FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page A

2012 Formulary Reference Guide

A list of medications that may lower your patients’ costs

Preferred Prescriptions® Rx Selections™

Express Scripts and Medco have come together as one company to manage the prescription benefits of your patients. FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page i

TABLE OF CONTENTS

INTRODUCTION ...... ii

The Preferred Prescriptions/Rx Selections Formularies . . . . . ii Using this formulary book to help contain costs ...... iii Knowing how this formulary information is organized . . . . iii Understanding the symbols used throughout this book . . . iv Considering preferred alternatives ...... iv Saving on out-of-pocket costs for patients ...... v Consulting your office when appropriate ...... v Getting answers to your questions ...... v

THERAPEUTIC CHAPTER INDEX ...... 1

PREFERRED PRESCRIPTIONS/RX SELECTIONS FORMULARIES ...... 4

INDEX ...... 56

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INTRODUCTION An independent committee of practicing physicians and a pharmacist has been established to help ensure that our formularies are medically sound and that they support your patients’ health. This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluates medications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories.

The Preferred Prescriptions/Rx Selections Formularies

• Preferred Prescriptions—available with open and incentive formulary designs. • Rx Selections—available with closed and incentive formulary designs.

In order to serve the diverse needs of patients and their plan sponsors, we make three options available in formulary design:

1. Open Formulary —Features uniform co-payments for medications that are preferred and nonpreferred brands, plus lower co-payments for generic drugs.

2. Incentive Formulary—Features different co-payments for medications that are on or off the formulary. In this type of formulary, the patient cost structure may be either a two-tier or three-tier design. In some cases, members may request a review of their non-preferred co-payment for special circumstances.

Two-tier design Three-tier design • Tier 1: Generic drugs = • Tier 1: Generic drugs = Lowest patient costs* Lower patient costs • Tier 2: Preferred brand-name drugs = Midlevel patient costs • Tier 2: Brand-name drugs = • Tier 3: Nonpreferred brand-name drugs = Higher patient costs Highest patient costs *Some generics may not be in Tier 1.

3. Closed Formulary—Features the requirement that prescribed drugs must be on the formulary in order for the member to receive coverage. This is the most restrictive formulary. If a prescription is written for a medication that is not on the formulary, the patient will be responsible for the full cost. If special circumstances necessitate that the patient take the nonpreferred drug, prescribers may request a coverage review. If coverage is approved, the medication will be covered. If coverage is not approved, the patient will be responsible for the full cost of the medication. Policies for coverage vary by plan sponsor. If your patient requires a coverage review, please call 1 800 753-2851 from 8:00 a.m. to 9:00 p.m., eastern time, Monday through Friday.

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USING THIS FORMULARY BOOK TO HELP CONTAIN COSTS

Many employers and other benefit sponsors use our formularies to help manage the overall cost of providing prescription drug benefits for your patients. These formularies offer a wide range of outpatient medications from which to choose.

We realize that these formularies may not include every drug from every manufacturer. However, choosing a preferred drug, when you feel it is appropriate, can help your patients gain access to the medications they need to stay healthy, at a cost that’s more affordable.

KNOWING HOW THIS FORMULARY INFORMATION IS ORGANIZED

The Preferred Prescriptions/Rx Selections Formularies are designed so that generic products are listed first in each drug category; corresponding brand-name versions for these generics are shown (in parentheses) for reference. The preferred brand-name products are listed next; likewise, corresponding generic names are shown (in parentheses) for reference.

PLEASE NOTE: If a generic product is listed in the generics section and its referenced brand-name product is not listed in the preferred brand-name section, then only the generic product is on the formulary. If a brand-name product is listed in the preferred brand-name section and its referenced generic product is not listed in the generics section, then a generic version is not available.

Here is an example:

FORMULARY PRODUCTS DRUG NAME 3.9.3.3 MISCELLANEOUS ANTIPSYCHOTICS GENERICS Clozapine (Clozaril) Loxapine Succinate (Loxitane) Risperidone (Risperdal) Thiothixene (Navane) BRANDS Clozaril (Clozapine) Geodon (Ziprasidone HCl) Moban (Molindone HCl) Orap (Pimozide) Seroquel (Quetiapine Fumarate) Seroquel XR (Quetiapine Fumarate) Zyprexa (Olanzapine) Zyprexa Zydis (Olanzapine)

• The generic version of Geodon is not available, since Ziprasidone HCl does not appear under GENERICS. • Only the generic version of Risperdal is on the formulary, since the brand-name does not appear under BRANDS. • Brand-name Clozaril and its generic version are on the formulary, since these drugs are referenced under both GENERICS and BRANDS.

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UNDERSTANDING THE SYMBOLS USED THROUGHOUT THIS BOOK

Throughout this book, you will see certain symbols that draw your attention to information that we would like you to consider before prescribing.

Safety Consideration Symbols We have placed an indicator next to medications that may require special safety considerations. Weigh risk of birth defects and other adverse outcomes.

Do not use during pregnancy.

CONSIDERING PREFERRED ALTERNATIVES

We realize that you may not always be able to prescribe preferred drugs for your patients. However, by referring to this book before prescribing, you can help ensure that your patients take full advantage of coverage provided by their prescription drug plan. Possible preferred alternatives are listed for commonly prescribed nonpreferred drugs. Pharmacies cannot substitute a preferred brand-name drug without your approval. Therefore, a pharmacist may contact you to obtain authorization to dispense an alternative preferred product when a nonpreferred drug is prescribed. Again, since your patients can often benefit by paying less for alternative preferred products, we ask that you consider prescribing these preferred alternatives whenever possible.

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SAVINGONOUT-OF-POCKET COSTS FOR PATIENTS

Your patients’ prescription drug plan determines the cost for generic, preferred brand-name, and nonpreferred brand-name drugs. Employers and other benefit providers often design prescription drug plans to encourage the use of generic and preferred brand-name drugs. For your patients, choosing nonpreferred drugs may mean paying higher out-of-pocket expenses (such as coinsurance, co-payments, and deductible amounts) or not receiving coverage at all. Patients may also pay less for generic drugs, or they may be asked to pay the cost difference between brand-name drugs and their generic equivalents, which are preferred by the plan.

CONSULTING YOUR OFFICE WHEN APPROPRIATE

When employers and other benefit sponsors design their prescription drug plans, they may choose to provide coverage only for certain medications or for particular uses, time periods, doses, or quantities (e.g., they may exclude coverage for medications for unapproved, unproven, or cosmetic indications, as well as over-the- counter medications). When coverage for medications is provided based on use or quantity, we may contact your office for additional information to determine whether coverage is available under the plan. Patients who are unsure whether these coverage rules apply for a particular medication can consult their prescription drug benefit manual or contact a Member Services representative to determine specific coverage requirements.

GETTING ANSWERS TO YOUR QUESTIONS

We maintain a national toll-free helpline exclusively for physicians and their staff. You or your office staff can call this phone number whenever you have a general question or don’t know the specific phone number you need. Just call 1 800 211-1456 from 8:00 a.m. to 8:00 p.m., eastern time, Monday through Friday, to reach our Physician Service Center. An experienced representative will answer your question or direct you to someone who can help you. If you know the specific phone number you want to reach, you may call that number directly.

You can also access up-to-date information about the formularies administered by us in the “Physicians” section of our website at Express-Scripts.com. In addition, you can direct comments about the clinical content of the Preferred Prescriptions/Rx Selections Formularies to:

Express Scripts Clinical Practices & Therapeutics Department of Medical Affairs 100 Parsons Pond Drive, MS F2-3 Franklin Lakes, NJ 07417

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THERAPEUTIC CHAPTER INDEX FOR THE PREFERRED PRESCRIPTIONS/RX SELECTIONS FORMULARIES FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page viii FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 1

CHAPTERS

1. Anti-Infectives ...... 5 3.3.1 NSAIDs/COX-2 Inhibitors ...... 13 1.1 Penicillins ...... 5 3.3.1.1 NSAIDs ...... 13 1.2 Tetracyclines ...... 5 3.3.1.2 NSAIDs-Specific COX-2 1.3 Cephalosporins ...... 5 Inhibitors ...... 14 1.3.1 First Generation Cephalosporins ...... 5 3.3.2 Salicylates ...... 14 1.3.2 Second Generation Cephalosporins ...... 5 3.3.3 Miscellaneous Analgesics ...... 14 1.3.3 Third Generation Cephalosporins ...... 6 3.3.4 Narcotic Antagonists ...... 14 1.4 Erythromycins & Other Macrolides ...... 6 3.4 Migraine & Cluster Headache Therapy ...... 14 1.4.1 Erythromycins & Other Macrolides ...... 6 3.4.1 Headache Therapy ...... 14 1.5 Quinolones ...... 6 3.4.2 Antivertigo & Antiemetic Drugs ...... 15 1.5.1 Fluoroquinolones ...... 6 3.5 Antiparkinsonism Agents ...... 15 1.6 Sulfas & Related Agents ...... 6 3.6 Anticonvulsants ...... 16 1.7 Urinary Tract Agents ...... 6 3.7 Miscellaneous Neurological Therapy ...... 17 1.8 Antivirals ...... 7 3.8 Muscle Relaxants & Antispasmodic 1.8.1 Miscellaneous Antivirals ...... 7 Therapy ...... 17 1.8.2 HIV/AIDS Therapy ...... 7 3.8.1 Muscle Relaxants & Antispasmodic 1.9 Antifungal Agents ...... 8 Agents ...... 17 1.10 Vancomycin ...... 8 3.8.2 Myasthenia Gravis ...... 18 1.11 Miscellaneous Anti-Infectives ...... 8 3.9 Psychotherapeutic Drugs ...... 18 1.11.1 Miscellaneous Anti-Infectives ...... 8 3.9.1 Hypnotic Agents ...... 18 1.11.2 Antiparasitics ...... 8 3.9.2 Antidepressant Agents ...... 18 1.11.3 Antimalarials ...... 9 3.9.2.1 Tricyclics ...... 18 1.11.4 Antimycobacterials ...... 9 3.9.2.2 Miscellaneous Antidepressants ...... 18 2. Antineoplastic & 3.9.2.3 MAO Inhibitors ...... 19 Immunosuppressant Drugs ...... 10 3.9.2.4 Selective Serotonin Reuptake Inhibitors ...... 19 2.1 Antineoplastic & Immunosuppressant Drugs ...... 10 3.9.3 Antipsychotics ...... 19 2.1.1 Alkylating Agents ...... 10 3.9.3.1 Phenothiazines ...... 19 2.1.2 Antimetabolites ...... 10 3.9.3.2 Butyrophenones ...... 20 2.1.3 Androgens, Estrogens, Hormones & 3.9.3.3 Miscellaneous Related Drugs ...... 10 Antipsychotics ...... 20 2.1.3.3 Hormones ...... 10 3.9.4 Miscellaneous Psychotherapeutic Agents ...... 21 2.1.3.4 Antiestrogens ...... 10 3.9.5 Anxiolytics ...... 21 2.1.3.5 Antiandrogens ...... 10 2.1.5 Immunosuppressant Drugs ...... 10 4. Cardiovascular, Hypertension & 2.1.6 Miscellaneous Antineoplastic Drugs ...... 11 Lipids ...... 22 2.2 Adjunctive Agents ...... 11 4.1 Antiarrhythmic Agents ...... 22 2.2.1 Adjunctive Agents ...... 11 4.2 Cardiac Glycosides ...... 22 3. Autonomic & CNS Drugs, 4.3 Nitrates ...... 22 Neurology & Psych ...... 12 4.3.1 Rapid Acting Nitrates ...... 22 4.3.2 Long Acting Nitrates ...... 22 3.1 Narcotic Analgesics ...... 12 4.4 Coagulation Therapy ...... 22 3.1.1 Narcotics ...... 12 4.4.1 Anticoagulants ...... 22 3.1.2 Combination Narcotic/Analgesics ...... 12 4.4.2 Antiplatelet Drugs ...... 22 3.3 Non-Narcotic Analgesics ...... 13 4.4.3 Heparin ...... 23 4.4.4 Vitamin K ...... 23 4.4.5 Hemostatics ...... 23 4.4.6 Miscellaneous Coagulation Agents ...... 23 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 2

4.5 Antihypertensive Therapy ...... 23 7.4.4 Gonadotropin & Related Agents ...... 34 4.5.1 Thiazide & Related Diuretics ...... 23 7.5 Diabetes Therapy ...... 34 4.5.2 Beta-Blockers ...... 24 7.5.1 Insulin Therapy ...... 34 4.5.3 Calcium Channel Blockers ...... 24 7.5.2 Non-Insulin Hypoglycemic Agents ...... 34 4.5.3.1 Calcium Channel Blockers/ 7.5.3 Glucose Elevating Agents ...... 35 Non-Dihydropyridines ...... 24 7.5.4 Insulin Syringes/Miscellaneous Durable 4.5.3.2 Calcium Channel Blockers/ Medical Equipment ...... 35 Dihydropyridines ...... 25 7.5.5 Blood Glucose Monitoring Devices 4.5.4 ACE Inhibitors ...... 25 & Supplies ...... 35 4.5.5 Adrenergic Antagonists & Related Drugs ...... 25 8. Gastroenterology ...... 36 4.5.6 Agents for Pheochromocytoma ...... 25 8.1 Ulcer Therapy ...... 36 4.5.7 Vasodilators ...... 25 8.1.1 H2 Antagonists ...... 36 4.5.8 Other Antihypertensive Combinations ...... 26 8.1.2 Prostaglandins ...... 36 4.5.9 Angiotensin II Receptor Blockers 8.1.3 Other Ulcer Therapy ...... 36 & Renin Inhibitors ...... 26 8.1.4 Proton Pump Inhibitors ...... 36 4.6 Lipid/Cholesterol Lowering Agents ...... 27 8.2 Antidiarrheals & Antispasmodics ...... 36 4.7 Miscellaneous Cardiovascular Agents ...... 27 8.2.1 Antidiarrheals ...... 36 8.2.2 Antispasmodics ...... 37 5. Dermatologicals/Topical Therapy ...... 28 8.2.3 Combination Anticholinergics ...... 37 5.1 Topical Corticosteroids ...... 28 8.3 Miscellaneous Gastrointestinal Agents ...... 37 5.1.1 Topical Corticosteroids Very High 8.3.1 Bile Acids ...... 37 Potency ...... 28 8.3.2 Digestive Enzymes ...... 37 5.1.2 Topical Corticosteroids High Potency ...... 28 8.3.3 Miscellaneous Gastrointestinal Agents ...... 38 5.1.3 Topical Corticosteroids Medium 8.3.4 Antivertigo & Antiemetic Agents ...... 39 Potency ...... 28 8.3.5 Bowel Evacuants ...... 39 5.1.4 Topical Corticosteroids Low Potency ...... 28 5.2 Topical Anesthetics ...... 29 9. Immunology, Vaccines & 5.3 Therapy for Acne ...... 29 Biotechnology ...... 40 5.4 Topical Antibacterials ...... 29 9.1 Biotechnology Drugs ...... 40 5.5 Topical Antifungals ...... 30 9.1.1 Erythroid Stimulants ...... 40 5.6 Topical Antivirals ...... 30 9.1.2 Myeloid Stimulants ...... 40 5.7 Burn Therapy ...... 30 9.1.3 Interferons ...... 40 5.8 Topical Enzymes ...... 30 9.1.4 Growth Hormones ...... 40 5.10 Antipsoriatic/Antiseborrheic ...... 30 9.1.5 Interleukins ...... 40 5.11 Topical Scabicides/Pediculicides ...... 31 5.12 Miscellaneous Dermatologicals ...... 31 10. Musculoskeletal & Rheumatology ...... 41 6. Ear, Nose & Throat Medications ...... 32 10.1 NSAID Agents ...... 41 6.1 Intranasal Steroids ...... 32 10.1.1 NSAIDs COX-2 Inhibitors ...... 41 6.2 Miscellaneous Otic Preparations ...... 32 10.1.1.1 NSAIDs ...... 41 6.3 Otic Steroid/Antibiotic ...... 32 10.1.1.2 NSAIDs-Specific COX-2 6.4 Miscellaneous Agents ...... 32 Inhibitors ...... 41 10.1.2 Salicylates ...... 41 7. Endocrine/Diabetes ...... 33 10.2 Gout Therapy ...... 41 7.1 Antithyroid Agents ...... 33 10.3 Other Rheumatologicals ...... 41 7.2 Thyroid Hormones ...... 33 10.3.1 Corticosteroids ...... 41 7.3 Adrenal Hormones ...... 33 10.3.2 Miscellaneous Rheumatological 7.4 Miscellaneous Hormones ...... 33 Agents ...... 41 7.4.1 Androgens ...... 33 10.3.3 Muscle Relaxants & Antispasmodic 7.4.2 Ovulatory Stimulants ...... 33 Therapy ...... 42 7.4.3 Miscellaneous Agents ...... 34 10.4 Osteoporosis Therapy ...... 42 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 3

11. Obstetrics & Gynecology ...... 43 13.3 Pulmonary Agents ...... 50 11.1 Oral Contraceptives & Related Agents ...... 43 13.3.1 Xanthines ...... 50 11.1.1 Monophasic/Biphasic/Triphasic 13.3.2 Beta Agonists Oral ...... 50 Agents ...... 43 13.3.3 Beta Agonist Inhalers ...... 50 11.1.2 Progestin Only ...... 44 13.3.4 Inhaled Corticosteroids ...... 51 11.2 Oxytocics ...... 44 13.3.5 Intranasal Steroids ...... 51 11.3 Estrogens & Progestins ...... 44 13.3.6 Miscellaneous Pulmonary Agents ...... 51 11.3.1 Progestins ...... 44 11.3.2 Estrogens ...... 44 14. Urologicals ...... 52 11.3.3 Estrogen Combinations ...... 45 14.1 Cholinergic Stimulants ...... 52 11.4 Miscellaneous OB/GYN ...... 45 14.2 Anticholinergic & Antispasmodics ...... 52 11.4.1 Drugs to Treat Infertility/ 14.3 Urinary Anesthetics ...... 52 IVF Agents ...... 45 14.4 Miscellaneous Urologicals ...... 52 11.4.2 Vaginal Cleanser/Anti-Infectives ...... 45 14.5 Benign Prostatic Hyperplasia (BPH) 11.4.3 Vaginal Antifungals ...... 45 Therapy ...... 52 11.4.4 Specialized OB/GYN Drugs ...... 45 11.4.5 Diaphragms & Other Non-Oral 15. Vitamins, Hematinics & Contraceptives ...... 45 Electrolytes ...... 53 15.1 Vitamins & Hematinics ...... 53 12. Ophthalmology ...... 46 15.2 Coagulation Therapy ...... 53 12.1 Beta-Blockers ...... 46 15.2.1 Anticoagulants ...... 53 12.2 Cholinesterase Inhibitor Miotics ...... 46 15.2.2 Antiplatelet Drugs ...... 53 12.3 Direct Acting Miotics ...... 46 15.2.3 Heparin ...... 54 12.4 Other Glaucoma Drugs ...... 46 15.2.4 Vitamin K ...... 54 12.5 Oral Drugs for Glaucoma ...... 46 15.2.5 Hemostatics ...... 54 12.6 Cycloplegic Mydriatics ...... 46 15.2.6 Miscellaneous Coagulation 12.7 Non-Steroidal Anti-Inflammatory Agents ...... 54 Agents ...... 47 15.3 Electrolytes ...... 54 12.8 Vasoconstrictor Decongestants ...... 47 15.3.1 Potassium ...... 54 12.9 Antibiotics ...... 47 15.3.2 Other Electrolytes ...... 54 12.10 Sulfonamides ...... 47 12.11 Steroids ...... 47 16. Diagnostics & Miscellaneous 12.12 Steroid-Antibiotic Combinations ...... 48 Agents ...... 55 12.13 Steroid-Sulfonamide Combinations ...... 48 16.1 Miscellaneous Agents ...... 55 12.14 Sympathomimetics ...... 48 16.2 Smoking Deterrents ...... 55 12.15 Miscellaneous Ophthalmologics ...... 48 16.3 Anorexiants ...... 55 12.16 Antivirals ...... 48 Index ...... 56 13. Respiratory, Allergy, Cough & Cold ...... 49 13.1 Antihistamine & Antiallergenic Agents ...... 49 13.1.1 Antihistamines ...... 49 13.1.2 Adrenergics ...... 49 13.1.3 Corticosteroids ...... 49 13.2 Cough & Cold Therapy ...... 49 13.2.1 Antitussive Combinations ...... 49 13.2.2 Expectorant Combinations ...... 49 13.2.3 Decongestant/Antihistamines ...... 50 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 4

PREFERRED PRESCRIPTIONS/RX SELECTIONS FORMULARIES FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 5

1. ANTI-INFECTIVES Preferred Prescriptions/Rx Selections Formulary

1.1 Penicillins 1.2 Tetracyclines FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME GENERICS GENERICS Amoxicillin Trihydrate (Amoxil) Doxycycline Hyclate (Doryx) Amoxicillin Trihydrate/Potassium Clavulanate (Augmentin) Doxycycline Hyclate Capsule (Vibramycin) Amoxicillin Trihydrate/Potassium Clavulanate (Augmentin XR) Doxycycline Hyclate Tablet (Vibra-Tabs) Ampicillin Trihydrate (Principen) Doxycycline Monohydrate (Adoxa) Dicloxacillin Sodium (Dynapen) Doxycycline Monohydrate (Monodox) Penicillin V Potassium (Pen-Vee K) Doxycycline Monohydrate (Vibramycin) BRANDS Minocycline HCl (Dynacin) Augmentin 250-62.5mg (Amoxicillin Trihydrate/Potassium Clavulanate Tablet, Minocycline HCl (Minocin) Chewable) Minocycline HCl (Solodyn) Augmentin 125-31.25mg/5mL (Amoxicillin Trihydrate/Potassium Clavulanate Tetracycline HCl (Achromycin V) Suspension, Oral) BRANDS Oracea (Doxycycline Monohydrate)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Amoxil Amoxicillin (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Augmentin ES Amox TR/Potassium Clavulanate (Various) Adoxa Doxycycline Monohydrate (Various) Augmentin Suspension, Oral Amox TR/Potassium Clavulanate (Various) Adoxa Pak Doxycycline Monohydrate (Various) 200-28.5mg/5mL, 400-57mg/5mL, Doryx Doxycycline Hyclate (Various) 250-62.5mg/5mL Dynacin Minocycline HCl (Various) 1 Augmentin Tablet Amox TR/Potassium Clavulanate (Various) Minocin Minocycline HCl (Various) Augmentin Tablet, Chewable Amox TR/Potassium Clavulanate (Various) Monodox Doxycycline Monohydrate (Various) 200-28.5mg, 400-57mg Periostat Doxycycline Hyclate (Various) Augmentin XR Amoxicillin/Clavulanate ER (Various) Solodyn Minocycline HCl (Various) Moxatag Amoxicillin (Various) Doxycycline Monohydrate (Various) Sumycin Tetracycline HCl (Various)

Vibramycin Syrup Vibramycin Suspension (Pfizer) Anti-Infectives

1.3 Cephalosporins FORMULARY PRODUCTS DRUG NAME 1.3.1 FIRST GENERATION CEPHALOSPORINS GENERICS Cefadroxil Hydrate (Duricef) Cephalexin Monohydrate (Keflex)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Duricef Cefadroxil (Various) Keflex Cephalexin (Various)

FORMULARY PRODUCTS DRUG NAME 1.3.2 SECOND GENERATION CEPHALOSPORINS GENERICS Cefaclor (Ceclor) Cefpodoxime Proxetil (Vantin) Cefuroxime Axetil (Ceftin)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Ceftin Cefuroxime Axetil (Various) Vantin Cefpodoxime Proxetil (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 5 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 6

1. ANTI-INFECTIVES (CONTINUED)

FORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME DRUG NAME POSSIBLE FORMULARY ALTERNATIVES 1.3.3 THIRD GENERATION CEPHALOSPORINS Cipro Ciprofloxacin HCl (Various) GENERICS Factive Ciprofloxacin HCl (Various) Cefdinir (Omnicef) Levofloxacin (Various)

Floxin Ofloxacin (Various) Levaquin Levofloxacin (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Proquin XR Ciprofloxacin HCl (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Cedax Cefaclor (Various) Cefdinir (Various) 1.6 Sulfa's & Related Agents Cefuroxime Axetil (Various) FORMULARY PRODUCTS Omnicef Cefdinir (Various) DRUG NAME Spectracef Cefaclor (Various) GENERICS Cefdinir (Various) Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole) Cefuroxime Axetil (Various) Sulfadiazine (Sulfadiazine) Suprax Cefdinir (Various) Sulfamethoxazole/Trimethoprim (Bactrim DS) Cefuroxime Axetil (Various) Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Sulfamethoxazole/Trimethoprim (Septra DS) Sulfisoxazole (Sulfisoxazole) 1.4 Erythromycins & Other Macrolides FORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME DRUG NAME POSSIBLE FORMULARY ALTERNATIVES 1.4.1 ERYTHROMYCINS & OTHER MACROLIDES Bactrim DS Sulfamethoxazole/Trimethoprim (Various) GENERICS Gantrisin Sulfisoxazole (Various) Septra DS Sulfamethoxazole/Trimethoprim (Various) Azithromycin (Zithromax) Clarithromycin (Biaxin) Clarithromycin ER (Biaxin XL) 1.7 Urinary Tract Agents Erythromycin Base (E-Mycin) Erythromycin Ethylsuccinate (E.E.S.) FORMULARY PRODUCTS Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole) DRUG NAME Erythromycin Stearate (Erythrocin Stearate) GENERICS BRANDS Methenamine Hippurate (Hiprex) Dificid (Fidaxomicin) Methenamine Mandelate (Mandelamine) Nitrofurantoin (Furadantin)

Nitrofurantoin Macrocrystal (Macrodantin) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Nitrofurantoin/Nitrofurantoin Macrocrystal (Macrobid) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Phenazopyridine HCl (Pyridium) Biaxin Clarithromycin (Various) Trimethoprim (Proloprim) Biaxin XL Clarithromycin ER (Various) Ery-Tab 500mg Erythromycin (Various) EryPed Erythromycin Ethylsuccinate (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS PCE Erythromycin (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Zithromax Azithromycin (Various) Hiprex Methenamine Hippurate (Various) Zmax Azithromycin (Various) Furadantin Nitrofurantoin Suspension (Various) Macrobid Nitrofurantoin Macrocrystal (Various) Macrodantin Nitrofurantoin (Various) 1.5 Quinolones Monurol Ciprofloxacin HCl (Various) Sulfamethoxazole/Trimethoprim (Various) FORMULARY PRODUCTS DRUG NAME Trimethoprim (Various) Noroxin (Merck & Co.) 1.5.1 FLUOROQUINOLONES Primsol Trimethoprim (Various) GENERICS Ciprofloxacin ER (Cipro XR) Ciprofloxacin HCl (Cipro) Levofloxacin (Levaquin) Ofloxacin (Floxin) BRANDS Avelox (Moxifloxacin HCl) Cipro (Ciprofloxacin Suspension, Microcapsule Reconstituted) Noroxin (Norfloxacin)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 6 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 7

1. ANTI-INFECTIVES (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

1.8 Antivirals FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 1.8.1 MISCELLANEOUS ANTIVIRALS 1.8.2 HIV/AIDS THERAPY GENERICS GENERICS Acyclovir (Zovirax) Abacavir Sulfate (Ziagen) Amantadine HCl (Symmetrel) Didanosine (Videx EC) Famciclovir (Famvir) Lamivudine (Epivir) Ribavirin (Rebetol) Lamivudine/Zidovudine (Combivir) Valacyclovir HCl (Valtrex) Nevirapine (Viramune) BRANDS Stavudine (Zerit) Baraclude (Entecavir) Zidovudine (Retrovir) Epivir HBV (Lamivudine) BRANDS Hepsera (Adefovir Dipivoxil) Agenerase (Amprenavir/Vitamin E) Incivek (Telaprevir) Agenerase (Amprenavir/Vitamin E/Propylene Glycol) Relenza (Zanamivir) Aptivus (Tipranavir) Synagis (Palivizumab) Atripla (Efavirenz/ Emtricitab/ Tenofovir) Tamiflu (Oseltamivir Phosphate) Crixivan (Indinavir Sulfate) Valcyte Tablet (Valganciclovir Hydrochloride) Edurant (Rilpivirine HCl) Victrelis (Boceprevir) Emtriva (Emtricitabine) Epivir Solution (Lamivudine) Epzicom (Abacavir Sulfate/Lamivudine) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Fuzeon (Enfuvirtide) 1 DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Intelence (Etravirine) Copegus Ribavirin (Various) Invirase (Saquinavir Mesylate) Cytovene Valcyte Tablet (Roche Laboratories) Isentress (Raltegravir Potassium) Famvir Famciclovir (Various) Kaletra (Ritonavir/Lopinavir) Flumadine Amantadine HCl (Various) Lexiva (Fosamprenavir Calcium) Relenza (GlaxoSmithKline) Norvir (Ritonavir) Tamiflu (Roche Laboratories) Prezista (Darunavir Ethanolate) Tyzeka Baraclude (Bristol-Myers Squibb) Anti-Infectives Rescriptor (Delavirdine Mesylate) Epivir HBV (GlaxoSmithKline) Reyataz (Atazanavir Sulfate) Hepsera (Gilead Sciences) Selzentry (Maraviroc) Valcyte Suspension Valcyte Tablet (Roche Laboratories) Sustiva (Efavirenz) Valtrex Valacyclovir HCl (Various) Trizivir (Abacavir Sulfate/Lamivudine/Zidovudine) Zovirax Acyclovir (Various) Truvada (Emtricitabine/Tenofovir Disoproxil Fumarate) Videx (Didanosine) Viracept (Nelfinavir Mesylate) Viread (Tenofovir Disoproxil Fumarate) Ziagen Oral Solution (Abacavir Sulfate)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Combivir Lamivudine/Zidovudine (Various) Epivir Tablet Lamivudine (Various) Videx EC Didanosine (Various) Viramune Nevirapine (Various) Viramune XR Nevirapine (Various) Zerit Stavudine (Various) Ziagen Tablet Abacavir (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 7 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 8

1. ANTI-INFECTIVES (CONTINUED)

1.9 Antifungal Agents 1.11 Miscellaneous Anti-infectives FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME GENERICS 1.11.1 MISCELLANEOUS ANTI-INFECTIVES Clotrimazole (Mycelex) GENERICS Fluconazole (Diflucan) Clindamycin HCl (Cleocin HCl) Flucytosine (Ancobon) Neomycin Sulfate (Neomycin Sulfate) Griseofulvin Ultramicrosize (Gris-Peg) BRANDS Itraconazole (Sporanox) Cayston (Aztreonam Lysine)

Ketoconazole (Nizoral) Dapsone (Dapsone) Nystatin (Mycostatin) Tobi (Tobramycin/0.25 Normal Saline Ampul for Nebulization) Terbinafine HCl (Lamisil) Xifaxan 550mg (Rifaximin)

Voriconazole (Vfend) Zyvox (Linezolid)

BRANDS Lamisil Oral Granules (Terbinafine HCl) Noxafil (Posaconazole) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Sporanox (Itraconazole Solution, Oral) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Cleocin HCl Clindamycin HCl (Various)

Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Cleocin Palmitate Clindamycin HCl (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Ketek Amox TR/Potassium Clavulanate (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Azithromycin (Various) Ancobon Flucytosine (Various) Levofloxacin (Various) Diflucan Fluconazole (Various) Xifaxan 200mg Azithromycin (Various) Grifulvin V Tablet Griseofulvin Ultramicrosize (Various) Ciprofloxacin HCl (Various) Itraconazole (Various) Ketoconazole (Various) Terbinafine HCl (Various) FORMULARY PRODUCTS DRUG NAME Gris-Peg Griseofulvin Ultramicrosize (Various) Itraconazole (Various) 1.11.2 ANTIPARASITICS Ketoconazole (Various) GENERICS Terbinafine HCl (Various) Mebendazole (Vermox) Lamisil Tablet Terbinafine HCl (Various) Metronidazole (Flagyl) Nizoral Ketoconazole (Various) Metronidazole (Flagyl ER) Oravig Clotrimazole (Various) Paromomycin Sulfate (Humatin) Fluconazole (Various) Tinidazole (Tindamax) Nystatin Suspension (Various) BRANDS Sporanox Capsule Itraconazole (Various) Albenza (Albendazole) Vfend Voriconazole (Various) Alinia (Nitazoxanide) Biltricide (Praziquantel) Mepron (Atovaquone) 1.10 Vancomycin Mintezol (Thiabendazole) FORMULARY PRODUCTS NebuPent (Pentamidine Isethionate) DRUG NAME Stromectol (Ivermectin) GENERICS Yodoxin (Iodoquinol) Vancomycin HCl (Vancocin) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Flagyl Metronidazole (Various) Vancocin Vancomycin HCl (Various) Flagyl ER Metronidazole (Various) Tindamax Tinidazole (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 8 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 9

1. ANTI-INFECTIVES (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

FORMULARY PRODUCTS DRUG NAME 1.11.3 ANTIMALARIALS GENERICS Atovaquone/Proguanil HCl (Malarone) Chloroquine Phosphate (Aralen Phosphate) Hydroxychloroquine Sulfate (Plaquenil) Mefloquine HCl (Lariam) Quinine Sulfate (Qualaquin) BRANDS Coartem (Artemether/Lumefantrin) Daraprim (Pyrimethamine) Fansidar (Pyrimethamine/Sulfadoxine) Primaquine (Primaquine Phosphate)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Malarone Atovaquone/Proguanil HCl (Various) Plaquenil Hydroxychloroquine Sulfate (Various) Qualaquin Quinine Sulfate (Various) 1 FORMULARY PRODUCTS DRUG NAME 1.11.4 ANTIMYCOBACTERIALS GENERICS Ethambutol HCl (Myambutol) Isoniazid (Isoniazid)

Pyrazinamide (Pyrazinamide) Anti-Infectives Rifampin (Rifadin) BRANDS Mycobutin (Rifabutin) Seromycin (Cycloserine)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Myambutol Ethambutol HCl (Various) Priftin Rifampin (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 9 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 10

2. ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS

2.1 Antineoplastic & Immunosuppressant Drugs COMMONLY PRESCRIBED NONFORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES DRUG NAME Arimidex Anastrozole (Various) 2.1.1 ALKYLATING AGENTS Aromasin Exemestane (Various) GENERICS Fareston Anastrozole (Various) Exemestane (Various) Cyclophosphamide (Cytoxan) Letrozole (Various) BRANDS Femara Letrozole (Various) Alkeran (Melphalan) CeeNu (Lomustine) Leukeran (Chlorambucil) FORMULARY PRODUCTS Myleran (Busulfan) DRUG NAME Temodar (Temozolomide) 2.1.3.5 ANTIANDROGENS Treanda (Bendamustine HCl) GENERICS Bicalutamide (Casodex) Flutamide (Eulexin) FORMULARY PRODUCTS DRUG NAME BRANDS Zytiga (Abiraterone Acetate) Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred 2.1.2 ANTIMETABOLITES GENERICS Mercaptopurine (Purinethol) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Methotrexate Sodium (Rheumatrex) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES BRANDS Casodex Bicalutamide (Various) Folotyn (Pralatrexate) Nilandron Bicalutamide (Various) Oforta (Fludarabine Phosphate) Flutamide (Various)

Thioguanine (Thioguanine)

Trexall (Methotrexate Sodium) FORMULARY PRODUCTS Vidaza (Azacitidine) DRUG NAME Xeloda (Capecitabine) 2.1.5 IMMUNOSUPPRESSANT DRUGS GENERICS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Azathioprine (Imuran) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Cyclosporine (Cyclosporine) Dacogen Vidaza (Pharmion Corporation) Cyclosporine, Modified (Cyclosporine) Purinethol Mercaptopurine (Various) Mycophenolate Mofetil (CellCept) Tacrolimus Anhydrous (Prograf) BRANDS FORMULARY PRODUCTS DRUG NAME Azasan (Azathioprine) 2.1.3 ANDROGENS, ESTROGENS, HORMONES & RELATED DRUGS CellCept (Mycophenolate Mofetil HCl Suspension) 2.1.3.3 HORMONES Neoral (Cyclosporine, Modified) Rapamune (Sirolimus) GENERICS Sandimmune (Cyclosporine) Megestrol Acetate (Megace)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES DRUG NAME POSSIBLE FORMULARY ALTERNATIVES CellCept Capsule Mycophenolate Mofetil (Various) Megace Megestrol Acetate (Various) CellCept Tablet Mycophenolate Mofetil (Various) Megace ES Megestrol Acetate Suspension, Oral Imuran Azathioprine (Various) (Various) Myfortic Mycophenolate Mofetil (Various) CellCept Suspension (Roche Laboratories) FORMULARY PRODUCTS Prograf Tacrolimus (Various)

DRUG NAME 2.1.3.4 ANTIESTROGENS GENERICS Anastrozole (Arimidex) Exemestane (Aromasin) Letrozole (Femara) Tamoxifen Citrate (Nolvadex)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 10 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 11

2. ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

FORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME DRUG NAME POSSIBLE FORMULARY ALTERNATIVES 2.1.6 MISCELLANEOUS ANTINEOPLASTIC DRUGS Hydrea Hydroxyurea (Various) GENERICS Inlyta Afinitor (Novartis) Etoposide (VePesid) Nexavar (Bayer) Hydroxyurea (Hydrea) Sutent (Pfizer) Leuprolide Acetate (Lupron) Iressa Tarceva (Genentech) Mitoxantrone HCl (Novantrone) Lupron Leuprolide Acetate (Various) Octreotide Acetate Vial (Sandostatin) Novantrone Mitoxantrone HCl (Various) Tretinoin (Vesanoid) Targretin Capsule Methotrexate Sodium Tablet (Various) Vinorelbine Tartrate (Navelbine) Vectibix Erbitux (Bristol-Myers Squibb BRANDS Oncology/Immunology) Zolinza Methotrexate (Various) Adcetris (Brentuximab Vedotin) Intron A (Schering Corporation) Afinitor (Everolimus)

Leukeran (GlaxoSmithKline) Arzerra (Ofatumumab) Avastin (Bevacizumab) Caprelsa (Vandetanib) 2.2 Adjunctive Agents Droxia (Hydroxyurea) Emcyt (Estramustine Phosphate Sodium) FORMULARY PRODUCTS Erbitux (Cetuximab) DRUG NAME Erivedge (Vismodegib) 2.2.1 ADJUNCTIVE AGENTS Firmagon (Degarelix Acetate) GENERICS 2 Gleevec (Imatinib Mesylate) Leucovorin Calcium (Leucovorin Calcium) Antineoplastic & Immunosuppressant Drugs Halaven (Eribulin Mesylate) Medroxyprogesterone Acetate (Depo-Provera) Herceptin (Trastuzumab) BRANDS Hexalen (Altretamine) Depo-Provera 400mg/ml (Medroxyprogesterone Acetate Vial) Hycamtin (Topotecan HCl Capsule) Kepivance (Palifermin) Istodax (Romidepsin) Leukine (Sargramostim) Ixempra (Ixabepilone) Mesnex (Mesna Tablet) Jakafi (Ruxolitinib Phosphate) Neulasta (Pegfilgrastim) Jevtana (Cabazitaxel) Neupogen (Filgrastim) Lupron Depot (Leuprolide Acetate) Procrit (Epoetin Alfa) Lupron Depot-Ped (Leuprolide Acetate) Xgeva (Denosumab) Lysodren (Mitotane) Matulane (Procarbazine HCl) Nexavar (Sorafenib Tosylate) Revlimid (Lenalidomide) Rituxan (Rituximab) Sandostatin LAR (Octreotide Acetate) Somatuline Depot (Lanreotide Acetate) Sprycel (Dasatinib) Supprelin LA (Histrelin AC) Sutent (Sunitinib Malate) Tarceva (Erlotinib HCl) Tasigna (Nilotinib HCl) Thalomid (Thalidomide) Torisel (Temsirolimus) Tykerb (Lapatinib Ditosylate) Vandetanib (Vandetanib) Vantas (Histrelin AC) Velcade (Bortezomib) Votrient (Pazopanib HCl) Xalkori (Crizotinib) Yervoy (Ipilimumab) Zelboraf (Vemurafenib) Zoladex (Goserelin Acetate)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 11 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 12

3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH

3.1 Narcotic Analgesics FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 3.1.1 NARCOTICS 3.1.2 COMBINATION NARCOTIC/ANALGESICS GENERICS GENERICS Buprenorphine HCl (Subutex) Acetaminophen/Butalbital (Phrenilin) Codeine Sulfate (Codeine Sulfate) Acetaminophen/Caffeine/Butalbital (Fioricet) Fentanyl (Duragesic) Aspirin/Caffeine/Butalbital (Fiorinal) Fentanyl Citrate (Actiq) Codeine Phosphate/Acetaminophen (Tylenol w/Codeine) Hydromorphone HCl (Dilaudid) Codeine Phosphate/Acetaminophen/Caffeine/Butalbital (Fioricet w/Codeine) Meperidine HCl (Demerol) Codeine Phosphate/Aspirin (Aspirin w/Codeine) Methadone HCl (Dolophine HCl) Codeine Phosphate/Aspirin/Caffeine/Butalbital (Fiorinal w/Codeine) Morphine Sulfate (Kadian) Hydrocodone Bit/Acetaminophen (Lortab) Morphine Sulfate (MS Contin) Hydrocodone Bit/Acetaminophen (Vicodin) Morphine Sulfate (RMS-Suppository) Oxycodone HCl/Acetaminophen (Percocet) Oxycodone HCl (Roxicodone) Oxycodone HCl/Acetaminophen (Tylox) Oxycodone HCl Concentrate, Oral (OxyFAST) Oxycodone HCl/Ibuprofen (Combunox) BRANDS Oxycodone/Aspirin (Percodan)

Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Avinza (Morphine Sulfate) Butrans (Buprenorphine) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Embeda (Morphine Sulfate/Naltrexone) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Fentora (Fentanyl Citrate) Anexsia Hydrocodone w/Acetaminophen (Various)

OxyContin (Oxycodone HCl) Capital w/Codeine Acetaminophen w/Codeine (Various)

OxyFAST (Oxycodone HCl) Combunox Oxycodone w/Ibuprofen (Various) Esgic Butalbital/APAP/Caffeine (Various)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Esgic-Plus Butalbital/APAP/Caffeine (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Fioricet Butalbital/APAP/Caffeine (Various) Abstral Fentanyl Citrate (Various) Fioricet w/Codeine Butalbital/Caff/APAP/Codeine (Various) Actiq Fentanyl Citrate (Various) Fiorinal Butalbital Compound (Various) Demerol Meperidine HCl (Various) Fiorinal w/Codeine Butalbital Compound w/Codeine (Various) Dilaudid Tablet Hydromorphone HCl (Various) Hycet Hydrocodone w/Acetaminophen (Various) Duragesic Fentanyl (Various) Lorcet 10/650 Hydrocodone w/Acetaminophen (Various) Exalgo Hydromorphone HCl (Various) Lorcet Plus Hydrocodone w/Acetaminophen (Various) Morphine Sulfate (Various) Lortab Hydrocodone w/Acetaminophen (Various) Avinza (Monarch Pharmaceutical) Maxidone Hydrocodone w/Acetaminophen (Various) OxyContin (Purdue Pharma LP) Norco Hydrocodone w/Acetaminophen (Various) Kadian Morphine Sulfate Tablet, Sustained Action Panlor SS Butalbital/APAP/Caffeine (Various) (Various) Acetaminophen w/Codeine (Various) Lazanda Fentanyl Citrate (Various) Hydrocodone w/Acetaminophen (Various) MS Contin Morphine Sulfate Tablet, Sustained Action Oxycodone w/Acetaminophen (Various) (Various) Percocet Oxycodone w/Acetaminophen (Various) Onsolis Fentanyl Citrate (Various) Percodan Oxycodone w/Aspirin (Various) Opana Hydromorphone HCl (Various) Phrenilin Butalbital/Acetaminophen (Various) Morphine Sulfate (Various) Roxicet Oral Solution Oxycodone HCl Solution, Oral (Various) Oxycodone HCl (Various) Sedapap Butalbital/Acetaminophen (Various) Opana ER Morphine Sulfate Tablet, Sustained Action Tylenol w/Codeine Acetaminophen w/Codeine (Various) (Various) Tylox Oxycodone w/Acetaminophen (Various) Oxycodone HCl Tablet, Sustained Release Vicodin Hydrocodone w/Acetaminophen (Various) 12hr (Various) Vicodin ES Hydrocodone w/Acetaminophen (Various) Avinza (Monarch Pharmaceutical) Vicodin HP Hydrocodone w/Acetaminophen (Various) OxyContin (Purdue Pharma LP) Vicoprofen Hydrocodone Bit-Ibuprofen (Various) OxyIR Oxycodone HCl (Various) Xodol Hydrocodone w/Acetaminophen (Various) Roxanol Oral Solution Morphine Sulfate (Various) Zydone Hydrocodone w/Acetaminophen (Various)

Roxicodone Oxycodone HCl (Various) Subsys Fentanyl Citrate (Various) Subutex Buprenorphine HCl (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 12 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 13

3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

3.3 Non-narcotic Analgesics Lodine Etodolac (Various) FORMULARY PRODUCTS DRUG NAME Mobic Meloxicam (Various) 3.3.1 NSAIDS/COX II INHIBITORS Motrin Ibuprofen (Various) Nalfon Etodolac (Various) 3.3.1.1 NSAIDS Ibuprofen (Various) GENERICS Indomethacin (Various) Etodolac (Lodine) Meclofenamate Sodium (Various) Etodolac (Lodine XL) Naproxen (Various) Flurbiprofen (Ansaid) Sulindac (Various) Ibuprofen (Motrin) Naprelan Naproxen Sodium (Various) Indomethacin (Indocin) Naprosyn Naproxen (Various) Indomethacin (Indocin SR) Pennsaid Etodolac (Various) Ketoprofen (Orudis) Ibuprofen (Various) Meclofenamate Sodium (Meclofenamate Sodium) Naproxen (Various) Meloxicam (Mobic) Ponstel Etodolac (Various) Nabumetone (Relafen) Ibuprofen (Various) Naproxen (Naprosyn) Indomethacin (Various) Naproxen Sodium (Anaprox) Meclofenamate Sodium (Various) Naproxen Sodium (Anaprox DS) Naproxen (Various) Naproxen Sodium (Naprelan) Sulindac (Various) Oxaprozin (Daypro) Relafen Nabumetone (Various) Piroxicam (Feldene) Sprix Etodolac (Various) Sulindac (Clinoril) Ibuprofen (Various) 3 Tolmetin Sodium (Tolectin) Naproxen (Various) Autonomic & CNS Drugs, Neurology & Psych BRANDS Toradol Etodolac (Various) Vimovo (Naproxen/Esomeprazole Mag) Ibuprofen (Various) Indomethacin (Various) Meclofenamate Sodium (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Naproxen (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Sulindac (Various) Anaprox DS Naproxen Sodium (Various) Voltaren Ibuprofen (Various) Ansaid Flurbiprofen (Various) Meloxicam (Various) Arthrotec Ibuprofen (Various) Naproxen (Various) Naproxen (Various) Voltaren-XR Ibuprofen (Various) Celebrex (Pharmacia/Upjohn) Meloxicam (Various) Cambia Etodolac (Various) Naproxen (Various) Ibuprofen (Various) Naproxen (Various) Cataflam Etodolac (Various) Ibuprofen (Various) Naproxen (Various) Clinoril Sulindac (Various) Daypro Oxaprozin (Various) Diclofenac Potassium Etodolac (Various) Ibuprofen (Various) Naproxen (Various) Diclofenac Sodium Etodolac (Various) Ibuprofen (Various) Naproxen (Various) Duexis Famotidine (Various) Ibuprofen (Various) Naproxen (Various) Omeprazole (Various) EC-Naprosyn Naproxen (Various) Feldene Piroxicam (Various) Flector Ibuprofen (Various) Meloxicam (Various) Naproxen (Various) Indocin Indomethacin (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 13 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 14

3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED)

FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 3.3.1.2 NSAIDS- SPECIFIC COX-II INHIBITORS 3.3.4 NARCOTIC ANTAGONISTS BRANDS GENERICS Celebrex (Celecoxib) Naltrexone HCl (ReVia)

BRANDS FORMULARY PRODUCTS Suboxone Film (Buprenorphine HCl/Naloxone HCl) DRUG NAME Vivitrol (Naltrexone Microspheres) 3.3.2 SALICYLATES GENERICS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Choline Salicylate/Magnesium Salicylate (Trilisate) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Diflunisal (Dolobid) Suboxone Tablets Suboxone Film (Reckitt Benckiser) Salsalate (Salsalate)

3.4 Migraine & Cluster Headache Therapy FORMULARY PRODUCTS DRUG NAME FORMULARY PRODUCTS DRUG NAME Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred 3.3.3 MISCELLANEOUS ANALGESICS GENERICS 3.4.1 HEADACHE THERAPY Butorphanol Tartrate Aerosol, Spray (Stadol) GENERICS Pentazocine HCl/Acetaminophen (Talacen) Acetaminophen/Butalbital (Phrenilin) Pentazocine HCl/Naloxone HCl (Talwin NX) Acetaminophen/Caffeine/Butalbital (Fioricet) Tramadol HCl (Ryzolt) Aspirin/Caffeine/Butalbital (Fiorinal) Tramadol HCl (Ultram) Dihydroergotamine Mesylate (D.H.E.45) Tramadol HCl (Ultram ER) Ergotamine Tartrate/Caffeine (Cafergot) Tramadol HCl/Acetaminophen (Ultracet) Isometheptene Mucate/Acetaminophen/Dichloralphenazone (Midrin) BRANDS Naratriptan HCl (Amerge) Nucynta (Tapentadol) Sumatriptan Succinate (Alsuma) Nucynta ER (Tapentadol) Sumatriptan Succinate (Imitrex) Synvisc (Hylan G-F 20) BRANDS Synvisc-One (Hylan G-F 20) Ergomar (Ergotamine Tartrate) Frova (Frovatriptan Succinate) Maxalt (Rizatriptan Benzoate) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Maxalt MLT (Rizatriptan Benzoate) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Relpax (Eletriptan Hydrobromide) Euflexxa Synvisc (Genzyme) Treximet (Sumatriptan Succinate/Naproxen) Hyalgan Synvisc (Genzyme) Zomig (Zolmitriptan) Orthovisc Synvisc (Genzyme) Zomig ZMT (Zolmitriptan)

Ryzolt Tramadol ER (Various) Supartz Synvisc (Genzyme) Talacen Pentazocine/Acetaminophen (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Talwin NX Pentazocine and Naloxone HCl (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Ultracet Tramadol HCl-Acetaminophen (Various) Alsuma Sumatriptan Succinate (Various) Acetaminophen w/Codeine (Various) Amerge Naratriptan HCl (Various) Ultram Tramadol HCl (Various) Axert Naratriptan HCl (Various) Ultram ER Tramadol HCl (Various) Sumatriptan Succinate (Various) Frova (Endo Pharmaceuticals Inc) Maxalt (Merck & Co.) Relpax (Pfizer) Zomig (AstraZeneca) Imitrex Sumatriptan Succinate (Various) Midrin APAP/Dichlphen/Isometheptene (Various) Migranal Naratriptan HCl (Various) Sumatriptan Nasal Spray (Various) Frova (Endo Pharmaceuticals Inc) Maxalt (Merck & Co.) Relpax (Pfizer) Zomig Nasal Spray (AstraZeneca)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 14 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:35 AM Page 15

3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

3.5 Antiparkinsonism Agents FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 3.4.2 ANTIVERTIGO & ANTIEMETIC DRUGS GENERICS GENERICS Amantadine HCl (Symmetrel) Granisetron HCl (Kytril) Benztropine Mesylate (Cogentin) Meclizine HCl (Antivert) Bromocriptine Mesylate (Parlodel) Ondansetron (Zofran ODT) Carbidopa/Levodopa (Sinemet) Ondansetron HCl (Zofran) Carbidopa/Levodopa (Sinemet CR) Prochlorperazine Maleate (Compazine) Carbidopa/Levodopa/Entacapone (Stalevo) Promethazine HCl (Phenergan) Diphenhydramine HCl (Benadryl 50mg) Trimethobenzamide HCl (Tigan) Entacapone (Comtan)

BRANDS Pramipexole Di-HCl (Mirapex) Anzemet (Dolasetron Mesylate Tablet) Ropinirole HCl (Requip) Emend (Aprepitant) Ropinirole HCl (Requip XL) Sancuso (Granisetron) Selegiline HCl (Eldepryl)

Transderm-Scop (Scopolamine Hydrobromide) Trihexyphenidyl HCl (Artane) BRANDS Apokyn (Apomorphine HCl) Azilect (Rasagiline Mesylate) Comtan (Entacapone) Lodosyn (Carbidopa) Mirapex ER (Pramipexole Di-HCl)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Eldepryl Selegiline HCl (Various) Mirapex Pramipexole Di-HCl (Various) Parcopa Carbidopa/Levodopa (Various) Parlodel Bromocriptine Mesylate (Various) Requip Ropinirole HCl (Various) Requip XL Ropinirole HCl (Various) Sinemet Carbidopa/Levodopa (Various) Sinemet CR Carbidopa/Levodopa Tablet, Sustained Action (Various) Stalevo Carbidopa/Levodopa/Entacapone (Various) Carbidopa/Levodopa (Various) Comtan (Novartis) Tasmar Comtan (Novartis) Zelapar Selegiline HCl (Various)

3 Autonomic & CNS Drugs, Neurology & Psych

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 15 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 16

3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED)

3.6 Anticonvulsants FORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME DRUG NAME POSSIBLE FORMULARY ALTERNATIVES GENERICS Banzel Oral Suspension Banzel Tablet (Eisai) Acetazolamide (Diamox) Carbatrol Carbamazepine (Various) Carbamazepine (Carbatrol) Depakote Divalproex Sodium (Various) Carbamazepine (Tegretol) Depakote ER Divalproex Sodium ER (Various) Carbamazepine (Tegretol XR) Depakote Sprinkle Divalproex Sodium (Various) Clonazepam (Klonopin) Dilantin Capsule 100mg Phenytoin Sodium Capsule (Various) Diazepam (Diastat AcuDial) Dilantin Oral Suspension Phenytoin (Various) Divalproex Sodium (Depakote) Equetro Carbamazepine (Various) Divalproex Sodium (Depakote ER) Divalproex Sodium (Various) Divalproex Sodium (Depakote Sprinkle) Lithium Carbonate (Various) Ethosuximide (Zarontin) Felbatol Felbamate (Various) Felbamate (Felbatol) Gralise Gabapentin (Various) Gabapentin (Neurontin) Keppra Levetiracetam (Various) Lamotrigine (Lamictal) Keppra XR Levetiracetam ER (Various) Levetiracetam (Keppra) Klonopin Clonazepam (Various)

Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Levetiracetam (Keppra XR) Lamictal Lamotrigine (Various) Mephobarbital (Mebaral) Mebaral Mephobarbital (Various) Oxcarbazepine (Trileptal) Mysoline Primidone (Various) Phenobarbital (Phenobarbital) Neurontin Gabapentin (Various) Phenytoin Sodium Extended (Dilantin 100mg) Onfi Felbamate (Various) Phenytoin Sodium Extended (Phenytek) Lamotrigine (Various) Phenytoin Suspension, Oral (Dilantin) Topiramate (Various) Primidone (Mysoline) Banzel Tablet (Eisai) Topiramate (Topamax) Phenytek Phenytoin Sodium (Various) Valproic Acid (Depakene) Potiga Carbamazepine (Various) BRANDS Levetiracetam (Various) Banzel (Rufinamide Tablet) Topiramate (Various) Celontin (Methsuximide) Banzel Tablet (Eisai) Diastat (Diazepam) Lyrica (Pfizer) Dilantin (Phenytoin Tablet, Chewable) Vimpat (UCB) Dilantin 30mg (Phenytoin Sodium Extended) Sabril Divalproex Sodium (Various) Gabitril (Tiagabine HCl) Lamotrigine (Various) Lamictal ODT (Lamotrigine) Levetiracetam (Various) Lamictal XR (Lamotrigine) Topiramate (Various) Lyrica (Pregabalin) Gabitril (Cephalon) Peganone (Ethotoin) Tegretol Carbamazepine (Various) Tegretol XR 100mg (Carbamazepine) Tegretol XR 200mg, 400mg Carbamazepine XR (Various) Vimpat (Lacosamide) Topamax Topiramate (Various) Trileptal Carbamazepine (Various) Zarontin Ethosuximide (Various) Zonegran Carbamazepine (Various) Clonazepam (Various) Ethosuximide (Various) Phenobarbital (Various) Phenytoin Sodium (Various) Lyrica (Pfizer)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 16 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 17

3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

3.7 Miscellaneous Neurological Therapy 3.8 Muscle Relaxants & Antispasmodic FORMULARY PRODUCTS Therapy DRUG NAME FORMULARY PRODUCTS GENERICS DRUG NAME Donepezil HCl (Aricept) 3.8.1 MUSCLE RELAXANTS & ANTISPASMODIC AGENTS Donepezil HCl (Aricept ODT) GENERICS Galantamine Hydrobromide (Razadyne) Baclofen (Lioresal) Galantamine Hydrobromide (Razadyne ER) Carisoprodol (Soma) Rivastigmine Tartrate Capsules (Exelon) Chlorzoxazone (Parafon Forte DSC) BRANDS Cyclobenzaprine HCl (Amrix) Aricept 23mg (Donepezil HCl) Cyclobenzaprine HCl (Flexeril) Copaxone (Glatiramer Acetate) Dantrolene Sodium (Dantrium) Exelon (Rivastigmine Tartrate Solution) Diazepam (Valium) Exelon (Rivastigmine Transdermal Patch) Metaxalone (Skelaxin) Gilyena (Fingolimod HCl) Methocarbamol (Robaxin) Namenda (Memantine HCl) Oxybutynin Chloride (Ditropan) Nuedexta (Dextromethorphan HBr/Quinidine) Oxybutynin Chloride (Ditropan XL) Xenazine (Tetrabenazine) Tolterodine Tartrate (Detrol) Trospium Chloride (Sanctura) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS BRANDS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Detrol LA (Tolterodine Tartrate) Aricept 5mg, 10mg Donepezil HCl (Various) Enablex (Darifenacin Hydrobromide) Aricept ODT Donepezil HCl (Various) Gelnique (Oxybutynin Chloride) 3 Autonomic & CNS Drugs, Neurology & Psych Cognex Donepezil HCl (Various) Oxytrol (Oxybutynin) Galantamine (Various) Sanctura XR (Trospium Chloride) Rivastigmine Tartrate (Various) Toviaz (Fesoterodine Fumarat) Exelon Capsules Rivastigmine Tartrate (Various) Vesicare (Solifenacin Succinate) Horizant Gabapentin (Various) Ropinirole HCl (Various) Mirapex ER (Boehringer) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Razadyne Galantamine (Various) Amrix Cyclobenzaprine HCl (Various) Razadyne ER Galantamine (Various) Equanil Diazepam (Various) Tysabri Avonex Administration Pack (Biogen-Idec) Lorazepam (Various) Betaseron (Berlex Laboratories) Flexeril Cyclobenzaprine HCl (Various) Copaxone (Sanofi-Aventis) Meprobamate Diazepam (Various) Lorazepam (Various) Miltown Diazepam (Various) Lorazepam (Various) Norflex Chlorzoxazone (Various) Cyclobenzaprine HCl (Various) Diazepam (Various) Methocarbamol (Various) Orphenadrine Citrate Chlorzoxazone (Various) Cyclobenzaprine HCl (Various) Diazepam (Various) Methocarbamol (Various) Robaxin Methocarbamol (Various) Skelaxin Metaxalone (Various) Soma Carisoprodol (Various) Tizanidine HCl Baclofen (Various) Cyclobenzaprine HCl (Various) Diazepam (Various) Zanaflex Baclofen (Various) Cyclobenzaprine HCl (Various) Diazepam (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 17 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 18

3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED)

FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 3.8.2 MYASTHENIA GRAVIS 3.9.2 ANTIDEPRESSANT AGENTS GENERICS 3.9.2.1 TRICYCLICS Pyridostigmine Bromide Tablet (Mestinon) GENERICS BRANDS Amitriptyline HCl (Elavil) Mestinon (Pyridostigmine Bromide Syrup) Amoxapine (Asendin) Mestinon (Pyridostigmine Bromide Tablet, Sustained Action) Clomipramine HCl (Anafranil) Prostigmin (Neostigmine Bromide) Desipramine HCl (Norpramin) Doxepin HCl (Sinequan) Imipramine HCl (Tofranil) 3.9 Psychotherapeutic Drugs Imipramine Pamoate (Tofranil-PM) FORMULARY PRODUCTS Nortriptyline HCl (Pamelor) DRUG NAME Protriptyline HCl (Vivactil) 3.9.1 HYPNOTIC AGENTS Trimipramine Maleate (Surmontil) GENERICS Chloral Hydrate (Somnote) Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Estazolam (ProSom) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Flurazepam HCl (Dalmane) Anafranil Clomipramine HCl (Various) Temazepam (Restoril) Norpramin Desipramine HCl (Various) Triazolam (Halcion) Pamelor Nortriptyline HCl (Various) Zaleplon (Sonata) Surmontil Trimipramine Maleate (Various) Zolpidem Tartrate (Ambien) Tofranil Imipramine HCl (Various) Zolpidem Tartrate (Ambien CR) Tofranil-PM Imipramine Pamoate (Various) BRANDS Vivactil Protriptyline HCl (Various) Silenor (Doxepin HCl) FORMULARY PRODUCTS DRUG NAME COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES 3.9.2.2 MISCELLANEOUS ANTIDEPRESSANTS Ambien Zolpidem Tartrate (Various) GENERICS Ambien CR Zolpidem Tartrate ER (Various) Bupropion HCl (Wellbutrin) Butisol Sodium Chloral Hydrate (Various) Bupropion HCl (Wellbutrin SR) Temazepam (Various) Bupropion HCl (Wellbutrin XL) Triazolam (Various) Maprotiline HCl (Ludiomil) Doral Temazepam (Various) Mirtazapine Tablet (Remeron) Triazolam (Various) Mirtazapine Tablet, Rapid Dissolve (Remeron Sol Tab) Zaleplon (Various) Trazodone HCl (Desyrel) Zolpidem Tartrate (Various) Venlafaxine HCl (Effexor) Edluar Zolpidem Tartrate (Various) Venlafaxine HCl (Effexor XR) Halcion Triazolam (Various) BRANDS Intermezzo Zaleplon (Various) Cymbalta (Duloxetine HCl) Lunesta Temazepam (Various) Pristiq (Desvenlafaxine Succinate)

Zolpidem Tartrate (Various) Nembutal Sodium Chloral Hydrate (Various) Temazepam (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Triazolam (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Restoril Temazepam (Various) Desyrel Trazodone HCl (Various) Rozerem Estazolam (Various) Effexor Venlafaxine HCl (Various) Temazepam (Various) Effexor XR Venlafaxine HCl ER (Various) Triazolam (Various) Oleptro ER Trazodone HCl (Various) Zolpidem Tartrate (Various) Remeron Mirtazapine Tablet (Various) Seconal Sodium Chloral Hydrate (Various) Remeron Sol Tab Mirtazapine Tablet, Rapid Dissolve Temazepam (Various) (Various) Triazolam (Various) Wellbutrin Bupropion HCl (Various) Sonata Zaleplon (Various) Wellbutrin SR Bupropion HCl Tablet, Sustained Action Zolpimist Zolpidem Tartrate (Various) (Various) Wellbutrin XL Bupropion HCl Tablet, Extended Release (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 18 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 19

3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 3.9.2.3 MAO INHIBITORS 3.9.3 ANTIPSYCHOTICS GENERICS 3.9.3.1 PHENOTHIAZINES Phenelzine Sulfate (Nardil) GENERICS Tranylcypromine Sulfate (Parnate) Chlorpromazine HCl (Thorazine) Fluphenazine HCl (Prolixin) Perphenazine (Trilafon) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Trifluoperazine HCl (Stelazine) Emsam Phenelzine Sulfate (Various)

Tranylcypromine Sulfate (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Nardil Phenelzine Sulfate (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Parnate Tranylcypromine Sulfate (Various) Mellaril Chlorpromazine HCl (Various)

Haloperidol (Various) FORMULARY PRODUCTS Quetiapine Fumarate (Various) DRUG NAME Risperidone (Various) 3.9.2.4 SELECTIVE SEROTONIN REUPTAKE INHIBITORS Thioridazine HCl Chlorpromazine HCl (Various) GENERICS Haloperidol (Various) Citalopram Hydrobromide (Celexa) Quetiapine Fumarate (Various) Risperidone (Various) Escitalopram Oxalate (Lexapro) Fluoxetine HCl (Prozac) 3 Fluvoxamine Maleate (Luvox) Autonomic & CNS Drugs, Neurology & Psych Paroxetine HCl (Paxil) Paroxetine HCl (Paxil CR) Sertraline HCl (Zoloft) BRANDS Viibryd (Vilazodone HCl)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Celexa Citalopram HBr (Various) Lexapro Escitalopram Oxalate (Various) Luvox CR Fluvoxamine Maleate (Various) Paxil Paroxetine HCl (Various) Paxil CR Paroxetine HCl (Various) Pexeva Paroxetine HCl (Various) Prozac Fluoxetine HCl (Various) Prozac Weekly Fluoxetine HCl (Various) Sarafem Fluoxetine HCl (Various) Zoloft Sertraline HCl (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 19 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 20

3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED)

FORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME DRUG NAME POSSIBLE FORMULARY ALTERNATIVES 3.9.3.2 BUTYROPHENONES Abilify Clozapine (Various) GENERICS Olanzapine (Various) Haloperidol (Haldol) Quetiapine Fumarate (Various) Haloperidol Lactate Concentrate, Oral (Haldol) Risperidone (Various) Ziprasidone HCl (Various) 3.9.3.3 MISCELLANEOUS ANTIPSYCHOTICS Seroquel XR (AstraZeneca) GENERICS Fanapt Clozapine (Various) Clozapine (Clozaril) Olanzapine (Various) Quetiapine Fumarate (Various) Clozapine (Fazaclo) Risperidone (Various) Loxapine Succinate (Loxitane) Ziprasidone HCl (Various) Olanzapine (Zyprexa) Seroquel XR (AstraZeneca) Olanzapine (Zyprexa Zydis) Geodon Ziprasidone HCl (Various) Quetiapine Fumarate (Seroquel) Invega Olanzapine (Various) Risperidone (Risperdal) Quetiapine Fumarate (Various) Thiothixene (Navane)

Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Risperidone (Various) Ziprasidone HCl (Geodon) Ziprasidone HCl (Various) BRANDS Seroquel XR (AstraZeneca) Clozaril (Clozapine) Risperdal Risperidone (Various) Moban (Molindone HCl) Risperdal Consta Olanzapine (Various) Orap (Pimozide) Saphris Clozapine (Various) Seroquel XR (Quetiapine Fumarate) Olanzapine (Various) Quetiapine Fumarate (Various) Risperidone (Various) Ziprasidone HCl (Various) Seroquel XR (AstraZeneca) Seroquel Quetiapine Fumarate (Various) Symbyax Fluoxetine HCl (Various) Olanzapine (Various) Quetiapine Fumarate (Various) Risperidone (Various) Seroquel XR (AstraZeneca) Zyprexa Olanzapine (Various) Zyprexa Relprevv Clozapine (Various) Olanzapine (Various) Quetiapine Fumarate (Various) Risperidone (Various) Ziprasidone HCl (Various) Seroquel XR (AstraZeneca) Zyprexa Zydis Olanzapine ODT (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 20 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 21

3. AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 3.9.4 MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS 3.9.5 ANXIOLYTICS GENERICS GENERICS Amphetamine Aspartate/Amphetamine Sulfate/Dextroamphetamine (Adderall) Alprazolam (Niravam) Amphetamine Aspartate/Amphetamine Sulfate/Dextroamphetamine Alprazolam (Xanax) (Adderall XR) Alprazolam (Xanax XR) Dextroamphetamine Sulfate (Dexedrine) Buspirone HCl (Buspar) Lithium Carbonate (Eskalith) Chlordiazepoxide HCl (Librium) Lithium Citrate (Lithium Citrate) Clorazepate Dipotassium (Tranxene T-Tab) Methamphetamine HCl (Desoxyn) Diazepam (Valium) Methylphenidate HCl (Concerta) Lorazepam (Ativan) Methylphenidate HCl (Metadate CD) Midazolam HCl (Versed) Methylphenidate HCl (Metadate ER) Oxazepam (Serax) Methylphenidate HCl (Ritalin) Methylphenidate HCl (Ritalin LA) Methylphenidate HCl (Ritalin-SR) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Modafinil (Provigil) Ativan Lorazepam (Various) BRANDS Buspar Buspirone HCl (Various) Daytrana (Methylphenidate) Diazepam Oral Concentrate Diazepam Tablet (Various)

Intuniv (Guanfacine HCl) Librium Chlordiazepoxide HCl (Various)

Metadate CD (Methylphenidate HCl) Niravam Alprazolam (Various) 3 Autonomic & CNS Drugs, Neurology & Psych Strattera (Atomoxetine HCl) Tranxene T-Tab Clorazepate Dipotassium (Various)

Vyvanse (Lisdexamfetamine Dimesylate) Valium Diazepam (Various)

Xyrem (Sodium Oxybate) Xanax Alprazolam (Various) Xanax XR Alprazolam XR (Various)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Adderall Amphetamine Salt Combo (Various) Adderall XR Dextroamphetamine-Amphetamine ER (Various) Desoxyn Methamphetamine HCl (Various) Dexedrine Dextroamphetamine Sulfate (Various) Focalin Dexmethylphenidate HCl (Various) Focalin XR Dextroamphetamine-Amphetamine ER (Various) Methylphenidate ER (Various) Daytrana (Shire US Inc.) Metadate CD (Celltech Pharm) Methylin ER (Mallinckrodt Pharmaceuticals) Kapvay Clonidine HCl (Various) Intuniv (Shire US Inc.) Liquadd Dextroamphetamine Sulfate (Various) Lithobid Lithium Carbonate Tablet, Sustained Action (Various) Methylin Oral Solution Methylphenidate HCl (Various) Methylin Tablet, Chewable Methylphenidate HCl (Various) Nuvigil Modafinil (Various) Provigil Modafinil (Various) Ritalin Methylphenidate HCl (Various) Ritalin LA Methylphenidate ER (Various) Dextroamphetamine Sulfate (Various) Dextroamphetamine-Amphetamine ER (Various) Daytrana (Shire US Inc.) Metadate CD (Celltech Pharm) Ritalin-SR Methylphenidate ER (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 21 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 22

4. CARDIOVASCULAR, HYPERTENSION & LIPIDS

4.1 Antiarrhythmic Agents FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME GENERICS 4.3.2 LONG ACTING NITRATES Amiodarone HCl (Cordarone) GENERICS Amiodarone HCl (Pacerone 400mg) Isosorbide Dinitrate (Isordil) Disopyramide Phosphate (Norpace) Isosorbide Mononitrate (Imdur) Disopyramide Phosphate (Norpace CR) Isosorbide Mononitrate (ISMO) Flecainide Acetate (Tambocor) Nitroglycerin Capsule, Sustained Action (Nitroglycerin) Mexiletine HCl (Mexitil) Nitroglycerin Ointment (Nitroglycerin) Procainamide HCl (Procanbid) Nitroglycerin Patch, Transdermal 24 Hours (Transderm-Nitro) Propafenone HCl (Rythmol) BRANDS Propafenone HCl (Rythmol SR) Dilatrate-SR (Isosorbide Dinitrate) Quinidine Gluconate (Quinaglute) Nitro-Dur (Nitroglycerin) Quinidine Sulfate (Quinidex)

Sotalol HCl (Betapace) Sotalol HCl (Betapace AF) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS BRANDS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES

Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Ethmozine (Moricizine HCl) Imdur Isosorbide Mononitrate (Various) Multaq (Dronedarone HCl) ISMO Isosorbide Mononitrate (Various) Pacerone 100mg, 200mg (Amiodarone HCl) Isordil Isosorbide Dinitrate (Various) Procanbid (Procainamide HCl) Minitran Nitroglycerin Patch, Transdermal 24 Hours Tikosyn (Dofetilide) (Various) Nitro-Dur (Schering)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES 4.4 Coagulation Therapy Betapace Sotalol (Various) FORMULARY PRODUCTS Betapace AF Sotalol (Various) DRUG NAME Cordarone Amiodarone HCl (Various) 4.4.1 ANTICOAGULANTS Norpace Disopyramide Phosphate (Various) GENERICS Norpace CR Disopyramide Phosphate (Various) Warfarin Sodium (Coumadin) Quinidex Quinidine Sulfate (Various) Rythmol Propafenone HCl (Various) BRANDS Rythmol SR Propafenone HCl (Various) Pradaxa (Dabigatran Etexilate Mesylate) Tambocor Flecainide Acetate (Various)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS 4.2 Cardiac Glycosides DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Coumadin Warfarin Sodium (Various) FORMULARY PRODUCTS Xarelto Warfarin Sodium (Various) DRUG NAME Pradaxa (Boehringer) GENERICS Digoxin (Lanoxin) FORMULARY PRODUCTS DRUG NAME COMMONLY PRESCRIBED NONFORMULARY PRODUCTS 4.4.2 ANTIPLATELET DRUGS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES GENERICS Lanoxin Digoxin (Various) Cilostazol (Pletal)

Clopidogrel Bisulfate (Plavix) Dipyridamole (Persantine) 4.3 Nitrates Ticlopidine HCl (Ticlid) FORMULARY PRODUCTS BRANDS DRUG NAME Aggrenox (Aspirin/Dipyridamole) 4.3.1 RAPID ACTING NITRATES Brilinta (Ticagrelor) GENERICS Effient (Prasugrel HCl) Nitroglycerin (Nitrostat) BRANDS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Nitrostat (Nitroglycerin) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Persantine Dipyridamole (Various) Plavix Clopidogrel Bisulfate (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Pletal Cilostazol (Various)

Nitrolingual Nitroglycerin Spray (Various) Nitromist Nitroglycerin Sublingual Tablet (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 22 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 23

4. CARDIOVASCULAR, HYPERTENSION & LIPIDS (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

4.5 Antihypertensive Therapy FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 4.4.3 HEPARIN 4.5.1 THIAZIDE & RELATED DIURETICS GENERICS GENERICS Enoxaparin Sodium (Lovenox) Amiloride HCl (Midamor) Fondaparinux Sodium (Arixtra) Amiloride HCl/Hydrochlorothiazide (Moduretic) Heparin Sodium,Porcine (Heparin Lock Flush) Bumetanide (Bumex) BRANDS Chlorothiazide (Diuril) Fragmin (Dalteparin Sodium,Porcine) Chlorthalidone (Hygroton)

Eplerenone (Inspra) Furosemide (Lasix) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Hydrochlorothiazide (HydroDIURIL) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Hydrochlorothiazide (Microzide) Arixtra Fondaparinux Sodium (Various) Indapamide (Lozol) Lovenox Enoxaparin Sodium (Various) Methyclothiazide (Enduron) Metolazone (Zaroxolyn) FORMULARY PRODUCTS Spironolactone (Aldactone) DRUG NAME Spironolactone/Hydrochlorothiazide (Aldactazide) 4.4.4 VITAMIN K Torsemide (Demadex) BRANDS Triamterene/Hydrochlorothiazide (Dyazide) Mephyton (Phytonadione Tablet) Triamterene/Hydrochlorothiazide (Maxzide) 4 FORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Cardiovascular, Hypertension & Lipids 4.4.5 HEMOSTATICS Aldactazide Spironolactone w/HCTZ (Various) GENERICS Aldactone Spironolactone (Various) Aminocaproic Acid (Amicar) Demadex Torsemide (Various) Dyazide Triamterene w/HCTZ (Various) BRANDS Dyrenium Amiloride HCl (Various) Humate-P (AHF, Human/VWF, Human) Triamterene w/HCTZ (Various) NovoSeven (Factor VIIa, Recombinant) Edecrin Bumetanide (Various) NovoSeven RT (Factor VIIa, Recombinant) Furosemide (Various) NPlate (Romiplostim) Torsemide (Various) Promacta (Eltrombopag Olamine) Enduron Methyclothiazide (Various) Wilate (AHF, Human/VWF, Human) Inspra Eplerenone (Various) Lasix Furosemide (Various) FORMULARY PRODUCTS Maxzide Triamterene w/HCTZ (Various) DRUG NAME Microzide Hydrochlorothiazide (Various) 4.4.6 MISCELLANEOUS COAGULATION AGENTS Zaroxolyn Metolazone (Various)

GENERICS Pentoxifylline Tablet, Sustained Action (Trental) BRANDS Xyntha (Antihemophilic Factor VIII) Xyntha Solofuse (Antihemophilic Factor VIII)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Trental Pentoxifylline (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 23 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 24

4. CARDIOVASCULAR, HYPERTENSION & LIPIDS (CONTINUED)

FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 4.5.2 BETA BLOCKERS 4.5.3 CALCIUM CHANNEL BLOCKERS GENERICS 4.5.3.1 CALCIUM CHANNEL BLOCKERS/NON-DIHYDROPYRIDINES Acebutolol HCl (Sectral) GENERICS Atenolol (Tenormin) Diltiazem HCl (Cardizem) Betaxolol HCl (Kerlone) Diltiazem HCl (Cardizem LA) Bisoprolol Fumarate (Zebeta) Diltiazem HCl (Tiazac) Carvedilol (Coreg) Diltiazem HCl (Cardizem SR) Labetalol HCl (Normodyne) Diltiazem HCl (Cardizem CD) Labetalol HCl (Trandate) Nimodipine (Nimotop) Metoprolol Succinate (Toprol XL) Verapamil HCl (Calan) Metoprolol Tartrate (Lopressor) Verapamil HCl (Verelan) Nadolol (Corgard) Verapamil HCl (Verelan PM) Pindolol (Visken) Verapamil HCl (Calan SR) Propranolol HCl (Inderal) Verapamil HCl (Isoptin S.R.)

Propranolol HCl (Inderal LA) BRANDS Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Propranolol HCl (Innopran XL) Cardizem LA 120mg (Diltiazem HCl) Timolol Maleate (Blocadren)

BRANDS Bystolic (Nebivolol HCl) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Coreg CR (Carvedilol Phosphate) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Calan SR Verapamil HCl Tablet, Sustained Action (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Cardizem Diltiazem HCl (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Cardizem CD Diltiazem HCl Capsule, Sustained Release Coreg Carvedilol (Various) 24 hr (Various) Corgard Nadolol (Various) Cardizem LA 180mg, Diltiazem ER (Various) Inderal Propranolol HCl (Various) 240mg, 300mg, 360mg, 420mg Inderal LA Propranolol HCl Capsule, Sustained Action Cardizem SR Diltiazem HCl Capsule, Sustained Release 24 hr (Various) 12 hr (Various) Innopran XL Propranolol HCl Capsule, Sustained Action Covera-HS Verapamil HCl Capsule, Sustained Release 24 hr (Various) 24 hr (Various) Kerlone Betaxolol HCl (Various) Dilacor XR Diltiazem XR (Various) Levatol Acebutolol HCl (Various) Isoptin S.R. Verapamil HCl Tablet, Sustained Action Atenolol (Various) (Various) Metoprolol Tartrate (Various) Nimotop Nimodipine (Various) Lopressor Metoprolol Tartrate (Various) Tiazac Diltiazem HCl Capsule, Sustained Release Sectral Acebutolol HCl (Various) 24 hr (Various) Tenormin Atenolol (Various) Verelan Verapamil HCl Capsule, Sustained Release Toprol XL Metoprolol Succinate (Various) 24 hr (Various) Trandate Labetalol HCl (Various) Verelan PM Verapamil HCl Capsule, Sustained Release Zebeta Bisoprolol Fumarate (Various) 24 hr (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 24 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 25

4. CARDIOVASCULAR, HYPERTENSION & LIPIDS (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 4.5.3.2 CALCIUM CHANNEL BLOCKERS/DIHYDROPYRIDINES 4.5.5 ADRENERGIC ANTAGONISTS & RELATED DRUGS GENERICS GENERICS Amlodipine Besylate (Norvasc) Clonidine HCl (Catapres) Felodipine (Plendil) Clonidine HCl (Catapres-TTS) Isradipine (DynaCirc) Doxazosin Mesylate (Cardura) Nifedipine (Adalat) Guanfacine HCl (Tenex) Nifedipine (Adalat CC) Methyldopa (Aldomet) Nifedipine (Procardia) Prazosin HCl (Minipress) Nifedipine (Procardia XL) Reserpine (Reserpine) Nisoldipine (Sular) Terazosin HCl (Hytrin)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Adalat CC Nifedipine ER (Various) Cardura Doxazosin Mesylate (Various) Amlodipine Besylate (Various) Catapres Clonidine HCl Tablet (Various) Nisoldipine (Various) Catapres-TTS Clonidine Patch (Various) Cardene SR Amlodipine Besylate (Various) Guanabenz Acetate Clonidine HCl (Various) Nifedipine ER (Various) Methyldopa (Various) Nisoldipine (Various) Hytrin Terazosin HCl Capsule (Various) DynaCirc CR Amlodipine Besylate (Various) Minipress Prazosin HCl (Various) 4 Nifedipine ER (Various) Nexiclon XR Clonidine HCl (Various)

Nisoldipine (Various) Tenex Guanfacine HCl (Various) Cardiovascular, Hypertension & Lipids Norvasc Amlodipine Besylate (Various) Wytensin Clonidine HCl (Various) Procardia XL Nifedipine ER (Various) Methyldopa (Various) Sular Nisoldipine (Various) Amlodipine Besylate (Various) FORMULARY PRODUCTS

Isradipine (Various) DRUG NAME Nifedipine ER (Various) 4.5.6 AGENTS FOR PHEOCHROMOCYTOMA BRANDS FORMULARY PRODUCTS Demser (Metyrosine) DRUG NAME Dibenzyline (Phenoxybenzamine HCl) 4.5.4 ACE INHIBITORS GENERICS FORMULARY PRODUCTS

Benazepril HCl (Lotensin) DRUG NAME Captopril (Capoten) 4.5.7 VASODILATORS Enalapril Maleate (Vasotec) Fosinopril Sodium (Monopril) GENERICS Lisinopril (Prinivil) Epoprostenol Sodium (Flolan) Lisinopril (Zestril) Hydralazine HCl (Apresoline) Moexipril HCl (Univasc) Minoxidil (Loniten) Perindopril Erbumine (Aceon) BRANDS Quinapril HCl (Accupril) BiDil (Isosorbide Dinitrate/Hydralazine HCl) Ramipril (Altace) Flolan (Epoprostenol Sodium) Trandolapril (Mavik) Remodulin (Treprostinil Sodium)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Accupril Quinapril (Various) Aceon Perindopril Erbumine (Various) Altace Ramipril (Various) Lotensin Benazepril HCl (Various) Mavik Trandolapril (Various) Monopril Fosinopril Sodium (Various) Prinivil Lisinopril (Various) Univasc Moexipril HCl (Various) Vasotec Enalapril Maleate (Various) Zestril Lisinopril (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 25 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 26

4. CARDIOVASCULAR, HYPERTENSION & LIPIDS (CONTINUED)

FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 4.5.8 OTHER ANTIHYPERTENSIVE COMBINATIONS 4.5.9 ANGIOTENSIN II RECEPTOR BLOCKERS & RENIN GENERICS INHIBITORS Amlodipine Besylate/Benazepril HCl (Lotrel) GENERICS Atenolol/Chlorthalidone (Tenoretic) Eprosartan Mesylate (Teveten 600mg) Benazepril HCl/Hydrochlorothiazide (Lotensin HCT) Irbesartan (Avapro) Bisoprolol Fumarate/Hydrochlorothiazide (Ziac) Irbesartan/Hydrochlorothiazide (Avalide) Captopril/Hydrochlorothiazide (Capozide) Losartan Potassium (Cozaar) Enalapril Maleate/Hydrochlorothiazide (Vaseretic) Losartan Potassium/Hydrochlorothiazide (Hyzaar) Fosinopril Sodium/Hydrochlorothiazide (Monopril HCT) Valsartan/Hydrochlorothiazide (Diovan HCT) Hydralazine HCl/Hydrochlorothiazide (Apresazide) BRANDS

Lisinopril/Hydrochlorothiazide (Prinzide) Amturnide (Aliskiren/Amlodipine/Hydrochlorothiazide) Lisinopril/Hydrochlorothiazide (Zestoretic) Atacand (Candesartan Cilexetil) Methyldopa/Hydrochlorothiazide (Aldoril) Atacand HCT (Candesartan Cilexetil/Hydrochlorothiazide) Metoprolol Tartrate/Hydrochlorothiazide (Lopressor HCT) Benicar (Olmesartan Medoxomil)

Moexipril/Hydrochlorothiazide (Uniretic) Benicar HCT (Olmesartan Medoxomil/Hydrochlorothiazide) Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Propranolol HCl/Hydrochlorothiazide (Inderide) Diovan (Valsartan) Quinapril HCl/Hydrochlorothiazide (Accuretic) Micardis (Telmisartan)

Trandolapril/Verapamil (Tarka) Micardis HCT (Telmisartan/Hydrochlorothiazide) BRANDS Tekamlo (Aliskiren/Amlodipine) Azor (Amlodipine Besylate/Olmesartan) Tekturna (Aliskiren Hemifumarate) Exforge (Amlodipine/Valsartan) Tekturna HCT (Aliskiren/Hydrochlorothiazide) Exforge HCT (Amlodipine/Valsartan/HCTZ) Valturna (Aliskiren/Valsartan) Tarka (Trandolapril/Verapamil) Tribenzor (Olmesartan Medoxomil/Amlodipine/HCTZ) Twynsta (Telmisartan/Amlodipine) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES

Avalide Irbesartan/Hydrochlorothiazide (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Avapro Irbesartan (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Cozaar Losartan Potassium (Various) Accuretic Quinapril/Hydrochlorothiazide (Various) Diovan HCT Valsartan/Hydrochlorothiazide (Various) Clorpres Clonidine HCl (Various) Edarbi Losartan Potassium (Various) Chlorthalidone (Various) Atacand (AstraZeneca) Corzide Bisoprolol Fumarate/HCTZ (Various) Benicar (Daiichi Sankyo) Metoprolol-Hydrochlorothiazide (Various) Diovan (Novartis) Propranolol HCl w/HCTZ (Various) Micardis (Boehringer Ingelheim) Dutoprol Hydrochlorothiazide (Various) Edarbyclor Irbesartan/Hydrochlorothiazide (Various) Metoprolol Succinate (Various) Losartan Potassium/Hydrochlorothiazide Lopressor HCT Metoprolol-Hydrochlorothiazide (Various) (Various) Lotensin HCT Benazepril HCl/Hydrochlorothiazide Valsartan/Hydrochlorothiazide (Various) (Various) Atacand HCT (AstraZeneca) Lotrel Amlodipine Besylate/Benazepril HCl Benicar HCT (Daiichi Sankyo) (Various) Micardis HCT (Boehringer Ingelheim) Prinzide Lisinopril-HCTZ (Various) Hyzaar Losartan Potassium/Hydrochlorothiazide Tenoretic Atenolol/Chlorthalidone (Various) (Various) Uniretic Moexipril/HCTZ (Various) Teveten Losartan Potassium (Various) Vaseretic Enalapril Maleate/HCTZ (Various) Atacand (AstraZeneca) Zestoretic Lisinopril-HCTZ (Various) Benicar (Daiichi Sankyo) Ziac Bisoprolol Fumarate/HCTZ (Various) Diovan (Novartis)

Micardis (Boehringer Ingelheim) Teveten HCT Losartan Potassium/Hydrochlorothiazide (Various) Valsartan/Hydrochlorothiazide (Various) Atacand HCT (AstraZeneca) Benicar HCT (Daiichi Sankyo) Micardis HCT (Boehringer Ingelheim)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 26 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 27

4. CARDIOVASCULAR, HYPERTENSION & LIPIDS (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

4.6 Lipid/Cholesterol Lowering Agents FORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME DRUG NAME POSSIBLE FORMULARY ALTERNATIVES GENERICS Advicor Atorvastatin Calcium (Various) Atorvastatin Calcium (Lipitor) Lovastatin (Various) Cholestyramine/Aspartame (Questran Light) Pravastatin (Various) Cholestyramine/Sucrose (Questran) Simvastatin (Various) Fenofibrate, Micronized (Lofibra) Crestor (AstraZeneca) Fluvastatin Sodium (Lescol) Niaspan (Abbott Laboratories) Gemfibrozil (Lopid) Vytorin (Merck/Schering-Plough) Lovastatin (Mevacor) Caduet Amlodipine Besylate (Various) Pravastatin Sodium (Pravachol) Atorvastatin Calcium (Various) Simvastatin (Zocor) Colestid Cholestyramine (Various) BRANDS Welchol (Daiichi Sankyo) Altoprev (Lovastatin) Fibricor Fenofibrate (Various) Antara (Fenofibrate, Micronized) Tricor (Abbott Laboratories) Crestor (Rosuvastatin Calcium) Triglide (Sciele Pharma I) Fenoglide (Fenofibrate) Trilipix (Abbott Laboratories) Lipofen (Fenofibrate) Lescol Fluvastatin Sodium (Various) Lovaza (Omega-3 Acid Ethyl Esters) Lescol XL Atorvastatin Calcium (Various) Niaspan (Niacin) Lovastatin (Various) Simcor (Niacin/Simvastatin) Simvastatin (Various) Tricor (Fenofibrate, Nanocrystallized) Altoprev (Sciele Pharma I) 4 Triglide (Fenofibrate) Crestor (AstraZeneca) Trilipix (Fenofibrate Acid) Vytorin (Merck/Schering-Plough) Cardiovascular, Hypertension & Lipids Vytorin (Ezetimibe/Simvastatin) Lipitor Atorvastatin Calcium (Various) Welchol (Colesevelam HCl) Livalo Atorvastatin Calcium (Various) Zetia (Ezetimibe) Lovastatin (Various) Pravastatin (Various) Simvastatin (Various) Crestor (AstraZeneca) Lofibra Fenofibrate (Various) Tricor (Abbott Laboratories) Triglide (Sciele Pharma I) Trilipix (Abbott Laboratories) Lopid Gemfibrozil (Various) Mevacor Lovastatin (Various) Pravachol Pravastatin Sodium (Various) Questran Cholestyramine (Various) Prevalite (Various) Questran Light Cholestyramine Light (Various) Prevalite (Various) Zocor Simvastatin (Various)

4.7 Miscellaneous Cardiovascular Agents FORMULARY PRODUCTS DRUG NAME BRANDS Ranexa (Ranolazine)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 27 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 28

5. DERMATOLOGICALS/TOPICAL THERAPY

5.1 Topical Corticosteroids FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 5.1.1 TOPICAL CORTICOSTEROIDS VERY HIGH POTENCY 5.1.3 TOPICAL CORTICOSTEROIDS MEDIUM POTENCY GENERICS GENERICS Betamethasone Dipropionate/Propylene Glycol (Diprolene) Betamethasone Valerate (Betatrex) Clobetasol Propionate (Clobex) Desoximetasone (Topicort LP) Clobetasol Propionate (Olux) Fluocinolone Acetonide (Synalar) Clobetasol Propionate (Temovate) Fluticasone Propionate (Cutivate) Clobetasol Propionate/Emollient (Temovate-E) Hydrocortisone Butyrate (Locoid) Diflorasone Diacetate (Psorcon) Hydrocortisone Valerate (Westcort) Halobetasol Propionate (Ultravate) Mometasone Furoate (Elocon) BRANDS Triamcinolone Acetonide (Kenalog) Clobex (Clobetasol Propionate) BRANDS Ultravate PAC (Halobetasol Propionate/Ammonium Lactate) Cordran (Flurandrenolide Tape, Medicated) Kenalog (Triamcinolone Acetonide) Locoid (Hydrocortisone Butyrate Lotion) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Locoid Lipocream (Hydrocortisone Butyrate/Emollient) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Diprolene Betamethasone DP Augmented (Various) Olux Clobetasol Propionate (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Clobex (Galderma) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Olux-E Clobetasol Propionate (Various) Cloderm Betamethasone Valerate Cream (Various) Clobex (Galderma) Cordran Lotion Betamethasone Valerate Lotion (Various) Olux-Olux-E Clobetasol Propionate (Various) Triamcinolone Acetonide Lotion (Various) Clobex (Galderma) Cordran SP Betamethasone Valerate Cream (Various) Psorcon Diflorasone Diacetate (Various) Desoximetasone Cream (Various) Temovate Clobetasol Propionate (Various) Fluocinolone Acetonide Cream (Various) Ultravate Halobetasol Propionate (Various) Hydrocortisone Valerate Cream (Various) Triamcinolone Acetonide Cream (Various) Cutivate Fluticasone Propionate (Various) FORMULARY PRODUCTS

DRUG NAME Dermatop Betamethasone Valerate (Various) 5.1.2 TOPICAL CORTICOSTEROIDS HIGH POTENCY Fluocinolone Acetonide (Various) Fluticasone Propionate (Various) GENERICS Hydrocortisone Butyrate (Various) Amcinonide (Cyclocort) Hydrocortisone Valerate (Various) Betamethasone Dipropionate (Diprolene) Triamcinolone Acetonide (Various) Betamethasone Dipropionate (Diprosone) Elocon Mometasone Furoate (Various) Betamethasone Dipropionate/Propylene Glycol (Diprolene AF) Locoid Cream Hydrocortisone Butyrate (Various) Betamethasone Valerate (Betatrex) Locoid Ointment Hydrocortisone Butyrate (Various) Desoximetasone (Topicort) Locoid Solution Hydrocortisone Butyrate (Various) Diflorasone Diacetate (Psorcon) Luxiq Hydrocortisone Butyrate Cream (Various) Fluocinonide (Lidex) Triamcinolone Acetonide Cream (Various) Fluocinonide/Emollient (Lidex-E) Triamcinolone Acetonide Lotion (Various) Triamcinolone Acetonide (Aristocort) Pandel Betamethasone Valerate Cream (Various) BRANDS Desoximetasone Cream (Various) Halog (Halcinonide) Fluocinolone Acetonide Cream (Various) Hydrocortisone Valerate Cream (Various) Triamcinolone Acetonide Cream (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Westcort Hydrocortisone Valerate (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Diprolene Betamethasone Dipropionate (Various) Diprolene AF Betamethasone Dipropionate (Various) FORMULARY PRODUCTS Lidex Fluocinonide (Various) DRUG NAME Psorcon Cream Diflorasone Diacetate Cream (Various) 5.1.4 TOPICAL CORTICOSTEROIDS LOW POTENCY Vanos Betamethasone DP Augmented (Various) GENERICS Clobetasol Propionate (Various) Alclometasone Dipropionate (Aclovate) Diflorasone Diacetate (Various) Desonide (DesOwen) Fluocinolone Acetonide (Derma-Smoothe FS) Fluocinolone Acetonide (Synalar) Hydrocortisone (Hytone) BRANDS Capex Shampoo (Fluocinolone Acetonide)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 28 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 29

5. DERMATOLOGICALS/TOPICAL THERAPY (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Aclovate Alclometasone Dipropionate (Various) Akne-Mycin Erythromycin (Various) Derma-Smoothe FS Fluocinolone Acetonide Solution (Various) Benzaclin Clindamycin Phosphate/Benzoyl Peroxide Capex Shampoo (Galderma) (Various) Desonate Desonide (Various) Benzamycin Erythromycin-Benzoyl Peroxide (Various) DesOwen Desonide (Various) Benzamycin Pak Erythromycin-Benzoyl Peroxide (Various) Verdeso Desonide (Various) Clindamycin Phosphate/Benzoyl Peroxide (Various) Acanya (Valeant) 5.2 Topical Anesthetics Duac (Stiefel Laboratories) FORMULARY PRODUCTS Benziq Benzoyl Peroxide (Various) DRUG NAME Brevoxyl Benzoyl Peroxide (Various) GENERICS Clenia Cream Sodium Sulfacetamide/Sulfur (Various) Hydrocortisone Acetate/Lidocaine HCl (Lida Mantle HC) Cleocin T Clindamycin Phosphate (Various) Lidocaine HCl (Lida Mantle) Clindagel Clindamycin Phosphate (Various) Lidocaine HCl (Xylocaine) Desquam-X Benzoyl Peroxide (Various)

BRANDS Evoclin Clindamycin Phosphate (Various) Lidoderm (Lidocaine) Metrocream Metronidazole Cream (Various) Metrolotion Metronidazole Lotion (Various)

Noritate Metronidazole (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Metrogel (Graceway Pharmaceuticals, DRUG NAME POSSIBLE FORMULARY ALTERNATIVES LLC) 5 Emla Cream Lidocaine-Prilocaine (Various) Plexion Sodium Sulfacetamide/Sulfur (Various) Lida Mantle HC Hydrocortisone (Various) Plexion SCT Sodium Sulfacetamide/Sulfur (Various) Lidocaine HCl (Various) Retin-A Tretinoin (Various) Dermatologicals/Topical Therapy Retin-A Micro Tretinoin Gel (Various) Differin (Galderma) 5.3 Therapy For Acne Retin-A Micro Pump Tretinoin Gel (Various) FORMULARY PRODUCTS Differin (Galderma) DRUG NAME Rosac Sodium Sulfacetamide/Sulfur (Various) GENERICS Rosanil Sodium Sulfacetamide/Sulfur (Various) Adapalene (Differin) Rosula Sodium Sulfacetamide/Sulfur (Various) Benzoyl Peroxide (Benzagel) Rosula CLK Sodium Sulfacetamide/Sulfur/Sunscreen Clindamycin Phosphate (Cleocin T) (Various) Clindamycin Phosphate/Benzoyl Peroxide (Benzaclin) Triaz Benzoyl Peroxide (Various) Clindamycin Phosphate/Benzoyl Peroxide (Duac) Vanoxide-HC Benzoyl Peroxide (Various) Erythromycin Base/Benzoyl Peroxide (Benzamycin) Ziana Clindamycin Phosphate (Various) Erythromycin Base/Ethyl Alcohol (A/T/S) Tretinoin (Various) Erythromycin Base/Ethyl Alcohol (Erycette) Zoderm Benzoyl Peroxide/Urea (Various)

Isotretinoin (Accutane) Metronidazole (Metrocream) 5.4 Topical Antibacterials Metronidazole (Metrolotion) Sulfacetamide Sodium/Sulfur (Sulfacet-R) FORMULARY PRODUCTS Tretinoin (Retin-A) DRUG NAME BRANDS GENERICS Acanya (Clindamycin Phosphate/Benzoyl Peroxide) Gentamicin Sulfate (Garamycin) Aczone (Dapsone) Mupirocin Ointment (Bactroban) Atralin (Tretinoin) Sulfacetamide Sodium (Klaron) Azelex (Azelaic Acid) Benzaclin (Clindamycin Phosphate/Benzoyl Peroxide/Hyaluronate Sodium) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Benzaclin Pump (Clindamycin Phosphate/Benzoyl Peroxide) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Differin (Adapalene) Altabax Mupirocin Ointment (Various) Duac (Clindamycin Phosphate/Benzoyl Peroxide) Bactroban Cream Gentamicin Sulfate Cream (Various) Duac CS (Clindamycin Phosphate/Benzoyl Peroxide) Bactroban Ointment Mupirocin Ointment (Various) Epiduo (Adapalene/Benzoyl Peroxide) Centany Mupirocin Ointment (Various) Finacea (Azelaic Acid) Klaron Sulfacetamide Sodium (Various) Metrogel 1% (Metronidazole) Sodium Sulfacetamide/Sulfur (Various) Tazorac (Tazarotene) Veltin (Clindamycin/Tretinoin)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 29 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 30

5. DERMATOLOGICALS/TOPICAL THERAPY (CONTINUED)

5.5 Topical Antifungals 5.7 Burn Therapy FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME GENERICS GENERICS Ciclopirox (Loprox) Silver Sulfadiazine (Silvadene) Ciclopirox (Penlac) Clotrimazole/Betamethasone Dipropionate (Lotrisone) Econazole Nitrate (Spectazole) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Ketoconazole (Extina) Silvadene Silver Sulfadiazine (Various) Ketoconazole (Nizoral) Nystatin (Mycostatin) Nystatin/Triamcinolone Acetonide (Mycolog II) 5.8 Topical Enzymes BRANDS Exelderm (Sulconazole Nitrate) FORMULARY PRODUCTS DRUG NAME Mentax (Butenafine HCl) GENERICS Trypsin/Balsam Peru/Castor Oil (Granulex) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS BRANDS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES

Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Santyl (Collagenase Clostridium Hist.) Ertazco Econazole Nitrate (Various) Ketoconazole (Various) Nystatin (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Extina Ketoconazole Foam (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Lamisil Cream Econazole Nitrate (Various) Granulex Santyl (Healthpoint) Ketoconazole (Various) Xenaderm Santyl (Healthpoint)

Nystatin (Various) Loprox Cream Econazole Nitrate Cream (Various) 5.10 Antipsoriatic/Antiseborrheic Ketoconazole Cream (Various) Nystatin Cream (Various) FORMULARY PRODUCTS Loprox Gel Econazole Nitrate Cream (Various) DRUG NAME Ketoconazole Cream (Various) GENERICS Nystatin Cream (Various) Calcipotriene (Dovonex) Loprox Shampoo Selenium Sulfide Shampoo (Various) Hydrocortisone Acetate/Pramoxine HCl (Pramosone) Capex Shampoo (Galderma) Selenium Sulfide (Selsun Rx) Lotrimin Clotrimazole (Various) Sulfacetamide Sodium (Ovace) Lotrisone Clotrimazole/Betamethasone (Various) BRANDS Monistat-Derm Econazole Nitrate (Various) Drithocreme HP (Anthralin) Ketoconazole (Various) Dritho-Scalp (Anthralin) Nystatin (Various) Pramosone (Hydrocortisone Acetate/Pramoxine HCl) Naftin Econazole Nitrate (Various) Pramosone E (Hydrocortisone Acetate/Pramoxine HCl/Emollient) Ketoconazole (Various) Soriatane (Acitretin) Nystatin (Various) Soriatane CK (Acitretin) Nizoral Cream Ketoconazole Cream (Various) Stelara (Ustekinumab) Nizoral Shampoo Ketoconazole Shampoo (Various) Tazorac (Tazarotene) Oxistat Econazole Nitrate (Various) Vectical (Calcitriol)

Ketoconazole (Various) Nystatin (Various) Penlac Ciclopirox Solution (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Spectazole Econazole Nitrate (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Xolegel Ketoconazole Cream (Various) Amevive Methotrexate Sodium Tablet (Various) Enbrel (Amgen) Dovonex Calcipotriene (Various) 5.6 Topical Antivirals Ovace Sodium Sulfacetamide (Various) Rosula NS Sodium Sulfacetamide/Sulfur (Various) FORMULARY PRODUCTS DRUG NAME Sorilux Calcipotriene (Various) BRANDS Taclonex Betamethasone Dipropionate (Various) Zovirax (Acyclovir) Calcipotriene (Various) Taclonex Scalp Betamethasone Dipropionate Lotion (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Calcipotriene Solution (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Denavir Zovirax (Biovail) Xerese Zovirax (Biovail)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 30 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 31

5. DERMATOLOGICALS/TOPICAL THERAPY (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

5.11 Topical Scabicides/Pediculicides 5.12 Miscellaneous Dermatologicals FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME GENERICS GENERICS Malathion (Ovide) Aluminum Chloride (Drysol) Permethrin (Elimite) Ammonium Lactate (Lac-Hydrin) Spinosad (Natroba) Dioxybenzone/Padimate O/Hydroquinone (Solaquin Forte) BRANDS Fluorouracil (Efudex) Eurax (Crotamiton) Hydroquinone (Eldoquin Forte) Natroba (Spinosad) Hydroquinone (Lustra) Ulesfia (Benzyl Alcohol) Hydroquinone/Ferric Oxide (Eldopaque Forte) Imiquimod (Aldara) Podofilox (Condylox) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Urea (Carmol 40) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES BRANDS Elimite Permethrin (Various) Carac (Fluorouracil) Lindane Malathion (Various) Condylox (Podofilox) Permethrin (Various) Efudex (Fluorouracil Cream) Ulesfia (Shionogi Pharma) Elidel (Pimecrolimus) Nix Liquid 1% Permethrin (Various) Oxsoralen (Methoxsalen) Malathion (Various) Oxsoralen-Ultra (Methoxsalen, Rapid) Ovide Malathion (Various) Panretin (Alitretinoin) Sklice Malathion (Various) Picato (Ingenol Mebutate) Eurax (Ranbaxy) 5 Protopic (Tacrolimus) Natroba (Paraproy)

Ulesfia (Shionogi Pharma)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Dermatologicals/Topical Therapy DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Aldara Imiquimod (Various) Carmol 40 Urea (Various) Carmol HC Hydrocortisone (Various) Urea (Various) Drysol Aluminum Chloride (Various) Hypercare (Various) Efudex Solution Fluorouracil Solution (Various) Eldopaque Forte Melpaque HP (Stratus Pharmaceuticals) Keralac Urea (Various) Lac-Hydrin Ammonium Lactate (Various) Lactinol Lactic Acid Lotion (Various) Lactinol-E Lactic Acid Cream (Various) Lustra Hydroquinone (Various) Solaraze Imiquimod (Various) Umecta Urea (Various) Veregen Imiquimod (Various) Condylox (Watson Pharmaceuticals) Xerac AC Aluminum Chloride (Various) Hypercare (Various) Zonalon Alclometasone Dipropionate (Various) Desonide (Various) Fluocinolone Acetonide (Various) Hydrocortisone (Various) Zyclara Imiquimod (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 31 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 32

6. EAR, NOSE & THROAT MEDICATIONS

6.1 Intranasal Steroids 6.4 Miscellaneous Agents FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME GENERICS GENERICS Flunisolide (Nasalide) Azelastine HCl (Astelin) Fluticasone Propionate (Flonase) Chlorhexidine Gluconate (Peridex) Triamcinolone Acetonide (Nasacort AQ) Hydrocortisone Acetate/Lidocaine HCl (Lida Mantle HC) BRANDS Ipratropium Bromide (Atrovent) Nasonex (Mometasone Furoate) Lidocaine HCl (Xylocaine) Rhinocort Aqua (Budesonide) Lidocaine HCl (Lida Mantle) Veramyst (Fluticasone Furoate) Triamcinolone Acetonide (Kenalog in Orabase) BRANDS Astelin (Azelastine HCl) 6.2 Miscellaneous Otic Preparations Astepro (Azelastine HCl) FORMULARY PRODUCTS DRUG NAME COMMONLY PRESCRIBED NONFORMULARY PRODUCTS GENERICS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Acetic Acid (VoSol) Aphthasol Triamcinolone Acetonide Paste (Various) Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Acetic Acid/Aluminum Acetate (Domeboro) Atrovent Ipratropium Bromide (Various) Acetic Acid/Hydrocortisone (VoSol HC) Bactroban Nasal Mupirocin (Various) Antipyrine/Benzocaine/Glycerin (Otogesic) Gel-Kam Solution Stannous Fluoride Solution (Various) Benzocaine (Otocain) Patanase Desloratadine (Various) Fluocinolone Acetonide Oil (DermOtic) Fexofenadine HCl (Various) Hydrocortisone/Pramoxine HCl/Chloroxylenol/Water (Cortane-B) Astelin (Meda) Ofloxacin (Floxin) Astepro (Meda) Clarinex (Schering) Peridex Chlorhexidine Gluconate (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Phos-Flur Gel Sodium Fluoride Gel (Various) Cetraxal Ofloxacin (Various) Ciprodex (Alcon) Floxin Ofloxacin (Various)

6.3 Otic Steroid/Antibiotic FORMULARY PRODUCTS DRUG NAME GENERICS Neomycin Sulfate/Polymyxin B Sulfate/Hydrocortisone (Cortisporin) BRANDS Ciprodex (Ciprofloxacin HCl/Dexamethasone)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Cipro HC Ciprodex (Alcon) Coly-Mycin S Neomycin/Polymyxin/HC (Various) Ofloxacin (Various) Cortisporin Neomycin/Polymyxin/HC (Various) Cortisporin-TC Neomycin/Polymyxin/HC (Various) Ofloxacin (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 32 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 33

7. ENDOCRINE/DIABETES Preferred Prescriptions/Rx Selections Formulary

7.1 Antithyroid Agents 7.4 Miscellaneous Hormones FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME GENERICS 7.4.1 ANDROGENS Methimazole (Tapazole) GENERICS Propylthiouracil (Propylthiouracil) Danazol (Danocrine) Testosterone Cypionate (Depo-Testosterone) Testosterone Propionate (Testosterone Propionate) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES BRANDS Tapazole Methimazole (Various) Androderm (Testosterone) Androgel (Testosterone) Axiron (Testosterone) 7.2 Thyroid Hormones Fortesta (Testosterone) Methitest (Methyltestosterone) FORMULARY PRODUCTS DRUG NAME

GENERICS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Levothyroxine Sodium (Levothroid) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Liothyronine Sodium (Cytomel) Android Methitest (Various) Thyroid (Armour Thyroid) Depo-Testosterone Testosterone Cypionate (Various) Oxandrin Methyltestosterone (Various) Androxy (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Striant Androderm (Watson Pharmaceuticals) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES 6 Armour Thyroid Thyroid (Various) Androgel (Abbott Laboratories) Testim Androgel (Abbott Laboratories) Levothyroxine Sodium (Various) Axiron (Eli Lilly) Cytomel Liothyronine Sodium (Various)

Fortesta (Endo Pharm) Ear, Nose & Throat Medications Levothroid Levothyroxine Sodium (Various) Testred Methitest (Various) Synthroid Levothyroxine Sodium (Various) Thyrolar Levothyroxine Sodium (Various) Tirosint Levothyroxine Sodium (Various) FORMULARY PRODUCTS DRUG NAME 7.4.2 OVULATORY STIMULANTS 7.3 Adrenal Hormones GENERICS FORMULARY PRODUCTS Clomiphene Citrate (Clomid) DRUG NAME BRANDS GENERICS Bravelle (Urofollitropin (FSH)) Cortisone Acetate (Cortone Acetate) Follistim AQ (Follitropin Beta, Recombinant) Dexamethasone (Decadron) Menopur (Menotropins) Fludrocortisone Acetate (Florinef Acetate) Ovidrel (HCG Alpha, Recombinant) Hydrocortisone (Cortef) Repronex (Menotropins) Methylprednisolone (Medrol) Serophene (Clomiphene Citrate) Prednisolone Sodium Phosphate (Pediapred) Prednisolone Syrup (Prelone) Prednisolone Tablet (Prednisolone) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Prednisone (Deltasone) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Clomid Clomiphene Citrate (Various) BRANDS Acthar H.P. (Corticotropin) Gonal-F Follistim AQ (Organon) Gonal-F RFF Follistim AQ (Organon) Luveris Follistim AQ (Organon) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Repronex (Ferring Pharmaceuticals Inc) 7

DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Celestone Dexamethasone (Various) Methylprednisolone (Various) Prednisolone (Various) Cortef Hydrocortisone (Various)

Dexamethasone Drops Dexamethasone Elixir (Various) Endocrine/Diabetes Dexpak Dexamethasone (Various) Florinef Acetate Fludrocortisone Acetate (Various) Medrol Methylprednisolone (Various) Orapred Prednisolone Sodium Phosphate (Various) Orapred ODT Prednisolone Sodium Phosphate (Various) Pediapred Prednisolone Sodium Phosphate (Various) Prelone Prednisolone (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 33 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 34

7. ENDOCRINE/DIABETES (CONTINUED)

7.5 Diabetes Therapy FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 7.4.3 MISCELLANEOUS AGENTS 7.5.1 INSULIN THERAPY GENERICS BRANDS Cabergoline (Dostinex) Apidra (Insulin Glulisine) Calcitonin, Salmon, Synthetic (Miacalcin) Apidra Solostar (Insulin Glulisine) Calcitriol (Rocaltrol) Humalog (Insulin Lispro) Desmopressin Acetate (DDAVP) Humalog Mix 50/50 (Insulin NPL/Insulin Lispro) Desmopressin Acetate/Sodium Phosphate, Dibasic/Citric Acid (DDAVP) Humalog Mix 75/25 (Insulin NPL/Insulin Lispro) Octreotide Acetate Vial (Sandostatin) Humulin (Insulin Human Recombinant) BRANDS Lantus (Insulin Glargine, Human Recombinant Analog) Aldurazyme (Laronidase) Lantus Solostar (Insulin Glargine, Human Recombinant Analog)

Cerezyme (Imiglucerase) Levemir (Insulin Detemir) NovoLog (Insulin Aspart) Elaprase (Idursulfase)

Novolog Mix 70/30 (Insulin Aspart Protamine Human/Insulin Aspart) Fabrazyme (Agalsidase Beta) Hectorol (Doxercalciferol) Kuvan (Sapropterin Dihydrochloride) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS

Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Lumizyme (Alglucosidase Alfa) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Myozyme (Alglucosidase Alfa) Novolin 70/30 Humulin 70/30 (Eli Lilly and Company) Naglazyme (Galsulfase) Novolin 70/30 InnoLet Humulin 70/30 (Eli Lilly and Company) Samsca (Tolvaptan) Novolin N Humulin N (Eli Lilly and Company) Sandostatin LAR (Octreotide Acetate) Novolin N InnoLet Humulin N (Eli Lilly and Company) Sensipar (Cinacalcet HCl) Novolin R Humulin R (Eli Lilly and Company) Somavert (Pegvisomant) Novolin R InnoLet Humulin R (Eli Lilly and Company)

Stimate (Desmopressin Acetate) Synarel (Nafarelin Acetate) FORMULARY PRODUCTS VPRIV (Velaglucerase Alfa) DRUG NAME Zemplar (Paricalcitol) 7.5.2 NON-INSULIN HYPOGLYCEMIC AGENTS GENERICS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Acarbose (Precose) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Acetohexamide (Acetohexamide) DDAVP Aerosol, Spray w/Pump Desmopressin Acetate Aerosol, Spray w/Pump Chlorpropamide (Diabinese) (Various) Glimepiride (Amaryl) DDAVP Desmopressin Acetate (Various) Glipizide (Glucotrol) Miacalcin Calcitonin-Salmon (Various) Glipizide (Glucotrol XL) Zavesca Cerezyme (Genzyme) Glipizide/Metformin HCl (Metaglip) Glyburide (DiaBeta) Glyburide (Micronase) FORMULARY PRODUCTS Glyburide, Micronized (Glynase) DRUG NAME Glyburide/Metformin HCl (Glucovance) 7.4.4 GONADOTROPIN & RELATED AGENTS Metformin HCl (Glucophage) GENERICS Metformin HCl (Glucophage XR) Gonadotropin, Chorionic, Human (Novarel) Nateglinide (Starlix) BRANDS Pioglitazone HCl (Actos) Cetrotide (Cetrorelix Acetate) Pioglitazone HCl/Metformin HCl (Actoplus Met) Tolazamide (Tolinase)

Tolbutamide (Orinase) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS BRANDS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Avandamet (Rosiglitazone Maleate/Metformin HCl) Ganirelix Acetate Cetrotide (Serono Inc) Avandaryl (Rosiglitazone Maleate/Glimepiride) Novarel Chorionic Gonadotropin (Various) Avandia (Rosiglitazone Maleate)

Bydureon (Exenatide Microspheres) Byetta (Exenatide) Duetact (Pioglitazone HCl/Glimepiride) Janumet (Sitagliptin Phosphate/Metformin HCl) Janumet XR (Sitagliptin Phosphate/Metformin HCl) Januvia (Sitagliptin Phosphate) Jentadueto (Linagliptin/Metformin) Kombiglyze XR (Saxagliptin HCl/Metformin HCl) Onglyza (Saxagliptin HCl) Prandin (Repaglinide) Riomet (Metformin HCl) Symlin (Pramlintide Acetate) Tradjenta (Linagliptin) Weigh risk of birth defects and other adverse outcomes. Victoza (Liraglutide) Do not use during pregnancy. 34 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 35

7. ENDOCRINE/DIABETES (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES DRUG NAME Actoplus Met Pioglitazone/Metformin (Various) 7.5.4 INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL Actoplus Met XR Metformin HCl ER (Various) EQUIPMENT Pioglitazone HCl (Various) BRANDS Actos Pioglitazone HCl (Various) Accu-Chek Active (Blood-Glucose Measuring Equipment Kit) Amaryl Glimepiride (Various) Accu-Chek Advantage (Blood-Glucose Measuring Equipment Kit) Cycloset Metformin HCl (Various) Accu-Chek Aviva (Blood-Glucose Measuring Equipment Kit) Byetta (Amylin Pharma) Accu-Chek Aviva Plus (Blood-Glucose Measuring Equipment Kit) Janumet (Merck) Accu-Chek Compact Plus (Blood-Glucose Measuring Equipment Kit) Januvia (Merck) Accu-Chek Multiclix (Lancets) Onglyza (Bristol-Myers Squibb) Accu-Chek Nano Smartview (Blood-Glucose Measuring Equipment Kit) DiaBeta Glyburide (Various) Accu-Chek Softclix (Lancets) Fortamet Metformin HCl ER (Various) Accu-Chek Soft Touch (Lancets) Metformin HCl Tablet (Various) B-D Insulin Syringe (Syringe w-Needle, Disposable, Insulin) Glucophage Metformin HCl (Various) Lancets (Lancets) Glucophage XR Metformin HCl ER (Various) Novofine (Needles, Insulin Disposable) Metformin HCl Tablet (Various) Novotwist (Needles, Insulin Disposable) Glucotrol Glipizide (Various) One Touch Basic System (Blood-Glucose Measuring Equipment Kit) Glucotrol XL Glipizide ER (Various) One Touch Ultra 2 (Blood-Glucose Measuring Equipment Kit) Glucovance Glyburide-Metformin HCl (Various) One Touch Ultra Smart (Blood-Glucose Measuring Equipment Kit) Glumetza Metformin HCl ER (Various) One Touch Ultra System (Blood-Glucose Measuring Equipment Kit) Glynase Glyburide Micronized (Various) 7 One Touch Ultramini (Blood-Glucose Measuring Equipment Kit) Glyset Acarbose (Various) One Touch Verio IQ (Blood-Glucose Measuring Equipment Kit) Juvisync Simvastatin (Various) Pen Needle (Needles, Insulin Disposable) Januvia (Merck) Surestep (Blood-Glucose Measuring Equipment Kit) Metaglip Glipizide-Metformin (Various) Surestep Pro (Blood-Glucose Measuring Equipment Kit) Prandimet Metformin HCl (Various)

Endocrine/Diabetes Prandin (Novo Nordisk) Precose Acarbose (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Starlix Nateglinide (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Allergist Syringe/Needle B-D Insulin Syringe (Becton Dickinson) Monoject Insulin Syringe B-D Insulin Syringe (Becton Dickinson) FORMULARY PRODUCTS Ultra Comfort B-D Insulin Syringe (Becton Dickinson) DRUG NAME 7.5.3 GLUCOSE ELEVATING AGENTS BRANDS FORMULARY PRODUCTS Glucagon (Glucagon, Human Recombinant) DRUG NAME 7.5.5 BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES GENERICS Alcohol Antiseptic Pads (Alcohol Prep) BRANDS Accu-Chek Active (Blood Sugar Diagnostic Strip) Accu-Chek Aviva (Blood Sugar Diagnostic Strip) Accu-Chek Aviva Plus (Blood Sugar Diagnostic Strip) Accu-Chek Comfort Curve (Blood Sugar Diagnostic Strip) Accu-Chek Compact (Blood Sugar Diagnostic Strip) Accu-Chek Smartview (Blood Sugar Diagnostic Strip) Chemstrip K (Blood Sugar Diagnostic Strip) Fast Take (Blood Sugar Diagnostic Strip) One Touch Test Strips (Blood Sugar Diagnostic Strip) One Touch Ultra Test Strips (Blood Sugar Diagnostic Strip) One Touch Verio (Blood Sugar Diagnostic Strip) Surestep (Blood Sugar Diagnostic Strip) Surestep Pro (Blood Sugar Diagnostic Strip)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 35 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 36

8. GASTROENTEROLOGY

8.1 Ulcer Therapy FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 8.1.1 H2 ANTAGONISTS 8.1.4 PROTON PUMP INHIBITORS GENERICS GENERICS Cimetidine HCl Liquid (Tagamet) Lansoprazole (Prevacid) Cimetidine Tablet (Tagamet) Omeprazole (Prilosec Rx) Famotidine (Pepcid) Omeprazole/Sodium Bicarbonate (Zegerid Rx) Nizatidine (Axid) Pantoprazole Sodium (Protonix) Ranitidine HCl (Zantac Rx) BRANDS BRANDS Nexium (Esomeprazole Magnesium Trihydrate) Axid Oral Solution (Nizatidine)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Aciphex Omeprazole (Various) Axid Pulvule Nizatidine (Various) Nexium (AstraZeneca) Pepcid Famotidine (Various) Dexilant Omeprazole (Various)

Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Pepcid Suspension Famotidine Tablet (Various) Nexium (AstraZeneca) Cimetidine Liquid (Various) Prevacid Lansoprazole (Various) Axid Oral Solution (Braintree Omeprazole (Various) Laboratories) Nexium (AstraZeneca) Tagamet Cimetidine (Various) Prilosec Rx Omeprazole (Various) Zantac Rx Ranitidine HCl (Various) Nexium (AstraZeneca) Zantac Rx Syrup Ranitidine HCl (Various) Protonix Suspension Nexium Suspension (AstraZeneca) Axid Oral Solution (Braintree Protonix Tablet Pantoprazole Sodium (Various) Laboratories) Omeprazole (Various) Nexium (AstraZeneca) Zegerid Omeprazole/Sodium Bicarbonate (Various) FORMULARY PRODUCTS

DRUG NAME Omeprazole (Various) Nexium (AstraZeneca) 8.1.2 PROSTAGLANDINS GENERICS Misoprostol (Cytotec) 8.2 Antidiarrheals & Antispasmodics

FORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME DRUG NAME POSSIBLE FORMULARY ALTERNATIVES 8.2.1 ANTIDIARRHEALS Cytotec Misoprostol (Various) GENERICS

Diphenoxylate HCl/Atropine Sulfate (Lomotil) FORMULARY PRODUCTS Loperamide HCl (Imodium) DRUG NAME Paregoric (Paregoric) 8.1.3 OTHER ULCER THERAPY BRANDS GENERICS Motofen (Difenoxin HCl/Atropine Sulfate) Sucralfate Tablet (Carafate) BRANDS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Carafate (Sucralfate Suspension, Oral) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Pylera (Bismuth/Metronid/Tetracycline) Lomotil Diphenoxylate w/Atropine (Various) Opium Tincture Diphenoxylate w/Atropine (Various)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Carafate Tablet Sucralfate (Various) Helidac Metronidazole (Various) Tetracycline HCl (Various) Prevpac Omeprazole (Various) Amoxicillin (Various) Clarithromycin (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 36 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 37

8. GASTROENTEROLOGY (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 8.2.2 ANTISPASMODICS 8.3.2 DIGESTIVE ENZYMES GENERICS GENERICS Dicyclomine HCl (Bentyl) Amylase/Lipase/Protease (Creon) Glycopyrrolate (Robinul) Amylase/Lipase/Protease (Pancrease) Hyoscyamine Sulfate (Levbid) Amylase/Lipase/Protease (Pancrease MT) Hyoscyamine Sulfate (Levsin) Amylase/Lipase/Protease (Ultrase) Hyoscyamine Sulfate (Levsin/SL) Amylase/Lipase/Protease (Ultrase MT) Hyoscyamine Sulfate (Nulev) BRANDS Methscopolamine Bromide (Pamine) Creon (Amylase/Lipase/Protease) BRANDS Pancrease MT 12K-4K-12K (Amylase/Lipase/Protease) Levbid (Hyoscyamine Sulfate) Ultrase (Amylase/Lipase/Protease) Ultrase MT (Amylase/Lipase/Protease) Viokase (Amylase/Lipase/Protease) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Zenpep (Amylase/Lipase/Protease) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Bentyl Dicyclomine HCl (Various) Cantil Belladonna w/Phenobarbital (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Cuvposa Glycopyrrolate (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Levsin Hyoscyamine Sulfate (Various) Pancrease Pancrelipase (Various) Levsin-SL Hyoscyamine Sulfate (Various) Creon (Solvay Pharmaceuticals) Nulev Hyoscyamine Sulfate (Various) Ultrase (Axcan Scandipha) 8 Pamine Methscopolamine Bromidel (Various) Pancrease MT 30-10-30, Creon (Solvay Pharmaceuticals) Pamine Forte Methscopolamine Bromidel (Various) 48-16-48, 56-20-44 Ultrase (Axcan Scandipha) Robinul Belladonna w/Phenobarbital (Various) Robinul Forte Dicyclomine HCl (Various) Hyoscyamine Sulfate (Various)

Symax Duotab Hyoscyamine Sulfate Tablet, Sustained Gastroenterology Release 12hr (Various)

FORMULARY PRODUCTS DRUG NAME 8.2.3 COMBINATION ANTICHOLINERGICS GENERICS Phenobarbital/Hyoscyamine/Atropine/Scop (Donnatal) Clidinium Bromide/Chlordiazepoxide (Librax)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Donnatal Belladonna w/Phenobarbital (Various)

8.3 Miscellaneous Gastrointestinal Agents FORMULARY PRODUCTS DRUG NAME 8.3.1 BILE ACIDS GENERICS Ursodiol (Actigall) Ursodiol (Urso) Ursodiol (Urso Forte)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Actigall Ursodiol (Various) Chenodal Ursodiol (Various) Urso Ursodiol (Various) Urso Forte Ursodiol (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 37 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 38

8. GASTROENTEROLOGY (CONTINUED)

FORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME DRUG NAME POSSIBLE FORMULARY ALTERNATIVES 8.3.3 MISCELLANEOUS GASTROINTESTINAL AGENTS Anamantle HC Lidocaine/Hydrocortisone (Various) GENERICS Anamantle HC Forte Lidocaine/Hydrocortisone (Various) Balsalazide Disodium (Colazal) Azulfidine Sulfasalazine (Various) Budesonide (Entocort EC) Cimzia Enbrel (Amgen) Cromolyn Sodium (Gastrocrom) Humira (Abbott Laboratories) Hydrocortisone (ProctoCream-HC) Remicade (Centocor) Hydrocortisone (Cortenema) Colazal Balsalazide Disodium (Various) Hydrocortisone Acetate (Anusol-HC) Dipentum Balsalazide Disodium (Various) Hydrocortisone Acetate/Lidocaine HCl (Anamantle HC) Sulfasalazine (Various) Hydrocortisone Acetate/Pramoxine HCl (Analpram-HC) Apriso (Salix Pharmaceuticals) Lactulose (Cephulac) Asacol (Procter & Gamble Lactulose (Chronulac) Pharmaceuticals) Mesalamine (Asacol) Pentasa (Shire US Inc.) Mesalamine (Rowasa) Entocort EC Budesonide EC (Various) Metoclopramide HCl (Reglan) Gastrocrom Cromolyn Sodium (Various)

Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Sulfasalazine (Azulfidine) Lialda Balsalazide Disodium (Various)

BRANDS Apriso (Salix Pharmaceuticals) Amitiza (Lubiprostone) Asacol (Procter & Gamble Pharmaceuticals) Analpram Advanced (Hydrocortisone Acetate/Pramoxine/Diosmin/Aloe/Policosanol) Canasa (Axcan) Pentasa (Shire US Inc.) Analpram E (Hydrocortisone Acetate/Pramoxine HCl/Emollient) Metozolv ODT Metoclopramide HCl (Various) Analpram-HC (Hydrocortisone Acetate/Pramoxine HCl) Osmoprep Peg 3350/Electrolyte (Various) Anusol-HC (Hydrocortisone) Polyethylene Glycol (Various) Apriso (Mesalamine) Halflytely (Braintree Laboratories) Asacol (Mesalamine) Reglan Metoclopramide HCl (Various) Asacol HD (Mesalamine) Rowasa Mesalamine Enema (Various) Canasa (Mesalamine) Visicol Peg 3350/Electrolyte (Various) Cortifoam (Hydrocortisone Acetate) Polyethylene Glycol (Various) Cystadane (Betaine) GoLYTELY (Braintree Laboratories) Kristalose (Lactulose) Halflytely (Braintree Laboratories) Lotronex (Alosetron HCl) NuLytely (Braintree Laboratories) Pentasa (Mesalamine) ProctoCream-HC (Hydrocortisone) ProctoFoam-HC (Hydrocortisone Acetate/Pramoxine HCl) Relistor (Methylnaltrexone Bromide) Remicade (Infliximab)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 38 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 39

8. GASTROENTEROLOGY (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

FORMULARY PRODUCTS DRUG NAME 8.3.4 ANTIVERTIGO & ANTIEMETIC AGENTS GENERICS Granisetron HCl (Kytril) Meclizine HCl (Antivert) Ondansetron (Zofran ODT) Ondansetron HCl (Zofran) Prochlorperazine Maleate (Compazine) Promethazine HCl (Phenergan) Trimethobenzamide HCl (Tigan) BRANDS Anzemet (Dolasetron Mesylate Tablet) Emend (Aprepitant) Sancuso (Granisetron) Transderm-Scop (Scopolamine Hydrobromide)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Antivert Meclizine HCl (Various) Cesamet Dexamethasone (Various) Granisetron HCl (Various) 8 Metoclopramide HCl (Various) Ondansetron HCl (Various) Emend (Merck & Co.) Kytril Granisetron HCl (Various) Zofran Ondansetron HCl (Various)

Zofran ODT Ondansetron ODT (Various) Gastroenterology

FORMULARY PRODUCTS DRUG NAME 8.3.5 BOWEL EVACUANTS GENERICS Sodium Sulfate/Sodium/Sodium Bicarbonate/Potassium Chloride/Polyethylene Glycols (GoLYTELY) Sodium Sulfate/Sodium/Sodium Bicarbonate/Potassium Chloride/Polyethylene Glycols (Colyte) BRANDS Colyte 227.1-21.5 (Sodium Sulfate/Sodium/Sodium Bicarbonate/Potassium Chloride/Polyethylene Glycols) GoLYTELY (Sodium Sulfate/Sodium/Sodium Bicarbonate/Potassium Chloride/Polyethylene Glycols) Halflytely (Bisacodyl/Sodium Chloride/Sodium Bicarbonate/Potassium Chloride/Polyethylene Glycol 3350) NuLytely (Sodium Chloride/Sodium Bicarbonate/Potassium Chloride/Polyethylene Glycols) Suprep (Sodium, Potassium, Magnesium Sulfates)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Colyte 240-22.72G Peg 3350/Electrolyte (Various) Moviprep Peg 3350/Electrolyte (Various) NuLytely (Braintree Laboratories)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 39 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 40

9. IMMUNOLOGY, VACCINES & BIOTECHNOLOGY

9.1 Biotechnology Drugs FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 9.1.1 ERYTHROID STIMULANTS 9.1.4 GROWTH HORMONES BRANDS BRANDS Aranesp (Darbepoetin Alfa in Polysorbate) Genotropin (Somatropin) Procrit (Epoetin Alfa) Humatrope (Somatropin) Norditropin (Somatropin) Norditropin Flexpro (Somatropin) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Epogen Procrit (Ortho Biotech) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Aranesp (Amgen) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Omnitrope Genotropin (Pfizer) Humatrope (Eli Lilly and Company) FORMULARY PRODUCTS

DRUG NAME Norditropin (Novo Nordisk) 9.1.2 MYELOID STIMULANTS Nutropin Genotropin (Pfizer) Humatrope (Eli Lilly and Company) BRANDS Norditropin (Novo Nordisk) Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Leukine (Sargramostim) Nutropin AQ Genotropin (Pfizer) Mozobil (Plerixafor) Humatrope (Eli Lilly and Company)

Neulasta (Pegfilgrastim) Norditropin (Novo Nordisk) Neupogen (Filgrastim) Nutropin AQ Nuspin Genotropin (Pfizer) Humatrope (Eli Lilly and Company) FORMULARY PRODUCTS Norditropin (Novo Nordisk) DRUG NAME Saizen Genotropin (Pfizer) 9.1.3 INTERFERONS Norditropin (Novo Nordisk) BRANDS Tev-Tropin Genotropin (Pfizer) Actimmune (Interferon Gamma-1b,Recombinant) Norditropin (Novo Nordisk) Avonex Administration Pack (Interferon Beta-1A/Albumin Human) Zorbtive Genotropin (Pfizer) Norditropin (Novo Nordisk) Avonex Pen (Interferon Beta-1A/Albumin Human) Betaseron (Interferon Beta-1b) Copaxone (Glatiramer Acetate) FORMULARY PRODUCTS Intron A (Interferon Alfa-2b,Recombinant Vial) DRUG NAME Peg-Intron (Peginterferon Alfa-2b) 9.1.5 INTERLEUKINS Peg-Intron Redipen (Peginterferon Alfa-2b) BRANDS Pegasys (Peginterferon Alfa-2A) Arcalyst (Rilonacept) Pegasys Proclick (Peginterferon Alfa-2A) Neumega (Oprelvekin) Proleukin (Aldesleukin) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Alferon N Intron A Vial (Schering Corporation) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Peg-Intron (Schering Corporation) Ilaris Arcalyst (Regeneron) Pegasys (Roche Laboratories) Infergen Peg-Intron (Schering Corporation) Pegasys (Roche Laboratories) Rebif Avonex Administration Pack (Biogen-Idec) Betaseron (Bayer) Copaxone (Teva) Sylatron Intron A Vial (Schering Corporation)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 40 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 41

10. MUSCULOSKELETAL & RHEUMATOLOGY Preferred Prescriptions/Rx Selections Formulary

10.1 NSAID Agents 10.3 Other Rheumatologicals FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 10.1.1 NSAIDS/COX II INHIBITORS 10.3.1 CORTICOSTEROIDS 10.1.1.1 NSAIDS GENERICS GENERICS Cortisone Acetate (Cortone Acetate) Etodolac (Lodine) Dexamethasone (Decadron) Etodolac (Lodine XL) Hydrocortisone (Cortef) Flurbiprofen (Ansaid) Methylprednisolone (Medrol) Ibuprofen (Motrin) Prednisolone Sodium Phosphate (Pediapred) Indomethacin (Indocin) Prednisolone Syrup (Prelone) Indomethacin (Indocin SR) Prednisolone Tablet (Prednisolone) Ketoprofen (Orudis) Prednisone (Deltasone) Meclofenamate Sodium (Meclofenamate Sodium) BRANDS Meloxicam (Mobic) Acthar H.P. (Corticotropin) Nabumetone (Relafen) Naproxen (Naprosyn) FORMULARY PRODUCTS

Naproxen Sodium (Anaprox) DRUG NAME Naproxen Sodium (Anaprox DS) 10.3.2 MISCELLANEOUS RHEUMATOLOGICAL AGENTS Naproxen Sodium (Naprelan) Oxaprozin (Daypro) GENERICS Piroxicam (Feldene) Azathioprine (Imuran) Gold Sodium Thiomalate (Myochrysine) Sulindac (Clinoril) 9 Tolmetin Sodium (Tolectin) Hydroxychloroquine Sulfate (Plaquenil)

Leflunomide (Arava) Immunology, Vaccines & Biotechnology BRANDS Methotrexate Sodium (Rheumatrex) Vimovo (Naproxen/Esomeprazole Mag) Sulfasalazine (Azulfidine) 10.1.1.2 NSAIDS- SPECIFIC COX-II INHIBITORS BRANDS BRANDS Actemra (Tocilizumab) Cuprimine (Penicillamine) Celebrex (Celecoxib) Enbrel (Etanercept) Humira (Adalimumab) FORMULARY PRODUCTS Orencia (Abatacept/Maltose) DRUG NAME Orencia SQ (Abatacept) 10.1.2 SALICYLATES Ridaura (Auranofin) GENERICS Savella (Milnacipran HCl) Choline Salicylate/Magnesium Salicylate (Trilisate) Trexall (Methotrexate Sodium) Diflunisal (Dolobid) Salsalate (Salsalate) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES 10.2 Gout Therapy Arava Leflunomide (Various) Benlysta Azathioprine (Various) FORMULARY PRODUCTS Mycophenolate Mofetil (Various) DRUG NAME Prednisone (Various) GENERICS Kineret Enbrel (Amgen) Allopurinol (Zyloprim) Humira (Abbott Laboratories) Colchicine (Colchicine) Simponi Enbrel (Amgen) Probenecid (Probenecid) Humira (Abbott Laboratories) BRANDS Remicade (Centocor) Colcrys (Colchicine) 10 Krystexxa (Pegloticase) Uloric (Febuxostat) Musculoskeletal & Rheumatology

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Zyloprim Allopurinol (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 41 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 42

10. MUSCULOSKELETAL & RHEUMATOLOGY (CONTINUED)

10.4 Osteoporosis Therapy FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 10.3.3 MUSCLE RELAXANTS & ANTISPASMODIC THERAPY GENERICS GENERICS Alendronate Sodium (Fosamax) Baclofen (Lioresal) Calcitonin,Salmon, Synthetic (Miacalcin) Carisoprodol (Soma) Estradiol/Norethindrone Acetate (Activella) Chlorzoxazone (Parafon Forte DSC) Ibandronate Sodium (Boniva) Cyclobenzaprine HCl (Amrix) BRANDS Cyclobenzaprine HCl (Flexeril) Evista (Raloxifene HCl) Dantrolene Sodium (Dantrium) Forteo (Teriparatide) Diazepam (Valium) Fosamax (Alendronate Sodium Solution) Metaxalone (Skelaxin) Premarin (Estrogens, Conjugated Tablet) Methocarbamol (Robaxin) Vivelle (Estradiol Patch, Transdermal) Oxybutynin Chloride (Ditropan) Vivelle DOT (Estradiol Patch, Transdermal) Oxybutynin Chloride (Ditropan XL) Tolterodine Tartrate (Detrol) Trospium Chloride (Sanctura) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred BRANDS Actonel 5mg Alendronate Sodium 5mg (Various) Detrol LA (Tolterodine Tartrate) Alendronate Sodium 10mg (Various)

Enablex (Darifenacin Hydrobromide) Ibandronate Sodium (Various)

Gelnique (Oxybutynin Chloride) Actonel 35mg Alendronate Sodium 35mg (Various)

Oxytrol (Oxybutynin) Alendronate Sodium 70mg (Various)

Sanctura XR (Trospium Chloride) Ibandronate Sodium (Various)

Toviaz (Fesoterodine Fumarate) Actonel 150mg Alendronate Sodium 35mg (Various)

Vesicare (Solifenacin Succinate) Alendronate Sodium 70mg (Various) Ibandronate Sodium (Various) Actonel with Calcium Alendronate Sodium (Various) Ibandronate Sodium (Various) Atelvia Alendronate Sodium (Various) Ibandronate Sodium (Various) Boniva Alendronate Sodium (Various) Boniva Syringe Kit Alendronate Sodium (Various) Ibandronate Sodium (Various) Fosamax Plus D Alendronate Sodium (Various) Ibandronate Sodium (Various) Fosamax Tablets Alendronate Sodium (Various) Prolia Alendronate Sodium (Various) Ibandronate Sodium (Various) Evista (Eli Lilly) Forteo (Eli Lilly)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 42 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 43

11. OBSTETRICS & GYNECOLOGY Preferred Prescriptions/Rx Selections Formulary

11.1 Oral Contraceptives & Related Agents Femcon Fe Zeosa (Teva-branded generic*) FORMULARY PRODUCTS DRUG NAME Levlite 0.1-0.02 Aviane 0.1-0.02 (Barr-branded generic*) 11.1.1 MONOPHASIC/BIPHASIC/TRIPHASIC AGENTS Lessina 0.1-0.02 (Barr-branded generic*) Lybrel (Wyeth) GENERICS Lo/Ovral Low-Ogestrel (Watson Labs-branded Desogestrel-Ethinyl Estradiol (Cyclessa) generic*) Desogestrel-Ethinyl Estradiol (Desogen) Loestrin Junel (Barr-branded generic*) Desogestrel-Ethinyl Estradiol (Ortho-Cept) Microgestin (Watson Labs-branded Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol (Mircette) generic*) Ethinyl Estradiol/Drospirenone (Yasmin) Loestrin Fe Junel Fe (Barr-branded generic*) Ethinyl Estradiol/Drospirenone (YAZ) Microgestin Fe (Watson Labs-branded Ethynodiol D-Ethinyl Estradiol (Demulen) generic*) Levonorgestrel (Plan B) LoSeasonique Amethia (Watson Labs-branded generic*) Levonorgestrel (Plan B One-Step) Camrese Lo (Teva-branded generic*) Levonorgestrel-Ethinyl Estradiol (Alesse) Lybrel Amethyst (Watson Labs-branded generic*) Levonorgestrel-Ethinyl Estradiol (Lybrel) Mircette Kariva (Barr-branded generic*) Levonorgestrel-Ethinyl Estradiol (Nordette) Modicon Necon (Watson Labs-branded generic*) Levonorgestrel-Ethinyl Estradiol (Seasonale) Nortrel (Barr-branded generic*) Levonorgestrel-Ethinyl Estradiol (Tri-Levlen) Nordette Levora (Watson Labs-branded generic*) Levonorgestrel-Ethinyl Estradiol (Triphasil) Portia (Barr-branded generic*) Levonorgestrel-Ethinyl Estradiol/Ethinyl Estradiol (LoSeasonique) Norinyl 1-0.035mg Necon 1-0.035mg (Watson Labs-branded Levonorgestrel-Ethinyl Estradiol/Ethinyl Estradiol (Seasonique) generic*) Norethindrone A-E Estradiol (Loestrin) Nortrel 1-0.035mg (Barr-branded 10 Norethindrone A-E Estradiol/Ferrous Fumarate (Loestrin Fe) generic*) Norethindrone-Ethinyl Estradiol (Brevicon) Norinyl 1-0.05mg Necon 1-0.05mg (Watson Labs-branded Norethindrone-Ethinyl Estradiol (Modicon) generic*) Musculoskeletal & Rheumatology Norethindrone-Ethinyl Estradiol (Norinyl) Ortho Tri-Cyclen Trinessa (Watson Labs-branded generic*) Norethindrone-Ethinyl Estradiol (Ortho-Novum) Tri-Previfem (Teva USA-branded generic*) Norethindrone-Ethinyl Estradiol/Ferrous Fumarate (Femcon Fe) Tri-Sprintec (Barr-branded generic*) Norethindrone-Mestranol (Norinyl) Ortho Tri-Cyclen Lo Trinessa (Watson Labs-branded generic*) Norethindrone-Mestranol (Ortho-Novum) Tri-Previfem (Teva USA-branded generic*) Norgestimate-Ethinyl Estradiol (Ortho Tri-Cyclen) Tri-Sprintec (Barr-branded generic*) Norgestimate-Ethinyl Estradiol (Ortho-Cyclen) Ortho-Cept Apri (Barr-branded generic*) Norgestrel-Ethinyl Estradiol (Lo/Ovral) Solia (Prasco Labs-branded generic*) Norgestrel-Ethinyl Estradiol (Ovral) Ortho-Cyclen Mononessa (Watson Labs-branded BRANDS generic*) Beyaz (Drospirenone/Ethinyl Estradiol/Levomefolate Calcium) Previfem (Teva USA-branded generic*) Ella (Ulipristal Acetate) Sprintec (Barr-branded generic*) Loestrin 24 Fe (Norethindrone A-E Estradiol/Ferrous Fumarate) Ortho-Novum Necon (Watson Labs-branded generic*) Lo Loestrin Fe (Norethindrone A-E Estradiol/Ferrous Fumarate) Nortrel (Barr-branded generic*) Natazia (Estradiol Valerate/Dienogest) Ovcon Necon (Watson Labs-branded generic*) Safyral (Drospirenone/Ethinyl Estradiol/Levomefolate) Ovral Ogestrel (Watson Labs-branded generic*) YAZ (Ethinyl Estradiol/Drospirenone) Plan B One-Step Next Choice One Dose (Watson Labs- branded generic*) Seasonale Amethyst (Watson Labs-branded generic*) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Jolessa (Barr-branded generic*) Alesse Aviane (Barr-branded generic*) Quasense (Watson Labs-branded generic*) Lessina (Barr-branded generic*) Seasonique Amethia (Watson Labs-branded generic*) Lutera (Watson Labs-branded generic*) Camrese (Teva-branded generic*) Lybrel (Wyeth) Tri-Norinyl Necon (Watson Labs-branded generic*) 11 Brevicon Necon 0.5-0.035 (Watson Labs-branded Nortrel (Barr-branded generic*) Yasmin Ocella (Barr-branded generic*) generic*) Nortrel 0.5-0.035 (Barr-branded generic*) Cyclessa Caziant (Watson Labs-branded generic*) Cesia (Praslo Labs-branded generic*) Obstetrics & Gynecology Velivet (Barr-branded generic*) Demulen Zovia (Watson Labs-branded generic*) Desogen Apri (Barr-branded generic*) Solia (Prasco Labs-branded generic*) Estrostep Fe Apri (Barr-branded generic*) Kariva (Barr-branded generic*) Microgestin Fe (Watson Labs-branded generic*)

Weigh risk of birth defects and other adverse outcomes. *Branded generics have the same co-payment as regular generics. Do not use during pregnancy. 43 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 44

11. OBSTETRICS & GYNECOLOGY (CONTINUED)

FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 11.1.2 PROGESTIN ONLY 11.3.2 ESTROGENS GENERICS GENERICS Norethindrone (Ortho Micronor) Estradiol Patch (Estradiol) Norethindrone Acetate (Aygestin) Estradiol Tablet (Estrace) Estropipate (Ogen) BRANDS 11.2 Oxytocics Cenestin (Estrogens, Conjugated, Synthetic A) FORMULARY PRODUCTS Climara (Estradiol) DRUG NAME Divigel (Estradiol) GENERICS Enjuvia (Estrogens ,Conjugated, Synthetic B) Methylergonovine Maleate (Methergine) Estrace (Estradiol Cream) Estraderm (Estradiol) Estring (Estradiol) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Evamist (Estradiol) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Premarin (Estrogens, Conjugated Tablet)

Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Methergine Methylergonovine Maleate (Various) Vagifem (Estradiol) Vivelle (Estradiol) 11.3 Estrogens & Progestins Vivelle DOT (Estradiol)

FORMULARY PRODUCTS DRUG NAME COMMONLY PRESCRIBED NONFORMULARY PRODUCTS 11.3.1 PROGESTINS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES GENERICS Alora Estradiol Patch, Transdermal Weekly (Various) Medroxyprogesterone Acetate (Provera) Climara (Berlex Laboratories) Norethindrone (Ortho Micronor) Estraderm (Novartis) Norethindrone Acetate (Aygestin) Vivelle (Novartis) Progesterone, Micronized (Prometrium) Elestrin Estradiol Patch, Transdermal Weekly BRANDS (Various) Crinone (Progesterone, Micronized) Climara (Berlex Laboratories) Depo-Provera 400mg/ml (Medroxyprogesterone Acetate Vial) Divigel (Upsher Smith) Endometrin (Progesterone, Micronized) Estraderm (Novartis) Makena (Hydroxyprogesterone Caproate) Vivelle (Novartis) Estrace Tablet Estradiol (Various)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Estrasorb Estradiol Patch, Transdermal Weekly DRUG NAME POSSIBLE FORMULARY ALTERNATIVES (Various) Aygestin Norethindrone Acetate (Various) Divigel (Upsher Smith) Depo-SubQ Provera Medroxyprogesterone Acetate Disposable Estriol Estradiol (Various) Syringe (Various) Estrogel Estradiol Patch, Transdermal Weekly Nor-Q-D Camila (Wyeth Pharm) (Various) Jolivette (Watson Labs) Climara (Berlex Laboratories) Nora-BE (Watson Labs) Divigel (Upsher Smith) Ortho Micronor Norethindrone Acetate (Various) Estraderm (Novartis) Prometrium Progesterone (Various) Vivelle (Novartis) Provera Medroxyprogesterone Acetate (Various) Femring Estrace Vaginal Cream (Warner Chilcott) Estring (Pharmacia/Upjohn) Femtrace Estradiol (Various) Menest Estradiol (Various) Estropipate (Various) Cenestin (Duramed/Barr) Enjuvia (Duramed/Barr) Premarin (Wyeth Pharm) Menostar Climara (Berlex Laboratories) Vivelle DOT (Novartis) Ogen Estropipate (Various) Premarin Vaginal Cream Estrace Vaginal Cream (Warner Chilcott)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 44 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 45

11. OBSTETRICS & GYNECOLOGY (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 11.3.3 ESTROGEN COMBINATIONS 11.4.2 VAGINAL CLEANSER/ANTI-INFECTIVES GENERICS GENERICS Estrogens, Esterified/Methyltestosterone (Estratest) Acetic Acid/Ricinoleic Acid/Oxyquinoline (Acid Jelly) Estrogens, Esterified/Methyltestosterone (Estratest H.S.) Clindamycin Phosphate (Clindesse) Estradiol/Norethindrone Acetate (Activella) Metronidazole (Metrogel) Norethindrone/Ethinyl Estradiol (Femhrt) BRANDS BRANDS AVC (Sulfanilamide) Combipatch (Estradiol/Norethindrone Acetate) Clindesse (Clindamycin Phosphate) Premphase (Estrogens, Conjugated/Medroxyprogesterone Acet) Prempro (Estrogens, Conjugated/Medroxyprogesterone Acet) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Cleocin Phosphate Clindamycin Phosphate (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Clindesse (Ther-Rx) Activella Estradiol/Norethindrone Acetate (Various) Metrogel Metronidazole (Various) Angeliq Estradiol/Norethindrone Acetate (Various) Premphase (Wyeth Pharm) FORMULARY PRODUCTS

Prempro (Wyeth Pharm) DRUG NAME Climara Pro Combipatch (Novartis) 11.4.3 VAGINAL ANTIFUNGALS Femhrt Norethindrone/Ethinyl Estradiol (Various) Ortho-Prefest Estradiol/Norethindrone Acetate (Various) GENERICS 11 Premphase (Wyeth Pharm) Fluconazole (Diflucan) Prempro (Wyeth Pharm) Miconazole Nitrate Suppository, Vaginal (Monistat 3) Prefest Estradiol/Norethindrone Acetate (Various) Nystatin (Nystatin) Premphase (Wyeth Pharm) Terconazole (Terazol) Prempro (Wyeth Pharm) BRANDS Obstetrics & Gynecology Gynazole-1 (Butoconazole Nitrate) 11.4 Miscellaneous OB/GYN COMMONLY PRESCRIBED NONFORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES DRUG NAME Monistat 3 Suppository, Vaginal Miconazole 3 Suppository, Vaginal (Various) 11.4.1 DRUGS TO TREAT INFERTILITY/IVF AGENTS Terazol Terconazole (Various) GENERICS Clomiphene Citrate (Clomid) FORMULARY PRODUCTS Gonadotropin, Chorionic, Human (Profasi) DRUG NAME Leuprolide Acetate (Lupron) 11.4.4 SPECIALIZED OB/GYN DRUGS BRANDS GENERICS Bravelle (Urofollitropin (FSH)) Isoxsuprine HCl (Vasodilan) Cetrotide (Cetrorelix Acetate) Terbutaline Sulfate (Brethine) Follistim AQ (Follitropin Beta, Recombinant) BRANDS Lupron Depot (Leuprolide Acetate) Lupron Depot-Ped (Leuprolide Acetate) Lysteda (Tranexamic Acid) Synarel (Nafarelin Acetate) Ovidrel (HCG Alpha, Recombinant) Repronex (Menotropins) Serophene (Clomiphene Citrate) FORMULARY PRODUCTS DRUG NAME 11.4.5 DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES BRANDS NuvaRing (Etonogestrel/Ethinyl Estradiol)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Ortho Evra Mononessa (Watson Labs-branded generic*) Trinessa (Watson Labs-branded generic*)

Weigh risk of birth defects and other adverse outcomes. *Branded generics have the same co-payment as regular generics. Do not use during pregnancy. 45 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 46

12. OPHTHALMOLOGY

12.1 Beta-blockers 12.4 Other Glaucoma Drugs FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME GENERICS GENERICS Betaxolol HCl (Betoptic) Dorzolamide HCl (Trusopt) Carteolol HCl (Ocupress) Dorzolamide/Timolol (Cosopt) Levobunolol HCl (Betagan) Latanoprost (Xalatan) Metipranolol (OptiPranolol) BRANDS Timolol Maleate (Timoptic) Azopt (Brinzolamide) Timolol Maleate (Timoptic-XE) Isopto Carbachol (Carbachol) BRANDS Lumigan (Bimatoprost) Betoptic S (Betaxolol HCl) Travatan (Travoprost) Travatan Z (Travoprost)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Betagan Levobunolol HCl (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Betimol Betaxolol (Various) Combigan Brimonidine Tartrate (Various) Timolol Maleate (Various) Timolol Maleate (Various) Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Istalol Timolol Maleate Gel-Forming Solution Cosopt Dorzolamide/Timolol (Various) (Various) Trusopt Dorzolamide HCl (Various) OptiPranolol Metipranolol (Various) Xalatan Latanoprost (Various) Timoptic Timolol Maleate (Various) Timoptic-XE Timolol Maleate Gel-Forming Solution (Various) 12.5 Oral Drugs For Glaucoma

FORMULARY PRODUCTS DRUG NAME 12.2 Cholinesterase Inhibitor Miotics GENERICS FORMULARY PRODUCTS Acetazolamide (Diamox) DRUG NAME Acetazolamide (Diamox Sequels) BRANDS Methazolamide (Neptazane) Phospholine Iodide (Echothiophate Iodide)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS 12.3 Direct Acting Miotics DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Diamox Sequels Acetazolamide (Various) FORMULARY PRODUCTS DRUG NAME GENERICS 12.6 Cycloplegic Mydriatics Pilocarpine HCl (Isopto Carpine) FORMULARY PRODUCTS BRANDS DRUG NAME Pilopine HS (Pilocarpine HCl) GENERICS Atropine Sulfate (Isopto Atropine) Cyclopentolate HCl (Cyclogyl) Homatropine HBr (Isopto Homatropine) Tropicamide (Mydriacyl)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Isopto Homatropine Homatropine Hydrobromide (Various) Isopto Hyoscine Atropine Sulfate (Various) Cyclopentolate HCl (Various) Homatropine Hydrobromide (Various) Tropicamide (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 46 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 47

12. OPHTHALMOLOGY (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

12.7 Non-steroidal Anti-inflammatory Agents COMMONLY PRESCRIBED NONFORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES DRUG NAME AzaSite Ciprofloxacin HCl (Various) GENERICS Tobramycin Sulfate (Various) Bromfenac Sodium (Xibrom) Zymar (Allergan Inc.) Diclofenac Sodium (Voltaren) Ciloxan Drops Ciprofloxacin HCl Drops (Various)

Flurbiprofen Sodium (Ocufen) Iquix Ofloxacin (Various)

Ketorolac Tromethamine (Acular) Besivance (Bausch & Lomb)

Ketorolac Tromethamine (Acular LS) Vigamox (Alcon) Zymar (Allergan Inc.) BRANDS Zymaxid (Allergan Inc.) Nevanac (Nepafenac) Ocuflox Ofloxacin (Various) Polysporin Ointment Bacitracin/Polymyxin Ointment (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Quixin Levofloxacin (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Tobrex Drops Tobramycin Sulfate (Various) Acular Ketorolac Tromethamine (Various) Acular LS Ketorolac Tromethamine (Various) Bromday Bromfenac Sodium (Various) 12.10 Sulfonamides Diclofenac Sodium (Various) FORMULARY PRODUCTS Flurbiprofen Sodium (Various) DRUG NAME Ketorolac Tromethamine (Various) GENERICS Voltaren Diclofenac Sodium (Various) Sulfacetamide Sodium (Bleph-10) Xibrom Bromfenac Sodium (Various) 12

12.11 Steroids 12.8 Vasoconstrictor Decongestants FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME GENERICS

GENERICS Dexamethasone Sodium Phosphate (Decadron) Ophthalmology Naphazoline HCl (Albalon) Fluorometholone (FML) Phenylephrine HCl (Neo-Synephrine) Prednisolone Acetate (Pred Forte)

Prednisolone Sodium Phosphate (Inflamase Forte) 12.9 Antibiotics BRANDS Alrex (Loteprednol Etabonate) FORMULARY PRODUCTS Durezol (Difluprednate) DRUG NAME FML S.O.P. (Fluorometholone) GENERICS Lotemax (Loteprednol Etabonate) Bacitracin (Bacitracin) Ozurdex (Dexamethasone) Bacitracin/Polymyxin B Sulfate (Polysporin) Pred Mild (Prednisolone Acetate) Ciprofloxacin HCl Drops (Ciloxan) Retisert (Fluocinolone Acetonide) Erythromycin Base (Ilotycin) Gentamicin Sulfate (Garamycin) Levofloxacin (Quixin) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Neomycin Sulfate/Bacitracin/Polymyxin B Ointment (Neosporin) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Neomycin Sulfate/Gramicidin D/Polymyxin B Drops (Neosporin) Flarex Fluorometholone (Various) Ofloxacin (Ocuflox) FML Fluorometholone (Various) Polymyxin B Sulfate/Trimethoprim (Polytrim) Pred Forte Prednisolone Acetate (Various) Tobramycin Sulfate Drops (Tobrex) Vexol Fluorometholone (Various) Alrex (Bausch & Lomb) BRANDS Lotemax (Bausch & Lomb) Besivance (Besifloxacin HCl) Ciloxan (Ciprofloxacin HCl Ointment) Moxeza (Moxifloxacin HCl) Natacyn (Natamycin) Tobrex (Tobramycin Sulfate Ointment) Vigamox (Moxifloxacin HCl) Zymar (Gatifloxacin) Zymaxid (Gatifloxacin)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 47 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 48

12. OPHTHALMOLOGY (CONTINUED)

12.12 Steroid-antibiotic Combinations 12.15 Miscellaneous Ophthalmologics FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME GENERICS GENERICS Neomycin Sulfate/Bacitracin Zinc/Polymyxin B/Hydrocortisone (Cortisporin) Azelastine HCl (Optivar) Neomycin Sulfate/Polymyxin B Sulfate/Hydrocortisone (Cortisporin) Cromolyn Sodium (Opticrom) Neomycin/Polymyxin B Sulfate/Dexamethasone (Maxitrol) Epinastine HCl (Elestat) Tobramycin Sulfate/Dexamethasone Drops (TobraDex) BRANDS BRANDS Lacrisert (Hydroxypropyl Cellulose) TobraDex Ointment (Tobramycin Sulfate/Dexamethasone) Lucentis (Ranibizumab) TobraDex ST (Tobramycin Sulfate/Dexamethasone) Pataday (Olopatadine HCl) Zylet (Tobramycin/Loteprednol Etabonate) Patanol (Olopatadine HCl) Restasis (Cyclosporine)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Cortisporin Neomycin/Polymyxin/HC (Various) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Maxitrol Neo/Polymyxin/Dexamethasone (Various) Alamast Azelastine HCl (Various) Poly-Pred Neo/Polymyxin/Dexamethasone (Various) Cromolyn Sodium (Various) Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Tobramycin Sulfate/Dexamethasone Patanol (Alcon Laboratories) (Various) Alocril Patanol (Alcon Laboratories) Zylet (Bausch & Lomb) Alomide Cromolyn Sodium (Various) Pred-G Neo/Polymyxin/Dexamethasone (Various) Patanol (Alcon Laboratories) Tobramycin Sulfate/Dexamethasone Bepreve Cromolyn Sodium (Various) (Various) Patanol (Alcon Laboratories) TobraDex Drops Tobramycin Sulfate/Dexamethasone Crolom Cromolyn Sodium (Various) (Various) Elestat Epinastine HCl (Various) Emadine Patanol (Alcon Laboratories) Eylea Lucentis (Genentech, Inc) 12.13 Steroid-sulfonamide Combinations Lastacaft Azelastine HCl (Various) FORMULARY PRODUCTS Epinastine HCl (Various) DRUG NAME Pataday (Alcon Laboratories) GENERICS Patanol (Alcon Laboratories) Sulfacetamide Sodium/Prednisolone Sodium Phosphate (Vasocidin) Macugen Lucentis (Genentech, Inc)

Optivar Azelastine HCl (Various) BRANDS Blephamide S.O.P. (Sulfacetamide Sodium/Prednisolone Acetate) 12.16 Antivirals COMMONLY PRESCRIBED NONFORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES DRUG NAME Blephamide Sulfacetamide w/Prednisolone (Various) GENERICS Trifluridine (Viroptic) 12.14 Sympathomimetics FORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME DRUG NAME POSSIBLE FORMULARY ALTERNATIVES GENERICS Viroptic Trifluridine (Various) Apraclonidine HCl (Iopidine) Zirgan Trifluridine (Various)

Brimonidine Tartrate (Alphagan) Brimonidine Tartrate (Alphagan P 0.15%) Dipivefrin HCl (Propine) BRANDS Alphagan P 0.1% (Brimonidine Tartrate)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Alphagan P 0.15% Brimonidine Tartrate (Various) Iopidine Apraclonidine HCl (Various) Brimonidine Tartrate (Various) Alphagan P 0.1% (Allergan Inc.)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 48 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 11/2/12 4:39 PM Page 49

13. RESPIRATORY, ALLERGY, COUGH & COLD Preferred Prescriptions/Rx Selections Formulary

13.1 Antihistamine & Antiallergenic 13.2 Cough & Cold Therapy Agents FORMULARY PRODUCTS DRUG NAME FORMULARY PRODUCTS DRUG NAME 13.2.1 ANTITUSSIVE COMBINATIONS 13.1.1 ANTIHISTAMINES GENERICS GENERICS Dextromethorphan HBr/Pseudoephedrine HCl/Brompheniramine Clemastine Fumarate (Tavist) (Bromfed-DM) Cyproheptadine HCl (Periactin) Guaifenesin/Codeine Phosphate (Robitussin A-C) Desloratadine (Clarinex) Guaifenesin/Codeine Phosphate (Tussi-Organidin Nr) Diphenhydramine HCl (Benadryl 50mg) Guaifenesin/Codeine Phosphate (Tussi-Organidin-S Nr) Fexofenadine HCl (Allegra) Guaifenesin/Dextromethorphan HBr (Duratuss DM) Hydroxyzine HCl (Atarax) Hydrocodone Bit/Homatropine (Hycodan) Hydroxyzine Pamoate (Vistaril) Hydrocodone Polistrx/Chlorpheniramine Polistirex (Tussionex) Levocetirizine Di-HCl (Xyzal) Phenylephrine HCl/Brompheniramine Maleate (Bromfed) Promethazine HCl (Phenergan) Phenylephrine HCl/Brompheniramine Maleate (Bromfed-PD) BRANDS BRANDS Allegra (Fexofenadine HCl Suspension, Oral) Rezira (Pseudoephedrine/Hydrocodone) Clarinex Reditabs (Desloratadine) TussiCaps (Hydrocodone Polistrx/Chlorpheniramine Polistirex) Clarinex Syrup (Desloratadine) Zutripto (Pseudoephedrine/Hydrocodone/Chlorpheniramine)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES DRUG NAME POSSIBLE FORMULARY ALTERNATIVES 12 Allegra Fexofenadine HCl (Various) Anaplex DMX Brompheniramine w/Pseudoephed (Various) Desloratadine (Various) Pseudoephedrine w/Chlorphenir (Various) Clarinex (Schering Corporation) Donatussin Guaifen/D-Methorphan HB/PE/CP Allegra ODT Fexofenadine HCl (Various) (Various) Clarinex Tablet Desloratadine (Various) Duratuss DM Guaifenesin w/Dextromethorphan (Various) Phenergan Promethazine HCl (Various) PanMist DM Syrup Guaifen/DM/P-ephed (Various) Syn-Rx DM Guaifenesin w/Dextromethorphan (Various) Vistaril Hydroxyzine Pamoate (Various) Ophthalmology Xyzal Levocetirizine Di-HCl (Various) Tussionex Hydrocodone/Chlorpheniramine (Various) Tussi-Organidin DM Nr Guaifenesin w/Dextromethorphan (Various) Tussi-Organidin DM-S Nr Guaifenesin w/Dextromethorphan (Various) FORMULARY PRODUCTS Tussi-Organidin Nr Guaifenesin w/Codeine (Various) DRUG NAME Tussi-Organidin-S Nr Guaifenesin w/Codeine (Various) 13.1.2 ADRENERGICS BRANDS FORMULARY PRODUCTS EpiPen (Epinephrine) DRUG NAME EpiPen Jr. (Epinephrine) 13.2.2 EXPECTORANT COMBINATIONS GENERICS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Guaifenesin (Liquibid) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Guaifenesin/Phenylephrine HCl (Despec) Twinject EpiPen (Dey Labs) Guaifenesin/Pseudoephedrine HCl (Syn-Rx DM) EpiPen Jr. (Dey Labs)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES DRUG NAME Deconex Phenylephrine/Guaifenesin (Various) 13.1.3 CORTICOSTEROIDS GENERICS Cortisone Acetate (Cortone Acetate) 13 Dexamethasone (Decadron)

Hydrocortisone (Cortef) Respiratory, Allergy, Cough & Cold Methylprednisolone (Medrol) Prednisolone Sodium Phosphate (Pediapred) Prednisolone Syrup (Prelone) Prednisolone Tablet (Prednisolone) Prednisone (Deltasone) BRANDS Acthar H.P (Corticotropin)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 49 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 50

13. RESPIRATORY, ALLERGY, COUGH & COLD (CONTINUED)

FORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME DRUG NAME POSSIBLE FORMULARY ALTERNATIVES 13.2.3 DECONGESTANT/ANTIHISTAMINES Theo-24 Theophylline Anhydrous Tablet, Extended GENERICS Release 12hr (Various) Carbetapentane Tannate/Pseudoephedrine Tannate (Respi-Tann) Uniphyl Theophylline Anhydrous Tablet, Extended Release (Various) Pseudoephedrine HCl/Brompheniramine Maleate (Bromfed) Pseudoephedrine HCl/Chlorpheniramine Maleate (Deconamine SR) Pseudoephedrine HCl/Chlorpheniramine Maleate Liquid (Histex) FORMULARY PRODUCTS Pseudoephedrine HCl/Fexofenadine HCl (Allegra-D 12 Hour) DRUG NAME Pseudoephedrine HCl/Fexofenadine HCl (Allegra-D 24 Hour) 13.3.2 BETA AGONISTS ORAL BRANDS GENERICS Clarinex-D 12 Hour (Pseudoephedrine/Desloratadine) Albuterol Sulfate (Proventil) Clarinex-D 24 Hour (Pseudoephedrine/Desloratadine) Metaproterenol Sulfate (Alupent) Terbutaline Sulfate (Brethine) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES COMMONLY PRESCRIBED NONFORMULARY PRODUCTS

Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Allegra-D 12 Hour Pseudoephedrine HCl/Fexofenadine DRUG NAME POSSIBLE FORMULARY ALTERNATIVES (Various) Vospire ER Albuterol Sulfate (Various) Allegra-D 24 Hour Pseudoephedrine HCl/Fexofenadine (Various) Deconamine Pseudoephedrine w/Chlorphenir (Various) FORMULARY PRODUCTS DRUG NAME Deconamine SR Pseudoephedrine w/Chlorphenir (Various) Durahist PE Brompheniramine w/Pseudoephed (Various) 13.3.3 BETA AGONISTS INHALERS Pseudoephedrine w/Chlorphenir (Various) GENERICS Histex SR Pseudoephedrine w/Chlorphenir (Various) Albuterol (Proventil) Nalex-A Rhinacon A (Various) Albuterol Sulfate (Accuneb) Ryna-12 Phenylephrine/Pyrilamine Tan (Various) Levalbuterol HCl (Xopenex) Ryna-12 S Phenylephrine/Pyrilamine Tan (Various) Metaproterenol Sulfate (Alupent) Rynatan Phenylephrine/Chlor Tan (Various) BRANDS Brompheniramine w/Pseudoephed (Various) Foradil (Formoterol Fumarate) Pseudoephedrine w/Chlorphenir (Various) Perforomist (Formoterol Fumarate) Rynatan Pediatric Phenylephrine/Chlor Tan (Various) ProAir HFA (Albuterol Sulfate) Brompheniramine w/Pseudoephed (Various) Serevent Diskus (Salmeterol Xinafoate) Pseudoephedrine w/Chlorphenir (Various) Xopenex HFA (Levalbuterol Tartrate) Semprex-D Brompheniramine w/Pseudoephed (Various) Pseudoephedrine w/Chlorphenir (Various) Sudal Brompheniramine w/Pseudoephed (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Pseudoephedrine HCl/Fexofenadine DRUG NAME POSSIBLE FORMULARY ALTERNATIVES (Various) Accuneb Albuterol Sulfate (Various)

Tussi-12 D-methorphan/P-ephed Arcapta Neohaler Foradil (Schering Corporation) HCl/Brompheniramine (Various) Serevent Diskus (GlaxoSmithKline)

Vazotan D-methorphan/P-ephed Brovana Foradil (Schering Corporation) HCl/Brompheniramine (Various) Perforomist (Dey Labs) ProAir HFA (Teva) Serevent Diskus (GlaxoSmithKline) 13.3 Pulmonary Agents Maxair Autohaler ProAir HFA (Teva) Xopenex HFA (Sepracor) FORMULARY PRODUCTS Proventil HFA ProAir HFA (Teva) DRUG NAME Xopenex HFA (Sepracor) 13.3.1 XANTHINES Ventolin HFA ProAir HFA (Teva) GENERICS Xopenex HFA (Sepracor) Aminophylline (Aminophylline) Xopenex Levalbuterol HCl (Various) Theophylline Anhydrous (Theo-Dur) BRANDS Elixophyllin (Theophylline Anhydrous)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 50 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 51

13. RESPIRATORY, ALLERGY, COUGH & COLD (CONTINUED) Preferred Prescriptions/Rx Selections Formulary

FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 13.3.4 INHALED CORTICOSTEROIDS 13.3.6 MISCELLANEOUS PULMONARY AGENTS GENERICS GENERICS Budesonide (Pulmicort 0.25mg/2mL) Acetylcysteine (Mucomyst) Budesonide (Pulmicort 0.5mg/2mL) Cromolyn Sodium Ampul for Nebulization (Intal) BRANDS Ipratropium/Albuterol Sulfate (Duoneb) Alvesco (Ciclesonide) Ipratropium Bromide Solution, Non-Oral (Atrovent) Asmanex (Mometasone Furoate) Montelukast Sodium (Singulair) Flovent Diskus (Fluticasone Propionate) Zafirlukast (Accolate) Flovent HFA (Fluticasone Propionate) BRANDS Pulmicort 1mg/2mL (Budesonide) Advair Diskus (Fluticasone Propionate/Salmeterol Xinafoate) Pulmicort Flexhaler (Budesonide) Advair HFA (Fluticasone Propionate/Salmeterol Xinafoate) QVAR (Beclomethasone Dipropionate) Atrovent HFA (Ipratropium Bromide) Berinert (C1 Esterase Inhibitor) Cinryze (C1 Esterase Inhibitor) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Combivent (Albuterol Sulfate/Ipratropium Bromide) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Combivent Respimat (Albuterol Sulfate/Ipratropium Bromide) Aerobid Asmanex (Schering Corporation) Daliresp (Roflumilast) Flovent HFA (GlaxoSmithKline) Dulera (Mometasone/Formoterol) Pulmicort Flexhaler (AstraZeneca) Intal (Cromolyn Sodium Aerosol) QVAR (IVAX Laboratories) Kalydeco (Ivacaftor) Aerobid-M Asmanex (Schering Corporation) 13 Letairis (Ambrisentan) Flovent HFA (GlaxoSmithKline) Pulmozyme (Dornase Alfa) Pulmicort Flexhaler (AstraZeneca) Revatio (Sildenafil Citrate) Respiratory, Allergy, Cough & Cold QVAR (IVAX Laboratories) Spiriva (Tiotropium Bromide) Azmacort Asmanex (Schering Corporation) Symbicort (Budesonide/Formoterol Fumarate) Flovent HFA (GlaxoSmithKline) Tracleer (Bosentan) Pulmicort Flexhaler (AstraZeneca) Tyvaso (Treprostinil) QVAR (IVAX Laboratories) Ventavis (Iloprost) Pulmicort 0.25mg/2mL Budesonide (Various)

Pulmicort 0.5mg/2mL Budesonide (Various)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES FORMULARY PRODUCTS DRUG NAME Accolate Zafirlukast (Various) 13.3.5 INTRANASAL STEROIDS Adcirca Revatio (Pfizer) Duoneb Ipratropium/Albuterol Sulfate (Various) GENERICS Firazyr Berinert (CSL Behring) Flunisolide (Nasalide) Cinryze (Viropharma) Fluticasone Propionate (Flonase) Kalbitor Berinert (CSL Behring) Triamcinolone Acetonide (Nasacort AQ) Singulair Montelukast Sodium (Various) BRANDS Xolair Asmanex (Schering Corporation) Nasonex (Mometasone Furoate) Flovent HFA (GlaxoSmithKline) Rhinocort Aqua (Budesonide) Pulmicort Flexhaler (AstraZeneca) Veramyst (Fluticasone Furoate) QVAR (IVAX Laboratories) Zyflo Montelukast Sodium (Various) Zyflo CR Montelukast Sodium (Various) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Beconase AQ Flunisolide (Various) Fluticasone Propionate (Various) Triamcinolone Acetonide (Various) Nasonex (Schering Corporation) Rhinocort Aqua (AstraZeneca) Veramyst (GlaxoSmithKline) Flonase Fluticasone Propionate (Various) Nasacort AQ Triamcinolone Acetonide (Various) Omnaris Flunisolide (Various) Fluticasone Propionate (Various) Triamcinolone Acetonide (Various) Nasonex (Schering Corporation) Rhinocort Aqua (AstraZeneca) Veramyst (GlaxoSmithKline)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 51 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 52

14. UROLOGICALS

14.1 Cholinergic Stimulants 14.4 Miscellaneous Urologicals FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME GENERICS BRANDS Bethanechol Chloride (Urecholine) Caverject (Alprostadil) Cialis (Tadalafil) Cystagon (Cysteamine Bitartrate) 14.2 Anticholinergics & Antispasmodics Elmiron (Pentosan Polysulfate Sodium) FORMULARY PRODUCTS Muse (Alprostadil) DRUG NAME Viagra (Sildenafil Citrate) GENERICS Dicyclomine HCl (Bentyl) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS

Flavoxate HCl (Urispas) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Hyoscyamine Sulfate (Levbid) Levitra Cialis (Eli Lilly and Company) Hyoscyamine Sulfate (Levsin) Viagra (Pfizer) Hyoscyamine Sulfate (Levsin/SL) Prosed-DS Methenamine Mandelate (Various) Hyoscyamine Sulfate (Nulev) Staxyn Cialis (Eli Lilly and Company) Oxybutynin Chloride (Ditropan) Viagra (Pfizer) Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred Oxybutynin Chloride (Ditropan XL) Uroqid-Acid No.2 Methenamine Mandelate (Various) Tolterodine Tartrate (Detrol) Trospium Chloride (Sanctura) BRANDS 14.5 Benign Prostatic Hyperplasia (BPH) Detrol LA (Tolterodine Tartrate) Therapy Enablex (Darifenacin Hydrobromide) Gelnique (Oxybutynin Chloride) FORMULARY PRODUCTS DRUG NAME Levbid (Hyoscyamine Sulfate) Oxytrol (Oxybutynin) GENERICS Sanctura XR (Trospium Chloride) Alfuzosin HCl (Uroxatral) Vesicare (Solifenacin Succinate) Doxazosin Mesylate (Cardura) Finasteride (Proscar)

Terazosin HCl (Hytrin) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS Tamsulosin HCl (Flomax) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES BRANDS Detrol Tolterodine Tartrate (Various) Avodart (Dutasteride) Ditropan XL Oxybutynin Chloride ER (Various) Jalyn (Dutasteride/Tamsulosin HCl) Sanctura Trospium Chloride (Various) Rapaflo (Silodosin)

14.3 Urinary Anesthetics COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES FORMULARY PRODUCTS DRUG NAME Flomax Tamsulosin HCl (Various) GENERICS Proscar Finasteride (Various) Phenazopyridine HCl (Pyridium) Uroxatral Alfuzosin HCl (Various)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Pyridium Phenazopyridine HCl (Various) Pyridium Plus Phenazopyridine HCl (Various)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 52 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 53

15. VITAMINS, HEMATINICS & ELECTROLYTES Preferred Prescriptions/Rx Selections Formulary

15.1 Vitamins & Hematinics FORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME DRUG NAME POSSIBLE FORMULARY ALTERNATIVES GENERICS Animi-3 Folic Acid (Various) Cyanocobalamin (Vitamin B-12) Cerefolin Folic Acid (Various) Ergocalciferol Capsule (Vitamin D 50000 Unit) Chromagen FA Folic Acid (Various) Ferrous Sulfate Drops (Feosol) Repliva 21/7 (Ther-Rx) Fluoride Ion/Iron/Vitamins A,C,and D (Tri-Vi-Flor w/Iron) Chromagen Forte Folic Acid (Various) Fluoride Ion/Multivitamins (Poly-Vi-Flor) Repliva 21/7 (Ther-Rx) Fluoride Ion/Multivitamins w-Iron (Poly-Vi-Flor w/Iron) Citracal Prenatal Rx Cal-Nate (Various) Fluoride Ion/Vitamins A,C,and D (Tri-Vi-Flor) Drisdol Capsule Vitamin D (Various) Folic Acid (Folvite) Duet Stuartnatal Prenatal Rx (Various) Prenatal Vitamin w-o Calcium/Fe Carbonyl-Fe Sulfate/Folic Acid (Natafort) Encora Prenatal Rx (Various) Prenatal Vitamin w-o Calcium/Ferrous Fumarate/Folic Acid (Natachew) Femtabs Vitacel (Various) Prenatal Vitamin w-o Vitamin A/Ferrous Fumarate/Folic Acid (Precare) Folgard Rx Folic Acid-Cyancobal-Pyridoxin (Various) Prenatal Vitamins/Ferrous Fumarate/Folic Acid (Stuartnatal Plus 3) Folic Acid (Various) Prenatal Vitamins/Ferrous Fumarate/Folic Acid/Selenium (Materna) Hemocyte-F Hematinic w/Folic Acid (Various) Prenatal Vitamins/Iron,Carbonyl/Docusate/Folic Acid (Prena-Cap) Luride Sodium Fluoride (Various) Prenatal Vitamins/Iron,Carbonyl/Folic Acid (Atabex) Materna Maternity (Various) Prenatal Vitamins/Iron Polysaccharides Complex/Folic Acid (Niferex-PN Forte) Metanx Folic Acid (Various) Sodium Fluoride (Luride) Nascobal Cyanocobalamin (Various) BRANDS Natachew Completenate (Various) FOLTX (Cyanocobalamin/Folic Acid/Pyridoxine) Natelle Vinate II (Various) 14 Neevo (Prenatal Vitamin with CA/Iron/FA/LM-Folate) Natelle Prefer Prenatal Rx (Various) Neevo DHA (Prenatal Vitamins/Iron/Folic Acid/LM-Folate/DHA) Natelle-EZ Vinate II (Various) Niferex Gold (Ferrous Bis-Glycinate Chelate/Iron Polysaccharides Nephro-Vite Rx Rena-Vite Rx (Various) Complex/Docusate/Ascorbic Acid/Folic Acid/Multivitamins Combin Dialyvite (Various) No.14) Folic Acid (Various) Niferex-150 Forte (Iron Polysaccharides Complex/Cyanocobalamin/Folic Acid) Nephrocaps Renal Caps (Various) PreCare Conceive (Prenatal Vitamin w-o Vitamin A/Fe Carbonyl-Fe Nephron FA Folic Acid (Various) Poly-Vi-Flor Multivitamin w/Fluoride (Various)

Fumarate/Folic Acid) Urologicals PreCare Premier (Prenatal Vitamins Combination No.7/Ferrous Asparto Prenate Essential PNV-Omega (Various) Glycinate/Docusate/Folic Acid) Zatean-PN Plus (Various) Prefera-OB (Prenatal Vitamins/Iron/Polysaccharides Complex/Fe Heme Strovite Advance Folic Acid (Various) Polypeptide/Folic Acid) Strovite Forte Vita S Forte (Various) Prefera-OB One (Prenatal Vitamins/Iron/Polysaccharides Complex/Fe Heme Vitafol Folic Acid (Various) Polypeptide/Folic Acid/DHA) Vitafol-OB Prenatal Rx (Various)

Prefera-OB Plus DHA (Prenatal Vitamins/Iron/Polysaccharides Complex/Fe Heme Polypeptide/Folic Acid/DHA) 15.2 Coagulation Therapy Prenate DHA (Prenatal Vitamins/Iron/DHA/Folic Acid/Docusate Sodium) Prenate Elite (Prenatal Vitamins/Iron,Carbonyl/Docusate/Folic Acid/L- FORMULARY PRODUCTS Methylfolate) DRUG NAME Primacare (Prenatal Vitamins/Ferrous Fumarate/Folic Acid/Fatty Acids) 15.2.1 ANTICOAGULANTS Primacare One (Prenatal Vitamins/Iron,Carbonyl/Omega-3 Fatty Acids/Folic GENERICS Acid/Fatty Acid Combo No.1) Warfarin Sodium (Coumadin) Repliva 21/7 (Ferrous Fumarate/Ferrous Bis-Glycinate Chelate/Ascorbic BRANDS Acid/Folic Acid/Multivitamins Combo No.11/Calcium Threonate) Pradaxa (Dabigatran Etexilate Mesylate)

FORMULARY PRODUCTS 15 DRUG NAME 15.2.2 ANTIPLATELET DRUGS

GENERICS Hematinics & ElectrolytesVitamins, Cilostazol (Pletal) Clopidogrel Bisulfate (Plavix) Dipyridamole (Persantine) Ticlopidine HCl (Ticlid) BRANDS Aggrenox (Aspirin/Dipyridamole) Brilinta (Ticagrelor) Effient (Prasugrel HCl)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 53 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 54

15. VITAMINS, HEMATINICS & ELECTROLYTES (CONTINUED)

15.3 Electrolytes FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME 15.2.3 HEPARIN 15.3.1 POTASSIUM GENERICS GENERICS Enoxaparin Sodium (Lovenox) Potassium Bicarbonate/Citric Acid (K-Lyte) Fondaparinux Sodium (Arixtra) Potassium Chloride (K-Dur) Heparin Sodium,Porcine (Heparin Lock Flush) Potassium Chloride (Micro-K) BRANDS Potassium Chloride (Kay Ciel) Fragmin (Dalteparin Sodium,Porcine) Potassium Chloride (K-Lor) Potassium Chloride (Slow-K) Potassium Chloride/Potassium Bicarbonate/Citric Acid (K-Lyte/Cl) FORMULARY PRODUCTS

DRUG NAME 15.2.4 VITAMIN K COMMONLY PRESCRIBED NONFORMULARY PRODUCTS BRANDS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Mephyton (Phytonadione Tablet) K-Dur Potassium Chloride (Various) Klor-Con 25mEq Potassium Chloride (Various) K-Tab Potassium Chloride (Various) Preferred Prescriptions/Rx Selections Formulary Prescriptions/Rx Preferred FORMULARY PRODUCTS Kaon-Cl Potassium Chloride (Various) DRUG NAME Micro-K Potassium Chloride (Various) 15.2.5 HEMOSTATICS GENERICS FORMULARY PRODUCTS Aminocaproic Acid (Amicar) DRUG NAME BRANDS 15.3.2 OTHER ELECTROLYTES Humate-P (AHF, Human/VWF, Human) GENERICS NovoSeven (Factor VIIa, Recombinant) Calcium Acetate (Phoslo) NovoSeven RT (Factor VIIa, Recombinant) Potassium Iodide/Iodine (Lugol's) NPlate (Romiplostim) Promacta (Eltrombopag Olamine) BRANDS Wilate (AHF, Human/VWF, Human) PhosLo (Calcium Acetate)

FORMULARY PRODUCTS COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME DRUG NAME POSSIBLE FORMULARY ALTERNATIVES 15.2.6 MISCELLANEOUS COAGULATION AGENTS Phoslyra Calcium Acetate (Various) GENERICS PhosLo (Fresenius) Pentoxifylline Tablet, Sustained Action (Trental) BRANDS Xyntha (Antihemophilic Factor VIII) Xyntha Solofuse (Antihemophilic Factor VIII)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 54 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:36 AM Page 55

16. DIAGNOSTICS & MISCELLANEOUS AGENTS Preferred Prescriptions/Rx Selections Formulary

16.1 Miscellaneous Agents 16.2 Smoking Deterrents FORMULARY PRODUCTS FORMULARY PRODUCTS DRUG NAME DRUG NAME GENERICS GENERICS Alendronate Sodium (Fosamax) Bupropion HCl (Zyban) Disulfiram (Antabuse) BRANDS Etidronate Disodium (Didronel) Chantix (Varenicline Tartrate) Levocarnitine (Carnitor) Nicotrol (Nicotine) Midodrine HCl (ProAmatine) Zyban (Bupropion HCl) Pilocarpine HCl (Salagen) Sodium Polystyrene Sulfonate (Kayexalate) Sodium Polystyrene Sulfonate Enema (Sodium Polystyrene Sulfonate) 16.3 Anorexiants BRANDS FORMULARY PRODUCTS Actonel 30mg (Risedronate Sodium) DRUG NAME Adagen (Pegademase Bovine) GENERICS Buphenyl (Sodium Phenylbutyrate) Diethylpropion HCl (Tenuate) Carbaglu (Carglumic Acid) Phendimetrazine Tartrate (Bontril PDM) Chemet (Succimer) Phentermine HCl (Fastin)

Evoxac (Cevimeline HCl) BRANDS Exjade (Deferasirox) Xenical (Orlistat) Fosrenol (Lanthanum Carbonate)

Orfadin (Nitisinone) Prolastin (Alpha-1-Proteinase Inhibitor) COMMONLY PRESCRIBED NONFORMULARY PRODUCTS 15 Prolastin C (Alpha-1-Proteinase Inhibitor) DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Renvela (Sevelamer Carbonate Tablet) Adipex-P Phentermine HCl (Various)

Rilutek (Riluzole) Bontril PDM Phendimetrazine Tartrate (Various) Hematinics & ElectrolytesVitamins, Soliris (Eculizumab) Didrex Diethylpropion HCl (Various) Xiaflex (Collagenase Clostridium Hist) Phentermine HCl (Various) Ionamin Phentermine HCl (Various)

COMMONLY PRESCRIBED NONFORMULARY PRODUCTS DRUG NAME POSSIBLE FORMULARY ALTERNATIVES Agrylin Anagrelide Hydrochloride (Various) Antabuse Disulfiram (Various) Aralast Prolastin (Talecris Biotherapeutics) Campral Naltrexone Hydrochloride (Various) Carnitor Levocarnitine (Various) Didronel Etidronate Disodium (Various) Alendronate Sodium (Various) Actonel 30mg (Procter & Gamble Pharmaceuticals) Glassia Prolastin (Talecris Biotherapeutics) Prolastin C (Talecris Biotherapeutics) Ferriprox Exjade (Novartis) Fosamax 40mg Alendronate Sodium (Various) ProAmatine Midodrine HCl (Various) Reclast Alendronate Sodium (Various) Boniva Tablet (Roche Laboratories) Renagel Renvela (Genzyme) Salagen Pilocarpine HCl (Various) Evoxac (Daiichi Sankyo) 16 Sodium Polystyrene Sulfonate Sodium Polystyrene Sulfonate Powder

Oral Suspension (Various) Diagnostics & Miscellaneous Agents Sodium Polystyrene Sulfonate Enema (Various) Zemaira Prolastin (Talecris Biotherapeutics)

Weigh risk of birth defects and other adverse outcomes. Do not use during pregnancy. 55 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:37 AM Page 56

INDEX

A Advair HFA ...... 51 A/T/S ...... 29 Advicor ...... 27 Abacavir ...... 7 Aerobid ...... 51 Abacavir Sulfate ...... 7 Aerobid-M ...... 51 Abacavir Sulfate/Lamivudine ...... 7 Afinitor ...... 11 Abacavir Sulfate/Lamivudine/Zidovudine ...... 7 Agalsidase Beta ...... 34 Abatacept ...... 41 Agenerase ...... 7 Abatacept/Maltose ...... 41 Agents For Pheochromocytoma ...... 25 Abilify ...... 20 Aggrenox ...... 22,53 Abiraterone Acetate ...... 10 Agrylin ...... 55 Abstral ...... 12 AHF, Human/VWF, Human ...... 23,54 Acanya ...... 29 Akne-Mycin ...... 29 Acarbose ...... 34,35 Alamast ...... 48 Accolate ...... 51 Albalon ...... 47 Accu-Chek Active ...... 35 Albendazole ...... 8 Accu-Chek Advantage ...... 35 Albenza ...... 8 Accu-Chek Aviva ...... 35 Albuterol ...... 50 Accu-Chek Aviva Plus ...... 35 Albuterol Sulfate ...... 50 Accu-Chek Comfort Curve ...... 35 Albuterol Sulfate/Ipratropium Bromide ...... 51 Accu-Chek Compact ...... 35 Alclometasone Dipropionate ...... 28,29,31 Accu-Chek Compact Plus ...... 35 Alcohol Antiseptic Pads ...... 35 Accu-Chek Multiclix ...... 35 Alcohol Prep ...... 35 Accu-Chek Nano Smartview ...... 35 Aldactazide ...... 23 Accu-Chek Smartview ...... 35 Aldactone ...... 23 Accu-Chek Soft Touch ...... 35 Aldara ...... 31 Accu-Chek Softclix ...... 35 Aldesleukin ...... 40 Accuneb ...... 50 Aldomet ...... 25 Accupril ...... 25 Aldoril ...... 26 Accuretic ...... 26 Aldurazyme ...... 34 Accutane ...... 29 Alendronate Sodium ...... 42,55 Ace Inhibitors ...... 25 Alendronate Sodium 10mg ...... 42 Acebutolol HCl ...... 24 Alendronate Sodium 35mg ...... 42 Aceon ...... 25 Alendronate Sodium 5mg ...... 42 Acetaminophen w/Codeine ...... 12,14 Alendronate Sodium 70mg ...... 42 Acetaminophen/Butalbital ...... 12,14 Alendronate Sodium Solution ...... 42 Acetaminophen/Caffeine/Butalbital ...... 12,14 Alesse ...... 43 Acetazolamide ...... 16,46 Alferon N ...... 40 Acetic Acid ...... 32 Alfuzosin HCl ...... 52 Acetic Acid/Aluminum Acetate ...... 32 Alglucosidase Alfa ...... 34 Acetic Acid/Hydrocortisone ...... 32 Alinia ...... 8 Acetic Acid/Ricinoleic Acid/Oxyquinoline ...... 45 Aliskiren Hemifumarate ...... 26 Acetohexamide ...... 34 Aliskiren/Amlodipine ...... 26 Acetohexamide ...... 34 Aliskiren/Amlodipine/Hydrochlorothiazide ...... 26 Acetylcysteine ...... 51 Aliskiren/Hydrochlorothiazide ...... 26 Achromycin V ...... 5 Aliskiren/Valsartan ...... 26 Acid Jelly ...... 45 Alitretinoin ...... 31 Aciphex ...... 36 Alkeran ...... 10 Acitretin ...... 30 Alkylating Agents ...... 10 Aclovate ...... 28,29 Allegra ...... 49 Actemra ...... 41 Allegra ODT ...... 49 Acthar H.P ...... 49 Allegra-D 12 Hour ...... 50 Acthar H.P...... 33,41 Allegra-D 24 Hour ...... 50 Actigall ...... 37 Allergist Syringe/Needle ...... 35 Actimmune ...... 40 Allopurinol ...... 41 Actiq ...... 12 Alocril ...... 48 Activella ...... 42,45 Alomide ...... 48 Actonel 150mg ...... 42 Alora ...... 44 Actonel 30mg ...... 55 Alosetron HCl ...... 38 Actonel 35mg ...... 42 Alpha-1-Proteinase Inhibitor ...... 55 Actonel 5mg ...... 42 Alphagan ...... 48 Actonel with Calcium ...... 42 Alphagan P 0.1% ...... 48 Actoplus Met ...... 34,35 Alphagan P 0.15% ...... 48 Actoplus Met XR ...... 35 Alprazolam ...... 21 Actos ...... 34,35 Alprazolam XR ...... 21 Acular ...... 47 Alprostadil ...... 52 Acular LS ...... 47 Alrex ...... 47 Acyclovir ...... 7,30 Alsuma ...... 14 Aczone ...... 29 Altabax ...... 29 Adagen ...... 55 Altace ...... 25 Adalat ...... 25 Altoprev ...... 27 Adalat CC ...... 25 Altretamine ...... 11 Adalimumab ...... 41 Aluminum Chloride ...... 31 Adapalene ...... 29 Alupent ...... 50 Adapalene/Benzoyl Peroxide ...... 29 Alvesco ...... 51 Adcetris ...... 11 Amantadine HCl ...... 7,15 Adcirca ...... 51 Amaryl ...... 34,35 Adderall ...... 21 Ambien ...... 18 Adderall XR ...... 21 Ambien CR ...... 18 Adefovir Dipivoxil ...... 7 Ambrisentan ...... 51 Adipex-P ...... 55 Amcinonide ...... 28 Adjunctive Agents ...... 11 Amerge ...... 14 Adjunctive Agents ...... 11 Amethia ...... 43 Adoxa ...... 5 Amethyst ...... 43 Adoxa Pak ...... 5 Amevive ...... 30 Adrenal Hormones ...... 33 Amicar ...... 23,54 Adrenergic Antagonists & Related Drugs ...... 25 Amiloride HCl ...... 23 Adrenergics ...... 49 Amiloride HCl/Hydrochlorothiazide ...... 23 Advair Diskus ...... 51 Aminocaproic Acid ...... 23,54 56 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:37 AM Page 57

Aminophylline ...... 50 Antivert ...... 15,39 Aminophylline ...... 50 Antivertigo & Antiemetic Agents ...... 39 Amiodarone HCl ...... 22 Antivertigo & Antiemetic Drugs ...... 15 Amitiza ...... 38 Antivirals ...... 7,48 Amitriptyline HCl ...... 18 Anusol-HC ...... 38 Amlodipine Besylate ...... 25,27 Anxiolytics ...... 21 Amlodipine Besylate/Benazepril HCl ...... 26 Anzemet ...... 15,39 Amlodipine Besylate/Olmesartan ...... 26 APAP/Dichlphen/Isometheptene ...... 14 Amlodipine/Valsartan ...... 26 Aphthasol ...... 32 Amlodipine/Valsartan/HCTZ ...... 26 Apidra ...... 34 Ammonium Lactate ...... 31 Apidra Solostar ...... 34 Amox TR/Potassium Clavulanate ...... 5,8 Apokyn ...... 15 Amoxapine ...... 18 Apomorphine HCl ...... 15 Amoxicillin ...... 5,36 Apraclonidine HCl ...... 48 Amoxicillin Trihydrate ...... 5 Aprepitant ...... 15,39 Amoxicillin Trihydrate/Potassium Apresazide ...... 26 Clavulanate ...... 5 Apresoline ...... 25 Amoxicillin Trihydrate/Potassium Apri ...... 43 Clavulanate Suspension, Oral ...... 5 Apriso ...... 38 Amoxicillin Trihydrate/Potassium Aptivus ...... 7 Clavulanate Tablet, Chewable ...... 5 Aralast ...... 55 Amoxicillin/Clavulanate ER ...... 5 Aralen Phosphate ...... 9 Amoxil ...... 5 Aranesp ...... 40 Amphetamine Aspartate/Amphetamine Sulfate/ Arava ...... 41 Dextroamphetamine ...... 21 Arcalyst ...... 40 Amphetamine Salt Combo ...... 21 Arcapta Neohaler ...... 50 Ampicillin Trihydrate ...... 5 Aricept ...... 17 Amprenavir/Vitamin E ...... 7 Aricept 23mg ...... 17 Amprenavir/Vitamin E/Propylene Glycol ...... 7 Aricept 5mg, 10mg ...... 17 Amrix ...... 17,42 Aricept ODT ...... 17 Amturnide ...... 26 Arimidex ...... 10 Amylase/Lipase/Protease ...... 37 Aristocort ...... 28 Anafranil ...... 18 Arixtra ...... 23,54 Anagrelide Hydrochloride ...... 55 Armour Thyroid ...... 33 Analpram Advanced ...... 38 Aromasin ...... 10 Analpram E ...... 38 Artane ...... 15 Analpram-HC ...... 38 Artemether/Lumefantrin ...... 9 Anamantle HC ...... 38 Arthrotec ...... 13 Anamantle HC Forte ...... 38 Arzerra ...... 11 Anaplex DMX ...... 49 Asacol ...... 38 Anaprox ...... 13,41 Asacol HD ...... 38 Anaprox DS ...... 13,41 Asendin ...... 18 Anastrozole ...... 10 Asmanex ...... 51 Ancobon ...... 8 Aspirin w/Codeine ...... 12 Androderm ...... 33 Aspirin/Caffeine/Butalbital ...... 12,14 Androgel ...... 33 Aspirin/Dipyridamole ...... 22,53 Androgens ...... 33 Astelin ...... 32 Androgens, Estrogens, Hormones & Related Drugs ...... 10 Astepro ...... 32 Android ...... 33 Atabex ...... 53 Androxy ...... 33 Atacand ...... 26 Anexsia ...... 12 Atacand HCT ...... 26 Angeliq ...... 45 Atarax ...... 49 Angiotensin Ii Receptor Blockers & Renin Atazanavir Sulfate ...... 7 Inhibitors ...... 26 Atelvia ...... 42 Animi-3 ...... 53 Atenolol ...... 24 Anorexiants ...... 55 Atenolol/Chlorthalidone ...... 26 Ansaid ...... 13,41 Ativan ...... 21 Antabuse ...... 55 Atomoxetine HCl ...... 21 Antara ...... 27 Atorvastatin Calcium ...... 27 Anthralin ...... 30 Atovaquone ...... 8 Antiandrogens ...... 10 Atovaquone/Proguanil HCl ...... 9 Antiarrhythmic Agents ...... 22 Atralin ...... 29 Antibiotics ...... 47 Atripla ...... 7 Anticholinergics & Antispasmodics ...... 52 Atropine Sulfate ...... 46 Anticoagulants ...... 22,53 Atrovent ...... 32,51 Anticonvulsants ...... 16 Atrovent HFA ...... 51 Antidepressant Agents ...... 18 Augmentin ...... 5 Antidiarrheals ...... 36 Augmentin 125-31.25mg/5mL ...... 5 Antidiarrheals & Antispasmodics ...... 36 Augmentin 250-62.5mg ...... 5 Antiestrogens ...... 10 Augmentin ES ...... 5 Antifungal Agents ...... 8 Augmentin Suspension, Oral 200-28.5mg/5mL, Antihemophilic Factor VIII ...... 23,54 400-57mg/5mL, 250-62.5mg/5mL ...... 5 Antihistamine & Antiallergenic Agents ...... 49 Augmentin Tablet ...... 5 Antihistamines ...... 49 Augmentin Tablet, Chewable 200-28.5mg, 400-57mg ...... 5 Antihypertensive Therapy ...... 23 Augmentin XR ...... 5 Antimalarials ...... 9 Auranofin ...... 41 Antimetabolites ...... 10 Avalide ...... 26 Antimycobacterials ...... 9 Avandamet ...... 34 Antineoplastic & Immunosuppressant Drugs ...... 10 Avandaryl ...... 34 Antiparasitics ...... 8 Avandia ...... 34 Antiparkinsonism Agents ...... 15 Avapro ...... 26 Antiplatelet Drugs ...... 22,53 Avastin ...... 11 Antipsoriatic/Antiseborrheic ...... 30 AVC ...... 45 Antipsychotics ...... 19 Avelox ...... 6 Antipyrine/Benzocaine/Glycerin ...... 32 Aviane ...... 43 Antispasmodics ...... 37 Aviane 0.1-0.02 ...... 43 Antithyroid Agents ...... 33 Avinza ...... 12 Antitussive Combinations ...... 49 Avodart ...... 52 57 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:37 AM Page 58

Avonex Administration Pack ...... 17,40 Betoptic ...... 46 Avonex Pen ...... 40 Betoptic S ...... 46 Axert ...... 14 Bevacizumab ...... 11 Axid ...... 36 Beyaz ...... 43 Axid Oral Solution ...... 36 Biaxin ...... 6 Axid Pulvule ...... 36 Biaxin XL ...... 6 Axiron ...... 33 Bicalutamide ...... 10 Aygestin ...... 44 BiDil ...... 25 Azacitidine ...... 10 Bile Acids ...... 37 Azasan ...... 10 Biltricide ...... 8 AzaSite ...... 47 Bimatoprost ...... 46 Azathioprine ...... 10,41 Biotechnology Drugs ...... 40 Azelaic Acid ...... 29 Bisacodyl/Sodium Chloride/Sodium Azelastine HCl ...... 32,48 Bicarbonate/Potassium Chloride/ Azelex ...... 29 Polyethylene Glycol 3350 ...... 39 Azilect ...... 15 Bismuth/Metronid/Tetracycline ...... 36 Azithromycin ...... 6,8 Bisoprolol Fumarate ...... 24 Azmacort ...... 51 Bisoprolol Fumarate/HCTZ ...... 26 Azopt ...... 46 Bisoprolol Fumarate/Hydrochlorothiazide ...... 26 Azor ...... 26 Bleph-10 ...... 47 Aztreonam Lysine ...... 8 Blephamide ...... 48 Azulfidine ...... 38,41 Blephamide S.O.P...... 48 Blocadren ...... 24 Blood Glucose Monitoring Devices & B Supplies ...... 35 B-D Insulin Syringe ...... 35 Blood Sugar Diagnostic Strip ...... 35 Bacitracin ...... 47 Blood-Glucose Measuring Equipment Kit ...... 35 Bacitracin ...... 47 Boceprevir ...... 7 Bacitracin/Polymyxin B Sulfate ...... 47 Boniva ...... 42 Bacitracin/Polymyxin Ointment ...... 47 Boniva Syringe Kit ...... 42 Baclofen ...... 17,42 Boniva Tablet ...... 55 Bactrim DS ...... 6 Bontril PDM ...... 55 Bactroban ...... 29 Bortezomib ...... 11 Bactroban Cream ...... 29 Bosentan ...... 51 Bactroban Nasal ...... 32 Bowel Evacuants ...... 39 Bactroban Ointment ...... 29 Bravelle ...... 33,45 Balsalazide Disodium ...... 38 Brentuximab Vedotin ...... 11 Banzel ...... 16 Brethine ...... 45,50 Banzel Oral Suspension ...... 16 Brevicon ...... 43 Banzel Tablet ...... 16 Brevoxyl ...... 29 Baraclude ...... 7 Brilinta ...... 22,53 Beclomethasone Dipropionate ...... 51 Brimonidine Tartrate ...... 46,48 Beconase AQ ...... 51 Brinzolamide ...... 46 Belladonna w/Phenobarbital ...... 37 Bromday ...... 47 Benadryl 50mg ...... 15,49 Bromfed ...... 49,50 Benazepril HCl ...... 25 Bromfed-DM ...... 49 Benazepril HCl/Hydrochlorothiazide ...... 26 Bromfed-PD ...... 49 Bendamustine HCl ...... 10 Bromfenac Sodium ...... 47 Benicar ...... 26 Bromocriptine Mesylate ...... 15 Benicar HCT ...... 26 Brompheniramine w/Pseudoephed ...... 49,50 Benign Prostatic Hyperplasia (bph) Therapy ...... 52 Brovana ...... 50 Benlysta ...... 41 Budesonide ...... 32,38,51 Bentyl ...... 37,52 Budesonide EC ...... 38 Benzaclin ...... 29 Budesonide/Formoterol Fumarate ...... 51 Benzaclin Pump ...... 29 Bumetanide ...... 23 Benzagel ...... 29 Bumex ...... 23 Benzamycin ...... 29 Buphenyl ...... 55 Benzamycin Pak ...... 29 Buprenorphine ...... 12 Benziq ...... 29 Buprenorphine HCl ...... 12 Benzocaine ...... 32 Buprenorphine HCl/Naloxone HCl ...... 14 Benzoyl Peroxide ...... 29 Bupropion HCl ...... 18,55 Benzoyl Peroxide/Urea ...... 29 Bupropion HCl Tablet, Extended Release ...... 18 Benztropine Mesylate ...... 15 Bupropion HCl Tablet, Sustained Action ...... 18 Benzyl Alcohol ...... 31 Burn Therapy ...... 30 Bepreve ...... 48 Buspar ...... 21 Berinert ...... 51 Buspirone HCl ...... 21 Besifloxacin HCl ...... 47 Busulfan ...... 10 Besivance ...... 47 Butalbital Compound ...... 12 Beta Agonists Inhalers ...... 50 Butalbital Compound w/Codeine ...... 12 Beta Agonists Oral ...... 50 Butalbital/Acetaminophen ...... 12 Beta Blockers ...... 24 Butalbital/APAP/Caffeine ...... 12 Beta-blockers ...... 46 Butalbital/Caff/APAP/Codeine ...... 12 Betagan ...... 46 Butenafine HCl ...... 30 Betaine ...... 38 Butisol Sodium ...... 18 Betamethasone Dipropionate ...... 28,30 Butoconazole Nitrate ...... 45 Betamethasone Dipropionate Lotion ...... 30 Butorphanol Tartrate Aerosol, Spray ...... 14 Betamethasone Dipropionate/Propylene Glycol ...... 28 Butrans ...... 12 Betamethasone DP Augmented ...... 28 Butyrophenones ...... 20 Betamethasone Valerate ...... 28 Bydureon ...... 34 Betamethasone Valerate Cream ...... 28 Byetta ...... 34,35 Betamethasone Valerate Lotion ...... 28 Bystolic ...... 24 Betapace ...... 22 Betapace AF ...... 22 Betaseron ...... 17,40 C Betatrex ...... 28 C1 Esterase Inhibitor ...... 51 Betaxolol ...... 46 Cabazitaxel ...... 11 Betaxolol HCl ...... 24,46 Cabergoline ...... 34 Bethanechol Chloride ...... 52 Caduet ...... 27 Betimol ...... 46 Cafergot ...... 14 58 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:37 AM Page 59

Cal-Nate ...... 53 CellCept Tablet ...... 10 Calan ...... 24 Celontin ...... 16 Calan SR ...... 24 Cenestin ...... 44 Calcipotriene ...... 30 Centany ...... 29 Calcipotriene Solution ...... 30 Cephalexin ...... 5 Calcitonin, Salmon, Synthetic ...... 34 Cephalexin Monohydrate ...... 5 Calcitonin,Salmon, Synthetic ...... 42 Cephalosporins ...... 5 Calcitonin-Salmon ...... 34 Cephulac ...... 38 Calcitriol ...... 30,34 Cerefolin ...... 53 Calcium Acetate ...... 54 Cerezyme ...... 34 Calcium Channel Blockers ...... 24 Cesamet ...... 39 Calcium Channel Blockers/Dihydropyridines ...... 25 Cesia ...... 43 Calcium Channel Blockers/Non- Cetraxal ...... 32 Dihydropyridines ...... 24 Cetrorelix Acetate ...... 34,45 Cambia ...... 13 Cetrotide ...... 34,45 Camila ...... 44 Cetuximab ...... 11 Campral ...... 55 Cevimeline HCl ...... 55 Camrese ...... 43 Chantix ...... 55 Camrese Lo ...... 43 Chemet ...... 55 Canasa ...... 38 Chemstrip K ...... 35 Candesartan Cilexetil ...... 26 Chenodal ...... 37 Candesartan Cilexetil/Hydrochlorothiazide ...... 26 Chloral Hydrate ...... 18 Cantil ...... 37 Chlorambucil ...... 10 Capecitabine ...... 10 Chlordiazepoxide HCl ...... 21 Capex Shampoo ...... 28,29,30 Chlorhexidine Gluconate ...... 32 Capital w/Codeine ...... 12 Chloroquine Phosphate ...... 9 Capoten ...... 25 Chlorothiazide ...... 23 Capozide ...... 26 Chlorpromazine HCl ...... 19 Caprelsa ...... 11 Chlorpropamide ...... 34 Captopril ...... 25 Chlorthalidone ...... 23,26 Captopril/Hydrochlorothiazide ...... 26 Chlorzoxazone ...... 17,42 Carac ...... 31 Cholestyramine ...... 27 Carafate ...... 36 Cholestyramine Light ...... 27 Carafate Tablet ...... 36 Cholestyramine/Aspartame ...... 27 Carbachol ...... 46 Cholestyramine/Sucrose ...... 27 Carbaglu ...... 55 Choline Salicylate/Magnesium Salicylate ...... 14,41 Carbamazepine ...... 16 Cholinergic Stimulants ...... 52 Carbamazepine XR ...... 16 Cholinesterase Inhibitor Miotics ...... 46 Carbatrol ...... 16 Chorionic Gonadotropin ...... 34 Carbetapentane Tannate/Pseudoephedrine Chromagen FA ...... 53 Tannate ...... 50 Chromagen Forte ...... 53 Carbidopa ...... 15 Chronulac ...... 38 Carbidopa/Levodopa ...... 15 Cialis ...... 52 Carbidopa/Levodopa Tablet, Sustained Ciclesonide ...... 51 Action ...... 15 Ciclopirox ...... 30 Carbidopa/Levodopa/Entacapone ...... 15 Ciclopirox Solution ...... 30 Cardene SR ...... 25 Cilostazol ...... 22,53 Cardiac Glycosides ...... 22 Ciloxan ...... 47 Cardizem ...... 24 Ciloxan Drops ...... 47 Cardizem CD ...... 24 Cimetidine ...... 36 Cardizem LA ...... 24 Cimetidine HCl Liquid ...... 36 Cardizem LA 120mg ...... 24 Cimetidine Liquid ...... 36 Cardizem LA 180mg, 240mg, 300mg, 360mg, Cimetidine Tablet ...... 36 420mg ...... 24 Cimzia ...... 38 Cardizem SR ...... 24 Cinacalcet HCl ...... 34 Cardura ...... 25,52 Cinryze ...... 51 Carglumic Acid ...... 55 Cipro ...... 6 Carisoprodol ...... 17,42 Cipro HC ...... 32 Carmol 40 ...... 31 Cipro XR ...... 6 Carmol HC ...... 31 Ciprodex ...... 32 Carnitor ...... 55 Ciprofloxacin ER ...... 6 Carteolol HCl ...... 46 Ciprofloxacin HCl ...... 6,8,47 Carvedilol ...... 24 Ciprofloxacin HCl Drops ...... 47 Carvedilol Phosphate ...... 24 Ciprofloxacin HCl Ointment ...... 47 Casodex ...... 10 Ciprofloxacin HCl/Dexamethasone ...... 32 Cataflam ...... 13 Ciprofloxacin Suspension, Microcapsule Catapres ...... 25 Reconstituted ...... 6 Catapres-TTS ...... 25 Citalopram HBr ...... 19 Caverject ...... 52 Citalopram Hydrobromide ...... 19 Cayston ...... 8 Citracal Prenatal Rx ...... 53 Caziant ...... 43 Clarinex ...... 32,49 Ceclor ...... 5 Clarinex Reditabs ...... 49 Cedax ...... 6 Clarinex Syrup ...... 49 CeeNu ...... 10 Clarinex Tablet ...... 49 Cefaclor ...... 5,6 Clarinex-D 12 Hour ...... 50 Cefadroxil ...... 5 Clarinex-D 24 Hour ...... 50 Cefadroxil Hydrate ...... 5 Clarithromycin ...... 6,36 Cefdinir ...... 6 Clarithromycin ER ...... 6 Cefpodoxime Proxetil ...... 5 Clemastine Fumarate ...... 49 Ceftin ...... 5 Clenia Cream ...... 29 Cefuroxime Axetil ...... 5,6 Cleocin HCl ...... 8 Celebrex ...... 13,14,41 Cleocin Palmitate ...... 8 Celecoxib ...... 14,41 Cleocin Phosphate ...... 45 Celestone ...... 33 Cleocin T ...... 29 Celexa ...... 19 Clidinium Bromide/Chlordiazepoxide ...... 37 CellCept ...... 10 Climara ...... 44 CellCept Capsule ...... 10 Climara Pro ...... 45 CellCept Suspension ...... 10 Clindagel ...... 29 59 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:37 AM Page 60

Clindamycin HCl ...... 8 Cozaar ...... 26 Clindamycin Phosphate ...... 29,45 Creon ...... 37 Clindamycin Phosphate/Benzoyl Peroxide ...... 29 Crestor ...... 27 Clindamycin Phosphate/Benzoyl Peroxide/ Crinone ...... 44 Hyaluronate Sodium ...... 29 Crixivan ...... 7 Clindamycin/Tretinoin ...... 29 Crizotinib ...... 11 Clindesse ...... 45 Crolom ...... 48 Clinoril ...... 13,41 Cromolyn Sodium ...... 38,48 Clobetasol Propionate ...... 28 Cromolyn Sodium Aerosol ...... 51 Clobetasol Propionate/Emollient ...... 28 Cromolyn Sodium Ampul for Nebulization ...... 51 Clobex ...... 28 Crotamiton ...... 31 Cloderm ...... 28 Cuprimine ...... 41 Clomid ...... 33,45 Cutivate ...... 28 Clomiphene Citrate ...... 33,45 Cuvposa ...... 37 Clomipramine HCl ...... 18 Cyanocobalamin ...... 53 Clonazepam ...... 16 Cyanocobalamin/Folic Acid/Pyridoxine ...... 53 Clonidine HCl ...... 21,25,26 Cyclessa ...... 43 Clonidine HCl Tablet ...... 25 Cyclobenzaprine HCl ...... 17,42 Clonidine Patch ...... 25 Cyclocort ...... 28 Clopidogrel Bisulfate ...... 22,53 Cyclogyl ...... 46 Clorazepate Dipotassium ...... 21 Cyclopentolate HCl ...... 46 Clorpres ...... 26 Cyclophosphamide ...... 10 Clotrimazole ...... 8,30 Cycloplegic Mydriatics ...... 46 Clotrimazole/Betamethasone ...... 30 Cycloserine ...... 9 Clotrimazole/Betamethasone Dipropionate ...... 30 Cycloset ...... 35 Clozapine ...... 20 Cyclosporine ...... 10 Clozaril ...... 20 Cyclosporine ...... 10,48 Coagulation Therapy ...... 22,53 Cyclosporine, Modified ...... 10 Coartem ...... 9 Cymbalta ...... 18 Codeine Phosphate/Acetaminophen ...... 12 Cyproheptadine HCl ...... 49 Codeine Phosphate/Acetaminophen/Caffeine/ Cystadane ...... 38 Butalbital ...... 12 Cystagon ...... 52 Codeine Phosphate/Aspirin ...... 12 Cysteamine Bitartrate ...... 52 Codeine Phosphate/Aspirin/Caffeine/ Cytomel ...... 33 Butalbital ...... 12 Cytotec ...... 36 Codeine Sulfate ...... 12 Cytovene ...... 7 Codeine Sulfate ...... 12 Cytoxan ...... 10 Cogentin ...... 15 Cognex ...... 17 D Colazal ...... 38 D-methorphan/P-ephed HCl/Brompheniramine ...... 50 Colchicine ...... 41 D.H.E.45 ...... 14 Colchicine ...... 41 Dabigatran Etexilate Mesylate ...... 22,53 Colcrys ...... 41 Dacogen ...... 10 Colesevelam HCl ...... 27 Daliresp ...... 51 Colestid ...... 27 Dalmane ...... 18 Collagenase Clostridium Hist ...... 55 Dalteparin Sodium,Porcine ...... 23,54 Collagenase Clostridium Hist...... 30 Danazol ...... 33 Coly-Mycin S ...... 32 Danocrine ...... 33 Colyte ...... 39 Dantrium ...... 17,42 Colyte 227.1-21.5 ...... 39 Dantrolene Sodium ...... 17,42 Colyte 240-22.72G ...... 39 Dapsone ...... 8 Combigan ...... 46 Dapsone ...... 8,29 Combination Anticholinergics ...... 37 Daraprim ...... 9 Combination Narcotic/Analgesics ...... 12 Darbepoetin Alfa in Polysorbate ...... 40 Combipatch ...... 45 Darifenacin Hydrobromide ...... 17,42,52 Combivent ...... 51 Darunavir Ethanolate ...... 7 Combivent Respimat ...... 51 Dasatinib ...... 11 Combivir ...... 7 Daypro ...... 13,41 Combunox ...... 12 Daytrana ...... 21 Compazine ...... 15,39 DDAVP ...... 34 Completenate ...... 53 DDAVP Aerosol, Spray w/Pump ...... 34 Comtan ...... 15 Decadron ...... 33,41,47,49 Concerta ...... 21 Deconamine ...... 50 Condylox ...... 31 Deconamine SR ...... 50 Copaxone ...... 17,40 Deconex ...... 49 Copegus ...... 7 Decongestant/Antihistamines ...... 50 Cordarone ...... 22 Deferasirox ...... 55 Cordran ...... 28 Degarelix Acetate ...... 11 Cordran Lotion ...... 28 Delavirdine Mesylate ...... 7 Cordran SP ...... 28 Deltasone ...... 33,41,49 Coreg ...... 24 Demadex ...... 23 Coreg CR ...... 24 Demerol ...... 12 Corgard ...... 24 Demser ...... 25 Cortane-B ...... 32 Demulen ...... 43 Cortef ...... 33,41,49 Denavir ...... 30 Cortenema ...... 38 Denosumab ...... 11 Corticosteroids ...... 41,49 Depakene ...... 16 Corticotropin ...... 33,41,49 Depakote ...... 16 Cortifoam ...... 38 Depakote ER ...... 16 Cortisone Acetate ...... 33,41,49 Depakote Sprinkle ...... 16 Cortisporin ...... 32,48 Depo-Provera ...... 11 Cortisporin-TC ...... 32 Depo-Provera 400mg/ml ...... 11,44 Cortone Acetate ...... 33,41,49 Depo-SubQ Provera ...... 44 Corzide ...... 26 Depo-Testosterone ...... 33 Cosopt ...... 46 Derma-Smoothe FS ...... 28,29 Cough & Cold Therapy ...... 49 Dermatop ...... 28 Coumadin ...... 22,53 DermOtic ...... 32 Covera-HS ...... 24 Desipramine HCl ...... 18 60 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:38 AM Page 61

Desloratadine ...... 32,49 Diphenoxylate w/Atropine ...... 36 Desmopressin Acetate ...... 34 Dipivefrin HCl ...... 48 Desmopressin Acetate Aerosol, Spray w/Pump ...... 34 Diprolene ...... 28 Desmopressin Acetate/Sodium Phosphate, Diprolene AF ...... 28 Dibasic/Citric Acid ...... 34 Diprosone ...... 28 Desogen ...... 43 Dipyridamole ...... 22,53 Desogestrel-Ethinyl Estradiol ...... 43 Direct Acting Miotics ...... 46 Desogestrel-Ethinyl Estradiol/Ethinyl Disopyramide Phosphate ...... 22 Estradiol ...... 43 Disulfiram ...... 55 Desonate ...... 29 Ditropan ...... 17,42,52 Desonide ...... 28,29,31 Ditropan XL ...... 17,42,52 DesOwen ...... 28,29 Diuril ...... 23 Desoximetasone ...... 28 Divalproex Sodium ...... 16 Desoximetasone Cream ...... 28 Divalproex Sodium ER ...... 16 Desoxyn ...... 21 Divigel ...... 44 Despec ...... 49 Dofetilide ...... 22 Desquam-X ...... 29 Dolasetron Mesylate Tablet ...... 15,39 Desvenlafaxine Succinate ...... 18 Dolobid ...... 14,41 Desyrel ...... 18 Dolophine HCl ...... 12 Detrol ...... 17,42,52 Domeboro ...... 32 Detrol LA ...... 17,42,52 Donatussin ...... 49 Dexamethasone ...... 33,39,41,47,49 Donepezil HCl ...... 17 Dexamethasone Drops ...... 33 Donnatal ...... 37 Dexamethasone Elixir ...... 33 Doral ...... 18 Dexamethasone Sodium Phosphate ...... 47 Dornase Alfa ...... 51 Dexedrine ...... 21 Doryx ...... 5 Dexilant ...... 36 Dorzolamide HCl ...... 46 Dexmethylphenidate HCl ...... 21 Dorzolamide/Timolol ...... 46 Dexpak ...... 33 Dostinex ...... 34 Dextroamphetamine Sulfate ...... 21 Dovonex ...... 30 Dextroamphetamine-Amphetamine ER ...... 21 Doxazosin Mesylate ...... 25,52 Dextromethorphan HBr/Pseudoephedrine HCl/ Doxepin HCl ...... 18 Brompheniramine ...... 49 Doxercalciferol ...... 34 Dextromethorphan HBr/Quinidine ...... 17 Doxycycline Hyclate ...... 5 DiaBeta ...... 34,35 Doxycycline Hyclate Capsule ...... 5 Diabetes Therapy ...... 34 Doxycycline Hyclate Tablet ...... 5 Diabinese ...... 34 Doxycycline Monohydrate ...... 5 Dialyvite ...... 53 Drisdol Capsule ...... 53 Diamox ...... 16,46 Dritho-Scalp ...... 30 Diamox Sequels ...... 46 Drithocreme HP ...... 30 Diaphragms And Other Non-Oral Dronedarone HCl ...... 22 Contraceptives ...... 45 Drospirenone/Ethinyl Estradiol/ Diastat ...... 16 Levomefolate ...... 43 Diastat AcuDial ...... 16 Drospirenone/Ethinyl Estradiol/ Diazepam ...... 16,17,21,42 Levomefolate Calcium ...... 43 Diazepam Oral Concentrate ...... 21 Droxia ...... 11 Diazepam Tablet ...... 21 Drugs To Treat Infertility/Ivf Agents ...... 45 Dibenzyline ...... 25 Drysol ...... 31 Diclofenac Potassium ...... 13 Duac ...... 29 Diclofenac Sodium ...... 13 Duac CS ...... 29 Diclofenac Sodium ...... 47 Duet Stuartnatal ...... 53 Dicloxacillin Sodium ...... 5 Duetact ...... 34 Dicyclomine HCl ...... 37,52 Duexis ...... 13 Didanosine ...... 7 Dulera ...... 51 Didrex ...... 55 Duloxetine HCl ...... 18 Didronel ...... 55 Duoneb ...... 51 Diethylpropion HCl ...... 55 Duragesic ...... 12 Difenoxin HCl/Atropine Sulfate ...... 36 Durahist PE ...... 50 Differin ...... 29 Duratuss DM ...... 49 Dificid ...... 6 Durezol ...... 47 Diflorasone Diacetate ...... 28 Duricef ...... 5 Diflorasone Diacetate Cream ...... 28 Dutasteride ...... 52 Diflucan ...... 8,45 Dutasteride/Tamsulosin HCl ...... 52 Diflunisal ...... 14,41 Dutoprol ...... 26 Difluprednate ...... 47 Dyazide ...... 23 Digestive Enzymes ...... 37 Dynacin ...... 5 Digoxin ...... 22 DynaCirc ...... 25 Dihydroergotamine Mesylate ...... 14 DynaCirc CR ...... 25 Dilacor XR ...... 24 Dynapen ...... 5 Dilantin ...... 16 Dyrenium ...... 23 Dilantin 100mg ...... 16 Dilantin 30mg ...... 16 E Dilantin Capsule 100mg ...... 16 E-Mycin ...... 6 Dilantin Oral Suspension ...... 16 E.E.S...... 6 Dilatrate-SR ...... 22 EC-Naprosyn ...... 13 Dilaudid ...... 12 Echothiophate Iodide ...... 46 Dilaudid Tablet ...... 12 Econazole Nitrate ...... 30 Diltiazem ER ...... 24 Econazole Nitrate Cream ...... 30 Diltiazem HCl ...... 24 Eculizumab ...... 55 Diltiazem HCl Capsule, Sustained Release 12 hr ...... 24 Edarbi ...... 26 Diltiazem HCl Capsule, Sustained Release 24 hr ...... 24 Edarbyclor ...... 26 Diltiazem XR ...... 24 Edecrin ...... 23 Diovan ...... 26 Edluar ...... 18 Diovan HCT ...... 26 Edurant ...... 7 Dioxybenzone/Padimate O/Hydroquinone ...... 31 Efavirenz ...... 7 Dipentum ...... 38 Efavirenz/ Emtricitab/ Tenofovir ...... 7 Diphenhydramine HCl ...... 15,49 Effexor ...... 18 Diphenoxylate HCl/Atropine Sulfate ...... 36 Effexor XR ...... 18 61 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:38 AM Page 62

Effient ...... 22,53 Esomeprazole Magnesium Trihydrate ...... 36 Efudex ...... 31 Estazolam ...... 18 Efudex Solution ...... 31 Estrace ...... 44 Elaprase ...... 34 Estrace Tablet ...... 44 Elavil ...... 18 Estrace Vaginal Cream ...... 44 Eldepryl ...... 15 Estraderm ...... 44 Eldopaque Forte ...... 31 Estradiol ...... 44 Eldoquin Forte ...... 31 Estradiol ...... 44 Electrolytes ...... 54 Estradiol Cream ...... 44 Elestat ...... 48 Estradiol Patch ...... 44 Elestrin ...... 44 Estradiol Patch, Transdermal ...... 42 Eletriptan Hydrobromide ...... 14 Estradiol Patch, Transdermal Weekly ...... 44 Elidel ...... 31 Estradiol Tablet ...... 44 Elimite ...... 31 Estradiol Valerate/Dienogest ...... 43 Elixophyllin ...... 50 Estradiol/Norethindrone Acetate ...... 42,45 Ella ...... 43 Estramustine Phosphate Sodium ...... 11 Elmiron ...... 52 Estrasorb ...... 44 Elocon ...... 28 Estratest ...... 45 Eltrombopag Olamine ...... 23,54 Estratest H.S...... 45 Emadine ...... 48 Estring ...... 44 Embeda ...... 12 Estriol ...... 44 Emcyt ...... 11 Estrogel ...... 44 Emend ...... 15,39 Estrogen Combinations ...... 45 Emla Cream ...... 29 Estrogens ...... 44 Emsam ...... 19 Estrogens & Progestins ...... 44 Emtricitabine ...... 7 Estrogens ,Conjugated, Synthetic B ...... 44 Emtricitabine/Tenofovir Disoproxil Estrogens, Conjugated Tablet ...... 42,44 Fumarate ...... 7 Estrogens, Conjugated, Synthetic A ...... 44 Emtriva ...... 7 Estrogens, Conjugated/Medroxyprogesterone Acet ...... 45 Enablex ...... 17,42,52 Estrogens, Esterified/Methyltestosterone ...... 45 Enalapril Maleate ...... 25 Estropipate ...... 44 Enalapril Maleate/HCTZ ...... 26 Estrostep Fe ...... 43 Enalapril Maleate/Hydrochlorothiazide ...... 26 Etanercept ...... 41 Enbrel ...... 30,38,41 Ethambutol HCl ...... 9 Encora ...... 53 Ethinyl Estradiol/Drospirenone ...... 43 Endometrin ...... 44 Ethmozine ...... 22 Enduron ...... 23 Ethosuximide ...... 16 Enfuvirtide ...... 7 Ethotoin ...... 16 Enjuvia ...... 44 Ethynodiol D-Ethinyl Estradiol ...... 43 Enoxaparin Sodium ...... 23,54 Etidronate Disodium ...... 55 Entacapone ...... 15 Etodolac ...... 13,41 Entecavir ...... 7 Etonogestrel/Ethinyl Estradiol ...... 45 Entocort EC ...... 38 Etoposide ...... 11 Epiduo ...... 29 Etravirine ...... 7 Epinastine HCl ...... 48 Euflexxa ...... 14 Epinephrine ...... 49 Eulexin ...... 10 EpiPen ...... 49 Eurax ...... 31 EpiPen Jr...... 49 Evamist ...... 44 Epivir ...... 7 Everolimus ...... 11 Epivir HBV ...... 7 Evista ...... 42 Epivir Solution ...... 7 Evoclin ...... 29 Epivir Tablet ...... 7 Evoxac ...... 55 Eplerenone ...... 23 Exalgo ...... 12 Epoetin Alfa ...... 11,40 Exelderm ...... 30 Epogen ...... 40 Exelon ...... 17 Epoprostenol Sodium ...... 25 Exelon Capsules ...... 17 Eprosartan Mesylate ...... 26 Exemestane ...... 10 Epzicom ...... 7 Exenatide ...... 34 Equanil ...... 17 Exenatide Microspheres ...... 34 Equetro ...... 16 Exforge ...... 26 Erbitux ...... 11 Exforge HCT ...... 26 Ergocalciferol Capsule ...... 53 Exjade ...... 55 Ergomar ...... 14 Expectorant Combinations ...... 49 Ergotamine Tartrate ...... 14 Extina ...... 30 Ergotamine Tartrate/Caffeine ...... 14 Eylea ...... 48 Eribulin Mesylate ...... 11 Ezetimibe ...... 27 Erivedge ...... 11 Ezetimibe/Simvastatin ...... 27 Erlotinib HCl ...... 11 Ertazco ...... 30 F Ery-Tab 500mg ...... 6 Fabrazyme ...... 34 Erycette ...... 29 Factive ...... 6 EryPed ...... 6 Factor VIIa, Recombinant ...... 23,54 Erythrocin Stearate ...... 6 Famciclovir ...... 7 Erythroid Stimulants ...... 40 Famotidine ...... 13,36 Erythromycin ...... 6,29 Famotidine Tablet ...... 36 Erythromycin Base ...... 6,47 Famvir ...... 7 Erythromycin Base/Benzoyl Peroxide ...... 29 Fanapt ...... 20 Erythromycin Base/Ethyl Alcohol ...... 29 Fansidar ...... 9 Erythromycin Ethylsuccinate ...... 6 Fareston ...... 10 Erythromycin Ethylsuccinate/Sulfisoxazole Fast Take ...... 35 Acetyl ...... 6 Fastin ...... 55 Erythromycin Stearate ...... 6 Fazaclo ...... 20 Erythromycin-Benzoyl Peroxide ...... 29 Febuxostat ...... 41 Erythromycins & Other Macrolides ...... 6 Felbamate ...... 16 Escitalopram Oxalate ...... 19 Felbatol ...... 16 Esgic ...... 12 Feldene ...... 13,41 Esgic-Plus ...... 12 Felodipine ...... 25 Eskalith ...... 21 Femara ...... 10 62 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:38 AM Page 63

Femcon Fe ...... 43 Focalin XR ...... 21 Femhrt ...... 45 Folgard Rx ...... 53 Femring ...... 44 Folic Acid ...... 53 Femtabs ...... 53 Folic Acid-Cyancobal-Pyridoxin ...... 53 Femtrace ...... 44 Follistim AQ ...... 33,45 Fenofibrate ...... 27 Follitropin Beta, Recombinant ...... 33,45 Fenofibrate Acid ...... 27 Folotyn ...... 10 Fenofibrate, Micronized ...... 27 FOLTX ...... 53 Fenofibrate, Nanocrystallized ...... 27 Folvite ...... 53 Fenoglide ...... 27 Fondaparinux Sodium ...... 23,54 Fentanyl ...... 12 Foradil ...... 50 Fentanyl Citrate ...... 12 Formoterol Fumarate ...... 50 Fentora ...... 12 Fortamet ...... 35 Feosol ...... 53 Forteo ...... 42 Ferriprox ...... 55 Fortesta ...... 33 Ferrous Bis-Glycinate Chelate/Iron Polysaccharides Complex/ Fosamax ...... 42,55 Docusate/Ascorbic Acid/Folic Acid/Multivitamins Combin No.14 ...... 53 Fosamax 40mg ...... 55 Ferrous Fumarate/Ferrous Bis-Glycinate Chelate/Ascorbic Acid/ Fosamax Plus D ...... 42 Folic Acid/ Multivitamins Combo No.11/Calcium Threonate ...... 53 Fosamax Tablets ...... 42 Ferrous Sulfate Drops ...... 53 Fosamprenavir Calcium ...... 7 Fesoterodine Fumarat ...... 17 Fosinopril Sodium ...... 25 Fesoterodine Fumarate ...... 42 Fosinopril Sodium/Hydrochlorothiazide ...... 26 Fexofenadine HCl ...... 32,49 Fosrenol ...... 55 Fexofenadine HCl Suspension, Oral ...... 49 Fragmin ...... 23,54 Fibricor ...... 27 Frova ...... 14 Fidaxomicin ...... 6 Frovatriptan Succinate ...... 14 Filgrastim ...... 11,40 Furadantin ...... 6 Finacea ...... 29 Furosemide ...... 23 Finasteride ...... 52 Fuzeon ...... 7 Fingolimod HCl ...... 17 Fioricet ...... 12,14 G Fioricet w/Codeine ...... 12 Gabapentin ...... 16,17 Fiorinal ...... 12,14 Gabitril ...... 16 Fiorinal w/Codeine ...... 12 Galantamine ...... 17 Firazyr ...... 51 Galantamine Hydrobromide ...... 17 Firmagon ...... 11 Galsulfase ...... 34 First Generation Cephalosporins ...... 5 Ganirelix Acetate ...... 34 Flagyl ...... 8 Gantrisin ...... 6 Flagyl ER ...... 8 Garamycin ...... 29,47 Flarex ...... 47 Gastrocrom ...... 38 Flavoxate HCl ...... 52 Gatifloxacin ...... 47 Flecainide Acetate ...... 22 Gel-Kam Solution ...... 32 Flector ...... 13 Gelnique ...... 17,42,52 Flexeril ...... 17,42 Gemfibrozil ...... 27 Flolan ...... 25 Genotropin ...... 40 Flomax ...... 52 Gentamicin Sulfate ...... 29,47 Flonase ...... 32,51 Gentamicin Sulfate Cream ...... 29 Florinef Acetate ...... 33 Geodon ...... 20 Flovent Diskus ...... 51 Gilyena ...... 17 Flovent HFA ...... 51 Glassia ...... 55 Floxin ...... 6,32 Glatiramer Acetate ...... 17,40 Fluconazole ...... 8,45 Gleevec ...... 11 Flucytosine ...... 8 Glimepiride ...... 34,35 Fludarabine Phosphate ...... 10 Glipizide ...... 34,35 Fludrocortisone Acetate ...... 33 Glipizide ER ...... 35 Flumadine ...... 7 Glipizide-Metformin ...... 35 Flunisolide ...... 32,51 Glipizide/Metformin HCl ...... 34 Fluocinolone Acetonide ...... 28,31,47 Glucagon ...... 35 Fluocinolone Acetonide Cream ...... 28 Glucagon, Human Recombinant ...... 35 Fluocinolone Acetonide Oil ...... 32 Glucophage ...... 34,35 Fluocinolone Acetonide Solution ...... 29 Glucophage XR ...... 34,35 Fluocinonide ...... 28 Glucose Elevating Agents ...... 35 Fluocinonide/Emollient ...... 28 Glucotrol ...... 34,35 Fluoride Ion/Iron/Vitamins A,C,and D ...... 53 Glucotrol XL ...... 34,35 Fluoride Ion/Multivitamins ...... 53 Glucovance ...... 34,35 Fluoride Ion/Multivitamins w-Iron ...... 53 Glumetza ...... 35 Fluoride Ion/Vitamins A,C,and D ...... 53 Glyburide ...... 34,35 Fluorometholone ...... 47 Glyburide Micronized ...... 35 Fluoroquinolones ...... 6 Glyburide, Micronized ...... 34 Fluorouracil ...... 31 Glyburide-Metformin HCl ...... 35 Fluorouracil Cream ...... 31 Glyburide/Metformin HCl ...... 34 Fluorouracil Solution ...... 31 Glycopyrrolate ...... 37 Fluoxetine HCl ...... 19,20 Glynase ...... 34,35 Fluphenazine HCl ...... 19 Glyset ...... 35 Flurandrenolide Tape, Medicated ...... 28 Gold Sodium Thiomalate ...... 41 Flurazepam HCl ...... 18 GoLYTELY ...... 38,39 Flurbiprofen ...... 13,41 Gonadotropin & Related Agents ...... 34 Flurbiprofen Sodium ...... 47 Gonadotropin, Chorionic, Human ...... 34,45 Flutamide ...... 10 Gonal-F ...... 33 Fluticasone Furoate ...... 32,51 Gonal-F RFF ...... 33 Fluticasone Propionate ...... 28,32,51 Goserelin Acetate ...... 11 Fluticasone Propionate/Salmeterol Gout Therapy ...... 41 Xinafoate ...... 51 Gralise ...... 16 Fluvastatin Sodium ...... 27 Granisetron ...... 15,39 Fluvoxamine Maleate ...... 19 Granisetron HCl ...... 15,39 FML ...... 47 Granulex ...... 30 FML S.O.P...... 47 Grifulvin V Tablet ...... 8 Focalin ...... 21 Gris-Peg ...... 8 63 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:38 AM Page 64

Griseofulvin Ultramicrosize ...... 8 Hydrocortisone Valerate Cream ...... 28 Growth Hormones ...... 40 Hydrocortisone/Pramoxine HCl/Chloroxylenol/ Guaifen/D-Methorphan HB/PE/CP ...... 49 Water ...... 32 Guaifen/DM/P-ephed ...... 49 HydroDIURIL ...... 23 Guaifenesin ...... 49 Hydromorphone HCl ...... 12 Guaifenesin w/Codeine ...... 49 Hydroquinone ...... 31 Guaifenesin w/Dextromethorphan ...... 49 Hydroquinone/Ferric Oxide ...... 31 Guaifenesin/Codeine Phosphate ...... 49 Hydroxychloroquine Sulfate ...... 9,41 Guaifenesin/Dextromethorphan HBr ...... 49 Hydroxyprogesterone Caproate ...... 44 Guaifenesin/Phenylephrine HCl ...... 49 Hydroxypropyl Cellulose ...... 48 Guaifenesin/Pseudoephedrine HCl ...... 49 Hydroxyurea ...... 11 Guanabenz Acetate ...... 25 Hydroxyzine HCl ...... 49 Guanfacine HCl ...... 21,25 Hydroxyzine Pamoate ...... 49 Gynazole-1 ...... 45 Hygroton ...... 23 Hylan G-F 20 ...... 14 Hyoscyamine Sulfate ...... 37,52 H Hyoscyamine Sulfate Tablet, Sustained H2 Antagonists ...... 36 Release 12hr ...... 37 Halaven ...... 11 Hypercare ...... 31 Halcinonide ...... 28 Hypnotic Agents ...... 18 Halcion ...... 18 Hytone ...... 28 Haldol ...... 20 Hytrin ...... 25,52 Halflytely ...... 38,39 Hyzaar ...... 26 Halobetasol Propionate ...... 28 Halobetasol Propionate/Ammonium Lactate ...... 28 Halog ...... 28 I Haloperidol ...... 19,20 Ibandronate Sodium ...... 42 Haloperidol Lactate Concentrate, Oral ...... 20 Ibuprofen ...... 13,41 HCG Alpha, Recombinant ...... 33,45 Idursulfase ...... 34 Headache Therapy ...... 14 Ilaris ...... 40 Hectorol ...... 34 Iloprost ...... 51 Helidac ...... 36 Ilotycin ...... 47 Hematinic w/Folic Acid ...... 53 Imatinib Mesylate ...... 11 Hemocyte-F ...... 53 Imdur ...... 22 Hemostatics ...... 23,54 Imiglucerase ...... 34 Heparin ...... 23,54 Imipramine HCl ...... 18 Heparin Lock Flush ...... 23,54 Imipramine Pamoate ...... 18 Heparin Sodium,Porcine ...... 23,54 Imiquimod ...... 31 Hepsera ...... 7 Imitrex ...... 14 Herceptin ...... 11 Immunosuppressant Drugs ...... 10 Hexalen ...... 11 Imodium ...... 36 Hiprex ...... 6 Imuran ...... 10,41 Histex ...... 50 Incivek ...... 7 Histex SR ...... 50 Indapamide ...... 23 Histrelin AC ...... 11 Inderal ...... 24 Hiv/Aids Therapy ...... 7 Inderal LA ...... 24 Homatropine HBr ...... 46 Inderide ...... 26 Homatropine Hydrobromide ...... 46 Indinavir Sulfate ...... 7 Horizant ...... 17 Indocin ...... 13,41 Hormones ...... 10 Indocin SR ...... 13,41 Humalog ...... 34 Indomethacin ...... 13,41 Humalog Mix 50/50 ...... 34 Infergen ...... 40 Humalog Mix 75/25 ...... 34 Inflamase Forte ...... 47 Humate-P ...... 23,54 Infliximab ...... 38 Humatin ...... 8 Ingenol Mebutate ...... 31 Humatrope ...... 40 Inhaled Corticosteroids ...... 51 Humira ...... 38,41 Inlyta ...... 11 Humulin ...... 34 Innopran XL ...... 24 Humulin 70/30 ...... 34 Inspra ...... 23 Humulin N ...... 34 Insulin Aspart ...... 34 Humulin R ...... 34 Insulin Aspart Protamine Human/Insulin Aspart ...... 34 Hyalgan ...... 14 Insulin Detemir ...... 34 Hycamtin ...... 11 Insulin Glargine, Human Recombinant Analog ...... 34 Hycet ...... 12 Insulin Glulisine ...... 34 Hycodan ...... 49 Insulin Human Recombinant ...... 34 Hydralazine HCl ...... 25 Insulin Lispro ...... 34 Hydralazine HCl/Hydrochlorothiazide ...... 26 Insulin NPL/Insulin Lispro ...... 34 Hydrea ...... 11 Insulin Syringes/Miscellaneous Durable Hydrochlorothiazide ...... 23,26 Medical Equipment ...... 35 Hydrocodone Bit-Ibuprofen ...... 12 Insulin Therapy ...... 34 Hydrocodone Bit/Acetaminophen ...... 12 Intal ...... 51 Hydrocodone Bit/Homatropine ...... 49 Intelence ...... 7 Hydrocodone Polistrx/Chlorpheniramine Interferon Alfa-2b,Recombinant Vial ...... 40 Polistirex ...... 49 Interferon Beta-1A/Albumin Human ...... 40 Hydrocodone w/Acetaminophen ...... 12 Interferon Beta-1b ...... 40 Hydrocodone/Chlorpheniramine ...... 49 Interferon Gamma-1b,Recombinant ...... 40 Hydrocortisone ...... 28,29,31,33,38,41,49 Interferons ...... 40 Hydrocortisone Acetate ...... 38 Interleukins ...... 40 Hydrocortisone Acetate/Lidocaine HCl ...... 29,32,38 Intermezzo ...... 18 Hydrocortisone Acetate/Pramoxine HCl ...... 30,38 Intranasal Steroids ...... 32 Hydrocortisone Acetate/Pramoxine HCl/ Intranasal Steroids ...... 51 Emollient ...... 30,38 Intron A ...... 11,40 Hydrocortisone Acetate/Pramoxine/Diosmin/ Intron A Vial ...... 40 Aloe/Policosanol ...... 38 Intuniv ...... 21 Hydrocortisone Butyrate ...... 28 Invega ...... 20 Hydrocortisone Butyrate Cream ...... 28 Invirase ...... 7 Hydrocortisone Butyrate Lotion ...... 28 Iodoquinol ...... 8 Hydrocortisone Butyrate/Emollient ...... 28 Ionamin ...... 55 Hydrocortisone Valerate ...... 28 Iopidine ...... 48 64 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:38 AM Page 65

Ipilimumab ...... 11 Kristalose ...... 38 Ipratropium Bromide ...... 32,51 Krystexxa ...... 41 Ipratropium Bromide Solution, Non-Oral ...... 51 Kuvan ...... 34 Ipratropium/Albuterol Sulfate ...... 51 Kytril ...... 15,39 Iquix ...... 47 Irbesartan ...... 26 Irbesartan/Hydrochlorothiazide ...... 26 L Iressa ...... 11 Labetalol HCl ...... 24 Iron Polysaccharides Complex/ Lac-Hydrin ...... 31 Cyanocobalamin/Folic Acid ...... 53 Lacosamide ...... 16 Isentress ...... 7 Lacrisert ...... 48 ISMO ...... 22 Lactic Acid Cream ...... 31 Isometheptene Mucate/Acetaminophen/ Lactic Acid Lotion ...... 31 Dichloralphenazone ...... 14 Lactinol ...... 31 Isoniazid ...... 9 Lactinol-E ...... 31 Isoniazid ...... 9 Lactulose ...... 38 Isoptin S.R...... 24 Lamictal ...... 16 Isopto Atropine ...... 46 Lamictal ODT ...... 16 Isopto Carbachol ...... 46 Lamictal XR ...... 16 Isopto Carpine ...... 46 Lamisil ...... 8 Isopto Homatropine ...... 46 Lamisil Cream ...... 30 Isopto Hyoscine ...... 46 Lamisil Oral Granules ...... 8 Isordil ...... 22 Lamisil Tablet ...... 8 Isosorbide Dinitrate ...... 22 Lamivudine ...... 7 Isosorbide Dinitrate/Hydralazine HCl ...... 25 Lamivudine/Zidovudine ...... 7 Isosorbide Mononitrate ...... 22 Lamotrigine ...... 16 Isotretinoin ...... 29 Lancets ...... 35 Isoxsuprine HCl ...... 45 Lancets ...... 35 Isradipine ...... 25 Lanoxin ...... 22 Istalol ...... 46 Lanreotide Acetate ...... 11 Istodax ...... 11 Lansoprazole ...... 36 Itraconazole ...... 8 Lanthanum Carbonate ...... 55 Itraconazole Solution, Oral ...... 8 Lantus ...... 34 Ivacaftor ...... 51 Lantus Solostar ...... 34 Ivermectin ...... 8 Lapatinib Ditosylate ...... 11 Ixabepilone ...... 11 Lariam ...... 9 Ixempra ...... 11 Laronidase ...... 34 Lasix ...... 23 Lastacaft ...... 48 J Latanoprost ...... 46 Jakafi ...... 11 Lazanda ...... 12 Jalyn ...... 52 Leflunomide ...... 41 Janumet ...... 34,35 Lenalidomide ...... 11 Janumet XR ...... 34 Lescol ...... 27 Januvia ...... 34,35 Lescol XL ...... 27 Jentadueto ...... 34 Lessina ...... 43 Jevtana ...... 11 Lessina 0.1-0.02 ...... 43 Jolessa ...... 43 Letairis ...... 51 Jolivette ...... 44 Letrozole ...... 10 Junel ...... 43 Leucovorin Calcium ...... 11 Junel Fe ...... 43 Leucovorin Calcium ...... 11 Juvisync ...... 35 Leukeran ...... 10,11 Leukine ...... 11,40 Leuprolide Acetate ...... 11,45 K Levalbuterol HCl ...... 50 K-Dur ...... 54 Levalbuterol Tartrate ...... 50 K-Lor ...... 54 Levaquin ...... 6 K-Lyte ...... 54 Levatol ...... 24 K-Lyte/Cl ...... 54 Levbid ...... 37,52 K-Tab ...... 54 Levemir ...... 34 Kadian ...... 12 Levetiracetam ...... 16 Kalbitor ...... 51 Levetiracetam ER ...... 16 Kaletra ...... 7 Levitra ...... 52 Kalydeco ...... 51 Levlite 0.1-0.02 ...... 43 Kaon-Cl ...... 54 Levobunolol HCl ...... 46 Kapvay ...... 21 Levocarnitine ...... 55 Kariva ...... 43 Levocetirizine Di-HCl ...... 49 Kay Ciel ...... 54 Levofloxacin ...... 6,8,47 Kayexalate ...... 55 Levonorgestrel ...... 43 Keflex ...... 5 Levonorgestrel-Ethinyl Estradiol ...... 43 Kenalog ...... 28 Levonorgestrel-Ethinyl Estradiol/Ethinyl Kenalog in Orabase ...... 32 Estradiol ...... 43 Kepivance ...... 11 Levora ...... 43 Keppra ...... 16 Levothroid ...... 33 Keppra XR ...... 16 Levothyroxine Sodium ...... 33 Keralac ...... 31 Levsin ...... 37,52 Kerlone ...... 24 Levsin-SL ...... 37 Ketek ...... 8 Levsin/SL ...... 37,52 Ketoconazole ...... 8,30 Lexapro ...... 19 Ketoconazole Cream ...... 30 Lexiva ...... 7 Ketoconazole Foam ...... 30 Lialda ...... 38 Ketoconazole Shampoo ...... 30 Librax ...... 37 Ketoprofen ...... 13,41 Librium ...... 21 Ketorolac Tromethamine ...... 47 Lida Mantle ...... 29,32 Kineret ...... 41 Lida Mantle HC ...... 29,32 Klaron ...... 29 Lidex ...... 28 Klonopin ...... 16 Lidex-E ...... 28 Klor-Con 25mEq ...... 54 Lidocaine ...... 29 Kombiglyze XR ...... 34 Lidocaine HCl ...... 29,32 65 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:39 AM Page 66

Lidocaine-Prilocaine ...... 29 Luvox CR ...... 19 Lidocaine/Hydrocortisone ...... 38 Luxiq ...... 28 Lidoderm ...... 29 Lybrel ...... 43 Linagliptin ...... 34 Lyrica ...... 16 Linagliptin/Metformin ...... 34 Lysodren ...... 11 Lindane ...... 31 Lysteda ...... 45 Linezolid ...... 8 Lioresal ...... 17,42 Liothyronine Sodium ...... 33 M Lipid/Cholesterol Lowering Agents ...... 27 Macrobid ...... 6 Lipitor ...... 27 Macrodantin ...... 6 Lipofen ...... 27 Macugen ...... 48 Liquadd ...... 21 Makena ...... 44 Liquibid ...... 49 Malarone ...... 9 Liraglutide ...... 34 Malathion ...... 31 Lisdexamfetamine Dimesylate ...... 21 Mandelamine ...... 6 Lisinopril ...... 25 Mao Inhibitors ...... 19 Lisinopril-HCTZ ...... 26 Maprotiline HCl ...... 18 Lisinopril/Hydrochlorothiazide ...... 26 Maraviroc ...... 7 Lithium Carbonate ...... 16,21 Materna ...... 53 Lithium Carbonate Tablet, Sustained Action ...... 21 Maternity ...... 53 Lithium Citrate ...... 21 Matulane ...... 11 Lithium Citrate ...... 21 Mavik ...... 25 Lithobid ...... 21 Maxair Autohaler ...... 50 Maxalt ...... 14 Livalo ...... 27 Maxalt MLT ...... 14 Lo Loestrin Fe ...... 43 Maxidone ...... 12 Lo/Ovral ...... 43 Maxitrol ...... 48 Locoid ...... 28 Maxzide ...... 23 Locoid Cream ...... 28 Mebaral ...... 16 Locoid Lipocream ...... 28 Mebendazole ...... 8 Locoid Ointment ...... 28 Meclizine HCl ...... 15,39 Locoid Solution ...... 28 Meclofenamate Sodium ...... 13,41 Lodine ...... 13,41 Meclofenamate Sodium ...... 13,41 Lodine XL ...... 13,41 Medrol ...... 33,41,49 Lodosyn ...... 15 Medroxyprogesterone Acetate ...... 11,44 Loestrin ...... 43 Medroxyprogesterone Acetate Disposable Loestrin 24 Fe ...... 43 Syringe ...... 44 Loestrin Fe ...... 43 Medroxyprogesterone Acetate Vial ...... 11,44 Lofibra ...... 27 Mefloquine HCl ...... 9 Lomotil ...... 36 Megace ...... 10 Lomustine ...... 10 Megace ES ...... 10 Long Acting Nitrates ...... 22 Megestrol Acetate ...... 10 Loniten ...... 25 Megestrol Acetate Suspension, Oral ...... 10 Loperamide HCl ...... 36 Mellaril ...... 19 Lopid ...... 27 Meloxicam ...... 13,41 Lopressor ...... 24 Melpaque HP ...... 31 Lopressor HCT ...... 26 Melphalan ...... 10 Loprox ...... 30 Memantine HCl ...... 17 Loprox Cream ...... 30 Menest ...... 44 Loprox Gel ...... 30 Menopur ...... 33 Loprox Shampoo ...... 30 Menostar ...... 44 Lorazepam ...... 17,21 Menotropins ...... 33,45 Lorcet 10/650 ...... 12 Mentax ...... 30 Lorcet Plus ...... 12 Meperidine HCl ...... 12 Lortab ...... 12 Mephobarbital ...... 16 Losartan Potassium ...... 26 Mephyton ...... 23,54 Losartan Potassium/Hydrochlorothiazide ...... 26 Meprobamate ...... 17 LoSeasonique ...... 43 Mepron ...... 8 Lotemax ...... 47 Mercaptopurine ...... 10 Lotensin ...... 25 Mesalamine ...... 38 Lotensin HCT ...... 26 Mesalamine Enema ...... 38 Loteprednol Etabonate ...... 47 Mesna Tablet ...... 11 Lotrel ...... 26 Mesnex ...... 11 Lotrimin ...... 30 Mestinon ...... 18 Lotrisone ...... 30 Metadate CD ...... 21 Lotronex ...... 38 Metadate ER ...... 21 Lovastatin ...... 27 Metaglip ...... 34,35 Lovaza ...... 27 Metanx ...... 53 Lovenox ...... 23,54 Metaproterenol Sulfate ...... 50 Low-Ogestrel ...... 43 Metaxalone ...... 17,42 Loxapine Succinate ...... 20 Metformin HCl ...... 34,35 Loxitane ...... 20 Metformin HCl ER ...... 35 Lozol ...... 23 Metformin HCl Tablet ...... 35 Lubiprostone ...... 38 Methadone HCl ...... 12 Lucentis ...... 48 Methamphetamine HCl ...... 21 Ludiomil ...... 18 Methazolamide ...... 46 Lugol's ...... 54 Methenamine Hippurate ...... 6 Lumigan ...... 46 Methenamine Mandelate ...... 6,52 Lumizyme ...... 34 Methergine ...... 44 Lunesta ...... 18 Methimazole ...... 33 Lupron ...... 11,45 Methitest ...... 33 Lupron Depot ...... 11,45 Methitest ...... 33 Lupron Depot-Ped ...... 11,45 Methocarbamol ...... 17,42 Luride ...... 53 Methotrexate ...... 11 Lustra ...... 31 Methotrexate Sodium ...... 10,41 Lutera ...... 43 Methotrexate Sodium Tablet ...... 11,30 Luveris ...... 33 Methoxsalen ...... 31 Luvox ...... 19 Methoxsalen, Rapid ...... 31 66 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:39 AM Page 67

Methscopolamine Bromide ...... 37 Mobic ...... 13,41 Methscopolamine Bromidel ...... 37 Modafinil ...... 21 Methsuximide ...... 16 Modicon ...... 43 Methyclothiazide ...... 23 Moduretic ...... 23 Methyldopa ...... 25 Moexipril HCl ...... 25 Methyldopa/Hydrochlorothiazide ...... 26 Moexipril/HCTZ ...... 26 Methylergonovine Maleate ...... 44 Moexipril/Hydrochlorothiazide ...... 26 Methylin ER ...... 21 Molindone HCl ...... 20 Methylin Oral Solution ...... 21 Mometasone Furoate ...... 28,32,51 Methylin Tablet, Chewable ...... 21 Mometasone/Formoterol ...... 51 Methylnaltrexone Bromide ...... 38 Monistat 3 ...... 45 Methylphenidate ...... 21 Monistat 3 Suppository, Vaginal ...... 45 Methylphenidate ER ...... 21 Monistat-Derm ...... 30 Methylphenidate HCl ...... 21 Monodox ...... 5 Methylprednisolone ...... 33,41,49 Monoject Insulin Syringe ...... 35 Methyltestosterone ...... 33 Mononessa ...... 43,45 Metipranolol ...... 46 Monophasic/Biphasic/Triphasic Agents ...... 43 Metoclopramide HCl ...... 38,39 Monopril ...... 25 Metolazone ...... 23 Monopril HCT ...... 26 Metoprolol Succinate ...... 24,26 Montelukast Sodium ...... 51 Metoprolol Tartrate ...... 24 Monurol ...... 6 Metoprolol Tartrate/Hydrochlorothiazide ...... 26 Moricizine HCl ...... 22 Metoprolol-Hydrochlorothiazide ...... 26 Morphine Sulfate ...... 12 Metozolv ODT ...... 38 Morphine Sulfate Tablet, Sustained Action ...... 12 Metrocream ...... 29 Morphine Sulfate/Naltrexone ...... 12 Metrogel ...... 29,45 Motofen ...... 36 Metrogel 1% ...... 29 Motrin ...... 13,41 Metrolotion ...... 29 Moviprep ...... 39 Metronidazole ...... 8,29,36,45 Moxatag ...... 5 Metronidazole Cream ...... 29 Moxeza ...... 47 Metronidazole Lotion ...... 29 Moxifloxacin HCl ...... 6,47 Metyrosine ...... 25 Mozobil ...... 40 Mevacor ...... 27 MS Contin ...... 12 Mexiletine HCl ...... 22 Mucomyst ...... 51 Mexitil ...... 22 Multaq ...... 22 Miacalcin ...... 34,42 Multivitamin w/Fluoride ...... 53 Micardis ...... 26 Mupirocin ...... 32 Micardis HCT ...... 26 Mupirocin Ointment ...... 29 Miconazole 3 Suppository, Vaginal ...... 45 Muscle Relaxants & Antispasmodic Agents ...... 17 Miconazole Nitrate Suppository, Vaginal ...... 45 Muscle Relaxants & Antispasmodic Therapy ...... 17.42 Micro-K ...... 54 Muse ...... 52 Microgestin ...... 43 Myambutol ...... 9 Microgestin Fe ...... 43 Myasthenia Gravis ...... 18 Micronase ...... 34 Mycelex ...... 8 Microzide ...... 23 Mycobutin ...... 9 Midamor ...... 23 Mycolog II ...... 30 Midazolam HCl ...... 21 Mycophenolate Mofetil ...... 10,41 Midodrine HCl ...... 55 Mycophenolate Mofetil HCl Suspension ...... 10 Midrin ...... 14 Mycostatin ...... 8,30 Migraine & Cluster Headache Therapy ...... 14 Mydriacyl ...... 46 Migranal ...... 14 Myeloid Stimulants ...... 40 Milnacipran HCl ...... 41 Myfortic ...... 10 Miltown ...... 17 Myleran ...... 10 Minipress ...... 25 Myochrysine ...... 41 Minitran ...... 22 Myozyme ...... 34 Minocin ...... 5 Mysoline ...... 16 Minocycline HCl ...... 5 Minoxidil ...... 25 N Mintezol ...... 8 Nabumetone ...... 13,41 Mirapex ...... 15 Nadolol ...... 24 Mirapex ER ...... 15,17 Nafarelin Acetate ...... 34,45 Mircette ...... 43 Naftin ...... 30 Mirtazapine Tablet ...... 18 Naglazyme ...... 34 Mirtazapine Tablet, Rapid Dissolve ...... 18 Nalex-A ...... 50 Miscellaneous Agents ...... 32,34,55 Nalfon ...... 13 Miscellaneous Analgesics ...... 14 Naltrexone HCl ...... 14 Miscellaneous Antidepressants ...... 18 Naltrexone Hydrochloride ...... 55 Miscellaneous Anti-infectives ...... 8 Naltrexone Microspheres ...... 14 Miscellaneous Antineoplastic Drugs ...... 11 Namenda ...... 17 Miscellaneous Antipsychotics ...... 20 Naphazoline HCl ...... 47 Miscellaneous Antivirals ...... 7 Naprelan ...... 13,41 Miscellaneous Cardiovascular Agents ...... 27 Naprosyn ...... 13,41 Miscellaneous Coagulation Agents ...... 23,54 Naproxen ...... 13,41 Miscellaneous Dermatologicals ...... 31 Naproxen Sodium ...... 13,41 Miscellaneous Gastrointestinal Agents ...... 37,38 Naproxen/Esomeprazole Mag ...... 13,41 Miscellaneous Hormones ...... 33 Naratriptan HCl ...... 14 Miscellaneous Neurological Therapy ...... 17 Narcotic Analgesics ...... 12 Miscellaneous OB/GYN ...... 45 Narcotic Antagonists ...... 14 Miscellaneous Ophthalmologics ...... 48 Narcotics ...... 12 Miscellaneous Otic Preparations ...... 32 Nardil ...... 19 Miscellaneous Psychotherapeutic Agents ...... 21 Nasacort AQ ...... 32,51 Miscellaneous Pulmonary Agents ...... 51 Nasalide ...... 32,51 Miscellaneous Rheumatological Agents ...... 41 Nascobal ...... 53 Miscellaneous Urologicals ...... 52 Nasonex ...... 32,51 Misoprostol ...... 36 Natachew ...... 53 Mitotane ...... 11 Natacyn ...... 47 Mitoxantrone HCl ...... 11 Natafort ...... 53 Moban ...... 20 Natamycin ...... 47 67 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:39 AM Page 68

Natazia ...... 43 Nizoral Shampoo ...... 30 Nateglinide ...... 34,35 Nolvadex ...... 10 Natelle ...... 53 Non-Insulin Hypoglycemic Agents ...... 34 Natelle Prefer ...... 53 Non-narcotic Analgesics ...... 13 Natelle-EZ ...... 53 Non-steroidal Anti-inflammatory Agents ...... 47 Natroba ...... 31 Nor-Q-D ...... 44 Navane ...... 20 Nora-BE ...... 44 Navelbine ...... 11 Norco ...... 12 Nebivolol HCl ...... 24 Nordette ...... 43 NebuPent ...... 8 Norditropin ...... 40 Necon ...... 43 Norditropin Flexpro ...... 40 Necon 0.5-0.035 ...... 43 Norethindrone ...... 44 Necon 1-0.035mg ...... 43 Norethindrone A-E Estradiol ...... 43 Necon 1-0.05mg ...... 43 Norethindrone A-E Estradiol/Ferrous Needles, Insulin Disposable ...... 35 Fumarate ...... 43 Neevo ...... 53 Norethindrone Acetate ...... 44 Neevo DHA ...... 53 Norethindrone-Ethinyl Estradiol ...... 43 Nelfinavir Mesylate ...... 7 Norethindrone-Ethinyl Estradiol/Ferrous Nembutal Sodium ...... 18 Fumarate ...... 43 Neo-Synephrine ...... 47 Norethindrone-Mestranol ...... 43 Neo/Polymyxin/Dexamethasone ...... 48 Norethindrone/Ethinyl Estradiol ...... 45 Neomycin Sulfate ...... 8 Norflex ...... 17 Neomycin Sulfate ...... 8 Norfloxacin ...... 6 Neomycin Sulfate/Bacitracin Zinc/PolymyxinB/Hydrocortisone ...... 48 Norgestimate-Ethinyl Estradiol ...... 43 Neomycin Sulfate/Bacitracin/Polymyxin B Norgestrel-Ethinyl Estradiol ...... 43 Ointment ...... 47 Norinyl ...... 43 Neomycin Sulfate/Gramicidin D/Polymyxin B Drops ...... 47 Norinyl 1-0.035mg ...... 43 Neomycin Sulfate/Polymyxin B Sulfate/ Norinyl 1-0.05mg ...... 43 Hydrocortisone ...... 32,48 Noritate ...... 29 Neomycin/Polymyxin B Sulfate/Dexamethasone ...... 48 Normodyne ...... 24 Neomycin/Polymyxin/HC ...... 32,48 Noroxin ...... 6 Neoral ...... 10 Norpace ...... 22 Neosporin ...... 47 Norpace CR ...... 22 Neostigmine Bromide ...... 18 Norpramin ...... 18 Nepafenac ...... 47 Nortrel ...... 43 Nephro-Vite Rx ...... 53 Nortrel 0.5-0.035 ...... 43 Nephrocaps ...... 53 Nortrel 1-0.035mg ...... 43 Nephron FA ...... 53 Nortriptyline HCl ...... 18 Neptazane ...... 46 Norvasc ...... 25 Neulasta ...... 11,40 Norvir ...... 7 Neumega ...... 40 Novantrone ...... 11 Neupogen ...... 11,40 Novarel ...... 34 Neurontin ...... 16 Novofine ...... 35 Nevanac ...... 47 Novolin 70/30 ...... 34 Nevirapine ...... 7 Novolin 70/30 InnoLet ...... 34 Nexavar ...... 11 Novolin N ...... 34 Nexiclon XR ...... 25 Novolin N InnoLet ...... 34 Nexium ...... 36 Novolin R ...... 34 Nexium Suspension ...... 36 Novolin R InnoLet ...... 34 Next Choice One Dose ...... 43 NovoLog ...... 34 Niacin ...... 27 Novolog Mix 70/30 ...... 34 Niacin/Simvastatin ...... 27 NovoSeven ...... 23,54 Niaspan ...... 27 NovoSeven RT ...... 23,54 Nicotine ...... 55 Novotwist ...... 35 Nicotrol ...... 55 Noxafil ...... 8 Nifedipine ...... 25 NPlate ...... 23,54 Nifedipine ER ...... 25 NSAID Agents ...... 41 Niferex Gold ...... 53 NSAIDs ...... 13,41 Niferex-150 Forte ...... 53 NSAIDS- Specific COX-II Inhibitors ...... 14,41 Niferex-PN Forte ...... 53 NSAIDS/COX II Inhibitors ...... 13,41 Nilandron ...... 10 Nucynta ...... 14 Nilotinib HCl ...... 11 Nucynta ER ...... 14 Nimodipine ...... 24 Nuedexta ...... 17 Nimotop ...... 24 Nulev ...... 37,52 Niravam ...... 21 NuLytely ...... 38,39 Nisoldipine ...... 25 Nutropin ...... 40 Nitazoxanide ...... 8 Nutropin AQ ...... 40 Nitisinone ...... 55 Nutropin AQ Nuspin ...... 40 Nitrates ...... 22 NuvaRing ...... 45 Nitro-Dur ...... 22 Nuvigil ...... 21 Nitrofurantoin ...... 6 Nystatin ...... 45 Nystatin ...... 8,30,45 Nitrofurantoin Macrocrystal ...... 6 Nystatin Cream ...... 30 Nitrofurantoin Suspension ...... 6 Nystatin Suspension ...... 8 Nitrofurantoin/Nitrofurantoin Macrocrystal ...... 6 Nystatin/Triamcinolone Acetonide ...... 30 Nitroglycerin ...... 22 Nitroglycerin ...... 22 Nitroglycerin Capsule, Sustained Action ...... 22 O Nitroglycerin Ointment ...... 22 Ocella ...... 43 Nitroglycerin Patch, Transdermal 24 Hours ...... 22 Octreotide Acetate ...... 11,34 Nitroglycerin Spray ...... 22 Octreotide Acetate Vial ...... 11,34 Nitroglycerin Sublingual Tablet ...... 22 Ocufen ...... 47 Nitrolingual ...... 22 Ocuflox ...... 47 Nitromist ...... 22 Ocupress ...... 46 Nitrostat ...... 22 Ofatumumab ...... 11 Nix Liquid 1% ...... 31 Ofloxacin ...... 6,32,47 Nizatidine ...... 36 Oforta ...... 10 Nizoral ...... 8,30 Ogen ...... 44 Nizoral Cream ...... 30 Ogestrel ...... 43 68 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:39 AM Page 69

Olanzapine ...... 20 Oxycodone HCl ...... 12 Olanzapine ODT ...... 20 Oxycodone HCl Concentrate, Oral ...... 12 Oleptro ER ...... 18 Oxycodone HCl Solution, Oral ...... 12 Olmesartan Medoxomil ...... 26 Oxycodone HCl Tablet, Sustained Release 12hr ...... 12 Olmesartan Medoxomil/Amlodipine/HCTZ ...... 26 Oxycodone HCl/Acetaminophen ...... 12 Olmesartan Medoxomil/Hydrochlorothiazide ...... 26 Oxycodone HCl/Ibuprofen ...... 12 Olopatadine HCl ...... 48 Oxycodone w/Acetaminophen ...... 12 Olux ...... 28 Oxycodone w/Aspirin ...... 12 Olux-E ...... 28 Oxycodone w/Ibuprofen ...... 12 Olux-Olux-E ...... 28 Oxycodone/Aspirin ...... 12 Omega-3 Acid Ethyl Esters ...... 27 OxyContin ...... 12 Omeprazole ...... 13,36 OxyFAST ...... 12 Omeprazole/Sodium Bicarbonate ...... 36 OxyIR ...... 12 Omnaris ...... 51 Oxytocics ...... 44 Omnicef ...... 6 Oxytrol ...... 17,42,52 Omnitrope ...... 40 Ozurdex ...... 47 Ondansetron ...... 15,39 Ondansetron HCl ...... 15,39 Ondansetron ODT ...... 39 P One Touch Basic System ...... 35 Pacerone 100mg, 200mg ...... 22 One Touch Test Strips ...... 35 Pacerone 400mg ...... 22 One Touch Ultra 2 ...... 35 Palifermin ...... 11 One Touch Ultra Smart ...... 35 Palivizumab ...... 7 Pamelor ...... 18 One Touch Ultra System ...... 35 Pamine ...... 37 One Touch Ultra Test Strips ...... 35 Pamine Forte ...... 37 One Touch Ultramini ...... 35 Pancrease ...... 37 One Touch Verio ...... 35 Pancrease MT ...... 37 One Touch Verio IQ ...... 35 Pancrease MT 12K-4K-12K ...... 37 Onfi ...... 16 Pancrease MT 30-10-30, 48-16-48, 56-20-44 ...... 37 Onglyza ...... 34,35 Pancrelipase ...... 37 Onsolis ...... 12 Pandel ...... 28 Opana ...... 12 Panlor SS ...... 12 Opana ER ...... 12 PanMist DM Syrup ...... 49 Opium Tincture ...... 36 Panretin ...... 31 Oprelvekin ...... 40 Pantoprazole Sodium ...... 36 Opticrom ...... 48 Parafon Forte DSC ...... 17,42 OptiPranolol ...... 46 Parcopa ...... 15 Optivar ...... 48 Paregoric ...... 36 Oracea ...... 5 Paregoric ...... 36 Oral Contraceptives & Related Agents ...... 43 Paricalcitol ...... 34 Oral Drugs For Glaucoma ...... 46 Parlodel ...... 15 Orap ...... 20 Parnate ...... 19 Orapred ...... 33 Paromomycin Sulfate ...... 8 Orapred ODT ...... 33 Paroxetine HCl ...... 19 Oravig ...... 8 Pataday ...... 48 Orencia ...... 41 Patanase ...... 32 Orencia SQ ...... 41 Patanol ...... 48 Orfadin ...... 55 Paxil ...... 19 Orinase ...... 34 Paxil CR ...... 19 Orlistat ...... 55 Pazopanib HCl ...... 11 Orphenadrine Citrate ...... 17 PCE ...... 6 Ortho Evra ...... 45 Pediapred ...... 33,41,49 Ortho Micronor ...... 44 Pediazole ...... 6 Ortho Tri-Cyclen ...... 43 Peg 3350/Electrolyte ...... 38,39 Ortho Tri-Cyclen Lo ...... 43 Peg-Intron ...... 40 Ortho-Cept ...... 43 Peg-Intron Redipen ...... 40 Ortho-Cyclen ...... 43 Pegademase Bovine ...... 55 Ortho-Novum ...... 43 Peganone ...... 16 Ortho-Prefest ...... 45 Pegasys ...... 40 Orthovisc ...... 14 Pegasys Proclick ...... 40 Orudis ...... 13,41 Pegfilgrastim ...... 11,40 Oseltamivir Phosphate ...... 7 Peginterferon Alfa-2A ...... 40 Osmoprep ...... 38 Peginterferon Alfa-2b ...... 40 Osteoporosis Therapy ...... 42 Pegloticase ...... 41 Other Antihypertensive Combinations ...... 26 Pegvisomant ...... 34 Other Electrolytes ...... 54 Pen Needle ...... 35 Other Glaucoma Drugs ...... 46 Pen-Vee K ...... 5 Other Rheumatologicals ...... 41 Penicillamine ...... 41 Other Ulcer Therapy ...... 36 Penicillin V Potassium ...... 5 Otic Steroid/Antibiotic ...... 32 Penicillins ...... 5 Otocain ...... 32 Penlac ...... 30 Otogesic ...... 32 Pennsaid ...... 13 Ovace ...... 30 Pentamidine Isethionate ...... 8 Ovcon ...... 43 Pentasa ...... 38 Ovide ...... 31 Pentazocine and Naloxone HCl ...... 14 Ovidrel ...... 33,45 Pentazocine HCl/Acetaminophen ...... 14 Ovral ...... 43 Pentazocine HCl/Naloxone HCl ...... 14 Ovulatory Stimulants ...... 33 Pentazocine/Acetaminophen ...... 14 Oxandrin ...... 33 Pentosan Polysulfate Sodium ...... 52 Oxaprozin ...... 13,41 Pentoxifylline ...... 23 Oxazepam ...... 21 Pentoxifylline Tablet, Sustained Action ...... 23,54 Oxcarbazepine ...... 16 Pepcid ...... 36 Oxistat ...... 30 Pepcid Suspension ...... 36 Oxsoralen ...... 31 Percocet ...... 12 Oxsoralen-Ultra ...... 31 Percodan ...... 12 Oxybutynin ...... 17,42,52 Perforomist ...... 50 Oxybutynin Chloride ...... 17,42,52 Periactin ...... 49 Oxybutynin Chloride ER ...... 52 Peridex ...... 32 69 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:39 AM Page 70

Perindopril Erbumine ...... 25 Precare ...... 53 Periostat ...... 5 PreCare Conceive ...... 53 Permethrin ...... 31 PreCare Premier ...... 53 Perphenazine ...... 19 Precose ...... 34,35 Persantine ...... 22,53 Pred Forte ...... 47 Pexeva ...... 19 Pred Mild ...... 47 Phenazopyridine HCl ...... 6,52 Pred-G ...... 48 Phendimetrazine Tartrate ...... 55 Prednisolone ...... 33,41,49 Phenelzine Sulfate ...... 19 Prednisolone ...... 33 Phenergan ...... 15,39,49 Prednisolone Acetate ...... 47 Phenobarbital ...... 16 Prednisolone Sodium Phosphate ...... 33,41,47,49 Phenobarbital ...... 16 Prednisolone Syrup ...... 33,41,49 Phenobarbital/Hyoscyamine/Atropine/Scop ...... 37 Prednisolone Tablet ...... 33,41,49 Phenothiazines ...... 19 Prednisone ...... 33,41,49 Phenoxybenzamine HCl ...... 25 Prefera-OB ...... 53 Phentermine HCl ...... 55 Prefera-OB One ...... 53 Phenylephrine HCl ...... 47 Prefera-OB Plus DHA ...... 53 Phenylephrine HCl/Brompheniramine Maleate ...... 49 Prefest ...... 45 Phenylephrine/Chlor Tan ...... 50 Pregabalin ...... 16 Phenylephrine/Guaifenesin ...... 49 Prelone ...... 33,41,49 Phenylephrine/Pyrilamine Tan ...... 50 Premarin ...... 42,44 Phenytek ...... 16 Premarin Vaginal Cream ...... 44 Phenytoin ...... 16 Premphase ...... 45 Phenytoin Sodium ...... 16 Prempro ...... 45 Phenytoin Sodium Capsule ...... 16 Prena-Cap ...... 53 Phenytoin Sodium Extended ...... 16 Prenatal Rx ...... 53 Phenytoin Suspension, Oral ...... 16 Prenatal Vitamin w-o Calcium/Fe Carbonyl- Phenytoin Tablet, Chewable ...... 16 Fe Sulfate/Folic Acid ...... 53 Phos-Flur Gel ...... 32 Prenatal Vitamin w-o Calcium/Ferrous Phoslo ...... 54 Fumarate/Folic Acid ...... 53 Phoslyra ...... 54 Prenatal Vitamin w-o Vitamin A/Fe Carbonyl- Phospholine Iodide ...... 46 Fe Fumarate/Folic Acid ...... 53 Phrenilin ...... 12,14 Prenatal Vitamin w-o Vitamin A/Ferrous Phytonadione Tablet ...... 23,54 Fumarate/Folic Acid ...... 53 Picato ...... 31 Prenatal Vitamin with CA/Iron/FA/LM-Folate ...... 53 Pilocarpine HCl ...... 46,55 Prenatal Vitamins Combination No.7/Ferrous Pilopine HS ...... 46 Asparto Glycinate/Docusate/Folic Acid ...... 53 Pimecrolimus ...... 31 Prenatal Vitamins/Ferrous Fumarate/Folic Pimozide ...... 20 Acid ...... 53 Pindolol ...... 24 Prenatal Vitamins/Ferrous Fumarate/Folic Pioglitazone HCl ...... 34,35 Acid/Fatty Acids ...... 53 Pioglitazone HCl/Glimepiride ...... 34 Prenatal Vitamins/Ferrous Fumarate/Folic Pioglitazone HCl/Metformin HCl ...... 34 Acid/Selenium ...... 53 Pioglitazone/Metformin ...... 35 Prenatal Vitamins/Iron Polysaccharides Piroxicam ...... 13,41 Complex/Folic Acid ...... 53 Plan B ...... 43 Prenatal Vitamins/Iron,Carbonyl/Docusate/ Plan B One-Step ...... 43 Folic Acid ...... 53 Plaquenil ...... 9,41 Prenatal Vitamins/Iron,Carbonyl/Docusate/ Plavix ...... 22,53 Folic Acid/L-Methylfolate ...... 53 Plendil ...... 25 Prenatal Vitamins/Iron,Carbonyl/Folic Acid ...... 53 Plerixafor ...... 40 Prenatal Vitamins/Iron,Carbonyl/Omega-3 Pletal ...... 22,53 Fatty Acids/Folic Acid/Fatty Acid Combo Plexion ...... 29 No.1 ...... 53 Plexion SCT ...... 29 Prenatal Vitamins/Iron/DHA/Folic Acid/ PNV-Omega ...... 53 Docusate Sodium ...... 53 Podofilox ...... 31 Prenatal Vitamins/Iron/Folic Acid/LM- Poly-Pred ...... 48 Folate/DHA ...... 53 Poly-Vi-Flor ...... 53 Prenatal Vitamins/Iron/Polysaccharides Poly-Vi-Flor w/Iron ...... 53 Complex/Fe Heme Polypeptide/Folic Acid ...... 53 Polyethylene Glycol ...... 38 Prenatal Vitamins/Iron/Polysaccharides Polymyxin B Sulfate/Trimethoprim ...... 47 Complex/Fe Heme Polypeptide/Folic Acid/DHA ...... 53 Polysporin ...... 47 Prenate DHA ...... 53 Polysporin Ointment ...... 47 Prenate Elite ...... 53 Polytrim ...... 47 Prenate Essential ...... 53 Ponstel ...... 13 Prevacid ...... 36 Portia ...... 43 Prevalite ...... 27 Posaconazole ...... 8 Previfem ...... 43 Potassium ...... 54 Prevpac ...... 36 Potassium Bicarbonate/Citric Acid ...... 54 Prezista ...... 7 Potassium Chloride ...... 54 Priftin ...... 9 Potassium Chloride/Potassium Bicarbonate/ Prilosec Rx ...... 36 Citric Acid ...... 54 Primacare ...... 53 Potassium Iodide/Iodine ...... 54 Primacare One ...... 53 Potiga ...... 16 Primaquine ...... 9 Pradaxa ...... 22,53 Primaquine Phosphate ...... 9 Pralatrexate ...... 10 Primidone ...... 16 Pramipexole Di-HCl ...... 15 Primsol ...... 6 Pramlintide Acetate ...... 34 Principen ...... 5 Pramosone ...... 30 Prinivil ...... 25 Pramosone E ...... 30 Prinzide ...... 26 Prandimet ...... 35 Pristiq ...... 18 Prandin ...... 34,35 ProAir HFA ...... 50 Prasugrel HCl ...... 22,53 ProAmatine ...... 55 Pravachol ...... 27 Probenecid ...... 41 Pravastatin ...... 27 Probenecid ...... 41 Pravastatin Sodium ...... 27 Procainamide HCl ...... 22 Praziquantel ...... 8 Procanbid ...... 22 Prazosin HCl ...... 25 Procarbazine HCl ...... 11 70 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:40 AM Page 71

Procardia ...... 25 Quinapril ...... 25 Procardia XL ...... 25 Quinapril HCl ...... 25 Prochlorperazine Maleate ...... 15,39 Quinapril HCl/Hydrochlorothiazide ...... 26 Procrit ...... 11,40 Quinapril/Hydrochlorothiazide ...... 26 ProctoCream-HC ...... 38 Quinidex ...... 22 ProctoFoam-HC ...... 38 Quinidine Gluconate ...... 22 Profasi ...... 45 Quinidine Sulfate ...... 22 Progesterone ...... 44 Quinine Sulfate ...... 9 Progesterone, Micronized ...... 44 Quinolones ...... 6 Progestin Only ...... 44 Quixin ...... 47 Progestins ...... 44 QVAR ...... 51 Prograf ...... 10 Prolastin ...... 55 Prolastin C ...... 55 R Proleukin ...... 40 Raloxifene HCl ...... 42 Prolia ...... 42 Raltegravir Potassium ...... 7 Prolixin ...... 19 Ramipril ...... 25 Proloprim ...... 6 Ranexa ...... 27 Promacta ...... 23,54 Ranibizumab ...... 48 Promethazine HCl ...... 15,39,49 Ranitidine HCl ...... 36 Prometrium ...... 44 Ranolazine ...... 27 Propafenone HCl ...... 22 Rapaflo ...... 52 Propine ...... 48 Rapamune ...... 10 Propranolol HCl ...... 24 Rapid Acting Nitrates ...... 22 Propranolol HCl Capsule, Sustained Action 24 hr ...... 24 Rasagiline Mesylate ...... 15 Propranolol HCl w/HCTZ ...... 26 Razadyne ...... 17 Propranolol HCl/Hydrochlorothiazide ...... 26 Razadyne ER ...... 17 Propylthiouracil ...... 33 Rebetol ...... 7 Propylthiouracil ...... 33 Rebif ...... 40 Proquin XR ...... 6 Reclast ...... 55 Proscar ...... 52 Reglan ...... 38 Prosed-DS ...... 52 Relafen ...... 13,41 ProSom ...... 18 Relenza ...... 7 Prostaglandins ...... 36 Relistor ...... 38 Prostigmin ...... 18 Relpax ...... 14 Proton Pump Inhibitors ...... 36 Remeron ...... 18 Protonix ...... 36 Remeron Sol Tab ...... 18 Protonix Suspension ...... 36 Remicade ...... 38,41 Protonix Tablet ...... 36 Remodulin ...... 25 Protopic ...... 31 Rena-Vite Rx ...... 53 Protriptyline HCl ...... 18 Renagel ...... 55 Proventil ...... 50 Renal Caps ...... 53 Proventil HFA ...... 50 Renvela ...... 55 Provera ...... 44 Repaglinide ...... 34 Provigil ...... 21 Repliva 21/7 ...... 53 Prozac ...... 19 Repronex ...... 33,45 Prozac Weekly ...... 19 Requip ...... 15 Pseudoephedrine HCl/Brompheniramine Requip XL ...... 15 Maleate ...... 50 Rescriptor ...... 7 Pseudoephedrine HCl/Chlorpheniramine Reserpine ...... 25 Maleate ...... 50 Reserpine ...... 25 Pseudoephedrine HCl/Chlorpheniramine Respi-Tann ...... 50 Maleate Liquid ...... 50 Restasis ...... 48 Pseudoephedrine HCl/Fexofenadine ...... 50 Restoril ...... 18 Pseudoephedrine HCl/Fexofenadine HCl ...... 50 Retin-A ...... 29 Pseudoephedrine w/Chlorphenir ...... 49,50 Retin-A Micro ...... 29 Pseudoephedrine/Desloratadine ...... 50 Retin-A Micro Pump ...... 29 Pseudoephedrine/Hydrocodone ...... 49 Retisert ...... 47 Pseudoephedrine/Hydrocodone/ Retrovir ...... 7 Chlorpheniramine ...... 49 Revatio ...... 51 Psorcon ...... 28 ReVia ...... 14 Psorcon Cream ...... 28 Revlimid ...... 11 Psychotherapeutic Drugs ...... 18 Reyataz ...... 7 Pulmicort 0.25mg/2mL ...... 51 Rezira ...... 49 Pulmicort 0.5mg/2mL ...... 51 Rheumatrex ...... 10,41 Pulmicort 1mg/2mL ...... 51 Rhinacon A ...... 50 Pulmicort Flexhaler ...... 51 Rhinocort Aqua ...... 32,51 Pulmonary Agents ...... 50 Ribavirin ...... 7 Pulmozyme ...... 51 Ridaura ...... 41 Purinethol ...... 10 Rifabutin ...... 9 Pylera ...... 36 Rifadin ...... 9 Pyrazinamide ...... 9 Rifampin ...... 9 Pyrazinamide ...... 9 Rifaximin ...... 8 Pyridium ...... 6,52 Rilonacept ...... 40 Pyridium Plus ...... 52 Rilpivirine HCl ...... 7 Pyridostigmine Bromide Syrup ...... 18 Rilutek ...... 55 Pyridostigmine Bromide Tablet ...... 18 Riluzole ...... 55 Pyridostigmine Bromide Tablet, Sustained Action ...... 18 Riomet ...... 34 Pyrimethamine ...... 9 Risedronate Sodium ...... 55 Pyrimethamine/Sulfadoxine ...... 9 Risperdal ...... 20 Risperdal Consta ...... 20 Risperidone ...... 19,20 Q Ritalin ...... 21 Qualaquin ...... 9 Ritalin LA ...... 21 Quasense ...... 43 Ritalin-SR ...... 21 Questran ...... 27 Ritonavir ...... 7 Questran Light ...... 27 Ritonavir/Lopinavir ...... 7 Quetiapine Fumarate ...... 19,20 Rituxan ...... 11 Quinaglute ...... 22 Rituximab ...... 11 71 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:40 AM Page 72

Rivastigmine Tartrate ...... 17 Sevelamer Carbonate Tablet ...... 55 Rivastigmine Tartrate Capsules ...... 17 Sildenafil Citrate ...... 51,52 Rivastigmine Tartrate Solution ...... 17 Silenor ...... 18 Rivastigmine Transdermal Patch ...... 17 Silodosin ...... 52 Rizatriptan Benzoate ...... 14 Silvadene ...... 30 RMS-Suppository ...... 12 Silver Sulfadiazine ...... 30 Robaxin ...... 17,42 Simcor ...... 27 Robinul ...... 37 Simponi ...... 41 Robinul Forte ...... 37 Simvastatin ...... 27,35 Robitussin A-C ...... 49 Sinemet ...... 15 Rocaltrol ...... 34 Sinemet CR ...... 15 Roflumilast ...... 51 Sinequan ...... 18 Romidepsin ...... 11 Singulair ...... 51 Romiplostim ...... 23,54 Sirolimus ...... 10 Ropinirole HCl ...... 15,17 Sitagliptin Phosphate ...... 34 Rosac ...... 29 Sitagliptin Phosphate/Metformin ...... 34 Rosanil ...... 29 Sitagliptin Phosphate/Metformin HCl ...... 34 Rosiglitazone Maleate ...... 34 Skelaxin ...... 17,42 Rosiglitazone Maleate/Glimepiride ...... 34 Sklice ...... 31 Rosiglitazone Maleate/Metformin HCl ...... 34 Slow-K ...... 54 Rosula ...... 29 Smoking Deterrents ...... 55 Rosula CLK ...... 29 Sodium Chloride/Sodium Bicarbonate/ Rosula NS ...... 30 Potassium Chloride/Polyethylene Glycols ...... 39 Rosuvastatin Calcium ...... 27 Sodium Fluoride ...... 53 Rowasa ...... 38 Sodium Fluoride Gel ...... 32 Roxanol Oral Solution ...... 12 Sodium Oxybate ...... 21 Roxicet Oral Solution ...... 12 Sodium Phenylbutyrate ...... 55 Roxicodone ...... 12 Sodium Polystyrene Sulfonate ...... 55 Rozerem ...... 18 Sodium Polystyrene Sulfonate ...... 55 Rufinamide Tablet ...... 16 Sodium Polystyrene Sulfonate Enema ...... 55 Ruxolitinib Phosphate ...... 11 Sodium Polystyrene Sulfonate Oral Ryna-12 ...... 50 Suspension ...... 55 Ryna-12 S ...... 50 Sodium Polystyrene Sulfonate Powder ...... 55 Rynatan ...... 50 Sodium Sulfacetamide ...... 30 Rynatan Pediatric ...... 50 Sodium Sulfacetamide/Sulfur ...... 29,30 Rythmol ...... 22 Sodium Sulfacetamide/Sulfur/Sunscreen ...... 29 Rythmol SR ...... 22 Sodium Sulfate/Sodium/Sodium Bicarbonate/ Ryzolt ...... 14 Potassium Chloride/Polyethylene Glycols ...... 39 Sodium, Potassium, Magnesium Sulfates ...... 39 S Solaquin Forte ...... 31 Sabril ...... 16 Solaraze ...... 31 Safyral ...... 43 Solia ...... 43 Saizen ...... 40 Solifenacin Succinate ...... 17,42,52 Salagen ...... 55 Soliris ...... 55 Salicylates ...... 14,41 Solodyn ...... 5 Salmeterol Xinafoate ...... 50 Soma ...... 17,42 Salsalate ...... 14,41 Somatropin ...... 40 Salsalate ...... 14,41 Somatuline Depot ...... 11 Samsca ...... 34 Somavert ...... 34 Sanctura ...... 17,42,52 Somnote ...... 18 Sanctura XR ...... 17,42,52 Sonata ...... 18 Sancuso ...... 15,39 Sorafenib Tosylate ...... 11 Sandimmune ...... 10 Soriatane ...... 30 Sandostatin ...... 11,34 Soriatane CK ...... 30 Sandostatin LAR ...... 11,34 Sorilux ...... 30 Santyl ...... 30 Sotalol ...... 22 Santyl| ...... 30 Sotalol HCl ...... 22 Saphris ...... 20 Specialized OB/GYN Drugs ...... 45 Sapropterin Dihydrochloride ...... 34 Spectazole ...... 30 Saquinavir Mesylate ...... 7 Spectracef ...... 6 Sarafem ...... 19 Spinosad ...... 31 Sargramostim ...... 11,40 Spiriva ...... 51 Savella ...... 41 Spironolactone ...... 23 Saxagliptin HCl ...... 34 Spironolactone w/HCTZ ...... 23 Saxagliptin HCl/Metformin HCl ...... 34 Spironolactone/Hydrochlorothiazide ...... 23 Scopolamine Hydrobromide ...... 15,39 Sporanox ...... 8 Seasonale ...... 43 Sporanox Capsule ...... 8 Seasonique ...... 43 Sprintec ...... 43 Seconal Sodium ...... 18 Sprix ...... 13 Second Generation Cephalosporins ...... 5 Sprycel ...... 11 Sectral ...... 24 Stadol ...... 14 Sedapap ...... 12 Stalevo ...... 15 Selective Serotonin Reuptake Inhibitors ...... 19 Stannous Fluoride Solution ...... 32 Selegiline HCl ...... 15 Starlix ...... 34,35 Selenium Sulfide ...... 30 Stavudine ...... 7 Selenium Sulfide Shampoo ...... 30 Staxyn ...... 52 Selsun Rx ...... 30 Stelara ...... 30 Selzentry ...... 7 Stelazine ...... 19 Semprex-D ...... 50 Steroid-antibiotic Combinations ...... 48 Sensipar ...... 34 Steroid-sulfonamide Combinations ...... 48 Septra DS ...... 6 Steroids ...... 47 Serax ...... 21 Stimate ...... 34 Serevent Diskus ...... 50 Strattera ...... 21 Seromycin ...... 9 Striant ...... 33 Serophene ...... 33,45 Stromectol ...... 8 Seroquel ...... 20 Strovite Advance ...... 53 Seroquel XR ...... 20 Strovite Forte ...... 53 Sertraline HCl ...... 19 Stuartnatal Plus 3 ...... 53 72 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:40 AM Page 73

Suboxone Film ...... 14 Telaprevir ...... 7 Suboxone Tablets ...... 14 Telmisartan ...... 26 Subsys ...... 12 Telmisartan/Amlodipine ...... 26 Subutex ...... 12 Telmisartan/Hydrochlorothiazide ...... 26 Succimer ...... 55 Temazepam ...... 18 Sucralfate ...... 36 Temodar ...... 10 Sucralfate Suspension, Oral ...... 36 Temovate ...... 28 Sucralfate Tablet ...... 36 Temovate-E ...... 28 Sudal ...... 50 Temozolomide ...... 10 Sular ...... 25 Temsirolimus ...... 11 Sulconazole Nitrate ...... 30 Tenex ...... 25 Sulfas & Related Agents ...... 6 Tenofovir Disoproxil Fumarate ...... 7 Sulfacet-R ...... 29 Tenoretic ...... 26 Sulfacetamide Sodium ...... 29,30,47 Tenormin ...... 24 Sulfacetamide Sodium/Prednisolone Acetate ...... 48 Tenuate ...... 55 Sulfacetamide Sodium/Prednisolone Sodium Terazol ...... 45 Phosphate ...... 48 Terazosin HCl ...... 25,52 Sulfacetamide Sodium/Sulfur ...... 29 Terazosin HCl Capsule ...... 25 Sulfacetamide w/Prednisolone ...... 48 Terbinafine HCl ...... 8 Sulfadiazine ...... 6 Terbutaline Sulfate ...... 45,50 Sulfadiazine ...... 6 Terconazole ...... 45 Sulfamethoxazole/Trimethoprim ...... 6 Teriparatide ...... 42 Sulfanilamide ...... 45 Testim ...... 33 Sulfasalazine ...... 38,41 Testosterone ...... 33 Sulfisoxazole ...... 6 Testosterone Cypionate ...... 33 Sulfisoxazole ...... 6 Testosterone Propionate ...... 33 Sulfonamides ...... 47 Testosterone Propionate ...... 33 Sulindac ...... 13,41 Testred ...... 33 Sumatriptan Nasal Spray ...... 14 Tetrabenazine ...... 17 Sumatriptan Succinate ...... 14 Tetracycline HCl ...... 5,36 Sumatriptan Succinate/Naproxen ...... 14 Tetracyclines ...... 5 Sumycin ...... 5 Tev-Tropin ...... 40 Sunitinib Malate ...... 11 Teveten ...... 26 Supartz ...... 14 Teveten 600mg ...... 26 Supprelin LA ...... 11 Teveten HCT ...... 26 Suprax ...... 6 Thalidomide ...... 11 Suprep ...... 39 Thalomid ...... 11 Surestep ...... 35 Theo-24 ...... 50 Surestep Pro ...... 35 Theo-Dur ...... 50 Surmontil ...... 18 Theophylline Anhydrous ...... 50 Sustiva ...... 7 Theophylline Anhydrous Tablet, Extended Sutent ...... 11 Release ...... 50 Sylatron ...... 40 Theophylline Anhydrous Tablet, Extended Symax Duotab ...... 37 Release 12hr ...... 50 Symbicort ...... 51 Therapy For Acne ...... 29 Symbyax ...... 20 Thiabendazole ...... 8 Symlin ...... 34 Thiazide & Related Diuretics ...... 23 Symmetrel ...... 7,15 Thioguanine ...... 10 Sympathomimetics ...... 48 Thioguanine ...... 10 Syn-Rx DM ...... 49 Thioridazine HCl ...... 19 Synagis ...... 7 Thiothixene ...... 20 Synalar ...... 28 Third Generation Cephalosporins ...... 6 Synarel ...... 34,45 Thorazine ...... 19 Synthroid ...... 33 Thyroid ...... 33 Synvisc ...... 14 Thyroid Hormones ...... 33 Synvisc-One ...... 14 Thyrolar ...... 33 Syringe w-Needle, Disposable, Insulin ...... 35 Tiagabine HCl ...... 16 Tiazac ...... 24 T Ticagrelor ...... 22,53 Taclonex ...... 30 Ticlid ...... 22,53 Taclonex Scalp ...... 30 Ticlopidine HCl ...... 22,53 Tacrolimus ...... 10,31 Tigan ...... 15,39 Tacrolimus Anhydrous ...... 10 Tikosyn ...... 22 Tadalafil ...... 52 Timolol Maleate ...... 24,46 Tagamet ...... 36 Timolol Maleate Gel-Forming Solution ...... 46 Talacen ...... 14 Timoptic ...... 46 Talwin NX ...... 14 Timoptic-XE ...... 46 Tambocor ...... 22 Tindamax ...... 8 Tamiflu ...... 7 Tinidazole ...... 8 Tamoxifen Citrate ...... 10 Tiotropium Bromide ...... 51 Tamsulosin HCl ...... 52 Tipranavir ...... 7 Tapazole ...... 33 Tirosint ...... 33 Tapentadol ...... 14 Tizanidine HCl ...... 17 Tarceva ...... 11 Tobi ...... 8 Targretin Capsule ...... 11 TobraDex ...... 48 Tarka ...... 26 TobraDex Drops ...... 48 Tasigna ...... 11 TobraDex Ointment ...... 48 Tasmar ...... 15 TobraDex ST ...... 48 Tavist ...... 49 Tobramycin Sulfate ...... 47 Tazarotene ...... 29,30 Tobramycin Sulfate Drops ...... 47 Tazorac ...... 29,30 Tobramycin Sulfate Ointment ...... 47 Tegretol ...... 16 Tobramycin Sulfate/Dexamethasone ...... 48 Tegretol XR ...... 16 Tobramycin Sulfate/Dexamethasone Drops ...... 48 Tegretol XR 100mg ...... 16 Tobramycin/0.25 Normal Saline Ampul for Tegretol XR 200mg, 400mg ...... 16 Nebulization ...... 8 Tekamlo ...... 26 Tobramycin/Loteprednol Etabonate ...... 48 Tekturna ...... 26 Tobrex ...... 47 Tekturna HCT ...... 26 Tobrex Drops ...... 47 73 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:40 AM Page 74

Tocilizumab ...... 41 Triphasil ...... 43 Tofranil ...... 18 Trizivir ...... 7 Tofranil-PM ...... 18 Tropicamide ...... 46 Tolazamide ...... 34 Trospium Chloride ...... 17,42,52 Tolbutamide ...... 34 Trusopt ...... 46 Tolectin ...... 13,41 Truvada ...... 7 Tolinase ...... 34 Trypsin/Balsam Peru/Castor Oil ...... 30 Tolmetin Sodium ...... 13,41 Tussi-12 ...... 50 Tolterodine Tartrate ...... 17,42,52 Tussi-Organidin DM Nr ...... 49 Tolvaptan ...... 34 Tussi-Organidin DM-S Nr ...... 49 Topamax ...... 16 Tussi-Organidin Nr ...... 49 Topical Anesthetics ...... 29 Tussi-Organidin-S Nr ...... 49 Topical Antibacterials ...... 29 TussiCaps ...... 49 Topical Antifungals ...... 30 Tussionex ...... 49 Topical Antivirals ...... 30 Twinject ...... 49 Topical Corticosteroids ...... 28 Twynsta ...... 26 Topical Corticosteroids High Potency ...... 28 Tykerb ...... 11 Topical Corticosteroids Low Potency ...... 28 Tylenol w/Codeine ...... 12 Topical Corticosteroids Medium Potency ...... 28 Tylox ...... 12 Topical Corticosteroids Very High Potency ...... 28 Tysabri ...... 17 Topical Enzymes ...... 30 Tyvaso ...... 51 Topical Scabicides/Pediculicides ...... 31 Tyzeka ...... 7 Topicort ...... 28 Topicort LP ...... 28 Topiramate ...... 16 U Topiramate ...... 16 Ulcer Therapy ...... 36 Topotecan HCl Capsule ...... 11 Ulesfia ...... 31 Toprol XL ...... 24 Ulipristal Acetate ...... 43 Toradol ...... 13 Uloric ...... 41 Torisel ...... 11 Ultra Comfort ...... 35 Torsemide ...... 23 Ultracet ...... 14 Toviaz ...... 17,42 Ultram ...... 14 Tracleer ...... 51 Ultram ER ...... 14 Tradjenta ...... 34 Ultrase ...... 37 Tramadol ER ...... 14 Ultrase MT ...... 37 Tramadol HCl ...... 14 Ultravate ...... 28 Tramadol HCl-Acetaminophen ...... 14 Ultravate PAC ...... 28 Tramadol HCl/Acetaminophen ...... 14 Umecta ...... 31 Trandate ...... 24 Uniphyl ...... 50 Trandolapril ...... 25 Uniretic ...... 26 Trandolapril/Verapamil ...... 26 Univasc ...... 25 Tranexamic Acid ...... 45 Urea ...... 31 Transderm-Nitro ...... 22 Urecholine ...... 52 Transderm-Scop ...... 15,39 Urinary Anesthetics ...... 52 Tranxene T-Tab ...... 21 Urinary Tract Agents ...... 6 Tranylcypromine Sulfate ...... 19 Urispas ...... 52 Trastuzumab ...... 11 Urofollitropin (FSH) ...... 33,45 Travatan ...... 46 Uroqid-Acid No.2 ...... 52 Travatan Z ...... 46 Uroxatral ...... 52 Travoprost ...... 46 Urso ...... 37 Urso Forte ...... 37 Trazodone HCl ...... 18 Ursodiol ...... 37 Treanda ...... 10 Ustekinumab ...... 30 Trental ...... 23,54 Treprostinil ...... 51 Treprostinil Sodium ...... 25 V Tretinoin ...... 11,29 Vagifem ...... 44 Tretinoin Gel ...... 29 Vaginal Antifungals ...... 45 Trexall ...... 10,41 Vaginal Cleanser/Antiinfectives ...... 45 Treximet ...... 14 Valacyclovir HCl ...... 7 Tri-Levlen ...... 43 Valcyte Suspension ...... 7 Tri-Norinyl ...... 43 Valcyte Tablet ...... 7 Tri-Previfem ...... 43 Valganciclovir Hydrochloride ...... 7 Tri-Sprintec ...... 43 Valium ...... 17,21,42 Tri-Vi-Flor ...... 53 Valproic Acid ...... 16 Tri-Vi-Flor w/Iron ...... 53 Valsartan ...... 26 Triamcinolone Acetonide ...... 28,32,51 Valsartan/Hydrochlorothiazide ...... 26 Triamcinolone Acetonide Cream ...... 28 Valtrex ...... 7 Triamcinolone Acetonide Lotion ...... 28 Valturna ...... 26 Triamcinolone Acetonide Paste ...... 32 Vancocin ...... 8 Triamterene w/HCTZ ...... 23 Vancomycin ...... 8 Triamterene/Hydrochlorothiazide ...... 23 Vancomycin HCl ...... 8 Triaz ...... 29 Vandetanib ...... 11 Triazolam ...... 18 Vandetanib ...... 11 Tribenzor ...... 26 Vanos ...... 28 Tricor ...... 27 Vanoxide-HC ...... 29 Tricyclics ...... 18 Vantas ...... 11 Trifluoperazine HCl ...... 19 Vantin ...... 5 Trifluridine ...... 48 Varenicline Tartrate ...... 55 Triglide ...... 27 Vaseretic ...... 26 Trihexyphenidyl HCl ...... 15 Vasocidin ...... 48 Trilafon ...... 19 Vasoconstrictor Decongestants ...... 47 Trileptal ...... 16 Vasodilan ...... 45 Trilipix ...... 27 Vasodilators ...... 25 Trilisate ...... 14,41 Vasotec ...... 25 Trimethobenzamide HCl ...... 15,39 Vazotan ...... 50 Trimethoprim ...... 6 Vectibix ...... 11 Trimipramine Maleate ...... 18 Vectical ...... 30 Trinessa ...... 43,45 Velaglucerase Alfa ...... 34 74 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:41 AM Page 75

Velcade ...... 11 X Velivet ...... 43 Xalatan ...... 46 Veltin ...... 29 Xalkori ...... 11 Vemurafenib ...... 11 Xanax ...... 21 Venlafaxine HCl ...... 18 Xanax XR ...... 21 Venlafaxine HCl ER ...... 18 Xanthines ...... 50 Ventavis ...... 51 Xarelto ...... 22 Ventolin HFA ...... 50 Xeloda ...... 10 VePesid ...... 11 Xenaderm ...... 30 Veramyst ...... 32,51 Xenazine ...... 17 Verapamil HCl ...... 24 Xenical ...... 55 Verapamil HCl Capsule, Sustained Release Xerac AC ...... 31 24 hr ...... 24 Xerese ...... 30 Verapamil HCl Tablet, Sustained Action ...... 24 Xgeva ...... 11 Verdeso ...... 29 Xiaflex ...... 55 Veregen ...... 31 Xibrom ...... 47 Verelan ...... 24 Xifaxan 200mg ...... 8 Verelan PM ...... 24 Xifaxan 550mg ...... 8 Vermox ...... 8 Xodol ...... 12 Versed ...... 21 Xolair ...... 51 Vesanoid ...... 11 Xolegel ...... 30 Vesicare ...... 17,42,52 Xopenex ...... 50 Vexol ...... 47 Xopenex HFA ...... 50 Vfend ...... 8 Xylocaine ...... 29,32 Viagra ...... 52 Xyntha ...... 23,54 Vibra-Tabs ...... 5 Xyntha Solofuse ...... 23,54 Vibramycin ...... 5 Xyrem ...... 21 Vibramycin Suspension ...... 5 Xyzal ...... 49 Vibramycin Syrup ...... 5 Vicodin ...... 12 Vicodin ES ...... 12 Y Vicodin HP ...... 12 Yasmin ...... 43 Vicoprofen ...... 12 YAZ ...... 43 Victoza ...... 35 Yervoy ...... 11 Victrelis ...... 7 Yodoxin ...... 8 Vidaza ...... 10 Videx ...... 7 Z Videx EC ...... 7 Zafirlukast ...... 51 Vigamox ...... 47 Zaleplon ...... 18 Viibryd ...... 19 Zanaflex ...... 17 Vilazodone HCl ...... 19 Zanamivir ...... 7 Vimovo ...... 13,41 Zantac Rx ...... 36 Vimpat ...... 16 Zantac Rx Syrup ...... 36 Vinate II ...... 53 Zarontin ...... 16 Vinorelbine Tartrate ...... 11 Zaroxolyn ...... 23 Viokase ...... 37 Zatean-PN Plus ...... 53 Viracept ...... 7 Zavesca ...... 34 Viramune ...... 7 Zebeta ...... 24 Viramune XR ...... 7 Zegerid ...... 36 Viread ...... 7 Viroptic ...... 48 Zegerid Rx ...... 36 Visicol ...... 38 Zelapar ...... 15 Visken ...... 24 Zelboraf ...... 11 Vismodegib ...... 11 Zemaira ...... 55 Vistaril ...... 49 Zemplar ...... 34 Vita S Forte ...... 53 Zenpep ...... 37 Vitacel ...... 53 Zeosa ...... 43 Vitafol ...... 53 Zerit ...... 7 Vitafol-OB ...... 53 Zestoretic ...... 26 Vitamin B-12 ...... 53 Zestril ...... 25 Vitamin D ...... 53 Zetia ...... 27 Vitamin D 50000 Unit ...... 53 Ziac ...... 26 Vitamin K ...... 23,54 Ziagen ...... 7 Vitamins & Hematinics ...... 53 Ziagen Oral Solution ...... 7 Vivactil ...... 18 Ziagen Tablet ...... 7 Vivelle ...... 42,44 Ziana ...... 29 Vivelle DOT ...... 42,44 Zidovudine ...... 7 Vivitrol ...... 14 Ziprasidone HCl ...... 20 Voltaren ...... 13,47 Zirgan ...... 48 Voltaren-XR ...... 13 Zithromax ...... 6 Voriconazole ...... 8 Zmax ...... 6 VoSol ...... 32 Zocor ...... 27 VoSol HC ...... 32 Zoderm ...... 29 Vospire ER ...... 50 Zofran ...... 15,39 Votrient ...... 11 Zofran ODT ...... 15,39 VPRIV ...... 34 Zoladex ...... 11 Vytorin ...... 27 Zolinza ...... 11 Vyvanse ...... 21 Zolmitriptan ...... 14 Zoloft ...... 19 Zolpidem Tartrate ...... 18 W Zolpidem Tartrate ER ...... 18 Warfarin Sodium ...... 22,53 Zolpimist ...... 18 Welchol ...... 27 Zomig ...... 14 Wellbutrin ...... 18 Zomig Nasal Spray ...... 14 Wellbutrin SR ...... 18 Zomig ZMT ...... 14 Wellbutrin XL ...... 18 Zonalon ...... 31 Westcort ...... 28 Zonegran ...... 16 Wilate ...... 23,54 Zorbtive ...... 40 Wytensin ...... 25 Zovia ...... 43 75 FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2_FB43315A - FORMULARY REFERENCE GUIDE 3Q12_v2 10/29/12 8:41 AM Page 76

Zovirax ...... 7,30 Zutripto ...... 49 Zyban ...... 55 Zyclara ...... 31 Zydone ...... 12 Zyflo ...... 51 Zyflo CR ...... 51 Zylet ...... 48 Zyloprim ...... 41 Zymar ...... 47 Zymaxid ...... 47 Zyprexa ...... 20 Zyprexa Relprevv ...... 20 Zyprexa Zydis ...... 20 Zytiga ...... 10 Zyvox ...... 8

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