GPI NAME NDC Drug Name

Acetaminophen Cap 325 MG 00045048720 TYLENOL CAP 325MG

Acetaminophen Cap 325 MG 00045048790 TYLENOL CAP 325MG

Acetaminophen Cap 325 MG 50428054774 PAIN RELIEF CAP 325MG

Acetaminophen Cap 500 MG 00904198760 MAPAP CAP 500MG

Acetaminophen Cap 500 MG 46122038841 GNP Acetaminophen Ex St

Acetaminophen Cap 500 MG 49348011610 SM PAIN REL CAP 500MG

Acetaminophen Cap 500 MG 49348070959 SM PAIN REL CAP 500MG

Acetaminophen Chew Tab 160 MG 00363023908 NON-ASPIRIN CHW 160MG JR

Acetaminophen Chew Tab 160 MG 00363039908 NON-ASPIRIN CHW 160MG JR

Acetaminophen Chew Tab 160 MG 15127028924 SB NON-ASA CHW 160MG

Acetaminophen Chew Tab 160 MG 41250017262 ASA FREE CHW 160MG JR

Acetaminophen Chew Tab 160 MG 50844039908 PAIN RELIEVE CHW 160MG JR

Acetaminophen Chew Tab 80 MG 15127083004 SB NON-ASA CHW 80MG FRT

Acetaminophen Chew Tab 80 MG 15127083204 SB NON-ASA CHW 80MG GRP

Acetaminophen Disintegrating Tab 160 MG 11673044908 PAIN RELIEVR TAB 160MG

Acetaminophen Disintegrating Tab 160 MG 11822062040 APAP MELTS TAB 160MG

Acetaminophen Disintegrating Tab 160 MG 11822062050 APAP MELTS TAB 160MG

Acetaminophen Disintegrating Tab 160 MG 36800036088 ACETAMINOPHE TAB 160MG

Acetaminophen Disintegrating Tab 160 MG 41163044908 EQL ACETAMIN TAB 160MG

Acetaminophen Disintegrating Tab 160 MG 41163045008 EQL ACETAMIN TAB 160MG

Acetaminophen Disintegrating Tab 160 MG 49035044908 EQ ACETAMIN TAB 160MG

Acetaminophen Disintegrating Tab 160 MG 49348006304 SM RPD MELT TAB 160MG

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

1

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Disintegrating Tab 80 MG 11822062030 APAP MELT TAB 80MG

Acetaminophen Disintegrating Tab 80 MG 11822574570 APAP MELT TAB 80MG

Acetaminophen Elixir 160 MG/5ML 54162012916 APAP

Acetaminophen Elixir 160 MG/5ML 59390000235 APRA ELX 160/5ML

Acetaminophen Elixir 160 MG/5ML 59390004035 APRA ELX 160/5ML

Acetaminophen Elixir 160 MG/5ML 59390004041 APRA ELX 160/5ML

Acetaminophen Elixir 160 MG/5ML 59390004046 APRA ELX 160/5ML

Acetaminophen Elixir 160 MG/5ML 59390004047 APRA ELX 160/5ML

Acetaminophen Gel Syrup 160 MG/5ML 51672250008 ELIXSURE GEL F/P BGUM

Acetaminophen Gel Syrup 160 MG/5ML 51672250108 ELIXSURE GEL F/P CHRY

Acetaminophen Gel Syrup 160 MG/5ML 51672250208 ELIXSURE GEL F/P GRPE

Acetaminophen Liquid 160 MG/5ML 00485005708 ED-APAP LIQ 80MG/2.5

Acetaminophen Liquid 160 MG/5ML 00904198500 MAPAP LIQ 160/5ML

Acetaminophen Liquid 160 MG/5ML 00904198516 MAPAP LIQ 160/5ML

Acetaminophen Liquid 160 MG/5ML 00904198520 MAPAP LIQ 160/5ML

Acetaminophen Liquid 160 MG/5ML 56184010124 LITTLE REMED LIQ 160/5ML

Acetaminophen Liquid 160 MG/5ML 56184010176 LITTLE REMED LIQ 160/5ML

Acetaminophen Liquid 160 MG/5ML 56184010177 LITTLE REMED LIQ 160/5ML

Acetaminophen Liquid 160 MG/5ML 56184010178 LITTLE REMED LIQ 160/5ML

Acetaminophen Liquid 160 MG/5ML 57896018016 PAIN RELIEF LIQ 160/5ML

Acetaminophen Liquid 160 MG/5ML 58657052016 ACETAMIN LIQ 160/5ML

Acetaminophen Liquid 167 MG/5ML 00904584709 MAPAP APAP LIQ 500/15ML

2

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Liquid 167 MG/5ML 11822064401 PAIN RELIEVR LIQ 500/15ML

Acetaminophen Liquid 167 MG/5ML 11917015799 PAIN RELIEVR LIQ 500/15ML

Acetaminophen Liquid 167 MG/5ML 46122035734 PAIN RELIEF LIQ 500/15ML

Acetaminophen Liquid 167 MG/5ML 49035027808 EQ Pain Relief/Rapid Burst

Acetaminophen Liquid 167 MG/5ML 50428695051 PAIN RELIEF LIQ 500/15ML

Acetaminophen Liquid 167 MG/5ML 57896020208 ACETAMIN LIQ 500/15ML

Acetaminophen Liquid 167 MG/5ML 69842094519 CVS Acetaminophen

Acetaminophen Liquid 167 MG/5ML 78112069400 CHLORASEPTIC LIQ SORE THR

Acetaminophen Powd Pack 950 MG 11530000302 STANBACK AF POW 950MG

Acetaminophen Powd Pack 950 MG 11530000324 STANBACK AF POW 950MG

Acetaminophen Soln 160 MG/5ML 00121065705 ACETAMIN SOL 160/5ML

Acetaminophen Suppos 120 MG 00363070653 FEVER REDUCE SUP 120MG

Acetaminophen Suppos 120 MG 00713011801 ACEPHEN SUP 120MG

Acetaminophen Suppos 120 MG 00713011812 ACEPHEN SUP 120MG

Acetaminophen Suppos 120 MG 00713011850 ACEPHEN SUP 120MG

Acetaminophen Suppos 120 MG 11917011271 PAIN/FEVER SUP 120MG

Acetaminophen Suppos 120 MG 11917012480 PAIN/FEVER SUP 120MG

Acetaminophen Suppos 120 MG 45802073200 ACETAMIN SUP 120MG

Acetaminophen Suppos 120 MG 45802073230 ACETAMIN SUP 120MG

Acetaminophen Suppos 120 MG 45802073233 ACETAMIN SUP 120MG

Acetaminophen Suppos 325 MG 00713016401 ACEPHEN SUP 325MG

Acetaminophen Suppos 325 MG 00713016412 ACEPHEN SUP 325MG

3

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Suppos 325 MG 00713016450 ACEPHEN SUP 325MG

Acetaminophen Suppos 325 MG 51672211602 FEVERALL SUP 325MG

Acetaminophen Suppos 325 MG 51672211604 FEVERALL SUP 325MG

Acetaminophen Suppos 650 MG 00713016501 ACEPHEN SUP 650MG

Acetaminophen Suppos 650 MG 00713016506 ACEPHEN SUP 650MG

Acetaminophen Suppos 650 MG 00713016512 ACEPHEN SUP 650MG

Acetaminophen Suppos 650 MG 00713016550 ACEPHEN SUP 650MG

Acetaminophen Suppos 650 MG 45802073030 ACETAMIN SUP 650MG

Acetaminophen Suppos 650 MG 45802073032 ACETAMIN SUP 650MG

Acetaminophen Suppos 650 MG 45802073033 ACETAMIN SUP 650MG

Acetaminophen Suppos 650 MG 51672211704 FEVERALL SUP 650MG

Acetaminophen Susp 160 MG/5ML 00113021226 PAIN & FEVER SUS 160/5ML

Acetaminophen Susp 160 MG/5ML 00113060826 PAIN & FEVER SUS 160/5ML

Acetaminophen Susp 160 MG/5ML 11822154530 FEVER/PAIN SUS 160/5ML

Acetaminophen Susp 160 MG/5ML 11822154540 FEVER/PAIN SUS 160/5ML

Acetaminophen Susp 160 MG/5ML 11822154550 FEVER/PAIN SUS 160/5ML

Acetaminophen Susp 160 MG/5ML 11822309680 FEVER/PAIN SUS 160/5ML

Acetaminophen Susp 160 MG/5ML 11822338430 FEVER/PAIN SUS 160/5ML

Acetaminophen Susp 160 MG/5ML 11822353390 FEVER/PAIN SUS 160/5ML

Acetaminophen Susp 160 MG/5ML 11822353410 FEVER/PAIN SUS 160/5ML

Acetaminophen Susp 160 MG/5ML 11822571760 FEVER/PAIN SUS 160/5ML

Acetaminophen Susp 160 MG/5ML 11822989540 FEVER/PAIN SUS 160/5ML

4

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Susp 160 MG/5ML 14832001106 PEDIACARE SUS 160/5ML

Acetaminophen Susp 160 MG/5ML 41250094616 PAIN & FEVER SUS 160/5ML

Acetaminophen Susp 160 MG/5ML 63162051012 NORTEMP SUS 160/5ML

Acetaminophen Tab 325 MG 00045049660 TYLENOL TAB 325MG

Acetaminophen Tab 325 MG 00363010412 PAIN RELIEVR TAB 325MG

Acetaminophen Tab 325 MG 00536322201 PAIN & FEVER TAB 325MG

Acetaminophen Tab 325 MG 00536322210 PAIN & FEVER TAB 325MG

Acetaminophen Tab 325 MG 00904198251 MAPAP TAB 325MG

Acetaminophen Tab 325 MG 00904198259 MAPAP TAB 325MG

Acetaminophen Tab 325 MG 00904198260 MAPAP TAB 325MG

Acetaminophen Tab 325 MG 00904198261 MAPAP TAB 325MG

Acetaminophen Tab 325 MG 00904198280 MAPAP TAB 325MG

Acetaminophen Tab 325 MG 00904671950 Acetaminophen

Acetaminophen Tab 325 MG 00904671960 Acetaminophen

Acetaminophen Tab 325 MG 00904671980 Acetaminophen

Acetaminophen Tab 325 MG 00904677361 Acetaminophen

Acetaminophen Tab 325 MG 10135012305 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 10135012310 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 10135012324 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 10135012330 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 10135012350 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 10135012360 ACETAMIN TAB 325MG

5

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 325 MG 10135012362 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 10135012365 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 10135012370 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 10135012390 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 10135016313 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 10135016314 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 11822046713 RA Pain Relief Acetaminophen

Acetaminophen Tab 325 MG 11822317640 RA ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 15127007208 NON-ASPIRIN TAB 325MG

Acetaminophen Tab 325 MG 15127007224 NON-ASPIRIN TAB 325MG

Acetaminophen Tab 325 MG 16103035307 PHARBETOL TAB 325MG

Acetaminophen Tab 325 MG 16103035308 PHARBETOL TAB 325MG

Acetaminophen Tab 325 MG 16103035311 PHARBETOL TAB 325MG

Acetaminophen Tab 325 MG 16103035399 PHARBETOL TAB 325MG

Acetaminophen Tab 325 MG 37864000101 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 37864000102 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 37864007039 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 41163051402 EQL ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 41250051055 ASPIRIN FREE TAB 325MG

Acetaminophen Tab 325 MG 43292055591 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 46122024778 PAIN RELIEF TAB 325MG

Acetaminophen Tab 325 MG 46122039078 PAIN RELIEF TAB 325MG

6

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 325 MG 46122043078 GNP Acetaminophen

Acetaminophen Tab 325 MG 47682014513 APAP TAB 325MG

Acetaminophen Tab 325 MG 47682014536 APAP TAB 325MG

Acetaminophen Tab 325 MG 47682014548 APAP TAB 325MG

Acetaminophen Tab 325 MG 47682014564 APAP TAB 325MG

Acetaminophen Tab 325 MG 47682080313 NON-ASPIRIN TAB 325MG

Acetaminophen Tab 325 MG 47682080333 NON-ASPIRIN TAB 325MG

Acetaminophen Tab 325 MG 47682080348 NON-ASPIRIN TAB 325MG

Acetaminophen Tab 325 MG 49035049101 PAIN RELIEVE TAB 325MG

Acetaminophen Tab 325 MG 49035052378 ACETAMINOPHN TAB 325MG

Acetaminophen Tab 325 MG 49348097310 PAIN RELIEVE TAB 325MG

Acetaminophen Tab 325 MG 49348097316 PAIN RELIEVE TAB 325MG

Acetaminophen Tab 325 MG 49483034001 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 49483034010 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 49781010451 PAIN RELIEVR TAB 325MG

Acetaminophen Tab 325 MG 50580060001 OTC (multiple source)

Acetaminophen Tab 325 MG 50580060002 TYLENOL TAB 325MG

Acetaminophen Tab 325 MG 50580060003 Tylenol

Acetaminophen Tab 325 MG 50804046902 GoodSense Pain Relief

Acetaminophen Tab 325 MG 51469030301 AMINOFEN TAB 325MG

Acetaminophen Tab 325 MG 53329064230 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 54738054801 ACETAMIN TAB 325MG

7

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 325 MG 54738054803 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 54738054850 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 57896010010 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 57896010101 NON-ASPIRIN TAB 325MG

Acetaminophen Tab 325 MG 57896010105 NON-ASPIRIN TAB 325MG

Acetaminophen Tab 325 MG 57896010110 NON-ASPIRIN TAB 325MG

Acetaminophen Tab 325 MG 57896010201 Acetaminophen

Acetaminophen Tab 325 MG 57896010205 Acetaminophen

Acetaminophen Tab 325 MG 57896010210 Acetaminophen

Acetaminophen Tab 325 MG 59606003020 PAIN RELIEF TAB 325MG

Acetaminophen Tab 325 MG 59779076678 CVS Pain Relief Regular St

Acetaminophen Tab 325 MG 62011003201 PAIN RELIEVE TAB 325MG

Acetaminophen Tab 325 MG 62011003202 PAIN RELIEVE TAB 325MG

Acetaminophen Tab 325 MG 62107005201 TACTINAL TAB 325MG

Acetaminophen Tab 325 MG 62107005210 TACTINAL TAB 325MG

Acetaminophen Tab 325 MG 63739044001 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 63739044004 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 63868008210 PAIN RELIEF TAB 325MG

Acetaminophen Tab 325 MG 63868031410 NON-ASPIRIN TAB 325MG

Acetaminophen Tab 325 MG 65504010505 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 65504023095 NON-ASPIRIN TAB 325MG

Acetaminophen Tab 325 MG 69618001001 ACETAMIN TAB 325MG

8

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 325 MG 69618001010 ACETAMIN TAB 325MG

Acetaminophen Tab 325 MG 70000015201 ACETAMINOPHN TAB 325MG

Acetaminophen Tab 325 MG 70000015202 ACETAMINOPHN TAB 325MG

Acetaminophen Tab 325 MG 70000015204 ACETAMINOPHN TAB 325MG

Acetaminophen Tab 325 MG 70000037401 Acetaminophen

Acetaminophen Tab 325 MG 75450029544 PAIN RELIEF TAB 325MG

Acetaminophen Tab 500 MG 00045044406 TYLENOL TAB 500MG

Acetaminophen Tab 500 MG 00045044427 TYLENOL TAB 500MG

Acetaminophen Tab 500 MG 00045044902 TYLENOL TAB 500MG

Acetaminophen Tab 500 MG 00045044905 TYLENOL TAB 500MG

Acetaminophen Tab 500 MG 00045044909 TYLENOL TAB 500MG

Acetaminophen Tab 500 MG 00045044910 TYLENOL TAB 500MG

Acetaminophen Tab 500 MG 00045044912 TYLENOL TAB 500MG

Acetaminophen Tab 500 MG 00045044915 TYLENOL TAB 500MG

Acetaminophen Tab 500 MG 00045048826 TYLENOL TAB 500MG/RR

Acetaminophen Tab 500 MG 00045048830 TYLENOL TAB 500MG/RR

Acetaminophen Tab 500 MG 00045049909 Tylenol Extra Strength

Acetaminophen Tab 500 MG 00045049923 Tylenol Extra Strength

Acetaminophen Tab 500 MG 00113002562 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 00113002571 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 00113002578 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 00113018771 PAIN RELIEF TAB 500MG

9

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 500 MG 00113018778 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 00113022771 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 00113048452 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 00113048462 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 00113048471 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 00113048478 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 00113048490 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 00113048493 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 00363017508 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 00363017512 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 00363017515 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 00363017529 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 00363051908 PAIN RELIEVE TAB 500MG/RR

Acetaminophen Tab 500 MG 00363051912 PAIN RELIEVE TAB 500MG/RR

Acetaminophen Tab 500 MG 00363051915 PAIN RELIEVE TAB 500MG/RR

Acetaminophen Tab 500 MG 00363051920 PAIN RELIEVE TAB 500MG/RR

Acetaminophen Tab 500 MG 00363051929 PAIN RELIEVE TAB 500MG/RR

Acetaminophen Tab 500 MG 00363051954 PAIN RELIEVE TAB 500MG/RR

Acetaminophen Tab 500 MG 00363053112 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 00363053115 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 00363053137 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 00536117201 Acetaminophen

10

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 500 MG 00536117210 Acetaminophen

Acetaminophen Tab 500 MG 00536321801 PAIN & FEVER TAB 500MG

Acetaminophen Tab 500 MG 00536323110 PAIN & FEVER TAB 500MG

Acetaminophen Tab 500 MG 00904198324 MAPAP TAB 500MG

Acetaminophen Tab 500 MG 00904198340 MAPAP TAB 500MG

Acetaminophen Tab 500 MG 00904198380 MAPAP TAB 500MG

Acetaminophen Tab 500 MG 00904198394 MAPAP TAB 500MG

Acetaminophen Tab 500 MG 00904198860 MAPAP TAB 500MG

Acetaminophen Tab 500 MG 00904672024 OTC (multiple source)

Acetaminophen Tab 500 MG 00904672040 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 00904672051 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 00904672059 OTC (multiple source)

Acetaminophen Tab 500 MG 00904672060 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 00904672080 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 00904673059 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 00904673060 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 00904673061 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 00904673080 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 00904674959 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 10135014405 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135014410 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135014424 ACETAMIN TAB 500MG

11

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 500 MG 10135014450 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135014460 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135014466 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135014470 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135015201 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135015210 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135015213 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135015224 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135015230 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135015250 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135015260 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135015266 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135015270 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 10135016413 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673020606 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673020608 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673020613 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673020619 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673020621 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673048471 TGT ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673048478 TGT ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673048485 TGT ACETAMIN TAB 500MG

12

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 500 MG 11673051912 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673051915 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673051920 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673051932 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673060608 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673060613 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673060619 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11673060621 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822010233 RA Pain Relief Acetaminophen

Acetaminophen Tab 500 MG 11822030300 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822030310 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822040310 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822041240 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822041250 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822074050 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822300230 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822317060 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822318000 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822338590 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822365670 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822371480 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822388720 ACETAMIN TAB 500MG

13

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 500 MG 11822505990 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822506040 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822510880 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11822511320 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11917001164 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11917001170 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11917004918 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11917006772 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11917006773 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11917007135 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 11917008502 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 11917008513 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 11917015435 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 11917015437 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 11917016373 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 11917017759 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 15127000741 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 15127003630 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 15127028106 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 15127036401 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 15127036411 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 15127036424 NON-ASPIRIN TAB 500MG

14

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 500 MG 15127036450 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 15127072013 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 15127073005 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 15127073006 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 15127073021 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 15127073030 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 15127073505 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 15127073508 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 15127073509 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 15127073516 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 15127099401 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 15127099424 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 15127099450 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 16103035004 PHARBETOL TAB 500MG

Acetaminophen Tab 500 MG 16103035008 PHARBETOL TAB 500MG

Acetaminophen Tab 500 MG 16103035011 PHARBETOL TAB 500MG

Acetaminophen Tab 500 MG 16103035099 PHARBETOL TAB 500MG

Acetaminophen Tab 500 MG 16103037606 PHARBETOL TAB 500MG

Acetaminophen Tab 500 MG 16103037608 PHARBETOL TAB 500MG

Acetaminophen Tab 500 MG 16103037611 PHARBETOL TAB 500MG

Acetaminophen Tab 500 MG 16103037699 PHARBETOL TAB 500MG

Acetaminophen Tab 500 MG 24385008778 PAIN RELIEF TAB 500MG

15

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 500 MG 24385014571 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 24385048447 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 24385048471 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 24385048478 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 24385048490 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 36800022771 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 36800022778 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 36800048447 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 36800048462 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 36800048471 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 36800048478 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 36800048490 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 37205059471 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 37205059478 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 37205065978 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 37864000103 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 37864000104 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 37864000110 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 37864000111 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 37864070699 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 41163019201 EQL ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 41163050001 EQ ACETAMIN TAB 500MG

16

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 500 MG 41163050004 EQ ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 41163050005 EQ ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 41163050006 EQ ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 41163052001 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 41163052003 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 41250048471 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 41250052127 ASPIRIN FREE TAB 500MG

Acetaminophen Tab 500 MG 41415000174 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 41415003973 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 41415005673 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 41415009373 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 41415022773 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 41415029173 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 41415029273 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 43292055589 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 43292055592 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 43292055615 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 43292055618 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 43292055621 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 43292055622 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 47682017513 APAP TAB 500MG

Acetaminophen Tab 500 MG 47682017533 APAP TAB 500MG

17

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 500 MG 47682017548 APAP TAB 500MG

Acetaminophen Tab 500 MG 47682017564 APAP TAB 500MG

Acetaminophen Tab 500 MG 47682080413 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 47682080433 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 47682080448 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 49035048462 ACETAMINOPHN TAB 500MG

Acetaminophen Tab 500 MG 49035048478 ACETAMINOPHN TAB 500MG

Acetaminophen Tab 500 MG 49035048482 ACETAMINOPHN TAB 500MG

Acetaminophen Tab 500 MG 49035048485 ACETAMINOPHN TAB 500MG

Acetaminophen Tab 500 MG 49035048490 ACETAMINOPHN TAB 500MG

Acetaminophen Tab 500 MG 49035049401 PAIN RELIEVR TAB 500MG

Acetaminophen Tab 500 MG 49035049424 PAIN RELIEVR TAB 500MG

Acetaminophen Tab 500 MG 49035051908 EQ ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 49035051912 EQ ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 49035051920 EQ ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 49035053112 EQ ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 49035091762 ACETAMINOPHN TAB 500MG

Acetaminophen Tab 500 MG 49035097583 ACETAMINOPHN TAB 500MG

Acetaminophen Tab 500 MG 49348004209 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 49348004210 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 49348004214 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 49348070309 PAIN RELIEF TAB 500MG/RR

18

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 500 MG 49348070310 PAIN RELIEF TAB 500MG/RR

Acetaminophen Tab 500 MG 49348073009 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 49348073010 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 49348099810 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 49483034101 ACETAMINOPHN TAB 500MG

Acetaminophen Tab 500 MG 49483034105 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 49483034110 ACETAMINOPHN TAB 500MG

Acetaminophen Tab 500 MG 49483034142 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 49483034150 ACETAMINOPHN TAB 500MG

Acetaminophen Tab 500 MG 49614012300 MEDI-TABS TAB 500MG

Acetaminophen Tab 500 MG 49614016871 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 49614016878 PAIN RELIEVE TAB 500MG

Acetaminophen Tab 500 MG 49614016971 PAIN RELIEVE TAB 500MG/RR

Acetaminophen Tab 500 MG 49614016978 PAIN RELIEVE TAB 500MG/RR

Acetaminophen Tab 500 MG 50428028552 CVS Acetaminophen Ex St

Acetaminophen Tab 500 MG 50428038706 CVS Acetaminophen Ex St

Acetaminophen Tab 500 MG 50428038730 CVS Acetaminophen Ex St

Acetaminophen Tab 500 MG 50428039691 CVS Acetaminophen Ex St

Acetaminophen Tab 500 MG 50428041924 CVS Acetaminophen Ex St

Acetaminophen Tab 500 MG 50428042752 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 50428043161 CVS Acetaminophen Ex St

Acetaminophen Tab 500 MG 50428092378 PAIN RELIEF TAB 500MG

19

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 500 MG 50428111047 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 50428534826 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 50428738104 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 50580041201 TYLENOL TAB 500MG

Acetaminophen Tab 500 MG 50580041202 TYLENOL TAB 500MG

Acetaminophen Tab 500 MG 50580041203 TYLENOL TAB 500MG

Acetaminophen Tab 500 MG 50580044935 TYLENOL TAB 500MG

Acetaminophen Tab 500 MG 50580044936 TYLENOL TAB 500MG

Acetaminophen Tab 500 MG 51469030401 AMINOFEN TAB 500MG

Acetaminophen Tab 500 MG 51824004901 Non-Aspirin Extra Strength

Acetaminophen Tab 500 MG 53598000301 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 53598000310 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 54738054001 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 54738054003 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 57896002201 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 57896020001 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 57896020005 Pain Relief Extra Strength

Acetaminophen Tab 500 MG 57896020010 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 57896020101 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 57896020110 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 57896020401 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 57896022101 ACETAMIN TAB 500MG

20

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 500 MG 57896022110 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 57896022201 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 57896025101 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 58154010001 SHAKE ACHE TAB 500MG

Acetaminophen Tab 500 MG 59779010112 CVS Pain Relief Extra Strength

Acetaminophen Tab 500 MG 59779048462 CVS Pain Relief

Acetaminophen Tab 500 MG 59779048471 CVS Pain Relief

Acetaminophen Tab 500 MG 59779048478 CVS Pain Relief

Acetaminophen Tab 500 MG 59779048493 CVS Pain Relief

Acetaminophen Tab 500 MG 59779053108 CVS Pain Relief Extra Strength

Acetaminophen Tab 500 MG 62011002301 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 62011002302 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 62011002303 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 62011002701 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 62011003401 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 62011004901 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 62107005001 TACTINAL TAB 500MG

Acetaminophen Tab 500 MG 62107005010 TACTINAL TAB 500MG

Acetaminophen Tab 500 MG 62107005101 TACTINAL TAB 500MG

Acetaminophen Tab 500 MG 62107005110 TACTINAL TAB 500MG

Acetaminophen Tab 500 MG 63868008405 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 63868008410 PAIN RELIEF TAB 500MG

21

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 500 MG 63868008420 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 63868008424 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 63868008450 PAIN RELIEF TAB 500MG

Acetaminophen Tab 500 MG 63868008801 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 63868008803 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 63868008824 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 63868008850 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 63868031510 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 63868031560 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 63868050350 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 63868050701 NON-ASPIRIN TAB 500MG

Acetaminophen Tab 500 MG 63868098710 NON-ASPIRIN TAB 500MG/RR

Acetaminophen Tab 500 MG 63868098750 NON-ASPIRIN TAB 500MG/RR

Acetaminophen Tab 500 MG 63981051905 PAIN RELIEVE TAB 500MG/RR

Acetaminophen Tab 500 MG 63981070090 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 65504010605 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 65504010705 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 69618001101 ACETAMINOPHN TAB 500MG

Acetaminophen Tab 500 MG 69618001110 ACETAMINOPHN TAB 500MG

Acetaminophen Tab 500 MG 70000015001 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 70000015003 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 70000015101 ACETAMIN TAB 500MG

22

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab 500 MG 70000015102 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 70000015103 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 70000015301 ACETAMIN TAB 500MG

Acetaminophen Tab 500 MG 70000031202 Acetaminophen

Acetaminophen Tab 500 MG 70000037301 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 70000037302 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 70000037303 OTC (multiple source)

Acetaminophen Tab 500 MG 70000037304 Acetaminophen Extra Strength

Acetaminophen Tab 500 MG 70000037305 Acetaminophen Extra Strength

Acetaminophen Tab ER 650 MG 00045029721 TYLENOL 8 HR TAB 650MG

Acetaminophen Tab ER 650 MG 00045083821 TYLENOL 8 HR TAB 650MG

Acetaminophen Tab ER 650 MG 00045083824 TYLENOL 8 HR TAB 650MG

Acetaminophen Tab ER 650 MG 00045083837 TYLENOL 8 HR TAB 650MG

Acetaminophen Tab ER 650 MG 00045083840 Tylenol 8 Hour Arthritis Pain

Acetaminophen Tab ER 650 MG 00113021771 PAIN RELIEF TAB 650MG

Acetaminophen Tab ER 650 MG 00113054462 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 00113054471 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 00113054478 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 00363033301 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 00363033304 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 00363033323 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 00363033350 ARTHRTS PAIN TAB 650MG

23

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab ER 650 MG 00363033355 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 00904576960 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 11673054478 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 11673054485 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 11822040192 RA 8 Hour Pain Relief

Acetaminophen Tab ER 650 MG 11822041923 8 HOUR PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 11822061283 RA Arthritis Pain Relief

Acetaminophen Tab ER 650 MG 11822301920 ACETAMIN TAB 650MG

Acetaminophen Tab ER 650 MG 11822319230 8 HOUR PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 11822330270 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 11822330410 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 11822512830 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 11917005670 ACETAMIN TAB 650MG

Acetaminophen Tab ER 650 MG 11917012353 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 11917012354 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 11917012498 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 11917014837 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 11917017966 Arthritis Pain Reliever

Acetaminophen Tab ER 650 MG 11917018001 Arthritis Pain Reliever

Acetaminophen Tab ER 650 MG 12843057122 MIDOL TAB 650MG

Acetaminophen Tab ER 650 MG 15127001192 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 15127053001 ARTHRTS PAIN TAB 650MG

24

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab ER 650 MG 15127053024 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 15127053050 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 24385062971 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 24385062978 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 36800054462 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 36800054471 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 36800054478 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 37205003478 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 37205047778 8 HOUR PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 37205066257 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 37205066258 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 41163054471 EQL ARTHRTS TAB 650MG

Acetaminophen Tab ER 650 MG 41163054478 EQL ARTHRTS TAB 650MG

Acetaminophen Tab ER 650 MG 41163054483 EQL ARTHRTS TAB 650MG

Acetaminophen Tab ER 650 MG 41250096647 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 41415028873 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 41415028973 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 46122006271 8 HOUR PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 46122006278 8 HOUR PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 46122017081 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 49035054447 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 49035054462 ARTHRTS PAIN TAB 650MG

25

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab ER 650 MG 49035054483 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 49035054485 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 49035054487 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 49035074101 EQ 8HR Arthritis Pain Relief

Acetaminophen Tab ER 650 MG 49035074178 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 49035096678 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 49348092109 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 49348092110 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 49348092409 8 HOUR PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 49348092410 8 HOUR PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 49614047371 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 49614047378 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 49781006251 8 HOUR PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 50428025773 PAIN RELIEF TAB 650MG

Acetaminophen Tab ER 650 MG 50428027315 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 51660033301 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 51660033601 8 HOUR PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 59779054447 CVS Arthritis Pain Relief

Acetaminophen Tab ER 650 MG 59779054462 CVS Arthritis Pain Relief

Acetaminophen Tab ER 650 MG 59779054471 CVS Arthritis Pain Relief

Acetaminophen Tab ER 650 MG 62011002601 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 62011033601 HM PAIN RLF TAB 650MG

26

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen Tab ER 650 MG 62011033701 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 62011033801 HM ARTHRTS TAB 650MG

Acetaminophen Tab ER 650 MG 63868008901 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 63868008905 NON-ASPIRIN TAB 650MG

Acetaminophen Tab ER 650 MG 63868008910 NON-ASPIRIN TAB 650MG

Acetaminophen Tab ER 650 MG 63868008950 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 63868009150 QC APAP 8 HR TAB 650MG

Acetaminophen Tab ER 650 MG 69842031278 CVS 8HR Muscle Aches & Pain

Acetaminophen Tab ER 650 MG 69842054447 CVS 8HR Arthritis Pain Relief

Acetaminophen Tab ER 650 MG 69842054478 CVS 8HR Arthritis Pain Relief

Acetaminophen Tab ER 650 MG 69842054485 CVS 8HR Arthritis Pain Relief

Acetaminophen Tab ER 650 MG 70000018001 8 HOUR PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 70000018002 8 HOUR PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 70000018003 8 HOUR PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 70000018004 8 Hour Arthritis Pain Reliever

Acetaminophen Tab ER 650 MG 70000030601 8 HOUR PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 70677001701 SM PAIN RLVR TAB 650MG

Acetaminophen Tab ER 650 MG 70677001801 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 70677001901 ARTHRTS PAIN TAB 650MG

Acetaminophen Tab ER 650 MG 75450028961 ARTHRTS PAIN TAB 650MG

Acetaminophen w/ Calcium Carbonate Tab 500-250 MG 00904785251 MAPAP PLUS TAB HEADACHE

Acetaminophen w/ DM Cap 325-15 MG 00085193502 DRIXORAL CAP CGH & ST

27

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen w/ DM Chew Tab 160-5 MG 00067618618 TRIAMINIC CHW

Acetaminophen w/ DM Liq 1000-30 MG/30ML 49348072437 SM COUGH LIQ SORE THR

Acetaminophen w/ DM Liq 325-15 MG/15ML 65504091710 DAYTIME LIQ COLD MED

Acetaminophen w/ DM Susp 160-5 MG/5ML 00045016904 TYLENOL CHIL SUS 160-5

Acetaminophen w/ Pamabrom Tab 325-25 MG 47682081013 CRAMP TAB

Acetaminophen w/ Pamabrom Tab 325-25 MG 47682081033 CRAMP TAB

Acetaminophen w/ Pamabrom Tab 325-25 MG 47682081048 CRAMP TAB

Acetaminophen w/ Pamabrom Tab 500-25 MG 00363038508 MENSTRUAL TAB 500-25MG

Acetaminophen w/ Pamabrom Tab 500-25 MG 12843056413 MIDOL CF TAB 500-25MG

Acetaminophen-Caffeine Cap 500-65 MG 59779097209 CVS Tension Headache

Acetaminophen-Caffeine Tab 500-65 MG 00067205024 EXCEDRIN TNS TAB HEADACHE

Acetaminophen-Caffeine Tab 500-65 MG 00067205050 EXCEDRIN TNS TAB HEADACHE

Acetaminophen-Caffeine Tab 500-65 MG 00067205091 EXCEDRIN TNS TAB HEADACHE

Acetaminophen-Caffeine Tab 500-65 MG 00067627220 EXCEDRIN TNS TAB EXPR GEL

Acetaminophen-Caffeine Tab 500-65 MG 00067627240 EXCEDRIN TNS TAB EXPR GEL

Acetaminophen-Caffeine Tab 500-65 MG 00067627280 EXCEDRIN TNS TAB EXPR GEL

Acetaminophen-Caffeine Tab 500-65 MG 11822574300 TENS HEADACH TAB 500-65

Acetaminophen-Caffeine Tab 500-65 MG 70000015901 TENSION TAB 500-65MG

Acetaminophen-Caffeine Tab 500-65 MG 70000015902 TENSION TAB 500-65MG

Acetaminophen-Caffeine-Pyrilamine Tab 500-60-15 MG 00280800516 MIDOL TAB COMPLETE

Acetaminophen-Caffeine-Pyrilamine Tab 500-60-15 MG 00280800524 MIDOL TAB COMPLETE

Acetaminophen-Caffeine-Pyrilamine Tab 500-60-15 MG 00280800540 MIDOL TAB COMPLETE

28

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetaminophen-Caffeine-Pyrilamine Tab 500-60-15 MG 00280801524 MIDOL TAB COMPLETE

Acetaminophen-Caffeine-Pyrilamine Tab 500-60-15 MG 11822321100 RA MENSTRUAL TAB RELIEF

Acetaminophen-Caffeine-Pyrilamine Tab 500-60-15 MG 11822321120 RA MENSTRUAL TAB RELIEF

Acetaminophen-Caffeine-Pyrilamine Tab 500-60-15 MG 11822511350 RA MENSTRUAL TAB COMPLETE

Acetaminophen-Caffeine-Pyrilamine Tab 500-60-15 MG 11917004940 MENSTRUAL TAB MAX ST

Acetaminophen-Caffeine-Pyrilamine Tab 500-60-15 MG 12843050132 MIDOL MAX ST TAB MENSTRUA

Acetaminophen-Caffeine-Pyrilamine Tab 500-60-15 MG 41163039010 EQL MENSTRUA TAB RELIEF

Acetaminophen-Caffeine-Pyrilamine Tab 500-60-15 MG 49035039010 EQL MENSTRUA TAB COMPLETE

Acetaminophen-Caffeine-Pyrilamine Tab 500-60-15 MG 50804018324 MENSTRUAL TAB RELIEF

Acetaminophen-Guaifenesin Tab 325-200 MG 00067622724 COMTREX DEEP TAB CHST CLD

Acetaminophen-Guaifenesin Tab 650-400 MG 10956080350 REFENESEN TAB CHST CNG

Acetaminophen-Magnesium Salicylate-Caff Tab 250-290-50 MG 47682007313 BACK PAINOFF TAB

Acetaminophen-Magnesium Salicylate-Caff Tab 250-290-50 MG 47682007333 BACK PAINOFF TAB

Acetaminophen-Magnesium Salicylate-Caff Tab 250-290-50 MG 47682007347 BACK PAINOFF TAB

Acetaminophen-Pamabrom-Pyrilamine Tab 500-25-15 MG 11822382300 MENSTRUAL TAB PAIN RLF

Acetaminophen-Pamabrom-Pyrilamine Tab 500-25-15 MG 41167030012 PAMPRIN TAB MULT-SYM

Acetaminophen-Pamabrom-Pyrilamine Tab 500-25-15 MG 41167030014 PAMPRIN TAB MULT-SYM

Acetaminophen-Pamabrom-Pyrilamine Tab 500-25-15 MG 41167030021 PAMPRIN MAX TAB PAIN FRM

Acetaminophen-Pamabrom-Pyrilamine Tab 500-25-15 MG 41167031021 PREMSYN PMS TAB

Acetaminophen-Pamabrom-Pyrilamine Tab 500-25-15 MG 41167031023 PREMSYN PMS TAB

Acetaminophen-Pamabrom-Pyrilamine Tab 500-25-15 MG 70000014501 MENSTRUAL TAB PAIN RLF

Acetaminophen-Pyrilamine Tab 325-25 MG 28595078001 HISTAFLEX TAB 325-25MG

29

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Acetone (Urine) Test Strip 00193252350 RELION KETON TES

Acetone (Urine) Test Strip 00193288021 KETOSTIX TES STRIP

Acetone (Urine) Test Strip 00193288050 KETOSTIX TES STRIP

Acetone (Urine) Test Strip 11917010873 KETONE TEST TES

Acetone (Urine) Test Strip 50924051510 CHEMSTRIP K TES

Acetone (Urine) Test Strip 56151060101 KETOCARE TES

Acetone (Urine) Test Strip 56151060150 KETOCARE TES

Acetone (Urine) Test Strip 81131006043 RELION TES KETONE

Adapalene Gel 0.1% 00299491015 DIFFERIN GEL 0.1%

Adapalene Gel 0.1% 00299491045 DIFFERIN GEL 0.1%

Adapalene Gel 0.1% 00299492045 Differin

Adhesive Bandages 00223044896 LEUKOSTRIP MIS 1/8X1.5"

Adhesive Bandages 00223044905 LEUKOSTRIP MIS 1/4"X3"

Adhesive Bandages 00223044911 LEUKOSTRIP MIS 1/4"X4"

Adhesive Bandages 00223044920 LEUKOSTRIP MIS 1/2"X4"

Adhesive Bandages 00536111932 Adhesive Bandages Sheer

Adhesive Bandages 08137004331 BAND AID MED MIS BUTTRFLY

Adhesive Bandages 08137004332 BAND-AID LG MIS BUTTRFLY

Adhesive Bandages 08137004408 BAND-AID MIS TOUGH

Adhesive Bandages 08137004424 BAND-AID MIS TOUGH-ST

Adhesive Bandages 08137004430 BAND-AID FLX MIS

Adhesive Bandages 08137004431 BAND-AID FLX MIS 3/4"X3"

30

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 08137004434 BAND-AID FLX MIS FABRIC

Adhesive Bandages 08137004436 BAND-AID FLX MIS FINGRTIP

Adhesive Bandages 08137004438 BAND-AID FLX MIS KNUCKLE

Adhesive Bandages 08137004444 BAND-AID FLX MIS 1"X3"

Adhesive Bandages 08137004446 BAND-AID MIS WTER BLK

Adhesive Bandages 08137004633 BAND-AID MIS SHEER

Adhesive Bandages 08137004634 BAND-AID MIS SHEER

Adhesive Bandages 08137004644 BAND-AID MIS SHEER

Adhesive Bandages 08137004650 BAND-AID MIS 3/4"X3"

Adhesive Bandages 08137004651 BAND AID MIS 1"

Adhesive Bandages 08137004666 BAND-AID MIS SHEER CF

Adhesive Bandages 08137004669 BAND-AID MIS SHEER CF

Adhesive Bandages 08137004708 BAND-AID CLR MIS 7/8"SPOT

Adhesive Bandages 08137004711 BAND-AID MIS VARIETY

Adhesive Bandages 08137004751 BAND-AID MIS HOT COLR

Adhesive Bandages 08137004752 BAND-AID MIS GLOW-DRK

Adhesive Bandages 08137004754 BAND-AID FLX MIS FABRIC

Adhesive Bandages 08137004833 BAND-AID MIS TOUGH WP

Adhesive Bandages 08137004834 BAND-AID MIS TOUGH WP

Adhesive Bandages 08137004848 BAND-AID MIS VARIETY

Adhesive Bandages 08137004930 BAND-AID MIS SHEER

Adhesive Bandages 08137005532 PROXI-STRIP MIS 1/4"X4"

31

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 08137005544 PROXI-STRIPS MIS 1/2"X4"

Adhesive Bandages 08137005566 BAND-AID MIS TOUGH XL

Adhesive Bandages 08137005616 BAND-AID MIS HL KITTY

Adhesive Bandages 08137005634 BAND-AID MIS SHEER

Adhesive Bandages 08137005635 BAND-AID MIS

Adhesive Bandages 08137005644 BAND-AID MIS SHEER

Adhesive Bandages 08137005658 BAND-AID MIS WTER BLK

Adhesive Bandages 08137005659 BAND-AID MIS WTER BLK

Adhesive Bandages 08137005664 BAND-AID MIS MEDICATE

Adhesive Bandages 08137005685 BAND-AID FLX MIS EXTRA LG

Adhesive Bandages 08137005701 BAND-AID CLR MIS STRIPS

Adhesive Bandages 08137005716 BAND-AID MIS X-LG

Adhesive Bandages 08137008042 BAND-AID FLX MIS 1" X 3"

Adhesive Bandages 08137008043 BAND-AID FLX MIS ASSORTED

Adhesive Bandages 08137008047 BAND-AID MIS 3/4"X3"

Adhesive Bandages 08137104653 BAND-AID MIS PRINCESS

Adhesive Bandages 08137105834 BAND AID MIS MICKEY

Adhesive Bandages 08137115078 BAND-AID FLX MIS FABRIC

Adhesive Bandages 08137115567 BAND-AID MIS TOUGH

Adhesive Bandages 08137116114 BAND-AID MIS

Adhesive Bandages 08137116286 BAND-AID MIS STAR WAR

Adhesive Bandages 08137116317 BAND-AID MIS FROZEN

32

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 08137116589 BAND-AID PAW MIS PATROL

Adhesive Bandages 08137117297 Band-Aid Hydro Seal

Adhesive Bandages 08137117299 Band-Aid Hydro Seal Fingers

Adhesive Bandages 08137117400 Band-Aid Hydro Seal

Adhesive Bandages 08137117401 Band-Aid Hydro Seal

Adhesive Bandages 08137117547 Band-Aid Hydro Seal

Adhesive Bandages 08137117548 Band-Aid Hydro Seal

Adhesive Bandages 08137117549 Band-Aid Hydro Seal

Adhesive Bandages 08137117582 Band-Aid

Adhesive Bandages 08137117584 Band-Aid

Adhesive Bandages 08137117847 Band-Aid

Adhesive Bandages 08137117877 Band-Aid

Adhesive Bandages 08137117878 Band-Aid

Adhesive Bandages 08225091120 CURITY CURAD MIS ASST FAB

Adhesive Bandages 08225091130 CURITY CURAD MIS 3/4 FABR

Adhesive Bandages 08225091140 CURAD FLEX MIS ASSORTED

Adhesive Bandages 08225091160 CURAD FAMILY MIS FLX ASST

Adhesive Bandages 08225091200 NEON STRIPS MIS 3/4 ASST

Adhesive Bandages 08225091300 CURAD WILD MIS TATTOO-U

Adhesive Bandages 08225091400 CURAD WILD MIS DESIGNIT

Adhesive Bandages 08225092300 CURAD SENSIT MIS 3/4"

Adhesive Bandages 08225092500 CURAD SENSIT MIS SPOTS

33

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 08225092600 CURAD SENSIT MIS EX LARGE

Adhesive Bandages 08225092900 CURAD SENSIT MIS ASSORTED

Adhesive Bandages 08225094110 CURAD 7/8" MIS ACTIFLEX

Adhesive Bandages 08225094120 CURAD ASSORT MIS ACTIFLEX

Adhesive Bandages 08225096100 ADVANC CURAD MIS AQUA-PRO

Adhesive Bandages 08225096200 ADVANC CURAD MIS COOL-WRP

Adhesive Bandages 08225096300 ADVANC CURAD MIS BLISTER

Adhesive Bandages 08225096400 ADVANC CURAD MIS SOF-GEL

Adhesive Bandages 08225602410 CURITY CURAD MIS 3/4 PLAS

Adhesive Bandages 08225603410 CURITY CURAD MIS 3/4 SHEE

Adhesive Bandages 08225606000 CURITY CURAD MIS 3/4 PLAS

Adhesive Bandages 08225607000 CURITY CURAD MIS 3/4 SHEE

Adhesive Bandages 08225608000 CURITY CURAD MIS PLASTIC

Adhesive Bandages 08225609000 CURITY CURAD MIS SHEER

Adhesive Bandages 08225653000 CURAD MIS JURASSIC

Adhesive Bandages 08225655000 CURAD MIS GODZILLA

Adhesive Bandages 08225742000 CURITY CURAD MIS 3/4 PLAS

Adhesive Bandages 08333154001 STERI-STRIP MIS 1/8"X3"

Adhesive Bandages 08333154101 STERI-STRIP MIS 1/4"X3"

Adhesive Bandages 08333154201 STERI-STRIP MIS 1/4"X1.5

Adhesive Bandages 08333154601 STERI-STRIP MIS 1/4"X4"

Adhesive Bandages 08333154701 STERI-STRIP MIS 1/2"X4"

34

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 08333154801 STERI-STRIP MIS 1" X 5"

Adhesive Bandages 08333154901 STERI-STRIP MIS 1/2"X2"

Adhesive Bandages 08333851201 STERI-STRIP MIS

Adhesive Bandages 08333851401 STERI-STRIP MIS

Adhesive Bandages 08333851601 STERI-STRIP MIS

Adhesive Bandages 10939028544 SM STURDY MIS STRIP

Adhesive Bandages 10939028644 SM Bandages Sheer

Adhesive Bandages 10939029444 SM BANDAGES MIS FAB 3/4"

Adhesive Bandages 11822037010 STRONG STRIP MIS BANDAGES

Adhesive Bandages 11822037020 RA BANDAGES MIS 3/4"

Adhesive Bandages 11822037030 RA BANDAGES MIS CLEAR

Adhesive Bandages 11822050390 SUPER STRIP MIS 1"X3"

Adhesive Bandages 11822054298 RA Bandages/Extra Long Fabric

Adhesive Bandages 11822086110 RA BANDAGES MIS EX-LRG

Adhesive Bandages 11822086120 RA BANDAGES MIS 3/4"X3"

Adhesive Bandages 11822086130 RA BANDAGES MIS ASSORTED

Adhesive Bandages 11822095270 RA BANDAGES MIS CLEAR

Adhesive Bandages 11822240690 CLEAR SPOT MIS 7/8"

Adhesive Bandages 11822311500 RA ADHESIVE MIS BANDAGES

Adhesive Bandages 11822311520 RA ADHESIVE MIS BANDAGES

Adhesive Bandages 11822311530 RA ADHESIVE MIS BANDAGES

Adhesive Bandages 11822311550 RA ADHESIVE MIS BANDAGES

35

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 11822311560 RA ADHESIVE MIS BANDAGES

Adhesive Bandages 11822311570 RA ADHESIVE MIS BANDAGES

Adhesive Bandages 11822312030 RA ADHESIVE MIS BANDAGES

Adhesive Bandages 11822332280 RA BANDAGES MIS EX-LRG

Adhesive Bandages 11822344390 STRONG STRIP MIS BANDAGES

Adhesive Bandages 11822350390 SUPER STRIP MIS 1"X3"

Adhesive Bandages 11822372380 FIRST AID MIS ANTIBACT

Adhesive Bandages 11822538160 FIRST AID MIS SHEER

Adhesive Bandages 11822573640 RA ADHESIVE MIS BANDAGES

Adhesive Bandages 11822573670 RA BANDAGES MIS EX-LRG

Adhesive Bandages 11822573680 RA BANDAGES MIS EX-LRG

Adhesive Bandages 11822573690 RA ADH BANDG MIS EX-LARGE

Adhesive Bandages 11822985610 BANDAGES CLR MIS ASSORTED

Adhesive Bandages 11822985620 FIRST AID MIS FLEX FAB

Adhesive Bandages 11822985630 RA ADHESIVE MIS BANDAGES

Adhesive Bandages 11822985640 RA BANDAGES MIS 1"X3"

Adhesive Bandages 11822985650 RA ADHESIVE MIS BANDAGES

Adhesive Bandages 11822985670 RA ADHESIVE MIS BANDAGES

Adhesive Bandages 11822985690 RA ADHESIVE MIS 2-1/4X3"

Adhesive Bandages 11822985700 RA ADH PADS MIS 3"X4"

Adhesive Bandages 11822985710 RA BUTTERFLY MIS BANDAGES

Adhesive Bandages 11917005067 ADH BANDAGE MIS STRONG

36

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 11917005068 ADH BANDAGE MIS STRONG

Adhesive Bandages 11917005069 ADH BANDAGE MIS WTR SHLD

Adhesive Bandages 11917005072 ADH BANDAGE MIS CLEAR

Adhesive Bandages 11917005100 ADH BANDAGE MIS PLASTIC

Adhesive Bandages 11917005101 ADH BANDAGE MIS FOAM

Adhesive Bandages 11917005102 ADH BANDAGE MIS FOAM

Adhesive Bandages 11917005103 ADH BANDAGE MIS FLEXIBLE

Adhesive Bandages 11917005104 ADH BANDAGE MIS FLEXIBLE

Adhesive Bandages 11917005105 ADH BANDAGE MIS SHEER

Adhesive Bandages 11917005106 ADH BANDAGE MIS SHEER

Adhesive Bandages 11917005107 ADH BANDAGE MIS CLEAR

Adhesive Bandages 11917005110 ADH BANDAGE MIS ANTIBACT

Adhesive Bandages 11917005153 ADH BANDAGE MIS PLASTIC

Adhesive Bandages 11917005747 CRAYON STRIP MIS BANDAGE

Adhesive Bandages 11917005748 ADH BANDAGE MIS STRONG

Adhesive Bandages 11917006303 PEANUTS MIS BANDAGES

Adhesive Bandages 11917006520 ADH BANDAGE MIS HYPO-ALL

Adhesive Bandages 11917007036 ADH BANDAGE MIS CLEAR

Adhesive Bandages 11917007038 ADH BANDAGE MIS SHEER

Adhesive Bandages 11917007039 ADH BANDAGE MIS WTR SHLD

Adhesive Bandages 11917007040 ADH BANDAGE MIS FLEXIBLE

Adhesive Bandages 11917008091 BLISTER REL MIS BANDAGE

37

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 11917008241 ADH BANDAGE MIS HEALTH

Adhesive Bandages 11917008243 SHR BANDAGES MIS ASSORTED

Adhesive Bandages 11917010456 ANTIBACTERIA MIS BANDAGES

Adhesive Bandages 11917010457 GNTL ADHESVE MIS BNDG XL

Adhesive Bandages 11917010591 ADH BANDAGE MIS PLASTIC

Adhesive Bandages 11917010592 FABRIC BANDG MIS FLEXIBLE

Adhesive Bandages 11917010596 ADH BANDAGE MIS SHEER

Adhesive Bandages 11917014223 ANTIBACTERAI MIS BANDAGES

Adhesive Bandages 11917014233 ANTIBAC BNDG MIS 7/8"

Adhesive Bandages 11917014798 SORESPOT MIS BANDAGES

Adhesive Bandages 11917015837 BUTTERFLY MIS CLOSURES

Adhesive Bandages 11917018497 Antibacterial Clear Bandage

Adhesive Bandages 13733030594 SHR BANDAGES MIS

Adhesive Bandages 35664000231 Coverlet Strips

Adhesive Bandages 38472042000 ADHESIVE KNT MIS 3"X5"

Adhesive Bandages 38472042050 ADHESIVE KNT MIS 3"X5"

Adhesive Bandages 38472050410 2ND SKIN PAD MIS BLISTER

Adhesive Bandages 38472050420 2ND SKIN PAD MIS BLISTER

Adhesive Bandages 38472050431 2ND SKIN CUT MIS CLOSURE

Adhesive Bandages 38472050441 2ND SKIN CUT MIS CLOSURE

Adhesive Bandages 38472053400 2ND SKIN PAD MIS BLISTER

Adhesive Bandages 38472053450 2ND SKIN PAD MIS BLISTER

38

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 38472079396 QUIKSTIK ADH MIS BANDAGES

Adhesive Bandages 38472079404 QUIKSTIK ADH MIS BANDAGES

Adhesive Bandages 38472079407 QUIKSTIK ADH MIS BANDAGES

Adhesive Bandages 38472079415 QUIKSTIK ADH MIS BANDAGES

Adhesive Bandages 41163023053 EQL SHEER MIS STRIPS

Adhesive Bandages 41163023057 EQL FLEXIBLE MIS FABRIC

Adhesive Bandages 41163023061 EQL SHEER MIS STRIPS

Adhesive Bandages 41163023342 EQL FLEXIBLE MIS FABRIC

Adhesive Bandages 41163023343 EQL FLEXIBLE MIS FABRIC

Adhesive Bandages 41163023344 PLASTIC STRP MIS

Adhesive Bandages 41163024464 ADHESIVE PAD MIS LARGE

Adhesive Bandages 41163024468 EQL SHEER MIS STRIPS

Adhesive Bandages 41163024469 EQL FLEXIBLE MIS FABRIC

Adhesive Bandages 41163025181 EQL FLEXIBLE MIS FOAM

Adhesive Bandages 41163040252 EQL SHEER MIS SPOTS

Adhesive Bandages 41163040256 EQL STRIPS MIS

Adhesive Bandages 41163040260 ADHESIVE PAD MIS MEDIUM

Adhesive Bandages 41163040885 EQL BUTTERFL MIS CLOSURE

Adhesive Bandages 41163040886 EQL HVY DUTY MIS STRIPS

Adhesive Bandages 41163041761 EQL HVY DUTY MIS STRIPS

Adhesive Bandages 41163044211 EQL STRIPS MIS

Adhesive Bandages 41163044213 EQL STRIPS MIS

39

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 41163046749 ADV HEALING MIS BANDAGES

Adhesive Bandages 41163047533 EQL FIRST MIS AID BAND

Adhesive Bandages 41163049072 VARIETY PACK MIS BANDAGES

Adhesive Bandages 41163049783 ANTIBAC FABR MIS STRIPS

Adhesive Bandages 41163049784 EQL PLASTIC MIS STRIPS

Adhesive Bandages 41163049785 HEAVY DUTY MIS BANDAGES

Adhesive Bandages 41163049786 ANIMAL PRINT MIS STRIPS

Adhesive Bandages 41163049787 EQL GENTLE MIS STRIPS

Adhesive Bandages 41163049818 STRONG STRIP MIS WATERPRF

Adhesive Bandages 41415006875 SUPERSTRIP MIS 1" X 3"

Adhesive Bandages 42167002730 ADH BANDAGE MIS RETENTIO

Adhesive Bandages 49348007547 SM KNUCKLE/ MIS FINGERTP

Adhesive Bandages 49348037744 SM BANDAGES MIS WTRSHELD

Adhesive Bandages 49348037844 SM BANDAGES MIS ANTIBACT

Adhesive Bandages 49348053644 SM BANDAGES MIS FAB 3/4"

Adhesive Bandages 49348053844 SM BANDAGES MIS FOAM

Adhesive Bandages 49348054601 SM BANDAGES MIS FOAM XL

Adhesive Bandages 49348054701 SM BANDAGES MIS FAB XL

Adhesive Bandages 49348054860 SM BANDAGES MIS FOAM

Adhesive Bandages 49348058159 SM BANDAGES MIS CLEAR

Adhesive Bandages 49348058244 SM BANDAGES MIS FLEXIBLE

Adhesive Bandages 49348058312 SM BANDAGES MIS PLASTIC

40

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 49348058501 SM BANDAGES MIS SHEER XL

Adhesive Bandages 49348066110 SM BANDAGES MIS CLR SPOT

Adhesive Bandages 49348068459 SM BANDAGES MIS SHEER

Adhesive Bandages 49348068512 SM BANDAGES MIS SHEER

Adhesive Bandages 49348070847 SM BANDAGES MIS STRNG ST

Adhesive Bandages 49348077044 HYPO-ALLERG MIS BANDAGE

Adhesive Bandages 49348081401 SM STRONG MIS STRIPS

Adhesive Bandages 49348081547 SM STRONG MIS STRIPS

Adhesive Bandages 49614061252 ADH BANDAGE MIS PLASTIC

Adhesive Bandages 49614061352 ADH BANDAGE MIS PLASTIC

Adhesive Bandages 49614061372 PLASTIC MIS BANDAGES

Adhesive Bandages 49614061600 FABRIC BANDG MIS ASSORTED

Adhesive Bandages 50428004449 ADV HEALING MIS BANDAGES

Adhesive Bandages 50428026559 CVS Sheer Bandages

Adhesive Bandages 50428026608 CVS Anti-Bacterial Bandages

Adhesive Bandages 50428037633 CVS Flexible Fabric Bandage

Adhesive Bandages 50428039020 CVS Anti-Bact Bandages Child

Adhesive Bandages 50428040416 CVS Anti-Bacterial Bandages

Adhesive Bandages 50428041570 CVS Flexible Fabric Bandage

Adhesive Bandages 50428041886 CVS Plastic Bandages

Adhesive Bandages 50428216515 SHEER BANDGE MIS 1"

Adhesive Bandages 50428235501 SHEER BANDGE MIS EX-LARGE

41

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 50428235502 PLASTC BANDG MIS 3/4"

Adhesive Bandages 50428334568 ADH BANDAGE MIS FOAM TOE

Adhesive Bandages 50428702514 SHEER BANDGE MIS ASSORTED

Adhesive Bandages 50428875952 FLEX BANDAGE MIS

Adhesive Bandages 50428955443 CVS SPOT BAN MIS SHEER

Adhesive Bandages 51131065288 COMFORT FAB MIS KNEE/ELB

Adhesive Bandages 51131066424 NEXCARE WATR MIS PRF BAND

Adhesive Bandages 51131066426 NEXCARE WATR MIS PRF BAND

Adhesive Bandages 51131066989 NEXCARE TATT MIS BANDAGES

Adhesive Bandages 51131066990 NEXCARE TATT MIS BANDAGES

Adhesive Bandages 51131081387 WATERPROOF MIS BANDAGES

Adhesive Bandages 51131083537 COMFORT FAB MIS 3/4"X3"

Adhesive Bandages 51131085042 NEXCARE TATT MIS BANDAGES

Adhesive Bandages 51131086261 NEXCARE TATT MIS BANDAGES

Adhesive Bandages 51131093750 HEAVY DUTY MIS CLR&TGH

Adhesive Bandages 51131093751 HEAVY DUTY MIS FAB BAND

Adhesive Bandages 51131093870 HEAVY DUTY MIS CLR&TGH

Adhesive Bandages 51131096160 NEXCARE TATT MIS BANDAGES

Adhesive Bandages 51131096470 ACT BRIGHTS MIS BANDAGES

Adhesive Bandages 51131097736 COMFORT FAB MIS ASSORTED

Adhesive Bandages 51131097737 NEXCARE WATR MIS PRF BAND

Adhesive Bandages 51131097800 HEAVY DUTY MIS FAB BAND

42

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 51131097801 HEAVY DUTY MIS FAB BAND

Adhesive Bandages 51131099524 WATERPROOF MIS BANDAGES

Adhesive Bandages 51131099526 SOFT 'N FLEX MIS

Adhesive Bandages 52569013322 ADH BANDAGE MIS ANTIBACT

Adhesive Bandages 52569013323 ADH BANDAGE MIS ANTIBACT

Adhesive Bandages 52569013324 ADH BANDAGE MIS ANTIBACT

Adhesive Bandages 52569013326 ADH BANDAGE MIS ANTIBACT

Adhesive Bandages 52569013327 ADH BANDAGE MIS ANTIBACT

Adhesive Bandages 52569013329 ADH BANDAGE MIS ANTIBACT

Adhesive Bandages 52569013333 ADH BANDAGE MIS ANTIBACT

Adhesive Bandages 52569013334 ADH BANDAGE MIS ANTIBACT

Adhesive Bandages 52569013339 ADH BANDAGE MIS ANTIBACT

Adhesive Bandages 52569013340 HM BUTTERFLY MIS CLOSURES

Adhesive Bandages 52569013496 ADH BANDAGE MIS ANTIBACT

Adhesive Bandages 78742009356 EQ STRONG MIS STRIPS

Adhesive Bandages 78742009357 FABRIC BANDG MIS FLEXIBLE

Adhesive Bandages 84389010830 Curad Comfort Fabric

Adhesive Bandages 87701025338 GNP SHEER ST MIS ASSORTED

Adhesive Bandages 87701040682 GNP Super Strip Waterseal

Adhesive Bandages 87701048567 GNP SHEER MIS STRIPS

Adhesive Bandages 87701048569 CLEAR STRIPS MIS 3/4"

Adhesive Bandages 87701048615 GNP PLASTIC MIS 3/4"

43

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 94542085100 SURESEAL MIS LARGE

Adhesive Bandages 94542085200 SURESEAL MIS EX LARGE

Adhesive Bandages 94542085300 SURESEAL MIS K

Adhesive Bandages 96295004728 BANDAGES FAB MIS ASSORTED

Adhesive Bandages 96295010253 SHR BANDAGES MIS ASSORTED

Adhesive Bandages 96295010254 SHR BANDAGES MIS EX-LARGE

Adhesive Bandages 96295010256 SHR BANDAGES MIS 3/4"

Adhesive Bandages 96295010625 SHR BANDAGES MIS

Adhesive Bandages 96295010676 WATERSHIELD MIS BANDAGES

Adhesive Bandages 96295010831 PLASTIC MIS BANDAGES

Adhesive Bandages 96295011127 CLEAR BANDAG MIS 3/4"

Adhesive Bandages 96295011166 BANDAGES FAB MIS 3/4"

Adhesive Bandages 96295011167 BANDAGE FABR MIS KNUC/FIN

Adhesive Bandages 96295011298 PEANUTS MIS BANDAGES

Adhesive Bandages 96295012695 Sheer Adhesive Bandages

Adhesive Bandages 98654000000 CarpalAid Small

Adhesive Bandages 98654000001 CarpalAid Large

Adhesive Bandages 98654000002 CarpalAid Large

Adhesive Bandages 98654000003 CarpalAid Large

Adhesive Bandages 98654000005 CarpalAid Small

Adhesive Bandages 98654000006 CarpalAid Small

Adhesive Bandages 98654000050 CarpalAid Practioner Pack Lg

44

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages 98654000051 CarpalAid Practioner Pack Smal

Adhesive Bandages 98654000062 CarpalAid Employee Survival Lg

Adhesive Bandages 98654000063 CarpalAid Employee Survival Sm

Adhesive Bandages - Pads 08137004731 EASY RELEASE PAD NONSTICK

Adhesive Bandages - Pads 08137004768 J & J ADHES PAD LARGE

Adhesive Bandages - Pads 08137016627 BAND-AID PAD ADHESIVE

Adhesive Bandages - Pads 08137016628 BAND-AID PAD ADHESIVE

Adhesive Bandages - Pads 08137116142 BAND-AID PAD 2"X3"

Adhesive Bandages - Pads 08137116143 BAND-AID PAD 3"X4"

Adhesive Bandages - Pads 08137116144 BAND-AID PAD LARGE

Adhesive Bandages - Pads 11822062242 FIRST AID NO PAD STICK

Adhesive Bandages - Pads 11822573660 RA SHEER ADH PAD LARGE

Adhesive Bandages - Pads 11917005113 ADHESIVE PAD 3"X4"

Adhesive Bandages - Pads 11917006302 ADHESIVE PAD 2"X3"

Adhesive Bandages - Pads 11917014473 MOLESKIN PAD FOAM

Adhesive Bandages - Pads 49348053701 SM ADHESIVE PAD 2"X3"

Adhesive Bandages - Pads 49348066001 SM ADHESIVE PAD 3"X4"

Adhesive Bandages - Pads 50428027642 ADHESIVE PAD 6"X6"

Adhesive Bandages - Pads 50428034263 ADHESIVE PAD 4"X4"

Adhesive Bandages - Pads 50428955542 ADHESIVE PAD PAD 2.25"X3"

Adhesive Bandages - Pads 51131019773 WATERPROOF PAD 3"X4"

Adhesive Bandages - Pads 52569013332 ADHESIVE PAD PAD ANTIBACT

45

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Bandages - Pads 52569013338 ADHESIVE PAD PAD ANTIBACT

Adhesive Bandages - Pads 76300017250 SOF-SET ADH PAD PATCH

Adhesive Bandages - Pads 87701040116 GNP ADHESIVE PAD 3" X 4"

Adhesive Bandages - Pads 96295011125 ADHESIVE PAD 2"X3"

Adhesive Bandages - Pads 96295011126 ADHESIVE PAD 3"X4"

Adhesive Tape - Tape 08011968602 SCANPOR TAP 1"X11YDS

Adhesive Tape - Tape 08011968622 SCANPOR TAP 1"X11YDS

Adhesive Tape - Tape 08011968624 SCANPOR TAP 2"X11YDS

Adhesive Tape - Tape 08080159610 KENDALL PAPR TAP 1/2"X10Y

Adhesive Tape - Tape 08080159611 KENDALL PAPR TAP .5"X10YD

Adhesive Tape - Tape 08080191411 KENDALL PAPR TAP 1"X1.5YD

Adhesive Tape - Tape 08080191412 KENDALL PAPR TAP 1"X10YD

Adhesive Tape - Tape 08080241910 KENDALL PAPR TAP 2"X10YD

Adhesive Tape - Tape 08080241911 KENDALL PAPR TAP 2"X1.5YD

Adhesive Tape - Tape 08080241912 KENDALL PAPR TAP 2"X10YD

Adhesive Tape - Tape 08080339410 KENDALL PAPR TAP 3"X10YD

Adhesive Tape - Tape 08080941110 KENDAL CLOTH TAP 1"X10YD

Adhesive Tape - Tape 08080941210 CLOTH TAPE TAP 2"X10YD

Adhesive Tape - Tape 08080941310 CLOTH TAPE TAP 3"X10YD

Adhesive Tape - Tape 08080941410 CLOTH TAPE TAP 4"X10YD

Adhesive Tape - Tape 08080941610 CLOTH TAPE TAP 6"X10YD

Adhesive Tape - Tape 08137005103 ZONAS POROUS TAP 0.5"X10Y

46

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Tape - Tape 08137005104 ZONAS POROUS TAP 1"X10YDS

Adhesive Tape - Tape 08137005105 ZONAS POROUS TAP 1.5X10YD

Adhesive Tape - Tape 08137005106 ZONAS POROUS TAP 2"X10YDS

Adhesive Tape - Tape 08137005107 ZONAS POROUS TAP 3"X10YDS

Adhesive Tape - Tape 08137005131 J&J WATERPRF TAP 2"X10YDS

Adhesive Tape - Tape 08137005132 J&J WATERPRF TAP 1"X10YDS

Adhesive Tape - Tape 08137005134 J&J WATERPRF TAP 2"X10YDS

Adhesive Tape - Tape 08137005135 J&J WATERPRF TAP 3"X10YDS

Adhesive Tape - Tape 08137005139 DERMICEL TAP 1" X 1YD

Adhesive Tape - Tape 08137005140 DERMICEL TAP 2" X 1YD

Adhesive Tape - Tape 08137005143 DERMICEL TAP 0.5"X10Y

Adhesive Tape - Tape 08137005145 DERMICEL TAP 2"X10YDS

Adhesive Tape - Tape 08137005146 DERMICEL TAP 3"X10YDS

Adhesive Tape - Tape 08137005178 DERMIFORM TAP 1" X 1YD

Adhesive Tape - Tape 08137005179 DERMIFORM TAP 2" X 1YD

Adhesive Tape - Tape 08137005180 DERMIFORM TAP 0.5"X10Y

Adhesive Tape - Tape 08137005182 DERMIFORM TAP 2"X10YDS

Adhesive Tape - Tape 08137005183 DERMIFORM TAP 3"X10YDS

Adhesive Tape - Tape 08137116145 BAND-AID TAP SMALL

Adhesive Tape - Tape 08137116146 BAND-AID TAP MEDIUM

Adhesive Tape - Tape 08137116152 BAND-AID TAP 1"X10YDS

Adhesive Tape - Tape 08137116153 BAND-AID TAP 1"X10YDS

47

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Tape - Tape 08137116155 BAND-AID TAP 1/2X10YD

Adhesive Tape - Tape 08137117120 Band-Aid Waterproof

Adhesive Tape - Tape 08225096500 CURAD ADVANC TAP 1"X5YD

Adhesive Tape - Tape 08225096600 CURAD ADVANC TAP 1/2"X5YD

Adhesive Tape - Tape 08225700000 WET-PRUF TAP 1/2"X5YD

Adhesive Tape - Tape 08225702000 WET-PRUF TAP 1"X5 YDS

Adhesive Tape - Tape 08333052701 TRANSPORE PL TAP 1"X 10YD

Adhesive Tape - Tape 08333052702 TRANSPORE PL TAP 2"X 10YD

Adhesive Tape - Tape 08333053000 MICROPORE TAP 1/2X10YD

Adhesive Tape - Tape 08333053001 MICROPORE TAP 1"X10YD

Adhesive Tape - Tape 08333053002 MICROPORE TAP 2"X10YD

Adhesive Tape - Tape 08333053801 DURAPORE CL TAP 1"X10YDS

Adhesive Tape - Tape 08333053802 DURAPORE CL TAP 2"X10YDS

Adhesive Tape - Tape 08333152500 BLENDERM TAP 1/2"X5YD

Adhesive Tape - Tape 08333152501 BLENDERM TAP 1"X5YDS

Adhesive Tape - Tape 08333152502 BLENDERM TAP 2"X5YDS

Adhesive Tape - Tape 08333152700 TRANSPORE TAP 1/2X10YD

Adhesive Tape - Tape 08333152701 TRANSPORE TAP 1"X10YDS

Adhesive Tape - Tape 08333152702 TRANSPORE TAP 2"X10YDS

Adhesive Tape - Tape 08333152703 TRANSPORE TAP 3"X10YDS

Adhesive Tape - Tape 08333152711 TRANSPORE TAP 1"X1.5YD

Adhesive Tape - Tape 08333152712 TRANSPORE TAP 2"X1.5YD

48

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Tape - Tape 08333152801 MICROFOAM TAP 1"X5.5YD

Adhesive Tape - Tape 08333152802 MICROFOAM TAP 2"X5.5YD

Adhesive Tape - Tape 08333152803 MICROFOAM TAP 3"X5.5YD

Adhesive Tape - Tape 08333152804 MICROFOAM TAP 4"X5.5YD

Adhesive Tape - Tape 08333153000 MICROPORE TAP 1/2X10YD

Adhesive Tape - Tape 08333153001 MICROPORE TAP 1"X10YDS

Adhesive Tape - Tape 08333153002 MICROPORE TAP 2"X10YDS

Adhesive Tape - Tape 08333153003 MICROPORE TAP 3"X10YDS

Adhesive Tape - Tape 08333153011 MICROPORE TAP 1"X1.5YD

Adhesive Tape - Tape 08333153012 MICROPORE TAP 2"X1.5YD

Adhesive Tape - Tape 08333153300 MICROPORE TAP 1/2X10YD

Adhesive Tape - Tape 08333153301 MICROPORE TAP 1"X10YDS

Adhesive Tape - Tape 08333153302 MICROPORE TAP 2"X10YDS

Adhesive Tape - Tape 08333153400 TRANSPORE WH TAP 1/2X10YD

Adhesive Tape - Tape 08333153401 TRANSPORE WH TAP 1"X10YDS

Adhesive Tape - Tape 08333153402 TRANSPORE WH TAP 2"X10YDS

Adhesive Tape - Tape 08333153403 TRANSPORE WH TAP 3"X10YDS

Adhesive Tape - Tape 08333153500 MICROPORE TAP 1/2X10YD

Adhesive Tape - Tape 08333153501 MICROPORE TAP 1"X10YDS

Adhesive Tape - Tape 08333153502 MICROPORE TAP 2"X10YDS

Adhesive Tape - Tape 08333153503 MICROPORE TAP 3"X10YDS

Adhesive Tape - Tape 08333153800 DURAPORE TAP 1/2X10YD

49

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Tape - Tape 08333153801 DURAPORE TAP 1"X10YDS

Adhesive Tape - Tape 08333153802 DURAPORE TAP 2"X10YDS

Adhesive Tape - Tape 08333153803 DURAPORE TAP 3"X10YDS

Adhesive Tape - Tape 08333153811 DURAPORE TAP 1"X1.5YD

Adhesive Tape - Tape 08333153812 DURAPORE TAP 2"X1.5YD

Adhesive Tape - Tape 08333156201 MICROFOAM TAP PTCH 4X7

Adhesive Tape - Tape 08333286101 MEDIPORE H TAP 1"X10YDS

Adhesive Tape - Tape 08333286201 MEDIPORE H TAP 2"X10YDS

Adhesive Tape - Tape 08333286203 MEDIPORE H TAP 2"X2YDS

Adhesive Tape - Tape 08333286301 MEDIPORE H TAP 3"X10YDS

Adhesive Tape - Tape 08333286401 MEDIPORE H TAP 4"X10YDS

Adhesive Tape - Tape 08333286403 MEDIPORE H TAP 4"X2YDS

Adhesive Tape - Tape 08333286601 MEDIPORE H TAP 6"X10YDS

Adhesive Tape - Tape 08333286603 MEDIPORE H TAP 6"X2YDS

Adhesive Tape - Tape 08333286801 MEDIPORE H TAP 8"X10YDS

Adhesive Tape - Tape 08333295000 CLOTH ADHESV TAP 1/2X10YD

Adhesive Tape - Tape 08333295001 CLOTH ADHESV TAP 1"X10YDS

Adhesive Tape - Tape 08333295002 CLOTH ADHESV TAP 2"X10YDS

Adhesive Tape - Tape 08333295003 CLOTH ADHESV TAP 3"X10YDS

Adhesive Tape - Tape 08333295401 MEDIPORE TAP DRESS-IT

Adhesive Tape - Tape 08333295501 MEDIPORE TAP DRESS-IT

Adhesive Tape - Tape 08333295601 MEDIPORE TAP DRESS-IT

50

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Tape - Tape 08333295701 MEDIPORE TAP DRESS-IT

Adhesive Tape - Tape 08333295801 MEDIPORE TAP DRESS-IT

Adhesive Tape - Tape 08333296101 MEDIPORE TAP 1"X10YDS

Adhesive Tape - Tape 08333296201 MEDIPORE TAP 2"X10YDS

Adhesive Tape - Tape 08333296203 MEDIPORE TAP 2"X2YDS

Adhesive Tape - Tape 08333296301 MEDIPORE TAP 3"X10YDS

Adhesive Tape - Tape 08333296401 MEDIPORE TAP 4"X10YDS

Adhesive Tape - Tape 08333296403 MEDIPORE TAP 4"X2YDS

Adhesive Tape - Tape 08333296601 MEDIPORE TAP 6"X10YDS

Adhesive Tape - Tape 08333296603 MEDIPORE TAP 6"X2YDS

Adhesive Tape - Tape 08333296801 MEDIPORE TAP 8"X10YDS

Adhesive Tape - Tape 11822037070 CLOTH TAPE TAP 1"X10YDS

Adhesive Tape - Tape 11822312680 RA ADHESIVE TAP 1/2"X5YD

Adhesive Tape - Tape 11822312690 RA ADHESIVE TAP 1/2"X10Y

Adhesive Tape - Tape 11822315970 RA ADHESIVE TAP

Adhesive Tape - Tape 11822538170 GENTLE PAPER TAP 1"X10YDS

Adhesive Tape - Tape 11822573650 PAIN-FREE TAP 3"X2.3YD

Adhesive Tape - Tape 11822644390 RA ADHESIVE TAP 1"X10YDS

Adhesive Tape - Tape 11822985660 RA ADHESIVE TAP 1"X5YDS

Adhesive Tape - Tape 11917005065 ADHESIVE TAP 1"X6YD

Adhesive Tape - Tape 11917005066 ADHESIVE TAP PAPER

Adhesive Tape - Tape 11917005262 ADHESIVE TAP 1/2"X6YD

51

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Tape - Tape 11917007037 SKIN CLOSURE TAP STRIPS

Adhesive Tape - Tape 11917011173 ADHESVE TAPE TAP 1/2"X12

Adhesive Tape - Tape 11917011174 PAPER TAPE TAP 1"X12YD

Adhesive Tape - Tape 11917011178 ADHESVE TAPE TAP 1/2"X6YD

Adhesive Tape - Tape 11917012647 CLOTH TAPE TAP 1"X10YDS

Adhesive Tape - Tape 11917015841 PAPER TAPE TAP 1"X10YD

Adhesive Tape - Tape 11917015842 CLEAR TAPE TAP 1"X10YDS

Adhesive Tape - Tape 11917015843 ADHESIVE TAP 1/2"X5YD

Adhesive Tape - Tape 11917015844 PAPER TAPE TAP 1"X10YD

Adhesive Tape - Tape 11917015845 ADHESIVE TAP 1/2X10YD

Adhesive Tape - Tape 11917016431 PAPER TAPE TAP DISPENSR

Adhesive Tape - Tape 11917016895 ELASTIC FOAM TAP 1"X5YD

Adhesive Tape - Tape 14179002010 KT TAPE PRO TAP 10"PRE

Adhesive Tape - Tape 14179002012 KT TAPE PRO TAP 10"PRE

Adhesive Tape - Tape 14179002013 KT TAPE PRO TAP 10"PRE

Adhesive Tape - Tape 14179002016 KT TAPE PRO TAP 10"PRE

Adhesive Tape - Tape 14179002019 KT RECOVERY TAP 6.7X3.7

Adhesive Tape - Tape 14179002024 KT TAPE PRO TAP 10"PRE

Adhesive Tape - Tape 14179002025 KT TAPE PRO TAP 10"PRE

Adhesive Tape - Tape 14179002026 KT TAPE PRO TAP 10"PRE

Adhesive Tape - Tape 14179002050 KT TAPE PROX TAP PRECUT

Adhesive Tape - Tape 14179002083 KT TAPE PRO TAP 10"PRE

52

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Tape - Tape 14179002084 KT TAPE PRO TAP 10"PRE

Adhesive Tape - Tape 14179002102 KT TAPE PRO TAP 10"PRE

Adhesive Tape - Tape 14179002107 KT TAPE PRO TAP 10"PRE

Adhesive Tape - Tape 14179002126 KT TAPE GNTL TAP 10"PRE

Adhesive Tape - Tape 41163023051 EQL ADHESIVE TAP 1/2X10YD

Adhesive Tape - Tape 41163023341 EQL ADHESIVE TAP 1"X5YD

Adhesive Tape - Tape 41163041759 EQL PAPER TAP 1"X10YD

Adhesive Tape - Tape 41163044283 FIRST AID TAP 1"X2.3YD

Adhesive Tape - Tape 41163044284 FIRST AID TAP 2"X2.3YD

Adhesive Tape - Tape 41163049802 TAPE DISPENS TAP 1"X10YD

Adhesive Tape - Tape 49022083300 ALTHLETIC TAP 1.5X10YD

Adhesive Tape - Tape 49348058686 WATERPRF ADH TAP 1/2X10YD

Adhesive Tape - Tape 49348058783 WATERPRF ADH TAP 1"X5YD

Adhesive Tape - Tape 49614080505 FIRST AID TAP PAPER

Adhesive Tape - Tape 50428025691 CVS Kinesiology

Adhesive Tape - Tape 50428152736 CVS ADHESIVE TAP 1.5"X10Y

Adhesive Tape - Tape 50428209995 CVS ADHESIVE TAP 1"X2.2YD

Adhesive Tape - Tape 50428210000 CVS ADHESIVE TAP 2"X2.2YD

Adhesive Tape - Tape 50428310412 CVS ADHESIVE TAP 1"X360"

Adhesive Tape - Tape 50428336795 CVS ADHESIVE TAP 1"X10YDS

Adhesive Tape - Tape 50428336797 CVS ADHESIVE TAP 2"X360"

Adhesive Tape - Tape 50428830963 PAPER TAPE TAP 1"X10YD

53

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Tape - Tape 50428830970 PAPER TAPE TAP 1"X10YD

Adhesive Tape - Tape 50989000206 KINESIO TEX TAP 2.5CMX5M

Adhesive Tape - Tape 50989000207 KINESIO TEX TAP 5CMX5M

Adhesive Tape - Tape 50989000208 KINESIO TEX TAP 7.5CMX5M

Adhesive Tape - Tape 50989000209 KINESIO TEX TAP 5CMX5M

Adhesive Tape - Tape 50989000210 KINESIO TEX TAP 5CMX5M

Adhesive Tape - Tape 50989000211 KINESIO TEX TAP 5CMX5M

Adhesive Tape - Tape 50989000212 KINESIO TEX TAP 5CMX31.5

Adhesive Tape - Tape 50989000213 KINESIO TEX TAP 5CMX31.5

Adhesive Tape - Tape 50989000214 KINESIO TEX TAP 5CMX31.5

Adhesive Tape - Tape 50989000215 KINESIO TEX TAP 5CMX31.5

Adhesive Tape - Tape 50989000229 KINESIO FAN TAP 5CMX30CM

Adhesive Tape - Tape 50989000230 KINESIO FAN TAP 5CMX30CM

Adhesive Tape - Tape 50989000231 KINESIO FAN TAP 5CMX30CM

Adhesive Tape - Tape 50989000232 KINESIO FAN TAP 5CMX30CM

Adhesive Tape - Tape 50989000233 KINESIO FAN TAP 8CMX30CM

Adhesive Tape - Tape 50989000236 KINESIO TEX TAP 5CMX31.5

Adhesive Tape - Tape 50989000237 KINESIO TEX TAP 5CMX5M

Adhesive Tape - Tape 50989000238 KINESIO TEX TAP 5CMX4M

Adhesive Tape - Tape 50989000239 KINESIO TEX TAP 5CMX4M

Adhesive Tape - Tape 50989000240 KINESIO TEX TAP 5CMX4M

Adhesive Tape - Tape 50989000241 KINESIO TEX TAP 5CMX4M

54

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Tape - Tape 50989000242 KINESIO TEX TAP 5CMX4M

Adhesive Tape - Tape 51131000014 GENTLE PAPER TAP 1/2"X10Y

Adhesive Tape - Tape 51131000015 GENTLE PAPER TAP 1"X10YD

Adhesive Tape - Tape 51131000016 GENTLE PAPER TAP 2"X10YD

Adhesive Tape - Tape 51131000020 DURABLE CLTH TAP 1"X10YD

Adhesive Tape - Tape 51131000021 DURABLE CLTH TAP 2"X10YD

Adhesive Tape - Tape 51131056655 GENTLE PAPER TAP 2"X10YD

Adhesive Tape - Tape 51131056660 FLEX CLEAR TAP 1"X10YD

Adhesive Tape - Tape 51131056661 FLEX CLEAR TAP 2"X10YD

Adhesive Tape - Tape 51131064124 STERI-STRIP TAP 1/2"X4"

Adhesive Tape - Tape 51131064125 STERI-STRIP TAP 1/4"X4"

Adhesive Tape - Tape 51131066775 WATERPROOF TAP 1"X5YD

Adhesive Tape - Tape 51131066777 SOFT CLOTH TAP 1"X6YD

Adhesive Tape - Tape 51131066875 NO HURT TAP 1"X2.2YD

Adhesive Tape - Tape 51131066992 GENTLE PAPER TAP 3/4"X8YD

Adhesive Tape - Tape 51131066993 DURABLE CLTH TAP 3/4"X6YD

Adhesive Tape - Tape 51131066994 FLEX CLEAR TAP 3/4"X7YD

Adhesive Tape - Tape 51131091382 FLEX CLEAR TAP 1"X10YD

Adhesive Tape - Tape 51131091386 GENTLE PAPER TAP 1"X10YD

Adhesive Tape - Tape 51131091389 DURABLE CLTH TAP 1"X10YD

Adhesive Tape - Tape 51144000580 KT FLEX KNEE TAP 10"PRE

Adhesive Tape - Tape 57879000361 KT TAPE PRO TAP 10"PRE

55

GPI NAME NDC Drug Name

List of covered over-the-counter items / Listado de cobertura de artculos fuera de recetario Last Review: 03-01-2019

Adhesive Tape - Tape 57879000362 KT TAPE PRO TAP 10"PRE

Adhesive Tape - Tape 746