San Diego County Medical Services Drug Formulary

DRUG FORMULARYCounty Medical Services (CMS) ProgramHealthcare Coverage Initiative (CI) ProgramRyan White Primary Care ProgramJune 2009This document has been prepared by AmeriChoice a UnitedHealthCompany Group for the San Diego County Medical Services Programand is updated on a regular basis throughout the year.Please be sure to confer with the CMS Formulary website to be surethis is the most recent version. The CMS Formulary website is:www2.sdcounty.ca.gov/hhsa/documents/Formulary.pdf

San Diego County Medical Services Drug FormularyThe County of San Diego has contracted with AmeriChoice as their Administrative Services Organization forthe County Medical Services (CMS) program. In turn, AmeriChoice has contracted with NMHC ProfessionalServices* to act as the Pharmacy Benefits Manager.This formulary serves the County Medical Services (CMS) Program, Coverage Initiative Program and RyanWhite Primary Care Program. The AIDS Drug Assistance Program (ADAP) is separate from the CMS programand has its own enrollment criteria and formulary. Patients with dual membership in CMS and ADAP must billADAP for products appearing in both the CMS and ADAP formulary.The CMS Pharmacy and Therapeutics (P&T) Committee determines the content of this formulary. Additionsto this formulary must be approved by the P&T Committee. To request the review of a new product,complete the “Request for Formulary Change” form located at the end of this document and fax to theMedical Management Services Manager at AmeriChoice at (858) 565-4091.FORMULARY FORMATGeneric Products1. The CMS Formulary is generic based.2. When a brand name drug is ordered and a generic equivalent is available, the generic will bedispensed by the pharmacy. The prescriber must justify any exception and the “Drug Prior Authorization”form must be completed and faxed to NMHC Professional Services* at (516) 403-2151. The Drug PriorAuthorization Form is also located at the end of the formulary.Maximum Allowable LimitsExcept as otherwise prescribed or noted below, patients can receive a 30-day supply of prescribedmedications. Exceptions:• Refills are allowed after 25 days.• One lost prescription and one vacation supply is allowed each yearCode 1 RestrictionsProducts with this notation are limited to prescriber’s specialty, to a restricted amount, diagnosis, or steptherapy.Formulary Exclusions• Drugs prescribed for conditions not covered by CMS• All OTC products not included in this listing• Psychotropic and psychotherapeutic drugs prescribed for mental health conditions• Oral birth control and birth control devices for non-pathological reasons• Nicotine and smoking cessation products• Experimental drugs• Drug and alcohol abuse treatmentAuthorization PolicyEvery provider has the right to request coverage of a non-formulary medication. However, medicaljustification for using a non-formulary medication is required. First, please review, any notations found underthe “Utilization Management” column in the drug category type of the non-formulary medication. Second,complete the “Drug Prior Authorization” form found at the end of this document and fax to NMHCProfessional Services* at (516) 403-2151. For your convenience, Drug Prior Authorizations can also becompleted on line at: www.nmhcrx.com. At the NMHC website, click “Client Information – ProviderServices” and then locate the “Provider Authorization Request Form” text (two forms are available on thiswebpage with similar names) and click to open. Then select the form titled “PA Form – San Diego CMS”.Additionally, the NMCH Professional Services’ Customer Service (800-777-0074) is available 24 hours a day,everyday, to assist with any formulary questions.*NMHC* Professional Services is transitioning into informedRx®June 2009 Page 2 of 42

Denials and AppealsSan Diego County Medical Services Drug FormularyWhen a product is excluded or is not medically justified, NMHC Professional Services* will issue a provisionaldenial to the pharmacy and/or the prescriber. If the CMS Program Medical Director completes the denial,the prescriber and the patient are issued written notification. Appeals are made directly to the CMSProgram and instructions are incorporated in the denial notice.Formulary DatesThis formulary is published on the Web and is updated on a quarterly basis. The most recent document islocated at: www2.sdcounty.ca.gov/hhsa/documents/Formulary.pdf*NMHC* Professional Services is transitioning into informedRx®June 2009 Page 3 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementPenicillinsAmoxicillin OralAmoxicillin & PotassiumClavulanate OralAmpicillin OralDicloxacillin Sodium OralPenicillin V Potassium OralCephalosporinsCefixime Tab 400mg OralCephalexin MonohydrateANTI-INFECTIVE AGENTSTrimoxAugmentinAmpicillinDicloxacillin SodiumPen-VK, VeetidsSupraxKeflexFluroquinolonesCiprofloxacin HCl 250mg,500mg, 750mg Tab OralLevofloxacin Tab OralCiproLevaquinLimited to 28/14 days.For CMS & Coverage Initiative: Code 1Restriction: For diagnosis of Pneumonia.Limited to 10 tablets/10 days.MacrolidesAzithromycin 250mg, 500mgTab OralAzithromycin Susp OralClarithromycin 250mg, 500mgTab OralErythromycin Base OralErythromycin DelayedRelease OralErythromycin w/EC ParticlesOrallErythromycin EthylsuccinateOralErythromycin Stearate OralMisc. Anti-InfectivesClindamycin HCL Cap OralDapsone OralMetronidazole Tab OralTrimethoprim/Sulfamethoxazole OralSulfonamidesSulfisoxazole PowderSulfisoxazole Acetyl OralZithromaxZithromaxBiaxinErythromycinE-Mycin, Eryc, Ery-Tab,PCEE.E.S.ErythrocinCleocinDapsoneFlagylBactrim, Bactrim DSSulfisoxazoleGantrisinFor CMS & Coverage Initiative: Limited to 6tablets/fill and 2 fills/month for 250mg; 3tablets/fill and 2 fills/month for 500mg.For CMS & Coverage Initiative: Code 1Restriction: For diagnosis of communityacquiredpneumonia only.For CMS & Coverage Initiative: Limited to 28tablets/14 days.June 2009 Page 4 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementTetracyclinesDoxycycline Hyclate Cap50mg & 100mg, Tab 100mgOralTetracycline HCl OralAmebicidesIodoquinol OralAminoglycosidesNeomycin Sulfate OralAntihelminticsMebendazole OralPyrantel Pamoate OralThiabendazole OralVibramycin,VibratabSumycinYodoxinNeomycin Sulfate,Neo-FradinVermoxPin-X, AntiminthMintezolAll Antihelmintics are coveredAntifungalsFluconazole Tab 150 mg Oral Diflucan Limited to 1 tablet/fill, 2 fills/monthGriseofulvin Microsize Oral Grifulvin VGriseofulvin Ultramicrosize Gris-pegKetoconazole Tab Oral NizoralNystatinMycostatinAntimalarialsChloroquine Phosphate TabOralHydroxychloroquine SulfateOralPrimaquine Phosphate OralPyrimethamine OralQuinine Sulfate Tab 324mgOralAralenPlaquenilPrimaquinephosphateDaraprimQualaquinAntimycobacterial AgentsIsoniazid OralNydrazidRifampin Oral Rifadin PA required for Tuberculosis.Antiviral – Herpes AgentsAcyclovir OralAntineoplastic AgentsZoviraxANTINEOPLASTIC AGENTSAll oral FDA-approved cancer therapy iscovered up to $350. PA required for agentsgreater than than $350.June 2009 Page 5 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementGlucocorticosteroidsCortisone Acetate OralDexamethasone OralHydrocortisone Tab OralPrednisolonePrednisolone SodiumPhosphate PowderPrednisolone SodiumPhosphate OralPrednisone OralMineralocorticoidsFludrocortisone Acetate OralENDOCRINE_AND METABOLIC DRUGSCortisoneDecadron, DexoneCortefPrelonePrednisoloneMeticorten,Deltasone,Liquid PredFlorinefDIABETIC AGENTSHuman InsulinLimited to vials only.Insulin Aspart Inj 100 U/mL Novolog Limited to 2 vials/monthInsulin Aspart Prot & Aspart Inj100 U/mLNovolog MixInsulin Detemir Inj U/mL LevemirInsulin Glargine Inj 100 U/mL Lantus (vials only) Limited to 4 vials/monthInsulin Lispro Inj 100 U/mL HumalogInsulin Lispro Prot & Lispro Inj100 U/mL (75-25)Humalog Mix 75/25Insulin Regular Inj 100 U/mL Humulin R, Novolin R Limited to 2 vials/monthInsulin Regular Inj 500 U/mL Humulin R Limited to 2 vials/monthInsulin Isophane Inj 100 U/mL Humulin N, Novolin N Limited to 2 vials/monthInsulin Regular & Isophane Inj100 U/mLInsulin Regular & Isophane Inj100 U/mL (50)Humulin 70/30Novolin 70/30Humulin 50/50Limited to 2 vials/monthLimited to 2 vials/monthInsulin Zinc Inj 100 U/mL Humulin L, Novolin L Limited to 2 vials/monthSulfonylureasGlimepiride Oral Amaryl Limited to 1/tablet/day for 1mg & 2mg and2 tablets/day for 4mgGlipizide Tab OralGlucotrolGlyburide Oral Diabeta, Micronase Limited to 120/30 daysGlyburide Micronized Glynase Limited to 120/30 daysBiguanides–MetforminMetformin HCL Oral Glucophage Limited to 2500 mg/dayJune 2009 Page 6 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementOther AntidiabeticsGlucagon Kit InjectionGlucose Chew Tab OralThiazolidinedionesPioglitazone OralRosiglitazone OralThyroid HormonesLevothyroxine Sodium OralLiothyronine Sodium OralGlucagon KitBD – Glucose ChwActosAvandiaSynthroid, L-Thyroxine,Levothroid, Levoxyl,EuthyroxCytomelContingent Therapy: Second-line agent tobe used in combination with an oraldiabetes agent or insulin. Limited to #1/dayContingent Therapy: Second-line agent tobe used in combination with an oraldiabetes agent or insulin and continuingtherapy only. Limited to #1/dayAvailable as “Do Not Substitute”Antithyroid AgentsMethimazole OralPropylthiouracil OralTapazolePropylthiouracil (PTU)VasopressinCabergoline OralDesmopressin Acetate Oral,Nasal SprayDostinexDDAVPAnti-ArrhythmiaDisopyramide PhosphateOralDofetilide OralFlecainide Acetate OralMexiletine HCLMoricizine HCL OralProcainamide HCL OralPropafenone HCL OralQuinidine Gluconate CR OralQuinidine Sulfate Tab OralACE InhibitorsBenazepril HCL OralCaptopril OralEnalapril OralLisinopril OralCARDIOVASCULAR AGENTSAll Anti-Arrhythmia are formularyNorpace CRTikosynTambocorMexiletineEthmozinePronestylRythmolQuinidineQuinidexLotensinCapotenVasotecPrinivil, ZestrilJune 2009 Page 7 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementAdrenolytics-CentralClonidine HCL OralMethyldopa OralCatapresAldometAvoid in elderly patientsAlpha-BlockersDoxazosin Mesylate OralPrazosin HCL OralTerazosin OralCarduraMinipressHytrinAngiotensin II InhibitorsOlmesartan OralValsartan OralBenicarDiovanCode 1 Restriction: For patient failingtherapy with or intolerant to ACE Inhibitors.Limited to 1/dayCode 1 Restriction: For patient failingtherapy with or intolerant to ACE Inhibitors.Limited to 1/dayAngiotensin II Inhibitor CombinationsOlmesartan-HCTZ Oral Benicar HCTValsartan OralDiovan HCTCode 1 Restriction: For patient failingtherapy with or intolerant to ACE Inhibitors.Limited to 1/dayCode 1 Restriction: For patient failingtherapy with or intolerant to ACE Inhibitors.Limited to 1/dayAnti-Anginals, OtherDipyridamole OralPersantineBeta-Blockers Non-SelectivePropranolol HCL OralSotalol HCl OralInderal, Inderal LABetapace,Betapace AFPatients with asthma or COPD at any levelof severity should not receive non-selectivebeta blockers.BetaBlockers Cardio-SelectiveAtenolol OralMetoprolol Succinate SR OralMetoprolol Tartrate OralTenorminToprol XLLopressorBeta-Blockers may worsen airway diseases.Use caution when using these medicationsin asthma/COPD patients.Code 1 Restriction: For Heart Failure.Limited to 1 tablet/dayAlpha-Beta BlockersPatients with asthma or COPD at any levelof severity should not receive non-selectivebeta blockers.June 2009 Page 8 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementCarvedilol Tab Oral Coreg Code 1 Restriction: For Heart Failure or MI.Limited to 2 tablets/dayLabetalol HCL OralTrandate,NormodyneCalcium BlockersAmlodipine Besylate Oral Norvasc Limited to 1 tablet/dayDiltiazem HCL CR OralCardizem SR,Diltiazem ERDiltiazem HCL OralCardizemDiltiazem HCL SR/24hr Oral Dilacor XR,Nimodipine Cap OralNimotopVerapamil HCL Tab Oral Calan, IsoptinVerapamil HCL Tab CR Oral Calan SR, Isoptin SRDigitalisDigoxin OralLanoxinNitratesIsosorbide Dinitrate OralIsosorbide Dinitrate SL OralIsosorbide Mononitrate OralNitroglycerin Buccal OralNitroglycerin SL Tab & AerOralNitroglycerin Intravenous SolnNitroglycerin CR OralNitroglycerin Oint 2%TransdermalNitroglycerin TD TransdermalIsordil, SorbitrateIsosorbide DinitrateOral Tabs & ChewTabsIsordilMonoket, ISMOImdurNitrogardNitrostat, Nitrotab,NitroquickNitroglycerinNitro-Time, NitroglynNitrobid, NitrolNitro-Dur, Minitran,Transderm-Nitro,Deponit, NitrodiscCarbonic Anhydrase InhibitorsAcetazolamide OralAcetazolamide SR OralMethazolamide OralAcetazolamideDiamox SequelsNeptazaneLoop DiureticsJune 2009 Page 9 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementFurosemide OralLasixPotassium Sparing DiureticsSpironolactone OralAldactoneThiazidesChlorthalidone 25mg, 50mg,100mg tablet OralHydrochlorthiazide (HCTZ)OralIndapamide OralMetolazone OralHygrotonHydrodiuril, Oretic,Esidrix, MicrozideLozolZaroxolynLimited to 1 tablet per dayCombination DiureticsSpironolaone & HCTZ OralTriamterene & HCTZ OralAldactazideDyazide, Maxzide-25, Maxzide 75/50VasodilatorsHydralazine HCL OralMinoxidil OralApresolineLonitenAnaphylaxis Therapy AgentsEpinephrine HCl Injection(Anaphylaxis)Epinephrine-ChlorpheniramineEpipen, Epipen Jr.Ana-KitBile SequestrantsCholestyramine Powder CanOral Cholestyramine Powder& Packets OralQuestran/Lite,PrevaliteAntihyperlipidemics: FenamatesGemfibrozil OralLopidFenofibrate OralTricor, Triglide, etcLimited to CMS and Coverage Initiativesonly. Contingent Therapy: For concurrenttherapy with Simvastatin or patient failingtherapy with or intolerant to gemfibrozil.Limited to 1/day the following strengths,dosage forms, and NDCs: 54mg tablet(NDC: 00115-5511-10), 67mg capsule (NDC:00115-0511-01, and 134mg capsule (NDC:00115-0522-01).Antihyperlipidemics: HMG-CoA Reduase InhibitorJune 2009 Page 10 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementLovastatin Oral Mevacor Limited to 1 tablet/daySimvastatin Oral Zocor Limited to 1 tablet/dayNicotinic Acid DerivativesNiacin Tab CRNiaspanContingent Therapy: For patient failingtherapy with or intolerant to niacin. Limitedto 1 tablet/dayAntihistamines-AlkylaminesCyproheptadine HCL OralDiphenhydramine HCLcapsule, tablet OralPromethazine HCL OralPromethazine HCL SupposRectalPeriactinRESPIRATORY AGENTSBenadryl, DiphedrylPhenergan,Phenergan FortePhenerganAntihistamines-Non-SedatingLoratadine 10mg Tab Oral(OTC)ClaritinLimited to 1 tablet/dayNasal SteroidsFlunisolide 0.025% NasalFluticasone Propionate NasalExpectorantsGuaifenesin OralNasalideFlonaseOrganidin NR,Diabetic Tus,Robitussin, NaldeconSrCode 1 Restriction: For diagnosis of nasalpolyps, chronic sinusitis, or asthma. Limitedto 1 unit/monthCode 1 Restriction: For diagnosis of nasalpolyps, chronic sinusitis, or asthma. Limitedto 1 unit/monthMiscellaneous RespiratorySodium Chloride Soln Nebu0.9%Broncho SalineDecongestant orDecongestant CombinationsBrompheniramine &Pseudoephedrine Syrup, ElixirOralChlorpheniramine &Phenylephrine Elixir 2-5mg/5ml OralBromfed, Dimetapp,Bromtapp,BromanateNovahistineJune 2009 Page 11 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementChlorpheniramine &Pseudoephedrine OralDexbrompheniramine &Pseudoephedrine OralPhenylephrine-GG OralPromethazine &Phenylephrine Syrup 6.25-5mg/5mL OralPseudoephedrine HCL OralPseudoephedrine w/DM-GGCap 30-10-200mg OralPseudoephedrine-GG/CROralTriprolidine &Pseudoephedrine OralSudafed Plus, Chlor-Trimeton, Histex,DeconamineSudexRescon-GGPhenergan VCSudafedRobitussin Cod/Cgh,Novahistine-DMXHumibid Guaif,Guaifed, RobitussinPE, Guaifed-PDActifedAntitussive-Antihistamine NarcoticCodine-GG OralTussi-Organi,Robitussin A-CNarcotic (codeine cough syr)Phenerganw/Codeine, etc.Limited to 240 mL/fill, maximum of 3fills/month.Antitussive Non-NarcoticChlorpheniramine-DM SyrupOralDextromethorphan-GGLiquid 10-100mg/5mL OralPhenylephrine-Chlorphen-DMOralPhenylephrine-Pyrilamine-DMOralPromethazine-DM Syrup OralPseudoephed-Bromphen-DMOralPseudoephed-Carbinoxamine-DM LiquidOralChlorpheniramine &Pseudoephedrine OralDexbrompheniramine &Pseudoephedrine OralPhenylephrine w/DM-GGOralScot-Tussin DM SFRobitussin DM,Diabetic Tus DMCerose-DMCodimal DM,Codituss DMPhenergan DMDimetane-DX,Bromatane DXRondec DMSudafed Plus, Chlor-Trimeton, Histex,DeconamineSudexTussexAll generic products are coveredFluticasone-Salmeterol Inhal Aerosol, PwdrDiskus,AnticholinergicsJune 2009 Page 12 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementIpratropium BromideIpratropium BromideInhalation IpratropiumBromide Inhalation SolnAtropine SulfateAtrovent, AtroventHFAAtropine SulfateMast Cell StabilizersCromolyn Sodium Inhalation Intal Limited to 30/month for aerosol solutionNedocromil SodiumInhalationTiladeBeta AdrenergicsAlbuterol InhalationAlbuterol Sulfate AeroInhalationAlbuterol Sulfate OralAlbuterol Sulfate Soln NebuInhalatioPirbuterol InhalationSalmeterol Xinafoate PowderDisks InhalationTerbutaline Sulfate OralAdrenergic CombinationsAlbuterol-Ipratropium AerosolInhalationFluticasone-Salmeterol InhalAerosol, Pwdr DiskusXanthines (Theophylline)Aminophylline OralTheophylline Cap CR OralTheophylline Tab OralTheophylline Tab CR OralTheophylline Elixir, Soln OralVentolin, ProventilVentolin HFA,Proventil HFAVentolin, ProventilVentolin, ProventilMaxair, MaxairAutohalerSerevent DiskusBrethineCombiventAdvair HFA, AdvairAminophylineSlo-Bid, Slo-Phyllin,Theo-24Slo-Phyllin, Theolair,Quibron-TTheo-Dur, Theolair-SR, Uniphyl, Uni-DurSlo-PhyllinLimited to Proair HFA only and 2cannisters/monthLimited to 1 unit/monthCode 1 Restriction: For diagnosis of COPDPA required. For patient failing therapy withor intolerant to inhaled steroids, Atrovent,Combivent, or Spiriva. Limited to 1unit/monthAll generic Xanthine products are covered.Steroid InhalantsBeclomethasoneDipropionate Inhal AeroFluticasone PropionateInhalationLeukotriene Receptor InhibitorsQVARFlovent HFAContingent Therapy: For patient failingtherapy with QVAR. Limited to 1 unit/monthJune 2009 Page 13 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementMontelukast Sodium OralZafirlukast OralSingulairAccolateContingent Therapy: For patient on currenttherapy with an inhaled steroid. Limited to30 tablets/monthContingent Therapy: For patient on currenttherapy with an inhaled steroid. Limited to60 tablets/monthAntiperistaltic AgentsDiphenoxylate w/ AtropineOralLoperamide HCL OralOpium Tinure 10% OralParegoric Tinure OralLomotil, LonoxGASTROINTESTINAL AGENTSImodium, ImodiumA-DOpium tinctureParegoric tinctureBelladonna AlkaloidsHyoscyamine Sulfate OralAntispasmodicsDicyclomine HCL OralAnticholinergic CombinationsPhenobarbital & BelladonnaAlkaloids OralLevsinex, Cystospaz-M, Levsin, Levsin SL,Anaspaz, Levbid,ColytrolBentylDonnatal, DonnatalExtentabH-2 AntagonistsFor Ulcer: Over 90% of gastric or duodenal ulcers are caused by H. pylori. If test results arepositive, patients should be treated with antimicrobials. Once H. pylori has been successfullyeradicated, continued maintenance therapy with Anti-Ulcer agents is no longer necessary.Cimetidine OralTagametFamotidine Tablet 40mg Oral PepcidRanitidine HCL Tablet 150mg,Zantac300mg OralAnti-Ulcers: Imidazoles (Proton-Pump Inhibitors)For Ulcer: Over 90% of gastric or duodenal ulcers are caused by H. pylori. If test results arepositive, patients should be treated with antimicrobials. Once H. pylori has been successfullyeradicated, continued maintenance therapy with Anti-Ulcer agents is no longer necessary.Omeprazole MagnesiumPrilosec (OTC) Limited to 2 tablets/dayTablet OralMiscellaneous Anti-UlcerJune 2009 Page 14 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementSucralfate OralCarafateUlcer Anti-Infective W/ Proton Pump InhibitorsAmoxicillin Cap-Clarithro Tab-Lansopraz Cap CR Therapy PrevPacPack OralLimited 1 fill/6 monthsAnti-Emetics-AnticholinergicMeclizine OralAntivertGallstone Solubilizing AgentsUrsodiol Capsule 300mg OralGI StimulantsMetoclopramide HCL OralActigallReglanIntestinal AcidifiersLactulose (Encephalopathy)Syr 10gm/15mL OralCephulac, EnuloseCalulose, Cholac,GenerlacMisc. GIMesalamine Enema Rectal,Suppos Rectal, OralSulfasalazine Tab & EC OralAsacol, Canasa,Rowasa, PentasaAzulfidineLimited to 2520mL/6 months for enemaDigestive AidsAmylase-Lipase-ProteaseOralPancreaseGENITOURINARY PRODUCTSCalcium Acetate (Phosphate Binder)Calcium Acetate (PhosphatePhosLoBinder) Cap 667mg OralUrinary Anti-InfectivesNitrofurantoin Susp OralNitrofurantoinMacrocrystalline OralNitrofurantoin MonohydrateMacrocrystalline OralUrinary AntispasmodicsBethanechol Chloride OralHyoscyamine Tab 0.15 mgOralOxybutynin Chloride Tab &Syr OralFuradantinMacrodantinMacrobidUrecholineCystospazDitropanVaginal Anti-InfectivesJune 2009 Page 15 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementClindamycin Phosphate CRVaginalMetronidazole Gel 0.75%VaginalVaginal AntifungalsNystatin Tab 100000 UVaginalClotrimazole VaginalClotrimazoleClotrimazole TabCream 1%, Kit VaginalMiconazole Nitrate VaginaMiconazole Nitrate VaginaKit,Miconazole Nitrate Cream,Suppos VaginalTerconazoleVaginalCleocin VaginalMetrogel Vag GelNystatin Vaginal TabGyne-LotriminMonistatUrinary AnalgesicsPhenazopyridine HCL TabOral, KitMisc. Genitourinary AgentsPentosan Polysulfate SodiumOralPotassium & Sodium Citratesw/Citric Acid OralGenitourinary IrrigantsSodium Chloride IrrigationSolnAzo-gesic, Pyridium,Urogesic, UroFemme KitElmironCytra K, Polycitra,TricitratesSodium ChlorideIrrigation SolnPSYCHOTHERAPEUTIC AGENTSBenzodiazepinesClonazepam Tab Oral Klonopin Code 1 Restriction: For seizureDiazepam Tab OralValiumCode 1 Restriction: For muscle spasms orseizure. Limited to 60/month.Miscellaneous Anti-Anxiety AgentsHydroxyzine HCL OralAtaraxHydroxyzine Pamoate Oral VistarilTricyclic AgentsAmitriptyline HCL OralElavilCode 1 Restriction: For diagnosis ofneuropathy or as an adjunct to painmanagement.June 2009 Page 16 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementAmoxapine OralClomipramine HCL OralDesipramine HCL OralDoxepin HCL OralImipramine HCL OralNortriptyline HCL OralProtriptyline HCL OralTrimipramine Maleate OralAscendinAnafranilNorpraminSinequanTofranilPamelorVivactilSurmontilPhenothiazinesProchlorperazine SupposRectalProchlorperazine MaleateOral ProchlorperazineMaleate Cap CR & Tab OralProchlorperazine EdisylateOralCompazineCompazineCompazineBarbiturate HypnoticsPhenobarbital Oral Phenobarbital Code 1 Restriction: For diagnosis of seizuresSalicylatesAspirin OralAspirin Suppos RectalSalsalate OralANALGESICS AND ANESTHETICSBayer ASA, Empirin,Ascriptin, ASA LowDose, Ecotrin,GenacoteAspirin SuppSalflex, Disalcid,AmigesicDoes not include single source brandedproductsDoes not include single source brandedproductsSalicylate CombinationsAspirin Buffered (mgCarbonate-Al Glycinate)325mg Tab OralAspirin Buffered 325mg TabOralAspirin Buffered,Gennin –FCBuffaprin, BufferedASAAnalgesics OtherAcetaminophen OralAcetaminophen SupposRectalTylenolFeverall, AcephenAnalgesic-SedativesJune 2009 Page 17 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementButalbital-Acetaminophen50-650mg Cap, 50-325mg &50-650mg Tab OrallAcetaminophen-Caffeine-Butalbital 325-40-50mg Tab &Cap OralAspirin-Caffeine-Butalbital325-40-50mg Tab & Cap OralPhrenilin, SedapapEsgic, Esgic Plus,FioricetFiorinal, Fiortal,Butalbital CPD,FortabsNarcotic AgonistMethadone HCL OralDolophine,MethadoseMorphine Sulfate Tab Oral MSIR Limited to 12 tablets/dayMorphine Sulfate Tab CR OralMS Contin,Limited to 4 tablets/dayOramorph SRTramadol HCL Tab 50mg Oral Ultram Limited to 8 tablets/dayNarcotic CombinationsOxycodone w/Acetaminophen 5-325mg,7.5-325mg, & 10-325mg TabOralRoxicetMaximum acetaminophen daily dose =4gm/dayCodeine CombinationsAcetaminophen w/ Codeine300-15mg, 300-30mg, 300-60mg, 650-30 mg Tab OralAcetaminophen w/ CodeineElixir, Soln, Susp OralAspirin w/ Codeine 325-15mg, 325-30mg, & 325-60mgTab OralHydrocodone CombinationsAcetaminophen w/Hydrocodone 5-500mg, 7.5-750mg, 10-325mg Tab OralAcetaminophen w/Hydrocodone 7.5-500mg/15mL Soln OralTylenol/Codeine #2,#3, #4VopacTylenol/CodeineEmpirin/Codeine #2,#3, #4Lortab 5mg, Norco10-325mg, Vicodin,Vicodin ESLortab ElixerMaximum acetaminophen daily dose =4gm/dayLimited to 60 tablets/monthLimited to 500mL/monthLimited to 60 tablets/monthMaximum acetaminophen daily dose =4gm/dayRyan White Program: 5-500mg – Bill ADAPLimited to 240 tablets/30 days for 5-500mg(CMS & Coverage Initiative); 150 tablet/30days for 7.5-750mg, and 360 tablets/30 daysfor 10-325mgLimited to 500mL/monthOpioid CombinationsMaximum acetaminophen daily dose =4gm/dayJune 2009 Page 18 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementButalbital-Acetaminophen-Caff w/ Cod 50-325-40-30mgCap OralButalbital-Aspirin-Caff w/Codeine 50-325-40-30mgCap OralPhrenilin w/ CodeineFiorinal w/ CodeineLimited to 30 capsules/monthLimited to 60 capsules/monthPropoxyphene CombinationsPropoxyphene-N w/ APAP 50-325mg Tab OralPropoxyphene-N w/ APAP100-650mg Tab OralDarvocet-N 50Darvocet-N 100Limited to 60 tablets/monthLimited to 60 tablets/monthNonsteroidal Anti-Inflammatory AgentsDiclofenac Potassium Oral CataflamDiclofenac Sodium EC Oral Voltaren Limited to 4 tablets/dayEtodolac Cap & Tab Oral LodineLimited to 3 capsules/day for 200mg &300mg capsules; 3 tablets/day for 400mgtablet and 2 tablets/day for 500mg tabletFenoprofen Calcium Oral NalfonFenoprofen Calcium OralIbuprofen OralMotrinIndomethacin Oral, SupposRectalIndocinMeloxicam Tab Oral Mobic Limited to 1 tablet/dayNaproxen OralNaprosynNaproxen Sodium Oral AnaproxOxaprozin Oral Daypro Limited to 2 tablets/dayPiroxicam OralFeldeneLimited to 2 capsules/day for 10mg and 1capsule/day for 20mgSulindac OralClinorilMethotrexateMethotrexate 2.5mg Tab OralRheumatrexMigraine ProductsAPAP-Isometheptane-Dichloral Cap 325-65-100mgOralMidrinSerotonin AgonistSumatriptan Spray NasalImitrex NSContingent Therapy: For patient failingtherapy with or intolerant to Cafergot,Midrin, Fioricet, or Fiorinal. Limited to 6units/monthJune 2009 Page 19 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementSumatriptan SuccinateInjectionSumatriptan Succinate TabOralErgot CombinationsErgotamine w/ Caffeine 1-100mg Tab OralImitrexImitrexWigraine, ErcafContingent Therapy: For patient failingtherapy with or intolerant to Cafergot,Midrin, Fioricet, or Fiorinal. Limited to 4packages (8 injections)/monthContingent therapy: For patient failingtherapy with or intolerant to Cafergot,Midrin, Fioricet, or Fiorinal. Limited to 18tablets/month for 25mg & 50mg and 9tablets/month for 100mgGoutAllopurinol Tab OralColchicineOralZyloprimColchicineUricosuricsProbenecid Oral ProbenecidTab 500 mgSulfinpyrazone OralBenemidAnturaneCombination Gout DrugsColchicine w/ProbenecidOral Coichicinew/Probenecid Tab 0.5-500mg OralProben-CHydantoinsPhenytoin Chew Tab 50 mgOralDilantinNEUROMUSCULAR AGENTSValproic AcidDivalproex Sodium EC CapOralDivalproex Sodium EC TabOralDivalproex Sodium SR 24 HrTab OralValproic Acid Cap 250mgOralDepakote SprinkleDepakote ECDepakote ERDepakeneJune 2009 Page 20 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementMiscellaneous AnticonvulsantsCarbamazepine Tab SR OralCarbamazepine Chew TabOralCarbamazepine Susp OralGabapentin 400mg Cap,400mg, 600mg, & 800mgTablet OralPrimidone Tablet OralZonisamide Capsule OralTegretol XRTegretolTegretolNeurontinMysolineZonegranLimited to patient intolerant to or failingtherapy with carbamazepine tabletsFor CMS & Coverage Initiative: Limited to 6capsules/day for 400mg capsules, 6tablets/day for 400mg tablets, 5 tablets/dayfor 600mg tablets, and 4 tablets/day for800mg tabletsCode 1 Restriction: Limited to diagnosis ofseizureAntiparkinsonian AgentsAll agents are covered.Central Muscle RelaxantsBaclofen Tab Oral Lioresal, Lioresal DS Limited to 4 tablets/dayCyclobenzaprine HCL 10mgTab OralFlexerilLimited to 3 tablets/dayMethocarbamol Oral Robaxin Limited to 6 tablets/dayAntimyasthenic AgentsNeostigmine Bromide Tab15mg OralPyridostigmine Bromide OralProstigminMestinonVitamin B-3Niacin OralNiacinNUTRITIONAL PRODUCTSVitamin B-6Pyridoxine HCL Cap , CapCR, Tab OralVitamin B-6Code 1 Restriction: For use with INH onlyVitamin KPhytonadione Tab 5mg OralMephytonNutritional Supplements (Ryan White Program)Nutritional Supplement LiquidBoost, EnsureRyan White Program: Limited to21600mL/fill, 3 fills/yearPotassiumPotassium Chloride Cap CR8mEq & 10mEq OralMicro-KJune 2009 Page 21 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementPotassium Chloride Tab CR8mEq, 10mEq, 15mEq &20mEq OralPotassium Chloride Oral Liq10% & 20% OralPotassium & SodiumPhosphates for Soln 278-164-250mg/75mL, Powder 278-164-250mg & 280-160-250mgOralSlow-K, Klor-Con, K-Tabs, K-Dur, Klortrix,Kaon-CLKlorvess, Kaochlor,Kay Ciel KCL, Kaon-CL SFNeutraphosPotassium Removing ResinSodium Polystyrene SulfonateSusp 15gm/60mL Oral/RectalSodium Polystyrene SulfonatePowder OralSodiumSodium Chloride InjectionSPSKayexalateNormal Saline (IV)Folic AcidFolic Acid OralIronFerrous Fumarate OralFerrous Gluconate OralFerrous Sulfate OralCoumarin AnticoagulantsWarfarin Sodium Tab OralPlatelet Aggregation InhibitorsDipyridamole Tab OralFolic AcidHEMATOLOGICAL AGENTSFeostatFerrous GluconateIron, Slow-Fe, Feosol,Fer-In-Sol, FeratabCoumadinPersantineHeparins And Heparinoid-Like AgentsEnoxaparin Sodium Injection Lovenox Limited to 14 units/6 monthsFondaparinux Sodium 2.5mg/0.5mL InjectionArixtraLimited to 7 units/7 daysThienopyridine DerivativesClopidogrel Bisulfate Tab OralOphthalmic AntibioticsPlavixCode 1 Restriction: For diagnosis of TIA,stroke, stent, or patient failing therapy orintolerant to Aspirin.TOPICAL PRODUCTSAll ophthalmic Anti-Infectives are coveredJune 2009 Page 22 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementBacitracin Oint 500 U/gmOphthalmicCiprofloxacin HCL Oint & Soln0.3% OphthalmicErythromycin Oint 5mg/gmOphthalmicGatifloxacin 0.3% SolnOphthalmicGentamicin Sulfate Soln &Oint 0.3% OphthalmicLevofloxacin 0.5% SolnOphthalmicMoxifloxacin 0.5% SolnOphthalmicOfloxacin Ophth Soln 0.3%OphthalmicSodium Sulfacetamide 10%OphthalmicTobramycin Sulfate Soln &Oint 0.3% OphthalmicOphthalmic Beta-BlockersBetaxolol HCL Soln -.5% & 1%and Susp 0.25% OphthalmicCarteolol HCL Soln 1%OphthalmicMetipranolol HCL Soln 0.3%OphthalmicLevobunolol HCL Soln 0.25%& 0.5% OphthalimcTimolol Maleate Soln 0.25% &0.5% OphthalmicTimolol Maleate Soln (GelForming) 0.25% & 0.5%ophthalmicAK-TracinCiloxanLlotycinZymarGaramycin,GenopticQuixinVigamoxOcufloxBleph-10, SodSulamydTobrexBetoptic, Betoptic-SOcupressOptipranololBetaganTimopticTimoptic XEAll ophthalmic beta-blockers are coveredOphthalmic Carbonic Anhydrase InhibitorsBrinzolamide Susp 1%AzoptOphthalmicOphthalmic Carbonic Anhydrase Inhibitors – Beta-Blocker CombinationDorzolamide-Timolol Soln 2-Cosopt0.5% OphthalmicOphthalmic SteroidsDexamethasone Susp 0.1%OphthalmicDexamethasone SodiumPhosphate Soln OphthalmicMaxidexDecadron, Dexa-solJune 2009 Page 23 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementFluorometholone SuspOphthalmicFluorometholone Oint 0.1%OphthalmicFluorometholone AcetateSusp 0.1% OphthalmicPrednisolone Acetate Susp1% OphthalmicPrednisolone SodiumPhosphate Soln 1%OphthalmicFML Liquifilm, FMLForteFML S.O.P.Flarex, EfloneEconopred Plus,Omnipred PredForteInflamase ForteOphthalmic SteroidCombinationsLoteprednol etabonate-Tobramycin Susp 0.5-0.3%OphthalmicNeomycin-DexamethasonePhos Soln 0.5-0.1%OphthalmicSulfacetamide Sodium-Prednisolone Soln 10-0.25%OphthalmicSulfacetamide Sodium-Prednisolone Susp10-0.2%OphthalmicSulfacetamide Sodium-Prednisolone Susp 10-0.25%OphthalmicSulfacetamide Sodium-Prednisolone Susp 10-0.5%OphthalmicSulfacetamide Sodium-Prednisolone Oint 10-0.2%OphthalmicSulfacetamide Sodium-Prednisolone Oint 10-0.25%OphthalmicSulfacetamide Sodium-Prednisolone Oint 10-0.5%OphthalmicTobramycin-DexamethasoneSusp & Oint 0.3-0.1%OphthalmicNeomycin-Polymyxin-Dexamethasone Susp & Oint0.1% OphthalmicNeomycin-Polymyxin-HC SuspOphthalmicAll ophthalmic steroid combinations are coveredZyletNeo-DecadronVasocidinBlephamideIso CetapredMetimydBlephamide S.O.P.CetapredMetimyd,VascocidinTobradexMaxitrol, DexacidinCortisporinJune 2009 Page 24 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementBacitracin-Polymyxin-Neomycin-HC OphthalmicOint 1%Cortisporin, AK-Spore HC, TripleAntibioticProstaglandin Agonists OphthalmicLatanoprost Soln 0.005%XalatanOphthalmicCycloplegicsAtropine Sulfate Soln 1%OphthalmicAtropine Sulfate Oint 1%OphthalmicCyclopentolate HCL Soln0.5%, 1%, 2% OphthalmicHomatropine HBr Soln 2%, 5%OphthalmicScopolamine HBr Soln 0.25%OphthalmicTropicamide Soln 0.5%, 1%OphthalmicIso AtropineOcu-tropineCyclogylIso HomatropineIso HyoscineMydriacyl, Infi-CyleCycloplegics Mydriatic CombinationsCyclopentolate w/Phenylephrine Soln 0.2-1% CyclomydrilOphthalmicScopolamine w/Phenylephrine Soln 0.3-10% Murocoll-2OphthalmicOphthalmic Decongestant CombinationsNaphazoline w/ AntazolineSoln 0.05-0.5% OphthalmicVasocon-ANaphazoline w/ PheniramineSoln 0.025-0.3% OphthalmicNaphcon-AOphthalmics – Direct ActingPilocarpine HCL Soln 0.5%,1%, 2%, 4%, 6% OphthalmicPilocarpine HCL Gel 4%OphthalmicAdrenergic MydriaticsDipivefrin Soln 0.1%OphthalmicAll ophthalmic miotic direct-acting agents are covered.Iso Carpine, PilocarPilopine HSPropine-CJune 2009 Page 25 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementOphthalmic Anti-AllergicOlopatadine HCL SolnOphthalmicPatanolContingent Therapy: For patient failingtherapy with or intolerant to Naphcon-A orVasacon-AOphthalmic Non-Steroidal Anti-Inflammatory AgentsDiclofenac Sodium Soln 0.1%OphthalmicVoltarenFlurbiprofen Soln 0.03%OphthalmicOcufenKetorolac Tromethamine Soln0.4%, 0.5% OphthalmicAcular LS, AcularNepafenac Susp 0.1%OphthalmicNevanacBromfenac Sodium Soln0.09% OphthalmicXibromCode 1 Restriction: For OphthalmologistLimited to #2.5mL/30 daysCode 1 Restriction: For OphthalmologistLimited to #2.5mL/30 daysCode 1 Restriction: For OphthalmologistLimited to #3mL/30 daysCode 1 Restriction: For OphthalmologistLimited to #2.5mL/30 daysOtic SteroidsHydrocortisone W/ AceticAcid 1-2% Soln OticOtic MiscellaneousAcetic Acid 2% Soln OticCarbamide Peroxide 6.5%Soln OticVosol-HCVosolDebroxOtic Steroid Antibiotic CombinationsBenzocaine-Antipyrine 1.4-Auralgan5.4% Soln OticNeomycin-Polymyxin-HC Susp3.5mg/mL-10000 U/mL-1% Cortisporin OticOticNeomycin-Polymyxin-HC SolnCortisporin Otic1% OticMouth & Throat (Local)Lidocaine HCL in Viscous Soln2% (Mouth-Throat)Nystatin Susp 100000 U/mL(Mouth/Throat)Pilocarpine HCL 5mg TabOralTriamcinolone Acetonide inOrabase 0.1% (Mouth)Lidocaine ViscousMycostatin, Bio-StatinSalagenKenalogDERMATOLOGICAL PRODUCTSAntibiotics – TopicalMupirocin 2% Oint External Bactroban Limited to 60gm/monthJune 2009 Page 26 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementAntifungals – TopicalCrotamiton ExternalNystatin ExternalTolnaftate Power ExternalEuraxMycostatin, Nystop,Pedi-DriTinactinTopical AntifungalsClotrimazole ExternalKetoconazole Cream 2%ExternalKetoconazole Shampoo 2%ExternalMiconazole Nitrate Cream2% ExternalDesenex, Lotrimin,Lotrimin AFNizoralNizoralMicatin, MonistatLimited to 120mL/monthAntifungals – Topical CombinationsClotrimazole w/Betamethasone Cream, LotrisoneExternalNystatin-TriamcinoloneMycolog IICream & Oint ExternalBurn ProductsSilver Sulfadiazine Cream 1%ExternalSilvadeneTar ProductsAllantoin-Coal Tar andCombinations ShampooExternalCoal Tar ExternalTegrin MedicatedShampoo 7%Fototar, G-Tar,Tegrin, MedotarCorticosteroids – TopicalBetamethasoneDipropionate Cream ExternalFluocinolone AcetonideCream, Soln ExternalFluocinonide Cream,Emusified Cream, Gel, Soln,Oint 0.05% ExternalDiprosone, MaxivateSynalar, Fluorosyn,Lidex, Lidex-ELimited to 90gm/mo for cream, & ointment,and 120ml/mo for lotion.Limited to 120 gm/mo for cream, &ointment, and 120ml/mo for solution.Limited to 120 gm/mo for cream, gel &ointment, and 120ml/mo for solution.June 2009 Page 27 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementHydrocortisone ExternalTriamcinolone AcetonideCream, Ointment ExternalCorticreme,Genasone,Dermacort, Cortaid,Hytone, DermatexHC, Nutracort,Hydrocort, Cortaid,Nercainal, LanacortHC, AC/Aloe, AnusolHC, Hydrocort/ AN,CotacortAristocort A,KenalogLimited to 120gm/mo for cream & ointment,and 120mL/mo for lotion.Limited to 80gm/mo for 0.025%, 0.1% and45gm/mo for 0.5%Anorectal ProductsHydrocortisone w/ PramoxineFoam 1-1% RectalPhenylephrine in Hard FatSuppos 0.25% RectalPramoxine Hcl Oint 1% RectalPramoxine-HC ExternalPramoxine w/ Zinc Oxide inMineral Oil Oint 1-12.5%RectalStarch Suppositories 51%RectalProctofoam-HCRectacaineTucksAnalpram-HC,Epifoam, PramosoneTucks, AnusolTucksAll generic rectal hydrocortisone productsare coveredEnzymesPapain-Urea OintmentExternalPapain & Urea-ChlorophyllinOintment ExternalTrypsin w/ Castor Oil &Peruvian Balsam OintmentExternalAccuzyme,EthezymePanafilXenadermKeratolyticsPodofilox Soln & Gel 0.5%ExternalCondyloxLocal Anesthetics – TopicalLidocaine HCL Gel 2%ExternalLidocaine HCL Viscous Soln2% Mouth/ThroatXylocaineXylocaineScabicides & PediculocidesCrotamiton Cream & Lotion10% ExternalScabicides and pediculicides are coveredEuraxJune 2009 Page 28 of 42

San Diego County Medical Services Drug FormularyGeneric NameRepresentativeBrand NameUtilization ManagementMalathion 0.5% LotionExternalPermethrin Cream Rinse 1%ExternalPermethrin Cream 5%ExternalPyrethrins-Piperonyl ButoxideExternalMiscellaneous TopicalCalcipotriene Soln ExternalCoal Tar (Crude) SolutionExternalOvideNix Cream RinseElimite, ActicinRid, A-200, ProntoDovonexCoal TarDiagnostic ReagentsAcetone TestGlucose Urine Test-(GlucoseOxidase)Glucose Urine Test-(CopperSulfate)DIAGNOSTIC PRODUCTSAcetest, KetostixDiastix, ClinistixClinitestGlucose Blood Test StripsMultiple Urine Test StripsUrine Glucose-Ketones TestStripsAscencia ContourAscencia Breeze 2ChemstripsChemstripsLimited to 50 per 30 days if not on insulin. Ifon insulin, allow limit 100 per 30 datys.Maximum of 3 fills/prescription. Limited toBayer Ascencia Contour Ascencia Breeze 2only.Limited to 51/month. Maximum of 3fills/prescriptionDiabetic SuppliesGlucose Blood CalibrationSolnGlucose Blood Monitoring KitControl SolutionsAscencia ContourAscencia Breeze 2Limited to 1 fill per year. Maximum of $60per fill. Limited to Ascencia Contour andBreeze 2 products.Insulin SyringesLancetsLancets DevicesB-D Insulin SyringesLancetsLancetsLimited to 100/month. Maximum of 3fills/prescriptionLimited to 51/month. Maximum of 3fills/prescriptionLimited to 2 fills/year, maximum$25/prescriptionJune 2009 Page 29 of 42

AA-200, 29AC/Aloe, 28Accolate, 14Accuzyme, 28ACE Inhibitors, 7Acephen, 17Acetaminophen Oral, 17Acetaminophen Suppos Rectal, 17Acetaminophen w/ Codeine 300-15mg, 300-30mg, 300-60mg, 650-30 mg Tab Oral, 18Acetaminophen w/ Codeine Elixir, 18Acetaminophen w/ Hydrocodone 5-500mg, 7.5-750mg,10-325mg Tab Oral, 18Acetaminophen w/ Hydrocodone 7.5-500mg/15mLSoln, 18Acetaminophen w/ Hydrocodone Cap, Tab Oral, 18Acetaminophen-Caffeine-Butalbital 325-40-50mg Tab &Cap Oral, 18Acetazolamide Oral, 9Acetazolamide SR Oral, 9Acetic Acid 2% Soln Otic, 26Acetone Test, 29Acticin, 29Actifed, 12Actigall, 15Actos, 7Acular, 26Acular L, 26Acyclovir Oral, 5Adrenergic Combinations, 13Adrenergic Mydriatics, 25Adrenolytics-Central, 8Advair, 13Advair HFA, 13AK-Spore HC, 25AK-Tracin, 23Albuterol Inhalation, 13Albuterol Sulfate Aero Inhalation, 13Albuterol Sulfate Oral, 13Albuterol Sulfate Soln Nebu Inhalatio, 13Albuterol-Ipratropium Aerosol Inhalation, 13Aldactazide, 10Aldactone, 10Aldomet, 8Allantoin-Coal Tar and Combinations Shampoo Externa,27Allopurinol Tab Oral, 20Alpha-Beta Blockers, 8Alpha-Blockers, 8Amaryl, 6Amebicides, 5Amigesic, 17Aminoglycosides, 5Aminophyline, 13Aminophylline Oral, 13Amitriptyline HCL Oral, 16Amlodipine Besylate Oral, 9Amoxapine Oral, 17Amoxicillin & Potassium, 4Amoxicillin Cap-Clarithro Tab-Lansopraz Cap CRTherapy Pack Oral, 15Amoxicillin Oral, 4Ampicillin, 4Ampicillin Oral, 4Amylase-Lipase-Protease Oral, 15Anafranil, 17Ana-Kit, 10Analgesics and Anesthetics, 26ANALGESICS AND ANESTHETICS, 17Analgesics Other, 17Analgesic-Sedatives, 17Analpram-HC, 28Anaprox, 19Anaspaz, Levbid, Colytrol, 14Angiotensin II Inhibitor Combinations, 8Angiotensin II Inhibitors, 8Anorectal Product, 28AntfFungals, 5Anti-Anginals, 8Anti-Arrhythmia, 7Antibiotics – Topical, 26Anticholinergic Combinations, 14Anticholinergics, 12Antidiabetics, 7Anti-Emetics-Anticholinergic, 15Antifungals – Topical, 27Antifungals – Topical Combinations, 27Antihelmintics, 5Antihistamines-Alkylamines, 11Antihistamines-Non-Sedating, 11Antihyperlipidemics: HMG-CoA Reduase Inhibitor, 10Antihyperlipidemics: Fenamates, 10ANTI-INFECTIVE AGENTS, 4Antimalarials, 5Antiminth, 5Antimyasthenic Agents, 21Antimycobacterial Agents, 5Antineoplastic Agents, 5ANTINEOPLASTIC AGENTS, 5Antiparkinsonian Agents, 21Antiperistaltic Agents, 14Antispasmodics, 14Antithyroid Agents, 7Antitussive Non-Narcotic Antitussive, 12Antitussive-Antihistamine Narcotic, 12Anti-Ulcers: Imidazoles, 14Antivert, 15Antiviral – Herpes Agents, 5Anusol, 28Anusol HC, 28APAP-Isometheptane-Dichloral Cap 325-65-100mg Oral,19Apresoline, 10Aralen, 5Aristocort A, 28Arixtra, 22ASA Low Dose, 17Asacol, 15Ascencia Breeze 2, 29Ascencia Contour, 29Ascendin, 17Ascriptin, 17Aspirin Buffered, 17Aspirin Buffered (mg Carbonate-Al Glycinate) 325mgTab Oral, 17June 2009 Page 30 of 42

Aspirin Buffered 325mg Tab Oral, 17Aspirin Oral, 17Aspirin Suppos Rectal, 17Aspirin w/ Codeine 325-15mg, 325-30mg, & 325-60mgTab Oral, 18Aspirin-Caffeine-Butalbital 325-40-50mg Tab & Cap Oral,18Atarax, 16Atenolol Oral, 8Atropine Sulfate, 13Atropine Sulfate Oint 1% Ophthalmic, 25Atropine Sulfate Soln 1% Ophthalmic, 25Atrovent, 13Atrovent HFA, 13Augmentin, 4Auralgan, 26Avandia, 7Azithromycin Susp Oral, 4Azithromycin Tab Oral, 4Azo-gesic, 16Azopt, 23Azulfidine, 15Bacitracin Oint 500 U/gm Ophthalmic, 23Bacitracin-Polymyxin-Neomycin-HC Ophthalmic Oint1%, 25Baclofen Tab 10 mg & 20mg Oral, 21Bactrim, 4Bactrim DS, 4Bactroban, 26Barbiturate Hypnotics, 17Bayer ASA, 17BD – Glucose Chw, 7B-D Insulin Syringes, 29Beclomethasone Dipropionate Inhal Aero, 13Belladonna Alkaloids, 14Benadryl, 11Benazepril HCL Oral, 7Benicar, 8Benicar HCT, 8Bentyl, 14Benzocaine-Antipyrine 1.4-5.4% Soln Otic, 26Benzodiazepines, 16Beta Adrenergics, 13BetaBlockers Cardio-Selective, 8Beta-Blockers Non-Selective, 8Betagan, 23Betamethasone Dipropionate Cream External, 27Betapace, 8Betapace AF, 8Betaxolol HCL Soln -.5% & 1% and Susp 0.25%Ophthalmic, 23Bethanechol Chloride Oral, 15Betoptic, Betoptic-S, 23Betoptic-S, 23Biaxin, 4Biguanides –Metformin, 6Bile Sequestrants, 10Bio-Statin, 26Bleph-10, 23Blephamide, 24Blephamide S.O.P., 24Boost, 21BBrethine, 13Brimonidine, 23Bromanate, 11Bromatane DX, 12Bromfed, 11Brompheniramine & Pseudoephedrine Syrup, Elixir Ora,11Bromtapp, 11Broncho Saline, 11Buffaprin, 17Buffered ASA, 17Butalbital CPD, 18Butalbital-Acetaminophen 50-650mg Cap, 50-325mg &50-650mg Tab Oral, 18Butalbital-Acetaminophen-Caff w/ Cod 50-325-40-30mgCap Oral, 19Butalbital-Aspirin-Caff w/ Codeine 50-325-40-30mg CapOral, 19June 2009 Page 31 of 42CCabergoline Oral, 7Calan, 9Calan SR, 9Calan, Isoptin, 9Calcipotriene Soln External, 29Calcium Acetate (Phosphate Binder) Cap 667mg Oral,15Calcium Blockers, 9Calcium Oral, 19Calulose, 15Canasa, 15Cap CR, 21Capoten, 7Captopril Oral, 7Carafate, 15Carbamazepine Chew Tab Oral, 21Carbamazepine Susp Oral, 21Carbamazepine Tab SR Oral, 21Carbamide Peroxide 6.5% Soln Otic, 26Carbonic Anhydrase Inhibitors, 9, 23CARDIOVASCULAR AGENTS, 7Cardizem SR, 9Cardura, 8Carteolol HCL Soln 1% Ophthalmic, 23Carvedilol Tab Oral, 9Cataflam, 19Catapres, 8Cefixime Tab 400mg Oral, 4Cephalexin Monohydrate, 4Cephalosporins, 4Cephulac, 15Cerose-DM, 12Cetapred, 24Chemstrips, 29Chloroquine Phosphate Tab Oral, 5Chlorpheniramine & Phenylephrine Elixir 2-5 mg/5mlOral, 11Chlorpheniramine & Pseudoephedrine Oral, 12Chlorpheniramine-DM, 12Chlorpheniramine-DM Syrup Oral, 12Chlorthalidone Oral, 10Chlor-Trimeton, 12Cholac, 15Cholestyramine Powder & Packets Oral, 10Cholestyramine Powder Can Oral, 10

Ciloxan, 23Cimetidine Oral, 14Cipro, 4Ciprofloxacin, 4Ciprofloxacin HCl 250mg, 500mg, 750mg Tab Oral, 4Ciprofloxacin HCL Oint & Soln 0.3% Ophthalmic, 23Clarithromycin 250mg, 500mg Tab Oral, 4Claritin, 11Cleocin, 4Cleocin Vaginal, 16Clindamycin HCL Cap Oral, 4Clindamycin Phosphate CR Vaginal, 16Clinistix, 29Clinitest, 29Clinoril, 19Clomipramine HCL Oral, 17Clonazepam Tab Oral, 16Clonidine HCL Oral, 8Clopidogrel Bisulfate Tab Oral, 22Clotrimazole, 16Clotrimazole External, 27Clotrimazole Tab, 16Clotrimazole Vaginal, 16Clotrimazole w/ Betamethasone Cream, External, 27Coal Tar (Crude) Solution External, 29Coal Tar External, 27Codeine Combinations, 18Codimal DM, 12Codine-GG Oral, 12Codituss DM, 12ColchicineOral, 20Combination Diuretics, 10Combivent, 13Compazine, 17Condylox, 28Control Solutions, 29Coreg, 9Cortaid, 28Cortef, 6Corticosteroids – Topical, 27Corticreme, 28Cortisone, 6Cortisone Acetate Oral, 6Cortisporin, 24, 25Cortisporin Otic, 26Cotacort, 28Coumadin, 22Coumarin Anticoagulant, 22Cream 1%, Kit Vaginal, 16Cromolyn Sodium Inhalation, 13Cromolyn Sodium Soln Nebu Inhalation, 13Crotamiton Cream & Lotion 10% External, 28Crotamiton External, 27Cyclobenzaprine HCL 10mg Tab Oral, 21Cyclogyl, 25Cyclomydri, 25Cyclopentolate HCL Soln 0.5%, 1%, 2% Ophthalmic, 25Cyclopentolate w/ Phenylephrine Soln 0.2-1%Ophthalmic, 25Cyproheptadine, 11Cyproheptadine HCL Oral, 11Cystospaz, 15Cystospaz-M, 14Cytomel, 7Cytra K, 16Dapsone Oral, 4Daraprim, 5Darvocet-N 100, 19Darvocet-N 50, 19Daypro, 19DDAVP, 7Debrox, 26Decadron, 6, 23Deconamine, 12Decongestant or Decongestant Combinations, 11Depakene, 20Depakote, 20Depakote EC, 20Depakote ER, 20Depakote Sprinkle, 20Deponit, 9Dermacort, 28Derma-Smooth Oil/FS, 27Dermatex HC, 28DERMATOLOGICAL PRODUCTS, 26Desenex,, 27Desipramine HCL Oral, 17Desmopressin Acetate Oral, 7Dexacidin, 24Dexamethasone Oral, 6Dexamethasone Sodium Phosphate Soln Ophthalmic,23Dexamethasone Susp 0.1% Ophthalmic, 23Dexa-sol, 23Dexbrompheniramine & Pseudoephedrine Oral, 12Dexone, 6Dextromethorphan-GG Liquid, 12Dextromethorphan-GG Liquid 10-100mg/5mL Oral, 12Diabeta,, 6Diabetic, 29DIABETIC AGENTS, 6Diabetic Supplies, 29Diabetic Tus, 11Diabetic Tus DM, 12DIAGNOSTIC PRODUCTS, 29Diagnostic Reagents, 29Diamox Sequels, 9Diastix, 29Diazepam Tab Oral, 16Diclofenac, 26Diclofenac Potassium Oral, 19Diclofenac Sodium EC Oral, 19Diclofenac Sodium Soln 0.1% Ophthalmic, 26Dicloxacillin Sodium Oral, 4Dicyclomine HCL Oral, 14Diflucan, 5Digitalis, 9Digoxin Oral, 9Dilacor XR, 9Dilantin, 20Diltiazem ER, 9Diltiazem HCL CR Oral, 9Diltiazem HCL Oral, 9Diltiazem HCL SR/24hr Oral, 9Dimetane-DX, 12Dimetapp, 11Diovan, 8Diovan HCT, 8Diphedryl, 11June 2009 Page 32 of 42D

Diphenhydramine HCL Oral, 11Diphenoxylate w/ Atropine Oral, 14Dipivefrin Soln 0.1% Ophthalmic, 25Diprosone, 27Dipyridamole Oral, 8Dipyridamole Tab Oral, 22Disalcid, 17Disopyramide Phosphate Oral, 7Ditropan, 15Divalproex Sodium EC Cap Oral, 20Divalproex Sodium EC Tab Oral, 20Divalproex Sodium SR 24 Hr Tab Oral, 20Dofetilide Ora, 7Dolophine, 18Donnatal, 14Donnatal Extentab, 14Dorzolamide-Timolol Soln 2-0.5% Ophthalmic, 23Dostinex, 7Dovonex, 29Doxazosin Mesylate Oral, 8Doxepin HCL Oral, 17Doxycycline Hyclate Cap 50mg & 100mg, Tab 100mgOral, 5Dyazide, 10Econopred Plus, 24Ecotrin, 17Eflone, 24Elavil, 16Elimite, 29Elixer, 18Elmiron, 16Empirin, 17Empirin/Codeine #2, #3, #4, 18E-Mycin, 4Enalapril Oral, 7ENDOCRINE, 6Enoxaparin Sodium Injection, 22Enulose, 15Enzymes, 28Epifoam, 28Epinephrine HCl Injection (Anaphylaxis), 10Epinephrine-Chlorpheniramine, 10Epipen, 10Epipen Jr, 10Ercaf, 20Ergot Combinations, 20Ergotamine w/ Caffeine 1-100mg Tab Oral, 20Eryc, 4Eryped, E.E.S., 4Ery-Tab, 4Erythrocin, 4Erythromycin, 4Erythromycin Base Oral, 4Erythromycin Delayed Release Oral, 4Erythromycin Ethylsuccinate Oral, 4Erythromycin Oint 5mg/gm Ophthalmic, 23Erythromycin Stearate Oral, 4Erythromycin w/EC Particles Oral, 4Esgic, 18Esgic Plus, 18Esidrix, 10Ethezyme, 28EEthmozine, 7Etodolac Cap & Tab Oral, 19Eurax, 27, 28Expectorants, 11Famotidine Tablet 40mg Oral, 14Feldene, 19Fenofibrate Oral, 10Fenoprofen, 19Fenoprofen Calcium Oral, 19Feosol, 22Feostat, 22Feratab, 22Fer-In-Sol, 22Ferrous Fumarate Oral, 22Ferrous Gluconate, 22Ferrous Gluconate Oral, 22Ferrous Sulfate Oral, 22Feverall, 17Fioricet, 18Fiorinal, 18Fiorinal w/ Codeine, 19Fiortal, 18Flagyl, 4Flarex, 24Flecainide Acetate Oral, 7Flexeril, 21Flonase, 11Florinef, 6Flovent HFA, 13Fluconazole Tab 150 mg Oral, 5Fludrocortisone Acetate Oral, 6Flunisolide 0.025% Nasal, 11Fluocinolone Acetonide Cream, Oil, Soln External, 27Fluocinonide Cream, Emusified Cream, Gel, Soln, Oint0.05% External, 27Fluorometholone Acetate Susp 0.1% Ophthalmic, 24Fluorometholone Oint 0.1% Ophthalmic, 24Fluorometholone Susp Ophthalmic, 24Fluorosyn, 27Flurbiprofen Soln 0.03% Ophthalmic, 26Fluroquinolones, 4Fluticasone Propionate Inhalation, 13Fluticasone Propionate Nasal, 11Fluticasone-Salmeterol Inhal Aerosol, Pwdr Diskus, 13FML Forte, 24FML Liquifilm, 24FML S.O.P., 24Folic Acid, 22Fondaparinux Sodium 2.5 mg/0.5mL Injection, 22Fortabs, 18Fototar,, 27Furadantin, 15Furosemide Oral, 10Gabapentin 400mg Cap, 400mg, 600mg, & 800mgTablet Oral, 21Gallstone Solubilizing Agents, 15Gantrisin, 4Garamycin, 23GASTROINTESTINAL AGENTS, 14FGJune 2009 Page 33 of 42

Gatifloxacin 0.3% Soln Ophthalmic, 23Gemfibrozil Oral, 10Genacote, 17Genasone, 28Generlac, 15Genitourinary Irrigants, 16GENITOURINARY PRODUCTS, 15Gennin –FC, 17Genoptic, 23Gentamicin Sulfate Soln & Oint 0.3% Ophthalmic, 23GI Stimulants, 15Glimepiride Oral, 6Glipizide Tab Oral, 6Glucagon, 7Glucagon Kit Injection, 7Glucocorticosteroids, 6Glucophage, 6Glucose, 29Glucose Blood Monitoring Kit, 29Glucose Blood Test Strips, 29Glucose Chew Tab Oral, 7Glucose Urine Test-(Copper Sulfate), 29Glucose Urine Test-(Glucose Oxidase), 29Glucotrol, 6Glyburide Micronized, 6Glyburide Oral, 6GRIFULVIN, 5Grifulvin V, 5Griseofulvin Microsize Oral, 5Griseofulvin Ultramicrosize, 5Gris-peg, 5G-Tar, 27Guaifed, 12Guaifed-PD. SeeGuaifenesin Oral, 11Gyne-Lotrimin, 16H-2 Antagonists, 14HC, 28HC AC/Aloe, 28HEMATOLOGICAL AGENTS, 22Heparins And Heparinoid-Like Agents, 22Histex, 12Homatropine HBr Soln 2%, 5% Ophthalmic, 25Humalog, 6Humalog Mix 75/25, 6Humibid Guaif, 12Humulin 50/50, 6Humulin 70/30, 6Humulin L, 6Humulin N, 6Humulin R, 6Hydralazine HCL Oral, 10Hydrochlorthiazide (HCTZ) Oral, 10Hydrocodone Combinations, 18Hydrocort, 28Hydrocort/AN, 28Hydrocortisone External, 28Hydrocortisone Tab Oral, 6Hydrocortisone W/ Acetic Acid 1-2% Soln Otic, 26Hydrocortisone w/ Pramoxine Foam 1-1% Rectal, 28Hydrodiuril, 10Hydroxychloroquine Sulfate Oral, 5HHydroxyzine HCL Oral, 16Hydroxyzine Pamoate Oral, 16Hygroton, 10Hyoscyamine, 14Hyoscyamine Sulfate Oral, 14Hyoscyamine Tab 0.15 mg Oral, 15Hytone, 28Hytrin, 8Ibuprofen Oral, 19Imdur, 9Imipramine HCL Oral, 17Imitrex, 20Imitrex NS, 19Imodium, 14Imodium A-D, 14Indapamide Oral, 10Inderal, 8Inderal LA, 8Indocin, 19Indomethacin Oral, Suppos Rectal, 19Infi-Cyle, 25Inflamase Forte, 24Insulin Aspart Inj 100 U/mL, 6Insulin Aspart Prot & Aspart Inj 100 U/mL (70-, 6Insulin Detemir Inj, 6Insulin Detemir Inj j100 U/mL, 6Insulin Glargine Inj 100 U/mL, 6Insulin Isophane Inj 100 U/mL, 6Insulin Lispro inj100 U/mL, 6Insulin Lispro Prot & Lispro Inj 100 U/mL (75-25), 6Insulin Regular & Isophane Inj 100 U/mL, 6Insulin Regular & Isophane Inj 100 U/mL (50), 6Insulin Regular Inj 100 U/mL, 6Insulin Syringes, 29Insulin Zinc (Human) Inj, 6Insulin Zinc Inj 100 U/mL, 6Intal, 13Intestinal Acidifiers, 15Iodoquinol Oral, 5iOphthalmics – Direct Acting, 25IOPIDINE, 23Ipratropium Bromide, 13Ipratropium Bromide Inhalation, 13Ipratropium Bromide Inhalation Sol, 13Iron, 22Irrigation Soln, 16ISMO, 9Iso Atropine, 25Iso Carpine, Pilocar, 25Iso Cetapred, 24Iso Homatropine, 25Iso Hyoscine, 25Isoniazid Oral, 5Isoptin, 9Isoptin SR, 9Isordil, 9Isosorbide Dinitrate Oral, 9Isosorbide Dinitrate Oral Tabs & Chew Tabs, 9Isosorbide Dinitrate SL Oral, 9Isosorbide Mononitrate Oral, 9IJune 2009 Page 34 of 42

Miscellaneous Respiratory Inhalants, 11Miscellaneous Topical, 29Mix 75/25, 6Mobic, 19Monistat, 16Monoket, 9Montelukast Sodium Oral, 14Moricizine HCI Oral, 7Morphine Sulfate Tab CR Oral, 18Morphine Sulfate Tab Oral, 18Motrin, 19Mouth & Throat (Local), 26Moxifloxacin 0.5% Soln Ophthalmic, 23MS Contin, 18MSIR, 18Multiple Urine Test Strips, 29Mupirocin 2% Oint External, 26Murocoll-2, 25Mycelex, 27Mycolog II, 27Mycostatin, 5, 26, 27Mydriacyl, 25NNaldecon Sr, 11Nalfon, 19Naphazoline w/ Pheniramine Soln 0.025-0.3%Ophthalmic, 25Naprosyn, 19Naproxen Oral, 19Naproxen Sodium Oral, 19Narcotic, 12Narcotic Agonist, 18Narcotic Combinations, 18Nasal Steroids, 11Nasalide, 11Nedocromil Sodium Inhalation, 13Neo-Decadron, 24Neo-Fradin, 5Neomycin Sulfate Oral, 5Neomycin-Dexamethasone Phos Soln 0.5-0.1%Ophthalmic, 24Neomycin-Polymyxin-Dexamethasone Susp & Oint 0.1%Ophthalmic, 24Neomycin-Polymyxin-HC Soln 1% Otic, 26Neomycin-Polymyxin-HC Susp 3.5mg/mL-10000 U/mL-1%Otic, 26Neomycin-Polymyxin-HC Susp Ophthalmic, 24Neostigmine Bromide Tab 15mg Oral, 21Nepafenac Susp 0.1% Ophthalmic, 26Neptazane, 9Nercainal, 28NEUROMUSCULAR AGENTS, 20Neurontin, 21Neutraphos, 22Nevanac, 26Niacin Oral, 21Niacin Tab CR, 11Niaspan, 11Nicotinic Acid Derivatives, 11Nilstat, 26Nimodipine Cap Oral, 9Nimotop, 9Nitrates, 9Nitro, 9Nitrobid, 9Nitrodisc, 9Nitro-Dur, 9Nitrofurantoin, 15Nitrofurantoin Macrocrystalline Oral, 15Nitrofurantoin Monohydrate Macrocrystalline Oral, 15Nitrofurantoin Susp Oral, 15Nitrogard, 9Nitroglycerin, 9Nitroglycerin Buccal Oral, 9Nitroglycerin CR Oral, 9Nitroglycerin Intravenous Soln, 9Nitroglycerin Oint 2%, 9Nitroglycerin Oint 2% Transdermal, 9Nitroglycerin SL Tab & Aer Oral, 9Nitroglycerin TD, 9Nitroglycerin TD Transdermal, 9Nitroquick, 9Nitrostat,, 9Nitrotab, 9Nitro-Time, 9Nix Cream Rinse, 29Nizoral, 5, 27Nonsteroidal Anti-Inflammatory Agents, 19Norco Vicodin, 18Normal Saline (IV), 22Normodyne, 9Norpace CR, 7Norpramin, 17Nortriptyline HCL Oral, 17Norvasc, 9Novahistine, 11Novahistine-DM, 12Novolin 70/30, 6Novolin L, 6Novolin N, 6Novolin R, 6Novolog, 6Novolog Mix, 6Nutracort, 28NUTRITIONAL PRODUCTS, 21Nutritional Supplements (Ryan White Program), 21Nydrazid, 5Nystatin, 5Nystatin External, 27Nystatin Susp 100000 U/mL (Mouth/Throat), 26Nystatin Tab 100000 U Vaginal, 16Nystatin Vaginal Tab, 16Nystatin-Triamcinolone Cream & Oint External, 27Nystop, 27OOcufen, 26Ocuflox, 23Ocupress, 23Ocu-tropine, 25Ofloxacin Ophth Soln 0.3% Ophthalmic, 23Olmesartan Oral, 8Olmesartan-HCTZ Oral, 8Olopatadine HCL Soln Ophthalmic, 26Omeprazole Magnesium Tablet Oral, 14Omnipred,, 24Ophthalmic Anti-Allergic, 26June 2009 Page 36 of 42

Ophthalmic Antibiotics, 22Ophthalmic Beta-Blockers, 23Ophthalmic Carbonic Anhydrase Inhibitors, 23Ophthalmic Non-Steroidal Anti-Inflammatory Agents, 26Ophthalmic Steroid, 23Ophthalmic Steroid Combinations, 24Opioid Combinations, 18Opium, 14Opium tincture, 14Opium Tinure 10% Oral, 14Optipranolol, 23Oramorph SR, 18Oretic, 10Organidin NR, 11Otic Miscellaneous, 26Otic Steroid Antibiotic Combinations, 26Otic Steroids, 26Otobiotic, 26Ovide, 29Oxaprozin Oral, 19Oxybutynin Chloride, 22Oxybutynin Chloride Tab & Syr Oral, 15Oxycodone w/ Acetaminophen 5-325mg, 7.5-325mg, &10-325mg Tab Oral, 18Pamelor, 17Panafil, 28Pancrease, 15Papain & Urea-Chlorophyllin Ointment External, 28Papain-Urea Ointment External, 28Paregoric tincture, 14Patanol, 26PCE, 4Penicillin V Potassium Oral, 4Penicillins, 4Pentasa, 15Pentosan Polysulfate Sodium Oral, 16Pen-VK, Veetids, 4Pepcid, 14Periactin, 11Permethrin Cream 5% External, 29Permethrin Cream Rinse 1% External, 29Persantine, 8, 22Phenazopyridine HCL Tab Oral, Kit, 16Phenergan, 11, 12Phenergan DM, 12Phenergan Forte, 11Phenergan VC, 12Phenergan w/Codeine, 12Phenobarbital & Belladonna Alkaloids Oral, 14Phenobarbital Oral, 17Phenothiazines, 17Phenylephrine in Hard Fat Suppos 0.25% Recta, 28Phenylephrine w/DM-GG Oral, 12Phenylephrine-Chlorphen-DM Oral, 12Phenylephrine-GG Oral, 12Phenylephrine-Pyrilamine-DM Oral, 12Phenytoin Chew Tab 50 mg Oral, 20PhosLo, 15Phrenilin, 18Phrenilin w/ Codeine, 19Phytonadione Tab 5mg Oral, 21Pilocarpine HCL 5mg Tab Oral, 26PPilocarpine HCL Gel 4% Ophthalmic, 25Pilocarpine HCL Soln 0.5%, 1%, 2%, 4%, 6% Ophthalmic,25Pilopine HS, 25Pin-X, 5Pioglitazone Oral, 7Pirbuterol Inhalation, 13Piroxicam, 19Piroxicam Ora, 19Plaquenil, 5Platelet Aggregation Inhibitors, 22Plavix, 22Podofilox Soln & Gel 0.5% External, 28Polycitra, 16Potassium, 21Potassium & Sodium Citrates w/Citric Acid Oral, 16Potassium & Sodium Phosphates for Soln 278-164-250mg/75mL, Powder 278-164-250mg & 280-160-250mg Oral, 22Potassium Chloride Cap CR 8mEq & 10mEq Oral, 21Potassium Chloride Oral Liq 10% & 20% Oral, 22Potassium Chloride Tab CR 8mEq, 10mEq, 15mEq &20mEq Oral, 22Potassium Removing Resin, 22Potassium Sparing Diuretics, 10Pramosone, 28Pramoxine Hcl Oint 1% Rectal, 28Pramoxine w/ Zinc Oxide in Mineral Oil Oint 1-12.5%Rectal, 28Pramoxine-HC External, 28Prazosin HCL Oral, 8Pred Forte, 24Prednisolone, 6Prednisolone Sodium Phosphate Powder, 6Prednisolone Syrup Oral, 6Prednisolone Acetate Susp 1% Ophthalmic, 24Prednisolone Sodium Phosphate Oral, 6Prednisolone Sodium Phosphate Soln 1% Ophthalmic, 24Prednisone Oral, 6Prelone, 6Prevalite, 10PrevPac, 15Prilosec (OTC), 14Primaquine Phosphate Oral, 5Prinivil, Zestril, 7Procainamide HCI Oral, 7Prochlorperazine Edisylate Oral, 17Prochlorperazine Maleate Cap CR & Tab Oral, 17Prochlorperazine Maleate Oral, 17Prochlorperazine Suppos Rectal, 17Proctofoam-HC, 28Promethazine & Phenylephrine Syrup 6.25-5mg/5mLOral, 12Promethazine HCL Oral, 11Promethazine HCL Suppos Rectal, 11Promethazine-DM Syrup Oral, 12Pronestyl, 7Pronto, 29Propafenone HCI Oral, 7Propine-C, 25Propoxyphene Combinations, 19Propoxyphene-N w/ APAP 100-650mg Tab Oral, 19Propoxyphene-N w/ APAP 50-325mg Tab Oral, 19Propranolol HCL Oral, 8Propylthiouracil (PTU), 7June 2009 Page 37 of 42

Propylthiouracil Oral, 7Prostaglandin Agonists Ophthalmi, 25Prostigmin, 21Protriptyline HCL Oral, 17Proventil, 13Proventil HFA, 13Pseudoephed-Bromphen-DM Oral, 12Pseudoephed-Carbinoxamine-DM Liquid Oral, 12Pseudoephedrine HCL Oral, 12Pseudoephedrine w/DM-GG Cap 30-10-200mg Oral, 12Pseudoephedrine-GG/CR Oral, 12PSYCHOTHERAPEUTIC AGENTS, 16Pyrantel Pamoate Ora, 5Pyrethrins-Piperonyl Butoxide External, 29Pyridium, 16Pyridostigmine Bromide Oral, 21Pyridoxine HCL Cap, 21Pyrimethamine Oral, 5QQualaquin, 5Questran/Lite, 10Quibron-T, 13Quinidex, 7Quinidine, 7Quinidine Gluconate CR Oral, 7Quinidine Sulfate Tab Oral, 7Quinine Sulfate, 5QUININE SULFATE, 5Quinine Sulfate Tab 324mg Oral, 5Quixin, 23QVAR, 13Ranitidine HCL Tablet 150mg, 300mg Oral, 14Rectacaine, 28Reglan, 15Rescon-GG, 12RESPIRATORY AGENTS, 11Rheumatrex, 19Rid, 29Rifadin, 5Rifampin Oral, 5Robaxin, 21Robimycin, 4Robitussin, 11Robitussin A-C, 12Robitussin Cod/Cgh, 12Robitussin DM, 12Robitussin PE, 12Rondec DM, 12Rosiglitazone, 7Rosiglitazone Oral, 7Rowasa, 15Roxicet, 18Rythmal, 7Salagen, 26Salflex, 17Salicylate Combinations, 17Salicylates, 17RSSalmeterol Xinafoate Powder Disks Inhalation, 13Salsalate Oral, 17Scabicides & Pediculocides, 28Scopolamine HBr Soln 0.25% Ophthalmic, 25Scopolamine w/ Phenylephrine Soln 0.3-10%Ophthalmic, 25Scot-Tussin DM SF, 12Sedapap, 18Serevent Diskus, 13Serotonin Agonist, 19Silvadene, 27Silver Sulfadiazine Cream 1% External, 27Simvastatin Oral, 11Sinequan, 17Singulair, 14Slo-Bid, 13Slo-Phyllin, 13Slow-Fe, 22Slow-K, 22Sod Sulamyd, 23Sodium Chloride, 16Sodium Chloride Injection, 22Sodium Chloride Irrigation, 16Sodium Chloride Soln Nebu 0.9%, 11Sodium Polystyrene Sulfonate Powder Oral, 22Sodium Polystyrene Sulfonate Susp 15gm/60mLOral/Rectal, 22Sodium Sulfacetamide 10% Ophthalmic, 23Soln, 16, 18Soln Oral, 13Sorbitrate, 9sordil, 9Sotalol HCl Oral, 8Spironolactone Oral, 10Spironolaone & HCTZ Oral, 10SPS, 22Starch Suppositories 51% Recta, 28Steroid Inhalants, 13Sucralfate Oral, 15Sudafed, 12Sudafed Plus, 12Sudex, 12Sulfacetamide Sodium-Prednisolone Oint 10-0.2%Ophthalmic, 24Sulfacetamide Sodium-Prednisolone Oint 10-0.25%Ophthalmic, 24Sulfacetamide Sodium-Prednisolone Oint 10-0.5%Ophthalmic, 24Sulfacetamide Sodium-Prednisolone Soln 10-0.25%Ophthalmic, 24Sulfacetamide Sodium-Prednisolone Susp 10-0.2%Ophthalmic, 24Sulfacetamide Sodium-Prednisolone Susp 10-0.25%Ophthalmic, 24Sulfacetamide Sodium-Prednisolone Susp 10-0.5%Ophthalmic, 24Sulfadiazine, 27Sulfasalazine, 15Sulfasalazine Tab & EC Oral, 15Sulfisoxazole, 4Sulfisoxazole Acetyl Oral, 4Sulfisoxazole Powder, 4Sulfonamides, 4Sulfonylureas, 6Sulindac Oral, 19June 2009 Page 38 of 42

WWarfarin Sodium Tab Oral, 22Wigraine, 20Xalatan, 25Xanthines, 13Xenaderm, 28Xylocaine, 28XZantac, 14Zaroxolyn, 10Zithromax, 4Zocor, 11Zovirax, 5Zylet, 24Zyloprim, 20Zymar, 23ZYodoxin, 5YJune 2009 Page 40 of 42

Customer Service Help Desk: (800) 777-0074If this is an URGENT REQUEST check here:Fax to the ‘Urgent Fax Line’ at 877-636-9001. Note: This line MUST be reserved for requests that are potentially life threatening or posea significant risk to the continuous care of the patient, in the provider's best professional judgment. NMHC Clinical Pharmacists reservejudgment of urgency and must meet definition above, therefore, please explain reason for urgency below. This fax line monitored for abuse.Top portion and medication request information to be completed by physician requesting prior authorization.Name of Member’s Health Plan:Member’s Program: CMS RW CI (circle one)Date of Request: Physician:MD office Contact Person: Signature:Physician’s Fax Number: Physician’s Phone Number:Physician’s Specialty:Pharmacy Name: Pharmacy Fax Number: ( )DRUG PRIOR AUTHORIZATION REQUESTCONFIDENTIAL PATIENT INFORMATIONSan Diego CMS ProgramFax to: 866-511-2202Pharmacy Contact: Pharmacy Phone Number: ( )Patient’s Last Name, First NamePatient’s ID# or SSN#Sex: Male Female Patient’s DOBPatient’s Phone NumberMEDICATION REQUEST NEW RENEWAL---RENEWAL ORIGINAL RX DATE:___________DIAGNOSIS (LIST RELEVANT):CURRENT MEDICATION(S):FORMULARY DRUGS TRIED AND MEDICAL JUSTIFICATION:DRUG AND STRENGTH: _____________________________________________ NDC: __________________________DIRECTIONS: _________________________________________ MONTHLY QTY: _________ #REFILLS: ________FOR Informed Rx USE ONLYApproved ___ Denied ___ Deferred for Additional Information ___ Approved As Modified ___ Pt. Not Eligible ___COMMENTS: ________________________________________________________________________________________________Authorizing Signature ____________________________________________________ Date __________________________NDC VALID: EXPIRES: _____________________June 2009 Page 41 of 42

SAN DIEGO COUNTY CMS PROGRAMREQUEST FOR FORMULARY CHANGE FORMFax Completed Form to (858) 565-4091Attention: Medical Management Services, ManagerDATE FORM COMPLETED: ____________________REQUESTED BY: ________________________________________________________________________________CLINIC ___________________________________ _SPECIALTY _______________________________________PHONE NUMBER: ___________________ FAX NUMBER: __________________ EMAIL: ___________ _____COMPARABLE DRUG(S) ON FORMULARY:1) _________________________________ __________2) _________________________________ __________DRUG INFORMATIONGENERIC NAME ____________________________MANUFACTURER _____________________________BRAND NAME ____________________________________DOSAGE: ________________________________________MEDICAL INDICATIONS: ________________________________________________________________________________________________________________________________________________________________________PRECAUTIONS/ALERTS: ___________________________________________________________________________________________________________________________________________________________________________ADVANTAGES AND DISADVANTAGES: (YOU MAY ATTACH REFERENCES OR PUBLICATIONS THAT SUPPORT THEEFFICACY OF THIS DRUG) _________________________________________________________________________________________________________________________________________________________________________- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -FOR CMS PROGRAM USE ONLYCOMMITTEE COMMENTS: _____________________________________________________________________________________________________________________________________________________________________DRUG COST PER MONTH_________________________ POTENTIAL OVERALL COST __________________________________ADVANTAGE/DISADVANTAGE ______________________________________________________________ACCEPTED: _______________ REJECTED: __________________ DATE: ________________DATE ADDED TO FORMULARY _______________________________________________________________ FORM 10/01/08June 2009 Page 42 of 42