Contractor Manual Supplement – Allowable Benefits List

NEWBORN SCREENING BENEFITS CONTRACTOR PROCEDURES MANUAL SUPPLEMENT

ALLOWABLE BENEFITS LIST

The lists below are the approved medications, formulas, dietary supplements, and vitamins that are indicated for the various screened disorders in the Newborn Screening Program. The physician specialist will determine the course of treatment and will prescribe the appropriate medical management for the patient. The patient/client is responsible for obtaining the prescriptions from the selected contract provider.

There are monthly benefit limitations per client:

• $1,500.00 per month for dietary supplements • $300.00 per month for vitamins • Other limits may be assessed if the price of the item affects available funding for priority populations

Medical foods (formulas), dietary supplements and vitamins are reimbursable at wholesale plus 15%.

Items not listed in these tables must have approval from NBS Benefits prior to dispensing or billing.

AMINO ACID DISORDERS

DISORDER ITEMS MANUFACTURER HCY Homocystinuria Formulas Hominex-1 Abbott Nutrition Hominex-2 Abbott Nutrition HCY 1 Mead Johnson HCY 2 Mead Johnson HOM 2 Milupa HCU Anamix Early Years Nutricia HCU Anamix Next Nutricia XMet Maxamaid – orange flavor Nutricia XMet Maxamum – orange flavor Nutricia HCU Gel Vitaflo HCU Express Vitaflo Pro-Phree Abbott Nutrition Super Soluble Duocal Nutricia PFD 1 Mead Johnson PFD 2 Mead Johnson Metanx Complex Essential MSD HCU Cooler 15

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 1

Dietary Supplements Cystine AA Supplement Vitaflo

Medications Cystadane Powder (Betaine) AnovoRx

Vitamins Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Cyanocobalamin (vitamin B12) Pyridoxine Tablets (50 mg) Vitamin B6 tablets Vitamin B12 tablets MSUD Maple Syrup Formulas Urine Disease MSUD Analog Nutricia New: MSUD Anamix Early Years Nutricia MSUD Maxamaid – orange flavor Nutricia MSUD Maxamum – orange flavor Nutricia MSUD 2 Mead Johnson BCAD 1 Mead Johnson BCAD 2 Abbot Nutrition Ketonex-1 Abbott Nutrition Ketonex-2 Nutricia Nutricia Complex MSUD Drink Mix – Nutricia Vanilla Nutricia Complex MSUD AA Bar – Vitaflo Chocolate Vitaflo Complex MSUD AA Blend Vitaflo MSUD Gel Nutricia MSUD Express Abbott Nutrition MSUD Express Cooler Mead Johnson MSUD Amino Acid Mix Mead Johnson Pro-Phree Nutricia PFD 1 PFD 2 Super Soluble Duocal Metanx Complex Essential MSD

Dietary Supplements Nutricia L-Valine AA Nutricia L-Isoleucine AA Vitaflo Isoleucine50 Vitaflo Isoleucine1000 Vitaflo Valine50 Vitaflo Valine1000

Vitamins Thiamin

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 2

Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 tablets PKU Phenylketonuria Formulas Phenex-1 Abbott Nutrition Phenex-2 Abbott Nutrition Phenex-2 – vanilla Abbott Nutrition Prophree Abbott Nutrition Super Soluble Duocal Nutricia Nutricia PhenylAde Drink Mix – chocolate Nutricia PhenylAde 40 Drink Mix – Nutricia unflavored Nutricia PhenylAde 40 Drink Mix – citrus Nutricia PhenylAde 60 Drink Mix – Vanilla Nutricia PhenylAde Essential Drink Mix – Nutricia All flavors Nutricia PhenylAde Amino Acid Blend- Nutricia pouches Nutricia PhenylAde MTE Amino Acid Nutricia Blend-can Nutricia PhenylAde Amino Acid Bar- All Nutricia flavors Nutricia PhenylAde PheBLOC Tablet Nutricia PhenylAde GMP Milupa Phenyl-Free 1 Milupa Phenyl-Free 2 Prekulab Phenyl-Free 2HP Prekulab PKU 2 Nutricia PKU 3 Nutricia PreKUnil Nutricia Neophe Nutricia PheBloc Nutricia XPhe Maxamaid – All flavors Nutricia Periflex LQ- All flavors Nutricia New: PKU Periflex Early Years Nutricia Phlexy-10 Drink Mix – All flavors Nutricia Phlexy-10 Tablets Vitaflo Phlexy-10 Capsules Vitaflo Phlexy-10 Vitaflo Lophlex Drink Mix – All flavors Nutricia PKU Easy Liquid Nutricia PKU Easy Microtabs PKU Gel PKU Express PKU Express Cooler PKU Cooler 20 Periflex Advance Periflex Jr Plus- All Flavors Periflex LQ- All Flavors

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 3

Glytactin Bettermilk 15 Cambrooke Glytactin Build 10 Cambrooke Glytactin Swirl Cambrooke Glytactin RTD 10 Cambrooke Glytactin RTD 15 Cambrooke Glytactin Complete 10 Cambrooke Glytactin Complete 15 Cambrooke Glytactin Restore 10 Cambrooke Glytactin Restore Lite 10 Cambrooke Camino Pro 15 Cambrooke Metanx Complex Essential MSD

Dietary Supplements Tyrosine1000 L-Tyrosine

Vitamins Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo

MVW Complete Formulation + MVW Nutritionals D3000 MVW Complete Formulation + MVW Nutritionals D5000 Vitamin B6 tablets Vitamin B12 tablets Tyrosinemia Formulas TYR I Type I Tyrex-1 Abbott Nutrition TYR II Type II Tyrex-2 Abbott Nutrition TYR III Type III New: TYR Anamix Early Years Nutricia Nutricia TYR Anamix Next Nutricia XPhe, XTyr Maxamaid Nutricia Super Soluble Duocal Milupa TYR 2 Mead Johnson TYROS 1 Mead Johnson TYROS 2 Abbott Nutrition Prophree Vitaflo TYR Gel TYR Vitaflo Express Cambrooke Tylactin RTD 15 Cambrooke Tylactin Restore 10 Metanx Complex Essential MSD

Medications Nitisinone (Orfadin) Tablets

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 4

Vitamins Vitamin D Solace Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Vitaflo Frutivits Vitamin B6 tablets Vitamin B12 tablets ARG Argininemia Formulas Solcarb Solace Nutrition CIT II Citrullinemia Polycal Nutricia Type II Super Soluble Duocal Nutricia UCD Trio Vitaflo EAA Supplement Vitaflo Metanx Complex Essential MSD

Dietary Supplements Arginine 500 Vitaflo Arginine 2000 Vitaflo Citrulline 200 Vitaflo Citrulline 1000 Vitaflo Leucine100 Vitaflo Valine50 Vitaflo Valine1000 Vitaflo

Vitamins Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 Tablets MET Hyper- methioninemia Benign HPhe Hyperphenyla- laninemia

BioptReg Biopterin Reg

BioptBS Biopterin BS

UREA CYCLE DISORDERS DISORDER ITEMS MANUFACTURER CIT Citrullinemia Formulas Cyclinex-1 Abbott Nutrition

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 5

ASA Argininosuccinic Cyclinex-2 Abbott Nutrition Acidemia Pro-Phree Abbott Nutrition WND 1 Mead Johnson WND 2 Mead Johnson PFD 1 Mead Johnson PFD 2 Mead Johnson UCD 2 Milupa Super Soluble Duocal Nutricia Essential Amino Acid Mix Nutricia Metanx Complex Essential MSD

Dietary Supplements L-Arginine Nutricia L-Leucine Nutricia L-Isoleucine Nutricia L-Valine Nutricia Citrulline Citrulline 200 Vitaflo Citrulline 1000 Vitaflo Arginine 2000 Vitaflo Arginine 500 Vitaflo Isoleucine 50 Vitaflo Isoleucine 1000 Vitaflo Leucine 100 Vitaflo Valine 50 Vitaflo Valine 1000 Vitaflo

Medications Buphenyl Powder Buphenyl Tablets Sodium Benzoate Powder (Spectrum) Na Benzoate Powder

Na Benzoate 10% Solution (100

mg/ml)

Acetyl Carnitine

L-Carnitine (100 mg/ml) Omeprazole

Vitamins Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 tablets

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 6 ORGANIC ACIDEMIAS DISORDERS

DISORDER ITEMS MANUFACTURER BKT Beta- Formulas Ketothiolase MSUD Anamix Early Years Nutricia Deficiency MSUD Anamix Next Nutricia MSUD Maxamaid – orange Nutricia MSUD Maxamum – orange Nutricia MSUD 2 Nutricia BCAD 1 Mead Johnson BCAD 2 Abbott Nutrition Ketonex-1 Abbott Nutrition Ketonex-2 Nutricia Nutricia Complex Junior MSD w/ DHA - Nutricia ARA Nutricia Complex MSD Drink Mix Nutricia Complex MSD Amino Acid Bar Nutricia Complex MSD Amino Acid Blend Vitaflo MSUD Gel Vitaflo MSUD Express Abbott Pro-Phree PFD 1 PFD 2 Nutricia Super Soluble Duocal Metanx Complex Essential MSD

Dietary Supplements Nutricia L-isoleucine Nutricia L-valine Vitaflo Isoleucine50 Vitaflo Isoleucine1000 Vitaflo Valine50 Vitaflo Valine1000

Vitamins Solace Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Vitaflo Frutivits Vitamin B6 tablets Vitamin B12 tablets GA1 Glutaric Formulas Aciduria, Type I Glutarex-1 Abbott Nutrition Glutarex-2 Abbott Nutrition Pro-Phree Abbott Nutrition GA Mead Johnson GA Gel Vitaflo GA Express 15 Vitaflo PFD 1 Mead Johnson PFD 2 Mead Johnson

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 7

Super Soluble Duocal Nutricia GA-1 Anamix Early Years Nutricia GA1 Anamix Next Nutricia XLys, XTrp Maxamaid – orange Nutricia XLys, XTrp Maxamum – orange Nutricia GlutarAde Essential GA-1 Nutricia GlutarAde Jr GA-1 Nutricia GlutarAde Amino Acid Blend Nutricia Metanx Complex Essential MDS

Medications Baclofen L-Carnitine Acetyl Carnitine

Vitamins Riboflavin Solace Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Vitaflo Frutivits Vitamin B6 tablets Vitamin B12 tablets Holocarboxylas Vitamins MCD e Synthetase Biotin Deficiency/ Nano VM (1-3) Solace Multiple Nano VM (4-8) Solace Carboxylase Nano VM (9-18) Solace Deficiency Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 tablets IVA Isovaleric Formulas Acidemia I-Valex-1 Abbott Nutrition I-Valex-2 Abbott Nutrition IVA Anamix Early Years Nutricia Nutricia IVA Anamix Next Nutricia XLeu Maxamaid – orange Nutricia XLeu Maxamum – orange Mead Johnson LMD Abbott Nutrition Pro-Phree Mead Johnson PFD 1 Mead Johnson PFD 2 Nutricia Super Soluble Duocal Metanx Complex Essential MSD

Dietary Supplements Glycine 500

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 8

Medications L-Carnitine (100mg/ml) Acetyl Carnitine

Vitamins Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 tablets MMA Methylmalonic Formulas Acidemia Propimex-1 Abbott Nutrition Propimex-2 Abbott Nutrition Cbl AB Cobalamin A B/ OA 1 Mead Johnson Homocystinuria OA 2 Mead Johnson MMA/PA Anamix Early Years MMA/PA Anamix Next Nutricia XMTVI Maxamaid – orange Nutricia XMTVI Maxamum – orange Nutricia Milupa OS 2 Nutricia MMA/PA Gel Nutricia MMA/PA Express Vitaflo Pro-Phree Vitaflo PFD 1 Abbott Nutrition PFD 2 Mead Johnson Super Soluble Duocal Mead Johnson Metanx Nutricia Complex Essential MSD

Medications L-Carnitine (100 mg/ml) Acetyl Carnitine Hydroxocobalamin IM (1 mg/ml)

Cystadane (Betaine)

Vitamins Cyanocobalamin Solace Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Vitaflo Frutivits Vitamin B6 tablets Vitamin B12 tablets MMA Methylmalonic Formulas (MUT) Acidemia Solcarb (Mutase Polycal Nutricia Deficiency) - Super Soluble Duocal Nutricia MUT MMA/PA Anamix Early Years Nutricia

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 9

MMA/PA Anamix Next Nutricia XMTVI Maxamaid Nutricia XMTVI Maxamum Nutricia Metanx Complex Essential MSD

Medications L-Carnitine Acetyl Carnitine

Vitamins

Cyanocobalamin Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 tablets PA Propionic Formulas (PROP) Acidemia Propimex-1 Abbott Nutrition Propimex-2 Abbott Nutrition OA 1 Mead Johnson OA 2 Mead Johnson MMA/PA Anamix Early Years Nutricia Nutricia MMA/PA Anamix Next Nutricia XMTVI Maxamaid Nutricia XMTVI Maxamum Nutricia Super Soluble Duocal Vitaflo MMA/PA Gel Vitaflo MMA/PA Express 15 Vitaflo MMA/PA Cooler 15 Abbott Nutrition Pro-Phree Mead Johnson PFD 1 Mead Johnson PFD 2 Metanx Complex Essential MSD Nestle SOS 20

Dietary Supplements Nutricia L- Leucine Nutricia L- Isoleucine Nutricia L- Valine Vitaflo Isoleucine50 Vitaflo Isoleucine1000 Vitaflo Leucine100 Vitaflo Valine50 Vitaflo Valine1000

Medications Acetyl Carnitine L-Carnitine

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 10

Vitamins Biotin Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 tablets HMG Hydroxymethyl -glutaric 3-MCC Aciduria 3-Methylcro tonyl-CoA Carboxylase Deficiency Cbl C Cbl C Formulas Solcarb Solace Polycal Nutricia Super Soluble Duocal Nutricia MMA/PA Anamix Early Years Nutricia MMA/PA Anamix Next Nutricia XMTVI Maxamaid Nutricia XMTVI Maxamum Nutricia MMA/PA Gel Vitaflo MMA/PA Express 15 Vitaflo MMA/PA Cooler 15 Vitaflo Pro-Phree Abbott Nutrition Metanx Complex Essential MSD

Medications Acetyl Carnitine L-Carnitine Cystadane Powder (Betaine)

Vitamins Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Folinic Acid Hydroxocobalamin, liquid injection Vitamin B6 tablets Vitamin B12 tablets Cbl D Cbl D MAL Malonic Acidemia

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 11

IBG Isobutyryl- glycinuria 2MBG 2MBG 3MGA 3MGA 2M3HBA 2M3HBA

FATTY ACID OXIDATION DISORDERS

DISORDER ITEMS MANUFACTURER CUD Carnitine Uptake Medications Defect L-Carnitine Acetyl Carnitine Vitamins Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 tablets MCAD Medium-chain Medications acyl-CoA L-Carnitine dehydrogenase Acetyl Carnitine

Vitamin Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 tablets LCHAD Long-Chain Formulas Hydroxy- Acyl- MCT Procal Vitaflo CoA Lipistart Vitaflo Dehydrogenase Liquigen MCT Nutricia Deficiency Metanx Complex Essential MSD

Dietary Supplements MCT Oil

Medication L-Carnitine Acetyl Carnitine

Vitamins Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 12

Vitamin B6 tablets Vitamin B12 tablets TFP Trifunctional Medications Protein L-Carnitine Deficiency Acetyl Carnitine

Vitamins Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 tablets VLCAD Very-Long-Chain Formulas Acyl-CoA MCT Procal Vitaflo Dehydrogenase Lipistart Vitaflo Deficiency Liquigen MCT Nutricia Metanx Complex Essential MSD

Dietary Supplements MCT Oil Medications L-Carnitine

Acetyl Carnitine

Vitamins Nano VM (1-3) Solace Nano VM (4-8) Solace Nano VM (9-18) Solace Nano VM T/F powder Solace Frutivits Vitaflo Vitamin B6 tablets Vitamin B12 tablets SCAD Short-Chain Formulas acyl-CoA MCT Procal Vitaflo dehydrogenase MCT Oil Mead Johnson Deficiency Enfaport Vitaflo Lipistart Vitaflo HADH Medium-Short- Liquigen MCT Nutricia M/SCHAD ChainL-3- Monogen Nuitricia hydroxyacl-CoA Portagen Mead Johnson dehydrogenase Metanx deficiency Complex Essential MSD

GA II Glutaric Acidemia Dietary Supplements Type II Glycine500 Vitaflo

MCKAT Medium-chain ketoacyl-CoA

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 13

thiolase deficiency 2,4 Dienoyl-CoA reductase Deficiency

Carnitine CPT I palmitoyltrans- ferase type I deficiency

Carnitine CPTII palmitoyltransfer ase type II deficiency

Carnitine CACT acylcarnitine translocase deficiency DE RED 2,4 Dienoyl-CoA reductase deficiency

ENDOCRINE DISORDERS

DISORDER MEDICATIONS MANUFACTURER CH Hypothyroidism Synthroid Abbott Laboratories Levothroid Forest Pharmaceuticals Levoxyl Jones Pharma CAH Congenital NaCl (salt) Adrenal Cortisone Hyperplasia Florinef

HEMOGLOBIN DISORDERS

DISORDER TREATMENT Sickling Hemoglobinopathies Penicillin Oxygen IV Fluids Antibiotics Analgesics Hydroxyurea Desferrin

OTHER DISORDERS

DISORDER MEDICATIONS MANUFACTURER BIOT Biotinidase Biotin Deficiency GALT Galactosemia Formulas Neocate Infant DHA/ARA Nutricia

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 14

Enfamil ProSobee Lipil Mead Johnson Similac Isomil Advance Abbott Nutrition Good Start Supreme Soy Nestle Parent’s Choice Soy Infant PBM Nutritionals Formula with a Blend of Lipids Metanx Complex Essential MSD

Vitamins Calcium Vitamin D

CYSTIC FIBROSIS DISORDER ITEMS MANUFACTURER Dietary Supplements PediaSure Abbott Nutrition PediaSure Enteral Abbott Nutrition Ensure Axcan Scandipharm, Inc Ensure Plus Nestle Nutrition Scandishakes Nestle Nutrition Peptamen Jr Abbott Nutrition Peptamen Jr 1.5 Nutricia Nutricia TwoCal HN Neocate Neocate Junior Abbott Nutrition EleCare Nestle Nutrition Nutren 1.5 Nestle Nutrition Nutren 2.0 Nestle Nutrition Nutren Jr Nestle Nutrition Carnation Instant Breakfast Plus Nestle Nutrition Carnation Instant Breakfast Very High Nestle Nutrition Calorie Nestle Nutrition Boost Kids Essentials Nestle Nutrition Boost Kids Essentials 1.5 Nestle Nutrition Boost Nestle Nutrition Boost Chocolate Abbott Nutrition Boost Plus Nestle Nutrition Enlive Nestle Nutrition Enlive Apple Benecalorie Scandical

Medications AstraZeneca Pharmaceuticals, LP Zantac Sepracor, Inc Albuterol Eurand NV Creon Wyeth Pharmaceuticals Nexium Axcan Scandipharm, Inc Ultrase Axcan Scandipharm, Inc Ultrase MT Solvay Pharmaceuticals Zenpep Digestive Care, Inc. Pancrecarb

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 15 Pancreaze Ortho-McNeil Pharmaceutical, Inc Pancreaze MT Ortho-McNeil Pharmaceutical, Inc Pancrecarb MS Digestive Care, Inc. Viokase tablets Axcan Scandipharm, Inc Ursodiol Teva Pharmaceuticals USA Actigall Novartis Pharmaceuticals Prevacid TAP Pharmaceuticals Inc Prilosec GlaxoSmithKline Protonix AstraZeneca Pharmaceuticals, LP Tobramycin (TOB 1) Wyeth Pulmozyme Genentech Azithromycin Xopenex Sunovion Atrovent GlaxoSmithKline Spiriva Boehringer-Ingelheim Pharmaceuticals Brovana Boehringer Pulmicort Ingelheim Pharmaceuticals Pro Air Sepracor, Inc Ventolin AstraZeneca Flovent Teva Specialty Pharmaceuticals Advair GlaxoSmithKline Symbicort GlaxoSmithKline Duocal GlaxoSmithKline Benecalorie AstraZeneca Canada Inc. Scandical Nutricia Hypertonic Saline (Sodium Chloride) Nestle Nutrition Lantus Cardinal Health Pharmaceuticals Novolog Aventis Pharmaceuticals, Inc Humalog Novo Nordisk Pharmaceuticals Inc NPH Eli Lily and Company

Vitamins Vitamin D Aton Pharma Inc Vitamin D2 Cardinal Health Pharmaceuticals Vitamin D3 Natures Products Vitamin E Axcan Scandipharm, Inc Vitamin K (Mephyton) Cholecalciferol Abbott Nutrition AquADEK (liquid or chewable tablets) Source CF Vitamax Dekas Plus Calcium Vitamin B6 tablets Vitamin B12 tablets Beta Carotene

NBS Benefits Contractor Procedures Manual Supplement – Medical Management Services – July 2018 Page 16