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2019 Horizon NJ TotalCare (HMO SNP) Additional Medicaid Drug Coverage List

EFFECTIVE JANUARY 1, 2019

The Formulary may change at any time. You will receive notice when necessary.Horizon Healthcare of New Jersey, Inc. (“HHNJ”) contracts with both CMS and the State of New Jersey Medicaid Program to provide a HMO Medicare Advantage Dual Special Needs plan. Enrollment in Horizon NJ TotalCare (HMO SNP) depends on contract renewal. Products are provided by HHNJ and Horizon Blue Cross Blue Shield of New Jersey, both of which are independent licensees of the Blue Cross and Blue Shield Association. Communications are issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all its companies. The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey. © 2018 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105. Y0090_H8298_EC001331_C

Additional Medicaid Drug Coverage ListThe list includes certain generic and brand name over-the-counter and prescription drugs that are covered by the Medicaid portion of your plan. You must have a provider (a doctor or other prescriber) write your prescription.

The formulary for Horizon NJ TotalCare (HMO SNP) includes an additional list of covered drugs.

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

1

Drug NameOver-the-Counter/Nutritional Supplementsacetaminophen cap 500 mgacetaminophen chew tab 80 mgacetaminophen chew tab 160 mgacetaminophen disintegrating tab 80 mgacetaminophen disintegrating tab 160 mgacetaminophen liquid 160 mg/5mlacetaminophen liquid 167 mg/5mlacetaminophen soln 100 mg/mlacetaminophen soln 160 mg/5mlacetaminophen suppos 80 mgacetaminophen suppos 120 mgacetaminophen suppos 325 mgacetaminophen suppos 650 mgacetaminophen susp 80 mg/0.8mlacetaminophen susp 160 mg/5mlacetaminophen tab er 650 mgacetaminophen tab 325 mgacetaminophen tab 500 mgacetaminophen w/ dm liq 160-5 mg/5mlacetaminophen w/ dm liq 1000-30 mg/30mlacetaminophen w/ dm susp 160-5 mg/5mlacetaminophen w/ pamabrom tab 500-25 mgacetaminophen-caffeine tab 500-65 mgacetaminophen-caffeine-pyrilamine tab 500-60-15 mgacetaminophen-pamabrom-pyrilamine tab

500-25-15 mgacetylcysteine cap 600 mgalbumin (urine) test stripallantoin cream 0.2%aloe vera lotionalpha-d-galactosidase capsulealpha-d-galactosidase tabletsalum & mag hydroxide-simethicone chew tab

200-200-25 mgalum & mag hydroxide-simethicone susp

200-200-20 mg/5mlalum & mag hydroxide-simethicone susp

400-400-40 mg/5mlaluminum & magnesium hydroxides susp

200-200 mg/5mlaluminum acetate solnaluminum chloride in alcohol solution 6.25%

Drug Namealuminum hydroxide gel susp 320 mg/5mlaluminum hydroxide ointaluminum hydroxide-magnesium carbonate chew tab

160-105 mgaluminum hydroxide-magnesium carbonate susp

508-475 mg/10mlaluminum hydroxide-magnesium carbonate susp

95-358 mg/15mlaluminum hydroxide-magnesium trisilicate chew tab

80-14.2 mgaluminum sulfate & calcium acetate powd packamino acids oral powderamino acids packamino acids-protein hydrolysate liquidantiseborrheic products misc - liquidarginine hcl (bulk) powderartificial saliva - solutionartificial tear ophth ointmentartificial tear ophth solutionascorbic acid cap er 500 mgascorbic acid chew tab 250 mgascorbic acid chew tab 500 mgascorbic acid chew tab 1000 mgascorbic acid syrup 500 mg/5mlascorbic acid tab er 500 mgascorbic acid tab er 1000 mgascorbic acid tab 100 mgascorbic acid tab 250 mgascorbic acid tab 500 mgascorbic acid tab 1000 mgaspirin buffered (ca carb-mg carb-mg ox) tab 325 mgaspirin chew tab 81 mgaspirin effer tab 325 mgaspirin suppos 300 mgaspirin tab delayed release 81 mgaspirin tab delayed release 325 mgaspirin tab 81 mgaspirin tab 325 mgaspirin tab 500 mgaspirin-acetaminophen-caffeine tab 250-250-65 mgb-complex vitamin capb-complex vitamin sublingual liquid

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.2

Drug Nameb-complex vitamin tabb-complex w/ c & calcium tabb-complex w/ c & e + zn tabb-complex w/ c & folic acid cap 1 mgb-complex w/ c & folic acid liquid 0.9 mg/15mlb-complex w/ c & folic acid liquid 0.9 mg/5mlb-complex w/ c & folic acid tabb-complex w/ c & folic acid tab 0.8 mgb-complex w/ c & folic acid tab 1 mgb-complex w/ c capb-complex w/ c tabb-complex w/ c tab erb-complex w/ c-biotin-vit e & folic acid tab 0.4 mgb-complex w/ c-biotin-vit e & folic acid tab 1 mgb-complex w/ c-zn & folic acid tab 0.8 mgb-complex w/ folic acid tabb-complex w/ minerals liqb-complex w/ minerals tabb-complex w/biotin & folic acid tabb-complex w/biotin & folic acid tab erbacitracin oint 500 unit/gmbacitracin zinc oint 500 unit/gmbacitracin-polymyxin b ointbacitracin-pramoxine hcl oint 500 unit/gm-10 mg/gmbanana flakes packbenzethonium chloride liquid 0.1%benzethonium chloride liquid 0.13%benzethonium chloride soln 0.2%benzocaine dental cream 20%benzocaine dental for susp 10%benzocaine dental gel 7.5%benzocaine dental gel 10%benzocaine dental gel 20%benzocaine dental liquid 10%benzocaine dental liquid 20%benzocaine oint 20%benzocaine rectal ointment 20%benzocaine-docusate sodium rectal enema 20-283 mgbenzocaine-menthol lozenge 15-2.6 mgbenzocaine-menthol lozenge 15-3.6 mgbenzocaine-resorcinol vaginal cream 5-2%benzocaine-resorcinol vaginal cream 20-3%

Drug Namebenzocaine-triclosan aerosol 20-0.13%benzoin compound tincturebenzonatate cap 100 mgbenzonatate cap 150 mgbenzonatate cap 200 mgbenzoyl peroxide bar 10%benzoyl peroxide creamy wash 4% &benzoyl peroxide

bar 5% kitbenzoyl peroxide cream 2.5%benzoyl peroxide cream 10%benzoyl peroxide foam 5.3%benzoyl peroxide gel 2.5%benzoyl peroxide gel 7%benzoyl peroxide gel 5%benzoyl peroxide gel 10%benzoyl peroxide liq 4%benzoyl peroxide liq 5%benzoyl peroxide liq 6%benzoyl peroxide liq 10%benzoyl peroxide lotion 10%benzoyl peroxide lotion 5%bioflavonoid products chew tabbioflavonoid products tabbioflavonoid products tab erbiotin cap 2.5 mgbiotin cap 5 mgbiotin liquid 5 mg/mbiotin tab 300 mcgbiotin tab 1000 mcgbiotin tab 5 mgbiotin tab 10 mgbisacodyl enema 10 mg/30mlbisacodyl suppos 10 mgbisacodyl tab delayed release 5 mgbismuth subsalicylate chew tab 262 mgbismuth subsalicylate susp 262 mg/15mlbismuth subsalicylate susp 525 mg/15mlbismuth subsalicylate tab 262 mgbrompheniramine & phenylephrine elixir 1-2.5 mg/5mlbrompheniramine & pseudoephedrine elixir

1-15 mg/5mlcaffeine tab 200 mg

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Namecalamine lotioncalamine phenolated lotioncalamine-zinc oxide lotioncalamine-zinc oxide susp 8-8%calcium & phosphorus w/ vit d chew tab

250 mg-107 mg-500 untcalcium & phosphorus w/ vit d chew tab

250 mg-115 mg-250 untcalcium alginate wound dressingcalcium ascorbate tab 500 mgcalcium carb-vit d w/ minerals chew tab 600 mg-400

unitcalcium carb-vit d w/ minerals chew tab 600 mg-800

unitcalcium carb-vit d w/ minerals tabs 600 mg-200 unitcalcium carb-vit d w/ minerals tabs 600 mg-400 unitcalcium carb-vit d w/ minerals tabs 600 mg-800 unitcalcium carbonate (antacid) chew tab 400 mgcalcium carbonate (antacid) chew tab 420 mgcalcium carbonate (antacid) chew tab 500 mgcalcium carbonate (antacid) chew tab 750 mgcalcium carbonate (antacid) chew tab 1000 mgcalcium carbonate (antacid) susp 1250 mg/5mlcalcium carbonate (antacid) tab 648 mgcalcium carbonate cap 1250 mg (500 mg elemental

ca)calcium carbonate chew tab 1250 mg (500 mg

elemental ca)calcium carbonate chew tab 260 mg (elemental ca)calcium carbonate susp 1250 mg/5ml (500 mg/5ml

elemental ca)calcium carbonate tab 600 mgcalcium carbonate tab 1250 mg (500 mg elemental ca)calcium carbonate tab 1500 mg (600 mg elemental ca)calcium carbonate-cholecalciferol cap 600 mg-400 unitcalcium carbonate-cholecalciferol cap 600 mg-500 unitcalcium carbonate-cholecalciferol chew tab

600 mg-800 unitcalcium carbonate-cholecalciferol chew tab

500 mg-100 unitcalcium carbonate-cholecalciferol chew tab

500 mg-400 unit

Drug Namecalcium carbonate-cholecalciferol tab 1000 mg-800

unitcalcium carbonate-cholecalciferol tab 250 mg-125 unitcalcium carbonate-cholecalciferol tab 500 mg-125 unitcalcium carbonate-cholecalciferol tab 500 mg-200 unitcalcium carbonate-cholecalciferol tab 500 mg-400 unitcalcium carbonate-cholecalciferol tab 500 mg-600 unitcalcium carbonate-cholecalciferol tab 600 mg-200 unitcalcium carbonate-cholecalciferol tab 600 mg-400 unitcalcium carbonate-cholecalciferol tab 600 mg-800 unitcalcium carbonate-ergocalciferol tab 250 mg-125 unitcalcium carbonate-ergocalciferol tab 500mg-200 unitcalcium carbonate-mag hydroxide chew tab

550-110 mgcalcium carbonate-mag hydroxide susp

400-135 mg/5mlcalcium carbonate-simethicone chew tab 1000-60 mgcalcium carbonate-vitamin d cap 600 mg-200 unitcalcium carbonate-vitamin d chew tab 600 mg-400

unitcalcium carbonate-vitamin d tab 250 mg-125 unitcalcium carbonate-vitamin d tab 500 mg-125 unitcalcium carbonate-vitamin d tab 500 mg-200 unitcalcium carbonate-vitamin d tab 500 mg-400 unitcalcium carbonate-vitamin d tab 600 mg-200 unitcalcium carbonate-vitamin d tab 600 mg-400 unitcalcium citrate tab 200 mg (elemental ca)calcium citrate tab 250 mgcalcium citrate tab 950 mg (200 mg elemental ca)calcium citrate-vitamin d tab 200 mg-125 unit

(elemental ca)calcium citrate-vitamin d tab 250 mg-100 unit

(elemental ca)calcium citrate-vitamin d tab 200 mg-250 unit

(elemental ca)calcium citrate-vitamin d tab 250 mg-200 unit

(elemental ca)calcium citrate-vitamin d tab 315 mg-200 unit

(elemental ca)calcium citrate-vitamin d tab 315 mg-250 unit

(elemental ca)calcium glubionate syrup 1.8 gm/5mlcalcium gluconate tab 500 mg

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.4

Drug Namecalcium pantothenate tab 500 mgcalcium phosphate-cholecalciferol chew tab

250 mg-400 unitcalcium polycarbophil tab 625 mgcalcium w/ magnesium tab 333-167 mgcalcium w/ vitamin c & d chew tab 500 mg-10 mg-250

unitcalcium w/ vitamin d & k chew tab 500 mg-100

unit-40 mcgcalcium w/ vitamin d & k chew tab 500 mg-200

unit-40 mcgcalcium w/ vitamin d & k chew tab 500 mg-500

unit-40 mcgcalcium w/ vitamin d & k chew tab 500 mg-1000

unit-40 mcgcalcium w/ vitamin d tab 600 mg-200 unitcalcium-boron tab 500-1.5 mgcalcium-cholecalciferol tab 200 mg-250 unitcalcium-magnesium w/ vit d tab er 24hr

600 mg-40 mg-500 unitcalcium-magnesium w/ vit d tab

400 mg-166.7 mg-133.3 unitcalcium-magnesium w/ vitamin d tab

500 mg-250 mg-200 unitcalcium-magnesium-zinc tab 333-133-5 mgcalcium-magnesium-zinc tab 334-134-5 mgcamphor & menthol gel 0.2-3.5%camphor & menthol lotion 0.5-0.5%camphor gel 0.45%camphor-eucalyptus-menthol - ointcamphor-menthol-methyl salicylate cream 4-10-30%camphor-menthol-methyl salicylate gel 3.1-16-10%capsaicin cream 0.033%capsaicin cream 0.025%capsaicin cream 0.075%capsaicin cream 0.1%capsaicin pad 0.025%capsaicin-menthol gel 0.025-10%capsicum oleoresin cream 0.025%carbamide peroxide soln 10%carbamide peroxide 6.5% otic solncarbonyl iron chew tab 15 mg (elemental iron)carbonyl iron tab 25 mg (elemental iron)

Drug Namecarbonyl iron tab 45 mg (elemental iron)carboxymethylcell-glyc-polysorb 80 (pf) ophth sol

0.5-1-0.5%carboxymethylcell-glycerin-polysorb 80 ophth soln

0.5-1-0.5%carboxymethylcellulose sodium (pf) ophth gel 1%carboxymethylcellulose sodium (pf) ophth soln 0.25%carboxymethylcellulose sodium (pf) ophth soln 1%carboxymethylcellulose sodium (pf) ophth soln 0.5%carboxymethylcellulose sodium ophth gel 1%carboxymethylcellulose sodium ophth soln 0.25%carboxymethylcellulose sodium ophth soln 1%carboxymethylcellulose sodium ophth soln 0.5%carboxymethylcellulose-glycerin ophth soln 0.5-0.9%carboxymethylcellulose-hypromellose gel 0.25-0.3%cetirizine hcl chew tab 5 mgcetirizine hcl chew tab 10 mgcetirizine hcl tab 5 mgcetirizine hcl tab 10 mgcetirizine-pseudoephedrine tab er 12hr 5-120 mgcharcoal activated cap 260 mgchlorhexidine gluconate liquid 2%chlorhexidine gluconate liquid 4%chlorphen-phenylephrine w/ apap tab 2-5-325 mgchlorpheniramine & phenylephrine tab 4-10 mgchlorpheniramine maleate syrup 2 mg/5mlchlorpheniramine maleate tab er 12 mgchlorpheniramine maleate tab 4 mgchlorpheniramine-dm liquid 1-7.5 mg/5mlchlorpheniramine-dm liquid 2-15 mg/15mlchlorpheniramine-dm liquid 2-15 mg/5mlchlorpheniramine-dm syrup 1-7.5 mg/5mlchlorpheniramine-dm tab 4-30 mgchlorpheniramine-pseudoephedrine-ibuprofen tab

2-30-200 mgcholecalciferol cap 4000 unitcholecalciferol cap 400 unitcholecalciferol cap 1000 unitcholecalciferol cap 2000 unitcholecalciferol cap 5000 unitcholecalciferol cap 10000 unitcholecalciferol cap 50000 unit

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Namecholecalciferol chew tab 400 unitcholecalciferol chew tab 1000 unitcholecalciferol chewable wafer 14000 unitcholecalciferol chewable wafer 50000 unitcholecalciferol drops 5000 unit/ml (1000 unit/0.2ml)cholecalciferol oral liquid 400 unit/mlcholecalciferol tab 3000 unitcholecalciferol tab 400 unitcholecalciferol tab 1000 unitcholecalciferol tab 2000 unitcholecalciferol tab 5000 unitcholecalciferol tab 50000 unitchromium picolinate cap 200 mcgchromium tab 200 mcgclotrimazole vaginal cream 1%clotrimazole vaginal cream 2%coal tar oint 2%coal tar shampoo 2%coal tar shampoo 0.5%coal tar shampoo 2.5%coal tar-salicylic acid shamp 10-5%cobalamine combination sl tabcobalamine combination tabcocoa buttercod liver oilcod liver oil capcoenzyme q10 cap 100 mgcoenzyme q10 cap 200 mgcolloidal oatmeal cream 1%colloidal oatmeal packetcontrol gel formula - dressingcorn dextrin oral powdercranberry (vaccinium macrocarpon) cap 200 mgcranberry (vaccinium macrocarpon) cap 250 mgcranberry-vitamin c-probiotic tab 250-30 mgcromolyn sodium nasal aerosol soln 5.2 mg/act (4%)cyanocobalamin inj 1000 mcg/mlcyanocobalamin liquid 1000 mcg/mlcyanocobalamin lozenge 500 mcgcyanocobalamin orally disintegrating tab 1500 mcgcyanocobalamin sl tab 500 mcgcyanocobalamin sl tab 1000 mcg

Drug Namecyanocobalamin sl tab 2500 mcgcyanocobalamin sl tab 5000 mcgcyanocobalamin sublingual liquid 5000 mcg/mlcyanocobalamin tab er 1000 mcgcyanocobalamin tab er 2000 mcgcyanocobalamin tab 2000 mcgcyanocobalamin tab 2500 mcgcyanocobalamin tab 100 mcgcyanocobalamin tab 250 mcgcyanocobalamin tab 500 mcgcyanocobalamin tab 1000 mcgdakin's solution 0.25% (half strength)dermatological products misc - geldextran 70-hypromellose (pf) ophth soln 0.1-0.3%dextran 70-hypromellose ophth soln 0.1-0.3%dextromethorphan hbr cap 15 mgdextromethorphan hbr liquid 10 mg/5mldextromethorphan hbr liquid 15 mg/5mldextromethorphan hbr syrup 15 mg/5mldextromethorphan hbr syrup 7.5 mg/5mldextromethorphan polistirex liquid cr 30 mg/5mldextromethorphan-apap-chlorpheniramine susp

5-160-1 mg/5mldextromethorphan-doxylamine-apap cap

15-6.25-325 mgdextromethorphan-doxylamine-apap liquid

30-12.5-1000 mg/30mldextromethorphan-guaifenesin cap 10-200 mgdextromethorphan-guaifenesin granules packet

5-100 mgdextromethorphan-guaifenesin liquid 15-200 mg/5mldextromethorphan-guaifenesin liquid 5-100 mg/5mldextromethorphan-guaifenesin liquid 10-100 mg/5mldextromethorphan-guaifenesin liquid 10-200 mg/5mldextromethorphan-guaifenesin syrup 10-100 mg/5mldextromethorphan-guaifenesin tab er 12hr 30-600 mgdextromethorphan-guaifenesin tab er 12hr

60-1200 mgdextromethorphan-guaifenesin tab 20-400 mgdextromethorphan-phenylephrine-apap cap

10-5-325 mgdextromethorphan-phenylephrine-apap liqd

10-5-325 mg/15ml

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.6

Drug Namedextromethorphan-phenylephrine-apap tab

10-5-325 mgdiaper rash products - ointmentdibucaine oint 1%dibucaine rectal ointment 1%dietary management product - packetdimenhydrinate tab 50 mgdimethicone cream 1.5%dimethicone cream 1%dimethicone cream 5%dimethicone lotion 1%dimethicone lotion 1.3%dimethicone ointment 1%dimethicone-zinc oxide-vitamin a-vitamin d cream

1-10%diphenhydramine hcl (sleep) cap 25 mgdiphenhydramine hcl (sleep) cap 50 mgdiphenhydramine hcl (sleep) liquid 50 mg/30mldiphenhydramine hcl (sleep) tab 25 mgdiphenhydramine hcl (sleep) tab 50 mgdiphenhydramine hcl cap 25 mgdiphenhydramine hcl cap 50 mgdiphenhydramine hcl chew tab 12.5 mgdiphenhydramine hcl cream 2%diphenhydramine hcl gel 2%diphenhydramine hcl liquid 12.5 mg/5mldiphenhydramine hcl syrup 12.5 mg/5mldiphenhydramine hcl tab disint 12.5 mgdiphenhydramine hcl tab 25 mgdiphenhydramine-acetaminophen tab 25-500 mg

(sleep)diphenhydramine-acetaminophen tab 38-500 mg

(sleep)diphenhydramine-phenylephrine liq 6.25-2.5 mg/5mldiphenhydramine-phenylephrine syrup

6.25-2.5 mg/5mldiphenhydramine-phenylephrine tab 25-10 mgdiphenhydramine-phenylephrine-apap tab

25-5-325 mgdiphenhydramine-zinc acetate cream 1-0.1%diphenhydramine-zinc acetate cream 2-0.1%diphenhydramine-zinc acetate liquid 2-0.1%docosahexaenoic acid cap 200 mg

Drug Namedocosanol cream 10%docusate calcium cap 240 mgdocusate sodium cap 50 mgdocusate sodium cap 100 mgdocusate sodium cap 250 mgdocusate sodium enema 283 mgdocusate sodium liquid 150 mg/15mldocusate sodium syrup 60 mg/15mldocusate sodium tab 100 mgdoxylamine succinate (sleep) tab 25 mgdoxylamine-dm liquid 6.25-15 mg/15mldyclonine hcl-benzethonium cl liqd 0.75-0.2%emollient - creamemollient - lotionemollient - ointmentergocalciferol cap 50000 unitergocalciferol soln 8000 unit/mlergocalciferol tab 2000 unitergocalciferol tab 400 uniteyelid cleansers - foameyelid cleansers - padsfamotidine tab 10 mgfamotidine-ca carbonate-mag hydroxide chew tab

10-800-165 mgfe asp gly-fe polysacc-succ ac-c-threon ac capfe fum-fe polysac-c-b3 cap 62.5-62.5-40-3 mg

(125 mg fe)ferrous fum-iron polysacch cap 162-115.2 mg (106 mg

fe)ferrous fumarate tab 325 mg (106 mg elemental fe)ferrous gluconate tab 239 mg (27 mg fe equivalent)ferrous gluconate tab 256 mg (28 mg elemental fe)ferrous gluconate tab 324 mg (38 mg elemental iron)ferrous gluconate tab 240 mg (27 mg elemental fe)ferrous gluconate tab 324 mg (37.5 mg elemental iron)ferrous gluconate tab 325 mg (36 mg elemental fe)ferrous sulfate dried tab er 45 mg (fe equivalent)ferrous sulfate dried tab er 160 mg (50 mg fe

equivalent)ferrous sulfate dried tab 200 mg (65 mg elemental fe)ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental

fe)

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Nameferrous sulfate liquid 220 mg/5ml (44 mg/5ml

elemental fe)ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe)ferrous sulfate syrup 300 mg/5ml (60 mg/5ml

elemental fe)ferrous sulfate tab cr 140 mg (45 mg fe equivalent)ferrous sulfate tab ec 324 mg (65 mg fe equivalent)ferrous sulfate tab ec 325 mg (65 mg fe equivalent)ferrous sulfate tab er 142 mg (45 mg fe equivalent)ferrous sulfate tab er 143 mg (45 mg fe equivalent)ferrous sulfate tab er 47.5 mg (elemental fe)ferrous sulfate tab er 50 mg (elemental fe)ferrous sulfate tab 90 mg (18 mg elemental fe)ferrous sulfate tab 27 mg (elemental fe)ferrous sulfate tab 325 mg (65 mg elemental fe)ferrous sulfate-vit c-folic acid tab cr 105-500-0.8 mgfexofenadine hcl orally disintegrating tab 30 mgfexofenadine hcl susp 30 mg/5ml (6 mg/ml)fexofenadine hcl tab 60 mgfexofenadine hcl tab 180 mgfexofenadine-pseudoephedrine tab er 12hr 60-120 mgfexofenadine-pseudoephedrine tab er 24hr

180-240 mgfish oil-cholecalciferol cap 1000 mg-1000 unitfolic ac-vit b2-vit b6-vit b12-vit d-calc-phosphorus tabfolic acid tab 400 mcgfolic acid tab 800 mcgfolic acid tab 1 mgfolic acid-vitamin b6-vitamin b12 tab 0.5-5-0.2 mgfolic acid-vitamin b6-vitamin b12 tab 0.8-10-0.115 mgfructose-dextrose-phosphoric acid oral solngentian violet soln 1%gentian violet soln 2%glucose chew tab 1 gmglucose chew tab 4 gmglucose gel 15 gm/32mlglucose gel 40%glucose gel 77.4%glucose-cholecalciferol oral gelglucose-cholecalciferol oral liquidglucose-vitamin c chew tab 4-6 gm-mgglucose-vitamin c-vitamin d chew tab

Drug Nameglycerin enema adult 5.4 gm/average delivered doseglycerin liquidglycerin liquid suppos 2.8 gm (2.7 ml)glycerin suppos 1 gmglycerin suppos 1.2 gmglycerin suppos 2 gmglycerin suppos 2.1 gmglycerin suppos 80.7%glycerin topical liquidglycerin-hypromellose-peg 400 ophth soln 0.2-0.2-1%glycerin-hypromellose-peg 400 ophth soln

0.2-0.36-1%guaifenesin granules packet 100 mgguaifenesin liquid 100 mg/5mlguaifenesin syrup 100 mg/5mlguaifenesin tab er 12hr 600 mgguaifenesin tab er 12hr 1200 mgguaifenesin tab 200 mgguaifenesin tab 400 mgguaifenesin-codeine soln 100-10 mg/5mlguar gum oral powderguar gum packethydroactive (sterile) dressinghydroactive (sterile) gelhydrocortisone acetate cream 0.5%hydrocortisone cream 0.5%hydrocortisone gel 1%hydrocortisone lotion 1%hydrocortisone oint 0.5%hydrocortisone soln 1%hydrocortisone-aloe vera cream 0.5%hydrocortisone-aloe vera cream 1%hyoscyamine sulfate tab 0.125 mghypertonic nasal wash - packethypromellose ophth gel 0.3%hypromellose ophth soln 0.2%hypromellose ophth soln 0.5%hypromellose ophth soln 0.3%hypromellose ophth soln 0.4%ibuprofen cap 200 mgibuprofen chew tab 100 mgibuprofen susp 40 mg/ml

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.8

Drug Nameibuprofen tab 100 mgibuprofen tab 200 mgibuprofen-diphenhydramine citrate tab 200-38 mgichthammol oint 20%incontinent cleanser - liquidincontinent cleanser - lotioninfant foods concinfant foods liquidinfant foods packetinfant foods powderinositol niacinate cap 500 mgiodine tinctureiron succinyl-protein complex soln 40mg/15ml

(element fe eq)iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mgiron-vitamin c tab 100-250 mgiron-vitamin c tab 65-125 mgisopropyl alcohol otic liquid 95%isopropyl alcohol wipes 70%ketoconazole shampoo 1%ketotifen fumarate ophth soln 0.025%lactic acid (ammonium lactate) lotion 5%lactobacillus - packetlactobacillus - waferlactobacillus acidophilus-pectin caplactobacillus acidophilus-pectin tablactobacillus caplactobacillus chew tablactobacillus rhamnosus (gg) caplactobacillus rhamnosus (gg) packetlactobacillus tablactobacillus-inulin caplanolin creamlidocaine aerosol 0.5%lidocaine anorectal cream 5%lidocaine cream 4%lidocaine cream 4% & transparent dressing kitlidocaine hcl gel 0.5%light mineral oil-mineral oil ophth emulsion 0.5-0.5%loperamide hcl liq 1 mg/7.5mlloperamide hcl liq 1 mg/5ml (0.2 mg/ml)loperamide hcl tab 2 mg

Drug Nameloperamide-simethicone tab 2-125 mgloratadine & pseudoephedrine tab er 12hr 5-120 mgloratadine & pseudoephedrine tab er 24hr 10-240 mgloratadine orally disintegrating tab 5 mgloratadine rapidly-disintegrating tab 10 mgloratadine syrup 5 mg/5mlloratadine tab 10 mgmagnesium cap 300 mgmagnesium carbonate liquid 54 mg/5ml

(elemental mg)magnesium chloride tab cr 535 mg (64 mg

elemental mg)magnesium chloride-calcium tab dr 64-106 mgmagnesium citrate solnmagnesium cl-ca carbonate tab dr 71.5-119 mg

(elemental)magnesium gluconate liquid 1000 mg/5ml (54 mg/5ml

magnesium)magnesium gluconate tab 500 mgmagnesium gluconate tab 500 mg (27 mg

elemental mg)magnesium gluconate tab 27.5 mg (elemental mg)magnesium hydroxide chew tab 311 mgmagnesium hydroxide chew tab 400 mgmagnesium hydroxide susp concentrate

2400 mg/10mlmagnesium hydroxide susp 400 mg/5mlmagnesium lactate tab cr 84 mg (elemental mg) (7

meq)magnesium oxide (laxative) tab 500 mgmagnesium oxide cap 140 mg (85 mg elemental mg)magnesium oxide cap 400 mgmagnesium oxide cap 400 mg (elemental mg) (mg

supplement)magnesium oxide cap 500 mgmagnesium oxide cap 500 mg (elemental mg)magnesium oxide tab 250 mgmagnesium oxide tab 400 mgmagnesium oxide tab 420 mgmagnesium oxide tab 400 mg (240 mg elemental mg)magnesium oxide tab 400 mg (241.3 mg

elemental mg)magnesium oxide tab 250 mg (mg supplement)

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

9

Drug Namemagnesium oxide tab 500 mg (mg supplement)magnesium oxide-pyridoxine hcl tab 362-20 mgmagnesium sulfate granulesmagnesium sulfate oral granulesmagnesium tab 200 mgmagnesium tab 250 mgmaltodextrin-xanthan gum oral thickening powdermeclizine hcl chew tab 25 mgmedium chain triglycerides oral emulsionmedium chain triglycerides oral oilmelatonin cap 5 mgmelatonin cap 10 mgmelatonin liquid 1 mg/4ml (2.5 mg/10ml)melatonin liquid 5 mg/15mlmelatonin liquid 1 mg/mlmelatonin sl tab 5 mgmelatonin tab cr 3 mgmelatonin tab er 10 mgmelatonin tab 300 mcgmelatonin tab 1 mgmelatonin tab 3 mgmelatonin tab 5 mgmelatonin-pyridoxine tab er 3-10 mgmelatonin-pyridoxine tab er 5-10 mgmelatonin-pyridoxine tab 1-10 mgmelatonin-pyridoxine tab 3-10 mgmelatonin-pyridoxine tab 3-1 mgmelatonin-pyridoxine tab 3-2 mgmelatonin-pyridoxine tab 5-1 mgmenthol cream 16%menthol gel 10%menthol gel 7%menthol gel 2%menthol gel 2.5%menthol gel 16%menthol liquid 16%menthol lotion 0.1%menthol lozenge 7 mgmenthol patch 5%menthol-methyl salicylate creammenthol-methyl salicylate ointmentmenthol-zinc oxide oint 0.44-20.6%

Drug Namementhol-zinc oxide oint 0.44-20.625%menthol-zinc oxide powdermethenamine-sodium salicylate tab 162-162.5 mgmethylcellulose powder laxativemethylcellulose tab 500 mgmethylcobalamin sl tab 1000 mcgmiconazole nit va app 100 mg (2%) & 2% cream &

wipes kitmiconazole nitrate aerosol pow 2%miconazole nitrate aerosol 2%miconazole nitrate cream 2%miconazole nitrate kit 2%miconazole nitrate ointment 2%miconazole nitrate powder 2%miconazole nitrate soln 2%miconazole nitrate va supp 1200 mg & 2% cream &

wipes kitmiconazole nitrate vaginal cream 2%miconazole nitrate vaginal cream 4% (200 mg/5gm)miconazole nitrate vaginal suppos 100 mgmiconazole nitrate vaginal supp 200 mg & 2% cream

9 gm kitmiconazole nitrate vaginal supp 1200 mg & 2% cream

kitmineral oilmineral oil emul 50%mineral oil enemamineral oil light (topical)mineral oil-hydrophilic petrolatum ointmentmisc natural product nasal solnmultiple minerals w/ vitamins chew tabmultiple minerals w/ vitamins tabmultiple vitamin capmultiple vitamin tabmultiple vitamins w/ calcium tabmultiple vitamins w/ iron tabmultiple vitamins w/ minerals & fa tab 1.25 mgmultiple vitamins w/ minerals capmultiple vitamins w/ minerals chew tabmultiple vitamins w/ minerals effer tabmultiple vitamins w/ minerals liquidmultiple vitamins w/ minerals lozenge

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.10

Drug Namemultiple vitamins w/ minerals powdermultiple vitamins w/ minerals tabnaphazoline w/ pheniramine ophth soln 0.025-0.3%naphazoline w/ pheniramine ophth soln 0.027-0.315%naphazoline-glycerin ophth soln 0.012-0.2%naphazoline-glycerin ophth soln 0.012-0.25%naphazoline-glycerin-zinc sulf ophth soln

0.012-0.25-0.25%naphazoline-polyethylene glycol 300 ophth soln

0.012-0.2%naproxen sodium cap 220 mgnaproxen sodium tab 220 mgneomycin-bacitracin-polymyxin ointneomycin-bacitracin-polymyxin-pramoxine oint 1%neomycin-polymyxin w/ pramoxine cream 1%niacin cap er 250 mgniacin cap er 500 mgniacin tab cr 1000 mgniacin tab er 250 mgniacin tab er 500 mgniacin tab er 750 mgniacin tab 50 mgniacin tab 100 mgniacin tab 250 mgniacin tab 500 mgniacin w/ inositol cap 400-100 mgniacinamide tab 100 mgniacinamide tab 500 mgnicotine polacrilex gum 2 mgnicotine polacrilex gum 4 mgnicotine polacrilex lozenge 2 mgnicotine polacrilex lozenge 4 mgnicotine td patch 24 hr kit 21-14-7 mg/24hrnicotine td patch 24hr 7 mg/24hrnicotine td patch 24hr 14 mg/24hrnicotine td patch 24hr 21 mg/24hrnonoxynol-9 film 28%nonoxynol-9 gel 3%nonoxynol-9 gel 4%nutritional supplement barnutritional supplement capsnutritional supplement chew tab

Drug Namenutritional supplement flavor packnutritional supplement kitnutritional supplement liquidnutritional supplement liquid (frozen)nutritional supplement miscnutritional supplement packnutritional supplement powdernutritional supplement puddingnutritional supplement suspnutritional supplement tabsnutritional supplement tabs delayed releasenutritional supplement therapy packomega fatty acids-vitamins - chew tabomega 3-omega 6-omega 9 fatty acids capomega-3 fatty acids - oral emulsionomega-3 fatty acids cap delayed release 1400 mgomega-3 fatty acids cap 1400 mgomega-3 fatty acids cap 183.33 mgomega-3 fatty acids chew tab 113.5 mgomega-3 fatty acids cap 500 mgomega-3 fatty acids cap 300 mgomega-3 fatty acids cap 1000 mgomega-3 fatty acids cap 1200 mgomega-3 fatty acids cap delayed release 1000 mgomega-3 fatty acids cap delayed release 1200 mgomeprazole magnesium cap dr 20.6 mg (20 mg base

equiv)omeprazole magnesium delayed release tab 20 mgophthalmic irrigation solutionoral electrolyte - packetoral electrolyte solutionoral electrolyte taboxymetazoline hcl nasal soln 0.05%oxyquinolone sulfate-ph 4 vaginal gel 0.025%oyster shell calcium tab 500 mgpanthenol-glycerin-dimethicone creampe-dm-apap cap & doxylamine-dm-apap cap day/night

ther packpediatric multiple vitamin chew tabpediatric multiple vitamin liqpediatric multiple vitamin w/ c & fa chew tabpediatric multiple vitamin w/ c soln 35 mg/ml

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

11

Drug Namepediatric multiple vitamin w/ extra c & fa chew tabpediatric multiple vitamin w/ minerals & c chew tabpediatric multiple vitamin w/ minerals & c chew tab

60 mgpediatric multiple vitamin w/ minerals & c drops 45 mg/

mlpediatric multiple vitamin w/ minerals oral powderpediatric multiple vitamins w/ iron chew tabpediatric multiple vitamins w/ iron chew tab 12 mgpediatric multiple vitamins w/ iron chew tab 15 mgpediatric multiple vitamins w/ iron drops 10 mg/mlpediatric vitamins acd w/ iron susp 10 mg/2mlpediatric vitamins adc drops 1500 unit-400 unit-35 mg/

mlpediatric vitamins adc drops 750 unit-400 unit-35 mg/

mlpermethrin aerosol 0.5%permethrin creme rinse 1%permethrin lotion 1%permethrin spray & pyrethins-piperonyl butoxide

shamp kitpetrolatum ointmentpetrolatum-zinc oxide oint 49-15%phenazopyridine hcl tab 99.5 mgphenazopyridine hcl tab 95 mgphenazopyridine hcl tab 100 mgphenazopyridine hcl tab 200 mgphenazopyridine hcl tab 97.5 mgphenol liquid 0.5%phenol liquid 1.4%phenyleph-chlorphen-dm w/apap susp

2.5-1-5-160 mg/5mlphenyleph-shark liver oil-cocoa butter suppos

0.25-3-85.5%phenylephrine hcl nasal soln 0.125%phenylephrine hcl nasal soln 0.25%phenylephrine hcl nasal soln 0.5%phenylephrine hcl nasal soln 1%phenylephrine hcl soln 2.5 mg/5mlphenylephrine hcl tab 10 mgphenylephrine in hard fat rectal suppos 0.25%phenylephrine w/ acetaminophen tab 5-325 mgphenylephrine w/ dm-gg liqd 2.5-5-50 mg/5ml

Drug Namephenylephrine w/ dm-gg liqd 5-10-100 mg/5mlphenylephrine w/ dm-gg liqd 2.5-5-100 mg/5mlphenylephrine w/ dm-gg liqd 5-10-200 mg/5mlphenylephrine w/ dm-gg syrup 5-10-100 mg/5mlphenylephrine-apap-gg tab 5-325-200 mgphenylephrine-brompheniramine-dm elixir

2.5-1-5 mg/5mlphenylephrine-brompheniramine-dm liquid

2.5-1-5 mg/5mlphenylephrine-brompheniramine-dm syrup

5-2-10 mg/5mlphenylephrine-chlorphen-dm liquid 10-4-15 mg/5mlphenylephrine-chlorphen-dm liquid 3.5-1-3 mg/mlphenylephrine-cocoa butter suppos 0.25-88.44%phenylephrine-dm soln 2.5-5 mg/5mlphenylephrine-dm syrup 2.5-5 mg/5mlphenylephrine-dm-gg w/ apap liq

5-10-200-325 mg/10mlphenylephrine-dm-gg w/ apap tab 5-10-100-325 mgphenylephrine-dm-gg w/ apap tab 5-10-200-325 mgphenylephrine-doxylamine-dm-apap liq

5-6.25-10-325 mg/15mlphenylephrine-guaifenesin liqd 2.5-100 mg/5mlphenylephrine-guaifenesin liqd 5-100 mg/5mlphenylephrine-guaifenesin tab 10-400 mgphenylephrine-shark liver oil-glyc-pet cream

0.25-3-12-18%phenylephrine-shark liver oil-mo-pet oint

0.25-3-14-71.9%phenylephrine-witch hazel rectal gel 0.25-50%phenyltoloxamine-acetaminophen tab 30-500 mgphytonadione tab 100 mcgplant sterols and stanols tab 450 mgpodiatric products - creampolyethylene glycol-propylene glycol ophth gel

0.4-0.3%polyethylene glycol-propylene glycol ophth soln

0.4-0.3%polysacch fe complex-cholecalciferol liq 125-100 mg-

unit/5mlpolysaccharide fe complex-fe heme polypeptide tab

28 mgpolysaccharide iron complex cap 150 mg (iron

equivalent)

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.12

Drug Namepolysaccharide iron complex liquid 15 mg/ml (fe equiv)polyvinyl alcohol ophth soln 1.4%polyvinyl alcohol-povidone (pf) ophth soln 1.4-0.6%polyvinyl alcohol-povidone ophth soln 1.4-0.6%polyvinyl alcohol-povidone ophth soln 2.7-2%polyvinyl alcohol-povidone ophth soln 5-6 mg/ml

(0.5-0.6%)potassium & sodium phosphates powder pack

280-160-250 mgpotassium gluconate tab 595 mg (99 mg equiv k)potassium tab 99 mgpovidone-iodine oint 10%povidone-iodine soln 7.5%povidone-iodine soln 10%povidone-iodine swabs 10%powderspramox-pe-glycerin-petrolatum rectal cream

1-0.25-14.4-15%pramoxine hcl lotion 1%pramoxine hcl rectal foam 1%pramoxine hcl wipes 1%pramoxine-calamine lotion 1-8%pramoxine-menthol cream 1-1%pramoxine-zinc acetate lotion 1-0.1%prenat w/ fe fum-fa tab 28-0.8 mg & omega 3 cap

223 mg pakprenat w/ fe fum-fa tab 28-0.8 mg & omega 3 cap

440 mg pakprenatal multivitamins & minerals w/iron & fa tab

0.8 mgprenatal vit w/ fe carbonyl-fa-omega 3 cap

28-0.8-235 mgprenatal vit w/ fe fumarate-fa tab 14-0.4 mgprenatal vit w/ fe fumarate-fa tab 27-0.8 mgprenatal vit w/ fe fumarate-fa tab 28-0.8 mgprenatal w/fe fum-fa tab 28-0.8 mg & dha cap 200 mg

packprobiotic product - chew tabprobiotic product - tabpromethazine w/ codeine syrup 6.25-10 mg/5mlpromethazine-dm syrup 6.25-15 mg/5mlpropylene glycol ophth soln 0.6%propylene glycol-glycerin ophth soln 0.6-0.6%

Drug Namepropylene glycol-glycerin ophth soln 1-0.3%protein oral packprotein oral powderprotein powder 80%pseudoeph-doxylamine-dm w/apap liq

60-12.5-30-1000 mg/30mlpseudoephed-bromphen-dm elixir 15-1-5 mg/5mlpseudoephed-bromphen-dm syrup 30-2-10 mg/5mlpseudoephed-chlorphen-dm liq 15-1-5 mg/5mlpseudoephedrine hcl liq 15 mg/5mlpseudoephedrine hcl syrup 30 mg/5mlpseudoephedrine hcl tab er 12hr 120 mgpseudoephedrine hcl tab 30 mgpseudoephedrine hcl tab 60 mgpseudoephedrine w/ cod-gg soln 30-10-100 mg/5mlpseudoephedrine w/ dm-gg liquid 15-5-50 mg/5mlpseudoephedrine w/ dm-gg liquid 30-15-200 mg/5mlpseudoephedrine-guaifenesin tab er 12hr 60-600 mgpseudoephedrine-guaifenesin tab er 12hr

120-1200 mgpseudoephedrine-guaifenesin tab 60-400 mgpseudoephedrine-ibuprofen cap 30-200 mgpseudoephedrine-ibuprofen tab 30-200 mgpsyllium cap 0.52 gmpsyllium powder packet 100%psyllium powder packet 28.3%psyllium powder packet 58.12%psyllium powder packet 58.6%psyllium powder packet 95%psyllium powder 63%psyllium powder 28.3%psyllium powder 30.9%psyllium powder 48.57%psyllium powder 58.6%psyllium powder 95%psyllium waferpyrantel pamoate susp 144 mg/ml (50 mg/ml base

equiv)pyreth-piperonyl butox sham-permeth aero-nit

remover gel kitpyrethrins-piperonyl butoxide liq 0.33-4%pyrethrins-piperonyl butoxide shampoo kit 0.33-4%

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

13

Drug Namepyrethrins-piperonyl butoxide shampoo 0.33-4%pyridoxine hcl tab 25 mgpyridoxine hcl tab 50 mgpyridoxine hcl tab 100 mgpyridoxine hcl tab 250 mgpyrithione zinc shampoo 1%ranitidine hcl tab 75 mgrectal protectant-emollient suppositoriesriboflavin tab 25 mgriboflavin tab 50 mgriboflavin tab 100 mgsaccharomyces boulardii cap 250 mgsaccharomyces boulardii packet 250 mgsalicylic acid & sulfur shampoo 2-2%salicylic acid gel 17%salicylic acid kit 17%salicylic acid liquid 17.6%salicylic acid liquid 2%salicylic acid liquid 3%salicylic acid liquid 17%salicylic acid pad 40%salicylic acid shampoo 2%salicylic acid shampoo 3%salicylic acid soln 12.6%salicylic acid soln 17%salicylic acid strip 40%saline nasal aerosol soln 0.9%saline nasal gelsaline nasal gel 0.2%saline nasal soln 0.65%saline nasal soln 2.65%saline nasal spray 0.65%scar treatment products - creamselenium sulfide lotion 1%selenium tab cr 200 mcgselenium tab 50 mcgselenium tab 200 mcgsenna syrup 176 mg/5mlsennosides cap 8.6 mgsennosides chew tab 15 mgsennosides syrup 8.8 mg/5mlsennosides tab 8.6 mg

Drug Namesennosides tab 15 mgsennosides tab 17.2 mgsennosides tab 25 mgsennosides-docusate sodium tab 8.6-50 mgsilver-carboxymethylcellulose sodium dressing 2"x2"silver-carboxymethylcellulose sodium dressing 6"x6"simethicone cap 125 mgsimethicone cap 180 mgsimethicone chew tab 80 mgsimethicone chew tab 125 mgsimethicone liquid 40 mg/0.6mlsimethicone oral strip 62.5 mgsimethicone susp 40 mg/0.6mlskin protectants miscskin protectants misc - creamskin protectants misc - liquidskin protectants misc - lotionskin protectants misc - ointmentskin protectants misc - pastesoap & cleansers - liquidsoap & cleansers - lotionsod chloride soln & sod chloride-sod bicarbonate pack

kitsodium bicarbonate tab 325 mgsodium bicarbonate tab 650 mgsodium chloride aero soln 0.9%sodium chloride external soln 0.9%sodium chloride hypertonic ophth oint 5%sodium chloride hypertonic ophth soln 2%sodium chloride hypertonic ophth soln 5%sodium chloride tab 1 gmsodium chloride-sodium bicarbonate packet kit

2300-700 mgsodium chloride-sodium bicarbonate packet 1.57 gmsodium chloride-sodium bicarbonate packet

1685-515 mgsodium chloride-sodium bicarbonate packet

2300-700 mgsodium fluoride cream 1.1%sodium fluoride rinse 0.044%sodium fluoride w/ calcium carb cap 8.3-364 mgsodium fluoride w/ calcium carb tab 8.3-364 mg

2019

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.14

Drug Namesodium phosphates - enemaspeciality vitamin product tabstannous fluoride gel 0.4%starch oral thickening liquidstarch oral thickening powderstarch oral thickening powder packetstarch-maltodextrin oral thickening powdertalc topical powderterbinafine gel 1%terbinafine hcl cream 1%tetrahydroz-glycerin-hypromellose-peg 400 ophth soln

0.05%tetrahydrozoline hcl ophth soln 0.05%tetrahydrozoline w/ zinc sulfate ophth soln 0.05-0.25%thiamine hcl tab 50 mgthiamine hcl tab 100 mgthiamine mononitrate tab 100 mgthroat lozenges - lozengestioconazole vaginal oint 6.5%tolnaftate aerosol pow 1%tolnaftate aerosol 1%tolnaftate cream 1%tolnaftate powder 1%tolnaftate soln 1%triclosan liq 0.15%triprolidine & pseudoephedrine tab 2.5-60 mgtrolamine salicylate cream 10%trolamine salicylate lotion 10%undecylenic acid liqd 25%undecylenic acid soln 25%urea cream 10%urea cream 20%urea lotion 10%vaginal cleanser - liquidvaginal lubricant - gelvitamin a cap 8000 unitvitamin a cap 10000 unitvitamin a tab 10000 unitvitamin a tab 15000 unitvitamin e cap 100 unitvitamin e cap 200 unitvitamin e cap 400 unit

Drug Namevitamin e cap 1000 unitvitamin e creamvitamin e cream 100 unit/gmvitamin e oilvitamin e oral oil 100 unit/0.25mlvitamin e soln 15 unit/0.3ml (50 unit/ml)vitamin e w/ a & d creamvitamins a & d ointvitamins w/ lipotropics capvitamins w/ lipotropics tabvitamins w/ lipotropics tab erwheat dextrin oral powderwheat dextrin packetwhite petrolatum gelwhite petrolatum ointmentwhite petrolatum topical gelwhite petrolatum-mineral oil ophth ointmentwitch hazel (hamamelis virginiana) cleansing padswitch hazel-glycerin cleansing padswound cleansers - liquidwound dressings - gelwound dressings - padsxanthan gum oral thickening gelzinc cap 30 mgzinc gluconate lozenge 10 mg (elemental zn)zinc gluconate tab 30 mgzinc gluconate tab 50 mg (elemental zn)zinc oxide cream 11.3%zinc oxide cream 13%zinc oxide oint 12.8%zinc oxide oint 16%zinc oxide oint 20%zinc oxide oint 40%zinc oxide oint 10%zinc oxide paste 25%zinc oxide paste 40%zinc oxide topical powderzinc sulfate cap 220 mg (50 mg elemental zn)zinc sulfate tab 220 mg (50 mg zinc equivalent)zinc tab 50 mg

Products and policies provided by Horizon Healthcare of New Jersey, Inc. d/b/a Horizon NJ Health and services provided by Horizon Blue Cross Blue Shield of New Jersey, each an independent licensee of the Blue Cross and Blue Shield Association. Communications may be issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all of its companies.

Notice of Nondiscrimination

Horizon NJ TotalCare (HMO SNP)

1700 American Blvd. Pennington, NJ 08534

Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal civil rights laws and does not discriminate against nor does it exclude people or treat them differently on the basis of race, color, gender, national origin, age, disability, pregnancy, gender identity, sex, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations.

Horizon BCBSNJ provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and information written in other languages.

Contacting Member Services Please call Member Services at 1-800-543-5656 (TTY 711) or the phone number on the back of your member ID card, if you need the free aids and services noted above and for all other Member Services issues, including:

• Claim, benefits or enrollment inquiries• Lost/stolen ID cards• Address changes• Any other inquiry related to your benefits or health plan

Filing a Section 1557 Grievance If you believe that Horizon BCBSNJ has failed to provide the free communication aids and services or discriminated on the basis of race, color, gender, national origin, age, or disability, you can file a discrimination complaint also known as a Section 1557 Grievance. Horizon BCBSNJ’s Civil Rights Coordinator can be reached by calling the Member Services number on the back of your member ID card or by writing to the following address:

Horizon BCBSNJ – Civil Rights Coordinator PO Box 820 Newark, NJ 07101

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

Office for Civil Rights Headquarters U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019 or 1-800-537-7697 (TDD)

OCR Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.

Para ayuda en español, llame a 1-800-543-5656 (TTY 711).

CMC0008179F (0717)

07008139

http://www.hhs.gov/ocr/office/file/index.html

   

Multi-Language Insert Multi‐language Interpreter Services

ATTENTION: If you speak Spanish, language assistance services, free of charge, are available

to you. Call 1-800-543-5656 (TTY 711).

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

Llame al 1-800-543-5656 (TTY 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-543-5656

（TTY 711）.

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

1-800-543-5656 (TTY 711) 번으로 전화해 주십시오.

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue

para 1-800-543-5656 (TTY 711).

ચુના: જો તમે જુરાતી બોલતા હો, તો િન: ુ ક ભાષા સહાય સેવાઓ તમારા માટ ઉપલ ધ છે. ફોન

કરો 1-800-543-5656 (TTY 711).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.

Zadzwoń pod numer 1-800-543-5656 (TTY 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza

linguistica gratuiti. Chiamare il numero 1-800-543-5656 (TTY 711).

(رقم 5656-543-800- 1قم ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل بر

).711ھاتف الصم والبكم

Y0090_MultiLangPost2017 Accepted

 

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong

sa wika nang walang bayad. Tumawag sa 1-800-543-5656 (TTY 711).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги

перевода. Звоните 1-800-543-5656 (телетайп 711).

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele

1-800-543-5656 (TTY 711).

यान द: यिद आप िहदंी बोलते ह तो आपके िलए मु त म भाषा सहायता सेवाएं उपल ध ह। 1-800-543-

5656 (TTY 711) पर कॉल कर।

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số

1-800-543-5656 (TTY 711).

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés

gratuitement. Appelez le 1-800-543-5656 (ATS 711).

خبردار: اگر آپ اردو بولتے ہيں، تو آپ کو زبان کی مدد کی خدمات مفت ميں دستياب ہيں ۔ کال کريں

1-800-543-5656 (TTY 711).

FORM#_51017_0000620_000_2019MDSUPPHZET_NO INDEX.PDFChaptersOver-the-Counter/Nutritional Supplements

DSNP_Nondiscrimination_Multilanguage Notice_English.pdfNJ_SNP_Nondiscrimination Notice_English_121118Notice of NondiscriminationOffice for Civil Rights Headquarters

NJ DSNP Multilanguage Tagline Flier_121118

DSNP_Nondiscrimination_Multilanguage Notice_English.pdfNJ_SNP_Nondiscrimination Notice_English_121118Notice of NondiscriminationOffice for Civil Rights Headquarters

NJ DSNP Multilanguage Tagline Flier_121118