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List of Covered Over-The-Counter Medications

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List of Covered Over-The-Counter Medications LIST OF COVERED OVER-THE-COUNTER MEDICATIONS DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS ANALGESICS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS ADULT ASPIRIN REGIMEN BRAND 1 aspirin ASPIR 81 BRAND 1 aspirin ASPIR-LOW BRAND 1 aspirin ASPIRIN (600 MG SUPPOSITORY, GS 81 MG CHEWABLE TAB, 325 MG TABLET, SM 81 MG CHEWABLE TAB, QC 81 MG CHEWABLE TAB, HM 325 MG TABLET, HM 81 MG generic 1 CHEWABLE TAB, 300 MG SUPPOSITORY, SM 325 MG TABLET, GS 325 MG TABLET, 81 MG CHEWABLE TABLET, QC 325 MG TABLET) ASPIRIN EC (SM 81 MG, 500 MG, SM 325 MG, 81 MG, HM 81 MG, HM 325 MG, QC 81 generic 1 MG, QC 325 MG, 325 MG) CHILDREN'S ASPIRIN (SM 81 MG CHW, 81 generic 1 MG CHEW) ECPIRIN BRAND 1 aspirin ANESTHETICS LOCAL ANESTHETICS lidocaine 3% cream generic 1 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS SMOKING CESSATION AGENTS NICORETTE (2 MG, 4 MG) BRAND 1 AL At least 18 yrs old nicotine polacrilex NICOTINE GUM (HM 4 MG, 2 MG, 4 MG, SM generic 1 AL At least 18 yrs old 2 MG, SM 4 MG, HM 2 MG) NICOTINE LOZENGE (2 MG MINI, 4 MG MINI, SM 2 MG, HM 2 MG MINI, GS 2 MG MINI, GS generic 1 AL At least 18 yrs old 4 MG MINI, 4 MG, GS 4 MG, 2 MG, HM 2 MG, SM 4 MG, HM 4 MG) NICOTINE PATCH (HM 7 MG/24HR PATCH, 7 generic 1 AL At least 18 yrs old PAGE 1 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS MG/24HR PATCH, TRANSDERMAL SYSTEM, SM 7 MG/24HR PATCH, HM 14 MG/24HR PATCH, SM 14 MG/24HR PATCH, SM 21 MG/24HR PATCH, HM 21 MG/24HR PATCH, 14 MG/24HR PATCH, 21 MG/24HR PATCH) ANTIFUNGALS 3 DAY VAGINAL BRAND 1 miconazole nitrate 3-DAY VAGINAL CREAM (SM, ) BRAND 1 clotrimazole CLOTRIMAZOLE (SM VAG, VAGINAL) generic 1 clotrimazole-3 2% cream generic 1 miconazole 1 combination pack generic 1 MICONAZOLE 3 4% CREAM BRAND 1 miconazole nitrate MICONAZOLE 7 (SM 7 100 MG VAG SUP, SM generic 1 7 CREAM, 7 100 MG VAG SUPP, 7 CREAM) MICONAZOLE NITRATE (VAGINAL, SM generic 1 VAGINAL, TOPICAL) qc miconazole-7 cream generic 1 BLOOD GLUCOSE REGULATORS INSULINS HUMULIN 70-30 insulin nph human isophane/insulin regular, BRAND 1 human HUMULIN 70/30 KWIKPEN insulin nph human isophane/insulin regular, BRAND 1 human HUMULIN N BRAND 1 insulin nph human isophane HUMULIN N KWIKPEN BRAND 1 insulin nph human isophane HUMULIN R BRAND 1 insulin regular, human NOVOLIN N BRAND 1 insulin nph human isophane NOVOLIN R BRAND 1 insulin regular, human PAGE 2 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM, OTHER 8 HOUR ACETAMINOPHEN ER 650 MG BRAND 1 acetaminophen SM 8 HOUR PAIN RELIEF 650 MG BRAND 1 acetaminophen 8HR ARTHRITIS PAIN BRAND 1 acetaminophen 8HR MUSCLE ACHE-PAIN ER 650 MG BRAND 1 acetaminophen acetaminophen 160 mg/5 ml liq generic 1 AL Up to 6 yrs old acetaminophen er 650 mg caplet generic 1 acetaminophen er 650 mg tablet generic 1 GS ARTHRITIS PAIN ER 650 MG BRAND 1 acetaminophen ARTHRITIS PAIN RELIEF (RELF ER 650 MG, SM ER 650 MG, QC ER 650 MG) BRAND 1 acetaminophen ARTHRITIS PAIN RELIEF (SM ARTHRIT RLF ER 650 MG, ARTHRITIS ER 650 MG CAPLT, HM ARTHRITIS ER 650 MG, HM ARTHRIT BRAND 1 RLF ER 650 MG) acetaminophen CHILDREN'S ACETAMINOPHEN (HM CHILD generic 1 AL Up to 6 yrs old 160 MG, CHLD 160 MG/5 ML, CHILD 160 MG) CHILD'S MAPAP 160 MG TAB CHEW BRAND 1 AL Up to 6 yrs old acetaminophen CHILDREN'S PAIN RELIEF (160 ML SUS, QC 160 ML) BRAND 1 AL Up to 6 yrs old acetaminophen CHILD'S PAIN RELIEVER SUSP BRAND 1 AL Up to 6 yrs old acetaminophen CHILDREN'S PAIN-FEVER (GS CHLD 160 ML, SM CHLD 160 ML, HM CHLD 160 ML, BRAND 1 AL Up to 6 yrs old CHILD 160 ML) acetaminophen CHILDREN'S SILAPAP BRAND 1 AL Up to 6 yrs old acetaminophen ED-APAP BRAND 1 AL Up to 6 yrs old acetaminophen 1 PAGE 3 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS INFANT PAIN-FEVER 160 MG/5 ML BRAND AL Up to 6 yrs old acetaminophen inf acetaminophen 160 mg/5 ml generic 1 AL Up to 6 yrs old INFANT PAIN RELIEF 160 MG/5 ML BRAND 1 AL Up to 6 yrs old acetaminophen QC INFANT PAIN RLF 160 MG/5 ML BRAND 1 AL Up to 6 yrs old acetaminophen INFANTS' PAIN-FEVER (INFANTS 160 ML, GS INFANT 160, SM INFANT 160, HM BRAND 1 AL Up to 6 yrs old INFANT 160) acetaminophen JR. STR NON-ASPIRIN PAIN BRAND 1 AL Up to 6 yrs old acetaminophen M-PAP BRAND 1 AL Up to 6 yrs old acetaminophen MAPAP ARTHRITIS PAIN BRAND 1 acetaminophen PAIN RELIEF ER 650 MG CAPLET BRAND 1 acetaminophen PAIN RELIEVER JUNIOR STRENGTH BRAND 1 AL Up to 6 yrs old acetaminophen DERMATOLOGICAL AGENTS VANALICE BRAND 1 piperonyl butoxide/pyrethrins ELECTROLYTES/MINERALS/METALS/VITAMINS ELECTROLYTE/MINERAL REPLACEMENT CALCITRATE BRAND 1 calcium citrate calcium 600 mg tablet generic 1 calcium carb 1,250 mg/5 ml sus generic 1 children's ferrous sulfate generic 1 FEOSOL (65 MG TABLET, 45 MG CAPLET) BRAND 1 ferrous sulfate FER-IN-SOL BRAND 1 ferrous sulfate FERATE BRAND 1 ferrous gluconate FEROSUL 325 MG TABLET BRAND 1 PAGE 4 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS ferrous sulfate FERRIMIN 150 BRAND 1 ferrous fumarate FERRO-TIME BRAND 1 ferrous sulfate ferrous fumarate 324 mg tab generic 1 ferrous gluconate 324 mg tab generic 1 FERROUS SULFATE (SULF 300 MG/5 ML LIQ, SULFATE 325 MG TABLET, SULF EC 325 MG TABLET, SULF 220 MG/5 ML ELIX, generic 1 SULF 44 MG IRON/5ML LQ, SULF EC 324 MG TABLET, SULF 15 MG IRON/ML DRP) FERROUSUL BRAND 1 ferrous sulfate HEMOCYTE BRAND 1 ferrous fumarate IRON (45 MG, 65 MG) generic 1 OYSCO-500 BRAND 1 calcium carbonate oyster shell calcium generic 1 hm slow release iron tablet generic 1 PHOSPHATE BINDERS calcium acetate 668 mg tablet generic 1 VITAMINS AQUADEKS PEDIATRIC LIQUID QL pediatric multivitamin no.40/phytonadione (vit BRAND 1 k1) AL Up to 3 yrs old AQUADEKS CHEWABLE TABLET multivitamin, minerals no.51/folic acid/vit BRAND 1 AL At least 4 yrs old k1/ubidecarenone CORVITA folic acid/multivitamin,ther and BRAND 1 minerals/lycopene/lutein POLY-VI-FLOR (0.25 MG DROPS, 0.5 MG TAB CHEW, 0.25 MG TAB CHEW, 1 MG TAB CHEW) BRAND 1 AL Up to 12 yrs old pediatric multivitamin no.33 with sodium fluoride POLY-VI-FLOR WITH IRON (0.25 MG, 0.5 MG) BRAND 1 AL Up to 12 yrs old pediatric multivitamin no.33/sodium fluoride/iron PAGE 5 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS carbonyl TRI-VI-FLOR pediatric multivitamin a,c,and d3 no.38 with BRAND 1 AL Up to 12 yrs old sodium fluoride GASTROINTESTINAL AGENTS GASTROINTESTINAL AGENTS, OTHER ANTACID (500 MG CHEW TABLET, GS 500 MG CHEWABLE TAB, HM 500 MG CHEW BRAND 1 TABLET) calcium carbonate ANTACID CALCIUM BRAND 1 calcium carbonate ANTACID EXTRA STRENGTH (HM EX-STR 750 MG CHWTB, XTRA STRENGTH CHEW BRAND 1 TAB, EX-STR 750 MG TAB CHEW) calcium carbonate ANTACID ULTRA STR 1,000 MG CHW BRAND 1 calcium carbonate CAL-GEST BRAND 1 calcium carbonate CALCIUM ANTACID (CALCIUM 750 MG TB CHEW, EX-STR TABLET CHEW, HM CAL 1000 MG CHEW TB, SM CAL 500 MG CHEW TAB, CALCIUM EX-STR TABLET, CALCIUM BRAND 1 500 MG CHW TAB, CALCIUM 1,000 MG TAB, GS CAL 500 MG CHEW TAB, HM CAL 750 MG CHEW TAB) calcium carbonate calcium carbonate 648 mg tab generic 1 TUMS (TABLET CHEWABLE, E-X TABLET CHEWABLE, KIDS 300 MG (750) CHEWTAB) BRAND 1 calcium carbonate TUMS FRESHERS BRAND 1 calcium carbonate TUMS SMOOTHIES BRAND 1 calcium carbonate TUMS ULTRA BRAND 1 calcium carbonate TUMS ULTRA STRENGTH BRAND 1 calcium carbonate TUMS X-STR BRAND 1 calcium carbonate PAGE 6 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS SM CALCIUM ANTACID TAB CHEW BRAND 1 calcium carbonate LAXATIVES CLEARLAX POWDER BRAND 1 polyethylene glycol 3350 ENEMEEZ (, PLUS) BRAND 1 AL At least 12 yrs old docusate sodium polyethylene glycol 3350 generic 1 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) PROGESTINS AFTERA BRAND 1 AL At least 12 yrs old levonorgestrel ECONTRA EZ BRAND 1 AL At least 12 yrs old levonorgestrel ECONTRA ONE-STEP BRAND 1 AL At least 12 yrs old levonorgestrel levonorgestrel generic 1 AL At least 12 yrs old MY CHOICE BRAND 1 AL At least 12 yrs old levonorgestrel MY WAY BRAND 1 AL At least 12 yrs old levonorgestrel NEW DAY BRAND 1 AL At least 12 yrs old levonorgestrel OPCICON ONE-STEP BRAND 1 AL At least 12 yrs old levonorgestrel PLAN B ONE-STEP BRAND 1 AL At least 12 yrs old levonorgestrel TAKE ACTION BRAND 1 AL At least 12 yrs old levonorgestrel MISCELLANEOUS THERAPEUTIC AGENTS ANTACID 750 MG CHEWABLE TABLET BRAND 1 calcium carbonate RESPIRATORY TRACT/PULMONARY AGENTS ANTIHISTAMINES ALL DAY ALLERGY (10 MG TABLET, QC 10 MG TAB, SM 10 MG TAB, HM 10 MG TAB) BRAND 1 cetirizine hcl PAGE 7 LAST UPDATED 04/2020 DRUG DESCRIPTION (OTC) BRAND/GEN TIER LIMITS & RESTRICTIONS ALLERGY (LORATADINE) 10 MG TAB BRAND 1 QL loratadine ALLERGY RELIEF 5 MG/5 ML SOLN BRAND 1 AL Up to 11 yrs old loratadine ALLERGY RELIEF (10 MG, GS 10 MG) BRAND 1 QL loratadine ALLERGY RELIEF (SM RELIEF 10 MG ODT, RELIEF 10 MG ODT, RLF (CETRZN) 10 MG BRAND 1 TAB) loratadine cetirizine hcl 1 mg/ml soln generic 1 AL Up to 11 yrs old CETIRIZINE HCL (5 MG, 10 MG) generic 1 CHILDREN'S ALL DAY ALLERGY (SM ER 1 MG/ML, GS ER 1 MG/ML, ERGY 1 MG/ML) BRAND 1 AL Up to 11 yrs old cetirizine hcl HM CHILD ALL DAY ALLER 1 MG/ML BRAND 1 AL Up to 11 yrs old cetirizine hcl CHILDREN'S ALLERGY (CHILD 5 MG/5 ML SOLN, QC CHILDREN'S 1 MG/ML) BRAND 1 AL Up to 11 yrs old loratadine SM CHILD ALLERGY 5 MG/5 ML SOL BRAND 1 AL Up to 11 yrs old loratadine CHILD ALLERGY RELIEF 1 MG/ML BRAND 1 AL Up to 11 yrs old cetirizine hcl CHILDREN'S CETIRIZINE HCL (HCL 1 generic 1 AL Up to 11 yrs old MG/ML, HM 1 MG/ML) CHILDREN'S LORATADINE (HM 5 ML, 5 ML generic 1 AL Up to
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