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VERSION 05/2004

Therapeutic Class

Generic Name

Electrolytic,Caloric CALCIUM ACETATE

& Water Balance

CALCIUM

CARBONATE

Replacement Preps

CALCIUM LACTATE ELECTROLYTES ORAL MAINTENANCE SOLUTION

Caloric Agents

FOLIC ACID POTASSIUM CHLORIDE

Brand Name

Calphron, Phoslo VARIOUS

VARIOUS PEDIALYTE

VARIOUS VARIOUS

Cap, Tab

500mg, 667mg

Chew, Cap,

650mg,

Tab, Susp

1250mg,

Tab

10 / 325mg, 650mg

Liq-Ready to

Sodium- 40-60

Use

mEq/L

Potassium-

20mEq/L;

Anions;

Carbohydrate

glucose/

dextrose 2 0%

Tab

1mg

CapCR,

8mEq, 10mEq,

TabER, Liq

20mEq,

90

$

90

$

Form

CHP

Relative

Cost

x

$

x

$

x QL

Strength

CHP Restrictions

$ $

Max. Qty. 4000ml per RX per dispensing

LEVOCARNITINE

Irrigating Soln

ACETIC ACID

SODIUM CHLORIDE SOLN

Vitamin D

CALCITRIOL

Vitamin K Activity Phytonadione (K1)

Multivitamin

VITAMINS- MINERAL

Preparations

- PRENATAL NON RX

VITAMINS ACD

VITAMINS ACS w/ IRON

VITAMINS, MULTI w/ Flouride

Vits ACD w/ Sodium Fluoride

CARNITOR

VARIOUS

VARIOUS ROCALTROL

AquaMEPHYTON PRENAVITE PRENATALS

TRI-VI-SOL

TRI-VI-SOL w/ IRON

Tab, Cap, Liq

0 E /1 250mg, 330mg,

Irrig Soln

100mg/mL 0.025%

Irrig Soln Cap

0.09% 0.25mcg,

Tab

0 5mcg 5mg

60-0.8mg

x

x x x

x PA

Chew, Soln, Drops Chew, Soln, Drops Chew, Drops 0.25mg, 0.5mg, 1mg, 0.25mg/mL, Chew, Drops 0.25mg, 0.5mg, 1mg, 0.25mg/mL, 0.25mg, 0.5mg, 0.25mg/mL, 0.25-10mg/mL, 0.25mg, 0.5mg, 1mg, 0.25mg/mL,

AL

AL

AL

AL

$$ $

Not >50% nor more than 100% of US RDA for pregnant women of A, D, B1, B2, B6, B12, C, Niacin, & not >200mg elemental Fe, may also contain up to US RDA of E, Folic Acid, Phosphorus, Magnesium, except for Iodine (200mcg) and Reimburseable for children up to 5th Birthday only

$

$

Reimburseable for children up to 5th Birthday only

$

Reimburseable for children up to 5th Birthday only

$

Reimburseable for children up to 5th Birthday only

$$

$ $ $$$$$

Anti-Alcohol

DISULFIRAM

ANTABUSE

Tab

250mg, 500mg

x

$$

Agents

Cevimeline HCl

Evoxac

Cap

30mg

x

$$$$

Medical Supplies

MEDICAL SUPPLIES

MEDICAL SUPPLIES

x

UNCLASSIFIED THERAPEUTIC AGENTS

Products listed in Medi-Cal section

19

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