Regencerx Preferred Medication List/Formulary Regencerx Preferred Effective February 1, 2008 ©2008

February1, 2008 Help to stretch your prescription dollar your prescription Help to stretch

2 Your Preferred Medication List/Formulary 3 Common Questions and Answers

Preferred/Formulary Medications 4-11 • By Category • A to Z Listing 12-17 – Generics 18-22 – Preferred/Formulary Brands

Non-Preferred/Non-Formulary Brands 23-27 • Generic and Preferred Brand Alternatives

Table of Contents Table Effective February 1, 2008 ©2008. RegenceRx. All Rights Reserved. RegenceRx is dedicated to provide the tools you need to understand your options and be a more informed consumer. This preferred medication list/formulary will help—with the answers you need to access affordable prescription benefits.

Determining Cost Newly-introduced How much you pay for a prescription generic medications depends on whether it’s a: When a generic is introduced to the • Generic marketplace, it immediately becomes • Preferred/formulary brand name available at the lowest copay. After a • Non-preferred/non-formulary generic is available, the brand name brand name (brand name medication will only be available at the medication not on the list) non-preferred/non-formulary copay.

Your cost is lowest for generic Preferred/formulary medications and highest for non- brand name medications preferred/non-formulary brand name Brand name medications on the medications. You can find specific preferred medication list (PML) coverage and copay information in have been chosen because our your summary of benefits. professional review has shown each Generic medications of them to be high-quality, effective, Generics provide the same and affordable. Preferred/formulary therapeutic benefits of their brand brand name medications are either name counterparts, without the more effective or equally effective—at brand name price. In fact, generic a lower cost—than other brand name medications are generally 20-60% medications not listed. less expensive. The U.S. Food and Non-preferred/non-formulary Drug Administration assures both brand name medications generic and brand name medications Non-preferred/non-formulary brand meet the same high standards for name medications are those that do strength, quality, and purity. not appear on the PML due to side effects, therapeutic performance, or higher cost. You may still opt for these medications, but your copay will be higher than any other prescription type.

Effective February 1, 2008 ©2008. RegenceRx. All Rights Reserved. How can I use the PML/formulary What if my medication needs to get the best benefit? prior authorization? Ask your doctor to prescribe Certain medications may need prior generic medications whenever authorization. This means that we possible. If a generic is not available, will need to review information from ask your doctor to choose a your doctor before the medication preferred/formulary brand name can be approved for coverage. For a medication. Take this list when you list of medications that need prior go to the doctor so you can discuss authorization, please visit our Web your options. site at www.regencerx.com or contact our Customer Service How can I tell if a listed medication Department at the phone number is a generic? listed on your member card. Generic medications are listed If you decide to purchase the in lower case bold, like this: medication without authorization, you fluconazole. will be responsible for the total cost of the prescription. How can I tell if a listed medication is a brand? What resources were used to Brand name medications start with determine what medications would a capital letter and are followed by be on the PML/formulary? a registered trademark symbol like Information from the US Food and this: ®. Drug Administration (FDA), medical Brand name medications listed in literature (including scientific studies), parentheses after a generic are: and national treatment guidelines were reviewed by the RegenceRx • non-preferred/non-formulary Pharmacy and Therapeutics (P&T) • only listed as a reference for a Committee. This committee includes generically available medication practicing doctors and pharmacists. When there are choices, medications Please remember that not all brands with the best value were included on are preferred/formulary. the PML/formulary. What if my medication is not on the PML/formulary? First, check with your doctor. There are preferred/formulary alternatives in most cases, and your doctor can determine an acceptable alternative for your medical If you have questions, please condition. If you remain on a contact our Customer Service non-preferred/non-formulary brand Department at the phone number name medication, your benefit will listed on your member card. Or depend on your coverage. visit us at www.regencerx.com.

This list can be used to assist you and your doctor in choosing a generic or preferred/formulary medication.

• Generic medications are listed in lower case bold. Example: fluconazole.

• Brand name medications start with a capital letter and are followed by a registered trademark symbol like this ®. Example: Ancobon®.

• Brand name medications listed in parenthesis after a generic are: - Non-preferred/non-formulary. - Only listed as a reference for a generically available medication. Example: fluconazole (Diflucan® )

Additional Information:

- Preferred/formulary medications are limited to the dosage form and strength listed; if no strength is listed, all strengths for the listed dosage form are preferred/formulary. - Sustained action/release (SA/SR), extended release (ER/XR), long-acting (LA), and enteric coated (EC) medications are only preferred/formulary if listed. - Occasionally, preferred/formulary medications may be contract exclusions and, therefore, are not covered. - Some medications may require prior authorization or have quantity limits.

Please note that the PML/formulary list may change. To view the most current list, visit our Web site at www.regencerx.com. For more detailed prescription benefit information, please refer to your benefits booklet.

ANTIFUNGALS (Systemic) ANTI-INFECTIVES (cont.) fluconazole tablet, oral suspension (Diflucan®) erythromycin ethyl suc tablet, suspension (EES®) griseofulvin microsize oral suspension (Grifulvin V®) erythromycin/sulfisox suspension (Pediazole®) griseofulvin microsize tablet (Fulvicin® U/F) ethambutol tablet (Myambutol®) griseofulvin ultramicrosize tablet (Fulvicin® P/G) hydroxychloroquine tablet (Plaquenil®) itraconazole capsule (Sporanox®)* isoniazid tablet ketoconazole tablet (Nizoral®) mebendazole chewtabs (Vermox®) nystatin suspension, tablet (Mycostatin®) metronidazole tablet (Flagyl®) terbinafine HCL tablet (Lamisil®)* minocycline capsule (Minocin®) Ancobon® capsule nitrofurantoin capsule (Macrodantin®, Macrobid®) Mycelex® Troche ofloxacin tablet(Floxin ®) Sporanox solution* penicillin V potassium tablet, suspension (Veetids®) Vfend® tablet, oral suspension pyrazinamide tablet rifampin capsule (Rifadin®) rifampin/isoniazid capsule (Rifamate®) ANTI-INFECTIVES sulfamethoxazole/trimethoprim tablet, suspension amoxicillin capsule, suspension, tablet, ® ® ® (Bactrim , Septra ) chews, drops (Amoxil ) sulfadiazine tablet (Microsulfon®) amoxicillin/pot. clavulanate tabs, chews, ® ® sulfisoxazole tablet, suspension (Gantrisin ) suspension (Augmentin ) ® ® tetracycline capsule (Achromycin ) azithromycin tablet, packet, suspension (Zithromax ) ® ® trimethoprim tablet (Proloprim ) cefaclor capsule, suspension (Ceclor ) ® ® Albenza tablet cefadroxil capsule, tablet, suspension (Duricef ) ® cefdinir capsule, suspension (Omnicef®) Alinia tablet, suspension ® cefprozil tablet, suspension (Cefzil®) Augmentin ES-600 oral suspension cefuroxime tablet (Ceftin®) Avelox® tablet cephalexin capsule (Keflex®) Biltricide® tablet cephradine capsule (Velosef®) Dapsone® tablet chloroquine tablet (Aralen®) Daraprim® tablet ciprofloxacin tablet, suspension (Cipro®) Fansidar® tablet clarithromycin tablet (Biaxin®) Furadantin® oral suspension clindamycin capsule (Cleocin®) Furoxone® tablet, oral suspension dicloxacillin capsule (Dynapen®) Humatin® capsule doxycycline capsule, tablet (Vibramycin®) Lamprene® capsule doxycycline hyclate tablet (Periostat®) Lariam® tablet erythromycin base EC tablet (Emycin®) Mepron® oral suspension

Effective February 1, 2008 *May not be a covered benefit under some plans. 4 ©2008. RegenceRx. All Rights Reserved. ANTI-INFECTIVES (cont.) ANTI-VIRALS/HIV/AIDS (cont.) Mintezol® oral suspension, chewable Kaletra® capsule, oral solution Mycobutin® capsule Lexiva® tablet Primaquine tablet Norvir® capsule, oral solution Seromycin® capsule Prezista™ tablet Stromectal® tablet Rebetol® oral solution Yodoxin® tablet Rescriptor® tablet Zyvox® tablet, oral suspension Reyataz® capsule Sustiva® capsule, tablet Tamiflu® capsule, suspension for reconstitution ANTINEOPLASTICS Trizivir® tablet ® cyclophosphamide tablet (Cytoxan ) Valtrex® tablet ® ® etoposide capsule (Toposar , Vepesid ) Videx® chew tab, solution, packet ® flutamide capsule (Eulexin ) Viracept® tablet, powder for oral solution ® hydroxyurea capsule (Hydrea ) Viramune® tablet, oral suspension ® leucovorin tablet (Wellcovorin ) Viread® tablet ® megestrol tablet, syrup (Megace ) Zerit® capsule, oral solution ® tamoxifen tablet (Nolvadex ) Ziagen® tablet, oral solution tretinoin capsule (Vesanoid®) ® Alkeran tablet BEHAVIOR MODIFICATION ® Arimidex tablet amphetamine/dextroamphetamine tablet (Adderall®) ® Aromasin tablet dextroamphetamine SR capsule ® Casodex tablet (Dexedrine Spansule®) CeeNu® capsule ®  dextroamphetamine tablet (Dexedrine ) Droxia capsule methylphenidate tablet (Ritalin®) ® Emcyt capsule methylphenidate ER tablet (Ritalin® SR) ® Fareston tablet Adderall XR™ capsule ® Femara tablet Antabuse® tablet ® Gleevec tablet, capsule Metadate® CD capsule Hexalen® capsule ® Leukeran tablet BLOOD MODIFIERS ® Lysodren tablet aminocaproic acid tablet (Amicar®) ® Matulane capsule anagrelide capsule (Agrylin®) ® Mesnex tablet cilostazol tablet (Pletal®) ® Myleran tablet dipyridamole tablet (Persantine®) ® Nolvadex tablet pentoxifylline tablet (Trental®) ® Purinethol tablet ticlopidine tablet (Ticlid®) ® Tarceva tablet warfarin tablet (Coumadin®) ® Temodar capsule Coumadin® tablet ® Thioguanine tablet Mephyton® tablet ® Xeloda tablet Plavix® tablet

BONE & JOINT ANTI-VIRALS/HIV/AIDS ® acyclovir tablet, capsule, suspension (Zovirax®) allopurinol tablet (Zyloprim ) amantadine capsule, syrup (Symmetrel®) colchicine tablet leflunomide tablet(Arava ®) didanosine capsule (Videx EC®) methotrexate tablet (Rheumatrex®) famciclovir tablet (Famvir®) ® probenecid tablet ganciclovir capsule (Cytovene ) sulfasalazine tablet (Azulfidine® EN-tabs®)  ribavirin capsule (Rebetol ) Actonel® tablet ribavirin tablet (Copegus) Actonel® with Calcium tablet rimantadine tablet (Flumadine®) Cuprimine® capsule zidovudine capsule, tablet, syrup (Retrovir®) Depen® tablet Agenerase® capsule, oral solution Didronel® tablet Atripla™ tablet Evista® tablet Baraclude® tablet, oral solution Fosamax® tablet, oral solution Combivir® tablet Fosamax Plus D™ tablet Crixivan® capsule Ridaura® capsule Emtriva® capsule Miacalcin® nasal spray Epivir® tablet, oral solution Epivir HBV® tablet, oral solution CARDIOVASCULAR Epzicom® tablet acebutolol capsule (Sectral®) Fortovase® capsule amiloride tablet (Midamor®) Hepsera® tablet amiloride/HCTZ tablet (Moduretic®) Hivid® tablet amiodarone tablet (Cordarone®) Invirase® capsule, tablet amlodipine besylate (Norvasc®)

Effective February 1, 2008 5 ©2008. RegenceRx. All Rights Reserved. CARDIOVASCULAR (cont.) CARDIOVASCULAR (cont.) amlodipine besylate/benazepril capsule (Lotrel®) quinidine gluconate tablet (Quinaglute®) atenolol tablet (Tenormin®) quinidine sulfate tablet (Quinidex®) atenolol/chlorthalidone tablet (Tenoretic®) ramipril capsule (Altace®) benazepril HCL tablet (Lotensin®) sotalol tablet (Betapace®) benazepril HCL/HCTZ tablet (Lotensin® HCT) spironolactone tablet (Aldactone®) betaxolol tablet (Kerlone®) spironolactone/HCTZ tablet (Aldactazide®) bumetanide tablet (Bumex®) terazosin capsule (Hytrin®) captopril tablet (Capoten®) timolol maleate tablet (Blocadren®) captopril/HCTZ tablet (Capozide®) trandolapril tablet (Mavik®) carvedilol tablet (Coreg®) triamterene/HCTZ tablet (Maxzide®) chlorothiazide tablet (Diuril®) verapamil tablet (Calan®) chlorthalidone tablet (Thalitone®) verapamil SR tablet (Calan SR®) clonidine tablet (Catapres®) Benicar™ tablet digoxin tablet, elixir (Lanoxin) Benicar HCT™ tablet diltiazem tablet (Cardizem®) Catapres-TTS® patch diltiazem SR capsule (Cardizem® SR) Cordarone® tablet diltiazem SR capsule (Cardizem® CD) Inderal® LA capsule diltiazem SR capsule (Dilacor® XR) Innopran XL™ capsule disopyramide & ER capsule (Norpace®, Norpace CR®) Kaon-CL-10® tablet doxazosin tablet (Cardura®) K-Dur® tablet enalapril tablet (Vasotec®) K-Lyte® DS tablet enalapril/HCTZ tablet (Vaseretic®) Lanoxicaps® felodipine tablet (Plendil) Lanoxin® tablet, elixir flecainide tablet(Tambocor ®) Micardis® tablet fosinopril tablet (Monopril®) Micardis HCT® tablet fosinopril/HCTZ tablet (Monopril HCT®) Micro-K® capsule furosemide tablet (Lasix®) Norpace® CR capsule guanfacine tablet (Tenex®) Procanbid® tablet hydralazine tablet (Apresoline®) Revatio™ tablet hydralazine/HCTZ tablet (Apresazide®) Sular® tablet hydrochlorothiazide tablet (Oretic®) Tikosyn® capsule indapamide tablet (Lozol®) Tracleer® tablet isosorbide dinitrate & ER tablet (Isordil® & Dilatrate® SR) CHOLESTEROL LOWERING isosorbide mononitrate & ER tablet cholestyramine/sucrose powder (Questran®) (Ismo® & Imdur®) colestipol HCL granules, tablet (Colestid®) labetalol tablet (Trandate®) fenofibrate microsphere capsule, tablet (Lofibra®) lisinopril tablet (Zestril®, Prinivil®) gemfibrozil capsule(Lopid ®) lisinopril/HCTZ tablet (Zestoretic®) lovastatin tablet (Mevacor®) methyclothiazide tablet (Enduron®) pravastatin tablet (Pravachol®) methyldopa tablet (Aldomet®) simvastatin tablet (Zocor®) metolazone tablet (Zaroxolyn®) Colestid® packet metoprolol tablet (Lopressor®) Crestor® tablet metoprolol succinate tablet (Toprol XL®) Niaspan® tablet mexiletine capsule (Mexitil®) Vytorin® tablet midodrine tablet (Proamatine®) minoxidil tablet (Loniten®) DIABETES moexipril/HCTZ tablet (Uniretic®) acetohexamide tablet (Dymelor®) moexipril HCL tablet (Univasc®) chlorpropamide tablet (Diabinese®) nadolol tablet (Corgard®) glimepiride tablet (Amaryl®) nicardipine capsule (Cardene®) glipizide tablet (Glucotrol®) nifedipine capsule (Procardia®) glipizide ER tablet (Glucotrol® XL) nifedipine SA tablet (Adalat® CC) glipizide-metformin (Metaglip™) nimodipine capsule (Nimotop®) glyburide tablet (Diabeta®) nitroglycerin patch (Minitran®, Nitro-Dur®) glyburide, micronized tablet (Glynase®) nitroglycerin capsule (NitroTime®) metformin tablet (Glucophage®) pindolol tablet (Visken®) metformin ER tablet (Glucophage® XR) potassium chloride tablet (K-Dur®) tolazamide tablet (Tolinase®) prazosin capsule (Minipress®) tolbutamide tablet (Orinase®) procainamide capsule (Pronestyl®) Actos® tablet procainamide SA tablet (Pronestyl SR®) Avandia® tablet propafenone tablet (Rythmol®) GlucaGen® injection propranolol tablet (Inderal®) Glucagon® injection propranolol/HCTZ tablet (Inderide®) Humalog® insulins quinapril tablet (Accupril®) Humulin® insulins quinapril/HCTZ tablet (Accuretic®) Lantus® insulin Effective February 1, 2008 6 ©2008. RegenceRx. All Rights Reserved. DIABETES (cont.) GASTROINTESTINAL (cont.) Lantus® SoloSTAR® insulin Anzemet® tablet Novolin® insulins Asacol®tablet, oral solution Novolog® insulins Canasa® rectal suppository Prandin® tablet Colyte® powder for reconstitution ® Compro® rectal suppository Precose tablet ® Proglycem® capsule, oral suspension Cortifoam rectal foam Creon® capsule ® DIABETIC SUPPLIES Dipentum capsule Epifoam® topical foam - Please check if these are covered by your prescription benefit: ® ® Golytely powder for reconstitution, packets Ascensia test strips* ® ® Helidac combopak Ascensia Breeze 2 test strips* ® ® Kristalose packet Ascensia Contour test strips* ® ® Kutrase capsule Novofine needles* Ku-zyme® capsule Lancets, needles, syringes (all products)* Ku-zyme® HP capsule Kytril® tablet, solution EAR/NOSE/THROAT NuLytely® powder for reconstitution acetic acid otic (Acetasol®) Pancrease® capsule acetic acid/hydrocortisone otic (Acetasol®-HC) Pancrease® MT capsule benzocaine/antipyrine otic (Aurodex®) Pancrecarb MS® capsule benzonatate capsule (Tessalon®) Pentasa® capsule clemastine tablet (Tavist®) Prevacid® capsule, suspension, tablet fexofenadine tablet (Allegra®) PrevPac® flunisolide nasal spray (Nasalide®) Prilosec OTC™ - Available at the generic copay. fluticasone propionate nasal spray (Flonase®) ProctoFoam®-HC rectal foam ® hydrocodone/homatropine tablet, syrup (Hycodan®) Ultrase capsule Ultrase® MT capsule hydrocort/polymyx/neomycin otic ® (Cortisporin® Otic) URSO tablet ® Viokase® tablet, powder ipratropium nasal spray (Atrovent ) ® Astelin®nasal spray Visicol tablet BromHist® oral solution Carboxine-PSE® liquid HORMONE/ENDOCRINE (ALSO SEE WOMEN’S HEALTH) Cerumenex® otic solution calcitriol capsule (Rocaltrol®) Ciprodex® otic suspension cortisone acetate tablet (Cortone®) Cipro® HC otic suspension desmopressin tablet, nasal spray, nasal solution (DDAVP®) Nasacort® AQ nasal spray ® ® dexamethasone tablet, elixir (Decadron ) Nasonex nasal spray ® ® fludrocortisone tablet(Florinef ) Relacon-HC syrup folic acid tablet (Folvite®) Rescon JR® capsule ® ® levothyroxine sodium tablet Rhinocort Aqua nasal spray methimazole tablet (Tapazole®) methylprednisolone tablet (Medrol®) GASTROINTESTINAL ® ® prednisolone 15mg/5ml syrup (Prelone ) cimetidine tablet, liquid (Tagamet ) ® ® prednisolone sod phosphate oral solution (Orapred ) dicyclomine capsule, tablet (Bentyl ) ® ® prednisone tablet, solution (Deltasone ) diphenoxylate/atropine tablet (Lomotil ) propylthiouracil tablet famotidine tablet (Pepcid®) ® thyroid dessicated tablet hyoscyamine capsule (Levsin ) triamcinolone tablet (Aristocort®) lactulose syrup (Enulose®) ® unithroid tablet loperamide capsule, liquid (Imodium ) ® ® Armour Thyroid tablet meclizine tablet (Antivert ) ® ® Cytomel tablet mesalamine enema (Rowasa ) DDAVP® nasal spray, nasal solution ® metoclopramide tablet, syrup (Reglan ) Dexamethasone Intensol® oral solution ® misoprostil tablet (Cytotec ) Levothroid® tablet ® omeprazole capsule (Prilosec ) Levoxyl® tablet ® ondansetron tablet (Zofran ODT ) Methitest® tablet ® ondansetron HCL tablet, oral solution (Zofran ) Nilandron® tablet ® pantoprazole sodium tablet (Protonix ) Pediapred® oral solution polyethylene glycol/electrolyte solution Prednisone Intensol® oral concentrate prochlorperazine tablet (Compazine®) ® ® Stimate nasal spray promethazine tablet, suppository (Phenergan ) ® ® Synthroid tablet ranitidine tablet, syrup (Zantac ) ® ® Teslac tablet sucralfate tablet (Carafate ) ® ® ® Testred tablet sulfasalazine tablet (Azulfidine EN-tabs ) Thyrolar® tablet trimethobenzamide capsule, suppository ® ® Westhroid tablet (Tigan ) Winstrol® tablet ursodiol capsule (Actigall®) Analpram HC® rectal cream, rectal lotion

Effective February 1, 2008 *May not be a covered benefit under some plans. 7 ©2008. RegenceRx. All Rights Reserved. IMMUNOSUPPRESSANTS MENTAL HEALTH (cont.) azathioprine tablet (Imuran®) Nardil® tablet ® Orap® tablet cyclosporine, modified capsule, solution(Neoral ) ® ® Risperdal tablet, solution cyclosporine capsule, solution (Sandimmune ) ® ® Seroquel tablet CellCept tablet, capsule, suspension ® ® Zyprexa tablet Myfortic ER tablet ® Prograf® capsule Zyprexa Zydis tablet Rapamune® tablet, solution Sandimmune® capsule, solution MUSCLE RELAXANTS baclofen tablet (Lioresal®) carisoprodol tablet (Soma®) MENTAL HEALTH ® ® carisoprodol/ASA tablet (Soma Compound) alprazolam tablet (Xanax ) ® ® cyclobenzaprine tablet (Flexeril ) amitriptyline tablet (Elavil ) ® ® dantrolene capsule (Dantrium ) amoxapine tablet (Asendin ) ® ® methocarbamol tablet (Robaxin ) bupropion SR tablet (Wellbutrin SR ) ® ® methocarbamol/ASA tablet (Robaxisal ) buspirone tablet (BuSpar ) tizanidine tablet (Zanaflex®) chloral hydrate capsule ® chlordiazepoxide capsule (Librium ) NEUROLOGICAL chlorpromazine tablet, drops, syrup ® ® benztropine tablet (Cogentin ) (Thorazine ) ®  bromocriptine capsule, tablet (Parlodel ) citalopram tablet (Celexa ) ® ® cabergoline tablet (Dostinex ) clomipramine capsule (Anafranil ) ® ® carbamazepine tablet, chews, suspension (Tegretol ) clonazepam tablet (Klonopin ) ® ® carbidopa/levodopa tablet (Sinemet ) clorazepate tablet (Tranxene )  ® ethosuximide syrup (Zarontin ) clozapine tablet (Clozaril ) ® ® gabapentin tablet, capsule (Neurontin ) desipramine tablet (Norpramin ) ® ® lamotrigine tablet (Lamictal ) diazepam tablet, solution (Valium ) oxcarbazepine tablet (Trileptal®) doxepin capsule (Sinequan®) ® phenobarbital tablet, elixir estazolam tablet (Prosom ) ® ® phenytoin sodium capsule (Dilantin ) fluoxetine capsule(Prozac ) primidone tablet (Mysoline®) fluphenazine tablet, concentrate, elixir ® ® selegiline tablet, capsule (Eldepryl ) (Prolixin ) ® ® trihexyphenidyl tablet (Artane ) flurazepam capsule (Dalmane ) ® ® valproic acid capsule, syrup (Depakene ) fluvoxamine tablet(Luvox ) ® ® valproate sodium syrup (Depakene ) haloperidol tablet, solution (Haldol ) ® ® zonisamide capsule (Zonegran ) hydroxyzine HCL tablet (Atarax ) ®  Aricept tablet hydroxyzine pamoate capsule (Vistaril ) ® ® Aricept ODT tablet imipramine tablet (Tofranil ) ® ® Carbatrol capsule lithium carbonate capsule (Eskalith ) Celontin® tablet, capsule lithium citrate syrup ® ® Cognex capsule lorazepam tablet (Ativan ) ® ® Comtan tablet loxapine succinate capsule (Loxitane ) ® ® Depakote tablet maprotiline tablet (Ludiomil ) ® ® Depakote ER tablet mirtazapine tablet (Remeron ) ® ® Depakote Sprinkle capsule nefazodone tablet (Serzone ) ® ® Diastat rectal gel nortriptyline capsule (Pamelor ) ® ® Diastat AcuDial™ rectal gel oxazepam capsule (Serax ) ® ® Dilantin capsule, chews, suspension paroxetine tablet (Paxil ) ® ® Epitol tablet perphenazine tablet (Trilafon ) ® ® Exelon capsule, solution protriptyline tablet (Vivactil ) ® ® Felbatol tablet, oral suspension sertraline tablet (Zoloft ) ® ® Gabitril tablet temazepam capsule (Restoril ) ® ® Kemadrin tablet thioridazine tablet, solution (Mellaril ) ® ® Keppra tablet, solution thiothixene capsule (Navane ) ® ® Lamictal tablet tranylcypromine sulfate tablet (Parnate ) ® ® Mebaral tablet trazodone tablet (Desyrel ) ® ® Mestinon tablet, syrup triazolam tablet (Halcion ) ® ® Mirapex tablet trifluoperazine tablet(Stelazine ) ® ® Mysoline tablet, oral suspension venlafaxine HCL tablet (Effexor ) Phenytek® capsule zolpidem tartrate tablet (Ambien®) ® Razadyne™ tablet, solution Effexor XR capsule ® ® Requip tablet Eskalith capsule, tablet ® ® Rilutek tablet Eskalith CR tablet ® ® Stalevo tablet Lithobid tablet ® ® Tegretol XR tablet Lorazepam Intensol oral concentrate ® Moban® tablet, oral concentrate Topamax tablet, sprinkle Zarontin® capsule, syrup

Effective February 1, 2008 8 ©2008. RegenceRx. All Rights Reserved. OPHTHALMIC PAIN & INFLAMMATORY DISEASE (cont.) acetazolamide tablet (Diamox®) ergotamine/caffeine tablet, suppository (Cafergot®) atropine ophthalmic solution (Atropair®) etodolac capsule (Lodine®) bacitracin ophthalmic solution fenoprofen tablet, capsule (Nalfon®) betaxolol ophthalmic solution fentanyl citrate lollipop (Actiq®) brimonidine ophthalmic solution (Alphagan®) fentanyl patch (Duragesic®) carteolol ophthalmic solution flurbiprofen tablet(Ansaid ®) cromolyn ophthalmic solution (Crolom) hydrocodone/APAP tablet (Vicodin®) dexamethasone sod phos ophthalmic suspension hydrocodone/ibuprofen tablet (Vicoprofen®) diclofenac sod ophthalmic solution hydromorphone tablet (Dilaudid®) dipivefrin ophthalmic solution (Propine) ibuprofen tablet (Motrin®) erythromycin base ophthalmic ointment indomethacin capsule (Indocin®) fluorometholone ophthalmic suspension(Fluor-Op ®) ketoprofen capsule (Orudis®) flurbiprofen ophthalmic solution (Ocufen®) ketoprofen ER capsule (Oruvail® SR) gentamicin ophthalmic solution (Genoptic®) meclofenamate capsule (Meclomen®) homatropine ophthalmic solution meloxicam tablet (Mobic®) (Isopto® Homatropine) meperidine tablet, syrup (Demerol®) ketotifen fumarate ophthalmic solution (Zaditor®) methadone tablet, solution, concentrate levobunolol ophthalmic solution (Betagan®) (Dolophine®) methazolamide tablet (Neptazane®) morphine sulfate tablet, capsule, solution naphazoline ophthalmic solution (Vasocon®) morphine SR tablet (MS Contin®) neo/polymyx/dexamethasone ophthalmic suspension, nabumetone tablet (Relafen®) ointment naproxen tablet (Naprosyn®) phenylephrine ophthalmic solution oxaprozin tablet (Daypro®) pilocarpine ophthalmic solution (Adsorbocarpine®) oxycodone capsule (OxyIR®) prednisolone acetate ophthalmic suspension oxycodone SR tablets (OxyContin®) (Pred Forte®) oxycodone/APAP tablet (Percocet®) prednisolone sod phosphate ophthalmic solution oxycodone/ASA tablet (Percodan®) (Inflamase Forte®) piroxicam capsule (Feldene®) ® sulfacetamide ophthalmic solution (Bleph -10) propoxyphene/APAP tablet (Darvocet N®-100) ® timolol maleate ophthalmic solution (Timoptic ) ® ® salsalate tablet (Disalcid ) tobramycin ophthalmic solution (Tobrex ) ® ® sulindac tablet (Clinoril ) trifluridine ophthalmic solution(Viroptic ) ® ® tolmetin tablet (Tolectin ) Acular ophthalmic solution tramadol tablet (Ultram®) Acular LS™ ophthalmic solution ® ® tramadol/APAP tablet (Ultracet ) Acular PF ophthalmic droperette ® ® Ergomar tablet Alocril ophthalmic solution ® Alphagan® P ophthalmic solution Imitrex tablet, nasal spray, injection Alrex® ophthalmic suspension Kadian® capsule Azopt® ophthalmic suspension Maxalt® tablet Betimol® ophthalmic solution Maxalt®-MLT tablet Betoptic S® ophthalmic suspension Migranal® nasal spray  Blephamide S.O.P. ophthalmic ointment Phrenalin® with caffeine/codeine capsule ® Ciloxan ophthalmic solution, ointment ® ® Relpax tablet Cosopt ophthalmic solution Zomig® tablet, nasal spray Cyclogyl® ophthalmic solution Diamox Sequels® capsule Zomig-ZMT™ tablet FML® S.O.P. ophthalmic ointment ® RESPIRATORY Isopto Atropine ophthalmic solution ® Isopto® Homatropine ophthalmic solution acetylcysteine solution (Mucomyst ) Lotemax® ophthalmic suspension albuterol oral inhaler, inhalation solution, Lumigan® ophthalmic solution tablet, syrup (Proventil®) Ocuflox® ophthalmic solution aminophylline tablet, liquid Patanol® ophthalmic solution cromolyn sodium solution (Intal®) Pilopine HS® ophthalmic gel ® ® dyphylline tablet (Lufyllin ) Pred-Mild ophthalmic suspension ® ® ipratropium bromide solution (Atrovent ) Timoptic-XE ophthalmic sol-gel ipratropium/albuterol inhalation solution (Duoneb®) TobraDex® ophthalmic suspension, ointment ® metaproterenol tablet, syrup, inhalation solution Travatan ophthalmic solution ® Travatan Z® ophthalmic solution (Alupent ) Trusopt® ophthalmic solution theophylline tablet, capsule, elixir Accolate® tablet Asmanex® twisthaler Atrovent® oral inhaler PAIN & INFLAMMATORY DISEASE ® ® Atrovent HFA oral inhaler choline mag trisalicylate tablet (Trilisate ) ® ® Azmacort oral inhaler codeine/APAP tablet (Tylenol #3) ® ® Beclovent oral inhaler diclofenac tablet (Voltaren ) ® diflunisal tablet (Dolobid®) Combivent oral inhaler

Effective February 1, 2008 9 ©2008. RegenceRx. All Rights Reserved. RESPIRATORY (cont.) SKIN/TOPICAL (cont.) Flovent® Diskus® oral inhaler Benzac W® gel Flovent HFA® oral inhaler Capex® shampoo Foradil® oral inhaler Carac® cream Intal® oral inhaler Centany® ointment Nebupent® powder for inhalation Cloderm® cream Peak Flow Meters Condylox® gel, solution ProAir® HFA oral inhaler Cordran® lotion, tape, ointment, cream Proventil HFA® oral inhaler Cutivate® cream, lotion, ointment Pulmicort Respules® Derma-Smooth/FS® oil Pulmicort® oral inhaler Differin® gel, cream, solution, swab Pulmozyme® inhalation solution Dovonex® ointment, cream, solution QVAR® oral inhaler Eurax® cream, lotion Serevent Diskus® oral inhaler Fluoroplex® cream, solution Singulair® tablet, granules, chews Loprox® shampoo Spacer devices Luxiq® foam Spiriva® oral inhaler MetroCream® Tilade® oral inhaler MetroGel® Tobi® oral inhalation solution Phisohex® liquid Uniphyl® tablet MetroLotion® Noritate® cream SKIN/TOPICAL Ovide® lotion amcinonide cream, ointment, lotion (Cyclocort®) Retin A Micro® gel* bacitracin/polymyxin ointment (Polysporin®) Soriatane® capsule Soriatane® CK kit betamethasone dipropionate cream, gel, lotion, ointment ® (Diprolene®) Tazorac cream, gel Topicort LP® cream betamethasone dipropionate augmented cream Ultravate® cream, ointment (Diprolene AF®) ® betamethasone valerate liquid, lotion (Beta-val ) UROLOGY ® betamethasone/clotrimazole cream (Lotrisone ) citric acid/sodium citrate solution (Bicitra®) ® ciclopirox cream, gel, topical suspension (Loprox ) bethanechol tablet (Urecholine®) ciclopirox topical solution (Penlac®)* finasteride tablet(Proscar ®) clindamycin topical gel, lotion, solution (Cleocin®) methenamine hippurate tablet (Hiprex®) clobetasol propionate cream, lotion, ointment methenamine mandelate tablet (Mandelamine®) (Temovate®) oxybutynin tablet (Ditropan®) desonide/petrolatum cream (Desonide®) oxybutynin chloride ER tablet (Ditropan® XL) desoximetasone gel, ointment, cream (Topicort®) phenazopyridine tablet (Pyridium®) diflorasone diacetate ointment, cream (Psorcon®) potassium citrate tablet (Urocit-K®) erythromycin base/benzoyl peroxide gel Detrol® LA capsule (Benzamycin®) Elmiron® capsule fluocinolone acetonide cream, ointment Uroxatral® tablet (Synalar®) fluocinonide cream, ointment, solution, gel WOMEN’S HEALTH (Lidex®) clomiphene citrate tablet (Clomid®)* fluorouracil cream, solution (Efudex®) cryselle tablet* gentamicin cream, ointment (Garamycin®) danazol capsule (Danocrine®) hydrocortisone cream, ointment, lotion estradiol tablet (Estrace) (Ala-cort®) estradiol transdermal patch hydrocortisone butyrate cream, ointment, solution (Locoid®) estropipate tablet (Ogen) isotretinoin (amnesteem, claravis, sotret) capsule (Accutane®) medroxyprogesterone acetate tablet ketoconazole shampoo (Nizoral®) menest tablet lidocaine viscous solution (Xylocaine®) metronidazole vaginal gel (MetroGel-Vaginal®) lindane lotion, shampoo (Kwell®) nora-BE tablet* mometasone cream, lotion, ointment (Elocon®) previfem tablet* mupirocin ointment (Bactroban®) tilia FE tablet* (Estrostep® FE) permethrin 5% cream (Elimite®) tri-legest FE tablet* (Estrostep® FE) podofilox solution (Condylox®) Alesse® tablet* silver sulfadiazine cream (Silvadene®) Anemagen® capsule sulfacetamide sodium/sulfur emulsion, medicated pad Cenestin® tablet (Plexion®) Demulen® tablet* tretinoin cream, gel, lotion (Retin A®)* Desogen® tablet* triamcinolone acetonide cream, ointment (Aristocort®) Diaphragms* urea cream, gel, lotion (Keralac®) Esclim® patch Aclovate® cream, ointment Estraderm® patch Azelex® cream FemHRT® tablet Bactroban® cream Gynazole®-1 vaginal cream Bactroban® nasal ointment Loestrin® tablet* Effective February 1, 2008 *May not be a covered benefit under some plans. 10 ©2008. RegenceRx. All Rights Reserved. WOMEN’S HEALTH (cont.) OTHER Loestrin® FE tablet* chlorhexidine gluconate oral rinse (Peridex®) Loestrin® 24 FE tablet* fluoride drops LoOvral® tablet* pilocarpine tablet (Salagen®) Methergine® tablet Buphenyl® tablet, powder Micronor® tablet* Carnitor® tablet, liquid Modicon® tablet* Chemet® capsule Nestab FA® tablet Cystadane® oral powder Nordette® tablet* Dialyvite® tablet Norinyl® tablet* Evoxac® tablet Nor-QD® tablet* Galzin® capsule Ortho Cept® tablet* PerioGard® oral liquid Ortho Cyclen® tablet* PhosLo® capsule, tablet Ortho Evra® patch* ® ® Radiogardase capsule Ortho Novum tablet* ® ® Sensipar tablet Ortho Prefest tablet Syprine® capsule Ortho Tri-Cyclen® tablet* Ortho Tri-Cyclen® Lo tablet* Ovral® tablet* Ovrette® tablet* Plan B® tablet* Premarin® tablet Premarin® vaginal cream Premphase® tablet Prempro® tablet Serophene® tablet* Terazol® vaginal cream Tri-Levlen® tablet* Tri-Norinyl® tablet* Triphasil® tablet* Vagifem® vaginal tablet Vivelle® patch Vivelle-DOT® patch

SELF-INJECTED cyanocobalamin injection heparin sodium injection leuprolide non-depot injection octreotide acetate injection (Sandostatin®) Apokyn® injection Aranesp® injection Avonex® injection Copaxone® injection Enbrel® injection Epipen® injection Epipen® Jr injection Epogen® injection Fragmin® injection Fuzeon® injection Increlex™ injection Innohep® injection Intron® A injection Leukine® injection Lovenox® injection Miacalcin® injection Neupogen® injection Nutropin AQ® injection*▼ Nutropin Depot® injection*▼ Nutropin® injection*▼ Pegasys® injection Peg-Intron® injection Peg-Intron® Redipen injection Procrit® injection Rebetron® injection Rebif® injection Saizen® injection*▼

Effective February 1, 2008 *May not be a covered benefit under some plans. 11 ▼Obtain from a designated Specialty Pharmacy. ©2008. RegenceRx. All Rights Reserved. A to Z Listing: Generics Effective February 1, 2008

This list can be used to assist you and your doctor in choosing a generic.

• Generic medications are listed in lower case bold.

• Non-preferred/non-formulary brands are listed only as a reference for generically available medications.

• Not all generics are listed. Those listed are examples of some of the generic medications available. Additional Information:

- Occasionally, generic medications may be contract exclusions and, therefore, are not covered. - Some medications may require prior authorization or have quantity limits.

Non-Preferred/Non- Non-Preferred/Non- Generic Generic Formulary Brand Name Formulary Brand Name A azathioprine tablet Imuran® acebutolol capsule Sectral® azithromycin tablet, packet, acetazolamide tablet Diamox® Zithromax® suspension acetic acid otic Acetasol® B acetic acid/hydrocortisone otic Acetasol®-HC bacitracin ophthalmic solution acetohexamide tablet Dymelor® bacitracin/polymyxin ointment Polysporin® acetylcysteine solution Mucomyst® baclofen tablet Lioresal® acyclovir tablet, capsule, Zovirax® ® suspension benazepril tablet Lotensin albuterol oral inhaler, benzocaine/antipyrine otic Aurodex® inhalation solution, tablet, Proventil® benzonatate capsule Tessalon® syrup benztropine tablet Cogentin® allopurinol tablet Zyloprim® betamethasone dipropionate Diprolene® alprazolam tablet Xanax® cream, gel, lotion, ointment amantadine capsule, syrup Symmetrel® betamethasone dipropionate Diprolene AF® amcinonide cream, ointment, augmented cream Cyclocort® lotion betamethasone valerate liquid, ® ® Beta-val amiloride tablet Midamor lotion amiloride/HCTZ tablet Moduretic® betamethasone/clotrimazole Lotrisone® aminocaproic acid tablet Amicar® cream aminophylline tablet, liquid betaxolol ophthalmic solution ® amiodarone tablet Cordarone®** betaxolol tablet Kerlone ® amitriptyline tablet Elavil® bethanechol tablet Urecholine ® brimonidine ophthalmic amlodipine besylate tablet Norvasc Alphagan® solution amlodipine besylate/benazepril ® Lotrel ® capsule bromocriptine capsule, tablet Parlodel ® amoxapine tablet Asendin® bumetanide tablet Bumex amoxicillin capsule, tablet, bupropion SR tablet Wellbutrin SR® Amoxil® suspension, chews, drops buspirone tablet BuSpar® amoxicillin/pot. clavulanate C Augmentin® tabs, chews, suspension cabergoline tablet Dostinex® amphetamine/ ® Adderall® calcitriol capsule Rocaltrol dextroamphetamine tablet captopril tablet Capoten® anagrelide capsule Agrylin® ® atenolol tablet Tenormin® captopril/HCTZ tablet Capozide atenolol/chlorthalidone tablet Tenoretic® carbamazepine tablet, chews, Tegretol® atropine ophthalmic solution Atropair® suspension carbidopa/levodopa tablet Sinemet® Effective February 1, 2008 **This brand is preferred/formulary. 12 ©2008. RegenceRx. All Rights Reserved. Non-Preferred/Non- Non-Preferred/Non- Generic Generic Formulary Brand Name Formulary Brand carisoprodol tablet Soma® cyclobenzaprine tablet Flexeril® ® carisoprodol/ASA tablet Soma Compound cyclophosphamide tablet Cytoxan® carteolol ophthalmic solution cyclosporine capsule, solution Sandimmune®** carvedilol tablet Coreg® cyclosporine, modified capsule, ® Neoral® cefaclor capsule, suspension Ceclor solution cefadroxil capsule, tablet, Duricef® D suspension danazol capsule Danocrine® ® cefdinir capsule, suspension Omnicef dantrolene capsule Dantrium® ® cefprozil tablet, suspension Cefzil desipramine tablet Norpramin® cefuroxime tablet Ceftin® desmopressin tablet, nasal DDAVP®** cephalexin capsule Keflex® spray, nasal solution cephradine capsule Velosef® desonide/petrolatum cream Desonide® desoximetasone gel, ointment, chloral hydrate capsule Topicort® chlordiazepoxide capsule Librium® cream chlorhexidine gluconate oral dexamethasone sod phos Peridex® rinse ophthalmic suspension ® chloroquine tablet Aralen® dexamethasone tablet, elixir Decadron ® chlorothiazide tablet Diuril® dextroamphetamine tablet Dexedrine chlorpromazine tablet, drops, dextroamphetamine SR ® Thorazine® Dexedrine Spansule syrup capsule ® chlorpropamide tablet Diabinese® diazepam tablet, solution Valium ® diclofenac sod ophthalmic chlorthalidone tablet Hygroton solution cholestyramine/sucrose ® Questran® diclofenac tablet Voltaren powder dicloxacillin capsule Dynapen® choline mag trisalicylate tablet Trilisate® dicyclomine capsule, tablet Bentyl® ciclopirox cream, gel, topical ® Loprox ® suspension didanosine capsule Videx EC ciclopirox topical solution* Penlac® diflorasone diacetate ointment, Psorcon® cilostazol tab Pletal® cream cimetidine tablet, liquid Tagamet® diflunisal tablet Dolobid® ciprofloxacin tablet, digoxin tablet, elixir Lanoxin** Cipro® suspension diltiazem SR capsule Cardizem® CD citalopram tablet Celexa diltiazem SR capsule Cardizem® SR citric acid/sodium citrate ® Bicitra® diltiazem SR capsule Dilacor XR solution diltiazem tablet Cardizem® ® clarithromycin tablet Biaxin diphenoxylate/atropine tablet Lomotil® clemastine tablet ® Tavist dipivefrin ophthalmic solution Propine® clindamycin capsule Cleocin® dipyridamole tablet Persantine® clindamycin topical gel, lotion, Cleocin® ® ® solution disopyramide & ER capsule Norpace , Norpace CR ** ® clobetasol propionate cream, doxazosin tablet Cardura Temovate® lotion, ointment doxepin capsule Sinequan® clomiphene citrate tablet* Clomid®* doxycycline capsule, tablet Vibramycin® ® clomipramine capsule Anafranil® doxycycline hyclate tablet Periostat ® clonazepam tablet Klonopin® dyphylline tablet Lufyllin clonidine tablet Catapres® E enalapril tablet Vasotec® clozapine tablet Clozaril® enalapril/HCTZ tablet Vaseretic® clorazepate tablet Tranxene® ergotamine/caffeine tablet, ® ® Cafergot codeine/APAP tablet Tylenol #3 suppository colchicine tablet erythromycin base EC tablet Emycin® colestipol HCL granules, tablet Colestid® erythromycin base ophthalmic cortisone acetate tablet Cortone® ointment  erythromycin base/benzoyl cromolyn ophthalmic solution Crolom Benzamycin® peroxide gel cromolyn neb sodium solution Intal® ® erythromycin ethylsuc tablet, cryselle tablet* Lo/Ovral ** EES® suspension cyanocobalamin injection

Effective February 1, 2008 *May not be a covered benefit under some plans. 13 **This brand is preferred/formulary. ©2008. RegenceRx. All Rights Reserved. Non-Preferred/Non- Non-Preferred/Non- Generic Generic Formulary Brand Name Formulary Brand Name erythromycin/sulfisoxazole ® Pediazole® glipizide tablet Glucotrol suspension glipizide ER tablet Glucotrol® XL estazolam tablet Prosom® estradiol tablet Estrace glipizide-metformin tablet Metaglip™ estradiol transdermal patch glyburide tablet Diabeta® estropipate tablet Ogen glyburide, micronized tablet Glynase® ® griseofulvin microsize oral ethambutol tablet Myambutol Grifulvin® V ethosuximide syrup Zarontin** suspension griseofulvin microsize tablet Fulvicin® U/F etodolac capsule Lodine® griseofulvin ultramicrosize ® ® Fulvicin® P/G etoposide capsule Toposar , Vepesid tablet F guanfacine tablet Tenex® famciclovir tablet Famvir® famotidine tablet Pepcid® H ® felodipine tablet Plendil haloperidol tablet, solution Haldol fenofibrate microsphere heparin sodium injection homatropine ophthalmic capsule, tablet Isopto® Homatropine** fenoprofen tablet, capsule Nalfon® solution ® fentanyl citrate lollipop Actiq® hydralazine tablet Apresoline ® fentanyl patch Duragesic® hydralazine/HCTZ tablet Apresazide fexofenadine tablet Allegra® hydrochlorothiazide tablet Oretic® finasteride tablet Proscar hydrocodone/APAP tablet Vicodin® flecainide tablet Tambocor® hydrocodone/homatropine Hycodan® fluconazole tablet, oral tablet, syrup Diflucan suspension hydrocodone/ibuprofen tablet Vicoprofen® fludrocortisone tablet Florinef® hydrocort/polymyx/neomycin otic Cortisporin® Otic flunisolide nasal spray Nasalide® hydrocortisone cream, Ala-cort® fluticasone propionate nasal ® ointment, lotion Flonase hydrocortisone butyrate spray Locoid® fluocinolone acetonide cream, cream, ointment, solution Synalar® ointment hydromorphone tablet Dilaudid® fluocinonide cream, ointment, hydroxychloroquine tablet Plaquenil® Lidex® solution, gel hydroxyurea capsule Hydrea® fluoride drops hydroxyzine HCL tablet Atarax® fluorometholone ophthalmic  Fluor-Op® hydroxyzine pamoate capsule Vistaril suspension hyoscyamine capsule Cystospaz-M® fluorouracil cream, solution Efudex® I fluoxetine capsule Prozac® ibuprofen tablet Motrin® fluphenazine tablet, ® Prolixin ® concentrate, elixir imipramine tablet Tofranil ® flurazepam capsule Dalmane® indapamide tablet Lozol indomethacin capsule Indocin® flurbiprofen ophthalmic ® Ocufen ® solution ipratropium bromide solution Atrovent flurbiprofen tablet Ansaid® ipratropium nasal spray Atrovent® ® flutamide capsule Eulexin ipratropium/albuterol ® inhalation solution Duoneb fluvoxamine tablet Luvox® isoniazid tablet folic acid tablet Folvite® isosorbide dinitrate & ER Isordil® & Dilatrate® SR fosinopril tablet Monopril® tablet ® isosorbide mononitrate & ER fosinopril/HCTZ tablet Monopril HCT Ismo® & Imdur® ® tablet furosemide tablet Lasix isotretinoin (amnesteem, G Accutane® ® claravis, sotret) capsule gabapentin capsule, tablet Neurontin itraconazole capsule* Sporanox® ganciclovir capsule Cytovene® K gemfibrozil capsule Lopid® ketoconazole shampoo, tablet Nizoral® gentamicin cream, ointment Garamycin® ketoprofen capsule Orudis® gentamicin ophthalmic Genoptic® ® solution ketoprofen ER capsule Oruvail SR ketotifen fumarate ophthalmic glimepiride tablet Amaryl® Zaditor® solution Effective February 1, 2008 *May not be a covered benefit under some plans. 14 **This brand is preferred/formulary. ©2008. RegenceRx. All Rights Reserved. Non-Preferred/Non- Non-Preferred/Non- Generic Generic Formulary Brand Name Formulary Brand Name L metronidazole vaginal gel MetroGel-Vaginal® ® labetalol tablet Trandate mexiletine capsule Mexitil® ® lactulose syrup Enulose midodrine tablet Proamatine® ® lamotrigine tablet Lamictal ** minocycline capsule Minocin® ® leflunomide tablet Arava minoxidil tablet Loniten® ® leucovorin tablet Wellcovorin mirtazapine tablet Remeron® leuprolide non-depot injection misoprostil tablet Cytotec® levobunolol ophthalmic Betagan® moexipril HCL tablet Univasc® solution ® levothyroxine sodium tablet moexipril/HCTZ tablet Uniretic mometasone cream, lotion, ® Elocon® lidocaine viscous solution Xylocaine ointment ® lindane lotion, shampoo Kwell morphine SR tablet MS Contin® ® ® lisinopril tablet Zestril , Prinivil mupirocin ointment Bactroban® ® lisinopril/HCTZ tablet Zestoretic N ® lithium carbonate capsule Eskalith nabumetone tablet Relafen® lithium citrate syrup nadolol tablet Corgard® loperamide capsule, liquid Imodium® naphazoline ophthalmic Vasocon® lorazepam tablet Ativan® solution naproxen tablet Naprosyn® lovastatin tablet Mevacor® nefazodone tablet Serzone® loxapine succinate capsule ® Loxitane neo/polymyx/dexamethasone M ophthalmic suspension, maprotiline tablet Ludiomil® ointment mebendazole chewtabs Vermox® nicardipine capsule Cardene® meclizine tablet Antivert® nifedipine capsule Procardia® meclofenamate capsule Meclomen® nifedipine SA tablet Adalat® CC medroxyprogesterone acetate nimodipine capsule Nimotop® tablet nitrofurantoin capsule Macrodantin®, Macrobid® ® megestrol tablet, syrup Megace nitroglycerin capsule NitroTime® meloxicam tablet Mobic® nitroglycerin patch Minitran®, Nitro-Dur® menest tablet nora-BE tablet* Nor-Q-D®*,** meperidine tablet, syrup Demerol® nortriptyline capsule Pamelor® mesalamine enema Rowasa® metaproterenol tablet, syrup, nystatin suspension, tablet Mycostatin® Alupent® inhalation solution O metformin ER tablet Glucophage® XR octreotide injection Sandostatin® metformin tablet Glucophage® ofloxacin tablet Floxin® methadone tablet, solution, Dolophine® ® concentrate omeprazole capsule Prilosec ® methazolamide tablet Neptazane® ondansetron Zofran ODT ® methenamine hippurate tablet Hiprex ondansetron HCL Zofran ® methenamine mandelate tablet Mandelamine® oxaprozin tablet Daypro ® methimazole tablet Tapazole® oxazepam capsule Serax ® methocarbamol tablet Robaxin® oxcarbazepine tablet Trileptal ® methocarbamol/ASA tablet Robaxisal® oxybutynin tablet Ditropan ® methotrexate tablet Rheumatrex® oxybutynin chloride ER tablet Ditropan XL ® methyclothiazide tablet Enduron® oxycodone capsule OxyIR ® methyldopa tablet Aldomet® oxycodone SR tablet OxyContin ® methylphenidate ER tablet Ritalin® SR oxycodone/APAP tablet Percocet ® methylphenidate tablet Ritalin® oxycodone/ASA tablet Percodan methylprednisolone tablet Medrol® P ® metoclopramide tablet, syrup Reglan® pantoprazole sodium tablet Protonix ® metolazone tablet Zaroxolyn® paroxetine tablet Paxil ® penicillin V potassium tablet, metoprolol tablet Lopressor Veetids® suspension metoprolol succinate tablet Toprol XL® pentoxifylline tablet Trental® metronidazole tablet Flagyl® permethrin 5% cream Elimite®

Effective February 1, 2008 *May not be a covered benefit under some plans. 15 **This brand is preferred/formulary. ©2008. RegenceRx. All Rights Reserved. Non-Preferred/Non- Non-Preferred/Non- Generic Generic Formulary Brand Name Formulary Brand Name perphenazine tablet Trilafon® selegiline tablet, capsule Eldepryl® phenazopyridine tablet Pyridium® sertraline tablet Zoloft® phenobarbital tablet, elixir silver sulfadiazine cream Silvadene® phenylephrine ophthalmic simvastatin tablet Zocor® solution sotalol tablet Betapace® phenytoin sodium capsule Dilantin®** spironolactone tablet Aldactone® pilocarpine ophthalmic solution Adsorbocarpine® spironolactone/HCTZ tablet Aldactazide® pilocarpine tablet Salagen® sucralfate tablet Carafate® ® sulfacetamide ophthalmic pindolol tablet Visken Bleph®-10 piroxicam capsule Feldene® solution sulfacetamide sodium/sulfur polyethylene glycol/electrolyte Plexion® solution emulsion, medicated pad potassium chloride tablet K-Dur®** sulfadiazine tablet Microsulfon® ® sulfamethoxazole/trimethoprim potassium citrate tablet Urocit-K Bactrim®, Septra® pravastatin Pravachol® tablet, suspension prazosin capsule Minipress® sulfasalazine tablet Azulfidine® EN-tabs® prednisolone 15mg/5ml syrup Prelone® sulfisoxazole tablet, suspension Gantrisin® prednisolone acetate ophthalmic sulindac tablet Clinoril® Pred Forte® suspension T prednisolone sod phosphate ® Inflamase Forte® tamoxifen tablet Nolvadex ** ophthalmic solution temazepam capsule Restoril® prednisolone sod phosphate ® Orapred® terazosin capsule Hytrin oral solution ® prednisone tablet, solution Deltasone® terbinafine HCL tablet* Lamisil ® previfem tablet tetracycline capsule Achromycin primaquine phosphate tablet theophylline tablet, capsule, elixir primidone tablet Mysoline®** thioridazine tablet, solution Mellaril® probenecid tablet thiothixene capsule Navane® procainamide capsule Pronestyl® thyroid dessicated tablet procainamide SA tablet Pronestyl SR® ticlopidine tablet Ticlid® prochlorperazine tablet Compazine® ® promethazine tablet, tilia FE tablet Estrostep FE Phenergan® suppository timolol maleate ophthalmic ® ® Betimol ** propafenone tablet Rythmol solution ® propoxyphene/APAP tablet Darvocet N -100 timolol maleate tablet Blocadren® ® propranolol tablet Inderal tizanidine tablet Zanaflex® propranolol/HCTZ tablet Inderide® tobramycin ophthalmic Tobrex® propylthiouracil tablet solution protriptyline tablet Vivactil® tolazamide tablet Tolinase® pyrazinamide tablet tolbutamide tablet Orinase® Q tolmetin tablet Tolectin® quinapril tablet Accupril® tramadol tablet Ultram® quinapril/ HCTZ tablet Accuretic® tramadol/APAP tablet Ultracet® ® quinidine gluconate tablet Quinaglute trandolapril tablet Mavik® ® quinidine sulfate tablet Quinidex tranylcypromine sulfate tablet Parnate® R trazodone tablet Desyrel® ramipril capsule Altace® tretinoin capsule Vesanoid® ranitidine tablet, syrup Zantac® tretinoin cream, gel, lotion* Retin A®* ribavirin capsule Rebetol® ® triamcinolone acetonide ribavirin tablet Copegus Aristocort® cream, ointment rifampin capsule Rifadin® ® rifampin/isoniazid capsule Rifamate® triamcinolone tablet Aristocort ® rimantadine tablet Flumadine® triamterene/HCTZ tablet Maxzide ® S triazolam tablet Halcion salsalate tablet Disalcid® trifluoperazine tablet Stelazine®

Effective February 1, 2008 *May not be a covered benefit under some plans. 16 **This brand is preferred/formulary. ©2008. RegenceRx. All Rights Reserved. Non-Preferred/Non- Generic Formulary Brand Name trifluridine ophthalmic Viroptic® solution trihexyphenidyl tablet Artane® tri-legest FE tablet Estrostep® FE trimethobenzamide capsule, ® suppository Tigan trimethoprim tablet Proloprim® U unithroid tablet urea cream, gel, lotion Keralac® ursodiol capsule Actigall® V valproic acid capsule, syrup Depakene® valproate sodium syrup Depakene® venlafaxine HCL tablet Effexor® verapamil tablet Calan® verapamil SR Calan SR® W warfarin tablet Coumadin®** Z zidovudine capsule, tablet, Retrovir® syrup zolpidem tartrate tablet Ambien® zonisamide capsule Zonegran®

This list can be used to assist you and your doctor in choosing a preferred/formulary brand.

Additional Information:

A Atripla™ tablet Accolate® tablet Atrovent® oral inhaler Aclovate® cream, ointment Atrovent HFA® oral inhaler Actonel® tablet Augmentin ES-600® suspension Actonel® with Calcium tablet Avandia® tablet Actos® tablet Avelox® tablet Acular® ophthalmic solution Avonex® injection Acular LS™ ophthalmic solution Azelex® cream Acular® PF ophthalmic droperette Azmacort® oral inhaler Adderall XR™ capsule Azopt®ophthalmic suspension Agenerase® capsule, solution B Albenza® tablet Bactroban Nasal® ointment Alesse® tablet* Bactroban® cream Alinia® tablet, suspension Baraclude® tablet, oral solution Alkeran® tablet Beclovent® oral inhaler Alocril® ophthalmic solution Benicar® tablet Alphagan® P ophthalmic solution Benicar HCT® tablet Alrex®ophthalmic suspension Benzac W® gel Analpram HC® rectal cream, rectal lotion Betimol® ophthalmic solution Ancobon® capsule Betoptic S® ophthalmic suspension Anemagen® capsule Biltricide® tablet Antabuse® tablet Blephamide® S.O.P. ophthalmic ointment Anzemet® tablet Bromhist® oral solution Apokyn® injection Buphenyl®oral powder, tablet Aranesp® injection C Aricept® tablet Canasa® rectal suppository Aricept ODT® tablet Capex® shampoo Arimidex® tablet Carac®cream Armour® Thyroid tablet Carbatrol® capsule Aromasin® tablet Carboxine-PSE® liquid Asacol® tablet, oral solution Carnitor® tablet, liquid Ascensia® test strips* Casodex® tablet - Please check if these are covered by your prescription benefit. Catapres-TTS® patch Ascensia Contour® test strips* Ceenu® capsule - Please check if these are covered by your prescription benefit. Cellcept capsule, tablet, suspension Ascensia Breeze® 2 test strips* Celontin® tablet, capsule - Please check if these are covered by your prescription benefit. Cenestin® tablet Asmanex® twisthaler Centany® ointment Astelin® nasal spray Cerumenex® otic solution

Effective February 1, 2008 *May not be a covered benefit under some plans. 18 ©2008. RegenceRx. All Rights Reserved. Chemet® capsule Epifoam® topical foam Ciloxan® ophthalmic solution, ophthalmic ointment Epipen® injection Ciprodex® otic suspension Epipen® Jr injection Cipro HC® otic suspension Epitol® tablet Cloderm® cream Epivir® tablet, solution Cognex® capsule Epivir HBV® tablet, solution Colestid® packets Epogen® injection Colyte® powder for reconstitution Epzicom® tablet Combivent® oral inhaler Ergomar® tablet Combivir® tablet Esclim® patch Compro® rectal suppository Eskalith® capsule, tablet Comtan® tablet Eskalith CR® tablet Condylox® gel, solution Estraderm® patch Copaxone® injection Eurax® cream, lotion Cordarone® tablet Evista® tablet Cordran® lotion, tape, ointment, cream Evoxac® capsule Cortifoam® rectal foam Exelon® capsule, solution Cosopt® ophthalmic solution F Coumadin® tablet Fansidar® tablet Creon® capsule Fareston® tablet Crestor® tablet Felbatol® tablet, oral suspension Crixivan® capsule Femara® tablet Cuprimine® capsule FemHRT® tablet Cutivate® cream, lotion, ointment Flovent® Diskus® oral inhaler Cyclogyl® ophthalmic solution Flovent HFA® oral inhaler Cystadane® oral powder Fluoroplex® cream, solution Cytomel® tablet FML® S.O.P. ointment D Foradil® oral inhaler Dapsone® tablet Fortovase® capsule Daraprim® tablet Fosamax® tablet, oral solution DDAVP® nasal solution, nasal spray Fosamax Plus D™ tablet Demulen® tablet* Fragmin® injection Depakote Sprinkle® capsule Furadantin® oral suspension Depakote® ER tablet Furoxone® tablet, oral suspension Depakote® tablet Fuzeon® injection Depen® tablet G Derma-Smoothe/FS® oil Gabitril® tablet Desogen® tablet* Galzin® capsule Detrol® LA capsule Gleevec® tablet, capsule Dexamethasone Intensol® oral solution GlucaGen® injection Diabetic supplies: lancets, needles, syringes* Glucagon® injection - Please check if these are covered by your prescription benefit. Golytely® powder for reconstitution, packets Dialyvite® tablet Gynazole-1® vaginal cream Diamox Sequels® capsule H Diaphragms* Helidac® combo pak Diastat® rectal gel Hepsera® tablet Diastat® AcuDial™ rectal gel Hexalen® capsule Didronel® tablet Hivid® tablet Differin® cream, gel, solution, swab Humalog® insulins Dilantin® capsule, chews, suspension Humatin® capsule Dipentum® capsule Humulin® insulins Dovonex® cream, ointment, solution I Droxia® capsule Imitrex® tablet, nasal spray, injection E Increlex™ injection Effexor XR® capsule Inderal® LA capsule Elmiron® capsule Innohep® injection Emcyt® capsule Innopran XL™ capsule Emtriva® capsule Intal® oral inhaler Enbrel® injection Intron® A injection Effective February 1, 2008 *May not be a covered benefit under some plans. 19 ©2008. RegenceRx. All Rights Reserved. Invirase® capsule, tablet Micro-K® capsule Isopto® Atropine ophthalmic solution Micronor® tablet* Isopto® Homatropine ophthalmic solution Migranal® nasal spray K Mintezol® oral suspension, chews Kadian® capsule Mirapex® tablet Kaletra®capsule, solution Moban® oral concentrate, tablet Kaon-CL-10® tablet Modicon® tablet* K-Dur® tablet Mycelex® troche Kemadrin® tablet Mycobutin® capsule Keppra® tablet, solution. Myfortic® ER tablet K-Lyte® DS tablet Myleran® tablet Kristalose® packet Mysoline® tablet, oral suspension Kutrase® capsule N Ku-Zyme® capsule Nardil® tablet Ku-Zyme® HP capsule Nasacort® AQ nasal spray Kytril® solution, tablet Nasonex® nasal spray L Nebupent® aerosol powder for inhalation Lamictal® tablet Nestabs FA® tablet Lamprene® capsule Neupogen® injection Lanoxicaps® capsule Niaspan® tablet Lanoxin® tablet, elixir Nilandron® tablet Lantus® insulin Nolvadex® tablet Lantus® SoloSTAR® insulin Novofine® needles* Lariam® tablet - Please check if these are covered by your prescription benefit. Leukeran® tablet Nordette® tablet* Leukine® injection Norinyl® tablet* Levothroid® tablet Noritate® cream Levoxyl® tablet Norpace® CR capsule Lexiva® tablet Nor-QD® tablet* Lithobid® tablet Norvir® capsule, solution Loestrin® tablet* Novolin® insulins Loestrin® FE tablet* Novolog® insulins Loestrin® 24 FE tablet* Nulytely® powder for reconstitution LoOvral® tablet* Nutropin® injection*▼ Loprox® shampoo Nutropin AQ® injection*▼ Lorazepam Intensol® oral concentrate Nutropin Depot® injection*▼ Lotemax® ophthalmic suspension O Lovenox® injection Ocuflox® ophthalmic solution Lumigan® ophthalmic solution Orap® tablet Luxiq® topical foam Ortho Cept® tablet* Lysodren® tablet Ortho Cyclen® tablet* M Ortho Evra® patch* Matulane® capsule Ortho Novum® tablet* Maxalt® tablet Ortho Prefest® tablet Maxalt MLT® tablet Ortho Tri-Cyclen® tablet* Mebaral® tablet Ortho Tri-Cyclen® Lo tablet* Mephyton® tablet Ovide® lotion Mepron® oral suspension Ovral® tablet* Mesnex® tablet Ovrette® tablet* Mestinon® tablet, syrup P Metadate® CD capsule Pancrease® capsule Methergine® tablet Pancrease® MT capsule Methitest® tablet Pancrecarb MS® capsule MetroCream® Patanol® ophthalmic solution MetroGel® Peak Flow Meters MetroLotion® Pediapred® solution Miacalcin® injection, nasal spray Pegasys® injection Micardis® tablet Peg-Intron® injection Micardis HCT® tablet Peg-Intron® Redipen injection Effective February 1, 2008 *May not be a covered benefit under some plans. 20 ▼Obtain from a designated Specialty Pharmacy. ©2008. RegenceRx. All Rights Reserved. Pentasa® capsule Serevent Diskus® oral inhaler PerioGard® oral liquid Seromycin® capsule Phenytek® capsule Serophene® tablet* Phisohex® liquid Seroquel® tablet Phoslo® capsule, tablet Singulair® tablet, chews, granules Phrenilin w/Caffeine & Codeine® capsule Soriatane® capsule Pilopine HS® ophthalmic gel Soriatane® CK kit Plan B® tablet* Spacer Device Plavix® tablet Spiriva® oral inhaler Prandin® tablet Sporanox® solution* Precose® tablet Stalevo® tablet Pred Mild® ophthalmic suspension Stimate® nasal spray Prednisone Intensol® oral concentrate Stromectol® tablet Premarin® tablet Sular® tablet Premarin® vaginal cream Sustiva® capsule, tablet Premphase® tablet Synthroid® tablet Prempro® tablet Syprine® capsule Prevacid® capsule, suspension, tablet T Prevpac® Tamiflu® capsule, suspension for reconstitution Prezista™ tablet Tarceva® tablet Prilosec OTC™ tablet - Available at generic copay. Tazorac® cream, gel Primaquine® tablet Tegretol® XR tablet Procanbid® tablet Temodar® capsule Procrit® injection Terazol® vaginal cream ProctoFoam®-HC rectal foam Teslac® tablet Proglycem® capsule, oral suspension Testred® capsule Prograf® capsule Thioguanine® tablet ProAir® HFA oral inhaler Thyrolar® tablet Proventil HFA® oral inhaler Tikosyn® capsule Pulmicort® oral inhaler Tilade® oral inhaler Pulmicort® respules Timoptic-XE® ophthalmic sol-gel Pulmozyme® inhalation solution Tobi® oral inhalation solution Purinethol® tablet TobraDex® ophthalmic suspension, ointment Q Topamax® tablet, sprinkle QVAR® oral inhaler Topicort LP® cream R Tracleer® tablet Radiogardase® capsule Travatan® ophthalmic solution Rapamune® tablet, solution Travatan Z® ophthalmic solution Rebetol® oral solution Tri-Levlen® tablet* Rebetron® injection Tri-Norinyl® tablet* Rebif® injection Triphasil® tablet* Relacon-HC® syrup Trizivir® tablet Relpax® tablet Trusopt® ophthalmic solution Remicade® - Covered only under the medical benefit. U Razadyne™ tablet, solution Ultrase® capsule Requip® tablet Ultrase® MT capsule Rescon JR® capsule Ultravate® cream, ointment Rescriptor® tablet Uniphyl® tablet Retin-A Micro® gel* Uroxatral® tablet Revatio™ tablet URSO® tablet Reyataz® capsule V Rhinocort Aqua® nasal spray Vagifem® vaginal tablet Ridaura® capsule Valtrex® tablet Rilutek® tablet Vfend® tablet, oral suspension Risperdal® tablet, solution Videx® chew tablets, solution, packets S Viokase® tablet, powder for oral solution Saizen® injection*▼ Viracept® tablet, powder for oral solution Sandimmune® capsule, solution Viramune® tablet, oral suspension Sensipar® tablet Viread® tablet Effective February 1, 2008 *May not be a covered benefit under some plans. 21 ▼Obtain from a designated Specialty Pharmacy. ©2008. RegenceRx. All Rights Reserved. Visicol® tablet Vivelle® patch Vivelle-DOT® patch Vytorin® tablet W Westhroid® tablet Winstrol® tablet X Xeloda® tablet Y Yodoxin® tablet Z Zarontin® capsule, syrup Zerit® capsule, oral solution Ziagen® tablet, oral solution Zomig® tablet, nasal spray Zomig-ZMT™ tablet Zyprexa® tablet Zyprexa® Zydis® tablet Zyvox® tablet, oral suspension

This list can be used to assist you and your doctor in choosing a generic or preferred/formulary alternative.

• Generic medications are listed in lower case bold. Example: fluconazole. • Non-preferred/non-formulary brands are listed in parenthesis only as a reference for generically available medications. • This is a partial list. New or rarely used medications may not be listed. • Other, less-expensive options may be available over the counter (OTC) without a prescription. OTC products generally are not a covered prescription benefit.

Additional Information:

Non-Preferred/ Non-Preferred/ Generic and Preferred Brand Generic and Preferred Brand Non-Formulary Non-Formulary Alternatives Alternatives Brand Name Brand Name A simvastatin (Zocor®), pravastatin ® ® ® ® ® clozapine (Clozaril ), haloperidol Advicor (Pravachol ), lovastatin (Mevacor ), Abilify ® ® ® ® (Haldol ), Risperdal , Zyprexa , Seroquel Crestor®, Vytorin® + Niaspan® Ascensia Breeze® 2 test strips*, Ascensia Accu-Chek® Asmanex®, Azmacort®, Flovent® Diskus®, Contour® test strips* Aerobid® / M Flovent® HFA, Pulmicort®, QVAR® benazepril (Lotensin®), enalapril ® (Vasotec®), fosinopril (Monopril®), cilostazol (Pletal ), dipyridamole ® ® Aceon® lisinopril (Zestril®, Prinivil®), moexipril Aggrenox (Persantine ) + aspirin (OTC), ticlopidine ® ® (Univasc®), quinapril (Accupril®), (Ticlid ), Plavix ® trandolapril (Mavik ) Acular®, Alocril®, cromolyn ophthalmic ® cimetidine (Tagamet ), famotidine Alamast® (Crolom®), ketotifen fumarate (Pepcid®), omeprazole (Prilosec®), ® ® Aciphex® ophthalmic solution (Zaditor ), Patanol pantoprazole (Protonix®), ranitidine Aldara® podofilox (Condylox®) (Zantac®), Prevacid®, Prilosec OTC™ estradiol (Estrace®) + OTC loratadine*, OTC Claritin-D®*, medroxyprogesterone (Provera®), Allegra-D® OTC Alavert-D™*, fexodenadine Activella® estradiol (Estrace®) + norethindrone (Allegra®) + decongestant* (Aygestin®), FemHRT®, Prempro®, ® Premphase® cromolyn ophthalmic (Crolom ), Alomide® ketotifen fumarate ophthalmic solution Adoxa® doxycycline (Vibramycin®) (Zaditor®), Alocril®, Patanol® (Asmanex®/Azmacort®/Flovent® Diskus®/ benazepril (Lotensin®), captopril Advair Diskus® Flovent®HFA/Pulmicort®/QVAR®) + (Capoten®), enalapril (Vasotec®), ® ® ® ® Serevent Diskus /Foradil ® fosinopril (Monopril ), lisinopril Altace ® ® ® (Asmanex®/Azmacort®/Flovent® Diskus®/ (Zestril , Prinivil ), moexipril (Univasc ), Advair® HFA Flovent® HFA/Pulmicort®/QVAR®) + quinapril (Accupril®), trandolapril Serevent®Diskus®/Foradil® (Mavik®)

Effective February 1, 2008 *May not be a covered benefit under some plans. 23 ©2008. RegenceRx. All Rights Reserved. Non-Preferred/ Non-Preferred/ Generic and Preferred Brand Generic and Preferred Brand Non-Formulary Non-Formulary Alternatives Alternatives Brand Name Brand Name flurazepam (Dalmane®), temazepam fentanyl transdermal (Duragesic®), Ambien CR™ (Restoril®), triazolam (Halcion®), hydromorphone (Dilaudid®), morphine zolpidem tartrate (Ambien®) Avinza® SR (MS Contin®), morphine sulfate, oxycodone SR (Oxycontin®), oxycodone, Amerge® Imitrex®, Maxalt®, Zomig®, Relpax® codeine sulfate, Kadian® lactulose, polyethylene glycol/electrolyte terazosin (Hytrin®), doxazosin (Cardura®), Amitiza® solution Avodart® finasteride (Proscar®), prazosin (Minipress®), Uroxatral® testosterone cypionate (Depo- ® ® ® ® ® ® ® Axert Imitrex , Maxalt , Zomig , Relpax Androderm Testosterone ), testosterone enanthate ® (Delatestryl®) bromocriptine (Parlodel ), pergolide Azilect® (Permax®), selegiline (Eldepryl®), testosterone cypionate (Depo- Comtan®, Mirapex®, Requip® Androgel® Testosterone®), testosterone enanthate B ® neomycin/polymyxin/bacitracin, (Delatestryl ) Bacitracin® neomycin/polymyxin/gramacidin Angeliq® FemHrt®, Premphase®, Prempro® ophthalmic (Neosporin®) Apidra® Humalog®, Novolog® flunisolide (Nasalide®), fluticasone Beconase AQ® propionate (Flonase®), Nasacort AQ®, Invirase®, Agenerase®, Reyataz®, Lexiva®, Aptivus® Nasonex, Rhinocort Aqua® Crixivan®, Viracept®, Norvir® ® erythromycin base/benzoyl peroxide ® BenzaClin diclofenac (Voltaren ), etodolac (Benzamycin®) (Lodine®), naproxen (Naprosyn®), Betaseron® Avonex®, Copaxone®, Rebif® Arthrotec® salsalate (Disalcid®), choline magnesium B-D® test strips Ascensia® test strips* ® trisalicylate (Trilisate ), meloxicam clarithromycin, erythromycin (E-mycin®, ® (Mobic ) Biaxin XL® EES®), doxycycline (Vibramycin®), benazapril (Lotensin®), Benicar™, azithromycin (Zithromax®) captopril (Capoten ®), enalapril Boniva® Fosamax®, Actonel® ® ® ® ® ® ® (Vasotec ), fosinopril (Monopril ), Brevoxyl benzoyl peroxide (Desquam , Benzac ) Atacand ® ® ® lisinopril (Zestril , Prinivil ), Micardis , C moexipril (Univasc ®), quinapril diltiazem SR (Cardizem SR®), (Accupril®), trandolapril (Mavik®) verapamil SR (Calan SR®), nifedipine lisinopril/HCTZ (Zestoretic®), captopril/ SA (Adalat CC®), felodipine (Plendil®) Caduet® HCTZ (Capozide®), enalapril/HCTZ ® Atacand HCT® + simvastatin (Zocor ), pravastatin (Vaseretic®), fosinopril/HCTZ (Monopril (Pravachol®), lovastatin (Mevacor®), HCT®), Benicar HCT™, Micardis HCT® Crestor®, Vytorin® Augmentin XR® amoxicillin/clavulanate (Augmentin®) diclofenac (Voltaren® XR), etodolac (Lodine® XL), naproxen (Naprosyn®), benazepril/HCTZ (Lotensin HCT®), Celebrex® salsalate (Disalcid®), choline magnesium Benicar HCT™, captopril/HCTZ trisalicylate (Trilisate®) (Capozide®), enalapril/HCTZ (Vasoretic®), fosinopril/HCTZ (Monopril Cipro XR® ciprofloxacin(Cipro ®) Avalide® HCT®), lisinopril/HCTZ (Zestoretic®, ® ® OTC loratadine*, OTC Claritin *, OTC ® ® Clarinex Prinzide ), Micardis HCT , moexipril/ Alavert™* ® HCTZ (Uniretic ), quinapril/HCTZ estradiol, estropipate, Esclim®, ® Climara® (Accuretic ) Estraderm®, Vivelle®, Vivelle DOT® glyburide (Diabeta®), glipizide Avandamet® Climara Pro® FemHRT®, Prempro®, Premphase® (Glucotrol®), metformin (Glucophage®) ® ™ clobetasol propionate (Temovate®), benazapril (Lotensin ), Benicar , Clobex® captopril (Capoten ®), enalapril betamethasone dipropionate (Diprolene®) ® ® ® (Vasotec ), fosinopril (Monopril ), sulfasalazine (Azulfidine Entabs®), Avapro ® ® ® Colazal® lisinopril (Zestril , Prinivil ), Micardis , Asacol®, Dipentum®, Pentasa® moexipril (Univasc ®), quinapril (Accupril®), trandolapril (Mavik®) Combipatch® FemHRT®, Prempro®, Premphase®

Effective February 1, 2008 24 ©2008. RegenceRx. All Rights Reserved. Non-Preferred/ Non-Preferred/ Generic and Preferred Brand Generic and Preferred Brand Non-Formulary Non-Formulary Alternatives Alternatives Brand Name Brand Name methylphenidate ER (Ritalin SR®), Exforge® amlodipine (Norvasc®) + Micardis®/Benicar® Concerta® Metadate CD®, Adderall XR® F prednisone (Deltasone®), dexamethasone ® ® ® estradiol (Estrace ), Premarin vaginal ® ® Femring Cortef (Decadron ), methylprednisolone cream ® (Medrol ) Finacea® Azelex® Cozaar® Benicar™, Micardis® fluorometholone(Fluor-Op ®), ® Cyclessa velivet, cesia Flarex® prednisolone sodium acetate (Pred bupropion SR (Wellbutrin SR®), Forte®), Alrex®, FML S.O.P. ® ® ® citalopram (Celexa ), fluoxetine ® Cymbalta ® ® terazosin (Hytrin ), prazosin (Prozac ), paroxetine (Paxil ), sertraline ® ® ® ® Flomax (Minipress ), doxazosin (Cardura ), (Zoloft ) ® D Uroxatral Denavir® acyclovir capsule (Zovirax®) methylphenidate ER (Ritalin SR®), Focalin® betamethasone valerate (Betaval®), Metadate CD® betamethasone dipropionate Foltx® folic acid + Vitamin B12 + Vitamin B6 Dermatop® (Diprolene®), flunisolone acetonide Fortamet® metformin (Glucophage®) (Synalar®), triamcinolone acetonide ® ® (Aristocort®) Freestyle test strips Ascensia test strips* Detrol LA®, oxybutynin (Ditropan®), Frova® Imitrex®, Maxalt®, Zomig®, Relpax® Detrol® oxybutynin chloride ER (Ditropan® XL) G Diovan® Benicar™, Micardis® Genotropin®*▼ Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼ Diovan HCT® Benicar HCT™, Micardis HCT® Geodon® Risperdal®, Zyprexa®, Seroquel ® ® Doryx doxycycline hyclate (Vibramycin ) ® ® glyburide (Diabeta ), glipizide erythromycin/benzoyl peroxide Glyset ® ® Duac® (Glucotrol ), metformin (Glucophage ) (Benzamycin®) H Duetact® glimepiride (Amaryl®) + Avandia®/Actos® Half-Lytely® polyethylene glycol/electrolyte solution ® diltiazem SR (Cardizem SR ) , Hectorol® calcitriol (Rocaltrol®) DynaCirc CR® verapamil SR (Calan SR®), nifedipine SA (Adalat CC®), felodipine (Plendil®) Humatrope®*▼ Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼ E methotrexate (Rheumatrex®), leflunomide Humira® triamcinolone (Aristocort®), (Arava®), Enbrel® Elidel® betamethasone dipropionate Hyzaar® Benicar HCT™, Micardis HCT® ® ® (Diprolene ), fluocinolone (Synalar ) I Anzemet®, Kytril®, metoclopramide ® ® propranolol (Inderal ), atenolol ® ®, Innopran XL ® ® ® (Reglan ), ondansetron HCL (Zofran (Tenormin ), Inderal LA Emend ® Zofran ODT ), prochlorperazine Risperdal®, Seroquel®, Zyprexa®, ® Ivega™ (Compazine ) Zyprexa® Zydis® oxybutynin (Ditropan®), oxybutynin J Enablex® chloride ER (Ditropan XL®), Detrol LA® glipizide (Glucotrol®), glyburide (Micronase®), Januvia® Entocort EC® prednisone, methylprednisolone metformin (Glucophage®), insulin K Estrace® estradiol, Premarin® vaginal cream, amoxicillin/clavulanate (Augmentin®), vaginal cream Vagifem® clarithromycin (Biaxin®), doxycycline ® ® Ketek® ® estradiol (Estrace ), estropipate (Ogen ), (Vibramycin®), azithromycin Estratest / H.S. ® ® Premarin , Cenestin (Zithromax®) estradiol, Premarin® vaginal cream, Estring® ® Vagifem® ® methotrexate (Rheumatrex ), leflunomide Kineret ® ® clotrimazole (Lotrimin®), econazole (Arava ), Enbrel (Spectazole®), ketoconazole (Nizoral®), benzoyl peroxide (Desquam®), Azelex®, Exelderm® nystatin (Mycostatin®), terbinafine Klaron® erythromycin/benzoyl peroxide (Lamisil®) (Benzamycin®)

Effective February 1, 2008 *May not be a covered benefit under some plans. 25 ▼Obtain from a designated Specialty Pharmacy. ©2008. RegenceRx. All Rights Reserved. Non-Preferred/ Non-Preferred/ Generic and Preferred Brand Generic and Preferred Brand Non-Formulary Non-Formulary Alternatives Alternatives Brand Name Brand Name L O simvastatin (Zocor®), pravastatin generic prenatal vitamins with ® ® ® O-Cal FA Lescol (Pravachol ), lovastatin (Mevacor ), folic acid ® ® Crestor , Vytorin Olux® clobetasol (Temovate®) simvastatin (Zocor®), pravastatin Omnitrope*▼ Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼ Lescol XL® (Pravachol®), lovastatin (Mevacor®), ® ® Crestor®, Vytorin® One-Touch test Ascensia Breeze 2 test strips*, Ascensia ® ® strips Contour test strips* ® ofloxacin(Floxin ), ciprofloxacin Levaquin ® ® ® (Cipro®), Avelox® One-Touch Ultra Ascensia Breeze 2 test strips*, Ascensia ® Lantus®, Humulin N®, Novolin N®, test strips Contour test strips* Levemir® Humalog 75/25®, Novolog 70/30® codeine sulfate, hydromorphone Levlen® aviane*, lessina*, levora*, portia* Opana® (Dilaudid®), morphine sulfate, oxycodone citalopram (Celexa®), fluoxetine Lexapro® (Prozac®), paroxetine (Paxil®), sertraline codeine sulfate, fentanyl transdermal (Zoloft®) (Duragesic®), hydromorphone ® ® ® amitriptyline (Elavil®), nortriptyline Opana ER (Dilaudid ), Kadian , morphine SR (MS Lidoderm® ® (Pamelor®), gabapentin (Neurontin®) Contin ), morphine sulfate, oxycodone, oxycodone SR (Oxycontin®), simvastatin (Zocor®), pravastatin Lipitor® (Pravachol®), lovastatin (Mevacor®), Ovcon® generic oral contraceptives * ® ® Crestor , Vytorin ® ® ® Detrol LA , oxybutynin (Ditropan ), ® Oxytrol cromolyn ophthalmic (Crolom ), oxybutynin chloride ER (Ditropan® XL) Livostin® ketotifen fumarate ophthalmic solution (Zaditor®), Alocril®, Patanol® miconazole (Monistat®), clotrimazole Oxistat® (Lotrimin®), ketoconazole (Nizoral®), fenofibrate, gemfibrozil(Lopid ®), lofibra, nystatin (Mycostatin®) Lovaza® lovastatin (Mevacor®), pravastatin (Pravachol®), simvastatin (Zocor®) P ® flurazepam (Dalmane®), temazepam citalopram (Celexa ), fluoxetine ® ® ® Lunesta® (Restoril®), triazolam (Halcion®), Paxil CR (Prozac ), paroxetine (Paxil ), sertraline ® zolpidem tartrate (Ambien®) (Zoloft ) M diclofenac (Voltaren®), etodolac hydroxychloroquine (Plaquenil®), ® ® ® (Lodine ), naproxen (Naprosyn ), ® ® Ponstel Malarone mefloquine (Lariam ), chloroquine salsalate (Disalcid®), choline magnesium (Aralen®) trisalicylate (trilisate®) Maxair® ProAir® HFA, Proventil HFA® Precare Prenatal® generic prenatal vitamins Mircette® Kariva* N Precision QID® Ascensia® test strips* ® ® ® Precision Xtra® Namenda Aricept , Exelon , Razadyne™ Ascensia® test strips* teststrips flunisolide (Nasalide®), Rhinocort Aqua®, ® ® generic prenatal vitamins Nasarel fluticasone propionate (Flonase ), Prenate Elite® Nasacort AQ®, Nasonex with folic acid generic prenatal vitamins with Prevident 5000 Plus sodium fluoride gel Natelle® folic acid cimetidine (Tagamet®), famotidine ® cimetidine (Tagamet ), famotidine ® ® ® (Pepcid ), omeprazole (Prilosec ), ® ® Prilosec ® ® (Pepcid ), omeprazole (Prilosec ), pantoprazole (Protonix ), ranitidine Nexium ® pantoprazole (Protonix ), ranitidine (Zantac®), Prevacid®, Prilosec OTC™ (Zantac®), Prevacid®, Prilosec OTC™ generic prenatal vitamins Primacare prenatal® Norditropin®*▼ Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼ with folic acid

® ® Norditropin ® ▼ ® ▼ ® ▼ Prometrium medroxyprogesterone (Provera ) ® ▼ Nutropin * , Nutropin AQ * , Saizen * Nordiflex * ® ® omeprazole (Prilosec ), pantoprazole ® Protonix NuvaRing generic oral contraceptives* (Protonix®), Prilosec OTC™

Effective February 1, 2008 *May not be a covered benefit under some plans. 26 ▼Obtain from a designated Specialty Pharmacy. ©2008. RegenceRx. All Rights Reserved. Non-Preferred/ Non-Preferred/ Generic and Preferred Brand Generic and Preferred Brand Non-Formulary Non-Formulary Alternatives Alternatives Brand Name Brand Name ® ® triamcinolone (Aristocort®), Tri-Levlen trivora*, enpresse*, Triphasil * Protopic® betamethasone dipropionate Truvada® Emtriva® + Viread® (Diprolene®), fluocinolone (Synalar®) Tussionex® hydrocodone bitartrate/homatropine ® ® Pennkinetic (Hycodan ), hydrocodone bitartrate/ methylphenidate ER (Ritalin SR ), ® dextroamphetamine (Dexedrine®), Suspension guaifenesin (Hycotuss ) Provigil® ® ® amphetamine/dextroamphetamine ® Baraclude™, Epivir HBV, Hepsera , Tyzeka ® ® (Adderall®) Intron A , Pegasys ® ® V Prozac Weekly fluoxetine (Prozac ) Valcyte® ganciclovir (Cytovene®) Pylera® Helidac®, PrevPac® Vantin® cefuroxime (Ceftin®), cefaclor (Ceclor®) R Ventolin HFA® ProAir® HFA,Proventil HFA® Renagel® PhosLo® flunisolide (Nasarel®, Nasalide®), ® ® ® Ritalin LA® methylphenidate ER, Metadate CD® Veramyst fluticasone (Flonase ), Nasacort AQ , ® ® ® ® Nasonex , Rhinocort Aqua ® sulfacetamide sodium/sulfur (Plexion ), ® Rosac ® oxybutynin (Ditropan ), oxybutynin benzoyl peroxide Vesicare ® ® ® chloride ER (Ditropan XL), Detrol LA flurazepam (Dalmane ), temazepam ® ® ® ® ® Vigamox ciprofloxacin (Ciloxan ), ofloxacin(Ocuflox ) Rozerem™ (Restoril ), triazolam (Halcion ), W zolpidem tartrate (Ambien®) cholestyramine (Questran®), Welchol® S colestipol HCL (Colestid®) Detrol LA®, oxybutynin (Ditropan®), Wellbutrin XL® bupropion SR (Wellbutrin SR®) Sanctura® oxybutynin chloride ER (Ditropan® XL) X ® ® ® ® Sarafem® fluoxetine(Prozac ®) Xalatan Travatan , Travatan Z , Lumigan ® ® Seasonale® levora,* portia,* Nordette®* Xanax XR alprazolam (Xanax ) flurbiprofen (Ocufen®), Acular®, Serostim*▼ Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼ Xibrom® Acular LS™, Acular® PF carisoprodol (Soma®), cyclobenzaprine azithromycin (Zithromax®), ciprofloxacin Skelaxin® Xifaxan® (Flexeril®), methocarbamol (Robaxin®) (Cipro®), ofloxacin(Floxin ®) Xopenex® albuterol flurazepam (Dalmane®), temazepam ® ® ® Sonata® (Restoril®), triazolam (Halcion®), Xopenex HFA ProAir HFA , Proventil HFA ® ® zolpidem tartrate (Ambien ) ® fexofenadine (Allegra ), OTC Alavert™*, Xyzal ® Spectracef® cefuroxime (Ceftin®), cefaclor (Ceclor®) OTC Claritin *, OTC loratadine* Y ® ® glyburide (Diabeta ), glipizide Yasmin® generic oral contraceptives* Starlix ® ® (Glucotrol ), metformin (Glucophage ) Z ® ® cimetidine (Tagamet ), famotidine ® methylphenidate ER, Metadate CD , ® ® Strattera ® Adderall XR ® (Pepcid ), omeprazole (Prilosec ), Zegerid ® ® ® ® ® pantoprazole (Protonix ), ranitidine (Asmanex /Azmacort /Flovent Diskus / ® ® ® ® ® ® (Zantac ), Prevacid , Prilosec OTC™ Symbicort Flovent HFA/Pulmicort /Qvar ) + simvastatin (Zocor®), pravastatin (Pravachol®), ® ® ® Zetia® Foradil /Sereven Diskus lovastatin (Mevacor®), Crestor®, Vytorin® ® ® ® Symbyax fluoxetine(Prozac) + Zyprexa clindamycin (Cleocin®), erythromycin T base/ethanol (Erygel®), sulfacetamide trandolapril (Mavik®)+ verapamil Ziana™ sodium (Klaron®), erythromycin Tarka® (Calan®) base/benzoyl peroxide (Benzamycin®), ® ® ® ofloxacin(Floxin ®), ciprofloxacin tretinoin (Retin A ), Differin , Tazorac Tequin® (Cipro®), Avelox® Zorbtive®*▼ Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼ ® ® Teveten Benicar™ , Micardis ® acyclovir (Zovirax) tablets, capsules or Zovirax ointment ® Tev-Tropin*▼ Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼ suspension, Valtrex tablet Zylet® TobraDex® ophthalmic suspension, ointment Tiazac® diltiazem SR (Dilacor XR®) OTC loratadine*, OTC Claritin®*, OTC ® ® Zyrtec® Trans-Derm Scop meclizine (Antivert ) Alavert™*, fexofenadine(Allegra®) Triaz® benzoyl peroxide (Desquam®) OTC loratadine* + decongestant* gemfibrozil(Lopid ®), fenofibrate Zyrtec-D® OTC Claritin-D®*, OTC Alavert-D™*, Tricor® (LoFibra) fexodenadine (Allegra®) + decongestant Effective February 1, 2008 *May not be a covered benefit under some plans. 27 ▼Obtain from a designated Specialty Pharmacy. ©2008. RegenceRx. All Rights Reserved. www.regencerx.com P.O. Box 1271, Portland, OR 97207-1271 P.O.