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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 GENERIC NAME DOSAGE FORM STRENGTH COMMON TRADE NAME PDL* Acne PRODUCTS Adapalene Gel Differin X Analgesics Acetaminophen Liquid 160mg/5ml Tylenol Acetaminophen Suspension 160mg/5ml Tylenol Acetaminophen Suppository 120mg Feverall Acetaminophen Suppository 325mg Feverall Acetaminophen Tablet 325mg Tylenol Acetaminophen Tablet 500mg Tylenol Aspirin Chewable Tablet 81mg Bayer Children's Aspirin Enteric-Coated Tablet 81mg Ecotrin Aspirin Enteric-Coated Tablet 325mg Ecotrin Aspirin Tablet 325mg Bayer Ibuprofen Drops 50 Advil/Motrin X Ibuprofen Suspension 100mg/5ml Advil/Motrin X Ibuprofen Chewable Tablet 100mg Advil/Motrin X Ibuprofen Tablet 100mg Advil/Motrin X Ibuprofen Capsule 200mg Advil/Motrin X Ibuprofen Tablet 200mg Advil/Motrin X Naproxen Sodium Capsule 220mg Aleve X

Hydrocortisone/Aloe Vera Cream 1% Cortizone Plus X Oxybutynin Patch 3.9mg/24h Oxytrol For Women X Cholecalciferol (Vitamin D3) Drops 400u/ml D-Vi-Sol X Magnesium Oxide Tablet 400mg Mag-Ox Multivitamin Chewable Tablet Poly-Vi-Sol X Multivitamin Drops 1500-400/ml Poly-Vi-Sol X Multivitamin with Iron Chewable Tablet 400mg Centrum Kids X

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