UPDATE FOR: JULY 21, 2008 WISCONSIN CHRONIC DISEASE PROGRAM LIST OF COVERED DRUGS - ADULT CYSTIC FIBROSIS PROGRAM NDC CODE DESCRIPTION EFF DATE COVERED COPAY 00074330803 ACETYLCYSTINE 20% VIAL 07/01/2004 YES $ 7.50 58914001006 ADEKS MULTIVITAMIN 07/01/2004 YES $15.00 00173069700 ADVAIR DISKU 500/50 07/01/2004 YES $15.00 00173069600 ADVAIR INH PWR 250/50MCG 07/01/2004 YES $15.00 00173069502 ADVAIR 100\50 07/01/2004 YES $15.00 00173069602 ADVAIR 250\50 07/01/2004 YES $15.00 00173069702 ADVAIR 500\50 07/01/2004 YES $15.00 00781185220 AMOX TR-K CLV 875-125MG TAB 07/01/2004 YES $ 7.50 00781261305 AMOXICILLIN 500 MG CAPSULE 07/01/2004 YES $ 7.50 00029600922 AMOXIL 250MG/5ML ORAL SUSP 07/01/2004 YES $15.00 00029600923 AMOXIL 250MG/5ML ORAL SUSP 07/01/2004 YES $15.00 00029603839 AMOXIL 50MG/ML PED DROPS 07/01/2004 YES $15.00 00029600732 AMOXIL 500MG CAPSULE 07/01/2004 YES $15.00 00015740220 AMPICILLIN 250MG POWDR 07/01/2004 YES $ 7.50 00007313116 ANCEF 500MG/10ML VIAL 07/01/2004 YES $15.00 00029607527 AUGMENTIN 250MG 07/01/2004 YES $15.00 00029608012 AUGMENTIN 500MG TABLET 07/01/2004 YES $15.00 00029608612 AUGMENTIN 875MG TABLET 07/01/2004 YES $15.00 00093714618 AZITHROMYCIN 250 MG TABLET 01/01/2007 YES $ 7.50 00093714656 AZITHROMYCIN 250 MG TABLET 01/01/2007 YES $ 7.50 59762306001 AZITHROMYCIN 250 MG TABLET 07/01/2006 YES $ 7.50 00173038700 CEFTIN 250MG 07/01/2004 YES $15.00 00173039442 CEFTIN 500MG 07/01/2004 YES $15.00 00004026001 CELLCEPT 500 MG 07/01/2004 YES $15.00 00026856220 CIPRO IV 10MG VIAL 07/01/2004 YES $15.00 00026856464 CIPRO IV 10MG VIAL 07/01/2004 YES $15.00 00026855236 CIPRO IV 200MG 07/01/2004 YES $15.00 00026855463 CIPRO IV 400MG 07/01/2004 YES $15.00 49884063701 CIPROFLAXACIN HCL 250MG TAB 12/01/2005 YES $ 7.50 63304070901 CIPROFLOXACIN HCL 250 MG TABLE 07/27/2005 YES $ 7.50 63304071001 CIPROFLOXACIN HCL 500 MG TABLE 07/27/2005 YES $ 7.50 63304071101 CIPROFLOXACIN HCL 750 MG TABLE 07/27/2005 YES $ 7.50 63304071150 CIPROFLOXACIN HCL 750 MG TABLE 07/27/2005 YES $ 7.50 63304072501 CLARITHROMYCIN 250 MG TABLET 07/27/2005 YES $ 7.50 63304072560 CLARITHROMYCIN 250 MG TABLET 07/27/2005 YES $ 7.50 63304072601 CLARITHROMYCIN 500 MG TABLET 07/27/2005 YES $ 7.50 63304072660 CLARITHROMYCIN 500 MG TABLET 07/27/2005 YES $ 7.50 00009022501 CLEOCIN HCL 150MG CAPSULE 07/01/2004 YES $15.00 00009022502 CLEOCIN HCL 150MG CAPSULE 07/01/2004 YES $15.00 00009022503 CLEOCIN HCL 150MG CAPSULE 07/01/2004 YES $15.00 00009033102 CLEOCIN HCL 75MG CAPSULE 07/01/2004 YES $15.00 00009076004 CLEOCIN PED 75MG/5ML SUSP 07/01/2004 YES $15.00 00009311601 CLEOCIN T-SOLUTION 07/01/2004 YES $15.00 00009039513 CLEOCIN 300MG 07/01/2004 YES $15.00 00009039514 CLEOCIN 300MG 07/01/2004 YES $15.00 00591570801 CLINDAMYCIN HCL 150MG CAPS 01/01/2007 YES $ 7.50 61570041451 COLY-MYCIN M 150 MG VIAL 07/01/2004 YES $15.00 00032121001 CREON 10 CAPSULE 07/01/2004 YES $15.00 00032121007 CREON 10MG CAP 07/01/2004 YES $15.00 00032122001 CREON 20 MG CAP 07/01/2004 YES $15.00 00032122007 CREON 20MG 07/01/2004 YES $15.00 00143314214 DOXCYCLINE 100 MG CAPSULE 07/01/2004 YES $ 7.50 00143314205 DOXYCYCLINE 100 MG CAPSULE 07/01/2004 YES $ 7.50 00143314225 DOXYCYCLINE 100 MG CAPSULE 07/01/2004 YES $ 7.50 00143314250 DOXYCYCLINE 100 MG CAPSULE 07/01/2004 YES $ 7.50 00591544005 DOXYCYCLINE 100 MG CAPSULE 07/01/2004 YES $ 7.50 00591544050 DOXYCYCLINE 100 MG CAPSULE 07/01/2004 YES $ 7.50 00677056202 DOXYCYCLINE 100 MG CAPSULE 07/01/2004 YES $ 7.50 00677056205 DOXYCYCLINE 100 MG CAPSULE 07/01/2004 YES $ 7.50 00904043051 DOXYCYCLINE 100 MG TABLET 07/01/2004 YES $ 7.50 00904042840 DOXYCYCLINE 100MG CAPSULE 07/01/2004 YES $ 7.50 53489011902 DOXYCYCLINE 100MG CAPSULE 07/01/2004 YES $ 7.50 53489011905 DOXYCYCLINE 100MG CAPSULE 07/01/2004 YES $ 7.50 00904043040 DOXYCYCLINE 100MG TAB 07/01/2004 YES $ 7.50 00143314150 DOXYCYCLINE 50 MG CAPSULE 07/01/2004 YES $ 7.50 00591553550 DOXYCYCLINE 50 MG CAPSULE 07/01/2004 YES $ 7.50 00677059802 DOXYCYCLINE 50 MG CAPSULE 07/01/2004 YES $ 7.50 00904042751 DOXYCYCLINE 50MG CAPS 07/01/2004 YES $ 7.50 53489011805 DOXYCYCLINE 50MG CAPSULE 07/01/2004 YES $ 7.50 00074636902 E.E.S. GRANULES 200MG/5ML 07/01/2004 YES $15.00 00074636910 E.E.S. GRANULES 200MG/5ML 07/01/2004 YES $15.00 00074630613 E.E.S. 200 ORAL SUSPENSION 07/01/2004 YES $15.00 00074630616 E.E.S. 200 ORAL SUSPENSION 07/01/2004 YES $15.00 00074572913 E.E.S. 400 FILMTAB 07/01/2004 YES $15.00 00074572953 E.E.S. 400 FILMTAB 07/01/2004 YES $15.00 00074637313 E.E.S. 400MG/5ML ORAL SUSP 07/01/2004 YES $15.00 00074637316 E.E.S. 400MG/5ML ORAL SUSP 07/01/2004 YES $15.00 00074630413 ERY-TAB 250MG TABLET EC 07/01/2004 YES $15.00 00074630453 ERY-TAB 250MG TABLET EC 07/01/2004 YES $15.00 00074632013 ERY-TAB 333MG TABLET EC 07/01/2004 YES $15.00 00074632113 ERY-TAB 500MG TABLET EC 07/01/2004 YES $15.00 00074630513 ERYPED 400MG/5ML SUSPENSION 07/01/2004 YES $15.00 00074630553 ERYPED 400MG/5ML SUSPENSION 07/01/2004 YES $15.00 00074634620 ERYTHROCIN FILMTAB 250MG 11/01/2004 YES $15.00 00074634653 ERYTHROCIN FILMTAB 250MG 11/01/2004 YES $15.00 00074631613 ERYTHROCIN FILMTAB 500MG 07/01/2004 YES $15.00 00256011101 EXTENDRYL SR CAPSULE 07/01/2004 YES $15.00 00256013301 EXTENDRYL TAB CHEW 07/01/2004 YES $15.00 00173045301 FLONASE AQ NASAL SPRAY 07/01/2004 YES $15.00 00173043400 FORTAZ ADD-VANTAGE 1GM 07/01/2004 YES $15.00 00173043500 FORTAZ ADD-VANTAGE 2GM 07/01/2004 YES $15.00 00173037934 FORTAZ 2GM 07/01/2004 YES $15.00 00173038237 FORTAZ 6MG VIAL 10/17/2004 YES $15.00 00004100328 GANTRISIN PED 500MG/5ML SUS 07/01/2004 YES $15.00 00049143066 GEOCILLIN 382MG TABLET 07/01/2004 YES $15.00 00338821070 HEPARIN N/A FLUSH 07/01/2004 YES $ 7.50 00777086902 KEFLEX PULVULE 250MG 07/01/2004 YES $15.00 00777086920 KEFLEX PULVULE 250MG 07/01/2004 YES $15.00 00777087102 KEFLEX PULVULE 500MG 07/01/2004 YES $15.00 00777087120 KEFLEX PULVULE 500MG 07/01/2004 YES $15.00 00149071001 MACROBID 100MG CAPSULES 07/01/2004 YES $15.00 00149000905 MACRODANTIN 100MG CAPSULE 07/01/2004 YES $15.00 00149000705 MACRODANTIN 25MG CAPSULE 07/01/2004 YES $15.00 00149000805 MACRODANTIN 50MG CAPSULE 07/01/2004 YES $15.00 00087057009 MUCOMYST 20PC VIAL 10/09/2006 YES $15.00 00087057202 MUCOMYST-10 10PC VIAL 10/09/2006 YES $15.00 00078024815 NEORAL 100 MG 07/01/2004 YES $15.00 00078024615 NEORAL 25 MG 07/01/2004 YES $15.00 00093002801 NEOTHYLLINE-G TABLET 07/01/2004 YES $ 7.50 00093002810 NEOTHYLLINE-G TABLET 07/01/2004 YES $ 7.50 00378170005 NITROFURANTOIN MCR MG CAP 07/01/2004 YES $ 7.50 00378170001 NITROFURANTOIN MCR 100 MG CAP 07/01/2004 YES $ 7.50 00378342201 NITROFURANTOIN MCR 100 MG CAP 07/01/2004 YES $ 7.50 00591325401 NITROFURANTOIN MCR 100 MG CAP 07/01/2004 YES $ 7.50 00591325001 NITROFURANTOIN MCR 100 MG CAPS 07/01/2004 YES $ 7.50 00378165001 NITROFURANTOIN MCR 50 MG CAP 07/01/2004 YES $ 7.50 00378165005 NITROFURANTOIN MCR 50 MG CAP 07/01/2004 YES $ 7.50 00591325301 NITROFURANTOIN MCR 50 MG CAP 07/01/2004 YES $ 7.50 60432053716 NYSTATIN 100000 U/ML SUSP 07/01/2004 YES $ 7.50 00074629060 PCE 333MG 07/01/2004 YES $15.00 00074338913 PCE 500MG 07/01/2004 YES $15.00 00003068154 PENICILLIN VK 125/5CC SUSP 10/09/2006 YES $15.00 00781120501 PENICILLIN VK 250MG TABLET 07/01/2004 YES $ 7.50 00781120510 PENICILLIN VK 250MG TABLET 07/01/2004 YES $ 7.50 00781165501 PENICILLIN VK 500MG TABLET 07/01/2004 YES $ 7.50 00015740499 POLYCILLIN-N 1GM VIAL 07/01/2004 YES $ 7.50 00015740599 POLYCILLIN-N 2GM VIAL 07/01/2004 YES $ 7.50 00015740299 POLYCILLIN-N 250MG VIAL 07/01/2004 YES $ 7.50 00015740320 POLYCILLIN-N 500MG VIAL 07/01/2004 YES $ 7.50 00015740399 POLYCILLIN-N 500MG VIAL 07/01/2004 YES $ 7.50 00781183001 PROMETHAZINE 25MG TABLET 07/01/2004 YES $ 7.50 00781183010 PROMETHAZINE 25MG TABLET 07/01/2004 YES $ 7.50 50242010040 PULMOZYME INHALENT SOLUTION 07/01/2004 YES $15.00 00277016901 RESPAIRE-120 S.R. CAPSULE 07/01/2004 YES $15.00 58914080144 SCANDISHAKE CHOCOLATE 07/01/2004 YES $15.00 58914082118 SCANDISHAKE NO SUGAR ADDED CHO 07/01/2004 YES $15.00 58914082018 SCANDISHAKE NO SUGAR ADDED VAN 07/01/2004 YES $15.00 58914080244 SCANDISHAKE STRAWBERRY 07/01/2004 YES $15.00 58914080044 SCANDISHAKE VANILLA 07/01/2004 YES $15.00 00173052100 SEREVENT DISK 50 MCG 07/01/2004 YES $15.00 00677062401 SPIRONOLACT W/HCTZ 25/25 TB 07/01/2004 YES $ 7.50 00677062410 SPIRONOLACT W/HCTZ 25/25 TB 07/01/2004 YES $ 7.50 00677062501 SPIRONOLACTONE 25MG TABLET 07/01/2004 YES $ 7.50 00677062510 SPIRONOLACTONE 25MG TABLET 07/01/2004 YES $ 7.50 00074159005 STERILE WATER FOR INJECTION 07/01/2004 YES $ 7.50 00677078401 SULFAMETHOX/TRIMETHOPRIM TB 07/01/2004 YES $ 7.50 53489014605 SULFAMETHOXAZOLE W/TMP DS 07/01/2004 YES $ 7.50 00677078301 SULFAMETOXAZOLE 07/01/2004 YES $ 7.50 00093008905 SULFATRIM DS 800/160 07/01/2004 YES $ 7.50 49884079933 SUMYCIN 125MG/5ML ORAL SUSP 12/01/2004 YES $15.00 49884079701 SUMYCIN 250MG TABLET 07/01/2004 YES $15.00 49884079801 SUMYCIN 500MG TABLET 07/01/2004 YES $15.00 00378010110 TETRACYCLINE HCL 250MG CAP 07/01/2004 YES $ 7.50 00378010201 TETRACYCLINE HCL 500MG CAP 07/01/2004 YES $ 7.50 00555001102 TETRACYCLINE 250MG CAP 07/01/2004 YES $ 7.50 00555001105 TETRACYCLINE 250MG CAP 07/01/2004 YES $ 7.50 00904241680 TETRACYCLINE 250MG CAPSULE 07/01/2004 YES $ 7.50 00555001002 TETRACYCLINE 500MG CAP 07/01/2004 YES $ 7.50 00555001005 TETRACYCLINE 500MG CAP 07/01/2004 YES $ 7.50 00029655022 TICAR 1GM VIAL 07/01/2004 YES $15.00 53905006501 TOBI 300MG/5ML SOLUTION 07/01/2004 YES $15.00 00074359002 TOBRAMYCIN 40 MG/ML VIAL 07/01/2004 YES $ 7.50 00703941601 TOBRAMYCIN 40 MG/ML VIAL 07/01/2004 YES $ 7.50 00029661025 TOTACILLIN-N 1GM VIAL 07/01/2004 YES $15.00 00029661321 TOTACILLIN-N 10GM VIAL 07/01/2004 YES $15.00 00009056601 TROBICIN W/DILUENT 2GM VIAL 07/01/2004 YES $15.00 58914000210 ULTRASE MT 12 CAPSULE EC 07/01/2004 YES $15.00 58914000410 ULTRASE MT20 07/01/2004 YES $15.00 58914000450 ULTRASE MT20 CAPSULES 07/01/2004 YES $15.00 00173093308 VALTREX 500 MG 07/01/2004 YES $15.00 00002312542 VANCOCIN 125MG CAP 07/01/2004 YES $15.00 00002312642 VANCOCIN 250MG CAP 07/01/2004 YES $15.00 00009361702 VANTIN 100MG 07/01/2004 YES $15.00 00003011450 VELOSEF 500 CAPSULE 07/01/2004 YES $15.00 00173068200 VENTOLIN INHALER 90 MCG AERO 07/01/2004 YES $15.00 00069099050 VIBRA-TABS 100MG TABLET 07/01/2004 YES $15.00 00069095050 VIBRAMYCIN 100MG CAPSULE 07/01/2004 YES $15.00 00069097065 VIBRAMYCIN 25MG/5ML SUSP 07/01/2004 YES $15.00 00069094050 VIBRAMYCIN 50MG CAPSULE 07/01/2004 YES $15.00 00069097193 VIBRAMYCIN 50MG/5ML SYRUP 07/01/2004 YES $15.00 00074488720 WATER FOR INJECTION FLIPTOP 07/01/2004 YES $ 7.50 00074488750 WATER FOR INJECTION FLIPTOP 07/01/2004 YES $ 7.50 00069306030 ZITHROMAX 250MG TAB 07/01/2004 YES $15.00 00069306075 ZITHROMAX 250MG Z-PAK TABS 07/01/2004 YES $15.00 00069307030 ZITHROMAX 500 MG 07/01/2004 YES $15.00 00069307075 ZITHROMAX 500 MG 07/01/2004 YES $15.00