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Arizona Complete Health-Complete Care Plan Behavioral Health Preferred Drug List

The Arizona Complete Health-Complete Care Plan Behavioral Health Drug List includes all of the behavioral health drugs listed on the AHCCCS Behavioral Health Drug List (BHDL). This is not a complete list of all covered behavioral health drugs. If you need a drug that is not in the behavioral health drug list, your doctor may request prior authorization to cover the drug.

The drug list is updated often and may change. You can view the latest drug list at www.azcompletehealth.com/providers/pharmacy.html

Pharmacy Program

Arizona Complete Health-Complete Care Plan provides appropriate, high quality, and cost effective drug therapy to all Arizona Complete Health-Complete Care Plan members. Arizona Complete Health-Complete Care Plan covers prescription drugs and certain over-the-counter (OTC) drugs when ordered by a doctor. Some drugs require prior authorization (PA) or have limits on age, dosage and maximum amounts.

Generic drugs have the same active ingredient as the brand name version. Generic drugs should be used as the first line of treatment. This is unless a drug specifically notes brand is preferred. If there is no generic available, there may be more than one brand name drug that can be used in your treatment. The Arizona Complete Health-Complete Care Plan Behavioral Health PDL is reviewed often by our Arizona Complete Health Pharmacy and Therapeutics (P&T) Committee. This helps promote the appropriate and cost-effective use of medications.

Dispensing Limits

You can get up to a maximum of thirty (30) day supply or one hundred (100) unit dose for each new prescription or refill. A total of 85% of the 30 day supply must have elapsed before the prescription can be refilled for most drugs.

Prior Authorization and Other Limits

Some drugs listed on the Arizona Complete Health-Complete Care Plan Behavioral Health PDL may require Prior Authorization (PA). Your doctor or pharmacist will request a PA for you. . This document is located on the Arizona Complete Health- Complete Care Plan web-site at https://www.azcompletehealth.com/providers/pharmacy.html Your provider can send a PA request electronically to https://www.covermymeds.com/epa/envolverx/ They may also fax the PA form to: 1-855-554-5233

Arizona Complete Health-Complete Care Plan will cover the medication if:

1. There is a behavioral health medical reason that requires the specific medication 2. Depending on the medication, other medications on the PDL have not worked

Antipsychotic drugs and on the drug list require a Prior Authorization if they are not prescribed by a behavioral health or other approved specialist.

If the request is approved, Arizona Complete Health-Complete Care Plan notifies your prescriber by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Arizona Complete Health-Complete Care Plan

will:  Review the request and notify you and your prescriber of our decision  Let you know about alternative medications if available  Provide information about what you can do to appeal our decision if you do not agree with it.

What it Abbreviation means How it works AL Age Limit Some drugs are only covered for certain ages.

These drugs are covered by Arizona Complete F Formulary Health-Complete Care Plan.

Maintenance These drugs are used to treat long-term conditions MP Product or illnesses.

These drugs require authorization to be covered by NF Non Formulary Arizona Complete Health-Complete Care Plan. Your doctor must ask for approval from Arizona Prior Complete Health-Complete Care Plan before some PA Authorization drugs will be covered. QL Quantity Limit Some drugs are only covered for a certain amount. These drugs are used to treat complex or rare Specialty conditions such as hepatitis C or rheumatoid SP Product arthritis. In some cases, you must first try certain drugs before Arizona Complete Health-Complete Care Plan covers another drug for your medical condition.

For example, if Drug A and Drug B both treat your medical condition, Arizona Complete Health- Complete Care Plan may not cover Drug B unless ST Step Therapy you try Drug A first.

Medical Necessity Requests

If you require a medication to treat a behavioral health condition that does not appear on the PDL, your doctor can make a medical necessity (MN) request for the medication.

Emergency Supply Policy

State and Federal laws require that a pharmacy dispense up to a 4 day supply of medication to any member awaiting PA determination .The purpose is to avoid interruption of current therapy or delay in the start of therapy. Network pharmacies are authorized to provide up to a 4 day supply of traditional behavioral health

(non-specialty) drugs. Have your Pharmacy call the Pharmacy Help Desk at 1- 888-624-1131 for help filling a 4 day emergency supply.

Exclusions

The Arizona Complete Health-Complete Care Plan Drug List does not include certain drugs. The following types of drugs are excluded from coverage. They are also not available for a 4 day emergency supply.  Drugs that are considered experimental or investigational  Drug Efficacy Study and Implementation (DESI) drugs  Prosthesis, appliances and devices  Medications to treat physical health conditions  Oral vitamins and minerals or OTC drugs (except those listed on the PDL)  Nutritional supplements  Medical marijuana  Drugs covered under Medicare Part D (for Medicare eligible members) except for drugs on the behavioral health drug list for SMI members.

Newly Approved Products

Arizona Complete Health-Complete Care Plan reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these drugs will be considered through the PA review process.

Filling a Prescription

You can have prescriptions filled at an Arizona Complete Health-Complete Care Plan network pharmacy. To find a network pharmacy, visit the Arizona Complete Health-Complete Care Plan website https://providersearch.azcompletehealth.com. You may also call member services for help finding a network pharmacy near you. When you pick a pharmacy, please bring your Arizona Complete Health-Complete Care Plan ID card with you. The pharmacy will need the information located on the card to fill your prescription.

For More information about your pharmacy benefits, please review your Member Handbook or call Member Services at 888-788-4408 (TTY/TDY 711).

Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- DEXEDRINE CP24 10 MG, OBESITY/ANOREXIANTS - Drugs to Treat 15 MG NF ADHD, and Eating Disorders ( Sulfate) DEXEDRINE CP24 5 MG QL(2 ea daily); TABS QL(2 ea daily) (Dextroamphetamine NF AL(At least 6 3.75MG-3.75MG-3.75MG- F Sulfate) yrs old) 3.75MG (- Dextroamphetamine) QL(2 ea daily); dextroamphetamine sulfate F AL(At least 6 ADDERALL TABS 5MG- QL(2 ea daily); cp24 5 mg, 10 mg, 15 mg yrs old) 5MG-5MG-5MG, 2.5MG- AL(At least 6 2.5MG-2.5MG-2.5MG, yrs old) DYANAVEL XR SUER 2.5 F PA 7.5MG-7.5MG-7.5MG- MG/ML 7.5MG, 1.25MG-1.25MG- QL(1 ea daily); VYVANSE CAPS F AL(At least 6 1.25MG-1.25MG, F 1.875MG-1.875MG- yrs old) 1.875MG-1.875MG, QL(1 ea daily); 3.125MG-3.125MG- VYVANSE CHEW F AL(At least 6 3.125MG-3.125MG yrs old) (Amphetamine- Dextroamphetamine) Attention-Deficit/Hyperactivity Disorder (ADHD) ADDERALL XR CP24 QL(1 ea daily); QL(2 ea daily); hcl caps 10 F 2.5MG-2.5MG-2.5MG- AL(At least 6 mg AL(At least 6 2.5MG, 7.5MG-7.5MG- yrs old) yrs old) 7.5MG-7.5MG, 1.25MG- atomoxetine hcl caps 18 QL(1 ea daily); mg, 25 mg, 40 mg, 60 mg, F AL(At least 6 1.25MG-1.25MG-1.25MG, F 3.75MG-3.75MG-3.75MG- 80 mg, 100 mg yrs old) 3.75MG, 6.25MG-6.25MG- QL(1 ea daily); 6.25MG-6.25MG hcl (adhd) tb24 F AL(At least 6 (Amphetamine- yrs old) Dextroamphetamine) QL(1 ea daily); ADDERALL XR CP24 QL(2 ea daily); INTUNIV TB24 NF (Guanfacine HCl (ADHD)) AL(At least 6 5MG-5MG-5MG-5MG F AL(At least 6 yrs old) (Amphetamine- yrs old) QL(4 ea daily); Dextroamphetamine) KAPVAY TB12 0.1 MG F )) AL(At least 6 amphetamine- QL(2 ea daily) ( HCl (ADHD yrs old) dextroamphetamine tabs F QL(2 ea daily); 3.75mg-3.75mg-3.75mg- STRATTERA CAPS 10 MG NF ) AL(At least 6 3.75mg (Atomoxetine HCl yrs old) amphetamine- QL(2 ea daily); STRATTERA CAPS 18 QL(1 ea daily); dextroamphetamine tabs AL(At least 6 MG, 25 MG, 40 MG, 60 NF AL(At least 6 5mg-5mg-5mg-5mg, yrs old) MG, 80 MG, 100 MG yrs old) 2.5mg-2.5mg-2.5mg- (Atomoxetine HCl) 2.5mg, 7.5mg-7.5mg- 7.5mg-7.5mg, 1.25mg- F Stimulants - Misc. 1.25mg-1.25mg-1.25mg, QL(1 ea daily); 1.875mg-1.875mg- APTENSIO XR CP24 F AL(At least 6 1.875mg-1.875mg, yrs old) 3.125mg-3.125mg- 3.125mg-3.125mg

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

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); RITALIN LA CP24 20 MG, QL(2 ea daily); DAYTRANA PTCH F AL(At least 6 30 MG (Methylphenidate NF AL(At least 6 yrs old) HCl) yrs old) QL(2 ea daily); QL(3 ea daily); FOCALIN TABS F RITALIN TABS NF ) AL(At least 6 ) AL(At least 6 (Dexmethylphenidate HCl yrs old) (Methylphenidate HCl yrs old) QL(2 ea daily); ANALGESICS - - Drugs to Treat Pain, FOCALIN XR CP24 F ) AL(At least 6 Muscle and Joint Conditions (Dexmethylphenidate HCl yrs old) QL(1 ea daily); Opioid Partial METADATE CD CPCR NF Smart PA ) AL(At least 6 hcl subl sl 2 (Methylphenidate HCl yrs old) F Required;AL(At mg, 8 mg least 6 yrs old) METHYLIN CHEW 5 MG, QL(3 ea daily); 10 MG, 2.5 MG NF AL(At least 6 SUBOXONE FILM F AL(At least 6 (Methylphenidate HCl) yrs old) yrs old) METHYLIN SOLN 5 QL(10 ml ANTIANXIETY AGENTS - Drugs to Treat MG/5ML, 10 MG/5ML F daily); AL(At (Methylphenidate HCl) least 6 yrs old) Antianxiety Agents - Misc. QL(3 ea daily); QL(2 ea daily); methylphenidate hcl chew F hcl tabs or 30 or 5 mg, 10 mg, 2.5 mg AL(At least 6 F AL(At least 6 yrs old) mg yrs old) methylphenidate hcl cp24 QL(2 ea daily); QL(4 ea daily); or 10 mg, 20 mg, 30 mg, F AL(At least 6 buspirone hcl tabs or 5 mg, F AL(At least 6 40 mg yrs old) 10 mg, 15 mg, 7.5 mg yrs old) methylphenidate hcl cpcr or QL(1 ea daily); HCL F PA 10 mg, 20 mg, 30 mg, 40 F AL(At least 6 SOLN IM 25 MG/ML mg, 50 mg, 60 mg yrs old) hydroxyzine hcl soln im 50 F PA QL(3 ea daily); mg/ml methylphenidate hcl tabs or F AL(At least 6 5 mg, 10 mg, 20 mg hydroxyzine hcl syrp or 10 F QL(4 ml daily) yrs old) mg/5ml METHYLPHENIDATE QL(2 ea daily); hydroxyzine hcl tabs or 10 F QL(8 ea daily) HYDROCHLORIDE ER F AL(At least 6 mg, 25 mg, 50 mg (LA) CP24 yrs old) HYDROXYZINE QL(4 ea daily); METHYLPHENIDATE QL(2 ea daily); PAMOATE CAPS OR 100 F AL(At least 6 HYDROCHLORIDE ER F AL(At least 6 MG yrs old) TB24 yrs old) hydroxyzine pamoate caps F QL(4 ea daily) QL(1 ea daily); or 25 mg, 50 mg QUILLICHEW ER CHER F AL(At least 6 yrs old) VISTARIL CAPS NF QL(4 ea daily) (Hydroxyzine Pamoate) QL(5 ml QUILLIVANT XR SUSR F daily,30 day(s) limit); AL(At Limit least 6 yrs old) to QL(2 ea daily); ALPRAZOLAM INTENSOL 4mg RITALIN LA CP24 10 MG F F daily;QL(60 ml ) AL(At least 6 CONC (Methylphenidate HCl yrs old) per 15 days retail); AL(At least 6 yrs old)

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

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit SOLN IJ 5 F PA alprazolam to MG/ML alprazolam tabs or 0.25 F mg, 0.5 mg, 1 mg 4mg daily;QL(4 QL(10 ml ea daily); AL(At DIAZEPAM SOLN OR 5 F daily); AL(At least 6 yrs old) MG/5ML least 6 yrs old) Limit QL(4 ea daily); alprazolam to diazepam tabs or 2 mg, 5 F AL(At least 6 alprazolam tabs or 2 mg F 4mg daily;QL(2 mg, 10 mg yrs old) ea daily); AL(At least 6 yrs old) QL(2 ml daily); conc or 2 mg/ml F AL(At least 6 Limit yrs old) alprazolam tb24 or 0.5 mg, alprazolam to F 4mg daily;QL(1 lorazepam soln ij 2 mg/ml, F PA 1 mg, 2 mg, 3 mg ea daily); AL(At 4 mg/ml, 20 mg/10ml least 6 yrs old) QL(4 ea daily); lorazepam tabs or 0.5 mg, F Limit 1 mg AL(At least 6 alprazolam to yrs old) alprazolam tbdp or 0.25 F 4mg daily;QL(4 QL(3 ea daily); mg, 0.5 mg, 1 mg ea daily); AL(At lorazepam tabs or 2 mg F AL(At least 6 least 6 yrs old) yrs old) Limit QL(2 ea daily); caps 10 mg, 15 F alprazolam to mg, 30 mg AL(At least 6 alprazolam tbdp or 2 mg F 4mg daily;QL(2 yrs old) ea daily); AL(At QL(2 ea daily); least 6 yrs old) OXAZEPAM CAPS 30 MG F AL(At least 6 ATIVAN SOLN IJ 2 PA yrs old) MG/ML, 4 MG/ML NF QL(4 ea daily); (Lorazepam) TRANXENE T TABS NF ( Dipotassium) AL(At least 6 QL(4 ea daily); yrs old) ATIVAN TABS OR 0.5 MG, NF 1 MG (Lorazepam) AL(At least 6 QL(4 ea daily); yrs old) VALIUM TABS (Diazepam) NF AL(At least 6 QL(3 ea daily); yrs old) ATIVAN TABS OR 2 MG NF (Lorazepam) AL(At least 6 Limit yrs old) alprazolam to XANAX TABS 0.25 MG, NF QL(2 ea daily); 0.5 MG, 1 MG (Alprazolam) 4mg daily;QL(4 hcl caps F AL(At least 6 ea daily); AL(At yrs old) least 6 yrs old) QL(2 ea daily); Limit clorazepate dipotassium F AL(At least 6 alprazolam to tabs 15 mg XANAX TABS 2 MG NF yrs old) (Alprazolam) 4mg daily;QL(2 QL(4 ea daily); ea daily); AL(At clorazepate dipotassium F AL(At least 6 least 6 yrs old) tabs 7.5 mg, 3.75 mg yrs old) Limit QL(2 ml daily); alprazolam to XANAX XR TB24 NF diazepam conc or 5 mg/ml F AL(At least 6 (Alprazolam) 4mg daily;QL(1 yrs old) ea daily); AL(At least 6 yrs old) DIAZEPAM SOAJ IM 10 F PA MG/2ML - Drugs to Treat Seizures

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

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Anticonvulsants - Benzodiazepines LAMICTAL XR TB24 25 AL(At least 6 QL(4 ea daily); MG, 50 MG, 100 MG, 200 NF yrs old) tabs or 0.5 F MG, 250 MG, 300 MG AL(At least 6 ) mg, 1 mg yrs old) (Lamotrigine QL(2 ea daily); lamotrigine chew or 5 mg, F AL(At least 6 clonazepam tabs or 2 mg F AL(At least 6 25 mg yrs old) yrs old) lamotrigine tabs or 25 mg, F AL(At least 6 QL(4 ea daily); 100 mg, 150 mg, 200 mg yrs old) clonazepam tbdp or 0.125 F AL(At least 6 lamotrigine tb24 or 25 mg, AL(At least 6 mg, 0.25 mg, 0.5 mg, 1 mg yrs old) 50 mg, 100 mg, 200 mg, F yrs old) QL(2 ea daily); 250 mg, 300 mg clonazepam tbdp or 2 mg F AL(At least 6 lamotrigine tbdp or 25 mg, F AL(At least 6 yrs old) 50 mg, 100 mg, 200 mg yrs old) QL(4 ea daily); NEURONTIN CAPS NF AL(At least 6 KLONOPIN TABS 0.5 MG, NF () yrs old) ) AL(At least 6 1 MG (Clonazepam yrs old) NEURONTIN SOLN NF AL(At least 6 QL(2 ea daily); (Gabapentin) yrs old) KLONOPIN TABS 2 MG NF AL(At least 6 (Clonazepam) NEURONTIN TABS NF AL(At least 6 yrs old) (Gabapentin) yrs old) Anticonvulsants - Misc. F AL(At least 6 susp yrs old) chew or F 100 mg F AL(At least 6 oxcarbazepine tabs yrs old) carbamazepine cp12 or F 100 mg, 200 mg, 300 mg TEGRETOL SUSP NF (Carbamazepine) carbamazepine susp or F 100 mg/5ml TEGRETOL TABS NF (Carbamazepine) carbamazepine tabs or 200 F mg TEGRETOL-XR TB12 NF (Carbamazepine) carbamazepine tb12 or 100 F mg, 200 mg, 400 mg TOPAMAX SPRINKLE NF AL(At least 6 CPSP (Topiramate) yrs old) CARBATROL CP12 NF (Carbamazepine) TOPAMAX TABS NF AL(At least 6 (Topiramate) yrs old) gabapentin caps or 100 F AL(At least 6 mg, 300 mg, 400 mg yrs old) topiramate cpsp or 15 mg, F AL(At least 6 25 mg yrs old) gabapentin soln or 250 F AL(At least 6 mg/5ml, 300 mg/6ml yrs old) topiramate tabs or 25 mg, F AL(At least 6 50 mg, 100 mg, 200 mg yrs old) gabapentin tabs or 600 mg, F AL(At least 6 800 mg yrs old) TRILEPTAL SUSP NF AL(At least 6 LAMICTAL CHEWABLE AL(At least 6 (Oxcarbazepine) yrs old) DISPERSIBLE CHEW NF yrs old) TRILEPTAL TABS NF AL(At least 6 (Lamotrigine) (Oxcarbazepine) yrs old) LAMICTAL ODT TBDP 25 AL(At least 6 Valproic Acid MG, 50 MG, 100 MG, 200 NF yrs old) DEPAKENE CAPS NF MG (Lamotrigine) (Valproic Acid) LAMICTAL TABS AL(At least 6 NF DEPAKENE SOLN NF (Lamotrigine) yrs old) (Valproate Sodium) Arizona Complete Health-Complete Care Plan Behavioral Health Effective October 1, 2018

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

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

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); PAXIL TABS 10 MG, 20 QL(1 ea daily); fluoxetine hcl caps or 10 F AL(At least 6 MG, 30 MG ( NF AL(At least 6 mg, 40 mg yrs old) HCl) yrs old) QL(4 ea daily); QL(1.5 ea fluoxetine hcl caps or 20 F PAXIL TABS 40 MG NF AL(At least 6 ) daily); AL(At mg yrs old) (Paroxetine HCl least 6 yrs old) QL(20 ml PA; AL(At least fluoxetine hcl soln or 20 F PEXEVA TABS F mg/5ml daily); AL(At 6 yrs old) least 6 yrs old) QL(2 ea daily); QL(3 ea daily); PROZAC CAPS 10 MG, 40 NF AL(At least 6 maleate cp24 F MG (Fluoxetine HCl) 100 mg AL(At least 6 yrs old) yrs old) QL(4 ea daily); QL(2 ea daily); PROZAC CAPS 20 MG NF AL(At least 6 fluvoxamine maleate cp24 F (Fluoxetine HCl) 150 mg AL(At least 6 yrs old) yrs old) QL(10 ml QL(3 ea daily); hcl conc or 20 F daily); AL(At fluvoxamine maleate tabs F mg/ml 100 mg AL(At least 6 least 6 yrs old) yrs old) QL(2 ea daily); QL(2 ea daily); sertraline hcl tabs or 100 F AL(At least 6 fluvoxamine maleate tabs F mg 25 mg AL(At least 6 yrs old) yrs old) QL(3 ea daily); QL(6 ea daily); sertraline hcl tabs or 25 mg F AL(At least 6 fluvoxamine maleate tabs F 50 mg AL(At least 6 yrs old) yrs old) QL(4 ea daily); LEXAPRO SOLN 5 QL(20 ml sertraline hcl tabs or 50 mg F AL(At least 6 MG/5ML (Escitalopram NF daily); AL(At yrs old) Oxalate) least 6 yrs old) QL(10 ml ZOLOFT CONC 20 MG/ML NF LEXAPRO TABS 10 MG, QL(1 ea daily); ) daily); AL(At 20 MG (Escitalopram NF AL(At least 6 (Sertraline HCl least 6 yrs old) Oxalate) yrs old) QL(2 ea daily); QL(2 ea daily); ZOLOFT TABS 100 MG NF AL(At least 6 LEXAPRO TABS 5 MG NF (Sertraline HCl) (Escitalopram Oxalate) AL(At least 6 yrs old) yrs old) QL(3 ea daily); QL(1 ea daily); ZOLOFT TABS 25 MG NF AL(At least 6 paroxetine hcl tabs 10 mg, F (Sertraline HCl) 20 mg, 30 mg AL(At least 6 yrs old) yrs old) QL(4 ea daily); ZOLOFT TABS 50 MG NF QL(1.5 ea ) AL(At least 6 paroxetine hcl tabs 40 mg F daily); AL(At (Sertraline HCl yrs old) least 6 yrs old) Serotonin Modulators QL(3 ea daily); paroxetine hcl tb24 25 mg, F QL(2 ea daily); 12.5 mg, 37.5 mg AL(At least 6 HCL TABS F AL(At least 6 yrs old) 100 MG yrs old) QL(3 ea daily); PAXIL CR TB24 NF QL(4 ea daily); (Paroxetine HCl) AL(At least 6 NEFAZODONE HCL TABS F AL(At least 6 yrs old) 150 MG yrs old) QL(30 ml PAXIL SUSP 10 MG/5ML F daily); AL(At least 6 yrs old) Arizona Complete Health-Complete Care Plan Behavioral Health Effective October 1, 2018

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); EFFEXOR XR CP24 75 QL(3 ea daily); nefazodone hcl tabs 50 F AL(At least 6 MG, 37.5 MG ( NF AL(At least 6 mg, 250 mg yrs old) HCl) yrs old) QL(3 ea daily); QL(4 ea daily); NEFAZODONE F PRISTIQ TB24 NF AL(At least 6 ) AL(At least 6 HYDROCHLORIDE TABS yrs old) ( Succinate yrs old) QL(4 ea daily); QL(1 ea daily); hcl tabs or 100 F AL(At least 6 venlafaxine hcl cp24 150 F AL(At least 6 mg yrs old) mg yrs old) QL(2 ea daily); QL(3 ea daily); trazodone hcl tabs or 150 F AL(At least 6 venlafaxine hcl cp24 75 F AL(At least 6 mg yrs old) mg, 37.5 mg yrs old) QL(1 ea daily); QL(4 ea daily); trazodone hcl tabs or 300 F AL(At least 6 venlafaxine hcl tabs 25 mg F AL(At least 6 mg yrs old) yrs old) QL(3 ea daily); QL(3 ea daily); trazodone hcl tabs or 50 F AL(At least 6 venlafaxine hcl tabs 50 mg, F AL(At least 6 mg yrs old) 100 mg, 37.5 mg yrs old) VIIBRYD STARTER PACK F PA; AL(At least QL(5 ea daily); KIT 6 yrs old) venlafaxine hcl tabs 75 mg F AL(At least 6 yrs old) VIIBRYD TABS F PA; AL(At least 6 yrs old) Agents Serotonin- Reuptake Inhibitors hcl tabs or 10 AL(At least 6 QL(4 ea daily); mg, 25 mg, 50 mg, 75 mg, F yrs old) CYMBALTA CPEP 20 MG, NF 100 mg, 150 mg 30 MG ( HCl) AL(At least 6 yrs old) TABS F AL(At least 6 QL(2 ea daily); yrs old) CYMBALTA CPEP 60 MG NF ) AL(At least 6 ANAFRANIL CAPS NF AL(At least 6 (Duloxetine HCl yrs old) ( HCl) yrs old) QL(1 ea daily); clomipramine hcl caps or AL(At least 6 DESVENLAFAXINE ER F F TB24 100 MG AL(At least 6 25 mg, 50 mg, 75 mg yrs old) yrs old) hcl tabs or 10 AL(At least 6 QL(2 ea daily); mg, 25 mg, 50 mg, 75 mg, F yrs old) DESVENLAFAXINE ER F TB24 50 MG AL(At least 6 100 mg, 150 mg yrs old) hcl caps or 10 mg, QL(3 ea daily); QL(4 ea daily); 25 mg, 50 mg, 75 mg, 100 F AL(At least 6 desvenlafaxine succinate F tb24 AL(At least 6 mg, 150 mg yrs old) yrs old) QL(6 ml daily); QL(4 ea daily); doxepin hcl conc or 10 F AL(At least 6 duloxetine hcl cpep or 20 F AL(At least 6 mg/ml yrs old) mg, 30 mg yrs old) ELAVIL TABS NF AL(At least 6 QL(2 ea daily); (Amitriptyline HCl) yrs old) duloxetine hcl cpep or 60 F AL(At least 6 mg hcl tabs or 10 F AL(At least 6 yrs old) mg, 25 mg, 50 mg yrs old) QL(1 ea daily); AL(At least 6 EFFEXOR XR CP24 150 NF imipramine pamoate caps F ) AL(At least 6 yrs old) MG (Venlafaxine HCl yrs old)

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

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NORPRAMIN TABS NF AL(At least 6 BENADRYL AL(At least 6 (Desipramine HCl) yrs old) TABS ( NF yrs old) HCl) hcl caps or 10 F AL(At least 6 mg, 25 mg, 50 mg, 75 mg yrs old) diphenhydramine hcl caps F AL(At least 6 or 25 mg yrs old) nortriptyline hcl soln or 10 F AL(At least 6 mg/5ml yrs old) AL(At least 6 diphenhydramine hcl caps F yrs old); PAMELOR CAPS NF AL(At least 6 or 50 mg (Nortriptyline HCl) yrs old) RX/OTC diphenhydramine hcl chew AL(At least 6 F AL(At least 6 F hcl tabs yrs old) or 12.5 mg yrs old) AL(At least 6 SURMONTIL CAPS NF AL(At least 6 diphenhydramine hcl elix or ( Maleate) yrs old) F yrs old); 12.5 mg/5ml RX/OTC TOFRANIL TABS NF AL(At least 6 (Imipramine HCl) yrs old) diphenhydramine hcl liqd or AL(At least 6 25 mg/10ml, 50 mg/20ml, F yrs old) trimipramine maleate caps F AL(At least 6 6.25 mg/ml, 12.5 mg/5ml or 25 mg, 50 mg, 100 mg yrs old) diphenhydramine hcl tabs F AL(At least 6 AND SPECIFIC ANTAGONISTS or 25 mg yrs old) F AL(At least 6 Opioid Antagonists SILPHEN COUGH SYRP yrs old) HCL SOCT IJ AL(At least 6 F VANAMINE PD LIQD NF AL(At least 6 0.4 MG/ML yrs old) (Diphenhydramine HCl) yrs old) naloxone hcl soln ij 0.4 F AL(At least 6 mg/ml, 4 mg/10ml yrs old) - Piperidines hcl tabs or AL(At least 6 NALOXONE HCL SOSY IJ F AL(At least 6 F 2 MG/2ML yrs old) 4 mg yrs old) ANTIHYPERTENSIVES - Drugs to Treat High F AL(At least 6 hcl tabs or yrs old) Blood Pressure F AL(At least 6 Antiadrenergic Antihypertensives NARCAN LIQD yrs old) CATAPRES TABS NF AL(At least 6 VIVITROL SUSR F AL(At least 6 (Clonidine HCl) yrs old) yrs old) 4 / mo;QL(0.15 CATAPRES-TTS-1 PTWK NF ANTIHISTAMINES - Drugs to Treat ) ea daily); AL(At (Clonidine HCl least 6 yrs old) Antihistamines - Ethanolamines CATAPRES-TTS-2 PTWK 4 / mo;QL(0.15 NF ea daily); AL(At F AL(At least 6 (Clonidine HCl) ALER-DRYL TABS yrs old) least 6 yrs old) BENADRYL ALLERGY AL(At least 6 4 / mo;QL(0.15 CATAPRES-TTS-3 PTWK NF CAPS (Diphenhydramine NF yrs old) (Clonidine HCl) ea daily); AL(At HCl) least 6 yrs old) BENADRYL ALLERGY AL(At least 6 clonidine hcl ptwk td 0.1 4 / mo;QL(0.15 CHILDRENS CHEW NF yrs old) mg/24hr, 0.2 mg/24hr, 0.3 F ea daily); AL(At (Diphenhydramine HCl) mg/24hr least 6 yrs old) BENADRYL ALLERGY AL(At least 6 clonidine hcl tabs or 0.1 F AL(At least 6 CHILDRENS LIQD NF yrs old) mg, 0.2 mg, 0.3 mg yrs old) (Diphenhydramine HCl) F AL(At least 6 guanfacine hcl tabs yrs old) Arizona Complete Health-Complete Care Plan Behavioral Health Effective October 1, 2018

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MINIPRESS CAPS AL(At least 6 QL(3 ea daily); NF GEODON CAPS OR 20 NF ( HCl) yrs old) ) AL(At least 6 MG ( HCl yrs old) prazosin hcl caps F AL(At least 6 yrs old) F PA; AL(At least GEODON SOLR IM 20 MG 18 yrs old) TENEX TABS (Guanfacine NF AL(At least 6 HCl) yrs old) QL(1 ea daily); LATUDA TABS F AL(At least 6 ANTIPARKINSON AND RELATED THERAPY yrs old) AGENTS - Drugs to Treat Parkinson's Disease QL(3 ea daily); Antiparkinson ziprasidone hcl caps 20 F AL(At least 6 mg, 40 mg, 60 mg yrs old) benztropine mesylate soln F PA ij 1 mg/ml QL(2 ea daily); ziprasidone hcl caps 80 mg F AL(At least 6 benztropine mesylate tabs F AL(At least 6 or 0.5 mg, 1 mg, 2 mg yrs old) yrs old) COGENTIN SOLN NF PA Benzisoxazoles (Benztropine Mesylate) INVEGA SUSTENNA QL(1 ml per 23 hcl elix 0.4 F SUSP 156 MG/ML, 78 F days retail); mg/ml MG/0.5ML, 117 AL(At least 18 MG/0.75ML yrs old) trihexyphenidyl hcl tabs 2 F AL(At least 6 mg, 5 mg yrs old) QL(2 ml per 23 Antiparkinson Dopaminergics INVEGA SUSTENNA F days retail); SUSP 234 MG/1.5ML AL(At least 18 amantadine hcl caps or F yrs old) 100 mg QL(0.0 ml per amantadine hcl syrp or 50 F INVEGA SUSTENNA F 23 days retail); mg/5ml SUSP 39 MG/0.25ML AL(At least 18 amantadine hcl tabs or 100 F yrs old) mg Try Invega /ANTIMANIC AGENTS - Sustenna first;1 Drugs to Treat Mood Disorders rtl pack lmt INVEGA TRINZA SUSP F amt,90 rtl pack Antimanic Agents lmt day(s),; caps or F AL(At least 18 150 mg, 300 mg, 600 mg yrs old) lithium carbonate tabs or F Limit 2 per 300 mg month;QL(2 ea RISPERDAL CONSTA per 30 days lithium carbonate tbcr or F F 300 mg, 450 mg SUSR retail); AL(At least 18 yrs LITHIUM SOLN F old) LITHOBID TBCR (Lithium QL(4 ea daily); NF RISPERDAL M-TAB TBDP NF Carbonate) ) AL(At least 6 0.5 MG ( yrs old) Antipsychotics - Misc. QL(3 ea daily); AL(At least 6 RISPERDAL M-TAB TBDP NF EQUETRO CP12 F ) AL(At least 6 yrs old) 1 MG (Risperidone yrs old)

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

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(8 ml HALDOL SOLN NF AL(At least 6 daily,240 ml ( Lactate) yrs old) RISPERDAL SOLN 1 NF per 30 days MG/ML (Risperidone) soln F AL(At least 18 retail); AL(At im 50 mg/ml, 100 mg/ml yrs old) least 6 yrs old) F AL(At least 6 QL(4 ea daily); haloperidol lactate conc yrs old) RISPERDAL TABS 0.25 NF MG, 0.5 MG (Risperidone) AL(At least 6 yrs old) F AL(At least 6 haloperidol lactate soln yrs old) RISPERDAL TABS 1 MG NF (Risperidone) haloperidol tabs or 0.5 mg, AL(At least 6 1 mg, 2 mg, 5 mg, 10 mg, F yrs old) QL(2 ea daily); 20 mg RISPERDAL TABS 3 MG NF ) AL(At least 6 (Risperidone yrs old) Dibenzapines QL(4 ea daily); ADASUVE AEPB F PA RISPERIDONE ODT TBDP F AL(At least 6 yrs old) QL(5 ea daily); QL(8 ml ODT TBDP F AL(At least 18 daily,240 ml yrs old) risperidone soln 1 mg/ml F per 30 days QL(5 ea daily); clozapine tabs 25 mg, 50 F retail); AL(At mg, 100 mg, 200 mg AL(At least 18 least 6 yrs old) yrs old) QL(4 ea daily); QL(5 ea daily); risperidone tabs 0.25 mg, clozapine tbdp 25 mg, 100 F F AL(At least 6 mg AL(At least 18 0.5 mg yrs old) yrs old) QL(3 ea daily); QL(5 ea daily); risperidone tabs 1 mg, 2 CLOZARIL TABS NF F AL(At least 6 (Clozapine) AL(At least 18 mg yrs old) yrs old) QL(2 ea daily); QL(5 ea daily); risperidone tabs 3 mg, 4 FAZACLO TBDP 25 MG, NF F AL(At least 6 100 MG (Clozapine) AL(At least 18 mg yrs old) yrs old) QL(4 ea daily); succinate caps F AL(At least 6 risperidone tbdp 0.25 mg, F AL(At least 6 yrs old) 0.5 mg yrs old) solr im 10 mg F PA QL(3 ea daily); risperidone tbdp 1 mg, 2 F AL(At least 6 QL(1 ea daily); mg olanzapine tabs or 15 mg, F yrs old) 20 mg AL(At least 6 QL(2 ea daily); yrs old) risperidone tbdp 3 mg, 4 F QL(1 ea mg AL(At least 6 yrs old) olanzapine tabs or 2.5 mg, F daily,30 day(s) 7.5 mg limit); AL(At Butyrophenones least 6 yrs old) HALDOL DECANOATE AL(At least 18 QL(2 ea daily); 100 SOLN (Haloperidol NF yrs old) olanzapine tabs or 5 mg, F AL(At least 6 Decanoate) 10 mg yrs old) HALDOL DECANOATE 50 AL(At least 18 QL(1 ea daily); SOLN (Haloperidol NF yrs old) olanzapine tbdp or 15 mg, F AL(At least 6 Decanoate) 20 mg yrs old)

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

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); HCL F AL(At least 6 olanzapine tbdp or 5 mg, F AL(At least 6 CONC OR 5 MG/ML yrs old) 10 mg yrs old) FLUPHENAZINE HCL F AL(At least 6 fumarate tabs QL(4 ea daily); ELIX OR 2.5 MG/5ML yrs old) 25 mg, 50 mg, 100 mg, 200 F AL(At least 6 FLUPHENAZINE HCL F PA; AL(At least mg yrs old) SOLN IJ 2.5 MG/ML 18 yrs old) QL(2 ea daily); quetiapine fumarate tabs fluphenazine hcl tabs or 1 F AL(At least 6 F AL(At least 6 mg, 5 mg, 10 mg, 2.5 mg yrs old) 300 mg, 400 mg yrs old) tabs or 2 mg, F AL(At least 6 QL(2 ea daily); 4 mg, 8 mg, 16 mg yrs old) SAPHRIS SUBL F AL(At least 6 yrs old) hcl tabs or 10 F AL(At least 6 mg, 25 mg, 50 mg, 100 mg yrs old) SEROQUEL TABS 25 MG, 100 MG, 200 MG, 400 MG NF hcl tabs F AL(At least 6 (Quetiapine Fumarate) yrs old) QL(2 ea daily); Quinolinone Derivatives SEROQUEL TABS 300 MG NF (Quetiapine Fumarate) AL(At least 6 1 rtl pack lmt yrs old) amt,30 rtl pack ABILIFY MAINTENA PRSY F lmt day(s),; ZYPREXA SOLR IM 10 NF PA MG (Olanzapine) AL(At least 18 QL(1 ea daily); yrs old) ZYPREXA TABS OR 15 NF 1 rtl pack lmt ) AL(At least 6 MG, 20 MG (Olanzapine yrs old) amt,30 rtl pack ABILIFY MAINTENA SRER F lmt day(s),; QL(1 ea AL(At least 18 ZYPREXA TABS OR 2.5 NF daily,30 day(s) MG, 7.5 MG (Olanzapine) limit); AL(At yrs old) least 6 yrs old) ABILIFY TABS 2 MG NF () ZYPREXA TABS OR 5 NF MG, 10 MG (Olanzapine) ABILIFY TABS 5 MG, 10 QL(1 ea daily); NF QL(1 ea daily); MG, 15 MG, 20 MG, 30 MG AL(At least 6 ZYPREXA ZYDIS TBDP 15 NF (Aripiprazole) yrs old) MG, 20 MG (Olanzapine) AL(At least 6 yrs old) aripiprazole soln 1 mg/ml F PA QL(2 ea daily); ZYPREXA ZYDIS TBDP 5 NF aripiprazole tabs 2 mg, 5 QL(1 ea daily); ) AL(At least 6 MG, 10 MG (Olanzapine yrs old) mg, 10 mg, 15 mg, 20 mg, F AL(At least 6 30 mg yrs old) Dihydroindolones aripiprazole tbdp 10 mg, 15 F PA MOLINDONE F PA mg HYDROCHLORIDE TABS 2 rtl MAX fill,365 rtl HCL PA ARISTADA INITIO PRSY F day(s) supply,; SOLN IJ 25 MG/ML, 50 F AL(At least 18 MG/2ML yrs old) chlorpromazine hcl tabs or AL(At least 6 1 rtl pack lmt 10 mg, 25 mg, 50 mg, 100 F yrs old) amt,30 rtl pack mg, 200 mg ARISTADA PRSY F lmt day(s),; AL(At least 18 fluphenazine decanoate F AL(At least 18 yrs old) soln ij yrs old) Arizona Complete Health-Complete Care Plan Behavioral Health Effective October 1, 2018

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNISOM SLEEPGELS QL(1 ea daily) CAPS (Diphenhydramine NF F AL(At least 6 )) thiothixene caps yrs old) HCl (Sleep UNISOM SLEEPMELTS QL(2 ea daily) BETA BLOCKERS - Drugs to Treat High Blood TBDP (Diphenhydramine NF Pressure HCl (Sleep)) Beta Blockers Non-Selective WAL-SLEEP Z LIQUID F QL(50 ml daily) SHOTS LIQD CORGARD TABS NF AL(At least 6 () yrs old) ZZZQUIL CAPS 25 MG QL(2 ea daily) (Diphenhydramine HCl NF nadolol tabs or 20 mg, 40 F AL(At least 6 mg, 80 mg yrs old) (Sleep)) hcl tabs or 10 AL(At least 6 ZZZQUIL LIQD 50 QL(30 ml daily) mg, 20 mg, 40 mg, 60 mg, F yrs old) MG/30ML NF 80 mg (Diphenhydramine HCl (Sleep)) HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders Non- QL(1 ea daily); Cobalamins AMBIEN TABS ( NF Tartrate) AL(At least 6 B-12 TABS OR 2500 MCG F AL(At least 6 yrs old) yrs old) PA; QL(1 ea AL(At least 6 INTERMEZZO SUBL 1.75 NF cyanocobalamin tabs F ) daily); AL(At yrs old) MG (Zolpidem Tartrate least 6 yrs old) Folic Acid/Folates QL(1 ea daily); RESTORIL CAPS NF AL(At least 6 () AL(At least 6 folic acid tabs F yrs old); yrs old) RX/OTC QL(1 ea daily); temazepam caps F AL(At least 6 HYPNOTICS//SLEEP DISORDER yrs old) AGENTS PA; QL(1 ea Hypnotics zolpidem tartrate subl sl F daily); AL(At 1.75 mg least 6 yrs old) diphenhydramine hcl F QL(2 ea daily) (sleep) caps 25 mg QL(1 ea daily); zolpidem tartrate tabs or 5 F AL(At least 6 diphenhydramine hcl F QL(1 ea daily) mg, 10 mg (sleep) caps 50 mg yrs old) diphenhydramine hcl F QL(30 ml daily) Selective Receptor Agonists (sleep) liqd 50 mg/30ml HETLIOZ CAPS F PA diphenhydramine hcl F QL(2 ea daily) (sleep) tabs 25 mg ST; QL(1 ea diphenhydramine hcl F QL(1 ea daily) ROZEREM TABS F daily); AL(At (sleep) tabs 50 mg least 6 yrs old) diphenhydramine hcl F QL(2 ea daily) (sleep) tbdp 25 mg LAXATIVES - Bowel Treatment Drugs NYTOL MAXIMUM QL(1 ea daily) Bulk Laxatives STRENGTH TABS NF ) NF AL(At least 6 (Diphenhydramine HCl EVAC POWD (Psyllium yrs old) (Sleep)) KONSYL DAILY FIBER NF AL(At least 6 POWD 100 % (Psyllium) yrs old) Arizona Complete Health-Complete Care Plan Behavioral Health Effective October 1, 2018

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KONSYL ORIGINAL AL(At least 6 AL(At least 6 FORMULADAILY FIBER NF yrs old) RA DRY MOUTH SOLN F yrs old); POWD (Psyllium) RX/OTC METAMUCIL ORIGINAL AL(At least 6 TEXTURE POWD NF yrs old) MULTIVITAMINS (Psyllium) Multiple Vitamins w/ Minerals METAMUCIL POWD 48.57 NF AL(At least 6 ADVANCED DIABETIC AL(At least 6 % (Psyllium) yrs old) MULTIVITAMIN FORMULA F yrs old); psyllium powd 33 %, 68 %, AL(At least 6 TABS RX/OTC 100 %, 28.3 %, 30.9 %, F yrs old) AL(At least 6 58.6 %, 48.57 %, ALIVE ENERGY 50+ TABS F yrs old); Surfactant Laxatives RX/OTC AL(At least 6 COLACE CAPS (Docusate NF AL(At least 6 ALIVE MENS ENERGY Sodium) yrs old) F yrs old); TABS RX/OTC docusate sodium caps or F AL(At least 6 100 mg, 250 mg yrs old) ALIVE ONCE DAILY AL(At least 6 WOMENS 50+ ULTRA F yrs old); MOUTH/THROAT/DENTAL AGENTS POTENCY TABS RX/OTC ALIVE ONCE DAILY AL(At least 6 Throat Products - Misc. WOMENS ULTRA F yrs old); AL(At least 6 POTENCY TABS RX/OTC F AQUORAL SOLN yrs old); AL(At least 6 RX/OTC ALIVE WOMENS 50+ F yrs old); BIOTENE DRY MOUTH AL(At least 6 TABS RX/OTC F MOISTURIZING SPRAY yrs old); AL(At least 6 SOLN RX/OTC ALIVE WOMENS ENERGY F yrs old); AL(At least 6 TABS RX/OTC F CAPHOSOL SOLN yrs old); AL(At least 6 RX/OTC ANTIOXIDANT FORTE F yrs old); AL(At least 6 TABS RX/OTC CVS DRY MOUTH SPRAY F SOLN yrs old); AL(At least 6 RX/OTC AP-ZEL TABS F yrs old); AL(At least 6 RX/OTC EQL DRY MOUTH ORAL F RINSE SOLN yrs old); AL(At least 6 RX/OTC BACMIN TABS F yrs old); AL(At least 6 RX/OTC F MOI-STIR SOLN yrs old); AL(At least 6 RX/OTC BASIC AM TABS F yrs old); AL(At least 6 RX/OTC F MOUTHKOTE SOLN yrs old); AL(At least 6 RX/OTC BASIC PM TABS F yrs old); AL(At least 6 RX/OTC F NUMOISYN LIQD yrs old); AL(At least 6 RX/OTC CAL-DAY 1000 TABS F yrs old); ORAL RELIEF SPRAY AL(At least 6 RX/OTC FOR DRYMOUTH & F yrs old); DISCOMFORT SOLN RX/OTC

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

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(At least 6 AL(At least 6 CENTRAVITES 50 PLUS F yrs old); CLINICAL NUTRIENTS F yrs old); TABS RX/OTC FOR MEN TABS RX/OTC AL(At least 6 AL(At least 6 CENTRAVITES ADULTS F yrs old); CLINICAL NUTRIENTS F yrs old); TABS RX/OTC FOR WOMEN TABS RX/OTC CENTRUM ADULTS TABS AL(At least 6 AL(At least 6 (Multiple Vitamins w/ NF yrs old); CVS ONE DAILY MENS F yrs old); Minerals) RX/OTC 50+ ADVANCED TABS RX/OTC AL(At least 6 AL(At least 6 CENTRUM CARDIO TABS F yrs old); CVS SPECTRAVITE F yrs old); RX/OTC ADULT 50+ TABS RX/OTC AL(At least 6 AL(At least 6 CENTRUM MEN TABS F yrs old); CVS SPECTRAVITE F yrs old); RX/OTC ULTRA MEN50+ TABS RX/OTC AL(At least 6 CVS SPECTRAVITE AL(At least 6 CENTRUM SILVER F yrs old); ULTRA MENS HEALTH F yrs old); ULTRA MENS TABS RX/OTC SENIOR TABS RX/OTC AL(At least 6 CVS SPECTRAVITE AL(At least 6 CENTRUM SILVER F yrs old); ULTRA MENS HEALTH F yrs old); ULTRA WOMENS TABS RX/OTC TABS RX/OTC AL(At least 6 AL(At least 6 CENTRUM SPECIALIST F yrs old); CVS SPECTRAVITE F yrs old); HEART TABS RX/OTC ULTRA WOMEN TABS RX/OTC AL(At least 6 CVS SPECTRAVITE AL(At least 6 CENTRUM SPECIALIST F yrs old); ULTRA WOMENS F yrs old); IMMUNE SUPPORT TABS RX/OTC HEALTH SENIOR TABS RX/OTC AL(At least 6 CVS SPECTRAVITE AL(At least 6 CENTRUM SPECIALIST F yrs old); ULTRA WOMENS F yrs old); VISION TABS RX/OTC HEALTH TABS RX/OTC AL(At least 6 AL(At least 6 CENTRUM ULTRA F yrs old); DERMAVITE TABS F yrs old); WOMENS TABS RX/OTC RX/OTC CERTAVITE AL(At least 6 EQ COMPLETE AL(At least 6 SENIOR/ANTIOXIDANT F yrs old); MULTIVITAMINADULTS F yrs old); NUTRIENTS TABS RX/OTC UNDER 50 TABS RX/OTC AL(At least 6 AL(At least 6 CLINICAL NUTRIENTS 45- F yrs old); EQ ONE DAILY MENS 50+ F yrs old); PLUS WOMEN TABS RX/OTC TABS RX/OTC AL(At least 6 AL(At least 6 CLINICAL NUTRIENTS 50- F yrs old); EQ ONE DAILY MENS F yrs old); PLUS MEN TABS RX/OTC HEALTH TABS RX/OTC CLINICAL NUTRIENTS AL(At least 6 AL(At least 6 FOR FEMALE TEENS F yrs old); EQ ONE DAILY WOMENS F yrs old); TABS RX/OTC 50+ TABS RX/OTC AL(At least 6 AL(At least 6 CLINICAL NUTRIENTS F yrs old); EQ ONE DAILY WOMENS F yrs old); FOR MALE TEENS TABS RX/OTC HEALTH TABS RX/OTC Arizona Complete Health-Complete Care Plan Behavioral Health Effective October 1, 2018

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(At least 6 AL(At least 6 EQL CENTURY MATURE F yrs old); ICAPS AREDS FORMULA F yrs old); ADULTS50+ TABS RX/OTC TABS RX/OTC AL(At least 6 AL(At least 6 EQL CENTURY MENS F yrs old); ICAPS PLUS TABS F yrs old); TABS RX/OTC RX/OTC EQL CENTURY WOMENS AL(At least 6 K-PAX IMMUNE AL(At least 6 F yrs old); SUPPORT FORMULA F yrs old); TABS RX/OTC PROFESSIONAL RX/OTC AL(At least 6 STRENGTH TABS EQL ONE DAILY MENS F yrs old); AL(At least 6 TABS MACULAR VITAMIN F RX/OTC BENEFIT TABS yrs old); AL(At least 6 RX/OTC FITNESS TABS FOR MEN F yrs old); AL(At least 6 AM/PM/LYCOPENE TABS MEGA MULTI FOR F RX/OTC WOMEN TABS yrs old); FITNESS TABS FOR AL(At least 6 RX/OTC WOMEN F yrs old); AL(At least 6 MEGA MULTIVITAMIN F AM/PM/LYCOPENE TABS RX/OTC FOR MEN TABS yrs old); AL(At least 6 RX/OTC FREEDAVITE TABS F yrs old); AL(At least 6 MEGA MULTIVITAMIN F RX/OTC FOR WOMEN TABS yrs old); AL(At least 6 RX/OTC GERI-FREEDA SENIOR F yrs old); AL(At least 6 FORMULA TABS MEGAVITE FRUITS & F RX/OTC VEGGIES TABS yrs old); AL(At least 6 RX/OTC HAIR-VITES TABS F yrs old); AL(At least 6 MEGAVITE GOLDEN F RX/OTC YEARS 55+ TABS yrs old); AL(At least 6 RX/OTC HM COMPLETE 50+ F yrs old); MENS 50+ MULTI AL(At least 6 MENS ULTIMATE TABS RX/OTC VITAMIN &MINERAL F yrs old); HM COMPLETE 50+ AL(At least 6 FORMULA TABS RX/OTC WOMENS ULTIMATE F yrs old); MENS MULTI VITAMIN & AL(At least 6 TABS RX/OTC MINERAL FORMULA F yrs old); AL(At least 6 TABS RX/OTC HM COMPLETE TABS F yrs old); AL(At least 6 MULTI-BETIC DIABETES F RX/OTC TABS yrs old); AL(At least 6 RX/OTC HM HAIR/SKIN/NAILS F yrs old); AL(At least 6 TABS MULTI-VITAMIN F RX/OTC MONOCAPS TABS yrs old); AL(At least 6 RX/OTC HM ONE DAILY MENS F yrs old); AL(At least 6 TABS multiple vitamins w/ F RX/OTC minerals tabs yrs old); AL(At least 6 RX/OTC HM ONE DAILY WOMENS F yrs old); AL(At least 6 TABS MULTIVITAMIN ADULTS F RX/OTC TABS yrs old); AL(At least 6 RX/OTC HYALEX TABS F yrs old); RX/OTC Arizona Complete Health-Complete Care Plan Behavioral Health Effective October 1, 2018

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(At least 6 AL(At least 6 MULTIVITAMIN MEN F yrs old); ONE-A-DAY MENOPAUSE F yrs old); TABS RX/OTC FORMULA TABS RX/OTC AL(At least 6 AL(At least 6 NAT-RUL THERAVITE- F yrs old); ONE-A-DAY MENS 50+ F yrs old); M/HIGHPOTENCY TABS RX/OTC ADVANTAGE TABS RX/OTC AL(At least 6 AL(At least 6 NATRUL-MEGA-75 TABS F yrs old); ONE-A-DAY MENS F yrs old); RX/OTC HEALTH FORMULA TABS RX/OTC AL(At least 6 AL(At least 6 NATRUL-VITES TABS F yrs old); ONE-A-DAY MENS PRO F yrs old); RX/OTC EDGE TABS RX/OTC AL(At least 6 AL(At least 6 NICADAN TABS F yrs old); ONE-A-DAY PROACTIVE F yrs old); RX/OTC 65+ TABS RX/OTC AL(At least 6 ONE-A-DAY TEEN AL(At least 6 NICADAN ZX TABS F yrs old); ADVANTAGEFOR HIM F yrs old); RX/OTC TABS RX/OTC AL(At least 6 AL(At least 6 NICAZEL FORTE TABS F yrs old); OPTI-WOMAN TABS F yrs old); RX/OTC RX/OTC AL(At least 6 AL(At least 6 NICAZEL TABS F yrs old); OPURITY TABS F yrs old); RX/OTC RX/OTC NO IRON MULTIPLE AL(At least 6 OSTEOPRIME AL(At least 6 VITAMIN/MINERALS F yrs old); PLUS/CALCIUM & F yrs old); TABS RX/OTC MAGNESIUM TABS RX/OTC AL(At least 6 AL(At least 6 NUTRICAP TABS F yrs old); PARVLEX TABS F yrs old); RX/OTC RX/OTC AL(At least 6 AL(At least 6 OCULAR VITAMINS TABS F yrs old); PHYTOMULTI TABS F yrs old); RX/OTC RX/OTC AL(At least 6 AL(At least 6 ONCOVITE TABS F yrs old); PRESERVISION AREDS F yrs old); RX/OTC TABS RX/OTC ONE DAILY MENS AL(At least 6 AL(At least 6 FORMULA W/O IRON F yrs old); PRO-CAL TABS F yrs old); TABS RX/OTC RX/OTC AL(At least 6 AL(At least 6 ONE DAILY PLUS IRON F yrs old); PROCERV HP TABS F yrs old); TABS RX/OTC RX/OTC AL(At least 6 AL(At least 6 ONE DAILY WOMENS F yrs old); PRORENAL+D TABS F yrs old); TABS RX/OTC RX/OTC AL(At least 6 AL(At least 6 ONE-A-DAY ENERGY F yrs old); PROVIT TABS F yrs old); TABS RX/OTC RX/OTC Arizona Complete Health-Complete Care Plan Behavioral Health Effective October 1, 2018

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(At least 6 AL(At least 6 QUENCH TABS F yrs old); SUPERB NAILS TABS F yrs old); RX/OTC RX/OTC AL(At least 6 AL(At least 6 QUIN B STRONG TABS F yrs old); T-VITES TABS F yrs old); RX/OTC RX/OTC AL(At least 6 AL(At least 6 QUINTABS-M TABS F yrs old); THERA M PLUS TABS F yrs old); RX/OTC RX/OTC AL(At least 6 AL(At least 6 RA CENTRAL-VITE TABS F yrs old); THERA-M TABS F yrs old); RX/OTC RX/OTC AL(At least 6 AL(At least 6 RA CENTRAL-VITE F yrs old); THERA-TABS M TABS F yrs old); UNDER 50MENS TABS RX/OTC RX/OTC RA CENTRAL-VITE AL(At least 6 AL(At least 6 UNDER 50WOMENS F yrs old); THERABETIC MULTI- F yrs old); TABS RX/OTC VITAMIN TABS RX/OTC AL(At least 6 THERAGRAN-M AL(At least 6 RENAPLEX-D TABS F yrs old); ADVANCED 50 PLUS F yrs old); RX/OTC TABS RX/OTC AL(At least 6 AL(At least 6 REQ 49+ TABS F yrs old); THERAGRAN-M F yrs old); RX/OTC ADVANCED TABS RX/OTC AL(At least 6 AL(At least 6 SENTRY SENIOR TABS F yrs old); THERAGRAN-M PREMIER F yrs old); RX/OTC 50 PLUS TABS RX/OTC AL(At least 6 AL(At least 6 SENTRY SENIOR/LUTEIN F yrs old); THERAGRAN-M PREMIER F yrs old); TABS RX/OTC TABS RX/OTC AL(At least 6 AL(At least 6 SENTRY TABS F yrs old); THERAGRAN-M TABS F yrs old); RX/OTC RX/OTC AL(At least 6 AL(At least 6 SIDEROL TABS F yrs old); THEREMS-H TABS F yrs old); RX/OTC RX/OTC AL(At least 6 AL(At least 6 SM ONE DAILY MENS F yrs old); THEREMS-M TABS F yrs old); TABS RX/OTC RX/OTC AL(At least 6 AL(At least 6 SM ONE DAILY WOMENS F yrs old); UNICOMPLEX-M TABS F yrs old); TABS RX/OTC RX/OTC AL(At least 6 AL(At least 6 SOLO TABS F yrs old); VITALINE TOTAL F yrs old); RX/OTC FORMULA 2 TABS RX/OTC AL(At least 6 AL(At least 6 STROVITE ONE TABS F yrs old); VITALINE TOTAL F yrs old); RX/OTC FORMULA 3 TABS RX/OTC Arizona Complete Health-Complete Care Plan Behavioral Health Effective October 1, 2018

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(At least 6 VITAMIN D3 COMPLETE F NUTRIENTS TABS yrs old); RX/OTC Misc. Nutritional Substances AL(At least 6 F AL(At least 6 VITASANA TABS F yrs old); FISH OIL CAPS yrs old) RX/OTC F AL(At least 6 AL(At least 6 FISH OIL CHEW yrs old) VITATRUM TABS F yrs old); RX/OTC F AL(At least 6 FISH OIL PEARLS CAPS yrs old) VITRUM 50+ SENIOR AL(At least 6 F yrs old); FISH OIL TRIPLE F AL(At least 6 MULTI TABS RX/OTC STRENGTH CAPS yrs old) AL(At least 6 FISH OIL ULTRA CAPS F AL(At least 6 VP-ZEL TABS F yrs old); yrs old) RX/OTC F AL(At least 6 HM FISH OIL CAPS yrs old) WHOLE FOOD AL(At least 6 F yrs old); OCEAN BLUE MINICAPS F AL(At least 6 MULTIVITAMIN TABS RX/OTC OMEGA-3 CAPS yrs old) WOMENS 50+ MULTI AL(At least 6 OMEGA POWER CAPS F AL(At least 6 VITAMIN& MINERAL F yrs old); yrs old) FORMULA TABS RX/OTC OMEGA-3 2100 CAPS F AL(At least 6 AL(At least 6 yrs old) WOMENS BIOMULTIPLE F yrs old); TABS F AL(At least 6 RX/OTC OMEGA-3 CAPS yrs old) WOMENS MULTI VITAMIN AL(At least 6 OMEGA-3 EPA FISH OIL F AL(At least 6 & MINERAL FORMULA F yrs old); CAPS yrs old) TABS RX/OTC F AL(At least 6 AL(At least 6 omega-3 fatty acids caps yrs old) YELETS TEENAGE F yrs old); FORMULA TABS F AL(At least 6 RX/OTC omega-3 fatty acids chew yrs old) Multivitamins OMEGA-3 FISH OIL F AL(At least 6 EXTRA STRENGTH CAPS yrs old) F AL(At least 6 ESTROFACTORS TABS yrs old) RA FISH OIL EXTRA F AL(At least 6 STRENGTH CAPS yrs old) F AL(At least 6 MULTI VITAMIN TABS yrs old) RA TRIPLE STRENGTH F AL(At least 6 FISH OIL CAPS yrs old) F AL(At least 6 MULTI VITAMIN/D-3 TABS yrs old) F AL(At least 6 SALMON CAPS yrs old) F AL(At least 6 multiple vitamin tabs yrs old) F AL(At least 6 SALMON OIL CAPS yrs old) F AL(At least 6 NEOMULTIVITE TABS yrs old) F AL(At least 6 SALMON OIL-1000 CAPS yrs old) F AL(At least 6 OMNICAP TABS yrs old) F AL(At least 6 SM FISH OIL CAPS yrs old) F AL(At least 6 QUINTABS TABS yrs old) SUPER TWIN EPA/DHA F AL(At least 6 CAPS yrs old) F AL(At least 6 THERA TABS yrs old) Arizona Complete Health-Complete Care Plan Behavioral Health Effective October 1, 2018

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F AL(At least 6 liothyronine sodium tabs or F AL(At least 6 ULTRA OMEGA 3 CAPS yrs old) 5 mcg, 25 mcg, 50 mcg yrs old) ULTRA OMEGA-3 FISH F AL(At least 6 NATURE-THROID TABS AL(At least 6 OIL BURP-LESS CAPS yrs old) 65 MG, 130 MG, 195 MG, F yrs old) 32.5 MG PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental and SYNTHROID TABS NF AL(At least 6 Emotional Conditions ( Sodium) yrs old) thyroid tabs or 30 mg, 60 F AL(At least 6 Agents for Chemical Dependency mg, 90 mg, 120 mg yrs old) F AL(At least 6 acamprosate calcium tbec yrs old) WESTHROID TABS 65 AL(At least 6 MG, 130 MG, 195 MG, F yrs old) ANTABUSE TABS NF AL(At least 6 32.5 MG (Disulfiram) yrs old) WP THYROID TABS 65 F AL(At least 6 disulfiram tabs or 250 mg, F AL(At least 6 MG, 130 MG, 32.5 MG yrs old) 500 mg yrs old) URINARY ANTISPASMODICS - Drugs to Treat Postherpetic Neuralgia (PHN)/Neuropathic Pain Miscellaneous Bladder Spasms F PA; AL(At least GRALISE TABS 6 yrs old) Urinary Antispasmodics - Agonists chloride tabs AL(At least 6 Premenstrual Dysphoric Disorder (PMDD) Agents or 5 mg, 10 mg, 25 mg, 50 F yrs old) QL(4 ea daily); mg FLUOXETINE CAPS F AL(At least 6 URECHOLINE TABS NF AL(At least 6 yrs old) (Bethanechol Chloride) yrs old) Psychotherapeutic and Neurological Agents - VITAMINS ORAP TABS () NF AL(At least 6 yrs old) Oil Soluble Vitamins AL(At least 6 pimozide tabs F F AL(At least 6 yrs old) KEY-E CHEW OR yrs old) Restless Leg Syndrome (RLS) Agents vitamin e caps or 100 unit, F AL(At least 6 200 unit, 400 unit yrs old) HORIZANT TBCR 600 MG F PA; AL(At least 6 yrs old) VITAMIN E CHEW OR 400 F AL(At least 6 UNIT yrs old) THYROID AGENTS - Drugs to Regulate Water Soluble Vitamins Thyroid Hormones F AL(At least 6 B-1 TABS yrs old) ARMOUR THYROID TABS AL(At least 6 30 MG, 60 MG, 90 MG, NF yrs old) pyridoxine hcl tabs F AL(At least 6 120 MG (Thyroid) yrs old) AL(At least 6 CYTOMEL TABS NF AL(At least 6 thiamine hcl tabs F (Liothyronine Sodium) yrs old) yrs old) levothyroxine sodium tabs AL(At least 6 or 25 mcg, 50 mcg, 75 yrs old) mcg, 88 mcg, 100 mcg, F 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg

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

19 Index ABILIFY11 buprenorphine hcl2 clozapine10 ABILIFY MAINTENA11 bupropion hcl5 CLOZAPINE ODT10 acamprosate calcium19 buspirone hcl2 CLOZARIL10 ADASUVE10 CAL-DAY 100013 COGENTIN9 ADDERALL1 CAPHOSOL13 COLACE13 ADDERALL XR1 carbamazepine4 CORGARD12 ADVANCED DIABETIC CARBATROL4 CVS DRY MOUTH SPRAY13 MULTIVITAMIN FORMULA13 CATAPRES8 CVS ONE DAILY MENS 50+ ALER-DRYL8 CATAPRES-TTS-18 ADVANCED14 ALIVE ENERGY 50+13 CVS SPECTRAVITE ADULT CATAPRES-TTS-28 ALIVE MENS ENERGY13 50+14 CATAPRES-TTS-38 CVS SPECTRAVITE ULTRA ALIVE ONCE DAILY WOMENS CELEXA5 MEN50+14 50+ ULTRA POTENCY13 CVS SPECTRAVITE ULTRA ALIVE ONCE DAILY WOMENS CENTRAVITES 50 PLUS14 MENS HEALTH14 ULTRA POTENCY13 CENTRAVITES ADULTS14 CVS SPECTRAVITE ULTRA ALIVE WOMENS 50+13 CENTRUM ADULTS14 MENS HEALTH SENIOR14 ALIVE WOMENS ENERGY13 CENTRUM CARDIO14 CVS SPECTRAVITE ULTRA alprazolam3 WOMEN14 CENTRUM MEN14 CVS SPECTRAVITE ULTRA ALPRAZOLAM INTENSOL2 CENTRUM SILVER ULTRA WOMENS HEALTH14 amantadine hcl9 MENS14 CVS SPECTRAVITE ULTRA AMBIEN12 CENTRUM SILVER ULTRA WOMENS HEALTH WOMENS14 amitriptyline hcl7 SENIOR14 CENTRUM SPECIALIST cyanocobalamin12 AMOXAPINE7 HEART14 amphetamine- CENTRUM SPECIALIST CYMBALTA7 dextroamphetamine1 IMMUNE SUPPORT14 cyproheptadine hcl8 ANAFRANIL7 CENTRUM SPECIALIST CYTOMEL19 ANTABUSE19 VISION14 DAYTRANA2 CENTRUM ULTRA ANTIOXIDANT FORTE13 WOMENS14 DEPAKENE4 AP-ZEL13 CERTAVITE DEPAKOTE5 APTENSIO XR1 SENIOR/ANTIOXIDANT DEPAKOTE ER5 NUTRIENTS14 AQUORAL13 DEPAKOTE SPRINKLES5 chlordiazepoxide hcl3 aripiprazole11 DERMAVITE14 CHLORPROMAZINE HCL11 ARISTADA11 desipramine hcl7 chlorpromazine hcl11 ARISTADA INITIO11 DESVENLAFAXINE ER7 citalopram hydrobromide5 ARMOUR THYROID19 CLINICAL NUTRIENTS 45- desvenlafaxine succinate7 ATIVAN3 PLUS WOMEN14 DEXEDRINE1 atomoxetine hcl1 CLINICAL NUTRIENTS 50- dextroamphetamine sulfate1 B-119 PLUS MEN14 diazepam3 CLINICAL NUTRIENTS FOR B-1212 FEMALE TEENS14 DIAZEPAM3 BACMIN13 CLINICAL NUTRIENTS FOR diazepam3 BASIC AM13 MALE TEENS14 diphenhydramine hcl8 CLINICAL NUTRIENTS FOR BASIC PM13 MEN14 diphenhydramine hcl (sleep)12 BENADRYL ALLERGY8 CLINICAL NUTRIENTS FOR disulfiram19 BENADRYL ALLERGY WOMEN14 divalproex sodium5 CHILDRENS8 clomipramine hcl7 docusate sodium13 benztropine mesylate9 clonazepam4 doxepin hcl7 bethanechol chloride19 clonidine hcl8 duloxetine hcl7 BIOTENE DRY MOUTH clorazepate dipotassium3 MOISTURIZING SPRAY13 DYANAVEL XR1

Index 1 EFFEXOR XR7 guanfacine hcl8 LATUDA9 ELAVIL7 guanfacine hcl (adhd)1 levothyroxine sodium19 EMSAM5 HAIR-VITES15 LEXAPRO6 EQ COMPLETE HALDOL10 liothyronine sodium19 MULTIVITAMINADULTS UNDER HALDOL DECANOATE LITHIUM9 5014 10010 lithium carbonate9 EQ ONE DAILY MENS 50+14 HALDOL DECANOATE 5010 LITHOBID9 EQ ONE DAILY MENS haloperidol10 HEALTH14 lorazepam3 haloperidol decanoate10 EQ ONE DAILY WOMENS loxapine succinate10 50+14 haloperidol lactate10 MACULAR VITAMIN EQ ONE DAILY WOMENS HETLIOZ12 BENEFIT15 HEALTH14 EQL CENTURY MATURE HM COMPLETE15 MAPROTILINE HCL5 ADULTS50+15 HM COMPLETE 50+ MENS MARPLAN5 EQL CENTURY MENS15 ULTIMATE15 MEGA MULTI FOR WOMEN15 HM COMPLETE 50+ EQL CENTURY WOMENS15 WOMENS ULTIMATE15 MEGA MULTIVITAMIN FOR MEN15 EQL DRY MOUTH ORAL HM FISH OIL18 RINSE13 MEGA MULTIVITAMIN FOR HM HAIR/SKIN/NAILS15 EQL ONE DAILY MENS15 WOMEN15 HM ONE DAILY MENS15 MEGAVITE FRUITS & EQUETRO9 HM ONE DAILY WOMENS15 VEGGIES15 escitalopram oxalate5 MEGAVITE GOLDEN YEARS HORIZANT19 ESTROFACTORS18 55+15 HYALEX15 MENS 50+ MULTI VITAMIN EVAC12 HYDROXYZINE HCL2 &MINERAL FORMULA15 FAZACLO10 MENS MULTI VITAMIN & hydroxyzine hcl2 FISH OIL18 MINERAL FORMULA15 HYDROXYZINE PAMOATE2 FISH OIL PEARLS18 METADATE CD2 FISH OIL TRIPLE hydroxyzine pamoate2 METAMUCIL13 STRENGTH18 ICAPS AREDS FORMULA15 METAMUCIL ORIGINAL FISH OIL ULTRA18 ICAPS PLUS15 TEXTURE13 FITNESS TABS FOR MEN imipramine hcl7 METHYLIN2 AM/PM/LYCOPENE15 imipramine pamoate7 methylphenidate hcl2 FITNESS TABS FOR WOMEN INTERMEZZO12 METHYLPHENIDATE AM/PM/LYCOPENE15 HYDROCHLORIDE ER2 FLUOXETINE19 INTUNIV1 METHYLPHENIDATE FLUOXETINE DR5 INVEGA SUSTENNA9 HYDROCHLORIDE ER (LA)2 fluoxetine hcl6 INVEGA TRINZA9 MINIPRESS9 fluphenazine decanoate11 K-PAX IMMUNE SUPPORT mirtazapine5 FORMULA PROFESSIONAL MOI-STIR13 FLUPHENAZINE HCL11 STRENGTH15 fluphenazine hcl11 MOLINDONE KAPVAY1 HYDROCHLORIDE11 fluvoxamine maleate6 KEY-E19 MOUTHKOTE13 FOCALIN2 KLONOPIN4 MULTI VITAMIN18 FOCALIN XR2 KONSYL DAILY FIBER12 MULTI VITAMIN/D-318 folic acid12 KONSYL ORIGINAL MULTI-BETIC DIABETES15 FORFIVO XL5 FORMULADAILY FIBER13 MULTI-VITAMIN FREEDAVITE15 LAMICTAL4 MONOCAPS15 gabapentin4 LAMICTAL CHEWABLE multiple vitamin18 DISPERSIBLE4 multiple vitamins w/ minerals15 GEODON9 LAMICTAL ODT4 GERI-FREEDA SENIOR MULTIVITAMIN ADULTS15 LAMICTAL XR4 FORMULA15 MULTIVITAMIN MEN16 GRALISE19 lamotrigine4

Index 2 nadolol12 ONE-A-DAY MENS 50+ QUINTABS18 NALOXONE HCL8 ADVANTAGE16 QUINTABS-M17 ONE-A-DAY MENS HEALTH naloxone hcl8 FORMULA16 RA CENTRAL-VITE17 NALOXONE HCL8 ONE-A-DAY MENS PRO RA CENTRAL-VITE UNDER naltrexone hcl8 EDGE16 50MENS17 ONE-A-DAY PROACTIVE RA CENTRAL-VITE UNDER NARCAN8 65+16 50WOMENS17 NARDIL5 ONE-A-DAY TEEN RA DRY MOUTH13 NAT-RUL THERAVITE- ADVANTAGEFOR HIM16 RA FISH OIL EXTRA M/HIGHPOTENCY 16 OPTI-WOMAN16 STRENGTH18 NATRUL-MEGA-7516 OPURITY16 RA TRIPLE STRENGTH FISH NATRUL-VITES16 ORAL RELIEF SPRAY FOR OIL18 NATURE-THROID19 DRYMOUTH & REMERON5 NEFAZODONE HCL6 DISCOMFORT13 REMERON SOLTAB5 ORAP19 nefazodone hcl7 RENAPLEX-D17 OSTEOPRIME REQ 49+17 NEFAZODONE PLUS/CALCIUM & HYDROCHLORIDE7 MAGNESIUM16 RESTORIL12 NEOMULTIVITE18 oxazepam3 RISPERDAL10 NEURONTIN4 OXAZEPAM3 RISPERDAL CONSTA9 NICADAN16 oxcarbazepine4 RISPERDAL M-TAB9 NICADAN ZX16 PAMELOR8 risperidone10 NICAZEL16 PARNATE5 RISPERIDONE ODT10 NICAZEL FORTE16 paroxetine hcl6 RITALIN2 NO IRON MULTIPLE RITALIN LA2 VITAMIN/MINERALS16 PARVLEX16 ROZEREM12 NORPRAMIN8 PAXIL6 SALMON18 nortriptyline hcl8 PAXIL CR6 SALMON OIL18 NUMOISYN13 perphenazine11 SALMON OIL-100018 NUTRICAP16 PEXEVA6 NYTOL MAXIMUM phenelzine sulfate5 SAPHRIS11 STRENGTH12 PHYTOMULTI16 SENTRY17 OCEAN BLUE MINICAPS pimozide19 SENTRY SENIOR17 OMEGA-318 SENTRY SENIOR/LUTEIN17 OCULAR VITAMINS16 prazosin hcl9 SEROQUEL11 olanzapine10 PRESERVISION AREDS16 sertraline hcl6 OMEGA POWER18 PRISTIQ7 SIDEROL17 OMEGA-318 PRO-CAL16 SILPHEN COUGH8 OMEGA-3 210018 PROCERV HP16 SM FISH OIL18 OMEGA-3 EPA FISH OIL18 propranolol hcl12 SM ONE DAILY MENS17 omega-3 fatty acids18 PRORENAL+D16 SM ONE DAILY WOMENS17 OMEGA-3 FISH OIL EXTRA protriptyline hcl8 STRENGTH18 PROVIT16 SOLO17 OMNICAP18 PROZAC6 STRATTERA1 ONCOVITE16 psyllium13 STROVITE ONE17 ONE DAILY MENS FORMULA pyridoxine hcl19 SUBOXONE2 W/O IRON16 17 SUPER TWIN EPA/DHA18 ONE DAILY PLUS IRON16 QUENCH 11 SUPERB NAILS17 ONE DAILY WOMENS16 quetiapine fumarate QUILLICHEW ER2 SURMONTIL8 ONE-A-DAY ENERGY16 SYNTHROID19 ONE-A-DAY MENOPAUSE QUILLIVANT XR2 FORMULA16 QUIN B STRONG17 T-VITES17

Index 3 TEGRETOL4 VIIBRYD STARTER PACK7 TEGRETOL-XR4 VISTARIL2 temazepam12 VITALINE TOTAL FORMULA TENEX9 217 VITALINE TOTAL FORMULA THERA18 317 THERA M PLUS17 VITAMIN D3 COMPLETE18 THERA-M17 vitamin e19 THERA-TABS M17 VITAMIN E19 THERABETIC MULTI- VITASANA18 VITAMIN17 VITATRUM18 THERAGRAN-M17 VITRUM 50+ SENIOR THERAGRAN-M MULTI18 ADVANCED17 THERAGRAN-M ADVANCED 50 VIVITROL8 PLUS17 VP-ZEL18 THERAGRAN-M PREMIER17 VYVANSE1 THERAGRAN-M PREMIER 50 WAL-SLEEP Z LIQUID PLUS17 SHOTS12 THEREMS-H17 WELLBUTRIN SR5 THEREMS-M17 WELLBUTRIN XL5 thiamine hcl19 WESTHROID19 thioridazine hcl11 WHOLE FOOD thiothixene12 MULTIVITAMIN18 WOMENS 50+ MULTI thyroid19 VITAMIN& MINERAL TOFRANIL8 FORMULA18 TOPAMAX4 WOMENS BIOMULTIPLE18 TOPAMAX SPRINKLE4 WOMENS MULTI VITAMIN & MINERAL FORMULA18 topiramate4 WP THYROID19 TRANXENE T3 XANAX3 tranylcypromine sulfate5 XANAX XR3 trazodone hcl7 YELETS TEENAGE trifluoperazine hcl11 FORMULA18 trihexyphenidyl hcl9 ziprasidone hcl9 TRILEPTAL4 ZOLOFT6 trimipramine maleate8 zolpidem tartrate12 ULTRA OMEGA 319 ZYPREXA11 ULTRA OMEGA-3 FISH OIL ZYPREXA ZYDIS11 BURP-LESS19 ZZZQUIL12 UNICOMPLEX-M17 UNISOM SLEEPGELS12 UNISOM SLEEPMELTS12 URECHOLINE19 VALIUM3 valproate sodium5 valproic acid5 VANAMINE PD8 venlafaxine hcl7 VIIBRYD7

Index 4