EAR, NOSE, & THROAT PRODUCTS

DIABETIC PRODUCTS acetone (urine) test strip Ketostix 100 strips alcohol swabs BD Swabs 200 swabs glucose Glucose Chewable Tablets 4 grams chewable 50 tablets glucose Insta-Glucose 40% gel 114 grams glucose-vitamin C Dex4 4-0.006 grams chewable 50 tablets injection device Autopen 1 device insulin syringe/needle BD Insulin Syringe various sizes 200 syringes/needles insulin pen needle Novofine various sizes 200 needles ketone blood test strip Nova Max Plus 25 strips lancets BD Lancets 200 lancets lancet devices, lancets kit Autolet N/A urine glucose-ketones test strip Keto-Diastix 100 strips EAR, NOSE, & THROAT PRODUCTS carbamide peroxide Debrox 6.50% otic solution 30 ml cromolyn sodium - nasal Nasalcrom 5.2 mg/spray (4%) nasal aerosol 26 ml oxymetazoline Afrin, Neo-Synephrine 0.05% nasal spray 30 ml phenylephrine Neo-Synephrine 0.25%, 1% nasal spray 30 ml saline nasal spray Ocean 0.65% nasal spray 90 ml EYE PRODUCTS artificial tears ointment Refresh PM, Lacri-lube ophth ointment 4 grams artificial tears solution Tears Naturale ophth solution 30 ml carboxymethylcellulose Refresh Plus 0.50% ophth solution 50 ml hypromellose Genteal 0.3%, 0.4% ophth solution 30 ml ketotifen fumarate Zyrtec Itchy Eye, Zaditor 0.03% ophth solution 10 ml polyethylene glycol-propylene glycol Systane 0.4-0.3% ophth solution 30 ml polyvinyl alcohol Akwa Tears 1.40% ophth solution 30 ml polyvinyl alcohol-povidone Murine Tears, Refresh 5-6 mg/ml (0.5-0.6%), 1.4-0.6% ophth solution 30 ml sodium chloride hypertonic Muro 128 5% ointment 3.5 grams sodium chloride hypertonic Muro 128 2%, 5% ophth solution 30 ml GASTROINTESTINAL Constipation bisacodyl Dulcolax 10 mg supp 50 supp bisacodyl Dulcolax 5 mg DR tablets 100 tablets calcium polycarbophil Fibercon 625 mg tablets 100 tablets docusate sodium Colace 50 mg, 100 mg, 250 mg capsules 100 capsules docusate sodium Colace 150 mg/15 ml liquid 960 ml docusate sodium Colace 60 mg/15 ml syrup 960 ml docusate sodium Enemeez Mini 283 mg enema 90 ml PW_10-13_781/DHS_Approved_10/10/2013 Page 1 of 8

glycerin Pedia-Lax 1 gram supp 25 supp glycerin Sani-Supp Adult various supp 25 supp magnesium citrate Citroma various solution 300 ml magnesium hydroxide Milk of Magnesia 400 mg/5 ml susp 480 ml methylcellulose Citrucel powder 1500 grams methylcellulose Citrucel 500 mg tablets 240 tablets mineral oil Mineral Oil oil 480 ml polyethylene glycol Miralax powder 527 grams psyllium capsules Metamucil.52 gram capsules 100 capsules psyllium powder Metamucil various powder 2260 grams senna Senna 187 mg tablets 100 tablets sennosides 8.8 mg/5 ml syrup 240 ml sennosides Senokot 8.6 mg tablets 100 tablets sennosides-docusate sodium Senokot S 8.6-50 mg tablets 100 tablets sodium phosphates rectal solution Fleet Enema enema N/A sorbitol Sorbitol 70% solution 500 ml Diarrhea bismuth subsalicylate Pepto Bismol various tablets, chewable 40 tablets bismuth subsalicylate Pepto Bismol various susp 480 ml loperamide Imodium A-D 2 mg tablets, capsules 30 tablets, capsules loperamide Imodium A-D 1 mg/5 ml (0.2 mg/ml) liquid 240 ml Heartburn, Indigestion aluminum & magnesium hydroxides/simethicone Mylanta, Maalox, Di-Gel various susp 780 ml calcium carbonate Tums, Rolaids various chewable 100 tablets famotidine Pepcid AC 10 mg tablets 100 tablets magnesium oxide Magnesium Oxide, MGO 250 mg, 400 mg tablets 100 tablets omeprazole DR Omeprazole 20 mg tablets 30 tablets omeprazole magnesium DR Prilosec OTC 20 mg tablets 30 tablets ranitidine Zantac 75 mg tablets 100 tablets sodium bicarbonate Sodium Bicarbonate 650 mg tablets 100 tablets Other Gastrointestinal lactase Lactaid various tablets, chewable 120 tablets simethicone Phazyme, Gas-X 125 mg chewable 100 tablets simethicone Gas-X 80 mg chewable 120 tablets simethicone Mylicon 40 mg/0.6 ml susp 30 ml MISCELLANEOUS PRODUCTS charcoal activated liquid Actidose-Aqua liquid 240 ml charcoal activated for oral susp Ez Char susp 240 ml meclizine Bonine, Dramamine, various chewable, tablets 100 tablets oral electrolytes Pedialyte solution 1000 ml stannous flouride Gel-Kam 0.4% gel 129 grams starch-maltodextrin oral thickening powder Thick-It powder N/A PW_10-13_781/DHS_Approved_10/10/2013 Page 2 of 8

Multivitamins multivitamin One-A-Day various tablets 100 tablets multivitamin with iron Geritol Extend various tablets 100 tablets multivitamin with minerals Centrum, Theragran-M various capsules, tablets 100 capsules, tablets multivitamin with minerals Centrum various liquid 240 ml pediatric vitamins A, D, and C Tri-Vi-Sol 1500 unit-400 unit-35 mg/ml drops 50 ml pediatric vitamins with C Poly-Vi-Sol 35 mg/ml drops 50 ml pediatric vitamins with C and folic acid Flintstones various chewable 100 tablets pediatric multivitamin with minerals and C Flintstones various chewable 100 tablets pediatric multivitamin with iron Fruity Chews with Iron 15 mg chewable 100 tablets pediatric multivitamin with iron Poly-Vi-Sol 10 mg/ml drops 50 ml pediatric vitamins A, D, and C with iron Tri-Vi-Sol 10 mg/ml drops 50 ml prenatal vitamins with iron fumarate and folic acid Prenavite various tablets 100 tablets PAIN RELIEVERS-FEVER REDUCERS acetaminophen Tylenol 500 mg capsules 300 capsules acetaminophen Tylenol 325 mg, 500 mg tablets 300 tablets acetaminophen Tylenol Arthritis 650 mg CR tablets 200 tablets acetaminophen Pain Reliever 80 mg, 160 mg chewable 100 tablets acetaminophen Tylenol 160 mg/5 ml liquid 240 ml acetaminophen Infants' Tylenol 80 mg/.8 ml susp 30 ml acetaminophen Children's Tylenol 160 mg/5 ml susp 240 ml acetaminophen Nortemp 100 mg/ml solution 30 ml acetaminophen Acetamin 160 mg/5 ml solution 240 ml 80 mg, 120 mg, 325 mg, acetaminophen Feverall 650 mg supp 24 supp acetaminophen Tylenol Meltaways 80 mg, 160 mg dispersible tablets 100 tablets aspirin Bayer 81 mg, 325 mg tablets 100 tablets aspirin Bayer Children's 81 mg chewable 100 tablets aspirin delayed release Ecotrin 81 mg, 162 mg, 325 mg tablets 100 tablets aspirin buffered Bufferin 325 mg tablets 100 tablets aspirin-acetaminophen-caffeine Excedrin 250-250-65 mg tablets 100 tablets ibuprofen Motrin IB, Advil 200 mg tablets 200 tablets ibuprofen Motrin Junior Strength 100 mg chewable 100 tablets ibuprofen Infants' Motrin 40 mg/ml susp 30 ml ibuprofen Children's Motrin 100 mg/5 ml susp 240 ml naproxen Aleve 220 mg tablets 200 tablets RESPIRATORY Antihistamines/Decongestants cetirizine Zyrtec Allergy 5 mg, 10 mg tablets 30 tablets cetirizine Children's Zyrtec Allergy 5 mg, 10 mg chewable 30 tablets cetirizine Children's Zyrtec Allergy 1 mg/1 ml (5 mg/5 ml) syrup 360 ml chlorpheniramine maleate Chlor-Trimeton 4 mg tablets 50 tablets PW_10-13_781/DHS_Approved_10/10/2013 Page 3 of 8

chlorpheniramine maleate Chlor-Trimeton 2 mg/5 ml syrup 240 ml diphenhydramine Benadryl 25 mg, 50 mg capsules 100 capsules diphenhydramine Benadryl Allergy 25 mg tablets 100 tablets diphenhydramine Children's Benadryl Allergy 12.5 mg chewable 100 tablets diphenhydramine Children's Benadryl Allergy 12.5 mg/5 ml liquid 240 ml diphenhydramine Altaryl 12.5 mg/5 ml elixir 240 ml diphenhydramine Dytuss 12.5 mg/5 ml syrup 480 ml diphenhydramine Triaminic Cough and Runny Nose 12.5 mg oral strip 100 strips diphenhydramine Theraflu Multi Symptom 25 mg oral strip 100 strips diphenhydramine Allergy Melts 12.5 mg dispersible tablets 100 tablets fexofenadine Children's Allegra Allergy 30 mg tablets, ODT 60 tablets fexofenadine Allegra 60 mg tablets 60 tablets fexofenadine Allegra 180 mg tablets 30 tablets fexofenadine Allegra 30 mg/5 ml susp 600 ml loratadine Claritin, Claritin RediTabs 10 mg tablets, RDT 30 tablets loratadine Claritin 5 mg chewable 60 tablets loratadine Claritin 5 mg/5 ml syrup 360 ml phenylephrine Sudafed PE 10 mg tablets 30 tablets pseudoephedrine Sudafed Congestion 30 mg tablets 72 tablets pseudoephedrine Sudafed Congestion 60 mg tablets 60 tablets pseudoephedrine Children's Sudafed 15 mg/5 ml liquid 240 ml pseudoephedrine Unifed 30 mg/5 ml liquid, syrup 240 ml pseudoephedrine Sudafed 12 Hour 120 mg SR capsules, SR table 60 capsules, tablets pseudoephedrine Sudafed 24 Hour 240 mg SR tablets 30 tablets Antitussives and Expectorants brompheniramine/phenylephrine Dimetapp Cold and Allergy 1-2.5 mg/5 ml elixir 240 ml cetirizine-pseudoephedrine Zyrtec-D Allergy/Congestion 5-120 mg SR tablets 60 tablets Robitussin Children's Cough, Triaminic Children's Cough, St. Joseph Cough dextromethorphan Syrup 7.5 mg/5 ml syrup 240 ml dextromethorphan polistirex Delsym 30 mg/5 ml CR liquid 240 ml dextromethorphan/guaifenesin Robitussin DM 10-100 mg/5 ml liquid, syrup 240 ml Mucinex-DM 12 Hour, Mucinex-DM 12 dextromethorphan/guaifenesin Hour Extra Strength 30-600 mg SR tablets 80 tablets Mucinex-DM 12 Hour, Mucinex-DM 12 dextromethorphan/guaifenesin Hour Extra Strength 60-1200 mg SR tablets 48 tablets fexofenadine/pseudoephedrine Allegra-D 12 Hour 60-120 mg ER tablets 60 tablets fexofenadine/pseudoephedrine Allegra-D 24 Hour 180-240 mg ER tablets 30 tablets guaifenesin Refenesen 200 mg, 400 mg tablets 100 tablets guaifenesin Mucus Relief 100 mg/5 ml liquid 240 ml guaifenesin Robitussin Chest Congestion 100 mg/5 ml syrup 240 ml guaifenesin Mucinex for Kids 50 mg, 100 mg granules packet 100 packets guaifenesin Mucinex, Mucinex Maximum Strength 600 mg SR tablets 100 tablets PW_10-13_781/DHS_Approved_10/10/2013 Page 4 of 8

guaifenesin Mucinex, Mucinex Maximum Strength 1200 mg SR tablets 70 tablets loratadine/pseudoephedrine Claritin-D 12 Hour 5-120 mg SR tablets 60 tablets loratadine/pseudoephedrine Claritin-D 24 Hour 10-240 mg SR tablets 30 tablets pseudoephedrine/guaifenesin Mucinex D 120-1200 mg SR tablets 72 tablets pseudoephedrine/guaifenesin Mucinex D 60-600 mg SR tablets 108 tablets Other Respiratory Products sodium chloride Sodium Chloride Neb 0.9% solution for nebulizer 600 ml SLEEP AIDS diphenhydramine (sleep) Sominex 25 mg tablets 50 tablets diphenhydramine-acetaminophen (sleep) Tylenol PM 25-500 mg tablets 50 tablets SMOKING CESSATION nicotine gum Nicorette 2 mg, 4mg gum N/A nicotine oral lozenges Nicorette 2 mg, 4mg oral lozenge N/A nicotine transdermal patches Nicoderm CQ 7mg, 14mg, 21 mg transdermal patches N/A SUPPLEMENTS ascorbic acid Vitamin C 250 mg, 500 mg, 1000 mg tablets, chewable 100 tablets B-complex-C-folic acid Strovite, B-Complex various tablets 100 tablets beta carotene Beta Carotene 10000 units, 25000 units capsules 100 capsules calcium carbonate Caltrate 600 mg, 1250 mg, 1500 mg tablets 100 tablets calcium carbonate Calcium Carbonate 1250 mg/5ml susp 500 ml calcium carbonate-vitamin D Caltrate various tablets, chewable 100 tablets calcium carbonate-vitamin D-minerals Caltrate 600 mg, 1200 mg chewable 100 tablets calcium carbonate-cholecalciferol Caltrate various tablets 100 tablets calcium citrate Calcitrate 950 mg tablets 100 tablets calcium citrate with vitamin D Citracal various tablets 100 tablets calcium with vitamin D Calcium/Vitamin D various tablets 100 tablets cholecalciferol Vitamin D various capsules, tablets 100 capsules, tablets cholecalciferol Vitamin D 400 unit/ml liquid 60 ml cyanocobalamin Vitamin B12, Vitamin B12 CR various tablets, CR tablets 100 tablets ergocalciferol Drisdol 8000 unit/ml solution 60 ml ferrous fumarate Hemocyte 325 mg tablets 100 tablets ferrous gluconate Fergon 240 mg, 324 mg, 325 mg tablets 100 tablets ferrous sulfate Ferrous Sulfate 325 mg tablets 100 tablets ferrous sulfate Slow FE 142 mg CR tablets 60 tablets ferrous sulfate FE Tabs 324 mg, 325 mg EC tablets 100 tablets ferrous sulfate Ferrous Sulfate 220 mg/5 ml elixir 480 ml ferrous sulfate Fer-In-Sol 75 mg/ml solution 50 ml ferrous sulfate, dried Slow FE 160 mg CR tablets 60 tablets folic acid Folic Acid 400 mcg, 800 mcg tablets 100 tablets magnesium Magnesium 250 mg tablets 100 tablets magnesium chloride Mag-SR 535 mg CR tablets 60 tablets magnesium gluconate Magtrate 500 mg tablets 100 tablets magnesium oxide Magox various tablets 100 tablets PW_10-13_781/DHS_Approved_10/10/2013 Page 5 of 8

50 mg, 100 mg, 250 mg, niacin Niacin 500 mg tablets 100 tablets niacin Niacin 250 mg, 500 mg CR capsules 100 capsules 250 mg, 500 mg, 750 mg, niacin Slo-Niacin 1000 mg CR tablets 100 tablets oyster shell calcium Oyst-Cal 500 mg tablets 100 tablets polysaccharide iron complex (iron equivalent) Iferex 150 mg capsules 100 capsules pyridoxine Vitamin B-6 25 mg, 50 mg, 100 mg tablets 100 tablets riboflavin Vitamin B-2 100 mg tablets 100 tablets sodium chloride Sodium Chloride 1 gram tablets 100 tablets thiamine Vitamin B-1 50 mg, 100 mg, 250 mg tablets 100 tablets vitamin a Vitamin A various capsules 100 capsules vitamin e Vitamin E various capsules 100 capsules TOPICAL PRODUCTS Acne benzoyl peroxide Panoxyl 2.5% liquid N/A benzoyl peroxide Panoxyl-4 4% liquid N/A benzoyl peroxide Benzoyl Peroxide Wash, Desquam 5%, 5.25% liquid N/A benzoyl peroxide BP Wash 7% liquid N/A benzoyl peroxide Panoxyl-8 8% liquid N/A benzoyl peroxide Benzac AC 10% liquid N/A benzoyl peroxide Clean&Clear 10% cream N/A benzoyl peroxide Benzoyl Peroxide Gel 2.5% gel N/A benzoyl peroxide Benzac AC 5%, 10% gel N/A benzoyl peroxide Brevoxyl 4%, 8% gel N/A benzoyl peroxide Clean&Clear 5%, 10% lotion N/A Antibacterial bacitracin Baciguent 500 units/gram ointment 90 grams bacitracin-zinc Bacitracin Zinc 500 units/gram ointment 90 grams bacitracin-polymyxin B Polysporin ointment 90 grams neomycin-bacitracin-polymyxin Neosporin ointment 90 grams Antifungals clotrimazole Fungicure 1% solution 90 ml clotrimazole Desenex 1% cream 90 grams ketoconazole Nizoral A-D 1% shampoo 120 ml powder, aerosol miconazole Lotrimin AF, Desenex 2% powder, cream 90 grams terbinafine Lamisil AT 1% cream 90 grams powder, aerosol, tolnaftate Lamisil, Tinactin 1% aerosol powder 160 grams tolnaftate Lamisil, Tinactin 1% cream 90 grams PW_10-13_781/DHS_Approved_10/10/2013 Page 6 of 8

Antipruritic (Anti-Itch) calamine Calamine Lotion lotion 120 ml hydrocortisone Hydrocort, Cortaid 0.5%, 1% cream, ointment 90 grams hydrocortisone Cortizone-10 1% lotion 120 ml Hydrocort, Lanacort, Demarest, hydrocortisone acetate Cortaid, Tucks 1% cream, ointment 90 grams Other Topicals capsaicin Zostrix 0.025%,.075% cream 60 grams capsaicin Capsaicin 0.035%, 0.1% cream 60 grams chlorhexidine gluconate Hibiclens 4% liquid 480 ml coal tar DHS Tar, Theraplex T 0.5%, 1% shampoo 240 ml dimethicone Neutraphor, Pacquin 1% cream 120 grams docosanol Abreva 10% cream 2 grams hydrogen peroxide Hydrogen Peroxide 3% solution 480 ml lactic acid (ammonium lactate) Lacticare, Lac-Hydrin 5%, 10%, 12% lotion N/A povidone-iodine Povidone-Iodine 10% ointment 30 grams povidone-iodine Betadine 10% solution 240 ml salicylic acid Compound W, Duofilm 17% liquid, solution 15 ml salicylic acid Compound W, MediPlast 40% pad, plaster 25 pads zinc oxide Aveeno Baby, Desitin 13% cream N/A zinc oxide Desitin, Triple Paste 12.8%, 20%, 40% ointment N/A Pediculosis (Lice Treatment) permethrin Nix 1% liquid 120 ml permethrin Permethrin 1% lotion 120 ml pyrethrins-piperonyl butoxide Rid 0.3-3%, 0.3-4% liquid 120 ml pyrethrins-piperonyl butoxide Tegrin, Pronto 0.3-3%, 0.3-4% shampoo 120 ml pyrethrins-piperonyl butoxide Rid Complete various kit 1 kit Rectal dibucaine Nupercainal 1% ointment 60 grams phenyleph-shark liver oil-cocoa butter Preparation H 0.25-3-85.5% supp N/A phenylephrine-shark liver oil-mo-pet Preparation H 0.25-3-14-71.9% ointment N/A VAGINAL PRODUCTS & CONTRACEPTIVES clotrimazole Gyne-Lotrimin, Mycelex 1% vaginal cream 45 grams clotrimazole Gyne-Lotrimin 2% vaginal cream 21 grams condoms - male Trojan, Lifestyles 12 condoms condoms - female FC, FC 2 12 condoms miconizole nitrate Monistat 4% vaginal cream 25 grams miconizole nitrate Monistat 2% vaginal cream 45 grams miconizole nitrate Monistat 7 100 mg vaginal supp 25 supp miconazole supp & cream kit Monistat 3 Kit various vaginal supp & cream 1 kit miconazole nitrate vaginal kit Miconazole 3 Kit various combo kit 1 kit nonoxynol-9 VCF Vaginal 28% film 9 films PW_10-13_781/DHS_Approved_10/10/2013 Page 7 of 8

nonoxynol-9 VCF Vaginal 12.5% foam 42 grams nonoxynol-9 Gynol II, Encare, Conceptrol various gel 108 grams nonoxynol-9 Conceptrol 150 mg insert 10 inserts nonoxynol-9 Encare 100 mg supp 24 supp octoxynol Ortho-Gynol 1% gel 108 grams KEY CR = controlled release DR = delayed release EC = enteric coated ER = extended release SR = sustained release mg = milligram ml = milliliter ODT = oral disintegrating tablets RDT = rapidly disintegrating tablets ophth = eye otic = ear supp = suppository susp = suspension PW_10-13_781/DHS_Approved_10/10/2013 Page 8 of 8

This information is available in other forms to people with disabilities by calling: TOLL FREE Member Services: 1-866-431-0801 TOLL FREE MINNESOTA RELAY TTY, Voice, ASCII, or Hearing Carry Over: 1-800-627-3529 or 711 TOLL FREE SPEECH-TO-SPEECH RELAY SERVICE 1-877-627-3848 Member Services 1-866-431-0801 PrimeWest Health will enroll all eligible people who select or are assigned to PrimeWest Health without regard to physical or mental condition, health status, need for health services, claims experience, medical history, genetic information, disability, marital status, age, sex, sexual orientation, national origin, race, color, religion, or political beliefs. PrimeWest Health will not use any policy or practice that has the effect of such discrimination. American Indians can continue or begin to use tribal and Indian Health Service (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For enrollees age 65 years and older, this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral. PW_2010_167R_10_12 DHS_Approved_11/06/2012