Non-Drug Product List

Effective November 15, 2013 Non-Drug Products Indicates Prior Authorization Required

Ammonium Lactate Lotion 12% Aquadeks Capsules  AquaADEKS Tabs  AquaADEKS Solution  Bacteriostatic Sodium Chloride Injection 0.9% Bacteriostatic Water for Injection Bacteriostatic Parabens Water for Injection Calcium Carbonate 500mg Chewable Tablets  Calcium Carbonate 750mg Chewable Tablets  Calcium Carbonate 1000mg Chewable Tablets  Calcium Carbonate 1250mg Chewable Tablets  Calcium Carbonate 1250mg/5ml Suspension  Calcium Carbonate 600mg Tablets  Calcium Carbonate-Vitamin D 500mg/200 unit  Calcium Carbonate Vitamin D 600mg/200 unit  Calcium Carbonate Vitamin D 600mg/400 unit Tablets  Calcium Citrate 950mg Tablets  Calcium Glubionate 1.8gm/5mL  Calcium Gluconate 650mg Tablets  Calcium Lactate 650mg Tablets  Calvite P&D Tablets  Cerovite Jr Chewable Tablets  Cerovite Liquid  Cholecalciferol 400 Unit Tablets  Epoprostenolol Diluents (Flolan) 0.5mg Epoprostenolol Diluents (Flolan) 1.5mg Ferrous Fumarate 325mg Tablets Ferrous Gluconate 324mg Tablets Ferrous Gluconate 325mg Tablets Ferrous Sulfate 75mg/0.6ml Drops Ferrous Sulfate 75mg/ml Drops Ferrous Sulfate 220mg/5ml Elixir Ferrous Sulfate 325mg Tablets Magnesium Chloride ER Tablet 535 (64mg) MG  Magnesium Gluconate 1000mg/5mL  Magnesium Oxide 400mg Tablets  Maximum D3 Capsules  Metronidazole Powder Multiple Vitamins Tablets  Nephro-vite Tablets  Niacin Tablets, 50mg Niacin Tablets, 100mg Niacin Tablets, 250mg Niacin Tablets, 500mg Pediatric Oral Electrolyte Solutions Phos-Nak Powder Concentrate  Polysaccharide Iron Complex 150mg Capsules  Poly-Vi-Sol Drops  Poly-Vi-Sol Drops/Iron  Progesterone Powder Progesterone Micronized Powder Pyridoxine Tablets 100mg  Pyridoxine Tablets 25mg  Pyridoxine Tablets 50mg  Slow-Mag Tablets  Sodium Bicarbonate 325mg Tablets  Sodium Bicarbonate 650mg Tablets  Sodium Chloride Injection Sodium Chloride Solution 0.9% for inhalation Thera-M Tablets Enhanced  Tri-Vi-Sol Drops  Tri-Vi-Sol Drops/Iron  Vitamin A Capsules 10000I U  Vitamin B-1 Tablets 100mg  Vitamin B-1 Tablets 50mg  Vitamin B-12 Tablets 1000 CR  Vitamin B-12 Tablets 1000 mcg  Vitamin C Chewable Tablets 500mg  Vitamin C Tablets 500mg  Vitamin C Tablets 1000mg  Vitamin D Drops 400 Unit  Vitamin D Tablets 1000 Unit  Vitamin D Tablets 2000 Unit  Vitamin D Tablets 400 Unit  Vitamin E Capsules 400 Unit 