Tenncare Covered OTC List - Effective 6/1/2021

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TennCare Covered OTC List - Effective 6/1/2021

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults ANTIHELMENTIC Please refer to TennCare's PDL for coverage of the following: PYRANTEL PAMOATE

EMERGENCY CONTRACEPTIVES Please refer to TennCare's PDL for coverage of the following: AFTERA® OTC PLAN B® ONE-STEP OTC TAKE ACTION® OTC

DIABETES

INSULIN PRODUCTS Please refer to TennCare's PDL for coverage of the following: HUMULIN 70/30 KWIKPEN HUMULIN 70-30 VIAL HUMULIN N VIAL HUMULIN R VIAL NOVOLIN R VIAL NOVOLIN 70-30 VIAL NOVOLIN N VIAL

00169183702 RELION NOVOLIN 70-30 VIAL INSULIN NPH HUM/REG INSULIN HM 70-30/ML 10 x x 00169183402 RELION NOVOLIN N 100 UNIT/ML INSULIN NPH HUMAN ISOPHANE 100/ML 10 x x 00169183302 RELION NOVOLIN R 100 UNIT/ML INSULIN REGULAR, HUMAN 100/ML 10 x x

GLUCOSE 00574006930 GLUTOSE 15 GEL DEXTROSE 40 % 37.5 x x 00574007030 GLUTOSE 15 GEL 40% DEXTROSE 40 % 37.5 x x 11917004681 GLUCOSE CHW ORANGE DEXTROSE 4 GM 50 x x 11917006843 GLUCOSE CHW 4GM DEXTROSE 4 GM 10 x x 11917006844 GLUCOSE CHW 4GM DEXTROSE 4 GM 10 x x 11917013294 GLUCOSE CHW ORANGE GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 50 x x 11917013315 GLUCOSE CHW TROP FRT GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 10 x x 11917016740 GLUCOSE CHW ORANGE GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 50 x x 11917016741 GLUCOSE CHW 4GM DEXTROSE 4 GM 50 x x 11917016744 GLUCOSE CHW RASPBRRY GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 10 x x 11917016944 GLUCOSE GEL 15GM/33G GLUCOSE GEL 15 GM/33GM 33 x x 38396051691 TGT GLUCOSE CHW GRAPE GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 10 x x 38396054132 GLUCOSE CHW ORANGE GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 50 x x 38396054363 DEX4 CHW GRAPE GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 50 x x 38396055025 GLUCOSE GEL 40% DEXTROSE 40 % 38 x x 38396055675 CVS GLUCOSE CHW TROP BLS GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 50 x x 38396061375 CVS GLUCOSE CHW FRUIT GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 100 x x 49348073401 SM GLUCOSE CHW SOUR APP DEXTROSE 4 GM 10 x x 50428001769 CVS GLUCOSE CHW ORANGE GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 50 x x 50428235154 CVS GLUCOSE CHW RASPBERY GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 10 x x 56151162501 TRUEPLS GLUC GEL 15/32ML GLUCOSE GEL 15 GM/32ML 32 x x 80681010000 GLUCOSE CHW 4GM DEXTROSE 4 GM 10 x x 83744025204 GLUCO BURST GEL 40% DEXTROSE 40 % 37.5 x x

SYRINGES/NEEDLES 08290301604 BD 10 ML SYRINGE SYRINGE, DISPOSABLE, 10 ML 100 x x 86227048125 10ML SYRINGE MIS LUER LOK SYRINGE, DISPOSABLE, 10 ML 100 x x 81131031167 RELION INS SYR 0.3 ML 29GX1/2" SYRING-NEEDL,DISP,INSUL,0.3 ML 29 G X1/2" 10 x x 08222092397 ULTICARE SYRIN 0.3 ML 29GX1/2" SYRING-NEEDL,DISP,INSUL,0.3 ML 29 G X1/2" 100 x x 11917001492 INSULIN 3/10 ML SYRINGE SYRING-NEEDL,DISP,INSUL,0.3 ML 29 GAUGE 100 x x 56151171101 TRUEPLUS SYR 0.3ML 29GX1/2" SYRING-NEEDL,DISP,INSUL,0.3 ML 29 G X1/2" 100 x x 86227090035 SURE COMFORT 3/10 ML SYRINGE SYRING-NEEDL,DISP,INSUL,0.3 ML 29 G X1/2" 100 x x 57515017459 INSULIN SYRIN 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 10 x x 81131031177 RELION SYRING 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 10 x x 08222074591 ULTICARE SYR 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 08222093394 ULTICARE SYR 0.3 ML 30GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 08222094599 ULTICARE SYR 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 08290328431 BD SYRINGE 0.3 ML 12.7MMX30G SYRING-NEEDL,DISP,INSUL,0.3 ML 30GX1/2" 100 x x 08290328468 BD INSULIN SYR 0.5 ML 8MMX31G SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 08396801000 ULTRA COMFORT 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 08396801900 CA INS SYR 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 08496303601 EASY TOUCH INSULIN SYR 0.3 ML SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 08496315601 EASY TOUCH INSULIN SYR 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 08881609231 MONOJECT SYRINGE 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 08881609800 ULTRA COMFORT 0.3 ML SYRINGE SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 11917002527 INSULIN 3/10 ML SYRINGE SYRING-NEEDL,DISP,INSUL,0.3 ML 30 GAUGE 100 x x 38396042008 LEADER SYRING 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 56151172101 TRUEPLUS SYR 0.3ML 30GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 56151173201 TRUEPLUS SYR 0.5ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 57515009459 ULTICARE SYR 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 81131031176 RELION SYRING 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 86227065055 SURE COMFORT 0.5 ML SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 86227070035 SURE COMFORT 3/10 ML SYRINGE SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 89134072202 ULTRA-THIN II INS 0.3 ML 30G SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 90166005635 INSULIN SYRG MIS 0.3/30G SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 90166015655 INSULIN SYRIN 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 90166045635 INSULIN SYRIN 0.3 ML 30GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 91237000188 EASY COMFORT 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 98302013930 COMFORT EZ INSULIN SYR 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 98302013931 COMFORT EZ INS 0.3ML 30GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 90166045035 INSULIN SYRG MIS 0.3/30G INSULIN SYRINGE/NEEDLE,0.3 ML 30 X 1/2" 100 x x 89134074202 INSULIN SYRG MIS 0.5/31G INSULIN SYRINGE/NEEDLE,0.5 ML 31 X 5/16" 200 x x 08222082589 ULTICARE SYRIN 0.5 ML 28GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 08290329461 BD INSULIN SYR 0.5 ML 28GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 08290329465 BD INSULIN SYR 0.5 ML 28GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 08396800100 ULTRA COMFORT 0.5 ML 28GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 08496285501 EASY TOUCH INSULIN SYR 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 08881600004 MONOJECT INSUL SYR U100 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 38396076339 SM INSULIN SYR 0.5 ML 28GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 56151170201 TRUEPLUS SYR 0.5ML 28GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 86227080055 SURE COMFORT 0.5 ML SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 81131031165 INSULIN SYRG MIS 0.5/29G SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 10 x x 08222092595 ULTICARE SYR 0.5 ML 29GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 08290305932 INSULIN SYRG MIS 0.5/29G SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 08496295501 EASY TOUCH INSULIN SYR 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 08881600350 MONOJECT INSUL SYR U100 SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 08881609350 ULTRA COMFORT 0.5 ML 29GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 11917001489 INSULIN 1/2 ML SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 29 GAUGE 100 x x 38396040408 LEADER INS SYR 0.5 ML 29GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 38396044364 GNP ULTRA COMFORT 0.5 ML SYR SYRINGE-NEEDLE,INSULIN,0.5 ML 29 GAUGE 100 x x 56151171201 TRUEPLUS SYR 0.5ML 29GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 57515009259 ULTICARE SYR 0.5 ML 29GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 86227090055 SURE COMFORT 0.5 ML SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 90166095055 INSULIN SYRIN 0.5 ML 29GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 89134052802 INSULIN SYRG MIS 0.5/29G SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 200 x x 08222093592 ULTICARE SYR 0.5 ML 30GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 08290305934 BD SAFTGLD INS SYR 0.5 ML 30G SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 08396800700 INSULIN SYRG MIS 0.5/30G SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 08496305601 EASY TOUCH INSULIN SYR 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 08881609700 ULTRA COMFORT 0.5 ML SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 11917002528 INSULIN 1/2 ML SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 30 GAUGE 100 x x 38396041537 TOPCARE ULTRA COMFORT SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 56151172201 TRUEPLUS SYR 0.5ML 30GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 57515009359 ULTICARE SYR 0.5 ML 30GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 86227070055 SURE COMFORT 0.5 ML SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 89134061802 ULTRA-THIN II INS 0.5 ML 30G SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 90166005655 INSULIN SYRIN 0.5 ML 30GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 94046000164 ADVOCATE INS 0.5 ML 30GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 98302013932 COMFORT EZ INSULIN SYR 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 08290328279 INSULIN SYRG MIS 0.5/30G INSULIN SYRINGE/NEEDLE,0.5 ML 30 X 1/2" 90 x x 08290329651 BD INSULIN SYR 1 ML 25GX5/8" SYRINGE AND NEEDLE,INSULIN,1ML 25GX5/8" 100 x x 08290324909 BD INSULIN SYR 0.3 ML 6MMX31G SYRING-NEEDL,DISP,INSUL,0.3 ML 31GX15/64" 100 x x 08290324910 BD SYR 0.3 ML 6MMX31G (1/2) SYRING-NEEDL,DISP,INSUL,0.3 ML 31GX15/64" 100 x x 81131013838 RELION INS SYR 0.3 ML 31GX6MM SYRING-NEEDL,DISP,INSUL,0.3 ML 31GX15/64" 100 x x 08222910066 ULTICARE INS 0.3 ML 31GX1/4" SYRING-NEEDL,DISP,INSUL,0.3 ML 31 G X1/4" 100 x x 08222910080 ULTICARE INS 0.5 ML 31GX1/4" SYRING-NEEDL,DISP,INSUL,0.5 ML 31 X 1/4" (6 MM) 100 x x 08496271501 EASY TOUCH 1 ML SYR 27GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 27GX1/2" 100 x x 08290329412 BD INSULIN SYR 1 ML 27GX5/8" SYRINGE AND NEEDLE,INSULIN,1ML 27GX5/8" 100 x x 08222082183 ULTICARE INS SYR 1 ML 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x 08290329410 BD INSULIN SYR 1 ML 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x 08290329420 BD INSULIN SYR 1 ML 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x 08290329424 BD INSULIN SYR 1 ML 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x 08396800200 ULTRA COMFORT 1 ML 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x 08496281501 EASY TOUCH INSULIN SYR 1 ML SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x 08881601101 MONOJECT 1 ML SYRN 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x 08881609101 ULTRA COMFORT 1 ML SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x 56151170301 TRUEPLUS SYR 1ML 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x 86227080105 SURE COMFORT 1 ML SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x 89134050302 MAXI-COMFORT INS 1 ML 28GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2" 100 x x 81131031163 RELION INS SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 10 x x 08222092199 ULTICARE INS SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 08290305930 BD INSULIN SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 08290329464 BD INSULIN SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 08396800500 ULTRA COMFORT 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 08496291501 EASY TOUCH INSULIN SYR 1 ML SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 08881601358 MONOJECT INSUL SYR U100 1 ML SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 08881609358 ULTRA COMFORT 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 38396040508 LEADER INS SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 38396041337 TOPCARE ULTRA COMFORT SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 56151171301 TRUEPLUS SYR 1ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 57515009219 ULTICARE INS SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 81131031162 RELION INS SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 86227090105 SURE COMFORT 1 ML SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 89134052902 ULTRA-THIN II INS SYR 1 ML 29G SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 90166095015 INSULIN SYRINGE 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 98302013938 COMFORT EZ SYR 1 ML 29GX1/2" SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 08222093196 ULTICARE SYR 1 ML 30GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x 08396800800 ULTRA COMFORT 1 ML 30GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x 08496301601 EASY TOUCH INSULIN SYR 1 ML SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x 08881609600 ULTRA COMFORT 1 ML 30GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x 11917002529 INSULIN 1 ML SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 30 GAUGE 100 x x 38396044764 GNP ULTRA COMFORT 1 ML SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 30 GAUGE 100 x x 56151172301 TRUEPLUS SYR 1ML 30GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x 57515009319 ULTICARE SYR 1 ML 30GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x 86227070105 SURE COMFORT 1 ML SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x 89134062002 ULTRA-THIN II INS SYR 1 ML 30G SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x 90166005615 INSULIN SYRINGE 1 ML 30GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x 91237000108 EASY COMFORT INSULIN 1 ML SYR SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x 98302013933 COMFORT EZ SYR 1 ML 30GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16" 100 x x 08496311611 EASY TOUCH INSULIN SYR 1 ML SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 10 x x 57515017419 INSULIN SYRINGE 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 10 x x 81131031175 RELION INS SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 10 x x 08222074195 ULTICARE SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 08222094193 ULTCARE INS SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 08290328418 INSULIN SYRG MIS 1ML/31G SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 08290329416 BD INSULIN SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 08396801100 ULTRA COMFORT 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 08396802000 CA INSULIN SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 08496311601 EASY-TOUCH INS 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 08881609131 MONOJECT SYRINGE 1 ML SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 11917004813 INSULIN SYRINGE 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 38396042108 LEADER INS SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 38396045164 INSULIN SYRG MIS 1ML/31G SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 38396047339 SM INSULIN SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 38415001631 INSULIN SYRINGE 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 56151173301 TRUEPLUS SYR 1ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 57515009419 ULTCARE INS SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 81131031174 RELION INS SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 86227065105 SURE COMFORT 1 ML SYRINGE SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 89134074402 ULTRA-THIN II 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 90166015615 INSULIN SYRINGE 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 91237000189 EASY COMFORT 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 94046000168 ADVOCATE INS 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 98302013919 COMFORT EZ SYR 1 ML 31GX5/16" SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16" 100 x x 81131031179 RELION SYRING 0.3 ML 31GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 10 x x 08222074393 ULTICARE SYR 0.3 ML 31GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 08222094391 ULTICARE SYR 0.3 ML 31GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 08290305937 BD SAFTGLD INS 0.3 ML 31GX5/16 SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 08290328438 BD INSULIN SYR 0.3 ML 8MMX31G SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 08290328440 BD SYR 0.3 ML 8MMX31G (1/2) SYRGE-NDL,INS 0.3 ML HALF MARK 31 GX5/16" 100 x x 08396800900 ULT CFT 0.3 ML 31GX5/16" (1/2) SYRGE-NDL,INS 0.3 ML HALF MARK 31 GX5/16" 100 x x 08396801800 INSULIN SYRG MIS 0.3/31G SYRGE-NDL,INS 0.3 ML HALF MARK 31 GX5/16" 100 x x 08496313601 EASY TOUCH INSULIN SYR 0.3 ML SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 08881609331 MONOJECT SYRINGE 0.3 ML SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 11917004815 INSULIN SYRIN 0.3 ML 31GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 38396041908 LEADER SYRING 0.3 ML 31GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 38396044964 GNP INSUL SYR 0.3 ML 31GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 56151173101 TRUEPLUS SYR 0.3ML 31GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 57515009439 ULTICARE SYR 0.3 ML 31GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 81131031178 RELION SYRING 0.3 ML 31GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 86227065035 SURE COMFORT 3/10 ML SYRINGE SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 86227065045 SURE COMFORT 0.3 ML SYRINGE SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 90166015635 INSULIN SYRIN 0.3 ML 31GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 81131013834 RELION INS SYR 1 ML 31GX15/64" INSULIN SYRINGE/NEEDLE,1 ML 31 X 15/64" 100 x x 08222093158 INSULIN SYRG MIS 1ML/30G INSULIN SYRINGE/NEEDLE,1 ML, 30G X 1/2" 100 x x 08222093554 INSULIN SYRG MIS 0.5/30G INSULIN SYRINGE/NEEDLE,0.5 ML 30 X 1/2" 100 x x 08222910097 INSULIN SYRG MIS 1ML/31G SYRING-NEEDL,DISP,INSUL,1 ML 31 X 1/4" (6 MM) 100 x x 08290324911 INSULIN SYRG MIS 0.5/31G INSULIN SYRINGE/NEEDLE,1/2 ML 31 X 15/64" 100 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 08290324912 INSULIN SYRG MIS 1ML/31G INSULIN SYRINGE/NEEDLE,1 ML 31 X 15/64" 100 x x 08290328411 INSULIN SYRG MIS 1ML/30G INSULIN SYRINGE/NEEDLE,1 ML, 30G X 1/2" 100 x x 08290328466 INSULIN SYRG MIS 0.5/30G INSULIN SYRINGE/NEEDLE,0.5 ML 30 X 1/2" 100 x x 08290329622 INSULIN SYRG MIS 1ML/25G SYRING-NEEDL,DISP,INSUL,1 ML 25 G X1" 100 x x 08290490901 INSULIN SYRG MIS 0.3/31G SYRING-NEEDL,DISP,INSUL,0.3 ML 31GX15/64" 10 x x 08290491101 INSULIN SYRG MIS 0.5/31G INSULIN SYRINGE/NEEDLE,1/2 ML 31 X 15/64" 10 x x 08290491201 INSULIN SYRG MIS 1ML/31G INSULIN SYRINGE/NEEDLE,1 ML 31 X 15/64" 10 x x 08484990435 INSULIN SYRG MIS 0.5/31G INSULIN SYRINGE/NEEDLE,0.5 ML 31 X 5/16" 100 x x 08496301501 INSULIN SYRG MIS 1ML/30G INSULIN SYRINGE/NEEDLE,1 ML, 30G X 1/2" 100 x x 11917001487 INSULIN SYRG MIS 1ML/29G SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2" 100 x x 11917004814 INSULIN SYRG MIS 0.5/31G INSULIN SYRINGE/NEEDLE,0.5 ML 31 X 5/16" 100 x x 38396040725 INSULIN SYRG MIS 0.5/30G SYRINGE, DISPOSABLE, 10 ML 100 x x 81131013835 INSULIN SYRG MIS 1ML/31G INSULIN SYRINGE/NEEDLE,1 ML 31 X 15/64" 10 x x 81131013836 INSULIN SYRG MIS 0.5/31G INSULIN SYRINGE/NEEDLE,1/2 ML 31 X 15/64" 100 x x 81131013837 INSULIN SYRG MIS 0.5/31G INSULIN SYRINGE/NEEDLE,1/2 ML 31 X 15/64" 10 x x 81131013839 INSULIN SYRG MIS 0.3/31G SYRING-NEEDL,DISP,INSUL,0.3 ML 31GX15/64" 10 x x 86227062105 INSULIN SYRG MIS 1ML/30G INSULIN SYRINGE/NEEDLE,1 ML, 30G X 1/2" 100 x x 90166005015 INSULIN SYRG MIS 1ML/30G INSULIN SYRINGE/NEEDLE,1 ML, 30G X 1/2" 100 x x 90166025635 INSULIN SYRG MIS 0.3/31G SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 98302013920 INSULIN SYRG MIS 0.3/31G SYRING-NEEDL,DISP,INSUL,0.3 ML 31 GX5/16" 100 x x 08290309626 1ML TB SYRNG MIS 25GX5/8" TUBERCULIN/ALLERGY SYRINGES,1 ML 25GX5/8" 100 x x 08290305945 1ML TB SYRNG MIS 27GX1/2" TUBERCULIN/ALLERGY SYRINGES,1 ML 27GX1/2" 100 x x 08290309623 1ML TB SYRNG MIS 27GX1/2" TUBERCULIN/ALLERGY SYRINGES,1 ML 27GX1/2" 100 x x 08290309580 3ML LL SYRNG MIS 18GX1.5" SYRINGE/NEEDLE (DISP) 3 ML 100 x x 08290309598 BD 3 ML SYRINGE WITH NEEDLE SYRINGE W-NEEDLE,DISPOSAB,3 ML 21 G X 1" 100 x x 08290309577 BD 3 ML SYRINGE WITH NEEDLE SYRINGE W-NEEDLE,DISPOSAB,3 ML 21GX1 1/2" 100 x x 08290309572 BD 3 ML SYRINGE WITH NEEDLE SYRINGE W-NEEDLE,DISPOSAB,3 ML 22GX1" 100 x x 08290309574 BD 3 ML SYRINGE WITH NEEDLE SYRINGE W-NEEDLE,DISPOSAB,3 ML 22GX1 1/2" 100 x x 08290309571 BD 3 ML SYRINGE WITH NEEDLE SYRINGE W-NEEDLE,DISPOSAB,3 ML 23GX1" 100 x x 08290309588 BD 3 ML SYRINGE WITH NEEDLE SYRINGE W-NEEDLE,DISPOSAB,3 ML 23GX1" 100 x x 08290309570 BD LUER-LOK SYR 3 ML 25GX5/8" SYRINGE W-NEEDLE,DISPOSAB,3 ML 25GX5/8" 100 x x 08290309581 BD 3 ML SYRINGE 25GX1" SYRINGE W-NEEDLE,DISPOSAB,3 ML 25GX1" 100 x x 08290309582 BD 3 ML SYRINGE 25GX1-1/2" SYRINGE W-NEEDLE,DISPOSAB,3 ML 25GX1 1/2" 100 x x

PEN NEEDLES 08396901734 RELION PEN NEEDLE 29GX1/2" PEN NEEDLE, DIABETIC 29 G X1/2" 50 x x 08222095121 ULTICARE PEN NEEDLES 12MM 29G PEN NEEDLE, DIABETIC 29 G X1/2" 100 x x 08470352901 UNIFINE PENTIPS 12MM 29G PEN NEEDLE, DIABETIC 29 G X1/2" 100 x x 08496290201 EASY TOUCH PEN NEEDLE 29GX1/2" PEN NEEDLE, DIABETIC 29 G X1/2" 100 x x 90166012122 PEN NEEDLES 12MM 29G PEN NEEDLE, DIABETIC 29 G X1/2" 100 x x 08290328203 BD ULTRA-FINE NDL 12.7MMX29G PEN NEEDLE, DIABETIC 29 G X1/2" 100 x x 86227010105 SURE COMFORT PEN NDL 29GX1/2" PEN NEEDLE, DIABETIC 29 G X1/2" 100 x x 86227011155 SURE COMFORT 30G PEN NEEDLE PEN NEEDLE, DIABETIC 30G X5/16" 100 x x 08470115001 UNIFINE PENTIPS 31GX3/16" PEN NEEDLE, DIABETIC 31 GX3/16" 30 x x 08214050757 UNIFINE PENTIPS PLUS 31GX3/16" PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x 08214085029 PUB UNIFINE PNTP PLUS 31GX3/16 PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x 08214385034 UNIFINE PENTIPS PLUS 31GX3/16" PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x 08290320119 BD ULTRA-FINE PEN NDL 5MMX31G PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x 08470355001 UNIFINE PENTIPS 31GX3/16" PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x 08470385001 UNIFINE PENTIPS PLUS 31GX3/16" PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x 08496310101 EASY TOUCH PEN NEEDLE 31GX3/16 PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x 86227012105 SURE COMFORT PEN NDL 31GX3/16" PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x 89134063102 MINI ULTRA-THIN II PEN NDL 31G PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x 90166063132 PEN NEEDLES 5MM 31G PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x 91237000163 EASY COMFORT PEN NDL 31GX3/16" PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x 94046000174 ADVOCATE PEN NEEDLES 5MM 31G PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x 98302000199 COMFORT EZ PEN NEEDLES 5MM 31G PEN NEEDLE, DIABETIC 31 GX3/16" 100 xx 08470119001 UNIFINE PENTIPS 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 30 x x 08222095657 ULTICARE PEN NEEDLES 6 MM 31 G PEN NEEDLE, DIABETIC 31 G X1/4" 50 x x 08396901534 RELION PEN NEEDLE 31GX1/4" PEN NEEDLE, DIABETIC 31 G X1/4" 50 x x 08396902400 RELION PEN NEEDLE 31GX1/4" PEN NEEDLE, DIABETIC 31 G X1/4" 50 x x 57515009565 PEN NEEDLES MIS 31GX6MM PEN NEEDLE, DIABETIC 31 G X1/4" 50 x x 08214090735 PEN NEEDLES 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 08214090737 PEN NEEDLES 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 08222095633 ULTICARE PEN NEEDLES 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 08222710048 ULTICARE PEN NEEDLES 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 08396900100 CLICKFINE 31G X 1/4" NEEDLES PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 08396900118 PEN NEEDLE 31G X 1/4" PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 08470359001 UNIFINE PENTIPS 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 08470389001 UNIFINE PENTIPS PLUS 31GX1/4" PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 08496310401 EASY TOUCH PEN NEEDLE 31GX1/4" PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 57515009563 ULTICARE PEN NEEDLES 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 57515071004 ULTICARE PEN NEEDLES 6MM 31G PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 91237000173 EASY COMFORT PEN NDL 31GX1/4" PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 08470113001 UNIFINE PENTIPS 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 30 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 08222095855 ULTICARE PEN NEEDLES 8 MM 31 G PEN NEEDLE, DIABETIC 31 GX5/16" 50 x x 08396901634 RELION PEN NEEDLE 31GX5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 50 x x 08396902700 RELION PEN NEEDLE 31GX5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 50 x x 08214030735 PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 08214030737 PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 08214030757 UNIFINE PENTIPS PLUS 31GX5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 08214383034 UNIFINE PENTIPS PLUS 31GX5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 08222095831 ULTICARE PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 08222710055 ULTICARE PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 08290320109 BD ULTRA-FINE PEN NDL 8MMX31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 08396900218 PEN NEEDLE 31G X 5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 08396900500 CLICKFINE UNIVERSAL 31GX5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 08470353001 UNIFINE PENTIPS 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 08470383001 UNIFINE PENTIPS PLUS 31GX5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 08496310601 EASY TOUCH PEN NEEDLE 31GX5/16 PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 57515009583 ULTICARE PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 86227012155 SURE COMFORT 31G PEN NEEDLE PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 89134063002 ULTRA-THIN II PEN NDL 31GX5/16 PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 90166083152 PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 91237000170 EASY COMFORT PEN NDL 31GX5/16" PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 94046000173 ADVOCATE PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 98302000198 COMFORT EZ PEN NEEDLES 8MM 31G PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 08470114001 UNFINE PNTP MIS 32GX4MM PEN NEEDLE, DIABETIC 32GX 5/32" 30 x x 08396900934 PEN NEEDLES MIS 32GX4MM PEN NEEDLE, DIABETIC 32GX 5/32" 50 x x 08396901434 RELION PEN NEEDLE 32GX5/32" PEN NEEDLE, DIABETIC 32GX 5/32" 50 x x 08396903500 RELION PEN NEEDLE 32GX5/32" PEN NEEDLE, DIABETIC 32GX 5/32" 50 x x 00169185550 NOVOFINE PLS MIS 32GX4MM PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 08214054080 PEN NEEDLES MIS 32GX5/32 PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 08214384034 UNIFINE PNTP MIS 32GX5/32 PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 08222710031 ULTICARE PEN NEEDLES 4MM 32G PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 08290320122 BD ULTRA-FINE PEN NDL 4MMX32G PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 08290320550 BD PEN NEEDL MIS 32GX5/32 PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 08396900718 PEN NEEDLE 32G X 5/32" PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 08396900800 CLICKFINE PEN NEEDLE 32GX5/32" PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 08470344001 PENTIPS MIS 32GX4MM PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 08470354001 UNFINE PNTP MIS 32GX4MM PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 08470384001 UNFINE PNTP MIS 32GX4MM PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 08496320801 EASY TOUCH MIS 32GX5/32 PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 56151210401 PEN NEEDLES MIS 32GX4MM PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 57513000630 PEN NEEDLES MIS 32GX4MM PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 86227013085 SURE COMFORT MIS 32GX5/32 PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 90166043152 PEN NEEDLES MIS 32GX4MM PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 90166043154 PEN NEEDLES MIS 32GX4MM PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 91237000177 EASY COMFORT MIS 32GX5/32 PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 98302014059 COMFORT EZ MIS 32GX4MM PEN NEEDLE, DIABETIC 32GX 5/32" 100 x x 00169185189 NOVOFINE 32G NEEDLES PEN NEEDLE, DIABETIC 32 GX 1/4" 100 x x 08496320401 EASY TOUCH PEN NEEDLE 32GX1/4" PEN NEEDLE, DIABETIC 32 GX 1/4" 100 x x 86227013055 SURE COMFORT PEN NDL 32GX1/4" PEN NEEDLE, DIABETIC 32 GX 1/4" 100 x x 08290305109 BD NEEDLES MIS 27GX1/2" NEEDLE (DISP) 27 G 100 x x 08290329515 AUTOSHIELD MIS 30GX5MM PEN NEEDLE, DIABETIC 30 G X 5 MM (1/5" OR 3/16") 100 x x 00169185275 NOVOFINE AUT MIS 30GX8MM PEN NEEDLE, DIABETIC 30G X5/16" 100 x x 08496300501 PEN NEEDLES MIS 30GX5/16 PEN NEEDLE, DIABETIC 30G X5/16" 100 x x 08214055080 PEN NEEDLES MIS 31GX3/16 PEN NEEDLE, DIABETIC 31 GX3/16" 100 x x 08214059080 PEN NEEDLES MIS 31GX1/4" PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 56151210201 PEN NEEDLES MIS 31GX6MM PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 81131038680 RELION PEN MIS 31GX6MM PEN NEEDLE, DIABETIC 31 G X1/4" 50 x x 98302000200 COMFORT EZ MIS 31GX6MM PEN NEEDLE, DIABETIC 31 G X1/4" 100 x x 08214053080 PEN NEEDLES MIS 31GX5/16 PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 08222720055 GNP ULTICARE MIS 31GX5/16 PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 08470343001 PENTIPS MIS 31GX8MM PEN NEEDLE, DIABETIC 31 GX5/16" 100 x x 81131038681 RELION PEN MIS 31GX8MM PEN NEEDLE, DIABETIC 31 GX5/16" 50 x x 00169185389 NOVOTWIST MIS 32GX5MM PEN NEEDLE, DIABETIC 32 G X 5 MM (1/5" OR 3/16") 100 x x 08496320101 EASY TOUCH MIS 32GX5MM PEN NEEDLE, DIABETIC 32 G X 5 MM (1/5" OR 3/16") 100 x x 08290320749 BD PEN NEEDL MIS 32GX6MM PEN NEEDLE, DIABETIC 32 GX 1/4" 100 x x 98302014174 COMFORT EZ MIS 32GX6MM PEN NEEDLE, DIABETIC 32 GX 1/4" 100 x x 08214056080 PEN NEEDLES MIS 33GX5/32 PEN NEEDLE, DIABETIC 33 G X 4 MM (1/6" OR 5/32") 100 x x 90166033042 PEN NEEDLES MIS 33GX4MM PEN NEEDLE, DIABETIC 33 G X 4 MM (1/6" OR 5/32") 100 x x

BLOOD GLUCOSE TESTING METERS Please refer to TennCare's PDL for coverage of the following: ABBOTT DIABETES CARE PRODUCTS (FREESTYLE, FREESTYLE LITE, PRECISION XTRA, ETC.) AGAMATRIX PRODUCTS (NON-PREFERRED) BAYER HEALTHCARE PRODUCTS (NON-PREFERRED) HOME DIAGNOSTICS PRODUCTS (NON-PREFERRED) LIFESCAN PRODUCTS (NON-PREFERRED)

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults ROCHE DIAGNOSTIC PRODUCTS (NON-PREFERRED)

08484070120 PRODIGY AUTOCODE METER KIT BLOOD-GLUCOSE METER 1 x x 08484071950 PRODIGY VOICE METER KIT BLOOD-GLUCOSE METER 1 x x

BLOOD GLUCOSE METER CONTROL SOLUTIONS 99073070432 FREESTYLE CONTROL SOLUTION BLOOD GLUCOSE CONTROL HIGH,LOW 1 x x 99073014002 FREESTYLE CONTROL SOLUTION BLOOD-GLUCOSE CONTROL, NORMAL 1x x 00193710901 CONTOUR SOLUTION BLOOD-GLUCOSE CONTROL, NORMAL 1x x

LANCETS 00193654621 MICROLET LANCETS LANCETS 28 GAUGE 100 x x 00193658621 MICROLET LANCETS LANCETS 28 GAUGE 100 x x 00363237001 LANCET ULTRA MIS THIN 30G LANCETS 30 GAUGE 100 x x 00363237102 MICRO THIN 33G LANCETS LANCETS 33 GAUGE 100 x x 00363237203 SUPER THIN 28G LANCETS LANCETS 28 GAUGE 100 x x 08214056529 PX LANCETS MIS 28G LANCETS 28 GAUGE 100 x x 08214065757 UNILET SUPER THIN 30G LANCETS LANCETS 30 GAUGE 100 x x 08271035100 LANCETS THIN 23G LANCETS 23 GAUGE 100 x x 08271036100 LANCETS ULTRA THIN 26G LANCETS 26 GAUGE 100 x x 08290322057 BD ULTRA-FINE 33G LANCETS LANCETS 33 GAUGE 100 x x 08317880128 TECHLITE 28G LANCETS LANCETS 28 GAUGE 100 x x 08463702930 LANCETS 30G LANCETS 30 GAUGE 100 x x 08470046501 UNILET COMFORTOUCH LANCET LANCETS 28 GAUGE 100 x x 08470056501 UNILET LANCT MIS 28G LANCETS 28 GAUGE 100 x x 08470058501 UNILET MICRO THIN 33G LANCETS LANCETS 33 GAUGE 100 x x 08470092501 UNILET GP LANCET LANCETS 26 GAUGE 100 x x 08484081028 PRODIGY TWIST TOP 28G LANCET LANCETS 28 GAUGE 100 x x 08484082026 PRODIGY SAFETY 26G LANCETS LANCETS 26 GAUGE 100 x x 08484990328 PRODIGY TWIST TOP 28G LANCET LANCETS 28 GAUGE 100 x x 08496280801 EASY TOUCH MIS LANC/28G LANCETS 28 GAUGE 100 x x 08496281001 EASY TOUCH TWIST 28G LANCETS LANCETS 28 GAUGE 100 x x 08496301001 EASY TOUCH TWIST 30G LANCETS LANCETS 30 GAUGE 100 x x 08496321001 EASY TOUCH TWIST 32G LANCETS LANCETS 32 GAUGE 100 x x 08496331001 EASY TOUCH TWIST 33G LANCETS LANCETS 33 GAUGE 100 x x 08554197101 AGAMATRIX MIS 33G LANCETS 33 GAUGE 100 x x 11917013416 TRUEPLUS SUPER THIN 28G LANCET LANCETS 28 GAUGE 100 x x 38396030118 KRO UNIVERSAL 1 THIN 26G LANCT LANCETS 26 GAUGE 100 x x 38396030318 KROGER SUPER THIN LANCETS LANCETS 30 GAUGE 100 x x 38396030800 E-ZJECT SUPER THIN 30G LANCETS LANCETS 30 GAUGE 100 x x 38396031618 MICRO THIN 33G LANCETS LANCETS 33 GAUGE 100 x x 38396034264 GNP UNIVERSAL 1 STANDARD 21G LANCETS 21 GAUGE 100 x x 38396050432 THIN LANCETS MIS 30G LANCETS 30 GAUGE 100 x x 38396054764 GNP UNIVERSAL 1 SUPER THIN 30G LANCETS 30 GAUGE 100 x x 50924045001 ACCU-CHEK MIS MLTICLIX LANCETS 102 x x 50924058510 SOFT TOUCH LANCETS LANCETS 28 GAUGE 100 x x 50924097110 SOFTCLIX MIS LANCETS LANCETS 28 GAUGE 100 x x 53885000810 ONETOUCH DEL MIS PLUS 33G LANCETS 33 GAUGE 100 x x 53885001110 ONETOUCH DEL MIS PLUS 30G LANCETS 30 GAUGE 100 x x 53885013610 ONETOUCH DELICA 33G LANCETS LANCETS 33 GAUGE 100 x x 53885014301 ONETOUCH DELICA 33G LANCETS LANCETS 33 GAUGE 100 x x 53885039310 ONETOUCH ULTRASOFT LANCETS LANCETS 28 GAUGE 100 x x 53885059501 ONETOUCH DELICA 30G LANCETS LANCETS 30 GAUGE 100 x x 56151014260 TRUEPLUS SUPER THIN 28G LANCET LANCETS 28 GAUGE 100 x x 56151014401 TRUEPLUS ULTRA THIN 30G LANCET LANCETS 30 GAUGE 100 x x 56151014701 TRUEPLUS 33G LANCETS LANCETS 33 GAUGE 100 x x 60913000101 AQUALANCE MIS 30G LANCETS 30 GAUGE 100 x x 65702015610 SOFTCLIX MIS LANCETS LANCETS 30 GAUGE 100 x x 65702028810 FASTCLIX MIS LANCETS LANCETS 30 GAUGE 102 x x 86227028105 SURE COMFORT 28G LANCETS LANCETS 28 GAUGE 100 x x 86227030105 SURE COMFORT 30G LANCETS LANCETS 30 GAUGE 100 x x 91237000116 EASY COMFORT MIS 30G LANCETS 30 GAUGE 100 x x 99073013001 FREESTYLE 28G LANCETS LANCETS 28 GAUGE 100 x x

LANCING DEVICES 08396706002 RELION KIT LANCING LANCING DEVICE 1 x x 08396706018 KRO LANCING DEVICE LANCING DEVICE 1 x x 08484990355 PRODIGY LANCING DEVICE LANCING DEVICE 1 x x 11917013481 LANCING DEVICE LANCING DEVICE 1 x x 38415051001 LANCING DEVICE LANCING DEVICE 1 x x 56151014201 TRUEDRAW LANCING DEVICE LANCING DEVICE 1 x x 65702048110 ACCU-CHEK KIT FASTCLIX LANCET DEVICES 1 x x 53885014201 ONETOUCH MIS LANC DEV LANCET DEVICES 1 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults ALCOHOL SWABS 00113200078 ALCOHOL 70% SWABS ALCOHOL ANTISEPTIC PADS 100 x x 08290326895 BD SINGLE USE SWAB ALCOHOL ANTISEPTIC PADS 100 x x 10939057933 SM ALCOHOL PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x 11673060010 ALCOHOL SWABS ALCOHOL ANTISEPTIC PADS 100 x x 11822515660 RA ALCOHOL SWABS ALCOHOL ANTISEPTIC PADS 100 x x 11917012805 ALCOHOL SWABS ALCOHOL ANTISEPTIC PADS 100 x x 30142080909 KRO ALCOHOL 70% SWABS ALCOHOL ANTISEPTIC PADS 100 x x 30142080931 KRO ALCOHOL 70% PREP PADS ALCOHOL ANTISEPTIC PADS 140 x x 37205015578 ALCOHOL 70% PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x 42423027101 EASY TOUCH ALCOHOL 70% PADS ALCOHOL ANTISEPTIC PADS 100 x x 46122004378 ALCOHOL SWAB ALCOHOL ANTISEPTIC PADS 100 x x 49348007753 SM ALCOHOL PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x 49348089610 SM ALCOHOL 70% PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x 50428085942 CVS ALCOHOL 70% PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x 60913000601 ALCOHOL 70% PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x 60913001702 ALCOHOL 70% PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x 68113099601 ALCOHOL PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x 81131006044 RELION ALCOHOL 70% SWABS ALCOHOL ANTISEPTIC PADS 100 x x 86227000000 SURE COMFORT ALCOHOL PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x 86227012605 ALCOHOL PREP PAD 70% ALCOHOL ANTISEPTIC PADS 100 x x 87701040724 GNP ALCOHOL SWAB ALCOHOL ANTISEPTIC PADS 100 x x 90166011103 PREP EASE ALCOHOL PADS ALCOHOL ANTISEPTIC PADS 100 x x 91237000128 ALCOHOL 70% PADS ALCOHOL ANTISEPTIC PADS 100 x x 98302000105 PHARM CHOICE ALCOHOL PREP PADS ALCOHOL ANTISEPTIC PADS 100 x x 08222440006 ULTICARE PAD ALCOHOL ALCOHOL ANTISEPTIC PADS 100 x x 11917014296 ALCOHOL PREP PAD ALCOHOL ANTISEPTIC PADS 200 x x 11917014455 ALCOHOL SWAB PAD ALCOHOL ANTISEPTIC PADS 100 x x 42423027102 ALCOHOL PREP PAD MED 70% ALCOHOL ANTISEPTIC PADS 200 x x 50428034618 ALCOHOL PREP PAD 70% ALCOHOL ANTISEPTIC PADS 120 x x 50632000703 PRO COMFORT PAD ALCOHOL ALCOHOL ANTISEPTIC PADS 100 x x 62379000506 ALCOHOL PREP PAD 70% ALCOHOL ANTISEPTIC PADS 100 x x 86227012205 ALCOHOL PAD PREP ALCOHOL ANTISEPTIC PADS 100 x x

URINE KETONE TEST STRIPS 00193252350 RELION KETON TES ACETONE (URINE) TEST 50 x x 00193288050 KETOSTIX REAGENT STRIPS URINE ACETONE TEST,STRIPS 50 x x 11917010873 KETONE TEST STRIPS URINE ACETONE TEST,STRIPS 50 x x 56151060150 TRUEPLUS KETONE TEST STRIPS URINE ACETONE TEST,STRIPS 50 x x 81131006043 RELION KETONE TEST STRIPS URINE ACETONE TEST,STRIPS 50 x x 56151060101 KETONE TES ACETONE (URINE) TEST 100 x x 00193288021 KETOSTIX TES STRIP ACETONE (URINE) TEST 100 x x 21292000146 KETONE TES ACETONE (URINE) TEST 50 x x

URINE ALBUMIN TEST STRIPS 08620219121 ALBUSTIX REAGENT STRIPS URINE ALBUMIN TEST 100 x x

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

BLOOD GLUCOSE TEST STRIP Please refer to TennCare's PDL for coverage of the following: ABBOTT DIABETES CARE PRODUCTS (FREESTYLE, FREESTYLE LITE, PRECISION XTRA, ETC.) AGAMATRIX PRODUCTS (NON-PREFERRED) BAYER HEALTHCARE PRODUCTS (NON-PREFERRED) HOME DIAGNOSTICS PRODUCTS (NON-PREFERRED) LIFESCAN PRODUCTS (NON-PREFERRED) ROCHE DIAGNOSTIC PRODUCTS (NON-PREFERRED)

BLOOD KETONE TEST STRIPS 57599074501 PRECISION XTR B-KETONE STRIP BLOOD KETONE TEST,STRIPS 10 x x

COUGH/COLD/ALLERGY/RESPIRATORY

ANTIHISTAMINES- CHLORPHENIRAMINE 00485009804 ED CHLORPED JR SYRUP CHLORPHENIRAMINE MALEATE 2 MG/5 ML 118 x x 00536100635 ALLER-CHLOR 4 MG TABLET CHLORPHENIRAMINE MALEATE 4 MG 24 x x 00904001224 ALLERGY 4 MG TABLET CHLORPHENIRAMINE MALEATE 4 MG 24 x x 24385046362 ALLERGY 4 MG TABLET CHLORPHENIRAMINE MALEATE 4 MG 24 x x 62011005901 HM ALLERGY RELIEF 4 MG TABLET CHLORPHENIRAMINE MALEATE 4 MG 24 x x 10135013330 CHLORPHENIRAMINE 4 MG TABLET CHLORPHENIRAMINE MALEATE 4 MG 30 x x 00536100601 ALLER-CHLOR 4 MG TABLET CHLORPHENIRAMINE MALEATE 4 MG 100 x x 00904001259 ALLERGY 4 MG TABLET CHLORPHENIRAMINE MALEATE 4 MG 100 x x 11822319750 RA CHLORPHENIRAMINE 4 MG TAB CHLORPHENIRAMINE MALEATE 4 MG 100 x x 70677000401 SM ALLERGY TAB 4MG CHLORPHENIRAMINE MALEATE 4 MG 100 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults

ANTIHISTAMINES- DEXBROMPHENIRAMINE MALEATE 50991078360 ALA-HIST IR TAB 2MG DEXBROMPHENIRAMINE MALEATE 2 MG 60 x x

ANTIHISTAMINES- TRIPROLIDINE 15310011242 TRIPROLIDINE DRO 0.938MG TRIPROLIDINE HCL DROPS 0.938MG 30 x x 28595080130 HISTEX PD DRO 0.938MG TRIPROLIDINE HCL DROPS 0.938MG 30 x x

ANTIHISTAMINES- DIPHENHYDRAMINE Please refer to TennCare's PDL for coverage of the following: All formulations of DIPHENHYDRAMINE HCL (for recipients under age 21 only)

ANTIHISTAMINES- CETIRIZINE Please refer to TennCare's PDL for coverage of the following: All formulations of CETIRIZINE (for recipients under age 21 only) ZYRTEC® PRODUCTS (NON-PREFERRED) (for recipients under age 21 only)

ANTIHISTAMINES- FEXOFENADINE Please refer to TennCare's PDL for coverage of the following: All formulations of FEXOFENADINE (for recipients under age 21 only) ALLEGRA® PRODUCTS (NON-PREFERRED) (for recipients under age 21 only)

ANTIHISTAMINES- LORATADINE Please refer to TennCare's PDL for coverage of the following: All formulations of LORATADINE (for recipients under age 21 only) CLARITIN® AND ALAVERT® PRODUCTS (NON-PREFERRED) (for recipients under age 21 only)

ANTIHISTAMINES- LEVOCETIRIZINE Please refer to TennCare's PDL for coverage of the following: XYZAL® 2.5 MG/5 ML SOLUTION (NON-PREFERRED) (for recipients under age 21 only)

DECONGESTANTS- PSEUDOEPHEDRINE 00113043262 NASAL DECONGESTANT 30 MG TAB PSEUDOEPHEDRINE HCL 30 MG 24 x x 00363011208 WAL-PHED 30 MG TABLET PSEUDOEPHEDRINE HCL 30 MG 24 x x 00363011222 WAL-PHED 30 MG TABLET PSEUDOEPHEDRINE HCL 30 MG 48 x x 00536360735 NASAL DECONGESTANT 30 MG TAB PSEUDOEPHEDRINE HCL 30 MG 24 x x 00904505324 SUDOGEST 30 MG TABLET PSEUDOEPHEDRINE HCL 30 MG 24 x x 24385043262 SUPHEDRIN 30 MG TABLET PSEUDOEPHEDRINE HCL 30 MG 24 x x 30142043262 KRO NASAL DECONGEST 30 MG TAB PSEUDOEPHEDRINE HCL 30 MG 24 x x 30142043267 KRO NASAL DECONGEST 30 MG TAB PSEUDOEPHEDRINE HCL 30 MG 48 x x 45802043262 PSEUDOEPHEDRINE 30 MG TABLET PSEUDOEPHEDRINE HCL 30 MG 24 x x 50580053604 CHILDS SUDAFED 15 MG/5 ML LIQ PSEUDOEPHEDRINE HCL 15 MG/5 ML 118 x x 48964011224 NEXAFED 30 MG TABLET PSEUDOEPHEDRINE HCL 30 MG 24 x x 53240015101 ZEPHREX-D 30 MG TABLET PSEUDOEPHEDRINE HCL 30 MG 24 x x 59779043262 NASAL DECONG TAB 30MG PSEUDOEPHEDRINE HCL 30 MG 24 x x 59779043267 NASAL DECONG TAB 30MG PSEUDOEPHEDRINE HCL 30 MG 48 x x

DECONGESTANTS- PHELYLEPHRINE 00904573373 SUDOGEST PE 10 MG TABLET PHENYLEPHRINE HCL 10 MG 36 x x

DECONGESTANTS- OXYMETAZOLINE HCL 00085047405 AFRIN MENTHL SPR 0.05% OXYMETAZOLINE HCL W/ MENTHOL 15 x x 00085411201 AFRIN SINUS SPR 0.05% OXYMETAZOLINE HCL 15 x x 45802041059 NASAL RELIEF SPR 0.05% OXYMETAZOLINE HCL 30 x x

NASAL STEROIDS- BUDESONIDE Please refer to TennCare's PDL for coverage of the following: BUDESONIDE 32 MCG NASAL SPRAY OTC BUDESONIDE 32 MCG NASAL SPRAY Rx REQUIRED (NON-PREFERRED)

NASAL STEROIDS- TRIAMCINOLONE ACETONIDE Please refer to TennCare's PDL for coverage of the following: NASACORT® OTC TRIAMCINOLONE NASAL SPRAYS (NON-PREFERRED)

MAST CELL STABLIZERS- CROMOLYN SODIUM 14832001103 NASALCROM 5.2 MG NASAL SPRAY CROMOLYN SODIUM 5.2 MG 13 x x 57782039726 CROMOLYN SODIUM NASAL SPRAY CROMOLYN SODIUM 5.2 MG 26 x x

SODIUM CHLORIDE NASAL SPRAY 00187526003 OCEAN 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 45 x x 00225038080 AYR SALINE 0.65% NOSE SPRAY SODIUM CHLORIDE 0.65 % 50 x x 00225038280 AYR NASAL DRO 0.65% SODIUM CHLORIDE 0.65 % 50 x x 00363032003 SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 30 x x 00363070530 CHILD SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 30 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 00536250676 SALINE MIST 0.65% NOSE SPRY SODIUM CHLORIDE 0.65 % 44 x x 00904386575 DEEP SEA 0.65% NOSE SPRAY SODIUM CHLORIDE 0.65 % 44 x x 11822320300 RA SALINE 0.65% NOSE SPRAY SODIUM CHLORIDE 0.65 % 45 x x 11917001257 SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 88 x x 11917002642 SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 44 x x 24385032558 SALINE 0.65% NOSE SPRAY SODIUM CHLORIDE 0.65 % 44 x x 41415023873 SALINE NASAL SPR 0.65% SODIUM CHLORIDE 0.65 % 88 x x 45802035758 SALINE MIST 0.65% NOSE SPRY SODIUM CHLORIDE 0.65 % 45 x x 49348035625 SM SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 44 x x 50428006205 CVS SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 88 x x 50428031180 SALINE NASAL SPR 0.65% SODIUM CHLORIDE 0.65 % 44 x x 50428891465 CVS SALINE 0.65% NOSE SPRAY SODIUM CHLORIDE 0.65 % 45 x x 52569013385 HM SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 44 x x 56184012011 LITTLE REMEDIES 0.65% SPRAY SODIUM CHLORIDE 0.65 % 30 x x 56184012141 LITTLE REMEDIES STUFFY NOSE KT SODIUM CHLORIDE 0.65 % 15 x x 62011008601 HM SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 44 x x 62011008602 HM SALINE 0.65% NASAL SPRAY SODIUM CHLORIDE 0.65 % 88 x x 81131070024 EQ NASAL 0.65% SPRAY SODIUM CHLORIDE 0.65 % 44 x x 87701040085 GNP NASAL MOIST 0.65% SPRAY SODIUM CHLORIDE 0.65 % 88 x x 87701055205 GNP SALINE 0.65% NOSE SPRAY SODIUM CHLORIDE 0.65 % 44 x x 00225052547 AYR SALINE NASAL GEL SODIUM CHLORIDE/ALOE VERA 14.1 x x 05928000099 NASOGEL GEL SODIUM CHLORIDE 0.65 % 28.4 x x 05928004530 NASOGEL GEL SODIUM CHLORIDE 0.65 % 30 x x

COUGH SUPPRESSANTS 24385026226 GNP CGH RELF LIQ 15MG/5ML DEXTROMETHORPHAN HBR 15 MG/5 ML 118 x x 24385049326 TUSSIN COUGH LIQUID DEXTROMETHORPHAN HBR 15 MG/5 ML 118 x x 00536106834 ROBAFEN CGH CAP 15MG DEXTROMETHORPHAN HBR 15MG 20 x x 00363030026 WAL-TUSSIN SYP 15MG/5ML DEXTROMETHORPHAN HBR 118 x x 00363038421 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 00363049421 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 00363089921 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 00904631256 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 11822619070 RA COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 30142038421 KRO COUGH DM ER 30 MG/5 ML SUS DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 37205069721 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 45802043321 DEXTROMETHORPHAN ER 30 MG/5 ML DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 46122014121 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 46122014221 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 49035038421 EQ COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 50428035047 CVS COUGH DM ER 30 MG/5 ML SUS DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 62011017601 HM COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 62011019801 HM COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 62011025101 HM COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 63824017163 DELSYM 30 MG/5 ML SUSPENSION DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 63824017563 DELSYM 30 MG/5 ML SUSPENSION DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 89 x x 00363038428 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x 00363095828 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x 46122014125 COUGH DM ER 30 MG/5 ML SUSP DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x 49035038428 EQ COUGH DM SUS 30MG/5ML DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x 50428040757 CVS COUGH DM ER 30 MG/5 ML SUS DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x 50428041780 CVS CHILD COUGH DM ER 30 MG/5 DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x 50428046507 CVS COUGH DM ER 30 MG/5 ML SUS DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x 63824017165 DELSYM 30 MG/5 ML SUSPENSION DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x 63824017565 DELSYM 30 MG/5 ML SUSPENSION DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x 63824017765 DELSYM CHILD SUS 30MG/5ML DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML 148 x x

EXPECTORANTS 00113006126 TUSSIN MUCUS-CONGEST 100 MG/5 GUAIFENESIN 100 MG/5ML 118 x x 00113028826 CHILDREN'S MUCUS RELIEF LIQ GUAIFENESIN 100 MG/5ML 118 x x 00363028826 CHILDREN'S CHEST CONGEST LIQ GUAIFENESIN 100 MG/5ML 118 x x 00536109597 COUGH SYRUP 200 MG/10 ML GUAIFENESIN 100 MG/5ML 118 x x 00904006100 ROBAFEN 100 MG/5 ML SYRUP GUAIFENESIN 100 MG/5ML 118 x x 10939032533 SM TUSSIN 100 MG/5 ML LIQUID GUAIFENESIN 100 MG/5ML 118 x x 11822771100 RA TUSSIN CHEST CONGESTION SYR GUAIFENESIN 100 MG/5ML 118 x x 30142031026 KRO TUSSIN 200 MG/10 ML SYRUP GUAIFENESIN 100 MG/5ML 118 x x 36800028826 CHILDREN'S MUCUS RELIEF LIQ GUAIFENESIN 100 MG/5ML 118 x x 36800031026 TUSSIN CHEST CONGESTION LIQUID GUAIFENESIN 100 MG/5ML 118 x x 49348013534 SM TUSSIN MUCUS-CONG 200 MG/10 GUAIFENESIN 100 MG/5ML 118 x x 54838011740 SILTUSSIN SA 100 MG/5 ML SYR GUAIFENESIN 100 MG/5ML 118 x x 60569006304 DIABETIC TUSSIN EX LIQUID GUAIFENESIN 100 MG/5ML 118 x x 62011008902 HM ADULT TUSSIN CHEST CONG LIQ GUAIFENESIN 100 MG/5ML 118 x x 63824028564 CHL MUCINEX CHEST CONGEST LIQ GUAIFENESIN 100 MG/5ML 118 x x 49348013537 SM TUSSIN MUCUS-CONG 200 MG/10 GUAIFENESIN 100 MG/5ML 236 x x 00113006134 TUSSIN MUCUS-CONGEST 100 MG/5 GUAIFENESIN 100 MG/5ML 237 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 00363031034 ADULT WAL-TUSSIN LIQUID GUAIFENESIN 100 MG/5ML 237 x x 11822001110 RA EXPECTORANT COUGH SYRUP GUAIFENESIN 100 MG/5ML 237 x x 24385031034 TUSSIN 100 MG/5 ML SYRUP GUAIFENESIN 100 MG/5ML 237 x x 54838011770 SILTUSSIN SA 100 MG/5 ML SYR GUAIFENESIN 100 MG/5ML 237 x x 62011008901 HM ADULT TUSSIN CHEST CONG LIQ GUAIFENESIN 100 MG/5ML 237 x x 11917010128 WAL-TUSSIN LIQ 100/5ML GUAIFENESIN 100 MG/5ML 237 x x 59779065034 TUSSIN ADULT LIQ 100/5ML GUAIFENESIN 100 MG/5ML 237 x x 00904515460 GUAIFENESIN TAB 200MG GUAIFENESIN 200 MG 100 x x 00363053201 MUCUS RELIEF 400 MG TABLET GUAIFENESIN 400 MG 30 x x 00904623246 MUCUS RELIEF 400 MG TABLET GUAIFENESIN 400 MG 30 x x 49348072909 SM CHEST CONGESTION RELIEF CAP GUAIFENESIN 400 MG 50 x x 62011006001 HM CHEST CONGEST RLF 400 MG TB GUAIFENESIN 400 MG 50 x x 00904681552 MUCUS RELIEF TAB 400MG GUAIFENESIN 400 MG 60 x x 54738098130 GUAIFENESIN TAB 400MG GUAIFENESIN 400 MG 30 x x 57896079401 MUCUS RELIEF TAB 400MG GUAIFENESIN 400 MG 100 x x 00363049860 MUCUS RELIEF ER 600 MG TABLET GUAIFENESIN 600 MG 20 x x 10939032244 SM MUCUS ER 600 MG TABLET GUAIFENESIN 600 MG 20 x x 00536116361 MUCUS RELIEF TAB 600MG ER GUAIFENESIN 600 MG 100 x x 00363007120 MUCUS RELIEF TAB 600MG ER GUAIFENESIN 600 MG 20 x x 00536116361 MUCUS RELIEF TAB 600MG ER GUAIFENESIN 600 MG 100 x x 46122041660 GNP MUCUS ER TAB 600MG GUAIFENESIN 600 MG 20 x x 49035028338 EQ 12 HR MUC TAB 600MG GUAIFENESIN 600 MG 40 x x 69842080601 CVS MUCUS ER TAB 600MG GUAIFENESIN 600 MG 20 x x 69842080649 CVS MUCUS ER TAB 600MG GUAIFENESIN 600 MG 40 x x 70677005501 SM MUCUS REL TAB 600MG ER GUAIFENESIN 600 MG 40 x x 45802032566 GUAIFENESIN TAB 1200 ER GUAIFENESIN 1200 MG 14 x x 63824002335 MUCINEX TAB 1200MG GUAIFENESIN 1200 MG 14 x x 45802032530 GUAIFENESIN TAB 1200 ER GUAIFENESIN 1200 MG 28 x x 63824002314 MUCINEX TAB 1200MG GUAIFENESIN 1200 MG 28 x x 63824002336 MUCINEX TAB 1200MG GUAIFENESIN 1200 MG 28 x x 70000047902 MUCUS RELIEF TAB 1200MG GUAIFENESIN 1200 MG 28 x x 63824002328 MUCINEX TAB 1200MG GUAIFENESIN 1200 MG 56 x x 00363007428 MUCUS RELIEF TAB 1200MG GUAIFENESIN 1200 MG 28 x x 59779070228 CVS MUCUS TAB 1200 ER GUAIFENESIN 1200 MG 28 x x 45802032566 GUAIFENESIN TAB 1200 ER GUAIFENESIN 1200 MG 14 x x

ANTIHISTAMINE/DECONGESTANT COMBINATIONS Please refer to TennCare's PDL for coverage of the following: CETIRIZINE HCL/PSEUDOEPHEDRINE 5MG/120MG (for recipients under age 21 only) ZYRTEC®-D (NON-PREFERRED)(for recipients under age 21 only) LORATADINE/PSEUDOEPHEDRINE 10MG/240MG (for recipients under age 21 only) CLARITIN®-D (NON-PREFERRED)(for recipients under age 21 only)

58407062530 STAHIST AD TAB 25-60MG CHLORCYCLIZINE & PSEUDOEPHEDRINE 30 x x 00904535124 SUDOGEST TAB 4-60MG CHLORPHENIRAMINE & PSEUDOEPH 24 x x 69367019760 DEXBRO/PHENY TAB 2-10MG DEXBROMPHENIRAMINE-PHENYLEPHRINE 60 x x 69367019901 DOXY/PHENYL TAB 7.5-10MG DOXYLAMINE-PHENYLEPHRINE 100 x x 50991062601 POLY HIST FO TAB 10.5-10 DOXYLAMINE-PHENYLEPHRINE 100 x x 58407062530 STAHIST AD TAB 25-60MG CHLORCYCLIZINE & PSEUDOEPHEDRINE 30 x x 00485025401 ED A-HIST TAB 4-10MG CHLORPHENIRAMINE & PHENYLEPHRINE 100 x x 50991078890 ALAHIST PE TAB 2-7.5MG DEXBROMPHENIRAMINE-PHENYLEPHRINE 90 x x 69367019760 DEXBRO/PHENY TAB 2-10MG DEXBROMPHENIRAMINE-PHENYLEPHRINE 60 x x 50991077601 ALAHIST D TAB PHENIRAMINE MALEATE-PHENYLEPHRINE HYDROCHLORIDE 100 x x 69367019901 DOXY/PHENYL TAB 7.5-10MG DOXYLAMINE-PHENYLEPHRINE 100 x x 50991062601 POLY HIST FO TAB 10.5-10 DOXYLAMINE-PHENYLEPHRINE 100 x x

COUGH/COLD COMBINATIONS 11822317370 RA TUSSIN COUGH LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 36800035926 TUSSIN DM LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 36800035934 TUSSIN DM LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 237 x x 53076011112 SAFETUSSIN DM LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 120 x x 54838013340 SILTUSSIN DM DAS LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 61787006204 DIABETIC TUSSIN DM LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 62011009201 HM ADT TUSSIN COUGH CONG DM LQ GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 00113057826 TUSSIN DM CLEAR LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 00363035926 ADULT WAL-TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 00363035934 ADULT WAL-TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 237 x x 00904646420 ROBAFEN DM CGH-CHEST CONG SYRP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 11822333230 RA TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 24385035926 TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 24385035934 TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 237 x x 24385057826 TUSSIN DM CLEAR SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 62011009101 HM ADULT TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 62011009102 HM ADULT TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 237 x x 36800079926 TUSSIN DM MAX LIQUID GUAIFENESIN/DEXTROMETHORPHAN 200-10MG/5 118 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 46122001734 TUSSIN DM MAX LIQUID GUAIFENESIN/DEXTROMETHORPHAN 200-10MG/5 237 x x 00904630620 ROBAFEN DM COUGH LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 00113035926 TUSSIN DM COUGH SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 120 x x 00113035934 TUSSIN DM COUGH & CHEST LIQUID GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 237 x x 00363057826 ADULT WAL-TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 00363057834 ADULT WAL-TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 237 x x 00536097097 COUGH SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 00904005300 ROBAFEN-DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 00904005309 ROBAFEN-DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 237 x x 49035035926 EQ TUSSIN DM COUGH-CHEST SYR GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 49035035934 EQ TUSSIN DM COUGH-CHEST SYR GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 237 x x 49348001734 SM TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 49348001737 SM TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 237 x x 49348086134 SM TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 49348086137 SM TUSSIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 237 x x 54838020940 SILTUSSIN DM COUGH SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x 54838020970 SILTUSSIN DM COUGH SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 237 x x 58657050508 GUAIFENESIN DM SYRUP GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 237 x x 59779035926 TUSSIN DM LIQ 10-100/5 GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 118 x x

RESPIRATORY PRODUCTS 00487590199 S2 NEB 2.25% RACEPINEPHRINE HCL 1 x x

GASTROINTESTINAL PRODUCTS

LAXATIVES- SALINE 00132000655 FLEET PEDIA-LAX TABLET CHEW MAGNESIUM HYDROXIDE 400MG(170) 30 x x 00132065501 FLEET PEDIA-LAX TABLET CHEW MAGNESIUM HYDROXIDE 400MG(170) 30 x x 00363192112 MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x 00363193112 MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x 00536247083 MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x 00904078814 MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x 11822039940 RA MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x 11917011505 MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x 12843035302 PHILLIPS' MILK OF MAGNESIA MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x 12843039324 PHILLIPS' MILK OF MAGNESIA MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x 37205083340 MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x 50428214916 CVS MILK OF MAGNESIA SUSP MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x 50428305623 CVS MILK OF MAGNESIA SUSP MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x 50428308240 CVS MILK OF MAGNESIA SUSP MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x 62011012301 HM MILK OF MAGNESIA SUSPENSION MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x 37205083440 MILK OF MAGN SUS MINT MAGNESIUM HYDROXIDE 400 MG/5ML 360 x x 00363419340 MILK OF MAGN SUS 1200/15 MAGNESIUM HYDROXIDE 400 MG/5ML 355 x x 00363013338 MAG CITRATE SOL GRAPE MAGNESIUM CITRATE 296 x x 00363020501 MAG CITRATE SOL LEMON MAGNESIUM CITRATE 296 x x 00904678744 MAG CITRATE SOL LEMON MAGNESIUM CITRATE 296 x x 11917010656 MAG CITRATE SOL CHERRY MAGNESIUM CITRATE 296 x x 11917010657 MAG CITRATE SOL GRAPE MAGNESIUM CITRATE 296 x x 11917020159 MAG CITRATE SOL GRAPE MAGNESIUM CITRATE 296 x x 49035050638 MAG CITRATE SOL LEMON MAGNESIUM CITRATE 296 x x 50428209452 MAG CITRATE SOL LEMON MAGNESIUM CITRATE 300 x x

LAXATIVES- BOWEL EVACUANTS Please refer to TennCare's PDL for coverage of the following: PEG 3350 POWDER 17G/DOSE products

00132020220 FLEET PEDIA-LAX ENEMA NA PHOS,M-B/NA PHOS,DI-BA 9.5-3.5/59 66 x x 62011027101 HM ENEMA READY TO USE NA PHOS,M-B/NA PHOS,DI-BA 19G-7G/118 133 x x 00132020145 FLEET ENEMA SODIUM PHOSPHATES 133 x x 00132020140 FLEET ENEMA SODIUM PHOSPHATES 133 x x 00132020142 FLEET ENEMA SODIUM PHOSPHATES 133 x x 00904632078 ENEMA READY- ENE -TO-USE SODIUM PHOSPHATES 133 x x

LAXATIVES- STIMULANT/IRRITANT 10135015461 BISACODYL EC 5 MG TABLET BISACODYL 5 MG 10 x x 50428317857 CVS GENTLE LAXATIVE EC 5 MG TB BISACODYL 5 MG 10 x x 00363032756 GENTLE LAXATIVE EC 5 MG TABLET BISACODYL 5 MG 25 x x 37205012863 BISACODYL EC 5 MG TABLET BISACODYL 5 MG 25 x x 10135015401 BISACODYL TAB 5MG EC BISACODYL 5 MG 100 x x 49035032712 GENTLE LAXAT TAB 5MG EC BISACODYL 5 MG 100 x x 50428166363 BISACODYL TAB 5MG EC BISACODYL 5 MG 50 x x 57896044101 BISACODYL TAB 5MG EC BISACODYL 5 MG 100 x x 11917016232 GENTLE LAXAT SUP 10MG BISACODYL 10 MG 8 x x 00363010908 GENTLE LAXATIVE 10 MG SUPPOSIT BISACODYL 10 MG 8 x x 00713010908 BISAC-EVAC SUP 10MG BISACODYL 10 MG 8 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 11822489250 RA FAST RELIEF LAX 10 MG SUPP BISACODYL 10 MG 8 x x 11917011593 GENTLE LAXATIVE 10 MG SUPPOSIT BISACODYL 10 MG 8 x x 11917014449 GENTLE LAXATIVE 10 MG SUPPOSIT BISACODYL 10 MG 8 x x 50428166371 CVS BISACODYL 10 MG SUPPOS BISACODYL 10 MG 8 x x 00574705012 BISACODYL 10 MG SUPPOSITORY BISACODYL 10 MG 12 x x 00904505812 BISCOLAX 10 MG SUPPOSITORY BISACODYL 10 MG 12 x x 50428690111 CVS GENTLE LAXATIVE 10 MG SUPP BISACODYL 10 MG 16 x x 00132070336 FLEET BISACODYL 10 MG ENEMA BISACODYL 10MG/30ML 37 x x 00121072208 SENNA SYRUP SENNA LEAF EXTRACT 176MG/5ML 237 x x 00121472215 SENNA SYP SENNA SYRUP 176 MG/5ML 15 x x 00363013830 SENNA TAB 8.6MG SENNOSIDES 8.6 MG 300 x x 00363018001 SENNA TAB 8.6MG SENNOSIDES 8.6 MG 100 x x 00363057501 SENNA TAB 8.6MG SENNOSIDES 8.6 MG 100 x x 00761022020 SENNA LAX TAB 8.6MG SENNOSIDES 8.6 MG 100 x x 00904652261 SENNA-LAX 8.6 MG TABLET SENNOSIDES 8.6 MG 100 x x 00904672559 SENNA TAB 8.6MG SENNOSIDES 8.6 MG 100 x x 49035029812 NAT VEG LAX TAB 8.6MG SENNOSIDES 8.6 MG 100 x x 49035089212 EQ NATURAL LAXATIVE 8.6 MG TAB SENNOSIDES 8.6 MG 100 x x 50428026496 CVS SENNA TAB 8.6MG SENNOSIDES 8.6 MG 50 x x 57896045401 GERI-KOT TAB 8.6MG SENNOSIDES 8.6 MG 100 x x 62011028901 HM SENNA 8.6 MG TABLET SENNOSIDES 8.6 MG 100 x x 62011036301 HM SENNA TAB 8.6MG SENNOSIDES 8.6 MG 100 x x 67618030010 SENOKOT TAB 8.6MG SENNOSIDES 8.6 MG 100 x x 67618030050 SENOKOT 8.6 MG TABLET SENNOSIDES 8.6 MG 50 x x 70677005801 SM SENNA LAX TAB 8.6MG SENNOSIDES 8.6 MG 100 x x 54162000708 SENNA 8.8 MG/5 ML SYRUP GRX SENNOSIDES 8.8MG/5ML 236 x x 66424056208 SENNA SYP 8.8MG/5 SENNOSIDES 8.8MG/5ML 236 x x 00536126659 SENNA LIQ 8.8/5ML SENNOSIDES 8.8MG/5ML 237 x x 54859080808 SENNA SYP 8.8/5ML SENNOSIDES 8.8MG/5ML 237 x x 57896045208 SENNA SYP 8.8MG/5 SENNOSIDES 8.8MG/5ML 237 x x 57896046208 SENNA 8.8 MG/5 ML SYRUP SENNOSIDES 8.8MG/5ML 237 x x 59390012541 SENNA SYP 8.8MG/5 SENNOSIDES 8.8MG/5ML 237 x x

LAXATIVES- BULK PRODUCING 00135008971 CITRUCEL POWDER METHYLCELLULOSE (WITH SUGAR) 850 x x 00904520065 NATURAL FIBER LAX POWDER PSYLLIUM SEED (WITH SUGAR) 368 x x 86790021620 BENEFIBER POWDER WHEAT DEXTRIN 3G/4G 248 x x 46017004408 UNIFIBER POW CELLULOSE 240 x x 96295013638 CLEAR FIBER POW CORN DEXTRIN 248 x x

LAXATIVES- EMOLLIENTS 00132030140 FLEET MINERAL OIL ENEMA MINERAL OIL 133 x x

LAXATIVES- HYPEROSMOTIC AGENTS 00132018582 FLEET GLYCERIN LIQUID SUPP GLYCERIN 5.4G/5.4ML 7.5 x x 00132008112 FLEET PEDIA-LAX SUPPOSITORIES GLYCERIN PEDIATRIC 12 x x 58980040912 GLYCERIN PEDIATRIC SUPPOSITORY GLYCERIN PEDIATRIC 12 x x 50428070109 CVS GLYCERIN SUPPOSITORY GLYCERIN PEDIATRIC 25 x x 58980040925 GLYCERIN SUP 1GM GLYCERIN PEDIATRIC 25 x x 11917011514 GLYCERIN SUPPOSITORY GLYCERIN PEDIATRIC 12 x x 11917013296 INFANT & CHILD GLYCERIN SUPPOS GLYCERIN PEDIATRIC 12 x x 46122022263 GLYCERIN SUPPOSITORY GLYCERIN PEDIATRIC 25 x x 00132007912 FLEET GLYCERIN ADULT SUPPOS GLYCERIN ADULT 12 x x 00132007924 FLEET GLYCERIN 2 GM ADULT SUPP GLYCERIN ADULT 24 x x 00132007950 GLYCERIN SUP 2GM GLYCERIN ADULT 50 x x 11917001006 GLYCERIN SUP 2.1GM GLYCERIN ADULT 12 x x 00132019012 FLEET PEDIA-LAX SUPPOSITORIES GLYCERIN 2.8G/2.7ML 4x x 11822332180 RA GLYCERIN PEDIATRIC SUPP GLYCERIN PEDIATRIC 25 x x 11917014445 GLYCERIN SUP 1GM GLYCERIN PEDIATRIC 12 x x 00363044025 GLYCERIN SUP 1.2GM GLYCERIN PEDIATRIC 25 x x 11917016258 GLYCERN CHLD SUP 1.2GM GLYCERIN PEDIATRIC 12 x x 11917019062 GLYCERIN SUP 2GM GLYCERIN ADULT 25 x x

STOOL SOFTENERS- DOCUSATE CALCIUM 00536106501 STOOL SOFTENER 240 MG SOFTGEL DOCUSATE CALCIUM 240 MG 100 x x 00904645959 KAO-TIN 240 MG SOFTGEL DOCUSATE CALCIUM 240 MG 100 x x

STOOL SOFTENERS- DOCUSATE SODIUM 00113048672 STOOL SOFTENER 100 MG CAPSULE DOCUSATE SODIUM 100 MG 60 x x 00363023806 STOOL SOFTNR CAP 100MG DOCUSATE SODIUM 100 MG 60 x x 00536106229 STOOL SOFTENER 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x 00603015021 DOC-Q-LACE 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x 00904645561 DOK 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x 00904645760 DOK 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x 10135011101 DOCUSATE SOD CAP 100MG DOCUSATE SODIUM 100 MG 100 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 11822512670 RA STOOL SOFTENER 100 MG CAP DOCUSATE SODIUM 100 MG 50 x x 12843003520 STOOL SOFTNR CAP 100MG DOCUSATE SODIUM 100 MG 30 x x 24385043678 STOOL SOFTENER 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x 36800048672 STOOL SOFTENER 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 60 x x 45802048678 DOCUSATE SODIUM 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x 46122023172 STOOL SOFTENER 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x 46122023178 STOOL SOFTENER 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 60 x x 49035007860 EQ STOOL CAP SOFTENER DOCUSATE SODIUM 100 MG 60 x x 50428310425 CVS STOOL SOFTENER 100 MG CAP DOCUSATE SODIUM 100 MG 100 x x 50428317683 STOOL SOFTNR CAP 100MG DOCUSATE SODIUM 100 MG 25 x x 50428488021 CVS STOOL SOFTENER 100 MG SFTG DOCUSATE SODIUM 100 MG 30 x x 52569013768 HM STOOL SOFTENER 100 MG SFTGL DOCUSATE SODIUM 100 MG 100 x x 54629060001 DOCUSATE SODIUM 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x 57896040101 DOCUSATE SODIUM 100 MG CAPSULE DOCUSATE SODIUM 100 MG 100 x x 57896040103 DOCUSATE SODIUM 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 30 x x 57896040801 STOOL SOFTNR CAP 100MG DOCUSATE SODIUM 100 MG 100 x x 57896040803 STOOL SOFTNR CAP 100MG DOCUSATE SODIUM 100 MG 30 x x 62011022401 HM STOOL SOFTENER 100 MG SFTGL DOCUSATE SODIUM 100 MG 100 x x 62011036101 HM STOOL SOF CAP 100MG DOCUSATE SODIUM 100 MG 100 x x 62107003301 DOCUSIL 100 MG SOFTGEL DOCUSATE SODIUM 100 MG 100 x x 63739047810 DOCUSATE SODIUM 100 MG CAPSULE DOCUSATE SODIUM 100 MG 100 x x 66424039901 STOOL SOFTNR CAP 100MG DOCUSATE SODIUM 100 MG 100 x x 69618004401 DOCUSATE SOD CAP 100MG DOCUSATE SODIUM 100 MG 100 x x 70677003401 STOOL SOFTNR CAP 100MG DOCUSATE SODIUM 100 MG 100 x x 81421002204 DULCOLAX SS CAP 100MG DOCUSATE SODIUM 100 MG 100 x x 00536106401 STOOL SOFTENER 250 MG SOFTGEL DOCUSATE SODIUM 250 MG 100 x x 00904586960 DOK 100 MG TABLET DOCUSATE SODIUM 100 MG TABLET 100 x x 37864000021 DOCUSATE SODIUM 100 MG TABLET DOCUSATE SODIUM 100 MG TABLET 100 x x 51645075001 DOCUSATE SOD TAB 100MG DOCUSATE SODIUM 100 MG TABLET 100 x x 57896042101 STOOL SOFTNR TAB 100MG DOCUSATE SODIUM 100 MG TABLET 100 x x 00132000106 FLEET PEDIA-LAX STOOL SOFTENER DOCUSATE SODIUM 50 MG/15ML 118 x x 00132010624 FLEET PEDIA-LAX STOOL SOFTENER DOCUSATE SODIUM 50 MG/15ML 118 x x 50383077116 DOCU LIQUID 50 MG/5 ML DOCUSATE SODIUM 50 MG/5 ML 473 x x 54838011680 SILACE 50 MG/5 ML LIQUID DOCUSATE SODIUM 50 MG/5 ML 473 x x 57896040316 DIOCTO 50 MG/5 ML LIQUID DOCUSATE SODIUM 50 MG/5 ML 473 x x 54838010780 SILACE 60 MG/15 ML SYRUP DOCUSATE SODIUM 60 MG/15ML 473 x x 57896040916 DIOCTO 60 MG/15 ML SYRUP DOCUSATE SODIUM 60 MG/15ML 473 x x 17433987603 ENEMEEZ MINI ENEMA DOCUSATE SODIUM 283 MG/5ML 5x x 17433987805 DOCUSOL MINI-ENEMA DOCUSATE SODIUM 283 MG 5 x x

LAXATIVES- COMBINATIONS 67618031030 SENOKOT S TAB 8.6-50MG SENNOSIDES-DOCUSATE SODIUM 30 x x 50428037837 CVS SENNA PL TAB 8.6-50MG SENNOSIDES-DOCUSATE SODIUM 30 x x 00363016060 SENNA S TAB 8.6-50MG SENNOSIDES-DOCUSATE SODIUM 60 x x 00536124701 SENEXON-S TAB 8.6-50MG SENNOSIDES-DOCUSATE SODIUM 100 x x 00536124801 STIMULANT TAB 8.6-50MG SENNOSIDES-DOCUSATE SODIUM 100 x x 49035000206 STOOL SOFTNR TAB 8.6-50MG SENNOSIDES-DOCUSATE SODIUM 60 x x 49035037730 EQ SENNA-S TAB 8.6-50MG SENNOSIDES-DOCUSATE SODIUM 30 x x 57896030401 STOOL SOFTNR TAB 8.6-50MG SENNOSIDES-DOCUSATE SODIUM 100 x x 59726016060 SENNA-S TAB 8.6-50MG SENNOSIDES-DOCUSATE SODIUM 60 x x

ANTI-DIARRHEALS Please refer to TennCare's PDL for coverage of the following: ALL LOPERAMIDE FORMULATIONS

PROBIOTICS 64980012950 FLORANEX TABLET L. acidophilus/L.bulgaricus 50 x x 71351001250 LACTOBACILLU TAB L. acidophilus/L.bulgaricus 50 x x 08290236850 LACTINEX CHEWABLE TABLET L. ACIDOPHILUS/L.BULGARICUS 1MM CELL 50 x x 08290236712 BD LACTINEX L. ACIDOPHILUS/L.BULGARICUS 100MM CELL 12 x x 64980014612 FLORANEX GRANULES PACKET L. ACIDOPHILUS/L.BULGARICUS 100MM CELL 12 x x 02359046020 BIOGAIA PROT DRO BABY LACTOBACILLUS REUTERI 5 x x 50000093560 GERBER SOOTHE COLIC DROPS LACTOBACILLUS REUTERI 10 x x 49100036374 CULTURELLE HLTH & WELLNESS CAP LACTOBACILLUS RHAMNOSUS GG 30 x x 49100040015 CULTURELLE KIDS CHEWABLE TAB LACTOBACILLUS RHAMNOSUS GG 30 x x 49100040037 CULTURELLE KIDS GENTLE-GO PCKT LACTOBACILLUS RHAMNOSUS GG 24 x x 49100040008 CULTURELLE KIDS PACKET LACTOBACILLUS RHAMNOSUS GG 30 x x 49100040063 CULTURELLE PAK PROBIOT LACTOBACILLUS RHAMNOSUS GG 90 x x 37000014343 ALIGN 4 MG CAPSULE BIFIDOBACTERIUM INFANTIS 4 MG 28 x x 39423044048 FLORAJEN3 CAPSULE L ACIDOPHIL/B LACTIS/B LONGUM 460 MG 30 x x 39423088048 FLORAJEN4KIDS CAPSULE L.ACID/L.RHAM/B.LAC BI07/B.LAC 300 MG 30 x x 64980014703 RISAQUAD CAPSULES L. ACIDOPHILUS/STREPT/LA P-CAS 8B CELL 30 x x 39423066048 FLORAJEN3 CAPSULE L acidophil/B lactis/B longum 60 x x 45749001781 VSL#3 CAPSULE Lactobacil 2-S.thermo-Bifido 1 60 x x 69355041203 VISBIOME HIG CAP POTENCY Lactobacil 2-S.thermo-Bifido 2 60 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 71351001760 HIGH POTENCY CAP PROBIOTI Lactobacil 2-S.thermo-Bifido 3 60 x x 49100040053 CULTURE BABY DRO GRW THVE PROBIOTIC PRODUCT 9 x x 45749001782 VSL#3 DS PACKET LACTOBAC #2-S. THERM-BIFIDO #1 900B CELL 20 x x 04142000024 FLORASTOR 250 MG CAPSULE SACCHAROMYCES BOULARDII 20 x x 04142000007 FLORASTOR CAP 250MG SACCHAROMYCES BOULARDII 50 x x 04142000040 FLORASTORKIDS 250 MG PACKET SACCHAROMYCES BOULARDII 20 x x 49100036404 CULTURELLE HLTH & WELLNESS CAP L. RHAMNOSUS GG/INULIN 10B-200 MG 30 x x 49100040009 CULTURELLE CAPSULE L. RHAMNOSUS GG/INULIN 10B-200 MG 30 x x 49100040012 CULTURELLE CAP DIGESTIV L. RHAMNOSUS GG/INULIN 10B-200 MG 30 x x 49100040021 CULTURELLE CAPSULE L. RHAMNOSUS GG/INULIN 10B-200 MG 50 x x 49100040022 CULTURELLE CHEWABLE TABLET L. RHAMNOSUS GG/INULIN 10B-200 MG 24 x x 02359046015 BIOGAIA PROTECTIS DROPS L. REUTERI/VITAMIN D3 100MM-400 10 x x 11917008543 PROBIOTIC CAP LACTOBACILLUS 60 x x 11917015492 PROBIOTIC CAP ADULT PROBIOTIC PRODUCT 30 x x 11917016995 PROBIOTIC CAP LACTOBACILLUS 30 x x 11917017566 PROBIOTIC CAP 250MG SACCHAROMYCES BOULARDII 20 x x 37000029417 ALIGN CAP 4MG PROBIOTIC PRODUCT 42 x x 39423011048 FLORAJEN CAP ACIDOPHI LACTOBACILLUS 30 x x 39423022048 FLORAJEN CAP ACIDOPHI LACTOBACILLUS 60 x x 43292050022 ACIDOPHILUS CAP LACTOBACILLUS 100 x x 49100040007 CULTURELLE CAP LACTOBACILLUS RHAMNOSUS GG 100 x x 64980015603 RISAQUAD-2 CAP PROBIOTIC PRODUCT 30 x x 64980016401 RISA-BID TAB PROBIO PROBIOTIC PRODUCT 100 x x

ANTACIDS 00536009185 ALUM HYDROX SUS 320/5ML ALUMINUM HYDROXIDE GEL 473 x x 00223172001 SODIUM BICARB 325 MG TABLET SODIUM BICARBONATE 325 MG 100 x x 00223172101 SODIUM BICARB 650 MG TABLET SODIUM BICARBONATE 650 MG 100 x x 00363022434 ANTACID CHW 500MG CALCIUM CARBONATE 200(500)MG 150 x x 00363031734 ANTACID 500 MG CHEW TABLET CALCIUM CARBONATE 200(500)MG 150 x x 00904641292 CALCIUM ANTACID 500 MG CHW TAB CALCIUM CARBONATE 200(500)MG 150 x x 69618002015 CALCIUM CARB CHW 500MG CALCIUM CARBONATE 200(500)MG 150 x x 07610028320 MAGNESIUM OXIDE 250 MG CAPLET MAGNESIUM OXIDE 250 MG 100 x x 43292055738 MAGNESIUM OXIDE 250 MG TABLET MAGNESIUM OXIDE 250 MG 100 x x 87701040778 GNP MAGNESIUM 250 MG TABLET MAGNESIUM OXIDE 250 MG 100 x x 40985022713 MAGNESIUM OXIDE 250 MG TABLET MAGNESIUM OXIDE 250 MG 110 x x 00603020922 MAGNESIUM OXIDE 400 MG TABLET MAGNESIUM OXIDE 400 MG 120 x x 51645078508 MAGNESIUM OXIDE 400 MG TABLET MAGNESIUM OXIDE 400 MG 120 x x 07610032024 MAG OXIDE TAB 400MG MAGNESIUM OXIDE 400 MG 120 x x 10006073038 MAG OXIDE TAB 400MG MAGNESIUM OXIDE 400 MG 120 x x 54738097312 MAG OXIDE TAB 400MG MAGNESIUM OXIDE 400 MG 120 x x 37205053040 ANTACID-ANTIGAS LIQUID mag hydrox/aluminum hyd/simeth 355 x x 49348030239 SM ANTACID SUS ADVANCED ALUM & MAG HYDROX-SIMETHICONE 355 x x

H2 ANTAGONISTS Please refer to TennCare's PDL for coverage of the following: FAMOTIDINE 10 MG TABLETS

ANTIEMETIC/ANTIVERTIGO AGENTS Please refer to TennCare's PDL for coverage of the following: MECLIZINE HCL 25MG TABLETS

31248000301 DRAMAMINE 25 MG TABLET CHEW DIMENHYDRINATE 25 MG 8 x x 31248000197 DRAMAMINE TAB 50MG DIMENHYDRINATE 50 MG 12 x x 31248000200 DRAMAMINE CHW 50MG DIMENHYDRINATE 50 MG 8 x x

LACTASE ENZYME 00904522452 LACTASE 3,000 UNIT CAPLET LACTASE 3000 UNIT 60 x x 00045008002 LACTAID TAB 3000UNIT LACTASE 3000 UNIT 120 x x 00450091060 LACTAID FAST ACT 9,000 UNIT LACTASE 9000 UNIT 60 x x

ANTIFLATULENTS 00536222075 GAS RELIEF 20 MG/0.3 ML DROPS SIMETHICONE 40MG/0.6ML 30 x x 00904589430 INF GAS REL 20 MG/0.3 ML DROP SIMETHICONE 40MG/0.6ML 30 x x 36800088210 GAS RELIEF DRO 40/0.6ML SIMETHICONE 40MG/0.6ML 30 x x 49348074027 SM INF GAS RELIEF 20 MG/0.3 ML SIMETHICONE 40MG/0.6ML 30 x x 50428511386 CVS GAS RELIEF EX-STR DROPS SIMETHICONE 40MG/0.6ML 30 x x 56184012041 LITTLE TUMMY DRO 20/0.3ML SIMETHICONE 40MG/0.6ML 30 x x 68163070902 GAS RELIEF DRO 20/0.3ML SIMETHICONE 40MG/0.6ML 30 x x 00904506860 MI-ACID GAS CHW 80MG SIMETHICONE 80 MG 100 x x 57896079101 SIMETHICONE CHW 80MG SIMETHICONE 80 MG 100 x x 69618003301 SIMETHICONE CHW 80MG SIMETHICONE 80 MG 100 x x 11917016242 GAS RELIEF CHW 125MG SIMETHICONE 125 MG 18 x x 69618003206 SIMETHICONE CHW 125MG SIMETHICONE 125 MG 60 x x 00363055072 GAS RELIEF CAP 125MG SIMETHICONE 125 MG 72 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults

TOPICAL AGENTS

TOPICALS- ANTIFUNGALS (INTRA-VAGINAL) Please refer to TennCare's PDL for coverage of the following: MICONAZOLE-3 KIT (COMBO PACK)

00472022041 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 45 x x 00472022063 CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 45 x x 49022008436 CLOTRIMAZOLE-7 CREAM CLOTRIMAZOLE 1 % 45 x x 49348079376 SM CLOTRIMAZOLE 1% CREAM CLOTRIMAZOLE 1 % 45 x x 51672200306 CLOTRIM 1% VAGINAL CREAM CLOTRIMAZOLE 1 % 45 x x 11917003586 CLOTRIMAZOLE 3 2% CREAM CLOTRIMAZOLE 2 % 21 x x 11917007847 CLOTRIMAZOLE 3 2% CREAM CLOTRIMAZOLE 2 % 21 x x 49348037954 3 DAY VAGINL CRE 2% CLOTRIMAZOLE 2 % 21 x x 51672206200 3-DAY VAGINAL CREAM CLOTRIMAZOLE 2 % 21 x x 00113021429 MICONAZOLE 7 CREAM MICONAZOLE NITRATE 2 % 45 x x 00113082529 MICONAZOLE 7 CRE 2% MICONAZOLE NITRATE 2 % 45 x x 00472073041 MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE 2 % 45 x x 00472073063 MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE 2 % 45 x x 00904773445 MICONAZOLE 7 CREAM MICONAZOLE NITRATE 2 % 45 x x 11822382270 RA MICONAZOLE 7 CREAM MICONAZOLE NITRATE 2 % 45 x x 24385059029 MICONAZOLE 7 CREAM MICONAZOLE NITRATE 2 % 45 x x 30142082529 KRO MICONAZOLE 7 CREAM MICONAZOLE NITRATE 2 % 45 x x 36800082529 MICONAZOLE 7 CRE 2% MICONAZOLE NITRATE 2 % 45 x x 49022008444 MICONAZOLE 7 CREAM MICONAZOLE NITRATE 2 % 45 x x 49035073007 EQ MICONAZOLE NITRATE 2% CRM MICONAZOLE NITRATE 2 % 45 x x 49348053077 SM MICONAZOLE 7 CREAM MICONAZOLE NITRATE 2 % 45 x x 49348087277 SM MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE 2 % 45 x x 51672203506 MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE 2 % 45 x x 00472173607 MICONAZOLE 7 SUP 100MG MICONAZOLE NITRATE 100MG SUP 7x x

TOPICALS- ANTIFUNGALS Please refer to TennCare's PDL for coverage of the following: CLOTRIMAZOLE 1% CREAM AND SOLUTION

00395100392 GENTIAN VIOL SOL 1% GENTIAN VIOLET 59 x x 51672208001 TERBINAFINE 1% CREAM TERBINAFINE HCL 1 % 15 x x 51672208002 TERBINAFINE 1% CREAM TERBINAFINE HCL 1 % 30 x x 11917009374 TERBINAFINE CRE 1% TERBINAFINE HCL 1 % 15 x x 00145150605 ZEASORB-AF POW 2% MICONAZOLE NITRATE 2 % 71 x x 00067094930 DESENEX 2% POWDER MICONAZOLE NITRATE 2 % 85 x x 11701003816 MICRO-GUARD 2% POWDER MICONAZOLE NITRATE 2 % 85 x x 11017041031 LOTRIMIN AF 2% SPRAY POWDER MICONAZOLE NITRATE 2 % 133 x x 00472073514 ANTIFUNGAL 2% CREAM MICONAZOLE NITRATE 2 % 14 x x 65197010305 MICATIN 2% ANTIFUNGAL CREAM MICONAZOLE NITRATE 2 % 14 x x 51672200101 MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE 2 % 15 x x 00472073556 ANTIFUNGAL 2% CREAM MICONAZOLE NITRATE 2 % 28 x x 49348068972 SM MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE 2 % 30 x x 51672200102 MICONAZOLE NITRATE 2% CREAM MICONAZOLE NITRATE 2 % 30 x x 00472073542 ANTIFUNGAL 2% CREAM MICONAZOLE NITRATE 2 % 42.5 x x 11086004002 TRIPLE PASTE AF 2% OINTMENT MICONAZOLE NITRATE 2 % 56.7 x x

TOPICALS- ANTI-INFECTIVES 45802006001 BACITRACIN 500 UNIT/GM OINTMNT BACITRACIN 500 UNIT/G 14 x x 14428000003 BACITRAYCIN PLUS 500 UNIT/GM BACITRACIN 500 UNIT/G 28 x x 45802006003 BACITRACIN 500 UNIT/GM OINTMNT BACITRACIN 500 UNIT/G 28 x x 00713028031 BACITRACIN 500 UNIT/GM OINTMNT BACITRACIN 500 UNIT/G 28.4 x x 37205027510 BACITRACIN OIN 500/GM BACITRACIN 500 UNIT/G 28.4 x x 62011009401 HM BACITRACIN ZN 500 UNIT/GM BACITRACIN ZINC 500 UNIT/G 28.4 x x 00472110534 BACITRACIN ZN 500 UNIT/GM OINT BACITRACIN ZINC 500 UNIT/G 14 x x 00472110556 BACITRACIN ZN 500 UNIT/GM OINT BACITRACIN ZINC 500 UNIT/G 28 x x 11917016394 BACITRACIN ZN 500 UNIT/GM OINT BACITRACIN ZINC 500 UNIT/G 28 x x 11917011354 BACITRACIN ZN 500 UNIT/GM OINT BACITRACIN ZINC 500 UNIT/G 28.4 x x 24385006003 BACITRACIN ZN 500 UNIT/GM OINT BACITRACIN ZINC 500 UNIT/G 28.4 x x 51672207502 BACITRACIN ZN 500 UNIT/GM OINT BACITRACIN ZINC 500 UNIT/G 28.4 x x 00363007564 BACITRACIN OIN 500/GM BACITRACIN ZINC 500 UNIT/G 28 x x 11917016408 BACITR ZINC OIN 500/GM BACITRACIN ZINC 500 UNIT/G 28.4 x x 00904073431 TRIPLE ANTIB OIN NEOMYCIN SU/BACITRAC ZN/POLY 3.5-400-5K 28 x x 11917005095 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5-400-5K 14 x x 11917009752 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5-400-5K 14 x x 50428322436 CVS ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5-400-5K 14 x x 00472017934 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5-400-5K 14.2 x x 00113006764 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5-400-5K 28 x x 00472017956 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5-400-5K 28 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 11917016407 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5-400-5K 28 x x 30142006764 KRO TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5-400-5K 28 x x 00713026831 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5-400-5K 28.4 x x 11917005491 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5-400-5K 28.4 x x 62011009801 HM TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5-400-5K 28.4 x x 37205027310 TRIPLE ANTIBIOTIC OINTMENT NEOMYCIN SU/BACITRAC ZN/POLY 3.5-400-5K 30 x x

TOPICALS- ANTISEPTICS 00234057504 HIBICLENS LIQ 4% CHLORHEXIDINE GLUCONATE 4 % 118 x x 00234057508 HIBICLENS 4% LIQUID CHLORHEXIDINE GLUCONATE 4 % 236 x x 00234057532 HIBICLENS 4% LIQUID CHLORHEXIDINE GLUCONATE 4 % 946 x x 00327000110 CLORPACTIN POW WCS-90 OXYCHLOROSENE SODIUM 2 x x 00436067216 DAKIN'S 0.125% SOLUTION SODIUM HYPOCHLORITE 0.125 % 473 x x 00436093616 DAKIN'S 0.25% SOLUTION SODIUM HYPOCHLORITE 0.25 % 473 x x 11917013266 POVIDONE-IODINE 10% SOLUTION POVIDONE-IODINE 10 % 236 x x 00904110309 POVIDONE-IODINE 10% SOLUTION POVIDONE-IODINE 10 % 240 x x 00904110231 POVIDONE-IODINE 10% OINTMENT POVIDONE-IODINE 10 % 28.35 x x 00234057516 HIBICLENS LIQ 4% CHLORHEXIDINE GLUCONATE 473 x x 00436094616 DAKINS SOL 0.5% SODIUM HYPOCHLORITE 473 x x 39328006325 HYSEPT SOL 0.25% SODIUM HYPOCHLORITE 473 x x 39328006412 H-CHLOR 12 SOL 0.125% SODIUM HYPOCHLORITE 473 x x

TOPICALS- ACNE- BENZOYL PEROXIDE 24470090004 BP WASH 5% LIQUID BENZOYL PEROXIDE 5 % 113 x x 45802028001 BENZOYL PER LIQ 5% WASH BENZOYL PEROXIDE 5 % 142 x x 00536125963 BENZOYL PER LIQ 5% WASH BENZOYL PEROXIDE 5 % 148 x x 67405082505 BENZOYL PEROXIDE 5% WASH BENZOYL PEROXIDE 5 % 148 x x 45802028034 BENZOYL PER LIQ 5% WASH BENZOYL PEROXIDE 5 % 227 x x 00536125919 BENZOYL PER LIQ 5% WASH BENZOYL PEROXIDE 5 % 236 x x 67405082508 BENZOYL PEROXIDE 5% WASH BENZOYL PEROXIDE 5 % 237 x x 24470090105 BP WASH 10% LIQUID BENZOYL PEROXIDE 10 % 142 x x 45802031801 BENZOYL PEROXIDE 10% WASH BENZOYL PEROXIDE 10 % 142 x x 67405083005 BENZOYL PEROXIDE 10% WASH BENZOYL PEROXIDE 10 % 148 x x 00145098505 PANOXYL 10% ACNE FOAMING WASH BENZOYL PEROXIDE 10 % 156 x x 00316022855 PANOXYL WASH LIQ 10% BENZOYL PEROXIDE 10 % 156 x x 49022067498 ACNE FOAMING 10% WASH BENZOYL PEROXIDE 10 % 156 x x 50428045366 CVS FOAMING ACNE FACE 10% WASH BENZOYL PEROXIDE 10 % 187 x x 45802031834 BENZOYL PEROXIDE 10% WASH BENZOYL PEROXIDE 10 % 227 x x 67405083008 BENZOYL PEROXIDE 10% WASH BENZOYL PEROXIDE 10 % 237 x x 70501001790 ON-THE-SPOT 2.5% ACNE CREAM BENZOYL PEROXIDE 2.5 % 21 x x 45802010196 BENZOYL PEROXIDE 2.5% GEL BENZOYL PEROXIDE 2.5 % 60 x x 00536105556 ACNE MEDICATION 5% GEL BENZOYL PEROXIDE 5 % 42.5 x x 24470090960 BP 5% GEL BENZOYL PEROXIDE 5 % 60 x x 45802021696 BENZOYL PEROXIDE 5% GEL BENZOYL PEROXIDE 5 % 60 x x 45802021601 BENZOYL PEROXIDE 5% GEL BENZOYL PEROXIDE 5 % 90 x x 00536105656 ACNE MEDICATION 10% GEL BENZOYL PEROXIDE 10 % 42.5 x x 24470091060 BP 10% GEL BENZOYL PEROXIDE 10 % 60 x x 45802030896 BENZOYL PEROXIDE 10% GEL BENZOYL PEROXIDE 10 % 60 x x 00536105775 ACNE MEDICATION 5% LOTION BENZOYL PEROXIDE 5 % 29.5 x x 00536105875 ACNE MEDICATION 10% LOTION BENZOYL PEROXIDE 10 % 29.5 x x 49022052320 ACNE MAX STR CRE 10% BENZOYL PEROXIDE 10 % 28 x x 50428041363 ACNE CLEANSE CRE CVS CONT BENZOYL PEROXIDE 10 % 142 x x

TOPICALS- ACNE- ADAPALENE Please refer to TennCare's PDL for coverage of the following: DIFFERIN 0.1% GEL OTC

TOPICALS- CORTICOSTEROIDS Please refer to TennCare's PDL for coverage of the following: HYDROCORTISONE CREAM AND OINTMENT 1% ALL FORMULATIONS

TOPICALS- EMOLLIENTS Please refer to TennCare's PDL for coverage of the following: AMMONIUM LACTATE 12% CREAM AND LOTION

00187137316 CERAVE MOISTURIZING CREAM CERAMIDES 1,3,6-11 453 x x 45334030001 VANICREAM CRE EMOLLIENT 453 x x 72140011015 EUCERIN INTENSIVE REPAIR LOT emollient combination no.72 250 x x 00187137112 CERAVE MOISTURIZING LOTION ceramides 1,3,6-11 355 x x 72140063377 AQUAPHOR OIN ADVANCED EMOLLIENT 85 x x 54162050002 HYDROPHOR 42% OINTMENT PETROLATUM,WHITE 42 % 100 x x 72140003147 AQUAPHOR 41% ORIGINAL OINTMENT PETROLATUM,WHITE 41 % 396 x x 72140063608 AQUAPHOR 41% HEALING OINTMENT PETROLATUM,WHITE 41 % 396 x x 37205001130 GLYCERIN 99.5% LIQUID glycerin 177 x x 10135010408 GLYCERIN LIQUID GLYCERIN 480 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 72140003868 EUCERIN CRE SKIN PROTECTANTS, MISC. 57 x x 00904775127 MINERIN CREME MINERAL OIL/PETROLATUM,WHITE 454 x x 00187137012 CERAVE HYDRATING CLEANSER ceramides 1,3,6-11 355 x x 00395103196 GLYCERIN 99.5% LIQUID GLYCERIN 99.5 % 177 x x 00395103116 GLYCERIN SKIN PROTECTANT LIQ GLYCERIN 99.5 % 473 x x 11917004980 PETROLEUM JELLY 100% PURE PETROLATUM,WHITE 106 x x 11917004964 PETROLEUM JELLY 100% PURE PETROLATUM,WHITE 368 x x 37205006927 PETROLEUM JELLY PETROLATUM,WHITE 368 x x

TOPICALS- ASTRINGENTS 57074000177 DOMEBORO PACKET CALCIUM ACETATE/ALUMINUM SULF 952-1347MG 12 x x 51224016212 ALUMINUM ACE POW ASTRINGN ALUMINUM SULFATE & CALCIUM ACETATE 12 x x

TOPICALS- DRYING AGENTS 00096070935 XERAC AC 6.25% SOLUTION ALUMINUM CHLORIDE 6.25% 35 x x 00096070960 XERAC AC 6.25% SOLUTION ALUMINUM CHLORIDE 6.25% 60 x x

TOPICALS- COUNTERIRRITANTS 00536252525 CAPSAICIN 0.025% CREAM CAPSAICIN 0.025 % 60 x x 00536126456 CAPSAICIN CRE 0.1% CAPSAICIN 0.1 % 42.5 x x

TOPICALS- SKIN PROTECTANTS 00168006231 ZINC OXIDE 20% OINTMENT ZINC OXIDE 20 % 28.35 x x 62103033302 BOUDREAUXS BUTT PASTE ZINC OXIDE 16 % 57 x x 00799000102 CALMOSEPTINE OINTMENT MENTHOL/ZINC OXIDE 0.44-20.6% 71 x x 00799000104 CALMOSEPTINE OINTMENT MENTHOL/ZINC OXIDE 0.44-20.6% 113 x x 00799000103 CALMOSEPTINE OIN MENTHOL-ZINC OXIDE 71 x x 11917017045 MOISTURE OIN BARRIER MENTHOL-ZINC OXIDE 113 x x 00536120473 MENTHOL ZINC OIN 0.45-20% MENTHOL-ZINC OXIDE 113 x x 43553325604 SENSI-CARE OIN 49-15% PETROLATUM-ZINC OXIDE 113 x x 67492010512 RESINOL OIN DERMATOLOGICAL PRODUCTS, MISC. 85.1 x x 67492010511 RESINOL OINTMENT RESOR/CALA/ZNOX/PET,WH/LAN 2%-55% 35.4 x x

TOPICALS- PEDICULIDES Please refer to TennCare's PDL for coverage of the following: ALL FORMULATIONS OF PERMETHRIN 1%

NICOTINE REPLACEMENT PRODUCTS Please refer to TennCare's PDL for coverage of the following: ALL FORMULATIONS OF NICOTINE PATCHES 7MG, 14MG AND 21MG/ 24 HRS ALL FORMULATIONS OF NICOTINE CHEWING GUM 2MG AND 4MG ALL FORMULATIONS OF NICOTINE LOZENGES 2MG AND 4MG

ANALGESICS

ANALGESICS- ASPIRIN 325MG 00363015712 ASPIRIN 325 MG TABLET ASPIRIN 325 MG 100 x x 00536105301 ASPIRIN 325 MG TABLET ASPIRIN 325 MG 100 x x 50428152314 CVS ASPIRIN TAB 325MG ASPIRIN 325 MG 100 x x 57896090101 ASPIRIN TAB 325MG ASPIRIN 325 MG 100 x x

ANALGESICS- ASPIRIN 81MG CHEWABLE 00113027468 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x 00113046768 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x 00363021807 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x 00536100836 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x 00904404073 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x 24385002868 CHILD ASPIRIN 81 MG CHEW TAB ASPIRIN 81 MG 36 x x 24385027868 ASPIRIN 81 MG CHEW TABLET ASPIRIN 81 MG 36 x x 30142046768 KRO ASPIRIN 81 MG CHEWABLE TAB ASPIRIN 81 MG 36 x x 36800027468 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x 49035046768 EQ ASPIRIN 81 MG CHEWABLE TAB ASPIRIN 81 MG 36 x x 49348019107 SM CHILD ASPIRIN 81 MG CHW TAB ASPIRIN 81 MG 36 x x 57896091136 ASPIRIN 81 MG CHEWABLE TABLET ASPIRIN 81 MG 36 x x 62011002101 HM ASPIRIN 81 MG CHEWABLE TAB ASPIRIN 81 MG 36 x x 62011021201 HM ASPIRIN CHW 81MG ASPIRIN 81 MG 36 x x 59779027468 ASPIRIN LOW CHW 81MG ASPIRIN 81 MG 36 x x

ANALGESICS- ASPIRIN 325MG ENTERIC 57896092101 ASPIRIN EC 325 MG TABLET ASPIRIN 325 MG 100 x x 00904201360 ASPIRIN TAB 325MG EC ASPIRIN 325 MG 100 x x 00363069112 ASPIRIN TAB 325MG ASPIRIN 325 MG 100 x x 69618001501 ASPIRIN TAB 325MG EC ASPIRIN 325 MG 100 x x

ANALGESICS- APAP 325MG

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 10135012330 ACETAMIN TAB 325MG ACETAMINOPHEN 325MG 30 x x 00904198251 MAPAP 325 MG TABLET ACETAMINOPHEN 325 MG 50 x x 10135012360 ACETAMINOPHEN 325 MG TABLET ACETAMINOPHEN 325 MG 60 x x 00363010412 PAIN RELIEVER 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x 00536322201 PAIN & FEVER 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x 00904198259 MAPAP 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x 00904198260 MAPAP 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x 00904198261 MAPAP 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x 00904671960 ACETAMINOPHE TAB 325MG ACETAMINOPHEN 325MG 100 x x 10135012301 ACETAMINOPHEN 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x 11822317640 RA ATHENOL 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x 30142040378 KRO ACETAMINOPHEN 325 MG TAB ACETAMINOPHEN 325 MG 100 x x 36800040378 PAIN RELIEF 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x 37864000101 ACETAMINOPHEN 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x 51645070301 ACETAMINOPHEN 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x 57896010101 ACETAMINOPHEN 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x 62011003201 HM PAIN RELIEVER 325 MG TABLET ACETAMINOPHEN 325 MG 100 x x 49035052378 ACETAMINOPHN TAB 325MG ACETAMINOPHEN 325 MG 100 x x 57896010201 ACETAMINOPHE TAB 325MG ACETAMINOPHEN 325 MG 100 x x 57896010205 ACETAMINOPHE TAB 325MG ACETAMINOPHEN 325 MG 50 x x 59779076678 PAIN RELIEF TAB 325MG ACETAMINOPHEN 325 MG 100 x x 69618001001 ACETAMIN TAB 325MG ACETAMINOPHEN 325 MG 100 x x

ANALGESICS- APAP 500MG/650MG TAB/CAP/GELCAP 00113022771 PAIN RELIEF 500 MG TABLET ACETAMINOPHEN 500 MG 50 x x 00113048462 PAIN RELIEF 500 MG CAPLET ACETAMINOPHEN 500 MG 24 x x 00113048471 PAIN RELIEF 500 MG CAPLET ACETAMINOPHEN 500 MG 50 x x 00113048478 PAIN RELIEF 500 MG CAPLET ACETAMINOPHEN 500 MG 100 x x 00363017512 PAIN RELIEVER 500 MG CAPLET ACETAMINOPHEN 500 MG 100 x x 00363017515 PAIN RELIEVER 500 MG CAPLET ACETAMINOPHEN 500 MG 50 x x 00363051908 PAIN RELIEVER 500 MG GELCAP ACETAMINOPHEN 500 MG 24 x x 00363051912 PAIN RELIEVER 500 MG GELCAP ACETAMINOPHEN 500 MG 100 x x 00363051915 PAIN RELIEVER 500 MG GELCAP ACETAMINOPHEN 500 MG 50 x x 00363053112 PAIN RELIEVER 500 MG TABLET ACETAMINOPHEN 500 MG 100 x x 00904198324 MAPAP 500 MG CAPLET ACETAMINOPHEN 500 MG 24 x x 10135014424 ACETAMINOPHEN 500 MG CAPLET ACETAMINOPHEN 500 MG 24 x x 11822030300 RA ACETAMINOPHEN 500 MG TABLET ACETAMINOPHEN 500 MG 50 x x 11822506040 RA ACETAMINOPHEN 500 MG CAPLET ACETAMINOPHEN 500 MG 24 x x 24385014571 PAIN RELIEVER 500 MG TABLET ACETAMINOPHEN 500 MG 50 x x 49035048462 EQ ACETAMINOPHEN 500 MG CAPLET ACETAMINOPHEN 500 MG 24 x x 62011002301 HM PAIN RELIEF 500 MG CAPLET ACETAMINOPHEN 500 MG 100 x x 62011002302 HM PAIN RELIEF 500 MG CAPLET ACETAMINOPHEN 500 MG 50 x x 62011004901 HM PAIN RELIEVER 500 MG TABLET ACETAMINOPHEN 500 MG 100 x x 00904576960 ARTHRTS PAIN TAB 650MG ACETAMINOPHEN 650MG 100 x x 70000018003 8 HOUR PAIN TAB 650MG ACETAMINOPHEN 650MG 100 x x 00113021771 PAIN RELIEF TAB 650MG ACETAMINOPHEN 650MG 50 x x 62011002601 ARTHRTS PAIN TAB 650MG ACETAMINOPHEN 650MG 100 x x 70000030601 8 HOUR PAIN TAB 650MG ACETAMINOPHEN 650MG 100 x x 10135014460 ACETAMIN TAB 500MG ACETAMINOPHEN 500MG 60 x x 00363017508 PAIN RELIEVE TAB 500MG ACETAMINOPHEN 500 MG 24 x x 00363053115 PAIN RELIEVE TAB 500MG ACETAMINOPHEN 500 MG 50 x x 10135015201 ACETAMIN TAB 500MG ACETAMINOPHEN 500 MG 100 x x 11917001164 ACETAMIN TAB 500MG ACETAMINOPHEN 500 MG 60 x x 50428028552 ACETAMINOPHN TAB 500MG ACETAMINOPHEN 500 MG 24 x x 57896020401 ACETAMINOPHE TAB 500MG ACETAMINOPHEN 500 MG 100 x x 57896022101 ACETAMIN TAB 500MG ACETAMINOPHEN 500 MG 100 x x 59779048462 PAIN RELIEF TAB 500MG ACETAMINOPHEN 500 MG 24 x x 59779048471 PAIN RELIEF TAB 500MG ACETAMINOPHEN 500 MG 50 x x 59779048478 PAIN RELIEF TAB 500MG ACETAMINOPHEN 500 MG 100 x x 69842093108 ACETAMINOPHN TAB 500MG ACETAMINOPHEN 500 MG 24 x x

ANALGESICS- APAP 160MG/5ML LIQUID/SOLN/SUSP/ELIX 00904198500 MAPAP 160 MG/5 ML LIQUID ACETAMINOPHEN 160 MG/5ML 118 x x 00904198520 MAPAP 160 MG/5 ML LIQUID ACETAMINOPHEN 160 MG/5ML 118 x x 54838014440 CHILDREN'S SILAPAP ELIXIR ACETAMINOPHEN 160 MG/5ML 118 x x 00363094610 INFANT PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 30 x x 00363059016 INFANT PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 59 x x 00363094616 INFANT PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 59 x x 11822353410 RA INFANT FEVER-PAIN REL SUSP ACETAMINOPHEN 160 MG/5ML 59 x x 11917013234 INFANT PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 59 x x 49348008130 SM INFANT PAIN-FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 59 x x 50428858863 CVS INFNT PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 59 x x 50428858864 CVS INFNT PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 59 x x 50428858867 CVS INFNT PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 59 x x 62011000101 HM INFANT PAIN-FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 59 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 62011000201 HM INFANT PAIN-FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 59 x x 00363076616 INFANT PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 60 x x 36800076616 INFANT PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 60 x x 49035059016 EQ INFANT PAIN-FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 60 x x 49035094616 EQ INFANT PAIN-FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 60 x x 00113010526 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x 00113021226 CHILD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 00113060826 CHILD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 00363016204 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x 00363016704 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x 00363034044 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x 00363034544 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x 00363075926 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x 00363080026 CHILD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 00904653620 MAPAP 160 MG/5 ML SUSPENSION ACETAMINOPHEN 160 MG/5ML 118 x x 11673010526 ACETAMINOPHEN 160 MG/5 ML SUSP ACETAMINOPHEN 160 MG/5ML 118 x x 11673013026 ACETAMINOPHEN 160 MG/5 ML SUSP ACETAMINOPHEN 160 MG/5ML 118 x x 11673075926 CHLD ACETAMINOPHEN 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 11822309680 RA NON-ASPIRIN 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 11822989540 RA NON-ASPIRIN 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 11917012082 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x 24385014626 CHILD'S PAIN RELIEVER SUSP ACETAMINOPHEN 160 MG/5ML 118 x x 36800010526 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x 36800075926 CHILD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 45802020126 CHLD ACETAMINOPHEN 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 45802020326 CHLD ACETAMINOPHEN 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 46122020926 CHILD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 46122021026 CHILD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 46122021126 CHILD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 46122021226 CHILD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 49035031326 PAIN & FEVER SUS 160/5ML ACETAMINOPHEN 160 MG/5ML 118 x x 49035095926 EQ INFANT PAIN-FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 118 x x 49348009334 SM CHLD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 49348011934 SM CHLD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 49348012334 SM CHLD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 49781001604 CHILD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 50428207688 CVS CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 50428521351 CVS CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 50428862227 CVS CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 62011018301 HM CHLD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 62011024701 HM CHLD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 63868017626 QC CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 30142059016 KRO INFANT PAIN-FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 59 x x 30142076616 KRO INFANT PAIN-FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 59 x x 00363016004 CHILD PAIN RLF 160 MG/5 ML SUS ACETAMINOPHEN 160 MG/5ML 118 x x 00536012297 CHILD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 30142001526 KRO CHILD PAIN-FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 118 x x 30142010526 KRO CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 30142039726 KRO CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 30142059026 KRO INFANT PAIN-FEVER 160 MG/5 ACETAMINOPHEN 160 MG/5ML 118 x x 30142095926 KRO CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 52569013661 HM CHLD PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 56062017526 PUB CHILD PAIN RLF 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 87701040662 GNP CHL PAIN-FEVER 160 MG/5 ML ACETAMINOPHEN 160 MG/5ML 118 x x 00363016116 PAIN & FEVER SUS 160/5ML ACETAMINOPHEN 160MG/5ML 59 x x 00363028404 PAIN & FEVER SUS 160/5ML ACETAMINOPHEN 160MG/5ML 118 x x 00363033016 PAIN & FEVER SUS 160/5ML ACETAMINOPHEN 160MG/5ML 59 x x 00363095926 PAIN & FEVER SUS 160/5ML ACETAMINOPHEN 160MG/5ML 118 x x 11917011372 PAIN & FEVER SUS 160/5ML ACETAMINOPHEN 160MG/5ML 118 x x 11917013221 PAIN & FEVER SUS 160/5ML ACETAMINOPHEN 160MG/5ML 60 x x 49035004226 PAIN & FEVER SUS 160/5ML ACETAMINOPHEN 160MG/5ML 118 x x 58602022124 AUROPHEN SUS 160/5ML ACETAMINOPHEN 160MG/5ML 118 x x 59779012626 PAIN & FEVER SUS 160/5ML ACETAMINOPHEN 160MG/5ML 118 x x 59779026326 PAIN & FEVER SUS 160/5ML ACETAMINOPHEN 160MG/5ML 118 x x

ANALGESICS- APAP SUPPOSITORIES 51672211402 FEVERALL 80 MG SUPPOSITORY ACETAMINOPHEN 80 MG 6 x x 45802073230 ACETAMINOPHEN 120 MG SUPPOS ACETAMINOPHEN 120 MG 12 x x 00363057953 PAIN/FEVER SUP 120MG ACETAMINOPHEN 120 MG 12 x x 51672211602 FEVERALL 325 MG SUPPOSITORY ACETAMINOPHEN 325 MG 6 x x 45802073030 ACETAMIN SUP 650MG ACETAMINOPHEN 650MG 12 x x

ANALGESICS- IBUPROFEN 200MG TAB/CAP/SOFTGEL 00113060462 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 24 x x 00113064762 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 24 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 00363029108 WAL-PROFEN 200 MG TABLET IBUPROFEN 200 MG 24 x x 00904791524 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 24 x x 11822506050 RA IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 24 x x 30142060462 KRO IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 24 x x 00113007471 IBUPROFEN TAB 200MG IBUPROFEN 200 MG 50 x x 00113051771 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 50 x x 00113060471 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x 00113064771 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 50 x x 00363029115 WAL-PROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x 00363039215 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x 00363039315 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 50 x x 00904791251 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 50 x x 00904791451 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x 00904791551 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x 11822017790 RA IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x 24385060471 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x 24385064771 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 50 x x 30142060471 KRO IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x 36800064771 IBUPROFEN TAB 200MG IBUPROFEN 200 MG 50 x x 49348019609 SM IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 50 x x 49348070609 SM IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x 50428037194 CVS IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x 62011001401 HM IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 50 x x 62011001501 HM IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 50 x x 00113007478 IBUPROFEN TAB 200MG IBUPROFEN 200 MG 100 x x 00113060478 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 00113064778 IBUPROFEN TAB 200MG IBUPROFEN 200 MG 100 x x 00363029112 WAL-PROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 00363039212 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 00363039312 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 100 x x 00363043812 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 00904791259 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 100 x x 00904791459 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 00904791461 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 00904791559 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 11822008130 RA IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 24385060478 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 24385064778 IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 100 x x 30142051778 KRO IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 100 x x 30142064778 KRO IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 100 x x 36800060478 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 49035091212 EQ IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 49348070610 SM IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 50428051962 CVS IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 57896094101 IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 62011001402 HM IBUPROFEN 200 MG TABLET IBUPROFEN 200 MG 100 x x 62011001502 HM IBUPROFEN 200 MG CAPLET IBUPROFEN 200 MG 100 x x 00363012140 IBUPROFEN CAP 200MG IBUPROFEN 200 MG 40 x x 11917010270 IBUPROFEN CAP 200MG IBUPROFEN 200 MG 20 x x 59779060462 IBUPROFEN TAB 200MG IBUPROFEN 200 MG 24 x x

ANALGESICS- IBUPROFEN 50MG/1.25ML DROPS 00113005705 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 15 x x 00363005705 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 15 x x 00363005710 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 30 x x 00363125224 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 30 x x 00904546335 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 15 x x 11822040280 RA INFANT IBUPROFEN SUSP DROP IBUPROFEN 50 MG/1.25 30 x x 11917006307 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 30 x x 24385055010 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 30 x x 45802005705 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 15 x x 45963012523 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 15 x x 45963012524 INFANT IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 30 x x 49348064227 SM INFANT IBUPROFEN SUSP DROP IBUPROFEN 50 MG/1.25 30 x x 62011000401 HM INF IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 30 x x 62011001201 HM INF IBUPROFEN 50 MG/1.25 ML IBUPROFEN 50 MG/1.25 15 x x

ANALGESICS- IBUPROFEN 100MG/5ML SUSP/LIQ 00363080626 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 00363126194 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 00472125594 IBUPROFEN SUS 100/5ML IBUPROFEN 100 MG/5ML 118 x x 00472126194 IBUPROFEN SUS 100/5ML IBUPROFEN 100 MG/5ML 118 x x 00472176094 IBUPROFEN SUS 100/5ML IBUPROFEN 100 MG/5ML 118 x x 00472176194 IBUPROFEN CH SUS 100/5ML IBUPROFEN 100 MG/5ML 118 x x 00472176394 IBUPROFEN SUS 100/5ML IBUPROFEN 100 MG/5ML 118 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 00472176494 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 00904557720 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 11822505950 RA CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 30142016626 KRO CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 30142068526 KRO CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 30142089726 KRO CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 45802013326 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 45802014026 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 45802089726 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 49035016626 EQ CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 49035066026 EQ CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 49035089726 EQ CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 50428456312 CVS CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 118 x x 69230030811 IBUPROFEN SUS 100/5ML IBUPROFEN 100 MG/5ML 118 x x 70000025901 IBUPROFEN SUS 100/5ML IBUPROFEN 100 MG/5ML 118 x x 00113016626 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 00113066026 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 00113068526 GS CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 00113089726 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 00363016626 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 00363066026 IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 120 x x 00363089726 IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 120 x x 00904530920 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 11673068526 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 11822239990 RA IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 120 x x 11822361590 RA IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 120 x x 11822361600 RA CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 24385000926 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 24385036126 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 24385037226 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 24385090526 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 36800068526 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 36800089726 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 46122011026 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 49348022934 SM IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 120 x x 49348049934 SM IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 120 x x 49348050034 SM IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 120 x x 49348087634 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 50428261925 IBUPROFEN SUS 100/5ML IBUPROFEN 100 MG/5ML 120 x x 51672213008 IBUPROFEN SUS 100/5ML IBUPROFEN 100 MG/5ML 120 x x 52569013256 HM CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 52569013279 HM CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 56062016626 PUB CHILDREN'S PROFENIB SUSP IBUPROFEN 100 MG/5ML 120 x x 56062089726 PUB CHILDREN'S PROFEN IB SUSP IBUPROFEN 100 MG/5ML 120 x x 62011001001 HM CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 62011001101 HM CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 62011003001 HM CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 62011021401 IBUPROFEN SUS 100/5ML IBUPROFEN 100 MG/5ML 120 x x 70000026201 IBUPROFEN SUS 100/5ML IBUPROFEN 100 MG/5ML 120 x x 70000026301 IBUPROFEN SUS 100/5ML IBUPROFEN 100 MG/5ML 120 x x 70000026401 IBUPROFEN SUS 100/5ML IBUPROFEN 100 MG/5ML 120 x x 87701084242 GNP CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 120 x x 62011003003 HM CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 150 x x 45802089734 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 237 x x 49035089734 EQ CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 237 x x 00113089734 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x 00904530909 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x 11822316940 RA CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x 24385000934 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x 24385036134 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x 24385090534 CHILDREN IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x 30142016634 KRO CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x 30142089734 KRO CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x 49348022937 SM IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 100 MG/5ML 240 x x 50428454601 CVS CHLD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x 52569013514 HM CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x 62011003002 HM CHILD IBUPROFEN 100 MG/5 ML IBUPROFEN 100 MG/5ML 240 x x 70000026302 IBUPROFEN SUS 100/5ML IBUPROFEN 100 MG/5ML 240 x x

ANALGESICS- NAPROXEN SOD 220MG TAB/CAP/GEL 00363036862 ALL DAY PAIN RLF 220 MG CAPLET NAPROXEN SODIUM 220 MG 24 x x 00363036871 ALL DAY PAIN RLF 220 MG CAPLET NAPROXEN SODIUM 220 MG 50 x x 00363049071 ALL DAY PAIN RELIEF 220 MG TAB NAPROXEN SODIUM 220 MG 50 x x 50428235637 CVS NAPROXEN SOD 220 MG CAPLET NAPROXEN SODIUM 220 MG 24 x x 62011001701 HM NAPROXEN SOD 220 MG CAPLET NAPROXEN SODIUM 220 MG 50 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults

URINARY PRODUCTS

URINARY ANALGESICS 49348007644 SM URINARY PAIN RLF 95 MG TAB PHENAZOPYRIDINE HCL 95 MG 30 x x 87651030152 AZO URINARY PAIN RLF 95 MG TAB PHENAZOPYRIDINE HCL 95 MG 30 x x 00363000030 URINARY PAIN TAB 95MG PHENAZOPYRIDINE HCL 95 MG 30 x x 70000024301 URINARY PAIN TAB 95MG PHENAZOPYRIDINE HCL 95 MG 30 x x 00363011312 URINARY PAIN RELIEF 97.5 MG TB PHENAZOPYRIDINE HCL 97.5 MG 12 x x 49348094102 SM URINARY PAIN REL 97.5 MG TB PHENAZOPYRIDINE HCL 97.5 MG 12 x x 87651012253 AZO STANDARD 97.5 MG TABLET PHENAZOPYRIDINE HCL 97.5 MG 12 x x 87651024153 AZO URINARY PAIN RLF 97.5 MG PHENAZOPYRIDINE HCL 97.5 MG 24 x x

URINARY ALKALINIZERS 58657031016 SODIUM CITRATE-CITRIC ACID CITRIC ACID/SODIUM CITRATE 473 x x 00121059516 SODIUM CITRATE-CITRIC ACID CITRIC ACID/SODIUM CITRATE 473 x x 58657031216 POTASSIUM CIT-CITRIC ACID SOLN POTASSIUM CITRATE/CITRIC ACID 473 x x

VITAMINS

VITAMINS- THIAMINE 11822033670 RA VITAMIN B-1 100 MG TABLET THIAMINE HCL 100 MG 100 x x 00761055520 VITAMIN B-1 TAB 100MG THIAMINE 100 MG 100 x x 10135013201 THIAMINE HCL TAB 100MG THIAMINE 100 MG 100 x x 31604001281 VITAMIN B-1 TAB 100MG THIAMINE 100 MG 100 x x 35046000116 B-1 TAB 100MG THIAMINE 100 MG 100 x x 40985021151 B-1 TAB 100MG THIAMINE 100 MG 110 x x 50428048545 CVS B-1 TAB 100MG THIAMINE 100 MG 100 x x 80681009800 VITAMIN B-1 TAB 100MG THIAMINE 100 MG 100 x x

VITAMINS- RIBOFLAVIN 74312000640 VITAMIN B-2 100 MG TABLET RIBOFLAVIN 100 MG 100 x x 63948016843 RIBOFLAVIN TAB 400MG RIBOFLAVIN 400 MG 30 x x

VITAMINS- NIACIN 00904227260 NIACIN 500 MG TABLET NIACIN 500 MG 100 x x

VITAMINS- PANTOTHENIC ACID 00536671701 PANTOTHENIC ACID 500 MG TABS PANTOTHENIC ACID 500 MG 100 x x

VITAMINS- PYRIDOXINE 00536440601 VITAMIN B-6 25 MG TABLET PYRIDOXINE HCL 25 MG 100 x x 00536440801 VITAMIN B-6 50 MG TABLET PYRIDOXINE HCL 50 MG 100 x x 00904052060 VITAMIN B-6 50 MG TABLET PYRIDOXINE HCL 50 MG 100 x x 61748009501 PYRIDOXINE 50 MG TABLET PYRIDOXINE HCL 50 MG 100 x x 10006070012 VITAMIN B-6 TAB 50MG PYRIDOXINE HCL 50 MG 100 x x 10006073017 VITAMIN B6 TAB 50MG PYRIDOXINE HCL 50 MG 100 x x 31604001284 VITAMIN B-6 TAB 50MG PYRIDOXINE HCL 50 MG 100 x x 11917013973 VITAMIN B-6 TAB 100MG PYRIDOXINE HCL 100 MG 100 x x 80681002500 VITAMIN B-6 TAB 100MG PYRIDOXINE HCL 100 MG 100 x x 00536440901 VITAMIN B-6 100 MG TABLET PYRIDOXINE HCL 100 MG 100 x x 00904051860 VITAMIN B-6 100 MG TABLET PYRIDOXINE HCL 100 MG 100 x x

VITAMINS- BIOTIN 50428459961 CVS BIOTIN 1,000 MCG TABLET BIOTIN 1 MG 100 x x 11845015615 BIOTIN 5,000 MCG TABLET BIOTIN 5 MG 60 x x 87701040734 GNP BIOTIN CAP 5000MCG BIOTIN 5 MG 60 x x 10542009512 BIOTIN TAB 5MG BIOTIN 5 MG 120 x x 74312051697 BIOTIN CAP 10MG BIOTIN 10 MG 120 x x

VITAMINS- VITAMIN C 00904052260 VITAMIN C 250 MG TABLET ASCORBIC ACID 250 MG 100 x x 11822880250 RA VITAMIN C 250 MG TABLET ASCORBIC ACID 250 MG 100 x x 20555000100 VITAMIN C TAB 250MG ASCORBIC ACID 250 MG 100 x x 00904052360 VITAMIN C 500 MG TABLET ASCORBIC ACID 500 MG 100 x x 11822880300 VITAMIN C TAB 500MG ASCORBIC ACID 500 MG 100 x x 11917007521 VITAMIN C 500 MG TABLET ASCORBIC ACID 500 MG 100 x x 50428038158 CVS VITAMIN C 500 MG CAPLET ASCORBIC ACID 500 MG 100 x x 57896084101 VITAMIN C 500 MG TABLET ASCORBIC ACID 500 MG 100 x x 00904052560 VITAMIN C 250 MG TABLET CHEW ASCORBIC ACID 250 MG 100 x x 31604001496 VITAMIN C 500 MG TABLET CHEW ASCORBIC ACID 500 MG 60 x x 10135014201 ASCORBIC ACD TAB 500MG ASCORBIC ACID 500 MG 100 x x 11917007518 VITAMIN C TAB 1000MG ASCORBIC ACID 1000 MG 100 x x 11917007523 VITAMIN C CHW 500MG ASCORBIC ACID 500 MG 100 x x 30768000517 VITAMIN C TAB 500MG ASCORBIC ACID 500 MG 100 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 31604001489 VITAMIN C TAB 1000MG ASCORBIC ACID 1000 MG 100 x x 54629006901 VITAMIN C TAB 250MG ASCORBIC ACID 250 MG 100 x x 57896084101 VITAMIN C TAB 500MG ASCORBIC ACID 500 MG 100 x x 80681016600 VITAMIN C TAB 1000MG ASCORBIC ACID 1000 MG 100 x x

VITAMINS- VITAMIN A 00904208560 VITAMIN A 10,000 UNITS CAPSULE VITAMIN A 10000 UNIT 100 x x 31604001306 VITAMIN A CAP 8000UNIT VITAMIN A 8000 UNIT 100 x x

VITAMINS- VITAMIN D2 (ERGOCALCIFEROL) 39328035760 CALCIDOL DROPS ERGOCALCIFEROL (VITAMIN D2) 8000/ML 60 x x 43199001560 ERGOCALCIFEROL 8,000 UNITS/ML ERGOCALCIFEROL (VITAMIN D2) 8000/ML 60 x x 47781064726 ERGOCALCIFER DRO 8000/ML ERGOCALCIFEROL (VITAMIN D2) 8000/ML 60 x x 69543023460 ERGOCALCIFEROL 8,000 UNITS/ML ERGOCALCIFEROL (VITAMIN D2) 8000/ML 60 x x 10432031202 VITAMIN D2 TAB 400UNIT ERGOCALCIFEROL (VITAMIN D2) 400 UNIT 250 x x 40985025073 VITAMIN D CAP 2000UNIT ERGOCALCIFEROL (VITAMIN D2) 2000 UNIT 60 x x 58487003711 VITAMIN D2 TAB 2000UNIT ERGOCALCIFEROL (VITAMIN D2) 2000 UNIT 250 x x

VITAMINS- VITAMIN D3 (CHOLECALCIFEROL) 11845011831 VITAMIN D3 400 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 400 UNIT 100 x x 54458032334 VITAMIN D3 1,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 30 x x 11845014775 VITAMIN D3 1,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 60 x x 11917011822 VITAMIN D3 1,000 UNITS SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 60 x x 11917014763 VITAMIN D3 1,000 UNITS SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 60 x x 54458032344 VITAMIN D3 1,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 60 x x 11917009905 VITAMIN D3 1,000 UNITS SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x 11917013940 VITAMIN D3 1,000 UNITS SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x 31604002675 VITAMIN D3 1,000 UNITS SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x 74312015605 D3-1000 CAP 1000UNIT CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 120 x x 54458032345 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 30 x x 11845015015 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 60 x x 11917008608 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 75 x x 11917011818 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 75 x x 11917013942 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 75 x x 31604002585 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 90 x x 00536379001 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 10939052444 SM VITAMIN D3 2,000 UNIT SFTGL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 11917012697 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 11917014679 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 11917017094 VITAMIN D3 2,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 50428016183 CVS VITAMIN D3 2,000 UNIT SFGL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 52569013400 HM VITAMIN D3 2,000 UNIT SFTGL CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 11845015339 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 50 x x 31604002621 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 90 x x 00904598660 VITAMIN D3 5,000 UNIT CAPSULE CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 11822490000 RA VITAMIN D3 5,000 UNIT SFTGL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 11845015331 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 11917011540 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 11917013981 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 11917014360 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 11917014767 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 11917017183 VITAMIN D3 5,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 50428016516 CVS VITAMIN D3 5,000 UNIT SFGL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 53191024401 VITAMIN D3 5,000 UNIT CAPSULE CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 81131031271 SV VITAMIN D3 5,000 UNIT SFTGL CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 74312019377 VITAMIN D3 CAP 5000UNIT CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 150 x x 66594099905 MAXIMUM D3 10,000 UNITS CAP CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT 5x x 63044040101 VITAMIN D3 10,000 UNIT SOFTGEL CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT 30 x x 67112090130 DECARA CAP 25000UNT CHOLECALCIFEROL (VITAMIN D3) 25000 UNIT 30 x x 75834002012 VITAMIN D3 50,000 UNITS CAPS CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT 12 x x 53191036201 VITAMIN D3 CAP 50000UNT CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT 100 x x 75834002001 VITAMIN D3 CAP 50000UNT CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT 100 x x 00904582360 VITAMIN D3 400 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 400 UNIT 100 x x 31604002671 VITAMIN D3 400 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 400 UNIT 100 x x 40985022661 VITAMIN D-400 TABLET CHOLECALCIFEROL (VITAMIN D3) 400 UNIT 100 x x 43292055881 VITAMIN D3 400 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 400 UNIT 100 x x 00904582489 VITAMIN D3 1,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 90 x x 00536333401 VITAMIN D3 1,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x 00904582460 VITAMIN D3 1,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x 00904582461 VITAMIN D3 1,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x 10432023701 VITAMIN D3 1,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x 31604001870 VITAMIN D3 1,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x 54629005024 VITAMIN D3 TAB 1000UNIT CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x 58487002371 VITAMIN D3 TAB 1000UNIT CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x 00904615760 VITAMIN D3 2,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 54629041120 VITAMIN D3 2,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 79854004112 VITAMIN D3 2,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 87701040751 GNP VITAMIN D3 2,000 UNIT TAB CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 54629794101 VITAMIN D3 5,000 UNIT TABLET CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 10542010008 DIALYVITE VIT D3 50,000 UNIT CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT 80 x x 11845015071 VITAMIN D3 400 UNIT TAB CHEW CHOLECALCIFEROL (VITAMIN D3) 400 UNIT 100 x x 11845015469 VITAMIN D3 1,000 UNIT TAB CHEW CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 50 x x 30768053491 VITAMIN D3 1,000 UNIT GUMMIES CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 90 x x 31604002844 VITAMIN D3 1,000 UNIT GUMMIES CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 90 x x 00087086644 D-VI-SOL 400 UNITS/ML DROP CHOLECALCIFEROL (VITAMIN D3) 400/ML 50 x x 50383091750 VITAMIN D3 400 UNIT/ML DROP CHOLECALCIFEROL (VITAMIN D3) 400/ML 50 x x 54838000650 VITAMIN D3 400 UNIT/ML DROP CHOLECALCIFEROL (VITAMIN D3) 400/ML 50 x x 54629077232 VITAMIN D3 400 UNIT/ML DROP CHOLECALCIFEROL (VITAMIN D3) 400/ML 52.5 x x 79854007723 VITAMIN D3 400 UNIT/ML DROP CHOLECALCIFEROL (VITAMIN D3) 400/ML 52.5 x x 54629077241 VITAMIN D3 5,000 UNIT/ML DROPS CHOLECALCIFEROL (VITAMIN D3) 5000/ML 52.5 x x 30768030405 VITAMIN D3 5,000 UNIT/ML DROPS CHOLECALCIFEROL (VITAMIN D3) 5000/ML 59 x x 02359046010 REPLESTA 50,000 UNITS WAFER CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT 4x x 00087086604 D-VI-SOL LIQ 400UNIT CHOLECALCIFEROL (VITAMIN D3) 400/ML 50 x x 10939086944 VITAMIN D3 CAP 5000UNIT CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 11917007630 VITAMIN D CAP 1000UNIT CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x 11917011602 VITAMIN D3 LIQ 1200UNIT CHOLECALCIFEROL (VITAMIN D3) 1200/ML 240 x x 11917011823 D3 CAP 400UNIT CHOLECALCIFEROL (VITAMIN D3) 400 UNIT 125 x x 11917013943 D3 CAP 2000UNIT CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 150 x x 11917018556 D3 CAP 10000 CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT 60 x x 30768029173 VITAMIN D3 CAP 5000UNIT CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 150 x x 30768050356 VITAMIN D3 CHW 1000UNIT CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 120 x x 31604002511 VITAMIN D CAP 1000UNIT CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 90 x x 31604002516 VITAMIN D3 TAB 2000UNIT CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 90 x x 31604002673 D3 TAB 2000UNIT CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 31604002920 VITAMIN D3 CHW 1000UNIT CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 150 x x 31604004071 D3 2000 TAB 2000UNIT CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 110 x x 40985027062 VITAMIN D3 TAB 1000UNIT CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT 110 x x 40985027111 VITAMIN D TAB 2000UNIT CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 110 x x 40985027288 VITAMIN D3 TAB 5000UNIT CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 110 x x 40985027504 VITAMIN D3 TAB 10000UNT CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT 110 x x 50428054266 VITAMIN D3 CAP 10000UNT CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT 60 x x 50428057523 VITAMIN D3 TAB 5000UNIT CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 40 x x 51663000500 OPTIMAL-D CAP 50000UNT CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT 4x x 54629009332 VITAMIN D3 CAP 10000 CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT 90 x x 54629090970 VITAMIN D3 CAP 2000UNIT CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 54629090980 VITAMIN D3 CAP 5000UNIT CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 67112090250 DECARA CAP 50000UNT CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT 50 x x 69618000901 VITAMIN D3 CAP 2000UNIT CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 69618001959 VITAMIN D DRO 400UNIT CHOLECALCIFEROL (VITAMIN D3) 400/ML 50 x x 74312001140 VITAMIN D TAB 400UNIT CHOLECALCIFEROL (VITAMIN D3) 400 UNIT 100 x x 74312017621 D3 CAP 50MCG CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 150 x x 74312035873 D3 CAP 250MCG CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT 72 x x 75834016724 WEEKLY-D CAP 50000UNT CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT 24 x x 79854007941 VITAMIN D3 TAB 5000UNIT CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 79854009332 VITAMIN D3 CAP 10000 CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT 90 x x 80681000900 VITAMIN D3 CAP 50MCG CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 80681013100 VITAMIN D3 CAP 5000UNIT CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 80681016800 VITAMIN D3 TAB 25MCG CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 90 x x 80681016900 VITAMIN D3 TAB 25MCG CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT 100 x x 80681017000 VITAMIN D3 TAB 50MCG CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 100 x x 80681017401 VITAMIN D3 CAP 50000UNT CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT 12 x x 87701040752 GNP VIT D TAB 5000UNIT CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 88395014110 VITAMIN D3 CAP 5000UNIT CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 120 x x 96295012846 VITAMIN D3 TAB 5000UNIT CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT 100 x x 96295012847 VITAMIN D3 TAB 2000UNIT CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT 75 x x

VITAMINS- VITAMIN E 00904027060 VITAMIN E 100 UNIT SOFTGEL VITAMIN E (DL,TOCOPHERYL ACET) 100 UNIT 100 x x 31604001155 VITAMIN E 200 UNITS CAPSULE VITAMIN E 200 UNIT 100 x x 00536479901 VITAMIN E 400 UNIT CAPSULE VITAMIN E (DL,TOCOPHERYL ACET) 400 UNIT 100 x x 11917017100 VITAMIN E CAP 400UNIT VITAMIN E (DL,TOCOPHERYL ACET) 400 UNIT 100 x x 00904027460 VITAMIN E 400 UNIT SOFTGEL VITAMIN E (DL,TOCOPHERYL ACET) 400 UNIT 100 x x 11917007513 VITAMIN E 400 UNIT SOFTGEL VITAMIN E (DL,TOCOPHERYL ACET) 400 UNIT 100 x x 54838000530 VITAMIN E 50 UNIT/ML DROPS VITAMIN E 50 UNIT/ML 30 x x 71321080230 VITAMIN E DRO 15/0.3ML VITAMIN E 50 UNIT/ML 30 x x 55212004010 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 79854008412 VITAMIN K TAB 100MCG PHYTONADIONE (VITAMIN K1) 100 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults

VITAMINS- MENAQUINONE (K-2) 31604002882 VITAMIN K2 CAP 100MCG MENAQUINONE (VITAMIN K2) 30 x x

VITAMINS- PRENATAL Please refer to TennCare's PDL for coverage of the following: ALL GENERIC PRENATAL VITAMIN FORMULATIONS ALL BRAND PRENATAL VITAMIN FORMULATIONS (NON-PREFERRED)

VITAMINS- B-COMPLEX VITAMINS AND COMBINATIONS Please refer to TennCare's PDL for coverage of the following: ALL GENERIC RENAL VITAMIN FORMULATIONS ALL BRAND RENAL VITAMIN FORMULATIONS (NON-PREFERRED)

00536478701 VITAMIN B COMPLEX CAPSULE VITAMIN B COMPLEX 100 x x 74312000530 B-COMPLEX-VIT C TIME REL TAB FOLIC ACID/VIT BCOMP,C 400 MCG 100 x x 69543026010 VIRT-CAPS (1 MG FA B COMP W-C) B complex w-C no.20/folic acid 100 x x 10542001010 BIFERA RX TABLET folic acid/vit B complex and C 100 x x 69543035610 VP VITE RX vit B comp no.3/folic/C/biotin 100 x x

VITAMINS- MULTIVITAMINS 68176000012 DEKAS ESSENTIAL CAPSULE A/D3/E/TOCOPHERSOLAN/VIT K1 2000-1000 60 x x 68176000013 DEKAS LIQ ESSENTIA A/D3/E/TOCOPHERSOLAN/VIT K1 2000-1000 60 x x 00536354701 DAILY-VITE TABLET MULTIVITAMIN 100 x x 00904053060 TAB-A-VITE TABLET MULTIVITAMIN 100 x x 11917007453 MULTIPLE VITAMINS TABLET MULTIVITAMIN 100 x x 54629003824 MULTIVITAMINS TABLET MULTIVITAMIN 100 x x 57896050401 ONE DAILY MULTIVITAMIN TAB MULTIVITAMIN 100 x x 11917017101 MULTIVITAMIN TAB IRON-FRE MULTIVITAMIN 100 x x 80681005000 DAILY-VITE TAB MULTIVITAMIN 100 x x

VITAMINS- MULTIVITAMINS WITH IRON Please refer to TennCare's PDL for coverage of the following: ALL GENERIC MULTIVITAMIN + IRON FORMULATIONS ALL BRAND MULTIVITAMIN + IRON FORMULATIONS (NON-PREFERRED)

VITAMINS- MULTIVITAMINS WITH FOLIC ACID 58204000400 COMPLETE FORMUL MULTIVIT SFTGL PEDIATRIC MULTIVIT #61/D3/VITK 1500-800 60 x x 68176000011 DEKAS PLUS SOFTGEL MULTIVIT WITH MIN #53/FA/K/Q10 200-1000 60 x x 00904264146 CERTAVITE-ANTIOXIDANT TABLET MULTIVITAMIN/IRON/FOLIC ACID 18MG-0.4MG 30 x x 51759000202 PRORENAL MULTIVITAMIN TABLET B,C/FERROUS FUM/FA/D3/ZINC OX 8MG-800MCG 90 x x 87701040792 GNP ONE DAILY PLUS IRON TABLET MULTIVITAMIN/IRON/FOLIC ACID 18MG-0.4MG 100 x x 58914001460 AQUADEKS CHEWABLE TABLET MV. MIN CMB#51/FA/VIT K1/UBI 100-350MCG 60 x x 68176000015 DEKAS PLUS CHEWABLE TABLET multivit-mins 56/folic/K/coQ10 60 x x 00005434462 CENTRUM MULTIVIT-MINERAL LIQ MULTIVIT-MINERALS/FERROUS GLUC 9 MG/15 ML 236 x x 10135017060 CHILDRENS CHW VITAMINS PEDIATRIC MULTIPLE VITAMIN W/ C & FA 60 x x

VITAMINS- PEDIATRIC VITAMINS 00087040303 TRI-VI-SOL DROPS VIT A PALMITATE/VIT C/VIT D3 750-35/ML 50 x x

VITAMINS- PEDIATRIC VITAMINS WITH FLUORIDE 44946103508 TRI-VITAMIN WITH FLUORIDE 0.25MG/ML ped mvit A,C,D3 no.21/fluoride 50 x x 44946103608 TRI-VITAMIN WITH FLUORIDE 0.5MG/ML ped mvit A,C,D3 no.21/fluoride 90 x x

VITAMINS- PEDIATRIC MULTIVITAMINS 80681004800 MULTIVITAMIN CHW CHILDREN MULTIVITAMIN 100 x x 80681004900 MULTIVITAMIN CHW CHILDREN MULTIVITAMIN 100 x x 00087040203 POLY-VI-SOL DROPS PEDIATRIC MULTIVIT COMB NO.81 750-35/ML 50 x x 00536430401 POLY-VITAMIN TAB CHEW MULTIVITAMIN 100 x x 00904262160 CHILD CHEW VITAMIN TABLET MULTIVITAMIN 100 x x 16500007818 FLINTSTONES TABLET CHEWABLE MULTIVITAMIN 60 x x 37864000042 ANIMAL CHEWS TABLET MULTIVITAMIN 100 x x 54629005001 CHILDREN'S CHEWABLE VITAMIN MULTIVITAMIN 100 x x 46122008972 CHILDREN'S CHEWABLES PEDIATRIC MULTIVIT COMB #25/FA 300 MCG 60 x x 16500008619 FLINTSTONES EXTRA C TAB CHEW MULTIVITAMIN 60 x x

VITAMINS- PEDIATRIC MULTVITAMINS WITH MINERALS 68176000010 DEKAS PLUS LIQUID pedi multivit no.128/vitamin K 60 x x 57771000104 NANOVM T/F POWDER PEDIATRIC MULTIVIT NO.93/IRON 2.75MG/5.4 275 x x 57771000105 NANOVM 9-18 YEARS PEDIATRIC MULTIPLE VITAMIN W/ MINERALS ORAL POWDER 275 x x 57771000113 NANOVM 1-3 YEARS PEDIATRIC MULTIPLE VITAMIN W/ MINERALS ORAL POWDER 275 x x 57771000148 NANO M 4-8 POWDER PEDIATRIC MULTIVIT #15/IRON/FA 5MG-100MCG 275 x x 11917008609 GUMMI BEAR MULTIVIT TAB CHEW MULTIVITAMIN 60 x x 11917014690 CHILDREN MULTIVITAMIN GUMMIES PEDIATRIC MULTIVIT COMB NO.73 60 x x 24385009072 ZOO CHEWS GUMMIE TABLET MULTIVITAMIN 60 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 58204000401 MVW COMPLETE CHW ORANGE PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C 60 x x 58204000408 MVW COMPLETE CHW BUBBLGUM PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C 60 x x 58204000411 MVW COMPLETE CHW D3000 PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C 60 x x 58204000415 MVW COMPLETE CHW GRAPE PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C 60 x x 16500055434 FLINTSTONES CHW COMPLETE PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C 70 x x 16500051627 FLINTSTONES MULTIVIT CHEW TAB PEDIATRIC MULTIVIT COMB #25/FA 300 MCG 30 x x 16500053879 FLINTSTONES GUMMIES CHEW TAB PEDIATRIC MULTIVIT COMB. NO.49 50 x x 16500008806 FLINTSTONES COMPLETE TABLET MULTIVIT WITH IRON-MINERALS 60 x x 00005423720 CENTRUM KIDS CHEW TAB PEDI MV NO.68/IRON CARBONYL 18 MG 80 x x 00536781601 POLYVITAMIN WITH IRON TAB CHEW MULTIVIT WITH IRON-MINERALS 100 x x 58914021460 AQUADEKS PEDIATRIC LIQUID PEDI MULTIVIT #40/PHYTONADIONE 400 MCG/ML 60 x x 61269016660 ABDEK PEDIAT DRO PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C 60 x x 58204000404 MVW COMPLETE DRO PEDIATRI PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C 30 x x

VITAMINS- PEDIATRIC MULTVITAMINS WITH FLUORIDE 44946102301 MULTIVIT-FLUOR 0.25MG pedi multivit no.17 w-fluoride 100 x x 59088010759 MULTIVIT-FLUOR 0.25MG pedi multivit no.17 w-fluoride 100 x x 44946102401 MULTIVITAMIN WITH FLOURIDE 0.5MG pedi multivit no.17 w-fluoride 100 x x 59088010859 MULTIVIT-FLUOR 0.5MG pedi multivit no.17 w-fluoride 90 x x 59088010959 MULTIVITAMIN WITH FLOURIDE 1MG pedi multivit no.17 w-fluoride 50 x x 61269016150 MULTIVITAMIN WITH FLUORIDE 0.25MG/ML pedi multivit no.2 w-fluoride 50 x x 58657032550 MULTIVIT-FLUOR 0.25 MG DROP pedi multivit no.2 w-fluoride 50 x x 58657032650 MULTIVITAMIN & FLUORIDE DROP 0.5 MG pedi multivit no.2 w-fluoride 50 x x

VITAMINS- PEDIATRIC MULTIVITAMINS WITH IRON 00536344901 CHEW-VITES-IRON TABLET CHEW MULTIVITAMIN WITH IRON 100 x x 00904053660 CHILD CHEW + IRON TAB CHEW MULTIVITAMIN WITH IRON 100 x x 62107004801 CHILD VITAMIN-IRON TAB CHEW MULTIVITAMIN WITH IRON 100 x x 00087040501 POLY-VI-SOL WITH IRON DROPS PEDI MV NO.80/FERROUS SULFATE 750-10/ML 50 x x 16500007909 FLINTSTONES PLUS IRON PEDIATRIC MULTIVITAMINS W IRON CHEW TAB 15MG 60 x x 00536344308 CEROVITE JR CHW MULTIVIT WITH IRON-MINERALS 60 x x 71399742005 POLY-VITE SOL IRON PEDI MV NO.80/FERROUS SULFATE 750-10/ML 50 x x

VITAMINS- PEDIATRIC MULTIVITAMINS WITH IRON AND FLUORIDE 58657032750 MULTI-VITAMIN W-FLUORIDE-IRON 0.25-10/ML pedi multivit 45/fluoride/iron 50 x x

MINERALS

MINERALS- CALCIUM SUPPLEMENTS 00536342608 CALCIUM 600 MG TABLET CALCIUM CARBONATE 600 MG 60 x x 57896074606 CALCIUM TAB 600MG CALCIUM CARBONATE 600 MG 60 x x 00904323252 CALCIUM 600 MG TABLET CALCIUM CARBONATE 600 MG 60 x x 00904323292 CALCIUM 600 MG TABLET CALCIUM CARBONATE 600 MG 150 x x 00121476605 CALCIUM CARB 1,250 MG/5 ML SUS CALCIUM CARBONATE 500 MG/5ML 5x x 00121076616 CALCIUM CARB 1,250 MG/5 ML SUS CALCIUM CARBONATE 500 MG/5ML 473 x x 00054311763 CALCIUM CARB 1,250 MG/5 ML SUS CALCIUM CARBONATE 500 MG/5ML 500 x x 00904506260 CALCITRATE 200 MG (950 MG) TAB CALCIUM CITRATE 200(950) MG 100 x x 00904188352 OYSTER SHELL CALCIUM 500 MG TB CALCIUM CARBONATE 500(1250) MG 60 x x 00904546052 OYSTER SHELL 500-VIT D3 200 TB CALCIUM CARBONATE/VITAMIN D3 500 MG-200 60 x x 11917011331 CALCIUM 600-VIT D3 400 TABLET CALCIUM CARBONATE/VITAMIN D3 600 MG-400 60 x x 00904188260 OYSTER SHELL 250 MG + VIT D TB CALCIUM CARBONATE/VITAMIN D3 250 MG-125 100 x x 00536781708 OYSCO 500-VIT D3 200 TABLET CALCIUM CARBONATE/VITAMIN D3 500 MG-200 60 x x 00088165475 OS-CAL 500-VIT D3 200 CAPLET CALCIUM CARBONATE/VITAMIN D3 500 MG-200 75 x x 54629037701 OYSTER SHELL CALCIUM-VIT D TAB CALCIUM CARBONATE/VITAMIN D3 500 MG-400 100 x x 00536342408 CALCIUM 600 TAB -D CALCIUM CARBONATE/VITAMIN D3 600 MG-400 60 x x 00904323352 CALCIUM 600-VIT D3 400 TABLET CALCIUM CARBONATE/VITAMIN D3 600 MG-400 60 x x 00005550919 CALTRATE 600 PLUS D3 TABLET CALCIUM CARBONATE/VITAMIN D3 600 MG-800 60 x x 00904323852 CALCIUM 500 MG CHEWABLE TABLET CALCIUM CARBONATE/VITAMIN D3 500 MG-100 60 x x 00904603652 CALCIUM 500+D TABLET CHEW CALCIUM CARBONATE/VITAMIN D3 500 MG-400 60 x x 00536322301 CIT CALC/D TAB 200-250 CALCIUM CITRATE-VITAMIN D 250 (200) UNIT ELEMENTAL 100 x x 11845009151 OYSTER SHELL TAB 500MG OYSTER SHELL CALCIUM 100 x x 11845014031 CALCIUM 600 CHW W/VIT D CALCIUM CARBONATE/VITAMIN D3 600 MG-400 100 x x 20555000500 CALCIUM TAB 600MG CALCIUM CARBONATE 600 MG 150 x x 80681002900 CALCIUM/D3 TAB 600-400 CALCIUM CARBONATE/VITAMIN D3 600 MG-400 60 x x 80681005800 OYSTER SHELL TAB 500MG OYSTER SHELL CALCIUM 60 x x 80681013700 CALCIUM CHW 500-10 CALCIUM CARBONATE-CHOLECALCIFEROL 500 MG-400 60 x x

MINERALS- MAGNESIUM SUPPLEMENTS 30768000617 MAGNESIUM OXIDE 250 MG TABLET MAGNESIUM OXIDE 250 MG 100 x x 37205035178 MAGNESIUM 250 MG TABLET MAGNESIUM 250 MG 100 x x 00187526701 MAGONATE 54 MG/5 ML LIQUID MAGNESIUM CARBONATE 54 MG/5 ML 355 x x 57896063412 MAG OXIDE TAB 400MG MAGNESIUM OXIDE 400 MG 120 x x 60569049460 MAGOX 400 TABLET MAGNESIUM OXIDE 400 MG 60 x x 60258017101 MAG OXIDE TAB 400MG MAGNESIUM OXIDE 400 MG 120 x x 64980033912 MAGNESIUM-OX TAB 400MG MAGNESIUM OXIDE 400 MG 120 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 31604001269 MAGNESIUM OXIDE 250 MG TABLET MAGNESIUM OXIDE 250 MG 100 x x 00904423960 MAGNESIUM OXIDE 500 MG TABLET MAGNESIUM OXIDE 500 MG 100 x x 74312005535 MAGNESIUM 500 MG TABLET MAGNESIUM OXIDE 500 MG 100 x x 11845009611 MAGNESIUM TAB 200MG MAGNESIUM 200 MG 100 x x 11917019729 MAGNESIUM TAB 400MG MAGNESIUM OXIDE 250 MG 120 x x 30768003999 MAGNESIUM TAB 500MG MAGNESIUM 500 MG 100 x x 31604001718 MAGNESIUM TAB 250MG MAGNESIUM 250 MG 200 x x 31604002576 MAGNESIUM CAP 400MG MAGNESIUM OXIDE 400 MG 60 x x 35046000322 MAGNESIUM GL TAB 500MG MAGNESIUM CARBONATE 500 MG 90 x x 60569049412 MAGOX 400 TAB 400MG MAGNESIUM OXIDE 400 MG 120 x x 69618002302 MAG OXIDE TAB 400MG MAGNESIUM OXIDE 400 MG 120 x x

MINERALS- FLUORIDE SUPPLEMENTS 44946100803 LUDENT FLUORIDE 0.25 MG TB CHW SODIUM FLUORIDE 0.25 MG 120 x x 59088010473 LUDENT FLUORIDE 0.25 MG TB CHW SODIUM FLUORIDE 0.25 MG 120 x x 59088010573 FLUORIDE 0.5 MG TB CHW SODIUM FLUORIDE 0.5 MG 120 x x 44946101003 LUDENT FLUORIDE 1 MG TB CHW SODIUM FLUORIDE 1 MG 120 x x 59088010673 FLUORIDE 1 MG TB CHW SODIUM FLUORIDE 1 MG 50 x x 44946103208 SODIUM FLUORIDE 0.5 MG/ML SODIUM FLUORIDE 0.5 MG/ML 50 x x 61269016550 SODIUM FLUORIDE 0.5 MG/ML SODIUM FLUORIDE 0.5 MG/ML 30 x x

MINERALS- MISC SUPPLEMENTS 60258000601 PHOS-NAK PACKET SODIUM,POTASSIUM PHOSPHATES 280-250MG 100 x x 71351001001 PHOSPHORUS POW SUPPLEME SODIUM,POTASSIUM PHOSPHATES 280-250MG 100 x x 00486112501 K-PHOS NEUTRAL SOD PHOS DI, MONO/K PHOS MONO 100 x x 64980010401 PHOSPHA 250 NEUTRAL TABLET SOD PHOS DI, MONO/K PHOS MONO 100 x x 69543026810 VIRT-PHOS 250 NEUTRAL TABLET SOD PHOS DI, MONO/K PHOS MONO 100 x x 00223176001 SODIUM CHLORIDE 1 GM TABLET SODIUM CHLORIDE 1 G 100 x x 69367022001 SOD CHLORIDE TAB 1GM SODIUM CHLORIDE 1 G 100 x x 00904533260 ZINC 50 MG CAPSULE ZINC SULFATE 220(50) MG 100 x x 68585000801 ZINC SULFATE 220 MG CAPSULE ZINC SULFATE 220(50) MG 100 x x 77333098310 ZINC SULFATE CAP 220MG ZINC SULFATE 220(50) MG 100 x x 80681013500 ZINC CAP 220MG ZINC SULFATE 220(50) MG 100 x x 10006073027 ZINC SULFATE TAB 220MG ZINC SULFATE 220(50) MG 100 x x 57896086501 ZINC SULFATE TAB 220MG ZINC SULFATE 220(50) MG 100 x x 11917013948 ZINC TAB 50MG ZINC SULFATE 220(50) MG 100 x x 80681000200 ZINC TAB 50MG ZINC SULFATE 220(50) MG 100 x x 40985021368 CHROMIUM PIC TAB 200MCG CHROMIUM PICOLINATE 200 MCG 100 x x 00904431460 CHROMIUM PICO 200 MCG TABLET CHROMIUM PICOLINATE 200 MCG 100 x x 30768000486 SELENIUM TAB 100MCG SELENIUM 100 MCG 100 x x 54629016300 SELENIUM TAB 200MCG SELENIUM 200 MCG 100 x x 38485086335 THERMOTABS TAB ORAL ELECTROLYTES 100 x x 00074647032 PEDIALYTE SOL UNFLAVOR ORAL ELECTROLYTES 1000 x x 70074080336 PEDIALYTE SOLUTION ELECTROLYTES/DEXTROSE 1000 x x 70074080365 PEDIALYTE SOL FRUIT ORAL ELECTROLYTES 1000 x x

NUTRIENTS

NUTRIENTS- LIPIDS 40093011257 MCT OIL MEDIUM CHAIN TRIGLYCERIDES 473 x x 41679036503 MCT OIL MEDIUM CHAIN TRIGLYCERIDES 946 x x 41679036513 MCT OIL MEDIUM CHAIN TRIGLYCERIDES 7.7KCAL/ML 946 x x

NUTRIENTS- PROTEINS/AMINO ACIDS 43900028410 BENEPROTEIN POWDER WHEY PROTEIN ISOLATE 6 G-25/7 G 227 x x 43900028430 BENEPROTEIN POWDER PACKET WHEY PROTEIN ISOLATE 6 G-25/7 G 75 x x 82028000694 LIQUACEL LIQ GRAPE AMINO ACIDS 960 x x 49735010124 COMPL AMINO POW ACID MIX AMINO ACIDS 200 x x 49735011490 ESSENTIAL AMINO ACID MIX POWD NUT TX,UREA CYCLE DIS W-O IRON 79G-316 200 x x 27434000211 NAC 600 CAP ACETYLCYSTEINE (NUTRIENT) 60 x x 40093010084 NAC CAP 600MG ACETYLCYSTEINE (NUTRIENT) 60 x x 54629409760 NAC CAP 600MG ACETYLCYSTEINE (NUTRIENT) 100 x x 79854004097 NAC CAP 600MG ACETYLCYSTEINE (NUTRIENT) 100 x x 90011007001 N-A-C SUST TAB 600MG ACETYLCYSTEINE (NUTRIENT) 100 x x 30768003446 L-ARGININE CAP 500MG ARGININE 500 MG 90 x x 00904421551 ARGININE 500 MG TABLET ARGININE 500 MG 50 x x 40985027086 L-ARGININE 1,000 MG TABLET ARGININE HCL 1000 MG 100 x x 51552069807 ARGININE-L POWDER ARGININE 100 % 1000 x x 62991273202 L-ARGININE BASE POWDER ARGININE 100 % 100 x x 62991273203 L-ARGININE BASE POWDER ARGININE 100 % 500 x x 16563009802 GLUTAMINE POW GLUTAMINE 226 x x 43900028300 GLUTASOLVE POW 15GM GLUTAMINE 22.5 x x 51552041204 L-ISOLEUCINE POWDER ISOLEUCINE 25 x x 51552041205 L-ISOLEUCINE POWDER ISOLEUCINE 100 x x 62991289101 L-ISOLEUCINE POWDER ISOLEUCINE 25 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 62991289102 L-ISOLEUCINE POWDER ISOLEUCINE 100 x x 31604001681 L-LYSINE TAB 500MG LYSINE 500 MG 100 x x 96295013583 L-LYSINE TAB 500MG LYSINE 500 MG 100 x x 62991119901 METHIONINE-L POWDER METHIONINE 100 x x 11845014935 L-TRYPTOPHAN CAP 500MG TRYPTOPHAN 500 MG 60 x x 51552039804 L-VALINE POWDER VALINE 25 x x 62991280702 L-VALINE POWDER VALINE 100 x x 00536741008 L-CARNITINE 250 MG CAPSULE LEVOCARNITINE TARTRATE 250 MG 60 x x 63102020590 LEVOCARNITIN TAB 330MG LEVOCARNITINE 330 MG 90 x x 11917013353 L-CARNITINE 500 MG TABLET LEVOCARNITINE 500 MG 60 x x 11917013911 L-CARNITINE TAB 500MG LEVOCARNITINE 500 MG 60 x x 30768003741 L-CARNITINE 500 MG TABLET LEVOCARNITINE 500 MG 30 x x 74312001683 L-CARNITINE TAB 500MG LEVOCARNITINE 500 MG 30 x x 43913040016 G-LEVOCARNIT SOL 1GM/10ML LEVOCARNITINE 1 GM/ 10ML 474 x x 63102030216 LEVOCARNITIN SOL 1GM/10ML LEVOCARNITINE 1 GM/ 10ML 474 x x 10006073026 L-CARNITINE CAP 250MG LEVOCARNITINE L-TARTRATE 250 MG 60 x x 11917005935 L-CARNITINE 500 MG CAPSULE LEVOCARNITINE TARTRATE 500 MG 60 x x 62991158602 L-ARGININE HCL POWDER ARGININE HCL 100 % 500 x x 38779104008 BETAINE POWDER BETAINE 100 % 500 x x 38779118605 L-CITRULLINE POWDER CITRULLINE 100 x x 51552066505 L-CITRULLINE POW CITRULLINE 100 x x

NUTRIENTS- LIPOTROPIC 00536398401 INOSITOL 500 MG TABLET INOSITOL 500 MG 100 x x

NUTRIENTS- MISC 47469000928 OMEGA-3 1,000 MG SOFTGEL OMEGA-3 FATTY ACIDS 1000 MG 90 x x 47469000929 OMEGA-3 CAP 1000MG OMEGA-3 FATTY ACIDS 1000 MG 60 x x 00536718706 SEA-OMEGA 50 CAP 1000MG OMEGA-3 FATTY ACIDS 1000 MG 50 x x 00904404360 FISH OIL CAP 1000MG OMEGA-3 FATTY ACIDS 1000 MG 100 x x 11917007157 FISH OIL CON CAP 1000MG OMEGA-3 FATTY ACIDS 1000 MG 100 x x 54629089309 OMEGA-3 CAP 1000MG OMEGA-3 FATTY ACIDS 1000 MG 90 x x

DIETARY PRODUCTS

DIETARY PRODUCTS- INFANT FOODS 00087512129 ENFAMIL NEUR LIQ INFANT INFANT FOODS 59 x x 70074056270 SIMILAC/IRON LIQ SPEC CAR INFANT FOODS 59 x x 70074059646 SIMILAC NEOSURE INFANT FORMULA infant formula with iron 59 x x 00087510298 ENFAMIL ENFACARE LIQUID infant formula, iron/dha/ara 237 x x 00087510300 ENFAMIL A.R. LIQUID INFANT FORMULA, IRON/DHA/ARA 2.5 G-5.1G 237 x x 70074053677 SIMILAC SENSITIVE FUSS-GAS LIQ infant formula, iron/dha/ara 237 x x 83744035009 BRIGHT BEGINNINGS SOY DRINK PED NUTRIT.,SOY,IRON,LACT-FREE 0.03G-1/ML 237 x x 70074056728 SIMILAC FOR SPIT-UP LIQUID INFANT FORMULA, IRON/DHA/ARA 2.14G/100 946 x x 70074057456 SIMILAC EXPERT CARE NEOSURE LQ INFANT FORMULA WITH IRON 946 x x 70074057512 SIMILAC ALIM LIQ EXP CARE INFANT FOODS 946 x x 70074057513 SIMILAC EXPERT CARE ALIMENTUM INFANT FORM. W-IRON LF/DHA/ARA 2.75G/100 946 x x 70074057534 SIMILAC SENSITIVE LIQUID INFANT FORM. W-IRON LF/DHA/ARA 2.14G/100 946 x x 70074054599 SIMILAC HUMAN MILK POWDER PKT INFANT FORM.IRON,HUMAN MILK FT 0.25G/0.9G 1x x 70074057541 SIMILAC SENSITIVE FUSS-GAS PWD INFANT FORMULA, IRON/DHA/ARA 2.1 G/100 340 x x 70074062600 SIMILAC TOTAL COMFORT POWDER INFANT FORMULA, IRON/DHA/ARA 2.32 G/100 340 x x 70074064712 SIMILAC ALIMENTUM POWDER INFANT FORM. W-IRON LF/DHA/ARA 2.75G/100 343 x x 70074064715 SIMILAC ALIMENTUM POWDER INFANT FORM. W-IRON LF/DHA/ARA 2.75G/100 343 x x 00087510069 ENFAMIL GENTLEASE POWDER INFANT FORMULA, IRON/DHA/ARA 2.3 G/100 352 x x 00087511132 ENFAMIL REGULINE POWDER INF FORM,IRON/DHA/ARA/POLY/GOS 2.3 G/100 352 x x 70074055958 SIMILAC ADVANCE WITH IRON POWD INFANT FORMULA, IRON/DHA/ARA 2.07G/100 352 x x 70074055964 SIMILAC SENS POW SOY ISOM INFANT FOODS 352 x x 00087136542 ENFAMIL INFANT POWDER INFANT FORMULA, IRON/DHA/ARA 2-5.3G/100 354 x x 00087123901 ENFA NUTRAMI POW LIPIL INFANT FOODS 357 x x 00087123941 NUTRAMIGEN ENFLORA-LGG POWDER INF FORM,SP.MET,IRON/LACT RHAM 2.8 G/100 357 x x 00087510734 NUTRAMIGEN TODDLER ENFLORA-LGG INF FORM,SP.MET,IRON/LACT RHAM 2.5 G/100 357 x x 50000021667 GERBER GOOD START GENTLE POWD INFANT FORMULA, IRON/DHA/ARA 11.6 G/100 360 x x 00087512208 ENFAMIL NEUR POW ENFACARE INFANT FOODS 363 x x 00087020142 ENFAMIL A.R. POWDER INFANT FORMULA, IRON/DHA/ARA 2.5 G-5.1G 366 x x 00087121441 ENFAMIL PROSOBEE LIPIL PWD INFANT FORMULA,SOY,W-IRON,LF 366 x x 50000003530 GOOD START POW SOY/IRON INFANT FOODS 366 x x 70074057431 SIMILAC EXPERT CARE NEOSURE PW INFANT FORMULA, IRON/DHA/ARA 2.8 G/100 371 x x 00087510480 PURAMINO DHA-ARA POWDER INF FORM/IRON/AMINO AC/DHA/ARA 2.8 G/100 400 x x 13034078821 ALFAMINO INFANT POWDER inf form,iron,lf/amino/dha/ara 400 x x 49735011436 NEOCATE SYNEO INFANT POWDER infnt formula,iron/FOS/B.breve 400 x x 50000059852 GERBER EXTENSIVE HA POWDER inf form,sp.met,lf,iron/B.anim 400 x x 70074060850 SIMILAC PM 60-40 POWDER INFANT FORMULA,REGULAR 400 x x 00087036701 PREGESTIMIL POWDER INFANT FORMULA WITH IRON 454 x x 70074057664 SIMILAC EXPERT CARE ALIMENTUM INFANT FORM. W-IRON LF/DHA/ARA 2.75G/100 454 x x 00087020165 ENFAMIL AR POW SPIT-UP INFANT FOODS 553 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 00087512119 ENFAMIL NEUR POW GENTLEAS INFANT FOODS 553 x x 00087123945 NUTRAMIGEN ENFLORA-LGG POWDER INF FORM,SP.MET,IRON/LACT RHAM 2.8 G/100 561 x x 70074064718 SIMILAC ALIM POW IRON INFANT FOODS 561 x x 00087146142 ENFAGROW POW GENTLEAS INFANT FOODS 567 x x 00087511157 ENFAMIL REGULINE POWDER INF FORM,IRON/DHA/ARA/POLY/GOS 2.3 G/100 578 x x 00087121442 ENFAMIL SOY POW PROSOBEE INFANT FOODS 593 x x 00087869376 ENFAMIL GENTLEASE POWDER INFANT FORMULA, IRON/DHA/ARA 2.3 G/100 610 x x 00087136560 ENFAMIL INFANT POWDER infant formula, iron/dha/ara 629 x x 70074050818 SIMILAC SENSITIVE FUSS-GAS PWD INFANT FORMULA, IRON/DHA/ARA 2.1 G/100 638 x x 70074053730 SIMILAC FOR SPIT-UP POWDER INFANT FORMULA, IRON/DHA/ARA 2.14G/100 638 x x 70074066082 SIMILAC PRO-SENSTV NON-GMO PWD infant formula, iron/dha/ara 638 x x 70074066084 SIMILAC PRO- POW SENSITIV INFANT FOODS 638 x x 70074050820 SIMILAC SOY ISOMIL POWDER inf form,soy,iron,lf/dha/ara 658 x x 70074066080 SIMILAC PRO- POW ADVANCE INFANT FOODS 658 x x 70074062952 SIMILAC SENS POW FUSS/GAS INFANT FOODS 845 x x 70074063362 SIMILAC ADV POW STAGE 2 INFANT FOODS 873 x x 00087869377 ENFAMIL GENTLEASE POWDER infant formula, iron/dha/ara 913 x x 00087201448 ENFAMIL HUMAN MILK FORTIFR PKT INFANT FORM.IRON,HUMAN MILK FT 0.275/0.71 100 x x 49735012595 NEOCATE INFANT DHA-ARA POWDER INFANT FORMULA, IRON/DHA/ARA 2.8 G-5.1G 400 x x 70074051121 PHENEX-1 POWDER INFANT FORM. FOR PKU,IRON, #2 15G-480 400 x x 70074053511 ELECARE INFANT FORMULA POWDER INFANT FORM. W-IRON LF/DHA/ARA 3.1 G/100 400 x x 70074054665 ELECARE AMINO ACID POWDER INFANT FORM. W-IRON LF/DHA/ARA 3.1 G/100 400 x x 70074054666 ELECARE AMINO ACID POWDER infant form.iron lac-f/dha/ara 400 x x 70074055251 ELECARE INFANT FORMULA POWDER INFANT FORM. W-IRON LF/DHA/ARA 3.1 G/100 400 x x

DIETARY PRODUCTS- NUTRITIONAL SUPPLEMENTS 13034078795 ALFAMINO JUNIOR POWDER nut.tx.impaired digest fxn 400 x x 70074064781 SIMILAC GO-GROW POWDER pediatric nutrit, iron/dha/ara 680 x x 50059034100 PKU EASY MICROTAB NUTRITIONAL TX FOR PKU, NO.56 70.8 G/110 110 x x 94688006866 XTRACAL LIQ PLUS NUTRITIONAL SUPPLEMENTS 45 x x 70074056642 ENSURE CLEAR LIQUID NUT.TX.IMPAIRED DIGEST FXN 0.035-1/ML 200 x x 41679067466 BOOST LIQUID LACTOSE-REDUCED FOOD 0.04G-1/ML 237 x x 41679067566 BOOST LIQUID LACTOSE-REDUCED FOOD 0.04G-1/ML 237 x x 41679093133 BOOST PLUS LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 41679093166 BOOST PLUS ENERGY DRINK LACTOSE-REDUCED FOOD 0.06 G-1.5 237 x x 41679093266 BOOST PLUS LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 41679094066 BOOST HI-PRO LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 43900018215 BOOST VHC NUTRITIONAL LIQUID nut tx, lact-reduced, iron 237 x x 43900018600 BOOST BREEZE VARIETY PACK LIQ lactose-reduced food 237 x x 43900018629 BOOST BREEZE LIQUID LACTOSE-REDUCED FOOD 0.04G-1.05 237 x x 43900018649 BOOST BREEZE LIQUID lactose-reduced food 237 x x 43900018666 BOOST BREEZE LIQUID LACTOSE-REDUCED FOOD 0.04G-1.05 237 x x 43900033500 BOOST 1.5CAL LIQ /FIBER NUTRITIONAL SUPPLEMENTS 237 x x 43900033511 BOOST KID ESSENTIALS LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G-1/ML 237 x x 43900033520 BOOST KID ESSENTIALS LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G-1/ML 237 x x 43900033530 BOOST 1.0CAL LIQ STRAWBRY NUTRITIONAL SUPPLEMENTS 237 x x 43900033540 BOOST KID ESSENTIALS LIQUID PEDIATRIC NUTRITION, IRON, LF 0.04G-1.5 237 x x 43900033588 BOOST KID ESSENTIALS LIQUID pedi nutrition,iron,lact-free 237 x x 43900067638 BOOST LIQ STRWBRY NUTRITIONAL SUPPLEMENTS 237 x x 43900093139 BOOST PLUS LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 43900093239 BOOST PLUS ENERGY DRINK LACTOSE-REDUCED FOOD 0.06 G-1.5 237 x x 43900093338 BOOST PLUS ENERGY DRINK LACTOSE-REDUCED FOOD 0.06 G-1.5 237 x x 43900094139 BOOST HIGH LIQ PROTEIN NUTRITIONAL SUPPLEMENTS 237 x x 70074040701 ENSURE LIQUID LACTOSE-REDUCED FOOD 237 x x 70074040702 ENSURE PLUS LIQUID LACTOSE-REDUCED FOOD 0.05 G-1.5 237 x x 70074040705 ENSURE LIQUID lactose-reduced food 237 x x 70074040707 ENSURE PLUS LIQUID LACTOSE-REDUCED FOOD 0.05 G-1.5 237 x x 70074040718 ENSURE PLUS LIQ STRWBERY NUTRITIONAL SUPPLEMENTS 237 x x 70074050461 ENSURE ORIGINAL LIQUID lactose-reduced food 237 x x 70074050463 ENSURE LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 70074050647 ENSURE PLUS LIQ STRWBERY NUTRITIONAL SUPPLEMENTS 237 x x 70074050649 ENSURE ORIGINAL LIQUID LACTOSE-REDUCED FOOD 0.04G-1.05 237 x x 70074051785 ENSURE LIQ BUT PECN NUTRITIONAL SUPPLEMENTS 237 x x 70074051804 PEDIASURE ENTERAL LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G-1/ML 237 x x 70074051805 PEDIASURE ENTERAL LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G-1/ML 237 x x 70074051807 PEDIASURE ENTERAL WITH FIBER PEDI NUTRIT,IRON,LAC-FREE,FIBR 0.03G-1/ML 237 x x 70074051881 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G-1/ML 237 x x 70074051883 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G-1/ML 237 x x 70074051885 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G-1/ML 237 x x 70074052101 ENSURE HIGH PROTEIN LIQUID lactose-reduced food 237 x x 70074053119 JEVITY 1.2 CAL LIQUID lactose-reduced food/fiber 237 x x 70074053432 ENSURE LIQUID lactose-reduced food 237 x x 70074053581 PEDIASURE LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074053582 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G-1/ML 237 x x 70074053588 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G-1/ML 237 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 70074053623 ENSURE LIQUID lactose-reduced food 237 x x 70074053818 PEDIASURE LIQUID pedi nutrition,iron,lact-free 237 x x 70074055898 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G-1/ML 237 x x 70074056016 ENSURE LIQUID lactose-reduced food 237 x x 70074056369 PEDIASURE WITH FIBER LIQUID PEDI NUTRIT,IRON,LAC-FREE,FIBR 0.03G-1/ML 237 x x 70074056410 PEDIASURE 1.5 LIQUID PEDIATRIC NUTRITION, IRON, LF 0.06 G-1.5 237 x x 70074056412 PEDIASURE 1.5 WITH FIBER LIQ PEDI NUTRIT,IRON,LAC-FREE,FIBR 0.06 G-1.5 237 x x 70074056417 PEDIASURE LIQ SIDEKICK NUTRITIONAL SUPPLEMENTS 237 x x 70074056423 PEDIASURE LIQ SIDEKICK NUTRITIONAL SUPPLEMENTS 237 x x 70074056524 PEDIASURE SIDEKICKS LIQUID PEDI NUTRIT,IRON,LAC-FREE,FIBR 0.03 G-0.6 237 x x 70074056656 PEDIASURE PEPTIDE 1.5 CAL LIQ NUTRITIONAL SUPPLEMENT 0.045G-1.5 237 x x 70074057231 ENSURE LIQUID LACTOSE-REDUCED FOOD 237 x x 70074057263 ENSURE PLUS LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074057802 GLUCERNA SHK LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074058050 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G-1/ML 237 x x 70074058053 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G-1/ML 237 x x 70074058056 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G-1/ML 237 x x 70074058059 PEDIASURE LIQUID PEDIATRIC NUTRITION, IRON, LF 0.03G-1/ML 237 x x 70074058062 PEDIASURE WITH FIBER LIQUID PEDI NUTRIT,IRON,LAC-FREE,FIBR 0.03G-1/ML 237 x x 70074058221 PEDIASURE WITH FIBER LIQUID PEDI NUTRIT,IRON,LAC-FREE,FIBR 0.03G-1/ML 237 x x 70074058294 ENSURE ORIGINAL LIQUID LACTOSE-REDUCED FOOD 0.04G-1.05 237 x x 70074058298 ENSURE ORIGINAL LIQUID LACTOSE-REDUCED FOOD 0.04G-1.05 237 x x 70074058304 ENSURE PLUS LIQUID lactose-reduced food 237 x x 70074062082 PEDIASUR G&G LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074062089 SUPLENA CARB STEADY LIQUID nut.tx.imp.renal fxn,lac-reduc 237 x x 70074062120 PEDIASURE PEPTIDE 1.0 CAL LIQ NUTRITIONAL SUPPLEMENT 0.03G-1/ML 237 x x 70074062122 PEDIASURE PEPTIDE 1.0 CAL LIQ NUTRITIONAL SUPPLEMENT 0.03G-1/ML 237 x x 70074062124 PEDIASURE PEPTIDE 1.0 CAL LIQ NUTRITIONAL SUPPLEMENT 0.03G-1/ML 237 x x 70074062485 PEDIASURE SIDEKICKS LIQUID PEDI NUTRIT,IRON,LAC-FREE,FIBR 0.03 G-0.6 237 x x 70074062487 PEDIASURE SIDEKICKS LIQUID PEDI NUTRIT,IRON,LAC-FREE,FIBR 0.03 G-0.6 237 x x 70074062932 ENSURE PLUS LIQ NUTRITIONAL SUPPLEMENTS 237 x x 70074064115 ENSURE ACTIV LIQ HP NUTRITIONAL SUPPLEMENTS 237 x x 70074064118 ENSURE ACTIV LIQ HP NUTRITIONAL SUPPLEMENTS 237 x x 70074064282 ENSURE ENLIV LIQ STRAWBER NUTRITIONAL SUPPLEMENTS 237 x x 70074064284 ENSURE ENLIV LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 70074064290 ENSURE ENLIV LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074064625 JEVITY 1.2 LIQ CAL NUTRITIONAL SUPPLEMENTS 237 x x 70074064899 ENSURE CLEAR LIQUID nut.tx.impaired digest fxn 237 x x 70074064901 ENSURE CLEAR LIQUID nut.tx.impaired digest fxn 237 x x 70074064903 ENSURE CLEAR LIQ APPLE NUTRITIONAL SUPPLEMENTS 237 x x 70074064904 ENSURE PLUS LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074064930 ENSURE ORIGINAL LIQUID lactose-reduced food 237 x x 70074066640 PEDIASURE SIDEKICKS LIQUID PEDI NUTRIT,IRON,LAC-FREE,FIBR LIQ 0.04 G-0.8 237 x x 70074066913 SIDEKICKS LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074066920 PEDIASURE LIQ S'MORES NUTRITIONAL SUPPLEMENTS 237 x x 70074067185 PEDIASUR G&G LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074067375 PEDIASUR 1.5 LIQ W/FIBER NUTRITIONAL SUPPLEMENTS 237 x x 70074067378 PEDIASUR 1.5 LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074067386 PEDIASUR 1.5 LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074067410 PEDIASUR 1.0 LIQ PEPTIDE NUTRITIONAL SUPPLEMENTS 237 x x 70074067412 PEDIASUR 1.0 LIQ PEPTIDE NUTRITIONAL SUPPLEMENTS 237 x x 70074067418 PEDIASUR 1.5 LIQ PEPTIDE NUTRITIONAL SUPPLEMENTS 237 x x 70074067522 PEDIASUR G&G LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074067523 PEDIASUR G&G LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 70074067524 PEDIASUR G&G LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 70074067525 PEDIASUR G&G LIQ STRAWBER NUTRITIONAL SUPPLEMENTS 237 x x 70074067526 PEDIASUR G&G LIQ STRAWBER NUTRITIONAL SUPPLEMENTS 237 x x 70074067528 PEDIASUR G&G LIQ BANANA NUTRITIONAL SUPPLEMENTS 237 x x 70074067530 PEDIASUR G&G LIQ W/FIBER NUTRITIONAL SUPPLEMENTS 237 x x 70074067535 PEDIASUR G&G LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 70074067536 PEDIASUR G&G LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 41679033251 BOOST KIDS LIQ VANILLA NUTRITIONAL SUPPLEMENTS 244 x x 24359050203 KETOVIE 4:1 LIQUID NUTRITIONAL TX, KETOGENIC,WHEY 3.4 G-144 250 x x 24359054403 GLYTACTIN RTD 15 PE LIQUID NUT. TX FOR PKU WITH IRON #41 6 G-80/100 250 x x 98716006062 NUTREN JUNIOR 1 CAL LIQUID NUTRITIONAL SUPPLEMENT 0.03G-1/ML 250 x x 98716006063 NUTREN JUNIOR FIBER 1 CAL LIQ NUTRIT SUPP/INULIN/FOS/FIBER 0.03G-1/ML 250 x x 98716006220 NUTREN 1.5 LIQUID NUTRITIONAL SUPPLEMENT 250 x x 98716006252 PEPTAMEN JR LIQ 1 CAL NUTRITIONAL SUPPLEMENTS 250 x x 98716007363 PEPTAMEN JUNIOR 1.5 CAL LIQUID NUTRITIONAL SUPPLEMENT 250 x x 98716016261 PEPTAMEN JR LIQ PREBIO1 NUTRITIONAL SUPPLEMENTS 250 x x 98716060140 PEPTAMEN JUNIOR 1 CAL LIQUID NUTRITIONAL SUPPLEMENT 0.03G-1/ML 250 x x 70074062481 ENSURE ACTIVE CLEAR LIQUID lactose-reduced food 296 x x 24359050302 GLYTACTIN RESTORE 10 PE LIQUID nut. therapy for PKU, no.49 500 x x 70074051806 PEDIASURE LIQ W/FIBER NUTRITIONAL SUPPLEMENTS 237 x x 70074067401 PEDIASURE LIQ ENTERAL NUTRITIONAL SUPPLEMENTS 237 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 70074067402 PEDIASURE LIQ ENTERAL NUTRITIONAL SUPPLEMENTS 237 x x 70074067404 PEDIASURE LIQ W/FIBER NUTRITIONAL SUPPLEMENTS 237 x x 58914080044 SCANDISHAKE POWDER PACKET DIETARY SUPPLEMENT 4x x 24359050801 GLYTACTIN 15 PE BETTERMILK NUT. TX FOR PKU WITH IRON #41 29 G-385 30 x x 70074063344 PEDIASURE SHAKE MIX POWDER PEDIATRIC NUT,MILK BASED,IRON 6 G-170/38 397 x x 49735010168 MSUD ANAMIX POW ERLY YRS NUTRITIONAL SUPPLEMENTS 400 x x 49735010627 NEOCATE JR WITH PREBIOTICS PWD NUT.TX.IMPAIRED DIGEST/FIBER 16 G-459 400 x x 49735011790 NEOCATE JUNIOR POWDER NUT.TX.IMPAIRED DIGEST FXN 16G-478 400 x x 49735012124 NEOCATE JUNIOR POWDER NUT.TX.IMPAIRED DIGEST FXN 16G-451 400 x x 49735012690 NEOCATE JUNIOR POWDER NUT.TX.IMPAIRED DIGEST FXN 16G-451 400 x x 49735012912 NEOCATE JR WITH PREBIOTICS PWD nut.tx.impaired digest/fiber 400 x x 49735016456 NEOCATE JR POW PREBIOTC NUTRITIONAL SUPPLEMENTS 400 x x 49735016739 NEOCATE NUTRA POWDER NUT.TX.IMPAIRED DIGEST FXN 8.2G-472 400 x x 49735018262 DUOCAL POWDER CALORIC SUPPLEMENT 400 x x 50600054623 RENA START POWDER NUT. TX,IMPAIRED RENAL FXN,WHEY 400 x x 70074051123 PHENEX-2 POWDER NUT. TX FOR PKU WITH IRON #1 30G-410 400 x x 70074051141 GLUTAREX-1 POW NUTRITIONAL SUPPLEMENTS 400 x x 70074053510 ELECARE POW DHA/ARA NUTRITIONAL SUPPLEMENTS 400 x x 70074055253 ELECARE JR POWDER NUT.TX.IMPAIRED DIGEST FXN 14.3 G-469 400 x x 70074055254 ELECARE JR POWDER NUT.TX.IMPAIRED DIGEST FXN 14.3 G-469 400 x x 70074056585 ELECARE JR POWDER nut.tx.impaired digest fxn 400 x x 70074056586 ELECARE JR POWDER NUT.TX.IMPAIRED DIGEST FXN 14.3 G-469 400 x x 70074059406 ELECARE POW NUTRITIONAL SUPPLEMENTS 400 x x 70074066271 ELECARE JR POWDER nut.tx.impaired digest fxn 400 x x 70074066273 ELECARE JR POW CHOCOLAT NUTRITIONAL SUPPLEMENTS 400 x x 70074066275 ELECARE JR POW BANANA NUTRITIONAL SUPPLEMENTS 400 x x 70074066276 ELECARE JR POW BANANA NUTRITIONAL SUPPLEMENTS 400 x x 70074066954 PEDIASURE POW VANILLA NUTRITIONAL SUPPLEMENTS 400 x x 00847095602 PHENYLADE60 POW NUTRITIONAL SUPPLEMENTS 454 x x 58914080244 SCANDISHAKE POWDER PACKET dietary supplement 4 x x 58914080344 SCANDISHAKE MIS BANANA NUTRITIONAL SUPPLEMENTS 4 x x 41679094166 BOOST HI-PRO LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 43900035980 ARGINAID PAK ORANGE NUTRITIONAL SUPPLEMENTS 56 x x 43900036500 DIABETISOURC LIQ AC NUTRITIONAL SUPPLEMENTS 250 x x 43900099290 IMPACT ADV LIQ VANILLA NUTRITIONAL SUPPLEMENTS 178 x x 59781020865 JUVEN POW GRAPE NUTRITIONAL SUPPLEMENTS 30 x x 59781066678 JUVEN POW ORANGE NUTRITIONAL SUPPLEMENTS 30 x x 59781066684 JUVEN POW FRT PNCH NUTRITIONAL SUPPLEMENTS 30 x x 59781066693 JUVEN POW ORANGE NUTRITIONAL SUPPLEMENTS 30 x x 70074040711 ENSURE LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074050240 GLUCERNA LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074050465 ENSURE PLUS LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074052603 GLUCERNA LIQ R-T-HANG NUTRITIONAL SUPPLEMENTS 1500 x x 70074054327 GLUCERNA SHK LIQ BUT PECN NUTRITIONAL SUPPLEMENTS 237 x x 70074056500 ENSURE CLEAR LIQ BBRY/POM NUTRITIONAL SUPPLEMENTS 296 x x 70074057334 JEVITY 1.5 LIQ CAL NUTRITIONAL SUPPLEMENTS 237 x x 70074058014 PIVOT LIQ 1.5 CAL NUTRITIONAL SUPPLEMENTS 237 x x 70074059722 PROMOD LIQ NUTRITIONAL SUPPLEMENTS 946 x x 70074059861 GLUCERNA SHK LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 70074062093 NEPRO/CARB LIQ MX BERRY NUTRITIONAL SUPPLEMENTS 237 x x 70074062682 JEVITY 1.5 LIQ CAL NUTRITIONAL SUPPLEMENTS 1000 x x 70074062690 JEVITY 1.5 LIQ CAL NUTRITIONAL SUPPLEMENTS 1500 x x 70074062759 ENSURE COMPL LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 70074062999 GLUCERNA SHK LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 70074063000 GLUCERNA SHK LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 70074064116 ENSURE ACTIV LIQ HP NUTRITIONAL SUPPLEMENTS 237 x x 70074064117 ENSURE ACTIV LIQ HP NUTRITIONAL SUPPLEMENTS 237 x x 70074064135 ENSURE HP LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 70074064137 ENSURE HP LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074064273 ENSURE HP LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074064297 ENSURE ENLIV LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 70074064626 JEVITY 1.5 LIQ CAL/FIBE NUTRITIONAL SUPPLEMENTS 237 x x 70074064795 NEPRO/CARB LIQ MX BERRY NUTRITIONAL SUPPLEMENTS 237 x x 70074064799 NEPRO/CARB LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074064833 PROMOTE 1.0 LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074064835 OSMOLITE 1.5 LIQ CAL NUTRITIONAL SUPPLEMENTS 237 x x 70074064894 ENSURE HP LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 70074064896 ENSURE HP LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074064936 ENSURE LIQ CHOCOLAT NUTRITIONAL SUPPLEMENTS 237 x x 70074065040 ENSURE PRE LIQ SURGERY NUTRITIONAL SUPPLEMENTS 296 x x 70074065044 ENSURE PRE LIQ SURGERY NUTRITIONAL SUPPLEMENTS 296 x x 70074065046 ENSURE SURGE LIQ VANILLA NUTRITIONAL SUPPLEMENTS 237 x x 70074066437 ENSURE PRE LIQ SURGERY NUTRITIONAL SUPPLEMENTS 296 x x 70074066547 ENSURE HP LIQ STRAWBER NUTRITIONAL SUPPLEMENTS 237 x x 83744055027 A-SOY LIQ NUTRITIONAL SUPPLEMENTS 237 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 94688001525 PROSOURCE LIQ NO CARB NUTRITIONAL SUPPLEMENTS 887 x x 94688001535 PROSOURCE LIQ NO CARB NUTRITIONAL SUPPLEMENTS 887 x x

DIETARY PRODUCTS- MEDICAL FOODS 51991080990 L-METHYLFOLATE 15 MG CAPLET LEVOMEFOLATE CALCIUM 15 MG 90 x x 76439035890 L-METHYLFOLATE CALCIUM 15 MG LEVOMEFOLATE CALCIUM 15 MG 90 x x 00525113990 DEPLIN-ALGAL OIL 7.5 MG CAP LEVOMEFOLATE/ALGAL OIL 7.5-90.314 90 x x 51991090890 L-METHYLFOLATE FORTE 7.5 MG CP LEVOMEFOLATE/ALGAL OIL 7.5-90.314 90 x x 00525110290 DEPLIN-ALGAL OIL 15 MG CAPSULE LEVOMEFOLATE/ALGAL OIL 15-90.314 90 x x 51991090990 L-METHYLFOLATE FORTE 15 MG CAP LEVOMEFOLATE/ALGAL OIL 15-90.314 90 x x 69206011030 ELFOLATE 7.5 MG TABLET LEVOMEFOLATE CALCIUM 7.5 MG 30 x x 51991080833 L-METHYLFOLATE 7.5 MG TABLET LEVOMEFOLATE CALCIUM 7.5 MG 30 x x 76439035930 L-METHYLFOLATE CALCIUM 7.5 MG LEVOMEFOLATE CALCIUM 7.5 MG 30 x x 76439035990 L-METHYLFOLATE CALCIUM 7.5 MG LEVOMEFOLATE CALCIUM 7.5 MG 90 x x 76439040190 LEVOMEFOLATE-ALGAL 7.5 MG CAP LEVOMEFOLATE/ALGAL OIL 7.5-90.314 90 x x 45749001780 VSL#3 PACKET LACTOBAC #2-S. THERM-BIFIDO #1 450B CELL 30 x x 00525050390 CEREFOLIN CAPLET vit B12/levomefolate/vit B6/B2 90 x x 58407150030 DENOVO CAP 15MG LEVOMEFOLATE CALCIUM 15 MG 30 x x

HEMATOPOIETICS

HEMATOPOIETICS- COBALAMINS 87701040731 VITAMIN B-12 100 MCG TABLET CYANOCOBALAMIN (VIT B-12) 100 MCG 100 x x 31604002732 B-12 CAP 1000MCG CYANOCOBALAMIN (VIT B-12) 1000 MCG 90 x x 11917013972 B-12 TAB 500MCG CYANOCOBALAMIN (VIT B-12) 500 MCG 100 x x 10006070022 VITAMIN B-12 TAB 1000MCG CYANOCOBALAMIN (VIT B-12) 1000 MCG 130 x x 10006073043 VITAMIN B-12 TAB 1000MCG CYANOCOBALAMIN (VIT B-12) 1000 MCG 100 x x 30768060693 VITAMIN B-12 TAB 1000MCG CYANOCOBALAMIN (VIT B-12) 1000 MCG 60 x x 37864091401 VITAMIN B-12 TAB 1000MCG CYANOCOBALAMIN (VIT B-12) 1000 MCG 100 x x 74312001380 VITAMIN B-12 TAB 1000MCG CYANOCOBALAMIN (VIT B-12) 1000 MCG 100 x x 11845009661 VITAMIN B-12 SUB 1000MCG CYANOCOBALAMIN (VIT B-12) 1000 MCG SUBLINGUAL 100 x x 35046001130 B-12 SUB 1000MCG CYANOCOBALAMIN (VIT B-12) 1000 MCG SUBLINGUAL 100 x x 74312003860 VITAMIN B-12 SUB 2500MCG CYANOCOBALAMIN (VIT B-12) 2500 MCG SUBLINGUAL 50 x x 74312058911 B-12 SUB 2500MCG CYANOCOBALAMIN (VIT B-12) 2500 MCG SUBLINGUAL 75 x x 74312071950 B-12 SUB 1000MCG METHYLCOBALAMIN 1000 MCG SUBLINGUAL 60 x x

HEMATOPOIETICS- FOLIC ACID 00536384401 FOLIC ACID 0.4 MG TABLET FOLIC ACID 0.4 MG 100 x x 80681009900 FOLIC ACID TAB 400MCG FOLIC ACID 0.4 MG 100 x x

HEMATOPOIETICS- IRON 46017009660 FEOSOL 45 MG CAPLET IRON,CARBONYL 45 MG 60 x x 61269091060 IRON CHEWS 15 MG TABLET CHEW IRON,CARBONYL 15 MG 60 x x 23359001204 WEE CARE 15 MG/1.25 ML SUSP IRON,CARBONYL 15MG/1.25 118 x x 63717010204 ICAR 15 MG/1.25 ML SUSPENSION IRON,CARBONYL 15MG/1.25 118 x x 00536100901 FERROUS SULF TAB 325MG FERROUS SULFATE 325(65) MG 100 x x 00904759060 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 00904759082 FEROSUL 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 00904759160 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 00904759161 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 00904759182 FEROSUL 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 10135024313 FERROUS SULF TAB 325MG FERROUS SULFATE 325(65) MG 100 x x 10939054944 SM IRON TAB 325MG FERROUS SULFATE 325(65) MG 100 x x 11822110990 RA IRON 65 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 11917009215 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 37864000041 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 49348018010 SM IRON 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 49483006301 FERRO-TIME 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 49483006401 FERRO-TIME 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 54629011090 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 57664007001 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 57664007101 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 57896070301 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 62107004401 FERROUSUL 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 81131074933 SV IRON 65 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 00574060801 FERROUS SULF EC 324 MG TABLET FERROUS SULFATE 324(65)MG 100 x x 00574060811 FERROUS SULF EC 324 MG TABLET FERROUS SULFATE 324(65)MG 100 x x 00245010811 FERROUS SULF TAB 325MG EC FERROUS SULFATE 324(65)MG 100 x x 00536115516 FERROUS SUL LIQ 220/5ML FERROUS SULFATE 220 (44)/5 473 x x 00904146516 FEROSUL 220 MG/5 ML ELIXIR FERROUS SULFATE 220 (44)/5 473 x x 50383077816 FERROUS SULF 220 MG/5 ML ELIX FERROUS SULFATE 220 (44)/5 473 x x 54838000180 FERROUS SULF 220 MG/5 ML ELIX FERROUS SULFATE 220 (44)/5 473 x x 00121053005 FERROUS SULF 300 MG/5 ML LIQ FERROUS SULFATE 300 MG/5ML 5 x x 39328005750 CHILDREN'S IRON 15 MG/ML DROPS FERROUS SULFATE 15 MG/ML 50 x x 50383062750 CHILD FERROUS SULFATE 15 MG/ML FERROUS SULFATE 15 MG/ML 50 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 54838001150 FERROUS SULF 15 MG IRON/ML DRP FERROUS SULFATE 15 MG/ML 50 x x 79854001109 FERROUS SULFATE 325 MG TABLET FERROUS SULFATE 325(65) MG 100 x x 00574050801 FERROUS GLUC TAB 324MG FERROUS GLUCONATE 324(38) MG 100 x x 00574050811 FERROUS GLUC TAB 324MG FERROUS GLUCONATE 324(38) MG 100 x x 00813001206 FERRETTS 325 MG TABLET FERROUS FUMARATE 325(106)MG 60 x x 60258018501 POLY-IRON 150 MG CAPSULE IRON POLYSACCHARIDE COMPLEX 150 MG 100 x x 63044020361 IFEREX 150 CAP IRON POLYSACCHARIDE COMPLEX 150 MG 100 x x 12830082430 EZFE 200 CAPSULE IRON POLYSACCHARIDE COMPLEX 200 MG 30 x x 12830082401 EZFE 200 CAP 200MG IRON POLYSACCHARIDE COMPLEX 200 MG 100 x x 52304071304 NOVAFERRUM 15 MG/ML DROPS IRON POLYSACCHARIDE COMPLEX 15 MG/ML 120 x x 10006073013 IRON TAB 45MG FERROUS SULFATE ER 140 (45) MG 30 x x 11917007454 FERROUS GLUC TAB 240MG FERROUS GLUCONATE 240(27) MG 100 x x 11917008581 IRON SLOW TAB 45MG FERROUS SULFATE DRIED 60 x x 11917014666 FERROUS GLUC TAB 240MG FERROUS GLUCONATE 240(27) MG 100 x x 11917017126 IRON TAB 325MG FERROUS SULFATE 325(65) MG 100 x x 11917017213 IRON TAB 45MG FERROUS SULFATE ER 142 (45) MG 60 x x 20555001900 FERROUS GLUC TAB 324MG FERROUS GLUCONATE 324(37.5) MG 100 x x 20555003400 FERROUS SULF TAB 325MG EC FERROUS SULFATE 324(65)MG 100 x x 40093010390 IRON TAB 65MG FERROUS SULFATE 325(65) MG 100 x x 50428029449 CVS IRON TAB 325MG FERROUS SULFATE 325(65) MG 90 x x 54629064501 FERROUS GLUC TAB 324MG FERROUS GLUCONATE 324(37.5) MG 100 x x 57896070916 IRON SUPPMNT ELX 220/5ML FERROUS SULFATE 220 (44)/6 473 x x 57896072401 FERROUS GLUC TAB 240MG FERROUS GLUCONATE 240(27) MG 100 x x 63629180801 FERROUS SULF ELX 220/5ML FERROUS SULFATE 220 (44)/7 120 x x 69367016604 FERROUS SULF TAB 325MG EC FERROUS SULFATE 324(65)MG 100 x x 69367016620 FERROUS SULF TAB 325MG EC FERROUS SULFATE 324(65)MG 100 x x 69618002601 FERROUS SULF TAB 325MG FERROUS SULFATE 325(65) MG 100 x x 74312041383 IRON TAB 325MG FERROUS SULFATE 325(65) MG 100 x x

HEMATOPOIETICS- HEMATOPOIETIC MIXTURES 63736012301 VITRON-C TAB 65-125 IRON-VITAMIN C 60 x x 52304071406 NOVAFERRUM 125 LIQUID IRON POLYSACCHARIDE COMPLEX/D3 125 MG/5ML 180 x x

OPHTHALMICS

OPHTHALMICS- ARTIFICIAL TEARS 00023079815 REFRESH TEARS 0.5% EYE DROPS CARBOXYMETHYLCELLULOSE SODIUM 0.5 % 15 x x 00023040370 REFRESH PLUS 0.5% EYE DROPS CARBOXYMETHYLCELLULOSE SODIUM 0.5 % 70 x x 00023455430 REFRESH CELLUVISC 1% EYE DROPS carboxymethylcellulose sodium 30 x x 00536108494 ARTIFICIAL TEARS 1.4 % DROPS POLYVINYL ALCOHOL 1.4 % 15 x x 00065042636 GENTEAL TEAR SOL MODERATE ARTIFICIAL TEAR SOLUTION 15 x x 00023024004 REFRESH P.M. OINTMENT MINERAL OIL/PETROLATUM,WHITE 42.5-57.3% 3.5 x x 00023031204 REFRESH LACRI-LUBE OINTMENT MINERAL OIL/PETROLATUM,WHITE 42.5-56.8% 3.5 x x 17478006235 ARTIFICIAL TEARS EYE OINTMENT MINERAL OIL/PETROLATUM,WHITE 15 %-83 % 3.5 x x 00065143105 SYSTANE ULTRA 0.4-0.3% EYE DRP PROPYLENE GLYCOL/PEG 400 0.3 %-0.4% 10 x x 00065042915 SYSTANE SOL POLYETHYLENE GLYCOL-PROPYLENE GLYCOL (OPHTH) 15 x x 00065045407 SYSTANE GEL EYE DROPS PROPYLENE GLYCOL/PEG 400 0.3 %-0.4% 10 x x 00023050601 REFRESH CLASSIC EYE DROPS POLYVINYL ALCOHOL/POVIDONE/PF 1.4 %-0.6% 30 x x 00065050935 SYSTANE NIGHTTIME EYE OINT MINERAL OIL/PETROLATUM,WHITE 3 %-94 % 3.5 x x 00065051801 GENTEAL TEAR OIN NT-TIME WHITE PETROLATUM-MINERAL OIL 3.5 x x 00904648838 LUBRIFRESH OIN P.M. WHITE PETROLATUM-MINERAL OIL 3.5 x x 57896018405 ARTIFICIAL DRO TEARS GLYCERIN-HYPROMELLOSE-POLYETHYLENE GLYCOL 400 15 x x 74300001067 VISINE TEARS DROPS PEG 400/HYPROMELLOSE/GLYCERIN 1-0.2-0.2% 15 x x 11917009597 ARTIFICIAL DRO TEARS PROPYLENE GLYCOL-GLYCERIN 15 x x 00023031204 REFRESH LACR OIN OP MINERAL OIL/PETROLATUM,WHITE 42.5-56.8% 3.5 x x 57896018105 ARTIFICIAL DRO TEARS GLYCERIN-HYPROMELLOSE-POLYETHYLENE GLYCOL 400 15 x x

OPHTHALMICS- ANTIHISTAMINE Please refer to TennCare's PDL for coverage of the following: ALL KETOTIFEN FUMARATE OTC FORMULATIONS

OPHTHALMICS- HYPERTONIC SOD CHLORIDE 24208027615 MURO-128 2% EYE DROPS SODIUM CHLORIDE 2 % 15 x x 00363904000 SODIUM CHLORIDE 5% EYE DROP SODIUM CHLORIDE 5 % 15 x x 24208027715 MURO 128 SOL 5% OP SODIUM CHLORIDE 5 % 15 x x 17478062235 SODIUM CHLORIDE 5% EYE OINT SODIUM CHLORIDE 5 % 3.5 x x 24208038556 MURO 128 OIN 5% OP SODIUM CHLORIDE 5 % 3.5 x x 17478062312 SOD CHLORIDE SOL 5% OP SODIUM CHLORIDE 5 % 15 x x 00363905000 SOD CHLORIDE OIN 5% OP SODIUM CHLORIDE 5 % 3.5 x x 24208038555 MURO 128 OIN 5% OP SODIUM CHLORIDE 5 % 3.5 x x 50428857883 SOD CHLORIDE OIN 5% OP SODIUM CHLORIDE 5 % 3.5 x x

OTICS

OTICS- EAR WAX REMOVAL

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 42037010478 DEBROX 6.5% EAR DROPS CARBAMIDE PEROXIDE 6.5 % 15 x x 00904662735 EAR DROPS DRO 6.5% CARBAMIDE PEROXIDE 6.5 % 15 x x 11917010546 EAR WAX REMV DRO 6.5% OT CARBAMIDE PEROXIDE 6.5 % 15 x x

ORAL TOPICAL

ORAL TOPICAL- MOUTHWASHES 48582000330 BIOTENE DRY MOUTH ORAL RINSE SALIVA SUBSTITUTE COMBO NO.9 473 x x 48582000155 BIOTENE MOISTURIZING MOUTH SPR SALIVA STIMULANT AGENTS COMB.3 44.3 x x

ORAL TOPICAL- ANESTHETICS 00573021341 ANBESOL LIQUID BENZOCAINE 10 % 12 x x 00283087131 HURRICAINE 20% GEL BENZOCAINE 20 % 30 x x 11917013226 ORAL ANESTHETIC 20% PASTE BENZOCAINE 20 % 12 x x

ALTERNATIVE MEDICATIONS

ALTERNATIVE MEDICATIONS- COENZYME Q-10 00904588246 COENZYME Q-10 100 MG SOFTGEL UBIDECARENONE 100 MG 30 x x 58487003230 COENZYME Q-10 50 MG TABLET UBIDECARENONE 50 MG 50 x x 11917008584 CO Q-10 CAP 200MG COENZYME Q10 (UBIDECARENONE) 90 x x

ALTERNATIVE MEDICATIONS- MELATONIN 74312015745 MELATONIN 5 MG SOFTGEL MELATONIN 5 MG 90 x x 74312019491 MELATONIN 10 MG CAPSULE MELATONIN 10 MG 60 x x 30768019484 MELATONIN 10 MG CAPSULE MELATONIN 10 MG 90 x x 30768000541 MELATONIN 300 MCG TABLET MELATONIN 300 MCG 120 x x 54629898360 MELATONIN TR 1 MG TABLET MELATONIN 1 MG 60 x x 00536111411 MELATONIN 1 MG TABLET MELATONIN 1 MG 90 x x 47469000465 MELATONIN 1 MG TABLET MELATONIN 1 MG 90 x x 00904518206 MELATONIN 3 MG TABLET MELATONIN 3 MG 50 x x 00536641208 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x 00536641268 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x 00904518252 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x 10006073044 MELATONIN TAB 3MG MELATONIN 3 MG 60 x x 51991001406 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x 54458021360 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x 54629060900 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x 87701040813 GNP MELATONIN 3 MG TABLET MELATONIN 3 MG 100 x x 50428035025 CVS MELATONIN 3 MG TABLET MELATONIN 3 MG 120 x x 00536109808 MELATONIN 5 MG TABLET MELATONIN 5 MG 60 x x 10006073039 MELATONIN TAB 5MG MELATONIN 5 MG 60 x x 10006073040 MELATONIN TAB 5MG MELATONIN 5 MG 90 x x 31604002743 MELATONIN TAB 5MG MELATONIN 5 MG 90 x x 11822511120 RA MELATONIN 5 MG TABLET MELATONIN 5 MG 100 x x 40985027087 MELATONIN TAB MAX ST MELATONIN 5 MG 120 x x 79854008983 MELATONIN TR TAB 1MG MELATONIN 1 MG 60 x x 54629050260 MELATONIN TR 3 MG TABLET MELATONIN 3 MG 60 x x 54629061500 MELATONIN 5 MG TABLET SL MELATONIN 5 MG SL 60 x x 79854000615 MELATONIN SUB 5MG MELATONIN 5 MG SL 60 x x 96295012565 MELATONIN 10 MG TABLET SL MELATONIN 10 MG SL 60 x x 47469000457 MELATONIN 1 MG LIQUID MELATONIN 1 MG/4 ML 60 x x 47469004408 MELATONIN LIQ 2.5MG MELATONIN 1 MG/4 ML 237 x x 30768016836 MELATONIN 1 MG/ML LIQUID MELATONIN 1 MG/ML 59 x x 11917014868 MELATONIN 3 MG ODT MELATONIN 3 MG ODT 30 x x 40093010164 MELATONIN TAB 5MG MELATONIN 5 MG CHEW 90 x x 11822880980 RA MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x 47469000510 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x 79854001609 MELATONIN 3 MG TABLET MELATONIN 3 MG 60 x x 47469000458 MELATONIN SR 3 MG TABLET MELATONIN 3 MG 100 x x 47469004837 MELATONIN TR 5 MG TABLET MELATONIN/PYRIDOXINE HCl (B6) 100 x x 11917017023 MELATONIN TAB 10MG MELATONIN 10 MG 60 x x 11917017248 MELATONIN CHW 5MG MELATONIN 5 MG CHEW 90 x x 11917017659 MELATONIN TAB 10MG MELATONIN 10 MG CHEW 90 x x 11917018468 MELATONIN LIQ 1MG/ML MELATONIN 1 MG/ML 58 x x 31604002741 MELATONIN TAB 3MG MELATONIN 3 MG 120 x x 35046000392 MELATONIN TAB 10MG CR MELATONIN 10 MG CR 60 x x 47469000511 MELATONIN TAB 3MG MELATONIN 3 MG 120 x x 47469005964 MELATONIN TAB 10MG CR MELATONIN 10 MG CR 60 x x 47469006211 MELATONIN TAB 10MG MELATONIN 10 MG CHEW 60 x x 57896086406 MELATONIN TAB 3MG MELATONIN 3 MG 60 x x 80681004000 MELATONIN TAB 5MG MELATONIN 5 MG 60 x x 80681004001 MELATONIN TAB 5MG MELATONIN 5 MG 90 x x 80681008500 MELATONIN TAB 3MG MELATONIN 3 MG 60 x x 80681008600 MELATONIN TAB 3MG MELATONIN 3 MG 60 x x

NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 96295013820 MELATONIN CAP 10MG MELATONIN 10 MG 120 x x

PEAK FLOW METERS / INHALER DEVICES

08373552900 SIDESTREAM PEDIATRIC FACE MASK INHALER,ASSIST DEVICE,ACCESORY 1x x 50632000727 SPACER CHAMB MIS ADULT SPACER/AEROSOL-HOLDING CHAMBERS 1 x x 50632000728 SPACER CHAMB MIS CHILD SPACER/AEROSOL-HOLDING CHAMBERS 1 x x 72217003902 PROCARE MIS CHILD SPACER/AEROSOL-HOLDING CHAMBERS 1 x x 73796069940 PEAK-AIR PEAK FLOW METER PEAK FLOW METER 1 x x 08373081111 PEDIATRIC SMALL MASK INHALER,ASSIST DEVICE,ACCESORY 1x x 08373081211 PEDIATRIC MEDIUM MASK INHALER,ASSIST DEVICE,ACCESORY 1x x

DELIVERY DEVICES

07249022224 THIK & CLEAR NECTAR POWDER PKT cellulose gum 1 x x 07249022225 THIK & CLEAR HONEY POWDER PKT cellulose gum 1 x x 07249022227 THIK & CLEAR POW CELLULOSE GUM-MALTODEXTRIN 227 x x 41679015194 THICKEN UP CLEAR POWDER MALTODEXTRIN/XANTHAN GUM 125 x x 43900015194 THICKEN UP CLEAR POWDER MALTODEXTRIN/XANTHAN GUM 125 x x 43900015191 THICKEN UP CLEAR POWDER PACKET MALTODEXTRIN/XANTHAN GUM 288 x x 43900022510 RESOURCE POW THICKENU STARCH 227 x x 72058061080 THICK-IT #2 POWDER STARCH 284 x x 72058061081 THICK-IT #2 POWDER STARCH 1020 x x 72058061078 THICK-IT POWDER STARCH 284 x x 11917013237 THICK NOW POWDER STARCH 850 x x 72058004076 THICK-IT POWDER STARCH 850 x x 72058061079 THICK-IT POWDER STARCH 1020 x x 20513007001 SIMPLYTHICK GEL EASY MIX XANTHAN GUM 6 x x 20513007005 SIMPLYTHICK GEL EASY MIX XANTHAN GUM 6 x x 20513008001 SIMPLYTHICK GEL EASY MIX XANTHAN GUM 12 x x 20513008005 SIMPLYTHICK GEL EASY MIX XANTHAN GUM 12 x x 20513002001 SIMPLYTHICK 30 GM PACKET XANTHAN GUM 30G 30 x x