Transcription of OTC COVERED PRODUCTS LIST
1 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 Naproxen Sodium Tablet 220mg Aleve X Anti-Diarrheals Loperamide
2 Hydrochloride Liquid 1mg/5ml Imodium AD Loperamide Hydrochloride Tablet 2mg Imodium AD Antifungals, Topical Butenafine HCL Cream 1% Lotrimin Ultra X Clotrimazole Cream 1% Lotrimin AF X Clotrimazole Solution 1% Lotrimin AF X Ketoconazole Shampoo 1% Nizoral AD X Miconazole Nitrate Cream 2% Neosporin AF X Miconazole Nitrate Liquid Spray 2% Lotrimin AF X Miconazole Nitrate Powder 2% Lotrimin AF X Miconazole Nitrate Spray Powder 2% Lotrimin AF X Miconazole Nitrate Ointment 2% Aloe Vesta X Miconazole Nitrate Tincture 2% Fungoid X Terbinafine Cream 1% Lamisil AT X Terbinafine Spray 1% Lamisil X Terbinafine Gel 1% Lamisil AT X Tolnaftate Cream 1% Tinactin X Tolnaftate Liquid Spray 1% Tinactin X Tolnaftate Powder 1% Tinactin X Tolnaftate Solution 1% Tinactin X Tolnaftate Spray Powder 1% Tinactin X Antihistamines and Antihistamine/Decongestant Combo Cetirizine Solution 5mg/5ml Zyrtec X Cetirizine Chewable Tablet 5mg Zyrtec X Cetirizine Tablet 5mg Zyrtec X Cetirizine Chewable Tablet 10mg Zyrtec X
3 Cetirizine Capsule 10mg Zyrtec X Cetirizine ODT 10mg Zyrtec X Cetirizine Tablet 10mg Zyrtec X Cetirizine/Pseudoephedrine Tablet 5mg-120mg Zyrtec-D 12 Hour X Diphenhydramine Liquid Benadryl Diphenhydramine Capsule 25mg Benadryl Doxylamine Tablet 25mg Unisom Fexofenadine Suspension 30mg/5ml Allegra X Fexofenadine ODT 30mg Children's Allegra Allergy X Fexofenadine Tablet 30mg Children's Allegra Allergy X Fexofenadine Tablet 60mg Allegra Allergy X Fexofenadine Tablet 180mg Allegra Allergy X Fexofenadine/Pseudoephedrine Tablet 60mg-240mg Allegra-D 12 Hour X Fexofenadine/Pseudoephedrine Tablet 180mg-240mg Allegra-D 24 Hour X Loratadine Solution 5mg/5ml Claritin X Loratadine Chewable Tablet 5mg Children's Claritin X Loratadine ODT 5mg Claritin X Loratadine Capsule 10mg Claritin X Loratadine ODT 10mg Claritin X Loratadine Tablet 10mg Claritin X Loratadine/Pseudoephedrine Tablet 5mg-120mg Claritin-D 12 Hour X Loratadine/Pseudoephedrine Tablet 10mg-240mg Claritin-D 24 Hour X Antivirals.
4 Topical Docosanol Cream 10% Abreva X Cough & Cold Brompheniramine/Phenylephrine/Dextrometh orphan Solution Dimetapp DM X Chlorpheniramine Maleate Tablet 4mg Chlor-Trimeton X Chlorpheniramine/Phenylephrine Liquid 4-10mg/5ml ED-A-Hist X Chlorpheniramine/Phenylephrine/Dextromet horphan Liquid 4-10-15mg/5ml ED-A-Hist DM X Dextromethorphan Polistirex Suspension 30mg/5ml Delsym ER 12 Hour X Guaifenesin Liquid 100mg/5ml Robitussin X Guaifenesin Tablet 200mg Mucus Relief X Guaifenesin Extended ReleaseTablet 600mg Mucinex X Guaifenesin Extended ReleaseTablet 1200mg Mucinex X Guaifenesin/Dextromethorphan Liquid 100-5mg/5ml Mucinex Fast-Max DM X Guaifenesin/Dextromethorphan Syrup 100-10mg/5ml Robitussin DM X Guaifenesin/Dextromethorphan Extended ReleaseTablet 600mg-30mg Mucinex DM X Guaifenesin/Dextromethorphan Extended ReleaseTablet 1200-60mg Mucinex DM X Guaifenesin/Pseudoephedrine Extended ReleaseTablet 600mg-60mg Mucinex D X Guaifenesin/Pseudoephedrine Extended ReleaseTablet 1200mg-120mg Mucinex D X Eye & Ear Preparations Ketotifen Fumarate Drops Zaditor X Mineral Oil/Petrolatum, White Ointment Lacri-Lube Polyvinyl Alchohol Drops Akwa Tears Polyvinyl Alchohol/Povidone Drops Artificial Tears Intranasal Agents Budesonide Spray 32mcg Rhinocort X Fluticasone Furoate Spray Flonase Sensimist X Fluticasone Propionate Spray 50mcg Flonase X Triamcinolone Acetonide Spray 55mcg Nasacort X Iron Replacements Ferrous Sulfate Drops 15mg/ml Fer-In-Sol Ferrous Sulfate Elixir 220mg/5ml Ferrous Sulfate Ferrous Sulfate Solution 220 (44)
5 /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 Docusate Sodium Liquid 50mg/5ml Diocto Polyethylene Glycol Powder 17G/Dose Miralax Sennosides Syrup Senokot Sennosides Tablet Senokot Sennosides/Docusate Sodium Tablet Senokot-S Osteoporosis Agents Calcium Carbonate Suspension 500mg/5ml Calcium Carbonate Calcium Carbonate Tablet 500mg Os-Cal 500 Calcium Carbonate/Vitamin D3 Tablet 250mg-125u Os-Cal 250 + D Calcium Carbonate/Vitamin D3 Tablet 500mg-200u Os-Cal 500 + D Calcium Carbonate/Vitamin D3 Tablet 600mg-400u Caltrate Calcium Citrate Tablet 200mg Citracal Calcium Citrate/Vitamin D3 Tablet 315mg-250u Citracal + D Other Electrolytes/Dextrose Popsicles/Solution Pedialyte Mineral Oil/Hydrophil Petrolat Ointment Aquaphor Mineral
6 Oil/Petrolatum,White Cream Eucerin Zinc Oxide Ointment 10% Desitin Pediculicide PRODUCTS Citric/Citronellyl/Hydrox/Meth Gel Lycelle X Permethrin Liquid 1% Nix X Permethrin Kit Nix Complete X Piperonyl Butoxide/Pyrethrins Kit Rid X Piperonyl Butoxide/Pyrethrins Liquid Rid X Piperonyl Butoxide/Pyrethrins Liquid Rid X Piperonyl Butoxide/Pyrethrins Shampoo Rid X Piperonyl Butoxide/Pyrethrins/Permethrin Kit Rid X Proton Pump Inhibitors Esomeprazole Magnesium Capsule 20mg Nexium X Lansoprazole Capsule 15mg Prevacid X Omeprazole Magnesium Capsule 20mg Prilosec X Omeprazole Magnesium Tablet 20mg Prilosec X Omeprazole/Sodium Bicarbonate Capsule 20mg-1g Zegerid X Steroids, Topical Hydrocortisone Cream Cortizone X Hydrocortisone Cream 1% Cortizone X Hydrocortisone Lotion Cortizone X Hydrocortisone Lotion 1% Cortizone X Hydrocortisone Ointment Cortizone X Hydrocortisone Ointment 1% Cortizone X Hydrocortisone Spray 1% Cortizone X Hydrocortisone/Aloe Vera Cream Cortizone Plus X Hydrocortisone/Aloe Vera Cream 1% Cortizone Plus X Urinary Tract Antispasmodics Oxybutynin Patch Oxytrol For Women X Vitamin/Mineral Cholecalciferol (Vitamin D3)
7 Drops 400u/ml D-Vi-Sol Magnesium Oxide Tablet 400mg Mag-Ox Multivitamin Chewable Tablet Poly-Vi-Sol Multivitamin Drops 1500-400/ml Poly-Vi-Sol Multivitamin Drops 750-35/ml Poly-Vi-Sol Multivitamin with Iron Chewable Tablet 400mg Centrum Kids Multivitamin with Iron Drops 1500-10/ml Poly-Vi-Sol with Iron Multivitamin with Iron Drops 750-10/ml Poly-Vi-Sol with Iron Multivitamin with Iron and Other Minerals Chewable Tablet Centrum Jr Multivitamin/Folic Acid/Vitamin K/Ubidecarenone Chewable Tablet 100-350mcg Aquakeks Multivitamin/Folic Acid/Vitamin K/Ubidecarenone Capsule 100-700mcg Aquakeks Multivitamin/Folic Acid/Vitamin K/Ubidecarenone Chewable Tablet 200-1000mcg Dekas Plus Multivitamin/Folic Acid/Vitamin K/Ubidecarenone Capsule 200-1000mcg Dekas Plus Multivitamin/Phytonadione Drops 400mcg/ml Aquakeks Multivitamin/Vitamin D3/Vitamin K Chewable Tablet 800-600mcg Choiceful Vitamins Multivitamin/Vitamin D3/Vitamin K Capsule 1000-700mcg Choiceful Vitamins Multivitamin/Vitamin D3/Vitamin K Capsule 1500-800mcg MVW Complete Formulation Multivitamin/Vitamin D3/Vitamin K Chewable Tablet 1500-1000mcg MVW Complete Formulation Multivitamin/Vitamin D3/Vitamin K Capsule 3000-800mcg MVW Complete Formulation Multivitamin/Vitamin D3/Vitamin K Chewable Tablet 3000-1000mcg MVW Complete Formulation Multivitamin/Vitamin D3/Vitamin K Capsule 5000-800mcg MVW Complete Formulation Multivitamin/Vitamin K Liquid 500mcg/ml Dekas Plus Multivitamin/Zinc Gluconate Drops 5mg/ml Source CF Vitamin A/Vitamin D3/Tocophersolan/Vitamin K Liquid 2000-2000mcg Dekas Essential Vitamin A/Vitamin D3/Vitamin E/Tocophersolan/Vit K Capsule 2000-1000mcg Dekas Essential
