Learning Center
Plans & pricing Sign in
Sign Out
Get this document free

Prescribing Information Loestrin 24 Fe - Excel

VIEWS: 435 PAGES: 46

Prescribing Information Loestrin 24 Fe document sample

More Info
									                                                    MAINECARE PREFERRED DRUG LIST *
                                                               -- INDEX --
                    DRUG CATEGORY                            Page #                            DRUG CATEGORY                               Page #
ACE AND THIAZIDE COMBO'S                                          9   ARTHRITIS - MISC.                                                        20
ACE INHIBITORS                                                    8   ARTIFICIAL SALIVA/STIMULANTS                                             30
ACE INHIBITORS AND CA CHANNEL BLOCKERS                            9   BETA BLOCKERS - ALPHA / BETA                                              8
ALCOHOL DETERRENTS                                               17   BETA BLOCKERS - CARDIO SELECTIVE                                          8
ALS DRUG                                                         18   BETA BLOCKERS - NON SELECTIVE                                             8
ALTERNATIVE MEDICINES                                            30   BETA BLOCKERS AND DIURETIC COMBO'S                                        9
ALZHEIMER - Cholinomimetics/nmda                                 17   BETA-LACTAMS / CLAVULANATE COMBO'S                                        1
AMINO GLYCOSIDES                                                  2   BPH                                                                      14
ANALGESICS - MISC.                                               17   Calcimmetic Agents SHPTH                                                  7
                                                                      CALCIUM CHANNEL BLOCKERS--Amlodipines, Bepridil, Diltiazems,
ANDROGENS / ANABOLICS                                             4   Felodipines, Isradipines, Nifedipines, Nisoldipine, and Verapamils        8
ANESTHETICS - MISC.                                              20   CANCER THERAPIES                                                         30
ANGIOTENSIN RECEPTOR BLOCKER                                      9   CARBAPENEMS                                                               3
ANORECTAL - MISC.                                                30   CARDIAC GLYCOSIDES                                                        7
ANTHELMINTICS                                                     2   CCB / LIPID                                                               9
ANTI INFECTIVE COMBO'S - MISC.                                    3   CEPHALOSPORINS                                                            1
ANTIANGINALS--Isosorbide Di-nitrate/Mono-Nitrates                 7   CHELATING AGENTS                                                         30
ANTIARRHYTHMICS                                                   8   CHOLESTEROL - BILE SEQUESTRANTS                                           9
ANTIASTHMATIC - ANTICHOLINERGICS INHALER                         10   CHOLESTEROL - FIBRIC ACID DERIVATIVES                                     9
ANTIASTHMATIC - ANTICHOLINERGICS NEBULIZER                       10   CHOLESTEROL - HGM COA + ABSORB INHIBITORS                                10
ANTIASTHMATIC - 5-Lipoxygenase Inhibitors                        11   CHOLINERGIC                                                               7
ANTIASTHMATIC - ADRENERGIC ANTICHOLINERGIC                       11   CONTRACEPTIVES - BI-PHASIC COMBINATIONS                                   5
ANTIASTHMATIC - ADRENERGIC COMBOS                                11   CONTRACEPTIVES - EMERGENCY CONTRACEPTIVE                                  5
ANTIASTHMATIC - ALPHA-PROTEINASE INHIBITOR                       11   CONTRACEPTIVES - INJECTABLE                                               5
ANTIASTHMATIC - ANTIINFLAMMATORY AGENTS                          10   CONTRACEPTIVES - PROGESTIN ONLY                                           5
ANTIASTHMATIC - BETA - ADRENERGICS                               11   CONTRACEPTIVES - TRI-PHASIC COMBINATIONS                                  5
ANTIASTHMATIC - HYDRO-LYTIC ENZYMES                              11   CONTRACEPTIVES -MONOPHASIC COMBINATION O/C'S                              5
ANTIASTHMATIC - MUCOLYTIC                                        11   CONTRACEPTIVES -PATCHES/ VAGINAL PRODUCTS                                 5
ANTIASTHMATIC - NASAL MISC.                                      10   COUGH/COLD                                                               11
ANTIASTHMATIC - NASAL STEROIDS                                   10   COX 2 INHIBITORS - HIGHLY SELECTIVE                                      19
ANTIASTHMATIC - STEROID INHALANTS                                11   COX 2 INHIBITORS-SELECTIVE                                               19
ANTIASTHMATIC - XANTHINES                                        11   CYTO-MEGALOVIRUS AGENTS                                                   3
ANTIASTHMATIC -LEUKOTRIENE RECEPTOR ANTAGONISTS                  11   DENTAL PRODUCTS                                                          29
ANTIBIOTICS - MISC.                                               2   DIABETIC - / THIAZOL                                                      6
ANTICOAGULANTS                                                   24   DIABETIC - INSULIN                                                        5
ANTICONVULSANTS                                                  20   DIABETIC - ALPHAGLUCOSIDASE                                               6
ANTIDEPRESSANTS - MAO INHIBITORS                                 14   DIABETIC - MEGLITINIDES                                                   6
ANTIDEPRESSANTS - SELECTED SSRI's                                14   DIABETIC - ORAL SULFONYLUREAS                                             6
ANTIDEPRESSANTS - TRI-CYCLICS                                    15   DIABETIC - OTHER                                                          6
ANTIEMETIC - 5-HT3 RECEPTOR ANTAGONISTS/ SUBSTANCE P             10   DIABETIC - PENFILLS                                                       5
ANTIEMETIC - ANTICHOLINERGIC / DOPAMINERGIC                      10   DIABETIC - SULFONYLUREA / BIGUANIDE                                       6
ANTIFUNGALS - ASSORTED                                            3   DIABETIC - THIAZOL / BIGUANIDE COMBO                                      6
ANTIHEMOPHILIC AGENTS                                            24   DIABETIC -ORAL BIGUANIDES                                                 6
ANTIHISTAMINES - NON-SEDATING                                    10   DIURETICS                                                                 9
ANTIHYPERTENSIVES - CENTRAL                                       9   EAR                                                                      29
ANTILEPROTIC                                                     30   ELECTROLYTES/ NUTRITIONALS                                               24
ANTIMALARIAL AGENTS                                               2   ERYTHROPOEITINS                                                          24
ANTIMYCOBACTERIALS / ANTITUBERCULOSIS                             2   ESTROGEN COMBO'S                                                          4
ANTIPSYCHOTICS - ATYPICALS                                       15   ESTROGENS - PATCHES                                                       4
ANTIPSYCHOTICS - SPECIAL ATYPICALS                               15   ESTROGENS - TABS                                                          4
ANTIPSYCHOTICS - TYPICAL                                         15   FLUOROQUINOLONES                                                          2
ANTIRETROVIRALS                                                   3   GH ANTAGONISTS                                                            7
ANTISPASMODICS                                                    7   GI - ANTI - FLATULENTS / GI STIMULANTS                                   12
ANTISPASMODICS - LONG ACTING                                      7   GI - ANTIDIARRHEAL / ANTACID - MISC.                                     11
ANTITHYROID THERAPIES                                             6   GI - ANTIPERISTALTIC AGENTS                                              11
ANXIOLYTICS - BENZODIAZEPINES                                    14   GI - DIGESTIVE ENZYMES                                                   12
ANXIOLYTICS - LONG ACTING                                        14   GI - H2-ANTAGONISTS                                                      12
ANXIOLYTICS - MISC.                                              14   GI - INFLAMMATORY BOWEL AGENTS                                           12
ARB'S AND DIURETICS                                               9   GI - IRRITABLE BOWEL SYNDROME AGENTS                                     13
GI - MISC.                                                       13   OP. - PROSTAGLANDINS                                                     26
GI - PROSTAGLANDINS                                              12   OP. - PROSTAGLANDINS                                                     26
GI - PROTON PUMP INHIBITOR                                       12   OP. - QUINOLONES                                                         25
GI - ULCER ANT-INFECTIVE                                         12   OP. - SELECTIVE ALPHA ADRENERGIC AGONISTS                                26
GLUCOCORTICOIDS/ MINERALOCORTICOIDS                           4   OPIOID DEPENDENCE TREATMENT                                      19
GOUT                                                         20   OSTEOPOROSIS                                                      7
GRANULOCYTE CSF                                              24   PARKINSONS - DOPAMINERGICS/CARBII/ LEVO                          21
GROWTH HORMONE                                                7   PARKINSONS - ANTICHOLINERGICS                                    21
HEMOSTATIC                                                   25   PARKINSONS - COMBO.                                              21
HEPATITIS B ONLY                                              3   PLATELET AGGR. INHIBITORS / COMBO'S - MISC.                      25
HEPATITIS C AGENTS                                            3   PLATELET AGGREGATION INHIBITORS                                  25
HEPATITS AGENTS - MISC.                                       3   PROGESTINS                                                        4
HERED. TYROSINEMIA                                            7   PSORIASIS BIOLOGICALS                                            30
HERPES AGENTS                                                 3   PSYCHOTHERAPEUTIC AGENTS - MISC.                                 17
IMMUNOSUPPRESSANTS                                           30   PSYCHOTHERAPEUTIC COMBINATION                                    16
IMPOTENCE AGENTS                                             10   PULMONARY ANTI-HYPERTENSIVES                                     10
INCRETIN MIMETIC                                              6   PURINE ANALOG                                                    30
INFLUENZA AGENTS                                              3   RHEUMATOID ARTHRITIS                                             20
K REMOVING RESINS                                            30   RSV PROPHYLAXIS                                                   4
LINCOSAMIDES / OXAZOLIDINONES / LEPROSTATICS                  3   SEDATIVE/HYPNOTICS - BARBITURATE                                 15
LITHIUM                                                      16   SEDATIVE/HYPNOTICS - BENZODIAZEPINES                             15
LONG ACTING - AMPHETAMINES                                   16   SEDATIVE/HYPNOTICS - Non-Benzodiazepines                         15
MACROLIDES / ERYTHROMYCIN'S                                   2   SOMATOSTATIC AGENTS                                               7
MIGRAINE - CARBOXYLIC ACID DERIVATIVES                       20   STIMULANT - AMPHETAMINES - LONG ACTING                           16
MIGRAINE - ERGOTAMINE DERIVATIVES                            20   STIMULANT - AMPHETAMINES -SHORT ACTING                           16
MIGRAINE - MISC.                                             20   STIMULANT - METHYLPHENIDATE                                      16
MIGRAINE - SELECTIVE SEROTONIN AGONISTS (5HT)--Tabs          20   STIMULANT - STIMULANT LIKE                                       17
MINERALS                                                     23   TETRACYCLINES                                                     2
MONO-NITRATES                                                 6   THYROID HORMONES                                                  6
MOUTH ANTI-INFECTIVES                                        29   TOPICAL - ANTIFUNGALS                                            27
MOUTH ANTISEPTICS                                            29   TOPICAL - CORTICOSTEROIDS                                        25
MULTIPLE SCLEROSIS AGENTS                                     4   TOPICAL - ACNE PREPARATIONS                                      26
MUSCLE RELAXANT -COMBINATIONS                                21   TOPICAL - ANTIBIOTIC                                             27
MUSCLE RELAXANTS                                             21   TOPICAL - ANTIPRURITICS                                          27
NARCOTIC - ANTAGONISTS                                       19   TOPICAL - ANTIPSORIATICS                                         27
NARCOTICS - MICS.                                            18   TOPICAL - ANTISEBORRHEICS                                        27
NARCOTICS - SELECTED                                         18   TOPICAL - ANTISEPTICS / DISINFECTANTS                            29
NARCOTICS-LONG ACTING                                        18   TOPICAL - ANTIVIRALS                                             27
NEUROLOGICS - MISC.                                           4   TOPICAL - ANTNEOPLASTICS                                         27
NICOTINE PATCHES / TABLETS                                   17   TOPICAL - ASTRINGENTS / PROTECTANTS                              26
NICOTINE REPLACEMENT - OTHER                                 17   TOPICAL - BURN PRODUCTS                                          27
NITRO - OINTMENT/CAP/CR                                       7   TOPICAL - CORTICOSTEROIDS                                        27
NITRO - PATCHES                                               7   TOPICAL - DEPIGMENTING AGENTS                                    28
NITRO - SUBLINGUAL/ SPRAY                                     8   TOPICAL - EMOLLIENTS                                             28
NSAID - PPI                                                  19   TOPICAL - ENZYMES / KERATOLYTICS / UREA                          28
NSAIDS                                                       19   TOPICAL - GENITAL WARTS                                          28
OP- Quinolones-4th Generation                                25   TOPICAL - IMMUNOMODULATORS                                       28
OP. - ADRENERGIC AGENTS                                      26   TOPICAL - LOCAL ANESTHETICS                                      28
OP. - ANTIALLERGICS                                          26   TOPICAL - SCABICIDES AND PEDICULICIDES                           28
OP. - ANTI-ALLERGICS- MASTCELL STABILIZER CLASS              26   TOPICAL - STEROID COMBINATIONS                                   28
OP. - ANTIBIOTICS                                            25   TOPICAL - STEROID LOCAL ANESTHETICS                              28
OP. - ANTIINFLAMMATORY / STEROIDS OPHTH.                     26   TOPICAL - WOUND / DECUBITUS CARE                                 29
OP. - ARTIFICIAL TEARS AND LUBRICANTS                        25   UROLOGICAL - MISC.                                               13
OP. - BETA - BLOCKERS                                        25   VAGINAL - ESTROGENS                                              14
OP. - CARBONIC ANHYDRASE INHIBITORS/COMBO                    26   VAGINAL - ANTI FUNGALS                                           14
OP. - CYCLOPLEGICS                                           26   VAGINAL - ANTIBACTERIALS                                         14
OP. - MIOTICS - DIRECT ACTING                                26   VAGINAL - CONTRACEPTIVES                                         14
OP. - MISC                                                   29   VAGINAL - OTHER                                                  14
OP. - NSAID'S                                                26   VASOPRESSINS                                                      7
OP. - OF INTEREST                                            26   VITAMINS                                                         21
PARKINSONS - COMT INHIBITORS                                 21   VITAMINS - MISC.                                                 22
PARKINSONS - SELECTED DOPAMIN AGONISTS                       21   WEIGHT LOSS                                                      17
PHOSPHATE BINDERS                                            14                                                 As of 03.01.2007
                                                                                     *Page numbers may be off due to formatting
                                                                                    Physicians' Summarized PDL                          Effective October 25, 2007

                                                                                                   Step                    NON-PREFERRED DRUGS
          CATEGORY                Step Order                 PREFERRED DRUGS                                                                                                            Comments
                                                                                                   Order                        PA Required
General Criteria for all PDL categories- For more information or help using the PDL, providers may call 1-888-445-0497; members should call 1-866-796-2463. To access PDL and PA materials via the internet:

General Criteria for all PDL categories- For more information or help using the PDL, providers may call 1-888-445-0497; members should call 1-866-796-2463. To access PDL and PA materials via the internet:

B: Requests for Non-preferred Drugs- Preferred drugs must be tried and failed due to lack of efficacy or intolerable side effects before non-preferred drugs will be approved, unless an acceptable clinical
exception is offered on the Prior Authorization form, such as the presence of a condition that prevents usage of the preferred drug or a significant potential drug interaction between another drug and the
preferred drug(s) exists.

C: Adequate Drug Trials- 1. The minimum trial period for each preferred and step order drug is two weeks, unless otherwise stated within specific PDL drug categories; trials with less than a two week
duration will be reviewed on a case-by-case basis; 2. A trial will not be considered valid if preferred or non-preferred products were readily available (by override, individual purchase, samples, etc.); 3.
Certain drug trials, such as with controlled substances, may require evidence that the preferred drugs were actually tried (example: with random pill counts and with urine drug tests, using methods of GC/MS
with no lower threshold); 4. Adequate trials require documentation of attempts to titrate dose of preferred agents toward desired clinical response. 5. Adequate trials include prevention/treatment of common
adverse effects associated with preferred agents (example: antinausea, antipruritics, etc.)

D: Step Order- When numbers appear in the "step order" column, it means drugs in this category must be used in the order specified, with the lower numbers having preference over the higher numbers.
Chart notes should be provided to confirm drug trials that do not appear in the member's MaineCare drug profile.

E: Brand Name Medication Requests- (Must be submitted on the Brand Name PA request form)- According to MaineCare Benefits Manual Chapter II (80.07-5), when medically necessary covered brand-name
drugs have an A-rated generic equivalent available, the most cost effective medically necessary version will be approved and reimbursed, since the brand-name and A-rated generic drugs have been
determined by the FDA to be chemically and therapeutically equivalent. The Bureau does not make determinations as to whether or not a generic drug is clinically inferior or inequivalent to its brand version.
This is the proper role of the FDA. Physicians should submit their reports of generic inequivalence directly to the FDA via the MEDWATCH.

F: PA requests for non- FDA Approved Indications- Decisions will be made on a case-by-case basis until the DUR committee is able to review the evidence and make a recommendation. Interim approvals and
DUR recommendations for approval of a drug for a non- FDA approved indication will require a minimum of two published, peer reviewed, non contradicted, double- blind, placebo-controlled randomized
clinical studies establishing both safety and efficacy.

G: Dose Consolidation Requirements- Some drugs may also be affected by dose consolidation requirements. Please see Dose Consolidation List and/or Splitting Tables provided in the PDL.

H. Trials from Multiple Drug Classes - Trial/failure/intolerance to preferred agents from multiple classes within the same category or other catagories of drugs may be required prior to the approval of non-
preferred agents (e.g., Cymbalta, Zofran, Elidel and others).

J. Drug-specific PA Forms- Drug-specific PA forms contain medical necessity documentation requirements and/or criteria that may not be repeated in the PDL. Drug-specific PA forms may be obtained on
the web at .

K. PA Exemptions for Prescribers- According to MaineCare Benefits Manual Chapter II (80.07-4), providers may receive a three (3) month exemption from prior authorization requirement for certain categories
of drugs when they demonstrate high compliance with the Department's PDL. The Department will notify providers in writing which drug categories are included and what dates apply to the exemption. If a
provider loses his/ her exemption, members who previously were not required to obtain a PA while the prescriber was exempt will be required to do so, and criteria for approval of that medication will need to
be met.

L: Drug-Drug Interactions (DDI)-The DUR Committee has implemented new drug-drug interation edits requiring prior authorization. Several drug-drug combinations and PDL drug catagories are affected by
new PA requirements. These will be indicated in the PDL with DDI notation. Please see the DDI document provided in the PDL.
                                                                                          ASSORTED ANTIBIOTICS
BETA-LACTAMS /                                 AMOXICILLIN                                                  AMOXIL 500MG TABS                                         1. Amoxil 500mg tabs are non-preferred. All
CLAVULANATE COMBO'S                            AMOXICILLIN/POTASSIUM CLA CHEW                                                                                         other Amoxil products are preferred.
                                                                                                                                                                      2.Principen 250 mg is available without PA.
                                               AMOXICILLIN/POTASSIUM CLA SUSR                               PRINCIPEN CAPS2
                                               AMOXICILLIN/POTASSIUM CLA TABS                               PRINCIPEN SUSR                                            3. Chewable 125mg & 250mg and Solution
                                               AMOXIL1                                                      AUGMENTIN ES-600 SUSR                                     125mg/5ml and 250mg/5ml available without
                                               AUGMENTIN XR TB12
                                               BICILLIN L-A SUSP                                                                                                      Use PA Form # 20420
                                               DICLOXACILLIN SODIUM CAPS
                                               DYNAPEN SUSR
                                               GEOCILLIN TABS
                                               OXACILLIN SODIUM SOLR
                                               PENICILLIN V POTASSIUM
                                               TICAR SOLR
                                               TIMENTIN SOLR
                                               UNASYN SOLR

CEPHALOSPORINS                                 CEFADROXIL HEMIHYDRATE                                       CECLOR1                                                   1. Both brand and generic are clinically non-
                                               CEFAZOLIN SODIUM SOLR                                        CEFACLOR1                                                 preferred.

                                                                                                 Page 3 of 46
                                                                                         1. Both brand and generic are clinically non-
                       CEDAX                               CEFADROXIL MONOHYDRATE TABS
                       CEFPODOXIME 200MG                   CEFPODOXIME 100MG
                       CEFUROXIME AXETIL TABS              CEFPODOXIME SUSP
                       CEFTIN SUSP                         CEFTIN
                       CERTRIAZONE                         DURICEF TABS
                       CEFZIL                              FORTAZ SOLN
                       CEPHALEXIN MONOHYDRATE              KEFLEX CAPS
                       DURICEF SUSR                        ROCEPHIN
                       FORTAZ SOLR                         TAZICEF SOLR                  Use PA Form # 20420
                       KEFZOL SOLR                         VANTIN 200MG
                       MAXIPIME SOLR
                       VANTIN 100MG
                       VANTIN SUSP
MACROLIDES /           BIAXIN XL1                          BIAXIN                        1. 7 - Day supply per month w/o PA
ERYTHROMYCIN'S         AZITHROMYCIN TABS                   CLARITHROMYCIN SUSP           Use PA Form # 20420
                       AZITHROMYCIN SUSP                   DYNABAC D5-PAK TBEC
                       CLARITHROMYCIN TABS                 ERYPED CHEW
                       E.E.S.                              PCE TBEC
                       E-MYCIN TBEC                        ZITHROMAX TABS
                       ERYPED 200 SUSR                     ZITHROMAX 1GM PAK
                       ERYPED 400 SUSR                     ZITHROMAX TRI-PAK
                       ERY-TAB TBEC                        ZITHROMAX SUSP.
                       ERYTHROCIN STEARATE TABS

TETRACYCLINES          DOXYCYCLINE HYCLATE                 DECLOMYCIN TABS               Use PA Form # 20420
                       MINOCYCLINE HCL CAPS                DORYX CPEP
                       SUMYCIN                             DOXYCYCLINE MONO CAPS
                       TETRACYCLINE HCL CAPS               DYNACIN CAPS
                       VIBRAMYCIN SYRP                     MONODOX CAPS
                                                           SOLODYN ER
FLUOROQUINOLONES       AVELOX SOLN                         CIPRO                         1. QL 3/script/month
                       AVELOX TABS                         FACTIVE
                       AVELOX ABC PACK TABS                FLOXIN TABS                   Use PA Form # 20420
                       CIPRO XR1                           LEVAQUIN
                       CIPROFLOXACIN                       NOROXIN TABS
                       PROQUIN XR                          TEQUIN
                       NEOMYCIN SULFATE TABS
                       TOBI NEBU
                       TOBRAMYCIN SULFATE SOLN
ANTIMYCOBACTERIALS /   ETHAMBUTOL HCL TABS                 RIMACTANE CAPS                Use PA Form # 20420
                       MYCOBUTIN CAPS
                       DARAPRIM TABS                       ISONARIF  1

                       HYDROXYCHLOROQUINE TABS             MALARONE TABS                 1. Ingredients available as preferred without
                       LARIAM TABS                         PLAQUENIL TABS                PA.
                       MEFLOQUINE HCL TABS                 QUALAQUIN
                       QUINACRINE HCL POWD
                       QUININE SULFATE
ANTHELMINTICS          ALBENZA TABS                        VERMOX CHEW                   Use PA Form # 20420
                       BILTRICIDE TABS
                       MEBENDAZOLE CHEW
                       STROMECTOL TABS
ANTIBIOTICS - MISC.    AZACTAM SOLR                        COLY-MYCIN-M SOLR             1. Need to fail other anti-protozoals
                       COLISTIMETHATE SODIUM SOLR          FLAGYL CAPS                   2. 375mg caps and 750mg tabs are non-
                       FUROXONE TABS                       FLAGYL TABS                   preferred. Please use available preferred
                                                                                         strengths(25omg & 500mg tabs) to obtain
                                                                                         required dose without PA.
                                                    Page 4 of 46
                                                                                                         2. 375mg caps and 750mg tabs are non-
                                                                                                         preferred. Please use available preferred
                                                                                                         strengths(25omg & 500mg tabs) to obtain
                           METRONIDAZOLE2                                 FLAGYL ER TBCR
                                                                                                         required dose without PA.
                           PENTAMIDINE ISETHIONATE SOLR                   KETEK
                           PRIMSOL SOLN                                   LORABID
                           TRIMETHOPRIM TABS                              METRONIDAZOLE 375MG CAPS2      Use PA Form # 20420
                           VANCOCIN HCL                                   METRONIDAZOLE 750MG TABS   2

                           VANCOMYCIN HCL                                 NEBUPENT SOLR
                                                                          PROLOPRIM TABS
CARBAPENEMS                                                               INVANZ SOLR                    Use PA form #20420.
                                                                          MERREM SOLR
LINCOSAMIDES /             CLEOCIN SOLN                                   CLEOCIN CAPS                   1. Use multiple 150's for Clindamycin instead
OXAZOLIDINONES /           CLEOCIN SUSR                                                                  of 300's.
                                                                          CLINDAMYCIN HCL 300CAPS1
                           CLINDAMYCIN HCL 150CAPS                        ZYVOX SUSR                     Zyvox: use PA Form # 30820
                           DAPSONE TABS                                   ZYVOX TABS                     Others: use PA Form # 20420
ANTI INFECTIVE COMBO'S -   ERYTHROMYCIN/SULF SUSR                         BACTRIM DS TABS                Use PA Form # 20420
MISC.                      SEPTRA/DS TABS
ANTIPROTOZOALS                                                            ALINIA1                        1. Alina is preferred for children less than 12
                                                                                                         years of age. Use PA Form # 20420

                                                                 ANTI - FUNGALS
ANTIFUNGALS - ASSORTED     ANCOBON CAPS                              5    LAMISIL TABS4                  1. QL--1/every 7-day period (150mg only). 2.
                           FLUCONAZOLE    1                                                              Sporanox QL 300cc/month with PA. See
                                                                     6    SPORANOX SOLN2
                                                                                                         quantity limit table. 3. Sporanox QL 30/month
                           GRIFULVIN                                 6    SPORANOX PULSEPAK CAPS3        with PA. See quantity limit table. Non-preferred
                           GRISEOFULVIN SUSP                         7    SPORANOX CAPS3                 products must be used in specified step order.
                           GRISEOFULVIN ULTRAMICROSI TABS   10       8    ERAXIS INJ6                    Continue to use Anti-Fungal PA form for non-
                                              10                     8    DIFLUCAN                       preferred products.
                           GRIS-PEG TABS
                           KETOCONAZOLE TABS8                        8    GRIFULVIN SUSP
                           NYSTATIN                                  8    NIZORAL TABS
                           TERBINAFINE TABS4                         8    NOXAFIL5                        4. Quantity limit of one tablet daily. Please
                           VFEND TABS                                                                    see dosage consolidation list.
                                                                                                         5. Approved if immuno suppressed/ HIV or if
                                                                                                         the member has failed a 7 day trial of a
                                                                                                         preferred antifungal therapy.

                                                                                                         6. Eraxis will be approved if submitting with
                                                                                                         documentation that it was initiated during a
                                                                                                         hospitalization and this request is to finish the
                                                                                                         hospital course.

                                                                                                         8. Quantity limits allowing 30 day supply
                                                                                                         without PA. PA will be required if using > 30

                                                                                                         10. For children < 18, quantity limits allows 8
                                                                                                         weeks supply without PA. PA will be required if
                                                                                                         using > than 8 weeks. If 18 and older PA will
                                                                                                         be required for any quantity. Not approving for
                                                                                                         Onychomycosis indication.
                                                                                                         Please use PA form #20420 for Noxafil.

                                                                  ANTI - VIRALS
ANTIRETROVIRALS            AGENERASE CAPS                                 DIDANOSINE                     Fuzeon use PA Form # 10620
                           APTIVUS                                        FUZEON                         1. Quantity limit of per per day
                           ATRIPLA1                                                                      2. Only preferred if Norvir script is in member's
                           COMBIVIR TABS                                                                 profile within past 30 days of filling Prezista
                           CRIXIVAN CAPS
                           EPIVIR / HBV
                           FORTOVASE CAPS
                           HIVID TABS
                           INVIRASE CAPS

                                                                  Page 5 of 46
                           RESCRIPTOR TABS
                           TRIZIVIR TABS
                           VIDEX / EC
                           VIRACEPT TABS
                           VIRAMUNE TABS
                           VIREAD TABS
                           ZIAGEN TABS
CYTO-MEGALOVIRUS AGENTS    FOSCARNET SODIUM                           CYTOVENE CAPS              Use PA Form # 20420
                           VALCYTE TABS                               GANCICLOVIR
HERPES AGENTS              ACYCLOVIR                                  FAMVIR TABS                Must fail Acyclovir and Valtrex before non-
                           VALTREX TABS                               ZOVIRAX                    preferred products. Use PA Form # 20420
INFLUENZA AGENTS           AMANTADINE                                 FLUMADINE TABS             1. Tamiflu 10 caps or 60cc's per month. Will be
                           RELENZA DISKHALER AEPB                     FLUMIST2                   audited for presence of positive influenza tests
                                                                                                 in patient or family member. 2. Flumist use
                           RIMANTADINE HCL TABS
                                                                                                 Form #10610.            Use PA Form #20420

                                                             IMMUNE SERUMS
                                                            HEPATITIS AGENTS
HEPATITIS C AGENTS         PEG-INTRON                            8    COPEGUS TABS
                                                                                                 1. Dosing limits apply, please see dosage
                           PEGASYS KIT                                                           consolidation list.
                           PEGASYS SOLN                                                           Use PA Form # 20420
                           REBETOL CAPS
                           REBETRON KIT
                           RIBAVIRIN CAPS
HEPATITIS AGENTS - MISC.                                              ACTIMMUNE                  Use PA Form # 20420
HEPATITIS B ONLY           HEPSERA TABS                               BARACLUDE
                                                            RSV PROPHYLAXIS
RSV PROPHYLAXIS                                                      RESPIGAM                    Use PA Form # 30120
                                                                      SYNAGIS1                   1. MaineCare will approve Synagis PA's for
                                                                                                 start date of November 5th for infants who
                                                                                                 meet the guidelines. PA will be approved for
                                                                                                 max of 5 doses and good thru March 31,
                                                                                                 unless Maine specific data suggests ongoing
                                                                                                 epidemic RSV activity.

                                                             MS TREATMENTS
MULTIPLE SCLEROSIS                                               5   AVONEX KIT                  Established users are grandfathered. Must
AGENTS                                                           5    BETASERON SOLR             follow specif step order. Use PA fomr #20430
                                                                 5    REBIF SOLN
                                                                 6    COPAXONE
                                                          ASSORTED NEUROLOGICS
NEUROLOGICS - MISC.        MESTINON                                   BOTOX                      1. Myobloc approval will be limited to Cervical
                           ORAP TABS                                  MYOBLOC1                   Dystonia.
                           PROSTIGMIN TABS                                                       Use PA Form #10210
GLUCOCORTICOIDS/           CELESTONE SUSP                            CORTEF 10 and 20 TABS       Use PA Form # 20420
MINERALOCORTICOIDS         CORTEF 5                                   DECADRON TABS
                           CORTISONE ACETATE TABS                     FLORINEF TABS
                           DELTASONE TABS                             MEDROL TABS
                           DEPO-MEDROL SUSP                           MEDROL DOSEPAK TABS
                           DEXAMETHASONE                              ORAPRED SOLN
                           ENTOCORT EC CP24                           PEDIAPRED LIQD
                           HYDROCORTISONE                             PRELONE SYRP
                           KENALOG                                    STERAPRED TABS
                           METHYLPREDNISOLONE TABS

                                                              Page 6 of 46
                            SOLU-CORTEF SOLR
                            SOLU-MEDROL SOLR
                                                      HORMONE REPLACEMENT THERAPIES
ANDROGENS / ANABOLICS       ANDRODERM PT24                            ANDRO LA 200 OIL                 1. Non Preferred effective 12.01.2005. Use the
                            ANDROID CAPS                              ANDROGEL PACK                    Oxandrin PA Form #20600.
                            DANAZOL CAPS                              DELATESTRYL OIL                  Use PA Form # 20420
                            DEPO-TESTOSTERONE OIL                     HALOTESTIN TABS
                            FLUOXYMESTERONE TABS                      METHITEST TABS
                            TESTODERM                                 OXANDRIN TABS1
                            TESTOSTERONE PROPIONATE
                            TESTRED CAPS
                            WINSTROL TABS
ESTROGENS - PATCHES         ESTRADERM PTTW                        5   ESTRADIOL PTWK                   All patches are non-preferred products (require
                                                                  8   ALORA PTTW                       PA). Products must be used in specified step
                            VIVELLE PTTW
                                                                  8   CLIMARA PTWK
                                                                  8   ESCLIM PTTW                      Use PA Form # 20420
                                                                  8   VIVELLE-DOT PTTW

ESTROGENS - TABS            CENESTIN TABS                             ENJUVIA                          Must fail preferred products before non-
                            DELESTROGEN OIL                           ESTRACE TABS                     preferred products. Use PA Form # 20420
                            ESTRADIOL                                 ESTRATAB TABS
                            ESTROPIPATE TABS                          OGEN TABS
                            MENEST TABS                               ORTHO-EST TABS
                            PREMARIN TABS
ESTROGEN COMBO'S            PREMPHASE TABS                            ACTIVELLA TABS                   Must fail Premphase and Prempro products
                            PREMPRO TABS                              COMBIPATCH PTTW                  before non-preferred products. Use PA Form
                                                                                                       # 20420
                                                                      FEMHRT 1/5 TABS
                                                                      ORTHO-PREFEST TABS
                                                                      SYNTEST H.S. TABS
PROGESTINS                  MEDROXYPROGESTERONE ACETA 2               AYGESTIN TABS                    1. PA approvals will require two 100 mg caps
                            NORETHINDRONE ACETATE TABS2               CYCRIN TABS                      instead of one 200mg.
                            PROGESTERONE POWD                         PROMETRIUM 100MG CAPS1
                                                                                                       2. Must fail Medroyxprogesterone and
                                                                      PROMETRIUM 200MG1
                                                                                                       Norethidrone products before non-preferred
                                                                      PROVERA TABS                     products. Use PA Form #20420
CONTRACEPTIVES -            CAMILA TABS                               ORTHO MICRONOR TABS              If member experienced advere reactions,
PROGESTIN ONLY              ERRIN                                     OVRETTE 28 TABS                  consider using Oral Contraceptives from other
                                                                                                       groups. Use PA Form # 20420
                            NORA-BE TABS
                            NOR-QD TABS
CONTRACEPTIVES -            DEPO-PROVERA SUSP                         LUNELLE SUSP                     Use PA Form # 20420
INJECTABLE                                                            MEDROXYPROGESTERONE ACETATE IM
CONTRACEPTIVE -             PLAN-B1                                                                    1. Allowed 4 tablets per 30 days without PA
CONTRACEPTIVES - PATCHES/   NUVARING RING3                                                             1. No PA required for users less than 21 years
VAGINAL PRODUCTS                               1,24                                                    of age. 2. The FDA has issued a public health
                            ORTHO EVRA PTWK
                                                                                                       warning of the potentials for increased
                                                                                                       exposure to estrogen with Ortho Eva use,
                                                                                                       possibly up to 60% estrogen exposoure.

                                                                                                       3. Quantity limit allowing 1 every 28 days with
                                                                                                       out PA.
                                                                                                       4. Dose limits apply allowing 3 patches per 28
                                                                                                       days supply. Please refer to Dose
                                                                                                       Consolidation Chart. Use PA Form # 20420

CONTRACEPTIVES -            ALESSE-28 TABS                            APRI TABS                        Loestrin FE and FE 1/20 are grandfathered for
MONOPHASIC COMBINATION      LEVLEN-28 TABS                            AVIANE TABS                      established users. If member experienced
O/C'S                                                                                                  advere reactions, consider using Oral
                            LEVLITE-28 TABS1                          BREVICON-28 TABS
                                                                                                       Contraceptives from other groups.
                            LO/OVRAL 21 TABS                          CRYSELLE-28 TABS
                            LO/OVRAL 28 TABS                          DEMULEN 1/35-21 TABS             1. Levlite is preferred until Alesse is available
                            MODICON TABS                              DESOGEN TABS                     again
                            MONONESSA                                 KARIVA TABS                      2. Preferred Levlen has the same active
                            ORTHO-CEPT-28 TABS                        LESSINA-28 TABS                  ingredient as Seasonale and is available
                                                                                                       without pa.

                                                               Page 7 of 46
                                                                                                                2. Preferred Levlen has the same active
                                                                                                                ingredient as Seasonale and is available
                                                                                                                without pa.
                             ORTHO-NOVUM 1/35-28 TABS                LEVORA
                             ORTHO-NOVUM 1/50-28 TABS                LOESTRIN TABS                              Use PA Form # 20420
                             OVCON-35/28 TABS                        LOESTRIN FE TABS
                             OVCON-50 28 TABS                        LOESTRIN FE 1/20 TABS
                             PREVIFEM                                LOESTRIN 1.5/30-21 TABS
                             SPRINTEC 28 TABS                        LOESTRIN 1/20-21 TABS
                                                                     LOW-OGESTREL TABS
                                                                     MICROGESTIN FE TABS
                                                                     MIRCETTE TABS
                                                                     NORDETTE-28 TABS
                                                                     OGESTREL TABS
                                                                     ORTHO-CYCLEN-28 TABS
                                                                     PORTIA-28 TABS
                                                                     YASMIN 28 TABS
CONTRACEPTIVES - BI-PHASIC   ORTHO-NOVUM 10/11-28 TABS               NECON 10/11-28 TABS                        If member experienced advere reactions,
COMBINATIONS                                                                                                    consider using Oral Contraceptives from other
                                                                                                                groups. Use PA Form # 20420

CONTRACEPTIVES - TRI-        ENPRESSE                                CYCLESSA TABS                              Use PA Form # 20420
PHASIC COMBINATIONS          NECON 7/7/7                             ESTROSTEP FE TABS
                             NORTREL 7/7/7                           ORTHO-NOVUM 7/7/7-28 TABS
                             TRI-LEVLEN TABS                         ORTHO TRI-CYCLEN TABS
                             TRI-PREVIFEM                            ORTHO TRI-CYCLEN LO TABS
                             TRIPHASIL 28 TABS                       TRI-NORINYL 28 TABS
                             TRIVORA-28 TABS
                                                            DIABETES THERAPIES
DIABETIC - INSULIN           ILETIN                                  HUMALOG                                    *Established users grandfathered until
                             LEVEMIR (effective 4.1.2006)            HUMULIN                                    6.30.2006                              Use PA
                                                                                                                Form # 20420
                             NOVOLIN                                 LANTUS SOLN (effective 5.1.2006)*
                             VELOSULIN BR SOLN
DIABETIC - PENFILLS                                              5   NOVOLIN PENFILL                            PA's will be granted for significant visual or
                                                                 5   LEVEMIR FLEXPEN (effective 4.1.2006)       neurological impairment. Products must be
                                                                                                                used in specified step order.
                                                                 5   NOVOLOG PENFILL SOLN
                                                                 5   NOVOLOG MIX PENFILL
                                                                 8   APIDRA OPTICLIK PEN (effective 5.1.2006)
                                                                 8   HUMALOG MIX 75/25 PEN SUSP
                                                                 8   LANTUS OPTICLIK PEN (effective 5.1.2006)
                                                                 8   HUMALOG PEN SOLN                           Use PA Form # 20420
                                                                 8   HUMULIN PEN
DIABETIC - INSULIN INHALED   EXUBERA1                                                                           1. Preferred if following condictions are met: A)
                                                                                                                On insulin or B) Have tried 2 oral
                                                                                                                hypoglycemics and C) Not using nicotine and
                                                                                                                no nicotine products are seen in current drug
                                                                                                                profile. and D) No asthma/COPD medications
                                                                                                                in profile and E) Member is >18. Use PA Form
                                                                                                                # 20420

DIABETIC - DPP- 4 ENZYME                                         8   JANUVIA1                                   1. Dosing limits apply. Please refer to Dose
INHIBITOR                                                                                                       consolidation list.
DIABETIC - OTHER                                                     SYMLIN                                     Use PA Form # 30150
DIABETIC MONITOR             FREESTYLE LITE SYSTEM KIT               ACCUCHECK                                  Effective October 25th, approvals for all non
                                                                                                                preferred meters/ test strips will require medical
                             FREESTYLE FLASH SYSTEM KIT              ASCENSIA
                                                                                                                necessity documenting clinically significant
                             FREESTYLE FREEDOM SYSTEM KIT            ASSURE                                     features that are not available on any of the
                             ONE TOUCH ULTRA 2 KIT                   EXACTECH                                   preferred meters.

                             ONE TOUCH ULTRA MINI KIT                PRODIGY

                                                              Page 8 of 46
                            ONE TOUCH ULTRA SMART KIT                                             Use PA Form # 20420
                            PRECISION XTRA METER
DIABETIC TEST STRIPS        FREESTYLE1                                ACCUCHECK                   Effective October 25th, approvals for all non
                                                                                                  preferred meters/ test strips will require medical
                            FREESTYLE LITE1                           ASCENSIA
                                                                                                  necessity documenting clinically significant
                            ONE TOUCH BASIC1                          ASSURE                      features that are not available on any of the
                                                 1                    EXACTECH                    preferred meters.
                            ONE TOUCH SURESTEP
                            ONE TOUCH FAST TAKE   1                   PRODIGY

                            ONE TOUCH ULTRA1                                                      1. Only 50 ct & 100 ct package size.
                            PRECISION XTRA   1                                                    Use PA Form # 20420
                            PRECISION XTRA BETA KETONE 10 CT
INCRETIN MIMETIC            BYETTA1                                                               1. Will not require PA if at least 18 years of age
                                                                                                  and if two of the following three are seen in the
                                                                                                  members drug profile: sulfonylurea, metformin
                                                                                                  and Actos/ Avandia or if a combo product with
                                                                                                  Actos/ Avandia is seen. If insulin is in members
                                                                                                  current drug profile (within the past 30 days) PA
                                                                                                  will be required. If the member is under 18
                                                                                                  years of age, PA will be required. Dosing limits
                                                                                                  for Byetta will still apply. There are 60 doses
                                                                                                  per each pen and each pen is a 30 day supply,
                                                                                                  so one prefilled pen is allowed per month.
                                                                                                  Please refer to PDL Dosage Consolidation List.
                                                                                                  Use PA Form # 10230

DIABETIC - ORAL             CHLORPROPAMIDE TABS                       AMARYL TABS                 Use PA Form # 20420
SULFONYLUREAS               GLIMEPIRIDE                               DIABETA TABS
                            GLIPIZIDE TABS                            GLUCOTROL TABS
                            GLIPIZIDE ER TABS                         GLUCOTROL XL TBCR
                            GLYBURIDE TABS                            GLYNASE TABS
                            GLYBURIDE MICRONIZED TABS                 MICRONASE TABS
                            TOLAZAMIDE TABS
                            TOLBUTAMIDE TABS
DIABETIC -ORAL BIGUANIDES   METFORMIN HCL TABS                        GLUCOPHAGE TABS             Metformin ER 750mg tabs are non-preferred.
                            METFORMIN ER 500MG                        GLUCOPHAGE XR TB24          Metformin ER 500mg tabs are preferred. Use
                                                                                                  PA Form # 20420
                                                                      METFORMIN ER 750MG

DIABETIC - THIAZOL /        ACTOPLUS MET                                                          1. Tentatively preferred. Will be formally
BIGUANIDE COMBO                         1                                                         reviewed at an upcoming DUR meeting.
DIABETIC - / THIAZOL        AVANDIA TABS1                             ACTOS 30MG TABS 2           1. Actos and Avandia preferred without PA if
                            ACTOS 15MG TABS1                                                      patient on insulin or sulfonylurea or metformin.
                                                                                                  Actos and Avandia non-preferred as
                            ACTOS 45MG TABS1                                                      monotherapy.
                                                                                                  2. Actos 30mg - use two 15mg instead Use
                                                                                                  PA Form # 20420

DIABETIC -                  GLYSET TABS                               PRECOSE TABS                Use PA Form # 20420
DIABETIC - SULFONYLUREA /   GLYBURIDE/METFORMIN                       GLUCOVANCE TABS             Use individual ingredients.
BIGUANIDE                                                             DUETACT
                                                                      METAGLIP TABS               Use PA Form # 20420
DIABETIC - MEGLITINIDES     STARLIX TABS                              PRANDIN TABS                Use PA Form # 20240
                            CYTOMEL TABS                              SYNTHROID TABS  1

                            LEVOTHROID TABS
                            LEVOTHYROXINE SODIUM TABS
                            LEVOXYL TABS
                            THYROID TABS
                            UNITHROID TABS
ANTITHYROID THERAPIES       METHIMAZOLE TABS                          TAPAZOLE TABS               Use PA Form # 20420

                                                               Page 9 of 46
                            PROPYLTHIOURACIL TABS
OSTEOPOROSIS                BONIVA TABS                                   ACTONEL TABS                   1. Approval only requires failure of Fosamax or
                            FOSAMAX TABS2                                 AREDIA SOLR                    Boniva. 2. Quantity Limits Apply
                            FOSAMAX PLUS D2                                                              Use PA Form # 20420
                                                                          BONIVA INJECTION KIT
                            FOSAMAX SOLN    2                             DIDRONEL TABS
                            MIACALCIN SOLN2                               EVISTA TABS1
                                                           CALCIMIMETIC/ SHPTH AGENTS
CALCIMIMETIC AGENTS -                                                     SENSIPAR                       Use PA Form # 30115
                                                                GROWTH HORMONE
GROWTH HORMONE                                                       5    GENOTROPIN                     Products must be used in specified step order.
                                                                     5    NUTROPIN                       All step 5 drugs must be tried.

                                                                     5    TEV-TROPIN
                                                                     8    HUMATROPE SOLR                 Use PA Form # 10710
                                                                     8    INCRELEX
                                                                     8    IPLEX
                                                                     8    NORDITROPIN CARTRIDGE SOLN
                                                                     8    SAIZEN SOLR
                                                          GROWTH HORMONE ANTAGONISTS
GH ANTAGONISTS                                                            SOMAVERT                       Use PA Form # 10710
                                                              URINARY INCONTINENCE
VASOPRESSINS                DESMOPRESSIN TABS                        5    DDAVP TABS                     Products must be used in specified step order.
                                                                     6    DDAVP SOLN                     Nocturnal enuresis patients will be encouraged
                                                                                                         to periodically attempt stopping DDAVP.
                                                                     6    DESMOPRESSIN SPRAY
                                                                                                         *Patients with a diagnosis of hemophilia or Von
                                                                     8    DESMOPRESSIN ACETATE SOLN      Willebrands disease will be exempt from prior
                                                                     8    STIMATE SOLN*                  authorization.Use PA Form # 20420

ANTISPASMODICS              OXYBUTYNIN                                    CYSTOSPAZ TABS                 Use PA Form # 20420
                            URISPAS TABS                                  DETROL TABS
ANTISPASMODICS - LONG       DETROL LA CP24                                DITROPAN XL TBCR               Use PA Form # 20420
ACTING                                                                    OXYTROL                        1. Vesicare 5mg and Enablex 7.5mg maximum
                            SANCTURA                                                                     doses if given with drugs known to be
                                                                                                         significant CYP3A4 inhibitors.(Ketoconazole,
                            VESICARE1                                                                    Sporanox, Erythromycin, Biaxin, Nefazodone,
                                                                                                         Nelfinavir, and Ritonavir)

HERED. TYROSINEMIA                                                        ORFADIN                        Use PA Form # 20420
                                                           ANTIHYPERTENSIVES / CARDIAC
ANTIANGINALS--Isosorbide    ISOSORBIDE MONONITRATE TABS                   DILATRATE SR CPCR              Use PA Form # 20420
                                                                          ISORDIL TITRADOSE TABS
                                                                          ISOSORBIDE DINITRATE SUBL
                                                                          ISOSORBIDE DINITRATE TABS
                                                                          ISOSORBIDE DINITRATE CR TBCR
                                                                          ISOSORBIDE DINITRATE ER TBCR
                                                                          ISOSORBIDE DINITRATE TD TBCR
                                                                          IMDUR TB24
                                                                          ISMO TABS
                                                                          MONOKET TABS
                            NITROGLYCERIN CPCR

                                                                  Page 10 of 46
                                    NITROL OINT
                                    NITRO-TIME CPCR
NITRO - PATCHES                 1   NITROGLYCERIN PT24                 NITRODISC PT24          At leaset 2 step 1's and step 3 of the preferred
                                1   NITREK PT24                        NITRO-DUR PT24          products must be used in specified order or PA
                                                                                               will be required. Use PA Form # 20420
                                1   NITRO-DUR PT 24 0.8MG
                                3   MINITRAN PT24                                              Use PA Form # 20420
NITRO - SUBLINGUAL/ SPRAY           NITROLINGUAL AERS                  NITROLINGUAL SOLN       Use PA Form # 20420
                                    NITROSTAT SUBL                     NITROQUICK SUBL
                                    NITROTAB SUBL
BETA BLOCKERS - NON                 CARVEDILOL                         CORGARD TABS            1. Recommend using BID since its effects do
SELECTIVE                           COREG TABS                         INDERAL TABS            not last 24 hours.
                                    COREG CR2                          INNOPRAN XL
                                    INDERAL LA CPCR                    PROPRANOLOL LA CAPS
                                    LEVATOL TABS                       RANEXA                  2. Coreg CR currently has dosing limitations
                                    NADOLOL TABS                                               allowing one capsule per day. Please refer to
                                                                                               the Dose Consolidation List.
                                    PINDOLOL TABS
                                    PROPRANOLOL HCL SOLN1                                      Use PA Form # 20420
                                    PROPRANOLOL HCL TABS1
                                    TIMOLOL MALEATE TABS
BETA BLOCKERS - CARDIO              ACEBUTOLOL HCL CAPS                KERLONE TABS            1. Recommend using Atenolol (and
SELECTIVE                                            1                 LOPRESSOR TABS          metoprolol) BID since its effects do not last 24
                                    ATENOLOL TABS
                                                                                               hours. Use PA Form 20420
                                    BETAXOLOL HCL TABS                 METOPROLOL ER
                                    BISOPROLOL FUMARATE TABS           SECTRAL CAPS
                                    METOPROLOL TARTRATE TABS1          TENORMIN TABS
                                    TOPROL XL TB24                     ZEBETA TABS
BETA BLOCKERS - ALPHA /             LABETALOL HCL TABS                 TRANDATE TABS           Use PA Form 20420
CALCIUM CHANNEL                     AMLODIPINE1                        NORVASC TABS1           1. Dosing limits apply, please see dose
BLOCKERS--Amlodipines,                                                                         consolidation list.
Bepridil, Diltiazems,
Felodipines, Isradipines,       1   CARDIZEM LA TB24               5   DILACOR XR CP24         Products must be used in specified order or PA
Nifedipines, Nisoldipine, and   1   DILTIA XT CP24                 6   TAZTIA                  will be required. Just write "Cardizem LA" or
Verapamils                                                                                     "Diltiazem 24-hour"and the pharmacy will use a
                                1   DILTIAZEM HCL ER CP24          7   TIAZAC CP24
                                                                                               preferred long acting diltiazem that does not
                                1   DILTIAZEM HCL XR CP24          8   CARDIZEM TABS           require PA.
                                1   DILTIAZEM CD 300MG CP24        8   CARDIZEM CD CP24
                                1   DILTIAZEM CD 360MG CP24        8   CARDIZEM SR CP12
                                4   CARTIA XT CP24                 8   DILTIAZEM HCL TABS      Use PA Form # 20420
                                4   DILTIAZEM CD CP24              8   DILTIAZEM HCL ER CP12
                                4   DILTIAZEM HCL ER CP24
                                4   DILTIAZEM XR CP24
                                                                       PLENDIL TB24            Use PA Form # 20420
                                                                       DYNACIRC CAPS           Use PA Form # 20420
                                                                       DYNACIRC CR TBCR  1     1. Grandfather established users
                                                                       CARDENE CAPS            Use PA Form # 20420
                                                                       CARDENE SR CPCR
                                                                       NICARDIPINE HCL CAPS
                                    AFEDITAB CR                    8   ADALAT CC TBCR          Established users of Adalat CC are
                                    NIFEDIAC CC                    8   NIFEDIPINE CAPS         grandfathered
                                    NIFEDICAL XL TBCR              8   PROCARDIA CAPS          Use PA Form # 20420
                                    NIFEDIPINE TBCR                8   PROCARDIA XL TBCR
                                    NIFEDIPINE ER TBCR

                                    SULAR TB24
                                    VERAPAMIL HCL CR TBCR              CALAN TABS              Products must be used in specified order or PA
                                    VERAPAMIL HCL ER TBCR              CALAN SR TBCR           will be required. Just write "Verapamil 24-hour"
                                                                                               and the pharmacy will use a preferred long
                                    VERAPAMIL HCL SR TBCR              COVERA-HS TBCR
                                                                                               acting generic that does not require PA.
                                    VERELAN PM CP24                    ISOPTIN-SR
                                                                       VERAPAMIL HCL ER CP24
                                                                       VERAPAMIL HCL SR CP24   Use PA Form # 20420
                                                                       VERAPAMIL HCL TABS
                                                                       VERELAN CP24
ANTIARRHYTHMICS                     AMIODARONE                         BETAPACE TABS           1. Prescription must be written by Cardiologist.
                                    FLECAINIDE                         BETAPACE AF TABS
                                    MEXILETINE                         CORDARONE               Use PA Form # 20420
                                    NORPACE                            DISOPYRAMIDE
                                    PROCAINAMIDE                       MEXITIL

                                                                Page 11 of 46
                           PROCANBID CR                         PACERONE
                           PROPAFENONE                          QUINIDEX
                           QUINAGLUTE                           RYTHMOL SR
                           QUINIDINE GLUCONATE                  TAMBOCOR
                           QUINIDINE SULFATE                    TIKOSYN1
                           SOTALOL HCL TABS

ACE INHIBITORS             BENAZEPRIL HCL                   5   MAVIK TABS               Non-preferred products must be used in
                           CAPTOPRIL TABS                   8   ACCUPRIL TABS            specified order.
                           ENALAPRIL MALEATE TABS           8   ACEON TABS
                           FOSINOPRIL SODIUM                8   ALTACE
                           LISINOPRIL TABS                  8   CAPOTEN TABS             Use PA Form # 20420
                           QUINAPRIL                        8   LOTENSIN TABS
                                                            8   MOEXIPRIL
                                                            8   MONOPRIL
                                                            8   PRINIVIL TABS
                                                            8   UNIVASC
                                                            8   VASOTEC TABS
                                                            8   ZESTRIL TABS
ANGIOTENSIN RECEPTOR       AVAPRO                               ATACAND TABS             Preferred products only available without PA if
BLOCKER                    BENICAR TABS                         TEVETEN TABS             patient on diabetic therapy or prior ACE
                           COZAAR TABS
                           MICARDIS TABS                                                 Use PA Form # 20420
ANTIHYPERTENSIVES -        CATAPRES-TTS                         CATAPRES TABS            Use PA Form # 20420
CENTRAL                    CLONIDINE HCL TABS                   GUANABENZ ACETATE TABS
                           GUANFACINE HCL TABS                  ISMELIN TABS
                           HYDRALAZINE HCL TABS                 MINIPRESS CAPS
                           HYLOREL TABS                         TENEX TABS
                           METHYLDOPA TABS
                           MINOXIDIL TABS
                           PRAZOSIN HCL CAPS
                           RESERPINE TABS
ACE INHIBITORS AND CA      LOTREL CAPS                          LEXXEL TBCR              Use PA Form # 20420
                           TARKA TBCR
                           CAPTOPRIL/HYDROCHLOROTHIA            CAPOZIDE TABS
                           ENALAPRIL MALEATE/HCTZ TABS          LOTENSIN HCT TABS
                           LISINOPRIL-HCTZ TABS                 MONOPRIL HCT TABS
                                                                PRINZIDE TABS
                                                                UNIRETIC TABS
                                                                VASERETIC TABS
                                                                ZESTORETIC TABS
BETA BLOCKERS AND          ATENOLOL/CHLORTHALIDONE              CORZIDE TABS             Use PA Form # 20420
                           PROPRANOLOL/HCTZ                     LOPRESSOR HCT TABS
                                                                TIMOLIDE 10/25 TABS
                                                                ZIAC TABS
ARB'S AND DIURETICS        AVALIDE TABS                         ATACAND HCT TABS         Preferred products only available without PA if
                           BENICAR HCT                          TEVETEN HCT TABX         patient on diabetic therapy or prior ACE
                                                                                         therapy. Use PA Form #20420
                           DIOVAN HCT TABS
                           HYZAAR TABS
                           MICARDIS HCT TABS
DIURETICS                  ACETAZOLAMIDE TABS                   ALDACTAZIDE TABS         1. Multiples of Spironolactone 25 mg are
                           AMILORIDE HCL                        ALDACTONE TABS           cheaper than 50 mg strength
                           BUMETANIDE                           BUMEX TABS               Inspra will be approved for severe breast
                           CHLOROTHIAZIDE TABS                  DEMADEX TABS             tenderness and male gynecomastia
                           CHLORTHALIDONE TABS                  DIAMOX                   Use PA Form # 20420
                           EDECRIN TABS                         DIURIL
                           FUROSEMIDE                           DYAZIDE CAPS
                           HYDROCHLOROTHIAZIDE                  ENDURON TABS
                           INDAPAMIDE TABS                      INSPRA
                           METHAZOLAMIDE TABS                   LASIX TABS

                                                         Page 12 of 46
                            METHYCLOTHIAZIDE TABS                          LOZOL TABS
                            SPIRONOLACTONE 25MG TABS                       MAXZIDE
                            SPIRONOLACTONE/HYDRO                           MICROZIDE CAPS
                            TORSEMIDE TABS                                 MIDAMOR TABS
                            TRIAMTERENE/HCTZ                               MODURETIC 5-50 TABS
                            ZAROXOLYN TABS                                 NAQUA TABS
                                                                           NATURETIN TABS
                                                                           SPIRONOLACTONE 50MG1
CCB / LIPID                 CADUET
                                                                    LIPID DRUGS
CHOLESTEROL - BILE          CHOLESTYRAMINE                                 PREVALITE              Use PA Form # 20420
SEQUESTRANTS                COLESTID                                       QUESTRAN
                                                                           WELCHOL TABS
CHOLESTEROL - FIBRIC ACID   GEMFIBROZIL TABS                               ANTARA                 Use PA Form # 20420
DERIVATIVES                 NIASPAN                                        LOPID TABS
                            TRICOR                                         LOFIBRA
CHOLESTEROL - HGM COA +     CRESTOR                                        ZOCOR TABS2            Zocor/simvastatin patients trying to use Zetia
ABSORB INHIBITORS MORE      LIPITOR TABS                                                          must use Vytorin instead.            1.
POTENT                                                                                            Preferred starting 01.01.2007. 2. Non
                                                                                                  preferred starting 01.01.2007. 3. Dosing limits
                            VYTORIN                                                               apply. Use PA Form #20420

CHOLESTEROL - HGM COA +     ADVICOR TBCR                                   ALTOPREV TB24          1. Zetia available w/o PA as add on to Lipitor
ABSORB INHIBITORS LESS      LESCOL CAPS                                    MEVACOR TABS           80mg, or Crestor 40mg. Zetia will also be
POTENT                                                                                            approved with a PA as add on for patients at
                            LESCOL XL TB24                                 PRAVACHOL TABS
DRUGS/COMBINATIONS                                                                                maximally tolerated doses of statins. 2.
                            LOVASTATIN TABS                                PRAVASTATIN 802, 3     Dosing limits apply.
                            PRAVASTATIN2                                   PRAVIGARD
                            ZETIA TABS1                                                           3. 80mg tablets requires pa. Use multiple
                                                                                                  pravastatin 40 tablets to obtain this dose
                                                                                                  without pa. Use PA Form #20420

                                                                 PULMONARY ANTI-HYPERTENSIVES
PULMONARY ANTI-             REVATIO1                                     FLOLAN                   1. All users need one time approval to
HYPERTENSIVES                                                                                     establish PAH diagnosis. Please refer to
                            VENTAVIS1                                      REMODULIN2
                                                                                                  criteria.Use PA Form # 20420
                                                                                                  2. There will be dosing limits of one 20ml
                                                                                                  multidose vial/ 30 days supply without pa.
                                                                                                  3. Viagra would be approved after a diagnosis
                                                                                                  of pulmonary hypertension is confirmed.

                                                                 IMPOTENCE AGENTS
IMPOTENCE AGENTS                                                                                  As of January 1, 2006, per CMS (federal govt.),
                                                                                                  impotence agents are no longer covered.

ANTIEMETIC - ANT-           MECLIZINE HCL TABS                             ANTIVERT TABS          Use PA Form # 20420
CHOLINERGIC /               PHENERGAN SUPP                                 PHENERGAN SOLN
                            PHENERGAN FORTIS SYRP                          PHENERGAN TABS
                            PROMETHAZINE SUPP                              PROMETHEGAN SUPP
                            PROMETHAZINE                                   TORECAN TABS
                            TRANSDERM-SCOP PT72
ANTIEMETIC - 5-HT3          EMEND                                          ALOXI                  *See quantity limit table.
RECEPTOR ANTAGONISTS/       MARINOL CAPS                                   ANZEMET TABS            1. Approvals will require diagnosis of chemo-
SUBSTANCE P NEUROKININ                                                                            induced nausea/vomiting and failed trials of all
                            ONDANSETRON TABS*2                             CESAMET1
                                                                                                  preferred anti-emetics, including 5-HT3 class
                            ONDANSETRON ODT TBDP*2                         KYTRIL
                                                                                                  (Zofran, Emend) and Marinol.
                            ZOFRAN SOLN*2                                  ZOFRAN TABS*
                                                                           ZOFRAN ODT TBDP*       2. Ondansetron will be preferred with CA diag
                                                                                                  and dosing limits still apply.
                                                                                                  Ondansetron: Use PA Form # 20610
                                                                                                  Others: Use PA Form # 20420
                                                    NON-SEDATING ANTIHISTAMINES / DECONGESTANTS
ANTIHISTIMINES - NON-       ALAVERT TABS1                             5    CLARINEX TABS2         1. Preferred drugs are OTC loratidines.
SEDATING                                             1                                            2. Claritin OTC syrup does not require a PA. 3.
                            CLARITIN ALLERGY (OTC)                    5    CLARINEX SYR   3
                                                                                                  Clarinex & Zyrtec and Clarinex syrup <6 yr w/o
                            CLARITIN SYRP (OTC) 2                     5    ZYRTEC3                PA. Must fail Clarinex Tabs and Zyrtec
                            TAVIST ND (OTC)1                          5    ZYRTEC SYR3            products before moving to next step product.
                                                                                                  Pseudoephedrine is available with
                                                                                                  prescription.Use PA Form # 20530
                                                                   Page 13 of 46
                                                                                                         PA. Must fail Clarinex Tabs and Zyrtec
                                                                                                         products before moving to next step product.
                                                                     8   ALLEGRA                         Pseudoephedrine is available with
                                                                                                         prescription.Use PA Form # 20530
                                                                     8   CLARITIN2
                                                                     9   FEXOFENADINE

                                                           ALLERGY / ASTHMA THERAPIES
ANTIASTHMATIC ANTI-             ATROVENT AERS                                                             1. Quantity limit of 1 inhalation daily (1
CHOLINERGICS - INHALER                                                                                   capsule for inhaltaion daily). Spiriva will require
                                ATROVENT HFA
                                                                                                         PA if Combivent or Atrovent inhaler/nebulizer
                                SPIRIVA1                                                                 solution is in member's current drug profile.
                                                                                                         Use PA Form # 20420

ANTIASTHMATIC ANTI-             IPRATROPIUM BROMIDE SOLN                 ATROVENT SOLN                   Use PA Form # 20420

ANTIASTMATIC -                  CROMOLYN SODIUM NEBU                     XOLAIR1                         1. Need max inhaled steroids and written by
ANTINFLAMMATORY AGENTS          INTAL AERS                                                               pulmonary or allergy specialist.
                                TILADE AERS                                                              Use PA Form # 20420
ANTIASTHMATIC - NASAL       1   FLUTICASONE SPR 2                        FLONASE SUSP                    1. All step 1 drugs must be tried.
STEROIDS                    1   NASACORT AQ AERS                         FLUNISOLIDE SOLN                2. Dosing limits apply, please see dosage
                            1   NASONEX SUSP                             NASACORT AERS                   consolidation list.
                            1   VERAMYST2                                RHINOCORT AERO
                            4   BECONASE AERS                            RHINOCORT AQUA SUSP
                            4   BECONASE AQ INHA1                        TRI-NASAL SOLN                  Use PA Form # 20420
                            4   NASAREL SOLN1                            VANCENASE POCKETHALER AERS
ANTIASTHMATIC - NASAL           NASALCROM                                ATROVENT NASAL SOL              1. Ipratropium will be approved if submitted with
MISC.                                                                                                    documentation supporting use of CPAP
                                                                         IPRATROPIUM NASAL SOL1
                                                                                                         machine. Use PA Form # 20420
ANTIASTHMATIC - BETA -          ALBUTEROL NEB                            ACCUNEB NEBU                    1. Xopenex users with prior asthma
ADRENERGICS                     MAXAIR                                                                   hospitalization due to albuterol nebulizer failure
                                                                         ALBUTEROL AER3
                                                                                                         will be grandfathered.
                                METAPROTERENOL                           ALBUTEROL HFA
                                                                                                         2. Quantity Limit: 12 cc/day.
                                SEREVENT                                 ALUPENT AERP
                                TERBUTALINE SULFATE TABS                 BRETHINE                        3. Dosing limits apply, please see dosage
                                XOPENEX HFA3                             FORADIL AEROLIZER CAPS          consolidation list.
                                                                         PROVENTIL                       Use PA Form # 20420
                                                                         PROVENTIL HFA AERS
                                                                         VENTOLIN AERS
                                                                         VENTOLIN HFA AERS
                                                                         VOLMAX TBCR
                                                                         VOSPIRE ER TB12
                                                                         XOPENEX NEBU1,2
ANTIASTHMATIC -                 COMBIVENT AERO                           DUONEB SOLN1                    Please use preferred individual ingredients.
ADRENERGIC-                                                                                              Albuterol and Ipratropium.Use PA Form #
ANTICHOLINERGIC                                                                                          20420

ANTIASTHMATIC - XANTHINES       AMINOPHYLLINE TABS                       QUIBRON CAPS                    Use PA Form # 20420
                                THEOCHRON TB12                           QUIBRON-T TABS
                                THEOLAIR-SR TB12                         QUIBRON-T/SR TB12
                                THEOPHYLLINE ELIX                        THEO-24 CP24
                                THEOPHYLLINE SOLN                        THEOLAIR TABS
                                THEOPHYLLINE ER CP12                     THEOPHYLLINE CR TB12
                                THEOPHYLLINE ER TB12                     T-PHYL TB12
                                UNIPHYL TBCR
ANTIASTHMATIC - STEROID         AEROBID AERS                             AEROBID-M AERS                  1. No PA for Pulmicort susp if under 8 years
INHALANTS                       ASMANEX                                                           2      old 2. No PA for Pulmicort turbohaler if under
                                                                         PULMICORT TURBUHALER AEPB
                                                                                                         14 yr.
                                AZMACORT AERS                            VANCERIL DOUBLE STRENGTH AERS
                                BECLOVENT AERS
                                FLOVENT HFA
                                PULMICORT SUSP1                                                          Use PA Form # 20420
                                QVAR AERS
                                VANCERIL AERS
ANTIASTHMATIC - 5-                                                       ZYFLO TABS                      Use PA Form # 20420
Lipoxygenase Inhibitors

                                                                 Page 14 of 46
ANTIASTHMATIC -                  SINGULAIR1                                          ACCOLATE TABS                                      1. To determine Singulair use for asthma vs
LEUKOTRIENE RECEPTOR                                                                                                                   non-asthma use, an asthma diag is required on
ANTAGONISTS                                                                                                                            the prescription or history of inhaled steroid
                                                                                                                                       use.                         Use PA Form #
ANTIASTHMATIC - ALPHA-                                                               PROLASTIN SUSR                                    Use PA Form # 20420
PROTEINASE INHIBITOR                                                                 ZEMAIRA
ANTIASTHMATIC - HYDRO-                                                               PULMOZYME SOLN                                    Use PA Form # 20420
ANTIASTHMATIC - MUCOLYTIC        ACETYLCYSTEINE1                                     MUCOMYST                                          1. Acetycysteine is covered with diagnosis of
                                                                                                                                       CF.Use PA Form # 20420
COUGH/COLD                       PSEUDOEPHEDRINE                                 All others are a non-covered service (this includes   All of cough cold preparations are not covered
                                 ROBITUSSIN DM SYRP                              antihistamines-decongestive combinations).            except these preferred products.
                                 ROBITUSSIN SUGAR FREE SYRP
                                                                 DIGESTIVE AIDS / ASSORTED GI
                              **Preferred drugs that used to require diag codes still require diag codes unless indicated otherwise.**
GI - ANTIPERISTALTIC AGENTS      DIPHENOXYLATE                                       ANTI-DIARRHEAL TABS                           Use PA Form # 20420
                                 DIPHENOXYLATE/ATROPINE                              LOFENE TABS
                                 IMODIUM A-D TABS                                    LONOX TABS
                                 LOPERAMIDE HCL CAPS                                 MOTOFEN TABS
                                 LOPERAMIDE HCL LIQD                                 SB ANTI-DIARRHEA TABS
                                 OPIUM TINCTURE TINC
                                 PAREGORIC TINC
GI - ANTIDIARRHEAL /             ALU-CAP CAPS                                        ANTACID EXTRA STRENGTH CHEW                       Use PA Form # 20420
ANTACID MISC.                    ANTACID CHEW                                        B & O 15-A SUPPRETTE SUPP
                                 ATROPINE SULFATE SOLN                               B & O 16-A SUPPRETTE SUPP
                                 BENTYL SYRP                                         BELLADONNA ALKALOIDS & OP
                                 BISMATROL                                           BENTYL TABS
                                 CALCIUM ANTACID                                     CHILDRENS MYLANTA CHEW
                                 CALCIUM CARBONATE                                   GLYCOPYRROLATE INJ
                                 CAL-GEST ANTACID CHEW                               LEVBID TB12
                                 CHEWABLE ANTACID CHEW                               LEVSIN ELIX
                                 DICYCLOMINE HCL                                     LEVSIN TABS
                                 GAVISCON SUSP                                       LEVSIN/SL SUBL
                                 GLYCOPYRROLATE TABS                                 NULEV TBDP
                                 HAPONAL TABS                                        ROBINUL TABS
                                 HYOSCYAMINE SULFATE                                 ROBINUL INJ
                                 IMODIUM ADVANCED CHEW                               URO-MAG CAPS
                                 K-PEC LIQD
                                 K-PEK SUSP
                                 MAGNESIUM OXIDE TABS
                                 MAG-OX 400 TABS
                                 MAG-OXIDE TABS
                                 PAMINE TABS
                                 PINK BISMUTH
                                 PROPANTHELINE BROMIDE TABS
                                 SAL-TROPINE TABS
                                 SCOPOLAMINE HYDROBROMIDE
                                 SODIUM BICARBONATE TABS
                                 V-R STOMACH RELIEF SUSP
                                 X-STR CHEW ANTACID CHEW
GI - H2-ANTAGONISTS              CIMETIDINE                                          AXID CAPS                                         1. Zantac syrup available without PA to users
                                 FAMOTIDINE                                          AXID AR TABS                                      less than 6 years old.
                                 RANITIDINE                                          NIZATIDINE CAPS                                   Use PA Form # 20420
                                 V-R ACID REDUCER TABS                               PEPCID
                                                                                     PEPCID AC
                                                                                     TAGAMET TABS
                                                                              6      OMEPRAZOLE CPDR 10MG1                             1. Dosing limits apply, please see dosage
                                 OTC PRILOSEC                                 7      ACIPHEX TBEC                                      consolidation list.

                                 PREVACID CPDR                                8      NEXIUM CPDR
                                 PREVACID ORAL SUSP                           8      PREVACID SOLUTABS**                               ** Prevacid Solutabs available without PA for
                                                                                                                                       children less than 9 years old. Use PA Form #
                                                                          Page 15 of 46
                                                                                                                                           ** Prevacid Solutabs available without PA for
                                 PROTONIX TBEC                                    8    PRILOSEC CPDR                                       children less than 9 years old. Use PA Form #
                                                                                  8    PROTONIX INJ
                                                                                  8    ZEGERID
PROSTAGLANDINS                   MISOPROSTOL TABS                                      CYTOTEC TABS                                        Use PA Form # 20420
GI - DIGESTIVE ENZYMES           LACTAID ULTRA                                    5    ULTRASE CPEP                                        Non-preferred products are a one time PA for
                                 LACTRASE CAPS                                    5    ULTRASE MT                                          life (for CF diagnosis). Non-preferred products
                                                                                                                                           must be used in specified step order.
                                                                                  5    VIOKASE
                                                                                  7    LIPRAM
                                                                                  7    PANCREASE
                                                                                  7    PANCRELIPASE
                                                                                  7    PANGESTYME                                          Use PA Form # 20420
                                                                                  7    PANOKASE TABS
                                                                                  8    CREON
                                                                                  8    KUTRASE CAPS
                                                                                  8    KU-ZYME CAPS
                                                                                  8    LIPRAM CR
                                                                                  8    PANCREASE MT
                                                                                  8    PANCRECARB MS-8 CPEP
GI - ANTI - FLATULENTS / GI      CALULOSE SYRP                                         AMITIZA1                                            Diag codes no longer necessary for preferred
STIMULANTS                       CONSTULOSE SYRP                                       CEPHULAC SYRP                                       products. Lactulose has 60cc/day QL
                                 ENULOSE SYRP                                          GAS-X CHEW
                                 GASTROCROM CONC                                       INFANTS GAS RELIEF SUSP                             1. Prior failed trials of multipsl other preferred
                                 GENERLAC SYRP                                         REGLAN TABS                                         GI agents must occour first. Such as OTC
                                                                                                                                           senna, docusate, lactulose, polyethylene glycol.
                                 LACTULOSE SYRP
                                 METOCLOPRAMIDE HCL
                                 SIMETHICONE                                                                                               Use PA Form # 20420
GI - INFLAMMATORY BOWEL          ASACOL TBEC                                           AZULFIDINE EN-TABS TBEC                             Use PA Form # 20420
AGENTS                           AZULFIDINE TABS                                       CANASA SUPP
                                 COLAZAL CAPS
                                 DIPENTUM CAPS
                                 PENTASA CPCR
                                 ROWASA ENEM
                                 SULFAZINE EC TBEC
                                 SULFASALAZINE TABS
GI - IRRITABLE BOWEL                                                                   LOTRONEX TABS                                       Use PA Form # 20420

                                                                          MISCELLANEOUS GI
                              **Preferred drugs that used to require diag codes still require diag codes unless indicated otherwise.**
GI - MISC.                       BISAC-EVAC SUPP                                     ACTIGALL CAPS                                 1. Quantity Limit: 255 g/90-day without PA for
                                 BISACODYL                                           BENEFIBER                                     greater than 18 years old. If under 18 years of
                                                                                                                                   age, allowed 17gms daily without PA.
                                 BISCOLAX SUPP                                       CARAFATE
                                 CINOBAC CAPS                                          COLACE CAPS
                                 CITRATE OF MAGNESIA SOLN                              COLYTE
                                                                                                                                           2. Must show evidence of trials of preferred
                                 CITRUCEL                                              DIOCTO-C SYRP
                                                                                                                                           agents that do not require PA, such as OTC
                                 D.O.S. CAPS                                           DOC SOD /CAS CAP                                    senna, docusate, mineral oil and prescription
                                 DIOCTO LIQD                                           DOC-Q-LAX CAPS                                      lactulose.
                                 DIOCTO SYRP                                           DOCUSATE SODIUM/CAS CAPS                            Use PA Form # 20420
                                 DIOCTYN CAPS                                          DOK PLUS
                                 DOC-Q-LACE CAPS                                       DULCOLAX SUPP
                                 DOCUSATE CALCIUM CAPS                                 FIBER CON TABS
                                 DOCUSATE SODIUM                                       FIBER-LAX TABS
                                 DOCUSIL CAPS                                          GOLYTELY SOLR
                                 DOK CAPS                                              MALTSUPEX
                                 FIBER LAXATIVE TABS                                   MIRALAX POWD
                                 FLEET                                                 MIRALAX PACK
                                 GENFIBER POWD                                         NULYTELY SOLR
                                 GLYCERIN                                              PEG 3350/ELECTROLYTES SOLR
                                 GLYCOLAX1                                             SENEXON TABS
                                 HIPREX TABS                                           SENOKOT TABS
                                 KRISTALOSE PACK                                       SENOKOT S TABS
                                 METAMUCIL                                             STOOL SOFTENER PLUS CAPS
                                 MILK OF MAGNESIA SUSP                                 UNI-CENNA TABS
                                 MINERAL OIL OIL                                       UNI-EASE PLUS CAPS

                                                                             Page 16 of 46
                               SENNA                                          URSO 250
                               SENOKOT GRAN                                   V-R NATURAL SENNA LAXATIV TABS
                               SENOKOT SYRP
                               SENOKOT CHILDRENS SYRP
                               SENOKOT XTRA TABS
                               STOOL SOFTENER CAPS
                               SUCRALFATE TABS
                               UNI-EASE CAPS
                               UNIFIBER POWD
                               URSO FORTE

                                                                   MISC. UROLOGICAL
UROLOGICAL - MISC.             ACETIC ACID 0.25% SOLN                        CITRIC ACID/SODIUM CITRAT SOLN    1. Elmiron requires adequate proof of Dx with
                               BICITRA SOLN                                   CYTRA-2 SOLN                     supportive testing.
                               CYTRA-K SOLN                                   ELMIRON CAPS1
                               FURADANTIN SUSP                                MACROBID CAPS
                               K-PHOS MF TABS                                 MANDELAMINE TABS
                               MACRODANTIN CAPS                               NITROFURANTOIN MACR CAPS
                               METHENAMINE MANDELATE TABS                     POLYCITRA-K CRYSTALS PACK        Use PA Form # 20420
                               MONUROL PACK                                   POTASSIUM CITRATE/CITRIC SOLN
                               NEOSPORIN GU IRRIGANT SOLN                     PYRIDIUM PLUS TABS
                               PHENAZOPYRIDINE HCL TABS                       PYRIDIUM TABS
                               PHENAZOPYRIDINE PLUS                           RENACIDIN SOLN
                               POLYCITRA SYRP
                               POLYCITRA-K SOLN
                               POLYCITRA-LC SOLN
                               PROSED/DS TABS
                               TRICITRATES SYRP
                               URELIEF PLUS
                               UREX TABS
                               URISED TABS
                               UROQID #2 TABS
                                                                   PHOSPHATE BINDERS
PHOSPHATE BINDERS              PHOSLO3                                        RENAGEL1,2                       1. Renagel will be approved for hypercalcemia,
                               MAGNEBIND - 400   3                                                             digoxin users, and in cases where maximum
                                                                                                               phoslo doses are insufficient. 2. Will be
                                                                                                               verifying patient compliance. Labs must be
                                                                                                               provided. Please refer to the Phosphate
                                                                                                               Binders PA form.
                                                                                                               3. Requires diag to be preferred
                                                                                                               Use PA Form #20720
VAGINAL- ANTIBACTERIALS    1   CLEOCIN CREA                                   METROGEL VAGINAL GEL2            1. Step order must be followed to avoid PA.
                           1   METRONIDAZOLE VAGINAL GEL   2                  VANDAZOLE                        Must fail Cleocin Cream and Metronidazole
                                                                                                               products before moving to next step product
                           3   CLEOCIN SUPP1
                                                                                                               without PA.

                                                                                                               2. Dosing limits apply, please see Dosage
                                                                                                               Consolidation List.                  Use PA
                                                                                                               Form #20420

VAGINAL- ANTIFUNGALS           CLOTRIMAZOLE CREA                              AVC CREAM                        1. Quantity limit: 1/script/2 weeks
                               GYNE-LOTRIMIN CREA                             CLOTRIMAZOLE 3 DAY CREA
                               MICONAZOLE CREA                                GYNAZOLE-1 CREA
                               MICONAZOLE 3 COMBO PACK KIT     1              GYNE-LOTRIMIN 3 TABS
                               MICONAZOLE 7 CREA                              MICONAZOLE 3 SUPP                Use PA Form # 20420
                               MICONAZOLE NITRATE CREA                        MONISTAT 3 SUPP
                               NYSTATIN TABS                                  TERAZOL 3 CREA
                               TERCONAZOLE 0.4MG                              TERAZOL 3 SUPP
                               VAGITROL                                       TERAZOL 7 CREA
                               V-R MICONAZOLE-7 CREA                          TERCONAZOLE 0.8MG
VAGINAL - CONTRACEPTIVES       GYNOL II EXTRA STRENGTH GEL                    DELFEN FOAM                      Use PA Form # 20420
VAGINAL- ESTROGENS             ESTRING RING                                   ESTRACE CREA                     Must fail all preferred products before non-
                               PREMARIN CREA                                  VAGIFEM TABS                     preferred.Use PA Form # 20420

                                                                     Page 17 of 46
VAGINAL- OTHER                  ACID JELLY GEL                                AMINO ACID CERVICAL CREA     Use PA Form # 20420
                                ACI-JEL GEL
                                CERVICAL AMINO ACID CREA
BPH                             AVODART                             5         FLOMAX CP24                  Non-preferred products must be used in
                                DOXAZOSIN MESYLATE TABS             8         CARDURA TABS                 specified order.
                                FINASTERIDE                         8         HYTRIN CAPS                  1. There will be dosing limits of 1 tab per day
                                TERAZOSIN HCL CAPS                  8         PROSCAR TABS                 with out PA.
                                                                    8         UROXATRAL
                                                                                                           Use PA Form # 20420
ANXIOLYTICS -                   ALPRAZOLAM TABS                               ATIVAN                       Use PA Form # 20420
                                CLORAZEPATE DIPOTASSIUM TABS                  SERAX
                                DIAZEPAM                                      TRANXENE
                                LORAZEPAM                                     XANAX TABS
                                OXAZEPAM CAPS
ANXIOLYTICS - LONG ACTING       XANAX XR1                                     ALPRAZOLAM ER                1. Xanax XR will be available if the long acting
                                                                                                           benzo clonazepam fails. Use PA Form #

ANXIOLYTICS - MISC.             BUSPIRONE HCL TABS                            ATARAX TABS                  Use PA Form # 20420
                                HYDROXYZINE HCL SOLN                          BUSPAR TABS
                                HYDROXYZINE HCL SYRP                          DROPERIDOL SOLN
                                HYDROXYZINE PAMOATE CAPS                      HYDROXYZINE HCL TABS
                                                                              HYDROXYZINE PAM 100MG CAPS
                                                                              INAPSINE SOLN
                                                                              MEPROBAMATE TABS
INHIBITORS                      PARNATE TABS
ANTIDEPRESSANTS - MAO                                                         EMSAM1                       1. Dosing limits apply, please refer to Dose
INHIBITORS TOPICAL                                                                                         consolidation list. Use PA Form # 20420

ANTIDEPRESSANTS -               BUPROPION HCL TABS                  5         CYMBALTA6                    Non-preferred products must be used in
SELECTED SSRI's/Other           BUPROPION SR                        6         EFFEXOR TABS                 specified step order.
                                CITALOPRAM4                         6         EFFEXOR XR CP24 3            1. Use Fluoxetine 20 mg in multiples.
                                FLUOXETINE HCL CAPS                 8         CELEXA                        2. See Zoloft splitting table. Sertraline requires
                                FLUOXETINE HCL LIQD                 8         DESYREL TABS                 splitting of scored tabs to avoid PA.
                                FLUOXETINE HCL 10mg TABS            8         FLUOXETINE 40 mg CAPS1
                                FLUVOXAMINE MALEATE TABS            8         FLUOXETINE 20mg TABS7
                                LEXAPRO4                            8         LUVOX TABS                   3. Strong caution with pediatric population.
                                MIRTAZAPINE                         8         MAPROTILINE HCL TABS         4. See Celexa/Citalopram and Lexapro splitting
                                NEFAZODONE                          8         MIRTAZAPINE ODT              table. Lexapro 5mg will require a PA.

                                PAROXETINE 3                        8         PAXIL3                       5. Max daily dose allowed is 60mg, only 1 per
                                PAXIL CR  3                         8         PROZAC                       day allowed for all strengths.
                                SERTRALINE                          8         PROZAC CAPS                  6. Use of a preferred antidepressant for
                                TRAZODONE HCL TABS                  8         PROZAC WEEKLY CPDR           anxiety will require PA to establish anxiety
                                WELLBUTRIN XL                       8         REMERON TABS
                                                                    9         REMERON SOLTAB TBDP          Special Kid <18yo Criteria for New Starters:
                                                                    8         SARAFEM CAPS                 7. Use Fluoxetine 10mg tabs or capsules in
                                                                    8         TRAZODONE HCL 300MG TABS     multiples.
                                                                    8         WELLBUTRIN TABS              Use PA Form # 20420
                                                                    8         WELLBUTRIN SR TBCR           Must have had fluoxetine trial for at least 30
                                                                    8         ZOLOFT                       days before accessing other preferred
                                                                                                           antidepressants without PA.

ANTIDEPRESSANTS - TRI-      *   AMITRIPTYLINE HCL TABS                        AMOXAPINE TABS               *PA required for new starters if over 65 years
CYCLICS                     *   AVENTYL SOLN                                  ANAFRANIL CAPS               old. Users over 65 years old are
                            *   CLOMIPRAMINE HCL CAPS                         ELAVIL TABS
                            *   DESIPRAMINE HCL TABS                          NORPRAMIN TABS               Use PA Form # 20420
                            *   DOXEPIN HCL                                   PAMELOR
                            *   IMIPRAMINE HCL TABS                           SINEQUAN
                                NORTRIPTYLINE HCL                             TOFRANIL
                            *   PROTRIPTYLINE HCL TABS                        VIVACTIL TABS
                            *   SURMONTIL CAPS

                                                                 Page 18 of 46
                                                               SEDATIVE / HYPNOTICS
SEDATIVE/HYPNOTICS -         BUTISOL SODIUM TABS                          LUMINAL SOLN              PA required for new users of preferred
BARBITURATE                  CHLORAL HYDRATE SYRP                         SECONAL CAPS              products if over 65 years old.
                             MEBARAL TABS                                 SOMNOTE CAPS              Use PA Form # 30110
SEDATIVE/HYPNOTICS -         DORAL TABS                                   DALMANE                   Previous quantity limits still apply.
BENZODIAZEPINES              ESTAZOLAM TABS                               HALCION TABS              Use PA Form # 30110
                             FLURAZEPAM HCL CAPS                          MIDAZOLAM HCL SYRP
                             TEMAZEPAM CAPS                               RESTORIL CAPS
                             TRIAZOLAM TABS
SEDATIVE/HYPNOTICS - Non-    AMBIEN CR1                               7   AMBIEN1                   Must fail all preferred products before non-
Benzodiazepines                       1                               8   ROZEREM                   preferred. 1.Quantity Limit of 12 per 34 days.
                                                                                                    Use PA Form # 30110
                             MIRTAZAPINE                              8   SONATA CAPS1
ANTIPSYCHOTICS - ATYPICALS   GEODON                                       ABILIFY TABS and SOL4     1. If prescribing 2 or more antipsychotics, PA
                             RISPERDAL                                    INVEGA                    will be required for both drugs, except if one is
                                                                                                    Clozapine. See Multiple Antipsychotic PA form
                             SEROQUEL TABS                                RISPERDAL CONSA 4
                                                                                                    #20440. Please use Miscellaneous PA form #
                                                                          RISPERDAL M TAB4          20420 for non-preferred single therapy atypical
                                                                          SEROQUEL 50MG TABS 3, 4   requests.
                                                                          ZYPREXA TABS 4            2. All atypicals have dosing limitations and
                                                                          ZYPREXA ZYDIS TBDP 4      maximum daily doses. Please refer to dose
                                                                                                    consolidation table for any potential dosing
                                                                                                    limits. Maximum daily doses are as follows:
                                                                                                    Abilify- 30mg daily max
                                                                                                    Risperdal- 8mg daily max
                                                                                                    Seroquel- 800mg daily max
                                                                                                    Zyprexa- 30mg daily max

                                                                                                    3. Please use multiple 25mg tablets.

                                                                                                    4. Established users of single therapy atypicals
                                                                                                    were grandfathered.

                                                                                                    Use PA form #10420 for requests exceeding
                                                                                                    these maximum daily doses.
ANTIPSYCHOTICS - SPECIAL     CLOZAPINE TABS                               CLOZARIL TABS             Use PA Form # 20420
ATYPICALS                                                                 FAZACLO
ANTISPYCHOTICS - TYPICAL     CHLORPROMAZINE HCL                           COMPAZINE                 Use PA Form # 20420
                             FLUPHENAZINE DECANOATE                       COMPRO SUPP               If prescribing 2 or more antipsychotics, PA will
                             FLUPHENAZINE HCL                             HALDOL DECANOATE          be required for both drugs, except if one is
                                                                                                    Clozapine. See Multiple Antipsychotic PA form
                             HALDOL                                       LOXITANE CAPS
                                                                                                    #20440. For PA requests for non preferred
                             HALOPERIDOL                                  MELLARIL                  single user antipsychotic medications, please
                             HALOPERIDOL DECANOATE SOLN                   NAVANE CAPS               use miscellaneous PA form #20420.
                             HALOPERIDOL LACTATE SOLN                     PROLIXIN
                             LOXAPINE SUCCINATE CAPS                      STELAZINE TABS
                             LOXITANE-C CONC                              THORAZINE
                             MOBAN TABS
                             THIORIDAZINE HCL
                             THORAZINE SUPP
                             TRIFLUOPERAZINE HCL TABS
LITHIUM                      ESKALITH CAPS
                             ESKALITH CR TBCR
                             LITHIUM CARBONATE
                             LITHIUM CITRATE SYRP
                                                         COMBINATION - PSYCHOTHERAPEUTIC
PSYCHOTHERAPEUTIC            CHLORDIAZEPOXIDE/AMITRIPT                 8   SYMBYAX1                 Use individual components, which are currently
COMBINIATION                                                                                        available without a PA.           Use PA
                                                                                                    Form # 20420
                                                                  Page 19 of 46
PSYCHOTHERAPEUTIC                                                                  Use individual components, which are currently
COMBINIATION                 PERPHENAZINE/AMITRIPTYLIN                             available without a PA.           Use PA
                                                                                   Form # 20420

                             DEXEDRINE                                             Preferred stimulants will be available without
                                                                                   PA if diagnosis of ADHD.As per recent FDA
                             DEXTROAMPHET SULF TABS
                                                                                   alert, Adderall & Dexedrine should not be used
                             DEXTROSTAT TABS
                                                                                   in patients with underlying heart defects since
                                                                                   they may be at increased risk for sudden death.
                                                                                   Stimulants have dosing limitations per strength
                                                                                   and maximum daily doses. Please refer to dose
                                                                                   consolidation table for any potential dosing
                                                                                   limits per strength. Maximum daily doses are as
                                                                                   follows: 50mg daily.

STIMULANT - - LONG ACTING    ADDERALL XR CP24                                      Preferred stimulants will be available
AMPHETAMINE SALT                       2                                           without PA if diagnosis of ADHD.
                                                                                   Stimulants have dosing limitations per
                                                                                   strength and maximum daily doses. Please
                                                                                   refer to dose consolidation table for any
                                                                                   potential dosing limits per strength.

                                                                                   1. As per recent FDA alert, Adderall should not
                                                                                   be used in patients with underlying heart
                                                                                   defects since they may be at increased risk for
                                                                                   sudden death.

                                                                                   2. FDA approval currently only for ages 6-12.
                                                                                   Will be available without PA for this age group.
                                                                                   Limit of one capsule daily. Max dose of 70MG
                                                                                   daily.            Use PA Form # 20420
LONG ACTING -                DEXEDRINE Cap CR                                      Preferred stimulants will be available without
AMPHETAMINES -               DEXTROAMPHET SULF CPCR                                PA if diagnosis of ADHD. As per recent FDA
                                                                                   alert, Adderall & Dexedrine should not be used
                                                                                   in patients with underlying heart defects since
                                                                                   they may be at increased risk for sudden death.
                                                                                   Stimulants have dosing limitations per strength
                                                                                   and maximum daily doses. Please refer to dose
                                                                                   consolidation table for any potential dosing
                                                                                   limits per strength. Maximum daily doses are as
                                                                                   follows:50mg daily.

STIMULANT -                  FOCALIN                                               Stimulants have dosing limitations per strength
METHYLPHENIDATE              METHYLIN TABS                                         and maximum daily doses. Please refer to dose
                                                                                   consolidation table for any potential dosing
                             METHYLIN SOL
                                                                                   limits per strength. Maximum daily doses are as
                             METHYLPHENIDATE HCL                                   follows:72mg daily

STIMULANT -                  CONCERTA TBCR                  5   METADATE CD CPCR   Preferred stimulants will be available without
METHYLPHENIDATE - LONG       DAYTRANA2                      8                      PA if diagnosis of ADHD. Non-preferred
                                                                RITALIN LA
ACTING                                                                             products must be used in specified step order.
                             FOCALIN XR1                                           Stimulants also have dosing limitations per
                                                                                   strength and maximum daily doses. Please
                                                                                   refer to dose consolidation table for any
                                                                                   potential dosing limits per strength. 1.
                                                                                   Available to those members needing sprinkles
                                                                                   with diagnosis of ADHD.
                                                                                   2. FDA approval currently only for ages 6-16.
                                                                                   Will be available without PA for this age group.
                                                                                   Limit of one patch daily. Max dose of 30MG
                                                                                   Use PA Form # 20420

STIMULANTS - STIMULANT                                      7   STRATTERA1, 2      1. Failure of both an amphetamine and
LIKE                                                        8   CAFCIT SOLN        methylphenidate is required for consideration
                                                                                   for approval of Strattera, unless history of
                                                            8   PROVIGIL TABS
                                                                                   substance abuse without current use of
                                                            9   DESOXYN TABS       abusable medication(s)
                                                            9   DESOXYN CR         2. Strattera currently has dosing limitations
                                                                                   allowing one tablet per day for all strengths if
                                                                                   obtain approval. Please refer to PDL dosage
                                                         Page 20 of 46
                                                                                                 abusable medication(s)
                                                                                                 2. Strattera currently has dosing limitations
                                                                                                 allowing one tablet per day for all strengths if
                                                                                                 obtain approval. Please refer to PDL dosage
                                                                                                 consolidation chart.3. Non-preferred products
                                                                                                 must be used in specified step order

                                                                                                 Provigil: Use PA Form # 20710
                                                             ANTI-CATAPLECTIC AGENTS
PSYCHOTHERAPEUTIC                                                         XYREM SOL.             Use PA Form # 20710
                                                                   WEIGHT LOSS
WEIGHT LOSS                                                                                      No longer covered: PHENTERMINE,
                                                                                                 XENICAL,DIDREX, and MERIDIA

                                                                ALZHEIMER DISEASE
ALZHEIMER - Cholinomimetics -   ARICEPT TABS1                         8   EXELON                 1. All new users need PA to establish
NMDA                            NAMENDA1                              8   RAZADYNE               dementia diagnosis and baseline mental status
                                                                                                 score. Must fail all preferred products before
                                                                      8   REMINLY
                                                                                                 moving to non-preferred.
                                                                      9   COGNEX CAPS
                                                                                                 Use PA Form # 20420 and MMSE form
                                                               SMOKING CESSATION
NICOTINE PATCHES / TABLETS      NICODERM CQ PT24                          CHANTIX1               Bupropion SR 150 mg is available without a
                                NICOTINE DIS PT24                                                prior authorization.
                                                                                                 1. Chantix will be approved if a
                                                                                                 trial of both a preferred nicotine replacement
                                                                                                 product and bupropion is seen. Initial Chantix
                                                                                                 approvals will be granted for three months. One
                                                                                                 additional three month
                                                                                                 approval will be granted if resubmit with
                                                                                                 documentation supporting that member is still
                                                                                                 not smoking.

NICOTINE REPLACEMENT -          NICOTINE POLACRILEX GUM               5   COMMIT LOZENGES1       Must fail all preferred products from smoking
OTHER                           NICORETTE GUM                             NICOTROL INHALER       cessation category (Nicoderm patch and
                                                                                                 nicotine gum) before moving to non-preferred.
                                                                          NICOTROL NASAL SPARY
                                                                                                 Must use Non-preferred products in specified
                                                                                                 step order. 1. Will be available to patients
                                                                                                 unable to tolerate preferred products. Use PA
                                                                                                 Form # 20420

                                                              ALCOHOL DETERRENTS
ALCOHOL DETERRENTS              DISULFIRAM TABS                                                  1. Should only be used in conjunction with
                                ANTABUSE TABS                                                    formal structured outpatient detoxification
                                NALTREXONE HCL TABS                                              Use PA Form # 20420

                                                            MISCELLANEOUS ANALGESICS
ANALGESICS - MISC.              ACEPHEN SUPP                             ASPIR-81 TBEC           Use PA Form # 20420
                                ACETAMIN TAB 325MG                        AXOCET CAPS
                                ACETAMINOPHEN                             DOLOBID TABS
                                ASPIRIN                                   EASPRIN TBEC
                                ASPIRIN EC                                EQUAGESIC TABS
                                ASPIR-LOW TBEC                            ESGIC-PLUS
                                BUFFERED ASPIRIN TABS                     EXCEDRIN TAB ASA FRE
                                BUTAL/ASA/CAFF                            FIORICET TABS
                                BUTALBITAL COMPOUND                       FIORINAL CAPS
                                BUTALBITAL/ACET TABS                      FIORTAL CAPS
                                BUTALBITAL/APAP CAPS                      FORTABS TABS
                                BUTALBITAL/APAP/CAFFEINE                  PHRENILIN TABS
                                CHILDRENS ASPIRIN CHEW                    PHRENILIN FORTE CAPS
                                CHILDRENS PAIN RELIEVER                   TRILISATE LIQD
                                CHOLINE MAGNESIUM TRISALI                 TRILISATE TABS
                                DIFLUNISAL TABS                           ZEBUTAL CAPS
                                ECOTRIN                                   ZORPRIN TBCR
                                FEVERALL SUPP

                                                                  Page 21 of 46
                          GENEBS TABS
                          HEADACHE FORMULA ADDED TABS
                          INFANTAIRE SOLN
                          INFANTS APAP SOLN
                          INFANTS PAIN RELIEVER SUSP
                          PAIN RELIEVER
                          Q-NOL TABS
                          SALSALATE TABS
                          TACTINAL EXTRA STRENGTH TABS
                          V-R CHILDRENS ASPIRIN CHEW
                          V-R NON-ASPIRIN TABS
                                                            LONG ACTING NARCOTICS
NARCOTICS - LONG ACTING   AVINZA                                    7    DURAGESIC PT721                  Non-preferred products must be used in
                          METHADONE                                 7                     1               specific order. 1. Duragesic, Fentanyl and
                                                                         FENTANYL PATCH
                                                                                                          Oxycontin will be available without PA for
                          METHADOSE                                 9    KADIAN CP 242                    patients treated for or dying from cancer or
                          MORPHINE SULFATE ER TB12   3              8    MORPHINE SULFATE SUPP            hospice patients. CA (cancer) or HO (hospice)
                                                                         MS CONTIN TB12                   diag code may be used but store must verify
                          OXYCODONE ER3                             8
                                                                         ORAMORPH SR TB12                 since all scripts will be audited and stores will
                                                                                                          be liable. 2. Established users are
                                                                    9    OXYCONTIN TB121                  grandfathered. 3. Oxycodone ER allowed only
                                                                                                          2 per day for all strengths except 80 mg, where
                                                                                                          4 are allowed to achieve max total daily dose of
                                                                                                          320mg. 4.Only preferred manufacturer's
                                                                                                          products will be available without prior
                                                                                                          authorization. Use PA Form # 20510

NARCOTICS - SELECTED      TRAMADOL HCL TABS                         8    BUPRENEX SOLN                    Use PA Form # 20420
                                                                    8    BUTORPHANOL
                                                                    8    NALBUPHINE HCL SOLN
                                                                    8    NUBAIN SOLN
                                                                    8    STADOL NS SOLN
                                                                    8    ULTRACET TABS
                                                                    8    ULTRAM TABS
                                                                    9    ULTRAM ER
                                                           MISCELLANEOUS NARCOTICS
NARCOTICS - MISC.         ACETAMINOPHEN/CODEINE                         ANEXSIA TABS                       1. Fentanyl OT loz (Barr) and Capital and
                          ASPIRIN/CODEINE TABS                           ASCOMP/CODEINE CAPS              codeine suspension products require PA for
                                                                                                          users over 18 years of age. PA is not required if
                          BUTAL/ASA/CAFF/COD CAPS                        BUTALBITAL/APAP/CAFFEINE/ CAPS
                                                                                                          under 18 years of age.
                          BUTALBITAL/ASPIRIN/CAFFEI CAPS                 COMBUNOX                         2. oxycodone/acet 10/650 is 8 times more
                                                     1                   DARVOCET-N                       expensive. Use twice as many of oxycod/acet
                          CAPITAL AND CODEINE SUSP
                                                                                                          5/325 instead.
                          CAPITAL/CODEINE SUSP   1                       DARVON
                          CODEINE PHOSPHATE SOLN                         DEMEROL
                          CODEINE SULFATE TABS                           DILAUDID                         3.Only preferred manufacturer's products will
                          ENDOCET TABS    3                              DILAUDID-HP SOLN                 be available without prior authorization.
                          ENDODAN TABS                                   FENTANYL CITRATE SOLN
                          FENTANYL OT LOZ1                               FENTORA
                          HYDROCODONE BITARTRATE/AP TABS                 FIORICET/CODEINE CAPS            You can mix and match preferred strengths of
                                                                                                          oxycodone and oxycodone/acet. to minimize
                          HYDROCODONE/ACETAMINOPHEN                      FIORINAL/CODEINE #3 CAPS         acet. dose similar to certain non-preferred
                          HYDROMORPHONE HCL3                             FIORTAL/CODEINE CAPS             drugs.
                          MEPERIDINE HCL                                 HYDROCODONE/IBUPROFEN            Use PA Form # 20420
                          OXYCODONE                                      LORCET                           Please refer to General Criteria Category E.
                          OXYCODONE/ACETAMINOPHEN2,3                     LORTAB
                          PENTAZOCINE/NALOXONE TABS                      MAXIDONE TABS
                          PROPOXYPHENE CMPND-65 CAPS                     NORCO TABS
                          PROPOXYPHENE COMPOUND CAPS                     PENTAZOCINE/ACET TABS
                          PROPOXYPHENE HCL CAPS                          PERCOCET TABS
                          PROPOXYPHENE/ACET TABS                         PERCODAN TABS
                          PROPOXYPHENE-N/ACET TABS                       PHRENILIN W/CAFFEINE/CODE CAPS
                          ROXICET                                        ROXICET 5/500 TABS
                          ROXIPRIN TABS                                  ROXICODONE TABS

                                                                 Page 22 of 46
                                                                    SYNALGOS-DC CAPS
                                                                    TALACEN TABS
                                                                    TALWIN NX TABS
                                                                    TYLENOL/CODEINE #3 TABS
                                                                    TYLOX CAPS
                                                                    VICOPROFEN TABS
                                                                    ZYDONE TABS
                                                                    ACTIQ LPOP
OPIOID DEPENDENCE           SUBOXONE1                               SUBUTEX                   1. Suboxone is preferred with max dosing limits
TREATMENTS                                                                                    of 32mg daily if the following conditions are
                                                                                              met: a.) There is not another Suboxone script
                                                                                              in member’s drug profile within the past 30
                                                                                              days. and b.) There is not more than one
                                                                                              narcotic fill in member’s drug profile between
                                                                                              today’s fill of suboxone and a prior suboxone fill
                                                                                              within the past 90 days. Please provide
                                                                                              evidence of monthly monitoring, including
                                                                                              random pill counts, urine drug tests, and
                                                                                              prescription monitoring program reports.

                                                        NARCOTIC ANTAGONISTS
NARCOTIC - ANTAGONISTS      NALTREXONE HCL TABS                     REVIA TABS1               1. Will only be approved for side effects
                                                                                              experienced with generic that are not described
                                                                    VIVITROL INJ              in the literature as occurring with the brand
                                                                                              version. Use PA Form # 20420
                                                                                              2. Please see the criteria listed on the Vivitrrol
                                                                                              PA form. Any narcotics attempting to be filled
                                                                                              during Vivitrol approval will require prior
                                                                                              authorization. Use PA Form # 30400

                                                            COX 2 / NSAIDS
COX 2 INHIBITORS - HIGHLY   CELEBREX CAPS                                                     The FDA has issued a Public Health Advisory
SELECTIVE                                                                                     warning of the potential for increased
                                                                                              cardiovascular risk & GI bleeding with Celebrex
                                                                                              use. Dosing limits will be set at a maximum of
                                                                                              200 mg once daily for PA requests or for
                                                                                              patients over 60 without PA. Use PA Form #

COX 2 INHIBITORS -          KETOROLAC TROMETHAMINE2,3               MOBIC                     The FDA has issued a Public Health Advisory
SELECTIVE                   MELOXICAM1                              MOBIC SUSP                warning of the potential for increased
                                                                                              cardiovascular risk & GI bleeding with NSAID
                            NABUMETONE TABS                         RELAFEN TABS              use.
                                                                    TORADOL                   1. Meloxicam has dosing limits allowing one
                                                                                              tablet daily of all strengths without PA.

                                                                                              2. Ketorolac Tromethamine is indicated for the
                                                                                              short term (up to 5 days) managment of
                                                                                              moderately sever acute pain that requires
                                                                                              analgesic at the opiod level in adults. Not
                                                                                              indicated for minor of chronic pain conditions.

                                                                                              3. Ketorolac has dosing limits allowing 24
                                                                                              tablets for a 5 day supply every 30 days. Use
                                                                                              PA Form # 10310

NSAIDS                      CHILDRENS IBUPROFEN                     ADVIL TABS                The FDA has issued a Public Health Advisory
                                                                                              warning of the potential for increased
                            DICLOFENAC POTASSIUM TABS               ANAPROX TABS
                                                                                              cardiovascular risk & GI bleeding with NSAID
                            DICLOFENAC SODIUM                       ANAPROX DS TABS           use. Use PA Form # 20420
                            ETODOLAC                                ANSAID TABS
                            FENOPROFEN CALCIUM TABS                 CATAFLAM TABS
                            FLURBIPROFEN TABS                       CHILDRENS ADVIL SUSP
                            IBUPROFEN                               CHILD'S IBUPROFEN SUSP
                            INDOMETHACIN                            CHILDRENS MOTRIN SUSP
                            KETOPROFEN                              CLINORIL TABS
                            MECLOFENAMATE SODIUM CAPS               DAYPRO TABS

                                                            Page 23 of 46
                                 NAPROSYN SUSP                              EC-NAPROSYN TBEC
                                 NAPROXEN SUSP                              ETODOLAC ER 600MG
                                 NAPROXEN TABS                              FELDENE CAPS
                                 NAPROXEN SODIUM TABS                       IBU-200
                                 OXAPROZIN TABS                             INDOCIN
                                 PIROXICAM CAPS                             LODINE
                                 SULINDAC TABS                              MOTRIN
                                 TOLMETIN SODIUM                            NALFON CAPS
                                                                            NAPRELAN TBCR
                                                                            NAPROSYN TABS
                                                                            NAPROXEN DR TBEC
                                                                            NAPROXEN SODIUM TBCR
                                                                            ORUVAIL CP24
                                                                            PONSTEL CAPS
                                                                            SB IBUPROFEN TABS
                                                                            V-R IBUPROFEN TABS
                                                                RHEUMATOID ARTHRITIS
RHEUMATOID ARTHRITIS         1   AZATHIOPRINE                          8    ARAVA TABS             1. Only one step 1 drug is required to obtain
                             1   LEFLUNOMIDE                           8    KINERET SOLN           Enbrel or Humira without PA. High doses of
                                                                                                   Enbrel 50mg twice weekly will require a PA.
                             1   HYDROXYCHLOROQUINE                    8    ORENCIA
                                                                                                   Please refer to the dose consolidation list.
                             1   METHOTREXATE                          8    REMICADE               Established users will be grandfathered for
                             1   SULFASALAZINE                                                     Enbrel and Humira.
                             2   ENBREL KIT1                                                       Use PA Form #10510
                             2   HUMIRA1
                                                               MISCELLANEOUS ARTHRITIS
ARTHRITIS - MISC.                RIDAURA CAPS                               ARTHROTEC1             1. The individual components of Arthrotec are
                                 MYOCHRYSINE SOLN                                                  available without PA.Use PA Form # 20420

                                                                 MIGRAINE THERAPIES
MIGRAINE - ERGOTAMINE            MIGRANAL SOLN                              D.H.E. 45 SOLN         Use PA Form # 10110
DERIVATIVES                      SANSERT TABS
MIGRAINE - SELECTIVE                                                        FROVA TABS             1. All step 1 medications must be tried. All
                             1   IMITREX TABS1
SEROTONIN AGONISTS (5HT)--                                                  AXERT TABS             drugs in this category have dosing limits.
                             1   MAXALT MLT1
Tabs                                                                                               Please refer to dose consolidation table.
                             1   RELPAX1                                    AMERGE TABS
                             1   MAXALT1                                    ZOMIG TABS
                                                                            ZOMIG ZMT TBDP         Use PA Form # 10110
                                                                            ZOMIG NASAL SPRAY
MIGRAINE - SELECTIVE             IMITREX KIT                                                       Use PA Form # 10110
                                 IMITREX STATDOSE PEN KIT
                                 IMITREX STATDOSE REFILL KIT
MIGRAINE MISC                    CAFERGOT SUPP                              MIGRAZONE CAPS         Use PA Form # 10110
                                 CAFERGOT TABS                              BELCOMP-PB SUPP
                                 SPASTRIN TABS
GOUT                             ALLOPURINOL TABS                          ZYLOPRIM TABS           Use PA Form # 20420
                                 COLCHICINE TABS
                                 PROBENECID TABS
                                 PROBENECID/COLCHICINE TABS
                                 SULFINPYRAZONE TABS
ANESTHETICS - MISC.              BUPIVACAINE HCL SOLN                       SENSORCAINE-MPF SOLN   Use PA Form # 30130
                                 LIDOCAINE HCL SOLN                         SYNVISC INJ
                                 MARCAINE SOLN                              XYLOCAINE SOLN
ANTICONVULSANTS - MISC.          CARBAMAZEPINE                         8    DEPAKENE               1. Quantity limit. 5/month
                                 CARBATROL CP12                        8    EQUETRO                 2. 200 mg requires a PA. Use two 100 mg
                                 CELONTIN CAPS                         8                           instead.Pharmaceutical supply issues will delay
                                                                                                   implementation until further notice.
                                 CLONAZEPAM TABS                       8    GABITRIL TABS
                                 DEPAKOTE TBEC                         8    KEPPRA TABS
                                 DEPAKOTE SPRINKLES CPSP               8    KLONOPIN TABS
                                 DIASTAT   1                           8    LYRICA

                                                                    Page 24 of 46
                            DILANTIN                            8   PRIMIDONE TABS                            Use PA Form # 20420
                            EPITOL TABS                         8   TOPAMAX
                            EQUETRO                             8   TRILEPTAL                                 All non-preferred meds must be used in
                            ETHOSUXIMIDE SYRP                   8   ZARONTIN SYRP                             specified order.
                            FELBATOL                            8   ZONISAMIDE
                            LAMICTAL                            9   NEURONTIN
                            MYSOLINE TABS                       9   ZONEGRAN CAPS
                            PHENYTOIN                       M ~ A                                             AT THE END OF THIS DOCUMENT
                                                                                                              M= Monotherapy                          A=
                            TEGRETOL2                       4 ~ 4   LAMICTAL
                            TEGRETOL-XR TB12                4 ~ 4   LITHIUM
                                                                                                              9= No Evidence
                            VALPROIC ACID                   4 ~ 4   CARBAMAZEPINE                             The step orders show the relative strength of
                            ZARONTIN CAPS                   4 ~ 4   VALPROATE                                 evidence for use in bi-polar and will guide prior
                                                            4 ~ 4   ATYPICAL ANTIPSYCHOTICS EXC. CLOZAPINE    authorization determinations.
                                                                                                              Step 4 drugs-no PA required.
                                                            5 ~ 5   TRILEPTAL
                                                            9 ~ 6   TOPAMAX
                                                            9 ~ 7   KEPPRA TABS
                                                            9 ~ 8   GABITRIL TABS
                                                            9 ~ 9   NEURONTIN
                                                            9 ~ 9   ZONEGRAN CAPS
                                                                    PEDIATRIC BIPOLAR1 DISORDER: STEP ORDER
                                                            M ~ A   (6-18 YEARS WITH OR WITHOUT PSYCHOSIS)    Two-step 1 preferred drugs must be tried
                                                            4 ~ 4                                             before Trileptal.
                                                                                                              The step orders show the relative strength of
                                                            4 ~ 4   CARBAMAZEPINE                             evidence for use in bi-polar and will guide prior
                                                            4 ~ 4   VALPROATE                                 authorization determinations.
                                                            4 ~ 4   ATYPICAL ANTIPSYCHOTICS EXC.CLOZAPINE     Step 4 drugs-no PA required.
                                                            4 ~ 4   LAMICTAL
                                                            5 ~ 5   TRILEPTA
                                                        ANTI-PARKINSON DRUGS
                            COGENTIN SOLN
                            KEMADRIN TABS
PARKINSONS - COMT           COMTAN TABS                             TASMAR TABS                               Use PA Form # 20420
PARKINSONS                  MIRAPEX TABS                                                                      Use PA Form # 20420

PARKINSONS -                AMANTADINE HCL                          APOKYN                                    *Only preferred manufacturer's products will be
DOPAMINERGICS/CARBII/       BROMOCRIPTINE MESYLATE                  AZILECT2                                  available without prior authorization.
                            CARBIDOPA/LEVODOPA TABS*                ELDEPRYL CAPS
                            CARBIDOPA/LEVODOPA ER                   PARLODEL CAPS                             1. Approvals will require concurrent therapy
                            LARODOPA TABS                           PARLODEL TABS                             with Levodopa and failed trials of Selegiline,
                                                                                                              Comtan, and Stalevo.
                            LODOSYN TABS                            SINEMET TABS
                            SELEGILINE HCL                          SINEMET TBCR
                                                                    SYMMETREL TABS
                                                                    ZELAPAR1,                                 2. Approvals will require trials of
                                                                                                              Carbidopa/Levodopa, Selegiline, Comtan, and

                                                                                                              Use PA Form # 20420
                                                         MUSCLE RELAXANTS
ALS DRUG                    RILUTEK TABS
MUSCLE RELAXANTS            BACLOFEN TABS                       7   ORPHENADRINE CITRATE                      Non-preferred drugs will not be approved if
                            CHLORZOXAZONE TABS                  8   CARISOPRODOL TABS                         members circumventing MaineCare prior
                                                                                                              authorization requirements by paying
                            CYCLOBENZAPRINE HCL TABS            8   DANTRIUM CAPS
                                                                                                              (prescribers failed to submit prior authorization
                            LIORESAL INTRATHECAL KIT            8   FLEXERIL TABS                             prior to cash narcotic scripts being filled by
                            METHOCARBAMOL TABS                  8   LIORESAL TABS                             member). Non-preferred products must be
                            TIZANIDINE HCL TABS                 8   NORFLEX TBCR                              used in specified step order. Use PA Form #
                                                                8   ROBAXIN-750 TABS
                                                                8   ZANAFLEX TABS
                                                                9   SKELAXIN TABS
                                                                9   SOMA TABS
MUSCLE RELAXANT -                                                   CARISOPRODOL/ASPIRIN TABS                 Use PA Form # 20420

                                                            Page 25 of 46
COMBINATIONS                                                                  CARISOPRODOL/ASPIRIN/CODE
                                                                              NORGESIC TABS
                                                                              ORPHENADRINE COMPOUND
                    **Preferred products that used to require diag codes still require diag codes unless indicated otherwise.**
VITAMINS                 ASCORBIC ACID TABS                                AQUASOL E SOLN                                  Use PA Form # 20420
                         BIOTIN                                               AQUAVIT-E SOLN
                         CYANOCOBALAMIN SOLN                                  DHT SOLN
                         FOLGARD RX 2.2 TABS                                  NASCOBAL GEL
                         FOLIC ACID TABS
                         FOLTX TABS
                         MEPHYTON TABS
                         NIACOR TABS
                         NICOTINIC ACID SR CPCR
                         PYRIDOXINE HCL TABS
                         SLO-NIACIN TBCR
                         THIAMINE HCL SOLN
                         VITAMIN B-1 TABS
                         VITAMIN B-12
                         VITAMIN B-6 TABS
                         VITAMIN C
                         VITAMIN E CAPS
                         VITAMIN E/D-ALPHA CAPS
                         VITAMIN K1 SOLN
                         V-R VITAMIN E CAPS
VITAMIN D's              CALCIFEROL SOLN1                                     DRISDOL CAPS                                      1. Diagnosis of dialysis (renal failure) required.

                         CALCITRIOL CAPS1                                     CALCIJEX                                          2. OTC Vitamin D no diagnosis required.
                         DRISDOL SOLN1                                        HECTOROL (ORAL)
                         VITAMIN D1,2                                         HECTOROL (PARENTERAL)
                                                               MISC MULTI-VITAMINS
                    **Preferred products that used to require diag codes still require diag codes unless indicated otherwise.**
VITAMINS - MISC.         CENTRUM LIQD                                      ADEKS                                           Diag codes are no longer required on
                         CENTRUM TABS                                         ADVANCED NATALCARE TABS                           prenatal vitamins.
                         CENTRUM JR/IRON CHEW                                 AQUADEKS                                          Use PA Form # 20420
                         CENTRUM SILVER TABS                                  CENTRUM JR/EXTRA C CHEW
                         CENTRUM-LUTEIN TABS                                  CENTRUM PERFORMANCE TABS
                         CEROVITE ADVANCED FO TABS                            DALYVITE LIQD
                         CHEWABLE MULTIVIT/FL CHEW                            EMBREX 600 MISC
                         COD LIVER OIL CAPS                                   IBERET
                         COMPLETE SENIOR TABS                                 MATERNA TABS
                         DAILY MULTI VIT/IRON                                 MULTIRET FOLIC -500 TBCR
                         DIALY VITE 800MG                                     NATAFORT TABS
                         FULL SPECTRUM B                                      NATALCARE CFE 60 TABS
                         M.V.I.-12 INJ                                        NATALCARE GLOSS TABS
                         MULTI-VIT/FLUORIDE                                   NATALCARE PIC TABS
                         NATACHEW CHEW                                        NATALCARE PIC FORTE TABS
                         NATALCARE RX TABS                                    NATALCARE PLUS TABS
                         O-CAL PRENATAL                                       NATALCARE THREE TABS
                         ONE DAILY TABS                                       NATALFIRST TABS
                         ONE-DAILY MULTIVITAMINS                              NATATAB RX TABS
                         ONE-TABLET-DAILY                                     NEPHPLEX RX TABS
                         POLY-VIT/IRON/FLUORID SOLN                           NEPHROCAPS CAPS
                         POLY-VITAMIN/FLUORIDE SOLN                           NEPHRO-VITE TABS
                         POLY-VITAMINS/IRON SOLN                              NESTABS RX TABS
                         PRENATAL TABS                                        NIFEREX
                         PRENATAL FORMULA 3 TABS                              NUTRINATE CHEW
                         PRENATAL PLUS TABS                                   OCUVITE TABS
                         PRENATAL PLUS NF TABS                                POLY-VI-FLOR SOLN

                                                                   Page 26 of 46
               PRENATAL PLUS/27MG IRON                            POLY-VI-SOL SOLN
               PRENATAL PLUS/IRON TABS                            POLY-VI-SOL/IRON SOLN
               PRENATAL RX/BETA-CAROTENE                          POLY-VITAMIN DROPS SOLN
               STRESS TAB NF TABS                                 PRECARE
               THERAPEUTIC-M TABS                                 PREMESIS RX TABS
               THERAVITE LIQD                                     PRENATABS CBF TABS
               TRI-VITAMIN/FLUORIDE SOLN                          PRENATAL 19 CHEW
               VITA CON FORTE CAPS                                PRENATAL CARE TABS
               VITAMIN B COMPLEX CAPS                             PRENATAL MR 90 TBCR
               VITAPLEX PLUS TABS                                 PRENATAL MTR/SELENIUM TABS
                                                                  PRENATAL OPTIMA ADVANCE TABS
                                                                  PRENATAL PC 40 TABS
                                                                  PRENATAL RX TABS
                                                                  PRENATE ELITE
                                                                  PRIMACARE MISC
                                                                  PROTEGRA CAPS
                                                                  RENAL CAPS
                                                                  RENAPHRO CAPS
                                                                  RENA-VITE RX TABS
                                                                  STUARTNATAL PLUS 3 TABS
                                                                  TRI-VI-SOL SOLN
                                                                  TRI-VI-SOL/IRON SOLN
                                                                  ULTRA NATALCARE TABS
                                                                  ULTRA-NATAL TABS
                                                                  VICON FORTE CAPS
                                                                  VINATAL FORTE TABS
                                                                  VINATE ADVANCED TABS
                                                 MISCELLANEOUS MINERALS
           **Preferred products that used to require diag codes still require diag codes unless indicated otherwise.**
MINERALS       CALCARB                                            ANEMAGEN                                        Use PA Form # 20420
               CALCI-MIX CAPSULE CAPS                             CALCET TABS
               CALCIQUID SYRP                                     CALCIUM 600-D TABS
               CALCITRATE/VITAMIN D TABS                          CALCIUM/VITAMIN D TABS
               CALCIUM                                            CALTRATE 600 PLUS/VIT D TABS
               CALCIUM CARBONATE                                  CALTRATE PLUS TABS
               CALCIUM CITRATE TABS                               CHROMAGEN
               CALCIUM GLUCONATE TABS                             CITRACAL PLUS TABS
               CALCIUM LACTATE TABS                               CONTRIN CAPS
               CALCIUM/MAGNESIUM TABS                             FEOGEN FORTE CAPS
               CALCIUM/VITAMIN D TABS                             FEROCON CAPS
               CALTRATE 600 TABS                                  FERREX 150 CAPS
               CHEWABLE CALCIUM CHEW                              FERRO-SEQUELS TBCR
               CITRACAL TABS                                      FE-TINIC CAPS
               CITRACAL + D TABS                                  FE-TINIC 150 FORTE CAPS
               CITRUS CALCIUM TABS                                FLUOR-A-DAY SOLN
               CITRUS CALCIUM 1500 + D TABS                       K-DUR TBCR
               DEXFERRUM SOLN                                     KLOR-CON PACK
               EFFERVESCENT POTASSIUM TBEF                        K-LYTE
               FEOSTAT CHEW                                       K-PHOS TABS
               FERATAB TABS                                       K-TABS TBCR
               FER-GEN-SOL SOLN                                   K-VESCENT PACK
               FERGON TABS                                        MICRO-K 10 MEG CPCR
               FER-IN-SOL SOLN                                    NU-IRON 150 CAPS
               FER-IRON SOLN                                      OYSTER SHELL CALCIUM/VITA TABS
               FERRONATE TABS                                     POLY-IRON 150 CAPS
               FERROUS FUMARATE TABS                              POLYSACCHARIDE IRON CAPS
               FERROUS GLUCONATE TABS                             POTASSIUM BICARB/CHLORIDE
               FERROUS SULFATE                                    SLOW FE TBCR
               FLUOR-A-DAY CHEW                                   TUMS 500 CHEW
               FLUORIDE CHEW                                      VIACTIV CHEW

                                                        Page 27 of 46
                FLUORITAB CHEW
                HEMOCYTE TABS
                HM CALCIUM TABS
                K+ POTASSIUM PACK
                KAON ELIX
                KAON-CL-10 TBCR
                KCL 0.075%/D5W/NACL 0.2% SOLN
                K-EFFERVESCENT TBEF
                KLOTRIX TBCR
                K-PHOS TABS
                K-VESCENT TBEF
                LURIDE CHEW
                MICRO-K 8 MEG
                OS-CAL TABS
                OS-CAL 500 + D TABS
                OYST-CAL TABS
                OYST-CAL D TABS
                OYST-CAL/VITAMIN D TABS
                OYSTER CALCIUM TABS
                OYSTER SHELL
                PHARMA FLUR
                PHOSPHA 250 NEUTRAL TABS
                POTASSIUM CHLORIDE
                SELENIUM TABS
                SLOW-MAG TBCR
                SODIUM FLUORIDE
                SSKI SOLN
                V-R CALCIUM
                V-R OYSTER SHELL CALCIUM
                ZINC SULFATE CAPS
                                             MISC. ELECTROLYTES/NUTRITIONALS
ELECTROLYTES/   FISH OIL CAPS                                 BOOST                         This list of nutritionals is incomplete. All
NUTRITIONALS    INTRALIPID EMUL                               CASEC POWD                    nutritionals still require a PA except for the
                                                                                            miscellaneous products listed as preferred.
                MCT OIL OIL                                   CHOICE DM LIQD
                                                                                            SGA form required for nutritionals unless
                ORALYTE SOLN                                  DELIVER 2.0 LIQD              member has a G/I tube.
                P.T.E. -5 SOLN                                ENFAMIL
                PEDIALYTE SOLN                                ENSURE
                                                              GLUCERNA                      Use PA Form # 20420 & SGA Form
                                                              ISOCAL LIQD
                                                              KINDERCAL TF LIQD
                                                              KINDERCAL TF/FIBER LIQD
                                                              L-CARNITINE CAPS
                                                              LIPISORB LIQD
                                                              MODULEN IBD POWD
                                                              NUTRAMIGEN POWD
                                                              NUTRITIONAL SUPPLEMENT LIQD
                                                              NUTRIVENT 1.5 LIQD
                                                              PKU 3 POWD
                                                              PREGESTIMIL POWD
                                                              PROBALANCE LIQD

                                                      Page 28 of 46
                                                                            SCANDISHAKE PACK
ERYTHROPOEITINS                                                        5  PROCRIT SOLN1            1. All products require PA but Procrit is first
                                                                       6  EPOGEN SOLN              choice. Still msut be used in specified step
                                                                       8    ARANESP SOLN           Use PA Form # 10520
                                                                 GRANULOCYTE CSF
GRANULOCYTE CSF                                                       8  LEUKINE                   Must be used in specified step order.1. 10 day
                                                                       8                           supply/month may be used without a PA. Use
                                                                            NEUPOGEN SOLN1
                                                                                                   PA Form # 20520
                                                                       9    NEULASTA
                                                          ANTICOAGULANTS / PLATELET AGENTS
ANTICOAGULANTS                ARIXTRA SOLN1                                 COUMADIN TABS          1. Arixtra, Fragmin and Lovenox therapy
                              FRAGMIN INJ1                                  IPRIVAS C              durations greater than 7 days require PA.
                              HEPARIN SODIUM/NACL 0.9% SOLN
                              HEP-LOCK SOLN
                              LOVENOX SOLN1                                                        Use PA Form # 20420
                              WARFARIN SODIUM TABS
                              HEPARIN LOCK SOLN
                              HEPARIN LOCK FLUSH SOLN
                              HEPARIN SODIUM SOLN
                              HEPARIN SODIUM LOCK FLUSH SOLN
ANTIHEMOPHILIC AGENTS         ALPHANATE                                     ADVATE1,2              1. Only if other products unavailable.
                              BENEFIX SOLR
                                                                                                   2. Advate may be available with PA in cases of
                              BIOCLATE                                                             large volume dosing in patients with poor
                              HELIXATE FS KIT                                                      venous access.
                              HEMOFIL - M                                                          Use PA Form # 20420
                              HUMATE-P SOLR
                              KOGENATE FS
                              KONYNE - 80
                              MONARC - M
                              MONOCLATE - P
                              NOVOSEVEN SOLR
                              PROPLEX -T
                              RECOMBINATE SOLR
PLATELET AGGREGATION          ASPIRIN                                  7    TICLOPIDINE HCL TABS   Use PA Form # 20420
INHIBITORS                                                             8    PERSANTINE TABS        1. As of 04.01.2005 Plavix is only available
                                                                                                   without PA if concurrent aspirin use (on
                              DIPYRIDAMOLE TABS                                                    prescription) within 100 days or documented
                                                                                                   failure or intolerance or other contraindication
                              PLAVIX TABS1                             8    TICLID TABS
                                                                                                   to aspirin.

PLATELET AGGR. INHIBITORS /   PENTOXIFYLLINE ER TBCR                        AGGRENOX CP121         1. Aspirin and dipyridamole are available
COMBO'S - MISC.               CILOSTAZOL                                    AGGRENOX2              separately without PA
                                                                            AGRYLIN CAPS           2. Aggrenox will be approved if submitted with
                                                                            PLETAL TABS            documentation supporting that it is being used
                                                                                                   for non-embolic stroke.                 Use PA
                                                                            TRENTAL TBCR           Form # 20420

MONOCLONAL ANTIBODY                                                         SOLIRIS                Use PA Form # 20420

HEMOSTATIC                    AMICAR
                              AMINOCAPROIC ACID
OP. ANTIBIOTICS               AK-SPORE OINT                                AK-POLY-BAC OINT        Use PA Form # 20420
                              BACITRACIN OINT                               AK-SULF OINT
                              BACITRACIN/NEOMYCIN/POLYM                     AK-TOB SOLN
                              BACITRACIN/POLYMYXIN B OINT                   BLEPH-10 SOLN
                              CHLOROPTIC SOLN                               GENTAK
                              ERYTHROMYCIN OINT                             ILOTYCIN OINT

                                                                   Page 29 of 46
                               GENTAMICIN SULFATE                  NEOMYCIN/BACI/POLYM OINT
                               NEOMYCIN/POLYMYXIN/GRAMIC           NEOSPORIN OINT
                               NEOSPORIN SOLN                      OCUSULF-10 SOLN
                               POLYSPORIN                          OCUTRICIN SOLN
                               SODIUM SULFACETAMIDE SOLN           TERAK OINT
                               SULFACETAMIDE SODIUM                TOBREX OINT
                               TERRAMYCIN OINT                     TRIFLURIDINE SOLN
                               TOBRAMYCIN SULFATE SOLN
                               TRIMETHOPRIM SULFATE/POLY
                               VIROPTIC SOLN
OP. QUINOLONES             1   CILOXAN OINT                                                    Step order must be followed to avoid PA. Must
                           1   CILOXAN SOLN                                                    fail Ocuflox and a Ciloxan product before
                                                                                               moving to next step product without PA. Use
                           1   OCUFLOX SOLN
                                                                                               PA Form # 20420
                           2   QUIXIN SOLN
GENERATIOIN                    ZYMAR
OP. ARTIFICIAL TEARS AND       AKWA TEARS OINT                     AKWA TEARS SOLN             Use PA Form # 20420
                               ARTIFICIAL TEARS SOLN               BION TEARS SOLN
                               CELLUVISC SOLN                      DRY EYES OINT
                               EYE LUBRICANT OINT                  DURATEARS OINT
                               GENTEAL                             HYPO TEARS
                               LIQUITEARS SOLN                     ISOPTO TEARS SOLN
                               MAJOR TEARS SOLN                    LACRI-LUBE
                               PURALUBE OINT                       LUBRIFRESH P.M. OINT
                               PURALUBE TEARS SOLN                 MURINE SOLN
                               REFRESH SOLN OP                     MUROCEL SOLN
                               REFRESH PLUS SOLN                   NATURE'S TEARS SOLN
                               REFRESH PM OINT                     REFRESH SOLN
                                                                   REFRESH TEARS SOLN
                                                                   TEARGEN SOLN
                                                                   TEARISOL SOLN
                                                                   TEARS NATURALE
                                                                   TEARS PURE SOLN
                                                                   TEARS RENEWED OINT
                                                                   THERATEARS SOLN
                                                                   V-R ARTIFICIAL TEARS SOLN
OP. BETA - BLOCKERS            BETOPTIC-S SUSP                     BETAGAN SOLN                Use PA Form # 20420
                               CARTEOLOL HCL SOLN                  BETAXOLOL HCL SOLN
                               LEVOBUNOLOL HCL SOLN                BETIMOL SOLN
                               METIPRANOLOL SOLN                   ISTALOL
                               TIMOLOL MALEATE SOLG (GEL)          OCUPRESS SOLN
                               TIMOLOL MALEATE SOLN                OPTIPRANOLOL SOLN
                                                                   TIMOPTIC SOLN
                                                                   TIMOPTIC-XE SOLG
OP. ANTIINFLAMMATORY /         AK-SPORE HC OINT                    AK-TROL SUSP                Use PA Form # 20420
STEROIDS OPHTH.                ALREX SUSP                          BAC/POLY/NEOMY/HC OINT
                               BLEPHAMIDE SUSP                     BLEPHAMIDE S.O.P. OINT
                               CORTISPORIN SUSP                    ECONOPRED
                               DEXAMETH SOD PHOS SOLN              EFLONE SUSP
                               FLAREX SUSP                         FLUOR-OP SUSP
                               FLUOROMETHOLONE SUSP                FML LIQUIFILM SUSP
                               FML S.O.P. OINT                     MAXITROL
                               FML-S LIQUIFILM SUSP                NEO/POLY/BAC/HC OINT
                               INFLAMASE SOLN                      PRED FORTE SUSP
                               LOTEMAX SUSP                        PRED-G SUSP
                               NEOM/POLIN/DEX                      PRED-G S.O.P. OINT
                               PRED MILD SUSP                      SULFACET SOD/PRED SOLN
                               PREDNISOLONE                        VASOCIDIN SOLN
                               TOBRADEX                            VEXOL SUSP

OP. PROSTAGLANDINS             LUMIGAN SOLN                        RESCULA SOLN                All preferred products must be used prior to
                                                                                               non-preffered products.
                               TRAVATAN SOLN                       XALATAN SOLN

                                                            Page 30 of 46
                                                                                           Use PA Form # 20420
OP. CYCLOPLEGICS            AK-PENTOLATE SOLN                    CYCLOGYL SOLN             Use PA Form # 20420
                            ATROPINE SULFATE                     ISOPTO ATROPINE SOLN
                            CYCLOPENTOLATE HCL SOLN              ISOPTO HOMATROPINE SOLN
                            ISOPTO HYOSCINE SOLN                 MUROCOLL-2 SOLN
                            ISOPTO CARPINE SOLN
                            PILOCAR SOLN
                            PILOCARPINE HCL SOLN
                            PILOPINE HS GEL
OP. ADRENERGIC AGENTS       DIPIVEFRIN HCL SOLN                  PROPINE SOLN              Use PA Form # 20420
                            EPIFRIN SOLN
OP. SELECTIVE ALPHA         ALPHAGAN SOLN                        IOPIDINE SOLN             Use PA Form # 20420
OP. ANTI-ALLERGICS          ELESTAT                              ALOCRIL SOLN              Use PA Form # 20420
                            PATADAY SOLN                         ALOMIDE SOLN
                            PATANOL SOLN                         EMADINE SOLN
                                                                 LIVOSTIN SUSP
                                                                 OPTICROM SOLN
OP. ANTI-ALLERGICS-         ALAMAST SOLN                                                   Must fail all preferred products before non-
MASTCELL STABILIER CLASS                                                                   preferred. Use PA form #20420

OP. CARBONIC ANHYDRASE      AZOPT SUSP                                                     Must fail all preferred products before non-
INHIBITORS/COMBO                                                                           preferred. Use PA form #20420
                            COSOPT SOLN
                            TRUSOPT SOLN
OP. NSAID'S                 ACULAR LS                            OCUFEN SOLN               Must fail all preferred products before non-
                                                                                           preferred. Use PA Form # 20420
                            ACULAR SOLN                          NEVANAC
                            FLURBIPROFEN SODIUM SOLN
                            VOLTAREN SOLN
OP. OF INTEREST             ENUCLENE SOLN                        BOTOX SOLR                1. Must have kerato conjuctivitus sicca and
                                                                 RESTASIS1                 failed other dry eye therapies. Use PA Form #

TOPICAL - ACNE              ACCUTANE CAPS                       ALTINAC CREA               1. For Tretinoin products, users over 24 will
PREPARATIONS                AZELEX CREA                          AVITA CREA                need a PA. Users 24 or under, PA will not be
                                                                                           required.                                   2.
                            BENZOYL PEROXIDE                     BENZAC
                                                                                           Dosing limits allowing one package per month.
                            CLINDAMYCIN PHOSPHATE2               BENZACLIN GEL             Please refer to Dose Consolidation list.
                            DIFFERIN                             BENZAGEL-10 GEL           If requesting any brands Use PA Form #
                            ERYDERM SOLN                         BENZAMYCIN GEL            10220, for all others use PA Form # 20420
                            ERYTHROMYCIN GEL                     BENZAMYCINPAK PACK
                            ERYTHROMYCIN PADS                    BREVOXYL
                            ERYTHROMYCIN SOLN                    CLEOCIN-T2
                            METRONIDAZOLE CREAM2                 CLINAC BPO GEL
                            METRONIDAZOLE GEL2                   CLINDAGEL GEL
                            METRONIDAZOLE LOTN2                  CLINDETS SWAB
                            PLEXION                              DESQUAM-E GEL
                            SODIUM SULFACET/SULF LOTN            DESQUAM-X
                            TRETINOIN   1, 2                     DUAC GEL
                                                                 EMGEL GEL
                                                                 ERYCETTE PADS
                                                                 ERYGEL GEL
                                                                 FINEVIN CREA
                                                                 KLARON LOTN
                                                                 METROCREAM CREAM2
                                                                 METROGEL GEL2
                                                                 METROLOTION LOTN2
                                                                 NEOBENZ MICRO
                                                                 NORITATE CREA
                                                                 RETIN-A MICRO GEL
                                                                 RETIN-A CREAM2
                                                                 RETIN-A GEL2

                                                         Page 31 of 46
                                                                      SULFACET-R LOTN

TOPICAL - ANTIBIOTIC        BACIT/NEOMYCIN/POLYM OINT                 CORTISPORIN                  1. Quantity limit of 30 g per month.
                            BACITRACIN OINT                           TRIPLE ANTIBIOTIC OINT
                            BACTROBAN1                                                             Use PA Form # 20420
                            CENTANY OINT 2%
                            GENTAMICIN SULFATE
TOPICAL ANTIFUNGALS         CICLOPIROX 0.77 CREAM                     EXELDERM                     Use PA Form # 10120
                            CICLOPIROX 0.77 SUSP                      FUNGIZONE CREA
                            CLOTRIMAZOLE                              HYDROCORT/IODOQ CREA
                            CLOTRIMAZOLE/BETA CREA                    LAMISIL
                            ECONAZOLE NITRATE CREAM                   LOPROX 0.77 LOTN
                            KETOCONAZOLE CREAM                        LOPROX 0.77 CREAM
                            LOPROX GEL                                LOPROX 0.77 SUSP
                            LOPROX 1.0 CREAM                          LOPROX SHAMPOO SHAM
                            LOPROX 1.O LOTN                           LOTRIMIN
                            LOPROX TS LOTN                            LOTRISONE
                            MICONAZOLE NITRATE CREA                   MENTAX CREA
                            MYCO-TRIACET II CREA                      MONISTAT-DERM CREA
                            NIZORAL SHAM                              MYCOGEN II CREA
                            NTA OINT                                  MYCOLOG-II CREA
                            NYSTATIN                                  MYCOSTATIN POWD
                            NYSTATIN/TRIAMCINOLONE                    NAFTIN
                            PEDI-DRI POWD                             NIZORAL CREA
                            TINACTIN                                  NYSTAT-RX POWD
                            TRI-STATIN II CREA                        NYSTOP POWD
                                                                      PENLAC NAIL LACQUER SOLN
                                                                      SPECTAZOLE CREAM

TOPICAL - ANTIPRURITICS     ZONALON CREA                              PRUDOXIN CREA                Use PA Form # 20420
TOPICAL - ANTIPSORIATICS    DOVONEX                                   OXSORALEN ULTRA CAPS         Must fail all preferred products before non-
                            SORIATANE CAPS                            PSORIATEC CREA               preferred. Use PA Form # 20420
                            TAZORAC                                   TACLONEX1                    1. Individual ingredients are available as
                                                                      VANAMIDE                     preferred without PA.

                            SELENIUM SULFIDE SHAM                     ZNP BAR BAR
                            SELSUN BLUE SHAM
TOPICAL - ANTIVIRALS                                                  DENAVIR CREA1                1. Must fail oral treatment with Acyclovir or
                                                                      ZOVIRAX OINT1
TOPICAL - ANTINEOPLASTICS   EFUDEX                                    CARAC CREA                   Use PA Form # 20420
                            FLUOROPLEX CREA
                            SOLARAZE GEL
TOPICAL - BURN PRODUCTS     FURACIN CREA                              SILVADENE CREA               Use PA Form # 20420
                            SSD CREA                                  SILVER SULFADIAZINE CREA
                            THERMAZENE CREA                           SSD AF CREA
TOPICAL -CORTICOSTEROIDS                   LOW POTENCY                ACLOVATE                     Use PA Form # 20420
                            DESOWEN                                   AMCINONIDE CREA
                            HYDROCORTISONE CREA                       ANUSOL HC-1 OINT
                            HYDROCORTISONE LOTN                       ARISTOCORT A
                            LACTICARE-HC LOTN                         CLOBEX
                            NUTRACORT LOTN                            CLODERM CREA
                            TEXACORT SOLN                             CORDRAN
                            TRIDESILON CREA                           CORMAX
                                         MEDIUM POTENCY               DERMATOP
                            CUTIVATE                                  DESONATE GEL
                            DESOXIMETASONE .05%                       DIPROLENE
                            ELOCON                                    ELOCON OINT
                            FLUOCINOLONE ACETONIDE .025-.01%          HYDROCORTISONE POWD
                            FLUROSYN CREA                             KENALOG AERS
                            HYDROCORTISONE BUTYRATE                   LIDA MANTLE HC CREA
                            HYDROCORTISONE OINT                       LIDEX

                                                               Page 32 of 46
                          HYDROCORTISONE VALERATE                   LIDEX-E CREA
                          MOMETASONE FUROATE OINT                   LOCOID
                          TRIAMCINOLONE ACETONIDE .025-.1%          LUXIQ FOAM
                                         HIGH POTENCY               OLUX FOAM
                          CYCLOCORT                                 PANDEL CREA
                          BETAMETHASONE DIPROPIONATE                PROCTOCORT CREA
                          DESOXIMETASONE .25%                       PSORCON
                          DESONIDE                                  PSORCON E
                          FLUOCINOLONE ACETONIDE .02%               SYNALAR OINT
                          FLUOCINONIDE                              TEMOVATE
                          HALOG                                     TOPICORT
                          HALOG-E CREA                              TOPICORT LP CREA
                          TRIAMCINOLONE ACETONIDE .5%               ULTRAVATE
                                       VERY HIGH POTENCY            VERDESO
                          AUGMENTED BETA DIP                        WESTCORT
                          BETAMETHASONE VALERATE
                          CLOBETASOL PROPIONATE
                          DIFLORASONE DIACETATE
                          CAPEX SHAM
                          DERMA-SMOOTHE/FS OIL
                          PROCTO-KIT CREA
TOPICAL - STEROID LOCAL   PRAMOSONE                                 EPIFOAM FOAM              Use PA Form # 20420
TOPICAL - STEROID         DERMA-SMOOTHE/FS ATOPIC P KIT             CARMOL-HC CREA            Use PA Form # 20420
TOPICAL - EMOLLIENTS      AMLACTIN CREA                             AMMONIUM LACTATE CREA     Use PA Form # 20420
                          CETAPHIL GENTLE CLEANSER LOTN             LACLOTION LOTN
                          LAC-HYDRIN                                LACTINOL LOTN
                          LACTINOL-E CREA                           MEDERMA GEL
                          UREACIN-20 CREA                           MIMYX
                          VITAMIN A & D MEDICATED OINT              RENOVA CREA
TOPICAL - ENZYMES /       GRANUL-DERM AERS                          CARMOL 40 CREA            Use PA Form # 20420
KERATOLYTICS / UREA       GRANULEX AERS                             SANTYL OINT
                          PANAFIL OINT                              SALEX CREAM
                          PANAFIL SE                                SALEX LOTION
                          PAPAIN-UREA-CHLORO OINT                   ZIOX OINT
                          TBC AERS
TOPICAL - GENITAL WARTS   ALDARA                                5   PODOFILOX SOLN            Non-preferred products must be used in
                                                                8   CONDYLOX                  specified order. Use PA Form # 20420
TOPICAL -                                                       8   ELIDEL CREA               Non-preferred products must be used in
IMMUNOMODULATORS                                                9   PROTOPIC OINT             specified order. The FDA has issued a Publilc
                                                                                              Health Advisory for both Elidel and Protopic
                                                                                              concerning the potential cancer risk associated
                                                                                              with their use. Use for children less than 2
                                                                                              years of age is not recommended. Use PA
                                                                                              Form # 20420.

TOPICAL - LOCAL           AF CAPSICUM OLEORESIN CREA                EMLA PADS                 1. Lidocaine/Prilocaine cream and Ela-Max
ANESTHETICS               CAPSAICIN CREA                            EMLA CREA                 products require PA for users over 18 years of
                          ELA-MAX1                                  LIDA MANTLE CREA
                          LIDOCAINE/PRILOCAINE CREA   1             LIDODERM PTCH             Use PA Form # 20420
                          XYLOCAINE                                 PONTOCAINE SOLN

TOPICAL -DEPIGMENTING                                           8   ALUSTRA CREA              Not covered for cosmetic purposes.
AGENTS                                                          8   EPIQUIN MICRO
                                                                8   GLYQUIN CREA              Use PA Form # 20420
                                                                8   HYDROQUINONE CREA
                                                                8   HYDROQUINONE/SUNSCREENS
                                                                8   SOLAQUIN FORTE CREA
                                                                8   TRI-LUMA CREA
                                                                9   ELDOQUIN

                                                             Page 33 of 46
TOPICAL - SCABICIDES AND   ACTICIN CREA                                LINDANE
PEDICULICIDES              ELIMITE CREA                                OVIDE LOTN
                           LICE KILLING SHAM
                           LICE TREATMENT CREME RINS LIQD
                           NIX CREME RINSE LIQD
                           PERMETHRIN LOTN
TOPICAL - WOUND /          ACCUZYME OINT                               REGRANEX GEL                     Use PA Form # 20420
DECUBITUS CARE             ACCUZYME SPRAY                              REGENECARE
                           ACCUZYME SE                                 RADIAPLEX RX
TOPICAL - ASTRINGENTS /    ALUMINUM CHLORIDE SOLN                      LOWILA BAR                       Use PA Form # 20420
PROTECTANTS                DRYSOL SOLN                                 MOISTURIN DRY SKIN CREA
                           XERAC AC SOLN                               PROSHIELD PLUS SKIN PROTE CREA
                                                                       SURGILUBE GEL
TOPICAL - ANTISEPTICS /    HIBICLENS LIQD                              BETADINE OINT                    Use PA Form # 20420
DISINFECTANTS              PHISOHEX LIQD                               FORMALYDE-10 AERS
                           POVIDONE-IODINE SOLN                        IODOSORB
                                                                       LAZERFORMALYDE SOLUTION SOLN
                                                             MISCELLANEOUS EYE
OP. MISC.                  AK-DILATE SOLN                              LENS PLUS REWETTING DROPS        Use PA Form # 20420
                           EYE WASH SOLN                               MURO 128
                           NAPHAZOLINE HCL SOLN                        NEO-SYNEPHRINE SOLN
                           PHENYLEPHRINE HCL SOLN
                           PONTOCAINE SOLN
                           SODIUM CHLORIDE
                                                            MISCELLANEOUS EAR
EAR                        A/B OTIC SOLN                              AERO OTIC HC SOLN                 Use PA Form # 20420
                           ACETASOL SOLN                               ANTIBIOTIC EAR SOLN
                           ACETASOL HC SOLN                            ANTIBIOTIC EAR SUSP
                           ACETIC ACID                                 AURALGAN SOLN
                           ACETIC ACID/HYDROCORTISON                   CIPRO HC SUSP
                           ALLERGEN SOLN                               COLY-MYCIN-S SUSP
                           ANTIPYRINE/BENZOCAINE SOLN                  CORTISPORIN SUSP
                           AURODEX SOLN                                CORTISPORIN-TC SUSP
                           AUROGUARD SOLN                              DEBROX SOLN
                           AUROTO OTIC SOLN                            DOMEBORO SOLN
                           CIPRODEX                                    PEDIOTIC SUSP
                           CORTISPORIN SOLN                            VOSOL-HC SOLN
                           CORTOMYCIN                                  ZOTANE HC SOLN
                           EAR DROPS SOLN                              ZOTO-HC SOLN
                           EAR DROPS RX SOLN
                           EAR WAX REMOVAL DROPS
                           EAR-GESIC SOLN
                           FLOXIN OTIC SOLN
                           OTICAINE OTIC SOLN
                                                            MOUTH ANTISEPTICS
MOUTH ANTI-INFECTIVES      NILSTAT SUSP                               MYCELEX TROC                      Use PA Form # 20420
                           EAR-GESIC SOLN                              MYCOSTATIN LOZG
                           NYSTATIN SUSP
MOUTH ANTISEPTICS          CHLORHEXIDINE GLUCONATE                     APHTHASOL PSTE                   Must fail all preferred products before non-
                           LIDOCAINE VISCOUS SOLN                      PERIDEX SOLN                     preferred.Use PA Form # 20420
                           TRIAMCINOLONE IN ORABASE PSTE               PERIOGARD SOLN
                                                                       XYLOCAINE VISCOUS SOLN

                                                            DENTAL PRODUCTS
DENTAL PRODUCTS            ETHEDENT CREA                             APF GEL GEL                        Use PA Form # 20420
                           GEL-KAM CONC                                DENTAGEL GEL
                           PHOS FLUR SOLN                              PHOS-FLUR GEL
                           PREVIDENT GEL                               PREVIDENT CREAM
                           PREVIDENT SOLN                              THERA-FLUR-N GEL

                                                               Page 34 of 46
                             SF 5000 PLUS CREA
                             SF GEL
                             STANNOUS FLUORIDE ORAL RI CONC
                                                            ARTIFICIAL SALIVA/STIMULANTS
ARTIFICIAL                   EVOXAC CAPS                                     RADIACARE SOLR           Use PA Form # 20420
                                                            MISCELLANEOUS ANORECTAL
ANORECTAL - MISC.            COLOCORT ENEM                               ANUSOL-HC CREA               Use PA Form # 20420
                             CORTENEMA ENEM                                 CORTIFOAM FOAM
                             ELA-MAX 5 CREA                                 PROCTOCREAM-HC CREA
                             HYDROCORTISONE ENEM                            PROCTOFOAM HC FOAM
                             PROCTOZONE-HC CREA                             PROCTO-KIT CREA
                                                                            PROCTOSOL HC CREA
                                                            T-CELL ACTIVATION INHIBITOR
PSORIASIS BIOLOGICALS        ENBREL1                                        AMEVIVE2                   1. Will not require a PA if at least one
                             RAPTIVA1                                                                 systemic drug such as methotrexate,
                                                                                                      cyclosporine, methoxsalen or acitretin is in
                                                                                                      members drug profile. High doses of Enbrel
                                                                                                      50mg twice weekly will require a PA. Please
                                                                                                      refer to dose consolidation list. 2. Trial of both
                                                                                                      preferred drugs are required.
                                                                                                      Use PA Form # 20910

                                                               ALTERNATIVE MEDICINES
ALTERNATIVE MEDICINES        DIMETHYL SULFOXIDE SOLN                       ARTHX DS CAPS              Use PA Form # 20420
                                                                            CO-ENZYME Q10
                                                                            DHEA TABS
                                                                            FLEXAGEN TABS
                                                                            HM GINKGO BILOBA TABS
                                                                            MELATONIN TABS
                                                                 CHELATING AGENTS
CHELATING AGENTS             CUPRIMINE CAPS                                DEPEN TITRATABS TABS       Use PA Form # 20420
ANTILEPROTIC                                                                THALOMID CAPS             Use PA Form # 20420
                                                  ANTINEOPLASTIC AGENTS - IMMUNOMODULATOR
ANTINEOPLASTIC AGENTS -                                                     REVLIMID1                 1. Quantity limits apply
                                                      ANTINEOPLASTIC AGENTS - ANTIADNDROGENS
                             GLEEVEC                                        SPRYCEL1                  1. Verification of diagnosis and prior trial of at
                                                                                                      least Gleevec is required.
                                                                                                      Use PA Form # 20420
CANCER                       ALIMTA                                         NEXAVAR1                  1. PA required to confirm FDA approved
                             AVASTIN                                                 1,2              indication
                             ERBITUX                                                                  2. Avoid CYP3AY drug drug interaction
IMMUNOSUPPRESSANTS           CELLCEPT                                    CYCLOSPORINE CAPS            1. Established users will require a one time
                             CYCLOSPORINE MODIFIED                          NEORAL   1                PA. Use PA Form # 20420
                             CYCLOSPORINE SOL MODIFIED
                             GENGRAF CAPS
                             PROGRAF CAPS
                                                                   PURINE ANALOG
PURINE ANALOG                AZASAN TABS                                    IMURAN TABS               Use PA Form # 20420

                                                                    Page 35 of 46
                                        AZATHIOPRINE TABS
                                                                                K REMOVING RESINS
K REMOVING RESINS                       KAYEXALATE POWD                                                                                           Use PA Form # 20420
                                        KIONEX POWD
                                        SODIUM POLYSTYRENE SULFON
                                        SPS SUSP
                                        SPS 30GM/120ML ENEMA SUSP
  New drugs are initially non-preferred until reviewed by the DUR Committee and the State. According to State policy, any drug requiring specific diagnosis still requires the specific
                                                                diagnosis unless otherwise noted within this document.

                                                                                    Page 36 of 46
                                                                                                                     Revised Nov. 1, 2005

                                                   ANTI-CONVULSANTS INDICATION CHART
                            POST          DIABETIC                                                    RESTLESS
                          HERPETIC      PERIPHERAL     MONOTHERAPY     ADJUNCTIVE       MIGRAINE         LEG

  GABITRIL       X                                          9              8

  KEPPRA         X                                          9              7

 LAMICTAL        X                                          4              4

  LYRICA         X        X(2nd line)    X(2nd line)

 NEURONTIN       X        X(2nd line)   X (2ND line)        9              9           X (2nd line)   X (2nd line)

 TOPAMAX         X                                          9              6           X (2nd line)

 TRILEPTAL       X                                          5              5

 ZONEGRAN        X                                          9              9

                                           PEDIATRIC ANTI-CONVULSANTS INDICATION CHART

                                           SEIZURES MONOTHERAPY BIPOLAR         ADJUNCTIVE BIPOLAR

               LITHIUM                                          1                       1

             CARBMAZEPINE                      X                1                       1

              VALPROATE                        X                1                       1

ATYPICAL ANTIPSYCHOTICS EXC. CLOZAPINE         X                1                       1

               LAMICTAL                        X                1                       1

                                               X                5                       5

              CLOZAPINE                        X                6                       6

                                                                Page 37 of 46
Last update 10/07                        PDL DOSAGE CONSOLIDATION LIST
Tabs/Caps/Patches: Quantities in units                               Shaded areas are non-preferred agents - Quantities of these
Sprays/Inhalers/Nebulizers: Quantities in GM, ML, OR MCG           non-preferred agents are available up the limit only with
Injectibles: Quantities in ML                                         prior authorization
      Drug Name                 Strength   Limit/Day        Limit/Days             Drug Name            Strength       Limit/Day          Limit/Days
        ABILIFY                  5MG             1            35/35                 AVANDIA               2MG               1.5             53/35
        ABILIFY                  10MG            1            35/35                 AVANDIA               4MG                1              35/35
        ABILIFY                  15MG            1            35/35                 AVAPRO               75MG               1.5             53/35
        ABILIFY                  20MG            1            35/35                 AVAPRO              150MG                1              35/35
        ABILIFY                  30MG            1            35/35              AXERT (Step 8)         6.25MG                              12/30
  ABILIFY SOLUTION              1MG/ML        30ML           1020/34             AXERT (Step 8)         12.5MG                              12/30
       ACCUPRIL                  5MG             1            35/35                 AZILECT           All Strengths          1              35/35
       ACCUPRIL                  10MG            1            35/35                AZMACORT             100MCG        16 INHALATIONS        40/30
       ACCUPRIL                  20MG            1            35/35              BECONASE AQ            42MCG         8 INHALATIONS         50/30
         ACEON                   2MG             1            35/35               BENAZEPRIL              5MG                1              35/35
         ACEON                   4MG             1            35/35               BENAZEPRIL             10MG               1.5             53/35
       ACTONEL                   5MG             1            35/35               BENAZEPRIL             20MG                1              35/35
       ACTONEL                   35MG         1/WK            5/35              BENAZEP/HCTZ             5-6.25              1              35/35
         ACTOS                   15MG            2            70/35             BENAZEP/HCTZ            10/12.5              1              35/35
         ACTOS                   45MG            1            35/35                 BONIVA               2.5MG               1              35/35
     ADDERALL XR           All Strengths         1            35/35                 BONIVA              150MG             1/MO              1/30
       AEROBID                  250MCG     8 INHALATIONS      21/35            BOTOX (ADULTS)          100U/ML        1 session/90 days   600U/90
      AEROBID-M                 250MCG     8 INHALATIONS      21/35           BOTOX (CHILDREN>12)      100U/ML        1 session/90 days   400U/90
 ALAVERT-NON DROW                 TAB            1            96/96                  BYETTA            5mcg inj          0.04ML           1.2ML/30
        ALDARA                    5%                          12/28                  BYETTA           10mcg inj          0.08ML           2.4ML/30
        ALTACE                  1.25MG           1            35/35                CALAN SR             120MG                1              35/35
        ALTACE                   2.5MG           1            35/35                CALAN SR             180MG                2              70/35
        ALTACE                   5MG             1            35/35                CALAN SR             240MG                2              70/35
        AMARYL                   1MG             1            35/35              CARDIZEM CD           120MG/24              1              35/35
        AMARYL                   2MG             1            35/35              CARDIZEM CD           180MG/24              1              35/35
        AMBIEN                   5MG                          12/34              CARDIZEM CD           240MG/24              1              35/35
        AMBIEN                   10MG                         12/34              CARDIZEM CD           300MG/24              1              35/35
      AMBIEN CR                 6.25MG                        12/34              CARDIZEM CD           360MG/24              1              35/35
      AMBIEN CR                 12.5MG                        12/34              CARDIZEM LA           120MG/24              1              35/35
   AMERGE (Step 8)               1MG                          12/30              CARDIZEM LA           180MG/24              1              35/35
   AMERGE (Step 8)               2.5MG                        12/30              CARDIZEM LA           240MG/24              1              35/35
     AMLODIPINE                  2.5MG          1.5         53/35 DAYS           CARDIZEM LA           300MG/24              1              35/35
     AMLODIPINE                  5MG            1.5         53/35 DAYS           CARDIZEM LA           360MG/24              1              35/35
 AMPHETAMINE SALT           5,10,15MG            3           105/35                 CARDURA               1MG                1              35/35
 AMPHETAMINE SALT                20MG            2            70/35                 CARDURA               2MG               1.5             53/35
 AMPHETAMINE SALT                30MG            1            35/35                 CARDURA               4MG               1.5             53/35
     ANDRODERM                   2.5MG           2            60/30                CARTIA XT            120MG                1              90/90
     ANDRODERM                   5MG             1            30/30                CARTIA XT            180MG                1              90/90
         ARAVA                   10MG            1            35/35                CARTIA XT            240MG                1              90/90
        ARICEPT                  5MG             1            35/35                CARTIA XT            300MG                1              90/90
        ARICEPT                  10MG            1            35/35             CATAPRES-TTS1         0.1 MG/24HR                           5/35
 ARIXTRA INJECTION         2.5MG/0.5ML                        7/30              CATAPRES- TTS2        0.2 MG/24HR                           5/35
 ARIXTRA INJECTION          5MG/0.4ML                         7/30              CATAPRES- TTS3        0.3 MG/24HR                           5/35
 ARIXTRA INJECTION         7.5MG/0.6ML                        7/30                 CELEBREX             100MG                1              35/35
 ARIXTRA INJECTION         10MG/0.8ML                         7/30                 CELEBREX             200MG                1              35/35
  ASMANEX 30 UNITS              220MCG     1 INHALATION      30U/30                  CELEXA              20mg               0.5             17/34
  ASMANEX 60 UNITS              220MCG     2 INHALATIONS     60U/30                  CELEXA              40mg                1              51/34
 ASMANEX 120 UNITS              220MCG     4 INHALATIONS     120U/30              CITALOPRAM             20MG               0.5             90/90
       ATACAND                   4MG            1.5           53/35               CITALOPRAM             40MG                1              90/90
       ATACAND                   8MG            1.5           53/35                CLARINEX            REDI TAB              1              35/35
       ATACAND                   16MG            1            35/35                CLEOCIN-T                          1 PACKAGE             1/30
        ATRIPLA                 600MG            1            35/35           CLINDAMYCIN PHOSPHATE                   1 PACKAGE             1/30
    ATROVENT HFA                17MCG      12 INHALATIONS    25.8/34              COMBIVENT           103-18MCG       12 INHALATIONS        30/35
   ATROVENT 30ML                0.03%      12 SPRAYS          30/30                CONCERTA           All Strengths          1              35/35
   ATROVENT 15ML                0.06%      16 SPRAYS          45/30              COPAXONE INJ            20MG                               1/32
      Drug Name                 Strength   Limit/Day        Limit/Days             Drug Name            Strength       Limit/Day          Limit/Days
   COPAXONE KIT       20MG/ML                         1/30          ENALAPRIL             2.5              1            90/90
     COREG CR       All Strengths          1          34/34         ENALAPRIL             5MG             1.5          135/90
      COZAAR             25MG              1.5        53/35         ENALAPRIL            10MG             1.5          135/90
      COZAAR             50MG              1.5        53/35       ENALAPR/HCTZ           5-12.5            1            90/90
     CRESTOR              5MG              1          35/35           ENBREL           25MG/ML                         7.84/28
     CRESTOR             10MG              1          35/35           ENBREL           50MG/ML                         3.92/28
     CRESTOR             20MG              1          35/35           ENBREL           50MG/ML                         7.84/28
     CRESTOR             40MG              1          35/35         ESTAZOLAM             1MG                           10/30
     CYMBALTA       All Strengths          1          35/35         ESTAZOLAM             2MG                           10/30
     DALMANE             15MG                         10/30        ESTRING MIS            2MG                           1/90
     DALMANE             30MG                         10/30         FELODIPINE           2.5MG             1            90/90
      DAYPRO            600MG              2          70/35         FELODIPINE            5MG             1.5          135/90
    DAYTRANA        10mg/9hr (27.5mg)      1          34/34         FENTANYL**        25MCG/HR                          11/33
    DAYTRANA        15mg/9hr (41.3mg)      1          34/34         FENTANYL**        50MCG/HR                          11/33
    DAYTRANA        20mg/9hr (55.0mg)      1          34/34         FENTANYL**        75MCG/HR                          11/33
    DAYTRANA        30mg/9hr (82.5mg)      1          34/34         FENTANYL**        100MCG/HR                         22/33
      DDAVP               5ML                         15/34        FINASTERIDE            5MG              1            90/90
  DEPO-PROVERA       150MG/ML                         1/90           FLONASE            50MCG          4 SPRAYS         32/34
  DEPO-PROVERA       400MG/ML                        2.5/90      FLOVENT HFA 44MCG      44MCG         4 INHALATIONS    10.6/30
DEPO-TESTOSTERONE    200MG/ML                         20/90      FLOVENT HFA 110MCG     110MCG        4 INHALATIONS     12/30
  DESMOPRESSIN          0.1MG              12        420/35      FLOVENT HFA 220MCG     220MCG        8 INHALATIONS     24/30
  DESMOPRESSIN          0.2MG              6         210/35        FLUCONAZOLE          150MG                            1/7
    DETROL LA             2MG              1          35/35         FLURAZEPAM           15MG                           10/30
    DEXEDRINE       All Strengths          3          90/30         FLURAZEPAM           30MG                           10/30
DEXTROAMPHETAMINE All Strengths            3          90/30         FLUOXETINE           20MG              4           140/35
     DIFLUCAN           150MG                          1/7       FLUTICASONE SPR                       4 SPRAYS         32/34
    DILACOR XR       240MG/24              1          35/35        FLUVOXAMINE           25MG              1            90/90
    DILACOR XR       120MG/24              1          35/35        FLUVOXAMINE           50MG              1            90/90
    DILACOR XR       180MG/24              1          35/35           FOCALIN         All Strengths        3           105/35
    DILTIA - XT      120MG/24              1          90/90         FOCALIN XR        All Strengths        1            35/35
    DILTIA - XT         180MG              1          90/90          FOSAMAX              5MG              1            35/35
    DILTIA - XT      240MG/24              1          90/90          FOSAMAX             10MG              1            35/35
 DILTIAZEM CAP ER       120MG              1          90/90          FOSAMAX             70MG            1/WK           5/35
 DILTIAZEM CAP XR       120MG              1          90/90          FOSAMAX             40MG            2/WK           10/35
  DILTIAZEM CAP      120MG/24              1          90/90         FOSINOPRIL           10MG             1.5          135/90
  DILTIAZEM CAP      180MG/24              1          90/90         FOSINOPRIL           20MG              2           180/90
 DILTIAZEM CAP ER       240MG              1          90/90        FRAGMIN INJ        10000U/ML           2ML           14/7
 DILTIAZEM CAP XR       240MG              1          90/90        FRAGMIN INJ        2500U/.2ML         0.4ML         2.80/7
 DILTIAZEM XR CAP    240MG/24              1          90/90        FRAGMIN INJ        25000U/ML          0.8ML          5.6/7
  DILTIAZEM CAP      240MG/24              1          90/90        FRAGMIN INJ        5000U/.2ML         0.4ML         2.80/7
  DILTIAZEM CAP      300MG/24              1          90/90        FRAGMIN INJ        7500U/.3ML         0.6ML          4.2/7
  DILTIAZEM CAP      360MG/24              1          90/90      FROVA TAB (Step 8)      2.5MG                         12/30
      DIOVAN             80MG              1          35/35           FUZEON              KIT              1            1/30
   DIOVAN - HCT        80 - 12.5           1          35/35         GABAPENTIN          300MG              3           270/90
   DITROPAN XL            5MG              1          35/35         GABAPENTIN          600MG              3           270/90
   DITROPAN XL           10MG              2          70/35           GEODON             20MG              2            70/35
      DORAL             7.5MG                         10/30           GEODON             40MG              2            70/35
      DORAL              15MG                         10/30           GEODON             60MG              2            70/35
    DOXAZOSIN             1MG              1          90/90           GEODON             80MG              2            70/35
    DOXAZOSIN             2MG              1.5       135/90           GEODON              INJ              2            70/35
    DOXAZOSIN             4MG              1.5       135/90        GLIMEPIRIDE            1MG              1            90/90
DURAGESIC PATCHES    25MCG/HR                         11/33        GLIMEPIRIDE            2MG              1            90/90
DURAGESIC PATCHES    50MCG/HR                         11/33      GLUCOSE TES STRP                          12          420/35
DURAGESIC PATCHES    75MCG/HR                         11/33         GLYCOLAX*           255GM                         255GM/90
DURAGESIC PATCHES   100MCG/HR                         22/33          HALCION            0.125MG                         10/35
       EDEX         All Strengths                     1/30           HALCION              0.25                          10/35
    EFFEXOR XR          37.5MG             1          35/35           HYTRIN              1MG              1            35/35
    EFFEXOR XR          75MG               1          35/35       * Available for once daily dosing to members under
      EMSAM         All Strengths          1          34/34                        the age of 18 years
    Drug Name          Strength         Limit/Day   Limit/Days      Drug Name           Strength       Limit/Day      Limit/Days
      HYTRIN              5MG              1          35/35      LUPRON DEPOT INJ       11.25MG           KIT           1/90
     HYZAAR           50-12.5            1              35/35         LUPRON DEPOT INJ           22.5             KIT            1/90
     IMDUR             30MG             1.5             53/35         LUPRON DEPOT INJ          30MG                             1/90
     IMDUR             60MG             1.5             53/35         LUPRON DEPOT INJ          30MG              KIT            1/90
 IMITREX (Step 1)      25MG                             12/30               MAVIK                1MG               1            35/35
 IMITREX (Step 1)      50MG                             12/30               MAVIK                2MG               1            35/35
IMITREX (Step 1)      100MG                             12/30           MAXAIR AUTO            200MCG        12 INHALATIONS     14/30
   IMITREX INJ       4MG/.5ML                        6 boxes/30        MAXALT (Step 1)           5MG                            12/30
   IMITREX INJ       6MG/.5ML                        6 boxes/30        MAXALT (Step 1)          10MG                            12/30
   IMITREX KIT       6MG/.5ML                           6/30          MAXALT MLT (Step 1)        5MG                            12/30
  IMITREX SPR           5MG                             12/30         MAXALT MLT (Step 1)       10MG              0.4           12/30
  IMITREX SPR          20MG                             12/30          MEDROXYPR AC           150MG/ML                           1/90
      INTAL           800MCG        8 INHALATIONS      28.4/34           MELOXICAM              7.5MG              1            35/35
IPRATROPIUM 30ML       0.03%        12 SPRAYS           90/90            MELOXICAM              15MG               1            35/35
IPRATROPIUM 15ML       0.06%        16 SPRAYS          135/90            METADATE ER           10,20MG             3            90/30
   ISOPTIN SR         180MG              2              70/35           METFORMIN ER           500MG               4           360/90
   ISOPTIN SR         240MG              2              70/35             METHYLIN           All Strengths         3            90/30
ISOSORBIDE MONO        30MG             1.5            135/90         METHYLPHENIDATE        All Strengths         3            90/30
ISOSORBIDE MONO        60 MG            1.5            135/90           METROCREAM                           1 PACKAGE           1/30
    JANUVIA         All Strengths        1              35/35             METROGEL                           1 PACKAGE           1/30
  KETOPROFEN          100MG              2             180/90           METROLOTION                          1 PACKAGE           1/30
  KETOPROFEN          200MG              1              90/90         METRONIDAZOLE CREAM                    1 PACKAGE           1/30
   KETOROLAC           10MG             4.8             24/30         METRONIDAZOLE GEL                      1 PACKAGE           1/30
    LAMICTAL           25MG              6             210/35         METRONIDAZOLE LOTION                   1 PACKAGE           1/30
    LAMICTAL        25MG CHW             6             210/35              MEVACOR              10MG              1.5           53/35
    LAMICTAL          100MG              2              70/35              MEVACOR              20MG              1.5           53/35
     LAMISIL          250MG              1              35/35            MIACALCIN                              3.75ml        1 bottle/34
  LAMOTRIGINE          25MG              6             540/90             MICARDIS              40MG              1.5           53/35
  LEFLUNOMIDE          10MG              1              90/90              MIRALAX              255G             8.5G         1 bottle/30
     LESCOL            20MG              1              35/35              MIRALAX           17G/PACKET      0.5 packet 15 packets/30
    LEVAQUIN          250MG              1              35/35               MOBIC              7.5 MG              1            35/35
    LEXAPRO             5MG             0.5             15/30               MOBIC               15MG               1            35/35
    LEXAPRO            10MG             0.5             15/30             MOEXIPRIL              7.5              1.5          135/90
    LEXAPRO            20MG              1              35/35             MONOPRIL              10MG              1.5           53/35
     LIPITOR           10MG              1              35/35             MONOPRIL              20MG               2            70/35
     LIPITOR           20MG              1              35/35           NABUMETONE             500MG               2           180/90
     LIPITOR           40MG             1.5             53/35           NABUMETONE             750MG               2           180/90
   LISINOPRIL          2.5MG             1              90/90           NASACORT AQ            55MCG          4 SPRAYS          17/30
   LISINOPRIL           5MG              1              90/90              NASAREL             0.025%        16 SPRAYS          75/35
   LISINOPRIL          10MG             1.5            135/90              NASONEX             50MCG          4 SPRAYS          17/30
   LISINOPRIL          20MG             1.5            135/90           NEUPOGEN INJ         300MCG/ML                          10/30
  LISINOP/HCTZ        10/12.5            1              90/90           NEUPOGEN INJ         480MCG/1.6                         16/30
    LOTENSIN            5MG              1              35/35           NEUPOGEN INJ         300MCG/.5ML                         5/30
    LOTENSIN           10MG             1.5             35/35           NEUPOGEN INJ         480MCG/.8ML                         8/30
    LOTENSIN           20MG              1              53/35            NEURONTIN             300MG               3           105/35
 LOTENSIN - HCT       5 - 6.25           1              35/35            NEURONTIN             600MG               3           105/35
 LOTENSIN - HCT       10 - 12.5          1              35/35              NEXIUM               20MG               1            35/35
   LOVASTATIN          10MG             1.5            135/90              NEXIUM               40MG               2            70/35
   LOVASTATIN          20MG             1.5            135/90           NIFEDIPINE CR           90MG               1            90/90
  LOVENOX INJ       30MG/.3ML           0.6         14 injections/7     NIFEDIPINE ER           60MG               1            90/90
  LOVENOX INJ       40MG/.4ML           0.8         14 injections/7     NIFEDIPINE ER           30MG               1            90/90
  LOVENOX INJ       60MG/.6ML           1.2         14 injections/7     NIFEDIPINE ER           60MG               1            90/90
  LOVENOX INJ       80MG/.8ML           1.6         14 injections/7     NIFEDIPINE ER           90MG               1            90/90
  LOVENOX INJ       100MG/ML             2          14 injections/7   NIFEDIPINE ER,CR          30MG               1            90/90
  LOVENOX INJ       120MG/.8ML          1.6         14 injections/7        NORVASC              2.5MG             1.5         53/35 DAYS
  LOVENOX INJ       150MG/ML             2          14 injections/7        NORVASC               5MG              1.5         53/35 DAYS
    LUNESTA             1MG                             12/34             Drug Name            Strength       Limit/Day       Limit/Days
    LUNESTA             2MG                             12/34             RISPERDAL             0.5MG             1.5           53/35
    LUNESTA             3MG                             12/34             RISPERDAL              1MG              1.5           53/35
   Drug Name          Strength      Limit/Day        Limit/Days           RISPERDAL              2MG              1.5           53/35
   NUVARING                            1/MO             1/28              RISPERDAL              3MG               2            70/35
  OMEPRAZOLE           10MG              1              90/90             RISPERDAL              4MG               2            70/35
 OMEPRAZOLE        20MG               2            180/90         RISPERDAL INJ         25MG                          2/28
ONDANSETRON*        4MG               3             90/30         RISPERDAL INJ         37.5                          2/28
ONDANSETRON*        8MG              1.5            45/30         RISPERDAL INJ         50MG                          2/28
ONDANSETRON*       24MG              0.5            15/30       RISPERDAL M-TAB        0.5MG            1.5          53/35
 ORTHO-EVRA                                         3/28        RISPERDAL M-TAB         1MG             1.5          53/35
  ORUVAIL         100MG               2             70/35       RISPERDAL M-TAB         2MG              4           140/35
  ORUVAIL         200MG               1             35/35        RISPERDAL SOL.       1MG/ML            8ML          280/35
 OXAPROZIN        600MG               2            180/90       SEREVENT DISKUS        50MCG        2 INHALATIONS    60/30
 OXYCODONE      10,20,40MG            2             70/35           SEROQUEL           100MG                         45/30
 OXYCODONE         80MG               4            140/35          SERTRALINE           25MG            0.5          18/35
OXYCONTIN**     10,20,40MG            2             70/35          SERTRALINE           50MG            0.5          18/35
OXYCONTIN**        80MG               4            140/35          SERTRALINE          100MG             3           105/35
 PAROXETINE        10MG              1.5           135/90         SIMVASTATIN           5MG              1           35/35
 PAROXETINE        20MG               1             90/90         SIMVASTATIN           10MG            1.5          53/35
    PAXIL          10MG              1.5            53/35         SIMVASTATIN           20MG            1.5          53/35
    PAXIL          20MG               1             35/35         SIMVASTATIN           40MG            1.5          53/35
 PEGASYS KIT                        KIT             1/28          SIMVASTATIN           80MG             1           35/35
   PLAN B                                        2/15 or 4/30       SINGULAIR           4MG              1           35/35
   PLENDIL         2.5MG              1             35/35           SINGULAIR           5MG              1           35/35
   PLENDIL          5MG              1.5            53/35           SINGULAIR           10MG             1           35/35
 PRAVACHOL         10MG               1             35/35            SONATA             5MG                          12/34
 PRAVACHOL         20MG               1             35/35            SONATA             10MG                         12/34
 PRAVACHOL         40MG               1             35/35            SPIRIVA         HANDIHLR       1 INHALTION      30/30
 PRAVACHOL         80MG               1             35/35         SPORANOX SOL        10MG/ML        10ML/ML        300cc/30
PRAVASTATIN        10MG               1             35/35       SPORANOX PULSEPAK      100MG                         30/30
PRAVASTATIN        20MG               1             35/35           SPORANOX           100MG                         30/30
PRAVASTATIN        40MG               2            180/90          STADOL INJ         1MG/ML                          9/35
PRAVASTATIN        80MG               1             35/35          STADOL INJ         2MG/ML                          9/35
  PREVACID         15MG               1             35/35           STRATTERA       All Strengths        1           35/35
  PREVACID         30MG               2            70/35              SULAR             10MG            1.5          53/35
 PREVPAC MIS    500MG-30MG                          14/30             SULAR             20MG             1           35/35
PRILOSEC OTC       20MG               2            168/84          SYNVISC INJ        8MG/ML                          2/30
  PRINIVIL         2.5MG              1             35/35           SYRINGES                             10         1000/100
  PRINIVIL          5MG               1             35/35         TAMIFLU CAPS          75MG                         10/30
  PRINIVIL         10MG              1.5            53/35         TAZTIA XT CAP      120MG/24            1           90/90
  PRINIVIL         20MG              1.5            53/35         TAZTIA XT CAP      180MG/24            1           90/90
  PRINZIDE        10-12.5             1             35/35         TAZTIA XT CAP      240MG/24            1           90/90
  PROTONIX         40MG               2             70/35         TAZTIA XT CAP      300MG/24            1           90/90
 PROVENTIL        90MCG         12 INHALATIONS      34/34         TAZTIA XT CAP      360MG/24            1           90/90
PROVENTIL HFA     90MCG         12 INHALATIONS      14/34          TEMAZEPAM           7.5MG                         10/30
   PROZAC          10MG              1.5            53/35          TEMAZEPAM            15MG                         10/30
 PULMICORT        200MCG        8 INHALATIONS       1/25           TEMAZEPAM            30MG                         10/30
 QUINAPRIL          5MG               1             90/90            TEQUIN            200MG             1           35/35
 QUINAPRIL         10MG               1             90/90           TERAZOSIN           1MG              1           90/90
 QUINAPRIL         20MG               1             90/90           TERAZOSIN           5MG              1           90/90
  RELAFEN         500MG               2             70/35          TERBINAFINE         250MG             1           35/35
  RELAFEN         750MG               2             70/35          TEST STRIPS      Blood Glucose        12          420/35
   RELPAX       All Strengths                       12/30             TIAZAC         120MG/24            1           35/35
  REMERON          15MG              1.5            53/35             TIAZAC         180MG/24            1           35/35
 REMODULIN      All Strengths                     1 MDV/30            TIAZAC         240MG/24            1           35/35
  RESTORIL         7.5MG                            10/30             TIAZAC         300MG/24            1           35/35
  RESTORIL         15MG                             10/30             TIAZAC         360MG/24            1           35/35
  RESTORIL         30MG                             10/30             TIAZAC         420MG/24            1           35/35
   RETIN-A                        1 TUBE          1 TUBE/30           TILADE           1.75MG       8 INHALATIONS   48.6/35
  REVLIMID      All Strengths         1             35/35
   REZINE          10MG               3             90/30
RHINOCORT AQ      32MCG          8 SPRAYS           18/30
 RISPERDAL        0.25MG             1.5            53/35
  Drug Name       Strength      Limit/Day        Limit/Days     *Cancer diagnosis with non-daily chemotherapy required
  TOPROL XL        25MG              1.5            53/35
  TOPROL XL        50MG              1.5            53/35       **Available without pa with CA and HO diag.
      TORADOL             10MG           4.8            24/30
     TRAMADOL             50MG            8            720/90        MDV=Multidose Vial
  TRAMADOL/ APAP       37.5/325MG         8            720/90
     TRETINOIN                        1 TUBE          1 TUBE/30
     TRIAZOLAM          0.125MG                         10/30
     TRIAZOLAM           0.25MG                         10/30
       ULTRAM             50MG            8            280/35
      UNIVASC            7.5MG           1.5         53/35 DAYS
     VASERETIC          5-12.5MG          1             35/35
      VASOTEC            2.5MG            1             35/35
      VASOTEC             5MG            1.5            53/35
      VASOTEC             10MG           1.5            53/35
   VENTOLIN HFA          90MCG      12 INHALATIONS      36/35
  VERAPAMIL ER, SR       120MG            1             90/90
VERAPAMIL ER, CR, SR     180MG            2             90/90
VERAPAMIL ER, CR, SR     240MG            2             90/90
     VERELAN SR          120MG            1             35/35
     VERAMYST           27.5MCG      4 sprays           10/30
      VYVANSE             30MG            1             35/35
      VYVANSE             50MG            1             35/35
      VYVANSE             70MG            1             35/35
      VERELAN            180MG            1             35/35
     VERELAN SR          180MG            1             35/35
     VERELAN SR          240MG            2             70/35
    XOPENEX HFA                     12 INHALATIONS   2 INHALERS/34
    XOPENEX NEB                        12CC            408/34
     ZESTORETIC          10-12.5          1             35/35
      ZESTRIL            2.5MG            1             35/35
      ZESTRIL             5MG             1             35/35
      ZESTRIL             10MG           1.5            53/35
      ZESTRIL             20MG           1.5            53/35
       ZOCOR              5MG             1             35/35
       ZOCOR              10MG           1.5            53/35
       ZOCOR              20MG           1.5            53/35
       ZOCOR              40MG           1.5            53/35
      ZOFRAN*             4MG             3             90/30
      ZOFRAN*             8MG            1.5            45/30
      ZOFRAN*             24MG           0.5            15/30
      ZOFRAN*           4MG/5ML        15ML            450/30
       ZOLOFT             25MG           0.5            18/35
       ZOLOFT             50MG           0.5            18/35
       ZOLOFT            100MG            3            105/35
     ZOLPIDEM             5MG                           12/34
     ZOLPIDEM             10MG                          12/34
   ZOMIG (Step 8)         5MG                           12/30
      ZYPREXA            2.5MG           1.5            53/35
      ZYPREXA             5MG             1             35/35
      ZYPREXA            7.5MG            1              35/35
      ZYPREXA             10MG            1             35/35
      ZYPREXA             15MG            1             35/35
      ZYPREXA             20MG            1             35/35
   ZYPREXA ZYDIS          5MG             1             35/35
   ZYPREXA ZYDIS          10MG            1             35/35
   ZYPREXA ZYDIS          15MG            1             35/35
   ZYPREXA ZYDIS          20MG            1             35/35

**Available without pa with CA and HO diag.

MDV=Multidose Vial
                The most cost effective way to utilize Celexa/citalopram

                                                          DESIRED                PREFERRED: NO PA Required                     savings per 30
 NON PREFERRED: PA NEEDED                                                                                                        day supply
                                                           DOSE                        (splitting tabs)
 10MG         20MG         40MG       COST/DAY            MG/DAY           10MG 20MG             40MG        COST/DAY
  30                                    $1.50              10mg                  15                            $0.75                $22.50
                30                      $1.50              20mg                                     15         $0.75                $22.50
                45                      $3.00              30mg                         15          15         $1.50                $45.00
                              30        $1.50              40mg                                     30         $1.50                 N/A
* Citalopram requires splitting of 20mg and/or 40mg scored tabs to avoid PA. Celexa is non-preferred but still requires splitting with a PA.
* At present these represent the most commonly written scripts. The shaded areas require no changes since they do not offer savings
opportunities. Celexa is flat priced across all strengths. They are scored and easily split. The unshaded rows on the left side all have less
expensive ways of being written involving splitting of the Celexa scored tabs.
* Max daily dose of Celexa / citalopram is 40mg. Clinical studies of effectiveness did not demonstrate an advantage for the 60mg/day dose over
the 40mg/day dose. There is an increased risk of side effects at doses greater than 40mg/day. (Celexa® Package Insert 2005 Forest
Laboratories, Inc.)

                                 LEXAPRO SPLITTING TABLE
                          The most cost effective way to utilize Lexapro
                                                          DESIRED                PREFERRED: NO PA Required                     savings per 30
 NON PREFERRED: PA NEEDED                                  DOSE                        (splitting tabs)                          day supply
 5MG          10MG         20MG       COST/DAY            MG/DAY           5MG 10MG              20MG        COST/DAY
15 tabs                                                    2.5MG          15 tabs
                15                        $0.75             5MG                         15                       $0.75              N/A
                30                        $1.50             10MG                                   15            $0.75             $22.50
                45                        $2.25             15MG                        15         15            $1.50             $22.50
                30                        $1.50             20MG                                   30            $1.50              N/A
* Lexapro requires splitting of 5mg, 10mg and/or 20mg scored tabs to avoid PA.
* At present these represent the most commonly written scripts. The shaded areas require no changes since they do not offer savings
opportunities. Lexapro is flat priced across all strengths. They are scored and easily split. The unshaded rows on the left side all have less
expensive ways of being written involving splitting of the Lexapro scored tabs.
* Max daily dose of Lexapro is 20mg.

                  The most cost effective way to utilize Zoloft/Sertraline
                                                          DESIRED               PREFERRED: NO PA Required                      savings per 30
 NON PREFERRED: PA NEEDED                                  DOSE                       (splitting tabs)                           day supply
25MG          50MG        100MG COST/DAY                  MG/DAY           25MG 50MG 100MG COST/DAY
15 tabs                           $1.00                   12.5mg          15 tabs            $1.00                                  N/A
  30                              $2.00                     25*                   15         $1.00                                 $30.00
  45                              $3.00                    37.5             15    15         $2.00                                 $30.00
                30                $2.00                     50*                        15    $1.00                                 $30.00
                45                $3.00                     75                    15   15    $2.00                                 $30.00
                            30    $2.00                    100*                        30    $2.00                                  N/A
    30                      30    $4.00                    125                    15   30    $3.00                                 $30.00
                30          30    $4.00                    150*                        45    $3.00                                 $30.00
    30          30          30    $6.00                    175                    15   45    $4.00                                 $60.00
                            60    $4.00                    200*                        60    $4.00                                  N/A
    30                      60    $6.00                    225                    15   60    $5.00                                 $30.00
                30          60    $6.00                    250*                        75    $5.00                                 $30.00
    30          30          60    $8.00                    275                    15   75    $6.00                                 $60.00
                               90           $6.00              300*                                    90            $6.00             N/A
* Sertraline requires splitting of scored tabs to avoid PA. Zoloft is non-preferred but still requires splitting with a PA.
* At present these represent the most commonly written scripts. The shaded areas require no changes since they do not offer savings
opportunities. Zoloft is flat priced across all strengths. They are scored and easily split. The unshaded rows on the left side all have less
expensive ways of being written involving splitting of the Zoloft scored tabs.

To top