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<br />X- <br />X- <br />L <br />L ~_ <br />X- <br />X <br /> <br />DRUG COVERAGE OPTIONS <br /> <br />Client: CITY OF PARIS <br /> <br />Yes - Covered Drug <br />No - Not a Covered Drug <br />YES NO <br />-1.. <br /> <br />LEGEND DRUGS (pRESCRIPTION DRUG) <br />ANABOLIC STEROIDS USED FOR BODY BUILDING <br /> <br />ANOREXlANTS (DIET AIDS) <br /> <br />ANTI-REJECTION DRUGS <br /> <br />ANTI-SMOKING AIDS (GUMSIPATCHES) <br /> <br />DRUGS USED TO TREAT AIDS AND AIDS RELATED CONDITIONS <br /> <br />DRUGS USED TO TREAT OR CURE BALDNESS <br /> <br />FERTILITY AGENTS <br /> <br />GROWI'H HORMONES <br /> <br />x.. <br /> <br />INJECT ABLE DRUGS <br /> <br />INSULIN <br /> <br />INSULIN SYRINGES & NEEDLES <br /> <br />INSULIN IN COMBINATION WITH NEEDLES/SYRINGES (pRE-DRAWN) <br /> <br />INSULIN TEST STRIPS <br /> <br />LEGEND CONTRACEPTIVES (ORAL) <br />TRETINOIN PRODUcrS (RETIN-A) UP TO AGE ~ <br /> <br />X- <br />L <br />X <br /> <br />vrr AMlNS REQUIRING A PRESCRIPTION <br /> <br />L <br /> <br />X. <br />.Y <br />.Y <br />'X <br />J <br /> <br />THE FOLLOWING ITEMS ARE FOR DOCUMENTATION ONLY: <br /> <br />THERAPEUTIC DEVICES OR APPLIANCES, INCLUDING HYPODERMIC <br />NEEDLES, SYRINGES, SUPPORT GARMENTS, AND OTHER NON-MEDICINAL <br />SUBSTANCES REGARDLESS OF INTENDED USE. <br /> <br />IMMUNIZATION AGENTS, BIOLOGICAL SERA, BLOOD OR BLOOD <br />PRODUCTS ADMINISI'ERED ON AN Our-PATIENT BASIS. <br /> <br />ANY CHARGE FOR THE ADMINISTRATION OF LEGEND DRUGS OR INSULIN. <br /> <br />ANY PRESCRIPTION REFILLED IN EXCESS OF THE NUMBER SPECIFIED BY <br />THE PHYSICIAN, OR FOR ANY REFILL DISPENSED AFTER ONE YEAR FROM <br />THE PHYSICIAN'S ORIGIN~ ORDER <br /> <br />ANY MEDICINE. LEGEND OR NOT, WHICH IS CONSUMED OR <br />ADMINISTERED AT THE PLACE WHERE IT IS DISPENSED. <br /> <br />DRUGS COVERED UNDER WORKERS COMPENSATION, MEDICARE OR MEDICAID <br />PROGRAMS. <br /> <br />NOTE: 1"0''''_ ~D"'I__ ___or.......0_1...-..... __Ia ..._olT..... <br /> <br />x <br /> <br />x <br /> <br />x <br /> <br />x <br /> <br />x <br /> <br />x <br />