Nutritional Products
Minerals and Electrolytes

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Carnitor generic.gif (400 bytes)
levocarnitine (with sugar)		 Solution   notreimb.gif (545 bytes)  

Not Applicable
Carnitor generic.gif (400 bytes)
levocarnitine		 tablet   notreimb.gif (545 bytes)  

Not Applicable
Eliphos generic.gif (400 bytes)
calcium acetate		 tablet   approved.gif (510 bytes)  

$$
FOSRENOL
lanthanum		 tablet, chewable   nonform.gif (625 bytes)  

Not Applicable
K-Dur generic.gif (400 bytes)
Potassium Chloride Crys CR		   approved.gif (510 bytes)  

$
K-Lor generic.gif (400 bytes)
potassium chloride		 Packet   approved.gif (510 bytes)  

$$
K-Lyte generic.gif (400 bytes)
potassium bicarb-citric acid		 tablet, effervescent   approved.gif (510 bytes)  

$$
K-Phos-Neutral generic.gif (400 bytes)
sod phos,di & mono-K phos mono		 250 mg tablet   approved.gif (510 bytes)  

$
Kaochlor generic.gif (400 bytes)
potassium bicarb & chloride		 20 mEq tablet, effervescent   approved.gif (510 bytes)  

$$
Klorvess
Potassium Bicarb & Chloride		 Powder Packet - 20meq   approved.gif (510 bytes)  

$$
Micro-K generic.gif (400 bytes)
potassium chloride		 capsule, extended release   approved.gif (510 bytes)  

$
PhosLo generic.gif (400 bytes)
calcium acetate		 667 mg capsule   approved.gif (510 bytes)  

$
Pima
Potassium Iodide		   approved.gif (510 bytes)  

$$
Renagel
sevelamer HCl		 400 mg tablet; 800 mg tablet   nonform.gif (625 bytes)  

Not Applicable
Renvela
sevelamer carbonate		 tablet   approved.gif (510 bytes)  

$$$$
Renvela
sevelamer carbonate		 Powder in Packet   notreimb.gif (545 bytes)  

Not Applicable
Slow-K generic.gif (400 bytes)
Potassium Chloride		 Tab CR - 8meq   approved.gif (510 bytes)  

$
SSKI
potassium iodide		 1 gram/mL Solution   approved.gif (510 bytes)  

$$

Key for Product(s) Listed Above
Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary
(Third tier coverage applies for selected plans)		 Not Reimbursed
Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans.
Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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