1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797

© PRAM INSURANCE SERVICES, INC.PG 1 OF 11

2021 RxBALANCE “SIGNATURE” FORMULARYThe following list contains both brand and generic drugs that are available to members

of the RxBalance Prescription Plan. The BRAND name drugs (listed in all CAPS) and generic drugs (listed in lower case) are available at a copay up to the monthly maximum benefit of

the plan. All drugs not contained on this list are not eligible for the copay benefit, however, are eligible at PRAM’s discounted rate. Please refer to your benefit materials for Limitations and

Exclusions; Quantity Limits per copay may apply to certain medications. This list is continually evaluated and changes can occur at any time. Please contact PRAM to confirm the most current drug

list. We encourage you to share this list with your physician at the time of your treatment.

*ONLY THOSE BRAND NAME DRUGS SHOWN IN ALL CAPS ARE COVERED UNDER THIS FORMULARY, ALL OTHER BRAND NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE COVERED GENERIC.

Category Covered Generic Name Brand Name*Anti-Infective Antibiotics Cephalosporins cefaclor Ceclor

cefadroxil Duricefcefdinir Omnicefcefpodoxime Vantincefprozil Cefzilcephalexin Keflex

Erythromycins & Other Macrolides

azithromycin Zithromax / Z-PAKclarithromycin Biaxin, Biaxin XLerythromycin base Ery-Tab, E-Mycinerythromycin ethylsuccinate EES, EryPed

Penicilins amoxicillin Amoxilamoxicillin / pot. Clav Augmentindicloxacillin Dicloxacillinpenicillin VK Pen-Vee K

Quinolones ciprofloxacin Ciprolevofloxacin Levaquinmoxifloxacin Aveloxofloxacin Floxin

Tetracyclines doxycycline Vibramycinminocycline Minocin

Antifungals clotrimazole Mycelexclotrimazole / betamethasone Lotrisoneeconazole Spectazolefluconazole Diflucangriseofulvin Gris-PEG / Grifulvinketoconazole Nizoralmetronidazole Flagylnystatin oral Mycostatinterbinafine Lamisiltolnaftate

Antifungals - (Vaginal) clotrimazole Mycelex-7fluconazole Diflucanmiconazole Monistat

Antihelminics mebendazole VermoxAnti-Infective SpecializedIndications

chloroquine phosphate Aralenethambutol HCI Myambutolhydroxychloroquine Plaquenilmebendazole Vermoxneomycinpyrazinamidethiabendazole Mintezol

1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797

© PRAM INSURANCE SERVICES, INC.PG 2 OF 11

Category Covered Generic Name Brand Name*Anti-Infective(cont.)

Antineoplastic/Immunosuppresants

azathioprine Imuranflutamide Eulexinhydroxyurea Hydrealeucovorin Wellcovorinmegestrol Megacemethotrexatetamoxifen Nolvadex

Anti-Tubercular ethambutol MyambutolAntivirals acyclovir Zovirax

amantadine Symmetrelnevirapine Viramumerimantadine Flumadinezidovudine Retrovir

OtherAnti-Infectives

clindamycin HCI Cleocinisoniazid Nydrazidmethenamine Urexmethanamine/ sod bis/ phenyl salicyl/ methylene blue / hyos

Urimax

nitrofurantoin Macrodantin/ Macrobidrifampin Rifadinsulfadiazinetrimethoprim Trimpex

Topical Antibacterial silver sulfadiazine SilvadeneTopical Antifungals ciclopirox Loprox

ketoconazole Nizoralnystatin / triaminolone Mycolog

Autonomicand CentralNervousSystem

Analgesics, Antimigrainal

pentazocine / naloxone Talacen / Talwin NXsumatriptan Imitrextramadol Ultram

Analgesics, Narcotics APAP / codeine Tylenol w/ CodeineAPAP / hydrocodone Vicodin / NorcoASA / codeine Empirin w/ Codeinebuprenorphine HCL/ Naloxone HCL Suboxonebuprenorphine HCI Subutexbutalbital/ acetaminophen Phrenlin, Sedapapbutalbital/ acetaminophen/ caffeine Floricetbutorphanol Stadol NScodeine sulfatehydrocodone/ ibuprofen Vicoprofenlevorphanolmeperidine Demerolmepiridine/ promethazine Meperganmorphine sulfate MSIR, MSContinoxycodone OxyIRoxycodone/ APAP Percocetoxycodone/ ASA Percodan

*ONLY THOSE BRAND NAME DRUGS SHOWN IN ALL CAPS ARE COVERED UNDER THIS FORMULARY, ALL OTHER BRAND NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE

COVERED GENERIC.

2021 RxBALANCE “SIGNATURE” FORMULARY

1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797

© PRAM INSURANCE SERVICES, INC.PG 3 OF 11

Category Covered Generic Name Brand Name*Autonomicand CentralNervousSystem (cont.)

Analgesics, Non-SteroidalAnti-Inflammatory

diclofenac potassium Cataflamdiclofenac sodium Voltaren XRdiflunisal Dolobidetodolac Lodineibuprofen Motrinindomethacin Indocinketorolac Toradolmeloxicam Mobicnabumetone Relafennaproxen Naprosynoxaprozin Daypropiroxicam Feldenetolmetin Tolectin/ DS

Anticonvulsants PEGANONEcarbamezepine Tegretolclorazepate Tranxenedivalproex NA Depakote Sprinkle/ Depakote ERethosuximide Zarontingabapentin Neurontinlithium carbonatephenobarbitalphenytoin/ pheyntoin extended Dilantinprimidone Mysoline

topiramate Topamaxvolproic acid/ valproate sodium Depakene/ Depakote

Antiparkinsons amantadine Symmetrelbenzatropine mesylate Cogentinbromocriptine Parlodelcarbidopa/ levodopa Sinemet/ Sinemet CRropinirole HCI Requipselegiline Eldepryltrihexyphenidyl Artane

Antipsychotics chlorpromazine Thorazineclozapine Clozarilfluphenazine Prolixinhaloperidol Haldolloxapine Loxitaneolanzapine Zyprexaperphenazinepimozide Orapquetiapine fumarate Seroquelrisperidone Risperdaltiagabine HCL Gabitrilthioridazine Mellarilthiothixene Navanetrifluoperazine Stelazinezonisamide Zonegran

*ONLY THOSE BRAND NAME DRUGS SHOWN IN ALL CAPS ARE COVERED UNDER THIS FORMULARY, ALL OTHER BRAND NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE

COVERED GENERIC.

2021 RxBALANCE “SIGNATURE” FORMULARY

1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797

© PRAM INSURANCE SERVICES, INC.PG 4 OF 11

*ONLY THOSE BRAND NAME DRUGS SHOWN IN ALL CAPS ARE COVERED UNDER THIS FORMULARY, ALL OTHER BRAND NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE

COVERED GENERIC.

Category Covered Generic Name Brand Name*Autonomicand CentralNervousSystem(cont.)

Antivertigo/ Antiemetics hydroxyzine Ataraxmeclizine HCI Antivertondansetron Zofranprochlorperazine Compazinepromethazine HCI Phenergan

promethazine HCI suppository, rectal

Phenergan

trimethobenzamide TiganAnxiolytics, Sedatives and Hypnotics

alprazolam Xanaxbuspirone Busparchloral hydrate Noctecchlordiazepoxide HCI Libriumclonazepam Klonopindiazepam Valiumestazolam Prosomfluzapam Dalmanelorazepam Ativanoxazepam Seraxtemapzepam Restoriltriazolam Halcionzolpidem tartrate Ambien

CNS Stimulants amphetamine / dextroamphetamine

Adderall

destroamphetamine Dexedrine / Destrostatmethylphenidate Ritalin / Methylinmemantine Namenda

Drugs to Prevent and Treat Gout allopurinol Zyloprimprobenecidsulfinpyrazone Anturane

Muscle Relaxants/ Antispasmodics baclofen Lioresalcarisoprodol Somacarisoprodol and aspirin Soma Compoundcarisoprodol, aspirin, codeine Soma Compound with Codeinechlorazoxazone Parafon Forte DSCcyclobenzaprine Flexerildantrolene Dantriummetaxalone Skelaxinmethocarbamol Robaxinorphenadrine / aspirin / caffeine Norgesictizanidine Zanaflex

Psychotherapeutics Antidepressants amitriphtyline Elavilamitriptyline / chlordiazepoxide Limbitrolamitriptyline / perphenazine Triavilamoxapine Asendinbupropion Wellbutrin & Wellbutrin SR, Wellbutrin XLcitalopram Celexaclomipramine Anafrildesirpramine Norpramin

2021 RxBALANCE “SIGNATURE” FORMULARY

1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797

© PRAM INSURANCE SERVICES, INC.PG 5 OF 11

Category Covered Generic Name Brand Name*Autonomicand CentralNervousSystem(cont.)

Psychotherapeutics(cont.)

Antidepressants(cont.)

doxepin Sinequanduloxetine Cymbalta

fluoxetine Prozacfluvoxamine Luvoximipramine Tofranilmaprotiline Ludiomilmirtazapine Remeronnefazodone Serzonenortriptyline Pamelorparoxetine Paxilsertraline Zolofttranylcypromine Parnatetrazodone Desyrelvenlafaxine HCI Effexor XR

Cardiovascular ACE Inhibitors benazepril Lotensincaptopril Capotenenalapril Vasotecfosinopril Monoprillisinopril Zestrilmoexipril Univascramipril Altacequinapril Accupril

Alpha Blockers doxazosin Carduraprazosin Minipressterazosin Hytrin

AngiotensinReceptor Blockers

irbesartan Avaprolosartan Cozaarolmesartan medoxomil Benicarvalsartan Diovan

Antiarrhythmics amiodarone Cordaronedisopyramide Norpacemexiletine Mexitilnitroglycerinprocainamide Procainamidepropafenone Rythmolquinidine

Beta-Adrenergic Antagonists

acebutolol Sectralatenolol Tenorminbetaxolol Kerlonebisoprolol Zebetacarvedilol Coreglabetolol Normodynemetoprolol Lopressormetoprolol succinate Toprol XLnadolol Corgardpindolol Viskenpropranolol Inderal

*ONLY THOSE BRAND NAME DRUGS SHOWN IN ALL CAPS ARE COVERED UNDER THIS FORMULARY, ALL OTHER BRAND NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE

COVERED GENERIC.

2021 RxBALANCE “SIGNATURE” FORMULARY

1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797

© PRAM INSURANCE SERVICES, INC.PG 6 OF 11

Category Covered Generic Name Brand Name*Cardiovascular(cont.)

Beta-Adrenergic Antagonists (cont.) sotalol Betapacetimolol Blocadren

Calcium Channel Blockers amlopidine Norvascdiltiazem Cardizem/ SR / Dilacor XRfelodipine Plendilisradipine Dynacircnicardipine Cardenenifedipine Procardia XLverapamil Calan SR / Isoptin SR

Cardiac Glycosides digoxin LanoxinCholesterol - Lowering atorvastatin Lipitor

cholestyramineezetimibe Zetiagemfibrozil Lopidlovastatin Mevacorniacinpravastatin Pravacholrosuvastatin Crestorsimvastatin Zocor

Diuretics amiloride / HCTZ Modureticbumetanide Bumexchlorthalidone Hygrotonfurosemide Lasixhydrochlorothiazideindapamide Lozolmethazolamidemetolazone Zaroxolynspironolactone Aldactonetorsemide Demadex

Diuretic Combinations atenolol / chlorthalidone Tenoreticbenazepril / hydrochlorthiazide Lotensin HCTbisoprolol / hydrochlorthiazide Ziaccaptopril / hydrochlorthiazide Capozidechlorothiazide Diurilenalapril / hydrochlorthiazide Vasoreticfosinopril / hydrochlorthiazide Monopril HCTlisinopril / hydrochlorthiazide Zestoreticmethyldopa / hydrochlorthiazide Aldorilmetoprolol / hydrochlorthiazide Lopress HCTpropranolol / hydrochlorthiazide Inderidequinapril / hydrochlorthiazide Accureticspironolactone / hydrochlorthiazide Aldactazidetriamterene / hydrochlorthiazide Dyazide

Other Antihypertensives clonidine Catapresguanfacine Tenexhydralazine Apresoline

*ONLY THOSE BRAND NAME DRUGS SHOWN IN ALL CAPS ARE COVERED UNDER THIS FORMULARY, ALL OTHER BRAND NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE

COVERED GENERIC.

2021 RxBALANCE “SIGNATURE” FORMULARY

1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797

© PRAM INSURANCE SERVICES, INC.PG 7 OF 11

Category Covered Generic Name Brand Name*Cardiovascular(cont.)

Other Antihypertensives(cont.)

methyldopa Aldometmidodrine ProAmatineminoxidil Lonitenquinine sulfate Qualaquinreserpine

Other Cardiovascular Drugs pentoxifylline TrentalVasodilating isosorbide dinitrate Isordil

isosorbide mononitrate Imdurisoxsuprine Vasodilan

Dermatologicals Anti-Acne benzoyl peroxide Triazclindamycin Celocin-T / Clindets Pledgetssulfacetamide Novacet / Sulfacet-R

Antipsoriasis selenium sulfide Exsel / SelsunOther Dermatological aluminum chloride Drysol

permethrin ElimiteTopical Corticosteroids alclometasone Aclovate

amcinonide Cyclocortaugmented betamethasone diproprionate

Diprosone, Maxivate

betamethasone valerate Valisoneclobetasol propionate Temovate/ Edesonide DesOwendesoximetasone Topicortdiflorasone diacetate CR Florone/ Efluocinaide Lidex-Efluocinolone acetonide Synalar / Derma SmootheFSfluticasone Cutivatehalobetsaol Ultravatemometasone furoate Eloconprednicarbate Dermatoptriamcinolone Aristocort

Ear, Nose & ThroatMedications

Drugs Affecting the Ear acetic acid VoSolacetic acid / aluminum acetate Domeboro Oticantipyrine / benzocaine Auralgan/ AB Otic Solutionhydrocortisone / acetic acid Acetasol HCneomycin / polymyxin / hc Cortisporinofloxacin Floxin Otic

Drugs Affecting the Throat and Mouth

chlorhexidine Peridexlidocaine HCI viscous solution Xylocaine Viscous Gel

EndocrineMedications

Adrenal Corticosteroid dexamethasone Hexadrolfludricortisone Florinefhydrocortisone Cortefmethylprednisolone Medrol / Medrol Pakprednisolone Orapred / Pediapredprednisone Deltasone

Antidiabetic Agents ACCU-CHEK STRIPSHUMALOGLANTUS VIAL

*ONLY THOSE BRAND NAME DRUGS SHOWN IN ALL CAPS ARE COVERED UNDER THIS FORMULARY, ALL OTHER BRAND NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE

COVERED GENERIC.

2021 RxBALANCE “SIGNATURE” FORMULARY

1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797

© PRAM INSURANCE SERVICES, INC.PG 8 OF 11

Category Covered Generic Name Brand Name*Endocrine Medications (cont.)

Antidiabetic Agents (cont.) NOVOLIN VIALNOVOLOG VIALONE-TOUCH STRIPS

TOUJEO SOLOSTARTOUJEO MAX

acarbose Precoseglimepiride Amarylglipizide Glucotrolglyburide Diabeta/ Glynaseglyburide / metformin Glucovancemetformin Glucophagemiglitol Glysetrepaglinide Prandinnateglinide Starlixpioglitazone Actos

Drugs to Treat Osteoporosis

alendronate sodium Fosamaxrisedronate sodium Actonel

Thyroid and Anti-Thyroid levothyroxine Synthroid / Levoxylliothyronine sodium Cytomelmethimazolepropylthiouracilthyroid

Gastrointestinal Antispasmodics diphenoxylate / atropine Lomotil

clidinium / chlordiazepoxide Libraxdicyclomine Bentylhyoscyamine Levsinmetoclopramide Reglan

Other Gastrointestinal ASACOLCREON/KU-ZYME/PANCRON/ VIOKASE/ PANCREASE-MTSUPREP

hydrocortisone suppositories Anusol HCgavilyte-N Nulytelymagnesium oxide Mag-Oxmisoprostol Cytotecpancrelipase / ECPEG 3350 / electrolytes solution Colytepramoxine / hydrocortisone / chloroxylenol

Cortane B

sulfasalizine AzulfidineProton Pump Inhibitors omeprazole Prilosec

lasoprazole Prevacidpantoprazole Protonix

Nutrition,BloodModifiers and Electrolytes

Drugs and VitaminsAffecting Coagulation

clopidogrel Plavixdipyridamole Persantineticlopidine Ticlidwarfarin Coumadin

*ONLY THOSE BRAND NAME DRUGS SHOWN IN ALL CAPS ARE COVERED UNDER THIS FORMULARY, ALL OTHER BRAND NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE

COVERED GENERIC.

2021 RxBALANCE “SIGNATURE” FORMULARY

1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797

© PRAM INSURANCE SERVICES, INC.PG 9 OF 11

Category Covered Generic Name Brand Name*Nutrition, Blood Modifiers and Electrolytes

Potassium Supplements potassium chloride K-DUR/ Micro-KVitamins / Minerals B-complex w/ c & folic acid

ergocalciferol Calciferolfolic acid Folateiron polysaccharide multivitaminsmultivitamins w/ mineralspyridoxinezinc sulfate

Ophthalmic Glaucoma TRAVATAN / TRAVATAN Zacetazolamide Diamoxapraclonidine Lopidinebetaxolol Betoptic / Sbrimonidine tartrate Alphagancarbachol Carbachol/ Carbastatcarteolol Ocupressdipivefrin AKProdorzolamide Trusoptlatanoprost Xalatanlevobunolol Betaganmetipranolol Optipranololpilocarpine Pilocartimolol Timoptic/ XE

Ophthalmic Topical Antibacterial

CILOXAN OINTMENTbacitracin Ak-Tracinciprofloxacin Ciloxan ofloxacin Ocufloxsulfacetamide Bleph-10tobramycin Tobrex

Ophthalmic Antihistamines azelastine HCL Optivar

Ophthalmic Anti-Infectives/ Corticosteroids

POLY-PREDgentamicin Garamycin

neomycin / bacitracin / polymyxin Neosporinneomycin / bacitracin / polysporin / hydrocortisone

Cortisporin

neomycin / dexamethasone / polymyxin Dexacidin/ Maxitrolpolymyxin B / trimethoprim Polytrimsulfacetamide / prednisolone Blephamidesulfacetamide / prednisone Vasocidin

Ophthalmic Corticosteroids ALREXLOTEMAX

dexamethasone Decadronfluroromethalone FML Liquifilmprednisolone Econopred Plus / Pred Forteprednisolone Forte

Ophthalmic Topical Antivirals trifluridine ViropticOther Ophthalmic atropine sulfate Isopto Atropine

cromolyn sodium

*ONLY THOSE BRAND NAME DRUGS SHOWN IN ALL CAPS ARE COVERED UNDER THIS FORMULARY, ALL OTHER BRAND NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE

COVERED GENERIC.

2021 RxBALANCE “SIGNATURE” FORMULARY

1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797

© PRAM INSURANCE SERVICES, INC.PG 10 OF 11

Category Covered Generic Name Brand Name*Ophthalmic (cont.)

Other Ophthalmic (cont.) cyclopentolate Cyclogylflurbiprofen Ocufennaphazoline AK Con/ Liquifilmphenylepinephrine Neo-Synephrinetetracainetetrahydrozoline

Obstetrical and Gynecological

AndrogensContraceptives

danazol DanocrineNUVARING

drosprienone/ehtinyl estradiol Yaz, Yazminethinyl estradiol and desogestrel Ortho-Cept/ Desogenethinyl estradiol and ethynodiol diacetate Zoviaethinyl estradiol and levonorgesterel Triphasil/ Levlennorethindrone NorQD/ Ortho Micronornorethindrone / estradiol / fe fumarate Loestrin-fenorethindrone / ethinyl estradiol Mircettenorethindrone / ethinyl estradiol Modiconnorethindrone / mestranol Ortho-Novumnorgestrimate / ethinyl estradiol Ortho Cyclennorgestrimate / ethinyl estradiol Ortho Tri-Cyclen

Estrogen Patches estradiol Vivelle/DotEstrogen/ ProgestinCombinations

METHERGINEPREMPHASEPREMPRO

Oral Estrogens PREMARINestradiol Estraceestropipate Ortho-Est/ Ogen

Prenatal Vitamins All vitamins are preferred on formularyProgestins medroxyprogesterone Provera

norethindrone Aygestinprogesterone Prometrium

Respiratory, Allergy, Coughand Cold

Antihistamines/ Anti-Allergenics

cyproheptadine Cyproheptaddexchlorpheniramine tablet SA Polaramine Repetabfexofenadine Allegrahydroxyzine pamoate Vistarilmontelukast sodium Singulair

Anti-Tussive Combinations guaifenesin / codeine Robitussin A-Cguaifenesin / PSE / hydrocodone Deconamine CXguaifenesin / hydrocodone Codiclearhydrocodone / homatropine Hydromethydrocodone / potassium guiaco CoTuss

phenylephrine / clorpheniramine / dextromethorphan

PE/GG LA

phenylephrine / hydrocodone / GG Levall 5.0pheylephrine / pyrilamine / DM PolyHist DMphenylephrine / pyrilamine / hydrocodone

Codimal DH

phenylephrine / chlorphen / hydrocodone

HC Tussive & Histinex HC

promethazine / codeine

*ONLY THOSE BRAND NAME DRUGS SHOWN IN ALL CAPS ARE COVERED UNDER THIS FORMULARY, ALL OTHER BRAND NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE

COVERED GENERIC.

2021 RxBALANCE “SIGNATURE” FORMULARY

1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797

© PRAM INSURANCE SERVICES, INC.PG 11 OF 11

Category Covered Generic Name Brand Name*Respiratory, Allergy, Coughand Cold (cont.)

Anti-Tussive Combinations (cont.) promethazine / DMpseudoephedrine / brompheniramine / dextromethorphan

Bromdec DM

pseudoephedrine / brompheniramine / hydrocodone

Brovex HC

pseudoephedrine w/ codeine / GG Codafedpseudoephedrine-chlor / codeinepseudoephedrine-CPM / hydrocodone Genecof-HCpseudoephedrine / hydrocodone Pancofpseudoephedrine / hydro / GG Hydrotussin

Beta AgonistInhalers

PROAIR HFAVENTOLIN HFA

metaproterenol AlupentInhaled CorticosteroidsIntranasal Steroids

QVARflunisolide Nasalide

Inhaled CorticosteroidsIntranasal Steroids (cont.)

fluticasone Flonasemometasone furoate Nasonex

Beta Agonist Oral VOSPIRE ER

albuterol Proventilalbuterol, multiphasic release Proventilmetaproterenol sulfate

Decongestants/ Antihistamines benzonatate Tessalon Perlechlorpheniramine / methylscopolamine Estendrylchlorpheniramine / phenylephrine R Tanna/ Phenabidcyproheptadine Periactinpseudoephedrine / chlorpheniramine tab / syrup / cap SA

Deconamine SR/ Deconamine

pseudoephedrine / methscopolamine Allerx-DExpectorant CombinationsLeukotriene ModifiersMiscellaneous Pulmonary Agents

guaifenesin / dextromethorphan Guaibidguaifenesin / PSE / hydrocodone Guaifed/ Deconsal/ Entex PSEmontelkast sodium Singulairacetylcysteine Mucomystcromolyn sodium ampul Intalipratropium Atrovent Inhaler/ Nasal Spray

Pulmonary Agents Xanthines aminophyllinedyphyllinetheophylline Theo-Dur/ Slo-Phyllin/ Theolair-SRtheophylline-guaifenesin Elixophyl GG

UrologicalMedications

Anticholinergics/ Antispasmodics flavoxate UrispasBenign Prostatic Hypertrophy tamsulosin HCL FlomaxMiscellaneous Urologicals oxybutynin Ditropan

phenazopyridine Pyridiumtamsulosin HCL Flomaxterazosin Hytrin

Other Genitourinary Products citric acid / potassium citrate Cytra-Kpotassium citrate Urocit-Kpotassium phosphate K-Phos

*ONLY THOSE BRAND NAME DRUGS SHOWN IN ALL CAPS ARE COVERED UNDER THIS FORMULARY, ALL OTHER BRAND NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE

COVERED GENERIC.

2021 RxBALANCE “SIGNATURE” FORMULARY