Medicaid Approved Formulary Drug List

Effective August 1, 2014

Introduction The Anthem Blue Cross Medicaid Managed Care Approved Formulary Drug List is a list of drugs covered under your benefit. These are commonly prescribed Food and Drug Administration (FDA)-approved drugs chosen by Anthem Blue Cross for their value and effectiveness. Select drugs may require prior authorization. Anthem Blue Cross’ Medicaid Managed Care Approved Formulary Drug List is updated quarterly and is subject to change without prior notification. To check for regular updates to the formulary, please visit us on the web at www.anthem.com. Alternatively, you can contact the Customer Service Center at the number listed on your Anthem Blue Cross ID card. We encourage you to share this drug list with your doctor.

Anthem Blue Cross is the trade name of Blue Cross of California and Anthem Blue Cross Partnership Plan is the trade name of Blue Cross of California Partnership Plan, Inc. Independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. WellPoint NextRx is a service mark of WellPoint, Inc. Services are provided by a WellPoint PBM. WellPoint NextRx is a division of WellPoint, Inc. WEB-ACA-0022-14 10.14 Brand name vs. generics A brand-name drug is one that is developed, patented and marketed by the original drug manufacturer. Until the patent expires, no other companies can produce that same particular brand-name drug. A generic drug has the same active ingredients as its brand-name counterpart. A generic drug may be manufactured by various drug companies after the original patent expires. A generic drug is identical to the brand-name drug in dosage form, strength, route of administration, quality and intended uses. Generics may differ from their brand-name equivalent in color and/or shape. Both brands and generics have to meet the same strict safety, purity and performance standards governed by the Food and Drug Administration (FDA). Quantity supply limit Quantity supply limit is the maximum amount of a drug that a pharmacy can dispense at a given time. The Anthem Blue Cross PDL adheres to FDA-approved dosing guidelines. If a prescribing provider feels that a quantity supply greater than the defined maximum is medically necessary, then we direct the prescriber to submit a prior authorization request detailing the need for exceeding the recommended quantity. Prior authorization The prior authorization program is designed to encourage appropriate use of medications. Drugs that require prior authorization are generally those that are either part of a step therapy regimen, have a high side effect potential, should be reserved for specific FDA indication, have high misuse or abuse potential, or have lower cost alternatives. Brand-name drugs with generic equivalents available require prior authorization to encourage utilization of appropriate generic alternatives as first line therapies. Prior to prescribing any brand name medications, physicians are encouraged to consider using its preferred generic alternative.

Select medications on the PDL may require prior authorization. If a medication requires prior authorization, a Prior Authorization form needs to be completed by the prescriber for submission to Anthem Blue Cross. To obtain a prior authorization form and a list of drugs which require prior authorization, please go to the website, www.anthem.com. Alternatively, you can contact Customer Care at 1-800-338-6180 for more information. Narrow therapeutic drugs Certain medications require that a physician carefully monitor the dosage to achieve optimal effect while preventing adverse side effects. For these select few drugs, the recommendation is to not switch between the brand and generic version of the drug.

The following is a list of narrow therapeutic index drugs:

Armour Thyroid Elixophyllin Lithobid Tirosint Carbatrol, -ER Epitol Myfortic Topamax (all forms) CellCept Equetro Mysoline Topiragen Cerebyx Gengraf Nature-Throid Trileptal Clozaril Hecoria Neoral Unithroid Cordarone Jantoven NP Thyroid Westhroid Coumadin Keppra, -XR Phenytek WP Thyroid Depacon Lamictal (all forms) Prograf Zarontin Depakene Lanoxin Sandimmune Zonegran Depakote, -ER Levothroid Stavzor Diastat Levothyroxine Synthroid Dilantin Levoxyl Tegretol, -XR

The Anthem Blue Cross pharmacy benefit will provide coverage for these brand-name medications for Anthem Blue Cross members currently receiving the brand-name medication.

2 How to use this guide The Anthem Blue Cross PDL lists the brand name or common name of a given drug. If a medication does not appear on this PDL, the medication will require prior authorization to be covered under the pharmacy benefit. A prior authorization form will need to be completed by the prescriber and submitted to Anthem Blue Cross before the prescription may be filled. To obtain a prior authorization form, please go to the website, www.anthem.com. Alternatively, you can contact Customer Care at 1-800-338-6180 for more information. Contact information If you have questions about the Anthem Blue Cross PDL, please contact Customer Care at 1-800-338-6180, or fax at 1-800-601-4829 for more information. Hours of operation are Monday through Friday 8 a.m.–9 p.m., and Saturday and Sunday 8 a.m. to 6 p.m. In addition, regular updates to the PDL are available by visiting www.anthem.com. .

Legend In each class, drugs are alphabetically listed by active ingredient. If only the word ‘generic’ appears within the parenthesis, only the generic is on Formulary. Example: Cefaclor (generic) means that the generic Cefaclor is covered and the brand is not covered. If the word ‘generic’ does not appear within the parentheses, the active ingredient is only available as a brand and is on Formulary. The drug name in parentheses is the brand name. Example: Levofloxacin (Levaquin) means that the brand Levaquin is covered and there is no generic available. Levaquin is the brand name. If the word ‘generic’ and the brand name both appear within the parentheses, both the generic and the brand-name drugs are on Formulary. Example: Warfarin (Coumadin/generic) means that both the brand and generic are available. Therefore, the brand Coumadin and the generic Warfarin are covered.

Contents Lincosamides ...... 5 Hyperglycemics ...... 5 Chemotherapeutics, Antibacterial, Miscellaneous Hypoglycemics, Biguanide Type ...... 5 Penicillins ...... 5 (PA Required) ...... 5 Hypoglycemics, Alpha-Glucosidase Inhib Type . . 6 Cephalosporins — 1st Generation ...... 5 Absorbable Sulfonamides ...... 5 Dipeptidyl Peptidase — Iv Inhib and Combos Cephalosporins — 2nd Generation ...... 5 Antineoplastic/Immunosuppresant Drugs (PA (ST Required) ...... 6 Cephalosporins — 3rd Generation ...... 5 Required) ...... 5 Hypoglycemics, Insulin — Macrolides ...... 5 Antineoplastic Lhrh (GnRH) Agonist, Pituitary Suppr . Response Enhancer ...... 6 Tetracyclines ...... 5 (PA Required) ...... 5 Blood Sugar Diagnostics ...... 6 Quinolones ...... 5 Glucocorticoids ...... 5 Diabetic Supplies ...... 6 Aminoglycosides ...... 5 Mineralocorticoids ...... 5 Thyroid Hormones ...... 6 Antimycobacterium Agents ...... 5 Androgenic Agents (PA Required) ...... 5 Antithyroid Preparations ...... 6 Antifungal Antibiotics ...... 5 Estrogenic Agents ...... 5 Oxytocics ...... 6 Antivirals, HIV-Specific ...... 5 Estrogen/Androgen Combinations ...... 5 Bone Resorption Inhibitors ...... 6 Antivirals, General ...... 5 Progestational Agents ...... 5 Growth Hormones (PA Required) ...... 6 Hepatitis B Treatment Agents (PA Required) . . 5. Contraceptives ...... 5 Somatostatic Agents (PA Required) ...... 6 Treatment Agents (PA Required) . . 5. Insulins ...... 5 Pituitary Suppressive Agents ...... 6 Plasmocides ...... 5 Antihyperglycemic, Amylin Analog-Type Antidiuretic and Vasopressor Hormones Amebacides ...... 5 (PA Required) ...... 5 (PA Required) ...... 6 Anthelmintics ...... 5 Antihypergly, Incretin Mimetic (GLP-1 Recep . Metabolic Deficiency Agents ...... 6 Anaerobic Antiprotozoal Agonist) (PA Required) ...... 5 Digitalis Glycosides ...... 6 Antibacterial Agents ...... 5 Hypoglycemics, Insulin — Release Vasodilators, Coronary ...... 6 Vancomycin and Derivatives ...... 5 Type ...... 5 Beta-Adrenergic Blocking Agents ...... 6

3 Alpha/Beta-Adrenergic Blocking Agents . . . . . 6 Alpha-2 Receptor Antagonist Antidepressants . . 7 Eye Antibiotic-Corticoid Combinations ...... 8 Calcium Channel Blocking Agents ...... 6 Serotonin-2 Antagonist/Reuptake Inhibitors Eye Antivirals ...... 8 Antiarrhythmics ...... 6 (SARIs) ...... 7 Artificial Tears ...... 8 Hypotensives, Ace Inhibitors, Combinations . . . 6 Mao Inhibitors ...... 7 Eye Vasoconstrictors (Rx Only) ...... 8 Hypotensives, Angiotensin Receptor Selective Serotonin Reuptake Inhibitor (SSRIs) 7 Eye Vasoconstrictors (OTC Only) ...... 8 Antagonist ...... 6 Serotonin-Norepinephrine Reuptake — Inhib Eye Local Anesthetics ...... 8 Hypotensives, Sympatholytic ...... 6 (SNRIs) ...... 7 Eye Antihistamines ...... 8 Drugs For Pheochromocytoma ...... 6 Tricyclic Antidepressants and Rel . Non-Sel . Ophthalmic Mast Cell Stabilizers ...... 9 Alpha-Adrenergic Blocking Agents ...... 6 Ru-Inhib ...... 7 Eye Anti-Inflammatory Agents ...... 9 Hypotensives, Vasodilators ...... 6 Norepinephrine and Reuptake Inhib Otic Preparations, Miscellaneous, Ace Inhibitor/Calcium Channel Block (NDRIs) ...... 7 Anti-Infectives ...... 9 Combination ...... 6 , Atypical ...... 7 Otic Preparations, Anti-Inflammatory — Hypotensives, Miscellaneous ...... 6 Antipsychotics, Typical ...... 7 Antibiotics ...... 8 Loop Diuretics ...... 6 / Otic Preparations, Local Anesthetics ...... 9 Potassium Sparing Diuretics ...... 6 Combinations ...... 7 Otic Preparations, Antibiotics ...... 9 Thiazide and Related Diuretics ...... 6 Tricyclic Antidepressant/Benzodiazepine Fluoride Preparations ...... 9 Adrenergic Vasopressor ...... 6 Combinations ...... 7 Periodontal Collagenase Inhibitors ...... 8 Anaphylaxis Therapy Agents ...... 6 Antimania Drugs ...... 7 Dental Aids and Preparations ...... 9 Lipotropics ...... 6 ...... 7 Hemorrhoidal Preparations ...... 9 ...... 6 Sedative-Hypnotics, Nonbarbiturates ...... 7 Vitamin A Derivatives (PA Required) ...... 9 Vasodilating Drugs (PA Required) ...... 6 Tx for Attention Deficit–Hyperact (ADHD)/ Keratolytics ...... 9 Antihistamines ...... 6 Narcolepsy ...... 7 Acne Agents, Systemic (PA Required) ...... 9 Expectorants ...... 6 Cholinesterase Inhibitors ...... 7 Acne Agents, Topical ...... 9 Nasal Anti-Inflammatory Steroids ...... 6. Smoking Deterrent Agents ...... 7 Rosacea Agents, Topical ...... 9 Nasal Antihistamine ...... 6 Drugs to Treat Multiple Sclerosis (PA Required) 8 Topical Antibiotics ...... 9 Antihistamine and Decongestant Antagonist ...... 8 Topical Antifungals ...... 9 Combinations ...... 6 Analgesic/Antipyretics, Salicylates ...... 8 Antipsoriatic Agents ...... 9 Decongestant – Expectorant Combinations Analgesic/Antipyretics, Nonsalicylate ...... 8 Topical Antivirals ...... 9 (PA Required Age < 2) ...... 6 Analgesics, Narcotics ...... 8 Topical Antineoplastic and Premaligant . . . . . 9 General Inhalation Agents ...... 6 Narcotic Antagonists ...... 8 Topical Anti-Inflammatory Non-narcotic Antitussive Combinations Nsaids, Cyclooxygenase Inhibitor — Type . . . . 8 Steroidal Agents ...... 9 (PA Required for Age < 2) ...... 6 Anti-Inflammatory Tumor Necrosis Factor Topical Agents, Miscellaneous ...... 9 Narcotic Antitussive Combinations Inhibitor ...... 8 Topical Immunomodulators (PA Required) . . . . 9 (PA Required Age < 2) ...... 6 Anti-Inflammatory, Pyrimidine Synthesis Topical Anesthetics ...... 9 General Bronchodilator Agents ...... 7 Inhibitor ...... 8 Topical Antiparasitics ...... 9 Mast Cell Stabilizers ...... 7 Antiarthritic, Folate Antagonist Agents . . . . . 8 Antiseptics, General ...... 9 Beta-Adrenergic Agents ...... 7 Hyperuricemia Tx — Purine Inhibitors ...... 8 Condoms ...... 9 Beta-Adrenergic Combination Agents ...... 7 Uricosuric Agents ...... 8 Diaphragms/Cervical Cap ...... 9 Inhaled Corticosteroids ...... 7 Urine Glucose Test Aids ...... 8 Needles/Needleless Devices ...... 9 Beta-Adrenergics and Glucocorticoids Colchicine ...... 8 Syringes and Accessories ...... 9 Combinations ...... 7 Anticonvulsants ...... 8 Respiratory Aids, Devices, Equipment ...... 9 Leukotriene Receptor Antagonists ...... 7 Antiparkinsonism Drugs, . . . . . 8 Rubber Syringes ...... 9 Immunoglobulin Antibodies (PA Required) . . . . 7 Antiparkinsonism Drugs, Other ...... 8 Immunosuppressants ...... 9 Methylxanthines ...... 7 Skeletal Muscle Relaxants ...... 8 Laxatives and Cathartics ...... 7 Other CNS/Autonomic Drugs ...... 8 Antidiarrheals ...... 7 Vitamin B1 Preparations ...... 8 Antacids ...... 7 Vitamin B6 Preparations ...... 8 Antispasmodics ...... 7 Vitamin B12 Preparations ...... 8 Gastric Acid Secretion Reducers ...... 7 Folic Acid Preparations ...... 8 Antiemetic/Antivertigo Agents ...... 7 Iron Replacement ...... 8 Pancreatic Enzymes ...... 7 Vitamin D Preparations ...... 8 Bile Salts ...... 7 Pediatric Vitamin Preparations ...... 8 Antiflatulents ...... 7 Prenatal Vitamin Preparations ...... 8 Intestinal Motility ...... 7 Calcium Replacement ...... 8 Drug Tx-Chronic Inflam . Colon Dx, Vitamin K Preparations ...... 8 5-Aminosalicylat ...... 7 Replacement ...... 8 Blood Detoxicants ...... 7 Potassium Replacement ...... 8 Parasympathetic Agents ...... 7 Electrolyte Replacement ...... 8 Urinary Tract Antispasmodic/ Hematinics, Other ...... 8 Anti-Incontinence Agent ...... 7 Heparin and Related Preparations ...... 8 Vaginal Antibiotics ...... 7 Oral Anticoagulants, Coumarin Type ...... 8 Vaginal Antifungals ...... 7 Antifibrinolytic Agents ...... 8 Vaginal Estrogen Preparations ...... 7 Platelet Aggregation Inhibitors ...... 8 Urinary pH Modifiers ...... 7 Hemorrheologic Agents ...... 8 Urinary Tract Anesthetic/Analgesic Agent . . . . 7 Platelet Reducing Agents ...... 8 Benign Prostatic Hypertrophy/Micturition Agents Miotics/Other Intraoc . Pressure Reducers . . . .8 (PA Required) ...... 7 Mydriatics ...... 8 Antianxiety Drugs ...... 7 Ophthalmic Antibiotics ...... 8

4 PENICILLINS Atripla AMEBACIDES Prednisolone Amoxicillin Complera Atovaquone Prednisone Amoxicillin Clavulanate, -ER Crixivan Tinidazole Ampicillin Didanosine Yodoxin MINERALOCORTICOIDS Dicloxacillin Edurant Fludrocortisone Penicillin VK Emtriva ANTHELMINTICS Epzicom Mebendazole ANDROGENIC AGENTS (PA REQUIRED) CEPHALOSPORINS — 1ST GENERATION Fuzeon Reese Pinworm Androderm Cefadroxil Intelence Testim Cephalexin Invirase ANAEROBIC ANTIPROTOZOAL Isentress ANTIBACTERIAL AGENTS ESTROGENIC AGENTS CEPHALOSPORINS — 2ND GENERATION Kaletra Metronidazole Estradiol Cefaclor, -ER Lamivudine, -Zidovidine Estropipate Cefdinir Lexiva VANCOMYCIN AND DERIVATIVES Femhrt Cefpodoxime Nevirapine, -ER Vancomycin (PA Required) Jinteli Cefprozil Norvir Menest Cefuroxime Prezista Premarin Rescriptor LINCOSAMIDES Clindamycin Premphase CEPHALOSPORINS — 3RD GENERATION Reyataz Prempro Selzentry Ceftibuten CHEMOTHERAPEUTICS, Xulane Ceftriaxone Stavudine Stribild ANTIBACTERIAL, Sustiva MISCELLANEOUS (PA REQUIRED) ESTROGEN/ANDROGEN OXAZOLIDINONE Tivicay Dapsone COMBINATIONS Zyvox Trizivir Methenamine Covaryx/H .S . Truvada Nitrofurantoin Eemt/H .S . MACROLIDES Viracept Essian/H .S . Azithromycin Viramune XR ABSORBABLE SULFONAMIDES Estradiol/Norethindrone Clarithromycin Viread Sulfadiazine Nuvaring Erythromycin-Sulfisox Zidovudine Sulfacetamide Sulfamethoxazole/Tmp PROGESTATIONAL AGENTS TETRACYCLINES ANTIVIRALS, GENERAL Sulfasalazine All oral generics Demeclocycline Acyclovir Doxycycline ANTINEOPLASTIC/ CONTRACEPTIVES Famciclovir IMMUNOSUPPRESANT DRUGS All oral generics Tetracycline Ganciclovir (PA REQUIRED) Relenza Alkeran INSULINS QUINOLONES Anastrozole Apidra Ciprofloxacin Tamiflu Bicultamide Humulin Levofloxacin Valacyclovir (PA Required) Cyclophosphamide Lantus Ofloxacin Valcyte Emcyt Novolin Etoposide AMINOGLYCOSIDES HEPATITIS B TREATMENT AGENTS Flutamide ANTIHYPERGLYCEMIC, AMYLIN (PA REQUIRED) Gleevec ANALOG-TYPE (PA REQUIRED) Tobramycin Adefovir Hexalen Symlin, Symlin Pen Baraclude Hydroxyurea Epivir HBV Letrozole ANTIHYPERGLY, INCRETIN MIMETIC ANTIMYCOBACTERIUM AGENTS Tyzeka Leucovorin (GLP-1 RECEP. AGONIST) Ethambutol Leuprolide (PA REQUIRED) Isoniazid HEPATITIS C TREATMENT AGENTS Leukeran Bydureon Mycobutin (PA REQUIRED) Megestrol Byetta Pyrazinamide Incivek Mercaptopurine Rifabutin Infergen Mesnex HYPOGLYCEMICS, INSULIN — RELEASE Rifampin, -INH/Pyraz Olysio Methotrexate STIMULANT TYPE Sulfadiazine Pegasys Myleran Glimepiride Pegintron Paregoric Glipizide, -ER, -XL, -metformin ANTIFUNGAL ANTIBIOTICS Tamoxifen Glyburide, -metformin Fluconazole Sovaldi Tretinoin Nateglinide Flucytosine Victrelis Tolazamide Griseofulvin ANTINEOPLASTIC LHRH (GNRH) Itraconazole (PA required) PLASMOCIDES AGONIST, PITUITARY SUPPR. HYPERGLYCEMICS Ketoconazole Chloroquine (PA REQUIRED) Glucagon Nystatin Daraprim Leuprolide Glucose Terbinafine (PA Required) Hydroxychloroquine Voriconazole (PA Required) Mefloquine GLUCOCORTICOIDS HYPOGLYCEMICS, BIGUANIDE TYPE Primaquine Cortisone Metformin, -ER ANTIVIRALS, HIV-SPECIFIC Quinine Dexamethasone Abacavir, -Lamiv/Zidov Hydrocortisone Aptivus Methylprednisolone 5

5 HYPOGLYCEMICS, ALPHA- METABOLIC DEFICIENCY AGENTS Guanfacine ANTIHISTAMINES GLUCOSIDASE INHIB TYPE Calcitriol , -Hctz Clemastine Acarbose Levocarnitine Reserpine Dexchlorpheniramine DIPEPTIDYL PEPTIDASE — IV INHIB DIGITALIS GLYCOSIDES ALPHA-ADRENERGIC BLOCKING AND COMBOS (ST REQUIRED) Digoxin AGENTS Fexofenadine Januvia Doxazosin Loratadine Janumet, -XR VASODILATORS, CORONARY Prazosin Kombiglyze XR Isosorbide Terazosin EXPECTORANTS Onglyza Nitroglycerin Guaifenesin HYPOTENSIVES, VASODILATORS HYPOGLYCEMICS, INSULIN — BETA-ADRENERGIC BLOCKING AGENTS Hydralazine, -Hctz NASAL ANTI-INFLAMMATORY RESPONSE ENHANCER Acebutolol Minoxidil STEROIDS Avandamet Atenolol Flunisolide Avandaryl Betaxolol ACE INHIBITOR/CALCIUM CHANNEL Fluticasone Avandia Bisoprolol BLOCK COMBINATION Ipratropium Pioglitazone, -metformin, Metoprolol Amlodipine/Benazepril glimepiride Nadolol Trandalopril/Verapamil NASACORT ALLERGY (OTC) NASAL Pindolol ANTIHISTAMINE BLOOD SUGAR DIAGNOSTICS Propranolol HYPOTENSIVES, MISCELLANEOUS Cromolyn TrueTest Sotalol Atenolol-Chlorthal Azelastine Timolol Bisoprolol/Hctz DIABETIC SUPPLIES Methyldopa/Hctz ANTIHISTAMINE AND DECONGESTANT Lancets ALPHA/BETA-ADRENERGIC BLOCKING Metoprolol/Hctz COMBINATIONS Lancet Device AGENTS Propranolol/Hctz Brompheniramine-Pse Control Solution Carvedilol Carbinoxamine Labetalol LOOP DIURETICS Fexofenadine-D (PA Required) THYROID HORMONES Levocetirizine-D Armour Thyroid CALCIUM CHANNEL BLOCKING Loratadine-D Levothroid AGENTS Torsemide Phenyleph-Bromphe Levothyroxine Amlodipine Phenylephrine Levoxyl Diltiazem POTASSIUM SPARING DIURETICS Pseudoephedrine Liothyronine Felodipine Amiloride, Amiloride/Hctz Nature Throid Isradipine Spironolactone, -Hctz DECONGESTANT — EXPECTORANT NP Throid Nicardipine Triamterene/Hctz COMBINATIONS (PA REQUIRED Synthroid Nifedipine AGE < 2) Unithroid Verapamil THIAZIDE AND RELATED DIURETICS Guaifen/Phenylephrine Westhroid Chlorothiazide Pseudoephedrine WP Throid ANTIARRHYTHMICS Chlorthalidone Pseudoephedrine-Guaifen Amiodarone Hctz ANTITHYROID PREPARATIONS Disopyramide Indapamide GENERAL INHALATION AGENTS Methimazole Flecainide Methyclothiazide Broncho Saline Propylthiouracil Mexiletine Metolazone Mucolytics Quinidine Pulmozyme (PA Required) OXYTOCICS Propafenone ADRENERGIC VASOPRESSOR Water for Inhalation Methylergonavine Midodrine HYPOTENSIVES, ACE INHIBITORS, NON-NARCOTIC ANTITUSSIVE BONE RESORPTION INHIBITORS COMBINATIONS ANAPHYLAXIS THERAPY AGENTS COMBINATIONS (PA REQUIRED Alendronate Benazepril, Benazepril/Hctz Epipen, -JR FOR AGE < 2) Calcitonin Captopril, Captopril/Hctz Twinject -Cp-Phenyl Fortical Enalapril, Enalapril/Hctz D- Raloxifene Fosinopril Fosinopril/Hctz LIPOTROPICS Dmethorphan-Pe-Chlorphenir Lisinopril, Lisinopril/Hctz Atorvastatin Carbetapentane-Chlorphenir GROWTH HORMONES (PA REQUIRED) Moexipril, Moexipril/Hctz Cholestyramine Guaife-Dextromethorphan Omnitrope Quinapril, Quinapril/Hctz Colestipol Hydrocodone-Homatropine Norditropin Ramipril Fenofibrate Phenylephrine Tev-Tropin Trandalopril Gemfibrozil -DM Lovastatin SOMATOSTATIC AGENTS (PA HYPOTENSIVES, ANGIOTENSIN Niacin NARCOTIC ANTITUSSIVE REQUIRED) RECEPTOR ANTAGONIST Niacinamide COMBINATIONS (PA REQUIRED Octreotide Candesartan, -/Hctz Pravastatin AGE < 2) Irbesartan, -/Hctz Simvastatin Brompheniramine-Hydroc-Pse PITUITARY SUPPRESSIVE AGENTS Losartan, -/Hctz Guaifenesin/Codeine Valsartan, -/Hctz VASODILATING DRUGS (PA REQUIRED) Hydrocodone/Guaifenesin Adcirca Hydrocod/Phenyle/Cp Phenyleph/Hcod ANTIDIURETIC AND VASOPRESSOR HYPOTENSIVES, SYMPATHOLYTIC Sildenafil Clonidine Hydrocodone Cp HORMONES (PA REQUIRED) Hydrocodone Hd Desmopressin Guanabenz 6 Promethazine/Codeine

6 GENERAL BRONCHODILATOR AGENTS ANTISPASMODICS Nystatin NOREPINEPHRINE AND DOPAMINE Atrovent HFA Dicyclomine Terconazole REUPTAKE INHIB (NDRIS) Ipratopium bromide Glycopyrrolate Bupropion, SR Spiriva Hyoscyamine-Propantheline VAGINAL ESTROGEN PREPARATIONS Premarin ANTIPSYCHOTICS, ATYPICAL MAST CELL STABILIZERS GASTRIC ACID SECRETION REDUCERS Abilify (PA Required) Cromolyn Famotidine URINARY PH MODIFIERS Famot/Calcium Carb/Mag Potassium Citrate BETA-ADRENERGIC AGENTS Misoprostol (PA Required) , -ODT Albuterol Nizatidine URINARY TRACT ANESTHETIC/ Metaproterenol Pantoprazole ANALGESIC AGENT , -ODT ProAir HFA Prevacid 24 hr Phenazopyridine Serevent Terbutaline Ranitidine Ventolin HFA Sucralfate BENIGN PROSTATIC HYPERTROPHY/ ANTIPSYCHOTICS, TYPICAL MICTURITION AGENTS (PA BETA-ADRENERGIC COMBINATION ANTIEMETIC/ANTIVERTIGO AGENTS REQUIRED) AGENTS Dronabinol (PA Required) Alfuzosin Atrovent HFA Meclizine Finasteride Moban Combivent Respimat Ondansetron Tamsulosin Ipratropium, -Albuterol Promethazine (PA Required for ages < 2) ANTIANXIETY DRUGS Thioridazine INHALED CORTICOSTEROIDS Prochlorperazine Alprazolam Thiothixene Asmanex Flovent (Budesonide Respules (PA Chlordiazepoxide Required age > 5 years) PANCREATIC ENZYMES Clorazepate TRICYCLIC ANTIDEPRESSANT/ Pulmicort Flexhaler QVAR Creon Diazepam PHENOTHIAZINE COMBINATIONS Lactase w/Perphenazine BETA-ADRENERGICS AND Pancrelipase Lorazepam GLUCOCORTICOIDS Oxazepam TRICYCLIC ANTIDEPRESSANT/ COMBINATIONS BILE SALTS BENZODIAZEPINE COMBINATIONS Advair HFA (ST Required) Ursodiol ALPHA-2 RECEPTOR ANTAGONIST Amitriptyline/Chlordiazepoxide Dulera (ST Required) ANTIDEPRESSANTS Symbicort (ST Required) ANTIFLATULENTS Mirtazapine ANTIMANIA DRUGS Simethicone Lithium Carbonate, -ER LEUKOTRIENE RECEPTOR ANTAGONISTS SEROTONIN-2 ANTAGONIST/REUPTAKE Montelkast INTESTINAL MOTILITY STIMULANTS INHIBITORS (SARIS) BARBITURATES Zafirlukast Trazodone IMMUNOGLOBULIN ANTIBODIES DRUG TX-CHRONIC INFLAM. COLON DX, SEDATIVE-HYPNOTICS, (PA REQUIRED) 5- AMINOSALICYLAT MAO INHIBITORS NONBARBITURATES Xolair Asacol HD Tranylcypromine Chloral Hydrate Balsalazide Diphenhydramine METHYLXANTHINES Colazal SELECTIVE SEROTONIN REUPTAKE Doxylamine Aminophylline Delzicol INHIBITOR (SSRIS) Estazolam Guaifenesin/Dyphylline Mesalamine Citalopram Flurazepam Pentasa Fluoxetine Temazepam Sulfasalazine Fluvoxamine Maleate Triazolam LAXATIVES AND CATHARTICS Paroxetine Zaleplon Bisacodyl BLOOD DETOXICANTS Sertraline Zolpidem Docusate Calcium Acetate Glycerin Eliphos SEROTONIN-NOREPINEPHRINE TX FOR ATTENTION DEFICIT-HYPERACT Lactulose Renvela (PA Required) REUPTAKE — INHIB (SNRIS) (ADHD)/NARCOLEPSY Venlafaxine, -ER Amphetamine/D-amphetamine Mineral Oil PARASYMPATHETIC AGENTS Citrate PEGs Bethanechol TRICYCLIC ANTIDEPRESSANTS AND Dextroamphetamine Sodium Phosphate REL. NON-SEL. RU-INHIB URINARY TRACT ANTISPASMODIC/ Amitriptyline , -ER, -SR ANTIDIARRHEALS ANTI-INCONTINENCE AGENT Strattera (ST Required) Bismuth Subsalicylate Oxybutynin, -ER Diphenoxylate/Atropine Oxytrol CHOLINESTERASE INHIBITORS Donepezil VAGINAL ANTIBIOTICS Galantamine ANTACIDS Clindamycin Maprotiline Namenda Aluminum Metronidazole Nortriptyline Rivastigmine Calcium Protriptyline Magnesium VAGINAL ANTIFUNGALS SMOKING DETERRENT AGENTS Simethicone Clotrimazole Bupropion, -SR Sodium Bicarbonate Miconazole Nicotine 7

7 DRUGS TO TREAT MULTIPLE Fenoprofen /Levo/ HEMORRHEOLOGIC AGENTS SCLEROSIS (PA REQUIRED) Flurbiprofen Entacapone Pentoxifylline Avonex Ibuprofen, -Apap, Diphehydramine Betaseron Indomethacin PLATELET REDUCING AGENTS Copaxone Ketoprofen Ketorolac Anagrelide Extavia Meclofenamate Gilenya Meloxicam SKELETAL MUSCLE RELAXANTS MIOTICS/OTHER INTRAOC. PRESSURE Rebif Nabumetone Baclofen REDUCERS Tecfidera Naproxen , –ASA, -Codeine Acetzolamide Oxaprozin Chlorzoxazone Apraclonidine ALCOHOL ANTAGONIST Piroxicam Cyclobenzaprine Betaxolol Disulfiram Sulindac Dantrolene Brimonidine Tolmetin Methocarbamol Carteolol ANALGESIC/ANTIPYRETICS, (PA Required) Dorzolamide SALICYLATES ANTI-INFLAMMATORY TUMOR Rilutek (PA Required) Dozolamide-Timolol Aspririn NECROSIS FACTOR INHIBITOR Tizanidine Latanoprost Choline Magnesium Enbrel (PA Required) Levobunolol Diflunisal Humira (PA Required) OTHER CNS/AUTONOMIC DRUGS Methozolamide Salsalate Pyridostigmine Metipranolol ANTI-INFLAMMATORY, PYRIMIDINE Pilocarpine ANALGESIC/ANTIPYRETICS, SYNTHESIS INHIBITOR VITAMIN B1 PREPARATIONS Timolol NONSALICYLATE Cuprimine APAP-Diphenhydramine Leflunomide VITAMIN B6 PREPARATIONS MYDRIATICS ASA-Diphenhydramine Ridaura Atropine VITAMIN B12 PREPARATIONS ANTIMIGRAINE PREPARATIONS ANTIARTHRITIC, FOLATE ANTAGONIST OPHTHALMIC ANTIBIOTICS Apap-Butalbital AGENTS FOLIC ACID PREPARATIONS Bacitracin Apap/Dichlphen/Isomethep Methotrexate Bacitracin-Polymyxin Apap/Asa/Caff IRON REPLACEMENT Ciprofloxacin Apap/Phenyltolox HYPERURICEMIA TX — PURINE Erythromycin Apap/Pyrilamine/Caff INHIBITORS Gentamicin Asa/Butalb/Caff/Cod Allopurinol VITAMIN D PREPARATIONS Levofloxacin Butalbital/Apap/Caffeine Neo-Bacit-Poly Butalbital/Caf/Apap/Cod URICOSURIC AGENTS PEDIATRIC VITAMIN PREPARATIONS Neomycin/Poly/Gram Butalbital/Asa/Caffeine Probenecid Ofloxacin Depakote ER PRENATAL VITAMIN PREPARATIONS Polymyxin, -TMP Divalproex URINE GLUCOSE TEST AIDS Sulfacetamide -Caffeine CALCIUM REPLACEMENT Tobramycin Naratriptan COLCHICINE Sumatriptan Probenecid-Colchicine VITAMIN K PREPARATIONS EYE ANTIBIOTIC-CORTICOID COMBINATIONS ANALGESICS, NARCOTICS ANTICONVULSANTS ZINC REPLACEMENT Neo-Bacit-Poly-Hc Acetaminophen/Cod Carbamazepine Neomycin-Poly-Hc /Codeine Clonazepam POTASSIUM REPLACEMENT Neo-Polymyxin-Dexameth Buprenorphine, -Naloxone Depakene Butorphanol Diazepam, Rectal ELECTROLYTE REPLACEMENT EYE ANTIVIRALS Carisoprodol Divalproex Trifluridine Codeine, -Apap Ethosuximide Fentanyl HEMATINICS, OTHER Procrit (PA Required) ARTIFICIAL TEARS Hydrocodone/Apap Gabapentin Hydrocodone/Ibuprofen Lamotrigine HEPARIN AND RELATED EYE VASOCONSTRICTORS (RX ONLY) Hydromorphone Levetiracetam Naphazoline Meperidine PREPARATIONS Oxcarbazepine Heparin Phenylephrine Phenytoin Morphine Primidone Oxycodone ORAL ANTICOAGULANTS, COUMARIN EYE VASOCONSTRICTORS (OTC ONLY) Tiagabine TYPE Tetrahydrozoline Oxycodone-Apap Oxycodone-Aspirin Warfarin Valproic Acid EYE LOCAL ANESTHETICS Pentazocine-Apap Zonisamide Pentazocine-Naloxone ANTIFIBRINOLYTIC AGENTS Proparacaine , -Apap Aminocaproic Acid ANTIPARKINSONISM DRUGS, EYE ANTIHISTAMINES ANTICHOLINERGIC NARCOTIC ANTAGONISTS PLATELET AGGREGATION INHIBITORS Alaway Benztropine Azelastine Naltrexone Cilostazol Clopidogrel Dypiradamole Epinastine Pradaxa (PA Required) Ketotifen NSAIDS, CYCLOOXYGENASE INHIBITOR ANTIPARKINSONISM DRUGS, OTHER — TYPE Ticlopidine Amantadine Xarelto (PA Required) Diclofenac Etodolac 8

8 OPHTHALMIC MAST CELL STABILIZERS Erythromycin-Benzoyl TOPICAL ANTIPARASITICS Cromolyn Gentamicin Malathion Iodoquinol/Hydrocortisone Permethrin EYE ANTI-INFLAMMATORY AGENTS Mupirocin Piperonyl, -pyrethrins, -permethrin Dexamethasone Neomycin-Bacitracin-Polymixin Diclofenac ANTISEPTICS, GENERAL Fluorometholone TOPICAL ANTIFUNGALS Alcohol Prep Swabs Flurbiprofen Ciclopirox Prednisolone Clotrimazole CONDOMS Clotrimazole-Betamethasone OTIC PREPARATIONS, ANTI- Econazole DIAPHRAGMS/CERVICAL CAP INFLAMMATORY — ANTIBIOTICS Ketoconazole Ciprodex (PA Required) Miconazole NEEDLES/NEEDLELESS DEVICES Neomycin-Polymixin-Dexa Nystatin Nystatin-Triamcinolone Sulfacetamide-Prednisolone SYRINGES AND ACCESSORIES Tobramycin-Dexamethasone Terbinafine Tolnaftate RESPIRATORY AIDS, DEVICES, OTIC PREPARATIONS, LOCAL EQUIPMENT ANESTHETICS ANTIPSORIATIC AGENTS Benzocaine 8-MOP Calcipotriene RUBBER SYRINGES Nasal Aspirator OTIC PREPARATIONS, ANTIBIOTICS Dovonex (PA Required) Neo/Polymyxin/HC Sulfacetamide Ofloxacin IMMUNOSUPPRESSANTS Pramoxine/HC TOPICAL ANTIVIRALS Azathioprine Abreva CellCept Acyclovir Cyclosporine FLUORIDE PREPARATIONS Gengraf Hecoria PERIODONTAL COLLAGENASE TOPICAL ANTINEOPLASTIC AND PREMALIGANT Mycophenolate INHIBITORS Rapamune Doxycycline Fluorouracil Targretin (PA Required) Sirolimus Tacrolimus DENTAL AIDS AND PREPARATIONS Triamcinolone TOPICAL ANTI-INFLAMMATORY STEROIDAL AGENTS HEMORRHOIDAL PREPARATIONS Alclometasone HC Pramoxine Amcinonide Lidocaine-Prilocaine Betamethasone Desonide Desoximetasone VITAMIN A DERIVATIVES (PA Diflorasone REQUIRED) Fluocinolone Adapalene Fluocinonide Fluticasone KERATOLYTICS Halobetasol Benzoyl Peroxide Hydrocortisone Mometasone ACNE AGENTS, SYSTEMIC (PA Pramoxine-HC REQUIRED) Prednicarbate Amnesteem Triamcinolone Claravis Sotret TOPICAL AGENTS, MISCELLANEOUS Papain-Urea-Chloro ACNE AGENTS, TOPICAL Trichloroacetic Acid Benzoyl Peroxide, -Clindamycin, Trypsin, –Balsam -Urea, Urea Clindamycin Eyrthromycin TOPICAL IMMUNOMODULATORS (PA Sod .Sulfacet/Sulfur, -Urea REQUIRED) Elidel ROSACEA AGENTS, TOPICAL Imiquimod Metronidazole Protopic

TOPICAL ANTIBIOTICS TOPICAL ANESTHETICS Bacitracin Lidocaine, -Prilocaine Bacitracin-Polymyxin Clindamycin Clioquinol/Hydrocortisone Erythromycin 9

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