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					                        Bridgeway Health Solutions
                             Acute Care Plan
                       Pharmacy Program Overview
                            Preferred Drug List
                                   2008




Introduction                                          Page 1 of 8
Bridgeway Health Solutions                           Revised 9/08
                      Bridgeway Health Solutions Pharmacy Program

Bridgeway Health Solutions covers prescription drugs and certain over-the-counter drugs when ordered
by a Bridgeway Health Solutions doctor. Some medications require prior authorization (PA) or have
limitations on age, dosage and/or maximum quantities.

I. Working with Our Pharmacy Benefit Manager (PBM)


Bridgeway Health Solutions works with US Script to process all pharmacy claims for prescribed drugs.
Certain drugs require Prior Authorization (PA) to be approved for payment by Bridgeway Health
Solutions. These include:
 •      All medications not listed on the Bridgeway Health Solutions Preferred Drug List (PDL)
 •      Some Bridgeway Health Solutions preferred drugs (designated PA on the PDL)

US Script is responsible for administering the Prior Authorization process for all prescribed drugs
requiring PA. All medications not listed on the Bridgeway Health Solutions PDL and some Bridgeway
Health Solutions preferred drugs require prior authorization to be approved for payment by Bridgeway
Health Solutions.

Follow these guidelines for efficient processing of your Prior Authorization requests:
1.      Complete the Bridgeway Health Solutions/US Script form: Request for Prior Authorization
2.      Fax to US Script at 1-866-399-0929
3.      Once approved, US Script notifies the prescriber by fax.
4.      If the clinical information provided does not explain the Prior for the requested PA medication, US
        Script responds to the prescriber by fax, offering PDL alternatives.
5.      For urgent or after-hours requests, a pharmacy can provide up to a 72-hour supply of most
        medications by calling the US Script Pharmacy Help Desk at: 1-800-460-8988.

II. Working with Our Specialty Pharmacy Provider

Caremark Specialty Pharmacy is the provider of biopharmaceuticals and specialty injectables for
Bridgeway Health Solutions. Most specialty injectables, billed for more than $250, require PA to be
approved for payment. Our Pharmacy Program Director and Medical Director oversee the clinical
review. Follow these guidelines for the most efficient processing of your Caremark Prior authorization
requests:

Providers can request that Caremark deliver the specialty drug to the office/member. If you want
Caremark to deliver the specialty drug to the office/member:

1.      Call Caremark at 1-800-237-2767 or fax the Caremark Enrollment form to 1-800-323-2445 for
        Prior authorization.

2.      If approved, Caremark will contact the provider or member for delivery confirmation.




 Introduction                                                                                   Page 2 of 8
 Bridgeway Health Solutions                                                                    Revised 9/08
ACTHAR             DEXFERRUM*        InFED*              NORDITROPIN        REMODULIN            THYROGEN
ACTIMMUNE          ELAPRASE          INFERGEN            NOVANTRONE         REVATIO              TOBI
ADAGEN*            ELIGARD           INNOHEP             NOVOSEVEN          REVLIMID             TRACLEER
ADVATE             ENBREL            INTRON A            NUTROPIN           RHOPHYLAC            TRELSTAR
ALDURAZYME         EPOGEN            IRESSA*             OCTAGAM            RIBAPAK              TYKERB
ALFERON N          EUFLEXXA          IVEEGAM             OCTREOTIDE         RIBASPHERE           TYSABRI
ALPHANATE          EXJADE            KINERET             OMNITROPE          RIBATAB              VANTAS
ALPHANINE SD       FABRAZYME         KOATE-DVI           ORENCIA            RIBAVIRIN            VENOFER*
AMEVIVE            FEIBA VH          KOGENATE FS         ORTHOVISC          RISPERDAL            VENOGLOBUL
ARALAST            FERRLECIT*        LEUKINE             PANGLOBULIN        RITUXAN              VENTAVIS
ARANESP            FLEBOGAMMA        LEUPROLIDE          PANHEMATIN*        ROFERON-A            VESANOID
ARIXTRA            FORTEO            LOVENOX             PEGASYS            SAIZEN               VIADUR
ATGAM              FRAGMIN           LUCENTIS            PEG-INTRON         SANDIMMUNE           VISUDYNE
AVONEX             FUZEON            LUPRON DEPOT        POLYGAM            SANDOSTATIN          VITRASERT*
AZASAN             GAMASTAN          LUPRON              PRIALT             SENSIPAR             VIVAGLOBIN
BEBULIN VH         GAMMAGARD         MACUGEN             PROCRIT            SEROSTIM             VIVITROL
BENEFIX            GAMUNEX           MITOXANTRONE        PROFILNINE         SIMULECT             WINRHO
BETASERON          GENOTROPIN        MONARC-M            PROGRAF            SOMAVERT             XELODA
BONIVA*            GLEEVEC           MONOCLATE-P         PROLEUKIN          SPRYCEL              XOLAIR
BOTOX              HELIXATE          MONONINE            PROPLEX T          SUPARTZ              ZENAPAX
CARIMUNE           HEMIN*            MYOBLOC             PULMOZYME          SUTENT               ZOLADEX
CELLCEPT IV        HEMOFIL-M         MYOZYME             RAPTIVA            SYNAGIS              ZOLINZA
CEREDASE           HUMATE-P          NAGLAZYME           REBETOL            SYNVISC              ZORBTIVE
CEREZYME           HUMATROPE         NATRECOR*           REBIF              TARCEVA
COPAXONE           HUMIRA            NEULASTA            RECLAST*           TEMODAR
COPEGUS            HYALGAN           NEUMEGA             RECOMBINATE        TEV-TROPIN
                   IMMUNE
CYCLOSPORINE       GLOBULIN          NEUPOGEN            REFACTO            THALOMID
CYTOGAM            INCRELEX          NEXAVAR             REMICADE           THYMOGLOBULN

        •   Indicates the product is not provided by Caremark. Requests for these products should be faxed
            to Bridgeway Health Solutions at (866) 638-6126 or call Bridgeway Health Solutions at (866) 475-
            3129.
        •   Lovenox: 5 day supply allowed at retail pharmacy, continuation of treatment beyond 5 days is
            administered through the Caremark Pharmacy
        •   Antineoplastics: 7 day supply allowed at retail pharmacy, continuation of treatment beyond 7
            days is administered through the Caremark Pharmacy
        •   Immunosupressants: 7 day supply allowed at retail pharmacy, continuation of treatment beyond
            7 days is administered through the Caremark Pharmacy




     Introduction                                                                              Page 3 of 8
     Bridgeway Health Solutions                                                               Revised 9/08
We help keep you informed
The Bridgeway Health Solutions Pharmacy Program Director, a registered pharmacist, compiles current
pharmacological policy and information about important seasonal topics such as Respiratory Syncytial
Virus (RSV) and influenza. The information is consistent with published guidelines and is mailed to
network providers as a service. The most current version of the Bridgeway Health Solutions PDL or PA
Request Forms and can be downloaded from our website at: www.bridgewayhs.com.

III. The Bridgeway Health Solutions Preferred Drug List (PDL)

The Bridgeway Health Solutions PDL describes the circumstances under which contracted pharmacy
providers will be reimbursed for medications dispensed to members covered under the program. The
PDL does not:
•         Require or prohibit the prescribing or dispensing of any medication;
•         Substitute for the independent professional judgment of the physician/clinician or pharmacist, or
•         Relieve the physician/clinician or pharmacist of any obligation to the patient or others

IV. Pharmacy and Therapeutics Committee (P&T)

The Bridgeway Health Solutions Pharmacy and Therapeutics Committee continually evaluates the
therapeutic classes included in the PDL. The committee is composed of the Bridgeway Health Solutions
medical director, pharmacy program manager and several community-based primary care physicians and
specialists. The primary purpose of the committee is to assist in developing and monitoring the
Bridgeway Health Solutions PDL and to establish programs and procedures that promote the appropriate
and cost-effective use of medications. The P&T committee schedules meetings at least quarterly during
the year, and coordinates therapeutic class reviews with the parent company’s national P&T committee.

V. Unapproved Use of Preferred Medication

Medication coverage under this program is limited to non-experimental indications as approved by the
FDA. Other indications may also be covered if they are accepted as safe and effective using current
medical and pharmaceutical reference texts and evidence-based medicine. Reimbursement decisions for
specific non-approved indications will be made by Bridgeway Health Solutions. Experimental drugs,
investigational drugs and drugs used for cosmetic purposes are excluded from coverage.

VI. Prior Authorization (PA) Process

The Bridgeway Health Solutions PDL includes a broad spectrum of generic and brand name drugs.
Clinicians are encouraged to prescribe from the Bridgeway Health Solutions PDL for their patients who
are members of Bridgeway Health Solutions. Some preferred drugs require PA. Medications requiring PA
are listed with a "PA" notation throughout the PDL, including the index. In addition, all injectable
medications (except Insulin, Glucagon Kit, Epi-pens, Imitrex, and medroxyprogesterone IM)
require PA.

The P & T committee has reviewed and approved, with input from its members and in consideration of
medical evidence, the list of drugs requiring Prior authorization. This PDL attempts to provide appropriate
and cost-effective drug therapy to all participants covered under the Bridgeway Health Solutions
pharmacy program. If a patient requires medication that does not appear on the PDL, the clinician can
submit a Prior authorization request for a non-preferred medication. It is anticipated that such exceptions


    Introduction                                                                                  Page 4 of 8
    Bridgeway Health Solutions                                                                   Revised 9/08
will be rare and that currently available PDL medications will be appropriate to treat the vast majority of
medical conditions encountered by Bridgeway Health Solutions Providers.

A phone or fax-in process is available for PA requests:
US Script Contacts            Prior Authorization Fax: 1-866-399-0929
                                 Prior Authorization Phone: 1-866-399-0928
                                 Clinical Hours: Monday-Friday 11:00 am-8:00 pm (EST)
                                 Mailing Address: US Script, 2425 W Shaw Ave, Fresno, CA 93711


When calling, please have patient information, including Medicaid number, complete diagnosis,
medication history and current medications readily available. Upon receipt of all necessary
information, US Script will respond by fax or phone within 24 hours except during weekends and holidays.
If the request is approved, information in the on-line pharmacy claims processing system will be
changed to allow the specific member to receive this specific drug. If the request is denied, information
about the denial will be provided to the clinician.

Clinicians are requested to utilize the PDL when prescribing medication for those patients covered by the
Bridgeway Health Solutions pharmacy program. If a pharmacist receives a prescription for a drug that
requires a Prior authorization request, the pharmacist should attempt to contact the clinician to request a
change to a product included in the Bridgeway Health Solutions PDL.

VII. Tobacco Cessation Medications

The following types of tobacco cessation medications may be covered in accordance with the Prior
Authorization guidelines:
    • Nicotine gum
    • Nicotine transdermal patches
    • Smoking cessation prescription only medications

Bridgeway Health Solutions authorizes benefits for tobacco cessation medications for the purpose of
supporting beneficiaries who are trying to quit tobacco use with the temporary assistance of nicotine
replacement therapy. It is expected that utilization of these products will be in accordance with medical
standards of practice, enrollment and completion in an ADHS smoking cessation program, FDA
guidelines and manufacturers’ recommendations. The prior authorization will limit all smoking
cessation products use to a maximum of 12 weeks within a 6 month timeline.

To enroll in an Arizona Department of Health Services (ADHS) smoking cessation program the
member must call 1-800-556-6222.

A physician’s prescription will be required for all (including over-the-counter) tobacco cessation
medications. Member must be at least 18 years of age to meet the age eligibility criteria of the smoking
cessation program.

Phone Numbers for Bridgeway Health Solutions Member Services
The above phone and fax lines are dedicated to clinicians requesting PA medication items only.
Members cannot be assisted if they call the PA toll-free number. The Bridgeway Health Solutions
Member Services phone number is 1-866-796-0530.

VIII. 72-Hour Emergency Supply Policy




 Introduction                                                                                    Page 5 of 8
 Bridgeway Health Solutions                                                                     Revised 9/08
State and Federal law require that a pharmacy dispense a 72-hour (3-day) supply of medication to any patient
awaiting a PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of
therapy. All participating pharmacies are authorized to provide a 72-hour supply of medication and will be
reimbursed for the ingredient cost and dispensing fee of the 72-hour supply of medication, whether or not the PA
request is ultimately approved or denied. The pharmacy must call the US Script Pharmacy Help Desk at 1-800-
460-8988 for a prescription override to submit the 72-hour medication supply for payment.
The following drug categories are not part of the Bridgeway Health Solutions preferred drug list and are not
covered by the 72-hour emergency supply policy:

        Anorectics: Drugs used for weight loss (unless prescribed for an indication other than obesity).
        Anti-Hemophilia Products.
        DESI ineffective drugs as designated by CMS
        Drugs used to treat infertility.
        Experimental/Investigational pharmaceuticals or products.
        Erectile dysfunction products prescribed to treat impotence.
        Hair growth restorers and other drugs used for cosmetic purposes.
        Immunizing agents.
        Injectable/Oral drugs administered by the provider in the office, in an outpatient clinic or and
         infusion center, or in a mental health center.
        Prostheses, appliances and devices (except products for Diabetics and products used for
         contraception).
        Injectable dugs or infusion therapy and supplies (except those listed in the PDL).
        Nutritional supplements.
        Oral vitamins and minerals (except those listed in the PDL).
        OTC drugs (except those listed in the PDL).
        Drugs covered under Medicare Part B and/or Medicare Part D.

IX. Newly Approved Products

Newly Approved drug products will not normally be placed on the preferred drug list during their first six
months on the market. During this period, access to these medications will be considered through the PA
review process.

X. Step Therapy

Medications requiring step therapy are listed with an "ST" notation throughout the preferred drug list. The
US Script claims system will automatically check the member profile for evidence of prior or current usage
of the required agent. If there is evidence of the required agent on the member's profile, the claim will
automatically process. If not, the claims system will notify the pharmacist that a PA is required.

XI. Policy for Injectable Drugs

Injections that are self-administered by the member and/or a family member and appear on the PDL are
covered by the Bridgeway Health Solutions pharmacy program. Insulin, Glucagon Kit, Epi-pen, Ana-
Kit, Imitrex, and medroxyprogesterone IM are covered by Bridgeway Health Solutions and do not
require a PA. All other injectables require PA.

XII. Dispensing Limits - Quantity Limit (QL) and Age Limit (AL)
Drugs may be dispensed up to a maximum 30-days’ supply for each new (original) or refill. A total of 80
percent (80%) of the days supplied must have elapsed before the prescription can be refilled.

Age Limits
The aged base limitations are marked throughout the PDL


 Introduction                                                                                        Page 6 of 8
 Bridgeway Health Solutions                                                                         Revised 9/08
Age Based PA Requirements
The aged base limitations are marked throughout the PDL
Mandatory Generic Substitution
Bridgeway Health Solutions requires that generic substitution be made when a generic equivalent
is available. All branded products that have an A-rated generic equivalent will be reimbursed at
the MAC price. The provision is waived for the following products due to their narrow therapeutic
index: Carbamazepine and Phenytoin.

XIII. Where to Call

PHYSICIANS

Preferred drug list (PDL) questions:
US Script                                        (800) 460-8988

Prior Authorizations:
US Script                                        (866) 399-0928
                                                 (866) 399-0929 Fax

Specialty Injectable Prior Authorizations:
Caremark                                         (800) 237-2767
                                                 (800) 323-2445 Fax

PHARMACISTS

Provider Network Questions:
US Script                                        (800) 460-8988

Claims Processing Customer Service:
US Script                                        (800) 460-8988

MEMBERS

Member Questions:
Bridgeway Member Services                        (800) 475-3129
                                                 (800) 687-0519

XIV. HMO Contacts for Medical Appeals

In the event that a patient and/or physician disagree with the decision regarding coverage of a
medication, the physician may appeal the decision in writing to the Medical Director at Bridgeway via fax
at (866) 638-6124 or US mail to the address below:

                                      Bridgeway Health Solutions
                                         Attn: Medical Director
                               1501 West Fountainhead Parkway, Suite 201
                                           Tempe, AZ 85282

XV. Pharmacy Network

Bridgeway will provide a comprehensive network of both chain and independent retail pharmacies
for our members to use. All pharmacies must pass an extensive credentialing process before


 Introduction                                                                                 Page 7 of 8
 Bridgeway Health Solutions                                                                  Revised 9/08
being allowed to participate with Bridgeway. This process ensures our members that only the
best pharmacies, meeting the highest standards, will be available for our members to use.

XVI. Annotations

       ST      =        This product requires step therapy
       QL      =        This product is limited to a specific quantity
       AL      =        This product is limited to a specific age group
       GL      =        This product is limited to gender specific treatment regiments
       PA      =        This product requires prior authorization
       OTC     =        This product is covered when written on a prescription
       FFQL    =        This product allows the member to receive 15 days of medication. Treatment
                        beyond 15 days must be administered through the Northern Arizona RBHA.

Dosage Form Legend

TAB = Tablets                  CAP = Capsules
SUSP = Suspension              SOLN = Solution
CHEW = Chewable tablet         SL = Sublingual
GEL = Gel                      SR = Sustained Release
SYRP = Syrup




 Introduction                                                                              Page 8 of 8
 Bridgeway Health Solutions                                                               Revised 9/08
                                          MEDICATION PRIOR AUTHORIZATION REQUEST FORM
                                                     BRIDGEWAY HEALTH PLAN


                                          FAX this completed form to 866-399-0929
                              OR Mail requests to: US Script PA Dept / 2425 West Shaw Avenue / Fresno, CA 93711
                                        Call 800-460-8988 to request a 72-hour supply of medication.
 I. Provider Information                                                                 II. Member Information
 Prescriber name (print):                                                                Member name:


 Prescriber Specialty:                                                                   Identification number:


 Fax:                                      Phone:                                        Date of Birth:


 Office Contact Name:                                                                    Medication allergies:


 III. Drug Information (One drug request per form)
 Drug name and strength:                                         Dosage form:            Dosage interval (sig):                              Qty per Day:


 Diagnosis relevant to this request:


 Expected length of therapy:


 Medication History for this Diagnosis
 A. Is member currently treated on this medication?
         yes; How Long?_______________          [go to item B]         no [skip items B & C; go to item D]

 B. Is this request for continuation of a previous approval?
         yes [go to item C]                                            no [skip item C; go to item D]

 C. Has strength, dosage, or quantity required per day increased or decreased?
         yes [go to item D]                                            no [skip item D; indicate rationale for continuation in Section IV and submit form]
 D. Please indicate previous treatment and outcomes below.
 Drug Name                                            Dates of Therapy                       Reason for Discontinuation
 (include strength and dosage)
    1


   2


   3


   4


 NOTE: Confirmation of use will be made from member history on file; prior use of preferred drugs is a part of the exception criteria. The Bridgeway
 Preferred Drug List (PDL) is available on the Bridgeway website at www.bridgewayhs.com . (Access from Member’s Section of homepage, then click on
 Preferred Drug List).
 IV. Rationale for Request / Pertinent Clinical Information (Required for all Prior Authorizations)




 Appropriate clinical information to support the request on      Provider Signature:                                                         Date:
 the basis of medical necessity must be submitted.

US Script will respond via fax or phone within 24 hours of receipt of all necessary information, except during weekends and holidays. Requests for prior
authorization (PA) must include member name, ID#, and drug name. Incomplete forms will delay processing. Please include lab reports with requests when
appropriate (e.g., Culture and Sensitivity; Hemoglobin A1C; Serum Creatinine; CD4; Hematocrit; WBC, etc.)
                                                                                                                 Specialty Pharmacy Services
                                                                                                                                      Enrollment Form
      Fax Referral To: 800-323-2445
          Phone: 800-237-2767                                                     Date:                              Needs by Date:
  Ship to:            Patient             Office             Other:
                              PATIENT INFORMATION                                                                                                 PRESCRIBER INFORMATION
      (Complete the following or send patient demographic sheet)                                               Prescriber’s Name:
     Patient Name:                                                                                                State License #:                                                          UPIN:
           Address:                                                                                                        DEA #:                                                           NPI #:
    City, State, Zip:                                                                                          Group or Hospital:
      Home Phone:                                                                                                         Address:
   Alternate Phone:                                                                                                City, State Zip:
               SS #:                                                                                                        Phone:                                                         Fax:
      Date of Birth:                      Gender:                                                                 Contact Person:                                                                 Phone:

                              INSURANCE INFORMATION (Please copy and attach the front and back of insurance and prescription drug card)
        Primary Insurance:             Subscriber:                                             ID#:                                       Name of Insurer:                                                 Phone:
     Secondary Insurance:              Subscriber:                                             ID#:                                       Name of Insurer:                                                 Phone:

                                                                                     STATEMENT OF MEDICAL NECESSITY
  Diagnosis:                                                                      Additional Clinical Information:
    Please include diagnosis name and ICD-9:                                      • Weight:                     kg/lbs                                 • Height:                                     in/cm
                                                                                  • Allergies:
                                                                                  • Lab Data:
                                                                                  • Concomitant Medications:
                                                                                  • Additional Comments:
  • Date of Diagnosis:
  Injection Training/Home Health Coordination:
  • Injection training/home health will be/has been conducted/coordinated by the Physician’s office.                                          Yes          No                     • If Yes, Date:
  • Specialty Pharmacy to coordinate injection training/home health nursing.                                   Yes          No               *Agency of Choice:

                                                                                            PRESCRIPTION INFORMATION
        MEDICATION                            STRENGTH                                                         DIRECTIONS                                                             QUANTITY                           REFILLS




      PRODUCT SUBSTITUTION PERMITTED                                                                 (Date)                   DISPENSE AS WRITTEN                                                                                  (Date)

IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If it is
received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should
such material be read or retained by anyone other than the named addressee, except by express authority of the sender to the named addressee. Specialty Pharmacy Services 072108
                              Table of Contents
Anti-Infective Agents ………………………………….                              1

Endocrine and Metabolic Agents ………………………                          6

Cardiovascular Agents …………………………………                               13

Respiratory Agents …………………………………….                                21

Gastrointestinal Agents ………………………………..                            22

Genitourinary Agents ………………………………….                               32

Central Nervous System Agents ………………………                           33

Analgesics …………………………………………….                                     41

Neuromuscular Agents ……………………………….                                45

Vitamins and Minerals ……………………………….                               48

Anticoagulants ……………………………………….                                   52

Ophthalmic and OTIC Agents …………………………                             53

Topical and Dermatological Agents ………………….                        55

Miscellaneous Agents …………………………………                                60




            Preferred Drug List (PDL) Medication Locator Instructions

  1.   With the PDF open, on the Edit menu, click Find.
  2.   In the Find what box, type the text you want to find.
  3.   Select any other options you want.
  4.   Click Find Next until you find the occurrence you're looking for.
  Therapeutic                                                                                Covered Brand Product
    Class         Common Brand Name(s)   Product Description                                  (unless FFQL or PA)    Limitations/Restrictions

PENICILLINS
                                         Penicillin V Potassium Tab 250 MG
                                         Penicillin V Potassium Tab 500 MG
                                         Penicillin V Potassium For Soln 125 MG/5ML
                                         Penicillin V Potassium For Soln 250 MG/5ML
                                         Amoxicillin (Trihydrate) Cap 250 MG
                                         Amoxicillin (Trihydrate) Cap 500 MG
                (Generic: AMOXIL)        Amoxicillin (Trihydrate) Tab 875 MG
                                         Amoxicillin (Trihydrate) Chew Tab 125 MG
                                         Amoxicillin (Trihydrate) Chew Tab 250 MG
                (Generic: AMOXIL)        Amoxicillin (Trihydrate) Chew Tab 400 MG          AMOXICILLIN
                                         Amoxicillin (Trihydrate) For Susp 50 MG/ML        AMOXIL
                                         Amoxicillin (Trihydrate) For Susp 125 MG/5ML
                (Generic: AMOXIL)        Amoxicillin (Trihydrate) For Susp 200 MG/5ML
                                         Amoxicillin (Trihydrate) For Susp 250 MG/5ML
                (Generic: AMOXIL)        Amoxicillin (Trihydrate) For Susp 400 MG/5ML
                                         Ampicillin Cap 250 MG
                                         Ampicillin Cap 500 MG
                                         Ampicillin For Susp 125 MG/5ML                    AMPICILLIN
                                         Ampicillin For Susp 250 MG/5ML                    AMPICILLIN
                                         Dicloxacillin Sodium Cap 250 MG
                                         Dicloxacillin Sodium Cap 500 MG
                (Generic: AUGMENTIN)     Amoxicillin & K Clavulanate Tab 250 MG                                      Max Qty=30/claim
                (Generic: AUGMENTIN)     Amoxicillin & K Clavulanate Tab 500 MG                                      Max Qty=20/claim
                (Generic: AUGMENTIN)     Amoxicillin & K Clavulanate Tab 875 MG                                      Max Qty=20/claim
                (Generic: AUGMENTIN)     Amoxicillin & K Clavulanate Chew Tab 200 MG                                 Max Qty=20/claim
                                         Amoxicillin & K Clavulanate Chew Tab 250 MG       AUGMENTIN                 Max Qty=30/claim
                (Generic: AUGMENTIN)     Amoxicillin & K Clavulanate Chew Tab 400 MG                                 Max Qty=20/claim
                                         Amoxicillin & K Clavulanate For Susp 125 MG/5ML   AUGMENTIN                 Package Limit=1/claim
                (Generic: AUGMENTIN)     Amoxicillin & K Clavulanate For Susp 200 MG/5ML                             Package Limit=1/claim
                                         Amoxicillin & K Clavulanate For Susp 250 MG/5ML   AUGMENTIN                 Package Limit=1/claim
                (Generic: AUGMENTIN)     Amoxicillin & K Clavulanate For Susp 400 MG/5ML                             Pkg Size 50: Package Limit=1/claim; Pkg Size
                                                                                                                     75: Package Limit=2/claim; Pkg Size 150:
                                                                                                                     Package Limit=2/claim
                (Generic: AUGMENTIN)     Amoxicillin & K Clavulanate For Susp 600 MG/5ML                             Package Limit=2/claim

CEPHALOSPORINS
             (Generic: KEFLEX)           Cephalexin Cap 250 MG
             (Generic: KEFLEX)           Cephalexin Cap 500 MG
             (Generic: KEFLEX)           Cephalexin For Susp 125 MG/5ML
             (Generic: KEFLEX)           Cephalexin For Susp 250 MG/5ML
                                         Cefaclor Cap 250 MG
                                         Cefaclor Cap 500 MG
                                         Cefaclor For Susp 125 MG/5ML                      CEFACLOR
                                         Cefaclor For Susp 250 MG/5ML                      CEFACLOR
                                         Cefaclor For Susp 375 MG/5ML                                                                                        1
 Therapeutic                                                                                    Covered Brand Product
   Class         Common Brand Name(s)   Product Description                                      (unless FFQL or PA)    Limitations/Restrictions
               (Generic: CEFZIL)        Cefprozil Tab 250 MG                                                            Max Qty=20/claim
               (Generic: CEFZIL)        Cefprozil Tab 500 MG                                                            Max Qty=20/claim
               (Generic: CEFZIL)        Cefprozil For Susp 125 MG/5ML                                                   Limited to Ages 12 and Under; Pkg Size 50:
                                                                                                                        Package Limit=1/claim; Pkg Size 75: Package
                                                                                                                        Limit=1/claim; Pkg Size 100: Package
                                                                                                                        Limit=2/claim
               (Generic: CEFZIL)        Cefprozil For Susp 250 MG/5ML                                                   Limited to Ages 12 and Under
               (Generic: CEFTIN)        Cefuroxime Axetil Tab 250 MG                                                    Max Qty=20/claim
               (Generic: CEFTIN)        Cefuroxime Axetil Tab 500 MG                                                    Max Qty=20/claim
               (Generic: CEFTIN)        Cefuroxime Axetil For Susp 125 MG/5ML                                           Limited to Ages 12 and Under; Package
                                                                                                                        Limit=1/claim
               (Generic: CEFTIN)        Cefuroxime Axetil For Susp 250 MG/5ML                                           Limited to Ages 12 and Under; Package
                                                                                                                        Limit=1/claim
               (Generic: OMNI-PAC,      Cefdinir Cap 300 MG                                                             Max Qty=20/claim
               OMNICEF)
               (Generic: OMNICEF)       Cefdinir For Susp 125 MG/5ML                                                    Package Limit=1/claim
               (Generic: OMNICEF)       Cefdinir For Susp 250 MG/5ML                                                    Package Limit=1/claim

MACROLIDES
                                        Erythromycin Tab 250 MG                               ERYTHROMYCIN
                                        Erythromycin Tab 500 MG                               ERYTHROMYCIN
                                        Erythromycin Tab Delayed Release 250 MG               E-MYCIN, ERY-TAB
                                        Erythromycin Tab Delayed Release 333 MG               ERY-TAB, ERYTHROMYCIN

                                        Erythromycin Tab Delayed Release 500 MG               ERY-TAB
               (Generic: ERYC)          Erythromycin w/ Enteric Coated Particles Cap 250 MG   ERYTHROMYCIN
                                        Erythromycin w/ Enteric Coated Particles Tab 333 MG   PCE
                                        Erythromycin w/ Enteric Coated Particles Tab 500 MG   PCE
                                        Erythromycin Stearate Tab 250 MG
                                        Erythromycin Stearate Tab 500 MG
                                        Erythromycin Ethylsuccinate Tab 400 MG
                                        Erythromycin Ethylsuccinate Susp 200 MG/5ML
                                        Erythromycin Ethylsuccinate Susp 400 MG/5ML
                                        Erythromycin Ethylsuccinate For Susp 100 MG/2.5ML     ERYPED
               (Generic: E.E.S. GRAN,   Erythromycin Ethylsuccinate For Susp 200 MG/5ML
               ERYPED 200)
                                        Erythromycin Ethylsuccinate For Susp 400 MG/5ML       ERYPED 400
               (Generic: ZITHROMAX)     Azithromycin Tab 250 MG                               ZITHROMAX                 Max Qty=6/claim
               (Generic: ZITHROMAX)     Azithromycin Tab 500 MG                                                         Max Qty=3/claim
               (Generic: ZITHROMAX)     Azithromycin Tab 600 MG                                                         Max Qty=3/claim
               (Generic: ZITHROMAX)     Azithromycin For Susp 100 MG/5ML                                                Package Limit=1/claim
               (Generic: ZITHROMAX)     Azithromycin For Susp 200 MG/5ML                      ZITHROMAX                 Pkg Size 15: Package Limit=1/claim; Pkg Size
                                                                                                                        22.5: Package Limit=2/claim; Pkg Size 30:
                                                                                                                        Package Limit=1/claim
                                        Azithromycin Powd Pack for Susp 1 GM                  AZITHROMYCIN,
                                                                                              ZITHROMAX
               (Generic: BIAXIN)        Clarithromycin Tab 250 MG                                                                                               2
  Therapeutic                                                                          Covered Brand Product
    Class         Common Brand Name(s)   Product Description                            (unless FFQL or PA)    Limitations/Restrictions
                (Generic: BIAXIN)        Clarithromycin Tab 500 MG
                (Generic: BIAXIN)        Clarithromycin For Susp 125 MG/5ML                                    Package Limit=1/claim
                (Generic: BIAXIN)        Clarithromycin For Susp 250 MG/5ML
                (Generic: BIAXIN XL)     Clarithromycin Tab SR 24HR 500 MG

TETRACYCLINES
                                         Doxycycline Hyclate Cap 50 MG
                (Generic: VIBRAMYCIN)    Doxycycline Hyclate Cap 100 MG
                (Generic: VIBRATAB)      Doxycycline Hyclate Tab 100 MG
                (Generic: MINOCIN)       Minocycline HCl Cap 50 MG
                (Generic: DYNACIN)       Minocycline HCl Cap 75 MG
                (Generic: MINOCIN)       Minocycline HCl Cap 100 MG
                                         Tetracycline HCl Cap 250 MG
                                         Tetracycline HCl Cap 500 MG

FLUOROQUINOLONES
                                         Ciprofloxacin HCl Tab 100 MG (Base Equiv)                             Max Qty=6/claim
                (Generic: CIPRO)         Ciprofloxacin HCl Tab 250 MG (Base Equiv)
                (Generic: CIPRO)         Ciprofloxacin HCl Tab 500 MG (Base Equiv)   CIPRO
                (Generic: CIPRO)         Ciprofloxacin HCl Tab 750 MG (Base Equiv)
                                         Levofloxacin Tab 250 MG                     LEVAQUIN                  Max Qty=14/claim
                                         Levofloxacin Tab 500 MG                     LEVAQUIN                  Max Qty=14/claim
                                         Levofloxacin Tab 750 MG                     LEVAQUIN                  Max Qty=14/claim; NDC 54569555701
                                                                                                               LEVAQUIN TAB LEVA-PAK: Max
                                                                                                               Qty=5/claim; NDC 00045153005 LEVAQUIN
                                                                                                               TAB LEVA-PAK: Max Qty=5/claim


                                         Ofloxacin Tab 200 MG                                                  Max Qty=56/claim
                                         Ofloxacin Tab 300 MG                                                  Max Qty=56/claim
                                         Ofloxacin Tab 400 MG                                                  Max Qty=56/claim

AMINOGLYCOSIDES
                                         Neomycin Sulfate Tab 500 MG

SULFONAMIDES
                                         Sulfisoxazole Acetyl Susp 500 MG/5ML        GANTRIS PED

ANTIMYCOBACTERIAL AGENTS
             (Generic: MYAMBUTOL)        Ethambutol HCl Tab 100 MG
             (Generic: MYAMBUTOL)        Ethambutol HCl Tab 400 MG
                                         Ethionamide Tab 250mg                       TRECATOR
                                         Isoniazid Tab 100 MG
                                         Isoniazid Tab 300 MG
                                         Isoniazid Syrup 50 MG/5ML                   ISONIAZID
                                         Pyrazinamide Tab 500 MG
                (Generic: RIFADIN)       Rifampin Cap 150 MG
                (Generic: RIFADIN)       Rifampin Cap 300 MG                                                                                      3
  Therapeutic                                                                              Covered Brand Product
    Class         Common Brand Name(s)   Product Description                                (unless FFQL or PA)    Limitations/Restrictions

ANTIFUNGALS
                                         Griseofulvin Microsize Tab 500 MG               GRIFULVIN V
                (Generic: GRIFULVIN V)   Griseofulvin Microsize Susp 125 MG/5ML
                                         Griseofulvin Ultramicrosize Tab 125 MG          GRIS-PEG
                                         Griseofulvin Ultramicrosize Tab 250 MG          GRIS-PEG, GRISEOFULVIN
                                         Nystatin Tab 500000 U                                                     Daily Dosage=6
                (Generic: NIZORAL)       Ketoconazole Tab 200 MG                                                   Daily Dosage=2
                (Generic: DIFLUCAN)      Fluconazole Tab 50 MG                                                     Max Qty=7/claim
                (Generic: DIFLUCAN)      Fluconazole Tab 100 MG                                                    Daily Dosage=1
                (Generic: DIFLUCAN)      Fluconazole Tab 150 MG                                                    Max Qty=2/claim
                (Generic: DIFLUCAN)      Fluconazole Tab 200 MG                                                    Daily Dosage=2
                (Generic: DIFLUCAN)      Fluconazole For Susp 10 MG/ML                                             Max Qty=70/claim
                (Generic: DIFLUCAN)      Fluconazole For Susp 40 MG/ML                                             Max Qty=70/claim

ANTIVIRALS
                                         Raltegravir Potassium Tab 400 MG (Base Equiv)   ISENTRESS                 Daily Dosage=2; Daily Dosage=2
                                         Amprenavir Oral Soln 15 MG/ML                   AGENERASE
                                         Atazanavir Sulfate Cap 100 MG (Base Equiv)      REYATAZ                   Daily Dosage=2
                                         Atazanavir Sulfate Cap 150 MG (Base Equiv)      REYATAZ                   Daily Dosage=2
                                         Atazanavir Sulfate Cap 200 MG (Base Equiv)      REYATAZ                   Daily Dosage=2
                                         Atazanavir Sulfate Cap 300 MG (Base Equiv)      REYATAZ                   Daily Dosage=2
                                         Darunavir Tab 300 MG                            PREZISTA
                                         Fosamprenavir Calcium Tab 700 MG (Base Equiv)   LEXIVA                    Daily Dosage=4
                                         Indinavir Sulfate Cap 100 MG                    CRIXIVAN
                                         Indinavir Sulfate Cap 200 MG                    CRIXIVAN
                                         Indinavir Sulfate Cap 333 MG                    CRIXIVAN
                                         Indinavir Sulfate Cap 400 MG                    CRIXIVAN
                                         Nelfinavir Mesylate Tab 250 MG                  VIRACEPT
                                         Nelfinavir Mesylate Tab 625 MG                  VIRACEPT
                                         Nelfinavir Mesylate Oral Powder 50 MG/GM        VIRACEPT
                                         Ritonavir Cap 100 MG                            NORVIR
                                         Ritonavir Oral Soln 80 MG/ML                    NORVIR
                                         Saquinavir Mesylate Cap 200 MG                  INVIRASE
                                         Saquinavir Mesylate Tab 500 MG                  INVIRASE
                                         Tipranavir Cap 250 MG                           APTIVUS
                                         Abacavir Sulfate Tab 300 MG (Base Equiv)        ZIAGEN
                                         Abacavir Sulfate Soln 20 MG/ML (Base Equiv)     ZIAGEN
                                         Didanosine For Soln 2 GM                        VIDEX
                                         Didanosine For Soln 4 GM                        VIDEX
                                         Didanosine Delayed Release Capsule 125 MG       VIDEX EC
                (Generic: VIDEX EC)      Didanosine Delayed Release Capsule 200 MG
                (Generic: VIDEX EC)      Didanosine Delayed Release Capsule 250 MG
                (Generic: VIDEX EC)      Didanosine Delayed Release Capsule 400 MG
                                         Emtricitabine Caps 200 MG                       EMTRIVA
                                         Emtricitabine Soln 10 MG/ML                     EMTRIVA
                                         Lamivudine Tab 150 MG                           EPIVIR                                                     4
  Therapeutic                                                                                           Covered Brand Product
    Class         Common Brand Name(s)   Product Description                                              (unless FFQL or PA)   Limitations/Restrictions
                                         Lamivudine Tab 300 MG                                        EPIVIR
                                         Lamivudine Oral Soln 10 MG/ML                                EPIVIR
                                         Stavudine Cap 15 MG                                          ZERIT
                                         Stavudine Cap 20 MG                                          ZERIT
                                         Stavudine Cap 30 MG                                          ZERIT
                                         Stavudine Cap 40 MG                                          ZERIT
                                         Stavudine For Oral Soln 1 MG/ML                              ZERIT
                (Generic: RETROVIR)      Zidovudine Cap 100 MG
                (Generic: RETROVIR)      Zidovudine Tab 300 MG
                (Generic: RETROVIR)      Zidovudine Syrup 10 MG/ML
                                         Tenofovir Disoproxil Fumarate Tab 300 MG                     VIREAD
                                         Delavirdine Mesylate Tab 100 MG                              RESCRIPTOR
                                         Delavirdine Mesylate Tab 200 MG                              RESCRIPTOR
                                         Efavirenz Cap 50 MG                                          SUSTIVA
                                         Efavirenz Cap 100 MG                                         SUSTIVA
                                         Efavirenz Cap 200 MG                                         SUSTIVA
                                         Efavirenz Tab 600 MG                                         SUSTIVA
                                         Etravirine Tab 100 MG                                        INTELENCE                 Daily Dosage=4
                                         Nevirapine Tab 200 MG                                        VIRAMUNE
                                         Nevirapine Susp 50 MG/5ML                                    VIRAMUNE
                                         Abacavir Sulfate-Lamivudine Tab 600-300 MG                   EPZICOM
                                         Emtricitabine-Tenofovir Disoproxil Fumarate Tab 200-300 MG   TRUVADA                   Daily Dosage=1

                                         Lamivudine-Zidovudine Tab 150-300 MG                         COMBIVIR                  Daily Dosage=2
                                         Lopinavir-Ritonavir Cap 133.3-33.3 MG                        KALETRA                   Daily Dosage=6
                                         Lopinavir-Ritonavir Tab 200-50 MG                            KALETRA
                                         Lopinavir-Ritonavir Soln 400-100 MG/5ML (80-20 MG/ML)        KALETRA                   Daily Dosage=13
                                         Abacavir Sulfate-Lamivudine-Zidovudine Tab 300-150-300 MG    TRIZIVIR                  Daily Dosage=2

                                         Efavirenz-Emtricitabine-Tenofovir DF Tab 600-200-300 MG      ATRIPLA                   Daily Dosage=1

                                         Ganciclovir Cap 250 MG
                                         Ganciclovir Cap 500 MG                                       GANCICLOVIR
                                         Valganciclovir HCl Tab 450 MG                                VALCYTE                   Daily Dosage=2
                (Generic: ZOVIRAX)       Acyclovir Cap 200 MG
                (Generic: ZOVIRAX)       Acyclovir Tab 400 MG
                (Generic: ZOVIRAX)       Acyclovir Tab 800 MG
                (Generic: ZOVIRAX)       Acyclovir Susp 200 MG/5ML
                                         Valacyclovir HCl Tab 500 MG                                  VALTREX                   Max DS/DU=Lesser Of Max Days
                                                                                                                                Sply=21/Max Qty=42
                                         Valacyclovir HCl Tab 1000 MG                                 VALTREX                   Max DS/DU=Lesser Of Max Days
                                                                                                                                Sply=21/Max Qty=21
                (Generic: FLUMADINE)     Rimantadine Hydrochloride Tab 100 MG
                                         Oseltamivir Phosphate Cap 75 MG (Base Equiv)                 TAMIFLU                   Max Qty=10/180 days
                                         Oseltamivir Phosphate For Susp 12 MG/ML (Base Equiv)         TAMIFLU                   Max Qty=75/180 days

ANTIMALARIALS                                                                                                                                                  5
  Therapeutic                                                                                             Covered Brand Product
    Class         Common Brand Name(s)      Product Description                                            (unless FFQL or PA)    Limitations/Restrictions
                                            Chloroquine Phosphate Tab 250 MG                                                      Max Qty=60/30 days
                (Generic: ARALEN)           Chloroquine Phosphate Tab 500 MG                                                      Max Qty=8/56 days
                (Generic: PLAQUENIL)        Hydroxychloroquine Sulfate Tab 200 MG
                (Generic: LARIAM)           Mefloquine HCl Tab 250 MG
                                            Primaquine Phosphate Tab 26.3 MG                            PRIMAQUINE

ANTHELMINTICS
                (Generic: VERMOX)           Mebendazole Chew Tab 100 MG
                                            Pyrantel Pamoate Susp 250 MG/5ML (50 MG/ML Base Equiv)                                Package Limit=1/claim

                                            Thiabendazole Chew Tab 500 MG                               MINTEZOL
                                            Thiabendazole Susp 500 MG/5ML                               MINTEZOL

ANTI-INFECTIVE AGENTS - MISC.
                (Generic: FLAGYL)           Metronidazole Tab 250 MG
                (Generic: FLAGYL)           Metronidazole Tab 500 MG
                (Generic: PROLOPRIM,        Trimethoprim Tab 100 MG
                TRIMPEX)
                (Generic: CLEOCIN)          Clindamycin HCl Cap 150 MG
                (Generic: CLEOCIN)          Clindamycin HCl Cap 300 MG
                                            Clindamycin Palmitate HCl For Soln 75 MG/5ML (Base Equiv)   CLEOCIN PED               Max Qty=300/claim

                                           Dapsone Tab 25 MG                                            DAPSONE
                                           Dapsone Tab 100 MG                                           DAPSONE
                (Generic: PEDIAZOLE)       Erythromycin & Sulfisoxazole For Susp 200-600 MG/5ML
                (Generic: BACTRIM, SEPTRA) Sulfamethoxazole-Trimethoprim Tab 400-80 MG

                (Generic: BACTRIM DS,       Sulfamethoxazole-Trimethoprim Tab 800-160 MG
                SEPTRA DS)
                                            Sulfamethoxazole-Trimethoprim Susp 200-40 MG/5ML

ANTINEOPLASTICS
                                            Altretamine Cap 50 MG                                       HEXALEN
                                            Busulfan Tab 2 MG                                           MYLERAN
                                            Chlorambucil Tab 2 MG                                       LEUKERAN
                (Generic: CYTOXAN)          Cyclophosphamide Tab 25 MG                                  CYCLOPHOSPH
                (Generic: CYTOXAN)          Cyclophosphamide Tab 50 MG                                  CYCLOPHOSPH
                                            Melphalan Tab 2 MG                                          ALKERAN
                                            Lomustine Cap 10 MG                                         CEENU
                                            Lomustine Cap 40 MG                                         CEENU
                                            Lomustine Cap 100 MG                                        CEENU
                                            Temozolomide Cap 5 MG                                       TEMODAR
                                            Temozolomide Cap 20 MG                                      TEMODAR
                                            Temozolomide Cap 100 MG                                     TEMODAR
                                            Temozolomide Cap 140 MG                                     TEMODAR
                                            Temozolomide Cap 180 MG                                     TEMODAR
                                            Temozolomide Cap 250 MG                                     TEMODAR                                              6
  Therapeutic                                                                               Covered Brand Product
    Class         Common Brand Name(s)   Product Description                                 (unless FFQL or PA)    Limitations/Restrictions
                                         Capecitabine Tab 150 MG                          XELODA
                                         Capecitabine Tab 500 MG                          XELODA
                (Generic: PURINETHOL)    Mercaptopurine Tab 50 MG
                                         Methotrexate Sodium Tab 2.5 MG (Base Equiv)
                                         Methotrexate Sodium Tab 5 MG (Base Equiv)        TREXALL
                                         Methotrexate Sodium Tab 7.5 MG (Base Equiv)      TREXALL
                                         Methotrexate Sodium Tab 10 MG (Base Equiv)       TREXALL
                                         Methotrexate Sodium Tab 15 MG (Base Equiv)       TREXALL
                                         Methotrexate Sodium Inj 25 MG/ML
                                         Thioguanine Tab 40 MG                            TABLOID
                                         Testolactone Tab 50 MG                           TESLAC
                                         Mitotane Tab 500 MG                              LYSODREN
                                         Bicalutamide Tab 50 MG                           CASODEX
                                         Flutamide Cap 125 MG
                                         Nilutamide Tab 150 MG                            NILANDRON
                (Generic: NOLVADEX)      Tamoxifen Citrate Tab 10 MG (Base Equivalent)
                                         Tamoxifen Citrate Tab 20 MG (Base Equivalent)
                                         Toremifene Citrate Tab 60 MG (Base Equivalent)   FARESTON
                                         Anastrozole Tab 1 MG                             ARIMIDEX
                                         Exemestane Tab 25 MG                             AROMASIN
                                         Letrozole Tab 2.5 MG                             FEMARA
                                         Estramustine Phosphate Sodium Cap 140 MG         EMCYT
                                         Megestrol Acetate Tab 20 MG
                                         Megestrol Acetate Tab 40 MG
                (Generic: MEGACE ORAL)   Megestrol Acetate Susp 40 MG/ML
                (Generic: VEPESID)       Etoposide Cap 50 MG
                                         Imatinib Mesylate Tab 100 MG (Base Equivalent)   GLEEVEC
                                         Imatinib Mesylate Tab 400 MG (Base Equivalent)   GLEEVEC
                (Generic: HYDREA)        Hydroxyurea Cap 500 MG
                                         Leucovorin Calcium Tab 5 MG
                                         Leucovorin Calcium Tab 10 MG
                                         Leucovorin Calcium Tab 15 MG                     LEUCOVOR CA
                                         Leucovorin Calcium Tab 25 MG

CORTICOSTEROIDS
                                         Cortisone Acetate Tab 25 MG
                                         Dexamethasone Tab 0.5 MG                         DEXAMETHASON
                                         Dexamethasone Tab 0.75 MG                        DEXAMETHASON
                                         Dexamethasone Tab 1 MG                           DEXAMETHASON
                                         Dexamethasone Tab 1.5 MG
                                         Dexamethasone Tab 2 MG                           DEXAMETHASON
                                         Dexamethasone Tab 4 MG
                                         Dexamethasone Tab 6 MG
                                         Dexamethasone Elixir 0.5 MG/5ML
                                         Dexamethasone Soln 0.5 MG/5ML
                (Generic: CORTEF)        Hydrocortisone Tab 5 MG
                (Generic: CORTEF)        Hydrocortisone Tab 10 MG                                                                              7
  Therapeutic                                                                                          Covered Brand Product
    Class         Common Brand Name(s)    Product Description                                           (unless FFQL or PA)    Limitations/Restrictions
                (Generic: CORTEF)         Hydrocortisone Tab 20 MG
                (Generic: MEDROL)         Methylprednisolone Tab 4 MG
                (Generic: MEDROL)         Methylprednisolone Tab 8 MG
                (Generic: MEDROL)         Methylprednisolone Tab 4 MG Dose Pack
                                          Prednisolone Tab 5 MG
                                          Prednisolone Syrup 5 MG/5ML
                (Generic: PRELONE)        Prednisolone Syrup 15 MG/5ML
                (Generic: PEDIAPRED)      Prednisolone Sodium Phosphate Liq 6.7 MG/5ML
                (Generic: ORAPRED)        Prednisolone Sod Phosphate Oral Soln 15 MG/5ML (Base                                 Max Qty=240/claim
                                          Equiv)
                                          Prednisone Tab 1 MG                                        PREDNISONE
                                          Prednisone Tab 2.5 MG
                                          Prednisone Tab 5 MG
                                          Prednisone Tab 10 MG
                                          Prednisone Tab 20 MG
                                          Prednisone Tab 50 MG                                       PREDNISONE
                                          Prednisone Conc 5 MG/ML                                    PREDNISONE
                                          Prednisone Oral Soln 5 MG/5ML                              PREDNISONE
                (Generic: STERAPRED)      Prednisone Tab 5 MG Dose Pack
                (Generic: STERAPRED DS)   Prednisone Tab 10 MG Dose Pack
                (Generic: FLORINEF)       Fludrocortisone Acetate Tab 0.1 MG

ANDROGENS-ANABOLIC
                                          Fluoxymesterone Tab 10 MG                                  ANDROXY
                                          Methyltestosterone Oral Tab 10 MG                          METHITEST
                                          Testosterone TD Patch 24HR 2.5 MG/24HR                     ANDRODERM                 Daily Dosage=1
                                          Testosterone TD Patch 24HR 5 MG/24HR                       ANDRODERM                 Daily Dosage=1

ESTROGENS
                                          Estrogens, Conjugated Tab 0.3 MG                           PREMARIN                  Limited to Female; Daily Dosage=1
                                          Estrogens, Conjugated Tab 0.45 MG                          PREMARIN                  Limited to Female; Daily Dosage=1
                                          Estrogens, Conjugated Tab 0.625 MG                         PREMARIN                  Limited to Female; Daily Dosage=1
                                          Estrogens, Conjugated Tab 0.9 MG                           PREMARIN                  Limited to Female; Daily Dosage=1
                                          Estrogens, Conjugated Tab 1.25 MG                          PREMARIN                  Limited to Female; Daily Dosage=1
                (Generic: ESTRACE)        Estradiol Tab 0.5 MG                                                                 Limited to Female
                (Generic: ESTRACE)        Estradiol Tab 1 MG                                                                   Limited to Female
                (Generic: ESTRACE)        Estradiol Tab 2 MG                                                                   Limited to Female
                                          Estradiol TD Patch Biweekly 0.025 MG/24HR                  ALORA, VIVELLE-DOT        Limited to Female; Daily Dosage=.29
                                          Estradiol TD Patch Biweekly 0.0375 MG/24HR                 VIVELLE-DOT               Limited to Female; Daily Dosage=.29
                                          Estradiol TD Patch Biweekly 0.05 MG/24HR                   ALORA, ESTRADERM,         Limited to Female; Daily Dosage=.29
                                                                                                     VIVELLE, VIVELLE-DOT
                                          Estradiol TD Patch Biweekly 0.075 MG/24HR                  ALORA, VIVELLE-DOT        Limited to Female; Daily Dosage=.29
                                          Estradiol TD Patch Biweekly 0.1 MG/24HR                    ALORA, ESTRADERM,         Limited to Female; Daily Dosage=.29
                                                                                                     VIVELLE, VIVELLE-DOT
                (Generic: CLIMARA)        Estradiol TD Patch Weekly 0.025 MG/24HR                                              Limited to Female; Daily Dosage=.14
                (Generic: CLIMARA)        Estradiol TD Patch Weekly 0.0375 MG/24HR (37.5 MCG/24HR)                             Limited to Female; Daily Dosage=.14
                                                                                                                                                                     8
  Therapeutic                                                                                            Covered Brand Product
    Class         Common Brand Name(s)       Product Description                                          (unless FFQL or PA)    Limitations/Restrictions
                (Generic: CLIMARA)           Estradiol TD Patch Weekly 0.05 MG/24HR                                              Limited to Female; Daily Dosage=.14
                (Generic: CLIMARA)           Estradiol TD Patch Weekly 0.06 MG/24HR                                              Limited to Female; Daily Dosage=.14
                (Generic: CLIMARA)           Estradiol TD Patch Weekly 0.075 MG/24HR                                             Limited to Female; Daily Dosage=.14
                (Generic: CLIMARA)           Estradiol TD Patch Weekly 0.1 MG/24HR                                               Limited to Female; Daily Dosage=.14
                (Generic: OGEN)              Estropipate Tab 0.75 MG                                                             Limited to Female; Daily Dosage=1
                (Generic: OGEN)              Estropipate Tab 1.5 MG                                                              Limited to Female; Daily Dosage=1
                (Generic: OGEN)              Estropipate Tab 3 MG                                                                Limited to Female; Daily Dosage=1
                                             Conjugated Estrogen-Medroxyprogest Acetate Tab 0.3-1.5 MG PREMPRO                   Limited to Female; Daily Dosage=1

                                             Conjugated Estrogen-Medroxyprogest Acetate Tab 0.45-1.5 MG PREMPRO                  Limited to Female; Daily Dosage=1

                                             Conjugated Estrogen-Medroxyprogest Acetate Tab 0.625-2.5  PREMPRO                   PA, Limited to Female; Daily Dosage=1
                                             MG
                                             Conjugated Estrogen-Medroxyprogest Acetate Tab 0.625-5 MG PREMPRO                   Limited to Female; Daily Dosage=1

                                             Estradiol-Norethindrone Ace TD PTTW 0.05-0.14MG/DAY          COMBIPATCH             Limited to Female; Daily Dosage=.29
                                             Estradiol-Norethindrone Ace TD PTTW 0.05-0.25MG/DAY          COMBIPATCH             Limited to Female; Daily Dosage=.29

CONTRACEPTIVES
             (Generic: NOR-QD, ORTHO         Norethindrone Tab 0.35 MG                                                           Limited to Female; Daily Dosage=1
             MICRON)
             (Generic: DEPO-PROVERA)         Medroxyprogesterone Acetate IM Susp 150 MG/ML                                       Limited to Female; Max Qty=1/claim; Min
                                                                                                                                 DS=84
                                             Levonorgestrel Tab 0.75 MG                                   PLAN B                 PA, Limited to Female; Max Qty=2/365 days

                                             Norelgestromin-Ethinyl Estradiol TD PTWK 150-20 MCG/24HR ORTHO EVRA                 Limited to Female; Max Qty=3/claim; Daily
                                                                                                                                 Dosage=.14
                                             Etonogestrel-Ethinyl Estradiol VA Ring 0.120-0.015 MG/24HR   NUVARING               Limited to Female; Max Qty=1/claim; Min
                                                                                                                                 DS=28
                (Generic: DESOGEN,      Desogestrel & Ethinyl Estradiol Tab 0.15 MG-30 MCG                                       Limited to Female; Daily Dosage=1
                DESOGEN-28, ORTHO-CEPT)

                (Generic: MIRCETTE)          Desogest-Eth Estrad & Eth Estrad Tab .15-.02/.01 MG (21/5)                          Limited to Female; Daily Dosage=1

                                             Drospirenone-Ethinyl Estradiol Tab 3-0.02 MG                 YAZ                    Limited to Female
                (Generic: YASMIN 28)         Drospirenone-Ethinyl Estradiol Tab 3-0.03 MG                                        Limited to Female; Daily Dosage=1
                                             Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG-35MCG                             Limited to Female; Daily Dosage=1
                                             Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG-50MCG                             Limited to Female; Daily Dosage=1
                (Generic: ALESSE, LEVLITE)   Levonorgestrel & Ethinyl Estradiol Tab 0.10 MG-20MCG                                Limited to Female; Daily Dosage=1

                (Generic: LEVLEN, LEVLEN- Levonorgestrel & Ethinyl Estradiol Tab 0.15 MG-30MCG                                   Limited to Female; Daily Dosage=1
                28, NORDETTE, NORDETTE-
                28)
                (Generic: OVCON-35)          Norethindrone & Ethinyl Estradiol Tab 0.4 MG-35MCG                                  Limited to Female; Daily Dosage=1
                (Generic: BREVICON,          Norethindrone & Ethinyl Estradiol Tab 0.5 MG-35MCG                                  Limited to Female; Daily Dosage=1
                MODICON)
                                                                                                                                                                             9
  Therapeutic                                                                                                Covered Brand Product
    Class         Common Brand Name(s)      Product Description                                               (unless FFQL or PA)    Limitations/Restrictions
                (Generic: NORINYL, ORTHO-   Norethindrone & Ethinyl Estradiol Tab 1 MG-35MCG                                         Limited to Female; Daily Dosage=1
                NOVUM)
                (Generic: LOESTRIN)         Norethindrone Ace & Ethinyl Estradiol Tab 1 MG-20MCG                                     Limited to Female; Daily Dosage=1
                (Generic: LOESTRIN 21)      Norethindrone Ace & Ethinyl Estradiol Tab 1.5 MG-30MCG                                   Limited to Female; Daily Dosage=1

                (Generic: NORINYL, ORTHO-   Norethindrone & Mestranol Tab 1 MG-50MCG                                                 Limited to Female; Daily Dosage=1
                NOVUM)
                (Generic: LO/OVRAL,         Norgestrel & Ethinyl Estradiol Tab 0.3 MG-30MCG                                          Limited to Female; Daily Dosage=1
                LO/OVRAL-28)
                                            Norgestrel & Ethinyl Estradiol Tab 0.5 MG-50MCG                OGESTREL                  Limited to Female; Daily Dosage=1
                (Generic: ORTHO-CYCLEN)     Norgestimate & Ethinyl Estradiol Tab 0.25MG-35MCG                                        Limited to Female; Daily Dosage=1
                (Generic: LOESTRIN FE)      Norethindrone Ace & Ethinyl Estradiol-FE Tab 1 MG-20MCG                                  PA, Brand; Limited to Female; Daily
                                                                                                                                     Dosage=1
                                            Norethindrone Ace-Ethinyl Estradiol-FE Tab 1 MG-20 MCG (24 LOESTRIN 24

                (Generic: LOESTRIN FE)      Norethindrone Ace & Ethinyl Estradiol-FE Tab 1.5 MG-30MCG                                PA, Brand; Limited to Female; Daily
                                                                                                                                     Dosage=1
                (Generic: ORTHO-NOVUM)      Norethindrone-Eth Estradiol Tab 0.5-35/1-35 MG-MCG (10/11)     NECON                     Limited to Female; Daily Dosage=1

                (Generic: CYCLESSA)         Desogest-Ethinyl Estrad Tab .1-.025/.125-.025/.15-.025 MG-MG                             Limited to Female; Daily Dosage=1

                (Generic: TRI-LEVLEN,       Levonorgestrel-Eth Estrad Tab .05-30/0.075-40/0.125-30MG-                                Limited to Female; Daily Dosage=1
                TRIPHASIL 28)               MCG
                (Generic: ORTHO-NOVUM)      Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35 MG-MCG ORTHO-NOVUM                   Limited to Female; Daily Dosage=1

                (Generic: TRI-NORINYL)      Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35 MG-MCG                                Limited to Female; Daily Dosage=1

                (Generic: ORTHO TRI-)       Norgestimate-Eth Estrad Tab 0.18-35/0.215-35/0.25-35 MG-                                 Limited to Female; Daily Dosage=1
                                            MCG
                (Generic: SEASONALE)        Levonorgestrel & Ethinyl Estradiol (91-Day) Tab 0.15-0.03 MG

                                            Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab             SEASONIQUE                Limited to Female; Max DS/DU=Lesser Of
                                            0.01MG(7)                                                                                Max Days Sply=91/Max Qty=91

PROGESTINS
                (Generic: PROVERA)          Medroxyprogesterone Acetate Tab 2.5 MG
                (Generic: PROVERA)          Medroxyprogesterone Acetate Tab 5 MG
                (Generic: PROVERA)          Medroxyprogesterone Acetate Tab 10 MG
                (Generic: AYGESTIN)         Norethindrone Acetate Tab 5 MG

ANTIDIABETICS
                                            Insulin Glargine Inj 100 U/ML                                  LANTUS, LANTUS FOR     Max Qty=30/30 days
                                            Insulin Lispro (Human) Inj 100 U/ML                            HUMALOG, HUMALOG KWIK, Max Qty=40/30 days
                                                                                                           HUMALOG PEN
                                            Insulin Regular (Human) Inj 100 U/ML                           HUMULIN R, NOVOLIN R,  Max Qty=40/30 days
                                                                                                           RELION R
                                                                                                                                                                           10
Therapeutic                                                                                            Covered Brand Product
  Class         Common Brand Name(s)    Product Description                                             (unless FFQL or PA)   Limitations/Restrictions
                                        Insulin Isophane (Human) Inj 100 U/ML                        HUMULIN N, HUMULIN N PN, Max Qty=40/30 days
                                                                                                     NOVOLIN N, RELION N
                                        Insulin Aspart & Aspart Prot (Human) Inj 100 U/ML (30-70)    NOVOLOG MIX              Max Qty=40/30 days

                                        Insulin Lispro Prot & Lispro (Human) Inj 100 Unit/ML (75-2   HUMALOG MIX, HUMALOG       Max Qty=40/30 days
                                                                                                     PEN
                                        Insulin Lispro Prot & Lispro (Human) Inj 100 Unit/ML (50-5   HUMALOG MIX, HUMALOG       Max Qty=40/30 days
                                                                                                     PEN
                                        Insulin Isophane & Regular (Human) Inj 100 U/ML (70-30)      HUMULIN, HUMULIN PEN,      Max Qty=40/30 days
                                                                                                     NOVOLIN, NOVOLIN 70/,
                                                                                                     RELION 70/30
                                        Insulin Isophane & Regular (Human) Inj 100 U/ML (50-50)      HUMULIN                    Max Qty=40/30 days
              (Generic: AMARYL)         Glimepiride Tab 1 MG                                                                    Daily Dosage=1
              (Generic: AMARYL)         Glimepiride Tab 2 MG                                                                    Daily Dosage=1
              (Generic: AMARYL)         Glimepiride Tab 4 MG                                                                    Daily Dosage=2
              (Generic: GLUCOTROL)      Glipizide Tab 5 MG
              (Generic: GLUCOTROL)      Glipizide Tab 10 MG
              (Generic: GLUCOTROL XL)   Glipizide Tab SR 24HR 2.5 MG
              (Generic: GLUCOTROL XL)   Glipizide Tab SR 24HR 5 MG
              (Generic: GLUCOTROL XL)   Glipizide Tab SR 24HR 10 MG
              (Generic: MICRONASE)      Glyburide Tab 1.25 MG                                        DIABETA, GLYBURIDE
              (Generic: MICRONASE)      Glyburide Tab 2.5 MG                                         DIABETA, GLYBURIDE
              (Generic: MICRONASE)      Glyburide Tab 5 MG                                           DIABETA, GLYBURIDE
              (Generic: GLYNASE)        Glyburide Micronized Tab 1.5 MG
              (Generic: GLYNASE)        Glyburide Micronized Tab 3 MG
              (Generic: GLYNASE)        Glyburide Micronized Tab 6 MG
              (Generic: GLUCOPHAGE)     Metformin HCl Tab 500 MG                                                                Daily Dosage=5
              (Generic: GLUCOPHAGE)     Metformin HCl Tab 850 MG                                                                Daily Dosage=3
              (Generic: GLUCOPHAGE)     Metformin HCl Tab 1000 MG                                                               Daily Dosage=2
              (Generic: GLUCOPHAGE)     Metformin HCl Tab SR 24HR 500 MG                                                        Daily Dosage=2
              (Generic: GLUCOPHAGE)     Metformin HCl Tab SR 24HR 750 MG                                                        Daily Dosage=2
                                        Glucagon (rDNA) For Inj Kit 1 MG                             GLUCAGON                   Max Qty=1/claim; Max Fills=1/15 days
                                        Glucagon HCl (rDNA) For Inj 1 MG (Base Equiv)                GLUCAGEN
                                        Glucose Chew Tab 4 GM                                        BL GLUCOSE, CVS            Max Qty=50/30 days
                                                                                                     GLUCOSE, DD GLUCOSE,
                                                                                                     DE GLUCOSE, DEX4
                                                                                                     GLUCOSE...
                                        Glucose Chew Tab 5 GM                                        BD GLUCOSE
                                        Pioglitazone HCl Tab 15 MG (Base Equiv)                      ACTOS                      Daily Dosage=1
                                        Pioglitazone HCl Tab 30 MG (Base Equiv)                      ACTOS                      Daily Dosage=1
                                        Pioglitazone HCl Tab 45 MG (Base Equiv)                      ACTOS                      Daily Dosage=1
                                        Rosiglitazone Maleate Tab 2 MG (Base Equiv)                  AVANDIA                    Daily Dosage=1
                                        Rosiglitazone Maleate Tab 4 MG (Base Equiv)                  AVANDIA                    Daily Dosage=1
                                        Rosiglitazone Maleate Tab 8 MG (Base Equiv)                  AVANDIA                    Daily Dosage=1
              (Generic: METAGLIP)       Glipizide-Metformin HCl Tab 2.5-250 MG
              (Generic: METAGLIP)       Glipizide-Metformin HCl Tab 2.5-500 MG
              (Generic: METAGLIP)       Glipizide-Metformin HCl Tab 5-500 MG                                                                                           11
  Therapeutic                                                                                  Covered Brand Product
    Class         Common Brand Name(s)    Product Description                                   (unless FFQL or PA)    Limitations/Restrictions
                (Generic: GLUCOVANCE)     Glyburide-Metformin Tab 1.25-250 MG
                (Generic: GLUCOVANCE)     Glyburide-Metformin Tab 2.5-500 MG
                (Generic: GLUCOVANCE)     Glyburide-Metformin Tab 5-500 MG
                                          Rosiglitazone Maleate-Glimepiride Tab 4-1 MG        AVANDARYL                Daily Dosage=1
                                          Rosiglitazone Maleate-Glimepiride Tab 4-2 MG        AVANDARYL                Daily Dosage=1
                                          Rosiglitazone Maleate-Glimepiride Tab 4-4 MG        AVANDARYL                Daily Dosage=1
                                          Rosiglitazone Maleate-Glimepiride Tab 8-2 MG        AVANDARYL                Daily Dosage=1
                                          Rosiglitazone Maleate-Glimepiride Tab 8-4 MG        AVANDARYL                Daily Dosage=1
                                          Pioglitazone HCl-Metformin HCl Tab 15-500 MG        ACTOPLUS MET
                                          Pioglitazone HCl-Metformin HCl Tab 15-850 MG        ACTOPLUS MET
                                          Rosiglitazone Maleate-Metformin HCl Tab 2-500 MG    AVANDAMET                Daily Dosage=2
                                          Rosiglitazone Maleate-Metformin HCl Tab 2-1000 MG   AVANDAMET                Daily Dosage=2
                                          Rosiglitazone Maleate-Metformin HCl Tab 4-500 MG    AVANDAMET                Daily Dosage=2
                                          Rosiglitazone Maleate-Metformin HCl Tab 4-1000 MG   AVANDAMET                Daily Dosage=2

THYROID AGENTS
              (Generic: SYNTHROID)        Levothyroxine Sodium Tab 0.025 MG
              (Generic: SYNTHROID)        Levothyroxine Sodium Tab 0.05 MG
              (Generic: SYNTHROID)        Levothyroxine Sodium Tab 0.075 MG
              (Generic: SYNTHROID)        Levothyroxine Sodium Tab 0.088 MG
              (Generic: SYNTHROID)        Levothyroxine Sodium Tab 0.1 MG
              (Generic: SYNTHROID)        Levothyroxine Sodium Tab 0.112 MG
              (Generic: SYNTHROID)        Levothyroxine Sodium Tab 0.125 MG
              (Generic: SYNTHROID)        Levothyroxine Sodium Tab 0.137 MG
              (Generic: SYNTHROID)        Levothyroxine Sodium Tab 0.15 MG
              (Generic: SYNTHROID)        Levothyroxine Sodium Tab 0.175 MG
              (Generic: SYNTHROID)        Levothyroxine Sodium Tab 0.2 MG
              (Generic: SYNTHROID)        Levothyroxine Sodium Tab 0.3 MG
                                          Liothyronine Sodium Tab 5 MCG                       CYTOMEL
                                          Liothyronine Sodium Tab 25 MCG                      CYTOMEL
                                          Liothyronine Sodium Tab 50 MCG                      CYTOMEL
                                          Liotrix Tab 15 MG                                   THYROLAR-1/4
                                          Liotrix Tab 30 MG                                   THYROLAR-1/2
                                          Liotrix Tab 60 MG                                   THYROLAR-1
                                          Liotrix Tab 120 MG                                  THYROLAR-2
                                          Liotrix Tab 180 MG                                  THYROLAR-3
                                          Thyroid Tab 15 MG (1/4 Grain)                       ARMOUR THYRO
                                          Thyroid Tab 30 MG (1/2 Grain)                       ARMOUR THYRO
                                          Thyroid Tab 60 MG (1 Grain)                         ARMOUR THYRO
                (Generic: NATURE-THROI,   Thyroid Tab 65 MG
                WESTHROID)
                                          Thyroid Tab 90 MG (1 1/2 Grain)                     ARMOUR THYRO
                                          Thyroid Tab 120 MG (2 Grain)                        ARMOUR THYRO
                                          Thyroid Tab 180 MG (3 Grain)                        ARMOUR THYRO
                                          Thyroid Tab 240 MG (4 Grain)                        ARMOUR THYRO
                                          Thyroid Tab 300 MG (5 Grain)                        ARMOUR THYRO
                (Generic: TAPAZOLE)       Methimazole Tab 5 MG                                                                                    12
  Therapeutic                                                                                         Covered Brand Product
    Class         Common Brand Name(s)     Product Description                                         (unless FFQL or PA)    Limitations/Restrictions
                (Generic: TAPAZOLE)        Methimazole Tab 10 MG
                                           Propylthiouracil Tab 50 MG

OXYTOCICS
                                           Methylergonovine Maleate Tab 0.2 MG                      METHERGINE

ENDOCRINE AND METABOLIC AGENTS - MISC.
              (Generic: FOSAMAX)           Alendronate Sodium Tab 5 MG                                                        Daily Dosage=1
              (Generic: FOSAMAX)           Alendronate Sodium Tab 10 MG                                                       Daily Dosage=1
              (Generic: FOSAMAX)           Alendronate Sodium Tab 35 MG                                                       Daily Dosage=.14
              (Generic: FOSAMAX)           Alendronate Sodium Tab 40 MG                                                       Daily Dosage=1
              (Generic: FOSAMAX)           Alendronate Sodium Tab 70 MG                                                       Daily Dosage=.14
                                           Alendronate Sodium Oral Soln 70 MG/75ML                  FOSAMAX                   Daily Dosage=5.36
                                           Alendronate Sodium-Cholecalciferol Tab 70-2800 MG-Unit   FOSAMAX + D               Daily Dosage=.14

                                           Alendronate Sodium-Cholecalciferol Tab 70-5600 MG-Unit   FOSAMAX + D               Daily Dosage=.14

                                           Calcitonin (Salmon) Inj 200 IU/ML                        MIACALCIN
                (Generic: MIACALCIN)       Calcitonin (Salmon) Nasal Soln 200 IU/ACT                                          Max Qty=4/claim; Min DS=30
                                           Raloxifene HCl Tab 60 MG                                 EVISTA                    Daily Dosage=1
                (Generic: DDAVP)           Desmopressin Acetate Tab 0.1 MG                                                    Daily Dosage=3
                (Generic: DDAVP)           Desmopressin Acetate Tab 0.2 MG                                                    Daily Dosage=3

CARDIOTONICS
                                           Digoxin Cap 0.1 MG                                       LANOXICAPS
                (Generic: LANOXIN)         Digoxin Tab 0.125 MG
                (Generic: LANOXIN)         Digoxin Tab 0.25 MG
                                           Digoxin Oral Soln 0.05 MG/ML

ANTIANGINAL AGENTS
              (Generic: ISORDIL)           Isosorbide Dinitrate Tab 5 MG
                                           Isosorbide Dinitrate Tab 10 MG
                                           Isosorbide Dinitrate Tab 20 MG
                                           Isosorbide Dinitrate Tab 30 MG
                                           Isosorbide Dinitrate Tab CR 40 MG
                                           Isosorbide Dinitrate SL Tab 2.5 MG
                                           Isosorbide Dinitrate SL Tab 5 MG
                (Generic: MONOKET)         Isosorbide Mononitrate Tab 10 MG                                                   Daily Dosage=2
                (Generic: ISMO, MONOKET)   Isosorbide Mononitrate Tab 20 MG                                                   Daily Dosage=2
                (Generic: IMDUR)           Isosorbide Mononitrate Tab SR 24HR 30 MG                                           Daily Dosage=1
                (Generic: IMDUR)           Isosorbide Mononitrate Tab SR 24HR 60 MG                                           Daily Dosage=1
                (Generic: IMDUR)           Isosorbide Mononitrate Tab SR 24HR 120 MG                                          Daily Dosage=1
                                           Nitroglycerin Cap CR 2.5 MG
                                           Nitroglycerin Cap CR 6.5 MG
                                           Nitroglycerin Cap CR 9 MG
                (Generic: NITROSTAT)       Nitroglycerin SL Tab 0.3 MG
                (Generic: NITROSTAT)       Nitroglycerin SL Tab 0.4 MG                                                                                     13
  Therapeutic                                                                        Covered Brand Product
    Class         Common Brand Name(s)   Product Description                          (unless FFQL or PA)    Limitations/Restrictions
                (Generic: NITROSTAT)     Nitroglycerin SL Tab 0.6 MG
                                         Nitroglycerin Oint 2%                     NITRO-BID
                (Generic: NITRO-DUR)     Nitroglycerin TD Patch 24HR 0.1 MG/HR
                (Generic: NITRO-DUR)     Nitroglycerin TD Patch 24HR 0.2 MG/HR
                (Generic: NITRO-DUR)     Nitroglycerin TD Patch 24HR 0.4 MG/HR
                (Generic: NITRO-DUR)     Nitroglycerin TD Patch 24HR 0.6 MG/HR

BETA BLOCKERS
                (Generic: CORGARD)       Nadolol Tab 20 MG                                                   Daily Dosage=2
                (Generic: CORGARD)       Nadolol Tab 40 MG                                                   Daily Dosage=2
                (Generic: CORGARD)       Nadolol Tab 80 MG                                                   Daily Dosage=2
                                         Nadolol Tab 160 MG                                                  Daily Dosage=2
                                         Pindolol Tab 5 MG                         PINDOLOL
                                         Pindolol Tab 10 MG
                                         Propranolol HCl Tab 10 MG
                                         Propranolol HCl Tab 20 MG
                (Generic: INDERAL)       Propranolol HCl Tab 40 MG
                (Generic: INDERAL)       Propranolol HCl Tab 60 MG
                (Generic: INDERAL)       Propranolol HCl Tab 80 MG
                                         Propranolol HCl Oral Soln 20 MG/5ML
                                         Propranolol HCl Oral Soln 40 MG/5ML
                (Generic: INDERAL LA)    Propranolol HCl Cap SR 24HR 60 MG                                   Daily Dosage=2
                (Generic: INDERAL LA)    Propranolol HCl Cap SR 24HR 80 MG                                   Daily Dosage=2
                (Generic: INDERAL LA)    Propranolol HCl Cap SR 24HR 120 MG                                  Daily Dosage=2
                (Generic: INDERAL LA)    Propranolol HCl Cap SR 24HR 160 MG                                  Daily Dosage=2
                (Generic: BETAPACE)      Sotalol HCl Tab 80 MG
                (Generic: BETAPACE)      Sotalol HCl Tab 120 MG
                (Generic: BETAPACE)      Sotalol HCl Tab 160 MG
                (Generic: BETAPACE)      Sotalol HCl Tab 240 MG
                (Generic: BETAPACE AF)   Sotalol HCl (AFIB/AFL) Tab 80 MG                                    Daily Dosage=2
                (Generic: BETAPACE AF)   Sotalol HCl (AFIB/AFL) Tab 120 MG                                   Daily Dosage=2
                (Generic: BETAPACE AF)   Sotalol HCl (AFIB/AFL) Tab 160 MG                                   Daily Dosage=2
                                         Timolol Maleate Tab 5 MG
                                         Timolol Maleate Tab 10 MG
                                         Timolol Maleate Tab 20 MG
                (Generic: SECTRAL)       Acebutolol HCl Cap 200 MG
                (Generic: SECTRAL)       Acebutolol HCl Cap 400 MG
                (Generic: TENORMIN)      Atenolol Tab 25 MG                                                  Daily Dosage=2
                (Generic: TENORMIN)      Atenolol Tab 50 MG                                                  Daily Dosage=2
                (Generic: TENORMIN)      Atenolol Tab 100 MG                                                 Daily Dosage=2
                (Generic: ZEBETA)        Bisoprolol Fumarate Tab 5 MG
                (Generic: ZEBETA)        Bisoprolol Fumarate Tab 10 MG
                (Generic: TOPROL XL)     Metoprolol Succinate Tab SR 24HR 25 MG                              Daily Dosage=1
                (Generic: TOPROL XL)     Metoprolol Succinate Tab SR 24HR 50 MG                              Daily Dosage=1
                (Generic: TOPROL XL)     Metoprolol Succinate Tab SR 24HR 100 MG                             Daily Dosage=1
                (Generic: TOPROL XL)     Metoprolol Succinate Tab SR 24HR 200 MG                             Daily Dosage=1
                                         Metoprolol Tartrate Tab 25 MG                                       Daily Dosage=2             14
  Therapeutic                                                                                       Covered Brand Product
    Class         Common Brand Name(s)   Product Description                                         (unless FFQL or PA)    Limitations/Restrictions
                (Generic: LOPRESSOR)     Metoprolol Tartrate Tab 50 MG                                                      Daily Dosage=2
                (Generic: LOPRESSOR)     Metoprolol Tartrate Tab 100 MG                                                     Daily Dosage=2
                (Generic: COREG)         Carvedilol Tab 3.125 MG                                                            Daily Dosage=3
                (Generic: COREG)         Carvedilol Tab 6.25 MG                                                             Daily Dosage=3
                (Generic: COREG)         Carvedilol Tab 12.5 MG                                                             Daily Dosage=3
                (Generic: COREG)         Carvedilol Tab 25 MG                                                               Daily Dosage=3
                                         Carvedilol Phosphate Cap SR 24HR 10 MG                    COREG CR                 Daily Dosage=1
                                         Carvedilol Phosphate Cap SR 24HR 20 MG                    COREG CR                 Daily Dosage=1
                                         Carvedilol Phosphate Cap SR 24HR 40 MG                    COREG CR                 Daily Dosage=1
                                         Carvedilol Phosphate Cap SR 24HR 80 MG                    COREG CR                 Daily Dosage=1
                (Generic: TRANDATE)      Labetalol HCl Tab 100 MG                                                           Daily Dosage=3
                (Generic: TRANDATE)      Labetalol HCl Tab 200 MG                                                           Daily Dosage=3
                (Generic: TRANDATE)      Labetalol HCl Tab 300 MG                                                           Daily Dosage=3

CALCIUM CHANNEL BLOCKERS
             (Generic: NORVASC)          Amlodipine Besylate Tab 2.5 MG                                                     Daily Dosage=1
             (Generic: NORVASC)          Amlodipine Besylate Tab 5 MG                                                       Daily Dosage=1
             (Generic: NORVASC)          Amlodipine Besylate Tab 10 MG                                                      Daily Dosage=1
             (Generic: CARDIZEM)         Diltiazem HCl Tab 30 MG                                                            Daily Dosage=3
             (Generic: CARDIZEM)         Diltiazem HCl Tab 60 MG                                                            Daily Dosage=3
             (Generic: CARDIZEM)         Diltiazem HCl Tab 90 MG                                                            Daily Dosage=3
             (Generic: CARDIZEM)         Diltiazem HCl Tab 120 MG                                                           Daily Dosage=3
                                         Diltiazem HCl Cap SR 12HR 60 MG                                                    Daily Dosage=2
                                         Diltiazem HCl Cap SR 12HR 90 MG                                                    Daily Dosage=2
                                         Diltiazem HCl Cap SR 12HR 120 MG                                                   Daily Dosage=2
                (Generic: DILACOR XR)    Diltiazem HCl Cap SR 24HR 120 MG                                                   Daily Dosage=1
                (Generic: DILACOR XR)    Diltiazem HCl Cap SR 24HR 180 MG                                                   Daily Dosage=1
                (Generic: DILACOR XR)    Diltiazem HCl Cap SR 24HR 240 MG                                                   Daily Dosage=1
                (Generic: TIAZAC)        Diltiazem HCl Extended Release Beads Cap SR 24HR 120 MG                            Daily Dosage=1

                (Generic: TIAZAC)        Diltiazem HCl Extended Release Beads Cap SR 24HR 180 MG                            Daily Dosage=1

                (Generic: TIAZAC)        Diltiazem HCl Extended Release Beads Cap SR 24HR 240 MG                            Daily Dosage=1

                (Generic: TIAZAC)        Diltiazem HCl Extended Release Beads Cap SR 24HR 300 MG                            Daily Dosage=1

                (Generic: TIAZAC)        Diltiazem HCl Extended Release Beads Cap SR 24HR 360 MG                            Daily Dosage=1

                (Generic: TIAZAC)        Diltiazem HCl Extended Release Beads Cap SR 24HR 420 MG                            Daily Dosage=1

                (Generic: CARDIZEM CD)   Diltiazem HCl Coated Beads Cap SR 24HR 120 MG                                      Daily Dosage=1
                (Generic: CARDIZEM CD)   Diltiazem HCl Coated Beads Cap SR 24HR 180 MG                                      Daily Dosage=1
                (Generic: CARDIZEM CD)   Diltiazem HCl Coated Beads Cap SR 24HR 240 MG                                      Daily Dosage=1
                (Generic: CARDIZEM CD)   Diltiazem HCl Coated Beads Cap SR 24HR 300 MG                                      Daily Dosage=1
                (Generic: PLENDIL)       Felodipine Tab SR 24HR 2.5 MG                                                      Daily Dosage=1
                (Generic: PLENDIL)       Felodipine Tab SR 24HR 5 MG                                                        Daily Dosage=1
                (Generic: PLENDIL)       Felodipine Tab SR 24HR 10 MG                                                       Daily Dosage=1             15
  Therapeutic                                                                             Covered Brand Product
    Class         Common Brand Name(s)      Product Description                            (unless FFQL or PA)    Limitations/Restrictions
                                            Nicardipine HCl Cap 20 MG
                                            Nicardipine HCl Cap 30 MG
                (Generic: PROCARDIA)        Nifedipine Cap 10 MG                                                  Daily Dosage=4
                                            Nifedipine Cap 20 MG                        NIFEDIPINE                Daily Dosage=4
                (Generic: ADALAT CC)        Nifedipine Tab SR 24HR 30 MG                                          Daily Dosage=1
                (Generic: ADALAT CC)        Nifedipine Tab SR 24HR 60 MG                                          Daily Dosage=1
                (Generic: ADALAT CC)        Nifedipine Tab SR 24HR 90 MG                                          Daily Dosage=1
                (Generic: PROCARDIA XL)     Nifedipine Tab SR 24HR Osmotic 30 MG                                  Daily Dosage=1
                (Generic: PROCARDIA XL)     Nifedipine Tab SR 24HR Osmotic 60 MG                                  Daily Dosage=1
                (Generic: PROCARDIA XL)     Nifedipine Tab SR 24HR Osmotic 90 MG                                  Daily Dosage=1
                (Generic: CALAN)            Verapamil HCl Tab 40 MG                                               Daily Dosage=3
                (Generic: CALAN)            Verapamil HCl Tab 80 MG                                               Daily Dosage=3
                (Generic: CALAN)            Verapamil HCl Tab 120 MG                                              Daily Dosage=3
                (Generic: CALAN SR, ISOPTIN Verapamil HCl Tab CR 120 MG                                           Daily Dosage=2
                SR)
                (Generic: CALAN SR, ISOPTIN Verapamil HCl Tab CR 180 MG                                           Daily Dosage=2
                SR)
                (Generic: CALAN SR, ISOPTIN Verapamil HCl Tab CR 240 MG                                           Daily Dosage=2
                SR)
                (Generic: VERELAN)          Verapamil HCl Cap SR 24HR 120 MG                                      Daily Dosage=2
                (Generic: VERELAN)          Verapamil HCl Cap SR 24HR 180 MG                                      Daily Dosage=2
                (Generic: VERELAN)          Verapamil HCl Cap SR 24HR 240 MG                                      Daily Dosage=2
                (Generic: VERELAN)          Verapamil HCl Cap SR 24HR 360 MG                                      Daily Dosage=1

ANTIARRHYTHMICS
                                            Moricizine HCl Tab 200 MG                   ETHMOZINE
                                            Moricizine HCl Tab 250 MG                   ETHMOZINE
                                            Moricizine HCl Tab 300 MG                   ETHMOZINE
                (Generic: NORPACE)          Disopyramide Phosphate Cap 100 MG
                (Generic: NORPACE)          Disopyramide Phosphate Cap 150 MG
                (Generic: NORPACE)          Disopyramide Phosphate Cap SR 12HR 150 MG
                (Generic: PRONESTYL)        Procainamide HCl Cap 250 MG
                                            Procainamide HCl Cap 500 MG                 PROCAINAMIDE
                                            Procainamide HCl Tab CR 750 MG              PROCAINAMIDE
                                            Quinidine Gluconate Tab CR 324 MG
                                            Quinidine Sulfate Tab 200 MG
                                            Quinidine Sulfate Tab 300 MG
                                            Quinidine Sulfate Tab CR 300 MG
                                            Mexiletine HCl Cap 150 MG                   MEXILETINE
                                            Mexiletine HCl Cap 200 MG                   MEXILETINE
                                            Mexiletine HCl Cap 250 MG                   MEXILETINE
                (Generic: TAMBOCOR)         Flecainide Acetate Tab 50 MG
                (Generic: TAMBOCOR)         Flecainide Acetate Tab 100 MG
                (Generic: TAMBOCOR)         Flecainide Acetate Tab 150 MG
                (Generic: RYTHMOL)          Propafenone HCl Tab 150 MG
                (Generic: RYTHMOL)          Propafenone HCl Tab 225 MG
                (Generic: RYTHMOL)          Propafenone HCl Tab 300 MG                                                                       16
  Therapeutic                                                                      Covered Brand Product
    Class         Common Brand Name(s)       Product Description                    (unless FFQL or PA)    Limitations/Restrictions
                (Generic: CORDARONE)         Amiodarone HCl Tab 200 MG
                                             Dofetilide Cap 125 MCG (0.125 MG)   TIKOSYN
                                             Dofetilide Cap 250 MCG (0.25 MG)    TIKOSYN
                                             Dofetilide Cap 500 MCG (0.5 MG)     TIKOSYN

ANTIHYPERTENSIVES
              (Generic: LOTENSIN)            Benazepril HCl Tab 5 MG                                       Daily Dosage=1
              (Generic: LOTENSIN)            Benazepril HCl Tab 10 MG                                      Daily Dosage=1
              (Generic: LOTENSIN)            Benazepril HCl Tab 20 MG            LOTENSIN                  Daily Dosage=1
              (Generic: LOTENSIN)            Benazepril HCl Tab 40 MG                                      Daily Dosage=1
              (Generic: CAPOTEN)             Captopril Tab 12.5 MG                                         Daily Dosage=3
              (Generic: CAPOTEN)             Captopril Tab 25 MG                                           Daily Dosage=3
              (Generic: CAPOTEN)             Captopril Tab 50 MG                                           Daily Dosage=3
              (Generic: CAPOTEN)             Captopril Tab 100 MG                                          Daily Dosage=3
              (Generic: VASOTEC)             Enalapril Maleate Tab 2.5 MG                                  Daily Dosage=2
              (Generic: VASOTEC)             Enalapril Maleate Tab 5 MG                                    Daily Dosage=2
              (Generic: VASOTEC)             Enalapril Maleate Tab 10 MG                                   Daily Dosage=2
              (Generic: VASOTEC)             Enalapril Maleate Tab 20 MG                                   Daily Dosage=2
              (Generic: MONOPRIL)            Fosinopril Sodium Tab 10 MG                                   Daily Dosage=1
              (Generic: MONOPRIL)            Fosinopril Sodium Tab 20 MG                                   Daily Dosage=1
              (Generic: MONOPRIL)            Fosinopril Sodium Tab 40 MG                                   Daily Dosage=1
              (Generic: ZESTRIL)             Lisinopril Tab 2.5 MG                                         Daily Dosage=1
              (Generic: PRINIVIL, ZESTRIL)   Lisinopril Tab 5 MG                                           Daily Dosage=1

                (Generic: PRINIVIL, ZESTRIL) Lisinopril Tab 10 MG                PRINIVIL                  Daily Dosage=1

                (Generic: PRINIVIL, ZESTRIL) Lisinopril Tab 20 MG                                          Daily Dosage=1

                (Generic: ZESTRIL)           Lisinopril Tab 30 MG                                          Daily Dosage=1
                (Generic: ZESTRIL)           Lisinopril Tab 40 MG                                          Daily Dosage=1
                (Generic: ACCUPRIL)          Quinapril HCl Tab 5 MG                                        Daily Dosage=1
                (Generic: ACCUPRIL)          Quinapril HCl Tab 10 MG                                       Daily Dosage=1
                (Generic: ACCUPRIL)          Quinapril HCl Tab 20 MG                                       Daily Dosage=1
                (Generic: ACCUPRIL)          Quinapril HCl Tab 40 MG                                       Daily Dosage=1
                (Generic: ALTACE)            Ramipril Cap 1.25 MG                                          Daily Dosage=2
                (Generic: ALTACE)            Ramipril Cap 2.5 MG                                           Daily Dosage=2
                (Generic: ALTACE)            Ramipril Cap 5 MG                                             Daily Dosage=2
                (Generic: ALTACE)            Ramipril Cap 10 MG                                            Daily Dosage=2
                (Generic: MAVIK)             Trandolapril Tab 1 MG                                         Daily Dosage=4
                (Generic: MAVIK)             Trandolapril Tab 2 MG                                         Daily Dosage=4
                (Generic: MAVIK)             Trandolapril Tab 4 MG                                         Daily Dosage=4
                                             Losartan Potassium Tab 25 MG        COZAAR                    Daily Dosage=1
                                             Losartan Potassium Tab 50 MG        COZAAR                    Daily Dosage=1
                                             Losartan Potassium Tab 100 MG       COZAAR                    Daily Dosage=1
                                             Valsartan Tab 40 MG                 DIOVAN                    Daily Dosage=1
                                             Valsartan Tab 80 MG                 DIOVAN                    Daily Dosage=1
                                             Valsartan Tab 160 MG                DIOVAN                    Daily Dosage=1             17
Therapeutic                                                                                        Covered Brand Product
  Class         Common Brand Name(s)    Product Description                                         (unless FFQL or PA)    Limitations/Restrictions
                                        Valsartan Tab 320 MG                                     DIOVAN                    Daily Dosage=1
              (Generic: CATAPRES)       Clonidine HCl Tab 0.1 MG
              (Generic: CATAPRES)       Clonidine HCl Tab 0.2 MG
              (Generic: CATAPRES)       Clonidine HCl Tab 0.3 MG
                                        Guanabenz Acetate Tab 4 MG
                                        Guanabenz Acetate Tab 8 MG
              (Generic: TENEX)          Guanfacine HCl Tab 1 MG
              (Generic: TENEX)          Guanfacine HCl Tab 2 MG
                                        Methyldopa Tab 250 MG
                                        Methyldopa Tab 500 MG
              (Generic: CARDURA)        Doxazosin Mesylate Tab 1 MG
              (Generic: CARDURA)        Doxazosin Mesylate Tab 2 MG
              (Generic: CARDURA)        Doxazosin Mesylate Tab 4 MG
              (Generic: CARDURA)        Doxazosin Mesylate Tab 8 MG
              (Generic: MINIPRESS)      Prazosin HCl Cap 1 MG
              (Generic: MINIPRESS)      Prazosin HCl Cap 2 MG
              (Generic: MINIPRESS)      Prazosin HCl Cap 5 MG
              (Generic: HYTRIN)         Terazosin HCl Cap 1 MG
              (Generic: HYTRIN)         Terazosin HCl Cap 2 MG
              (Generic: HYTRIN)         Terazosin HCl Cap 5 MG
              (Generic: HYTRIN)         Terazosin HCl Cap 10 MG
                                        Reserpine Tab 0.1 MG
                                        Reserpine Tab 0.25 MG
                                        Hydralazine HCl Tab 10 MG
                                        Hydralazine HCl Tab 25 MG
              (Generic: APRESOLINE)     Hydralazine HCl Tab 50 MG
                                        Hydralazine HCl Tab 100 MG
              (Generic: LOTREL)         Benazepril HCl-Amlodipine Besylate Cap 10-2.5 MG                                   Daily Dosage=1
              (Generic: LOTREL)         Benazepril HCl-Amlodipine Besylate Cap 10-5 MG                                     Daily Dosage=1
              (Generic: LOTREL)         Benazepril HCl-Amlodipine Besylate Cap 20-5 MG                                     Daily Dosage=1
              (Generic: LOTREL)         Amlodipine Besylate-Benazepril HCl Cap 10-20 MG                                    Daily Dosage=1
              (Generic: LOTENSIN HCT)   Benazepril & Hydrochlorothiazide Tab 5-6.25 MG                                     Daily Dosage=1
              (Generic: LOTENSIN HCT)   Benazepril & Hydrochlorothiazide Tab 10-12.5 MG                                    Daily Dosage=1
              (Generic: LOTENSIN HCT)   Benazepril & Hydrochlorothiazide Tab 20-12.5 MG                                    Daily Dosage=1
              (Generic: LOTENSIN HCT)   Benazepril & Hydrochlorothiazide Tab 20-25 MG                                      Daily Dosage=1
              (Generic: CAPOZIDE)       Captopril & Hydrochlorothiazide Tab 25-15 MG                                       Daily Dosage=2
              (Generic: CAPOZIDE)       Captopril & Hydrochlorothiazide Tab 25-25 MG                                       Daily Dosage=2
              (Generic: CAPOZIDE)       Captopril & Hydrochlorothiazide Tab 50-15 MG                                       Daily Dosage=2
              (Generic: CAPOZIDE)       Captopril & Hydrochlorothiazide Tab 50-25 MG                                       Daily Dosage=2
              (Generic: VASERETIC)      Enalapril Maleate & Hydrochlorothiazide Tab 5-12.5 MG                              Daily Dosage=2
              (Generic: VASERETIC)      Enalapril Maleate & Hydrochlorothiazide Tab 10-25 MG                               Daily Dosage=2
              (Generic: MONOPRIL HCT)   Fosinopril Sodium & Hydrochlorothiazide Tab 10-12.5 MG                             Daily Dosage=1
              (Generic: MONOPRIL HCT)   Fosinopril Sodium & Hydrochlorothiazide Tab 20-12.5 MG                             Daily Dosage=1
              (Generic: PRINZIDE,       Lisinopril & Hydrochlorothiazide Tab 10-12.5 MG                                    Daily Dosage=1
              ZESTORETIC)
              (Generic: PRINZIDE,       Lisinopril & Hydrochlorothiazide Tab 20-12.5 MG                                    Daily Dosage=1
              ZESTORETIC)                                                                                                                             18
  Therapeutic                                                                                         Covered Brand Product
    Class         Common Brand Name(s)   Product Description                                           (unless FFQL or PA)    Limitations/Restrictions
                (Generic: PRINZIDE,      Lisinopril & Hydrochlorothiazide Tab 20-25 MG                                        Daily Dosage=1
                ZESTORETIC)
                (Generic: TENORETIC)     Atenolol & Chlorthalidone Tab 50-25 MG                                               Daily Dosage=1
                (Generic: TENORETIC)     Atenolol & Chlorthalidone Tab 100-25 MG                                              Daily Dosage=1
                (Generic: ZIAC)          Bisoprolol & Hydrochlorothiazide Tab 2.5-6.25 MG
                (Generic: ZIAC)          Bisoprolol & Hydrochlorothiazide Tab 5-6.25 MG
                (Generic: ZIAC)          Bisoprolol & Hydrochlorothiazide Tab 10-6.25 MG
                (Generic: LOPRESS HCT)   Metoprolol & Hydrochlorothiazide Tab 50-25 MG                                        Daily Dosage=2
                (Generic: LOPRESS HCT)   Metoprolol & Hydrochlorothiazide Tab 100-25 MG                                       Daily Dosage=2
                (Generic: LOPRESS HCT)   Metoprolol & Hydrochlorothiazide Tab 100-50 MG                                       Daily Dosage=2
                (Generic: INDERIDE)      Propranolol & Hydrochlorothiazide Tab 40-25 MG
                                         Propranolol & Hydrochlorothiazide Tab 80-25 MG
                                         Losartan Potassium & Hydrochlorothiazide Tab 50-12.5 MG    HYZAAR                    Daily Dosage=1

                                         Losartan Potassium & Hydrochlorothiazide Tab 100-12.5 MG   HYZAAR                    Daily Dosage=1

                                         Losartan Potassium & Hydrochlorothiazide Tab 100-25 MG     HYZAAR                    Daily Dosage=1

                                         Valsartan-Hydrochlorothiazide Tab 80-12.5 MG               DIOVAN HCT                Daily Dosage=1
                                         Valsartan-Hydrochlorothiazide Tab 160-12.5 MG              DIOVAN HCT                Daily Dosage=1
                                         Valsartan-Hydrochlorothiazide Tab 160-25 MG                DIOVAN HCT                Daily Dosage=1
                                         Valsartan-Hydrochlorothiazide Tab 320-12.5 MG              DIOVAN HCT                Daily Dosage=1
                                         Valsartan-Hydrochlorothiazide Tab 320-25 MG                DIOVAN HCT                Daily Dosage=1
                                         Hydralazine & HCTZ Cap 25-25 MG
                                         Hydralazine & HCTZ Cap 50-50 MG

DIURETICS
                                         Acetazolamide Tab 125 MG
                                         Acetazolamide Tab 250 MG
                                         Acetazolamide Cap SR 12HR 500 MG                           DIAMOX
                                         Methazolamide Tab 25 MG
                                         Methazolamide Tab 50 MG
                (Generic: BUMEX)         Bumetanide Tab 0.5 MG
                (Generic: BUMEX)         Bumetanide Tab 1 MG
                (Generic: BUMEX)         Bumetanide Tab 2 MG
                (Generic: LASIX)         Furosemide Tab 20 MG
                (Generic: LASIX)         Furosemide Tab 40 MG
                (Generic: LASIX)         Furosemide Tab 80 MG
                                         Furosemide Oral Soln 8 MG/ML
                                         Furosemide Oral Soln 10 MG/ML
                (Generic: DEMADEX)       Torsemide Tab 5 MG                                                                   Daily Dosage=1
                (Generic: DEMADEX)       Torsemide Tab 10 MG                                                                  Daily Dosage=1
                (Generic: DEMADEX)       Torsemide Tab 20 MG                                                                  Daily Dosage=1
                (Generic: DEMADEX)       Torsemide Tab 100 MG                                                                 Daily Dosage=1
                (Generic: ALDACTONE)     Spironolactone Tab 25 MG
                (Generic: ALDACTONE)     Spironolactone Tab 50 MG
                (Generic: ALDACTONE)     Spironolactone Tab 100 MG                                                                                       19
  Therapeutic                                                                                  Covered Brand Product
    Class         Common Brand Name(s)   Product Description                                    (unless FFQL or PA)    Limitations/Restrictions
                                         Chlorthalidone Tab 25 MG
                                         Chlorthalidone Tab 50 MG
                                         Chlorthalidone Tab 100 MG
                (Generic: MICROZIDE)     Hydrochlorothiazide Cap 12.5 MG
                                         Hydrochlorothiazide Tab 25 MG
                                         Hydrochlorothiazide Tab 50 MG
                                         Indapamide Tab 1.25 MG
                                         Indapamide Tab 2.5 MG
                (Generic: ZAROXOLYN)     Metolazone Tab 2.5 MG
                (Generic: ZAROXOLYN)     Metolazone Tab 5 MG
                (Generic: ZAROXOLYN)     Metolazone Tab 10 MG
                (Generic: ALDACTAZIDE)   Spironolactone & Hydrochlorothiazide Tab 25-25 MG
                (Generic: DYAZIDE)       Triamterene & Hydrochlorothiazide Cap 37.5-25 MG                              Daily Dosage=1
                                         Triamterene & Hydrochlorothiazide Cap 50-25 MG                                Daily Dosage=1
                (Generic: MAXZIDE-25)    Triamterene & Hydrochlorothiazide Tab 37.5-25 MG                              Daily Dosage=1
                (Generic: MAXZIDE)       Triamterene & Hydrochlorothiazide Tab 75-50 MG                                Daily Dosage=1

VASOPRESSORS
                (Generic: PROAMATINE)    Midodrine HCl Tab 2.5 MG
                (Generic: PROAMATINE)    Midodrine HCl Tab 5 MG
                (Generic: PROAMATINE)    Midodrine HCl Tab 10 MG
                                         Epinephrine HCl Inj Device 1:2000                   EPIPEN-JR                 Max Qty=2/30 days
                                         Epinephrine HCl Inj Device 1:1000                   EPIPEN, EPIPEN 2-PAK      Max Qty=2/30 days

ANTIHYPERLIPIDEMICS
               (Generic: QUESTRAN)       Cholestyramine Powder 4 GM
               (Generic: QUESTRAN)       Cholestyramine Powder Packets 4 GM
               (Generic: QUESTRAN)       Cholestyramine Light Powder 4 GM/DOSE
               (Generic: QUESTRAN)       Cholestyramine Light Powder Packets 4 GM
               (Generic: LOFIBRA)        Fenofibrate Tab 54 MG                                                         Daily Dosage=3
               (Generic: LOFIBRA)        Fenofibrate Tab 160 MG                              TRIGLIDE                  Daily Dosage=1
               (Generic: LOFIBRA)        Fenofibrate Micronized Cap 67 MG                                              Daily Dosage=2
               (Generic: LOFIBRA)        Fenofibrate Micronized Cap 134 MG                                             Daily Dosage=1
               (Generic: LOFIBRA)        Fenofibrate Micronized Cap 200 MG                                             Daily Dosage=1
               (Generic: LOPID)          Gemfibrozil Tab 600 MG                                                        Daily Dosage=2
               (Generic: MEVACOR)        Lovastatin Tab 10 MG                                                          Daily Dosage=1
               (Generic: MEVACOR)        Lovastatin Tab 20 MG                                                          Daily Dosage=1
               (Generic: MEVACOR)        Lovastatin Tab 40 MG                                                          Daily Dosage=1
               (Generic: PRAVACHOL)      Pravastatin Sodium Tab 10 MG                                                  Daily Dosage=1
               (Generic: PRAVACHOL)      Pravastatin Sodium Tab 20 MG                                                  Daily Dosage=1
               (Generic: PRAVACHOL)      Pravastatin Sodium Tab 40 MG                                                  Daily Dosage=1
               (Generic: ZOCOR)          Simvastatin Tab 5 MG                                                          Daily Dosage=1
               (Generic: ZOCOR)          Simvastatin Tab 10 MG                                                         Daily Dosage=1
               (Generic: ZOCOR)          Simvastatin Tab 20 MG                                                         Daily Dosage=1
               (Generic: ZOCOR)          Simvastatin Tab 40 MG                                                         Daily Dosage=1
               (Generic: ZOCOR)          Simvastatin Tab 80 MG                                                         Daily Dosage=1
                                                                                                                                                  20
  Therapeutic                                                                                Covered Brand Product
    Class      Common Brand Name(s)            Product Description                            (unless FFQL or PA)    Limitations/Restrictions
CARDIOVASCULAR AGENTS - MISC.
                                               Papaverine HCl Cap CR 150 MG

ANTIHISTAMINES
                                               Chlorpheniramine Maleate Cap CR 8 MG                                  Daily Dosage=3
                                               Chlorpheniramine Maleate Cap CR 12 MG        CHLORPHENIR              Daily Dosage=2
                 (Generic: CHLOR-TRIMET)       Chlorpheniramine Maleate Tab 4 MG                                     Daily Dosage=6
                 (Generic: CHLOR-TRIMET)       Chlorpheniramine Maleate Syrup 2 MG/5ML                               Max Qty=240/claim; Daily Dosage=60
                                               Dexchlorpheniramine Maleate Tab CR 4 MG
                                               Dexchlorpheniramine Maleate Syrup 2 MG/5ML
                 (Generic: TAVIST, TAVIST-1)   Clemastine Fumarate Tab 1.34 MG

                 (Generic: BENADRYL,           Diphenhydramine HCl Cap 25 MG
                 BENADRYL DF)
                                               Diphenhydramine HCl Cap 50 MG
                 (Generic: BENADRYL)           Diphenhydramine HCl Tab 25 MG
                                               Diphenhydramine HCl Tab 50 MG
                 (Generic: BENADRYL ALL)       Diphenhydramine HCl Liquid 12.5 MG/5ML
                                               Diphenhydramine HCl Elixir 12.5 MG/5ML
                                               Diphenhydramine HCl Syrup 12.5 MG/5ML
                                               Promethazine HCl Tab 12.5 MG                                          Limited to Ages 2 and Older
                                               Promethazine HCl Tab 25 MG                                            Limited to Ages 2 and Older
                                               Promethazine HCl Tab 50 MG                                            Limited to Ages 2 and Older
                                               Promethazine HCl Syrup 6.25 MG/5ML           PROMETHAZINE             Limited to Ages 2 and Older; Max
                                                                                                                     Qty=240/claim; Daily Dosage=80
                                               Promethazine HCl Suppos 12.5 MG                                       Limited to Ages 2 and Older; Max
                                                                                                                     Qty=12/claim
                                               Promethazine HCl Suppos 25 MG                                         Limited to Ages 2 and Older; Max
                                                                                                                     Qty=12/claim
                                               Promethazine HCl Suppos 50 MG                                         Limited to Ages 2 and Older; Max
                                                                                                                     Qty=12/claim
                                               Cyproheptadine HCl Tab 4 MG
                                               Cyproheptadine HCl Syrup 2 MG/5ML
                 (Generic: ZYRTEC)             Cetirizine HCl Tab 5 MG                      ZYRTEC                   Daily Dosage=1
                 (Generic: ZYRTEC, ZYRTEC      Cetirizine HCl Tab 10 MG                     ZYRTEC                   Daily Dosage=1
                 ALLGY, ZYRTEC HIVES)

                 (Generic: ZYRTEC, ZYRTEC      Cetirizine HCl Chew Tab 5 MG                                          Daily Dosage=1
                 CHILD)
                 (Generic: ZYRTEC, ZYRTEC      Cetirizine HCl Chew Tab 10 MG                                         Daily Dosage=1
                 CHILD)
                 (Generic: ZYRTEC CHILD,       Cetirizine HCl Syrup 5 MG/5ML                ZYRTEC                   Limited to Ages 12 and Under; Daily
                 ZYRTEC HIVES)                                                                                       Dosage=10
                 (Generic: ALLEGRA)            Fexofenadine HCl Tab 30 MG                                            Daily Dosage=2
                 (Generic: ALLEGRA)            Fexofenadine HCl Tab 60 MG                                            Daily Dosage=2
                 (Generic: CLARITIN)           Loratadine Tab 10 MG                                                  Daily Dosage=1
                 (Generic: CLARITIN)           Loratadine Syrup 10 MG/10ML                                           Daily Dosage=10                       21
  Therapeutic                                                                                         Covered Brand Product
    Class         Common Brand Name(s) Product Description                                             (unless FFQL or PA)    Limitations/Restrictions
                (Generic: CLARITIN, CLARITIN Loratadine Rapidly-Disintegrating Tab 10 MG                                      Daily Dosage=1
                RDT)

NASAL AGENTS - SYSTEMIC AND TOPICAL
               (Generic: SUDAFED)             Pseudoephedrine HCl Tab 30 MG
                                              Pseudoephedrine HCl Tab 60 MG
                (Generic: SUDAFED CHLD)       Pseudoephedrine HCl Liq 15 MG/5ML                                               Max Qty=240/claim
                                              Pseudoephedrine HCl Liq 30 MG/5ML                                               Max Qty=240/claim
                                              Pseudoephedrine HCl Syrup 30 MG/5ML                                             Max Qty=240/claim
                (Generic: PEDIACARE)          Pseudoephedrine HCl Soln 7.5 MG/0.8ML                                           Max Qty=30/claim
                                              Pseudoephedrine HCl Tab SR 12HR 120 MG                                          Daily Dosage=2
                                              Epinephrine HCl Nasal Soln 0.1%                       ADRENALIN
                                              Beclomethasone Dipropionate Monohyd Nasal Susp 42     BECONASE AQ               Min DS=25; Package Limit=1/claim
                                              MCG/SPRAY
                (Generic: NASALIDE)           Flunisolide Nasal Soln 0.025%                                                   Min DS=12; Package Limit=1/claim
                (Generic: NASAREL)            Flunisolide Nasal Soln 29 MCG/ACT
                (Generic: FLONASE)            Fluticasone Propionate Nasal Susp 50 MCG/ACT                                    Min DS=12; Package Limit=1/claim
                                              Mometasone Furoate Nasal Susp 50 MCG/ACT              NASONEX                   Max Qty=17/30 days; Step Therapy
                                              Triamcinolone Acetonide Nasal Inhal 55 MCG/ACT        NASACORT AQ               Step Therapy
                                              Mupirocin Calcium Nasal Oint 2%                       BACTROBAN
                (Generic: ATROVENT NAS)       Ipratropium Bromide Nasal Soln 0.03% (21 MCG/SPRAY)                             Min DS=28; Package Limit=1/claim
                (Generic: ATROVENT NAS)       Ipratropium Bromide Nasal Soln 0.06% (42 MCG/SPRAY)                             Min DS=10; Package Limit=1/claim
                (Generic: NASALCROM)          Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%)                              Min DS=16; Package Limit=1/claim
                (Generic: OCEAN NASAL)        Saline Nasal Spray 0.65%
                                              Saline Nasal Soln 0.65%                               AYR NASAL
                                              Saline Nasal Gel                                      AYR SALINE, NASOGEL

COUGH/COLD/ALLERGY
              (Generic: HYCODAN)              Hydrocodone w/ Homatropine Syrup 5-1.5 MG/5ML                                   Max Qty=240/claim
              (Generic: TESSALON PER)         Benzonatate Cap 100 MG                                                          Daily Dosage=3
              (Generic: TESSALON)             Benzonatate Cap 200 MG
              (Generic: TRIAMINIC)            Dextromethorphan HBr Liquid 7.5 MG/5ML                                          Max Qty=240/claim
                                              Dextromethorphan Polistirex Liquid CR 30 MG/5ML       DELSYM                    Max Qty=240/claim
                (Generic: ORGANIDIN NR)       Guaifenesin Liquid 100 MG/5ML                                                   Max Qty=240/claim
                (Generic: ROBITUSSIN)         Guaifenesin Syrup 100 MG/5ML                                                    Max Qty=240/claim
                                              Guaifenesin Granules Packet 50 MG                     MUCINEX CHLD              Daily Dosage=2
                                              Guaifenesin Granules Packet 100 MG                    MUCINEX JR                Daily Dosage=2
                (Generic: HUMIBID)            Guaifenesin Tab SR 12HR 600 MG                        MUCINEX                   Daily Dosage=2
                (Generic: DURATUSS G)         Guaifenesin Tab SR 12HR 1200 MG                                                 Daily Dosage=2
                                              Acetylcysteine Inhal Soln 10%
                                              Acetylcysteine Inhal Soln 20%
                                              Sodium Chloride Soln Nebu 0.45%                       SODIUM CHLOR
                                              Sodium Chloride Soln Nebu 0.9%
                                              Sodium Chloride Soln Nebu 3%
                                              Sodium Chloride Soln Nebu 10%
                                              Sodium Chloride Aero Soln 0.9%                                                  Max Qty=240/claim
                                                                                                                                                                 22
Therapeutic                                                                                          Covered Brand Product
  Class         Common Brand Name(s)    Product Description                                           (unless FFQL or PA)    Limitations/Restrictions
              (Generic: CEPACOL CHLD)   Pseudoephedrine w/ Acetaminophen Liquid 15-160 MG/5ML      TYLENOL CHLD              Max Qty=240/claim

              (Generic: ADVIL COLD/)    Pseudoephedrine-Ibuprofen Tab 30-200 MG
              (Generic: CHILD MOTRIN)   Pseudoephedrine-Ibuprofen Susp 15-100 MG/5ML                                         Max Qty=240/claim
                                        Phenylephrine-APAP-Caffeine Tab 5-500-75 MG            MEDI-GRAINE                   Daily Dosage=4
              (Generic: ALLERX-D)       Pseudoephedrine-Methscopolamine Tab SR 12HR 120-2.5 MG

                                        Brompheniramine & Phenylephrine Liqd 2-5 MG/ML             DECON-A                   Max Qty=240/claim
                                        Brompheniramine & Phenylephrine Elixir 2-5 MG/5ML          DECON-A                   Max Qty=240/claim
                                        Brompheniramine & Pseudoephedrine Cap CR 6-60 MG                                     Daily Dosage=2
              (Generic: BROMFED)        Brompheniramine & Pseudoephedrine Cap CR 12-120 MG                                   Daily Dosage=2

              (Generic: DIMETAPP)       Brompheniramine & Pseudoephedrine Elixir 1-15 MG/5ML                                 Max Qty=240/claim
                                        Brompheniramine & Pseudoephedrine Syrup 4-45 MG/5ML                                  Max Qty=240/claim

              (Generic: ZYRTEC-D ALG)   Cetirizine-Pseudoephedrine Tab SR 12HR 5-120 MG            ZYRTEC-D                  Daily Dosage=2
              (Generic: RONDEC)         Chlorpheniramine & Phenylephrine Liquid 1-3.5 MG/ML                                  Max Qty=30/claim
              (Generic: RONDEC)         Chlorpheniramine & Phenylephrine Syrup 4-12.5 MG/5ML                                 Max Qty=240/claim
              (Generic: DECONAMINE)     Chlorpheniramine & Pseudoephedrine Cap CR 8-120 MG                                   Daily Dosage=2
              (Generic: HISTEX)         Chlorpheniramine & Pseudoephedrine Liquid 2-30 MG/5ML                                Max Qty=240/claim

              (Generic: DECONAMINE)     Chlorpheniramine & Pseudoephedrine Syrup 2-30 MG/5ML                                 Max Qty=240/claim

                                        Chlorpheniramine & Pseudoephedrine Soln 2-30 MG/5ML                                  Max Qty=240/claim
              (Generic: RYNATAN PED)    Chlorpheniramine Tan-Phenylephrine Tan Susp 4.5-5 MG/5ML                             Max Qty=120/claim

                                        Diphenhydramine & Pseudoephedrine Cap CR 25-60 MG          BENAPHEN
              (Generic: BENADRYL DEC)   Diphenhydramine & Pseudoephedrine Tab 25-60 MG
                                        Diphenhydramine & Pseudoephedrine Liquid 12.5-30 MG/5ML  BENADRYL ALL, BENADRYL- Max Qty=240/claim
                                                                                                 D
              (Generic: CLARITIN-D)     Loratadine & Pseudoephedrine Tab SR 12HR 5-120 MG                                Daily Dosage=2
              (Generic: CLARITIN-D)     Loratadine & Pseudoephedrine Tab SR 24HR 10-240 MG                               Daily Dosage=1
                                        Promethazine & Phenylephrine Syrup 6.25-5 MG/5ML                                 Limited to Ages 2 and Older; Max
                                                                                                                         Qty=240/claim
                                        Chlorphen Tan-Pyrilamine Tan-PE Tan Susp 2-12.5-5 MG/5ML                         Max Qty=120/claim

                                        Chlorphen-PE-Methscopolamine Tab 4-10-1.25 MG              DALLERGY
              (Generic: EXTENDRYL)      Chlorpheniramine-PE-Methscopolamine Chew Tab 2-10-1.25                               Limited to Ages 6 and Under; Daily Dosage=2
                                        MG
              (Generic: DALLERGY)       Chlorpheniramine-PE-Methscopolamine Syrup 2-8-0.75
                                        MG/5ML
                                        Chlorphen-PE-Methscopolamine Syrup 2-10-0.625 MG/5ML                                 Max Qty=240/claim

                                        Chlorpheniramine-PE-Methscopolamine Syrup 2-10-1.25                                  Max Qty=240/claim
                                        MG/5ML
              (Generic: DURAHIST PE)    Chlorphen-PE-Methscopolamine Tab SR 12HR 8-20-1.25 MG                                Daily Dosage=2
                                                                                                                                                                   23
Therapeutic                                                                                          Covered Brand Product
  Class         Common Brand Name(s)   Product Description                                            (unless FFQL or PA)    Limitations/Restrictions
                                       Chlorphen-PE-Methscopolamine Tab SR 12HR 8-20-2.5 MG                                  Daily Dosage=2

              (Generic: ALKA-SELT+)    Chlorphen-Pseudoephedrine w/ APAP Cap 2-30-325 MG
              (Generic: SCOT-TUSSIN)   Phenir-PE w/ Sod Salicyl & Caff Cit Liq 13-4-83-25 MG/5ML                             Max Qty=240/claim

                                       Promethazine w/ Codeine Syrup 6.25-10 MG/5ML                                          Limited to Ages 2 and Older; Max
                                                                                                                             Qty=240/claim
                                       Phenylephrine-Promethazine w/ Codeine Syrup 5-6.25-10                                 Limited to Ages 2 and Older; Max
                                       MG/5ML                                                                                Qty=240/claim
                                       Phenyleph-Chlorphen w/ Hydrocodone Syrup 5-2-1.67 MG/5ML                              Max Qty=240/claim

                                       Phenyleph-Chlorphen w/ Hydrocodone Syrup 5-2-2.5 MG/5ML                               Max Qty=240/claim

                                       Phenyleph-Pyrilamine w/ Hydrocodone Syrup 5-5-5 MG/5ML                                Max Qty=240/claim

              (Generic: CODIMAL DH)    Phenyleph-Pyrilamine w/ Hydrocodone Syrup 5-8.33-1.66                                 Max Qty=240/claim
                                       MG/5ML
                                       PE-Pheniramine-COD-Sod Salicylate-Sod Cit-Caff Liquid       TUSSIREX-SF               Max Qty=240/claim
                                       Acetaminophen w/ DM Liq 160-5 MG/5ML                                                  Max Qty=240/claim
                                       Pseudoephedrine-DM Liqd 15-7.5 MG/5ML                                                 Max Qty=240/claim
              (Generic: VICKS 44D)     Pseudoephedrine-DM Elixir 20-10 MG/5ML                                                Max Qty=240/claim
              (Generic: PEDIACARE)     Pseudoephedrine-DM Soln 7.5-2.5 MG/0.8ML                                              Max Qty=30/claim
                                       Chlorpheniramine-DM Liquid 2-15 MG/5ML                                                Max Qty=240/claim
                                       Chlorpheniramine-DM Syrup 1-7.5 MG/5ML                      DIMETAPP                  Max Qty=240/claim
                                       Chlorpheniramine-DM Syrup 2-10 MG/5ML                       TRICODENE SF              Max Qty=240/claim
                                       Promethazine-DM Syrup 6.25-15 MG/5ML                                                  Limited to Ages 2 and Older; Max
                                                                                                                             Qty=240/claim
              (Generic: DONATUSSIN)    Phenylephrine-Chlorphen-DM Liquid 1.5-1-3 MG/ML                                       Max Qty=60/claim
              (Generic: NOREL DM)      Phenylephrine-Chlorphen-DM Liquid 10-4-15 MG/5ML                                      Max Qty=240/claim
              (Generic: RONDEC-DM)     Phenylephrine-Chlorphen-DM Liquid 3.5-1-3 MG/ML                                       Max Qty=30/claim
              (Generic: POLY-TUSSIN)   Phenylephrine-Chlorphen-DM Syrup 5-2-15 MG/5ML                                        Max Qty=240/claim
                                       Phenylephrine-Chlorphen-DM Syrup 6-2-15 MG/5ML                                        Max Qty=240/claim
                                       Phenylephrine-Chlorphen-DM Syrup 10-2-15 MG/5ML                                       Max Qty=240/claim
              (Generic: RONDEC-DM)     Phenylephrine-Chlorphen-DM Syrup 12.5-4-15 MG/5ML                                     Max Qty=240/claim
                                       Phenylephrine-Chlorphen-DM Susp 7.5-2-15 MG/5ML             RICOTUSS                  Max Qty=240/claim
              (Generic: PHENABID DM)   Phenylephrine-Chlorphen-DM Tab SR 12HR 20-8-30 MG                                     Daily Dosage=2; Daily Dosage=2
              (Generic: CODIMAL DM)    Phenylephrine-Pyrilamine-DM Syrup 5-8.33-10 MG/5ML                                    Max Qty=240/claim
              (Generic: PEDIACARE)     Pseudoephed-Chlorphen-DM Liq 15-1-5 MG/5ML                                            Max Qty=240/claim
              (Generic: PEDIACARE,     Pseudoephed-Chlorphen-DM Liq 15-1-7.5 MG/5ML                                          Max Qty=240/claim
              ROBITUSSIN, TRIAMINIC)
                                       Pseudoephed-Bromphen-DM Liquid 30-1-20 MG/5ML               DELTUSS DMX               Max Qty=240/claim
                                       Pseudoephed-Bromphen-DM Elixir 15-1-5 MG/5ML                                          Max Qty=240/claim
                                       Pseudoephed-Bromphen-DM Syrup 30-2-10 MG/5ML                                          Max Qty=240/claim
                                       Pseudoephed-Bromphen-DM Syrup 45-4-15 MG/5ML                                          Max Qty=240/claim
                                       Pseudoeph-Chlorphen-DM w/ APAP Syrup 60-4-30-500            MULTIDEXOL M              Max Qty=240/claim
                                       MG/20ML
                                                                                                                                                                24
Therapeutic                                                                                           Covered Brand Product
  Class         Common Brand Name(s)    Product Description                                            (unless FFQL or PA)    Limitations/Restrictions
                                        Pseudoeph-Doxylamine-DM w/ APAP Cap 30-6.25-10-250 MG

              (Generic: NYQUIL)         Pseudoeph-Doxylamine-DM w/ APAP Liq 60-7.5-30-                                        Max Qty=240/claim
                                        1000MG/30ML
                                        Pseudoeph-Doxylamine-DM w/APAP Liquid 60-12.5-30-                                     Max Qty=240/claim
                                        1000MG/30ML
                                        Phenylephrine-Guaifenesin Liqd 2.5-100 MG/5ML              MUCINEX COLD               Max Qty=240/claim
              (Generic: RESCON-GG)      Phenylephrine-Guaifenesin Liqd 5-100 MG/5ML                                           Max Qty=240/claim
              (Generic: NUMONYL NR)     Phenylephrine-Potassium Guaiacolsulfonate Liqd 5-75 MG/5ML KGS-PE                     Max Qty=240/claim

              (Generic: ROBITUSSIN)     Pseudoephedrine-Guaifenesin Syrup 30-100 MG/5ML                                       Max Qty=240/claim
                                        Pseudoephedrine-Guaifenesin Tab SR 12HR 60-600 MG           MUCINEX D                 Daily Dosage=2
                                        Pseudoephedrine-Guaifenesin Tab SR 12HR 120-600 MG          GUAIMAX-D                 Daily Dosage=2

                                        Pseudoephedrine-Guaifenesin Tab SR 12HR 120-1200 MG                                   Daily Dosage=2

                                        Phenylephrine-GG-Potassium Citrate Soln 5-110-80 MG/5ML     VITA-NUMONYL              Max Qty=240/claim

                                        Phenylephrine-Chlorphen-GG Soln 2-1-20 MG/ML                                          Max Qty=30/claim
                                        Phenylephrine-APAP-GG Tab SR 12HR 30-250-1100 MG            LUSONEX PLUS
              (Generic: DAY TIME)       Dextromethorphan-Phenylephrine-APAP Cap 10-5-325 MG

              (Generic: ALKA-SELTZER)   Pseudoephedrine w/ APAP-DM Caps 30-250-10 MG
                                        Pseudoephedrine w/ APAP-DM Cap 30-325-15 MG
                                        Pseudoephedrine w/ APAP-DM Liq 60-650-20 MG/30ML                                      Max Qty=240/claim
              (Generic: TUSSI-ORGANI)   Guaifenesin-Codeine Liquid 300-10 MG/5ML                                              Max Qty=240/claim
              (Generic: TUSSI-ORGANI)   Guaifenesin-Codeine Soln 100-10 MG/5ML                                                Max Qty=240/claim
                                        DM-Pot Guaiacolsulfonate Liqd 10-75 MG/5ML (2-15 MG/ML)     ALBATUSSIN, GUACOL DM     Max Qty=30/claim

              (Generic: PROLEX DM)      Dextromethorphan-Pot Guaiacolsulfonate Liqd 15-300 MG/5ML                             Max Qty=240/claim

                                        Dextromethorphan-Guaifenesin Cap 10-200 MG                  CORICIDIN                 Max Qty=20/claim
                                        Dextromethorphan-Guaifenesin Tab 15-200 MG
              (Generic: RECOFEN "D")    Dextromethorphan-Guaifenesin Liquid 5-100 MG/5ML                                      Max Qty=240/claim
              (Generic: CHERACOL,       Dextromethorphan-Guaifenesin Liquid 10-100 MG/5ML                                     Max Qty=240/claim
              CHERACOL-D)
              (Generic: ROBITUSSIN,     Dextromethorphan-Guaifenesin Liquid 10-200 MG/5ML                                     Max Qty=240/claim
              ROBITUSSN DM)
                                        Dextromethorphan-Guaifenesin Liquid 15-25 MG/5ML            TRISPEC DMX               Max Qty=240/claim
                                        Dextromethorphan-Guaifenesin Liquid 15-200 MG/5ML           SCOT-TUSSIN               Max Qty=240/claim
                                        Dextromethorphan-Guaifenesin Liquid 20-200 MG/5ML                                     Max Qty=240/claim
                                        Dextromethorphan-Guaifenesin Liquid 30-200 MG/5ML                                     Max Qty=240/claim
                                        Dextromethorphan-Guaifenesin Elixir 20-200 MG/5ML                                     Max Qty=240/claim
              (Generic: ROBITUSSN DM)   Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML                                      Max Qty=240/claim
              (Generic: SCOT-TUSSIN)    Dextromethorphan-Guaifenesin Syrup 15-100 MG/5ML                                      Max Qty=240/claim
                                        Dextromethorphan-Guaifenesin Soln 15-250 MG/5ML (3-50       VITA-NUMONYL              Max Qty=240/claim
                                        MG/M                                                                                                             25
  Therapeutic                                                                                        Covered Brand Product
    Class         Common Brand Name(s)    Product Description                                         (unless FFQL or PA)     Limitations/Restrictions
                                          Dextromethorphan-Guaifenesin Granules Packet 5-100 MG    MUCINEX CGH                Daily Dosage=2

                                          Dextromethorphan-Guaifenesin Tab SR 12HR 30-600 MG       MUCINEX DM                 Daily Dosage=2
                                          Dextromethorphan-Guaifenesin Tab SR 12HR 60-1200 MG                                 Daily Dosage=2

                (Generic: PNEUMOTUSSIN)   Hydrocodone-Guaifenesin Tab 2.5-300 MG
                                          Hydrocodone-Guaifenesin Liquid 5-100 MG/5ML              PHANATUSS HC               Max Qty=240/claim
                (Generic: HYCOTUSS EXP)   Hydrocodone-Guaifenesin Syrup 5-100 MG/5ML                                          Max Qty=240/claim
                                          Hydrocodone-Guaifenesin Tab SR 12HR 5-600 MG             XPECT-HC                   Daily Dosage=2
                (Generic: ATUSS G)        Phenylephrine w/ Hydrocodone-GG Syrup 10-2-100 MG/5ML                               Max Qty=240/claim

                                          Pseudoephedrine w/ COD-GG Soln 30-10-100 MG/5ML                                     Max Qty=240/claim
                                          Pseudoephedrine w/ Hydrocodone-GG Liqd 15-2.5-100      GENECOF-XP                   Max Qty=240/claim
                                          MG/5ML
                                          Pseudoephedrine w/ Hydrocodone-GG Liqd 15-3-100 MG/5ML                              Max Qty=240/claim

                                          Pseudoephedrine w/ Hydrocodone-GG Elixir 30-2.5-100                                 Max Qty=240/claim
                                          MG/5ML
                                          Phenyleph-Chlorphen w/ DM-GG Syrup 10-2-7.5-100 MG/5ML                              Max Qty=240/claim

                (Generic: DONATUSSIN)     Phenyleph-Chlorphen w/ DM-GG Syrup 10-2-15-100 MG/5ML                               Max Qty=240/claim

                                          Pseudoephedrine-DM-GG w/ APAP Liq 30-10-100-324                                     Max Qty=240/claim
                                          MG/15ML
                                          Dextromethorphan-APAP-Chlorpheniramine Cap 15-325-4 MG DIABETIC

                (Generic: CLEAR COUGH)    Dextromethorphan-Doxylamine-APAP Liquid 30-12.5-1000                                Max Qty=240/claim
                                          MG/30ML

ANTIASTHMATIC AND BRONCHODILATOR AGENTS
                                     Ipratropium Bromide Inhal Soln 0.02%                                                     Max Qty=375/25 days
                                     Ipratropium Bromide HFA Inhal Aerosol 17 MCG/ACT              ATROVENT HFA               Max Qty=26/30 days
                                     Tiotropium Bromide Monohydrate Inhal Cap 18 MCG (Base         SPIRIVA                    Daily Dosage=1
                                     Equiv)
              (Generic: INTAL)       Cromolyn Sodium Soln Nebu 20 MG/2ML                                                       Max Qty=240/30 days
                                     Cromolyn Sodium Inhal Aerosol Soln 800 MCG/ACT (1             INTAL 112, INTAL 200, INTAL
                                     MG/Valve)                                                     INH
                                     Nedocromil Sodium Inhal Aerosol 1.75 MG/ACT                   TILADE                      Max Qty=32/30 days
              (Generic: PROVENTIL)   Albuterol Inhal Aerosol 90 MCG/ACT                                                        Max Qty=34/30 days
                                     Albuterol Sulfate Tab 2 MG
                                     Albuterol Sulfate Tab 4 MG
              (Generic: VENTOLIN)    Albuterol Sulfate Syrup 2 MG/5ML
              (Generic: PROVENTIL)   Albuterol Sulfate Soln Nebu 0.083%                                                       Max Qty=375/25 days
                                     Albuterol Sulfate Soln Nebu 0.5% (5 MG/ML)                                               Daily Dosage=2
                                     Albuterol Sulfate Inhal Aero 120 MCG/ACT (100MCG Base         PROAIR HFA, VENTOLIN       PA, PROVENTIL
                                     Equiv)                                                        HFA
                                                                                                                                                         26
Therapeutic                                                                                             Covered Brand Product
  Class         Common Brand Name(s)    Product Description                                              (unless FFQL or PA)    Limitations/Restrictions
              (Generic: VOSPIRE ER)     Albuterol Sulfate Tab SR 12HR 4 MG
              (Generic: VOSPIRE ER)     Albuterol Sulfate Tab SR 12HR 8 MG
                                        Formoterol Fumarate Inhal Cap 12 MCG                          FORADIL                   Daily Dosage=2
                                        Levalbuterol Tartrate Inhal Aerosol 45 MCG/ACT (Base Equiv)   XOPENEX HFA

                                        Metaproterenol Sulfate Tab 10 MG                              METAPROTEREN
                                        Metaproterenol Sulfate Tab 20 MG                              METAPROTEREN
                                        Metaproterenol Sulfate Syrup 10 MG/5ML                                                  Daily Dosage=30
                                        Metaproterenol Sulfate Soln Nebu 0.4%                                                   Daily Dosage=8
                                        Metaproterenol Sulfate Soln Nebu 0.6%                                                   Daily Dosage=8
                                        Metaproterenol Sulfate Inhal Aerosol Pow 0.65 MG/ACT          ALUPENT INH               Max Qty=28/30 days
                                        Pirbuterol Acetate Breath Activated Inhal Aerosol 200MCG/I    MAXAIR AUTOH              Max Qty=14/30 days

                                        Salmeterol Xinafoate Aer Pow BA 50 MCG/DOSE (Base Equiv) SEREVENT DIS

              (Generic: BRETHINE)       Terbutaline Sulfate Tab 2.5 MG
              (Generic: BRETHINE)       Terbutaline Sulfate Tab 5 MG
              (Generic: DUONEB)         Albuterol-Ipratropium Nebu Soln 2.5(3)-0.5 MG/3ML
                                        Albuterol-Ipratropium Aerosol 120-20 MCG/ACT (18-             COMBIVENT                 Max Qty=30/30 days
                                        103MCG/ACT)
                                        Fluticasone-Salmeterol Inhal Aerosol 45-21 MCG/ACT            ADVAIR HFA                Max Qty=12/30 days
                                        Fluticasone-Salmeterol Inhal Aerosol 115-21 MCG/ACT           ADVAIR HFA                Max Qty=12/30 days
                                        Fluticasone-Salmeterol Inhal Aerosol 230-21 MCG/ACT           ADVAIR HFA                Max Qty=12/30 days
                                        Fluticasone-Salmeterol Powder Disks 100-50 MCG/DOSE           ADVAIR DISKU              Max Qty=60/30 days
                                        Fluticasone-Salmeterol Powder Disks 250-50 MCG/DOSE           ADVAIR DISKU              Max Qty=60/30 days
                                        Fluticasone-Salmeterol Powder Disks 500-50 MCG/DOSE           ADVAIR DISKU              Max Qty=60/30 days
                                        Aminophylline Tab 100 MG
                                        Aminophylline Tab 200 MG
                                        Dyphylline Tab 400 MG                                         LUFYLLIN
                                        Theophylline Elixir 80 MG/15ML                                ELIXOPHYLLIN
                                        Theophylline Cap SR 24HR 100 MG                               THEO-24
                                        Theophylline Cap SR 24HR 200 MG                               THEO-24
                                        Theophylline Cap SR 24HR 300 MG                               THEO-24
                                        Theophylline Cap SR 24HR 400 MG                               THEO-24
                                        Theophylline Tab SR 12HR 100 MG
              (Generic: THEO-DUR)       Theophylline Tab SR 12HR 200 MG
              (Generic: QUIBRON-T SR,   Theophylline Tab SR 12HR 300 MG
              THEO-DUR)
                                        Theophylline Tab SR 12HR 450 MG
              (Generic: UNIPHYL)        Theophylline Tab SR 24HR 400 MG
              (Generic: UNIPHYL)        Theophylline Tab SR 24HR 600 MG
                                        Beclomethasone Dipropionate Inhal Aero Soln 40 MCG/ACT        QVAR                      Max Qty=15/30 days

                                        Beclomethasone Dipropionate Inhal Aero Soln 80 MCG/ACT        QVAR                      Max Qty=15/30 days

                                        Budesonide Inhalation Susp 0.25 MG/2ML                        PULMICORT                 Limited to Ages 6 and Under; Max Qty=120/30
                                                                                                                                days                                  27
  Therapeutic                                                                                           Covered Brand Product
    Class         Common Brand Name(s)    Product Description                                            (unless FFQL or PA)    Limitations/Restrictions
                                          Budesonide Inhalation Susp 0.5 MG/2ML                       PULMICORT                 Limited to Ages 6 and Under; Max Qty=120/30
                                                                                                                                days
                                          Budesonide Inhalation Susp 1 MG/2ML                         PULMICORT                 Limited to Ages 6 and Under; Max Qty=120/30
                                                                                                                                days
                                          Budesonide Inhal Powder 90 MCG/ACT                          PULMICORT                 Max Qty=1/25 days
                                          Budesonide Inhal Powder 180 MCG/ACT                         PULMICORT                 Max Qty=1/25 days
                                          Fluticasone Propionate Aer Pow BA 50 MCG/BLISTER            FLOVENT DISK
                                          Fluticasone Propionate HFA Inhal Aerosol 44 MCG/ACT         FLOVENT HFA               Max Qty=11/25 days
                                          Fluticasone Propionate HFA Inhal Aerosol 110 MCG/ACT        FLOVENT HFA               Max Qty=12/25 days
                                          Fluticasone Propionate HFA Inhal Aerosol 220 MCG/ACT        FLOVENT HFA               Max Qty=12/25 days
                                          Triamcinolone Acetonide Inhal Aerosol 100MCG/ACT            AZMACORT                  Max Qty=20/30 days
                                          (200/Valve)
                                          Montelukast Sodium Tab 10 MG (Base Equiv)                   SINGULAIR                 Daily Dosage=1
                                          Montelukast Sodium Chew Tab 4 MG (Base Equiv)               SINGULAIR                 Retail only: Package Limit=1/month
                                          Montelukast Sodium Chew Tab 5 MG (Base Equiv)               SINGULAIR                 Retail only: Package Limit=1/month
                                          Montelukast Sodium Oral Granules Packet 4 MG (Base Equiv)   SINGULAIR                 Retail only: Package Limit=1/month

                                          Zafirlukast Tab 10 MG                                       ACCOLATE                  Retail only: Package Limit=2/month
                                          Zafirlukast Tab 20 MG                                       ACCOLATE                  Retail only: Package Limit=2/month
                                          Theophylline-Guaifenesin Cap 300-180 MG                     QUIBRON-300

LAXATIVES
                                          Magnesium Hydroxide Susp 400 MG/5ML                         CVS MILK OF               Max Qty=960/30 days
                                          Magnesium Citrate Soln
                (Generic: FLEET)          *Sodium Phosphates - Enema***
                (Generic: DULCOLAX)       Bisacodyl Tab Delayed Release 5 MG                                                    Daily Dosage=1
                (Generic: DULCOLAX)       Bisacodyl Suppos 10 MG                                                                Max Qty=12/claim
                                          Senna Tab 187 MG
                                          Senna Powder
                (Generic: SENOKOT)        Sennosides Tab 8.6 MG
                (Generic: METAMUCIL)      Psyllium Cap 0.52 GM
                                          Psyllium Powder 28%
                                          Psyllium Powder 28.3%
                                          Psyllium Powder 30.9%
                                          Psyllium Powder 33%
                (Generic: METAMUCIL)      Psyllium Powder 48.57%                                      WAL-MUCIL
                                          Psyllium Powder 50%
                                          Psyllium Powder 58.6%
                                          Psyllium Powder 68%
                (Generic: EVAC, KONSYL)   Psyllium Powder 100%
                (Generic: COLACE)         Docusate Sodium Cap 100 MG                                                            Daily Dosage=3
                                          Docusate Sodium Cap 250 MG                                                            Daily Dosage=3
                (Generic: COLACE)         Docusate Sodium Liquid 150 MG/15ML
                                          Glycerin Suppos 1.5 GM                                                                Max Qty=12/claim
                                          Glycerin Suppos 3 GM                                                                  Max Qty=24/claim
                                          Lactulose Solution 10 GM/15ML
                (Generic: MIRALAX)        Polyethylene Glycol 3350 Oral Powder                                                  Daily Dosage=17                      28
  Therapeutic                                                                                          Covered Brand Product
    Class         Common Brand Name(s)     Product Description                                          (unless FFQL or PA)    Limitations/Restrictions
                (Generic: MIRALAX)         Polyethylene Glycol 3350 Oral Packet                      MIRALAX
                                           Phenolphthalein-DSS Tab 65-100 MG
                (Generic: SENOKOT S)       Sennosides-Docusate Sodium Tab 8.6-50 MG
                (Generic: NULYTELY)        PEG 3350-KCl-Sod Bicarb-NaCl For Soln 420 GM                                        Package Limit=1/claim
                                           PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 236 GM    GOLYTELY                  Package Limit=1/claim

                (Generic: COLYTE,          PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 240 GM                              Package Limit=1/claim
                COLYTE/FLAVR)

ANTIDIARRHEALS
              (Generic: LOMOTIL)           Diphenoxylate w/ Atropine Tab 2.5-0.025 MG
              (Generic: LOMOTIL)           Diphenoxylate w/ Atropine Liq 2.5-0.025 MG/5ML
                                           Loperamide HCl Cap 2 MG
                                           Loperamide HCl Liq 1 MG/5ML
                (Generic: KAOPECTATE)      Attapulgite Liq 750 MG/15ML
                (Generic: PEPTO-BISMOL)    Bismuth Subsalicylate Chew Tab 262 MG
                (Generic: PEPTO-BISMOL)    Bismuth Subsalicylate Susp 527 MG/30ML

ANTACIDS
                                           Aluminum Hydroxide Gel Susp 320 MG/5ML
                                           Aluminum Hydroxide Gel Susp 600 MG/5ML                                              Daily Dosage=30
                                           Sodium Bicarbonate Tab 325 MG                                                       Daily Dosage=3
                                           Sodium Bicarbonate Tab 650 MG                                                       Daily Dosage=3
                (Generic: TUMS, TUMS       Calcium Carbonate (Antacid) Chew Tab 500 MG
                LASTING)
                (Generic: MAG-OX 400)      Magnesium Oxide Tab 400 MG
                (Generic: MAALOX SUS)      Aluminum & Magnesium Hydroxides Susp 225-200 MG/5ML                                 Max Qty=720/30 days

                (Generic: MYLANTA)         Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML                             Max Qty=720/30 days



ULCER DRUGS
                (Generic: ANASPAZ, LEVSIN) Hyoscyamine Sulfate Tab 0.125 MG

                (Generic: LEVSIN/SL)       Hyoscyamine Sulfate Tab SL 0.125 MG
                (Generic: LEVSIN)          Hyoscyamine Sulfate Elixir 0.125 MG/5ML
                (Generic: LEVSIN)          Hyoscyamine Sulfate Soln 0.125 MG/ML
                (Generic: LEVSINEX)        Hyoscyamine Sulfate Cap SR 12HR 0.375 MG
                (Generic: BENTYL)          Dicyclomine HCl Cap 10 MG
                (Generic: BENTYL)          Dicyclomine HCl Tab 20 MG
                (Generic: BENTYL)          Dicyclomine HCl Oral Soln 10 MG/5ML                                                 Daily Dosage=40
                (Generic: DONNATAL)        Belladonna Alkaloids-Phenobarbital Tab 16.2 MG
                (Generic: DONNATAL)        Belladonna Alkaloids-Phenobarbital Elixir 16 MG/5ML
                (Generic: TAGAMET,         Cimetidine Tab 200 MG
                TAGAMET HB)
                (Generic: TAGAMET)         Cimetidine Tab 300 MG
                (Generic: TAGAMET)         Cimetidine Tab 400 MG                                                                                          29
  Therapeutic                                                                                            Covered Brand Product
    Class          Common Brand Name(s)     Product Description                                           (unless FFQL or PA)    Limitations/Restrictions
                                            Cimetidine Tab 800 MG
                                            Cimetidine HCl Soln 300 MG/5ML                                                       Daily Dosage=27
                 (Generic: TALADINE,        Ranitidine HCl Cap 150 MG                                                            Daily Dosage=2
                 ZANTAC)
                 (Generic: ZANTAC 75)       Ranitidine HCl Tab 75 MG
                 (Generic: ZANTAC, ZANTAC   Ranitidine HCl Tab 150 MG
                 150)
                 (Generic: ZANTAC)          Ranitidine HCl Tab 300 MG
                 (Generic: ZANTAC)          Ranitidine HCl Syrup 75 MG/5ML                                                       Limited to Ages 6 and Under
                 (Generic: PEPCID AC)       Famotidine Tab 10 MG
                 (Generic: PEPCID)          Famotidine Tab 20 MG
                 (Generic: PEPCID)          Famotidine Tab 40 MG
                                            Famotidine For Susp 40 MG/5ML                                PEPCID                  Daily Dosage=5
                                            Nizatidine Tab 75 MG                                         AXID AR
                 (Generic: CYTOTEC)         Misoprostol Tab 100 MCG
                 (Generic: CYTOTEC)         Misoprostol Tab 200 MCG
                                            Lansoprazole Tab Delayed Release Orally Disintegrating 15 MG PREVACID                Limited to Ages 6 and Under; Daily Dosage=1

                                            Lansoprazole Tab Delayed Release Orally Disintegrating 30 MG PREVACID                Limited to Ages 6 and Under; Daily Dosage=1

                                            Omeprazole Magnesium Delayed Release Tab 20 MG (Base      PRILOSEC OTC               Retail only: Daily Dosage=4
                                            Equiv)
                 (Generic: CARAFATE)        Sucralfate Tab 1 GM                                                                  Daily Dosage=4

ANTIEMETICS
                 (Generic: ANTIVERT)        Meclizine HCl Tab 12.5 MG
                 (Generic: ANTIVERT)        Meclizine HCl Tab 25 MG
                 (Generic: ZOFRAN)          Ondansetron HCl Tab 4 MG                                                             Max Qty=10/30 days
                 (Generic: ZOFRAN)          Ondansetron HCl Tab 8 MG                                                             Max Qty=10/30 days
                                            Ondansetron HCl Tab 24 MG                                                            Max Qty=1/14 days
                 (Generic: ZOFRAN)          Ondansetron HCl Oral Soln 4 MG/5ML                                                   Max Qty=100/30 days
                 (Generic: ZOFRAN ODT)      Ondansetron Orally Disintegrating Tab 4 MG                                           Max Qty=10/30 days
                 (Generic: ZOFRAN ODT)      Ondansetron Orally Disintegrating Tab 8 MG                                           Max Qty=10/30 days

DIGESTIVE AIDS
                                            Amylase-Lipase-Protease Cap 30000-8000-30000 U            KU-ZYME-HP
                                            Amylase-Lipase-Protease Cap 15000-1200-15000 U            ENZYCAP, KU-ZYME,
                                                                                                      LAPASE
                                            Amylase-Lipase-Protease Cap 30000-2400-30000 U            DYGASE, KUTRASE
                                            Amylase-Lipase-Protease Tab 12500-1000-12500 U            ENZYMAX
                                            Amylase-Lipase-Protease Tab 30000-8000-30000 U            PANCRELIPASE,
                                                                                                      PANOKASE, PLARETASE,
                                                                                                      VIOKASE 8
                                            Amylase-Lipase-Protease Tab 60000-16000-60000 U           PANOKASE-16, VIOKASE 16

                                            Amylase-Lipase-Protease Powd 70000-16800-70000 U          VIOKASE
                                            Amy-Lip-Prot EC Particles Cap 12000-4000-12000 U          PANCREASE MT                                                     30
  Therapeutic                                                                                      Covered Brand Product
    Class         Common Brand Name(s)   Product Description                                        (unless FFQL or PA)    Limitations/Restrictions
                                         Amy-Lip-Prot EC Particles Cap 16600-5000-18750 U       CREON 5
                                         Amy-Lip-Prot EC Particles Cap 20000-4500-25000 U       LIPRAM 4500,
                                                                                                PANCRELIPASE,
                                                                                                PANGESTYM EC,
                                                                                                PANOCAPS, ULTRASE
                                         Amy-Lip-Prot EC Particles Cap 25000-4000-25000 U       PANCRECARB
                                         Amy-Lip-Prot EC Particles Cap 30000-10000-30000 U      LIPRAM-PN10, PANCREASE
                                                                                                MT, PANCRELIPASE

                                         Amy-Lip-Prot EC Particles Cap 33200-10000-37500 U      CREON 10, PALCAPS 10,
                                                                                                PANCRON 10, PANGES CN
                                                                                                10
                                         Amy-Lip-Prot EC Particles Cap 39000-12000-39000 U      LIPRAM-UL12, PANGES UL
                                                                                                12, ULTRASE MT12
                                         Amy-Lip-Prot EC Particles Cap 40000-8000-45000 U       PANCRECARB
                                         Amy-Lip-Prot EC Particles Cap 48000-16000-48000 U      LIPRAM-PN16, PANCREASE
                                                                                                MT, PANCRELIPASE,
                                                                                                PANGES MT 16, PANOCAPS

                                         Amy-Lip-Prot DR Particles Cap 52000-16000-52000 Unit   PANCRECARB
                                         Amy-Lip-Prot EC Particles Cap 56000-20000-44000 U      LIPRAM-PN20, PANCREASE
                                                                                                MT, PANCRELIPASE,
                                                                                                PANOCAPS

                                         Amy-Lip-Prot EC Particles Cap 58500-18000-58500 U      LIPRAM-UL18, PANGES UL
                                                                                                18, ULTRASE MT18
                                         Amy-Lip-Prot EC Particles Cap 66400-20000-75000 U      CREON 20, PALCAPS 20,
                                                                                                PANCRON 20, PANGES CN
                                                                                                20
                                         Amy-Lip-Prot EC Particles Cap 65000-20000-65000 U      LIPRAM-UL20, PANGES UL
                                                                                                20, ULTRACAPS, ULTRASE
                                                                                                MT20

GASTROINTESTINAL AGENTS - MISC.
              (Generic: ACTIGALL)        Ursodiol Cap 300 MG
              (Generic: GAS-X, MYLANTA   Simethicone Chew Tab 80 MG
              GAS)
                                         Simethicone Liquid 40 MG/0.6ML                                                    Max Qty=30/claim
                (Generic: MYLICON)       Simethicone Susp 40 MG/0.6ML                                                      Max Qty=30/claim
                (Generic: REGLAN)        Metoclopramide HCl Tab 5 MG
                (Generic: REGLAN)        Metoclopramide HCl Tab 10 MG
                                         Metoclopramide HCl Soln 5 MG/5ML
                                         Lactulose (Encephalopathy) Solution 10 GM/15ML
                                         Mesalamine Cap CR 250 MG                               PENTASA
                                         Mesalamine Cap CR 500 MG                               PENTASA
                                         Mesalamine Tab Delayed Release 400 MG                  ASACOL                     Daily Dosage=6
                (Generic: ROWASA)        Mesalamine Enema 4 GM                                                                                        31
  Therapeutic                                                                                        Covered Brand Product
    Class         Common Brand Name(s)    Product Description                                         (unless FFQL or PA)    Limitations/Restrictions
                (Generic: AZULFIDINE)     Sulfasalazine Tab 500 MG
                (Generic: AZULFIDINE)     Sulfasalazine Tab Delayed Release 500 MG
                                          Calcium Acetate (Phosphate Binder) Cap 667 MG            PHOSLO

URINARY ANTI-INFECTIVES
                                          Methenamine Mandelate Tab 0.5 GM                         MANDELAMINE
                                          Methenamine Mandelate Tab 1 GM                           MANDELAMINE
                (Generic: MACRODANTIN)    Nitrofurantoin Macrocrystalline Cap 50 MG
                (Generic: MACRODANTIN)    Nitrofurantoin Macrocrystalline Cap 100 MG
                (Generic: MACROBID)       Nitrofurantoin Monohydrate Macrocrystalline Cap 100 MG



URINARY ANTISPASMODICS
              (Generic: URECHOLINE)       Bethanechol Chloride Tab 5 MG                            URECHOLINE
              (Generic: URECHOLINE)       Bethanechol Chloride Tab 10 MG
              (Generic: URECHOLINE)       Bethanechol Chloride Tab 25 MG
              (Generic: URECHOLINE)       Bethanechol Chloride Tab 50 MG
              (Generic: URISPAS)          Flavoxate HCl Tab 100 MG
              (Generic: DITROPAN)         Oxybutynin Chloride Tab 5 MG                                                       Daily Dosage=3
              (Generic: DITROPAN)         Oxybutynin Chloride Syrup 5 MG/5ML
              (Generic: DITROPAN XL)      Oxybutynin Chloride Tab SR 24HR 5 MG                                               Daily Dosage=2
              (Generic: DITROPAN XL)      Oxybutynin Chloride Tab SR 24HR 10 MG                                              Daily Dosage=2
              (Generic: DITROPAN XL)      Oxybutynin Chloride Tab SR 24HR 15 MG                                              Daily Dosage=2
                                          Tolterodine Tartrate Tab 1 MG                            DETROL                    Daily Dosage=2
                                          Tolterodine Tartrate Tab 2 MG                            DETROL                    Daily Dosage=2
                                          Tolterodine Tartrate Cap SR 24HR 2 MG                    DETROL LA                 Daily Dosage=1
                                          Tolterodine Tartrate Cap SR 24HR 4 MG                    DETROL LA                 Daily Dosage=1

VAGINAL PRODUCTS
              (Generic: CLEOCIN VAG)      Clindamycin Phosphate Vaginal Cream 2%                                             Max Qty=40/claim
              (Generic: METROGEL-VAG)     Metronidazole Vaginal Gel 0.75%                                                    Max Qty=70/claim
                                          Butoconazole Nitrate (One Dose) Vaginal Cream 2%         GYNAZOLE-1
                (Generic: GYNE-LOTRIM,    Clotrimazole Vaginal Cream 1%                                                      Max Qty=45/claim
                MYCELEX-7)
                (Generic: GYNE-LOTRIMI)   Clotrimazole Vaginal Cream 2%                                                      Max Qty=30/claim
                (Generic: MONISTAT 7)     Miconazole Nitrate Vaginal Cream 2%                                                Max Qty=45/claim
                (Generic: MONISTAT 7)     Miconazole Nitrate Vaginal Suppos 100 MG                                           Max Qty=7/claim
                                          Miconazole Nitrate Vaginal Suppos 200 MG                 MICONAZOLE 3              Max Qty=3/claim
                (Generic: TERAZOL 7)      Terconazole Vaginal Cream 0.4%
                (Generic: TERAZOL 3)      Terconazole Vaginal Cream 0.8%
                                          Terconazole Vaginal Suppos 80 MG                         TERAZOL 3
                (Generic: MONISTAT 1,     Tioconazole Vaginal Oint 6.5%
                VAGISTAT-1)
                                          Estradiol Vaginal Cream 0.1 MG/GM                        ESTRACE VAG               Max Qty=43/claim
                                          Estrogens, Conjugated Vaginal Cream 0.625 MG/GM          PREMARIN VAG              Limited to Female; Max Qty=43/claim

GENITOURINARY AGENTS - MISCELLANEOUS                                                                                                                               32
  Therapeutic                                                                        Covered Brand Product
    Class         Common Brand Name(s)   Product Description                          (unless FFQL or PA)    Limitations/Restrictions
                (Generic: UROCIT-K 5)    Potassium Citrate Tab CR 540 MG (5 MEQ)
                (Generic: UROCIT-K 10)   Potassium Citrate Tab CR 1080 MG (10 MEQ)
                (Generic: PYRIDIUM)      Phenazopyridine HCl Tab 100 MG
                (Generic: PYRIDIUM)      Phenazopyridine HCl Tab 200 MG
                                         Sodium Chloride Irrigation Soln 0.9%
                (Generic: PROSCAR)       Finasteride Tab 5 MG                                                Daily Dosage=1

ANTIANXIETY AGENTS
              (Generic: XANAX)           Alprazolam Tab 0.25 MG                                              Daily Dosage=4
              (Generic: XANAX)           Alprazolam Tab 0.5 MG                                               Daily Dosage=4
              (Generic: XANAX)           Alprazolam Tab 1 MG                                                 Daily Dosage=4
              (Generic: XANAX)           Alprazolam Tab 2 MG                                                 Daily Dosage=4
              (Generic: LIBRIUM)         Chlordiazepoxide HCl Cap 5 MG                                       Daily Dosage=3
              (Generic: LIBRIUM)         Chlordiazepoxide HCl Cap 10 MG                                      Daily Dosage=3
              (Generic: LIBRIUM)         Chlordiazepoxide HCl Cap 25 MG                                      Daily Dosage=3
              (Generic: TRANXENE T)      Clorazepate Dipotassium Tab 3.75 MG                                 Daily Dosage=3
              (Generic: TRANXENE T)      Clorazepate Dipotassium Tab 7.5 MG                                  Daily Dosage=3
              (Generic: TRANXENE T)      Clorazepate Dipotassium Tab 15 MG                                   Daily Dosage=3
              (Generic: VALIUM)          Diazepam Tab 2 MG                                                   Daily Dosage=4
              (Generic: VALIUM)          Diazepam Tab 5 MG                                                   Daily Dosage=4
              (Generic: VALIUM)          Diazepam Tab 10 MG                                                  Daily Dosage=4
                                         Diazepam Soln 1 MG/ML                                               Max Qty=500/claim
                (Generic: ATIVAN)        Lorazepam Tab 0.5 MG                                                Daily Dosage=3
                (Generic: ATIVAN)        Lorazepam Tab 1 MG                                                  Daily Dosage=3
                (Generic: ATIVAN)        Lorazepam Tab 2 MG                                                  Daily Dosage=3
                (Generic: SERAX)         Oxazepam Cap 10 MG                                                  Daily Dosage=4
                (Generic: SERAX)         Oxazepam Cap 15 MG                                                  Daily Dosage=4
                (Generic: SERAX)         Oxazepam Cap 30 MG                                                  Daily Dosage=4
                (Generic: BUSPAR)        Buspirone HCl Tab 5 MG                                              Daily Dosage=3
                (Generic: VANSPAR)       Buspirone HCl Tab 7.5 MG                                            Daily Dosage=3
                (Generic: BUSPAR)        Buspirone HCl Tab 10 MG                                             Daily Dosage=3
                (Generic: BUSPAR)        Buspirone HCl Tab 15 MG                                             Daily Dosage=3
                (Generic: BUSPAR)        Buspirone HCl Tab 30 MG                                             Daily Dosage=3
                                         Hydroxyzine HCl Tab 10 MG
                                         Hydroxyzine HCl Tab 25 MG
                                         Hydroxyzine HCl Tab 50 MG
                                         Hydroxyzine HCl Syrup 10 MG/5ML
                (Generic: VISTARIL)      Hydroxyzine Pamoate Cap 25 MG
                (Generic: VISTARIL)      Hydroxyzine Pamoate Cap 50 MG
                                         Hydroxyzine Pamoate Cap 100 MG
                                         Meprobamate Tab 200 MG
                                         Meprobamate Tab 400 MG

ANTIDEPRESSANTS
                                         Mirtazapine Tab 7.5 MG                                              Daily Dosage=1
                (Generic: REMERON)       Mirtazapine Tab 15 MG                                               Daily Dosage=1
                (Generic: REMERON)       Mirtazapine Tab 30 MG                                               Daily Dosage=1             33
Therapeutic                                                                                 Covered Brand Product
  Class         Common Brand Name(s)    Product Description                                  (unless FFQL or PA)    Limitations/Restrictions
              (Generic: REMERON)        Mirtazapine Tab 45 MG                                                       Daily Dosage=1
              (Generic: REMERON SLTB)   Mirtazapine Orally Disintegrating Tab 15 MG                                 Daily Dosage=1
              (Generic: REMERON SLTB)   Mirtazapine Orally Disintegrating Tab 30 MG                                 Daily Dosage=1
              (Generic: REMERON SLTB)   Mirtazapine Orally Disintegrating Tab 45 MG                                 Daily Dosage=1
                                        Phenelzine Sulfate Tab 15 MG                      NARDIL
              (Generic: PARNATE)        Tranylcypromine Sulfate Tab 10 MG
                                        Nefazodone HCl Tab 50 MG
                                        Nefazodone HCl Tab 100 MG
                                        Nefazodone HCl Tab 150 MG
                                        Nefazodone HCl Tab 200 MG
                                        Nefazodone HCl Tab 250 MG
                                        Trazodone HCl Tab 50 MG
                                        Trazodone HCl Tab 100 MG
                                        Trazodone HCl Tab 150 MG
                                        Trazodone HCl Tab 300 MG                                                    Daily Dosage=2
              (Generic: CELEXA)         Citalopram Hydrobromide Tab 10 MG (Base Equiv)                              Daily Dosage=1
              (Generic: CELEXA)         Citalopram Hydrobromide Tab 20 MG (Base Equiv)                              Daily Dosage=1
              (Generic: CELEXA)         Citalopram Hydrobromide Tab 40 MG (Base Equiv)                              Daily Dosage=1
              (Generic: CELEXA)         Citalopram Hydrobromide Oral Soln 10 MG/5ML                                 Daily Dosage=20
              (Generic: PROZAC)         Fluoxetine HCl Cap 10 MG                                                    Daily Dosage=4
              (Generic: PROZAC)         Fluoxetine HCl Cap 20 MG                                                    Daily Dosage=4
              (Generic: PROZAC)         Fluoxetine HCl Cap 40 MG
              (Generic: PROZAC)         Fluoxetine HCl Tab 10 MG                                                    Daily Dosage=4
              (Generic: RAPIFLUX)       Fluoxetine HCl Tab 20 MG                                                    Daily Dosage=4
              (Generic: PROZAC)         Fluoxetine HCl Solution 20 MG/5ML                                           Daily Dosage=4
                                        Fluvoxamine Maleate Tab 25 MG                                               Daily Dosage=2
                                        Fluvoxamine Maleate Tab 50 MG                                               Daily Dosage=2
                                        Fluvoxamine Maleate Tab 100 MG                                              Daily Dosage=2
              (Generic: PAXIL)          Paroxetine HCl Tab 10 MG                                                    Daily Dosage=2
              (Generic: PAXIL)          Paroxetine HCl Tab 20 MG                                                    Daily Dosage=2
              (Generic: PAXIL)          Paroxetine HCl Tab 30 MG                                                    Daily Dosage=2
              (Generic: PAXIL)          Paroxetine HCl Tab 40 MG                                                    Daily Dosage=2
              (Generic: PAXIL)          Paroxetine HCl Oral Susp 10 MG/5ML (Base Equiv)                             Daily Dosage=40
              (Generic: ZOLOFT)         Sertraline HCl Tab 25 MG                                                    Daily Dosage=1.5
              (Generic: ZOLOFT)         Sertraline HCl Tab 50 MG                                                    Daily Dosage=1.5
              (Generic: ZOLOFT)         Sertraline HCl Tab 100 MG                                                   Daily Dosage=2
              (Generic: ZOLOFT)         Sertraline HCl Oral Conc 20 MG/ML                                           Daily Dosage=2
              (Generic: EFFEXOR)        Venlafaxine HCl Tab 25 MG
              (Generic: EFFEXOR)        Venlafaxine HCl Tab 37.5 MG
              (Generic: EFFEXOR)        Venlafaxine HCl Tab 50 MG
              (Generic: EFFEXOR)        Venlafaxine HCl Tab 75 MG
              (Generic: EFFEXOR)        Venlafaxine HCl Tab 100 MG
                                        Venlafaxine HCl Cap SR 24HR 37.5 MG               EFFEXOR XR                Daily Dosage=2
                                        Venlafaxine HCl Cap SR 24HR 75 MG                 EFFEXOR XR                Daily Dosage=2
                                        Venlafaxine HCl Cap SR 24HR 150 MG                EFFEXOR XR                Daily Dosage=2
                                        Amitriptyline HCl Tab 10 MG
                                        Amitriptyline HCl Tab 25 MG                                                                            34
Therapeutic                                                                 Covered Brand Product
  Class         Common Brand Name(s)   Product Description                   (unless FFQL or PA)    Limitations/Restrictions
                                       Amitriptyline HCl Tab 50 MG
                                       Amitriptyline HCl Tab 75 MG
                                       Amitriptyline HCl Tab 100 MG
                                       Amitriptyline HCl Tab 150 MG
                                       Amoxapine Tab 25 MG
                                       Amoxapine Tab 50 MG
                                       Amoxapine Tab 100 MG
                                       Amoxapine Tab 150 MG
              (Generic: ANAFRANIL)     Clomipramine HCl Cap 25 MG
              (Generic: ANAFRANIL)     Clomipramine HCl Cap 50 MG
              (Generic: ANAFRANIL)     Clomipramine HCl Cap 75 MG
              (Generic: NORPRAMIN)     Desipramine HCl Tab 10 MG
              (Generic: NORPRAMIN)     Desipramine HCl Tab 25 MG                                    Daily Dosage=2
              (Generic: NORPRAMIN)     Desipramine HCl Tab 50 MG
              (Generic: NORPRAMIN)     Desipramine HCl Tab 75 MG
              (Generic: NORPRAMIN)     Desipramine HCl Tab 100 MG
              (Generic: NORPRAMIN)     Desipramine HCl Tab 150 MG
                                       Doxepin HCl Cap 10 MG
                                       Doxepin HCl Cap 25 MG
                                       Doxepin HCl Cap 50 MG
                                       Doxepin HCl Cap 75 MG
                                       Doxepin HCl Cap 100 MG
                                       Doxepin HCl Cap 150 MG
                                       Doxepin HCl Conc 10 MG/ML
              (Generic: TOFRANIL)      Imipramine HCl Tab 10 MG
              (Generic: TOFRANIL)      Imipramine HCl Tab 25 MG
              (Generic: TOFRANIL)      Imipramine HCl Tab 50 MG
                                       Imipramine Pamoate Cap 75 MG       IMIPRAM PAM, TOFRANIL-    Daily Dosage=1
                                                                          PM
                                       Imipramine Pamoate Cap 100 MG      IMIPRAM PAM, TOFRANIL-    Daily Dosage=3
                                                                          PM
                                       Imipramine Pamoate Cap 125 MG      IMIPRAM PAM, TOFRANIL-    Daily Dosage=2
                                                                          PM
                                       Imipramine Pamoate Cap 150 MG      IMIPRAM PAM, TOFRANIL-    Daily Dosage=2
                                                                          PM
              (Generic: PAMELOR)       Nortriptyline HCl Cap 10 MG
              (Generic: PAMELOR)       Nortriptyline HCl Cap 25 MG
              (Generic: PAMELOR)       Nortriptyline HCl Cap 50 MG
              (Generic: PAMELOR)       Nortriptyline HCl Cap 75 MG
              (Generic: PAMELOR)       Nortriptyline HCl Soln 10 MG/5ML                             Daily Dosage=20
                                       Maprotiline HCl Tab 25 MG          MAPROTILINE
                                       Maprotiline HCl Tab 50 MG          MAPROTILINE
                                       Maprotiline HCl Tab 75 MG          MAPROTILINE
              (Generic: WELLBUTRIN)    Bupropion HCl Tab 75 MG                                      Daily Dosage=3
              (Generic: WELLBUTRIN)    Bupropion HCl Tab 100 MG                                     Daily Dosage=3
              (Generic: WELLBUTRIN)    Bupropion HCl Tab SR 12HR 100 MG                             Daily Dosage=2
              (Generic: WELLBUTRIN)    Bupropion HCl Tab SR 12HR 150 MG                             Daily Dosage=2             35
  Therapeutic                                                                         Covered Brand Product
    Class         Common Brand Name(s)    Product Description                          (unless FFQL or PA)    Limitations/Restrictions
                (Generic: WELLBUTRIN)     Bupropion HCl Tab SR 12HR 200 MG                                    Daily Dosage=2
                (Generic: WELLBUTRIN)     Bupropion HCl Tab SR 24HR 150 MG          BUDEPRION XL              Daily Dosage=1
                (Generic: WELLBUTRIN)     Bupropion HCl Tab SR 24HR 300 MG          BUDEPRION XL              Daily Dosage=1

ANTIPSYCHOTICS
              (Generic: RISPERDAL)        Risperidone Tab 0.25 MG                                             FFQL; Daily Dosage=2
              (Generic: RISPERDAL)        Risperidone Tab 0.5 MG                                              FFQL; Daily Dosage=2
              (Generic: RISPERDAL)        Risperidone Tab 1 MG                                                FFQL; Daily Dosage=2
              (Generic: RISPERDAL)        Risperidone Tab 2 MG                                                FFQL; Daily Dosage=2
              (Generic: RISPERDAL)        Risperidone Tab 3 MG                                                FFQL; Daily Dosage=2
              (Generic: RISPERDAL)        Risperidone Tab 4 MG                                                FFQL; Daily Dosage=2
                                          Risperidone Soln 1 MG/ML                  RISPERDAL                 FFQL; Daily Dosage=2
                                          Haloperidol Tab 0.5 MG                                              Daily Dosage=3
                                          Haloperidol Tab 1 MG                                                Daily Dosage=3
                                          Haloperidol Tab 2 MG
                                          Haloperidol Tab 5 MG
                                          Haloperidol Tab 10 MG                                               Daily Dosage=3
                                          Haloperidol Tab 20 MG
                                          Haloperidol Lactate Oral Conc 2 MG/ML
                (Generic: HALDOL DECAN)   Haloperidol Decanoate IM Soln 50 MG/ML
                (Generic: HALDOL DECAN)   Haloperidol Decanoate IM Soln 100 MG/ML
                (Generic: CLOZARIL)       Clozapine Tab 25 MG                                                 FFQL; Daily Dosage=3
                                          Clozapine Tab 50 MG                                                 FFQL; Daily Dosage=3
                (Generic: CLOZARIL)       Clozapine Tab 100 MG                                                FFQL; Daily Dosage=9
                                          Clozapine Tab 200 MG                                                FFQL; Daily Dosage=3
                                          Quetiapine Fumarate Tab 25 MG             SEROQUEL                  FFQL; Daily Dosage=2
                                          Quetiapine Fumarate Tab 50 MG             SEROQUEL                  FFQL; Daily Dosage=2
                                          Quetiapine Fumarate Tab 100 MG            SEROQUEL                  FFQL; Daily Dosage=2
                                          Quetiapine Fumarate Tab 200 MG            SEROQUEL                  FFQL; Daily Dosage=2
                                          Quetiapine Fumarate Tab 300 MG            SEROQUEL                  FFQL; Daily Dosage=2
                                          Quetiapine Fumarate Tab 400 MG            SEROQUEL                  FFQL; Daily Dosage=2
                                          Quetiapine Fumarate Tab SR 24HR 200 MG    SEROQUEL XR               FFQL; Daily Dosage=1
                                          Quetiapine Fumarate Tab SR 24HR 300 MG    SEROQUEL XR               FFQL; Daily Dosage=2
                                          Quetiapine Fumarate Tab SR 24HR 400 MG    SEROQUEL XR               FFQL; Daily Dosage=2
                (Generic: LOXITANE)       Loxapine Succinate Cap 5 MG                                         FFQL; Daily Dosage=4
                (Generic: LOXITANE)       Loxapine Succinate Cap 10 MG                                        FFQL; Daily Dosage=4
                (Generic: LOXITANE)       Loxapine Succinate Cap 25 MG                                        FFQL; Daily Dosage=4
                (Generic: LOXITANE)       Loxapine Succinate Cap 50 MG                                        FFQL; Daily Dosage=4
                                          Olanzapine Tab 2.5 MG                     ZYPREXA                   FFQL; Daily Dosage=1
                                          Olanzapine Tab 5 MG                       ZYPREXA                   FFQL; Daily Dosage=1
                                          Olanzapine Tab 7.5 MG                     ZYPREXA                   FFQL; Daily Dosage=1
                                          Olanzapine Tab 10 MG                      ZYPREXA                   FFQL; Daily Dosage=1
                                          Olanzapine Tab 15 MG                      ZYPREXA                   FFQL; Daily Dosage=1
                                          Olanzapine Tab 20 MG                      ZYPREXA                   FFQL; Daily Dosage=2
                                          Molindone HCl Tab 5 MG                    MOBAN                     FFQL; Daily Dosage=4
                                          Molindone HCl Tab 10 MG                   MOBAN                     FFQL; Daily Dosage=4
                                          Molindone HCl Tab 25 MG                   MOBAN                     FFQL; Daily Dosage=4       36
Therapeutic                                                                                     Covered Brand Product
  Class         Common Brand Name(s)   Product Description                                       (unless FFQL or PA)    Limitations/Restrictions
                                       Molindone HCl Tab 50 MG                                MOBAN                     FFQL; Daily Dosage=4
                                       Chlorpromazine HCl Tab 10 MG                                                     Daily Dosage=3
                                       Chlorpromazine HCl Tab 25 MG                                                     Daily Dosage=3
                                       Chlorpromazine HCl Tab 50 MG                                                     Daily Dosage=3
                                       Chlorpromazine HCl Tab 100 MG                                                    Daily Dosage=3
                                       Chlorpromazine HCl Tab 200 MG                                                    Daily Dosage=3
                                       Fluphenazine HCl Tab 1 MG
                                       Fluphenazine HCl Tab 2.5 MG
                                       Fluphenazine HCl Tab 5 MG
                                       Fluphenazine HCl Tab 10 MG
                                       Fluphenazine Decanoate Inj 25 MG/ML
                                       Perphenazine Tab 2 MG                                                            Daily Dosage=4
                                       Perphenazine Tab 4 MG                                                            Daily Dosage=4
                                       Perphenazine Tab 8 MG                                                            Daily Dosage=4
                                       Perphenazine Tab 16 MG                                                           Daily Dosage=4
              (Generic: COMPAZINE)     Prochlorperazine Suppos 25 MG
                                       Prochlorperazine Maleate Tab 5 MG
                                       Prochlorperazine Maleate Tab 10 MG
                                       Thioridazine HCl Tab 10 MG                                                       Daily Dosage=3
                                       Thioridazine HCl Tab 25 MG                                                       Daily Dosage=3
                                       Thioridazine HCl Tab 50 MG                                                       Daily Dosage=3
                                       Thioridazine HCl Tab 100 MG                                                      Daily Dosage=3
                                       Trifluoperazine HCl Tab 1 MG                                                     Daily Dosage=3
                                       Trifluoperazine HCl Tab 2 MG                                                     Daily Dosage=3
                                       Trifluoperazine HCl Tab 5 MG                                                     Daily Dosage=3
                                       Trifluoperazine HCl Tab 10 MG                                                    Daily Dosage=3
                                       Aripiprazole Tab 2 MG                                  ABILIFY                   FFQL; Daily Dosage=1
                                       Aripiprazole Tab 5 MG                                  ABILIFY                   FFQL; Daily Dosage=1
                                       Aripiprazole Tab 10 MG                                 ABILIFY                   FFQL; Daily Dosage=1
                                       Aripiprazole Tab 15 MG                                 ABILIFY                   FFQL; Daily Dosage=1
                                       Aripiprazole Tab 20 MG                                 ABILIFY                   FFQL; Daily Dosage=1
                                       Aripiprazole Tab 30 MG                                 ABILIFY                   FFQL; Daily Dosage=1
                                       Aripiprazole Oral Solution 1 MG/ML                     ABILIFY                   FFQL; Daily Dosage=5
                                       Thiothixene Cap 1 MG                                                             Daily Dosage=3
              (Generic: NAVANE)        Thiothixene Cap 2 MG                                                             Daily Dosage=3
              (Generic: NAVANE)        Thiothixene Cap 5 MG                                                             Daily Dosage=3
              (Generic: NAVANE)        Thiothixene Cap 10 MG                                                            Daily Dosage=3
                                       Ziprasidone HCl Cap 20 MG                              GEODON                    FFQL; Daily Dosage=2
                                       Ziprasidone HCl Cap 40 MG                              GEODON                    FFQL; Daily Dosage=2
                                       Ziprasidone HCl Cap 60 MG                              GEODON                    FFQL; Daily Dosage=2
                                       Ziprasidone HCl Cap 80 MG                              GEODON                    FFQL; Daily Dosage=2
                                       Ziprasidone Mesylate For Inj 20 MG (Base Equivalent)   GEODON                    PA
                                       Lithium Carbonate Cap 150 MG
                                       Lithium Carbonate Cap 300 MG
                                       Lithium Carbonate Cap 600 MG
                                       Lithium Carbonate Tab 300 MG                           LITHIUM CARB
              (Generic: LITHOBID)      Lithium Carbonate Tab CR 300 MG                                                                             37
  Therapeutic                                                                            Covered Brand Product
    Class         Common Brand Name(s)    Product Description                             (unless FFQL or PA)    Limitations/Restrictions
                                          Lithium Carbonate Tab CR 450 MG
                                          Lithium Citrate Oral Soln 8 mEq/5ML

HYPNOTICS
                                          Phenobarbital Tab 15 MG
                                          Phenobarbital Tab 16.2 MG
                                          Phenobarbital Tab 30 MG
                                          Phenobarbital Tab 32.4 MG
                                          Phenobarbital Tab 60 MG
                                          Phenobarbital Tab 64.8 MG                     PHENOBARB
                                          Phenobarbital Tab 97.2 MG
                                          Phenobarbital Tab 100 MG
                                          Phenobarbital Elixir 20 MG/5ML
                                          Chloral Hydrate Cap 500 MG                    SOMNOTE
                                          Chloral Hydrate Syrup 500 MG/5ML                                       Max Qty=240/claim
                                          Chloral Hydrate Suppos 500 MG                                          Daily Dosage=2
                (Generic: DALMANE)        Flurazepam HCl Cap 15 MG                                               Daily Dosage=1
                (Generic: DALMANE)        Flurazepam HCl Cap 30 MG                                               Daily Dosage=1
                (Generic: RESTORIL)       Temazepam Cap 15 MG                                                    Daily Dosage=1
                (Generic: RESTORIL)       Temazepam Cap 30 MG                                                    Daily Dosage=1
                (Generic: HALCION)        Triazolam Tab 0.125 MG
                (Generic: HALCION)        Triazolam Tab 0.25 MG
                (Generic: AMBIEN)         Zolpidem Tartrate Tab 5 MG                                             Daily Dosage=1
                (Generic: AMBIEN)         Zolpidem Tartrate Tab 10 MG                                            Daily Dosage=1
                (Generic: NYTOL MX-STR)   Diphenhydramine HCl (Sleep) Tab 50 MG

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
                                      Dextroamphetamine Sulfate Tab 5 MG                                         Limited to Ages 3 and Older; Daily Dosage=3

                (Generic: DEXTROSTAT)     Dextroamphetamine Sulfate Tab 10 MG                                    Limited to Ages 3 and Older; Daily Dosage=3

                (Generic: DEXEDRINE)      Dextroamphetamine Sulfate Cap SR 24HR 5 MG                             Limited to Ages 6 and Older; Daily Dosage=1

                (Generic: DEXEDRINE)      Dextroamphetamine Sulfate Cap SR 24HR 10 MG                            Limited to Ages 6 and Older; Daily Dosage=1

                (Generic: DEXEDRINE)      Dextroamphetamine Sulfate Cap SR 24HR 15 MG                            Limited to Ages 6 and Older; Daily Dosage=1

                (Generic: ADDERALL)       Amphetamine-Dextroamphetamine Tab 5 MG                                 Limited to Ages 3 and Older; Daily Dosage=2

                (Generic: ADDERALL)       Amphetamine-Dextroamphetamine Tab 7.5 MG                               Limited to Ages 3 and Older; Daily Dosage=2

                (Generic: ADDERALL)       Amphetamine-Dextroamphetamine Tab 10 MG                                Limited to Ages 3 and Older; Daily Dosage=2

                (Generic: ADDERALL)       Amphetamine-Dextroamphetamine Tab 12.5 MG                              PA, Limited to Ages 3 and Older; Daily
                                                                                                                 Dosage=2
                (Generic: ADDERALL)       Amphetamine-Dextroamphetamine Tab 15 MG                                PA, Limited to Ages 3 and Older; Daily
                                                                                                                 Dosage=2                                 38
Therapeutic                                                                                Covered Brand Product
  Class         Common Brand Name(s)   Product Description                                  (unless FFQL or PA)    Limitations/Restrictions
              (Generic: ADDERALL)      Amphetamine-Dextroamphetamine Tab 20 MG                                     PA, Limited to Ages 3 and Older; Daily
                                                                                                                   Dosage=2
              (Generic: ADDERALL)      Amphetamine-Dextroamphetamine Tab 30 MG                                     PA, Limited to Ages 3 and Older; Daily
                                                                                                                   Dosage=2
                                       Amphetamine-Dextroamphetamine Cap SR 24HR 5 MG    ADDERALL XR               PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=1
                                       Amphetamine-Dextroamphetamine Cap SR 24HR 10 MG   ADDERALL XR               PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=1
                                       Amphetamine-Dextroamphetamine Cap SR 24HR 15 MG   ADDERALL XR               PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=1
                                       Amphetamine-Dextroamphetamine Cap SR 24HR 20 MG   ADDERALL XR               PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=1
                                       Amphetamine-Dextroamphetamine Cap SR 24HR 25 MG   ADDERALL XR               PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=1
                                       Amphetamine-Dextroamphetamine Cap SR 24HR 30 MG   ADDERALL XR               PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=1
                                       Methylphenidate HCl Cap CR 10 MG                  METADATE CD               PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=1
                                       Methylphenidate HCl Cap CR 20 MG                  METADATE CD               PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=1
                                       Methylphenidate HCl Cap CR 30 MG                  METADATE CD               PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=1
                                       Methylphenidate HCl Cap CR 40 MG                  METADATE CD               PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=1
                                       Methylphenidate HCl Cap CR 50 MG                  METADATE CD               PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=1
                                       Methylphenidate HCl Cap CR 60 MG                  METADATE CD               PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=1
              (Generic: RITALIN)       Methylphenidate HCl Tab 5 MG                                                PA, Limited to Ages 3 and Older; Daily
                                                                                                                   Dosage=3
              (Generic: RITALIN)       Methylphenidate HCl Tab 10 MG                                               PA, Limited to Ages 3 and Older; Daily
                                                                                                                   Dosage=3
              (Generic: RITALIN)       Methylphenidate HCl Tab 20 MG                                               PA, Limited to Ages 3 and Older; Daily
                                                                                                                   Dosage=3
              (Generic: METADATE)      Methylphenidate HCl Tab CR 10 MG                                            PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=2
              (Generic: RITALIN SR)    Methylphenidate HCl Tab CR 20 MG                                            PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=2
                                       Methylphenidate HCl Tab SA OSM 18 MG              CONCERTA                  PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=2
                                       Methylphenidate HCl Tab SA OSM 27 MG              CONCERTA                  PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=2
                                       Methylphenidate HCl Tab SA OSM 36 MG              CONCERTA                  PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=2
                                       Methylphenidate HCl Tab SA OSM 54 MG              CONCERTA                  PA, Limited to Ages 6 and Older; Daily
                                                                                                                   Dosage=1
                                                                                                                                                            39
  Therapeutic                                                                                        Covered Brand Product
    Class         Common Brand Name(s)      Product Description                                       (unless FFQL or PA)    Limitations/Restrictions

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
                                    Donepezil Hydrochloride Tab 5 MG                               ARICEPT                   Daily Dosage=1
                                    Donepezil Hydrochloride Tab 10 MG                              ARICEPT                   Daily Dosage=1
            (Generic: ZYBAN)        Bupropion HCl (Smoking Deterrent) Tab SR 150 MG                                          Daily Dosage=2; 12 weeks/180 days
            (Generic: NICODERM CQ)  Nicotine TD Patch 24HR 7 MG/24HR                                                         Daily Dosage=1; 12 weeks/180 days
            (Generic: NICODERM CQ)  Nicotine TD Patch 24HR 14 MG/24HR                                                        Daily Dosage=1; 12 weeks/180 days
            (Generic: NICODERM CQ)  Nicotine TD Patch 24HR 21 MG/24HR                                                        Daily Dosage=1; 12 weeks/180 days
            (Generic: NICORETTE,    Nicotine Polacrilex Gum 2 MG                                                             Package Limit=1/claim; 12 weeks/180 days
            NICORETTE ST)
            (Generic: NICORETTE,    Nicotine Polacrilex Gum 4 MG                                                             Package Limit=1/claim; 12 weeks/180 days
            NICORETTE ST)
                                            Varenicline Tartrate 0.5mg                             CHANTIX                   PA; Daily Dosage=2; 12 weeks/180 days
                                            Varenicline Tartrate 1mg                               CHANTIX                   PA; Daily Dosage=2; 12 weeks/180 days
                (Generic: PROZAC)           Fluoxetine HCl (PMDD) Cap 10 MG                        SARAFEM, SELFEMRA         Daily Dosage=1
                                            Disulfiram Tab 250 MG                                  ANTABUSE
                                            Perphenazine-Amitriptyline Tab 2-10 MG                 DUO-VIL                   Daily Dosage=4
                                            Perphenazine-Amitriptyline Tab 2-25 MG                 DUO-VIL, PERPHEN/AMIT     Daily Dosage=4
                                            Perphenazine-Amitriptyline Tab 4-10 MG                                           Daily Dosage=4
                                            Perphenazine-Amitriptyline Tab 4-25 MG                 PERPHEN/AMIT              Daily Dosage=4
                                            Perphenazine-Amitriptyline Tab 4-50 MG                 PERPHEN/AMIT              Daily Dosage=4
                                            Olanzapine-Fluoxetine HCl Cap 3-25 MG                  SYMBYAX
                                            Olanzapine-Fluoxetine HCl Cap 6-25 MG                  SYMBYAX
                                            Olanzapine-Fluoxetine HCl Cap 6-50 MG                  SYMBYAX
                                            Olanzapine-Fluoxetine HCl Cap 12-25 MG                 SYMBYAX
                                            Olanzapine-Fluoxetine HCl Cap 12-50 MG                 SYMBYAX

ANALGESICS - NonNarcotic
                                          Aspirin Tab 81 MG
                                          Aspirin Tab 325 MG
                (Generic: ST JOSEPH)      Aspirin Chew Tab 75 MG
                (Generic: BAYER CHILD)    Aspirin Chew Tab 81 MG
                (Generic: BUFFERIN)       Aspirin Tab Delayed Release 81 MG
                (Generic: ECOTRIN, THERAP Aspirin Tab Delayed Release 325 MG
                BAYER)
                (Generic: ECOTRIN M/S)    Aspirin Tab Delayed Release 500 MG
                                          Aspirin Suppos 60 MG
                                          Aspirin Suppos 120 MG
                                          Aspirin Suppos 200 MG
                                          Aspirin Suppos 325 MG
                                          Aspirin Suppos 600 MG
                                          Diflunisal Tab 500 MG                                    DIFLUNISAL
                                          Salsalate Tab 500 MG
                                          Salsalate Tab 750 MG
                (Generic: BUFFERIN)       Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 MG
                                          Aspirin Buffered (Mg Carbonate-Al Aminoace) Tab 325 MG
                                                                                                                                                                     40
  Therapeutic                                                                                       Covered Brand Product
    Class         Common Brand Name(s)       Product Description                                     (unless FFQL or PA)    Limitations/Restrictions
                                             Aspirin Buffered Tab 325 MG
                                             Acetaminophen Cap 500 MG
                                             Acetaminophen Tab 160 MG
                (Generic: TYLENOL)           Acetaminophen Tab 325 MG
                (Generic: TYLENOL)           Acetaminophen Tab 500 MG
                (Generic: TYLENOL 8 HR,      Acetaminophen Tab CR 650 MG                          CVS ACETAMIN
                TYLENOL ARTH)
                                             Acetaminophen Chew Tab 80 MG
                                             Acetaminophen Chew Tab 160 MG
                                             Acetaminophen Liquid 160 MG/5ML
                                             Acetaminophen Elixir 160 MG/5ML
                (Generic: TYLENOL INF)       Acetaminophen Susp 80 MG/0.8ML
                (Generic: TYLENOL CHLD)      Acetaminophen Susp 160 MG/5ML
                                             Acetaminophen Soln 100 MG/ML
                                             Acetaminophen Soln 160 MG/5ML
                                             Acetaminophen Suppos 120 MG
                                             Acetaminophen Suppos 325 MG
                                             Acetaminophen Suppos 650 MG
                (Generic: PHRENILIN)         Butalbital-Acetaminophen Tab 50-325 MG
                (Generic: SEDAPAP)           Butalbital-Acetaminophen Tab 50-650 MG               TENCON                    Daily Dosage=4
                (Generic: ESGIC)             Butalbital-Acetaminophen-Caffeine Cap 50-325-40 MG                             Daily Dosage=4
                (Generic: ESGIC, FIORICET)   Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG                             Daily Dosage=4
                (Generic: ESGIC-PLUS)        Butalbital-Acetaminophen-Caffeine Tab 50-500-40 MG                             Daily Dosage=4
                (Generic: FIORINAL)          Butalbital-Aspirin-Caffeine Cap 50-325-40 MG                                   Daily Dosage=4
                                             Butalbital-Aspirin-Caffeine Tab 50-325-40 MG                                   Daily Dosage=4

ANALGESICS - OPIOID
                                             Codeine Sulfate Tab 15 MG
                                             Codeine Sulfate Tab 30 MG
                                             Codeine Sulfate Tab 60 MG
                (Generic: DILAUDID)          Hydromorphone HCl Tab 2 MG                                                     Daily Dosage=8
                (Generic: DILAUDID)          Hydromorphone HCl Tab 4 MG                                                     Daily Dosage=8
                (Generic: DILAUDID)          Hydromorphone HCl Tab 8 MG                                                     Daily Dosage=4
                (Generic: DILAUDID)          Hydromorphone HCl Suppos 3 MG                                                  Max Qty=12/claim
                (Generic: DEMEROL)           Meperidine HCl Tab 50 MG                                                       Daily Dosage=4
                (Generic: DEMEROL)           Meperidine HCl Tab 100 MG                                                      Daily Dosage=4
                (Generic: DEMEROL)           Meperidine HCl Oral Soln 50 MG/5ML                                             Max Qty=500/claim
                (Generic: DOLOPHINE)         Methadone HCl Tab 5 MG                                                         Daily Dosage=4
                (Generic: DOLOPHINE)         Methadone HCl Tab 10 MG                                                        Daily Dosage=8
                                             Morphine Sulfate Tab 15 MG                                                     Daily Dosage=6
                                             Morphine Sulfate Tab 30 MG                                                     Daily Dosage=6
                                             Morphine Sulfate Oral Soln 10 MG/5ML                 MORPHINE SUL              Max Qty=500/30 days
                                             Morphine Sulfate Oral Soln 20 MG/5ML                                           Max Qty=500/30 days
                (Generic: ROXANOL)           Morphine Sulfate Oral Soln 20 MG/ML                                            Max Qty=240/claim
                (Generic: RMS)               Morphine Sulfate Suppos 5 MG                                                   Max Qty=24/claim
                (Generic: RMS)               Morphine Sulfate Suppos 10 MG                                                  Max Qty=24/claim
                (Generic: RMS)               Morphine Sulfate Suppos 20 MG                                                  Max Qty=24/claim           41
Therapeutic                                                                                            Covered Brand Product
  Class         Common Brand Name(s)      Product Description                                           (unless FFQL or PA)    Limitations/Restrictions
              (Generic: RMS)              Morphine Sulfate Suppos 30 MG                                                        Max Qty=24/claim
              (Generic: MS CONTIN,        Morphine Sulfate Tab SR 12HR 15 MG                         ORAMORPH SR               Retail only: Daily Dosage=3
              ORAMORPH SR)
              (Generic: MS CONTIN,        Morphine Sulfate Tab SR 12HR 30 MG                         ORAMORPH SR               Retail only: Daily Dosage=3
              ORAMORPH SR)
              (Generic: MS CONTIN)        Morphine Sulfate Tab SR 12HR 60 MG                         ORAMORPH SR               Retail only: Daily Dosage=3
              (Generic: MS CONTIN,        Morphine Sulfate Tab SR 12HR 100 MG                        ORAMORPH SR               Retail only: Daily Dosage=3
              ORAMORPH SR)
              (Generic: MS CONTIN)        Morphine Sulfate Tab SR 12HR 200 MG                                                  Retail only: Daily Dosage=3
              (Generic: OXYIR)            Oxycodone HCl Cap 5 MG                                                               Daily Dosage=6
              (Generic: ROXICODONE)       Oxycodone HCl Tab 5 MG                                                               Daily Dosage=6
              (Generic: ROXICODONE)       Oxycodone HCl Tab 15 MG                                                              Daily Dosage=6
              (Generic: ROXICODONE)       Oxycodone HCl Tab 30 MG                                                              Daily Dosage=6
              (Generic: ROXICODONE)       Oxycodone HCl Conc 20 MG/ML                                                          Daily Dosage=6
              (Generic: DARVON)           Propoxyphene HCl Cap 65 MG                                                           Daily Dosage=4
              (Generic: ULTRAM)           Tramadol HCl Tab 50 MG                                                               Daily Dosage=8
              (Generic: TYLOX)            Oxycodone w/ Acetaminophen Cap 5-500 MG                                              Daily Dosage=6
              (Generic: PERCOCET)         Oxycodone w/ Acetaminophen Tab 5-325 MG                                              Daily Dosage=6
                                          Oxycodone w/ Acetaminophen Tab 5-500 MG                    ROXICET                   Daily Dosage=6
              (Generic: PERCOCET)         Oxycodone w/ Acetaminophen Tab 7.5-325 MG                                            Daily Dosage=6
              (Generic: PERCOCET)         Oxycodone w/ Acetaminophen Tab 7.5-500 MG                                            Daily Dosage=6
              (Generic: PERCOCET)         Oxycodone w/ Acetaminophen Tab 10-325 MG                                             Daily Dosage=6
              (Generic: PERCOCET)         Oxycodone w/ Acetaminophen Tab 10-650 MG                                             Daily Dosage=6
                                          Oxycodone w/ Acetaminophen Soln 5-325 MG/5ML               ROXICET                   Daily Dosage=30
              (Generic: PERCODAN)         Oxycodone w/ Aspirin Tab Full Strength                                               Daily Dosage=6
                                          Acetaminophen w/ Codeine Tab 300-15 MG                                               Daily Dosage=6
              (Generic: TYLENOL/COD)      Acetaminophen w/ Codeine Tab 300-30 MG                                               Daily Dosage=6
              (Generic: TYLENOL/COD)      Acetaminophen w/ Codeine Tab 300-60 MG                                               Daily Dosage=6
                                          Acetaminophen w/ Codeine Soln 120-12 MG/5ML                                          Daily Dosage=30
                                          Aspirin w/ Codeine Tab 325-30 MG                                                     Daily Dosage=6
                                          Aspirin w/ Codeine Tab 325-60 MG                                                     Daily Dosage=6
              (Generic: FIORICET/COD)     Butalbital-Acetaminophen-Caff w/ COD Cap 50-325-40-30 MG                             Daily Dosage=4

              (Generic: FIORINAL/COD)     Butalbital-Aspirin-Caff w/ Codeine Cap 50-325-40-30 MG                               Daily Dosage=4
              (Generic: NORCO)            Hydrocodone-Acetaminophen Tab 10-325 MG                                              Daily Dosage=6
              (Generic: LORTAB 5,         Hydrocodone-Acetaminophen Tab 5-500 MG                                               Daily Dosage=8
              VICODIN)
              (Generic: LORTAB 7.5)       Hydrocodone-Acetaminiphen Tab 7.5-500 MG                                             Daily Dosage=6
              (Generic: LORTAB 10)        Hydrocodone-Acetaminophen Tab 10-500 MG                                              Daily Dosage=6
              (Generic: ANEXSIA, LORCET   Hydrocodone-Acetaminophen Tab 7.5-650 MG                                             Daily Dosage=6
              PLUS)
              (Generic: LORCET)           Hydrocodone-Acetaminophen Tab 10-650 MG                                              Daily Dosage=6
              (Generic: ANEXSIA)          Hydrocodone-Acetaminophen Tab 10-660 MG                                              Daily Dosage=6
              (Generic: VICODIN ES)       Hydrocodone-Acetaminophen Tab 7.5-750 MG                                             Daily Dosage=6
              (Generic: NORCO)            Hydrocodone-Acetaminophen Tab 5-325 MG                                               Daily Dosage=12
              (Generic: NORCO)            Hydrocodone-Acetaminophen Tab 7.5-325 MG                                             Daily Dosage=8
              (Generic: LORTAB)           Hydrocodone-Acetaminophen Soln 7.5-500 MG/15ML                                       Daily Dosage=120              42
  Therapeutic                                                                              Covered Brand Product
    Class         Common Brand Name(s)     Product Description                              (unless FFQL or PA)    Limitations/Restrictions
                (Generic: DARVOCET-N)      Propoxyphene-N w/ APAP Tab 50-325 MG                                    Daily Dosage=4
                (Generic: DARVOCET-N)      Propoxyphene-N w/ APAP Tab 100-650 MG                                   Daily Dosage=4
                (Generic: ULTRACET)        Tramadol-Acetaminophen Tab 37.5-325 MG                                  Daily Dosage=4

ANALGESICS - ANTI-INFLAMMATORY
                                           Celecoxib Caps                                CELEBREX                  PA
                                           Diclofenac Sodium Tab Delayed Release 25 MG   DICLOFENAC
                                           Diclofenac Sodium Tab Delayed Release 50 MG
                (Generic: VOLTAREN)        Diclofenac Sodium Tab Delayed Release 75 MG
                (Generic: VOLTAREN-XR)     Diclofenac Sodium Tab SR 24HR 100 MG
                (Generic: CATAFLAM)        Diclofenac Potassium Tab 50 MG
                                           Etodolac Cap 200 MG
                                           Etodolac Cap 300 MG
                                           Etodolac Tab 400 MG
                                           Etodolac Tab 500 MG
                                           Etodolac Tab SR 24HR 400 MG
                                           Etodolac Tab SR 24HR 500 MG
                                           Etodolac Tab SR 24HR 600 MG
                                           Flurbiprofen Tab 50 MG
                (Generic: ANSAID)          Flurbiprofen Tab 100 MG
                (Generic: ADVIL, NUPRIN)   Ibuprofen Tab 200 MG
                (Generic: MOTRIN)          Ibuprofen Tab 400 MG
                (Generic: MOTRIN)          Ibuprofen Tab 600 MG
                (Generic: MOTRIN)          Ibuprofen Tab 800 MG
                                           Ibuprofen Chew Tab 50 MG                      CHILD ADVIL, CHILD
                                                                                         MOTRIN
                (Generic: CHILD MOTRIN)    Ibuprofen Chew Tab 100 MG
                (Generic: CHILD ADVIL,     Ibuprofen Susp 40 MG/ML
                CHLRNS MOTRN, MOTRIN)
                (Generic: CHILD ADVIL,     Ibuprofen Susp 100 MG/5ML
                CHILD MOTRIN, MOTRIN)
                                           Indomethacin Cap 25 MG
                                           Indomethacin Cap 50 MG
                (Generic: INDOCIN SR)      Indomethacin Cap CR 75 MG
                                           Ketoprofen Cap 50 MG
                                           Ketoprofen Cap 75 MG
                                           Ketoprofen Cap SR 24HR 200 MG                 KETOPROFEN
                (Generic: TORADOL ORAL)    Ketorolac Tromethamine Tab 10 MG                                        Max Qty=20/30 days
                (Generic: MOBIC)           Meloxicam Tab 7.5 MG
                (Generic: MOBIC)           Meloxicam Tab 15 MG
                                           Nabumetone Tab 500 MG
                                           Nabumetone Tab 750 MG
                (Generic: NAPROSYN)        Naproxen Tab 250 MG
                (Generic: NAPROSYN)        Naproxen Tab 375 MG
                (Generic: NAPROSYN)        Naproxen Tab 500 MG
                (Generic: NAPROSYN)        Naproxen Susp 125 MG/5ML
                (Generic: ALEVE)           Naproxen Sodium Tab 220 MG                                              Daily Dosage=2             43
  Therapeutic                                                                                    Covered Brand Product
    Class         Common Brand Name(s)   Product Description                                      (unless FFQL or PA)    Limitations/Restrictions
                (Generic: ANAPROX)       Naproxen Sodium Tab 275 MG
                (Generic: ANAPROX DS)    Naproxen Sodium Tab 550 MG
                (Generic: DAYPRO)        Oxaprozin Tab 600 MG
                (Generic: FELDENE)       Piroxicam Cap 10 MG
                (Generic: FELDENE)       Piroxicam Cap 20 MG
                                         Sulindac Tab 150 MG
                (Generic: CLINORIL)      Sulindac Tab 200 MG
                (Generic: RHEUMATREX)    Methotrexate Sodium Tab 2.5 MG (Antirheumatic)

MIGRAINE PRODUCTS
              (Generic: D.H.E. 45)       Dihydroergotamine Mesylate Inj 1 MG/ML
                                         Dihydroergotamine Mesylate Nasal Spray 4 MG/ML        MIGRANAL
                                         Almotriptan Malate Tab 6.25 MG                        AXERT                     Max Qty=6/30 days
                                         Almotriptan Malate Tab 12.5 MG                        AXERT                     Max Qty=6/30 days
                                         Eletriptan Hydrobromide Tab 20 MG (Base Equivalent)   RELPAX                    Max Qty=6/30 days
                                         Eletriptan Hydrobromide Tab 40 MG (Base Equivalent)   RELPAX                    Max Qty=6/30 days
                                         Sumatriptan Nasal Spray 5 MG/ACT                      IMITREX                   Max Qty=6/30 days
                                         Sumatriptan Nasal Spray 20 MG/ACT                     IMITREX                   Max Qty=6/30 days
                                         Sumatriptan Succinate Tab 25 MG                       IMITREX                   Max Qty=9/30 days
                                         Sumatriptan Succinate Tab 50 MG                       IMITREX                   Max Qty=9/30 days
                                         Sumatriptan Succinate Tab 100 MG                      IMITREX                   Max Qty=9/30 days
                                         Sumatriptan Succinate Inj 12 MG/ML                    IMITREX                   Max Qty=2/30 days
                                         Sumatriptan Succinate Inj Kit 4 MG/0.5ML              IMITREX                   Max Qty=2/30 days
                                         Sumatriptan Succinate Inj Kit                         IMITREX                   Max Qty=2/30 days
                                         Zolmitriptan Tab 2.5 MG                               ZOMIG                     Max Qty=6/30 days
                                         Zolmitriptan Tab 5 MG                                 ZOMIG                     Max Qty=6/30 days
                                         Zolmitriptan Nasal Spray 5 MG/Spray Unit              ZOMIG                     Max Qty=6/30 days
                                         Zolmitriptan Orally Disintegrating Tab 2.5 MG         ZOMIG ZMT                 Max Qty=6/30 days
                                         Zolmitriptan Orally Disintegrating Tab 5 MG           ZOMIG ZMT                 Max Qty=6/30 days
                (Generic: MIDRIN)        APAP-Isometheptene-Dichloral Cap 325-65-100 MG
                (Generic: CAFERGOT)      Ergotamine w/ Caffeine Tab 1-100 MG

GOUT AGENTS
                (Generic: ZYLOPRIM)      Allopurinol Tab 100 MG
                (Generic: ZYLOPRIM)      Allopurinol Tab 300 MG
                                         Colchicine Tab 0.6 MG
                                         Probenecid Tab 500 MG
                                         Colchicine w/ Probenecid Tab 0.5-500 MG

ANTICONVULSANTS
             (Generic: KLONOPIN)         Clonazepam Tab 0.5 MG                                                           Daily Dosage=3
             (Generic: KLONOPIN)         Clonazepam Tab 1 MG                                                             Daily Dosage=3
             (Generic: KLONOPIN)         Clonazepam Tab 2 MG                                                             Daily Dosage=3
                                         Diazepam Rectal Gel Delivery System 2.5 MG            DIASTAT PED               PA, Limited to Ages 21 and Under; Max
                                                                                                                         Qty=1/claim
                                         Diazepam Rectal Gel Delivery System 10 MG             DIASTAT ACDL              PA, Limited to Ages 21 and Under; Max
                                                                                                                         Qty=1/claim                             44
Therapeutic                                                                                      Covered Brand Product
  Class         Common Brand Name(s)    Product Description                                        (unless FFQL or PA)   Limitations/Restrictions
                                        Diazepam Rectal Gel Delivery System 20 MG              DIASTAT ACDL              PA, Limited to Ages 21 and Under; Max
                                                                                                                         Qty=1/claim
                                        Felbamate Tab 400 MG                                   FELBATOL
                                        Felbamate Tab 600 MG                                   FELBATOL
                                        Felbamate Susp 600 MG/5ML                              FELBATOL
                                        Tiagabine HCl Tab 2 MG                                 GABITRIL
                                        Tiagabine HCl Tab 4 MG                                 GABITRIL
                                        Tiagabine HCl Tab 12 MG                                GABITRIL
                                        Tiagabine HCl Tab 16 MG                                GABITRIL
                                        Phenytoin Chew Tab 50 MG                               DILANTIN
              (Generic: DILANTIN-125)   Phenytoin Susp 125 MG/5ML
                                        Phenytoin Sodium Extended Cap 30 MG                    DILANTIN
              (Generic: DILANTIN)       Phenytoin Sodium Extended Cap 100 MG
              (Generic: ZARONTIN)       Ethosuximide Cap 250 MG
              (Generic: ZARONTIN)       Ethosuximide Soln 250 MG/5ML
              (Generic: DEPAKOTE)       Divalproex Sodium Tab Delayed Release 125 MG                                     Daily Dosage=2
              (Generic: DEPAKOTE)       Divalproex Sodium Tab Delayed Release 250 MG           DEPAKOTE                  Daily Dosage=3
              (Generic: DEPAKOTE)       Divalproex Sodium Tab Delayed Release 500 MG                                     Daily Dosage=7
                                        Divalproex Sodium Cap Sprinkle 125 MG                  DEPAKOTE SPR              Daily Dosage=8
                                        Divalproex Sodium Tab SR 24 HR 250 MG                  DEPAKOTE ER               Daily Dosage=3
                                        Divalproex Sodium Tab SR 24 HR 500 MG                  DEPAKOTE ER               Daily Dosage=7
              (Generic: DEPAKENE)       Valproate Sodium Syrup 250 MG/5ML
              (Generic: DEPAKENE)       Valproic Acid Cap 250 MG
              (Generic: TEGRETOL)       Carbamazepine Tab 200 MG
              (Generic: TEGRETOL)       Carbamazepine Chew Tab 100 MG
              (Generic: TEGRETOL)       Carbamazepine Susp 100 MG/5ML
                                        Carbamazepine Tab SR 12HR 100 MG                       TEGRETOL XR
                                        Carbamazepine Tab SR 12HR 200 MG                       TEGRETOL XR
                                        Carbamazepine Tab SR 12HR 400 MG                       TEGRETOL XR
              (Generic: NEURONTIN)      Gabapentin Cap 100 MG                                  NEURONTIN                 Daily Dosage=4
              (Generic: NEURONTIN)      Gabapentin Cap 300 MG                                                            Daily Dosage=4
              (Generic: NEURONTIN)      Gabapentin Cap 400 MG                                                            Daily Dosage=4
                                        Gabapentin Tab 100 MG                                  GABARONE                  Daily Dosage=4
                                        Gabapentin Tab 400 MG                                  GABARONE                  Daily Dosage=4
              (Generic: NEURONTIN)      Gabapentin Tab 600 MG                                                            Daily Dosage=4
              (Generic: NEURONTIN)      Gabapentin Tab 800 MG                                                            Daily Dosage=4
                                        Gabapentin Oral Soln 250 MG/5ML                        NEURONTIN
              (Generic: LAMICTAL)       Lamotrigine Tab 25 MG
              (Generic: LAMICTAL)       Lamotrigine Tab 100 MG
              (Generic: LAMICTAL)       Lamotrigine Tab 150 MG
              (Generic: LAMICTAL)       Lamotrigine Tab 200 MG
                                        Lamotrigine Tab 25 MG (35) Starter Kit                 LAMICTAL
                                        Lamotrigine Tab 25 MG (42) & 100 MG (7) Starter Kit    LAMICTAL
                                        Lamotrigine Tab 25 MG (84) & 100 MG (14) Starter Kit   LAMICTAL
              (Generic: LAMICTAL)       Lamotrigine Tab Disp 5 MG
              (Generic: LAMICTAL)       Lamotrigine Tab Disp 25 MG
                                        Levetiracetam Tab 250 MG                               KEPPRA                    Daily Dosage=4                          45
  Therapeutic                                                                          Covered Brand Product
    Class         Common Brand Name(s)    Product Description                           (unless FFQL or PA)    Limitations/Restrictions
                                          Levetiracetam Tab 500 MG                   KEPPRA                    Daily Dosage=4
                                          Levetiracetam Tab 750 MG                   KEPPRA                    Daily Dosage=4
                                          Levetiracetam Tab 1000 MG                  KEPPRA
                                          Levetiracetam Soln 100 MG/ML               KEPPRA
                (Generic: TRILEPTAL)      Oxcarbazepine Tab 150 MG
                (Generic: TRILEPTAL)      Oxcarbazepine Tab 300 MG
                (Generic: TRILEPTAL)      Oxcarbazepine Tab 600 MG
                                          Oxcarbazepine Susp 300 MG/5ML (60 MG/ML)   TRILEPTAL
                (Generic: MYSOLINE)       Primidone Tab 50 MG
                (Generic: MYSOLINE)       Primidone Tab 250 MG
                (Generic: ZONEGRAN)       Zonisamide Cap 25 MG
                                          Zonisamide Cap 50 MG
                (Generic: ZONEGRAN)       Zonisamide Cap 100 MG

ANTIPARKINSON AGENTS
                                          Benztropine Mesylate Tab 0.5 MG
                                          Benztropine Mesylate Tab 1 MG
                                          Benztropine Mesylate Tab 2 MG
                                          Trihexyphenidyl HCl Tab 2 MG
                (Generic: ARTANE)         Trihexyphenidyl HCl Tab 5 MG
                                          Amantadine HCl Cap 100 MG
                                          Amantadine HCl Syrup 50 MG/5ML
                (Generic: PARLODEL)       Bromocriptine Mesylate Cap 5 MG
                (Generic: PARLODEL)       Bromocriptine Mesylate Tab 2.5 MG
                (Generic: SINEMET)        Carbidopa & Levodopa Tab 10-100 MG
                (Generic: SINEMET)        Carbidopa & Levodopa Tab 25-100 MG
                (Generic: SINEMET)        Carbidopa & Levodopa Tab 25-250 MG
                (Generic: SINEMET CR)     Carbidopa & Levodopa Tab CR 25-100 MG
                (Generic: SINEMET CR)     Carbidopa & Levodopa Tab CR 50-200 MG
                (Generic: ELDEPRYL)       Selegiline HCl Cap 5 MG
                                          Selegiline HCl Tab 5 MG                    SELEGILINE
                                          Carbidopa Tab 25 MG                        LODOSYN

MUSCULOSKELETAL THERAPY AGENTS
                                          Baclofen Tab 10 MG
                                          Baclofen Tab 20 MG
                (Generic: SOMA)           Carisoprodol Tab 350 MG                                              Daily Dosage=4
                (Generic: PARAFON FORT)   Chlorzoxazone Tab 500 MG
                (Generic: FLEXERIL)       Cyclobenzaprine HCl Tab 5 MG                                         Daily Dosage=3
                (Generic: FLEXERIL)       Cyclobenzaprine HCl Tab 10 MG                                        Daily Dosage=3
                (Generic: ROBAXIN)        Methocarbamol Tab 500 MG
                (Generic: ROBAXIN-750)    Methocarbamol Tab 750 MG
                                          Orphenadrine Citrate Tab SR 12HR 100 MG
                (Generic: ZANAFLEX)       Tizanidine HCl Tab 2 MG
                (Generic: ZANAFLEX)       Tizanidine HCl Tab 4 MG
                (Generic: DANTRIUM)       Dantrolene Sodium Cap 25 MG
                (Generic: DANTRIUM)       Dantrolene Sodium Cap 50 MG                                                                     46
  Therapeutic                                                                     Covered Brand Product
    Class         Common Brand Name(s)   Product Description                       (unless FFQL or PA)    Limitations/Restrictions
                (Generic: DANTRIUM)      Dantrolene Sodium Cap 100 MG

ANTIMYASTHENIC AGENTS
              (Generic: MESTINON)        Pyridostigmine Bromide Tab 60 MG
                                         Pyridostigmine Bromide Tab CR 180 MG   MESTINON

VITAMINS
                                         Thiamine HCl Tab 50 MG                                           Daily Dosage=3
                                         Thiamine HCl Tab 100 MG                                          Daily Dosage=3
                                         Thiamine HCl Tab 250 MG                                          Daily Dosage=3
                                         Thiamine HCl Tab 500 MG                                          Daily Dosage=3
                                         Thiamine Mononitrate Tab 100 MG        VITAMIN B-1               Daily Dosage=3
                                         Riboflavin Tab 25 MG                                             Daily Dosage=3
                                         Riboflavin Tab 50 MG                                             Daily Dosage=3
                                         Riboflavin Tab 100 MG
                                         Niacin Cap CR 250 MG
                                         Niacin Cap CR 500 MG
                                         Niacin Tab 500 MG
                (Generic: SLO-NIACIN)    Niacin Tab CR 500 MG
                (Generic: SLO-NIACIN)    Niacin Tab CR 750 MG
                                         Niacin Tab CR 1000 MG                  NIACIN TR
                                         Pyridoxine HCl Tab 25 MG
                                         Pyridoxine HCl Tab 50 MG
                                         Pyridoxine HCl Tab 100 MG
                                         Ascorbic Acid Tab 250 MG
                                         Ascorbic Acid Tab 500 MG               KROGER VITAM
                                         Ascorbic Acid Tab 1000 MG              VITAMIN C TA
                                         Ascorbic Acid Tab 1500 MG
                (Generic: DRISDOL)       Ergocalciferol Cap 50000 IU
                (Generic: ROCALTROL)     Calcitriol Cap 0.25 MCG
                (Generic: ROCALTROL)     Calcitriol Cap 0.5 MCG
                                         Vitamin E Cap 100 IU
                                         Vitamin E Cap 200 IU
                                         Vitamin E Cap 400 IU
                                         Vitamin E Chew Tab 400 IU
                                         Phytonadione Tab 5 MG                  MEPHYTON

MULTIVITAMINS
                                         *B-Complex Vitamin Cap**
                                         *B-Complex Vitamin Tab**                                         Daily Dosage=1
                                         *B-Complex w/ C Cap**
                (Generic: CARDENZ,       *Multiple Vitamin Tab**
                LYSIPLEX, ONE-A-DAY,
                THERAGRAN)
                (Generic: GERITOL EXT,   *Multiple Vitamins w/ Iron Tab**       STRESS FORMU
                STRESSTABS)
                                                                                                                                     47
Therapeutic                                                                                              Covered Brand Product
  Class         Common Brand Name(s)    Product Description                                               (unless FFQL or PA)    Limitations/Restrictions
              (Generic: CAROMEGA,       *Multiple Vitamins w/ Minerals Tab**                           ANTIOXIDANT, B-50
              CENTRUM, COMPLERE,                                                                       FORMULA, BACMIN, BONE
              FEMTABS, FOSFREE...)                                                                     SMART, CENTRUM CARB...
              (Generic: TRI-VI-SOL)     *Pediatric Vitamins ADC Drops 1500IU-400IU-35 MG/ML***                                   Max Qty=50/claim

                                        *Pediatric Multiple Vitamin w/ C & FA Chew Tab**                                         PA, Limited to Ages 21 and Under; Max
                                                                                                                                 Qty=50/claim
              (Generic: POLY-VI-SOL)    *Pediatric Multiple Vitamin w/ C Soln 35 MG/ML**                                         PA, Limited to Ages 21 and Under; Max
                                                                                                                                 Qty=50/claim
                                        *Pediatric Multiple Vitamin w/ Minerals & C Chew Tab 60 MG** VITAMAX

                                        *Pediatric Multiple Vitamins w/ Iron Chew Tab 15 MG**
                                        *Pediatric Multiple Vitamins w/ Iron Drops 10 MG/ML**
                                        *Pediatric Vitamins ACD w/ Fluoride Chew Tab 1 MG***                                     PA, Limited to Ages 21 and Under; Max
                                                                                                                                 Qty=50/claim
              (Generic: TRI-VI-FLOR)    *Pediatric Vitamins ACD w/ Fluoride Soln 0.25 MG/ML***                                   PA, Limited to Ages 21 and Under; Max
                                                                                                                                 Qty=50/claim
                                        *Pediatric Vitamins ACD w/ Fluoride Soln 0.5 MG/ML***                                    PA, Limited to Ages 21 and Under; Max
                                                                                                                                 Qty=50/claim
                                        *Pediatric Multiple Vitamins w/ Fluoride Chew Tab 0.25 MG***                             PA, Limited to Ages 21 and Under; Max
                                                                                                                                 Qty=50/claim
                                        *Pediatric Multiple Vitamins w/ Fluoride Chew Tab 0.5 MG***                              PA, Limited to Ages 21 and Under; Max
                                                                                                                                 Qty=50/claim
                                        *Pediatric Multiple Vitamins w/ Fluoride Chew Tab 1 MG***                                PA, Limited to Ages 21 and Under; Max
                                                                                                                                 Qty=50/claim
              (Generic: POLY-VI-FLOR)   *Pediatric Multiple Vitamins w/ Fluoride Soln 0.25 MG/ML***                              PA, Limited to Ages 21 and Under; Max
                                                                                                                                 Qty=50/claim
              (Generic: POLY-VI-FLOR)   *Pediatric Multiple Vitamins w/ Fluoride Soln 0.5 MG/ML***                               PA, Limited to Ages 21 and Under; Max
                                                                                                                                 Qty=50/claim
                                        *Pediatric Multiple Vitamins w/ Fl-Fe Chew Tab 0.5-12 MG**                               Daily Dosage=1

                                        *Pediatric Multiple Vitamins w/ Fl-Fe Chew Tab 1-12 MG**                                 PA, Limited to Ages 21 and Under; Max
                                                                                                                                 Qty=50
                                        *Pediatric Multiple Vitamins w/ Fl-Fe Drops 0.25-10 MG/ML**                              PA, Limited to Ages 21 and Under; Max
                                                                                                                                 Qty=50/claim
                                        *Pediatric Multiple Vitamins w/ Fl-Fe Drops 0.5-10 MG/ML**                               PA, Limited to Ages 21 and Under; Max
                                                                                                                                 Qty=50/claim
                                        *Pediatric Vitamins ACD Fluoride & Fe Drops 0.25-10 MG/ML***                             PA, Limited to Ages 21 and Under; Max
                                                                                                                                 Qty=50/claim
                                        *Prenatal Vitamin Fast Dissolving Tab**                        CALNA                     PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                 Female
                                        *Prenatal Multivitamins & Minerals w/ Iron & FA Cap 0.1MG***   TYLER PRENAT              PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                 Female
              (Generic: MYNATAL)        *Prenatal Multivitamins & Minerals w/ Iron & FA Cap 1 MG***                              PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                 Female

                                                                                                                                                                         48
Therapeutic                                                                                             Covered Brand Product
  Class         Common Brand Name(s)   Product Description                                                (unless FFQL or PA)   Limitations/Restrictions
                                       *Prenatal Multivitamins & Minerals w/ Iron & FA Tab 0.1MG***   KPN                       PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
                                       *Prenatal Multivitamins & Minerals w/ Fe & FA Tab 0.25 MG***   NUTRICION                 PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
                                       *Prenatal Multivitamins & Minerals w/ Iron & FA Tab 0.8MG***                             PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
                                       *Prenatal Multivitamins & Minerals w/ Iron & FA Tab 1 MG***                              PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
              (Generic: NESTABS RX)    *Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG***                                         PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
              (Generic: NESTABS CBF)   *Prenatal Vit w/ Iron Carbonyl-FA Tab 50-1 MG***                                         PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
                                       *Prenatal Vit w/ Fe Fumarate-FA Cap 13.5-0.4 MG***             PERRY PRENAT              PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
                                       *Prenatal Vit w/ Fe Fumarate-FA Tab 15-1 MG***                 O-CAL                     PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
              (Generic: NOVASTART)     *Prenatal Vit w/ Fe Fumarate-FA Tab 17-1 MG***                                           PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
                                       *Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.5 MG***                                         PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
                                       *Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG***               RIGHT STEP                PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
                                       *Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG***                                           PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
              (Generic: STUART PREN)   *Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG***                                         PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
                                       *Prenatal Vit w/ Fe Fumarate-FA Tab 28-1 MG***                 GESTICARE                 PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
              (Generic: NESTABS FA)    *Prenatal Vit w/ Fe Fumarate-FA Tab 29-1 MG***                                           PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
                                       *Prenatal Vit w/ Fe Fumarate-FA Tab 60-1 MG***                                           PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
              (Generic: LACTOCAL-F)    *Prenatal Vit w/ Fe Fumarate-FA Tab 65-1 MG***                 VITAFOL-OB, VITAFOL-PN    PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
                                       *Prenatal Vit w/ Fe Fumarate-FA Tab 75-1 MG***                 NATALVIT                  PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
              (Generic: NATACHEW)      *Prenatal Vit w/ Fe Fumarate-FA Chew Tab 29-1 MG***                                      PA, Limited to Ages 50 and Under; Limited to
                                                                                                                                Female
                                       *Prenatal Vit w/ Fe Gluconate-FA Tab 30-0.4 MG***              MISSION PREN              Limited to Female; Limited to Ages 50 and
                                                                                                                                Under
                                       *Prenatal Vit w/ Fe Gluconate-FA Tab 30-0.8 MG***                                        Limited to Female; Limited to Ages 50 and
                                                                                                                                Under
                                       *Prenatal Vit w/ Fe Sulfate-FA Tab 27-0.8 MG***                PRENATAL                  Limited to Female; Limited to Ages 50 and
                                                                                                                                Under
                                       *Prenatal Vit w/ Fe Polysac Cmplx-FA Tab 60-1 MG***                                      Limited to Female; Limited to Ages 50 and
                                                                                                                                Under
                                                                                                                                                                       49
  Therapeutic                                                                                          Covered Brand Product
    Class         Common Brand Name(s)     Product Description                                          (unless FFQL or PA)    Limitations/Restrictions
                (Generic: CITRACAL,        *Prenatal Vit w/ Iron Carbonyl-Fe Gluc-FA Tab 27-1MG***   CAL-NATE, VINATE CAL      Limited to Female; Limited to Ages 50 and
                CITRANATAL)                                                                                                    Under
                (Generic: CENOGEN ULTR)    *Prenatal w/o A Vit w/ Fe Fumarate-FA Cap 106-1 MG***                               Limited to Female; Limited to Ages 50 and
                                                                                                                               Under
                (Generic: NOVANATAL)       *Prenatal w/o A Vit w/ Fe Carbonyl-FA Tab 29-1 MG***                                Limited to Female; Limited to Ages 50 and
                                                                                                                               Under
                                           *Prenatal without A w/ Fe Carbonyl-Docusate-FA Tab 90-                              Limited to Female; Limited to Ages 50 and
                                           1MG***                                                                              Under
                                           *Prenatal Vit w/ Sel-Fe Fumarate-FA Tab 27-1 MG***                                  Limited to Female; Limited to Ages 50 and
                                                                                                                               Under
                                           *Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG***                                Limited to Female; Limited to Ages 50 and
                                                                                                                               Under; Daily Dosage=1
                                           *Prenatal Vit w/ DSS-Fe Fumarate-FA Tab CR 90-1 MG***                               Limited to Female; Limited to Ages 50 and
                                                                                                                               Under
                                           *Prenatal w/FE Polys Cmplx-FA-Ca Tab & Omega 3 Cap        MARNATAL-F                Limited to Female; Limited to Ages 50 and
                                           Pack***                                                                             Under
                                           *Vitamins w/ Lipotropics Cap**                                                      Daily Dosage=1
                (Generic: IBERET-500,      *Iron w/ Vitamin Tab CR**
                IBERET-FOLIC)

MINERALS & ELECTROLYTES
                                           Oyster Shell Calcium Tab 500 MG
                                           Calcium 500 MG w/ Vitamin D Tab
                                           Calcium Carbonate-Vitamin D Tab 250MG-125IU
                                           Calcium Carbonate-Vitamin D Tab 500MG-125IU
                                           Calcium Carbonate-Vitamin D Tab 500MG-200IU
                                           Calcium Carbonate-Vitamin D Tab 600MG-200IU                                         Daily Dosage=1
                                           Calcium Carbonate-Vitamin D Tab 600 MG-400 Unit                                     Daily Dosage=2
                (Generic: LURIDE)          Sodium Fluoride Chew Tab 0.25MG F (from 0.55 MG NaF)

                (Generic: LURIDE)          Sodium Fluoride Chew Tab 0.5MG F (from 1.1 MG NaF)
                (Generic: LURIDE)          Sodium Fluoride Chew Tab 1 MG F (from 2.2 MG NaF)
                (Generic: LURIDE)          Sodium Fluoride Soln 0.5 MG/ML F (from 1.1 MG/ML NaF)
                                           Potassium Iodide Soln 1 GM/ML                           SSKI
                                           Potassium & Sodium Phosphates For Soln 278-164-250      NEUTRA-PHOS                 Daily Dosage=2
                                           MG/75ML
                (Generic: K-LYTE-ORANG)    Potassium Bicarbonate Effer Tab 25 mEq
                (Generic: MICRO-K)         Potassium Chloride Cap CR 10 mEq
                                           Potassium Chloride Tab CR 8 mEq
                (Generic: K-TABS)          Potassium Chloride Tab CR 10 mEq
                                           Potassium Chloride Oral Liq 10%
                                           Potassium Chloride Oral Liq 20%
                (Generic: K-LOR)           Potassium Chloride Powder Packet 20 mEq
                                           Potassium Chloride Powder Packet 25 mEq                 KLOR-CON-25
                (Generic: K-DUR, K-TABS)   Potassium Chloride Microencapsulated CRYS CR Tab 10 mEq

                                                                                                                                                                      50
  Therapeutic                                                                                           Covered Brand Product
    Class         Common Brand Name(s)   Product Description                                             (unless FFQL or PA)    Limitations/Restrictions
                                         Potassium Chloride Microencapsulated Crys CR Tab 15 mEq      KLOR-CON M15

                (Generic: K-DUR)         Potassium Chloride Microencapsulated CRYS CR Tab 20 mEq

                                         Zinc Sulfate Cap 220 MG
                (Generic: EQUALYTE,      *Oral Electrolyte Solution***                                CERALYTE 50, CERASPORT,
                PEDIALYTE)                                                                            ENFALYTE, PEDIALYTE



HEMATOPOIETIC AGENTS
                                         Cyanocobalamin Inj 1000 MCG/ML                                                         Max Qty=10/270 days
                                         Folic Acid Tab 1 MG
                (Generic: ICAR)          Iron Chew Tab 15 MG
                                         Ferrous Sulfate Tab 83 MG                                                              Daily Dosage=3
                                         Ferrous Sulfate Tab 324 MG                                                             Daily Dosage=3
                                         Ferrous Sulfate Tab 325 MG (65 MG Elemental Fe)
                                         Ferrous Sulfate Tab EC 325 MG (65 MG Fe Equivalent)
                (Generic: FEOSOL)        Ferrous Sulfate Elixir 220 MG/5ML (44 MG/5ML Elemental Fe)                             Daily Dosage=16

                                         Ferrous Sulfate Soln 75 MG/0.6ML                                                       Max Qty=50/claim
                (Generic: SLOW FE)       Ferrous Sulfate Dried Tab CR 160 MG (50 MG Fe Equivalent)                              Daily Dosage=3

                                         Ferrous Gluconate Tab 216 MG
                (Generic: FERGON)        Ferrous Gluconate Tab 240 MG                                                           Daily Dosage=3
                                         Ferrous Gluconate Tab 300 MG                                 FERROUS GLUC              Daily Dosage=3
                                         Ferrous Gluconate Tab 324 MG                                 FERROUS GLUC
                                         Ferrous Gluconate Tab 325 MG
                                         Ferrous Gluconate Tab 225 MG (27 MG Fe Equivalent)                                     Daily Dosage=3
                                         Ferrous Gluconate Tab 246 MG (28 MG Elemental Fe)                                      Daily Dosage=3

ANTICOAGULANTS
                                         Heparin Sodium (Porcine) Inj 1000 U/ML
                                         Heparin Sodium (Porcine) Inj 5000 U/ML
                                         Heparin Sodium (Porcine) Inj 10000 U/ML
                                         Heparin Sodium (Porcine) Inj 20000 U/ML
                                         Enoxaparin Sodium Inj 10 MG/0.1ML                            LOVENOX                   5 day supply retail; specialty med
                                         Enoxaparin Sodium Inj 150 MG/ML                              LOVENOX                   5 day supply retail; specialty med
                (Generic: COUMADIN)      Warfarin Sodium Tab 1 MG
                (Generic: COUMADIN)      Warfarin Sodium Tab 2 MG
                (Generic: COUMADIN)      Warfarin Sodium Tab 2.5 MG
                (Generic: COUMADIN)      Warfarin Sodium Tab 3 MG
                (Generic: COUMADIN)      Warfarin Sodium Tab 4 MG
                (Generic: COUMADIN)      Warfarin Sodium Tab 5 MG
                (Generic: COUMADIN)      Warfarin Sodium Tab 6 MG
                (Generic: COUMADIN)      Warfarin Sodium Tab 7.5 MG
                (Generic: COUMADIN)      Warfarin Sodium Tab 10 MG
                                                                                                                                                                     51
  Therapeutic                                                                                       Covered Brand Product
    Class       Common Brand Name(s)    Product Description                                          (unless FFQL or PA)    Limitations/Restrictions
HEMATOLOGICAL AGENTS - MISC.
              (Generic: PERSANTINE)     Dipyridamole Tab 25 MG
              (Generic: PERSANTINE)     Dipyridamole Tab 50 MG
              (Generic: PERSANTINE)     Dipyridamole Tab 75 MG
                                        Clopidogrel Bisulfate Tab 75 MG (Base Equiv)              PLAVIX                    Daily Dosage=1
              (Generic: TRENTAL)        Pentoxifylline Tab CR 400 MG

OPHTHALMIC AGENTS
                                        Bacitracin Ophth Oint 500 U/GM                                                      Package Limit=1/claim
              (Generic: CILOXAN)        Ciprofloxacin HCl Ophth Soln 0.3%                                                   Package Limit=1/claim
                                        Ciprofloxacin HCl Ophth Oint 0.3%                         CILOXAN                   Package Limit=1/claim
                                        Erythromycin Ophth Oint 5 MG/GM                                                     Package Limit=1/claim
              (Generic: GARAMYCIN)      Gentamicin Sulfate Ophth Soln 0.3%                                                  Package Limit=1/claim
                                        Gentamicin Sulfate Ophth Oint 0.3%                        GARAMYCIN, GENTAMICIN     Package Limit=1/claim
              (Generic: OCUFLOX)        Ofloxacin Ophth Soln 0.3%                                                           Package Limit=1/claim
              (Generic: TOBREX)         Tobramycin Sulfate Ophth Soln 0.3%                                                  Package Limit=1/claim
                                        Tobramycin Sulfate Ophth Oint 0.3%                        TOBREX                    Package Limit=1/claim
              (Generic: BLEPH-10)       Sulfacetamide Sodium Ophth Soln 10%                                                 Package Limit=1/claim
                                        Sulfacetamide Sodium Ophth Oint 10%                       SULFACET SOD              Package Limit=1/claim
              (Generic: VIROPTIC)       Trifluridine Ophth Soln 1%                                                          Package Limit=1/claim
              (Generic: POLYSPORIN)     Bacitracin-Polymyxin B Ophth Oint                                                   Package Limit=1/claim
              (Generic: POLYTRIM)       Polymyxin B-Trimethoprim Ophth Soln 10000 UNITS/ML-0.1%                             Package Limit=1/claim

                                        Neomycin-Bacitracin Zn-Polymyx 3.5(5)MG-400U-10000U Op                              Package Limit=1/claim
                                        Oint
              (Generic: NEOSPORIN)      Neomycin-Polymyxin B-Gramicidin Ophth Soln                                          Package Limit=1/claim
              (Generic: LIQUIFILM)      Polyvinyl Alcohol Ophth Soln 1.4%                                                   Package Limit=1/claim
              (Generic: AKWA TEARS,     *Artificial Tear Ophth Ointment***                                                  Max Qty=4/claim
              LACRI-LUBE, MOISTURE
              EYE, REFRESH-PM)
                                        Polyethylene Glycol-Polyvinyl Alcohol Ophth Soln 1-1%                               Package Limit=1/claim
                                        Betaxolol HCl Ophth Susp 0.25%                            BETOPTIC-S                Package Limit=1/claim
                                        Betaxolol HCl Ophth Soln 0.5%                                                       Package Limit=1/claim
              (Generic: BETAGAN)        Levobunolol HCl Ophth Soln 0.5%                                                     Package Limit=1/claim
              (Generic: TIMOPTIC,       Timolol Maleate Ophth Soln 0.25%                                                    Package Limit=1/claim
              TIMOPTIC OCU)
              (Generic: TIMOPTIC,       Timolol Maleate Ophth Soln 0.5%                                                     Package Limit=1/claim
              TIMOPTIC OCU)
              (Generic: TIMOPTIC-XE)    Timolol Maleate Ophth Gel Forming Soln 0.5%                                         Package Limit=1/claim
                                        Dorzolamide-Timolol Ophth Soln 2-0.5% (Base Equiv)        COSOPT                    Package Limit=1/claim
                                        Dexamethasone Sodium Phosphate Ophth Soln 0.1%                                      Package Limit=1/claim
              (Generic: FML LIQUIFLM)   Fluorometholone Ophth Susp 0.1%                                                     Package Limit=1/claim
                                        Fluorometholone Ophth Oint 0.1%                           FML S.O.P.                Package Limit=1/claim
                                        Prednisolone Acetate Ophth Susp 0.12%                     PRED MILD                 Package Limit=1/claim
              (Generic: ECONOPRED PL,   Prednisolone Acetate Ophth Susp 1%                                                  Package Limit=1/claim
              OMNIPRED, PRED FORTE)
                                        Prednisolone Sodium Phosphate Ophth Soln 1%               PRED SOD PHO              Package Limit=1/claim      52
Therapeutic                                                                                           Covered Brand Product
  Class         Common Brand Name(s)    Product Description                                            (unless FFQL or PA)    Limitations/Restrictions
                                        Rimexolone Ophth Susp 1%                                    VEXOL                     Package Limit=1/claim
                                        Gentamicin-Prednisolone Ace Ophth Susp 0.3-1%               PRED-G                    Package Limit=1/claim
                                        Sulfacetamide Sodium-Prednisolone Ophth Susp 10-0.2%        BLEPHAMIDE,               Package Limit=1/claim
                                                                                                    PREDNIS/SULF,
                                                                                                    SULF/PREDNIS
                                        Sulfacetamide Sodium-Prednisolone Ophth Soln 10-0.25%                                 Package Limit=1/claim

                                        Sulfacetamide Sodium-Prednisolone Ophth Oint 10-0.2%        BLEPHAMIDE                Package Limit=1/claim
                                        Tobramycin-Dexamethasone Ophth Susp 0.3-0.1%                TOBRADEX                  Package Limit=1/claim
                                        Tobramycin-Dexamethasone Ophth Oint 0.3-0.1%                TOBRADEX                  Package Limit=1/claim
              (Generic: MAXITROL)       Neomycin-Polymyxin-Dexamethasone Ophth Susp 0.1%                                      Package Limit=1/claim
              (Generic: MAXITROL)       Neomycin-Polymyxin-Dexamethasone Ophth Oint 0.1%                                      Package Limit=1/claim
              (Generic: CORTISPORIN)    Neomycin-Polymyxin-HC Ophth Susp                                                      Package Limit=1/claim
                                        Neomycin-Polymyxin-Prednisolone Ace Ophth Susp 0.5% (new)   POLY-PRED                 Package Limit=1/claim

                                        Latanoprost Ophth Soln 0.005%                               XALATAN                   Package Limit=1/claim
              (Generic: ISO ATROPINE)   Atropine Sulfate Ophth Soln 1%                                                        Package Limit=1/claim
                                        Atropine Sulfate Ophth Oint 1%                                                        Package Limit=1/claim
                                        Cyclopentolate HCl Ophth Soln 0.5%                          CYCLOGYL                  Package Limit=1/claim
              (Generic: CYCLOGYL)       Cyclopentolate HCl Ophth Soln 1%                                                      Package Limit=1/claim
                                        Cyclopentolate HCl Ophth Soln 2%                            CYCLOGYL                  Package Limit=1/claim
                                        Homatropine HBr Ophth Soln 2%                               ISO HOMATROP              Package Limit=1/claim
              (Generic: ISO HOMATROP)   Homatropine HBr Ophth Soln 5%                                                         Package Limit=1/claim
                                        Tropicamide Ophth Soln 0.5%                                                           Package Limit=1/claim
              (Generic: MYDRIACYL)      Tropicamide Ophth Soln 1%                                                             Package Limit=1/claim
              (Generic: ALBALON,        Naphazoline HCl Ophth Soln 0.1%                                                       Package Limit=1/claim
              NAPHCON FORT)
              (Generic: MYDFRIN)        Phenylephrine HCl Ophth Soln 2.5%                                                     Package Limit=1/claim
                                        Phenylephrine HCl Ophth Soln 2.5% (Refrigerated)                                      Package Limit=1/claim
                                        Carbachol Ophth Soln 1.5%                                   ISO CARBACHO
              (Generic: ISO CARBACHO)   Carbachol Ophth Soln 3%
              (Generic: ISO CARPINE)    Pilocarpine HCl Ophth Soln 0.5%
              (Generic: ISOPTO CARP)    Pilocarpine HCl Ophth Soln 1%
              (Generic: ISOPTO CARP)    Pilocarpine HCl Ophth Soln 2%
              (Generic: ISOPTO CARP)    Pilocarpine HCl Ophth Soln 3%
              (Generic: ISOPTO CARP)    Pilocarpine HCl Ophth Soln 4%
                                        Pilocarpine HCl Ophth Soln 6%
              (Generic: PROPINE)        Dipivefrin HCl Ophth Soln 0.1%
                                        Apraclonidine HCl Ophth Soln 0.5% (Base Equivalent)         IOPIDINE
                                        Apraclonidine HCl Ophth Soln 1% (Base Equivalent)           IOPIDINE
                                        Brimonidine Tartrate Ophth Soln 0.2%                                                  Package Limit=1/claim
                                        Azelastine HCl Ophth Soln 0.05%                             OPTIVAR                   Package Limit=1/claim; Step Therapy
              (Generic: CROLOM)         Cromolyn Sodium Ophth Soln 4%                                                         Package Limit=1/claim
              (Generic: ZADITOR)        Ketotifen Fumarate Ophth Soln 0.025% (Base Equiv)                                     Package Limit=1/claim
                                        Lodoxamide Tromethamine Ophth Soln 0.1%                     ALOMIDE                   Package Limit=1/claim; Step Therapy
                                        Nedocromil Sodium Ophth Soln 2%                             ALOCRIL                   Package Limit=1/claim
                                        Brinzolamide Ophth Susp 1%                                  AZOPT                     Package Limit=1/claim                 53
  Therapeutic                                                                                              Covered Brand Product
    Class         Common Brand Name(s)      Product Description                                             (unless FFQL or PA)    Limitations/Restrictions
                                            Dorzolamide HCl Ophth Soln 2%                                TRUSOPT                   Package Limit=1/claim
                (Generic: VOLTAREN)         Diclofenac Sodium Ophth Soln 0.1%                            VOLTAREN                  Package Limit=1/claim
                (Generic: OCUFEN)           Flurbiprofen Sodium Ophth Soln 0.03%                                                   Package Limit=1/claim
                                            Ketorolac Tromethamine Ophth Soln 0.5%                       ACULAR, ACULAR PF         Package Limit=1/claim; Step Therapy

OTIC AGENTS
                (Generic: FLOXIN OTIC)      Ofloxacin Otic Soln 0.3%                                                               Package Limit=1/claim
                                            Fluocinolone Acetonide (Otic) Oil 0.01%                      DERMOTIC
                                            Hydrocortisone w/ Acetic Acid Otic Soln 1-2%                                           Package Limit=1/claim
                                            Acetic Acid Otic Soln 2%                                                               Package Limit=1/claim
                                            Acetic Acid 2% in Aluminum Acetate Otic Soln
                (Generic: DEBROX)           Carbamide Peroxide 6.5% Otic Soln                                                      Package Limit=1/claim
                                            Ciprofloxacin-Dexamethasone Otic Susp 0.3-0.1%               CIPRODEX                  Package Limit=1/claim
                (Generic: CORTISPORIN,      Neomycin-Polymyxin-HC Otic Susp 3.5 MG/ML-10000 U/ML-                                  Package Limit=1/claim
                PEDIOTIC)                   1%
                (Generic: CORTISPORIN)      Neomycin-Polymyxin-HC Otic Soln 1%                                                     Package Limit=1/claim
                                            Benzocaine-Antipyrine Otic Soln 1.4-5.4%
                (Generic: CORTANE-B,        Pramoxine-HC-Chloroxylenol Otic Soln 10-10-1 MG/ML
                OTICIN HC)
                (Generic: CORTANE-B)        Pramoxine-HC-Chloroxylenol Aqueous Otic Soln 10-10-
                                            1MG/ML

MOUTH/THROAT/DENTAL AGENTS
                                           Nystatin Susp 100000 U/ML                                                               Package Limit=1/claim
                (Generic: PERIDEX)         Chlorhexidine Gluconate Soln 0.12%
                                           Zinc Lozenge 15 MG
                                           Triamcinolone Acetonide in Orabase 0.1%                                                 Package Limit=1/claim
                (Generic: XYLOCAINE)       Lidocaine HCl Viscous Soln 2%                                                           Package Limit=1/claim
                (Generic: PREVIDENT)       Sodium Fluoride Cream 1.1%                                                              Package Limit=1/claim
                (Generic: PREVIDENT, THERA-Sodium Fluoride Gel 1.1%                                                                Package Limit=1/claim
                FLUR-N)
                (Generic: PREVIDENT)       Sodium Fluoride Paste 1.1%                                                              Package Limit=1/claim

ANORECTAL AGENTS
             (Generic: ANUSOL-HC)           Hydrocortisone Rectal Cream 2.5%
             (Generic: ANUSOL-HC)           Hydrocortisone Acetate Suppos 25 MG                                                    Daily Dosage=2
             (Generic: CORTENEMA)           Hydrocortisone Enema 100 MG/60ML                                                       Package Limit=1/claim
                                            Hydrocortisone Acetate w/ Pramoxine Rectal Cream 1-1%        ANALPRAM-HC               Package Limit=1/claim

                                            Hydrocortisone Acetate w/ Pramoxine Rectal Cream 2.5-1%      ANALPRAM-HC               Max Qty=30/claim

                                            Hydrocortisone Acetate w/ Pramoxine Rectal Lotn 2.5-1%       ANALPRAM-HC               Package Limit=1/claim

                (Generic: PREPARATION)      Phenyleph-Shark Liver Oil-Cocoa Butter Suppos 0.25-3-85.5%                             Package Limit=1/claim

                (Generic: PREPARATION)      Phenylephrine-Shark Liver Oil-MO-Pet Oint 0.25-3-14-71.9%                              Package Limit=1/claim
                                                                                                                                                                         54
  Therapeutic                                                                            Covered Brand Product
    Class         Common Brand Name(s)   Product Description                              (unless FFQL or PA)    Limitations/Restrictions

DERMATOLOGICALS
             (Generic: BENZAC AC,        Benzoyl Peroxide Liq 5%
             BENZAC W, DESQUAM-X)
             (Generic: BENZAC AC,        Benzoyl Peroxide Liq 10%
             BENZAC W, DESQUAM-X)
             (Generic: BENZAC AC,        Benzoyl Peroxide Gel 2.5%
             BENZAC W)
             (Generic: BENZAC AC,        Benzoyl Peroxide Gel 5%
             BENZAC W, BENZAGEL-5,
             DESQUAM-E, DESQUAM-X)
                (Generic: BENZAC AC,     Benzoyl Peroxide Gel 10%
                BENZAC W, BENZAGEL-10,
                DESQUAM-E, DESQUAM-X)
                                         Benzoyl Peroxide Lotion 5%
                                         Benzoyl Peroxide Lotion 10%
                                         Benzoyl Peroxide-Sulfur Lotion 5-2%           SULFOXYL                  Max Qty=60/claim
                                         Benzoyl Peroxide-Sulfur Lotion 10-5%          SULFOXYL                  Max Qty=60/claim
                (Generic: ACCUTANE)      Isotretinoin Cap 10 MG                                                  Limited to Ages 12 and Older; Daily Dosage=2

                (Generic: ACCUTANE)      Isotretinoin Cap 20 MG                                                  Limited to Ages 12 and Older; Daily Dosage=2

                (Generic: ACCUTANE)      Isotretinoin Cap 40 MG                                                  Limited to Ages 12 and Older; Daily Dosage=2

                (Generic: RETIN-A)       Tretinoin Cream 0.025%                                                  Max Qty=20/claim
                (Generic: RETIN-A)       Tretinoin Cream 0.05%                                                   Max Qty=20/claim
                (Generic: RETIN-A)       Tretinoin Cream 0.1%                                                    Max Qty=20/claim
                (Generic: RETIN-A)       Tretinoin Gel 0.01%                                                     Max Qty=15/claim
                (Generic: RETIN-A)       Tretinoin Gel 0.025%
                (Generic: CLEOCIN-T)     Clindamycin Phosphate Soln 1%
                (Generic: CLEOCIN-T)     Clindamycin Phosphate Gel 1%                  CLINDAGEL                 Package Limit=1/claim
                (Generic: CLEOCIN-T)     Clindamycin Phosphate Lotion 1%                                         Package Limit=1/claim
                                         Erythromycin Soln 2%
                (Generic: ERYGEL)        Erythromycin Gel 2%
                                         Erythromycin Oint 2%                          AKNE-MYCIN                Package Limit=1/claim
                (Generic: KLARON)        Sulfacetamide Sodium Lotion 10% (Acne)                                  Package Limit=1/claim
                (Generic: PLEXION TS)    Sulfacetamide Sodium w/ Sulfur Susp 10-5%                               Package Limit=1/claim
                (Generic: NOVACET,       Sulfacetamide Sodium w/ Sulfur Lotion 10-5%                             Package Limit=1/claim
                SULFACET-R)
                (Generic: METROCREAM)    Metronidazole Cream 0.75%                                               Package Limit=1/claim
                                         Metronidazole Gel 0.75%                                                 Package Limit=1/claim
                (Generic: METROLOTION)   Metronidazole Lotion 0.75%
                (Generic: BACIGUENT)     Bacitracin Oint 500 U/GM                                                Package Limit=1/claim
                                         Bacitracin Zinc Oint 500 U/GM
                                         Gentamicin Sulfate Cream 0.1%                                           Package Limit=1/claim
                                         Gentamicin Sulfate Oint 0.1%                                            Package Limit=1/claim
                (Generic: BACTROBAN)     Mupirocin Oint 2%                                                       Package Limit=1/claim                 55
Therapeutic                                                                                   Covered Brand Product
  Class         Common Brand Name(s)       Product Description                                 (unless FFQL or PA)    Limitations/Restrictions
                                           Mupirocin Calcium Cream 2%                       BACTROBAN                 Package Limit=1/claim
                                           *Bacitracin-Polymyxin B Powder***                POLYSPORIN
              (Generic: POLYSPORIN)        *Bacitracin-Polymyxin B Oint***
              (Generic: NEOSPORIN,         *Neomycin-Bacitracin-Polymyxin Oint***                                     Package Limit=1/claim
              TRIPLE ANTIB)
              (Generic: MYCOSTATIN)        *Nystatin Topical Powder**                                                 Package Limit=1/claim
                                           Nystatin Cream 100000 U/GM                                                 Package Limit=1/claim
                                           Nystatin Oint 100000 U/GM                                                  Package Limit=1/claim
              (Generic: NP-27, TINACTIN)   Tolnaftate Cream 1%                              TINEACIDE                 Max Qty=30/claim
              (Generic: LAMISIL AT,        Terbinafine HCl Cream 1%                                                   Package Limit=1/claim
              LAMISIL AT C)
              (Generic: LOTRIMIN AF,       Clotrimazole Soln 1%                                                       Max Qty=30/claim
              MYCELEX OTC)
              (Generic: LOTRIMIN AF,       Clotrimazole Cream 1%                                                      Package Limit=1/claim
              MYCELEX OTC)
                                           Ketoconazole Cream 2%                                                      Package Limit=1/claim
                                           Ketoconazole Shampoo 1%                          NIZORAL A-D               Package Limit=1/claim
              (Generic: NIZORAL)           Ketoconazole Shampoo 2%                                                    Package Limit=1/claim
              (Generic: MICATIN, MICATIN   Miconazole Nitrate Cream 2%                                                Package Limit=1/claim
              JOCK, MONISTAT)
              (Generic: LOTRISONE)         Clotrimazole w/ Betamethasone Cream 1-0.05%                                Package Limit=1/claim
              (Generic: LOTRISONE)         Clotrimazole w/ Betamethasone Lotion 1-0.05%                               Package Limit=1/claim
                                           Nystatin-Triamcinolone Cream 100000-0.1 U/GM-%                             Package Limit=1/claim
                                           Nystatin-Triamcinolone Oint 100000-0.1 U/GM-%                              Package Limit=1/claim
              (Generic: BENADRYL M-S)      Diphenhydramine HCl Cream 2%                                               Package Limit=1/claim
              (Generic: DERMAREST)         Diphenhydramine HCl Gel 2%
              (Generic: BENADRYL,          Diphenhydramine-Zinc Acetate Cream 1-0.1%
              BENADRYL ITC)
              (Generic: DOVONEX)           Calcipotriene Soln 0.005% (50 MCG/ML)                                      Package Limit=1/claim
                                           Calcipotriene Cream 0.005%                       DOVONEX                   Package Limit=1/claim
                                           Tazarotene Cream 0.05%                           TAZORAC                   Package Limit=1/claim
                                           Tazarotene Cream 0.1%                            TAZORAC                   Package Limit=1/claim
                                           Tazarotene Gel 0.05%                             TAZORAC                   Package Limit=1/claim
                                           Tazarotene Gel 0.1%                              TAZORAC                   Package Limit=1/claim
              (Generic: SELSUN BLUE)       Selenium Sulfide Lotion 1%                                                 Package Limit=1/claim
              (Generic: SELSUN)            Selenium Sulfide Lotion 2.5%                                               Package Limit=1/claim
              (Generic: OVACE WASH)        Sulfacetamide Sodium Liquid 10%                                            Package Limit=1/claim
              (Generic: CARMOL SCALP)      Sulfacetamide Sodium-Urea Lotion 10-10%
                                           Acyclovir Cream 5%                               ZOVIRAX                   Package Limit=1/claim
                                           Acyclovir Oint 5%                                ZOVIRAX                   Package Limit=1/claim
              (Generic: EFUDEX)            Fluorouracil Soln 2%                                                       Package Limit=1/claim
              (Generic: EFUDEX)            Fluorouracil Soln 5%                                                       Package Limit=1/claim
                                           Fluorouracil Cream 0.5%                          CARAC                     Package Limit=1/claim
              (Generic: EFUDEX)            Fluorouracil Cream 5%                                                      Package Limit=1/claim
              (Generic: SILVADENE)         Silver Sulfadiazine Cream 1%                                               Package Limit=1/claim
              (Generic: ACLOVATE)          Alclometasone Dipropionate Cream 0.05%
                                           Betamethasone Dipropionate Cream 0.05%                                     Package Limit=1/claim      56
Therapeutic                                                                                   Covered Brand Product
  Class         Common Brand Name(s)    Product Description                                    (unless FFQL or PA)    Limitations/Restrictions
                                        Betamethasone Dipropionate Lotion 0.05%                                       Package Limit=1/claim
                                        Betamethasone Dipropionate Oint 0.05%                                         Package Limit=1/claim
              (Generic: DIPROLENE AF)   Augmented Betamethasone Dipropionate Cream 0.05%                              Package Limit=1/claim
                                        Augmented Betamethasone Dipropionate Gel 0.05%                                Package Limit=1/claim
              (Generic: DIPROLENE)      Augmented Betamethasone Dipropionate Lotion 0.05%                             Package Limit=1/claim
              (Generic: DIPROLENE)      Augmented Betamethasone Dipropionate Oint 0.05%                               Package Limit=1/claim
                                        Betamethasone Valerate Cream 0.1%                                             Package Limit=1/claim
                                        Betamethasone Valerate Lotion 0.1%                                            Package Limit=1/claim
                                        Betamethasone Valerate Oint 0.1%                                              Package Limit=1/claim
              (Generic: TEMOVATE)       Clobetasol Propionate Soln 0.05%                                              Package Limit=1/claim
              (Generic: TEMOVATE)       Clobetasol Propionate Cream 0.05%                                             Package Limit=1/claim
              (Generic: TEMOVATE)       Clobetasol Propionate Gel 0.05%                                               Package Limit=1/claim
              (Generic: TEMOVATE)       Clobetasol Propionate Oint 0.05%                                              Package Limit=1/claim
              (Generic: TEMOVATE,       Clobetasol Propionate Emollient Base Cream 0.05%                              Package Limit=1/claim
              TEMOVATE E)
              (Generic: DESOWEN)        Desonide Cream 0.05%                                                          Package Limit=1/claim
              (Generic: DESOWEN)        Desonide Lotion 0.05%                                                         Package Limit=1/claim
              (Generic: DESOWEN)        Desonide Oint 0.05%                                                           Package Limit=1/claim
              (Generic: TOPICORT LP)    Desoximetasone Cream 0.05%                                                    Package Limit=1/claim
              (Generic: TOPICORT)       Desoximetasone Cream 0.25%                                                    Package Limit=1/claim
              (Generic: TOPICORT)       Desoximetasone Gel 0.05%                                                      Package Limit=1/claim
              (Generic: TOPICORT)       Desoximetasone Oint 0.25%                                                     Package Limit=1/claim
              (Generic: SYNALAR)        Fluocinolone Acetonide Soln 0.01%                   FLUOCIN ACET              Package Limit=1/claim
                                        Fluocinolone Acetonide Cream 0.01%                                            Package Limit=1/claim
              (Generic: SYNALAR)        Fluocinolone Acetonide Cream 0.025%                 FLUOCIN ACET              Package Limit=1/claim
              (Generic: SYNALAR)        Fluocinolone Acetonide Oint 0.025%                                            Package Limit=1/claim
              (Generic: LIDEX)          Fluocinonide Soln 0.05%                                                       Package Limit=1/claim
              (Generic: LIDEX)          Fluocinonide Cream 0.05%                                                      Package Limit=1/claim
              (Generic: LIDEX)          Fluocinonide Gel 0.05%                                                        Package Limit=1/claim
              (Generic: LIDEX)          Fluocinonide Oint 0.05%                                                       Package Limit=1/claim
              (Generic: LIDEX-E)        Fluocinonide Emulsified Base Cream 0.05%                                      Package Limit=1/claim
              (Generic: ULTRAVATE)      Halobetasol Propionate Cream 0.05%                                            Package Limit=1/claim
              (Generic: ULTRAVATE)      Halobetasol Propionate Oint 0.05%                                             Package Limit=1/claim
                                        Hydrocortisone Cream 0.5%                                                     Package Limit=1/claim
              (Generic: PROCTOCORT)     Hydrocortisone Cream 1%                                                       Package Limit=1/claim
              (Generic: HYTONE)         Hydrocortisone Cream 2.5%                                                     Package Limit=1/claim
                                        Hydrocortisone Lotion 1%                                                      Package Limit=1/claim
                                        Hydrocortisone Lotion 2.5%                                                    Package Limit=1/claim
                                        Hydrocortisone Oint 2.5%                                                      Package Limit=1/claim
              (Generic: ANUSERT HC-1,   Hydrocortisone Acetate Oint 1%
              ANUSOL HC-1, TUCKS)
              (Generic: WESTCORT)       Hydrocortisone Valerate Cream 0.2%                                            Package Limit=1/claim
              (Generic: WESTCORT)       Hydrocortisone Valerate Oint 0.2%                                             Package Limit=1/claim
              (Generic: LOCOID)         Hydrocortisone Butyrate Soln 0.1%
              (Generic: LOCOID)         Hydrocortisone Butyrate Cream 0.1%
              (Generic: LOCOID)         Hydrocortisone Butyrate Oint 0.1%
              (Generic: ELOCON)         Mometasone Furoate Solution 0.1% (Lotion)                                     Package Limit=1/claim      57
Therapeutic                                                                                 Covered Brand Product
  Class         Common Brand Name(s)       Product Description                               (unless FFQL or PA)    Limitations/Restrictions
              (Generic: ELOCON)            Mometasone Furoate Cream 0.1%                  ELOCON                    Package Limit=1/claim
              (Generic: ELOCON)            Mometasone Furoate Oint 0.1%                                             Package Limit=1/claim
                                           Triamcinolone Acetonide Cream 0.025%                                     Package Limit=2/claim
              (Generic: ARISTOCORT A,      Triamcinolone Acetonide Cream 0.1%                                       Package Limit=1/claim
              KENALOG)
                                          Triamcinolone Acetonide Cream 0.5%                                        Package Limit=1/claim
                                          Triamcinolone Acetonide Lotion 0.025%                                     Package Limit=1/claim
              (Generic: KENALOG)          Triamcinolone Acetonide Lotion 0.1%                                       Package Limit=1/claim
                                          Triamcinolone Acetonide Oint 0.025%                                       Package Limit=1/claim
              (Generic: KENALOG)          Triamcinolone Acetonide Oint 0.1%                                         Package Limit=1/claim
                                          Triamcinolone Acetonide Oint 0.5%                                         Package Limit=1/claim
                                          Pramoxine-HC Aerosol Foam 1-1%                  EPIFOAM
              (Generic: LAC-HYDRIN)       Lactic Acid (Ammonium Lactate) Cream 12%                                  Package Limit=1/claim
              (Generic: LAC-HYDRIN)       Lactic Acid (Ammonium Lactate) Lotion 12%                                 Package Limit=1/claim
                                          Urea Cream 40%                                                            Package Limit=1/claim
              (Generic: CARMOL 40)        Urea Lotion 40%                                                           Package Limit=1/claim
              (Generic: CONDYLOX)         Podofilox Soln 0.5%                                                       Package Limit=1/claim
              (Generic: KERALYT)          Salicylic Acid Gel 6%                                                     Package Limit=1/claim
                                          Salicylic Acid Gel 3%                           KERALYT                   Package Limit=1/claim
                                          Imiquimod Cream 5%                              ALDARA                    Max Qty=12/31 days; Min DS=28
                                          Capsicum Oleoresin Cream 0.025%
                                          Capsicum Oleoresin Cream 0.075%
              (Generic: ZOSTRIX)          Capsaicin Cream 0.025%                                                    Package Limit=1/claim
                                          Capsaicin Cream 0.035%                          CAPZASIN-P
                                          Dibucaine Oint 1%                                                         Package Limit=1/claim
                                          Lidocaine Oint 5%                                                         Package Limit=1/claim
              (Generic: LIDAMANTLE)       Lidocaine HCl Cream 3%
              (Generic: XYLOCAINE)        Lidocaine HCl Gel 2%                                                      Package Limit=1/claim
              (Generic: EMLA)             Lidocaine-Prilocaine Cream 2.5-2.5%                                       Max Qty=30/claim
                                          Crotamiton Cream 10%                            EURAX                     Package Limit=1/claim
                                          Crotamiton Lotion 10%                           EURAX                     Package Limit=1/claim
                                          Permethrin Liq Spray 0.25%                      NIX LICE
              (Generic: NIX COMPLETE, NIX Permethrin Creme Rinse 1%
              CREME)
                                          Permethrin Aerosol 0.4%                         PRONTO
                                          Permethrin Aerosol 0.5%
              (Generic: ELIMITE)          Permethrin Cream 5%                                                       Package Limit=1/claim
                                          Permethrin Lotion 1%                                                      Package Limit=1/claim
                                          *Nit Remover - Shampoo***                       KLOUT
                                          *Nit Remover - Kit***                           KLOUT LICE
              (Generic: RID)              Pyrethrins-Piperonyl Butoxide Liq 0.3-3%
                                          Pyrethrins-Piperonyl Butoxide Liq 0.33-4%
                                          Pyrethrins-Piperonyl Butoxide Foam 0.33-4%      RID LICE KIL
                                          Pyrethrins-Piperonyl Butoxide Gel 0.3-3%
                                          Pyrethrins-Piperonyl Butoxide Gel 0.33-4%       A-200
              (Generic: TEGRIN-LT)        Pyrethrins-Piperonyl Butoxide Shampoo 0.3-3%
              (Generic: PRONTO)           Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4%                                                             58
  Therapeutic                                                                                           Covered Brand Product
    Class         Common Brand Name(s)    Product Description                                            (unless FFQL or PA)      Limitations/Restrictions
                (Generic: PRONTO)         Pyrethrins-Piperonyl Butoxide Shampoo Kit
                                          Pyrethrins Spray & Pyrethins-Piperonyl Butoxide Shamp Kit

                                          Pyreth-Piper But Spray & Pyreth-Piper But Shamp Kit         LICE COMBIN, LICIDE
                                                                                                      TREAT, TEGRIN-LT, TISIT
                (Generic: A-200)          Permethrin Spray & Pyrethins-Piperonyl Butoxide Shamp Kit

                (Generic: RID COMPLETE)   Pyreth-Piperonyl Butox Sham-Permeth Aero-Nit Remover Gel
                                          Kit
                (Generic: DRYSOL)         Aluminum Chloride Soln 20%
                (Generic: EUCERIN)        *Skin Protectants Misc - Cream***                           BASIS FACIAL, BASIS OVER,
                                                                                                      DAMOR TISSUE,
                                                                                                      DERMAGRAN BC,
                                                                                                      DERMALINE...


ANTISEPTICS & DISINFECTANTS
                                          Chlorhexidine Gluconate Liquid 4%

ANTIDOTES
                                          Ipecac Syrup                                                GNP IPECAC, IPECAC, QC
                                                                                                      IPECAC, RA IPECAC, V-R
                                                                                                      IPECAC
                                          Succimer Cap 100 MG                                         CHEMET
                (Generic: REVIA)          Naltrexone HCl Tab 50 MG

DIAGNOSTIC PRODUCTS
                                          Acetone (Urine) Test Strip                                  CHEK-STIX, CHEMSTRIP K,
                                                                                                      KETOCARE, KETOSTIX,
                                                                                                      RELION KETON
                                          Glucose Blood Test Strip                                    ONE-TOUCH, TRUE TRACK       NDC 56151085050 TRUETRACK TES: Max
                                                                                                                                  Qty=200/30 days; Daily Dosage=5

MEDICAL DEVICES
                                          Insulin Syringe (Disp) U-100 1 ML                           INSULIN SYRG                Daily Dosage=5
                                          Insulin Syringe/Needle U-100 0.3 ML 28 x 1/2"               INSULIN SYRG                Daily Dosage=5
                                          Insulin Syringe/Needle U-100 0.3 ML 29 x 1/2"               INS SYRINGE, INSULIN        Daily Dosage=5
                                                                                                      SYRG
                                          Insulin Syringe/Needle U-100 0.3 ML 30 x 3/8"               INSULIN SYRG                Daily Dosage=5
                                          Insulin Syringe/Needle U-100 0.3 ML 30 x 5/16"              INSULIN SYRG                Daily Dosage=5
                                          Insulin Syringe/Needle U-100 0.3 ML 30 x 1/2"               INS SYRINGE, INSULIN        Daily Dosage=5
                                                                                                      SYRG
                                          Insulin Syringe/Needle U-100 0.3 ML 30 x 7/16"              INSULIN SYRG                Daily Dosage=5
                                          Insulin Syringe/Needle U-100 1/2 ML 27 x 1/2"               INSULIN SYRG                Daily Dosage=5
                                          Insulin Syringe/Needle U-100 0.3 ML 28 G x 1"               INSULIN SYRG                Daily Dosage=5
                                          Insulin Syringe/Needle U-100 1/2 ML 29 x 7/16"              INSULIN SYRG                Daily Dosage=5
                                          Insulin Syringe/Needle U-100 1/2 ML 30 x 3/8"               INSULIN SYRG                Daily Dosage=5
                                          Insulin Syringe/Needle U-100 1/2 ML 30 x 7/16"              INSULIN SYRG                Daily Dosage=5                59
Therapeutic                                                                             Covered Brand Product
  Class       Common Brand Name(s)   Product Description                                  (unless FFQL or PA)   Limitations/Restrictions
                                     Insulin Syringe/Needle U-100 1/2 ML 30 G x 1"    INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1/2 ML 31 x 5/16"   INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1/2 ML 28 x 1/2"    INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1/2 ML 29 x 1"      INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1/2 ML 28 x 1"      INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1/2 ML 29 x 5/16"   INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1/2 ML 29 x 1/2"    INS SYRINGE, INSULIN      Daily Dosage=5
                                                                                      SYRG
                                     Insulin Syringe/Needle U-100 1/2 ML 30 x 5/16"   INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1/2 ML 30 x 1/2"    INS SYRINGE, INSULIN      Daily Dosage=5
                                                                                      SYRG
                                     Insulin Syringe/Needle U-100 1 ML 25 x 5/8"      INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1 ML 25 x 1"        INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1 ML 26 x 1/2"      INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1 ML 27 x 1/2"      INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1 ML 27 x 5/8"      INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1 ML 28 x 5/16"     INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1 ML 28 x 1/2"      INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1 ML 30 G x 1"      INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1 ML 29 x 7/16"     INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1 ML 29 x 1/2"      INS SYRINGE, INSULIN      Daily Dosage=5
                                                                                      SYRG
                                     Insulin Syringe/Needle U-100 1 ML 29 x 1"        INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1 ML 29 x 5/16"     INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1 ML 30 x 5/16"     INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1 ML 30 x 7/16"     INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 1 ML 30 x 1/2"      INS SYRINGE, INSULIN      Daily Dosage=5
                                                                                      SYRG
                                     Insulin Syringe/Needle U-100 1 ML 31 x 5/16"     INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 0.3 ML 31 x 5/16"   INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 2 ML 27.5 x 5/8"    INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 2 ML 29 x 1/2"      INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 0.3 ML 29 x 7/16"   INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 0.3 ML 29 x 5/16"   INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 0.3 ML 29 x 1"      INSULIN SYRG              Daily Dosage=5
                                     Insulin Syringe/Needle U-100 0.3 ML 30 x 1"      INSULIN SYRG              Daily Dosage=5
                                     *Insulin Pen Needle***                           PEN NEEDLES, ULTILET      Max Qty=150/30 days
                                                                                      PEN, UNIFINE PNTP
                                     Insulin Pen Needle 29 G X 12 MM                  AUTOSHIELD, EASY TOUCH,   Max Qty=150/30 days
                                                                                      INSULIN PEN, INSUPEN
                                                                                      ULTR, LB PEN NEEDL...

                                     Insulin Pen Needle 29 G X 12.7 MM                PEN NEEDLES, SURE-FINE, Max Qty=150/30 days
                                                                                      ULTR-THIN II
                                     Insulin Pen Needle 30 G X 8 MM                   INSUPEN ULTR, NOVOFINE, Max Qty=150/30 days
                                                                                      NOVOFINE AUT
                                                                                                                                           60
  Therapeutic                                                                                          Covered Brand Product
    Class         Common Brand Name(s)   Product Description                                            (unless FFQL or PA)     Limitations/Restrictions
                                         Insulin Pen Needle 31 G X 5 MM                              PEN NEEDLES, RA PEN        Max Qty=150/30 days
                                                                                                     NEEDL, SURE COMFORT,
                                                                                                     SURE-FINE
                                         Insulin Pen Needle 31 G X 6 MM                              CLICKFINE, EASY TOUCH, Max Qty=150/30 days
                                                                                                     INSUPEN ULTR, NOVOFINE
                                                                                                     31, PEN NEEDLES...
                                         Insulin Pen Needle 31 G X 8 MM                              BD UF SHORT, CLICKFINE, Max Qty=150/30 days
                                                                                                     EASY TOUCH, INSULIN PEN,
                                                                                                     INSUPEN ULTR...
                                         *Respiratory Therapy Supplies - Misc**                      ACE AERO CLD, ACTIVITY Max Qty=1/360 days
                                                                                                     PCH, ADULT MASK,
                                                                                                     AEROSOL MASK, AEROTRC
                                                                                                     PLUS...
                                         *Spacer/Aerosol-Holding Chambers - Device***                AERCHMBR PLS,              Max Qty=1/360 days
                                                                                                     AERCHMBR Z-,
                                                                                                     AEROCHAMBER,
                                                                                                     BREATHERITE, E-Z
                                                                                                     SPACER...
                                         *Spacer/Aerosol-Holding Chamber Supplies - Bags***          INSPIREASE                 Max Qty=3/180 days
                                         *Spacer/Aerosol-Holding Chamber Supplies - Mouthpieces***   INSPIREASE                 Max Qty=1/180 days

                                         *Blood Glucose Calibration - Liquid***                      ONE-TOUCH, TRUE TRACK      Max Qty=1/90 days
                                         *Blood Glucose Calibration - Liquid - High***               ONE-TOUCH, TRUE TRACK      Max Qty=1/90 days
                                         *Blood Glucose Calibration - Liquid - Normal***             ONE-TOUCH, TRUE TRACK      Max Qty=1/90 days
                                         *Blood Glucose Calibration - Liquid - Low***                ONE-TOUCH, TRUE TRACK      Max Qty=1/90 days
                                         *Blood Glucose Monitoring Devices****                       ONE-TOUCH, TRUE TRACK      Max Qty=1/720 days
                                         *Blood Glucose Monitoring Kit w/ Device****                 ONE-TOUCH, TRUE TRACK      Max Qty=1/720 days
                                         *Lancets****                                                ONE-TOUCH, TRUE TRACK      Max Qty=200/30 days
                                         *Lancet Devices****                                         ADVOCATE, ALTRNATE SIT,    Max Qty=1/180 days
                                                                                                     AUTO-LANCET, AUTO-
                                                                                                     LANCETS, AUTOLET LANC...

                                         Condoms Latex Lubricated                                    ATLAS CONDOM, CLASS        Max Qty=36/30 days
                                                                                                     ACT, ELEXA, EXTRA
                                                                                                     SENSIT, FANTASY...
                                         *Alcohol Swabs***                                           ALCOHOL, ALCOHOL PREP, Max Qty=400/claim
                                                                                                     ALCOHOL SWAB, BD
                                                                                                     SWABS, CURITY PREP...



PHARMACEUTICAL ADJUVANTS
                                         Sorbitol                                                    SORBITOL

ASSORTED CLASSES
                                         Penicillamine Cap 125 MG                                    CUPRIMINE
                                         Penicillamine Cap 250 MG                                    CUPRIMINE
                (Generic: SANDIMMUNE)    Cyclosporine Cap 25 MG                                                                 7 day supply retail; specialty med   61
Therapeutic                                                                                     Covered Brand Product
  Class         Common Brand Name(s)   Product Description                                       (unless FFQL or PA)    Limitations/Restrictions
              (Generic: SANDIMMUNE)    Cyclosporine Cap 100 MG                                                          7 day supply retail; specialty med
              (Generic: SANDIMMUNE)    Cyclosporine Oral Soln 100 MG/ML                                                 7 day supply retail; specialty med
              (Generic: NEORAL)        Cyclosporine Modified Cap 25 MG                                                  7 day supply retail; specialty med
                                       Cyclosporine Modified Cap 50 MG                                                  7 day supply retail; specialty med
              (Generic: NEORAL)        Cyclosporine Modified Cap 100 MG                                                 7 day supply retail; specialty med
              (Generic: NEORAL)        Cyclosporine Modified Oral Soln 100 MG/ML                                        7 day supply retail; specialty med
                                       Mycophenolate Mofetil Cap 250 MG                        CELLCEPT                 7 day supply retail; specialty med
                                       Mycophenolate Mofetil Tab 500 MG                        CELLCEPT                 7 day supply retail; specialty med
                                       Mycophenolate Mofetil For Oral Susp 200 MG/ML           CELLCEPT                 7 day supply retail; specialty med
                                       Mycophenolate Sodium Tab DR 180 MG (Mycophenolic Acid   MYFORTIC                 7 day supply retail; specialty med
                                       Equiv)
                                       Mycophenolate Sodium Tab DR 360 MG (Mycophenolic Acid   MYFORTIC                 7 day supply retail; specialty med
                                       Equiv)
                                       Sirolimus Tab 1 MG                                      RAPAMUNE                 7 day supply retail; specialty med
                                       Sirolimus Tab 2 MG                                      RAPAMUNE                 7 day supply retail; specialty med
                                       Sirolimus Oral Soln 1 MG/ML                             RAPAMUNE                 7 day supply retail; specialty med
                                       Tacrolimus Cap 0.5 MG                                   PROGRAF                  7 day supply retail; specialty med
                                       Tacrolimus Cap 1 MG                                     PROGRAF                  7 day supply retail; specialty med
                                       Tacrolimus Cap 5 MG                                     PROGRAF                  7 day supply retail; specialty med
              (Generic: IMURAN)        Azathioprine Tab 50 MG                                                           7 day supply retail; specialty med
                                       Azathioprine Tab 75 MG                                  AZASAN                   7 day supply retail; specialty med
                                       Azathioprine Tab 100 MG                                 AZASAN                   7 day supply retail; specialty med
                                       Sodium Polystyrene Sulfonate Oral Susp 15 GM/60ML
              (Generic: KAYEXALATE)    Sodium Polystyrene Sulfonate Powder                                              Max Qty=454/claim




                                                                                                                                                             62
Medication                                           Page   Medication                                               Page
A-200                                                58      ALCOHOL, ALCOHOL PREP, ALCOHOL SWAB, BD SWABS,           61
                                                             CURITY PREP...
Abacavir Sulfate                                      4      ALDACTAZIDE                                              20
Abacavir Sulfate-Lamivudine-Zidovudine                5      ALDACTONE                                                20
ABILIFY                                              37      ALDARA                                                   58
ACCOLATE                                             28      Alendronate Sodium                                       13
ACCUPRIL                                             17      Alendronate Sodium-Cholecalciferol                       13
ACCUTANE                                             56      ALESSE,LEVLITE                                           10
ACE AERO CLD, ACTIVITY PCH, ADULT MASK, AEROSOL      61      ALEVE                                                    43
MASK, AEROTRC PLUS...
Acebutolol HCl                                       14      ALKA-SELT+                                               24
Acetaminophen                                        41      ALKA-SELTZER                                             26
Acetaminophen w/ Codeine                             42      ALKERAN                                                  6
Acetaminophen w/ DM                                  24      ALLEGRA                                                  22
Acetazolamide                                        19      ALLERX-D                                                 23
Acetic Acid 2% in Aluminum Acetate                   54      Allopurinol                                              44
Acetic Acid Otic Soln                                54      Almotriptan Malate                                       44
Acetone Urine Test Strip                             59      ALOCRIL                                                  53
Acetylcysteine Inhal Soln                            22      ALOMIDE                                                  53
ACLOVATE                                             56      ALORA, ESTRADERM, VIVELLE, VIVELLE-DOT                   9
ACTIGALL                                             31      ALORA, VIVELLE-DOT                                       9
ACTOPLUS MET                                         12      Alprazolam                                               33
ACTOS                                                12      ALTACE                                                   18
ACULAR, ACULAR PF                                    54      Altretamine                                              6
Acyclovir cream, ointment                            56      Alum & Mag Hydroxide-Simethicone                         30
Acyclovir oral                                        5      Aluminum & Magnesium Hydroxides                          30
ADALATCC                                             16      Aluminum Chloride                                        60
ADDERALL                                             38      Aluminum Hydroxide                                       30
ADDERALL XR                                          38      ALUPENT INH                                              27
ADRENALIN                                            22      Amantadine HCl                                           46
ADVAIR DISKU                                         27      AMARYL                                                   11
ADVAIR HFA                                           28      AMBIEN                                                   38
ADVIL,NUPRIN                                         43      Aminophylline                                            27
ADVILCOLD                                            23      Amiodarone HCl                                           17
ADVOCATE, ALTRNATE SIT, AUTO-LANCET, AUTO-LANCETS,   61      Amitriptyline HCl                                        34
AUTOLET LANC...
AERCHMBR PLS, AERCHMBR Z-, AEROCHAMBER,              61      Amlodipine Besylate                                      15
BREATHERITE, E-Z SPACER...

AGENERASE                                             4      Amlodipine Besylate-Benazepril HCl                       19
AKNE-MYCIN                                           55      Amoxapine                                                35
AKWATEARS,LACRI-LUBE,MOISTUREEYE,REFRESH-PM          53      AMOXICILLIN                                              1

ALBALON,NAPHCONFORT                                  53      Amoxicillin & K Clavulanate                              1
ALBATUSSIN, GUACOL DM                                25      Amoxicillin Trihydrate                                   1
Albuterol                                            26      AMOXIL                                                   1
Albuterol Sulfate tablet                             26      Amphetamine-Dextroamphetamine                            38
Albuterol-Ipratropium                                27      AMPICILLIN                                               1
Alclometasone Dipropionate                           56      Ampicillin                                               1
Alcohol Swabs                                        61      Amprenavir                                               4




             Index                                                                                    Page 1 of 19
             Bridgeway Health Solutions                                                                 11/11/2008
Medication                                       Page   Medication                                                Page
Amylase-Lipase-Protease                           31    ATRIPLA                                                   5
Amy-Lip-Prot DR Particles                         32    Atropine Sulfate                                          53
Amy-Lip-Prot EC Particles                         31    ATROVENT HFA                                              27
ANAFRANIL                                         35    ATROVENTNAS                                               22
ANALPRAM-HC                                       54    Attapulgite                                               29
ANAPROX                                           44    ATUSSG                                                    26
ANAPROX DS                                        44    Augmented Betamethasone Dipropionate                      57
ANASPAZ,LEVSIN                                    30    AUGMENTIN                                                 1
Anastrozole                                       7     AUTOSHIELD, EASY TOUCH, INSULIN PEN, INSUPEN ULTR,        61
                                                        LB PEN NEEDL...
ANDRODERM                                         8     AVANDAMET                                                 12
ANDROXY                                           8     AVANDARYL                                                 12
ANEXSIA                                           42    AVANDIA                                                   12
ANEXSIA,LORCETPLUS                                42    AXERT                                                     44
ANSAID                                            43    AXID AR                                                   30
ANTABUSE                                          40    AYGESTIN                                                  11
ANTIOXIDANT, B-50 FORMULA, BACMIN, BONE SMART,    48    AYR NASAL                                                 23
CENTRUM CARB...
ANTIVERT                                          30    AYR SALINE, NASOGEL                                       23
ANUSERTHC-1,ANUSOLHC-1,TUCKS                      57    AZASAN                                                    62
ANUSOL-HC                                         54    BIAXINXL                                                  3
APAP-Isometheptene-Dichloral                      44    Azathioprine                                              64
Apraclonidine HCl                                 53    Azelastine HCl                                            54
APRESOLINE                                        19    Azithromycin                                              2
APTIVUS                                           4     AZITHROMYCIN, ZITHROMAX                                   3
ARALEN                                            6     AZMACORT                                                  28
ARICEPT                                           39    AZOPT                                                     54
ARIMIDEX                                          7     AZULFIDINE                                                32
Aripiprazole                                      37    BACIGUENT                                                 55
ARISTOCORTA,KENALOG                               57    Bacitracin                                                55
ARMOUR THYRO                                      13    Bacitracin Ophth Oint                                     52
AROMASIN                                          7     Bacitracin Zinc                                           55
ARTANE                                            46    Bacitracin-Polymyxin B                                    52
Artificial Tear Ophth Ointment                    52    Bacitracin-Polymyxin B Oint                               55
ASACOL                                            31    Bacitracin-Polymyxin B Powder                             55
Ascorbic Acid                                     47    Baclofen                                                  46
Aspirin                                           40    BACTRIM,SEPTRA                                            6
Aspirin Buffered                                  40    BACTRIMDS,SEPTRADS                                        6
Aspirin Buffered Ca Carb-Mg Carb-Mg Ox            40    BACTROBAN                                                 55
Aspirin Buffered Mg Carbonate-Al Aminoace         40    BASIS FACIAL, BASIS OVER, DAMOR TISSUE, DERMAGRAN         59
                                                        BC, DERMALINE...
Aspirin w/ Codeine                                42    BAYERCHILD                                                40
Atazanavir Sulfate                                4     B-Complex Vitamin Tab                                     47
Atenolol                                          15    B-Complex w/ C Cap                                        47
Atenolol & Chlorthalidone                         19    BD GLUCOSE                                                12
ATIVAN                                            33    BD UF SHORT, CLICKFINE, EASY TOUCH, INSULIN PEN,          60
                                                        INSUPEN ULTR...
ATLAS CONDOM, CLASS ACT, ELEXA, EXTRA SENSIT,     61    Beclomethasone Dipropionate                               28
FANTASY...




               Index                                                                               Page 2 of 19
               Bridgeway Health Solutions                                                            11/11/2008
Medication                                         Page   Medication                                            Page
Beclomethasone Dipropionate Monohyd                 22    Brinzolamide                                           54
BECONASE AQ                                         22    BROMFED                                                23
Belladonna Alkaloids-Phenobarbital                  29    Bromocriptine Mesylate                                 46
BENADRYL                                            21    Brompheniramine & Phenylephrine                        23
BENADRYL ALL, BENADRYL-D                            23    Brompheniramine & Pseudoephedrine                      23
BENADRYL,BENADRYLDF                                 21    Budesonide Inhal                                       27
BENADRYL,BENADRYLITC                                54    BUFFERIN                                               40
BENADRYLALL                                         21    Bumetanide                                             20
BENADRYLDEC                                         23    BUMEX                                                  20
BENADRYLM-S                                         55    Bupropion HCl                                          35
BENAPHEN                                            23    Bupropion HCl Smoking Deterrent                        39
Benazepril & Hydrochlorothiazide                    19
Benazepril HCl                                      17    BUSPAR                                                 33
Benazepril HCl-Amlodipine Besylate                  19    Buspirone HCl                                          33
BENTYL                                              29    Busulfan                                               6
BENZACAC,BENZACW,BENZAGEL-10,DESQUAM-               55    Butalbital-Acetaminophen                               41
E,DESQUAM-X
BENZACAC,BENZACW,BENZAGEL-5,DESQUAM-E,DESQUAM-      54    Butalbital-Acetaminophen-Caff w/ COD                   42
X
Benzocaine-Antipyrine                               54    Butalbital-Acetaminophen-Caffeine                      41
Benzonatate                                         23    Butoconazole Nitrate                                   32
Benzoyl Peroxide                                    55    CAFERGOT                                               44
Benztropine Mesylate                                46    CALAN                                                  16
BETAGAN                                             52    CALANSR,ISOPTINSR                                      16
Betamethasone Dipropionate                          56    Calcipotriene solution                                 56
Betamethasone Valerate                              56    Calcipotriene cream                                    56
BETAPACE                                            14    Calcitonin Salmon                                      13
BETAPACEAF                                          15    Calcitriol                                             47
Betaxolol HCl                                       52    Calcium 500 MG w/ Vitamin D Tab                        50
Bethanechol Chloride                                32    Calcium Acetate Phosphate Binder                       32
BETOPTIC-S                                          52    Calcium Carbonate Antacid                              30
BIAXIN                                               3    Calcium Carbonate-Vitamin D                            51
Bicalutamide                                         7    CALNA                                                  48
Bisacodyl                                           28    CAL-NATE, VINATE CAL                                   50
Bismuth Subsalicylate                               28    Capecitabine                                           7
Bisoprolol & Hydrochlorothiazide                    19    CAPOTEN                                                17
Bisoprolol Fumarate                                 15    CAPOZIDE                                               19
BL GLUCOSE, CVS GLUCOSE, DD GLUCOSE, DE GLUCOSE,    12    Capsaicin                                              58
DEX4 GLUCOSE...
BLEPH-10                                            52    Capsicum Oleoresin                                     58
BLEPHAMIDE, PREDNIS/SULF, SULF/PREDNIS              53    Captopril                                              17

Blood Glucose Calibration - Liquid                  60    Captopril & Hydrochlorothiazide                        19
Blood Glucose Monitoring Devices                    61    CAPZASIN-P                                             58
Blood Glucose Monitoring Kit w/ Device              61    CARAC                                                  56
BRETHINE                                            27    CARAFATE                                               30
BREVICON,MODICON                                    10    Carbachol Ophth                                        53
Brimonidine Tartrate                                53    Carbamazepine                                          45




              Index                                                                              Page 3 of 19
              Bridgeway Health Solutions                                                           11/11/2008
Medication                                           Page   Medication                                              Page
Carbamide Peroxide                                     54   Chlorhexidine Gluconate                                  58
Carbidopa                                              46   Chlorhexidine Gluconate Soln                             54
Carbidopa & Levodopa                                   46   Chloroquine Phosphate                                     6
CARDENZ,LYSIPLEX,ONE-A-DAY,THERAGRAN                   47   Chlorphen Tan-Pyrilamine Tan-PE Tan                      24
CARDIZEM                                               15   CHLORPHENIR                                              21
CARDIZEMCD                                             16   Chlorpheniramine & Phenylephrine                         23
CARDURA                                                18   Chlorpheniramine & Pseudoephedrine                       23
Carisoprodol                                           46   Chlorpheniramine Maleate                                 21
CARMOL40                                               56   Chlorpheniramine Tan-Phenylephrine Tan                   24
CARMOLSCALP                                            56   Chlorpheniramine-DM                                      25
CAROMEGA,CENTRUM,COMPLERE,FEMTABS,FOSFREE...           48   Chlorpheniramine-PE-Methscopolamine                      24

Carvedilol                                             15   Chlorphen-Pseudoephedrine w/ APAP                        24
Carvedilol Phosphate                                   15   Chlorpromazine HCl                                       36
CASODEX                                                7    Chlorthalidone                                           20
CATAFLAM                                               43   CHLOR-TRIMET                                             21
CATAPRES                                               18   Chlorzoxazone                                            46
CEENU                                                  6    Cholestyramine Light Powder                              21
CEFACLOR                                               1    Cholestyramine Powder                                    21
Cefaclor                                               1    CILOXAN                                                  52
Cefdinir                                               2    Cimetidine HCl                                           30
Cefprozil                                              2    CIPRO                                                    3
CEFTIN                                                 2    CIPRODEX                                                 54
Cefuroxime Axetil                                      2    Ciprofloxacin HCl                                        52
CEFZIL                                                 2    Ciprofloxacin HCl                                        3
CELEBREX                                               43   Ciprofloxacin-Dexamethasone                              54
CELEXA                                                 34   Citalopram Hydrobromide                                  34
CELLCEPT                                               61   CITRACAL,CITRANATAL                                      51
CENOGENULTR                                            50   Clarithromycin                                           3
CEPACOLCHLD                                            23   CLARITIN,CLARITINRDT                                     22
Cephalexin                                             1    CLARITIN-D                                               24
CERALYTE 50, CERASPORT, ENFALYTE, PEDIALYTE            51   CLEARCOUGH                                               27

Cetirizine HCl                                         22   Clemastine Fumarate                                      21
Cetirizine-Pseudoephedrine                             23   CLEOCIN                                                  6
CHANTIX                                                40   CLEOCIN PED                                              6
CHEK-STIX, CHEMSTRIP K, KETOCARE, KETOSTIX, RELION     59   CLEOCIN-T                                                55
KETON
CHEMET                                                 59   CLEOCINVAG                                               33
CHERACOL,CHERACOL-D                                    26   CLICKFINE, EASY TOUCH, INSUPEN ULTR, NOVOFINE            61
                                                            31, PEN NEEDLES...
CHILD ADVIL, CHILD MOTRIN                              43   CLIMARA                                                  9
CHILDADVIL,CHILDMOTRIN,MOTRIN                          43   CLINDAGEL                                                55
CHILDMOTRIN                                            23   Clindamycin                                              6
CHILDMOTRIN                                            43   Clindamycin Palmitate HCl                                6
Chloral Hydrate                                        38   Clindamycin Phosphate                                    55
Chlorambucil                                           6    Clindamycin Phosphate Vaginal Cream                      33
Chlordiazepoxide HCl                                   33   CLINORIL                                                 44




             Index                                                                                   Page 4 of 19
             Bridgeway Health Solutions                                                                11/11/2008
Medication                                       Page   Medication                                      Page
Clobetasol Propionate                            57      Cromolyn Sodium Nasal Aerosol                   23
Clomipramine HCl                                 34      Cromolyn Sodium Ophth Soln                      53
Clonazepam                                       44      Cromolyn Sodium Soln Nebu                       27
Clonidine HCl                                    18      Crotamiton                                      58
Clopidogrel Bisulfate                            52      CUPRIMINE                                       61
Clorazepate Dipotassium                          33      CVS ACETAMIN                                    41
Clotrimazole                                     32      CVS MILK OF                                     29
Clotrimazole w/ Betamethasone                    56      Cyanocobalamin                                  51
Clozapine                                        36      CYCLESSA                                        10
CLOZARIL                                         36      Cyclobenzaprine HCl                             46
Codeine Sulfate                                  42      CYCLOGYL                                        53
CODIMALDH                                        24      Cyclopentolate HCl                              53
CODIMALDM                                        25      CYCLOPHOSPH                                      6
COLACE                                           29      Cyclophosphamide                                 6
Colchicine                                       44      Cyclosporine                                    62
Colchicine w/ Probenecid                         44      Cyproheptadine HCl                              22
COLYTE,COLYTE/FLAVR                              29      CYTOMEL                                         12
COMBIPATCH                                        9      CYTOTEC                                         30
COMBIVENT                                        28      CYTOXAN                                          6
COMBIVIR                                          5      D.H.E.45                                        44
COMPAZINE                                        37      DALLERGY                                        24
CONCERTA                                         39      DALLERGY                                        24
Condoms Latex Lubricated                         61      DALMANE                                         38
CONDYLOX                                         57      DANTRIUM                                        47
Conjugated Estrogen-Medroxyprogest Acetate        9      Dantrolene Sodium                               47
CORDARONE                                        17      Dapsone                                          6
COREG                                            15      DAPSONE                                          6
COREG CR                                         15      Darunavir                                        4
CORGARD                                          14      DARVOCET-N                                      42
CORICIDIN                                        26      DARVON                                          42
CORTANE-B,OTICINHC                               54      DAYPRO                                          44
CORTEF                                            8      DAYTIME                                         26
CORTENEMA                                        54      DDAVP                                           13
Cortisone Acetate Tab 25 MG                       7      DEBROX                                          54
CORTISPORIN,PEDIOTIC                             54      DECON-A                                         23
COSOPT                                           52      DECONAMINE                                      24
COUMADIN                                         51      DILANTIN                                        45
COZAAR                                           18      Delavirdine Mesylate                             5
CREON 10, PALCAPS 10, PANCRON 10, PANGES CN 10   30      DELSYM                                          23

CREON 20, PALCAPS 20, PANCRON 20, PANGES CN 20   31      DELTUSS DMX                                     25

CREON 5                                          30      DEMADEX                                         20
CRIXIVAN                                          4      DEMEROL                                         41
CROLOM                                           53      DEPAKENE                                        45
Cromolyn Sodium Inhal Aerosol                    27      DEPAKOTE                                        45




               Index                                                                     Page 5 of 19
               Bridgeway Health Solutions                                                  11/11/2008
Medication                                 Page   Medication                                               Page

DEPO-PROVERA                               9       Diflunisal                                               40
DERMAREST                                  56      Digoxin                                                  13
DERMOTIC                                   54      Dihydroergotamine Mesylate                               44
Desipramine HCl                            35      DILACORXR                                                15
Desmopressin Acetate                       13      DILANTIN-125                                             45
DESOGEN,DESOGEN-28,ORTHO-CEPT               9      DILAUDID                                                 41
Desogestrel & Ethinyl Estradiol G           9      Diltiazem HCl                                            15
Desonide                                   57      DIMETAPP                                                 25
DESOWEN                                    57      DIMETAPP                                                 23
Desoximetasone                             57      DIOVAN                                                   18
DETROL                                     32      DIOVAN HCT                                               19
DETROL LA                                  32      Diphenhydramine & Pseudoephedrine                        24
DEXAMETHASON                                7      Diphenhydramine HCl                                      21
Dexamethasone                               7      Diphenhydramine HCl                                      56
Dexamethasone Sodium Phosphate             52      Diphenhydramine HCl Elixir 12.5 MG/5ML                   21
Dexchlorpheniramine Maleate                21      Diphenhydramine HCl Sleep                                38
DEXEDRINE                                  38      Diphenhydramine-Zinc Acetate Cream                       56
Dextroamphetamine Sulfate                  38      Diphenoxylate w/ Atropine                                29
Dextromethorphan HBr                       23      Dipivefrin HCl                                           53
Dextromethorphan Polistirex                23      DIPROLENE                                                57
Dextromethorphan-APAP-Chlorpheniramine     27      DIPROLENEAF                                              57
Dextromethorphan-Doxylamine-APAP           27      Dipyridamole                                             52
Dextromethorphan-Guaifenesin               26      Disopyramide Phosphate                                   17
Dextromethorphan-Phenylephrine-APAP        26      Disulfiram Tab 250 MG                                    40
Dextromethorphan-Pot Guaiacolsulfonate     26      DITROPAN                                                 32
DEXTROSTAT                                 38      DITROPANXL                                               32
DIABETA, GLYBURIDE                         11      Divalproex Sodium                                        45
DIABETIC                                   27      DM-Pot Guaiacolsulfonate                                 26
DIAMOX                                     20      Docusate Sodium                                          29
DIASTAT ACDL                               44      Dofetilide                                               17
DIASTAT PED                                44      DOLOPHINE                                                41
Diazepam                                   33      DONATUSSIN                                               27
Diazepam Rectal Gel Delivery System        44      Donepezil Hydrochloride                                  39
Dibucaine                                  57      DONNATAL                                                 29
DICLOFENAC                                 43      Dorzolamide HCl Ophth Soln                               54
Diclofenac Potassium                       43      Dorzolamide-Timolol Ophth Soln                           52
Diclofenac Sodium                          43      DOVONEX                                                  56
Diclofenac Sodium Ophth                    54      Doxazosin Mesylate                                       18
Dicloxacillin Sodium                        1      Doxepin HCl                                              35
Dicyclomine                                29      Doxycycline Hyclate                                      3
Didanosine                                  4      DRISDOL                                                  47
Didanosine For Soln                         4      Drospirenone-Ethinyl Estradiol                           9
DIFLUCAN                                    4      DRYSOL                                                   59
DIFLUNISAL                                 40      DULCOLAX                                                 29




              Index                                                                         Page 6 of 19
              Bridgeway Health Solutions                                                      11/11/2008
Medication                                    Page   Medication                                                 Page
DUONEB                                        27      ERYC                                                       2
DUO-VIL                                       40      ERYGEL                                                    55
DUO-VIL, PERPHEN/AMIT                         40      ERYPED                                                     2
DURAHISTPE                                    24      ERYPED 400                                                 2
DURATUSSG                                     23      ERY-TAB, ERYTHROMYCIN                                      2
DYAZIDE                                       20      ERYTHROMYCIN                                               2
DYGASE, KUTRASE                               31      Erythromycin                                               2
DYNACIN                                        3      Erythromycin & Sulfisoxazole                               6
Dyphylline Tab 400 MG                         28      Erythromycin Ethylsuccinate                                2
E.E.S.GRAN,ERYPED200                           2      Erythromycin Ophth Oint                                   52
ECONOPREDPL,OMNIPRED,PREDFORTE                53      Erythromycin Soln                                         55
ECOTRIN,THERAPBAYER                           40      ESGIC                                                     41
ECOTRINM/S                                    40      ESGIC,FIORICET                                            41
Efavirenz                                      5      ESGIC-PLUS                                                41
Efavirenz-Emtricitabine-Tenofovir DF           5      ESTRACE                                                    8
EFFEXOR                                       34      ESTRACE VAG                                               32
EFFEXOR XR                                    34      Estradiol                                                  8
EFUDEX                                        56      Estradiol TD Patch                                         9
ELDEPRYL                                      46      Estradiol-Norethindrone Ace                                9
Eletriptan Hydrobromide                       44      Estramustine Phosphate                                     7
ELIMITE                                       58      Estrogens                                                  8
ELIXOPHYLLIN                                  28      Estrogens, Conjugated Vaginal Cream                       32
ELOCON                                        58      Estropipate                                                9
EMCYT                                          7      Ethionamide                                                3
EMLA                                          58      ETHMOZINE                                                 16
Emtricitabine                                  5      Ethosuximide                                              45
Emtricitabine-Tenofovir Disoproxil Fumarate    5      Ethynodiol Diacetate & Ethinyl Estradiol                  10

EMTRIVA                                        5      Etodolac                                                  43
E-MYCIN, ERY-TAB                               2      Etonogestrel-Ethinyl Estradiol VA Ring                     9

Enalapril Maleate                             17      Etoposide                                                  7
Enalapril Maleate & Hydrochlorothiazide       19      Etravirine                                                 5
Enoxaparin Sodium                             51      EUCERIN                                                   59
ENZYCAP, KU-ZYME, LAPASE                      30      EURAX                                                     59
ENZYMAX                                       30      EVAC,KONSYL                                               29
EPIFOAM                                       58      EVISTA                                                    13
Epinephrine HCl                               22      Exemestane                                                 7
Epinephrine HCl Inj Device                    20      EXTENDRYL                                                 24
EPIPEN, EPIPEN 2-PAK                          20      Famotidine                                                30
EPIPEN-JR                                     20      FARESTON                                                   7
EPIVIR                                         5      Felbamate                                                 45
EPZICOM                                        5      FELBATOL                                                  45
EQUALYTE,PEDIALYTE                            51      FELDENE                                                   44
Ergocalciferol                                47      Felodipine                                                16
Ergotamine w/ Caffeine                        44      FEMARA                                                     7




             Index                                                                               Page 7 of 19
             Bridgeway Health Solutions                                                            11/11/2008
Medication                                  Page   Medication                                               Page
Fenofibrate                                 21     FML S.O.P.                                               53
FEOSOL                                      51     FMLLIQUIFLM                                              52
FERGON                                      51     Folic Acid                                               51
FERROUS GLUC                                51     FORADIL                                                  26
Ferrous Gluconate                           51     Formoterol Fumarate                                      26
Ferrous Sulfate                             51     FOSAMAX                                                  13
Fexofenadine                                22     FOSAMAX + D                                              13
Finasteride                                 32     Fosamprenavir Calcium                                     4
FIORICET/COD                                42     Fosinopril Sodium                                        17
FIORINAL                                    41     Fosinopril Sodium & Hydrochlorothiazide                  19
FIORINAL/COD                                42     Furosemide                                               20
FLAGYL                                       6     Gabapentin                                               45
Flavoxate HCl                               33     GABARONE                                                 45
Flecainide Acetate                          17     GABITRIL                                                 45
FLEET                                       29     Ganciclovir                                               5
FLEXERIL                                    46     GANCICLOVIR                                               5
FLONASE                                     22     GANTRIS PED                                               3
FLORINEF                                     8     GARAMYCIN                                                52
FLOVENT DISK                                28     GARAMYCIN, GENTAMICIN                                    52
FLOVENT HFA                                 28     GAS-X,MYLANTAGAS                                         31
FLOXINOTIC                                  54     Gemfibrozil                                              21
Fluconazole                                 4      GENECOF-XP                                               26
Fludrocortisone Acetate                      8     Gentamicin Sulfate                                       52
FLUMADINE                                    6     Gentamicin Sulfate                                       56
Flunisolide                                 22     Gentamicin-Prednisolone Ace                              53
FLUOCIN ACET                                57     GEODON                                                   37
Fluocinolone Acetonide                      57     GERITOLEXT,STRESSTABS                                    48
Fluocinolone Acetonide Otic Oil             54     GESTICARE                                                49
Fluocinonide                                57     GLEEVEC                                                   7
Fluorometholone                             52     Glimepiride                                              11
Fluorouracil                                57     Glipizide                                                11
Fluoxetine HCl                              34     Glipizide-Metformin HCl                                  12
Fluoxetine HCl PMDD                         40     GLUCAGEN                                                 11
Fluoxymesterone                              8     Glucagon HCl rDNA For Inj                                11
Fluphenazine Decanoate                      36     Glucagon rDNA For Inj Kit                                11
Fluphenazine HCl                            36     GLUCOPHAGE                                               11
Flurazepam HCl                              38     Glucose Blood Test Strip                                 59
Flurbiprofen                                43     Glucose Chew Tab                                         12
Flurbiprofen Sodium                         54     GLUCOTROL                                                11
Flutamide                                    7     GLUCOTROLXL                                              11
Fluticasone Propionate                      22     GLUCOVANCE                                               12
Fluticasone Propionate HFA                  27     Glyburide                                                11
Fluticasone-Salmeterol                      27     Glyburide-Metformin                                      12
Fluvoxamine Maleate                         34     Glycerin Suppos                                          28




               Index                                                                         Page 8 of 19
               Bridgeway Health Solutions                                                      11/11/2008
Medication                                      Page   Medication                                               Page
GLYNASE                                         11      Hydrocortisone Cream                                     57
GNP IPECAC, IPECAC, QC IPECAC, RA IPECAC, V-R   59      Hydrocortisone Rectal Cream                              54
IPECAC
GOLYTELY                                        29      Hydrocortisone Valerate                                  57
GRIFULVINV                                       4      Hydrocortisone w/ Acetic Acid                            54
Griseofulvin Microsize                           4      Hydromorphone HCl                                        41
Griseofulvin Ultramicrosize                      4      Hydroxychloroquine Sulfate                               6
GRIS-PEG                                         4      Hydroxyurea                                              7
GRIS-PEG, GRISEOFULVIN                           4      Hydroxyzine HCl                                          33
Guaifenesin                                     23      Hydroxyzine Pamoate                                      33
Guaifenesin-Codeine                             26      Hyoscyamine Sulfate                                      29
GUAIMAX-D                                       25      HYTONE                                                   57
Guanabenz Acetate                               18      HYTRIN                                                   18
Guanfacine HCl                                  18      HYZAAR                                                   19
GYNAZOLE-1                                      32      IBERET-500,IBERET-FOLIC                                  50
GYNE-LOTRIM,MYCELEX-7                           32      Ibuprofen                                                43
GYNE-LOTRIMI                                    32      ICAR                                                     51
HALCION                                         38      Imatinib Mesylate                                        7
HALDOLDECAN                                     36      IMDUR                                                    14
Halobetasol Propionate                          57      IMIPRAM PAM, TOFRANIL-PM                                 35
Haloperidol                                     36      Imipramine HCl                                           35
Haloperidol Decanoate                           36      Imipramine Pamoate                                       35
Haloperidol Lactate                             36      Imiquimod Cream                                          57
Heparin Sodium Porcine Inj                      51      IMITREX                                                  44
HEXALEN                                          6      IMURAN                                                   62
HISTEX                                          23      Indapamide                                               20
Homatropine HBr                                 53      INDERAL                                                  14
HUMALOG MIX, HUMALOG PEN                        11      INDERALLA                                                14
HUMIBID                                         23      INDERIDE                                                 19
HUMULIN                                         11      Indinavir Sulfate                                        4
HYCODAN                                         23      INDOCINSR                                                43
HYCOTUSSEXP                                     26      Indomethacin                                             43
Hydralazine & HCTZ                              20      INS SYRINGE, INSULIN SYRG                                60
Hydralazine HCl                                 19      INSPIREASE                                               61
HYDREA                                           7      Insulin Aspart & Aspart Prot Human Inj                   11

Hydrochlorothiazide                             20      Insulin Glargine Inj                                     11
Hydrocodone w/ Homatropine Syrup                23      Insulin Isophane & Regular Human Inj                     11
Hydrocodone-Acetaminophen                       42      Insulin Isophane Human                                   11
Hydrocodone-Guaifenesin                         26      Insulin Lispro Prot & Lispro Human Inj                   11

Hydrocortisone                                  57      Insulin Pen Needle                                       61
Hydrocortisone                                   8      Insulin Regular Human                                    11
Hydrocortisone Acetate                          54      INSULIN SYRG                                             60
Hydrocortisone Acetate Oint                     57      Insulin Syringe Disp                                     60
Hydrocortisone Acetate w/ Pramoxine             55      Insulin Syringe/Needle                                   61
Hydrocortisone Butyrate                         57      INSUPEN ULTR, NOVOFINE, NOVOFINE AUT                     61




              Index                                                                              Page 9 of 19
              Bridgeway Health Solutions                                                           11/11/2008
Medication                                  Page   Medication                                               Page
INTAL                                        27     KLOR-CON-25                                              50
INTAL 112, INTAL 200, INTAL INH              27     KLOUT                                                    59
INTELENCE                                    5      KLOUT LICE                                               59
INVIRASE                                     4      K-LYTE-ORANG                                             50
IOPIDINE                                     53     KPN                                                      49
Ipecac Syrup                                 59     KROGER VITAM                                             47
Ipratropium Bromide                          23     K-TABS                                                   50
Iron Chew Tab                                51     KU-ZYME-HP                                               30
Iron w/ Vitamin Tab CR                       50     Labetalol HCl                                            15
ISENTRESS                                    4      LAC-HYDRIN                                               57
ISMO,MONOKET                                 14     Lactic Acid Ammonium                                     57
ISO CARBACHO                                 53     LACTOCAL-F                                               49
ISO HOMATROP                                 53     Lactulose Encephalopathy                                 31
ISOATROPINE                                  53     Lactulose Solution                                       28
ISOCARBACHO                                  53     LAMICTAL                                                 45
ISOCARPINE                                   53     LAMISILAT,LAMISILATC                                     56
ISOHOMATROP                                  53     Lamivudine                                               5
ISONIAZID                                    4      Lamivudine-Zidovudine                                    5
Isoniazid                                    3      Lamotrigine                                              45
ISOPTOCARP                                   53     Lancet Devices                                           61
ISORDIL                                      13     Lancets                                                  61
Isosorbide Dinitrate                         14     LANOXICAPS                                               13
Isosorbide Dinitrate SL                      14     LANOXIN                                                  13
Isosorbide Mononitrate                       14     Lansoprazole G                                           31
Isotretinoin                                 55     LANTUS, LANTUS FOR                                       11
KALETRA                                      5      LARIAM                                                   6
KAOPECTATE                                   29     LASIX                                                    20
KAYEXALATE                                   62     Latanoprost Ophth                                        53
K-DUR                                        51     Letrozole                                                7
K-DUR,K-TABS                                 51     LEUCOVOR CA                                              7
KEFLEX                                       1      Leucovorin Calcium                                       7
KENALOG                                      57     LEUKERAN                                                 6
KEPPRA                                       46     Levalbuterol Tartrate I                                  27
KERALYT                                      57     LEVAQUIN                                                 3
Ketoconazole                                 4      Levetiracetam                                            46
Ketoprofen                                   43     LEVLEN,LEVLEN-28,NORDETTE,NORDETTE-28                    10

KETOPROFEN                                   43     Levobunolol HCl                                          52
Ketorolac Tromethamine                       43     Levofloxacin                                             3
Ketotifen Fumarate                           54     Levonorgestrel                                           9
KGS-PE                                       25     Levonorgestrel & Ethinyl Estradiol                       10
KLARON                                       55     Levonorg-Eth Est                                         10
KLONOPIN                                     44     Levothyroxine Sodium                                     12
K-LOR                                        50     LEVSIN                                                   29
KLOR-CON M15                                 51     LEVSIN/SL                                                29




               Index                                                                        Page 10 of 19
               Bridgeway Health Solutions                                                     11/11/2008
Medication                                        Page   Medication                                                 Page
LEVSINEX                                          29     LORCET                                                     42
LEXIVA                                             4     LORTAB                                                     42
LIBRIUM                                           33     LORTAB10                                                   42
LICE COMBIN, LICIDE TREAT, TEGRIN-LT, TISIT       58     LORTAB5,VICODIN                                            42

LIDAMANTLE                                        58     LORTAB7.5                                                  42
LIDEX                                             57     Losartan Potassium                                         18
LIDEX-E                                           57     Losartan Potassium & Hydrochlorothiazide                   19
Lidocaine                                         58     LOTENSIN                                                   17
Lidocaine-Prilocaine                              58     LOTENSINHCT                                                19
Liothyronine Sodium                               12     LOTREL                                                     19
Liotrix                                           13     LOTRIMINAF,MYCELEXOTC                                      56
LIPRAM 4500, PANCRELIPASE, PANGESTYM EC,          30     LOTRISONE                                                  56
PANOCAPS, ULTRASE
LIPRAM-PN10, PANCREASE MT, PANCRELIPASE           30     Lovastatin                                                 21

LIPRAM-PN16, PANCREASE MT, PANCRELIPASE, PANGES   31     LOVENOX                                                    51
MT 16, PANOCAPS

LIPRAM-PN20, PANCREASE MT, PANCRELIPASE,          31     Loxapine Succinate                                         36
PANOCAPS
LIPRAM-UL12, PANGES UL 12, ULTRASE MT12           30     LOXITANE                                                   36

LIPRAM-UL18, PANGES UL 18, ULTRASE MT18           31     LUFYLLIN                                                   27

LIPRAM-UL20, PANGES UL 20, ULTRACAPS, ULTRASE     31     LURIDE                                                     50
MT20
LIQUIFILM                                         52     LUSONEX PLUS                                               25
Lisinopril                                        17     LYSODREN                                                   7
Lisinopril & Hydrochlorothiazide                  19     MAALOX SUS                                                 29
LITHIUM CARB                                      37     MACROBID                                                   32
Lithium Carbonate                                 37     MACRODANTIN                                                32
Lithium Citrate                                   37     Magnesium Citrate Soln                                     29
LITHOBID                                          37     Magnesium Hydroxide                                        29
LO/OVRAL,LO/OVRAL-28                              10     Magnesium Oxide                                            30
LOCOID                                            57     MAG-OX400                                                  30
LODOSYN                                           46     MANDELAMINE                                                32
Lodoxamide Tromethamine                           54     MAPROTILINE                                                35
LOESTRIN                                          10     Maprotiline HCl                                            35
LOESTRIN 24                                       10     MARNATAL-F                                                 50
LOESTRIN21                                        10     MAVIK                                                      18
LOESTRINFE                                        10     MAXAIR AUTOH                                               27
LOFIBRA                                           21     MAXITROL                                                   53
LOMOTIL                                           29     MAXZIDE                                                    20
Lomustine                                          7     MAXZIDE-25                                                 20
Loperamide HCl                                    29     Mebendazole                                                6
LOPID                                             21     Meclizine HCl                                              30
Lopinavir-Ritonavir                                5     MEDI-GRAINE                                                23
LOPRESSHCT                                        19     MEDROL                                                     8
LOPRESSOR                                         15     Medroxyprogesterone Acetate                                11
Loratadine                                        22     Mefloquine HCl                                             6
Loratadine & Pseudoephedrine                      24     MEGACEORAL                                                 7
Lorazepam                                         33     Megestrol Acetate                                          7




             Index                                                                                  Page 11 of 19
             Bridgeway Health Solutions                                                               11/11/2008
Medication                                Page   Medication                                          Page
Meloxicam                                 43     MICRONASE                                            11
Melphalan                                  6     MICROZIDE                                            20
Meperidine HCl                            41     Midodrine HCl                                        20
MEPHYTON                                  47     MIDRIN                                               44
Meprobamate                               33     MIGRANAL                                             44
Mercaptopurine                             7     MINIPRESS                                            18
Mesalamine                                31     MINOCIN                                              3
MESTINON                                  47     Minocycline HCl                                      3
METADATE                                  39     MINTEZOL                                             6
METADATE CD                               39     MIRALAX                                              29
METAGLIP                                  12     MIRCETTE                                             9
METAMUCIL                                 29     Mirtazapine                                          33
METAPROTEREN                              27     Misoprostol                                          30
Metaproterenol Sulfate                    27     MISSION PREN                                         49
Metformin HCl                             11     Mitotane                                             7
Methadone HCl                             41     MOBAN                                                36
Methazolamide                             20     MOBIC                                                43
Methenamine Mandelate                     31     Molindone HCl                                        36
METHERGINE                                13     Mometasone Furoate                                   57
Methimazole                               13     MONISTAT1,VAGISTAT-1                                 32
METHITEST                                  8     MONISTAT7                                            32
Methocarbamol                             46     MONOKET                                              14
Methotrexate Sodium                        7     MONOPRIL                                             17
Methyldopa                                18     MONOPRILHCT                                          19
Methylergonovine Maleate                  13     Montelukast Sodium                                   28
Methylphenidate HCl                       39     Moricizine HCl                                       17
Methyltestosterone                         8     MORPHINE SUL                                         41
Metoclopramide HCl                        31     Morphine Sulfate                                     42
Metolazone                                20     MOTRIN                                               43
Metoprolol & Hydrochlorothiazide          19     MSCONTIN                                             42
Metoprolol Succinate                      15     MSCONTIN,ORAMORPHSR                                  41
Metoprolol Tartrate                       15     MUCINEX                                              23
METROCREAM                                56     MUCINEX CGH                                          26
METROGEL-VAG                              32     MUCINEX CHLD                                         23
METROLOTION                               55     MUCINEX COLD                                         25
Metronidazole                             32     MUCINEX D                                            25
MEVACOR                                   21     MUCINEX DM                                           26
MEXILETINE                                17     MUCINEX JR                                           23
Mexiletine HCl                            17     MULTIDEXOL M                                         25
MIACALCIN                                 13     Multiple Vitamin Tab                                 47
MICATIN,MICATINJOCK,MONISTAT              56     Multiple Vitamins w/ Iron Tab                        48
MICONAZOLE 3                              32     Multiple Vitamins w/ Minerals Tab                    48
Miconazole Nitrate                        33     Mupirocin                                            55
MICRO-K                                   50     Mupirocin Calcium Cream                              55




             Index                                                                   Page 12 of 19
             Bridgeway Health Solutions                                                11/11/2008
Medication                                  Page   Medication                                                 Page

                                                                                                               52
Mupirocin Calcium Nasal                      22    NEOSPORIN
MYAMBUTOL                                    3     NEOSPORIN,TRIPLEANTIB                                       56
Mycophenolate Mofetil                        62    NESTABSCBF                                                  49
Mycophenolate Sodium                         62    NESTABSFA                                                   49
MYCOSTATIN                                   56    NESTABSRX                                                   49
MYDFRIN                                      53    NEURONTIN                                                   45
MYDRIACYL                                    53    NEUTRA-PHOS                                                 50
MYFORTIC                                     62    Nevirapine                                                  5
MYLANTA                                      29    Niacin                                                      47
MYLERAN                                      6     NIACIN TR                                                   47
MYLICON                                      31    Nicardipine HCl                                             16
MYNATAL                                      49    NICODERMCQ                                                  40
MYSOLINE                                     46    NICORETTE,NICORETTEST                                       40
Nabumetone                                   43    Nicotine Polacrilex                                         40
Nadolol                                      14    Nicotine TD Patch                                           40
Naltrexone HCl                               59    NIFEDIPINE                                                  16
Naphazoline HCl                              53    Nifedipine                                                  16
NAPROSYN                                     43    NILANDRON                                                   7
Naproxen                                     43    Nilutamide                                                  7
Naproxen Sodium                              43    Nit Remover - Kit                                           59
NARDIL                                       33    Nit Remover - Shampoo                                       59
NASACORT AQ                                  22    NITRO-BID                                                   14
NASALCROM                                    23    NITRO-DUR                                                   14
NASALIDE                                     22    Nitrofurantoin Macrocrystalline                             31
NASAREL                                      22    Nitroglycerin                                               14
NASONEX                                      22    NITROSTAT                                                   14
NATACHEW                                     49    NIX LICE                                                    58
NATALVIT                                     49    NIXCOMPLETE,NIXCREME                                        58
NATURE-THROI,WESTHROID                       13    Nizatidine                                                  30
NAVANE                                       37    NIZORAL Oral                                                4
NECON                                        10    NIZORAL A-D                                                 56
Nedocromil Sodium                            53    NOLVADEX                                                    7
Nedocromil Sodium Inhal Aerosol              26    NORCO                                                       42
Nefazodone HCl                               33    NORELDM                                                     25
Nelfinavir Mesylate                          4     Norelgestromin-Ethinyl Estradiol TD PTWK                    9
Neomycin Sulfate                             3     Norethindrone                                               9
Neomycin-Bacitracin Zn-Polymyx               52    Norethindrone & Ethinyl Estradiol                           10
Neomycin-Bacitracin-Polymyxin Oint           56    Norethindrone & Mestranol                                   10
Neomycin-Polymyxin B-Gramicidin              52    Norethindrone Ace-Ethinyl Estradiol-FE                      10
Neomycin-Polymyxin-Dexamethasone             53    Norethindrone Acetate                                       11
Neomycin-Polymyxin-HC Ophth                  53    Norethindrone-Eth Estradiol                                 10
Neomycin-Polymyxin-HC Otic                   54    Norgestimate & Ethinyl Estradiol                            10
Neomycin-Polymyxin-Prednisolone Ace Ophth    53    Norgestrel & Ethinyl Estradiol                              10
NEORAL                                       62    NORINYL,ORTHO-NOVUM                                         10




            Index                                                                             Page 13 of 19
            Bridgeway Health Solutions                                                          11/11/2008
Medication                                Page   Medication                                                        Page

NORPACE                                   17     ORTHO EVRA                                                         9
NORPRAMIN                                 35     ORTHO-CYCLEN                                                       10
NOR-QD,ORTHOMICRON                        9      ORTHO-NOVUM                                                        10
Nortriptyline HCl                         35     ORTHO-NOVUM                                                        10
NORVASC                                   15     ORTHOTRI-                                                          10
NORVIR                                    4      Oseltamivir Phosphate                                              6
NOVACET,SULFACET-R                        56     OVACE WASH                                                         56
NOVANATAL                                 50     OVCON-35                                                           10
NOVASTART                                 49     Oxaprozin                                                          44
NOVOLOG MIX                               11     Oxazepam                                                           33
NP-27,TINACTIN                            56     Oxcarbazepine                                                      46
NULYTELY                                  29     Oxcarbazepine Susp                                                 46
NUMONYLNR                                 25     Oxybutynin Chloride                                                32
NUTRICION                                 49     Oxycodone HCl                                                      42
NUVARING                                  9      Oxycodone w/ Acetaminophen                                         42
NYQUIL                                    25     Oxycodone w/ Aspirin                                               42
Nystatin                                  4      OXYIR                                                              42
Nystatin Oint                             56     Oyster Shell Calcium                                               50
Nystatin Susp                             54     PAMELOR                                                            35
Nystatin Topical Powder                   56     PANCREASE MT                                                       30
Nystatin-Triamcinolone                    56     PANCRECARB                                                         30
NYTOLMX-STR                               38     PANCRELIPASE, PANOKASE, PLARETASE, VIOKASE 8                       30

O-CAL                                     49     PANOKASE-16, VIOKASE 16                                            30
OCEANNASAL                                23     PARAFONFORT                                                        46
OCUFEN                                    54     PARLODEL                                                           46
OCUFLOX                                   52     PARNATE                                                            33
Ofloxacin                                 3      Paroxetine HCl                                                     34
Ofloxacin Ophth Soln                      52     PAXIL                                                              34
Ofloxacin Otic Soln                       54     PCE                                                                2
OGEN                                      9      PEDIACARE                                                          22
OGESTREL                                  10     PEDIACARE,ROBITUSSIN,TRIAMINIC                                     25
Olanzapine                                36     PEDIAPRED                                                          8
Olanzapine-Fluoxetine HCl                 40     Pediatric Multiple Vitamin w/ C & FA Chew Tab                      48
Omeprazole Magnesium                      30     Pediatric Multiple Vitamin w/ C Soln                               48
OMNICEF                                   2      Pediatric Multiple Vitamin w/ Minerals & C Chew                    48
OMNI-PAC,OMNICEF                          2      Pediatric Multiple Vitamins w/ Fl-Fe                               48
Ondansetron                               30     Pediatric Multiple Vitamins w/ Fluoride                            48
One-Touch                                 59     Pediatric Multiple Vitamins w/ Iron                                48
OPTIVAR                                   53     Pediatric Vitamins ACD Fluoride & Fe                               48
Oral Electrolyte Solution                 50     Pediatric Vitamins ADC                                             48
ORAMORPH SR                               41     PEDIAZOLE                                                          6
ORAPRED                                   8      PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate                             29
ORGANIDINNR                               23     PEG 3350-KCl-Sod Bicarb-NaCl                                       29
Orphenadrine Citrate                      46     PEN NEEDLES, RA PEN NEEDL, SURE COMFORT, SURE-FINE                 61




             Index                                                                                 Page 14 of 19
             Bridgeway Health Solutions                                                              11/11/2008
Medication                                                  Page   Medication                                                     Page
PEN NEEDLES, SURE-FINE, ULTR-THIN II                        61     Phenytoin                                                       45
PEN NEEDLES, ULTILET PEN, UNIFINE PNTP                      61     Phenytoin Sodium                                                45
Penicillamine                                               62     Phenytoin Susp                                                  45
Penicillin V Potassium                                       1     PHOSLO                                                          32
PENTASA                                                     31     PHRENILIN                                                       41
Pentoxifylline                                              52     Phytonadione                                                    47
PEPCID                                                      30     Pilocarpine HCl                                                 53
PEPCIDAC                                                    30     PINDOLOL                                                        14
PE-Pheniramine-COD-Sod Salicylate-Sod Cit-Caff Liquid       24     Pindolol                                                        14
PEPTO-BISMOL                                                30     Pioglitazone HCl                                                12
PERCOCET                                                    42     Pioglitazone HCl-Metformin HCl                                  12
PERCODAN                                                    42     Pirbuterol Acetate Breath Activated Inhal                       27
PERIDEX                                                     54     Piroxicam                                                       44
Permethrin                                                  59     PLAN B                                                          9
Permethrin Spray & Pyrethins-Piperonyl Butoxide Shamp Kit   59     PLAQUENIL                                                       6
PERPHEN/AMIT                                                40     PLAVIX                                                          52
Perphenazine                                                37     PLENDIL                                                         16
Perphenazine-Amitriptyline                                  40     PLEXIONTS                                                       55
PERRY PRENAT                                                49     PNEUMOTUSSIN                                                    26
PERSANTINE                                                  52     Podofilox                                                       58
PHANATUSS HC                                                26     Polyethylene Glycol 3350                                        29
PHENABIDDM                                                  25     Polyethylene Glycol-Polyvinyl                                   52
Phenazopyridine                                             33     Polymyxin B-Trimethoprim Ophth                                  52
Phenelzine Sulfate                                          34     POLY-PRED                                                       53
Phenir-PE w/ Sod Salicyl & Caff Cit                         24     POLYSPORIN                                                      56
PHENOBARB                                                   38     POLYTRIM                                                        52
Phenobarbital                                               38     POLY-TUSSIN                                                     25
Phenolphthalein-DSS                                         29     POLY-VI-FLOR                                                    48
Phenyleph-Chlorphen w/ DM-GG                                27     Polyvinyl Alcohol Ophth                                         52
Phenyleph-Chlorphen w/ Hydrocodone                          24     POLY-VI-SOL                                                     48
Phenyleph-Pyrilamine w/ Hydrocodone                         24     Potassium & Sodium Phosphates                                   50
Phenylephrine HCl Ophth                                     53     Potassium Bicarbonate Effer                                     50
Phenylephrine w/ Hydrocodone-GG Syrup                       26     Potassium Chloride                                              50
Phenylephrine-APAP-Caffeine                                 23     Potassium Chloride Microencapsulated CRYS CR                    51

Phenylephrine-APAP-GG                                       25     Potassium Citrate                                               33
Phenylephrine-Chlorphen-DM                                  25     Potassium Iodide                                                50
Phenylephrine-Chlorphen-GG                                  25     Pramoxine-HC Aerosol                                            58
Phenylephrine-GG-Potassium Citrate                          25     Pramoxine-HC-Chloroxylenol                                      54
Phenylephrine-Guaifenesin                                   25     PRAVACHOL                                                       21
Phenylephrine-Potassium Guaiacolsulfonate                   25     Pravastatin Sodium                                              21
Phenylephrine-Promethazine w/ Codeine                       24     Prazosin HCl                                                    18
Phenylephrine-Pyrilamine-DM                                 25     PRED MILD                                                       52
Phenylephrine-Shark Liver Oil-MO-Pet                        55     PRED SOD PHO                                                    52
Phenyleph-Shark Liver Oil-Cocoa Butter                      55     PRED-G                                                          52




             Index                                                                                                Page 15 of 19
             Bridgeway Health Solutions                                                                             11/11/2008
Medication                                      Page   Medication                                                       Page
Prednisolone                                     8      Prochlorperazine                                                 37
Prednisolone Acetate Ophth                       52     Prochlorperazine Maleate                                         37
Prednisolone Sodium Phosphate                    8      PROCTOCORT                                                       57
Prednisolone Sodium Phosphate Ophth              52     PROGRAF                                                          62
Prednisone                                       8      PROLEXDM                                                         26
PREDNISONE                                       8      PROLOPRIM,TRIMPEX                                                6
PRELONE                                          8      PROMETHAZINE                                                     22
PREMARIN                                         8      Promethazine & Phenylephrine                                     24
PREMARIN VAG                                     32     Promethazine HCl                                                 22
PREMPRO                                          9      Promethazine w/ Codeine                                          24
PRENATAL                                         49     Promethazine-DM                                                  25
Prenatal Multivitamins & Minerals w/ Fe & FA     49     PRONESTYL                                                        17
Prenatal Vit w/ DSS-Fe Fumarate-FA               50     PRONTO                                                           58
Prenatal Vit w/ DSS-Iron Carbonyl-FA             50     PROPINE                                                          53
Prenatal Vit w/ Fe Fumarate-FA                   49     Propoxyphene HCl                                                 42
Prenatal Vit w/ Fe Gluconate-FA                  49     Propoxyphene-N w/ APAP                                           42
Prenatal Vit w/ Fe Polysac Cmplx-FA              50     Propranolol & Hydrochlorothiazide                                19
Prenatal Vit w/ Fe Sulfate-FA                    49     Propranolol HCI                                                  14
Prenatal Vit w/ Iron Carbonyl-FA                 49     Propylthiouracil                                                 13
Prenatal Vit w/ Iron Carbonyl-Fe Gluc-FA         50     PROSCAR                                                          33
Prenatal Vit w/ Sel-Fe Fumarate-FA               50     PROVENTIL                                                        27
Prenatal Vitamin Fast Dissolving Tab             48     PROVERA                                                          10
Prenatal w/FE Polys Cmplx-FA-Ca Tab & Omega      50     PROZAC Oral                                                      34
Prenatal w/o A Vit w/ Fe Carbonyl-FA             50     PROZAC PMDD                                                      40
Prenatal w/o A Vit w/ Fe Fumarate-FA             50     Pseudoeph-Doxylamine-DM w/APAP                                   25
Prenatal without A w/ Fe Carbonyl-Docusate-FA    50     Pseudoephed-Bromphen-DM                                          25
PREPARATION                                      55     Pseudoephed-Chlorphen-DM                                         25
PREVACID                                         31     Pseudoephedrine HCl                                              22
PREVIDENT,THERA-FLUR-N                           54     Pseudoephedrine w/ Acetaminophen Liquid 15-160 MG/5ML            23

PREZISTA                                         4      Pseudoephedrine w/ APAP-DM                                       26
PRILOSEC OTC                                     31     Pseudoephedrine w/ COD-GG                                        26
PRIMAQUINE                                       6      Pseudoephedrine w/ Hydrocodone-GG                                26
Primaquine Phosphate                             6      Pseudoephedrine-DM                                               25
Primidone                                        46     Pseudoephedrine-DM-GG w/ APAP                                    27
PRINIVIL                                         17     Pseudoephedrine-Guaifenesin                                      25
PRINIVIL,ZESTRIL                                 18     Pseudoephedrine-Ibuprofen                                        23
PRINZIDE,ZESTORETIC                              19     Pseudoephedrine-Methscopolamine                                  23
PROAIR HFA, VENTOLIN HFA                         27     Psyllium                                                         29
PROAMATINE                                       20     PULMICORT                                                        28
Probenecid                                       45     PURINETHOL                                                       7
PROCAINAMIDE                                     17     Pyrantel Pamoate                                                 6
Procainamide HCl                                 17     Pyrazinamide                                                     4
PROCARDIA                                        16     Pyreth-Piper But Spray & Pyreth-Piper But Shamp Kit              59

PROCARDIAXL                                      16     Pyreth-Piperonyl Butox Sham-Permeth Aero-Nit Remover Gel Kit     59




             Index                                                                                      Page 16 of 19
             Bridgeway Health Solutions                                                                   11/11/2008
Medication                                        Page   Medication                                            Page
Pyrethrins Spray & Pyrethins-Piperonyl Butoxide   59     RISPERDAL                                              36

Pyrethrins-Piperonyl Butoxide                     59     Risperidone                                            36
PYRIDIUM                                          33     RITALIN                                                39
Pyridostigmine Bromide                            47     RITALINSR                                              39
Pyridoxine HCl                                    47     Ritonavir                                              4
QUESTRAN                                          21     RMS                                                    41
Quetiapine Fumarate                               36     ROBAXIN                                                46
QUIBRON-300                                       29     ROBAXIN-750                                            46
QUIBRON-TSR,THEO-DUR                              28     ROBITUSSIN                                             25
Quinapril HCl                                     18     ROBITUSSIN,ROBITUSSNDM                                 26
Quinidine Gluconate                               17     ROCALTROL                                              47
Quinidine Sulfate                                 17     RONDEC                                                 23
QVAR                                              28     RONDEC-DM                                              25
Raloxifene HCl                                    13     Rosiglitazone Maleate                                  12
Raltegravir Potassium                              4     Rosiglitazone Maleate-Glimepiride                      12
Ramipril                                          18     Rosiglitazone Maleate-Metformin HCl                    12
Ranitidine HCl                                    30     ROWASA                                                 31
RAPAMUNE                                          62     ROXANOL                                                41
RAPIFLUX                                          34     ROXICET                                                42
RECOFEN"D"                                        26     ROXICODONE                                             42
REGLAN                                            32     RYNATANPED                                             24
RELPAX                                            44     RYTHMOL                                                17
REMERON                                           33     Salicylic Acid                                         58
REMERONSLTB                                       33     Saline Nasal                                           23
RESCON-GG                                         25     Salmeterol Xinafoate Aer Pow                           27
RESCRIPTOR                                         5     Salsalate                                              40
Reserpine                                         18     SANDIMMUNE                                             62
Respiratory Therapy Supplies - Misc               61     Saquinavir Mesylate                                     4
RESTORIL                                          38     SARAFEM, SELFEMRA                                      40
RETIN-A                                           55     SCOT-TUSSIN                                            26
RETROVIR                                           5     SCOT-TUSSIN                                            26
REVIA                                             59     SEASONALE                                              10
REYATAZ                                            4     SEASONIQUE                                             10
RHEUMATREX                                        44     SECTRAL                                                15
Riboflavin                                        47     SEDAPAP                                                41
RICOTUSS                                          25     SELEGILINE                                             46
RID                                               58     Selegiline HCl                                         46
RID LICE KIL                                      58     Selenium Sulfide                                       56
RIDCOMPLETE                                       58     SELSUN                                                 56
RIFADIN                                           58     SELSUNBLUE                                             56
Rifampin                                           4     Senna                                                  29
RIGHT STEP                                        49     Sennosides                                             29
Rimantadine Hydrochloride                          6     Sennosides-Docusate Sodium                             29
Rimexolone Ophth                                  53     SENOKOT                                                29




             Index                                                                             Page 17 of 19
             Bridgeway Health Solutions                                                          11/11/2008
Medication                                       Page   Medication                                                 Page
SENOKOTS                                          29     STJOSEPH                                                   40
SERAX                                             33     STRESS FORMU                                               48
SEREVENT DIS                                      27     STUARTPREN                                                 49
SEROQUEL                                          36     Succimer                                                   59
SEROQUEL XR                                       36     Sucralfate                                                 31
Sertraline HCl                                    34     SUDAFED                                                    22
SILVADENE                                         56     SUDAFEDCHLD                                                22
Silver Sulfadiazine                               56     SULFACET SOD                                               52
Simethicone                                       32     Sulfacetamide Sodium                                       52
Simvastatin                                       21     Sulfacetamide Sodium w/ Sulfur                             55
SINEMET                                           46     Sulfacetamide Sodium-Prednisolone Ophth                    53

SINEMETCR                                         46     Sulfacetamide Sodium-Urea Lotion                           57
SINGULAIR                                         28     Sulfamethoxazole-Trimethoprim                              6
Sirolimus                                         62     Sulfasalazine                                              32
Skin Protectants Misc - Cream                     59     Sulfisoxazole Acetyl                                       3
SLO-NIACIN                                        47     SULFOXYL                                                   55
SLOWFE                                            51     Sulindac                                                   44
Sodium Bicarbonate                                30     Sumatriptan Nasal Spray                                    44
SODIUM CHLOR                                      23     Sumatriptan Succinate                                      44
Sodium Chloride Aero Soln                         23     SUSTIVA                                                    5
Sodium Chloride Irrigation Soln                   33     SYMBYAX                                                    40
Sodium Chloride Soln                              23     SYNALAR                                                    57
Sodium Fluoride                                   54     SYNTHROID                                                  12
Sodium Fluoride Chew Tab                          50     TABLOID                                                    7
Sodium Fluoride Soln                              50     Tacrolimus                                                 62
Sodium Phosphates - Enema                         29     TAGAMET,TAGAMETHB                                          30
Sodium Polystyrene Sulfonate                      62     TALADINE,ZANTAC                                            30
Sodium Polystyrene Sulfonate Powder               62     TAMBOCOR                                                   17

SOMA                                              46     TAMIFLU                                                    6
SOMNOTE                                           39     Tamoxifen Citrate                                          7
Sorbitol                                          62     TAPAZOLE                                                   13
SORBITOL                                          62     TAVIST,TAVIST-1                                            21
Sotalol HCl                                       14     Tazarotene                                                 56
Sotalol HCl AFIB/AFL                              14     TAZORAC                                                    56
Spacer/Aerosol-Holding Chamber Supplies - Bags    61     TEGRETOL                                                   45

Spacer/Aerosol-Holding Chambers - Device          61     TEGRETOL XR                                                45

SPIRIVA                                           27     TEGRIN-LT                                                  58
Spironolactone                                    20     Temazepam                                                  38
Spironolactone & Hydrochlorothiazide              20     TEMODAR                                                    7

SSKI                                              50     TEMOVATE,TEMOVATEE                                         57
Stavudine                                         5      Temozolomide                                               7
Stavudine For Oral Soln                           5      TENCON                                                     41
STERAPRED                                         8      TENEX                                                      18
STERAPREDDS                                       8      Tenofovir Disoproxil Fumarate                              5




              Index                                                                                Page 18 of 19
              Bridgeway Health Solutions                                                             11/11/2008
Medication                                 Page   Medication                   Page
TENORETIC                                  19
TENORMIN                                   15
TERAZOL3                                   33
TERAZOL7                                   33
Terazosin HCl                              18
Terbutaline Sulfate                        27
Terconazole                                33
TESLAC                                      7
TESSALON                                   23
TESSALONPER                                23
Testolactone                                7
Testosterone TD                             8
Tetracycline HCl                            3




              Index                                            Page 19 of 19
              Bridgeway Health Solutions                         11/11/2008

				
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