CENPATICO INTEGRATED CARE BEHAVIORAL HEALTH DRUG LIST BY DRUG CLASS

ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS MIRTAZAPINE ODT TABLETS 15 MG REMERON SOL 90 30 MIRTAZAPINE ODT TABLETS 30 MG REMERON SOL 45 30 MIRTAZAPINE ODT TABLETS 45 MG REMERON SOL 30 30 MIRTAZAPINE TABLET 7.5 MG, 15 MG REMERON 90 30 MIRTAZAPINE TABLET 30 MG REMERON 45 30 MIRTAZAPINE TABLET 45 MG REMERON 30 30 MONOAMINE OXIDASE INHIBITORS (MAOIs) ISOCARBOXAZID TABLETS MARPLAN PHENELZINE SULFATE TABLETS NARDIL SELIGILENE TD PATCH EMSAM X TRANYLCYPROMINE SULFATE TABLETS PARNATE NOREPINEPHRINE and DOPAMINE REUPTAKE INHIBITORS (NDRIs) BUPROPION HCL IR TABLETS 75MG, 100MG WELLBUTRIN 120 30 BUPROPION HCL ER TABLETS WELLBUTRIN SR 60 30 BUPROPION HCL ER TABLETS 150MG WELLBUTRIN XL 90 30 BUPROPION HCL ER TABLETS 300MG WELLBUTRIN XL 30 30 MAPROTILINE HCL TABLETS LUDIOMIL PA for ages < 6 years SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) CITALOPRAM HBR SOLUTION 900ML 30 CITALOPRAM HBR TABLETS 10 MG, 20 MG CELEXA 60 30 CITALOPRAM HBR TABLETS 40 MG CELEXA 30 30 ESCITALOPRAM OXALATE SOLUTION LEXAPRO 600 ML 30 ESCITALOPRAM OXALATE TABLETS 5 MG, 10 MG LEXAPRO 60 30 ESCITALOPRAM OXALATE TABLETS 20 MG LEXAPRO 30 30 FLUOXETINE HCL CAPSULES 10 MG, 20 MG PROZAC 120 30 FLUOXETINE HCL CAPSULES 40 MG PROZAC 60 30 FLUOXETINE HCL SOLUTION PROZAC 240 ML 30 FLUOXETINE HCL DR CAPSULES PROZAC WEEKLY X FLUVOXAMINE MALEATE ER CAPSULES 100 MG LUVOX CR 90 30 FLUVOXAMINE MALEATE ER CAPSULES 150 MG LUVOX CR 60 30 FLUVOXAMINE MALEATE TABLETS 25 MG, 50 MG LUVOX 180 30 FLUVOXAMINE MALEATE TABLETS 100 MG LUVOX 90 30 PAROXETINE HCL SUSPENSION PAXIL 900 ML 30 PAROXETINE HCL ER TABLETS 12.5 MG PAXIL CR 90 30 PAROXETINE HCL ER TABLETS 25 MG PAXIL CR 60 30 PAROXETINE HCL ER TABLETS 37.5 MG PAXIL CR 30 30 PAROXETINE HCL TABLETS 10 MG, 20 MG PAXIL 90 30 PAROXETINE HCL TABLETS 30 MG PAXIL 60 30 PAROXETINE HCL TABLETS 40 MG PAXIL 45 30 PAROXETINE MESYLATE TABLETS PEXEVA X SERTRALINE HCL CONCENTRATE ZOLOFT 300 ML 30 SERTRALINE HCL TABLETS 25 MG, 50 MG ZOLOFT 120 30 SERTRALINE HCL TABLETS 100 MG ZOLOFT 60 30 VILAZODONE HCL TABLETS VIIBRYD X SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIs) NEFAZODONE TABLETS TRAZODONE TABLETS SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs) DESVENLAFAXINE ER TABLETS 25 MG PRISTIQ 90 30 Page 1 of 7

DESVENLAFAXINE ER TABLETS 50 MG PRISTIQ 60 30 DESVENLAFAXINE ER TABLETS 100 MG PRISTIQ 30 30 DULOXETINE CAPSULES 20 MG, 30 MG CYMBALTA 120 30 DULOXETINE CAPSULES 60 MG CYMBALTA 60 30 VENLAFAXINE HCL ER CAPSULES 37.5 MG VENLAXINE 120 30 VENLAFAXINE HCL ER CAPSULES 75 MG EFFEXOR XR 150 30 VENLAFAXINE HCL ER CAPSULES 150 MG EFFEXOR XR 60 30 VENLAFAXINE HCL TABLETS (IMMEDIATE RELEASE ONLY) VENLAFAXINE 90 30 TRICYCLIC ANTIDEPRESSANTS & RELATED NON-SELECTIVE REUPTAKE INHIBITORS AMITRIPTYLINE HCL TABLETS ELAVIL PA for ages < 6 years AMOXAPINE TABLETS ASENDIN PA for ages < 6 years CLOMIPRAMINE HCL TABLETS ANAFRANIL PA for ages < 6 years DESIPRAMINE HCL TABLETS NORPRAMIN PA for ages < 6 years DOXEPIN HCL CAPSULES SINEQUAN PA for ages < 6 years DOXEPIN HCL CONCENTRATE SINEQUAN PA for ages < 6 years IMIPRAMINE HCL CAPSULES TOFRANIL PA for ages < 6 years IMIPRAMINE HCL TABLETS TOFRANIL PA for ages < 6 years NORTRIPTYLINE HCL CAPSULES PAMELOR PA for ages < 6 years NORTRYIPTYLINE HCL SOLUTION PAMELOR PA for ages < 6 years PROTRIPTYLINE HCL TABLETS VIVACTIL PA for ages < 6 years TRIMIPRAMINE MALEATE CAPSULES TRIMIPRAMINE PA for ages < 6 years ANTIPSYCHOTICS ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL ORAL AGENTS ARIPIPRAZOLE TABLETS ABILIFY PA for ages < 6 years 30 30 ASENAPINE MALEATE TABLETS SUBLINGUAL SAPHRIS Brand Only PA for ages < 6 years 60 30 CLOZAPINE ORALLY DISINTEGRATING TABLETS CLOZAPINE ODT PA for ages < 6 years 270 30 CLOZAPINE TABLETS CLOZAPINE PA for ages < 6 years 270 30 LURASIDONE TABLETS LATUDA Brand Only PA for ages < 6 years 30 30 OLANZAPINE ORALLY DISINTEGRATING TABLETS 5MG OLANZAPINE ODT PA for ages < 6 years 120 30 OLANZAPINE ORALLY DISINTEGRATING TABLETS 10MG OLANZAPINE ODT PA for ages < 6 years 60 30 OLANZAPINE ORALLY DISINTEGRATING TABLETS 15MG, 20MG OLANZAPINE ODT PA for ages < 6 years 30 30 OLANZAPINE TABLETS 2.5MG, 5MG OLANZAPINE PA for ages < 6 years 120 30 OLANZAPINE TABLETS 7.5MG, 10MG OLANZAPINE PA for ages < 6 years 60 30 OLANZAPINE TABLETS 15MG, 20MG OLANZAPINE PA for ages < 6 years 30 30 QUETIAPINE FUMARATE TABLETS 25MG, 50MG, 100MG, 150MG, 200MG QUETIAPINE PA for ages < 6 years 120 30 QUETIAPINE FUMARATE TABLETS 300MG, 400MG QUETIAPINE PA for ages < 6 years 60 30 RISPERIDONE ORALLY DISINTEGRATING TABLETS 0.25 MG, 0.5MG RISPERIDONE ODT PA for ages < 6 years 120 30 RISPERIDONE ORALLY DISINTEGRATING TABLETS 1MG, 2MG RISPERIDONE ODT PA for ages < 6 years 90 30 RISPERIDONE ORALLY DISINTEGRATING TABLETS 3MG, 4MG RISPERIDONE ODT PA for ages < 6 years 60 30 RISPERIDONE SOLUTION RISPERIDONE PA for ages < 6 years 60ML 30 RISPERIDONE TABLETS 0.25MG, 0.5MG RISPERIDONE PA for ages < 6 years 120 30 RISPERIDONE TABLETS 1MG, 2MG RISPERIDONE PA for ages < 6 years 90 30 RISPERIDONE TABLETS 3MG, 4MG RISPERIDONE PA for ages < 6 years 60 30 ZIPRASIDONE HCL CAPSULES 20MG, 40MG, 60MG ZIPRASIDONE PA for ages < 6 years 90 30 ZIPRASIDONE HCL CAPSULES 80MG ZIPRASIDONE PA for ages < 6 years 60 30 ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL LONG-ACTING INJECTABLES Page 2 of 7

ARIPIPRAZOLE LAUROXIL ARISTADA Brand Only PA for ages < 18 years 1 30 ARIPIPRAZOLE SUSPENSION ABILIFY MAINTENA Brand Only PA for ages < 18 years 1 30 PALIPERIDONE PALMITATE SUSPENSION INVEGA SUSTENNA Brand Only PA for ages < 18 years 1 30 PALIPERIDONE PALMITATE SUSPENSION INVEGA TRINZA Brand Only PA for ages < 18 years 1 90 RISPERIDONE MICROSPHERES SUSPENSION RISPERDAL CONSTA Brand Only PA for ages < 6 years 2 28 ANTIPSYCHOTICS - FIRST GENERATION - TYPICAL ORAL AGENTS CHLORPROMAZINE HCL TABLETS THORAZINE PA for ages < 6 years FLUPHENAZINE HCL ELIXIR FLUPHENAZINE PA for ages < 6 years FLUPHENAZINE HCL ORAL CONCENTRATE FLUPHENAZINE PA for ages < 6 years FLUPHENAZINE HCL TABLETS FLUPHENAZINE PA for ages < 6 years HALOPERIDOL LACTATE CONCENTRATE HALDOL PA for ages < 6 years HALOPERIDOL TABLETS HALDOL PA for ages < 6 years LOXAPINE SUCCINATE CAPSULES LOXITANE PA for ages < 6 years PERPHENAZINE TABLETS TRILAFON PA for ages < 6 years PIMOZIDE TABLETS ORAP PA for ages < 6 years THIORIDAZINE HCL TABLETS MELLARIL PA for ages < 6 years THIOTHIXENE CAPSULES NAVANE PA for ages < 6 years TRIFLUOPERAZINE HCL TABLETS STELAZINE PA for ages < 6 years ANTIPSYCHOTICS - FIRST GENERATION - TYPICAL - LONG ACTING INJECTIONS FLUPHENAZINE DECANOATE SOLUTION FLUPHENAZINE DECANOATE PA for ages < 6 years HALOPERIDOL DECANOATE SOLUTION HALDOL DECANOATE PA for ages < 6 years ANTICONVULSANTS CARBAMAZEPINE CHEWABLE TABLETS TEGRETOL CARBAMAZEPINE ER CAPSULES CARBATROL 90 30 CARBAMAZEPINE ER CAPSULES EQUETRO 90 30 CARBAMAZEPINE SUSPENSION TEGRETOL CARBAMAZEPINE ER TABLETS TEGRETOL XR 90 30 CARBAMAZEPINE TABLETS TEGRETOL DIVALPROEX CAPSULES SPRINKLE DPAKOTE SPRINKLES 180 30 DIVALPROEX DR TABLETS DEPAKOTE 90 30 DIVALPROEX ER TABLETS DEPAKOTE 90 30 GABAPENTIN CAPSULES 100MG, 300MG, 400MG NEURONTIN 180 30 GABAPENTIN ER TABLETS HORIZANT X GABAPENTIN ER TABLETS GRALISE X GABAPENTIN SOLUTION NEURONTIN 1440 ML 30 GABAPENTIN TABLETS 600MG, NEURONTIN 120 30 GABAPENTIN TABLETS 800MG NEURONTIN 90 30 LAMOTRIGINE CHEW TABLETS LAMICTAL 120 30 LAMOTRIGINE ER TABLETS LAMICTAL XR X LAMOTRIGINE ODT TABLETS 25 MG, 50MG LAMICTAL ODT 120 30 LAMOTRIGINE ODT TABLETS 100 MG LAMICTAL ODT 60 30 LAMOTRIGINE ODT TABLETS 200 MG LAMICTAL ODT 30 30 LAMOTRIGINE TABLETS 25 MG LAMICTAL 120 30 LAMOTRIGINE TABLETS 100 MG LAMICTAL 90 30 LAMOTRIGINE TABLETS 150 MG, 200 MG LAMICTAL 60 30 Page 3 of 7

OXCARBAZEPINE SOLUTON TRILEPTAL 1050 ML 30 OXCABAZEPINE TABLETS TRILEPTAL 90 30 TOPIRAMATE CAPSULES TOPAMAX TOPIRAMATE TABLETS TOPAMAX VALPROATE SODIUM CAPSULES DEPAKENE VALPROATE SODIUM SOLUTION DEPAKENE VALPROATE SODIUM SYRUP DEPAKENE ANTIMANIC AGENTS LITHIUM CARBONATE CAPSULES LITHIUM LITHIUM CARBONATE ER TABLETS LITHOBID LITHIUM CITRATE SOLUTION LITHIUM ADHD AGENTS AMPHETAMINES AMPHETAMINE-DEXTROAMPHETAMINE TABLETS 5MG, 7.5MG, 10MG, 12.5MG ADDERALL Brand and Generic PA for ages < 6 years 90 30 AMPHETAMINE-DEXTROAMPHETAMINE TABLETS 15MG, 20MG, 30MG ADDERALL Brand and Generic PA for ages < 6 years 60 30 AMPHETAMINE-DEXTROAMPHETAMINE CAPSULES CONTROLLED RELEASE ADDERALL XR Brand Only PA for ages < 6 years 60 30 DEXTROAMPEHTAMINE SULFATE CAPSULE 24-HOUR PA for ages < 6 years 60 30 DEXTROAMPHETAMINE SULFATE TABLETS PA for ages < 6 years 90 30 LISDEXAMFETAMINE ER CAPSULES 10MG, 20MG VYVANSE Brand Only PA for ages < 6 years 90 30 LISDEXAMFETAMINE ER CAPSULES 30MG VYVANSE Brand Only PA for ages < 6 years 60 30 LISDEXAMFETAMINE ER CAPSULES 40MG, 50MG, 60MG, 70MG VYVANSE Brand Only PA for ages < 6 years 30 30 STIMULANTS DEXMETHYLPHENIDATE HCL ER CAPSULE 5MG, 10MG, 15MG, 20MG FOCALIN XR Brand Only PA for ages < 6 years 60 30 DEXMETHYLPHENIDATE HCL ER CAPSULE 25MG, 30MG, 35MG, 40MG FOXALIN XR Brand Only PA for ages < 6 years 30 30 DEXMETHYLPHENIDATE HCL TABLETS FOCALIN Brand Only PA for ages < 6 years 60 60 METHYLPEHNIDATE HCL CHEWABLET TABLET QUILLICHEW Brand Only PA for ages < 6 years 30 30 METHYLPHENIDATE HCL CHEWABLE TABLETS METHYLIN Brand Only PA for ages < 6 years 120 30 METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE 10MG RITALIN LA Brand Only PA for ages < 6 years 120 30 METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE 20MG METHYLPHENIDATE LA PA for ages < 6 years 90 30 METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE 30MG METHYLPHENIDATE LA PA for ages < 6 years 60 30 METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE 40MG, 60MG METHYLPHENIDATE LA PA for ages < 6 years 30 30 METHYLPHENIDATE HCL TD PATCH DAYTRANA Brand Only PA for ages < 6 years 30 30 METHYLPHENIDATE HCL SOLUTION METHYLIN PA for ages < 6 years 900ML 30 METHYLPHENIDATE HCL SUSPENSION QUILLIVANT XR Brand Only PA for ages < 6 years 150 ML 30 METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE 18MG METHYLPEHNIDATE ER PA for ages < 6 years 120 30 METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE 27MG, 36MG METHYLPEHNIDATE ER PA for ages < 6 years 60 30 METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE 54MG METHYLPHENIDATE ER PA for ages < 6 years 30 30 METHYLPHENIDATE HCL TABLETS RITALIN PA for ages < 6 years 120 30 METHYLPHENIDATE HCL TABLET ER 20MG METHYLPHENIDATE ER PA for ages < 6 years 90 30 METHYLPHENIDATE HCL TABLET ER 30MG METHYLPHENIDATE ER PA for ages < 6 years 60 30 METHYLPHENIDATE HCL TABLET ER 40MG METHYLPHENIDATE ER PA for ages < 6 years 60 30 METHYLPHENIDATE HCL TABLET SUSTAINED RELEASE RITALIN SR PA for ages < 6 years 60 30 MISCELLANEOUS AGENTS ATOMOXETINE CAPSULES 10MG, 18MG, 25MG, 40MG STRATTERA Brand Only PA for ages < 6 years 60 30 ATOMOXETINE CAPSULES 60MG, 80MG 100MG STRATTERA Brand Only PA for ages < 6 years 30 30 CENTRAL ALPHA-AGONISTS CLONIDINE HCL (ADHD) TABLET 12-HOUR KAPVAY Brand Only PA for ages < 6 years 120 30 CLONIDINE HCL TABLETS CATAPRES PA for ages < 6 years CLONIDINE HCL TD PATCH CATAPRES TTS PA for ages < 6 years 4 30 GUANFACINE HCL (ADHD)TABLET 24-HOUR GUANFACINE HCL ER PA for ages < 6 years 30 30 GUANFACINE HCL TABLETS TENEX PA for ages < 6 years Page 4 of 7

SUBSTANCE ABUSE OPIOID AGONISTS/PARTIAL AGONISTS BUPRENORPHINE HCL SL TABLETS SUBUTEX PA BUPRENORPHINE HCL / NALOXONE SL FILM SUBOXONE FILM Brand Only METHADONE * DOLOPHINE* OPIOID AGONISTS NALOXONE NASAL NARCAN NASAL NALOXONE SYRINGE NALOXONE NALOXONE VIAL NALOXONE NALTREXONE TABLETS REVIA 60 30 NALTREXONE INJECTION VIVITROL MISCELLANEOUS AGENTS ACAMPROSATE TABLET DELAYED RELEASE CAMPRAL 180 30 DILSULFIRAM TABLETS ANTABUSE ANXIOLYTICS AND HYPNOTICS BENZODIAZEPINES ALPRAZOLAM CONCENTRATE ALPRAZOLAM INTENSOL PA for > 1 Anxiolytics Fill 60ML 30 ALPRAZOLAM ER TABLET XANAX ER PA for > 1 Anxiolytics Fill 30 30 ALPRAZOLAM ODT TABLET 0.25MG, 0.5MG, 1MG NIRAVAM PA for > 1 Anxiolytics Fill 120 30 ALPRAZOLAM ODT TABLET 2MG NIRAVAM PA for > 1 Anxiolytics Fill 60 30 ALPRAZOLAM TABLET 0.25MG, 0.5MG, 1MG XANAX PA for > 1 Anxiolytics Fill 120 30 ALPRAZOLAM TABLET 2MG XANAX PA for > 1 Anxiolytics Fill 60 30 CHLORDIAZEPOXIDE HCL CAPSULES LIBRIUM PA for > 1 Anxiolytics Fill 60 30 CLONAZEPAM ODT TABLET 0.125MG, 0.25MG, 0.5MG, 1MG KLONOPIN PA for > 1 Anxiolytics Fill 120 30 CLONAZEPAM ODT TABLET 2MG KLONOPIN PA for > 1 Anxiolytics Fill 60 30 CLONAZEPAM TABLETS 0.5MG, 1MG KLONOPIN PA for > 1 Anxiolytics Fill 120 30 CLONAZEPAM TABLETS 2MG KLONOPIN PA for > 1 Anxiolytics Fill 60 30 CLORAZEPATE DIPOTASSIUM TAB 15 MG PA for > 1 Anxiolytics Fill 60.00 30.00 CLORAZEPATE DIPOTASSIUM TAB 3.75 MG PA for > 1 Anxiolytics Fill 120.00 30.00 CLORAZEPATE DIPOTASSIUM TAB 7.5 MG PA for > 1 Anxiolytics Fill 120.00 30.00 DIAZEPAM CONCENTRATE DIAZEPAM INTENSOL PA for > 1 Anxiolytics Fill 60ML 30 DIAZEPAM SOLUTION DIAZEPAM PA for > 1 Anxiolytics Fill 300ML 30 DIAZEPAM TABLETS VALIUM PA for > 1 Anxiolytics Fill 90 30 LORAZEPAM CONCENTRATE LORAZEPAM INTENSOL PA for > 1 Anxiolytics Fill 120ML 30 LORAZEPAM TABLETS 0.5MG, 1MG ATIVAN PA for > 1 Anxiolytics Fill 120 30 LORAZEPAM TABLETS 2MG ATIVAN PA for > 1 Anxiolytics Fill 90 30 OXAZEPAM CAPSULES OXAZEPAM PA for > 1 Anxiolytics Fill 60 30 MISCELLANEOUS ANXIOLYTICS BUSPIRONE HCL TABLETS 0.5 MG, 7.5 MG, 10 MG, 15 MG BUSPIRONE HCL 120 30 BUSPIRONE HCL TABLETS 30 MG BUSPIRONE HCL 60 30 HYDROXYZINE HCL SYRUP HYDROXYZINE HCL HYDROXYZINE HCL TABLETS HYDROXYZINE HCL HYDROXYZINE PAMOATE CAPSULES VISTARIL MISCELLANEOUS SEDATIVE & HYPNOTICS DOXEPIN HCL TABLETS SILENOR PA for ages < 6 years X ESZOPICLONE TABLETS LUNESTA PA for > 1 Hypnotics Fill 30 30 ESTAZOLAM TABLETS PA for > 1 Hypnotics Fill 30 30 FLURAZEPAM HCL CAPSULES DALMANE PA for > 1 Hypnotics Fill 30 30 MEPROBAMATE TABLETS PA for > 1 Anxiolytics Fill RAMELTEON TABLETS ROZEREM PA for > 1 Hypnotics Fill 30 30 TEMAZEPAM CAPSULES 15MG, 30MG RESTORIL PA for > 1 Hypnotics Fill 30 30 Page 5 of 7

TRIAZOLAM TABLETS HALCION PA for > 1 Hypnotics Fill 30 30 ZALEPLON CAPSUELS SONATA PA for > 1 Hypnotics Fill 30 30 ZOLPIDEM CAPSULES AMBIEN PA for > 1 Hypnotics Fill 30 30 ZOLPIDEM ER TABLETS AMBIEN CR PA for > 1 Hypnotics Fill X 30 30 ZOLPIDEM SL TABLETS INTERMEZZO SL PA for > 1 Hypnotics Fill X 30 30 ZOLPIDEM SL TABLETS EDULAR PA for > 1 Hypnotics Fill X 30 30 ZOLPIDEM SOLUTION ZOLPIMIST PA for > 1 Hypnotics Fill X 30 30 ANTIHISTAMINES CYPROHEPTADINE HCL TABLETS DIPHENHYDRAMINE HCL CAPSULES DIPHENHYDRAMINE HCL CHEWABLE TABLETS DIPHENHYDRAMINE HCL ELIXIR DIPHENHYDRAMINE HCL LIQUID DIPHENHYDRAMINE HCL SYRUP DIPHENHYDRAMINE HCL TABLETS HYDROXYZINE HCL TABLETS ATARAX HYDROXYZINE PAMOATE CAPSULES VISTARIL DOPAMINE AGONISTS AMANTADINE HCL CAPSULES SYMMETREL AMANTADINE HCL TABLETS SYMMETREL AUTONOMIC AGONISTS PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS BETHANECHOL CHLORIDE TABLETS URECHOLINE ANTICHOLINERGIC AGENTS BENZTROPINE MESYLATE TABLETS COGENTIN TRIHEXPHENIDYL HCL TABLETS ARTANE CARDIOVASCULAR DRUGS ALPHA-1 ADRENERGIC BLOCKING AGENTS PRAZOSIN HCL CAPSULES MINIPRESS 90 30 BETA-ADRENERGIC BLOCKING AGENTS NADOLOL TABLETS CORGARD PROPRANOLOL HCL TABLETS INDERAL THRYOID AGENTS LEVOTHYROXINE SODIUM TABLETS LEVOTHROID / SYNTHROID LIOTHYRONINE TABLETS CYTOMEL THRYOID TABLETS ARMOUR THYROID VITAMINS AND OTHER MISCELLANEOUS AGENTS ALPHA-TOCOPHEROL CAPSULES VITAMIN E - CYANOCOBALAMIN TABLETS VITAMIN B12 - FOLIC ACID TABLETS OMEGA 3 FATTY ACID CAPSULES PYRIDOXINE HCL TABLETS VITAMIN B6 - THIAMINE HCL TABLETS VITAMIN B1 - MULTIPLE VITAMIN TABLETS MULTIPLE VITAMIN W/ MINERAL TABLETS SALIVA SUBSTITUTE SPRAY SALIVART DOCUSATE SODIUM CAPSULES COLACE KEY: Drugs listed in Bold/Italic CAPITAL LETTERS indicate the medication is only available as a brand name product. (*) Indicates that medication can only be obtained from an Opioid Treatment Program (OTP) provider. (X) Indicates that the medication requires prior authorization. Page 6 of 7

Abbreviations: Cap = capsule HCL = hydrochloride SOLN = solution Chew = chewable IM = intramuscular SR = sustained release Conc = concentrate Inj = injectable Susp = suspension DR = Delayed Release IR = Immediate release Syr = Syrup Elix = Elixir LA = long acting Tab = tablet ER = extended release ODT = orally disintegrating tablet TD = transdermal hbr = hydrobromide SL = sublingual XL = extended release Page 7 of 7