List of Covered Drugs for (Medicaid Formulary)

Transcription

1 List of Covered s for 2015 (Medicaid Formulary)

2 Name Respiratory Tract/Pulmonary Agents Respiratory Tract Agents, Other hydrocodone bitartrate/homatropine methylbromide tablet 3 DP 1.5mg; 5mg hydrocodone polistirex/chlorpheniramine polistirex liquid 3 DP extended release 8mg/5ml; 10mg/5ml Therapeutic Nutrients/Minerals/Electrolytes Electrolyte/Mineral Replacement chromium chloride injection 4mcg/ml 3 DP corvita 150 tablet 120mg; 15mcg; 1.25mg; 150mg; 10mg; 3 DP 25mg dexferrum injection 50mg/ml 3 DP FERRAPLUS 90 TABLET 120MG; 12MCG; 50MG; 1MG; 3 DP 90MG MANGANESE TRACE METAL INJECTION 0.1MG/ML 3 DP tl icon capsule 75mg; 15mcg; 110mg; 0.5mg; 240mg 3 DP VENOFER INJECTION 20MG/ML 3 DP Vitamins infuvite injection 200mg/10ml; 200unit/10ml; 5mcg/10ml; 15mg/10ml; 600mcg/10ml; 40mg/10ml; 6mg/10ml; 3.6mg/10ml; 6mg/10ml; 10unit/10ml; 3300unit/10ml; 3 DP 150mcg/10ml thiamine hcl injection 100mg/ml 3 DP vitamin k1 injection 1mg/0.5ml 3 DP Unclassified No Classification BACTERIOSTATIC WATER FOR INJECTION/BENZYL ALCOHOL INJECTION 0.9%; 0 3 DP COPPER TRACE METAL INJECTION 0.4MG/ML 3 DP FERAHEME INJECTION 510MG/17ML 3 DP ZINC TRACE METAL INJECTION 1MG/ML 3 DP Page 1 of 12

3 OTC products Name Anesthetics Local Anesthetics LMX 4 PLUS KIT 4% 3 DP Antibacterials Antibacterials, Other bacitracin zinc ointment 500unit/gm 3 DP double antibiotic ointment 500unit/gm; 10000unit/gm 3 DP gnp triple antibiotic plus ointment 500unit/gm; 3.5mg/gm; 3 DP 10000unit/gm; 10mg/gm hm double antibiotic ointment 500unit/gm; unit/gm 3 DP povidone-iodine ointment 10% 3 DP triple antibiotic ointment 400unit/gm; 3.5mg/gm; 5000unit/gm 3 DP Antiemetics Antiemetics, Other dimenhydrinate tablet 50mg 3 DP Antifungals Antifungals LAMISIL ADVANCED GEL 1% 3 DP lamisil af defense aerosol powder 1% 3 DP VAGISTAT-1 OINTMENT 6.5% 3 DP Antiparasitics Anthelmintics reeses pinworm medicine suspension 144mg/ml 3 DP Pediculicides/Scabicides complete lice treatment kit kit 0.5%; 4%; 0.33% 3 DP lice killing maximum strength shampoo 4%; 0.33% 3 DP Blood Glucose Regulators Glycemic Agents SM GLUCOSE TABLET CHEWABLE 4GM 3 DP Dermatological Agents Dermatological Agents aluminum acetate astringent packet 1191mg; 839mg 3 DP AMLACTIN ULTRA CREAM 3 DP AQUABASE OINTMENT 0 3 DP ATRAC-TAIN CREAM 10% 3 DP BENZOIN COMPOUND TINCTURE TINCTURE 0 3 DP hemorrhoidal ointment 14%; 71.9%; 0.25%; 3% 3 DP HYDROUS EMULSIFIED BASE CREAM 0; 0; 0; 0; 0; 0; 0; 3 DP 0; 0 itch relief extra strength cream 2%; 0.1% 3 DP NAIL SCRUB LIQUID 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0 3 DP PENTRAVAN CREAM 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0; 0 3 DP periguard ointment 0 3 DP PREPARATION H OINTMENT 14%; 71.9%; 0.25%; 3% 3 DP PREPARATION H SUPPOSITORY 85.5%; 0.25%; 3% 3 DP qc hemorrhoidal suppository 85.5%; 0.25%; 3% 3 DP salactic film solution 17% 3 DP SEBULEX SHAMPOO 2%; 2% 3 DP Page 2 of 12

4 Name SENSI-CARE PROTECTIVE BARRIER OINTMENT 49%; 3 DP 15% SOOTHE & COOL FREE MOISTURE BARRIER 3 DP OINTMENT 98.3% SOOTHE & COOL FREE MOISTURE BARRIER 3 DP OINTMENT 98.3% ZIKS ARTHRITIS PAIN RELIEF CREAM 0.025%; 1%; 3 DP 12% Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers LACTRASE CAPSULE 250MG 3 DP Gastrointestinal Agents Gastrointestinal Agents, Other ACIDOPHILUS/CITRUS PECTIN TABLET 0; 100MG 3 DP acidophilus/l-sporogenes extra strength tablet 0; 0 3 DP bisac-evac suppository 10mg 3 DP enemeez plus enema 20mg; 283mg 3 DP FLEET OIL ENEMA 0 3 DP formulation r cream 12%; 18%; 0.25%; 3% 3 DP GAS-X EXTRA STRENGTH TABLET CHEWABLE 3 DP 125MG GAVISCON SUSPENSION 95MG/15ML; 358MG/15ML 3 DP gnp foaming antacid tablet chewable 80mg; 20mg 3 DP konsyl capsule 520mg 3 DP KONSYL PACKET 60.3% 3 DP konsyl powder 30.9% 3 DP KONSYL POWDER 60.3% 3 DP KONSYL POWDER 71.67% 3 DP maalox advanced suspension 200mg/5ml; 200mg/5ml; 3 DP 20mg/5ml magnesium oxide tablet 400mg 3 DP senna-time tablet 8.6mg 3 DP Laxatives gnp fiber therapy tablet 500mg 3 DP milk of magnesia suspension 1200mg/15ml 3 DP senexon-s tablet 50mg; 8.6mg 3 DP sm oral saline laxative solution 0.9gm/5ml; 2.4gm/5ml 3 DP Genitourinary Agents Phosphate Binders MAGNEBIND 300 TABLET 250MG; 300MG 3 DP Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) sm hydrocortisone cream 1% 3 DP Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ALPHA LIPOIC ACID CAPSULE 300MG 3 DP arginine tablet 500mg 3 DP CO Q-10 PLUS CAPSULE 100MG; 20MG 3 DP DIASTIX STRIP 0 3 DP Page 3 of 12

5 Name fish oil ultra capsule 200mg; 300mg; 1000mg 3 DP KETO-DIASTIX STRIP 0 3 DP LACTOSE POWDER 0 3 DP natural coenzyme q10 capsule 100mg 3 DP ORA-BLEND SF SUSPENSION 0; 0; 0; 0; 0 3 DP ORA-BLEND SUSPENSION 0; 0; 0; 0; 0; 0 3 DP ORA-PLUS LIQUID 0; 0; 0; 0 3 DP ORA-SWEET SF SYRUP 9%; 10% 3 DP ORA-SWEET SYRUP 5%; 4%; 54% 3 DP PREMIUM CONDOMS LUBRICATED MISCELLANEOUS3 DP q-gel mega capsule 100mg 3 DP Ophthalmic Agents Ophthalmic Agents, Other akwa tears ointment 2%; 15%; 83% 3 DP artificial tears solution 1.4% 3 DP FRESHKOTE SOLUTION 2.7%; 2% 3 DP GENTEAL SEVERE GEL 0.3% 3 DP gnp lubricant eye drops solution 0.4%; 0.3% 3 DP REFRESH PLUS SOLUTION 0.5% 3 DP sterilube ointment 15%; 85% 3 DP SYSTANE BALANCE RESTORATIVE FORMULA 3 DP SOLUTION 0.6% tears naturale forte solution 0.1%; 0.2%; 0.3% 3 DP tears naturale ii solution 0.01%; 0; 0.05%; 0.3% 3 DP tears naturale solution 0.1%; 0.3% 3 DP Ophthalmic Anti-inflammatories ZADITOR SOLUTION 0.025% 3 DP Otic Agents Otic Agents ear wax remover solution 6.5% 3 DP Respiratory Tract/Pulmonary Agents Antihistamines alavert tablet dispersible 10mg 3 DP all day allergy-d tablet extended release 12 hour 5mg; 120mg 3 DP dayhist allergy 12 hour relief tablet 1.34mg 3 DP DIMETAPP COLD & ALLERGY ELIXIR 1MG/5ML; 3 DP 2.5MG/5ML ed-chlortan tablet 4mg 3 DP sudogest sinus & allergy tablet 4mg; 60mg 3 DP Bronchodilators, Sympathomimetic EPHEDRINE SULFATE CAPSULE 25MG 3 DP Respiratory Tract Agents, Other AFRIN MENTHOL SOLUTION 0; 0.05% 3 DP allergy multi-symptom tablet 325mg; 2mg; 5mg 3 DP CAPCOF SYRUP 2MG/5ML; 10MG/5ML; 5MG/5ML 3 DP CAPMIST DM TABLET 15MG; 400MG; 60MG 3 DP CAPMIST DM TABLET 30MG; 400MG; 30MG 3 DP CAPRON DM LIQUID 7.5MG/5ML; 7.5MG/5ML 3 DP Page 4 of 12

6 Name CODITUSS DM SYRUP 10MG/5ML; 5MG/5ML; 3 DP 8.33MG/5ML cold head congestion severe daytime tablet 325mg; 10mg; 3 DP 200mg; 5mg cold multi-symptom daytime tablet 325mg; 10mg; 5mg 3 DP COMTREX COLD & COUGH NIGHTTIME MAXIMUM 3 DP STRENGTH TABLET 325MG; 2MG; 10MG; 5MG CONEX COLD/ALLERGY TABLET 2MG; 60MG 3 DP DELSYM LIQUID EXTENDED RELEASE 30MG/5ML 3 DP DIMETAPP DM COLD & COUGH LIQUID 1MG/5ML; 3 DP 5MG/5ML; 2.5MG/5ML DIMETAPP LONG ACTING COUGH PLUS COLD SYRUP 3 DP 1MG/5ML; 7.5MG/5ML dimetapp nighttime cold &congestion liquid 6.25mg/5ml; 3 DP 2.5mg/5ml ed bron gp liquid 100mg/5ml; 5mg/5ml 3 DP gnp night time sinus capsule 325mg; 6.25mg; 5mg 3 DP guaiatussin ac syrup 10mg/5ml; 100mg/5ml 3 DP guaifenesin dac solution 10mg/5ml; 100mg/5ml; 30mg/5ml 3 DP M-END PE LIQUID 1.33MG/5ML; 6.33MG/5ML; 3 DP 3.33MG/5ML nasal decongestant pe maximum strength tablet 10mg 3 DP nite-time multi-symptom cold/flu relief liquid 500mg/15ml; 3 DP 15mg/15ml; 6.25mg/15ml PHENYLHISTINE DH LIQUID 2MG/5ML; 10MG/5ML; 3 DP 30MG/5ML qc tussin cf liquid 10mg/5ml; 100mg/5ml; 5mg/5ml 3 DP RESPAIRE-30 CAPSULE 150MG; 30MG 3 DP RYDEX LIQUID 1.33MG/5ML; 6.33MG/5ML; 10MG/5ML 3 DP sinus congestion & pain daytime tablet 325mg; 5mg 3 DP sm flu relief therapy severe cold nighttime liquid 325mg/15ml; 3 DP 12.5mg/15ml; 5mg/15ml TRIAMINIC MULTI-SYMPTOM FEVER SYRUP 3 DP 160MG/5ML; 1MG/5ML; 7.5MG/5ML Therapeutic Nutrients/Minerals/Electrolytes Electrolyte/Mineral Replacement CALCI-MIX CAPSULE 1250MG 3 DP CALCIUM LACTATE TABLET 648MG 3 DP calcium plus vitamin d3 capsule 600mg; 500unit 3 DP CALTRATE 600+D PLUS MINERALS TABLET 3 DP CHEWABLE 600MG; 800UNIT; 1MG; 50MG; 0; 0; 1.8MG; 250MCG; 7.5MG ferrous drops solution 15mg/ml 3 DP iferex 150 capsule 150mg 3 DP iron tablet 27mg 3 DP MAG-TAB SR TABLET EXTENDED RELEASE 84MG 3 DP MAGONATE LIQUID 1000MG/5ML 3 DP magonate tablet 500mg 3 DP oyster shell calcium/vitamin d tablet 200unit; 500mg 3 DP Page 5 of 12

7 Name PHOS-NAK POWDER CONCENTRATE PACKET 250MG; 3 DP 280MG; 160MG sm calcium citrate w/vitamin d3 tablet 315mg; 250unit 3 DP Vitamins ADEKS TABLET CHEWABLE 60MG; 3MG; 50MCG; 3 DP 400UNIT; 12MCG; 0.2MG; 10MG; 10MG; 150MCG; 1500MCG; 1300MCG; 1200MCG; 4000UNIT; 150UNIT; 7.5MG aquadeks liquid 45mg/ml; 3mg/ml; 15mcg/ml; 3mg/ml; 3 DP 400unit/ml; 2mg/ml; 6mg/ml; 400mcg/ml; 0.6mg/ml; 0.6mg/ml; 10mcg/ml; 0.6mg/ml; 50unit/ml; 5751unit/ml; 15mg/ml; 5mg/ml AQUADEKS TABLET CHEWABLE 0; 50MCG; 6MG; 3 DP 400UNIT; 5MG; 6MCG; 100MCG; 5MG; 350MCG; 0.95MG; 0.85MG; 37.5MCG; 5MG; 35MG; 0.75MG; 50UNIT; UNIT; 15MG; 5MG aqueous vitamin e solution 15unit/0.3ml 3 DP centavite a-z complete multivitamin/minerals tablet 90mg; 3 DP 1250unit; 35mcg; 40mg; 7.5mg; 15mcg; 2mg; 9mcg; 0.4mg; 150mcg; 27mg; 100mg; 5mg; 15mcg; 30mg; 10mg; 31mg; 7.5mg; 3mg; 3.4mg; 10mcg; 3mg; 5000unit; 400unit; 30unit; 15mg CENTRUM ADULTS TABLET 60MG; 0; 30MCG; 75MCG; 3 DP 200MG; 10MG; 72MG; 400UNIT; 35MCG; 0.5MG; 6MCG; 18MG; 400MCG; 50MG; 2.3MG; 20MG; 5MCG; 20MG; 25MCG; 80MG; 150MCG; 2MG; 1.7MG; 2MG; 10MCG; 45MCG; 55MCG; 10MCG; 1.5MG; 30UNIT; 3500UNIT; 11MG CENTRUM LIQUID 60MG/15ML; 300MCG/15ML; 3 DP 25MCG/15ML; 6MCG/15ML; 150MCG/15ML; 9MG/15ML; 2.5MG/15ML; 25MCG/15ML; 20MG/15ML; 10MG/15ML; 2MG/15ML; 1.7MG/15ML; 1.5MG/15ML; 2500UNIT/15ML; 400UNIT/15ML; 30UNIT/15ML; 3MG/15ML cerovite jr tablet chewable 60mg; 0; 45mcg; 108mg; 10mg; 3 DP 400unit; 20mcg; 2mg; 6mcg; 18mg; 400mcg; 40mg; 1mg; 20mg; 50mg; 10mcg; 150mcg; 2mg; 1.7mg; 0; 20mcg; 1.5mg; 30unit; 3500unit; 15mg D-VI-SOL LIQUID 400UNIT/ML 3 DP DIALYVITE VITAMIN D3 MAX TABLET 50000UNIT 3 DP EZFE FORTE CAPSULE 45MG; 150MCG; 10MG; 3 DP 1000MCG; 1000MCG; 20MG; 155MG; 25MG; 1.7MG; 1.5MG FOSFREE TABLET 50MG; 300MG; 2MG; 14.5MG; 10MG; 3 DP 1MG; 3MG; 2MG; 5MG; 1500UNIT; 200UNIT Page 6 of 12

8 Name gnp century ultimate womens senior formula tablet 100mg; 0; 3 DP 30mcg; 500mg; 5mg; 20mg; 72mg; 800unit; 50mcg; 0.5mg; 50mcg; 8mg; 400mcg; 300mcg; 50mg; 2.3mg; 14mg; 5mcg; 50mcg; 80mg; 150mcg; 5mg; 1.1mg; 2mg; 150mcg; 10mcg; 50mcg; 55mcg; 1.1mg; 35unit; 3500unit; 15mg gnp one daily maximum tablet 60mg; 0; 30mcg; 150mcg; 3 DP 162mg; 10mg; 109mg; 72mg; 400unit; 65mcg; 2mg; 6mcg; 18mg; 400mcg; 100mg; 3.5mg; 20mg; 5mcg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 10mcg; 160mcg; 20mcg; 10mcg; 1.5mg; 30unit; 2500unit; 15mg healthy eyes tablet 60mg; 2mg; 6mg; 30unit; 15mg 3 DP icaps capsule 226mg; 14320unit; 0.8mg; 200mg; 34.8mg 3 DP meribin capsule 5mg 3 DP MULTI-DELYN/IRON LIQUID 60MG/5ML; 4.5MCG/5ML; 3 DP 10MG/5ML; 13.5MG/5ML; 1.05MG/5ML; 1.2MG/5ML; 1.05MG/5ML; 15UNIT/5ML; 2500UNIT/5ML; 400UNIT/5ML multilex-t&m tablet 150mg; 10mg; 400unit; 1mg; 7.5mcg; 3 DP 15mg; 5mg; 1mg; 100mg; 0.15mg; 2mg; 10mg; 15mg; 5.5unit; 10000unit; 1.5mg MYKIDZ IRON SUSPENSION 35MG/2ML; 400UNIT/2ML; 3 DP 10MG/2ML; 1500UNIT/2ML OCUVITE ADULT 50+ CAPSULE 150MG; 1MG; 90MG; 3 DP 160MG; 5MG; 250MG; 30UNIT; 1MG; 9MG PRESERVISION AREDS 2 CAPSULE 113MG; 0.4MG; 3 DP 87.5MG; 162.5MG; 2.5MG; 250MG; 100UNIT; 0.5MG; 17.4MG qc maximum daily multivitamin/multimineral tablet 50mg; 0; 3 DP 30mcg; 162mg; 10mg; 109mg; 72mg; 400unit; 65mcg; 2mg; 6mcg; 18mg; 400mcg; 100mg; 3.5mg; 20mg; 5mcg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 160mcg; 20mcg; 10mcg; 1.5mg; 30unit; 2500unit; 15mg qc therin-m tablet 90mg; 0; 30mcg; 40mg; 10mg; 7.5mg; 3 DP 400unit; 50mcg; 2mg; 12mcg; 9mg; 400mcg; 100mg; 2mg; 20mg; 5mcg; 31mg; 28mcg; 7.5mg; 150mcg; 6mg; 3.4mg; 2mg; 150mcg; 10mcg; 75mcg; 70mcg; 10mcg; 3mg; 60unit; 5000unit; 15mg sm complete senior formula tablet 60mg; 0; 30mcg; 220mg; 3 DP 10mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg; 250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 20mg; 30mcg; 80mg; 150mcg; 3mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg; 1.5mg; 50unit; 2500unit; 11mg stress formula w/iron tablet 600mg; 12mcg; 81mg; 0.4mg; 3 DP 100mg; 20mg; 25mg; 15mg; 15mg; 30unit stress formula/iron tablet 600mg; 12mcg; 81mg; 0.4mg; 3 DP 100mg; 20mg; 0; 15mg; 0; 30unit STRESS-600/ZINC TABLET 600MG; 45MCG; 3MG; 12MCG; 400MCG; 100MG; 20MG; 5MG; 10MG; 20MG; 30UNIT; 23.9MG 3 DP Page 7 of 12

9 Name THERA-M TABLET 90MG; 0; 30MCG; 30MG; 10MG; 3 DP 50MCG; 2MG; 12MCG; 400UNIT; 9MG; 400MCG; 100MG; 2MG; 20MG; 5MCG; 23MG; 28MCG; 7.5MG; 7MG; 150MCG; 6MG; 3.4MG; 6MG; 150MCG; 10MCG; 75MCG; 70MCG; 10MCG; 3MG; 60UNIT; 5000UNIT; 15MG therems tablet 90mg; 30mcg; 10mg; 45mg; 400unit; 9mcg; 3 DP 400mcg; 20mg; 10mg; 3mg; 3.4mg; 3mg; 30unit; 5000unit tri-vitamin solution 35mg/ml; 400unit/ml; 1500unit/ml 3 DP vitamin c tablet 500mg 3 DP Unclassified No Classification AQUA-E LIQUID 30MG/ML; 2MG/ML 3 DP b-complex plus vitamin c tablet 300mg; 150mg; 10mg; 50mg; 3 DP 5mg; 10.2mg; 15mg CALCET PETITES TABLET 200MG; 250UNIT 3 DP CALCIONATE SYRUP 1.8GM/5ML 3 DP calcitrate tablet 950mg 3 DP calvite p&d tablet 105mg; 120unit; 81mg 3 DP CLINITEST TABLET 0 3 DP CVS KETONE CARE STRIP 0 3 DP CYTO-Q MAX LIQUID 100MG/ML 3 DP fiber laxative tablet 625mg 3 DP FRUCTOSE GRANULES 0 3 DP GLYCERIN LIQUID 99.5% 3 DP gnp artificial tears solution 0.5%; 0.6% 3 DP gnp calcium plus 600 +d tablet 600mg; 200unit; 1mg; 40mg; 3 DP 1.8mg; 250mcg; 7.5mg gnp castor oil oil 100% 3 DP gnp century ultimate mens complete tablet 90mg; 0; 40mcg; 3 DP 210mg; 15mg; 20mg; 72mg; 600unit; 35mcg; 0.9mg; 6mcg; 8mg; 200mcg; 600mcg; 100mg; 2.3mg; 16mg; 5mcg; 60mcg; 80mg; 150mcg; 2mg; 1.3mg; 2mg; 150mcg; 10mcg; 50mcg; 100mcg; 10mcg; 1.2mg; 45unit; 3500unit; 11mg gnp century ultimate mens senior formula tablet 120mg; 0; 3 DP 30mcg; 250mg; 10mg; 20mg; 72mg; 600unit; 60mcg; 0.7mg; 100mcg; 300mcg; 300mcg; 600mcg; 50mg; 4mg; 20mg; 5mcg; 60mcg; 80mg; 150mcg; 6mg; 1.7mg; 2mg; 150mcg; 10mcg; 50mcg; 100mcg; 1.5mg; 60unit; 3500unit; 15mg gnp iron tablet extended release 45mg 3 DP gnp multi-symptom cold nighttime liquid 325mg/15ml; 3 DP 10mg/15ml; 6.25mg/15ml; 5mg/15ml hm cold & sinus relief tablet 200mg; 30mg 3 DP L-CITRULLINE POWDER 0 3 DP L-GLUTATHIONE CRYSTALS 0 3 DP L-ISOLEUCINE POWDER 0 3 DP LIQ-10 SYRUP 50MG/5ML; 15UNIT/5ML 3 DP LOLLIBASE POWDER 0 3 DP MULTISTIX 10 SG STRIP 0 3 DP OYSTER SHELL CALCIUM TABLET 250MG 3 DP Page 8 of 12

10 Name PRO-CLEAR AC SYRUP 9MG/5ML; 8.33MG/5ML 3 DP PRO-RED AC SYRUP 9MG/5ML; 1MG/5ML; 5MG/5ML 3 DP TRIXAICIN CREAM 0.025% 3 DP VANAHIST PD LIQUID 0.625MG/ML 3 DP Page 9 of 12

11 Index Name Page # ACIDOPHILUS/CITRUS PECTIN 3 acidophilus/l-sporogenes extra strength 3 ADEKS 6 AFRIN MENTHOL 4 akwa tears 4 alavert 4 all day allergy-d 4 allergy multi-symptom 4 ALPHA LIPOIC ACID 3 aluminum acetate astringent 2 AMLACTIN ULTRA 2 AQUABASE 2 aquadeks 6 AQUA-E 8 aqueous vitamin e 6 arginine 3 artificial tears 4 ATRAC-TAIN 2 bacitracin zinc 2 BACTERIOSTATIC WATER FOR 1 INJECTION/BENZYL ALCOHOL b-complex plus vitamin c 8 BENZOIN COMPOUND TINCTURE 2 bisac-evac 3 CALCET PETITES 8 CALCI-MIX 5 CALCIONATE 8 calcitrate 8 CALCIUM LACTATE 5 calcium plus vitamin d3 5 CALTRATE 600+D PLUS MINERALS 5 calvite p&d 8 CAPCOF 4 CAPMIST DM 4 CAPRON DM 4 centavite a-z complete 6 multivitamin/minerals CENTRUM 6 CENTRUM ADULTS 6 cerovite jr 6 chromium chloride 1 CLINITEST 8 CO Q-10 PLUS 3 CODITUSS DM 5 cold head congestion severe daytime 5 cold multi-symptom daytime 5 complete lice treatment kit 2 Page 10 of 12 Name Page # COMTREX COLD & COUGH 5 NIGHTTIME MAXIMUM STRENGTH CONEX COLD/ALLERGY 5 COPPER TRACE METAL 1 corvita CVS KETONE CARE 8 CYTO-Q MAX 8 dayhist allergy 12 hour relief 4 DELSYM 5 dexferrum 1 DIALYVITE VITAMIN D3 MAX 6 DIASTIX 3 dimenhydrinate 2 DIMETAPP COLD & ALLERGY 4 DIMETAPP DM COLD & COUGH 5 DIMETAPP LONG ACTING COUGH 5 PLUS COLD dimetapp nighttime cold &congestion 5 double antibiotic 2 D-VI-SOL 6 ear wax remover 4 ed bron gp 5 ed-chlortan 4 enemeez plus 3 EPHEDRINE SULFATE 4 EZFE FORTE 6 FERAHEME 1 FERRAPLUS 90 1 ferrous drops 5 fiber laxative 8 fish oil ultra 4 FLEET OIL 3 formulation r 3 FOSFREE 6 FRESHKOTE 4 FRUCTOSE 8 GAS-X EXTRA STRENGTH 3 GAVISCON 3 GENTEAL SEVERE 4 GLYCERIN 8 gnp artificial tears 8 gnp calcium plus 600 +d 8 gnp castor oil 8 gnp century ultimate mens complete 8 gnp century ultimate mens senior formula 8 gnp century ultimate womens senior formula 7 gnp fiber therapy 3 gnp foaming antacid 3 gnp iron 8 gnp lubricant eye drops 4

12 Name Page # gnp multi-symptom cold nighttime 8 gnp night time sinus 5 gnp one daily maximum 7 gnp triple antibiotic plus 2 guaiatussin ac 5 guaifenesin dac 5 healthy eyes 7 hemorrhoidal 2 hm cold & sinus relief 8 hm double antibiotic 2 hydrocodone bitartrate/homatropine 1 methylbromide hydrocodone polistirex/chlorpheniramine 1 polistirex HYDROUS EMULSIFIED BASE 2 icaps 7 iferex infuvite 1 iron 5 itch relief extra strength 2 KETO-DIASTIX 4 konsyl 3 LACTOSE 4 LACTRASE 3 LAMISIL ADVANCED 2 lamisil af defense 2 L-CITRULLINE 8 L-GLUTATHIONE 8 lice killing maximum strength 2 LIQ-10 8 L-ISOLEUCINE 8 LMX 4 PLUS 2 LOLLIBASE 8 maalox advanced 3 MAGNEBIND magnesium oxide 3 MAGONATE 5 MAG-TAB SR 5 MANGANESE TRACE METAL 1 M-END PE 5 meribin 7 milk of magnesia 3 MULTI-DELYN/IRON 7 multilex-t&m 7 MULTISTIX 10 SG 8 MYKIDZ IRON 7 NAIL SCRUB 2 nasal decongestant pe maximum strength 5 natural coenzyme q10 4 nite-time multi-symptom cold/flu relief 5 Name Page # OCUVITE ADULT ORA-BLEND 4 ORA-BLEND SF 4 ORA-PLUS 4 ORA-SWEET 4 ORA-SWEET SF 4 OYSTER SHELL CALCIUM 8 oyster shell calcium/vitamin d 5 PENTRAVAN 2 periguard 2 PHENYLHISTINE DH 5 PHOS-NAK POWDER CONCENTRATE 6 povidone-iodine 2 PREMIUM CONDOMS LUBRICATED 4 PREPARATION H 2 PRESERVISION AREDS 2 7 PRO-CLEAR AC 9 PRO-RED AC 9 qc hemorrhoidal 2 qc maximum daily 7 multivitamin/multimineral qc therin-m 7 qc tussin cf 5 q-gel mega 4 reeses pinworm medicine 2 REFRESH PLUS 4 RESPAIRE-30 5 RYDEX 5 salactic film 2 SEBULEX 2 senexon-s 3 senna-time 3 SENSI-CARE PROTECTIVE BARRIER 3 sinus congestion & pain daytime 5 sm calcium citrate w/vitamin d3 6 sm complete senior formula 7 sm flu relief therapy severe cold nighttime 5 SM GLUCOSE 2 sm hydrocortisone 3 sm oral saline laxative 3 SOOTHE & COOL FREE MOISTURE 3 BARRIER sterilube 4 stress formula w/iron 7 stress formula/iron 7 STRESS-600/ZINC 7 sudogest sinus & allergy 4 SYSTANE BALANCE RESTORATIVE 4 FORMULA tears naturale 4 Page 11 of 12

13 Name Page # tears naturale forte 4 tears naturale ii 4 THERA-M 8 therems 8 thiamine hcl 1 tl icon 1 TRIAMINIC MULTI-SYMPTOM FEVER 5 triple antibiotic 2 tri-vitamin 8 TRIXAICIN 9 VAGISTAT-1 2 VANAHIST PD 9 VENOFER 1 vitamin c 8 vitamin k1 1 ZADITOR 4 ZIKS ARTHRITIS PAIN RELIEF 3 ZINC TRACE METAL 1 Page 12 of 12

14 4349 Easton Way, Suite 200 Columbus, OH Telephone: TTY: 711