Non-Drug Product List Effective November 15, 2013 Non-Drug Products Indicates Prior Authorization Required Ammonium Lactate Lotion 12% Aquadeks Capsules AquaADEKS Tabs AquaADEKS Solution Bacteriostatic Sodium Chloride Injection 0.9% Bacteriostatic Water for Injection Bacteriostatic Parabens Water for Injection Calcium Carbonate 500mg Chewable Tablets Calcium Carbonate 750mg Chewable Tablets Calcium Carbonate 1000mg Chewable Tablets Calcium Carbonate 1250mg Chewable Tablets Calcium Carbonate 1250mg/5ml Suspension Calcium Carbonate 600mg Tablets Calcium Carbonate-Vitamin D 500mg/200 unit Calcium Carbonate Vitamin D 600mg/200 unit Calcium Carbonate Vitamin D 600mg/400 unit Tablets Calcium Citrate 950mg Tablets Calcium Glubionate 1.8gm/5mL Calcium Gluconate 650mg Tablets Calcium Lactate 650mg Tablets Calvite P&D Tablets Cerovite Jr Chewable Tablets Cerovite Liquid Cholecalciferol 400 Unit Tablets Epoprostenolol Diluents (Flolan) 0.5mg Epoprostenolol Diluents (Flolan) 1.5mg Ferrous Fumarate 325mg Tablets Ferrous Gluconate 324mg Tablets Ferrous Gluconate 325mg Tablets Ferrous Sulfate 75mg/0.6ml Drops Ferrous Sulfate 75mg/ml Drops Ferrous Sulfate 220mg/5ml Elixir Ferrous Sulfate 325mg Tablets Magnesium Chloride ER Tablet 535 (64mg) MG Magnesium Gluconate 1000mg/5mL Magnesium Oxide 400mg Tablets Maximum D3 Capsules Metronidazole Powder Multiple Vitamins Tablets Nephro-vite Tablets Niacin Tablets, 50mg Niacin Tablets, 100mg Niacin Tablets, 250mg Niacin Tablets, 500mg Pediatric Oral Electrolyte Solutions Phos-Nak Powder Concentrate Polysaccharide Iron Complex 150mg Capsules Poly-Vi-Sol Drops Poly-Vi-Sol Drops/Iron Progesterone Powder Progesterone Micronized Powder Pyridoxine Tablets 100mg Pyridoxine Tablets 25mg Pyridoxine Tablets 50mg Slow-Mag Tablets Sodium Bicarbonate 325mg Tablets Sodium Bicarbonate 650mg Tablets Sodium Chloride Injection Sodium Chloride Solution 0.9% for inhalation Thera-M Tablets Enhanced Tri-Vi-Sol Drops Tri-Vi-Sol Drops/Iron Vitamin A Capsules 10000I U Vitamin B-1 Tablets 100mg Vitamin B-1 Tablets 50mg Vitamin B-12 Tablets 1000 CR Vitamin B-12 Tablets 1000 mcg Vitamin C Chewable Tablets 500mg Vitamin C Tablets 500mg Vitamin C Tablets 1000mg Vitamin D Drops 400 Unit Vitamin D Tablets 1000 Unit Vitamin D Tablets 2000 Unit Vitamin D Tablets 400 Unit Vitamin E Capsules 400 Unit .