Select Drug Program® FormularyeFFective January 1, 2010

www.amerihealth.com

✓=New

Form

ulary D

rugs

1

Dear Participant:

In an effort to continue our commitment to provide you with comprehensive prescription drug coverage, a formulary feature is included in your prescription drug benefit. A formulary is a list of selected FDA-approved prescription medications reviewed by the FutureScripts® Pharmacy and Therapeutics Committee. These prescription medications have been selected for their reported medical effectiveness, safety, and value, while providing you with the highest level of coverage under your prescription program.

The following information serves as a guide when reviewing the list of formulary drugs on the following pages:

• Bolded drug = Formulary generic available at lowest copay.• Non-bolded drug = Formulary brand available at middle copay.• Drug in parenthesis ( ) = Non-formulary brand drug available at the highest copay. It is displayed next to the equivalent formulary generic

drug that is available at the lowest copay. For example: amoxicillin is the formulary generic drug available at the lowest copay. (Amoxil) is the non-formulary brand available at the highest copay. In most cases when brand drugs have a generic equivalent, the generic version is formulary and the brand version is non-formulary.

• Covered generic drugs not listed are formulary and are available at the lowest copay.• Covered brand drugs not listed are non-formulary and are available at the highest copay.

PA = Prior authorization must be requested by the physician.Q = Quantity level limits apply. ✓= New formulary drug.

The above information is highlighted in a key box on every other page of the formulary list.

Our pharmacy benefits manager, FutureScripts, continuously monitors effectiveness and safety of drugs and drug prescribing patterns. Several procedures support safe prescribing patterns for our prescription drug programs, such as:

• prior authorization;• age and gender limits;• quantity level limits;• 96-Hour Temporary Supply Program;• coverage for medications not on the formulary.

These procedures are designed to optimize your prescription drug benefits by promoting appropriate utilization. These procedures are based on U.S. Food and Drug Administration (FDA) guidelines, and the criteria are endorsed by the FutureScripts Pharmacy and Therapeutics Committee.

A detailed description of the procedures that support safe prescribing is included at the end of the formulary list.

Please note: Because prescription drug programs vary by group, the inclusion of a drug in this formulary does not imply coverage. This formulary was current at the time of printing and is subject to change. Please call 1-888-678-7012 if you have any questions about your prescription drug benefits. Please discuss any questions or concerns about your drug therapy with your physician or pharmacist. Select Drug Program Formulary information can also be obtained on the AmeriHealth website, www.amerihealth.com.

2

Dear Physician:

This is a listing of formulary medications to be considered for your patient, a Select Drug Program participant. Please refer to this formulary guide in order to choose a medication. Because prescription drug programs vary by group, the inclusion of a drug in this formulary does not imply cover-age. This formulary was current at the time of printing and is subject to change.

Please understand that this formulary is not intended as a substitute for your independent professional judgment. Rather, it is offered as a tool to help our members recognize formulary drugs. We hope that you will refer to the formulary as a guide to prescribing formulary drugs.

3

KeyType of covered drug* You pay

• Bolded drug is a formulary generic.• Non-bolded drug is a formulary brand.• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent

formulary generic drug that is available at the lowest copay.• Covered generic drugs not listed are formulary.• Covered brand drugs not listed are non-formulary.

Lowest copayMiddle copayHighest copay

Lowest copayHighest copay

PA = Prior authorization must be requested by the physician.Q = Quantity level limits apply.✓ = New formulary drug.

* Unless specifically excluded from your contract.

ANTIBIOTICS & OTHER DRUGS USED FOR 1. INFECTION

DRUg NAme acyclovir (Zovirax) Agenerase amantadine (Symmetrel) amoxicillin (Amoxil) amoxicillin/clavulanate (Augmentin) ampicillin (Principen) Augmentin XR Atripla azithromycin (Zithromax) cefaclor (Ceclor) cefaclor ER cefadroxil (Duricef) cefdinir (Omnicef) cefuroxime axetil (Ceftin) cephalexin (Keflex) chloroquine phosphate (Aralen) Cipro oral suspension ciprofloxacin ER tabs (Cipro XR) ciprofloxacin tabs (Cipro) clarithromycin (Biaxin) clarithromycin SR (Biaxin XL) clindamycin (Cleocin) clotrimazole troches (mycelex) Combivir Crixivan Dapsone Daraprim demeclocycline (Declomycin) dicloxacillin didanosine (Videx eC) doxycycline hyclate (Vibramycin, Periostat) doxycycline monohydrate (monodox)

emtriva epivir Epzicom erythromycin delayed release (eryc, ery-Tab) erythromycin ethylsuccinate (eeS, eryPed) erythromycin stearate (erythrocin) erythromycin susp w/sulfa (Pediazole) ethambutol (myambutol) famciclovir (Famvir) Fansidar Flagyl eR fluconazole (Diflucan) Fortovase Fuzeon ganciclovir (Cytovene) grifulvin V tabs gris-Peg griseofulvin microsize susp (grifulvin V) Hepsera HIVID hydroxychloroquine (Plaquenil) Isentress isoniazid (Sporonax) itraconazole ketoconazole tabs (Nizoral tabs) Levaquin Lexiva mebendazole (Vermox) mefloquine (Lariam) mepron methenamine hippurate (Hiprex, Urex) metronidazole (Flagyl) minocycline caps (minocin, Dynacin) minocycline tabs

4

ANTIBIOTICS & OTHER DRUGS USED FOR 1. INFECTION (Cont.)

DRUg NAme Mintezol mycobutin nitrofurantoin macrocrystals (macrodantin) Norvir nystatin (mycostatin) ofloxacin (Floxin) penicillin VK (Veetids) phenazopyridine (Pyridium) Prezista Primaquine pyrazinamide Rescriptor Reyataz ribavirin (Rebetol) rifampin (Rifadin) Rifater rimantadine (Flumadine) Selzentry stavudine (Zerit) sulfamethoxazole/tmp (Bactrim, Bactrim DS,

Septra DS) sulfisoxazole tabs SustivaQ Tamiflu terbinafine tabs (Lamisil tabs) tetracycline (Sumycin) Tobi tinidazole (Tindamax) Trizivir Truvada Valcyte Valtrex Vfend Videx Viracept Viramune Viread Xifaxan Ziagen zidovudine (Retrovir)

CANCER & ORGAN TRANSPLANT DRUGS2.

DRUg NAme Alkeran Aromasin azathioprine (Imuran) Casodex

CeeNU cyclophosphamide (Cytoxan) cyclosporine (Sandimmune, Neoral) danazol (Danocrine) emcyt etoposide (VePesid) Fareston Femara flutamide (eulexin)PA gleevec Hexalen hydroxyurea (Hydrea) leucovorin calcium Leukeran Lysodren matulane megestrol (megace) mercaptopurine (Purinethol) methotrexate mycophenolate (Cellcept) myleran prednisone (Deltasone) Rapamune✓ tacrolimus (Prograf) tamoxifen (Nolvadex) Targretin Temodar thioguanine Xeloda

PAIN, NERVOUS SYSTEM, & PSYCH3.

DRUg NAme acetaminophen/butalbital Q acetaminophen/codeine acetazolamide alprazolam (Xanax) amantadine (Symmetrel) amitriptyline amoxapine amphetamine aspartate/amphetamine sulfate/

dextroamphetamine (Adderall) amphetamine aspartate/amphetamine sulfate/

dextroamphetamine ER (Adderall XR) Aricept Aricept ODTQ aspirin with codeine Q Avinza benztropine bromocriptine mesylate (Parlodel)

5

KeyType of covered drug* You pay

• Bolded drug is a formulary generic.• Non-bolded drug is a formulary brand.• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent

formulary generic drug that is available at the lowest copay.• Covered generic drugs not listed are formulary.• Covered brand drugs not listed are non-formulary.

Lowest copayMiddle copayHighest copay

Lowest copayHighest copay

PA = Prior authorization must be requested by the physician.Q = Quantity level limits apply.✓ = New formulary drug.

* Unless specifically excluded from your contract.

PAIN, NERVOUS SYSTEM, & PSYCH (Cont.)3.

DRUg NAme bupropion (Wellbutrin) bupropion SR (Wellbutrin SR) bupropion XR (Wellbutrin XR) buspirone (BuSpar)Q butalbital/apap/caffeine (Fioricet)Q butalbital/aspirin/caffeine (Fiorinal) carbamazepine (Tegretol) carbamazepine XR (Tegretol XR) carbidopa/levodopa (Sinemet) carbidopa/levodopa CR (Sinemet CR) carbidopa/levodopa ODT (Parcopa) Celontin chlorpromazine HCl choline magnesium trisalicylate citalopram (Celexa) clomipramine HCl (Anafranil) clonazepam (Klonopin) clozapine (Clozaril) codeine tabs Comtan Concerta desipramine (Norpramin) dexmethylphenidate (Focalin) diazepam (Valium) diclofenac potassium (Cataflam) diclofenac sodium (Voltaren XR) diflunisal (Dolobid) divalproex sodium (Depakote) divalproex sodium ER (Depakote eR) divalproex sprinkle cap (Depakote Sprinkle Caps) doxepin (Sinequan) ergotamine/tartrate/caffeine (Cafergot) ethosuximide (Zarontin) etodolac (Lodine XL)

fenoprofen calcium (Nalfon)Q, PA fentanyl citrate OTFC (Actiq)Q fentanyl transdermal (Duragesic) fluoxetine (Prozac) fluphenazine flurbiprofen (Ansaid) fluvoxamine gabapentin (Neurontin) galantamine (Razadyne) galantamine ER (Razadyne eR) haloperidol Q hydrocodone/acetaminophen (Vicodin,

Norco, maxidone)Q hydrocodone/acetaminophen elixir (Lortab) hydrocodone/acetaminophen ES (Vicodin eS)Q hydrocodone/ibuprofen (Vicoprofen)Q hydromorphone HCl (Dilaudid) ibuprofen/oxycodone HCl (Combunox) imipramine (Tofranil) indomethacin (Indocin SR) isometheptene/dichloralphenazone/apap (midrin) ketoprofen (Oruvail, Orudis) ketorolac (Toradol oral) lamotrigine (Lamictal) levetiracetam (Keppra) Lexapro lithium carbonate (eskalith) lithium carbonate SR (eskalith CR, Lithobid) lorazepam (Ativan) loxapine (Loxitane) maprotiline Q maxalt, maxalt-mLT meclofenamate Q meperidine HCl (Demerol)

6

PAIN, NERVOUS SYSTEM, & PSYCH (Cont.)3.

DRUg NAme methadone (Dolophine) methamphetamine (Desoxyn) methylphenidate SR (Ritalin SR) migergot (Cafergot) mirapex mirtazapine (Remeron) mirtazapine rapid dissolve tabs (Remeron SolTab)Q morphine sulfate (mSIR)Q morphine sulfate, extended release (mS Contin) morphine sulfate supp (RmS) nabumetone (Relafen) Namenda naproxen (Naprosyn) naproxen sodium (Anaprox DS) naproxen sodium SA (Naprelan) Nardil nefazodone Neurontin soln nortriptyline (Pamelor) oxaprozin (Daypro) oxazepam (Serax) oxcarbazepine (Trileptal)Q oxycodone (OxyIR)Q oxycodone/apap (Roxicet, Percocet, Tylox)Q oxycodone/aspirin (Percodan)Q oxycodone CR 12 hour tabs (OxyContin) Parnate paroxetine (Paxil) paroxetine HCl ext-release (Paxil CR) perphenazine phenobarbital phenytoin piroxicam (Feldene) primidone (mysoline) propoxyphene HCl/apap Q propoxyphene napsylate/apap (Darvocet-N) Prostigmin pyridostigmine (mestinon) risperidone (Risperdal, Risperdal m-Tab) ropinirole (Requip) salsalate selegiline HCl (eldepryl) Seroquel sertraline (Zoloft) Strattera sulindac (Clinoril)Q sumatriptan (Imitrex)Q temazepam (Restoril)

thioridazine thiothixene (Navane) tolmetin sodium topiramate (Topamax) topiramate sprinkle cap (Topamax Sprinkle Capsules) tramadol (Ultram) tranycypromine sulfate (Parnate) trazodone (Desyrel) trifluoperazine trihexyphenidyl valproic acid (Depakene) venlafaxine (effexor)Q zaleplon (Sonata)Q zolpidem tartrate (Ambien)Q Zomig nasal sprayQ Zomig, Zomig ZmT Zyprexa

HEART, BLOOD PRESSURE, & CHOLESTEROL4.

DRUg NAme acebutolol (Sectral) amiloride (midamor) amiloride/HCTZ (moduretic) aminocaproic acid (Amicar) amiodarone HCl (Cordarone) amlodipine (Norvasc) amlodipine/benazepril (Lotrel) anagrelide (Agrylin) atenolol (Tenormin) atenolol/chlorthalidone (Tenoretic)PA Azor benazepril (Lotensin) benazepril/HCTZ (Lotensin HCT)PA BenicarPA Benicar HCT betaxolol (Kerlone) bisoprolol/HCTZ (Ziac) Bystolic bumetanide (Bumex) captopril (Capoten) captopril/HCTZ (Capozide) carvedilol (Coreg) chlorothiazide chlorthalidone cholestyramine (Questran Light) cilostazol (Pletal) clonidine (Catapres tablets)✓ clonidine patch (Catapres-TTS) colestipol HCl (Colestid)

7

KeyType of covered drug* You pay

• Bolded drug is a formulary generic.• Non-bolded drug is a formulary brand.• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent

formulary generic drug that is available at the lowest copay.• Covered generic drugs not listed are formulary.• Covered brand drugs not listed are non-formulary.

Lowest copayMiddle copayHighest copay

Lowest copayHighest copay

PA = Prior authorization must be requested by the physician.Q = Quantity level limits apply.✓ = New formulary drug.

* Unless specifically excluded from your contract.

HEART, BLOOD PRESSURE, & CHOLESTEROL (Cont.)4.

DRUg NAme Coumadin PA Crestor digoxin Dilatrate-SR diltiazem (Cardizem) diltiazem extended release (Cardizem CD,

Dilacor XR) diltiazem ER 24 hour (Tiazac) diltiazem SR (Cardizem SR)PA DiovanPA Diovan HCT dipyridamole (Persantine) disopyramide (Norpace) disopyramide CR 150mg (Norpace CR) doxazosin mesylate (Cardura) edecrin enalapril (Vasotec) enalapril/HCTZ (Vaseretic) eplerenone (Inspra) felodipine ER (Plendil) fenofibrate (Lofibra)✓ fenofibric acid (Fibricor) flecainide (Tambocor) fosinopril (monopril) furosemide (Lasix) gemfibrozil (Lopid) guanabenz (Tenex) guanfacine HCl hydralazine hydrochlorothiazide (Microzide) indapamide (Lozol) isosorbide dinitrate (Isordil tabs) isosorbide dinitrate ER isosorbide mononitrate (Ismo)

isosorbide mononitrate ER (Imdur) isradipine (DynaCirc) labetalol HCl (Trandate) Lanoxin lisinopril (Prinivil) lisinopril/HCTZ (Prinzide) lovastatin (mevacor) mephyton methyldopa metolazone (Zaroxolyn) metoprolol tartrate (Lopressor) metoprolol succinate (Toprol XL) mexiletine HCl (mexitil) minoxidil (Loniten) moexipril/HCTZ (Uniretic) nadolol (Corgard) nadolol-bendroflume thiazide (Corzide) Niaspan nifedipine ER (Adalat CC, Procardia XL) Nimotop nisoldipine (Sular) Nitro-Bid nitroglycerin patches (Nitro-Dur) nitroglycerin SL (Nitrostat SL) nitroglycerin ER pentoxifylline (Trental) pindolol Visken pravastatin (Pravachol) prazosin (minipress) procainamide (Pronestyl) Procanbid propafenone (Rythmol) propranolol (Inderal, Inderal LA) propranolol/HCTZ (Inderide) quinapril HCl (Accupril)

8

HEART, BLOOD PRESSURE, & CHOLESTEROL (Cont.)4.

DRUg NAme quinapril/HCTZ (Accuretic) quinapril gluconate quinidine gluconate ER quinidine sulfate ramipril (Altace) simvastatin (Zocor) sotalol HCl (Betapace AF) spironolactone (Aldactone) spironolactone/HCTZ (Aldactazide) terazosin (Hytrin) ticlopidine HCl (Ticlid) timolol (Blocadren) torsemide (Demadex) trandolapril (mavik) triamterene/HCTZ (Dyazide, Maxzide) Tricor verapamil HCl (Calan, Verelan) warfarin Zetia

SKIN MEDICATIONS5.

DRUg NAme alclometasone dipropionate cream (Aclovate) amcinonide (Cyclocort) anthralin (Psoriatec) Bactroban cream✓ bencort lotion kit (Vanoxide-HC) benzoyl peroxide gel (Brevoxyl gel) benzoyl peroxide/erythromycin (Benzamycin gel) benzoyl peroxide/urea cream (Zoderm) betamethasone dipropionate (Diprosone) betamethasone dipropionate augmented

(Diprolene, Diprolene AF) betamethasone valerate (Beta-Val) betamethasone/clotrimazole (Lotrisone) calcipotriene soln (Dovonex Soln) ciclopirox cream, susp (Loprox) ciclopirox solution (Penlac) clindamycin (Cleocin T)✓ clindamycin-benzoyl peroxide gel (BenzaClin) clobetasol (Temovate) desoximetasone (Topicort) diflorasone diacetate (Psorcon) econazole (Spectazole) efudex cream erythromycin gel (erygel, emgel) erythromycin solution

erythromycin swabs (erycette) fluocinolone acetonide cream, soln (Synalar) fluocinonide gel, oint, cream (Lidex, Lidex e) Fluoroplex fluorouracil solution (efudex) fluticasone propionate (Cutivate) gentamicin topical cream, oint HC acetate/lidocaine HCl (Senatec HC) hydrocortisone 2.5% (Hytone) hydrocortisone butyrate 0.1% (Locoid) hydrocortisone valerate 0.2% (Westcort) isotretinoin (Accutane) ketoconazole cream (Nizoral cream) ketoconazole shampoo (Nizoral shampoo) lidocaine (Xylocaine) lindane lotion Loprox gel malathion lotion (Ovide) mometasone cream (elocon) metronidazole cream (metroCream) metronidazole lotion (metrolotion) mupirocin oint (Bactroban) nystatin (mycostatin) nystatin/triamcinolone (mycolog II) Oxsoralen lotion 1% Oxsoralen Ultra permethrin (elimite) podofilox soln (Condylox) prednicarbate ointment (Dermatop) prilocaine/lidocaine (emla cream) Regranex selenium sulfide (Selsun Rx) silver sulfadiazine (Silvadene) sodium sulfacetamide lotion (Klaron) sodium sulfacetamide/sulfur (Sulfacet-R, Plexion) sulfacetamide sodium (Sebizon) sulfacetamide sodium/urea lotion

(Carmol scalp lotion) tretinoin (Retin-A, Avita) triamcinolone (Kenalog) urea cream (Keralac cream) Zovirax oint

EAR, NOSE, THROAT MEDICATIONS6.

DRUg NAme acetic acid HC (Acetasol HC) Bactroban nasal oint benzocaine/antipyrine (Benzotic) chlorhexidine gluconate (Peridex)

9

KeyType of covered drug* You pay

• Bolded drug is a formulary generic.• Non-bolded drug is a formulary brand.• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent

formulary generic drug that is available at the lowest copay.• Covered generic drugs not listed are formulary.• Covered brand drugs not listed are non-formulary.

Lowest copayMiddle copayHighest copay

Lowest copayHighest copay

PA = Prior authorization must be requested by the physician.Q = Quantity level limits apply.✓ = New formulary drug.

* Unless specifically excluded from your contract.

EAR, NOSE, THROAT MEDICATIONS (Cont.)6.

DRUg NAme Cipro HC Otic flunisolide (Nasarel) fluticasone propionate nasal susp (Flonase) ipratropium (Atrovent nasal spray) Nasacort AQ Nasonex neomycin/polymyxin/hydrocortisone

(Cortisporin Otic) ofloxacin otic (Floxin Otic) triamcinolone (Kenalog in Orabase)

DIABETES, THYROID, STEROIDS & OTHER 7. MISCELLANEOUS HORMONES

DRUg NAme acarbose (Precose) Ascenscia Autodisc Test Strips Ascenscia Breeze 2 Test Strips Ascensia Contour Test Strips Ascensia elite Test Strips Ascenscia glucometer Actoplus met Actos Androgel Avandamet Avandaryl Avandia BD Insulin Syringe micro-FinePA Byetta calcitriol capsules (Rocaltrol capsules) danazol (Danocrine) desmopressin acetate (DDAVP) dexamethasone (Decadron) fludrocortisone acetate (Florinef)

FreeStyle meter FreeStyle Test Strips FreeStyle Lite glucometer FreeStyle Lite Test Strips glimepiride (Amaryl) glipizide (glucotrol) glipizide ER (glucotrol XL) glucagon emergency kit glyburide (Diabeta, micronase) glyburide micronized (glynase) Humalog Humulin insulins hydrocortisone (Cortef) Iletin insulins Insulin syringes Lancets Lantus vial, cartridge levothyroxine (Levoxyl, Synthroid) liothyronine (Cytomel) metformin (glucophage) metformin ER (glucophage XR) metformin/glyburide (glucovance) methimazole (Tapazole) methylprednisolone (medrol)✓ nateglinide (Starlix) Novolin Novolog Novolog mix oxandrolone (Oxandrin) Prandin Precision XTRA glucometer Precision XTRA Test Strips prednisolone sodium phosphate

(Pediapred, Orapred) prednisolone syrup (Prelone)

10

DIABETES, THYROID, STEROIDS & OTHER 7. MISCELLANEOUS HORMONES (Cont.)

DRUg NAme prednisone tabs (Deltasone) propylthiouracil SensiparPA Symlin tolbutamide Zavesca

STOMACH, ULCER, & BOWEL MEDS8.

DRUg NAme Asacol balsalazide (Colazal) Canasa supp Carafate susp chlordiazepoxide/clidinium cimetidine (Tagamet) dicyclomine (Bentyl) diphenoxylate HCl/atropine (Lomotil) dronabinol (marinol)Q emend famotidine 40mg (Pepcid) gastrocrom granisetron (Kytril) hydrocortisone (Anusol-HC) hydrocortisone retention enema (Colocort) hyoscyamine (Levsin, Levsinex, Levbid) Kristalose lactulose soln PA, ✓ lansoprazole (Prevacid) mesalamine rectal susp (Rowasa) metoclopramide (Reglan) misoprostol (Cytotec)PA Nexium nizatidine (Axid) omeprazole (Prilosec) ondansetron HCl (Zofran) pancrelipase EC/SA (Pancrease, Pancrease mT)PA pantoprazole (Protonix) PEG 3350 & electrolytes (Nulytely) Pentasa phenobarb/hyoscyamine/atrop/scop (Donnatal) prochlorperazine (Compazine) Proctofoam-HC promethazine (Phenergan) ranitidine 300mg (Zantac) sucralfate tabs (Carafate) sulfasalazine (Azulfidine)

trimethobenzamide (Tigan) ursodiol (Actigall) Zantac syrup

BIOTECHNOLOGY9.

DRUg NAme Avonex Copaxone Lovenox Peg-Intron Procrit

BONES, JOINTS, & MUSCLES 10.

DRUg NAmeQ ActonelQ alendronate (Fosamax) allopurinol (Zyloprim) azathioprine (Imuran) baclofen calcitonin-salmon (rDNA origin) nasal spray

(miacalcin) carisoprodol (Soma) chlorzoxazone (Parafon Forte) choline magnesium trisalicylate colchicine cyclobenzaprine (Flexeril) dexamethasone (Decadron) diazepam (Valium) diclofenac potassium (Cataflam) diclofenac sodium (Voltaren XR) diflunisal (Dolobid) enbrel kit, disp syr etodolac (Lodine XL) evista fenoprofen calcium (Nalfon) flurbiprofen (Ansaid)PA Humira hydrocortisone (Cortef) hydroxychloroquine (Plaquenil) ibuprofen (motrin) indomethacin (Indocin) indomethacin SR (Indocin SR) ketoprofen (Orudis) ketoprofen SR (Oruvail) ketorolac (Toradol oral) leflunomide (Arava) meclofenamate PA meloxicam (mobic)

11

KeyType of covered drug* You pay

• Bolded drug is a formulary generic.• Non-bolded drug is a formulary brand.• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent

formulary generic drug that is available at the lowest copay.• Covered generic drugs not listed are formulary.• Covered brand drugs not listed are non-formulary.

Lowest copayMiddle copayHighest copay

Lowest copayHighest copay

PA = Prior authorization must be requested by the physician.Q = Quantity level limits apply.✓ = New formulary drug.

* Unless specifically excluded from your contract.

BONES, JOINTS, & MUSCLES (Cont.)10.

DRUg NAme methocarbamol (Robaxin) methotrexate methylprednisolone (medrol) nabumetone (Relafen) naproxen (Naprosyn) naproxen sodium (Anaprox DS) naproxen sodium SA (Naprelan) oxaprozin (Daypro) piroxicam (Feldene) prednisolone sodium phosphate (Pediapred,

Orapred) prednisolone syrup (Prelone) prednisone tabs (Deltasone) probenecid salsalate Skelaxin sulfasalazine (Azulfidine) sulfinpyrazone sulindac (Clinoril) tizanidine (Zanaflex) tolmetin

FEMALE, HORMONE REPLACEMENT, BIRTH 11. CONTROL

DRUg NAme Bravelle Cenestin clindamycin cream (Cleocin) Depo-Provera Depo-SubQ Provera desogestrel/ethinyl estradiol esterified estrogens/methyltestosterone estraderm estradiol (estrace)

estradiol transdermal (Climara) Estratest HS estring estropipate (Ogen) ethinyl estradiol/drospirenone (Yasmin) Femhrt fluconazole 150mg (Diflucan) Follistim Follistim AQ levonorgestrel/ethinyl estradiol

(Seasonale, Triphasil) Lunelle medroxyprogesterone acetate (Provera) menopur methergine metronidazole vaginal gel (metrogel) norethindrone norethindrone acetate (Aygestin) norethindrone acetate/ethinyl estradiol/ferrous

fumarate (estrostep Fe) norethindrone/ethinyl estradiol norethindrone/ethinyl estradiol, Fe norethindrone/mestranol norgestimate/ethinyl estradiol norgestrel/ethinyl estradiol Novarel Nuvaring nystatin Ortho evra Premarin Premarin vaginal cream Premphase Prempro Prometrium

12

FEMALE, HORMONE REPLACEMENT, 11. BIRTH CONTROL (Cont.)

DRUg NAme Repronex terconazole cream (Terazol 3)✓ tri-lo-sprintec (Ortho Tri-Cyclen Lo) Vivelle, Vivelle Dot Yaz

EYE MEDICATIONS12.

DRUg NAme acetazolamide acetazolamide ER (Diamox Sequels) Acular, LS, PF Alrex atropine sulfate (Isopto Atropine) Azopt bacitracin ophth bacitracin/polymyxin B ophth oint (Polysporin) betaxolol Betimol Betoptic S Blephamide✓ brimonidine tartrate (Alphagan P) carbachol 3% (Isopto Carbachol 3%) carteolol ciprofloxacin (Ciloxan) cromolyn ophth (Crolom) cyclopentolate HCl (Cyclogyl) dexamethasone ophth ✓ diclofenac sodium (Voltaren) dipivefrin HCl (Propine) dorzolamide HCl 2% (Trusopt) dorzolamide-timolol (Cosopt) erythromycin fluorometholone (FmL, Liquifilm) gentamicin ophth (gentak) HMS homatropine 5% (Isopto Homatropine) levobunolol (Betagan) Lotemax Lumigan methazolamide neomycin/polymyxin B/dexamethasone (maxitrol) ofloxacin (Ocuflox) Optivar Patanol Phospholine Iodide pilocarpine (Pilocar, Isopto Carpine) Pilopine HS gel

polymyxin B/neo/bacitracin (Neosporin oint) polymyxin B/neo/gramicidin (Neosporin soln) prednisolone acetate (econopred Plus, Pred-Forte) prednisolone sodium phosphate (Inflamase Forte) prednisolone/sodium sulfacetamide (Vasocidin oint) sulfacetamide (Bleph 10) timolol ophth (Timoptic) timolol XE (Timoptic Xe) tobramycin (Tobrex) tobramycin-dexamethasone (Tobradex) trifluridine (Viroptic) trimethoprim sulfate/polymyxin B (Polytrim) tropicamide (mydriacyl) Vexol Vigamox Xalatan

ALLERGY, COUGH & COLD, LUNG MEDS13.

DRUg NAme acetylcysteine (mucomyst) Advair Diskus✓ Advair HFA albuterol inhaler (Proventil, Ventolin) albuterol soln Alupent aerosol aminophylline tabs Astelin Atrovent HFA Azmacort benzonatate (Tessalon Perles) brompheniramine/phenylephrine (Brovex D) chlorpheniramine/phenylephrine (Rynatan) chlorpheniramine/phenylephrine/

methscopolamine chewable tabs, syrup (extendryl)

chlorpheniramine/phenylephrine/ methscopolamine extended release (Hista-Vent DA)

Combivent mDI cromolyn inhalation soln (Intal soln) cyproheptadine dexamethasone (Decadron) elixophyllin epiPen epiPen Jr. Auto-Injector/e*Z extendryl SR fexofenadine (Allegra) Flovent HFA flunisolide (Nasarel) Foradil

13

KeyType of covered drug* You pay

• Bolded drug is a formulary generic.• Non-bolded drug is a formulary brand.• Drug in parenthesis ( ) is a non-formulary brand drug. It is displayed to help you identify the equivalent

formulary generic drug that is available at the lowest copay.• Covered generic drugs not listed are formulary.• Covered brand drugs not listed are non-formulary.

Lowest copayMiddle copayHighest copay

Lowest copayHighest copay

PA = Prior authorization must be requested by the physician.Q = Quantity level limits apply.✓ = New formulary drug.

* Unless specifically excluded from your contract.

ALLERGY, COUGH & COLD, LUNG MEDS (Cont.)13.

DRUg NAme guaifenesin/codeine (guiatuss AC) guaifenesin/codeine/pseudopephedrine

(guiatuss DAC) guaifenesin/hydrocodone guaifenesin/phenylephrine/hydrocodone (Duratuss

HD elixir) guaifenesin/pseudoephedrine/codeine (guiatuss

DAC, Novahistine) hydrocodone/homatropine syrup (Hycodan) hydrocortisone (Cortef) hydroxyzine HCl hydroxyzine pamoate (Vistaril) Intal ipratropium-albuterol (Duoneb) ipratropium inhalation soln (Atrovent soln)✓ levalbuterol inhalation solution (Xopenex

inhalation solution) maxair metaproterenol tabs, syrup, inh soln methylprednisolone (medrol) Nasacort AQ Nasonex phenylephrine HCl/COD/prometh (Phenergan VC

w/codeine) phenylephrinecarbinoxamine w/ hydrocodone

liquid (Max HC) phenylephrine/cpm/hydrocodone (Histussin-HC) phenylephrine/hydrocodone/BPM (Flutuss HC liquid) phenylephrine/hydrocodone/CP (Maxituss HC) prednisolone sodium phosphate

(Pediapred, Orapred) prednisolone syrup (Prelone) prednisone tabs (Deltasone) ProAir HFA

promethazine (Phenergan) promethazine/codeine promethazine/dextromethorphan promethazine/phenylephrine/codeine Proventil HFA pseudoephedrine/brompheniramine/hydrocodone

liquid (Brovex HC) pseudoephedrine/chlorpheniramine (Kronofed-A Jr.) pseudoephedrine/cpm/codeine (Novahistine DH) pseudoephedrine/guaifenesin extended release

(Zephrex LA) Pulmicort Pulmozyme Serevent DiskusPA Singulair Spiriva✓ Symbicort terbutaline sulfate tabs (Brethine) Theo-24 theophylline extended release (Theochron, Uniphyl) Tilade Tracleer Vospire eR

URINARY & PROSTATE MEDS14.

DRUg NAme bethanechol (Urecholine) doxazosin mesylate (Cardura) enablex finasteride (Proscar) flavoxate (Urispas) methenamine/methylene blue/benzoic acid/

salicylic acid/atropine (Prosed eC tab) methenamine/phenylsalicylate/atropine/

hyoscyamine/benzoic acid/methylene blue (Urised)

14

URINARY & PROSTATE MEDS (Cont.)14.

DRUg NAmeQ, PA muse oxybutynin (Ditropan) oxybutynin ER (Ditropan XL) phenazopyridine (Pyridium) potassium citrate (Urocit-K) terazosin (Hytrin)Q, PA Viagra

VITAMINS & ELECTROLYTES15.

DRUg NAme ergocalciferol (Calciferol) fluoride folic acid iron, carbonyl 15mg (Icar) Multigen (Chromagen) Multigen Plus (Chromagen Forte) multivitamin with fluoride drops, tabs (Tri-Vi-Flor,

Poly-Vi-Flor with and without iron)

potassium bicarbonate/potassium citrate effervescent (K-Lyte)

potassium chloride (Klor-Con, Kaon-CL, Klotrix, K-Tab, K-Dur, micro-K)

sodium fluoride drops (Luride drops)

DIAGNOSTICS & MISCELLANEOUS AGENTS16.

DRUg NAme benzoyl peroxide calcium acetate (PhosLo) Chemet etidronate disodium (Didronel) midodrine HCl (ProAmatine) pilocarpine HCl (Salagen)

15

PROCEDURES THAT SUPPORT SAFE PRESCRIBINGAmeriHealth utilizes an independent pharmacy benefits management (PBM) company, FutureScripts, to manage the administration of its commercial prescription drug programs. As our PBm, FutureScripts is responsible for providing a network of participating pharmacies, administering pharmacy benefits, and providing customer service to our members and providers.

Prior authorizationAmeriHealth requires prior authorization of certain covered drugs to ensure that the drug prescribed is medically necessary and appropriate and is being prescribed according to FDA guidelines. The approval criteria were developed and endorsed by the FutureScripts Pharmacy and Therapeutics Committee, which is an established group of medical directors and practicing area physicians and pharmacists.

Using these approved criteria, clinical pharmacists evaluate requests for these drugs based on clinical data, information submitted by the member’s prescribing physician, and the member’s available prescription drug therapy history. Their review includes a determination that there are no drug interactions or contraindications, that dosing and length of therapy are appropriate, and that other drug therapies, if necessary, were utilized.

Without prior authorization, the member's prescription will not be covered at the retail or mail order pharmacy (see “96-Hour Temporary Supply Program” on page 17). The prior authorization process may take up to two working days once complete information from the prescribing physician has been received. Incomplete information will result in a delayed decision.

Prior authorization approvals for some drugs may be limited to 6 to 12 months. If the prior authorization for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician wants a member to continue the drug therapy after the expiration date, a new prior authorization request will need to be submitted and approved in order for coverage to continue.

Currently, the drugs listed below are a part of the prior authorization program. Prior authorization applies to all formulations of these specific drugs, including, but not limited to, tablet, capsule, and oral suspension.

The above list is subject to change.

*All diabetic test strips require prior authorization except the following: Autodisc®, Breeze® 2, Contour®, FreeStyle Lite®, and Precision XTRA®.

AcipHex®

Actiq®

AdcircaTm

Afinitor®

AlodoxTm

AltabaxTm

Alvesco®

Ambien CR®

AmeviveTm

AmRIX®

AplenzinTm

Atacand®/ Atacand HCT®

Avapro®/ Avalide®

AvidoxyTm DKAzor®

BanzelTm

Benicar®/ Benicar HCT®

BiDil®

Botox®

Byetta®

Caduet®

Caverject®

Celebrex®

Cesamet®

Cialis®

Cimzia®

Cozaar®/ Hyzaar®

Crestor®

Cymbalta®

DaytranaTm

Diabetic test strips*Diovan®/ Diovan HCT®

edex®

edluar™

effient™

enbrel®

exforge®/ Exforge HCT®

exjade®

Fentora®

Flector® patchForteoTm

genotropin®

gleevec®

GlumetzaTm

Humatrope®

Humira®

HYCAMTIN® capsulesInvegaTm

Iressa®

JanumetTm

JanuviaTm

KapidexTm

Keppra XRTm

Kineret®

Levitra®

Lipitor®

Lunesta®

Lyrica®

magnacetTm

micardis®/ Micardis HCT®

mobic®

mUSe®

myobloc®

Nexavar®

Nexium®

Norditropin®

Noxafil®

Nucynta™

NutriDoxTm

Nutropin®/ Nutropin AQ®

Nuvigil®

Omnitrope®

Onglyza™

Onsolis™

Opana®/Opana® eROracea®

PatadayTm

PrandimetTm

Prevacid®

Prevacid/NapraPac®

Prilosec® suspensionPristiqTm

Protonix®

Provigil®

PyleraTm

Qualaquin®

Ranexa®

Renvela®

Requip® XLTm

RevatioTm

Revlimid®

RozeremTm

RyzoltTm

Sabril®

Saizen®

Saphris®

SavellaTm

Seroquel XR®

Serostim®

Simcor®

SimponiTm

Singulair®

Sprycel®

Sutent®

Symlin®

Taclonex®

Taclonex Scalp® SuspensionTarceva®

Tasigna®

Tekturna®/ Tekturna HCT®

Temodar® OralTeveten®/ Teveten HCT®

Tev-Tropin®

Thalomid®

ToviazTm

TreximetTm

TrilipixTm

Tykerb®

Uloric®

Ultram® eRValturna®

VecticalTm

VeramystTm

Viagra®

VimatTm

Voltaren® gelVytorin®

Vyvanse®

XenazineTm

Xyzal®

Zelapar®

ZmaxTm

Zolinza®

Zorbtive®

Zyvox®

16

Age and gender limitsThe FDA has established specific procedures that govern prescription prescribing practices. These rules are designed to prevent potential harm to patients and to ensure that the medication is being prescribed according to FDA guidelines. For example, some drugs are approved by the FDA only for individuals age 14 and older, such as ciprofloxacin, or prescribed only for females, such as prenatal vitamins. The pharmacist’s computer provides up-to-date information about FDA rules. If the member’s prescription falls outside of the FDA guidelines, it will not be covered until prior authorization is obtained. The prescribing physician may request preapproval of restricted medications when medically necessary. The approval criteria for this review were developed and endorsed by the FutureScripts Pharmacy and Therapeutics Committee, which is an established group of medical directors and practicing area physicians and pharmacists. The member should contact the prescribing physician to request that he or she initiate the preapproval process. To determine if a covered prescription drug prescribed for you has an age or gender limit, call FutureScripts at 1-888-678-7012.

Quantity level limitsQuantity level limits are designed to allow a sufficient supply of medication based upon FDA-approved maximum daily doses and length of therapy of a particular drug. We have several different types of quantity level limits that are explained in detail below.

Rolling 30-day periodThis quantity limit is based on dosing guidelines over a rolling 30-day period. Examples of quantity level limits per rolling 30-day period are:

Emend® (four 125mg capsules + eight 80mg capsules or four trifold packs [one 125mg capsule + two 80mg capsules]); Boniva® (two 150mg tablets); Avonex® (one kit, four injections); Betaseron® (15 vials); Copaxone® (32 vials); Fosamax Plus DTM (five tablets); and Rebif®(12 injections);

migraine drugs, such as:

Amerge® (nine 2.5mg tablets), Imitrex® (36 50mg tablets), Maxalt® (12 10mg tablets), Migranal® (eight 4mg nasal spray units), Stadol NS® (four 10mg units), and Zomig® (nine 5mg tablets);

fertility agents (if covered under the group contract), such as:

Fertinex® (60 ampules), Follistim® (60 ampules), Gonal-F® (60 ampules), Humegon® (60 ampules), Pergonal® (60 ampules), and Repronex® (60 ampules);

sedative hypnotic drugs, such as:

Sonata® (14 capsules) and Ambien® (14 tablets);

and oral narcotic drugs, such as:

OxyContin® (90 units), Percocet® (180 units), and Percodan® (180 units).

For example, if a member went to the pharmacy on October 1, 2009, for one of these medications, the computer system would have looked back 30 days to September 1, 2009, to see how much medication was dispensed. The purpose of these limits is to make certain that these drugs are being used appropriately and to guard against overuse or stockpiling.

• Refill too soon

With this quantity level limit, if a member used less than 75 percent of the total day supply dispensed, the claim will be rejected at the pharmacy. This will ensure that the medication is being taken in accordance with the prescribed dose and frequency of administration.

• Therapeuticdrugclass

This quantity level limit applies to some classes of drugs, such as narcotics (i.e., short-acting and long-acting). If a member uses more than one drug within the same class, he or she may be unsafely duplicating medications and would be affected by the total quantity limits for a therapeutic drug class. Members will be able to obtain only a 30-day total supply of any combination of drugs in the same therapeutic drug class each month.

If a physician requires that a member needs a medication therapy that exceeds any of the quantity level limits described above, the physician must request a quantity limit override. The member is required to contact the prescribing physician to initiate a preapproval request for an override.

17

1 Members with an integrated drug benefit (e.g., CMM and Major Medical) will pay the discounted cost of the 96-hour supply as well as the remainder of the prescription order (if approved) at the time of purchase, and the medical claim for reimbursement will be processed through standard procedures.

Some drugs may have a time period for quantity limit exceptions of 6 to 12 months. If the exception for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician wants a member to continue the drug therapy that exceeds a quantity limit after the expiration date, a new request for a quantity limit exception will need to be submitted and approved in order for coverage to continue.

To determine if a covered prescription drug prescribed for you has a quantity level limit, call FutureScripts at 1-888-678-7012.

96-Hour Temporary Supply ProgramThe 96-Hour Temporary Supply Program applies to the following covered medications:

• most medications that require prior authorization;

• medications that are subject to age limits (preapproval required for ages outside of recommended ranges);

• migraine medications with quantity level limits, such as Amerge®, Imitrex®, maxalt®, migranal®, Stadol NS®, and Zomig® (preapproval of quantity override required for amounts over the quantity level limits).

Under the 96-Hour Temporary Supply Program, if a member's doctor writes a prescription for a drug that requires prior authorization, has an age limit, or exceeds the quantity level limit for a medication, and prior authorization/preapproval has not been obtained by the doctor, the following steps will occur:

1. The participating retail pharmacy will be instructed to release a 96-hour supply of the drug to the member with no out-of-pocket cost-sharing at that time.1

2. By the next business day, our PBM will contact the member's doctor to request that he or she submit the necessary documentation of medical necessity or medical appropriateness for review.

3. Once the completed medical documentation is received by our PBM, the review will be completed, and the medication will be approved or denied.

4. If approved, the remainder of the prescription order will be filled, and the appropriate prescription drug out-of-pocket cost-sharing will be applied.1

5. If denied, notification will be sent to the doctor and the member.

Obtaining a 96-hour temporary supply does not guarantee that the prior authorization/preapproval request will be approved. Some medications are not eligible for the 96-Hour Temporary Supply Program due to packaging or other limitations such as Retin-A® (tube), enbrel® (two-week injection kit), medroxyprogesterone acetate (monthly injectable), and erectile dysfunction drugs. Additionally, certain drugs to treat hemophilia (antihemophilic factors) are not usually purchased at the pharmacy and must be special-ordered; therefore, they are not eligible for the 96-hour temporary supply.

The process for requesting a prior authorization/preapproval or override is as follows:• The physician prescribing the medication completes a prior authorization form or writes a letter of medical necessity and submits it to our PBM

by fax at 215-241-3073 or 1-888-671-5285. A member's physician may request the form by calling 1-888-678-7012. Members may request the form through Customer Service on behalf of their physician, but it must be completed and submitted by the doctor.

• The PBM will review the prior authorization request or letter of medical necessity. If a clinical pharmacist cannot approve the request based on established criteria, a medical director will review the document.

• A decision is made regarding the request.

• If approved, the prescribing physician will be notified of approval via fax or telephone, and the claims system will be coded with the approval.

18

• The member may call the Customer Service phone number on his or her identification card to determine if the prescription is approved.

• If denied, the prescribing physician will be notified via letter, fax, or telephone.

• The member is also notified of all denied requests via letter.

• The appeals process will be detailed on the denial letters sent to the members and physicians.

Coverage for medications not on the formulary (specific to Select Drug Program members only)Providers may request formulary coverage of a covered non-formulary medication when all formulary alternatives have been exhausted or there are contraindications to using the formulary alternatives. The provider should complete the covered non-formulary appeal form, providing details to support use of the covered non-formulary medication, and should fax the request to 215-241-3073 or 1-888-671-5285. If the non-formulary request is approved, the drug will be paid at the appropriate formulary benefit level. If the request is denied, the member and provider will receive a denial letter with the appropriate appeals language. Whether or not an appeal is filed, the member may always obtain benefits for the covered non-formulary drug at the appropriate non-formulary benefit level. Out-of-pocket expenses for non-formulary drugs are higher than for formulary drugs.

Appealing a decisionIf a request for prior authorization/preapproval or override results in a denial, the member, or physician on the member's behalf, may file an appeal. Both the member and his or her provider will receive written notification of a denial, which will include the appropriate telephone number and address to direct an appeal. In all cases, the physician needs to be involved in the appeals process to provide the required medical information for the basis of the appeal.

19

Amaryl 9Ambien 6Ambien CR 15amcinonide 8Amevive 15Amicar 6amiloride 6amiloride/HCTZ 6aminocaproic acid 6aminophylline tabs 12amiodarone HCl 6amitriptyline 4amlodipine 6amlodipine/benazepril 6amoxapine 4amoxicillin 3amoxicillin/clavulanate 3Amoxil 3amphetamine aspartate/amphetamine sulfate/

dextroamphetamine 4amphetamine aspartate/amphetamine sulfate/

dextroamphetamine eR 4ampicillin 3AmRIX 15Anafranil 5anagrelide 6Anaprox DS 6, 11Androgel 9Ansaid 5, 10anthralin 8Anusol-HC 10Aplenzin 15Aralen 3Arava 10Aricept 4Aricept ODT 4Aromasin 4Asacol 10Ascenscia Autodisc Test Strips 9Ascenscia Breeze 2 Test Strips 9Ascenscia glucometer 9Ascensia Contour Test Strips 9Ascensia elite Test Strips 9aspirin with codeine 4Astelin 12Atacand/

Atacand HCT 15atenolol 6

A

acarbose 9Accupril 7Accuretic 8Accutane 8acebutolol 6acetaminophen/butalbital 4acetaminophen/codeine 4Acetasol HC 8acetazolamide 4, 12acetazolamide ER 12acetic acid HC 8acetylcysteine 12AcipHex 15Aclovate 8Actigall 10Actiq 5, 15Actonel 10Actoplus met 9Actos 9Acular, LS, PF 12acyclovir 3Adalat CC 7Adcirca 15Adderall 4Adderall XR 4Advair Diskus 12Afinitor 15Agenerase 3Agrylin 6albuterol inhaler 12albuterol soln 12alclometasone dipropionate cream 8Aldactazide 8Aldactone 8alendronate 10Alkeran 4Allegra 12allopurinol 10Alodox 15Alphagan P 12alprazolam 4Alrex 12Altabax 15Altace 8Alupent aerosol 12Alvesco 15amantadine 3, 4

20

benzonatate 12Benzotic 8benzoyl peroxide 8, 14benzoyl peroxide/erythromycin 8benzoyl peroxide gel 8benzoyl peroxide/urea cream 8benztropine 4Betagan 12betamethasone/clotrimazole 8betamethasone dipropionate 8betamethasone dipropionate augmented 8betamethasone valerate 8Betapace AF 8Beta-Val 8betaxolol 6, 12bethanechol 13Betimol 12Betoptic S 12Biaxin 3Biaxin XL 3BiDil 15bisoprolol/HCTZ 6Bleph 10 12Blephamide 12Blocadren 8Botox 15Bravelle 11Brethine 13Brevoxyl gel 8brimonidine 12bromocriptine mesylate 4brompheniramine/phenylephrine 12Brovex D 12Brovex HC 13bumetanide 6Bumex 6bupropion 5bupropion SR 5bupropion XR 5BuSpar 5buspirone 5butalbital/apap/caffeine 5butalbital/aspirin/caffeine 5Byetta 9, 15Bystolic 6

atenolol/chlorthalidone 6Ativan 5Atripla 3atropine sulfate 12Atrovent HFA 12Atrovent nasal spray 9Atrovent soln 13Augmentin 3Augmentin XR 3Avalide 15Avandamet 9Avandaryl 9Avandia 9Avapro 15AvidoxyTm DK 15Avinza 4Avita 8Avonex 10Axid 10Aygestin 11azathioprine 4, 10azithromycin 3Azmacort 12Azopt 12Azor 6, 15Azulfidine 10, 11

B

bacitracin ophth 12bacitracin/polymyxin B ophth oint 12baclofen 10Bactrim 4Bactrim DS 4Bactroban 8Bactroban cream 8Bactroban nasal oint 8balsalazide 10Banzel 15BD Insulin Syringe micro-Fine 9benazepril 6benazepril/HCTZ 6Benicar 6Benicar/

Benicar HCT 15Benicar HCT 6Bentyl 10Benzamycin gel 8benzocaine/antipyrine 8

21

Cesamet 15Chemet 14chlordiazepoxide/clidinium 10chlorhexidine gluconate 8chloroquine phosphate 3chlorothiazide 6chlorpheniramine/phenylephrine 12chlorpromazine HCl 5chlorthalidone 6chlorzoxazone 10cholestyramine 6choline magnesium trisalicylate 5, 10Chromagen 14Chromagen Forte 14Cialis 15ciclopirox cream, susp 8ciclopirox solution 8cilostazol 6Ciloxan 12cimetidine 10Cimzia 15Cipro 3, 9ciprofloxacin 3, 12ciprofloxacin eR tabs 3ciprofloxacin tabs 3Cipro HC Otic 9Cipro oral suspension 3Cipro XR 3citalopram 5clarithromycin 3clarithromycin SR 3Cleocin 3, 8, 11Cleocin T 8Climara 11clindamycin 3, 8, 11clindamycin cream 11Clinoril 6, 11clobetasol 8clomipramine HCl 5clonazepam 5clonidine 6clotrimazole troches 3clozapine 5Clozaril 5codeine tabs 5Colazal 10colchicine 10Colestid 6

C

Caduet 15Cafergot 5, 6Calan 8Calciferol 14calcipotriene soln 8calcitriol capsules 9calcium acetate 14Canasa supp 10Capoten 6Capozide 6captopril 6captopril/HCTZ 6Carafate 10Carafate susp 10carbachol 3% 12carbamazepine 5carbamazepine XR 5carbidopa/levodopa 5carbidopa/levodopa CR 5carbidopa/levodopa ODT 5Cardizem 7Cardizem CD 7Cardizem SR 7Cardura 7, 13carisoprodol 10Carmol scalp lotion 8carteolol 12cartridge 9carvedilol 6Casodex 4Cataflam 5, 10Catapres tablets 6Caverject 15Ceclor 3CeeNU 4cefaclor 3cefaclor eR 3cefadroxil 3cefdinir 3Ceftin 3cefuroxime axetil 3Celebrex 15Celexa 5Cellcept 4Celontin 5Cenestin 11cephalexin 3

22

colestipol HCl 6Colocort 10Combivent mDI 12Combivir 3Combunox 5Compazine 10Comtan 5Concerta 5Condylox 8Copaxone 10Cordarone 6Coreg 6Corgard 7Cortef 9, 10, 13Cortisporin Otic 9Corzide 7Cosopt 12Coumadin 7Cozaar 15Crestor 7, 15Crixivan 3Crolom 12cromolyn inhalation soln 12cromolyn ophth 12Cutivate 8cyclobenzaprine 10Cyclocort 8Cyclogyl 12cyclopentolate HCl 12cyclophosphamide 4cyclosporine 4Cymbalta 15cyproheptadine 12Cytomel 9Cytotec 10Cytovene 3Cytoxan 4

D

danazol 4, 9Danocrine 4, 9Dapsone 3Daraprim 3Darvocet-N 6Daypro 6, 11Daytrana 15DDAVP 9Decadron 9, 10, 12

Declomycin 3Deltasone 4, 10, 11, 13Demadex 8demeclocycline 3Demerol 5Depakene 6Depakote 5Depakote eR 5Depakote Sprinkle Caps 5Depo-Provera 11Depo Sub Q Provera 11Dermatop 8desipramine 5desmopressin acetate 9desogestrel/ethinyl estradiol 11desoximetasone 8Desoxyn 6Desyrel 6dexamethasone 9, 10, 12dexamethasone ophth 12dexmethylphenidate 5Diabeta 9Diamox Sequels 12diazepam 5, 10diclofenac potassium 5, 10diclofenac sodium 5, 10, 12dicloxacillin 3dicyclomine 10didanosine 3Didronel 14diflorasone diacetate 8Diflucan 3, 11diflunisal 5, 10digoxin 7Dilacor XR 7Dilatrate-SR 7Dilaudid 5diltiazem 7diltiazem ER 24 hour 7diltiazem extended release 7diltiazem SR 7Diovan 7Diovan/Diovan HCT 15Diovan HCT 7diphenoxylate HCl/atropine 10dipivefrin HCl 12Diprolene 8Diprolene AF 8

23

enablex 13enalapril 7enalapril/HCTZ 7enbrel 15enbrel kit, disp syr 10epiPen 12epiPen Jr. Auto-Injector/e*Z 12epivir 3eplerenone 7Epzicom 3ergocalciferol 14ergotamine/tartrate/caffeine 5eryc 3erycette 8erygel 8eryPed 3ery-Tab 3erythrocin 3erythromycin 3, 8, 12erythromycin delayed release 3erythromycin ethylsuccinate 3erythromycin gel 8erythromycin solution 8erythromycin stearate 3erythromycin susp w/sulfa 3erythromycin swabs 8eskalith 5eskalith CR 5esterified estrogens/methyltestosterone 11estrace 11estraderm 11estradiol 11estradiol transdermal 11Estratest HS 11estring 11estropipate 11estrostep Fe 11ethambutol 3ethinyl estradiol/drospirenone 11ethosuximide 5etidronate disodium 14etodolac 5, 10etoposide 4eulexin 4evista 10exforge 15Exforge HCT 15exjade 15

Diprosone 8dipyridamole 7disopyramide 7disopyramide CR 150mg 7Ditropan 14Ditropan XL 14divalproex sodium 5divalproex sodium eR 5divalproex sprinkle cap 5Dolobid 5, 10Dolophine 6Donnatal 10dorzolamide HCl 2% 12dorzolamide-timolol 12Dovonex Soln 8doxazosin mesylate 7, 13doxepin 5doxycycline hyclate 3doxycycline monohydrate 3dronabinol 10Duoneb 13Duragesic 5Duratuss HD elixir 13Duricef 3Dyazide 8Dynacin 3DynaCirc 7

E

econazole 8econopred Plus 12edecrin 7edex 15edluar 15eeS 3effexor 6effient 15efudex 8efudex cream 8eldepryl 6elimite 8elixophyllin 12elocon 8emcyt 4emend 10emgel 8emla cream 8emtriva 3

24

fluticasone propionate nasal susp 9Flutuss HC liquid 13fluvoxamine 5FmL 12Focalin 5folic acid 14Follistim 11Follistim AQ 11Foradil 12Forteo 15Fortovase 3Fosamax 10fosinopril 7FreeStyle Lite glucometer 9FreeStyle Lite Test Strips 9FreeStyle meter 9FreeStyle Test Strips 9furosemide 7Fuzeon 3

G

gabapentin 5galantamine 5galantamine eR 5ganciclovir 3gastrocrom 10gemfibrozil 7genotropin 15gentak 12gentamicin ophth 12gentamicin topical cream, oint 8gleevec 4, 15glimepiride 9glipizide 9glipizide ER 9glucagon emergency kit 9glucophage 9glucophage XR 9glucotrol 9glucotrol XL 9glucovance 9Glumetza 15glyburide 9glyburide micronized 9glynase 9granisetron 10grifulvin V 3grifulvin V tabs 3

extendryl 12extendryl SR 12

F

famciclovir 3famotidine 40mg 10Famvir 3Fansidar 3Fareston 4Feldene 6, 11felodipine eR 7Femara 4Femhrt 11fenofibrate 7fenoprofen calcium 5, 10fentanyl citrate OTFC 5fentanyl transdermal 5Fentora 15fexofenadine 12finasteride 13Fioricet 5Fiorinal 5Flagyl 3Flagyl eR 3flavoxate 13flecainide 7Flector patch 15Flexeril 10Flonase 9Florinef 9Flovent HFA 12Floxin 4, 9Floxin Otic 9fluconazole 3, 11fluconazole 150mg 11fludrocortisone acetate 9Flumadine 4flunisolide 9, 12fluocinolone acetonide cream, soln 8fluoride 14fluorometholone 12Fluoroplex 8fluorouracil solution 8fluoxetine 5fluphenazine 5flurbiprofen 5, 10flutamide 4fluticasone propionate 8, 9

25

Hytrin 8, 14Hyzaar 15

I

ibuprofen 5, 10ibuprofen/oxycodone HCl 5Icar 14Iletin insulins 9Imdur 7imipramine 5Imitrex 6Imuran 4, 10indapamide 7Inderal 7Inderal LA 7Inderide 7Indocin 5, 10Indocin SR 5, 10indomethacin 5, 10indomethacin SR 10Inflamase Forte 12Inspra 7Insulin syringes 9Intal 12, 13Intal soln 12Invega 15ipratropium 9, 13ipratropium-albuterol 13ipratropium inhalation soln 13Iressa 15iron, carbonyl 15mg 14Isentress 3Ismo 7isometheptene/dichloralphenazone/apap 5isoniazid 3Isopto Atropine 12Isopto Carbachol 3% 12Isopto Carpine 12Isopto Homatropine 12Isordil tabs 7isosorbide dinitrate 7isosorbide dinitrate eR 7isosorbide mononitrate 7isosorbide mononitrate eR 7isotretinoin 8isradipine 7itraconazole 3

griseofulvin microsize susp 3gris-Peg 3guaifenesin/codeine 13guaifenesin/hydrocodone 13guaifenesin/phenylephrine/hydrocodone 13guaifenesin/pseudoephedrine/codeine 13guanabenz 7guanfacine HCl 7guiatuss AC 13guiatuss DAC 13

H

haloperidol 5HC acetate/lidocaine HCl 8Hepsera 3Hexalen 4Hiprex 3Hista-Vent DA 12Histussin-HC 13HIVID 3HMS 12homatropine 5% 12Humalog 9Humatrope 15Humira 10, 15Humulin insulins 9HYCAMTIN capsules 15Hycodan 13hydralazine 7Hydrea 4hydrochlorothiazide 7hydrocodone/acetaminophen 5hydrocodone/acetaminophen elixir 5hydrocodone/acetaminophen eS 5hydrocodone/homatropine syrup 13hydrocodone/ibuprofen 5hydrocortisone 8, 9, 10, 13hydrocortisone 2.5% 8hydrocortisone butyrate 0.1% 8hydrocortisone retention enema 10hydrocortisone valerate 0.2% 8hydromorphone HCl 5hydroxychloroquine 3, 10hydroxyurea 4hydroxyzine HCl 13hydroxyzine pamoate 13hyoscyamine 10, 13Hytone 8

26

levetiracetam 5Levitra 15levobunolol 12levonorgestrel/ethinyl estradiol 11levothyroxine 9Levoxyl 9Levsin 10Levsinex 10Lexapro 5Lexiva 3Lidex, Lidex e 8lidocaine 8lindane lotion 8liothyronine 9Lipitor 15Liquifilm 12lisinopril 7lisinopril/HCTZ 7lithium carbonate 5lithium carbonate SR 5Lithobid 5Locoid 8Lodine XL 5, 10Lofibra 7Lomotil 10Loniten 7Lopid 7Lopressor 7Loprox 8Loprox gel 8lorazepam 5Lortab 5Lotemax 12Lotensin 6Lotensin HCT 6Lotrel 6Lotrisone 8lovastatin 7Lovenox 10loxapine 5Loxitane 5Lozol 7Lumigan 12Lunelle 11Lunesta 15Luride drops 14Lyrica 15Lysodren 4

J

Janumet 15Januvia 15

K

Kaon-CL 14Kapidex 15K-Dur 14Keflex 3Kenalog 8, 9Kenalog in Orabase 9Keppra 5Keppra XR 15Keralac cream 8Kerlone 6ketoconazole cream 8ketoconazole shampoo 8ketoconazole tabs 3ketoprofen 5, 10ketoprofen SR 10ketorolac 5, 10Kineret 15Klaron 8Klonopin 5Klor-Con 14Klotrix 14K-Lyte 14Kristalose 10Kronofed-A Jr. 13K-Tab 14Kytril 10

L

labetalol HCl 7lactulose soln 10Lamictal 5Lamisil tabs 4lamotrigine 5Lancets 9Lanoxin 7Lantus vial 9Lariam 3Lasix 7leflunomide 10leucovorin calcium 4Leukeran 4Levaquin 3Levbid 10

27

metoprolol tartrate 7metroCream 8metrogel 11metrolotion 8metronidazole 3, 8, 11metronidazole cream 8metronidazole lotion 8metronidazole vaginal gel 11mevacor 7mexiletine HCl 7mexitil 7miacalcin 10micardis/

Micardis HCT 15micro-K 14micronase 9Microzide 7midamor 6midodrine HCl 14midrin 5migergot 6minipress 7minocin 3minocycline caps 3minocycline tabs 3minoxidil 7Mintezol 4mirapex 6mirtazapine 6mirtazapine rapid dissolve tabs 6misoprostol 10mobic 10, 15moduretic 6moexipril/HCTZ 7mometasone cream 8monodox 3monopril 7morphine sulfate 6morphine sulfate, extended release 6morphine sulfate supp 6motrin 10mS Contin 6mSIR 6mucomyst 12multigen 14multigen Plus 14multivitamin with fluoride drops, tabs 14mupirocin oint 8

M

macrodantin 4magnacet 15malathion lotion 8maprotiline 5marinol 10matulane 4mavik 8maxair 13maxalt, maxalt-mLT 5Max HC 13maxidone 5maxitrol 12Maxituss HC 13Maxzide 8mebendazole 3meclofenamate 5, 10medrol 9, 11, 13medroxyprogesterone acetate 11mefloquine 3megace 4megestrol 4meloxicam 10menopur 11meperidine HCl 5mephyton 7mepron 3mercaptopurine 4mesalamine rectal susp 10mestinon 6metaproterenol tabs, syrup, inh soln 13metformin 9metformin eR 9metformin/glyburide 9methadone 6methamphetamine 6methazolamide 12methenamine hippurate 3methergine 11methimazole 9methocarbamol 11methotrexate 4, 11methyldopa 7methylphenidate SR 6methylprednisolone 9, 11, 13metoclopramide 10metolazone 7metoprolol succinate 7

28

nitroglycerin SL 7Nitrostat SL 7nizatidine 10Nizoral cream 8Nizoral shampoo 8Nizoral tabs 3Nolvadex 4Norco 5Norditropin 15norethindrone 11norethindrone acetate 11norethindrone acetate/ethinyl estradiol/ferrous fumarate 11norethindrone/ethinyl estradiol 11norethindrone/ethinyl estradiol, Fe 11norethindrone/mestranol 11norgestimate/ethinyl estradiol 11norgestrel/ethinyl estradiol 11Norpace 7Norpace CR 7Norpramin 5nortriptyline 6Norvasc 6Norvir 4Novahistine 13Novahistine DH 13Novarel 11Novolin 9Novolog 9Novolog mix 9Noxafil 15Nucynta 15Nulytely 10NutriDox 15Nutropin/Nutropin AQ 15Nuvaring 11Nuvigil 15nystatin 4, 8, 11nystatin/triamcinolone 8

O

Ocuflox 12ofloxacin 4, 9, 12ofloxacin otic 9Ogen 11omeprazole 10Omnicef 3Omnitrope 15ondansetron HCl 10

muse 14mUSe 15myambutol 3mycelex 3mycobutin 4mycolog II 8mycophenolate 4mycostatin 4, 8mydriacyl 12myleran 4myobloc 15mysoline 6

N

nabumetone 6, 11nadolol 7nadolol-bendroflume thiazide 7Nalfon 5, 10Namenda 6Naprelan 6, 11Naprosyn 6, 11naproxen 6, 11naproxen sodium 6, 11naproxen sodium SA 6, 11Nardil 6Nasacort AQ 9, 13Nasarel 9, 12Nasonex 9, 13Navane 6nefazodone 6neomycin/polymyxin B/dexamethasone 12neomycin/polymyxin/hydrocortisone 9Neoral 4Neosporin oint 12Neosporin soln 12Neurontin 5, 6Neurontin soln 6Nexavar 15Nexium 10, 15Niaspan 7nifedipine eR 7Nimotop 7nisoldipine 7Nitro-Bid 7Nitro-Dur 7nitrofurantoin macrocrystals 4nitroglycerin eR 7nitroglycerin patches 7

29

pentoxifylline 7Pepcid 10Percocet 6Percodan 6Peridex 8Periostat 3permethrin 8perphenazine 6Persantine 7phenazopyridine 4, 14Phenergan 10, 13phenobarb/hyoscyamine/atrop/scop 10phenobarbital 6phenylephrine HCl/COD/prometh 13phenylephrinecarbinoxamine w/ hydrocodone liquid 13phenylephrine/cpm/hydrocodone 13phenylephrine/hydrocodone/BPm 13phenylephrine/hydrocodone/CP 13phenytoin 6PhosLo 14Phospholine Iodide 12Pilocar 12pilocarpine 12, 14pilocarpine HCl 14Pilopine HS gel 12pindolol 7piroxicam 6, 11Plaquenil 3, 10Plendil 7Pletal 6Plexion 8podofilox soln 8polymyxin B/neo/bacitracin 12polymyxin B/neo/gramicidin 12Polysporin 12Polytrim 12Poly-Vi-Flor with and without iron 14potassium chloride 14potassium citrate 14Prandimet 15Prandin 9Pravachol 7pravastatin 7prazosin 7Precision XTRA glucometer 9Precision XTRA Test Strips 9Precose 9Pred-Forte 12

Onglyza 15Onsolis 15Opana/Opana eR 15Optivar 12Oracea 15Orapred 9, 11, 13Ortho evra 11Orudis 5, 10Oruvail 5, 10Ovide 8Oxandrin 9oxandrolone 9oxaprozin 6, 11oxazepam 6oxcarbazepine 6Oxsoralen lotion 1% 8Oxsoralen Ultra 8oxybutynin 14oxybutynin eR 14oxycodone 6oxycodone/apap 6oxycodone/aspirin 6oxycodone CR 12 hour tabs 6OxyContin 6OxyIR 6

P

Pamelor 6Pancrease, Pancrease mT 10pancrelipase eC/SA 10pantoprazole 10Parafon Forte 10Parcopa 5Parlodel 4Parnate 6paroxetine 6paroxetine HCl ext-release 6Pataday 15Patanol 12Paxil 6Paxil CR 6Pediapred 9, 11, 13Pediazole 3PEG 3350 & electrolytes 10Peg-Intron 10penicillin VK 4Penlac 8Pentasa 10

30

Prosed eC tab 13Prostigmin 6Protonix 10, 15Proventil 12, 13Proventil HFA 13Provera 11Provigil 15Prozac 5pseudoephedrine/brompheniramine/hydrocodone liquid 13pseudoephedrine/chlorpheniramine 13pseudoephedrine/cpm/codeine 13pseudoephedrine/guaifenesin extended release 13Psorcon 8Psoriatec 8Pulmicort 13Pulmozyme 13Purinethol 4Pylera 15pyrazinamide 4Pyridium 4, 14pyridostigmine 6

Q

Qualaquin 15Questran Light 6quinapril gluconate 8quinapril HCl 7quinapril/HCTZ 8quinidine gluconate ER 8quinidine sulfate 8

R

ramipril 8Ranexa 15ranitidine 300mg 10Rapamune 4Razadyne 5Razadyne ER 5Rebetol 4Reglan 10Regranex 8Relafen 6, 11Remeron 6Remeron SolTab 6Renvela 15Repronex 12Requip 6Requip XL 15

prednicarbate ointment 8prednisolone acetate 12prednisolone sodium phosphate 9, 11, 12, 13prednisolone/sodium sulfacetamide 12prednisolone syrup 9, 11, 13prednisone 4, 10, 11, 13prednisone tabs 10, 11, 13Prelone 9, 11, 13Premarin 11Premarin vaginal cream 11Premphase 11Prempro 11Prevacid 10, 15Prevacid/ NapraPac 15Prezista 4prilocaine/lidocaine 8Prilosec 10Prilosec suspension 15Primaquine 4primidone 6Principen 3Prinivil 7Prinzide 7Pristiq 15ProAir HFA 13ProAmatine 14probenecid 11procainamide 7Procanbid 7Procardia XL 7prochlorperazine 10Procrit 10Proctofoam-HC 10Prograf 4promethazine 10, 13promethazine/codeine 13promethazine/dextromethorphan 13promethazine/phenylephrine/codeine 13Prometrium 11Pronestyl 7propafenone 7Propine 12propoxyphene HCl/apap 6propoxyphene napsylate/apap 6propranolol 7propranolol/HCTZ 7propylthiouracil 10Proscar 13

31

Serostim 15sertraline 6Silvadene 8silver sulfadiazine 8Simcor 15Simponi 15simvastatin 8Sinemet 5Sinemet CR 5Sinequan 5Singulair 13, 15Skelaxin 11sodium fluoride drops 14sodium sulfacetamide lotion 8sodium sulfacetamide/sulfur 8Soma 10Sonata 6sotalol HCl 8Spectazole 8Spiriva 13spironolactone 8spironolactone/HCTZ 8Sporonax 3Sprycel 15Starlix 9stavudine 4Strattera 6sucralfate tabs 10Sular 7sulfacetamide 8, 12sulfacetamide sodium 8sulfacetamide sodium/urea lotion 8Sulfacet-R 8sulfamethoxazole/tmp 4sulfasalazine 10, 11sulfinpyrazone sulindac 11sulfisoxazole tabs 4sulindac 6sumatriptan 6Sumycin 4Sustiva 4Sutent 15Symbicort 13Symlin 10, 15Symmetrel 3, 4Synalar 8Synthroid 9

Rescriptor 4Restoril 6Retin-A 8Retrovir 4Revatio 15Revlimid 15Reyataz 4ribavirin 4Rifadin 4rifampin 4Rifater 4rimantadine 4Risperdal, Risperdal m-Tab 6risperidone 6Ritalin SR 6RmS 6Robaxin 11Rocaltrol capsules 9ropinirole 6Rowasa 10Roxicet 6Rozerem 15Rynatan 12Rythmol 7Ryzolt 15

S

Sabril 15Saizen 15Salagen 14salsalate 6, 11Sandimmune 4Saphris 15Savella 15Seasonale 11Sebizon 8Sectral 6selegiline HCl 6selenium sulfide 8Selsun Rx 8Selzentry 4Senatec HC 8Sensipar 10Septra DS 4Serax 6Serevent Diskus 13Seroquel 6Seroquel XR 15

32

tinidazole 4tizanidine 11Tobi 4Tobradex 12tobramycin 12tobramycin-dexamethasone 12Tobrex 12Tofranil 5tolbutamide 10tolmetin 6, 11tolmetin sodium 6Topamax 6Topamax Sprinkle Capsules 6Topicort 8topiramate 6topiramate sprinkle cap 6Toprol XL 7Toradol oral 5, 10torsemide 8Toviaz 15Tracleer 13tramadol 6Trandate 7trandolapril 8tranycypromine sulfate 6trazodone 6Trental 7tretinoin 8Treximet 15triamcinolone 8, 9triamterene/HCTZ 8Tricor 8trifluoperazine 6trifluridine 12trihexyphenidyl 6Trileptal 6Trilipix 15trimethobenzamide 10trimethoprim sulfate/polymyxin B 12Triphasil 11Tri-Vi-Flor 14Trizivir 4tropicamide 12Trusopt 12Truvada 4Tykerb 15Tylox 6

T

Taclonex 15Taclonex Scalp Suspension 15Tagamet 10Tambocor 7Tamiflu 4tamoxifen 4Tapazole 9Tarceva 15Targretin 4Tasigna 15Tegretol 5Tegretol XR 5Tekturna/Tekturna HCT 15temazepam 6Temodar 4Temodar Oral 15Temovate 8Tenex 7Tenoretic 6Tenormin 6Terazol 3 12terazosin 8, 14terbinafine tabs 4terbutaline sulfate tabs 13terconazole cream 12Tessalon Perles 12tetracycline 4Teveten/Teveten HCT 15Tev-Tropin 15Thalomid 15Theo-24 13Theochron 13theophylline extended release 13thioguanine 4thioridazine 6thiothixene 6Tiazac 7Ticlid 8ticlopidine HCl 8Tigan 10Tilade 13timolol 8, 12timolol ophth 12timolol Xe 12Timoptic 12Timoptic Xe 12Tindamax 4

33

Vistaril 13Vivelle 12Vivelle Dot 12Voltaren 5, 10, 12Voltaren gel 15Voltaren XR 5, 10Vospire eR 13Vytorin 15Vyvanse 15

W

warfarin 8Wellbutrin 5Wellbutrin SR 5Wellbutrin XR 5Westcort 8

X

Xalatan 12Xanax 4Xeloda 4Xenazine 15Xifaxan 4Xylocaine 8Xyzal 15

Y

Yasmin 11Yaz 12

Z

zaleplon 6Zanaflex 11Zantac 10Zantac syrup 10Zarontin 5Zaroxolyn 7Zavesca 10Zelapar 15Zephrex LA 13Zerit 4Zetia 8Ziac 6Ziagen 4zidovudine 4Zithromax 3Zmax 15Zocor 8

U

Uloric 15Ultram 6Ultram eR 15Uniphyl 13Uniretic 7urea cream 8Urecholine 13Urex 3Urised 13Urispas 13Urocit-K 14ursodiol 10

V

Valcyte 4Valium 5, 10valproic acid 6Valtrex 4Valturna 15Vaseretic 7Vasocidin oint 12Vasotec 7Vectical 15Veetids 4venlafaxine 6Ventolin 12VePesid 4Veramyst 15verapamil HCl 8Verelan 8Vermox 3Vexol 12Vfend 4Viagra 14, 15Vibramycin 3Vicodin 5Vicodin eS 5Vicoprofen 5Videx 3, 4Videx eC 3Vigamox 12Vimpat 15Viracept 4Viramune 4Viread 4Viroptic 12Visken 7

34

Zoderm 8Zofran 10Zolinza 15Zoloft 6zolpidem tartrate 6Zomig nasal spray 6Zomig, Zomig ZmT 6Zorbtive 15Zovirax 3, 8Zovirax oint 8Zyloprim 10Zyprexa 6Zyvox 15

Prescription Drug Program provider payment informationA pharmacy benefits management (PBm) company administers our prescription drug benefits and is responsible for providing a network of participating pharmacies and processing pharmacy claims. The PBm also negotiates price discounts with pharmaceutical manufacturers and provides drug utilization and quality reviews. Price discounts may include rebates from a drug manufacturer based on the volume purchased.

AmeriHealth anticipates that it will pass on a high percentage of the expected rebates it receives from its PBM through reductions in the overall cost of pharmacy benefits. Under most benefits plans, prescription drugs are subject to a member copayment.

009569 (2008-0569) 08/09

AHPADE

009569 (2009-0356) 11/09

AHPADE

AmeriHealth Select Drug Program Formulary offered by: AmeriHealth HMO, Inc.

QCC Insurance Company, d/b/a AmeriHealth Insurance Company