2013 PHP Salud Formulary/Preferred Drug Listing By Therapeutic ...

2013 PHP Salud Formulary/Preferred Drug ListingBy Therapeutic ClassPresbyterian SaludSome medications may be excluded as determined by benefit.AnalgesicsDrug Name Dosage Form Noteacephen (325mg) SUPP (OTC) (QL)acephen (650mg) SUPP (OTC) (QL)acetaminophen (325mg) TABS (OTC) (QL)acetaminophen (500mg) TABS (OTC) (QL)acetaminophen extra strength LIQD (OTC) (QL)acetaminophen/codeine #2 TABS (QL)acetaminophen/codeine #3 TABS (QL)acetaminophen/codeine #4 TABS (QL)ADULT ASPIRIN LOW STRENGTH TBDP (AG)arthritis pain relief TBCR (OTC) (QL)aspirin CHEW (AG)aspirin ec TBEC (AG)aspirin low dose TABS (AG)AVINZA (120MG) CP24 (QL) (ST)AVINZA (30MG) CP24 (QL) (ST)AVINZA (45MG) CP24 (QL) (ST)AVINZA (60MG) CP24 (QL) (ST)AVINZA (75MG) CP24 (QL) (ST)AVINZA (90MG) CP24 (QL) (ST)butalbital/acetaminophen/caffeine * (QL)butalbital/acetaminophen/caffeine CAPS (QL)butalbital/acetaminophen/caffeine (325mg; 50mg; 40mg) TABS (QL)butalbital/acetaminophen/caffeine (325mg; 50mg; 40mg) TABS (QL)butalbital/acetaminophen/caffeine (500mg; 50mg; 40mg) TABS (QL)butalbital/acetaminophen/caffeine/codeine CAPS (QL)butalbital/aspirin/caffeie/codeinecarisoprodol/aspirincarisoprodol/aspirin/codeineCAPSTABSTABSCELEBREX CAPS (QL) (ST)childrens ibuprofen SUSP (OTC)CODEINE SULFATE TABS (QL)diclofenac sodium drdiclofenac sodium erTBECTB24[MPC031203] Page 1 of 48 August 15, 2013

Drug Name Dosage Form NotediflunisalDOLGIC PLUSTABSTABSendocet TABS (QL)etodolac *etodolac erTB24fentanyl PT72 (ST) (QL)feverall SUPP (OTC) (QL)FEVERALL INFANTS SUPP (OTC) (QL)flurbiprofenTABShydrocodone bitartrate/acetaminophen TABS (QL)hydrocodone/acetaminophen SOLN (QL)hydrocodone/acetaminophen (325mg; 10mg) TABS (QL)hydrocodone/acetaminophen (325mg; 5mg) TABS (QL)hydrocodone/acetaminophen (325mg; 7.5mg) TABS (QL)hydrocodone/acetaminophen (500mg; 10mg) TABS (QL)hydrocodone/acetaminophen (500mg; 2.5mg) TABS (QL)hydrocodone/acetaminophen (500mg; 5mg) TABS (QL)hydrocodone/acetaminophen (500mg; 7.5mg) TABS (QL)hydrocodone/acetaminophen (650mg; 10mg) TABS (QL)hydrocodone/acetaminophen (650mg; 7.5mg) TABS (QL)hydrocodone/acetaminophen (660mg; 10mg) TABS (QL)hydrocodone/acetaminophen (750mg; 7.5mg) TABS (QL)hydrocodone/ibuprofenTABShydrogesic CAPS (QL)hydromorphone hcl TABS (QL)hydromorphone hcl LIQD (QL)ibuprofen *ibuprofenTABSibuprofen * (OTC)ibuprofen TABS (OTC)ibuprofenSUSPibuprofen junior strength CHEW (OTC)INDOCIN *indomethacinindomethacin erCAPSCPCRjr strength non-aspirin TBDP (OTC) (QL)KADIAN CP24 (QL) (ST)ketoprofenKETOPROFEN ERCAPSCP24MELOXICAM *meloxicam *MEPERIDINE HCLSOLNmeperidine hcl TABS (QL)methadone hcl TABS (PA) (QL)[MPC031203] Page 2 of 48 August 15, 2013

Drug Name Dosage Form NoteMETHADONE HCL SOLN (PA)MORPHINE SULFATE TABS (QL)morphine sulfate (10mg/5ml) SOLN (QL)morphine sulfate (20mg/5ml) SOLN (QL)morphine sulfate (20mg/ml) SOLN (QL)morphine sulfate er CP24 (QL) (ST)morphine sulfate er TBCR (QL)motrin ib TABS (OTC)nabumetoneTABSnaproxen *naproxen drnaproxen sodiumoxaprozinTBECTABSTABSOXYCODONE HCL SOLN (QL)OXYCODONE HCL CONC (QL)oxycodone hcl TABS (QL)oxycodone/acetaminophen * (QL)oxycodone/acetaminophen (325mg; 10mg) TABS (QL)oxycodone/acetaminophen (325mg; 5mg) TABS (QL)oxycodone/acetaminophen (325mg; 7.5mg) TABS (QL)oxycodone/acetaminophen (500mg; 7.5mg) TABS (QL)oxycodone/acetaminophen (650mg; 10mg) TABS (QL)oxycodone/aspirinTABSOXYMORPHONE HYDROCHLORIDE ER TB12 (ST) (QL)OXYMORPHONE HYDROCHLORIDE ER TB12 (QL) (ST)oxymorphone hydrochloride er TB12 (ST) (QL)pain & fever childrens CHEW (OTC) (QL)piroxicamCAPSq-pap LIQD (OTC) (QL)q-pap childrens SUSP (OTC) (QL)q-pap infants SOLN (OTC) (QL)ROXICET SOLN (QL)ROXICET TABS (QL)salsalateTABSST JOSEPH ADULT CHEW (AG)sulindacTABStramadol hcl TABS (QL)TYLENOL INFANTS SUSP (OTC) (QL)AnestheticsDrug Name Dosage Form Noteantipyrine/benzocaineSOLN[MPC031203] Page 3 of 48 August 15, 2013

Drug Name Dosage Form NotelidocainelidocaineLIDOCAINE HCLlidocaine viscouslidocaine/prilocaineOINTCREALOTNSOLNCREALIDODERM PTCH (PA) (QL)Anti-Addiction/Substance Abuse Treatment AgentsDrug Name Dosage Form Noteacamprosate calcium dr TBEC (PA) (QL)buprenorphine hcl SUBL (PA) (QL)buproban TB12 (QL)bupropion hcl sr TB12 (QL)CHANTIX TABS (QL)CHANTIX STARTING MONTH PAK TABS (QL)disulfiramnaltrexone hclTABSTABSSUBOXONE * (PA) (QL)SUBOXONE (12MG; 3MG) FILM (PA) (QL)SUBOXONE (2MG; 0.5MG) FILM (PA) (QL)SUBOXONE (4MG; 1MG) FILM (PA) (QL)SUBOXONE (8MG; 2MG) FILM (PA) (QL)VIVITROL SUSR (PA) (QL) (SP)Anti-inflammatory AgentsDrug Name Dosage Form NoteADULT ASPIRIN LOW STRENGTH TBDP (AG)aspirin CHEW (AG)aspirin ec TBEC (AG)aspirin low dose TABS (AG)CELEBREX CAPS (QL) (ST)childrens ibuprofen SUSP (OTC)COLY-MYCIN Sdiclofenac sodium drdiclofenac sodium erdiflunisalSUSPTBECTB24TABSetodolac *etodolac erflurbiprofenhydrocortisone/acetic acidTB24TABSSOLN[MPC031203] Page 4 of 48 August 15, 2013

Drug Name Dosage Form Noteibuprofen *ibuprofenibuprofenTABSSUSPibuprofen * (OTC)ibuprofen TABS (OTC)ibuprofen junior strength CHEW (OTC)INDOCIN *indomethacinindomethacin erketoprofenKETOPROFEN ERCAPSCPCRCAPSCP24meloxicam *MELOXICAM *motrin ib TABS (OTC)nabumetoneTABSnaproxen *naproxen drnaproxen sodiumNEOMYCIN/POLYMYXIN/HYDROCORTISONEneomycin/polymyxin/hydrocortisoneneomycin/polymyxin/hydrocortisoneTBECTABSSUSPSOLNSUSPnystatin/triamcinolone *NYSTATIN/TRIAMCINOLONE *oxaprozinpiroxicamTABSCAPSST JOSEPH ADULT CHEW (AG)sulindacTABSAntibacterialsDrug Name Dosage Form Noteak-poly-bacAKNE-MYCINOINTOINTAMOXICILLIN *amoxicillin *amoxicillin/clavulanate potassium *amoxicillin/potassium clavulanateSUSRAMPICILLIN *ampicillin *azithromycin *BACITRACINOINTbacitracin OINT (OTC)bacitracin/polymyxin bOINT[MPC031203] Page 5 of 48 August 15, 2013

Drug Name Dosage Form NoteBACTROBAN NASALBLEPHAMIDEBLEPHAMIDE S.O.P.cefaclorOINTSUSPOINTCAPScefdinir *cefpodoxime proxetil *cefprozil *cefuroxime axetil *cephalexin *CIPROSUSRCIPRODEX SUSP (AG) (PA) (QL)ciprofloxacin hclciprofloxacin hclclarithromycinSOLNTABSSUSRclarithromycin TABS (QL)CLEOCINclindamycin hclclindamycin palmitate hclclindamycin phosphateCOLY-MYCIN SCORTISPORINCORTISPORINdicloxacillin sodiumSUPPCAPSSOLRCREASUSPCREAOINTCAPSDIFICID TABS (PA) (QL)doxycycline hyclate *doxycycline hyclate TABS (QL)E.E.S. 400E.E.S. GRANULESERY-TABERYPED 200ERYPED 400ERYTHROCIN STEARATEerythromycinTABSSUSRTBECSUSRSUSRTABSOINTERYTHROMYCIN *erythromycin *ERYTHROMYCIN BASEERYTHROMYCIN ETHYLSUCCINATEerythromycin/sulfisoxazolegaramycingentakgentamicin sulfateTABSTABSSUSROINTOINTSOLNGENTAMICIN SULFATE *levofloxacin *[MPC031203] Page 6 of 48 August 15, 2013

Drug Name Dosage Form NoteMACRODANTINmethenamine hippurateMETHENAMINE MANDELATEmethenamine mandelateCAPSTABSTABSTABSmetronidazole *metronidazolemetronidazole vaginalminocycline hclmupirocinneomycin sulfateneomycin/bacitracin/polymyxinneomycin/polymyxin b sulfatesneomycin/polymyxin/bacitracin/hydrocortisoneTABSGELCAPSOINTTABSOINTSOLNOINTneomycin/polymyxin/dexamethasone *neomycin/polymyxin/gramicidinNEOMYCIN/POLYMYXIN/HYDROCORTISONEneomycin/polymyxin/hydrocortisoneneomycin/polymyxin/hydrocortisonenitrofurantoinnitrofurantoin macrocrystallinenitrofurantoin monohydrateofloxacinSOLNSUSPSOLNSUSPSUSPCAPSCAPSSOLNpenicillin v potassium *polycin bpolymyxin b sulfate/trimethoprim sulfatesilver sulfadiazinesulfacetamide sodiumOINTSOLNCREASOLNsulfamethoxazole/trimethoprim *sulfamethoxazole/trimethoprim dsTETRACYCLINE HCLTOBITABSCAPSNEBUTOBI PODHALER CAPS (QL)tobramycin sulfatetrimethoprimvancomycin hclSOLNTABSSOLRvancomycin hcl CAPS (PA)VIBRAMYCINSUSRXIFAXAN TABS (PA) (QL)ZYVOX * (PA)AnticonvulsantsDrug Name Dosage Form Note[MPC031203] Page 7 of 48 August 15, 2013

Drug Name Dosage Form Notecarbamazepine *carbamazepine er *clonazepam TABS (QL)clonazepam odt TBDP (QL)diazepam TABS (QL)DIAZEPAM GEL (ST)DILANTINdivalproex sodiumdivalproex sodium drdivalproex sodium erCAPSCPSPTBECTB24ethosuximide *gabapentin *LAMICTAL CHEW (QL)lamotrigine CHEW (QL)lamotrigine (100mg) TABS (QL)lamotrigine (150mg) TABS (QL)lamotrigine (200mg) TABS (QL)lamotrigine (25mg) TABS (QL)levetiracetam *LYRICA (100MG) CAPS (PA) (QL)LYRICA (150MG) CAPS (PA) (QL)LYRICA (200MG) CAPS (PA) (QL)LYRICA (225MG) CAPS (PA) (QL)LYRICA (25MG) CAPS (PA) (QL)LYRICA (300MG) CAPS (PA) (QL)LYRICA (50MG) CAPS (PA) (QL)LYRICA (75MG) CAPS (PA) (QL)oxcarbazepineTABSPHENOBARBITAL *phenobarbital *phenytoinphenytoinphenytoin sodium extendedCHEWSUSPCAPSPOTIGA TABS (PA) (QL)primidoneTEGRETOL-XRTABSTB12topiramate *valproic acidvalproic acidzonisamideCAPSSYRPCAPSAntidementia Agents[MPC031203] Page 8 of 48 August 15, 2013

Drug Name Dosage Form NoteDrug Name Dosage Form Notedonepezil hcl * (QL)ERGOLOID MESYLATESgalantamine hydrobromideTABSCP24galantamine hydrobromide *AntidepressantsDrug Name Dosage Form NoteABILIFY SOLN (PA) (QL)ABILIFY TABS (PA) (QL)ABILIFY DISCMELT TBDP (PA) (QL)ABILIFY MAINTENA SUSR (MB) (PA) (SP)amitriptyline hclAMOXAPINETABSTABSbudeprion sr TB12 (QL)bupropion hcl TABS (QL)bupropion hcl sr TB12 (QL)bupropion hcl xl TB24 (QL)citalopram hydrobromide SOLN (QL)citalopram hydrobromide (10mg) TABS (QL)citalopram hydrobromide (20mg) TABS (QL)citalopram hydrobromide (40mg) TABS (QL)clomipramine hclCAPSCYMBALTA (20MG) CPEP (PA) (QL)CYMBALTA (30MG) CPEP (PA) (QL)CYMBALTA (60MG) CPEP (PA) (QL)desipramine hclTABSdoxepin hcl *DOXEPIN HCL *EMSAM PT24 (PA) (QL)escitalopram oxalate SOLN (QL)escitalopram oxalate (10mg) TABS (QL)escitalopram oxalate (20mg) TABS (QL)escitalopram oxalate (5mg) TABS (QL)FLUOXETINE HCL * (QL)fluoxetine hcl SOLN (QL)fluoxetine hcl * (QL)fluoxetine hcl (10mg) CAPS (QL)fluoxetine hcl (20mg) CAPS (QL)fluoxetine hcl (40mg) CAPS (QL)fluvoxamine maleate (100mg) TABS (QL) (ST)fluvoxamine maleate (25mg) TABS (QL) (ST)[MPC031203] Page 9 of 48 August 15, 2013

Drug Name Dosage Form Notefluvoxamine maleate (50mg) TABS (QL) (ST)imipramine hclMAPROTILINE HCLTABSTABSmirtazapine * (QL)mirtazapine odt TBDP (QL)NEFAZODONE HCL TABS (QL)nefazodone hcl TABS (QL)nortriptyline hclCAPSparoxetine hcl (10mg) TABS (QL)paroxetine hcl (20mg) TABS (QL)paroxetine hcl (30mg) TABS (QL)paroxetine hcl (40mg) TABS (QL)paroxetine hcl er TB24 (ST)PAXIL SUSP (QL)PERPHENAZINE/AMITRIPTYLINEphenelzine sulfateTABSTABSquetiapine fumarate (100mg) TABS (AG) (QL)quetiapine fumarate (200mg) TABS (AG) (QL)quetiapine fumarate (25mg) TABS (AG) (QL)quetiapine fumarate (300mg) TABS (AG) (QL)quetiapine fumarate (400mg) TABS (AG) (QL)quetiapine fumarate (50mg) TABS (AG) (QL)selegiline hcl *sertraline hcl CONC (QL)sertraline hcl (100mg) TABS (QL)sertraline hcl (25mg) TABS (QL)sertraline hcl (50mg) TABS (QL)tranylcypromine sulfatetrazodone hclTABSTABSvenlafaxine hcl TABS (QL)venlafaxine hcl er (150mg) TB24 (QL)venlafaxine hcl er (150mg) CP24 (QL)venlafaxine hcl er (37.5mg) CP24 (QL)venlafaxine hcl er (37.5mg) TB24 (QL)venlafaxine hcl er (75mg) CP24 (QL)venlafaxine hcl er (75mg) TB24 (QL)VIIBRYD TABS (PA) (QL)AntiemeticsDrug Name Dosage Form NoteALOXI SOLN (PA) (QL)ANZEMET TABS (PA) (QL)[MPC031203] Page 10 of 48 August 15, 2013

Drug Name Dosage Form Notechlorpromazine hclcomproTABSSUPPEMEND SOLR (PA) (QL) (SP)EMEND (0) CAPS (PA) (QL)EMEND (125MG) CAPS (PA) (QL)EMEND (40MG) CAPS (PA) (QL)EMEND (80MG) CAPS (PA) (QL)granisetron hclSOLNgranisetron hcl TABS (QL) (ST)hydroxyzine hcl *hydroxyzine pamoateHYDROXYZINE PAMOATECAPSCAPSmetoclopramide hcl *ondansetron hcl TABS (QL)ondansetron odt TBDP (QL)perphenazinephenadozprochlorperazinePROCHLORPERAZINE EDISYLATEprochlorperazine maleateTABSSUPPSUPPSOLNTABSpromethazine hcl *promethazine hcl plainPROMETHEGANtrimethobenzamide hclSYRPSUPPCAPSAntifungalsDrug Name Dosage Form NoteBIO-STATINciclopiroxciclopiroxCAPSSUSPGELciclopirox nail lacquer SOLN (QL)ciclopirox olamineCREAclotrimazole CREA (OTC)clotrimazoleTROCclotrimazole 3 day CREA (OTC)clotrimazole anti-fungal CREA (OTC)clotrimazole/betamethasone dipropionate *econazole nitrateCREAfluconazole *GRIFULVIN VGRIS-PEGgriseofulvin microsizeTABSTABSSUSP[MPC031203] Page 11 of 48 August 15, 2013

Drug Name Dosage Form NoteketoconazoleTABSketoconazole *nyamycnystatinPOWDSUSPnystatin *nystatinNYSTATIN VAGINALTABSTABSnystatin/triamcinolone *NYSTATIN/TRIAMCINOLONE *nystoppedi-driPOWDPOWDterbinafine hcl TABS (QL)terconazole *VFEND SUSR (PA) (QL)voriconazole TABS (PA) (QL)Antigout AgentsDrug Name Dosage Form NoteallopurinolCOLCRYSprobenecidprobenecid/colchicineTABSTABSTABSTABSULORIC TABS (PA) (QL)Antimigraine AgentsDrug Name Dosage Form Notebutalbital/acetaminophen/caffeine (325mg; 50mg; 40mg) TABS (QL)butalbital/acetaminophen/caffeine (325mg; 50mg; 40mg) TABS (QL)butalbital/acetaminophen/caffeine (500mg; 50mg; 40mg) TABS (QL)CAFERGOTdivalproex sodiumdivalproex sodium drdivalproex sodium erMIGERGOTTABSCPSPTBECTB24SUPPnaratriptan hcl TABS (QL) (ST)rizatriptan benzoate TABS (ST) (QL)SUMATRIPTAN SOLN (QL)sumatriptan succinate SOLN (QL)sumatriptan succinate TABS (QL)[MPC031203] Page 12 of 48 August 15, 2013

Drug Name Dosage Form Notetopiramate *valproic acidCAPSAntimyasthenic AgentsDrug Name Dosage Form NoteMESTINONpyridostigmine bromideSYRPTABSAntimycobacterialsDrug Name Dosage Form NoteCYCLOSERINEDAPSONEethambutol hclISONIAZIDisoniazidMYCOBUTINPASERpyrazinamiderifampinSEROMYCINCAPSTABSTABSSYRPTABSCAPSPACKTABSCAPSCAPSAntineoplasticsDrug Name Dosage Form NoteAFINITOR TABS (PA) (SP)AFINITOR DISPERZ TBSO (PA) (SP)ALIMTA SOLR (PA)ALKERANanastrozoleTABSTABSAVASTIN SOLN (PA)BOSULIF TABS (PA) (QL) (SP)CAMPATH SOLN (PA)CAPRELSA TABS (PA)CEENU CAPS (PA) (SP)COMETRIQ KIT (PA)CYCLOPHOSPHAMIDETABSEMCYT CAPS (PA) (SP)ERIVEDGE CAPS (PA) (QL) (SP)ERWINAZE SOLR (PA) (SP)[MPC031203] Page 13 of 48 August 15, 2013

Drug Name Dosage Form NoteETHYOL SOLR (PA)ETOPOSIDE CAPS (SP)FARESTON TABS (PA) (SP)GLEEVEC TABS (PA) (SP)HEXALEN CAPS (PA) (SP)HYCAMTIN CAPS (PA) (SP)hydroxyureaCAPSINLYTA TABS (PA) (SP)IRESSA TABS (PA)JAKAFI TABS (PA) (SP)KADCYLA SOLR (MB) (PA) (SP)KYPROLIS SOLR (PA) (SP)leucovorin calciumLEUCOVORIN CALCIUMTABSTABSLEUKERAN TABS (PA) (SP)MATULANE CAPS (PA) (SP)MEKINIST TABS (PA) (QL) (SP)mercaptopurineTABSMYLERAN TABS (PA) (SP)NEXAVAR TABS (PA) (SP)PERJETA SOLN (PA) (SP)POMALYST CAPS (PA) (SP) (QL)REVLIMID CAPS (PA) (SP)RITUXAN CONC (PA)SPRYCEL TABS (PA) (SP)STIVARGA TABS (PA) (QL) (SP)SUTENT CAPS (PA) (SP)SYLATRON KIT (PA) (SP)TABLOID TABS (PA) (SP)TAFINLAR CAPS (PA) (QL) (SP)tamoxifen citrateTABSTARCEVA TABS (PA) (SP)TARGRETIN CAPS (PA) (SP)TASIGNA CAPS (PA) (SP)temozolomide CAPS (PA) (SP)THALOMID CAPS (PA)TYKERB TABS (PA) (SP)VOTRIENT TABS (PA) (SP)XALKORI (200MG) CAPS (PA) (SP)XALKORI (250MG) CAPS (PA) (SP)XELODA TABS (PA) (SP)YERVOY SOLN (PA)ZALTRAP SOLN (PA) (SP)ZELBORAF TABS (PA) (SP)[MPC031203] Page 14 of 48 August 15, 2013

Drug Name Dosage Form NoteZOLINZA CAPS (PA) (SP)ZYTIGA TABS (PA) (SP)AntiparasiticsDrug Name Dosage Form NoteA-200 GEL (OTC)chloroquine phosphatehydroxychloroquine sulfateTABSTABSlicide AERO (OTC)lindane *MEPRONNEBUPENTNEUTREXINPENTAM 300permethrinSUSPSOLRSOLRSOLRCREApermethrin LOTN (OTC)pin-x SUSP (OTC) (QL)PIN-X CHEW (OTC) (QL)PRIMAQUINE PHOSPHATETABSreeses pinworm medicine SUSP (OTC) (QL)REESES PINWORM MEDICINE TABS (OTC) (QL)Antiparkinson AgentsDrug Name Dosage Form Noteamantadine hcl *AMANTADINE HCL *APOKYN SOLN (PA) (SP)benztropine mesylateTABSbromocriptine mesylate *carbidopa/levodopacarbidopa/levodopa ercarbidopa/levodopa odtCOGENTINCOMTANTABSTBCRTBDPSOLNTABSEMSAM PT24 (PA) (QL)pramipexole dihydrochloride (0.125mg)pramipexole dihydrochloride (0.25mg)pramipexole dihydrochloride (0.5mg)pramipexole dihydrochloride (0.75mg)pramipexole dihydrochloride (1.5mg)TABSTABSTABSTABSTABS[MPC031203] Page 15 of 48 August 15, 2013

Drug Name Dosage Form Notepramipexole dihydrochloride (1mg)ropinirole hclTABSTABSselegiline hcl *trihexyphenidyl hcl *AntipsychoticsDrug Name Dosage Form NoteABILIFY SOLN (PA) (QL)ABILIFY TABS (PA) (QL)ABILIFY DISCMELT TBDP (PA) (QL)ABILIFY MAINTENA SUSR (MB) (PA) (SP)chlorpromazine hclTABSclozapine (100mg) TABS (QL)clozapine (200mg) TABS (QL)clozapine (25mg) TABS (QL)clozapine (50mg) TABS (QL)CLOZAPINE ODT (100MG) TBDP (QL)CLOZAPINE ODT (12.5MG) TBDP (QL)CLOZAPINE ODT (25MG) TBDP (QL)comproSUPPfluphenazine hcl *FLUPHENAZINE HCL *haloperidolloxapine succinateTABSCAPSolanzapine (10mg) TABS (AG) (QL)olanzapine (15mg) TABS (AG) (QL)olanzapine (2.5mg) TABS (AG) (QL)olanzapine (20mg) TABS (AG) (QL)olanzapine (5mg) TABS (AG) (QL)olanzapine (7.5mg) TABS (AG) (QL)olanzapine odt TBDP (PA) (QL)perphenazinePERPHENAZINE/AMITRIPTYLINEprochlorperazinePROCHLORPERAZINE EDISYLATEprochlorperazine maleateTABSTABSSUPPSOLNTABSquetiapine fumarate (100mg) TABS (AG) (QL)quetiapine fumarate (200mg) TABS (AG) (QL)quetiapine fumarate (25mg) TABS (AG) (QL)quetiapine fumarate (300mg) TABS (AG) (QL)quetiapine fumarate (400mg) TABS (AG) (QL)quetiapine fumarate (50mg) TABS (AG) (QL)[MPC031203] Page 16 of 48 August 15, 2013

Drug Name Dosage Form NoteRISPERDAL CONSTA SUSR (PA) (QL) (SP)risperidone odt (0.25mg) TBDP (PA) (QL)thioridazine hclthiothixenetrifluoperazine hclTABSCAPSTABSziprasidone hcl CAPS (AG) (QL)Antispasticity AgentsDrug Name Dosage Form Notebaclofentizanidine hclTABSTABSAntiviralsDrug Name Dosage Form Noteabacavir TABS (QL)acyclovir *ALFERON N SOLN (SP)amantadine hcl *AMANTADINE HCL *APTIVUS SOLN (QL)APTIVUS CAPS (QL)ATRIPLA TABS (QL)COMPLERA TABS (SP)CRIXIVAN CAPS (QL)didanosine CPDR (QL)EDURANT TABS (SP)EMTRIVASOLNEMTRIVA CAPS (QL)EPIVIR SOLN (QL)EPIVIR HBV *EPZICOM TABS (QL)famciclovirTABSFUZEON KIT (QL)INCIVEK TABS (PA) (QL) (SP)INFERGEN INJ (SP)INTELENCE (100MG) TABS (QL) (SP)INTELENCE (200MG) TABS (QL) (SP)INTELENCE (25MG) TABS (QL) (SP)INTRON-A SOLN (SP)INTRON-A W/DILUENT SOLR (SP)[MPC031203] Page 17 of 48 August 15, 2013

Drug Name Dosage Form NoteINVIRASE * (QL)ISENTRESS TABS (QL)KALETRASOLNKALETRA TABS (QL)lamivudine TABS (QL)lamivudine/zidovudine TABS (QL)LEXIVA TABS (QL)LEXIVASUSPNEVIRAPINE SUSP (QL)nevirapine TABS (QL)NORVIR * (QL)NORVIR SOLN (QL)PEG-INTRON KIT (PA) (SP)PEG-INTRON REDIPEN PAK 4 KIT (PA) (SP)PEGASYS * (PA) (SP)PREZISTA SUSP (QL)PREZISTA (150MG) TABS (QL)PREZISTA (400MG) TABS (QL)PREZISTA (600MG) TABS (QL)PREZISTA (75MG) TABS (QL)PREZISTA (800MG) TABS (QL)RELENZA DISKHALER AEPB (QL)RESCRIPTOR TABS (QL) (SP)RESCRIPTOR TABS (QL)REYATAZ CAPS (QL)ribasphere CAPS (SP)ribavirin TABS (SP)SELZENTRY TABS (QL)SELZENTRY TABS (QL) (SP)stavudine CAPS (QL)stavudine SOLR (QL)STRIBILD TABS (QL) (SP)SUSTIVA * (QL)TAMIFLU CAPS (QL)TAMIFLU SUSR (QL)trifluridineSOLNTRIZIVIR TABS (QL)TRUVADATABSVALCYTE TABS (PA) (QL)VALCYTE SOLR (PA) (QL)VICTRELIS CAPS (PA) (QL) (SP)VIDEX PEDIATRIC SOLR (QL) (SP)VIRACEPT TABS (QL)VIRAMUNE XR TB24 (QL)[MPC031203] Page 18 of 48 August 15, 2013

Drug Name Dosage Form NoteVIREAD * (QL)VIREAD (150MG) TABS (QL)VIREAD (200MG) TABS (QL)VIREAD (250MG) TABS (QL)VIREAD (300MG) TABS (QL)ZIAGEN SOLN (QL)zidovudine * (QL)zidovudineZOVIRAXSYRPCREAZOVIRAX OINT (QL)AnxiolyticsDrug Name Dosage Form Notealprazolam (0.25mg) TABS (QL)alprazolam (0.5mg) TABS (QL)alprazolam (1mg) TABS (QL)alprazolam (2mg) TABS (QL)ALPRAZOLAM INTENSOLCONCbuspirone hcl TABS (QL)chlordiazepoxide hcl CAPS (QL)clonazepam TABS (QL)clonazepam odt TBDP (QL)CYMBALTA (20MG) CPEP (PA) (QL)CYMBALTA (30MG) CPEP (PA) (QL)CYMBALTA (60MG) CPEP (PA) (QL)diazepam TABS (QL)DOXEPIN HCL *doxepin hcl *escitalopram oxalate SOLN (QL)escitalopram oxalate (10mg) TABS (QL)escitalopram oxalate (20mg) TABS (QL)escitalopram oxalate (5mg) TABS (QL)hydroxyzine hcl *hydroxyzine pamoateHYDROXYZINE PAMOATECAPSCAPSlorazepam TABS (QL)lorazepammeprobamateCONCTABSparoxetine hcl (10mg) TABS (QL)paroxetine hcl (20mg) TABS (QL)paroxetine hcl (30mg) TABS (QL)paroxetine hcl (40mg) TABS (QL)[MPC031203] Page 19 of 48 August 15, 2013

Drug Name Dosage Form Noteparoxetine hcl er TB24 (ST)PAXIL SUSP (QL)sertraline hcl CONC (QL)sertraline hcl (100mg) TABS (QL)sertraline hcl (25mg) TABS (QL)sertraline hcl (50mg) TABS (QL)venlafaxine hcl TABS (QL)venlafaxine hcl er (150mg) TB24 (QL)venlafaxine hcl er (150mg) CP24 (QL)venlafaxine hcl er (37.5mg) CP24 (QL)venlafaxine hcl er (37.5mg) TB24 (QL)venlafaxine hcl er (75mg) CP24 (QL)venlafaxine hcl er (75mg) TB24 (QL)Bipolar AgentsDrug Name Dosage Form NoteABILIFY TABS (PA) (QL)ABILIFY SOLN (PA) (QL)ABILIFY DISCMELT TBDP (PA) (QL)ABILIFY MAINTENA SUSR (MB) (PA) (SP)carbamazepine *carbamazepine er *divalproex sodiumdivalproex sodium drdivalproex sodium erCPSPTBECTB24LAMICTAL CHEW (QL)lamotrigine CHEW (QL)lamotrigine (100mg) TABS (QL)lamotrigine (150mg) TABS (QL)lamotrigine (200mg) TABS (QL)lamotrigine (25mg) TABS (QL)lithium carbonate *lithium carbonate erLITHIUM CITRATETBCRSOLNolanzapine (10mg) TABS (AG) (QL)olanzapine (15mg) TABS (AG) (QL)olanzapine (2.5mg) TABS (AG) (QL)olanzapine (20mg) TABS (AG) (QL)olanzapine (5mg) TABS (AG) (QL)olanzapine (7.5mg) TABS (AG) (QL)olanzapine odt TBDP (PA) (QL)quetiapine fumarate (100mg) TABS (AG) (QL)[MPC031203] Page 20 of 48 August 15, 2013

Drug Name Dosage Form Notequetiapine fumarate (200mg) TABS (AG) (QL)quetiapine fumarate (25mg) TABS (AG) (QL)quetiapine fumarate (300mg) TABS (AG) (QL)quetiapine fumarate (400mg) TABS (AG) (QL)quetiapine fumarate (50mg) TABS (AG) (QL)RISPERDAL CONSTA SUSR (PA) (QL) (SP)risperidone SOLN (AG) (QL)risperidone (0.25mg) TABS (AG) (QL)risperidone (0.5mg) TABS (AG) (QL)risperidone (1mg) TABS (AG) (QL)risperidone (2mg) TABS (AG) (QL)risperidone (3mg) TABS (AG) (QL)risperidone (4mg) TABS (AG) (QL)risperidone odt (0.25mg) TBDP (PA) (QL)risperidone odt (0.5mg) TBDP (PA) (QL)risperidone odt (1mg) TBDP (PA) (QL)risperidone odt (2mg) TBDP (PA) (QL)risperidone odt (3mg) TBDP (PA) (QL)risperidone odt (4mg) TBDP (PA) (QL)TEGRETOL-XRvalproic acidTB12CAPSziprasidone hcl CAPS (AG) (QL)Blood Glucose RegulatorsDrug Name Dosage Form NoteacarboseTABSAVANDAMET TABS (ST)AVANDIA TABS (ST)BYETTA (10MCG/0.04ML) SOLN (PA) (QL)BYETTA (5MCG/0.02ML) SOLN (PA) (QL)CHLORPROPAMIDEglimepirideglipizideglipizide erglipizide/metformin hclGLUCAGENGLUCAGON EMERGENCY KITglyburideglyburide/metformin hclTABSTABSTABSTB24TABSSOLRKITTABSTABSJANUMET TABS (QL) (ST)JANUMET XR (1000MG; 100MG) TB24 (QL) (ST)[MPC031203] Page 21 of 48 August 15, 2013

Drug Name Dosage Form NoteJANUMET XR (1000MG; 50MG) TB24 (QL) (ST)JANUMET XR (500MG; 50MG) TB24 (QL) (ST)JANUVIA TABS (QL) (ST)KOMBIGLYZE XR TB24 (PA)LANTUS SOLN (QL)LANTUS SOLOSTAR SOLN (QL)LEVEMIR SOLN (QL)LEVEMIR FLEXPEN SOLN (QL)metformin hclmetformin hcl ernateglinideTABSTB24TABSNOVOLIN 70/30 SUSP (QL)NOVOLIN N SUSP (QL)NOVOLIN R SOLN (QL)NOVOLOG SOLN (QL)NOVOLOG FLEXPEN SOLN (QL)NOVOLOG MIX 70/30 SUSP (QL)NOVOLOG MIX 70/30 PREFILLED FLEXPEN SUSP (QL)NOVOLOG PENFILL SOLN (QL)ONGLYZA TABS (PA) (QL)pioglitazone hcl TABS (ST)pioglitazone hcl-glimepiride TABS (ST)pioglitazone hcl/metformin hcl TABS (ST)PRANDIMET TABS (ST)SYMLINPEN 120 SOLN (PA)tolazamideTOLAZAMIDETABSTABSVICTOZA SOLN (PA) (QL)WELCHOL *Blood Products/Modifiers/Volume ExpandersDrug Name Dosage Form Noteanagrelide hydrochlorideCAPSARANESP ALBUMIN FREE SOLN (PA) (SP)BERINERT KIT (PA) (SP)BRILINTA TABS (PA) (QL)cilostazolTABSCINRYZE SOLR (PA)clopidogreldipyridamoleTABSTABSEFFIENT TABS (PA)enoxaparin sodium (100mg/ml) SOLN (QL)[MPC031203] Page 22 of 48 August 15, 2013

Drug Name Dosage Form Noteenoxaparin sodium (120mg/0.8ml) SOLN (QL)enoxaparin sodium (150mg/ml) SOLN (QL)enoxaparin sodium (300mg/3ml) SOLN (QL)enoxaparin sodium (30mg/0.3ml) SOLN (QL)enoxaparin sodium (40mg/0.4ml) SOLN (QL)enoxaparin sodium (60mg/0.6ml) SOLN (QL)enoxaparin sodium (80mg/0.8ml) SOLN (QL)EPOGEN SOLN (PA) (SP)fondaparinux sodium SOLN (PA)HEPARIN LOCK FLUSHheparin lock flushHEPARIN SODIUMheparin sodiumheparin sodium lock flushheparin sodium lock flushHEPARIN SODIUM/D5Wheparin sodium/d5wHEPARIN SODIUM/NACL 0.45%heparin sodium/sodium chloride 0.9% premixjantovenSOLNSOLNSOLNSOLNSOLNKITSOLNSOLNSOLNSOLNTABSNEULASTA SOLN (PA) (SP)NEUMEGA SOLR (PA) (SP)NEUPOGEN SOLN (PA) (SP)PROCRIT SOLN (PA) (SP)SOLIRIS SOLN PA, SPticlopidine hclwarfarin sodiumTABSTABSXARELTO TABS (QL)Cardiovascular AgentsDrug Name Dosage Form Noteacebutolol hclacetazolamideACETAZOLAMIDECAPSTABSTABSADVICOR TB24 (ST)ALDACTAZIDEamiloride hclamiloride/hydrochlorothiazideamiodarone hclamlodipine besylateTABSTABSTABSTABSTABSAMLODIPINE BESYLATE/ATORVASTATIN CALCIUM TABS (QL) (ST)amlodipine besylate/benazepril hclCAPS[MPC031203] Page 23 of 48 August 15, 2013

Drug Name Dosage Form Noteamlodipine besylate/benazepril hydrochlorideatenololCAPSTABSatorvastatin calcium TABS (QL) (ST)benazepril hclbenazepril hcl/hydrochlorothiazidebetaxolol hclbisoprolol fumaratebisoprolol fumarate/hydrochlorothiazidebumetanideTABSTABSTABSTABSTABSTABScandesartan cilexetil TABS (ST)candesartan cilexetil/hydrochlorothiazide TABS (ST)captoprilCAPTOPRIL/HYDROCHLOROTHIAZIDEcartia xtcarvedilolCHLORTHALIDONETABSTABSCP24TABSTABScholestyramine *cholestyramine light *clonidine hclTABSdigoxin *DIGOXIN *DILATRATE SRdilt-cddiltiazem cdCPCRCP24CP24diltiazem hcl *diltiazem hclCP24diltiazem hcl er *diltiazem hcl erdiltiazem hcl erdiltzacCP24CP24CP24DIOVAN TABS (ST)disopyramide phosphatedoxazosin mesylateDUTOPROLDYRENIUMEDECRINenalapril maleateenalapril maleate/hydrochlorothiazidefelodipine erfenofibratefenofibrate micronizedCAPSTABSTB24CAPSTABSTABSTABSTB24TABSCAPSFIRAZYR SOLN (PA) (SP)flecainide acetatefosinopril sodiumTABSTABS[MPC031203] Page 24 of 48 August 15, 2013

Drug Name Dosage Form Notefosinopril sodium/hydrochlorothiazideTABSFUROSEMIDE *furosemide *gemfibrozilguanfacine hclhydralazine hclTABSTABSTABShydrochlorothiazide *indapamideTABSISOSORBIDE DINITRATE *isosorbide dinitrate *isosorbide dinitrate erisosorbide mononitrateisosorbide mononitrate erlabetalol hcllisinoprillisinopril/hydrochlorothiazidelosartan potassiumlosartan potassium/hydrochlorothiazidelovastatinmethyldopametolazonemetoprolol succinate ermetoprolol tartratemetoprolol/hydrochlorothiazidemexiletine hclmidodrine hclminoxidilmoexipril hclmoexipril/hydrochlorothiazideTBCRTABSTB24TABSTABSTABSTABSTABSTABSTABSTABSTB24TABSTABSCAPSTABSTABSTABSTABSMULTAQ TABS (PA) (QL)nadololNIASPANnifediac ccnifedical xlnifedipinenifedipine ernimodipineNISOLDIPINENITRO-BIDNITRO-DURnitroglycerin ernitroglycerin transdermal (0.1mg/hr)nitroglycerin transdermal (0.2mg/hr)nitroglycerin transdermal (0.4mg/hr)TABSTBCRTB24TB24CAPSTB24CAPSTB24OINTPT24CPCRPT24PT24PT24[MPC031203] Page 25 of 48 August 15, 2013

Drug Name Dosage Form Notenitroglycerin transdermal (0.6mg/hr)NITROSTATNORPACE CRpaceronepentoxifylline erPINDOLOLpravastatin sodiumprazosin hclprevalitepropafenone hclPT24SUBLCP12TABSTBCRTABSTABSCAPSPOWDTABSpropranolol hcl *PROPRANOLOL HCL *propranolol hcl erquinapril hclquinapril/hydrochlorothiazidequinidine gluconate erquinidine sulfateramiprilCP24TABSTABSTBCRTABSCAPSRANEXA TB12 (ST)SIMCOR TB24 (ST)simvastatinsotalol hclsotalol hcl (af)spironolactonespironolactone/hydrochlorothiazidetaztia xtterazosin hclTIMOLOL MALEATETABSTABSTABSTABSTABSCP24CAPSTABStriamterene/hydrochlorothiazide *valsartan/hydrochlorothiazide TABS (ST)verapamil hclVERAPAMIL HCLTABSTABSverapamil hcl er *verapamil hcl srCP24VYTORIN TABS (ST)WELCHOL *ZETIATABSCentral Nervous System AgentsDrug Name Dosage Form Noteamphetamine/dextroamphetamine CP24 (AG) (QL) (ST)[MPC031203] Page 26 of 48 August 15, 2013

Drug Name Dosage Form Noteamphetamine/dextroamphetamine (1.25mg; 1.25mg; TABS1.25mg; 1.25mg)amphetamine/dextroamphetamine (1.875mg; 1.875mg; TABS1.875mg; 1.875mg)amphetamine/dextroamphetamine (2.5mg; 2.5mg; 2.5mg; TABS2.5mg)amphetamine/dextroamphetamine (3.125mg; 3.125mg; TABS3.125mg; 3.125mg)amphetamine/dextroamphetamine (3.75mg; 3.75mg; TABS3.75mg; 3.75mg)amphetamine/dextroamphetamine (5mg; 5mg; 5mg; 5mg) TABS(AG) (QL)(AG) (QL)(AG) (QL)(AG) (QL)(AG) (QL)(AG) (QL)amphetamine/dextroamphetamine (7.5mg; 7.5mg; 7.5mg; TABS(AG) (QL)7.5mg)AMPYRA TB12 (PA) (QL) (SP)AVONEX KIT (SP)butalbital/acetaminophen/caffeine/codeine CAPS (QL)butalbital/asa/caffeinebutalbital/aspirin/caffeie/codeineBUTALBITAL/ASPIRIN/CAFFEINEcaffeine citrateCAPSCAPSTABSSOLNCOPAXONE KIT (SP)CYMBALTA (20MG) CPEP (PA) (QL)CYMBALTA (30MG) CPEP (PA) (QL)CYMBALTA (60MG) CPEP (PA) (QL)dextroamphetamine sulfate TABS (AG) (QL)dextroamphetamine sulfate er CP24 (AG) (QL)EXTAVIA SOLR (PA) (SP)LYRICA (100MG) CAPS (PA) (QL)LYRICA (150MG) CAPS (PA) (QL)LYRICA (200MG) CAPS (PA) (QL)LYRICA (225MG) CAPS (PA) (QL)LYRICA (25MG) CAPS (PA) (QL)LYRICA (300MG) CAPS (PA) (QL)LYRICA (50MG) CAPS (PA) (QL)LYRICA (75MG) CAPS (PA) (QL)methylphenidate hcl TABS (AG) (QL)methylphenidate hcl cd CPCR (AG) (QL)METHYLPHENIDATE HCL ER (10MG) TBCR (AG) (QL)methylphenidate hcl er (18mg) TBCR (AG) (QL) (ST)methylphenidate hcl er (20mg) TBCR (AG) (QL)methylphenidate hcl er (27mg) TBCR (AG) (QL) (ST)methylphenidate hcl er (36mg) TBCR (AG) (QL) (ST)methylphenidate hcl er (54mg) TBCR (AG) (QL) (ST)REBIF SOLN (PA) (SP)REBIF TITRATION PACK SOLN (PA) (SP)STRATTERA CAPS (QL) (ST)[MPC031203] Page 27 of 48 August 15, 2013

Drug Name Dosage Form NoteCLARAVIS CAPS (QL)clindamax *clindamycin phosphate *clobetasol propionate *clobetasol propionate eCREAclotrimazole/betamethasone dipropionate *cormax scalp applicationSOLNcortaid intensive therapycooling spray SOLN (OTC)CORTISPORINCREAdesonide *ELIDEL CREA (PA)ERYTHROMYCIN *erythromycin *erythromycin/benzoyl peroxideFINACEAGELGELfluocinolone acetonide *fluocinolone acetonidefluocinolone acetonide bodyfluocinolone acetonide scalpOILOILOILfluocinonide *fluorouracil *fluticasone propionate *hydrocortisone *hydrocortisone * (OTC)hydrocortisone valerate *imiquimod CREA (QL)lanacort 10 CREA (OTC)lidocaine hcl/hydrocortisone acetatelokaraCREALOTNmometasone furoate *NOVACORTOXSORALEN ULTRAGELCAPSpanoxyl wash LIQD (OTC)podofiloxproctocream hcproctosol hcSOLNCREACREAPROTOPIC OINT (PA) (QL)rosanil cleanserselenium sulfideEMULLOTNSODIUM SULFACETAMIDE/SULFUR *sodium sulfacetamide/sulfur *sodium sulfacetamide/sulfurCREAsotret CAPS (QL)sulfacetamide sodium/sulfur cleanserEMUL[MPC031203] Page 29 of 48 August 15, 2013

Drug Name Dosage Form Notetretinoin CREA (AG)tretinoin GEL (AG)TRIAMCINOLONE ACETONIDE *triamcinolone acetonide *TRIANEXOINTEnzyme Replacement/ModifiersDrug Name Dosage Form NoteCREONPANCREAZECPEPCPEPGastrointestinal AgentsDrug Name Dosage Form NoteACIPHEX TBEC (QL) (ST)CARAFATEcimetidinecimetidine hclCOLYTE-FLAVOR PACKSconstuloseSUSPTABSSOLNSOLRSOLNDICYCLOMINE HCL *dicyclomine hcl *diocto SYRP (OTC)DIPHENOXYLATE/ATROPINELIQDdocusate sodium * (OTC)famotidine *glycopyrrolate *GOLYTELYSOLRhyoscyamine sulfate *hyoscyamine sulfate erISOPTO HYOSCINElactuloselactuloseTB12SOLNSOLNSOLNlansoprazole CPDR (QL) (ST)LINZESS CAPS (PA) (QL)LOTRONEXTABSmetoclopramide hcl *misoprostolomeprazoleTABSCPDRomeprazole/sodium bicarbonate CAPS (QL) (ST)pantoprazole sodium TBEC (QL)[MPC031203] Page 30 of 48 August 15, 2013

Drug Name Dosage Form Notepeg 3350/electrolytespeg-3350/electrolytespolyethylene glycol 3350SOLRSOLRPOWDPREVACID SOLUTAB TBDP (PA)PROPANTHELINE BROMIDETABSranitidine hcl *senna lax TABS (OTC)sucralfateTABSursodiol *XIFAXAN TABS (PA) (QL)ZEGERID PACK (QL) (ST)Genitourinary AgentsDrug Name Dosage Form NoteAVODART CAPS (ST)bethanechol chlorideCUPRIMINEDEPEN TITRATABSDETROL LAdoxazosin mesylateTABSCAPSTABSCP24TABSENABLEX TB24 (ST)finasterideTABSoxybutynin chloride *oxybutynin chloride erphenazopyridine hclprazosin hclRENAGELRENVELAtamsulosin hclterazosin hcltolterodine tartrateTB24TABSCAPSTABSTABSCAPSCAPSTABStrospium chloride TABS (ST)VESICARE TABS (ST)Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)Drug Name Dosage Form Notea-hydrocortalclometasone dipropionateSOLROINTaugmented betamethasone dipropionate *betamethasone dipropionate *[MPC031203] Page 31 of 48 August 15, 2013

Drug Name Dosage Form Notebetamethasone valerate *clobetasol propionate *clobetasol propionate eCREAclotrimazole/betamethasone dipropionate *cormax scalp applicationSOLNcortaid intensive therapycooling spray SOLN (OTC)desonide *DEXAMETHASONE *dexamethasone *DEXAMETHASONE INTENSOLfludrocortisone acetateCONCTABSfluocinolone acetonide *fluocinolone acetonidefluocinolone acetonide bodyfluocinolone acetonide scalpOILOILOILfluocinonide *fluticasone propionate *hydrocortisoneENEMhydrocortisone * (OTC)hydrocortisoneTABShydrocortisone *hydrocortisone valerate *lanacort 10 CREA (OTC)lidocaine hcl/hydrocortisone acetatelokaraMEDROLmethylprednisolonemethylprednisolone dose packMILLIPREDMILLIPRED DPCREALOTNTABSTABSTABSTABSTABSmometasone furoate *prednisoloneprednisolone sodium phosphateSOLNSOLNPREDNISONE *prednisone *proctocream hcproctosol hcSOLU-CORTEFCREACREASOLRTRIAMCINOLONE ACETONIDE *triamcinolone acetonide *TRIANEXOINTHormonal Agents, Stimulant/Replacement/Modifying (Pituitary)[MPC031203] Page 32 of 48 August 15, 2013

Drug Name Dosage Form NoteDrug Name Dosage Form Notedesmopressin acetatedesmopressin acetatedesmopressin acetateSOLNTABSSOLNINCRELEX SOLN (PA) (SP)NORDITROPIN FLEXPRO SOLN (PA) (SP)NORDITROPIN NORDIFLEX PEN SOLN (PA) (SP)OMNITROPE SOLN (PA) (SP)TEV-TROPIN SOLR (PA) (SP)Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)Drug Name Dosage Form NotemisoprostolTABSHormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)Drug Name Dosage Form NoteALORA PTTW (QL)altaveraalyacen 1/35TABSTABSANDRODERM (2MG/24HR) PT24 (PA) (QL)ANDRODERM (4MG/24HR) PT24 (PA) (QL)ANDROGEL (25MG/2.5GM) GEL (PA) (QL)ANDROGEL (50MG/5GM) GEL (PA) (QL)ANDROGEL PUMP (1%) GEL (PA) (QL)ANDROGEL PUMP (1.62%) GEL (PA) (QL)ANDROXY TABS (PA)apriaranelleavianeazurettebalzivacamilacaziantcesiaTABSTABSTABSTABSTABSTABSTABSTABSCOMBIPATCH PTTW (ST)cryselle-28cyclafem 1/35cyclafem 7/7/7danazolTABSTABSTABSCAPS[MPC031203] Page 33 of 48 August 15, 2013

Drug Name Dosage Form Notedrospirenone/ethinyl estradiolemoquetteenpresse-28enskyceerrinESTRACETABSTABSTABSTABSTABSCREAestradiol *estradiol/norethindrone acetateESTROPIPATEestropipateEVISTATABSTABSTABSTABSFORTESTA GEL (PA) (QL)gildess fe 1.5/30gildess fe 1/20heatherJINTELIjolivettejunel 1.5/30junel 1/20junel fe 1.5/30junel fe 1/20karivakelnor 1/35kurveloleenalessinaTABSTABSTABSTABSTABSTABSTABSTABSTABSTABSTABSTABSTABSTABSlevonorgestrel TABS (QL)levora 0.15/30-28LOESTRIN 24 FElow-ogestrelluteramarlissamedroxyprogesterone acetatemedroxyprogesterone acetateTABSTABSTABSTABSTABSSUSPTABSMEGACE ES SUSP (PA)megestrol acetate *MENESTmicrogestin 1.5/30microgestin 1/20microgestin femicrogestin fe 1.5/30mimveymononessanecon 0.5/35-28TABSTABSTABSTABSTABSTABSTABSTABS[MPC031203] Page 34 of 48 August 15, 2013

Drug Name Dosage Form Notenecon 1/35NECON 1/50-28necon 7/7/7NEXPLANONTABSTABSTABSIMPLnext choice TABS (QL)nora-benorethindronenorethindrone acetatenorgestimate/ethinyl estradiolnorgestimate/ethinyl estradiolnortrel 0.5/35 (28)nortrel 1/35nortrel 7/7/7ocellaorsythiaORTHO TRI-CYCLEN LOortho-estphilithpirmella 1/35pirmella 7/7/7portia-28PREFESTPREMARINPREMARINPREMPHASEPREMPROprevifemprogesteronereclipsensoliasprintec 28sronyxsyedaTABSTABSTABSTABSTABSTABSTABSTABSTABSTABSTABSTABSTABSTABSTABSTABSTABSTABSCREATABSTABSTABSCAPSTABSTABSTABSTABSTABSTESTIM GEL (PA) (QL)TESTOPEL PLLT (PA) (QL)testosterone cypionate OIL (PA)testosterone enanthate OIL (PA)tilia fetri-legest fetri-linyahtri-previfemtri-sprintectrinessatrivora-28TABSTABSTABSTABSTABSTABSTABS[MPC031203] Page 35 of 48 August 15, 2013

Drug Name Dosage Form NotevelivetTABSVIVELLE-DOT PTTW (QL)zarahzenchentzovia 1/35eZOVIA 1/50ETABSTABSTABSTABSHormonal Agents, Stimulant/Replacement/Modifying (Thyroid)Drug Name Dosage Form Notelevothroidlevothyroxine sodiumlevoxylliothyronine sodiumnp thyroid 30np thyroid 60np thyroid 90unithroidWESTHROIDTABSTABSTABSTABSTABSTABSTABSTABSTABSHormonal Agents, Suppressant (Adrenal)Drug Name Dosage Form NoteLYSODRENTABSHormonal Agents, Suppressant (Parathyroid)Drug Name Dosage Form NoteSENSIPAR TABS (PA)Hormonal Agents, Suppressant (Pituitary)Drug Name Dosage Form Notebromocriptine mesylate *ELIGARD KIT (SP)ELIGARD KIT (SP)ELIGARD KIT (SP)ELIGARD KIT (SP)leuprolide acetateLUPRON DEPOT-PEDKITKIT[MPC031203] Page 36 of 48 August 15, 2013

Drug Name Dosage Form NoteZOLADEXIMPLHormonal Agents, Suppressant (Sex Hormones/Modifiers)Drug Name Dosage Form NoteAVODART CAPS (ST)bicalutamide TABS (ST)finasterideflutamideTABSCAPSXTANDI CAPS (PA) (QL) (SP)Hormonal Agents, Suppressant (Thyroid)Drug Name Dosage Form NotemethimazolepropylthiouracilTABSTABSImmunological AgentsDrug Name Dosage Form NoteACTIMMUNE SOLN (SP)AVONEX KIT (SP)azathioprineTABSBENLYSTA SOLR (PA)BIVIGAM SOLN (PA)CARIMUNE NANOFILTEREDCELLCEPTCUPRIMINEcyclosporineSOLRSUSRCAPSCAPSCYCLOSPORINE MODIFIED *cyclosporine modified *cyclosporine modified (100mg/ml)cyclosporine modified (100mg/ml)SOLNSOLNCYTOGAM INJ (PA)DEPEN TITRATABSTABSELIDEL CREA (PA)ENBREL * (PA) (SP)EXTAVIA SOLR (PA) (SP)FLEBOGAMMA SOLN (PA)FLEBOGAMMA DIF SOLN (PA)GAMASTAN S/D INJ (PA)[MPC031203] Page 37 of 48 August 15, 2013

Drug Name Dosage Form NoteGAMMAGARD LIQUID SOLN (PA)GAMMAGARD S/D SOLR (PA)GAMMAGARD S/D IGA LESS THAN 1MCG/ML SOLR (PA)GAMMAPLEXSOLNGAMUNEX SOLN (PA)GAMUNEX-C SOLN (PA)gengraf *hecoriaCAPSHEPAGAM B SOLN (PA)HIZENTRA SOLN (PA) (SP)HUMIRA KIT (PA) (SP)leflunomidemercaptopurinemethotrexateTABSTABSTABSmethotrexate sodium *mycophenolate mofetil *ORENCIA * (PA) (SP)PRIVIGEN SOLN (PA)PROTOPIC OINT (PA) (QL)PROVENGESUSPREBIF SOLN (PA) (SP)REBIF TITRATION PACK SOLN (PA) (SP)REMICADE SOLR (PA) (SP)RIDAURASANDIMMUNESYNAGIStacrolimusTREXALLCAPSSOLNSOLNCAPSTABSTYSABRI CONC (PA) (SP)ZOSTAVAX SOLR (AG)Inflammatory Bowel Disease AgentsDrug Name Dosage Form Notea-hydrocortSOLRAPRISO CP24 (QL) (ST)ASACOL TBEC (ST)balsalazide disodiumCANASACAPSSUPPDEXAMETHASONE *dexamethasone *DEXAMETHASONE INTENSOLhydrocortisoneCONCENEM[MPC031203] Page 38 of 48 August 15, 2013

Drug Name Dosage Form NotehydrocortisoneMEDROLmesalaminemesalaminemethylprednisolonemethylprednisolone dose packMILLIPREDMILLIPRED DPTABSTABSENEMKITTABSTABSTABSTABSPENTASA CPCR (ST)prednisoloneprednisolone sodium phosphateSOLNSOLNPREDNISONE *prednisone *SOLU-CORTEFSOLRsulfasalazine *Metabolic Bone Disease AgentsDrug Name Dosage Form Notealendronate sodiumALENDRONATE SODIUMcalcitonin-salmonTABSTABSSOLNcalcitriol *FORTEO SOLN (PA) (SP)HECTOROLCAPSibandronate sodium TABS (QL) (ST)PROLIA SOLN (PA) (SP)XGEVA SOLN (PA) (SP)zoledronic acid * (MB) (PA)Miscellaneous Therapeutic AgentsDrug Name Dosage Form NoteACCU-CHEK ACTIVE STRIPS STRP (QL)ACCU-CHEK AVIVA STRP (QL)ACCU-CHEK COMFORT CURVE TEST STRIPS STRP (QL)ACCU-CHEK COMPACT STRIPS STRP (QL)ASSESS PEAK FLOW METER LOW RANGEBD INSULIN SYRINGESBD PEN NEEDLESDEVIMISCMISCBOTOX SOLR (PA)EUFLEXXA SOLN (SP)[MPC031203] Page 39 of 48 August 15, 2013

Drug Name Dosage Form NoteKALBITOR SOLN (PA)methylergonovine maleateNOVOFINE PEN NEEDLESNOVOTWIST PEN NEEDLESTABSMISCMISCSYNVISC INJ (SP)SYNVISC ONE INJ (SP)Ophthalmic AgentsDrug Name Dosage Form NoteacetazolamideACETAZOLAMIDEacetazolamide erALPHAGAN PTABSTABSCP12SOLNALREX SUSP (ST)ATROPINE SULFATE *atropine sulfate *AZOPTbetaxolol hclBETOPTIC-SBLEPHAMIDEBLEPHAMIDE S.O.P.brimonidine tartratecarteolol hclSUSPSOLNSUSPSUSPOINTSOLNSOLNCIPRODEX SUSP (AG) (PA) (QL)cromolyn sodiumdexamethasone sodium phosphatediclofenac sodiumdorzolamide hclfluorometholoneFMLFML FORTEhomatropaireISOPTO CARBACHOLISOPTO HOMATROPINEketorolac tromethamineketotifen fumaratelatanoprostLEVOBUNOLOL HCLlevobunolol hclSOLNSOLNSOLNSOLNSUSPOINTSUSPSOLNSOLNSOLNSOLNSOLNSOLNSOLNSOLNLOTEMAX SUSP (ST)LUMIGANSOLN[MPC031203] Page 40 of 48 August 15, 2013

Drug Name Dosage Form NotemethazolamideNAPHCON-Aneomycin/polymyxin/bacitracin/hydrocortisoneTABSSOLNOINTneomycin/polymyxin/dexamethasone *OPCON-Aphenylephrine hclSOLNSOLNphenylephrine hcl SOLN (OTC)PHOSPHOLINE IODIDEpilocarpine hclPRED MILDprednisolone acetatePREDNISOLONE SODIUM PHOSPHATESOLRSOLNSUSPSUSPSOLNRESTASIS EMUL (PA)timolol maleatetimolol maleate ophthalmic gel formingtropicamideSOLNSOLGSOLNOtic AgentsDrug Name Dosage Form Noteacetic acidACETIC ACID/ALUMINUM ACETATEantipyrine/benzocaineCOLY-MYCIN Shydrocortisone/acetic acidneomycin/polymyxin/hydrocortisoneNEOMYCIN/POLYMYXIN/HYDROCORTISONEneomycin/polymyxin/hydrocortisoneSOLNSOLNSOLNSUSPSOLNSOLNSUSPSUSPRespiratory Tract AgentsDrug Name Dosage Form NoteacetylcysteineSOLNADVAIR DISKUS AEPB (PA) (QL)ADVAIR HFA AERO (PA) (QL)albuterol sulfate *albuterol sulfate erTB12ALLEGRA ALLERGY CHILDRENS TABS (OTC)ALLEGRA ALLERGY CHILDRENS SUSP (OTC)allergy relief TBDP (OTC)ASMANEX 30 METERED DOSESASMANEX 60 METERED DOSESAEPBAEPB[MPC031203] Page 41 of 48 August 15, 2013

Drug Name Dosage Form NoteATROVENT HFAAUVI-QAERSDEVIazelastine hcl SOLN (PA)broncho saline AERS (OTC)budesonide SUSP (AG)cetirizine hcl * (OTC)cetirizine hcl childrens allergy SYRP (OTC)childrens loratadine SYRP (OTC)COMBIVENTAEROCOMBIVENT RESPIMAT AERS (QL)cromolyn sodium AERS (OTC)cromolyn sodiumNEBUcyproheptadine hcl *DALIRESP TABS (PA) (QL)DULERA AERO (ST) (QL)ELIXOPHYLLINELIXfexofenadine hcl TABS (OTC)FLOVENT DISKUSFLOVENT HFAFLUNISOLIDEfluticasone propionateFORADIL AEROLIZERAEPBAEROSOLNSUSPCAPShydroxyzine hcl *hydroxyzine pamoateHYDROXYZINE PAMOATEipratropium bromideipratropium bromideipratropium bromide/albuterol sulfateCAPSCAPSSOLNSOLNSOLNLETAIRIS TABS (PA) (QL) (SP)loratadine TABS (OTC)METAPROTERENOL SULFATE *micronefrin NEBU (OTC)montelukast sodium * (QL)phenadozPROAIR HFASUPPAERSpromethazine hcl *promethazine hcl plainPROMETHEGANPULMICORT FLEXHALERPULMOZYMEQVARSEREVENT DISKUSSYRPSUPPAEPBSOLNAERSAEPBsildenafil citrate TABS (PA) (QL)sodium chloride (0.9%)NEBU[MPC031203] Page 42 of 48 August 15, 2013

Drug Name Dosage Form Notesodium chloride (7%)SPIRIVA HANDIHALERNEBUCAPSSYMBICORT (160MCG/ACT; 4.5MCG/ACT) AERO (QL) (ST)SYMBICORT (80MCG/ACT; 4.5MCG/ACT) AERO (QL) (ST)terbutaline sulfatetheophylline crTABSTB12theophylline er *triamcinolone acetonideTUDORZA PRESSAIRVENTOLIN HFAINHAAEPBAERSXOLAIR SOLR (PA) (SP)zafirlukastTABSSkeletal Muscle RelaxantsDrug Name Dosage Form Notecarisoprodolcarisoprodol/aspirincarisoprodol/aspirin/codeinechlorzoxazonecyclobenzaprine hclmethocarbamolTABSTABSTABSTABSTABSTABSSleep Disorder AgentsDrug Name Dosage Form NoteLUNESTA TABS (PA) (QL)modafinil TABS (PA) (QL)PHENOBARBITAL *phenobarbital *ROZEREM TABS (PA) (QL)temazepam CAPS (QL)triazolam TABS (QL)XYREMSOLNzaleplon CAPS (QL)zolpidem tartrate TABS (QL)zolpidem tartrate er TBCR (PA) (QL)Therapeutic Nutrients/Minerals/ElectrolytesDrug Name Dosage Form Note[MPC031203] Page 43 of 48 August 15, 2013

Drug Name Dosage Form Notecalciferol SOLN (OTC)calcium acetateCAPScalcium/vitamin d TABS (OTC)calcium/vitamin d TABS (OTC)clinpro 5000CUPRIMINEcytra-2DEPEN TITRATABSPSTECAPSSOLNTABSdexferrum SOLN (PA)dialyviteeffervescent potassiumTABSTBEFferosul ELIX (AG)FERRLECIT SOLN (PA)FERROUS GLUCONATE TABS (OTC)ferrous gluconate TABS (OTC)ferrous gluconate iron TABS (OTC)FERROUS SULFATE SYRP (AG)FLUORABON SOLN (AG)FLURA-DROPS SOLN (AG)flura-drops SOLN (AG)folic acidgildess fe 1.5/30gildess fe 1/20TABSTABSTABSinfed SOLN (PA)junel fe 1.5/30junel fe 1/20TABSTABSK-BICARB CAPS (OTC)kalexatePOWDkionex *klor-conklor-con 10KLOR-CON 25klor-con 8klor-con m10KLOR-CON M15klor-con m20klor-con/efLOESTRIN 24 FEPACKTBCRPACKTBCRTBCRTBCRTBCRTBEFTABSLOZI-FLUR LOZG (AG)MEPHYTONmicrogestin femicrogestin fe 1.5/30multi-vit/fluoridemulti-vit/iron/fluorideTABSTABSTABSSOLNSOLN[MPC031203] Page 44 of 48 August 15, 2013

Drug Name Dosage Form Notemultivitamins/fluorideMYNATALnephronexCHEWCAPSTABSniacin TABS (OTC)niacin er CPCR (OTC)niacin sr TBCR (OTC)NIACIN TR TBCR (OTC)niacin tr TBCR (OTC)NIACORORACITTABSSOLNoyster shell calcium/vitamin d TABS (OTC)phos-flurPHOSLYRAphospha 250 neutralpotassium chloridePOTASSIUM CHLORIDEGELSOLNTABSLIQDLIQDpotassium chloride er *potassium chloride erPOTASSIUM CITRATETBCRTBCRrena-vite TABS (OTC)rena-vite rxrenalrenalprenreno capsTABSCAPSCAPSCAPSs.s.s. tonic LIQD (OTC)sfGELsodium ferric gluconate complex/sucrose SOLN (PA)sodium fluoride * (AG)strovite plusTABSsuper b-complex/vitamin c TABS (OTC)tilia fetri-legest fetriphrocapsUROCIT-K 15TABSTABSCAPSTBCRVENOFER SOLN (PA)vitamin dvol-care rxCAPSTABSUnClassifiedDrug Name Dosage Form NoteADCETRIS SOLR (PA)CHEMSTRIP UGKSTRP[MPC031203] Page 45 of 48 August 15, 2013

Drug Name Dosage Form NoteFERAHEME SOLN (PA)MCT OIL OIL (OTC)PRECISION XTRASTRPPlease see following page for disclaimer and explanation of terms.[MPC031203] Page 46 of 48 August 15, 2013

DISCLAIMERPlease be sure a prescription drug benefit is part of your specific coverage beforeconsulting this list. If you do not know which list is correct, please contact thePresbyterian Customer Service Center at (505) 923-5200 or toll-free at 1-888-977-2333,Monday through Friday from 7:00 a.m. to 6:00 p.m. TTY users may call 1-888-872-7568.Coverage for some drugs may be limited to specific dosage forms and/or strengths.Your benefit design determines what is covered for you and what your copayment willbe. Please refer to your benefit materials for your specific coverage information.The medications listed on this Formulary/Preferred Drug Listing (PDL) are subject tochange pursuant to the Formulary/PDL management activities of Presbyterian HealthPlan. This list is not all-inclusive nor does it imply a guarantee of coverage. In addition,coverage for some drugs listed may be limited to specific dosage forms and/orstrengths. Substitution of a generic product for a brand-name drug is mandatory when ageneric equivalent is available. If a member requests the brand-name drug in thissituation, a Prior Authorization may be required and the member must pay thedifference in cost between the generic and branded versions. Non-formularymedications are not considered for coverage unless trial and failure of formularyalternatives are documented.Explanation of Terms in your FormularyYou may see these indicators next to some drug names:Explanation of Terms in your Formulary1. Age Limitation (AG) -- a coverage limit based on minimum or maximum age of themember imposed as a result of safety, efficacy or dosage form considerations.2. Generics preferred/Generic equivalent available (GP -- if there is a genericavailable and the patient receives the brand name product, the patient pays the copayfor the generic drug plus the difference in cost between the brand and the generic.3. Medical Drugs (MED) -- Medications obtained through the medical benefit. Medicaldrugs are defined as medications administered in the office or facility that require ahealth care professional to administer. These medications include, but are not limited to,injectable, infused, oral or inhaled drugs. They may involve unique distribution and maybe provided by a specialty pharmacy vendor. Some Medical Drugs may require BenefitCertification before they can be obtained. Office administered applies to all outpatientsettings including, but are not limited to, physician's offices, emergency rooms, urgentcare facilities and outpatient surgery facilities. For a complete list of Medical Drugs andto determine which require Benefit Certification please see the Presbyterian Pharmacyweb site at: http://www.phs.org/PHS/programs/pharmacy/formulary/index.htm4. Prior Authorization (PA) -- a drug that requires prior approval before the Plan willcover it, and when the patient meets the established criteria. The doctor must submit a[MPC031203] Page 47 of 48 August 15, 2013

Pharmacy Prior Authorization Form. The doctor can submit the request by fax, phone,or regular mail.5. Quantity Limit (QL) -- a coverage limit on the medication quantity covered for adefined days' supply (usually 30 or 90 days) based on safety, efficacy and/or doseoptimization issues.6. Specialty (SP) -- Tier 4 medications obtained through the pharmacy benefit. Tier 4medications are defined as high cost (greater than $600 per 30 day supply) injectable,infused, oral or inhaled drugs that generally require complex care and supervision.These medications involve unique distribution and are usually provided by a specialtypharmacy vendor. Specialty pharmaceuticals are self-administered, meaning they areadministered by the patient or to the patient by a family member or caregiver. Nonformularymedications, when approved by prior authorization, may be subject tospecialty pharmacy requirements.7. Step Edit (ST) -- a drug that requires a prescription history of specific drugs in thepharmacy claims or data system, and these specific drugs must be taken during a giventime frame. After the specific drugs have been taken within the given time frame, onlinecoverage of the newly-prescribed drug occurs at the pharmacy. Step Edits make iteasier to access drugs that would normally require a Prior Authorization.8. Medical Exception -- a drug that is not on the Plan’s formulary. Non-formularydrugs require an Exception to the formulary due to allergy, adverse reactions, or noresponse to all formulary drugs.[MPC031203] Page 48 of 48 August 15, 2013