South Country Health Alliance Member Services
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ABILITYCARE & SENIORCARE COMPLETE 2012 SUPPLEMENTAL DRUG LIST This list contains selected Barbiturates, Benzodiazepines, Cough-Cold Products, Over-The-Counter products, Vitamins, and other Part D excluded drugs which are covered as part of your Medical Assistance benefits. Drugs are listed by their generic names. Certain brand name drugs may be covered. Please check with your pharmacist for more details. South Country Health Alliance Member Services 1-866-567-7242 • TTY 711 8 a.m. to 8 p.m. 7 days a week. Calls to both numbers are free. Generic Description PAIN RELIEVERS-FEVER REDUCERS acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen Brand Examples Strengths Dosage forms Tylenol Tylenol Extra Strength 325 mg 500 mg 500 mg 650 mg 80 mg 160 mg 160 mg/5 mL 160 mg/5 mL 160 mg/5 mL 160 mg/5 mL 80 mg/0.8 ml 100 mg/mL 120 mg 325 mg tablets tablets capsules tablets, ER chew tablets chew tablets elixir liquid susp soln susp soln (drops) suppositories suppositories Tylenol Arthritis Tylenol Tylenol South Country Health Alliance is a coordinated care health plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid program. 2419, 5703_1841 CMS Approved xx/xx/2011 1 acetaminophen acetaminophen acetaminophen acetaminophen/diphenhydramine aspirin aspirin aspirin aspirin aspirin buffered aspirin buffered aspirin buffered aspirin buffered aspirin enteric-coated aspirin enteric-coated aspirin enteric-coated aspirin aspirin aspirin/acetaminophen/caffeine ibuprofen Tylenol Childrens Meltaways Tylenol Jr Meltaways Tylenol PM Bayer Childrens Bayer Bufferin Bufferin Extra Strength Ascriptin Ascriptin Maximum Strength Ecotrin Ecotrin Maximum Strength Bayer Low Dose 650 mg 80 mg 160 mg 500-25 mg 81 mg 81 mg 325 mg 500 mg 325 mg 500 mg 325 mg 500 mg 325 mg 500 mg 81 mg 300 mg, 600 mg 162 mg 250-250-65 mg 100 mg/5 mL suppositories dispersable tabs dispersable tabs tablets chew tablets tablets tablets tablets tablets tablets tablets tablets tablets, DR tablets, DR tablets, DR suppositories tablets, DR tablets suspension 40 mg/mL 100 mg suspension chew tablets 100 mg 200 mg 220 mg tablets tablets tablets vaginal cream vaginal cream vaginal tablets vaginal tablets/ vaginal cream vaginal cream vaginal cream vaginal tablets vaginal tablets & cream kit ibuprofen ibuprofen naproxen sodium Halfprin Excedrin Migraine Childrens Motrin, Childrens Advil Motrin Infants, Childrens Advil Advil Jr Strength, Children's Motrin Jr Strength Motrin Junior Strength Advil, Motrin IB Aleve FUNGAL INFECTIONS - vaginal clotrimazole clotrimazole clotrimazole clotrimazole Gyne-Lotrimin, Mycelex 7 Gyne-Lotrimin 3 Gyne-Lotrimin Mycelex-7 Combo Pack 1% 2% 100 mg 100 mg/1% miconazole miconazole miconazole miconazole supp & cream kit Monistat 7 Monistat 3 Monistat 7 Monistat 2% 4% 100 mg various ibuprofen ibuprofen BIRTH CONTROL condoms Conceptrol (nonoxynol-8) South Country Health Alliance is a coordinated care health plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid program. 2419, 5703_1841 CMS Approved xx/xx/2011 all 4% all gel 2 (nonoxynol-9) VCF Vaginal Contraceptive Foam Encare (nonoxynol-9) Gynol II (nonoxynol-9) Gynol II Extra Strength (nonoxynol-9) nonoxynol-9 EAR, NOSE, THROAT benzocaine carbamide peroxide cromolyn sodium - nasal spray oxymetazoline phenol phenylephrine sodium chloride sodium chloride EYE PRODUCTS artificial tears gel artificial tears soln artificial tears ointment carboxymethylcellulose hypromellose hypromellose ketotifen polyethylene glycol/propylene alcohol polyethylene glycol/propylene glycol polyvinyl alcohol propylene glycol/povidone propylene glycol/glycerine sodium chloride ophthalmic sodium chloride ophthalmic white petrolatum/mineral oil Hurricaine Debrox Nasalcrom Afrin Chloraseptic Spray Neo-Synephrine Ayr Saline Ocean Genteal Tears Naturale Refresh, P.M. Refresh, Celluvisc Tearisol, Isopto Tears Genteal Zaditor Hypotears Systane Akwa Tears artificial tears Soothe Muro-128 Muro-128, AK-NACL Lacri-Lube GASTROINTESTINAL Heartburn, Indigestion aluminum & magnesium hydroxides aluminum & magnesium hydroxides/ Mylanta simethicone South Country Health Alliance is a coordinated care health plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid program. 2419, 5703_1841 CMS Approved xx/xx/2011 12.5% foam 2.27% 2% 3% 100 mg suppository gel gel suppository 0.2 6.5% 5.2 mg/act 0.05% 1.40% 0.25%, 1% 0.65% oral solution otic solution nasal aerosol nasal spray oral liquid nasal solution nasal gel nasal spray 0.5%, 1%, 2% 0.2%, 0.3%, 0.5% 0.025% ophth gel ophth soln ophth ointment ophth soln ophth soln ophth soln ophth soln 0.4%-0.3% 1.4% 0.6%/0.6% 5% 2%, 5% 225-200 mg/5 mL 200-200-20 mg/5 mL, 400-400-40 mg/ 5 mL ophth soln ophth soln ophth soln ophth soln ophth oint ophth soln ophth oint susp susp 3 aluminum hydroxide gel susp aluminum hydroxide gel susp calcium carbonate calcium carbonate calcium carbonate calcium carbonate calcium carbonate cimetidine famotidine Alternagel Tums Ultra Childrens Mylanta Tums Maalox Tums E-X Tagamet HB Pepcid AC 320 mg/5 mL 600 mg/5 ml 1000 mg 400 mg 500 mg 600 mg 750 mg 200 mg 10 mg famotidine Pepcid AC Maximum Strength 20 mg nizatidine omeprazole delayed-release omeprazole magnesium delayed-release ranitidine sodium bicarbonate Axid AR Prilosec OTC 75 mg 20 mg 20 mg Zantac 75 mg tablets tablets, pwd, granules Dulcolax Dulcolax Dulcolax Fibercon Unifiber Colace 5 mg 10 mg/30 mL 10 mg 625 mg tablets, DR enema suppository caplets oral powder capsules capsules liquid liquid syrup enema suppository suppository suppository suppository oral solution USP susp Constipation bisacodyl bisacodyl bisacodyl calcium polycarbophil cellulose powder docusate sodium docusate sodium docusate sodium docusate sodium docusate sodium glycerin glycerin glycerin glycerin glycerin magnesium citrate Colace Fleet Babylax magnesium hydroxide Milk of Magnesia magnesium hydroxide methylcellulose mineral oil Milk of Magnesia Citrucel South Country Health Alliance is a coordinated care health plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid program. 2419, 5703_1841 CMS Approved xx/xx/2011 100 mg 250 mg 150 mg/ 15 mL 50 mg/5 mL 60 mg/15 mL 2.3 g 2.1 g 1.2 g 1.5 g 3g 400 mg/5 mL, 800 mg/5 mL 311 mg susp susp chewable tablets chewable tablets chewable tablets chewable tablets chewable tablets tablets chewable tablets, tablets chewable tablets, tablets tablets tablets, DR tablets, DR chew tablets powder oral liquid 4 mineral oil enema PEG 3350 oral powder psyllium powder senna sennosides sennosides sennosides sennosides sennosides/docusate sodium sodium phosphates rectal soln sodium phosphates soln sorbital sorbital Diarrhea bismuth subsalicylate bismuth subsalicylate loperamide loperamide simethicone simethicone simethicone Miscellaneous GI lactase simethicone RESPIRATORY Antihistamines/decongestants brompheniramine/phenylephrine brompheniramine/pseudoephedrine brompheniramine/pseudoephedrine cetirizine cetirizine cetirizine cetirizine cetirizine cetirizine/pseudoephedrine chlorpheniramine 70% 70% enema powder powder tablets chew tablets tablets tablets tablets tablets enema oral soln oral solution solution Pepto Bismol Pepto Bismol Imodium A-D Imodium A-D Gas-X Gas-X Extra Strength Phazyme various 262 mg 2 mg 1 mg/5 mL 80 mg 125 mg 180 mg suspension tablets tablets soln chew tablets chew tablets capsules Lactaid various Mylicon 40 mg/0.6 mL caps, tablets, liquid susp Dimetapp Cold and Allergy 1-2.5 mg/5 mL 1 mg-15 mg/5 mL 4 mg-20 mg/5 mL 10 mg 5 mg 5 mg/5 mL elixir elixir liquid chew tablets chew tablets syrup 10 mg tablets 5 mg 5 mg/120 mg 12 mg tablets tablets CR capsule Miralax Metamucil, Fiber-Eze Ex-Lax Ex-Lax Ex-Lax Maximum Strength Senokot Senokot-S Fleets Phospho Soda Enema Fleets Phospho Soda Lohist PSB Zyrtec Childrens Allergy Zyrtec Childrens Allergy Zyrtec Children's Allergy Zyrtec Children’s Hives Zyrtec Allergy, Zyrtec Hives Relief Zyrtec-D Chlor-Trimeton South Country Health Alliance is a coordinated care health plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid program. 2419, 5703_1841 CMS Approved xx/xx/2011 various 187 mg 15 mg 15 mg 25 mg 8.6 mg 8.6-50 mg 5 chlorpheniramine Chlor-Trimeton chlorpheniramine Chlor-Trimeton chlorpheniramine/pseudoephedrine chlorpheniramine/pseudoephedrine clemastine fumarate diphenhydramine diphenhydramine diphenhydramine diphenhydramine diphenhydramine diphenhydramine diphenhydramine diphenhydramine (for sleep) diphenhydramine (for sleep) diphenhydramine (for sleep) doxylamine (for sleep) fexofenadine loratadine loratadine loratadine loratadine loratadine/pseudoephedrine loratadine/pseudoephedrine phenylephrine pseudoephedrine pseudoephedrine pseudoephedrine pseudoephedrine pseudoephedrine pseudoephedrine pseudoephedrine pseudoephedrine Antitussives and Expectorants brompheniramine/phenylephrine/ dextromethorphan Tavist Allergy Benadryl Benadryl Benadryl Allergy Benadryl Unisom Sleep Gels Sominex Nytol Maximum Strength Unisom Allegra Claritin Claritin Reditablets Claritin Alavert, Claritin Claritin D 24 HR Claritin D 12 HR Sudafed PE Sudafed Childrens Sudafed 12 HR Sudafed 24 Hour Sudafed Dimetapp DM South Country Health Alliance is a coordinated care health plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid program. 2419, 5703_1841 CMS Approved xx/xx/2011 2 mg/5 mL 4 mg 1-15 mg/5 mL, 2-30 mg/5 mL, 0.8-9 mg/ mL 8-120 mg/, 2-30 mg 1.34 mg 25 mg, 50 mg 12.5 mg syrup tablets liquid 5 mg/5 mL 10 mg 10-240 mg 5-120 mg 10 mg 120 mg 15 mg/5 mL 30 mg/5 mL 30 mg/5 mL 120 mg 240 mg 30 mg 60 mg CR capsule, chew tablets tablets capsules chew tablets, orally dissolving strips elixir liquid syrup tablets tablets capsules tablets tablets tablets tablets chew tablets orally disintegrating tablets syrup tablets ER tablets ER tablets tablets ER capsules liquid liquid syrup tablets tablets tablets tablets 1-2.5-5 mg/5 mL elixir 12.5mg/5 mL 12.5mg/5 mL 12.5mg/5 mL 25 mg 50 mg 50 mg 25 mg 50 mg 25 mg 180 mg 5 mg 10 mg 6 brompheniramine/phenylephrine/ dextromethorphan Dimetapp DX dextromethorphan polistirex dextromethorphan/guaifensin dextromethorphan/guaifensin dextromethorphan/guaifensin Delsym Cheracol-D Mucinex Cough-Childrens Mucinex DM Maximum Strength Mucinex DM Robitussin DM Sorbutuss NR dextromethorphan/guaifensin dextromethorphan/guaifensin dextromethorphan/guaifensin-potassium citrate guaifenesin guaifenesin guaifenesin guaifenesin guaifenesin guaifenesin guaifenesin guaifenesin/phenylephrine SKIN Acne benzoyl peroxide benzoyl peroxide salicylic acid Antibacterials-topical bacitracin zinc neomycin/polymyxin B/bacitracin Antifungals-topical clotrimazole ketoconazole miconazole miconazole miconazole miconazole terbinafine tolnaftate Antipruritics collodial oatmeal calamine lotn 2 mg-30 mg-10 mg/ 5 mL; 4 mg-60 mg-30 mg/ 5 mL 30 mg/5 mL 10-100 mg/5 mL 5-100 mg/5 mL 30-1200 mg syrup SR tabs syrup liquid Liquibid Rescon-GG 30-600 mg 10-100 mg/5 mL 10-100-85 mg/ 5 mL 50 mg, 100 mg 100 mg/5 mL 1200 mg 600 mg 100 mg/5 mL 200 mg 400 mg 100-5 mg/5 mL Clean & Clear 10% 5% 0.5%, 2% cream, gel, lotn gel, lotn liquid 500 U/g ointment ointment 1% 1% 2% 2% 2% 2% 1% 1% various shampoo aerosol aerosol powder cream powder various various Mucinex Cough for Kids Mucinex for Kids Mucinex Mucinex Robitussin Neosporin, Triple Antibiotic Lotrimin AF Nizoral A-D Desenex Spray Lotrimin AF Micatin Desenex Shake Powder Lamisil AT Tinactin Aveeno South Country Health Alliance is a coordinated care health plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid program. 2419, 5703_1841 CMS Approved xx/xx/2011 CR liquid liquid liquid SR tabs granules liquid SR tablets SR tablets syrup tablets tablets liquid packets lotn 7 hydrocortisone hydrocortisone acetate Pediculosis permethrin permethrin piperonyl butoxide/pyrethrins/ permethrin pyrethrins/piperonyl butoxide Other Topicals benzocaine capsaicin cream capsicum chlorhexidine gluconate coal tar coal tar/salicylic acid dibucaine docosanol hydroactive dressings hydrocortisone hydrogen peroxide isopropyl alcohol lactic acid/ammonium lactate povidone/iodine ointment povidone/iodine solution salicylic acid gel salicylic acid liquid salicylic acid patches salicylic acid patches salicylic acid plaster salicylic acid selenium sulfide trolamine salicylate white petrolatum wound dressing gel zinc oxide SMOKING CESSATION nicotine gum nicotine oral lozenges Hytone 1% 1% crm, lotn, oint crm, oint Nix Crème Rinse 1% 1% cream rinse lotion Rid Complete Tegrin-LT, Pronto Americaine Zostrix Hibiclens Ionil-T, T/Gel Tarsum Nupercainal Abreva Aquaflo Hydrogel, Curafil Hydrogel Proctocort rubbing alcohol Lac-Hydrin Betadine Keralyt Compound W, DuoFilm shampoo 20% aerosol 0.025%, 0.075% 2%, 4% 1%, 2.5% 5%, 10% 1% 10% cream liquid shampoo shampoo rectal ointment topical cream dressings, pads 1%, 2.5% 3% 70% 5% 10% 7.5%, 10% 3% 17% 40% 17% 40% 3.0% 1%, 3% 10% rectal cream solution solution 2 mg, 4 mg 2 mg, 4 mg gum oral lozenges Trans-ver-sal Pediapatch MediPlast Psoriasis Liquid Selsun Blue Myoflex, Aspercreme Vaseline Curafil, Nu-Gel, Curasol Balmex, Boudreauox Butt Paste, various Desitin Nicorette Nicorette South Country Health Alliance is a coordinated care health plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid program. 2419, 5703_1841 CMS Approved xx/xx/2011 ointment solution gel liquid pad patches plaster liquid lotion (shampoo) cream, lotion gel, ointment gel ointment 8 nicotine transdermal patches SUPPLEMENTS beta carotene calcium carbonate calcium carbonate calcium carbonate calcium carbonate calcium carbonate calcium carbonate/cholecalciferol calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D/ minerals calcium citrate calcium citrate/vitamin D cholecalciferol cyanocobalamin (Vitamin B12) cyanocobalamin (Vitamin B12) ergocalciferol ergocalciferol ferrous gluconate ferrous sulfate ferrous sulfate ferrous sulfate ferrous sulfate ferrous sulfate, dried folic acid Nicoderm CQ 7 mg, 14 mg, 21 mg 15 mg, 30 mg, 10000 units, 25000 units 1250 mg/5 mL 500 mg Cal-Mint, Os-Cal 500 chewables 500 mg Caltrate 600 1500 mg (600 mg Ca) 600 mg Os-cal chews various OsCal 500 +D Caltrate 600 +D Citracal + D Vitamin D3 Vitamin D2 Vitamin D2 Slow Fe South Country Health Alliance is a coordinated care health plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid program. 2419, 5703_1841 CMS Approved xx/xx/2011 500mg/125U 500mg/200U 600mg/125U 600mg/200U 600mg-400U 500 mg-400I 600mg-400U, 1200mg-1000U 600 mg-200 units/ various 950mg (200mg Ca) 315mg/200U various strengths 1000 mcg, 1500 mcg, 2000 mcg various 8000 units/ mL 400 units various 220 mg/5 mL 325 mg transermal patches caps susp tablets chew tablets tablets tablets tablets, chew tablets, capsules tablets tablets tablets tablets tablets chew tablets chew tablets tablets tablets tablets capsules CR tablets tablets drops tablets tablets elixir enteric-coated tablets 15 mg/ mL solution various tablets 160 mg ER tablets 200 mcg, 400 mcg, tablets 800 mcg 9 glucosamine 500 mg, 750 mg, 1000 mg 500 mg, 750 mg, 1000 mg various glucosamine sulfate glucosamine/chondroitin iron iron iron complex, polysaccharide iron complex, polysaccharide; vitamin B-12; folic acid levocarnitine levocarnitine levocarnitine lutein lutein-zeaxanthin magnesium magnesium chloride magnesium chloride-calcium carbonate magnesium lactate magnesium oxide magnesium oxide omega-3 fatty acids niacin niacin Iferex-150 Irofol Slow Mag Slow Mag Mag-Ox Slo-Niacin niacin oyster shell calcium oyster shell calcium/vitamin D sodium chloride vitamin A vitamin B-1 (Thiamine) Oyst-Cal vitamin B-2 (Riboflavin) vitamin B-6 (Pyridoxine) vitamin C vitamin E vitamin E South Country Health Alliance is a coordinated care health plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid program. 2419, 5703_1841 CMS Approved xx/xx/2011 66 mg 15 mg/1.5 mL 150 mg 150 mg0.025-1 mg 250 mg, 500 mg 150 mg, 330 mg, 500 mg 10 mg various various strengths 535 mg 71.5 mg/119 mg 84 mg 250 mg, 500 mg 400 mg various 250 mg, 500 mg 250 mg, 500 mg, 750 mg, 1000 mg 50 mg, 100 mg, 250 mg, 500 mg 500 mg 500 mg 1000 mg various 50 mg, 100 mg, 250 mg 25 mg, 50 mg, 100 mg various strengths 100 mg, 250 mg, 500 mg, 1000 mg various 50U/ mL tablets capsules capsules, tablets, oral liquid tablets suspension capsules tablets capsules tablets tablets capsules, tabs capsules, tabs CR tablets tablets tablets tablets tablets capsules CR capsules ER tablets tablets tablets tablets tablets capsules tablets tablets tablets tablets capsules solution 10 vitamin K zinc gluconate zinc sulfate Multivitamins B-complex w/C, folic acid multiple vitamins multiple vitamins with iron multiple vitamins with minerals multiple vitamins with minerals multiple vitamins with minerals multiple vitamins with minerals pediatric multiple vitamins pediatric multiple vitamins with C pediatric multiple vitamins with vitamin C and folic acid pediatric multiple vitamins with fluoride pediatric multiple vitamins with fluoride pediatric multiple vitamins with fluoride and iron pediatric multiple vitamins with iron pediatric vitamin drops with ADC pediatric vitamin drops with ADC and iron prenatal vitamins/folic acid/iron (ferrous fumarate) prenatal vitamins/selenium/folic acid/iron (ferrous fumarate) 100 mcg various 220 mg Dialyvite, Rena-vite One-A-Day Essential Ocuvite, Preservision Ocuvite, Preservision Centrum Chew Centrum, Cerovite Pediavit Poly-Vi-Sol Fruity Chewables, My First Flintstones various 0.25 mg, 0.5 mg, 1 mg 0.25 mg, 0.5 mg, 1 mg 0.25 mg-10 mg/ mL Flintstones Plus Iron, Centrum Kids Tri-Vi-Sol Tri-Vi-Sol/Iron OTHER PRODUCTS activated charcoal dimenhydrinate Dramamine elastic bandages and supports T.E.D., Kendall, J&J glucose meclizine meclizine Bonine South Country Health Alliance is a coordinated care health plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid program. 2419, 5703_1841 CMS Approved xx/xx/2011 tablets tablets capsules tablets tablets tablets tablets capsules chew tabs liquid liquid, chewable tabs, drops drops, liquid chewable tablets chewable tablets drops drops chew tablets 10 mg/ mL drops drops all tablets 50 mg 25 mg 12.5 mg, 25 mg caps, tablets, liq chew tablets, tablets various, including hose, stockings, wraps tablets, gel chew tablets tablets 11 oral electrolyte replacement Oralyte, Pedialyte ostomy supplies, kits Hollister, Kendall, Bard, Convatec syringe/needles, disposable B-D, Kendall OTHER PRESCRIPTION PRODUCTS Barbiturates phenobarbital phenobarbital Barbiturate combinations (headache analgesic) butalbital-acetaminophen Phrenilin butalbital-acetaminophen Sedapap butalbital-acetaminophen-caffeine Esgic butalbital-acetaminophen-caffeine Esgic, Fioricet butalbital-aspirin-caffeine Fiorinal butalbital-aspirin-caffeine Benzodiazepines alprazolam Xanax alprazolam concentrate Alprazolam Intensol alprazolam ER Xanax XR diazepam Valium diazepam concentrate Diazepam Intensol diazepam solution Diazepam Solution lorazepam Ativan lorazepam concentrate lorazepam solution estazolam temazepam Lorazepam Intensol triazolam clonazepam clonazepam ODT Cough and Cold Products benzonatate codeine/guaifenesin codeine/guaifenesin Halcion Klonopin Klonopin Wafers Restoril Tessalon Tusso-C packets, colution various, including drains, caps, belts, pouches, skin gel 1 mL, 3 mL, various needle gauge/lengths 20 mg/5 mL various strengths solution tablets 50-325 mg 50-650 mg 50-325-40 mg 50-325-40 mg 50-325-40 mg 50-325-40 mg tablets tablets capsules tablets capsules tablets various strengths 1 mg/mL various strengths 2 mg, 5 mg, 10 mg 5 mg/mL 1 mg/mL 0.5 mg, 1 mg, 2 mg 2 mg/mL 2 mg/mL 1 mg, 2 mg 7.5 mg, 15 mg, 22.5 mg, 30 mg 0.125 mg, 0.25 mg 0.5 mg, 1 mg, 2 mg various strengths tablets solution ER tablets tablets solution solution tablets 100 mg, 200 mg 10-100 mg/5 mL 10-200 mg/5 mL capsules solution syrup South Country Health Alliance is a coordinated care health plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid program. 2419, 5703_1841 CMS Approved xx/xx/2011 solution inject solution tablets capsules tablets tablets tablets 12 codeine/guaifenesin Brontex Liquid pseudoephedrine-chlorpheniramine- Phenylhistine DH codeine Opioid Analgesics morphine sulfate morphine sulfate morphine sulfate morphine sulfate morphine sulfate preservative free oxycodone Roxicodone Prescription Supplements calcitriol cyanocobalamin (Vitamin B12) cyanocobalamin (Vitamin B12) ergocalciferol folic acid potassium chloride Rocaltrol Nascobal Drisdol potassium chloride potassium and sodium acid phosphates sodium fluoride K-Phos MF, K-Phos No 2 sodium fluoride vitamin K (phytonadione) vitamin K (phytonadione) 10-300 mg/20 mL 30-2-10 mg/5 mL syrup solution 1 mg/mL, 5 mg/ mL, 10 mg/mL, 15 mg/mL, 25 mg/ mL, 50 mg/mL 1 mg/mL, 2 mg/ mL, 3 mg/mL, 4 mg/mL, 5 mg/mL, 8 mg/mL, 10 mg/ mL, 15 mg/mL, 25 mg/mL, 50 mg/mL 20 mg/10 mL 1 mg/mL 5 mg, 10 mg, 20 mg, 30 mg 20 mg/mL IV solution 1 mcg/mL 1000 mcg/mL 500 mcg/0.1 mL 50,000 units 1 mg 5%, 10%, 15%, 20% 15 mEq, 20 mEq, 25 mEq, 13.4 mE1 155 mg/350 mg, 305 mg/700 mg various strengths oral solution inject solution nasal solution capsules tablets oral solution various strengths Mephyton 5 mg 2 mg/mL, 10 mg/ mL injectable solution oral solution inject solution suppositories oral concentrate powder packets tablets topical rinse, gel, foam, cream, paste tablets, chewable tablets, oral solution tablets inject solution Miscellaneous South Country Health Alliance is a coordinated care health plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid program. 2419, 5703_1841 CMS Approved xx/xx/2011 13 aluminum chloride aminocaproic acid atropine sulfate atropine belladonna/opium benzocaine/antipyrine bisacodyl tab & PEG 3350/KCL/sodium bicarb/sodium chloride hydrocortisone Amicar Isopto Atropine Sal-Tropin Half-lytely hydrocortisone acetate hyoscyamine sulfate nitroglycerin Levsin pilocarpine hcl Isopto Carpine urea South Country Health Alliance is a coordinated care health plan with a Medicare Advantage contract and a contract with the Minnesota Medicaid program. 2419, 5703_1841 CMS Approved xx/xx/2011 20% 500 mg 1% 0.4 mg 16.2 mg/30 mg, 16.2 mg/60 mg 1.4%-5.4% solution tablets ophth solution tablets suppositories otic solution powder for oral solution 0.5% cream, ointment 1% ointment 0.125 mg, 0.25 mg tablets 2.5 mg, 6.5 mg, 9 CR capsules mg 0.5%, 1%, 2%$, ophth solution 3%, 4%, 6% 40% cream, gel 14
