 60 mg yrs old) HUMIRA PEN PNKT F PA; SP QL(2 ea daily); HUMIRA PEN-CD/UC/HS PA; SP METHYLPHENIDATE HCL F ER TBCR AL(At least 6 STARTER PNKT 40 F yrs old) MG/0.8ML QL(3 ea daily); methylphenidate hcl tabs or HUMIRA PEN-PS/UV F PA; SP F AL(At least 6 STARTER PNKT 5 mg, 10 mg, 20 mg yrs old) PA; SP methylphenidate hcl tbcr or QL(2 ea daily); HUMIRA PSKT F 18 mg, 27 mg, 36 mg, 54 F AL(At least 6 mg yrs old) Nonsteroidal Anti-inflammatory Agents (NSAIDs) METHYLPHENIDATE QL(2 ea daily); ADVIL CAPS () NF HYDROCHLORIDE ER F AL(At least 6 TB24 yrs old) ADVIL MIGRAINE CAPS NF (Ibuprofen) QL(1 ea daily); QUILLICHEW ER CHER F AL(At least 6 ALEVE CAPS ( NF yrs old) Sodium) QL(5 ml daily); ANAPROX DS TABS NF QUILLIVANT XR SUSR F AL(At least 6 (Naproxen Sodium) yrs old) ARTHROTEC 50 TBEC NF QL(2 ea daily); (Diclofenac w/ Misoprostol) RITALIN LA CP24 10 MG F AL(At least 6 (Methylphenidate HCl) ARTHROTEC 75 TBEC NF yrs old) (Diclofenac w/ Misoprostol) RITALIN LA CP24 20 MG, QL(2 ea daily); CELEBREX CAPS NF PA; QL(2 ea 30 MG, 40 MG NF AL(At least 6 (Celecoxib) daily) (Methylphenidate HCl) yrs old) celecoxib caps or 50 mg, F PA; QL(2 ea QL(3 ea daily); 100 mg, 200 mg, 400 mg daily) RITALIN TABS NF AL(At least 6 (Methylphenidate HCl) CHILDRENS ADVIL SUSP NF RX/OTC yrs old) (Ibuprofen) AMINOGLYCOSIDES - Drugs to Treat Bacterial CHILDRENS MOTRIN NF RX/OTC Infections SUSP (Ibuprofen) Aminoglycosides DAYPRO TABS NF (Oxaprozin) BETHKIS NEBU F PA; SP diclofenac potassium tabs F 50 mg KITABIS PAK NEBU F PA diclofenac sodium tb24 or F sulfate tabs or F 100 mg

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diclofenac sodium tbec or F LODINE TABS (Etodolac) NF 25 mg, 50 mg, 75 mg MECLOFENAMATE diclofenac w/ misoprostol F tbec SODIUM CAPS OR 50 F MG, 100 MG EC-NAPROSYN TBEC NF (Naproxen) mefenamic acid caps or F 250 mg etodolac caps F meloxicam tabs or 15 mg, F 7.5 mg etodolac tabs F MOBIC TABS (Meloxicam) NF etodolac tb24 F nabumetone tabs or 500 F mg, 750 mg FELDENE CAPS NF (Piroxicam) NALFON CAPS F FENOPROFEN CALCIUM F CAPS OR 400 MG NAPROSYN SUSP NF (Naproxen) fenoprofen calcium tabs or F 600 mg NAPROSYN TABS NF (Naproxen) FENORTHO CAPS 400 F MG naproxen sodium caps or F 220 mg flurbiprofen tabs or 50 mg, F 100 mg naproxen sodium tabs or F 275 mg, 550 mg ibuprofen caps or 200 mg F naproxen susp or 125 F ibuprofen chew or 100 mg F mg/5ml naproxen tabs or 250 mg, F ibuprofen susp or 100 F RX/OTC 375 mg, 500 mg mg/5ml naproxen tbec or 375 mg, F ibuprofen tabs or 400 mg, F 500 mg 600 mg, 800 mg oxaprozin tabs 600 mg F INDOCIN SUPP F piroxicam caps or 10 mg, F INDOCIN SUSP F 20 mg PONSTEL CAPS NF indomethacin caps or 25 F (Mefenamic Acid) mg, 50 mg sulindac tabs or 150 mg, F indomethacin cpcr or 75 F 200 mg mg TOLMETIN SODIUM F ketoprofen caps or 50 mg, F CAPS 400 MG 75 mg tolmetin sodium caps 400 F KETOPROFEN CAPS OR F mg 50 MG, 75 MG TOLMETIN SODIUM TABS F KETOPROFEN ER CP24 F 200 MG, 600 MG Pyrimidine Synthesis Inhibitors ketorolac tromethamine F QL(20 ea per tabs or 10 mg 30 days retail) ARAVA TABS NF (Leflunomide)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits leflunomide tabs or 10 mg, F EXTRA 20 mg STRENGTH TABS NF (Acetaminophen) Soluble Tumor Necrosis Factor Receptor Agents TYLENOL INFANTS ENBREL SOSY 50 MG/ML, F PA; SP PAIN+FEVER SUSP NF 25 MG/0.5ML (Acetaminophen) ENBREL SURECLICK PA; SP F TYLENOL INFANTS SUSP NF SOAJ (Acetaminophen) ANALGESICS - NonNarcotic - Drugs to Treat TYLENOL TABS NF Pain, Muscle and Joint Conditions (Acetaminophen) Combinations Salicylates butalbital-acetaminophen- QL(6 ea daily) F buffered (cal carb- F caps mag carb-mag oxide) tabs butalbital-acetaminophen- F QL(6 ea daily) caffeine tabs aspirin chew or 81 mg F butalbital-aspirin-caffeine F QL(6 ea daily) ASPIRIN SUPP RE 120 caps 50mg-40mg-325mg MG, 200 MG, 300 MG, 600 F BUTALBITAL/ASPIRIN/CA QL(6 ea daily) MG FFEINE TABS 50MG- F aspirin supp re 300 mg, F 40MG-325MG 600 mg ESGIC TABS (Butalbital- NF QL(6 ea daily) aspirin tabs or 325 mg F Acetaminophen-Caffeine) FIORICET CAPS QL(6 ea daily) aspirin tbec or 81 mg, 324 F (Butalbital-Acetaminophen- NF mg, 325 mg, 500 mg Caffeine) BUFFERIN TABS (Aspirin Buffered (Cal Carb-Mag NF FIORINAL CAPS NF QL(6 ea daily) (Butalbital-Aspirin-Caffeine) Carb-Mag Oxide)) Analgesics Other choline & mag salicylate F liqd acetaminophen caps or F 500 mg diflunisal tabs F acetaminophen chew or 80 F DISALCID TABS NF mg (Salsalate) acetaminophen elix or 160 F ECOTRIN MAXIMUM mg/5ml, 80 mg/2.5ml STRENGTH TBEC NF acetaminophen liqd or 160 F (Aspirin) mg/5ml ECOTRIN REGULAR acetaminophen supp re F STRENGTH TBEC NF 120 mg, 325 mg, 650 mg (Aspirin) acetaminophen susp or F salsalate tabs or 500 mg, F 160 mg/5ml, 80 mg/2.5ml 750 mg acetaminophen tabs or 325 F ANALGESICS - OPIOID - Drugs to Treat Pain, mg, 500 mg Muscle and Joint Conditions TYLENOL CHILDRENS NF SUSP (Acetaminophen) Opioid Agonists DEMEROL TABS OR 100 NF MG (Meperidine HCl)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DILAUDID LIQD OR 1 QL(16 ml daily) tramadol hcl tabs or 50 mg F QL(6 ea daily) MG/ML (Hydromorphone NF HCl) tramadol hcl tb24 or 100 F PA DILAUDID TABS OR 2 QL(6 ea daily) mg, 200 mg, 300 mg MG, 4 MG, 8 MG NF ULTRAM TABS (Tramadol NF QL(6 ea daily) (Hydromorphone HCl) HCl) DURAGESIC PT72 NF PA XTAMPZA ER C12A F PA (Fentanyl) EMBEDA CPCR F PA Opioid Combinations acetaminophen w/ codeine F QL(16 ml daily) fentanyl pt72 12 mcg/hr, 25 PA soln 120mg/5ml-12mg/5ml mcg/hr, 50 mcg/hr, 75 F mcg/hr, 100 mcg/hr acetaminophen w/ codeine QL(6 ea daily) tabs 300mg-15mg, 300mg- F hydromorphone hcl liqd or F QL(16 ml daily) 30mg, 300mg-60mg 1 mg/ml butalbital-acetaminophen- F QL(6 ea daily) 12 per caffeine w/ codeine caps HYDROMORPHONE HCL F month;QL(0.4 SUPP RE 3 MG ea daily,12 ea butalbital-aspirin-caffeine QL(6 ea daily) per fill retail) w/cod caps 50mg-40mg- F 30mg-325mg hydromorphone hcl tabs or F QL(6 ea daily) 2 mg, 4 mg, 8 mg FIORICET/CODEINE QL(6 ea daily) CAPS (Butalbital- NF meperidine hcl tabs or 50 F Acetaminophen-Caffeine w/ mg, 100 mg Codeine) 500 per FIORINAL/CODEINE #3 QL(6 ea daily) morphine sulfate soln or 10 F mg/5ml, 20 mg/5ml month;QL(16.6 CAPS (Butalbital-Aspirin- NF 7 ml daily) Caffeine w/Cod) MORPHINE SULFATE QL(6 ea daily) hydrocodone- QL(16 ml daily) SUPP RE 5 MG, 10 MG, F acetaminophen soln 20 MG, 30 MG 2.5mg/5ml-108mg/5ml, F MORPHINE SULFATE F QL(6 ea daily) 5mg/10ml-217mg/10ml, TABS OR 15 MG, 30 MG 7.5mg/15ml-325mg/15ml morphine sulfate tbcr or 15 PA hydrocodone- QL(6 ea daily) mg, 30 mg, 60 mg, 100 mg, F acetaminophen tabs 5mg- 200 mg 300mg, 5mg-325mg, 10mg-300mg, 10mg- F MS CONTIN TBCR NF PA (Morphine Sulfate) 325mg, 2.5mg-325mg, 7.5mg-300mg, 7.5mg- oxycodone hcl caps or 5 F QL(6 ea daily) 325mg mg hydrocodone-ibuprofen F QL(6 ea daily) oxycodone hcl conc or 100 F QL(6 ml daily) tabs mg/5ml IBUDONE TABS NF QL(6 ea daily) oxycodone hcl soln or 5 F QL(6 ml daily) (Hydrocodone-Ibuprofen) mg/5ml NORCO TABS QL(6 ea daily) oxycodone hcl tabs or 5 QL(6 ea daily) NF F (Hydrocodone- mg, 10 mg, 15 mg, 20 mg, Acetaminophen) 30 mg oxycodone w/ F QL(6 ea daily) ROXICODONE TABS NF QL(6 ea daily) acetaminophen tabs (Oxycodone HCl)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits oxycodone-aspirin tabs F QL(6 ea daily) ANDROXY TABS F

200 per AXIRON SOLN NF PA OXYCODONE/ACETAMIN F month;QL(6.67 (Testosterone) OPHEN SOLN ml daily) danazol caps or 50 mg, F PERCOCET TABS QL(6 ea daily) 100 mg, 200 mg (Oxycodone w/ NF DEPO-TESTOSTERONE PA Acetaminophen) SOLN (Testosterone NF PRIMLEV TABS 5MG- F QL(6 ea daily) Cypionate) 300MG, 10MG-300MG testosterone cypionate soln F PA REPREXAIN TABS NF QL(6 ea daily) im 100 mg/ml, 200 mg/ml (Hydrocodone-Ibuprofen) testosterone enanthate F PA tramadol-acetaminophen F QL(3 ea daily) soln im tabs 37.5mg-325mg testosterone gel td 25 F PA TYLENOL/CODEINE #3 QL(6 ea daily) mg/2.5gm TABS (Acetaminophen w/ NF TESTOSTERONE GEL TD F PA Codeine) 25 MG/2.5GM TYLENOL/CODEINE #4 QL(6 ea daily) testosterone soln td 30 F PA TABS (Acetaminophen w/ NF mg/act Codeine) ANORECTAL AGENTS - Rectal Drugs to Treat ULTRACET TABS NF QL(3 ea daily) (Tramadol-Acetaminophen) Pain, Swelling and Itching XODOL TABS QL(6 ea daily) Intrarectal Steroids (Hydrocodone- NF CORTENEMA ENEM Acetaminophen) (Hydrocortisone NF )) Opioid Partial Agonists (Intrarectal CORTIFOAM FOAM F buprenorphine hcl subl sl 2 F Smart PA mg, 8 mg Required hydrocortisone (intrarectal) F BUPRENORPHINE PTWK F enem 100 mg/60ml Rectal Combinations BUTRANS PTWK F ANALPRAM HC CREA (Hydrocortisone Acetate w/ NF F AL(At least 6 SUBOXONE FILM yrs old) Pramoxine) ANDROGENS-ANABOLIC - Drugs to Regulate ANALPRAM HC SINGLES Hormones CREA (Hydrocortisone NF Acetate w/ Pramoxine) Androgens ANALPRAM-HC CREA ANDRODERM PT24 F PA 1%-1% (Hydrocortisone NF Acetate w/ Pramoxine) ANDROGEL GEL 25 PA NF hydrocortisone acetate w/ F MG/2.5GM (Testosterone) pramoxine crea ANDROGEL GEL 40.5 PA MG/2.5GM, 20.25 F PROCORT CREA F MG/1.25GM Rectal Steroids ANDROGEL PUMP GEL F PA ANUSOL-HC CREA NF (Hydrocortisone (Rectal)) Arizona Complete Health-Complete Care Plan Effective October 1, 2018

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydrocortisone (rectal) crea F TUMS E-X 750 CHEW (Calcium Carbonate NF ()) PROCTOCORT CREA 1 % NF (Hydrocortisone (Rectal)) TUMS EXTRA STRENGTH 750 CHEW (Calcium NF Carbonate (Antacid)) Antacid Combinations TUMS KIDS CHEW alum & mag hydrox- (Calcium Carbonate NF (Antacid)) simethicone liqd F 200mg/5ml-20mg/5ml- TUMS LASTING EFFECTS 200mg/5ml CHEW (Calcium Carbonate NF alum & mag hydrox- (Antacid)) simethicone susp TUMS SMOOTHIES 200mg/5ml-20mg/5ml- CHEW (Calcium Carbonate NF 200mg/5ml, 200mg/5ml- F (Antacid)) 200mg/5ml-20mg/5ml- TUMS ULTRA 1000 CHEW 20mg/5ml-200mg/5ml- (Calcium Carbonate NF 200mg/5ml (Antacid)) Antacids - Calcium Salts Antacids - Magnesium Salts ANTACID CHEW F magnesium oxide tabs 400 F mg ANTACID SOFT CHEWS F CHEW ANTHELMINTICS - Drugs to Treat Worm Infections calcium carbonate Anthelmintics (antacid) chew 400 mg, F 420 mg, 500 mg, 750 mg, ALBENZA TABS F PA 1000 mg BILTRICIDE TABS calcium carbonate F NF (antacid) tabs 648 mg (Praziquantel) PA CALCIUM CARBONATE F ivermectin tabs or 3 mg F TABS OR 648 MG CHILDRENS praziquantel tabs or 600 F MYLANTAUPSET mg STOMACH RELIEF CHEW NF pyrantel pamoate susp or F (Calcium Carbonate (Antacid)) REESES PINWORM F MEDICINE TABS MAALOX CHEW F STROMECTOL TABS NF PA (Ivermectin) TUMS CHEW (Calcium NF Carbonate (Antacid)) ANTI-INFECTIVE AGENTS - MISC. - Drugs to TUMS CHEWY BITES Treat Bacterial Infections CHEW (Calcium Carbonate NF (Antacid)) Anti-infective Agents - Misc. FIRST-VANCOMYCIN 25 PA TUMS CHEWY DELIGHTS F F CHEW SOLN FIRST-VANCOMYCIN 50 F PA SOLN

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLAGYL CAPS NF ZYVOX SUSR OR 100 NF PA (Metronidazole) MG/5ML () FLAGYL TABS NF ZYVOX TABS OR 600 MG NF PA (Metronidazole) (Linezolid) metronidazole caps or 375 F AGENTS - Drugs to Treat Chest mg Pain metronidazole tabs or 250 F mg, 500 mg -Other RANEXA TB12 F PA trimethoprim tabs or 100 F mg Nitrates VANCOCIN HCL CAPS NF PA (Vancomycin HCl) DILATRATE SR CPCR F VANCOMYCIN HCL + F PA SYRSPENDSF PH4 SUSP ISORDIL TITRADOSE MP TABS 5 MG (Isosorbide NF vancomycin hcl caps or F PA Dinitrate) 125 mg, 250 mg ISOSORBIDE DINITRATE F MP vancomycin hcl solr iv 1000 F ER TBCR mg isosorbide dinitrate tabs F MP Anti-infective Misc. - Combinations BACTRIM DS TABS isosorbide mononitrate tabs F MP (Sulfamethoxazole- NF Trimethoprim) isosorbide mononitrate F MP BACTRIM TABS tb24 (Sulfamethoxazole- NF NITRO-BID OINT F Trimethoprim) sulfamethoxazole- NITRO-DUR PT24 0.1 MP trimethoprim susp or F MG/HR, 0.2 MG/HR, 0.4 NF 40mg/5ml-200mg/5ml MG/HR, 0.6 MG/HR sulfamethoxazole- (Nitroglycerin) trimethoprim tabs or 80mg- F NITRO-DUR PT24 0.3 F 400mg, 160mg-800mg MG/HR, 0.8 MG/HR Leprostatics nitroglycerin cpcr or 9 mg, F MP 2.5 mg, 6.5 mg dapsone tabs or 25 mg, F 100 mg nitroglycerin pt24 td 0.1 MP mg/hr, 0.2 mg/hr, 0.4 F Lincosamides mg/hr, 0.6 mg/hr CLEOCIN CAPS OR 75 nitroglycerin subl sl 0.3 mg, F MP MG, 150 MG, 300 MG NF 0.4 mg, 0.6 mg (Clindamycin HCl) NITROSTAT SUBL NF MP clindamycin hcl caps or 75 F (Nitroglycerin) mg, 150 mg, 300 mg ANTIANXIETY AGENTS - Drugs to Treat Anxiety Oxazolidinones Antianxiety Agents - Misc. linezolid susr or 100 F PA mg/5ml hcl tabs or 30 QL(2 ea daily); PA F AL(At least 6 linezolid tabs or 600 mg F mg yrs old)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(4 ea daily); QL(4 ea daily); buspirone hcl tabs or 5 mg, F ATIVAN TABS OR 0.5 MG, NF AL(At least 6 ) AL(At least 6 10 mg, 15 mg, 7.5 mg yrs old) 1 MG (Lorazepam yrs old) hcl syrp or 10 QL(10 ml daily) QL(3 ea daily); F ATIVAN TABS OR 2 MG NF mg/5ml ) AL(At least 6 (Lorazepam yrs old) hydroxyzine hcl tabs or 10 F QL(8 ea daily) mg, 25 mg, 50 mg QL(2 ea daily); HYDROXYZINE QL(4 ea daily) chlordiazepoxide hcl caps F AL(At least 6 PAMOATE CAPS OR 100 F yrs old) MG QL(2 ea daily); clorazepate dipotassium F AL(At least 6 hydroxyzine pamoate caps F QL(4 ea daily) tabs 15 mg or 25 mg, 50 mg yrs old) QL(4 ea daily); VISTARIL CAPS NF QL(4 ea daily) clorazepate dipotassium (Hydroxyzine Pamoate) F AL(At least 6 tabs 7.5 mg, 3.75 mg yrs old) Benzodiazepines QL(2 ml daily) Limit diazepam conc or 5 mg/ml F alprazolam to DIAZEPAM SOLN OR 5 F QL(10 ml daily) 4mg MG/5ML ALPRAZOLAM INTENSOL F daily;QL(60 ml CONC per 15 days QL(4 ea daily); diazepam tabs or 2 mg, 5 F retail); AL(At mg, 10 mg AL(At least 6 least 6 yrs old) yrs old) Limit QL(2 ml daily); alprazolam to lorazepam conc or 2 mg/ml F AL(At least 6 alprazolam tabs or 0.25 F 4mg daily;QL(4 yrs old) mg, 0.5 mg, 1 mg ea daily); AL(At QL(4 ea daily); lorazepam tabs or 0.5 mg, F least 6 yrs old) 1 mg AL(At least 6 Limit yrs old) alprazolam to QL(3 ea daily); alprazolam tabs or 2 mg F 4mg daily;QL(2 lorazepam tabs or 2 mg F AL(At least 6 ea daily); AL(At yrs old) least 6 yrs old) QL(2 ea daily); oxazepam caps 10 mg, 15 F Limit mg, 30 mg AL(At least 6 alprazolam to yrs old) alprazolam tb24 or 0.5 mg, F 1 mg, 2 mg, 3 mg 4mg daily;QL(1 QL(2 ea daily); ea daily); AL(At OXAZEPAM CAPS 30 MG F AL(At least 6 least 6 yrs old) yrs old) Limit QL(4 ea daily); alprazolam to TRANXENE T TABS NF AL(At least 6 alprazolam tbdp or 0.25 F (Clorazepate Dipotassium) mg, 0.5 mg, 1 mg 4mg daily;QL(4 yrs old) ea daily); AL(At QL(4 ea daily); least 6 yrs old) VALIUM TABS (Diazepam) NF AL(At least 6 Limit yrs old) alprazolam to Limit alprazolam tbdp or 2 mg F 4mg daily;QL(2 alprazolam to ea daily); AL(At XANAX TABS 0.25 MG, NF ) 4mg daily;QL(4 least 6 yrs old) 0.5 MG, 1 MG (Alprazolam ea daily); AL(At least 6 yrs old) Arizona Complete Health-Complete Care Plan Effective October 1, 2018

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit TIKOSYN CAPS NF PA alprazolam to (Dofetilide) XANAX TABS 2 MG NF ) 4mg daily;QL(2 (Alprazolam ea daily); AL(At ANTIASTHMATIC AND BRONCHODILATOR least 6 yrs old) AGENTS - Drugs to Treat Lung Conditions Limit Anti-Inflammatory Agents alprazolam to cromolyn sodium nebu in XANAX XR TB24 NF F ) 4mg daily;QL(1 20 mg/2ml (Alprazolam ea daily); AL(At least 6 yrs old) Bronchodilators - Anticholinergics ANTIARRHYTHMICS - Drugs to treat abnormal ATROVENT HFA AERS F heart rhythms soln in F Antiarrhythmics Type I-A 0.02 % SPIRIVA HANDIHALER disopyramide phosphate F F caps CAPS 18 MCG NORPACE CAPS NF Leukotriene Modulators (Disopyramide Phosphate) ACCOLATE TABS NF NORPACE CR CP12 F (Zafirlukast) montelukast sodium chew F QL(1 ea daily) gluconate tbcr or F or 4 mg, 5 mg 324 mg QL(1 ea daily); QUINIDINE SULFATE montelukast sodium pack F AL(Up to 3 yrs TABS OR 200 MG, 300 F or 4 mg old ) MG montelukast sodium tabs or F QL(1 ea daily) Antiarrhythmics Type I-B 10 mg mexiletine hcl caps F SINGULAIR CHEW 4 MG, QL(1 ea daily) 5 MG (Montelukast NF Antiarrhythmics Type I-C Sodium) QL(1 ea daily); flecainide acetate tabs F SINGULAIR PACK 4 MG NF ) AL(Up to 3 yrs (Montelukast Sodium old ) propafenone hcl cp12 F SINGULAIR TABS 10 MG NF QL(1 ea daily) (Montelukast Sodium) propafenone hcl tabs F zafirlukast tabs F RYTHMOL SR CP12 NF (Propafenone HCl) Steroid Inhalants RYTHMOL TABS NF ASMANEX TWISTHALER (Propafenone HCl) 120 METERED DOSES F Antiarrhythmics Type III AEPB ASMANEX TWISTHALER amiodarone hcl tabs or 100 F mg, 200 mg 14 METERED DOSES F PA AEPB dofetilide caps F ASMANEX TWISTHALER PA 30 METERED DOSES F MULTAQ TABS F AEPB

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ASMANEX TWISTHALER levalbuterol hcl nebu in AL(Up to 3 yrs 60 METERED DOSES F 0.31 mg/3ml, 0.63 mg/3ml, F old ) AEPB 1.25 mg/3ml, 1.25 ASMANEX TWISTHALER mg/0.5ml 7 METERED DOSES F SEREVENT DISKUS F PA AEPB AEPB FLOVENT HFA AERO F STIOLTO RESPIMAT F PA AERS PULMICORT FLEXHALER F ST; Try AEPB , SYMBICORT AERO F , or PULMICORT SUSP F AL(Up to 4 yrs (Budesonide (Inhalation)) old ) inhaler first Sympathomimetics ST; Try VENTOLIN HFA AERS F Budesonide, XOPENEX AL(Up to 3 yrs Fluticasone, or CONCENTRATE NEBU NF old ) F Mometasone ) ADVAIR DISKUS AEPB inhaler (Levalbuterol HCl first;AL(At least XOPENEX NEBU NF AL(Up to 3 yrs 6 yrs old - Up (Levalbuterol HCl) old ) to 12 yrs old) ST; Try Budesonide, soln F Fluticasone, or theophylline tb12 F F Mometasone ADVAIR HFA AERO inhaler first;AL(At least theophylline tb24 F 4 yrs old - Up to 12 yrs old) ANTICOAGULANTS - Blood Thinners albuterol sulfate nebu in 0.63 mg/3ml, 0.083 %, 0.5 F Coumarin Anticoagulants %, 1.25 mg/3ml COUMADIN TABS NF (Warfarin Sodium) albuterol sulfate syrp or 2 F mg/5ml warfarin sodium tabs F albuterol sulfate tabs or 2 F mg, 4 mg Direct Factor Xa Inhibitors ELIQUIS STARTER PACK QL(74 ea per BEVESPI AEROSPHERE F PA F AERO TABS 30 days retail) QL(2 ea daily) COMBIVENT RESPIMAT F ELIQUIS TABS 2.5 MG F AERS ST; Try ELIQUIS TABS 5 MG F QL(74 ea per Budesonide, 30 days retail) DULERA AERO F Fluticasone, or PA; 51 per XARELTO STARTER F Mometasone PACK TBPK month;QL(1.7 inhaler first ea daily) ipratropium-albuterol soln F XARELTO TABS F QL(2 ea daily) Heparins And Heparinoid-Like Agents Arizona Complete Health-Complete Care Plan Effective October 1, 2018

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(180 ml per HEPARIN SODIUM/NACL F 30 days retail)3 0.45% SOLN enoxaparin sodium soln ij F 300 mg/3ml rtl MAX fill,365 HEPARIN rtl day(s) SODIUM/SODIUM supply, CHLORIDE 0.9% SOLN NF QL(60 ml per (Heparin (Porcine) in Sodium Chloride) enoxaparin sodium soln sc 30 days retail)3 F rtl MAX fill,365 HEPARIN 100 mg/ml, 150 mg/ml rtl day(s) SODIUM/SODIUM F supply, CHLORIDE SOLN IJ QL(18 ml per 2UNIT/ML-0.9% 30 days retail)3 QL(180 ml per enoxaparin sodium soln sc F 30 mg/0.3ml rtl MAX fill,365 LOVENOX SOLN IJ 300 30 days retail)3 rtl day(s) MG/3ML (Enoxaparin NF rtl MAX fill,365 supply, Sodium) rtl day(s) QL(24 ml per supply, 30 days retail)3 QL(60 ml per enoxaparin sodium soln sc F 40 mg/0.4ml rtl MAX fill,365 LOVENOX SOLN SC 100 30 days retail)3 rtl day(s) MG/ML (Enoxaparin NF rtl MAX fill,365 supply, Sodium) rtl day(s) QL(36 ml per supply, 30 days retail)3 LOVENOX SOLN SC 150 QL(60 ml per enoxaparin sodium soln sc F 60 mg/0.6ml rtl MAX fill,365 MG/ML (Enoxaparin NF 30 days retail) rtl day(s) Sodium) supply, LOVENOX SOLN SC 30 QL(18 ml per QL(48 ml per MG/0.3ML (Enoxaparin NF 30 days retail) 30 days retail)3 Sodium) enoxaparin sodium soln sc F rtl MAX fill,365 80 mg/0.8ml, 120 mg/0.8ml rtl day(s) LOVENOX SOLN SC 40 QL(24 ml per supply, MG/0.4ML (Enoxaparin NF 30 days retail) Sodium) heparin (porcine) in sodium F chloride soln LOVENOX SOLN SC 60 QL(36 ml per MG/0.6ML (Enoxaparin NF 30 days retail) HEPARIN LOCK FLUSH F Sodium) SOLN LOVENOX SOLN SC 80 QL(48 ml per heparin sod (porcine) in F MG/0.8ML, 120 MG/0.8ML NF 30 days retail) d5w soln (Enoxaparin Sodium) heparin sodium (porcine) SASH KIT FOR FLUSHING lock flush & nacl lock flush F VASCULAR ACCESS F kit DEVICES KIT heparin sodium (porcine) F lock flush soln Thrombin Inhibitors PRADAXA CAPS F QL(2 ea daily) heparin sodium (porcine) F soln ANTICONVULSANTS - Drugs to Treat Seizures HEPARIN SODIUM/D5W F SOLN Anticonvulsants - Benzodiazepines HEPARIN SODIUM/DEXTROSE F clonazepam tabs or 0.5 QL(4 ea daily); SOLN F AL(At least 6 mg, 1 mg yrs old) Arizona Complete Health-Complete Care Plan Effective October 1, 2018

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); gabapentin soln or 250 F clonazepam tabs or 2 mg F AL(At least 6 mg/5ml, 300 mg/6ml yrs old) gabapentin tabs or 600 mg, F QL(4 ea daily); 800 mg clonazepam tbdp or 0.125 F AL(At least 6 mg, 0.25 mg, 0.5 mg, 1 mg KEPPRA SOLN OR 100 NF yrs old) MG/ML (Levetiracetam) QL(2 ea daily); KEPPRA TABS OR 250 clonazepam tbdp or 2 mg F AL(At least 6 MG, 500 MG, 750 MG, NF yrs old) 1000 MG (Levetiracetam) QL(2 ea per 30 DIASTAT ACUDIAL GEL F KEPPRA XR TB24 NF days retail) (Levetiracetam) DIASTAT PEDIATRIC GEL F QL(2 ea per 30 LAMICTAL CHEWABLE days retail) DISPERSIBLE CHEW NF DIAZEPAM GEL RE 10 F QL(2 ea per 30 (Lamotrigine) MG, 20 MG, 2.5 MG days retail) LAMICTAL ODT TBDP 25 DIAZEPAM RECTAL GEL F QL(2 ea per 30 MG, 50 MG, 100 MG, 200 NF GEL days retail) MG (Lamotrigine) QL(4 ea daily); LAMICTAL TABS NF KLONOPIN TABS 0.5 MG, NF ) 1 MG (Clonazepam) AL(At least 6 (Lamotrigine yrs old) LAMICTAL XR TB24 25 QL(2 ea daily); MG, 50 MG, 100 MG, 200 KLONOPIN TABS 2 MG NF NF ) AL(At least 6 MG, 250 MG, 300 MG (Clonazepam yrs old) (Lamotrigine) ONFI SUSP F PA lamotrigine chew or 5 mg, F 25 mg PA ONFI TABS F lamotrigine tabs or 25 mg, F 100 mg, 150 mg, 200 mg Anticonvulsants - Misc. lamotrigine tb24 or 25 mg, PA 50 mg, 100 mg, 200 mg, F BANZEL SUSP F 250 mg, 300 mg PA BANZEL TABS F lamotrigine tbdp or 25 mg, F 50 mg, 100 mg, 200 mg carbamazepine chew or F levetiracetam soln or 100 F 100 mg mg/ml, 500 mg/5ml carbamazepine cp12 or F levetiracetam tabs or 250 100 mg, 200 mg, 300 mg mg, 500 mg, 750 mg, 1000 F mg carbamazepine susp or F 100 mg/5ml levetiracetam tb24 or 500 F mg, 750 mg carbamazepine tabs or 200 F mg LYRICA CAPS F PA carbamazepine tb12 or 100 F mg, 200 mg, 400 mg LYRICA SOLN F PA CARBATROL CP12 NF (Carbamazepine) MYSOLINE TABS NF (Primidone) gabapentin caps or 100 F mg, 300 mg, 400 mg NEURONTIN CAPS NF (Gabapentin)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEURONTIN SOLN NF FELBATOL SUSP 600 NF (Gabapentin) MG/5ML (Felbamate) NEURONTIN TABS NF FELBATOL TABS 400 MG NF QL(9 ea daily) (Gabapentin) (Felbamate) oxcarbazepine susp F FELBATOL TABS 600 MG NF QL(6 ea daily) (Felbamate) oxcarbazepine tabs F GABA Modulators ST GABITRIL TABS 12 MG, NF PA OXTELLAR XR TB24 F 16 MG (Tiagabine HCl) GABITRIL TABS 2 MG, 4 PA; primidone tabs or 50 mg, F NF 250 mg MG (Tiagabine HCl) tiagabine hcl tabs 12 mg, PA TEGRETOL SUSP NF F (Carbamazepine) 16 mg tiagabine hcl tabs 2 mg, 4 PA; TEGRETOL TABS NF F (Carbamazepine) mg TEGRETOL-XR TB12 NF Hydantoins (Carbamazepine) DILANTIN CAPS 100 MG TOPAMAX SPRINKLE NF (Phenytoin Sodium NF CPSP (Topiramate) Extended) TOPAMAX TABS NF DILANTIN INFATABS NF (Topiramate) CHEW (Phenytoin) topiramate cpsp or 15 mg, F DILANTIN-125 SUSP NF 25 mg (Phenytoin) topiramate tabs or 25 mg, F PHENYTEK CAPS 50 mg, 100 mg, 200 mg (Phenytoin Sodium NF Extended) TRILEPTAL SUSP NF (Oxcarbazepine) phenytoin chew or 50 mg F TRILEPTAL TABS NF (Oxcarbazepine) phenytoin sodium extended F caps VIMPAT SOLN OR 10 F PA MG/ML phenytoin susp or 125 F mg/5ml VIMPAT TABS OR 50 MG, F PA 100 MG, 150 MG, 200 MG Succinimides ZONEGRAN CAPS NF ethosuximide caps or 250 F (Zonisamide) mg zonisamide caps or 25 mg, F ethosuximide soln or 250 F 50 mg, 100 mg mg/5ml Carbamates ZARONTIN CAPS NF (Ethosuximide) felbamate susp 600 F mg/5ml ZARONTIN SOLN NF (Ethosuximide) felbamate tabs 400 mg F QL(9 ea daily) Valproic Acid QL(6 ea daily) felbamate tabs 600 mg F DEPAKENE CAPS NF (Valproic Acid)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEPAKENE SOLN NF QL(2 ea daily); (Valproate Sodium) hcl tb12 or 100 F AL(At least 6 mg, 150 mg, 200 mg yrs old) DEPAKOTE ER TB24 NF (Divalproex Sodium) QL(1 ea daily); bupropion hcl tb24 or 150 F AL(At least 6 DEPAKOTE SPRINKLES NF mg, 300 mg CSDR (Divalproex Sodium) yrs old) DEPAKOTE TBEC 125 QL(16 ea daily) HCL TABS F AL(At least 6 MG, 250 MG (Divalproex NF yrs old) Sodium) QL(2 ea daily); WELLBUTRIN SR TB12 NF AL(At least 6 DEPAKOTE TBEC 500 MG NF QL(8 ea daily) (Bupropion HCl) (Divalproex Sodium) yrs old) divalproex sodium csdr or QL(1 ea daily); F WELLBUTRIN XL TB24 NF 125 mg ) AL(At least 6 (Bupropion HCl yrs old) divalproex sodium tb24 or F 250 mg, 500 mg Monoamine Oxidase Inhibitors (MAOIs) PA; AL(At least divalproex sodium tbec or F QL(16 ea daily) EMSAM PT24 F 125 mg, 250 mg 6 yrs old) AL(At least 6 divalproex sodium tbec or F QL(8 ea daily) MARPLAN TABS F 500 mg yrs old) NARDIL TABS (Phenelzine AL(At least 6 valproate sodium soln or F NF 250 mg/5ml Sulfate) yrs old) valproic acid caps 250 mg F PARNATE TABS NF AL(At least 6 ( Sulfate) yrs old) ANTIDEPRESSANTS - Drugs to Treat phenelzine sulfate tabs or F AL(At least 6 Depression 15 mg yrs old) Alpha-2 Receptor Antagonists (Tetracyclics) tranylcypromine sulfate F AL(At least 6 tabs 10 mg yrs old) QL(1 ea daily); tabs or 15 mg, F Selective Serotonin Reuptake Inhibitors (SSRIs) 30 mg, 45 mg AL(At least 6 yrs old) QL(3 ea daily); CELEXA TABS 10 MG NF QL(1 ea daily) ) AL(At least 6 mirtazapine tabs or 7.5 mg F (Citalopram Hydrobromide yrs old) QL(1 ea daily); CELEXA TABS 20 MG, 40 QL(1 ea daily); mirtazapine tbdp or 15 mg, F 30 mg, 45 mg AL(At least 6 MG (Citalopram NF AL(At least 6 yrs old) Hydrobromide) yrs old) QL(1 ea daily); QL(20 ml REMERON SOLTAB TBDP NF citalopram hydrobromide (Mirtazapine) AL(At least 6 F daily); AL(At yrs old) soln 10 mg/5ml least 6 yrs old) QL(1 ea daily); QL(3 ea daily); REMERON TABS NF citalopram hydrobromide (Mirtazapine) AL(At least 6 F AL(At least 6 yrs old) tabs 10 mg yrs old) Antidepressants - Misc. QL(1 ea daily); citalopram hydrobromide F QL(4 ea daily); tabs 20 mg, 40 mg AL(At least 6 bupropion hcl tabs or 75 F AL(At least 6 yrs old) mg, 100 mg yrs old) QL(20 ml escitalopram oxalate soln 5 F daily); AL(At mg/5ml least 6 yrs old)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 45 per QL(2 ea daily); LEXAPRO TABS 5 MG NF escitalopram oxalate tabs F month;QL(1.5 ) AL(At least 6 10 mg ea daily); AL(At (Escitalopram Oxalate yrs old) least 6 yrs old) QL(1 ea daily); QL(1 ea daily); paroxetine hcl tabs 10 mg, F AL(At least 6 escitalopram oxalate tabs F 20 mg, 30 mg 20 mg AL(At least 6 yrs old) yrs old) 45 per QL(2 ea daily); F month;QL(1.5 escitalopram oxalate tabs 5 F AL(At least 6 paroxetine hcl tabs 40 mg ea daily); AL(At mg yrs old) least 6 yrs old) PA; AL(At least QL(3 ea daily); FLUOXETINE DR CPDR F paroxetine hcl tb24 25 mg, F 6 yrs old) 12.5 mg, 37.5 mg AL(At least 6 QL(2 ea daily); yrs old) fluoxetine hcl caps or 10 F AL(At least 6 QL(3 ea daily); mg, 40 mg PAXIL CR TB24 NF yrs old) (Paroxetine HCl) AL(At least 6 QL(4 ea daily); yrs old) fluoxetine hcl caps or 20 F AL(At least 6 QL(30 ml mg yrs old) PAXIL SUSP 10 MG/5ML F daily); AL(At QL(20 ml least 6 yrs old) fluoxetine hcl soln or 20 F daily); AL(At PAXIL TABS 10 MG, 20 QL(1 ea daily); mg/5ml least 6 yrs old) MG, 30 MG (Paroxetine NF AL(At least 6 QL(3 ea daily); HCl) yrs old) fluvoxamine maleate cp24 F 100 mg AL(At least 6 45 per yrs old) PAXIL TABS 40 MG NF month;QL(1.5 QL(2 ea daily); (Paroxetine HCl) ea daily); AL(At fluvoxamine maleate cp24 F least 6 yrs old) 150 mg AL(At least 6 yrs old) PEXEVA TABS F PA; AL(At least QL(3 ea daily); 6 yrs old) fluvoxamine maleate tabs F AL(At least 6 QL(2 ea daily); 100 mg PROZAC CAPS 10 MG, 40 NF yrs old) MG (Fluoxetine HCl) AL(At least 6 QL(2 ea daily); yrs old) fluvoxamine maleate tabs F AL(At least 6 QL(4 ea daily); 25 mg PROZAC CAPS 20 MG NF yrs old) (Fluoxetine HCl) AL(At least 6 QL(6 ea daily); yrs old) fluvoxamine maleate tabs F AL(At least 6 QL(10 ml 50 mg sertraline hcl conc or 20 F yrs old) mg/ml daily); AL(At LEXAPRO SOLN 5 QL(20 ml least 6 yrs old) MG/5ML (Escitalopram NF daily); AL(At QL(2 ea daily); ) sertraline hcl tabs or 100 F Oxalate least 6 yrs old) mg AL(At least 6 45 per yrs old) LEXAPRO TABS 10 MG NF month;QL(1.5 QL(3 ea daily); (Escitalopram Oxalate) ea daily); AL(At sertraline hcl tabs or 25 mg F AL(At least 6 least 6 yrs old) yrs old) QL(1 ea daily); QL(4 ea daily); LEXAPRO TABS 20 MG NF F ) AL(At least 6 sertraline hcl tabs or 50 mg AL(At least 6 (Escitalopram Oxalate yrs old) yrs old)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(10 ml QL(4 ea daily); ZOLOFT CONC 20 MG/ML NF succinate F ) daily); AL(At AL(At least 6 (Sertraline HCl least 6 yrs old) tb24 yrs old) QL(2 ea daily); QL(4 ea daily); ZOLOFT TABS 100 MG NF duloxetine hcl cpep or 20 F ) AL(At least 6 AL(At least 6 (Sertraline HCl yrs old) mg, 30 mg yrs old) QL(3 ea daily); QL(2 ea daily); ZOLOFT TABS 25 MG NF duloxetine hcl cpep or 60 F ) AL(At least 6 AL(At least 6 (Sertraline HCl yrs old) mg yrs old) QL(4 ea daily); QL(1 ea daily); ZOLOFT TABS 50 MG NF EFFEXOR XR CP24 150 NF ) AL(At least 6 ) AL(At least 6 (Sertraline HCl yrs old) MG ( HCl yrs old) Serotonin Modulators EFFEXOR XR CP24 75 QL(3 ea daily); MG, 37.5 MG (Venlafaxine NF AL(At least 6 QL(2 ea daily); ) HCL TABS F AL(At least 6 HCl yrs old) 100 MG yrs old) QL(4 ea daily); PRISTIQ TB24 NF QL(4 ea daily); (Desvenlafaxine Succinate) AL(At least 6 NEFAZODONE HCL TABS F AL(At least 6 yrs old) 150 MG yrs old) QL(1 ea daily); venlafaxine hcl cp24 150 F QL(2 ea daily); mg AL(At least 6 nefazodone hcl tabs 50 F AL(At least 6 yrs old) mg, 250 mg yrs old) QL(3 ea daily); venlafaxine hcl cp24 75 F QL(3 ea daily); mg, 37.5 mg AL(At least 6 NEFAZODONE F AL(At least 6 yrs old) HYDROCHLORIDE TABS yrs old) QL(4 ea daily); F QL(4 ea daily); venlafaxine hcl tabs 25 mg AL(At least 6 hcl tabs or 100 F AL(At least 6 yrs old) mg yrs old) QL(3 ea daily); venlafaxine hcl tabs 50 mg, F QL(2 ea daily); 100 mg, 37.5 mg AL(At least 6 trazodone hcl tabs or 150 F AL(At least 6 yrs old) mg yrs old) QL(5 ea daily); F QL(1 ea daily); venlafaxine hcl tabs 75 mg AL(At least 6 trazodone hcl tabs or 300 F yrs old) mg AL(At least 6 yrs old) Tricyclic Agents QL(3 ea daily); hcl tabs or 10 AL(At least 6 trazodone hcl tabs or 50 F AL(At least 6 mg, 25 mg, 50 mg, 75 mg, F yrs old) mg yrs old) 100 mg, 150 mg F PA; AL(At least F AL(At least 6 VIIBRYD TABS 6 yrs old) TABS yrs old) Serotonin- Reuptake Inhibitors ANAFRANIL CAPS NF AL(At least 6 ) QL(4 ea daily); ( HCl yrs old) CYMBALTA CPEP 20 MG, NF clomipramine hcl caps or AL(At least 6 ) AL(At least 6 F 30 MG (Duloxetine HCl yrs old) 25 mg, 50 mg, 75 mg yrs old) QL(2 ea daily); hcl tabs or 10 AL(At least 6 CYMBALTA CPEP 60 MG NF mg, 25 mg, 50 mg, 75 mg, F yrs old) ) AL(At least 6 (Duloxetine HCl yrs old) 100 mg, 150 mg

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hcl caps or 10 mg, QL(3 ea daily); glipizide-metformin hcl tabs F MP 25 mg, 50 mg, 75 mg, 100 F AL(At least 6 mg, 150 mg yrs old) GLUCOVANCE TABS NF MP (Glyburide-Metformin) doxepin hcl conc or 10 QL(6 ml daily); F AL(At least 6 glyburide-metformin tabs F MP mg/ml yrs old) PA ELAVIL TABS NF AL(At least 6 GLYXAMBI TABS F (Amitriptyline HCl) yrs old) PA hcl tabs or 10 F AL(At least 6 JANUMET TABS F mg, 25 mg, 50 mg yrs old) JANUMET XR TB24 F PA F AL(At least 6 imipramine pamoate caps yrs old) JENTADUETO TABS F PA; NORPRAMIN TABS NF AL(At least 6 (Desipramine HCl) yrs old) JENTADUETO XR TB24 F PA hcl caps or 10 F AL(At least 6 mg, 25 mg, 50 mg, 75 mg yrs old) KOMBIGLYZE XR TB24 F PA nortriptyline hcl soln or 10 F AL(At least 6 mg/5ml yrs old) pioglitazone hcl-metformin F MP hcl tabs PAMELOR CAPS NF AL(At least 6 (Nortriptyline HCl) yrs old) Biguanides AL(At least 6 hcl tabs F GLUCOPHAGE TABS NF MP yrs old) (Metformin HCl) SURMONTIL CAPS AL(At least 6 NF GLUCOPHAGE XR TB24 NF MP ( Maleate) yrs old) (Metformin HCl) TOFRANIL TABS AL(At least 6 NF metformin hcl tabs or 500 F MP (Imipramine HCl) yrs old) mg, 850 mg, 1000 mg trimipramine maleate caps AL(At least 6 F metformin hcl tb24 or 500 F MP or 25 mg, 50 mg, 100 mg yrs old) mg, 750 mg ANTIDIABETICS - Drugs to Regulate Blood METFORMIN F Sugar HYDROCHLORIDE SOLN Alpha-Glucosidase Inhibitors RIOMET SOLN F acarbose tabs F Diabetic Other PRECOSE TABS NF CVS BITS F (Acarbose) CHEW Antidiabetic - Amylin Analogs CVS GLUCOSE CHEW 4 F PA GM SYMLINPEN 120 SOPN F DEX4 FAST ACTING PA GLUCOSEGO-POUCH F SYMLINPEN 60 SOPN F GEL Antidiabetic Combinations DEX4 QUICK DISSOLVE F GLUCOSE CHEW ACTOPLUS MET TABS MP (Pioglitazone HCl- NF dextrose (diabetic use) gel F Metformin HCl) 40 %, 15 gm/38gm ACTOPLUS MET XR TB24 F

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 per HUMALOG MIX 50/50 F GLUCAGON F month;QL(0.03 KWIKPEN SUPN EMERGENCY KIT KIT 4 ea daily) HUMALOG MIX 50/50 F GLUCOSE CHEW 4 GM F SUSP HUMALOG MIX 75/25 F GLUCOSE GEL 15 F KWIKPEN SUPN GM/33GM HUMALOG MIX 75/25 F GNP GLUCOSE CHEW 4 F SUSP GM HUMALOG SOCT F GNP QUICK DISSOLVE F GLUCOSE CHEW HUMALOG SOLN F INSTA-GLUCOSE GEL F HUMULIN 70/30 KWIKPEN LEADER QUICK SUPN 70UNIT/ML- F DISSOLVE GLUCOSE F 30UNIT/ML CHEW HUMULIN 70/30 SUSP F SM GLUCOSE CHEW 4 F 70UNIT/ML-30UNIT/ML GM HUMULIN N KWIKPEN F GLUCOSE F SUPN 100 UNIT/ML CHEW 4 GM HUMULIN N SUSP 100 F Dipeptidyl Peptidase-4 (DPP-4) Inhibitors UNIT/ML JANUVIA TABS F PA HUMULIN R SOLN F PA HUMULIN R U-500 F PA ONGLYZA TABS F (CONCENTRATED) SOLN TRADJENTA TABS F PA; HUMULIN R U-500 F PA KWIKPEN SOPN Incretin Mimetic Agents (GLP-1 Receptor LANTUS SOLN 100 F UNIT/ML BYDUREON PEN PEN F PA LANTUS SOLOSTAR F SOPN 100 UNIT/ML BYDUREON SRER F PA LEVEMIR FLEXTOUCH F BYETTA SOPN F PA SOPN LEVEMIR SOLN F VICTOZA SOPN F PA NOVOLOG FLEXPEN F Insulin Sensitizing Agents SOPN 100 UNIT/ML NOVOLOG MIX 70/30 ACTOS TABS NF MP (Pioglitazone HCl) PREFILLED FLEXPEN F SUPN pioglitazone hcl tabs F MP NOVOLOG MIX 70/30 F Insulin SUSP NOVOLOG PENFILL HUMALOG JUNIOR F F KWIKPEN SOPN SOCT 100 UNIT/ML Meglitinide Analogues HUMALOG KWIKPEN F SOPN

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nateglinide tabs F MP PEPTO-BISMOL INSTACOOL CHEW NF (Bismuth Subsalicylate) PRANDIN TABS NF (Repaglinide) PEPTO-BISMOL SUSP repaglinide tabs F 262 MG/15ML (Bismuth NF Subsalicylate) STARLIX TABS NF MP PEPTO-BISMOL TO-GO (Nateglinide) CHEW (Bismuth NF Sulfonylureas Subsalicylate) Antiperistaltic Agents AMARYL TABS NF MP (Glimepiride) diphenoxylate w/ atropine F tabs glimepiride tabs F MP DIPHENOXYLATE/ATROP F glipizide tabs or 5 mg, 10 F MP INE LIQD mg IMODIUM A-D CAPS 2 MG NF RX/OTC glipizide tb24 or 5 mg, 10 F MP (Loperamide HCl) mg, 2.5 mg IMODIUM A-D LIQD 1 GLUCOTROL TABS NF MP MG/7.5ML (Loperamide NF (Glipizide) HCl) GLUCOTROL XL TB24 MP NF IMODIUM A-D TABS 2 MG NF (Glipizide) (Loperamide HCl) MP glyburide micronized tabs F LOMOTIL TABS NF (Diphenoxylate w/ Atropine) glyburide tabs or 5 mg, 2.5 MP F loperamide hcl caps or 2 F RX/OTC mg, 1.25 mg mg GLYNASE TABS MP NF loperamide hcl liqd or 1 F (Glyburide Micronized) mg/5ml, 1 mg/7.5ml TOLAZAMIDE TABS F loperamide hcl susp or 1 F mg/7.5ml TOLBUTAMIDE TABS F loperamide hcl tabs or 2 F mg ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea ANTIDOTES AND SPECIFIC ANTAGONISTS Antidiarrheal/Probiotic Agents - Misc. Opioid Antagonists bismuth subsalicylate chew F NALOXONE HCL SOCT IJ F or 262 mg 0.4 MG/ML bismuth subsalicylate susp naloxone hcl soln ij 0.4 F or 262 mg/15ml, 525 F mg/ml, 4 mg/10ml mg/30ml, 527 mg/30ml NALOXONE HCL SOSY IJ F bismuth subsalicylate tabs F 2 MG/2ML or 262 mg naltrexone hcl tabs or F PEPTO BISMOL TABS NF (Bismuth Subsalicylate) NARCAN LIQD F PEPTO-BISMOL CHEW 262 MG (Bismuth NF VIVITROL SUSR F SP Subsalicylate)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIEMETICS - Drugs to Treat Nausea and LAMISIL TABS NF QL(90 ea per Vomiting (Terbinafine HCl) 365 days retail) 5-HT3 Receptor Antagonists nystatin tabs or 500000 unit F PA ANZEMET TABS F terbinafine hcl tabs or 250 F QL(90 ea per mg 365 days retail) granisetron hcl tabs or 1 F PA mg Imidazole-Related Antifungals DIFLUCAN SUSR 10 QL(20 ml daily) ondansetron hcl tabs or 4 F QL(1 ea daily) NF mg, 8 mg MG/ML (Fluconazole) QL(1 ea daily) DIFLUCAN SUSR 40 NF ondansetron tbdp F MG/ML (Fluconazole) DIFLUCAN TABS 50 MG, QL(2 ea daily) ZOFRAN ODT TBDP NF QL(1 ea daily) (Ondansetron) 100 MG, 150 MG, 200 MG NF (Fluconazole) ZOFRAN TABS 4 MG, 8 NF QL(1 ea daily) MG (Ondansetron HCl) fluconazole susr or 10 F QL(20 ml daily) mg/ml Antiemetics - Anticholinergic fluconazole susr or 40 F dimenhydrinate tabs or 50 F mg/ml mg fluconazole tabs or 50 mg, F QL(2 ea daily) DRAMAMINE CHEW 50 F 100 mg, 150 mg, 200 mg MG - Drugs to Treat DRAMAMINE TABS NF (Dimenhydrinate) Antihistamines - Alkylamines meclizine hcl chew or 25 F mg CHLOR-TRIMETON SYRP (Chlorpheniramine NF meclizine hcl tabs or 25 F RX/OTC Maleate) mg, 12.5 mg CHLOR-TRIMETON TABS TIGAN CAPS OR 300 MG NF (Chlorpheniramine NF (Trimethobenzamide HCl) Maleate) trimethobenzamide hcl F chlorpheniramine maleate F caps or 300 mg syrp or 2 mg/5ml Substance P/Neurokinin 1 (NK1) Receptor chlorpheniramine maleate F tabs or 4 mg aprepitant caps 40 mg, 80 F QL(6 ea per 21 mg, days retail) Antihistamines - Ethanolamines EMEND CAPS OR 40 MG, NF QL(6 ea per 21 80 MG (Aprepitant) days retail) ALER-DRYL TABS F EMEND TRIPACK CAPS NF QL(6 ea per 21 (Aprepitant) days retail) CAPS (Diphenhydramine NF HCl) ANTIFUNGALS - Drugs to Treat Fungal Infections BENADRYL ALLERGY Antifungals CHILDRENS CHEW NF (Diphenhydramine HCl) griseofulvin microsize susp F BENADRYL ALLERGY CHILDRENS LIQD NF griseofulvin microsize tabs F (Diphenhydramine HCl)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BENADRYL ALLERGY CLARITIN CHEW 5 MG F QL(1 ea daily) TABS (Diphenhydramine NF HCl) CLARITIN CHEW 5 MG NF QL(1 ea daily) () clemastine fumarate tabs F or 1.34 mg CLARITIN CHILDRENS NF QL(1 ea daily) CHEW (Loratadine) diphenhydramine hcl caps F or 25 mg CLARITIN REDITABS NF QL(1 ea daily) TBDP 10 MG (Loratadine) diphenhydramine hcl caps F RX/OTC or 50 mg CLARITIN REDITABS F QL(1 ea daily) TBDP 5 MG diphenhydramine hcl chew F or 12.5 mg CLARITIN SYRP 5 NF QL(5 ml daily) MG/5ML (Loratadine) diphenhydramine hcl elix or F RX/OTC 12.5 mg/5ml CLARITIN TABS 10 MG NF QL(1 ea daily) diphenhydramine hcl liqd or (Loratadine) 25 mg/10ml, 50 mg/20ml, F hcl susp or 30 F QL(5 ml daily) 12.5 mg/5ml mg/5ml diphenhydramine hcl tabs F fexofenadine hcl tabs or 60 F QL(1 ea daily) or 25 mg mg, 180 mg SILPHEN COUGH SYRP F loratadine caps or 10 mg F QL(1 ea daily)

TAVIST ALLERGY TABS NF loratadine chew or 5 mg F QL(1 ea daily) (Clemastine Fumarate) Antihistamines - Non-Sedating loratadine soln or 5 mg/5ml F QL(5 ml daily) ALLEGRA ALLERGY QL(5 ml daily) loratadine syrp or 5 mg/5ml F QL(5 ml daily) CHILDRENS SUSP 30 NF MG/5ML (Fexofenadine HCl) loratadine tabs or 10 mg F QL(1 ea daily) ALLEGRA ALLERGY F QL(1 ea daily) QL(1 ea daily) CHILDRENS TBDP 30 MG loratadine tbdp or 10 mg F ALLEGRA ALLERGY QL(1 ea daily) NF ZYRTEC ALLERGY CAPS NF QL(1 ea daily) TABS (Fexofenadine HCl) ( HCl) QL(1 ea daily) cetirizine hcl caps 10 mg F ZYRTEC ALLERGY F QL(1 ea daily) CHILDRENS TBDP cetirizine hcl chew 5 mg, QL(1 ea daily) F ZYRTEC ALLERGY TABS NF QL(1 ea daily) 10 mg (Cetirizine HCl) cetirizine hcl soln 1 mg/ml, F QL(5 ml daily); QL(1 ea daily) 5 mg/5ml RX/OTC ZYRTEC ALLERGY TBDP F cetirizine hcl syrp 1 mg/ml, F QL(5 ml daily); ZYRTEC CHILDRENS QL(5 ml daily); 5 mg/5ml RX/OTC ALLERGY SOLN NF RX/OTC (Cetirizine HCl) cetirizine hcl tabs 5 mg, 10 F QL(1 ea daily) mg Antihistamines - CLARITIN ALLERGY QL(5 ml daily) hcl soln or F CHILDRENS SYRP NF 6.25 mg/5ml (Loratadine) promethazine hcl supp re F CLARITIN CAPS 10 MG NF QL(1 ea daily) 25 mg, 50 mg, 12.5 mg (Loratadine)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits promethazine hcl syrp or F fenofibrate micronized caps F 6.25 mg/5ml 67 mg promethazine hcl tabs or F fenofibrate tabs or 48 mg, F MP 25 mg, 50 mg, 12.5 mg 145 mg, 160 mg Antihistamines - Piperidines fenofibrate tabs or 54 mg F hcl syrp or F 2 mg/5ml FENOFIBRIC ACID TABS F cyproheptadine hcl tabs or F 4 mg FIBRICOR TABS F ANTIHYPERLIPIDEMICS - Drugs to Treat High gemfibrozil tabs or 600 mg F MP Cholesterol Bile Acid Sequestrants LOFIBRA CAPS 134 MG, MP 200 MG (Fenofibrate NF cholestyramine light pack F MP Micronized) LOFIBRA CAPS 67 MG NF cholestyramine light powd F MP (Fenofibrate Micronized) LOFIBRA TABS 160 MG MP cholestyramine pack or 4 F MP NF gm (Fenofibrate) LOFIBRA TABS 54 MG cholestyramine powd or 4 F MP NF gm/dose (Fenofibrate) COLESTID FLAVORED MP LOPID TABS (Gemfibrozil) NF MP GRAN 5 GM (Colestipol NF HCl) TRICOR TABS NF MP (Fenofibrate) COLESTID GRAN NF MP (Colestipol HCl) TRIGLIDE TABS F MP COLESTID PACK NF MP (Colestipol HCl) HMG CoA Reductase Inhibitors atorvastatin calcium tabs or QL(1 ea daily); COLESTID TABS NF MP (Colestipol HCl) 10 mg, 20 mg, 40 mg, 80 F MP mg colestipol hcl gran F MP LIPITOR TABS NF QL(1 ea daily); (Atorvastatin Calcium) MP colestipol hcl pack F MP lovastatin tabs F MP colestipol hcl tabs F MP MEVACOR TABS NF MP (Lovastatin) QUESTRAN LIGHT POWD NF MP (Cholestyramine Light) PRAVACHOL TABS NF MP (Pravastatin Sodium) QUESTRAN PACK NF MP (Cholestyramine) pravastatin sodium tabs F MP QUESTRAN POWD NF MP (Cholestyramine) simvastatin tabs or 5 mg, MP 10 mg, 20 mg, 40 mg, 80 F Fibric Acid Derivatives mg fenofibrate micronized caps MP F ZOCOR TABS NF MP 134 mg, 200 mg (Simvastatin) Intestinal Cholesterol Absorption Inhibitors Arizona Complete Health-Complete Care Plan Effective October 1, 2018

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ezetimibe tabs 10 mg F PA Angiotensin II Receptor Antagonists AVAPRO TABS NF MP ZETIA TABS (Ezetimibe) NF PA (Irbesartan) ST; Try ANTIHYPERTENSIVES - Drugs to Treat High BENICAR TABS NF ) losartan and Blood Pressure (Olmesartan Medoxomil irbesartan first ACE Inhibitors COZAAR TABS (Losartan NF MP Potassium) ACCUPRIL TABS NF MP (Quinapril HCl) DIOVAN TABS (Valsartan) NF MP ACEON TABS (Perindopril NF Erbumine) irbesartan tabs F MP ALTACE CAPS (Ramipril) NF MP losartan potassium tabs F MP benazepril hcl tabs or 5 F MP mg, 10 mg, 20 mg, 40 mg ST; Try olmesartan medoxomil tabs F or 5 mg, 20 mg, 40 mg losartan and captopril tabs or 25 mg, 50 F MP irbesartan first mg, 100 mg, 12.5 mg valsartan tabs F MP enalapril maleate tabs or 5 F MP mg, 10 mg, 20 mg, 2.5 mg Antiadrenergic Antihypertensives EPANED SOLN F CARDURA TABS NF MP ( Mesylate) EPANED SOLR F CATAPRES TABS NF MP (Clonidine HCl) fosinopril sodium tabs F MP CATAPRES-TTS-1 PTWK NF AL(At least 6 lisinopril tabs or 5 mg, 10 MP (Clonidine HCl) yrs old); MP mg, 20 mg, 30 mg, 40 mg, F CATAPRES-TTS-2 PTWK NF AL(At least 6 2.5 mg (Clonidine HCl) yrs old); MP LOTENSIN TABS MP NF CATAPRES-TTS-3 PTWK NF AL(At least 6 (Benazepril HCl) (Clonidine HCl) yrs old); MP MAVIK TABS (Trandolapril) NF MP clonidine hcl ptwk td 0.1 AL(At least 6 mg/24hr, 0.2 mg/24hr, 0.3 F yrs old); MP moexipril hcl tabs F mg/24hr clonidine hcl tabs or 0.1 F MP perindopril erbumine tabs F mg, 0.2 mg, 0.3 mg MP doxazosin mesylate tabs or F MP PRINIVIL TABS (Lisinopril) NF 1 mg, 2 mg, 4 mg, 8 mg MP quinapril hcl tabs F MP guanfacine hcl tabs F MP ramipril caps F MP tabs F

MP MINIPRESS CAPS NF MP trandolapril tabs F ( HCl) VASOTEC TABS (Enalapril NF MP prazosin hcl caps F MP Maleate) MP TENEX TABS (Guanfacine NF MP ZESTRIL TABS (Lisinopril) NF HCl) Arizona Complete Health-Complete Care Plan Effective October 1, 2018

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hcl caps F MP LOTREL CAPS MP (Amlodipine Besylate- NF Antihypertensive Combinations Benazepril HCl) ACCURETIC TABS metoprolol & F MP (Quinapril- NF hydrochlorothiazide tabs Hydrochlorothiazide) METOPROLOL/HYDROCH F MP LOROTHIAZIDE TABS amlodipine besylate- F MP benazepril hcl caps moexipril- F hydrochlorothiazide tabs & chlorthalidone F MP tabs & F AVALIDE TABS MP bendroflumethiazide tabs (Irbesartan- NF ST; Try Hydrochlorothiazide) olmesartan medoxomil- F losartan hctz hydrochlorothiazide tabs and irbesartan benazepril & F MP hydrochlorothiazide tabs hctz first ST; Try /HYDROC F BENICAR HCT TABS losartan hctz HLOROTHIAZIDE TABS (Olmesartan Medoxomil- NF quinapril- ) and irbesartan F Hydrochlorothiazide hctz first hydrochlorothiazide tabs TENORETIC 100 TABS MP bisoprolol & F MP NF hydrochlorothiazide tabs (Atenolol & Chlorthalidone) TENORETIC 50 TABS MP CAPTOPRIL/HYDROCHL F MP NF OROTHIAZIDE TABS (Atenolol & Chlorthalidone) valsartan- MP CORZIDE TABS (Nadolol NF F & Bendroflumethiazide) hydrochlorothiazide tabs DIOVAN HCT TABS MP VASERETIC TABS MP (Valsartan- NF (Enalapril Maleate & NF Hydrochlorothiazide) Hydrochlorothiazide) ZESTORETIC TABS MP enalapril maleate & F MP hydrochlorothiazide tabs (Lisinopril & NF Hydrochlorothiazide) fosinopril sodium & F MP hydrochlorothiazide tabs ZIAC TABS (Bisoprolol & NF MP HYZAAR TABS (Losartan MP Hydrochlorothiazide) Potassium & NF Selective Aldosterone Receptor Antagonists Hydrochlorothiazide) eplerenone tabs F PA irbesartan- F MP hydrochlorothiazide tabs INSPRA TABS NF PA lisinopril & F MP (Eplerenone) hydrochlorothiazide tabs Vasodilators LOPRESSOR HCT TABS MP (Metoprolol & NF hydralazine hcl tabs or 10 F MP Hydrochlorothiazide) mg, 25 mg, 50 mg, 100 mg minoxidil tabs or 10 mg, 2.5 MP losartan potassium & F MP F hydrochlorothiazide tabs mg LOTENSIN HCT TABS MP ANTIMALARIALS - Drugs to Treat Malaria (Benazepril & NF (Parasitic Infections) Hydrochlorothiazide) Arizona Complete Health-Complete Care Plan Effective October 1, 2018

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antimalarial Combinations ISONIAZID SYRP OR 50 F MG/5ML atovaquone-proguanil hcl F tabs isoniazid tabs or 100 mg, F 300 mg COARTEM TABS F MYAMBUTOL TABS NF MALARONE TABS (Ethambutol HCl) (Atovaquone-Proguanil NF pyrazinamide tabs or F HCl) Antimalarials RIFADIN CAPS OR 150 NF MG, 300 MG (Rifampin) CHLOROQUINE PHOSPHATE TABS OR F rifampin caps or 150 mg, F 250 MG 300 mg ANTINEOPLASTICS AND ADJUNCTIVE chloroquine phosphate F tabs or 500 mg THERAPIES - Drugs to Treat Cancer hydroxychloroquine sulfate F Antimetabolites tabs or 200 mg mercaptopurine tabs or F PLAQUENIL TABS (Hydroxychloroquine NF methotrexate sodium tabs F Sulfate) or 2.5 mg PRIMAQUINE F PHOSPHATE TABS PURIXAN SUSP F QUALAQUIN CAPS NF Antineoplastic - Hormonal and Related Agents (Quinine Sulfate) anastrozole tabs or 1 mg F PA quinine sulfate caps or 324 F mg ARIMIDEX TABS NF PA (Anastrozole) ANTIMYASTHENIC/CHOLINERGIC AGENTS AROMASIN TABS NF PA Antimyasthenic/Cholinergic Agents (Exemestane) PA; SP MESTINON SYRP 60 F ELIGARD KIT F MG/5ML PA MESTINON TABS 60 MG NF exemestane tabs 25 mg F (Pyridostigmine Bromide) MESTINON TIMESPAN FARESTON TABS F PA TBCR (Pyridostigmine NF Bromide) FEMARA TABS (Letrozole) NF pyridostigmine bromide F tabs or 60 mg flutamide caps F pyridostigmine bromide F tbcr or 180 mg letrozole tabs or 2.5 mg F ANTIMYCOBACTERIAL AGENTS - Drugs to leuprolide acetate kit ij F PA; SP Treat Tuberculosis (Bacterial Infections) LUPRON DEPOT (1- F PA; SP Antimycobacterial Agents MONTH) KIT ethambutol hcl tabs or 100 F LUPRON DEPOT (3- F PA; SP mg, 400 mg MONTH) KIT

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LUPRON DEPOT (4- F PA; SP SUTENT CAPS F PA; SP MONTH) KIT PA; SP LUPRON DEPOT (6- F PA; SP TARCEVA TABS F MONTH) KIT TASIGNA CAPS 150 MG, PA; SP MEGACE ORAL SUSP NF F (Megestrol Acetate) 200 MG PA; SP megestrol acetate susp or F TYKERB TABS F 40 mg/ml, 400 mg/10ml VOTRIENT TABS F PA; SP megestrol acetate tabs or F 20 mg, 40 mg XALKORI CAPS F PA; SP tamoxifen citrate tabs or 10 F mg, 20 mg ZOLINZA CAPS F PA; SP XTANDI CAPS F PA; SP Antineoplastics Misc. Antineoplastic Enzyme Inhibitors ACTIMMUNE SOLN F PA; SP AFINITOR DISPERZ TBSO F PA; SP ALFERON N SOLN F PA; SP AFINITOR TABS F PA; SP bexarotene caps 75 mg F PA; SP ALECENSA CAPS F PA; SP HYDREA CAPS NF BELEODAQ SOLR F PA; SP (Hydroxyurea) hydroxyurea caps or 500 F CAPRELSA TABS F PA; SP mg INTRON A SOLN F PA; SP COTELLIC TABS F PA; SP INTRON A SOLR F PA; SP GLEEVEC TABS (Imatinib NF PA Mesylate) INTRON A W/DILUENT F PA; SP ICLUSIG TABS F PA; SP SOLR MATULANE CAPS F imatinib mesylate tabs F PA SYLATRON KIT F PA; SP IMBRUVICA CAPS 140 F PA; SP MG TARGRETIN CAPS OR 75 NF PA; SP INLYTA TABS F PA; SP MG (Bexarotene) tretinoin (chemotherapy) F AL(Up to 26 yrs IRESSA TABS F PA; SP caps old ) Chemotherapy Rescue/Antidote Agents JAKAFI TABS F PA; SP LEUCOVORIN CALCIUM F PA NEXAVAR TABS F PA; SP TABS OR 10 MG, 15 MG leucovorin calcium tabs or F PA NINLARO CAPS F PA; SP 5 mg, 25 mg Mitotic Inhibitors SPRYCEL TABS F PA; SP ETOPOSIDE CAPS OR 50 F PA; SP MG

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIPARKINSON AND RELATED THERAPY pramipexole AGENTS - Drugs to Treat Parkinson's Disease dihydrochloride tabs 0.125 F mg, 0.25 mg, 0.75 mg, 0.5 Antiparkinson Anticholinergics mg, 1 mg, 1.5 mg benztropine mesylate tabs F pramipexole or 0.5 mg, 1 mg, 2 mg dihydrochloride tb24 0.375 F trihexyphenidyl hcl elix F mg, 0.75 mg, 3 mg, 1.5 mg, 4.5 mg, 3.75 mg trihexyphenidyl hcl tabs F REQUIP TABS (Ropinirole NF Hydrochloride) Antiparkinson COMT Inhibitors REQUIP XL TB24 NF (Ropinirole Hydrochloride) COMTAN TABS NF (Entacapone) ropinirole hydrochloride F tabs entacapone tabs 200 mg F ropinirole hydrochloride F Antiparkinson Dopaminergics tb24 SINEMET CR TBCR hcl caps or F NF 100 mg (Carbidopa-Levodopa) SINEMET TABS amantadine hcl syrp or 50 F NF mg/5ml (Carbidopa-Levodopa) amantadine hcl tabs or 100 F Antiparkinson Monoamine Oxidase Inhibitors mg ELDEPRYL CAPS NF mesylate F ( HCl) caps or 5 mg selegiline hcl caps or 5 mg F bromocriptine mesylate F tabs or 2.5 mg selegiline hcl tabs or 5 mg F carbidopa-levodopa tabs F ANTIPSYCHOTICS/ANTIMANIC AGENTS - carbidopa-levodopa tbcr F Drugs to Treat Mood Disorders Antimanic Agents carbidopa-levodopa tbdp F lithium carbonate caps or F AL(At least 6 MIRAPEX ER TB24 0.375 150 mg, 300 mg, 600 mg yrs old) MG, 0.75 MG, 3 MG, 1.5 lithium carbonate tabs or F AL(At least 6 MG, 4.5 MG, 3.75 MG NF 300 mg yrs old) (Pramipexole lithium carbonate tbcr or F AL(At least 6 Dihydrochloride) 300 mg, 450 mg yrs old) MIRAPEX TABS F AL(At least 6 (Pramipexole NF LITHIUM SOLN yrs old) Dihydrochloride) LITHOBID TBCR (Lithium NF AL(At least 6 PARLODEL CAPS NF Carbonate) yrs old) (Bromocriptine Mesylate) Antipsychotics - Misc. PARLODEL TABS NF (Bromocriptine Mesylate) EQUETRO CP12 F GEODON CAPS OR 20 QL(3 ea daily); MG, 40 MG ( NF AL(At least 6 HCl) yrs old) Arizona Complete Health-Complete Care Plan Effective October 1, 2018

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); QL(4 ea daily); F RISPERDAL TABS 0.25 NF LATUDA TABS AL(At least 6 ) AL(At least 6 yrs old) MG, 0.5 MG ( yrs old) QL(3 ea daily); QL(3 ea daily); ziprasidone hcl caps 20 F RISPERDAL TABS 1 MG NF AL(At least 6 ) AL(At least 6 mg, 40 mg, 60 mg yrs old) (Risperidone yrs old) QL(2 ea daily); QL(2 ea daily); F RISPERDAL TABS 3 MG NF ziprasidone hcl caps 80 mg AL(At least 6 ) AL(At least 6 yrs old) (Risperidone yrs old) Benzisoxazoles QL(4 ea daily); F 1 per RISPERIDONE ODT TBDP AL(At least 6 INVEGA SUSTENNA month;QL(1 ml yrs old) QL(8 ml SUSP 156 MG/ML, 39 F per 30 days MG/0.25ML, 117 retail); AL(At daily,240 ml MG/0.75ML least 18 yrs risperidone soln 1 mg/ml F per 30 days old); SP retail); AL(At 1 per least 6 yrs old) month;QL(1.5 QL(4 ea daily); risperidone tabs 0.25 mg, F AL(At least 6 INVEGA SUSTENNA F ml per 30 days 0.5 mg SUSP 234 MG/1.5ML retail); AL(At yrs old) least 18 yrs QL(3 ea daily); old); SP risperidone tabs 1 mg, 2 F mg AL(At least 6 QL(1 ml per 23 yrs old) INVEGA SUSTENNA F days retail); QL(2 ea daily); SUSP 78 MG/0.5ML AL(At least 18 risperidone tabs 3 mg, 4 F AL(At least 6 yrs old); SP mg yrs old) ST; Try Invega risperidone tbdp 0.25 mg, QL(4 ea daily); INVEGA TRINZA SUSP F Sustenna first; F AL(At least 6 AL(At least 18 0.5 mg yrs old) yrs old); SP QL(3 ea daily); 2 per risperidone tbdp 1 mg, 2 F AL(At least 6 month;QL(2 ea mg yrs old) RISPERDAL CONSTA F per 28 days QL(2 ea daily); SUSR retail); AL(At risperidone tbdp 3 mg, 4 F AL(At least 6 least 18 yrs mg yrs old) old); SP QL(4 ea daily); Butyrophenones RISPERDAL M-TAB TBDP NF HALDOL DECANOATE AL(At least 18 ) AL(At least 6 0.5 MG (Risperidone yrs old) 100 SOLN ( NF yrs old); SP QL(3 ea daily); Decanoate) RISPERDAL M-TAB TBDP NF HALDOL DECANOATE 50 AL(At least 18 ) AL(At least 6 1 MG (Risperidone yrs old) SOLN (Haloperidol NF yrs old); SP QL(8 ml Decanoate) daily,240 ml HALDOL SOLN NF AL(At least 6 RISPERDAL SOLN 1 NF (Haloperidol Lactate) yrs old); SP ) per 30 days MG/ML (Risperidone retail); AL(At soln F AL(At least 18 least 6 yrs old) im 50 mg/ml, 100 mg/ml yrs old); SP

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits haloperidol lactate conc or F AL(At least 6 QL(2 ea daily); 2 mg/ml yrs old) SAPHRIS SUBL F AL(At least 6 yrs old) haloperidol lactate soln ij 5 F AL(At least 6 mg/ml yrs old); SP SEROQUEL TABS 100 haloperidol tabs or 0.5 mg, AL(At least 6 MG, 200 MG, 400 MG NF 1 mg, 2 mg, 5 mg, 10 mg, F yrs old) ( Fumarate) 20 mg QL(4 ea daily); SEROQUEL TABS 25 MG NF ) AL(At least 6 Dibenzapines (Quetiapine Fumarate yrs old) QL(5 ea daily); QL(2 ea daily); ODT TBDP F AL(At least 18 SEROQUEL TABS 300 MG NF ) AL(At least 6 yrs old) (Quetiapine Fumarate yrs old) QL(5 ea daily); clozapine tabs 25 mg, 50 F ZYPREXA TABS OR 10 NF AL(At least 18 ) mg, 100 mg, 200 mg yrs old) MG ( ZYPREXA TABS OR 15 QL(1 ea daily); clozapine tbdp 12.5 mg F QL(5 ea daily) MG, 20 MG, 2.5 MG, 7.5 NF AL(At least 6 MG (Olanzapine) yrs old) QL(5 ea daily); clozapine tbdp 25 mg, 100 F AL(At least 18 QL(2 ea daily); mg ZYPREXA TABS OR 5 MG NF yrs old) ) AL(At least 6 (Olanzapine yrs old) QL(5 ea daily); CLOZARIL TABS NF AL(At least 18 QL(1 ea daily); (Clozapine) ZYPREXA ZYDIS TBDP 15 NF yrs old) ) AL(At least 6 MG, 20 MG (Olanzapine yrs old) FAZACLO TBDP 12.5 MG NF QL(5 ea daily) (Clozapine) QL(2 ea daily); ZYPREXA ZYDIS TBDP 5 NF ) AL(At least 6 QL(5 ea daily); MG, 10 MG (Olanzapine yrs old) FAZACLO TBDP 25 MG, NF ) AL(At least 18 100 MG (Clozapine yrs old) Phenothiazines hcl tabs or AL(At least 6 F AL(At least 6 succinate caps yrs old) 10 mg, 25 mg, 50 mg, 100 F yrs old) mg, 200 mg olanzapine tabs or 15 mg, QL(1 ea daily); F AL(At least 6 fluphenazine decanoate F AL(At least 18 20 mg, 2.5 mg, 7.5 mg yrs old) soln ij yrs old); SP QL(2 ea daily); FLUPHENAZINE HCL F AL(At least 6 olanzapine tabs or 5 mg, F AL(At least 6 CONC OR 5 MG/ML yrs old) 10 mg yrs old) FLUPHENAZINE HCL F AL(At least 6 QL(1 ea daily); ELIX OR 2.5 MG/5ML yrs old) olanzapine tbdp or 15 mg, F AL(At least 6 20 mg fluphenazine hcl tabs or 1 F AL(At least 6 yrs old) mg, 5 mg, 10 mg, 2.5 mg yrs old) QL(2 ea daily); olanzapine tbdp or 5 mg, tabs or 2 mg, F AL(At least 6 F AL(At least 6 4 mg, 8 mg, 16 mg yrs old) 10 mg yrs old) maleate F AL(At least 6 quetiapine fumarate tabs QL(4 ea daily); tabs or 5 mg, 10 mg yrs old) 25 mg, 50 mg, 100 mg, 200 F AL(At least 6 F AL(At least 6 mg yrs old) prochlorperazine supp yrs old) QL(2 ea daily); quetiapine fumarate tabs hcl tabs or 10 F AL(At least 6 F AL(At least 6 mg, 25 mg, 50 mg, 100 mg yrs old) 300 mg, 400 mg yrs old)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F AL(At least 6 hcl tabs yrs old) ANTIVIRALS - Drugs to Treat Viral Infections Quinolinone Derivatives Antiretrovirals 1 per abacavir sulfate soln F month;QL(1 ea per 30 days abacavir sulfate tabs F retail)1 rtl pack ABILIFY MAINTENA PRSY F lmt amt,30 rtl abacavir sulfate-lamivudine F pack lmt tabs 600mg-300mg day(s),; AL(At abacavir sulfate- least 18 yrs lamivudine-zidovudine tabs F old); SP 300mg-150mg-300mg 1 per month;QL(1 ea APTIVUS CAPS F per 30 days retail)1 rtl pack APTIVUS SOLN F ABILIFY MAINTENA SRER F lmt amt,30 rtl pack lmt atazanavir sulfate caps F day(s),; AL(At least 18 yrs ATRIPLA TABS F old); SP BIKTARVY TABS F QL(1 ea daily) ABILIFY TABS 2 MG NF () COMBIVIR TABS NF ABILIFY TABS 5 MG, 10 QL(1 ea daily); (Lamivudine-Zidovudine) MG, 15 MG, 20 MG, 30 MG NF AL(At least 6 (Aripiprazole) yrs old) COMPLERA TABS F aripiprazole tabs 2 mg, 5 QL(1 ea daily); mg, 10 mg, 15 mg, 20 mg, F AL(At least 6 CRIXIVAN CAPS F 30 mg yrs old) DESCOVY TABS F 2 rtl MAX fill,365 rtl didanosine cpdr 200 mg, F ARISTADA INITIO PRSY F day(s) supply,; 400 mg AL(At least 18 yrs old); SP EDURANT TABS F 1 rtl pack lmt amt,30 rtl pack efavirenz caps F ARISTADA PRSY F lmt day(s),; AL(At least 18 efavirenz tabs F yrs old); SP EMTRIVA CAPS F F AL(At least 6 EMTRIVA SOLN F thiothixene caps yrs old) EPIVIR SOLN NF ANTISEPTICS & DISINFECTANTS (Lamivudine) Antiseptics & Disinfectants EPIVIR TABS (Lamivudine) NF hydrogen peroxide soln ex F EPZICOM TABS (Abacavir NF 3 % Sulfate-Lamivudine)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EVOTAZ TABS F NORVIR TABS 100 MG NF (Ritonavir) fosamprenavir calcium tabs F ODEFSEY TABS F PA; 1 rtl pack PREZCOBIX TABS F F lmt amt,30 rtl FUZEON SOLR pack lmt PREZISTA SUSP 100 F day(s),; SP MG/ML GENVOYA TABS F PREZISTA TABS 75 MG, F 600 MG, 800 MG INTELENCE TABS F RESCRIPTOR TABS F INVIRASE CAPS F RETROVIR CAPS NF (Zidovudine) INVIRASE TABS F RETROVIR SYRP NF (Zidovudine) ISENTRESS CHEW F REYATAZ CAPS 150 MG, 200 MG, 300 MG NF ISENTRESS PACK F (Atazanavir Sulfate) ISENTRESS TABS F REYATAZ PACK 50 MG F

KALETRA SOLN ritonavir tabs F 400MG/5ML-100MG/5ML NF (Lopinavir-Ritonavir) SELZENTRY SOLN F PA KALETRA TABS 100MG- F 25MG, 200MG-50MG SELZENTRY TABS F PA lamivudine soln F stavudine caps F lamivudine tabs F STRIBILD TABS F lamivudine-zidovudine tabs F 150mg-300mg SUSTIVA CAPS NF (Efavirenz) LEXIVA SUSP 50 MG/ML F SUSTIVA TABS (Efavirenz) NF LEXIVA TABS 700 MG NF (Fosamprenavir Calcium) tenofovir disoproxil F fumarate tabs lopinavir-ritonavir soln F TIVICAY TABS 50 MG F nevirapine susp 50 mg/5ml F TRIUMEQ TABS F nevirapine tabs 200 mg F TRIZIVIR TABS (Abacavir Sulfate-Lamivudine- NF nevirapine tb24 400 mg F Zidovudine) PA NORVIR CAPS 100 MG F TRUVADA TABS F QL(1 ea daily) NORVIR SOLN 80 MG/ML F TYBOST TABS F

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIDEX EC CPDR 125 MG F VALCYTE TABS NF PA (Valganciclovir HCl) VIDEX EC CPDR 200 MG, NF PA 400 MG (Didanosine) valganciclovir hcl solr F VIDEXPEDIATRIC SOLR 4 F valganciclovir hcl tabs F PA GM VIRACEPT TABS F Hepatitis Agents adefovir dipivoxil tabs 10 F PA VIRAMUNE SUSP NF mg (Nevirapine) BARACLUDE SOLN 0.05 F PA VIRAMUNE TABS NF MG/ML (Nevirapine) BARACLUDE TABS 0.5 NF PA VIRAMUNE XR TB24 400 NF MG, 1 MG (Entecavir) MG (Nevirapine) COPEGUS TABS NF PA VIREAD POWD 40 MG/GM F (Ribavirin (Hepatitis C)) PA VIREAD TABS 300 MG entecavir tabs F (Tenofovir Disoproxil NF ) EPIVIR HBV SOLN 5 F Fumarate MG/ML VITEKTA TABS F EPIVIR HBV TABS 100 NF MG (Lamivudine (HBV)) ZERIT CAPS 15 MG, 20 MG, 30 MG, 40 MG NF HEPSERA TABS (Adefovir NF PA (Stavudine) Dipivoxil) ZERIT SOLR 1 MG/ML F lamivudine (hbv) tabs F PA; SP ZIAGEN SOLN (Abacavir NF MAVYRET TABS F Sulfate) MODERIBA 1200 DOSE PA ZIAGEN TABS (Abacavir NF F Sulfate) PACK TABS MODERIBA 800 DOSE F PA zidovudine caps F PACK TABS PEG-INTRON REDIPEN F PA; SP zidovudine syrp F KIT 50 MCG/0.5ML PEGASYS PROCLICK F PA; SP zidovudine tabs F SOLN CMV Agents PEGASYS SOLN F PA; SP cidofovir soln F PA REBETOL SOLN F PA CYTOVENE SOLR NF PA (Ganciclovir Sodium) RIBASPHERE RIBAPAK F PA TABS 400 MG, 600 MG FOSCAVIR SOLN F PA RIBASPHERE TABS F PA ganciclovir sodium solr 500 F PA mg ribavirin (hepatitis c) caps F PA VALCYTE SOLR NF PA PA (Valganciclovir HCl) ribavirin (hepatitis c) tabs F

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYZEKA TABS F PA tabs F MP

VEMLIDY TABS F PA COREG TABS (Carvedilol) NF MP

Herpes Agents hcl tabs or 100 F MP mg, 200 mg, 300 mg acyclovir caps or 200 mg F Beta Blockers Cardio-Selective acyclovir susp or 200 F atenolol tabs or 25 mg, 50 F MP mg/5ml mg, 100 mg acyclovir tabs or 400 mg, F MP 800 mg bisoprolol fumarate tabs F famciclovir tabs or 125 mg, F PA LOPRESSOR TABS NF MP 250 mg, 500 mg (Metoprolol Tartrate) FAMVIR TABS NF PA metoprolol succinate tb24 F MP (Famciclovir) metoprolol tartrate tabs or MP valacyclovir hcl tabs or 1 F F gm, 500 mg, 1000 mg 25 mg, 50 mg, 100 mg METOPROLOL VALTREX TABS NF (Valacyclovir HCl) TARTRATE TABS OR 37.5 F MG ZOVIRAX CAPS OR 200 NF MG (Acyclovir) TENORMIN TABS NF MP (Atenolol) ZOVIRAX SUSP OR 200 NF MG/5ML (Acyclovir) TOPROL XL TB24 NF MP (Metoprolol Succinate) ZOVIRAX TABS OR 400 NF MG, 800 MG (Acyclovir) ZEBETA TABS (Bisoprolol NF MP Fumarate) Influenza Agents FLUMADINE TABS Beta Blockers Non-Selective (Rimantadine NF BETAPACE AF TABS NF MP Hydrochloride) (Sotalol HCl (AFIB/AFL)) BETAPACE TABS (Sotalol MP oseltamivir phosphate caps F QL(20 ea per NF or 30 mg, 45 mg, 75 mg 270 days retail) HCl) CORGARD TABS MP oseltamivir phosphate susr F NF or 6 mg/ml (Nadolol) INDERAL LA CP24 MP RELENZA DISKHALER F NF AEPB (Propranolol HCl) nadolol tabs or 20 mg, 40 MP rimantadine hydrochloride F F tabs 100 mg mg, 80 mg TAMIFLU CAPS 30 MG, 45 QL(20 ea per propranolol hcl cp24 or 60 MP MG, 75 MG (Oseltamivir NF 270 days retail) mg, 80 mg, 120 mg, 160 F Phosphate) mg PROPRANOLOL HCL TAMIFLU SUSR 6 MG/ML NF F (Oseltamivir Phosphate) SOLN OR 20 MG/5ML BETA BLOCKERS - Drugs to Treat High Blood PROPRANOLOL HCL F MP Pressure SOLN OR 40 MG/5ML propranolol hcl tabs or 10 F MP Alpha-Beta Blockers mg, 20 mg, 40 mg, 80 mg

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits propranolol hcl tabs or 60 F NORVASC TABS NF QL(1 ea daily); mg (Amlodipine Besylate) MP sotalol hcl (afib/afl) tabs F MP PROCARDIA CAPS NF MP (Nifedipine) MP sotalol hcl tabs F PROCARDIA XL TB24 NF MP (Nifedipine) CALCIUM CHANNEL BLOCKERS - Drugs to TIAZAC CP24 (Diltiazem QL(1 ea daily); Treat High Blood Pressure HCl Extended Release NF MP Calcium Channel Blockers Beads) hcl cp24 or 100 MP ADALAT CC TB24 NF QL(2 ea daily); (Nifedipine) MP mg, 120 mg, 180 mg, 200 F mg, 300 mg amlodipine besylate tabs or F QL(1 ea daily); 5 mg, 10 mg, 2.5 mg MP verapamil hcl cp24 or 240 F mg CALAN SR TBCR NF MP (Verapamil HCl) VERAPAMIL HCL SR F MP CP24 CALAN TABS (Verapamil NF MP HCl) verapamil hcl tabs or 40 F MP mg, 80 mg, 120 mg CARDIZEM CD CP24 QL(1 ea daily); (Diltiazem HCl Coated NF MP verapamil hcl tbcr or 120 F MP Beads) mg, 180 mg, 240 mg VERELAN CP24 120 MG, MP CARDIZEM TABS NF MP NF (Diltiazem HCl) 180 MG (Verapamil HCl) diltiazem hcl coated beads QL(1 ea daily); VERELAN CP24 240 MG NF cp24 120 mg, 180 mg, 240 F MP (Verapamil HCl) mg, 300 mg, 360 mg VERELAN CP24 360 MG F MP diltiazem hcl cp12 or 120 F mg VERELAN PM CP24 NF MP (Verapamil HCl) diltiazem hcl cp12 or 60 F QL(2 ea daily); mg, 90 mg MP CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm diltiazem hcl cp24 or 120 F QL(2 ea daily); mg MP Cardiac Glycosides diltiazem hcl cp24 or 180 QL(1 ea daily); F DIGOXIN SOLN OR 0.05 F MP mg, 240 mg MP MG/ML diltiazem hcl extended QL(1 ea daily); F digoxin tabs or 0.125 mg, F MP release beads cp24 MP 125 mcg diltiazem hcl tabs or 30 mg, MP F digoxin tabs or 0.25 mg, F 60 mg, 90 mg, 120 mg 250 mcg MP felodipine tb24 F LANOXIN TABS OR 125 NF MP MCG (Digoxin) nifedipine caps or 10 mg, MP F LANOXIN TABS OR 250 NF 20 mg MCG (Digoxin) nifedipine tb24 or 30 mg, MP F LANOXIN TABS OR 62.5 F 60 mg, 90 mg MCG nifedipine tb24 or 30 mg, F QL(2 ea daily); 60 mg, 90 mg MP CARDIOVASCULAR AGENTS - MISC. - Drugs to Treat Heart and Circulation Conditions

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Prostaglandin Vasodilators CEPHALEXIN TABS 250 F MG, 500 MG epoprostenol sodium solr F PA; SP KEFLEX CAPS NF (Cephalexin) FLOLAN SOLR NF PA; SP (Epoprostenol Sodium) Cephalosporins - 2nd Generation PA; SP TYVASO REFILL SOLN F cefaclor caps 250 mg, 500 F mg PA; SP TYVASO SOLN F CEFACLOR ER TB12 F TYVASO STARTER SOLN F PA; SP CEFACLOR SUSR 125 MG/5ML, 250 MG/5ML, F VELETRI SOLR F PA; SP 375 MG/5ML cefprozil susr F VENTAVIS SOLN F PA; SP Pulmonary - Endothelin Receptor cefprozil tabs F PA; SP LETAIRIS TABS F CEFTIN SUSR 125 F MG/5ML, 250 MG/5ML PA; SP TRACLEER TABS F CEFTIN TABS 500 MG NF (Cefuroxime Axetil) Pulmonary Hypertension - Phosphodiesterase cefuroxime axetil tabs F ADCIRCA TABS (Tadalafil NF PA; SP (Pulmonary Hypertension)) Cephalosporins - 3rd Generation REVATIO SUSR OR 10 F PA MG/ML cefdinir caps F REVATIO TABS OR 20 PA cefdinir susr F MG (Sildenafil Citrate NF (Pulmonary Hypertension)) 50ml per sildenafil citrate (pulmonary PA cefixime susr 100 mg/5ml F month;QL(1.67 hypertension) tabs or 20 F ml daily) mg cefpodoxime proxetil susr F tadalafil (pulmonary F PA; SP hypertension) tabs 20 mg cefpodoxime proxetil tabs F CEPHALOSPORINS - Drugs to Treat Bacterial Infections SUPRAX CAPS 400 MG F Cephalosporins - 1st Generation SUPRAX CHEW 100 MG, F 200 MG cefadroxil caps F 50ml per SUPRAX SUSR 100 NF cefadroxil susr F ) month;QL(1.67 MG/5ML (Cefixime ml daily) cefadroxil tabs F CONTRACEPTIVES - Drugs to Prevent Pregnancy cephalexin caps 250 mg, F 500 mg, 750 mg Combination Contraceptives - Oral cephalexin susr 125 F mg/5ml, 250 mg/5ml

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BREVICON-28 TABS MODICON TABS (Norethindrone & Eth NF (Norethindrone & Eth NF Estradiol) Estradiol) CYCLESSA TABS NECON 1/50-28 TABS F (Desogestrel-Ethinyl NF Estradiol (Triphasic)) NECON 10/11-28 TABS F DESOGEN TABS (Desogestrel & Ethinyl NF norethin acet & estrad-fe F QL(1 ea daily) Estradiol) tabs 75mg-20mcg-1mg norethindrone & eth desogestrel & ethinyl F F estradiol tabs estradiol tabs norethindrone acet & eth desogestrel-ethinyl F F estradiol (biphasic) tabs estra tabs norethindrone acetate- desogestrel-ethinyl F estradiol (triphasic) tabs ethinyl estradiol-fe tabs F 75mg-1mg drospirenone-ethinyl F estradiol tabs norethindrone-eth estradiol F ESTROSTEP FE TABS (triphasic) tabs (Norethindrone Acetate- NF norgestimate-ethinyl F Ethinyl Estradiol-Fe) estradiol (triphasic) tabs norgestimate-ethinyl ethynodiol diacet & eth F estrad tabs estradiol tabs 0.25mg- F 35mcg levonorgestrel & eth F estradiol tabs norgestrel & ethinyl F estradiol tabs levonorgestrel-eth estradiol F (triphasic) tabs NORINYL 1+35 TABS (Norethindrone & Eth NF levonorgestrel-ethinyl F estradiol (91-day) tabs Estradiol) levonorgestrel-ethinyl F OGESTREL TABS F estradiol (continuous) tabs ORTHO TRI-CYCLEN LO LOESTRIN 1.5/30-21 TABS (Norgestimate- NF TABS (Norethindrone Acet NF Ethinyl Estradiol & Eth Estra) (Triphasic)) LOESTRIN 1/20-21 TABS ORTHO TRI-CYCLEN (Norethindrone Acet & Eth NF TABS (Norgestimate- NF Estra) Ethinyl Estradiol LOESTRIN FE 1/20 TABS QL(1 ea daily) (Triphasic)) (Norethin Acet & Estrad- NF ORTHO-CYCLEN TABS Fe) (Norgestimate-Ethinyl NF LOSEASONIQUE TABS Estradiol) (Levonorgestrel-Ethinyl NF ORTHO-NOVUM 1/35 Estradiol (91-Day)) TABS (Norethindrone & Eth NF MIRCETTE TABS Estradiol) (Desogestrel-Ethinyl NF ORTHO-NOVUM 7/7/7 Estradiol (Biphasic)) TABS (Norethindrone-Eth NF Estradiol (Triphasic))

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OVCON-35 TABS norethindrone (Norethindrone & Eth NF (contraceptive) tabs 0.35 F Estradiol) mg SEASONIQUE TABS ORTHO MICRONOR (Levonorgestrel-Ethinyl NF TABS (Norethindrone NF Estradiol (91-Day)) (Contraceptive)) TRI-NORINYL 28 TABS - Steroid Hormone Drugs to (Norethindrone-Eth NF Treat Systemic Swelling Conditions Estradiol (Triphasic)) YASMIN 28 TABS Glucocorticosteroids (Drospirenone-Ethinyl NF budesonide cpep or 3 mg F Estradiol) CORTEF TABS YAZ TABS (Drospirenone- NF NF Ethinyl Estradiol) (Hydrocortisone) elix or 0.5 F Combination Contraceptives - Vaginal mg/5ml NUVARING RING F DEXAMETHASONE F INTENSOL CONC Emergency Contraceptives DEXAMETHASONE SOLN F levonorgestrel (emergency F OR 0.5 MG/5ML oc) tabs 1.5 mg dexamethasone tabs or PLAN B ONE-STEP TABS 0.75 mg, 0.5 mg, 4 mg, 6 F (Levonorgestrel NF mg, 1.5 mg (Emergency OC)) DEXAMETHASONE TABS F Progestin Contraceptives - Injectable OR 1 MG, 2 MG DEPO-PROVERA dexamethasone tbpk or 1.5 F mg CONTRACEPTIVE SUSP NF (Medroxyprogesterone DEXPAK 13 DAY TBPK NF Acetate (Contraceptive)) (Dexamethasone) DEPO-PROVERA ENTOCORT EC CPEP NF CONTRACEPTIVE SUSY NF (Budesonide) (Medroxyprogesterone hydrocortisone tabs or 5 F Acetate (Contraceptive)) mg, 10 mg, 20 mg DEPO-SUBQ PROVERA F PA 104 SUSY KENALOG-10 SUSP F medroxyprogesterone MEDROL DOSEPAK TBPK NF acetate (contraceptive) F (Methylprednisolone) susp medroxyprogesterone MEDROL TABS 2 MG F acetate (contraceptive) F MEDROL TABS 4 MG, 8 susy MG, 16 MG NF Progestin Contraceptives - Oral (Methylprednisolone) NOR-QD TABS methylprednisolone sod F PA (Norethindrone NF succ solr )) (Contraceptive methylprednisolone tabs or F 4 mg, 8 mg, 16 mg

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methylprednisolone tbpk or F Antitussives 4 mg benzonatate caps F MILLIPRED TABS 5 MG F DELSYM COUGH ORAPRED ODT TBDP CHILDRENS SUER NF ( Sodium NF ( Phosphate) Polistirex) prednisolone sodium DELSYM SUER phosphate soln or 5 F (Dextromethorphan NF mg/5ml Polistirex) prednisolone sodium dextromethorphan hbr caps F phosphate tbdp or 10 mg, F or 15 mg 15 mg, 30 mg dextromethorphan hbr syrp F prednisolone soln or F or 15 mg/5ml dextromethorphan F PREDNISOLONE SOLN F polistirex suer 30 mg/5ml OR QL(240 ml per prednisolone syrp or F hydrocodone w/ homatropine syrp 5mg/5ml- F 12 days retail); 1.5mg/5ml AL(At least 18 PREDNISONE INTENSOL F yrs old) CONC hydrocodone w/ AL(At least 18 PREDNISONE SOLN OR 5 F homatropine tabs 5mg- F yrs old) MG/5ML 1.5mg prednisone tabs or 1 mg, 5 F ROBITUSSIN LINGERING mg, 10 mg, 20 mg, 2.5 mg COLDLONG-ACTING NF PREDNISONE TABS OR F COUGHGELS CAPS 50 MG (Dextromethorphan HBr) PREDNISONE TBPK OR 5 F TESSALON PERLES NF MG, 10 MG CAPS (Benzonatate) SOLU-CORTEF SOLR F PA Cough/Cold/Allergy Combinations ACTIDOM DMX LIQD F QL(16 ml daily) SOLU-MEDROL SOLR 2 F PA GM, 500 MG ALLEGRA-D 12 HOUR QL(2 ea daily) SOLU-MEDROL SOLR 40 PA ALLERGY & MG, 125 MG, 1000 MG NF CONGESTION TB12 NF (Methylprednisolone Sod (Fexofenadine- Succ) ) F PA ALLEGRA-D 24 HOUR QL(1 ea daily) ACETONIDE PF SUSP ALLERGY & TRIAMCINOLONE PA CONGESTION TB24 NF ACETONIDE SUSP IJ 50 F (Fexofenadine- MG/ML Pseudoephedrine) Mineralocorticoids BALAMINE DM SYRP F fludrocortisone acetate F tabs or 0.1 mg BIOBRON SF SYRP F QL(16 ml daily) COUGH/COLD/ALLERGY - Drugs to Treat QL(16 ml daily) Cough, Cold and Allergy Symptoms BIODESP DM SYRP F Arizona Complete Health-Complete Care Plan Effective October 1, 2018

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits brompheniramine & QL(8 ml daily) dextromethorphan- pseudoeph elix 1mg/5ml- F syrp 10mg/5ml- 15mg/5ml 100mg/5ml, 10mg/5ml- F brompheniramine & QL(8 ml daily) 10mg/5ml-100mg/5ml- pseudoeph liqd 1mg/5ml- F 100mg/5ml 15mg/5ml dextromethorphan- QL(2 ea daily) guaifenesin tabs 20mg- F BRONKIDS LIQD F 400mg, 20mg-20mg- 400mg-400mg BRONTUSS DX LIQD F QL(16 ml daily) dextromethorphan- QL(2 ea daily) guaifenesin tb12 30mg- F BROTAPP DM LIQD F 600mg cetirizine-pseudoephedrine F QL(2 ea daily) DOMETUSS-DMX LIQD F QL(16 ml daily) tb12 CHERACOL PLUS LIQD QL(16 ml daily) ED BRON GP LIQD F (Dextromethorphan- NF Guaifenesin) EXACTUSS LIQD NF QL(16 ml CHERACOL-D COUGH QL(16 ml daily) ( w/ DM-GG) daily); RX/OTC LIQD (Dextromethorphan- NF EXACTUSS TR TABS F RX/OTC Guaifenesin) FATHER JOHNS chlorpheniramine & F F pseudoeph tabs MEDICINE PLUS SOLN CLARITIN-D 12 HOUR QL(2 ea daily) fexofenadine- QL(2 ea daily) TB12 (Loratadine & NF pseudoephedrine tb12 F Pseudoephedrine) 60mg-120mg CLARITIN-D 24 HOUR QL(1 ea daily) fexofenadine- QL(1 ea daily) TB24 (Loratadine & NF pseudoephedrine tb24 F Pseudoephedrine) 180mg-240mg DECONEX DMX TABS G-TUSICOF LIQD F QL(16 ml daily) 15MG-380MG-10MG NF (Phenylephrine w/ DM-GG) G-ZYNCOF SYRP F DESGEN DM SYRP QL(16 ml daily) 15MG/5ML-100MG/5ML- F GILTUSS COUGH & COLD QL(16 ml daily) 5MG/5ML LIQD 29MG/5ML- F 390MG/5ML-10MG/5ML dextromethorphan- QL(16 ml daily) guaifenesin liqd 10mg/5ml- GILTUSS COUGH & COLD F RX/OTC 100mg/5ml, 10mg/5ml- TABS 28MG-388MG-10MG 200mg/5ml, 20mg/10ml- GILTUSS LIQD NF QL(16 ml 200mg/10ml, 20mg/10ml- F (Phenylephrine w/ DM-GG) daily); RX/OTC 400mg/10ml, 15mg/7.5ml- RX/OTC 150mg/7.5ml, 10mg/5ml- GILTUSS TR TABS F 10mg/5ml-100mg/5ml- QL(240 ml per 100mg/5ml guaifenesin-codeine liqd F 12 days retail); dextromethorphan- QL(16 ml daily) 100mg/5ml-10mg/5ml AL(At least 18 yrs old) guaifenesin soln 10mg/5ml- F 100mg/5ml, 20mg/10ml- 200mg/10ml

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(240 ml per NEOTUSS PLUS LIQD F guaifenesin-codeine soln F 12 days retail); 100mg/5ml-10mg/5ml AL(At least 18 NEOTUSS-D LIQD F QL(16 ml daily) yrs old) QL(240 ml per NIVANEX DMX TABS F guaifenesin-codeine syrp F 12 days retail); 100mg/5ml-10mg/5ml AL(At least 18 phenylephrine w/ dm-gg QL(16 ml daily) yrs old) liqd 5mg/ml-100mg/ml- QL(16 ml daily) 2.5mg/ml, 10mg/5ml- LOHIST-D LIQD F 100mg/5ml-5mg/5ml, QL(16 ml daily) 10mg/5ml-200mg/5ml- LOHIST-DM SYRP F 5mg/5ml, 5mg/5ml- loratadine & QL(2 ea daily) 75mg/5ml-2.5mg/5ml, pseudoephedrine tb12 F 15mg/5ml-350mg/5ml- F 5mg-120mg 10mg/5ml, 5mg/5ml- 100mg/5ml-2.5mg/5ml, loratadine & QL(1 ea daily) 20mg/20ml-400mg/20ml- pseudoephedrine tb24 F 10mg/20ml, 10mg/5ml- 10mg-240mg, 10mg-10mg- 10mg/5ml-100mg/5ml- 240mg-240mg 100mg/5ml-5mg/5ml- MUCINEX CHILDRENS QL(16 ml daily) 5mg/5ml MULTI-SYMPTOM COLD NF phenylephrine w/ dm-gg QL(16 ml LIQD (Phenylephrine w/ liqd 5mg/ml-50mg/ml- daily); RX/OTC DM-GG) 2.5mg/ml, 7.5mg/ml- MUCINEX CONGESTION QL(16 ml daily) 88mg/ml-2.5mg/ml, F & COUGH CHILDRENS NF 15mg/5ml-300mg/5ml- LIQD (Phenylephrine w/ 10mg/5ml, 28mg/5ml- DM-GG) 388mg/5ml-10mg/5ml, MUCINEX D TB12 7.5mg/2.5ml-150mg/2.5ml- (Pseudoephedrine- NF 5mg/2.5ml Guaifenesin) phenylephrine w/ dm-gg QL(16 ml daily) MUCINEX DM TB12 QL(2 ea daily) syrp 10mg/5ml-100mg/5ml- F (Dextromethorphan- NF 5mg/5ml Guaifenesin) phenylephrine w/ dm-gg MUCINEX FAST-MAX QL(16 ml daily) tabs 15mg-380mg-10mg, F SEVERE CONGESTION & 20mg-400mg-10mg COUGH CLEAR & COOL NF phenylephrine- QL(16 ml daily) LIQD (Phenylephrine w/ brompheniramine-dm elix DM-GG) 1mg/5ml-5mg/5ml- MUCINEX FAST-MAX QL(16 ml daily) 2.5mg/5ml, 1mg/5ml- F SEVERE CONGESTION & 1mg/5ml-5mg/5ml- 5mg/5ml-2.5mg/5ml- COUGH LIQD NF 20MG/20ML-400MG/20ML- 2.5mg/5ml 10MG/20ML phenylephrine-chlorphen- F (Phenylephrine w/ DM-GG) dm liqd MUCINEX STUFFY NOSE phenylephrine-guaifenesin F & COLD CHILDRENS NF liqd 100mg/5ml-2.5mg/5ml LIQD (Phenylephrine- phenylephrine-guaifenesin Guaifenesin) tabs 400mg-10mg, 400mg- F 400mg-10mg-10mg Arizona Complete Health-Complete Care Plan Effective October 1, 2018

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits promethazine & F QL(16 ml daily) ROBITUSSIN PEAK COLD QL(16 ml daily) phenylephrine soln MULTI-SYMPTOM COLD NF LIQD (Phenylephrine w/ promethazine & F QL(16 ml daily) phenylephrine syrp DM-GG) QL(240 ml per ROBITUSSIN TO GO QL(16 ml daily) COUGH &COLD CF LIQD NF promethazine w/codeine F 12 days retail); soln AL(At least 18 (Phenylephrine w/ DM-GG) yrs old) RYCONTUSS LIQD QL(240 ml per (Phenylephrine-Chlorphen- NF DM) promethazine w/codeine F 12 days retail); syrp AL(At least 18 SUPRESS-PE PEDIATRIC F yrs old) LIQD promethazine-dm syrp F QL(16 ml daily) QL(240 ml per F 12 days retail); TRICODE GF LIQD AL(At least 18 PROMETHAZINE/PHENYL F QL(16 ml daily) EPHRINE SYRP yrs old) QL(16 ml daily) pseudoephed-bromphen- F TUSICOF LIQD F dm elix QL(240 ml per pseudoephed-bromphen- F dm syrp F 12 days retail); TUSNEL C SYRP AL(At least 18 QL(240 ml per yrs old) pseudoephedrine w/ F 12 days retail); codeine-gg soln AL(At least 18 TUSSI-PRES PEDIATRIC QL(16 ml daily) yrs old) LIQD (Phenylephrine w/ NF DM-GG) pseudoephedrine w/ dm-gg liqd 10mg/5ml-30mg/5ml- F ZYNCOF SYRP F 100mg/5ml pseudoephedrine- ZYRTEC-D QL(2 ea daily) guaifenesin tb12 60mg- F ALLERGY/CONGESTION NF 600mg TB12 (Cetirizine- Pseudoephedrine) QC MEDIFIN PE TABS (Phenylephrine- NF Expectorants Guaifenesin) guaifenesin liqd or 100 QL(16 ml daily) mg/5ml, 200 mg/10ml, 400 F ROBITUSSIN CHILDRENS F QL(16 ml daily) COUGH & COLD CF LIQD mg/20ml ROBITUSSIN PEAK COLD QL(16 ml daily) guaifenesin soln or 100 QL(16 ml daily) COUGH+ CHEST mg/5ml, 200 mg/10ml, 300 F mg/15ml CONGESTION DM MAX NF STRENGTH LIQD guaifenesin syrp or 100 F QL(16 ml daily) (Dextromethorphan- mg/5ml, 200 mg/10ml Guaifenesin) guaifenesin tabs or 200 F ROBITUSSIN PEAK COLD mg, 400 mg DM SYRP NF guaifenesin tb12 or 600 F (Dextromethorphan- mg, 1200 mg Guaifenesin) HERBAL EXPEC LIQD F QL(16 ml daily)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MUCINEX MAXIMUM benzoyl peroxide foam ex F STRENGTH TB12 NF 9.8 % (Guaifenesin) benzoyl peroxide gel ex 10 F RX/OTC MUCINEX TB12 NF % (Guaifenesin) BENZOYL PEROXIDE F YODEFAN-NF CHEST F QL(16 ml daily) GEL EX 2.5 % CONGESTION LIQD benzoyl peroxide gel ex 5 F Misc. Respiratory Inhalants % HYPER-SAL NEBU benzoyl peroxide liqd ex 4 F (Sodium Chloride NF %, 7 % (Inhalant)) benzoyl peroxide liqd ex 5 F RX/OTC HYPERSAL NEBU 7 % %, 10 %, 2.5 % (Sodium Chloride NF benzoyl peroxide lotn ex 6 F (Inhalant)) % sodium chloride (inhalant) F BP GEL GEL F nebu 3 %, 7 % DERMATOLOGICALS - Drugs to Treat Skin CLEAN & CLEAR Conditions ADVANTAGE 3-IN-1 F EXFOLIATING CLEANSER Acne Products LOTN ABSORICA CAPS F PA CLEOCIN-T LOTN (Clindamycin Phosphate NF ACNE 10 F (Topical)) LOTN CLEOCIN-T SOLN ACNE MEDICATION 5 F (Clindamycin Phosphate NF LOTN (Topical)) BENZAC AC WASH LIQD RX/OTC NF clindamycin phosphate F (Benzoyl Peroxide) (topical) lotn 1 % BENZEFOAM FOAM RX/OTC NF clindamycin phosphate F (Benzoyl Peroxide) (topical) soln 1 % BENZEFOAM ULTRA NF DESQUAM-X WASH LIQD NF RX/OTC FOAM (Benzoyl Peroxide) (Benzoyl Peroxide) BENZIQ GEL F ERYGEL GEL NF (Erythromycin (Acne Aid)) BENZIQ LS GEL F erythromycin (acne aid) gel F 2 % BENZIQ WASH LIQD F erythromycin (acne aid) F pads 2 % benzoyl peroxide bar ex 10 F % erythromycin (acne aid) F soln 2 % BENZOYL PEROXIDE F CLEANSER LOTN isotretinoin caps or 10 mg, F PA 20 mg, 30 mg, 40 mg benzoyl peroxide crea ex F 10 %, 2.5 % KLARON LOTN (Sulfacetamide Sodium NF benzoyl peroxide foam ex F RX/OTC (Acne)) 5.3 %

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ON-THE- BACTROBAN CREA SPOT ACNE TREATMENT NF ( Calcium NF CREA (Benzoyl Peroxide) (Topical)) OC8 GEL F CENTANY OINT 2 % F

PANOXYL LIQD (Benzoyl NF RX/OTC gentamicin sulfate (topical) F Peroxide) crea 0.1 % PANOXYL-4 CREAMY gentamicin sulfate (topical) F WASH LIQD (Benzoyl NF oint 0.1 % Peroxide) mupirocin calcium (topical) F RETIN-A CREA 0.025 %, NF AL(Up to 26 yrs crea 2 % 0.05 %, 0.1 % (Tretinoin) old ) mupirocin oint ex 2 % F RETIN-A MICRO GEL NF AL(Up to 26 yrs (Tretinoin Microsphere) old ) neomycin-bacitracin- F RETIN-A MICRO PUMP AL(Up to 26 yrs polymyxin oint GEL 0.04 %, 0.1 % NF old ) neomycin-bacitracin- F (Tretinoin Microsphere) polymyxin-pramoxine oint RETIN-A MICRO PUMP F AL(Up to 26 yrs NEOSPORIN ORIGINAL GEL 0.08 % old ) OINT (Neomycin- NF Bacitracin-Polymyxin) RIAX FOAM F POLYSPORIN OINT NF sulfacetamide sodium F (Bacitracin-Polymyxin B) (acne) lotn 10 % Antifungals - Topical F AL(Up to 26 yrs TRETIN-X CREA 0.075 % old ) ALOE VESTA ANTIFUNGAL OINT NF tretinoin crea ex 0.025 %, F AL(Up to 26 yrs (Miconazole Nitrate 0.05 %, 0.1 % old ) (Topical)) F AL(Up to 26 yrs ALOE VESTA CLEAR tretinoin microsphere gel old ) ANTIFUNGAL OINT NF (Miconazole Nitrate ZACLIR CLEANSING F LOTN (Topical)) Anti-inflammatory Agents - Topical butenafine hcl crea 1 % F RX/OTC diclofenac sodium (topical) F QL(200 gm per gel 1 % 30 days retail) ciclopirox olamine susp ex F 0.77 % VOLTAREN GEL QL(200 gm per (Diclofenac Sodium NF 30 days retail) clotrimazole (topical) crea 1 F RX/OTC (Topical)) % clotrimazole (topical) soln 1 F RX/OTC Antibiotics - Topical % BACIGUENT OINT NF clotrimazole w/ (Bacitracin (Topical)) crea 1%- F bacitracin (topical) oint 500 F 0.05% unit/gm ketoconazole (topical) crea F bacitracin zinc oint ex 500 F 2 % unit/gm ketoconazole (topical) F bacitracin-polymyxin b oint F sham 2 %

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAMISIL AT CREA NF terbinafine hcl (topical) crea F (Terbinafine HCl (Topical)) 1 % LAMISIL AT JOCK ITCH TINACTIN AERO NF CREA (Terbinafine HCl NF (Tolnaftate) (Topical)) TINACTIN AERP NF LOPROX SUSP 0.77 % NF (Tolnaftate) (Ciclopirox Olamine) TINACTIN CREA NF LOTRIMIN AF AERO 2 % F (Tolnaftate) TINACTIN DEODORANT NF LOTRIMIN AF CREA 1 % NF RX/OTC AERP (Tolnaftate) (Clotrimazole (Topical)) TINACTIN JOCK ITCH NF LOTRIMIN AF FOR HER RX/OTC AERP (Tolnaftate) CREA (Clotrimazole NF TINACTIN JOCK ITCH NF (Topical)) CREA (Tolnaftate) LOTRIMIN AF JOCK ITCH RX/OTC CREA (Clotrimazole NF tolnaftate aero ex 1 % F (Topical)) tolnaftate aerp ex 1 % F LOTRIMIN ULTRA CREA NF RX/OTC (Butenafine HCl) tolnaftate crea ex 1 % F LOTRIMIN ULTRA CREA 1 F RX/OTC % tolnaftate liqd ex 1 % F LOTRISONE CREA (Clotrimazole w/ NF tolnaftate soln ex 1 % F Betamethasone) MENTAX CREA 1 % F RX/OTC XOLEGEL GEL 2 % F MICATIN CREA Antihistamines-Topical (Miconazole Nitrate NF diphenhydramine hcl F (Topical)) (topical) crea miconazole nitrate (topical) F diphenhydramine hcl F aerp (topical) gel miconazole nitrate (topical) F diphenhydramine hcl F crea (topical) soln miconazole nitrate (topical) F oint Antiseborrheic Products OVACE PLUS WASH LIQD miconazole nitrate (topical) F NF powd (Sulfacetamide Sodium) OVACE WASH LIQD MICONAZOLE NITRATE F NF POWD (Sulfacetamide Sodium) selenium sulfide lotn ex 2.5 NIZORAL SHAM NF F (Ketoconazole (Topical)) % sulfacetamide sodium liqd F nystatin (topical) crea F ex 10 % nystatin (topical) oint F Antivirals - Topical Limit 2 per nystatin (topical) powd F ABREVA CREA F month;QL(0.06 7 gm daily)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits acyclovir topical oint 5 % F ELOCON CREA NF (Mometasone Furoate) ZOVIRAX OINT EX 5 % NF ELOCON OINT NF (Acyclovir Topical) (Mometasone Furoate) Burn Products fluocinolone acetonide oil F ex 0.01 % SILVADENE CREA (Silver NF Sulfadiazine) fluocinonide crea ex 0.05 % F silver sulfadiazine crea ex F 1 % F QL(60 gm per fluocinonide oint ex 0.05 % fill retail) Corticosteroids - Topical betamethasone fluocinonide soln ex 0.05 % F dipropionate (topical) lotn F crea F 0.05 % ex 0.05 % betamethasone fluticasone propionate oint F dipropionate augmented F ex 0.005 % crea 0.05 % halobetasol propionate F QL(2 gm daily) betamethasone valerate F crea 0.05 % crea ex 0.1 % halobetasol propionate oint F QL(2 gm daily) betamethasone valerate F 0.05 % lotn ex 0.1 % hydrocortisone (topical) F betamethasone valerate F crea 0.5 %, 2.5 % oint ex 0.1 % hydrocortisone (topical) F RX/OTC CAPEX SHAM 0.01 % F crea 1%, 1 % hydrocortisone (topical) gel clobetasol propionate crea F QL(60 gm per F ex 0.05 % fill retail) 1 % hydrocortisone (topical) lotn clobetasol propionate F F emollient base crea 0.05 % 1 %, 2.5 % hydrocortisone (topical) oint clobetasol propionate gel F QL(118 gm per F ex 0.05 % fill retail) 0.5 %, 2.5 % hydrocortisone (topical) oint RX/OTC clobetasol propionate oint F QL(60 gm per F ex 0.05 % fill retail) 1 % hydrocortisone acetate clobetasol propionate soln F F ex 0.05 % (topical) crea mometasone furoate crea CVS HDYROCORTISONE F F ACETATE CREA ex 0.1 % DERMA-SMOOTHE/FS mometasone furoate oint F BODY OIL (Fluocinolone NF ex 0.1 % Acetonide) mometasone furoate soln F DERMA-SMOOTHE/FS ex 0.1 % SCALP OIL (Fluocinolone NF MONISTAT SOOTHING RX/OTC Acetonide) CARE ITCH RELIEF CREA NF DIPROLENE AF CREA (Hydrocortisone (Topical)) (Betamethasone NF TEMOVATE CREA NF QL(60 gm per Dipropionate Augmented) (Clobetasol Propionate) fill retail)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEMOVATE E CREA NOBLE MYSTIQUE EMU- F (Clobetasol Propionate NF LAC CREA Emollient Base) Immunomodulating Agents - Topical TEMOVATE OINT NF QL(60 gm per ) ALDARA CREA NF (Clobetasol Propionate fill retail) (Imiquimod) (topical) crea 0.025 %, 0.1 F imiquimod crea ex 5 % F %, 0.5 % triamcinolone acetonide Keratolytic/Antimitotic Agents (topical) lotn 0.025 %, 0.1 F AMBI EVEN & CLEAR % EXFOLIATING WASH F triamcinolone acetonide LIQD (topical) oint 0.025 %, 0.1 F AMBI EVEN & CLEAR %, 0.5 % FOAMINGCLEANSER F LIQD ULTRAVATE CREA NF QL(2 gm daily) (Halobetasol Propionate) BETASAL SHAM F ULTRAVATE OINT NF QL(2 gm daily) (Halobetasol Propionate) CLEAN & CLEAR ACNE TRIPLECLEAR BUBBLE F Emollient/Keratolytic Agents FOAM CLEANSER FOAM ATRAC-TAIN CREA 10 % NF CLEAN & CLEAR (Urea) ADVANTAGE OIL F ABSORBING CLEANSER CARMOL 20 CREA (Urea) NF CREA REA-LO CREA 30 % F CLEAN & CLEAR BLACKHEAD ERASER NF SCRUB CREA (Salicylic urea crea ex 10 %, 20 %, F 50 % Acid) urea crea ex 40 % F RX/OTC CLEAN & CLEAR DEEP CLEANING ASTRINGENT F Emollients SENSITIVE SKIN LIQD LAC-HYDRIN CREA RX/OTC CLN ACNE CLEANSER F (Lactic Acid (Ammonium NF LIQD Lactate)) COMPOUND W LIQD NF LAC-HYDRIN LOTN RX/OTC (Salicylic Acid) (Lactic Acid (Ammonium NF COMPOUND W MAXIMUM Lactate)) STRENGTH GEL (Salicylic NF LAC-HYDRIN TWELVE RX/OTC Acid) LOTN (Lactic Acid NF CONDYLOX SOLN NF (Ammonium Lactate)) (Podofilox) CORN & CALLUS lactic acid (ammonium F RX/OTC F lactate) crea 12 % REMOVER SOLN CVS PSORIASIS lactic acid (ammonium F lactate) lotn 10 % MEDICATED SHAMPOO F PLUS CONDITIONER lactic acid (ammonium F RX/OTC lactate) lotn 12 % SHAM

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS THERAPEUTIC salicylic acid lotn ex 0.5 %, F DANDRUFFMAXIMUM F 6 % STRENGTH SHAM salicylic acid sham ex 6 % F CVS THERAPEUTIC MAXIMUM STRENGTH F salicylic acid soln ex 17 %, F SHAM 26 % DENOREX EXTRA F SALVAX FOAM (Salicylic NF PA STRENGTH 2-IN-1 SHAM Acid) DERMAREST PSORIASIS F SELSUN BLUE DEEP F GEL 3 % CLEANSING SHAM DERMAREST PSORIASIS SELSUN BLUE MEDICATED SHAMPOO F NATURALS DRYSCALP F PLUS CONDITIONER SHAM SHAM SELSUN BLUE F FREEZONE LIQD F NATURALS SHAM THERAPEUTIC T+PLUS GOLD BOND PSORIASIS MAXIMUM STRENGTH F RELIEF MULTI-SYMPTOM F SHAM CREA Local Anesthetics - Topical KERALYT GEL 3 % F lidocaine crea ex 4 % F KERALYT GEL 6 % NF (Salicylic Acid) lidocaine hcl crea ex 4 % F MG217 PSORIASIS MULTI-SYMPTOM CREA 3 F lidocaine hcl gel ex 2 % F RX/OTC % lidocaine hcl soln ex 4 % F MOSCO CALLUS/CORN F REMOVER SOLN lidocaine oint ex 5 % F PA; QL(50 gm NEUTROGENA T/SAL F per fill retail) SHAM lidocaine ptch ex 5 % F PA; QL(3 ea P & S SHAM F daily) lidocaine-prilocaine crea F podofilox soln ex 0.5 % F 2.5%-2.5% LIDODERM PTCH NF PA; QL(3 ea SALAC FOAM F (Lidocaine) daily) SALEX SHAM (Salicylic NF LMX 4 CREA (Lidocaine) NF Acid) PREDATOR CREA salicylic acid crea ex 2 %, 6 F NF % (Lidocaine HCl) salicylic acid foam ex 6 % F PA XOLIDO CREA F Misc. Topical salicylic acid gel ex 2 %, 6 F %, 17 % CALAMINE LOTN EX F salicylic acid liqd ex 2 %, 3 F %, 17 %, 26 % DRYSOL SOLN 20 % F

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEIJER CALAMINE LOTN F NIX CREME RINSE LIQD NF (Permethrin) QC CALAMINE LOTN F permethrin crea ex 5 % F

SM CALAMINE LOTN F permethrin liqd ex 1 % F zinc oxide (topical) crea 13 F pyrethrins-piperonyl % butoxide-permethrin-nit F remover kit 0.5%-0.33%- zinc oxide (topical) oint 20 F %, 40 % 4% Rosacea Agents RA LICE SOLUTION KIT F KIT 0.5%-0.33%-4% METROCREAM CREA NF (Metronidazole (Topical)) RID COMPLETE LICE ELIMINATION KIT METROLOTION LOTN NF (Pyrethrins-Piperonyl NF (Metronidazole (Topical)) Butoxide-Permethrin-Nit metronidazole (topical) F Remover) crea 0.75 % SCHOOLTIME SHAMPOO F metronidazole (topical) gel F SHAM 0.75 % SKLICE LOTN F PA metronidazole (topical) lotn F 0.75 % SPINOSAD SUSP F PA Scabicides & Pediculicides A-200 GEL EX 0.33%-4% F DIAGNOSTIC PRODUCTS Diagnostic Tests crotamiton lotn ex 10 % F PA ALBUSTIX STRP F ELIMITE CREA NF (Permethrin) CHEMSTRIP-MICRAL F STRP EURAX CREA 10 % F PA INSULIN EURAX LOTN (Crotamiton) NF PA USERS LIMITED TO 150 PER 30 KLOUT SHAM F TRUE METRIX BLOOD GLUCOSETEST STRIPS F DAYS, NON- STRP INSULIN LICEMD GEL 0.33%-4% F USERS LIMITED TO lindane sham F 100 PER 90 DAYS;RX/OTC LINDANE SHAM F

LYCELLE GEL F

NATROBA SUSP F PA nit remover gel F

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN INSULIN USERS USERS LIMITED TO LIMITED TO TRUE METRIX SELF 150 PER 30 150 PER 30 F DAYS, NON- F DAYS, NON- MONITORING BLOOD INSULIN TRUETRACK TEST STRP INSULIN GLUCOSE STRIPS STRP USERS USERS LIMITED TO LIMITED TO 100 PER 90 100 PER 90 DAYS;RX/OTC DAYS;RX/OTC INSULIN DIGESTIVE AIDS - Drugs to Treat Low Digestive USERS Enzymes LIMITED TO Digestive Enzymes TRUETEST BLOOD 150 PER 30 GLUCOSE TEST STRIPS F DAYS, NON- 500 per STRP INSULIN CREON CPEP F month;QL(16.6 USERS 7 ea daily) LIMITED TO PA 100 PER 90 SUCRAID SOLN F DAYS;RX/OTC ZENPEP CPEP 500 per INSULIN 10000UNIT-3000UNIT- month;;QL(16.6 USERS 14000UNIT, 32000UNIT- 7 ea daily) LIMITED TO 10000UNIT-42000UNIT, F 150 PER 30 63000UNIT-20000UNIT- TRUETEST BLOOD F DAYS, NON- 84000UNIT, 126000UNIT- GLUCOSE TEST STRP INSULIN 40000UNIT-168000UNIT USERS ZENPEP CPEP 500 per LIMITED TO 17000UNIT-5000UNIT- month;QL(16.6 100 PER 90 24000UNIT, 47000UNIT- F 7 ea daily) DAYS;RX/OTC 15000UNIT-63000UNIT, INSULIN 79000UNIT-25000UNIT- USERS 105000UNIT LIMITED TO 150 PER 30 DIURETICS - Drugs to Treat Heart, Circulation Conditions and Blood Pressure TRUETEST STRIPS STRP F DAYS, NON- INSULIN Carbonic Anhydrase Inhibitors USERS acetazolamide cp12 or 500 F LIMITED TO mg 100 PER 90 DAYS;RX/OTC acetazolamide tabs or 125 F mg, 250 mg INSULIN USERS DIAMOX CP12 NF LIMITED TO (Acetazolamide) 150 PER 30 methazolamide tabs or 25 F mg, 50 mg TRUETRACK BLOOD F DAYS, NON- GLUCOSE TEST STRP INSULIN NEPTAZANE TABS NF USERS (Methazolamide) LIMITED TO 100 PER 90 Diuretic Combinations DAYS;RX/OTC

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALDACTAZIDE TABS MP amiloride hcl tabs or 5 mg F 25MG-25MG NF (Spironolactone & DYRENIUM CAPS F Hydrochlorothiazide) spironolactone tabs or 25 MP ALDACTAZIDE TABS F F 50MG-50MG mg, 50 mg, 100 mg amiloride & F Thiazides and Thiazide-Like Diuretics hydrochlorothiazide tabs CHLOROTHIAZIDE TABS F MP DYAZIDE CAPS MP 250 MG (Triamterene & NF MP Hydrochlorothiazide) chlorothiazide tabs 500 mg F MAXZIDE TABS MP MP (Triamterene & NF chlorthalidone tabs F Hydrochlorothiazide) DIURIL SUSP F MAXZIDE-25 TABS MP (Triamterene & NF hydrochlorothiazide caps or F MP Hydrochlorothiazide) 12.5 mg spironolactone & MP F hydrochlorothiazide tabs or F MP hydrochlorothiazide tabs 25 mg, 50 mg triamterene & F MP MP hydrochlorothiazide caps indapamide tabs F METHYCLOTHIAZIDE triamterene & F MP F hydrochlorothiazide tabs TABS MP TRIAMTERENE/HYDROC F MP metolazone tabs F HLOROTHIAZIDE CAPS MICROZIDE CAPS NF MP Loop Diuretics (Hydrochlorothiazide) bumetanide tabs or 0.5 mg, F MP 1 mg, 2 mg ENDOCRINE AND METABOLIC AGENTS - MISC. - Drugs to Treat Bone Disease and BUMEX TABS NF MP Regulate Hormones (Bumetanide) Bone Density Regulators DEMADEX TABS NF MP (Torsemide) ALENDRONATE SODIUM F TABS 40 MG furosemide soln or 10 F MP mg/ml alendronate sodium tabs 5 F mg, 10 mg, 35 mg, 70 mg FUROSEMIDE SOLN OR 8 F MP MG/ML FOSAMAX TABS NF (Alendronate Sodium) furosemide tabs or 20 mg, F MP 40 mg, 80 mg Growth Hormones MP LASIX TABS (Furosemide) NF GENOTROPIN MINIQUICK F PA; SP SOLR MP torsemide tabs F GENOTROPIN SOLR 12 F PA; SP MG Potassium Sparing Diuretics NORDITROPIN FLEXPRO PA; SP ALDACTONE TABS NF MP SOLN 30 MG/3ML, 15 F (Spironolactone) MG/1.5ML Hormone Receptor Modulators Arizona Complete Health-Complete Care Plan Effective October 1, 2018

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EVISTA TABS (Raloxifene NF ESTRACE TABS NF HCl) (Estradiol) raloxifene hcl tabs 60 mg F estradiol pttw td 0.0375 mg/24hr, 0.025 mg/24hr, F Insulin-Like Growth Factors (Somatomedins) 0.075 mg/24hr, 0.05 mg/24hr, 0.1 mg/24hr PA; SP INCRELEX SOLN F estradiol ptwk td 0.025 mg/24hr, 0.075 mg/24hr, Metabolic Modifiers 0.05 mg/24hr, 0.06 F calcitriol caps or 0.25 mcg, F mg/24hr, 0.1 mg/24hr, 37.5 0.5 mcg mcg/24hr PA; SP ELAPRASE SOLN F estradiol tabs or 0.5 mg, 1 F mg, 2 mg ROCALTROL CAPS 0.25 NF MCG, 0.5 MCG (Calcitriol) ESTROPIPATE TABS F PA SENSIPAR TABS F MENEST TABS F

Posterior Pituitary Hormones MENOSTAR PTWK F DDAVP SOLN NA 0.01 % F MINIVELLE PTTW F DDAVP SOLN NA 0.01 % (Desmopressin Acetate NF PREMARIN TABS OR Spray) 0.625 MG, 0.45 MG, 0.3 F MG, 0.9 MG, 1.25 MG DDAVP TABS OR 0.1 MG, PA 0.2 MG (Desmopressin NF VIVELLE-DOT PTTW NF Acetate) (Estradiol) FLUOROQUINOLONES - Drugs to Treat Bacterial desmopressin acetate F spray refrigerated soln Infections desmopressin acetate F Fluoroquinolones spray soln 0.01 % CIPRO TABS 250 MG, 500 NF desmopressin acetate tabs F PA MG (Ciprofloxacin HCl) or 0.1 mg, 0.2 mg CIPROFLOXACIN HCL F STIMATE SOLN F SP TABS OR 100 MG ciprofloxacin hcl tabs or F ESTROGENS - Hormone Replacement/Modifying 250 mg, 500 mg, 750 mg Drugs LEVAQUIN TABS NF Estrogen Combinations (Levofloxacin) levofloxacin soln or 25 F CLIMARA PRO PTWK F mg/ml QL(1 ea daily) PREMPRO TABS F levofloxacin tabs or 250 F mg, 500 mg, 750 mg Estrogens ofloxacin tabs 400 mg F ALORA PTTW F GASTROINTESTINAL AGENTS - MISC. - CLIMARA PTWK NF Miscellaneous Gastrointestinal Drugs (Estradiol) Antiflatulents

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GAS-X CHEW NF ASACOL HD TBEC F QL(9 ea daily) (Simethicone) GAS-X EXTRA ASACOL HD TBEC NF QL(9 ea daily) STRENGTH CHEW 125 NF (Mesalamine) MG (Simethicone) AZULFIDINE EN-TABS NF QL(8 ea daily) MYLICON INFANTS GAS TBEC (Sulfasalazine) RELIEF SUSP NF AZULFIDINE TABS NF QL(8 ea daily) (Simethicone) (Sulfasalazine) MYLICON SUSP NF balsalazide disodium caps F QL(9 ea daily) (Simethicone) COLAZAL CAPS QL(9 ea daily) PHAZYME CAPS NF NF (Simethicone) (Balsalazide Disodium) PHAZYME ULTRA DIPENTUM CAPS F QL(4 ea daily) STRENGTH CAPS NF (Simethicone) GIAZO TABS F QL(9 ea daily) simethicone caps or F 125mg, 125 mg, 180 mg mesalamine enem re 4 gm F QL(60 ml daily) simethicone chew or 80 F mg, 125 mg mesalamine tbec or 800 F QL(9 ea daily) mg simethicone susp or 20 F mg/0.3ml, 40 mg/0.6ml PENTASA CPCR F QL(9 ea daily) Gallstone Solubilizing Agents SFROWASA ENEM F QL(60 ml daily) ACTIGALL CAPS NF (Ursodiol) sulfasalazine tabs or 500 F QL(8 ea daily) mg URSO 250 TABS NF (Ursodiol) sulfasalazine tbec or 500 F QL(8 ea daily) mg URSO FORTE TABS NF (Ursodiol) Intestinal Acidifiers ursodiol caps or 300 mg F lactulose (encephalopathy) F soln ursodiol tabs or 250 mg, F 500 mg Irritable Bowel Syndrome (IBS) Agents PA Gastrointestinal Chloride Channel Activators LINZESS CAPS F AMITIZA CAPS F PA Phosphate Binder Agents calcium acetate (phosphate F Gastrointestinal Stimulants binder) caps 667 mg metoclopramide hcl soln or F calcium acetate (phosphate F RX/OTC 5 mg/5ml, 10 mg/10ml binder) tabs 667 mg metoclopramide hcl tabs or F ELIPHOS TABS (Calcium RX/OTC 5 mg, 10 mg Acetate (Phosphate NF METOCLOPRAMIDE ODT F Binder)) TBDP FOSRENOL CHEW 500 PA REGLAN TABS NF MG, 750 MG, 1000 MG NF (Metoclopramide HCl) (Lanthanum Carbonate) Inflammatory Bowel Agents

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FOSRENOL PACK 750 F PA PROSCAR TABS NF MG, 1000 MG (Finasteride) lanthanum carbonate chew F PA hcl caps 0.4 mg F

RENAGEL TABS F Urinary Analgesics phenazopyridine hcl tabs or F RENVELA PACK 0.8 GM, 100 mg, 200 mg 2.4 GM (Sevelamer F Carbonate) PYRIDIUM TABS NF (Phenazopyridine HCl) RENVELA TABS 800 MG NF (Sevelamer Carbonate) GOUT AGENTS - Drugs to Treat Gout sevelamer carbonate tabs F 800 mg Gout Agents allopurinol tabs or 100 mg, F GENITOURINARY AGENTS - MISCELLANEOUS 300 mg - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System COLCHICINE TABS OR F PA 0.6 MG Alkalinizers COLCRYS TABS 0.6 MG F PA potassium citrate F (alkalinizer) tbcr ULORIC TABS F PA potassium citrate-citric acid RX/OTC soln 1100mg/5ml- ZYLOPRIM TABS NF 334mg/5ml, 1100mg/5ml- F (Allopurinol) 1100mg/5ml-334mg/5ml- 334mg/5ml Uricosurics UROCIT-K 10 TBCR probenecid tabs F (Potassium Citrate NF (Alkalinizer)) HEMATOLOGICAL AGENTS - MISC. - Drugs to UROCIT-K 15 TBCR Treat Blood Disorders (Potassium Citrate NF Hematorheologic Agents (Alkalinizer)) UROCIT-K 5 TBCR pentoxifylline tbcr or F (Potassium Citrate NF (Alkalinizer)) Platelet Aggregation Inhibitors PA Interstitial Cystitis Agents BRILINTA TABS 90 MG F PA ELMIRON CAPS F cilostazol tabs F

Prostatic Hypertrophy Agents clopidogrel bisulfate tabs or F 75 mg, 300 mg AVODART CAPS NF (Dutasteride) dipyridamole tabs or 25 F mg, 50 mg, 75 mg dutasteride caps or 0.5 mg F PLAVIX TABS (Clopidogrel NF Bisulfate) finasteride tabs or 5 mg F HEMATOPOIETIC AGENTS - Drugs to Treat FLOMAX CAPS NF Blood Disorders (Tamsulosin HCl) Agents for Gaucher Disease

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CEREZYME SOLR F PA; SP ferrous sulfate tbec F

Cobalamins HEMOCYTE TABS NF (Ferrous Fumarate) B-12 TABS OR 2500 MCG F SM IRON TABS F cyanocobalamin tabs F HEMOSTATICS - Drugs to Stop Bleeding/Treat Folic Acid/Folates Blood Disorders folic acid tabs 1 mg F RX/OTC Hemostatics - Systemic AMICAR SOLN F folic acid tabs 400 mcg, F 800 mcg AMICAR TABS F Hematopoietic Growth Factors PA; SP HYPNOTICS/SEDATIVES/SLEEP DISORDER EPOGEN SOLN F AGENTS NEULASTA ONPRO KIT F PA; SP Hypnotics PSKT diphenhydramine hcl F QL(2 ea daily) NEULASTA SOSY F PA; SP (sleep) caps 25 mg diphenhydramine hcl F QL(1 ea daily) NEUPOGEN SOLN F PA; SP (sleep) caps 50 mg PA; SP diphenhydramine hcl F QL(30 ml daily) NEUPOGEN SOSY F (sleep) liqd 50 mg/30ml PROCRIT SOLN 2000 PA; SP diphenhydramine hcl F QL(2 ea daily) UNIT/ML, 3000 UNIT/ML, (sleep) tabs 25 mg 4000 UNIT/ML, 10000 F diphenhydramine hcl F QL(1 ea daily) UNIT/ML, 20000 UNIT/ML, (sleep) tabs 50 mg 40000 UNIT/ML diphenhydramine hcl F QL(2 ea daily) PROMACTA TABS F PA; SP (sleep) tbdp 25 mg doxylamine succinate F Iron (sleep) tabs 25 mg FEMIRON TABS F NYTOL MAXIMUM QL(1 ea daily) STRENGTH TABS NF F (Diphenhydramine HCl FERRETTS TABS (Sleep)) FERRIMIN 150 TABS F UNISOM SLEEPGELS QL(1 ea daily) CAPS (Diphenhydramine NF FERROUS FUMARATE F HCl (Sleep)) TABS OR 29 MG UNISOM SLEEPMELTS QL(2 ea daily) ferrous fumarate tabs or F TBDP (Diphenhydramine NF 324 mg HCl (Sleep)) ferrous gluconate tabs or F UNISOM TABS 27 mg, 240 mg (Doxylamine Succinate NF (Sleep)) FERROUS GLUCONATE F TABS OR 324 MG WAL-SLEEP Z LIQUID F QL(50 ml daily) SHOTS LIQD ferrous sulfate tabs F

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZZZQUIL CAPS 25 MG QL(2 ea daily) METAMUCIL POWD 48.57 NF (Diphenhydramine HCl NF % (Psyllium) (Sleep)) psyllium caps 0.52 gm, 520 F ZZZQUIL LIQD 50 QL(30 ml daily) mg MG/30ML NF psyllium powd 30 %, 33 %, (Diphenhydramine HCl 68 %, 100 %, 28.3 %, 30.9 F (Sleep)) %, 58.6 %, 48.57 %, Barbiturate Hypnotics Laxative Combinations phenobarbital elix or 20 F COLYTE-FLAVOR PACKS mg/5ml SOLR (PEG 3350-KCl-Sod NF phenobarbital soln or 20 F Bicarb-Sod Chloride-Sod mg/5ml Sulfate) PHENOBARBITAL TABS GOLYTELY SOLR 236GM- OR 15 MG, 30 MG, 60 MG, F 22.74GM-5.86GM-2.97GM- 100 MG 6.74GM (PEG 3350-KCl- NF phenobarbital tabs or 16.2 Sod Bicarb-Sod Chloride- mg, 32.4 mg, 64.8 mg, 97.2 F Sod Sulfate) mg peg 3350-kcl-sod bicarb- sod chloride-sod sulfate F Non-Barbiturate Hypnotics solr AMBIEN TABS (Zolpidem NF QL(1 ea daily) ) sennosides-docusate F Tartrate sodium tabs RESTORIL CAPS 15 MG, NF QL(1 ea daily) ) SENOKOT S TABS 30 MG (Temazepam (Sennosides-Docusate NF temazepam caps 15 mg, F QL(1 ea daily) Sodium) 30 mg Laxatives - Miscellaneous zolpidem tartrate tabs or 5 F QL(1 ea daily) mg, 10 mg lactulose soln F Selective Melatonin Receptor Agonists MIRALAX PACK NF RX/OTC ST; QL(1 ea (Polyethylene Glycol 3350) ROZEREM TABS F daily); AL(At MIRALAX POWD NF RX/OTC least 6 yrs old) (Polyethylene Glycol 3350) LAXATIVES - Bowel Treatment Drugs polyethylene glycol 3350 F RX/OTC pack or Bulk Laxatives polyethylene glycol 3350 F RX/OTC EVAC POWD (Psyllium) NF powd or Laxatives KONSYL DAILY FIBER NF POWD 100 % (Psyllium) FLEET ENEMA ENEM NF (Sodium Phosphates) KONSYL ORIGINAL FORMULADAILY FIBER NF FLEET ENEMA SIX PACK POWD (Psyllium) ENEM (Sodium NF Phosphates) METAMUCIL CAPS 0.52 NF GM (Psyllium) FLEET PEDIATRIC ENEM NF (Sodium Phosphates) METAMUCIL ORIGINAL TEXTURE POWD NF (Psyllium) Arizona Complete Health-Complete Care Plan Effective October 1, 2018

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits magnesium citrate soln or lidocaine hcl (local anesth.) F PA 1.745gm/30ml, 1.745 F soln 0.5 %, 1 %, 2 % gm/30ml, LIDOCAINE HCL SOLN IJ F PA magnesium hydroxide susp 4 % or 7.75 %, 400 mg/5ml, F XYLOCAINE SOLN IJ 0.5 PA 1200 mg/15ml, 2400 %, 1 %, 2 % (Lidocaine HCl NF mg/30ml, (Local Anesth.)) MILK OF MAGNESIA F XYLOCAINE-MPF SOLN PA CONCENTRATE SUSP 0.5 %, 1 %, 2 % (Lidocaine NF sodium phosphates enem F HCl (Local Anesth.)) MACROLIDES - Drugs to Treat Bacterial sodium phosphates soln F Infections Laxatives Azithromycin AZITHROMYCIN PACK F bisacodyl supp re 10 mg F OR 1 GM azithromycin susr or 100 F bisacodyl tbec or 5 mg F mg/5ml, 200 mg/5ml DULCOLAX SUPP NF azithromycin tabs or 250 F (Bisacodyl) mg, 500 mg, 600 mg DULCOLAX TBEC NF ZITHROMAX PACK OR 1 F (Bisacodyl) GM EX-LAX MAXIMUM ZITHROMAX SUSR OR STRENGTH TABS NF 100 MG/5ML, 200 MG/5ML NF (Sennosides) (Azithromycin) EX-LAX TABS NF ZITHROMAX TABS OR (Sennosides) 250 MG, 500 MG, 600 MG NF (Azithromycin) sennosides tabs 15 mg, 25 F mg, 8.6 mg, 17.2 mg ZITHROMAX TRI-PAK NF TABS (Azithromycin) SENOKOT TABS NF ) (Sennosides ZITHROMAX Z-PAK TABS NF (Azithromycin) SENOKOT XTRA TABS NF (Sennosides) ZMAX SUSR F Surfactant Laxatives Clarithromycin COLACE CAPS (Docusate NF Sodium) BIAXIN SUSR NF (Clarithromycin) COLACE CLEAR CAPS NF (Docusate Sodium) BIAXIN TABS NF (Clarithromycin) docusate calcium caps F CLARITHROMYCIN SUSR OR 125 MG/5ML, 250 F docusate sodium caps or F 50 mg, 100 mg, 250 mg MG/5ML clarithromycin susr or 125 F LOCAL ANESTHETICS-Parenteral - Drugs for mg/5ml, 250 mg/5ml Numbing clarithromycin tabs or 250 F Local Anesthetics - Amides mg, 500 mg

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clarithromycin tb24 or 500 F 1/ 90 mg TRUETEST GLUCOSE F days;QL(0.012 CONTROLLEVEL 3 LIQD ea daily) MEDICAL DEVICES AND SUPPLIES URIN-TEK KIT F Bandages-Dressings-Tape Misc. Devices GAUZE PADS 2X2, 3X3, F 4X4 ALCOHOL SWABS F Contraceptives Parenteral Therapy Supplies CONDOMS F INSULIN SYRINGES AND F PEN NEEDLES DIAPHRAGMS F Respiratory Therapy Supplies OMNIFLEX DIAPHRAGM F Limit 2 per year DPRH SPACER/AEROCHAMBER F Diabetic Supplies MIGRAINE PRODUCTS - Drugs to Treat Migraine Headaches INSULIN PUMP INFUSION F SUPPLIES Migraine Combinations LANCETS AND LANCET F 10 per DEVICES CAFERGOT TABS NF ) month;QL(0.34 1/ 90 ( w/ Caffeine ea daily) LIBERTY GLUCOSE F CONTROL LEVEL 1 SOLN days;QL(0.012 10 per ea daily) ergotamine w/ caffeine tabs F month;QL(0.34 LIBERTY GLUCOSE 1/ 90 ea daily) F days;QL(0.012 12 per month; CONTROL LEVEL 2 SOLN ea daily) MIGERGOT SUPP F TRUE METRIX CONTROL 1/ 90 SOLUTION LEVEL 1 F days;QL(0.012 Serotonin Agonists SOLN ea daily) 9 per AMERGE TABS NF TRUE METRIX CONTROL 1/ 90 (Naratriptan HCl) month;;QL(0.3 SOLUTION LEVEL 2 F days;QL(0.012 ea daily) SOLN ea daily) IMITREX SOLN NA 5 6 per TRUE METRIX CONTROL 1/ 90 MG/ACT, 20 MG/ACT NF month;QL(0.2 SOLUTION LEVEL 3 F days;QL(0.012 (Sumatriptan) ea daily) SOLN ea daily) 4 doses (2ml) IMITREX SOLN SC 6 per TRUECONTROL 1/ 90 MG/0.5ML (Sumatriptan NF GLUCOSE CONTROL F days;QL(0.012 Succinate) month;QL(0.06 LEVEL 0 LIQD ea daily) 7 ml daily) TRUECONTROL 1/ 90 IMITREX STATDOSE 4 doses (2ml) GLUCOSE CONTROL F days;QL(0.012 REFILL SOCT NF per LEVEL 1 LIQD ea daily) ) month;QL(0.06 (Sumatriptan Succinate 7 ml daily) 1/ 90 TRUETEST GLUCOSE F IMITREX STATDOSE 4 doses (2ml) CONTROLLEVEL 1 LIQD days;QL(0.012 ea daily) SYSTEM SOAJ 6 NF per MG/0.5ML (Sumatriptan month;QL(0.06 1/ 90 Succinate) 7 ml daily) TRUETEST GLUCOSE F days;QL(0.012 CONTROLLEVEL 2 LIQD ea daily)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits IMITREX TABS OR 25 MG, 9 per 9 per 50 MG, 100 MG NF month;QL(0.3 month;;QL(0.3 (Sumatriptan Succinate) ea daily) zolmitriptan tbdp or 5 mg F ea daily,9 ea 18 per per 30 days MAXALT TABS (Rizatriptan NF retail) ) month;QL(0.6 Benzoate ea daily) 9 per ZOMIG TABS OR 5 MG, NF 18 per 2.5 MG (Zolmitriptan) month;;QL(0.3 MAXALT-MLT TBDP NF ea daily) ) month;QL(0.6 (Rizatriptan Benzoate ea daily) 9 per ZOMIG ZMT TBDP 2.5 MG NF 9 per (Zolmitriptan) month;;QL(0.3 naratriptan hcl tabs F month;;QL(0.3 ea daily) ea daily) 9 per 18 per month;;QL(0.3 ZOMIG ZMT TBDP 5 MG NF rizatriptan benzoate tabs F month;QL(0.6 (Zolmitriptan) ea daily,9 ea ea daily) per 30 days retail) 18 per rizatriptan benzoate tbdp F month;QL(0.6 MINERALS & ELECTROLYTES ea daily) Calcium sumatriptan soln na 5 6 per F month;QL(0.2 CAL-CITRATE CAPS F mg/act, 20 mg/act ea daily) 4 doses (2ml) CAL-LAC CAPS F sumatriptan succinate soaj F per sc 6 mg/0.5ml month;QL(0.06 CAL-MINT CHEW F 7 ml daily) 4 doses (2ml) CALCI-CHEW CHEW F sumatriptan succinate soct F per sc 4 mg/0.5ml, 6 mg/0.5ml month;QL(0.06 CALCIUM ACETATE TABS F 7 ml daily) OR 4 doses (2ml) CALCIUM ASPARTATE F TABS sumatriptan succinate soln F per sc 6 mg/0.5ml month;QL(0.06 7 ml daily) CALCIUM CAPS 250 MG F 4 doses (2ml) CALCIUM CARBONATE F SUMATRIPTAN CHEW OR 260 MG SUCCINATE SOSY SC 6 F per MG/0.5ML month;QL(0.06 calcium carbonate tabs or 7 ml daily) 600mg, 500 mg, 600 mg, F 9 per 1250 mg, 1500 mg sumatriptan succinate tabs F month;QL(0.3 or 25 mg, 50 mg, 100 mg calcium carbonate-vitamin F ea daily) d caps 9 per zolmitriptan tabs or 5 mg, calcium carbonate-vitamin F F month;;QL(0.3 d chew 2.5 mg ea daily) calcium carbonate-vitamin F 9 per d tabs zolmitriptan tbdp or 2.5 mg F month;;QL(0.3 ea daily) CALCIUM CHEW 500 MG F

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CALCIUM CITRATE TABS magnesium oxide (mg F OR 200 MG, 250 MG, 1040 F supplement) tabs MG MAGNESIUM OXIDE F calcium citrate tabs or 200 F CAPS 400 MG mg, 950 mg MAGOX 400 TABS CALCIUM GLUCONATE F (Magnesium Oxide (Mg NF TABS OR 50 MG, 500 MG Supplement)) CALCIUM LACTATE TABS F Mineral Combinations 100 MG, 750 MG BONE ESSENTIALS CAPS F CALCIUM PLUS VITAMIN F D CAPS CAL-MAG-K CHELA MAX F calcium tabs 500 mg, 600 F CAPS mg CALCIUM & VITAMIN D3 F CALCIUM TABS 600MG- F BONEHEALTH LIQD 200UNIT COLAMINE TABS F calcium w/ tabs F CVS CALCIUM CHELATED CALCIUM F CHEWABLES 600PLUS F TABS CHEW ELITE CALCIUM TABS F MULTI-MINERALS TABS F oyster shell tabs F multiple minerals tabs F RA CALCIUM HI- NF FORMULAS CALCIUM F CAL/VITAMIND TABS F MAGNESIUM LIQD 500MG-125UNIT NUTRA-SUPPORT BONE F Fluoride CAPS LOZI-FLUR LOZG F Potassium CHELATED POTASSIUM F LURIDE SOLN (Sodium NF TABS Fluoride) K-TAB TBCR 10 MEQ NF sodium fluoride chew or (Potassium Chloride) 0.25 mg, 0.5 mg, 1 mg, 1.1 F K-TAB TBCR 8 MEQ, 20 F mg, 2.2 mg MEQ sodium fluoride soln or 0.5 F mg/ml KLOR-CON M15 TBCR F SODIUM FLUORIDE TABS F OR 0.5 MG, 1 MG KLOR-CON/25 PACK F Magnesium MICRO-K CPCR NF MAG-200 TABS (Potassium Chloride) (Magnesium Oxide (Mg NF potassium chloride cpcr or F Supplement)) 8 meq, 10 meq POTASSIUM CHLORIDE MAGNESIUM CAPS 400 F F MG ER TBCR POTASSIUM CHLORIDE RX/OTC magnesium oxide (mg F F supplement) caps GRAN XX

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits potassium chloride mycophenolate mofetil susr F SP microencapsulated crystals F er tbcr mycophenolate mofetil tabs F SP potassium chloride pack or F 20 meq mycophenolate sodium F SP tbec potassium chloride soln or F 10 %, 20 % MYFORTIC TBEC NF SP (Mycophenolate Sodium) potassium chloride tbcr or F 8 meq, 10 meq NEORAL CAPS SP (Cyclosporine Modified (For NF POTASSIUM TABS 75 MG NF (Potassium) Microemulsion)) NEORAL SOLN SP potassium tabs 75 mg, 99 F mg (Cyclosporine Modified (For NF Microemulsion)) MISCELLANEOUS THERAPEUTIC CLASSES PROGRAF CAPS OR 0.5 SP MG, 1 MG, 5 MG NF Chelating Agents (Tacrolimus) CUPRIMINE CAPS 250 F RAPAMUNE SOLN 1 F SP MG MG/ML Immunomodulators RAPAMUNE TABS 1 MG, NF SP 2 MG (Sirolimus) REVLIMID CAPS F PA; SP SANDIMMUNE CAPS OR NF SP THALOMID CAPS F PA; SP 100 MG (Cyclosporine) SANDIMMUNE SOLN OR F SP Immunosuppressive Agents 100 MG/ML ASTAGRAF XL CP24 F SP sirolimus tabs or 1 mg, 2 F SP mg azathioprine tabs or 50 mg F tacrolimus caps or 0.5 mg, F SP 1 mg, 5 mg CELLCEPT CAPS NF SP PA; SP (Mycophenolate Mofetil) ZORTRESS TABS F CELLCEPT SUSR NF SP Potassium Removing Agents (Mycophenolate Mofetil) KAYEXALATE POWD CELLCEPT TABS NF SP (Sodium Polystyrene NF (Mycophenolate Mofetil) Sulfonate) cyclosporine caps or 100 SP F sodium polystyrene F mg sulfonate powd or cyclosporine modified (for SP sodium polystyrene microemulsion) caps 25 F sulfonate susp or 15 F mg, 100 mg gm/60ml cyclosporine modified (for SP microemulsion) soln 100 F MOUTH/THROAT/DENTAL AGENTS mg/ml Anesthetics Topical Oral IMURAN TABS NF (Azathioprine) lidocaine hcl (mouth-throat) F soln 2 % mycophenolate mofetil F SP caps Anti-infectives - Throat

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clotrimazole lozg mt 10 mg F CO-NATAL FA TABS F clotrimazole troc mt 10 mg F COMPLETENATE CHEW F nystatin (mouth-throat) F CVS PRENATAL TABS F susp Antiseptics - Mouth/Throat EQL PRENATAL F FORMULA TABS chlorhexidine gluconate F (mouth-throat) soln 0.12 % GNP DAILY PRENATAL F MISC PERIDEX SOLN (Chlorhexidine Gluconate NF GNP PRENATAL TABS F (Mouth-Throat)) GOODSENSE PRENATAL F Steroids - Mouth/Throat VITAMINS TABS triamcinolone acetonide F HM ONE DAILY F (mouth) pste PRENATAL COMBO MISC Throat Products - Misc. HM PRENATAL TABS F AQUORAL SOLN F RX/OTC INATAL GT TABS F BIOTENE DRY MOUTH RX/OTC MOISTURIZING SPRAY F KP PRENATAL F SOLN MULTIVITAMINS TABS CAPHOSOL SOLN F RX/OTC KPN PRENATAL TABS F RX/OTC CVS DRY MOUTH SPRAY F RX/OTC M-VIT TABS F SOLN MYNATAL ADVANCE EQL DRY MOUTH ORAL F RX/OTC F RINSE SOLN TABS MOI-STIR SOLN F RX/OTC MYNATAL CAPS F

MOUTHKOTE SOLN F RX/OTC MYNATAL PLUS TABS F RX/OTC MYNATAL ULTRACAPLET F NUMOISYN LIQD F TABS ORAL RELIEF SPRAY RX/OTC MYNATAL-Z TABS F FOR DRYMOUTH & F DISCOMFORT SOLN MYNATE 90 PLUS TBCR F RA DRY MOUTH SOLN F RX/OTC NAT-RUL PRENATAL F VITAMINS TABS MULTIVITAMINS NATALVIT TABS F Multivitamins NEONATAL PLUS TABS F RX/OTC MULTIVITAMINS /W F MINERALS NIVA-PLUS TABS F RX/OTC Prenatal Vitamins NUTRICION PORVIDA CLASSIC PRENATAL F F TABS TABS

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits O-CAL FA TABS F RX/OTC PRENATAL TABS 30UNIT- 4000UNIT-25MG-1.8MG- O-CAL PRENATAL TABS F 200MG-28MG-20MG- 1.7MG-8MCG-400UNIT- 0.8MG-2.6MG-120MG, ONE-A-DAY WOMENS F PRENATAL MISC 30UNIT-25MG-1.8MG- 200MG-28MG-20MG- PERRY PRENATAL CAPS F 1.7MG-4000UNIT-8MCG- 400UNIT-800MCG-2.6MG- PNV FERROUS 120MG, 30UNIT- FUMARATE/DOCUSATE/F F 4000UNIT-25MG-1.8MG- OLIC ACID TABS 200MG-28MG-20MG- F PNV FOLIC ACID + IRON F RX/OTC 1.7MG-8MCG-400UNIT- MULTIVITAMIN TABS 800MCG-2.6MG-120MG, 4000UNIT-30UNIT-200MG- PNV PRENATAL PLUS F RX/OTC MULTIVITAMIN TABS 25MG-1.8MG-28MG- 20MG-1.7MG-8MCG- PNV TABS 29-1 TABS F 400UNIT-800MCG-2.6MG- 120MG, 4000UNIT- PNV-VP-U CAPS F 30UNIT-25MG-1.8MG- 200MG-28MG-20MG- PRE-NATAL FORMULA F 1.7MG-8MCG-400UNIT- TABS 800MCG-2.6MG-120MG PRENATABS FA TABS F PRENATAL TABS 4000UNIT-200MG-11UNIT- PRENATABS RX TABS F 27MG-25MG-1.84MG- F 18MG-1.7MG-4MCG- PRENATAL 19 CHEW F 400UNIT-0.8MG-2.6MG- 100MG PRENATAL 19 TABS F PRENATAL VITAMIN & F MINERAL TABS PRENATAL AND IRON F TABS PRENATAL F VITAMIN/IRON TABS PRENATAL FORTE TABS F PRENATAL VITAMINS F RX/OTC PLUS LOW IRON TABS PRENATAL F MULTIVITAMIN TABS PRENATAL VITAMINS F TABS PRENATAL PLUS IRON F TABS PRENATAL-U CAPS F PRENATAL PLUS TABS F RX/OTC PREPLUS TABS F RX/OTC PRENATAL TABS 22MG- RX/OTC 2MG-25MG-1.84MG- PRETAB TABS F 200MG-27MG-4000UNIT- F 20MG-3MG-12MCG- PX PRENATAL F 400UNIT-1MG-10MG- MULTIVITAMINS TABS 120MG QC PRENATAL TABS F

RA ONE DAILY MISC F

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RA PRENATAL hcl tabs or F FORMULA/FOLICACID F 5 mg, 10 mg TABS methocarbamol tabs or 500 F RA PRENATAL TABS F mg, 750 mg ROBAXIN TABS OR 500 NF SE-NATAL 19 CHEW F MG (Methocarbamol) ROBAXIN-750 TABS NF SE-NATAL 19 TABS F (Methocarbamol) hcl tabs or 2 mg, SM ONE DAILY F F PRENATAL MISC 4 mg ZANAFLEX TABS 4 MG SM PRENATAL VITAMINS F NF TABS (Tizanidine HCl) Direct Muscle Relaxants THERANATAL CORE F RX/OTC NUTRITION TABS DANTRIUM CAPS 25 MG NF (Dantrolene Sodium) THRIVITE 19 TABS F dantrolene sodium caps or F THRIVITE RX TABS F 25 mg, 100 mg NASAL AGENTS - SYSTEMIC AND TOPICAL - TRIADVANCE TABS F Drugs to treat the Nose or Sinus Nasal Antiallergy TRICARE TABS F RX/OTC hcl soln na 0.1 F TRINATAL GT TABS F %, 137 mcg/spray cromolyn sodium (nasal) F TRINATAL RX 1 TABS F aers 5.2 mg/act NASALCROM AERS NF VIL-RX TABS F (Cromolyn Sodium (Nasal)) Nasal Anticholinergics VINATE M TABS F ipratropium bromide (nasal) F VINATE ONE TABS F soln Nasal Steroids VIRT-ADVANCE TABS F FLONASE ALLERGY RX/OTC RELIEF CHILDRENS NF VIRT-VITE GT TABS F SUSP (Fluticasone Propionate (Nasal)) VITAFOL-OB TABS F FLONASE ALLERGY RX/OTC RX/OTC RELIEF SUSP (Fluticasone NF VOL-PLUS TABS F Propionate (Nasal)) VOL-TAB RX TABS F SOLN F

MUSCULOSKELETAL THERAPY AGENTS - fluticasone propionate F RX/OTC Drugs to Treat Spasms (nasal) susp 50 mcg/act NASACORT ALLERGY RX/OTC Central Muscle Relaxants 24HR AERO NF baclofen tabs or 10 mg, 20 F (Triamcinolone Acetonide mg (Nasal))

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NASACORT ALLERGY F RX/OTC HM FISH OIL CAPS F 24HR AERO 55 MCG/ACT NASACORT ALLERGY RX/OTC OMEGA POWER CAPS F 24HR CHILDRENS AERO NF (Triamcinolone Acetonide OMEGA-3 2100 CAPS F (Nasal)) triamcinolone acetonide F RX/OTC OMEGA-3 CAPS F (nasal) aero 55 mcg/act OMEGA-3 EPA FISH OIL F Sympathomimetic CAPS NASAL F LIQD omega-3 fatty acids caps F NASAL DECONGESTANT F SYRP omega-3 fatty acids chew F OMEGA-3 FISH OIL pseudoephedrine hcl tabs F F or 30 mg, 60 mg EXTRA STRENGTH CAPS RA FISH OIL EXTRA pseudoephedrine hcl tb12 F F or 120 mg STRENGTH CAPS SUDAFED 24 HOUR TB24 F RA TRIPLE STRENGTH F FISH OIL CAPS SUDAFED CONGESTION TABS (Pseudoephedrine NF SALMON CAPS F HCl) SALMON OIL CAPS F SUDAFED NASAL DECONGESTANT SALMON OIL-1000 CAPS F MAXIMUM STRENGTH NF TABS (Pseudoephedrine SM FISH OIL CAPS F HCl) NEUROMUSCULAR AGENTS - Drugs to SUPER TWIN EPA/DHA F Relax/Paralyze Muscles CAPS ALS Agents ULTRA OMEGA 3 CAPS F RILUTEK TABS (Riluzole) NF ULTRA OMEGA-3 FISH F OIL BURP-LESS CAPS riluzole tabs 50 mg F OPHTHALMIC AGENTS - Drugs to Treat the Eye NUTRIENTS Artificial Tears and Lubricants Misc. Nutritional Substances artificial tear ointment oint F

FISH OIL CAPS F artificial tear solution soln F FISH OIL CHEW F carboxymethylcellulose sodium (ophth) soln 0.25 F FISH OIL PEARLS CAPS F %, 0.5 % CVS LUBRICANT GEL FISH OIL TRIPLE F F STRENGTH CAPS DROPS GEL FISH OIL ULTRA CAPS F GENTEAL MILD SOLN F

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GENTEAL MILD TO COSOPT SOLN MODERATE SOLN NF (Dorzolamide HCl-Timolol NF (Hypromellose (Ophth)) Maleate) GENTEAL SEVERE GEL F dorzolamide hcl-timolol maleate soln 2%-0.5%, F GONIOVISC SOLN F 22.3mg/ml-6.8mg/ml DORZOLAMIDE hypromellose (ophth) soln F HCL/TIMOLOL MALEATE F SOLN ISOPTO TEARS SOLN F ISTALOL SOLN F polyethylene glycol- ISTALOL SOLN (Timolol NF propylene glycol (ophth) F Maleate (Ophth)) soln 0.4%-0.3% hcl soln 0.5 % F REFRESH LIQUIGEL F SOLN REFRESH TEARS SOLN SOLN F (Carboxymethylcellulose NF Sodium (Ophth)) timolol maleate (ophth) solg F SYSTANE OVERNIGHT timolol maleate (ophth) soln F THERAPY LUBRICANT F EYE GEL TIMOLOL MALEATE SYSTANE SOLN OPHTHALMIC GEL F (Polyethylene Glycol- NF FORMING SOLG Propylene Glycol (Ophth)) TIMOPTIC OCUDOSE F SYSTANE ULTRA HOME SOLN & AWAY PACK SOLN NF TIMOPTIC SOLN (Timolol NF (Polyethylene Glycol- Maleate (Ophth)) Propylene Glycol (Ophth)) TIMOPTIC-XE SOLG 0.25 SYSTANE ULTRA SOLN % (Timolol Maleate NF (Polyethylene Glycol- NF (Ophth)) Propylene Glycol (Ophth)) TIMOPTIC-XE SOLG 0.25 F THERATEARS SOLN 0.25 %, 0.5 % % (Carboxymethylcellulose NF Sodium (Ophth)) Cycloplegic Mydriatics ATROPINE SULFATE F Beta-blockers - Ophthalmic OINT OP 1 % BETAGAN SOLN NF ATROPINE SULFATE F (Levobunolol HCl) SOLN OP 1 % betaxolol hcl (ophth) soln F CYCLOGYL SOLN 1 %, 2 NF % (Cyclopentolate HCl) BETIMOL SOLN F cyclopentolate hcl soln op 1 F %, 2 % BETOPTIC-S SUSP F homatropine hbr soln F hcl (ophth) soln F ISOPTO ATROPINE SOLN F CARTEOLOL HCL SOLN F

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MYDRIACYL SOLN NF neomycin-polymyxin- (Tropicamide) gramicidin soln F 0.025mg/ml-10000unit/ml- tropicamide soln op 0.5 %, F 1 % 1.75mg/ml NEOSPORIN SOLN Miotics (Neomycin-Polymyxin- NF ISOPTO CARPINE SOLN NF Gramicidin) (Pilocarpine HCl) OCUFLOX SOLN NF pilocarpine hcl soln op 1 %, F (Ofloxacin (Ophth)) 2 %, 4 % ofloxacin (ophth) soln 0.3 F Ophthalmic Agents % ALPHAGAN P SOLN 0.1 % F polymyxin b-trimethoprim F soln 0.1%-10000unit/ml ALPHAGAN P SOLN 0.15 NF POLYTRIM SOLN % ( Tartrate) (Polymyxin B- NF Trimethoprim) brimonidine tartrate soln op F 0.15 %, 0.2 % sulfacetamide sodium F Ophthalmic Anti-infectives (ophth) soln 10 % SULFACETAMIDE BACITRACIN OINT OP F QL(4 gm per 7 F 500 UNIT/GM days retail) SODIUM OINT OP 10 % tobramycin (ophth) soln 0.3 bacitracin-polymyxin b F F (ophth) oint % BLEPH-10 SOLN TOBREX OINT 0.3 % F (Sulfacetamide Sodium NF (Ophth)) TOBREX SOLN NF (Tobramycin (Ophth)) CILOXAN OINT 0.3 % F trifluridine soln op 1 % F CILOXAN SOLN NF (Ciprofloxacin HCl (Ophth)) VIGAMOX SOLN NF (Moxifloxacin HCl (Ophth)) ciprofloxacin hcl (ophth) F soln 0.3 % VIROPTIC SOLN NF (Trifluridine) erythromycin (ophth) oint F Ophthalmic Decongestants GENTAK OINT F w/ F pheniramine soln gentamicin sulfate (ophth) F NAPHCON-A SOLN oint (Naphazoline w/ NF gentamicin sulfate (ophth) F Pheniramine) soln OPCON-A SOLN levofloxacin (ophth) soln F (Naphazoline w/ NF Pheniramine) moxifloxacin hcl (ophth) F phenylephrine hcl (ophth) F soln 0.5 % soln 10 % NATACYN SUSP F phenylephrine hcl (ophth) F QL(16 ml daily) soln 2.5 % neomycin-bacitracin zn- F polymyxin oint Ophthalmic Immunomodulators

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RESTASIS EMUL 0.05 % F PA PRED-G SUSP F

RESTASIS MULTIDOSE F PA prednisolone acetate F EMUL 0.05 % (ophth) susp Ophthalmic Steroids PREDNISOLONE F ACETATE P-F SUSP bacitracin-poly-neomycin- F hc oint PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1 F BLEPHAMIDE S.O.P. F OINT % sulfacetamide sod- F BLEPHAMIDE SUSP F prednisolone soln DEXAMETHASONE TOBRADEX OINT 0.3%- F QL(4 gm per 7 SODIUM PHOSPHATE F 0.1% days retail) SOLN OP 0.1 % TOBRADEX SUSP (Tobramycin- NF fluorometholone (ophth) F susp Dexamethasone) tobramycin- FML FORTE SUSP F dexamethasone susp F 0.3%-0.1% FML LIQUIFILM SUSP NF (Fluorometholone (Ophth)) Ophthalmics - Misc. FML OINT F ACULAR LS SOLN (Ketorolac Tromethamine NF MAXIDEX SUSP 0.1 % F (Ophth)) ACULAR SOLN (Ketorolac NF MAXITROL OINT Tromethamine (Ophth)) (Neomycin-Polymy- NF PA Dexameth) AZOPT SUSP F MAXITROL SUSP cromolyn sodium (ophth) F (Neomycin-Polymy- NF soln Dexameth) diclofenac sodium (ophth) F neomycin-polymy- F soln dexameth oint dorzolamide hcl soln 2 % F neomycin-polymy- F dexameth susp DORZOLAMIDE HCL F NEOMYCIN/POLYMYXIN/ SOLN 2 % HYDROCORTISONE F flurbiprofen sodium soln F SUSP 0.03 % OMNIPRED SUSP ketorolac tromethamine F (Prednisolone Acetate NF (ophth) soln (Ophth)) ketotifen fumarate (ophth) F PRED FORTE SUSP soln 0.025 % (Prednisolone Acetate NF (Ophth)) OCUFEN SOLN NF (Flurbiprofen Sodium) PRED MILD SUSP F TRUSOPT SOLN NF (Dorzolamide HCl) PRED-G S.O.P. OINT F

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZADITOR SOLN (Ketotifen NF PASSIVE IMMUNIZING AND TREATMENT Fumarate (Ophth)) AGENTS - Antibody Drugs to Treat Low Immune Prostaglandins - Ophthalmic System latanoprost soln op 0.005 F QL(2.5 ml per Monoclonal Antibodies % fill retail) SYNAGIS SOLN F PA; SP LATANOPROST SOLN OP F QL(2.5 ml per 0.005 % fill retail) PENICILLINS - Drugs to Treat Bacterial Infections TRAVATAN Z SOLN F PA Aminopenicillins PA TRAVOPROST SOLN F caps 250 mg, F 500 mg XALATAN SOLN QL(2.5 ml per NF AMOXICILLIN CHEW 125 F (Latanoprost) fill retail) MG, 250 MG ZIOPTAN SOLN F PA amoxicillin susr 125 mg/5ml, 200 mg/5ml, 250 F OTIC AGENTS - Drugs to Treat the Ear mg/5ml, 400 mg/5ml amoxicillin tabs 500 mg, F Otic Agents - Miscellaneous 875 mg carbamide peroxide (otic) F ampicillin caps 250 mg, F soln 6.5 % 500 mg DEBROX SOLN AMPICILLIN CAPS 500 F (Carbamide Peroxide NF MG (Otic)) AMPICILLIN SUSR 125 F Otic Anti-infectives MG/5ML, 250 MG/5ML FLOXIN OTIC SOLN NF Natural Penicillins (Ofloxacin (Otic)) PENICILLIN V ofloxacin (otic) soln 0.3 % F POTASSIUM SOLR 125 F MG/5ML, 250 MG/5ML Otic Combinations penicillin v potassium solr F CIPRODEX SUSP F 125 mg/5ml, 250 mg/5ml penicillin v potassium tabs F neomycin-polymyxin-hc F 250 mg, 500 mg (otic) soln Penicillin Combinations neomycin-polymyxin-hc F (otic) susp amoxicillin & pot F clavulanate susr Otic Steroids amoxicillin & pot F hydrocortisone w/acetic F clavulanate tabs acid soln amoxicillin & pot F OXYTOCICS - Drugs to Prevent/Control Uterine clavulanate tb12 Bleeding AMOXICILLIN/CLAVULAN F Oxytocics ATE POTASSIUM CHEW AUGMENTIN ES-600 methylergonovine maleate F tabs or 0.2 mg SUSR (Amoxicillin & Pot NF Clavulanate)

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AUGMENTIN SUSR F PSYCHOTHERAPEUTIC AND NEUROLOGICAL 125MG/5ML-31.25MG/5ML AGENTS - MISC. - Drugs to Treat Mental and AUGMENTIN SUSR Emotional Conditions 250MG/5ML-62.5MG/5ML NF (Amoxicillin & Pot Agents for Chemical Dependency Clavulanate) acamprosate calcium tbec F AUGMENTIN TABS ANTABUSE TABS 500MG-125MG, 875MG- NF NF 125MG (Amoxicillin & Pot (Disulfiram) Clavulanate) disulfiram tabs or 250 mg, F AUGMENTIN XR TB12 500 mg (Amoxicillin & Pot NF Antidementia Agents Clavulanate) ARICEPT TABS (Donepezil NF PA Penicillinase-Resistant Penicillins Hydrochloride) donepezil hydrochloride F PA dicloxacillin sodium caps F tabs PROGESTINS - Hormone Replacement/Modifying donepezil hydrochloride F PA Drugs tbdp Progestins EXELON CAPS NF PA (Rivastigmine Tartrate) AYGESTIN TABS NF (Norethindrone Acetate) EXELON PT24 NF PA (Rivastigmine) hydroxyprogesterone F PA; SP caproate oil im 250 mg/ml galantamine hydrobromide F PA cp24 8 mg, 16 mg, 24 mg MAKENA OIL IM 250 PA; SP GALANTAMINE PA MG/ML NF (Hydroxyprogesterone HYDROBROMIDE SOLN 4 F Caproate) MG/ML galantamine hydrobromide PA MAKENA SOAJ SC 275 F PA; SP F MG/1.1ML tabs 4 mg, 8 mg, 12 mg medroxyprogesterone memantine hcl soln 2 F PA acetate tabs or 5 mg, 10 F mg/ml mg, 2.5 mg memantine hcl tabs 10 mg F QL(6 ea daily) MEGACE ES SUSP (Megestrol Acetate NF memantine hcl tabs 5 mg F PA; QL(6 ea (Appetite)) daily) NAMENDA TABS 10 MG QL(6 ea daily) megestrol acetate F NF (appetite) susp 625 mg/5ml (Memantine HCl) NAMENDA TABS 5 MG PA; QL(6 ea norethindrone acetate tabs F NF or 5 mg (Memantine HCl) daily) RAZADYNE ER CP24 PA progesterone micronized F caps or 100 mg, 200 mg (Galantamine NF Hydrobromide) PROMETRIUM CAPS NF (Progesterone Micronized) RAZADYNE TABS PA (Galantamine NF PROVERA TABS Hydrobromide) (Medroxyprogesterone NF Acetate) rivastigmine pt24 F PA

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits rivastigmine tartrate caps F PA CHANTIX CONTINUING F QL(180 ea per MONTHPAK TABS 180 days retail) Multiple Sclerosis Agents CHANTIX STARTING F QL(180 ea per MONTH PAK TABS 180 days retail) AVONEX KIT F PA; SP F QL(180 ea per CHANTIX TABS 180 days retail) AVONEX PEN AJKT F PA; SP NICODERM CQ PT24 NF QL(180 ea per AVONEX PSKT F PA; SP (Nicotine) 180 days retail) GUM NF QL(180 ea per BETASERON KIT F PA; SP (Nicotine Polacrilex) 180 days retail) NICORETTE LOZG NF QL(180 ea per COPAXONE SOSY 20 PA; SP (Nicotine Polacrilex) 180 days retail) MG/ML (Glatiramer F Acetate) NICORETTE MINI LOZG NF QL(180 ea per (Nicotine Polacrilex) 180 days retail) COPAXONE SOSY 40 PA; SP MG/ML (Glatiramer NF NICORETTE STARTER QL(180 ea per Acetate) KIT GUM (Nicotine NF 180 days retail) Polacrilex) EXTAVIA KIT F PA; SP nicotine polacrilex gum mt F QL(180 ea per 2 mg, 4 mg 180 days retail) GILENYA CAPS 0.5 MG F PA; SP nicotine polacrilex lozg mt 2 F QL(180 ea per mg, 4 mg 180 days retail) glatiramer acetate sosy 40 F PA; SP mg/ml F QL(180 ea per nicotine pt24 180 days retail) REBIF REBIDOSE SOAJ F PA; SP NICOTINE QL(180 ea per REBIF REBIDOSE F PA; SP TRANSDERMAL SYSTEM F 180 days retail) TITRATIONPACK SOAJ KIT PA; SP REBIF SOSY F NICOTROL INHALER F QL(180 ea per INHA 180 days retail) REBIF TITRATION PACK PA; SP F F QL(180 ml per SOSY NICOTROL NS SOLN 180 days retail) Postherpetic Neuralgia (PHN)/Neuropathic Pain ZYBAN TB12 (Bupropion NF QL(180 ea per HCl (Smoking Deterrent)) 180 days retail) GRALISE TABS F PA RESPIRATORY AGENTS - MISC. - Drugs to Psychotherapeutic and Neurological Agents - Treat Lung Conditions ) NF AL(At least 6 Alpha-Proteinase Inhibitor (Human) ORAP TABS (Pimozide yrs old) ARALAST NP SOLR F PA F AL(At least 6 pimozide tabs yrs old) GLASSIA SOLN F PA Restless Leg Syndrome (RLS) Agents PA PROLASTIN-C SOLR 1000 F PA HORIZANT TBCR F MG PA Smoking Deterrents ZEMAIRA SOLR F bupropion hcl (smoking F QL(180 ea per deterrent) tb12 150 mg 180 days retail) Cystic Fibrosis Agents PULMOZYME SOLN F PA; SP

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SULFONAMIDES - Drugs to Treat Bacterial MONODOX CAPS 100 MG Infections (Doxycycline NF (Monohydrate)) Sulfonamides TARGADOX TABS F SULFADIAZINE TABS OR F 500 MG tetracycline hcl caps or 250 F TETRACYCLINES - Drugs to Treat Bacterial mg, 500 mg Infections TETRACYCLINE HCL Tetracyclines CAPS OR 250 MG, 500 NF MG (Tetracycline HCl) ACTICLATE TABS NF (Doxycycline Hyclate) VIBRAMYCIN CAPS 100 NF MG (Doxycycline Hyclate) ADOXA PAK 1/100 TABS (Doxycycline NF THYROID AGENTS - Drugs to Regulate Thyroid (Monohydrate)) Hormones ADOXA PAK 2/100 TABS Antithyroid Agents (Doxycycline NF methimazole tabs or 5 mg, F (Monohydrate)) 10 mg ADOXA TABS 50 MG, 100 MG (Doxycycline NF propylthiouracil tabs or F (Monohydrate)) TAPAZOLE TABS NF demeclocycline hcl tabs F PA (Methimazole) Thyroid Hormones DORYX MPC TBEC F ARMOUR THYROID TABS 15 MG, 30 MG, 60 MG, 90 NF DORYX TBEC NF (Doxycycline Hyclate) MG, 120 MG (Thyroid) ARMOUR THYROID TABS doxycycline (monohydrate) F F caps 50 mg, 100 mg 180 MG, 240 MG CYTOMEL TABS doxycycline (monohydrate) F NF tabs 50 mg, 100 mg (Liothyronine Sodium) levothyroxine sodium tabs doxycycline hyclate caps or F 50 mg, 100 mg or 25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, F doxycycline hyclate tabs or 112 mcg, 125 mcg, 137 20 mg, 75 mg, 100 mg, 150 F mcg, 150 mcg, 175 mcg, mg 200 mcg, 300 mcg DOXYCYCLINE HYCLATE F liothyronine sodium tabs or F TABS OR 50 MG 5 mcg, 25 mcg, 50 mcg doxycycline hyclate tbec or NATURE-THROID NT-2.5 F 50 mg, 75 mg, 100 mg, 150 F TABS mg, 200 mg MINOCIN CAPS OR 50 NATURE-THROID TABS F MG, 75 MG, 100 MG NF (Minocycline HCl) SYNTHROID TABS NF (Levothyroxine Sodium) minocycline hcl caps or 50 F mg, 75 mg, 100 mg thyroid tabs or 15 mg, 30 F mg, 60 mg, 90 mg, 120 mg minocycline hcl tabs or 50 F mg, 75 mg, 100 mg Arizona Complete Health-Complete Care Plan Effective October 1, 2018

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WESTHROID TABS F LEVBID TB12 NF QL(2 ea daily) (Hyoscyamine Sulfate) WP THYROID TABS F LEVSIN TABS OR 0.125 NF QL(4 ea daily) MG (Hyoscyamine Sulfate) TOXOIDS LEVSIN/SL SUBL NF QL(4 ea daily) (Hyoscyamine Sulfate) Toxoid Combinations methscopolamine bromide F DIPHTHERIA/TETANUS tabs or 5 mg, 2.5 mg TOXOIDS ADSORBED F PROPANTHELINE PEDIATRIC SUSP BROMIDE TABS OR 15 F TENIVAC INJ F MG ROBINUL FORTE TABS NF TETANUS/DIPHTHERIA (Glycopyrrolate) TOXOIDS-ADSORBED F SUSP ROBINUL TABS OR 1 MG NF (Glycopyrrolate) ULCER DRUGS - Drugs to Treat Bowel, Intestine and Stomach Conditions SYMAX DUOTAB TBCR F Antispasmodics H-2 Antagonists ANASPAZ TBDP QL(4 ea daily) NF DEPRIZINE FUSEPAQ F (Hyoscyamine Sulfate) SUSR BENTYL CAPS OR 10 MG NF DEPRIZINE RAPIDPAQ F (Dicyclomine HCl) SUSR BENTYL TABS OR 20 MG NF famotidine susr or 40 F (Dicyclomine HCl) mg/5ml CUVPOSA SOLN F famotidine tabs or 10 mg, F 40 mg dicyclomine hcl caps or 10 F RX/OTC mg famotidine tabs or 20 mg F dicyclomine hcl soln or 10 F PEPCID AC EZ CHEWS mg/5ml MAXIMUM STRENGTH F CHEW dicyclomine hcl tabs or 20 F mg PEPCID AC MAXIMUM RX/OTC STRENGTH TABS NF glycopyrrolate tabs or 1 F mg, 2 mg (Famotidine) PEPCID AC TABS hyoscyamine sulfate elix or F NF 0.125 mg/5ml (Famotidine) PEPCID SUSR 40 MG/5ML hyoscyamine sulfate soln F QL(8 ml daily) NF or 0.125 mg/ml (Famotidine) PEPCID TABS 20 MG RX/OTC hyoscyamine sulfate subl sl F QL(4 ea daily) NF 0.125 mg (Famotidine) PEPCID TABS 40 MG hyoscyamine sulfate tabs F QL(4 ea daily) NF or 0.125 mg (Famotidine) ranitidine hcl caps or 150 hyoscyamine sulfate tb12 F QL(2 ea daily) F or 0.375 mg mg, 300 mg hyoscyamine sulfate tbdp F QL(4 ea daily) or 0.125 mg

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ranitidine hcl syrp or 15 omeprazole cpdr or 20 mg F RX/OTC mg/ml, 75 mg/5ml, 150 F mg/10ml OMEPRAZOLE TBEC OR F 20 MG ranitidine hcl tabs or 150 F RX/OTC mg pantoprazole sodium tbec F or 20 mg, 40 mg ranitidine hcl tabs or 75 F mg, 300 mg PREVACID 24HR CPDR NF RX/OTC ZANTAC 150 MAXIMUM RX/OTC (Lansoprazole) STRENGTH TABS NF PREVACID CPDR 15 MG NF RX/OTC (Ranitidine HCl) (Lansoprazole) ZANTAC 75 TABS NF PREVACID CPDR 30 MG NF (Ranitidine HCl) (Lansoprazole) ZANTAC TABS OR 150 RX/OTC NF PRILOSEC CPDR 10 MG, NF MG (Ranitidine HCl) 40 MG (Omeprazole) ZANTAC TABS OR 300 NF PRILOSEC CPDR 20 MG NF RX/OTC MG (Ranitidine HCl) (Omeprazole) Misc. Anti-Ulcer PROTONIX PACK OR 40 F MG CARAFATE TABS 1 GM NF (Sucralfate) PROTONIX TBEC OR 20 MG, 40 MG (Pantoprazole NF sucralfate tabs or 1 gm F Sodium) Proton Pump Inhibitors PX OMEPRAZOLE TBEC F

CVS OMEPRAZOLE TBEC F RA OMEPRAZOLE TBEC F

EQ OMEPRAZOLE TBEC F SB OMEPRAZOLE TBEC F

EQL OMEPRAZOLE TBEC F SM OMEPRAZOLE TBEC F FIRST-LANSOPRAZOLE F SUSP SW OMEPRAZOLE TBEC F FIRST-OMEPRAZOLE F SUSP TGT OMEPRAZOLE TBEC F GNP OMEPRAZOLE F Ulcer Drugs - Prostaglandins TBEC CYTOTEC TABS NF HM OMEPRAZOLE TBEC F (Misoprostol) misoprostol tabs or 100 F KLS OMEPRAZOLE TBEC F mcg, 200 mcg RX/OTC URINARY ANTI-INFECTIVES - Drugs to Treat lansoprazole cpdr or 15 mg F Bladder/ Infections lansoprazole cpdr or 30 mg F Urinary Anti-infectives FURADANTIN SUSP NF OMEPRAZOLE + (Nitrofurantoin) SYRSPEND SFALKA F SUSP MACROBID CAPS (Nitrofurantoin Monohyd NF omeprazole cpdr or 10 mg, F Macro) 40 mg Arizona Complete Health-Complete Care Plan Effective October 1, 2018

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MACRODANTIN CAPS MENACTRA INJ F (Nitrofurantoin NF Macrocrystal) MENOMUNE-A/C/Y/W-135 F nitrofurantoin macrocrystal INJ caps or 25 mg, 50 mg, 100 F MENVEO SOLR F mg AL nitrofurantoin monohyd F PNEUMONIA VACCINE F macro caps 100 mg Viral Vaccines nitrofurantoin susp or 25 F mg/5ml CERVARIX SUSP F URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms ENGERIX-B INJ F Urinary Antispasmodic - Antimuscarinics ENGERIX-B SUSP F ST; Try DETROL LA CP24 NF oxybutynin or (Tolterodine Tartrate) tolterodine IR GARDASIL 9 SUSP F first GARDASIL 9 SUSY F DETROL TABS NF ST (Tolterodine Tartrate) GARDASIL SUSP F DITROPAN XL TB24 NF QL(1 ea daily) (Oxybutynin Chloride) HAVRIX SUSP F oxybutynin chloride syrp or F 5 mg/5ml INFLUENZA VACCINE F AL oxybutynin chloride tabs or F 5 mg M-M-R II INJ F oxybutynin chloride tb24 or F QL(1 ea daily) 5 mg, 10 mg, 15 mg RECOMBIVAX HB SUSP F ST; Try Limit 2 doses tolterodine tartrate cp24 2 F oxybutynin or per mg, 4 mg tolterodine IR lifetime;QL(1 first ea per fill SHINGRIX SUSR F retail,2 ea per tolterodine tartrate tabs 1 F ST mg, 2 mg 999 days retail); AL(At trospium chloride tabs 20 F mg least 50 yrs old) Urinary Antispasmodics - Cholinergic Agonists TWINRIX SUSP F bethanechol chloride tabs or 5 mg, 10 mg, 25 mg, 50 F mg VAQTA SUSP F URECHOLINE TABS NF VARIVAX INJ F (Bethanechol Chloride) VAGINAL PRODUCTS - Drugs to Treat Vaginal VACCINES Infections and Low Hormones Bacterial Vaccines Miscellaneous Vaginal Products BEXSERO SUSY F

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NONOXYNOL F MONISTAT 7 SIMPLY SPERMICIDES CURE CREA (Miconazole NF Nitrate Vaginal) Vaginal Anti-infectives TERAZOL 3 CREA NF AVC CREA F (Terconazole Vaginal) CLEOCIN CREA VA 2 % TERAZOL 7 CREA NF (Clindamycin Phosphate NF (Terconazole Vaginal) Vaginal) TERCONAZOLE CREA F CLEOCIN SUPP VA 100 F MG terconazole vaginal crea F 0.4 %, 0.8 % clindamycin phosphate F vaginal crea Vaginal Estrogens clotrimazole vaginal crea F ESTRACE CREA (Estradiol NF Vaginal) GYNE-LOTRIMIN 3 CREA NF (Clotrimazole Vaginal) estradiol vaginal crea F GYNE-LOTRIMIN CREA NF estradiol vaginal tabs F (Clotrimazole Vaginal) METROGEL-VAGINAL ESTRING RING F GEL (Metronidazole NF Vaginal) FEMRING RING 0.1 F PA MG/24HR metronidazole vaginal gel F 0.75 % PREMARIN CREA VA F PA 0.625 MG/GM MICONAZOLE 3 SUPP F VAGIFEM TABS (Estradiol NF Vaginal) miconazole nitrate vaginal F crea VASOPRESSORS - Drugs to Treat Heart and miconazole nitrate vaginal F Circulation Conditions kit Anaphylaxis Therapy Agents miconazole nitrate vaginal F supp Limit 2 per epinephrine (anaphylaxis) F month;QL(0.06 MONISTAT 1 COMBO soaj 0.15 mg/0.3ml 7 ea daily) PACK KIT (Miconazole NF Nitrate Vaginal) Limit 2 per epinephrine (anaphylaxis) month;QL(2 ea MONISTAT 1 DAY OR soaj 0.15 mg/0.3ml, 0.3 F mg/0.3ml per 30 days NIGHT COMBO PACK KIT NF retail) (Miconazole Nitrate Vaginal) Vasopressors MONISTAT 3 hcl tabs F QL(2 ea daily) COMBINATION PACK KIT NF (Miconazole Nitrate VITAMINS Vaginal) MONISTAT 3 CREA Oil Soluble Vitamins (Miconazole Nitrate NF cholecalciferol caps or 400 Vaginal) unit, 1000 unit, 2000 unit, F 5000 unit, 10000 unit, MONISTAT 7 F COMBINATION PACK KIT 50000 unit

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cholecalciferol tabs or 400 niacinamide tabs F unit, 1000 unit, 2000 unit, F 5000 unit, 50000 unit niacinamide tbcr F DECARA CAPS F pyridoxine hcl tabs F DRISDOL CAPS NF (Ergocalciferol) SLO-NIACIN TBCR NF (Niacin) ergocalciferol caps F thiamine hcl tabs F HM VITAMIN D3 CAPS F

F AL(At least 6 KEY-E CHEW OR yrs old) MEPHYTON TABS NF (Phytonadione) NATURAL VITAMIN E F TABS OPTIMAL D3 M CAPS F phytonadione tabs or 5 mg F SM VITAMIN D3 MAXIMUM STRENGTH F CAPS THERA-D 4000 TABS F

VITAMIN D2 TABS F

VITAMIN D3 TABS OR F 3000 UNIT, 10000 UNIT vitamin e caps or 100 unit, 200 unit, 400 unit, 600 unit, F 1000 unit VITAMIN E CHEW OR 400 F AL(At least 6 UNIT yrs old) VITAMIN E TABS OR 100 F UNIT, 200 UNIT vitamin e tabs or 400 unit F Water Soluble Vitamins B-1 TABS F niacin cpcr F niacin tabs F niacin tbcr F

Arizona Complete Health-Complete Care Plan Effective October 1, 2018

77 Index A-20049 ALBUSTIX49 AMOXAPINE17 abacavir sulfate31 albuterol sulfate11 amoxicillin69 abacavir sulfate-lamivudine31 ALCOHOL SWABS58 AMOXICILLIN69 abacavir sulfate-lamivudine- ALDACTAZIDE51 amoxicillin69 zidovudine 31 ALDACTONE51 amoxicillin & pot clavulanate69 ABILIFY31 ALDARA47 AMOXICILLIN/CLAVULANATE ABILIFY MAINTENA31 ALECENSA27 POTASSIUM69 ABREVA45 amphetamine- ALENDRONATE SODIUM51 ABSORICA43 dextroamphetamine1 alendronate sodium51 ampicillin69 acamprosate calcium70 ALER-DRYL21 AMPICILLIN69 acarbose18 ALEVE2 ANAFRANIL17 ACCOLATE10 ALFERON N27 ANALPRAM HC6 ACCUPRIL24 ALLEGRA ALLERGY22 ANALPRAM HC SINGLES6 ACCURETIC25 ALLEGRA ALLERGY ANALPRAM-HC6 ACEON24 CHILDRENS22 ANAPROX DS2 acetaminophen4 ALLEGRA-D 12 HOUR ANASPAZ73 acetaminophen w/ codeine5 ALLERGY & CONGESTION39 anastrozole26 acetazolamide50 ALLEGRA-D 24 HOUR ANDRODERM6 ACNE MEDICATION 1043 ALLERGY & ANDROGEL6 ACNE MEDICATION 543 CONGESTION39 ANDROGEL PUMP6 ACTICLATE72 allopurinol54 ALOE VESTA ANDROXY6 ACTIDOM DMX39 ANTIFUNGAL44 ANTABUSE70 ACTIGALL53 ALOE VESTA CLEAR ANTACID7 ACTIMMUNE27 ANTIFUNGAL44 ANTACID SOFT CHEWS7 ACTOPLUS MET18 ALORA52 ANUSOL-HC6 ACTOPLUS MET XR18 ALPHAGAN P67 ANZEMET21 ACTOS19 alprazolam9 aprepitant21 ACULAR68 ALPRAZOLAM INTENSOL9 APTENSIO XR1 ACULAR LS68 ALTACE24 APTIVUS31 acyclovir34 alum & mag hydrox- simethicone7 AQUORAL62 acyclovir topical46 amantadine hcl28 ARALAST NP71 ADALAT CC35 AMARYL20 ARAVA3 ADCIRCA36 AMBI EVEN & CLEAR ARICEPT70 ADDERALL1 EXFOLIATING WASH47 ARIMIDEX26 ADDERALL XR1 AMBI EVEN & CLEAR FOAMINGCLEANSER47 aripiprazole31 adefovir dipivoxil33 AMBIEN56 ARISTADA31 ADOXA72 AMERGE58 ARISTADA INITIO31 ADOXA PAK 1/10072 AMICAR55 ARMOUR THYROID72 ADOXA PAK 2/10072 amiloride & AROMASIN26 ADVAIR DISKUS11 hydrochlorothiazide51 ARTHROTEC 502 ADVAIR HFA11 amiloride hcl51 ARTHROTEC 752 ADVIL2 amiodarone hcl10 artificial tear ointment65 ADVIL MIGRAINE2 AMITIZA53 artificial tear solution65 AFINITOR27 amitriptyline hcl17 ASACOL HD53 AFINITOR DISPERZ27 amlodipine besylate35 ASMANEX TWISTHALER 120 ALBENZA7 amlodipine besylate-benazepril METERED DOSES10 hcl25

Index 1 ASMANEX TWISTHALER 14 bacitracin zinc44 BETHKIS2 METERED DOSES10 bacitracin-poly-neomycin-hc BETIMOL66 ASMANEX TWISTHALER 30 68 BETOPTIC-S66 METERED DOSES10 bacitracin-polymyxin b44 ASMANEX TWISTHALER 60 BEVESPI AEROSPHERE11 bacitracin-polymyxin b METERED DOSES11 bexarotene27 ASMANEX TWISTHALER 7 (ophth)67 METERED DOSES11 baclofen64 BEXSERO75 aspirin4 BACTRIM8 BIAXIN57 ASPIRIN4 BACTRIM DS8 BIKTARVY31 aspirin4 BACTROBAN44 BILTRICIDE7 aspirin buffered (cal carb-mag BALAMINE DM39 BIOBRON SF39 carb-mag oxide)4 balsalazide disodium53 BIODESP DM39 ASTAGRAF XL61 BANZEL13 BIOTENE DRY MOUTH MOISTURIZING SPRAY62 atazanavir sulfate31 BARACLUDE33 bisacodyl57 atenolol34 BELEODAQ27 bismuth subsalicylate20 atenolol & chlorthalidone25 BENADRYL ALLERGY21 ATIVAN9 bisoprolol & BENADRYL ALLERGY hydrochlorothiazide25 atomoxetine hcl1 CHILDRENS21 bisoprolol fumarate34 atorvastatin calcium23 benazepril & hydrochlorothiazide25 BLEPH-1067 atovaquone-proguanil hcl26 benazepril hcl24 BLEPHAMIDE68 ATRAC-TAIN47 BENICAR24 BLEPHAMIDE S.O.P.68 ATRIPLA31 BENICAR HCT25 BONE ESSENTIALS60 ATROPINE SULFATE66 BENTYL73 BP GEL43 ATROVENT HFA10 BENZAC AC WASH43 BREVICON-2837 AUGMENTIN70 BENZEFOAM43 BRILINTA54 AUGMENTIN ES-60069 BENZEFOAM ULTRA43 brimonidine tartrate67 AUGMENTIN XR70 BENZIQ43 bromocriptine mesylate28 AVALIDE25 BENZIQ LS43 brompheniramine & AVAPRO24 pseudoeph40 BENZIQ WASH43 AVC76 BRONKIDS40 benzonatate39 AVODART54 BRONTUSS DX40 benzoyl peroxide43 AVONEX71 BROTAPP DM40 BENZOYL PEROXIDE43 AVONEX PEN71 budesonide38 benzoyl peroxide43 BUFFERIN4 AXIRON6 BENZOYL PEROXIDE AYGESTIN70 CLEANSER43 bumetanide51 azathioprine61 benztropine mesylate28 BUMEX51 azelastine hcl64 BETAGAN66 BUPRENORPHINE6 AZITHROMYCIN57 betamethasone dipropionate buprenorphine hcl6 azithromycin57 (topical)46 bupropion hcl15 betamethasone dipropionate AZOPT68 bupropion hcl (smoking augmented46 deterrent)71 AZULFIDINE53 betamethasone valerate46 buspirone hcl8,9 AZULFIDINE EN-TABS53 BETAPACE34 butalbital-acetaminophen- B-177 BETAPACE AF34 caffeine4 B-1255 BETASAL47 butalbital-acetaminophen- caffeine w/ codeine5 BACIGUENT44 BETASERON71 butalbital-aspirin-caffeine4 BACITRACIN67 betaxolol hcl (ophth)66 butalbital-aspirin-caffeine bacitracin (topical)44 bethanechol chloride75 w/cod5

Index 2 BUTALBITAL/ASPIRIN/CAFFEIN carboxymethylcellulose sodium CHILDRENS MYLANTAUPSET E4 (ophth)65 STOMACH RELIEF7 butenafine hcl44 CARDIZEM35 CHLOR-TRIMETON21 BUTRANS6 CARDIZEM CD35 chlordiazepoxide hcl9 BYDUREON19 CARDURA24 chlorhexidine gluconate (mouth- BYDUREON PEN19 CARMOL 2047 throat)62 CHLOROQUINE BYETTA19 CARTEOLOL HCL66 PHOSPHATE26 CAFERGOT58 carteolol hcl (ophth)66 chloroquine phosphate26 CAL-CITRATE59 carvedilol34 CHLOROTHIAZIDE51 CAL-LAC59 CATAPRES24 chlorothiazide51 CAL-MAG-K CHELA MAX60 CATAPRES-TTS-124 chlorpheniramine & CAL-MINT59 CATAPRES-TTS-224 pseudoeph40 CALAMINE48 CATAPRES-TTS-324 chlorpheniramine maleate21 CALAN35 cefaclor36 chlorpromazine hcl30 CALAN SR35 CEFACLOR36 chlorthalidone51 CALCI-CHEW59 CEFACLOR ER36 cholecalciferol76,77 calcitriol52 cefadroxil36 cholestyramine23 CALCIUM59 cefdinir36 cholestyramine light23 calcium60 cefixime36 choline & mag salicylate4 CALCIUM60 cefpodoxime proxetil36 ciclopirox olamine44 CALCIUM & VITAMIN D3 cefprozil36 cidofovir33 BONEHEALTH60 CEFTIN36 cilostazol54 CALCIUM ACETATE59 cefuroxime axetil36 CILOXAN67 calcium acetate (phosphate CIPRO52 binder)53 CELEBREX2 CIPRODEX69 CALCIUM ASPARTATE59 celecoxib2 CIPROFLOXACIN HCL52 CALCIUM CARBONATE7,59 CELEXA15 ciprofloxacin hcl52 calcium carbonate59 CELLCEPT61 ciprofloxacin hcl (ophth)67 calcium carbonate (antacid)7 CENTANY44 citalopram hydrobromide15 calcium carbonate-vitamin d59 cephalexin36 CLARITHROMYCIN57 CALCIUM CITRATE60 CEPHALEXIN36 clarithromycin57,58 calcium citrate60 CEREZYME55 CLARITIN22 CALCIUM GLUCONATE60 CERVARIX75 CLARITIN ALLERGY CALCIUM LACTATE60 cetirizine hcl22 CHILDRENS22 CALCIUM PLUS VITAMIN D60 cetirizine-pseudoephedrine CLARITIN CHILDRENS22 40 calcium w/ vitamin d60 CHANTIX71 CLARITIN REDITABS22 CAPEX46 CHANTIX CONTINUING CLARITIN-D 12 HOUR40 CAPHOSOL62 MONTHPAK71 CLARITIN-D 24 HOUR40 CAPRELSA27 CHANTIX STARTING MONTH CLASSIC PRENATAL62 captopril24 PAK71 CLEAN & CLEAR ACNE CAPTOPRIL/HYDROCHLOROT CHELATED CALCIUM60 TRIPLECLEAR BUBBLE FOAM HIAZIDE 25 CHELATED POTASSIUM60 CLEANSER47 CARAFATE74 CHEMSTRIP-MICRAL49 CLEAN & CLEAR ADVANTAGE 3-IN-1 EXFOLIATING carbamazepine13 CHERACOL PLUS40 CLEANSER43 carbamide peroxide (otic)69 CHERACOL-D COUGH40 CLEAN & CLEAR ADVANTAGE CARBATROL13 CHILDRENS ADVIL2 OIL ABSORBING carbidopa-levodopa28 CHILDRENS MOTRIN2 CLEANSER47 CLEAN & CLEAR BLACKHEAD ERASER SCRUB47

Index 3 CLEAN & CLEAR DEEP COMTAN28 cyclosporine61 CLEANING ASTRINGENT CONCERTA1 cyclosporine modified (for SENSITIVE SKIN47 CONDOMS58 microemulsion)61 clemastine fumarate22 CYMBALTA17 CONDYLOX47 CLEOCIN8,76 cyproheptadine hcl23 COPAXONE71 CLEOCIN-T43 CYTOMEL72 COPEGUS33 CLIMARA52 CYTOTEC74 COREG34 CLIMARA PRO52 CYTOVENE33 clindamycin hcl8 CORGARD34 CORN & CALLUS danazol6 clindamycin phosphate DANTRIUM64 (topical)43 REMOVER47 clindamycin phosphate CORTEF38 dantrolene sodium64 vaginal76 CORTENEMA6 dapsone8 CLN ACNE CLEANSER47 CORTIFOAM6 DAYPRO2 clobetasol propionate46 CORZIDE25 DAYTRANA1 clobetasol propionate emollient COSOPT66 DDAVP52 base46 COTELLIC27 DEBROX69 clomipramine hcl17 COUMADIN11 DECARA77 clonazepam12,13 COZAAR24 DECONEX DMX40 clonidine hcl24 CREON50 DELSYM39 clopidogrel bisulfate54 CRIXIVAN31 DELSYM COUGH clorazepate dipotassium9 cromolyn sodium10 CHILDRENS39 clotrimazole62 DEMADEX51 cromolyn sodium (nasal)64 clotrimazole (topical)44 demeclocycline hcl72 cromolyn sodium (ophth)68 clotrimazole vaginal76 DEMEROL4 crotamiton49 clotrimazole w/ DENOREX EXTRA STRENGTH betamethasone44 CUPRIMINE61 2-IN-148 clozapine30 CUVPOSA73 DEPAKENE14 CLOZAPINE ODT30 CVS CALCIUM CHEWABLES DEPAKOTE15 600PLUS60 CLOZARIL30 DEPAKOTE ER15 CVS DRY MOUTH SPRAY62 CO-NATAL FA62 DEPAKOTE SPRINKLES15 CVS GLUCOSE18 COARTEM26 DEPO-PROVERA CVS GLUCOSE BITS18 COLACE57 CONTRACEPTIVE38 CVS HDYROCORTISONE DEPO-SUBQ PROVERA COLACE CLEAR57 ACETATE46 10438 COLAMINE60 CVS LUBRICANT GEL DEPO-TESTOSTERONE6 DROPS65 COLAZAL53 DEPRIZINE FUSEPAQ73 CVS OMEPRAZOLE74 COLCHICINE54 DEPRIZINE RAPIDPAQ73 CVS PRENATAL62 COLCRYS54 DERMA-SMOOTHE/FS CVS PSORIASIS MEDICATED BODY46 COLESTID23 SHAMPOO PLUS COLESTID FLAVORED23 DERMA-SMOOTHE/FS CONDITIONER47 SCALP46 CVS THERAPEUTIC colestipol hcl23 DERMAREST PSORIASIS48 COLYTE-FLAVOR PACKS56 DANDRUFFMAXIMUM STRENGTH48 DERMAREST PSORIASIS COMBIVENT RESPIMAT11 CVS THERAPEUTIC MEDICATED SHAMPOO PLUS COMBIVIR31 MAXIMUM STRENGTH48 CONDITIONER48 COMPLERA31 cyanocobalamin55 DESCOVY31 COMPLETENATE62 CYCLESSA37 DESGEN DM40 COMPOUND W47 cyclobenzaprine hcl64 desipramine hcl17 COMPOUND W MAXIMUM CYCLOGYL66 desmopressin acetate52 STRENGTH47 cyclopentolate hcl66 desmopressin acetate spray52

Index 4 desmopressin acetate spray didanosine31 DORZOLAMIDE HCL/TIMOLOL refrigerated52 DIFLUCAN21 MALEATE66 DESOGEN37 doxazosin mesylate24 diflunisal4 desogestrel & ethinyl doxepin hcl18 DIGOXIN35 estradiol37 doxycycline (monohydrate)72 desogestrel-ethinyl estradiol digoxin35 doxycycline hyclate72 (biphasic)37 DILANTIN14 desogestrel-ethinyl estradiol DOXYCYCLINE HYCLATE72 DILANTIN INFATABS14 (triphasic)37 doxycycline hyclate72 DILANTIN-12514 DESQUAM-X WASH43 doxylamine succinate desvenlafaxine succinate17 DILATRATE SR8 (sleep)55 DETROL75 DILAUDID5 DRAMAMINE21 DETROL LA75 diltiazem hcl35 DRISDOL77 DEX4 FAST ACTING diltiazem hcl coated beads35 drospirenone-ethinyl GLUCOSEGO-POUCH18 diltiazem hcl extended release estradiol37 DEX4 QUICK DISSOLVE beads35 DRYSOL48 GLUCOSE18 dimenhydrinate21 DULCOLAX57 dexamethasone38 DIOVAN24 DULERA11 DEXAMETHASONE38 DIOVAN HCT25 duloxetine hcl17 dexamethasone38 DIPENTUM53 DURAGESIC5 DEXAMETHASONE38 diphenhydramine hcl22 dutasteride54 dexamethasone38 diphenhydramine hcl DYAZIDE51 DEXAMETHASONE (sleep)55 INTENSOL38 diphenhydramine hcl DYRENIUM51 DEXAMETHASONE SODIUM (topical)45 EC-NAPROSYN3 PHOSPHATE68 diphenoxylate w/ atropine20 ECOTRIN MAXIMUM DEXEDRINE1 DIPHENOXYLATE/ATROPINE STRENGTH4 DEXPAK 13 DAY38 20 ECOTRIN REGULAR STRENGTH4 dextroamphetamine sulfate1 DIPHTHERIA/TETANUS TOXOIDS ADSORBED ED BRON GP40 dextromethorphan hbr39 PEDIATRIC73 EDURANT31 dextromethorphan polistirex39 DIPROLENE AF46 efavirenz31 dextromethorphan-guaifenesin dipyridamole54 40 EFFEXOR XR17 DISALCID4 dextrose (diabetic use)18 ELAPRASE52 disopyramide phosphate10 DIAMOX50 ELAVIL18 disulfiram70 DIAPHRAGMS58 ELDEPRYL28 DITROPAN XL75 DIASTAT ACUDIAL13 ELIGARD26 DIURIL51 DIASTAT PEDIATRIC13 ELIMITE49 divalproex sodium15 diazepam9 ELIPHOS53 docusate calcium57 DIAZEPAM9 ELIQUIS11 docusate sodium57 diazepam9 ELIQUIS STARTER PACK11 dofetilide10 DIAZEPAM13 ELITE CALCIUM60 DOMETUSS-DMX40 DIAZEPAM RECTAL GEL13 ELMIRON54 donepezil hydrochloride70 diclofenac potassium2 ELOCON46 DORYX72 diclofenac sodium2,3 EMBEDA5 DORYX MPC72 diclofenac sodium (ophth)68 EMEND21 dorzolamide hcl68 diclofenac sodium (topical)44 EMEND TRIPACK21 DORZOLAMIDE HCL68 diclofenac w/ misoprostol3 EMSAM15 dorzolamide hcl-timolol EMTRIVA31 dicloxacillin sodium70 maleate66 dicyclomine hcl73 enalapril maleate24

Index 5 enalapril maleate & EX-LAX MAXIMUM FIRST-VANCOMYCIN 257 hydrochlorothiazide25 STRENGTH57 FIRST-VANCOMYCIN 507 ENBREL4 EXACTUSS40 FISH OIL65 ENBREL SURECLICK4 EXACTUSS TR40 FISH OIL PEARLS65 ENGERIX-B75 EXELON70 FISH OIL TRIPLE enoxaparin sodium12 exemestane26 STRENGTH65 entacapone28 EXTAVIA71 FISH OIL ULTRA65 entecavir33 ezetimibe24 FLAGYL8 ENTOCORT EC38 famciclovir34 flecainide acetate10 EPANED24 famotidine73 FLEET ENEMA56 epinephrine (anaphylaxis)76 FAMVIR34 FLEET ENEMA SIX PACK56 EPIVIR31 FARESTON26 FLEET PEDIATRIC56 EPIVIR HBV33 FATHER JOHNS MEDICINE FLOLAN36 eplerenone25 PLUS40 FLOMAX54 FAZACLO30 EPOGEN55 FLONASE ALLERGY felbamate14 epoprostenol sodium36 RELIEF64 FELBATOL14 FLONASE ALLERGY RELIEF EPZICOM31 FELDENE3 CHILDRENS64 EQ OMEPRAZOLE74 FLOVENT HFA11 felodipine35 EQL DRY MOUTH ORAL FLOXIN OTIC69 RINSE62 FEMARA26 fluconazole21 EQL OMEPRAZOLE74 FEMIRON55 fludrocortisone acetate39 EQL PRENATAL FORMULA62 FEMRING76 FLUMADINE34 EQUETRO28 fenofibrate23 FLUNISOLIDE64 ergocalciferol77 fenofibrate micronized23 fluocinolone acetonide46 ergotamine w/ caffeine58 FENOFIBRIC ACID23 fluocinonide46 ERYGEL43 FENOPROFEN CALCIUM3 fluorometholone (ophth)68 erythromycin (acne aid)43 fenoprofen calcium3 FLUOXETINE DR16 erythromycin (ophth)67 FENORTHO3 fluoxetine hcl16 escitalopram oxalate15,16 fentanyl5 fluphenazine decanoate30 ESGIC4 FERRETTS55 FLUPHENAZINE HCL30 ESTRACE52 FERRIMIN 15055 fluphenazine hcl30 estradiol52 FERROUS FUMARATE55 flurbiprofen3 estradiol vaginal76 ferrous fumarate55 flurbiprofen sodium68 ESTRING76 ferrous gluconate55 flutamide26 ESTROPIPATE52 FERROUS GLUCONATE55 fluticasone propionate46 ESTROSTEP FE37 ferrous sulfate55 fluticasone propionate ethambutol hcl26 fexofenadine hcl22 (nasal)64 ethosuximide14 fexofenadine-pseudoephedrine fluvoxamine maleate16 40 ethynodiol diacet & eth FML68 estrad37 FIBRICOR23 FML FORTE68 etodolac3 finasteride54 FML LIQUIFILM68 ETOPOSIDE27 FIORICET4 FOCALIN1 EURAX49 FIORICET/CODEINE5 FOCALIN XR1 EVAC56 FIORINAL4 folic acid55 EVISTA52 FIORINAL/CODEINE #35 FOSAMAX51 EVOTAZ32 FIRST-LANSOPRAZOLE74 fosamprenavir calcium32 EX-LAX57 FIRST-OMEPRAZOLE74 FOSCAVIR33

Index 6 fosinopril sodium24 GLUCAGON EMERGENCY heparin sod (porcine) in d5w12 fosinopril sodium & KIT19 heparin sodium (porcine)12 hydrochlorothiazide25 GLUCOPHAGE18 heparin sodium (porcine) lock FOSRENOL53,54 GLUCOPHAGE XR18 flush12 FREEZONE48 GLUCOSE19 heparin sodium (porcine) lock FURADANTIN74 GLUCOTROL20 flush & nacl lock flush12 HEPARIN SODIUM/D5W12 furosemide51 GLUCOTROL XL20 HEPARIN FUROSEMIDE51 GLUCOVANCE18 SODIUM/DEXTROSE12 furosemide51 glyburide20 HEPARIN SODIUM/NACL FUZEON32 glyburide micronized20 0.45%12 HEPARIN SODIUM/SODIUM G-TUSICOF40 glyburide-metformin18 CHLORIDE12 G-ZYNCOF40 glycopyrrolate73 HEPARIN SODIUM/SODIUM gabapentin13 GLYNASE20 CHLORIDE 0.9%12 GABITRIL14 GLYXAMBI18 HEPSERA33 galantamine hydrobromide70 GNP DAILY PRENATAL62 HERBAL EXPEC42 GALANTAMINE GNP GLUCOSE19 HM FISH OIL65 HYDROBROMIDE70 GNP OMEPRAZOLE74 HM OMEPRAZOLE74 galantamine hydrobromide70 GNP PRENATAL62 HM ONE DAILY PRENATAL COMBO62 ganciclovir sodium33 GNP QUICK DISSOLVE GARDASIL75 GLUCOSE19 HM PRENATAL62 GARDASIL 975 GOLD BOND PSORIASIS HM VITAMIN D377 GAS-X53 RELIEF MULTI- homatropine hbr66 SYMPTOM48 HORIZANT71 GAS-X EXTRA STRENGTH53 GOLYTELY56 GAUZE PADS 2X2, 3X3, HUMALOG19 4X458 GONIOVISC66 HUMALOG JUNIOR gemfibrozil23 GOODSENSE PRENATAL KWIKPEN19 VITAMINS62 HUMALOG KWIKPEN19 GENOTROPIN51 GRALISE71 HUMALOG MIX 50/5019 GENOTROPIN MINIQUICK51 granisetron hcl21 GENTAK67 HUMALOG MIX 50/50 griseofulvin microsize21 KWIKPEN19 gentamicin sulfate (ophth)67 guaifenesin42 HUMALOG MIX 75/2519 gentamicin sulfate (topical)44 guaifenesin-codeine40 HUMALOG MIX 75/25 GENTEAL MILD65 guanfacine hcl24 KWIKPEN19 GENTEAL MILD TO HUMIRA2 MODERATE66 guanfacine hcl (adhd)1 HUMIRA PEDIATRIC CROHNS GENTEAL SEVERE66 GYNE-LOTRIMIN76 DISEASE STARTER PACK2 GENVOYA32 GYNE-LOTRIMIN 376 HUMIRA PEN2 GEODON28 HALDOL29 HUMIRA PEN-CD/UC/HS STARTER2 GIAZO53 HALDOL DECANOATE 10029 HUMIRA PEN-PS/UV GILENYA71 HALDOL DECANOATE 5029 STARTER2 GILTUSS40 halobetasol propionate46 HUMULIN 70/3019 GILTUSS COUGH & COLD40 haloperidol30 HUMULIN 70/30 KWIKPEN19 GILTUSS TR40 haloperidol decanoate29 HUMULIN N19 GLASSIA71 haloperidol lactate30 HUMULIN N KWIKPEN19 glatiramer acetate71 HAVRIX75 HUMULIN R19 GLEEVEC27 HUMULIN R U-500 HEMOCYTE55 (CONCENTRATED)19 glimepiride20 heparin (porcine) in sodium HUMULIN R U-500 glipizide20 chloride12 KWIKPEN19 glipizide-metformin hcl18 HEPARIN LOCK FLUSH12 hydralazine hcl25

Index 7 HYDREA27 INDERAL LA34 KAPVAY1 hydrochlorothiazide51 INDOCIN3 KAYEXALATE61 hydrocodone w/ indomethacin3 KEFLEX36 homatropine39 INFLUENZA VACCINE75 KENALOG-1038 hydrocodone-acetaminophen5 INLYTA27 KEPPRA13 hydrocodone-ibuprofen5 INSPRA25 KEPPRA XR13 hydrocortisone38 INSTA-GLUCOSE19 KERALYT48 hydrocortisone (intrarectal)6 INSULIN PUMP INFUSION ketoconazole (topical)44 hydrocortisone (rectal)7 SUPPLIES58 ketoprofen3 hydrocortisone (topical)46 INSULIN SYRINGES AND PEN KETOPROFEN3 hydrocortisone acetate NEEDLES58 (topical)46 INTELENCE32 KETOPROFEN ER3 hydrocortisone acetate w/ INTRON A27 ketorolac tromethamine3 pramoxine6 INTRON A W/DILUENT27 ketorolac tromethamine hydrocortisone w/acetic acid69 (ophth)68 INTUNIV1 hydrogen peroxide31 ketotifen fumarate (ophth)68 INVEGA SUSTENNA29 hydromorphone hcl5 KEY-E77 INVEGA TRINZA29 HYDROMORPHONE HCL5 KITABIS PAK2 INVIRASE32 hydromorphone hcl5 KLARON43 ipratropium bromide10 KLONOPIN13 hydroxychloroquine sulfate26 ipratropium bromide hydroxyprogesterone (nasal)64 KLOR-CON M1560 caproate70 ipratropium-albuterol11 KLOR-CON/2560 hydroxyurea27 irbesartan24 KLOUT49 hydroxyzine hcl9 irbesartan-hydrochlorothiazide KLS OMEPRAZOLE74 HYDROXYZINE PAMOATE9 25 KOMBIGLYZE XR18 hydroxyzine pamoate9 IRESSA27 KONSYL DAILY FIBER56 hyoscyamine sulfate73 ISENTRESS32 KONSYL ORIGINAL HYPER-SAL43 ISONIAZID26 FORMULADAILY FIBER56 HYPERSAL43 isoniazid26 KP PRENATAL MULTIVITAMINS62 hypromellose (ophth)66 ISOPTO ATROPINE66 KPN PRENATAL62 HYZAAR25 ISOPTO CARPINE67 labetalol hcl34 IBUDONE5 ISOPTO TEARS66 LAC-HYDRIN47 ibuprofen3 ISORDIL TITRADOSE8 LAC-HYDRIN TWELVE47 ICLUSIG27 isosorbide dinitrate8 lactic acid (ammonium imatinib mesylate27 ISOSORBIDE DINITRATE lactate)47 IMBRUVICA27 ER8 lactulose56 isosorbide mononitrate8 imipramine hcl18 lactulose (encephalopathy)53 isotretinoin43 imipramine pamoate18 LAMICTAL13 ISTALOL66 imiquimod47 LAMICTAL CHEWABLE ivermectin7 IMITREX58,59 DISPERSIBLE13 IMITREX STATDOSE JAKAFI27 LAMICTAL ODT13 REFILL58 JANUMET18 LAMICTAL XR13 IMITREX STATDOSE JANUMET XR18 LAMISIL21 SYSTEM58 JANUVIA19 LAMISIL AT45 IMODIUM A-D20 JENTADUETO18 LAMISIL AT JOCK ITCH45 IMURAN61 JENTADUETO XR18 lamivudine32 INATAL GT62 K-TAB60 lamivudine (hbv)33 INCRELEX52 KALETRA32 lamivudine-zidovudine32 indapamide51

Index 8 lamotrigine13 lidocaine hcl48 LOTRIMIN AF JOCK ITCH45 LANCETS AND LANCET LIDOCAINE HCL57 LOTRIMIN ULTRA45 DEVICES58 lidocaine hcl (local LOTRISONE45 LANOXIN35 anesth.)57 lovastatin23 lansoprazole74 lidocaine hcl (mouth- LOVENOX12 lanthanum carbonate54 throat)61 lidocaine-prilocaine48 loxapine succinate30 LANTUS19 LIDODERM48 LOZI-FLUR60 LANTUS SOLOSTAR19 lindane49 LUPRON DEPOT (1- LASIX51 MONTH)26 LINDANE49 latanoprost69 LUPRON DEPOT (3- linezolid8 LATANOPROST69 MONTH)26 LINZESS53 LUPRON DEPOT (4- LATUDA29 liothyronine sodium72 MONTH)27 LEADER QUICK DISSOLVE LUPRON DEPOT (6- GLUCOSE19 LIPITOR23 MONTH)27 leflunomide4 lisinopril24 LURIDE60 LETAIRIS36 lisinopril & LYCELLE49 hydrochlorothiazide25 letrozole26 LYRICA13 LITHIUM28 LEUCOVORIN CALCIUM27 M-M-R II75 lithium carbonate28 leucovorin calcium27 M-VIT62 LITHOBID28 leuprolide acetate26 MAALOX7 LMX 448 levalbuterol hcl11 MACROBID74 LODINE3 LEVAQUIN52 MACRODANTIN75 LOESTRIN 1.5/30-2137 LEVBID73 MAG-20060 LOESTRIN 1/20-2137 LEVEMIR19 MAGNESIUM60 LOESTRIN FE 1/2037 LEVEMIR FLEXTOUCH19 magnesium citrate57 LOFIBRA23 levetiracetam13 magnesium hydroxide57 LOHIST-D41 levobunolol hcl66 magnesium oxide7 LOHIST-DM41 levofloxacin52 MAGNESIUM OXIDE60 LOMOTIL20 levofloxacin (ophth)67 magnesium oxide (mg levonorgestrel & eth loperamide hcl20 supplement)60 estradiol37 LOPID23 MAGOX 40060 levonorgestrel (emergency lopinavir-ritonavir32 MAKENA70 oc)38 LOPRESSOR34 levonorgestrel-eth estradiol MALARONE26 (triphasic)37 LOPRESSOR HCT25 MAPROTILINE HCL15 levonorgestrel-ethinyl estradiol LOPROX45 MARPLAN15 (91-day)37 loratadine22 MATULANE27 levonorgestrel-ethinyl estradiol loratadine & MAVIK24 (continuous)37 pseudoephedrine41 MAVYRET33 levothyroxine sodium72 lorazepam9 MAXALT59 LEVSIN73 losartan potassium24 LEVSIN/SL73 losartan potassium & MAXALT-MLT59 LEXAPRO16 hydrochlorothiazide25 MAXIDEX68 LEXIVA32 LOSEASONIQUE37 MAXITROL68 LIBERTY GLUCOSE CONTROL LOTENSIN24 MAXZIDE51 LEVEL 158 LOTENSIN HCT25 MAXZIDE-2551 LIBERTY GLUCOSE CONTROL LEVEL 258 LOTREL25 meclizine hcl21 LICEMD49 LOTRIMIN AF45 MECLOFENAMATE SODIUM3 lidocaine48 LOTRIMIN AF FOR HER45 MEDROL38

Index 9 MEDROL DOSEPAK38 METIPRANOLOL66 MODERIBA 800 DOSE medroxyprogesterone metoclopramide hcl53 PACK33 MODICON37 acetate70 METOCLOPRAMIDE ODT53 medroxyprogesterone acetate moexipril hcl24 metolazone51 (contraceptive)38 moexipril-hydrochlorothiazide mefenamic acid3 metoprolol & 25 hydrochlorothiazide25 MEGACE ES70 MOI-STIR62 metoprolol succinate34 MEGACE ORAL27 mometasone furoate46 metoprolol tartrate34 MONISTAT 1 COMBO megestrol acetate27 METOPROLOL megestrol acetate (appetite)70 PACK76 TARTRATE34 MONISTAT 1 DAY OR NIGHT MEIJER CALAMINE49 METOPROLOL/HYDROCHLO COMBO PACK76 ROTHIAZIDE 25 meloxicam3 MONISTAT 376 METROCREAM49 memantine hcl70 MONISTAT 3 COMBINATION METROGEL-VAGINAL76 MENACTRA75 PACK76 METROLOTION49 MONISTAT 7 COMBINATION MENEST52 metronidazole8 PACK76 MENOMUNE-A/C/Y/W-135 75 MONISTAT 7 SIMPLY metronidazole (topical)49 MENOSTAR52 CURE76 metronidazole vaginal76 MENTAX45 MONISTAT SOOTHING CARE MEVACOR23 ITCH RELIEF46 MENVEO75 mexiletine hcl10 MONODOX72 meperidine hcl5 MG217 PSORIASIS MULTI- montelukast sodium10 MEPHYTON77 SYMPTOM48 morphine sulfate5 mercaptopurine26 MICATIN45 MORPHINE SULFATE5 mesalamine53 MICONAZOLE 376 morphine sulfate5 MESTINON26 MICONAZOLE NITRATE45 MOSCO CALLUS/CORN MESTINON TIMESPAN26 miconazole nitrate (topical)45 REMOVER48 METADATE CD1 miconazole nitrate vaginal76 MOUTHKOTE62 METAMUCIL56 MICRO-K60 moxifloxacin hcl (ophth)67 METAMUCIL ORIGINAL MICROZIDE51 MS CONTIN5 TEXTURE56 midodrine hcl76 MUCINEX43 metformin hcl18 MIGERGOT58 MUCINEX CHILDRENS MULTI- METFORMIN SYMPTOM COLD41 HYDROCHLORIDE18 MILK OF MAGNESIA MUCINEX CONGESTION & methazolamide50 CONCENTRATE57 COUGH CHILDRENS41 MILLIPRED39 methimazole72 MUCINEX D41 MINIPRESS24 methocarbamol64 MUCINEX DM41 MINIVELLE52 methotrexate sodium26 MUCINEX FAST-MAX SEVERE MINOCIN72 CONGESTION & COUGH41 methscopolamine bromide73 minocycline hcl72 MUCINEX FAST-MAX SEVERE METHYCLOTHIAZIDE51 CONGESTION & COUGH minoxidil25 methyldopa24 CLEAR & COOL41 MIRALAX56 methylergonovine maleate69 MUCINEX MAXIMUM MIRAPEX28 STRENGTH43 METHYLIN1,2 MIRAPEX ER28 MUCINEX STUFFY NOSE & methylphenidate hcl2 COLD CHILDRENS41 METHYLPHENIDATE HCL MIRCETTE37 MULTAQ10 ER2 mirtazapine15 MULTI-MINERALS60 METHYLPHENIDATE misoprostol74 multiple minerals60 HYDROCHLORIDE ER2 MOBIC3 methylprednisolone38,39 MULTIVITAMINS /W MODERIBA 1200 DOSE MINERALS62 methylprednisolone sod PACK33 succ38 mupirocin44

Index 10 mupirocin calcium (topical)44 NATURE-THROID NT-2.572 NICOTROL INHALER71 MYAMBUTOL26 NECON 1/50-2837 NICOTROL NS71 mycophenolate mofetil61 NECON 10/11-2837 nifedipine35 mycophenolate sodium61 NEFAZODONE HCL17 NINLARO27 MYDRIACYL67 nefazodone hcl17 nit remover49 MYFORTIC61 NEFAZODONE NITRO-BID8 MYLICON53 HYDROCHLORIDE17 NITRO-DUR8 neomycin sulfate2 MYLICON INFANTS GAS nitrofurantoin75 neomycin-bacitracin zn- RELIEF53 nitrofurantoin macrocrystal75 MYNATAL62 polymyxin67 neomycin-bacitracin-polymyxin nitrofurantoin monohyd MYNATAL ADVANCE62 44 macro75 MYNATAL PLUS62 neomycin-bacitracin-polymyxin- nitroglycerin8 MYNATAL ULTRACAPLET62 pramoxine 44 NITROSTAT8 neomycin-polymy- MYNATAL-Z62 dexameth68 NIVA-PLUS62 MYNATE 90 PLUS62 neomycin-polymyxin-gramicidin NIVANEX DMX41 MYSOLINE13 67 NIX CREME RINSE49 nabumetone3 neomycin-polymyxin-hc NIZORAL45 (otic)69 nadolol34 NEOMYCIN/POLYMYXIN/HYD NOBLE MYSTIQUE EMU- nadolol & ROCORTISONE 68 LAC47 NONOXYNOL bendroflumethiazide25 NEONATAL PLUS62 NALFON3 SPERMICIDES76 NEORAL61 NOR-QD38 NALOXONE HCL20 NEOSPORIN67 NORCO5 naloxone hcl20 NEOSPORIN ORIGINAL44 NORDITROPIN FLEXPRO51 NALOXONE HCL20 NEOTUSS PLUS41 norethin acet & estrad-fe37 naltrexone hcl20 NEOTUSS-D41 norethindrone & eth estradiol37 NAMENDA70 NEPTAZANE50 norethindrone naphazoline w/ pheniramine67 NEULASTA55 (contraceptive)38 NAPHCON-A67 NEULASTA ONPRO KIT55 norethindrone acet & eth estra37 NAPROSYN3 NEUPOGEN55 naproxen3 norethindrone acetate70 NEURONTIN13 norethindrone acetate-ethinyl naproxen sodium3 NEUTROGENA ON-THE- estradiol-fe37 naratriptan hcl59 SPOT ACNE norethindrone-eth estradiol NARCAN20 TREATMENT44 (triphasic)37 NARDIL15 NEUTROGENA T/SAL48 norgestimate-ethinyl nevirapine32 estradiol37 NASACORT ALLERGY norgestimate-ethinyl estradiol 24HR64,65 NEXAVAR27 (triphasic)37 NASACORT ALLERGY 24HR NF FORMULAS CALCIUM norgestrel & ethinyl estradiol37 CHILDRENS65 MAGNESIUM60 NASAL DECONGESTANT65 niacin77 NORINYL 1+3537 NASALCROM64 niacinamide77 NORPACE10 NAT-RUL PRENATAL NICODERM CQ71 NORPACE CR10 VITAMINS62 NICORETTE71 NORPRAMIN18 NATACYN67 NICORETTE MINI71 nortriptyline hcl18 NATALVIT62 NICORETTE STARTER NORVASC35 nateglinide20 KIT71 NORVIR32 NATROBA49 nicotine71 NOVOLOG FLEXPEN19 NATURAL VITAMIN E77 nicotine polacrilex71 NOVOLOG MIX 70/3019 NATURE-THROID72 NICOTINE TRANSDERMAL SYSTEM71

Index 11 NOVOLOG MIX 70/30 ORAL RELIEF SPRAY FOR PEPCID73 PREFILLED FLEXPEN19 DRYMOUTH & PEPCID AC73 62 NOVOLOG PENFILL19 DISCOMFORT PEPCID AC EZ CHEWS NUMOISYN62 ORAP71 MAXIMUM STRENGTH73 NUTRA-SUPPORT BONE60 ORAPRED ODT39 PEPCID AC MAXIMUM NUTRICION PORVIDA62 ORTHO MICRONOR38 STRENGTH73 PEPTO BISMOL20 NUVARING38 ORTHO TRI-CYCLEN37 PEPTO-BISMOL20 nystatin21 ORTHO TRI-CYCLEN LO37 ORTHO-CYCLEN37 PEPTO-BISMOL nystatin (mouth-throat)62 INSTACOOL20 nystatin (topical)45 ORTHO-NOVUM 1/3537 PEPTO-BISMOL TO-GO20 NYTOL MAXIMUM ORTHO-NOVUM 7/7/737 PERCOCET6 STRENGTH55 oseltamivir phosphate34 PERIDEX62 O-CAL FA63 OVACE PLUS WASH45 perindopril erbumine24 O-CAL PRENATAL63 OVACE WASH45 permethrin49 OC844 OVCON-3538 perphenazine30 OCUFEN68 oxaprozin3 PERRY PRENATAL63 OCUFLOX67 oxazepam9 PEXEVA16 ODEFSEY32 OXAZEPAM9 PHAZYME53 ofloxacin52 oxcarbazepine14 PHAZYME ULTRA ofloxacin (ophth)67 OXTELLAR XR14 STRENGTH53 ofloxacin (otic)69 oxybutynin chloride75 phenazopyridine hcl54 OGESTREL37 oxycodone hcl5 phenelzine sulfate15 olanzapine30 oxycodone w/ phenobarbital56 olmesartan medoxomil24 acetaminophen5 PHENOBARBITAL56 olmesartan medoxomil- oxycodone-aspirin6 phenobarbital56 hydrochlorothiazide 25 OXYCODONE/ACETAMINOPH phenylephrine hcl (ophth)67 OMEGA POWER65 EN6 phenylephrine w/ dm-gg41 OMEGA-365 oyster shell60 P & S48 phenylephrine-brompheniramine- OMEGA-3 210065 dm 41 OMEGA-3 EPA FISH OIL65 PAMELOR18 phenylephrine-chlorphen-dm omega-3 fatty acids65 PANOXYL44 41 OMEGA-3 FISH OIL EXTRA PANOXYL-4 CREAMY phenylephrine-guaifenesin41 STRENGTH65 WASH44 PHENYTEK14 omeprazole74 pantoprazole sodium74 phenytoin14 OMEPRAZOLE74 PARLODEL28 phenytoin sodium extended14 OMEPRAZOLE + SYRSPEND PARNATE15 phytonadione77 SFALKA74 paroxetine hcl16 pilocarpine hcl67 OMNIFLEX DIAPHRAGM58 PAXIL16 pimozide71 OMNIPRED68 PAXIL CR16 pioglitazone hcl19 ondansetron21 peg 3350-kcl-sod bicarb-sod pioglitazone hcl-metformin ondansetron hcl21 chloride-sod sulfate56 hcl18 ONE-A-DAY WOMENS PEG-INTRON REDIPEN33 piroxicam3 PRENATAL63 PEGASYS33 PLAN B ONE-STEP38 ONFI13 PEGASYS PROCLICK33 PLAQUENIL26 ONGLYZA19 PENICILLIN V PLAVIX54 OPCON-A67 POTASSIUM69 PNEUMONIA VACCINE75 OPTIMAL D3 M77 penicillin v potassium69 PENTASA53 PNV FERROUS FUMARATE/DOCUSATE/FOLIC pentoxifylline54 ACID63

Index 12 PNV FOLIC ACID + IRON PREDNISONE39 PROMACTA55 MULTIVITAMIN63 prednisone39 promethazine & PNV PRENATAL PLUS PREDNISONE39 phenylephrine42 MULTIVITAMIN63 promethazine hcl22 PNV TABS 29-163 PREDNISONE INTENSOL39 promethazine w/codeine42 PNV-VP-U63 PREMARIN52,76 promethazine-dm42 PREMPRO52 podofilox48 PROMETHAZINE/PHENYLEPHR polyethylene glycol 335056 PRENATABS FA63 INE 42 polyethylene glycol-propylene PRENATABS RX63 PROMETRIUM70 glycol (ophth)66 PRENATAL63 propafenone hcl10 polymyxin b-trimethoprim67 PRENATAL 1963 PROPANTHELINE POLYSPORIN44 PRENATAL AND IRON63 BROMIDE73 POLYTRIM67 PRENATAL FORTE63 propranolol hcl34 PONSTEL3 PRENATAL PROPRANOLOL HCL34 POTASSIUM61 MULTIVITAMIN63 propranolol hcl34,35 potassium61 PRENATAL PLUS63 PROPRANOLOL/HYDROCHLOR potassium chloride60 PRENATAL PLUS IRON63 OTHIAZIDE 25 propylthiouracil72 POTASSIUM CHLORIDE60 PRENATAL VITAMIN & MINERAL63 PROSCAR54 potassium chloride61 PRENATAL PROTONIX74 POTASSIUM CHLORIDE VITAMIN/IRON63 protriptyline hcl18 ER60 PRENATAL VITAMINS63 potassium chloride PRENATAL VITAMINS PLUS PROVERA70 microencapsulated crystals PROZAC16 er61 LOW IRON63 potassium citrate PRENATAL-U63 pseudoephed-bromphen-dm42 (alkalinizer)54 PREPLUS63 pseudoephedrine hcl65 potassium citrate-citric acid54 PRETAB63 pseudoephedrine w/ codeine- PRADAXA12 PREVACID74 gg42 pseudoephedrine w/ dm-gg42 pramipexole dihydrochloride28 PREVACID 24HR74 pseudoephedrine-guaifenesin PRANDIN20 PREZCOBIX32 42 PRAVACHOL23 PREZISTA32 psyllium56 pravastatin sodium23 PRILOSEC74 PULMICORT11 praziquantel7 PRIMAQUINE PULMICORT FLEXHALER11 PHOSPHATE26 prazosin hcl24 PULMOZYME71 primidone14 PRE-NATAL FORMULA63 PURIXAN26 PRIMLEV6 PRECOSE18 PX OMEPRAZOLE74 PRINIVIL24 PRED FORTE68 PX PRENATAL PRED MILD68 PRISTIQ17 MULTIVITAMINS63 PRED-G68 probenecid54 pyrantel pamoate7 PRED-G S.O.P.68 PROCARDIA35 pyrazinamide26 PREDATOR48 PROCARDIA XL35 pyrethrins-piperonyl butoxide- prochlorperazine30 permethrin-nit remover49 prednisolone39 PYRIDIUM54 PREDNISOLONE39 prochlorperazine maleate30 PROCORT6 pyridostigmine bromide26 prednisolone acetate (ophth)68 pyridoxine hcl77 PREDNISOLONE ACETATE P- PROCRIT55 F68 PROCTOCORT7 QC CALAMINE49 prednisolone sodium progesterone micronized70 QC MEDIFIN PE42 phosphate39 PROGRAF61 QC PRENATAL63 PREDNISOLONE SODIUM QUALAQUIN26 PHOSPHATE68 PROLASTIN-C71 QUESTRAN23

Index 13 QUESTRAN LIGHT23 REPREXAIN6 ROBITUSSIN PEAK COLD quetiapine fumarate30 REQUIP28 COUGH+ CHEST CONGESTION DM MAX STRENGTH42 QUILLICHEW ER2 REQUIP XL28 ROBITUSSIN PEAK COLD QUILLIVANT XR2 RESCRIPTOR32 DM42 quinapril hcl24 RESTASIS68 ROBITUSSIN PEAK COLD MULTI-SYMPTOM COLD42 quinapril-hydrochlorothiazide RESTASIS MULTIDOSE68 25 ROBITUSSIN TO GO COUGH RESTORIL56 &COLD CF42 quinidine gluconate10 RETIN-A44 ROCALTROL52 QUINIDINE SULFATE10 RETIN-A MICRO44 ropinirole hydrochloride28 quinine sulfate26 RETIN-A MICRO PUMP44 ROXICODONE5 RA CALCIUM HI- CAL/VITAMIND60 RETROVIR32 ROZEREM56 RA DRY MOUTH62 REVATIO36 RYCONTUSS42 RA FISH OIL EXTRA REVLIMID61 RYTHMOL10 STRENGTH65 REYATAZ32 RYTHMOL SR10 RA LICE SOLUTION KIT49 RIAX44 SALAC48 RA OMEPRAZOLE74 RIBASPHERE33 SALEX48 RA ONE DAILY63 RIBASPHERE RIBAPAK33 salicylic acid48 RA PRENATAL64 ribavirin (hepatitis c)33 SALMON65 RA PRENATAL RID COMPLETE LICE SALMON OIL65 FORMULA/FOLICACID64 ELIMINATION49 RA TRIPLE STRENGTH FISH SALMON OIL-100065 RIFADIN26 OIL65 salsalate4 rifampin26 raloxifene hcl52 SALVAX48 RILUTEK65 ramipril24 SANDIMMUNE61 riluzole65 RANEXA8 SAPHRIS30 ranitidine hcl73,74 rimantadine hydrochloride34 SASH KIT FOR FLUSHING RAPAMUNE61 RIOMET18 VASCULAR ACCESS RAZADYNE70 RISPERDAL29 DEVICES12 74 RAZADYNE ER70 RISPERDAL CONSTA29 SB OMEPRAZOLE 49 REA-LO47 RISPERDAL M-TAB29 SCHOOLTIME SHAMPOO 64 REBETOL33 risperidone29 SE-NATAL 19 38 REBIF71 RISPERIDONE ODT29 SEASONIQUE 28 REBIF REBIDOSE71 RITALIN2 selegiline hcl REBIF REBIDOSE RITALIN LA2 selenium sulfide45 TITRATIONPACK71 ritonavir32 SELSUN BLUE DEEP REBIF TITRATION PACK71 CLEANSING48 rivastigmine70 48 RECOMBIVAX HB75 SELSUN BLUE NATURALS rivastigmine tartrate71 SELSUN BLUE NATURALS REESES PINWORM rizatriptan benzoate59 48 MEDICINE7 DRYSCALP 32 REFRESH LIQUIGEL66 ROBAXIN64 SELZENTRY 57 REFRESH TEARS66 ROBAXIN-75064 sennosides ROBINUL73 sennosides-docusate REGLAN53 sodium56 ROBINUL FORTE73 RELENZA DISKHALER34 SENOKOT57 ROBITUSSIN CHILDRENS REMERON15 COUGH & COLD CF42 SENOKOT S56 REMERON SOLTAB15 ROBITUSSIN LINGERING SENOKOT XTRA57 RENAGEL54 COLDLONG-ACTING SENSIPAR52 COUGHGELS39 RENVELA54 SEREVENT DISKUS11 repaglinide20 SEROQUEL30

Index 14 sertraline hcl16 STRIBILD32 tacrolimus61 sevelamer carbonate54 STROMECTOL7 tadalafil (pulmonary SFROWASA53 SUBOXONE6 hypertension)36 TAMIFLU34 SHINGRIX75 SUCRAID50 tamoxifen citrate27 sildenafil citrate (pulmonary sucralfate74 tamsulosin hcl54 hypertension)36 SUDAFED 24 HOUR65 SILPHEN COUGH22 TAPAZOLE72 SUDAFED CONGESTION65 SILVADENE46 SUDAFED NASAL TARCEVA27 silver sulfadiazine46 DECONGESTANT MAXIMUM TARGADOX72 simethicone53 STRENGTH65 TARGRETIN27 simvastatin23 sulfacetamide sod- TASIGNA27 prednisolone68 SINEMET28 sulfacetamide sodium45 TAVIST ALLERGY22 SINEMET CR28 SULFACETAMIDE TEGRETOL14 SINGULAIR10 SODIUM67 TEGRETOL-XR14 sirolimus61 sulfacetamide sodium temazepam56 (acne)44 SKLICE49 sulfacetamide sodium TEMOVATE46 SLO-NIACIN77 (ophth)67 TEMOVATE E47 SM CALAMINE49 SULFADIAZINE72 TENEX24 SM FISH OIL65 sulfamethoxazole- TENIVAC73 SM GLUCOSE19 trimethoprim8 tenofovir disoproxil fumarate32 sulfasalazine53 SM IRON55 TENORETIC 10025 sulindac3 SM OMEPRAZOLE74 TENORETIC 5025 sumatriptan59 SM ONE DAILY PRENATAL64 TENORMIN34 sumatriptan succinate59 SM PRENATAL VITAMINS64 TERAZOL 376 SUMATRIPTAN SM VITAMIN D3 MAXIMUM SUCCINATE59 TERAZOL 776 STRENGTH77 sumatriptan succinate59 terazosin hcl25 sodium chloride (inhalant)43 SUPER TWIN EPA/DHA65 terbinafine hcl21 sodium fluoride60 SUPRAX36 terbinafine hcl (topical)45 SODIUM FLUORIDE60 SUPRESS-PE PEDIATRIC42 TERCONAZOLE76 sodium phosphates57 terconazole vaginal76 sodium polystyrene SURMONTIL18 sulfonate61 SUSTIVA32 TESSALON PERLES39 SOLU-CORTEF39 SUTENT27 testosterone6 SOLU-MEDROL39 SW OMEPRAZOLE74 TESTOSTERONE6 sotalol hcl35 SYLATRON27 testosterone6 sotalol hcl (afib/afl)35 SYMAX DUOTAB73 testosterone cypionate6 SPACER/AEROCHAMBER58 SYMBICORT11 testosterone enanthate6 SPINOSAD49 SYMLINPEN 12018 TETANUS/DIPHTHERIA TOXOIDS-ADSORBED73 SPIRIVA HANDIHALER10 SYMLINPEN 6018 tetracycline hcl72 spironolactone51 SYNAGIS69 TETRACYCLINE HCL72 spironolactone & SYNTHROID72 TGT OMEPRAZOLE74 hydrochlorothiazide51 SYSTANE66 THALOMID61 SPRYCEL27 SYSTANE OVERNIGHT STARLIX20 THERAPY LUBRICANT theophylline11 stavudine32 EYE66 THERA-D 400077 STIMATE52 SYSTANE ULTRA66 THERANATAL CORE NUTRITION64 STIOLTO RESPIMAT11 SYSTANE ULTRA HOME & AWAY PACK66 THERAPEUTIC T+PLUS STRATTERA1 MAXIMUM STRENGTH48

Index 15 THERATEARS66 tranylcypromine sulfate15 TRUECONTROL GLUCOSE thiamine hcl77 TRAVATAN Z69 CONTROL LEVEL 058 TRUECONTROL GLUCOSE thioridazine hcl30 TRAVOPROST69 CONTROL LEVEL 158 thiothixene31 trazodone hcl17 TRUETEST BLOOD GLUCOSE THRIVITE 1964 TRETIN-X44 TEST50 TRUETEST BLOOD GLUCOSE THRIVITE RX64 tretinoin44 TEST STRIPS50 thyroid72 tretinoin (chemotherapy)27 TRUETEST GLUCOSE tiagabine hcl14 tretinoin microsphere44 CONTROLLEVEL 158 TIAZAC35 TRI-NORINYL 2838 TRUETEST GLUCOSE CONTROLLEVEL 258 TIGAN21 TRIADVANCE64 TRUETEST GLUCOSE TIKOSYN10 TRIAMCINOLONE CONTROLLEVEL 358 timolol maleate (ophth)66 ACETONIDE39 TRUETEST STRIPS50 triamcinolone acetonide TIMOLOL MALEATE TRUETRACK BLOOD (mouth)62 GLUCOSE TEST50 OPHTHALMIC GEL triamcinolone acetonide FORMING66 (nasal)65 TRUETRACK TEST50 TIMOPTIC66 triamcinolone acetonide TRUSOPT68 TIMOPTIC OCUDOSE66 (topical)47 TRUVADA32 TIMOPTIC-XE66 TRIAMCINOLONE TUMS7 ACETONIDE PF39 TINACTIN45 triamterene & TUMS CHEWY BITES7 TINACTIN DEODORANT45 hydrochlorothiazide51 TUMS CHEWY DELIGHTS7 TINACTIN JOCK ITCH45 TRIAMTERENE/HYDROCHLO TUMS E-X 7507 TIVICAY32 ROTHIAZIDE 51 TUMS EXTRA STRENGTH TRICARE64 tizanidine hcl64 7507 TRICODE GF42 TOBI2 TUMS KIDS7 TRICOR23 TOBRADEX68 TUMS LASTING EFFECTS7 trifluoperazine hcl31 tobramycin (ophth)67 TUMS SMOOTHIES7 trifluridine67 tobramycin-dexamethasone68 TUMS ULTRA 10007 TRIGLIDE23 TOBREX67 TUSICOF42 trihexyphenidyl hcl28 TOFRANIL18 TUSNEL C42 TRILEPTAL14 TOLAZAMIDE20 TUSSI-PRES PEDIATRIC42 trimethobenzamide hcl21 TOLBUTAMIDE20 TWINRIX75 trimethoprim8 TOLMETIN SODIUM3 TYBOST32 trimipramine maleate18 tolmetin sodium3 TYKERB27 TRINATAL GT64 TOLMETIN SODIUM3 TYLENOL4 TRINATAL RX 164 tolnaftate45 TYLENOL CHILDRENS4 TRIUMEQ32 TYLENOL EXTRA tolterodine tartrate75 TRIZIVIR32 STRENGTH4 TOPAMAX14 tropicamide67 TYLENOL INFANTS4 TOPAMAX SPRINKLE14 TYLENOL INFANTS trospium chloride75 topiramate14 PAIN+FEVER4 TRUE METRIX BLOOD TYLENOL/CODEINE #36 TOPROL XL34 GLUCOSETEST STRIPS49 torsemide51 TRUE METRIX CONTROL TYLENOL/CODEINE #46 TRACLEER36 SOLUTION LEVEL 158 TYVASO36 TRUE METRIX CONTROL TYVASO REFILL36 TRADJENTA19 SOLUTION LEVEL 258 tramadol hcl5 TRUE METRIX CONTROL TYVASO STARTER36 tramadol-acetaminophen6 SOLUTION LEVEL 358 TYZEKA34 TRUE METRIX SELF trandolapril24 ULORIC54 MONITORING BLOOD ULTRA OMEGA 365 TRANXENE T9 GLUCOSE STRIPS50

Index 16 ULTRA OMEGA-3 FISH OIL VIDEX EC33 XOLIDO48 BURP-LESS65 VIDEXPEDIATRIC33 XOPENEX11 ULTRACET6 VIGAMOX67 XOPENEX CONCENTRATE11 ULTRAM5 VIIBRYD17 XTAMPZA ER5 ULTRAVATE47 VIL-RX64 XTANDI27 UNISOM55 VIMPAT14 XYLOCAINE57 UNISOM SLEEPGELS55 VINATE M64 XYLOCAINE-MPF57 UNISOM SLEEPMELTS55 VINATE ONE64 YASMIN 2838 urea47 VIRACEPT33 YAZ38 URECHOLINE75 VIRAMUNE33 YODEFAN-NF CHEST URIN-TEK58 VIRAMUNE XR33 CONGESTION43 UROCIT-K 1054 ZACLIR CLEANSING44 VIREAD33 UROCIT-K 1554 ZADITOR69 VIROPTIC67 UROCIT-K 554 zafirlukast10 VIRT-ADVANCE64 URSO 25053 ZANAFLEX64 VIRT-VITE GT64 URSO FORTE53 ZANTAC74 VISTARIL9 ursodiol53 ZANTAC 150 MAXIMUM VITAFOL-OB64 VAGIFEM76 STRENGTH74 VITAMIN D277 ZANTAC 7574 valacyclovir hcl34 VITAMIN D377 ZARONTIN14 VALCYTE33 vitamin e77 ZEBETA34 valganciclovir hcl33 VITAMIN E77 ZEMAIRA71 VALIUM9 vitamin e77 ZENPEP50 valproate sodium15 VITEKTA33 ZERIT33 valproic acid15 VIVELLE-DOT52 ZESTORETIC25 valsartan24 VIVITROL20 valsartan-hydrochlorothiazide ZESTRIL24 25 VOL-PLUS64 ZETIA24 VALTREX34 VOL-TAB RX64 ZIAC25 VANCOCIN HCL8 VOLTAREN44 ZIAGEN33 vancomycin hcl8 VOTRIENT27 zidovudine33 VANCOMYCIN HCL + VYVANSE1 zinc oxide (topical)49 SYRSPENDSF PH48 WAL-SLEEP Z LIQUID ZIOPTAN69 VAQTA75 SHOTS55 ziprasidone hcl29 VARIVAX75 WALGREENS GLUCOSE19 ZITHROMAX57 VASERETIC25 warfarin sodium11 ZITHROMAX TRI-PAK57 VASOTEC24 WELLBUTRIN SR15 ZITHROMAX Z-PAK57 VELETRI36 WELLBUTRIN XL15 ZMAX57 VEMLIDY34 WESTHROID73 ZOCOR23 venlafaxine hcl17 WP THYROID73 ZOFRAN21 VENTAVIS36 XALATAN69 ZOFRAN ODT21 VENTOLIN HFA11 XALKORI27 ZOLINZA27 verapamil hcl35 XANAX9,10 zolmitriptan59 VERAPAMIL HCL SR35 XANAX XR10 ZOLOFT17 VERELAN35 XARELTO11 zolpidem tartrate56 VERELAN PM35 XARELTO STARTER PACK11 ZOMIG59 VIBRAMYCIN72 XODOL6 ZOMIG ZMT59 VICTOZA19 XOLEGEL45 ZONEGRAN14

Index 17 zonisamide14 ZORTRESS61 ZOVIRAX34,46 ZYBAN71 ZYLOPRIM54 ZYNCOF42 ZYPREXA30 ZYPREXA ZYDIS30 ZYRTEC ALLERGY22 ZYRTEC ALLERGY CHILDRENS22 ZYRTEC CHILDRENS ALLERGY22 ZYRTEC-D ALLERGY/CONGESTION42 ZYVOX8 ZZZQUIL56

Index 18