Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP)

Transcription

1 PAIN RELIEVERS-FEVER REDUCERS acetaminophen Tylenol 325 mg tablets acetaminophen Tylenol Extra Strength 500 mg tablets acetaminophen 650 mg tablets acetaminophen 500 mg capsules acetaminophen Tylenol Arthritis 650 mg tablets, ER acetaminophen 80 mg chewable tablets acetaminophen 160 mg chewable tablets acetaminophen Tylenol Go 500 mg chewable tablets acetaminophen 160 mg/5 ml elixir acetaminophen 160 mg/5 ml liquid acetaminophen Tylenol 167 mg/5 ml liquid acetaminophen 500 mg/5 ml liquid acetaminophen Tylenol 160 mg/5 ml suspension acetaminophen 160 mg/5 ml solution acetaminophen 325 mg/5 ml solution acetaminophen Triaminic Fever Reducer 160 mg/5 ml syrup acetaminophen Tylenol 80 mg/0.8 ml suspension acetaminophen 100 mg/ml solution (drops) acetaminophen Feverall 80 mg suppositories acetaminophen 120 mg suppositories acetaminophen 325 mg suppositories acetaminophen 650 mg suppositories acetaminophen Tylenol Children's Meltaways 80 mg dispersable tablets acetaminophen Tylenol Jr. Meltaways 160 mg dispersable tablets acetaminophen 500 mg dispersable tablets acetaminophen/caffeine Excedrin Tension Headache 500 mg-65 mg tablets acetaminophen/caffeine/pyrilamine Midol Complete 500 mg-60 mg-15 mg tablets PW_12-13_1049/DHS_Approved_01/24/2014 Page 1 of 19

2 acetaminophen/diphenhydramine Tylenol PM 500 mg-25 mg tablets acetaminophen/diphenhydramine Excedrin PM 500 mg-38 mg tablets acetaminophen/diphenhydramine Unisom PM Pain 325 mg-50 mg tablets acetaminophen/diphenhydramine Tylenol PM 1000 mg-50 mg/30 ml liquid aspirin St. Joseph 75 mg chewable tablets aspirin Bayer Chewable Low Dose 81 mg chewable tablets aspirin 81 mg tablets aspirin 325 mg tablets aspirin Bayer Advanced 500 mg tablets aspirin buffered Bufferin Low Dose 81 mg tablets aspirin buffered Bufferin 325 mg tablets aspirin buffered Bufferin Extra Strength 500 mg tablets aspirin buffered Ascriptin 325 mg tablets aspirin buffered Ascriptin Maximum Strength 500 mg tablets aspirin enteric-coated Ecotrin 325 mg tablets, DR aspirin enteric-coated Ecotrin Maximum Strength 500 mg tablets, DR aspirin enteric-coated Bayer Low Dose 81 mg tablets, DR aspirin 81 mg dispersable tablets aspirin 300 mg, 600 mg suppositories aspirin 60 mg, 120 mg, 200 mg suppositories aspirin enteric-coated Halfprin 162 mg tablets, DR aspirin/acetaminophen/ caffeine Excedrin Migraine mg tablets 400 mg-32 mg, 500 mgaspirin/caffeine 32.5 mg tablets ibuprofen Children's Motrin, Children's Advil 100 mg/5 ml suspension ibuprofen Motrin Infants, Children's Advil 40 mg/ml suspension Advil Jr. Strength, Children's Motrin ibuprofen Jr. Strength 100 mg chewable tablets ibuprofen Advil, Motrin IB 200 mg tablets naproxen sodium Aleve 220 mg tablets PW_12-13_1049/DHS_Approved_01/24/2014 Page 2 of 19

3 FUNGAL INFECTIONS - vaginal clotrimazole Gyne-Lotrimin 1% vaginal cream clotrimazole Gyne-Lotrimin 3 2% vaginal cream miconazole 2% vaginal cream miconazole 4% vaginal cream miconazole 100 mg vaginal tablets miconazole suppository & cream kit various vaginal tablets & cream kit BIRTH CONTROL condoms all all Conceptrol (nonoxynol-9) 4% gel nonoxynol-9 VCF Vaginal Contraceptive Foam 12.5% foam nonoxynol-9 VCF Vaginal Contraceptive Film 28% film nonoxynol-9 Shur-seal 2% gel Gynol II (nonoxynol-9) 3% gel levonorgestrel Plan B 0.75 mg tablets levonorgestrel Plan B 1.5 mg tablets nonoxynol-9 Encare 100 mg suppository EAR, NOSE, THROAT benzocaine Hurricaine 20% oral solution carbamide peroxide Debrox 6.5% otic solution cromolyn sodium - nasal Nasalcrom 5.2 mg/act nasal aerosol oxymetazoline Afrin 0.05% nasal spray phenol Chloraseptic Spray 1.4% oral liquid phenylephrine Neo-Synephrine 0.25%, 1% nasal spray sodium chloride Ayr Saline nasal gel sodium chloride Ocean 0.65% nasal spray sodium chloride Rhinaris 0.2% nasal spray sodium chloride Ayr Nasal 0.65% nasal solution sodium chloride Nasadrops 0.9% nasal solution PW_12-13_1049/DHS_Approved_01/24/2014 Page 3 of 19

4 sodium chloride Ayr Allergy and Sinus 2.65% nasal solution EYE PRODUCTS artificial tears gel Genteal, Systane ophth gel artificial tears solution Tears Naturale ophth solution artificial tears ointment Refresh P.M. ophth ointment carboxymethylcellulose Refresh ophth solution hypromellose Tearisol, Isopto Tears 0.4%, 0.5%, 2% ophth solution hypromellose Genteal 0.2%, 0.3% ophth solution ketotifen Zaditor 0.025% ophth solution polyethylene glycol/polyvinyl alcohol Hypotears polyethylene glycol/propylene glycol Systane 0.4%-0.3% ophth solution polyvinyl alcohol Nutratear 0.6% ophth solution polyvinyl alcohol Akwa Tears 1.4% ophth solution polyvinyl alcohol/povidone artificial tears ophth solution propylene glycol/glycerin Soothe 0.6%/0.6% ophth solution propylene glycol/glycerin artificial tears 1%/0.3% ophth solution sodium chloride ophthalmic Muro-128 5% ophth ointment sodium chloride ophthalmic Muro-128 2%, 5% ophth solution white petrolatum-mineral oil Genteal PM, Systane ophth ointment GASTROINTESTINAL Heartburn, Indigestion aluminum & magnesium hydroxides mg/5ml suspension aluminum & magnesium mg/5 ml, 400- hydroxides/simethicone Mylanta mg/5 ml suspension aluminum & magnesium mg, hydroxides/simethicone 25 mg chewable tablets aluminum hydroxide gel suspension 320 mg/5ml suspension calcium carbonate Tums Ultra 1000 mg chewable tablets calcium carbonate Children's Mylanta 400 mg chewable tablets calcium carbonate Tums 500 mg chewable tablets PW_12-13_1049/DHS_Approved_01/24/2014 Page 4 of 19

5 calcium carbonate Maalox 600 mg chewable tablets calcium carbonate Tums E-X 750 mg chewable tablets calcium carbonate 420 mg, 1177 mg chewable tablets cimetidine Tagamet HB 200 mg tablets famotidine Pepcid AC 10 mg chewable tablets, tablets famotidine Pepcid AC Maximum Strength 20 mg chewable tablets nizatidine Axid AR 75 mg tablets omeprazole delayed-release 20 mg tablets, DR omeprazole magnesium delayed-release Prilosec OTC 20 mg tablets, DR ranitidine Zantac 75 mg tablets sodium bicarbonate tablets, powder Constipation bisacodyl Dulcolax 5 mg tablets, DR bisacodyl Fleet Bisacodyl 10 mg/30 ml enema bisacodyl Dulcolax 10 mg suppository calcium polycarbophil FiberCon 625 mg caplets calcium polycarbophil Equalactin 625 mg chewable tablets docusate sodium Colace 50 mg, 100 mg capsules docusate sodium 250 mg capsules docusate sodium 150 mg/15 ml liquid docusate sodium Pedia-Lax 50 mg/15 ml liquid docusate sodium 60 mg/15 ml syrup docusate sodium 100 mg tablets docusate sodium 283 mg enema glycerin Fleet 5.6 g enema glycerin 2.1 g suppository glycerin 1.2 g suppository glycerin 1.5 g suppository glycerin 2 g suppository glycerin 3 g suppository PW_12-13_1049/DHS_Approved_01/24/2014 Page 5 of 19

6 glycerin Pedia-Lax 1 g, 2.8 g suppository glycerin 80.7% suppository magnesium citrate oral solution 400 mg/5 ml, magnesium hydroxide Milk of Magnesia 800 mg/5 ml suspension magnesium hydroxide Milk of Magnesia 2400 mg/10 ml concentrate magnesium hydroxide Milk of Magnesia 311 mg chewable tablets magnesium hydroxide Pedia-Lax 400 mg chewable tablets methylcellulose Citrucel powder methylcellulose Citrucel 500 mg tablets mineral oil oral liquid mineral oil enema enema PEG 3350 oral powder Miralax powder psyllium powder Metamucil, Fiber-Eze powder psyllium Metamucil 0.52 g capsules psyllium Metamucil 1.7 g wafers senna 187 mg tablets senna powder, syrup sennosides 25 mg/15 ml, 8.8 mg/ml liquid sennosides 8.8 mg/5 ml syrup sennosides 8.6 mg capsules sennosides 10 mg chewable tablets sennosides Ex-Lax 15 mg chewable tablets sennosides Ex-Lax 15 mg tablets sennosides Ex-Lax Maximum Strength 25 mg tablets sennosides Senokot 8.6 mg tablets sennosides Senokot Xtra 17.2 mg tablets sennosides-docusate sodium Senokot-S mg tablets sodium phosphates rectal solution Fleet Enema enema sodium phosphates solution oral solution PW_12-13_1049/DHS_Approved_01/24/2014 Page 6 of 19

7 sorbitol 70% oral solution Diarrhea bismuth subsalicylate Pepto Bismol various suspension bismuth subsalicylate Pepto Bismol 262 mg chewable tablets, tablets loperamide 2 mg capsules loperamide Imodium A-D 2 mg chewable tablets, tablets loperamide Imodium A-D 1 mg/7.5 ml solution loperamide 1 mg/5 ml solution simethicone Gas-X 80 mg chewable tablets simethicone Gas-X Extra Strength 125 mg chewable tablets simethicone Mylanta Gas 125 mg capsules simethicone Phazyme 180 mg capsules simethicone Gas-X Infant 40 mg/0.6 ml liquid simethicone Gas-X Children's 40 mg oral strips simethicone Gas-X Extra Strength 62.5 mg oral strips simethicone Mylicon 40 mg/0.6 ml suspension simethicone 80 mg, 125 mg tablets Miscellaneous GI lactase Lactaid various capsules, chewable tablets, tablets RESPIRATORY Antihistamines/decongestants brompheniramine/ phenylephrine Dimetapp Cold and Allergy 1-2.5mg/5mL elixir brompheniramine/ pseudoephedrine 4-60 mg capsules brompheniramine/ pseudoephedrine 1 mg-15 mg/5 ml elixir brompheniramine/ pseudoephedrine mg/ml liquid brompheniramine/ pseudoephedrine 4 mg-20 mg/5 ml liquid PW_12-13_1049/DHS_Approved_01/24/2014 Page 7 of 19

8 cetirizine Zyrtec Children's Allergy 10 mg chewable tablets cetirizine Zyrtec Children's Allergy 5 mg chewable tablets Zyrtec Children's Allergy, Zyrtec cetirizine Children's Hives 5 mg/5 ml syrup cetirizine Zyrtec Allergy, Zyrtec Hives Relief 10 mg tablets cetirizine 5 mg tablets cetirizine/ pseudoephedrine Zyrtec-D 5 mg/120 mg tablets, ER chlorpheniramine Chlor-Trimeton 12 mg capsules, ER chlorpheniramine Chlor-Trimeton 2 mg/5 ml syrup chlorpheniramine Chlor-Trimeton 4 mg tablets chlorpheniramine/pseudoephedrine 2 mg-30 mg/5 ml liquid chlorpheniramine/pseudoephedrine 2 mg-30 mg chewable tablets chlorpheniramine/pseudoephedrine 0.8 mg-9 mg/ml drops chlorpheniramine/pseudoephedrine 1-15 mg/5 ml syrup chlorpheniramine/pseudoephedrine 4 mg-60 mg tablets clemastine fumarate Tavist Allergy 1.34 mg tablets diphenhydramine Benadryl 25 mg capsules diphenhydramine 12.5 mg dispersable tablets diphenhydramine Benadryl 12.5 mg chewable tablets, orally dissolving strips diphenhydramine 12.5 mg/5 ml elixir diphenhydramine Benadryl Allergy 12.5 mg/5 ml liquid diphenhydramine Triaminic Allergy 12.5 mg orally dissolving strips diphenhydramine 12.5 mg/5 ml syrup diphenhydramine Benadryl 25 mg tablets diphenhydramine 50 mg capsules, tablets diphenhydramine (for sleep) ZZZquil 25 mg capsules diphenhydramine (for sleep) Unisom SleepGels 50 mg capsules diphenhydramine (for sleep) Unisom SleepMelts 25 mg dispersable tablets diphenhydramine (for sleep) ZZZquil 50 mg/30 ml liquid PW_12-13_1049/DHS_Approved_01/24/2014 Page 8 of 19

9 diphenhydramine (for sleep) Sominex 25 mg tablets diphenhydramine (for sleep) Nytol Maximum Strength 50 mg tablets fexofenadine Allegra Allergy 30 mg/5 ml suspension fexofenadine Allegra Allergy 30 mg orally disintegrating tablets fexofenadine Allegra Allergy 30 mg, 60 mg, 180 mg tablets fexofenadine/pseudoephedrine Allegra-D 12 HR mg tablets, ER fexofenadine/pseudoephedrine Allegra-D 24 HR mg tablets, ER loratadine Claritin 10 mg capsules loratadine Claritin 5 mg chewable tablets loratadine Claritin Reditablets 5 mg orally disintegrating tablets loratadine Claritin Reditablets 10 mg orally disintegrating tablets loratadine Claritin 5 mg/5ml syrup loratadine Alavert, Claritin 10 mg tablets loratadine/pseudoephedrine Claritin-D 24 HR mg tablets, ER loratadine/pseudoephedrine Claritin-D 12 HR mg tablets, ER phenylephrine Little Colds 2.5 mg/ml liquid phenylephrine Pediacare Children's Decongestant 2.5 mg/5 ml oral solution phenylephrine 5 mg tablets phenylephrine Sudafed PE 10 mg tablets pseudoephedrine Sudafed Children's 15 mg/5 ml liquid pseudoephedrine 30 mg/5 ml liquid pseudoephedrine 30 mg/5 ml syrup pseudoephedrine Sudafed 12 HR 120 mg tablets, ER pseudoephedrine Sudafed 24 HR 240 mg tablets, ER pseudoephedrine Sudafed 30 mg tablets pseudoephedrine 60 mg tablets Antitussives and Expectorants brompheniramine/ phenylephrine/dextromethorphan Dimetapp DM mg/5ml elixir PW_12-13_1049/DHS_Approved_01/24/2014 Page 9 of 19

10 brompheniramine/ pseudoephedrine/ dextromethorphan Dimetane DX 2 mg-30 mg-10 mg/5 ml syrup brompheniramine/ pseudoephedrine/ dextromethorphan Neo DM 3 mg-50 mg-30 mg/5 ml syrup dextromethorphan polistirex Delsym 30 mg/5 ml liquid, ER dextromethorphan/guaifensin Coricidin HBP 10 mg-200 mg capsules dextromethorphan/guaifensin Mucinex Cough for Kids mg granules dextromethorphan/guaifensin Cheracol-D mg/5 ml liquid dextromethorphan/guaifensin Mucinex Cough-Children's mg/5 ml liquid Robitussin Cough & Congestion DM dextromethorphan/guaifensin Max mg/5 ml liquid dextromethorphan/guaifensin Vicks Dayquil Mucus Control DM mg/15 ml liquid mg/5 ml, mg/5 ml, mg/5 ml, mg/30 ml, mg/5 ml, mg/5 ml, mg/5 dextromethorphan/guaifensin ml liquid dextromethorphan/guaifensin Mucinex DM Maximum Strength 60 mg-1200 mg tablets, ER dextromethorphan/guaifensin Mucinex DM mg tablets, ER dextromethorphan/guaifensin Robitussin DM mg/5 ml syrup mg/5 ml, 20- dextromethorphan/ 200 mg/15 ml, guaifensin mg/5 ml syrup dextromethorphan/guaifensin 15 mg-400 mg tablets dextromethorphan/guaifensin 20 mg-400 mg tablets dextromethorphan-guaifenesin-potassium citrate Sorbutuss NR mg/5 ml liquid guaifenesin Mucinex for Kids 50 mg, 100 mg granules PW_12-13_1049/DHS_Approved_01/24/2014 Page 10 of 19

11 guaifenesin Mucinex for Kids 100 mg/5 ml liquid guaifenesin 100 mg/6.25 ml, 150 mg/15 ml, 200 mg/5 ml liquid guaifenesin 50 mg/5 ml oral solution guaifenesin Mucinex 1200 mg tablets, ER guaifenesin Mucinex 600 mg tablets, ER guaifenesin Robitussin 100 mg/5 ml syrup guaifenesin 200 mg tablets guaifenesin Liquibid 400 mg tablets guaifenesin/phenylephrine Rescon GG 100 mg-5 mg/5 ml liquid Peak Flow Meters ASSESS ASSESS ASSESS ASSESS ASSESS ASSESS AsthmaMentor AsthmaMentor Peak Air Personal Personal Personal PocketPeak SKIN Acne benzoyl peroxide 10% cream, lotion, gel benzoyl peroxide 2.5% cream, lotion benzoyl peroxide 5% gel, lotion benzoyl peroxide 2.5%, 7% gel PW_12-13_1049/DHS_Approved_01/24/2014 Page 11 of 19

12 benzoyl peroxide Panoxyl 4%, 8% lotion benzoyl peroxide 3.5%, 5.25% lotion salicylic acid Clean & Clear 0.5%, 2%, cream, gel, liquid, lotion salicylic acid Clean & Clear 21% ointment Antibacterials-topical bacitracin zinc 500U/g ointment neomycin/polymyxin B/bacitracin Neosporin, Triple Antibiotic ointment Antifungals-topical clotrimazole Lotrimin AF 1% various ketoconazole Nizoral A-D 1% shampoo miconazole Desenex Spray 2% aerosol miconazole Lotrimin AF 2% aerosol powder miconazole Micatin 2% cream miconazole 2% lotion, solution miconazole Aloe Vesta Antifungal 2% ointment miconazole Desenex Shake Powder 2% powder terbinafine Lamisil AT 1% various tolnaftate Tinactin 1% various Antipruritics collodial oatmeal Aveeno packets calamine lotion lotion hydrocortisone 0.5% cream, ointment hydrocortisone Hytone 1% cream, lotion, ointment, solution hydrocortisone acetate 1% cream, ointment Pediculosis permethrin 1% creme rinse permethrin 1% lotion permethrin Rid 0.5% aerosol piperonyl butoxide/ pyrethrins/permethrin Rid Complete shampoo PW_12-13_1049/DHS_Approved_01/24/2014 Page 12 of 19

13 pyrethrins/piperonyl butoxide Tegrin-LT, Pronto shampoo Other Topicals capsaicin Zostrix cream, gel, liquid, lotion, pad capsicum 0.025%, 0.075% cream chlorhexidine gluconate Hibiclens 2%, 4% liquid coal tar 1%, 5%, 10% lotion coal tar Ionil-T, T/Gel 0.5%, 1%, 2.5% shampoo coal tar 2.8%, 3%, 10% shampoo coal tar/salicylic acid Tarsum 10%-5% shampoo dibucaine Nupercainal 1% rectal ointment docosanol Abreva 10% topical cream ethyl alcohol Rubbing alcohol 70%, 95% solution hydroactive dressings Curafil Hydrogel dressings, pads hydrocortisone Proctocort 1%, 2.5% rectal cream hydrogen peroxide 3% solution isopropyl alcohol Rubbing alcohol 70% solution lactic acid/ammonium lactate Lac-Hydrin 5% lotion lactic acid/ammonium lactate Lac-Hydrin 12% lotion menthol/zinc oxide Calmoseptine % ointment povidone/iodine 10% ointment povidone/iodine Betadine 7.5%, 10% solution povidone/iodine 0.75%, 1%, 5% solution povidone/iodine 1%, 10% gel povidone/iodine 7.5%, 10% swabs salicylic acid gel Keralyt 3% gel salicylic acid liquid Compound W, DuoFilm 17% liquid salicylic acid patches 40% pad salicylic acid patches Trans-ver-sal Pediapatch 15% patches salicylic acid plaster MediPlast 40% plaster salicylic acid Psoriasis Liquid 3% liquid PW_12-13_1049/DHS_Approved_01/24/2014 Page 13 of 19

14 selenium sulfide Selsun Blue 1% lotion (shampoo) trolamine salicylate Myoflex, Aspercreme 10% cream, lotion trolamine salicylate 10% aerosol white petrolatum Vaseline gel, ointment wound dressing gel Curafil, Nu-Gel, Curasol gel Balmex, Boudreaux's Butt Paste, zinc oxide Desitin various cream, ointment, paste, powder, stick SMOKING CESSATION nicotine gum Nicorette 2 mg, 4 mg gum nicotine oral lozenges Nicorette 2 mg, 4 mg oral lozenges nicotine transdermal patches Nicoderm CQ 7 mg, 14 mg, 21 mg transdermal patches SUPPLEMENTS 15 mg, 30 mg, 10000U, beta carotene 25000U capsules 200 mg, 1250 mg (500 calcium carbonate mg Ca) capsules calcium carbonate 1250 mg/5 ml suspension calcium carbonate 1250 mg (500 mg Ca) tablets calcium carbonate Cal-Mint, Os-Cal 500 Chewables 260 mg, 500 mg chewable tablets calcium carbonate Caltrate mg (600 mg Ca) tablets calcium carbonate 600 mg tablets calcium carbonate/cholecalciferol Os-Cal chews various tablets, chewable tablets, capsules 300 mg-100u, 500 mgcalcium carbonate/vitamin D 50U capsules calcium carbonate/vitamin D 600 mg-200u capsules calcium carbonate/vitamin D 250 mg-125u tablets calcium carbonate/vitamin D 500 mg/125u tablets calcium carbonate/vitamin D 500 mg/200u tablets calcium carbonate/vitamin D 500 mg/400u tablets calcium carbonate/vitamin D 600 mg/125u tablets calcium carbonate/vitamin D 600 mg/200u tablets PW_12-13_1049/DHS_Approved_01/24/2014 Page 14 of 19

15 calcium carbonate/vitamin D 600 mg-400u tablets calcium carbonate/vitamin D Caltrate 600 +D 600 mg-400u chewable tablets calcium carbonate/ 600 mg-200u, 600 mgvitamin D/minerals 400U/various tablets, chewable tablets calcium citrate 950 mg (200 mg Ca) tablets 150 mg, 200 mg, 250 mg, calcium citrate 1040 mg tablets calcium citrate 760 mg/3.5 g granules calcium citrate/vitamin D 315mg/200U tablets 200 mg-250u, 250 mgcalcium citrate/vitamin D Citracal +D 200U, 315 mg-250u tablets 200 mg-125u, 250 mgcalcium citrate/vitamin D 50U, 250 mg-100u tablets calcium citrate/vitamin D 500 mg-400u chewable tablets carbonyl iron Icar 15 mg (elemental iron) chewable tablets 15 mg/1.25 ml carbonyl iron Icar (elemental iron) suspension carbonyl iron 25 mg (elemental iron) tablets carbonyl iron Feosol 45 mg (elemental iron) tablets cholecalciferol Vitamin D3 various strengths capsules, chewable tablets, liquid, orally disintegrating tablets, tablets, wafers cyanocobalamin (Vitamin B12) 1000 mcg, 1500 mcg, 2000 mcg tablets, ER cyanocobalamin (Vitamin B12) various tablets cyanocobalamin (Vitamin B12) 500 mcg, 1000 mcg, 2500 mcg sublingual tablets ergocalciferol Vitamin D2 8000U/mL drops ergocalciferol Vitamin D2 400U, 2000U tablets ferrous gluconate various tablets PW_12-13_1049/DHS_Approved_01/24/2014 Page 15 of 19

16 ferrous sulfate 220 mg/5 ml elixir ferrous sulfate 324 mg, 325 mg enteric-coated tablets ferrous sulfate 15 mg/ml solution ferrous sulfate 300 mg/5 ml syrup ferrous sulfate various tablets ferrous sulfate various tablets, ER ferrous sulfate, dried Feosol 200 mg tablets ferrous sulfate, dried 143 mg tablets, ER ferrous sulfate, dried Slow Fe 160 mg tablets, ER folic acid 400 mcg, 800 mcg tablets iron 15 mg/1.5 ml suspension 50 mg, 150 mg, 180 mg, iron complex, polysaccharide 200 mg capsules iron complex, polysaccharide 15 mg/0.5 ml, 15 mg/ml liquid iron complex, polysaccharide; vitamin B-12; folic acid Irofol 150 mg mg tablets iron complex, polysaccharide; vitamin B-12; folic acid Hematron 15 mg mg-4 mg/ml liquid levocarnitine 250 mg, 500 mg capsules, tablets lutein 10 mg tablets lutein/zeaxanthin various capsules, tablets magnesium various strengths capsules, tablets magnesium chloride 535 mg tablets, ER magnesium chloride/calcium carbonate Slow Mag 71.5 mg/119 mg tablets, DR magnesium lactate 84 mg tablets, ER magnesium oxide 400 mg, 500 mg capsules magnesium oxide 250 mg, 500 mg tablets magnesium oxide Mag-Ox 400 mg tablets niacin 250 mg, 500 mg capsules, ER PW_12-13_1049/DHS_Approved_01/24/2014 Page 16 of 19

17 250 mg, 500 mg, 750 mg, niacin Slo-Niacin 1000 mg tablets, ER 50 mg, 100 mg, 250 mg, niacin 500 mg tablets oyster shell calcium 500 mg tablets oyster shell calcium/vitamin D 500 mg, 600 mg tablets sodium chloride 1000 mg tablets vitamin A various capsules, tablets vitamin B-1 (Thiamine) 50 mg, 100 mg, 250 mg tablets 25 mg, 50 mg, 100 mg, vitamin B-2 (Riboflavin) 400 mg capsules, tablets vitamin B-6 (Pyridoxine) various strengths tablets vitamin B-6 (Pyridoxine) 200 mg tablets, ER 100 mg, 250 mg, 500 mg, vitamin C 1000 mg chewable tablets, tablets vitamin C 500 mg capsules, ER 500 mg, 1000 mg, 1500 vitamin C mg tablets, ER vitamin E various capsules, chewable tablets, tablets vitamin E 50U/mL solution vitamin K 100 mcg tablets zinc gluconate various tablets zinc gluconate 10 mg, 13.3 mg lozenges zinc sulfate 220 mg capsules Multivitamins B-complex w/c, folic acid Dialyvite, Rena-vite tablets B-complex w/c, folic acid Nephrocaps capsules multiple vitamin One-A-Day Essential tablets multiple vitamin capsules, chewable tablets, liquid multiple vitamin with iron tablets multiple vitamins with minerals Ocuvite, Preservision tablets PW_12-13_1049/DHS_Approved_01/24/2014 Page 17 of 19

18 multiple vitamin with minerals Ocuvite, Preservision capsules multiple vitamin with minerals Centrum, Cerovite liquid pediatric multiple vitamin Pediavit liquid, chewable tablets, drops pediatric multiple vitamin with C Poly-Vi-Sol various drops, liquid Fruity Chewables, My First pediatric multiple vitamin with C and folic acid Flintstones chewable tablets pediatric multiple vitamin with fluoride 0.25 mg, 0.5 mg, 1 mg chewable tablets pediatric multiple vitamin with fluoride 0.25 mg, 0.5 mg drops pediatric multiple vitamin with fluoride and iron 0.25 mg-10 mg/ml drops pediatric multiple vitamin with iron Flintstones Plus Iron, Centrum Kids chewable tablets pediatric vitamin drops with ADC Tri-Vi-Sol drops prenatal vitamins/folic acid/iron (ferrous fumarate) prenatal vitamins/selenium/folic acid/iron (ferrous fumarate) all tablets OTHER PRODUCTS activated charcoal capsules, tablets, liquid, for suspension dimenhydrinate Dramamine 50 mg chewable tablets, tablets elastic bandages and supports T.E.D, Kendall, J&J various, including hose, stockings, wraps glucose chewable tablets, gel, liquid ipecac syrup meclizine 25 mg chewable tablets meclizine 12.5 mg, 25 mg, 32 mg tablets oral electrolyte replacement Oralyte, Pedialyte packets, solution ostomy supplies, kits Hollister, Kendall, Bard, Convatec various, including drains, caps, belts, pouches, skin gel PW_12-13_1049/DHS_Approved_01/24/2014 Page 18 of 19

19 1 ml, 3 ml, various syringes/needles, disposable B-D, Kendall needle gauges/lengths OTHER PRESCRIPTION PRODUCTS Cough and Cold Products codeine/guaifenesin mg/5 ml solution pseudoephedrine/chlorpheniramine-codeine Phenylhistine DH mg/5 ml solution Prescription Supplements calcitriol Rocaltrol 1 mcg/ml oral solution cyanocobalamin (Vitamin B12) 1000 mcg/ml injectable solution cyanocobalamin (Vitamin B12) Nascobal 500 mcg/0.1 ml nasal solution ergocalciferol Drisdol 50,000U capsules folic acid 1 mg tablets vitamin K (phytonadione) Mephyton 5 mg tablets vitamin K (phytonadione) 2 mg/ml, 10 mg/ml injectable solution Key CR = controlled release DR = delayed release ER = extended release SR = sustained release ophth = eye otic = ear U = units PW_12-13_1049/DHS_Approved_01/24/2014 Page 19 of 19