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Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description PAIN RELIEVERS-FEVER REDUCERS acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen 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 PW_2013_026/DHS_Approved_11/15/2012 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 650 mg 80 mg 160 mg 500 mg-25 mg 81 mg 81 mg 325 mg 500 mg 325 mg 500 mg 325 mg 500 mg 325 mg 500 mg 81 mg tablets tablets capsules ER tablets chewable tablets chewable tablets elixir liquid suspension solution suspension solution (drops) suppositories suppositories suppositories dispersable tablets dispersable tablets tablets chewable tablets tablets tablets tablets tablets tablets tablets tablets DR tablets DR tablets DR tablets Tylenol Arthritis Tylenol Tylenol Tylenol Children's Meltaways Tylenol Jr. Meltaways Tylenol P.M. Bayer Children's Bayer Bufferin Bufferin Extra Strength Ascriptin Ascriptin Maximum Strength Ecotrin Ecotrin Maximum Strength Bayer Low Dose Page 1 of 13 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description aspirin aspirin aspirin/acetaminophen/caffeine ibuprofen ibuprofen ibuprofen ibuprofen ibuprofen naproxen sodium FUNGAL INFECTIONS - vaginal clotrimazole clotrimazole clotrimazole clotrimazole miconazole miconazole miconazole miconazole suppository & cream kit BIRTH CONTROL condoms nonoxynol-9 nonoxynol-9 nonoxynol-9 nonoxynol-9 nonoxynol-9 nonoxynol-9 EAR, NOSE, THROAT benzocaine carbamide peroxide cromolyn sodium - nasal PW_2013_026/DHS_Approved_11/15/2012 Brand Examples Strengths 300 mg, 600 mg 162 mg 250-250-65 mg 100 mg/5 mL 40 mg/mL Dosage Forms suppositories DR tablets tablets suspension suspension 100 mg 100 mg 200 mg 220 mg chewable tablets tablets tablets tablets Gyne-Lotrimin, Mycelex 7 Gyne-Lotrimin 3 Gyne-Lotrimin 1% 2% 100 mg Mycelex-7 Combo Pack Monistat 7 Monistat 3 Monistat 7 Monistat 100 mg/1% 2% 4% 100 mg various vaginal cream vaginal cream vaginal tablets vaginal tablets/ vaginal cream vaginal cream vaginal cream vaginal tablets vaginal tablets & cream kit Conceptrol VCF Vaginal Contraceptive Foam Encare Gynol II Gynol II Extra Strength all 4% 12.5% 2.27% 2% 3% 100 mg all gel foam suppository gel gel suppository Hurricaine Debrox Nasalcrom 20% 6.5% 5.2 mg/act oral solution otic solution nasal aerosol Halfprin Excedrin Migraine Children's Motrin, Children's Advil Motrin Infants, Children's Advil Advil Jr. Strength, Children's Motrin Jr. Strength Motrin Jr. Strength Advil, Motrin IB Aleve Page 2 of 13 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description oxymetazoline phenol phenylephrine sodium chloride sodium chloride EYE PRODUCTS artificial tears gel artificial tears solution artificial tears ointment carboxymethylcellulose hypromellose hypromellose ketotifen polyethylene glycol/polyvinyl alcohol polyethylene glycol/propylene glycol polyvinyl alcohol polyvinyl alcohol/povidone propylene glycol/glycerin sodium chloride ophthalmic sodium chloride ophthalmic white petrolatum-mineral oil GASTROINTESTINAL Heartburn, Indigestion aluminum & magnesium hydroxides aluminum & magnesium hydroxides/ simethicone aluminum hydroxide gel suspension aluminum hydroxide gel suspension calcium carbonate calcium carbonate calcium carbonate calcium carbonate PW_2013_026/DHS_Approved_11/15/2012 Brand Examples 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 Mylanta Alternagel Tums Ultra Childrens Mylanta Tums Maalox Strengths 0.05% 1.40% 0.25%, 1% 0.65% Dosage Forms 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 solution ophth ointment ophth solution ophth solution ophth solution ophth solution 0.4%-0.3% 1.4% 0.6%-0.6% 5% 2%, 5% 225-200 mg/5mL 200-200-20 mg/5 mL, 400-400-40 mg/5 mL 320 mg/5 mL 600 mg/5 mL 1000 mg 400 mg 500 mg 600 mg ophth solution ophth solution ophth solution ophth solution ophth ointment ophth solution ophth ointment suspension suspension suspension suspension chewable tablets chewable tablets chewable tablets chewable tablets Page 3 of 13 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description calcium carbonate cimetidine famotidine famotidine nizatidine omeprazole delayed-release omeprazole magnesium delayed-release ranitidine sodium bicarbonate 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 magnesium hydroxide magnesium hydroxide methylcellulose mineral oil mineral oil enema PEG 3350 oral powder PW_2013_026/DHS_Approved_11/15/2012 Brand Examples Tums E-X Tagamet HB Pepcid AC Pepcid AC Maximum Strength Axid AR Prilosec OTC Zantac Dulcolax Dulcolax Dulcolax FiberCon Unifiber Colace Colace Fleet Babylax Milk of Magnesia Milk of Magnesia Citrucel Miralax Strengths 750 mg 200 mg 10 mg 20 mg 75 mg 20 mg 20 mg 75 mg Dosage Forms chewable tablets tablets tablets, chewable tablets tablets, chewable tablets tablets DR tablets DR tablets tablets tablets, powder, granules 5 mg 10 mg/30 mL 10 mg 625 mg DR tablets enema suppository caplets oral powder capsules capsules liquid liquid syrup enema suppository suppository suppository suppository oral solution suspension chewable tablets powder oral liquid enema powder 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 Page 4 of 13 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description psyllium powder senna sennosides sennosides sennosides sennosides sennosides/docusate sodium sodium phosphates rectal solution sodium phosphates solution 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 PW_2013_026/DHS_Approved_11/15/2012 Brand Examples Metamucil, Fiber-Eze 70% 70% Dosage Forms powder tablets chewable tablets tablets tablets tablets tablets enema oral solution 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 solution chewable tablets chewable tablets capsules Lactaid Mylicon various 40 mg/0.6 mL capsules, tablets, liquid suspension Dimetapp Cold and Allergy 1 mg-2.5 mg/5 mL 1 mg-15 mg/5 mL 4 mg-20 mg/5 mL 10 mg 5 mg elixir elixir liquid chewable tablets chewable tablets 5 mg/5 mL 10 mg syrup tablets Ex-Lax Ex-Lax Ex-Lax Maximum Strength Senokot Senokot-S Fleets Phospho Soda Enema Fleets Phospho Soda Lohist PSB Zyrtec Children's Allergy Zyrtec Children's Allergy Zyrtec Children's Allergy, Zyrtec Children's Hives Zyrtec Allergy, Zyrtec Hives Relief Strengths 187 mg 15 mg 15 mg 25 mg 8.6 mg 8.6-50 mg Page 5 of 13 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description cetirizine cetirizine/pseudoephedrine chlorpheniramine chlorpheniramine chlorpheniramine chlorpheniramine/pseudoephedrine Strengths 5 mg 5 mg/120 mg 12 mg 2 mg/5 mL 4 mg 1 mg-15 mg/5 mL; 2 mg-30 mg/5 mL; 0.8 mg-9 mg/mL chlorpheniramine/pseudoephedrine clemastine fumarate diphenhydramine 8 mg-120 mg; 2 mg-30 mg 1.34 mg 25 mg, 50 mg diphenhydramine diphenhydramine diphenhydramine diphenhydramine diphenhydramine diphenhydramine diphenhydramine (for sleep) diphenhydramine (for sleep) diphenhydramine (for sleep) doxylamine (for sleep) fexofenadine fexofenadine loratadine loratadine loratadine loratadine loratadine/pseudoephedrine loratadine/pseudoephedrine phenylephrine pseudoephedrine PW_2013_026/DHS_Approved_11/15/2012 Brand Examples Zyrtec-D Chlor-Trimeton Chlor-Trimeton Chlor-Trimeton Tavist Allergy Benadryl Benadryl Benadryl Allergy Benadryl Unisom SleepGels Sominex Nytol Maximum Strength Unisom Allegra Allergy Allegra Allergy Claritin Claritin Reditablets Claritin Alavert, Claritin Claritin D 24-hour Claritin D 12-hour Sudafed PE 12.5 mg 12.5 mg/5 mL 12.5 mg/5 mL 12.5 mg/5 mL 25 mg 50 mg 50 mg 25 mg 50 mg 25 mg 30 mg/5 mL 30 mg, 60 mg, 180 mg 5 mg 10 mg 5 mg/5 mL 10 mg 10-240 mg 5-120 mg 10 mg 120 mg Dosage Forms tablets tablets CR capsules syrup tablets liquid CR capsules, chewable tablets tablets capsules chewable tablets, orally dissolving strips elixir liquid syrup tablets tablets capsules tablets tablets tablets suspension tablets chewable tablets orally disintegrating tablets syrup tablets ER tablets ER tablets tablets ER capsules Page 6 of 13 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description pseudoephedrine pseudoephedrine pseudoephedrine pseudoephedrine pseudoephedrine pseudoephedrine pseudoephedrine Antitussives and Expectorants brompheniramine/phenylephrine/ dextromethorphan brompheniramine/pseudoephedrine/ dextromethorphan dextromethorphan polistirex dextromethorphan/guaifensin dextromethorphan/guaifensin dextromethorphan/guaifensin dextromethorphan/guaifensin dextromethorphan/guaifensin dextromethorphan/guaifenesin/potassium citrate guaifenesin guaifenesin guaifenesin guaifenesin guaifenesin guaifenesin guaifenesin guaifenesin/phenylephrine SKIN Acne benzoyl peroxide benzoyl peroxide salicylic acid PW_2013_026/DHS_Approved_11/15/2012 Brand Examples Sudafed Children's Strengths 15 mg/5 mL 30 mg/5 mL 30 mg/5 mL 240 mg 120 mg 30 mg 60 mg Dosage Forms liquid liquid syrup tablets tablets tablets tablets elixir Liquibid Rescon-GG 1 mg-2.5 mg-5 mg/5 mL 2 mg-30 mg-10 mg/5 mL; 4 mg-60 mg-30 mg/5 mL 30 mg/5 mL 10 mg-100 mg/5 mL 5 mg-100 mg/5 mL 30mg -1200 mg 30 mg-600 mg 10 mg-100 mg/5 mL 10 mg-100 mg-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 mg-5 mg/5 mL syrup CR liquid liquid liquid SR tablets SR tablets syrup liquid granules liquid SR tablets SR tablets syrup tablets tablets liquid Clean & Clear 10% 5% 0.5%, 2%, cream, lotion, gel gel, lotion liquid Sudafed 24-hour Sudafed 12-hour Sudafed Dimetapp DM Dimetane DX Delsym Cheracol-D Mucinex Cough-Children's Mucinex DM Maximum Strength Mucinex DM Robitussin DM Sorbutuss NR Mucinex Cough for Kids Mucinex for Kids Mucinex Mucinex Robitussin Page 7 of 13 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description Antibacterials-topical bacitracin zinc neomycin/polymyxin B/bacitracin Antifungals-topical clotrimazole ketoconazole miconazole miconazole miconazole miconazole terbinafine tolnaftate Antipruritics colloidal oatmeal calamine lotion 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 PW_2013_026/DHS_Approved_11/15/2012 Brand Examples Strengths Dosage Forms 500 U/g ointment ointment 1% 1% 2% 2% 2% 2% 1% 1% various shampoo aerosol aerosol powder cream powder various various Hytone 1% 1% packets lotion cream, lotion, ointment cream, ointment Nix Crème Rinse 1% 1% creme rinse lotion Neosporin, Triple Antibiotic Lotrimin AF Nizoral A-D Desenex Spray Lotrimin AF Micatin Desenex Shake Powder Lamisil AT Tinactin Aveeno Rid Complete Tegrin-LT, Pronto Americaine Zostrix Hibiclens Ionil-T, T/Gel Tarsum Nupercainal Abreva Aquaflo Hydrogel, Curafil Hydrogel shampoo 20% aerosol 0.025%, 0.075% 2%, 4% 1%, 2.5% 10%-5% 1% 10% cream liquid shampoo shampoo rectal ointment topical cream dressings, pads Page 8 of 13 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description 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 nicotine transdermal patches SUPPLEMENTS beta carotene calcium carbonate calcium carbonate calcium carbonate calcium carbonate calcium carbonate calcium carbonate/cholecalciferol PW_2013_026/DHS_Approved_11/15/2012 Brand Examples Proctocort rubbing alcohol Lac-Hydrin Betadine Keralyt Compound W, DuoFilm Trans-ver-sal Pediapatch MediPlast Psoriasis Liquid Selsun Blue Myoflex, Aspercreme Vaseline Curafil, Nu-Gel, Curasol Balmex, Boudreauox Butt Paste, Desitin Nicorette Nicorette Nicoderm CQ Cal-Mint, Os-Cal 500 chewables Caltrate 600 Os-cal chewables Strengths 1%, 2.5% 3% 70% 5% 10% 7.5%, 10% 3% 17% 40% 17% 40% 3% 1%, 3% 10% Dosage Forms rectal cream solution solution various ointment 2 mg, 4 mg 2 mg, 4 mg 7 mg, 14 mg, 21 mg gum oral lozenges transdermal patches 15 mg, 30 mg, 10000U, 25000U 1250 mg/5 mL 1250 mg (500 mg Ca) 500 mg 1500 mg (600 mg Ca) 600 mg various ointment solution gel liquid pad patches plaster liquid lotion (shampoo) cream, lotion gel, ointment gel capsules suspension tablets chewable tablets tablets tablets tablets, chewable tablets, capsules Page 9 of 13 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D Brand Examples calcium carbonate/vitamin D calcium carbonate/vitamin D/minerals calcium citrate calcium citrate/vitamin D carbonyl iron Caltrate 600 +D carbonyl iron carbonyl iron carbonyl iron cholecalciferol Icar cyanocobalamin (Vitamin B12) cyanocobalamin (Vitamin B12) ergocalciferol ergocalciferol ferrous gluconate ferrous sulfate ferrous sulfate enteric-coated ferrous sulfate ferrous sulfate ferrous sulfate, dried folic acid glucosamine sulfate PW_2013_026/DHS_Approved_11/15/2012 OsCal 500 +D Citracal +D Icar Feosol Vitamin D3 Vitamin D2 Vitamin D2 Slow Fe Strengths 500 mg-125U 500 mg-200U 600 mg-125U 600 mg-200U 600 mg-400U 500 mg-400U 600 mg-400U, 1200 mg-1000U 600 mg-200U/various 950 mg (200 mg Ca) 315 mg-200U 15 mg (elemental iron) 15 mg/1.25 mL (elemental iron) 25 mg (elemental iron) 45 mg (elemental iron) various strengths 1000 mcg, 1500 mcg, 2000 mcg various 8000 U/mL 400 U various 220 mg/5 mL 325 mg 15 mg/mL various 160 mg 200 mcg, 400 mcg, 800 mcg 500 mg, 750 mg, 1000 mg Dosage Forms tablets tablets tablets tablets tablets chewable tablets chewable tablets tablets tablets tablets chewable tablets suspension tablets tablets capsules CR tablets tablets drops tablets tablets elixir tablets solution tablets ER tablets tablets capsules Page 10 of 13 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description 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 niacin oyster shell calcium oyster shell calcium/vitamin D sodium chloride vitamin A vitamin B-1 (Thiamine) vitamin B-2 (Riboflavin) vitamin B-6 (Pyridoxine) PW_2013_026/DHS_Approved_11/15/2012 Brand Examples Strengths Iferex-150 various 66 mg 15 mg/1.5 mL 150 mg Dosage Forms capsules, tablets, oral liquid tablets suspension capsules Irofol 150 mg-0.025 mg-1 mg tablets 250 mg, 500 mg 250 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-200U 1000 mg Various 50 mg, 100 mg, 250 mg 25 mg, 50 mg, 100 mg various strengths capsules tablets tablets capsules, tablets capsules, tablets CR tablets tablets tablets tablets tablets capsules CR capsules Slow Mag Slow Mag Mag-Ox Slo-Niacin Oyst-Cal ER tablets tablets tablets tablets tablets capsules tablets tablets tablets Page 11 of 13 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description vitamin C vitamin E vitamin E vitamin K zinc gluconate zinc sulfate Multivitamins B-complex w/C, folic acid multiple vitamin multiple vitamin with iron multiple vitamins with minerals multiple vitamin with minerals multiple vitamin with minerals Brand Examples Dialyvite, Rena-vite One-A-Day Essential Pediavit Poly-Vi-Sol pediatric multiple vitamin with C and folic acid pediatric multiple vitamin with fluoride pediatric multiple vitamin with fluoride Fruity chewables, My First Flintstones pediatric multiple vitamin with fluoride and iron pediatric multiple vitamin with iron Flintstones Plus Iron, Centrum Kids pediatric vitamin drops with ADC Tri-Vi-Sol pediatric vitamin drops with ADC and iron Tri-Vi-Sol/Iron prenatal vitamins/folic acid/iron (ferrous fumarate) prenatal vitamins/selenium/folic acid/iron (ferrous fumarate) OTHER PRODUCTS activated charcoal Dosage Forms tablets capsules solution tablets tablets capsules various tablets tablets tablets tablets capsules liquid liquid, chewable tablets, drops drops, liquid 0.25 mg, 0.5 mg, 1 mg 0.25 mg, 0.5 mg, 1 mg chewable tablets chewable tablets drops Ocuvite, Preservision Ocuvite, Preservision Centrum, Cerovite pediatric multiple vitamin pediatric multiple vitamin with C PW_2013_026/DHS_Approved_11/15/2012 Strengths 100 mg, 250 mg, 500 mg, 1000 mg various 50U/mL 100 mcg various 220 mg 0.25 mg-10 mg/mL 10 mg/mL drops chewable tablets drops drops all tablets capsules, tablets, liquid Page 12 of 13 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description Brand Examples Strengths dimenhydrinate Dramamine 50 mg elastic bandages and supports glucose meclizine meclizine oral electrolyte replacement T.E.D., Kendall ostomy supplies, kits Hollister, Kendall, Bard, Convatec syringe/needles, disposable Bonine 25 mg 12.5 mg, 25 mg Oralyte, Pedialyte B-D, Kendall Dosage Forms chewable tablets, tablets various, including hose, stockings, and wraps tablets, gel chewable tablets tablets packets, solution various, including drains, caps, belts, pouches, and skin gel 1 mL, 3 mL, various needle gauges/lengths Key CR = controlled release DR = delayed release ER = extended release SR = sustained release ophth = eye otic = ear U = units PW_2013_026/DHS_Approved_11/15/2012 Page 13 of 13
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