Drug Benefit List 2012

88:00 VITAMINS

88:04.00 VITAMIN A

VITAMIN A

ST 10,000IU Capsule

00557447 VIT A VTH *

00297720 VITAMIN A JAM

ST 25,000IU Capsule

00021067 VITAMIN A TEV

ST 50,000IU Capsule

00021075 VITAMIN A TEV

88:08.00 VITAMIN B COMPLEX

CYANOCOBALAMIN

100mcg/mL Injection

00497533 VITAMIN B12 ABB

02241500 VITAMIN B12 SDZ

1,000mcg/mL Injection

01987003 CYANOCOBALAMIN CYX

02052717 CYANOCOBALAMIN TAR

00521515 VIT B12 SDZ

00038830 VITAMIN B12 ABB

ST 25mcg Tablet

00406988 VITAMIN B12 JAM *

ST 50mcg Tablet

00305243 VITAMIN B12 JAM

ST 100mcg Tablet

00450642 VIT B12 VTH *

02023598 VITAMIN B12 PMT

ST 250mcg Tablet

00335940 VITAMIN B12 JAM

ST 1000mcg Tablet

02237736 VITAMIN B12 SWS

80003575 VITAMIN B12 PMT

FOLIC ACID

ST 1mg Tablet

00318973 FOLIC ACID JAM

00647039 FOLIC ACID VTH

02048841 FOLIC ACID PMT

02236747 FOLIC ACID PED

ST 5mg Tablet

00426849 APO-FOLIC ACID APX

02285673 EURO-FOLIC EUR

02366061 JAMP FOLIC ACID JMP

NIACIN

ST 50mg Tablet

00041084 NIACIN PMS

ST 100mg Tablet

00268585 NIACIN VAE

ST 500mg Tablet

00294950 NIACIN VAE

01939130 NIACIN ODN

02247004 NIACIN PMT

00557412 NIACIN YEAST FREE VTH

00309737 VITAMIN B3 JAM

PYRIDOXINE HCL

ST 25mg Tablet

00122645 VITAMIN B6 JAM

00232475 VITAMIN B6 PMS

01943200 VITAMIN B6 ODN

80002890 VITAMIN B6 JMP

ST 50mg Tablet

00252689 VITAMIN B6 VAE

00305227 VITAMIN B6 JAM

00608599 VITAMIN B6 PMS *

ST 100mg Tablet

00263958 VITAMIN B6 ICN

00329185 VITAMIN B6 JAM

00450677 VITAMIN B6 VTH *

02239348 VITAMIN B6 PMT

THIAMINE HCL

100mg/mL Injection

02241983 BETAXIN ABB

02243525 THIAMINE CYX

00816078 VITAMIN B1 SDZ

ST 50mg Tablet

02245506 EURO-B1 EUR

80009633 JAMP-VITAMIN B1 JMP

00268631 VITAMIN B1 VAE

ST 100mg Tablet

00232467 VITAMIN B1 PMS *

00294853 VITAMIN B1 ICN

00407011 VITAMIN B1 JAM

88:12.00 VITAMIN C

ASCORBIC ACID

ST 250mg Chewable Tablet

00266051 VITAMIN C PMT

ST 500mg Chewable Tablet

00274240 VITAMIN C PED

00322326 VITAMIN C LAL

00784591 VITAMIN C VTH *

02243893 VITAMIN C PMT

02245721 VITAMIN C PMT

ST 1000mg Sustained Release Tablet

00760587 VITAMIN C PMT

ST 250mg Tablet

00557811 VIT C VTH *

00162515 VITAMIN C PMT

00221244 VITAMIN C ADA

ST 500mg Tablet

00266086 ASCORBIC ACID PMT

00036188 VITAMIN C PED

00041114 VITAMIN C ADA

00322997 VITAMIN C LAL *

00557838 VITAMIN C VTH *

01922378 VITAMIN C SWS

02244469 VITAMIN C PMT

ST 1000mg Tablet

00354376 VITAMIN C PMT

88:16.00 VITAMIN D

ALFACALCIDOL

ST 0.25mcg Capsule

00474517 ONE-ALPHA LEO

ST 1mcg Capsule

00474525 ONE-ALPHA LEO

ST 2mcg/mL Oral Liquid

02240329 ONE-ALPHA LEO

CALCITRIOL

ST 0.25mcg Capsule

00481823 ROCALTROL HLR

ST 0.5mcg Capsule

00481815 ROCALTROL HLR

ST 1mcg/mL Solution

00824291 ROCALTROL HLR

CHOLECALCIFEROL

ST 400IU Capsule

02242651 EURO D EUR

80006629 JAMP-VITAMIN D JMP

80005560 RIVA-D 400 UNIT CAP RIV

ST 800IU Capsule

80007769 JAMP-VITAMIN D JMP

ST 10,000IU Capsule

02253178 EURO D EUR

ST 50,000IU Capsule

02301911 OSTOFORTE TRT

ST 400IU Drop

80001869 BABY DDROPS DDP

80001792 DDROPS VITAMIN D DDP

ST 400IU/mL Drop

00762881 D VI SOL MJO

80003038 JAMP-VITAMIN D JMP

02231624 PEDIAVIT D EUR

ST 1000IU Drop

80001791 DDROPS VITAMIN D DDP

ST 400IU Tablet

00765384 VITAMIN D LAL

02238729 VITAMIN D VTH

02240624 VITAMIN D WAM

02240858 VITAMIN D PMT

ST 1,000IU Tablet

02245842 VITAMIN D PMT

ST 10,000IU Tablet

00821772 D-TABS RIV

ERGOCALCIFEROL

ST 50,000IU Capsule

02237450 D-FORTE EUR

ST 8,288IU/mL Solution

02017598 DRISDOL SAC

VITAMIN D

ST 400IU Capsule

80008590 VITAMIN D BMI

ST 800IU Capsule

80003010 EURO D EUR

80008446 VITAMIN D BMI

ST 400IU Tablet

80002452 VITAMIN D WNP

80009578 VITAMIN D SWS

ST 1000IU Tablet

80000436 VITAMIN D JAM

80009580 VITAMIN D SWS

VITAMIN D3

ST 1000IU Tablet

02240507 VITAMIN D WNP

88:20.00 VITAMIN E

ALPHA TOCOPHERYL

ST 400IU Capsule

00122858 VITAMIN E NATUAL SOURCE JAM

VITAMIN E

ST 200IU Capsule

00122831 VITAMIN E JAM

ST 50IU/mL Liquid

02162075 AQUASOL E NVC

88:28.00 MULTIVITAMIN PREPARATIONS

MULTIVITAMINS (PEDIATRIC)

Limited use benefit (prior approval is not required).

Pediatric multivitamins are benefits for children up to 6 years of age.

ST Drop

00762946 POLY-VI-SOL MJO

ST Liquid

00558079 INFANTOL HOR

ST Tablet

80011134 CENTRUM JUNIOR COMPLETE PFI

80020794 CENTRUM JUNIOR COMPLETE PFI

02247975 FLINTSTONES EXTRA C BCD

MULTIVITAMINS (PRENATAL)

Limited use benefit (prior approval is not required.).

Prenatal and postnatal vitamins are benefits only for women of childbearing age (12 to 50 years).

ST Tablet

80001842 CENTRUM MATERNA WAY

02229535 MULTI-PRE AND POST NATAL PED

80005770 PRENATAL & POSTPARTUM PMT

02241235 PRENATAL AND POSTPARTUM SDR

VITAMIN A, CHOLECALCIFEROL, ASCORBIC ACID

Limited use benefit (prior approval is not required).

Pediatric multivitamins are benefits for children up to 6 years of age.

ST 2,500IU & 666.67IU & 50mg/mL Drop

02229790 PEDIAVIT EUR

00762903 TR- VI-SOL MJO

ST Oral Liquid

80008471 JAMP-MULTIVITAMIN A/D/C DROPS JMP