Drug Benefit List
40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE
40:08.00 ALKALINIZING AGENTS
CITRIC ACID, SODIUM CITRATE
- 66.8MG & 100MG/ML Solution
- 00721344 DICITRATE PMS
SODIUM BICARBONATE
- 300MG Tablet
- 00481912 SODIUM
BICARBONATE XEN
40:12.00 REPLACEMENT PREPARATIONS
CALCIUM CARBONATE
- 500MG Tablet
- 00682039 APO-CAL 500 APX
- 00674346 CAL-500 PDL
- 00621722 CALCIUM HAL
- 02240240 CALCIUM PMT
- 00688983 CALCIUM 500 TRI
- 02243626 CALCIUM 500 NUR
- 00645923 NOVO-CALCIUM NOP
- 00618098 NU-CAL ODN
- 00622443 O-CALCIUM 500 VTH
- 02042991 OS-CAL WAY
CALCIUM CARBONATE, CHOLECALCIFEROL
- 500MG & 125IU Tablet
- 00752673 CAL-500-D PRO
- 00688770 CALCITE D-500 RIV
- 00702986 CALCIUM 500MG
WITH VIT D HAL
- 00718580 CALCIUM 500MG
WITH VIT D SDR
- 00730599 CALCIUM CARBONATE
WITH VIT D PMT
- 00688975 CALCIUM D-500 TRI
- 00775681 EQUATE
CALCIUM 500MG WITH VIT D EUR
- 02237351 EURO-CAL D EUR
- 00720798 NEO
CAL-D-500 NEO
- 02043025 OS-CAL
D 500MG WAY
ELECTROLYTE & DEXTROSE
- 3.56G & 300MG & 470MG & 530MG Powder
- 01931563 GASTROLYTE REG SAC
- 25MG & 2.2MG & 2.2MG & 0.9MG/ML Solution
- 00630365 PEDIALYTE ABB
- 02219883 PEDIATRIC ELECTROLYTE PMS
POTASSIUM CHLORIDE
- 25MEQ Effervescent Tablet
- 02085992 K LYTE WPC
- 8MMOL Long Acting Capsule
- 02242291 EURO-K8 NVR
- 02042304 MICRO-K EXTENCAPS WAY
- 02244068 RIVA-K RIV
- 10MMOL Long Acting Capsule
- 02042312 MICRO-K-10 WAY
- 8MMOL Long Acting Tablet
- 00602884 APO-K APX
- 02246734 EURO-K
600 EUR
- 00613274 PRO-600K PDL
- 00074225 SLOW
K NVR
- 20MMOL Long Acting Tablet
- 02242261 EURO-K
20 EUR
- 00713376 K-DUR KEY
- 02243975 RIVA-K
20 RIV
- 1.33MEQ/ML Oral Liquid
- 01918303 K 10 GSK
- 02238604 PMS-POTASSIUM PMS
- 20MEQ Powder
- 00481211 K-LOR ABB
- 25MEQ Powder
- 02089580 K LYTE WPC
POTASSIUM GLUCONATE
- 1.33MEQ/ML Oral Liquid
- 02063840 KAON PMJ
SODIUM CHLORIDE
- 0.9% Inhalation Diluent
- 02094657 BACTERIOSTATIC
NACL BIO
- 00801267 SODIUM
CHLORIDE UNK *
- 02058235 SODIUM
CHLORIDE BDH
- 0.9% Injection
- 00060208 SODIUM
CHLORIDE BAT
- 00402249 SODIUM
CHLORIDE ABB
- 02150204 SODIUM
CHLORIDE OMG
- 99002329 SODIUM
CHLORIDE AUT *
40:17.00 CALCIUM-REMOVING RESINS
CALCIUM POLYSTYRENE SULFONATE
- 1G binds with approx 1.6mmol K Powder
- 02017741 RESONIUM CALCIUM SAC
40:18.00 ION-REMOVING AGENTS
SODIUM POLYSTYRENE SULFONATE
- 1G binds with approx 1mmol K Powder
- 02026961 KAYEXALATE SAC
- 00765252 K-EXIT OMG
- 00755338 PMS-SOD POLYSTYRENE
SULFONA PMS
- 250MG/ML Oral Suspension
- 00769541 PMS-SOD POLYSTYRENE
SULF PMS
- 250MG/ML Retention Enema
- 00769533 PMS-SOD POLYSTYRENE
SULF PMS
40:20.00 CALORIC AGENTS
LEVOCARNITINE
Limited use benefit (prior approval required).
For treatment of carnitine deficiency.
- 100MG/ML Oral Liquid
- 02144336 CARNITOR SIG
- 200MG/ML Solution
- 02144344 CARNITOR IV SIG
- 330MG Tablet
- 02144328 CARNITOR SIG
40:28.00 DIURETICS
AMILORIDE HCL, HYDROCHLOROTHIAZIDE
- 5MG & 50MG Tablet
- 00870943 AMI-HYDRO PDL
- 00784400 APO-AMILZIDE APX
- 02257378 GEN-AMILAZIDE GEN
- 00487813 MODURET OBP
- 01937219 NOVAMILOR NOP
- 00886106 NU-AMILZIDE NXP
- 02231254 PENTA-AMILOR
HCTZ PEN
INDAPAMIDE
- 1.25MG Tablet
- 02245246 APO-INDAPAMIDE APX
- 02239913 DOM-INDAPAMIDE DPC
- 02240067 GEN-INDAPAMIDE GEN
- 02227339 INDAPAMIDE PRO
- 02179709 LOZIDE SEV
- 02240349 PHL-INDAPAMIDE PHH
- 02239619 PMS-INDAPAMIDE PMS
- 02247245 RIVA-INDAPAMIDE RIV
40:28.08 LOOP DIURETICS
ETHACRYNIC ACID
- 25MG Tablet
- 02258528 EDECRIN FRS
FUROSEMIDE
- 10MG/ML Solution
- 02224720 LASIX SAC
- 20MG Tablet
- 00396788 APO-FUROSEMIDE APX
- 02247371 BIO-FUROSEMIDE BMI
- 02248124 DOM-FUROSEMIDE BMI
- 00496723 FUROSEMIDE PDL
- 02224690 LASIX SAC
- 00337730 NOVO-SEMIDE NOP
- 02239224 NU-FUROSEMIDE NXP
- 02247493 PMS-FUROSEMIDE PMS
- 40MG Tablet
- 00362166 APO-FUROSEMIDE APX
- 02247372 BIO-FUROSEMIDE BMI
- 02248125 DOM-FUROSEMIDE BMI
- 00397792 FUROSEMIDE PDL
- 02224704 LASIX SAC
- 00337749 NOVO-SEMIDE NOP
- 02239225 NU-FUROSEMIDE NXP
- 02247494 PMS-FUROSEMIDE PMS
- 80MG Tablet
- 00707570 APO-FUROSEMIDE APX
- 00667080 FUROSEMIDE PDL
- 00765953 NOVO-SEMIDE NOP
- 500MG Tablet
- 02224755 LASIX SAC
40:28.16 POTASSIUM SPARING DIURETICS
AMILORIDE HCL
- 5MG Tablet
- 02249510 APO-AMILORIDE APX
- 00487805 MIDAMOR OBP
AMILORIDE HCL, HYDROCHLOROTHIAZIDE
TRIAMTERENE, HYDROCHLOROTHIAZIDE
- 50MG & 25MG Tablet
- 00441775 APO-TRIAZIDE APX
- 00532657 NOVO-TRIAMZIDE NOP
- 00865532 NU-TRIAZIDE NXP
- 02238638 PENTA-TRIAMTERENCE
HCTZ PEN
- 00519367 PRO-TRIAZIDE PRO
- 02240846 RIVA-ZIDE RIV
40:28.20 TIAZIDE DIURETICS
HYDROCHLOROTHIAZIDE
- 25MG Tablet
- 00326844 APO-HYDROCLOROTHIAZIDE APX
- 02247170 BIO-HYDROCHLOROTHIAZIDE BMI
- 02248134 DOM-HYDROCHLOROTHIAZIDE DPC
- 00341975 HYDROCHLOROTHIAZIDE PDL
- 00021474 NOVO-HYDRAZIDE NOP
- 02250659 NU-HYDRO NXP
- 02247386 PMS-HYDROCHLOROTHIAZIDE PMS
- 50MG Tablet
- 00312800 APO-HYDRO APX
- 02247171 BIO-HYDROCHLOROTHIAZIDE BMI
- 02248135 DOM-HYDROCHLOROTHIAZIDE DPC
- 00156604 HYDROCHLOROTHIAZIDE PRO
- 00021482 NOVO-HYDRAZIDE NOP
- 02250667 NU-HYDRO NXP
- 02247387 PMS-HYDROCHLOROTHIAZIDE PMS
- 100MG Tablet
- 00644552 APO-HYDRO APX
- 00532088 HYDROCHLOROTHIAZIDE PDL
SPIRONOLACTONE, HYDROCHLOROTHIAZIDE
- 25MG & 25MG Tablet
- 00180408 ALDACTAZIDE-25 PFI
- 00613231 NOVO-SPIROZINE-25 NOP
- 50MG & 50MG Tablet
- 00594377 ALDACTAZIDE-50 PFI
- 00657182 NOVO-SPIROZINE-50 NOP
40:28.24 THIAZIDE LIKE DIURETICS
CHLORTHALIDONE
- 50MG Tablet
- 00360279 APO-CHLORTHALIDONE APX
- 100MG Tablet
- 00360287 APO-CHLORTHALIDONE APX
INDAPAMIDE
- 2.5MG Tablet
- 02223678 APO-INDAPAMIDE APX
- 02239917 DOM-INDAPAMIDE DPC
- 02153483 GEN-INDAPAMIDE GEN
- 02049341 INDAPAMIDE PRO
- 00564966 LOZIDE SEV
- 02231184 NOVO-INDAPAMIDE NOP
- 02223597 NU-INDAPAMIDE NXP
- 02229762 PDL-INDAPAMIDE PDL
- 02239620 PMS-INDAPAMIDE PMS
- 02242125 RIVA-INDAPAMIDE RIV
METOLAZONE
- 2.5MG Tablet
- 00888400 ZAROXOLYN AVT
40:40.00 URICOSURIC AGENTS
PROBENECID
- 500MG Tablet
- 00294926 BENURYL VAE
SULFINPYRAZONE
- 100MG Tablet
- 00441759 APO-SULFINPYRAZONE APX
- 02045680 NU-SULFINPYRAZONE NXP
- 200MG Tablet
- 00441767 APO-SULFINPYRAZONE APX
- 02045699 NU-SULFINPYRAZONE NXP
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