Department of Human Services IOWA Medicaid Program Draft PDL for March 9, 2006 P & T Committee Meeting PDL DRUG LIST (Two Drug Columns)

Highlighted categories denote new changes to the PDL since previous update

Column Header Explanations:

P, N, R, or NR: B, G or O: P = Preferred B = Brand N = Non-Preferred G = Generic R = Recommended O = OTC NR = Non-Recommended

COM: 13 PA Required > 90 days 1 ANTIVERT 50mg - Use two MECLIZINE HCL 25 mg instead 14 PA Required > Quantity Limit 10 Days 2 BENZONATATE 200mg - Use two BENZONATATE 100mg instead 15 PA Required for > 4 Bottles/30 Days 3 BUSPIRONE 30mg - Use 2 BUSPIRONE 15mg tablets 16 PA Required from Day 1 4 CLINDAMYCIN HCL 300MG - Use Multiples of CLINDAMYCIN HCL 150mg 17 PA Required: > 18 Units/30Days Supply 5 FLUMIST NASAL VACCINE 200 - Preferred 5 - 49 yo until 3/15/2006. 18 Preferred < 14yo 6 FLUOXETINE HCL 20mg TABS - Use 19 Preferred < 8yo FLUOXETINE HCL 20mg CAPS instead 7 Grandfather 21 PROZAC,FLUOXETINE HCL 40mg CAPS - Use 8 Grandfather for Seizure Disorder two FLUOXETINE HCL 20mg CAPS instead 22 RHEUMATREX - Write METHOTREXATE 9 HYDROXYZINE HCL - Use HYDROXYZINE instead PAMOATE 23 ULTRACET - Use Tramadol & Acetaminophen 10 HYDROXYZINE PAMOATE 100mg - Use two separately HYDROXYZINE PAMOATE 50mg instead 24 PA Required >= 21 yo 11 PA Required 25 PA Required: > 14 Units/30Days Supply 12 PA Required > 60 days 26 Levaquin: Levaquin is non-preferred except for continuation of a verified course of therapy started in the hospital. An in-patient hospital stay must be verified by reviewing the member’s hospital discharge order. Then, the pharmacy may override the non-preferred status with a Medical Certification Code = 2 and a PA Type Code= 6. 27 Oxycodone ER: Effective April 16, 2006 only the ENDO Brand (NDC# 60951) of oxycodone ER will be preferred.

28 After 30 days only the generic will be preferred.

NEW DRUG REVIEW PROCESS: See Page 2. PDL IMPLEMENTATION DATE 01-15-05 Iowa Medicaid Preferred Drug List (PDL) New Drug Process

1). Therapeutic classes of drugs already reviewed by the Pharmaceutical and Therapeutics (P&T) Committee

· New drug entities (including new generics), and new drug product dosage forms of existing drug entities) in therapeutic classes already reviewed by the P&T Committee will be identified weekly and immediately be coded as "Non-preferred-Prior Authorization required" until presented at the next quarterly scheduled P&T Committee meeting. These prior authorization restrictions will continue through the review process, including while committee recommendations are being made, and lasting until DHS makes a final determination.

2). Therapeutic classes of drugs not yet reviewed by the Pharmaceutical and Therapeutics (P&T) Committee

· New drug entities in therapeutic classes not yet reviewed by the P&T Committee will remain payable, in effect preferred by default, until the therapeutic class is discussed. Once this review occurs for the class, the non- preferred default policy will apply to subsequent new drug entries.

3). Exceptions to the Non-preferred default policy for new PDL drugs

There are two major potential exceptions to the non-preferred default policy for new PDL drugs:

A). If a new medication is classified as a priority drug by the FDA, the State may indicate that such a drug is preferred, until the drug is reviewed by the P&T Committee at the nearest scheduled meeting.

B). The State may decide to designate a new drug as "draft preferred" and provide immediate access and increased therapeutic choice to physicians until the drug is reviewed by the P&T Committee at the nearest scheduled meeting if: - a new drug is therapeutically equivalent or superior to existing preferred or non-preferred choices, and - is as safe or safer than existing preferred or non-preferred choices, and - the net cost, adjusted for all rebates, is less expensive than all existing preferred choices.

4). Existing PDL Drugs

· Although the State discourages supplemental rebate offers on existing PDL drugs between annual bidding periods, it may entertain such bids and may accept them if they are determined to represent significant additional savings or if they would replace a delinquent manufacturer's product or a preferred drug pulled from the marketplace or significantly restricted by the FDA. This interim preferred status will remain in effect until the drug is reviewed by the P&T Committee at the next scheduled meeting. Supplemental rebates will only be invoiced for approved drugs under contract. Draft preferred drugs with supplemental rebates will not be invoiced until approved by the Committee and accepted by the State. At that time, the supplemental rebates will be invoiced back to the effective date of the agreement, which is the date the drug began to benefit from preferred status. TABLE OF CONTENTS

Page Page CATEGORY DESCRIPTION CATEGORY DESCRIPTION Number Number ACE AND THIAZIDE COMBO'S 7 ANTIHISTAMINES - NON-SEDATING / 12 DECONGESTANTS ACE INHIBITORS 7 ANTIHISTAMINES - OTHER 12 ACE INHIBITORS AND CA CHANNEL BLOCKERS 7 ANTIHISTAMINES/DECONGESTANTS 13 ACNE PRODUCTS: ISOTRETINOIN 7 ANTIHYPERTENSIVE COMBOS 13 AGENTS FOR FABRYS DISEASE 7 ANTIHYPERTENSIVES - CENTRAL 13 AGENTS FOR GAUCHER DISEASE 7 ANTILEPROTIC 14 AGENTS FOR PHEOCHROMOCYTOMA 7 ANTIMALARIAL AGENTS 14 ALCOHOL DETERRENTS 7 ANTIMYCOBACTERIALS / ANTITUBERCULOSIS 14 ALS DRUG 7 ANTINEOPLASTICS - ALKYLATING AGENTS 49 ALZHEIMER - CHOLINOMIMETICS 7 ANTINEOPLASTICS - ANTIADRENALS 49 AMINO GLYCOSIDES 7 ANTINEOPLASTICS - ANTIANDROGENS 49 ANALGESICS - MISC. 7 ANTINEOPLASTICS - ANTIBIOTICS 49 ANAPHYLAXIS THERAPY 8 ANTINEOPLASTICS - ANTIESTROGENS 49 ANDROGENS / ANABOLICS 8 ANTINEOPLASTICS - ANTIMETABOLITES 49 ANGIOTENSIN RECEPTOR BLOCKER 8 ANTINEOPLASTICS - AROMATASE INHIBITORS 49 ANORECTAL - MISC. 8 ANTINEOPLASTICS - CARDIAC PROTECTIVE AGENTS 49 ANTHELMINTICS 8 ANTINEOPLASTICS - COMBINATIONS 49 ANTI INFECTIVE COMBO'S - MISC. 8 ANTINEOPLASTICS - ESTROGEN RECEPTOR 49 ANTIANGINALS--ISOSORBIDE NITRATE 8 ANTAGONIST ANTIARRHYTHMICS 9 ANTINEOPLASTICS - ESTROGENS 49 ANTIASTHMATIC - ADRENERGIC COMBOS 9 ANTINEOPLASTICS - FOLIC ACID ANTAGONISTS 49 ANTIASTHMATIC - ALPHA-PROTEINASE INHIBITOR 9 RESCUE AGENTS ANTIASTHMATIC - ANTI-CHOLINERGICS 9 ANTINEOPLASTICS - IMIDAZOTETRAZINES 49 ANTIASTHMATIC - ANTIINFLAMMATORY AGENTS 9 ANTINEOPLASTICS - INTERLEUKINS 49 ANTIASTHMATIC - BETA - ADRENERGICS 9 ANTINEOPLASTICS - LHRH ANALOGS 49 ANTIASTHMATIC - HYDRO-LYTIC ENZYMES 9 ANTINEOPLASTICS - MISC. 50 ANTIASTHMATIC - LEUKOTRIENE RECEPTOR 9 ANTINEOPLASTICS - MITOTIC INHIBITORS 50 ANTAGONISTS ANTINEOPLASTICS - NITROGEN MUSTARDS 50 ANTIASTHMATIC - MISC. RESPIRATORY INHALANTS 9 ANTINEOPLASTICS - NITROSOUREAS 50 ANTIASTHMATIC - MIXED ADRENERGICSS 9 ANTINEOPLASTICS - PROGESTINS 50 ANTIASTHMATIC - MUCOLYTICS 10 ANTINEOPLASTICS - PROTEIN-TYROSINE KINASE 50 ANTIASTHMATIC - NASAL MISC. 10 INHIBITORS ANTIASTHMATIC - NASAL STEROIDS 10 ANTINEOPLASTICS - RETINOIDS 50 ANTIASTHMATIC - STEROID INHALANTS 10 ANTINEOPLASTICS - SELECTIVE RETINOID X 50 RECEPTOR AGONISTS ANTIASTHMATIC - XANTHINES 10 ANTINEOPLASTICS - TOPOISOMERASE I INHIBITORS 50 ANTIBIOTICS - MISC. 10 ANTINEOPLASTICS - URINARY TRACT PROTECTIVE 50 ANTI-CATAPLECTIC AGENTS 10 AGENTS ANTICOAGULANTS 10 ANTI-PARKINSONIAN DRUGS 14 ANTICONVULSANTS 10 ANTIPROTOZOAL AGENTS 14 ANTIDEPRESSANTS - MAO INHIBITORS 45 ANTI-PSORIATICS - BIOLOGICALS 14 ANTIDEPRESSANTS - SELECTED SSRI'S 45 ANTI-PSORIATICS - NON-BIOLOGICALS 14 ANTIDEPRESSANTS - TRI-CYCLICS 45 ANTIPSYCHOTICS - ATYPICALS 45 ANTIDOTES 11 ANTIPSYCHOTICS - SPECIAL ATYPICALS 45 ANTIDOTES - CHELATING AGENTS 11 ANTIPSYCHOTICS - TYPICAL 45 ANTIEMETIC - 5-HT3 RECEPTOR ANTAGONISTS/ 11 ANTIRETROVIRAL COMBINATIONS 50 SUBSTANCE P NEUROKININ ANTIRETROVIRALS 50 ANTIEMETIC - ANTICHOLINERGIC / DOPAMINERGIC 11 ANTIRETROVIRALS - FUSION INHIBITORS 50 ANTIFUNGALS - ASSORTED 11 ANTIRETROVIRALS - PROTEASE INHIBITORS 50 ANTIHEMOPHILIC AGENTS 49 ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE 50 ANTIHISTAMINES - NON-SEDATING 12 ANALOGUES ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- 50 COUGH/COLD - DECONGESTANT W/ EXPECTORANT 20 PURINES COUGH/COLD - DECONGESTANT-ANTIHISTAMINE W/ 21 ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- 50 EXPECTORANT PYRIMIDINES COUGH/COLD - DECONGESTANT-ANTIHISTAMINE- 21 ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- 51 ANTICHOLINERGIC THYMIDINES COUGH/COLD - EXPECTORANT MIXTURES 21 ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES 51 COUGH/COLD - EXPECTORANTS 21 ANTISPASMODICS 14 COUGH/COLD - NARCOTIC ANTITUSSIVE- 21 ANTISPASMODICS - LONG ACTING 14 ANTIHISTAMINE ANTITHYROID THERAPIES 14 COUGH/COLD - NARCOTIC ANTITUSSIVE- 21 DECONGESTANT ANXIOLYTICS - BENZODIAZEPINES 46 COUGH/COLD - NARCOTIC ANTITUSSIVE- 21 ANXIOLYTICS - LONG ACTING 46 DECONGESTANT-ANTIHISTAMINE ANXIOLYTICS - MISC. 46 COUGH/COLD - NON-NARC ANTITUSSIVE- 21 ARB'S AND DIURETICS 14 ANTIHISTAMINE ARTHRITIS - MISC. 14 COUGH/COLD - NON-NARC ANTITUSSIVE- 22 DECONGESTANT ARTIFICIAL SALIVA/STIMULANTS 15 COUGH/COLD - NON-NARC ANTITUSSIVE- 22 BETA BLOCKERS - ALPHA / BETA 15 DECONGESTANT-ANTIHISTAMINE BETA BLOCKERS - CARDIO SELECTIVE 15 COUGH/COLD - SYSTEMIC DECONGESTANTS 22 BETA BLOCKERS - NON SELECTIVE 15 COUGH/COLD - TOPICAL DECONGESTANTS 22 BETA BLOCKERS AND DIURETIC COMBO'S 15 COX 2 INHIBITORS - HIGHLY SELECTIVE 22 BETA-LACTAMS / CLAVULANATE COMBO'S 15 COX 2 INHIBITORS - SELECTIVE 22 BPH 16 CYTO-MEGALOVIRUS AGENTS 22 CALCIUM CHANNEL BLOCKERS--AMLODIPINES 16 DENTAL PRODUCTS 22 CALCIUM CHANNEL BLOCKERS--DILTIAZEMS 16 DIABETIC - ALPHAGLUCOSIDASE 22 CALCIUM CHANNEL BLOCKERS--FELODIPINES 16 DIABETIC - INSULIN 22 CALCIUM CHANNEL BLOCKERS--ISRADIPINES 16 DIABETIC - INSULIN PENFILLS 23 CALCIUM CHANNEL BLOCKERS--NIFEDIPINES 16 DIABETIC - MEGLITINIDES 23 CALCIUM CHANNEL BLOCKERS--NISOLDIPINE 16 DIABETIC - ORAL BIGUANIDES 23 CALCIUM CHANNEL BLOCKERS--VERAPAMILS 16 DIABETIC - ORAL SULFONYLUREAS 23 CARBAPENEMS 17 DIABETIC - OTHER 23 CARDIAC GLYCOSIDES 17 DIABETIC - SULFONYLUREA / BIGUANIDE 23 CARNITINE REPLENISHER - AGENTS 17 DIABETIC - THIAZOL 23 CCB / LIPID 17 DIABETIC - THIAZOL / BIGUANIDE COMBO 23 CEPHALOSPORINS 17 DIAGNOSTIC BIOLOGICALS 23 CHELATING AGENTS 17 DIURETICS 23 CHOLESTEROL - BILE SEQUESTRANTS 17 DOPAMINE RECEPTOR AGONISTS 24 CHOLESTEROL - FIBRIC ACID DERIVATIVES 18 EAR 24 CHOLESTEROL - HMG COA + ABSORB INHIBITORS 18 ELECTROLYTES/ NUTRITIONALS 24 CHOLINERGIC 18 ERYTHROPOEISIS STIMULATING AGENTS 24 COMPOUNDING MATERIALS 18 ESTROGEN COMBO'S 25 CONTRACEPTIVES - BI-PHASIC COMBINATIONS 18 ESTROGENS - PATCHES 25 CONTRACEPTIVES - INJECTABLE 18 ESTROGENS - TABS 25 CONTRACEPTIVES - MONOPHASIC COMBINATION O/ 18 FLUOROQUINOLONES 25 C'S GI - ANTI - FLATULENTS / GI STIMULANTS 25 CONTRACEPTIVES - PATCHES/ VAGINAL PRODUCTS 19 GI - ANTIDIARRHEAL / ANTACID - MISC. 25 CONTRACEPTIVES - PROGESTIN ONLY 19 GI - ANTIPERISTALTIC AGENTS 26 CONTRACEPTIVES - TRI-PHASIC COMBINATIONS 19 GI - DIGESTIVE ENZYMES 26 COUGH/COLD - ANTITUSSIVE - NARCOTIC 19 GI - H2-ANTAGONISTS 26 COUGH/COLD - ANTITUSSIVE - NONNARCOTIC 19 GI - INFLAMMATORY BOWEL AGENTS 27 COUGH/COLD - ANTITUSSIVE-EXPECTORANT 19 GI - IRRITABLE BOWEL SYNDROME AGENTS 27 COUGH/COLD - ANTITUSSIVE-EXPECTORANT - 19 GI - MISC. 27 DECONGEST-ANTIHIST COUGH/COLD - ANTITUSSIVE-EXPECTORANTS- 20 GI - MISC. ANTI-ULCER 27 DECONGESTANT GI - PROSTAGLANDINS 27 COUGH/COLD - DECONGESTANT & 20 GI - PROTON PUMP INHIBITOR 27 ANTICHOLINERGIC GI - PROTON PUMP INHIBITOR/NSAID COMBO 27 GI - ULCER ANTI-INFECTIVE 27 OP. ANTIINFLAMMATORY / STEROIDS OPHTH. 34 GLUCOCORTICOIDS - CORTICOTROPIN 27 OP. BETA - BLOCKERS 35 GLUCOCORTICOIDS - MINERALOCORTICOIDS 27 OP. CARBONIC ANHYDRASE INHIBITORS/COMBO 35 GOUT 28 OP. CYCLOPLEGICS 35 GRANULOCYTE CSF 28 OP. MIOTICS - DIRECT ACTING 35 GROWTH HORMONE 28 OP. MISC 35 HEMOSTATIC 28 OP. NSAID'S 35 HEPATITIS B ONLY 28 OP. PROSTAGLANDINS 35 HEPATITIS C AGENTS 28 OP. QUINOLONES 35 HEREDITARY TYROSINEMIA TYPE 1 (HT-1) 28 OP. SELECTIVE ALPHA ADRENERGIC AGONISTS 35 TREATMENT - AGENTS OSTEOPOROSIS 36 HERPES AGENTS 28 OXYTOCICS 36 HYPERPARATHYROID TREATMENT - VITAMIN D 28 PARKINSONS - ANTICHOLINERGICS 36 ANALOGS HYPERPARATHYROID TREATMENT - VITAMIN D 28 PARKINSONS - COMT INHIBITORS 36 ANALOGS AND CALCIMIMETICS PARKINSONS - SELECTED DOPAMIN AGONISTS 36 IMMUNE SERUMS 28 PERIPHERAL VASODILATORS 36 IMMUNOSUPPRESSANTS 51 PHOSPHATE BINDERS 36 INFLUENZA AGENTS 29 PHOSPHODIESTERASE INHIBITORS 36 IRRIGATION SOLUTIONS 29 PLATELET AGGR. INHIBITORS / COMBO'S - MISC. 36 K REMOVING RESINS 29 PLATELET AGGREGATION INHIBITORS 36 LINCOSAMIDES / OXAZOLIDINONES / LEPROSTATICS 29 PRESSORS 36 LITHIUM 46 PROGESTINS 36 MACROLIDES / ERYTHROMYCIN'S / KETOLIDES 29 PSYCHOTHERAPEUTIC COMBINATION 46 MIGRAINE - CARBOXYLIC ACID DERIVATIVES 29 PULMONARY ANTI-HYPERTENSIVES 36 MIGRAINE - ERGOTAMINE DERIVATIVES 29 PURINE ANALOG 36 MIGRAINE - MISC. 29 RHEUMATOID ARTHRITIS - BIOLOGICALS 36 MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT) 29 RHEUMATOID ARTHRITIS - NON-BIOLOGICALS 37 --INJECTABLES RSV PROPHYLAXIS 37 MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT) 30 --TABS SEDATIVE/HYPNOTICS - BARBITURATE 47 MINERALS 30 SEDATIVE/HYPNOTICS - BENZODIAZEPINES 47 MOUTH - ANESTHETICS TOPICAL ORAL 31 SEDATIVE/HYPNOTICS - NON-BENZODIAZEPINES 47 MOUTH - STEROIDS 31 SOMATOSTATIC AGENTS 36 MOUTH ANTI-INFECTIVES 31 STIMULANTS - AMPHETAMINES - LONG ACTING 47 MOUTH ANTISEPTICS 31 STIMULANTS - AMPHETAMINES - SHORT ACTING 47 MUCOPOLYSACCHARIDOSIS 31 STIMULANTS - METHYLPHENIDATE 47 MULTIPLE SCLEROSIS AGENTS 31 STIMULANTS - METHYLPHENIDATE - LONG ACTING 47 MUSCLE RELAXANT -COMBINATIONS 31 STIMULANTS - OTHER STIMULANTS / LIKE 47 STIMULANTS MUSCLE RELAXANTS 31 TETRACYCLINES 37 NARCOTIC - ANTAGONISTS 31 THYROID HORMONES 37 NARCOTICS - MISC. 31 TISSUE PLASMINOGEN ACTIVATOR 37 NARCOTICS - SELECTED 32 TOPICAL - ACNE PREPARATIONS 37 NARCOTICS-LONG ACTING 32 TOPICAL - ANTIBIOTIC 38 NEUROLOGICS - MISC. 33 TOPICAL - ANTIFUNGALS 38 NEUROMUSCULAR BLOCKING AGENTS 33 TOPICAL - ANTINEOPLASTICS 39 NEW DRUG PROCESS 2 TOPICAL - ANTIPRURITICS 39 NICARDIPINES 33 TOPICAL - ANTISEBORRHEICS 39 NITRO - OINTMENT/CAP/CR 33 TOPICAL - ANTISEPTICS / DISINFECTANTS 39 NITRO - PATCHES 33 TOPICAL - ANTIVIRALS 39 NITRO - SUBLINGUAL/ SPRAY 33 TOPICAL - ASTRINGENTS / PROTECTANTS 39 NSAIDS 33 TOPICAL - BURN PRODUCTS 39 OP. ADRENERGIC AGENTS 34 TOPICAL - CAUTERIZING AGENTS 39 OP. ANTIALLERGICS - ANTIHISTAMINES 34 TOPICAL - CORTICOSTEROIDS 39 OP. ANTIALLERGICS - MAST CELL STABILIZERS 34 TOPICAL - EMOLLIENTS 40 OP. ANTIBIOTICS 34 TOPICAL - ENZYMES / KERATOLYTICS / UREA 40 TOPICAL - GENITAL WARTS 40 TOPICAL - IMMUNOMODULATORS 40 TOPICAL - LOCAL ANESTHETICS 40 TOPICAL - NASAL ANTIBIOTICS 41 TOPICAL - SCABICIDES AND PEDICULICIDES 41 TOPICAL - STEROID COMBINATIONS 41 TOPICAL - STEROID LOCAL ANESTHETICS 41 TOPICAL - TRETINOIDS 41 TOPICAL - WOUND / DECUBITUS CARE 41 UREA CYCLE DISORDER - AGENTS 41 UROLOGICAL - MISC. 41 VAGINAL - ANTI FUNGALS 42 VAGINAL - ANTIBACTERIALS 42 VAGINAL - CONTRACEPTIVES 42 VAGINAL - ESTROGENS 42 VAGINAL - OTHER 42 VASOPRESSINS 42 VITAMINS 42 VITAMINS - MISC. 43 WEIGHT LOSS 44

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 6 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories AGENTS FOR PHEOCHROMOCYTOMA ACE AND THIAZIDE COMBO'S B P PHENTOLAMINE MESYLATE

B N LOTENSIN HCT B N DEMSER G N benazepril & hydrochlorothiazide ALCOHOL DETERRENTS B N CAPOZIDE B N CAMPRAL G P captopril & hydrochlorothiazide B P ANTABUSE B N VASERETIC

G P enalapril maleate & hydrochlorothiazide ALS DRUG

B P MONOPRIL HCT B P RILUTEK G N fosinopril sodium & hydrochlorothiazide ALZHEIMER - CHOLINOMIMETICS B N PRINZIDE

B N ZESTORETIC B P ARICEPT

G P lisinopril & hydrochlorothiazide B P ARICEPT ODT

B P UNIRETIC B 7 N REMINYL

B N ACCURETIC B N RAZADYNE ER

G N quinapril-hydrochlorothiazide B P EXELON

ACE INHIBITORS B P NAMENDA

B P NAMENDA TITRATION PAK B N LOTENSIN AMINO GLYCOSIDES G N benazepril hcl

B N CAPOTEN B P AMIKIN

G P captopril G P amikacin sulfate

B N VASOTEC B N GARAMYCIN

G P enalapril maleate G P gentamicin sulfate

B P MONOPRIL G P gentamicin in saline

G N fosinopril sodium B P KANTREX

B N PRINIVIL G P kanamycin sulfate

B N ZESTRIL G P neomycin sulfate

G P lisinopril B P HUMATIN

B N UNIVASC G P paromomycin sulfate

B N ACEON B P STREPTOMYCIN SULFATE

B N ACCUPRIL B P TOBI

G N quinapril hcl B N TOBRAMYCIN SULFATE ADD-VA

B P ALTACE G P tobramycin sulfate B N MAVIK ANALGESICS - MISC. ACE INHIBITORS AND CA CHANNEL BLOCKERS O P aspirin tab 81 mg

B P LOTREL O P aspirin tab 325 mg

B N LEXXEL O P ASPIRIN TAB 650 MG

B P TARKA B N ZORPRIN

ACNE PRODUCTS: ISOTRETINOIN O P aspirin chew tab 81 mg

O P aspirin tab delayed release 81 mg B 11 P ACCUTANE O P aspirin tab delayed release 325 mg G 11 N isotretinoin O P aspirin tab delayed release 650 mg AGENTS FOR FABRYS DISEASE G P aspirin tab delayed release 975 mg

B N DOLOBID B P FABRAZYME G P diflunisal tab 500 mg AGENTS FOR GAUCHER DISEASE G P salsalate tab 500 mg

B P CEREZYME G P salsalate tab 750 mg

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 7 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - G P testosterone cypionate im in oil 200 mg/ml ANALGESICS - MISC. B N DELATESTRYL - Continued - G P testosterone enanthate im in oil 200 mg/ml G P aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg B P OXANDRIN

O P aspirin buffered tab 325 mg B P WINSTROL G P choline & mag salicylate ANGIOTENSIN RECEPTOR BLOCKER B P PRIALT

O P acetaminophen tab 325 mg B N ATACAND

O P acetaminophen tab 500 mg B P TEVETEN

O P acetaminophen elixir 160 mg/5ml B N AVAPRO

O P acetaminophen soln 100 mg/ml B P COZAAR

O P acetaminophen suppos 120 mg B P BENICAR

B N DURABAC B P MICARDIS

B N PHRENILIN FORTE B P DIOVAN

B N PHRENILIN ANORECTAL - MISC. G P butalbital-acetaminophen tab 50-325 mg B N ANUSOL-HC G N butalbital-acetaminophen tab 50-650 mg G P hydrocortisone rectal cream 2.5% B N EQUAGESIC G P hydrocortisone enema 100 mg/60ml G N phenyltoloxamine w/ mag salicylate tab 25-600 mg B N CORTIFOAM G P butalbital-acetaminophen-caffeine cap 50-325-40 mg B N ANAMANTLE HC G N butalbital-acetaminophen-caffeine cap 50-500-40 mg G N lidocaine-hydrocortisone acetate rectal cream kit 3-0.5% B N ESGIC B P ANALPRAM-HC B N FIORICET G N hydrocortisone acetate w/ pramoxine rectal cream 2.5-1% G P butalbital-acetaminophen-caffeine tab 50-325-40 mg B N PROCTOFOAM HC B N ESGIC-PLUS

G P butalbital-acetaminophen-caffeine tab 50-500-40 mg ANTHELMINTICS

B N DOLGIC PLUS B P ALBENZA B P FIORINAL B P STROMECTOL G N butalbital-aspirin-caffeine cap 50-325-40 mg B P VERMOX G P butalbital-aspirin-caffeine tab 50-325-40 mg G N mebendazole chew tab 100 mg ANAPHYLAXIS THERAPY B P BILTRICIDE

B P MINTEZOL B P EPIPEN-JR

B P EPIPEN ANTI INFECTIVE COMBO'S - MISC.

ANDROGENS / ANABOLICS B N PEDIAZOLE

G P erythromycin-sulfisoxazole for susp 200-600 mg/5ml G N danazol cap 50 mg B N BACTRIM G N danoxol G P sulfamethoxazole-trimethoprim tab 400-80 mg G N danazol cap 100 mg G P trimethoprim-sulfamethoxazole tab 80-400 mg B P DANOCRINE CAP 200MG B N SEPTRA DS G N danazol cap 200 mg G P sulfamethoxazole-trimethoprim tab 800-160 mg B P FLUOXYMESTERONE B N SEPTRA B P ANDROID G P sulfamethoxazole-trimethoprim susp 200-40 mg/5ml B P TESTRED

B N METHITEST ANTIANGINALS--ISOSORBIDE NITRATE

B P ANDROGEL B N DILATRATE SR B N ANDROGEL PUMP B N ISORDIL TITRADOSE B N TESTIM G P isosorbide dinitrate B P ANDRODERM B N IMDUR B P DEPO-TESTOSTERONE G P isosorbide mononitrate

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 8 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B N PROVENTIL ANTIARRHYTHMICS G P albuterol inhal aerosol 90 mcg/act G P albuterol sulfate tab 2 mg

B N ETHMOZINE G P albuterol sulfate tab 4 mg

B P NORPACE G P albuterol sulfate syrup 2 mg/5ml

B P NORPACE CR G P albuterol sulfate soln nebu 0.083%

G N disopyramide phosphate G P albuterol sulfate soln nebu 0.5% (5 mg/ml)

B P PRONESTYL B P ACCUNEB

G P procainamide hcl G P albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)

G N procainamide hcl sr B N ALBUTEROL SULFATE HFA

B N PROCAINAMIDE HCL ER B N PROVENTIL HFA

B P PROCANBID B N VENTOLIN HFA

G P quinidine gluconate B P VOSPIRE ER

G P quinidine sulfate B P FORADIL AEROLIZER

B N QUINIDINE SULFATE ER B P XOPENEX

G N lidocaine hcl (cardiac) B N XOPENEX HFA

G P mexiletine hcl B P METAPROTEREN TAB 10MG

B P TAMBOCOR B P METAPROTEREN TAB 20MG

G N flecainide acetate G P metaproterenol sulfate syrup 10 mg/5ml

B P RYTHMOL B N ALUPENT INH AER 0.65/ACT

G N propafenone hcl B P MAXAIR AUTOHALER

B P RYTHMOL SR B P SEREVENT

B N CORDARONE B P SEREVENT DISKUS

G P amiodarone hcl tab 200 mg B P BRETHINE TAB 2.5MG

B N PACERONE G N terbutaline sulfate tab 2.5 mg

G N amiodarone hcl tab 400 mg B P BRETHINE TAB 5MG

B P TIKOSYN G N terbutaline sulfate tab 5 mg

ANTIASTHMATIC - ADRENERGIC COMBOS B N BRETHINE INJ 1MG/ML

G N terbutaline sulfate inj 1 mg/ml B P DUONEB ANTIASTHMATIC - HYDRO-LYTIC ENZYMES B P COMBIVENT

B P ADVAIR DISKUS B 11 P PULMOZYME

ANTIASTHMATIC - ALPHA-PROTEINASE INHIBITOR ANTIASTHMATIC - LEUKOTRIENE RECEPTOR ANTAGONISTS B 11 N ARALAST B P SINGULAIR

B 11 P PROLASTIN B N ACCOLATE B 11 N ZEMAIRA ANTIASTHMATIC - MISC. RESPIRATORY INHALANTS ANTIASTHMATIC - ANTI-CHOLINERGICS G P sodium chloride soln nebu 0.9%

G P ipratropium bromide inhal soln 0.02% O P sodium chloride aero soln 0.9% B P ATROVENT ANTIASTHMATIC - MIXED ADRENERGICS B 11 N SPIRIVA HANDIHALER

ANTIASTHMATIC - ANTIINFLAMMATORY AGENTS G P epinephrine hcl inj 0.1 mg/ml B N ADRENALIN

B N INTAL G P epinephrine hcl inj 1 mg/ml G P cromolyn sodium soln nebu 20 mg/2ml ANTIASTHMATIC - MUCOLYTICS B P INTAL INHALER

B P TILADE B P MUCOMYST-10

B 11 N XOLAIR B P MUCOMYST

ANTIASTHMATIC - BETA - ADRENERGICS G P acetylcysteine

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 9 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - G P metronidazole tab 250 mg ANTIASTHMATIC - NASAL MISC. G P metronidazole tab 500 mg B N FLAGYL ER

B P ATROVENT G N metronidazole tab sr 24hr 750 mg

G N ipratropium bromide (nasal) G P metronidazole in nacl 0.79% iv soln 500 mg/100ml

ANTIASTHMATIC - NASAL STEROIDS B P PENTAM 300

B P NEBUPENT B P BECONASE AQ B N XIFAXAN B N RHINOCORT AQUA B N PROLOPRIM G N flunisolide nasal soln 0.025% G P trimethoprim tab 100 mg B P NASAREL B P VANCOCIN HCL CAP 125MG B P FLONASE B P VANCOCIN HCL CAP 250MG B P NASONEX G P vancomycin hcl for inj 500 mg B N NASACORT AQ G P vancomycin hcl for inj 1000 mg ANTIASTHMATIC - STEROID INHALANTS G P vancomycin hcl for inj 5000 mg

G P vancomycin hcl for inj 10 gm B P QVAR B N VANCOCIN HCL INJ B 19 P PULMICORT SUS 0.25MG/2 B P VANCOCIN HCL ISO-OSMOTIC B 19 P PULMICORT SUS 0.5MG/2 B N POLYMYXIN B SULFATE B 18 P PULMICORT TURBUHALER B P TYGACIL B P AEROBID B P XIGRIS B P AEROBID-M

B P FLOVENT ANTI-CATAPLECTIC AGENTS

B P FLOVENT ROTADISK B P XYREM B P FLOVENT HFA ANTICOAGULANTS B P ASMANEX

B P AZMACORT G P hep flush-10

ANTIASTHMATIC - XANTHINES G P hep-lock

G P heparin lock G P aminophylline G P heparin lock flush G N dyphylline G P heparin sodium lock flush B P ELIXOPHYLLIN G P heparin sodium B P THEO-24 B P HEPARIN SODIUM DCU B N QUIBRON-T/SR G N heparin sodium lock flush B N UNIPHYL G P heparin (porcine) in sodium chloride G P theophylline B 14 P FRAGMIN G N dyphylline-guaifenesin B 14 P LOVENOX B N QUIBRON B 14 P INNOHEP B N ELIXOPHYLLIN-GG B 14 P ARIXTRA ANTIBIOTICS - MISC. G P warfarin sodium

B P COUMADIN B P SULFADIAZINE

B P SULFISOXAZOLE ANTICONVULSANTS

B P SULFISOXIZOLE B P EQUETRO B P GANTRISIN PEDIATRIC B 8 N KLONOPIN B P AZACTAM G P clonazepam B N COLY-MYCIN-M B 8 N KLONOPIN WAFERS G P colistimethate sodium for inj 150 mg B P DIASTAT PEDIATRIC B N LORABID B P DIASTAT UNIVERSAL B N FLAGYL B P DIASTAT G N metronidazole cap 375 mg

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 10 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - ANTIDOTES - CHELATING AGENTS ANTICONVULSANTS - Continued - B N EXJADE B P DIASTAT ADULT B P CHEMET B P FELBATOL ANTIEMETIC - 5-HT3 RECEPTOR ANTAGONISTS/ B P GABITRIL SUBSTANCE P NEUROKININ B N ANZEMET B 8 N PEGANONE B N KYTRIL B 8 N CEREBYX G N ondansetron B P DILANTIN INFATABS B P ZOFRAN G 8 N phenytoin susp 125 mg/5ml B P ZOFRAN ODT G P phenytoin sodium inj 50 mg/ml B N ALOXI B P PHENYTOIN SODIUM PROMPT B P EMEND B P DILANTIN B P MARINOL G P phenytoin sodium extended cap 100 mg

B P PHENYTEK ANTIEMETIC - ANTICHOLINERGIC / DOPAMINERGIC

B P ZARONTIN CAP 250MG G N promethazine tab 12.5mg G 8 N ethosuximide cap 250 mg G P promethazine tab 25mg B 8 N ZARONTIN SYP 250/5ML G P promethazine tab 50mg G P ethosuximide soln 250 mg/5ml G P promethazine syp 6.25/5ml B P CELONTIN B N PHENERGAN INJ 25MG/ML B P DEPAKOTE G N promethazine inj 25mg/ml B P DEPAKOTE SPRINKLES B N PHENERGAN INJ 50MG/ML G P valproate sodium syrup 250 mg/5ml G N promethazine inj 50mg/ml G P valproate sodium inj 100 mg/ml B P PHENERGAN SUP 12.5MG B 8 N DEPAKENE G P promethazine sup 12.5mg G P valproic acid cap 250 mg B P PHENERGAN SUP 25MG B 8 N TEGRETOL TAB 200MG G P promethazine sup 25mg G P carbamazepine tab 200 mg B P PHENERGAN SUP 50MG B P TEGRETOL CHW 100MG G P promethazine sup 50mg G 8 N carbamazepine chew tab 100 mg B N ANTIVERT TAB 12.5MG B P TEGRETOL SUS 100/5ML O P meclizine hcl tab 12.5 mg G 8 N carbamazepine susp 100 mg/5ml B N ANTIVERT TAB 25MG B P CARBATROL B 1 N ANTIVERT TAB 50MG B P TEGRETOL-XR O P meclizine hcl tab 25 mg G 8 N gabapentin B P TRANSDERM-SCOP B P NEURONTIN B N SCOPACE B P LAMICTAL G P scopolamine hydrobromide tab 0.4 mg B P KEPPRA B N TIGAN CAP 300MG B P TRILEPTAL G P trimethobenzamide hcl cap 300 mg B P LYRICA B N TIGAN INJ 100MG/ML G 8 N primidone tab 50 mg ANTIFUNGALS - ASSORTED B P MYSOLINE

G P primidone tab 250 mg B 13 P FUNGIZONE

G N topiramate G 11 N amphotericin b

B 8 N TOPAMAX B 13 P AMBISOME

G N zonisamide B 13 P ANCOBON

B P ZONEGRAN B 13 P GRIFULVIN-V

ANTIDOTES G 11 N griseofulvin microsize

B 13 P GRIS-PEG B P DESFERAL G P nystatin tab 500000 unit

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 11 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B N BROVEX ANTIFUNGALS - ASSORTED G P chlorpheniramine maleate cap cr 8 mg - Continued - G P chlorpheniramine maleate cap cr 12 mg B P NYSTATIN ORAL POWDER O P chlorpheniramine maleate tab 4 mg

G 11 N terbinafine G N dexchlorpheniramine maleate tab cr 4 mg

B 11 N LAMISIL G N dexchlorpheniramine maleate tab cr 6 mg

B 11 N NIZORAL TAB 200MG B N PALGIC

G 13 P ketoconazole B N HISTEX PD

G 11 N fluconazole tab 50 mg G N carbinoxamine maleate liquid 4 mg/5ml

G 13 P fluconazole tab 100 mg B N HISTEX IE

G 13 P fluconazole tab 150 mg B N HISTEX CT

G 13 P fluconazole tab 200 mg G N carbinoxamine maleate tab sr 12hr 8 mg

G 13 P fluconazole sus 10mg/ml G N clemastine fumarate tab 2.68 mg

B 13 P DIFLUCAN G N clemastine fumarate syrup 0.67 mg/5ml

G 13 P fluconazole sus 40mg/ml O P diphenhydramine hcl cap 25 mg

B 13 P DIFLUCAN IN NACL G P diphenhydramine hcl cap 50 mg

B 13 P DIFLUCAN IN ISO-OSMOTIC D O P diphenhydramine hcl liquid 12.5 mg/5ml

B 11 N SPORANOX PULSEPAK O P diphenhydramine hcl elixir 12.5 mg/5ml

G 11 N itraconazole O P diphenhydramine hcl syrup 12.5 mg/5ml

B 11 N SPORANOX B P BENADRYL

B 13 P VFEND G P diphenhydramine hcl inj 50 mg/ml

B 13 P VFEND IV G N diphenhydramine tannate susp 25 mg/5ml

B 13 P CANCIDAS G P cyproheptad tab 4mg

B P MYCAMINE B P CYPROHEPTAD SYP 2MG/5ML

B 13 P MYCELEX TRO 10MG B N HISTEX PD 12

G 11 N clotrimazole tro 10mg B N POLY-HISTINE

ANTIHISTAMINES - NON-SEDATING G P hydroxyzine hcl tab 10 mg

G 9 N hydroxyzine hcl tab 25 mg B 11 P ZYRTEC G 9 N hydroxyzine hcl tab 50 mg B 11 P CLARINEX B N ATARAX B 11 P CLARINEX REDITABS G P hydroxyzine hcl syrup 10 mg/5ml G 11 N fexofenadine hcl tab 30 mg G P hydroxyzine hcl im soln 25 mg/ml G 11 N fexofenadine hcl tab 60 mg G P hydroxyzine hcl im soln 50 mg/ml B 11 N ALLEGRA B N VISTARIL CAP 25MG G 11 N fexofenadine hcl tab 180 mg G P hydroxyzine pamoate cap 25 mg O P loratadine tab 10 mg B P VISTARIL CAP 50MG O P loratadine syrup 10 mg/10ml G P hydroxyzine pamoate cap 50 mg B 11 N ASTELIN G 10 N hydroxyzine pamoate cap 100 mg ANTIHISTAMINES - NON-SEDATING / B N VISTARIL SUS 25MG/5ML DECONGESTANTS B N PROCHLORPER SUP 2.5MG B P ZYRTEC-D B N PROCHLORPER SUP 5MG G 11 N dexchlorphen tan & pseudoephed tan susp 2.5-75 mg/5ml B N COMPAZINE SUP 25MG G 11 N Fexofenadine-Pseudoephedrine ER G P prochlorperazine suppos 25 mg B 11 N ALLEGRA-D B N COMPAZINE TAB 5MG B 11 N ALLEGRA-D 24 HOUR G P prochlorperazine maleate tab 5 mg B 11 N SUDAL 12 B N COMPAZINE TAB 10MG ANTIHISTAMINES - OTHER G P prochlorperazine maleate tab 10 mg

G N brompheniramine maleate tab sr 12hr 6 mg B P COMPAZINE INJ 5MG/ML

B N BROVEX CT G N prochlorperazine edisylate inj 5 mg/ml

B N LODRANE XR Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 12 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B N MINIZIDE ANTIHISTAMINES/DECONGESTANTS B P HYDRAL/HCTZ CAP 25/25 B P HYDRAL/HCTZ CAP 50/50 B N SEMPREX-D ANTIHYPERTENSIVES - CENTRAL B N TRINALIN REPETABS

B N BROMFED-PD B N CATAPRES

G N brompheniramine & phenyleph G P clonidine hcl

B N BROMFED B P CATAPRES-TTS-1

G P CARDEC SYP 4-45MG/5 B P CATAPRES-TTS-2

B N HISTEX SR B P CATAPRES-TTS-3

B N LODRANE 12D B N GUANABENZ ACETATE

G N brompheniramine & pseudoeph B N TENEX

B N COLDEC D G P guanfacine hcl

B N PEDIATEX-D B N ALDOMET

B N RONDEC G P methyldopa

B N PALGIC D B N MINIPRESS

B N RONDEC-TR G P prazosin hcl

G N carbinoxamine & pseudoeph B P RESERPINE

B N RESCON-JR B N APRESOLINE

B N DALLERGY JR G P hydralazine hcl

B N DECONAMINE SR B N LONITEN

G N cpm/pse cap 8-120 cr G P minoxidil

G N cpm/pse cap 8-120 sr ANTILEPROTIC B N PEDIOX B P THALOMID B N DECONAMINE

G N cpm/pse syp ANTIMALARIAL AGENTS

B N QDALL B P CHLOROQUINE PHOSPHATE TAB 250 MG B N BIOHIST LA B N ARALEN G N chlorpheniramine & pseudoeph G P chloroquine phosphate tab 500 mg G N chlorphen tan & pseudoeph tan B N PLAQUENIL B N RYNATAN G P hydroxychloroquine sulfate B N DALLERGY-JR B P LARIAM B N RYNATAN PEDIATRIC G N mefloquine hcl G N chlorpheniramine tannate-phenylephrine tannate B P DARAPRIM B N TANAFED DP G P quinine sulfate G N dexbrompheniramine & pseudoephedrine B P MALARONE B N PROMETHAZINE VC ANTIMYCOBACTERIALS / ANTITUBERCULOSIS B N RYNA-12

B N RYNA-12 S G P ethambutol hcl

G N pyrilamine tannate-phenylephrine tannate B P TRECATOR

B N NALEX-A G P isoniazid

G N chlorphen-phenyltolox-pe G P pyrazinamide

G N chlorpheniramine-pyrilamine & phenylephrine B N MYCOBUTIN

ANTIHYPERTENSIVE COMBOS G P rifampin cap 150 mg

B N RIFADIN B N ENDURONYL FORTE G P rifampin cap 300 mg B N CLORPRES ANTI-PARKINSONIAN DRUGS B N ALDORIL-15

B N ALDORIL-25 G P amantadine hcl cap 100 mg

G P methyldopa & hydrochlorothiazide G N amantadine hcl tab 100 mg

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 13 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B P VESICARE ANTI-PARKINSONIAN DRUGS G N oxybutynin er - Continued - B P DETROL LA B N SYMMETREL B N SANCTURA G P amantadine hcl syrup 50 mg/5ml ANTITHYROID THERAPIES B P PARLODEL

G N bromocriptine mesylate B P TAPAZOLE TAB 5MG

B N SINEMET G N methimazole tab 5mg

B N SINEMET CR B N TAPAZOLE TAB 10MG

G P carbidopa-levodopa G N methimazole tab 10mg

B N PARCOPA B N METHIMAZOLE TAB 20MG

B P STALEVO G P propylthiouracil tab 50 mg

B N ELDEPRYL CAP 5MG ARB'S AND DIURETICS G P selegiline hcl cap 5 mg B N ATACAND HCT G P selegiline hcl tab 5 mg B P TEVETEN HCT B P LODOSYN B N AVALIDE G N atracurium besylate B P HYZAAR ANTIPROTOZOAL AGENTS B P BENICAR HCT

B N TINDAMAX B P MICARDIS HCT

B P MEPRON B P DIOVAN HCT

B P ALINIA ARTHRITIS - MISC. B P NEUTREXIN B P RIDAURA ANTI-PSORIATICS - BIOLOGICALS B P MYOCHRYSINE

B P ENBREL B 22 N RHEUMATREX

B N AMEVIVE G P methotrexate sodium tab 2.5 mg (antirheumatic)

B P RAPTIVA ARTIFICIAL SALIVA/STIMULANTS ANTI-PSORIATICS - NON-BIOLOGICALS B P EVOXAC

B N PSORIATEC B N SALAGEN

G P anthralin cream 1% G N pilocarpine hcl tab 5 mg

B P DOVONEX BETA BLOCKERS - ALPHA / BETA B P TAZORAC B N NORMODYNE B N SORIATANE B N TRANDATE B P OXSORALEN ULTRA G P labetalol hcl ANTISPASMODICS BETA BLOCKERS - CARDIO SELECTIVE B P URISPAS B N SECTRAL G N flavoxate hcl tab 100 mg G P acebutolol hcl G P oxybutynin chloride tab 5 mg B N TENORMIN TAB 25MG B N DITROPAN G P atenolol tab 25 mg G P oxybutynin chloride syrup 5 mg/5ml B N TENORMIN TAB 50MG B P CYSTOSPAZ G P atenolol tab 50 mg G P hyoscyamine tab 0.15 mg B N TENORMIN TAB 100MG B N DETROL G P atenolol tab 100 mg ANTISPASMODICS - LONG ACTING B P KERLONE

B P ENABLEX G N betaxolol hcl

B N OXYTROL B P ZEBETA

B P DITROPAN XL G N bisoprolol fumarate

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 14 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - G P penicillin v potassium tab 250 mg BETA BLOCKERS - CARDIO SELECTIVE G P penicillin v potassium tab 500 mg - Continued - G P penicillin v potassium for soln 125 mg/5ml B N BREVIBLOC G P penicillin v potassium for soln 250 mg/5ml

B P TOPROL XL G P amoxicillin (trihydrate) cap 250 mg

G P metoprolol tab 25mg G P amoxicillin (trihydrate) cap 500 mg

G P metoprolol tab 50mg G P amoxil cap 500mg

B N LOPRESSOR B P AMOXIL TAB 500MG

G P metoprolol tab 100mg G P amoxicillin (trihydrate) tab 500 mg

G P metoprolol inj 1mg/ml B P AMOXIL TAB 875MG

BETA BLOCKERS - NON SELECTIVE G N amoxicillin (trihydrate) tab 875 mg

G P amoxicillin (trihydrate) chew tab 125 mg B N CARTROL B N AMOXIL CHW 200MG B N CORGARD G N amoxicillin (trihydrate) chew tab 200 mg G P nadolol G P amoxicillin (trihydrate) chew tab 250 mg B P LEVATOL B N AMOXIL CHW 400MG G P pindolol G N amoxicillin (trihydrate) chew tab 400 mg B N INDERAL B P AMOXIL DRO 50MG/ML G P propranolol hcl G P amoxicillin (trihydrate) for susp 125 mg/5ml B P INDERAL LA CAP 60MG G P amoxil sus 125/5ml B P INDERAL LA CAP 80MG B N AMOXIL SUS 200/5ML B P INDERAL LA CAP 120MG G N amoxicillin (trihydrate) for susp 200 mg/5ml B P INDERAL LA CAP 160MG G P amoxicillin (trihydrate) for susp 250 mg/5ml B N INNOPRAN XL G P amoxil sus 250/5ml B N BETAPACE B N AMOXIL SUS 400/5ML G P sotalol hcl G N amoxicillin (trihydrate) for susp 400 mg/5ml G N sotalol hcl (afib/afl) B N DISPERMOX B P BETAPACE AF G P ampicillin G P timolol maleate tab 5 mg G P dicloxacillin sodium cap 250 mg B N BLOCADREN G P dicloxacillin sodium cap 500 mg G P timolol maleate tab 10 mg G P nafcillin sodium for inj 1 gm G P timolol maleate tab 20 mg G P nafcillin sodium for iv soln 1 gm B P COREG G P nafcillin sodium for iv soln 2 gm BETA BLOCKERS AND DIURETIC COMBO'S B P NAFCILLIN SODIUM

B P OXACILLIN SODIUM B N TENORETIC B P BACTOCILL IN DEXTROSE G P atenolol & chlorthalidone B P GEOCILLIN B N ZIAC B P PIPERACILLIN SODIUM G P bisoprolol & hydrochlorothiazide B P BICILLIN C-R B N LOPRESSOR HCT B P AUGMENTIN TAB 250MG G N metoprolol & hydrochlorothiazide B N AUGMENTIN TAB 500MG B N CORZIDE G P amoxicillin & k clavulanate tab 500-125 mg B N INDERIDE 40/25 B N AUGMENTIN TAB 875MG B N INDERIDE 80/25 G P amoxicillin & k clavulanate tab 875-125 mg G P propranolol & hydrochlorothiazide B P AUGMENTIN CHW 200MG B N TIMOLIDE 10/25 G N amoxicillin & k clavulanate chew tab 200-28.5 mg BETA-LACTAMS / CLAVULANATE COMBO'S B P AUGMENTIN CHW 250MG

B P PFIZERPEN-G B P AUGMENTIN CHW 400MG

B P PENICILLIN G POTASSIUM IN G N amoxicillin & k clavulanate chew tab 400-57 mg

B P BICILLIN L-A B P AUGMENTIN SUS 125/5ML Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 15 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - CALCIUM CHANNEL BLOCKERS--ISRADIPINES BETA-LACTAMS / CLAVULANATE COMBO'S - Continued - B 7 N DYNACIRC B P AUGMENTIN SUS 200/5ML B 7 N DYNACIRC CR G N amoxicillin & k clavulanate for susp 200-28.5 mg/5ml CALCIUM CHANNEL BLOCKERS--NIFEDIPINES B P AUGMENTIN SUS 250/5ML B N PROCARDIA B P AUGMENTIN SUS 400/5ML G P nifedipine G N amoxicillin & k clavulanate for susp 400-57 mg/5ml G N afeditab cr B P AUGMENTIN ES-600 G N nifediac cc G N amoxicillin & k clavulanate for susp 600-42.9 mg/5ml B P ADALAT CC B P AUGMENTIN XR G N nifedical xl B P UNASYN B N PROCARDIA XL G N ampicillin G N nifedipine er B P UNASYN ADD-VANTAGE B N NIMOTOP B P UNASYN BULK PACK

B P TIMENTIN CALCIUM CHANNEL BLOCKERS--NISOLDIPINE

B P ZOSYN B P SULAR BPH CALCIUM CHANNEL BLOCKERS--VERAPAMILS

B N CARDURA B N CALAN TAB 40MG G P doxazosin mesylate G P verapamil tab 40mg B N HYTRIN B N CALAN TAB 80MG G P terazosin hcl G P verapamil tab 80mg B P AVODART B N CALAN TAB 120MG B P PROSCAR G P verapamil tab 120mg B 11 N UROXATRAL B N CALAN SR B 11 N FLOMAX B N ISOPTIN SR CALCIUM CHANNEL BLOCKERS--AMLODIPINES G P verapamil hcl cr

G N verapamil inj 2.5mg/ml B P NORVASC B P VERELAN CAP 120MG SR CALCIUM CHANNEL BLOCKERS--DILTIAZEMS B N VERELAN CAP 180MG

B N CARDIZEM B N VERELAN CAP 240MG SR

G P diltiazem hcl G P verapamil hcl er

B N DILTIAZEM HCL IV FOR SOLN 100 MG B P VERELAN PM

B N DILACOR XR B N VERELAN CAP 360MG SR

G P diltia xt G P verapamil hcl sr

G P diltiazem hcl er B N COVERA-HS G P diltiazem xr CARBAPENEMS G N diltiazem hcl extended release beads B P INVANZ B P TIAZAC B P MERREM G N diltiazem hcl coated beads B N PRIMAXIN IV B N CARDIZEM CD B N PRIMAXIN IV ADD-VANTAGE B P CARDIZEM LA B N PRIMAXIN I.M. CALCIUM CHANNEL BLOCKERS--FELODIPINES CARDIAC GLYCOSIDES G N felodipine tab sr 24hr 2.5 mg B P LANOXICAPS G N felodipine tab sr 24hr 5 mg B P LANOXIN B N PLENDIL G P digoxin G N felodipine tab sr 24hr 10 mg

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 16 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B P FORTAZ CARNITINE REPLENISHER - AGENTS B N CEDAX G N ceftriaxone

B P CARNITOR B P ROCEPHIN

CCB / LIPID B P ROCEPHIN IN ISO-OSMOTIC D

B P MAXIPIME B P CADUET CHELATING AGENTS B N BIDIL

CEPHALOSPORINS B P SYPRINE

B N CUPRIMINE G P cefadroxil cap 500 mg B P DEPEN TITRATABS G N cefadroxil tab 1 gm CHOLESTEROL - BILE SEQUESTRANTS B P DURICEF

G P cefazolin sodium for inj 500 mg G P cholestyramine powder 4 gm/dose

G N cefazolin sodium for inj 1 gm B N QUESTRAN

G P cefazolin sodium for iv soln 1 gm G P cholestyramine powder packets 4 gm

B P ANCEF G P cholestyramine light powder 4 gm/dose

G P cefazolin sodium for inj 10 gm B N QUESTRAN LIGHT

G P cefazolin sodium for inj 20 gm G P cholestyramine light powder packets 4 gm

B P CEFAZOLIN SODIUM B N WELCHOL

G P cephalexin cap 250 mg B P COLESTID B N KEFLEX CHOLESTEROL - FIBRIC ACID DERIVATIVES G P cephalexin cap 500 mg

B P CEPHALEXIN MONOHYDRATE B P TRIGLIDE

G P cephalexin for susp 125 mg/5ml B N ANTARA

G P cephalexin for susp 250 mg/5ml B N LOFIBRA

B N VELOSEF B P TRICOR

G P cefaclor cap 250 mg B N LOPID

G N cefaclor cap 500 mg G P gemfibrozil tab 600 mg

G N cefaclor for susp 125 mg/5ml B P NIASPAN

G N cefaclor for susp 187 mg/5ml CHOLESTEROL - HMG COA + ABSORB INHIBITORS G P cefaclor for susp 250 mg/5ml B P ZETIA B N CECLOR B P LIPITOR G N cefaclor for susp 375 mg/5ml B P LESCOL G N cefaclor monohydrate tab sr 12hr 500 mg B P LESCOL XL B P CEFZIL B N MEVACOR G P cefuroxime axetil tab 250 mg G N lovastatin G P cefuroxime axetil tab 500 mg B P ALTOPREV B N CEFTIN B P CRESTOR B P ZINACEF B N PRAVACHOL B P OMNICEF B P ZOCOR B N SPECTRACEF B N PRAVIGARD PAC B P SUPRAX B P ADVICOR G N cefpodoxime proxetil tab 100 mg B N OMACOR G N cefpodoxime proxetil tab 200 mg B P VYTORIN B P VANTIN

B P CLAFORAN CHOLINERGIC

G N ceftazidime for inj 1 gm B N URECHOLINE B P FORTAZ INFUSION PACK G P bethanechol chloride G N ceftazidime for inj 2 gm

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 17 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B N NORINYL 1+35 COMPOUNDING MATERIALS B P ORTHO-NOVUM 1/35-28 G N norethindrone & ethinyl estradiol tab 1 mg-35 mcg

B P STERILE DILUENT FOR FLOLA B P OVCON-50 28

G P water for injection B N LOESTRIN 1/20-21

G P water for iv injection G N norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg

G P water for inject, bacteriostatic B N LOESTRIN 1.5/30-21

G P water for inject, bacteriostatic benzyl alcohol G N norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg

B P BACTERIOSTATIC WATER PARA B P NORINYL 1+50

G P saline injection bacteriostatic B P ORTHO-NOVUM 1/50-28

B P SODIUM CHLORIDE BACTERIOS G N norethindrone & mestranol tab 1 mg-50 mcg

B P CEBO #1 BLUE B P LO/OVRAL 28

B P CEBO #2 GREEN G N norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg

B P CEBO #3 ORANGE G N norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg

CONTRACEPTIVES - BI-PHASIC COMBINATIONS B P ORTHO-CYCLEN-28

G N norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg B P ORTHO-NOVUM 10/11-28 B N LOESTRIN FE 1/20 G N norethindrone-eth estradiol tab 0.5-35/1-35 mg-mcg (10/11) G N norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg CONTRACEPTIVES - EMERGENCY CONTRACEPTIVE B N LOESTRIN FE

G N norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg B P PLAN B B N SEASONALE CONTRACEPTIVES - INJECTABLE CONTRACEPTIVES - PATCHES/ VAGINAL PRODUCTS B P DEPO-PROVERA CONTRACEPTIV B P ORTHO EVRA G N medroxyprogesterone acetate im susp 150 mg/ml B P NUVARING B P DEPO-SUBQ PROVERA 104

B N LUNELLE CONTRACEPTIVES - PROGESTIN ONLY

CONTRACEPTIVES - MONOPHASIC COMBINATION O/ B N ABRAXANE C'S B N NOR-QD B N DESOGEN B P ORTHO MICRONOR B P ORTHO-CEPT-28 G N norethindrone tab 0.35 mg G N desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg B N OVRETTE 28 B P MIRCETTE

G N desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) CONTRACEPTIVES - TRI-PHASIC COMBINATIONS

B N YASMIN 28 B P CYCLESSA B P DEMULEN 1/35-28 G N desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg G N ethynodiol diacetate & ethinyl estradiol tab 1 mg-35mcg B P TRI-LEVLEN B P DEMULEN 1/50-28 B P TRIPHASIL 28 G N ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg G N levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg B P ALESSE-28 B P ORTHO-NOVUM 7/7/7-28 B P LEVLITE-28 G N norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg G N levonorgestrel & ethinyl estradiol tab 0.10 mg-20 mcg B N TRI-NORINYL 28 B N LEVLEN CONTRACT PACK G N norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg B N LEVLEN-28 B N ORTHO TRI-CYCLEN LO B P NORDETTE-21 B P ORTHO TRI-CYCLEN B P NORDETTE-28 G N norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg G N levonorgestrel & ethinyl estradiol tab 0.15 mg-30mcg B N ESTROSTEP FE B P OVCON-35/28 COUGH/COLD - ANTITUSSIVE - NARCOTIC B N BREVICON-28

B P MODICON-28 B N HYCODAN TAB 5MG

G N norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg G N hydrocodone/ tab homatrop Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 18 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - G N tussitab COUGH/COLD - ANTITUSSIVE - NARCOTIC B N HYCOTUSS EXPECTORANT - Continued - G N hydrocodone-guaifenesin G N hydrocod/hom syp 5-1.5/5 B N M-CLEAR JR

G N hydromet syp 5-1.5/5 B P PRO-CLEAR SYP

COUGH/COLD - ANTITUSSIVE - NONNARCOTIC B N PRO-CLEAR

B N PROLEX DH G N benzonatate cap 100 mg G N hydrocodone-potassium guaiacolsulfonate B N TESSALON B N HUMIBID DM G 2 N benzonatate cap 200 mg COUGH/COLD - ANTITUSSIVE-EXPECTORANT - COUGH/COLD - ANTITUSSIVE-EXPECTORANT DECONGEST-ANTIHIST G N pseudoephed-bromphen-dm-gg syrup 30-2-5-50 mg/5ml B N BRONTEX COUGH/COLD - ANTITUSSIVE-EXPECTORANTS- G N gg/codeine tab 300-10 DECONGESTANT B N TUSSI-ORGANIDIN NR B N ENTEX HC

B N TUSSI-ORGANIDIN-S NR B N LEVALL 5.0

B N DIABETIC TUSSIN C G N phenylephrine w/hydrocodone-gg

G P CHERATUSSIN SYP AC B N DURATUSS HD

G N codeine-guaifenesin B N NUCOFED EXPECTORANT

G N gg/codeine syp 100-10/5 B N NOVAHISTINE EXPECTORANT

B N PROLEX DM G N pseudoephedrine w/ codeine-gg

G N dextromethorphan-potassium guaiacolsulfonate B N Z-COF DMX

G N drituss dm G P TRI-VENT DM SYP

G N guiadrine dm G N coldmist dm syp 40-15-10

G N ht-tuss dm G N pseudoephedrine w/ dm-gg syrup 40-15-100 mg/5ml

G N hydro-tussin dm B N PROFEN II DM

G N su-tuss dm G N pseudoephedrine w/ dm-gg tab sr 12hr 45-30-800 mg

O P dextromethorphan-guaifenesin syrup 10-100 mg/5ml B N PANMIST DM

B N DURATUSS DM G N coldmist dm tab 12hr

B N DURADEX G N pseudoephedrine w/ dm-gg tab sr 12hr 48-32-595 mg

G N dextromethorphan/guaifene G N pseudoephedrine w/ dm-gg tab sr 12hr 60-30-600 mg

G N amibid dm B N AQUATAB C

G N aquabid-dm B N MAXIFED DMX

G N gg/dm cr tab 600-30mg B N PROFEN FORTE DM

G N gg/dm sr tab 600-30mg G N pseudoephedrine w/ dm-gg

G N guaifenex dm B N PANCOF EXP

G N q-bid-dm G N pseudoephedrine-dihydrocodeine-guaifenesin

B N Z-COF LAX G N pseudoephedrine w/ hydrocodone-gg syrup 15-3-100 mg/5ml

G N exefen-dm G N pseudoeph w/hydrocodone-gg

B N MUCO-FEN DM B N LEVALL

G N gfn 1000/dm 60 G N phenylephrine-carbetapentane-guaifenesin G N gg/dm la tab COUGH/COLD - DECONGESTANT & G N guaifenesin tab dm ANTICHOLINERGIC B N AQUATAB DM B N ALLERX-D

G N entab-dm G N pseudoephedrine-methscopolamine

G N g-bid dm COUGH/COLD - DECONGESTANT W/ EXPECTORANT G N gfn 1200/dm 60 B N ENTEX G N guaifenesin tab /dm er B N GUAIFED-PD G N guaifenesin/dm sr B N ENTEX ER G N tussi-bid B N GUAIFED Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 19 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B N ALLERX DOSE PACK COUGH/COLD - DECONGESTANT W/ EXPECTORANT B N DURAHIST - Continued - B N MESCOLOR B N DECONSAL II G N chlorpheniramine-pseudoephedrine & methscopolamine

B N ENTEX LA B N EXTENDRYL JR

B N PROLEX PD B N EXTENDRYL

B N PROLEX D B N EXTENDRYL SR

B N MAXIPHEN-G B N DURAHIST PE

B N DURAPHEN II B N OMNIHIST II LA

B N DURATUSS B N DALLERGY

B N DURATUSS GP G N chlorpheniramine-phenylephrine-methscopolamine B N J-MAX COUGH/COLD - EXPECTORANT MIXTURES B N LIQUIBID-D

B N MAXIPHEN B N HUMIBID LA

G N phenylephrine-guaifenesin COUGH/COLD - EXPECTORANTS B N ALDEX G B N ORGANIDIN NR B N SINA-12X G N guaifenesin B N RESPAIRE-60

B N PANMIST S COUGH/COLD - NARCOTIC ANTITUSSIVE- ANTIHISTAMINE G N pseudoephedrine-guaifenesin syrup 40-200 mg/5ml B N TUSSIONEX PENNKINETIC EXT B N LEVALL G G N PROMETH/COD SYP 6.25-10 B N ENTEX PSE G N promethazine w/ codeine syrup 6.25-10 mg/5ml G N pseudoephedrine-guaifenesin tab sr 12hr 45-800 mg COUGH/COLD - NARCOTIC ANTITUSSIVE- B N PANMIST JR DECONGESTANT G N pseudoephedrine-guaifenesin tab sr 12hr 60-600 mg B N NALEX DH

G N pseudoephedrine-guaifenesin tab sr 12hr 60-1200 mg G P phenyleph-hydrocodone

B N AQUATAB D G P pseudoephedrine w/ hydrocodone

B N MAXIFED B N NUCOFED G N pseudoephedrine-guaifenesin tab sr 12hr 80-800 mg COUGH/COLD - NARCOTIC ANTITUSSIVE- G N PSEUDO/GG LA TAB 12HR DECONGESTANT-ANTIHISTAMINE B N PANMIST LA B N PROMETHAZINE VC/CODEINE

G N pseudoephedrine-guaifenesin tab sr 12hr 85-795 mg B N CODIMAL PH

B N H 9600 SR B N PANCOF PD

B N PROFEN FORTE G N phenylephrine-chlorpheniramine-dihydrocodeine

B N DYNEX G N pseudoeph-chlorphen w/ cod

G N GG/PSE CR TAB 600-120 B N Phenyleph-CPM w/ Hydrocod

G N GUAIFENEX TAB PSE 120 G N Phenyleph-CPM w/ Hydrocod

G N MIRAPHEN PSE TAB 120-600 B N B-TUSS

B N ZEPHREX LA G N HISTINEX HC SYP

G N pseudoephedrine-guaifenesin tab sr 12hr 120-600 mg G N CODITUSS DH SYP

G N pseudoephedrine-guaifenesin B N CODIMAL DH

G N pseudoephedrine-guaifenesin tab sr 12hr 120-1200 mg G N phenyleph-pyril w/ hydrocod

COUGH/COLD - DECONGESTANT-ANTIHISTAMINE W/ B N PRO-RED SYP EXPECTORANT B N PRO-RED

B N RYNA-12X B N BROVEX HC

COUGH/COLD - DECONGESTANT-ANTIHISTAMINE- B N M-END (REFORMULATED) ANTICHOLINERGIC G N pseudoephed-cpm w/ hydrocod B N PANNAZ S B N PANCOF B N PANNAZ G N pseudoephedrine-chlorpheniramine-dihydrocodeine G N carbinoxamine-pseudoephedrine-methscopolamine G N PSE/HYDROCOD LIQ /CARBINX

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 20 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - O P pseudoephedrine hcl syrup 30 mg/5ml COUGH/COLD - NARCOTIC ANTITUSSIVE- COUGH/COLD - TOPICAL DECONGESTANTS DECONGESTANT-ANTIHISTAMINE - Continued - G N TRI-VENT HC LIQ B N ADRENALIN

B N HISTEX HC B N TYZINE PEDIATRIC NASAL DR

G N pseudoephedrine-carbinoxamine w/ hydrocodone B N TYZINE

COUGH/COLD - NON-NARC ANTITUSSIVE- COX 2 INHIBITORS - HIGHLY SELECTIVE ANTIHISTAMINE B N TUSSI-12 B 11 P CELEBREX

G N tussizone-12 tab 5-60mg COX 2 INHIBITORS - SELECTIVE B N TUSSI-12 S G 11 N ketorolac tromethamine tab 10 mg G N chlorpheniramine tannate-carbetapentane tannate G P ketorolac tromethamine inj 15 mg/ml G N tussizone-12 sus 4-30mg/5 B 11 N TORADOL IV/IM G N PROMETHAZINE SYP DM G P ketorolac tromethamine inj 30 mg/ml G N promethazine-dm B 11 N MOBIC TAB 15MG COUGH/COLD - NON-NARC ANTITUSSIVE- DECONGESTANT B 11 N MOBIC SUS 7.5/5ML B N RESPI-TANN B 11 N RELAFEN

O P pseudoephedrine-dm liqd 30-15 mg/15ml G P nabumetone

O P pseudoephedrine-dm liqd 15-7.5 mg/5ml CYTO-MEGALOVIRUS AGENTS O P pseudoephedrine-dm liqd 20-10 mg/5ml B P VISTIDE O P pseudoephedrine-dm liqd 30-15 mg/5ml B P FOSCAVIR O P pseudoephedrine-dm elixir 20-10 mg/5ml B P CYTOVENE CAP 250MG O P pseudoephedrine-dm syrup 15-5 mg/5ml B P CYTOVENE CAP 500MG O P pseudoephedrine-dm syrup 15-7.5 mg/5ml G P ganciclovir O P pseudoephedrine-dm syrup 30-15 mg/5ml B N CYTOVENE INJ 500MG O P pseudoephedrine-dm soln 7.5-2.5 mg/0.8ml B P VALCYTE COUGH/COLD - NON-NARC ANTITUSSIVE- DECONGESTANT-ANTIHISTAMINE DENTAL PRODUCTS G N phenylephrine-chlorphen-dm B P PREVIDENT G N phenyleph tannate-chlorphen tannate-carbetapentane tannate B P PREVIDENT 5000 PLUS G N phenylephrine-pyrilamine-dm G P sodium fluoride cream 1.1% B N TUSSI-12D B P PREVIDENT 5000 BOOSTER B N TUSSI-12D S B P PREVIDENT FLUORIDE G N pseudoephedrine tan-chlorphen tan-dextromethorphan tan B N THERA-FLUR-N B N DELTUSS DMX G P sodium fluoride gel 1.1% (0.5% f) G N ANDEHIST DM SYP NR B P GEL-KAM ORAL CARE RINSE G N BROMAXEFED SYP DM RF G P stannous fluoride conc 0.63% G N pseudoephed-bromphen-dm

B N TANAFED DMX DIABETIC - ALPHAGLUCOSIDASE

B N PEDIATEX DM B N PRECOSE B N CORDRON-DM B P GLYSET B N RONDEC DM DIABETIC - INSULIN G N pseudoephed-carbinox-dm

B N RYNATUSS O P ILETIN II REGULAR/PORK

B N RYNATUSS PEDIATRIC O P ILETIN II NPH/PORK

G N phenylephrine-ephedrine-chlorpheniramine w/ carbetapentane B P NOVOLOG

COUGH/COLD - SYSTEMIC DECONGESTANTS B N LEVEMIR

B P LANTUS O P pseudoephedrine hcl tab 30 mg B N HUMALOG O P pseudoephedrine hcl tab 60 mg

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 21 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B P BYETTA DIABETIC - INSULIN G P chlorpropamide - Continued - B N AMARYL O P NOVOLIN R G P glimepiride

O P RELION R B N GLUCOTROL

B N HUMULIN R G P glipizide

O P VELOSULIN BR B N GLUCOTROL XL

B N HUMULIN N G N glipizide er

O P NOVOLIN N G N glipizide xl

O P RELION N B N DIABETA

B N HUMULIN L B N MICRONASE

B N HUMULIN U G P glyburide

B P NOVOLOG MIX 70/30 B N GLYNASE

B N HUMALOG MIX 75/25 G P glyburide micronized

B N HUMULIN 70/30 B N TOLINASE

O P NOVOLIN 70/30 G P tolazamide

O P RELION 70/30 B P TOLBUTAMIDE B N HUMULIN 50/50 DIABETIC - OTHER DIABETIC - INSULIN PENFILLS B P SYMLIN

B 11 P NOVOLOG FLEXPEN B N GLUCAGEN

B 11 P NOVOLOG PENFILL B P GLUCAGON EMERGENCY KIT

B 11 P LANTUS OPTICLIK B P PROGLYCEM

B 11 N HUMALOG B P GLUCAGON B 11 N HUMALOG PEN DIABETIC - SULFONYLUREA / BIGUANIDE O 11 P NOVOLIN R INNOLET

O 11 P NOVOLIN R U-100 PENFILL B N METAGLIP

B 11 N HUMULIN N U-100 PEN B P GLUCOVANCE

O 11 P NOVOLIN N INNOLET G N glyburide-metformin

O 11 P NOVOLIN N U-100 PENFILL B P AVANDARYL

B 11 P NOVOLOG MIX 70/30 PENFILL DIABETIC - THIAZOL B 11 P NOVOLOG MIX 70/30 PREFILL B P ACTOS B 11 N HUMALOG MIX 75/25 PEN B P AVANDIA B 11 N HUMULIN 70/30 PEN

O 11 P NOVOLIN 70/30 INNOLET DIABETIC - THIAZOL / BIGUANIDE COMBO

O 11 P NOVOLIN 70/30 PENFILL B P ACTOPLUS MET DIABETIC - MEGLITINIDES B P AVANDAMET

B P STARLIX DIAGNOSTIC BIOLOGICALS

B N PRANDIN B P APLISOL DIABETIC - ORAL BIGUANIDES B N TUBERSOL

B N GLUCOPHAGE DIURETICS

G P metformin hcl B 11 P INSPRA B N RIOMET G P acetazolamide B N GLUMETZA B N DIAMOX B N GLUCOPHAGE XR G P methazolamide G N metformin hcl er B N BUMEX B N FORTAMET G P bumetanide DIABETIC - ORAL SULFONYLUREAS B P EDECRIN

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 22 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - G N antibiot ear sus 1% otic DIURETICS G N cortomycin sus 1% otic - Continued - G N neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% B N LASIX B P CORTISPORIN SOL 1% OTIC

G P furosemide G P antibiot ear sol 1% otic

B N DEMADEX G P cortomycin sol 1% otic

G P torsemide G P neomycin-polymyxin-hc otic soln 1%

B N MIDAMOR B N COLY-MYCIN-S

G P amiloride hcl tab 5 mg B N CORTISPORIN-TC

B N ALDACTONE G P benzocaine & antipyrine

G P spironolactone B N CORTANE-B-OTIC

B N NATURETIN G N pramoxine-hc-chloroxylenol

G P chlorothiazide B N CORTANE-B AQUEOUS

B N DIURIL G N pramoxine-hc-chloroxylenol aqueous

B N DIURIL IV B N TYMPAGESIC DROPS

B N THALITONE G P benzocaine-phenylephrine-antipyrine G P chlorthalidone ELECTROLYTES/ NUTRITIONALS B N MICROZIDE

G P hydrochlorothiazide O P *oral electrolyte solution***

B N LOZOL B N MULTILYTE-20

G P indapamide G P lactated ringer's solution

G P methyclothiazide G P kcl 0.15% in nacl 0.9%

B P ZAROXOLYN G P dextrose 5% w/ kcl 0.15%

G P metolazone G P dextrose 5% w/ kcl 0.224%

B N MODURETIC 5-50 G P dextrose 5% w/ sodium chloride 0.2%

G P amiloride & hydrochlorothiazide G P dextrose 5% w/ sodium chloride 0.45%

B P ALDACTAZIDE TAB 25/25 G P dextrose 5% w/ sodium chloride 0.9%

G P spironolactone & hydrochlorothiazide G P dextrose 10% w/ sodium chloride 0.2%

B P ALDACTAZIDE TAB 50/50 G P dextrose 5% in lactated ringers

B N DYAZIDE G P kcl 0.075% in d5/0.2% nacl

B N MAXZIDE-25 G P kcl 0.075% in d5/0.45% nacl

B N MAXZIDE G P kcl 0.15% in d5/0.33% nacl

G P triamterene & hydrochlorothiazide G P kcl 0.15% in d5/0.45% nacl

DOPAMINE RECEPTOR AGONISTS G P kcl 0.224% in d5/0.45% nacl G P dextrose inj 5%

B P DOSTINEX G P dextrose inj 10%

EAR G P dextrose inj 50%

G P dextrose inj 70% B P FLOXIN OTIC B N LIPOSYN III B N FLOXIN OTIC SINGLES G P fat emulsion iv soln 20% G P benzocaine (otic) B N FREAMINE III G N hydrocortisone w/acetic acid B P PREMASOL G P acetic acid (otic) B P TRAVASOL B N DOMEBORO B N TROPHAMINE G P acetic acid-aluminum acetate B P AMINOSYN II B N CORTANE-B G N *amino acid infusion 15%*** B P CIPRODEX G N albumin, human inj 5% B P CIPRO HC G P buminate inj 25% B P CORTISPORIN SUS 1% OTIC G P flexbumin inj 25% B P PEDIOTIC G P plasbumin-25 inj 25%

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 23 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B P CIPRO CYSTITIS ERYTHROPOEISIS STIMULATING AGENTS B N CIPRO G P ciprofloxacin hcl

B 11 N ARANESP B N PROQUIN XR

B 11 N EPOGEN B P CIPRO I.V.

B 11 P PROCRIT B 26 N LEVAQUIN LEVA-PAK

ESTROGEN COMBOS G N levofloxacin

B 26 N LEVAQUIN B N ANGELIQ B 26 N LEVAQUIN PREMIX ESTROGEN COMBO'S B P AVELOX ABC PACK

B P AVELOX G N estradiol & testosterone cypionates im in oil 2-50 mg/ml B N NOROXIN G N estradiol val & testosterone enanthate im in oil 4-90 mg/ml B N FLOXIN G N estradiol val & testosterone enanthate im in oil 8-180 mg/ml G N ofloxacin B P PREMPRO G N gatifloxacin B P PREMPHASE B N TEQUIN B N ACTIVELLA B N FACTIVE B N COMBIPATCH

B N FEMHRT 1/5 GI - ANTI - FLATULENTS / GI STIMULANTS

G N Estradiol-Norgestimate B N VISICOL TAB 1.5GM B N PREFEST O P senna tab 187 mg ESTROGENS - PATCHES O P sennosides tab 8.6 mg

O P SENNOSIDES GRANULES 15 MG/TSP (15 MG/3GM) B N ESTROGEL G P lactulose solution 10 gm/15ml B N ALORA B N KRISTALOSE PAK 10GM B N ESCLIM B N KRISTALOSE PAK 20GM B P ESTRADERM B N MIRALAX POW 3350 NF B P VIVELLE G N polyethylene glycol 3350 oral powder B P VIVELLE-DOT B N MIRALAX PAK 3350 NF B N MENOSTAR G N polyethylene glycol 3350 oral packet B N CLIMARA B P NULYTELY SOL G N estradiol G P peg 3350-kcl-sod bicarb-nacl for soln 420 gm ESTROGENS - TABS B P COLYTE SOL

B P PREMARIN B P COLYTE-FLAV SOL

B P CENESTIN B P GOLYTELY SOL PINEAPPL

B P MENEST B P COLYTE/FLAVR SOL PACKS

B N ESTRACE G P peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm

G P estradiol B P GOLYTELY SOL

G P gynodiol B P GASTROCROM CON 100/5ML

B P DEPO-ESTRADIOL B N REGLAN TAB 5MG

G N estradiol cypionate G P metoclopramide hcl tab 5 mg

B N DELESTROGEN B N REGLAN TAB 10MG

G N estradiol valerate G P metoclopramide hcl tab 10 mg

B N ESTRONE G P metoclopramide hcl syrup 5 mg/5ml

B N OGEN G P metoclopramide hcl inj 5 mg/ml

G P estropipate G P lactulose (encephalopathy) solution 10 gm/15ml

FLUOROQUINOLONES GI - ANTIDIARRHEAL / ANTACID - MISC.

B P CIPROFLOXACIN O 11 P sodium bicarbonate tab 325 mg

B P CIPRO XR O 11 P sodium bicarbonate tab 650 mg

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 24 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B 11 N KU-ZYME GI - ANTIDIARRHEAL / ANTACID - MISC. B 11 N LAPASE - Continued - B 11 N DYGASE O 11 P magnesium oxide cap 140 mg (85 mg elemental mg) B 11 N KUTRASE

O 11 P magnesium oxide tab 400 mg B 11 N VIOKASE 8

B P SAL-TROPINE G 11 P amylase-lipase-protease tab 30000-8000-30000 unit

G P atropine sulfate B 11 N VIOKASE 16

B N BELLADONNA ALKALOIDS G 11 N amylase-lipase-protease tab 60000-16000-60000 unit

B P ANASPAZ B 11 N VIOKASE

B N SYMAX DUOTAB B 11 N PANCREASE MT 4

B N LEVSIN/SL B 11 N CREON 5

G P hyoscyamine sub 0.125mg G 11 P lipram-cr5

G P hyoscyamine elx 0.125/5 B 11 N PANCREASE

B N LEVSIN B 11 N PANOCAPS

G P hyoscyamine dro 0.125/ml G 11 P lipram 4500

B N LEVSINEX G 11 P pancrelipase

B N NULEV G 11 P pangestyme ec

G P hyoscyamine tab 0.125mg G 11 P ultrase

B N LEVBID B 11 N PANCRECARB MS-4

G P hyoscyamine tab 0.375mg B 11 N PANCREASE MT 10

G P hyoscyamine sulfate G 11 P lipram-pn10

B P ROBINUL TAB 1MG B 11 N CREON 10

B P ROBINUL FORTE B 11 N PALCAPS 10

B N ROBINUL INJ 0.2MG/ML G 11 P lipram-cr10

G N glycopyrrolate G 11 P pangestyme cn 10

B P PAMINE B 11 P ULTRASE MT 12

B P PAMINE FORTE G 11 P lipram-ul12

B P PROPANTHELINE BROMIDE G 11 P pangestyme ul 12

B N BENTYL CAP 10MG B 11 N PANCRECARB MS-8

B N BENTYL TAB 20MG B 11 N PANCREASE MT 16

G P dicyclomine hcl B 11 N PANOCAPS MT 16

B P BENTYL SYP 10MG/5ML G 11 P lipram-pn16

B N B & O 15-A SUPPRETTE G 11 P pancrelipase mst-16

G P belladonna alkaloids & opium suppos 16.2-30 mg G 11 P pangestyme mt 16

B N B & O 16-A SUPPRETTE B 11 N PANCREASE MT 20

G N belladonna alkaloids & opium suppos 16.2-60 mg B 11 N PANOCAPS MT 20

GI - ANTIPERISTALTIC AGENTS G 11 P lipram-pn20

B 11 P ULTRASE MT 18 B N LOMOTIL G 11 P pangestyme ul 18 G P diphenoxylate w/ atropine B 11 N CREON 20 B N MOTOFEN B 11 N PALCAPS 20 G P loperamide cap 2mg G 11 P lipram-cr20 O P loperamide hcl tab 2 mg G 11 P pangestyme cn 20 O P loperamide hcl liq 1 mg/5ml (0.2 mg/ml) B 11 P ULTRACAPS MT 20 B P OPIUM TINCTURE B 11 P ULTRASE MT 20 G P paregoric G 11 P lipram-ul20 GI - DIGESTIVE ENZYMES G 11 P pangestyme ul 20

G 11 N digestive enzymes w/ anticholinergics GI - H2-ANTAGONISTS

B 11 N KU-ZYME HP G P cimetidine tab 200 mg

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 25 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - GI - MISC. ANTI-ULCER GI - H2-ANTAGONISTS - Continued - B N CARAFATE TAB 1GM G P cimetidine tab 300 mg G P sucralfate tab 1 gm

B N TAGAMET B P CARAFATE SUS 1GM/10ML G P cimetidine tab 400 mg GI - PROSTAGLANDINS G P cimetidine tab 800 mg B P CYTOTEC G P cimetidine hcl G N misoprostol G N ranitidine cap 150mg

G N ranitidine cap 300mg GI - PROTON PUMP INHIBITOR

B N ZANTAC TAB 150MG B 11 N NEXIUM G P ranitidine tab 150mg B 12 P PREVACID B N ZANTAC TAB 300MG B 12 P PREVACID SOLUTAB G P ranitidine tab 300mg B 11 N ZEGERID B N ZANTAC TAB 150MG EF G 11 N omeprazole caps B N RANITIDINE SYP 75MG/5ML B 11 N PRILOSEC B P ZANTAC SYP 75MG/5ML O 12 P OMEPRAZOLE MAGNESIUM DELAYED RELEASE TAB 20 MG (BASE EQUIV) B N ZANTAC INJ 25MG/ML B 12 P PROTONIX G P ranitidine inj 150/6ml B 11 N ACIPHEX G P ranitidine inj 50mg/2ml GI - PROTON PUMP INHIBITOR/NSAID COMBO B N PEPCID

G P famotidine B 12 P PREVACID NAPRAPAC G N nizatidine GI - ULCER ANTI-INFECTIVE B N AXID

GI - INFLAMMATORY BOWEL AGENTS B P HELIDAC B 12 P PREVPAC B P COLAZAL GLUCOCORTICOIDS - CORTICOTROPIN B P PENTASA

B P ASACOL B P ACTHAR HP B P ROWASA GLUCOCORTICOIDS - MINERALOCORTICOIDS G P mesalamine enema 4 gm B P CELESTONE B P CANASA B P ENTOCORT EC B P DIPENTUM G P cortisone acetate B P AZULFIDINE B P DEXAMETHASONE INTENSOL G P sulfasalazine tab 500 mg B N DECADRON B P AZULFIDINE EN-TABS G P dexamethasone G N sulfasalazine tab delayed release 500 mg G P dexamethasone sodium phosphate inj 4 mg/ml B N REMICADE G P dexamethasone sodium phosphate inj 10 mg/ml GI - IRRITABLE BOWEL SYNDROME AGENTS B P HYDROCORTONE

B N LOTRONEX B P CORTEF

B 11 N ZELNORM G P hydrocortisone

GI - MISC. B P SOLU-CORTEF B N MEDROL

B P HALFLYTELY BOWEL PREP KIT G P methylprednisolone

B P ACTIGALL B P DEPO-MEDROL

G P ursodiol cap 300 mg G N methylprednisolone acetate

B P URSO B P SOLU-MEDROL

B P URSO 250 G N methylprednisolone sod succ

B P SORBITOL B N PRELONE

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 26 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - HEMOSTATIC GLUCOCORTICOIDS - MINERALOCORTICOIDS - Continued - B P AMICAR G P prednisolone G P aminocaproic acid

B P PEDIAPRED B N SURGICEL FIBRILLAR ABSORB

B P ORAPRED B N SURGICEL ABSORBABLE HEMOS

G N prednisolone sodium phosphate B N SURGICEL NU-KNIT ABSORBAB

G P deltasone HEPATITIS B ONLY G P orasone B P HEPSERA B N PREDNISONE INTENSOL B P BARACLUDE G P prednisone

B P KENALOG-10 HEPATITIS C AGENTS

B P KENALOG-40 B N INFERGEN B N CELESTONE-SOLUSPAN B P PEGASYS B P FLORINEF B P PEG-INTRON G N fludrocortisone acetate B P PEG-INTRON REDIPEN GOUT B P PEG-INTRON REDIPEN PAK 4

B P REBETOL B N ZYLOPRIM G N ribavirin cap 200 mg G P allopurinol B N COPEGUS B N COLCHICINE TAB 0.6 MG B P REBETRON G P colchicine

G P probenecid HEREDITARY TYROSINEMIA TYPE 1 (HT-1) TREATMENT - AGENTS B P SULFINPYRAZONE B P ORFADIN G P colchicine w/ probenecid HERPES AGENTS GRANULOCYTE CSF

B N ZOVIRAX CAP 200MG B 11 P NEUPOGEN G P acyclovir cap 200mg B 11 N NEULASTA B N ZOVIRAX TAB 400MG B 11 N LEUKINE G P acyclovir tab 400mg B 11 N NEUMEGA B N ZOVIRAX TAB 800MG GROWTH HORMONE G P acyclovir tab 800mg

B P ZOVIRAX SUS 200/5ML B 11 N PROTROPIN G N acyclovir sus 200/5ml B 11 N NUTROPIN AQ G P acyclovir sodium B 11 N NUTROPIN AQ PEN B P VALTREX B 11 N NORDITROPIN CARTRIDGE B N FAMVIR B 11 N NORDITROPIN NORDIFLEX PEN

B 11 N IPLEX HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS B 11 N HUMATROPE COMBO PACK B P HECTOROL B 11 N NUTROPIN INJ 5MG HYPERPARATHYROID TREATMENT - VITAMIN D B 11 P TEV-TROPIN ANALOGS AND CALCIMIMETICS B 11 P GENOTROPIN INTRA-MIX B N ZEMPLAR

B 11 P GENOTROPIN B N SENSIPAR

B 11 N NUTROPIN INJ 10MG B P NAGLAZYME B 11 N HUMATROPE IMMUNE SERUMS B 11 P GENOTROPIN MINIQUICK

B 11 N NUTROPIN DEPOT B N CYTOGAM

B 11 N SAIZEN B N BAYHEP B

B 11 N ZORBTIVE G P hepatitis b immune globulin (human) inj

B 11 N INCRELEX G N immune globulin (human) inj Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 27 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B P CLEOCIN INJ 900MG IMMUNE SERUMS B 11 P ZYVOX - Continued - B P CUBICIN G P GAMMAGARD SD INJ 0.5GM HU B P DAPSONE G N gammagard s/d MACROLIDES / ERYTHROMYCIN'S / KETOLIDES G N POLYGAM S/D SOL 2.5GM

G P immune globulin (human) iv for soln 5 gm B P ERYTHROMYCIN BASE

G N immune globulin (human) iv for soln 6 gm B P ERY-TAB

G P immune globulin (human) iv for soln 10 gm B N ERYC

B P FLEBOGAMMA G P erythromycin w/ delayed release particles cap 250 mg

G P GAMMAGARD LIQUID B N PCE

B P GAMIMUNE N G P erythromycin stearate tab 250 mg

B P GAMUNEX G P erythromycin stearate tab 500 mg

G N immune globulin (human) iv soln 10% B P ERYTHROMYCIN ESTOLATE

G P rabies immune globulin (human) inj 150 unit/ml G P erythromycin ethylsuccinate tab 400 mg

B P WINRHO SDF G P erythromycin ethylsuccinate susp 200 mg/5ml

G P rho d immune globulin (human) im inj 50 mcg G P erythromycin ethylsuccinate susp 400 mg/5ml

B P RHOGAM HUMAN B P ERYPED

B P BAYTET B P E.E.S. GRANULES

INFLUENZA AGENTS B P ERYPED 200 B P ERYPED 400

B N FLUMADINE TAB 100MG B P ZITHROMAX TAB 250MG

G P rimantadine hydrochloride tab 100 mg B P ZITHROMAX Z-PAK

B P FLUMADINE SYP 50MG/5ML G N azithromycin tab 250 mg

B 25 P TAMIFLU B P ZITHROMAX TAB 500MG

B P RELENZA DISKHALER B P ZITHROMAX TRI-PAK

B P FLUARIX 2005-2006 G N azithromycin tab 500 mg

B 5 P FLUMIST NASAL VACCINE 200 B P ZITHROMAX TAB 600MG

IRRIGATION SOLUTIONS G N azithromycin tab 600 mg

B P ZITHROMAX SUS 100/5ML G P water for irrigation, sterile irrigation soln B P ZITHROMAX SUS 200/5ML K REMOVING RESINS B P ZITHROMAX SUS 200MG/5

B P ZMAX G P sodium polystyrene sulfonate oral susp 15 gm/60ml B N ZITHROMAX INJ 500MG G P sodium polystyrene sulfonate rectal susp 30 gm/120ml B N ZITHROMAX POW 1GM PAK B P KAYEXALATE B N BIAXIN TAB 250MG G P sodium polystyrene sulfonate powder G N clarithromycin tab 250 mg LINCOSAMIDES / OXAZOLIDINONES / LEPROSTATICS B N BIAXIN TAB 500MG

G N chloramphenicol sodium succinate for iv inj 1 gm G N clarithromycin tab 500 mg

B N LINCOCIN B P BIAXIN SUS 125/5ML

B N CLEOCIN CAP 150MG B P BIAXIN SUS 250/5ML

G P clindamycin hcl cap 150 mg G N clarithromycin er

B N CLEOCIN CAP 300MG B P BIAXIN XL

G 4 N clindamycin hcl cap 300 mg B P BIAXIN XL PAC

B P CLEOCIN PEDIATRIC GRANULE B N DYNABAC D5-PAK

B P CLEOCIN INJ 300MG B N KETEK

B P CLEOCIN INJ 9GM MIGRAINE - CARBOXYLIC ACID DERIVATIVES G P clindamycin phosphate inj 150 mg/ml B P DEPAKOTE ER G P clindamycin phosphate iv soln 150 mg/ml

B P CLEOCIN INJ 600MG

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 28 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - G P sodium fluoride chew tab 2.2 mg (1 mg f) MIGRAINE - ERGOTAMINE DERIVATIVES G P sodium fluoride soln 0.275 mg/drop (0.125 mg/drop f) G P sodium fluoride soln 0.55 mg/drop (0.25 mg/drop f)

B 11 N D.H.E. 45 B P LURIDE

G 17 P dihydroergotamine mesylate inj 1 mg/ml B N PEDIAFLOR

B 17 P MIGRANAL G P sodium fluoride soln 1.1 mg/ml (0.5 mg/ml f)

MIGRAINE - MISC. B P PIMA

B P SSKI B 11 N CAFERGOT TAB 1-100MG G P magnesium sulfate inj 50% G 11 N ergotamine w/ caffeine tab 1-100 mg B 11 P MAGNEBIND 400 B 17 P CAFERGOT SUP 2/100 G P potassium phosphate dibasic inj 3 mmole/ml MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT)- B P K-PHOS -INJECTABLES G P sodium phosphate inj 3 mmole/ml B 17 P IMITREX SPR 5MG/ACT B N K-PHOS NEUTRAL B 17 P IMITREX SPR 20MG/ACT G P pot phos monobasic w/sod phos di & monobas tab 155-852-130mg B 17 P IMITREX INJ 6MG/0.5 B N POTASSIUM ACETATE B 17 P IMITREX STATDOSE PEN G P potassium acetate inj 2 meq/ml B 17 P IMITREX STATDOSE REFILL B N K-LYTE B 11 N ZOMIG G P potassium bicarbonate effer tab 25 meq MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT)- -TABS B N K-LYTE DS B 11 N AXERT B P MICRO-K

B 17 P RELPAX G P potassium chloride cap cr 10 meq

B 11 N FROVA G P potassium chloride tab cr 8 meq

B 11 N AMERGE B N K-TABS

B 17 P MAXALT G P potassium chloride tab cr 10 meq

B 17 P MAXALT-MLT G P potassium chloride oral liq 10%

B 17 P IMITREX TAB 25MG B N RUM-K

B 17 P IMITREX TAB 50MG B N KAON-CL

B 17 P IMITREX TAB 100MG G P potassium chloride oral liq 20%

B 11 N ZOMIG G P potassium chloride inj 2 meq/ml

B 11 N ZOMIG ZMT B N POTASSIUM CHLORIDE

MINERALS G P potassium chloride powder packet 20 meq B N KLOR-CON 25 G P sodium acetate inj 2 meq/ml G P potassium chloride microencapsulated crys cr tab 10 meq B N SODIUM ACETATE TRIHYDRATE B N KLOR-CON M15 G P sodium bicarbonate inj 8.4% B P K-DUR O 11 P calcium carbonate tab 600 mg G P potassium chloride microencapsulated crys cr tab 20 meq O 11 P calcium carbonate chew tab 1250 mg (500 mg elemental ca) B N K-LYTE/CL O 11 P calcium carbonate susp 1250 mg/5ml G N pot bicarbonate & chloride effer tab 25 meq O 11 P calcium gluconate tab 650 mg G P sodium chloride inj 0.45% G 11 N calcium gluconate inj 10% G P sodium chloride inj 0.9% O P calcium lactate tab 650 mg G P sodium chloride iv soln 0.9% O 11 P calcium carbonate-vitamin d tab 500 mg-200 unit G N sodium chloride inj 5% O 11 P calcium carbonate-vitamin d tab 600 mg-200 unit B N SODIUM CHLORIDE B 11 N CALVITE P&D G N sodium chloride inj 4 meq/ml (23.4%) B 11 N CALCIFOL G N sodium chloride inj 2.5 meq/ml (14.6%) B N AMMONIUM CHLORIDE G N zinc sulfate cap 220 mg B P SODIUM FLUORIDE B P ZINC SULFATE G P sodium fluoride chew tab 0.55 mg (0.25mg f) B N GLUTOFAC-MX G P sodium fluoride chew tab 1.1 mg (0.5mg f) G N selenious acid inj 40 mcg/ml Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 29 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - G P baclofen MINERALS B P LIORESAL INTRATHECAL - Continued - B 11 N SOMA B N TRACE METALS ADDITIVE FTV G P carisoprodol

G N trace min (cr-cu-mn-se-zn) inj 4-400-100-20-1000 mcg/ml B 11 N PARAFON FORTE DSC

G P trace min (cr-cu-mn-se-zn) inj 10-1000-500-60-5000 mcg/ml G P chlorzoxazone

B N M.T.E. 7 B 11 N FLEXERIL

O P FERROUS SULFATE TAB 300 MG G P cyclobenzapr tab 10mg

O P ferrous sulfate tab 325 mg B 11 N SKELAXIN

O P ferrous sulfate elixir 220 mg/5ml B 11 N ROBAXIN

O P ferrous sulfate soln 75 mg/0.6ml (15 mg/0.6ml elemental fe) B 11 N ROBAXIN-750

O P ferrous gluconate tab 325 mg G P methocarbamol

O P ferrous fumarate tab 325 mg B 11 N NORFLEX

G P iron dextran inj 50 mg/ml G P orphenadrine citrate

B N VENOFER B 11 N ZANAFLEX

MOUTH - ANESTHETICS TOPICAL ORAL G 11 N tizanidine hcl

B 11 N DANTRIUM B P XYLOCAINE SOL 2% VISC G 11 N dantrolene sodium G P lidocaine hcl viscous soln 2% NARCOTIC - ANTAGONISTS MOUTH - STEROIDS

B N NARCAN G P triamcinolone acetonide in orabase 0.1% G N naloxone hcl inj 0.4 mg/ml MOUTH ANTI-INFECTIVES B N REVIA

G P naltrexone hcl tab 50 mg G P nystatin susp 100000 u/ml

MOUTH ANTISEPTICS NARCOTICS - MISC.

B P CODEINE PHOSPHATE B N PERIDEX ORAL RINSE B P CODEINE SULFATE G P chlorhexidine gluconate soln 0.12% G P fentanyl citrate inj 0.05 mg/ml B N DEBACTEROL B 11 N ACTIQ MUCOPOLYSACCHARIDOSIS G P hydromorphon tab 2mg

B P ALDURAZYME G P hydromorphon tab 4mg

MULTIPLE SCLEROSIS AGENTS G P hydromorphon tab 8mg B N DILAUDID-5 B 7 N COPAXONE G P hydromorphon inj 2mg/ml B P REBIF B N DILAUDID-HP B P REBIF TITRATION PACK G P hydromorphon inj 10mg/ml B P AVONEX G P hydromorphon inj 50mg/5ml B P BETASERON B N DILAUDID B N TYSABRI G N hydromorphon sup 3mg

MUSCLE RELAXANT -COMBINATIONS B N DEMEROL TAB 50MG

G P meperidine tab 50mg B 11 N SOMA COMPOUND B N DEMEROL TAB 100MG G 11 N carisoprodol w/ asa tab 200-325 mg G P meperidine tab 100mg B 11 N SOMA COMPOUND/CODEINE G P meperitab G 11 N carisoprodol w/ asa & codeine tab 200-325-16 mg B P DEMEROL SYP 50MG/5ML G P orphenadrine w/ aspirin & caffeine tab 25-385-30 mg G N meperidine syp 50mg/5ml B P NORGESIC FORTE B N DEMEROL INJ 25MG/ML G 11 N orphenadrine w/ aspirin & caffeine tab 50-770-60 mg B N DEMEROL INJ 100/2ML MUSCLE RELAXANTS B N DEMEROL INJ 50MG/ML

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 30 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B N TYLENOL/CODEINE #3 NARCOTICS - MISC. B N TYLENOL/CODEINE #4 - Continued - B N VOPAC B N DEMEROL INJ 75MG/1.5 G P acetaminophen w/ codeine

G P meperidine inj 50mg/ml B N CAPITAL/CODEINE

B P DEMEROL INJ 75MG/ML G P aspirin w/ codeine

B P DEMEROL INJ 100MG/ML B N FIORICET/CODEINE

G P meperidine inj 100mg/ml G N butalbital-acetaminophen-caffeine w/ codeine

G P msir B P FIORINAL/CODEINE #3

B P ROXANOL G N butalbital-aspirin-caffeine w/cod

B N ROXANOL-T B N PANLOR DC

G P morphine sul sol 20mg/ml B N PANLOR SS

B P MORPHINE SUL TAB 10MG B N SYNALGOS-DC

G P morphine sul tab 15mg B N LORCET-HD

G P morphine sul tab 30mg B N LORTAB 2.5 TAB

B N OXYIR CAP 5MG B N LORTAB 5 TAB

G P oxycodone cap 5mg B N VICODIN

B P ROXICODONE TAB 5MG B N LORTAB 7.5 TAB

G N oxycodone hcl tab 5 mg B N LORTAB 10 TAB

B P ROXICODONE TAB 15MG B P ANEXSIA

G P oxycodone hcl tab 15 mg B P LORCET PLUS

B P ROXICODONE TAB 30MG B N LORCET 10/650

G P oxycodone hcl tab 30 mg B N MAXIDONE

B N ROXICODONE INTENSOL B N NORCO

G P oxycodone con 20mg/ml B N ZYDONE

G P oxydose B P XODOL

G P oxyfast B N HYCET

B P ROXICODONE SOL 5MG/5ML B N LORTAB ELX

G P oxycodone sol 5mg/5ml G P hydrocodone-acetaminophen

B N DARVON B N REPREXAIN

G P propoxyphene hcl B N VICOPROFEN

B N DARVON-N G N hydrocodone-ibuprofen

B P SUBUTEX B N DARVON COMPOUND-65

B P SUBOXONE SUB 2-0.5MG G P propoxyphene hcl w/ apap

B P SUBOXONE SUB 8-2MG B N DARVOCET-N 50

B P TALWIN NX G P propoxyphene-n w/ apap tab 50-325 mg

G N pentazocine w/ naloxone G N BALACET 325

B N TYLOX B N TRYCET

G P oxycod/apap cap 5-500mg G N propoxyphene-n w/ apap tab 100-325 mg

G P oxycod/apap tab 5-325mg B N DARVOCET A500

G P oxycodone w/ acetaminophen tab 5-325 mg B N DARVOCET-N 100

G N oxycodone w/ acetaminophen tab 7.5-325 mg G P propoxyphene-n w/ apap tab 100-650 mg

G P oxycodone w/ acetaminophen tab 7.5-500 mg B P TALACEN

G N oxycodone w/ acetaminophen tab 10-325 mg G N pentazocine w/ apap B N PERCOCET NARCOTICS - SELECTED G N oxycodone w/ acetaminophen tab 10-650 mg

B P ROXICET B N ULTRAM

B P PERCODAN G P tramadol hcl tab 50 mg

G P oxycodone w/ aspirin G N tramadol hcl tab sr 24hr

B N COMBUNOX B N ULTRAM ER

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 31 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B P PROSTIGMIN NARCOTICS - SELECTED B N MESTINON TAB 60MG - Continued - G P pyridostigmine bromide tab 60 mg B N BUPRENEX B P MESTINON TIMESPAN

B 11 N STADOL NS B P MESTINON SYP 60MG/5ML G 15 P butorphanol tartrate nasal soln 10 mg/ml NEUROMUSCULAR BLOCKING AGENTS G P nalbuphine hcl inj 10 mg/ml

B N NUBAIN B N MYOBLOC

G P nalbuphine hcl inj 20 mg/ml B N BOTOX

B 23 N ULTRACET NICARDIPINES NARCOTICS-LONG ACTING B N CARDENE

B 7 N DURAGESIC G N nicardipine hcl

G N fentanyl B N CARDENE SR

G P methadone hcl NITRO - OINTMENT/CAP/CR G P morphine sul inj 2mg/ml G P nitroglycerin B P MORPHINE SUL INJ 4MG/ML B P NITROBID G P morphine sul inj 5mg/ml G N nitroglycerin in d5w G P morphine sul inj 8mg/ml

G P morphine sul inj 10mg/ml NITRO - PATCHES

G P morphine sul inj 15mg/ml B N NITRO-DUR DIS 0.1MG/HR G P morphine sul inj 25mg/ml G P nitroglycerin td patch 24hr 0.1 mg/hr G N morphine sul inj 50mg/ml B N NITRO-DUR DIS 0.2MG/HR B P MORPHINE SUL SOL 10MG/5ML G P nitroglycerin td patch 24hr 0.2 mg/hr B P MORPHINE SUL SOL 20MG/10 B N NITRO-DUR DIS 0.3MG/HR B P MORPHINE SUL SOL 20MG/5ML B N NITRO-DUR DIS 0.4MG/HR G N morphine sul sup 5mg G P nitroglycerin td patch 24hr 0.4 mg/hr G P morphine sul sup 10mg B N NITRO-DUR DIS 0.6MG/HR B P RMS G P nitroglycerin td patch 24hr 0.6 mg/hr G P morphine sul sup 20mg B P NITRO-DUR DIS 0.8MG/HR B N KADIAN NITRO - SUBLINGUAL/ SPRAY B N MS CONTIN TAB 15MG CR

G P morphine sulfate tab sr 12hr 15 mg B P NITROSTAT SUB 0.3MG

B N MS CONTIN TAB 30MG CR G P nitroglycerin sl tab 0.3 mg

G N morphine sulfate tab sr 12hr 30 mg B N NITROSTAT SUB 0.4MG

B N MS CONTIN TAB 60MG CR G P nitroglycerin sl tab 0.4 mg

G N morphine sulfate tab sr 12hr 60 mg B P NITROSTAT SUB 0.6MG

B N MS CONTIN TAB 100MG CR G P nitroglycerin sl tab 0.6 mg

B N ORAMORPH SR B N NITROLINGUAL PUMPSPRAY G N morphine sulfate tab sr 12hr 100 mg NSAIDS B N MS CONTIN TAB 200MG CR

G N morphine sulfate tab sr 12hr 200 mg B 11 N VOLTAREN TAB 50MG EC

B P AVINZA G P diclofenac sodium

B N DEPODUR B 11 N VOLTAREN TAB 75MG EC

B N OXYCONTIN G P diclofenac sodium dr

G 27 P oxycodone hcl er G P diclofenac sodium ec

NEUROLOGICS - MISC. B 11 N VOLTAREN-XR G 11 N diclofenac sodium er

G P ergoloid mesylates tab 1 mg G 11 N diclofenac sodium xr

B P ORAP B 11 N CATAFLAM

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 32 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B N OPTIVAR NSAIDS B N EMADINE - Continued - B P ELESTAT G 11 N diclofenac potassium B N ZADITOR

B 11 N LODINE B N LIVOSTIN

G 11 N etodolac B P PATANOL G P fenoprofen calcium OP. ANTIALLERGICS - MAST CELL STABILIZERS B 11 N ANSAID

G P flurbiprofen B N CROLOM

O P ibuprofen tabs G P cromolyn sodium ophth soln 4%

B 11 N MOTRIN B N ALOMIDE

O P ibuprofen susp 100 mg/5ml B N ALOCRIL

G P indomethacin cap 25mg B P ALAMAST

G P indomethacin cap 50mg OP. ANTIBIOTICS G 11 N indomethacin cr G P bacitracin ophth oint 500 unit/gm G 11 N indomethacin er G P erythromycin ophth oint 5 mg/gm B 11 N INDOCIN G P gentamicin sulfate ophth soln 0.3% G 11 N indomethacin sup 50mg B P GARAMYCIN B 11 N ORUVAIL B P GENTAK G P ketoprofen G P gentamicin sulfate ophth oint 0.3% B 11 N MECLOFENAMATE SODIUM G P tobramycin sulfate ophth soln 0.3% B 11 N PONSTEL B N TOBREX B 11 N MEFENAMIC ACID B P BLEPH-10 B 11 N NAPROSYN TAB 250MG G P sulfacetamide sodium ophth soln 10% B 11 N NAPROSYN TAB 375MG B P SULFACETAMIDE SODIUM B 11 N NAPROSYN TAB 500MG B P VIROPTIC B 11 N EC-NAPROSYN G N trifluridine ophth soln 1% B P NAPROSYN SUS 125/5ML B N POLYSPORIN G P naproxen G P bacitracin-polymyxin b ophth oint B 11 N ANAPROX B P TERRAMYCIN W/POLYMYXIN B G 11 N naproxen sodium tab 275 mg B P POLYTRIM B 11 N ANAPROX DS G P polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% G 11 N naproxen sodium tab 550 mg B N NEOSPORIN B 11 N NAPRELAN G P neomycin-bacitrac zn-polymyx 3.5(5)mg-400unt-10000unt op oin G 11 N naproxen sodium tab sr 24hr 500 mg (base equiv) G P neomycin-polymyxin b-gramicidin ophth soln B 11 N DAYPRO

G P oxaprozin OP. ANTIINFLAMMATORY / STEROIDS OPHTH.

G P piroxicam cap 10 mg B N MAXIDEX B 11 N FELDENE G N dexamethasone sodium phosphate ophth soln 0.1% G P piroxicam cap 20 mg B P FML LIQUIFILM B 11 N CLINORIL G N fluorometholone ophth susp 0.1% G P sulindac B P FML FORTE G 11 N tolmetin sodium B P FML S.O.P. B 11 N ARTHROTEC B P FLAREX OP. ADRENERGIC AGENTS B P ALREX

B P LOTEMAX B N PROPINE B P HMS LIQUIFILM G P dipivefrin hcl ophth soln 0.1% B P PRED MILD OP. ANTIALLERGICS - ANTIHISTAMINES B N ECONOPRED PLUS

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 33 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B N ISOPTO ATROPINE OP. ANTIINFLAMMATORY / STEROIDS OPHTH. G P atropine sulfate (ophthalmic) - Continued - G P cyclopentolate hcl B P PRED FORTE B N CYCLOGYL

G N prednisolone acetate ophth susp 1% B N ISOPTO HOMATROPINE

B N INFLAMASE MILD B P ISOPTO HYOSCINE

B N INFLAMASE FORTE B P MYDRIACYL

G N prednisolone sodium phosphate ophth soln 1% G P tropicamide

B N VEXOL B N CYCLOMYDRIL B N PRED-G OP. MIOTICS - DIRECT ACTING B N PRED-G S.O.P.

B N ZYLET B P ISOPTO CARBACHOL

B P FML-S LIQUIFILM B N ISOPTO CARPINE

B P BLEPHAMIDE G P pilocarpine hcl

B N VASOCIDIN B P PILOPINE HS

G N sulfacetamide sodium-prednisolone ophth soln 10-0.25% B P PHOSPHOLINE IODIDE

B N BLEPHAMIDE S.O.P. OP. MISC B P TOBRADEX O P *artificial tear ophth solution*** G P neomycin-polymyxin-dexamethasone ophth susp 0.1% O P *artificial tear ophth ointment*** B N MAXITROL G P naphazoline hcl ophth soln 0.1% G P neomycin-polymyxin-dexamethasone ophth oint 0.1% G P phenylephrine hcl ophth soln 2.5% B P CORTISPORIN SUS OP 1% G P phenylephrine hcl ophth soln 10% G N neomycin-polymyxin-hc ophth susp B N PHENYLEPHRINE HCL B N POLY-PRED B N RESTASIS B P CORTISPORIN OIN OP 1% B N ALCAINE G N bacitracin-polymyxin-neomycin-hc ophth oint 1% B N OPHTHETIC OP. BETA - BLOCKERS G P proparacaine hcl ophth soln 0.5%

B P BETOPTIC-S G P tetracaine hcl ophth soln 0.5%

G N betaxolol hcl ophth soln 0.5% B N BSS PLUS

G P carteolol hcl ophth soln 1% O P SODIUM CHLORIDE HYPERTONIC OPHTH SOLN 5%

B N OPTIPRANOLOL O P SODIUM CHLORIDE HYPERTONIC OPHTH OINT 5%

G P metipranolol ophth soln 0.3% B N NEVANAC

G P levobunolol hcl ophth soln 0.25% G N fluorescein sodium inj 10%

B N BETAGAN G N fluorescein sodium inj 25%

G P levobunolol hcl ophth soln 0.5% OP. NSAID'S B P BETIMOL B N XIBROM G P timolol maleate ophth soln 0.25% B P VOLTAREN SOL 0.1% OP B N ISTALOL B N OCUFEN B N TIMOPTIC G P flurbiprofen sodium ophth soln 0.03% G P timolol maleate ophth soln 0.5% B P ACULAR LS G N timolol maleate ophth gel forming soln 0.25% B P ACULAR B P TIMOPTIC-XE B N ACULAR PF G N timolol maleate ophth gel forming soln 0.5%

OP. CARBONIC ANHYDRASE INHIBITORS/COMBO OP. PROSTAGLANDINS

B P LUMIGAN B P COSOPT B P XALATAN B P AZOPT B P TRAVATAN B P TRUSOPT B N RESCULA OP. CYCLOPLEGICS

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 34 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B P REQUIP OP. QUINOLONES PERIPHERAL VASODILATORS

G P ciprofloxacin hcl ophth soln 0.3% G P papaverine hcl cap cr 150 mg

B P CILOXAN G P papaverine hcl inj 30 mg/ml

B P ZYMAR PHOSPHATE BINDERS B P QUIXIN B P PHOSLO B P VIGAMOX B P FOSRENOL B P OCUFLOX B P RENAGEL G N ofloxacin ophth soln 0.3%

OP. SELECTIVE ALPHA ADRENERGIC AGONISTS PHOSPHODIESTERASE INHIBITORS

B N PRIMACOR B N IOPIDINE

B P ALPHAGAN P PLATELET AGGR. INHIBITORS / COMBO'S - MISC.

G N brimonidine tartrate ophth soln 0.2% G P cilostazol tab 50 mg OSTEOPOROSIS B N PLETAL

G P cilostazol tab 100 mg B P FOSAMAX G P anagrelide hcl cap 0.5 mg B P FOSAMAX PLUS D B N AGRYLIN B 7 N DIDRONEL G P anagrelide hcl cap 1 mg B N BONIVA B P AGGRENOX B N AREDIA B N TRENTAL G N pamidronate disodium G P pentoxifylline tab cr 400 mg B P ACTONEL

B P ACTONEL WITH CALCIUM PLATELET AGGREGATION INHIBITORS

B N ZOMETA B N PERSANTINE B N MIACALCIN INJ 200/ML G P dipyridamole G N FORTICAL B P PLAVIX B P MIACALCIN SPR 200/ACT B N TICLID B N FORTEO G P ticlopidine hcl B N EVISTA PRESSORS OXYTOCICS

G N ephedrine sulfate (pressors) B P METHERGINE B P PROAMATINE PARKINSONS - ANTICHOLINERGICS G N midodrine hcl

G P benztropine mesylate PROGESTINS

B P COGENTIN B N PROVERA B P AKINETON G P medroxyprogesterone acetate B P KEMADRIN B P AYGESTIN G P trihexyphenidyl hcl G N norethindrone acetate PARKINSONS - COMT INHIBITORS G N progesterone inj 50mg/ml

B N PROMETRIUM B N TASMAR

B P COMTAN PULMONARY ANTI-HYPERTENSIVES

PARKINSONS - SELECTED DOPAMIN AGONISTS B P REVATIO

B N TRACLEER B N PERMAX B P FLOLAN G N pergolide mesylate B P VENTAVIS B P APOKYN

B P MIRAPEX PURINE ANALOG

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 35 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B N DORYX PURINE ANALOG B P VIBRAMYCIN SYP 50MG/5ML - Continued - B N DYNACIN B N IMURAN G P minocycline hcl

G P azathioprine tab 50 mg B N MINOCIN

B P AZASAN G P tetracycline hcl

RHEUMATOID ARTHRITIS - BIOLOGICALS B P SUMYCIN

THYROID HORMONES B N KINERET

B P HUMIRA G P levothyroxin tab 25mcg

B P ENBREL G P levothyroxin tab 50mcg

B N ORENCIA G P levothyroxin tab 75mcg

RHEUMATOID ARTHRITIS - NON-BIOLOGICALS G P levothyroxin tab 88mcg

G P levothyroxin tab 100mcg G P leflunomide tab 10 mg G P levothyroxin tab 112mcg B 28 P ARAVA G P levothyroxin tab 125mcg G P leflunomide tab 20 mg G P levothyroxin tab 137mcg RSV PROPHYLAXIS G P levothyroxin tab 150mcg

G P levothyroxin tab 175mcg B 11 P SYNAGIS G P levothyroxin tab 200mcg SEDATIVE/HYPNOTICS - NON-BENZODIAZEPINES G P unithroid

B P LUNESTA B 7 N SYNTHROID

B 7 N SONATA G P levothroid

B N ROZEREM G P levothyroxin tab 300mcg

B N AMBIEN G P levoxyl

B N AMBIEN CR G N levothyroxin inj 200mcg

SOMATOSTATIC AGENTS G N levothyroxin inj 500mcg B P CYTOMEL G N octreotide acetate inj 0.05 mg/ml B P THYROLAR-1/2 G N octreotide acetate inj 0.1 mg/ml B P THYROLAR-1 G N octreotide acetate inj 0.2 mg/ml B P THYROLAR-2 G N octreotide acetate inj 0.5 mg/ml B P THYROLAR-3 B P SANDOSTATIN G P thyroid G N octreotide acetate inj 1 mg/ml B P ARMOUR THYROID B P SANDOSTATIN LAR DEPOT TISSUE PLASMINOGEN ACTIVATOR B N SOMAVERT

TETRACYCLINES B P CATHFLO ACTIVASE B P ACTIVASE B N DECLOMYCIN TOPICAL - ACNE PREPARATIONS G N demeclocycline hcl

B N MONODOX B 11 P DIFFERIN

G N doxycycline (monohydrate) B 11 P AZELEX

B N ADOXA B 11 N BREVOXYL-4 CREAMY WASH

B N ADOXA PAK 1/100 B 11 N BENZAC AC WASH

B N ADOXA PAK 2/100 O P benzoyl peroxide liq 5%

B N VIBRAMYCIN SUS 25MG/5ML B 11 N BREVOXYL-8 CREAMY WASH

B N VIBRAMYCIN CAP 50MG O 11 P benzoyl peroxide liq 10%

B N VIBRAMYCIN CAP 100MG B 11 N BENZASHAVE 5

B N PERIOSTAT G 11 N benzoyl peroxide cream 10%

G P doxycycline hyclate B 11 N TRIAZ GEL 3%

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 36 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B 11 P PLEXION TOPICAL - ACNE PREPARATIONS G 11 N sulfacetamide sodium w/ sulfur emulsion 10-5% - Continued - B 11 P PLEXION TS O 11 P benzoyl peroxide gel 5% G 11 N sulfacetamide sodium w/ sulfur susp 10-5%

B 11 N TRIAZ GEL 6% B 11 P PLEXION SCT

B 11 N BREVOXYL G 11 N sulfacetamide sodium w/ sulfur cream 10-5%

B 11 P BENZAC AC GEL 10% B 11 N AVAR

B 11 P BENZAC W GEL 10% B 11 N AVAR GREEN

B 11 P DESQUAM-E GEL 10% B 11 N SULFACET-R

B 11 P DESQUAM-X GEL 10% G 11 N sulfacetamide sodium w/ sulfur lotion 10-5%

O 11 P benzoyl peroxide gel 10% B 11 N PLEXION CLEANSING CLOTH

B 11 N CLINAC BPO B 11 N ROSULA

B 11 P TRIAZ GEL 9% B 11 P ROSAC

B 11 N BREVOXYL CLEANSING B 11 N FINACEA G P benzoyl peroxide lotion 4% TOPICAL - ANTIBIOTIC O P benzoyl peroxide lotion 5%

B 11 N BREVOXYL-8 CLEANSING O P bacitracin oint 500 unit/gm

G P benzoyl peroxide lotion 8% G P gentamicin sulfate cream 0.1%

B 11 P TRIAZ CLEANSER G P gentamicin sulfate oint 0.1%

O P benzoyl peroxide lotion 10% B P BACTROBAN OIN 2%

B 11 P TRIAZ PAD 3% G N mupirocin oint 2%

B 11 P TRIAZ PAD 6% B P BACTROBAN CRE 2%

B 11 P TRIAZ PAD 9% O P *neomycin-bacitracin-polymyxin oint***

B 11 N SULFOXYL REGULAR B N CORTISPORIN CRE 0.5%

B 11 N SULFOXYL STRONG B N CORTISPORIN OIN 1%

B 11 P METROCREAM TOPICAL - ANTIFUNGALS G 11 N metronidazole cream 0.75% B N MENTAX B 11 N NORITATE B N PENLAC NAIL LACQUER B 11 P METROGEL B N LOPROX SHAMPOO B 11 P METROLOTION G P ciclopirox olamine cream 0.77% (base equiv) G 11 P clindamycin phosphate soln 1% B N LOPROX B 11 N EVOCLIN G P ciclopirox olamine lotion 0.77% (base equiv) B 11 N CLINDAGEL B P NAFTIN G 11 N clindamycin phosphate gel 1% B N MYCOSTATIN G 11 N clindamycin phosphate lotion 1% G P nystatin topical powder B 11 P CLEOCIN-T B N NYSTAT-RX G 11 N clindamycin phosphate swab 1% B N NYSTATIN (BULK) POWDER G 11 P erythromycin soln 2% G P nystatin cream 100000 unit/gm B 11 P ERYGEL G P nystatin oint 100000 unit/gm G 11 P erythromycin gel 2% O P tolnaftate soln 1% B 11 P AKNE-MYCIN B P TOLNAFTATE G 11 P erythromycin pads 2% O P tolnaftate powder 1% B 11 N KLARON O P tolnaftate cream 1% B N ACZONE GEL B N LAMISIL B 11 P BENZAMYCINPAK G P clotrimazole soln 1% B 11 P BENZAMYCIN G P clotrimazole cream 1% G 11 N benzoyl peroxide-erythromycin gel 5-3% B P SPECTAZOLE B 11 N ZODERM G N econazole nitrate cream 1% B 11 N BENZACLIN G N ketoconazole cream 2% B 11 P DUAC

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 37 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B N DRYSOL TOPICAL - ANTIFUNGALS G P aluminum chloride soln 20% - Continued - B N WITCH HAZEL B P NIZORAL SHA 2% B P XERAC AC G N ketoconazole shampoo 2% TOPICAL - BURN PRODUCTS O P miconazole nitrate cream 2%

B N OXISTAT B N SULFAMYLON

B P ERTACZO B N FURACIN

B N EXELDERM B N SILVADENE

B P LOTRISONE CRE G P silver sulfadiazine cream 1%

G P clotrimazole w/ betamethasone cream 1-0.05% TOPICAL - CAUTERIZING AGENTS B P LOTRISONE LOT B P SILVER NITRATE G N clotrimazole w/ betamethasone lotion 1-0.05%

G P nystatin-triamcinolone cream 100000-0.1 unit/gm-% TOPICAL - CORTICOSTEROIDS

B N MYCOLOG-II B N ACLOVATE G P nystatin-triamcinolone oint 100000-0.1 unit/gm-% G N alclometasone dipropionate oint 0.05% TOPICAL - ANTINEOPLASTICS B N CYCLOCORT CRE 0.1%

G P amcinonide cream 0.1% G P fluorouracil soln 2% B P CYCLOCORT LOT 0.1% G P fluorouracil soln 5% B P CYCLOCORT OIN 0.1% B N CARAC G N amcinonide oint 0.1% B P FLUOROPLEX G P betamethasone dipropionate cream 0.05% B P EFUDEX B P DIPROSONE B P SOLARAZE G P betamethasone dipropionate lotion 0.05% TOPICAL - ANTIPRURITICS G P betamethasone dipropionate oint 0.05%

B P ZONALON B N DIPROLENE AF

G N doxepin hcl cream 5% G P augmented betamethasone dipropionate cream 0.05%

TOPICAL - ANTISEBORRHEICS G N augmented betamethasone dipropionate gel 0.05% B P DIPROLENE

B P CAPITROL G N augmented betamethasone dipropionate oint 0.05%

B P SELSUN SHAMPOO G P betamethasone valerate cream 0.1%

G P selenium sulfide lotion 2.5% B N LUXIQ

B P OVACE WASH G P betamethasone valerate lotion 0.1%

G P sulfacetamide sodium liquid 10% G P betamethasone valerate oint 0.1%

B N OVACE B N TEMOVATE

B N CARMOL SCALP TREATMENT G P clobetasol propionate soln 0.05%

B N SELSEB G P clobetasol propionate cream 0.05%

TOPICAL - ANTISEPTICS / DISINFECTANTS B N OLUX

G P clobetasol propionate gel 0.05% B N LAZERFORMALYDE SOLUTION G P clobetasol propionate oint 0.05% B N FORMALYDE-10 B N CLOBEX B P PHISOHEX G P clobetasol propionate emollient base cream 0.05% B N OPERAND POVIDONE/IODINE B N CLODERM TOPICAL - ANTIVIRALS B P DESOWEN CRE 0.05%

B P TRIDESILON B N ZOVIRAX CRE 5% G P desonide cream 0.05% B P ZOVIRAX OIN 5% B N DESOWEN LOT 0.05% B N DENAVIR G P desonide lotion 0.05% TOPICAL - ASTRINGENTS / PROTECTANTS B P DESOWEN OIN 0.05%

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 38 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - G N hydrocortisone butyrate soln 0.1% TOPICAL - CORTICOSTEROIDS B N LOCOID - Continued - G N hydrocortisone butyrate oint 0.1% G P desonide oint 0.05% B N LOCOID LIPOCREAM

B P DESOXIMETASONE G N mometasone furoate cream 0.1%

G P desoximetasone cream 0.25% G N mometasone furoate lotion 0.1%

G P desoximetasone gel 0.05% B P ELOCON

B N TOPICORT G N mometasone furoate oint 0.1%

G P desoximetasone oint 0.25% B N DERMATOP

G N diflorasone diacetate cream 0.05% G P triamcinolone acetonide cream 0.025%

G N diflorasone diacetate oint 0.05% G P triamcinolone acetonide cream 0.1%

G N diflorasone diacetate emollient base cream 0.05% B N ARISTOCORT A

B P DERMA-SMOOTHE/FS G P triamcinolone acetonide cream 0.5%

B P SYNALAR G P triamcinolone acetonide lotion 0.025%

G P fluocinolone acetonide soln 0.01% B N KENALOG

G P fluocinolone acetonide cream 0.01% G P triamcinolone acetonide lotion 0.1%

G P fluocinolone acetonide cream 0.025% G P triamcinolone acetonide oint 0.025%

G P fluocinolone acetonide oint 0.025% G P triamcinolone acetonide oint 0.1%

B P CAPEX G P triamcinolone acetonide oint 0.5% G P fluocinonide soln 0.05% TOPICAL - EMOLLIENTS G P fluocinonide cream 0.05%

B N VANOS G N lactic acid (ammonium lactate) cream 12%

G P fluocinonide gel 0.05% B N LACTINOL

B N LIDEX B N LAC-HYDRIN

G P fluocinonide oint 0.05% O P lactic acid (ammonium lactate) lotion 12%

B N LIDEX-E B N LACTINOL-E

G P fluocinonide emulsified base cream 0.05% G P lactic acid w/ vitamin e cream 10%-3500 unit/30gm

B N CORDRAN SP B N UMECTA

B N CORDRAN B P VANAMIDE

B N CORDRAN TAPE G N urea cream 40%

G N fluticasone propionate cream 0.05% G N urea gel 40%

B P CUTIVATE G N urea gel 50%

G N fluticasone propionate oint 0.005% B N KERALAC

B P HALOG G P urea lotion 35%

G N halobetasol propionate cream 0.05% B N CARMOL 40

B P ULTRAVATE G P urea lotion 40%

G N halobetasol propionate oint 0.05% TOPICAL - ENZYMES / KERATOLYTICS / UREA B N TEXACORT B N SANTYL B N PROCTOCORT B N GRANULEX G P hydrocortisone cream 1% G P trypsin w/ castor oil & peruvian balsam spray G P hydrocortisone cream 2.5% B P XENADERM G P hydrocortisone lotion 1% B P PANAFIL B N HYTONE G P *papain-urea-chlorophyllin ointment*** G P hydrocortisone lotion 2.5% G P podophyllum resin soln 25% G P hydrocortisone oint 1% O P salicylic acid liquid 17% G N hydrocortisone oint 2.5% B P SALEX G P hydrocortisone valerate cream 0.2%

B N WESTCORT TOPICAL - GENITAL WARTS

G N hydrocortisone valerate oint 0.2% G N podofilox soln 0.5% B N PANDEL

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 39 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - G N permethrin cream 5% TOPICAL - GENITAL WARTS O P pyrethrins-piperonyl butoxide liq 0.33-4% - Continued - O P pyrethrins-piperonyl butoxide shampoo 0.3-3% B N CONDYLOX O P pyrethrins-piperonyl butoxide shampoo 0.33-4% B P ALDARA TOPICAL - STEROID COMBINATIONS TOPICAL - IMMUNOMODULATORS B N CARMOL-HC

B P ELIDEL G N urea-hc acetate cream 1% B N PROTOPIC TOPICAL - STEROID LOCAL ANESTHETICS TOPICAL - LOCAL ANESTHETICS G N lidocaine-hydrocortisone acetate rectal cream 3-0.5%

B P MARCAINE B P LIDAMANTLE CRE HC3-0.5%

B P MARCAINE W/O EPI G N lidocaine-hydrocortisone acetate cream 3-0.5%

G N bupivacaine 0.75% in dextrose inj 8.25% B N LIDAMANTLE LOT HC3-0.5%

B P XYLOCAINE INJ -MPF 1% B N EPIFOAM B P XYLOCAINE INJ 1% TOPICAL - TRETINOIDS G P lidocaine hcl local inj 1%

B P XYLOCAINE INJ 2% G 11 N tretinoin cream 0.025%

G P lidocaine hcl local inj 2% G 11 N tretinoin cream 0.05%

G N lidocaine hcl local inj 4% G 11 N tretinoin cream 0.1%

B N CARBOCAINE G 11 N tretinoin gel 0.01%

B N PONTOCAINE B 11 P RETIN-A

G P lidocaine inj 1% w/ epinephrine-1:100000 G 11 N tretinoin gel 0.025%

G P lidocaine inj 1.5% w/ epinephrine-1:200000 B 11 N RETIN-A MICRO

G P lidocaine inj 2% w/ epinephrine-1:100000 TOPICAL - WOUND / DECUBITUS CARE B N AMERICAINE B P ETHEZYME B N COCAINE HCL B P ACCUZYME B N SYNERA G P papain-urea ointment 0.83 mmu-100 mg/gm (usp ref std f-3) B N LIDODERM B N RADIAPLEXRX B P XYLOCAINE SOL 4% G N *wound dressings - gel*** G P lidocaine hcl soln 4% B 11 N REGRANEX G P lidocaine hcl cream 3% B N REGENECARE WOUND B P XYLOCAINE GEL 2%

G P lidocaine hcl gel 2% UREA CYCLE DISORDER - AGENTS

B N LIDAMANTLE B P AMMONUL G P lidocaine hcl oint 5% B N BUPHENYL B N ANESTHETIC SKIN REFRIGERA UROLOGICAL - MISC. B P EMLA

G N lidocaine-prilocaine cream 2.5-2.5% B P MONUROL

B P EMLA/TEGADERM B N MANDELAMINE

TOPICAL - NASAL ANTIBIOTICS G P methenamine mandelate

B N HIPREX B P BACTROBAN NASAL B P UREX TOPICAL - SCABICIDES AND PEDICULICIDES G N methenamine hippurate

B N NEGGRAM B P EURAX B P FURADANTIN B N LINDANE B P MACRODANTIN G N lindane shampoo 1% B N NITROFURANTOIN MACROCRYST B N OVIDE G N nitrofurantoin macrocrystal O P permethrin creme rinse 1% B N MACROBID B P ELIMITE

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 40 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - B N TERAZOL 7 UROLOGICAL - MISC. G N terconazole vaginal cream 0.4% - Continued - B N TERAZOL 3 W/APPLICATOR G N nitrofurantoin monohyd macro B N ZAZOLE

B P UROQID #2 G N terconazole vaginal cream 0.8%

B N URISED B N TERAZOL 3 G P meth-bell-meth bl-phenyl sal VAGINAL - ANTIBACTERIALS B N URIMAX

G N methenamine-hyosc-methylene blue-sod biphos-phenyl sal B P CLEOCIN VAG CRE 2%

B P PROSED/DS B P CLEOCIN SUP 100MG

G N methenamine-methylene blue-benz acd-phenyl sal-atrop-hyosc B P METROGEL VAGINAL

B P PROSED EC VAGINAL - ESTROGENS B P PYRIDIUM PLUS B N VAGIFEM G N phenazopyridine-butabarbital-hyoscyamine B N ESTRACE B P K-PHOS NO 2 B N ESTRING B P UROCIT-K 5 B N FEMRING B P UROCIT-K 10 B P PREMARIN B P BICITRA B P PREMARIN W/APPLICATOR G N sodium citrate & citric acid

B P POLYCITRA-K VAGINAL - OTHER

G P cytra-k G P amino acid-urea cervical cream B P POLYCITRA-K CRYSTALS G P acetic acid vaginal gel G N cytra k crystals B N RELAGARD B P POLYCITRA G N acetic acid-oxyquinoline vaginal gel 0.9-0.025% G P pot & sod citrates w/citric ac VASOPRESSINS B P POLYCITRA-LC

B N PYRIDIUM B 11 P DDAVP TAB 0.1MG

G P phenazopyridine hcl B 11 P DDAVP TAB 0.2MG

B N CYSTAGON B 11 P STIMATE

B N ELMIRON B 11 N DDAVP INJ 4MCG/ML

B N LITHOSTAT G 11 N desmopressin acetate inj 4 mcg/ml

B N THIOLA B 11 P DDAVP SOL 0.01%

B P RENACIDIN G 11 N desmopressin acetate nasal soln 0.01% (refrigerated)

G P acetic acid G 11 N minirin

G P sodium chloride (gu irrigant) G 11 N desmopressin acetate nasal spray soln 0.01% (refrigerated)

B P NEOSPORIN GU IRRIGANT B 11 P DDAVP SPR 0.01%

VAGINAL - ANTI FUNGALS G 11 N desmopressin acetate nasal spray soln 0.01%

G 11 N vasopressin inj 20 unit/ml G P clindamycin phosphate vaginal cream 2% VITAMINS B P CLINDESSE

B P NYSTATIN VAGINAL TAB 100000 UNIT G 11 P thiamine hcl

B N AVC O P niacin tab 50 mg

B N GYNAZOLE-1 O P niacin tab 100 mg

O P miconazole nitrate vaginal cream 2% O P niacin tab 250 mg

O P miconazole nitrate vaginal suppos 100 mg O P niacin tab 500 mg

B N MONISTAT 3 G 11 P pyridoxine hcl

G N miconazole nitrate vaginal suppos 200 mg B 11 N DRISDOL

B P MONISTAT 7 COMBINATION PA G 11 N ergocalciferol

G N miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit B 11 N CALCIJEX

B P MONISTAT DUAL-PAK B 11 P ROCALTROL

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 41 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - G 11 P *pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml*** VITAMINS B 11 N NESTABS RX - Continued - G 11 N *prenatal vit w/ iron carbonyl-fa tab 29-1 mg*** G 11 N calcitriol B 11 N NESTABS CBF

B 11 N DHT B 11 N ATABEX PRENATAL

B 11 N DHT INTENSOL B 11 N NOVASTART

B 11 P MEPHYTON G 11 N *prenatal vit w/ fe fumarate-fa tab 17-1 mg***

B 11 P AQUA-MEPHYTON G P *prenatal vit w/ fe fumarate-fa tab 27-0.5 mg***

G 11 P phytonadione G P *prenatal vit w/ fe fumarate-fa tab 27-1 mg***

G 11 P cyanocobalamin inj 1000 mcg/ml B 11 N STUARTNATAL PLUS 3

B 11 N CYANOCOBALAMIN CRYSTALS G 11 N *prenatal vit w/ fe fumarate-fa tab 28-1 mg***

B 11 N NASCOBAL B 11 N NESTABS FA

G 11 P folic acid G 11 N *prenatal vit w/ fe fumarate-fa tab 29-1 mg***

VITAMINS - MISC. G 11 N *prenatal vit w/ fe fumarate-fa tab 60-1 mg***

B 11 N LACTOCAL-F B 11 N NEPHROCAPS G P *prenatal vit w/ fe fumarate-fa tab 65-1 mg*** G 11 N *b-complex w/ c & folic acid cap 1 mg*** B 11 N NATACHEW B 11 N CEFOL G P *prenatal vit w/ fe fumarate-fa chew tab 29-1 mg*** G 11 N *b-complex w/ c & folic acid tab*** G 11 N *prenatal vit w/ fe polysac cmplx-fa tab 60-1 mg*** B 11 N NEPHRO-VITE RX G 11 N *prenatal vit w/ iron carbonyl-fe sulf-fa tab 60-1 mg*** G 11 P *b-complex w/ c & folic acid tab 1 mg*** B 11 N CITRACAL PRENATAL RX B 11 N DIATX G P *prenatal vit w/ iron carbonyl-fe gluc-fa tab 27-1 mg*** G 11 N *b-complex w/ c & folic acid tab 5 mg*** B 11 N NATELLE G 11 N *b-complex w/ c-min-fe & folic acid tab 106-1 mg*** B P DUET TAB B 11 P DIALYVITE/ZINC B 11 N VINATE II B 11 P NEPHPLEX RX B 11 N DUET CHW B 11 P M.V.I. -12 B 11 N PRECARE PRENATAL G 11 N *multiple vitamin inj** B 11 N PRECARE G 11 P *multiple vitamins w/ minerals cap** B 11 N NOVANATAL G 11 P *multiple vitamins w/ minerals tab** G 11 N *prenatal without a w/ fe carbonyl-docusate-fa tab 90-1mg*** B 11 N RENAX B 11 N PRENATE ELITE G 11 P *pediatric vitamins acd w/ fluoride chew tab 1 mg*** B 11 N PRECARE CONCEIVE B 11 N TRI-VI-FLOR B 11 N ANEMAGEN OB G 11 P *pediatric vitamins acd w/ fluoride soln 0.25 mg/ml*** G P *prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg*** G 11 P *pediatric vitamins acd w/ fluoride soln 0.5 mg/ml*** G 11 N *prenatal vit w/ dss-iron carbonyl-fa tab 29-1 mg*** B 11 N POLY-VI-FLOR CHW 0.25MG G P *prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg*** G 11 P *pediatric multiple vitamins w/ fluoride chew tab 0.25 mg*** G 11 N *prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg*** B 11 P POLY-VI-FLOR CHW 0.5MG G P *prenatal vit w/ dss-fe fumarate-fa tab cr 90-1 mg*** G 11 P *pediatric multiple vitamins w/ fluoride chew tab 0.5 mg*** B 11 N EMBREX 600 B 11 N POLY-VI-FLOR CHW 1MG G P *prenatal mv-min w/fe-fa tab & ca chew tab therapy pack*** G 11 P *pediatric multiple vitamins w/ fluoride chew tab 1 mg*** G 11 P *iron w/ vitamin tab** B 11 N POLY-VI-FLOR DRO 0.25MG B 11 N IBERET-FOLIC-500 G 11 P *pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml*** G 11 N *iron w/ vitamin tab cr** G 11 P *pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml*** B 11 P FOLGARD RX 2.2 G 11 P *pediatric multiple vitamins w/ fl-fe chew tab 0.5-12 mg** G 11 N folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg G 11 P *pediatric multiple vitamins w/ fl-fe chew tab 1-12 mg** G 11 N folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg B 11 N POLY-VI-FLOR/IRON G 11 N folic acid-vitamin b6-vitamin b12 tab 2.5-25-2 mg G 11 P *pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml** B 11 P MYO VYT G 11 P *pediatric multiple vitamins w/ fl-fe drops 0.5-10 mg/ml** G 11 N *iron combination cap*** B 11 N TRI-VI-FLOR/IRON G 11 P iron polysacch complex-vit b12-fa cap 150-0.025-1 mg Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 42 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR PDL Categories - Continued - VITAMINS - MISC. - Continued - B 11 N FERO-FOLIC-500

G 11 P ferrous sulfate-vit c-folic acid tab cr 105-500-0.8 mg

B 11 N ICAR-C PLUS

B 11 N CHROMAGEN FA

G 11 N fe fumarate-vit c-vit b12-fa cap 200-250-0.01-1 mg

G 11 N fe fumarate-vit c-vit b12-fa cap 460-60-0.01-1 mg

B 11 N CHROMAGEN

B 11 N NEPHRON FA

B 11 N TRINSICON

G 11 P fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg

B 11 N CHROMAGEN FORTE

B 11 N NIFEREX-150 FORTE

WEIGHT LOSS

B 11 P XENICAL

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 43 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR Mental Health Categories PDL/RDL G P bupropion hcl tab 100 mg ANTIDEPRESSANTS - MAO INHIBITORS B P WELLBUTRIN TAB 100MG SR G N bupropion hcl tab sr 12hr 100 mg

B R NARDIL B P WELLBUTRIN TAB 150MG SR

B R PARNATE G N bupropion hcl er

ANTIDEPRESSANTS - SELECTED SSRI'S G N bupropion hcl tab sr 12hr 150 mg

B P WELLBUTRIN TAB 200MG SR B P REMERON G N bupropion hcl tab sr 12hr 200 mg B P REMERON SOLTAB B R WELLBUTRIN XL G P mirtazapine B NR EFFEXOR G P nefazodone hcl B NR EFFEXOR XR G P trazodone hcl tab 50 mg ANTIDEPRESSANTS - TRI-CYCLICS G P trazodone hcl tab 100 mg

G P trazodone hcl tab 150 mg G P amitriptyline hcl tab 10 mg

B N DESYREL G P amitriptyline hcl tab 25 mg

G N trazodone hcl tab 300 mg G P amitriptyline hcl tab 50 mg

G N citalopram ODT B N ELAVIL

B N CELEXA G P amitriptyline hcl tab 75 mg

G P citalopram hydrobromide G P amitriptyline hcl tab 100 mg

B R LEXAPRO G P amitriptyline hcl tab 150 mg

B N PROZAC CAP 10MG B R AMOXAPINE

G P fluoxetine hcl cap 10 mg B N ANAFRANIL

B N PROZAC CAP 20MG G P clomipramine hcl

B N SARAFEM B N NORPRAMIN

G P fluoxetine hcl cap 20 mg G P desipramine hcl

B 21 N PROZAC CAP 40MG B N SINEQUAN

G 21 N fluoxetine hcl cap 40 mg G P doxepin hcl

B N PROZAC TAB 10MG B N TOFRANIL

G P fluoxetine hcl tab 10 mg G P imipramine hcl

B N RAPIFLUX B NR TOFRANIL-PM

G 6 N fluoxetine hcl tab 20 mg B N AVENTYL

B P PROZAC LIQ 20MG/5ML B N PAMELOR

G P fluoxetine liq 20mg/5ml G P nortriptyline hcl

G P fluoxetine sol 20mg/5ml B R VIVACTIL

B N PROZAC WEEKLY B R SURMONTIL G P fluvoxamine maleate ANTIPSYCHOTICS - ATYPICALS B P PAXIL TAB 10MG

B P PAXIL TAB 20MG B R RISPERDAL

B P PAXIL TAB 30MG B NR RISPERDAL M-TAB

B P PAXIL TAB 40MG B NR RISPERDAL CONSTA

G N paroxetine hcl B R SEROQUEL

B R PAXIL SUS 10MG/5ML B NR ZYPREXA

B R PAXIL CR B NR ZYPREXA ZYDIS

B NR PEXEVA B NR ABILIFY

G N sertraline B R GEODON

B P ZOLOFT ANTIPSYCHOTICS - SPECIAL ATYPICALS B NR CYMBALTA G P clozapine tab 25 mg G R maprotiline hcl B 7 N CLOZARIL G P bupropion hcl tab 75 mg G P clozapine tab 100 mg B P WELLBUTRIN

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 44 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR Mental Health Categories PDL/RDL - Continued - G P thioridazine hcl tab 25 mg ANTIPSYCHOTICS - SPECIAL ATYPICALS G P thioridazine hcl tab 50 mg - Continued - G P thioridazine hcl tab 100 mg G P clozapine tab 200 mg B P THIORIDAZINE HCL

B P FAZACLO G P trifluoperazine hcl tab 1 mg

ANTIPSYCHOTICS - TYPICAL G P trifluoperazine hcl tab 2 mg

G P trifluoperazine hcl tab 5 mg G P haloperidol tab 0.5 mg G P trifluoperazine hcl tab 10 mg G P haloperidol tab 1 mg G P thiothixene cap 1 mg G P haloperidol tab 2 mg G P thiothixene cap 2 mg G P haloperidol tab 5 mg G P thiothixene cap 5 mg G P haloperidol tab 10 mg G P thiothixene cap 10 mg B P HALOPERIDOL B N NAVANE G P haloperidol lactate oral conc 2 mg/ml ANXIOLYTICS - BENZODIAZEPINES B P HALDOL

B P HALOPERIDOL LACTATE B 11 N XANAX

G P haloperidol lactate inj 5 mg/ml G P alprazolam

B N HALDOL DECANOATE-50 B R ALPRAZOLAM INTENSOL

G P haloperidol decanoate im soln 50 mg/ml B 11 N NIRAVAM

B N HALDOL DECANOATE-100 B 11 N LIBRIUM

G P haloperidol decanoate im soln 100 mg/ml G P chlordiazepoxide hcl

G P loxapine succinate cap 5 mg B P TRANXENE T TAB 3.75MG

G P loxapine succinate cap 10 mg G P cloraz dipot tab 3.75mg

G P loxapine succinate cap 25 mg B 11 N TRANXENE T TAB 7.5MG

B N LOXITANE G P cloraz dipot tab 7.5mg

G P loxapine succinate cap 50 mg B 11 N TRANXENE T TAB 15MG

B NR MOBAN G P cloraz dipot tab 15mg

G P chlorpromazine hcl tab 10 mg B 11 N TRANXENE-SD

G P chlorpromazine hcl tab 25 mg G P diazepam tab 2mg

G P chlorpromazine hcl tab 50 mg G P diazepam tab 5mg

G P chlorpromazine hcl tab 100 mg G P diazepam tab 10mg

B N THORAZINE B R DIAZEPAM INTENSOL

G P chlorpromazine hcl tab 200 mg B R DIAZEPAM SOL 1MG/ML

G P chlorpromazine hcl conc 100 mg/ml B 11 N VALIUM

G P chlorpromazine hcl inj 25 mg/ml G P diazepam inj 5mg/ml

G P fluphenazine hcl tab 1 mg G P lorazepam tab 0.5mg

G P fluphenazine hcl tab 2.5 mg G P lorazepam tab 1mg

G P fluphenazine hcl tab 5 mg G P lorazepam tab 2mg

G P fluphenazine hcl tab 10 mg B P LORAZEPAM CON 2MG/ML

G P fluphenazine hcl elixir 2.5 mg/5ml G P lorazepam inj 2mg/ml

B N PROLIXIN B 11 N ATIVAN

G P fluphenazine hcl oral conc 5 mg/ml G P lorazepam inj 4mg/ml

B R FLUPHENAZINE HCL B 11 N SERAX

B N PROLIXIN DECANOATE G P oxazepam

G P fluphenazine decanoate inj 25 mg/ml G NR flumazenil G P perphenazine tab 2 mg ANXIOLYTICS - LONG ACTING G P perphenazine tab 4 mg

G P perphenazine tab 8 mg B 11 NR XANAX XR

G P perphenazine tab 16 mg ANXIOLYTICS - MISC. G P thioridazine hcl tab 10 mg

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 45 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR Mental Health Categories PDL/RDL - Continued - B N PROSOM ANXIOLYTICS - MISC. G P estazolam - Continued - B N DALMANE G P buspirone hcl tab 5 mg G P flurazepam hcl

B N VANSPAR G P midazolam syp 2mg/ml

G P buspirone hcl tab 7.5 mg B N VERSED

G P buspirone hcl tab 10 mg G P midazolam inj 1mg/ml

G P buspirone hcl tab 15 mg G P midazolam inj 2mg/2ml

B 3 N BUSPAR B R DORAL

G 3 N buspirone hcl tab 30 mg B R RESTORIL CAP 7.5MG

B N INAPSINE B N RESTORIL CAP 15MG

G P droperidol inj 2.5 mg/ml B NR RESTORIL CAP 22.5MG

G P meprobamate tab 200 mg B N RESTORIL CAP 30MG

B N MILTOWN G P temazepam

G P meprobamate tab 400 mg B N HALCION

LITHIUM G P triazolam

STIMULANTS - AMPHETAMINES - LONG ACTING G P lithium carbonate cap 150 mg

B P ESKALITH B 24 P DEXEDRINE

G P lithium carbonate cap 300 mg G 24 N dextroamphetamine sulfate

G N lithium carbonate cap 600 mg B 24 R ADDERALL XR B P LITHIUM CARBONATE STIMULANTS - AMPHETAMINES - SHORT ACTING B P LITHOBID

G N lithium carbonate tab cr 300 mg B 24 P DEXEDRINE

B P ESKALITH CR G 24 N dextroamphetamine sulfate tab 5 mg

G N lithium carbonate tab cr 450 mg B 24 P DEXTROSTAT

G P lithium citrate syrup 8 meq/5ml G 24 P dextroamphetamine sulfate tab 10 mg

PSYCHOTHERAPEUTIC COMBINATION B 24 P ADDERALL G 24 N amphetamine-dextroamphetamine B N LIMBITROL STIMULANTS - METHYLPHENIDATE G P chlordiazepoxide-amitriptyline tab 5-12.5 mg

B N LIMBITROL DS B 24 R FOCALIN

G P chlordiazepoxide-amitriptyline tab 10-25 mg G 24 P methylphenidate hcl tab 5 mg

G P perphenazine-amitriptyline tab 2-25 mg G 24 P methylphenidate hcl tab 10 mg

G P perphenazine-amitriptyline tab 4-10 mg B 24 N RITALIN

G P perphenazine-amitriptyline tab 4-25 mg G 24 P methylphenidate hcl tab 20 mg

B R PERPHENAZINE/AMITRIPTYLIN STIMULANTS - METHYLPHENIDATE - LONG ACTING B NR SYMBYAX B 24 R FOCALIN XR SEDATIVE/HYPNOTICS - BARBITURATE B 24 R METADATE CD

B R BUTISOL SODIUM B 24 P METADATE ER

B R MEBARAL G 24 P methylphenidate hcl tab cr 10 mg

G P phenobarbital B 24 NR RITALIN SR

B NR PHENOBARBITAL SODIUM G 24 P methylphenidate hcl tab cr 20 mg

B NR LUMINAL B 24 R CONCERTA

B NR SECONAL B 24 NR RITALIN LA

B NR SOMNOTE STIMULANTS - OTHER STIMULANTS / LIKE G P chloral hydrate syrup 500 mg/5ml STIMULANTS G 24 R methamphetamine hcl B NR CHLORAL HYDRATE CRYSTALS B NR DOPRAM SEDATIVE/HYPNOTICS - BENZODIAZEPINES B NR STRATTERA

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 46 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR Mental Health Categories PDL/RDL - Continued - STIMULANTS - OTHER STIMULANTS / LIKE STIMULANTS - Continued - B 24 NR PROVIGIL

G 24 N pemoline tab 18.75 mg

G 24 NR pemoline tab 37.5 mg

G 24 NR pemoline tab 75 mg

G 24 NR pemoline

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 47 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR Other RDL Categories G NR cytarabine for inj 100 mg ANTIHEMOPHILIC AGENTS G NR cytarabine for inj 500 mg B NR DEPOCYT

B R HEMOFIL M HUMAN B NR FLUOROURACIL

B R MONARC-M G R fluorouracil inj 50 mg/ml

B R KOATE-DVI B R GEMZAR

B R ALPHANATE B R ARRANON

G NR kogenate B R PURINETHOL

B R RECOMBINATE G NR mercaptopurine tab 50 mg

B R HELIXATE FS G R methotrexate sodium tab 2.5 mg (base equiv)

B NR ADVATE B R TREXALL

B R HUMATE-P G R methotrexate sodium inj 25 mg/ml

B NR FEIBA VH IMMUNO B R ALIMTA

G R antiinhibitor coagulant complex for inj B R THIOGUANINE

B R NOVOSEVEN B R AVASTIN

B R ALPHANINE SD B R ERBITUX

B R MONONINE B R HERCEPTIN

B R BENEFIX B R BEXXAR

B R PROFILNINE SD B R BEXXAR 131 IODINE

ANTINEOPLASTICS - ALKYLATING AGENTS ANTINEOPLASTICS - AROMATASE INHIBITORS

B R MYLERAN B R ARIMIDEX

B R BUSULFEX B R AROMASIN

B NR PLATINOL AQ B R FEMARA G R cisplatin inj 1 mg/ml ANTINEOPLASTICS - CARDIAC PROTECTIVE AGENTS ANTINEOPLASTICS - ANTIADRENALS B R ZINECARD B R LYSODREN ANTINEOPLASTICS - COMBINATIONS ANTINEOPLASTICS - ANTIANDROGENS B NR IFEX/MESNEX COMBO PACK

B R CASODEX G R ifosfamide & mesna inj kit 1000-1000 mg B R EULEXIN ANTINEOPLASTICS - ESTROGEN RECEPTOR G NR flutamide cap 125 mg ANTAGONIST B R NILANDRON B R FASLODEX

ANTINEOPLASTICS - ANTIBIOTICS ANTINEOPLASTICS - ESTROGENS

B NR BLENOXANE B R EMCYT

G R bleomycin sulfate for inj 15 unit ANTINEOPLASTICS - FOLIC ACID ANTAGONISTS B NR ADRIAMYCIN PFS RESCUE AGENTS G R leucovorin calcium G R doxorubicin hcl inj 2 mg/ml

B R DOXIL ANTINEOPLASTICS - IMIDAZOTETRAZINES

ANTINEOPLASTICS - ANTIESTROGENS B R TEMODAR

B NR NOLVADEX ANTINEOPLASTICS - INTERLEUKINS

G R tamoxifen citrate B R PROLEUKIN B R FARESTON ANTINEOPLASTICS - LHRH ANALOGS ANTINEOPLASTICS - ANTIMETABOLITES

B R TESLAC B R VIDAZA B R ZOLADEX B R XELODA B R LUPRON DEPOT-PED B R CYTOSAR-U B R LUPRON DEPOT

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 48 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR Other RDL Categories - Continued - B R VESANOID ANTINEOPLASTICS - LHRH ANALOGS ANTINEOPLASTICS - SELECTIVE RETINOID X - Continued - RECEPTOR AGONISTS B R TRELSTAR DEPOT B R TARGRETIN

B R TRELSTAR LA ANTINEOPLASTICS - TOPOISOMERASE I INHIBITORS ANTINEOPLASTICS - MISC. B R CAMPTOSAR

B NR HYDREA B R HYCAMTIN

G R hydroxyurea cap 500 mg ANTINEOPLASTICS - URINARY TRACT PROTECTIVE B R MATULANE AGENTS B R ETHYOL B NR ROFERON-A B R MESNEX B NR INTRON-A W/DILUENT

B NR INTRON-A ANTIRETROVIRAL COMBINATIONS

B NR ACTIMMUNE B R COMBIVIR B NR DROXIA B R KALETRA ANTINEOPLASTICS - MITOTIC INHIBITORS B R TRIZIVIR

B R TAXOTERE ANTIRETROVIRALS

B R VEPESID B R EPZICOM G NR etoposide B R TRUVADA B R TAXOL ANTIRETROVIRALS - FUSION INHIBITORS G NR paclitaxel iv conc 6 mg/ml

G R vincristine sulfate iv soln 1 mg/ml B R FUZEON B R VINBLASTINE SULFATE ANTIRETROVIRALS - PROTEASE INHIBITORS B R NAVELBINE

ANTINEOPLASTICS - NITROGEN MUSTARDS B R AGENERASE B R REYATAZ

B R LEUKERAN B R LEXIVA

G NR cyclophosphamide B R CRIXIVAN

B R CYTOXAN B R VIRACEPT

B R ALKERAN B R NORVIR

ANTINEOPLASTICS - NITROSOUREAS B R FORTOVASE

B R INVIRASE B R GLIADEL B R APTIVUS B R GLIADEL WAFER ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE B R CEENU ANALOGUES ANTINEOPLASTICS - PROGESTINS B R RESCRIPTOR

B R SUSTIVA B R DEPO-PROVERA B R VIRAMUNE G R megestrol acetate ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- B R MEGACE ORAL PURINES G NR megestrol acetate susp 40 mg/ml B R ZIAGEN

B R MEGACE ES B R VIDEX

ANTINEOPLASTICS - PROTEIN-TYROSINE KINASE B R VIDEX EC INHIBITORS G R didanosine B NR NEXAVAR ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- B R TARCEVA PYRIMIDINES B R IRESSA B R EMTRIVA

B R GLEEVEC B R EPIVIR HBV

B R VELCADE B R EPIVIR

ANTINEOPLASTICS - RETINOIDS B R HIVID

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 49 of 50 B, COM P , B, COM P , G, N, Therapeutic Category G, N, Therapeutic Category or R, or or R, or O NR O NR Other RDL Categories - Continued - ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUES- THYMIDINES B R ZERIT

G R zidovudine tab 300 mg

B NR RETROVIR

G R zidovudine syrup 10 mg/ml

ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES

B R VIREAD

IMMUNOSUPPRESSANTS

G NR cyclosporine

G NR cyclosporine iv soln 50 mg/ml

B R SANDIMMUNE

B R CYCLOSPORINE MODIFIED

G R cyclosporine modified (for microemulsion)

B R NEORAL

G R cyclosporine modified oral soln 100 mg/ml

B R CELLCEPT

B R MYFORTIC

B R RAPAMUNE

B R PROGRAF

Report_1010_PDL_A1 rev_zzzk_March 9 P&T 03/03/2006 Page 50 of 50