2015 Lististahan Ng Mga Sakop Na Gamot (Formulary)

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Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) 2015 Lististahan ng Mga Sakop na Gamot (Formulary)

Ini-update ang listahan ng gamot na ito noong 12/1/2015 . Kung mayroon kayong mga katanungan, mangyaring tawagan ang Health Net Cal MediConnect sa 1-855-464-3571 para sa Los Angeles County o sa 1-855-464-3572 para sa San Diego County, TTY: 711, 24 oras bawat araw, 7 araw bawat linggo. Libre ang tawag. Para sa karagdagang impormasyon, pumunta sa www.healthnet.com/calmediconnect.

Formulary ID: 15417 Version: 37 Material ID #H3237_2015_0095_A_TAG CMS Approved 09112014 Listahan ito ng mga gamot na makukuha ng mga miyembro sa Health Net Cal MediConnect. • "OH )FBMUI /FU $Bl MFEJ$POOFDU • :PV DBO HFU UIJT JOGPSNBUJPO GPS GSFF JO BZ JTBOH QMBOPOH QBOHLBMVTVHBO OB PUIFS MBOHVBHFT $BMM GPS OBLBLPOUSBUB TB .FEJDBSF BU .FEJ$BM -PT "OHFMFT $PVOUZ PS VQBOH NBHCJHBZ OH NHB CFOFQJTZP OH GPS 4BO %JFHP $PVOUZ 55: ThF DBMM LBQXBOH QSPHSBNB TB NHB OBLBFOSPM JT GSFF • "OH NHB #FOFQJTZP -JTUBIBO OH .HB 4BLPQ OB (BNPU NHB OFUXPSL OH UBHBQBHMBBO BUP NHB DPQBZNFOU BZ NBBBSJOH NBHCBHP QBOBQBOBIPO TB CVPOH UBPO BU TB &OFSP OH CBXBU UBPO • "OVNBOH PSBT BZ NBUJUJOHOBO NP POMJOF BOH OBTBTBQBOBIPOH -JTUBIBO OH .HB 4BLPQ OB (BNPU OH )FBMUI /FU $Bl .FEJ$POOFDU TB XXXIFBMUIOFUDPN DBMNFEJDPOOFDU P TB QBNBNBHJUBO OH QBHUBXBH TB QBSB TB -PT "OHFMFT $PVOUZ P TB QBSB TB 4BO %JFHP $PVOUZ 55: • .BBBSJ NPOH IJOHJO BOH JNQPSNBTZPO OB JUP TB JCBOH NHB BZPT UVMBE OH #SBJMMF P NBMBLJOH MFUSB 5VNBXBH TB QBSB TB -PT "OHFMFT $PVOUZ P TB QBSB TB 4BO %JFHP $PVOUZ 55: -JCSF BOg tBXBH

• .BBBSJOH QBJSBMJO BOH NHB MJNJUBTZPO DPQBZ BU SFTUSJLTZPO 1BSB TB LBSBHEBHBOH JNQPSNBTZPO UBXBHBO BOH )FBMUI /FU $Bl MFEJ$POOFDU .FNCFS 4FSWJDFT P CBTBIJO BOH )BOECPPL OH .JZFNCSP OH )FBMUI /FU $Bl MFEJ$POOFDU • "OH NHB DPQBZ QBSB TB NHB JOJSFTFUBOH HBNPU BZ NBBBSJOH NBHJCB CBUBZ TB BOUBT OH %BHEBH OB 5VMPOH OB JOZPOH OBUBUBOHHBQ .BOHZBSJOH NBLJQBH VHOBZBOBO TB QMBOP QBSB TB NHB EFUBMZF

Mga Madalas

*UBOPOH (FAQ)

.BHIBOBQ OH NHB TBHPU EJUP QBSB TB NHB UBOPOH OB NBZSPPO LB UVOHLPL TB -JTUBIBO

OH .HB 4BLPQ OB (BNPU OB JUP .BCBCBTB NP BOH MBIBU OH '"2 QBSB NBUVUP QB P NBHIBOBQ OH UBOPOH BU TBHPU

1. Ang mga de-resetang gamot ang nasa Listahan ng Mga Sakop na Gamot? (Tinatawag namin ang Listahan ng Mga Sakop na Gamot na maikling pangalang “Listahan ng Gamot”.) "OH NHB HBNPU TB -JTUBIBO OH (BNPU BZ BOH NHB HBNPU OB TBLPQ OH )FBMUI /FU $Bl MFEJ$POOFDU .BCJCJMJ BOH NHB HBNPU TB NHB QBSNBTZB TB MPPC OH BNJOH OFUXPSL "OH QBSNBTZB BZ OBTB OFUXPSL OBNJO LVOH NBZSPPO LBNJOH LBTVOEVBO TB LBOJMB OB NBHUSBCBIP OBOH LBTBNB LBNJ BU NBHMBBO OH NHB TFSCJTZP TB JZP 5JOVUVLPZ OBNJO BOH NHB QBSNBTZBOH JUP CJMBOH iNHB QBSNBTZB OH OFUXPSLw

4BTBLVQJO OH )FBMUI /FU $Bl MFEJ$POOFDU MBIBU OH NFEJLBM OB LBJMBOHBOH HBNPU TB -JTUBIBO OH (BNPU LVOH

• TJOBCJ OH JZPOH EPLUPS P OBHSFTFUB OB LBJMBOHBO NP JUP QBSB HVNBMJOH P NBOBUJMJOH NBMVTPH at • QJOVOBO NP BOH SFTFUB TB JTBOH QBSNBTZB OH OFUXPSL OH )FBMUI /FU $Bl MFEJ$POOFDU 4B JMBOH NHB LBTP NBZ LBJMBOHBO LBOH HBXJO CBHP LB NBLBLVIB OH HBNPU UJOHOBO BOH UBOPOH TB JCBCB .BUJUJOHOBO NP SJO TB BNJOH XFCTJUF BOH OBTBTBQBOBIPOH MJTUBIBO OH NHB HBNPU OB BNJOH TJOBTBLPQ TB XXXIFBMUIOFUDPN DBMNFEJDPOOFDU P UVNBXBH TB .FNCFS 4FSWJDFT TB QBSB TB -PT "OHFMFT $PVOUZ P TB QBSB TB 4BO %JFHP $PVOUZ 55:

ii 2. Nagbabago ba ang Listahan ng Gamot? • "OVNBOH PSBT BZ NBBBSJ NPOH 0P .BBBSJOH NBHEBHEBH P NBH UJOHOBO BOH POMJOF OB OBTBTBQBOBIPOH BMJT OH NHB HBNPU BOH )FBMUI /FU -JTUBIBO OH (BNPU OH )FBMUI /FU $Bl MFEJ$POOFDU TB -JTUBIBO OH (BNPU TB $Bl .FEJ$POOFDU TB XXXIFBMUIOFUDPN UBPO 4B QBOHLBMBIBUBO NBHCBCBHP MBOH DBMNFEJDPOOFDU .BBBSJ LB SJOH UVNBXBH BOH -JTUBIBO OH (BNPU LVOH TB .FNCFS 4FSWJDFT QBSB UJOHOBO BOH LBTBMVLVZBOH -JTUBIBO OH (BNPU TB • NBZSPPOH NBT NVSBOH HBNPU OB QBSB TB -PT "OHFMFT EVNBUJOH OB LBTJOHCJTB OH HBNPU OB $PVOUZ P TB QBSB TB OBTB -JTUBIBO OH (BNPU OHBZPO o 4BO %JFHP $PVOUZ 55: • OBMBNBO OBNJO OB IJOEJ MJHUBT BOH JTBOH HBNPU 3. Ano ang mangyayari kapag may mas .BBBSJ SJO OBNJOH CBHVIJO BOH NHB murang gamot na dumating na kasing- QBUBLBSBO OBNJO UVOHLPM TB NHB HBNPU bisa ng gamot na nasa Listahan ng )BMJNCBXB NBBBSJ LBNJOH Gamot ngayon? ,VOH VNJJOPN LB OH HBNPU OB JOBMJT EBIJM • .BHQBTZBOH JBUBT P IJOEJ JBUBT BOH NBZ NBT NVSBOH HBNPU OB LBTJOH CJTB QBVOBOH QBIJOUVMPU QBSB TB JTBOH HBNPU BOH EVNBUJOH TBTBCJIJO OBNJO TB JZP Ang paunang pahintulot BZ QBIJOUVMPU 4BTBCJIJO OBNJO TB JZP OBOH IJOEJ CBCBCB NVMB TB )FBMUI /FU $Bl MFEJ$POOFDU TB BSBX CBHP OBNJO JUP BMJTJO NVMB CBHP LB NBLBLVIB OH HBNPU TB -JTUBIBO OH (BNPU o LBQBH IVNJOHJ • .BHEBHEBH P NBHCBHP OH EBNJ OH LB OH SefiMM 1BHLBUBQPT BZ NBLBLBLVIB HBNPU OB NBLVLVIB NP UJOBUBXBH OB LB OH BSBX OB TVQQMZ OH HBNPU CBHP iNHB MJNJUBTZPO TB EBNJw BMJTJO BOH HBNPU NVMB TB MJTUBIBO OH HBNPU ,VOH HVNBXB LBNJ OH BOVNBOH • .BHEBHEBH P NBHCBHP OH NHB JCBOH OFHBUJCPOH QBHCBCBHP TB -JTUBIBO SFTUSJLTJZPO OH TUFQ UIFSBQZ TB JTBOH OH (BNPU QBEBEBMIBO LB OBNJO OH HBNPU "OH LBIVMVHBO OH step therapy MJIBN OB OBHTBTBCJ TB JZP UVOHLPM TB BZ LBJMBOHBOJO NPOH TVCVLBO BOH JTBOH NHB QBHCBCBHPOH JUP *MBMBHBZ EJO OBNJO HBNPU CBHP OBNJO TBTBLVQJO BOH JCBOH BOH NHB QBHCBCBHP TB BNJOH XFCTJUF TB HBNPU XXXIFBMUIOFUDPNDBMNFEJDPOOFDU 1BSB TB EBHEBH OB JNQPSNBTZPO TB NHB QBUBLBSBO TB HBNPU OB JUP UJOHOBO BOH 4. Ano ang mangyayari kapag nalaman QBIJOB JW naming hindi ligtas ang isang gamot? ,VOH TJOBCJ OH 'PPE BOE %SVH 4BTBCJIJO OBNJO TB JZP LBQBH BOH HBNPU OB "ENJOJTUSBUJPO '%" OB IJOEJ MJHUBT BOH JOJJOPN NP BZ JOBMJT NVMB TB -JTUBIBO OH HBNPU OB JOJJOPN NP BBMJTJO OBNJO JUP (BNPU 4BTBCJIJO EJO OBNJO TB JZP LBQBH BHBE TB -JTUBIBO OH (BNPU .BHQBQBEBMB CJOBHP OBNJO BOH NHB QBUBLBSBO OBNJO TB EJO LBNJ OH TVMBU TB JZP OB JZBO BOH QBHTBLPQ OH JTBOH HBNPU "OH NHB UBOPOH TJOBTBCJ ,VOH NBLBUBOHHBQ LB OH JTB TB BU TB JCBCB BZ NBZ NBT NBSBNJOH NHB MJIBN OB JUP NBOHZBSJOH UBXBHBO BOH JNQPSNBTZPO UVOHLPM TB LVOH BOP BOH EPLUPS NP QBSB QBHVTBQBO BOH NHB JCBOH NBOHZBZBSJ LBQBH OBHCBHP BOH -JTUBIBO PQTZPO TB HBNPU Og GaNPU

? Kung mayroon kayong mga katanungan, mangyaring tawagan ang Health Net Cal MediConnect sa 1-855-464-3571 para sa Los Angeles County o sa 1-855-464-3572 para sa San Diego County, TTY: 711, 24 oras bawat araw, 7 araw bawat linggo. Libre ang tawag. Para sa karagdagang impormasyon, pumunta sa www.healthnet.com/ calmediconnect. iii 5. Mayroon bang anumang restriksiyon • ,VOH JLBX BZ OBTB JTBOH OVSTJOH IPNF o limitasyon sa sakop sa gamot? O P JCBOH QBTJMJEBE TB QBOHNBUBHBMBOH may anubang inaatas na pagkilos na QBHBBMBHB BU LBJMBOHBO OH HBNPU OB XBMB gagawin upang makuha ang ilang mga TB -JTUBIBO OH (BNPU P LVOH IJOEJ NP gamot? NBEBMJOH NBLVIB BOH LBJMBOHBO NPOH 0P BOH JMBOH NHB HBNPU BZ NBZ NHB HBNPU NBLBLBUVMPOH LBNJ 4BTBLVQJO QBUBLBSBO TB TBLPQ P NBZ NHB MJNJUBTZPO OBNJO BOH BSBX OB FNFSIFOTJZBOH TB EBNJ OH NBLVLVIB NP 4B JMBOH NHB TVQQMZ OH LBJMBOHBO OJOZPOH HBNPU LBTP NBZ EBQBU LBOH HBXJO CBHP NP NBMJCBO LVOH NBZSPPO LBOH HBNPU NBLVIB BOH HBNPU )BMJNCBXB QBSB TB JMBOH BSBX JLBX NBO BZ CBHPOH NJZFNCSP P IJOEJ OH )FBMUI /FU • Paunang pag-apruba (o paunang $Bl MFEJ$POOFDU #JCJHZBO LB OJUP OH pahintulot): 1BSB TB JMBOH NHB HBNPU PSBT QBSB NBLJQBHVTBQ TB JZPOH EPLUPS JLBX P BOH JZPOH EPLUPS P JCBOH P JCBOH OBHSFSFTFUB .BUVUVMVOHBO LB OBHSFTFUB BZ EBQBU LVNVIB OH QBIJOUVMPU OJZBOH NBHEFTJTZPO LVOH NBZSPPOH NVMB TB )FBMUI /FU $Bl MFEJ$POOFDU LBUVMBE OB HBNPU TB -JTUBIBO OH (BNPU CBHP NP QVOBO BOH JZPOH SFTFUB ,BQBH OB NBBBSJ NPOH JOVNJO TB IBMJQ P IJOEJ LB OBLBLVIB BOH QBIJOUVMPU LVOH IJIJMJOH OH IJOEJ QBHTBTBNB NBBBSJOH IJOEJ TBLVQJO OH )FBMUI /FU .BOHZBSJOH UJOHOBO BOH 5BOPOH QBSB $Bl MFEJ$POOFDU BOH HBNPU TB LBSBHEBHBOH JNQPSNBTZPO UVOHLPM TB • Mga limitasyon sa dami: .JOTBO NHB IJOEJ LBTBNB OJMJMJNJUB OH )FBMUI /FU $Bl MFEJ$POOFDU BOH EBNJ OH HBNPU OB NBLVLVIB NP 6. Paano mo malalaman kung ang • Step therapy: .JOTBO BBUBTBO LB OH ninanais mong gamot ay mayroong )FBMUI /FU $Bl MFEJ$POOFDU OB HVNBXB mga limitasyon o kung mayroong mga OH TUFQ UIFSBQZ /BOHBOHBIVMVHBO JUP OB kailangang gawin na pagkilos para LBLBJMBOHBOJO NPOH TVCVLBO BOH NHB makuha ang gamot? HBNPU TB QBSUJLVMBS OB QBHLBLBTVOPE "OH -JTUBIBO OH NHB 4BLPQ OB (BNPU TB TVOPE QBSB TB JZPOH NFEJLBM OB QBIJOB BZ NBZ IBOBZ OB NBZ NBSLBOH LBMBHBZBO .BBBSJOH LBJMBOHBOJO NPOH i.HB LJOBLBJMBOHBOH QBHLJMPT QBHIJIJHQJU TVCVLBO BOH JTBOH HBNPU CBHP OBNJO P MJNJUBTZPO TB QBHHBNJUw TBTBLVQJO BOH JCBOH HBNPU ,VOH TB QBMBHBZ OH EPLUPS NP BZ IJOEJ HVNBHBOB 7. Ano ang mangyayari kung babaguhin BOH VOBOH HBNPU QBSB TB JZP TBTBLVQJO namin ang aming mga tuntunin sa OBNJO BOH QBOHBMBXB kung paano namin sinasakop ang .BMBMBNBO NP LVOH BOH HBNPU NP BZ ilan sa mga gamot? Halimbawa, NBZ BOVNBOH NHB LBSBHEBHBOH JOBBUBT kung magdadagdag kami ng P NHB MJNJUBTZPO TB QBNBNBHJUBO OH paunang pahintulot (pag-apruba), QBHUJOHJO TB NHB UBMBIBOBZBO TB QBIJOB o mga limitasyon sa dami at/o mga *OEJTF .BLBLBLVIB LB SJO OH IJHJU QBOH paghihigpit ng step therapy sa isang JNQPSNBTZPO TB QBNBNBHJUBO OH QBHCJTJUB gamot. TB BNJOH XFCTJUF TB XXXIFBMUIOFUDPN 4BTBCJIJO OBNJO TB JZP LVOH NBHEBEBHEBH DBMNFEJDPOOFDU /BHQBTLJM LBNJ OH NHB LBNJ OH QBVOBOH QBHBQSVCB NHB POMJOF OB EPLVNFOUP OB OBHQBQBMJXBOBH MJNJUBTZPO TB EBNJ BUP NHB QBHIJIJHQJU TB BNJOH QBVOBOH QBIJOUVMPU BU NHB OH TUFQ UIFSBQZ TB JTBOH HBNPU 4BTBCJIJO SFTUSJLTJZPO TB TUFQ UIFSBQZ .BBBSJ NP SJO OBNJO TB JZP OBOH IJOEJ CBCBCB TB BSBX LBNJOH IJMJOHBO OB QBEBMIBO LB OH LPQZB CBHP JEBHEBH BOH QBHIJIJHQJU P TB TVTVOPE OB IVNJOHJ LB OH SefiMM TB JZPOH QBSNBTZB .BBBSJ LB SJOH IVNJOHJ OH iQBHXBXBMBZw P 1BHLBUBQPT NBBBSJ LBOH NBLBLVIB OH IJOEJ QBHTBNB NVMB TB NHB MJNJUBTZPOH JUP BSBX OB TVQQMZ OH HBNPU CBHP HBXJO BOH .BOHZBSJOH UJOHOBO BOH 5BOPOH QBSB QBHCBCBHP TB NHB UVOUVOJO OH QBHTBLPQ TB IJHJU QBOH JNQPSNBTZPO TB NHB IJOEJ #JOJCJHZBO LB OJUP OB PSBT QBSB NBLJQBH QBHTBNB VTBQ TB JZPOH EPLUPS P JCBOH OBHSFSFTFUB UVOHLPM TB LVOH BOP BOH TVTVOPE OB EBQBU HBXJO iv 8. Paano ka makakahanap ng gamot sa QBHTBTBNB QBSB TBLVQJO BOH JZPOH Listahan ng Gamot? HBNPU .BOHZBSJOH UJOHOBO BOH 5BOPOH .BZ EBMBXBOH QBSBBO QBSB NBHIBOBQ OH QBSB TB LBSBHEBHBOH JNQPSNBTZPO HBNPU UVOHLPM TB NHB IJOEJ LBTBNB • .BBBSJ LBOH NBHIBOBQ OBOH OBLBBZPT TB BMQBCFUP LVOH BMBN NP LVOH QBBOP 10. Paano kung isa kang bagong CBZCBZJO BOH HBNPU o miyembro ng Health Net Cal MediConnect at hindi mahanap • .BBBSJ LBOH NBHIBOBQ TB QBNBNBHJUBO ang iyong gamot sa Listahan ng OH NFEJLBM OB LPOEJTZPO Gamot o mayroong problema sa 1BSB NBHIBOBQ OBOH nakaayos sa pagkuha ng iyong gamot? alpabeto TB TFLTZPO OH -JTUBIBO OB .BLBLBUVMPOH LBNJ .BBBSJ OBNJO /BLBBZPT TB "MQBCFUP .BIBIBOBQ NP TBLVQJO BOH QBOTBNBOUBMBOH BSBX JUP TB *OEJTF OB OBHTJTJNVMB TB QBIJOB OB TVQQMZ OH JZPOH HBNPU TB QBOBIPO *OEJTF 1BSB NBHIBOBQ sa pamamagitan OH VOBOH BSBX OB NJZFNCSP LBZP OH ng medikal na kondisyon IBOBQJO BOH )FBMUI /FU $Bl MFEJ$POOFDU #JCJHZBO LB TFLTZPO OB NBZ NBSLBOH i-JTUBIBO OH NHB OJUP OH PSBT QBSB NBLJQBHVTBQ TB JZPOH HBNPU BZPO TB NFEJLBM OB LPOEJTZPOw TB EPLUPS P JCBOH OBHSFSFTFUB .BUVUVMVOHBO QBIJOB 1BHLBUBQPT IBOBQJO BOH JZPOH LB OJZBOH NBHEFTJTZPO LVOH NBZSPPOH NFEJLBM OB LPOEJTZPO )BMJNCBXB LVOH LBUVMBE OB HBNPU TB -JTUBIBO OH (BNPU NBZSPPO LBOH LBSBNEBNBO TB QVTP OB NBBBSJ NPOH JOVNJO TB IBMJQ P LVOH LBJMBOHBO NPOH NBHIBOBQ TB LBUFHPSZBOH IJIJMJOH OH IJOEJ QBHTBTBNB JZPO %PPO NP NBIBIBOBQ BOH NHB 4BTBLVQJO OBNJO BOH BSBX OB TVQQMZ OH HBNPU OB HVNBHBNPU TB NHB LBSBNEBNBO JZPOH HBNPU LVOH Ta pVTP • VNJJOPN LB OH HBNPU OB XBMB TB BNJOH 9. Paano kung ang gamot na gusto mong -JTUBIBO OH (BNPU o inumin ay wala sa Listahan ng Gamot? • IJOEJ LB QJOBQBZBHBO OH NHB UVOUVOJO ,VOH IJOEJ NP NBLJLJUB BOH JZPOH HBNPU OH QMBOPOH QBOHLBMVTVHBO OB NBLVIB TB -JTUBIBO OH (BNPU UBXBHBO BOH BOH EBNJ OB JOVUPT OH OBHSFSFTFUB TB JZP .FNCFS 4FSWJDFT TB QBSB TB o -PT "OHFMFT $PVOUZ P QBSB • BOH HBNPU BZ OBOHBOHBJMBOHBO OH TB 4BO %JFHP $PVOUZ 55: BU UBOVOHJO QBVOBOH QBHBQSVCB OH )FBMUI /FU BOH UVOHLPM EJUP ,VOH NBMBMBNBO $Bl MFEJ$POOFDU o NP OB IJOEJ TBTBLVQJO OH )FBMUI /FU $Bl MFEJ$POOFDU BOH HBNPU NBBBSJ NPOH • VNJJOPN LB OH HBNPU OB CBIBHJ OH HBXJO BOH JTB TB NHB CBHBZ OB JUP QBHIJIJHQJU OH TUFQ UIFSBQZ • )VNJOHJ OH MJTUBIBO OH NHB HBNPU ,VOH OBLBUJSB LB TB JTBOH OVSTJOH IPNF TB .FNCFS 4FSWJDFT LBUVMBE OH JTB OB P JCBOH QBTJMJEBE QBSB TB QBOHNBUBHBMBOH HVTUP NPOH JOVNJO 1BHLBUBQPT JQBLJUB QBOHBOHBMBHB NBBBSJ NPOH JQBSefiMM BOH MJTBIBO TB JZPOH EPLUPS P JCBOH BOH JOZPOH HBNPU OH LBTJOH IBCB OH OBHSFSFTFUB .BBBSJ TJZBOH NBHSFTFUB BSBX .BBBSJ NPOH JQBSefiMM BOH HBNPU OH HBNPU OB OBTB -JTUBIBO OH (BNPU OB OBOH NBSBNJOH CFTFT TB QBOBIPO OH LBUVMBE OH JTB OB HVTUP NPOH JOVNJO O BSBX #JOJCJHZBO OJUP OH QBOBIPO BOH OBHSFSFTFUB TB JZP OB QBMJUBO BOH NHB • .BBBSJ NPOH IJMJOHJO TB QMBOPOH HBNPU NP OH NHB OBTB -JTUBIBO OH (BNPU QBOHLBMVTVHBO OB HVNBXB OH IJOEJ P IVNJMJOH OH IJOEJ QBHTBTBNB

11. Maaari ka bang humingi ng hindi 14. Ano ang mga generic na gamot? pagsasama para sakupin ang iyong Ang mga generic na gamot BZ CJOVCVP OH gamot? QBSFIPOH NHB TBOHLBQ LBUVMBE OH NHB 0P .BBBSJ NPOH IJMJOHJO TB )FBMUI /FU HBNPU OB NBZ UBUBL ,BSBOJXBO NBT NVSB $Bl MFEJ$POOFDU OB HVNBXB OH IJOEJ BOH NHB JUP LBZTB TB HBNPU OB NBZ UBUBL QBHTBTBNB QBSB TBLVQJO BOH HBNPU OB XBMB BU BOH LBOJMBOH NHB QBOHBMBO BZ IJOEJ TB -JTUBIBO OH (BNPU NBTZBEPOH LJMBMB "OH NHB HFOFSJD OB HBNPU BZ BQSVCBEP OH 'PPE BOE %SVH .BBBSJ NP SJOH IJMJOHJO TB BNJO OB "ENJOJTUSBUJPO '%" CBHVIJO BOH NHB UVOUVOJO TB JZPOH HBNPU 4JOBTBLPQ OH )FBMUI /FU $Bl MFEJ$POOFDU • )BMJNCBXB NBBBSJOH MJNJUBIBO OH BOH QBSFIPOH NHB HBNPU OB NBZ UBUBL BU )FBMUI /FU $Bl MFEJ$POOFDU BOH EBNJ HFOFSJD OH HBNPU OB BNJOH TBTBLVQJO ,VOH NBZ MJNJUBTZPO BOH JZPOH HBNPU NBBBSJ NPOH IJMJOHJO TB BNJO OB CBHVIJO BOH MJNJUBTZPO BU EBHEBHBO BOH QBHTBLPQ • *CBOH NHB IBMJNCBXB .BBBSJ NPOH IJMJOHJO TB BNJO OB BMJTJO BOH NHB QBHIJIJHQJU OH TUFQ UIFSBQZ P NHB QBOHBOHBJMBOHBO OH QBVOBOH QBH BQSVCB

vi 15. Ano ang mga OTC na gamot? 17. Ano ang iyong co-pay? "OH OTC BZ OBOHBOHBIVMVHBOH .BBBSJ NPOH CBTBIJO BOH -JTUBIBO OH iPWFSUIFDPVOUFSw (BNPU OH )FBMUI /FU $Bl MFEJ$POOFDU QBSB NBMBNBO BOH UVOHLPM TB DPQBZ QBSB 4JOBTBLPQ OH )FBMUI /FU $Bl MFEJ$POOFDU TB CBXBU HBNPU BOH JMBOH NHB 05$ OB HBNPU LBQBH JTJOVMBU BOH NHB JUP OH JOZPOH UBHBQBHMBBO "OH NHB NJZFNCSP OH )FBMUI /FU CJMBOH NHB SFTFUB $Bl MFEJ$POOFDU OB OBLBUJSB TB NHB OVSTJOH IPNF P JCBOH NHB QBTJMJEBE QBSB .BBBSJ NPOH CBTBIJO BOH -JTUBIBO OH TB QBOHNBUBHBMBOH QBOHBOHBMBHB BZ XBMBOH (BNPU OH )FBMUI /FU $Bl MFEJ$POOFDU NHB DPQBZ "OH JMBOH NHB NJZFNCSP QBSB NBLJUB LVOH BOVBOPOH NHB 05$ OB OB OBLBLBLVIB OH QBOHNBUBHBMBOH HBNPU BOH TJOBTBLPQ QBOHBOHBMBHB TB LPNVOJEBE BZ XBMB SJOH NHB DPQBZ 16. Sakop ba ng Health Net Cal MediConnect ang mga OTC na "OH NHB DPQBZ BZ OBLBMJTUB TB BZPO TB hindi gamot na produkto? NHB BOUBT "OH NHB "OUBT BZ NHB QBOHLBU 4JOBTBLPQ OH )FBMUI /FU $Bl MFEJ$POOFDU OH HBNPU OB NBZ QBSFIPOH DPQBZ BOH JMBOH NHB 05$ OB IJOEJ HBNPU OB • "OH NHB HBNPU OB OBTB "OUBT BZ NBZ QSPEVLUP LBQBH JTJOVMBU BOH NHB JUP OH NBCBCBOH DPQBZ "OH NHB JUP BZ NHB JOZPOH UBHBQBHMBBO CJMBOH NHB SFTFUB HFOFSJD OB HBNPU "OH DPQBZ BZ NVMB .BBBSJ NPOH CBTBIJO BOH -JTUBIBO OH IBOHHBOH %FQFOEF JUP TB (BNPU OH )FBMUI /FU $Bl MFEJ$POOFDU JZPOH BOUBT OH QBHTBLPQ OH .FEJ$BM QBSB NBLJUB LVOH BOVBOPOH NHB 05$ OB • "OH NHB HBNPU OB OBTB "OUBT BZ NBZ HBNPU BOH TJOBTBLPQ NBT NBUBBT OB DPQBZ "OH NHB JUP BZ NHB HBNPU OB NBZ UBUBL "OH DPQBZ BZ NVMB IBOHHBOH %FQFOEF JUP TB JZPOH BOUBT OH QBHTBLPQ OH .FEJ$BM • "OH NHB HBNPU OB OBTB "OUBT BZ NBZ OB DPQBZ "OH NHB JUP BZ NHB JOJSFTFUB BU 05$ OB HBNPU OB TJOBTBLPQ OH .FEJ$BM

Mga Ano ang kahulugan Paano ito gumagana Pagpapaikli nito "- Limitasyon ng Edad Ang ilang mga gamot ay maaaring kailangan ng paunang pahintulot kung hindi umabot ang edad mo sa gabay ng gumawa ng gamot, ng FDA o klinika. #% Medicare Bahagi B Ang ilang mga gamot at nangangailangan ng vs. Bahagi D paunang pahintulot para magpasya kung ang gamot ay dapat sakupin sa ilalim ng Medicare Bahagi B o Bahagi D. Ito ay patakaran ng Medicare. Ang doktor mo o ang ibang nagreseta ay maaaring kailangang magbigay ng mas marami pang katotohanan para tulungan kaming gawin ang pasyang ito. (- Limitasyon sa Ang ilang mga gamot ay maaaring ligtas lang Kasarian sa mga lalaki o mga babae. -" Limitadong Access Ang ilang mga gamot ay maaaring mahanap lang sa isa o sa ilang mga parmasya, dahil: t/JMJMJNJUBOH'%"BOHHBNPUTBJMBOHNHB pasilidad, parmasya o mga nagrereseta, o t"OHJMBOHNHBHBNPUBZOBOHBOHBJMBOHBO ng espesyal na pag-aalaga o pagsasanay sa pasyente na hindi maibibigay sa tingiang parmasya. Dapat mong kausapin ang iyong doktor o ibang nagrereseta tungkol sa pagkuha ng ilang gamot na limitado ang access. .0 Mail Order Makukuha mo ang gamot na ito sa mail order na parmasya ng Health Net Cal MediConnect.

viii Mga Ano ang kahulugan Paano ito gumagana Pagpapaikli nito /' Hindi Sakop Hindi sakop ang gamot na ito sa Listahan ng Gamot. Maaari kang humingi ng hindi pagsama para masakop ang gamot. /5 Hindi Bahagi D Ang gamot na ito ay hindi isang “Bahagi D na gamot.” Ang halagang binabayad mo kapag pinunan mo ang reseta sa gamot na ito ay hindi mabibilang patungo sa mga kabuuan mong gastos sa gamot (iyon ay, ang halagang binabayad mo ay hindi nakakatulong na maging kwalipikado ka para sa sakop sa sakuna). 1" Paunang Pahintulot Para sa ilang mga gamot, ikaw o ang iyong doktor ay dapat kumuha ng pahintulot mula sa Health Net Cal MediConnect bago mo punan ang iyong reseta. Kapag hindi ka nakakuhan ang pahintulot, maaaring hindi namin sakupin ang gamot. 2- Limitasyon sa Dami Minsan, nililimita ng Health Net Cal MediConnect ang dami ng gamot na makukuha mo. 3905$ Reseta at OTC Ang ilang mga gamot ay ginagawa sa kapwa de-resetang uri at OTC na uri. 45 Step Therapy Minsan, pagagawin ka ng Health Net Cal MediConnect ng step therapy. Nangangahulugan ito na kakailanganin mong subukan ang mga gamot sa partikular na pagkakasunod-sunod para sa iyong medikal na kalagayan. Maaaring kailanganin mong subukan ang isang gamot bago namin sasakupin ang ibang gamot. Kung sa palagay ng doktor mo ay hindi gumagana ang unang gamot para sa iyo, sasakupin namin ang pangalawa.

x List of drugs by medical condition What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) ADHD/ANTI-NARCOLEPSY/ANTI- $0 PA; MO; NT OBESITY/ANOREXIANTS - Drugs to Treat phentermine hcl (Tier ADHD, Sleep and Eating Disorders 3) $0 PA; NT Amphetamines QSYMIA (Tier ADDERALL XR (Use MO 3) NF Amphetamine- $0 PA; MO; NT Dextroamphetamine) REGIMEX (Tier $0- MO 3) amphetamine- $2.65 $0 PA; MO; NT dextroamphetamine (Tier SUPRENZA (Tier 1) 3) DESOXYN (Use NF MO Methamphetamine HCl) Anti-Obesity Agents DEXEDRINE 10 MG,15 MO $0 PA; NT ALLI (Tier MG,5 MG (Use NF Dextroamphetamine 3) Sulfate) $0 PA; MO; NT $0- MO BELVIQ (Tier dextroamphetamine sulfate $2.65 3) cp24 10 mg, 15 mg, 5 mg (Tier $0 PA; MO; NT 1) CONTRAVE (Tier $0- MO 3) dextroamphetamine sulfate $2.65 $0 PA; MO; NT tabs 10 mg, 5 mg (Tier SAXENDA (Tier 1) 3) $0- MO Attention-Deficit/Hyperactivity Disorder (ADHD) $2.65 methamphetamine hcl $0- MO (Tier $2.65 1) clonidine hcl (adhd) (Tier Anorexiants Non-Amphetamine 1) ADIPEX-P (Use PA; MO; NT $0- AL; MO NF $2.65 Phentermine HCl) guanfacine hcl (adhd) $0 PA; MO; NT (Tier diethylpropion hcl tabs 25 (Tier 1) mg 3) $0- AL; MO DIETHYLPROPION HCL PA; MO; NT INTUNIV (Use Guanfacine $6.60 TABS 25 MG (Use NF HCl (ADHD)) (Tier Diethylpropion HCl) 2) $0 PA; MO; NT KAPVAY (Use Clonidine NF MO diethylpropion hcl tb24 75 (Tier HCl (ADHD)) mg 3)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

1 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- PA; MO $6.60 $2.65 STRATTERA (Tier modafinil (Tier 2) 1) Stimulants - Misc. PROVIGIL (Use Modafinil) NF PA; MO CONCERTA 27 MG, 36 MO MG (Use Methylphenidate NF RITALIN (Use NF MO HCl) Methylphenidate HCl) $0- MO RITALIN LA 20 MG, 30 MO dexmethylphenidate hcl $2.65 MG, 40 MG (Use NF cp24 15 mg (Tier Methylphenidate HCl) 1) $0- $6.60 $0- MO RITALIN LA 60 MG dexmethylphenidate hcl $2.65 (Tier tabs 10 mg, 2.5 mg, 5 mg (Tier 2) 1) RITALIN SR (Use NF MO Methylphenidate HCl) FOCALIN (Use NF MO Dexmethylphenidate HCl) ALTERNATIVE MEDICINES FOCALIN XR 15 MG (Use NF MO Dexmethylphenidate HCl) Alternative Medicine - A's METADATE CD (Use MO $0 NT NF ALPHA LIPOIC ACID (Tier Methylphenidate HCl) CAPS OR 50 MG $0- MO 3) methylphenidate hcl cp24 $2.65 $0 NT or 20 mg, 30 mg, 40 mg (Tier ALPHA-LIPOIC ACID (Tier 1) 3) $0- MO $0 MO; NT methylphenidate hcl cpcr or alpha-lipoic acid (thioctic (Tier $2.65 acid) caps 100 mg 10 mg, 20 mg, 30 mg, 40 (Tier 3) mg, 50 mg, 60 mg 1) Alternative Medicine - C's $0- MO $0 NT methylphenidate hcl tabs or $2.65 CHEW Q 100 MG (Tier 10 mg, 20 mg, 5 mg (Tier 3) 1) coenzyme q10 $0 NT $0- MO (ubidecarenone) caps 10 (Tier methylphenidate hcl tb24 $2.65 mg, 60 mg 3) or 27 mg, 36 mg (Tier 1) coenzyme q10 $0 MO; NT (ubidecarenone) caps 150 (Tier $0- MO mg, 30 mg 3) methylphenidate hcl tbcr or $2.65 $0 20 mg, 27 mg, 36 mg (Tier COENZYME Q10 CHEW NT 1) (Tier OR 60 MG 3) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

2 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0- MO COENZYME Q10 TABS (Tier gentamicin in saline 0.9%- $2.65 OR 25 MG 3) 0.8mg/ml (Tier 1) Alternative Medicine - G's $0- $0 MO; NT gentamicin in saline 0.9%- glucosamine sulfate caps (Tier $2.65 or 500 mg 1.2mg/ml, 0.9%-1.6mg/ml, (Tier 3) 0.9%-1mg/ml 1) $0 NT glucosamine sulfate tabs or (Tier $0- MO 500 mg 3) gentamicin sulfate soln ij 40 $2.65 mg/ml (Tier Alternative Medicine - L's 1) $0 NT $0- lutein caps or 6 mg (Tier gentamicin sulfate soln iv $2.65 3) 10 mg/ml (Tier 1) Alternative Medicine Combinations $0- $0 NT MO glucosamine-chondroitin (Tier $2.65 caps 200mg-250mg neomycin sulfate tabs or (Tier 3) 1) $0 MO; NT glucosamine-chondroitin (Tier $0- MO tabs 200mg-250mg $2.65 3) paromomycin sulfate (Tier $0 NT 1) LIQ-10 50MG/5ML- (Tier 15UNIT/5ML 3) TOBI (Use Tobramycin) NF B/D VITALINE $0 NT $0- COQ10/VITAMIN E (Tier $6.60 100MG-300UNIT 3) TOBI PODHALER (Tier AMINOGLYCOSIDES - Drugs to Treat Bacterial 2) Infections $0- B/D Aminoglycosides $2.65 tobramycin nebu in (Tier $0- MO 1) amikacin sulfate soln ij 1 $2.65 $0- gm/4ml, 500 mg/2ml (Tier tobramycin sulfate soln ij MO 1) $2.65 1.2 gm/30ml, 40 mg/ml, 80 (Tier $0- B/D mg/2ml 1) $6.60 BETHKIS (Tier $0- 2) tobramycin sulfate soln ij $2.65 10 mg/ml (Tier 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

3 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- $0- PA tobramycin sulfate solr ij $2.65 $6.60 1.2 gm (Tier OTREXUP (Tier 1) 2) ANALGESICS - ANTI-INFLAMMATORY - Drugs $0- PA $6.60 to Treat Pain, Swelling, Muscle and Joint RASUVO Conditions (Tier 2) Anti-TNF-alpha - Monoclonal Antibodies Gold Compounds $0- PA $6.60 $0- MO HUMIRA $6.60 (Tier RIDAURA 2) (Tier 2) $0- PA HUMIRA PEDIATRIC $6.60 Interleukin-1 Blockers CROHNS DISEASE (Tier STARTER PACK $0- LA 2) $6.60 ARCALYST $0- PA (Tier $6.60 2) HUMIRA PEN (Tier Interleukin-1 Receptor Antagonist (IL-1Ra) 2) $0- PA $0- PA $6.60 HUMIRA PEN-CROHNS $6.60 KINERET (Tier DISEASESTARTER (Tier 2) 2) $0- PA Interleukin-1beta Blockers HUMIRA PEN-PSORIASIS $6.60 $0- LA $6.60 STARTER (Tier ILARIS 2) (Tier $0- PA 2) $6.60 SIMPONI Interleukin-6 Receptor Inhibitors (Tier $0- PA 2) $6.60 $0- PA ACTEMRA (Tier $6.60 2) SIMPONI ARIA (Tier 2) Nonsteroidal Anti-inflammatory Agents (NSAIDs) MO; NT Antirheumatic - Enzyme Inhibitors ADVIL (Use Ibuprofen) NF $0- PA ADVIL MIGRAINE (Use NF MO; NT $6.60 Ibuprofen) XELJANZ (Tier 2) ALEVE CAPS (Use NF NT Naproxen Sodium) Antirheumatic Antimetabolites You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

4 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- ANAPROX (Use Naproxen NF MO MO Sodium) $2.65 diclofenac w/ misoprostol (Tier ANAPROX DS (Use NF MO Naproxen Sodium) 1) EC-NAPROSYN (Use MO ARTHROTEC 50 (Use NF MO NF Diclofenac w/ Misoprostol) Naproxen) $0- MO ARTHROTEC 75 (Use NF MO Diclofenac w/ Misoprostol) etodolac caps or 200 mg, $2.65 300 mg (Tier CATAFLAM (Use NF MO 1) Diclofenac Potassium) $0- MO $0- MO etodolac tabs or 400 mg, $2.65 CELEBREX (Use $6.60 500 mg (Tier Celecoxib) (Tier 1) 2) $0- MO $0- MO etodolac tb24 or 400 mg, $2.65 $2.65 celecoxib 500 mg, 600 mg (Tier (Tier 1) 1) MO $0 NT FELDENE (Use Piroxicam) NF CHILDRENS MOTRIN (Tier CHEW 50 MG 3) $0- MO flurbiprofen tabs or 100 mg, $2.65 CHILDRENS MOTRIN MO; NT 50 mg (Tier JUNIOR STRENGTH (Use NF 1) Ibuprofen) $0 MO; NT CHILDRENS MOTRIN NT ibuprofen caps or 200 mg (Tier SUSP 40 MG/ML (Use NF 3) ) Ibuprofen $0 MO; NT DAYPRO (Use Oxaprozin) NF MO ibuprofen chew or 100 mg (Tier 3) $0- MO $0- RX/OTC; MO $2.65 diclofenac potassium ibuprofen susp or 100 $2.65 (Tier mg/5ml (Tier 1) 1) $0- MO $0 NT diclofenac sodium tb24 or $2.65 ibuprofen susp or 40 (Tier 100 mg (Tier mg/ml, 50 mg/1.25ml 3) 1) $0 NT $0- MO ibuprofen tabs or 100 mg (Tier diclofenac sodium tbec or $2.65 3) 25 mg, 50 mg, 75 mg (Tier 1) $0 MO; NT ibuprofen tabs or 200 mg (Tier 3) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

5 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- QL(8 ea daily); MOBIC TABS 15 MG, 7.5 NF MO $2.65 MO MG (Use Meloxicam) ibuprofen tabs or 400 mg (Tier MOTRIN INFANTS (Use NF NT 1) Ibuprofen) $0- QL(5 ea daily); MOTRIN INFANTS NF NT $2.65 MO DROPS (Use Ibuprofen) ibuprofen tabs or 600 mg (Tier 1) MOTRIN JUNIOR MO; NT STRENGTH CHEW (Use NF $0- QL(4 ea daily); Ibuprofen) $2.65 MO ibuprofen tabs or 800 mg (Tier MOTRIN JUNIOR NT 1) STRENGTH TABS (Use NF Ibuprofen) $0- AL; MO indomethacin caps or 25 $2.65 $0- MO $2.65 mg, 50 mg (Tier nabumetone 1) (Tier 1) $0- AL; MO indomethacin cpcr or 75 $2.65 NAPROSYN (Use NF MO mg (Tier Naproxen) 1) $0 NT naproxen sodium caps or (Tier INFANTS ADVIL (Use NF NT 220 mg Ibuprofen) 3) $0- MO $0- MO ketoprofen caps or 50 mg, $2.65 naproxen sodium tabs or $2.65 75 mg (Tier 275 mg, 550 mg (Tier 1) 1) $0- AL; MO $0- MO ketorolac tromethamine $2.65 naproxen tabs or 250 mg, $2.65 soln ij 15 mg/ml, 30 mg/ml (Tier 375 mg, 500 mg (Tier 1) 1) $0- AL; MO $0- MO ketorolac tromethamine $2.65 naproxen tbec or 375 mg, $2.65 soln im 30 mg/ml, 60 (Tier 500 mg (Tier mg/2ml 1) 1) $0- MO $0- MO $2.65 $2.65 oxaprozin mefenamic acid caps or (Tier (Tier 1) 1) $0- MO $0- MO meloxicam tabs or 15 mg, $2.65 piroxicam caps or 10 mg, $2.65 7.5 mg (Tier 20 mg (Tier 1) 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

6 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) PONSTEL (Use Mefenamic MO $0- PA NF $6.60 Acid) ENBREL SURECLICK $0- MO (Tier sulindac tabs or 150 mg, $2.65 2) 200 mg (Tier ANALGESICS - NonNarcotic - Drugs to Treat 1) Pain, Muscle and Joint Conditions $0- MO tolmetin sodium caps 400 $2.65 Analgesic Combinations $0 mg (Tier acetaminophen-caffeine- NT 1) (Tier pyrilamine 3) $0- MO tolmetin sodium tabs 200 $2.65 $0 NT mg (Tier BIPHENOX (Tier 1) 3) MIDOL COMPLETE NT VOLTAREN-XR (Use NF MO Diclofenac Sodium) 500MG-15MG-60MG (Use NF Acetaminophen-Caffeine- Phosphodiesterase 4 (PDE4) Inhibitors Pyrilamine) $0- PA MIDOL MAXIMUM NT $6.60 OTEZLA STRENGTH MENSTRUAL NF (Tier (Use Acetaminophen- 2) Caffeine-Pyrilamine) Pyrimidine Synthesis Inhibitors MIDOL MAXIMUM NT MO STRENGTH MENSTRUAL ARAVA (Use Leflunomide) NF FORMULA (Use NF $0- MO Acetaminophen-Caffeine- leflunomide tabs or 10 mg, $2.65 Pyrilamine) 20 mg (Tier Analgesics Other 1) $0 NT acetaminophen chew or (Tier Selective Costimulation Modulators 160 mg $0- PA 3) $6.60 $0 MO; NT ORENCIA acetaminophen chew or 80 (Tier (Tier mg 2) 3) Soluble Tumor Necrosis Factor Receptor Agents $0 NT acetaminophen elix or 160 (Tier $0- PA mg/5ml, 80 mg/2.5ml 3) $6.60 ENBREL $0 (Tier acetaminophen liqd or 160 MO; NT 2) (Tier mg/5ml 3) acetaminophen soln or 100 $0 MO; NT mg/ml, 160 mg/5ml, 80 (Tier mg/0.8ml 3) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

7 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0 MO; NT acetaminophen supp re (Tier aspirin buffered (cal carb- (Tier 120 mg 3) mag carb-mag oxide) 3) $0 MO; NT $0 NT acetaminophen susp or (Tier ASPIRIN SUPP RE 120 (Tier 160 mg/5ml, 80 mg/2.5ml 3) MG, 200 MG 3) $0 NT $0 NT acetaminophen susp or 80 (Tier aspirin supp re 300 mg, (Tier mg/0.8ml 3) 600 mg 3) $0 MO; NT $0 MO; NT acetaminophen tbdp or 160 (Tier aspirin tabs or 325 mg (Tier mg 3) 3) $0 NT $0 NT acetaminophen tbdp or 80 (Tier aspirin tabs or 81 mg (Tier mg 3) 3) $0 NT $0 MO; NT ELIXSURE FEVER/PAIN (Tier aspirin tbec or 324 mg, 325 (Tier 3) mg, 500 mg, 81 mg 3) $0 NT BUFFERIN (Use Aspirin MO; NT FEVERALL INFANTS (Tier Buffered (Cal Carb-Mag NF 3) Carb-Mag Oxide)) TYLENOL CHILDRENS NF MO; NT $0- MO (Use Acetaminophen) $2.65 diflunisal TYLENOL MO; NT (Tier 1) CHILDRENS/FLAVORCRE NF ATOR (Use ECOTRIN MAXIMUM NF MO; NT Acetaminophen) STRENGTH (Use Aspirin) TYLENOL INFANTS 160 MO; NT ECOTRIN REGULAR NF MO; NT MG/5ML (Use NF STRENGTH (Use Aspirin) Acetaminophen) ANALGESICS - OPIOID - Drugs to Treat Pain, TYLENOL INFANTS 80 NT Muscle and Joint Conditions MG/0.8ML (Use NF Acetaminophen) Opioid Agonists TYLENOL JR MO; NT ACTIQ 1200 MCG, 1600 PA; QL(4 ea MELTAWAYS (Use NF MCG, 400 MCG, 600 MCG, NF daily); MO Acetaminophen) 800 MCG (Use Fentanyl Citrate) Salicylates ACTIQ 200 MCG (Use NF PA; QL(6 ea $0 NT Fentanyl Citrate) daily); MO ASCRIPTIN (Tier 3) DEMEROL SOLN IJ 100 MO MG/ML, 50 MG/ML (Use NF Meperidine HCl)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

8 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) DEMEROL SOLN IJ 25 $0- QL(0.7 ea $2.65 MG/ML (Use Meperidine NF fentanyl 25 mcg/hr daily); MO HCl) (Tier DILAUDID LIQD OR 1 QL(30 ml 1) MG/ML (Use NF daily); MO $0- QL(0.74 ea $2.65 Hydromorphone HCl) fentanyl 50 mcg/hr daily); MO $0- MO (Tier DILAUDID SOLN IJ 2 $6.60 1) MG/ML (Tier $0- QL(0.61 ea 2) $2.65 daily); MO fentanyl 75 mcg/hr (Tier DILAUDID TABS OR 2 MG NF QL(29 ea (Use Hydromorphone HCl) daily); MO 1) $0- PA; QL(4 ea DILAUDID TABS OR 4 MG NF QL(14 ea fentanyl citrate lpop bu (Use Hydromorphone HCl) daily); MO $2.65 daily); MO 1200 mcg, 1600 mcg, 400 (Tier mcg, 600 mcg, 800 mcg DILAUDID TABS OR 8 MG NF QL(7 ea daily); 1) (Use Hydromorphone HCl) MO $0- PA; QL(6 ea DILAUDID-HP SOLN 10 MO fentanyl citrate lpop bu 200 $2.65 daily); MO MG/ML (Use NF mcg (Tier Hydromorphone HCl) 1) DOLOPHINE 10 MG (Use NF QL(19 ea $0- QL(30 ml Methadone HCl) daily); MO hydromorphone hcl liqd or $2.65 daily); MO DOLOPHINE 5 MG (Use NF QL(38 ea 1 mg/ml (Tier Methadone HCl) daily); MO 1) DURAGESIC 100 MCG/HR NF QL(1 ea daily); $0- MO (Use Fentanyl) MO hydromorphone hcl soln ij $2.65 10 mg/ml, 2 mg/ml, 50 (Tier DURAGESIC 12 MCG/HR NF QL(1.44 ea mg/5ml, 500 mg/50ml (Use Fentanyl) daily); MO 1) $0- QL(29 ea DURAGESIC 25 MCG/HR NF QL(0.7 ea (Use Fentanyl) daily); MO hydromorphone hcl tabs or $2.65 daily); MO 2 mg (Tier DURAGESIC 50 MCG/HR NF QL(0.74 ea (Use Fentanyl) daily); MO 1) $0- QL(14 ea DURAGESIC 75 MCG/HR NF QL(0.61 ea (Use Fentanyl) daily); MO hydromorphone hcl tabs or $2.65 daily); MO 4 mg (Tier $0- QL(1 ea daily); 1) $2.65 MO fentanyl 100 mcg/hr (Tier $0- QL(7 ea daily); 1) hydromorphone hcl tabs or $2.65 MO 8 mg (Tier $0- QL(1.44 ea 1) $2.65 daily); MO fentanyl 12 mcg/hr (Tier 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

9 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- PA; QL(2 ea $0- QL(40 ml HYSINGLA ER 100 MG, $6.60 daily) methadone hcl soln or 5 $2.65 daily); MO 120 MG (Tier mg/5ml (Tier 2) 1) $0- PA; QL(2 ea $0- QL(19 ea HYSINGLA ER 20 MG, 30 $6.60 daily); MO methadone hcl tabs or 10 $2.65 daily); MO MG, 40 MG, 60 MG, 80 MG (Tier mg (Tier 2) 1) $0- KADIAN 100 MG (Use NF QL(6 ea daily); QL(38 ea Morphine Sulfate) MO methadone hcl tabs or 5 $2.65 daily); MO KADIAN 20 MG, 30 MG, 50 QL(5 ea daily); mg (Tier MG, 60 MG, 80 MG (Use NF MO 1) Morphine Sulfate) METHADOSE 10 MG/ML NF QL(4 ml daily); $0- PA; QL(6 ea (Use Methadone HCl) MO $6.60 daily); MO METHADOSE SUGAR- QL(4 ml daily); LAZANDA 100 MCG/ACT (Tier FREE (Use Methadone NF MO 2) HCl) $0- PA; QL(4 ea $0- QL(6 ea daily); $6.60 daily) morphine sulfate cp24 or $2.65 MO LAZANDA 400 MCG/ACT (Tier 100 mg (Tier 2) 1) $0- $0- MO morphine sulfate cp24 or QL(5 ea daily); meperidine hcl soln ij 100 $2.65 $2.65 MO mg/ml, 50 mg/ml (Tier 20 mg, 30 mg, 50 mg, 60 (Tier 1) mg, 80 mg 1) $0- $0- meperidine hcl soln ij 25 $2.65 morphine sulfate soln ij 0.5 $2.65 mg/ml (Tier mg/ml (Tier 1) 1) $0- AL; MO $0- MO meperidine hcl soln or 50 $2.65 morphine sulfate soln ij 1 $2.65 mg/5ml (Tier mg/ml (Tier 1) 1) $0- QL(4 ml daily); $0- QL(60 ml methadone hcl conc or 10 $2.65 MO morphine sulfate soln or 10 $2.65 daily); MO mg/ml (Tier mg/5ml (Tier 1) 1) $0- QL(20 ml $0- QL(6 ml daily); methadone hcl soln or 10 $2.65 daily); MO morphine sulfate soln or $2.65 MO mg/5ml (Tier 100 mg/5ml, 20 mg/ml (Tier 1) 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

10 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- QL(30 ml $0- QL(15 ea morphine sulfate soln or 20 $2.65 daily); MO oxycodone hcl tabs or 30 $2.65 daily); MO mg/5ml (Tier mg (Tier 1) 1) $0- QL(8 ea daily); $0- QL(17 ea MORPHINE SULFATE $6.60 MO $2.65 daily); MO TABS OR 15 MG (Tier oxycodone hcl tabs or 5 mg (Tier 2) 1) $0- QL(14 ea $0- QL(4 ea daily); MORPHINE SULFATE $6.60 daily); MO oxymorphone hcl tabs 10 $2.65 MO TABS OR 30 MG (Tier mg (Tier 2) 1) $0- $0- morphine sulfate tbcr or MO QL(8 ea daily); $2.65 $2.65 MO 100 mg, 200 mg, 30 mg, 60 (Tier oxymorphone hcl tabs 5 mg (Tier mg 1) 1) $0- QL(8 ea daily); $0- QL(2.67 ea morphine sulfate tbcr or 15 $2.65 MO oxymorphone hcl tb12 15 $2.65 daily); MO mg (Tier mg (Tier 1) 1) MS CONTIN 100 MG, 200 MO $0- QL(5 ea daily); MG, 30 MG, 60 MG (Use NF oxymorphone hcl tb12 7.5 $2.65 MO Morphine Sulfate) mg (Tier 1) MS CONTIN 15 MG (Use NF QL(8 ea daily); Morphine Sulfate) MO ROXICODONE 15 MG NF QL(11 ea (Use Oxycodone HCl) daily); MO OPANA TABS OR 10 MG NF QL(4 ea daily); (Use Oxymorphone HCl) MO ROXICODONE 30 MG NF QL(15 ea (Use Oxycodone HCl) daily); MO OPANA TABS OR 5 MG NF QL(8 ea daily); (Use Oxymorphone HCl) MO ROXICODONE 5 MG (Use NF QL(17 ea $0- QL(17 ea Oxycodone HCl) daily); MO oxycodone hcl caps or 5 $2.65 daily); MO $0- PA; QL(6 ea mg (Tier SUBSYS 100 MCG, 200 $6.60 daily); MO 1) MCG (Tier $0- QL(4 ml daily); 2) oxycodone hcl conc or 100 $2.65 MO $0- PA; QL(4 ea mg/5ml, 20 mg/ml (Tier SUBSYS 1200 MCG, 1600 $6.60 daily) 1) MCG (Tier $0- QL(11 ea 2) oxycodone hcl tabs or 15 $2.65 daily); MO $0- PA; QL(4 ea mg (Tier SUBSYS 400 MCG, 600 $6.60 daily); MO 1) MCG, 800 MCG (Tier 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

11 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- QL(8 ea daily); hydrocodone- QL(184 ml $2.65 $0- tramadol hcl tabs or 50 mg MO acetaminophen soln $2.65 daily); MO (Tier 2.5mg/5ml-108mg/5ml, 1) (Tier 5mg/10ml-217mg/10ml, 1) $0- QL(3 ea daily); 7.5mg/15ml-325mg/15ml tramadol hcl tb24 or 100 $2.65 MO hydrocodone- $0- QL(13 ea mg (Tier acetaminophen tabs 10mg- $2.65 daily); MO 1) 300mg, 5mg-300mg, (Tier $0- QL(1 ea daily); 7.5mg-300mg 1) tramadol hcl tb24 or 200 $2.65 MO hydrocodone- $0- QL(12 ea mg, 300 mg (Tier acetaminophen tabs 10mg- $2.65 daily); MO 1) 325mg, 5mg-325mg, (Tier 7.5mg-325mg 1) ULTRAM (Use Tramadol NF QL(8 ea daily); HCl) MO $0- MO $2.65 ULTRAM ER 100 MG (Use NF QL(3 ea daily); hydrocodone-ibuprofen Tramadol HCl) MO (Tier 1) ULTRAM ER 200 MG, 300 NF QL(1 ea daily); MG (Use Tramadol HCl) MO $0- QL(61 ml daily) oxycodone w/ $2.65 $0- acetaminophen soln ZOHYDRO ER C12A 10 PA; QL(2 ea (Tier $6.60 daily); MO 5mg/5ml-325mg/5ml 1) MG, 15 MG, 20 MG, 30 (Tier MG, 40 MG, 50 MG 2) oxycodone w/ $0- QL(12 ea acetaminophen tabs 10mg- $2.65 daily); MO $0- ZOHYDRO ER CP12 10 PA; QL(2 ea 325mg, 2.5mg-325mg, (Tier $6.60 daily) 5mg-325mg, 7.5mg-325mg 1) MG, 15 MG, 20 MG, 30 (Tier MG, 40 MG, 50 MG 2) $0- MO $2.65 Opioid Combinations oxycodone-aspirin (Tier $0- QL(166 ml 1) acetaminophen w/ codeine $2.65 daily); MO PERCODAN (Use NF MO soln 120mg/5ml-12mg/5ml (Tier Oxycodone-Aspirin) 1) $0- QL(12 ea $0- QL(13 ea $2.65 daily); MO acetaminophen w/ codeine $2.65 tramadol-acetaminophen tabs 300mg-15mg, 300mg- daily); MO (Tier (Tier 1) 30mg, 300mg-60mg 1) ULTRACET (Use NF QL(12 ea $0- AL; MO Tramadol-Acetaminophen) daily); MO butalbital-aspirin-caffeine $2.65 w/cod (Tier VICOPROFEN (Use NF MO 1) Hydrocodone-Ibuprofen) FIORINAL/CODEINE #3 AL; MO Opioid Partial Agonists (Use Butalbital-Aspirin- NF BUPRENEX (Use NF MO Caffeine w/Cod) Buprenorphine HCl)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

12 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO buprenorphine hcl soln ij $2.65 oxandrolone tabs or 10 mg, $2.65 0.3 mg/ml (Tier 2.5 mg (Tier 1) 1) $0- PA; QL(16 ea Androgens buprenorphine hcl subl sl 2 $2.65 daily); MO $0- GL; MO mg (Tier $6.60 1) ANDRODERM (Tier $0- PA; QL(4 ea 2) buprenorphine hcl subl sl 8 $2.65 daily); MO $0- GL; MO mg (Tier ANDROGEL 20.25 $6.60 1) MG/1.25GM,40.5 (Tier $0- MG/2.5GM buprenorphine hcl- PA; QL(16 ea 2) $2.65 daily); MO naloxone hcl dihydrate (Tier $0- GL; MO 2mg-0.5mg ANDROGEL 25 $6.60 1) MG/2.5GM,50 MG/5GM (Tier $0- (Use Testosterone) buprenorphine hcl- PA; QL(4 ea 2) $2.65 daily); MO naloxone hcl dihydrate (Tier $0- GL; MO 8mg-2mg $6.60 1) ANDROGEL PUMP (Tier $0- MO 2) butorphanol tartrate soln ij $2.65 $0- LA 2 mg/ml (Tier $6.60 1) AVEED (Tier $0- QL(4.2 ml 2) butorphanol tartrate soln na $2.65 daily); MO $0- 10 mg/ml (Tier MO 1) danazol caps or 100 mg, $2.65 200 mg, 50 mg (Tier $0- MO 1) nalbuphine hcl soln ij 10 $2.65 $0- mg/ml, 20 mg/ml (Tier $2.65 1) fluoxymesterone tabs or (Tier ANDROGENS-ANABOLIC - Drugs to Regulate 1) Hormones $0- GL; MO Anabolic Steroids $6.60 TESTIM (Tier $0- MO 2) $6.60 ANADROL-50 (Tier $0- MO 2) $2.65 testosterone cypionate (Tier OXANDRIN (Use NF MO 1) Oxandrolone)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

13 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO Rectal Products - Misc. testosterone enanthate $2.65 (Tier $0 MO; NT soln im starch (topical) (Tier 1) 3) $0- TESTOSTERONE GEL TD GL; MO $6.60 TUCKS (Use Starch NF MO; NT 1 %, 25 MG/2.5GM, 50 (Tier (topical)) MG/5GM 2) Rectal Steroids $0- GL; MO $0- MO testosterone gel td 25 $2.65 $2.65 mg/2.5gm, 50 mg/5gm (Tier hydrocortisone (rectal) (Tier 1) 1) $0- GL; MO PROCTOCORT CREA 1 % MO $6.60 TESTOSTERONE PUMP (Use Hydrocortisone NF (Tier (Rectal)) 2) Vasodilating Agents $0- GL; MO $6.60 $0- MO VOGELXO $6.60 (Tier RECTIV 2) (Tier 2) $0- GL; MO $6.60 ANTACIDS - Ulcer and Stomach Acid Drugs VOGELXO PUMP (Tier 2) Antacid Combinations ANORECTAL AGENTS - Rectal Drugs to Treat $0 NT Pain, Swelling and Itching ALMACONE (Tier 3) Intrarectal Steroids alum & mag hydrox- $0 NT CORTENEMA (Use MO simethicone chew 200mg- (Tier Hydrocortisone NF 25mg-200mg 3) (Intrarectal)) alum & mag hydrox- MO; NT $0- MO simethicone liqd $0 $2.65 hydrocortisone (intrarectal) 200mg/5ml-20mg/5ml- (Tier (Tier 200mg/5ml, 400mg/5ml- 3) 1) 40mg/5ml-400mg/5ml $0- UCERIS FOAM RE 2 $6.60 MG/ACT (Tier 2) Rectal Combinations $0 NT phenylephrine-shark liver (Tier oil-glycerin-petrolatum 3) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

14 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) alum & mag hydrox- MO; NT MAALOX (Use Calcium NF NT simethicone susp Carbonate (Antacid)) 200mg/5ml-200mg/5ml- TUMS (Use Calcium NF MO; NT 20mg/5ml-20mg/5ml- Carbonate (Antacid)) 200mg/5ml-200mg/5ml, $0 200mg/5ml-20mg/5ml- (Tier TUMS E-X 750 (Use MO; NT 200mg/5ml, 400mg/5ml- 3) Calcium Carbonate NF 400mg/5ml-40mg/5ml- (Antacid)) 40mg/5ml-400mg/5ml- TUMS KIDS (Use Calcium NF MO; NT 400mg/5ml, 400mg/5ml- Carbonate (Antacid)) 40mg/5ml-400mg/5ml TUMS LASTING EFFECTS MO; NT $0 NT (Use Calcium Carbonate NF aluminum hydroxide-mag (Tier (Antacid)) trisil 3) TUMS SMOOTHIES 750 MO; NT GELUSIL 200MG-25MG- NT MG (Use Calcium NF 200MG (Use Alum & Mag NF Carbonate (Antacid)) Hydrox-Simethicone) ANTHELMINTICS - Drugs to Treat Worm HYVEE ADVANCED MO; NT Infections ANTACID MAXIMUM NF STRENGTH (Use Alum & Anthelmintics Mag Hydrox-Simethicone) $0- MO $6.60 MYLANTA DOUBLE- MO; NT ALBENZA STRENGTH (Use Alum & NF (Tier Mag Hydrox-Simethicone) 2) MYLANTA SUSP MO; NT $0- MO $2.65 200MG/5ML-20MG/5ML- NF ivermectin tabs or 200MG/5ML (Use Alum & (Tier Mag Hydrox-Simethicone) 1) $0- MO Antacids - Aluminum Salts STROMECTOL (Use $6.60 $0 NT Ivermectin) (Tier ALUMINUM HYDROXIDE (Tier 2) 3) ANTI-INFECTIVE AGENTS - MISC. - Drugs to Antacids - Calcium Salts Treat Bacterial Infections $0 MO; NT Anti-infective Agents - Misc. calcium carbonate (Tier (antacid) 500 mg, 750 mg 3) AZACTAM (Use NF MO Aztreonam) $0 NT calcium carbonate (Tier $0- MO (antacid) 600 mg 3) $2.65 aztreonam (Tier $0 MO; NT 1) CALCIUM CARBONATE (Tier TABS OR 648 MG 3)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

15 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- VANCOCIN HCL (Use PA; MO $6.60 NF CAYSTON Vancomycin HCl) (Tier $0- PA; MO 2) vancomycin hcl caps or $2.65 $0- MO 125 mg, 250 mg (Tier $2.65 colistimethate sodium solr ij 1) (Tier $0- 1) VANCOMYCIN HCL IN $6.60 COLY-MYCIN M (Use NF MO DEXTROSE (Tier Colistimethate Sodium) 2) $0- FLAGYL (Use NF MO Metronidazole) vancomycin hcl solr iv 10 $2.65 $0- MO gm, 1000 mg, 5000 mg (Tier metronidazole caps or 375 $2.65 1) mg (Tier $0- MO 1) vancomycin hcl solr iv 500 $2.65 $0- mg (Tier $2.65 1) metronidazole in nacl (Tier $0- MO $6.60 1) XIFAXAN $0- MO (Tier metronidazole tabs or 250 $2.65 2) mg, 500 mg (Tier Anti-infective Misc. - Combinations 1) BACTRIM (Use MO $0- MO; B/D Sulfamethoxazole- NF $6.60 Trimethoprim) NEBUPENT (Tier 2) BACTRIM DS (Use MO Sulfamethoxazole- NF $0- MO Trimethoprim) $6.60 PENTAM 300 (Tier $0- MO 2) sulfamethoxazole- $2.65 trimethoprim (Tier TINDAMAX (Use NF MO 1) Tinidazole) Antiprotozoal Agents $0- MO tinidazole tabs or 250 mg, $2.65 $0- MO $6.60 500 mg (Tier ALINIA TABS 500 MG 1) (Tier 2) $0- MO $2.65 $0- MO trimethoprim tabs or $2.65 (Tier atovaquone 1) (Tier 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

16 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) MEPRON (Use NF MO CLEOCIN CAPS OR 150 MO Atovaquone) MG, 300 MG, 75 MG (Use NF Clindamycin HCl) Carbapenems $0- MO CLEOCIN IN D5W (Use $2.65 Clindamycin Phosphate in NF imipenem-cilastatin (Tier D5W) 1) CLEOCIN PHOSPHATE IJ MO $0- MO 600 MG/4ML, 900 MG/6ML NF $6.60 (Use Clindamycin INVANZ IJ (Tier Phosphate) 2) CLEOCIN PHOSPHATE IV $0- MO 300MG/50ML-5%, $2.65 600MG/50ML-5%, NF meropenem (Tier 900MG/50ML-5% (Use 1) Clindamycin Phosphate in D5W) MERREM (Use NF MO Meropenem) $0- MO clindamycin hcl caps or 150 $2.65 PRIMAXIN IV (Use NF MO mg, 300 mg, 75 mg (Tier Imipenem-Cilastatin) 1) Chloramphenicols $0- MO $0- clindamycin palmitate $2.65 chloramphenicol sodium $2.65 hydrochloride (Tier succinate (Tier 1) 1) $0- clindamycin phosphate in $2.65 Cyclic Lipopeptides d5w (Tier $0- 1) $6.60 CUBICIN (Tier $0- 2) clindamycin phosphate soln $2.65 ij 150 mg/ml, 9000 mg/60ml (Tier Glycylcyclines 1) $0- $0- MO $6.60 TYGACIL clindamycin phosphate soln $2.65 (Tier ij 600 mg/4ml, 900 mg/6ml (Tier 2) 1) Leprostatics $0- $0- MO clindamycin phosphate soln $2.65 dapsone tabs or 100 mg, $2.65 iv 150 mg/ml, 600 mg/4ml (Tier 25 mg (Tier 1) 1) Lincosamides

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

17 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- $6.60 $6.60 LINCOCIN (Tier SYNERCID (Tier 2) 2) Oxazolidinones ANTIANGINAL AGENTS - Drugs to Treat Chest $0- Pain $2.65 Antianginals-Other linezolid soln iv 2 mg/ml (Tier 1) $0- PA; MO $6.60 $0- MO RANEXA (Tier $2.65 2) linezolid tabs or 600 mg (Tier 1) Nitrates $0- ISORDIL TITRADOSE 5 MO $6.60 MG (Use Isosorbide NF SIVEXTRO SOLR IV (Tier Dinitrate) 2) $0- MO $0- MO isosorbide dinitrate tabs or $2.65 $6.60 10 mg, 20 mg, 30 mg, 5 mg (Tier SIVEXTRO TABS OR (Tier 1) 2) $0- MO $0- isosorbide dinitrate tbcr or $2.65 ZYVOX SOLN IV 2 MG/ML $6.60 40 mg (Tier (Use Linezolid) (Tier 1) 2) $0- MO $0- MO isosorbide mononitrate tabs $2.65 ZYVOX SUSR OR 100 $6.60 10 mg, 20 mg (Tier MG/5ML (Tier 1) 2) $0- MO $0- MO isosorbide mononitrate $2.65 ZYVOX TABS OR 600 MG $6.60 tb24 120 mg, 30 mg, 60 mg (Tier (Use Linezolid) (Tier 1) 2) NITRO-DUR 0.1 MG/HR, MO Polymyxins 0.2 MG/HR, 0.4 MG/HR, NF 0.6 MG/HR (Use $0- Nitroglycerin) $2.65 polymyxin b sulfate solr ij (Tier $0- MO 1) NITROGLYCERIN $6.60 LINGUAL (Tier Streptogramins 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

18 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- AL; MO nitroglycerin pt24 td 0.1 $2.65 hydroxyzine pamoate caps $2.65 mg/hr, 0.2 mg/hr, 0.4 (Tier or 25 mg, 50 mg (Tier mg/hr, 0.6 mg/hr 1) 1) $0- MO VISTARIL (Use NF AL; MO nitroglycerin soln tl 0.4 $2.65 Hydroxyzine Pamoate) mg/spray (Tier 1) Benzodiazepines NITROLINGUAL MO $0- MO PUMPSPRAY (Use NF alprazolam tabs or 0.25 $2.65 Nitroglycerin) mg, 0.5 mg, 1 mg, 2 mg (Tier 1) $0- MO $6.60 $0- MO NITROMIST (Tier alprazolam tb24 or 0.5 mg, $2.65 1 mg, 2 mg, 3 mg (Tier 2) 1) $0- MO $6.60 $0- MO NITROSTAT (Tier alprazolam tbdp or 0.25 $2.65 mg, 0.5 mg, 1 mg, 2 mg (Tier 2) 1) ANTIANXIETY AGENTS - Drugs to Treat Anxiety ATIVAN SOLN IJ 2 MG/ML NF MO (Use Lorazepam) Antianxiety Agents - Misc. ATIVAN SOLN IJ 4 MG/ML $0- NF buspirone hcl tabs or 10 MO (Use Lorazepam) $2.65 ATIVAN TABS OR 0.5 MG, MO mg, 15 mg, 30 mg, 5 mg, (Tier 7.5 mg 1 MG, 2 MG (Use NF 1) Lorazepam) $0- AL; MO $0- MO hydroxyzine hcl soln im 25 $2.65 $2.65 mg/ml, 50 mg/ml (Tier clorazepate dipotassium (Tier 1) 1) $0- AL; MO $0- MO hydroxyzine hcl soln or 10 $2.65 $2.65 mg/5ml (Tier diazepam conc or 5 mg/ml (Tier 1) 1) $0- AL; MO $0- MO hydroxyzine hcl syrp or 10 $2.65 $2.65 mg/5ml (Tier diazepam soln or 1 mg/ml (Tier 1) 1) $0- AL; MO $0- MO hydroxyzine hcl tabs or 10 $2.65 diazepam tabs or 10 mg, 2 $2.65 mg, 25 mg, 50 mg (Tier mg, 5 mg (Tier 1) 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

19 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO $2.65 quinidine gluconate tbcr or $2.65 lorazepam conc or 2 mg/ml (Tier 324 mg (Tier 1) 1) $0- MO $0- MO lorazepam soln ij 2 mg/ml, $2.65 $2.65 20 mg/10ml (Tier quinidine sulfate (Tier 1) 1) $0- Antiarrhythmics Type I-B $2.65 lorazepam soln ij 4 mg/ml $0- MO (Tier $2.65 1) mexiletine hcl (Tier $0- MO 1) lorazepam tabs or 0.5 mg, $2.65 1 mg, 2 mg (Tier Antiarrhythmics Type I-C 1) $0- QL(4 ea daily); $2.65 MO NIRAVAM (Use NF MO flecainide acetate 100 mg Alprazolam) (Tier 1) $0- MO $2.65 $0- QL(2 ea daily); oxazepam $2.65 (Tier flecainide acetate 150 mg MO 1) (Tier 1) TRANXENE T (Use NF MO Clorazepate Dipotassium) $0- QL(8 ea daily); $2.65 MO VALIUM (Use Diazepam) NF MO flecainide acetate 50 mg (Tier 1) MO XANAX (Use Alprazolam) NF $0- MO $2.65 XANAX XR (Use NF MO propafenone hcl Alprazolam) (Tier 1) ANTIARRHYTHMICS - Drugs to treat abnormal RYTHMOL (Use NF MO heart rhythms Propafenone HCl) Antiarrhythmics Type I-A RYTHMOL SR (Use NF MO $0- AL; MO Propafenone HCl) $2.65 Antiarrhythmics Type III disopyramide phosphate (Tier 1) $0- MO amiodarone hcl tabs or 100 $2.65 NORPACE (Use NF AL; MO mg, 200 mg, 400 mg (Tier Disopyramide Phosphate) 1) CORDARONE (Use NF MO Amiodarone HCl)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

20 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- 60 $6.60 $6.60 MULTAQ SPIRIVA RESPIMAT 1.25 actuations;QL( (Tier MCG/ACT (Tier 0.14 gm daily) 2) 2) $0- $0- 60 $6.60 TIKOSYN SPIRIVA RESPIMAT 2.5 $6.60 actuations;QL( (Tier MCG/ACT (Tier 0.14 gm daily); 2) 2) MO ANTIASTHMATIC AND BRONCHODILATOR $0- 28 AGENTS - Drugs to Treat Lung Conditions SPIRIVA RESPIMAT 2.5 $6.60 actuations;QL( MCG/ACT (Tier 0.28 gm daily); Anti-Inflammatory Agents 2) MO $0- MO; B/D $0- QL(0.04 ea $2.65 cromolyn sodium nebu in $6.60 daily); MO (Tier TUDORZA PRESSAIR (Tier 1) 2) Antiasthmatic - Monoclonal Antibodies Leukotriene Modulators $0- PA; LA ACCOLATE (Use NF MO $6.60 Zafirlukast) XOLAIR (Tier 2) $0- MO montelukast sodium chew $2.65 Asthma and Bronchodilator Agent Combinations 4 mg, 5 mg (Tier $0 NT 1) dyphylline-guaifenesin (Tier $0- MO 3) montelukast sodium tabs $2.65 Bronchodilators - Anticholinergics 10 mg (Tier 1) $0- QL(0.86 gm $6.60 daily); MO SINGULAIR CHEW 4 MG, MO ATROVENT HFA (Tier 5 MG (Use Montelukast NF 2) Sodium) $0- QL(1 ea daily); SINGULAIR TABS 10 MG NF MO $6.60 MO (Use Montelukast Sodium) INCRUSE ELLIPTA (Tier $0- MO $2.65 2) zafirlukast $0- MO; B/D (Tier $2.65 1) ipratropium bromide soln in (Tier Selective Phosphodiesterase 4 (PDE4) Inhibitors 1) $0- QL(1 ea daily); $0- QL(1 ea daily); $6.60 MO $6.60 DALIRESP SPIRIVA HANDIHALER MO (Tier (Tier 2) 2) Steroid Inhalants You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

21 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- QL(0.6 gm $0- MO $6.60 daily); MO $6.60 AEROSPAN (Tier ADVAIR DISKUS (Tier 2) 2) $0- QL(1 ea daily); $0- QL(4 gm daily); $6.60 MO $6.60 MO ARNUITY ELLIPTA (Tier ADVAIR HFA (Tier 2) 2) $0- MO; B/D $0- MO; B/D budesonide (inhalation) $2.65 albuterol sulfate nebu in $2.65 0.25 mg/2ml, 0.5 mg/2ml (Tier 0.083 %, 0.5 %, 0.63 (Tier 1) mg/3ml, 1.25 mg/3ml 1) $0- QL(20 ea $0- MO FLOVENT DISKUS 100 $6.60 daily); MO albuterol sulfate syrp or 2 $2.65 MCG/BLIST (Tier mg/5ml (Tier 2) 1) $0- QL(8 ea daily); $0- MO FLOVENT DISKUS 250 $6.60 MO albuterol sulfate tabs or 2 $2.65 MCG/BLIST (Tier mg, 4 mg (Tier 2) 1) $0- QL(40 ea $0- MO FLOVENT DISKUS 50 $6.60 daily); MO albuterol sulfate tb12 or 4 $2.65 MCG/BLIST (Tier mg, 8 mg (Tier 2) 1) $0- QL(0.8 gm $0- QL(2 ea daily); FLOVENT HFA 110 $6.60 daily); MO $6.60 MO MCG/ACT, 220 MCG/ACT (Tier ANORO ELLIPTA (Tier 2) 2) $0- QL(0.36 gm Limited to 2 FLOVENT HFA 44 $6.60 daily); MO $0- inhalers per MCG/ACT (Tier BREO ELLIPTA $6.60 month 2) 25MCG/INH-100MCG/INH, (Tier 25MCG/INH-200MCG/INH (Institutional PULMICORT 0.25 MO; B/D 2) Pack);QL(2 ea daily); MO MG/2ML, 0.5 MG/2ML NF (Use Budesonide $0- BREO ELLIPTA Limit 1 inhaler (Inhalation)) $6.60 per month;QL(2 25MCG/INH-100MCG/INH, (Tier $0- QL(0.87 gm 25MCG/INH-200MCG/INH ea daily); MO $6.60 2) QVAR daily); MO (Tier $0- MO 2) $6.60 COMBIVENT RESPIMAT (Tier Sympathomimetics 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

22 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- QL(4 gm daily); $0- QL(2 ea daily); $6.60 MO $6.60 MO DULERA (Tier SEREVENT DISKUS (Tier 2) 2) DUONEB (Use NF MO; B/D $0- Limited to 1 ) $6.60 Ipratropium-Albuterol STIOLTO RESPIMAT inhaler per $0 NT (Tier month;QL(0.14 EPHEDRINE HCL TABS (Tier 2) gm daily); MO OR 3) $0- QL(0.14 gm $6.60 $0 MO; NT STRIVERDI RESPIMAT daily); MO EPHEDRINE SULFATE (Tier (Tier CAPS OR 3) 2) $0- MO $0- Institutional $6.60 epinephrine hcl sosy 0.1 $2.65 STRIVERDI RESPIMAT Pack;QL(0.28 mg/ml (Tier (Tier gm daily); MO 1) 2) $0- QL(2 ea daily); $0- MO $6.60 MO terbutaline sulfate tabs or $2.65 FORADIL AEROLIZER (Tier 2.5 mg, 5 mg (Tier 2) 1) $0- MO; B/D XOPENEX (Use NF MO; B/D $2.65 Levalbuterol HCl) ipratropium-albuterol (Tier XOPENEX MO; B/D 1) CONCENTRATE (Use NF levalbuterol hcl nebu in $0- MO; B/D Levalbuterol HCl) 0.31 mg/3ml, 0.63 mg/3ml, $2.65 Xanthines 1.25 mg/0.5ml, 1.25 (Tier mg/3ml 1) $0- MO $2.65 $0- MO aminophylline (Tier $6.60 1) PROAIR HFA (Tier 2) $0- MO theophylline tb12 100 mg, $2.65 $0- MO 200 mg, 300 mg, 450 mg (Tier $6.60 1) PROAIR RESPICLICK (Tier 2) $0- MO theophylline tb24 400 mg, $2.65 $0- MO 600 mg (Tier $6.60 1) PROVENTIL HFA (Tier 2) ANTICOAGULANTS - Blood Thinners Coumarin Anticoagulants

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

23 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) COUMADIN TABS OR 1 MO $0- MG, 10 MG, 2 MG, 2.5 MG, FRAGMIN 95000 $6.60 3 MG, 4 MG, 5 MG, 6 MG, NF UNIT/3.8ML (Tier 7.5 MG (Use Warfarin 2) Sodium) $0- MO $2.65 $0- MO heparin sodium (porcine) $2.65 (Tier warfarin sodium (Tier 1) 1) LOVENOX (Use NF MO Direct Factor Xa Inhibitors Enoxaparin Sodium) $0- MO Thrombin Inhibitors $6.60 ELIQUIS $0- MO (Tier $2.65 2) argatroban 250 mg/2.5ml (Tier $0- MO 1) $6.60 XARELTO $0- MO (Tier $6.60 2) PRADAXA (Tier $0- MO 2) XARELTO STARTER $6.60 PACK (Tier ANTICONVULSANTS - Drugs to Treat Seizures 2) AMPA Glutamate Receptor Antagonists Heparins And Heparinoid-Like Agents $0- QL(1.2 ea ARIXTRA (Use NF MO $6.60 daily); MO Fondaparinux Sodium) FYCOMPA 10 MG (Tier $0- MO 2) $2.65 enoxaparin sodium $0- QL(1 ea daily); (Tier $6.60 MO 1) FYCOMPA 12 MG (Tier $0- MO 2) $2.65 fondaparinux sodium $0- QL(6 ea daily); (Tier $6.60 MO 1) FYCOMPA 2 MG (Tier FRAGMIN 10000 UNIT/ML, MO 2) 12500 UNIT/0.5ML, 15000 $0- QL(3 ea daily); UNIT/0.6ML, 18000 $0- $6.60 MO UNT/0.72ML, 2500 $6.60 FYCOMPA 4 MG (Tier UNIT/0.2ML, 25000 (Tier 2) UNIT/ML, 5000 2) $0- QL(2 ea daily); UNIT/0.2ML, 7500 $6.60 MO UNIT/0.3ML FYCOMPA 6 MG (Tier 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

24 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- QL(1.5 ea $0- MO $6.60 daily); MO $6.60 FYCOMPA 8 MG (Tier ONFI (Tier 2) 2) Anticonvulsants - Benzodiazepines Anticonvulsants - Misc. $0- QL(40 ea $0- QL(6 ea daily); $2.65 daily); MO $6.60 MO clonazepam tabs or 0.5 mg (Tier APTIOM 200 MG (Tier 1) 2) $0- QL(20 ea $0- QL(3 ea daily); $2.65 daily); MO $6.60 MO clonazepam tabs or 1 mg (Tier APTIOM 400 MG (Tier 1) 2) $0- QL(10 ea $0- QL(2 ea daily); $2.65 daily); MO $6.60 MO clonazepam tabs or 2 mg (Tier APTIOM 600 MG (Tier 1) 2) $0- $0- clonazepam tbdp or 0.125 MO QL(1 ea daily); $2.65 $6.60 MO mg, 0.25 mg, 0.5 mg, 1 mg, (Tier APTIOM 800 MG (Tier 2 mg 1) 2) $0- MO $0- MO $6.60 $6.60 DIASTAT ACUDIAL (Tier BANZEL (Tier 2) 2) $0- MO $0- MO $6.60 carbamazepine chew or $2.65 DIASTAT PEDIATRIC (Tier 100 mg (Tier 2) 1) $0- MO $0- MO DIAZEPAM GEL RE 10 $6.60 carbamazepine cp12 or $2.65 MG, 2.5 MG, 20 MG (Tier 100 mg, 200 mg, 300 mg (Tier 2) 1) $0- KLONOPIN 0.5 MG (Use NF QL(40 ea MO Clonazepam) daily); MO carbamazepine susp or $2.65 100 mg/5ml (Tier KLONOPIN 1 MG (Use NF QL(20 ea Clonazepam) daily); MO 1) $0- MO KLONOPIN 2 MG (Use NF QL(10 ea Clonazepam) daily); MO carbamazepine tabs or 200 $2.65 mg (Tier 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

25 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO carbamazepine tb12 or 200 $2.65 lamotrigine tabs 100 mg, $2.65 mg, 400 mg (Tier 150 mg, 200 mg, 25 mg (Tier 1) 1) $0- CARBATROL (Use NF MO lamotrigine tb24 100 mg, MO Carbamazepine) $2.65 200 mg, 25 mg, 250 mg, (Tier $0- MO 300 mg, 50 mg gabapentin caps or 100 $2.65 1) mg, 300 mg, 400 mg (Tier LEVETIRACETAM SOLN 1) IV 1000MG/100ML- $0- $0- MO 750MG/100ML, $6.60 gabapentin soln or 250 $2.65 1500MG/100ML- (Tier mg/5ml (Tier 540MG/100ML, 2) 1) 500MG/100ML- 820MG/100ML $0- MO gabapentin tabs or 600 mg, $2.65 $0- MO 800 mg (Tier levetiracetam soln iv 500 $2.65 1) mg/5ml (Tier 1) KEPPRA (Use NF MO Levetiracetam) $0- MO levetiracetam soln or 100 $2.65 KEPPRA XR (Use NF MO mg/ml, 500 mg/5ml (Tier Levetiracetam) 1) LAMICTAL CHEWABLE MO $0- MO DISPERSIBLE (Use NF levetiracetam tabs or 1000 $2.65 Lamotrigine) mg, 250 mg, 500 mg, 750 (Tier LAMICTAL TABS 100 MG, MO mg 1) 150 MG, 200 MG, 25 MG NF $0- MO (Use Lamotrigine) levetiracetam tb24 or 500 $2.65 $0- MO mg, 750 mg (Tier $6.60 LAMICTAL XR KIT 1) (Tier $0- QL(6 ea daily); 2) $6.60 MO LAMICTAL XR TB24 100 MO LYRICA CAPS 100 MG (Tier MG, 200 MG, 25 MG, 250 NF 2) MG, 300 MG, 50 MG (Use $0- QL(4 ea daily); Lamotrigine) $6.60 MO $0- MO LYRICA CAPS 150 MG (Tier lamotrigine chew 25 mg, 5 $2.65 2) mg (Tier $0- QL(3 ea daily); 1) $6.60 MO LYRICA CAPS 200 MG (Tier 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

26 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- QL(2 ea daily); $0- QL(24 ea LYRICA CAPS 225 MG, $6.60 MO $6.60 daily); MO 300 MG (Tier POTIGA 50 MG (Tier 2) 2) $0- QL(24 ea $0- MO $6.60 daily); MO primidone tabs or 250 mg, $2.65 LYRICA CAPS 25 MG (Tier 50 mg (Tier 2) 1) $0- QL(12 ea TEGRETOL (Use MO $6.60 NF LYRICA CAPS 50 MG daily); MO Carbamazepine) (Tier $0- MO 2) $6.60 $0- QL(8 ea daily); TEGRETOL-XR 100 MG (Tier $6.60 LYRICA CAPS 75 MG MO 2) (Tier TEGRETOL-XR 200 MG, MO 2) 400 MG (Use NF $0- QL(30 ml Carbamazepine) $6.60 daily); MO LYRICA SOLN 20 MG/ML TOPAMAX (Use NF MO (Tier Topiramate) 2) TOPAMAX SPRINKLE NF MO MYSOLINE (Use NF MO (Use Topiramate) Primidone) $0- MO NEURONTIN (Use NF MO topiramate cpsp or 15 mg, $2.65 Gabapentin) 25 mg (Tier $0- MO 1) $2.65 oxcarbazepine $0- MO (Tier topiramate tabs or 100 mg, $2.65 1) 200 mg, 25 mg, 50 mg (Tier $0- QL(6 ea daily); 1) $6.60 MO POTIGA 200 MG TRILEPTAL (Use NF MO (Tier Oxcarbazepine) 2) $0- $0- QL(4 ea daily); VIMPAT SOLN IV 200 $6.60 $6.60 POTIGA 300 MG MO MG/20ML (Tier (Tier 2) 2) $0- MO $0- QL(3 ea daily); VIMPAT SOLN OR 10 $6.60 $6.60 POTIGA 400 MG MO MG/ML (Tier (Tier 2) 2) $0- MO VIMPAT TABS OR 100 $6.60 MG, 150 MG, 200 MG, 50 (Tier MG 2) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

27 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- ZONEGRAN (Use NF MO MO Zonisamide) fosphenytoin sodium 500 $2.65 $0- MO mg pe/10ml (Tier $2.65 1) zonisamide (Tier $0- MO 1) $6.60 PEGANONE (Tier Carbamates 2) $0- MO $0- MO $2.65 felbamate $2.65 (Tier phenytoin chew or 50 mg (Tier 1) 1) FELBATOL (Use NF MO $0- MO Felbamate) $2.65 phenytoin sodium extended GABA Modulators (Tier $0- MO 1) $6.60 $0- GABITRIL 12 MG, 16 MG $2.65 (Tier phenytoin sodium soln ij 2) (Tier 1) GABITRIL 2 MG, 4 MG NF MO (Use Tiagabine HCl) $0- MO $0- LA phenytoin susp or 125 $2.65 $6.60 mg/5ml (Tier SABRIL (Tier 1) 2) Succinimides $0- MO $0- MO $2.65 tiagabine hcl $6.60 (Tier CELONTIN (Tier 1) 2) Hydantoins $0- MO CEREBYX 100 MG ethosuximide caps or 250 $2.65 PE/2ML (Use Fosphenytoin NF mg (Tier Sodium) 1) CEREBYX 500 MG MO $0- MO PE/10ML (Use NF ethosuximide soln or 250 $2.65 Fosphenytoin Sodium) mg/5ml (Tier 1) DILANTIN-125 (Use NF MO Phenytoin) ZARONTIN 250 MG (Use NF MO Ethosuximide) $0- fosphenytoin sodium 100 $2.65 Valproic Acid mg pe/2ml (Tier DEPACON (Use Valproate NF 1) Sodium)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

28 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) DEPAKENE (Use NF MO REMERON (Use NF MO Valproate Sodium) Mirtazapine) DEPAKENE (Use Valproic NF MO REMERON SOLTAB (Use NF MO Acid) Mirtazapine) DEPAKOTE (Use NF MO Antidepressants - Misc. ) Divalproex Sodium $0- QL(4.5 ea DEPAKOTE ER (Use NF MO bupropion hcl tabs or 100 $2.65 daily); MO Divalproex Sodium) mg (Tier 1) DEPAKOTE SPRINKLES NF MO (Use Divalproex Sodium) $0- QL(6 ea daily); $0- MO bupropion hcl tabs or 75 $2.65 MO $2.65 mg (Tier divalproex sodium (Tier 1) 1) $0- QL(4 ea daily); $0- bupropion hcl tb12 or 100 $2.65 MO $6.60 mg (Tier STAVZOR (Tier 1) 2) $0- QL(2 ea daily); $0- bupropion hcl tb12 or 150 $2.65 MO valproate sodium soln iv $2.65 mg, 200 mg (Tier 100 mg/ml, 500 mg/5ml (Tier 1) 1) $0- QL(3 ea daily); $0- MO bupropion hcl tb24 or 150 $2.65 MO valproate sodium soln or $2.65 mg (Tier 250 mg/5ml (Tier 1) 1) $0- QL(1 ea daily); $0- MO bupropion hcl tb24 or 300 $2.65 MO valproate sodium syrp or $2.65 mg (Tier 250 mg/5ml (Tier 1) 1) $0- MO $6.60 $0- MO FORFIVO XL $2.65 (Tier valproic acid caps or (Tier 2) 1) $0- MO $2.65 ANTIDEPRESSANTS - Drugs to Treat Depression maprotiline hcl (Tier Alpha-2 Receptor Antagonists (Tetracyclics) 1) $0- MO WELLBUTRIN 100 MG NF QL(4.5 ea $2.65 (Use Bupropion HCl) daily); MO mirtazapine (Tier WELLBUTRIN 75 MG (Use NF QL(6 ea daily); 1) Bupropion HCl) MO

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

29 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- WELLBUTRIN SR 100 MG NF QL(4 ea daily); QL(4 ea daily); (Use Bupropion HCl) MO citalopram hydrobromide $2.65 MO WELLBUTRIN SR 150 MG, QL(2 ea daily); tabs 10 mg (Tier 200 MG (Use Bupropion NF MO 1) HCl) $0- QL(2 ea daily); citalopram hydrobromide $2.65 MO WELLBUTRIN XL 150 MG NF QL(3 ea daily); (Use Bupropion HCl) MO tabs 20 mg (Tier 1) WELLBUTRIN XL 300 MG NF QL(1 ea daily); (Use Bupropion HCl) MO $0- QL(1 ea daily); citalopram hydrobromide $2.65 MO Monoamine Oxidase Inhibitors (MAOIs) tabs 40 mg (Tier $0- MO 1) $6.60 EMSAM $0- MO (Tier $2.65 2) escitalopram oxalate (Tier $0- MO 1) $6.60 MARPLAN $0- MO (Tier fluoxetine hcl caps or 10 $2.65 2) mg, 20 mg, 40 mg (Tier 1) NARDIL (Use Phenelzine NF MO Sulfate) $0- MO $2.65 PARNATE (Use NF MO fluoxetine hcl cpdr or 90 mg Tranylcypromine Sulfate) (Tier $0- MO 1) $2.65 $0- MO phenelzine sulfate tabs or (Tier fluoxetine hcl soln or 20 $2.65 1) mg/5ml (Tier $0- MO 1) $2.65 $0- MO tranylcypromine sulfate (Tier fluoxetine hcl tabs or 10 $2.65 1) mg, 20 mg (Tier 1) Selective Serotonin Reuptake Inhibitors (SSRIs) $0- MO CELEXA 10 MG (Use NF QL(4 ea daily); $2.65 Citalopram Hydrobromide) MO fluvoxamine maleate (Tier CELEXA 20 MG (Use NF QL(2 ea daily); 1) Citalopram Hydrobromide) MO LEXAPRO (Use NF MO CELEXA 40 MG (Use NF QL(1 ea daily); Escitalopram Oxalate) Citalopram Hydrobromide) MO LUVOX CR (Use NF MO $0- QL(20 ml Fluvoxamine Maleate) citalopram hydrobromide $2.65 daily); MO soln 10 mg/5ml (Tier 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

30 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO $2.65 $2.65 paroxetine hcl (Tier nefazodone hcl (Tier 1) 1) $0- PAXIL CR (Use Paroxetine NF MO trazodone hcl tabs or 100 MO HCl) $2.65 mg, 150 mg, 300 mg, 50 (Tier $0- MO mg $6.60 1) PAXIL SUSP 10 MG/5ML (Tier $0- ST; MO $6.60 2) VIIBRYD PAXIL TABS 10 MG, 20 MO (Tier MG, 30 MG, 40 MG (Use NF 2) Paroxetine HCl) $0- ST $6.60 PROZAC (Use Fluoxetine NF MO VIIBRYD STARTER PACK HCl) (Tier 2) PROZAC WEEKLY (Use NF MO Fluoxetine HCl) Serotonin-Norepinephrine Reuptake Inhibitors $0- MO CYMBALTA (Use NF MO sertraline hcl conc or 20 $2.65 Duloxetine HCl) mg/ml (Tier $0- ST; MO 1) DESVENLAFAXINE ER $6.60 $0- MO 100 MG, 50 MG (Tier sertraline hcl tabs or 100 $2.65 2) mg, 25 mg, 50 mg (Tier $0- ST; Fumarate 1) DESVENLAFAXINE ER $6.60 100 MG, 50 MG (Tier ZOLOFT (Use Sertraline NF MO HCl) 2) Serotonin Modulators $0- MO duloxetine hcl 20 mg, 30 $2.65 $0- ST; QL(2 ea mg, 60 mg (Tier $6.60 daily); MO 1) BRINTELLIX 10 MG (Tier 2) EFFEXOR XR 150 MG NF QL(1 ea daily); (Use Venlafaxine HCl) MO $0- ST; QL(1 ea $6.60 daily); MO EFFEXOR XR 37.5 MG NF QL(6 ea daily); BRINTELLIX 20 MG (Tier (Use Venlafaxine HCl) MO 2) EFFEXOR XR 75 MG (Use NF QL(3 ea daily); $0- ST; QL(4 ea Venlafaxine HCl) MO $6.60 daily); MO $0- ST; QL(1 ea BRINTELLIX 5 MG (Tier FETZIMA 120 MG, 40 MG, $6.60 daily); MO 2) 80 MG (Tier 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

31 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- ST; QL(2 ea $0- QL(10 ea $6.60 daily); MO venlafaxine hcl tabs 37.5 $2.65 daily); MO FETZIMA 20 MG (Tier mg (Tier 2) 1) $0- ST; MO $0- QL(7.5 ea FETZIMA TITRATION $6.60 $2.65 daily); MO PACK (Tier venlafaxine hcl tabs 50 mg (Tier 2) 1) $0- ST; MO $0- QL(5 ea daily); $6.60 $2.65 MO KHEDEZLA (Tier venlafaxine hcl tabs 75 mg (Tier 2) 1) $0- ST; MO $0- QL(1 ea daily); $6.60 venlafaxine hcl tb24 150 $2.65 MO PRISTIQ (Tier mg (Tier 2) 1) $0- QL(1 ea daily); $0- QL(6 ea daily); venlafaxine hcl cp24 150 $2.65 MO venlafaxine hcl tb24 37.5 $2.65 MO mg (Tier mg (Tier 1) 1) $0- QL(6 ea daily); $0- QL(3 ea daily); venlafaxine hcl cp24 37.5 $2.65 MO $2.65 MO mg (Tier venlafaxine hcl tb24 75 mg (Tier 1) 1) $0- QL(3 ea daily); Tricyclic Agents $2.65 venlafaxine hcl cp24 75 mg MO $0- AL; MO (Tier $2.65 1) amitriptyline hcl (Tier $0- ST; QL(1 ea 1) $6.60 VENLAFAXINE HCL ER daily); MO $0- MO (Tier $2.65 2) amoxapine (Tier $0- QL(3.5 ea 1) venlafaxine hcl tabs 100 $2.65 daily); MO mg (Tier ANAFRANIL (Use NF AL; MO 1) Clomipramine HCl) $0- QL(15 ea $0- AL; MO $2.65 daily); MO clomipramine hcl caps or $2.65 venlafaxine hcl tabs 25 mg (Tier 25 mg, 50 mg, 75 mg (Tier 1) 1) $0- MO desipramine hcl tabs or 10 $2.65 mg, 100 mg, 150 mg, 25 (Tier mg, 50 mg, 75 mg 1) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

32 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- AL; MO doxepin hcl caps or 10 mg, $2.65 ANTIDIABETICS - Drugs to Regulate Blood Sugar 100 mg, 150 mg, 25 mg, 50 (Tier Alpha-Glucosidase Inhibitors mg, 75 mg 1) $0- QL(3 ea daily); $0- AL; MO $2.65 MO doxepin hcl conc or 10 $2.65 acarbose (Tier mg/ml (Tier 1) 1) $0- QL(3 ea daily); $0- AL; MO $6.60 MO imipramine hcl tabs or 10 $2.65 GLYSET (Tier mg, 25 mg, 50 mg (Tier 2) 1) ) NF QL(3 ea daily); $0- AL; MO PRECOSE (Use Acarbose MO $2.65 imipramine pamoate (Tier Antidiabetic - Amylin Analogs 1) $0- QL(0.4 ml $6.60 daily); MO NORPRAMIN (Use NF MO SYMLINPEN 120 Desipramine HCl) (Tier $0- MO 2) nortriptyline hcl caps or 10 $2.65 $0- QL(0.4 ml $6.60 mg, 25 mg, 50 mg, 75 mg (Tier SYMLINPEN 60 daily); MO 1) (Tier $0- MO 2) nortriptyline hcl soln or 10 $2.65 Antidiabetic Combinations mg/5ml (Tier ACTOPLUS MET (Use QL(3 ea daily); 1) Pioglitazone HCl-Metformin NF MO PAMELOR (Use NF MO HCl) Nortriptyline HCl) DUETACT (Use QL(1.5 ea $0- MO Pioglitazone HCl- NF daily); MO $2.65 protriptyline hcl Glimepiride) (Tier $0- QL(8 ea daily); 1) glipizide-metformin hcl $2.65 MO $0- AL; MO 2.5mg-250mg (Tier $6.60 SURMONTIL 1) (Tier $0- QL(4 ea daily); 2) glipizide-metformin hcl $2.65 MO TOFRANIL-PM (Use NF AL; MO 2.5mg-500mg, 5mg-500mg (Tier Imipramine Pamoate) 1) $0- AL; MO GLUCOVANCE 1.25MG- AL; QL(8 ea trimipramine maleate caps $2.65 250MG (Use Glyburide- NF daily); MO or 100 mg, 25 mg, 50 mg (Tier Metformin) 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

33 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) GLUCOVANCE 2.5MG- AL; QL(4 ea $0- QL(1 ea daily); 500MG, 5MG-500MG (Use NF daily); MO KOMBIGLYZE XR 5MG- $6.60 MO Glyburide-Metformin) 1000MG, 5MG-500MG (Tier $0- AL; QL(8 ea 2) glyburide-metformin $2.65 daily); MO $0- QL(2 ea daily); $6.60 1.25mg-250mg (Tier OSENI 12.5MG-15MG MO 1) (Tier $0- AL; QL(4 ea 2) glyburide-metformin 2.5mg- $2.65 daily); MO OSENI 12.5MG-30MG, $0- QL(1 ea daily); 500mg, 5mg-500mg (Tier 12.5MG-45MG, 25MG- $6.60 MO 1) 15MG, 25MG-30MG, (Tier $0- QL(2 ea daily); 25MG-45MG 2) INVOKAMET 150MG- $6.60 $0- 1000MG, 150MG-500MG, MO QL(1.5 ea (Tier $2.65 daily); MO 50MG-1000MG 2) pioglitazone hcl-glimepiride (Tier $0- QL(4 ea daily); 1) INVOKAMET 50MG- $6.60 MO $0- QL(3 ea daily); 500MG (Tier pioglitazone hcl-metformin $2.65 MO 2) hcl (Tier $0- QL(2 ea daily); 1) $6.60 $0- JANUMET MO QL(5 ea daily); (Tier $6.60 MO 2) PRANDIMET (Tier $0- QL(1 ea daily); 2) JANUMET XR 100MG- $6.60 MO Biguanides 1000MG (Tier 2) FORTAMET 1000 MG (Use NF QL(2 ea daily); Metformin HCl) MO $0- QL(2 ea daily); JANUMET XR 50MG- $6.60 MO FORTAMET 500 MG (Use NF Osmotic;QL(5 1000MG, 50MG-500MG (Tier Metformin HCl) ea daily); MO 2) GLUCOPHAGE 1000 MG NF QL(2.5 ea $0- QL(2 ea daily); (Use Metformin HCl) daily); MO $6.60 MO GLUCOPHAGE 500 MG NF QL(5 ea daily); JENTADUETO (Tier (Use Metformin HCl) MO 2) GLUCOPHAGE 850 MG NF QL(3 ea daily); $0- QL(2 ea daily); (Use Metformin HCl) MO $6.60 MO KAZANO GLUCOPHAGE XR 500 NF QL(4 ea daily); (Tier MG (Use Metformin HCl) MO 2) GLUCOPHAGE XR 750 NF QL(2 ea daily); $0- QL(2 ea daily); MG (Use Metformin HCl) MO KOMBIGLYZE XR 2.5MG- $6.60 MO 1000MG (Tier 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

34 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- $0 QL(2 ea daily); dextrose (diabetic use) gel MO; NT $6.60 MO (Tier GLUMETZA 1000 MG (Tier 15 gm/38gm, 40 % 3) 2) $0- MO $0- $6.60 QL(4 ea daily); GLUCAGEN HYPOKIT $6.60 MO (Tier GLUMETZA 500 MG (Tier 2) 2) $0- MO $0- $2.65 QL(2.5 ea glucagon (rdna) metformin hcl tabs or 1000 $2.65 daily); MO (Tier mg (Tier 1) 1) $0 MO; NT $0- QL(5 ea daily); GLUCOSE CHEW 4 GM (Tier metformin hcl tabs or 500 $2.65 MO 3) mg (Tier $0 MO; NT 1) GNP GLUCOSE 4 GM (Tier $0- QL(3 ea daily); 3) metformin hcl tabs or 850 $2.65 MO $0 MO; NT mg (Tier GNP QUICK DISSOLVE (Tier 1) GLUCOSE 3) $0- QL(2 ea daily); $0 MO; NT metformin hcl tb24 or 1000 $2.65 MO LEADER QUICK (Tier mg, 750 mg (Tier DISSOLVE GLUCOSE 3) 1) $0 MO; NT $0- Osmotic;QL(5 MS QUICK DISSOLVE (Tier metformin hcl tb24 or 500 $2.65 ea daily); MO GLUCOSE 3) mg (Tier 1) $0- MO $6.60 $0- QL(4 ea daily); PROGLYCEM (Tier metformin hcl tb24 or 500 $2.65 MO 2) mg (Tier 1) $0 MO; NT SM GLUCOSE 4 GM (Tier Diabetic Other 3) $0 NT $0 MO; NT BD GLUCOSE (Tier ULTILET GLUCOSE (Tier 3) 3) $0 MO; NT $0 MO; NT CVS GLUCOSE 4 GM (Tier WALGREENS GLUCOSE (Tier 3) 4 GM 3) $0 MO; NT Dipeptidyl Peptidase-4 (DPP-4) Inhibitors DEX4 QUICK DISSOLVE (Tier GLUCOSE 3)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

35 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- QL(4 ea daily); $6.60 $6.60 LA; MO JANUVIA (Tier AVANDIA 2 MG (Tier 2) 2) $0- MO $0- QL(2 ea daily); $6.60 $6.60 LA; MO NESINA (Tier AVANDIA 4 MG (Tier 2) 2) $0- MO $0- QL(1 ea daily); $6.60 $6.60 LA; MO ONGLYZA (Tier AVANDIA 8 MG (Tier 2) 2) $0- MO $0- QL(3 ea daily); $6.60 $2.65 MO TRADJENTA (Tier pioglitazone hcl 15 mg (Tier 2) 1) Dopamine Receptor Agonists - Antidiabetic $0- QL(1 ea daily); $0- pioglitazone hcl 30 mg, 45 $2.65 MO QL(6 ea daily); mg (Tier $6.60 MO CYCLOSET (Tier 1) 2) Insulin Incretin Mimetic Agents (GLP-1 Receptor $0- QL(1.5 ml $6.60 $0- ST; MO HUMALOG daily); MO $6.60 (Tier BYDUREON (Tier 2) 2) $0- QL(1.5 ml $6.60 $0- ST; MO HUMALOG KWIKPEN daily); MO $6.60 (Tier BYETTA (Tier 2) 2) $0- QL(1.5 ml $6.60 daily); MO $0- ST; QL(0.3 ml HUMALOG MIX 50/50 (Tier $6.60 daily); MO VICTOZA (Tier 2) 2) $0- QL(1.5 ml HUMALOG MIX 50/50 $6.60 daily); MO Insulin Sensitizing Agents KWIKPEN (Tier 2) ACTOS 15 MG (Use NF QL(3 ea daily); Pioglitazone HCl) MO $0- QL(1.5 ml $6.60 daily); MO ACTOS 30 MG, 45 MG NF QL(1 ea daily); HUMALOG MIX 75/25 (Use Pioglitazone HCl) MO (Tier 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

36 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- QL(1.5 ml $0- QL(1.5 ml HUMALOG MIX 75/25 $6.60 daily); MO $6.60 daily); MO KWIKPEN (Tier LANTUS SOLOSTAR (Tier 2) 2) $0- QL(1.5 ml $0- QL(1.5 ml $6.60 daily); MO $6.60 daily); MO HUMULIN 70/30 (Tier LEVEMIR (Tier 2) 2) $0- QL(1.5 ml $0- QL(1.5 ml $6.60 daily); MO $6.60 daily); MO HUMULIN 70/30 KWIKPEN (Tier LEVEMIR FLEXPEN (Tier 2) 2) $0- QL(1.5 ml $0- QL(1.5 ml $6.60 daily); MO $6.60 daily); MO HUMULIN 70/30 PEN (Tier LEVEMIR FLEXTOUCH (Tier 2) 2) $0- QL(1.5 ml $0- Limited to $6.60 HUMULIN N daily); MO $6.60 15mls per (Tier TOUJEO SOLOSTAR (Tier month;QL(0.5 2) 2) ml daily); MO $0- QL(1.5 ml Meglitinide Analogues $6.60 daily); MO HUMULIN N KWIKPEN (Tier $0- QL(3 ea daily); 2) $2.65 MO nateglinide (Tier $0- QL(1.5 ml 1) $6.60 HUMULIN N U-100 PEN daily); MO (Tier PRANDIN 0.5 MG (Use NF QL(32 ea 2) Repaglinide) daily); MO $0- QL(1.5 ml PRANDIN 1 MG (Use NF QL(16 ea $6.60 Repaglinide) daily); MO HUMULIN R daily); MO (Tier PRANDIN 2 MG (Use NF QL(8 ea daily); 2) Repaglinide) MO $0- QL(1.5 ml $0- QL(32 ea $2.65 HUMULIN R U-500 $6.60 daily); MO repaglinide 0.5 mg daily); MO (CONCENTRATED) (Tier (Tier 2) 1) $0- QL(1.5 ml $0- QL(16 ea $2.65 $6.60 daily); MO repaglinide 1 mg daily); MO LANTUS (Tier (Tier 2) 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

37 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- QL(8 ea daily); $0- QL(8 ea daily); $2.65 MO $2.65 MO repaglinide 2 mg (Tier glimepiride 1 mg (Tier 1) 1) $0- ) NF QL(3 ea daily); QL(4 ea daily); STARLIX (Use Nateglinide MO $2.65 MO glimepiride 2 mg (Tier Sodium-Glucose Co-Transporter 2 (SGLT2) 1) $0- MO $0- QL(2 ea daily); $6.60 FARXIGA $2.65 MO (Tier glimepiride 4 mg (Tier 2) 1) $0- MO $0- QL(4 ea daily); $6.60 INVOKANA $2.65 MO (Tier glipizide tabs or 10 mg (Tier 2) 1) $0- QL(2 ea daily); $0- QL(8 ea daily); $6.60 JARDIANCE 10 MG MO $2.65 MO (Tier glipizide tabs or 5 mg (Tier 2) 1) $0- QL(1 ea daily); $0- QL(2 ea daily); $6.60 JARDIANCE 25 MG MO $2.65 MO (Tier glipizide tb24 or 10 mg (Tier 2) 1) Sulfonylureas $0- QL(8 ea daily); $2.65 MO AMARYL 1 MG (Use NF QL(8 ea daily); glipizide tb24 or 2.5 mg Glimepiride) MO (Tier 1) AMARYL 2 MG (Use NF QL(4 ea daily); Glimepiride) MO $0- QL(4 ea daily); $2.65 MO AMARYL 4 MG (Use NF QL(2 ea daily); glipizide tb24 or 5 mg Glimepiride) MO (Tier 1) $0- AL; QL(16 ea DIABETA 1.25 MG (Use $6.60 daily); MO GLUCOTROL 10 MG (Use NF QL(4 ea daily); Glyburide) (Tier Glipizide) MO 2) GLUCOTROL 5 MG (Use NF QL(8 ea daily); $0- AL; QL(8 ea Glipizide) MO DIABETA 2.5 MG (Use $6.60 daily); MO GLUCOTROL XL 10 MG NF QL(2 ea daily); Glyburide) (Tier (Use Glipizide) MO 2) GLUCOTROL XL 2.5 MG NF QL(8 ea daily); $0- AL; QL(4 ea (Use Glipizide) MO DIABETA 5 MG (Use $6.60 daily); MO GLUCOTROL XL 5 MG NF QL(4 ea daily); Glyburide) (Tier (Use Glipizide) MO 2) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

38 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- AL; QL(16 ea $2.65 ANTIDIARRHEALS - Drugs to Treat Diarrhea glyburide 1.25 mg daily); MO (Tier Antidiarrheal Agents - Misc. 1) $0 MO; NT $0- AL; QL(8 ea bismuth subsalicylate chew (Tier $2.65 daily); MO or 262 mg 3) glyburide 2.5 mg (Tier 1) bismuth subsalicylate susp $0 MO; NT or 262 mg/15ml, 525 (Tier $0- AL; QL(4 ea mg/15ml, 527 mg/30ml 3) $2.65 daily); MO glyburide 5 mg $0 (Tier bismuth subsalicylate tabs NT 1) (Tier or 262 mg 3) $0- AL; QL(8 ea glyburide micronized 1.5 $2.65 daily); MO PEPTO BISMOL (Use NF NT mg (Tier Bismuth Subsalicylate) 1) PEPTO-BISMOL (Use NF MO; NT $0- AL; QL(4 ea Bismuth Subsalicylate) $2.65 daily); MO PEPTO-BISMOL MO; NT glyburide micronized 3 mg (Tier INSTACOOL (Use Bismuth NF 1) Subsalicylate) $0- AL; QL(2 ea PEPTO-BISMOL MAX MO; NT $2.65 daily); MO STRENGTH (Use Bismuth NF glyburide micronized 6 mg (Tier Subsalicylate) 1) PEPTO-BISMOL TO-GO MO; NT (Use Bismuth NF GLYNASE 1.5 MG (Use NF AL; QL(8 ea Glyburide Micronized) daily); MO Subsalicylate) GLYNASE 3 MG (Use NF AL; QL(4 ea Antiperistaltic Agents Glyburide Micronized) daily); MO $0- MO GLYNASE 6 MG (Use NF AL; QL(2 ea $2.65 Glyburide Micronized) daily); MO diphenoxylate w/ atropine (Tier $0- QL(4 ea daily); 1) $2.65 MO tolazamide 250 mg LOMOTIL (Use NF MO (Tier Diphenoxylate w/ Atropine) 1) $0- RX/OTC; MO $0- QL(2 ea daily); loperamide hcl caps or 2 $2.65 $2.65 tolazamide 500 mg MO mg (Tier (Tier 1) 1) ANTIDOTES - Drugs to Treat Overdose or $0- QL(6 ea daily); Toxicity $2.65 MO tolbutamide (Tier Antidotes - Chelating Agents 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

39 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- LA $0- MO $6.60 ondansetron hcl soln ij 4 $2.65 EXJADE (Tier mg/2ml, 40 mg/20ml (Tier 2) 1) $0- PA; LA $0- MO; B/D $6.60 ondansetron hcl soln or 4 $2.65 FERRIPROX (Tier mg/5ml (Tier 2) 1) $0- $0- MO; B/D $6.60 ondansetron hcl tabs or 24 $2.65 JADENU (Tier mg, 4 mg, 8 mg (Tier 2) 1) Antidotes ZOFRAN ODT (Use NF MO; B/D ) $0 NT Ondansetron IPECAC (Tier ZOFRAN SOLN IJ 40 MO 3) MG/20ML (Use NF $0 NT Ondansetron HCl) SM IPECAC SYRUP (Tier ZOFRAN SOLN OR 4 MO; B/D 3) MG/5ML (Use Ondansetron NF HCl) Opioid Antagonists ZOFRAN TABS OR 4 MG, MO; B/D $0- MO 8 MG (Use Ondansetron NF naloxone hcl soln ij 1 $2.65 HCl) mg/ml (Tier 1) Antiemetics - Anticholinergic $0- MO $0 MO; NT $2.65 meclizine hcl chew 25 mg (Tier naltrexone hcl tabs or (Tier 3) 1) $0- RX/OTC; MO ANTIEMETICS - Drugs to Treat Nausea and meclizine hcl tabs 12.5 mg, $2.65 Vomiting 25 mg (Tier 1) 5-HT3 Receptor Antagonists $0- AL; MO $0- MO; B/D TIGAN SOLN IM 100 $6.60 granisetron hcl tabs or 1 $2.65 MG/ML (Tier mg (Tier 2) 1) $0- MO $0- MO; B/D $6.60 $2.65 TRANSDERM-SCOP ondansetron (Tier (Tier 2) 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

40 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- AL; MO $0- MO trimethobenzamide hcl soln $2.65 $6.60 im 100 mg/ml (Tier MYCAMINE (Tier 1) 2) Antiemetics - Miscellaneous Antifungals $0- MO; B/D $0- $6.60 $6.60 CESAMET (Tier ABELCET (Tier 2) 2) $0- MO; B/D $0- $2.65 $6.60 dronabinol (Tier AMBISOME (Tier 1) 2) $0- MARINOL (Use NF MO; B/D MO Dronabinol) $2.65 amphotericin b solr ij 50 mg (Tier Substance P/Neurokinin 1 (NK1) Receptor 1) $0- MO; B/D ANCOBON (Use NF MO EMEND CAPS OR 125 $6.60 Flucytosine) MG, 80 MG (Tier 2) $0- MO $2.65 $0- PA; MO flucytosine $6.60 (Tier EMEND CAPS OR 40 MG (Tier 1) 2) GRIS-PEG (Use NF MO Griseofulvin Ultramicrosize) ANTIFUNGALS - Drugs to Treat Fungal Infections $0- MO $2.65 Antifungal - Glucan Synthesis Inhibitors griseofulvin microsize (Tier $0- 1) $6.60 CANCIDAS 50 MG $0- MO (Tier $2.65 2) griseofulvin ultramicrosize (Tier $0- MO 1) $6.60 CANCIDAS 70 MG LAMISIL TABS 250 MG NF MO (Tier (Use Terbinafine HCl) 2) $0- MO $0- $2.65 $6.60 nystatin tabs or ERAXIS 100 MG (Tier (Tier 1) 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

41 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO $2.65 NOXAFIL SUSP OR 40 $6.60 terbinafine hcl tabs or (Tier MG/ML (Tier 1) 2) Imidazole-Related Antifungals $0- MO $0- NOXAFIL TBEC OR 100 $6.60 MO MG (Tier CRESEMBA CAPS OR $6.60 2) 186 MG (Tier 2) SPORANOX CAPS 100 NF MO ) $0- MG (Use Itraconazole CRESEMBA SOLR IV 372 $6.60 SPORANOX PULSEPAK NF MO MG (Tier (Use Itraconazole) 2) VFEND IV (Use NF Voriconazole) DIFLUCAN (Use NF MO Fluconazole) VFEND TABS 200 MG, 50 NF MO $0- MG (Use Voriconazole) $2.65 fluconazole in dextrose $0- (Tier $2.65 1) voriconazole solr iv 200 mg (Tier $0- 1) fluconazole in nacl $2.65 $0- MO 200mg/100ml-0.9%, (Tier 400mg/200ml-0.9% voriconazole tabs or 200 $2.65 1) mg, 50 mg (Tier $0- MO 1) fluconazole susr or 10 $2.65 mg/ml, 40 mg/ml (Tier ANTIHISTAMINES - Drugs to Treat Allergies 1) Antihistamines - Alkylamines $0- MO fluconazole tabs or 100 CHLOR-TRIMETON (Use NF AL; MO; NT $2.65 Chlorpheniramine Maleate) mg, 150 mg, 200 mg, 50 (Tier mg 1) $0 AL; MO; NT chlorpheniramine maleate (Tier $0- MO syrp or 2 mg/5ml 3) $2.65 itraconazole caps or $0 (Tier chlorpheniramine maleate AL; MO; NT 1) (Tier tabs or 4 mg 3) $0- MO $2.65 $0 AL; NT ketoconazole tabs or (Tier ED CHLORPED (Tier 1) 3) $0- Antihistamines - Ethanolamines NOXAFIL SOLN IV 300 $6.60 MG/16.7ML (Tier 2) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

42 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 AL; NT $0- AL; MO ALER-DRYL (Tier diphenhydramine hcl soln ij $2.65 3) 50 mg/ml (Tier 1) BENADRYL (Use NF AL; MO; NT Diphenhydramine HCl) $0 AL; RX/OTC; diphenhydramine hcl syrp (Tier BENADRYL ALLERGY AL; MO; NT or 12.5 mg/5ml NT (Use Diphenhydramine NF 3) $0 HCl) diphenhydramine hcl tabs AL; MO; NT BENADRYL ALLERGY AL; NT (Tier or 25 mg 3) CHILDRENS CHEW 12.5 NF MG (Use Diphenhydramine $0 AL; NT TRIAMINIC COUGH & (Tier HCl) RUNNY NOSE BENADRYL ALLERGY AL; MO; NT 3) CHILDRENS LIQD 12.5 NF Antihistamines - Non-Sedating MG/5ML (Use $0- RX/OTC; MO Diphenhydramine HCl) $2.65 BENADRYL DYE-FREE AL; MO; NT cetirizine hcl soln 1 mg/ml (Tier ALLERGYLIQUID-GELS NF 1) (Use Diphenhydramine $0- RX/OTC; MO HCl) cetirizine hcl syrp 1 mg/ml, $2.65 $0- AL; MO 5 mg/5ml (Tier $2.65 1) carbinoxamine maleate (Tier CLARINEX REDITABS 5 NF MO 1) MG (Use Desloratadine) $0- AL; MO CLARINEX TABS 5 MG NF MO clemastine fumarate tabs $2.65 (Use Desloratadine) or 2.68 mg (Tier 1) $0- MO $2.65 $0 desloratadine tabs 5 mg diphenhydramine hcl caps AL; MO; NT (Tier (Tier 1) or 25 mg 3) $0- MO $0 AL; NT $2.65 diphenhydramine hcl chew (Tier desloratadine tbdp 5 mg or 12.5 mg (Tier 3) 1) $0- RX/OTC $0- MO diphenhydramine hcl elix or $2.65 levocetirizine $2.65 12.5 mg/5ml (Tier dihydrochloride (Tier 1) 1) diphenhydramine hcl liqd or $0 AL; MO; NT XYZAL (Use Levocetirizine NF MO 12.5 mg/5ml, 25 mg/10ml, (Tier Dihydrochloride) 50 mg/20ml 3) Antihistamines - Phenothiazines

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

43 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- AL; MO $0- MO promethazine hcl soln ij 25 $2.65 LOVAZA (Use Omega-3- $6.60 mg/ml, 50 mg/ml (Tier acid Ethyl Esters) (Tier 1) 2) $0- AL; MO $0- MO promethazine hcl soln or $2.65 $2.65 6.25 mg/5ml (Tier omega-3-acid ethyl esters (Tier 1) 1) $0- AL; MO $0- MO promethazine hcl supp re $2.65 $6.60 12.5 mg, 25 mg (Tier VASCEPA (Tier 1) 2) $0- AL; MO Bile Acid Sequestrants promethazine hcl syrp or $2.65 $0- MO 6.25 mg/5ml (Tier $2.65 1) cholestyramine light (Tier $0- AL; MO 1) promethazine hcl tabs or $2.65 $0- 12.5 mg, 25 mg, 50 mg (Tier MO 1) cholestyramine pack or 4 $2.65 gm (Tier Antihistamines - Piperidines 1) $0- AL; MO $0- MO cyproheptadine hcl syrp or $2.65 cholestyramine powd or 4 $2.65 2 mg/5ml (Tier gm/dose (Tier 1) 1) $0- AL; MO COLESTID (Use Colestipol NF MO cyproheptadine hcl tabs or $2.65 HCl) 4 mg (Tier COLESTID FLAVORED MO 1) GRAN 5 GM (Use NF ANTIHYPERLIPIDEMICS - Drugs to Treat High Colestipol HCl) Cholesterol $0- MO Antihyperlipidemics - Combinations $2.65 colestipol hcl (Tier $0- 1) $6.60 LIPTRUZET (Tier $0- MO 2) $6.60 WELCHOL (Tier Antihyperlipidemics - Misc. 2) $0- PA; LA Fibric Acid Derivatives $6.60 KYNAMRO (Tier ANTARA 130 MG, 43 MG MO 2) (Use Fenofibrate NF Micronized)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

44 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- QL(3 ea daily); $0- MO $6.60 MO fluvastatin sodium caps 20 $2.65 ANTARA 30 MG (Tier mg, 40 mg (Tier 2) 1) $0- QL(1 ea daily); LESCOL (Use Fluvastatin NF MO $6.60 MO Sodium) ANTARA 90 MG (Tier LIPITOR (Use Atorvastatin NF MO 2) Calcium) $0- MO $0- MO $2.65 choline fenofibrate $2.65 (Tier lovastatin (Tier 1) 1) $0- MO MEVACOR (Use NF MO $2.65 Lovastatin) fenofibrate micronized (Tier 1) PRAVACHOL (Use NF MO Pravastatin Sodium) $0- MO fenofibrate tabs 145 mg, $2.65 $0- MO $2.65 160 mg, 48 mg, 54 mg (Tier pravastatin sodium 1) (Tier 1) $0- MO $2.65 $0- QL(8 ea daily); gemfibrozil tabs or $2.65 (Tier simvastatin tabs or 10 mg MO 1) (Tier 1) MO LOPID (Use Gemfibrozil) NF $0- QL(4 ea daily); $2.65 MO TRICOR (Use Fenofibrate) NF MO simvastatin tabs or 20 mg (Tier 1) $0- MO $6.60 $0- QL(2 ea daily); TRIGLIDE $2.65 (Tier simvastatin tabs or 40 mg MO 2) (Tier 1) TRILIPIX (Use Choline NF MO Fenofibrate) $0- QL(16 ea $2.65 daily); MO HMG CoA Reductase Inhibitors simvastatin tabs or 5 mg (Tier $0- MO 1) $2.65 atorvastatin calcium $0- QL(1 ea daily); (Tier $2.65 MO 1) simvastatin tabs or 80 mg (Tier $0- ST; MO 1) $6.60 CRESTOR ZOCOR 10 MG (Use NF QL(8 ea daily); (Tier Simvastatin) MO 2) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

45 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) ZOCOR 20 MG (Use NF QL(4 ea daily); Proprotein Convertase Subtilisin/Kexin Type 9 ) Simvastatin MO $0- PA; QL(0.08 ml ZOCOR 40 MG (Use NF QL(2 ea daily); PRALUENT SOPN 150 $6.60 daily); MO Simvastatin) MO MG/ML (Tier 2) ZOCOR 5 MG (Use NF QL(16 ea Simvastatin) daily); MO $0- PA; QL(0.15 ml PRALUENT SOPN 75 $6.60 daily); MO ZOCOR 80 MG (Use NF QL(1 ea daily); Simvastatin) MO MG/ML (Tier 2) Intestinal Cholesterol Absorption Inhibitors $0- PA; QL(0.08 ml $0- MO PRALUENT SOSY 150 $6.60 daily); MO $6.60 ZETIA MG/ML (Tier (Tier 2) 2) $0- PA; QL(0.15 ml Microsomal Triglyceride Transfer Protein (MTP) PRALUENT SOSY 75 $6.60 daily); MO $0- PA; QL(6 ea MG/ML (Tier $6.60 2) JUXTAPID 10 MG daily); LA (Tier ANTIHYPERTENSIVES - Drugs to Treat High 2) Blood Pressure $0- PA; QL(3 ea $6.60 ACE Inhibitors JUXTAPID 20 MG daily); LA (Tier ACCUPRIL (Use Quinapril NF MO 2) HCl) $0- PA; QL(2 ea ACEON 4 MG (Use NF QL(4 ea daily); $6.60 daily); LA Perindopril Erbumine) MO JUXTAPID 30 MG (Tier ACEON 8 MG (Use NF QL(2 ea daily); 2) Perindopril Erbumine) MO $0- PA; QL(1 ea MO $6.60 ALTACE (Use Ramipril) NF JUXTAPID 40 MG, 60 MG daily); LA (Tier $0- MO 2) benazepril hcl tabs or 10 $2.65 $0- PA; QL(12 ea mg, 20 mg, 40 mg, 5 mg (Tier $6.60 JUXTAPID 5 MG daily); LA 1) (Tier $0- MO 2) captopril tabs or 100 mg, $2.65 Nicotinic Acid Derivatives 12.5 mg, 25 mg, 50 mg (Tier $0- MO 1) $2.65 $0- MO niacin (antihyperlipidemic) enalapril maleate tabs or $2.65 (Tier 10 mg, 2.5 mg, 20 mg, 5 1) (Tier mg 1) NIASPAN (Use Niacin NF MO (Antihyperlipidemic))

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

46 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO UNIVASC (Use Moexipril NF MO $2.65 HCl) fosinopril sodium (Tier VASOTEC (Use Enalapril NF MO 1) Maleate) $0- MO MO lisinopril tabs or 10 mg, 2.5 $2.65 ZESTRIL (Use Lisinopril) NF mg, 20 mg, 30 mg, 40 mg, (Tier 5 mg 1) Agents for Pheochromocytoma $0- MO LOTENSIN (Use NF MO Benazepril HCl) $6.60 DEMSER (Tier MAVIK (Use Trandolapril) NF MO 2) $0- MO $0- MO $2.65 DIBENZYLINE (Use $6.60 moexipril hcl (Tier Phenoxybenzamine HCl) (Tier 1) 2) $0- MO $0- MO $2.65 phenoxybenzamine hcl $2.65 perindopril erbumine 2 mg (Tier caps or (Tier 1) 1) $0- QL(4 ea daily); Angiotensin II Receptor Antagonists $2.65 MO perindopril erbumine 4 mg ATACAND (Use NF MO (Tier Candesartan Cilexetil) 1) AVAPRO (Use Irbesartan) NF MO $0- QL(2 ea daily); $2.65 perindopril erbumine 8 mg MO $0- MO (Tier $2.65 1) candesartan cilexetil (Tier 1) PRINIVIL (Use Lisinopril) NF MO COZAAR (Use Losartan NF MO $0- MO Potassium) $2.65 MO quinapril hcl (Tier DIOVAN (Use Valsartan) NF 1) $0- MO $0- MO $2.65 $2.65 eprosartan mesylate ramipril (Tier (Tier 1) 1) $0- MO $0- MO $2.65 $2.65 irbesartan trandolapril (Tier (Tier 1) 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

47 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO $2.65 $2.65 losartan potassium (Tier prazosin hcl (Tier 1) 1) $0- TEVETEN (Use Eprosartan NF MO MO Mesylate) RESERPINE TABS OR 0.1 $6.60 $0- MO MG, 0.25 MG (Tier $2.65 2) valsartan (Tier TENEX (Use Guanfacine NF AL; MO 1) HCl) Antiadrenergic Antihypertensives $0- MO $2.65 terazosin hcl CARDURA (Use NF MO (Tier Doxazosin Mesylate) 1) CATAPRES (Use Clonidine NF MO HCl) Antihypertensive Combinations ACCURETIC (Use MO CATAPRES-TTS-1 (Use NF MO Clonidine HCl) Quinapril- NF Hydrochlorothiazide) CATAPRES-TTS-2 (Use NF MO Clonidine HCl) $0- MO amlodipine besylate- $2.65 CATAPRES-TTS-3 (Use NF MO benazepril hcl (Tier Clonidine HCl) 1) $0- MO ATACAND HCT (Use MO clonidine hcl ptwk td 0.1 $2.65 mg/24hr, 0.2 mg/24hr, 0.3 Candesartan Cilexetil- NF (Tier Hydrochlorothiazide) mg/24hr 1) $0- MO $0- MO $2.65 clonidine hcl tabs or 0.1 $2.65 atenolol & chlorthalidone (Tier mg, 0.2 mg, 0.3 mg (Tier 1) 1) AVALIDE (Use Irbesartan- NF MO $0- MO Hydrochlorothiazide) $2.65 doxazosin mesylate (Tier $0- MO 1) benazepril & $2.65 hydrochlorothiazide (Tier $0- AL; MO 1) $2.65 guanfacine hcl (Tier $0- MO 1) bisoprolol & $2.65 hydrochlorothiazide (Tier MINIPRESS (Use Prazosin NF MO 1) HCl)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

48 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO LOTREL (Use Amlodipine NF MO candesartan cilexetil- $2.65 Besylate-Benazepril HCl) hydrochlorothiazide (Tier $0- AL; MO 1) methyldopa & $2.65 $0- MO hydrochlorothiazide (Tier captopril & $2.65 1) hydrochlorothiazide (Tier $0- MO 1) metoprolol & $2.65 CORZIDE (Use Nadolol & NF MO hydrochlorothiazide (Tier Bendroflumethiazide) 1) DIOVAN HCT (Use MO $0- MO Valsartan- NF moexipril- $2.65 Hydrochlorothiazide) hydrochlorothiazide (Tier $0- MO 1) enalapril maleate & $2.65 $0- MO hydrochlorothiazide (Tier nadolol & $2.65 1) bendroflumethiazide (Tier $0- MO 1) fosinopril sodium & $2.65 $0- MO hydrochlorothiazide (Tier quinapril- $2.65 1) hydrochlorothiazide (Tier HYZAAR (Use Losartan MO 1) Potassium & NF $0- MO $6.60 Hydrochlorothiazide) TEKTURNA HCT $0- MO (Tier irbesartan- $2.65 2) hydrochlorothiazide (Tier TENORETIC 100 (Use NF MO 1) Atenolol & Chlorthalidone) $0- MO TENORETIC 50 (Use NF MO lisinopril & $2.65 Atenolol & Chlorthalidone) hydrochlorothiazide (Tier UNIRETIC (Use Moexipril- NF MO 1) Hydrochlorothiazide) LOPRESSOR HCT (Use MO $0- MO Metoprolol & NF valsartan- $2.65 Hydrochlorothiazide) hydrochlorothiazide (Tier $0- MO 1) losartan potassium & $2.65 VASERETIC (Use Enalapril MO hydrochlorothiazide (Tier Maleate & NF 1) Hydrochlorothiazide) LOTENSIN HCT (Use MO ZESTORETIC (Use MO Benazepril & NF Lisinopril & NF Hydrochlorothiazide) Hydrochlorothiazide)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

49 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- ZIAC (Use Bisoprolol & NF MO MO Hydrochlorothiazide) chloroquine phosphate tabs $2.65 or 250 mg, 500 mg (Tier Direct Renin Inhibitors 1) $0- MO $0- MO $6.60 TEKTURNA $6.60 (Tier DARAPRIM (Tier 2) 2) Selective Aldosterone Receptor Antagonists $0- MO $0- MO hydroxychloroquine sulfate $2.65 $2.65 tabs or (Tier eplerenone (Tier 1) 1) $0- MO INSPRA (Use Eplerenone) NF MO $2.65 mefloquine hcl (Tier Vasodilators 1) $0- MO PLAQUENIL (Use MO hydralazine hcl tabs or 10 $2.65 Hydroxychloroquine NF mg, 100 mg, 25 mg, 50 mg (Tier Sulfate) 1) $0- MO $0- MO PRIMAQUINE $6.60 minoxidil tabs or 10 mg, 2.5 $2.65 PHOSPHATE (Tier mg (Tier 2) 1) QUALAQUIN (Use Quinine NF PA; MO Sulfate) ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections) $0- PA; MO $2.65 Antimalarial Combinations quinine sulfate caps or (Tier $0- MO 1) atovaquone-proguanil hcl $2.65 250mg-100mg (Tier ANTIMYASTHENIC/CHOLINERGIC AGENTS 1) Antimyasthenic/Cholinergic Agents $0- MO $6.60 $0- COARTEM $2.65 (Tier guanidine hcl 2) (Tier 1) MALARONE 250MG- MO 100MG (Use Atovaquone- NF MESTINON TABS 60 MG MO Proguanil HCl) (Use Pyridostigmine NF Bromide) Antimalarials $0- MESTINON TIMESPAN MO ARALEN (Use Chloroquine NF MO $6.60 Phosphate) (Use Pyridostigmine (Tier Bromide) 2) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

50 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO pyridostigmine bromide $2.65 $6.60 tabs or 60 mg (Tier PRIFTIN (Tier 1) 2) $0- MO $0- MO pyridostigmine bromide $2.65 $2.65 tbcr or 180 mg (Tier pyrazinamide (Tier 1) 1) ANTIMYCOBACTERIAL AGENTS - Drugs to $0- MO Treat Tuberculosis (Bacterial Infections) $2.65 rifabutin (Tier Anti TB Combinations 1) $0- MO RIFADIN 300 MG,600 MG NF MO $2.65 (Use Rifampin) isoniazid & rifampin (Tier 1) $0- MO rifampin caps or 150 mg, $2.65 $0- MO 300 mg (Tier $6.60 1) RIFATER (Tier 2) $0- MO $2.65 rifampin solr iv 600 mg Antimycobacterial Agents (Tier $0- MO 1) $2.65 aminosalicylic acid pack or $0- MO (Tier $6.60 1) TRECATOR (Tier $0- 2) $6.60 CAPASTAT SULFATE ANTINEOPLASTICS AND ADJUNCTIVE (Tier THERAPIES - Drugs to Treat Cancer 2) $0- MO Alkylating Agents ethambutol hcl tabs or 100 $2.65 ALKERAN SOLR IV 50 MG NF mg, 400 mg (Tier (Use Melphalan HCl) 1) $0- MO; B/D $6.60 $0- MO ALKERAN TABS OR 2 MG isoniazid tabs or 100 mg, $2.65 (Tier 300 mg (Tier 2) 1) $0- $6.60 MYAMBUTOL (Use NF MO BICNU Ethambutol HCl) (Tier $0- MO 2) MYCOBUTIN (Use $6.60 Rifabutin) (Tier 2) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

51 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- $0- $6.60 $2.65 BUSULFEX (Tier ifosfamide solr 1 gm (Tier 2) 1) $0- $0- carboplatin 150 mg/15ml, $2.65 $6.60 600 mg/60ml (Tier IFOSFAMIDE SOLR 3 GM (Tier 1) 2) $0- MO $0- MO carboplatin 450 mg/45ml, $2.65 $6.60 50 mg/5ml (Tier LEUKERAN (Tier 1) 2) $0- $0- $2.65 $2.65 cisplatin (Tier lomustine 10 mg (Tier 1) 1) $0- B/D $0- cyclophosphamide tabs or $2.65 LOMUSTINE 100 MG, 40 $6.60 25 mg, 50 mg (Tier MG (Tier 1) 2) ELOXATIN (Use MO $0- NF $2.65 Oxaliplatin) melphalan hcl $0- (Tier $6.60 1) GLEOSTINE (Tier $0- $6.60 2) MUSTARGEN $0- MO (Tier $6.60 2) HEXALEN (Tier $0- MO 2) oxaliplatin soln 100 $2.65 mg/20ml, 50 mg/10ml (Tier IFEX 1 GM (Use NF Ifosfamide) 1) $0- $0- $6.60 oxaliplatin solr 100 mg, 50 $2.65 IFEX 3 GM (Tier mg (Tier 2) 1) $0- $0- $6.60 ifosfamide soln 1 gm/20ml, $2.65 TEMODAR 3 gm/60ml (Tier (Tier 1) 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

52 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- $0- $6.60 $2.65 THIOTEPA SOLR IJ (Tier cytarabine soln 100 mg/ml (Tier 2) 1) $0- $0- MO $6.60 $2.65 TREANDA (Tier cytarabine soln 20 mg/ml (Tier 2) 1) $0- DACOGEN (Use $6.60 NF YONDELIS Decitabine) (Tier $0- 2) $2.65 $0- MO decitabine (Tier $6.60 1) ZANOSAR (Tier FLUDARA (Use NF MO 2) Fludarabine Phosphate) Antimetabolites $0- MO $0- fludarabine phosphate solr $2.65 $6.60 50 mg (Tier ALIMTA 100 MG (Tier 1) 2) $0- $0- MO fluorouracil soln iv 1 $2.65 $6.60 gm/20ml (Tier ALIMTA 500 MG (Tier 1) 2) $0- fluorouracil soln iv 2.5 MO $0- $2.65 gm/50ml, 5 gm/100ml, 500 (Tier $6.60 mg/10ml ARRANON (Tier 1) 2) $0- $6.60 $0- FOLOTYN $2.65 (Tier azacitidine (Tier 2) 1) $0- $6.60 $0- MO GEMCITABINE $2.65 (Tier cladribine (Tier 2) 1) $0- MO $0- gemcitabine hcl 1 gm, 200 $2.65 $6.60 mg (Tier CLOLAR (Tier 1) 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

53 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- $0- $2.65 $6.60 gemcitabine hcl 2 gm (Tier ZALTRAP (Tier 1) 2) GEMZAR (Use NF MO Antineoplastic - Antibodies ) Gemcitabine HCl $0- $0- MO $6.60 $2.65 ARZERRA mercaptopurine tabs or (Tier (Tier 2) 1) $0- PA methotrexate sodium soln ij $0- $6.60 1 gm/40ml, 100 mg/4ml, $2.65 BLINCYTO (Tier 200 mg/8ml, 25 mg/ml, 250 (Tier 2) mg/10ml, 50 mg/2ml 1) $0- $0- $6.60 methotrexate sodium solr ij $2.65 ERBITUX (Tier 1 gm (Tier 2) 1) $0- LA $0- methotrexate sodium tabs MO $6.60 $2.65 GAZYVA (Tier or 10 mg, 15 mg, 2.5 mg, 5 (Tier mg, 7.5 mg 2) 1) $0- PURINETHOL (Use NF MO $6.60 Mercaptopurine) HERCEPTIN (Tier $0- 2) $6.60 PURIXAN $0- (Tier $6.60 2) KADCYLA (Tier $0- MO 2) $6.60 TABLOID $0- (Tier $6.60 2) KEYTRUDA (Tier VIDAZA (Use Azacitidine) NF 2) $0- $6.60 Antineoplastic - Angiogenesis Inhibitors OPDIVO $0- (Tier $6.60 2) AVASTIN (Tier $0- $6.60 2) PERJETA $0- LA (Tier $6.60 2) CYRAMZA (Tier 2) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

54 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- $0- $6.60 $6.60 RITUXAN (Tier ELIGARD (Tier 2) 2) $0- $0- MO $6.60 $6.60 VECTIBIX (Tier EMCYT (Tier 2) 2) $0- $0- MO $6.60 $2.65 YERVOY (Tier exemestane (Tier 2) 1) Antineoplastic - Hedgehog Pathway Inhibitors $0- MO $6.60 $0- LA FARESTON $6.60 (Tier ERIVEDGE (Tier 2) 2) $0- MO $6.60 $0- PA FASLODEX $6.60 (Tier ODOMZO (Tier 2) 2) FEMARA (Use Letrozole) NF MO Antineoplastic - Hormonal and Related Agents $0- $0- MO $6.60 $2.65 FIRMAGON anastrozole tabs or (Tier (Tier 2) 1) $0- MO ARIMIDEX (Use NF MO $2.65 Anastrozole) flutamide (Tier 1) AROMASIN (Use NF MO Exemestane) $0- MO $2.65 $0- MO letrozole $2.65 (Tier bicalutamide (Tier 1) 1) $0- $2.65 CASODEX (Use NF MO leuprolide acetate kit ij Bicalutamide) (Tier $0- MO 1) $6.60 $0- DEPO-PROVERA $6.60 (Tier LUPRON DEPOT 2) (Tier 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

55 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- $6.60 $6.60 LYSODREN (Tier ZOLADEX (Tier 2) 2) MEGACE ORAL (Use AL; MO $0- NF $6.60 Megestrol Acetate) ZYTIGA $0- AL; MO (Tier megestrol acetate susp or $2.65 2) 40 mg/ml, 400 mg/10ml (Tier Antineoplastic - Immunomodulators 1) $0- LA $0- AL; MO $6.60 megestrol acetate tabs or $2.65 POMALYST (Tier 20 mg, 40 mg (Tier 2) 1) Antineoplastic Antibiotics $0- MO $6.60 $0- MO NILANDRON $2.65 (Tier bleomycin sulfate 15 unit 2) (Tier 1) $0- MO $6.60 $0- SOLTAMOX $2.65 (Tier bleomycin sulfate 30 unit 2) (Tier 1) $0- MO tamoxifen citrate tabs or 10 $2.65 $0- MO $6.60 mg, 20 mg (Tier COSMEGEN 1) (Tier 2) $0- $6.60 $0- TRELSTAR $2.65 (Tier daunorubicin hcl 2) (Tier 1) $0- $6.60 $0- TRELSTAR MIXJECT $6.60 (Tier DAUNOXOME 2) (Tier 2) $0- $6.60 DOXIL (Use Doxorubicin NF VANTAS (Tier HCl Liposomal) 2) $0- $2.65 $0- PA; LA doxorubicin hcl liposomal $6.60 (Tier XTANDI (Tier 1) 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

56 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- doxorubicin hcl soln 2 $2.65 $6.60 mg/ml (Tier AFINITOR DISPERZ (Tier 1) 2) $0- $0- $2.65 $6.60 doxorubicin hcl solr 10 mg (Tier BELEODAQ (Tier 1) 2) $0- MO $0- PA $2.65 $6.60 doxorubicin hcl solr 50 mg (Tier BOSULIF (Tier 1) 2) ELLENCE (Use Epirubicin MO $0- LA NF $6.60 HCl) CAPRELSA $0- MO (Tier epirubicin hcl soln 200 $2.65 2) mg/100ml, 50 mg/25ml (Tier $0- 1) $6.60 COMETRIQ (Tier IDAMYCIN PFS (Use NF Idarubicin HCl) 2) $0- $0- 140 MG Dose $6.60 $2.65 COMETRIQ Kit;MO idarubicin hcl (Tier (Tier 1) 2) $0- MO $0- PA; LA $6.60 mitomycin solr iv 20 mg, 40 $2.65 FARYDAK mg, 5 mg (Tier (Tier 1) 2) $0- $0- LA $6.60 $2.65 GILOTRIF mitoxantrone hcl (Tier (Tier 1) 2) $0- $0- $6.60 $6.60 GLEEVEC VALSTAR (Tier (Tier 2) 2) $0- LA Antineoplastic Enzyme Inhibitors $6.60 $0- IBRANCE (Tier $6.60 2) AFINITOR (Tier 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

57 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- LA $0- PA; LA $6.60 $6.60 ICLUSIG (Tier LYNPARZA (Tier 2) 2) $0- PA $0- $6.60 $6.60 IMBRUVICA (Tier MEKINIST (Tier 2) 2) $0- PA; LA $0- LA $6.60 $6.60 INLYTA (Tier NEXAVAR (Tier 2) 2) $0- LA $0- $6.60 $6.60 IRESSA (Tier SPRYCEL (Tier 2) 2) $0- $0- PA; LA $6.60 $6.60 ISTODAX (Tier STIVARGA (Tier 2) 2) $0- LA $0- $6.60 $6.60 JAKAFI (Tier SUTENT (Tier 2) 2) $0- PA $0- LENVIMA 10MG DAILY $6.60 $6.60 DOSE (Tier TAFINLAR (Tier 2) 2) $0- PA $0- LENVIMA 14MG DAILY $6.60 $6.60 DOSE (Tier TARCEVA (Tier 2) 2) $0- PA $0- LENVIMA 20MG DAILY $6.60 $6.60 DOSE (Tier TASIGNA (Tier 2) 2) $0- PA $0- LENVIMA 24MG DAILY $6.60 $6.60 DOSE (Tier TORISEL (Tier 2) 2)

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58 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- $0- LA $6.60 $6.60 TYKERB (Tier ACTIMMUNE (Tier 2) 2) $0- $0- $6.60 $2.65 VELCADE (Tier bexarotene (Tier 2) 1) $0- $0- $6.60 $2.65 VOTRIENT (Tier dacarbazine 100 mg (Tier 2) 1) $0- $0- MO $6.60 $2.65 XALKORI (Tier dacarbazine 200 mg (Tier 2) 1) $0- LA HYDREA (Use MO $6.60 NF ZELBORAF Hydroxyurea) (Tier $0- MO 2) $2.65 $0- hydroxyurea caps or (Tier $6.60 ZOLINZA 1) (Tier $0- 2) $6.60 $0- PA INTRON A (Tier $6.60 ZYDELIG 2) (Tier $0- 2) $6.60 $0- PA; LA INTRON A W/DILUENT (Tier $6.60 ZYKADIA 2) (Tier $0- LA 2) $6.60 MATULANE Antineoplastic Enzymes (Tier $0- 2) $6.60 $0- ERWINAZE $6.60 (Tier PROLEUKIN 2) (Tier $0- 2) $6.60 $0- ONCASPAR $6.60 (Tier SYLATRON 2) (Tier 2) Antineoplastics Misc.

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Health Net Cal MediConnect 2015 Drug List

59 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- $0- MO $6.60 $2.65 SYNRIBO (Tier amifostine crystalline (Tier 2) 1) $0- $0- $6.60 $2.65 TARGRETIN 1 %,75 MG (Tier dexrazoxane (Tier 2) 1) $0- ETHYOL (Use Amifostine NF MO TARGRETIN 75 MG (Use $6.60 Crystalline) Bexarotene) (Tier $0- 2) $6.60 $0- MO FUSILEV (Tier $6.60 THERACYS 2) (Tier $0- MO 2) leucovorin calcium solr ij $2.65 $0- MO 100 mg, 200 mg, 350 mg (Tier $6.60 TICE BCG 1) (Tier $0- 2) leucovorin calcium solr ij 50 $2.65 $0- MO mg, 500 mg (Tier $2.65 tretinoin (chemotherapy) 1) (Tier $0- MO 1) leucovorin calcium tabs or $2.65 $0- MO 10 mg, 15 mg, 25 mg, 5 mg (Tier $6.60 TRISENOX 1) (Tier $0- 2) $6.60 $0- LEVOLEUCOVORIN (Tier $6.60 UVADEX 2) (Tier $0- 2) $2.65 levoleucovorin calcium Chemotherapy Adjuncts (Tier $0- 1) $6.60 $0- MO ELITEK $2.65 (Tier mesna 2) (Tier $0- MO 1) $6.60 MESNEX SOLN IV 100 NF MO KEPIVANCE (Tier MG/ML (Use Mesna) 2) Chemotherapy Rescue/Antidote Agents

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Health Net Cal MediConnect 2015 Drug List

60 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MESNEX TABS OR 400 $6.60 $6.60 MG (Tier HALAVEN (Tier 2) 2) $0- $0- $6.60 $6.60 TOTECT (Tier IXEMPRA KIT (Tier 2) 2) $0- ZINECARD (Use NF Dexrazoxane) $6.60 JEVTANA (Tier Mitotic Inhibitors 2) $0- MO NAVELBINE (Use NF MO $6.60 Vinorelbine Tartrate) ABRAXANE (Tier 2) $0- MO paclitaxel 100 mg/16.7ml, $2.65 $0- $6.60 30 mg/5ml, 300 mg/50ml (Tier DOCEFREZ (Tier 1) 2) $0- $2.65 $0- paclitaxel 150 mg/25ml docetaxel conc 140 $2.65 (Tier mg/7ml, 20 mg/ml, 80 (Tier 1) mg/4ml 1) TAXOL (Use Paclitaxel) NF MO $0- DOCETAXEL CONC 20 $6.60 $0- MG/ML, 80 MG/4ML (Tier TAXOTERE (Use $6.60 2) Docetaxel) (Tier 2) $0- DOCETAXEL SOLN 160 $6.60 $0- MO MG/16ML, 20 MG/2ML, $2.65 (Tier vinblastine sulfate 200 MG/20ML, 80 MG/8ML 2) (Tier 1) $0- MO $6.60 $0- MO ETOPOPHOS $2.65 (Tier vincristine sulfate 2) (Tier 1) $0- MO etoposide soln iv 1 $2.65 $0- MO $2.65 gm/50ml, 100 mg/5ml (Tier vinorelbine tartrate 1) (Tier 1) $0- etoposide soln iv 500 $2.65 Topoisomerase I Inhibitors mg/25ml (Tier 1) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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61 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) CAMPTOSAR 100 MO $0- AL; MO MG/5ML, 40 MG/2ML (Use NF benztropine mesylate tabs $2.65 Irinotecan HCl) or 0.5 mg, 1 mg, 2 mg (Tier $0- 1) CAMPTOSAR 300 $6.60 COGENTIN (Use NF MO MG/15ML (Tier Benztropine Mesylate) 2) $0- AL; MO $2.65 HYCAMTIN (Use NF MO trihexyphenidyl hcl Topotecan HCl) (Tier $0- MO 1) irinotecan hcl 100 mg/5ml, $2.65 Antiparkinson COMT Inhibitors 40 mg/2ml (Tier COMTAN (Use NF MO 1) Entacapone) $0- $2.65 $0- MO irinotecan hcl 500 mg/25ml $2.65 (Tier entacapone (Tier 1) 1) $0- $0- MO TOPOTECAN HCL SOLN $6.60 $6.60 4 MG/4ML (Tier TASMAR (Use Tolcapone) (Tier 2) 2) $0- MO $2.65 $0- MO topotecan hcl solr 4 mg $2.65 (Tier tolcapone (Tier 1) 1) ANTIPARKINSON AGENTS - Drugs to Treat Parkinson's Disease Antiparkinson Dopaminergics $0- MO Antiparkinson Adjuvants amantadine hcl caps or 100 $2.65 $0- MO mg (Tier $2.65 1) carbidopa tabs or (Tier $0- MO 1) amantadine hcl syrp or 50 $2.65 mg/5ml (Tier LODOSYN (Use NF MO Carbidopa) 1) Antiparkinson Anticholinergics $0- MO amantadine hcl tabs or 100 $2.65 $0- MO mg (Tier benztropine mesylate soln $2.65 1) ij 1 mg/ml (Tier 1) $0- LA $6.60 APOKYN (Tier 2)

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Health Net Cal MediConnect 2015 Drug List

62 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO SINEMET CR (Use NF MO bromocriptine mesylate $2.65 Carbidopa-Levodopa) caps or 5 mg (Tier 1) Antiparkinson Monoamine Oxidase Inhibitors $0- MO $0- MO $6.60 bromocriptine mesylate $2.65 AZILECT tabs or 2.5 mg (Tier (Tier 1) 2) $0- MO ELDEPRYL (Use Selegiline NF MO $2.65 HCl) carbidopa-levodopa (Tier $0- MO $2.65 1) selegiline hcl caps or $0- B/D (Tier $6.60 1) DUOPA (Tier $0- MO $2.65 2) selegiline hcl tabs or MIRAPEX (Use MO (Tier Pramipexole NF 1) Dihydrochloride) ANTIPSYCHOTICS/ANTIMANIC AGENTS - $0- MO Drugs to Treat Mood Disorders $6.60 Antimanic Agents NEUPRO (Tier 2) $0- MO $2.65 lithium PARLODEL (Use NF MO (Tier Bromocriptine Mesylate) 1) pramipexole $0- MO $0- MO dihydrochloride tabs 0.125 $2.65 lithium carbonate caps or $2.65 mg, 0.25 mg, 0.5 mg, 0.75 (Tier 150 mg, 300 mg, 600 mg (Tier mg, 1 mg, 1.5 mg 1) 1) REQUIP (Use Ropinirole NF MO LITHIUM CARBONATE MO Hydrochloride) CAPS OR 600 MG (Use NF Lithium Carbonate) REQUIP XL (Use NF MO Ropinirole Hydrochloride) $0- MO $0- MO lithium carbonate tabs or $2.65 $2.65 300 mg (Tier ropinirole hydrochloride (Tier 1) 1) $0- MO $0- MO lithium carbonate tbcr or $2.65 $6.60 300 mg, 450 mg (Tier RYTARY (Tier 1) 2) LITHOBID (Use Lithium NF MO Carbonate) SINEMET (Use Carbidopa- NF MO Levodopa) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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63 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Antipsychotics - Misc. $0- QL(8 ea daily); INVEGA 1.5 MG (Use $6.60 $0- MO MO $6.60 Paliperidone) (Tier EQUETRO (Tier 2) 2) $0- QL(4 ea daily); INVEGA 3 MG (Use $6.60 MO GEODON CAPS OR 20 MO Paliperidone) (Tier MG, 40 MG, 60 MG, 80 MG NF 2) (Use Ziprasidone HCl) $0- QL(2 ea daily); $0- MO INVEGA 6 MG (Use $6.60 MO $6.60 GEODON SOLR IM 20 MG Paliperidone) (Tier (Tier 2) 2) $0- QL(1 ea daily); $0- QL(1 ea daily); INVEGA 9 MG (Use $6.60 MO $6.60 LATUDA 120 MG MO Paliperidone) (Tier (Tier 2) 2) $0- MO $0- QL(8 ea daily); $6.60 $6.60 INVEGA SUSTENNA LATUDA 20 MG MO (Tier (Tier 2) 2) $0- $0- QL(4 ea daily); $6.60 $6.60 INVEGA TRINZA LATUDA 40 MG MO (Tier (Tier 2) 2) $0- QL(8 ea daily); $0- QL(2.67 ea $2.65 MO $6.60 paliperidone 1.5 mg LATUDA 60 MG daily); MO (Tier (Tier 1) 2) $0- QL(4 ea daily); $0- QL(2 ea daily); $2.65 MO $6.60 paliperidone 3 mg LATUDA 80 MG MO (Tier (Tier 1) 2) $0- QL(2 ea daily); $0- MO $2.65 MO $2.65 paliperidone 6 mg ziprasidone hcl (Tier (Tier 1) 1) $0- QL(1 ea daily); Benzisoxazoles $2.65 paliperidone 9 mg MO $0- MO (Tier $6.60 1) FANAPT (Tier RISPERDAL (Use NF MO 2) Risperidone)

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Health Net Cal MediConnect 2015 Drug List

64 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- QL(0.29 ea $0- RISPERDAL CONSTA $6.60 daily); MO $2.65 12.5 MG (Tier clozapine (Tier 2) 1) $0- QL(0.15 ea $0- RISPERDAL CONSTA 25 $6.60 daily); MO $6.60 MG (Tier CLOZAPINE ODT (Tier 2) 2) $0- QL(0.08 ea CLOZARIL (Use NF RISPERDAL CONSTA $6.60 daily); MO Clozapine) 37.5 MG, 50 MG (Tier $0- 2) FAZACLO 100 MG,25 MG $6.60 RISPERDAL M-TAB (Use NF MO (Use Clozapine) (Tier Risperidone) 2) $0- MO $0- $2.65 FAZACLO 12.5 MG,150 $6.60 risperidone (Tier MG,200 MG (Tier 1) 2) Butyrophenones $0- MO loxapine succinate 10 mg, $2.65 HALDOL (Use Haloperidol NF MO 25 mg, 5 mg, 50 mg (Tier Lactate) 1) HALDOL DECANOATE MO $0- MO 100 (Use Haloperidol NF $2.65 Decanoate) olanzapine (Tier HALDOL DECANOATE 50 MO 1) (Use Haloperidol NF $0- MO Decanoate) $2.65 $0- MO quetiapine fumarate (Tier $2.65 haloperidol 1) (Tier $0- QL(2 ea daily); 1) $6.60 MO $0- MO SAPHRIS 10 MG (Tier haloperidol decanoate soln $2.65 2) im 100 mg/ml, 50 mg/ml (Tier $0- QL(8 ea daily); 1) $6.60 MO $0- MO SAPHRIS 2.5 MG (Tier $2.65 haloperidol lactate 2) (Tier $0- QL(4 ea daily); 1) $6.60 SAPHRIS 5 MG MO Dibenzapines (Tier 2)

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Health Net Cal MediConnect 2015 Drug List

65 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- SEROQUEL (Use NF MO MO Quetiapine Fumarate) fluphenazine hcl tabs or 1 $2.65 $0- PA; QL(18 ml mg, 10 mg, 2.5 mg, 5 mg (Tier $6.60 daily) 1) VERSACLOZ (Tier $0- MO 2) perphenazine tabs or 16 $2.65 mg, 2 mg, 4 mg, 8 mg (Tier ZYPREXA (Use NF MO Olanzapine) 1) $0- $0- MO $2.65 ZYPREXA RELPREVV 210 $6.60 prochlorperazine MG (Tier (Tier 2) 1) $0- MO ZYPREXA ZYDIS (Use NF MO Olanzapine) prochlorperazine edisylate $2.65 soln ij (Tier Phenothiazines 1) $0- MO $0- MO chlorpromazine hcl soln ij $2.65 prochlorperazine maleate $2.65 25 mg/ml (Tier tabs or 10 mg, 5 mg (Tier 1) 1) $0- $0- AL; MO chlorpromazine hcl soln ij $2.65 thioridazine hcl tabs or 10 $2.65 50 mg/2ml (Tier mg, 100 mg, 25 mg, 50 mg (Tier 1) 1) $0- chlorpromazine hcl tabs or MO $0- MO $2.65 $2.65 10 mg, 100 mg, 200 mg, 25 (Tier trifluoperazine hcl mg, 50 mg (Tier 1) 1) $0- MO Quinolinone Derivatives fluphenazine decanoate $2.65 soln ij (Tier $0- QL(3 ea daily) 1) ABILIFY DISCMELT 10 $6.60 MG (Tier $0- MO 2) fluphenazine hcl conc or 5 $2.65 mg/ml (Tier $0- QL(2 ea daily) 1) ABILIFY DISCMELT 15 $6.60 MG (Tier $0- MO 2) fluphenazine hcl soln ij 2.5 $2.65 mg/ml (Tier $0- MO 1) $6.60 ABILIFY MAINTENA (Tier 2)

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Health Net Cal MediConnect 2015 Drug List

66 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- QL(4 ml daily); $0- QL(3 ea daily); ABILIFY SOLN IM 9.75 $6.60 MO $2.65 MO MG/1.3ML (Tier aripiprazole tabs 10 mg (Tier 2) 1) $0- QL(30 ml $0- QL(2 ea daily); ABILIFY SOLN OR 1 $6.60 daily); MO $2.65 MO MG/ML (Tier aripiprazole tabs 15 mg (Tier 2) 1) $0- QL(3 ea daily); $0- QL(15 ea ABILIFY TABS OR 10 MG $6.60 MO $2.65 daily); MO (Use Aripiprazole) (Tier aripiprazole tabs 2 mg (Tier 2) 1) $0- QL(2 ea daily); $0- QL(1 ea daily); ABILIFY TABS OR 15 MG $6.60 MO aripiprazole tabs 20 mg, 30 $2.65 MO (Use Aripiprazole) (Tier mg (Tier 2) 1) $0- QL(15 ea $0- QL(6 ea daily); ABILIFY TABS OR 2 MG $6.60 daily); MO $2.65 MO (Use Aripiprazole) (Tier aripiprazole tabs 5 mg (Tier 2) 1) $0- QL(1 ea daily); $0- PA; QL(16 ea ABILIFY TABS OR 20 MG, $6.60 MO $6.60 daily); MO 30 MG (Use Aripiprazole) (Tier REXULTI 0.25 MG (Tier 2) 2) $0- QL(6 ea daily); $0- PA; QL(8 ea ABILIFY TABS OR 5 MG $6.60 MO $6.60 daily); MO (Use Aripiprazole) (Tier REXULTI 0.5 MG (Tier 2) 2) $0- QL(3 ea daily) $0- PA; QL(4 ea ARIPIPRAZOLE ODT 10 $6.60 $6.60 daily); MO MG (Tier REXULTI 1 MG (Tier 2) 2) $0- QL(2 ea daily) $0- PA; QL(2 ea ARIPIPRAZOLE ODT 15 $6.60 $6.60 daily); MO MG (Tier REXULTI 2 MG (Tier 2) 2) $0- QL(30 ml $0- PA; QL(1 ea $2.65 daily); MO $6.60 daily); MO aripiprazole soln 1 mg/ml (Tier REXULTI 3 MG, 4 MG (Tier 1) 2) Thioxanthenes

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Health Net Cal MediConnect 2015 Drug List

67 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO COMBIVIR (Use MO $2.65 NF thiothixene Lamivudine-Zidovudine) (Tier $0- MO 1) $6.60 COMPLERA ANTISEPTICS & DISINFECTANTS - Drugs to (Tier Prevent Bacterial Skin Infections 2) $0- MO Chlorine Antiseptics $6.60 $0 CRIXIVAN BENZALKONIUM RX/OTC; NT (Tier (Tier 2) CHLORIDE SOLN 3) $0- MO $0 NT $2.65 CETAPHIL (Tier didanosine ANTIBACTERIAL (Tier 3) 1) $0 MO; NT $0- MO dakin's solution 0.25 %, 0.5 (Tier % $6.60 3) EDURANT (Tier $0 RX/OTC; NT 2) PEDI-WHIRL (Tier CONCENTRATE $0- MO 3) $6.60 EMTRIVA (Tier ANTIVIRALS - Drugs to Treat Viral Infections 2) Antiretrovirals $0- MO $0- MO EPIVIR SOLN 10 MG/ML $6.60 $2.65 (Use Lamivudine) (Tier abacavir sulfate (Tier 2) 1) EPIVIR TABS 150 MG, 300 NF MO $0- MO MG (Use Lamivudine) abacavir sulfate- $2.65 $0- MO $6.60 lamivudine-zidovudine (Tier EPZICOM 1) (Tier $0- MO 2) $6.60 $0- MO APTIVUS CAPS 250 MG $6.60 (Tier EVOTAZ 2) (Tier $0- 2) APTIVUS SOLN 100 $6.60 $0- $6.60 MG/ML (Tier FUZEON 2) (Tier $0- MO 2) $6.60 ATRIPLA (Tier 2) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

68 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO INTELENCE 100 MG, 200 $6.60 $6.60 MG (Tier LEXIVA (Tier 2) 2) $0- $0- MO $6.60 NEVIRAPINE SUSP 50 $6.60 INTELENCE 25 MG (Tier MG/5ML (Tier 2) 2) $0- MO $0- MO $6.60 $2.65 INVIRASE (Tier nevirapine tabs 200 mg (Tier 2) 1) $0- QL(6 ea daily); $0- ISENTRESS CHEW 100 $6.60 MO $2.65 MG (Tier nevirapine tb24 100 mg (Tier 2) 1) $0- QL(24 ea $0- MO $6.60 daily); MO $2.65 ISENTRESS CHEW 25 MG (Tier nevirapine tb24 400 mg (Tier 2) 1) $0- QL(2 ea daily) $0- MO ISENTRESS PACK 100 $6.60 $6.60 MG (Tier NORVIR (Tier 2) 2) $0- MO $0- MO ISENTRESS TABS 400 $6.60 $6.60 MG (Tier PREZCOBIX (Tier 2) 2) $0- MO $0- MO $6.60 PREZISTA SUSP 100 $6.60 KALETRA (Tier MG/ML (Tier 2) 2) $0- MO $0- MO $2.65 PREZISTA TABS 150 MG, $6.60 lamivudine (Tier 600 MG, 800 MG (Tier 1) 2) $0- MO $0- $2.65 PREZISTA TABS 400 MG, $6.60 lamivudine-zidovudine (Tier 75 MG (Tier 1) 2)

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Health Net Cal MediConnect 2015 Drug List

69 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO TRIZIVIR (Use Abacavir MO $6.60 RESCRIPTOR Sulfate-Lamivudine- NF (Tier Zidovudine) 2) $0- MO RETROVIR (Use NF MO $6.60 Zidovudine) TRUVADA (Tier $0- 2) $6.60 $0- MO RETROVIR IV INFUSION (Tier $6.60 2) TYBOST (Tier $0- MO 2) REYATAZ CAPS 150 MG, $6.60 VIDEX EC (Use NF MO 200 MG, 300 MG (Tier Didanosine) 2) $0- MO $0- $6.60 $6.60 VIDEXPEDIATRIC REYATAZ PACK 50 MG (Tier (Tier 2) 2) $0- MO $0- MO $6.60 $6.60 VIRACEPT SELZENTRY (Tier (Tier 2) 2) $0- MO $0- MO VIRAMUNE SUSP 50 $6.60 $2.65 stavudine MG/5ML (Tier (Tier 2) 1) VIRAMUNE TABS 200 MG NF MO $0- MO (Use Nevirapine) $6.60 STRIBILD $0- (Tier $6.60 2) VIRAMUNE XR 100 MG (Tier $0- MO 2) $6.60 SUSTIVA VIRAMUNE XR 400 MG NF MO (Tier (Use Nevirapine) 2) $0- MO $0- MO $6.60 $6.60 VIREAD POWD 40 MG/GM TIVICAY (Tier (Tier 2) 2) $0- MO $0- MO VIREAD TABS 150 MG, $6.60 $6.60 TRIUMEQ 200 MG, 300 MG (Tier (Tier 2) 2)

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Health Net Cal MediConnect 2015 Drug List

70 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- $0- MO $6.60 $2.65 VIREAD TABS 250 MG (Tier adefovir dipivoxil (Tier 2) 1) $0- $0- MO $6.60 $6.60 VITEKTA (Tier BARACLUDE 0.05 MG/ML (Tier 2) 2) ZERIT (Use Stavudine) NF MO $0- MO BARACLUDE 0.5 MG,1 $6.60 $0- MO MG (Use Entecavir) (Tier $6.60 2) ZIAGEN SOLN 20 MG/ML (Tier COPEGUS (Use Ribavirin NF 2) (Hepatitis C)) ZIAGEN TABS 300 MG NF MO $0- MO (Use Abacavir Sulfate) $2.65 entecavir $0- MO (Tier $2.65 1) zidovudine (Tier $0- MO 1) EPIVIR HBV SOLN 5 $6.60 CMV Agents MG/ML (Tier 2) $0- $2.65 EPIVIR HBV TABS 100 MO cidofovir (Tier MG (Use Lamivudine NF 1) (HBV)) $0- PA CYTOVENE (Use NF MO Ganciclovir Sodium) $6.60 HARVONI (Tier $0- MO 2) $2.65 ganciclovir sodium (Tier HEPSERA (Use Adefovir NF MO 1) Dipivoxil) $0- MO $0- PA $6.60 VALCYTE TABS 450 MG $6.60 INCIVEK (Use Valganciclovir HCl) (Tier (Tier 2) 2) $0- MO $0- MO $2.65 $2.65 lamivudine (hbv) valganciclovir hcl (Tier (Tier 1) 1) $0- PA VISTIDE (Use Cidofovir) NF $6.60 OLYSIO (Tier Hepatitis Agents 2) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

71 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- $0- PA $6.60 $6.60 PEG-INTRON (Tier VIEKIRA PAK (Tier 2) 2) $0- Herpes Agents $6.60 PEG-INTRON REDIPEN $0- MO (Tier $2.65 2) acyclovir caps or 200 mg (Tier $0- 1) PEG-INTRON REDIPEN $6.60 $0- PAK 4 (Tier 2) acyclovir sodium soln 50 $2.65 mg/ml (Tier $0- 1) $6.60 PEGASYS (Tier $0- MO 2) acyclovir sodium solr 500 $2.65 mg (Tier $0- 1) $6.60 PEGASYS PROCLICK (Tier $0- MO 2) acyclovir susp or 200 $2.65 mg/5ml (Tier $0- 1) $6.60 PEGINTRON (Tier $0- MO 2) acyclovir tabs or 400 mg, $2.65 800 mg (Tier REBETOL CAPS 200 MG 1) NF (Use Ribavirin (Hepatitis $0- MO C)) $2.65 $0- famciclovir (Tier $2.65 ribavirin (hepatitis c) 1) (Tier MO 1) FAMVIR (Use Famciclovir) NF $0- PA $0- MO $6.60 SOVALDI valacyclovir hcl tabs or 1 $2.65 (Tier gm, 1000 mg, 500 mg (Tier 2) 1) $0- MO VALTREX (Use NF MO $6.60 Valacyclovir HCl) TYZEKA (Tier 2) ZOVIRAX CAPS OR 200 NF MO MG (Use Acyclovir) $0- PA $6.60 ZOVIRAX SUSP OR 200 NF MO VICTRELIS (Tier MG/5ML (Use Acyclovir) 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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72 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) ZOVIRAX TABS OR 400 MO $0- MO $6.60 MG, 800 MG (Use NF DEPEN TITRATABS Acyclovir) (Tier 2) Influenza Agents $0- MO FLUMADINE (Use MO $6.60 Rimantadine NF SYPRINE (Tier Hydrochloride) 2) $0- MO $6.60 Enzymes RELENZA DISKHALER (Tier $0 NT papaya chew 5mg-5mg- (Tier 2) 3mg-2mg-20mg $0- MO 3) $2.65 rimantadine hydrochloride Immunomodulators (Tier $0- LA 1) $6.60 $0- MO REVLIMID (Tier $6.60 TAMIFLU 2) (Tier $0- 2) $6.60 THALOMID Respiratory Syncytial Virus (RSV) Agents (Tier $0- 2) $6.60 VIRAZOLE Immunosuppressive Agents (Tier $0- MO; B/D 2) $6.60 ASTAGRAF XL ASSORTED CLASSES - Miscellaneous Drugs (Tier 2) Assorted Classes $0- MO; B/D $0 NT azathioprine tabs or 100 $2.65 gelatin caps or 650 mg (Tier mg, 50 mg, 75 mg (Tier 3) 1) $0 NT CELLCEPT CAPS 250 MG MO; B/D NULLO (Tier (Use Mycophenolate NF 3) Mofetil) Chelating Agents $0- B/D CELLCEPT $6.60 $0- MO INTRAVENOUS (Tier $6.60 2) CUPRIMINE (Tier 2) $0- MO; B/D CELLCEPT SUSR 200 $6.60 MG/ML (Use (Tier Mycophenolate Mofetil) 2)

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73 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) CELLCEPT TABS 500 MG MO; B/D $0- MO; B/D (Use Mycophenolate NF RAPAMUNE SOLN 1 $6.60 Mofetil) MG/ML (Tier $0- MO; B/D 2) cyclosporine caps or 100 $2.65 RAPAMUNE TABS 0.5 MG NF MO; B/D mg, 25 mg (Tier (Use Sirolimus) 1) $0- MO; B/D $0- MO; B/D RAPAMUNE TABS 1 MG, $6.60 cyclosporine modified (for $2.65 2 MG (Use Sirolimus) (Tier microemulsion) caps 100 (Tier 2) mg, 25 mg, 50 mg 1) SANDIMMUNE CAPS OR MO; B/D $0- B/D 100 MG, 25 MG (Use NF cyclosporine soln iv 50 $2.65 Cyclosporine) mg/ml (Tier SANDIMMUNE SOLN IV B/D 1) 50 MG/ML (Use NF IMURAN (Use NF MO; B/D Cyclosporine) Azathioprine) $0- MO; B/D $0- MO; B/D SANDIMMUNE SOLN OR $6.60 $2.65 mycophenolate mofetil 100 MG/ML (Tier (Tier 2) 1) $0- B/D $0- MO; B/D $6.60 $2.65 SIMULECT mycophenolate sodium (Tier (Tier 2) 1) $0- MO; B/D MYFORTIC (Use NF MO; B/D $2.65 Mycophenolate Sodium) sirolimus (Tier NEORAL CAPS 100 MG, MO; B/D 1) $0- 25 MG (Use Cyclosporine NF MO; B/D Modified (For tacrolimus caps or 0.5 mg, $2.65 Microemulsion)) 1 mg, 5 mg (Tier $0- B/D 1) $6.60 $0- B/D NULOJIX $6.60 (Tier THYMOGLOBULIN 2) (Tier PROGRAF CAPS OR 0.5 MO; B/D 2) MG, 1 MG, 5 MG (Use NF $0- MO; B/D $6.60 Tacrolimus) ZORTRESS $0- B/D (Tier PROGRAF SOLN IV 5 $6.60 2) MG/ML (Tier Irrigation Solutions 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

74 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- $0- MO irrigation solutions, $2.65 labetalol hcl tabs or 100 $2.65 physiological (Tier mg, 200 mg, 300 mg (Tier 1) 1) $0- TRANDATE (Use Labetalol NF MO PHYSIOSOL IRRIGATION $6.60 HCl) PH 7.4 (Tier 2) Beta Blockers Cardio-Selective $0- MO $0- MO $2.65 acebutolol hcl caps or 200 $2.65 water for irrigation, sterile (Tier mg, 400 mg (Tier 1) 1) $0- MO Potassium Removing Resins atenolol tabs or 100 mg, 25 $2.65 KAYEXALATE (Use MO mg, 50 mg (Tier Sodium Polystyrene NF 1) Sulfonate) $0- MO $0- MO $2.65 sodium polystyrene $2.65 betaxolol hcl (Tier sulfonate powd or (Tier 1) 1) $0- MO $0- MO $2.65 sodium polystyrene $2.65 bisoprolol fumarate (Tier sulfonate susp or 15 (Tier 1) gm/60ml 1) KERLONE (Use Betaxolol NF MO Systemic Lupus Erythematosus Agents HCl) $0- LOPRESSOR TABS OR MO $6.60 100 MG, 50 MG (Use NF BENLYSTA 120 MG (Tier Metoprolol Tartrate) 2) $0- MO $2.65 BETA BLOCKERS - Drugs to Treat High Blood metoprolol succinate Pressure (Tier 1) Alpha-Beta Blockers $0- MO $0- MO metoprolol tartrate tabs or $2.65 $2.65 carvedilol 100 mg, 25 mg, 50 mg (Tier (Tier 1) 1) SECTRAL (Use Acebutolol NF MO COREG (Use Carvedilol) NF MO HCl) MO $0- MO TENORMIN (Use Atenolol) NF $6.60 COREG CR TOPROL XL (Use NF MO (Tier Metoprolol Succinate) 2) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

75 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) ZEBETA (Use Bisoprolol NF MO BIOLOGICALS MISC - Drugs to Treat Low Fumarate) Enzymes Beta Blockers Non-Selective Biologicals Misc BETAPACE (Use Sotalol NF tabs;MO $0- LA HCl) $6.60 ADAGEN (Tier BETAPACE AF (Use NF MO Sotalol HCl (AFIB/AFL)) 2) CORGARD (Use Nadolol) NF MO CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure INDERAL LA (Use NF MO Propranolol HCl) Calcium Channel Blockers $0- MO ADALAT CC (Use NF MO nadolol tabs or 20 mg, 40 $2.65 Nifedipine) mg, 80 mg (Tier $0- QL(1 ea daily); 1) amlodipine besylate tabs or $2.65 MO $0- MO 10 mg (Tier $2.65 1) pindolol (Tier $0- QL(4 ea daily); 1) amlodipine besylate tabs or $2.65 MO $0- MO 2.5 mg (Tier propranolol hcl cp24 or 120 $2.65 1) mg, 160 mg, 60 mg, 80 mg (Tier $0- QL(2 ea daily); 1) amlodipine besylate tabs or $2.65 MO $0- MO 5 mg (Tier propranolol hcl tabs or 10 $2.65 1) mg, 20 mg, 40 mg, 60 mg, (Tier CALAN (Use Verapamil NF MO 80 mg 1) HCl) $0- tabs;MO CALAN SR (Use Verapamil NF MO $2.65 HCl) sotalol hcl (Tier CARDIZEM (Use Diltiazem NF MO 1) HCl) $0- MO CARDIZEM CD (Use MO $2.65 sotalol hcl (afib/afl) Diltiazem HCl Coated NF (Tier Beads) 1) CARDIZEM LA 180 MG, MO Sotalol Hcl IV Soln NF 240 MG, 300 MG, 360 MG, NF 420 MG (Use Diltiazem HCl $0- Coated Beads) $6.60 SOTYLIZE $0- MO (Tier $2.65 2) diltiazem hcl coated beads (Tier 1)

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76 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- diltiazem hcl cp12 or 120 $2.65 $6.60 mg, 60 mg, 90 mg (Tier NYMALIZE (Tier 1) 2) $0- MO PROCARDIA XL (Use NF MO diltiazem hcl cp24 or 120 $2.65 Nifedipine) mg, 180 mg, 240 mg (Tier MO 1) SULAR (Use Nisoldipine) NF $0- MO TIAZAC (Use Diltiazem HCl NF MO diltiazem hcl extended $2.65 Extended Release Beads) release beads (Tier verapamil hcl cp24 or 100 $0- MO 1) mg, 120 mg, 180 mg, 200 $2.65 $0- MO mg, 240 mg, 300 mg, 360 (Tier diltiazem hcl tabs or 120 $2.65 mg 1) mg, 30 mg, 60 mg, 90 mg (Tier $0- MO 1) verapamil hcl tabs or 120 $2.65 $0- MO mg, 40 mg, 80 mg (Tier $2.65 felodipine 1) (Tier $0- MO 1) verapamil hcl tbcr or 120 $2.65 $0- MO mg, 180 mg, 240 mg (Tier nicardipine hcl caps or 20 $2.65 1) mg, 30 mg (Tier VERELAN (Use Verapamil NF MO 1) HCl) $0- MO VERELAN PM (Use NF MO nifedipine tb24 or 30 mg, $2.65 Verapamil HCl) 60 mg, 90 mg (Tier 1) CARDIOTONICS - Drugs to Treat Heart Failure $0- MO and Abnormal Heart Rhythm $2.65 nimodipine caps or Cardiac Glycosides (Tier $0- MO 1) DIGOXIN SOLN OR 0.05 $6.60 $0- MO MG/ML (Tier nisoldipine 17 mg, 34 mg, $2.65 2) 8.5 mg (Tier $0- MO 1) digoxin tabs or 0.125 mg, $2.65 0.25 mg, 125 mcg, 250 NORVASC 10 MG (Use NF QL(1 ea daily); (Tier Amlodipine Besylate) MO mcg 1) NORVASC 2.5 MG (Use NF QL(4 ea daily); LANOXIN TABS OR 125 MO Amlodipine Besylate) MO MCG, 250 MCG (Use NF Digoxin) NORVASC 5 MG (Use NF QL(2 ea daily); Amlodipine Besylate) MO

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77 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- LA LANOXIN TABS OR 187.5 $6.60 $6.60 MCG, 62.5 MCG (Tier TRACLEER (Tier 2) 2) CARDIOVASCULAR AGENTS - MISC. - Drugs to Pulmonary Hypertension - Phosphodiesterase Treat Heart and Circulation Conditions $0- PA Cardiovascular Agents Misc. - Combinations $6.60 ADCIRCA (Tier $0- PA; MO 2) $6.60 ENTRESTO (Tier REVATIO SOLN IV 10 $0- PA 2) MG/12.5ML (Use Sildenafil $6.60 Citrate (Pulmonary (Tier Prostaglandin Vasodilators Hypertension)) 2) $0- LA; B/D REVATIO TABS OR 20 PA $6.60 REMODULIN MG (Use Sildenafil Citrate NF (Tier (Pulmonary Hypertension)) 2) $0- PA $0- LA; B/D sildenafil citrate (pulmonary $2.65 $6.60 TYVASO hypertension) (Tier (Tier 1) 2) $0- LA; B/D Sinus Node Inhibitors $6.60 $0- QL(2 ea daily); TYVASO REFILL $6.60 (Tier CORLANOR MO 2) (Tier 2) $0- LA; B/D $6.60 TYVASO STARTER CEPHALOSPORINS - Drugs to Treat Bacterial (Tier Infections 2) Cephalosporins - 1st Generation $0- LA; B/D $6.60 $0- MO VENTAVIS $2.65 (Tier cefadroxil 2) (Tier 1) Pulmonary Hypertension - Endothelin Receptor $0- MO $0- LA cefazolin sodium solr ij 1 $2.65 $6.60 LETAIRIS gm, 10 gm, 500 mg (Tier (Tier 1) 2) $0- MO $0- cephalexin caps 250 mg, $2.65 $6.60 OPSUMIT 500 mg, 750 mg (Tier (Tier 1) 2)

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78 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO cephalexin susr 125 $2.65 $2.65 mg/5ml, 250 mg/5ml (Tier cefdinir (Tier 1) 1) KEFLEX (Use Cephalexin) NF MO $0- $2.65 cefixime chew 100 mg Cephalosporins - 2nd Generation (Tier 1) $0- MO cefaclor caps 250 mg, 500 $2.65 $0- MO $2.65 mg (Tier cefixime chew 200 mg 1) (Tier 1) $0- MO $2.65 $0- MO cefprozil (Tier cefixime susr 100 mg/5ml, $2.65 1) 200 mg/5ml (Tier 1) $0- MO CEFTIN SUSR 125 $6.60 $0- $2.65 MG/5ML (Tier cefixime tabs 400 mg 2) (Tier 1) CEFTIN TABS 250 MG, MO 500 MG (Use Cefuroxime NF $0- MO Axetil) cefotaxime sodium 1 gm, $2.65 10 gm (Tier $0- MO 1) $2.65 cefuroxime axetil (Tier $0- 1) cefotaxime sodium 2 gm, $2.65 500 mg (Tier $0- 1) cefuroxime sodium ij 1.5 $2.65 gm, 7.5 gm (Tier $0- MO 1) $2.65 cefpodoxime proxetil (Tier $0- MO 1) cefuroxime sodium ij 750 $2.65 mg (Tier $0- MO 1) $2.65 ceftazidime ij 1 gm, 2 gm (Tier ZINACEF SOLR IJ 1.5 GM, 1) 7.5 GM (Use Cefuroxime NF Sodium) $0- $2.65 ceftazidime ij 6 gm ZINACEF SOLR IJ 750 MG NF MO (Tier (Use Cefuroxime Sodium) 1) Cephalosporins - 3rd Generation

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Health Net Cal MediConnect 2015 Drug List

79 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- QL(4 ea daily); $0- ceftriaxone sodium solr ij 1 $2.65 MO SUPRAX SUSR 500 $6.60 gm (Tier MG/5ML (Tier 1) 2) $0- QL(2 ea daily); Cephalosporins - 4th Generation ceftriaxone sodium solr ij 2 $2.65 MO $0- MO gm (Tier $2.65 1) cefepime hcl (Tier $0- QL(16 ea 1) ceftriaxone sodium solr ij $2.65 daily); MO $0- 250 mg (Tier 1) CEFEPIME SOLN 1 $6.60 GM/50ML, 2 GM/100ML (Tier $0- QL(8 ea daily); 2) ceftriaxone sodium solr ij $2.65 MO 500 mg (Tier MAXIPIME IJ 1 GM, 2 GM NF MO 1) (Use Cefepime HCl) $0- QL(4 ea daily) Cephalosporins - 5th Generation ceftriaxone sodium solr iv 1 $2.65 $0- gm (Tier $6.60 1) TEFLARO 400 MG (Tier $0- MO 2) ceftriaxone sodium solr iv $2.65 10 gm (Tier CHEMICALS 1) Acids, Bases, & Buffers $0- QL(2 ea daily); $0 RX/OTC; MO; ceftriaxone sodium solr iv 2 $2.65 MO LACTIC ACID (Tier NT gm (Tier 3) 1) $0 RX/OTC; MO; CLAFORAN IJ 1 GM, 10 MO LACTIC ACID RACEMIC (Tier NT GM (Use Cefotaxime NF 3) Sodium) CLAFORAN IJ 2 GM, 500 Bulk Chemicals - S's $0 MG (Use Cefotaxime NF SODIUM CITRATE NT Sodium) (Tier DIHYDRATE 3) FORTAZ SOLR IJ 1 GM, 2 NF MO GM (Use Ceftazidime) Liquids FORTAZ SOLR IJ 6 GM NF $0 RX/OTC; MO; (Use Ceftazidime) GLYCERIN LIQD 99 %, (Tier 99.5 % NT $0- MO 3) $6.60 SUPRAX CAPS 400 MG $0 RX/OTC; MO; (Tier GLYCERINE (Tier NT 2) 3)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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80 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 RX/OTC; MO; FEMCON FE (Use MO GLYCEROL FORMAL (Tier NT Norethindrone & Ethinyl NF 3) Estradiol-Fe) Semi-Solids $0- MO $0 RX/OTC; MO; levonorgestrel & eth $2.65 COAL TAR SOLN XX (Tier NT estradiol (Tier 3) 1) $0- MO Solids levonorgestrel-eth estradiol $2.65 SODIUM $0 NT (triphasic) (Tier CHLORIDE/SODIUM (Tier 1) BICARBONATE 3) $0- MO $0 RX/OTC; MO; levonorgestrel-ethinyl $2.65 THYMOL (Tier NT estradiol (91-day) (Tier 3) 1) CONTRACEPTIVES - Drugs to Prevent LOSEASONIQUE (Use MO Pregnancy Levonorgestrel-Ethinyl NF Estradiol (91-Day)) Combination Contraceptives - Oral MODICON (Use MO BREVICON-28 (Use MO Norethindrone & Eth NF Norethindrone & Eth NF Estradiol) Estradiol) $0- MO DESOGEN (Use MO norethin acet & estrad-fe $2.65 Desogestrel & Ethinyl NF 75mg-20mcg-1mg, 75mg- (Tier Estradiol) 30mcg-1.5mg 1) $0- MO $0- MO desogestrel & ethinyl $2.65 norethindrone & eth $2.65 estradiol (Tier estradiol (Tier 1) 1) $0- MO $0- MO desogestrel-ethinyl $2.65 norethindrone & ethinyl $2.65 estradiol (biphasic) (Tier estradiol-fe 0.4mg-35mcg (Tier 1) 1) $0- MO $0- MO drospirenone-ethinyl $2.65 norethindrone acet & eth $2.65 estradiol (Tier estra (Tier 1) 1) $0- MO $0- MO ethynodiol diacet & eth $2.65 norethindrone-eth estradiol $2.65 estrad (Tier (triphasic) (Tier 1) 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

81 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO norgestimate-ethinyl $2.65 norelgestromin-ethinyl $2.65 estradiol (Tier estradiol (Tier 1) 1) $0- MO $0- MO norgestimate-ethinyl $2.65 ORTHO EVRA (Use $6.60 estradiol (triphasic) (Tier Norelgestromin-Ethinyl (Tier 1) Estradiol) 2) $0- MO Combination Contraceptives - Vaginal norgestrel & ethinyl $2.65 $0- MO estradiol (Tier $6.60 1) NUVARING (Tier NORINYL 1+35 (Use MO 2) Norethindrone & Eth NF Estradiol) Emergency Contraceptives ORTHO TRI-CYCLEN (Use MO $0- $6.60 Norgestimate-Ethinyl NF ELLA Estradiol (Triphasic)) (Tier 2) ORTHO-CEPT (Use MO Desogestrel & Ethinyl NF $0- Estradiol) levonorgestrel (emergency $2.65 oc) 0.75 mg (Tier ORTHO-CYCLEN (Use MO 1) Norgestimate-Ethinyl NF Estradiol) $0- RX/OTC levonorgestrel (emergency $2.65 ORTHO-NOVUM 1/35 MO oc) 1.5 mg (Tier (Use Norethindrone & Eth NF 1) Estradiol) PLAN B ONE-STEP (Use RX/OTC ORTHO-NOVUM 7/7/7 MO Levonorgestrel (Emergency NF (Use Norethindrone-Eth NF OC)) Estradiol (Triphasic)) SEASONIQUE (Use MO Progestin Contraceptives - Injectable Levonorgestrel-Ethinyl NF DEPO-PROVERA MO Estradiol (91-Day)) CONTRACEPTIVE (Use NF YASMIN 28 (Use MO Medroxyprogesterone Drospirenone-Ethinyl NF Acetate (Contraceptive)) Estradiol) $0- MO medroxyprogesterone $2.65 YAZ (Use Drospirenone- NF MO Ethinyl Estradiol) acetate (contraceptive) (Tier 1) Combination Contraceptives - Transdermal Progestin Contraceptives - Oral

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Health Net Cal MediConnect 2015 Drug List

82 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) NOR-QD (Use MO $0- MO Norethindrone NF dexamethasone elix or 0.5 $2.65 (Contraceptive)) mg/5ml (Tier $0- MO 1) norethindrone $2.65 $0- Preservative (contraceptive) (Tier dexamethasone sodium $2.65 Free;MO 1) phosphate soln ij 10 mg/ml (Tier ORTHO MICRONOR (Use MO 1) $0- Norethindrone NF dexamethasone sodium (Contraceptive)) $2.65 phosphate soln ij 10 mg/ml, (Tier CORTICOSTEROIDS - Steroid Hormone Drugs to 120 mg/30ml 1) Treat Systemic Swelling Conditions dexamethasone sodium $0- MO Glucocorticosteroids phosphate soln ij 100 $2.65 $0- MO mg/10ml, 20 mg/5ml, 4 (Tier ARISTOSPAN INTRA- $6.60 mg/ml 1) ARTICULAR (Tier $0- MO 2) dexamethasone soln or 0.5 $2.65 $0- MO mg/5ml (Tier betamethasone sod $2.65 1) phosphate & acetate (Tier $0- MO 1) dexamethasone tabs or 0.5 $2.65 mg, 0.75 mg, 1 mg, 1.5 mg, (Tier $0- MO 2 mg, 4 mg, 6 mg $2.65 1) budesonide cp24 or (Tier ENTOCORT EC (Use NF MO 1) Budesonide) CELESTONE-SOLUSPAN MO $0- MO (Use Betamethasone Sod NF hydrocortisone sod $2.65 Phosphate & Acetate) succinate (Tier 1) CORTEF (Use NF MO Hydrocortisone) $0- MO $0- MO hydrocortisone tabs or 10 $2.65 $2.65 mg, 20 mg, 5 mg (Tier cortisone acetate tabs or (Tier 1) 1) $0- MO $6.60 $0- MO KENALOG-10 DEPO-MEDROL 20 $6.60 (Tier MG/ML (Tier 2) 2) $0- MO DEPO-MEDROL 40 MO $6.60 KENALOG-40 (Tier MG/ML, 80 MG/ML (Use NF Methylprednisolone 2) Acetate)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

83 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) MEDROL 16 MG, 32 MG, 4 MO $0- MO MG, 8 MG (Use NF prednisone soln or 5 $2.65 Methylprednisolone) mg/5ml (Tier $0- MO 1) $6.60 $0- MO MEDROL 2 MG prednisone tabs or 1 mg, $2.65 (Tier 10 mg, 2.5 mg, 20 mg, 5 2) (Tier mg, 50 mg 1) MEDROL DOSEPAK (Use NF MO Methylprednisolone) $0- MO $0- MO SOLU-CORTEF 100 MG, $6.60 methylprednisolone acetate $2.65 250 MG, 500 MG (Tier susp ij 40 mg/ml, 80 mg/ml (Tier 2) 1) $0- $6.60 $0- MO SOLU-CORTEF 1000 MG methylprednisolone sod $2.65 (Tier succ (Tier 2) 1) SOLU-MEDROL 1000 MG, MO $0- MO 125 MG, 40 MG (Use NF methylprednisolone tabs or $2.65 Methylprednisolone Sod 16 mg, 32 mg, 4 mg, 8 mg (Tier Succ) 1) Mineralocorticoids ORAPRED ODT 10 MG,15 MO $0- MO MG,30 MG (Use NF fludrocortisone acetate tabs $2.65 Prednisolone Sodium or (Tier Phosphate) 1) $0- MO COUGH/COLD/ALLERGY - Drugs to Treat $2.65 Cough, Cold and Allergy Symptoms prednisolone (Tier 1) Antitussives prednisolone sodium $0- MO $0 MO; NT benzonatate 100 mg, 200 (Tier phosphate soln or 15 $2.65 mg mg/5ml, 5 mg/5ml, 6.7 (Tier 3) mg/5ml 1) $0 MO; NT hydrocodone w/ (Tier $0- MO homatropine prednisolone sodium $2.65 3) phosphate tbdp or 10 mg, (Tier 15 mg, 30 mg TESSALON PERLES (Use NF MO; NT 1) Benzonatate) $0- MO Cough/Cold/Allergy Combinations prednisone conc or 5 $2.65 $0 mg/ml (Tier ADVIL ALLERGY & AL; NT 1) (Tier CONGESTION 3)

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84 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 NT $0 AL; MO; NT ALBATUSSIN NN (Tier dexbrompheniramine & (Tier 3) pseudoephedrine 3) BENADRYL ALLERGY & AL; NT DIMETAPP COLD & AL; NT COLD (Use ALLERGY ELIX 1MG/5ML- Diphenhydramine- NF 2.5MG/5ML (Use NF Phenylephrine- Brompheniramine & Acetaminophen) Phenyleph) BENADRYL ALLERGY & AL; NT diphenhydramine- $0 AL; NT SINUSHEADACHE (Use phenylephrine liqd (Tier Diphenhydramine- NF 12.5mg/5ml-5mg/5ml 3) Phenylephrine- diphenhydramine- $0 AL; NT Acetaminophen) phenylephrine soln (Tier BENADRYL-D ALLERGY & AL; NT 12.5mg/5ml-5mg/5ml 3) SINUS (Use NF diphenhydramine- $0 AL; NT Diphenhydramine- phenylephrine tabs 25mg- (Tier Phenylephrine) 10mg 3) $0 AL; NT diphenhydramine- AL; NT brompheniramine & (Tier phenyleph phenylephrine- $0 3) acetaminophen susp (Tier $0 AL; NT 12.5mg/5ml-160mg/5ml- 3) brompheniramine & (Tier pseudoeph 2.5mg/5ml 3) diphenhydramine- AL; NT $0 AL; NT phenylephrine- $0 BRONCOPECTOL (Tier acetaminophen tabs 3) (Tier 12.5mg-12.5mg-325mg- 3) $0 AL; NT 325mg-5mg-5mg, 12.5mg- chlorpheniramine & (Tier 325mg-5mg phenylephrine 3) diphenhydramine- $0 AL; NT chlorpheniramine & $0 AL; NT pseudoephedrine- (Tier pseudoeph syrp 15mg/5ml- (Tier acetaminophen 3) 1mg/5ml 3) DRIXORAL AL; MO; NT $0 COLD/ALLERGY (Use chlorpheniramine w/ AL; RX/OTC; NF (Tier NT Dexbrompheniramine & codeine 3) Pseudoephedrine) chlorpheniramine- AL; NT $0 AL; NT phenylephrine- $0 ED CHLORPED D (Tier acetaminophen susp (Tier 3) 1mg/5ml-160mg/5ml- 3) $0 NT 2.5mg/5ml GILTUSS PED-C (Tier $0 AL; NT 3) DECON-A ELIX 2MG/5ML- (Tier 5MG/5ML 3) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

85 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT SUDAFED PE SEVERE AL; NT guaifenesin-codeine liqd (Tier 100mg/5ml-10mg/5ml COLD MULTI-SYMPTOM 3) (Use Diphenhydramine- NF $0 MO; NT Phenylephrine- guaifenesin-codeine soln (Tier Acetaminophen) 100mg/5ml-10mg/5ml 3) triprolidine & $0 AL; RX/OTC; $0 MO; NT pseudoephedrine liqd (Tier NT guaifenesin-codeine syrp (Tier 0.938mg/ml-10mg/ml 3) 100mg/5ml-10mg/5ml 3) triprolidine & $0 AL; MO; NT $0 pseudoephedrine tabs hydrocodone polistirex- AL; MO; NT (Tier (Tier 2.5mg-2.5mg-60mg-60mg, 3) chlorpheniramine polistirex 3) 2.5mg-60mg $0 AL; RX/OTC; $0 AL; NT TUSNEL CAPS 2MG- (Tier LEXUSS 210 (Tier NT 15MG-200MG 3) 3) $0 NT TUSSIONEX AL; MO; NT NEXAFED SINUS (Tier PENNKINETIC PRESSURE +PAIN 3) EXTENDED RELEASE NF PEDIATEX TD (Use AL; RX/OTC; (Use Hydrocodone Triprolidine & NF NT Polistirex-Chlorpheniramine Pseudoephedrine) Polistirex) $0 AL; MO; NT TYLENOL CHILDRENS AL; NT phenyleph-promethazine (Tier PLUS COLD & ALLERGY w/ cod 3) (Use Diphenhydramine- NF Phenylephrine- $0 AL; MO; NT Acetaminophen) promethazine w/codeine (Tier 3) TYLENOL CHILDRENS AL; NT PLUS COLD (Use $0 AL; MO; NT Chlorpheniramine- NF promethazine-dm (Tier Phenylephrine- 3) Acetaminophen) $0 NT pseudoephedrine- (Tier Misc. Respiratory Inhalants acetaminophen 3) $0 NT $0 NT sodium chloride (inhalant) (Tier pseudoephedrine-ibuprofen (Tier 3) susp 100mg/5ml-15mg/5ml 3) Mucolytics $0 AL; NT $0- MO; B/D RYMED (Tier acetylcysteine soln in 10 %, $2.65 3) 20 % (Tier 1) DERMATOLOGICALS - Drugs to Treat Skin Conditions

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

86 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Acne Products $0- MO $0- benzoyl peroxide- $2.65 erythromycin (Tier ABSORICA 10 MG,20 $6.60 1) MG,25 MG,35 MG,40 MG (Tier 2) CLEOCIN-T (Use MO NF $0- Clindamycin Phosphate ABSORICA 30 MG (Use $6.60 (Topical)) Isotretinoin) (Tier $0- MO $6.60 2) CLINDAGEL $0 MO; NT (Tier ACNE MEDICATION (Tier 2) 3) $0- MO $0 MO; NT clindamycin phosphate $2.65 ACNE MEDICATION 10 (Tier (topical) (Tier 3) 1) $0- MO $0- MO $2.65 clindamycin phosphate- $2.65 adapalene crea 0.1 % (Tier benzoyl peroxide (Tier 1) 1) $0- $0- MO clindamycin phosphate- MO $2.65 $2.65 adapalene gel 0.1 % benzoyl peroxide (Tier (Tier (refrigerate) 1) 1) $0 NT DIFFERIN CREA 0.1 % NF MO ADULT ACNOMEL (Tier (Use Adapalene) 3) DIFFERIN GEL 0.1 % (Use NF MO $0 NT Adapalene) BENSULFOID (Tier DUAC (Use Clindamycin MO 3) Phosphate-Benzoyl NF BENZACLIN (Use MO Peroxide (Refrigerate)) Clindamycin Phosphate- NF $0- MO Benzoyl Peroxide) erythromycin (acne aid) $2.65 BENZACLIN WITH PUMP MO soln (Tier 1) (Use Clindamycin NF Phosphate-Benzoyl EVOCLIN (Use MO Peroxide) Clindamycin Phosphate NF BENZAMYCIN (Use MO (Topical)) Benzoyl Peroxide- NF $0- Erythromycin) isotretinoin caps or 10 mg, $2.65 $0 20 mg, 30 mg, 40 mg (Tier benzoyl peroxide gel ex 5 RX/OTC; MO; (Tier NT 1) % 3)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

87 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) KLARON (Use MO Antibiotics - Topical Sulfacetamide Sodium NF )) BACIGUENT (Use NF MO; NT (Acne Bacitracin (Topical)) RETIN-A (Use Tretinoin) NF MO $0 MO; NT bacitracin (topical) (Tier RETIN-A MICRO (Use NF MO 3) Tretinoin Microsphere) $0 MO; NT RETIN-A MICRO PUMP MO bacitracin zinc oint ex (Tier 0.04 %, 0.1 % (Use NF 3) Tretinoin Microsphere) $0 MO; NT $0 MO; NT bacitracin-polymyxin b (Tier REZAMID (Tier 3) 3) BACTROBAN (Use MO $0- MO Mupirocin Calcium NF sulfacetamide sodium $2.65 (Topical)) (acne) (Tier 1) BACTROBAN (Use NF MO Mupirocin) $0- MO tretinoin crea ex 0.025 %, $2.65 $0- MO $6.60 0.05 %, 0.1 % (Tier CENTANY 1) (Tier 2) $0- MO tretinoin gel ex 0.01 %, $2.65 $0- MO $2.65 0.025 % (Tier gentamicin sulfate (topical) 1) (Tier 1) $0- MO $2.65 $0- MO tretinoin microsphere $2.65 (Tier mupirocin calcium (topical) 1) (Tier 1) Analgesics - Topical $0- MO $0 MO; NT $2.65 menthol (topical analgesic) (Tier mupirocin oint ex pads 5 % (Tier 3) 1) Anti-inflammatory Agents - Topical $0 NT neomycin-bacitracin- (Tier $0- PA; MO polymyxin w/ lidocaine $6.60 3) FLECTOR (Tier POLYSPORIN OINT (Use NF MO; NT 2) Bacitracin-Polymyxin B) $0- MO Antifungals - Topical $6.60 VOLTAREN $0 NT (Tier ALEVAZOL (Tier 2) 3) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

88 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO $2.65 $2.65 ciclopirox gel 0.77 % (Tier ketoconazole (topical) (Tier 1) 1) $0- MO LAMISIL AT CREA (Use MO; NT $2.65 NF ciclopirox olamine crea ex Terbinafine HCl (Topical)) (Tier LAMISIL AT JOCK ITCH MO; NT 1) (Use Terbinafine HCl NF $0- MO (Topical)) $2.65 MO ciclopirox olamine susp ex (Tier LOPROX (Use Ciclopirox) NF 1) LOPROX SHAMPOO (Use NF MO $0- MO Ciclopirox) $2.65 ciclopirox sham 1 % LOTRISONE (Use MO (Tier Clotrimazole w/ NF 1) Betamethasone) $0- MO MICATIN (Use Miconazole NF RX/OTC; MO; $2.65 Nitrate (Topical)) NT ciclopirox soln 8 % (Tier $0 1) miconazole nitrate (topical) RX/OTC; MO; (Tier NT $0- RX/OTC; MO crea 3) $2.65 clotrimazole (topical) crea (Tier $0- MO 1) $6.60 NAFTIN CREA 2 % (Tier $0- RX/OTC; MO 2) $2.65 clotrimazole (topical) soln (Tier $0- MO 1) $6.60 NAFTIN GEL 2 % (Tier $0- MO 2) clotrimazole w/ $2.65 betamethasone (Tier NIZORAL (Use NF MO 1) Ketoconazole (Topical)) $0 NT $0 MO; NT CLOVERINE SALVE (Tier NIZORAL A-D (Tier 3) 3) $0- MO $0- MO $2.65 $2.65 nystatin (topical) econazole nitrate (Tier (Tier 1) 1) $0- MO EXTINA (Use NF MO Ketoconazole (Topical)) $2.65 nystatin-triamcinolone (Tier 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

89 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) PENLAC NAIL LACQUER MO $0- MO NF $2.65 (Use Ciclopirox) fluorouracil (topical) $0 MO; NT (Tier terbinafine hcl (topical) (Tier 1) 3) $0- MO FLUOROURACIL CREA $6.60 TINACTIN CREA (Use NF MO; NT Tolnaftate) EX 0.5 % (Tier 2) TINACTIN JOCK ITCH NF MO; NT CREA (Use Tolnaftate) $0- MO $6.60 $0 MO; NT PANRETIN (Tier tolnaftate crea ex (Tier 2) 3) $0- MO $0 MO; NT $6.60 tolnaftate liqd ex (Tier PICATO (Tier 3) 2) $0 MO; NT SOLARAZE (Use MO tolnaftate soln ex (Tier Diclofenac Sodium (Actinic NF 3) Keratoses)) $0 NT $0- UNDELENIC TINCTURE (Tier $6.60 3) TARGRETIN 1 %,75 MG (Tier Antihistamines-Topical 2) $0 NT $0- PA diphenhydramine hcl $6.60 (Tier VALCHLOR (topical) crea 3) (Tier $0 NT 2) diphenhydramine-zinc (Tier acetate crea 0.1%-1% Antipsoriatics 3) $0- MO $2.65 Antineoplastic or Premalignant Lesion Agents - acitretin $0- MO (Tier $6.60 1) CARAC (Tier $0- MO $2.65 2) calcipotriene $0- MO (Tier diclofenac sodium (actinic $2.65 1) keratoses) (Tier $0- PA; LA 1) $6.60 COSENTYX (Tier EFUDEX (Use Fluorouracil NF MO (Topical)) 2)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

90 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- PA; LA $0 MO; NT COSENTYX $6.60 pyrithione zinc liqd 0.25 % (Tier SENSOREADY PEN (Tier 3) 2) $0 MO; NT pyrithione zinc sham 2 % (Tier DOVONEX (Use NF MO Calcipotriene) 3) $0- MO $0- MO $2.65 selenium sulfide lotn ex 2.5 $2.65 methoxsalen rapid (Tier % (Tier 1) 1) $0- MO Antivirals - Topical OXSORALEN ULTRA (Use $6.60 $0- MO Methoxsalen Rapid) (Tier $2.65 2) acyclovir topical (Tier SORIATANE (Use NF MO 1) Acitretin) $0- MO $0- PA; $6.60 $6.60 DENAVIR STELARA (Tier (Tier 2) 2) $0- MO $0- MO $6.60 $6.60 ZOVIRAX CREA EX 5 % TAZORAC (Tier (Tier 2) 2) ZOVIRAX OINT EX 5 % NF MO Antiseborrheic Products (Use Acyclovir Topical) $0 MO; NT Bath Products DERMAZINC BABY (Tier $0 MO; NT 3) AVEENO SKIN RELIEF (Tier $0 MO; NT SHOWER& BATH 3) DERMAZINC SCALP (Tier $0 MO; NT 3) bath products oil 40%-40%- (Tier 40%-40%, 5%-5%-5% DERMAZINC SPRAY (Use NF MO; NT 3) Pyrithione Zinc) $0 MO; NT DHS ZINC (Use Pyrithione NF MO; NT BODI WHIRL OIL (Tier Zinc) 3) $0 NT $0 MO; NT NOBLE FORMULA BAR 2 (Tier % GERISILK BATH OIL (Tier 3) 3) $0 MO; NT $0 MO; NT P & S LIQD (Tier ULTRA DERM BATH OIL (Tier 3) 3)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

91 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Burn Products $0- MO betamethasone valerate $2.65 $0- MO $2.65 oint ex 0.1 % (Tier mafenide acetate pack ex (Tier 1) 1) $0- MO clobetasol propionate crea $2.65 SILVADENE (Use Silver NF MO ex (Tier Sulfadiazine) 1) $0- MO $0- MO $2.65 silver sulfadiazine crea ex clobetasol propionate $2.65 (Tier emollient base (Tier 1) 1) SULFAMYLON PACK 5 % NF MO $0- MO (Use Mafenide Acetate) clobetasol propionate $2.65 Corticosteroids - Topical emulsion (Tier $0- MO 1) $2.65 $0- MO alclometasone dipropionate (Tier clobetasol propionate foam $2.65 1) ex (Tier $0- MO 1) $2.65 $0- MO amcinonide crea (Tier clobetasol propionate gel $2.65 1) ex (Tier $0- MO 1) betamethasone $2.65 $0- MO dipropionate (topical) (Tier clobetasol propionate lotn $2.65 1) ex (Tier $0- MO 1) betamethasone $2.65 $0- MO dipropionate augmented (Tier clobetasol propionate oint $2.65 1) ex (Tier $0- MO 1) betamethasone valerate $2.65 $0- MO crea ex 0.1 % (Tier clobetasol propionate sham $2.65 1) ex (Tier $0- MO 1) betamethasone valerate $2.65 $0- MO foam ex 0.12 % (Tier clobetasol propionate soln $2.65 1) ex (Tier $0- MO 1) betamethasone valerate $2.65 CLOBEX LOTN (Use NF MO lotn ex 0.1 % (Tier Clobetasol Propionate) 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

92 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- CLOBEX SHAM (Use NF MO MO Clobetasol Propionate) $2.65 diflorasone diacetate oint (Tier CUTIVATE (Use NF MO Fluticasone Propionate) 1) $0 NT DIPROLENE (Use MO CVS HDYROCORTISONE (Tier Betamethasone NF ACETATE 3) Dipropionate Augmented) DERMA-SMOOTHE/FS MO DIPROLENE AF (Use MO BODY (Use Fluocinolone NF Betamethasone NF Acetonide) Dipropionate Augmented) DERMA-SMOOTHE/FS MO ELOCON CREA (Use NF MO SCALP (Use Fluocinolone NF Mometasone Furoate) Acetonide) ELOCON OINT (Use NF MO Mometasone Furoate) DERMATOP CREA (Use NF MO Prednicarbate) $0- MO $0- MO fluocinolone acetonide crea $2.65 $2.65 ex 0.01 %, 0.025 % (Tier desonide crea ex (Tier 1) 1) $0- MO $0- MO fluocinolone acetonide oil $2.65 $2.65 ex 0.01 % (Tier desonide lotn ex (Tier 1) 1) $0- MO $0- MO fluocinolone acetonide oint $2.65 $2.65 ex 0.025 % (Tier desonide oint ex (Tier 1) 1) $0- MO fluocinolone acetonide soln $2.65 DESOWEN 0.05 % (Use NF MO Desonide) ex 0.01 % (Tier 1) $0- MO desoximetasone crea ex $2.65 $0- MO $2.65 0.25 % (Tier fluocinonide crea ex 0.05 % 1) (Tier 1) $0- MO desoximetasone gel ex $2.65 $0- MO 0.05 % (Tier fluocinonide emulsified $2.65 1) base (Tier 1) $0- MO desoximetasone oint ex $2.65 $0- MO $2.65 0.25 % (Tier fluocinonide gel ex 0.05 % 1) (Tier 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

93 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0 MO; NT $2.65 hydrocortisone (topical) oint (Tier fluocinonide oint ex 0.05 % (Tier 0.5 % 3) 1) $0- RX/OTC; MO $0- MO hydrocortisone (topical) oint $2.65 $2.65 1 % (Tier fluocinonide soln ex 0.05 % (Tier 1) 1) $0- MO $0- MO hydrocortisone (topical) oint $2.65 fluticasone propionate crea $2.65 2.5 % (Tier ex 0.05 % (Tier 1) 1) $0 hydrocortisone (topical) NT $0- MO (Tier fluticasone propionate lotn $2.65 soln 1 % 3) ex 0.05 % (Tier $0 NT 1) hydrocortisone acetate (Tier (topical) $0- MO 3) fluticasone propionate oint $2.65 $0- MO ex 0.005 % (Tier $2.65 1) hydrocortisone butyrate (Tier $0- MO 1) $2.65 halobetasol propionate $0- MO (Tier hydrocortisone butyrate $2.65 1) hydrophilic lipo base (Tier $0 MO; NT 1) hydrocortisone (topical) (Tier crea 0.5 % $0- MO 3) $2.65 hydrocortisone valerate $0- RX/OTC; MO (Tier hydrocortisone (topical) $2.65 1) crea 1 % (Tier $0 NT 1) hydrocortisone-aloe vera (Tier $0- MO 3) hydrocortisone (topical) $2.65 LOCOID CREA (Use NF MO crea 2.5 % (Tier Hydrocortisone Butyrate) 1) LOCOID LIPOCREAM MO $0 MO; NT (Use Hydrocortisone hydrocortisone (topical) (Tier NF lotn 1 % Butyrate Hydrophilic Lipo 3) Base) $0- MO LOCOID OINT (Use NF MO hydrocortisone (topical) $2.65 Hydrocortisone Butyrate) lotn 2.5 % (Tier 1) LOCOID SOLN (Use NF MO Hydrocortisone Butyrate)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

94 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0 NT LUXIQ (Use $6.60 TUCKS ANTI-ITCH (Tier Betamethasone Valerate) (Tier 3) 2) ULTRAVATE (Use NF MO $0- MO Halobetasol Propionate) mometasone furoate crea $2.65 WESTCORT (Use NF MO ex (Tier Hydrocortisone Valerate) 1) $0- MO Emollient/Keratolytic Agents mometasone furoate oint $2.65 $0 NT ex (Tier CARMOL (Tier 1) 3) $0- MO CARMOL 20 (Use Urea) NF MO; NT mometasone furoate soln $2.65 ex (Tier ULTRA MIDE 25 (Use NF MO; NT 1) Urea) $0 MO; NT OLUX (Use Clobetasol NF MO Propionate) urea crea ex 20 % (Tier 3) OLUX-E (Use Clobetasol NF MO Propionate Emulsion) $0 MO; NT $0- MO urea lotn ex 25 % (Tier $2.65 3) prednicarbate crea (Tier Emollients 1) LAC-HYDRIN (Use Lactic NF RX/OTC; MO SYNALAR (Use NF MO Acid (Ammonium Lactate)) Fluocinolone Acetonide) $0- RX/OTC; MO TEMOVATE (Use NF MO lactic acid (ammonium $2.65 Clobetasol Propionate) lactate) crea 12 % (Tier TEMOVATE E (Use MO 1) Clobetasol Propionate NF $0- RX/OTC; MO Emollient Base) lactic acid (ammonium $2.65 $0- MO lactate) lotn 12 % (Tier triamcinolone acetonide $2.65 1) (topical) crea 0.025 %, 0.1 (Tier %, 0.5 % $0 MO; NT 1) lactic acid (ammonium (Tier lactate) lotn 5 % $0- 3) triamcinolone acetonide MO $2.65 $0 NT (topical) lotn 0.025 %, 0.1 (Tier % PANTHODERM (Tier 1) 3) $0- MO $0 NT triamcinolone acetonide $2.65 (topical) oint 0.025 %, 0.1 PETROLATUM (Tier (Tier 3) %, 0.5 % 1) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

95 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0- MO SUPER E CREA (Tier $6.60 3) ELIDEL (Tier $0 MO; NT 2) SUPER E DAY (Tier $0- MO 3) PROTOPIC (Use $6.60 $0 MO; NT Tacrolimus (Topical)) (Tier SUPER E EYE (Tier 2) 3) $0- MO $2.65 $0 MO; NT tacrolimus (topical) SUPER E NIGHT (Tier (Tier 3) 1) vitamin e (topical) crea $0 MO; NT Keratolytic/Antimitotic Agents 1000 unit, 1500 unit/30gm, (Tier CONDYLOX SOLN (Use NF MO 30000 unit/60gm, 6000 unit 3) Podofilox) vitamin e (topical) oil 100 NT $0 NT unit/5drop, 12000 unit, $0 MEDIPLAST (Tier 20000 unit, 28000 unit, (Tier 3) 28000 unit/29ml, 400 3) $0 NT unit/ml, 4000 unit, 49000 MOSCO CALLUS/CORN (Tier unit/52ml, 933.333 unit/ml REMOVER 3) Enzymes - Topical $0 NT $0- MO P & S SHAM (Tier $6.60 3) SANTYL (Tier $0- MO 2) $2.65 podofilox soln ex Immunomodulating Agents - Topical (Tier 1) ALDARA (Use Imiquimod) NF MO Liniments $0- MO $0 NT $2.65 ARTHRICARE DOUBLE imiquimod crea ex (Tier (Tier ICE PAIN RELIEVING RUB 3) 1) $0 NT $0- MO ARTHRICARE PAIN (Tier $6.60 RELIEVINGRUB ZYCLARA 3) (Tier ARTHRICARE TRIPLE $0 NT 2) MEDICATED PAIN (Tier $0- MO RELIEVING RUB 3) $6.60 ZYCLARA PUMP $0 NT (Tier BIOFLEXOR (Tier 2) 3) Immunosuppressive Agents - Topical You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

96 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0 NT BLUE-EMU SUPER (Tier lidocaine hcl gel ex 0.5 % (Tier STRENGTH 3) 3) $0 NT $0- RX/OTC; MO DEEP BLUE RELIEF (Tier $2.65 3) lidocaine hcl gel ex 2 % (Tier 1) liniments & rubs crea $0 MO; NT 0.01%-5%-10%, 1.2%- $0- MO (Tier $2.65 2.6%-4.7%, 10%-0.025%- 3) lidocaine hcl soln ex 4 % 15% (Tier $0 NT 1) liniments & rubs oint (Tier $0- MO 0.25%, 8%-2% $2.65 3) lidocaine oint ex 5 % $0 NT (Tier SM PAIN (Tier 1) RELIEF/MENTHOL 3) $0- PA; MO $2.65 $0 MO; NT lidocaine ptch ex 5 % VICKS BABYRUB (Tier (Tier 3) 1) $0- MO Local Anesthetics - Topical $2.65 $0 NT lidocaine-prilocaine crea (Tier AXSAIN (Tier 1) 3) LIDODERM (Use NF PA; MO $0 NT Lidocaine) capsaicin in lidocaine (Tier vehicle $0 NT 3) pramoxine-camphor-zinc (Tier $0 NT acetate 3) DERMOPLAST (Tier 3) $0 NT REGENECARE HA (Tier $0 NT 3) DERMOPLAST PAIN (Tier RELIEVINGSPRAY 3) SOLARCAINE ALOE NT EXTRA GEL (Use NF EMLA (Use Lidocaine- NF MO Lidocaine HCl) Prilocaine) $0 NT $0 MO; NT SOLARCAINE ALOE (Tier ITCH-X GEL (Tier VERA 3) 3) XYLOCAINE EX 4 % (Use NF MO $0 NT Lidocaine HCl) LANACANE (Tier 3) Misc. Dermatological Products

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97 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 RX/OTC; MO; $0 MO; NT ATOPICLAIR (Tier NT NEW SKIN (Tier 3) 3) $0 $0 AURSTAT ANTI-ITCH RX/OTC; MO; RX/OTC; MO; (Tier NT NIVATOPIC PLUS (Tier NT HYDROGEL 3) 3) $0 MO; NT $0 RX/OTC; MO; BURN SPRAY (Tier NONYX (Tier NT 3) 3) $0 MO; NT $0 RX/OTC; MO; DERMAGRAN AERO (Tier OC8 (Tier NT 3) 3) $0 RX/OTC; MO; $0 RX/OTC; MO; DERMAREST ROSACEA (Tier NT PRUCLAIR (Tier NT 3) 3) dermatological products, $0 RX/OTC; MO; $0 RX/OTC; MO; misc. crea 0.17%-2.7%, (Tier NT PRUMYX (Tier NT 4%-2%-0.5% 3) 3) $0 RX/OTC; MO; $0 MO; NT SUMMERS EVE (Tier ELETONE (Tier NT DEODORANT SPRAY 3) 3) $0 RX/OTC; MO; SUMMERS EVE $0 MO; NT ELETONE TWINPACK (Tier NT DEODORANT SPRAY (Tier 3) ULTRA 3) $0 $0 FRESH'N FEMININE MO; NT RX/OTC; MO; (Tier YODORA DEODORANT (Tier NT DEODORANT 3) 3) $0 RX/OTC; MO; Misc. Topical HPR PLUS CREA (Tier NT 3) A & D ZINC OXIDE (Use NT Dimethicone-Zinc Oxide- NF $0 RX/OTC; MO; Vitamin A-Vitamin D) HYLATOPIC PLUS CREA (Tier NT 3) $0 MO; NT A-MANTLE (Tier $0 RX/OTC; MO; 3) NASALGUARD (Tier NT 3) $0 MO; NT ACNE-AID (Tier $0 RX/OTC; MO; 3) NEOSALUS CP (Tier NT 3) $0 RX/OTC; NT ACUICYN DAILY EYELID (Tier $0 RX/OTC; MO; & EYELASH CLEANSER 3) NEOSALUS CREA (Tier NT 3)

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98 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 NT $0 MO; NT ALOE VESTA MULTI (Tier BASIS ALL CLEAR (Tier PURPOSECLEANSING 3) 3) $0 MO; NT $0 MO; NT ALUMINUM ACETATE (Tier BASIS COMBINATION (Tier SOLN EX 3) 3) $0 NT $0 MO; NT aluminum hydroxide (Tier BASIS EXTRA DRY (Tier 3) 3) $0 MO; NT $0 MO; NT aluminum sulfate & calcium (Tier BASIS NORMAL/DRY (Tier acetate 3) 3) $0 MO; NT $0 MO; NT AMBI COCOA BUTTER (Tier BASIS SENSITIVE SKIN (Tier CLEANSING 3) 3) $0 MO; NT $0 NT AMBI COMPLEXION (Tier BODY WASH & (Tier CLEANSING 3) SHAMPOO 3) $0 MO; NT $0 NT ANTI-BACTERIAL HAND (Tier CALAMINE LOTN EX (Tier LOTION 3) 3) $0 MO; NT $0 Calamine-Zinc AQUANIL SKIN (Tier CLEANSER CALAMINE LOTN EX (Tier Oxide 3) 3) Lotion;MO; NT AVEENO ACTIVE $0 MO; NT $0 NT NATURALS PURE (Tier CALAMINE PHENOLATED (Tier RENEWAL SHAMPOO 3) 3) $0 MO; NT $0 NT AVEENO MOISTURIZING (Tier CARRAFOAM FOAM (Tier 3) 3) AVEENO POSITIVELY $0 MO; NT $0 MO; NT CAVILON NO STING (Tier AGELESSDAILY (Tier BARRIERFILM EXFOLIATING CLEANSER 3) 3) $0 MO; NT $0 MO; NT AVEENO POSITIVELY CETAPHIL GENTLE (Tier (Tier CLEANSER RADIANTCLEANSER 3) 3) $0 NT $0 MO; NT AVEENO ULTRA- CETAPHIL GENTLE (Tier (Tier CLEANSING CALMING CLEANSER 3) 3) $0 RX/OTC; NT $0 MO; NT AVENOVA (Tier CONTI CASTILE SOAP (Tier 3) 3)

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Health Net Cal MediConnect 2015 Drug List

99 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 NT $0 MO; NT CVS SALINE WOUND (Tier GENTLE RAIN SHAMPOO (Tier WASH 3) AND SKIN CLEANSER 3) $0 MO; NT $0 MO; NT DARA (Tier GENTLE SKIN CLEANSER (Tier 3) 3) DERMAGRAN OINT (Use NT $0 MO; NT NF GERI-SHAMPOO/SHEA (Tier Aluminum Hydroxide) BUTTER $0 MO; NT 3) DHS (Tier $0 Calamine-Zinc 3) GNP CALAMINE (Tier Oxide $0 3) Lotion;MO; NT DHS COLOR SAFE MO; NT (Tier $0 NT SHAMPOO 3) GNP CALAMINE (Tier PHENOLATED $0 3) DHS CONDITIONING MO; NT (Tier $0 NT RINSE 3) GNP SALINE WOUND (Tier WASH $0 3) DIABETIDERM MO; NT (Tier $0 MO; NT CLEANSING 3) GRANDPAS BAKING (Tier SODA SOAP $0 3) dimethicone-zinc oxide- NT (Tier $0 MO; NT vitamin a-vitamin d 3) GRANDPAS INDIAN (Tier CORN SOAP DOMEBORO 1347MG- MO; NT 3) 952MG (Use Aluminum NF $0 MO; NT GRANDPAS LOVE MY (Tier Sulfate & Calcium Acetate) LOOFAH SOAP $0 NT 3) ELTA CLEANSE FOAM (Tier $0 MO; NT GRANDPAS OATMEAL (Tier 3) SOAP $0 MO; NT 3) FORMULA 405 FACIAL & (Tier $0 MO; NT BODYCLEANSING GRANDPAS ORANGE (Tier 3) ESSENCE SOAP $0 MO; NT 3) FORMULA 405 (Tier $0 MO; NT MOISTURIZINGSOAP GRANDPAS PATCHOULI (Tier 3) SOAP $0 MO; NT 3) FREE & CLEAR (Tier $0 MO; NT GRANDPAS SHEA (Tier 3) BUTTER SOAP $0 MO; NT 3) GENTLE RAIN EXTRA $0 (Tier GRANDPAS WITCH MO; NT MILD 3) (Tier HAZEL SOAP 3)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

100 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 Calamine-Zinc NEUTROGENA FACIAL $0 MO; NT HM CALAMINE (Tier Oxide SOAP ORIGINAL (Tier 3) Lotion;MO; NT FORMULA 3) $0 NT $0 MO; NT HYDROPEL (Tier NEUTROGENA (Tier 3) NATURALS FACE& BODY 3) $0 MO; NT $0 MO; NT JOHNSONS BABY BAR (Tier NEUTROGENA (Tier 3) SHAMPOO 3) $0 MO; NT $0 MO; NT JOHNSONS BUDDIES (Tier NEUTROGENA TRIPLE (Tier EASY-GRIP SUDZING 3) MOISTURE UV SHIELD 3) $0 MO; NT $0 MO; NT JOHNSONS KIDS SUPER (Tier NIVEA MOISTURIZING (Tier SUDZER E-Z GRIP SOAP 3) BODY WASH 3) $0 NT $0 MO; NT lanolin (topical) (Tier NIVEA MOISTURIZING (Tier 3) BODY WASH 2 IN 1 3) $0 LOBOB CONTACT LENS MO; NT NIVEA TOUCH OF $0 MO; NT (Tier SMOOTHNESS WEARERS SOAP 3) (Tier MOISTURIZING BODY 3) $0 MO; NT WASH LOWILA (Tier $0 MO; NT 3) NIVEA VISAGE GENTLE (Tier CLEANSING $0 NT 3) MEIJER CALAMINE (Tier $0 MO; NT 3) NO-STING SKIN-PREP (Tier $0 MO; NT 3) NATURE DE FRANCE (Tier ALGOLI SOAP $0 MO; NT 3) OCUSOFT HAND SOAP (Tier $0 MO; NT 3) NATURE DE FRANCE (Tier ARGILE BLANCHE SOAP $0 RX/OTC; NT 3) OCUSOFT LID SCRUB (Tier FOAMING $0 MO; NT 3) NATURE DE FRANCE (Tier ARGIMIEL SOAP $0 RX/OTC; NT 3) OCUSOFT LID SCRUB (Tier ORIGINAL $0 MO; NT 3) NEUTROGENA ACNE (Tier CLEANSING SOAP $0 MO; NT 3) OILATUM (Tier $0 MO; NT 3) NEUTROGENA CLEAN (Tier REPLENISHING 3)

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Health Net Cal MediConnect 2015 Drug List

101 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0 NT PHACID (Tier skin protectants, misc. liqd (Tier 3) 3) $0 NT $0 NT PROSHIELD FOAM & (Tier SM CALAMINE (Tier SPRAY CLEANSER 3) 3) $0 MO; NT $0 NT PURPOSE BAR (Tier SM CALAMINE (Tier 3) PHENOLATED 3) $0 Calamine-Zinc $0 RX/OTC; NT STYGIENE STERILE (Tier PX CALAMINE (Tier Oxide EYELID CLEANSER 3) Lotion;MO; NT 3) $0 NT SUMMERS EVE NIGHT- $0 MO; NT QC CALAMINE (Tier TIME (Tier 3) CLEANSING/SENSITIVE 3) $0 MO; NT SKIN RA BEAUTY BAR (Tier $0 MO; NT 3) TERSASEPTIC (Tier GLYCERINE CLEANSING $0 Calamine-Zinc 3) RA CALAMINE LOTN (Tier Oxide $0 MO; NT 6.971%-6.971% 3) Lotion;MO; NT TOPICLEAR (Tier $0 NT 3) RA SALINE WOUND (Tier $0 MO; NT WASH 3) ULTRASWIM (Tier $0 NT 3) SAFE WASH (Tier $0 MO; NT ULTRASWIM ULTRA (Tier 3) REPAIR $0 NT 3) SALINE WOUND WASH (Tier $0 MO; NT UNIVERSAL REMOVER (Tier 3) WIPES $0 NT 3) SALJET (Tier $0 MO; NT URO-PREP PROTECTIVE (Tier 3) SKINWIPES $0 NT 3) SALJET RINSE (Tier $0 MO; NT 3) VANICREAM BAR (Tier $0 MO; NT 3) SAYMAN LANOLIN (Tier $0 NT 3) witch hazel-glycerin (Tier $0 MO; NT 3) SAYMAN WITCH HAZEL (Tier 3)

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102 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 NT $0 NT WOUND WASH SALINE (Tier permethrin aero xx 0.5 % (Tier 3) 3) Rosacea Agents $0- MO $2.65 $0- MO permethrin crea ex 5 % $6.60 (Tier FINACEA GEL (Tier 1) 2) $0 MO; NT permethrin liqd ex 1 % (Tier METROCREAM (Use NF MO 3) Metronidazole (Topical)) $0 MO; NT METROGEL (Use NF MO permethrin lotn ex 1 % (Tier Metronidazole (Topical)) 3) METROLOTION (Use NF MO PRONTO SHAM EX NT Metronidazole (Topical)) 0.33%-4% (Use Pyrethrins- NF $0- MO Piperonyl Butoxide) $2.65 metronidazole (topical) $0 NT (Tier PYRETHINS/PIPERONYL (Tier 1) BUTOXIDE 3) $0- PA; MO $0 NT $6.60 pyrethrins-piperonyl MIRVASO (Tier (Tier butoxide 3) 2) NT Scabicides & Pediculicides RID (Use Permethrin) NF $0- MO RID (Use Pyrethrins- NF NT $2.65 Piperonyl Butoxide) lindane lotn (Tier 1) Sunscreens $0 RX/OTC; NT $0 MO; NT BULL FROG QUIK GEL (Tier LYCELLE (Tier SPF 36 3) 3) $0- MO $0 MO; NT BULL FROG QUIK GEL (Tier $2.65 SPF 50 malathion (Tier 3) 1) $0 MO; NT BULL FROG QUIK GEL (Tier $0 RX/OTC; NT SPORTSPF 36 nit remover (Tier 3) 3) $0 MO; NT BULL FROG QUIK GEL (Tier NIX CREME RINSE (Use NF MO; NT SPORTSPRAY SPF 50 Permethrin) 3) $0 MO; NT OVIDE 0.5 % (Use NF MO Malathion) BULL FROG SPF 36 (Tier 3)

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Health Net Cal MediConnect 2015 Drug List

103 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) BULL FROG WATER $0 MO; NT $0 NT GRANDPAS PINE TAR (Tier ARMOR SPORT QUIK (Tier SOAP GEL SPF 50 3) 3) BULL FROG WATER $0 MO; NT $0 NT ARMOR SPORT QUIK (Tier MG217 MEDICATED TAR (Tier SPRAY SPF 50 3) 3) $0 MO; NT $0 NT NIVEA VISAGE EYE (Tier POLYTAR BAR (Tier CONTOUR 3) 3) $0 MO; NT $0 MO; NT PRESUN ULTRA/PARSOL (Tier TARSUM (Tier GEL 3%-5%-7.5%-6% 3) 3) $0 MO; NT THERAPLEX T (Use Coal NF NT SHADE OIL FREE CLEAR (Tier Tar Extract) GELSPF 25 3) Wound Care Products $0 MO; NT $0- MO SOLBAR PF LIQUID/GEL (Tier SPF30 $6.60 3) REGRANEX (Tier Tar Products 2) $0 NT BALNETAR LIQUIM (Tier DIAGNOSTIC PRODUCTS 3) Diagnostic Drugs $0 NT $0 NT coal tar extract sham 1 % (Tier GLUTOL (Tier 3) 3) $0 MO; NT coal tar extract sham 1 %, (Tier Diagnostic Tests 15 % 3) $0 MO; NT $0 NT ALBUSTIX (Tier COAL TAR SOLN EX (Tier 3) 3) $0 MO; NT CHEK-STIX COMBO PAK (Tier $0 MO; NT URINALYSIS CONTROL CUTAR (Tier 3) 3) $0 MO; NT $0 NT CHEK-STIX CONTROL (Tier ELTA LITE TAR (Tier 3) 3) $0 MO; NT $0 NT CHEMSTRIP -10 WITH SG (Tier ELTA TAR (Tier 3) 3) $0 MO; NT CHEMSTRIP 10 MD (Tier 3)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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104 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0 MO; NT CHEMSTRIP 2 GP (Tier HEMA-COMBISTIX (Tier STRIPS 3) 3) $0 MO; NT $0 MO; NT CHEMSTRIP 2 LN STRIPS (Tier KETO-DIASTIX (Tier 3) 3) $0 MO; NT $0 MO; NT CHEMSTRIP 5 OB (Tier KETOCARE (Tier 3) 3) $0 MO; NT $0 MO; NT CHEMSTRIP 7 (Tier KETONE TEST STRIPS (Tier 3) 3) $0 MO; NT $0 MO; NT CHEMSTRIP 9 STRIPS (Tier KETOSTIX (Tier 3) 3) $0 MO; NT $0 MO; NT CHEMSTRIP UGK (Tier LABSTIX (Tier 3) 3) $0 MO; NT $0 MO; NT CHEMSTRIP-K (Tier MULTISTIX (Tier 3) 3) $0 MO; NT $0 MO; NT CHEMSTRIP-MICRAL (Tier MULTISTIX 10 SG (Tier 3) 3) $0 MO; NT $0 MO; NT CLINISTIX (Tier MULTISTIX 5 (Tier 3) 3) $0 NT $0 MO; NT CLINITEST (Tier MULTISTIX 7 (Tier 3) 3) $0 NT $0 MO; NT CLINITEST REAGENT (Tier MULTISTIX 8 SG (Tier 3) 3) $0 MO; NT $0 MO; NT COMBISTIX (Tier MULTISTIX 9 (Tier 3) 3) $0 MO; NT $0 MO; NT CVS KETONE CARE (Tier MULTISTIX 9 SG (Tier 3) 3) $0 MO; NT $0 MO; NT DIASTIX (Tier NITRATEST PAPER (Tier 3) 3)

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105 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0 RX/OTC; NT NOVA MAX PLUS (Tier SULFZIX (Tier KETONE TESTSTRIPS 3) 3) $0 MO; NT $0 RX/OTC; NT PRECISION XTRA (Tier XIZFLUS (Tier 3) 3) $0 MO; NT Nutritional Supplements PTS PANELS KETONE (Tier TEST 3) DEXATRIM MAX PACK PA; NT 1MG-5.5UNIT-34MCG- $0 MO; NT 72MG-75MG-0.35MG- $0 RELION KETONE (Tier 70MG-45MG-0.263MG- (Tier 3) 10MG-1.8MG-3.5MG- 3) $0 MO; NT 0.3MG-3MCG-70MCG- RELION KETONE TEST (Tier 0.35MG-25MG-30MG STRIPS 3) DIGESTIVE AIDS - Drugs to Treat Low Digestive $0 MO; NT Enzymes UNIVERSAL PH STRIPS (Tier 3) Digestive Enzymes $0 MO; NT $0- MO $6.60 URISTIX (Tier CREON 3) (Tier 2) $0 MO; NT URISTIX 4 (Tier $0- MO $6.60 3) PANCREAZE $0 (Tier MO; NT 2) WFHC PH PAPER (Tier 3) DIURETICS - Drugs to Treat Heart, Circulation DIETARY PRODUCTS/DIETARY MANAGEMENT Conditions and Blood Pressure PRODUCTS Carbonic Anhydrase Inhibitors Dietary Management Products $0- MO $0 acetazolamide cp12 or 500 $2.65 MO; NT (Tier CEREFOLIN (Tier mg 3) 1) $0- $0 MO; NT MO folic acid-pyridoxine- (Tier acetazolamide tabs or 250 $2.65 cyancobalamin 3) mg (Tier 1) $0 MO; NT L-METHYL-MC (Tier DIAMOX (Use NF MO 3) Acetazolamide) $0 MO; NT METAFOLBIC (Tier 3) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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106 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO methazolamide tabs or 25 $2.65 furosemide soln or 10 $2.65 mg, 50 mg (Tier mg/ml (Tier 1) 1) Diuretic Combinations $0- MO furosemide tabs or 20 mg, $2.65 ALDACTAZIDE 25MG- MO 40 mg, 80 mg (Tier 25MG (Use Spironolactone NF 1) & Hydrochlorothiazide) MO $0- MO LASIX (Use Furosemide) NF amiloride & $2.65 hydrochlorothiazide (Tier $0- MO 1) torsemide tabs or 10 mg, $2.65 100 mg, 20 mg, 5 mg (Tier DYAZIDE (Use MO 1) Triamterene & NF Hydrochlorothiazide) Potassium Sparing Diuretics MAXZIDE (Use MO ALDACTONE (Use NF MO Triamterene & NF Spironolactone) Hydrochlorothiazide) $0- MO $2.65 MAXZIDE-25 (Use MO amiloride hcl Triamterene & NF (Tier Hydrochlorothiazide) 1) $0- MO $0- MO spironolactone & $2.65 spironolactone tabs or 100 $2.65 hydrochlorothiazide (Tier mg, 25 mg, 50 mg (Tier 1) 1) $0- MO Thiazides and Thiazide-Like Diuretics triamterene & $2.65 $0- MO hydrochlorothiazide (Tier $2.65 1) chlorothiazide 500 mg (Tier Loop Diuretics 1) $0- MO $0- MO bumetanide tabs or 0.5 mg, $2.65 chlorthalidone 25 mg, 50 $2.65 1 mg, 2 mg (Tier mg (Tier 1) 1) MO $0- MO BUMEX (Use Bumetanide) NF hydrochlorothiazide caps or $2.65 12.5 mg (Tier DEMADEX (Use NF MO Torsemide) 1) $0- MO $0- MO $2.65 hydrochlorothiazide tabs or $2.65 furosemide soln ij 10 mg/ml (Tier 12.5 mg, 25 mg, 50 mg (Tier 1) 1)

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107 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO FOSAMAX (Use QL(0.15 ea $2.65 NF indapamide Alendronate Sodium) daily); MO (Tier $0- QL(0.04 ml 1) ibandronate sodium soln iv $2.65 daily); MO $0- MO 3 mg/3ml (Tier $2.65 metolazone 1) (Tier $0- QL(0.036 ea 1) ibandronate sodium tabs or $2.65 daily); MO MICROZIDE (Use NF MO 150 mg (Tier Hydrochlorothiazide) 1) $0- ZAROXOLYN (Use NF MO MO Metolazone) MIACALCIN IJ 200 $6.60 UNIT/ML (Tier ENDOCRINE AND METABOLIC AGENTS - 2) MISC. - Drugs to Treat Bone Disease and Regulate Hormones MIACALCIN NA 200 MO UNIT/ACT (Use Calcitonin NF Bone Density Regulators (Salmon)) $0- MO $0- PA; LA alendronate sodium tabs $2.65 $6.60 10 mg, 5 mg (Tier NATPARA (Tier 1) 2) $0- QL(0.15 ea $0- QL(0.01 ml alendronate sodium tabs $2.65 daily); MO $6.60 daily) 35 mg, 70 mg (Tier PROLIA (Tier 1) 2) BONIVA SOLN IV 3 QL(0.04 ml RECLAST (Use Zoledronic NF QL(0.28 ml MG/3ML (Use Ibandronate NF daily); MO Acid) daily) Sodium) $0- QL(0.243 ml BONIVA TABS OR 150 MG NF QL(0.036 ea $6.60 daily) (Use Ibandronate Sodium) daily); MO XGEVA (Tier $0- MO 2) $2.65 calcitonin (salmon) $0- (Tier zoledronic acid conc 4 $2.65 1) mg/5ml (Tier $0- QL(0.09 ml 1) $6.60 FORTEO daily) $0- QL(0.28 ml (Tier zoledronic acid soln 5 $2.65 daily) 2) mg/100ml (Tier $0- MO 1) $6.60 FORTICAL $0- (Tier $2.65 2) zoledronic acid solr 4 mg (Tier 1) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

108 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) ZOMETA CONC 4 $0- PA MG/5ML (Use Zoledronic NF NORDITROPIN FLEXPRO $6.60 Acid) 10 MG/1.5ML, 5 MG/1.5ML (Tier 2) Corticotropin $0- PA $0- PA; LA NUTROPIN AQ NUSPIN $6.60 $6.60 H.P. ACTHAR 20 (Tier (Tier 2) 2) $0- PA Fertility Regulators NUTROPIN AQ PEN 20 $6.60 $0- MG/2ML (Tier chorionic gonadotropin solr $2.65 2) im (Tier $0- PA 1) OMNITROPE SOLN 10 $6.60 Growth Hormone Receptor Antagonists MG/1.5ML, 5 MG/1.5ML (Tier 2) $0- LA $6.60 $0- PA SOMAVERT $6.60 (Tier SEROSTIM 4 MG, 6 MG 2) (Tier 2) Growth Hormone Releasing Hormones (GHRH) $0- PA $0- $6.60 $6.60 TEV-TROPIN EGRIFTA 2 MG (Tier (Tier 2) 2) $0- PA $6.60 Growth Hormones ZOMACTON 5 MG $0- PA (Tier $6.60 2) GENOTROPIN 5 MG (Tier Hormone Receptor Modulators 2) EVISTA (Use Raloxifene NF QL(1 ea daily); $0- PA HCl) MO GENOTROPIN MINIQUICK $6.60 0.4 MG (Tier $0- QL(1 ea daily); 2) $2.65 MO raloxifene hcl (Tier $0- PA 1) $6.60 HUMATROPE (Tier Insulin-Like Growth Factors (Somatomedins) 2) $0- LA $6.60 $0- PA INCRELEX HUMATROPE COMBO $6.60 (Tier PACK (Tier 2) 2) LHRH/GnRH Agonist Analog Pituitary

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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109 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- 3 Month Kit; $0- MO LUPRON DEPOT-PED $6.60 levocarnitine (metabolic $2.65 11.25 MG (Tier modifiers) tabs or 330 mg (Tier 2) 1) $0- $0- LA LUPRON DEPOT-PED $6.60 $6.60 11.25 MG, 15 MG, 7.5 MG (Tier LUMIZYME (Tier 2) 2) $0- $0- LA LUPRON DEPOT-PED 30 $6.60 $6.60 MG (Tier MYALEPT (Tier 2) 2) $0- MO $0- LA $6.60 $6.60 SYNAREL (Tier MYOZYME (Tier 2) 2) Metabolic Modifiers $0- LA $6.60 $0- MO NAGLAZYME (Tier calcitriol caps or 0.25 mcg, $2.65 2) 0.5 mcg (Tier 1) $0- LA $6.60 $0- MO ORFADIN $2.65 (Tier calcitriol soln or 1 mcg/ml (Tier 2) 1) $0- MO paricalcitol caps or 1 mcg, $2.65 CARNITOR TABS OR 330 MO 2 mcg, 4 mcg (Tier MG (Use Levocarnitine NF 1) (Metabolic Modifiers)) ROCALTROL (Use NF MO $0- LA Calcitriol) $6.60 FABRAZYME 35 MG (Tier $0- 2) $6.60 SENSIPAR (Tier $0- 2) KUVAN PACK 100 MG, $6.60 500 MG (Tier $0- 2) $6.60 VIMIZIM (Tier $0- LA $6.60 2) KUVAN TBSO 100 MG (Tier ZEMPLAR CAPS OR 1 MO 2) MCG, 2 MCG, 4 MCG (Use NF Paricalcitol) Posterior Pituitary Hormones

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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110 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) DDAVP (Use MO $0- Desmopressin Acetate NF SANDOSTATIN LAR $6.60 Refrigerated) DEPOT 20 MG, 30 MG (Tier DDAVP (Use MO 2) Desmopressin Acetate NF $0- LA Spray) $6.60 SIGNIFOR (Tier DDAVP (Use NF MO Desmopressin Acetate) 2) $0- MO $0- QL(0.11 ea $6.60 desmopressin acetate $2.65 SIGNIFOR LAR 20 MG daily) refrigerated (Tier (Tier 1) 2) $0- MO $0- QL(0.036 ea desmopressin acetate soln $2.65 SIGNIFOR LAR 40 MG, 60 $6.60 daily) ij 4 mcg/ml (Tier MG (Tier 1) 2) $0- MO $0- $6.60 desmopressin acetate $2.65 SOMATULINE DEPOT spray (Tier (Tier 1) 2) $0- MO Vasopressin Receptor Antagonists desmopressin acetate $2.65 $0- spray refrigerated (Tier $6.60 1) SAMSCA (Tier $0- MO 2) desmopressin acetate tabs $2.65 ESTROGENS - Hormone Replacement/Modifying or 0.1 mg, 0.2 mg (Tier Drugs 1) Estrogen Combinations Prolactin Inhibitors ACTIVELLA (Use Estradiol NF AL; MO $0- MO & Norethindrone Acetate) $2.65 cabergoline (Tier $0- AL; MO 1) estradiol & norethindrone $2.65 acetate (Tier Somatostatic Agents 1) $0- octreotide acetate 100 $0- AL; MO $2.65 $2.65 mcg/ml, 1000 mcg/5ml, (Tier estradiol-norgestimate 200 mcg/ml, 50 mcg/ml (Tier 1) 1) SANDOSTATIN 100 $0- AL; MO MCG/ML, 200 MCG/ML, 50 NF norethindrone acetate- $2.65 MCG/ML (Use Octreotide ethinyl estradiol 5mcg-1mg (Tier Acetate) 1) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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111 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO FLUOROQUINOLONES - Drugs to Treat Bacterial $6.60 Infections PREMPHASE (Tier 2) Fluoroquinolones $0- AL; MO CIPRO I.V.-IN D5W $6.60 200MG/100ML-5% (Use NF PREMPRO (Tier Ciprofloxacin in D5W) 2) CIPRO I.V.-IN D5W MO Estrogens 400MG/200ML-5% (Use NF Ciprofloxacin in D5W) AL; MO CLIMARA (Use Estradiol) NF CIPRO TABS 250 MG, 500 MO MG (Use Ciprofloxacin NF $0- MO HCl) DELESTROGEN 10 $6.60 MG/ML (Tier CIPRO XR (Use MO 2) Ciprofloxacin-Ciprofloxacin NF HCl) DELESTROGEN 20 MO $0- MG/ML, 40 MG/ML (Use NF ciprofloxacin hcl tabs or MO Estradiol Valerate) $2.65 100 mg, 250 mg, 500 mg, (Tier $0- MO 750 mg 1) $6.60 DIVIGEL (Tier $0- 2) ciprofloxacin in d5w $2.65 200mg/100ml-5% (Tier estradiol ptwk td 0.025 $0- AL; MO 1) mg/24hr, 0.05 mg/24hr, $2.65 0.06 mg/24hr, 0.075 $0- MO (Tier ciprofloxacin in d5w $2.65 mg/24hr, 0.1 mg/24hr, 37.5 1) mcg/24hr 400mg/200ml-5% (Tier 1) $0- AL; MO estradiol tabs or 0.5 mg, 1 $2.65 $0- MO mg, 2 mg (Tier ciprofloxacin soln iv 400 $2.65 1) mg/40ml (Tier 1) $0- MO estradiol valerate oil im 10 $2.65 $0- MO mg/ml, 20 mg/ml, 40 mg/ml (Tier ciprofloxacin-ciprofloxacin $2.65 1) hcl (Tier 1) $0- AL; MO estropipate 0.75 mg, 1.5 $2.65 LEVAQUIN SOLN IV mg (Tier 250MG/50ML-5%, NF 1) 500MG/100ML-5% (Use Levofloxacin in D5W) $0- AL; MO PREMARIN TABS OR 0.3 $6.60 LEVAQUIN SOLN IV MO MG, 0.45 MG, 0.625 MG, (Tier 750MG/150ML-5% (Use NF 0.9 MG, 1.25 MG 2) Levofloxacin in D5W) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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112 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) LEVAQUIN SOLN OR 25 NF MO Gallstone Solubilizing Agents ) MG/ML (Use Levofloxacin MO LEVAQUIN TABS OR 250 MO ACTIGALL (Use Ursodiol) NF MG, 500 MG, 750 MG (Use NF $0- LA Levofloxacin) $2.65 $0- chenodiol (Tier levofloxacin in d5w $2.65 250mg/50ml-5%, 1) (Tier MO 500mg/100ml-5% 1) URSO 250 (Use Ursodiol) NF $0- MO URSO FORTE (Use NF MO levofloxacin in d5w $2.65 Ursodiol) 750mg/150ml-5% (Tier $0- MO 1) $2.65 $0- ursodiol caps or 300 mg (Tier levofloxacin soln iv 25 $2.65 1) mg/ml (Tier $0- MO 1) ursodiol tabs or 250 mg, $2.65 $0- MO 500 mg (Tier levofloxacin soln or 25 $2.65 1) mg/ml (Tier 1) Gastrointestinal Antiallergy Agents $0- MO $0- MO levofloxacin tabs or 250 $2.65 cromolyn sodium $2.65 mg, 500 mg, 750 mg (Tier (mastocytosis) (Tier 1) 1) GASTROCROM (Use MO GASTROINTESTINAL AGENTS - MISC. - Cromolyn Sodium NF Miscellaneous Gastrointestinal Drugs (Mastocytosis)) Antiflatulents Gastrointestinal Stimulants GAS-X EXTRA MO; NT $0- MO STRENGTH CHEW 125 NF metoclopramide hcl soln or $2.65 MG (Use Simethicone) 10 mg/10ml, 5 mg/5ml (Tier MYLANTA GAS (Use NF MO; NT 1) Simethicone) $0- MO MYLANTA GAS RELIEF MO; NT metoclopramide hcl tabs or $2.65 MAXIMUM STRENGTH NF 10 mg, 5 mg (Tier (Use Simethicone) 1) $0 MO; NT simethicone caps or 125 REGLAN (Use NF MO (Tier Metoclopramide HCl) mg 3) Inflammatory Bowel Agents $0 MO; NT simethicone chew or 125 (Tier mg 3) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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113 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO $6.60 $2.65 APRISO (Tier mesalamine w/ cleanser (Tier 2) 1) $0- MO $0- PA $6.60 $6.60 ASACOL HD (Tier REMICADE (Tier 2) 2) AZULFIDINE (Use NF MO ROWASA (Use NF MO Sulfasalazine) Mesalamine w/ Cleanser) AZULFIDINE EN-TABS MO $0- MO NF $2.65 (Use Sulfasalazine) sulfasalazine tabs or $0- MO (Tier $2.65 1) balsalazide disodium (Tier $0- MO $2.65 1) sulfasalazine tbec or $0- PA (Tier $6.60 1) CIMZIA (Tier Intestinal Acidifiers 2) $0- MO $0- PA $2.65 $6.60 lactulose (encephalopathy) CIMZIA STARTER KIT (Tier (Tier 1) 2) Irritable Bowel Syndrome (IBS) Agents COLAZAL (Use NF MO Balsalazide Disodium) $0- MO $2.65 $0- MO alosetron hcl (Tier $6.60 1) DELZICOL (Tier 2) $0- MO $6.60 $0- MO LINZESS (Tier $6.60 2) DIPENTUM (Tier 2) $0- MO LOTRONEX (Use $6.60 $0- PA Alosetron HCl) (Tier $6.60 2) ENTYVIO (Tier 2) Peripheral Opioid Receptor Antagonists $0- MO $0- $2.65 RELISTOR KIT 12 $6.60 mesalamine enem re (Tier MG/0.6ML (Tier 1) 2)

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114 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO RELISTOR SOLN 12 $6.60 UROCIT-K 5 (Use $6.60 MG/0.6ML, 8 MG/0.4ML (Tier Potassium Citrate (Tier 2) (Alkalinizer)) 2) Phosphate Binder Agents Genitourinary Irrigants $0- MO $0- MO calcium acetate (phosphate $2.65 $2.65 binder) caps (Tier acetic acid ir 0.25 % (Tier 1) 1) $0- MO $0- MO $6.60 $2.65 FOSRENOL (Tier neomycin/polymyxin b gu (Tier 2) 1) PHOSLO (Use Calcium MO $0- MO Acetate (Phosphate NF sodium chloride (gu $2.65 Binder)) irrigant) (Tier $0- MO 1) $6.60 RENVELA PACK 2.4 GM Prostatic Hypertrophy Agents (Tier $0- MO 2) $2.65 $0- MO alfuzosin hcl (Tier $6.60 RENVELA TABS 800 MG 1) (Tier $0- GL; MO 2) AVODART (Use $6.60 $0- MO Dutasteride) (Tier SEVELAMER $6.60 2) CARBONATE (Tier $0- GL; MO 2) $2.65 dutasteride GENITOURINARY AGENTS - MISCELLANEOUS (Tier - Miscellaneous Drugs to Treat Reproductive 1) Organs and Urinary System $0- GL; MO Alkalinizers $2.65 finasteride tabs or (Tier $0- MO 1) potassium citrate $2.65 (alkalinizer) 1080 mg, 540 (Tier FLOMAX (Use Tamsulosin NF MO mg 1) HCl) $0- MO $0- GL; MO UROCIT-K 10 (Use $6.60 $6.60 JALYN Potassium Citrate (Tier (Tier (Alkalinizer)) 2) 2) PROSCAR (Use NF GL; MO Finasteride)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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115 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO $2.65 $2.65 tamsulosin hcl (Tier probenecid (Tier 1) 1) UROXATRAL (Use NF MO HEMATOLOGICAL AGENTS - MISC. - Drugs to Alfuzosin HCl) Treat Blood Disorders Urinary Analgesics Bradykinin B2 Receptor Antagonists $0 MO; NT $0- phenazopyridine hcl tabs or (Tier 100 mg, 200 mg $6.60 3) FIRAZYR (Tier 2) PYRIDIUM (Use NF MO; NT ) Phenazopyridine HCl Complement Inhibitors GOUT AGENTS - Drugs to Treat Gout $0- $6.60 Gout Agent Combinations BERINERT (Tier $0- MO 2) $2.65 colchicine w/ probenecid $0- LA (Tier $6.60 1) CINRYZE (Tier Gout Agents 2) $0- QL(8 ea daily); $0- $6.60 $2.65 MO RUCONEST allopurinol tabs or 100 mg (Tier (Tier 1) 2) $0- QL(2 ea daily); Hematorheologic Agents $2.65 allopurinol tabs or 300 mg MO $0- MO (Tier $2.65 1) pentoxifylline tbcr or (Tier $0- MO 1) $6.60 Plasma Kallikrein Inhibitors COLCHICINE TABS OR (Tier 2) $0- $6.60 $0- MO KALBITOR (Tier $6.60 2) COLCRYS (Tier 2) Platelet Aggregation Inhibitors $0- MO ZYLOPRIM 100 MG (Use NF QL(8 ea daily); Allopurinol) MO $6.60 AGGRENOX (Tier ZYLOPRIM 300 MG (Use NF QL(2 ea daily); Allopurinol) MO 2) AGRYLIN (Use Anagrelide NF MO Uricosurics HCl) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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116 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- AL $2.65 $2.65 anagrelide hcl (Tier ticlopidine hcl (Tier 1) 1) $0- MO $0- MO $6.60 $6.60 ASPIRIN/DIPYRIDAMOLE (Tier ZONTIVITY (Tier 2) 2) $0- MO HEMATOPOIETIC AGENTS - Drugs to Treat $6.60 Blood Disorders BRILINTA (Tier 2) Agents for Gaucher Disease $0- MO $0- PA $6.60 $2.65 CERDELGA cilostazol (Tier (Tier 1) 2) $0- $0- LA $6.60 clopidogrel bisulfate 300 $2.65 CEREZYME mg (Tier (Tier 1) 2) $0- MO $0- $6.60 $2.65 ELELYSO clopidogrel bisulfate 75 mg (Tier (Tier 1) 2) $0- AL; MO $0- $6.60 dipyridamole tabs or 25 $2.65 VPRIV mg, 50 mg, 75 mg (Tier (Tier 1) 2) $0- MO $0- LA $6.60 $6.60 ZAVESCA EFFIENT (Tier (Tier 2) 2) PERSANTINE (Use NF AL; MO Agents for Sickle Cell Anemia Dipyridamole) $0- MO $6.60 PLAVIX 300 MG (Use NF DROXIA Clopidogrel Bisulfate) (Tier 2) PLAVIX 75 MG (Use NF MO Clopidogrel Bisulfate) Cobalamins PLETAL (Use Cilostazol) NF MO $0 MO; NT cyanocobalamin subl sl (Tier 1000 mcg 3)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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117 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0- PA cyanocobalamin tabs or (Tier $6.60 250 mcg 3) NEUMEGA (Tier 2) Folic Acid/Folates $0- PA $0 NT $6.60 FA-8 (Tier NEUPOGEN (Tier 3) 2) $0 NT FOLIC ACID CAPS OR 20 (Tier $0- PA MG, 5 MG $6.60 3) PROCRIT (Tier $0 RX/OTC; MO; 2) folic acid tabs or 1 mg (Tier NT 3) $0- QL(12 ea $6.60 daily); LA $0 PROMACTA 12.5 MG folic acid tabs or 400 mcg, MO; NT (Tier (Tier 2) 800 mcg 3) $0- QL(6 ea daily); $6.60 Hematopoietic Growth Factors PROMACTA 25 MG LA $0- PA (Tier ARANESP ALBUMIN $6.60 2) FREE (Tier $0- QL(3 ea daily); 2) $6.60 PROMACTA 50 MG LA $0- PA (Tier $6.60 2) EPOGEN (Tier $0- QL(2 ea daily); 2) $6.60 PROMACTA 75 MG LA $0- PA (Tier $6.60 2) GRANIX (Tier $0- PA 2) $6.60 ZARXIO $0- PA (Tier $6.60 2) LEUKINE (Tier Hematopoietic Mixtures 2) $0 NT $0- PA B-6 FOLIC ACID (Tier $6.60 3) NEULASTA (Tier 2) FOLGARD RX (Use Folic MO; NT Acid-Vitamin B6-Vitamin NF $0- PA B12) NEULASTA DELIVERY $6.60 KIT (Tier $0 RX/OTC; MO; 2) FOLIC + B12 (Tier NT 3)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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118 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0 NT folic acid-vitamin b6- (Tier ferrous gluconate 240 mg, (Tier vitamin b12 3) 27 mg 3) $0 $0 RX/OTC; MO; ferrous sulfate dried tbcr NT FOLTRATE (Tier NT (Tier 3) 160 mg 3) $0 RX/OTC; NT $0 MO; NT HEMOCYTE-F (Tier ferrous sulfate elix or 220 (Tier 3) mg/5ml 3) $0 RX/OTC; NT $0 NT I.L.X. B-12 (Tier FERROUS SULFATE LIQD (Tier 3) OR 220 MG/5ML 3) $0 $0 RX/OTC; MO; ferrous sulfate soln or 15 MO; NT iron combinations (Tier NT (Tier 3) mg/ml 3) $0 $0 RX/OTC; MO; FERROUS SULFATE NT MTX SUPPORT (Tier NT (Tier 3) SYRP OR 300 MG/5ML 3) $0 $0 OPURITY B12/FOLIC RX/OTC; MO; ferrous sulfate tabs or 325 MO; NT (Tier NT (Tier ACID 3) mg, 65 mg 3) $0 NT $0 NT PRE-FOLIC (Tier ferrous sulfate tbcr or 50 (Tier 3) mg 3) $0 $0 RX/OTC; MO; FERROUS SULFATE MO; NT VITAMIN B12/FOLIC ACID (Tier NT (Tier 3) TBEC OR 324 MG 3) Iron $0 NT ferrous sulfate tbec or 325 (Tier mg FER-IN-SOL (Use Ferrous NF MO; NT 3) Sulfate) HEMOCYTE (Use Ferrous NF MO; NT FERGON 240 MG (Use NF NT Fumarate) Ferrous Gluconate) $0 MO; NT $0 ferrous fumarate tabs or MO; NT IRON CHEWS PEDIATRIC (Tier (Tier 3) 324 mg, 325 mg 3) $0 MO; NT $0 FERROUS FUMARATE NT IRON TABS 256 MG (Tier (Tier 3) TABS OR 90 MG 3) $0 NT $0 FERROUS GLUCONATE NT IRON TABS 28 MG (Tier (Tier 3) 225 MG 3)

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119 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT Barbiturate Hypnotics polysaccharide iron (Tier complex 150 mg $0- MO 3) $6.60 $0 MO; NT BUTISOL SODIUM (Tier PROFERRIN ES (Tier 2) 3) $0- AL; MO SLOW FE 160 MG (Use NF NT phenobarbital elix or 20 $2.65 Ferrous Sulfate Dried) mg/5ml (Tier $0 NT 1) SLOW RELEASE IRON (Tier $0- AL; MO 3) phenobarbital soln or 20 $2.65 Stem Cell Mobilizers mg/5ml (Tier 1) $0- $6.60 phenobarbital tabs or 100 $0- AL; MO MOZOBIL (Tier mg, 15 mg, 16.2 mg, 30 $2.65 2) mg, 32.4 mg, 60 mg, 64.8 (Tier mg, 97.2 mg 1) HEMOSTATICS - Drugs to Stop Bleeding/Treat Blood Disorders Hypnotics - Tricyclic Agents $0- MO Hemostatics - Systemic $6.60 $0- MO SILENOR (Tier $6.60 2) AMICAR TABS 500 MG (Tier 2) Non-Barbiturate Hypnotics $0- MO AMBIEN 10 MG (Use NF AL; QL(1 ea aminocaproic acid tabs or $2.65 Zolpidem Tartrate) daily); MO 500 mg (Tier AMBIEN 5 MG (Use NF AL; QL(2 ea 1) Zolpidem Tartrate) daily); MO CYKLOKAPRON (Use NF AMBIEN CR 12.5 MG (Use NF AL; QL(1 ea Tranexamic Acid) Zolpidem Tartrate) daily); MO LYSTEDA (Use NF MO AMBIEN CR 6.25 MG (Use NF AL; QL(2 ea Tranexamic Acid) Zolpidem Tartrate) daily); MO $0- HALCION (Use Triazolam) NF MO tranexamic acid soln iv 100 $2.65 mg/ml (Tier RESTORIL (Use NF MO 1) Temazepam) $0- MO AL; MO tranexamic acid tabs or $2.65 SONATA (Use Zaleplon) NF 650 mg (Tier $0- MO 1) $2.65 temazepam HYPNOTICS/SEDATIVES/SLEEP DISORDER (Tier AGENTS 1)

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Health Net Cal MediConnect 2015 Drug List

120 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO $2.65 $6.60 triazolam (Tier ROZEREM (Tier 1) 2) $0- AL; MO $2.65 LAXATIVES - Bowel Treatment Drugs zaleplon (Tier Bulk Laxatives 1) $0 MO; NT $0- AL; QL(1 ea calcium polycarbophil (Tier zolpidem tartrate tabs 10 $2.65 daily); MO 3) mg (Tier 1) CITRUCEL FIBER MO; NT LAXATIVE (Use NF $0- AL; QL(2 ea Methylcellulose (Laxative)) $2.65 daily); MO zolpidem tartrate tabs 5 mg $0 (Tier CVS NATURAL FIBER NT 1) (Tier SUPPLEMENT 3) $0- AL; QL(1 ea zolpidem tartrate tbcr 12.5 $2.65 daily); MO $0 NT mg (Tier EQL NATURAL FIBER (Tier 1) 3) $0- AL; QL(2 ea EVAC (Use Psyllium) NF MO; NT zolpidem tartrate tbcr 6.25 $2.65 daily); MO mg (Tier FIBERCON (Use Calcium NF MO; NT 1) Polycarbophil) $0 MO; NT Orexin Receptor Antagonists HYDROCIL INSTANT (Tier $0- PA; QL(2 ea PACK 3) $6.60 daily); MO BELSOMRA 10 MG HYDROCIL INSTANT NF MO; NT (Tier POWD (Use Psyllium) 2) $0 MO; NT $0- PA; QL(1 ea KONSYL PACK 100 % (Tier BELSOMRA 15 MG, 20 $6.60 daily); MO 3) MG (Tier 2) $0 NT KONSYL PACK 28.3 %, (Tier $0- PA; QL(4 ea 60.3 % 3) $6.60 BELSOMRA 5 MG daily); MO (Tier KONSYL POWD 100 % NF MO; NT 2) (Use Psyllium) $0 NT Selective Melatonin Receptor Agonists KONSYL POWD 60.3 %, (Tier $0- PA 71.67 % 3) $6.60 $0 HETLIOZ (Tier MO; NT KONSYL-D (Tier 2) 3)

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121 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) METAMUCIL CAPS 0.52 NF MO; NT GOLYTELY 236GM- MO GM (Use Psyllium) 22.74GM-5.86GM-2.97GM- METAMUCIL $0 NT 6.74GM (Use PEG 3350- NF MULTIHEALTH FIBER (Tier KCl-Sod Bicarb-Sod 55.46 % 3) Chloride-Sod Sulfate) METAMUCIL ORIGINAL MO; NT NULYTELY/FLAVOR MO TEXTURE 48.57 % (Use NF PACKS (Use PEG 3350- NF Psyllium) Potassium Chloride-Sod Bicarbonate-Sod Chloride) METAMUCIL POWD 48.57 NF MO; NT % (Use Psyllium) $0- MO peg 3350-kcl-sod bicarb- $2.65 $0 METAMUCIL SMOOTH NT sod chloride-sod sulfate (Tier (Tier 1) TEXTUREFIBER SINGLES 3) $0- MO methylcellulose (laxative) $0 MO; NT peg 3350-potassium $2.65 powd 2 gm/10.2gm, 2 (Tier chloride-sod bicarbonate- (Tier gm/19gm 3) sod chloride 1) $0 MO; NT $0- MO psyllium caps 0.52 gm, 520 (Tier mg $6.60 3) SUPREP BOWEL PREP (Tier $0 MO; NT 2) psyllium powd 100 %, (Tier 48.57 %, 58.6 %, 95 % 3) Laxatives - Miscellaneous psyllium powd 28.3 %, 30 $0 NT $0 MO; NT %, 30.9 %, 33 %, 49 %, 68 (Tier CEO-TWO (Tier % 3) 3) $0 NT $0 MO; NT FLEET LIQUID GLYCERIN (Tier UNIFIBER (Tier SUPPOSITORIES 3) 3) $0- MO Laxative Combinations $2.65 $0- lactulose COLYTE-FLAVOR PACKS (Tier $6.60 1) 227.1GM-21.5GM-5.53GM- (Tier 2.82GM-6.36GM $0- RX/OTC; MO 2) polyethylene glycol 3350 $2.65 COLYTE-FLAVOR PACKS MO pack or (Tier 240GM-22.72GM-5.84GM- 1) 2.98GM-6.72GM (Use PEG NF $0- RX/OTC; MO 3350-KCl-Sod Bicarb-Sod polyethylene glycol 3350 $2.65 Chloride-Sod Sulfate) powd or (Tier 1) Saline Laxatives

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122 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0 MO; NT MILK OF MAGNESIA (Tier docusate calcium (Tier CONCENTRATE 3) 3) $0 NT $0 MO; NT PHILLIPS MILK OF (Tier docusate sodium caps or (Tier MAGNESIA CHEWABLE 3) 100 mg, 250 mg, 50 mg 3) PHILLIPS MILK OF $0 NT $0 MO; NT docusate sodium enem re (Tier MAGNESIA (Tier 283 mg CONCENTRATED 3) 3) Stimulant Laxatives $0 MO; NT docusate sodium liqd or (Tier $0 MO; NT 150 mg/15ml, 50 mg/5ml 3) bisacodyl supp re 10 mg (Tier 3) $0 MO; NT docusate sodium syrp or 60 (Tier $0 MO; NT mg/15ml 3) bisacodyl tbec or 5 mg (Tier 3) $0 NT docusate sodium tabs or (Tier 100 mg DULCOLAX (Use NF MO; NT 3) Bisacodyl) $0 NT $0 DULCOLAX BOWEL PREP NT DOCUSOL KIDS (Tier (Tier 3) KIT 3) LOCAL ANESTHETICS-Parenteral - Drugs for EX-LAX TABS (Use NF MO; NT Sennosides) Numbing $0 MO; NT Local Anesthetics - Amides FLEET BISACODYL (Tier $0- MO 3) lidocaine hcl (local anesth.) $2.65 $0 MO; NT 1 %, 2 % (Tier sennosides tabs 15 mg, 8.6 (Tier 1) mg 3) XYLOCAINE IJ 1 %, 2 % MO (Use Lidocaine HCl (Local NF SENOKOT (Use NF MO; NT Sennosides) Anesth.)) XYLOCAINE-MPF 1 % MO SENOKOT TO GO (Use NF MO; NT Sennosides) (Use Lidocaine HCl (Local NF Anesth.)) Surfactant Laxatives $0 MO; NT MACROLIDES - Drugs to Treat Bacterial benzocaine-docusate (Tier Infections sodium 3) Azithromycin COLACE (Use Docusate NF MO; NT $0- MO Sodium) $2.65 azithromycin solr iv 500 mg (Tier COLACE CLEAR (Use NF MO; NT Docusate Sodium) 1)

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123 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- QL(16 ea azithromycin susr or 100 $2.65 erythromycin base tabs 250 $2.65 daily); MO mg/5ml, 200 mg/5ml (Tier mg (Tier 1) 1) $0- MO $0- QL(8 ea daily); azithromycin tabs or 250 $2.65 erythromycin base tabs 500 $2.65 MO mg, 500 mg, 600 mg (Tier mg (Tier 1) 1) $0- ZITHROMAX SOLR IV 500 NF MO QL(10 ea MG (Use Azithromycin) erythromycin $2.65 daily); MO ZITHROMAX SUSR OR MO ethylsuccinate tabs or (Tier 100 MG/5ML, 200 MG/5ML NF 1) (Use Azithromycin) $0- 500 MG;QL(8 $2.65 ZITHROMAX TABS OR MO erythromycin lactobionate ea daily) 250 MG, 500 MG, 600 MG NF (Tier (Use Azithromycin) 1) $0- QL(16 ea ZITHROMAX TRI-PAK NF MO (Use Azithromycin) $2.65 daily); MO erythromycin stearate (Tier ZITHROMAX Z-PAK (Use NF MO 1) Azithromycin) Fidaxomicin Clarithromycin $0- MO BIAXIN (Use NF MO $6.60 Clarithromycin) DIFICID (Tier BIAXIN XL (Use NF MO 2) Clarithromycin) MEDICAL DEVICES BIAXIN XL PAC (Use NF MO Clarithromycin) Bandages-Dressings-Tape $0- MO $0- RX/OTC; MO clarithromycin susr or 125 $2.65 $2.65 mg/5ml, 250 mg/5ml (Tier gauze pads 2" x 2" (Tier 1) 1) $0- MO clarithromycin tabs or 250 $2.65 Contraceptives mg, 500 mg (Tier $0 1) CONDOMS (Tier $0- MO 3) clarithromycin tb24 or 500 $2.65 Misc. Devices mg (Tier $0- RX/OTC; MO 1) $6.60 ALCOHOL PADS Erythromycins (Tier 2)

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124 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Parenteral Therapy Supplies QL(1 ea per $0- MO $0 365 days INSULIN SYRINGES AND $6.60 AEROCHAMBER PLUS (Tier retail,1 ea per PEN NEEDLES (Tier FLOW-VU 3) 365 days mail); 2) RX/OTC; MO; NT MEDICAL DEVICES AND SUPPLIES QL(1 ea per 365 days Contraceptives $0 AEROCHAMBER PLUS (Tier retail,1 ea per $0 NT FLOW-VU/LARGE MASK 3) 365 days mail); OMNIFLEX DIAPHRAGM (Tier RX/OTC; MO; 3) NT $0 NT QL(1 ea per ORTHO DIAPHRAGM (Tier 365 days ALL-FLEX/65MM $0 3) AEROCHAMBER PLUS (Tier retail,1 ea per $0 NT FLOW-VU/MASK 3) 365 days mail); ORTHO DIAPHRAGM (Tier RX/OTC; MO; ALL-FLEX/70MM 3) NT $0 NT QL(1 ea per ORTHO DIAPHRAGM (Tier 365 days ALL-FLEX/75MM $0 3) AEROCHAMBER PLUS (Tier retail,1 ea per FLOW-VU/MEDIUM MASK 365 days mail); $0 3) ORTHO DIAPHRAGM NT RX/OTC; MO; (Tier NT ALL-FLEX/80MM 3) QL(1 ea per Respiratory Therapy Supplies $0 365 days QL(1 ea per AEROCHAMBER PLUS (Tier retail,1 ea per FLOW-VU/SMALL MASK 365 days mail); $0 365 days 3) AEROCHAMBER MINI retail,1 ea per RX/OTC; MO; (Tier NT AEROSOLCHAMBER 3) 365 days mail); RX/OTC; MO; QL(1 ea per NT 365 days AEROCHAMBER Z-STAT $0 QL(1 ea per (Tier retail,1 ea per PLUS VALVED HOLDING 365 days mail); $0 365 days CHAMBER W/FLOW VU 3) retail,1 ea per RX/OTC; MO; AEROCHAMBER MV (Tier NT 3) 365 days mail); RX/OTC; MO; QL(1 ea per NT $0 365 days QL(1 ea per AEROCHAMBER Z-STAT (Tier retail,1 ea per PLUS/FLOWSIGNAL 365 days mail); $0 365 days 3) AEROCHAMBER PLUS retail,1 ea per RX/OTC; MO; (Tier NT FLOW VU 3) 365 days mail); RX/OTC; MO; NT

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125 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 QL(1 ea per ASSESS LOW RANGE RX/OTC; MO; 365 days (Tier NT $0 PEAK FLOW METER 3) AEROCHAMBER Z-STAT (Tier retail,1 ea per PLUS/LARGE MASK 365 days mail); $0 3) ASSESS PEAK FLOW RX/OTC; MO; RX/OTC; MO; (Tier NT NT METER FULL RANGE 3) QL(1 ea per $0 RX/OTC; MO; 365 days ASSESS PEAK FLOW (Tier $0 METER LOW RANGE NT AEROCHAMBER Z-STAT (Tier retail,1 ea per 3) PLUS/MEDIUM MASK 3) 365 days mail); $0 RX/OTC; MO; ASTHMA CHECK METER- RX/OTC; MO; (Tier NT NT ZONE SYSTEM 3) QL(1 ea per $0 RX/OTC; MO; $0 365 days ASTHMAMENTOR (Tier NT AEROCHAMBER Z-STAT (Tier retail,1 ea per 3) PLUS/SMALL MASK 3) 365 days mail); RX/OTC; MO; QL(1 ea per NT $0 365 days retail,1 ea per QL(1 ea per BREATHERITE (Tier 3) 365 days mail); $0 365 days RX/OTC; MO; AEROCHAMBER/FLOWSI (Tier retail,1 ea per NT GNAL 3) 365 days mail); RX/OTC; MO; QL(1 ea per NT $0 365 days BREATHERITE retail,1 ea per QL(1 ea per COLLAPSIBLEADULT (Tier SPACER W/MASK 3) 365 days mail); AEROVENT PLUS $0 365 days RX/OTC; MO; HOLDING (Tier retail,1 ea per NT 3) 365 days mail); CHAMBER/COLLAPSIBLE RX/OTC; MO; QL(1 ea per NT BREATHERITE $0 365 days (Tier retail,1 ea per $0 RX/OTC; MO; COLLAPSIBLECHILD 365 days mail); AIRZONE PEAK FLOW (Tier SPACER W/MASK 3) METER NT RX/OTC; MO; 3) NT QL(1 ea per QL(1 ea per 365 days $0 BREATHERITE $0 365 days (Tier retail,1 ea per retail,1 ea per ARIAL CHAMBER 365 days mail); COLLAPSIBLEINFANT (Tier 3) 3) 365 days mail); RX/OTC; MO; SPACER W/MASK RX/OTC; MO; NT NT $0 ASSESS FULL RANGE RX/OTC; MO; (Tier NT PEAK FLOW METER 3)

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126 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) QL(1 ea per QL(1 ea per BREATHERITE $0 365 days $0 365 days COLLAPSIBLESMALL (Tier retail,1 ea per E-Z SPACER THE BODY (Tier retail,1 ea per 3) 365 days mail); GUARDS PACK 3) 365 days mail); CHILD SPACER W/MASK RX/OTC; MO; RX/OTC; MO; NT NT QL(1 ea per QL(1 ea per BREATHERITE $0 365 days $0 365 days COLLAPSIBLESPACER (Tier retail,1 ea per EASIVENT (Tier retail,1 ea per 3) 365 days mail); 3) 365 days mail); W/ NEONATE MASK RX/OTC; MO; RX/OTC; MO; NT NT QL(1 ea per QL(1 ea per $0 365 days $0 365 days BREATHERITE RIGID (Tier retail,1 ea per EASIVENT/MASK-LARGE (Tier retail,1 ea per SPACERW/MASK 3) 365 days mail); 3) 365 days mail); RX/OTC; MO; RX/OTC; MO; NT NT QL(1 ea per QL(1 ea per $0 365 days $0 365 days BREATHERITE W/LARGE (Tier retail,1 ea per EASIVENT/MASK- (Tier retail,1 ea per MASK 3) 365 days mail); MEDIUM 3) 365 days mail); RX/OTC; MO; RX/OTC; MO; NT NT QL(1 ea per QL(1 ea per $0 365 days $0 365 days BREATHERITE (Tier retail,1 ea per EASIVENT/MASK-SMALL (Tier retail,1 ea per W/MEDIUM MASK 3) 365 days mail); 3) 365 days mail); RX/OTC; MO; RX/OTC; MO; NT NT QL(1 ea per QL(1 ea per $0 365 days $0 365 days BREATHERITE W/SMALL (Tier retail,1 ea per FLEXICHAMBER (Tier retail,1 ea per MASK 3) 365 days mail); 3) 365 days mail); RX/OTC; MO; RX/OTC; MO; NT NT QL(1 ea per QL(1 ea per $0 365 days INSPIRACHAMBER/ANTI- $0 365 days E-Z SPACER (Tier retail,1 ea per STATIC (Tier retail,1 ea per 3) 365 days mail); 3) 365 days mail); RX/OTC; MO; VALVED/MOUTHPIECE RX/OTC; MO; NT NT

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127 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 QL(1 ea per MINI WRIGHT PEAK RX/OTC; MO; 365 days (Tier NT INSPIRACHAMBER/SOOT $0 FLOW METER 3) HERMASK/INSPIRAMASK (Tier retail,1 ea per /MEDIUM 3) 365 days mail); QL(1 ea per RX/OTC; MO; 365 days NT $0 NESSI SPACER/LARGE (Tier retail,1 ea per QL(1 ea per MASK 3) 365 days mail); 365 days RX/OTC; MO; INSPIRACHAMBER/SOOT $0 NT HERMASK/INSPIRAMASK (Tier retail,1 ea per /SMALL 3) 365 days mail); QL(1 ea per RX/OTC; MO; 365 days NT $0 NESSI (Tier retail,1 ea per QL(1 ea per SPACER/MOUTHPIECE 3) 365 days mail); 365 days RX/OTC; MO; $0 NT INSPIREASE DRUG (Tier retail,1 ea per DELIVERYSYSTEM 3) 365 days mail); QL(1 ea per RX/OTC; MO; 365 days NT NESSI $0 SPACER/SMALL/MED (Tier retail,1 ea per QL(1 ea per MASK 3) 365 days mail); 365 days RX/OTC; MO; $0 NT LITEAIRE (Tier retail,1 ea per 3) 365 days mail); QL(1 ea per RX/OTC; MO; 365 days NT $0 OPTICHAMBER (Tier retail,1 ea per QL(1 ea per ADVANTAGE 3) 365 days mail); 365 days RX/OTC; MO; $0 NT MICROCHAMBER (Tier retail,1 ea per 3) 365 days mail); QL(1 ea per RX/OTC; MO; 365 days NT OPTICHAMBER $0 ADVANTAGE/LARGE (Tier retail,1 ea per $0 365 days mail); MICROLIFE DIGITAL RX/OTC; MO; MASK 3) (Tier NT RX/OTC; MO; PEAK FLOW METER 3) NT QL(1 ea per QL(1 ea per $0 365 days OPTICHAMBER $0 365 days MICROSPACER (Tier retail,1 ea per ADVANTAGE/MEDIUM (Tier retail,1 ea per 3) 365 days mail); 3) 365 days mail); RX/OTC; MO; FACE MASK RX/OTC; MO; NT NT MINI WRIGHT AFS PEAK $0 RX/OTC; MO; FLOWMETER LOW (Tier NT RANGE 3)

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128 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) QL(1 ea per QL(1 ea per OPTICHAMBER $0 365 days $0 365 days ADVANTAGE/SMALL (Tier retail,1 ea per OPTICHAMBER FACE (Tier retail,1 ea per 3) 365 days mail); MASK/SMALL 3) 365 days mail); FACE MASK RX/OTC; MO; RX/OTC; MO; NT NT QL(1 ea per QL(1 ea per $0 365 days $0 365 days OPTICHAMBER (Tier retail,1 ea per OPTIHALER (Tier retail,1 ea per DIAMOND 3) 365 days mail); 3) 365 days mail); RX/OTC; MO; RX/OTC; MO; NT NT QL(1 ea per QL(1 ea per OPTICHAMBER $0 365 days $0 365 days DIAMOND/LARGEFACE (Tier retail,1 ea per OPTIHALER MDI DRUG (Tier retail,1 ea per 3) 365 days mail); DELIVERY SYSTEM 3) 365 days mail); MASK RX/OTC; MO; RX/OTC; MO; NT NT QL(1 ea per PEAK AIR PEAK FLOW $0 RX/OTC; MO; 365 days METERADULT/PEDIATRI (Tier NT OPTICHAMBER $0 3) DIAMOND/MEDIUM FACE (Tier retail,1 ea per C MASK 3) 365 days mail); $0 RX/OTC; MO; RX/OTC; MO; PEAK FLOW METER (Tier NT NT 3) QL(1 ea per $0 RX/OTC; MO; 365 days PERSONAL BEST FULL (Tier OPTICHAMBER $0 RANGE NT (Tier retail,1 ea per 3) DIAMOND/SMALLFACE 365 days mail); MASK 3) $0 RX/OTC; MO; PERSONAL BEST LOW RX/OTC; MO; NT (Tier NT RANGE 3) QL(1 ea per $0 365 days RX/OTC; MO; $0 PIKO 1 ELECTRONIC (Tier NT OPTICHAMBER FACE (Tier retail,1 ea per 3) MASK/LARGE 3) 365 days mail); RX/OTC; MO; QL(1 ea per NT $0 365 days retail,1 ea per QL(1 ea per POCKET CHAMBER (Tier 3) 365 days mail); $0 365 days RX/OTC; MO; OPTICHAMBER FACE (Tier retail,1 ea per NT MASK/MEDIUM 365 days mail); 3) $0 RX/OTC; MO; POCKET PEAK FLOW RX/OTC; MO; NT (Tier NT METER 3)

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129 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) QL(1 ea per MIGRAINE PRODUCTS - Drugs to Treat Migraine $0 365 days Headaches retail,1 ea per POCKET SPACER (Tier Migraine Products 3) 365 days mail); RX/OTC; MO; D.H.E. 45 (Use MO NT Dihydroergotamine NF POCKETPEAK PEAK $0 RX/OTC; MO; Mesylate) FLOW METER LOW (Tier NT $0- MO RANGE 3) dihydroergotamine $2.65 POCKETPEAK PEAK RX/OTC; MO; mesylate soln ij 1 mg/ml (Tier $0 1) FLOW (Tier NT METER/UNIVERSAL 3) $0- RANGE $2.65 ergotamine tartrate subl sl POCKETPEAK PEAK RX/OTC; MO; (Tier $0 1) FLOW (Tier NT METER/UNIVERSAL 3) Serotonin Agonists RANGE 50-720 LPM $0- QL(0.27 ml QL(1 ea per $6.60 ALSUMA daily); MO $0 365 days (Tier (Tier retail,1 ea per 2) RITEFLO 365 days mail); 3) AMERGE (Use Naratriptan NF QL(0.3 ea RX/OTC; MO; HCl) daily); MO NT IMITREX SOLN SC 6 QL(0.27 ml $0 TRUZONE PEAK FLOW RX/OTC; MO; MG/0.5ML (Use NF daily); MO (Tier NT Sumatriptan Succinate) METER 3) IMITREX STATDOSE QL(0.14 ml QL(1 ea per REFILL 4 MG/0.5ML (Use NF daily); MO $0 365 days Sumatriptan Succinate) VALVED HOLDING retail,1 ea per (Tier IMITREX STATDOSE QL(0.27 ml CHAMBER 3) 365 days mail); RX/OTC; MO; REFILL 6 MG/0.5ML (Use NF daily); MO NT Sumatriptan Succinate) QL(1 ea per IMITREX STATDOSE QL(0.14 ml 365 days SYSTEM 4 MG/0.5ML (Use NF daily); MO $0 Sumatriptan Succinate) VORTEX VALVED (Tier retail,1 ea per HOLDING CHAMBER 3) 365 days mail); IMITREX STATDOSE QL(0.27 ml RX/OTC; MO; SYSTEM 6 MG/0.5ML (Use NF daily); MO NT Sumatriptan Succinate) QL(1 ea per IMITREX TABS OR 100 QL(0.3 ea $0 365 days MG (Use Sumatriptan NF daily); MO WATCHHALER (Tier retail,1 ea per Succinate) 3) 365 days mail); RX/OTC; MO; NT You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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130 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) IMITREX TABS OR 25 MG QL(0.9 ea $0- QL(0.14 ml (Use Sumatriptan NF daily); MO sumatriptan succinate soct $2.65 daily); MO Succinate) sc 4 mg/0.5ml (Tier IMITREX TABS OR 50 MG QL(0.6 ea 1) (Use Sumatriptan NF daily); MO $0- QL(0.27 ml Succinate) sumatriptan succinate soct $2.65 daily); MO sc 6 mg/0.5ml (Tier MAXALT 10 MG (Use NF QL(0.4 ea Rizatriptan Benzoate) daily); MO 1) $0- QL(0.27 ml MAXALT 5 MG (Use NF QL(0.8 ea Rizatriptan Benzoate) daily); MO sumatriptan succinate soln $2.65 daily); MO sc 6 mg/0.5ml (Tier MAXALT-MLT 10 MG (Use NF QL(0.4 ea 1) Rizatriptan Benzoate) daily); MO $0- QL(0.3 ea MAXALT-MLT 5 MG (Use NF QL(0.8 ea sumatriptan succinate tabs $2.65 daily); MO Rizatriptan Benzoate) daily); MO or 100 mg (Tier $0- QL(0.3 ea 1) $2.65 naratriptan hcl daily); MO $0- QL(0.9 ea (Tier sumatriptan succinate tabs $2.65 daily); MO 1) or 25 mg (Tier $0- QL(0.4 ea 1) rizatriptan benzoate tabs $2.65 daily); MO $0- QL(0.6 ea 10 mg (Tier sumatriptan succinate tabs $2.65 daily); MO 1) or 50 mg (Tier $0- QL(0.8 ea 1) rizatriptan benzoate tabs 5 $2.65 daily); MO $0- QL(4 ea daily); mg (Tier $2.65 MO 1) zolmitriptan tabs 2.5 mg (Tier $0- QL(0.4 ea 1) rizatriptan benzoate tbdp $2.65 daily); MO $0- QL(2 ea daily); 10 mg (Tier $2.65 MO 1) zolmitriptan tabs 5 mg (Tier $0- QL(0.8 ea 1) rizatriptan benzoate tbdp 5 $2.65 daily); MO $0- QL(4 ea daily); mg (Tier $2.65 MO 1) zolmitriptan tbdp 2.5 mg (Tier $0- QL(0.14 ml 1) sumatriptan succinate soaj $2.65 daily); MO $0- QL(2 ea daily); sc 4 mg/0.5ml (Tier $2.65 MO 1) zolmitriptan tbdp 5 mg (Tier $0- QL(0.27 ml 1) sumatriptan succinate soaj $2.65 daily); MO ZOMIG TABS OR 2.5 MG NF QL(4 ea daily); sc 6 mg/0.5ml (Tier (Use Zolmitriptan) MO 1)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

131 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) ZOMIG TABS OR 5 MG NF QL(2 ea daily); calcium carbonate-vitamin $0 MO; NT (Use Zolmitriptan) MO d tabs 200unit-500mg, (Tier 500mg-200unit, 500mg- ZOMIG ZMT 2.5 MG (Use NF QL(4 ea daily); 3) Zolmitriptan) MO 500mg-200unit-200unit $0 MO; NT ZOMIG ZMT 5 MG (Use NF QL(2 ea daily); calcium citrate tabs or 200 Zolmitriptan) MO (Tier mg, 950 mg 3) MINERALS & ELECTROLYTES $0 MO; NT CALCIUM CITRATE TABS (Tier Calcium OR 250 MG 3) $0 NT calcium citrate-vitamin d $0 MO; NT CALCI-CHEW (Tier 250mg-200unit, 315mg- (Tier 3) 200unit 3) $0 MO; NT $0 MO; NT CALCI-MIX (Tier calcium gluconate soln iv (Tier 3) 10 % 3) $0 MO; NT $0 NT CALCIONATE (Tier CALCIUM GLUCONATE (Tier 3) TABS OR 500 MG 3) $0 NT $0 MO; NT CALCIUM & MAGNESIUM (Tier CALCIUM LACTATE 648 (Tier 3) MG 3) $0 NT $0 NT calcium carbonate chew or (Tier 1250 mg calcium tabs 600 mg (Tier 3) 3) calcium carbonate tabs or $0 MO; NT $0 NT 1250 mg, 500 mg, 600 mg, (Tier calcium w/ magnesium (Tier 600mg 3) 500mg-250mg 3) $0 NT $0 MO; NT calcium carbonate tabs or (Tier 1500 mg CALCIUM/VITAMIN D (Tier 3) 3) calcium carbonate- $0 NT $0 MO; NT cholecalciferol caps (Tier CALCIUM/VITAMIN D3 (Tier 600mg-500unit 3) 3) calcium carbonate- $0 MO; NT CITRACAL/VITAMIN D MO; NT cholecalciferol chew (Tier (Use Calcium Citrate- NF 500mg-100unit 3) Vitamin D) calcium carbonate-vitamin $0 NT $0 NT d tabs 125unit-250mg, CORAL CALCIUM TABS (Tier (Tier OR 500 MG 125unit-500mg, 250mg- 3) 3) 125unit, 500mg-125unit

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132 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 NT $0 MO; NT EQL CALCIUM/VITAMIN D (Tier ENFAMIL ENFALYTE (Tier 3) 3) $0 NT $0- MAGNEBIND 200 (Tier $2.65 3) lactated ringer's (Tier $0 MO; NT 1) oyster shell (Tier $0 NT 3) MEDI-LYTE (Tier 3) Chloride $0- MO $2.65 ammonium chloride soln iv (Tier 1) Electrolyte Mixtures CERALYTE 70 SOLN $0 MO; NT 60MEQ/L-70MEQ/L- (Tier 20MEQ/L-30MEQ/L, 3) 70MEQ/L-20MEQ/L $0 MO; NT CERASPORT EX1 SOLN (Tier 3) CERASPORT SOLN MO; NT 4MEQ/L-18MEQ/L- $0 20MEQ/L-69MEQ/L, (Tier 4MEQ/L-18MEQ/L- 3) 20MEQ/L-6MEQ/L $0- $2.65 dextrose in lactated ringers (Tier 1) $0- dextrose w/ sodium $2.65 chloride 0.45%-2.5%, (Tier 0.45%-5% 1) $0- MO dextrose w/ sodium $2.65 chloride 0.9%-5% (Tier 1) $0 MO; NT ENFALYTE (Tier 3)

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133 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) oral electrolytes soln MO; NT 20meq/l-7.8mg/l-25 16meq/473ml- 21meq/473ml-9meq/473ml- $0 NT oral electrolytes tabs (Tier 11gm/473ml, 18.8meq/l- 287mg-180mg-15mg 42.4meq/l-33.2meq/l- 3) 4.8gm/l-18.8gm/l, $0- B/D 20meq/1000ml- $2.65 45meq/1000ml- parenteral electrolytes (Tier 35meq/1000ml- 1) 25gm/1000ml, 20meq/l- PEDIALYTE FREEZER MO; NT 20meq/l-45meq/l-45meq/l- POPS (Use Oral NF 35meq/l-25gm/l, 20meq/l- Electrolytes) 20meq/l-45meq/l-45meq/l- 35meq/l-35meq/l-30meq/l- PEDIALYTE SOLN MO; NT 30meq/l-25gm/l-25gm/l, 20MEQ/L-45MEQ/L- 20meq/l-20meq/l-45meq/l- 35MEQ/L-30MEQ/L- 45meq/l-35meq/l-35meq/l- 25GM/L, 20MEQ/L- NF 30meq/l-30meq/l-5gm/l- 45MEQ/L-35MEQ/L- 20gm/l, 20meq/l-45meq/l- 5GM/L-20GM/L (Use Oral 35meq/l-25gm/l, 20meq/l- Electrolytes) 45meq/l-35meq/l-30meq/l- $0- potassium chloride in 25gm/l, 20meq/l-45meq/l- $0 $2.65 35meq/l-30meq/l-5gm/l- dextrose & sodium chloride (Tier (Tier 0.45%-20meq/l-5% 20gm/l, 20meq/l-45meq/l- 3) 1) 35meq/l-30meq/l-5gm/l- $0 NT 25gm/l, 20meq/l-45meq/l- THERMOTABS (Tier 35meq/l-5gm/l-20gm/l, 3) 20meq/l-45meq/l-35meq/l- 7.8mg/l-25gm, 20meq/l- Fluoride 45meq/l-35meq/l-7.8mg/l- $0 MO; NT 25gm/l, 20meq/l-45meq/l- FLORICAL CAPS (Tier 35meq/l-7.8mg/l-25meq/l, 3) 20meq/l-45meq/l-45meq/l- $0 MO; NT 35meq/l-5gm/l-20gm/l, MONOCAL (Tier 35meq/l-45meq/l-20meq/l- 3) 20gm/l, 35meq/l-45meq/l- 20meq/l-25gm/l, 35meq/l- Iodine Products 45meq/l-20meq/l-30meq/l- $0 MO; NT 25gm/l, 35meq/l-45meq/l- IODINE STRONG (Tier 20meq/l-30meq/l-30gm/l, 3) 35meq/l-45meq/l-20meq/l- $0 NT 30meq/l-5gm/l-20gm/l, POTASSIUM IODIDE (Tier 35meq/l-45meq/l-20meq/l- TABS OR 3) 5gm/l-20gm/l, 35meq/l- 45meq/l-20meq/l-7.5mg/l- Magnesium 25meq/l, 35meq/l-45meq/l- You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

134 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT $0- MO MAG-TAB SR (Tier potassium chloride cpcr or $2.65 3) 10 meq, 8 meq (Tier $0 NT 1) MAGINEX (Tier $0- MO 3) POTASSIUM CHLORIDE $2.65 $0 NT ER (Tier MAGINEX DS (Tier 1) 3) $0- potassium chloride MO $0 NT $2.65 MAGNESIUM CHLORIDE microencapsulated crystals (Tier (Tier cr HEXAHYDRATE 3) 1) $0 MO; NT $0- MO magnesium chloride tbcr or (Tier potassium chloride soln iv 2 $2.65 535 mg, 64 mg 3) meq/ml (Tier 1) $0 NT MAGNESIUM (Tier $0- ELEMENTAL TABS 30 MG 3) potassium chloride soln or $2.65 10 % (Tier MAGNESIUM $0 NT 1) GLUCONATE TABS OR (Tier 250 MG, 500 MG, 550 MG 3) $0- MO potassium chloride soln or $2.65 $0- MO 20 % (Tier magnesium sulfate soln ij $2.65 1) 50 % (Tier 1) $0- MO potassium chloride tbcr or $2.65 $0 magnesium tabs 250 mg, NT 10 meq, 8 meq (Tier (Tier 1) 250mg 3) Sodium Phosphate $0- $0 MO; NT sodium chloride soln iv $2.65 PHOS-NAK POWDER (Tier CONCENTRATE 0.45 % (Tier 3) 1) Potassium $0- MO sodium chloride soln iv 0.9 $2.65 K-TAB 10 MEQ (Use NF MO Potassium Chloride) % (Tier $0- MO 1) $6.60 K-TAB 8 MEQ Trace Minerals (Tier $0 NT 2) chromium 200 mcg (Tier MICRO-K (Use Potassium NF MO 3) Chloride)

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Health Net Cal MediConnect 2015 Drug List

135 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 NT $0 MO; NT chromium picolinate caps (Tier zinc tabs or 50 mg (Tier or 200 mcg 3) 3) $0 MO; NT chromium picolinate tabs or (Tier MOUTH/THROAT/DENTAL AGENTS 200 mcg 3) Anesthetics Topical Oral $0 MO; NT BABY ANBESOL (Use NF NT MULTITRACE-4 (Tier Benzocaine (Dental)) 3) BABY ORAJEL GEL (Use NF NT $0 MO; NT Benzocaine (Dental)) SELENIUM SOLN IV 40 (Tier MCG/ML 3) $0 NT BABY ORAJEL LIQD (Tier $0 NT 3) selenium tabs or 100 mcg (Tier 3) $0 NT benzocaine (dental) gel 7.5 (Tier $0 MO; NT % 3) selenium tabs or 50 mcg (Tier 3) $0 MO; NT benzocaine (dental) pste (Tier $0 NT 20 % 3) trace minerals (cr-cu-mn- (Tier zn) $0 3) benzocaine (dental) soln 20 RX/OTC; MO; (Tier NT Zinc % 3) $0 MO; NT HURRICAINE ONE (Use NF RX/OTC; MO; ORAZINC (Tier Benzocaine (Dental)) NT 3) HURRICAINE SOLN (Use NF RX/OTC; MO; $0 NT Benzocaine (Dental)) NT ZINC 15 (Tier $0- MO 3) lidocaine hcl (mouth-throat) $2.65 $0 zinc gluconate lozg mt 10 NT 2 % (Tier (Tier 1) mg 3) ORABASE (Use NF MO; NT $0 MO; NT Benzocaine (Dental)) zinc gluconate tabs or 50 (Tier mg $0 MO; NT 3) ZILACTIN (Tier $0 MO; NT 3) ZINC SULFATE SOLN IV 1 (Tier MG/ML, 5 MG/ML 3) Anti-infectives - Throat $0 NT $0 MO; NT zinc tabs or 25 mg (Tier carbamide peroxide soln mt (Tier 3) 3)

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Health Net Cal MediConnect 2015 Drug List

136 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0 MO; NT $2.65 AQUORAL (Tier clotrimazole lozg mt (Tier 3) 1) $0- MO $0- MO $2.65 $2.65 cevimeline hcl (Tier clotrimazole troc mt (Tier 1) 1) EVOXAC (Use Cevimeline NF MO $0 NT HCl) hydrogen peroxide (mouth- (Tier throat) $0- MO 3) $2.65 $0 pilocarpine hcl (oral) hydrogen peroxide-benzyl MO; NT (Tier (Tier 1) alcohol 3) SALAGEN (Use NF MO $0- MO Pilocarpine HCl (Oral)) $2.65 nystatin (mouth-throat) (Tier MULTIVITAMINS 1) B-Complex Vitamins PEROXYL SOLN EX 1.5%- MO; NT 6% (Use Hydrogen NF b-complex vitamins caps or MO; NT Peroxide-Benzyl Alcohol) 3.33mg-0.4mg-0.33mg- 0.66mcg-0.11mg, 60mg- $0 MO; NT 60mg-3mg-5mg-20mg- $0 ULCEREASE (Tier 3mg-1mcg-0.5mg, 60mg- (Tier 3) 60mg-5mg-20mg-3mg- 3) Antiseptics - Mouth/Throat 1mcg-3mg-0.5mg, 70mg- $0- MO 100mg-1mg-10mg-2mg- chlorhexidine gluconate $2.65 1.5mg-100mcg (mouth-throat) (Tier b-complex vitamins inj ij MO; NT 1) 2mg/ml-100mg/ml-2mg/ml- $0 PERIDEX (Use MO 100mg/ml-2mg/ml, 2mg/ml- (Tier Chlorhexidine Gluconate NF 2%-100mg/ml-2mg/ml- 3) (Mouth-Throat)) 100mg/ml-2mg/ml $0 NT b-complex vitamins soln ij $0 MO; NT phenol (antiseptic) aers (Tier 2mg/ml-2%-100mg/ml- (Tier 3) 2mg/ml-100mg/ml-2mg/ml 3) Steroids - Mouth/Throat $0- MO triamcinolone acetonide $2.65 (mouth) (Tier 1) Throat Products - Misc.

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Health Net Cal MediConnect 2015 Drug List

137 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) b-complex vitamins tabs or MO; NT b complex w/ c tabs NT 0.1mg-20mg-2mg-5mcg- 10.2mg-10.2mg-10mg- 3mg-1mg, 100mg-50mg- 10mg-50mg-50mg-15mg- 40mg-10mg-20mg-5mg- 15mg-5mg-5mg-300mg- 4.6mg-1mcg-5mg-1mg, 300mg, 100mg-100mg- 10mg-10mg-2mg-1.5mg- 25mg-20mg-6mg-15mcg- 0.2mg, 10mg-14mg- 100mg-5mcg-2mg-150mg, 25mcg-7mg-4.5mg, 15mg- 100mg-100mg-5.5mg- 2mg-5mg-2mcg-2mg-2mg, $0 20mg-15mcg-25mg- 30mg-50mg-50mg-50mg- (Tier 400mcg-5mcg-2mg-150mg, 50mg-50mg-50mcg-50mg- 3) 100mg-10mg-20mg- 100mcg-50mcg-50mg, 10mcg-15mg-5mg-500mg, 3mg-10mg-20mg-3mg- 100mg-20mg-5.5mg- 6mcg-2mg, 3mg-20mg- 15mcg-2mg-25mg-150mg- 3mg-10mg-6mcg-2mg, 400mcg-5mcg-150mg, $0 3mg-3mg-20mg-20mg- 10mg-10mg-15mg-50mg- (Tier 3mg-3mg-10mg-10mg- 5mg-300mg, 15mg- 3) 6mcg-6mcg-2mg-2mg, 10.2mg-10mg-50mg-5mg- 83mg-3mg-20mg-2mg- 300mg, 15mg-10mg-50mg- 5mcg-1mg 10.2mg-5mg-300mg, 15mg-10mg-50mg-10.2mg- B-Complex w/ C 6mcg-400mcg-5mg-300mg, b complex w/ c caps NT 15mg-150mg-10mg-50mg- 10.2mg-10mg-15mg-50mg- 10.2mg-5mg-300mg, 5mg-300mg, 10mg-50mg- $0 15mg-20mg-50mg-10mg- 10.2mg-15mg-5mg-300mg, (Tier 10mcg-5mg-300mg, 15mg- 10mg-50mg-10mg-15mg- 3) 50mg-10.2mg-10mg-5mg- 5mg-300mg, 15mg-10mg- 300mg, 50mg-10.2mg- 50mg-10mg-5mg-300mg 10mg-15mg-5mg-300mg, 50mg-10mg-10mg-15mg- 5mg-300mg, 50mg-15mg- 10mg-10.2mg-5mg-300mg B-Complex w/ Folic Acid $0 MO; NT B-100 COMPLEX (Tier 3) b-complex w/ c & folic acid MO; NT tabs 10mg-20mg-1.5mg- $0 1mg-1.5mg-5mg-300mcg- (Tier 50mg-60mg, 20mg-1.5mg- 3) 10mg-1mg-1.5mg-5mg- 300mcg-50mg-60mg

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138 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) b-complex w/ folic acid tabs MO; NT $0 NT 1.5mg-20mg-1.7mg-6mcg- MULTI-DELYN/IRON (Tier 400mcg-2mg, 1.7mg- 3) 10mg-6mcg-1.2mg-20mg- pediatric multiple vitamins MO; NT 0.4mg-2mg, 100mg- w/ iron soln 0.6mg/ml- 100mg-100mg-100mcg- 10mg/ml-5unit/ml-8mg/ml- 400mcg-100mg, 100mg- 1500unit/ml-400unit/ml- $0 100mg-100mg-100mg- 0.5mg/ml-0.4mg/ml- 10mcg-400mcg-100mcg- (Tier 35mg/ml, 1500unit/ml- 3) 100mg, 10mg-10mg-50mg- 10mg/ml-5unit/ml- 10mg-10mg-10mg-10mcg- $0 400unit/ml-8mg/ml- 10mg-400mcg-10mcg- (Tier 0.6mg/ml-0.5mg/ml- 10mg, 10mg-20mg-1.7mg- 3) 0.4mg/ml-35mg/ml 6mcg-1.5mg-400mcg-2mg, 15mg-100mg-200mg- Ped Multi Vitamins w/Fl & FE 17mg-60mcg-400mcg- $0 MO; NT 20mg, 30mg-20mg-50mg- ped multivitamins w/fl & (Tier 30mg-10mg-10mcg- iron 3) 400mcg-8mg, 40mcg-1mg- $0 MO; NT 6mg-5mcg-3mg-2mcg- TRI-VIT/FLUORIDE/IRON (Tier 19mcg, 50mg-50mg-50mg- 3) 50mcg-50mg-400mcg- 50mcg-50mg Pediatric Multiple Vitamins b-complex w/ folic acid tbcr NT $0 NT EQL CHILDRENS (Tier 100mg-100mg-100mg- MULTIVITAMINS 100mg-100mcg-400mcg- 3) 100mcg-100mg, 125mg- $0 MO; NT 125mg-125mg-125mg- pediatric multiple vitamin w/ (Tier $0 c 125mcg-125mg-125mg- (Tier 3) 400mcg-125mcg-125mg, 3) $0 NT 50mg-50mg-50mg-50mg- pediatric multiple vitamin w/ (Tier 50mcg-0.4mg-50mcg- extra c & fa 3) 50mg, 50mg-50mg-50mg- 50mg-50mcg-100mcg- Pediatric Vitamins 50mcg-50mg $0 MO; NT $0 NT pediatric vitamins adc (Tier NERVO B-12 SL (Tier 3) 3) Prenatal Vitamins Ped MV w/ Fluoride $0 NT ONE A DAY WOMENS (Tier $0 MO; NT PRENATAL/DHA pediatric vitamins acd w/ (Tier 3) fluoride 3) Ped MV w/ Iron

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139 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) PRENATAL FORMULA NT $0 RX/OTC; NT NORWEGIAN COD LIVER (Tier CAPS 35MG-30UNIT- OIL 4000UNIT-200MG-25MG- $0 3) 1.8MG-200MG-28MG- (Tier $0 RX/OTC; NT 20MG-1.7MG-8MCG- 3) QC COD LIVER OIL (Tier 400UNIT-800MCG-2.6MG- 3) 120MG $0 RX/OTC; NT Specialty Vitamins Products RA COD LIVER OIL (Tier $0 MO; NT 3) ULTRA MAN (Tier vitamins a & d caps MO; NT 3) 10000unit-400unit, $0 MO; NT 10000unit-5000unit, $0 ULTRA WOMAN (Tier 1250unit-133unit, 1250unit- (Tier 3) 135unit, 5000unit-400unit, 3) 700unit-400unit, 8000unit- Vitamin Mixtures 400unit cod liver oil caps 10 minim, NT 110mg-2664unit-1000mg- Vitamins w/ Lipotropics 100mg-200unit, 1250unit- 130unit, 1250unit- 133.33unit, 1250unit- 133unit, 1250unit-135unit, 200unit-4000unit, 20mg- 35mg-1250unit-45mg- $0 133.333unit, 34mg- (Tier 1250unit-415mg-32mg- 3) 135unit, 50mg-110mg- 250unit-110mg-100unit- 10unit, 52mg-2500unit- 600mg-52mg-270unit, 530mg-1250unit-130unit, 90mg-37mg-415mg-36mg- 1250unit-135unit $0 RX/OTC; NT COD LIVER OIL FOR KIDS (Tier 3) COD LIVER OIL OIL RX/OTC; NT 4000UNIT/5ML- $0 400UNIT/5ML, (Tier 5000UNIT/5ML- 3) 500UNIT/5ML $0 RX/OTC; NT CVS COD LIVER OIL (Tier 3)

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Health Net Cal MediConnect 2015 Drug List

140 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) vitamins w/ lipotropics tabs MO; NT 30mg-8mg, 25mg-40mg- 10000unit-10mg-18mg- 20mg-3.4mg-20mg-12mcg- 100unit-225mcg-10mg- 3mg-20mg-400mcg- 150mg-100mg-30mg- 30mcg-4mg-150mg, 25mg- 10mg-25mg-25mg-50mg- 40mg-20mg-3.4mg-20mg- 50mg-10mg-50mg-50mg- 12mcg-3mg-20mg-400mg- 200mcg-400unit-50mg- 30mcg-4mg, 266. 400mcg-50mg-250mg, MUSCULOSKELETAL THERAPY AGENTS - 100mg-100mg-100mg- Drugs to Treat Spasms 100mcg-100mg-100mcg- 100mcg-100mg, 100mg- Central Muscle Relaxants 100mg-100mg-100mg- $0- QL(8 ea daily); 100mg-100mg-100mcg- $2.65 MO 100mg-100mcg-100mcg- baclofen tabs or 10 mg (Tier 100mg, 100mg-100mg- 1) 100mg-100mg-100mg- $0- QL(4 ea daily); 100mg-100mg-100mcg- $2.65 MO 100mcg-100mcg-100mg, baclofen tabs or 20 mg (Tier 100mg-100mg-100mg- 1) 100mg-100mg-100mg- 100mg-100mcg-100mg- $0- AL; MO carisoprodol tabs or 350 $2.65 200mcg-100mcg-100mg, $0 100mg-111.3mg-0.33mg- mg (Tier (Tier 1) 1.7mg-1.7mcg-0.33mg- 3) 111.3mg-3.3mg-0.33mg- $0- AL; MO $2.65 100mg, 100mg-12.5mg- chlorzoxazone 100mg-100mg-12.5mg- (Tier 12.5mg-100mg-100mcg- 1) 100mcg-100mcg-100mg, $0- AL; MO 100mg-43.33mg-111.3mg- cyclobenzaprine hcl tabs or $2.65 0.33mg-1.7mg-1.7mcg- 10 mg, 5 mg (Tier 0.33mg-111.3mg-3.3mg- 1) 0.33mg-100mg, 200mg- $0- AL; MO 29mg-0.333mg-1.666mg- $2.65 3.33mg-111.333mg- metaxalone (Tier 111.333mg-1mg- 1) 1.666mcg-0.333mg- 100mg, 200mg-29mg- $0- AL; MO 0.33mg-1.67mg-3.33mg- methocarbamol tabs or 500 $2.65 111.33mg-111.33mg-1mg- mg, 750 mg (Tier 1.67mcg-0.33mg-100mg, 1) 200mg-29mg-0.34mg- PARAFON FORTE DSC NF AL; MO 1.67mg-3.34mg-111mg- (Use Chlorzoxazone) 111mg-1mg-1.67mcg- ROBAXIN TABS OR 500 NF AL; MO 0.34mg-100mg, 20mg- MG (Use Methocarbamol) 50mg-30mg-10mg-10mcg- You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

141 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 ROBAXIN-750 (Use NF AL; MO NT Methocarbamol) ENTSOL NASAL SPRAY (Tier 3) SKELAXIN (Use NF AL; MO Metaxalone) $0 NT ENTSOL NASAL WASH (Tier SOMA 350 MG (Use NF AL; MO Carisoprodol) 3) $0- MO $0 MO; NT tizanidine hcl caps or 2 mg, $2.65 GELONASAL (Tier 4 mg, 6 mg (Tier 3) 1) OCEAN NASAL SPRAY NF MO; NT $0- MO (Use Saline) tizanidine hcl tabs or 2 mg, $2.65 $0 MO; NT 4 mg (Tier PONARIS (Tier 1) 3) $0 MO; NT ZANAFLEX (Use NF MO Tizanidine HCl) saline gel na (Tier 3) Direct Muscle Relaxants $0 saline soln na 0.65 %, MO; NT DANTRIUM (Use NF MO (Tier Dantrolene Sodium) 0.65%, 0.65%-0.002% 3) $0- MO $0 NT dantrolene sodium caps or $2.65 SALTAIRE (Tier 100 mg, 25 mg, 50 mg (Tier 3) 1) Nasal Antiallergy NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus $0- MO $2.65 Nasal Agents - Misc. azelastine hcl 0.1 % (Tier AFRIN PURESEA $0 MO; NT 1) GENTLE MISTNASAL (Tier $0- MO RINSE 3) $2.65 olopatadine hcl (nasal) AFRIN PURESEA $0 MO; NT (Tier MEDIUM STREAM NASAL (Tier 1) RINSE 3) $0- MO AFRIN PURESEA ULTRA- $0 MO; NT PATANASE (Use $6.60 GENTLE MIST NASAL (Tier Olopatadine HCl (Nasal)) (Tier RINSE 3) 2) $0 NT Nasal Anticholinergics AYR NASAL DROPS (Tier ATROVENT (Use MO 3) Ipratropium Bromide NF $0 NT (Nasal)) ENTSOL HYPERTONIC (Tier NASAL IRRIGATION MIST 3)

You can find information on what the symbols and abbreviations on this table mean by going to page viii.

Health Net Cal MediConnect 2015 Drug List

142 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO NEO-SYNEPHRINE 0.25 MO; NT $2.65 NF ipratropium bromide (nasal) % (Use Phenylephrine HCl) (Tier $0 MO; NT 1) NEO-SYNEPHRINE 0.5 % (Tier Nasal Steroids 3) $0- MO NEO-SYNEPHRINE COLD MO; NT $2.65 & SINUS MILD (Use NF budesonide (nasal) (Tier Phenylephrine HCl) 1) $0 MO; NT NEO-SYNEPHRINE COLD (Tier FLONASE (Use RX/OTC; MO & SINUS REGULAR Fluticasone Propionate NF 3) (Nasal)) $0 MO; NT phenylephrine hcl soln na (Tier $0- MO 0.25 % $2.65 3) flunisolide (nasal) (Tier $0 MO; NT 1) pseudoephedrine hcl liqd or (Tier 15 mg/5ml $0- RX/OTC; MO 3) fluticasone propionate $2.65 $0 MO; NT (nasal) (Tier pseudoephedrine hcl tabs (Tier 1) or 30 mg, 60 mg 3) $0- MO SUDAFED (Use NF MO; NT RHINOCORT AQUA (Use $6.60 Pseudoephedrine HCl) Budesonide (Nasal)) (Tier SUDAFED CHILDRENS MO; NT 2) (Use Pseudoephedrine NF $0- RX/OTC; MO HCl) triamcinolone acetonide $2.65 SUDAFED CONGESTION MO; NT (nasal) (Tier (Use Pseudoephedrine NF 1) HCl) Sympathomimetic Decongestants SUDAFED NASAL MO; NT $0 NT DECONGESTANT BENZEDREX INHALER (Tier MAXIMUM STRENGTH NF 3) (Use Pseudoephedrine $0 NT HCl) ELIXSURE CONGESTION (Tier SUDAFED PE $0 NT 3) CHILDRENS NASAL (Tier $0 MO; NT DECONGESTANT 3) NASAL DECONGESTANT (Tier LIQD NEUROMUSCULAR AGENTS - Drugs to 3) Relax/Paralyze Muscles $0 NT ALS Agents NASAL DECONGESTANT (Tier SYRP 3) RILUTEK (Use Riluzole) NF MO

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143 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0 NT $2.65 MCT OIL (Tier riluzole (Tier 3) 1) $0 MO; NT Neuromuscular Blocking Agent - Neurotoxins MICROLIPID (Tier 3) $0- PA $6.60 BOTOX 200 UNIT Lipotropics (Tier $0 MO; NT 2) INOSITOL TABS OR 500 (Tier MG $0- PA 3) $6.60 XEOMIN $0 MO; NT (Tier lecithin caps or (Tier 2) 3) NUTRIENTS $0 NT LECITHIN (Tier CONCENTRATE Carbohydrates 3) $0- B/D Misc. Nutritional Substances $2.65 dextrose soln iv 10 % $0 MO; NT (Tier docosahexaenoic acid 200 (Tier 1) mg 3) $0- MO; B/D EXPECTA LIPIL (Use NF MO; NT $2.65 Docosahexaenoic Acid) dextrose soln iv 5 % (Tier 1) omega-3 fatty acids caps NT 180mg-120mg, 300mg, $0 GLUCOSE NURSETTE NF NT 300mg-160mg-1000mg- (Tier (Use Glucose) 100mg-5unit, 300mg- 3) $0 NT 772.5mg-90mg-180mg glucose soln 5 % (Tier omega-3 fatty acids caps MO; NT 3) 180mg-500mg-120mg, $0 NT 27mg-244mg-500mg- POLYCOSE (Tier 89mg, 300mg-1000mg- $0 3) 200mg, 300mg-200mg, 500 (Tier Lipids mg, 500mg, 500mg- 3) 270mg-135mg, 500mg- $0- B/D 320mg-130mg, 90mg- $2.65 500mg-60mg fat emulsion 20 gm/100ml (Tier 1) Proteins LIPOSYN III $0- B/D $0 NT 1.2GM/100ML- $6.60 ADD-INS COMPLETE (Tier 10GM/100ML- (Tier 3) 2.5GM/100ML 2)

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144 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- B/D $0 MO; NT $2.65 amino acids-protein (Tier amino acid infusion 15% (Tier hydrolysate 3) 1) AMINOSYN II 15% (Use NF B/D $0 NT amino acid infusion) amino acids caps 130mg- (Tier 10mg-130mg-130mg $0 NT 3) ARGIMENT (Tier amino acids tabs 100mg- MO; NT 3) 6.15mg-2.1mg-0.85mg- $0 NT 1.95mg-0.55mg-2.3mg- ARGIMENT AT (Tier 1.95mg-0.75mg-1.15mg- 3) 0.6mg-3.65mg-0.65mg- 3.25mg-3.8mg-1.95mg- $0 NT 1.7mg-0.7mg-1.05mg, arginine tabs 500 mg (Tier 115.333mg-54.667mg- 3) 21mg-33.333mg- $0 MO; NT COMPLEX MSUD AMINO (Tier 33.333mg-46.667mg- ACID BAR 14.167mg-46.667mg- 3) 40mg-53.333mg- $0 NT 18.167mg-41mg- GLUTAMENT (Tier 66.667mg-40mg- 3) 30.667mg-17.333mg- $0 NT 14mg, 115.3mg-54.7mg- HEPAMENT (Tier 21mg-33.3mg-13.3mg- 3) 33.3mg-63.3mg-14.2mg- $0 46.7mg-40mg-53.3mg- $0 NT (Tier L-CARNITINE TABS OR (Tier 18.2mg-41mg-66.7mg- 3) 250 MG 40mg-30.7mg-17.3mg- 3) 14mg, 1200mg-100mg, $0 NT 18.33mg-200mg-33.33mg- L-CITRULLINE CAPS OR (Tier 50mg-23.16mg-58.33mg- 3) 18.33mg-75mg-108.33mg, $0 MO; NT 200mg-33.33mg-50mg- levocarnitine caps or 250 (Tier 23.16mg-18.33mg- mg 3) 58.33mg-18.33mg-75mg- $0 MO; NT 108.33mg, 35mg-29.5mg- PHENYLADE AMINO ACID (Tier 24.667mg-4.833mg- 3) 17.667mg-24.667mg- 12.5mg-24mg-19mg-36mg- $0 NT PHENYLADE AMINO ACID (Tier 17.5mg-4.667mg-75mg- BLEND 15mg, 74mg-50mg-0.7mg- 3) 77mg-1.4mg-72mg-64mg- $0 NT PHENYLADE MTE AMINO (Tier 27mg-54mg-70mg-41mg- ACIDBLEND 17mg-109mg-7mg-27mg- 3) 68mg-47mg-41mg-64mg

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145 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 MO; NT XPHE MAXAMUM PACK NT PHENYLADE PHEBLOC (Tier TABS 153MG-280MG-41MCG- 3) 1114UNIT-29MCG- $0 NT 13MCG-0.9MG-410MCG- PHENYLADE40 DRINK (Tier 4.5MG-569MG-7.4MG- MIX 3) 9.2UNIT-18.5MCG- 65.5MCG-592MG-280MG- $0 NT 350MG-2.9MG-40MG- PHLEXY-10 CAPS (Tier 215MG-0.49MG-2.5MG- 3) 1.6MCG-166UNIT-0.46MG- $0 $0 MO; NT 246MCG-12.3MCG-0.8MG- PROTEINEX (Tier (Tier 31MG, 153MG-280MG- 3) 3) 41MCG-29MCG-13MCG- $0 NT 0.9MG-410MCG-4.5MG- SOLVIL (Tier 569MG-7.4MG-9.2UNIT- 3) 18.5MCG-65.5MCG- $0 MO; NT 592MG-280MG-350MG- SUPER-AMINO 1600 (Tier 1114UNIT-2.9MG-40MG- 3) 215MG-0.49MG-2.5MG- 1.6MCG-166UNIT-0.46MG- $0 NT 246MCG-12.3MCG-0.8MG- SYMPT-X G.I. (Tier 31MG 3) $0 MO; NT OPHTHALMIC AGENTS - Drugs to Treat the Eye TRIAMINO (Tier 3) Artificial Tears and Lubricants $0 NT GENTEAL MILD TO MO; NT tyrosine tabs 500 mg (Tier MODERATE (Use NF 3) Hypromellose (Ophth)) $0 MO; NT hypromellose (ophth) 0.3 (Tier %, 3 mg/ml 3) $0 MO; NT ISOPTO TEARS (Tier 3) $0 NT NUTRATEAR (Tier 3) $0 MO; NT polyvinyl alcohol soln op (Tier 3) $0 NT TEARS AGAIN NIGHT & (Tier DAY 3)

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146 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 NT $0- MO TGT LUBRICANT EYE (Tier ISOPTO CARPINE (Use $6.60 DROPS 3) Pilocarpine HCl) (Tier 2) Beta-blockers - Ophthalmic $0- BETAGAN (Use NF MO $6.60 Levobunolol HCl) PHOSPHOLINE IODIDE (Tier $0- MO 2) $2.65 betaxolol hcl (ophth) $0- MO (Tier pilocarpine hcl soln op 1 %, $2.65 1) 2 %, 4 % (Tier $0- MO 1) $2.65 carteolol hcl (ophth) (Tier Ophthalmic Adrenergic Agents 1) $0- MO $6.60 COSOPT (Use MO ALPHAGAN P 0.1 % Dorzolamide HCl-Timolol NF (Tier Maleate) 2) $0- MO ALPHAGAN P 0.15 % (Use NF MO dorzolamide hcl-timolol $2.65 Brimonidine Tartrate) maleate (Tier $0- MO $2.65 1) apraclonidine hcl $0- MO (Tier $2.65 1) levobunolol hcl 0.5 % (Tier $0- MO $2.65 1) brimonidine tartrate $0- MO (Tier $2.65 1) timolol maleate (ophth) (Tier IOPIDINE 0.5 % (Use NF MO 1) Apraclonidine HCl) TIMOPTIC (Use Timolol NF MO Ophthalmic Anti-infectives )) Maleate (Ophth $0- MO TIMOPTIC-XE (Use NF MO bacitracin-polymyxin b $2.65 Timolol Maleate (Ophth)) (ophth) (Tier Cycloplegic Mydriatics 1) $0- MO BLEPH-10 (Use MO cyclopentolate hcl soln op $2.65 Sulfacetamide Sodium NF 1 % (Tier (Ophth)) 1) CILOXAN SOLN (Use NF MO Ciprofloxacin HCl (Ophth)) Miotics

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147 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO $2.65 sulfacetamide sodium $2.65 ciprofloxacin hcl (ophth) (Tier (ophth) (Tier 1) 1) $0- MO $0- MO $2.65 $2.65 erythromycin (ophth) (Tier tobramycin (ophth) (Tier 1) 1) $0- MO TOBREX SOLN (Use MO $2.65 NF gatifloxacin (ophth) Tobramycin (Ophth)) (Tier $0- MO 1) $2.65 $0- MO trifluridine soln op (Tier $2.65 gentamicin sulfate (ophth) 1) (Tier $0- MO 1) $6.60 $0- MO VIGAMOX (Tier $2.65 2) levofloxacin (ophth) (Tier VIROPTIC (Use NF MO 1) Trifluridine) $0- MO ZYMAXID (Use NF MO neomycin-bacitracin zn- $2.65 Gatifloxacin (Ophth)) polymyxin (Tier 1) Ophthalmic Decongestants $0- MO $0 MO; NT naphazoline w/ (Tier neomycin-polymyxin- $2.65 pheniramine 0.025%-0.3% gramicidin (Tier 3) 1) NAPHCON-A (Use MO; NT Naphazoline w/ NF OCUFLOX (Use Ofloxacin NF MO (Ophth)) Pheniramine) $0- MO $0 NT $2.65 VISINE-LR (Tier ofloxacin (ophth) (Tier 3) 1) Ophthalmic Immunomodulators $0- MO $0- MO $2.65 polymyxin b-trimethoprim $6.60 (Tier RESTASIS (Tier 1) 2) POLYTRIM (Use NF MO Polymyxin B-Trimethoprim) Ophthalmic Local Anesthetics

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148 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO $2.65 sulfacetamide sod- $2.65 proparacaine hcl soln op (Tier prednisolone (Tier 1) 1) Ophthalmic Steroids TOBRADEX SUSP (Use MO NF $0- MO Tobramycin- bacitracin-poly-neomycin- $2.65 Dexamethasone) hc (Tier $0- MO 1) tobramycin- $2.65 $0- MO dexamethasone (Tier dexamethasone sodium $2.65 1) phosphate (ophth) (Tier Ophthalmics - Misc. 1) ACULAR (Use Ketorolac NF MO $0- MO Tromethamine (Ophth)) $2.65 fluorometholone (ophth) ACULAR LS (Use MO (Tier Ketorolac Tromethamine NF 1) (Ophth)) FML LIQUIFILM (Use NF MO $0- MO Fluorometholone (Ophth)) $2.65 $0- MO azelastine hcl (ophth) (Tier $6.60 LOTEMAX OINT 1) (Tier $0- MO 2) $6.60 MAXITROL (Use MO AZOPT (Tier Neomycin-Polymy- NF 2) Dexameth) $0- Once daily $0- MO $2.65 dosing;MO neomycin-polymy- $2.65 bromfenac sodium (ophth) (Tier dexameth (Tier 1) 1) $0- MO OMNIPRED (Use MO $2.65 Prednisolone Acetate NF cromolyn sodium (ophth) (Tier (Ophth)) 1) PRED FORTE (Use MO $0- Limited to 60 Prednisolone Acetate NF $6.60 ml per 28 (Ophth)) CYSTARAN (Tier days;QL(2.15 $0- MO 2) ml daily); LA prednisolone acetate $2.65 $0- MO (ophth) (Tier $2.65 1) diclofenac sodium (ophth) (Tier 1)

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149 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO $2.65 $6.60 dorzolamide hcl (Tier NEVANAC (Tier 1) 2) ELESTAT (Use Epinastine NF MO OCUFEN (Use Flurbiprofen NF MO HCl (Ophth)) Sodium) $0 MO; NT OPTIVAR (Use Azelastine NF MO ENUCLENE (Tier HCl (Ophth)) 3) $0- MO $0- MO $6.60 $2.65 PATADAY epinastine hcl (ophth) (Tier (Tier 2) 1) $0 MO; NT $0 MO; NT sodium chloride hypertonic (Tier EYE STREAM (Tier 3) 3) TRUSOPT (Use NF MO $0- MO Dorzolamide HCl) $2.65 flurbiprofen sodium ZADITOR (Use Ketotifen NF MO; NT (Tier Fumarate (Ophth)) 1) $0- MO Prostaglandins - Ophthalmic $6.60 $0- MO ILEVRO $6.60 (Tier BIMATOPROST 2) (Tier $0- MO 2) ketorolac tromethamine $2.65 $0- MO $2.65 (ophth) (Tier latanoprost 1) (Tier $0 MO; NT 1) ketotifen fumarate (ophth) (Tier $0- MO $6.60 3) LUMIGAN MURO 128 OINT 5 % (Use MO; NT (Tier Sodium Chloride NF 2) Hypertonic) $0- MO $6.60 $0 MO; NT TRAVATAN Z MURO 128 SOLN 2 % (Tier (Tier 3) 2) MURO 128 SOLN 5 % MO; NT XALATAN (Use NF MO (Use Sodium Chloride NF Latanoprost) Hypertonic) OTIC AGENTS - Drugs to Treat the Ear Otic Agents - Miscellaneous

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150 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO $2.65 hydrocortisone w/acetic $2.65 acetic acid (otic) (Tier acid (Tier 1) 1) $0- MO VOSOL HC (Use MO acetic acid-aluminum $2.65 Hydrocortisone w/Acetic NF acetate (Tier Acid) 1) OXYTOCICS - Drugs to Prevent/Control Uterine $0 MO; NT Bleeding carbamide peroxide (otic) (Tier 3) Oxytocics $0- MO DEBROX (Use Carbamide NF MO; NT Peroxide (Otic)) methylergonovine maleate $2.65 tabs or 0.2 mg (Tier Otic Anti-infectives 1) $0- MO $2.65 PASSIVE IMMUNIZING AGENTS - Antibody ofloxacin (otic) (Tier Drugs to Treat Low Immune System 1) Immune Serums Otic Combinations $0- B/D $6.60 $0 NT BIVIGAM boric acid in isopropyl (Tier (Tier 3) 2) $0- MO $0- B/D $6.60 $6.60 FLEBOGAMMA DIF 10 % CIPRODEX (Tier (Tier 2) 2) CORTISPORIN SOLN OT MO $0- B/D $6.60 10000UNIT/ML-3.5MG/ML- NF GAMASTAN S/D 1% (Use Neomycin- (Tier Polymyxin-HC (Otic)) 2) $0- MO $0- B/D $6.60 neomycin-polymyxin-hc $2.65 GAMMAGARD LIQUID (otic) (Tier (Tier 1) 2) $0- B/D Otic Steroids $6.60 DERMOTIC (Use MO GAMMAKED (Tier Fluocinolone Acetonide NF 2) (Otic)) $0- B/D $0- MO $6.60 fluocinolone acetonide $2.65 GAMUNEX-C (Tier (otic) (Tier 2) 1) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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151 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- B/D $0- MO $6.60 ampicillin caps 250 mg, $2.65 HIZENTRA (Tier 500 mg (Tier 2) 1) $0- B/D $0- MO OCTAGAM 10 GM/100ML, $6.60 ampicillin sodium ij 1 gm, 2 $2.65 2 GM/20ML, 20 (Tier gm (Tier GM/200ML, 5 GM/50ML 2) 1) $0- B/D $0- $6.60 $2.65 PRIVIGEN (Tier ampicillin sodium ij 125 mg (Tier 2) 1) $0- $0- $6.60 $2.65 VARIZIG (Tier ampicillin sodium iv 10 gm (Tier 2) 1) Monoclonal Antibodies Natural Penicillins $0- $0- MO $6.60 $6.60 SYNAGIS 50 MG/0.5ML (Tier BICILLIN L-A (Tier 2) 2) Passive Immunizing Agents - Combinations $0- MO penicillin g potassium 20 $2.65 $0- mu, 20000000 unit, (Tier $6.60 5000000 unit HYQVIA (Tier 1) 2) $0- MO $2.65 penicillin v potassium PENICILLINS - Drugs to Treat Bacterial Infections (Tier 1) Aminopenicillins Penicillin Combinations $0- MO amoxicillin caps 250 mg, $2.65 $0- MO 500 mg (Tier amoxicillin & pot $2.65 1) clavulanate (Tier 1) $0- MO amoxicillin susr 125 $2.65 $0- MO mg/5ml, 200 mg/5ml, 250 (Tier ampicillin & sulbactam $2.65 mg/5ml, 400 mg/5ml 1) sodium ij 1gm-2gm (Tier 1) $0- MO amoxicillin tabs 500 mg, $2.65 $0- 875 mg (Tier ampicillin & sulbactam $2.65 1) sodium iv 5gm-10gm (Tier 1)

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152 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) AUGMENTIN ES-600 (Use MO $0- Amoxicillin & Pot NF nafcillin sodium ij 1 gm, 10 $2.65 Clavulanate) gm (Tier AUGMENTIN SUSR MO 1) 250MG/5ML-62.5MG/5ML $0- MO NF $2.65 (Use Amoxicillin & Pot nafcillin sodium ij 2 gm Clavulanate) (Tier AUGMENTIN TABS MO 1) 500MG-125MG, 875MG- $0- NF $2.65 125MG (Use Amoxicillin & oxacillin sodium 10 gm Pot Clavulanate) (Tier AUGMENTIN XR (Use MO 1) Amoxicillin & Pot NF $0- MO $2.65 Clavulanate) oxacillin sodium 2 gm $0- MO (Tier BICILLIN C-R $6.60 1) 300000UNIT/ML- (Tier PHARMACEUTICAL ADJUVANTS 300000UNIT/ML 2) $0- BICILLIN C-R Liquid Vehicles $6.60 $0 RX/OTC; MO; 900000UNIT/2ML- (Tier CHERRY CONCENTRATE 300000UNIT/2ML (Tier NT 2) SYRP 3) $0- $0 RX/OTC; MO; piperacillin sodium- $2.65 CHERRY SYRUP (Tier NT tazobactam sodium (Tier 3) 1) $0 PROPYLENE GLYCOL RX/OTC; MO; UNASYN 1GM-2GM (Use MO (Tier NT Ampicillin & Sulbactam NF SOLN EX 3) Sodium) $0 RX/OTC; NT $0- ZOSYN SOLN RASPBERRY SYRUP (Tier $6.60 3) 0.5GM/100ML- (Tier 4GM/100ML-5% 2) Pharmaceutical Excipients ZOSYN SOLR 0.25GM- $0 RX/OTC; MO; 2GM, 0.375GM-3GM, KARAYA GUM GUM (Tier NT 0.5GM-4GM, 4.5GM-36GM NF 3) (Use Piperacillin Sodium- Semi Solid Vehicles Tazobactam Sodium) $0 MO; NT Penicillinase-Resistant Penicillins hydrophilic ointment (Tier $0- MO 3) $2.65 $0 dicloxacillin sodium RX/OTC; NT (Tier LANOLIN ANHYDROUS (Tier 1) 3) You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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153 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 RX/OTC; NT $0- MO LANOLIN ANHYDROUS- (Tier $2.65 GRX 3) acamprosate calcium (Tier $0 RX/OTC; NT 1) lanolin oint ex (Tier CAMPRAL (Use NF MO 3) Acamprosate Calcium) PROGESTINS - Hormone Replacement/Modifying $0- MO Drugs disulfiram tabs or 250 mg, $2.65 500 mg (Tier Progestins 1) $0- MO medroxyprogesterone $2.65 Anti-Cataplectic Agents acetate (Tier $0- LA 1) $6.60 XYREM (Tier $0- AL; MO 2) MEGACE ES (Use $6.60 Megestrol Acetate (Tier Antidementia Agents (Appetite)) 2) ARICEPT (Use Donepezil NF MO $0- AL; MO Hydrochloride) megestrol acetate $2.65 ARICEPT ODT (Use NF MO (appetite) (Tier Donepezil Hydrochloride) 1) $0- MO $0- MO $2.65 norethindrone acetate tabs $2.65 donepezil hydrochloride (Tier or (Tier 1) 1) EXELON CAPS OR 1.5 MO $0- MO MG, 3 MG, 4.5 MG, 6 MG NF progesterone micronized $2.65 (Use Rivastigmine Tartrate) caps or 100 mg, 200 mg (Tier 1) EXELON PT24 TD 13.3 $0- MO MG/24HR, 4.6 MG/24HR, $6.60 PROMETRIUM (Use NF MO 9.5 MG/24HR (Use (Tier Progesterone Micronized) Rivastigmine) 2) PROVERA (Use MO $0- MO Medroxyprogesterone NF $2.65 Acetate) galantamine hydrobromide (Tier PSYCHOTHERAPEUTIC AND NEUROLOGICAL 1) AGENTS - MISC. - Drugs to Treat Mental and $0- AL; MO Emotional Conditions memantine hcl soln 2 $2.65 mg/ml (Tier Agents for Chemical Dependency 1)

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154 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- MO memantine hcl tabs 10 mg, $2.65 $2.65 5 mg (Tier rivastigmine tartrate (Tier 1) 1) $0- AL; MO Combination Psychotherapeutics NAMENDA SOLN 10 $6.60 MG/5ML (Use Memantine (Tier $0- AL; MO HCl) 2) chlordiazepoxide- $2.65 amitriptyline (Tier $0- MO 1) NAMENDA TABS 10 MG, 5 $6.60 $0- MO MG (Use Memantine HCl) (Tier $2.65 2) olanzapine-fluoxetine hcl (Tier $0- MO 1) NAMENDA TITRATION $6.60 $0- AL; MO PAK (Use Memantine HCl) (Tier $2.65 2) perphenazine-amitriptyline (Tier $0- QL(2 ea daily); 1) $6.60 NAMENDA XR 14 MG MO (Tier SYMBYAX (Use NF MO 2) Olanzapine-Fluoxetine HCl) $0- QL(1 ea daily); Movement Disorder Drug Therapy NAMENDA XR 21 MG, 28 $6.60 MO $0- MG (Tier $2.65 2) tetrabenazine (Tier $0- QL(4 ea daily); 1) $6.60 NAMENDA XR 7 MG MO $0- LA (Tier XENAZINE (Use $6.60 2) Tetrabenazine) (Tier $0- MO 2) NAMENDA XR TITRATION $6.60 Multiple Sclerosis Agents PACK (Tier 2) $0- $6.60 RAZADYNE (Use MO AMPYRA (Tier Galantamine NF 2) Hydrobromide) $0- PA RAZADYNE ER (Use MO $6.60 Galantamine NF AUBAGIO (Tier Hydrobromide) 2) $0- MO $0- PA $2.65 rivastigmine $6.60 (Tier AVONEX (Tier 1) 2)

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155 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- PA $0- PA $6.60 $6.60 AVONEX PEN (Tier REBIF (Tier 2) 2) $0- PA $0- PA $6.60 $6.60 BETASERON (Tier REBIF REBIDOSE (Tier 2) 2) $0- PA $0- PA COPAXONE 20 MG/ML $6.60 REBIF REBIDOSE $6.60 (Use Glatiramer Acetate) (Tier TITRATIONPACK (Tier 2) 2) $0- PA $0- PA $6.60 $6.60 COPAXONE 40 MG/ML (Tier REBIF TITRATION PACK (Tier 2) 2) $0- PA $0- PA $6.60 $6.60 EXTAVIA (Tier TECFIDERA (Tier 2) 2) $0- PA $0- PA $6.60 TECFIDERA STARTER $6.60 GILENYA (Tier PACK (Tier 2) 2) $0- PA $0- PA $2.65 $6.60 glatiramer acetate (Tier TYSABRI (Tier 1) 2) $0- PA; LA Premenstrual Dysphoric Disorder (PMDD) Agents $6.60 LEMTRADA (Tier fluoxetine hcl (pmdd) cap NF 2) 10 mg, 20 mg $0- PA Pseudobulbar Affect (PBA) Agents $6.60 PLEGRIDY $0- MO (Tier $6.60 2) NUEDEXTA (Tier $0- PA 2) PLEGRIDY STARTER $6.60 Psychotherapeutic and Neurological Agents - PACK (Tier 2) $0- AL; MO $2.65 ergoloid mesylates tabs or (Tier 1)

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156 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- QL(17 ea $6.60 $6.60 daily); MO ORAP (Use Pimozide) (Tier NICOTROL INHALER (Tier 2) 2) $0- MO $0- MO $2.65 $6.60 pimozide (Tier NICOTROL NS (Tier 1) 2) Smoking Deterrents ZYBAN (Use Bupropion NF QL(2 ea daily); )) $0- QL(2 ea daily); HCl (Smoking Deterrent MO bupropion hcl (smoking $2.65 MO Vasomotor Symptom Agents deterrent) (Tier $0- MO 1) $6.60 $0- PA; MO BRISDELLE (Tier $6.60 2) CHANTIX (Tier 2) RESPIRATORY AGENTS - MISC. - Drugs to Treat Lung Conditions $0- PA; MO CHANTIX CONTINUING $6.60 Alpha-Proteinase Inhibitor (Human) MONTHPAK (Tier $0- LA 2) $6.60 ARALAST NP 1000 MG (Tier NICODERM CQ (Use NF MO; NT Nicotine) 2) $0- LA NICORETTE (Use Nicotine NF PA; MO; NT Polacrilex) $6.60 PROLASTIN-C (Tier NICORETTE MINI (Use NF PA; MO; NT 2) Nicotine Polacrilex) $0- LA NICORETTE STARTER PA; MO; NT $6.60 KIT (Use Nicotine NF ZEMAIRA (Tier Polacrilex) 2) $0 MO; NT nicotine (Tier Cystic Fibrosis Agents 3) $0- PA $0 PA; MO; NT KALYDECO PACK 50 MG, $6.60 nicotine polacrilex gum mt (Tier 75 MG (Tier 2 mg, 4 mg 3) 2) $0 PA; MO; NT $0- PA; LA nicotine polacrilex lozg mt $6.60 (Tier KALYDECO TABS 150 MG 2 mg, 4 mg 3) (Tier 2) $0 NT NICOTINE (Tier TRANSDERMAL SYSTEM 3)

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157 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- PA $0- MO $6.60 $2.65 ORKAMBI (Tier demeclocycline hcl (Tier 2) 1) $0- B/D DORYX 150 MG (Use MO $6.60 NF PULMOZYME Doxycycline Hyclate) (Tier $0- MO 2) doxycycline (monohydrate) $2.65 caps 100 mg, 50 mg, 75 (Tier Pulmonary Fibrosis Agents mg $0- PA; LA 1) $6.60 $0- MO ESBRIET (Tier doxycycline (monohydrate) $2.65 2) susr 25 mg/5ml (Tier $0- PA; QL(2 ea 1) $6.60 daily); LA $0- MO OFEV doxycycline (monohydrate) $2.65 (Tier tabs 100 mg, 150 mg, 50 2) (Tier mg, 75 mg 1) SULFONAMIDES - Drugs to Treat Bacterial Infections $0- MO doxycycline hyclate caps or $2.65 Sulfonamides 100 mg, 50 mg (Tier $0- MO 1) $2.65 sulfadiazine tabs or $0- MO (Tier doxycycline hyclate solr iv $2.65 1) 100 mg (Tier 1) TETRACYCLINES - Drugs to Treat Bacterial Infections $0- MO doxycycline hyclate tabs or $2.65 Tetracyclines 100 mg, 20 mg (Tier ADOXA PAK 1/100 (Use MO 1) Doxycycline NF $0- MO (Monohydrate)) doxycycline hyclate tbec or $2.65 ADOXA PAK 1/150 (Use MO 150 mg (Tier Doxycycline NF 1) (Monohydrate)) MINOCIN CAPS OR 100 MO ADOXA PAK 2/100 (Use MO MG, 50 MG, 75 MG (Use NF Doxycycline NF Minocycline HCl) (Monohydrate)) $0- MO ADOXA TABS 100 MG, 50 MO minocycline hcl caps or 100 $2.65 mg, 50 mg, 75 mg (Tier MG, 75 MG (Use NF Doxycycline 1) (Monohydrate))

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158 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO SYNTHROID (Use NF MO minocycline hcl tabs or 100 $2.65 Levothyroxine Sodium) mg, 50 mg (Tier 1) TOXOIDS MONODOX (Use MO Toxoid Combinations Doxycycline NF (Monohydrate)) $0- $6.60 $0- MO ADACEL (Tier tetracycline hcl caps or 250 $2.65 2) mg, 500 mg (Tier 1) $0- $6.60 VIBRAMYCIN CAPS 100 MO BOOSTRIX (Tier MG (Use Doxycycline NF 2) Hyclate) $0- VIBRAMYCIN SUSR 25 MO $6.60 MG/5ML (Use Doxycycline NF DAPTACEL (Tier (Monohydrate)) 2) THYROID AGENTS - Drugs to Regulate Thyroid $0- Hormones DIPHTHERIA/TETANUS $6.60 TOXOIDS ADSORBED Antithyroid Agents (Tier PEDIATRIC 2) $0- MO methimazole tabs or 10 $2.65 $0- $6.60 mg, 5 mg (Tier INFANRIX 1) (Tier 2) $0- MO $2.65 $0- propylthiouracil tabs or $6.60 (Tier TENIVAC 1) (Tier 2) Thyroid Hormones $0- CYTOMEL (Use NF MO TETANUS/DIPHTHERIA $6.60 Liothyronine Sodium) TOXOIDS-ADSORBED (Tier levothyroxine sodium tabs MO 2) or 100 mcg, 112 mcg, 125 $0- $0- mcg, 137 mcg, 150 mcg, $2.65 TETANUS/DIPHTHERIA $6.60 175 mcg, 200 mcg, 25 (Tier TOXOIDS-ADSORBED (Tier mcg, 300 mcg, 50 mcg, 75 1) ADULT 2) mcg, 88 mcg Toxoids $0- MO liothyronine sodium tabs or $2.65 $0- B/D 25 mcg, 5 mcg, 50 mcg (Tier TETANUS TOXOID $6.60 1) ADSORBED (Tier 2)

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159 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) ULCER DRUGS - Drugs to Treat Bowel, Intestine $0- RX/OTC; MO and Stomach Conditions $2.65 cimetidine tabs or 200 mg (Tier Antispasmodics 1) BENTYL CAPS OR 10 MG NF MO $0- MO (Use Dicyclomine HCl) cimetidine tabs or 300 mg, $2.65 400 mg, 800 mg (Tier BENTYL TABS OR 20 MG NF MO (Use Dicyclomine HCl) 1) $0- $0- MO famotidine soln iv 20 $2.65 $2.65 dicyclomine hcl caps 10 mg mg/2ml, 200 mg/20ml, 40 (Tier (Tier mg/4ml 1) 1) $0- MO $0- MO $2.65 famotidine susr or 40 $2.65 dicyclomine hcl tabs 20 mg (Tier mg/5ml (Tier 1) 1) $0- MO $0 MO; NT glycopyrrolate soln ij 0.2 $2.65 famotidine tabs or 10 mg (Tier mg/ml (Tier 3) 1) $0- RX/OTC; MO $2.65 $0- MO famotidine tabs or 20 mg glycopyrrolate tabs or 1 $2.65 (Tier mg, 2 mg (Tier 1) 1) $0- MO $2.65 $0- MO famotidine tabs or 40 mg methscopolamine bromide $2.65 (Tier tabs or 2.5 mg, 5 mg (Tier 1) 1) $0- MO nizatidine caps 150 mg, $2.65 PAMINE (Use NF MO Methscopolamine Bromide) 300 mg (Tier 1) PAMINE FORTE (Use NF MO Methscopolamine Bromide) PEPCID 40 MG/5ML (Use NF MO Famotidine) ROBINUL FORTE (Use NF MO Glycopyrrolate) $0 NT ROBINUL SOLN IJ 0.2 MO PEPCID AC CHEW (Tier MG/ML (Use NF 3) Glycopyrrolate) PEPCID AC TABS (Use NF MO; NT Famotidine) ROBINUL TABS OR 1 MG NF MO (Use Glycopyrrolate) $0- MO ranitidine hcl caps or 150 $2.65 H-2 Antagonists mg, 300 mg (Tier AXID CAPS 300 MG (Use NF MO 1) Nizatidine)

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160 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- MO $0- ST; MO ranitidine hcl syrp or 15 $2.65 esomeprazole magnesium $2.65 mg/ml, 150 mg/10ml, 75 (Tier 40 mg (Tier mg/5ml 1) 1) $0- RX/OTC; MO $0- ST ranitidine hcl tabs or 150 $2.65 ESOMEPRAZOLE $6.60 mg (Tier STRONTIUM (Tier 1) 2) $0- MO $0- RX/OTC; MO ranitidine hcl tabs or 300 $2.65 $2.65 mg (Tier lansoprazole cpdr or 15 mg (Tier 1) 1) $0 MO; NT $0- MO ranitidine hcl tabs or 75 mg (Tier $2.65 3) lansoprazole cpdr or 30 mg (Tier 1) ZANTAC 75 (Use NF MO; NT Ranitidine HCl) $0- ST; RX/OTC; $6.60 ZANTAC SYRP OR 15 MO NEXIUM CPDR 20 MG MO MG/ML (Use Ranitidine NF (Tier HCl) 2) $0- ST; RX/OTC; ZANTAC TABS OR 150 NF RX/OTC; MO NEXIUM CPDR 20 MG MG (Use Ranitidine HCl) $6.60 MO (Use Esomeprazole (Tier Magnesium) ZANTAC TABS OR 300 NF MO 2) MG (Use Ranitidine HCl) $0- ST; MO Misc. Anti-Ulcer $6.60 NEXIUM CPDR 40 MG (Tier CARAFATE TABS 1 GM NF MO (Use Sucralfate) 2) $0- $0- MO NEXIUM CPDR 40 MG ST; MO $2.65 $6.60 sucralfate tabs or (Use Esomeprazole (Tier (Tier Magnesium) 1) 2) Proton Pump Inhibitors $0- ST; MO NEXIUM PACK 10 MG, 2.5 $6.60 $0- ST; MO MG, 20 MG, 40 MG, 5 MG (Tier $6.60 2) DEXILANT (Tier 2) $0- MO omeprazole cpdr or 10 mg, $2.65 $0- ST; RX/OTC; 20 mg, 40 mg (Tier esomeprazole magnesium $2.65 MO 1) 20 mg (Tier 1)

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161 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- $0- MO pantoprazole sodium solr iv $2.65 omeprazole-sodium $2.65 40 mg (Tier bicarbonate 40mg-1100mg (Tier 1) 1) $0- MO PREVPAC (Use MO pantoprazole sodium tbec $2.65 Amoxicillin-Clarithromycin NF or 20 mg, 40 mg (Tier w/ Lansoprazole) 1) ZEGERID CAPS 20MG- RX/OTC; MO PREVACID 15 MG (Use NF RX/OTC; MO 1100MG (Use Omeprazole- NF Lansoprazole) Sodium Bicarbonate) PREVACID 30 MG (Use NF MO ZEGERID CAPS 40MG- MO Lansoprazole) 1100MG (Use Omeprazole- NF PRILOSEC CPDR 10 MG, MO Sodium Bicarbonate) 20 MG, 40 MG (Use NF $0- ST; MO Omeprazole) ZEGERID PACK 20MG- $6.60 PROTONIX SOLR IV 40 1680MG (Tier MG (Use Pantoprazole NF 2) Sodium) URINARY ANTI-INFECTIVES - Drugs to Treat PROTONIX TBEC OR 20 MO Bladder/Kidney Infections MG, 40 MG (Use NF Pantoprazole Sodium) Urinary Anti-infectives HIPREX (Use NF MO Ulcer Drugs - Prostaglandins Methenamine Hippurate) CYTOTEC (Use NF MO MACROBID (Use MO Misoprostol) Nitrofurantoin Monohyd NF $0- MO Macro) misoprostol tabs or 100 $2.65 MACRODANTIN 100 MG, AL; MO mcg, 200 mcg (Tier 50 MG (Use Nitrofurantoin NF 1) Macrocrystal) Ulcer Therapy Combinations $0- MO $2.65 $0- MO methenamine hippurate amoxicillin-clarithromycin $2.65 (Tier w/ lansoprazole (Tier 1) 1) $0- AL; MO $0- MO nitrofurantoin macrocrystal $2.65 $6.60 caps or 100 mg, 50 mg (Tier OMECLAMOX-PAK (Tier 1) 2) $0- MO $0- RX/OTC; MO nitrofurantoin monohyd $2.65 omeprazole-sodium $2.65 macro (Tier bicarbonate 20mg-1100mg (Tier 1) 1) URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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162 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Urinary Antispasmodic - Antimuscarinics $0- $6.60 MENACTRA DETROL (Use Tolterodine NF MO (Tier Tartrate) 2) DETROL LA (Use NF MO $0- Tolterodine Tartrate) $6.60 MENOMUNE-A/C/Y/W-135 DITROPAN XL (Use NF MO (Tier Oxybutynin Chloride) 2) $0- MO $0- $2.65 oxybutynin chloride $6.60 (Tier MENVEO (Tier 1) 2) SANCTURA (Use NF MO $0- Trospium Chloride) $6.60 PEDVAX HIB (Tier SANCTURA XR (Use NF MO Trospium Chloride) 2) $0- MO $0- $6.60 $2.65 TYPHIM VI tolterodine tartrate (Tier (Tier 1) 2) $0- MO Mixed Vaccine Combinations $2.65 trospium chloride $0- (Tier $6.60 1) COMVAX (Tier Urinary Antispasmodics - Cholinergic Agonists 2) $0- MO Viral Vaccines bethanechol chloride 10 $2.65 $0- mg, 25 mg, 5 mg, 50 mg (Tier $6.60 1) CERVARIX (Tier Urinary Antispasmodics - Direct Muscle Relaxants 2) $0- MO $0- B/D $2.65 ENGERIX-B SUSP IJ 10 $6.60 flavoxate hcl (Tier MCG/0.5ML, 20 MCG/ML (Tier 1) 2) $0- VACCINES $6.60 GARDASIL Bacterial Vaccines (Tier 2) $0- $6.60 $0- ACTHIB $6.60 (Tier HAVRIX 2) (Tier 2)

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163 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0- B/D $0- IMOVAX RABIES $6.60 $6.60 (H.D.C.V.) (Tier VAQTA (Tier 2) 2) $0- $0- $6.60 $6.60 IPOL INACTIVATED IPV (Tier VARIVAX (Tier 2) 2) $0- $0- $6.60 $6.60 IXIARO (Tier YF-VAX (Tier 2) 2) $0- $0- $6.60 $6.60 M-M-R II (Tier ZOSTAVAX (Tier 2) 2) $0- VAGINAL PRODUCTS - Drugs to Treat Vaginal $6.60 Infections and Low Hormones PROQUAD (Tier 2) Miscellaneous Vaginal Products $0- B/D $0 NT benzocaine-resorcinol (Tier $6.60 vaginal 2%-5% RABAVERT (Tier 3) 2) $0 NT $0- B/D FEMINEASE (Tier $6.60 3) RECOMBIVAX HB (Tier $0 MO; NT 2) TRIMO-SAN (Tier $0- 3) $6.60 ROTARIX VAGISIL (Use Benzocaine- NF NT (Tier Resorcinol Vaginal) 2) Spermicides $0- $6.60 $0 NT ROTATEQ (Tier ENCARE (Tier 2) 3) $0- $0 MO; NT $6.60 nonoxynol-9 (Tier TWINRIX (Tier 3) 2) OPTIONS CONCEPTROL $0 NT VAGINAL (Tier CONTRACEPTIVE 3)

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164 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) OPTIONS GYNOL II $0 MO; NT $0- MO $2.65 VAGINALCONTRACEPTIV (Tier terconazole vaginal E 3) (Tier $0 NT 1) SHUR-SEAL (Tier $0 NT 3) tioconazole vaginal (Tier $0 3) VCF VAGINAL NT (Tier VAGISTAT-1 (Use NF NT CONTRACEPTIVE FILM 3) Tioconazole Vaginal) $0 NT Vaginal Estrogens VCF VAGINAL (Tier CONTRACEPTIVE FOAM $0- MO 3) $2.65 estradiol vaginal Vaginal Anti-infectives (Tier CLEOCIN CREA VA 2 % MO 1) (Use Clindamycin NF $0- MO Phosphate Vaginal) PREMARIN CREA VA $6.60 $0- MO 0.625 MG/GM (Tier clindamycin phosphate $2.65 2) vaginal (Tier VASOPRESSORS - Drugs to Treat Heart and 1) Circulation Conditions $0 MO; NT clotrimazole vaginal 1 % (Tier Anaphylaxis Therapy Agents 3) $0- MO $6.60 ADRENACLICK GYNE-LOTRIMIN (Use NF MO; NT (Tier Clotrimazole Vaginal) 2) METROGEL-VAGINAL MO $0- MO (Use Metronidazole NF $6.60 Vaginal) AUVI-Q (Tier $0- MO 2) $2.65 metronidazole vaginal $0- MO (Tier EPINEPHRINE SOAJ IJ $6.60 1) 0.15 MG/0.15ML, 0.3 (Tier $0 MO; NT MG/0.3ML 2) miconazole nitrate vaginal (Tier supp 100 mg $0- MO 3) $6.60 EPIPEN 2-PAK TERAZOL 3 (Use NF MO (Tier Terconazole Vaginal) 2) TERAZOL 7 (Use NF MO $0- MO Terconazole Vaginal) $6.60 EPIPEN-JR 2-PAK (Tier 2)

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165 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) Vasopressors DRISDOL (Use NF MO; NT ) $0- Ergocalciferol $2.65 $0 MO; NT dobutamine hcl ergocalciferol caps or (Tier (Tier 50000 unit 1) 3) $0- MO $0 MO; NT ergocalciferol soln or 8000 (Tier $2.65 unit/ml midodrine hcl (Tier 3) 1) $0 MO; NT MEPHYTON (Tier VITAMINS 3) Oil Soluble Vitamins $0 MO; NT phytonadione tabs or 100 (Tier $0 NT mcg 3) A-25 (Tier 3) $0 MO; NT vitamin a caps 10000 unit (Tier BABY DDROPS (Use NF NT 3) Cholecalciferol) $0 NT $0 VITAMIN A CAPS 25000 BETA CAROTENE CAPS NT (Tier (Tier UNIT 3) OR 10000 UNIT 3) $0 NT $0 beta carotene caps or MO; NT vitamin a caps 8000 unit (Tier (Tier 3) 25000 unit 3) $0 NT cholecalciferol caps or $0 MO; NT VITAMIN A TABS (Tier 1000 unit, 2000 unit, 400 (Tier 10000UNIT-1000UNIT 3) unit, 5000 unit 3) $0 NT $0 cholecalciferol liqd or 400 MO; NT vitamin e caps or 100 unit (Tier (Tier 3) unit/ml 3) $0 MO; NT $0 cholecalciferol liqd or 400 NT vitamin e caps or 1000 unit (Tier (Tier 3) unt/0.03ml 3) $0 NT $0 vitamin e liqd or 400 cholecalciferol tabs or 1000 MO; NT (Tier (Tier unit/15ml 3) unit, 2000 unit, 400 unit 3) $0 MO; NT $0 vitamin e soln or 15 cholecalciferol tabs or 5000 NT (Tier (Tier unit/0.3ml 3) unit 3) $0 RX/OTC; NT D-VI-SOL (Use NF MO; NT WHEAT GERM (Tier Cholecalciferol) 3) Water Soluble Vitamins You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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166 What What the the drug Necessary drug Necessary will actions, will actions, Name of drug cost restrictions, or Name of drug cost restrictions, or you limits on use you limits on use (tier (tier level) level) $0 NT $0 MO; NT AMINOBENZOATE (Tier niacin tbcr or 250 mg, 500 (Tier POTASSIUM 3) mg, 750 mg 3) $0 MO; NT $0 MO; NT ascorbic acid chew or 250 (Tier NIACIN TR (Tier mg, 250mg 3) 3) $0 MO; NT $0 NT ascorbic acid cpcr or 500 (Tier niacinamide tabs or 100 mg (Tier mg 3) 3) $0 MO; NT $0 MO; NT ascorbic acid soln ij 500 (Tier niacinamide tabs or 500 mg (Tier mg/ml 3) 3) $0 MO; NT $0 MO; NT ascorbic acid syrp or 500 (Tier pyridoxine hcl tabs or 100 (Tier mg/5ml 3) mg, 25 mg, 50 mg 3) $0 NT $0 MO; NT ascorbic acid tabs or 100 (Tier riboflavin tabs or 100 mg (Tier mg 3) 3) $0 MO; NT $0 NT ascorbic acid tabs or 250 (Tier riboflavin tabs or 25 mg, 50 (Tier mg 3) mg 3) $0 NT SLO-NIACIN 500 MG,750 MO; NT ascorbic acid tbcr or 1000 (Tier NF mg MG (Use Niacin) 3) $0 MO; NT $0 MO; NT thiamine hcl tabs or 100 (Tier ascorbic acid tbcr or 30mg- (Tier mg, 50 mg 500mg, 500 mg, 500mg 3) 3) $0 NT $0 MO; NT thiamine mononitrate (Tier biotin tabs or 300 mcg (Tier 3) 3) $0 NT biotin tabs or 5 mg, 5000 (Tier mcg, 800 mcg 3) $0 NT calcium ascorbate tabs or (Tier 3) $0 MO; NT niacin cpcr or 250 mg, 500 (Tier mg 3) $0 MO; NT niacin tabs or 100 mg, 250 (Tier mg, 50 mg, 500 mg 3)

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Health Net Cal MediConnect 2015 Drug List

167 Index A & D ZINC OXIDE98 acetylcysteine 10 %, 20 %86 ADVIL MIGRAINE4 A-25166 acitretin90 AEROCHAMBER MINI A-MANTLE98 ACNE MEDICATION87 AEROSOLCHAMBER125 AEROCHAMBER MV125 abacavir sulfate68 ACNE MEDICATION 1087 AEROCHAMBER PLUS FLOW abacavir sulfate-lamivudine- ACNE-AID98 VU125 zidovudine 68 ACTEMRA4 AEROCHAMBER PLUS FLOW- ABELCET41 ACTHIB163 VU125 ABILIFY 1 MG/ML67 AEROCHAMBER PLUS FLOW- ACTIGALL113 ABILIFY 10 MG67 VU/LARGE MASK125 ACTIMMUNE59 AEROCHAMBER PLUS FLOW- ABILIFY 15 MG67 ACTIQ 1200 MCG, 1600 MCG, VU/MASK125 ABILIFY 2 MG67 400 MCG, 600 MCG, 800 AEROCHAMBER PLUS FLOW- ABILIFY 20 MG, 30 MG67 MCG8 VU/MEDIUM MASK125 ABILIFY 5 MG67 ACTIQ 200 MCG8 AEROCHAMBER PLUS FLOW- VU/SMALL MASK125 ABILIFY 9.75 MG/1.3ML67 ACTIVELLA111 AEROCHAMBER Z-STAT PLUS ABILIFY DISCMELT 10 MG66 ACTOPLUS MET33 VALVED HOLDING CHAMBER ABILIFY DISCMELT 15 MG66 ACTOS 15 MG36 W/FLOW VU125 ACTOS 30 MG, 45 MG36 AEROCHAMBER Z-STAT ABILIFY MAINTENA66 PLUS/FLOWSIGNAL125 ABRAXANE61 ACUICYN DAILY EYELID & EYELASH CLEANSER98 AEROCHAMBER Z-STAT PLUS/LARGE MASK126 ABSORICA87 ACULAR149 acamprosate calcium154 AEROCHAMBER Z-STAT ACULAR LS149 PLUS/MEDIUM MASK126 acarbose33 acyclovir 200 mg72 AEROCHAMBER Z-STAT ACCOLATE21 acyclovir 200 mg/5ml72 PLUS/SMALL MASK126 ACCUPRIL46 AEROCHAMBER/FLOWSIGNAL acyclovir 400 mg, 800 mg72 126 ACCURETIC48 acyclovir sodium 50 mg/ml72 AEROSPAN22 acebutolol hcl 200 mg, 400 mg75 acyclovir sodium 500 mg72 AEROVENT PLUS HOLDING CHAMBER/COLLAPSIBLE 126 ACEON 4 MG46 acyclovir topical91 AFINITOR57 ACEON 8 MG46 ADACEL159 AFINITOR DISPERZ57 acetaminophen 100 mg/ml, 160 ADAGEN76 mg/5ml, 80 mg/0.8ml7 AFRIN PURESEA GENTLE ADALAT CC76 MISTNASAL RINSE142 acetaminophen 120 mg8 adapalene 0.1 %87 AFRIN PURESEA MEDIUM acetaminophen 160 mg7 ADCIRCA78 STREAM NASAL RINSE142 acetaminophen 160 mg/5ml7 AFRIN PURESEA ULTRA- ADD-INS COMPLETE144 GENTLE MIST NASAL acetaminophen 160 mg/5ml, 80 ADDERALL XR1 mg/2.5ml7 RINSE142 acetaminophen 80 mg7 adefovir dipivoxil71 AGGRENOX116 acetaminophen 80 mg/0.8ml8 ADIPEX-P1 AGRYLIN116 acetaminophen w/ codeine ADOXA 100 MG, 50 MG, 75 AIRZONE PEAK FLOW 120mg/5ml-12mg/5ml12 MG158 METER126 acetaminophen w/ codeine ADOXA PAK 1/100158 ALBATUSSIN NN85 300mg-15mg, 300mg-30mg, ADOXA PAK 1/150158 ALBENZA15 300mg-60mg12 ADOXA PAK 2/100158 ALBUSTIX104 acetaminophen-caffeine- pyrilamine7 ADRENACLICK165 albuterol sulfate 0.083 %, 0.5 %, 0.63 mg/3ml, 1.25 mg/3ml22 acetazolamide 250 mg106 ADULT ACNOMEL87 albuterol sulfate 2 mg, 4 mg22 acetazolamide 500 mg106 ADVAIR DISKUS22 albuterol sulfate 2 mg/5ml22 acetic acid (otic)151 ADVAIR HFA22 albuterol sulfate 4 mg, 8 mg22 acetic acid 0.25 %115 ADVIL4 alclometasone dipropionate92 acetic acid-aluminum ADVIL ALLERGY & acetate151 CONGESTION84 ALCOHOL PADS124

Index 1 ALDACTAZIDE 25MG- ALUMINUM HYDROXIDE15 amino acids 100mg-6.15mg- 25MG107 aluminum hydroxide99 2.1mg-0.85mg-1.95mg-0.55mg- ALDACTONE107 aluminum hydroxide-mag 2.3mg-1.95mg-0.75mg-1.15mg- ALDARA96 trisil15 0.6mg-3.65mg-0.65mg-3.25mg- alendronate sodium 10 mg, 5 aluminum sulfate & calcium 3.8mg-1.95mg-1.7mg-0.7mg- mg108 acetate99 1.05mg, 115.333mg-54.667mg- alendronate sodium 35 mg, 70 21mg-33.333mg-33.333mg- amantadine hcl 100 mg62 46.667mg-14.167mg-46.667mg- mg108 amantadine hcl 50 mg/5ml62 ALER-DRYL43 40mg-53.333mg-18.167mg- AMARYL 1 MG38 41mg-66.667mg-40mg- ALEVAZOL88 AMARYL 2 MG38 30.667mg-17.333mg-14mg, ALEVE4 115.3mg-54.7mg-21mg-33.3mg- AMARYL 4 MG38 13.3mg-33.3mg-63.3mg-14.2mg- alfuzosin hcl115 AMBI COCOA BUTTER ALIMTA 100 MG53 46.7mg-40mg-53.3mg-18.2mg- CLEANSING99 41mg-66.7mg-40mg-30.7mg- ALIMTA 500 MG53 AMBI COMPLEXION 17.3mg-14mg, 1200mg-100mg, ALINIA 500 MG16 CLEANSING99 18.33mg-200mg-33.33mg-50mg- AMBIEN 10 MG120 ALKERAN 2 MG51 23.16mg-58.33mg-18.33mg- AMBIEN 5 MG120 ALKERAN 50 MG51 75mg-108.33mg, 200mg- AMBIEN CR 12.5 MG120 33.33mg-50mg-23.16mg- ALLI1 AMBIEN CR 6.25 MG120 18.33mg-58.33mg-18.33mg- allopurinol 100 mg116 75mg-108.33mg, 35mg-29.5mg- AMBISOME41 allopurinol 300 mg116 24.667mg-4.833mg-17.667mg- amcinonide92 ALMACONE14 24.667mg-12.5mg-24mg-19mg- 36mg-17.5mg-4.667mg-75mg- ALOE VESTA MULTI AMERGE130 AMICAR 500 MG120 15mg, 74mg-50mg-0.7mg-77mg- PURPOSECLEANSING99 1.4mg-72mg-64mg-27mg-54mg- alosetron hcl114 amifostine crystalline60 70mg-41mg-17mg-109mg-7mg- ALPHA LIPOIC ACID 50 MG2 amikacin sulfate 1 gm/4ml, 500 27mg-68mg-47mg-41mg-64mg ALPHA-LIPOIC ACID2 mg/2ml3 145 amiloride & amino acids 130mg-10mg- alpha-lipoic acid (thioctic acid) hydrochlorothiazide107 100 mg2 130mg-130mg145 amiloride hcl107 ALPHAGAN P 0.1 %147 amino acids-protein amino acid infusion 15%145 hydrolysate145 ALPHAGAN P 0.15 %147 AMINOBENZOATE alprazolam 0.25 mg, 0.5 mg, 1 POTASSIUM167 mg, 2 mg19 aminocaproic acid 500 mg120 alprazolam 0.5 mg, 1 mg, 2 mg, 3 mg19 aminophylline23 ALSUMA130 aminosalicylic acid51 ALTACE46 AMINOSYN II 15% (Use amino acid infusion)145 alum & mag hydrox-simethicone amiodarone hcl 100 mg, 200 mg, 200mg-25mg-200mg14 400 mg20 alum & mag hydrox-simethicone 200mg/5ml-200mg/5ml- amitriptyline hcl32 20mg/5ml-20mg/5ml-200mg/5ml- amlodipine besylate 10 mg76 200mg/5ml, 200mg/5ml- amlodipine besylate 2.5 mg76 20mg/5ml-200mg/5ml, amlodipine besylate 5 mg76 400mg/5ml-400mg/5ml- amlodipine besylate-benazepril 40mg/5ml-40mg/5ml-400mg/5ml- hcl48 400mg/5ml, 400mg/5ml- ammonium chloride133 40mg/5ml-400mg/5ml 15 alum & mag hydrox-simethicone amoxapine32 200mg/5ml-20mg/5ml- amoxicillin & pot 200mg/5ml, 400mg/5ml- clavulanate152 40mg/5ml-400mg/5ml 14 amoxicillin 125 mg/5ml, 200 ALUMINUM ACETATE99 mg/5ml, 250 mg/5ml, 400 mg/5ml152

Index 2 amoxicillin 250 mg, 500 mg152 ARCALYST4 aspirin 324 mg, 325 mg, 500 mg, amoxicillin 500 mg, 875 mg152 argatroban 250 mg/2.5ml24 81 mg8 aspirin 325 mg8 amoxicillin-clarithromycin w/ ARGIMENT145 aspirin 81 mg8 lansoprazole162 ARGIMENT AT145 amphetamine- aspirin buffered (cal carb-mag dextroamphetamine1 arginine 500 mg145 carb-mag oxide)8 amphotericin b 50 mg41 ARIAL CHAMBER126 ASPIRIN/DIPYRIDAMOLE 117 ampicillin & sulbactam sodium ARICEPT154 ASSESS FULL RANGE PEAK 1gm-2gm152 ARICEPT ODT154 FLOW METER126 ampicillin & sulbactam sodium ASSESS LOW RANGE PEAK 5gm-10gm152 ARIMIDEX55 FLOW METER126 ampicillin 250 mg, 500 mg152 aripiprazole 1 mg/ml67 ASSESS PEAK FLOW METER ampicillin sodium 1 gm, 2 aripiprazole 10 mg67 FULL RANGE126 gm152 aripiprazole 15 mg67 ASSESS PEAK FLOW METER ampicillin sodium 10 gm152 LOW RANGE126 aripiprazole 2 mg67 ASTAGRAF XL73 ampicillin sodium 125 mg152 aripiprazole 20 mg, 30 mg67 ASTHMA CHECK METER-ZONE AMPYRA155 aripiprazole 5 mg67 SYSTEM126 ANADROL-5013 ARIPIPRAZOLE ODT 10 ASTHMAMENTOR126 ANAFRANIL32 MG67 ATACAND47 anagrelide hcl117 ARIPIPRAZOLE ODT 15 MG67 ATACAND HCT48 ANAPROX5 ARISTOSPAN INTRA- atenolol & chlorthalidone48 ANAPROX DS5 ARTICULAR83 atenolol 100 mg, 25 mg, 50 anastrozole55 ARIXTRA24 mg75 ARNUITY ELLIPTA22 ATIVAN 0.5 MG, 1 MG, 2 ANCOBON41 MG19 ANDRODERM13 AROMASIN55 ATIVAN 2 MG/ML19 ANDROGEL13 ARRANON53 ATIVAN 4 MG/ML19 ANDROGEL PUMP13 ARTHRICARE DOUBLE ICE PAIN RELIEVING RUB96 ATOPICLAIR98 ANORO ELLIPTA22 ARTHRICARE PAIN atorvastatin calcium45 ANTARA 130 MG, 43 MG44 RELIEVINGRUB96 atovaquone16 ANTARA 30 MG45 ARTHRICARE TRIPLE atovaquone-proguanil hcl 250mg- ANTARA 90 MG45 MEDICATED PAIN RELIEVING 100mg50 96 ANTI-BACTERIAL HAND RUB ATRIPLA68 ARTHROTEC 505 LOTION99 ATROVENT142 ARTHROTEC 755 APOKYN62 ATROVENT HFA21 ARZERRA54 apraclonidine hcl147 AUBAGIO155 APRISO114 ASACOL HD114 AUGMENTIN 250MG/5ML- APTIOM 200 MG25 ascorbic acid 100 mg167 62.5MG/5ML 153 APTIOM 400 MG25 ascorbic acid 1000 mg167 AUGMENTIN 500MG-125MG, ascorbic acid 250 mg167 875MG-125MG153 APTIOM 600 MG25 AUGMENTIN ES-600153 APTIOM 800 MG25 ascorbic acid 250 mg, 250mg167 AUGMENTIN XR153 APTIVUS 100 MG/ML68 ascorbic acid 30mg-500mg, AURSTAT ANTI-ITCH APTIVUS 250 MG68 500 mg, 500mg167 HYDROGEL98 AQUANIL SKIN CLEANSER99 ascorbic acid 500 mg167 AUVI-Q165 AQUORAL137 ascorbic acid 500 mg/5ml167 AVALIDE48 ARALAST NP 1000 MG157 ascorbic acid 500 mg/ml167 AVANDIA 2 MG36 ARALEN50 ASCRIPTIN8 AVANDIA 4 MG36 ARANESP ALBUMIN ASPIRIN 120 MG, 200 MG8 AVANDIA 8 MG36 FREE118 aspirin 300 mg, 600 mg8 AVAPRO47 ARAVA7 AVASTIN54

Index 3 AVEED13 b complex w/ c 10.2mg- b-complex vitamins 2mg/ml- AVEENO ACTIVE NATURALS 10.2mg-10mg-10mg-50mg- 100mg/ml-2mg/ml-100mg/ml- PURE RENEWAL 50mg-15mg-15mg-5mg-5mg- 2mg/ml, 2mg/ml-2%-100mg/ml- SHAMPOO99 300mg-300mg, 100mg-100mg- 2mg/ml-100mg/ml-2mg/ml 137 AVEENO MOISTURIZING99 25mg-20mg-6mg-15mcg- b-complex vitamins 2mg/ml-2%- AVEENO POSITIVELY 100mg-5mcg-2mg-150mg, 100mg/ml-2mg/ml-100mg/ml- 100mg-100mg-5.5mg-20mg- 2mg/ml 137 AGELESSDAILY EXFOLIATING b-complex vitamins 3.33mg- CLEANSER99 15mcg-25mg-400mcg-5mcg- AVEENO POSITIVELY 2mg-150mg, 100mg-10mg- 0.4mg-0.33mg-0.66mcg-0.11mg, RADIANTCLEANSER99 20mg-10mcg-15mg-5mg- 60mg-60mg-3mg-5mg-20mg- AVEENO SKIN RELIEF 500mg, 100mg-20mg-5.5mg- 3mg-1mcg-0.5mg, 60mg-60mg- SHOWER& BATH91 15mcg-2mg-25mg-150mg- 5mg-20mg-3mg-1mcg-3mg- AVEENO ULTRA-CALMING 400mcg-5mcg-150mg, 10mg- 0.5mg, 70mg-100mg-1mg-10mg- CLEANSER99 10mg-15mg-50mg-5mg-300mg, 2mg-1.5mg-100mcg 137 b-complex w/ c & folic acid 10mg- AVENOVA99 15mg-10.2mg-10mg-50mg- 5mg-300mg, 15mg-10mg- 20mg-1.5mg-1mg-1.5mg-5mg- AVODART115 50mg-10.2mg-5mg-300mg, 300mcg-50mg-60mg, 20mg- AVONEX155 15mg-10mg-50mg-10.2mg- 1.5mg-10mg-1mg-1.5mg-5mg- AVONEX PEN156 6mcg-400mcg-5mg-300mg, 300mcg-50mg-60mg 138 b-complex w/ folic acid 1.5mg- AXID 300 MG160 15mg-150mg-10mg-50mg- 10.2mg-5mg-300mg, 15mg- 20mg-1.7mg-6mcg-400mcg-2mg, AXSAIN97 20mg-50mg-10mg-10mcg-5mg- 1.7mg-10mg-6mcg-1.2mg-20mg- AYR NASAL DROPS142 300mg, 15mg-50mg-10.2mg- 0.4mg-2mg, 100mg-100mg- azacitidine53 10mg-5mg-300mg, 50mg- 100mg-100mcg-400mcg-100mg, 100mg-100mg-100mg-100mg- AZACTAM15 10.2mg-10mg-15mg-5mg- 300mg, 50mg-10mg-10mg- 10mcg-400mcg-100mcg-100mg, azathioprine 100 mg, 50 mg, 75 10mg-10mg-50mg-10mg-10mg- mg73 15mg-5mg-300mg, 50mg- 15mg-10mg-10.2mg-5mg- 10mg-10mcg-10mg-400mcg- azelastine hcl (ophth)149 300mg 138 10mcg-10mg, 10mg-20mg- azelastine hcl 0.1 %142 b complex w/ c 10.2mg-10mg- 1.7mg-6mcg-1.5mg-400mcg- AZILECT63 15mg-50mg-5mg-300mg, 2mg, 15mg-100mg-200mg-17mg- azithromycin 100 mg/5ml, 200 10mg-50mg-10.2mg-15mg- 60mcg-400mcg-20mg, 30mg- mg/5ml124 5mg-300mg, 10mg-50mg- 20mg-50mg-30mg-10mg-10mcg- azithromycin 250 mg, 500 mg, 10mg-15mg-5mg-300mg, 400mcg-8mg, 40mcg-1mg-6mg- 600 mg124 15mg-10mg-50mg-10mg-5mg- 5mcg-3mg-2mcg-19mcg, 50mg- azithromycin 500 mg123 300mg 138 50mg-50mg-50mcg-50mg- B-100 COMPLEX138 400mcg-50mcg-50mg 139 AZOPT149 b-complex w/ folic acid 100mg- aztreonam15 B-6 FOLIC ACID118 100mg-100mg-100mg-100mcg- b-complex vitamins 0.1mg- 400mcg-100mcg-100mg, 125mg- AZULFIDINE114 20mg-2mg-5mcg-3mg-1mg, AZULFIDINE EN-TABS114 125mg-125mg-125mg-125mcg- 100mg-50mg-40mg-10mg- 125mg-125mg-400mcg-125mcg- 20mg-5mg-4.6mg-1mcg-5mg- 125mg, 50mg-50mg-50mg-50mg- 1mg, 10mg-10mg-2mg-1.5mg- 50mcg-0.4mg-50mcg-50mg, 0.2mg, 10mg-14mg-25mcg- 50mg-50mg-50mg-50mg-50mcg- 7mg-4.5mg, 15mg-2mg-5mg- 100mcg-50mcg-50mg 139 2mcg-2mg-2mg, 30mg-50mg- BABY ANBESOL136 50mg-50mg-50mg-50mg- 50mcg-50mg-100mcg-50mcg- BABY DDROPS166 50mg, 3mg-10mg-20mg-3mg- BABY ORAJEL136 6mcg-2mg, 3mg-20mg-3mg- BACIGUENT88 10mg-6mcg-2mg, 3mg-3mg- bacitracin (topical)88 20mg-20mg-3mg-3mg-10mg- 10mg-6mcg-6mcg-2mg-2mg, bacitracin zinc88 83mg-3mg-20mg-2mg-5mcg- bacitracin-poly-neomycin-hc 1mg 138 149 bacitracin-polymyxin b88

Index 4 bacitracin-polymyxin b BENZAMYCIN87 BIMATOPROST150 (ophth)147 BENZEDREX INHALER143 BIOFLEXOR96 baclofen 10 mg141 benzocaine (dental) 20 %136 biotin 300 mcg167 baclofen 20 mg141 benzocaine (dental) 7.5 biotin 5 mg, 5000 mcg, 800 BACTRIM16 %136 mcg167 BACTRIM DS16 benzocaine-docusate BIPHENOX7 BACTROBAN88 sodium123 bisacodyl 10 mg123 benzocaine-resorcinol vaginal BALNETAR LIQUIM104 2%-5%164 bisacodyl 5 mg123 balsalazide disodium114 benzonatate 100 mg, 200 bismuth subsalicylate 262 BANZEL25 mg84 mg39 bismuth subsalicylate 262 BARACLUDE71 benzoyl peroxide 5 %87 benzoyl peroxide- mg/15ml, 525 mg/15ml, 527 BASIS ALL CLEAR99 erythromycin87 mg/30ml39 BASIS COMBINATION99 benztropine mesylate 0.5 mg, 1 bisoprolol & hydrochlorothiazide48 BASIS EXTRA DRY99 mg, 2 mg62 bisoprolol fumarate75 BASIS NORMAL/DRY99 benztropine mesylate 1 mg/ml62 BIVIGAM151 BASIS SENSITIVE SKIN99 BERINERT116 bleomycin sulfate 15 unit56 bath products 40%-40%-40%- BETA CAROTENE 10000 bleomycin sulfate 30 unit56 40%, 5%-5%-5%91 UNIT166 BLEPH-10147 BD GLUCOSE35 beta carotene 25000 unit166 BLINCYTO54 BELEODAQ57 BETAGAN147 BELSOMRA 10 MG121 BLUE-EMU SUPER betamethasone dipropionate STRENGTH97 BELSOMRA 15 MG, 20 (topical)92 MG121 betamethasone dipropionate BODI WHIRL OIL91 BELSOMRA 5 MG121 augmented92 BODY WASH & SHAMPOO99 BELVIQ1 betamethasone sod phosphate BONIVA 150 MG108 & acetate83 BENADRYL43 betamethasone valerate 0.1 BONIVA 3 MG/3ML108 BENADRYL ALLERGY43 %92 BOOSTRIX159 BENADRYL ALLERGY & betamethasone valerate 0.12 boric acid in isopropyl151 COLD85 %92 BOSULIF57 BENADRYL ALLERGY & BETAPACE76 BOTOX 200 UNIT144 SINUSHEADACHE85 BETAPACE AF76 BENADRYL ALLERGY BREATHERITE126 CHILDRENS 12.5 MG43 BETASERON156 BREATHERITE BENADRYL ALLERGY betaxolol hcl75 COLLAPSIBLEADULT SPACER CHILDRENS 12.5 MG/5ML43 betaxolol hcl (ophth)147 W/MASK126 BENADRYL DYE-FREE bethanechol chloride 10 mg, 25 BREATHERITE ALLERGYLIQUID-GELS43 mg, 5 mg, 50 mg163 COLLAPSIBLECHILD SPACER BENADRYL-D ALLERGY & BETHKIS3 W/MASK126 SINUS85 BREATHERITE benazepril & bexarotene59 COLLAPSIBLEINFANT SPACER hydrochlorothiazide48 BIAXIN124 W/MASK126 benazepril hcl 10 mg, 20 mg, 40 BIAXIN XL124 BREATHERITE mg, 5 mg46 COLLAPSIBLESMALL CHILD BENLYSTA 120 MG75 BIAXIN XL PAC124 SPACER W/MASK127 BENSULFOID87 bicalutamide55 BREATHERITE BICILLIN C-R 300000UNIT/ML- COLLAPSIBLESPACER W/ BENTYL 10 MG160 300000UNIT/ML 153 NEONATE MASK127 BENTYL 20 MG160 BICILLIN C-R BREATHERITE RIGID BENZACLIN87 900000UNIT/2ML- SPACERW/MASK127 BENZACLIN WITH PUMP87 300000UNIT/2ML 153 BREATHERITE W/LARGE 127 BENZALKONIUM BICILLIN L-A152 MASK BICNU51 BREATHERITE W/MEDIUM CHLORIDE68 MASK127

Index 5 BREATHERITE W/SMALL bupropion hcl 150 mg29 calcium carbonate-cholecalciferol MASK127 bupropion hcl 150 mg, 200 600mg-500unit132 BREO ELLIPTA 25MCG/INH- mg29 calcium carbonate-vitamin d 100MCG/INH, 25MCG/INH- bupropion hcl 300 mg29 125unit-250mg, 125unit-500mg, 200MCG/INH 22 250mg-125unit, 500mg- BREVICON-2881 bupropion hcl 75 mg29 125unit132 BRILINTA117 BURN SPRAY98 calcium carbonate-vitamin d buspirone hcl 10 mg, 15 mg, 30 200unit-500mg, 500mg-200unit, brimonidine tartrate147 mg, 5 mg, 7.5 mg19 500mg-500mg-200unit-200unit BRINTELLIX 10 MG31 BUSULFEX52 132 BRINTELLIX 20 MG31 butalbital-aspirin-caffeine calcium citrate 200 mg, 950 BRINTELLIX 5 MG31 w/cod12 mg132 BUTISOL SODIUM120 CALCIUM CITRATE 250 BRISDELLE157 MG132 bromfenac sodium (ophth)149 butorphanol tartrate 10 calcium citrate-vitamin d 250mg- mg/ml13 200unit, 315mg-200unit132 bromocriptine mesylate 2.5 butorphanol tartrate 2 mg63 mg/ml13 calcium gluconate 10 %132 bromocriptine mesylate 5 mg63 BYDUREON36 CALCIUM GLUCONATE 500 brompheniramine & MG132 phenyleph85 BYETTA36 CALCIUM LACTATE 648 brompheniramine & cabergoline111 MG132 pseudoeph85 CALAMINE99 calcium polycarbophil121 BRONCOPECTOL85 CALAMINE calcium w/ magnesium 500mg- budesonide83 PHENOLATED99 250mg132 budesonide (inhalation) 0.25 CALAN76 CALCIUM/VITAMIN D132 mg/2ml, 0.5 mg/2ml22 CALAN SR76 CALCIUM/VITAMIN D3132 budesonide (nasal)143 CALCI-CHEW132 CAMPRAL154 BUFFERIN8 CALCI-MIX132 CAMPTOSAR 100 MG/5ML, 40 MG/2ML62 BULL FROG QUIK GEL SPF CALCIONATE132 36103 CAMPTOSAR 300 BULL FROG QUIK GEL SPF calcipotriene90 MG/15ML62 50103 calcitonin (salmon)108 CANCIDAS 50 MG41 BULL FROG QUIK GEL calcitriol 0.25 mcg, 0.5 CANCIDAS 70 MG41 SPORTSPF 36103 mcg110 BULL FROG QUIK GEL candesartan cilexetil47 calcitriol 1 mcg/ml110 candesartan cilexetil- SPORTSPRAY SPF 50103 CALCIUM & BULL FROG SPF 36103 hydrochlorothiazide 49 MAGNESIUM132 CAPASTAT SULFATE51 BULL FROG WATER ARMOR calcium 600 mg132 CAPRELSA57 SPORT QUIK GEL SPF 50104 calcium acetate (phosphate BULL FROG WATER ARMOR binder)115 capsaicin in lidocaine vehicle97 SPORT QUIK SPRAY SPF calcium ascorbate167 captopril & 50104 hydrochlorothiazide49 bumetanide 0.5 mg, 1 mg, 2 calcium carbonate (antacid) 500 mg, 750 mg15 captopril 100 mg, 12.5 mg, 25 mg107 mg, 50 mg46 BUMEX107 calcium carbonate (antacid) 600 mg15 CARAC90 BUPRENEX12 calcium carbonate 1250 CARAFATE 1 GM161 buprenorphine hcl 0.3 mg/ml13 mg132 carbamazepine 100 mg25 buprenorphine hcl 2 mg13 calcium carbonate 1250 mg, carbamazepine 100 mg, 200 mg, 500 mg, 600 mg, 600mg132 300 mg25 buprenorphine hcl 8 mg13 calcium carbonate 1500 buprenorphine hcl-naloxone hcl mg132 carbamazepine 100 mg/5ml25 dihydrate 2mg-0.5mg13 CALCIUM CARBONATE 648 carbamazepine 200 mg25 buprenorphine hcl-naloxone hcl MG15 carbamazepine 200 mg, 400 dihydrate 8mg-2mg13 calcium carbonate- mg26 bupropion hcl (smoking cholecalciferol 500mg- carbamide peroxide136 deterrent)157 100unit132 151 bupropion hcl 100 mg29 carbamide peroxide (otic)

Index 6 CARBATROL26 CEFTIN 125 MG/5ML79 cetirizine hcl 1 mg/ml43 carbidopa62 CEFTIN 250 MG, 500 MG79 cetirizine hcl 1 mg/ml, 5 carbidopa-levodopa63 ceftriaxone sodium 1 gm80 mg/5ml43 cevimeline hcl137 carbinoxamine maleate43 ceftriaxone sodium 10 gm80 CHANTIX157 carboplatin 150 mg/15ml, 600 ceftriaxone sodium 2 gm80 CHANTIX CONTINUING mg/60ml52 ceftriaxone sodium 250 mg80 carboplatin 450 mg/45ml, 50 MONTHPAK157 mg/5ml52 ceftriaxone sodium 500 mg80 CHEK-STIX COMBO PAK CARDIZEM76 cefuroxime axetil79 URINALYSIS CONTROL104 CHEK-STIX CONTROL104 CARDIZEM CD76 cefuroxime sodium 1.5 gm, 7.5 CARDIZEM LA 180 MG, 240 MG, gm79 CHEMSTRIP -10 WITH SG104 300 MG, 360 MG, 420 MG76 cefuroxime sodium 750 mg79 CHEMSTRIP 10 MD104 CARDURA48 CELEBREX5 CHEMSTRIP 2 GP STRIPS105 carisoprodol 350 mg141 celecoxib5 CHEMSTRIP 2 LN STRIPS105 CARMOL95 CELESTONE-SOLUSPAN83 CHEMSTRIP 5 OB105 CARMOL 2095 CELEXA 10 MG30 CHEMSTRIP 7105 CARNITOR 330 MG110 CELEXA 20 MG30 CHEMSTRIP 9 STRIPS105 CARRAFOAM99 CELEXA 40 MG30 CHEMSTRIP UGK105 carteolol hcl (ophth)147 CELLCEPT 200 MG/ML73 CHEMSTRIP-K105 carvedilol75 CELLCEPT 250 MG73 CHEMSTRIP-MICRAL105 CASODEX55 CELLCEPT 500 MG74 chenodiol113 CATAFLAM5 CELLCEPT CHERRY CONCENTRATE153 INTRAVENOUS73 CATAPRES48 CHERRY SYRUP153 CELONTIN28 CATAPRES-TTS-148 CHEW Q 100 MG2 CENTANY88 CATAPRES-TTS-248 CHILDRENS MOTRIN 40 CEO-TWO122 CATAPRES-TTS-348 MG/ML5 cephalexin 125 mg/5ml, 250 CHILDRENS MOTRIN 50 MG5 CAVILON NO STING mg/5ml79 BARRIERFILM99 CHILDRENS MOTRIN JUNIOR cephalexin 250 mg, 500 mg, STRENGTH5 CAYSTON16 750 mg78 CHLOR-TRIMETON42 cefaclor 250 mg, 500 mg79 CERALYTE 70 60MEQ/L- chloramphenicol sodium cefadroxil78 70MEQ/L-20MEQ/L-30MEQ/L, 70MEQ/L-20MEQ/L133 succinate17 cefazolin sodium 1 gm, 10 gm, CERASPORT 4MEQ/L- chlordiazepoxide-amitriptyline 500 mg78 18MEQ/L-20MEQ/L-69MEQ/L, 155 cefdinir79 4MEQ/L-18MEQ/L-20MEQ/L- chlorhexidine gluconate (mouth- CEFEPIME 1 GM/50ML, 2 6MEQ/L 133 throat)137 chloroquine phosphate 250 mg, GM/100ML80 CERASPORT EX1133 80 500 mg50 cefepime hcl CERDELGA117 cefixime 100 mg79 chlorothiazide 500 mg107 CEREBYX 100 MG chlorpheniramine & cefixime 100 mg/5ml, 200 PE/2ML28 mg/5ml79 phenylephrine85 CEREBYX 500 MG chlorpheniramine & pseudoeph cefixime 200 mg79 PE/10ML28 15mg/5ml-1mg/5ml85 cefixime 400 mg79 CEREFOLIN106 chlorpheniramine maleate 2 cefotaxime sodium 1 gm, 10 CEREZYME117 mg/5ml42 gm79 CERVARIX163 chlorpheniramine maleate 4 cefotaxime sodium 2 gm, 500 mg42 mg79 CESAMET41 chlorpheniramine w/ codeine85 cefpodoxime proxetil79 CETAPHIL chlorpheniramine-phenylephrine- ANTIBACTERIAL68 cefprozil79 CETAPHIL GENTLE acetaminophen 1mg/5ml- ceftazidime 1 gm, 2 gm79 160mg/5ml-2.5mg/5ml 85 CLEANSER99 chlorpromazine hcl 10 mg, 100 ceftazidime 6 gm79 CETAPHIL GENTLE CLEANSING99 mg, 200 mg, 25 mg, 50 mg66

Index 7 chlorpromazine hcl 25 mg/ml66 cisplatin52 clindamycin phosphate-benzoyl chlorpromazine hcl 50 citalopram hydrobromide 10 peroxide87 mg/2ml66 mg30 clindamycin phosphate-benzoyl chlorthalidone 25 mg, 50 citalopram hydrobromide 10 peroxide (refrigerate)87 mg107 mg/5ml30 CLINISTIX105 chlorzoxazone141 citalopram hydrobromide 20 CLINITEST105 cholecalciferol 1000 unit, 2000 mg30 CLINITEST REAGENT105 citalopram hydrobromide 40 unit, 400 unit166 clobetasol propionate92 cholecalciferol 1000 unit, 2000 mg30 unit, 400 unit, 5000 unit166 CITRACAL/VITAMIN D132 clobetasol propionate emollient base92 cholecalciferol 400 unit/ml166 CITRUCEL FIBER LAXATIVE121 clobetasol propionate cholecalciferol 400 emulsion92 cladribine53 unt/0.03ml166 CLOBEX92 cholecalciferol 5000 unit166 CLAFORAN 1 GM, 10 GM80 CLOLAR53 cholestyramine 4 gm44 CLAFORAN 2 GM, 500 MG80 clomipramine hcl 25 mg, 50 mg, cholestyramine 4 gm/dose44 75 mg32 CLARINEX 5 MG43 cholestyramine light44 clonazepam 0.125 mg, 0.25 mg, CLARINEX REDITABS 5 choline fenofibrate45 0.5 mg, 1 mg, 2 mg25 MG43 clonazepam 0.5 mg25 chorionic gonadotropin109 clarithromycin 125 mg/5ml, 250 clonazepam 1 mg25 chromium 200 mcg135 mg/5ml124 chromium picolinate 200 clarithromycin 250 mg, 500 clonazepam 2 mg25 mcg136 mg124 clonidine hcl (adhd)1 ciclopirox 0.77 %89 clarithromycin 500 mg124 clonidine hcl 0.1 mg, 0.2 mg, 0.3 clemastine fumarate 2.68 ciclopirox 1 %89 mg48 mg43 clonidine hcl 0.1 mg/24hr, 0.2 ciclopirox 8 %89 CLEOCIN 150 MG, 300 MG, 75 mg/24hr, 0.3 mg/24hr48 ciclopirox olamine89 MG17 clopidogrel bisulfate 300 cidofovir71 CLEOCIN 2 %165 mg117 cilostazol117 CLEOCIN IN D5W17 clopidogrel bisulfate 75 mg117 CILOXAN147 CLEOCIN PHOSPHATE clorazepate dipotassium19 300MG/50ML-5%, clotrimazole137 cimetidine 200 mg160 600MG/50ML-5%, cimetidine 300 mg, 400 mg, 800 900MG/50ML-5%17 clotrimazole (topical)89 mg160 CLEOCIN PHOSPHATE 600 clotrimazole vaginal 1 %165 CIMZIA114 MG/4ML, 900 MG/6ML17 clotrimazole w/ CIMZIA STARTER KIT114 CLEOCIN-T87 betamethasone89 CINRYZE116 CLIMARA112 CLOVERINE SALVE89 CIPRO 250 MG, 500 MG112 CLINDAGEL87 clozapine65 CIPRO I.V.-IN D5W clindamycin hcl 150 mg, 300 CLOZAPINE ODT65 200MG/100ML-5%112 mg, 75 mg17 CLOZARIL65 CIPRO I.V.-IN D5W clindamycin palmitate COAL TAR81 400MG/200ML-5%112 hydrochloride17 coal tar extract 1 %104 CIPRO XR112 clindamycin phosphate (topical)87 coal tar extract 1 %, 15 %104 CIPRODEX151 clindamycin phosphate 150 COARTEM50 ciprofloxacin 400 mg/40ml112 mg/ml, 600 mg/4ml17 ciprofloxacin hcl (ophth)148 clindamycin phosphate 150 ciprofloxacin hcl 100 mg, 250 mg, mg/ml, 9000 mg/60ml17 500 mg, 750 mg112 clindamycin phosphate 600 ciprofloxacin in d5w mg/4ml, 900 mg/6ml17 200mg/100ml-5%112 clindamycin phosphate in ciprofloxacin in d5w d5w17 400mg/200ml-5%112 clindamycin phosphate ciprofloxacin-ciprofloxacin vaginal165 hcl112

Index 8 cod liver oil 10 minim, 110mg- CONDOMS124 CVS SALINE WOUND 2664unit-1000mg-100mg- CONDYLOX96 WASH100 200unit, 1250unit-130unit, cyanocobalamin 1000 mcg117 CONTI CASTILE SOAP99 1250unit-133.33unit, 1250unit- cyanocobalamin 250 mcg118 CONTRAVE1 133unit, 1250unit-135unit, cyclobenzaprine hcl 10 mg, 5 200unit-4000unit, 20mg-35mg- COPAXONE156 mg141 1250unit-45mg-133.333unit, COPEGUS71 34mg-1250unit-415mg-32mg- cyclopentolate hcl 1 %147 CORAL CALCIUM 500 cyclophosphamide 25 mg, 50 135unit, 50mg-110mg-250unit- 132 110mg-100unit-10unit, 52mg- MG mg52 2500unit-600mg-52mg-270unit, CORDARONE20 CYCLOSET36 530mg-1250unit-130unit, 90mg- COREG75 cyclosporine 100 mg, 25 mg74 37mg-415mg-36mg-1250unit- COREG CR75 cyclosporine 50 mg/ml74 135unit 140 CORGARD76 cyclosporine modified (for COD LIVER OIL 4000UNIT/5ML- CORLANOR78 microemulsion) 100 mg, 25 mg, 400UNIT/5ML, 5000UNIT/5ML- 50 mg74 CORTEF83 500UNIT/5ML 140 CYKLOKAPRON120 COD LIVER OIL FOR KIDS140 CORTENEMA14 CYMBALTA31 coenzyme q10 (ubidecarenone) cortisone acetate83 cyproheptadine hcl 2 mg/5ml44 10 mg, 60 mg2 CORTISPORIN coenzyme q10 (ubidecarenone) 10000UNIT/ML-3.5MG/ML-1% cyproheptadine hcl 4 mg44 150 mg, 30 mg2 151 CYRAMZA54 3 COENZYME Q10 25 MG CORZIDE49 CYSTARAN149 2 COENZYME Q10 60 MG COSENTYX90 cytarabine 100 mg/ml53 62 COGENTIN COSENTYX SENSOREADY cytarabine 20 mg/ml53 123 PEN91 COLACE CYTOMEL159 123 COSMEGEN56 COLACE CLEAR CYTOTEC162 114 COSOPT147 COLAZAL CYTOVENE71 COLCHICINE116 COUMADIN 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 D-VI-SOL166 116 colchicine w/ probenecid MG, 6 MG, 7.5 MG24 D.H.E. 45130 116 COLCRYS COZAAR47 dacarbazine 100 mg59 44 COLESTID CREON106 dacarbazine 200 mg59 COLESTID FLAVORED 5 CRESEMBA 186 MG42 GM44 DACOGEN53 colestipol hcl44 CRESEMBA 372 MG42 dakin's solution 0.25 %, 0.5 %68 16 CRESTOR45 colistimethate sodium DALIRESP21 COLY-MYCIN M16 CRIXIVAN68 cromolyn sodium21 danazol 100 mg, 200 mg, 50 COLYTE-FLAVOR PACKS mg13 cromolyn sodium 227.1GM-21.5GM-5.53GM- DANTRIUM142 2.82GM-6.36GM 122 (mastocytosis)113 cromolyn sodium (ophth)149 dantrolene sodium 100 mg, 25 COLYTE-FLAVOR PACKS 142 240GM-22.72GM-5.84GM- mg, 50 mg CUBICIN17 dapsone 100 mg, 25 mg17 2.98GM-6.72GM 122 CUPRIMINE73 COMBISTIX105 DAPTACEL159 CUTAR104 COMBIVENT RESPIMAT22 DARA100 CUTIVATE93 COMBIVIR68 DARAPRIM50 CVS COD LIVER OIL140 COMETRIQ57 daunorubicin hcl56 CVS GLUCOSE 4 GM35 DAUNOXOME56 COMPLERA68 CVS HDYROCORTISONE COMPLEX MSUD AMINO ACID ACETATE93 DAYPRO5 BAR145 CVS KETONE CARE105 DDAVP111 COMTAN62 CVS NATURAL FIBER DEBROX151 COMVAX163 SUPPLEMENT121 decitabine53 CONCERTA 27 MG, 36 MG2

Index 9 DECON-A 2MG/5ML- desmopressin acetate dextrose (diabetic use) 15 5MG/5ML85 refrigerated111 gm/38gm, 40 %35 DEEP BLUE RELIEF97 desmopressin acetate dextrose 10 %144 DELESTROGEN 10 spray111 dextrose 5 %144 desmopressin acetate spray MG/ML112 dextrose in lactated ringers133 DELESTROGEN 20 MG/ML, 40 refrigerated111 MG/ML112 DESOGEN81 dextrose w/ sodium chloride desogestrel & ethinyl 0.45%-2.5%, 0.45%-5%133 DELZICOL114 dextrose w/ sodium chloride DEMADEX107 estradiol81 desogestrel-ethinyl estradiol 0.9%-5%133 demeclocycline hcl158 (biphasic)81 DHS100 DEMEROL 100 MG/ML, 50 desonide93 DHS COLOR SAFE MG/ML8 SHAMPOO100 DESOWEN93 DEMEROL 25 MG/ML9 DHS CONDITIONING desoximetasone 0.05 %93 DEMSER47 RINSE100 desoximetasone 0.25 %93 DHS ZINC91 DENAVIR91 DESOXYN1 DIABETA 1.25 MG38 DEPACON28 DESVENLAFAXINE ER 100 DIABETA 2.5 MG38 DEPAKENE29 MG, 50 MG31 DIABETA 5 MG38 DEPAKOTE29 DETROL163 DIABETIDERM DEPAKOTE ER29 DETROL LA163 CLEANSING100 DEPAKOTE SPRINKLES29 DEX4 QUICK DISSOLVE DIAMOX106 DEPEN TITRATABS73 GLUCOSE35 DIASTAT ACUDIAL25 dexamethasone 0.5 mg, 0.75 DEPO-MEDROL 20 MG/ML83 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, DIASTAT PEDIATRIC25 DEPO-MEDROL 40 MG/ML, 80 6 mg83 DIASTIX105 MG/ML83 dexamethasone 0.5 diazepam 1 mg/ml19 DEPO-PROVERA55 mg/5ml83 diazepam 10 mg, 2 mg, 5 DEPO-PROVERA dexamethasone sodium mg19 CONTRACEPTIVE82 phosphate (ophth)149 DIAZEPAM 10 MG, 2.5 MG, 20 DERMA-SMOOTHE/FS dexamethasone sodium MG25 BODY93 phosphate 10 mg/ml83 DERMA-SMOOTHE/FS dexamethasone sodium diazepam 5 mg/ml19 SCALP93 phosphate 10 mg/ml, 120 DIBENZYLINE47 DERMAGRAN98 mg/30ml83 diclofenac potassium5 DERMAREST ROSACEA98 dexamethasone sodium diclofenac sodium (actinic dermatological products, misc. phosphate 100 mg/10ml, 20 keratoses)90 mg/5ml, 4 mg/ml83 diclofenac sodium (ophth)149 0.17%-2.7%, 4%-2%-0.5%98 DEXATRIM MAX 1MG- DERMATOP93 5.5UNIT-34MCG-72MG-75MG- diclofenac sodium 100 mg5 DERMAZINC BABY91 0.35MG-70MG-45MG- diclofenac sodium 25 mg, 50 mg, DERMAZINC SCALP91 0.263MG-10MG-1.8MG-3.5MG- 75 mg5 diclofenac w/ misoprostol5 DERMAZINC SPRAY91 0.3MG-3MCG-70MCG- 0.35MG-25MG-30MG 106 dicloxacillin sodium153 DERMOPLAST97 dexbrompheniramine & dicyclomine hcl 10 mg160 DERMOPLAST PAIN pseudoephedrine85 RELIEVINGSPRAY97 DEXEDRINE1 dicyclomine hcl 20 mg160 DERMOTIC151 DEXILANT161 didanosine68 desipramine hcl 10 mg, 100 mg, dexmethylphenidate hcl 10 mg, diethylpropion hcl 25 mg1 150 mg, 25 mg, 50 mg, 75 2.5 mg, 5 mg2 DIETHYLPROPION HCL 25 mg32 dexmethylphenidate hcl 15 MG1 desloratadine 5 mg43 mg2 diethylpropion hcl 75 mg1 desmopressin acetate 0.1 mg, dexrazoxane60 DIFFERIN 0.1 %87 0.2 mg111 dextroamphetamine sulfate 10 DIFICID124 desmopressin acetate 4 mg, 15 mg, 5 mg1 mcg/ml111 dextroamphetamine sulfate 10 diflorasone diacetate93 mg, 5 mg1 DIFLUCAN42

Index 10 diflunisal8 diphenhydramine-zinc acetate doxorubicin hcl 10 mg57 DIGOXIN 0.05 MG/ML77 0.1%-1%90 doxorubicin hcl 2 mg/ml57 diphenoxylate w/ atropine39 digoxin 0.125 mg, 0.25 mg, 125 doxorubicin hcl 50 mg57 DIPHTHERIA/TETANUS mcg, 250 mcg77 doxorubicin hcl liposomal56 dihydroergotamine mesylate 1 TOXOIDS ADSORBED mg/ml130 PEDIATRIC159 doxycycline (monohydrate) 100 DIPROLENE93 mg, 150 mg, 50 mg, 75 mg158 DILANTIN-12528 doxycycline (monohydrate) 100 DILAUDID 1 MG/ML9 DIPROLENE AF93 mg, 50 mg, 75 mg158 DILAUDID 2 MG9 dipyridamole 25 mg, 50 mg, 75 doxycycline (monohydrate) 25 mg117 DILAUDID 2 MG/ML9 mg/5ml158 disopyramide phosphate20 doxycycline hyclate 100 mg158 DILAUDID 4 MG9 disulfiram 250 mg, 500 doxycycline hyclate 100 mg, 20 DILAUDID 8 MG9 mg154 mg158 DILAUDID-HP 10 MG/ML9 DITROPAN XL163 doxycycline hyclate 100 mg, 50 diltiazem hcl 120 mg, 180 mg, divalproex sodium29 mg158 240 mg77 DIVIGEL112 doxycycline hyclate 150 mg158 diltiazem hcl 120 mg, 30 mg, 60 DRISDOL166 mg, 90 mg77 dobutamine hcl166 DOCEFREZ61 DRIXORAL diltiazem hcl 120 mg, 60 mg, 90 COLD/ALLERGY85 mg77 docetaxel 140 mg/7ml, 20 dronabinol41 diltiazem hcl coated beads76 mg/ml, 80 mg/4ml61 DOCETAXEL 160 MG/16ML, drospirenone-ethinyl diltiazem hcl extended release estradiol81 beads77 20 MG/2ML, 200 MG/20ML, 80 DIMETAPP COLD & ALLERGY MG/8ML61 DROXIA117 1MG/5ML-2.5MG/5ML85 DOCETAXEL 20 MG/ML, 80 DUAC87 dimethicone-zinc oxide-vitamin a- MG/4ML61 DUETACT33 docosahexaenoic acid 200 vitamin d100 DULCOLAX123 DIOVAN47 mg144 docusate calcium123 DULCOLAX BOWEL PREP DIOVAN HCT49 KIT123 123 DIPENTUM114 docusate sodium 100 mg DULERA23 docusate sodium 100 mg, 250 diphenhydramine hcl mg, 50 mg123 duloxetine hcl 20 mg, 30 mg, 60 (topical)90 docusate sodium 150 mg/15ml, mg31 diphenhydramine hcl 12.5 50 mg/5ml123 DUONEB23 mg43 DUOPA63 diphenhydramine hcl 12.5 docusate sodium 283 mg123 mg/5ml43 docusate sodium 60 DURAGESIC 100 MCG/HR9 diphenhydramine hcl 12.5 mg/15ml123 DURAGESIC 12 MCG/HR9 mg/5ml, 25 mg/10ml, 50 DOCUSOL KIDS123 DURAGESIC 25 MCG/HR9 mg/20ml43 DOLOPHINE 10 MG9 DURAGESIC 50 MCG/HR9 diphenhydramine hcl 25 mg43 DOLOPHINE 5 MG9 DURAGESIC 75 MCG/HR9 diphenhydramine hcl 50 DOMEBORO 1347MG- mg/ml43 952MG100 dutasteride115 diphenhydramine-phenylephrine donepezil hydrochloride154 DYAZIDE107 12.5mg/5ml-5mg/5ml85 dyphylline-guaifenesin21 diphenhydramine-phenylephrine DORYX 150 MG158 25mg-10mg85 dorzolamide hcl150 E-Z SPACER127 diphenhydramine-phenylephrine- dorzolamide hcl-timolol E-Z SPACER THE BODY acetaminophen 12.5mg-12.5mg- maleate147 GUARDS PACK127 325mg-325mg-5mg-5mg, DOVONEX91 EASIVENT127 12.5mg-325mg-5mg85 EASIVENT/MASK-LARGE 127 diphenhydramine-phenylephrine- doxazosin mesylate48 doxepin hcl 10 mg, 100 mg, EASIVENT/MASK-MEDIUM acetaminophen 12.5mg/5ml- 127 160mg/5ml-2.5mg/5ml 85 150 mg, 25 mg, 50 mg, 75 diphenhydramine- mg33 EASIVENT/MASK-SMALL 127 pseudoephedrine-acetaminophen doxepin hcl 10 mg/ml33 EC-NAPROSYN5 85 DOXIL56 econazole nitrate89

Index 11 ECOTRIN MAXIMUM enoxaparin sodium24 erythromycin base 500 mg124 STRENGTH8 entacapone62 erythromycin ECOTRIN REGULAR entecavir71 ethylsuccinate124 STRENGTH8 erythromycin lactobionate124 ED CHLORPED42 ENTOCORT EC83 erythromycin stearate124 ED CHLORPED D85 ENTRESTO78 ESBRIET158 EDURANT68 ENTSOL HYPERTONIC NASAL IRRIGATION escitalopram oxalate30 EFFEXOR XR 150 MG31 MIST142 esomeprazole magnesium 20 EFFEXOR XR 37.5 MG31 ENTSOL NASAL SPRAY142 mg161 EFFEXOR XR 75 MG31 ENTSOL NASAL WASH142 esomeprazole magnesium 40 EFFIENT117 mg161 ENTYVIO114 ESOMEPRAZOLE EFUDEX90 ENUCLENE150 STRONTIUM161 EGRIFTA 2 MG109 EPHEDRINE HCL23 estradiol & norethindrone ELDEPRYL63 acetate111 EPHEDRINE SULFATE23 estradiol 0.025 mg/24hr, 0.05 ELELYSO117 epinastine hcl (ophth)150 mg/24hr, 0.06 mg/24hr, 0.075 ELESTAT150 EPINEPHRINE 0.15 mg/24hr, 0.1 mg/24hr, 37.5 ELETONE98 MG/0.15ML, 0.3 mcg/24hr112 ELETONE TWINPACK98 MG/0.3ML165 estradiol 0.5 mg, 1 mg, 2 23 mg112 ELIDEL96 epinephrine hcl 0.1 mg/ml 165 estradiol vaginal165 ELIGARD55 EPIPEN 2-PAK EPIPEN-JR 2-PAK165 estradiol valerate 10 mg/ml, 20 ELIQUIS24 mg/ml, 40 mg/ml112 epirubicin hcl 200 mg/100ml, 50 ELITEK60 mg/25ml57 estradiol-norgestimate111 ELIXSURE CONGESTION143 EPIVIR 10 MG/ML68 estropipate 0.75 mg, 1.5 mg112 ELIXSURE FEVER/PAIN8 EPIVIR 150 MG, 300 MG68 ethambutol hcl 100 mg, 400 ELLA82 EPIVIR HBV 100 MG71 mg51 ELLENCE57 EPIVIR HBV 5 MG/ML71 ethosuximide 250 mg28 ELOCON93 eplerenone50 ethosuximide 250 mg/5ml28 ELOXATIN52 EPOGEN118 ethynodiol diacet & eth estrad81 ELTA CLEANSE FOAM100 eprosartan mesylate47 ETHYOL60 ELTA LITE TAR104 EPZICOM68 etodolac 200 mg, 300 mg5 ELTA TAR104 EQL CALCIUM/VITAMIN etodolac 400 mg, 500 mg5 EMCYT55 D133 EQL CHILDRENS etodolac 400 mg, 500 mg, 600 EMEND 125 MG, 80 MG41 MULTIVITAMINS139 mg5 EMEND 40 MG41 EQL NATURAL FIBER121 ETOPOPHOS61 EMLA97 EQUETRO64 etoposide 1 gm/50ml, 100 mg/5ml61 EMSAM30 ERAXIS 100 MG41 etoposide 500 mg/25ml61 EMTRIVA68 ERBITUX54 EVAC121 enalapril maleate & ergocalciferol 50000 unit166 hydrochlorothiazide49 EVISTA109 ergocalciferol 8000 enalapril maleate 10 mg, 2.5 mg, EVOCLIN87 20 mg, 5 mg46 unit/ml166 EVOTAZ68 ENBREL7 ergoloid mesylates156 EVOXAC137 ENBREL SURECLICK7 ergotamine tartrate130 EX-LAX123 ENCARE164 ERIVEDGE55 ERWINAZE59 EXELON 1.5 MG, 3 MG, 4.5 MG, ENFALYTE133 6 MG154 ENFAMIL ENFALYTE133 erythromycin (acne aid)87 EXELON 13.3 MG/24HR, 4.6 ENGERIX-B 10 MCG/0.5ML, 20 erythromycin (ophth)148 MG/24HR, 9.5 MG/24HR154 MCG/ML163 erythromycin base 250 exemestane55 mg124

Index 12 EXJADE40 FERROUS GLUCONATE 225 FLOVENT HFA 44 EXPECTA LIPIL144 MG119 MCG/ACT22 ferrous gluconate 240 mg, 27 fluconazole 10 mg/ml, 40 EXTAVIA156 mg119 mg/ml42 EXTINA89 ferrous sulfate 15 mg/ml119 fluconazole 100 mg, 150 mg, 200 EYE STREAM150 ferrous sulfate 220 mg, 50 mg42 FA-8118 mg/5ml119 fluconazole in dextrose42 FERROUS SULFATE 220 fluconazole in nacl 200mg/100ml- FABRAZYME 35 MG110 MG/5ML119 0.9%, 400mg/200ml-0.9%42 famciclovir72 FERROUS SULFATE 300 flucytosine41 famotidine 10 mg160 MG/5ML119 FLUDARA53 famotidine 20 mg160 FERROUS SULFATE 324 MG119 fludarabine phosphate 50 famotidine 20 mg/2ml, 200 mg53 ferrous sulfate 325 mg119 mg/20ml, 40 mg/4ml160 fludrocortisone acetate84 famotidine 40 mg160 ferrous sulfate 325 mg, 65 mg119 FLUMADINE73 famotidine 40 mg/5ml160 ferrous sulfate 50 mg119 flunisolide (nasal)143 FAMVIR72 ferrous sulfate dried 160 fluocinolone acetonide FANAPT64 mg119 (otic)151 FARESTON55 FETZIMA 120 MG, 40 MG, 80 fluocinolone acetonide 0.01 MG31 %93 FARXIGA38 FETZIMA 20 MG32 fluocinolone acetonide 0.01 %, FARYDAK57 FETZIMA TITRATION 0.025 %93 FASLODEX55 PACK32 fluocinolone acetonide 0.025 %93 fat emulsion 20 gm/100ml144 FEVERALL INFANTS8 fluocinonide 0.05 %93 FAZACLO65 FIBERCON121 fluocinonide emulsified base93 felbamate28 FINACEA103 fluorometholone (ophth)149 FELBATOL28 finasteride115 fluorouracil (topical)90 FELDENE5 FIORINAL/CODEINE #312 FLUOROURACIL 0.5 %90 felodipine77 FIRAZYR116 fluorouracil 1 gm/20ml53 FEMARA55 FIRMAGON55 fluorouracil 2.5 gm/50ml, 5 FEMCON FE81 FLAGYL16 gm/100ml, 500 mg/10ml53 FEMINEASE164 flavoxate hcl163 fluoxetine hcl (PMDD) cap 10 mg, fenofibrate 145 mg, 160 mg, 48 FLEBOGAMMA DIF 10 %151 20 mg156 fluoxetine hcl 10 mg, 20 mg30 mg, 54 mg45 flecainide acetate 100 mg20 fenofibrate micronized45 fluoxetine hcl 10 mg, 20 mg, 40 flecainide acetate 150 mg20 fentanyl 100 mcg/hr9 mg30 flecainide acetate 50 mg20 fluoxetine hcl 20 mg/5ml30 fentanyl 12 mcg/hr9 FLECTOR88 fluoxetine hcl 90 mg30 fentanyl 25 mcg/hr9 FLEET BISACODYL123 fluoxymesterone13 fentanyl 50 mcg/hr9 FLEET LIQUID GLYCERIN fluphenazine decanoate66 fentanyl 75 mcg/hr9 SUPPOSITORIES122 fluphenazine hcl 1 mg, 10 mg, 2.5 fentanyl citrate 1200 mcg, 1600 FLEXICHAMBER127 mg, 5 mg66 mcg, 400 mcg, 600 mcg, 800 FLOMAX115 fluphenazine hcl 2.5 mg/ml66 mcg9 fentanyl citrate 200 mcg9 FLONASE143 fluphenazine hcl 5 mg/ml66 FER-IN-SOL119 FLORICAL134 flurbiprofen 100 mg, 50 mg5 FLOVENT DISKUS 100 flurbiprofen sodium150 FERGON119 MCG/BLIST22 FERRIPROX40 FLOVENT DISKUS 250 flutamide55 ferrous fumarate 324 mg, 325 MCG/BLIST22 fluticasone propionate mg119 FLOVENT DISKUS 50 (nasal)143 FERROUS FUMARATE 90 MCG/BLIST22 fluticasone propionate 0.005 MG119 FLOVENT HFA 110 MCG/ACT, %94 220 MCG/ACT22

Index 13 fluticasone propionate 0.05 furosemide 10 mg/ml107 gentamicin sulfate (ophth)148 %94 furosemide 20 mg, 40 mg, 80 gentamicin sulfate (topical)88 fluvastatin sodium 20 mg, 40 mg107 gentamicin sulfate 10 mg/ml3 mg45 FUSILEV60 fluvoxamine maleate30 gentamicin sulfate 40 mg/ml3 FUZEON68 FML LIQUIFILM149 GENTEAL MILD TO FYCOMPA 10 MG24 MODERATE146 FOCALIN2 FYCOMPA 12 MG24 GENTLE RAIN EXTRA FOCALIN XR 15 MG2 FYCOMPA 2 MG24 MILD100 FOLGARD RX118 GENTLE RAIN SHAMPOO AND FYCOMPA 4 MG24 FOLIC + B12118 SKIN CLEANSER100 FYCOMPA 6 MG24 GENTLE SKIN CLEANSER100 folic acid 1 mg118 FYCOMPA 8 MG25 GEODON 20 MG64 FOLIC ACID 20 MG, 5 MG118 gabapentin 100 mg, 300 mg, GEODON 20 MG, 40 MG, 60 folic acid 400 mcg, 800 400 mg26 MG, 80 MG64 mcg118 gabapentin 250 mg/5ml26 GERI-SHAMPOO/SHEA folic acid-pyridoxine- BUTTER100 cyancobalamin 106 gabapentin 600 mg, 800 folic acid-vitamin b6-vitamin mg26 GERISILK BATH OIL91 b12119 GABITRIL 12 MG, 16 MG28 GILENYA156 FOLOTYN53 GABITRIL 2 MG, 4 MG28 GILOTRIF57 FOLTRATE119 galantamine GILTUSS PED-C85 hydrobromide154 fondaparinux sodium24 glatiramer acetate156 GAMASTAN S/D151 FORADIL AEROLIZER23 GLEEVEC57 GAMMAGARD LIQUID151 FORFIVO XL29 GLEOSTINE52 GAMMAKED151 FORMULA 405 FACIAL & glimepiride 1 mg38 GAMUNEX-C151 BODYCLEANSING100 glimepiride 2 mg38 FORMULA 405 ganciclovir sodium71 glimepiride 4 mg38 MOISTURIZINGSOAP100 GARDASIL163 FORTAMET 1000 MG34 GAS-X EXTRA STRENGTH glipizide 10 mg38 FORTAMET 500 MG34 125 MG113 glipizide 2.5 mg38 FORTAZ 1 GM, 2 GM80 GASTROCROM113 glipizide 5 mg38 FORTAZ 6 GM80 gatifloxacin (ophth)148 glipizide-metformin hcl 2.5mg- gauze pads 2" X 2"124 250mg33 FORTEO108 glipizide-metformin hcl 2.5mg- FORTICAL108 GAZYVA54 500mg, 5mg-500mg33 FOSAMAX108 gelatin 650 mg73 GLUCAGEN HYPOKIT35 fosinopril sodium47 GELONASAL142 glucagon (rdna)35 fosinopril sodium & GELUSIL 200MG-25MG- GLUCOPHAGE 1000 MG34 200MG15 hydrochlorothiazide49 GLUCOPHAGE 500 MG34 fosphenytoin sodium 100 mg GEMCITABINE53 pe/2ml28 gemcitabine hcl 1 gm, 200 GLUCOPHAGE 850 MG34 fosphenytoin sodium 500 mg mg53 GLUCOPHAGE XR 500 MG34 pe/10ml28 gemcitabine hcl 2 gm54 GLUCOPHAGE XR 750 MG34 FOSRENOL115 gemfibrozil45 glucosamine sulfate 500 mg3 FRAGMIN 10000 UNIT/ML, GEMZAR54 glucosamine-chondroitin 200mg- 12500 UNIT/0.5ML, 15000 250mg3 UNIT/0.6ML, 18000 UNT/0.72ML, GENOTROPIN 5 MG109 2500 UNIT/0.2ML, 25000 GENOTROPIN MINIQUICK 0.4 GLUCOSE 4 GM35 UNIT/ML, 5000 UNIT/0.2ML, MG109 glucose 5 %144 7500 UNIT/0.3ML24 gentamicin in saline 0.9%- GLUCOSE NURSETTE144 FRAGMIN 95000 0.8mg/ml3 GLUCOTROL 10 MG38 UNIT/3.8ML24 gentamicin in saline 0.9%- GLUCOTROL 5 MG38 FREE & CLEAR100 1.2mg/ml, 0.9%-1.6mg/ml, FRESH'N FEMININE 0.9%-1mg/ml3 GLUCOTROL XL 10 MG38 DEODORANT98 GLUCOTROL XL 2.5 MG38

Index 14 GLUCOTROL XL 5 MG38 GRANDPAS SHEA BUTTER HUMALOG MIX 75/25 GLUCOVANCE 1.25MG- SOAP100 KWIKPEN37 250MG33 GRANDPAS WITCH HAZEL HUMATROPE109 GLUCOVANCE 2.5MG-500MG, SOAP100 HUMATROPE COMBO 5MG-500MG34 granisetron hcl 1 mg40 PACK109 GLUMETZA 1000 MG35 GRANIX118 HUMIRA4 GLUMETZA 500 MG35 GRIS-PEG41 HUMIRA PEDIATRIC CROHNS GLUTAMENT145 griseofulvin microsize41 DISEASE STARTER PACK4 HUMIRA PEN4 GLUTOL104 griseofulvin ultramicrosize41 HUMIRA PEN-CROHNS glyburide 1.25 mg39 guaifenesin-codeine DISEASESTARTER4 glyburide 2.5 mg39 100mg/5ml-10mg/5ml86 HUMIRA PEN-PSORIASIS guanfacine hcl48 glyburide 5 mg39 STARTER4 guanfacine hcl (adhd)1 glyburide micronized 1.5 mg39 HUMULIN 70/3037 guanidine hcl50 glyburide micronized 3 mg39 HUMULIN 70/30 KWIKPEN37 GYNE-LOTRIMIN165 glyburide micronized 6 mg39 HUMULIN 70/30 PEN37 glyburide-metformin 1.25mg- H.P. ACTHAR109 HUMULIN N37 250mg34 HALAVEN61 HUMULIN N KWIKPEN37 glyburide-metformin 2.5mg- HALCION120 HUMULIN N U-100 PEN37 500mg, 5mg-500mg34 HALDOL65 HUMULIN R37 GLYCERIN 99 %, 99.5 %80 HALDOL DECANOATE HUMULIN R U-500 GLYCERINE80 10065 (CONCENTRATED)37 GLYCEROL FORMAL81 HALDOL DECANOATE 5065 HURRICAINE136 glycopyrrolate 0.2 mg/ml160 halobetasol propionate94 HURRICAINE ONE136 glycopyrrolate 1 mg, 2 mg160 haloperidol65 HYCAMTIN62 GLYNASE 1.5 MG39 haloperidol decanoate 100 hydralazine hcl 10 mg, 100 mg, GLYNASE 3 MG39 mg/ml, 50 mg/ml65 25 mg, 50 mg50 haloperidol lactate65 GLYNASE 6 MG39 HYDREA59 HARVONI71 hydrochlorothiazide 12.5 GLYSET33 HAVRIX163 mg107 GNP CALAMINE100 hydrochlorothiazide 12.5 mg, 25 GNP CALAMINE HEMA-COMBISTIX105 mg, 50 mg107 PHENOLATED100 HEMOCYTE119 HYDROCIL INSTANT121 GNP GLUCOSE 4 GM35 HEMOCYTE-F119 hydrocodone polistirex- GNP QUICK DISSOLVE HEPAMENT145 chlorpheniramine polistirex86 GLUCOSE35 heparin sodium (porcine)24 hydrocodone w/ GNP SALINE WOUND homatropine84 WASH100 HEPSERA71 hydrocodone-acetaminophen GOLYTELY 236GM-22.74GM- HERCEPTIN54 10mg-300mg, 5mg-300mg, 5.86GM-2.97GM-6.74GM 122 HETLIOZ121 7.5mg-300mg12 GRANDPAS BAKING SODA hydrocodone-acetaminophen SOAP100 HEXALEN52 10mg-325mg, 5mg-325mg, GRANDPAS INDIAN CORN HIPREX162 7.5mg-325mg12 SOAP100 HIZENTRA152 hydrocodone-acetaminophen GRANDPAS LOVE MY LOOFAH HM CALAMINE101 2.5mg/5ml-108mg/5ml, SOAP100 5mg/10ml-217mg/10ml, GRANDPAS OATMEAL HPR PLUS98 7.5mg/15ml-325mg/15ml12 SOAP100 HUMALOG36 hydrocodone-ibuprofen12 GRANDPAS ORANGE HUMALOG KWIKPEN36 ESSENCE SOAP100 hydrocortisone (intrarectal)14 GRANDPAS PATCHOULI HUMALOG MIX 50/5036 hydrocortisone (rectal)14 SOAP100 HUMALOG MIX 50/50 hydrocortisone (topical) 0.5 GRANDPAS PINE TAR KWIKPEN36 %94 SOAP104 HUMALOG MIX 75/2536 hydrocortisone (topical) 1 %94

Index 15 hydrocortisone (topical) 2.5 ibuprofen 100 mg5 INOSITOL 500 MG144 %94 ibuprofen 100 mg/5ml5 INSPIRACHAMBER/ANTI- hydrocortisone 10 mg, 20 mg, 5 ibuprofen 200 mg5 STATIC mg83 VALVED/MOUTHPIECE127 hydrocortisone acetate ibuprofen 40 mg/ml, 50 INSPIRACHAMBER/SOOTHER (topical)94 mg/1.25ml5 MASK/INSPIRAMASK/MEDIUM hydrocortisone butyrate94 ibuprofen 400 mg6 128 hydrocortisone butyrate ibuprofen 600 mg6 INSPIRACHAMBER/SOOTHER hydrophilic lipo base94 ibuprofen 800 mg6 MASK/INSPIRAMASK/SMALL hydrocortisone sod 128 succinate83 ICLUSIG58 INSPIREASE DRUG hydrocortisone valerate94 IDAMYCIN PFS57 DELIVERYSYSTEM128 hydrocortisone w/acetic idarubicin hcl57 INSPRA50 acid151 IFEX 1 GM52 INSULIN SYRINGES AND PEN hydrocortisone-aloe vera94 IFEX 3 GM52 NEEDLES125 INTELENCE 100 MG, 200 hydrogen peroxide (mouth- ifosfamide 1 gm52 throat)137 MG69 hydrogen peroxide-benzyl ifosfamide 1 gm/20ml, 3 INTELENCE 25 MG69 alcohol137 gm/60ml52 IFOSFAMIDE 3 GM52 INTRON A59 hydromorphone hcl 1 mg/ml9 INTRON A W/DILUENT59 hydromorphone hcl 10 mg/ml, 2 ILARIS4 mg/ml, 50 mg/5ml, 500 ILEVRO150 INTUNIV1 mg/50ml9 IMBRUVICA58 INVANZ17 hydromorphone hcl 2 mg9 imipenem-cilastatin17 INVEGA 1.5 MG64 hydromorphone hcl 4 mg9 imipramine hcl 10 mg, 25 mg, INVEGA 3 MG64 hydromorphone hcl 8 mg9 50 mg33 INVEGA 6 MG64 HYDROPEL101 imipramine pamoate33 INVEGA 9 MG64 hydrophilic ointment153 imiquimod96 INVEGA SUSTENNA64 hydroxychloroquine sulfate50 IMITREX 100 MG130 INVEGA TRINZA64 hydroxyurea59 IMITREX 25 MG131 INVIRASE69 hydroxyzine hcl 10 mg, 25 mg, 50 IMITREX 50 MG131 INVOKAMET 150MG-1000MG, mg19 IMITREX 6 MG/0.5ML130 150MG-500MG, 50MG- hydroxyzine hcl 10 mg/5ml19 IMITREX STATDOSE REFILL 1000MG34 hydroxyzine hcl 25 mg/ml, 50 4 MG/0.5ML130 INVOKAMET 50MG-500MG34 mg/ml19 IMITREX STATDOSE REFILL INVOKANA38 hydroxyzine pamoate 25 mg, 50 6 MG/0.5ML130 IODINE STRONG134 mg19 IMITREX STATDOSE SYSTEM HYLATOPIC PLUS98 4 MG/0.5ML130 IOPIDINE 0.5 %147 hypromellose (ophth) 0.3 %, 3 IMITREX STATDOSE SYSTEM IPECAC40 mg/ml146 6 MG/0.5ML130 IPOL INACTIVATED IPV164 HYQVIA152 IMOVAX RABIES ipratropium bromide21 (H.D.C.V.)164 HYSINGLA ER 100 MG, 120 ipratropium bromide (nasal)143 MG10 IMURAN74 HYSINGLA ER 20 MG, 30 MG, INCIVEK71 ipratropium-albuterol23 40 MG, 60 MG, 80 MG10 INCRELEX109 irbesartan47 HYVEE ADVANCED ANTACID irbesartan-hydrochlorothiazide MAXIMUM STRENGTH15 INCRUSE ELLIPTA21 49 HYZAAR49 indapamide108 IRESSA58 I.L.X. B-12119 INDERAL LA76 irinotecan hcl 100 mg/5ml, 40 ibandronate sodium 150 indomethacin 25 mg, 50 mg6 mg/2ml62 mg108 indomethacin 75 mg6 irinotecan hcl 500 mg/25ml62 ibandronate sodium 3 INFANRIX159 IRON 256 MG119 mg/3ml108 IRON 28 MG119 IBRANCE57 INFANTS ADVIL6 INLYTA58 IRON CHEWS PEDIATRIC119

Index 16 iron combinations119 K-TAB 8 MEQ135 KONSYL-D121 irrigation solutions, KADCYLA54 KUVAN 100 MG110 physiological75 KADIAN 100 MG10 KUVAN 100 MG, 500 MG110 ISENTRESS 100 MG69 KADIAN 20 MG, 30 MG, 50 KYNAMRO44 ISENTRESS 25 MG69 MG, 60 MG, 80 MG10 L-CARNITINE 250 MG145 ISENTRESS 400 MG69 KALBITOR116 L-CITRULLINE145 isoniazid & rifampin51 KALETRA69 L-METHYL-MC106 isoniazid 100 mg, 300 mg51 KALYDECO 150 MG157 labetalol hcl 100 mg, 200 mg, 300 ISOPTO CARPINE147 KALYDECO 50 MG, 75 mg75 ISOPTO TEARS146 MG157 LABSTIX105 KAPVAY1 ISORDIL TITRADOSE 5 MG18 LAC-HYDRIN95 KARAYA GUM153 isosorbide dinitrate 10 mg, 20 lactated ringer's133 KAYEXALATE75 mg, 30 mg, 5 mg18 LACTIC ACID80 isosorbide dinitrate 40 mg18 KAZANO34 lactic acid (ammonium lactate) 12 isosorbide mononitrate 10 mg, 20 KEFLEX79 %95 mg18 KENALOG-1083 lactic acid (ammonium lactate) 5 isosorbide mononitrate 120 mg, KENALOG-4083 %95 30 mg, 60 mg18 LACTIC ACID RACEMIC80 isotretinoin 10 mg, 20 mg, 30 mg, KEPIVANCE60 lactulose122 40 mg87 KEPPRA26 lactulose (encephalopathy)114 ISTODAX58 KEPPRA XR26 ITCH-X97 LAMICTAL 100 MG, 150 MG, KERLONE75 200 MG, 25 MG26 itraconazole42 KETO-DIASTIX105 LAMICTAL CHEWABLE ivermectin15 KETOCARE105 DISPERSIBLE26 IXEMPRA KIT61 ketoconazole42 LAMICTAL XR26 LAMICTAL XR 100 MG, 200 MG, IXIARO164 ketoconazole (topical)89 JADENU40 25 MG, 250 MG, 300 MG, 50 KETONE TEST STRIPS105 MG26 JAKAFI58 ketoprofen 50 mg, 75 mg6 LAMISIL 250 MG41 JALYN115 ketorolac tromethamine LAMISIL AT89 JANUMET34 (ophth)150 LAMISIL AT JOCK ITCH89 JANUMET XR 100MG- ketorolac tromethamine 15 1000MG34 mg/ml, 30 mg/ml6 lamivudine69 JANUMET XR 50MG-1000MG, ketorolac tromethamine 30 lamivudine (hbv)71 50MG-500MG34 mg/ml, 60 mg/2ml6 lamivudine-zidovudine69 JANUVIA36 KETOSTIX105 lamotrigine 100 mg, 150 mg, 200 JARDIANCE 10 MG38 ketotifen fumarate (ophth)150 mg, 25 mg26 JARDIANCE 25 MG38 KEYTRUDA54 lamotrigine 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg26 KHEDEZLA32 JENTADUETO34 lamotrigine 25 mg, 5 mg26 KINERET4 JEVTANA61 LANACANE97 KLARON88 JOHNSONS BABY BAR101 lanolin154 JOHNSONS BUDDIES EASY- KLONOPIN 0.5 MG25 lanolin (topical)101 GRIP SUDZING101 KLONOPIN 1 MG25 JOHNSONS KIDS SUPER LANOLIN ANHYDROUS153 SUDZER E-Z GRIP SOAP101 KLONOPIN 2 MG25 LANOLIN ANHYDROUS- JUXTAPID 10 MG46 KOMBIGLYZE XR 2.5MG- GRX154 1000MG34 JUXTAPID 20 MG46 LANOXIN 125 MCG, 250 KOMBIGLYZE XR 5MG- MCG77 JUXTAPID 30 MG46 1000MG, 5MG-500MG34 LANOXIN 187.5 MCG, 62.5 JUXTAPID 40 MG, 60 MG46 KONSYL 100 %121 MCG78 JUXTAPID 5 MG46 KONSYL 28.3 %, 60.3 %121 lansoprazole 15 mg161 K-TAB 10 MEQ135 KONSYL 60.3 %, 71.67 lansoprazole 30 mg161 %121

Index 17 LANTUS37 levetiracetam 100 mg/ml, 500 lidocaine hcl 4 %97 LANTUS SOLOSTAR37 mg/5ml26 lidocaine-prilocaine97 levetiracetam 1000 mg, 250 LASIX107 mg, 500 mg, 750 mg26 LIDODERM97 latanoprost150 LEVETIRACETAM LINCOCIN18 LATUDA 120 MG64 1000MG/100ML- lindane103 750MG/100ML, LATUDA 20 MG64 1500MG/100ML- linezolid 2 mg/ml18 LATUDA 40 MG64 540MG/100ML, 500MG/100ML- linezolid 600 mg18 LATUDA 60 MG64 820MG/100ML 26 liniments & rubs 0.01%-5%-10%, LATUDA 80 MG64 levetiracetam 500 mg, 750 1.2%-2.6%-4.7%, 10%-0.025%- mg26 15%97 LAZANDA 100 MCG/ACT10 levetiracetam 500 mg/5ml26 liniments & rubs 0.25%, 8%- LAZANDA 400 MCG/ACT10 levobunolol hcl 0.5 %147 2%97 LEADER QUICK DISSOLVE LINZESS114 GLUCOSE35 levocarnitine (metabolic modifiers) 330 mg110 liothyronine sodium 25 mcg, 5 lecithin144 levocarnitine 250 mg145 mcg, 50 mcg159 LECITHIN LIPITOR45 CONCENTRATE144 levocetirizine dihydrochloride43 LIPOSYN III 1.2GM/100ML- leflunomide 10 mg, 20 mg7 levofloxacin (ophth)148 10GM/100ML-2.5GM/100ML LEMTRADA156 144 levofloxacin 25 mg/ml113 LENVIMA 10MG DAILY LIPTRUZET44 DOSE58 levofloxacin 250 mg, 500 mg, LIQ-10 50MG/5ML- LENVIMA 14MG DAILY 750 mg113 15UNIT/5ML3 DOSE58 levofloxacin in d5w lisinopril & LENVIMA 20MG DAILY 250mg/50ml-5%, hydrochlorothiazide49 DOSE58 500mg/100ml-5%113 lisinopril 10 mg, 2.5 mg, 20 mg, LENVIMA 24MG DAILY levofloxacin in d5w 30 mg, 40 mg, 5 mg47 DOSE58 750mg/150ml-5%113 LITEAIRE128 LEVOLEUCOVORIN60 LESCOL45 lithium63 LETAIRIS78 levoleucovorin calcium60 lithium carbonate 150 mg, 300 levonorgestrel & eth mg, 600 mg63 letrozole55 estradiol81 leucovorin calcium 10 mg, 15 mg, levonorgestrel (emergency oc) lithium carbonate 300 mg63 25 mg, 5 mg60 0.75 mg82 lithium carbonate 300 mg, 450 leucovorin calcium 100 mg, 200 levonorgestrel (emergency oc) mg63 mg, 350 mg60 1.5 mg82 LITHIUM CARBONATE 600 leucovorin calcium 50 mg, 500 levonorgestrel-eth estradiol MG63 mg60 (triphasic)81 LITHOBID63 LEUKERAN52 levonorgestrel-ethinyl estradiol LOBOB CONTACT LENS LEUKINE118 (91-day)81 WEARERS SOAP101 leuprolide acetate55 levothyroxine sodium 100 mcg, LOCOID94 112 mcg, 125 mcg, 137 mcg, LOCOID LIPOCREAM94 levalbuterol hcl 0.31 mg/3ml, 0.63 150 mcg, 175 mcg, 200 mcg, mg/3ml, 1.25 mg/0.5ml, 1.25 25 mcg, 300 mcg, 50 mcg, 75 LODOSYN62 mg/3ml23 mcg, 88 mcg159 LOMOTIL39 LEVAQUIN 25 MG/ML113 LEXAPRO30 lomustine 10 mg52 LEVAQUIN 250 MG, 500 MG, LEXIVA69 LOMUSTINE 100 MG, 40 750 MG113 52 LEVAQUIN 250MG/50ML-5%, LEXUSS 21086 MG loperamide hcl 2 mg39 500MG/100ML-5%112 lidocaine 5 %97 LEVAQUIN 750MG/150ML- lidocaine hcl (local anesth.) 1 LOPID45 5%112 %, 2 %123 LOPRESSOR 100 MG, 50 LEVEMIR37 lidocaine hcl (mouth-throat) 2 MG75 LEVEMIR FLEXPEN37 %136 LOPRESSOR HCT49 LEVEMIR FLEXTOUCH37 lidocaine hcl 0.5 %97 LOPROX89 lidocaine hcl 2 %97 LOPROX SHAMPOO89

Index 18 lorazepam 0.5 mg, 1 mg, 2 MACRODANTIN 100 MG, 50 MEGACE ES154 mg20 MG162 MEGACE ORAL56 lorazepam 2 mg/ml20 mafenide acetate92 megestrol acetate lorazepam 2 mg/ml, 20 MAG-TAB SR135 (appetite)154 mg/10ml20 MAGINEX135 megestrol acetate 20 mg, 40 lorazepam 4 mg/ml20 MAGINEX DS135 mg56 losartan potassium48 megestrol acetate 40 mg/ml, 400 MAGNEBIND 200133 losartan potassium & mg/10ml56 hydrochlorothiazide49 magnesium 250 mg, MEIJER CALAMINE101 250mg135 LOSEASONIQUE81 magnesium chloride 535 mg, MEKINIST58 LOTEMAX149 64 mg135 meloxicam 15 mg, 7.5 mg6 LOTENSIN47 MAGNESIUM CHLORIDE melphalan hcl52 LOTENSIN HCT49 HEXAHYDRATE135 memantine hcl 10 mg, 5 mg155 MAGNESIUM ELEMENTAL 30 LOTREL49 MG135 memantine hcl 2 mg/ml154 LOTRISONE89 MAGNESIUM GLUCONATE MENACTRA163 LOTRONEX114 250 MG, 500 MG, 550 MENOMUNE-A/C/Y/W-135 MG135 lovastatin45 163 magnesium sulfate 50 %135 menthol (topical analgesic) 5 LOVAZA44 MALARONE 250MG- %88 LOVENOX24 100MG50 MENVEO163 LOWILA101 malathion103 meperidine hcl 100 mg/ml, 50 loxapine succinate 10 mg, 25 mg, maprotiline hcl29 mg/ml10 5 mg, 50 mg65 MARINOL41 meperidine hcl 25 mg/ml10 LUMIGAN150 MARPLAN30 meperidine hcl 50 mg/5ml10 LUMIZYME110 MATULANE59 MEPHYTON166 LUPRON DEPOT55 MAVIK47 MEPRON17 LUPRON DEPOT-PED 11.25 mercaptopurine54 MG110 MAXALT 10 MG131 LUPRON DEPOT-PED 11.25 MAXALT 5 MG131 meropenem17 MG, 15 MG, 7.5 MG110 MAXALT-MLT 10 MG131 MERREM17 LUPRON DEPOT-PED 30 MAXALT-MLT 5 MG131 mesalamine114 MG110 mesalamine w/ cleanser114 lutein 6 mg3 MAXIPIME 1 GM, 2 GM80 mesna60 LUVOX CR30 MAXITROL149 MESNEX 100 MG/ML60 LUXIQ95 MAXZIDE107 MESNEX 400 MG61 LYCELLE103 MAXZIDE-25107 MESTINON 60 MG50 LYNPARZA58 MCT OIL144 MESTINON TIMESPAN50 LYRICA 100 MG26 meclizine hcl 12.5 mg, 25 mg40 METADATE CD2 LYRICA 150 MG26 meclizine hcl 25 mg40 METAFOLBIC106 LYRICA 20 MG/ML27 MEDI-LYTE133 METAMUCIL 0.52 GM122 LYRICA 200 MG26 MEDIPLAST96 METAMUCIL 48.57 %122 LYRICA 225 MG, 300 MG27 MEDROL 16 MG, 32 MG, 4 METAMUCIL MULTIHEALTH LYRICA 25 MG27 MG, 8 MG84 FIBER 55.46 %122 LYRICA 50 MG27 MEDROL 2 MG84 METAMUCIL ORIGINAL LYRICA 75 MG27 MEDROL DOSEPAK84 TEXTURE122 METAMUCIL SMOOTH LYSODREN56 medroxyprogesterone acetate154 TEXTUREFIBER SINGLES122 LYSTEDA120 medroxyprogesterone acetate metaxalone141 M-M-R II164 (contraceptive)82 metformin hcl 1000 mg35 MAALOX15 mefenamic acid6 metformin hcl 1000 mg, 750 MACROBID162 mefloquine hcl50 mg35

Index 19 metformin hcl 500 mg35 metoprolol & minocycline hcl 100 mg, 50 mg, metformin hcl 850 mg35 hydrochlorothiazide49 75 mg158 metoprolol succinate75 minoxidil 10 mg, 2.5 mg50 methadone hcl 10 mg10 metoprolol tartrate 100 mg, 25 MIRAPEX63 methadone hcl 10 mg/5ml10 mg, 50 mg75 mirtazapine29 methadone hcl 10 mg/ml10 METROCREAM103 MIRVASO103 methadone hcl 5 mg10 METROGEL103 misoprostol 100 mcg, 200 methadone hcl 5 mg/5ml10 METROGEL-VAGINAL165 mcg162 METHADOSE10 METROLOTION103 mitomycin 20 mg, 40 mg, 5 METHADOSE SUGAR- metronidazole (topical)103 mg57 FREE10 metronidazole 250 mg, 500 mitoxantrone hcl57 methamphetamine hcl1 mg16 MOBIC 15 MG, 7.5 MG6 methazolamide 25 mg, 50 metronidazole 375 mg16 modafinil2 mg107 metronidazole in nacl16 MODICON81 methenamine hippurate162 metronidazole vaginal165 moexipril hcl47 methimazole 10 mg, 5 mg159 MEVACOR45 moexipril-hydrochlorothiazide methocarbamol 500 mg, 750 49 mg141 mexiletine hcl20 mometasone furoate95 methotrexate sodium 1 gm54 MG217 MEDICATED methotrexate sodium 1 gm/40ml, TAR104 MONOCAL134 100 mg/4ml, 200 mg/8ml, 25 MIACALCIN 200 MONODOX159 mg/ml, 250 mg/10ml, 50 UNIT/ACT108 montelukast sodium 10 mg21 mg/2ml54 MIACALCIN 200 UNIT/ML108 montelukast sodium 4 mg, 5 methotrexate sodium 10 mg, 15 mg21 MICATIN89 mg, 2.5 mg, 5 mg, 7.5 mg54 morphine sulfate 0.5 mg/ml10 91 miconazole nitrate (topical)89 methoxsalen rapid morphine sulfate 1 mg/ml10 methscopolamine bromide 2.5 miconazole nitrate vaginal 100 mg, 5 mg160 mg165 morphine sulfate 10 mg/5ml10 methylcellulose (laxative) 2 MICRO-K135 morphine sulfate 100 mg10 gm/10.2gm, 2 gm/19gm122 MICROCHAMBER128 morphine sulfate 100 mg, 200 methyldopa & mg, 30 mg, 60 mg11 49 MICROLIFE DIGITAL PEAK hydrochlorothiazide FLOW METER128 morphine sulfate 100 mg/5ml, 20 methylergonovine maleate 0.2 mg/ml10 mg151 MICROLIPID144 MORPHINE SULFATE 15 methylphenidate hcl 10 mg, 20 MICROSPACER128 MG11 mg, 30 mg, 40 mg, 50 mg, 60 MICROZIDE108 morphine sulfate 15 mg11 mg2 midodrine hcl166 morphine sulfate 20 mg, 30 mg, methylphenidate hcl 10 mg, 20 50 mg, 60 mg, 80 mg10 mg, 5 mg2 MIDOL COMPLETE 500MG- methylphenidate hcl 20 mg, 27 15MG-60MG7 morphine sulfate 20 mg/5ml11 mg, 36 mg2 MIDOL MAXIMUM STRENGTH MORPHINE SULFATE 30 methylphenidate hcl 20 mg, 30 MENSTRUAL7 MG11 mg, 40 mg2 MIDOL MAXIMUM STRENGTH MOSCO CALLUS/CORN methylphenidate hcl 27 mg, 36 MENSTRUAL FORMULA7 REMOVER96 mg2 MILK OF MAGNESIA MOTRIN INFANTS6 methylprednisolone 16 mg, 32 CONCENTRATE123 MOTRIN INFANTS DROPS6 mg, 4 mg, 8 mg84 MINI WRIGHT AFS PEAK FLOWMETER LOW MOTRIN JUNIOR methylprednisolone acetate 40 STRENGTH6 mg/ml, 80 mg/ml84 RANGE128 MINI WRIGHT PEAK FLOW MOZOBIL120 methylprednisolone sod MS CONTIN 100 MG, 200 MG, succ84 METER128 metoclopramide hcl 10 mg, 5 MINIPRESS48 30 MG, 60 MG11 mg113 MINOCIN 100 MG, 50 MG, 75 MS CONTIN 15 MG11 metoclopramide hcl 10 mg/10ml, MG158 MS QUICK DISSOLVE 5 mg/5ml113 minocycline hcl 100 mg, 50 GLUCOSE35 metolazone108 mg159 MTX SUPPORT119

Index 20 MULTAQ21 NAMENDA XR 21 MG, 28 NERVO B-12 SL139 MULTI-DELYN/IRON139 MG155 NESINA36 NAMENDA XR 7 MG155 MULTISTIX105 NESSI SPACER/LARGE NAMENDA XR TITRATION MULTISTIX 10 SG105 MASK128 PACK155 NESSI MULTISTIX 5105 naphazoline w/ pheniramine SPACER/MOUTHPIECE128 MULTISTIX 7105 0.025%-0.3%148 NESSI SPACER/SMALL/MED MULTISTIX 8 SG105 NAPHCON-A148 MASK128 MULTISTIX 9105 NAPROSYN6 NEULASTA118 naproxen 250 mg, 375 mg, 500 MULTISTIX 9 SG105 NEULASTA DELIVERY KIT118 mg6 NEUMEGA118 MULTITRACE-4136 naproxen 375 mg, 500 mg6 NEUPOGEN118 mupirocin88 naproxen sodium 220 mg6 NEUPRO63 mupirocin calcium (topical)88 naproxen sodium 275 mg, 550 MURO 128 2 %150 mg6 NEURONTIN27 naratriptan hcl131 NEUTROGENA ACNE MURO 128 5 %150 CLEANSING SOAP101 MUSTARGEN52 NARDIL30 NEUTROGENA CLEAN MYALEPT110 NASAL REPLENISHING101 DECONGESTANT143 MYAMBUTOL51 NEUTROGENA FACIAL SOAP NASALGUARD98 ORIGINAL FORMULA101 MYCAMINE41 nateglinide37 NEUTROGENA NATURALS MYCOBUTIN51 NATPARA108 FACE& BODY101 mycophenolate mofetil74 NEUTROGENA NATURE DE FRANCE ALGOLI SHAMPOO101 mycophenolate sodium74 SOAP101 NEUTROGENA TRIPLE MYFORTIC74 NATURE DE FRANCE ARGILE MOISTURE UV SHIELD101 MYLANTA 200MG/5ML- BLANCHE SOAP101 NATURE DE FRANCE NEVANAC150 20MG/5ML-200MG/5ML 15 nevirapine 100 mg69 MYLANTA DOUBLE- ARGIMIEL SOAP101 STRENGTH15 NAVELBINE61 nevirapine 200 mg69 MYLANTA GAS113 NEBUPENT16 nevirapine 400 mg69 MYLANTA GAS RELIEF nefazodone hcl31 NEVIRAPINE 50 MG/5ML69 MAXIMUM STRENGTH113 NEO-SYNEPHRINE 0.25 NEW SKIN98 MYOZYME110 %143 NEXAFED SINUS PRESSURE MYSOLINE27 NEO-SYNEPHRINE 0.5 +PAIN86 %143 NEXAVAR58 nabumetone6 NEO-SYNEPHRINE COLD & nadolol & SINUS MILD143 NEXIUM 10 MG, 2.5 MG, 20 MG, bendroflumethiazide49 NEO-SYNEPHRINE COLD & 40 MG, 5 MG161 nadolol 20 mg, 40 mg, 80 SINUS REGULAR143 NEXIUM 20 MG161 mg76 neomycin sulfate3 NEXIUM 40 MG161 nafcillin sodium 1 gm, 10 gm153 neomycin-bacitracin zn- niacin (antihyperlipidemic)46 polymyxin148 nafcillin sodium 2 gm153 niacin 100 mg, 250 mg, 50 mg, neomycin-bacitracin-polymyxin 500 mg167 NAFTIN 2 %89 w/ lidocaine88 niacin 250 mg, 500 mg167 NAGLAZYME110 neomycin-polymy- niacin 250 mg, 500 mg, 750 nalbuphine hcl 10 mg/ml, 20 dexameth149 mg167 mg/ml13 neomycin-polymyxin-gramicidin 148 NIACIN TR167 naloxone hcl 1 mg/ml40 neomycin-polymyxin-hc niacinamide 100 mg167 naltrexone hcl40 (otic)151 niacinamide 500 mg167 NAMENDA 10 MG, 5 MG155 neomycin/polymyxin b gu115 NIASPAN46 NAMENDA 10 MG/5ML155 NEORAL 100 MG, 25 MG74 nicardipine hcl 20 mg, 30 mg77 NAMENDA TITRATION NEOSALUS98 NICODERM CQ157 PAK155 NEOSALUS CP98 NAMENDA XR 14 MG155 NICORETTE157

Index 21 NICORETTE MINI157 NONYX98 NUTROPIN AQ PEN 20 NICORETTE STARTER NOR-QD83 MG/2ML109 KIT157 NORDITROPIN FLEXPRO 10 NUVARING82 nicotine157 MG/1.5ML, 5 MG/1.5ML109 NYMALIZE77 nicotine polacrilex 2 mg, 4 norelgestromin-ethinyl nystatin41 mg157 estradiol82 nystatin (mouth-throat)137 NICOTINE TRANSDERMAL norethin acet & estrad-fe 75mg- SYSTEM157 20mcg-1mg, 75mg-30mcg- nystatin (topical)89 NICOTROL INHALER157 1.5mg81 nystatin-triamcinolone89 NICOTROL NS157 norethindrone & eth OC898 estradiol81 nifedipine 30 mg, 60 mg, 90 norethindrone & ethinyl OCEAN NASAL SPRAY142 mg77 estradiol-fe 0.4mg-35mcg81 OCTAGAM 10 GM/100ML, 2 NILANDRON56 norethindrone GM/20ML, 20 GM/200ML, 5 nimodipine77 (contraceptive)83 GM/50ML152 norethindrone acet & eth octreotide acetate 100 mcg/ml, NIRAVAM20 1000 mcg/5ml, 200 mcg/ml, 50 nisoldipine 17 mg, 34 mg, 8.5 estra81 norethindrone acetate154 mcg/ml111 mg77 OCUFEN150 nit remover103 norethindrone acetate-ethinyl estradiol 5mcg-1mg111 OCUFLOX148 NITRATEST PAPER105 norethindrone-eth estradiol OCUSOFT HAND SOAP101 NITRO-DUR 0.1 MG/HR, 0.2 (triphasic)81 MG/HR, 0.4 MG/HR, 0.6 OCUSOFT LID SCRUB norgestimate-ethinyl FOAMING101 MG/HR18 estradiol82 nitrofurantoin macrocrystal 100 OCUSOFT LID SCRUB norgestimate-ethinyl estradiol ORIGINAL101 mg, 50 mg162 (triphasic)82 nitrofurantoin monohyd norgestrel & ethinyl ODOMZO55 macro162 estradiol82 OFEV158 nitroglycerin 0.1 mg/hr, 0.2 mg/hr, NORINYL 1+3582 ofloxacin (ophth)148 0.4 mg/hr, 0.6 mg/hr19 ofloxacin (otic)151 nitroglycerin 0.4 mg/spray19 NORPACE20 OILATUM101 NITROGLYCERIN LINGUAL18 NORPRAMIN33 NITROLINGUAL nortriptyline hcl 10 mg, 25 mg, olanzapine65 PUMPSPRAY19 50 mg, 75 mg33 olanzapine-fluoxetine hcl155 NITROMIST19 nortriptyline hcl 10 mg/5ml33 olopatadine hcl (nasal)142 NITROSTAT19 NORVASC 10 MG77 OLUX95 NIVATOPIC PLUS98 NORVASC 2.5 MG77 OLUX-E95 NIVEA MOISTURIZING BODY NORVASC 5 MG77 OLYSIO71 WASH101 NORVIR69 NIVEA MOISTURIZING BODY OMECLAMOX-PAK162 NORWEGIAN COD LIVER omega-3 fatty acids 180mg- WASH 2 IN 1101 OIL140 NIVEA TOUCH OF NOVA MAX PLUS KETONE 120mg, 300mg, 300mg-160mg- SMOOTHNESS MOISTURIZING TESTSTRIPS106 1000mg-100mg-5unit, 300mg- 772.5mg-90mg-180mg144 BODY WASH101 NOXAFIL 100 MG42 NIVEA VISAGE EYE omega-3 fatty acids 180mg- CONTOUR104 NOXAFIL 300 MG/16.7ML42 500mg-120mg, 27mg-244mg- NIVEA VISAGE GENTLE NOXAFIL 40 MG/ML42 500mg-89mg, 300mg-1000mg- CLEANSING101 NUEDEXTA156 200mg, 300mg-200mg, 500 mg, NIX CREME RINSE103 500mg, 500mg-270mg-135mg, NULLO73 500mg-320mg-130mg, 90mg- nizatidine 150 mg, 300 mg160 NULOJIX74 500mg-60mg144 NIZORAL89 NULYTELY/FLAVOR omega-3-acid ethyl esters44 NIZORAL A-D89 PACKS122 omeprazole 10 mg, 20 mg, 40 NO-STING SKIN-PREP101 NUTRATEAR146 mg161 NOBLE FORMULA 2 %91 NUTROPIN AQ NUSPIN omeprazole-sodium bicarbonate 20109 20mg-1100mg162 nonoxynol-9164

Index 22 omeprazole-sodium bicarbonate OPTIONS GYNOL II ORKAMBI158 40mg-1100mg162 VAGINALCONTRACEPTIVE ORTHO DIAPHRAGM ALL- OMNIFLEX DIAPHRAGM125 165 FLEX/65MM125 OMNIPRED149 OPTIVAR150 ORTHO DIAPHRAGM ALL- OMNITROPE 10 MG/1.5ML, 5 OPURITY B12/FOLIC FLEX/70MM125 MG/1.5ML109 ACID119 ORTHO DIAPHRAGM ALL- ONCASPAR59 ORABASE136 FLEX/75MM125 ORTHO DIAPHRAGM ALL- ondansetron40 oral electrolytes 16meq/473ml- 21meq/473ml-9meq/473ml- FLEX/80MM125 ondansetron hcl 24 mg, 4 mg, 8 ORTHO EVRA82 mg40 11gm/473ml, 18.8meq/l- ondansetron hcl 4 mg/2ml, 40 42.4meq/l-33.2meq/l-4.8gm/l- ORTHO MICRONOR83 mg/20ml40 18.8gm/l, 20meq/1000ml- ORTHO TRI-CYCLEN82 45meq/1000ml-35meq/1000ml- ondansetron hcl 4 mg/5ml40 25gm/1000ml, 20meq/l- ORTHO-CEPT82 ONE A DAY WOMENS 20meq/l-45meq/l-45meq/l- ORTHO-CYCLEN82 PRENATAL/DHA139 35meq/l-25gm/l, 20meq/l- ORTHO-NOVUM 1/3582 ONFI25 20meq/l-45meq/l-45meq/l- ORTHO-NOVUM 7/7/782 ONGLYZA36 35meq/l-35meq/l-30meq/l- 30meq/l-25gm/l-25gm/l, OSENI 12.5MG-15MG34 OPANA 10 MG11 OSENI 12.5MG-30MG, 12.5MG- OPANA 5 MG11 20meq/l-20meq/l-45meq/l- 45meq/l-35meq/l-35meq/l- 45MG, 25MG-15MG, 25MG- OPDIVO54 30meq/l-30meq/l-5gm/l-20gm/l, 30MG, 25MG-45MG34 OPSUMIT78 20meq/l-45meq/l-35meq/l- OTEZLA7 OPTICHAMBER 25gm/l, 20meq/l-45meq/l- OTREXUP4 ADVANTAGE128 35meq/l-30meq/l-25gm/l, OVIDE103 OPTICHAMBER 20meq/l-45meq/l-35meq/l- oxacillin sodium 10 gm153 ADVANTAGE/LARGE 30meq/l-5gm/l-20gm/l, 20meq/l- MASK128 45meq/l-35meq/l-30meq/l- oxacillin sodium 2 gm153 OPTICHAMBER 5gm/l-25gm/l, 20meq/l-45meq/l- oxaliplatin 100 mg, 50 mg52 ADVANTAGE/MEDIUM FACE 35meq/l-5gm/l-20gm/l, 20meq/l- oxaliplatin 100 mg/20ml, 50 MASK128 45meq/l-35meq/l-7.8mg/l-25gm, mg/10ml52 OPTICHAMBER 20meq/l-45meq/l-35meq/l- OXANDRIN13 ADVANTAGE/SMALL FACE 7.8mg/l-25gm/l, 20meq/l- oxandrolone 10 mg, 2.5 mg13 MASK129 45meq/l-35meq/l-7.8mg/l- OPTICHAMBER DIAMOND129 25meq/l, 20meq/l-45meq/l- oxaprozin6 OPTICHAMBER 45meq/l-35meq/l-5gm/l-20gm/l, oxazepam20 DIAMOND/LARGEFACE 35meq/l-45meq/l-20meq/l- oxcarbazepine27 MASK129 20gm/l, 35meq/l-45meq/l- OXSORALEN ULTRA91 OPTICHAMBER 20meq/l-25gm/l, 35meq/l- DIAMOND/MEDIUM FACE 45meq/l-20meq/l-30meq/l- oxybutynin chloride163 MASK129 25gm/l, 35meq/l-45meq/l- oxycodone hcl 100 mg/5ml, 20 OPTICHAMBER 20meq/l-30meq/l-30gm/l, mg/ml11 DIAMOND/SMALLFACE 35meq/l-45meq/l-20meq/l- oxycodone hcl 15 mg11 MASK129 30meq/l-5gm/l-20gm/l, 35meq/l- oxycodone hcl 30 mg11 OPTICHAMBER FACE 45meq/l-20meq/l-5gm/l-20gm/l, oxycodone hcl 5 mg11 MASK/LARGE129 35meq/l-45meq/l-20meq/l- oxycodone w/ acetaminophen OPTICHAMBER FACE 7.5mg/l-25meq/l, 35meq/l- MASK/MEDIUM129 10mg-325mg, 2.5mg-325mg, 45meq/l-20meq/l-7.8mg/l-25 5mg-325mg, 7.5mg-325mg12 OPTICHAMBER FACE 134 MASK/SMALL129 oxycodone w/ acetaminophen oral electrolytes 287mg-180mg- 5mg/5ml-325mg/5ml12 OPTIHALER129 15mg134 oxycodone-aspirin12 OPTIHALER MDI DRUG ORAP157 oxymorphone hcl 10 mg11 DELIVERY SYSTEM129 ORAPRED ODT84 OPTIONS CONCEPTROL oxymorphone hcl 15 mg11 ORAZINC136 VAGINAL oxymorphone hcl 5 mg11 CONTRACEPTIVE164 ORENCIA7 oxymorphone hcl 7.5 mg11 ORFADIN110

Index 23 oyster shell133 pediatric multiple vitamin w/ PEROXYL 1.5%-6%137 P & S91 extra c & fa139 perphenazine 16 mg, 2 mg, 4 mg, pediatric multiple vitamins w/ paclitaxel 100 mg/16.7ml, 30 8 mg66 iron 0.6mg/ml-10mg/ml- perphenazine-amitriptyline 155 mg/5ml, 300 mg/50ml61 5unit/ml-8mg/ml-1500unit/ml- paclitaxel 150 mg/25ml61 400unit/ml-0.5mg/ml-0.4mg/ml- PERSANTINE117 paliperidone 1.5 mg64 35mg/ml, 1500unit/ml-10mg/ml- PERSONAL BEST FULL paliperidone 3 mg64 5unit/ml-400unit/ml-8mg/ml- RANGE129 PERSONAL BEST LOW paliperidone 6 mg64 0.6mg/ml-0.5mg/ml-0.4mg/ml- 35mg/ml 139 RANGE129 paliperidone 9 mg64 pediatric vitamins acd w/ PETROLATUM95 PAMELOR33 fluoride139 PHACID102 PAMINE160 pediatric vitamins adc139 phenazopyridine hcl 100 mg, 200 PAMINE FORTE160 PEDVAX HIB163 mg116 PANCREAZE106 peg 3350-kcl-sod bicarb-sod phenelzine sulfate30 chloride-sod sulfate122 phenobarbital 100 mg, 15 mg, PANRETIN90 peg 3350-potassium chloride- 16.2 mg, 30 mg, 32.4 mg, 60 mg, PANTHODERM95 sod bicarbonate-sod 64.8 mg, 97.2 mg120 pantoprazole sodium 20 mg, 40 chloride122 phenobarbital 20 mg/5ml120 mg162 PEG-INTRON72 phenol (antiseptic)137 pantoprazole sodium 40 PEG-INTRON REDIPEN72 mg162 phenoxybenzamine hcl47 papaya 5mg-5mg-3mg-2mg- PEG-INTRON REDIPEN PAK phentermine hcl1 20mg73 472 PEGANONE28 PHENYLADE AMINO ACID145 PARAFON FORTE DSC141 PHENYLADE AMINO ACID parenteral electrolytes134 PEGASYS72 BLEND145 paricalcitol 1 mcg, 2 mcg, 4 PEGASYS PROCLICK72 PHENYLADE MTE AMINO mcg110 PEGINTRON72 ACIDBLEND145 PARLODEL63 penicillin g potassium 20 mu, PHENYLADE PHEBLOC146 PARNATE30 20000000 unit, 5000000 PHENYLADE40 DRINK MIX146 paromomycin sulfate3 unit152 penicillin v potassium152 phenyleph-promethazine w/ paroxetine hcl31 PENLAC NAIL LACQUER90 cod86 PATADAY150 phenylephrine hcl 0.25 %143 PENTAM 30016 PATANASE142 phenylephrine-shark liver oil- PAXIL 10 MG, 20 MG, 30 MG, 40 pentoxifylline116 glycerin-petrolatum14 MG31 PEPCID160 phenytoin 125 mg/5ml28 PAXIL 10 MG/5ML31 PEPCID AC160 phenytoin 50 mg28 PAXIL CR31 PEPTO BISMOL39 phenytoin sodium28 PEAK AIR PEAK FLOW PEPTO-BISMOL39 phenytoin sodium extended28 METERADULT/PEDIATRIC PEPTO-BISMOL PHILLIPS MILK OF MAGNESIA 129 INSTACOOL39 CHEWABLE123 PEAK FLOW METER129 PEPTO-BISMOL MAX PHILLIPS MILK OF MAGNESIA ped multivitamins w/fl & STRENGTH39 CONCENTRATED123 iron139 PEPTO-BISMOL TO-GO39 PHLEXY-10146 PEDI-WHIRL PERCODAN12 PHOS-NAK POWDER CONCENTRATE68 PERIDEX137 CONCENTRATE135 PEDIALYTE 20MEQ/L-45MEQ/L- PHOSLO115 35MEQ/L-30MEQ/L-25GM/L, perindopril erbumine 2 mg47 20MEQ/L-45MEQ/L-35MEQ/L- perindopril erbumine 4 mg47 PHOSPHOLINE IODIDE147 PHYSIOSOL IRRIGATION PH 5GM/L-20GM/L 134 perindopril erbumine 8 mg47 PEDIALYTE FREEZER 7.475 POPS134 PERJETA54 phytonadione 100 mcg166 PEDIATEX TD86 permethrin 0.5 %103 PICATO90 pediatric multiple vitamin w/ permethrin 1 %103 PIKO 1 ELECTRONIC129 c139 permethrin 5 %103

Index 24 pilocarpine hcl (oral)137 potassium chloride 2 PREMARIN 0.3 MG, 0.45 MG, pilocarpine hcl 1 %, 2 %, 4 meq/ml135 0.625 MG, 0.9 MG, 1.25 %147 potassium chloride 20 %135 MG112 pimozide157 POTASSIUM CHLORIDE PREMARIN 0.625 MG/GM165 pindolol76 ER135 PREMPHASE112 potassium chloride in dextrose PREMPRO112 pioglitazone hcl 15 mg36 & sodium chloride 0.45%- pioglitazone hcl 30 mg, 45 20meq/l-5%134 PRENATAL FORMULA 35MG- mg36 potassium chloride 30UNIT-4000UNIT-200MG- pioglitazone hcl-glimepiride34 microencapsulated crystals 25MG-1.8MG-200MG-28MG- pioglitazone hcl-metformin cr135 20MG-1.7MG-8MCG-400UNIT- hcl34 potassium citrate (alkalinizer) 800MCG-2.6MG-120MG 140 piperacillin sodium-tazobactam 1080 mg, 540 mg115 PRESUN ULTRA/PARSOL 3%- sodium153 POTASSIUM IODIDE134 5%-7.5%-6%104 PREVACID 15 MG162 piroxicam 10 mg, 20 mg6 POTIGA 200 MG27 PREVACID 30 MG162 PLAN B ONE-STEP82 POTIGA 300 MG27 PREVPAC162 PLAQUENIL50 POTIGA 400 MG27 PREZCOBIX69 PLAVIX 300 MG117 POTIGA 50 MG27 PLAVIX 75 MG117 PREZISTA 100 MG/ML69 PRADAXA24 PREZISTA 150 MG, 600 MG, PLEGRIDY156 PRALUENT 150 MG/ML46 800 MG69 PLEGRIDY STARTER PRALUENT 75 MG/ML46 PREZISTA 400 MG, 75 MG69 PACK156 pramipexole dihydrochloride PLETAL117 PRIFTIN51 0.125 mg, 0.25 mg, 0.5 mg, PRILOSEC 10 MG, 20 MG, 40 POCKET CHAMBER129 0.75 mg, 1 mg, 1.5 mg63 MG162 POCKET PEAK FLOW pramoxine-camphor-zinc PRIMAQUINE PHOSPHATE50 METER129 acetate97 POCKET SPACER130 PRANDIMET34 PRIMAXIN IV17 POCKETPEAK PEAK FLOW PRANDIN 0.5 MG37 primidone 250 mg, 50 mg27 METER LOW RANGE130 PRANDIN 1 MG37 PRINIVIL47 POCKETPEAK PEAK FLOW PRISTIQ32 METER/UNIVERSAL PRANDIN 2 MG37 RANGE130 PRAVACHOL45 PRIVIGEN152 POCKETPEAK PEAK FLOW pravastatin sodium45 PROAIR HFA23 METER/UNIVERSAL RANGE 50- prazosin hcl48 PROAIR RESPICLICK23 720 LPM130 probenecid116 podofilox96 PRE-FOLIC119 PRECISION XTRA106 PROCARDIA XL77 POLYCOSE144 prochlorperazine66 polyethylene glycol 3350122 PRECOSE33 PRED FORTE149 prochlorperazine edisylate66 polymyxin b sulfate18 prochlorperazine maleate 10 mg, polymyxin b-trimethoprim148 prednicarbate95 5 mg66 polysaccharide iron complex 150 prednisolone84 PROCRIT118 mg120 prednisolone acetate PROCTOCORT 1 %14 POLYSPORIN88 (ophth)149 prednisolone sodium PROFERRIN ES120 POLYTAR104 phosphate 10 mg, 15 mg, 30 progesterone micronized 100 mg, POLYTRIM148 mg84 200 mg154 polyvinyl alcohol146 prednisolone sodium PROGLYCEM35 POMALYST56 phosphate 15 mg/5ml, 5 PROGRAF 0.5 MG, 1 MG, 5 mg/5ml, 6.7 mg/5ml84 PONARIS142 MG74 prednisone 1 mg, 10 mg, 2.5 PROGRAF 5 MG/ML74 PONSTEL7 mg, 20 mg, 5 mg, 50 mg84 PROLASTIN-C157 potassium chloride 10 %135 prednisone 5 mg/5ml84 PROLEUKIN59 potassium chloride 10 meq, 8 prednisone 5 mg/ml84 meq135 PROLIA108

Index 25 PROMACTA 12.5 MG118 psyllium 28.3 %, 30 %, 30.9 %, ranitidine hcl 150 mg, 300 PROMACTA 25 MG118 33 %, 49 %, 68 %122 mg160 PTS PANELS KETONE ranitidine hcl 300 mg161 PROMACTA 50 MG118 TEST106 ranitidine hcl 75 mg161 PROMACTA 75 MG118 PULMICORT 0.25 MG/2ML, 0.5 promethazine hcl 12.5 mg, 25 MG/2ML22 RAPAMUNE 0.5 MG74 mg44 PULMOZYME158 RAPAMUNE 1 MG, 2 MG74 promethazine hcl 12.5 mg, 25 PURINETHOL54 RAPAMUNE 1 MG/ML74 mg, 50 mg44 RASPBERRY SYRUP153 promethazine hcl 25 mg/ml, 50 PURIXAN54 mg/ml44 PURPOSE102 RASUVO4 promethazine hcl 6.25 PX CALAMINE102 RAZADYNE155 mg/5ml44 pyrazinamide51 RAZADYNE ER155 promethazine w/codeine86 PYRETHINS/PIPERONYL REBETOL 200 MG72 promethazine-dm86 BUTOXIDE103 REBIF156 pyrethrins-piperonyl PROMETRIUM154 REBIF REBIDOSE156 PRONTO 0.33%-4%103 butoxide103 PYRIDIUM116 REBIF REBIDOSE propafenone hcl20 TITRATIONPACK156 pyridostigmine bromide 180 proparacaine hcl149 mg51 REBIF TITRATION PACK156 propranolol hcl 10 mg, 20 mg, 40 pyridostigmine bromide 60 RECLAST108 mg, 60 mg, 80 mg76 mg51 RECOMBIVAX HB164 propranolol hcl 120 mg, 160 mg, pyridoxine hcl 100 mg, 25 mg, RECTIV14 60 mg, 80 mg76 50 mg167 PROPYLENE GLYCOL153 pyrithione zinc 0.25 %91 REGENECARE HA97 propylthiouracil159 pyrithione zinc 2 %91 REGIMEX1 PROQUAD164 QC CALAMINE102 REGLAN113 PROSCAR115 QC COD LIVER OIL140 REGRANEX104 PROSHIELD FOAM & SPRAY QSYMIA1 RELENZA DISKHALER73 CLEANSER102 QUALAQUIN50 RELION KETONE106 PROTEINEX146 RELION KETONE TEST quetiapine fumarate65 PROTONIX 20 MG, 40 MG162 STRIPS106 quinapril hcl47 PROTONIX 40 MG162 RELISTOR 12 MG/0.6ML114 quinapril-hydrochlorothiazide PROTOPIC96 RELISTOR 12 MG/0.6ML, 8 49 MG/0.4ML115 protriptyline hcl33 quinidine gluconate 324 REMERON29 PROVENTIL HFA23 mg20 quinidine sulfate20 REMERON SOLTAB29 PROVERA154 REMICADE114 PROVIGIL2 quinine sulfate50 QVAR22 REMODULIN78 PROZAC31 RENVELA 2.4 GM115 PROZAC WEEKLY31 RA BEAUTY BAR102 RA CALAMINE 6.971%- RENVELA 800 MG115 PRUCLAIR98 6.971%102 repaglinide 0.5 mg37 PRUMYX98 RA COD LIVER OIL140 repaglinide 1 mg37 pseudoephedrine hcl 15 RA SALINE WOUND repaglinide 2 mg38 mg/5ml143 WASH102 REQUIP63 pseudoephedrine hcl 30 mg, 60 RABAVERT164 mg143 REQUIP XL63 raloxifene hcl109 pseudoephedrine-acetaminophen RESCRIPTOR70 86 ramipril47 RESERPINE 0.1 MG, 0.25 pseudoephedrine-ibuprofen RANEXA18 100mg/5ml-15mg/5ml86 MG48 ranitidine hcl 15 mg/ml, 150 RESTASIS148 psyllium 0.52 gm, 520 mg122 mg/10ml, 75 mg/5ml161 RESTORIL120 psyllium 100 %, 48.57 %, 58.6 %, ranitidine hcl 150 mg161 95 %122 RETIN-A88

Index 26 RETIN-A MICRO88 rizatriptan benzoate 10 SAXENDA1 RETIN-A MICRO PUMP 0.04 %, mg131 SAYMAN LANOLIN102 rizatriptan benzoate 5 mg131 0.1 %88 SAYMAN WITCH HAZEL102 RETROVIR70 ROBAXIN 500 MG141 SEASONIQUE82 RETROVIR IV INFUSION70 ROBAXIN-750142 SECTRAL75 REVATIO 10 MG/12.5ML78 ROBINUL 0.2 MG/ML160 selegiline hcl63 REVATIO 20 MG78 ROBINUL 1 MG160 selenium 100 mcg136 REVLIMID73 ROBINUL FORTE160 SELENIUM 40 MCG/ML136 REXULTI 0.25 MG67 ROCALTROL110 selenium 50 mcg136 REXULTI 0.5 MG67 ropinirole hydrochloride63 selenium sulfide 2.5 %91 REXULTI 1 MG67 ROTARIX164 SELZENTRY70 REXULTI 2 MG67 ROTATEQ164 sennosides 15 mg, 8.6 mg123 REXULTI 3 MG, 4 MG67 ROWASA114 SENOKOT123 REYATAZ 150 MG, 200 MG, 300 ROXICODONE 15 MG11 SENOKOT TO GO123 MG70 ROXICODONE 30 MG11 REYATAZ 50 MG70 SENSIPAR110 ROXICODONE 5 MG11 REZAMID88 SEREVENT DISKUS23 ROZEREM121 RHINOCORT AQUA143 SEROQUEL66 RUCONEST116 ribavirin (hepatitis c)72 SEROSTIM 4 MG, 6 MG109 RYMED86 riboflavin 100 mg167 sertraline hcl 100 mg, 25 mg, 50 RYTARY63 mg31 riboflavin 25 mg, 50 mg167 RYTHMOL20 sertraline hcl 20 mg/ml31 RID103 RYTHMOL SR20 SEVELAMER RIDAURA4 SABRIL28 CARBONATE115 rifabutin51 SHADE OIL FREE CLEAR SAFE WASH102 RIFADIN51 GELSPF 25104 SALAGEN137 SHUR-SEAL165 rifampin 150 mg, 300 mg51 saline142 SIGNIFOR111 rifampin 600 mg51 saline 0.65 %, 0.65%, 0.65%- SIGNIFOR LAR 20 MG111 RIFATER51 0.002%142 SIGNIFOR LAR 40 MG, 60 RILUTEK143 SALINE WOUND WASH102 MG111 riluzole144 SALJET102 sildenafil citrate (pulmonary rimantadine hydrochloride73 SALJET RINSE102 hypertension)78 RISPERDAL64 SALTAIRE142 SILENOR120 RISPERDAL CONSTA 12.5 SAMSCA111 SILVADENE92 MG65 SANCTURA163 silver sulfadiazine92 RISPERDAL CONSTA 25 simethicone 125 mg113 MG65 SANCTURA XR163 RISPERDAL CONSTA 37.5 MG, SANDIMMUNE 100 MG, 25 SIMPONI4 50 MG65 MG74 SIMPONI ARIA4 RISPERDAL M-TAB65 SANDIMMUNE 100 SIMULECT74 MG/ML74 risperidone65 simvastatin 10 mg45 SANDIMMUNE 50 MG/ML74 RITALIN2 SANDOSTATIN 100 MCG/ML, simvastatin 20 mg45 RITALIN LA 20 MG, 30 MG, 40 200 MCG/ML, 50 simvastatin 40 mg45 MG2 MCG/ML111 simvastatin 5 mg45 RITALIN LA 60 MG2 SANDOSTATIN LAR DEPOT simvastatin 80 mg45 RITALIN SR2 20 MG, 30 MG111 SINEMET63 RITEFLO130 SANTYL96 SINEMET CR63 RITUXAN55 SAPHRIS 10 MG65 SINGULAIR 10 MG21 rivastigmine155 SAPHRIS 2.5 MG65 SINGULAIR 4 MG, 5 MG21 rivastigmine tartrate155 SAPHRIS 5 MG65

Index 27 sirolimus74 SPIRIVA HANDIHALER21 SULFAMYLON 5 %92 SIVEXTRO18 SPIRIVA RESPIMAT 1.25 sulfasalazine114 SKELAXIN142 MCG/ACT21 SULFZIX106 SPIRIVA RESPIMAT 2.5 skin protectants, misc.102 MCG/ACT21 sulindac 150 mg, 200 mg7 SLO-NIACIN167 spironolactone & sumatriptan succinate 100 SLOW FE 160 MG120 hydrochlorothiazide107 mg131 spironolactone 100 mg, 25 mg, sumatriptan succinate 25 SLOW RELEASE IRON120 50 mg107 mg131 SM CALAMINE102 SPORANOX 100 MG42 sumatriptan succinate 4 mg/0.5ml131 SM CALAMINE SPORANOX PULSEPAK42 PHENOLATED102 sumatriptan succinate 50 SM GLUCOSE 4 GM35 SPRYCEL58 mg131 sumatriptan succinate 6 SM IPECAC SYRUP40 starch (topical)14 STARLIX38 mg/0.5ml131 SM PAIN SUMMERS EVE DEODORANT RELIEF/MENTHOL97 stavudine70 SPRAY98 sodium chloride (gu STAVZOR29 SUMMERS EVE DEODORANT irrigant)115 STELARA91 SPRAY ULTRA98 sodium chloride (inhalant)86 SUMMERS EVE NIGHT-TIME STIOLTO RESPIMAT23 sodium chloride 0.45 %135 CLEANSING/SENSITIVE STIVARGA58 sodium chloride 0.9 %135 SKIN102 STRATTERA2 SUPER E96 sodium chloride hypertonic150 SODIUM CHLORIDE/SODIUM STRIBILD70 SUPER E DAY96 BICARBONATE81 STRIVERDI RESPIMAT23 SUPER E EYE96 SODIUM CITRATE STROMECTOL15 SUPER E NIGHT96 DIHYDRATE80 STYGIENE STERILE EYELID SUPER-AMINO 1600146 sodium polystyrene CLEANSER102 SUPRAX 400 MG80 sulfonate75 SUBSYS 100 MCG, 200 sodium polystyrene sulfonate 15 MCG11 SUPRAX 500 MG/5ML80 gm/60ml75 SUBSYS 1200 MCG, 1600 SUPRENZA1 SOLARAZE90 MCG11 SUPREP BOWEL PREP122 SOLARCAINE ALOE EXTRA SUBSYS 400 MCG, 600 MCG, GEL97 800 MCG11 SURMONTIL33 SOLARCAINE ALOE VERA97 sucralfate161 SUSTIVA70 SOLBAR PF LIQUID/GEL SUDAFED143 SUTENT58 SPF30104 SUDAFED CHILDRENS143 SYLATRON59 SOLTAMOX56 SUDAFED SYMBYAX155 SOLU-CORTEF 100 MG, 250 CONGESTION143 SYMLINPEN 12033 MG, 500 MG84 SUDAFED NASAL SYMLINPEN 6033 SOLU-CORTEF 1000 MG84 DECONGESTANT MAXIMUM SOLU-MEDROL 1000 MG, 125 STRENGTH143 SYMPT-X G.I.146 MG, 40 MG84 SUDAFED PE CHILDRENS SYNAGIS 50 MG/0.5ML152 SOLVIL146 NASAL SYNALAR95 SOMA 350 MG142 DECONGESTANT143 SUDAFED PE SEVERE COLD SYNAREL110 SOMATULINE DEPOT111 MULTI-SYMPTOM86 SYNERCID18 SOMAVERT109 SULAR77 SYNRIBO60 SONATA120 sulfacetamide sod- SYNTHROID159 SORIATANE91 prednisolone149 SYPRINE73 sulfacetamide sodium sotalol hcl76 (acne)88 TABLOID54 sotalol hcl (afib/afl)76 sulfacetamide sodium tacrolimus (topical)96 Sotalol Hcl IV Soln76 (ophth)148 tacrolimus 0.5 mg, 1 mg, 5 SOTYLIZE76 sulfadiazine158 mg74 SOVALDI72 sulfamethoxazole-trimethoprim TAFINLAR58 16

Index 28 TAMIFLU73 testosterone enanthate14 TOBI3 tamoxifen citrate 10 mg, 20 TESTOSTERONE PUMP14 TOBI PODHALER3 mg56 TETANUS TOXOID TOBRADEX149 tamsulosin hcl116 ADSORBED159 tobramycin3 TARCEVA58 TETANUS/DIPHTHERIA tobramycin (ophth)148 TARGRETIN60 TOXOIDS-ADSORBED159 TETANUS/DIPHTHERIA tobramycin sulfate 1.2 gm4 TARSUM104 TOXOIDS-ADSORBED tobramycin sulfate 1.2 gm/30ml, TASIGNA58 ADULT159 40 mg/ml, 80 mg/2ml3 TASMAR62 tetrabenazine155 tobramycin sulfate 10 mg/ml3 TAXOL61 tetracycline hcl 250 mg, 500 tobramycin- mg159 TAXOTERE61 dexamethasone149 TEV-TROPIN109 TOBREX148 TAZORAC91 TEVETEN48 TEARS AGAIN NIGHT & TOFRANIL-PM33 DAY146 TGT LUBRICANT EYE tolazamide 250 mg39 DROPS147 TECFIDERA156 tolazamide 500 mg39 THALOMID73 TECFIDERA STARTER tolbutamide39 PACK156 theophylline 100 mg, 200 mg, 300 mg, 450 mg23 tolcapone62 TEFLARO 400 MG80 theophylline 400 mg, 600 tolmetin sodium 200 mg7 TEGRETOL27 mg23 tolmetin sodium 400 mg7 TEGRETOL-XR 100 MG27 THERACYS60 tolnaftate90 TEGRETOL-XR 200 MG, 400 THERAPLEX T104 tolterodine tartrate163 MG27 THERMOTABS134 TOPAMAX27 TEKTURNA50 thiamine hcl 100 mg, 50 TEKTURNA HCT49 mg167 TOPAMAX SPRINKLE27 temazepam120 thiamine mononitrate167 TOPICLEAR102 TEMODAR52 thioridazine hcl 10 mg, 100 mg, topiramate 100 mg, 200 mg, 25 mg, 50 mg27 TEMOVATE95 25 mg, 50 mg66 THIOTEPA53 topiramate 15 mg, 25 mg27 TEMOVATE E95 thiothixene68 topotecan hcl 4 mg62 TENEX48 THYMOGLOBULIN74 TOPOTECAN HCL 4 TENIVAC159 MG/4ML62 THYMOL81 TENORETIC 10049 TOPROL XL75 tiagabine hcl28 TENORETIC 5049 TORISEL58 TIAZAC77 TENORMIN75 torsemide 10 mg, 100 mg, 20 mg, TICE BCG60 TERAZOL 3165 5 mg107 ticlopidine hcl117 TOTECT61 TERAZOL 7165 TIGAN 100 MG/ML40 TOUJEO SOLOSTAR37 terazosin hcl48 TIKOSYN21 trace minerals (cr-cu-mn- terbinafine hcl42 timolol maleate (ophth)147 zn)136 terbinafine hcl (topical)90 TRACLEER78 TIMOPTIC147 terbutaline sulfate 2.5 mg, 5 TRADJENTA36 mg23 TIMOPTIC-XE147 tramadol hcl 100 mg12 terconazole vaginal165 TINACTIN90 tramadol hcl 200 mg, 300 TERSASEPTIC GLYCERINE TINACTIN JOCK ITCH90 mg12 CLEANSING102 TINDAMAX16 tramadol hcl 50 mg12 TESSALON PERLES84 tinidazole 250 mg, 500 mg16 tramadol-acetaminophen12 TESTIM13 tioconazole vaginal165 TESTOSTERONE 1 %, 25 TRANDATE75 MG/2.5GM, 50 MG/5GM14 TIVICAY70 trandolapril47 testosterone 25 mg/2.5gm, 50 tizanidine hcl 2 mg, 4 mg142 tranexamic acid 100 mg/ml120 mg/5gm14 tizanidine hcl 2 mg, 4 mg, 6 tranexamic acid 650 mg120 testosterone cypionate13 mg142

Index 29 TRANSDERM-SCOP40 TRUSOPT150 ULTRAM ER 100 MG12 TRANXENE T20 TRUVADA70 ULTRAM ER 200 MG, 300 tranylcypromine sulfate30 TRUZONE PEAK FLOW MG12 ULTRASWIM102 TRAVATAN Z150 METER130 TUCKS14 ULTRASWIM ULTRA trazodone hcl 100 mg, 150 mg, REPAIR102 300 mg, 50 mg31 TUCKS ANTI-ITCH95 ULTRAVATE95 TREANDA53 TUDORZA PRESSAIR21 UNASYN 1GM-2GM153 TRECATOR51 TUMS15 UNDELENIC TINCTURE90 TRELSTAR56 TUMS E-X 75015 UNIFIBER122 TRELSTAR MIXJECT56 TUMS KIDS15 UNIRETIC49 tretinoin (chemotherapy)60 TUMS LASTING UNIVASC47 tretinoin 0.01 %, 0.025 %88 EFFECTS15 tretinoin 0.025 %, 0.05 %, 0.1 TUMS SMOOTHIES15 UNIVERSAL PH STRIPS106 %88 TUSNEL 2MG-15MG- UNIVERSAL REMOVER tretinoin microsphere88 200MG86 WIPES102 TUSSIONEX PENNKINETIC urea 20 %95 TRI-VIT/FLUORIDE/IRON 139 EXTENDED RELEASE86 urea 25 %95 triamcinolone acetonide TWINRIX164 (mouth)137 URISTIX106 TYBOST70 triamcinolone acetonide URISTIX 4106 (nasal)143 TYGACIL17 URO-PREP PROTECTIVE triamcinolone acetonide (topical) TYKERB59 SKINWIPES102 0.025 %, 0.1 %95 TYLENOL CHILDRENS8 UROCIT-K 10115 triamcinolone acetonide (topical) 0.025 %, 0.1 %, 0.5 %95 TYLENOL CHILDRENS PLUS UROCIT-K 5115 TRIAMINIC COUGH & RUNNY COLD86 UROXATRAL116 NOSE43 TYLENOL CHILDRENS PLUS COLD & ALLERGY86 URSO 250113 TRIAMINO146 TYLENOL URSO FORTE113 triamterene & CHILDRENS/FLAVORCREAT ursodiol 250 mg, 500 mg113 hydrochlorothiazide107 OR8 triazolam121 TYLENOL INFANTS 160 ursodiol 300 mg113 TRICOR45 MG/5ML8 UVADEX60 trifluoperazine hcl66 TYLENOL INFANTS 80 VAGISIL164 MG/0.8ML8 VAGISTAT-1165 trifluridine148 TYLENOL JR MELTAWAYS8 TRIGLIDE45 valacyclovir hcl 1 gm, 1000 mg, TYPHIM VI163 500 mg72 trihexyphenidyl hcl62 tyrosine 500 mg146 VALCHLOR90 TRILEPTAL27 TYSABRI156 VALCYTE 450 MG71 TRILIPIX45 TYVASO78 valganciclovir hcl71 trimethobenzamide hcl 100 mg/ml41 TYVASO REFILL78 VALIUM20 trimethoprim16 TYVASO STARTER78 valproate sodium 100 mg/ml, 500 TYZEKA72 mg/5ml29 trimipramine maleate 100 mg, 25 valproate sodium 250 mg, 50 mg33 UCERIS 2 MG/ACT14 mg/5ml29 TRIMO-SAN164 ULCEREASE137 valproic acid29 triprolidine & pseudoephedrine ULTILET GLUCOSE35 0.938mg/ml-10mg/ml86 valsartan48 triprolidine & pseudoephedrine ULTRA DERM BATH OIL91 valsartan-hydrochlorothiazide 2.5mg-2.5mg-60mg-60mg, ULTRA MAN140 49 2.5mg-60mg86 ULTRA MIDE 2595 VALSTAR57 TRISENOX60 ULTRA WOMAN140 VALTREX72 VALVED HOLDING TRIUMEQ70 ULTRACET12 TRIZIVIR70 CHAMBER130 ULTRAM12 VANCOCIN HCL16 trospium chloride163

Index 30 vancomycin hcl 10 gm, 1000 mg, VIEKIRA PAK72 vitamins a & d 10000unit-400unit, 5000 mg16 VIGAMOX148 10000unit-5000unit, 1250unit- vancomycin hcl 125 mg, 250 133unit, 1250unit-135unit, mg16 VIIBRYD31 5000unit-400unit, 700unit- vancomycin hcl 500 mg16 VIIBRYD STARTER PACK31 400unit, 8000unit-400unit140 VANCOMYCIN HCL IN VIMIZIM110 vitamins w/ lipotropics 10000unit- DEXTROSE16 VIMPAT 10 MG/ML27 10mg-18mg-100unit-225mcg- VANICREAM102 10mg-150mg-100mg-30mg- VIMPAT 100 MG, 150 MG, 200 10mg-25mg-25mg-50mg-50mg- VANTAS56 MG, 50 MG27 10mg-50mg-50mg-200mcg- VAQTA164 VIMPAT 200 MG/20ML27 400unit-50mg-400mcg-50mg- VARIVAX164 vinblastine sulfate61 250mg, 100mg-100mg-100mg- VARIZIG152 vincristine sulfate61 100mcg-100mg-100mcg- vinorelbine tartrate61 100mcg-100mg, 100mg-100mg- VASCEPA44 100mg-100mg-100mg-100mg- VASERETIC49 VIRACEPT70 100mcg-100mg-100mcg- VASOTEC47 VIRAMUNE 200 MG70 100mcg-100mg, 100mg-100mg- VCF VAGINAL VIRAMUNE 50 MG/5ML70 100mg-100mg-100mg-100mg- CONTRACEPTIVE FILM165 VIRAMUNE XR 100 MG70 100mg-100mcg-100mcg- VCF VAGINAL 100mcg-100mg, 100mg-100mg- CONTRACEPTIVE FOAM165 VIRAMUNE XR 400 MG70 100mg-100mg-100mg-100mg- VECTIBIX55 VIRAZOLE73 100mg-100mcg-100mg-200mcg- VELCADE59 VIREAD 150 MG, 200 MG, 300 100mcg-100mg, 100mg- MG70 111.3mg-0.33mg-1.7mg-1.7mcg- venlafaxine hcl 100 mg32 VIREAD 250 MG71 0.33mg-111.3mg-3.3mg-0.33mg- venlafaxine hcl 150 mg32 VIREAD 40 MG/GM70 100mg, 100mg-12.5mg-100mg- 100mg-12.5mg-12.5mg-100mg- venlafaxine hcl 25 mg32 VIROPTIC148 venlafaxine hcl 37.5 mg32 100mcg-100mcg-100mcg- VISINE-LR148 100mg, 100mg-43.33mg- venlafaxine hcl 50 mg32 VISTARIL19 111.3mg-0.33mg-1.7mg-1.7mcg- venlafaxine hcl 75 mg32 VISTIDE71 0.33mg-111.3mg-3.3mg-0.33mg- VENLAFAXINE HCL ER32 VITALINE COQ10/VITAMIN E 100mg, 200mg-29mg-0.333mg- VENTAVIS78 100MG-300UNIT3 1.666mg-3.33mg-111.333mg- 111.333mg-1mg-1.666mcg- verapamil hcl 100 mg, 120 mg, vitamin a 10000 unit166 0.333mg-100mg, 200mg-29mg- 180 mg, 200 mg, 240 mg, 300 VITAMIN A 10000UNIT- 0.33mg-1.67mg-3.33mg- mg, 360 mg77 1000UNIT166 111.33mg-111.33mg-1mg- verapamil hcl 120 mg, 180 mg, VITAMIN A 25000 UNIT166 240 mg77 1.67mcg-0.33mg-100mg, 200mg- verapamil hcl 120 mg, 40 mg, 80 vitamin a 8000 unit166 29mg-0.34mg-1.67mg-3.34mg- mg77 VITAMIN B12/FOLIC 111mg-111mg-1mg-1.67mcg- VERELAN77 ACID119 0.34mg-100mg, 20mg-50mg- vitamin e (topical) 100 30mg-10mg-10mcg-30mg-8mg, VERELAN PM77 unit/5drop, 12000 unit, 20000 25mg-40mg-20mg-3.4mg-20mg- VERSACLOZ66 unit, 28000 unit, 28000 12mcg-3mg-20mg-400mcg- VFEND 200 MG, 50 MG42 unit/29ml, 400 unit/ml, 4000 30mcg-4mg-150mg, 25mg-40mg- VFEND IV42 unit, 49000 unit/52ml, 933.333 20mg-3.4mg-20mg-12mcg-3mg- unit/ml96 20mg-400mg-30mcg-4mg, VIBRAMYCIN 100 MG159 vitamin e (topical) 1000 unit, 266.141 VIBRAMYCIN 25 MG/5ML159 1500 unit/30gm, 30000 VITEKTA71 VICKS BABYRUB97 unit/60gm, 6000 unit96 VOGELXO14 vitamin e 100 unit166 VICOPROFEN12 VOGELXO PUMP14 vitamin e 1000 unit166 VICTOZA36 VOLTAREN88 vitamin e 15 unit/0.3ml166 VICTRELIS72 VOLTAREN-XR7 vitamin e 400 unit/15ml166 VIDAZA54 voriconazole 200 mg42 VIDEX EC70 voriconazole 200 mg, 50 mg42 VIDEXPEDIATRIC70

Index 31 VORTEX VALVED HOLDING XPHE MAXAMUM 153MG- ZEGERID 40MG-1100MG162 CHAMBER130 280MG-41MCG-1114UNIT- ZELBORAF59 VOSOL HC151 29MCG-13MCG-0.9MG- ZEMAIRA157 VOTRIENT59 410MCG-4.5MG-569MG- 7.4MG-9.2UNIT-18.5MCG- ZEMPLAR 1 MCG, 2 MCG, 4 VPRIV117 65.5MCG-592MG-280MG- MCG110 WALGREENS GLUCOSE 4 350MG-2.9MG-40MG-215MG- ZERIT71 GM35 0.49MG-2.5MG-1.6MCG- ZESTORETIC49 warfarin sodium24 166UNIT-0.46MG-246MCG- ZESTRIL47 WATCHHALER130 12.3MCG-0.8MG-31MG, ZETIA46 water for irrigation, sterile75 153MG-280MG-41MCG- 29MCG-13MCG-0.9MG- ZIAC50 WELCHOL44 410MCG-4.5MG-569MG- ZIAGEN 20 MG/ML71 WELLBUTRIN 100 MG29 7.4MG-9.2UNIT-18.5MCG- ZIAGEN 300 MG71 WELLBUTRIN 75 MG29 65.5MCG-592MG-280MG- zidovudine71 WELLBUTRIN SR 100 MG30 350MG-1114UNIT-2.9MG- ZILACTIN136 WELLBUTRIN SR 150 MG, 200 40MG-215MG-0.49MG-2.5MG- MG30 1.6MCG-166UNIT-0.46MG- ZINACEF 1.5 GM, 7.5 GM79 WELLBUTRIN XL 150 MG30 246MCG-12.3MCG-0.8MG- ZINACEF 750 MG79 31MG 146 136 WELLBUTRIN XL 300 MG30 XTANDI56 ZINC 15 136 WESTCORT95 XYLOCAINE 1 %, 2 %123 zinc 25 mg 136 WFHC PH PAPER106 XYLOCAINE 4 %97 zinc 50 mg 136 WHEAT GERM166 XYLOCAINE-MPF 1 %123 zinc gluconate 10 mg 136 witch hazel-glycerin102 XYREM154 zinc gluconate 50 mg WOUND WASH SALINE103 ZINC SULFATE 1 MG/ML, 5 XYZAL43 MG/ML136 XALATAN150 YASMIN 2882 ZINECARD61 XALKORI59 YAZ82 ziprasidone hcl64 XANAX20 YERVOY55 ZITHROMAX 100 MG/5ML, 200 XANAX XR20 YF-VAX164 MG/5ML124 ZITHROMAX 250 MG, 500 MG, XARELTO24 YODORA DEODORANT98 XARELTO STARTER PACK24 600 MG124 YONDELIS53 ZITHROMAX 500 MG124 XELJANZ4 ZADITOR150 ZITHROMAX TRI-PAK124 XENAZINE155 zafirlukast21 ZITHROMAX Z-PAK124 XEOMIN144 zaleplon121 ZOCOR 10 MG45 XGEVA108 ZALTRAP54 ZOCOR 20 MG46 XIFAXAN16 ZANAFLEX142 ZOCOR 40 MG46 XIZFLUS106 ZANOSAR53 ZOCOR 5 MG46 XOLAIR21 ZANTAC 15 MG/ML161 ZOCOR 80 MG46 XOPENEX23 ZANTAC 150 MG161 ZOFRAN 4 MG, 8 MG40 XOPENEX CONCENTRATE23 ZANTAC 300 MG161 ZOFRAN 4 MG/5ML40 ZANTAC 75161 ZOFRAN 40 MG/20ML40 ZARONTIN28 ZOFRAN ODT40 ZAROXOLYN108 ZOHYDRO ER 10 MG, 15 MG, ZARXIO118 20 MG, 30 MG, 40 MG, 50 ZAVESCA117 MG12 ZEBETA76 ZOLADEX56 ZEGERID 20MG- zoledronic acid 4 mg108 1100MG162 zoledronic acid 4 mg/5ml108 ZEGERID 20MG- zoledronic acid 5 mg/100ml108 1680MG162

Index 32 ZOLINZA59 zolmitriptan 2.5 mg131 zolmitriptan 5 mg131 ZOLOFT31 zolpidem tartrate 10 mg121 zolpidem tartrate 12.5 mg121 zolpidem tartrate 5 mg121 zolpidem tartrate 6.25 mg121 ZOMACTON 5 MG109 ZOMETA 4 MG/5ML109 ZOMIG 2.5 MG131 ZOMIG 5 MG132 ZOMIG ZMT 2.5 MG132 ZOMIG ZMT 5 MG132 ZONEGRAN28 zonisamide28 ZONTIVITY117 ZORTRESS74 ZOSTAVAX164 ZOSYN 0.25GM-2GM, 0.375GM- 3GM, 0.5GM-4GM, 4.5GM- 36GM153 ZOSYN 0.5GM/100ML- 4GM/100ML-5% 153 ZOVIRAX 200 MG72 ZOVIRAX 200 MG/5ML72 ZOVIRAX 400 MG, 800 MG73 ZOVIRAX 5 %91 ZYBAN157 ZYCLARA96 ZYCLARA PUMP96 ZYDELIG59 ZYKADIA59 ZYLOPRIM 100 MG116 ZYLOPRIM 300 MG116 ZYMAXID148 ZYPREXA66 ZYPREXA RELPREVV 210 MG66 ZYPREXA ZYDIS66 ZYTIGA56 ZYVOX 100 MG/5ML18 ZYVOX 2 MG/ML18 ZYVOX 600 MG18

Index 33 Ini-update ang listahan ng gamot na ito noong 12/1/2015 . Kung mayroon kayong mga katanungan, mangyaring tawagan ang Health Net Cal MediConnect sa 1-855-464-3571 para sa Los Angeles County o sa 1-855-464-3572 para sa San Diego County, TTY: 711, 24 oras bawat araw, 7 araw bawat linggo. Libre ang tawag. Para sa karagdagang impormasyon, pumunta sa www.healthnet.com/calmediconnect.

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