Department of Human Services
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- Maximillian Logan
- 7 years ago
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1 Department of Human Services Proposed PDL for IOWA Medicaid Program Listing Covered OTC Drugs: Effective Date: 10/13/2015 Note: Not all s may be represented and the status of those listed are subject to change without notification. DRUG CATEGORY Drug Description PA: "" denotes ANALGESICS - MISC. Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab 325 PHARBEST PHARMACEUTICALS, Aspirin Tab 325 PHARBEST PHARMACEUTICALS, Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab Aspirin Tab 325 TIME-CAP LABS, Aspirin Tab 325 Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab 81 Page 1 of 28
2 Drug Description PA: "" denotes ANALGESICS - MISC. Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab 81 PHARBEST PHARMACEUTICALS, Aspirin Chew Tab 81 PHARBEST PHARMACEUTICALS, Aspirin Chew Tab 81 PRIME MARKETING LLC Aspirin Chew Tab 81 QUALITEST PHARMACEUTICALS, Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab 81 TIME-CAP LABS, Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab Aspirin Chew Tab DRUG COMPANY DRUG COMPANY DRUG COMPANY MCKESSON PACKAGING SERVICE, A DIVISION MCKESSON PACKAGING SERVICE, A DIVISION PHARBEST PHARMACEUTICALS, PHARBEST PHARMACEUTICALS, PRIME MARKETING LLC PRIME MARKETING LLC QUALITEST PHARMACEUTICALS, QUALITEST PHARMACEUTICALS, Page 2 of 28
3 Drug Description PA: "" denotes ANALGESICS - MISC TIME-CAP LABS, TIME-CAP LABS, Aspirin Tab Delayed Release Aspirin Tab Delayed Release Aspirin Tab Delayed Release Aspirin Tab Delayed Release Aspirin Tab Delayed Release 325 LNK INTERNATIONAL, Aspirin Tab Delayed Release Aspirin Tab Delayed Release Aspirin Tab Delayed Release Aspirin Tab Delayed Release Aspirin Tab Delayed Release Aspirin Tab Delayed Release Aspirin Tab Delayed Release Aspirin Tab Delayed Release 325 MCKESSON PACKAGING SERVICE, A DIVISION Aspirin Tab Delayed Release 325 PHARBEST PHARMACEUTICALS, Aspirin Tab Delayed Release 325 PHARBEST PHARMACEUTICALS, Aspirin Tab Delayed Release 325 PRIME MARKETING LLC Aspirin Tab Delayed Release 325 PRIME MARKETING LLC Aspirin Tab Delayed Release 325 QUALITEST PHARMACEUTICALS, Aspirin Tab Delayed Release 325 QUALITEST PHARMACEUTICALS, Aspirin Tab Delayed Release 325 QUALITEST PHARMACEUTICALS, Aspirin Tab Delayed Release Aspirin Tab Delayed Release Aspirin Tab Delayed Release Aspirin Tab Delayed Release 325 Acetaminophen Tab Acetaminophen Tab Acetaminophen Tab Acetaminophen Tab Acetaminophen Tab Acetaminophen Tab Acetaminophen Tab Acetaminophen Tab Acetaminophen Tab 325 MCKESSON PACKAGING SERVICE, A DIVISION Acetaminophen Tab 325 PHARBEST PHARMACEUTICALS, Acetaminophen Tab 325 PHARBEST PHARMACEUTICALS, Acetaminophen Tab 325 PHARBEST PHARMACEUTICALS, Acetaminophen Tab 325 PRIME MARKETING LLC Acetaminophen Tab 325 PRIME MARKETING LLC Acetaminophen Tab 325 QUALITEST PHARMACEUTICALS, Acetaminophen Tab 325 Page 3 of 28
4 Drug Description PA: "" denotes ANALGESICS - MISC. Acetaminophen Tab 325 QUALITEST PHARMACEUTICALS, Acetaminophen Tab Acetaminophen Tab Acetaminophen Tab Acetaminophen Tab Acetaminophen Tab Acetaminophen Tab DRUG COMPANY DRUG COMPANY DRUG COMPANY DRUG COMPANY DRUG COMPANY Page 4 of 28
5 Drug Description PA: "" denotes ANALGESICS - MISC PHARBEST PHARMACEUTICALS, PHARBEST PHARMACEUTICALS, PHARBEST PHARMACEUTICALS, PRIME MARKETING LLC PRIME MARKETING LLC PRIME MARKETING LLC PRIME MARKETING LLC QUALITEST PHARMACEUTICALS, QUALITEST PHARMACEUTICALS, Acetaminophen Soln 100 /ML QUALITEST PHARMACEUTICALS, Acetaminophen Soln 100 /ML SILAR PHARMACEUTICALS, Acetaminophen Soln 100 /ML SILAR PHARMACEUTICALS, Acetaminophen Soln 100 /ML Page 5 of 28
6 Drug Description PA: "" denotes ANALGESICS - MISC. Acetaminophen Suppos Acetaminophen Suppos 120 G&W LABORATORIES, INC Acetaminophen Suppos 120 G&W LABORATORIES, INC Acetaminophen Suppos 120 G&W LABORATORIES, INC Acetaminophen Suppos Acetaminophen Suppos Acetaminophen Suppos 120 TARO PHARMACEUTICALS USA, Acetaminophen Suppos 120 TARO PHARMACEUTICALS USA, Acetaminophen Suppos 120 ANTIEMETIC - ANTICHOLINERGIC / DOPAMINERGIC Meclizine HCl Tab Meclizine HCl Tab Meclizine HCl Tab Meclizine HCl Tab Meclizine HCl Tab 12.5 Meclizine HCl Tab Meclizine HCl Tab Meclizine HCl Tab Meclizine HCl Tab 25 Meclizine HCl Chew Tab Meclizine HCl Chew Tab Meclizine HCl Chew Tab Meclizine HCl Chew Tab Meclizine HCl Chew Tab 25 TRIGEN LABORATORIES, LLC Meclizine HCl Chew Tab 25 TRIGEN LABORATORIES, LLC Meclizine HCl Chew Tab 25 ANTIHISTAMINES - NON-SEDATING Cetirizine HCl Tab 5 MYLAN PHARMACEUTICALS, Cetirizine HCl Tab 5 RISING PHARMACEUTICALS, INC Cetirizine HCl Tab 5 SANDOZ Cetirizine HCl Tab 5 AMERICAN HEALTH PACKAGING AMERICAN HEALTH PACKAGING APOTE CORP APOTE CORP DR. REDDY'S LABORATORIES, Page 6 of 28
7 Drug Description PA: "" denotes ANTIHISTAMINES - NON-SEDATING MYLAN INSTITUTIONAL, INC MYLAN INSTITUTIONAL, INC MYLAN PHARMACEUTICALS, MYLAN PHARMACEUTICALS, NORTHSTAR R LLC NORTHSTAR R LLC OHM PHARMACEUTICALS, RISING PHARMACEUTICALS, INC RISING PHARMACEUTICALS, INC SANDOZ Cetirizine HCl Oral Soln 1 /ML (5 /5ML) DRUG COMPANY DRUG COMPANY Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Page 7 of 28
8 Drug Description PA: "" denotes ANTIHISTAMINES - NON-SEDATING Cetirizine HCl Oral Soln 1 /ML (5 /5ML) PRECISION DOSE, PRECISION DOSE, SILAR PHARMACEUTICALS, TARO PHARMACEUTICALS USA, TARO PHARMACEUTICALS USA, Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) Cetirizine HCl Oral Soln 1 /ML (5 /5ML) AMERICAN HEALTH PACKAGING AMERICAN HEALTH PACKAGING DRUG COMPANY APOTE CORP APOTE CORP Page 8 of 28
9 Drug Description PA: "" denotes ANTIHISTAMINES - NON-SEDATING MYLAN INSTITUTIONAL, INC MYLAN INSTITUTIONAL, INC OHM PHARMACEUTICALS, OHM PHARMACEUTICALS, OHM PHARMACEUTICALS, SANDOZ Loratadine Syrup 10 /10ML Loratadine Syrup 10 /10ML DRUG COMPANY Loratadine Syrup 10 /10ML Loratadine Syrup 10 /10ML Loratadine Syrup 10 /10ML Loratadine Syrup 10 /10ML Loratadine Syrup 10 /10ML Loratadine Syrup 10 /10ML Loratadine Syrup 10 /10ML SILAR PHARMACEUTICALS, Loratadine Syrup 10 /10ML SILAR PHARMACEUTICALS, Loratadine Syrup 10 /10ML TARO PHARMACEUTICALS USA, Loratadine Syrup 10 /10ML TARO PHARMACEUTICALS USA, Loratadine Syrup 10 /10ML TARO PHARMACEUTICALS USA, Loratadine Syrup 10 /10ML ANTIHISTAMINES - OTHER Page 9 of 28
10 Drug Description PA: "" denotes ANTIHISTAMINES - OTHER Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab 4 EDWARDS PHARMACEUTICALS, Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab Chlorpheniramine Maleate Tab CONTRACT PHARMACAL CORP CONTRACT PHARMACAL CORP EON LABS, EON LABS, PHARBEST PHARMACEUTICALS, PHARBEST PHARMACEUTICALS, PHARBEST PHARMACEUTICALS, QUALITEST PHARMACEUTICALS, QUALITEST PHARMACEUTICALS, QUALITEST PHARMACEUTICALS, Page 10 of 28
11 Drug Description PA: "" denotes ANTIHISTAMINES - OTHER SDA LABORATORIES SDA LABORATORIES Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML QUALITEST PHARMACEUTICALS, Diphenhydramine HCl Liquid 12.5 /5ML QUALITEST PHARMACEUTICALS, Diphenhydramine HCl Liquid 12.5 /5ML QUALITEST PHARMACEUTICALS, Diphenhydramine HCl Liquid 12.5 /5ML QUALITEST PHARMACEUTICALS, Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML SILAR PHARMACEUTICALS, Diphenhydramine HCl Liquid 12.5 /5ML SILAR PHARMACEUTICALS, Diphenhydramine HCl Liquid 12.5 /5ML SILAR PHARMACEUTICALS, Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Liquid 12.5 /5ML Diphenhydramine HCl Syrup 12.5 /5ML QUALITEST PHARMACEUTICALS, Diphenhydramine HCl Syrup 12.5 /5ML SILAR PHARMACEUTICALS, Diphenhydramine HCl Syrup 12.5 /5ML SILAR PHARMACEUTICALS, Diphenhydramine HCl Syrup 12.5 /5ML SILAR PHARMACEUTICALS, Diphenhydramine HCl Syrup 12.5 /5ML COUGH/COLD /5ML /5ML /5ML /5ML /5ML Page 11 of 28
12 Drug Description PA: "" denotes COUGH/COLD /5ML PHARMACEUTICAL ASSOCIATES, PHARMACEUTICAL ASSOCIATES, QUALITEST PHARMACEUTICALS, QUALITEST PHARMACEUTICALS, QUALITEST PHARMACEUTICALS, SILAR PHARMACEUTICALS, SILAR PHARMACEUTICALS, SILAR PHARMACEUTICALS, COUGH/COLD - SYSTEMIC DECONGESTANTS Pseudoephedrine HCl Tab /5ML /5ML /5ML /5ML /5ML /5ML /5ML /5ML /5ML /5ML /5ML /5ML /5ML /5ML /5ML /5ML /5ML /5ML /5ML /5ML Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab 30 Page 12 of 28
13 Drug Description PA: "" denotes COUGH/COLD - SYSTEMIC DECONGESTANTS Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab 30 Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab Pseudoephedrine HCl Tab 60 Pseudoephedrine HCl Syrup 30 /5ML NASAL DECON SYP 30/5ML DIABETIC - INSULIN Insulin Regular (Human) Inj 100 Unit/ML ELI LILLY AND COMPANY HUMULIN R INJ U-100 ELI LILLY AND COMPANY HUMULIN R INJ U-100 NOVO NORDISK, NOVOLIN R INJ RELION NOVO NORDISK, NOVOLIN R INJ U-100 Insulin Isophane (Human) Inj 100 Unit/ML ELI LILLY AND COMPANY HUMULIN N INJ U-100 ELI LILLY AND COMPANY HUMULIN N INJ U-100 NOVO NORDISK, NOVOLIN N INJ RELION NOVO NORDISK, NOVOLIN N INJ U-100 Insulin Isophane & Regular (Human) Inj 100 Unit/ML (70-30) ELI LILLY AND COMPANY HUMULIN INJ 70/30 ELI LILLY AND COMPANY HUMULIN INJ 70/30 NOVO NORDISK, NOVOLIN70/30 INJ RELION NOVO NORDISK, NOVOLIN INJ 70/30 GI - ANTI - FLATULENTS / GI STIMULANTS Sennosides Tab Sennosides Tab Sennosides Tab 8.6 CYPRESS PHARMACEUTICAL, LLC Sennosides Tab 8.6 GOLDLINE LABORATORIES, Sennosides Tab 8.6 GOLDLINE LABORATORIES, Sennosides Tab Sennosides Tab Sennosides Tab Sennosides Tab Sennosides Tab Sennosides Tab Sennosides Tab 8.6 Page 13 of 28
14 Drug Description PA: "" denotes GI - ANTI - FLATULENTS / GI STIMULANTS Sennosides Tab 8.6 PHARBEST PHARMACEUTICALS, PHARBEST PHARMACEUTICALS, PRIME MARKETING LLC PURDUE PRODUCTS, L.P. PURDUE PRODUCTS, L.P. PURDUE PRODUCTS, L.P. PURDUE PRODUCTS, L.P. QUALITEST PHARMACEUTICALS, QUALITEST PHARMACEUTICALS, TIME-CAP LABS, TIME-CAP LABS, Sennosides Tab 8.6 Sennosides Tab 8.6 Sennosides Tab 8.6 Sennosides Tab 8.6 SENOKOT TAB 8.6 SENOKOT TAB 8.6 SENOKOT TAB 8.6 SENOKOT TAB 8.6 Sennosides Tab 8.6 Sennosides Tab 8.6 Sennosides Tab 8.6 Sennosides Tab 8.6 Sennosides Tab 8.6 Sennosides Tab 8.6 Sennosides Tab 8.6 DRUG COMPANY DRUG COMPANY DRUG COMPANY GAVIS PHARMACEUTICALS, LLC GAVIS PHARMACEUTICALS, LLC KREMERS URBAN, KREMERS URBAN, KREMERS URBAN, KREMERS URBAN, KREMERS URBAN, KREMERS URBAN, Page 14 of 28
15 Drug Description PA: "" denotes GI - ANTI - FLATULENTS / GI STIMULANTS GI - ANTIPERISTALTIC AGENTS DRUG COMPANY OHM PHARMACEUTICALS, Loperamide HCl Liq 1 /5ML (0.2 /ML) Loperamide HCl Liq 1 /5ML (0.2 /ML) HI-TECH PHARMACAL CO Loperamide HCl Liq 1 /5ML (0.2 /ML) HI-TECH PHARMACAL CO Loperamide HCl Liq 1 /5ML (0.2 /ML) HI-TECH PHARMACAL CO Loperamide HCl Liq 1 /5ML (0.2 /ML) HI-TECH PHARMACAL CO Loperamide HCl Liq 1 /5ML (0.2 /ML) HI-TECH PHARMACAL CO Loperamide HCl Liq 1 /5ML (0.2 /ML) Page 15 of 28
16 Drug Description PA: "" denotes GI - MISC. Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML PHARMACEUTICAL ASSOCIATES, Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Magnesium Hydroxide Susp 400 /5ML Sennosides Syrup 8.8 /5ML Sennosides Syrup 8.8 /5ML Sennosides Syrup 8.8 /5ML Sennosides-Docusate Sodium Tab AMERICAN HEALTH PACKAGING CYPRESS PHARMACEUTICAL, LLC GOLDLINE LABORATORIES, GOLDLINE LABORATORIES, Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Page 16 of 28
17 Drug Description PA: "" denotes GI - MISC. Sennosides-Docusate Sodium Tab MCKESSON PACKAGING SERVICE, A DIVISION MCKESSON PACKAGING SERVICE, A DIVISION PURDUE PRODUCTS, L.P. PURDUE PRODUCTS, L.P. PURDUE PRODUCTS, L.P. PURDUE PRODUCTS, L.P. PURDUE PRODUCTS, L.P. PURDUE PRODUCTS, L.P. PURDUE PRODUCTS, L.P. QUALITEST PHARMACEUTICALS, QUALITEST PHARMACEUTICALS, QUALITEST PHARMACEUTICALS, QUALITEST PHARMACEUTICALS, TIME-CAP LABS, TIME-CAP LABS, NICOTINE PATCHES / TABLETS Nicotine TD Patch 24HR 7 /24HR Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab SENOKOT S TAB SENOKOT S TAB SENOKOT S TAB SENOKOT S TAB Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab Sennosides-Docusate Sodium Tab DR. REDDY'S LABORATORIES, Nicotine TD Patch 24HR 7 /24HR DR. REDDY'S LABORATORIES, Nicotine TD Patch 24HR 7 /24HR GLAOSMITHKLINE NICODERM CQ DIS 7/24HR GLAOSMITHKLINE NICODERM CQ DIS 7/24HR Nicotine TD Patch 24HR 7 /24HR Nicotine TD Patch 24HR 7 /24HR NOVARTIS CONSUMER HEALTH, Nicotine TD Patch 24HR 7 /24HR NOVARTIS CONSUMER HEALTH, Nicotine TD Patch 24HR 7 /24HR NOVARTIS CONSUMER HEALTH, Nicotine TD Patch 24HR 7 /24HR Page 17 of 28
18 Drug Description PA: "" denotes NICOTINE PATCHES / TABLETS Nicotine TD Patch 24HR 7 /24HR Nicotine TD Patch 24HR 7 /24HR Nicotine TD Patch 24HR 14 /24HR DR. REDDY'S LABORATORIES, Nicotine TD Patch 24HR 14 /24HR DR. REDDY'S LABORATORIES, Nicotine TD Patch 24HR 14 /24HR GLAOSMITHKLINE NICODERM CQ DIS 14/24H GLAOSMITHKLINE NICODERM CQ DIS 14/24H GLAOSMITHKLINE NICODERM CQ DIS 14/24H Nicotine TD Patch 24HR 14 /24HR Nicotine TD Patch 24HR 14 /24HR NOVARTIS CONSUMER HEALTH, Nicotine TD Patch 24HR 14 /24HR NOVARTIS CONSUMER HEALTH, Nicotine TD Patch 24HR 14 /24HR NOVARTIS CONSUMER HEALTH, Nicotine TD Patch 24HR 14 /24HR Nicotine TD Patch 24HR 14 /24HR Nicotine TD Patch 24HR 21 /24HR DR. REDDY'S LABORATORIES, Nicotine TD Patch 24HR 21 /24HR DR. REDDY'S LABORATORIES, Nicotine TD Patch 24HR 21 /24HR DR. REDDY'S LABORATORIES, Nicotine TD Patch 24HR 21 /24HR GLAOSMITHKLINE NICODERM CQ DIS 21/24H GLAOSMITHKLINE NICODERM CQ DIS 21/24H GLAOSMITHKLINE NICODERM CQ DIS 21/24H GLAOSMITHKLINE NICODERM CQ DIS 21/24H GLAOSMITHKLINE NICODERM CQ DIS 21/24H Nicotine TD Patch 24HR 21 /24HR Nicotine TD Patch 24HR 21 /24HR Nicotine TD Patch 24HR 21 /24HR NOVARTIS CONSUMER HEALTH, Nicotine TD Patch 24HR 21 /24HR NOVARTIS CONSUMER HEALTH, Nicotine TD Patch 24HR 21 /24HR NOVARTIS CONSUMER HEALTH, Nicotine TD Patch 24HR 21 /24HR NOVARTIS CONSUMER HEALTH, Nicotine TD Patch 24HR 21 /24HR Nicotine TD Patch 24HR 21 /24HR NICOTINE REPLACEMENT - OTHER Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum 2 GLAOSMITHKLINE NICORETTE ST GUM 2 ORIG GLAOSMITHKLINE NICORETTE GUM 2 ORIG GLAOSMITHKLINE NICORETTE GUM 2 ORIG GLAOSMITHKLINE NICORETTE ST GUM 2 MINT GLAOSMITHKLINE NICORETTE GUM 2 MINT GLAOSMITHKLINE NICORETTE GUM 2 MINT GLAOSMITHKLINE NICORETTE GUM 2 MINT GLAOSMITHKLINE NICORETTE GUM 2FRUIT GLAOSMITHKLINE NICORETTE GUM 2FRUIT GLAOSMITHKLINE NICORETTE GUM 2FRUIT GLAOSMITHKLINE NICORETTE GUM 2FRUIT GLAOSMITHKLINE NICORETTE GUM 2FRUIT Page 18 of 28
19 Drug Description PA: "" denotes NICOTINE REPLACEMENT - OTHER Nicotine Polacrilex Gum 2 GLAOSMITHKLINE NICORETTE GUM 2 CINN GLAOSMITHKLINE NICORETTE GUM 2 CINN GLAOSMITHKLINE NICORETTE GUM 2 CINN GLAOSMITHKLINE NICORETTE GUM 2 CINN GLAOSMITHKLINE NICORETTE GUM 2 MINT GLAOSMITHKLINE NICORETTE GUM 2 MINT GLAOSMITHKLINE NICORETTE GUM 2 MINT GLAOSMITHKLINE NICORETTE GUM 2 MINT GLAOSMITHKLINE NICORETTE GUM 2 MINT Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum 2 Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum 4 GLAOSMITHKLINE NICORETTE ST GUM 4 ORIG GLAOSMITHKLINE NICORETTE GUM 4 ORIG GLAOSMITHKLINE NICORETTE GUM 4 ORIG GLAOSMITHKLINE NICORETTE GUM 4 MINT GLAOSMITHKLINE NICORETTE GUM 4 MINT GLAOSMITHKLINE NICORETTE GUM 4 MINT Page 19 of 28
20 Drug Description PA: "" denotes NICOTINE REPLACEMENT - OTHER Nicotine Polacrilex Gum 4 GLAOSMITHKLINE NICORETTE GUM 4 MINT GLAOSMITHKLINE NICORETTE GUM 4FRUIT GLAOSMITHKLINE NICORETTE GUM 4FRUIT GLAOSMITHKLINE NICORETTE GUM 4FRUIT GLAOSMITHKLINE NICORETTE GUM 4FRUIT GLAOSMITHKLINE NICORETTE GUM 4FRUIT GLAOSMITHKLINE NICORETTE GUM 4FRUIT GLAOSMITHKLINE NICORETTE GUM 4 CINN GLAOSMITHKLINE NICORETTE GUM 4 CINN GLAOSMITHKLINE NICORETTE GUM 4 CINN GLAOSMITHKLINE NICORETTE GUM 4 MINT GLAOSMITHKLINE NICORETTE GUM 4 MINT GLAOSMITHKLINE NICORETTE GUM 4 MINT GLAOSMITHKLINE NICORETTE GUM 4 MINT GLAOSMITHKLINE NICORETTE GUM 4 MINT Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum Nicotine Polacrilex Gum 4 Nicotine Polacrilex Lozenge Nicotine Polacrilex Lozenge 2 Page 20 of 28
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28 Drug Description PA: "" denotes VAGINAL - ANTI FUNGALS Miconazole Nitrate Vaginal Cream 2% G&W LABORATORIES, INC TARO PHARMACEUTICALS USA, Miconazole Nitrate Vaginal Suppos Miconazole Nitrate Vaginal Cream 2% Miconazole Nitrate Vaginal Cream 2% Miconazole Nitrate Vaginal Cream 2% Miconazole Nitrate Vaginal Cream 2% Miconazole Nitrate Vaginal Cream 2% Miconazole Nitrate Vaginal Cream 2% Miconazole Nitrate Vaginal Cream 2% Miconazole Nitrate Vaginal Cream 2% Miconazole Nitrate Vaginal Cream 2% Miconazole Nitrate Vaginal Suppos 100 G&W LABORATORIES, INC Miconazole Nitrate Vaginal Suppos Miconazole Nitrate Vaginal Suppos 100 Page 28 of 28
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