TennCare Covered OTC Products - Magellan Health · TennCare Covered OTC List Effective 7/1/19 NDC...

TennCare Covered OTC List Effective 12/15/2019

NDC Label Name Generic NamePackage Size

Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults

Not Covered‐ Adults

ANTIHELMENTIC

10956061801 REESE'S PINWORM 144 MG/ML SUSP PYRANTEL PAMOATE 50 MG/ML 30 x x10956061821 REESE'S PINWORM 144 MG/ML SUSP PYRANTEL PAMOATE 50 MG/ML 60 x x23513061801 REESE'S PINWORM 144 MG/ML SUSP PYRANTEL PAMOATE 50 MG/ML 30 x x23513061821 REESE'S PINWORM 144 MG/ML SUSP PYRANTEL PAMOATE 50 MG/ML 60 x x

EMERGENCY CONTRACEPTIVES

LEVONORGESTREL 1.5MG TABLET51285010388 AFTERA 1.5 MG TABLET LEVONORGESTREL 1.5 MG 1 x x51285014619 PLAN B ONE‐STEP 1.5 MG TABLET LEVONORGESTREL 1.5 MG 1 x x51285016288 PLAN B ONE‐STEP 1.5 MG TABLET LEVONORGESTREL 1.5 MG 1 x x51285010088 TAKE ACTION 1.5 MG TABLET LEVONORGESTREL 1.5 MG 1 x x

DIABETES

INSULIN PRODUCTS00002880359 HUMULIN 70/30 KWIKPEN INSULIN NPH HUM/REG INSULIN HM 70‐30/ML 3 x x00002871501 HUMULIN 70‐30 VIAL INSULIN NPH HUM/REG INSULIN HM 70‐30/ML 10 x x00002871517 HUMULIN 70‐30 VIAL INSULIN NPH HUM/REG INSULIN HM 70‐30/ML 3 x x00169183711 NOVOLIN 70‐30 100 UNIT/ML VIAL INSULIN NPH HUM/REG INSULIN HM 70‐30/ML 10 x x00169183702 RELION NOVOLIN 70‐30 VIAL INSULIN NPH HUM/REG INSULIN HM 70‐30/ML 10 x x00002831501 HUMULIN N 100 UNITS/ML VIAL INSULIN NPH HUMAN ISOPHANE 100/ML 10 x x00002831517 HUMULIN N 100 UNITS/ML VIAL INSULIN NPH HUMAN ISOPHANE 100/ML 3 x x00169183411 NOVOLIN N 100 UNITS/ML VIAL INSULIN NPH HUMAN ISOPHANE 100/ML 10 x x00169183402 RELION NOVOLIN N 100 UNIT/ML INSULIN NPH HUMAN ISOPHANE 100/ML 10 x x00002880559 HUMULIN N 100 UNITS/ML KWIKPEN INSULIN NPH HUMAN ISOPHANE 100/ML (3) 3 x x00002821501 HUMULIN R 100 UNITS/ML VIAL INSULIN REGULAR, HUMAN 100/ML 10 x x00002821517 HUMULIN R 100 UNITS/ML VIAL INSULIN REGULAR, HUMAN 100/ML 3 x x00169183311 NOVOLIN R 100 UNITS/ML VIAL INSULIN REGULAR, HUMAN 100/ML 10 x x00169183302 RELION NOVOLIN R 100 UNIT/ML INSULIN REGULAR, HUMAN 100/ML 10 x x

GLUCOSE00574006930 GLUTOSE 15 GEL DEXTROSE 40 % 37.5 x x

SYRINGES/NEEDLES

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Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


8290328440 BD SYR 0.3 ML 8MMX31G (1/2) SYRGE‐NDL,INS 0.3 ML HALF MARK 31 GX5/16" 100 x x8396800900 ULT CFT 0.3 ML 31GX5/16" (1/2) SYRGE‐NDL,INS 0.3 ML HALF MARK 31 GX5/16" 100 x x8290324910 BD SYR 0.3 ML 6MMX31G (1/2) SYRGE‐NDL,INS 0.3 ML HALF MARK 31GX15/64" 100 x x8290329651 BD INSULIN SYR 1 ML 25GX5/8" SYRINGE AND NEEDLE,INSULIN,1ML 25GX5/8" 100 x x8496271501 EASY TOUCH 1 ML SYR 27GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 27GX1/2" 100 x x8290329412 BD INSULIN SYR 1 ML 27GX5/8" SYRINGE AND NEEDLE,INSULIN,1ML 27GX5/8" 100 x x8290329410 BD INSULIN SYR 1 ML 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x8290329420 BD INSULIN SYR 1 ML 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x8290329424 BD INSULIN SYR 1 ML 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x8496281501 EASY TOUCH INSULIN SYR 1 ML SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x89134050302 MAXI‐COMFORT INS 1 ML 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x8881601101 MONOJECT 1 ML SYRN 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x86227080105 SURE COMFORT 1 ML SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x56151170301 TRUEPLUS SYR 1ML 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x8222082183 ULTICARE INS SYR 1 ML 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x8396800200 ULTRA COMFORT 1 ML 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x8881609101 ULTRA COMFORT 1 ML SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x8290305930 BD INSULIN SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x8290329464 BD INSULIN SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x98302013938 COMFORT EZ SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x8496291501 EASY TOUCH INSULIN SYR 1 ML SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x90166095015 INSULIN SYRINGE 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x38396040508 LEADER INS SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x8881601358 MONOJECT INSUL SYR U100 1 ML SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x81131031162 RELION INS SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x81131031163 RELION INS SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 10 x x86227090105 SURE COMFORT 1 ML SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x38396041337 TOPCARE ULTRA COMFORT SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x56151171301 TRUEPLUS SYR 1ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x8222092199 ULTICARE INS SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x57515009219 ULTICARE INS SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x8396800500 ULTRA COMFORT 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x8881609358 ULTRA COMFORT 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x89134052902 ULTRA‐THIN II INS SYR 1 ML 29G SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x38396044764 GNP ULTRA COMFORT 1 ML SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 30 GAUGE 100 x x11917002529 INSULIN 1 ML SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 30 GAUGE 100 x x98302013933 COMFORT EZ SYR 1 ML 30GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


91237000108 EASY COMFORT INSULIN 1 ML SYR SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x8496301601 EASY TOUCH INSULIN SYR 1 ML SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x90166005615 INSULIN SYRINGE 1 ML 30GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x86227070105 SURE COMFORT 1 ML SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x56151172301 TRUEPLUS SYR 1ML 30GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x8222093196 ULTICARE SYR 1 ML 30GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x57515009319 ULTICARE SYR 1 ML 30GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x8396800800 ULTRA COMFORT 1 ML 30GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x8881609600 ULTRA COMFORT 1 ML 30GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x89134062002 ULTRA‐THIN II INS SYR 1 ML 30G SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x94046000168 ADVOCATE INS 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x8290329416 BD INSULIN SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x8396802000 CA INSULIN SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x98302013919 COMFORT EZ SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x91237000189 EASY COMFORT 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x8496311611 EASY TOUCH INSULIN SYR 1 ML SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 10 x x8496311601 EASY‐TOUCH INS 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x11917004813 INSULIN SYRINGE 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x38415001631 INSULIN SYRINGE 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x57515017419 INSULIN SYRINGE 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 10 x x90166015615 INSULIN SYRINGE 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x38396042108 LEADER INS SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x8881609131 MONOJECT SYRINGE 1 ML SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x81131031174 RELION INS SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x81131031175 RELION INS SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 10 x x38396047339 SM INSULIN SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x86227065105 SURE COMFORT 1 ML SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x56151173301 TRUEPLUS SYR 1ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x8222094193 ULTCARE INS SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x57515009419 ULTCARE INS SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x8222074195 ULTICARE SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x8396801100 ULTRA COMFORT 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x89134074402 ULTRA‐THIN II 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x8290309598 BD 3 ML SYRINGE WITH NEEDLE SYRINGE W‐NEEDLE,DISPOSAB,3 ML 21 G X 1" 100 x x8290309577 BD 3 ML SYRINGE WITH NEEDLE SYRINGE W‐NEEDLE,DISPOSAB,3 ML 21GX1 1/2" 100 x x8290309574 BD 3 ML SYRINGE WITH NEEDLE SYRINGE W‐NEEDLE,DISPOSAB,3 ML 22GX1 1/2" 100 x x8290309572 BD 3 ML SYRINGE WITH NEEDLE SYRINGE W‐NEEDLE,DISPOSAB,3 ML 22GX1" 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


8290309571 BD 3 ML SYRINGE WITH NEEDLE SYRINGE W‐NEEDLE,DISPOSAB,3 ML 23GX1" 100 x x8290309588 BD 3 ML SYRINGE WITH NEEDLE SYRINGE W‐NEEDLE,DISPOSAB,3 ML 23GX1" 100 x x8290309582 BD 3 ML SYRINGE 25GX1‐1/2" SYRINGE W‐NEEDLE,DISPOSAB,3 ML 25GX1 1/2" 100 x x8290309581 BD 3 ML SYRINGE 25GX1" SYRINGE W‐NEEDLE,DISPOSAB,3 ML 25GX1" 100 x x8290309570 BD LUER‐LOK SYR 3 ML 25GX5/8" SYRINGE W‐NEEDLE,DISPOSAB,3 ML 25GX5/8" 100 x x8290301604 BD 10 ML SYRINGE SYRINGE, DISPOSABLE, 10 ML 100 x x8290329461 BD INSULIN SYR 0.5 ML 28GX1/2" SYRINGE‐NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x8290329465 BD INSULIN SYR 0.5 ML 28GX1/2" SYRINGE‐NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x8496285501 EASY TOUCH INSULIN SYR 0.5 ML SYRINGE‐NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x8881600004 MONOJECT INSUL SYR U100 0.5 ML SYRINGE‐NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x38396076339 SM INSULIN SYR 0.5 ML 28GX1/2" SYRINGE‐NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x86227080055 SURE COMFORT 0.5 ML SYRINGE SYRINGE‐NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x56151170201 TRUEPLUS SYR 0.5ML 28GX1/2" SYRINGE‐NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x8222082589 ULTICARE SYRIN 0.5 ML 28GX1/2" SYRINGE‐NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x8396800100 ULTRA COMFORT 0.5 ML 28GX1/2" SYRINGE‐NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x8496295501 EASY TOUCH INSULIN SYR 0.5 ML SYRINGE‐NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x90166095055 INSULIN SYRIN 0.5 ML 29GX1/2" SYRINGE‐NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x38396040408 LEADER INS SYR 0.5 ML 29GX1/2" SYRINGE‐NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x8881600350 MONOJECT INSUL SYR U100 SYRINGE‐NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x86227090055 SURE COMFORT 0.5 ML SYRINGE SYRINGE‐NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x56151171201 TRUEPLUS SYR 0.5ML 29GX1/2" SYRINGE‐NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x8222092595 ULTICARE SYR 0.5 ML 29GX1/2" SYRINGE‐NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x57515009259 ULTICARE SYR 0.5 ML 29GX1/2" SYRINGE‐NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x8881609350 ULTRA COMFORT 0.5 ML 29GX1/2" SYRINGE‐NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x38396044364 GNP ULTRA COMFORT 0.5 ML SYR SYRINGE‐NEEDLE,INSULIN,0.5 ML 29 GAUGE 100 x x11917001489 INSULIN 1/2 ML SYRINGE SYRINGE‐NEEDLE,INSULIN,0.5 ML 29 GAUGE 100 x x11917002528 INSULIN 1/2 ML SYRINGE SYRINGE‐NEEDLE,INSULIN,0.5 ML 30 GAUGE 100 x x94046000164 ADVOCATE INS 0.5 ML 30GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x8290305934 BD SAFTGLD INS SYR 0.5 ML 30G SYRINGE‐NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x98302013932 COMFORT EZ INSULIN SYR 0.5 ML SYRINGE‐NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x8496305601 EASY TOUCH INSULIN SYR 0.5 ML SYRINGE‐NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x90166005655 INSULIN SYRIN 0.5 ML 30GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x86227070055 SURE COMFORT 0.5 ML SYRINGE SYRINGE‐NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x38396041537 TOPCARE ULTRA COMFORT SYRINGE SYRINGE‐NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x56151172201 TRUEPLUS SYR 0.5ML 30GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x8222093592 ULTICARE SYR 0.5 ML 30GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x57515009359 ULTICARE SYR 0.5 ML 30GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


8881609700 ULTRA COMFORT 0.5 ML SYRINGE SYRINGE‐NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x89134061802 ULTRA‐THIN II INS 0.5 ML 30G SYRINGE‐NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x8222910080 ULTICARE INS 0.5 ML 31GX1/4" SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 G X1/4" 100 x x8290328468 BD INSULIN SYR 0.5 ML 8MMX31G SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x8396801900 CA INS SYR 0.5 ML 31GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x98302013930 COMFORT EZ INSULIN SYR 0.5 ML SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x91237000188 EASY COMFORT 0.5 ML 31GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x8496315601 EASY TOUCH INSULIN SYR 0.5 ML SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x57515017459 INSULIN SYRIN 0.5 ML 31GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 10 x x90166015655 INSULIN SYRIN 0.5 ML 31GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x38396042008 LEADER SYRING 0.5 ML 31GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x8881609231 MONOJECT SYRINGE 0.5 ML SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x81131031176 RELION SYRING 0.5 ML 31GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x81131031177 RELION SYRING 0.5 ML 31GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 10 x x86227065055 SURE COMFORT 0.5 ML SYRINGE SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x56151173201 TRUEPLUS SYR 0.5ML 31GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x8222074591 ULTICARE SYR 0.5 ML 31GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x8222094599 ULTICARE SYR 0.5 ML 31GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x57515009459 ULTICARE SYR 0.5 ML 31GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x8396801000 ULTRA COMFORT 0.5 ML 31GX5/16" SYRINGE‐NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x81131031167 RELION INS SYR 0.3 ML 29GX1/2" SYRING‐NEEDL,DISP,INSUL,0.3 ML 29 G X1/2" 10 x x86227090035 SURE COMFORT 3/10 ML SYRINGE SYRING‐NEEDL,DISP,INSUL,0.3 ML 29 G X1/2" 100 x x56151171101 TRUEPLUS SYR 0.3ML 29GX1/2" SYRING‐NEEDL,DISP,INSUL,0.3 ML 29 G X1/2" 100 x x8222092397 ULTICARE SYRIN 0.3 ML 29GX1/2" SYRING‐NEEDL,DISP,INSUL,0.3 ML 29 G X1/2" 100 x x11917001492 INSULIN 3/10 ML SYRINGE SYRING‐NEEDL,DISP,INSUL,0.3 ML 29 GAUGE 100 x x11917002527 INSULIN 3/10 ML SYRINGE SYRING‐NEEDL,DISP,INSUL,0.3 ML 30 GAUGE 100 x x98302013931 COMFORT EZ INS 0.3ML 30GX5/16" SYRING‐NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x8496303601 EASY TOUCH INSULIN SYR 0.3 ML SYRING‐NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x90166045635 INSULIN SYRIN 0.3 ML 30GX5/16" SYRING‐NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x86227070035 SURE COMFORT 3/10 ML SYRINGE SYRING‐NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x56151172101 TRUEPLUS SYR 0.3ML 30GX5/16" SYRING‐NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x8222093394 ULTICARE SYR 0.3 ML 30GX5/16" SYRING‐NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x8881609800 ULTRA COMFORT 0.3 ML SYRINGE SYRING‐NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x89134072202 ULTRA‐THIN II INS 0.3 ML 30G SYRING‐NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x8290328431 BD SYRINGE 0.3 ML 12.7MMX30G SYRING‐NEEDL,DISP,INSUL,0.3 ML 30GX1/2" 100 x x8222910066 ULTICARE INS 0.3 ML 31GX1/4" SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 G X1/4" 100 x x8290328438 BD INSULIN SYR 0.3 ML 8MMX31G SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


8290305937 BD SAFTGLD INS 0.3 ML 31GX5/16 SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x8496313601 EASY TOUCH INSULIN SYR 0.3 ML SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x38396044964 GNP INSUL SYR 0.3 ML 31GX5/16" SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x11917004815 INSULIN SYRIN 0.3 ML 31GX5/16" SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x90166015635 INSULIN SYRIN 0.3 ML 31GX5/16" SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x38396041908 LEADER SYRING 0.3 ML 31GX5/16" SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x8881609331 MONOJECT SYRINGE 0.3 ML SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x81131031178 RELION SYRING 0.3 ML 31GX5/16" SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x81131031179 RELION SYRING 0.3 ML 31GX5/16" SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 10 x x86227065045 SURE COMFORT 0.3 ML SYRINGE SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x86227065035 SURE COMFORT 3/10 ML SYRINGE SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x56151173101 TRUEPLUS SYR 0.3ML 31GX5/16" SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x8222074393 ULTICARE SYR 0.3 ML 31GX5/16" SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x8222094391 ULTICARE SYR 0.3 ML 31GX5/16" SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x57515009439 ULTICARE SYR 0.3 ML 31GX5/16" SYRING‐NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x8290324909 BD INSULIN SYR 0.3 ML 6MMX31G SYRING‐NEEDL,DISP,INSUL,0.3 ML 31GX15/64" 100 x x81131013838 RELION INS SYR 0.3 ML 31GX6MM SYRING‐NEEDL,DISP,INSUL,0.3 ML 31GX6MM 100 x x81131013834 RELION INS SYR 1 ML 31GX15/64" SYRING‐NEEDL,INSUL,1 ML 31 GX15/64" 100 x x

PEN NEEDLES8290328203 BD ULTRA‐FINE NDL 12.7MMX29G PEN NEEDLE, DIABETIC 29 G X1/2" 100 x x8496290201 EASY TOUCH PEN NEEDLE 29GX1/2" PEN NEEDLE, DIABETIC 29 G X1/2" 100 x x90166012122 PEN NEEDLES 12MM 29G PEN NEEDLE, DIABETIC 29 G X1/2" 100 x x8396901734 RELION PEN NEEDLE 29GX1/2" PEN NEEDLE, DIABETIC 29 G X1/2" 50 x x86227010105 SURE COMFORT PEN NDL 29GX1/2" PEN NEEDLE, DIABETIC 29 G X1/2" 100 x x8222095121 ULTICARE PEN NEEDLES 12MM 29G PEN NEEDLE, DIABETIC 29 G X1/2" 100 x x8470352901 UNIFINE PENTIPS 12MM 29G PEN NEEDLE, DIABETIC 29 G X1/2" 100 x x86227011155 SURE COMFORT 30G PEN NEEDLE PEN NEEDLE, DIABETIC 30G X5/16" 100 x x8396900100 CLICKFINE 31G X 1/4" NEEDLES PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x91237000173 EASY COMFORT PEN NDL 31GX1/4" PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x8496310401 EASY TOUCH PEN NEEDLE 31GX1/4" PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x8396900118 PEN NEEDLE 31G X 1/4" PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x8214090735 PEN NEEDLES 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x61059090737 PEN NEEDLES 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x8396901534 RELION PEN NEEDLE 31GX1/4" PEN NEEDLE, DIABETIC 31 G X1/4" 50 x x8222095657 ULTICARE PEN NEEDLES 6 MM 31 G PEN NEEDLE, DIABETIC 31 G X1/4" 50 x x8222095633 ULTICARE PEN NEEDLES 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


8222710048 ULTICARE PEN NEEDLES 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x57515009563 ULTICARE PEN NEEDLES 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x57515071004 ULTICARE PEN NEEDLES 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x8470119001 UNIFINE PENTIPS 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 30 x x8470359001 UNIFINE PENTIPS 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x8470389001 UNIFINE PENTIPS PLUS 31GX1/4" PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x94046000174 ADVOCATE PEN NEEDLES 5MM 31G PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x8290320119 BD ULTRA‐FINE PEN NDL 5MMX31G PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x98302000199 COMFORT EZ PEN NEEDLES 5MM 31G PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x91237000163 EASY COMFORT PEN NDL 31GX3/16" PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x8496310101 EASY TOUCH PEN NEEDLE 31GX3/16 PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x89134063102 MINI ULTRA‐THIN II PEN NDL 31G PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x90166063132 PEN NEEDLES 5MM 31G PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x8214085029 PUB UNIFINE PNTP PLUS 31GX3/16 PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x86227012105 SURE COMFORT PEN NDL 31GX3/16" PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x8470115001 UNIFINE PENTIPS 31GX3/16" PEN NEEDLE, DIABETIC 31 GX3/16" 30 x x8470355001 UNIFINE PENTIPS 31GX3/16" PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x8214050757 UNIFINE PENTIPS PLUS 31GX3/16" PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x8214385034 UNIFINE PENTIPS PLUS 31GX3/16" PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x8470385001 UNIFINE PENTIPS PLUS 31GX3/16" PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x94046000173 ADVOCATE PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x8290320109 BD ULTRA‐FINE PEN NDL 8MMX31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x8396900500 CLICKFINE UNIVERSAL 31GX5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x98302000198 COMFORT EZ PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x91237000170 EASY COMFORT PEN NDL 31GX5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x8496310601 EASY TOUCH PEN NEEDLE 31GX5/16 PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x8396900218 PEN NEEDLE 31G X 5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x8214030735 PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x8214030737 PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x90166083152 PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x8396901634 RELION PEN NEEDLE 31GX5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 50 x x86227012155 SURE COMFORT 31G PEN NEEDLE PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x8222095855 ULTICARE PEN NEEDLES 8 MM 31 G PEN NEEDLE, DIABETIC 31 GX5/16" 50 x x8222095831 ULTICARE PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x8222710055 ULTICARE PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x57515009583 ULTICARE PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x89134063002 ULTRA‐THIN II PEN NDL 31GX5/16 PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


8470113001 UNIFINE PENTIPS 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 30 x x8470353001 UNIFINE PENTIPS 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x8214030757 UNIFINE PENTIPS PLUS 31GX5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x8214383034 UNIFINE PENTIPS PLUS 31GX5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x8470383001 UNIFINE PENTIPS PLUS 31GX5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x8496320401 EASY TOUCH PEN NEEDLE 32GX1/4" PEN NEEDLE, DIABETIC 32 GX 1/4" 100 x x00169185189 NOVOFINE 32G NEEDLES PEN NEEDLE, DIABETIC 32 GX 1/4" 100 x x86227013055 SURE COMFORT PEN NDL 32GX1/4" PEN NEEDLE, DIABETIC 32 GX 1/4" 100 x x8290320122 BD ULTRA‐FINE PEN NDL 4MMX32G PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x8396900800 CLICKFINE PEN NEEDLE 32GX5/32" PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x8396900718 PEN NEEDLE 32G X 5/32" PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x8396901434 RELION PEN NEEDLE 32GX5/32" PEN NEEDLE, DIABETIC 32GX 5/32" 50 x x8222710031 ULTICARE PEN NEEDLES 4MM 32G PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x

BLOOD GLUCOSE TESTING METERS00193737701 CONTOUR NEXT METER BLOOD‐GLUCOSE METER 1 x x99073070914 FREESTYLE FREEDOM LITE METER BLOOD‐GLUCOSE METER 1 x x99073071143 FREESTYLE INSULINX GLUCOSE SYS BLOOD‐GLUCOSE METER 1 x x99073070805 FREESTYLE LITE METER BLOOD‐GLUCOSE METER 1 x x57599881401 PRECISION XTRA MONITOR BLOOD‐GLUCOSE METER 1 x x8484070120 PRODIGY AUTOCODE METER KIT BLOOD‐GLUCOSE METER 1 x x8484071950 PRODIGY VOICE METER KIT BLOOD‐GLUCOSE METER 1 x x

BLOOD GLUCOSE METER CONTROL SOLUTIONS99073070432 FREESTYLE CONTROL SOLUTION BLOOD GLUCOSE CONTROL HIGH,LOW 1 x x00193710901 CONTOUR SOLUTION BLOOD‐GLUCOSE CONTROL, NORMAL 1 x x99073014002 FREESTYLE CONTROL SOLUTION BLOOD‐GLUCOSE CONTROL, NORMAL 1 x x

LANCETS38396030318 KROGER SUPER THIN LANCETS LANCETS 100 x x00193654621 MICROLET LANCETS LANCETS 100 x x00193658621 MICROLET LANCETS LANCETS 100 x x53885039310 ONETOUCH ULTRASOFT LANCETS LANCETS 100 x x50924058510 SOFT TOUCH LANCETS LANCETS 100 x x8470046501 UNILET COMFORTOUCH LANCET LANCETS 100 x x8470092501 UNILET GP LANCET LANCETS 100 x x38396034264 GNP UNIVERSAL 1 STANDARD 21G LANCETS 21 GAUGE 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


8271035100 LANCETS THIN 23G LANCETS 23 GAUGE 100 x x38396030118 KRO UNIVERSAL 1 THIN 26G LANCT LANCETS 26 GAUGE 100 x x8271036100 LANCETS ULTRA THIN 26G LANCETS 26 GAUGE 100 x x8484082026 PRODIGY SAFETY 26G LANCETS LANCETS 26 GAUGE 100 x x8496281001 EASY TOUCH TWIST 28G LANCETS LANCETS 28 GAUGE 100 x x99073013001 FREESTYLE 28G LANCETS LANCETS 28 GAUGE 100 x x8484081028 PRODIGY TWIST TOP 28G LANCET LANCETS 28 GAUGE 100 x x8484990328 PRODIGY TWIST TOP 28G LANCET LANCETS 28 GAUGE 100 x x00363237203 SUPER THIN 28G LANCETS LANCETS 28 GAUGE 100 x x86227028105 SURE COMFORT 28G LANCETS LANCETS 28 GAUGE 100 x x8317880128 TECHLITE 28G LANCETS LANCETS 28 GAUGE 100 x x11917013416 TRUEPLUS SUPER THIN 28G LANCET LANCETS 28 GAUGE 100 x x56151014260 TRUEPLUS SUPER THIN 28G LANCET LANCETS 28 GAUGE 100 x x8496301001 EASY TOUCH TWIST 30G LANCETS LANCETS 30 GAUGE 100 x x38396030800 E‐ZJECT SUPER THIN 30G LANCETS LANCETS 30 GAUGE 100 x x38396054764 GNP UNIVERSAL 1 SUPER THIN 30G LANCETS 30 GAUGE 100 x x8463702930 LANCETS 30G LANCETS 30 GAUGE 100 x x53885059501 ONETOUCH DELICA 30G LANCETS LANCETS 30 GAUGE 100 x x86227030105 SURE COMFORT 30G LANCETS LANCETS 30 GAUGE 100 x x56151014401 TRUEPLUS ULTRA THIN 30G LANCET LANCETS 30 GAUGE 100 x x8214065757 UNILET SUPER THIN 30G LANCETS LANCETS 30 GAUGE 100 x x8496321001 EASY TOUCH TWIST 32G LANCETS LANCETS 32 GAUGE 100 x x8290322057 BD ULTRA‐FINE 33G LANCETS LANCETS 33 GAUGE 100 x x8496331001 EASY TOUCH TWIST 33G LANCETS LANCETS 33 GAUGE 100 x x00363237102 MICRO THIN 33G LANCETS LANCETS 33 GAUGE 100 x x38396031618 MICRO THIN 33G LANCETS LANCETS 33 GAUGE 100 x x53885013610 ONETOUCH DELICA 33G LANCETS LANCETS 33 GAUGE 100 x x53885014301 ONETOUCH DELICA 33G LANCETS LANCETS 33 GAUGE 100 x x56151014701 TRUEPLUS 33G LANCETS LANCETS 33 GAUGE 100 x x8470058501 UNILET MICRO THIN 33G LANCETS LANCETS 33 GAUGE 100 x x

LANCING DEVICES8396706018 KRO LANCING DEVICE LANCING DEVICE 1 x x11917013481 LANCING DEVICE LANCING DEVICE 1 x x38415051001 LANCING DEVICE LANCING DEVICE 1 x x8484990355 PRODIGY LANCING DEVICE LANCING DEVICE 1 x x56151014201 TRUEDRAW LANCING DEVICE LANCING DEVICE 1 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


ALCOHOL SWABS91237000128 ALCOHOL 70% PADS ALCOHOL ANTISEPTIC PADS 100 x x37205015578 ALCOHOL 70% PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x60913000601 ALCOHOL 70% PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x60913001702 ALCOHOL 70% PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x00113200078 ALCOHOL 70% SWABS ALCOHOL ANTISEPTIC PADS 100 x x68113099601 ALCOHOL PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x46122004378 ALCOHOL SWAB ALCOHOL ANTISEPTIC PADS 100 x x11673060010 ALCOHOL SWABS ALCOHOL ANTISEPTIC PADS 100 x x11917012805 ALCOHOL SWABS ALCOHOL ANTISEPTIC PADS 100 x x8290326895 BD SINGLE USE SWAB ALCOHOL ANTISEPTIC PADS 100 x x50428085942 CVS ALCOHOL 70% PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x42423027101 EASY TOUCH ALCOHOL 70% PADS ALCOHOL ANTISEPTIC PADS 100 x x87701040724 GNP ALCOHOL SWAB ALCOHOL ANTISEPTIC PADS 100 x x30142080931 KRO ALCOHOL 70% PREP PADS ALCOHOL ANTISEPTIC PADS 140 x x30142080909 KRO ALCOHOL 70% SWABS ALCOHOL ANTISEPTIC PADS 100 x x98302000105 PHARM CHOICE ALCOHOL PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x90166011103 PREP EASE ALCOHOL PADS ALCOHOL ANTISEPTIC PADS 100 x x11822515660 RA ALCOHOL SWABS ALCOHOL ANTISEPTIC PADS 100 x x81131006044 RELION ALCOHOL 70% SWABS ALCOHOL ANTISEPTIC PADS 100 x x49348089610 SM ALCOHOL 70% PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x10939057933 SM ALCOHOL PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x49348007753 SM ALCOHOL PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x86227000000 SURE COMFORT ALCOHOL PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x86227012605 SURE COMFORT ALCOHOL PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x

URINE KETONE TEST STRIPS11917010873 KETONE TEST STRIPS URINE ACETONE TEST,STRIPS 50 x x00193288050 KETOSTIX REAGENT STRIPS URINE ACETONE TEST,STRIPS 50 x x81131006043 RELION KETONE TEST STRIPS URINE ACETONE TEST,STRIPS 50 x x56151060150 TRUEPLUS KETONE TEST STRIPS URINE ACETONE TEST,STRIPS 50 x x

URINE ALBUMIN TEST STRIPS8620219121 ALBUSTIX REAGENT STRIPS URINE ALBUMIN TEST 100 x x

URINE MULTIPLE TEST STRIPS




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00193288250 KETO‐DIASTIX REAGENT STRIPS URINE GLUCOSE‐ACET TEST STRIP 50 x x

BLOOD GLUCOSE TEST STRIP00193731025 CONTOUR NEXT STRIPS BLOOD SUGAR DIAGNOSTIC 25 x x00193731150 CONTOUR NEXT STRIPS BLOOD SUGAR DIAGNOSTIC 50 x x00193731221 CONTOUR NEXT STRIPS BLOOD SUGAR DIAGNOSTIC 100 x x00193708050 CONTOUR TEST STRIPS BLOOD SUGAR DIAGNOSTIC 50 x x00193709021 CONTOUR TEST STRIPS BLOOD SUGAR DIAGNOSTIC 100 x x99073071231 FREESTYLE INSULINX TEST STRIP BLOOD SUGAR DIAGNOSTIC 50 x x99073071227 FREESTYLE INSULINX TEST STRIPS BLOOD SUGAR DIAGNOSTIC 100 x x99073070822 FREESTYLE LITE TEST STRIP BLOOD SUGAR DIAGNOSTIC 50 x x99073070827 FREESTYLE LITE TEST STRIP BLOOD SUGAR DIAGNOSTIC 100 x x99073070819 FREESTYLE LITE TEST STRIP NFRS BLOOD SUGAR DIAGNOSTIC 50 x x93815071577 FREESTYLE PREC NEO TEST STRIPS BLOOD SUGAR DIAGNOSTIC 25 x x99073012050 FREESTYLE TEST STRIPS BLOOD SUGAR DIAGNOSTIC 50 x x99073012101 FREESTYLE TEST STRIPS BLOOD SUGAR DIAGNOSTIC 100 x x53885024450 ONETOUCH ULTRA TEST STRIPS BLOOD SUGAR DIAGNOSTIC 50 x x53885024510 ONETOUCH ULTRA TEST STRIPS BLOOD SUGAR DIAGNOSTIC 100 x x53885027150 ONETOUCH VERIO TEST STRIP BLOOD SUGAR DIAGNOSTIC 50 x x53885027210 ONETOUCH VERIO TEST STRIP BLOOD SUGAR DIAGNOSTIC 100 x x57599972804 PRECISION XTRA TEST STRIPS BLOOD SUGAR DIAGNOSTIC 50 x x57599987705 PRECISION XTRA TEST STRIPS BLOOD SUGAR DIAGNOSTIC 100 x x8484052800 PRODIGY NO CODING TEST STRIPS BLOOD SUGAR DIAGNOSTIC 50 x x8484072500 PRODIGY NO CODING TEST STRIPS BLOOD SUGAR DIAGNOSTIC 50 x x8484073200 PRODIGY NO CODING TEST STRIPS BLOOD SUGAR DIAGNOSTIC 50 x x

BLOOD KETONE TEST STRIPS57599074501 PRECISION XTR B‐KETONE STRIP BLOOD KETONE TEST,STRIPS 10 x x

COUGH/COLD/ALLERGY

ANTIHISTAMINES‐ CHLORPHENIRAMINE00485009804 ED CHLORPED JR SYRUP CHLORPHENIRAMINE MALEATE 2 MG/5 ML 118 x x00536100601 ALLER‐CHLOR 4 MG TABLET CHLORPHENIRAMINE MALEATE 4 MG 100 x x00536100635 ALLER‐CHLOR 4 MG TABLET CHLORPHENIRAMINE MALEATE 4 MG 24 x x00904001224 ALLERGY 4 MG TABLET CHLORPHENIRAMINE MALEATE 4 MG 24 x x00904001259 ALLERGY 4 MG TABLET CHLORPHENIRAMINE MALEATE 4 MG 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


24385046362 ALLERGY 4 MG TABLET CHLORPHENIRAMINE MALEATE 4 MG 24 x x10135013330 CHLORPHENIRAMINE 4 MG TABLET CHLORPHENIRAMINE MALEATE 4 MG 30 x x62011005901 HM ALLERGY RELIEF 4 MG TABLET CHLORPHENIRAMINE MALEATE 4 MG 24 x x11822319750 RA CHLORPHENIRAMINE 4 MG TAB CHLORPHENIRAMINE MALEATE 4 MG 100 x x

ANTIHISTAMINES‐ DIPHENHYDRAMINE00904122800 BANOPHEN ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x11673071012 CHILD'S ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 236 x x36800037926 CHILD'S ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x36800037934 CHILD'S ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 236 x x00363037926 CHILD'S WAL‐DRYL 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x00363010104 CHILD'S WAL‐DRYL 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x50428029730 CVS ALLERGY 50 MG/20 ML LIQ DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x24385037926 DIPHEDRYL 12.5 MG/5 ML ELIXIR DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x00536077097 DIPHENHIST 12.5 MG/5 ML SOLN DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x11383017908 DIPHENHYDRAMINE 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 236 x x53807016001 DIPHENHYDRAMINE 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 120 x x53807020404 DIPHENHYDRAMINE 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 120 x x53807020408 DIPHENHYDRAMINE 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 240 x x53807015408 DIPHENHYDRAMINE COUGH SYRUP DIPHENHYDRAMINE HCL 12.5MG/5ML 240 x x49035010104 EQ CHILD ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x49035037926 EQ CHILD ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x49035037934 EQ CHILD ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 237 x x00113037926 GS CHILD ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x52569013351 HM CHILD ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x62011005701 HM CHILD ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x30142040426 KRO CHILD ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x30142040434 KRO CHILD ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 236 x x63868082354 QC CHILD ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x11822002050 RA CHILD ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x11822447100 RA CHILD ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x11822332050 RA DIPHEDRYL 12.5 MG/5 ML ELIX DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x11822304050 RA DIPHEDRYL 12.5 MG/5 ML LIQ DIPHENHYDRAMINE HCL 12.5MG/5ML 236 x x54838013540 SILADRYL 12.5 MG/5 ML LIQUID DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x49348004534 SM ALLERGY RELIEF 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x49348004537 SM ALLERGY RELIEF 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 237 x x00363041804 WAL‐DRYL ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00363010612 WAL‐DRYL ALLERGY 12.5 MG/5 ML DIPHENHYDRAMINE HCL 12.5MG/5ML 118 x x36800046262 ALLERGY 25 MG CAPSULE DIPHENHYDRAMINE HCL 25 MG 24 x x36800046267 ALLERGY 25 MG CAPSULE DIPHENHYDRAMINE HCL 25 MG 48 x x24385047962 ALLERGY 25 MG TABLET DIPHENHYDRAMINE HCL 25 MG 24 x x30142047962 ALLERGY 25 MG TABLET DIPHENHYDRAMINE HCL 25 MG 24 x x00113046262 ALLERGY RELIEF 25 MG CAPSULE DIPHENHYDRAMINE HCL 25 MG 24 x x00113047962 ALLERGY RELIEF 25 MG TABLET DIPHENHYDRAMINE HCL 25 MG 24 x x00113047978 ALLERGY RELIEF 25 MG TABLET DIPHENHYDRAMINE HCL 25 MG 100 x x00904203524 BANOPHEN 25 MG CAPSULE DIPHENHYDRAMINE HCL 25 MG 24 x x00904530660 BANOPHEN 25 MG CAPSULE DIPHENHYDRAMINE HCL 25 MG 100 x x00904555124 BANOPHEN 25 MG TABLET DIPHENHYDRAMINE HCL 25 MG 24 x x00904555159 BANOPHEN 25 MG TABLET DIPHENHYDRAMINE HCL 25 MG 100 x x50428839138 CVS ALLERGY 25 MG CAPSULE DIPHENHYDRAMINE HCL 25 MG 36 x x50428661736 CVS ALLERGY 25 MG SOFTGEL DIPHENHYDRAMINE HCL 25 MG 24 x x50428477066 CVS ALLERGY 25 MG TABLET DIPHENHYDRAMINE HCL 25 MG 24 x x50428477068 CVS ALLERGY 25 MG TABLET DIPHENHYDRAMINE HCL 25 MG 48 x x24385047978 DIPHEDRYL 25 MG TABLET DIPHENHYDRAMINE HCL 25 MG 100 x x00536101001 DIPHENHIST 25 MG CAPSULE DIPHENHYDRAMINE HCL 25 MG 100 x x00536101601 DIPHENHIST 25 MG CAPTAB DIPHENHYDRAMINE HCL 25 MG 100 x x00904530661 DIPHENHYDRAMINE 25 MG CAPSULE DIPHENHYDRAMINE HCL 25 MG 100 x x10135014924 DIPHENHYDRAMINE 25 MG CAPSULE DIPHENHYDRAMINE HCL 25 MG 24 x x66424002001 DIPHENHYDRAMINE 25 MG CAPSULE DIPHENHYDRAMINE HCL 25 MG 100 x x81131018722 EQ ALLERGY RELIEF 25 MG CAP DIPHENHYDRAMINE HCL 25 MG 24 x x52569013352 HM ALLERGY 25 MG TABLET DIPHENHYDRAMINE HCL 25 MG 24 x x56062047962 PUB ALLERGY 25 MG TABLET DIPHENHYDRAMINE HCL 25 MG 24 x x11822454350 RA ALLERGY 25 MG TABLET DIPHENHYDRAMINE HCL 25 MG 48 x x00363010722 WAL‐DRYL ALLERGY 25 MG CAPSULE DIPHENHYDRAMINE HCL 25 MG 48 x x11917007192 WAL‐DRYL ALLERGY 25 MG CAPSULE DIPHENHYDRAMINE HCL 25 MG 24 x x00363032907 WAL‐DRYL ALLERGY 25 MG MINITAB DIPHENHYDRAMINE HCL 25 MG 36 x x00363032908 WAL‐DRYL ALLERGY 25 MG MINITAB DIPHENHYDRAMINE HCL 25 MG 24 x x00363032922 WAL‐DRYL ALLERGY 25 MG MINITAB DIPHENHYDRAMINE HCL 25 MG 48 x x00363029908 WAL‐DRYL ALLERGY 25 MG SOFTGEL DIPHENHYDRAMINE HCL 25 MG 24 x x00904530760 BANOPHEN 50 MG CAPSULE DIPHENHYDRAMINE HCL 50 MG 100 x x00904205661 DIPHENHYDRAMINE 50 MG CAPSULE DIPHENHYDRAMINE HCL 50 MG 100 x x

ANTIHISTAMINES‐ CETIRIZINE51672210208 CETIRIZINE HCL 1 MG/1 ML SOLN CETIRIZINE HCL 1 MG/ML 120 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


51672208808 CETIRIZINE HCL 1 MG/ML SOLN CETIRIZINE HCL 1 MG/ML 120 x x45802097426 CETIRIZINE HCL 1 MG/ML SYRUP CETIRIZINE HCL 1 MG/ML 118 x x00113097426 CHILD ALL DAY ALLERGY 1 MG/ML CETIRIZINE HCL 1 MG/ML 118 x x00904637220 CHILD ALL DAY ALLERGY 1 MG/ML CETIRIZINE HCL 1 MG/ML 118 x x24385018826 CHILD ALL DAY ALLERGY 1 MG/ML CETIRIZINE HCL 1 MG/ML 118 x x46122002026 CHILD ALL DAY ALLERGY 1 MG/ML CETIRIZINE HCL 1 MG/ML 120 x x46122010126 CHILD ALL DAY ALLERGY 1 MG/ML CETIRIZINE HCL 1 MG/ML 118 x x46122020326 CHILD ALL DAY ALLERGY 1 MG/ML CETIRIZINE HCL 1 MG/ML 120 x x70030014847 CHILD ALL DAY ALLERGY 1 MG/ML CETIRIZINE HCL 1 MG/ML 118 x x54838055240 CHILD CETIRIZINE HCL 1 MG/ML CETIRIZINE HCL 1 MG/ML 120 x x00363047526 CHILD WAL‐ZYR 1 MG/ML SOLUTION CETIRIZINE HCL 1 MG/ML 120 x x00363088426 CHILD WAL‐ZYR 1 MG/ML SOLUTION CETIRIZINE HCL 1 MG/ML 120 x x11917012054 CHILD WAL‐ZYR 1 MG/ML SOLUTION CETIRIZINE HCL 1 MG/ML 120 x x11917012314 CHILD WAL‐ZYR 1 MG/ML SOLUTION CETIRIZINE HCL 1 MG/ML 240 x x11917013588 CHILD WAL‐ZYR 1 MG/ML SOLUTION CETIRIZINE HCL 1 MG/ML 120 x x50428040525 CVS CHILD ALLERGY RELF 1 MG/ML CETIRIZINE HCL 1 MG/ML 120 x x50428045563 CVS CHILD ALLERGY RELF 1 MG/ML CETIRIZINE HCL 1 MG/ML 120 x x50428901406 CVS CHILD ALLERGY RELF 1 MG/ML CETIRIZINE HCL 1 MG/ML 240 x x50428044192 CVS CHILD ALLERGY RELF 1MG/ML CETIRIZINE HCL 1 MG/ML 240 x x49035010608 EQ CHILD ALLERGY RELF 1 MG/ML CETIRIZINE HCL 1 MG/ML 120 x x62011009301 HM CHILD CETIRIZINE 1 MG/ML CETIRIZINE HCL 1 MG/ML 118 x x62011018001 HM CHILD CETIRIZINE 1 MG/ML CETIRIZINE HCL 1 MG/ML 120 x x30142018926 KRO CHLD ALL DAY ALLER 1 MG/ML CETIRIZINE HCL 1 MG/ML 120 x x30142047526 KRO CHLD ALL DAY ALLER 1 MG/ML CETIRIZINE HCL 1 MG/ML 118 x x10939035444 SM CHILD ALL DAY ALLER 1 MG/ML CETIRIZINE HCL 1 MG/ML 118 x x49348007834 SM CHILD ALL DAY ALLER 1 MG/ML CETIRIZINE HCL 1 MG/ML 118 x x49348032634 SM CHILD ALL DAY ALLER 1 MG/ML CETIRIZINE HCL 1 MG/ML 120 x x49348093434 SM CHILD ALL DAY ALLER 1 MG/ML CETIRIZINE HCL 1 MG/ML 118 x x30142045839 ALL DAY ALLERGY 10 MG TABLET CETIRIZINE HCL 10 MG 30 x x36800045839 ALL DAY ALLERGY 10 MG TABLET CETIRIZINE HCL 10 MG 30 x x00536408807 CETIRIZINE HCL 10 MG TABLET CETIRIZINE HCL 10 MG 30 x x00536408888 CETIRIZINE HCL 10 MG TABLET CETIRIZINE HCL 10 MG 14 x x45802091939 CETIRIZINE HCL 10 MG TABLET CETIRIZINE HCL 10 MG 30 x x51660093930 CETIRIZINE HCL 10 MG TABLET CETIRIZINE HCL 10 MG 30 x x51660093954 CETIRIZINE HCL 10 MG TABLET CETIRIZINE HCL 10 MG 14 x x50428444236 CVS ALLERGY RELIEF 10 MG TAB CETIRIZINE HCL 10 MG 14 x x50428444238 CVS ALLERGY RELIEF 10 MG TAB CETIRIZINE HCL 10 MG 30 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00904671746 CETIRIZINE HCL 10 MG TABLET CETIRIZINE HCL 10 MG 30 x x16714079901 CETIRIZINE HCL 10 MG TABLET CETIRIZINE HCL 10 MG 30 x x63868013230 QC ALL DAY ALLERGY 10 MG TAB CETIRIZINE HCL 10 MG 30 x x11822505370 RA CETIRIZINE HCL 10 MG TABLET CETIRIZINE HCL 10 MG 14 x x11822505380 RA CETIRIZINE HCL 10 MG TABLET CETIRIZINE HCL 10 MG 30 x x49348098446 SM ALL DAY ALLERGY 10 MG TAB CETIRIZINE HCL 10 MG 14 x x00363045866 WAL‐ZYR 10 MG TABLET CETIRIZINE HCL 10 MG 14 x x00363049539 WAL‐ZYR 10 MG TABLET CETIRIZINE HCL 10 MG 30 x x00781528364 CETIRIZINE HCL 5 MG CHEW TAB CETIRIZINE HCL 5 MG 30 x x47335034383 CHILD CETIRIZINE 5 MG CHEW TAB CETIRIZINE HCL 5 MG 30 x x

ANTIHISTAMINES‐ FEXOFENADINE41167412003 ALLEGRA ALLERGY 180 MG TABLET FEXOFENADINE HCL 180 MG 30 x x50428847260 CVS ALLERGY RELIEF 180 MG TAB FEXOFENADINE HCL 180 MG 30 x x49035078430 EQ ALLERGY RELIEF 180 MG TAB FEXOFENADINE HCL 180 MG 30 x x00378078293 FEXOFENADINE HCL 180 MG TABLET FEXOFENADINE HCL 180 MG 30 x x55111078430 FEXOFENADINE HCL 180 MG TABLET FEXOFENADINE HCL 180 MG 30 x x62011031502 HM FEXOFENADINE HCL 180 MG TAB FEXOFENADINE HCL 180 MG 30 x x00363057139 WAL‐FEX ALLERGY 180 MG TABLET FEXOFENADINE HCL 180 MG 30 x x00363078430 WAL‐FEX ALLERGY 180 MG TABLET FEXOFENADINE HCL 180 MG 30 x x41167042444 CHLD ALLEGRA ALLERGY 30 MG/5 FEXOFENADINE HCL 30 MG/5 ML 120 x x41167424401 CHLD ALLEGRA ALLERGY 30 MG/5 FEXOFENADINE HCL 30 MG/5 ML 240 x x41167424404 CHLD ALLEGRA ALLERGY 30 MG/5 FEXOFENADINE HCL 30 MG/5 ML 120 x x50428044029 CVS CHILD ALLERGY RLF 30 MG/5 FEXOFENADINE HCL 30 MG/5 ML 118 x x00472052794 FEXOFENADINE HCL 30 MG/5 ML FEXOFENADINE HCL 30 MG/5 ML 118 x x41167413102 ALLEGRA ALLERGY 60 MG TABLET FEXOFENADINE HCL 60 MG 12 x x41167413104 ALLEGRA ALLERGY 60 MG TABLET FEXOFENADINE HCL 60 MG 24 x x00378078191 FEXOFENADINE HCL 60 MG TABLET FEXOFENADINE HCL 60 MG 60 x x

ANTIHISTAMINES‐ LORATADINE00573262119 ALAVERT 10 MG ODT LORATADINE 10 MG 18 x x00113061239 ALLERGY RELIEF 10 MG TABLET LORATADINE 10 MG 30 x x00113061246 ALLERGY RELIEF 10 MG TABLET LORATADINE 10 MG 10 x x00113061260 ALLERGY RELIEF 10 MG TABLET LORATADINE 10 MG 20 x x30142061265 ALLERGY RELIEF 10 MG TABLET LORATADINE 10 MG 30 x x36800061265 ALLERGY RELIEF 10 MG TABLET LORATADINE 10 MG 30 x x49035061246 EQ ALLERGY RELIEF 10 MG TABLET LORATADINE 10 MG 10 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00113061265 GS ALLERGY RELIEF 10 MG TABLET LORATADINE 10 MG 30 x x00067067430 LORATADINE 10 MG TABLET LORATADINE 10 MG 30 x x24385047152 LORATADINE 10 MG TABLET LORATADINE 10 MG 10 x x24385047199 LORATADINE 10 MG TABLET LORATADINE 10 MG 30 x x45802065065 LORATADINE 10 MG TABLET LORATADINE 10 MG 30 x x16714089001 LORATADINE 10 MG TABLET LORATADINE 10 MG 30 x x51660052631 LORATADINE 10 MG TABLET LORATADINE 10 MG 30 x x00904572887 NON‐DROWSY ALLERGY 10 MG TAB LORATADINE 10 MG 30 x x11822312760 RA LORATADINE 10 MG TABLET LORATADINE 10 MG 10 x x11822331520 RA LORATADINE 10 MG TABLET LORATADINE 10 MG 30 x x00363069965 WAL‐ITIN 10 MG TABLET LORATADINE 10 MG 30 x x11917010300 WAL‐ITIN 10 MG TABLET LORATADINE 10 MG 10 x x41100080521 CLARITIN 5 MG REDITABS LORATADINE 5 MG 30 x x24385053126 ALLERGY RELIEF 5 MG/5 ML SOLN LORATADINE 5 MG/5 ML 120 x x46122016426 CHILD LORATADINE 5 MG/5 ML SYR LORATADINE 5 MG/5 ML 120 x x51672209208 CHILD LORATADINE 5 MG/5 ML SYR LORATADINE 5 MG/5 ML 120 x x50428912837 CVS ALLERGY RELIEF 5 MG/5 ML LORATADINE 5 MG/5 ML 240 x x50428912845 CVS ALLERGY RELIEF 5 MG/5 ML LORATADINE 5 MG/5 ML 120 x x62011007201 HM CHILD LORATADINE 5 MG/5 ML LORATADINE 5 MG/5 ML 120 x x62011018101 HM CHILD LORATADINE 5 MG/5 ML LORATADINE 5 MG/5 ML 120 x x30142009208 KRO CHILD ALLERGY RELIEF SOLN LORATADINE 5 MG/5 ML 120 x x00904623420 LORATADINE 5 MG/5 ML SOLN LORATADINE 5 MG/5 ML 120 x x51672207308 LORATADINE 5 MG/5 ML SYRUP LORATADINE 5 MG/5 ML 120 x x51672208508 LORATADINE 5 MG/5 ML SYRUP LORATADINE 5 MG/5 ML 120 x x54838055840 LORATADINE ALLERGY 5 MG/5 ML LORATADINE 5 MG/5 ML 120 x x10939059544 SM CHILD LORATADINE 5 MG/5 ML LORATADINE 5 MG/5 ML 120 x x49348033334 SM CHILD LORATADINE 5 MG/5 ML LORATADINE 5 MG/5 ML 120 x x10939079233 SM LORATADINE 5 MG/5 ML SYRUP LORATADINE 5 MG/5 ML 120 x x49348063634 SM LORATADINE 5 MG/5 ML SYRUP LORATADINE 5 MG/5 ML 120 x x00363008816 WAL‐ITIN 5 MG/5 ML SYRUP LORATADINE 5 MG/5 ML 120 x x

ANTIHISTAMINES‐ LEVOCETIRIZINE41167035301 XYZAL 2.5 MG/5 ML SOLUTION LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 MG/5 ML 148 x x41167353001 XYZAL 2.5 MG/5 ML SOLUTION LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 MG/5 ML 148 x x

DECONGESTANTS‐ PSEUDOEPHEDRINE50580053604 CHILDS SUDAFED 15 MG/5 ML LIQ PSEUDOEPHEDRINE HCL 15 MG/5 ML 118 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


30142043262 KRO NASAL DECONGEST 30 MG TAB PSEUDOEPHEDRINE HCL 30 MG 24 x x30142043267 KRO NASAL DECONGEST 30 MG TAB PSEUDOEPHEDRINE HCL 30 MG 48 x x00113043262 NASAL DECONGESTANT 30 MG TAB PSEUDOEPHEDRINE HCL 30 MG 24 x x00536360735 NASAL DECONGESTANT 30 MG TAB PSEUDOEPHEDRINE HCL 30 MG 24 x x48964011224 NEXAFED 30 MG TABLET PSEUDOEPHEDRINE HCL 30 MG 24 x x45802043262 PSEUDOEPHEDRINE 30 MG TABLET PSEUDOEPHEDRINE HCL 30 MG 24 x x00904505324 SUDOGEST 30 MG TABLET PSEUDOEPHEDRINE HCL 30 MG 24 x x24385043262 SUPHEDRIN 30 MG TABLET PSEUDOEPHEDRINE HCL 30 MG 24 x x00363011208 WAL‐PHED 30 MG TABLET PSEUDOEPHEDRINE HCL 30 MG 24 x x00363011222 WAL‐PHED 30 MG TABLET PSEUDOEPHEDRINE HCL 30 MG 48 x x53240015101 ZEPHREX‐D 30 MG TABLET PSEUDOEPHEDRINE HCL 30 MG 24 x x

DECONGESTANTS‐ PHELYLEPHRINE00904573373 SUDOGEST PE 10 MG TABLET PHENYLEPHRINE HCL 10 MG 36 x x

NASAL STEROIDS‐ BUDESONIDE00536111248 BUDESONIDE 32 MCG NASAL SPRAY BUDESONIDE 32MCG 8.43 x x46122038976 BUDESONIDE 32 MCG NASAL SPRAY BUDESONIDE 32MCG 9.43 x x60505612902 BUDESONIDE 32 MCG NASAL SPRAY BUDESONIDE 32MCG 8.43 x x50428052804 CVS BUDESONIDE 32 MCG SPRAY BUDESONIDE 32MCG 8.43 x x

NASAL STEROIDS‐ TRIAMCINOLONE ACETONIDE41167059002 CHILD NASACORT ALLERGY 24 HR TRIAMCINOLONE ACETONIDE 55 MCG 10.8 x x41167590002 CHILD NASACORT ALLERGY 24 HR TRIAMCINOLONE ACETONIDE 55 MCG 10.8 x x41167058002 NASACORT ALLERGY 24HR SPRAY TRIAMCINOLONE ACETONIDE 55 MCG 16.9 x x41167058003 NASACORT ALLERGY 24HR SPRAY TRIAMCINOLONE ACETONIDE 55 MCG 10.8 x x41167058005 NASACORT ALLERGY 24HR SPRAY TRIAMCINOLONE ACETONIDE 55 MCG 16.9 x x41167580002 NASACORT ALLERGY 24HR SPRAY TRIAMCINOLONE ACETONIDE 55 MCG 16.9 x x41167580003 NASACORT ALLERGY 24HR SPRAY TRIAMCINOLONE ACETONIDE 55 MCG 10.8 x x41167580005 NASACORT ALLERGY 24HR SPRAY TRIAMCINOLONE ACETONIDE 55 MCG 16.9 x x

MAST CELL STABLIZERS‐ CROMOLYN SODIUM57782039726 CROMOLYN SODIUM NASAL SPRAY CROMOLYN SODIUM 5.2 MG 26 x x14832001103 NASALCROM 5.2 MG NASAL SPRAY CROMOLYN SODIUM 5.2 MG 13 x x

SODIUM CHLORIDE NASAL SPRAY00225038080 AYR SALINE 0.65% NOSE SPRAY SODIUM CHLORIDE 0.65 % 50 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00363070530 CHILD SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 30 x x50428006205 CVS SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 88 x x50428891465 CVS SALINE 0.65% NOSE SPRAY SODIUM CHLORIDE 0.65 % 45 x x00904386575 DEEP SEA 0.65% NOSE SPRAY SODIUM CHLORIDE 0.65 % 44 x x81131070024 EQ NASAL 0.65% SPRAY SODIUM CHLORIDE 0.65 % 44 x x87701040085 GNP NASAL MOIST 0.65% SPRAY SODIUM CHLORIDE 0.65 % 88 x x87701055205 GNP SALINE 0.65% NOSE SPRAY SODIUM CHLORIDE 0.65 % 44 x x52569013385 HM SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 44 x x62011008601 HM SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 44 x x62011008602 HM SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 88 x x56184012011 LITTLE REMEDIES 0.65% SPRAY SODIUM CHLORIDE 0.65 % 30 x x56184012141 LITTLE REMEDIES STUFFY NOSE KT SODIUM CHLORIDE 0.65 % 15 x x00187526003 OCEAN 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 45 x x11822320300 RA SALINE 0.65% NOSE SPRAY SODIUM CHLORIDE 0.65 % 45 x x00363032003 SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 30 x x11917001257 SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 88 x x11917002642 SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 44 x x24385032558 SALINE 0.65% NOSE SPRAY SODIUM CHLORIDE 0.65 % 44 x x00536250676 SALINE MIST 0.65% NOSE SPRY SODIUM CHLORIDE 0.65 % 44 x x45802035758 SALINE MIST 0.65% NOSE SPRY SODIUM CHLORIDE 0.65 % 45 x x49348035625 SM SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 44 x x00225052547 AYR SALINE NASAL GEL SODIUM CHLORIDE/ALOE VERA 14.1 x x

COUGH SUPPRESSANTS24385049326 TUSSIN COUGH LIQUID DEXTROMETHORPHAN HBR 15 MG/5 ML 118 x x00363038421 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x00363038428 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x00363049421 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x00363089921 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x00363095828 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x00904631256 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x37205069721 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x46122014121 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x46122014125 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x46122014221 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x50428041780 CVS CHILD COUGH DM ER 30 MG/5 DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x50428035047 CVS COUGH DM ER 30 MG/5 ML SUS DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


50428040757 CVS COUGH DM ER 30 MG/5 ML SUS DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x50428046507 CVS COUGH DM ER 30 MG/5 ML SUS DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x63824017163 DELSYM 30 MG/5 ML SUSPENSION DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x63824017165 DELSYM 30 MG/5 ML SUSPENSION DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x63824017563 DELSYM 30 MG/5 ML SUSPENSION DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x63824017565 DELSYM 30 MG/5 ML SUSPENSION DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x45802043321 DEXTROMETHORPHAN ER 30 MG/5 ML DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x49035038421 EQ COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x62011017601 HM COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x62011019801 HM COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x62011025101 HM COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x30142038421 KRO COUGH DM ER 30 MG/5 ML SUS DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x11822619070 RA COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x

EXPECTORANTS00363031034 ADULT WAL‐TUSSIN LIQUID GUAIFENESIN 100 MG/5ML 237 x x00363028826 CHILDREN'S CHEST CONGEST LIQ GUAIFENESIN 100 MG/5ML 118 x x00113028826 CHILDREN'S MUCUS RELIEF LIQ GUAIFENESIN 100 MG/5ML 118 x x36800028826 CHILDREN'S MUCUS RELIEF LIQ GUAIFENESIN 100 MG/5ML 118 x x63824028564 CHL MUCINEX CHEST CONGEST LIQ GUAIFENESIN 100 MG/5ML 118 x x00536109597 COUGH SYRUP 200 MG/10 ML GUAIFENESIN 100 MG/5ML 118 x x60569006304 DIABETIC TUSSIN EX LIQUID GUAIFENESIN 100 MG/5ML 118 x x62011008901 HM ADULT TUSSIN CHEST CONG LIQ GUAIFENESIN 100 MG/5ML 237 x x62011008902 HM ADULT TUSSIN CHEST CONG LIQ GUAIFENESIN 100 MG/5ML 118 x x30142031026 KRO TUSSIN 200 MG/10 ML SYRUP GUAIFENESIN 100 MG/5ML 118 x x11822001110 RA EXPECTORANT COUGH SYRUP GUAIFENESIN 100 MG/5ML 237 x x11822771100 RA TUSSIN CHEST CONGESTION SYR GUAIFENESIN 100 MG/5ML 118 x x00904006100 ROBAFEN 100 MG/5 ML SYRUP GUAIFENESIN 100 MG/5ML 118 x x54838011740 SILTUSSIN SA 100 MG/5 ML SYR GUAIFENESIN 100 MG/5ML 118 x x54838011770 SILTUSSIN SA 100 MG/5 ML SYR GUAIFENESIN 100 MG/5ML 237 x x10939032533 SM TUSSIN 100 MG/5 ML LIQUID GUAIFENESIN 100 MG/5ML 118 x x49348013534 SM TUSSIN MUCUS‐CONG 200 MG/10 GUAIFENESIN 100 MG/5ML 118 x x49348013537 SM TUSSIN MUCUS‐CONG 200 MG/10 GUAIFENESIN 100 MG/5ML 236 x x24385031034 TUSSIN 100 MG/5 ML SYRUP GUAIFENESIN 100 MG/5ML 237 x x36800031026 TUSSIN CHEST CONGESTION LIQUID GUAIFENESIN 100 MG/5ML 118 x x00113006126 TUSSIN MUCUS‐CONGEST 100 MG/5 GUAIFENESIN 100 MG/5ML 118 x x00113006134 TUSSIN MUCUS‐CONGEST 100 MG/5 GUAIFENESIN 100 MG/5ML 237 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


62011006001 HM CHEST CONGEST RLF 400 MG TB GUAIFENESIN 400 MG 50 x x30142010730 KRO MUCUS RELIEF 400 MG TABLET GUAIFENESIN 400 MG 30 x x00363053201 MUCUS RELIEF 400 MG TABLET GUAIFENESIN 400 MG 30 x x00363053211 MUCUS RELIEF 400 MG TABLET GUAIFENESIN 400 MG 60 x x00904623246 MUCUS RELIEF 400 MG TABLET GUAIFENESIN 400 MG 30 x x49348072909 SM CHEST CONGESTION RELIEF CAP GUAIFENESIN 400 MG 50 x x00363049860 MUCUS RELIEF ER 600 MG TABLET GUAIFENESIN 600 MG 20 x x10939032244 SM MUCUS ER 600 MG TABLET GUAIFENESIN 600 MG 20 x x

ANTIHISTAMINE/DECONGESTANT COMBINATIONS59779017662 CVS ALLERGY RELIEF‐D TABLET CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG‐120MG 24 x x00363092962 WAL‐ZYR D TABLET CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG‐120MG 24 x x00113017662 ALL DAY ALLERGY‐D TABLET CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG‐120MG 24 x x00113217662 ALL DAY ALLERGY‐D TABLET CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG‐120MG 24 x x45802072153 CETIRIZINE‐PSE ER 5‐120 MG TAB CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG‐120MG 12 x x45802072162 CETIRIZINE‐PSE ER 5‐120 MG TAB CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG‐120MG 24 x x24385017562 GNP ALL DAY ALLERGY‐D TABLET CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG‐120MG 24 x x62011005501 HM ALLERGY COMPLETE‐D TABLET CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG‐120MG 24 x x49348085104 SM ALL DAY ALLERGY‐D TABLET CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG‐120MG 24 x x00363057708 WAL‐ZYR D TABLET CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG‐120MG 24 x x51660072415 ALLERGY RELIEF‐NASAL DECONG TB LORATADINE/PSEUDOEPHEDRINE 10MG‐240MG 15 x x51660072469 ALLERGY RELIEF‐NASAL DECONG TB LORATADINE/PSEUDOEPHEDRINE 10MG‐240MG 10 x x62011007101 HM ALLERGY RLF‐NASAL DECONG TB LORATADINE/PSEUDOEPHEDRINE 10MG‐240MG 10 x x00904583315 LORATADINE‐D 24HR TABLET LORATADINE/PSEUDOEPHEDRINE 10MG‐240MG 10 x x00904583348 LORATADINE‐D 24HR TABLET LORATADINE/PSEUDOEPHEDRINE 10MG‐240MG 15 x x49348054301 SM LORATA‐DINE D 24HR TABLET LORATADINE/PSEUDOEPHEDRINE 10MG‐240MG 10 x x49348054357 SM LORATA‐DINE D 24HR TABLET LORATADINE/PSEUDOEPHEDRINE 10MG‐240MG 15 x x00363016513 WAL‐ITIN D 24 HOUR TABLET LORATADINE/PSEUDOEPHEDRINE 10MG‐240MG 5 x x00363016522 WAL‐ITIN D 24 HOUR TABLET LORATADINE/PSEUDOEPHEDRINE 10MG‐240MG 15 x x00363072415 WAL‐ITIN D 24 HOUR TABLET LORATADINE/PSEUDOEPHEDRINE 10MG‐240MG 15 x x00363072569 WAL‐ITIN D 24 HOUR TABLET LORATADINE/PSEUDOEPHEDRINE 10MG‐240MG 10 x x59779001360 CVS ALLERGY RELIEF‐D12 TABLET LORATADINE/PSEUDOEPHEDRINE 5 MG‐120MG 20 x x62011012001 HM ALLERGY‐CONGESTION 12HR TAB LORATADINE/PSEUDOEPHEDRINE 5 MG‐120MG 20 x x46122010952 LORATADINE‐D 12 HOUR TABLET LORATADINE/PSEUDOEPHEDRINE 5 MG‐120MG 10 x x49348018347 SM LORATADINE D 12 HOUR TABLET LORATADINE/PSEUDOEPHEDRINE 5 MG‐120MG 20 x x00363001339 WAL‐ITIN D 12 HOUR TABLET LORATADINE/PSEUDOEPHEDRINE 5 MG‐120MG 30 x x00363061752 WAL‐ITIN D 12 HOUR TABLET LORATADINE/PSEUDOEPHEDRINE 5 MG‐120MG 10 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


COUGH/COLD COMBINATIONS00363035926 ADULT WAL‐TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x00363035934 ADULT WAL‐TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 237 x x00363057826 ADULT WAL‐TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x00363057834 ADULT WAL‐TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 237 x x00536097097 COUGH SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x61787006204 DIABETIC TUSSIN DM LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x49035035926 EQ TUSSIN DM COUGH‐CHEST SYR GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x49035035934 EQ TUSSIN DM COUGH‐CHEST SYR GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 237 x x58657050508 GUAIFENESIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 237 x x62011009201 HM ADT TUSSIN COUGH CONG DM LQ GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x62011009101 HM ADULT TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x62011009102 HM ADULT TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 237 x x11822317370 RA TUSSIN COUGH LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x11822333230 RA TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x00904646420 ROBAFEN DM CGH‐CHEST CONG SYRP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x00904630620 ROBAFEN DM COUGH LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x00904005300 ROBAFEN‐DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x00904005309 ROBAFEN‐DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 237 x x53076011112 SAFETUSSIN DM LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 120 x x54838020940 SILTUSSIN DM COUGH SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x54838020970 SILTUSSIN DM COUGH SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 237 x x54838013340 SILTUSSIN DM DAS LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x49348001734 SM TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x49348001737 SM TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 237 x x49348086134 SM TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x49348086137 SM TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 237 x x00113057826 TUSSIN DM CLEAR LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x24385057826 TUSSIN DM CLEAR SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x00113035934 TUSSIN DM COUGH & CHEST LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 237 x x00113035926 TUSSIN DM COUGH SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 120 x x36800035926 TUSSIN DM LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x36800035934 TUSSIN DM LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 237 x x24385035926 TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 118 x x24385035934 TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100‐10MG/5 237 x x36800079926 TUSSIN DM MAX LIQUID GUAIFENESIN/DEXTROMETHORPHAN 200‐10MG/5 118 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


46122001734 TUSSIN DM MAX LIQUID GUAIFENESIN/DEXTROMETHORPHAN 200‐10MG/5 237 x x

GASTROINTESTINAL PRODUCTS

LAXATIVES‐ SALINE50428214916 CVS MILK OF MAGNESIA SUSP MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x50428305623 CVS MILK OF MAGNESIA SUSP MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x50428308240 CVS MILK OF MAGNESIA SUSP MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x62011012301 HM MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x00363192112 MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x00363193112 MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x00536247083 MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x00904078814 MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x11917011505 MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x37205083340 MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x12843035302 PHILLIPS' MILK OF MAGNESIA MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x12843039324 PHILLIPS' MILK OF MAGNESIA MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x11822039940 RA MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x00132000655 FLEET PEDIA‐LAX TABLET CHEW MAGNESIUM HYDROXIDE 400MG(170) 30 x x00132065501 FLEET PEDIA‐LAX TABLET CHEW MAGNESIUM HYDROXIDE 400MG(170) 30 x x

LAXATIVES‐ BOWEL EVACUANTS62011027101 HM ENEMA READY TO USE NA PHOS,M‐B/NA PHOS,DI‐BA 19G‐7G/118 133 x x00132020220 FLEET PEDIA‐LAX ENEMA NA PHOS,M‐B/NA PHOS,DI‐BA 9.5‐3.5/59 66 x x36800030601 CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 119 x x36800030602 CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 238 x x62011028701 HM CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 238 x x62011028702 HM CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 510 x x37205061271 CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 119 x x37205061272 CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 238 x x37205061273 CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 510 x x46122001431 CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 119 x x46122001433 CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 238 x x46122001471 CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 510 x x49035030603 EQ CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 510 x x43386031208 GAVILAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 238 x x43386031214 GAVILAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 510 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


30142030603 GENTLELAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 510 x x62175019015 GLYCOLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 255 x x62175019031 GLYCOLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 527 x x62011015301 HM CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 510 x x62011015302 HM CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 238 x x62011015304 HM CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 119 x x30142030602 KRO GENTLELAX 17 GRAM POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 238 x x00536105224 PEG3350 POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 238 x x00536105227 PEG3350 POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 510 x x00904602576 POLYETHYLENE GLYCOL 3350 POWD POLYETHYLENE GLYCOL 3350 17G/DOSE 510 x x45802086801 POLYETHYLENE GLYCOL 3350 POWD POLYETHYLENE GLYCOL 3350 17G/DOSE 119 x x45802086802 POLYETHYLENE GLYCOL 3350 POWD POLYETHYLENE GLYCOL 3350 17G/DOSE 238 x x45802086803 POLYETHYLENE GLYCOL 3350 POWD POLYETHYLENE GLYCOL 3350 17G/DOSE 510 x x57896048914 POLYETHYLENE GLYCOL 3350 POWD POLYETHYLENE GLYCOL 3350 17G/DOSE 238 x x57896048930 POLYETHYLENE GLYCOL 3350 POWD POLYETHYLENE GLYCOL 3350 17G/DOSE 510 x x11822353540 RA LAXATIVE PEG 3350 POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 510 x x11822393550 RA LAXATIVE PEG 3350 POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 238 x x11822393560 RA LAXATIVE PEG 3350 POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 119 x x49348014370 SM CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 238 x x49348089392 SM CLEARLAX POWDER POLYETHYLENE GLYCOL 3350 17G/DOSE 510 x x

LAXATIVES‐ STIMULANT/IRRITANT00574705012 BISACODYL 10 MG SUPPOSITORY BISACODYL 10 MG 12 x x00904505812 BISCOLAX 10 MG SUPPOSITORY BISACODYL 10 MG 12 x x50428166371 CVS BISACODYL 10 MG SUPPOS BISACODYL 10 MG 8 x x50428690111 CVS GENTLE LAXATIVE 10 MG SUPP BISACODYL 10 MG 16 x x00363010908 GENTLE LAXATIVE 10 MG SUPPOSIT BISACODYL 10 MG 8 x x11917011593 GENTLE LAXATIVE 10 MG SUPPOSIT BISACODYL 10 MG 8 x x11917014449 GENTLE LAXATIVE 10 MG SUPPOSIT BISACODYL 10 MG 8 x x11822489250 RA FAST RELIEF LAX 10 MG SUPP BISACODYL 10 MG 8 x x00132070336 FLEET BISACODYL 10 MG ENEMA BISACODYL 10MG/30ML 37 x x10135015461 BISACODYL EC 5 MG TABLET BISACODYL 5 MG 10 x x37205012863 BISACODYL EC 5 MG TABLET BISACODYL 5 MG 25 x x50428317857 CVS GENTLE LAXATIVE EC 5 MG TB BISACODYL 5 MG 10 x x00363032756 GENTLE LAXATIVE EC 5 MG TABLET BISACODYL 5 MG 25 x x00121072208 SENNA SYRUP SENNA LEAF EXTRACT 176MG/5ML 237 x x49035089212 EQ NATURAL LAXATIVE 8.6 MG TAB SENNOSIDES 8.6 MG 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


62011028901 HM SENNA 8.6 MG TABLET SENNOSIDES 8.6 MG 100 x x00904652261 SENNA‐LAX 8.6 MG TABLET SENNOSIDES 8.6 MG 100 x x67618030050 SENOKOT 8.6 MG TABLET SENNOSIDES 8.6 MG 50 x x57896045208 SENNA 8.8 MG/5 ML SYRUP SENNOSIDES 8.8MG/5ML 237 x x54162000708 SENNA 8.8 MG/5 ML SYRUP GRX SENNOSIDES 8.8MG/5ML 236 x x

LAXATIVES‐ BULK PRODUCING00135008971 CITRUCEL POWDER METHYLCELLULOSE (WITH SUGAR) 850 x x00904520065 NATURAL FIBER LAX POWDER PSYLLIUM SEED (WITH SUGAR) 368 x x86790021620 BENEFIBER POWDER WHEAT DEXTRIN 3G/4G 248 x x

LAXATIVES‐ EMOLLIENTS00132030140 FLEET MINERAL OIL ENEMA MINERAL OIL 133 x x

LAXATIVES‐ HYPEROSMOTIC AGENTS00132019012 FLEET PEDIA‐LAX SUPPOSITORIES GLYCERIN 2.8G/2.7ML 4 x x00132018582 FLEET GLYCERIN LIQUID SUPP GLYCERIN 5.4G/5.4ML 7.5 x x00132007924 FLEET GLYCERIN 2 GM ADULT SUPP GLYCERIN ADULT 24 x x00132007912 FLEET GLYCERIN ADULT SUPPOS GLYCERIN ADULT 12 x x50428070109 CVS GLYCERIN SUPPOSITORY GLYCERIN PEDIATRIC 25 x x00132008112 FLEET PEDIA‐LAX SUPPOSITORIES GLYCERIN PEDIATRIC 12 x x58980040912 GLYCERIN PEDIATRIC SUPPOSITORY GLYCERIN PEDIATRIC 12 x x11917011514 GLYCERIN SUPPOSITORY GLYCERIN PEDIATRIC 12 x x46122022263 GLYCERIN SUPPOSITORY GLYCERIN PEDIATRIC 25 x x11917013296 INFANT & CHILD GLYCERIN SUPPOS GLYCERIN PEDIATRIC 12 x x11822332180 RA GLYCERIN PEDIATRIC SUPP GLYCERIN PEDIATRIC 25 x x

STOOL SOFTENERS‐ DOCUSATE CALCIUM00904645959 KAO‐TIN 240 MG SOFTGEL DOCUSATE CALCIUM 240 MG 100 x x00536106501 STOOL SOFTENER 240 MG SOFTGEL DOCUSATE CALCIUM 240 MG 100 x x

STOOL SOFTENERS‐ DOCUSATE SODIUM50428310425 CVS STOOL SOFTENER 100 MG CAP DOCUSATE SODIUM 100 MG 100 x x50428488021 CVS STOOL SOFTENER 100 MG SFTG DOCUSATE SODIUM 100 MG 30 x x00603015021 DOC‐Q‐LACE 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x57896040101 DOCUSATE SODIUM 100 MG CAPSULE DOCUSATE SODIUM 100 MG 100 x x63739047810 DOCUSATE SODIUM 100 MG CAPSULE DOCUSATE SODIUM 100 MG 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


45802048678 DOCUSATE SODIUM 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x54629060001 DOCUSATE SODIUM 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x57896040103 DOCUSATE SODIUM 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 30 x x37864000021 DOCUSATE SODIUM 100 MG TABLET DOCUSATE SODIUM 100 MG 100 x x62107003301 DOCUSIL 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x00904645561 DOK 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x00904645760 DOK 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x00904586960 DOK 100 MG TABLET DOCUSATE SODIUM 100 MG 100 x x52569013768 HM STOOL SOFTENER 100 MG SFTGL DOCUSATE SODIUM 100 MG 100 x x62011022401 HM STOOL SOFTENER 100 MG SFTGL DOCUSATE SODIUM 100 MG 100 x x11822512670 RA STOOL SOFTENER 100 MG CAP DOCUSATE SODIUM 100 MG 50 x x00113048672 STOOL SOFTENER 100 MG CAPSULE DOCUSATE SODIUM 100 MG 60 x x00536106229 STOOL SOFTENER 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x24385043678 STOOL SOFTENER 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x36800048672 STOOL SOFTENER 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 60 x x46122023172 STOOL SOFTENER 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x46122023178 STOOL SOFTENER 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 60 x x00536106401 STOOL SOFTENER 250 MG SOFTGEL DOCUSATE SODIUM 250 MG 100 x x17433987805 DOCUSOL MINI‐ENEMA DOCUSATE SODIUM 283 MG 5 x x17433987603 ENEMEEZ MINI ENEMA DOCUSATE SODIUM 283 MG/5ML 5 x x00132000106 FLEET PEDIA‐LAX STOOL SOFTENER DOCUSATE SODIUM 50 MG/15ML 118 x x00132010624 FLEET PEDIA‐LAX STOOL SOFTENER DOCUSATE SODIUM 50 MG/15ML 118 x x57896040316 DIOCTO 50 MG/5 ML LIQUID DOCUSATE SODIUM 50 MG/5 ML 473 x x50383077116 DOCU LIQUID 50 MG/5 ML DOCUSATE SODIUM 50 MG/5 ML 473 x x54838011680 SILACE 50 MG/5 ML LIQUID DOCUSATE SODIUM 50 MG/5 ML 473 x x00536100185 DIOCTO 60 MG/15 ML SYRUP DOCUSATE SODIUM 60 MG/15ML 473 x x57896040916 DIOCTO 60 MG/15 ML SYRUP DOCUSATE SODIUM 60 MG/15ML 473 x x54838010780 SILACE 60 MG/15 ML SYRUP DOCUSATE SODIUM 60 MG/15ML 473 x x

ANTI‐DIARRHEALS50383061804 LOPERAMIDE 1 MG/5 ML LIQUID LOPERAMIDE HCL 1 MG/5 ML 118 x x49035064526 EQ LOPERAMIDE 1 MG/7.5 ML SUSP LOPERAMIDE HCL 1MG/7.5ML 118 x x52569013549 HM LOPERAMIDE 1 MG/7.5 ML LIQ LOPERAMIDE HCL 1MG/7.5ML 120 x x62011038501 HM LOPERAMIDE 1 MG/7.5 ML LIQ LOPERAMIDE HCL 1MG/7.5ML 120 x x70677005401 SM ANTI‐DIARRHEAL 1 MG/7.5 ML LIQ LOPERAMIDE HCL 1MG/7.5ML 120 x x46122011126 LOPERAMIDE 1 MG/7.5 ML LIQUID LOPERAMIDE HCL 1MG/7.5ML 120 x x00113064526 LOPERAMIDE 1 MG/7.5 ML SUSP LOPERAMIDE HCL 1MG/7.5ML 120 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00363064526 LOPERAMIDE 1 MG/7.5 ML SUSP LOPERAMIDE HCL 1MG/7.5ML 120 x x00904625620 LOPERAMIDE 1 MG/7.5 ML SUSP LOPERAMIDE HCL 1MG/7.5ML 120 x x11822440980 RA LOPERAMIDE 1 MG/7.5 ML SUSP LOPERAMIDE HCL 1MG/7.5ML 120 x x49348099934 SM LOPERAMIDE 1 MG/7.5 ML LIQ LOPERAMIDE HCL 1MG/7.5ML 120 x x00113022453 ANTI‐DIARRHEAL 2 MG CAPLET LOPERAMIDE HCL 2 MG 12 x x00363037502 ANTI‐DIARRHEAL 2 MG CAPLET LOPERAMIDE HCL 2 MG 12 x x00363037508 ANTI‐DIARRHEAL 2 MG CAPLET LOPERAMIDE HCL 2 MG 24 x x00904772512 ANTI‐DIARRHEAL 2 MG CAPLET LOPERAMIDE HCL 2 MG 12 x x00904772524 ANTI‐DIARRHEAL 2 MG CAPLET LOPERAMIDE HCL 2 MG 24 x x37205037053 ANTI‐DIARRHEAL 2 MG CAPLET LOPERAMIDE HCL 2 MG 12 x x51660012312 ANTI‐DIARRHEAL 2 MG CAPLET LOPERAMIDE HCL 2 MG 12 x x50428232907 CVS ANTI‐DIARRHEAL 2 MG CAPLET LOPERAMIDE HCL 2 MG 24 x x62011015001 HM ANTI‐DIARRHEAL 2 MG CAPLET LOPERAMIDE HCL 2 MG 12 x x62011015002 HM ANTI‐DIARRHEAL 2 MG CAPLET LOPERAMIDE HCL 2 MG 24 x x

PROBIOTICS37000014343 ALIGN 4 MG CAPSULE BIFIDOBACTERIUM INFANTIS 4 MG 28 x x39423044048 FLORAJEN3 CAPSULE L ACIDOPHIL/B LACTIS/B LONGUM 460 MG 30 x x39423066048 FLORAJEN3 CAPSULE L ACIDOPHIL/B LACTIS/B LONGUM 460 MG 60 x x64980012950 FLORANEX TABLET L. acidophilus/L.bulgaricus 50 x x8290236712 BD LACTINEX L. ACIDOPHILUS/L.BULGARICUS 100MM CELL 12 x x64980014612 FLORANEX GRANULES PACKET L. ACIDOPHILUS/L.BULGARICUS 100MM CELL 12 x x8290236850 LACTINEX CHEWABLE TABLET L. ACIDOPHILUS/L.BULGARICUS 1MM CELL 50 x x64980014703 RISAQUAD CAPSULES L. ACIDOPHILUS/STREPT/LA P‐CAS 8B CELL 30 x x2359046015 BIOGAIA PROTECTIS DROPS L. REUTERI/VITAMIN D3 100MM‐400 10 x x49100040009 CULTURELLE CAPSULE L. RHAMNOSUS GG/INULIN 10B‐200 MG 30 x x49100040021 CULTURELLE CAPSULE L. RHAMNOSUS GG/INULIN 10B‐200 MG 50 x x49100040022 CULTURELLE CHEWABLE TABLET L. RHAMNOSUS GG/INULIN 10B‐200 MG 24 x x49100036404 CULTURELLE HLTH & WELLNESS CAP L. RHAMNOSUS GG/INULIN 10B‐200 MG 30 x x39423088048 FLORAJEN4KIDS CAPSULE L.ACID/L.RHAM/B.LAC BI07/B.LAC 300 MG 30 x x45749001781 VSL#3 CAPSULE LACTOBAC #2‐S. THERM‐BIFIDO #1 900B CELL 60 x x45749001782 VSL#3 DS PACKET LACTOBAC #2‐S. THERM‐BIFIDO #1 900B CELL 20 x x50000093560 GERBER SOOTHE COLIC DROPS LACTOBACILLUS REUTERI 10 x x49100036374 CULTURELLE HLTH & WELLNESS CAP LACTOBACILLUS RHAMNOSUS GG 15B CELL 30 x x49100040015 CULTURELLE KIDS CHEWABLE TAB LACTOBACILLUS RHAMNOSUS GG 5B CELL 30 x x49100040008 CULTURELLE KIDS PACKET LACTOBACILLUS RHAMNOSUS GG 5B CELL 30 x x49100040037 CULTURELLE KIDS GENTLE‐GO PCKT LACTOBACILLUS RHAMNOSUS/FIBER 24 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


4142000024 FLORASTOR 250 MG CAPSULE SACCHAROMYCES BOULARDII 250 MG 20 x x04142000040 FLORASTOR 250 MG PACKET SACCHAROMYCES BOULARDII 250 MG 20 x x

ANTACIDS00363031734 ANTACID 500 MG CHEW TABLET CALCIUM CARBONATE 200(500)MG 150 x x00904641292 CALCIUM ANTACID 500 MG CHW TAB CALCIUM CARBONATE 200(500)MG 150 x x37205053040 ANTACID‐ANTIGAS LIQUID MAG HYDROX/ALUMINIUM HYD/SIMETH 355 x x87701040778 GNP MAGNESIUM 250 MG TABLET MAGNESIUM OXIDE 250 MG 100 x x7610028320 MAGNESIUM OXIDE 250 MG CAPLET MAGNESIUM OXIDE 250 MG 100 x x40985022713 MAGNESIUM OXIDE 250 MG TABLET MAGNESIUM OXIDE 250 MG 110 x x43292055738 MAGNESIUM OXIDE 250 MG TABLET MAGNESIUM OXIDE 250 MG 100 x x00603020922 MAGNESIUM OXIDE 400 MG TABLET MAGNESIUM OXIDE 400 MG 120 x x51645078508 MAGNESIUM OXIDE 400 MG TABLET MAGNESIUM OXIDE 400 MG 120 x x00223172001 SODIUM BICARB 325 MG TABLET SODIUM BICARBONATE 325 MG 100 x x00223172101 SODIUM BICARB 650 MG TABLET SODIUM BICARBONATE 650 MG 100 x x

H2 ANTAGONISTS00093274865 FAMOTIDINE 10 MG TABLET FAMOTIDINE 10 MG 30 x x50428695189 CVS RANITIDINE 75 MG TABLET RANITIDINE HCL 75 MG 30 x x00363027139 WAL‐ZAN 75 MG TABLET RANITIDINE HCL 75 MG 30 x x

ANTIEMETIC/ANTIVERTIGO AGENTS31248000301 DRAMAMINE 25 MG TABLET CHEW DIMENHYDRINATE 25 MG 8 x x00363040421 MOTION SICKNESS RELIEF TB CHEW MECLIZINE HCL 25 MG 16 x x00536101801 TRAVEL SICKNESS 25 MG TAB CHEW MECLIZINE HCL 25 MG 100 x x

LACTASE ENZYME00904522452 LACTASE 3,000 UNIT CAPLET LACTASE 3000 UNIT 60 x x00450091060 LACTAID FAST ACT 9,000 UNIT LACTASE 9000 UNIT 60 x x

ANTIFLATULENTS49348074027 SM INF GAS RELIEF 20 MG/0.3 ML SIMETHICONE 20MG/0.3ML 30 x x50428511386 CVS GAS RELIEF EX‐STR DROPS SIMETHICONE 40MG/0.6ML 30 x x00536222075 GAS RELIEF 20 MG/0.3 ML DROPS SIMETHICONE 40MG/0.6ML 30 x x00904589430 INF GAS REL 20 MG/0.3 ML DROP SIMETHICONE 40MG/0.6ML 30 x x

TOPICAL AGENTS




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


TOPICALS‐ ANTIFUNGALS (INTRA‐VAGINAL)51672200306 CLOTRIM 1% VAGINAL CREAM CLOTRIMAZOLE 1 % 45 x x00472022041 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 45 x x00472022063 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 45 x x49022008436 CLOTRIMAZOLE‐7 CREAM CLOTRIMAZOLE 1 % 45 x x49348079376 SM CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 45 x x51672206200 3‐DAY VAGINAL CREAM CLOTRIMAZOLE 2 % 21 x x11917003586 CLOTRIMAZOLE 3 2% CREAM CLOTRIMAZOLE 2 % 21 x x11917007847 CLOTRIMAZOLE 3 2% CREAM CLOTRIMAZOLE 2 % 21 x x49035073007 EQ MICONAZOLE NITRATE 2% CRM MICONAZOLE NITRATE 2 % 45 x x30142082529 KRO MICONAZOLE 7 CREAM MICONAZOLE NITRATE 2 % 45 x x00113021429 MICONAZOLE 7 CREAM MICONAZOLE NITRATE 2 % 45 x x00904773445 MICONAZOLE 7 CREAM MICONAZOLE NITRATE 2 % 45 x x24385059029 MICONAZOLE 7 CREAM MICONAZOLE NITRATE 2 % 45 x x49022008444 MICONAZOLE 7 CREAM MICONAZOLE NITRATE 2 % 45 x x00472073041 MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE 2 % 45 x x00472073063 MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE 2 % 45 x x51672203506 MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE 2 % 45 x x11822382270 RA MICONAZOLE 7 CREAM MICONAZOLE NITRATE 2 % 45 x x49348053077 SM MICONAZOLE 7 CREAM MICONAZOLE NITRATE 2 % 45 x x49348087277 SM MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE 2 % 45 x x30142008100 KRO MICONAZOLE 3 COMBO PACK MICONAZOLE NITRATE 200 MG‐2 % 1 x x00113008100 MICONAZOLE 3 COMBO PACK MICONAZOLE NITRATE 200 MG‐2 % 1 x x00904541501 MICONAZOLE 3 COMBO PACK MICONAZOLE NITRATE 200 MG‐2 % 1 x x24385060602 MICONAZOLE 3 COMBO PACK MICONAZOLE NITRATE 200 MG‐2 % 1 x x49348035543 SM MICONAZOLE 3 COMBO PACK MICONAZOLE NITRATE 200 MG‐2 % 1 x x

TOPICALS‐ ANTIFUNGALS24385020501 ANTIFUNGAL 1% CREAM CLOTRIMAZOLE 1 % 15 x x24385020503 ANTIFUNGAL 1% CREAM CLOTRIMAZOLE 1 % 30 x x32953009907 ATHLETE'S FOOT 1% CREAM CLOTRIMAZOLE 1 % 35.4 x x00179801430 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 28.4 x x00904782231 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 28.35 x x00904782236 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 14.17 x x11673091012 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 30 x x11822471250 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 14 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


11917005426 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 30 x x11917005427 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 15 x x11917012991 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 28 x x11917012992 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 14 x x37205076010 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 28 x x45802043401 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 15 x x45802043411 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 30 x x51672200201 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 15 x x51672200202 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 30 x x51672203701 CLOTRIMAZOLE 1% SOLUTION CLOTRIMAZOLE 1 % 10 x x49035012307 EQ JOCK ITCH 1% CREAM CLOTRIMAZOLE 1 % 15 x x00085096315 LOTRIMIN AF 1% CREAM CLOTRIMAZOLE 1 % 12 x x00085096317 LOTRIMIN AF 1% CREAM CLOTRIMAZOLE 1 % 24 x x11822307820 RA CLOTRIMAZOLE AF 1% CREAM CLOTRIMAZOLE 1 % 28 x x11822039260 RA JOCK ITCH CREAM CLOTRIMAZOLE 1 % 14 x x49348027972 SM ANTIFUNGAL 1% CREAM CLOTRIMAZOLE 1 % 30 x x00472073514 ANTIFUNGAL 2% CREAM MICONAZOLE NITRATE 2 % 14 x x00472073542 ANTIFUNGAL 2% CREAM MICONAZOLE NITRATE 2 % 42.5 x x00472073556 ANTIFUNGAL 2% CREAM MICONAZOLE NITRATE 2 % 28 x x00067094930 DESENEX 2% POWDER MICONAZOLE NITRATE 2 % 85 x x11017041031 LOTRIMIN AF 2% SPRAY POWDER MICONAZOLE NITRATE 2 % 133 x x65197010305 MICATIN 2% ANTIFUNGAL CREAM MICONAZOLE NITRATE 2 % 14 x x51672200101 MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE 2 % 15 x x51672200102 MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE 2 % 30 x x11701003816 MICRO‐GUARD 2% POWDER MICONAZOLE NITRATE 2 % 85 x x49348068972 SM MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE 2 % 30 x x11086004002 TRIPLE PASTE AF 2% OINTMENT MICONAZOLE NITRATE 2 % 56.7 x x51672208001 TERBINAFINE 1% CREAM TERBINAFINE HCL 1 % 15 x x51672208002 TERBINAFINE 1% CREAM TERBINAFINE HCL 1 % 30 x x

TOPICALS‐ ANTI‐INFECTIVES00713028031 BACITRACIN 500 UNIT/GM OINTMNT BACITRACIN 500 UNIT/G 28.4 x x45802006001 BACITRACIN 500 UNIT/GM OINTMNT BACITRACIN 500 UNIT/G 14 x x45802006003 BACITRACIN 500 UNIT/GM OINTMNT BACITRACIN 500 UNIT/G 28 x x14428000003 BACITRAYCIN PLUS 500 UNIT/GM BACITRACIN 500 UNIT/G 28 x x00472110534 BACITRACIN ZN 500 UNIT/GM OINT BACITRACIN ZINC 500 UNIT/G 14 x x00472110556 BACITRACIN ZN 500 UNIT/GM OINT BACITRACIN ZINC 500 UNIT/G 28 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


11917011354 BACITRACIN ZN 500 UNIT/GM OINT BACITRACIN ZINC 500 UNIT/G 28.4 x x11917016394 BACITRACIN ZN 500 UNIT/GM OINT BACITRACIN ZINC 500 UNIT/G 28 x x24385006003 BACITRACIN ZN 500 UNIT/GM OINT BACITRACIN ZINC 500 UNIT/G 28.4 x x51672207502 BACITRACIN ZN 500 UNIT/GM OINT BACITRACIN ZINC 500 UNIT/G 28.4 x x62011009401 HM BACITRACIN ZN 500 UNIT/GM BACITRACIN ZINC 500 UNIT/G 28.4 x x50428322436 CVS ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5‐400‐5K 14 x x62011009801 HM TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5‐400‐5K 28.4 x x30142006764 KRO TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5‐400‐5K 28 x x00113006764 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5‐400‐5K 28 x x00472017934 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5‐400‐5K 14.2 x x00472017956 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5‐400‐5K 28 x x00713026831 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5‐400‐5K 28.4 x x11917005095 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5‐400‐5K 14 x x11917005491 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5‐400‐5K 28.4 x x11917009752 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5‐400‐5K 14 x x11917016407 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5‐400‐5K 28 x x37205027310 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5‐400‐5K 30 x x

TOPICALS‐ ANTISEPTICS00234057508 HIBICLENS 4% LIQUID CHLORHEXIDINE GLUCONATE 4 % 236 x x00904110231 POVIDONE‐IODINE 10% OINTMENT POVIDONE‐IODINE 10 % 28.35 x x00904110309 POVIDONE‐IODINE 10% SOLUTION POVIDONE‐IODINE 10 % 240 x x11917013266 POVIDONE‐IODINE 10% SOLUTION POVIDONE‐IODINE 10 % 236 x x00436067216 DAKIN'S 0.125% SOLUTION SODIUM HYPOCHLORITE 0.125 % 473 x x00436093616 DAKIN'S 0.25% SOLUTION SODIUM HYPOCHLORITE 0.25 % 473 x x

TOPICALS‐ ACNE PREPARATIONS49022067498 ACNE FOAMING 10% WASH BENZOYL PEROXIDE 10 % 156 x x00536105656 ACNE MEDICATION 10% GEL BENZOYL PEROXIDE 10 % 42.5 x x45802030896 BENZOYL PEROXIDE 10% GEL BENZOYL PEROXIDE 10 % 60 x x10939018611 BENZOYL PEROXIDE 10% LOTION BENZOYL PEROXIDE 10 % 30 x x45802031801 BENZOYL PEROXIDE 10% WASH BENZOYL PEROXIDE 10 % 142 x x45802031834 BENZOYL PEROXIDE 10% WASH BENZOYL PEROXIDE 10 % 227 x x67405083005 BENZOYL PEROXIDE 10% WASH BENZOYL PEROXIDE 10 % 148 x x67405083008 BENZOYL PEROXIDE 10% WASH BENZOYL PEROXIDE 10 % 237 x x24470091060 BP 10% GEL BENZOYL PEROXIDE 10 % 60 x x24470090105 BP WASH 10% LIQUID BENZOYL PEROXIDE 10 % 142 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


50428216549 CVS ACNE 10% CREAM BENZOYL PEROXIDE 10 % 30 x x50428045366 CVS FOAMING ACNE FACE 10% WASH BENZOYL PEROXIDE 10 % 187 x x00145098505 PANOXYL 10% ACNE FOAMING WASH BENZOYL PEROXIDE 10 % 156 x x45802010196 BENZOYL PEROXIDE 2.5% GEL BENZOYL PEROXIDE 2.5 % 60 x x70501001790 ON‐THE‐SPOT 2.5% ACNE CREAM BENZOYL PEROXIDE 2.5 % 21 x x00536105556 ACNE MEDICATION 5% GEL BENZOYL PEROXIDE 5 % 42.5 x x00536105775 ACNE MEDICATION 5% LOTION BENZOYL PEROXIDE 5 % 29.5 x x45802021601 BENZOYL PEROXIDE 5% GEL BENZOYL PEROXIDE 5 % 90 x x45802021696 BENZOYL PEROXIDE 5% GEL BENZOYL PEROXIDE 5 % 60 x x67405082505 BENZOYL PEROXIDE 5% WASH BENZOYL PEROXIDE 5 % 148 x x67405082508 BENZOYL PEROXIDE 5% WASH BENZOYL PEROXIDE 5 % 237 x x24470090960 BP 5% GEL BENZOYL PEROXIDE 5 % 60 x x24470090004 BP WASH 5% LIQUID BENZOYL PEROXIDE 5 % 113 x x

TOPICALS‐ ACNE‐ ADAPALENE00299491015 DIFFERIN 0.1% GEL ADAPALENE 15 x x00299491045 DIFFERIN 0.1% GEL ADAPALENE 45 x x

TOPICALS‐ CORTICOSTEROIDS00113054164 ANTI‐ITCH 1% CREAM HYDROCORTISONE 1 % 28 x x00113097364 ANTI‐ITCH 1% CREAM HYDROCORTISONE 1 % 28 x x41167000350 CORTIZONE‐10 1% CREME HYDROCORTISONE 1 % 28 x x41167000391 CORTIZONE‐10 1% CREME HYDROCORTISONE 1 % 28 x x41167001056 CORTIZONE‐10 PLUS 1% CREME HYDROCORTISONE 1 % 28 x x62011009501 HM HYDROCORTISONE 1% CREAM HYDROCORTISONE 1 % 28.4 x x62011009601 HM HYDROCORTISONE 1% CREAM HYDROCORTISONE 1 % 28.4 x x00168015431 HYDROCORTISONE 1% CREAM HYDROCORTISONE 1 % 28.35 x x00363036964 HYDROCORTISONE 1% CREAM HYDROCORTISONE 1 % 28 x x00472034356 HYDROCORTISONE 1% CREAM HYDROCORTISONE 1 % 28 x x11917004958 HYDROCORTISONE 1% CREAM HYDROCORTISONE 1 % 28.4 x x11917006655 HYDROCORTISONE 1% CREAM HYDROCORTISONE 1 % 28.4 x x24385002103 HYDROCORTISONE 1% CREAM HYDROCORTISONE 1 % 28.4 x x37205016210 HYDROCORTISONE 1% CREAM HYDROCORTISONE 1 % 30 x x45802043803 HYDROCORTISONE 1% CREAM HYDROCORTISONE 1 % 28 x x51672201301 HYDROCORTISONE 1% CREAM HYDROCORTISONE 1 % 14.2 x x51672206902 HYDROCORTISONE 1% CREAM HYDROCORTISONE 1 % 28.4 x x00168018131 HYDROCORTISONE 1% OINTMENT HYDROCORTISONE 1 % 28.35 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00472034556 HYDROCORTISONE 1% OINTMENT HYDROCORTISONE 1 % 28 x x11917006914 HYDROCORTISONE 1% OINTMENT HYDROCORTISONE 1 % 28.4 x x45802027603 HYDROCORTISONE 1% OINTMENT HYDROCORTISONE 1 % 28 x x51672201802 HYDROCORTISONE 1% OINTMENT HYDROCORTISONE 1 % 28.4 x x41415004775 PUB HYDROCREAM 1% HYDROCORTISONE 1 % 28.4 x x11822372390 RA ANTI‐ITCH 1% CREAM HYDROCORTISONE 1 % 28 x x11822314320 RA ANTI‐ITCH 1% OINTMENT HYDROCORTISONE 1 % 28 x x11822358780 RA HYDROCORTISONE 1% CREAM HYDROCORTISONE 1 % 28.4 x x49348052272 SM HYDROCORTISONE 1% OINTMENT HYDROCORTISONE 1 % 28.4 x x

TOPICALS‐ EMOLLIENTS00245002322 AMLACTIN 12% LOTION AMMONIUM LACTATE 12 % 225 x x45802051377 AMMONIUM LACTATE 12% CREAM AMMONIUM LACTATE 12 % 140 x x63044040420 AMMONIUM LACTATE 12% CREAM AMMONIUM LACTATE 12 % 140 x x00904598426 AMMONIUM LACTATE 12% LOTION AMMONIUM LACTATE 12 % 226 x x45802052555 AMMONIUM LACTATE 12% LOTION AMMONIUM LACTATE 12 % 227 x x00187137012 CERAVE MOISTURIZING CREAM CERAMIDES 1,3,6‐11 355 x x00187137112 CERAVE MOISTURIZING CREAM CERAMIDES 1,3,6‐11 355 x x00187137316 CERAVE MOISTURIZING CREAM CERAMIDES 1,3,6‐11 453 x x72140011015 EUCERIN INTENSIVE REPAIR LOT emollient combination no.72 250 x x10135010408 GLYCERIN LIQUID GLYCERIN 480 x x51552009404 GLYCERIN LIQUID GLYCERIN 100 % 100 x x00395103196 GLYCERIN 99.5% LIQUID GLYCERIN 99.5 % 177 x x37205001130 GLYCERIN 99.5% LIQUID GLYCERIN 99.5 % 177 x x00395103116 GLYCERIN SKIN PROTECTANT LIQ GLYCERIN 99.5 % 473 x x00904775127 MINERIN CREME MINERAL OIL/PETROLATUM,WHITE 454 x x37205006927 PETROLEUM JELLY PETROLATUM,WHITE 368 x x11917004964 PETROLEUM JELLY 100% PURE PETROLATUM,WHITE 368 x x11917004980 PETROLEUM JELLY 100% PURE PETROLATUM,WHITE 106 x x72140063608 AQUAPHOR 41% HEALING OINTMENT PETROLATUM,WHITE 41 % 396 x x72140003147 AQUAPHOR 41% ORIGINAL OINTMENT PETROLATUM,WHITE 41 % 396 x x54162050002 HYDROPHOR 42% OINTMENT PETROLATUM,WHITE 42 % 100 x x

TOPICALS‐ ANESTHETICS00113094424 HEMORRHOIDAL CREAM PHENYLEPH/PRAMOXIN/GLYCR/W.PET 0.25%‐1% 51 x x00037682315 PROCTOFOAM 1% FOAM PRAMOXINE HCL 1 % 15 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


TOPICALS‐ ASTRINGENTS16500002324 DOMEBORO PACKET CALCIUM ACETATE/ALUMINUM SULF 952‐1347MG 12 x x

TOPICALS‐ DRYING AGENTS00096070935 XERAC AC 6.25% SOLUTION ALUMINUM CHLORIDE 6.25% 35 x x00096070960 XERAC AC 6.25% SOLUTION ALUMINUM CHLORIDE 6.25% 60 x x

TOPICALS‐ COUNTERIRRITANTS00536252525 CAPSAICIN 0.025% CREAM CAPSAICIN 0.025 % 60 x x

TOPICALS‐ SKIN PROTECTANTS00799000102 CALMOSEPTINE OINTMENT MENTHOL/ZINC OXIDE 0.44‐20.6% 71 x x00799000104 CALMOSEPTINE OINTMENT MENTHOL/ZINC OXIDE 0.44‐20.6% 113 x x67492010511 RESINOL OINTMENT RESOR/CALA/ZNOX/PET,WH/LAN 2%‐55% 35.4 x x62103033302 BOUDREAUXS BUTT PASTE ZINC OXIDE 16 % 57 x x00168006231 ZINC OXIDE 20% OINTMENT ZINC OXIDE 20 % 28.35 x x

TOPICALS‐ PEDICULIDES62011025501 HM LICE TREATMENT 1% CRM RINSE PERMETHRIN 1 % 59 x x00363095526 LICE TREATMENT 1% CREME RINSE PERMETHRIN 1 % 59 x x46122010846 LICE TREATMENT 1% CREME RINSE PERMETHRIN 1 % 59 x x49781002802 LICE TREATMENT 1% CREME RINSE PERMETHRIN 1 % 59 x x63736012002 NIX 1% CREME RINSE LIQUID PERMETHRIN 1 % 59 x x63736012003 NIX 1% CREME RINSE LIQUID PERMETHRIN 1 % 59 x x11822985580 RA LICE TREATMENT 1% CRM RINSE PERMETHRIN 1 % 59 x x49348015078 SM LICE TREATMENT 1% CRM RINSE PERMETHRIN 1 % 59 x x

NICOTINE REPLACEMENT PRODUCTS

NICOTINE REPLACEMENT‐ TRANSDERMAL49035019502 EQ NICOTINE 14 MG/24HR PATCH NICOTINE 14MG/24HR 14 x x62011017201 HM NICOTINE 14 MG/24HR PATCH NICOTINE 14MG/24HR 14 x x59450000274 KRO NICOTINE 14 MG/24HR PATCH NICOTINE 14MG/24HR 14 x x00363089588 NICOTINE 14 MG/24 HR PATCH NICOTINE 14MG/24HR 14 x x00536110788 NICOTINE 14 MG/24HR PATCH NICOTINE 14MG/24HR 14 x x00536589588 NICOTINE 14 MG/24HR PATCH NICOTINE 14MG/24HR 14 x x43598044770 NICOTINE 14 MG/24HR PATCH NICOTINE 14MG/24HR 7 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


43598044774 NICOTINE 14 MG/24HR PATCH NICOTINE 14MG/24HR 14 x x11822222600 RA NICOTINE 14 MG/24HR PATCH NICOTINE 14MG/24HR 14 x x49035019401 EQ NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 7 x x49035019402 EQ NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 14 x x62011017301 HM NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 14 x x59450000374 KRO NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 14 x x00766142020 NICODERM CQ 21 MG/24HR PATCH NICOTINE 21 MG/24HR 14 x x00766145020 NICODERM CQ 21 MG/24HR PATCH NICOTINE 21 MG/24HR 14 x x00363089653 NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 7 x x00363089688 NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 14 x x00363918002 NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 14 x x00536110888 NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 14 x x00536589688 NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 14 x x43598044828 NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 28 x x43598044870 NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 7 x x43598044874 NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 14 x x11822452590 RA NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 14 x x11822452610 RA NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 7 x x49348014446 SM NICOTINE 21 MG/24HR PATCH NICOTINE 21 MG/24HR 14 x x43598044556 NICOTINE TRANSDERMAL SYSTEM NICOTINE 21‐14‐7MG 56 x x49035019602 EQ NICOTINE 7 MG/24HR PATCH NICOTINE 7MG/24HR 14 x x62011005001 HM NICOTINE 7 MG/24HR PATCH NICOTINE 7MG/24HR 14 x x59450000174 KRO NICOTINE 7 MG/24HR PATCH NICOTINE 7MG/24HR 14 x x00766144020 NICODERM CQ 7 MG/24HR PATCH NICOTINE 7MG/24HR 14 x x00363089488 NICOTINE 7 MG/24HR PATCH NICOTINE 7MG/24HR 14 x x00536110688 NICOTINE 7 MG/24HR PATCH NICOTINE 7MG/24HR 14 x x00536589488 NICOTINE 7 MG/24HR PATCH NICOTINE 7MG/24HR 14 x x43598044670 NICOTINE 7 MG/24HR PATCH NICOTINE 7MG/24HR 7 x x43598044674 NICOTINE 7 MG/24HR PATCH NICOTINE 7MG/24HR 14 x x11822333120 RA NICOTINE 7 MG/24HR PATCH NICOTINE 7MG/24HR 14 x x

NICOTINE REPLACEMENT‐ CHEWING GUM49035045660 EQ NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 20 x x49035045678 EQ NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 100 x x62011004702 HM NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 110 x x30142035278 KRO NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 100 x x00904573411 NICORELIEF 2 MG GUM NICOTINE POLACRILEX 2 MG 110 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00113020625 NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 110 x x00363042098 NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 170 x x00363042816 NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 160 x x00363042844 NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 100 x x00363045678 NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 100 x x00363048044 NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 100 x x00536136206 NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 50 x x00536136223 NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 110 x x00536302906 NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 50 x x00536302923 NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 110 x x00536302934 NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 20 x x00536311201 NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 100 x x00536340401 NICOTINE 2 MG CHEWING GUM NICOTINE POLACRILEX 2 MG 100 x x50428718184 CVS NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 100 x x49035053278 EQ NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 100 x x62011017001 HM NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 110 x x00113042225 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 110 x x00363042162 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 110 x x00363042198 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 170 x x00363042944 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 100 x x00363048144 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 100 x x00363048344 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 100 x x00363053278 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 100 x x00363060998 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 170 x x00536137206 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 50 x x00536137223 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 110 x x00536303006 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 50 x x00536303023 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 110 x x00536311301 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 100 x x00536340501 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 100 x x24385059871 NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 50 x x49348057236 SM NICOTINE 4 MG CHEWING GUM NICOTINE POLACRILEX 4 MG 110 x x

NICOTINE REPLACEMENT‐ LOZENGES50428331733 CVS NICOTINE 2 MG LOZENGE NICOTINE POLACRILEX 2 MG 48 x x37205098769 NICOTINE 2 MG LOZENGE NICOTINE POLACRILEX 2 MG 72 x x49348085216 SM NICOTINE 2 MG LOZENGE NICOTINE POLACRILEX 2 MG 72 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


49035087303 EQ NICOTINE 4 MG LOZENGE NICOTINE POLACRILEX 4 MG 24 x x62011017101 HM NICOTINE 4 MG LOZENGE NICOTINE POLACRILEX 4 MG 72 x x00363087305 NICOTINE 4 MG LOZENGE NICOTINE POLACRILEX 4 MG 72 x x00363087310 NICOTINE 4 MG LOZENGE NICOTINE POLACRILEX 4 MG 108 x x45802087305 NICOTINE 4 MG LOZENGE NICOTINE POLACRILEX 4 MG 72 x x46122017708 NICOTINE 4 MG LOZENGE NICOTINE POLACRILEX 4 MG 72 x x49348085316 SM NICOTINE 4 MG LOZENGE NICOTINE POLACRILEX 4 MG 72 x x

ANALGESICS

ANALGESICS‐ ASPIRIN 325MG00363015712 ASPIRIN 325 MG TABLET ASPIRIN 325 MG 100 x x00536105301 ASPIRIN 325 MG TABLET ASPIRIN 325 MG 100 x x

ANALGESICS‐ ASPIRIN 81MG CHEWABLE24385027868 ASPIRIN 81 MG CHEW TABLET ASPIRIN 81 MG 36 x x00113027468 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x00113046768 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x00363021807 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x00536100836 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x00904404073 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x36800027468 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x37205070868 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x57896091136 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x24385002868 CHILD ASPIRIN 81 MG CHEW TAB ASPIRIN 81 MG 36 x x37205046768 CHILD ASPIRIN 81 MG CHEW TAB ASPIRIN 81 MG 36 x x49035046768 EQ ASPIRIN 81 MG CHEWABLE TAB ASPIRIN 81 MG 36 x x62011002101 HM ASPIRIN 81 MG CHEWABLE TAB ASPIRIN 81 MG 36 x x30142027468 KRO ASPIRIN 81 MG CHEWABLE TAB ASPIRIN 81 MG 36 x x30142046768 KRO ASPIRIN 81 MG CHEWABLE TAB ASPIRIN 81 MG 36 x x11822361530 RA ASPIRIN 81 MG CHEWABLE TAB ASPIRIN 81 MG 36 x x49348019107 SM CHILD ASPIRIN 81 MG CHW TAB ASPIRIN 81 MG 36 x x

ANALGESICS‐ ASPIRIN 325MG ENTERIC00536331301 ASPIRIN EC 325 MG TABLET ASPIRIN 325 MG 100 x x57896092101 ASPIRIN EC 325 MG TABLET ASPIRIN 325 MG 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


ANALGESICS‐ APAP 325MG10135012301 ACETAMINOPHEN 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x10135012360 ACETAMINOPHEN 325 MG TABLET ACETAMINOPHEN 325 MG 60 x x37864000101 ACETAMINOPHEN 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x51645070301 ACETAMINOPHEN 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x57896010101 ACETAMINOPHEN 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x62011003201 HM PAIN RELIEVER 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x30142040378 KRO ACETAMINOPHEN 325 MG TAB ACETAMINOPHEN 325 MG 100 x x00904198251 MAPAP 325 MG TABLET ACETAMINOPHEN 325 MG 50 x x00904198259 MAPAP 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x00904198260 MAPAP 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x00904198261 MAPAP 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x00536322201 PAIN & FEVER 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x36800040378 PAIN RELIEF 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x00363010412 PAIN RELIEVER 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x11822317640 RA ATHENOL 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x

ANALGESICS‐ APAP 500MG TAB/CAP/GELCAP10135014401 ACETAMINOPHEN 500 MG CAPLET ACETAMINOPHEN 500 MG 100 x x10135014424 ACETAMINOPHEN 500 MG CAPLET ACETAMINOPHEN 500 MG 24 x x50428456227 CVS PAIN RELIEF 500 MG EZ‐TAB ACETAMINOPHEN 500 MG 24 x x49035048462 EQ ACETAMINOPHEN 500 MG CAPLET ACETAMINOPHEN 500 MG 24 x x62011002301 HM PAIN RELIEF 500 MG CAPLET ACETAMINOPHEN 500 MG 100 x x62011002302 HM PAIN RELIEF 500 MG CAPLET ACETAMINOPHEN 500 MG 50 x x00904198324 MAPAP 500 MG CAPLET ACETAMINOPHEN 500 MG 24 x x00904198351 MAPAP 500 MG CAPLET ACETAMINOPHEN 500 MG 50 x x00904198359 MAPAP 500 MG CAPLET ACETAMINOPHEN 500 MG 100 x x00904198859 MAPAP 500 MG TABLET ACETAMINOPHEN 500 MG 100 x x00904198860 MAPAP 500 MG TABLET ACETAMINOPHEN 500 MG 100 x x00536323101 PAIN & FEVER 500 MG TABLET ACETAMINOPHEN 500 MG 100 x x00113048462 PAIN RELIEF 500 MG CAPLET ACETAMINOPHEN 500 MG 24 x x00113048471 PAIN RELIEF 500 MG CAPLET ACETAMINOPHEN 500 MG 50 x x00113048478 PAIN RELIEF 500 MG CAPLET ACETAMINOPHEN 500 MG 100 x x00113022771 PAIN RELIEF 500 MG TABLET ACETAMINOPHEN 500 MG 50 x x00363017512 PAIN RELIEVER 500 MG CAPLET ACETAMINOPHEN 500 MG 100 x x00363017515 PAIN RELIEVER 500 MG CAPLET ACETAMINOPHEN 500 MG 50 x x00363051908 PAIN RELIEVER 500 MG GELCAP ACETAMINOPHEN 500 MG 24 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00363051912 PAIN RELIEVER 500 MG GELCAP ACETAMINOPHEN 500 MG 100 x x00363051915 PAIN RELIEVER 500 MG GELCAP ACETAMINOPHEN 500 MG 50 x x00363053112 PAIN RELIEVER 500 MG TABLET ACETAMINOPHEN 500 MG 100 x x24385014571 PAIN RELIEVER 500 MG TABLET ACETAMINOPHEN 500 MG 50 x x11822506040 RA ACETAMINOPHEN 500 MG CAPLET ACETAMINOPHEN 500 MG 24 x x11822030300 RA ACETAMINOPHEN 500 MG TABLET ACETAMINOPHEN 500 MG 50 x x

ANALGESICS‐ APAP 160MG/5ML LIQUID/SOLN/SUSP/ELIX

11673010526 ACETAMINOPHEN 160 MG/5 ML SUSP ACETAMINOPHEN 160 MG/5ML 118 x x11673013026 ACETAMINOPHEN 160 MG/5 ML SUSP ACETAMINOPHEN 160 MG/5ML 118 x x00113010526 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x00363016004 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x00363016204 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x00363016704 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x00363034044 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x00363034544 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x00363075926 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x11917012082 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x36800010526 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x00113021226 CHILD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x00113060826 CHILD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x00363080026 CHILD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x00536012297 CHILD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x36800075926 CHILD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x46122020926 CHILD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x46122021026 CHILD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x46122021126 CHILD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x46122021226 CHILD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x49781001604 CHILD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x54838014440 CHILDREN'S SILAPAP ELIXIR ACETAMINOPHEN 160 MG/5ML 118 x x24385014626 CHILD'S PAIN RELIEVER SUSP ACETAMINOPHEN 160 MG/5ML 118 x x11673075926 CHLD ACETAMINOPHEN 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x45802020126 CHLD ACETAMINOPHEN 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x45802020326 CHLD ACETAMINOPHEN 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x50428207688 CVS CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x50428521351 CVS CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


50428862227 CVS CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x50428858863 CVS INFNT PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 59 x x50428858864 CVS INFNT PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 59 x x50428858867 CVS INFNT PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 59 x x49035059016 EQ INFANT PAIN‐FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 60 x x49035094616 EQ INFANT PAIN‐FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 60 x x49035095926 EQ INFANT PAIN‐FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 118 x x87701040662 GNP CHL PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x52569013661 HM CHLD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x62011018301 HM CHLD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x62011024701 HM CHLD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x62011000101 HM INFANT PAIN‐FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 59 x x62011000201 HM INFANT PAIN‐FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 59 x x00363059016 INFANT PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 59 x x00363076616 INFANT PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 60 x x00363094610 INFANT PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 30 x x00363094616 INFANT PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 59 x x11917013234 INFANT PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 59 x x36800076616 INFANT PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 60 x x30142010526 KRO CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x30142039726 KRO CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x30142095926 KRO CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x30142001526 KRO CHILD PAIN‐FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 118 x x30142059016 KRO INFANT PAIN‐FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 59 x x30142059026 KRO INFANT PAIN‐FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 118 x x30142076616 KRO INFANT PAIN‐FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 59 x x00904198500 MAPAP 160 MG/5 ML LIQUID ACETAMINOPHEN 160 MG/5ML 118 x x00904198520 MAPAP 160 MG/5 ML LIQUID ACETAMINOPHEN 160 MG/5ML 118 x x00904653620 MAPAP 160 MG/5 ML SUSPENSION ACETAMINOPHEN 160 MG/5ML 118 x x56062017526 PUB CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x63868017626 QC CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x11822353410 RA INFANT FEVER‐PAIN REL SUSP ACETAMINOPHEN 160 MG/5ML 59 x x11822309680 RA NON‐ASPIRIN 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x11822989540 RA NON‐ASPIRIN 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x49348009334 SM CHLD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x49348011934 SM CHLD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x49348012334 SM CHLD PAIN‐FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


49348008130 SM INFANT PAIN‐FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 59 x x

ANALGESICS‐ APAP SUPPOSITORIES45802073230 ACETAMINOPHEN 120 MG SUPPOS ACETAMINOPHEN 120 MG 12 x x00713016412 ACEPHEN 325 MG SUPPOSITORY ACETAMINOPHEN 325 MG 12 x x51672211602 FEVERALL 325 MG SUPPOSITORY ACETAMINOPHEN 325 MG 6 x x51672211402 FEVERALL 80 MG SUPPOSITORY ACETAMINOPHEN 80 MG 6 x x

ANALGESICS‐ IBUPROFEN 200MG TAB/CAP/SOFTGEL

50428037194 CVS IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x50428051962 CVS IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x49035091212 EQ IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x62011001501 HM IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 50 x x62011001502 HM IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 100 x x62011001401 HM IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x62011001402 HM IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x00113051771 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 50 x x00113064762 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 24 x x00113064771 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 50 x x00363039312 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 100 x x00363039315 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 50 x x00904791251 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 50 x x00904791259 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 100 x x24385064771 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 50 x x24385064778 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 100 x x00113060462 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 24 x x00113060471 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x00113060478 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x00363039212 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x00363039215 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x00363043812 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x00904791451 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x00904791459 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x00904791461 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x00904791524 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 24 x x00904791551 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00904791559 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x24385060471 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x24385060478 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x36800060478 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x57896094101 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x30142051778 KRO IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 100 x x30142064778 KRO IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 100 x x30142060462 KRO IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 24 x x30142060471 KRO IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x11822008130 RA IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x11822017790 RA IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x11822506050 RA IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 24 x x49348019609 SM IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 50 x x49348070609 SM IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x49348070610 SM IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x00363029108 WAL‐PROFEN 200 MG TABLET IBUPROFEN 200 MG 24 x x00363029112 WAL‐PROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x00363029115 WAL‐PROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x

ANALGESICS‐ IBUPROFEN 50MG/1.25ML DROPS62011000401 HM INF IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 30 x x62011001201 HM INF IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 15 x x00113005705 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 15 x x00363005705 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 15 x x00363005710 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 30 x x00363125224 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 30 x x00904546335 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 15 x x11917006307 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 30 x x24385055010 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 30 x x45802005705 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 15 x x45963012523 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 15 x x45963012524 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 30 x x11822040280 RA INFANT IBUPROFEN SUSP DROP IBUPROFEN 50 MG/1.25 30 x x49348064227 SM INFANT IBUPROFEN SUSP DROP IBUPROFEN 50 MG/1.25 30 x x

ANALGESICS‐ IBUPROFEN 100MG/5ML SUSP/LIQ00113016626 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00113066026 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x00113089726 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x00113089734 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x00363016626 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x00363080626 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x00363126194 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x00472176494 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x00904530909 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x00904530920 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x00904557720 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x11673068526 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x24385000926 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x24385000934 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x24385036126 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x24385036134 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x24385037226 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x24385090526 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x24385090534 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x36800068526 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x36800089726 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x45802013326 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x45802014026 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x45802089726 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x45802089734 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 237 x x46122011026 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x49348087634 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x50428454601 CVS CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x50428456312 CVS CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x49035016626 EQ CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x49035066026 EQ CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x49035089726 EQ CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x49035089734 EQ CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 237 x x87701084242 GNP CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x00113068526 GS CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x52569013514 HM CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x62011003002 HM CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x62011003003 HM CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 150 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


52569013256 HM CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x52569013279 HM CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x62011001001 HM CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x62011001101 HM CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x62011003001 HM CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x00363066026 IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 120 x x00363089726 IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 120 x x30142016626 KRO CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x30142016634 KRO CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x30142068526 KRO CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x30142089726 KRO CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x30142089734 KRO CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x56062089726 PUB CHILDREN'S PROFEN IB SUSP IBUPROFEN 100 MG/5ML 120 x x56062016626 PUB CHILDREN'S PROFENIB SUSP IBUPROFEN 100 MG/5ML 120 x x11822316940 RA CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x11822361600 RA CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x11822505950 RA CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x11822239990 RA IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 120 x x11822361590 RA IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 120 x x49348022934 SM IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 120 x x49348022937 SM IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 240 x x49348049934 SM IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 120 x x49348050034 SM IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 120 x x

ANALGESICS‐ NAPROXEN SOD 220MG TAB/CAP/GEL

00363049071 ALL DAY PAIN RELIEF 220 MG TAB NAPROXEN SODIUM 220 MG 50 x x00363036862 ALL DAY PAIN RLF 220 MG CAPLET NAPROXEN SODIUM 220 MG 24 x x00363036871 ALL DAY PAIN RLF 220 MG CAPLET NAPROXEN SODIUM 220 MG 50 x x50428235637 CVS NAPROXEN SOD 220 MG CAPLET NAPROXEN SODIUM 220 MG 24 x x62011001701 HM NAPROXEN SOD 220 MG CAPLET NAPROXEN SODIUM 220 MG 50 x x

ANALGESICS‐ URINARY87651030152 AZO URINARY PAIN RLF 95 MG TAB PHENAZOPYRIDINE HCL 95 MG 30 x x49348007644 SM URINARY PAIN RLF 95 MG TAB PHENAZOPYRIDINE HCL 95 MG 30 x x87651012253 AZO STANDARD 97.5 MG TABLET PHENAZOPYRIDINE HCL 97.5 MG 12 x x87651024153 AZO URINARY PAIN RLF 97.5 MG PHENAZOPYRIDINE HCL 97.5 MG 24 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


49348094102 SM URINARY PAIN REL 97.5 MG TB PHENAZOPYRIDINE HCL 97.5 MG 12 x x00363011312 URINARY PAIN RELIEF 97.5 MG TB PHENAZOPYRIDINE HCL 97.5 MG 12 x x

VITAMINS

VITAMINS‐ THIAMINE11822033670 RA VITAMIN B‐1 100 MG TABLET THIAMINE HCL 100 MG 100 x x

VITAMINS‐ RIBOFLAVIN74312000640 VITAMIN B‐2 100 MG TABLET RIBOFLAVIN 100 MG 100 x x

VITAMINS‐ NIACIN00904227260 NIACIN 500 MG TABLET NIACIN 500 MG 100 x x

VITAMINS‐ PANTOTHENIC ACID00536671701 PANTOTHENIC ACID 500 MG TABS PANTOTHENIC ACID 500 MG 100 x x

VITAMINS‐ PYRIDOXINE00536440901 VITAMIN B‐6 100 MG TABLET PYRIDOXINE HCL 100 MG 100 x x00904051860 VITAMIN B‐6 100 MG TABLET PYRIDOXINE HCL 100 MG 100 x x00536440601 VITAMIN B‐6 25 MG TABLET PYRIDOXINE HCL 25 MG 100 x x61748009501 PYRIDOXINE 50 MG TABLET PYRIDOXINE HCL 50 MG 100 x x00536440801 VITAMIN B‐6 50 MG TABLET PYRIDOXINE HCL 50 MG 100 x x00904052060 VITAMIN B‐6 50 MG TABLET PYRIDOXINE HCL 50 MG 100 x x

VITAMINS‐ BIOTIN50428459961 CVS BIOTIN 1,000 MCG TABLET BIOTIN 1 MG 100 x x11845015615 BIOTIN 5,000 MCG TABLET BIOTIN 5 MG 60 x x

VITAMINS‐ VITAMIN C11822880250 RA VITAMIN C 250 MG TABLET ASCORBIC ACID 250 MG 100 x x00904052260 VITAMIN C 250 MG TABLET ASCORBIC ACID 250 MG 100 x x00904052560 VITAMIN C 250 MG TABLET CHEW ASCORBIC ACID 250 MG 100 x x50428038158 CVS VITAMIN C 500 MG CAPLET ASCORBIC ACID 500 MG 100 x x00904052360 VITAMIN C 500 MG TABLET ASCORBIC ACID 500 MG 100 x x11917007521 VITAMIN C 500 MG TABLET ASCORBIC ACID 500 MG 100 x x57896084101 VITAMIN C 500 MG TABLET ASCORBIC ACID 500 MG 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


31604001496 VITAMIN C 500 MG TABLET CHEW ASCORBIC ACID 500 MG 60 x x

VITAMINS‐ VITAMIN A00904208560 VITAMIN A 10,000 UNITS CAPSULE VITAMIN A 10000 UNIT 100 x x

VITAMINS‐ VITAMIN D2 (ERGOCALCIFEROL)39328035760 CALCIDOL DROPS ERGOCALCIFEROL (VITAMIN D2) 8000/ML 60 x x43199001560 ERGOCALCIFEROL 8,000 UNITS/ML ERGOCALCIFEROL (VITAMIN D2) 8000/ML 60 x x69543023460 ERGOCALCIFEROL 8,000 UNITS/ML ERGOCALCIFEROL (VITAMIN D2) 8000/ML 60 x x

VITAMINS‐ VITAMIN D3 (CHOLECALCIFEROL)30768053491 VITAMIN D3 1,000 UNIT GUMMIES CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 90 x x31604002844 VITAMIN D3 1,000 UNIT GUMMIES CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 90 x x11845014775 VITAMIN D3 1,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 60 x x54458032334 VITAMIN D3 1,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 30 x x54458032344 VITAMIN D3 1,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 60 x x11845015469 VITAMIN D3 1,000 UNIT TAB CHEW CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 50 x x00536333401 VITAMIN D3 1,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x00904582460 VITAMIN D3 1,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x00904582461 VITAMIN D3 1,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x00904582489 VITAMIN D3 1,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 90 x x10432023701 VITAMIN D3 1,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x31604001870 VITAMIN D3 1,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x11917009905 VITAMIN D3 1,000 UNITS SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x11917011822 VITAMIN D3 1,000 UNITS SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 60 x x11917013940 VITAMIN D3 1,000 UNITS SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x11917014763 VITAMIN D3 1,000 UNITS SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 60 x x31604002675 VITAMIN D3 1,000 UNITS SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x66594099905 MAXIMUM D3 10,000 UNITS CAP CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT 5 x x63044040101 VITAMIN D3 10,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT 30 x x50428016183 CVS VITAMIN D3 2,000 UNIT SFGL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x87701040751 GNP VITAMIN D3 2,000 UNIT TAB CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x52569013400 HM VITAMIN D3 2,000 UNIT SFTGL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x10939052444 SM VITAMIN D3 2,000 UNIT SFTGL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x00536379001 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x11845015015 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 60 x x11917008608 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 75 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


11917011818 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 75 x x11917012697 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x11917013942 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 75 x x11917014679 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x11917017094 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x31604002585 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 90 x x54458032345 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 30 x x00904615760 VITAMIN D3 2,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x54629041120 VITAMIN D3 2,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x79854004112 VITAMIN D3 2,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x11845011831 VITAMIN D3 400 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 400 UNIT 100 x x11845015071 VITAMIN D3 400 UNIT TAB CHEW CHOLECALCIFEROL (VITAMIN D3) 400 UNIT 100 x x00904582360 VITAMIN D3 400 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 400 UNIT 100 x x31604002671 VITAMIN D3 400 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 400 UNIT 100 x x43292055881 VITAMIN D3 400 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 400 UNIT 100 x x40985022661 VITAMIN D‐400 TABLET CHOLECALCIFEROL (VITAMIN D3) 400 UNIT 100 x x00087086644 D‐VI‐SOL 400 UNITS/ML DROP CHOLECALCIFEROL (VITAMIN D3) 400/ML 50 x x50383091750 VITAMIN D3 400 UNIT/ML DROP CHOLECALCIFEROL (VITAMIN D3) 400/ML 50 x x54629077232 VITAMIN D3 400 UNIT/ML DROP CHOLECALCIFEROL (VITAMIN D3) 400/ML 52.5 x x54838000650 VITAMIN D3 400 UNIT/ML DROP CHOLECALCIFEROL (VITAMIN D3) 400/ML 50 x x79854007723 VITAMIN D3 400 UNIT/ML DROP CHOLECALCIFEROL (VITAMIN D3) 400/ML 52.5 x x50428016516 CVS VITAMIN D3 5,000 UNIT SFGL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x11822490000 RA VITAMIN D3 5,000 UNIT SFTGL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x81131031271 SV VITAMIN D3 5,000 UNIT SFTGL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x00904598660 VITAMIN D3 5,000 UNIT CAPSULE CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x53191024401 VITAMIN D3 5,000 UNIT CAPSULE CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x11845015331 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x11845015339 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 50 x x11917011540 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x11917013981 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x11917014360 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x11917014767 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x11917017183 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x31604002621 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 90 x x54629794101 VITAMIN D3 5,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x30768030405 VITAMIN D3 5,000 UNIT/ML DROPS CHOLECALCIFEROL (VITAMIN D3) 5000/ML 59 x x54629077241 VITAMIN D3 5,000 UNIT/ML DROPS CHOLECALCIFEROL (VITAMIN D3) 5000/ML 52.5 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


10542010008 DIALYVITE VIT D3 50,000 UNIT CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT 80 x x2359046010 REPLESTA 50,000 UNITS WAFER CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT 4 x x75834002012 VITAMIN D3 50,000 UNITS CAPS CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT 12 x x

VITAMINS‐ VITAMIN E00904027060 VITAMIN E 100 UNIT SOFTGEL VITAMIN E (DL,TOCOPHERYL ACET) 100 UNIT 100 x x00536479901 VITAMIN E 400 UNIT CAPSULE VITAMIN E (DL,TOCOPHERYL ACET) 400 UNIT 100 x x00904027460 VITAMIN E 400 UNIT SOFTGEL VITAMIN E (DL,TOCOPHERYL ACET) 400 UNIT 100 x x11917007513 VITAMIN E 400 UNIT SOFTGEL VITAMIN E (DL,TOCOPHERYL ACET) 400 UNIT 100 x x31604001155 VITAMIN E 200 UNITS CAPSULE VITAMIN E 200 UNIT 100 x x54838000530 VITAMIN E 50 UNIT/ML DROPS VITAMIN E 50 UNIT/ML 30 x x55212004010 AQUA‐E LIQUID VITAMIN E MIXED/TOCOTRIENOL 30‐2 MG/ML 237 x x

VITAMINS‐ PHYTONADIONE (K‐1)54629084121 VITAMIN K 100 MCG TABLET PHYTONADIONE (VIT K1) 100 x x

VITAMINS‐ PRENATAL60258019701 PRENATAL 19 CHEWABLE TABLET PNV NO.118/IRON FUMARATE/FA 29 MG‐1 MG 100 x x70030013333 GS PRENATAL VITAMINS TABLET PNV NO.133/FERROUS FUM/FA 30 x x79854040070 PRENATAL FORMULA TABLET PNV95/FERROUS FUMARATE/FA 28MG‐0.8MG 100 x x51645083701 PRENATAL TABLET PNV95/FERROUS FUMARATE/FA 28MG‐0.8MG 100 x x54738005001 PRENATAL TABLET PNV95/FERROUS FUMARATE/FA 28MG‐0.8MG 100 x x00536408501 PRENATAL VITAMINS TABLET PNV95/FERROUS FUMARATE/FA 28MG‐0.8MG 100 x x10939045433 SM PRENATAL VITAMINS TABLET PNV95/FERROUS FUMARATE/FA 28MG‐0.8MG 100 x x11917015670 PRENATAL MULTI‐DHA SOFTGEL PRENATAL NO.40/IRON/FA/DHA 27‐0.8‐250 30 x x10432003301 KPN TABLET PRENATAL VIT CALC,IRON,FOLIC 100 x x37864083703 PRENATAL VITAMIN TABLET PRENATAL VIT NO.124/IRON/FA 27MG‐0.8MG 30 x x37864083730 PRENATAL VITAMIN TABLET PRENATAL VIT NO.124/IRON/FA 27MG‐0.8MG 100 x x00536406301 CLASSIC PRENATAL TABLET PRENATAL VIT NO.126/IRON/FA 28MG‐0.8MG 100 x x58487003131 PRENATAL ONE DAILY TABLET PRENATAL VIT NO.129/IRON/FA 27MG‐0.8MG 100 x x

VITAMINS‐ B‐COMPLEX VITAMINS AND COMBINATIONS

54859051608 NEPHRONEX LIQUID B COMPLEX C NO.10/FOLIC ACID 900MCG/5ML 240 x x60258016201 RENAL CAPS B COMPLEX C NO.20/FOLIC ACID 100 x x63044062201 RENO CAPS SOFTGEL B COMPLEX C NO.20/FOLIC ACID 100 x x13811052501 TRIPHROCAP SOFTGEL B COMPLEX C NO.20/FOLIC ACID 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


69543026010 VIRT‐CAPS (1 MG FA B COMP W‐C) B COMPLEX C NO.20/FOLIC ACID 100 x x10542001010 BIFERA RX TABLET FOLIC ACID/VIT BCOMP, C 100 x x10542007010 DIALYVITE 800 TABLET FOLIC ACID/VIT BCOMP, C 0.8 MG 100 x x00536730001 NEPHRO‐VITE TABLET FOLIC ACID/VIT BCOMP, C 0.8 MG 100 x x60258016001 RENA‐VITE TABLET FOLIC ACID/VIT BCOMP, C 0.8 MG 100 x x74312000530 B‐COMPLEX‐VIT C TIME REL TAB FOLIC ACID/VIT BCOMP, C 400 MCG 100 x x60258016101 RENA‐VITE RX TABLET FOLIC ACID/VIT BCOMP/BIOTIN, C 100 x x69543035610 VP VITE RX FOLIC ACID/VIT BCOMP/BIOTIN, C 100 x x00536478701 VITAMIN B COMPLEX CAPSULE VITAMIN B COMPLEX 100 x x

VITAMINS‐ MULTIVITAMINS68176000012 DEKAS ESSENTIAL CAPSULE A/D3/E/TOCOPHERSOLAN/VIT K1 2000‐1000 60 x x00536354701 DAILY‐VITE TABLET MULTIVITAMIN 100 x x11917007453 MULTIPLE VITAMINS TABLET MULTIVITAMIN 100 x x54629003824 MULTIVITAMINS TABLET MULTIVITAMIN 100 x x57896050401 ONE DAILY MULTIVITAMIN TAB MULTIVITAMIN 100 x x00904053060 TAB‐A‐VITE TABLET MULTIVITAMIN 100 x x

VITAMINS‐ MULTIVITAMINS WITH IRON57896052401 ONE‐DAILY MULTI‐VIT‐IRON TAB MULTIVITAMIN/FERROUS SULFATE 18 MG 100 x x74312001580 MULTI‐DAY PLUS IRON TABLET MULTIVITAMIN/IRON/FOLIC ACID 18MG‐0.4MG 100 x x

VITAMINS‐ MULTIVITAMINS WITH FOLIC ACID51759000202 PRORENAL MULTIVITAMIN TABLET B,C/FERROUS FUM/FA/D3/ZINC OX 8MG‐800MCG 90 x x68176000011 DEKAS PLUS SOFTGEL MULTIVIT WITH MIN #53/FA/K/Q10 200‐1000 60 x x00904264146 CERTAVITE‐ANTIOXIDANT TABLET MULTIVITAMIN/IRON/FOLIC ACID 18MG‐0.4MG 30 x x87701040792 GNP ONE DAILY PLUS IRON TABLET MULTIVITAMIN/IRON/FOLIC ACID 18MG‐0.4MG 100 x x00005434462 CENTRUM MULTIVIT‐MINERAL LIQ MULTIVIT‐MINERALS/FERROUS GLUC 9 MG/15 ML 236 x x68176000015 DEKAS PLUS CHEWABLE TABLET MULTIVIT‐MINERALS/FOLIC/K/COQ10 60 x x58914001460 AQUADEKS CHEWABLE TABLET MV. MIN CMB#51/FA/VIT K1/UBI 100‐350MCG 60 x x58204000400 COMPLETE FORMUL MULTIVIT SFTGL PEDIATRIC MULTIVIT #61/D3/VITK 1500‐800 60 x x

VITAMINS‐ PEDIATRIC VITAMINS00087040303 TRI‐VI‐SOL DROPS VIT A PALMITATE/VIT C/VIT D3 750‐35/ML 50 x x

VITAMINS‐ PEDIATRIC MULTIVITAMINS37864000042 ANIMAL CHEWS TABLET MULTIVITAMIN 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00904262160 CHILD CHEW VITAMIN TABLET MULTIVITAMIN 100 x x54629005001 CHILDREN'S CHEWABLE VITAMIN MULTIVITAMIN 100 x x16500008619 FLINTSTONES EXTRA C TAB CHEW MULTIVITAMIN 60 x x16500007818 FLINTSTONES TABLET CHEWABLE MULTIVITAMIN 60 x x00536430401 POLY‐VITAMIN TAB CHEW MULTIVITAMIN 100 x x46122008972 CHILDREN'S CHEWABLES PEDIATRIC MULTIVIT COMB #25/FA 300 MCG 60 x x00087040203 POLY‐VI‐SOL DROPS PEDIATRIC MULTIVIT COMB NO.81 750‐35/ML 50 x x

VITAMINS‐ PEDIATRIC MULTIVITAMINS WITH FLUORIDE

44946103508 TRI‐VITAMIN WITH FLUORIDE PED MULTIVIT A, C, D3 NO.21/FLUORIDE 50 x x44946103608 TRI‐VITAMIN WITH FLUORIDE PED MULTIVIT A, C, D3 NO.21/FLUORIDE 50 x x44946102401 MULTIVITAMIN WITH FLOURIDE PED MULTIVIT NO.17/FLUORIDE 100 x x59088010959 MULTIVITAMIN WITH FLOURIDE PED MULTIVIT NO.17/FLUORIDE 100 x x44946102301 MULTIVIT‐FLUOR PED MULTIVIT NO.17/FLUORIDE 100 x x59088010759 MULTIVIT‐FLUOR PED MULTIVIT NO.17/FLUORIDE 100 x x59088010859 MULTIVIT‐FLUOR PED MULTIVIT NO.17/FLUORIDE 100 x x58657032650 MULTIVITAMIN & FLUORIDE DROP PED MULTIVIT NO.2/FLUORIDE 50 x x61269016150 MULTIVITAMIN WITH FLUORIDE PED MULTIVIT NO.2/FLUORIDE 50 x x58657032550 MULTIVIT‐FLUOR 0.25 MG DROP PED MULTIVIT NO.2/FLUORIDE 50 x x58657032750 MULTI‐VITAMIN W‐FLUORIDE‐IRON PED MULTIVIT NO.45/FLUORIDE 50 x x

VITAMINS‐ PEDIATRIC MULTIVITAMINS WITH IRON

00536344901 CHEW‐VITES‐IRON TABLET CHEW MULTIVITAMIN WITH IRON 100 x x00904053660 CHILD CHEW + IRON TAB CHEW MULTIVITAMIN WITH IRON 100 x x62107004801 CHILD VITAMIN‐IRON TAB CHEW MULTIVITAMIN WITH IRON 100 x x00087040501 POLY‐VI‐SOL WITH IRON DROPS PEDI MV NO.80/FERROUS SULFATE 750‐10/ML 50 x x

VITAMINS‐PEDIATRIC MULTVITAMINS WITH MINERALS

16500008806 FLINTSTONES COMPLETE TABLET MULTIVIT WITH IRON‐MINERALS 60 x x00536781601 POLYVITAMIN WITH IRON TAB CHEW MULTIVIT WITH IRON‐MINERALS 100 x x11917008609 GUMMI BEAR MULTIVIT TAB CHEW MULTIVITAMIN 60 x x24385009072 ZOO CHEWS GUMMIE TABLET MULTIVITAMIN 60 x x58914021460 AQUADEKS PEDIATRIC LIQUID PEDI MULTIVIT #40/PHYTONADIONE 400 MCG/ML 60 x x68176000010 DEKAS PLUS LIQUID pedi multivit no.128/vitamin K 60 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00005423720 CENTRUM KIDS CHEW TAB PEDI MV NO.68/IRON CARBONYL 18 MG 80 x x57771000148 NANO VM 4‐8 POWDER PEDIATRIC MULTIVIT #15/IRON/FA 5MG‐100MCG 275 x x16500051627 FLINTSTONES MULTIVIT CHEW TAB PEDIATRIC MULTIVIT COMB #25/FA 300 MCG 30 x x11917014690 CHILDREN MULTIVITAMIN GUMMIES PEDIATRIC MULTIVIT COMB NO.73 60 x x16500053879 FLINTSTONES GUMMIES CHEW TAB PEDIATRIC MULTIVIT COMB. NO.49 50 x x57771000104 NANOVM T/F POWDER PEDIATRIC MULTIVIT NO.93/IRON 2.75MG/5.4 275 x x

MINERALS

MINERALS‐ CALCIUM SUPPLEMENTS00054311763 CALCIUM CARB 1,250 MG/5 ML SUS CALCIUM CARBONATE 500 MG/5ML 500 x x00121076616 CALCIUM CARB 1,250 MG/5 ML SUS CALCIUM CARBONATE 500 MG/5ML 473 x x00121476605 CALCIUM CARB 1,250 MG/5 ML SUS CALCIUM CARBONATE 500 MG/5ML 5 x x00904188352 OYSTER SHELL CALCIUM 500 MG TB CALCIUM CARBONATE 500(1250) 60 x x00536342608 CALCIUM 600 MG TABLET CALCIUM CARBONATE 600 MG 60 x x00904323252 CALCIUM 600 MG TABLET CALCIUM CARBONATE 600 MG 60 x x00904323292 CALCIUM 600 MG TABLET CALCIUM CARBONATE 600 MG 150 x x00904188260 OYSTER SHELL 250 MG + VIT D TB CALCIUM CARBONATE/VITAMIN D3 250 MG‐125 100 x x00904323852 CALCIUM 500 MG CHEWABLE TABLET CALCIUM CARBONATE/VITAMIN D3 500 MG‐100 60 x x00088165475 OS‐CAL 500‐VIT D3 200 CAPLET CALCIUM CARBONATE/VITAMIN D3 500 MG‐200 75 x x00536781708 OYSCO 500‐VIT D3 200 TABLET CALCIUM CARBONATE/VITAMIN D3 500 MG‐200 60 x x00904546052 OYSTER SHELL 500‐VIT D3 200 TB CALCIUM CARBONATE/VITAMIN D3 500 MG‐200 60 x x00904603652 CALCIUM 500+D TABLET CHEW CALCIUM CARBONATE/VITAMIN D3 500 MG‐400 60 x x54629037701 OYSTER SHELL CALCIUM‐VIT D TAB CALCIUM CARBONATE/VITAMIN D3 500 MG‐400 100 x x00904323352 CALCIUM 600‐VIT D3 400 TABLET CALCIUM CARBONATE/VITAMIN D3 600 MG‐400 60 x x11917011331 CALCIUM 600‐VIT D3 400 TABLET CALCIUM CARBONATE/VITAMIN D3 600 MG‐400 60 x x00005550919 CALTRATE 600 PLUS D3 TABLET CALCIUM CARBONATE/VITAMIN D3 600 MG‐800 60 x x

MINERALS‐ FLUORIDE SUPPLEMENTS59088010573 FLUORIDE 0.5 MG TB CHW FLUORIDE (SODIUM) 120 x x59088010673 FLUORIDE 1 MG TB CHW FLUORIDE (SODIUM) 120 x x44946100803 LUDENT FLUORIDE 0.25 MG TB CHW FLUORIDE (SODIUM) 120 x x59088010473 LUDENT FLUORIDE 0.25 MG TB CHW FLUORIDE (SODIUM) 120 x x44946101003 LUDENT FLUORIDE 1 MG TB CHW FLUORIDE (SODIUM) 120 x x44946103208 SODIUM FLUORIDE 0.5 MG/ML FLUORIDE (SODIUM) 50 x x61269016550 SODIUM FLUORIDE 0.5 MG/ML FLUORIDE (SODIUM) 30 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


MINERALS‐ MAGNESIUM SUPPLEMENTS37205035178 MAGNESIUM 250 MG TABLET MAGNESIUM 250 MG 100 x x00187526701 MAGONATE 54 MG/5 ML LIQUID MAGNESIUM CARBONATE 54 MG/5 ML 355 x x30768000617 MAGNESIUM OXIDE 250 MG TABLET MAGNESIUM OXIDE 250 MG 100 x x31604001269 MAGNESIUM OXIDE 250 MG TABLET MAGNESIUM OXIDE 250 MG 100 x x60569049460 MAGOX 400 TABLET MAGNESIUM OXIDE 400 MG 60 x x74312005535 MAGNESIUM 500 MG TABLET MAGNESIUM OXIDE 500 MG 100 x x00904423960 MAGNESIUM OXIDE 500 MG TABLET MAGNESIUM OXIDE 500 MG 100 x x

MINERALS‐ MISC SUPPLEMENTS00904431460 CHROMIUM PICO 200 MCG TABLET CHROMIUM PICOLINATE 200 MCG 100 x x58657031016 SODIUM CITRATE‐CITRIC ACID CITRIC ACID/SODIUM CITRATE 473 x x70074080336 PEDIALYTE SOLUTION ELECTROLYTES/DEXTROSE 1000 x x58657031216 POTASSIUM CITRATE‐CITRIC ACID SOLN POTASSIUM CITRATE/CITRIC ACID 473 x x00486112501 K‐PHOS NEUTRAL SOD PHOS DI, MONO/K PHOS MONO 100 x x64980010401 PHOSPHA 250 NEUTRAL TABLET SOD PHOS DI, MONO/K PHOS MONO 100 x x69543026810 VIRT‐PHOS 250 NEUTRAL TABLET SOD PHOS DI, MONO/K PHOS MONO 100 x x00223176001 SODIUM CHLORIDE 1 GM TABLET SODIUM CHLORIDE 1 G 100 x x60258000601 PHOS‐NAK PACKET SODIUM,POTASSIUM PHOSPHATES 280‐250MG 100 x x00904533260 ZINC 50 MG CAPSULE ZINC SULFATE 220(50) MG 100 x x68585000801 ZINC SULFATE 220 MG CAPSULE ZINC SULFATE 220(50) MG 100 x x

NUTRIENTS

NUTRIENTS‐ LIPIDS41679036513 MCT OIL MEDIUM CHAIN TRIGLYCERIDES 7.7KCAL/ML 946 x x

NUTRIENTS‐ PROTEINS/AMINO ACIDS57771000110 CYTO CARN POWDER ACETYLCARNITINE 1G/SCOOP 150 x x57654000602 NEOKE ALCAR POWDER ACETYLCARNITINE 1G/SCOOP 150 x x27434000426 ACETYL L‐CARNITINE 500 MG CAP ACETYLCARNITINE 500 MG 30 x x58487001771 TRIAMINO TABLET ALANINE/GLUTAMIC ACID/GLYCINE 200‐200 MG 100 x x88856000045 K‐PAX PROTEIN BLEND POWDER AMINO AC/MULTIVIT‐MIN/HERB 139 20G‐400MCG 917 x x11845054809 AMINO ACID CAPSULE AMINO ACIDS 90 x x54629024001 AMINO ACTION 1,000 MG TABLET AMINO ACIDS 100 x x79854020240 AMINO ACTION 1,000 MG TABLET AMINO ACIDS 100 x x11845119105 DAILY AMINO 6,000 MG TAB CHEW AMINO ACIDS 60 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


11845054501 HIGH PROTEIN TABLET AMINO ACIDS 100 x x81262020001 NUTRAMINE POWDER AMINO ACIDS 230 x x12622000601 NUTRASENTIALS AMINO ACID DRINK AMINO ACIDS 238 x x12622000603 NUTRASENTIALS AMINO ACID DRINK AMINO ACIDS 200 x x12622000605 NUTRASENTIALS AMINO ACID DRINK AMINO ACIDS 235 x x12622000606 NUTRASENTIALS AMINO ACID DRINK AMINO ACIDS 238 x x12622000607 NUTRASENTIALS AMINO ACID DRINK AMINO ACIDS 200 x x52083054090 PRE PROTEIN TABLET AMINO ACIDS 90 x x54859071512 PROTEINEX TABLET AMINO ACIDS 120 x x11845008239 AMINO ACIDS 700 MG TABLET AMINO ACIDS 700 MG 90 x x49735000124 COMPLETE AMINO ACID MIX POWDER AMINO ACIDS 82G‐328 200 x x49735013341 COMPLETE AMINO ACID MIX POWDER AMINO ACIDS 82G‐328 200 x x49735010124 COMPLETE AMINO ACID MIX PWD AMINO ACIDS 82G‐328 200 x x11845119705 PROTEIN 2,000 MG TABLET AMINO ACIDS/PROTEIN SUPPLEMENT 60 x x59781066687 JUVEN PACKET ARGIN/GLUT/CAHMB/COLLAG/MV‐MIN 7G‐7G‐1.5G 30 x x59781066688 JUVEN PACKET ARGIN/GLUT/CAHMB/COLLAG/MV‐MIN 7G‐7G‐1.5G 1 x x00847001200 L‐ARGININE POWDER ARGININE 50 x x51552069807 ARGININE‐L POWDER ARGININE 100 % 1000 x x62991273202 L‐ARGININE BASE POWDER ARGININE 100 % 100 x x62991273203 L‐ARGININE BASE POWDER ARGININE 100 % 500 x x50600050267 ARGININE 2000 POWDER PACKET ARGININE 2000 MG 30 x x00904421551 ARGININE 500 MG TABLET ARGININE 500 MG 50 x x50600054692 ARGININE PACKET ARGININE 500 MG 30 x x58487080171 FNP L‐ARGININE 500 MG TABLET ARGININE 500 MG 60 x x07610011210 L‐ARGININE 500 MG CAPSULE ARGININE 500 MG 50 x x48107000192 L‐ARGININE 500 MG CAPSULE ARGININE 500 MG 90 x x74312000090 L‐ARGININE 500 MG CAPSULE ARGININE 500 MG 50 x x81131011152 SV L‐ARGININE 500 MG CAPSULE ARGININE 500 MG 50 x x62991158602 L‐ARGININE HCL POWDER ARGININE HCL 100 % 500 x x11845016229 L‐ARGININE 1,000 MG TABLET ARGININE HCL 1000 MG 50 x x40985027086 L‐ARGININE 1,000 MG TABLET ARGININE HCL 1000 MG 100 x x11822363280 RA L‐ARGININE 1,000 MG TABLET ARGININE HCL 1000 MG 100 x x65883050214 PURE L‐ARGININE HCL 500 MG CAP ARGININE HCL 500 MG 100 x x65883050219 PURE L‐ARGININE HCL 500 MG CAP ARGININE HCL 500 MG 250 x x83268010461 PURE L‐ARGININE HCL 500 MG CAP ARGININE HCL 500 MG 100 x x83268010462 PURE L‐ARGININE HCL 500 MG CAP ARGININE HCL 500 MG 250 x x29135040504 L‐ARGININE SR 350 MG TABLET ARGININE OXOGLURATE 350 MG 400 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


29135040518 L‐ARGININE SR 350 MG TABLET ARGININE OXOGLURATE 350 MG 180 x x94688001201 ARGIMENT POWDER PACKET ARGININE/GLUTAMINE 7.5G‐10G 1 x x59781022550 JUVEN PACKET ARGININE/GLUTAMINE/CALCIUM BMB 7G‐7G‐1.5G 1 x x59781022551 JUVEN PACKET ARGININE/GLUTAMINE/CALCIUM BMB 7G‐7G‐1.5G 30 x x59781054000 JUVEN PACKET ARGININE/GLUTAMINE/CALCIUM BMB 7G‐7G‐1.5G 30 x x59781054001 JUVEN PACKET ARGININE/GLUTAMINE/CALCIUM BMB 7G‐7G‐1.5G 30 x x59781054002 JUVEN PACKET ARGININE/GLUTAMINE/CALCIUM BMB 7G‐7G‐1.5G 1 x x59781056094 JUVEN PACKET ARGININE/GLUTAMINE/CALCIUM BMB 7G‐7G‐1.5G 30 x x59781056430 JUVEN PACKET ARGININE/GLUTAMINE/CALCIUM BMB 7G‐7G‐1.5G 1 x x59781056431 JUVEN PACKET ARGININE/GLUTAMINE/CALCIUM BMB 7G‐7G‐1.5G 30 x x59781056432 JUVEN PACKET ARGININE/GLUTAMINE/CALCIUM BMB 7G‐7G‐1.5G 30 x x59781056433 JUVEN PACKET ARGININE/GLUTAMINE/CALCIUM BMB 7G‐7G‐1.5G 30 x x59781056623 JUVEN PACKET ARGININE/GLUTAMINE/CALCIUM BMB 7G‐7G‐1.5G 8 x x59781056626 JUVEN PACKET ARGININE/GLUTAMINE/CALCIUM BMB 7G‐7G‐1.5G 8 x x59781057935 JUVEN PACKET ARGININE/GLUTAMINE/CALCIUM BMB 7G‐7G‐1.5G 30 x x59781058012 JUVEN PACKET ARGININE/GLUTAMINE/CALCIUM BMB 7G‐7G‐1.5G 30 x x38779104008 BETAINE POWDER BETAINE 100 % 500 x x94688001169 PROSOURCE PROTEIN POWDER PACK CALCIUM CASEINATE/WHEY 7.5G 1 x x38779118605 L‐CITRULLINE POWDER CITRULLINE 100 x x57771000116 CYTOLLINE POWDER CITRULLINE 275 x x50600055095 CITRULLINE 1000 POWDER SACHETS CITRULLINE 1 G/4 G 30 x x50600050281 CITRULLINE 200 POWDER PACKET CITRULLINE 200 MG/4 G 30 x x65883044014 PURE L‐CITRULLINE 600 MG CAP CITRULLINE 600 MG 100 x x83268010441 PURE L‐CITRULLINE 600 MG CAP CITRULLINE 600 MG 100 x x65883044030 PURE L‐CITRULLINE POWDER CITRULLINE NONE 150 x x65883050535 PURE L‐CITRULLINE POWDER CITRULLINE NONE 1000 x x83268010503 PURE L‐CITRULLINE POWDER CITRULLINE NONE 150 x x83268010505 PURE L‐CITRULLINE POWDER CITRULLINE NONE 1000 x x27434000122 L‐CYSTEINE 500 MG CAPSULE CYSTEINE HCL 500 MG 60 x x50600054777 CYSTINE POWDER CYSTINE 0.5G‐15/4G 1 x x94688004230 GLUTAMENT POWDER PACKET GLUTAMINE 10 G 1 x x43900028300 GLUTASOLVE GLUTAMINE POWD PCKT GLUTAMINE 15 G 1 x x66536001390 L‐GLUTAMINE 500 MG CAPSULE GLUTAMINE 500 MG 100 x x58487002461 L‐GLUTAMINE 500 MG TABLET GLUTAMINE 500 MG 100 x x50600054456 GLYCINE 500 MG POWDER PACKET GLYCINE 500 MG 30 x x65883048114 PURE GLYCINE 500 MG CAPSULE GLYCINE 500 MG 100 x x83268010481 PURE GLYCINE 500 MG CAPSULE GLYCINE 500 MG 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00847001300 GLYCINE POWDER GLYCINE NONE 50 x x58487001853 GLYCINE POWDER GLYCINE NONE 480 x x65883043211 PURE L‐HISTIDINE 600 MG CAP HISTIDINE 600 MG 50 x x83268010432 PURE L‐HISTIDINE 600 MG CAP HISTIDINE 600 MG 50 x x51552041205 L‐ISOLEUCINE POWDER ISOLEUCINE 100 x x62991289102 L‐ISOLEUCINE POWDER ISOLEUCINE 100 x x00847001400 L‐ISOLEUCINE POWDER ISOLEUCINE 50 x x50600055118 ISOLEUCINE 1000 POWDER SACHET ISOLEUCINE SUPP IN CARBOHYDRAT 1 G/4 G 30 x x50600054302 ISOLEUCINE PACKET ISOLEUCINE SUPP IN CARBOHYDRAT 50 MG/4 G 30 x x50600054920 LEUCINE POWDER PACKET LEUCINE 0.1G‐15/4G 30 x x57771000112 NEOKE BCAA4 POWDER LEUCINE/ISOLEUCINE/VALINE 82 G‐328 300 x x11845016135 L‐CARNITINE 500 MG TABLET LEVOCARNITINE 500 MG 60 x x74312001683 L‐CARNITINE 500 MG TABLET LEVOCARNITINE 500 MG 30 x x11917013353 L‐CARNITINE 500 MG TABLET LEVOCARNITINE 500 MG 60 x x30768003741 L‐CARNITINE 500 MG TABLET LEVOCARNITINE 500 MG 30 x x81131011148 SV L‐CARNITINE 500 MG TABLET LEVOCARNITINE 500 MG 30 x x00536741008 L‐CARNITINE 250 MG CAPSULE LEVOCARNITINE TARTRATE 250 MG 60 x x43913020190 MCCARNITINE 330 MG TABLET LEVOCARNITINE TARTRATE 330 MG 90 x x11917005935 L‐CARNITINE 500 MG CAPSULE LEVOCARNITINE TARTRATE 500 MG 60 x x50428249649 CVS LYSINE 1,000 MG TABLET LYSINE 1000 MG 100 x x54629077005 LYSINE 1,000 MG TABLET LYSINE 1000 MG 50 x x79854060060 LYSINE 1,000 MG TABLET LYSINE 1000 MG 50 x x11822880940 RA L‐LYSINE 1,000 MG TABLET LYSINE 1000 MG 60 x x78742006795 SV L‐LYSINE 1,000 MG TABLET LYSINE 1000 MG 100 x x50428300265 CVS L‐LYSINE 500 MG TABLET LYSINE 500 MG 250 x x50428249706 CVS LYSINE 500 MG TABLET LYSINE 500 MG 100 x x41163023174 EQL L‐LYSINE 500 MG TABLET LYSINE 500 MG 100 x x00536673101 L‐LYSINE 500 MG TABLET LYSINE 500 MG 100 x x00904268760 L‐LYSINE 500 MG TABLET LYSINE 500 MG 100 x x10939037733 L‐LYSINE 500 MG TABLET LYSINE 500 MG 100 x x11845072101 L‐LYSINE 500 MG TABLET LYSINE 500 MG 100 x x43072000498 L‐LYSINE 500 MG TABLET LYSINE 500 MG 100 x x43292050012 L‐LYSINE 500 MG TABLET LYSINE 500 MG 100 x x43292055745 L‐LYSINE 500 MG TABLET LYSINE 500 MG 250 x x10135018501 LYSINE 500 MG TABLET LYSINE 500 MG 100 x x10135018510 LYSINE 500 MG TABLET LYSINE 500 MG 1000 x x11917005574 LYSINE 500 MG TABLET LYSINE 500 MG 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


11917005580 LYSINE 500 MG TABLET LYSINE 500 MG 300 x x50268051911 LYSINE 500 MG TABLET LYSINE 500 MG 1 x x50268051915 LYSINE 500 MG TABLET LYSINE 500 MG 50 x x54629076501 LYSINE 500 MG TABLET LYSINE 500 MG 100 x x79854060055 LYSINE 500 MG TABLET LYSINE 500 MG 100 x x11822880950 RA L‐LYSINE 500 MG TABLET LYSINE 500 MG 100 x x49348005310 SM L‐LYSINE 500 MG TABLET LYSINE 500 MG 100 x x87701040811 GNP L‐LYSINE 600 MG TABLET LYSINE 600 MG 100 x x37205055278 L‐LYSINE 600 MG TABLET LYSINE 600 MG 100 x x96295011771 L‐LYSINE 600 MG TABLET LYSINE 600 MG 100 x x50600054449 LYSINE 4000 POWDER PACKET LYSINE ACETATE 4000 MG 30 x x11917007501 L‐LYSINE HCL 500 MG TABLET LYSINE HCL 500 MG 100 x x11917013912 L‐LYSINE HCL 500 MG TABLET LYSINE HCL 500 MG 300 x x31604001681 L‐LYSINE HCL 500 MG TABLET LYSINE HCL 500 MG 100 x x58487002421 L‐LYSINE HCL 500 MG TABLET LYSINE HCL 500 MG 100 x x96295012852 L‐LYSINE HCL 500 MG TABLET LYSINE HCL 500 MG 100 x x78742049923 SV L‐LYSINE HCL 500 MG TABLET LYSINE HCL 500 MG 250 x x40985021062 L‐LYSINE 600 MG TABLET LYSINE HCL 600 MG 90 x x49735000180 L‐METHIONINE POWDER METHIONINE 50 x x50600055440 METHIONINE POWDER SACHET METHIONINE SUPP IN CARBOHYDRAT 100 MG/4 G 30 x x49735011490 ESSENTIAL AMINO ACID MIX POWD NUT TX,UREA CYCLE DIS W‐O IRON 79G‐316 200 x x50600054944 PHENYLALANINE POWDER PACKET PHENYLALANINE 50 MG 30 x x58487001971 L‐PHENYLALANINE 500 MG TAB PHENYLALANINE 500 MG 100 x x70074062317 LIQUID PROTEIN FORTIFIER PROTEIN HYDROLYSATE,MILK 1G‐4KCAL/6 54 x x54629055002 PROTEIN TABLET PROTEIN SUPPLEMENT 975 MG 200 x x79854060090 PROTEIN TABLET PROTEIN SUPPLEMENT 975 MG 200 x x27434000198 MEGA TAURINE 1,000 MG CAPSULE TAURINE 1000 MG 50 x x65883047014 PURE TAURINE 500 MG CAPSULE TAURINE 500 MG 100 x x83268010470 PURE TAURINE 500 MG CAPSULE TAURINE 500 MG 100 x x49735000190 L‐THREONINE POWDER THREONINE 50 x x58487002881 L‐THREONINE 500 MG TABLET THREONINE 500 MG 100 x x65883047514 PURE L‐THREONINE 500 MG CAP THREONINE 500 MG 100 x x83268010475 PURE L‐THREONINE 500 MG CAP THREONINE 500 MG 100 x x00847001600 L‐TYROSINE POWDER TYROSINE 50 x x50600054791 TYROSINE POWDER TYROSINE 1 G‐15/4 G 1 x x00536103206 L‐TYROSINE 500 MG CAPSULE TYROSINE 500 MG 50 x x65883045014 PURE L‐TYROSINE 500 MG CAPSULE TYROSINE 500 MG 100 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


65883045019 PURE L‐TYROSINE 500 MG CAPSULE TYROSINE 500 MG 250 x x83268010451 PURE L‐TYROSINE 500 MG CAPSULE TYROSINE 500 MG 100 x x83268010452 PURE L‐TYROSINE 500 MG CAPSULE TYROSINE 500 MG 250 x x51552039804 L‐VALINE POWDER VALINE 25 x x62991280702 L‐VALINE POWDER VALINE 100 x x00847001700 L‐VALINE POWDER VALINE 50 x x50600055132 VALINE 1000 POWDER SACHET VALINE SUPPL IN CARBOHYDRATE 1 G/4 G 30 x x50600054333 VALINE PACKET VALINE SUPPL IN CARBOHYDRATE 50 MG/4 G 30 x x91717023833 IMMULIFE POWDER WHEY NONE 660 x x54629906516 WHEY PROTEIN CONCENTRATE POWD WHEY PROTEIN CONCEN/AMINO ACID 20 G‐120 331 x x79854090651 WHEY PROTEIN CONCENTRATE POWD WHEY PROTEIN CONCEN/AMINO ACID 20 G‐120 331 x x83076000022 CARDIO WHEY PROTEIN POWDER WHEY PROTEIN CONCEN/AMINO ACID 21G‐180/47 658 x x83076000020 CARDIO WHEY PROTEIN POWDER WHEY PROTEIN CONCEN/AMINO ACID 21G‐190/52 728 x x76420033301 PROSYNMINIC POWDER WHEY PROTEIN CONCEN/AMINO ACID 24G‐120/30 453.5 x x52083083310 PRE‐PROTEIN POWDER WHEY PROTEIN ISOLAT/AMINO ACID 6 G‐25/7.4 270 x x52083083301 PRE‐PROTEIN POWDER PACKET WHEY PROTEIN ISOLAT/AMINO ACID 6 G‐25/7.4 1 x x56215000033 UNJURY POWDER WHEY PROTEIN ISOLATE 21 G‐90/24 360 x x56215000005 UNJURY POWDER WHEY PROTEIN ISOLATE 21G‐100/27 462 x x56215000011 UNJURY POWDER WHEY PROTEIN ISOLATE 21G‐100/27 464 x x56215000022 UNJURY POWDER WHEY PROTEIN ISOLATE 21G‐100/27 459 x x56215000077 UNJURY POWDER WHEY PROTEIN ISOLATE 21G‐100/27 468 x x56215000055 UNJURY POWDER PACKET WHEY PROTEIN ISOLATE 21G‐100/27 1 x x43900028410 BENEPROTEIN POWDER WHEY PROTEIN ISOLATE 6 G‐25/7 G 227 x x43900028430 BENEPROTEIN POWDER PACKET WHEY PROTEIN ISOLATE 6 G‐25/7 G 75 x x50428032629 CVS WHEY PROTEIN POWDER PACKET WHEY PROTEIN, CONCENT‐ISOLATE 26G‐150/39 1 x x50428042854 CVS WHEY PROTEIN POWDER PACKET WHEY PROTEIN, CONCENT‐ISOLATE 26G‐150/39 1 x x

NUTRIENTS‐ LIPOTROPIC00536398401 INOSITOL 500 MG TABLET INOSITOL 500 MG 100 x x

NUTRIENTS‐ MISC47469000928 OMEGA‐3 1,000 MG SOFTGEL OMEGA‐3 FATTY ACIDS 1000 MG 90 x x

DIETARY PRODUCTS

DIETARY PRODUCTS‐ INFANT FOODS00087511132 ENFAMIL REGULINE POWDER INF FORM,IRON/DHA/ARA/POLY/GOS 2.3 G/100 352 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00087511157 ENFAMIL REGULINE POWDER INF FORM,IRON/DHA/ARA/POLY/GOS 2.3 G/100 578 x x00087510734 NUTRAMIGEN TODDLER ENFLORA‐LGG INF FORM,SP.MET,IRON/LACT RHAM 2.5 G/100 357 x x00087123941 NUTRAMIGEN ENFLORA‐LGG POWDER INF FORM,SP.MET,IRON/LACT RHAM 2.8 G/100 357 x x00087123945 NUTRAMIGEN ENFLORA‐LGG POWDER INF FORM,SP.MET,IRON/LACT RHAM 2.8 G/100 561 x x00087510480 PURAMINO DHA‐ARA POWDER INF FORM/IRON/AMINO AC/DHA/ARA 2.8 G/100 400 x x49735011436 NEOCATE SYNEO INFANT POWDER INFANT FORM, IRON, FOS/B.BREVE 400 x x70074054666 ELECARE AMINO ACID POWDER INFANT FORM, IRON, LF/DHA/ARA 400 x x70074051121 PHENEX‐1 POWDER INFANT FORM. FOR PKU,IRON, #2 15G‐480 400 x x70074057534 SIMILAC SENSITIVE LIQUID INFANT FORM. W‐IRON LF/DHA/ARA 2.14G/100 946 x x70074064712 SIMILAC ALIMENTUM POWDER INFANT FORM. W‐IRON LF/DHA/ARA 2.75G/100 343 x x70074064715 SIMILAC ALIMENTUM POWDER INFANT FORM. W‐IRON LF/DHA/ARA 2.75G/100 343 x x70074057513 SIMILAC EXPERT CARE ALIMENTUM INFANT FORM. W‐IRON LF/DHA/ARA 2.75G/100 946 x x70074057664 SIMILAC EXPERT CARE ALIMENTUM INFANT FORM. W‐IRON LF/DHA/ARA 2.75G/100 454 x x70074054665 ELECARE AMINO ACID POWDER INFANT FORM. W‐IRON LF/DHA/ARA 3.1 G/100 400 x x70074053511 ELECARE INFANT FORMULA POWDER INFANT FORM. W‐IRON LF/DHA/ARA 3.1 G/100 400 x x70074055251 ELECARE INFANT FORMULA POWDER INFANT FORM. W‐IRON LF/DHA/ARA 3.1 G/100 400 x x49735000164 PKU PERIFLEX EARLY YEARS POWD INFANT FORM.FOR PKU,IRON NO.4 13.5 G‐473 400 x x49735010164 PKU PERIFLEX EARLY YEARS POWD INFANT FORM.FOR PKU,IRON NO.4 13.5 G‐473 400 x x49735018326 PERIFLEX INFANT POWDER INFANT FORM.FOR PKU,IRON NO.4 13G‐421 400 x x70074054599 SIMILAC HUMAN MILK POWDER PKT INFANT FORM.IRON,HUMAN MILK FT 0.25G/0.9G 1 x x00087201448 ENFAMIL HUMAN MILK FORTIFR PKT INFANT FORM.IRON,HUMAN MILK FT 0.275/0.71 100 x x00087036701 PREGESTIMIL POWDER INFANT FORMULA WITH IRON 454 x x70074057456 SIMILAC EXPERT CARE NEOSURE LQ INFANT FORMULA WITH IRON 946 x x00087869377 ENFAMIL GENTLEASE POWDER INFANT FORMULA, IRON/DHA/ARA 913 x x00087136560 ENFAMIL INFANT POWDER INFANT FORMULA, IRON/DHA/ARA 629 x x70074066082 SIMILAC PRO‐SENSTV NON‐GMO PWD INFANT FORMULA, IRON/DHA/ARA 638 x x50000021667 GERBER GOOD START GENTLE POWD INFANT FORMULA, IRON/DHA/ARA 11.6 G/100 360 x x70074055958 SIMILAC ADVANCE WITH IRON POWD INFANT FORMULA, IRON/DHA/ARA 2.07G/100 352 x x70074050818 SIMILAC SENSITIVE FUSS‐GAS PWD INFANT FORMULA, IRON/DHA/ARA 2.1 G/100 638 x x70074057541 SIMILAC SENSITIVE FUSS‐GAS PWD INFANT FORMULA, IRON/DHA/ARA 2.1 G/100 340 x x70074056728 SIMILAC FOR SPIT‐UP LIQUID INFANT FORMULA, IRON/DHA/ARA 2.14G/100 946 x x70074053730 SIMILAC FOR SPIT‐UP POWDER INFANT FORMULA, IRON/DHA/ARA 2.14G/100 638 x x00087510069 ENFAMIL GENTLEASE POWDER INFANT FORMULA, IRON/DHA/ARA 2.3 G/100 352 x x00087869376 ENFAMIL GENTLEASE POWDER INFANT FORMULA, IRON/DHA/ARA 2.3 G/100 610 x x70074062600 SIMILAC TOTAL COMFORT POWDER INFANT FORMULA, IRON/DHA/ARA 2.32 G/100 340 x x00087510300 ENFAMIL A.R. LIQUID INFANT FORMULA, IRON/DHA/ARA 2.5 G‐5.1G 237 x x00087020142 ENFAMIL A.R. POWDER INFANT FORMULA, IRON/DHA/ARA 2.5 G‐5.1G 366 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


70074057431 SIMILAC EXPERT CARE NEOSURE PW INFANT FORMULA, IRON/DHA/ARA 2.8 G/100 371 x x49735002595 NEOCATE INFANT DHA‐ARA POWDER INFANT FORMULA, IRON/DHA/ARA 2.8 G‐5.1G 400 x x49735012595 NEOCATE INFANT DHA‐ARA POWDER INFANT FORMULA, IRON/DHA/ARA 2.8 G‐5.1G 400 x x00087136542 ENFAMIL INFANT POWDER INFANT FORMULA, IRON/DHA/ARA 2‐5.3G/100 354 x x13034078821 ALFAMINO INFANT POWDER INFANT FORMULA, IRON/LF/AMINO/DHA/ARA 400 x x50000059852 GERBER EXTENSIVE HA POWDER INFANT FORMULA, S.P. MET, LF, IRON/B.ANIM 400 x x70074050820 SIMILAC SOY ISOMIL POWDER INFANT FORMULA, SOY, IRON/LF/DHA/ARA 658 x x70074060850 SIMILAC PM 60‐40 POWDER INFANT FORMULA,REGULAR 400 x x00087121441 ENFAMIL PROSOBEE LIPIL PWD INFANT FORMULA,SOY,W‐IRON,LF 366 x x83744035009 BRIGHT BEGINNINGS SOY DRINK PED NUTRIT.,SOY,IRON,LACT‐FREE 0.03G‐1/ML 237 x x

DIETARY PRODUCTS‐ MEDICAL FOODS45749001780 VSL#3 PACKET LACTOBAC #2‐S. THERM‐BIFIDO #1 450B CELL 30 x x51991080990 L‐METHYLFOLATE 15 MG CAPLET LEVOMEFOLATE CALCIUM 15 MG 90 x x76439035890 L‐METHYLFOLATE CALCIUM 15 MG LEVOMEFOLATE CALCIUM 15 MG 90 x x69206011030 ELFOLATE 7.5 MG TABLET LEVOMEFOLATE CALCIUM 7.5 MG 30 x x51991080833 L‐METHYLFOLATE 7.5 MG TABLET LEVOMEFOLATE CALCIUM 7.5 MG 30 x x76439035930 L‐METHYLFOLATE CALCIUM 7.5 MG LEVOMEFOLATE CALCIUM 7.5 MG 30 x x00525110290 DEPLIN‐ALGAL OIL 15 MG CAPSULE LEVOMEFOLATE/ALGAL OIL 15‐90.314 90 x x51991090990 L‐METHYLFOLATE FORTE 15 MG CAP LEVOMEFOLATE/ALGAL OIL 15‐90.314 90 x x00525113990 DEPLIN‐ALGAL OIL 7.5 MG CAP LEVOMEFOLATE/ALGAL OIL 7.5‐90.314 90 x x51991090890 L‐METHYLFOLATE FORTE 7.5 MG CP LEVOMEFOLATE/ALGAL OIL 7.5‐90.314 90 x x00525050390 CEREFOLIN CAPLET VIT B12/LEVOMEFOLATE/VIT B6/B2 90 x x

DIETARY PRODUCTS‐ NUTRITIONAL SUPPLEMENTS

49735018262 DUOCAL POWDER CALORIC SUPPLEMENT 400 x x58914080044 SCANDISHAKE POWDER PACKET DIETARY SUPPLEMENT 4 x x58914080244 SCANDISHAKE POWDER PACKET DIETARY SUPPLEMENT 4 x x43900018649 BOOST BREEZE LIQUID LACTOSE‐REDUCED FOOD 237 x x43900018600 BOOST BREEZE VARIETY PACK LIQ LACTOSE‐REDUCED FOOD 237 x x70074062481 ENSURE ACTIVE CLEAR LIQUID LACTOSE‐REDUCED FOOD 296 x x70074052101 ENSURE HIGH PROTEIN LIQUID LACTOSE‐REDUCED FOOD 237 x x70074040701 ENSURE LIQUID LACTOSE‐REDUCED FOOD 237 x x70074040705 ENSURE LIQUID LACTOSE‐REDUCED FOOD 237 x x70074053432 ENSURE LIQUID LACTOSE‐REDUCED FOOD 237 x x70074053623 ENSURE LIQUID LACTOSE‐REDUCED FOOD 237 x x70074056016 ENSURE LIQUID LACTOSE‐REDUCED FOOD 237 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


70074057231 ENSURE LIQUID LACTOSE‐REDUCED FOOD 237 x x70074050461 ENSURE ORIGINAL LIQUID LACTOSE‐REDUCED FOOD 237 x x70074064930 ENSURE ORIGINAL LIQUID LACTOSE‐REDUCED FOOD 237 x x70074058304 ENSURE PLUS LIQUID LACTOSE‐REDUCED FOOD 237 x x43900018629 BOOST BREEZE LIQUID LACTOSE‐REDUCED FOOD 0.04G‐1.05 237 x x43900018666 BOOST BREEZE LIQUID LACTOSE‐REDUCED FOOD 0.04G‐1.05 237 x x70074050649 ENSURE ORIGINAL LIQUID LACTOSE‐REDUCED FOOD 0.04G‐1.05 237 x x70074058294 ENSURE ORIGINAL LIQUID LACTOSE‐REDUCED FOOD 0.04G‐1.05 237 x x70074058298 ENSURE ORIGINAL LIQUID LACTOSE‐REDUCED FOOD 0.04G‐1.05 237 x x41679067466 BOOST LIQUID LACTOSE‐REDUCED FOOD 0.04G‐1/ML 237 x x41679067566 BOOST LIQUID LACTOSE‐REDUCED FOOD 0.04G‐1/ML 237 x x70074040702 ENSURE PLUS LIQUID LACTOSE‐REDUCED FOOD 0.05 G‐1.5 237 x x70074040707 ENSURE PLUS LIQUID LACTOSE‐REDUCED FOOD 0.05 G‐1.5 237 x x41679093166 BOOST PLUS ENERGY DRINK LACTOSE‐REDUCED FOOD 0.06 G‐1.5 237 x x43900093239 BOOST PLUS ENERGY DRINK LACTOSE‐REDUCED FOOD 0.06 G‐1.5 237 x x43900093338 BOOST PLUS ENERGY DRINK LACTOSE‐REDUCED FOOD 0.06 G‐1.5 237 x x70074053119 JEVITY 1.2 CAL LIQUID LACTOSE‐REDUCED FOOD/FIBER 237 x x24359051302 GLYTACTIN RESTORE 10 PE LITE NUT. THERAPY FOR PKU, NO.49 2 G‐14/100 500 x x24359051502 GLYTACTIN RESTORE 10 PE LITE NUT. THERAPY FOR PKU, NO.49 2 G‐14/100 500 x x24359050502 GLYTACTIN RESTORE 10 PE LIQUID NUT. THERAPY FOR PKU, NO.49 2 G‐34/100 500 x x24359052107 GLYTACTIN RESTORE 5 PE POWD PK NUT. THERAPY FOR PKU, NO.63 25 G‐363 60 x x24359052207 GLYTACTIN RESTORE 5 PE POWD PK NUT. THERAPY FOR PKU, NO.63 25 G‐363 60 x x43900018215 BOOST VHC NUTRITIONAL LIQUID NUT. TX , LACTOSE REDUCED, IRON 237 x x24359050302 GLYTACTIN RESTORE 10 PE LIQUID NUT. TX FOR PKU #49 500 x x24359050801 GLYTACTIN 15 PE BETTERMILK NUT. TX FOR PKU WITH IRON #41 29 G‐385 30 x x24359050901 GLYTACTIN 15 PE BETTERMILK NUT. TX FOR PKU WITH IRON #41 29 G‐385 30 x x24359035001 GLYTACTIN 15 PE BETTERMILK PKT NUT. TX FOR PKU WITH IRON #41 31 G‐327 30 x x24359054403 GLYTACTIN RTD 15 PE LIQUID NUT. TX FOR PKU WITH IRON #41 6 G‐80/100 250 x x50600051806 PKU TRIO POWDER NUT. TX FOR PKU WITH IRON #48 30 G‐404 400 x x50600051813 PKU TRIO POWDER NUT. TX FOR PKU WITH IRON #48 30 G‐404 400 x x49735018309 PERIFLEX JUNIOR POWDER NUT. TX FOR PKU WITH IRON NO.3 25 G‐374 454 x x49735018310 PERIFLEX JUNIOR POWDER NUT. TX FOR PKU WITH IRON NO.3 25 G‐374 454 x x49735018308 PERIFLEX JUNIOR POWDER NUT. TX FOR PKU WITH IRON NO.3 25 G‐394 454 x x49735017792 XPHE MAXAMAID POWDER NUT. TX FOR PKU WITH IRON NO.5 25G‐324 454 x x49735017793 XPHE MAXAMAID POWDER NUT. TX FOR PKU WITH IRON NO.5 25G‐324 454 x x49735017794 XPHE MAXAMAID POWDER NUT. TX FOR PKU WITH IRON NO.5 25G‐324 454 x x49735012311 XPHE MAXAMUM PACKET NUT. TX FOR PKU WITH IRON NO.6 40G‐305 30 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


49735012312 XPHE MAXAMUM PACKET NUT. TX FOR PKU WITH IRON NO.6 40G‐305 30 x x49735018323 XPHE MAXAMUM POWDER NUT. TX FOR PKU WITH IRON NO.6 40G‐305 454 x x49735018324 XPHE MAXAMUM POWDER NUT. TX FOR PKU WITH IRON NO.6 40G‐305 454 x x49735002311 XPHE MAXAMUM POWDER PACKET NUT. TX FOR PKU WITH IRON NO.6 40G‐305 1 x x49735002312 XPHE MAXAMUM POWDER PACKET NUT. TX FOR PKU WITH IRON NO.6 40G‐305 1 x x49735012301 XPHE MAXAMUM POWDER PACKET NUT. TX FOR PKU WITH IRON NO.6 40G‐305 30 x x49735012302 XPHE MAXAMUM POWDER PACKET NUT. TX FOR PKU WITH IRON NO.6 40G‐305 30 x x49735012167 LOPHLEX PACKET NUT. TX FOR PKU WITH IRON NO.7 10G‐41 30 x x49735012169 LOPHLEX PACKET NUT. TX FOR PKU WITH IRON NO.7 10G‐41 30 x x49735011161 PHENYLADE GMP MIX‐IN POWDR PKT NUT. TX FOR PKU,NO.66 80 G‐334 20 x x50600054623 RENA START POWDER NUT. TX,IMPAIRED RENAL FXN,WHEY 400 x x70074062089 SUPLENA CARB STEADY LIQUID NUT. TX IMP RENAL FXN, LAC ‐ REDUC 237 x x70074051123 PHENEX‐2 POWDER NUT.THERAPY FOR PKU, IRON NO.1 30G‐410 400 x x70074055756 PHENEX‐2 POWDER NUT.THERAPY FOR PKU, IRON NO.1 30G‐410 400 x x00087510172 PHENYL‐FREE 1 POWDER NUT.THERAPY FOR PKU,IRON NO.10 16.2G‐500 454 x x50600054906 EAA POWDER NUT.TX FOR PKU WITH IRON NO.13 5G‐36KCAL 50 x x49735012524 PERIFLEX LQ PKU LIQUID NUT.TX FOR PKU WITH IRON NO.2 0.06G‐0.64 250 x x49735012551 PERIFLEX LQ PKU LIQUID NUT.TX FOR PKU WITH IRON NO.2 0.06G‐0.64 250 x x49735018306 PERIFLEX ADVANCE PKU POWDER NUT.TX FOR PKU WITH IRON NO.20 35 G‐369 454 x x49735018307 PERIFLEX ADVANCE PKU POWDER NUT.TX FOR PKU WITH IRON NO.20 35 G‐369 454 x x49735018305 PERIFLEX ADVANCE PKU POWDER NUT.TX FOR PKU WITH IRON NO.20 35G‐385 454 x x81361093460 PKU 2 POWDER NUT.TX FOR PKU WITH IRON NO.21 67G‐290 500 x x81361093470 PKU 3 POWDER NUT.TX FOR PKU WITH IRON NO.21 68G‐280 500 x x49735012643 LANAFLEX POWDER PACKET NUT.TX FOR PKU WITH IRON NO.25 33G‐253 40 x x50059034103 PKU EASY LIQUID PACKET NUT.TX FOR PKU WITH IRON NO.26 15 G‐97.5 130 x x50059034104 PKU EASY LIQUID PACKET NUT.TX FOR PKU WITH IRON NO.26 15 G‐97.5 130 x x00847095604 PHENYLADE60 POWDER PACKET NUT.TX FOR PKU WITH IRON NO.27 10G‐49 30 x x00847095624 PHENYLADE60 POWDER PACKET NUT.TX FOR PKU WITH IRON NO.27 10G‐49 30 x x00847095404 PHENYLADE40 DRINK MIX PWDER NUT.TX FOR PKU WITH IRON NO.27 10G‐84/25G 20 x x00847095414 PHENYLADE40 DRINK MIX PWDER NUT.TX FOR PKU WITH IRON NO.27 10G‐84/25G 20 x x00847095112 PHENYLADE DRINK MIX POWDER NUT.TX FOR PKU WITH IRON NO.27 25G‐400 454 x x00847095222 PHENYLADE DRINK MIX POWDER NUT.TX FOR PKU WITH IRON NO.27 25G‐400 454 x x00847095332 PHENYLADE DRINK MIX POWDER NUT.TX FOR PKU WITH IRON NO.27 25G‐400 454 x x00847095442 PHENYLADE DRINK MIX POWDER NUT.TX FOR PKU WITH IRON NO.27 25G‐400 454 x x00847095602 PHENYLADE60 DRINK MIX POWDER NUT.TX FOR PKU WITH IRON NO.27 60G‐295 454 x x00847095622 PHENYLADE60 DRINK MIX POWDER NUT.TX FOR PKU WITH IRON NO.27 60G‐327 454 x x00847095084 PHENYLADE ESSENTIAL POWD PCKT NUT.TX FOR PKU WITH IRON NO.35 10G‐156/40 16 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00847095014 PHENYLADE ESSENTIAL POWDER NUT.TX FOR PKU WITH IRON NO.35 10G‐156/40 16 x x00847095024 PHENYLADE ESSENTIAL POWDER NUT.TX FOR PKU WITH IRON NO.35 10G‐156/40 16 x x00847095034 PHENYLADE ESSENTIAL POWDER NUT.TX FOR PKU WITH IRON NO.35 10G‐156/40 16 x x00847095044 PHENYLADE ESSENTIAL POWDER NUT.TX FOR PKU WITH IRON NO.35 10G‐156/40 16 x x00847095012 PHENYLADE ESSENTIAL DRINK POWD NUT.TX FOR PKU WITH IRON NO.35 25G‐390 454 x x00847095022 PHENYLADE ESSENTIAL DRINK POWD NUT.TX FOR PKU WITH IRON NO.35 25G‐390 454 x x00847095032 PHENYLADE ESSENTIAL DRINK POWD NUT.TX FOR PKU WITH IRON NO.35 25G‐390 454 x x00847095042 PHENYLADE ESSENTIAL DRINK POWD NUT.TX FOR PKU WITH IRON NO.35 25G‐390 454 x x00847095082 PHENYLADE ESSENTIAL DRINK POWD NUT.TX FOR PKU WITH IRON NO.35 25G‐390 454 x x50600051318 PKU COOLER 10 LIQ COOLER NUT.TX FOR PKU WITH IRON NO.4 0.12G‐0.71 87 x x50600054852 PKU COOLER 10 LIQ COOLER NUT.TX FOR PKU WITH IRON NO.4 0.12G‐0.71 87 x x50600054876 PKU COOLER 10 LIQ COOLER NUT.TX FOR PKU WITH IRON NO.4 0.12G‐0.71 87 x x50600054999 PKU COOLER 10 LIQ COOLER NUT.TX FOR PKU WITH IRON NO.4 0.12G‐0.71 87 x x50600051998 PKU COOLER 15 LIQ COOLER NUT.TX FOR PKU WITH IRON NO.4 0.12G‐0.71 130 x x50600054500 PKU COOLER 15 LIQ COOLER NUT.TX FOR PKU WITH IRON NO.4 0.12G‐0.71 130 x x50600054562 PKU COOLER 15 LIQ COOLER NUT.TX FOR PKU WITH IRON NO.4 0.12G‐0.71 130 x x50600054975 PKU COOLER 15 LIQ COOLER NUT.TX FOR PKU WITH IRON NO.4 0.12G‐0.71 130 x x50600052001 PKU COOLER 20 LIQ COOLER NUT.TX FOR PKU WITH IRON NO.4 0.12G‐0.71 174 x x50600054814 PKU COOLER 20 LIQ COOLER NUT.TX FOR PKU WITH IRON NO.4 0.12G‐0.71 174 x x50600054838 PKU COOLER 20 LIQ COOLER NUT.TX FOR PKU WITH IRON NO.4 0.12G‐0.71 174 x x50600055019 PKU COOLER 20 LIQ COOLER NUT.TX FOR PKU WITH IRON NO.4 0.12G‐0.71 174 x x49735016129 PKU LOPHLEX LQ 20 POUCH NUT.TX FOR PKU WITH IRON NO.40 20‐116/125 125 x x49735016130 PKU LOPHLEX LQ 20 POUCH NUT.TX FOR PKU WITH IRON NO.40 20‐116/125 125 x x49735019535 PKU LOPHLEX LQ 20 POUCH NUT.TX FOR PKU WITH IRON NO.40 20‐116/125 125 x x24359030103 CAMINO PRO 15 PE PKU LIQ PACK NUT.TX FOR PKU WITH IRON NO.41 15‐140/140 140 x x24359030203 CAMINO PRO 15 PE PKU LIQ PACK NUT.TX FOR PKU WITH IRON NO.41 15‐140/140 140 x x24359034001 GLYTACTIN 15 PE COMPLETE BAR NUT.TX FOR PKU WITH IRON NO.41 15G‐320/81 7 x x24359035101 GLYTACTIN 20PE BETTERMILK LITE NUT.TX FOR PKU WITH IRON NO.41 39 G‐294 30 x x24359056403 GLYTACTIN RTD 10 PE LIQUID NUT.TX FOR PKU WITH IRON NO.41 4 G‐61/100 250 x x24359057403 GLYTACTIN RTD 10 PE LIQUID NUT.TX FOR PKU WITH IRON NO.41 4 G‐61/100 250 x x24359058403 GLYTACTIN RTD 15 PE LIQUID NUT.TX FOR PKU WITH IRON NO.41 6 G‐80/100 250 x x49735015096 PKU LOPHLEX LQ 20 POUCH NUT.TX FOR PKU WITH IRON NO.42 20‐115/125 125 x x00087510003 PHENYL‐FREE 2 POWDER NUT.TX FOR PKU WITH IRON NO.45 22G‐410 454 x x00087510010 PHENYL‐FREE 2HP POWDER NUT.TX FOR PKU WITH IRON NO.45 40G‐390 454 x x50600051455 PKU GEL POWDER PACKET NUT.TX FOR PKU WITH IRON NO.47 41.7 G‐317 30 x x50600051462 PKU GEL POWDER PACKET NUT.TX FOR PKU WITH IRON NO.47 41.7 G‐317 30 x x50600051448 PKU GEL POWDER PACKET NUT.TX FOR PKU WITH IRON NO.47 41.7 G‐338 30 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


00847095668 PHENYLADE RTD PKU 10 LIQUID NUT.TX FOR PKU WITH IRON NO.50 10G‐60/75 75 x x50600053220 PKU EXPRESS15 POWDER PACKET NUT.TX FOR PKU WITH IRON NO.52 60 G‐279 30 x x50600053305 PKU EXPRESS15 POWDER PACKET NUT.TX FOR PKU WITH IRON NO.52 60 G‐279 30 x x50600053336 PKU EXPRESS15 POWDER PACKET NUT.TX FOR PKU WITH IRON NO.52 60 G‐279 30 x x50600051769 PKU EXPRESS20 POWDER PACKET NUT.TX FOR PKU WITH IRON NO.52 60 G‐279 30 x x50600051776 PKU EXPRESS20 POWDER PACKET NUT.TX FOR PKU WITH IRON NO.52 60 G‐279 30 x x50600051783 PKU EXPRESS20 POWDER PACKET NUT.TX FOR PKU WITH IRON NO.52 60 G‐279 30 x x50600053206 PKU EXPRESS15 POWDER PACKET NUT.TX FOR PKU WITH IRON NO.52 60 G‐297 30 x x50600051639 PKU EXPRESS20 POWDER PACKET NUT.TX FOR PKU WITH IRON NO.52 60 G‐297 30 x x49735009474 PKU PERIFLEX JUNIOR PLUS POWD NUT.TX FOR PKU WITH IRON NO.55 28 G‐377 400 x x49735009476 PKU PERIFLEX JUNIOR PLUS POWD NUT.TX FOR PKU WITH IRON NO.55 28 G‐377 400 x x49735009478 PKU PERIFLEX JUNIOR PLUS POWD NUT.TX FOR PKU WITH IRON NO.55 28 G‐377 400 x x49735019474 PKU PERIFLEX JUNIOR PLUS POWD NUT.TX FOR PKU WITH IRON NO.55 28 G‐377 400 x x49735019476 PKU PERIFLEX JUNIOR PLUS POWD NUT.TX FOR PKU WITH IRON NO.55 28 G‐377 400 x x49735019478 PKU PERIFLEX JUNIOR PLUS POWD NUT.TX FOR PKU WITH IRON NO.55 28 G‐377 400 x x49735009477 PKU PERIFLEX JUNIOR PLUS POWD NUT.TX FOR PKU WITH IRON NO.55 28 G‐385 400 x x49735019477 PKU PERIFLEX JUNIOR PLUS POWD NUT.TX FOR PKU WITH IRON NO.55 28 G‐385 400 x x49735006832 PHENYLADE GMP DRINK POWDER NUT.TX FOR PKU WITH IRON NO.57 30 G‐396 400 x x49735016832 PHENYLADE GMP DRINK POWDER NUT.TX FOR PKU WITH IRON NO.57 30 G‐396 400 x x49735008324 PHENYLADE GMP DRINK POWDER PKT NUT.TX FOR PKU WITH IRON NO.57 30 G‐396 1 x x49735014116 PHENYLADE GMP DRINK POWDER PKT NUT.TX FOR PKU WITH IRON NO.57 30 G‐396 16 x x49735018304 PHENYLADE GMP DRINK POWDER PKT NUT.TX FOR PKU WITH IRON NO.57 30 G‐396 16 x x24359070503 PHENACTIN AA PLUS 20 PE LIQUID NUT.TX FOR PKU WITH IRON NO.59 8 G‐74/100 250 x x50059034101 PKU GO POWDER PACKET NUT.TX FOR PKU WITH IRON NO.60 50 G‐325 30 x x13034078795 ALFAMINO JUNIOR POWDER NUT.TX.IMPAIRED DIGEST FXN 400 x x70074056642 ENSURE CLEAR LIQUID NUT.TX.IMPAIRED DIGEST FXN 0.035‐1/ML 200 x x70074064899 ENSURE CLEAR LIQUID NUT.TX.IMPAIRED DIGEST FXN 0.035‐1/ML 237 x x70074064901 ENSURE CLEAR LIQUID NUT.TX.IMPAIRED DIGEST FXN 0.035‐1/ML 237 x x70074055253 ELECARE JR POWDER NUT.TX.IMPAIRED DIGEST FXN 14.3 G‐469 400 x x70074055254 ELECARE JR POWDER NUT.TX.IMPAIRED DIGEST FXN 14.3 G‐469 400 x x70074056585 ELECARE JR POWDER NUT.TX.IMPAIRED DIGEST FXN 14.3 G‐469 400 x x70074056586 ELECARE JR POWDER NUT.TX.IMPAIRED DIGEST FXN 14.3 G‐469 400 x x70074066271 ELECARE JR POWDER NUT.TX.IMPAIRED DIGEST FXN 14.3 G‐469 400 x x49735012124 NEOCATE JUNIOR POWDER NUT.TX.IMPAIRED DIGEST FXN 16G‐451 400 x x49735012690 NEOCATE JUNIOR POWDER NUT.TX.IMPAIRED DIGEST FXN 16G‐451 400 x x49735011790 NEOCATE JUNIOR POWDER NUT.TX.IMPAIRED DIGEST FXN 16G‐478 400 x x49735016739 NEOCATE NUTRA POWDER NUT.TX.IMPAIRED DIGEST FXN 8.2G‐472 400 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


49735010627 NEOCATE JR WITH PREBIOTICS PWD NUT.TX.IMPAIRED DIGEST/FIBER 16 G‐459 400 x x49735012912 NEOCATE JR WITH PREBIOTICS PWD NUT.TX.IMPAIRED DIGEST/FIBER 16 G‐459 400 x x98716006063 NUTREN JUNIOR FIBER 1 CAL LIQ NUTRIT SUPP/INULIN/FOS/FIBER 0.03G‐1/ML 250 x x98716006220 NUTREN 1.5 LIQUID NUTRITIONAL SUPPLEMENT 250 x x98716007363 PEPTAMEN JUNIOR 1.5 CAL LIQUID NUTRITIONAL SUPPLEMENT 250 x x98716006062 NUTREN JUNIOR 1 CAL LIQUID NUTRITIONAL SUPPLEMENT 0.03G‐1/ML 250 x x70074062120 PEDIASURE PEPTIDE 1.0 CAL LIQ NUTRITIONAL SUPPLEMENT 0.03G‐1/ML 237 x x70074062122 PEDIASURE PEPTIDE 1.0 CAL LIQ NUTRITIONAL SUPPLEMENT 0.03G‐1/ML 237 x x70074062124 PEDIASURE PEPTIDE 1.0 CAL LIQ NUTRITIONAL SUPPLEMENT 0.03G‐1/ML 237 x x98716060140 PEPTAMEN JUNIOR 1 CAL LIQUID NUTRITIONAL SUPPLEMENT 0.03G‐1/ML 250 x x70074056656 PEDIASURE PEPTIDE 1.5 CAL LIQ NUTRITIONAL SUPPLEMENT 0.045G‐1.5 237 x x00847095706 PHENYLADE AMINO ACID BAR NUTRITIONAL TX FOR PKU NO.31 10G‐270 1 x x00847095906 PHENYLADE AMINO ACID BAR NUTRITIONAL TX FOR PKU NO.31 10G‐270 1 x x00847095000 PHENYLADE AMINO ACID POWDER NUTRITIONAL TX FOR PKU NO.31 10G‐42/13G 454 x x00847095004 PHENYLADE AMINO ACID POWDER NUTRITIONAL TX FOR PKU NO.31 10G‐42/13G 30 x x00847095960 PHENYLADE MTE AMINO ACID POWD NUTRITIONAL TX FOR PKU NO.31 10G‐42/13G 454 x x00847095964 PHENYLADE MTE AMINO ACID POWD NUTRITIONAL TX FOR PKU NO.31 10G‐42/13G 30 x x00847095806 PHENYLADE AMINO ACID BAR NUTRITIONAL TX FOR PKU NO.32 10G‐270 1 x x00847095501 PHENYLADE PHEBLOC TABLET NUTRITIONAL TX FOR PKU NO.33 750 MG 550 x x24359035307 GLYTACTIN BUILD 10 PE POWD PK NUTRITIONAL TX FOR PKU NO.64 63 G‐338 30 x x24359035207 GLYTACTIN RESTORE 10 PE LITE NUTRITIONAL TX FOR PKU NO.65 53 G‐342 30 x x12539002111 PKU SPHERE20 POWDER PACKET NUTRITIONAL TX FOR PKU NO.67 56 G‐337 30 x x12539002112 PKU SPHERE20 POWDER PACKET NUTRITIONAL TX FOR PKU NO.67 56 G‐337 30 x x50600021117 PKU SPHERE20 POWDER PACKET NUTRITIONAL TX FOR PKU NO.67 56 G‐337 30 x x50600021124 PKU SPHERE20 POWDER PACKET NUTRITIONAL TX FOR PKU NO.67 56 G‐337 30 x x24359061004 GLYTACTIN SWIRL 15 PE PWDR PKT NUTRITIONAL TX FOR PKU NO.69 19 G‐390 14 x x12539002166 PKU AIR15 LIQUID POUCH NUTRITIONAL TX FOR PKU NO.70 15 G‐75 130 x x12539002167 PKU AIR15 LIQUID POUCH NUTRITIONAL TX FOR PKU NO.70 15 G‐75 130 x x12539002168 PKU AIR15 LIQUID POUCH NUTRITIONAL TX FOR PKU NO.70 15 G‐75 130 x x50600021667 PKU AIR15 LIQUID POUCH NUTRITIONAL TX FOR PKU NO.70 15 G‐75 130 x x50600021674 PKU AIR15 LIQUID POUCH NUTRITIONAL TX FOR PKU NO.70 15 G‐75 130 x x50600021681 PKU AIR15 LIQUID POUCH NUTRITIONAL TX FOR PKU NO.70 15 G‐75 130 x x12539002169 PKU AIR20 LIQUID POUCH NUTRITIONAL TX FOR PKU NO.70 20 G‐100 174 x x12539002170 PKU AIR20 LIQUID POUCH NUTRITIONAL TX FOR PKU NO.70 20 G‐100 174 x x12539002171 PKU AIR20 LIQUID POUCH NUTRITIONAL TX FOR PKU NO.70 20 G‐100 174 x x50600021698 PKU AIR20 LIQUID POUCH NUTRITIONAL TX FOR PKU NO.70 20 G‐100 174 x x50600021704 PKU AIR20 LIQUID POUCH NUTRITIONAL TX FOR PKU NO.70 20 G‐100 174 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


50600021711 PKU AIR20 LIQUID POUCH NUTRITIONAL TX FOR PKU NO.70 20 G‐100 174 x x49735011467 PHLEXY‐10 DRINK MIX POWDER NUTRITIONAL TX FOR PKU NO.8 8.33G‐69 30 x x49735011910 PHLEXY‐10 DRINK MIX POWDER NUTRITIONAL TX FOR PKU NO.8 8.33G‐69 30 x x00847095504 PHENYLADE PHEBLOC POWDER PKT NUTRITIONAL TX FOR PKU, NO.43 2.2G‐10/3G 110 x x50059034100 PKU EASY MICROTAB NUTRITIONAL TX FOR PKU, NO.56 70.8 G/110 110 x x24359034005 GLYTACTIN 10 PE COMPLETE BAR NUTRITIONAL TX FOR PKU, NO.62 10 G‐210 7 x x24359034006 GLYTACTIN 10 PE COMPLETE BAR NUTRITIONAL TX FOR PKU, NO.62 10 G‐220 7 x x49735001951 PHLEXY‐10 TABLET NUTRITIONAL TX PKU WITH NO.54 8.33G‐35 75 x x24359050203 KETOVIE 4:1 LIQUID NUTRITIONAL TX, KETOGENIC,WHEY 3.4 G‐144 250 x x70074056524 PEDIASURE SIDEKICKS LIQUID PEDI NUTRIT,IRON,LAC‐FREE,FIBR 0.03 G‐0.6 237 x x70074062485 PEDIASURE SIDEKICKS LIQUID PEDI NUTRIT,IRON,LAC‐FREE,FIBR 0.03 G‐0.6 237 x x70074062487 PEDIASURE SIDEKICKS LIQUID PEDI NUTRIT,IRON,LAC‐FREE,FIBR 0.03 G‐0.6 237 x x70074051807 PEDIASURE ENTERAL WITH FIBER PEDI NUTRIT,IRON,LAC‐FREE,FIBR 0.03G‐1/ML 237 x x70074056369 PEDIASURE WITH FIBER LIQUID PEDI NUTRIT,IRON,LAC‐FREE,FIBR 0.03G‐1/ML 237 x x70074058062 PEDIASURE WITH FIBER LIQUID PEDI NUTRIT,IRON,LAC‐FREE,FIBR 0.03G‐1/ML 237 x x70074058221 PEDIASURE WITH FIBER LIQUID PEDI NUTRIT,IRON,LAC‐FREE,FIBR 0.03G‐1/ML 237 x x70074056412 PEDIASURE 1.5 WITH FIBER LIQ PEDI NUTRIT,IRON,LAC‐FREE,FIBR 0.06 G‐1.5 237 x x70074064781 SIMILAC GO‐GROW POWDER PEDIATRIC NUT, IRON/DHA/ARA 680 x x70074063344 PEDIASURE SHAKE MIX POWDER PEDIATRIC NUT,MILK BASED,IRON 6 G‐170/38 397 x x43900033511 BOOST KID ESSENTIALS LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x43900033520 BOOST KID ESSENTIALS LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x70074051804 PEDIASURE ENTERAL LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x70074051805 PEDIASURE ENTERAL LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x70074051881 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x70074051883 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x70074051885 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x70074053582 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x70074053588 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x70074053818 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x70074055898 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x70074058050 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x70074058053 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x70074058056 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x70074058059 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G‐1/ML 237 x x43900033540 BOOST KID ESSENTIALS LIQUID PEDIATRIC NUTRITION, IRON, LF 0.04G‐1.5 237 x x43900033588 BOOST KID ESSENTIALS LIQUID PEDIATRIC NUTRITION, IRON, LF 0.04G‐1.5 237 x x70074056410 PEDIASURE 1.5 LIQUID PEDIATRIC NUTRITION, IRON, LF 0.06 G‐1.5 237 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


HEMATOPOIETICS

HEMATOPOIETICS‐ FOLIC ACID00536384401 FOLIC ACID 0.4 MG TABLET FOLIC ACID 0.4 MG 100 x x

HEMATOPOIETICS‐ IRON00813001206 FERRETTS 325 MG TABLET FERROUS FUMARATE 325(106)MG 60 x x50383062750 CHILD FERROUS SULFATE 15 MG/ML FERROUS SULFATE 15 MG/ML 50 x x39328005750 CHILDREN'S IRON 15 MG/ML DROPS FERROUS SULFATE 15 MG/ML 50 x x54838001150 FERROUS SULF 15 MG IRON/ML DRP FERROUS SULFATE 15 MG/ML 50 x x00904146516 FEROSUL 220 MG/5 ML ELIXIR FERROUS SULFATE 220 (44)/5 473 x x50383077816 FERROUS SULF 220 MG/5 ML ELIX FERROUS SULFATE 220 (44)/5 473 x x54838000180 FERROUS SULF 220 MG/5 ML ELIX FERROUS SULFATE 220 (44)/5 473 x x00121053005 FERROUS SULF 300 MG/5 ML LIQ FERROUS SULFATE 300 MG/5ML 5 x x00574060801 FERROUS SULF EC 324 MG TABLET FERROUS SULFATE 324(65)MG 100 x x00574060811 FERROUS SULF EC 324 MG TABLET FERROUS SULFATE 324(65)MG 100 x x00904759082 FEROSUL 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x00904759182 FEROSUL 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x49483006301 FERRO‐TIME 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x49483006401 FERRO‐TIME 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x00904759060 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x00904759160 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x00904759161 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x11917009215 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x37864000041 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x54629011090 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x57664007101 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x57896070301 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x79854001109 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x62107004401 FERROUSUL 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x11822110990 RA IRON 65 MG TABLET FERROUS SULFATE 325(65) MG 100 x x49348018010 SM IRON 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x81131074933 SV IRON 65 MG TABLET FERROUS SULFATE 325(65) MG 100 x x52304071304 NOVAFERRUM 15 MG/ML DROPS IRON POLYSACCHARIDE COMPLEX 15 MG/ML 120 x x60258018501 POLY‐IRON 150 MG CAPSULE IRON POLYSACCHARIDE COMPLEX 150 MG 100 x x12830082430 EZFE 200 CAPSULE IRON POLYSACCHARIDE COMPLEX 200 MG 30 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


61269091060 IRON CHEWS 15 MG TABLET CHEW IRON,CARBONYL 15 MG 60 x x63717010204 ICAR 15 MG/1.25 ML SUSPENSION IRON,CARBONYL 15MG/1.25 118 x x23359001204 WEE CARE 15 MG/1.25 ML SUSP IRON,CARBONYL 15MG/1.25 118 x x46017009660 FEOSOL 45 MG CAPLET IRON,CARBONYL 45 MG 60 x x

HEMATOPOIETICS‐ HEMATOPOIETIC MIXTURES52304071406 NOVAFERRUM 125 LIQUID IRON POLYSACCHARIDE COMPLEX/D3 125 MG/5ML 180 x x

OPHTHALMICSOPHTHALMICS‐ ARTIFICIAL TEARS

00023040370 REFRESH PLUS 0.5% EYE DROPS CARBOXYMETHYLCELLULOSE SODIUM 0.5 % 70 x x00023079815 REFRESH TEARS 0.5% EYE DROPS CARBOXYMETHYLCELLULOSE SODIUM 0.5 % 15 x x00023455430 REFRESH CELLUVISC 1% EYE DROPS CARBOXYMETHYLCELLULOSE SODIUM 1 % 30 x x17478006235 ARTIFICIAL TEARS EYE OINTMENT MINERAL OIL/PETROLATUM,WHITE 15 %‐83 % 3.5 x x00065050935 SYSTANE NIGHTTIME EYE OINT MINERAL OIL/PETROLATUM,WHITE 3 %‐94 % 3.5 x x00023031204 REFRESH LACRI‐LUBE OINTMENT MINERAL OIL/PETROLATUM,WHITE 42.5‐56.8% 3.5 x x00023024004 REFRESH P.M. OINTMENT MINERAL OIL/PETROLATUM,WHITE 42.5‐57.3% 3.5 x x74300001067 VISINE TEARS DROPS PEG 400/HYPROMELLOSE/GLYCERIN 1‐0.2‐0.2% 15 x x00536108494 ARTIFICIAL TEARS 1.4 % DROPS POLYVINYL ALCOHOL 1.4 % 15 x x00023050601 REFRESH CLASSIC EYE DROPS POLYVINYL ALCOHOL/POVIDONE/PF 1.4 %‐0.6% 30 x x00065045407 SYSTANE GEL EYE DROPS PROPYLENE GLYCOL/PEG 400 0.3 %‐0.4% 10 x x00065143105 SYSTANE ULTRA 0.4‐0.3% EYE DRP PROPYLENE GLYCOL/PEG 400 0.3 %‐0.4% 10 x x

OPHTHALMICS‐ ANTIHISTAMINE24208060110 ALAWAY 0.025% EYE DROPS KETOTIFEN FUMARATE 0.025 % 10 x x49035092301 EQ EYE ITCH RELIEF 0.025% DROP KETOTIFEN FUMARATE 0.025 % 10 x x00363906000 EYE ITCH RELIEF 0.025% DROPS KETOTIFEN FUMARATE 0.025 % 10 x x62011023201 HM EYE ITCH RELIEF 0.025% DROP KETOTIFEN FUMARATE 0.025 % 5 x x00179860105 KETOTIFEN FUM 0.025% EYE DROPS KETOTIFEN FUMARATE 0.025 % 5 x x17478071710 KETOTIFEN FUM 0.025% EYE DROPS KETOTIFEN FUMARATE 0.025 % 5 x x00065401105 ZADITOR 0.025% (0.035%) DROPS KETOTIFEN FUMARATE 0.025 % 5 x x

OPHTHALMICS‐ HYPERTONIC SOD CHLORIDE24208027615 MURO‐128 2% EYE DROPS SODIUM CHLORIDE 2 % 15 x x00363904000 SODIUM CHLORIDE 5% EYE DROP SODIUM CHLORIDE 5 % 15 x x17478062235 SODIUM CHLORIDE 5% EYE OINT SODIUM CHLORIDE 5 % 3.5 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


OTICS

OTICS‐ EAR WAX REMOVAL42037010478 DEBROX 6.5% EAR DROPS CARBAMIDE PEROXIDE 6.5 % 15 x x

ORAL TOPICAL

ORAL TOPICAL‐ MOUTHWASHES48582000155 BIOTENE MOISTURIZING MOUTH SPR SALIVA STIMULANT AGENTS COMB.3 44.3 x x48582000330 BIOTENE DRY MOUTH ORAL RINSE SALIVA SUBSTITUTE COMBO NO.9 473 x x

ORAL TOPICAL‐ ANESTHETICS00573021341 ANBESOL LIQUID BENZOCAINE 10 % 12 x x00283087131 HURRICAINE 20% GEL BENZOCAINE 20 % 30 x x11917013226 ORAL ANESTHETIC 20% PASTE BENZOCAINE 20 % 12 x x

ALTERNATIVE MEDICATIONSALTERNATIVE MEDICATIONS‐ COENZYME Q‐10

00904588246 COENZYME Q‐10 100 MG SOFTGEL UBIDECARENONE 100 MG 30 x x58487003230 COENZYME Q‐10 50 MG TABLET UBIDECARENONE 50 MG 50 x x

ALTERNATIVE MEDICATIONS‐ MELATONIN00536111411 MELATONIN 1 MG TABLET MELATONIN 1 MG 90 x x47469000465 MELATONIN 1 MG TABLET MELATONIN 1 MG 90 x x54629898360 MELATONIN TR 1 MG TABLET MELATONIN 1 MG 60 x x47469000457 MELATONIN 1 MG LIQUID MELATONIN 1 MG/4 ML 60 x x30768016836 MELATONIN 1 MG/ML LIQUID MELATONIN 1 MG/ML 59 x x30768019484 MELATONIN 10 MG CAPSULE MELATONIN 10 MG 90 x x74312019491 MELATONIN 10 MG CAPSULE MELATONIN 10 MG 60 x x96295012565 MELATONIN 10 MG TABLET SL MELATONIN 10 MG 60 x x50428035025 CVS MELATONIN 3 MG TABLET MELATONIN 3 MG 120 x x87701040813 GNP MELATONIN 3 MG TABLET MELATONIN 3 MG 100 x x00536641208 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x00536641268 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x00904518206 MELATONIN 3 MG TABLET MELATONIN 3 MG 50 x x00904518252 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x11845112805 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x




Covered‐ Kids

PA only‐ Kids

Covered‐ Adults

PA only‐ Adults


47469000510 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x51991001406 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x54458021360 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x54629060900 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x79854001609 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x47469000458 MELATONIN SR 3 MG TABLET MELATONIN 3 MG 100 x x54629050260 MELATONIN TR 3 MG TABLET MELATONIN 3 MG 60 x x11822880980 RA MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x11917014868 MELATONIN 3 MG ODT MELATONIN 3 MG ODT 30 x x30768000541 MELATONIN 300 MCG TABLET MELATONIN 300 MCG 120 x x74312015745 MELATONIN 5 MG SOFTGEL MELATONIN 5 MG 90 x x00536109808 MELATONIN 5 MG TABLET MELATONIN 5 MG 60 x x54629061500 MELATONIN 5 MG TABLET SL MELATONIN 5 MG 60 x x11822511120 RA MELATONIN 5 MG TABLET MELATONIN 5 MG 100 x x47469004837 MELATONIN TR 5 MG TABLET MELATONIN/PYRIDOXINE HCL (B6) 100 x x

PEAK FLOW METERS / INHALER DEVICES8373081211 PEDIATRIC MEDIUM MASK INHALER,ASSIST DEVICE,ACCESORY 1 x x8373081111 PEDIATRIC SMALL MASK INHALER,ASSIST DEVICE,ACCESORY 1 x x8373552900 SIDESTREAM PEDIATRIC FACE MASK INHALER,ASSIST DEVICE,ACCESORY 1 x x73796069940 PEAK‐AIR PEAK FLOW METER PEAK FLOW METER 1 x x

DELIVERY DEVICES07249022225 THIK & CLEAR HONEY POWDER PKT CELLULOSE GUM 1 x x07249022224 THIK & CLEAR NECTAR POWDER PKT CELLULOSE GUM 1 x x41679015194 THICKEN UP CLEAR POWDER MALTODEXTRIN/XANTHAN GUM 125 x x43900015194 THICKEN UP CLEAR POWDER MALTODEXTRIN/XANTHAN GUM 125 x x43900015191 THICKEN UP CLEAR POWDER PACKET MALTODEXTRIN/XANTHAN GUM 288 x x11917013237 THICK NOW POWDER STARCH 850 x x


TennCare Covered OTC Products - Magellan Health · TennCare Covered OTC List Effective 7/1/19 NDC...

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Transcript of TennCare Covered OTC Products - Magellan Health · TennCare Covered OTC List Effective 7/1/19 NDC...