commonly covered over-the counter items...anti-infective agents anthelmintics reese's pinworm...

77
BlueChoice® HealthPlan of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC, an independent company, for services to support administration of Healthy Connections. Commonly Covered Over-the Counter Items Legend In each class, drugs are listed alphabetically by either brand name or generic name. Brand name drug: Uppercase in bold type Generic drug: Lowercase in plain type AL: Age Limit Restrictions OTC: Over the counter medication available with a prescription. (Prescribers please indicate OTC on the prescription) PA: Prior authorization is required. Prior authorization is the process of obtaining approval of benefits before certain prescriptions are filled. QL: Quantity limits; certain prescription medications have specific quantity limits per prescription or per month.

Upload: others

Post on 04-Jul-2020

5 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

BlueChoice® HealthPlan of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC, an independent company, for services to support administration of Healthy Connections.

Commonly Covered

Over-the Counter Items

Legend

In each class, drugs are listed alphabetically by either brand name or generic name.

Brand name drug: Uppercase in bold type

Generic drug: Lowercase in plain type

AL: Age Limit Restrictions

OTC: Over the counter medication available with a prescription. (Prescribers please indicate OTC on the prescription)

PA: Prior authorization is required. Prior authorization is the process of obtaining approval of benefits before certain prescriptions are filled.

QL: Quantity limits; certain prescription medications have specific quantity limits per prescription or per month.

Page 2: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

CURRENT AS OF 7/23/2019

Drug Name Reference Notes

ALTERNATIVE THERAPY

ALTERNATIVE THERAPY

ANTIOXIDANT A/C/E/SELENIUM ORAL CAPSULE

OTC

e-400 c-500 and beta carotene oral tablet OTC

eye health plus lutein oral tablet OTC

glucosamine-chondroitin complx oral capsule

OTC

healthy eyes oral tablet OTC

healthy eyes supervision oral capsule OTC

icaps areds oral capsule OTC

i-vite oral tablet OTC

i-vite protect oral tablet OTC

kelp-lecithin-b6 oral tablet OTC

lecithin-kelp-b6 (100-8.3) oral tablet OTC

lecithin-kelp-b6 (400-20) oral tablet OTC

lecithin-kelp-b6 oral capsule OTC

opti-vitamins oral tablet OTC

prosight oral tablet OTC

super antioxidant oral capsule OTC

ULTRA ANTIOXIDANT FORMULA ORAL TABLET

OTC

ANALGESIC, ANTI-INFLAMMATORY OR ANTIPYRETIC

ANALGESIC/ANTIPYRETICS, NON-SALICYLATE

acetadryl oral tablet AL; OTC

aceta-gesic oral tablet AL; OTC

acetaminophen pm extra str oral tablet OTC

acetaminophen pm oral tablet OTC

diphenhydramine-acetaminophen oral tablet

Acetadryl OTC

headache pm oral tablet OTC

headache relief pm oral tablet OTC

mapap pm oral tablet OTC

2

Page 3: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

menstrual relief oral tablet OTC

midol pm oral tablet OTC

non-aspirin pain relief pm oral tablet OTC

non-aspirin pm oral tablet OTC

pain relief pm oral tablet OTC

pain relief pm rapid release oral tablet OTC

pain reliever pm ex-strength oral tablet AL; OTC

pain reliever pm oral tablet AL; OTC

percogesic extra strength oral tablet AL; OTC

percogesic oral tablet AL; OTC

ANALGESIC/ANTIPYRETICS, SALICYLATES

added strength headache relief oral tablet OTC

antacid and pain relief oral tablet, effervescent

OTC

aspir-81 oral tablet,delayed release (dr/ec) OTC

aspirin childrens oral tablet,chewable OTC

aspirin low dose oral tablet,delayed release (dr/ec)

OTC

aspirin oral tablet Bayer Aspirin OTC

aspirin oral tablet,chewable Aspirin Childrens OTC

aspirin oral tablet,delayed release (dr/ec) OTC

aspirin rectal suppository OTC

aspirin, buffered oral tablet Buffered Aspirin OTC

aspir-low oral tablet,delayed release (dr/ec)

OTC

aspir-trin oral tablet,delayed release (dr/ec)

OTC

back and body pain reliever oral tablet OTC

bayer advanced oral tablet OTC

bayer aspirin oral tablet OTC

bufferin oral tablet OTC

children's aspirin oral tablet,chewable OTC

e.c. prin oral tablet,delayed release (dr/ec) OTC

efferves pain relief antacid oral tablet, effervescent

OTC

headache relief (asa-acet-caf) oral tablet OTC

lite coat aspirin oral tablet OTC

3

Page 4: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

migraine formula oral tablet OTC

migraine relief oral tablet OTC

pain reliever (acetam-aspirin) oral tablet OTC

pain reliever plus oral tablet OTC

pain-off oral tablet OTC

tri-buffered aspirin oral tablet OTC

ANALGESICS, NON-NARCOTIC

8 hour pain reliever oral tablet extended release

OTC

acetaminophen extra strength oral tablet OTC

acetaminophen oral elixir Non-Aspirin OTC

acetaminophen oral liquid Children's Silapap OTC

acetaminophen oral solution Mapap (acetaminophen) OTC

acetaminophen oral suspension BetaTemp OTC

acetaminophen oral tablet Athenol OTC

acetaminophen oral tablet extended release

8 Hour Pain Reliever OTC

acetaminophen oral tablet,disintegrating Children's Acetaminophen OTC

acetaminophen pain relief oral tablet OTC

acetaminophen rectal suppository Feverall OTC

arthritis pain relief (acetam) oral tablet extended release

OTC

arthritis pain reliever oral tablet extended release

OTC

athenol oral tablet OTC

betatemp oral suspension OTC

child pain rel-fever reducer rectal suppository

OTC

children's acetaminophen oral suspension OTC

children's acetaminophen oral tablet,chewable

OTC

children's acetaminophen oral tablet,disintegrating

OTC

children's easy-melts oral tablet,disintegrating

OTC

children's fever reducing rectal suppository

OTC

children's non-aspirin oral suspension OTC

children's non-aspirin oral tablet,chewable OTC

4

Page 5: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

children's pain relief oral suspension OTC

children's pain reliever oral suspension OTC

children's pain-fever relief oral suspension OTC

children's pain-fever relief oral tablet,disintegrating

OTC

children's silapap oral liquid OTC

children's tactinal oral tablet,chewable OTC

ed-apap oral liquid OTC

fever reducer an pain reliever oral suspension

OTC

fever reducer rectal suppository OTC

feverall rectal suppository OTC

infant fever reducer-pain relf oral suspension

OTC

infant pain reliever oral suspension OTC

infants' pain and fever oral suspension OTC

infant's pain relief oral drops,suspension OTC

infants' pain relief oral suspension OTC

infant's pain relief oral suspension OTC

infant's pain reliever oral drops,suspension

OTC

jr. acetaminophen oral tablet,disintegrating

OTC

jr. str non-aspirin pain oral tablet,disintegrating

OTC

jr. strength pain reliever oral tablet,disintegrating

OTC

little remedies fever and pain oral liquid OTC

mapap (acetaminophen) oral capsule OTC

mapap (acetaminophen) oral liquid OTC

mapap (acetaminophen) oral tablet OTC

mapap arthritis pain oral tablet extended release

OTC

mapap extra strength oral tablet OTC

masophen oral tablet OTC

non-aspirin childrens oral drops OTC

non-aspirin extra strength oral liquid OTC

non-aspirin extra strength oral tablet OTC

non-aspirin oral elixir OTC

5

Page 6: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

non-aspirin oral suspension OTC

non-aspirin oral tablet OTC

non-aspirin oral tablet,chewable OTC

non-aspirin pain relief oral tablet OTC

nortemp oral drops OTC

nortemp oral suspension OTC

pain and fever oral tablet OTC

pain relief adult oral liquid OTC

pain relief extra strength oral tablet OTC

pain relief oral liquid OTC

pain relief oral tablet OTC

pain relief oral tablet extended release OTC

pain relief regular strength oral tablet OTC

pain reliever extra strength oral tablet OTC

pain reliever jr strength oral tablet,chewable

OTC

pain reliever oral tablet OTC

pediacare fever reducer oral suspension OTC

pharbetol oral tablet OTC

pre-menstrual relief oral tablet OTC

premsyn pms oral tablet OTC

tactinal extra strength oral tablet OTC

tactinal oral tablet OTC

tylophen oral capsule OTC

NSAIDS

advil oral tablet OTC

advil oral tablet,chewable OTC

all day pain relief oral tablet OTC

all day relief oral tablet OTC

children's advil oral suspension OTC

children's ibuprofen oral suspension 100 mg/5 ml

OTC

children's profen ib oral suspension OTC

flanax (naproxen) oral tablet OTC

ibuprofen ib oral tablet OTC

ibuprofen ib oral tablet,chewable OTC

ibuprofen jr strength oral tablet,chewable OTC

6

Page 7: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

ibuprofen oral capsule Advil Liqui-Gel OTC

ibuprofen oral drops,suspension Infant's Advil OTC

ibuprofen oral suspension Children's Advil OTC

ibuprofen oral tablet Advil OTC

ibuprofen pm oral tablet OTC

infant's ibuprofen oral drops,suspension OTC

infants profenib oral drops,suspension OTC

i-prin oral tablet OTC

mediproxen oral tablet OTC

motrin pm oral tablet OTC

naproxen sodium oral capsule Aleve OTC

naproxen sodium oral tablet Aleve OTC

provil oral tablet OTC

QC CHILD IBUPROFEN 100 MG/5 ML OTC

wal-profen oral capsule OTC

wal-profen oral tablet OTC

wal-proxen oral tablet OTC

ANORECTAL PREPARATIONS

HEMORRHOIDAL PREPARATIONS

hemorrhoid rectal ointment OTC

hemorrhoidal (phenyleph-cocoa) rectal suppository

OTC

hemorrhoidal rectal ointment OTC

hemorrhoidal rectal suppository OTC

hemorrhoidal suppository rectal suppository

OTC

ANTI-INFECTIVE AGENTS

ANTHELMINTICS

reese's pinworm medicine oral suspension OTC

ANTISEPTICS AND DISINFECTANTS

ANTISEPTICS, GENERAL

alcohol pads topical pads, medicated OTC

alcohol prep pads topical pads, medicated OTC

alcohol swabs topical pads, medicated Alcohol Pads OTC

alcohol wipes topical pads, medicated OTC

7

Page 8: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

antiseptic skin clnsr(chlorhe) topical liquid OTC

betasept surgical scrub topical liquid OTC

chlorhexidine gluconate topical liquid Dyna-Hex OTC

curity alcohol swabs topical pads, medicated

OTC

easy touch alcohol prep pads topical pads, medicated

OTC

hibiclens topical liquid OTC

hydrogen peroxide solution OTC

sure comfort alcohol prep pads topical pads, medicated

OTC

webcol topical pads, medicated OTC

DISINFECTANTS - OTHER

alcoh-wipe towelette OTC

CARDIOVASCULAR THERAPY AGENTS

LIPOTROPICS

fish oil concentrate oral capsule OTC

fish oil oral capsule,delayed release(dr/ec) OTC

GRAM-O-LECI ORAL TABLET,CHEWABLE

OTC

inositol oral tablet OTC

lecithin oral capsule OTC

lecithin, soy oral capsule OTC

maxepa oral capsule OTC

niacin oral tablet Niacor OTC

omega-3 fatty acids oral capsule Fish Oil Concentrate OTC

prenatal dha oral capsule OTC

super omega-3 oral capsule OTC

SUPER TWIN EPA-DHA ORAL CAPSULE

OTC

vitamin e oral capsule OTC

CENTRAL NERVOUS SYSTEM AGENTS

SEDATIVE-HYPNOTICS, NON-BARBITURATES

alka-seltzer plus allergy oral tablet OTC

diphenhydramine 50 mg capsule (otc) Banophen OTC

8

Page 9: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

diphenhydramine 50 mg capsule u-d (otc) Banophen OTC

diphenhydramine 50 mg capsule u-d, 10x10 (otc)

Banophen OTC

diphenhydramine hcl oral capsule 25 mg Aler-CapOTC; QL (120 capsules per 30 days)

diphenhydramine hcl oral tablet Alka-Seltzer Plus Allergy OTC

nightime sleep oral capsule OTC

nighttime sleep aid (diphen) oral capsule OTC

nighttime sleep aid (diphen) oral tablet OTC

simply sleep oral tablet OTC

sleep aid (diphenhydramine) oral capsule OTC

sleep aid (diphenhydramine) oral tablet OTC

sleep aid (doxylamine) oral tablet OTC

sleep aid max str (diphenhydr) oral capsule

OTC

sleep ii oral tablet OTC

sleep tablet (diphenhydramine) oral tablet OTC

sleep-tabs oral tablet OTC

unisom sleepgels oral capsule OTC

wal-som (diphenhydramine) oral capsule OTC

CHEMICAL DEPENDENCY, AGENTS TO TREAT

SMOKING DETERRENT AGENTS

nicorelief buccal gum OTC

nicotine (polacrilex) buccal gum Nicorelief OTC

nicotine (polacrilex) buccal lozenge Nicorette OTC

nicotine (polacrilex) buccal mini lozenge Nicorette OTC

nicotine transdermal patch 24 hour Nicoderm CQ OTC

nicotine transdermal patch, td daily, sequential

OTC

quit 2 buccal gum OTC

quit 4 buccal gum OTC

stop smoking aid buccal lozenge OTC

CHEMICALS-PHARMACEUTICAL ADJUVANTS

CHEMICALS - SOLVENTS

alcohol, rubbing solution OTC

isopropyl alcohol solution OTC

9

Page 10: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

PHARMACEUTICAL ADJUVANT

petrolatum topical ointment OTC

petroleum jelly topical gel OTC

petroleum jelly, white topical gel OTC

white petrolatum topical gel Lip Treatment OTC

white petroleum jelly topical gel OTC

CONTRACEPTIVES

CONTRACEPTIVES

TODAY CONTRACEPTIVE SPONGE VAGINAL CONTRACEPTIVE SPONGE

OTC

VAGINAL CONTRACEPTIVE FILM VAGINAL FILM

OTC

vaginal contraceptive foam vaginal foam OTC

VCF CONTRACEPTIVE FILM VAGINAL FILM

OTC

EMERGENCY CONTRACEPTIVES

econtra ez oral tabletOTC; QL (1 tablet per 30 days)

econtra one-step oral tabletOTC; QL (1 tablet per 30 days)

levonorgestrel oral tablet AfteraOTC; QL (1 tablet per 30 days)

my choice oral tabletOTC; QL (1 tablet per 30 days)

my way oral tabletOTC; QL (1 tablet per 30 days)

new day oral tabletOTC; QL (1 tablet per 30 days)

next choice one dose oral tabletOTC; QL (1 tablet per 30 days)

opcicon one-step oral tabletOTC; QL (1 tablet per 30 days)

option-2 oral tabletOTC; QL (1 tablet per 30 days)

DENTAL AIDS AND PREPARATIONS

ANTISEPTICS, GENERAL

chloraseptic mucous membrane aerosol,spray

OTC

10

Page 11: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

sore throat (hexylresorcinol) mucous membrane lozenge

OTC

FLUORIDE PREPARATIONS

fluoride (sodium) oral drops OTC; QL (2 mL per 1 day)

fluoride (sodium) oral tablet,chewable Fluoritab OTC

fluoritab oral tablet,chewable OTC

ludent fluoride oral tablet,chewable OTC

perio med dental solution OTC

MOUTH AND THROAT AGENTS

cherry cough drops mucous membrane lozenge

OTC

cherry menthol mucous membrane lozenge

OTC

chloraseptic sore throat mucous membrane lozenge

OTC

chloraseptic throat spray mucous membrane aerosol,spray

OTC

cough drops (with eucalyptus) mucous membrane lozenge

OTC

honey lemon mucous membrane lozenge OTC

medikoff drops mucous membrane lozenge

OTC

menthol drops mucous membrane lozenge

OTC

sore throat (benzocaine-menth) mucous membrane lozenge

OTC

sore throat relief (pectin) mucous membrane lozenge on a handle

OTC

throat drops mucous membrane lozenge OTC

throat lozenges mucous membrane lozenge

OTC

zinc with vitamins a and c oral lozenge OTC

DERMATOLOGICAL

ACNE AGENTS, TOPICAL

acne cleanser topical cleanser OTC

acne cleansing bar topical bar OTC

acne foaming wash topical cleanser OTC

acne medication topical gel OTC

11

Page 12: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

acne medication topical lotionOTC; QL (177 mL per 30 days)

acne pads topical pads, medicated OTC

acne treatment (benzoyl perox) topical gel OTC

acne vanishing topical cream OTC

acne-clear topical gel OTC

advanced acne wash topical cleanser,extended release

OTC

benzepro topical foam OTC

benzoyl peroxide topical cleanser Acne Control Cleanser OTC

benzoyl peroxide topical foam BenzePrO OTC

benzoyl peroxide topical gel OTC

bp foam topical foam OTC

bp gel topical gel OTC

bp topical gel OTC

bp wash acne treatment topical kit OTC

bp wash topical cleanser OTC

bpo-10 topical cleanser OTC

bpo-5 topical cleanser OTC

creamy acne face topical cleanser OTC

daily face wash topical cleanser OTC

foaming acne face wash topical cleanser OTC

NEUTROGENA ON THE SPOT TOPICAL CREAM

OTC

OC8 TOPICAL GEL OTC

panoxyl topical bar OTC

panoxyl topical cleanser OTC

persa-gel topical gel OTC

rapid clear treatment pads topical pads, medicated

OTC

RIAX TOPICAL FOAM OTC

targeted acne spot treatment topical cream

OTC

SCABICIDE AND PEDICULICIDES

complete lice treatment topical kit OTC; QL (1 kit per 30 days)

lice bedding spray aerosol,spray OTC

lice complete kit 1-2-3 topical kit OTC; QL (1 kit per 30 days)

12

Page 13: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

lice killing (permethrin) topical liquidOTC; QL (60 mL per 30 days)

lice killing topical shampoo OTC

lice pyrinyl shampoo topical shampoo OTC

lice solution topical kit OTC; QL (1 kit per 30 days)

lice treatment (permethrin) topical liquidOTC; QL (60 mL per 30 days)

lice treatment topical liquidOTC; QL (60 mL per 30 days)

lice treatment topical shampoo OTC

rid complete lice elim kit topical kit OTC; QL (1 kit per 30 days)

TOPICAL AGENTS, MISCELLANEOUS

a and d (lan, pet) topical ointment OTC

absorbine pain relieving topical gel OTC

advanced healing (petrolatum) topical ointment

OTC

alphabath topical oil OTC

ameriphor topical ointment OTC

amlactin topical lotion OTC

ammonium lactate topical cream Geri-Hydrolac OTC

ammonium lactate topical lotion AmLactin OTC

anti-dandruff topical shampoo OTC

aqua glycolic face topical cream OTC

aqua glycolic topical shampoo OTC

aqua lube topical lubricant OTC

arthricream rub topical cream OTC

aveeno intense relief topical cream OTC

bath oil topical oil OTC

beta care topical cream OTC

beta care topical lotion OTC

blue gel topical gel OTC

calamine phenolated topical lotion OTC

calamine-zinc oxide topical lotion OTC

calamine-zinc oxide-phenol topical suspension

OTC

callus remover topical adhesive patch,medicated

OTC

13

Page 14: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

callus removers topical adhesive patch,medicated

OTC

cam topical lotion OTC

CERAVE PM TOPICAL LOTION,EXTENDED RELEASE

OTC

CERAVE SUNSCREEN TOPICAL LOTION

OTC

CERAVE TOPICAL CLEANSER OTC

CERAVE TOPICAL CREAM OTC

cetaphil moisturizing topical cream OTC

cloverine topical ointment OTC

compound w topical liquid OTC

corn remover topical adhesive patch,medicated

OTC

corn-callus remover topical liquid OTC

daily moisturizing lotion topical lotion OTC

dermabase topical cream OTC

dermacerin topical cream OTC

dermaphor topical ointment OTC

dermavantage topical lotion OTC

DESENEX FOOT-SNEAKER DEODORANT TOPICAL AEROSOL POWDER

OTC

diaper rash relief topical ointment OTC

diaper rash topical ointment OTC

dr scholl's clear away topical adhesive patch,medicated

OTC

dry skin care topical lotion OTC

dry skin therapy moisturizing topical lotion OTC

dry skin therapy topical cream OTC

duofilm topical liquid OTC

emollient topical cream Aqua Glycolic Face OTC

eucerin original topical lotion OTC

excel-gel topical gel OTC

finger cream topical cream OTC

geri-hydrolac topical cream OTC

geri-hydrolac topical lotion OTC

glycerin topical liquid OTC

glycerin topical solution OTC

14

Page 15: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

gordon's vite a topical cream OTC

gordons-vite e topical cream OTC

hydrocerin (with petrolatum) topical cream OTC

hydrocerin topical lotion OTC

hydrolatum topical ointment OTC

HYPERCARE TOPICAL LIQUID OTC

ice blue gel topical gel OTC

lan-o-soothe topical cream OTC

liquid corn and callus remover topical liquid

OTC

lubriderm daily moisture (pet) topical lotion OTC

lubriderm skin nourishing topical lotion OTC

lubrisilk topical lotion OTC

lubrisoft topical lotion OTC

mapo bath topical oil OTC

mediplast corn-callus-wart topical adhesive patch,medicated

OTC

mineral oil light topical oil OTC

mineral oil topical oil Lobana Bath OTC

minerin creme topical cream OTC

minerin topical lotion OTC

moisturizing cream topical cream OTC

moiturizing lotion topical lotion OTC

mosco callus-corn remover topical liquid OTC

mosco corn remover topical adhesive patch,medicated

OTC

natural oatmeal bath treatment topical packet

OTC

oatmeal bath regular topical packet OTC

pain relief (menthol) topical gel OTC

pain relieving (menthol) topical gel OTC

pediatric oint (cod liver oil) topical ointment

OTC

petrolatum topical ointment OTC

petroleum jelly topical gel OTC

petroleum jelly, white topical gel OTC

plantar wart remover topical adhesive patch,medicated

OTC

15

Page 16: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

protective ointment topical ointment OTC

psoriasis medicated topical shampoo OTC

salactic film topical liquid OTC

sal-plant topical gel OTC

scar gel topical gel OTC

sebex topical shampoo OTC

secura protective topical ointment OTC

selsun blue (salicylic acid) topical shampoo

OTC

selsun blue naturals topical shampoo OTC

selsun blue topical shampoo OTC

skin treatment topical lotion OTC

sorbidon hydrate topical cream OTC

special care lotion topical lotion OTC

sween cream topical cream OTC

sween topical cream OTC

thera bath topical oil OTC

thera-derm topical lotion OTC

therapeutic blue topical gel OTC

therapeutic moisturizing topical cream OTC

therapeutic t plus topical shampoo OTC

ultra mide 25 topical lotion OTC

unscented cold cream topical cream OTC

urea topical cream Gormel OTC

urea topical lotion Aqua Care OTC

vanicream topical cream OTC

vitamin a and d topical ointment OTC

vitamin e plus topical cream OTC

vitamin e topical cream Gordons-Vite E OTC

vitamin e topical oil OTC

vits a and d-white pet-lanolin topical ointment

A and D (lan, pet) OTC

vits a and d-white pet-lanolin topical ointment in packet

Vitamin A and D GRx OTC

walgreens dry skin treatment topical ointment

OTC

wart remover topical adhesive patch,medicated

OTC

16

Page 17: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

wart remover topical gel OTC

wart remover topical liquid OTC

wart remover topical plaster OTC

white petrolatum topical gel Lip Treatment OTC

white petrolatum topical ointment Cloverine OTC

white petrolatum topical ointment in packet

Vaseline White Petroleum OTC

white petroleum jelly topical gel OTC

x-seb t pearl topical shampoo OTC

zinc oxide topical ointment OTC

TOPICAL ANTIBIOTICS

antibiotic (bacitracin zinc) topical ointmentOTC; QL (30 grams per 30 days)

antibiotic (neomy-bacit-polym) topical ointment

OTC; QL (30 grams per 30 days)

antibiotic-pain relief (bacit) topical ointment

OTC; QL (30 grams per 30 days)

bacitracin topical ointment Bacitraycin PlusOTC; QL (30 grams per 30 days)

bacitracin topical packetOTC; QL (30 grams per 30 days)

bacitracin zinc topical ointment Antibiotic (bacitracin zinc)OTC; QL (30 grams per 30 days)

bacitracin zinc topical packetOTC; QL (30 grams per 30 days)

bacitracin-polymyxin b topical ointment Double Antibiotic OTC

bacitracin-polymyxin b topical packet Polysporin OTC

bacitraycin plus topical ointmentOTC; QL (30 grams per 30 days)

double antibiotic (b.tracn zn) topical ointment

OTC

double antibiotic topical ointment OTC

neosporin plus painrelief(bac) topical ointment

OTC; QL (30 grams per 30 days)

POLY BACITRACIN (ZINC) TOPICAL OINTMENT

OTC

triple antibiotic plus topical ointmentOTC; QL (30 grams per 30 days)

triple antibiotic topical ointmentOTC; QL (30 grams per 30 days)

17

Page 18: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

triple antibiotic topical ointment in packet OTC

wal-sporin topical ointment OTC

TOPICAL ANTIFUNGALS

af topical aerosol powder OTC

ALEVAZOL TOPICAL OINTMENT OTC

antifungal (clotrimazole) topical creamOTC; QL (30 grams per 30 days)

antifungal (tolnaftate) topical aerosol,spray

OTC

antifungal (tolnaftate) topical cream OTC

antifungal (tolnaftate) topical powder OTC

antifungal cream (miconazole) topical cream

OTC

antifungal spray topical aerosol powder OTC

antifungal topical liquid OTC

antifungal topical solution OTC

athlete's foot (clotrimazole) topical creamOTC; QL (30 grams per 30 days)

athlete's foot (terbinafine) topical cream OTC

athlete's foot (tolnaftate) topical aerosol powder

OTC

athlete's foot (tolnaftate) topical aerosol,spray

OTC

athlete's foot (tolnaftate) topical cream OTC

athlete's foot af topical cream OTC

athlete's foot topical aerosol powder OTC

athlete's foot topical powder OTC

athletic foot cream topical creamOTC; QL (30 grams per 30 days)

azolen tincture topical tincture OTC

baza antifungal topical cream OTC

baza cream hospital care pack topical combo pack

OTC

blis-to-sol (tolnaftate) topical solution OTC

clotrimazole af topical creamOTC; QL (30 grams per 30 days)

clotrimazole topical cream Antifungal (clotrimazole)OTC; QL (30 grams per 30 days)

clotrimazole topical solution OTC

18

Page 19: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

critic-aid clear af topical ointment OTC

DERMAFUNGAL TOPICAL OINTMENT OTC

ELON DUAL DEFENSE TOPICAL SOLUTION

OTC

foot and sneaker topical aerosol powder OTC

FUNGI CURE TOPICAL SPRAY,NON-AEROSOL

OTC

FUNGI-NAIL TOPICAL SOLUTION OTC

fungoid tincture topical tincture OTC

fungoid-d topical cream OTC

GORDOCHOM TOPICAL SOLUTION OTC

HONGO CURA SPRAY TOPICAL AEROSOL,SPRAY

OTC

inzo antifungal topical cream OTC

itch relief (clotrimazole) topical creamOTC; QL (30 grams per 30 days)

jock itch (clotrimazole) topical creamOTC; QL (30 grams per 30 days)

jock itch (terbinafine) topical cream OTC

jock itch topical aerosol powder OTC

LAMISIL (AEROSOL) TOPICAL AEROSOL,SPRAY

OTC

LAMISIL AF TOPICAL AEROSOL POWDER

OTC

LAMISIL AT TOPICAL CREAM OTC

LOTRIMIN AF (CLOTRIMAZOLE) TOPICAL CREAM

OTC; QL (30 grams per 30 days)

LOTRIMIN AF JOCK ITCH POWDER TOPICAL AEROSOL POWDER

OTC

LOTRIMIN AF POWDER TOPICAL AEROSOL POWDER

OTC

LOTRIMIN AF TOPICAL AEROSOL,SPRAY

OTC

LOTRIMIN AF TOPICAL POWDER OTC

micatin topical cream OTC

miconazole nitrate topical aerosol powder Athlete's Foot OTC

miconazole nitrate topical creamAntifungal Cream (miconazole)

OTC

miconazorb af topical powder OTC

micro-guard topical powder OTC

19

Page 20: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

MYCO NAIL A TOPICAL SOLUTION OTC

MYCO NAIL TOPICAL LIQUID OTC

NIZORAL A-D TOPICAL SHAMPOO OTC

odor control foot-sneaker topical aerosol powder

OTC

remedy antifungal topical cream OTC

remedy antifungal topical powder OTC

remedy phytoplex antifungal topical ointment

OTC

remedy phytoplex antifungal topical powder

OTC

ringworm topical creamOTC; QL (30 grams per 30 days)

secura antifungal extra thick topical cream OTC

secura antifungal topical cream OTC

terbinafine hcl topical cream Antifungal (terbinafine) OTC

tinactin topical aerosol powder OTC

tinactin topical aerosol,spray OTC

tinactin topical cream OTC

tolnaftate topical aerosol powder AF OTC

tolnaftate topical cream Antifungal (tolnaftate) OTC

tolnaftate topical powder Antifungal (tolnaftate) OTC

triple paste af topical ointment OTC

UNDELENIC TOPICAL TINCTURE OTC

zeasorb af topical powder OTC

TOPICAL ANTI-INFLAMMATORY STEROIDAL AGENTS

anti-itch (hc) topical creamOTC; QL (30 grams per 30 days)

anti-itch (hc) topical ointment OTC

anti-itch plus topical creamOTC; QL (30 grams per 30 days)

cortisone (hydrocortisone) topical creamOTC; QL (30 grams per 30 days)

cortisone with aloe topical creamOTC; QL (30 grams per 30 days)

eczema anti-itch topical creamOTC; QL (30 grams per 30 days)

20

Page 21: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

hydrocortisone acetate topical cream 0.5 %

OTC

hydrocortisone acetate topical cream 1 % Vanicream HCOTC; QL (30 grams per 30 days)

hydrocortisone acetate topical ointment OTC

hydrocortisone plus topical creamOTC; QL (30 grams per 30 days)

hydrocortisone topical cream Ala-CortOTC; QL (30 grams per 30 days)

hydrocortisone topical cream in packet OTC

hydrocortisone topical ointment OTC

hydrocortisone-aloe vera topical creamAnti-Itch(hydrocortisone)-Aloe

OTC; QL (30 grams per 30 days)

hydrocream topical creamOTC; QL (30 grams per 30 days)

noble formula hc topical creamOTC; QL (30 grams per 30 days)

scalp relief topical solution OTC

scalpicin anti-itch topical solution OTC

TOPICAL ANTIVIRALS

ABREVA TOPICAL CREAM OTC

VITAMIN A DERIVATIVES

DIFFERIN TOPICAL GELOTC; QL (45 grams per 30 days)

DIAGNOSTIC AGENTS

DIAGNOSTIC - MULTIPLE URINE TESTS

AZO TEST STRIPS STRIP OTC

URINARY TRACT INF.TEST (WBCS) STRIP

OTC

EATING DISORDER THERAPY

ANTI-OBESITY AGENTS

ALLI ORAL CAPSULEPA; OTC; QL (6 capsules per 1 day)

ELECTROLYTE BALANCE-NUTRITIONAL PRODUCTS

BIOFLAVONOID COMBINATIONS

ear care oral tablet OTC

ear health formula oral tablet OTC

21

Page 22: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

CALCIUM REPLACEMENT

ca-d3-mag ox-zinc-cop-mang-bor oral tablet

Calcium 600-D3 Plus OTC

ca-d3-mag ox-zinc-cop-mang-bor oral tablet,chewable

OTC

ca-d3-mag-zinc-cop-mang-bor oral tablet OTC

calci-chew oral tablet,chewable OTC

calcitrate oral tablet OTC

calcium 500 + d (d3) oral tablet OTC

calcium 500 + d oral tablet OTC

calcium 500 + d oral tablet,chewable OTC

calcium 500 oral tablet,chewable OTC

calcium 500 with d oral tablet OTC

calcium 600 + d(3) oral capsule OTC

calcium 600 + d(3) oral tablet OTC

calcium 600 + minerals oral tablet OTC

calcium 600 oral tablet OTC

CALCIUM 600 WITH VITAMIN D3 ORAL CAPSULE

OTC

calcium 600 with vitamin d3 oral tablet,chewable

OTC

CALCIUM 600-D3 PLUS ORAL TABLET OTC

calcium carb and citrate-vitd3 oral tablet extended release

Citracal + D Slow Release OTC

calcium carbonate oral suspension OTC

calcium carbonate oral tablet Calcium 600 OTC

calcium carbonate oral tablet,chewableAntacid Ext Str (calcium carb)

OTC

calcium carbonate-vit d3-min oral tablet Calcium 600 + Minerals OTC

calcium carbonate-vitamin d3 oral capsule OTC

calcium carbonate-vitamin d3 oral tablet Calcium 500 + D OTC

calcium carbonate-vitamin d3 oral tablet,chewable

Calcium 500 + D OTC

calcium citrate + d oral tablet OTC

calcium citrate oral tablet Calcitrate OTC

calcium citrate-vitamin d2 oral tablet OTC

calcium citrate-vitamin d3 oral tablet Calcium Citrate + D OTC

calcium for women oral tablet,chewable OTC

22

Page 23: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

calcium gluconate oral tablet OTC

calcium lactate oral tablet OTC

calcium magnesium oral tablet OTC

calcium soft chew oral tablet,chewable OTC

calcium with vitamin d oral tablet OTC

calcium-folic acid-vitamin d oral wafer OTC

calcium-magnesium-zinc oral tablet OTC

calcium-vitamin d3-vitamin k oral tablet,chewable

Calcium Soft Chew OTC

citrus calcium oral tablet OTC

hi-cal plus vit d oral tablet OTC

oysco 500/d oral tablet OTC

oysco-500 oral tablet OTC

oyster shell + d3 oral tablet OTC

oyster shell calcium 500 oral tablet OTC

oyster shell calcium oral tablet OTC

oyster shell calcium-vit d2 oral tablet OTC

oyster shell calcium-vit d3 oral tablet OTC

oystercal-d oral tablet OTC

risacal-d oral tablet OTC

super calcium oral tablet OTC

DIETARY PRODUCTS

hair, skin and nails advanced oral tablet OTC

ELECTROLYTE REPLACEMENT

CERALYTE-70 ORAL SOLUTIONOTC; QL (6000 mL per 30 days)

electrolytes-dextrose oral solution Enfamil EnfalyteOTC; QL (6000 mL per 30 days)

oralyte oral solutionOTC; QL (6000 mL per 30 days)

pedialyte freezer pops oral solutionOTC; QL (6000 mL per 30 days)

pedialyte oral solutionOTC; QL (6000 mL per 30 days)

pedialyte singles oral solutionOTC; QL (6000 mL per 30 days)

pediatric electrolyte oral solutionOTC; QL (6000 mL per 30 days)

23

Page 24: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

pediatric freezer pops oral solutionOTC; QL (6000 mL per 30 days)

FOLIC ACID PREPARATIONS

elfolate oral tablet OTC

fabb oral tablet OTC

folbee oral tablet OTC

folbic oral tablet OTC

folic acid oral tablet OTC

folic acid-vit b6-vit b12 oral tablet Folplex 2.2 OTC

folplex 2.2 oral tablet OTC

levomefolate calcium oral tablet Elfolate OTC

l-methylfolate oral tablet OTC

virt-gard oral tablet OTC

virt-vite oral tablet OTC

IRON REPLACEMENT

centratex oral capsule OTC

chewable iron oral tablet,chewable OTC

children's iron oral drops OTC

corvita 150 oral tablet OTC

duofer oral tablet OTC

ezfe 200 oral capsule OTC

fe c oral tablet OTC

fe c plus oral tablet OTC; QL (1 tablet per 1 day)

ferate oral tablet OTC

ferocon oral capsule OTC

ferosul oral elixir OTC

ferosul oral tablet OTC

ferraplus 90 oral tablet OTC

ferretts oral tablet OTC

ferrex 150 forte plus oral capsule OTC

ferrex 150 oral capsule OTC

ferrex 150 plus oral capsule OTC

ferric x-150 oral capsule OTC

ferrocite oral tablet OTC

ferrocite plus oral tablet OTC

ferro-time oral tablet OTC

ferrous fumarate oral tablet Ferrocite OTC

24

Page 25: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

ferrous gluconate oral tablet Ferate OTC

ferrous sulfate oral drops Children's Iron OTC

ferrous sulfate oral elixir FeroSul OTC

ferrous sulfate oral liquid OTC

ferrous sulfate oral solution OTC

ferrous sulfate oral tablet Feosol OTC

ferrous sulfate oral tablet,delayed release (dr/ec)

OTC

ferrousul oral tablet OTC

folitab oral tablet extended release OTC

folivane-f oral capsule OTC

folivane-plus oral capsule OTC

hematinic plus vit/minerals oral tablet OTC

hematinic/folic acid oral tablet OTC

hematogen fa oral capsule OTC

hematogen forte oral capsule OTC

hematogen oral capsule OTC

hemetab oral tablet OTC; QL (1 tablet per 1 day)

high potency iron oral tablet OTC

iferex 150 oral capsule OTC

iron (dried) oral tablet extended release OTC

iron (ferrous sulfate) oral tablet OTC

iron 100 plus oral tablet OTC; QL (1 tablet per 1 day)

iron chews oral tablet,chewable OTC

iron oral tablet OTC

iron oral tablet extended release OTC

iron, carbonyl oral tablet Feosol OTC

iron,carbonyl-vitamin c oral tablet FE C OTC

multigen folic oral tablet OTC

multigen oral tablet OTC

multigen plus oral tablet OTC

myferon 150 forte oral capsule OTC

myferon 150 oral capsule OTC

pedia iron oral drops OTC

poly-iron oral capsule OTC

slow release iron oral tablet extended release

OTC

25

Page 26: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

stress formula oral tablet OTC

taron forte oral capsule OTC

tricon oral capsule OTC

trigels-f forte oral capsule OTC

wee care oral suspension OTC

IRRIGATION SOLUTIONS

sterile saline irrigation solution OTC

MINERALS AND ELECTROLYTES AGENTS

calcium-magnesium-copper-zinc oral tablet

OTC

k-phos-neutral oral tablet OTC

laxative dietary supplement oral tablet OTC

mag 64 oral tablet,delayed release (dr/ec) OTC

mag-g oral tablet OTC

magnesium gluconate oral tablet Mag-G OTC

magnesium oral tablet OTC

magnesium oxide oral capsule OTC

magnesium oxide oral tablet 200 mg magnesium, 250 mg magnesium, 420 mg

OTC

magnesium oxide oral tablet 400 mg (241.3 mg magnesium)

MagOxOTC; QL (4 tablets per 1 day)

magnesium oxide oral tablet 400 mg magnesium

OTC; QL (4 tablets per 1 day)

magnesium oxide oral tablet 500 mgLaxative Dietary Supplement

OTC

mgo oral tabletOTC; QL (4 tablets per 1 day)

phospha 250 neutral oral tablet OTC

phosphorous oral tablet OTC

phospho-trin 250 neutral oral tablet OTC

virt-phos 250 neutral oral tablet OTC

MULTIVITAMINS

a thru z advanced formula oral tablet OTC

a thru z high potency oral tablet OTC

a thru z oral tablet OTC

a thru z select 50plus formula oral tablet OTC

a thru z select oral tablet OTC

26

Page 27: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

a thru z select women's oral tablet OTC

abc plus oral tablet OTC

actical oral capsule OTC

adults 50 plus oral tablet OTC

ANTIOXIDANT A/C/E/SELENIUM ORAL CAPSULE

OTC

apatate forte oral liquid OTC

biosupp oral liquid OTC

biotect plus oral liquid OTC

biovol oral syrup OTC

calcium citrate plus (vit b6) oral tablet OTC

centamin oral liquid OTC

centravites 50 plus oral tablet OTC

centravites oral tablet OTC

centrum women oral tablet OTC

century adults 50 plus oral tablet OTC

century cardio oral tablet OTC

century mature oral tablet OTC

century oral tablet OTC

century ultimate women's oral tablet OTC

cerovite advanced formula oral tablet OTC

cerovite senior oral tablet OTC

certa plus oral tablet OTC

certavite senior-antioxidant oral tablet OTC

certavite-antioxidant oral tablet OTC

chewable-vite oral tablet,chewable OTC

compete oral tablet OTC

complete 50+ oral tablet OTC

complete multi 50+ oral tablet OTC

complete multi oral tablet OTC

complete multivitamin oral tablet OTC

complete multivitamin-mineral oral tablet OTC

complete oral tablet OTC

complete premium vitamin oral tablet OTC

complete senior oral tablet OTC

complete women oral tablet OTC

corvita oral tablet OTC

27

Page 28: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

daily multiple for men oral tablet OTC

daily multiple oral tablet OTC

daily multiple vitamins/iron oral tablet OTC

daily multi-vitamin oral tablet OTC

daily multivitamin with iron oral tablet OTC

daily multivitamin-minerals oral tablet OTC

daily value oral tablet OTC

daily vitamin formula oral tablet OTC

daily vitamin formula-iron oral tablet OTC

daily vitamin formula-minerals oral tablet OTC

daily vitamin with iron oral tablet OTC

daily vites/iron oral tablet OTC

daily-vite oral tablet OTC

e-400 c-500 and beta carotene oral tablet OTC

eldertonic oral elixir OTC

essentia oral tablet OTC

essential daily oral tablet OTC

eye health plus lutein oral tablet OTC

fosfree oral tablet OTC

hair vitamins oral tablet OTC

hair,skin and nails oral tablet OTC

healthy eyes oral tablet OTC

healthy eyes supervision oral capsule OTC

icaps areds oral capsule OTC

i-vite oral tablet OTC

i-vite protect oral tablet OTC

macuvite eye care oral tablet OTC

maximum daily multivitamin oral tablet OTC

mega multi for women oral tablet OTC

mega multiple/chelated mineral oral tablet OTC

mega multivitamin for men oral tablet OTC

mega multivitamin with mineral oral tablet OTC

men's daily multivit-mineral oral tablet OTC

men's one daily oral tablet OTC

milltrium senior oral tablet OTC

multi complete with iron oral tablet OTC

multi for her oral tablet OTC

28

Page 29: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

multi-day with iron oral tablet OTC

multi-delyn with iron oral liquid OTC

multiple vitamin-minerals oral tablet OTC

multiple vitamins oral tablet OTC

multivitamin 50 plus oral tablet OTC

multi-vitamin hp/minerals oral capsule OTC

multivitamin oral capsule OTC

multivitamin oral tablet Daily Multi-Vitamin OTC

multivitamin with iron oral tablet Daily Multiple Vitamins/Iron OTC

multivitamin with minerals oral liquid OTC

multivitamin with minerals oral tablet Daily Multivitamin-Minerals OTC

my-vitalife oral capsule OTC

ocutabs oral tablet OTC

omnicap oral tablet OTC

once daily oral tablet OTC

one daily calcium/iron oral tablet OTC

one daily complete oral tablet OTC

one daily energy oral tablet OTC

one daily essential oral tablet OTC

one daily for men 50+ advanced oral tablet

OTC

one daily for women oral tablet OTC

one daily maximum oral tablet OTC

one daily men's 50 plus memory oral tablet

OTC

one daily multi-vit w-mineral oral tablet OTC

one daily multivitamin oral tablet OTC

one daily multivit-iron(folic) oral tablet OTC

one daily oral tablet OTC

one daily plus iron oral tablet OTC

one daily plus minerals oral tablet OTC

one daily with iron oral tablet OTC

one daily womens 50 plus oral tablet OTC

one daily women's health oral tablet OTC

one daily women's oral tablet OTC

ONE-A-DAY ESSENTIAL ORAL TABLET

OTC

29

Page 30: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

ONE-A-DAY MAXIMUM FORMULA ORAL TABLET

OTC

ONE-A-DAY TEEN ADVANTAGE ORAL TABLET

OTC

opti-vitamins oral tablet OTC

purevit dualfe plus oral capsule OTC

quintabs-m iron free oral tablet OTC

senior tabs oral tablet OTC

sentry oral tablet OTC

sentry senior oral tablet OTC

se-tan plus oral capsule OTC

spectravite adult 50 plus oral tablet OTC

SPECTRAVITE ADVANCED FORMULA ORAL TABLET

OTC

SPECTRAVITE MEN'S ORAL TABLET OTC

SPECTRAVITE SENIOR ORAL TABLET OTC

SPECTRAVITE ULTRA WOMEN ORAL TABLET

OTC

SPECTRAVITE ULTRA WOMEN'S SR ORAL TABLET

OTC

sunvite oral tablet OTC

super antioxidant oral capsule OTC

super multiple oral tablet OTC

super multivitamin oral tablet OTC

super thera vite m oral tablet OTC

support oral liquid OTC

tab-a-vite oral tablet OTC

tab-a-vite/iron oral tablet OTC

thera m plus (ferrous fumarat) oral tablet OTC

thera oral tablet OTC

theralogix companion oral tablet OTC

thera-m oral tablet OTC

therapeutic liquid oral liquid OTC

therapeutic-m oral tablet OTC

therapeutic-m vitamin/minerals oral tablet OTC

thera-tabs m oral tablet OTC

thera-tabs oral tablet OTC

theratrum complete 50 plus/lut oral tablet OTC

30

Page 31: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

theratrum complete 50 plus-lyc oral tablet OTC

theratrum complete with lutein oral tablet OTC

therems oral tablet OTC

therems-m oral tablet OTC

thrivite-19 oral tablet OTC; QL (1 tablet per 1 day)

tyr cooler oral liquid OTC

ultimate women's complete 50+ oral tablet OTC

ULTRA ANTIOXIDANT FORMULA ORAL TABLET

OTC

unicomplex-m oral tablet OTC

UROSEX ORAL TABLET OTC

v-c forte oral capsule OTC

vic-forte oral capsule OTC

vit 3 oral capsule OTC

vitacel (with lutein) oral tablet OTC

vitalee oral tablet OTC

vitamins a and d oral capsule OTC

vitamins and minerals oral tablet OTC

vitamins for hair oral tablet OTC

vitatrum oral tablet OTC

vitrum senior oral tablet OTC

women's daily formula oral tablet OTC

yelets oral tablet OTC

PEDIATRIC VITAMIN PREPARATIONS

animal chews oral tablet,chewable OTC

animal shape vitamins oral tablet,chewable

OTC

animal shapes complete oral tablet,chewable

OTC

cerovite jr oral tablet,chewable OTC

chewable-vite oral tablet,chewable OTC

chewable-vite with iron oral tablet,chewable

OTC

children's chewable multivitmn oral tablet,chewable

OTC

children's chewable vitamin oral tablet,chewable

OTC

31

Page 32: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

children's chewables extra c oral tablet,chewable

OTC

children's chewables oral tablet,chewable OTC

children's chewables with iron oral tablet,chewable

OTC

childs chew vite oral tablet,chewable OTC

child's chewable vitamins/iron oral tablet,chewable

OTC

childs/iron oral tablet,chewable OTC

dino-life oral tablet,chewable OTC

dino-life with extra c oral tablet,chewable OTC

dino-life with iron-zinc oral tablet,chewable OTC

FLINTSTONES MULTI-VIT GUMMIES ORAL TABLET,CHEWABLE

OTC

gummi bear multivitamin oral tablet,chewable

OTC

gummy dinos oral tablet,chewable OTC

honey bears oral tablet,chewable OTC

little animals oral tablet,chewable OTC

little animals-iron oral tablet,chewable OTC

lysiplex plus oral liquid OTC

multi-vit with fluoride-iron oral drops OTC

multi-vitamin with fluoride oral drops OTC

multivitamin with fluoride oral tablet,chewable

OTC

multi-vitamin with fluoride oral tablet,chewable

OTC

multivitamins with fluoride oral tablet,chewable

OTC

mvc-fluoride oral tablet,chewable OTC

PEDIA POLY-VITE ORAL DROPS OTC

polyvitamin with iron oral tablet,chewable OTC

poly-vitamins oral tablet,chewable OTC

triple vitamin with fluoride oral drops OTC

tri-vitamin with fluoride oral drops OTC

tri-vite with fluoride oral drops OTC

vitalets oral tablet,chewable OTC

vitamins a,c,d and fluoride oral drops OTC

zoo chews oral tablet,chewable OTC

32

Page 33: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

POTASSIUM REPLACEMENT

potassium gluconate oral tablet OTC

PRENATAL VITAMIN PREPARATIONS

classic prenatal oral tablet OTC; QL (1 tablet per 1 day)

daily prenatal oral combo packOTC; QL (2 tablets per 1 day)

kpn oral tablet OTC; QL (1 tablet per 1 day)

one daily prenatal oral combo packOTC; QL (2 tablets per 1 day)

perry prenatal oral capsuleOTC; QL (1 capsule per 1 day)

pnv cmb#95-ferrous fumarate-fa oral tablet

Prenatal OTC; QL (1 tablet per 1 day)

prenatal + dha oral combo packOTC; QL (2 tablets per 1 day)

prenatal 19 (with docusate) oral tablet OTC; QL (1 tablet per 1 day)

prenatal 19 oral tablet,chewable OTC; QL (1 tablet per 1 day)

prenatal complete oral tablet OTC; QL (1 tablet per 1 day)

prenatal formula oral tablet OTC; QL (1 tablet per 1 day)

prenatal multi-dha (algal oil) oral capsuleOTC; QL (1 capsule per 1 day)

prenatal multivitamins oral tablet OTC; QL (1 tablet per 1 day)

prenatal one daily oral tablet OTC; QL (1 tablet per 1 day)

prenatal oral tablet OTC; QL (1 tablet per 1 day)

prenatal tablet oral tablet OTC; QL (1 tablet per 1 day)

prenatal vitamin oral tablet OTC; QL (1 tablet per 1 day)

prenatal vitamin with minerals oral tablet OTC; QL (1 tablet per 1 day)

prenatal vit-iron fum-folic ac oral tablet Prenatal Tablet OTC; QL (1 tablet per 1 day)

prenatal vits96-iron fum-folic oral tablet OTC; QL (1 tablet per 1 day)

thrivite-19 oral tablet OTC; QL (1 tablet per 1 day)

VITAMIN A PREPARATIONS

vitamin a oral capsule OTC

VITAMIN B PREPARATIONS

apetigen plus oral liquid OTC

b complex 1 oral tablet OTC

b complex 100 oral tablet OTC

b complex-vitamin b12 oral tablet OTC

33

Page 34: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

b complex-vitamin c-folic acid oral tablet OTC

b-100 complex oral tablet extended release

OTC

b-12 dots oral tablet OTC

balance b-100 oral tablet OTC

balance b-50 oral tablet OTC

balanced b-100 complex oral tablet extended release

OTC

balanced b-100 oral tablet OTC

balanced b-50 complex oral tablet OTC

balanced b-50 oral tablet OTC

b-complex oral tablet OTC

b-complex with vitamin c oral capsule Super B/C OTC

b-complex with vitamin c oral tablet Super B Complex-Vitamin C OTC

b-complex with vitamin c oral tablet extended release

OTC

complex b-100 oral tablet extended release

OTC

cyanocobalamin (vitamin b-12) oral liquid Liquid B-12 OTC

cyanocobalamin (vitamin b-12) oral tablet Vitamin B-12 OTC

cyanocobalamin (vitamin b-12) oral tablet extended release

Vitamin B-12 OTC

cyanocobalamin (vitamin b-12) sublingual drops

OTC

cyanocobalamin (vitamin b-12) sublingual lozenge

OTC

cyanocobalamin (vitamin b-12) sublingual tablet

Vitamin B-12 OTC

dialyvite 800 oral tablet OTC

dialyvite oral tablet OTC

fabb oral tablet OTC

folbee oral tablet OTC

folbee plus oral tablet OTC

folbic oral tablet OTC

folic acid-vit b6-vit b12 oral tablet Folplex 2.2 OTC

folplex 2.2 oral tablet OTC

foltabs 800 oral tablet OTC

full spectrum b-vitamin c oral tablet OTC

kobee oral tablet OTC

34

Page 35: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

mynephrocaps oral capsule OTC

mynephron oral capsule OTC

natural b-100 complex oral tablet OTC

nephplex rx oral tablet OTC

nephronex oral liquid OTC

nephronex-sl oral tablet,disintegrating OTC

nephro-vite rx oral tablet OTC

niacin (inositol niacinate) oral capsule Niacin Flush Free OTC

niacin (niacinamide) oral tablet OTC

niacin flush free oral capsule OTC

niacin oral capsule, extended release 250 mg

OTC; QL (2 capsules per 1 day)

niacin oral capsule, extended release 500 mg

OTC; QL (4 capsules per 1 day)

niacin oral tablet OTC

niacin oral tablet extended release Endur-Acin OTC

niacinamide oral tablet Niacin (niacinamide) OTC

pantothenic acid (vit b5) oral tablet OTC

pyridoxine (vitamin b6) oral tablet Vitamin B-6 OTC

renal caps oral capsule OTC

rena-vite oral tablet OTC

rena-vite rx oral tablet OTC

reno caps oral capsule OTC

riboflavin (vitamin b2) oral tablet Vitamin B-2 OTC

slo-niacin oral tablet extended release OTC

stress b plus zinc oral tablet OTC

stress b with zinc oral tablet OTC

stress formula 600 c oral tablet OTC

stress formula oral tablet OTC

stress formula with iron oral tablet OTC

stress formula with iron(sulf) oral tablet OTC

stress formula with zinc oral tablet OTC

super b complex-vitamin c oral tablet OTC

super b maxi complex oral tablet OTC

super b/c oral capsule OTC

super b-50 complex oral capsule OTC

super b-50 complex plus oral tablet OTC

35

Page 36: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

super quints b-50 oral tablet OTC

super quints oral tablet OTC

superplex-t oral tablet OTC

thiamine hcl (vitamin b1) oral tablet Vitamin B-1 OTC

thiamine mononitrate (vit b1) oral tablet Vitamin B-1 (mononitrate) OTC

total b/c oral tablet OTC

triphrocaps oral capsule OTC

ultra b-100 complex oral tablet OTC

virt-gard oral tablet OTC

virt-vite oral tablet OTC

vitamin b complex oral capsule Super B-50 Complex OTC

vitamin b complex oral tablet B Complex 1 OTC

vitamin b complex-folic acid oral tablet B Complex 100 OTC

vitamin b-1 (mononitrate) oral tablet OTC

vitamin b-1 oral tablet OTC

vitamin b-12 oral tablet OTC

vitamin b-12 oral tablet extended release OTC

vitamin b-12 sublingual tablet OTC

vitamin b-2 oral tablet OTC

vitamin b-6 oral tablet OTC

vitamins b complex oral capsule OTC

vitamins b complex oral tablet OTC

vitamins for hair oral tablet OTC

vp-vite rx oral tablet OTC

VITAMIN C PREPARATIONS

acerola c-500 oral wafer OTC

ascorbate calcium (vitamin c) oral tablet OTC

ascorbic acid (vitamin c) oral capsule, extended release

Vitamin C OTC

ascorbic acid (vitamin c) oral syrup OTC

ascorbic acid (vitamin c) oral tablet C-1000 OTC

ascorbic acid (vitamin c) oral tablet extended release

OTC

ascorbic acid (vitamin c) oral tablet,chewable

Acerola C OTC

c complex oral tablet extended release OTC

c-1000 oral tablet OTC

c-1000 oral tablet extended release OTC

36

Page 37: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

c-1000 with rose hips oral tablet OTC

c-500 oral tablet OTC

c-500 oral tablet extended release OTC

c-500 oral tablet,chewable OTC

endur-c with rose hips oral tablet extended release

OTC

fruit c oral tablet,chewable OTC

fruit c-500 oral tablet,chewable OTC

halls defense oral lozenge OTC

soothing pureway-c oral tablet OTC

strawberry c oral tablet,chewable OTC

vita-c oral crystals OTC

vitamin c drops oral lozenge OTC

vitamin c oral capsule, extended release OTC

vitamin c oral powder OTC

vitamin c oral tablet OTC

vitamin c oral tablet extended release OTC

vitamin c oral tablet,chewable OTC

vitamin c with rose hips oral tablet OTC

vitamin c with rose hips oral tablet extended release

OTC

VITAMIN D PREPARATIONS

calcidol oral drops OTC

cholecalciferol (vitamin d3) oral capsule Dialyvite Vitamin D OTC

cholecalciferol (vitamin d3) oral drops D-Vi-Sol OTC

cholecalciferol (vitamin d3) oral tablet Delta D3 OTC

cholecalciferol (vitamin d3) oral tablet,chewable

Kids First Vitamin D3 OTC

d3-2000 oral capsule OTC

delta d3 oral tablet OTC

dialyvite vitamin d oral capsule OTC

ergocalciferol (vitamin d2) oral drops Calcidol OTC

ergocalciferol (vitamin d2) oral tablet OTC

replesta oral wafer OTC

thera-d oral tablet OTC

vitajoy daily d oral tablet,chewable OTC

vitamin d3 oral capsule OTC

vitamin d3 oral tablet OTC

37

Page 38: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

vitamin d3 oral tablet,chewable OTC

VITAMIN E PREPARATIONS

vitamin e (dl, acetate) oral capsule OTC

vitamin e acetate oral capsule OTC

vitamin e mixed oral capsule OTC

vitamin e oral capsule OTC

VITAMIN K PREPARATIONS

phytonadione (vitamin k1) oral tablet OTC

VITAMINS

biotin oral capsule Meribin OTC

biotin oral tablet OTC

ZINC REPLACEMENT

chelated zinc oral tablet OTC

zinc amino acid chelate oral tablet OTC

zinc gluconate oral tablet OTC

zinc oral tablet Chelated Zinc OTC

zinc sulfate oral capsule Orazinc OTC

zinc sulfate oral tablet OTC

zinc-220 oral capsule OTC

zinc-vit c-pyridoxine (vit b6) oral lozenge OTC

ENDOCRINE

HYPERGLYCEMICS

dex4 glucose bits oral tablet,chewable OTC

dex4 glucose oral tablet,chewable OTC

dex4 glucose pouch pack oral tablet,chewable

OTC

dex4 glucose quick dissolve oral tablet,chewable

OTC

dextrose oral gel Dex4 Glucose OTC

gluco burst oral gel OTC

glucose bits oral tablet,chewable OTC

glucose gel oral gel OTC

glucose oral tablet,chewable Dex4 Glucose OTC

38

Page 39: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

GASTROINTESTINAL THERAPY AGENTS

ANTACIDS

acid gone antacid e.strength oral tablet,chewable

OTC

acid gone antacid oral suspension OTC

advanced antacid-antigas oral suspension OTC

alcalak oral tablet,chewable OTC

almacone-2 oral suspension OTC

aluminum hydroxide gel oral suspension OTC

antacid (calcium carb-mag hyd) oral tablet,chewable

OTC

antacid (calcium carbonate) oral tablet,chewable 200 mg calcium (500 mg)

OTC; QL (150 tablets per 30 days)

antacid (calcium carbonate) oral tablet,chewable 215 mg calcium (500 mg)

OTC

antacid anti-gas oral suspension OTC

antacid exst (mag carb-al hyd) oral tablet,chewable

OTC

antacid ext str (calcium carb) oral tablet,chewable

OTC

antacid extra-strength oral suspension OTC

antacid extra-strength oral tablet,chewable

OTC

antacid liquid oral suspension OTC

antacid m oral suspension OTC

antacid maximum strength oral suspension

OTC

antacid oral suspension OTC

antacid plus anti-gas oral suspension OTC

antacid regular strength oral suspension OTC

antacid supreme oral suspension OTC

antacid ultra strength oral tablet,chewable OTC

antacid-antigas oral suspension OTC

antacid-simethicone oral suspension OTC

calcium antacid oral tablet,chewable 200 mg calcium (500 mg)

OTC; QL (150 tablets per 30 days)

39

Page 40: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

calcium antacid oral tablet,chewable 300 mg (750 mg), 320 mg calcium (750 mg), 400 mg calcium (1,000 mg), 430 mg calcium (1,000 mg)

OTC

calcium antacid tropical oral tablet,chewable

OTC

calcium antacid ultra max st oral tablet,chewable

OTC

calcium carbonate oral suspension OTC

calcium carbonate oral tabletOTC; QL (4 tablets per 1 day)

calcium carbonate oral tablet,chewable 200 mg calcium (500 mg)

Antacid (calcium carbonate)OTC; QL (150 tablets per 30 days)

calcium carbonate oral tablet,chewable 300 mg (750 mg)

Antacid Ext Str (calcium carb)

OTC

calcium carbonate oral tablet,chewable 320 mg calcium (750 mg)

Antacid (calcium carbonate) OTC

calcium carbonate oral tablet,chewable 400 mg calcium (1,000 mg)

Antacid Ultra Strength OTC

cal-gest antacid oral tablet,chewableOTC; QL (150 tablets per 30 days)

children's pepto oral tablet,chewable OTC

children's soothe oral tablet,chewable OTC

comfort gel extra strength oral suspension OTC

comfort gel oral suspension OTC

flavor chews antacid oral tablet,chewable OTC

foaming antacid oral suspension OTC

foaming antacid oral tablet,chewable OTC

geri-lanta oral suspension OTC

heartburn antacid oral tablet,chewable OTC

heartburn relief oral tablet,chewable OTC

liquid antacid oral suspension OTC

maalox maximum strength oral suspension

OTC

mag-al plus extra strength oral suspension

OTC

mag-al plus oral suspension OTC

magnesium oxide oral tablet MagOxOTC; QL (4 tablets per 1 day)

masanti double strength oral suspension OTC

40

Page 41: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

mi-acid oral suspension OTC

mi-acid oral tablet,chewable OTC

mintox maximum strength oral suspension OTC

mintox oral suspension OTC

mintox plus oral tablet,chewable OTC

ri-gel ii oral suspension OTC

ri-gel oral suspension OTC

riginic oral suspension OTC

ri-mag oral suspension OTC

ri-mag plus oral suspension OTC

ri-mox oral suspension OTC

ri-mox plus oral suspension OTC

smooth antacid oral tablet,chewable OTC

sodium bicarbonate oral tablet OTC

tums ultra oral tablet,chewable OTC

ultra strength antacid oral tablet,chewable OTC

ultra strength calcium antacid oral tablet,chewable

OTC

ANTIDIARRHEALS

anti-diarrheal (loperamide) oral capsuleOTC; QL (4 capsules per 1 day)

anti-diarrheal (loperamide) oral liquid OTC; QL (80 mL per 1 day)

anti-diarrheal (loperamide) oral tabletOTC; QL (4 tablets per 1 day)

bismatrol oral suspension 262 mg/15 mlOTC; QL (80 mL per 30 days)

bismatrol oral suspension 525 mg/15 ml OTC

bismatrol oral tablet,chewable OTC

bismuth oral tablet OTC

bismuth oral tablet,chewable OTC

bismuth subsalicylate oral tablet,chewable Bismatrol OTC

diamode oral tabletOTC; QL (4 tablets per 1 day)

diarrhea relief (bismuth subs) oral suspension

OTC; QL (80 mL per 30 days)

diotame oral tablet,chewable OTC

kaopectate (bismuth subsalicy) oral suspension

OTC; QL (80 mL per 30 days)

41

Page 42: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

kaopectate ex str (bismuth ss) oral suspension

OTC

kao-tin (bismuth subsalicylat) oral suspension

OTC; QL (80 mL per 30 days)

k-pec antidiarrheal (bism sub) oral suspension

OTC; QL (80 mL per 30 days)

loperamide oral capsule Anti-Diarrheal (loperamide)OTC; QL (4 capsules per 1 day)

loperamide oral tablet Anti-Diarrheal (loperamide)OTC; QL (4 tablets per 1 day)

peptic relief oral tablet,chewable OTC

pepto-bismol oral tablet,chewable OTC

pepto-bismol to-go oral tablet,chewable OTC

pink bismuth maximum strength oral suspension

OTC

pink bismuth oral suspension 262 mg/15 ml

OTC; QL (80 mL per 30 days)

pink bismuth oral suspension 525 mg/15 ml

OTC

pink bismuth oral tablet OTC

pink bismuth oral tablet,chewable OTC

soothe (bismuth subsalicylate) oral tablet OTC

soothe (bismuth subsalicylate) oral tablet,chewable

OTC

soothe regular strength oral suspensionOTC; QL (80 mL per 30 days)

stomach relief max strength oral suspension

OTC

stomach relief oral suspension 262 mg/15 ml

OTC; QL (80 mL per 30 days)

stomach relief oral suspension 525 mg/15 ml

OTC

stomach relief oral tablet OTC

stomach relief oral tablet,chewable OTC

stomach relief original oral suspensionOTC; QL (80 mL per 30 days)

ANTIEMETIC/ANTIVERTIGO AGENTS

anti-nausea oral solution OTC

dimenhydrinate oral tablet Dramamine OTC

42

Page 43: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

dramamine less drowsy oral tablet OTC

driminate oral tablet OTC

formula em oral solution OTC

meclizine oral tablet OTC

meclizine oral tablet,chewableMotion Sickness Relief(mecliz)

OTC

medi-meclizine oral tablet OTC

motion relief (meclizine) oral tablet OTC

motion sickness (meclizine) oral tablet OTC

motion sickness ii oral tablet OTC

motion sickness oral tablet OTC

motion sickness relief oral tablet OTC

motion sickness relief(mecliz) oral tablet OTC

motion sickness relief(mecliz) oral tablet,chewable

OTC

nausea control oral solution OTC

nausea relief oral solution OTC

travel sickness (meclizine) oral tablet,chewable

OTC

travel sickness oral tablet OTC

wal-dram oral tablet OTC

ANTIFLATULENTS

anti-gas ultra strength oral capsule OTC

bicarsim forte oral tablet OTC

gas relief 80 oral tablet,chewable OTC

gas relief extra strength oral capsule OTC

gas relief extra strength oral tablet,chewable

OTC

gas relief oral capsule OTC

gas relief oral drops,suspension OTC

gas relief oral tablet,chewable OTC

gas relief ultra strength oral capsule OTC

infants gas relief oral drops,suspension OTC

mi-acid gas relief oral tablet,chewable OTC

simethicone oral capsule Anti-Gas Ultra Strength OTC

simethicone oral drops,suspension Gas Relief OTC

simethicone oral tablet,chewable Gas Relief OTC

43

Page 44: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

GASTRIC ACID SECRETION REDUCERS

acid control (ranitidine) oral tabletOTC; QL (4 tablets per 1 day)

acid controller complete oral tablet,chewable

OTC

acid controller oral tablet OTC

acid reducer (famotidine) oral tablet OTC

acid reducer (omeprazole) oral capsule,delayed release(dr/ec)

OTC; QL (1 capsule per 1 day)

acid reducer (ranitidine) oral tablet 150 mgOTC; QL (4 tablets per 1 day)

acid reducer (ranitidine) oral tablet 75 mg OTC

acid reducer complete (famot) oral tablet,chewable

OTC

complete oral tablet,chewable OTC

cvs esomeprazole mag 20 mg cap (otc) Heartburn TreatmentOTC; QL (2 capsules per 1 day)

cvs esomeprazole mag 20 mg cap inner (otc)

Heartburn TreatmentOTC; QL (2 capsules per 1 day)

cvs esomeprazole mag 20 mg cap outer (otc)

Heartburn TreatmentOTC; QL (2 capsules per 1 day)

dual action complete oral tablet,chewable OTC

eq ranitidine 150 mg tablet maximum strength (otc)

Acid Control (ranitidine)OTC; QL (4 tablets per 1 day)

esomeprazole mag dr 20 mg cap (otc) Heartburn TreatmentOTC; QL (2 capsules per 1 day)

esomeprazole mag dr 20 mg cap inner (otc)

Heartburn TreatmentOTC; QL (2 capsules per 1 day)

esomeprazole mag dr 20 mg cap outer (otc)

Heartburn TreatmentOTC; QL (2 capsules per 1 day)

famotidine oral tablet Acid Controller OTC

heartburn prevention oral tablet OTC

heartburn relief (famotidine) oral tablet OTC

heartburn relief (ranitidine) oral tablet 150 mg

OTC; QL (4 tablets per 1 day)

heartburn relief (ranitidine) oral tablet 75 mg

OTC

heartburn treatment 24 hour oral capsule,delayed release(dr/ec)

OTC; QL (2 capsules per 1 day)

44

Page 45: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

hm esomeprazole mag dr 20 mg (otc) Heartburn TreatmentOTC; QL (2 capsules per 1 day)

lansoprazole oral capsule,delayed release(dr/ec)

Heartburn Treatment 24 Hour

OTC; QL (1 capsule per 1 day)

NEXIUM 24HR ORAL CAPSULE,DELAYED RELEASE(DR/EC)

OTC; QL (2 capsules per 1 day)

NEXIUM 24HR ORAL TABLET,DELAYED RELEASE (DR/EC)

OTC; QL (2 capsules per 1 day)

omeprazole magnesium oral capsule,delayed release(dr/ec)

Acid Reducer (omeprazole)OTC; QL (2 capsules per 1 day)

omeprazole oral tablet,delayed release (dr/ec)

OTC; QL (2 tablets per 1 day)

omeprazole oral tablet,disintegrat, delay rel

OTC

OMEPRAZOLE-SODIUM BICARBONATE ORAL CAPSULE

OmePPiOTC; QL (1 capsule per 1 day)

pepcid ac oral tablet OTC

PREVACID 24HR ORAL CAPSULE,DELAYED RELEASE(DR/EC)

OTC; QL (2 capsules per 1 day)

PRILOSEC OTC ORAL TABLET,DELAYED RELEASE (DR/EC)

OTC; QL (2 tablets per 1 day)

pub ranitidine 150 mg tablet (otc) Acid Control (ranitidine)OTC; QL (4 tablets per 1 day)

ra esomeprazole mag dr 20 mg (otc) Heartburn TreatmentOTC; QL (2 capsules per 1 day)

ranitidine 150 mg tablet (otc) Acid Control (ranitidine)OTC; QL (4 tablets per 1 day)

ranitidine 150 mg tablet maximum strength (otc)

Acid Control (ranitidine)OTC; QL (4 tablets per 1 day)

ranitidine hcl oral tablet 75 mg Acid Control (ranitidine) OTC

sm esomeprazole mag dr 20 mg (otc) Heartburn TreatmentOTC; QL (2 capsules per 1 day)

wal-zan 150 oral tabletOTC; QL (4 tablets per 1 day)

wal-zan 75 oral tablet OTC

ZANTAC 75 ORAL TABLET OTC

zantac maximum strength oral tabletOTC; QL (4 tablets per 1 day)

ZEGERID OTC ORAL CAPSULEOTC; QL (1 capsule per 1 day)

45

Page 46: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

LAXATIVES AND CATHARTICS

alophen oral tablet,delayed release (dr/ec)OTC; QL (33 tablets per 30 days)

bisacodyl oral tablet,delayed release (dr/ec)

AlophenOTC; QL (33 tablets per 30 days)

bisacodyl rectal suppository Dulcolax (bisacodyl) OTC

bisa-lax oral tablet,delayed release (dr/ec)OTC; QL (33 tablets per 30 days)

chocolate laxative oral tablet,chewable OTC

citrate of magnesia oral solution OTC

citroma oral solution OTC

citrucel oral tablet OTC

clearlax oral powder OTC

col-rite oral capsule 100 mgOTC; QL (3 capsules per 1 day)

col-rite oral capsule 250 mg OTC

diocto oral liquid OTC

diocto oral syrup OTC

dioctyl oral syrup OTC

docu oral liquid OTC

docuprene oral tablet OTC

docusate calcium oral capsule Kao-Tin (docusate calcium) OTC

docusate sodium oral capsule 100 mg Col-RiteOTC; QL (3 capsules per 1 day)

docusate sodium oral capsule 250 mg Col-Rite OTC

docusate sodium oral liquid Diocto OTC

docusate sodium oral tablet Docuprene OTC

docusil oral capsuleOTC; QL (3 capsules per 1 day)

dok oral capsule 100 mgOTC; QL (3 capsules per 1 day)

dok oral capsule 250 mg OTC

dok oral tablet OTC

dok plus oral tablet OTC

dss oral capsule OTC

ducodyl oral tablet,delayed release (dr/ec)OTC; QL (33 tablets per 30 days)

dulcoease oral capsuleOTC; QL (3 capsules per 1 day)

46

Page 47: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

dulcolax stool softener (dss) oral capsuleOTC; QL (3 capsules per 1 day)

easy fiber oral powder OTC

enema disposable rectal enema OTC

enema rectal enema OTC

epsom salt oral granules OTC

fiber (calcium polycarbophil) oral tablet OTC

fiber (dextrin) oral powder OTC

fiber (psyllium husk) oral capsule OTC

fiber (psyllium husk/sugar) oral powder OTC

fiber (with aspartame) oral powder OTC

fiber laxative (ca polycarbo) oral tablet OTC

fiber laxative (methylcellulo) oral tablet OTC

fiber laxative (psyllium husk) oral capsule OTC

fiber oral powder OTC

fiber smooth (sucrose) oral powder OTC

fiber smooth oral powder OTC

fiber supplement (inulin) oral tablet,chewable

OTC

fiber therapy (ca polycarboph) oral tablet OTC

fiber therapy (m-cell/sugar) oral powder OTC

fiber therapy (m-cellulose) oral tablet OTC

fiber therapy laxative (husk) oral capsule OTC

fiber-caps (psyllium husk) oral capsule OTC

fiber-lax oral tablet OTC

fiber-tabs oral tablet OTC

fleet enema rectal enema OTC

fleet glycerin (adult) rectal suppository OTC

fleet laxative oral tablet,delayed release (dr/ec)

OTC; QL (33 tablets per 30 days)

gavilax oral powder OTC

gentle laxative oral tablet,delayed release (dr/ec)

OTC; QL (33 tablets per 30 days)

gentle laxative rectal suppository OTC

gentlelax oral powder OTC

geri-kot oral tablet OTC

glycerin (adult) rectal suppository Fleet Glycerin (Adult) OTC

glycerin (child) rectal suppository Fleet Glycerin (Child) OTC

47

Page 48: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

glycolax oral powder OTC

healthylax oral powder in packetOTC; QL (34 grams per 1 day)

kao-tin (docusate calcium) oral capsule OTC

konsyl (sugar) oral powder OTC

laxacin oral tablet OTC

laxaclear oral powder OTC

laxative (bisacodyl) oral tablet OTC

laxative (bisacodyl) oral tablet,delayed release (dr/ec)

OTC; QL (33 tablets per 30 days)

laxative (bisacodyl) rectal suppository OTC

laxative (sennosides) oral tablet OTC

laxative (sennosides) oral tablet,chewable OTC

laxative feminine oral tablet OTC

laxative maximum strength oral tablet OTC

laxative peg 3350 oral powder OTC

laxative pills oral tablet OTC

laxative pills regular oral tablet OTC

laxative plus stool softener oral tablet OTC

magnesium citrate oral solution Citrate of Magnesia OTC

magnesium hydroxide oral suspension Milk of Magnesia OTC

milk of magnesia concentrated oral suspension

OTC

milk of magnesia oral suspension OTC

mineral oil extra heavy oral oil OTC

mineral oil heavy oral oil OTC

mineral oil oral oil Mineral Oil Extra Heavy OTC

mineral oil rectal enema Fleet Mineral Oil OTC

miralax oral powder in packetOTC; QL (2 packets per 1 day)

natural fiber laxative (sugar) oral powder OTC

natural fiber laxative oral capsule OTC

natural fiber laxative therapy oral powder OTC

natural fiber laxative(aspart) oral powder OTC

natural fiber supplement oral powder in packet

OTC

natural veg laxative(sennosid) oral tablet OTC

natural vegetable (psyllium) oral powder OTC

48

Page 49: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

natural vegetable oral powder OTC

natural vegetable powder oral powder OTC

oral saline laxative oral liquid OTC

p-col rite oral tablet OTC

perdiem overnight relief oral tablet OTC

phosphate laxative oral liquid OTC

polyethylene glycol 3350 oral powder ClearLax OTC

polyethylene glycol 3350 oral powder in packet

ClearLaxOTC; QL (34 grams per 1 day)

promolaxin oral tablet OTC

psyllium husk oral capsule Daily Fiber OTC

purelax oral powder OTC

purelax oral powder in packetOTC; QL (34 grams per 1 day)

ready-to-use enema rectal enema OTC

reguloid oral powder OTC

reguloid, sugar free oral powder OTC

senexon-s oral tablet OTC

senna lax oral tablet OTC

senna laxative oral tablet OTC

senna oral syrup OTC

senna oral tablet OTC

senna plus oral tablet OTC

senna with docusate sodium oral tablet OTC

senna-extra oral tablet OTC

senna-s oral tablet OTC

senna-time s oral tablet OTC

senno oral tablet OTC

sennosides-docusate sodium oral tablet Colace 2-In-1 OTC

sen-o-tab oral tablet OTC

silace oral liquid OTC

silace oral syrup OTC

smoothlax oral powder OTC

smoothlax oral powder in packetOTC; QL (34 grams per 1 day)

sof-lax oral capsuleOTC; QL (3 capsules per 1 day)

stimulant laxative plus oral tablet OTC

49

Page 50: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

stool softener (docusate cal) oral capsule OTC

stool softener oral capsule 100 mgOTC; QL (3 capsules per 1 day)

stool softener oral capsule 250 mg, 50 mg OTC

stool softener oral liquid OTC

stool softener oral syrup OTC

stool softener oral tablet OTC

stool softener-laxative oral tablet OTC

stool softener-stimulant laxat oral tablet OTC

surfak oral capsule OTC

the magic bullet rectal suppository OTC

vegetable laxative oral tablet OTC

wal-mucil fiber (aspartame) oral powder OTC

wal-mucil fiber (sugar) oral powder OTC

wal-mucil fiber oral capsule OTC

wal-mucil natural fiber lax oral powder OTC

woman's laxative oral tablet OTC

woman's laxative oral tablet,delayed release (dr/ec)

OTC; QL (33 tablets per 30 days)

women's gentle laxative(bisac) oral tablet,delayed release (dr/ec)

OTC; QL (33 tablets per 30 days)

women's laxative (bisacodyl) oral tablet OTC

PANCREATIC ENZYMES

dairy aid oral tablet,chewable OTC

dairy digestive oral tablet OTC

dairy digestive supplement oral tablet OTC

dairy relief oral tablet OTC

dairy relief oral tablet,chewable OTC

lac-dose oral tablet OTC

lactase fast acting oral tablet OTC

lactase fast acting oral tablet,chewable OTC

lactase oral tablet Dairy Relief OTC

ultra dairy digestive oral tablet OTC

GENITOURINARY THERAPY

URINARY ACIDIFIER

k-phos-neutral oral tablet OTC

phospha 250 neutral oral tablet OTC

50

Page 51: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

phosphorous oral tablet OTC

phospho-trin 250 neutral oral tablet OTC

virt-phos 250 neutral oral tablet OTC

URINARY PH MODIFIERS

cytra-2 oral solution OTC

cytra-3 oral solution OTC

cytra-k oral solution OTC

pot,sodium citrate-citric acid oral solution Cytra-3 OTC

potassium citrate-citric acid oral solution Cytra-K OTC

sodium citrate-citric acid oral solution Cytra-2 OTC

tricitrates oral solution OTC

virtrate-2 oral solution OTC

virtrate-3 oral solution OTC

virtrate-k oral solution OTC

URINARY TRACT ANESTHETIC/ANALGESIC AGENT

urinary pain relief oral tablet OTC

URINARY TRACT ANTISPASMODIC/ANTI-INCONTINENCE AGENT

OXYTROL FOR WOMEN TRANSDERMAL PATCH 4 DAY

OTC

HEMATOLOGICAL AGENTS

PLATELET AGGREGATION INHIBITORS

aspir-81 oral tablet,delayed release (dr/ec) OTC

aspirin childrens oral tablet,chewable OTC

aspirin low dose oral tablet,delayed release (dr/ec)

OTC

aspirin oral tablet Bayer Aspirin OTC

aspirin oral tablet,chewable Aspirin Childrens OTC

aspirin oral tablet,delayed release (dr/ec) Adult Aspirin Regimen OTC

aspir-low oral tablet,delayed release (dr/ec)

OTC

aspir-trin oral tablet,delayed release (dr/ec)

OTC

bayer advanced oral tablet OTC

51

Page 52: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

bayer aspirin oral tablet OTC

children's aspirin oral tablet,chewable OTC

e.c. prin oral tablet,delayed release (dr/ec) OTC

lite coat aspirin oral tablet OTC

MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT (DME)

ANTISEPTICS - OTHER

alcoh-wipe towelette OTC

BLOOD SUGAR DIAGNOSTICS

TRUE METRIX GLUCOSE TEST STRIP STRIP

OTC; QL (50 strips per 30 days)

TRUETEST TEST STRIPS STRIPOTC; QL (50 strips per 30 days)

CONDOMS

AIMSCO LATEX CONDOM DEVICE OTC

CONDOMS-PREM LUBRICATED DEVICE

OTC

FANTASY CONDOM DEVICE OTC

FC2 FEMALE CONDOM OTC

KIMONO CONDOMS(NON-LUBRICATED) DEVICE

OTC

KIMONO MAXX CONDOMS DEVICE OTC

KIMONO MICROTHIN AQUA LUBE CON DEVICE

OTC

KIMONO MICROTHIN CONDOMS DEVICE

OTC

KIMONO MICROTHIN LARGE CONDOMS DEVICE

OTC

KIMONO TEXTURED CONDOMS DEVICE

OTC

TRUSTEX LATEX CONDOM DEVICE OTC

TRUSTEX LUBRICATED CONDOMS DEVICE

OTC

TRUSTEX NON-LUB CONDOMS DEVICE

OTC

TRUSTEX-RIA LUB/SPERMICIDE DEVICE

OTC

52

Page 53: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

TRUSTEX-RIA LUBRICATED CONDOMS DEVICE

OTC

TRUSTEX-RIA NON-LUB CONDOMS DEVICE

OTC

MEDICAL SUPPLIES AND DME - GLUCOSE MONITORING TEST SUPPLIES

1ST TIER UNILET COMFORTOUCHOTC; QL (102 lancets per 30 days)

ADJUSTABLE LANCING DEVICE OTC

ADVANCED LANCING DEVICE KIT OTC

ADVANCED TRAVEL LANCETSOTC; QL (102 lancets per 30 days)

ADVOCATE LANCING DEVICE OTC

ADVOCATE RAPID-SAFE LANCING OTC

ALTERNATE SITE LANCETOTC; QL (102 lancets per 30 days)

ALTERNATE SITE LANCING DEVICE OTC

AQUA LANCE LANCING DEVICE OTC

ASSURE HAEMOLANCE PLUS 1.2 MMOTC; QL (100 units per 30 days)

ASSURE HAEMOLANCE PLUS 18 GAUGE, 21 GAUGE, 25 GAUGE, 28 GAUGE

OTC; QL (102 lancets per 30 days)

ASSURE LANCEOTC; QL (102 lancets per 30 days)

ASSURE LANCE PLUSOTC; QL (102 lancets per 30 days)

AUTO-LANCET MINIOTC; QL (102 lancets per 30 days)

AUTOLET IMPRESSION LANC DEV KIT OTC

AUTOLET LANCING DEVICE OTC

AUTOLET PLUS LANCING DEVICE OTC

CAREONE LANCING DEVICE OTC

CAREONE ULTRA THIN LANCETOTC; QL (102 lancets per 30 days)

CARETOUCH LANCING DEVICE OTC

CARETOUCH TWIST LANCET 28 GAUGE, 30 GAUGE

OTC; QL (102 lancets per 30 days)

53

Page 54: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

CARETOUCH TWIST LANCET 33 GAUGE

OTC; QL (102 units per 30 days)

COLOR LANCETSOTC; QL (102 lancets per 30 days)

COMFORT LANCETSOTC; QL (102 lancets per 30 days)

DROPLET LANCING DEVICE OTC

EASY MINI EJECT LANCING DEVICE OTC

EASY TOUCH LANCETSOTC; QL (102 lancets per 30 days)

EASY TOUCH LANCING DEVICE OTC

EASY TOUCH SAFETY LANCETSOTC; QL (102 lancets per 30 days)

EASY TOUCH TWIST LANCETSOTC; QL (102 lancets per 30 days)

E-Z JECT LANCETSOTC; QL (102 lancets per 30 days)

E-Z JECT THIN LANCETSOTC; QL (102 lancets per 30 days)

EZ SMART LANCETSOTC; QL (102 lancets per 30 days)

FINE 30 UNIVERSAL LANCETSOTC; QL (102 lancets per 30 days)

FORA LANCING DEVICE OTC

FORACARE LANCETSOTC; QL (102 lancets per 30 days)

GLUCOCOM LANCETSOTC; QL (102 lancets per 30 days)

HEALTHY ACCENTS AUTOLET OTC

HEALTHY ACCENTS UNILET LANCETOTC; QL (102 lancets per 30 days)

HYPOLANCE AST LANCING KIT OTC

INCONTROL LANCING DEVICE OTC

INCONTROL SUPER THIN LANCETSOTC; QL (102 lancets per 30 days)

INCONTROL ULTRA THIN LANCETSOTC; QL (102 lancets per 30 days)

INVACARE LANCETSOTC; QL (102 lancets per 30 days)

lancetsAccu-Chek Fastclix Lancet Drum

OTC; QL (102 lancets per 30 days)

54

Page 55: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

LANZO LANCING DEVICE KIT OTC

LITE TOUCH LANCING DEVICE OTC

MICRO THIN LANCETSOTC; QL (102 lancets per 30 days)

MICROLET NEXT LANCING DEVICE KIT

OTC

MINI LANCING DEVICE OTC

MONOLET LANCETSOTC; QL (102 lancets per 30 days)

MONOLET THIN LANCETSOTC; QL (102 lancets per 30 days)

MULTI-LANCET DEVICE 2 KIT OTC

MYGLUCOHEALTH LANCETSOTC; QL (102 lancets per 30 days)

ON CALL LANCING DEVICE OTC

ON CALL PLUS LANCING DEVICE OTC

ON-THE-GO LANCETSOTC; QL (102 lancets per 30 days)

PRODIGY LANCING DEVICE OTC

RELIAMED MINI LANCING DEVICE OTC

RELION THIN LANCETSOTC; QL (102 lancets per 30 days)

RELION ULTRA THIN PLUS LANCETSOTC; QL (102 lancets per 30 days)

RIGHTEST GD500 LANCING DEVICE OTC

RIGHTEST GL300 LANCETSOTC; QL (102 lancets per 30 days)

SAFETY LANCETSOTC; QL (102 lancets per 30 days)

SMART SENSE LANCETSOTC; QL (102 lancets per 30 days)

SMARTDIABETES VANTAGEOTC; QL (100 units per 30 days)

STERILANCE TLOTC; QL (102 lancets per 30 days)

SUPER THIN LANCETSOTC; QL (102 lancets per 30 days)

SURE COMFORT LANCING PEN OTC

SUREFLEX LANCING DEVICE OTC

SURE-PEN LANCING DEVICE OTC

55

Page 56: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

TECHLITE LANCETSOTC; QL (102 lancets per 30 days)

THIN LANCETSOTC; QL (102 lancets per 30 days)

TOPCARE UNIVERSAL1 LANCETOTC; QL (102 lancets per 30 days)

TRUE METRIX AIR GLUCOSE METER OTC

TRUE METRIX LEVEL 1 SOLUTION OTC

TRUE METRIX LEVEL 2 SOLUTION OTC

TRUE METRIX LEVEL 3 SOLUTION OTC

TRUEDRAW LANCING DEVICE OTC

TRUEPLUS LANCETSOTC; QL (102 lancets per 30 days)

TWIST LANCETSOTC; QL (102 lancets per 30 days)

ULTI-LANCE OTC

ULTRA THIN LANCETSOTC; QL (102 lancets per 30 days)

ULTRA THIN PLUS LANCETSOTC; QL (102 lancets per 30 days)

ULTRA-CARE LANCETSOTC; QL (102 lancets per 30 days)

UNILET COMFORTOUCH LANCETOTC; QL (102 lancets per 30 days)

UNILET EXCELITE II LANCETOTC; QL (102 lancets per 30 days)

UNILET EXCELITE LANCETOTC; QL (102 lancets per 30 days)

UNILET GP LANCETOTC; QL (102 lancets per 30 days)

UNILET LANCETOTC; QL (102 lancets per 30 days)

UNILET LANCETSOTC; QL (102 lancets per 30 days)

UNILET SUPER THIN LANCETSOTC; QL (102 lancets per 30 days)

UNISTIK 2 DEVICE KIT OTC

UNISTIK 3 COMFORT DEVICE KIT OTC

UNISTIK 3 COMFORT LANCETOTC; QL (102 lancets per 30 days)

56

Page 57: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

UNISTIK 3 EXTRA LANCETOTC; QL (102 lancets per 30 days)

UNISTIK 3 GENTLEOTC; QL (102 lancets per 30 days)

UNISTIK 3 KIT OTC

UNISTIK 3 LANCETSOTC; QL (102 lancets per 30 days)

UNISTIK 3 NEONATAL DEVICE KIT OTC

UNISTIK 3 NEONATAL KIT OTC

UNISTIK 3 NORMAL LANCETOTC; QL (102 lancets per 30 days)

UNISTIK CZT LANCETOTC; QL (102 lancets per 30 days)

UNISTIK PRO LANCETOTC; QL (102 lancets per 30 days)

UNISTIK SAFETYOTC; QL (102 lancets per 30 days)

UNISTIK TOUCH LANCETSOTC; QL (102 lancets per 30 days)

UNIVERSAL 1 LANCETSOTC; QL (102 lancets per 30 days)

MEDICAL SUPPLIES AND DME - PEAK FLOW METERS

AIRZONE PEAK FLOW METER DEVICE OTC

ASTHMA CHECK METER DEVICE OTC

IN-CHECK NASAL WITH MASK DEVICE OTC

IN-CHECK ORAL FLOW METER DEVICE

OTC

MICROLIFE PEAK FLOW METER DEVICE

OTC

PEAK AIR PEAK FLOW METER DEVICE

OTC

PERSONAL BEST FULL RANGE DEVICE

OTC

PERSONAL BEST LOW RANGE DEVICE

OTC

PIKO 1 DEVICE OTC

POCKET PEAK FLOW METER DEVICE OTC

MEDICAL SUPPLIES AND DME

CUT N CRUSH OTC

57

Page 58: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

TABLET CUTTER OTC

NEEDLES/NEEDLELESS DEVICES, SYRINGES AND ACCESSORIES

BD AUTOSHIELD DUO PEN NEEDLE NEEDLE

OTC

BD LUER-LOK SYRINGE SYRINGE OTC

BD ULTRA-FINE MICRO PEN NEEDLE NEEDLE

OTC

BD ULTRA-FINE MINI PEN NEEDLE NEEDLE

OTC

BD ULTRA-FINE NANO PEN NEEDLE NEEDLE

OTC

BD ULTRA-FINE ORIG PEN NEEDLE NEEDLE

OTC

RESPIRATORY AIDS, SPACERS, DEVICES AND EQUIPMENT

PANDA MASK DEVICEOTC; QL (2 units per 365 days)

PEDIATRIC MEDIUM MASK DEVICEOTC; QL (2 units per 365 days)

PEDIATRIC PANDA MASK DEVICEOTC; QL (2 units per 365 days)

PEDIATRIC SMALL MASK DEVICEOTC; QL (2 units per 365 days)

SIDESTREAM PEDIATRIC FACE MASK DEVICE

OTC; QL (2 units per 365 days)

URINE KETONE TEST AIDS

KETONE CARE STRIPOTC; QL (100 strips per 30 days)

KETONE URINE TEST STRIPOTC; QL (100 strips per 30 days)

KETOSTIX STRIPOTC; QL (100 strips per 30 days)

TRUEPLUS KETONE STRIPOTC; QL (100 strips per 30 days)

OPHTHALMIC AGENTS

ARTIFICIAL TEARS

advanced eye relief ophthalmic (eye) drops

OTC

58

Page 59: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

artificial tears (petro/min) ophthalmic (eye) ointment

OTC

artificial tears (pf) ophthalmic (eye) dropperette

OTC

artificial tears (polyvin alc) ophthalmic (eye) drops

OTC

artificial tears(dext70-hypro) ophthalmic (eye) drops

OTC

artificial tears(glycerin-peg) ophthalmic (eye) drops

OTC

artificial tears(pg-hypm-glyc) ophthalmic (eye) drops

OTC

dry eye relief ophthalmic (eye) drops OTC

eye drop tears ophthalmic (eye) drops OTC

eye drops (with povidone) ophthalmic (eye) drops

OTC

eye drops advanced relief ophthalmic (eye) drops

OTC

for sty relief ophthalmic (eye) ointment OTC

liquitears ophthalmic (eye) drops OTC

lubricant (p-glycol-glycerin) ophthalmic (eye) drops

OTC

lubricant eye drops ophthalmic (eye) drops

OTC

lubricant eye ophthalmic (eye) ointment OTC

moisture drops ophthalmic (eye) drops OTC

polyvinyl alcohol ophthalmic (eye) drops Artificial Tears (polyvin alc) OTC

tears again (pva) ophthalmic (eye) drops OTC

ultra fresh ophthalmic (eye) drops OTC

OPHTHALMIC ANTIHISTAMINES

alaway ophthalmic (eye) dropsOTC; QL (1 bottle per 30 days)

allergy eye (ketotifen) ophthalmic (eye) drops

OTC; QL (1 bottle per 30 days)

children's alaway ophthalmic (eye) dropsOTC; QL (1 bottle per 30 days)

eye allergy relief ophthalmic (eye) drops 0.025-0.3 %

OTC; QL (15 mL per 30 days)

eye allergy relief ophthalmic (eye) drops 0.02675-0.315 %

OTC

59

Page 60: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

eye itch relief ophthalmic (eye) dropsOTC; QL (1 bottle per 30 days)

itchy eye drops ophthalmic (eye) dropsOTC; QL (1 bottle per 30 days)

ketotifen fumarate ophthalmic (eye) drops AlawayOTC; QL (1 bottle per 30 days)

redness reliever lubricant ophthalmic (eye) drops

OTC

wal-zyr (ketotifen) ophthalmic (eye) dropsOTC; QL (1 bottle per 30 days)

OPHTHALMIC DECONGESTANT

altazine ophthalmic (eye) dropsOTC; QL (15 mL per 30 days)

eye drops (tetrahydrozoline) ophthalmic (eye) drops

OTC; QL (15 mL per 30 days)

opti-clear ophthalmic (eye) dropsOTC; QL (15 mL per 30 days)

redness reliever eye drops ophthalmic (eye) drops

OTC; QL (15 mL per 30 days)

redness reliever lubricant ophthalmic (eye) drops

OTC

sterile eye drops ophthalmic (eye) dropsOTC; QL (15 mL per 30 days)

OPHTHALMIC, OTHER

artificial tears(dext70-hypro) ophthalmic (eye) drops

OTC

OTIC

OTIC PREPARATIONS, MISCELLANEOUS ANTI-INFECTIVES

carbamoxide ear drops otic (ear) drops OTC

ear drops (carbamide peroxide) otic (ear) drops

OTC

ear drops otc otic (ear) drops OTC

ear wax removal drops otic (ear) drops OTC

ear wax removal kit otic (ear) drops OTC

murine ear wax removal system otic (ear) drops

OTC

60

Page 61: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

RESPIRATORY AIDS, SPACERS, DEVICES AND EQUIPMENT

RESPIRATORY AIDS, SPACERS, DEVICES AND EQUIPMENT

1ST TIER UNILET COMFORTOUCHOTC; QL (102 lancets per 30 days)

ADJUSTABLE LANCING DEVICE OTC

ADVANCED LANCING DEVICE KIT OTC

ADVANCED TRAVEL LANCETSOTC; QL (102 lancets per 30 days)

ADVOCATE LANCING DEVICE OTC

ADVOCATE RAPID-SAFE LANCING OTC

AIMSCO LATEX CONDOM DEVICE OTC

AIRZONE PEAK FLOW METER DEVICE OTC

ALTERNATE SITE LANCETOTC; QL (102 lancets per 30 days)

ALTERNATE SITE LANCING DEVICE OTC

AQUA LANCE LANCING DEVICE OTC

ASSURE HAEMOLANCE PLUS 1.2 MMOTC; QL (100 units per 30 days)

ASSURE HAEMOLANCE PLUS 18 GAUGE, 21 GAUGE, 25 GAUGE, 28 GAUGE

OTC; QL (102 lancets per 30 days)

ASSURE LANCEOTC; QL (102 lancets per 30 days)

ASSURE LANCE PLUSOTC; QL (102 lancets per 30 days)

ASTHMA CHECK METER DEVICE OTC

AUTO-LANCET MINIOTC; QL (102 lancets per 30 days)

AUTOLET IMPRESSION LANC DEV KIT OTC

AUTOLET LANCING DEVICE OTC

AUTOLET PLUS LANCING DEVICE OTC

AZO TEST STRIPS STRIP OTC

BD AUTOSHIELD DUO PEN NEEDLE NEEDLE

OTC

BD LUER-LOK SYRINGE SYRINGE OTC

BD ULTRA-FINE MICRO PEN NEEDLE NEEDLE

OTC

61

Page 62: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

BD ULTRA-FINE MINI PEN NEEDLE NEEDLE

OTC

BD ULTRA-FINE NANO PEN NEEDLE NEEDLE

OTC

BD ULTRA-FINE ORIG PEN NEEDLE NEEDLE

OTC

CAREONE LANCING DEVICE OTC

CAREONE ULTRA THIN LANCETOTC; QL (102 lancets per 30 days)

CARETOUCH LANCING DEVICE OTC

CARETOUCH TWIST LANCET 28 GAUGE, 30 GAUGE

OTC; QL (102 lancets per 30 days)

CARETOUCH TWIST LANCET 33 GAUGE

OTC; QL (102 units per 30 days)

COLOR LANCETSOTC; QL (102 lancets per 30 days)

COMFORT LANCETSOTC; QL (102 lancets per 30 days)

CONDOMS-PREM LUBRICATED DEVICE

OTC

CUT N CRUSH OTC

DROPLET LANCING DEVICE OTC

EASY MINI EJECT LANCING DEVICE OTC

EASY TOUCH LANCETSOTC; QL (102 lancets per 30 days)

EASY TOUCH LANCING DEVICE OTC

EASY TOUCH SAFETY LANCETSOTC; QL (102 lancets per 30 days)

EASY TOUCH TWIST LANCETSOTC; QL (102 lancets per 30 days)

E-Z JECT LANCETSOTC; QL (102 lancets per 30 days)

E-Z JECT THIN LANCETSOTC; QL (102 lancets per 30 days)

EZ SMART LANCETSOTC; QL (102 lancets per 30 days)

FANTASY CONDOM DEVICE OTC

FC2 FEMALE CONDOM OTC

FINE 30 UNIVERSAL LANCETSOTC; QL (102 lancets per 30 days)

FORA LANCING DEVICE OTC

62

Page 63: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

FORACARE LANCETSOTC; QL (102 lancets per 30 days)

GLUCOCOM LANCETSOTC; QL (102 lancets per 30 days)

HEALTHY ACCENTS AUTOLET OTC

HEALTHY ACCENTS UNILET LANCETOTC; QL (102 lancets per 30 days)

HYPOLANCE AST LANCING KIT OTC

IN-CHECK NASAL WITH MASK DEVICE OTC

IN-CHECK ORAL FLOW METER DEVICE

OTC

INCONTROL LANCING DEVICE OTC

INCONTROL SUPER THIN LANCETSOTC; QL (102 lancets per 30 days)

INCONTROL ULTRA THIN LANCETSOTC; QL (102 lancets per 30 days)

INVACARE LANCETSOTC; QL (102 lancets per 30 days)

KETONE CARE STRIPOTC; QL (100 strips per 30 days)

KETONE URINE TEST STRIPOTC; QL (100 strips per 30 days)

KETOSTIX STRIPOTC; QL (100 strips per 30 days)

KIMONO CONDOMS(NON-LUBRICATED) DEVICE

OTC

KIMONO MAXX CONDOMS DEVICE OTC

KIMONO MICROTHIN AQUA LUBE CON DEVICE

OTC

KIMONO MICROTHIN CONDOMS DEVICE

OTC

KIMONO MICROTHIN LARGE CONDOMS DEVICE

OTC

KIMONO TEXTURED CONDOMS DEVICE

OTC

lancetsAccu-Chek Fastclix Lancet Drum

OTC; QL (102 lancets per 30 days)

LANZO LANCING DEVICE KIT OTC

LITE TOUCH LANCING DEVICE OTC

MICRO THIN LANCETSOTC; QL (102 lancets per 30 days)

63

Page 64: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

MICROLET NEXT LANCING DEVICE KIT

OTC

MICROLIFE PEAK FLOW METER DEVICE

OTC

MINI LANCING DEVICE OTC

MONOLET LANCETSOTC; QL (102 lancets per 30 days)

MONOLET THIN LANCETSOTC; QL (102 lancets per 30 days)

MULTI-LANCET DEVICE 2 KIT OTC

MYGLUCOHEALTH LANCETSOTC; QL (102 lancets per 30 days)

ON CALL LANCING DEVICE OTC

ON CALL PLUS LANCING DEVICE OTC

ON-THE-GO LANCETSOTC; QL (102 lancets per 30 days)

PANDA MASK DEVICEOTC; QL (2 units per 365 days)

PEAK AIR PEAK FLOW METER DEVICE

OTC

PEDIATRIC MEDIUM MASK DEVICEOTC; QL (2 units per 365 days)

PEDIATRIC PANDA MASK DEVICEOTC; QL (2 units per 365 days)

PEDIATRIC SMALL MASK DEVICEOTC; QL (2 units per 365 days)

PERSONAL BEST FULL RANGE DEVICE

OTC

PERSONAL BEST LOW RANGE DEVICE

OTC

PIKO 1 DEVICE OTC

POCKET PEAK FLOW METER DEVICE OTC

PRODIGY LANCING DEVICE OTC

RELIAMED MINI LANCING DEVICE OTC

RELION THIN LANCETSOTC; QL (102 lancets per 30 days)

RELION ULTRA THIN PLUS LANCETSOTC; QL (102 lancets per 30 days)

RIGHTEST GD500 LANCING DEVICE OTC

RIGHTEST GL300 LANCETSOTC; QL (102 lancets per 30 days)

64

Page 65: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

SAFETY LANCETSOTC; QL (102 lancets per 30 days)

SIDESTREAM PEDIATRIC FACE MASK DEVICE

OTC; QL (2 units per 365 days)

SMART SENSE LANCETSOTC; QL (102 lancets per 30 days)

SMARTDIABETES VANTAGEOTC; QL (100 units per 30 days)

STERILANCE TLOTC; QL (102 lancets per 30 days)

SUPER THIN LANCETSOTC; QL (102 lancets per 30 days)

SURE COMFORT LANCING PEN OTC

SUREFLEX LANCING DEVICE OTC

SURE-PEN LANCING DEVICE OTC

TABLET CUTTER OTC

TECHLITE LANCETSOTC; QL (102 lancets per 30 days)

THIN LANCETSOTC; QL (102 lancets per 30 days)

TOPCARE UNIVERSAL1 LANCETOTC; QL (102 lancets per 30 days)

TRUE METRIX AIR GLUCOSE METER OTC

TRUE METRIX GLUCOSE TEST STRIP STRIP

OTC; QL (50 strips per 30 days)

TRUE METRIX LEVEL 1 SOLUTION OTC

TRUE METRIX LEVEL 2 SOLUTION OTC

TRUE METRIX LEVEL 3 SOLUTION OTC

TRUEDRAW LANCING DEVICE OTC

TRUEPLUS KETONE STRIPOTC; QL (100 strips per 30 days)

TRUEPLUS LANCETSOTC; QL (102 lancets per 30 days)

TRUETEST TEST STRIPS STRIPOTC; QL (50 strips per 30 days)

TRUSTEX LATEX CONDOM DEVICE OTC

TRUSTEX LUBRICATED CONDOMS DEVICE

OTC

TRUSTEX NON-LUB CONDOMS DEVICE

OTC

65

Page 66: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

TRUSTEX-RIA LUB/SPERMICIDE DEVICE

OTC

TRUSTEX-RIA LUBRICATED CONDOMS DEVICE

OTC

TRUSTEX-RIA NON-LUB CONDOMS DEVICE

OTC

TWIST LANCETSOTC; QL (102 lancets per 30 days)

ULTI-LANCE OTC

ULTRA THIN LANCETSOTC; QL (102 lancets per 30 days)

ULTRA THIN PLUS LANCETSOTC; QL (102 lancets per 30 days)

ULTRA-CARE LANCETSOTC; QL (102 lancets per 30 days)

UNILET COMFORTOUCH LANCETOTC; QL (102 lancets per 30 days)

UNILET EXCELITE II LANCETOTC; QL (102 lancets per 30 days)

UNILET EXCELITE LANCETOTC; QL (102 lancets per 30 days)

UNILET GP LANCETOTC; QL (102 lancets per 30 days)

UNILET LANCETOTC; QL (102 lancets per 30 days)

UNILET LANCETSOTC; QL (102 lancets per 30 days)

UNILET SUPER THIN LANCETSOTC; QL (102 lancets per 30 days)

UNISTIK 2 DEVICE KIT OTC

UNISTIK 3 COMFORT DEVICE KIT OTC

UNISTIK 3 COMFORT LANCETOTC; QL (102 lancets per 30 days)

UNISTIK 3 EXTRA LANCETOTC; QL (102 lancets per 30 days)

UNISTIK 3 GENTLEOTC; QL (102 lancets per 30 days)

UNISTIK 3 KIT OTC

UNISTIK 3 LANCETSOTC; QL (102 lancets per 30 days)

UNISTIK 3 NEONATAL DEVICE KIT OTC

66

Page 67: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

UNISTIK 3 NEONATAL KIT OTC

UNISTIK 3 NORMAL LANCETOTC; QL (102 lancets per 30 days)

UNISTIK CZT LANCETOTC; QL (102 lancets per 30 days)

UNISTIK PRO LANCETOTC; QL (102 lancets per 30 days)

UNISTIK SAFETYOTC; QL (102 lancets per 30 days)

UNISTIK TOUCH LANCETSOTC; QL (102 lancets per 30 days)

UNIVERSAL 1 LANCETSOTC; QL (102 lancets per 30 days)

URINARY TRACT INF.TEST (WBCS) STRIP

OTC

RESPIRATORY THERAPY AGENTS

ANTIHISTAMINE AND DECONGESTANT COMBINATIONS

alavert d-12 allergy-sinus oral tablet extended release 12 hr

AL; OTC

allerclear d-12hr oral tablet extended release 12 hr

AL; OTC

allerclear d-24hr oral tablet extended release 24 hr

AL; OTC

allergy and congestion relief oral tablet extended release 12 hr

AL; OTC

allergy and congestion relief oral tablet extended release 24 hr

AL; OTC

allergy relief d12 oral tablet extended release 12 hr

AL; OTC

allergy relief d-24hr oral tablet extended release 24 hr

AL; OTC

allergy relief,nasal decongest oral tablet extended release 24 hr

AL; OTC

allergy relief-d (loratadine) oral tablet extended release 12 hr

AL; OTC

allergy relief-d(fexofenadine) oral tablet extended release 12 hr

AL; OTC; QL (2 tablets per 1 day)

67

Page 68: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

allergy-congestion relief-d oral tablet extended release 24 hr

AL; OTC

aprodine oral tablet AL; OTC

ed a-hist pse oral tablet AL; OTC

fexofenadine-pseudoephedrine oral tablet extended release 12 hr

Allegra-D 12 HourAL; OTC; QL (2 tablets per 1 day)

lohist - d oral liquid AL; OTC

lorata-d oral tablet extended release 24 hr AL; OTC

lorata-dine d oral tablet extended release 24 hr

AL; OTC

loratadine-d oral tablet extended release 12 hr

AL; OTC

loratadine-d oral tablet extended release 24 hr

AL; OTC

ritifed oral syrup AL; OTC

rynex pse oral liquid AL; OTC

wal-act d cold and allergy oral tablet AL; OTC

wal-fex d 12 hour oral tablet extended release 12 hr

AL; OTC; QL (2 tablets per 1 day)

wal-fex d 24 hour oral tablet extended release 24 hr

AL; OTC; QL (1 tablet per 1 day)

wal-itin d 12 hour oral tablet extended release 12 hr

AL; OTC

wal-itin d oral tablet extended release 24 hr

AL; OTC

ANTIHISTAMINES

alavert oral tablet,disintegrating OTC; QL (1 tablet per 1 day)

aler-cap oral capsuleOTC; QL (120 capsules per 30 days)

alka-seltzer plus allergy oral tablet OTC

aller-chlor oral tablet OTC

allerclear oral tablet OTC; QL (1 tablet per 1 day)

aller-ease oral tablet 180 mg OTC; QL (1 tablet per 1 day)

aller-ease oral tablet 60 mgOTC; QL (2 tablets per 1 day)

aller-fex oral tablet OTC; QL (1 tablet per 1 day)

aller-g-time oral tablet OTC

allergy (chlorpheniramine) oral tablet OTC

allergy (diphenhydramine) oral capsuleOTC; QL (120 capsules per 30 days)

68

Page 69: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

allergy (diphenhydramine) oral liquidOTC; QL (120 mL per 30 days)

allergy (diphenhydramine) oral tablet OTC

allergy 4-hour oral tablet OTC

allergy medication oral capsuleOTC; QL (120 capsules per 30 days)

allergy medicine oral tablet OTC

allergy relief (clemastine) oral tablet OTC

allergy relief (fexofenadine) oral tablet 180 mg

OTC; QL (1 tablet per 1 day)

allergy relief (fexofenadine) oral tablet 60 mg

OTC; QL (2 tablets per 1 day)

allergy relief (loratadine) oral solution OTC

allergy relief (loratadine) oral tablet OTC; QL (1 tablet per 1 day)

allergy relief (loratadine) oral tablet,disintegrating

OTC; QL (1 tablet per 1 day)

allergy relief(chlorpheniramn) oral tablet OTC

ALLERGY RELIEF(CHLORPHENIRAMN) ORAL TABLET EXTENDED RELEASE

OTC

allergy relief(diphenhydramin) oral capsule

OTC; QL (120 capsules per 30 days)

allergy relief(diphenhydramin) oral liquidOTC; QL (120 mL per 30 days)

allergy relief(diphenhydramin) oral tablet OTC

allergy-time oral tablet OTC

banophen oral capsule 25 mgOTC; QL (120 capsules per 30 days)

banophen oral capsule 50 mg OTC

banophen oral tablet OTC

child allergy relief (diphen) oral tablet,disintegrating

OTC

children's allegra allergy oral suspension OTC; QL (10 mL per 1 day)

children's allegra allergy oral tablet,disintegrating

OTC

children's allergy (diphenhyd) oral liquidOTC; QL (120 mL per 30 days)

CHILDREN'S ALLERGY RELIEF(FEX) ORAL SUSPENSION

OTC; QL (10 mL per 1 day)

children's allergy relief(lor) oral solution OTC

69

Page 70: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

children's wal-dryl allergy oral liquidOTC; QL (120 mL per 30 days)

children's wal-dryl allergy oral prefilled spoon

OTC

children's wal-dryl allergy oral tablet,disintegrating

OTC

CHILDREN'S WAL-FEX ORAL SUSPENSION

OTC; QL (10 mL per 1 day)

chlorhist oral tablet OTC

chlorpheniramine maleate oral tablet Aller-Chlor OTC

chlorpheniramine maleate oral tablet extended release

Allergy Relief(chlorpheniramn)

OTC

chlortabs oral tablet OTC

complete allergy medicine oral capsuleOTC; QL (120 capsules per 30 days)

complete allergy medicine oral tablet OTC

complete allergy oral capsuleOTC; QL (120 capsules per 30 days)

complete allergy oral tablet OTC

dayhist allergy oral tablet OTC

diphedryl allergy oral liquidOTC; QL (120 mL per 30 days)

diphedryl oral capsuleOTC; QL (120 capsules per 30 days)

diphedryl oral liquidOTC; QL (120 mL per 30 days)

diphedryl oral tablet OTC

diphen oral tablet OTC

diphenhist oral capsuleOTC; QL (120 capsules per 30 days)

diphenhydramine 50 mg capsule (otc) Banophen OTC

diphenhydramine 50 mg capsule u-d (otc) Banophen OTC

diphenhydramine 50 mg capsule u-d, 10x10 (otc)

Banophen OTC

diphenhydramine hcl oral capsule 25 mg Aler-CapOTC; QL (120 capsules per 30 days)

diphenhydramine hcl oral elixirOTC; QL (120 mL per 30 days)

diphenhydramine hcl oral liquid Allergy (diphenhydramine)OTC; QL (120 mL per 30 days)

70

Page 71: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

diphenhydramine hcl oral syrup OTC

diphenhydramine hcl oral tablet Alka-Seltzer Plus Allergy OTC

ed chlorped jr oral syrup OTC

fexofenadine oral suspension Children's Allegra Allergy OTC; QL (10 mL per 1 day)

fexofenadine oral tablet 180 mg Allegra AllergyPA; OTC; QL (1 tablet per 1 day)

fexofenadine oral tablet 60 mg Allegra AllergyOTC; QL (2 tablets per 1 day)

loradamed oral tablet OTC; QL (1 tablet per 1 day)

loratadine oral capsule Claritin Liqui-Gel OTC

loratadine oral solution Allergy Relief (loratadine) OTC

loratadine oral tablet Allerclear OTC; QL (1 tablet per 1 day)

loratadine oral tablet,disintegrating Alavert OTC; QL (1 tablet per 1 day)

nightime sleep oral capsule OTC

nighttime sleep aid (diphen) oral capsule OTC

nighttime sleep aid (diphen) oral tablet OTC

non-drowsy allergy oral tablet OTC; QL (1 tablet per 1 day)

pharbechlor oral tablet OTC

pharbedryl oral capsule 25 mgOTC; QL (120 capsules per 30 days)

pharbedryl oral capsule 50 mg OTC

siladryl sa oral liquidOTC; QL (120 mL per 30 days)

simply sleep oral tablet OTC

sleep aid (diphenhydramine) oral capsule OTC

sleep aid (diphenhydramine) oral tablet OTC

sleep aid max str (diphenhydr) oral capsule

OTC

sleep ii oral tablet OTC

sleep tablet (diphenhydramine) oral tablet OTC

sleep-tabs oral tablet OTC

unisom sleepgels oral capsule OTC

valu-dryl allergy oral capsuleOTC; QL (120 capsules per 30 days)

wal-dryl allergy oral capsuleOTC; QL (120 capsules per 30 days)

wal-dryl allergy oral liquidOTC; QL (120 mL per 30 days)

wal-dryl allergy oral tablet OTC

71

Page 72: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

wal-fex allergy oral tablet 180 mg OTC; QL (1 tablet per 1 day)

wal-fex allergy oral tablet 60 mgOTC; QL (2 tablets per 1 day)

wal-finate oral tablet OTC

wal-itin oral solution OTC

wal-itin oral tablet OTC; QL (1 tablet per 1 day)

wal-som (diphenhydramine) oral capsule OTC

ANTITUSSIVES - NONNARCOTIC

cough drops mucous membrane lozenge OTC

EXPECTORANTS

adult tussin chest congestion oral liquid AL; OTC

adult wal-tussin oral liquid OTC

chest congestion relief oral tablet OTC

child mucus relief expectorant oral liquid OTC

children's chest congestion oral liquid OTC

cough syrup oral liquid OTC

diabetic siltussin das-na oral liquid OTC

diabetic tussin ex oral liquid OTC

expectorant cough syrup oral liquid OTC

expectorant oral liquid OTC

fenesin ir oral tablet OTC

geri-tussin oral liquid OTC

guaifenesin oral liquidAdult Tussin Chest Congestion

OTC

guaifenesin oral tablet Expectorant OTC

mucosa oral tablet OTC

mucus relief chest oral tablet OTC

mucus relief oral tablet OTC

ri-tussin oral liquid OTC

robafen oral liquid OTC

scot-tussin expectorant oral liquid OTC

siltussin sa oral liquid OTC

tussin chest congestion oral liquid OTC

tussin expectorant oral liquid OTC

tussin honey oral liquid OTC

tussin mucus-chest congestion oral liquid AL; OTC

tussin oral liquid OTC

72

Page 73: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

tussin oral tablet OTC

MAST CELL STABILIZERS

cromolyn nasal spray,non-aerosolNasal Allergy Symptom Control

OTC

nasal allergy symptom control nasal spray,non-aerosol

OTC

NASAL CORTICOSTEROIDS

24 hour allergy relief nasal spray,suspension

OTC; QL (1 bottle per 30 days)

24 HOUR NASAL ALLERGY NASAL AEROSOL,SPRAY

OTC; QL (1 inhaler per 30 days)

aller-flo nasal spray,suspensionOTC; QL (16 mL per 30 days)

allergy relief (fluticasone) nasal spray,suspension 50 mcg/actuation

OTC; QL (1 inhaler per 30 days)

CHILDREN'S FLONASE ALLERGY RLF NASAL SPRAY,SUSPENSION

OTC; QL (1 bottle per 30 days)

CHILDREN'S NASACORT NASAL AEROSOL,SPRAY

OTC; QL (1 bottle per 30 days)

CLARISPRAY NASAL SPRAY,SUSPENSION

OTC; QL (16 mL per 30 days)

FLONASE ALLERGY RELIEF NASAL SPRAY,SUSPENSION

OTC; QL (1 bottle per 30 days)

fluticasone propionate nasal spray,suspension

24 Hour Allergy ReliefOTC; QL (1 inhaler per 30 days)

NASACORT NASAL AEROSOL,SPRAYOTC; QL (1 bottle per 30 days)

nasal allergy nasal aerosol,sprayOTC; QL (1 bottle per 30 days)

QC ALLERGY RELIEF 50 MCG SPRAYOTC; QL (1 inhaler per 30 days)

triamcinolone acetonide nasal aerosol,spray

24 Hour Nasal AllergyOTC; QL (1 inhaler per 30 days)

NASAL, OTHER

altamist nasal aerosol,spray OTC

ayr saline nasal aerosol,spray OTC

ayr saline nasal drops OTC

baby ayr saline nasal drops OTC

children's saline nasal spray nasal aerosol,spray

OTC

73

Page 74: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

deep sea nasal nasal aerosol,spray OTC

little remedies nasal aerosol,spray OTC

nasal mist nasal aerosol,spray OTC

nasal moisturizing nasal aerosol,spray OTC

nasal spray (sodium chloride) nasal aerosol,spray

OTC

ocean nasal nasal aerosol,spray OTC

saline mist nasal aerosol,spray OTC

saline nasal mist nasal aerosol,spray OTC

saline nasal nasal aerosol,spray OTC

saline nose nasal aerosol,spray OTC

sterile saline nasal aerosol,spray OTC

NON-NARCOTIC ANTITUSSIVE COMBINATIONS

adult robitussin peak cold dm oral liquid AL; OTC

adult tussin cough congest dm oral liquid AL; OTC

adult tussin dm oral syrup AL; OTC

antitussive dm oral syrup AL; OTC

biocotron oral liquid AL; OTC

biogil oral liquid AL; OTC

brotapp dm oral elixir AL; OTC

child chest congestion-cough oral liquid AL; OTC

child mucus relief cough oral liquid AL; OTC

children's cough oral liquid AL; OTC

CHILDREN'S MUCINEX COUGH ORAL LIQUID

AL; OTC

cough dm er oral suspension,extended rel 12 hr

OTC

cough relief oral liquid OTC

cough syrup dm oral syrup AL; OTC

day-time cough oral syrup OTC

despec eda cough-cold drops oral drops AL; OTC

dextromethorphan polistirex oral suspension,extended rel 12 hr

12-Hour Cough Relief OTC

dextromethorphan-guaifenesin oral syrup Adult Tussin DM AL; OTC

diabetic siltussin-dm oral liquid AL; OTC

diabetic tussin dm oral liquid AL; OTC

g-tron oral liquid AL; OTC

74

Page 75: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

MUCINEX DM ORAL TABLET EXTENDED RELEASE 12 HR

AL; OTC

MUCINEX FAST-MAX DM MAX ORAL LIQUID

AL; OTC

mucus relief cough oral liquid AL; OTC

mucus relief dm max oral liquid AL; OTC

neo-tuss oral liquid AL; OTC

non-aspirin flu oral tablet OTC

pediatric cough and cold oral liquid AL; OTC

ri-tussin dm oral syrup AL; OTC

robafen dm cough oral liquid AL; OTC

robafen dm cough-chest congest oral syrup

AL; OTC

siltussin dm das oral liquid AL; OTC

siltussin-dm oral syrup AL; OTC

supress dx oral drops AL; OTC

tusnel diabetic oral liquid AL; OTC

tussin cough (dm only) oral liquid OTC

tussin cough-chest congestion oral liquid AL; OTC

tussin dm clear oral syrup AL; OTC

tussin dm cough and chest oral syrup AL; OTC

tussin dm oral liquid AL; OTC

tussin dm oral syrup AL; OTC

tussin maximum strength cough oral syrup OTC

VICKS DAYQUIL COUGH ORAL SYRUP OTC

wal-tussin cough oral liquid OTC

wal-tussin dm oral syrup AL; OTC

wal-tussin max strength cough oral syrup OTC

SYSTEMIC SYMPATHOMIMETIC DECONGESTANTS

12 hour decongestant oral tablet extended release

OTC

12 hour nasal decongest (pse) oral tablet extended release

OTC

children's silfedrine oral liquid OTC

nasal decongestant (pseudoeph) oral tablet

OTC

nasal decongestant (pseudoeph) oral tablet extended release

OTC

75

Page 76: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

pedia relief infant nasal oral drops OTC

pseudoephedrine hcl oral tabletNasal Decongestant (pseudoeph)

OTC

pseudoephedrine hcl oral tablet extended release

12 Hour Decongestant AL; OTC

sinus 12 hour oral tablet extended release OTC

sudogest 12-hour oral tablet extended release

OTC

sudogest oral tablet OTC

suphedrin oral liquid OTC

suphedrin oral tablet OTC

suphedrine 12 hour oral tablet extended release

OTC

suphedrine oral tablet OTC

wal-phed 12 hour oral tablet extended release

OTC

wal-phed d oral tablet extended release AL; OTC

wal-phed oral tablet OTC

VAGINAL PRODUCTS

VAGINAL ANTIFUNGALS

3 day vaginal vaginal cream OTC

3-day vaginal vaginal cream OTC

clotrimazole 3 day vaginal cream OTC

clotrimazole vaginal cream Clotrimazole-7 OTC

clotrimazole-3 vaginal cream OTC

clotrimazole-7 vaginal cream OTC

miconazole 7 vaginal cream OTC

miconazole 7 vaginal suppository OTC

miconazole nitrate vaginal comb pack,prefill appl, cream

Miconazole-3 OTC

miconazole nitrate vaginal cream Miconazole 7 OTC

miconazole nitrate vaginal kit Monistat 1 Combo Pack OTC

miconazole-3 prefil,cream,wipe vaginal kit OTC

miconazole-3 vaginal comb pack,prefill appl, cream

OTC

miconazole-3 vaginal cream OTC

miconazole-3 vaginal kit OTC

miconazole-skin clnsr17 vaginal kitMiconazole-3 prefil,cream,wipe

OTC

76

Page 77: Commonly Covered Over-the Counter Items...ANTI-INFECTIVE AGENTS ANTHELMINTICS reese's pinworm medicine oral suspension OTC ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENERAL alcohol

Drug Name Reference Notes

tioconazole vaginal ointment 1-Day OTC

tioconazole-1 vaginal ointment OTC

77