OTC COVERED PRODUCTS LIST

OTC COVERED PRODUCTS LIST

*Preferred Drug List - Items listed as being a part of a Preferred Drug List Edit may require prior authorization. Edit documents containing approval criteria can be found at .

**90 Day Supply - Items listed are allowed to be dispensed in a 90 day supply.

GENERIC NAME

Adapalene

Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Acetaminophen Aspirin Aspirin Aspirin Aspirin Diclofenac Ibuprofen Ibuprofen Ibuprofen Ibuprofen Ibuprofen Ibuprofen Naproxen Sodium Naproxen Sodium

Loperamide Hydrochloride Loperamide Hydrochloride

Butenafine HCL Clotrimazole Clotrimazole Ketoconazole Miconazole Nitrate Miconazole Nitrate Miconazole Nitrate Miconazole Nitrate

DOSAGE FORM Acne Products

Gel Analgesics

Liquid Suspension Suppository Suppository Tablet Tablet Chewable Tablet Enteric-Coated Tablet Enteric-Coated Tablet Tablet Gel Drops Suspension Chewable Tablet Tablet Capsule Tablet Capsule Tablet

Anti-Diarrheals Liquid Tablet

Antifungals, Topical Cream Cream Solution Shampoo Cream Liquid Spray Powder Spray Powder

STRENGTH

COMMON TRADE NAME

0.1% Differin

160mg/5ml Tylenol 160mg/5ml Tylenol

120mg Feverall 325mg Feverall 325mg Tylenol 500mg Tylenol

81mg Bayer Children's 81mg Ecotrin 325mg Ecotrin 325mg Bayer

1% Voltaren 50mg/1.25ml Advil/Motrin

100mg/5ml Advil/Motrin 100mg Advil/Motrin 100mg Advil/Motrin 200mg Advil/Motrin 200mg Advil/Motrin 220mg Aleve 220mg Aleve

1mg/5ml Imodium AD 2mg Imodium AD

1% Lotrimin Ultra 1% Lotrimin AF 1% Lotrimin AF 1% Nizoral AD 2% Neosporin AF 2% Lotrimin AF 2% Lotrimin AF 2% Lotrimin AF

PDL* 90 Days**

X

X X X X X X X X X X X X X X X

X X X X X X X X

Miconazole Nitrate

Ointment

2% Aloe Vesta

Miconazole Nitrate

Tincture

2% Fungoid

Terbinafine

Cream

1% Lamisil AT

Terbinafine

Spray

1% Lamisil

Terbinafine

Gel

1% Lamisil AT

Tolnaftate

Cream

1% Tinactin

Tolnaftate

Liquid Spray

1% Tinactin

Tolnaftate

Powder

1% Tinactin

Tolnaftate

Solution

1% Tinactin

Tolnaftate

Spray Powder

1% Tinactin

Antihistamines and Antihistamine/Decongestant Combo

Cetirizine

Solution

5mg/5ml Zyrtec

Cetirizine

Chewable Tablet

5mg Zyrtec

Cetirizine

Tablet

5mg Zyrtec

Cetirizine

Chewable Tablet

10mg Zyrtec

Cetirizine

Capsule

10mg Zyrtec

Cetirizine

ODT

10mg Zyrtec

Cetirizine

Tablet

10mg Zyrtec

Cetirizine/Pseudoephedrine

Tablet

5mg-120mg Zyrtec-D 12 Hour

Diphenhydramine

Liquid

12.5mg/5ml Benadryl

Diphenhydramine

Capsule

25mg Benadryl

Doxylamine

Tablet

25mg Unisom

Fexofenadine

Suspension

30mg/5ml Allegra

Fexofenadine

ODT

30mg Children's Allegra Allergy

Fexofenadine

Tablet

60mg Allegra Allergy

Fexofenadine

Tablet

180mg Allegra Allergy

Fexofenadine/Pseudoephedrine

Tablet

60mg-240mg Allegra-D 12 Hour

Fexofenadine/Pseudoephedrine

Tablet

180mg-240mg Allegra-D 24 Hour

Loratadine

Solution

5mg/5ml Claritin

Loratadine

Chewable Tablet

5mg Children's Claritin

Loratadine

ODT

5mg Claritin

Loratadine

Capsule

10mg Claritin

Loratadine

ODT

10mg Claritin

Loratadine

Tablet

10mg Claritin

Loratadine/Pseudoephedrine

Tablet

5mg-120mg Claritin-D 12 Hour

Loratadine/Pseudoephedrine

Tablet

10mg-240mg Claritin-D 24 Hour

Antivirals, Topical

Docosanol

Cream

10% Abreva

Cough & Cold

Brompheniramine/Phenylephrine/Dextrometh

Solution

1-2.5-5mg/5ml Dimetapp DM

X X X X X X X X X X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Chlorpheniramine Maleate

Tablet

4mg Chlor-Trimeton

Chlorpheniramine/Phenylephrine

Liquid

4-10mg/5ml ED-A-Hist

Chlorpheniramine/Phenylephrine/Dextrometh

Liquid

4-10-15mg/5ml ED-A-Hist DM

Dextromethorphan Polistirex

Suspension

30mg/5ml Delsym ER 12 Hour

Guaifenesin

Liquid

100mg/5ml Robitussin

Guaifenesin

Tablet

200mg Mucus Relief

Guaifenesin

Extended ReleaseTablet

600mg Mucinex

Guaifenesin

Extended ReleaseTablet

1200mg Mucinex

Guaifenesin/Dextromethorphan

Liquid

100-5mg/5ml Mucinex Fast-Max DM

Guaifenesin/Dextromethorphan

Syrup

100-10mg/5ml Robitussin DM

Guaifenesin/Dextromethorphan

Extended ReleaseTablet

600mg-30mg Mucinex DM

Guaifenesin/Dextromethorphan

Extended ReleaseTablet

1200-60mg Mucinex DM

Guaifenesin/Pseudoephedrine

Extended ReleaseTablet

600mg-60mg Mucinex D

Guaifenesin/Pseudoephedrine

Extended ReleaseTablet 1200mg-120mg Mucinex D

Eye & Ear Preparations

Ketotifen Fumarate

Drops

0.025% Zaditor

Mineral Oil/Petrolatum, White

Ointment

42.5-56.8% Lacri-Lube S.O.P.

Olopatadine Hcl

Drops

0.1% Patanol

Olopatadine Hcl

Drops

0.2% Pataday

Olopatadine Hcl

Drops

0.7% Pataday

Polyvinyl Alchohol

Drops

1.4% Akwa Tears

Polyvinyl Alchohol/Povidone

Drops

0.5%-0.6% Artificial Tears

Intranasal Agents

Budesonide

Spray

32mcg Rhinocort

Fluticasone Furoate

Spray

27.5mcg Flonase Sensimist

Fluticasone Propionate

Spray

50mcg Flonase

Triamcinolone Acetonide

Spray

55mcg Nasacort

Iron Replacements

Ferrous Sulfate

Drops

15mg/ml Fer-In-Sol

Ferrous Sulfate

Elixir

220mg/5ml Ferrous Sulfate

Ferrous Sulfate

Solution

220 (44)/5ml Ferrous Sulfate

Ferrous Sulfate

Enteric-Coated Tablet

325mg Ferrous Sulfate

Ferrous Sulfate

Tablet

325mg Ferrous Sulfate

Iron Polysaccharide Comples

Capsule

150mg Niferex-150

Laxatives, Cathartics, Bulk Producers, Stool Softeners

Bisacodyl

Enteric-Coated Tablet

5mg Dulcolax

Bisacodyl

Suppository

10mg Dulcolax

Docusate Calcium

Capsule

240mg Surfak

Docusate Sodium

Capsule

100mg Colace

Docusate Sodium

Enema

283mg Enemeez

X X X X X X X X X X X X X X

X

X X X

X X

X X X X

X X X X X X

X

X X

Docusate Sodium Polyethylene Glycol Sennosides Sennosides Sennosides/Docusate Sodium

Calcium Carbonate Calcium Carbonate Calcium Carbonate/Vitamin D3 Calcium Carbonate/Vitamin D3 Calcium Carbonate/Vitamin D3 Calcium Citrate Calcium Citrate/Vitamin D3

Electrolytes/Dextrose Mineral Oil/Hydrophil Petrolat Mineral Oil/Petrolatum,White Zinc Oxide

Citric/Citronellyl/Hydrox/Meth Ivermectin Mineral Oil/Dimethicone Permethrin Piperonyl Butoxide/Pyrethrins Piperonyl Butoxide/Pyrethrins Piperonyl Butoxide/Pyrethrins Piperonyl Butoxide/Pyrethrins/Permethrin

Esomeprazole Magnesium Lansoprazole Omeprazole Magnesium Omeprazole Magnesium Omeprazole/Sodium Bicarbonate

Melatonin Melatonin Melatonin

Hydrocortisone Hydrocortisone

Liquid Powder Syrup Tablet Tablet

Osteoporosis Agents Suspension Tablet Tablet Tablet Tablet Tablet Tablet

Other Popsicles/Solution Ointment Cream Ointment

Pediculicide Products Gel Lotion Solution Liquid Kit Liquid Shampoo Kit

Proton Pump Inhibitors Capsule Capsule Capsule Tablet Capsule

Sleep Aid Tablet Tablet Tablet

Steroids, Topical Cream Cream

50mg/5ml Diocto 17G/Dose Miralax 8.8mg/5ml Senokot

8.6mg Senokot 8.6-50mg Senokot-S

500mg/5ml Calcium Carbonate 500mg Os-Cal 500

250mg-125u Os-Cal 250 + D 500mg-200u Os-Cal 500 + D 600mg-400u Caltrate

200mg Citracal 315mg-250u Citracal + D

Pedialyte Aquaphor Eucerin 10% Desitin

Lycelle 0.5% Sklice

Nix Ultra 1% Nix

Rid Rid 4-0.33% Rid 4-0.33-0.5% Rid

20mg Nexium 15mg Prevacid 20mg Prilosec 20mg Prilosec 20mg-1g Zegerid

1mg Melatonin 3mg Melatonin 5mg Melatonin

0.5% Cortizone 1% Cortizone

X X

X X X X X X X

X X X X X X X X

X X X X X

X X X

X X

Hydrocortisone Hydrocortisone Hydrocortisone Hydrocortisone Hydrocortisone Hydrocortisone/Aloe Vera Hydrocortisone/Aloe Vera

Oxybutynin

Cholecalciferol (Vitamin D3) Cholecalciferol (Vitamin D3) Magnesium Oxide Multivitamin Multivitamin Multivitamin with Iron Multivitamin with Iron Multivitamin with Iron and Other Minerals Multivitamin/Folic Acid/Vit K/Ubidecarenone Multivitamin/Folic Acid/Vit K/Ubidecarenone Multivitamin/Folic Acid/Vit K/Ubidecarenone Multivitamin/Phytonadione Multivitamin/Vitamin D3/Vitamin K Multivitamin/Vitamin D3/Vitamin K Multivitamin/Vitamin D3/Vitamin K Multivitamin/Vitamin D3/Vitamin K Multivitamin/Vitamin D3/Vitamin K Multivitamin/Vitamin D3/Vitamin K Multivitamin/Vitamin D3/Vitamin K Multivitamin/Vitamin K Vit A/Vit D3/Tocophersolan/Vit K Vit A/Vit D3/Vit E/Tocophersolan/Vit K

Lotion

0.5% Cortizone

X

Lotion

1% Cortizone

X

Ointment

0.5% Cortizone

X

Ointment

1% Cortizone

X

Spray

1% Cortizone

X

Cream

0.5% Cortizone Plus

X

Cream

1% Cortizone Plus

X

Urinary Tract Antispasmodics

Patch

3.9mg/24h Oxytrol For Women

X

Vitamin/Mineral

Drops

10mcg/drop Baby D Drops

X

Drops

400u/ml D-Vi-Sol

X

Tablet

400mg Mag-Ox

X

Chewable Tablet

Poly-Vi-Sol

X

Drops

250-50/ml Poly-Vi-Sol

X

Chewable Tablet

400mg Centrum Kids

X

Drops

11mg/ml Poly-Vi-Sol with Iron

X

Chewable Tablet

Centrum Jr

X

Chewable Tablet

100-350mcg Aquakeks

X

Chewable Tablet

200-1000mcg Dekas Plus

X

Capsule

200-1000mcg Dekas Plus

X

Drops

400mcg/ml Aquakeks

X

Chewable Tablet

800-600mcg Choiceful Vitamins

X

Capsule

1000-700mcg Choiceful Vitamins

X

Capsule

1500-800mcg MVW Complete Formulation

X

Chewable Tablet

1500-1000mcg MVW Complete Formulation

X

Capsule

3000-800mcg MVW Complete Formulation

X

Chewable Tablet

3000-1000mcg MVW Complete Formulation

X

Capsule

5000-800mcg MVW Complete Formulation

X

Liquid

500mcg/ml Dekas Plus

X

Liquid

2000-2000mcg Dekas Essential

X

Capsule

2000-1000mcg Dekas Essential

X

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download