Over-the-Counter

Drug List

The following is a list of covered over-the-counter (OTC) medications for Medica Choice Care, Medica MinnesotaCare, Medica DUAL Solution, Medica Choice Care MSC+, and Medica AccessAbility Solution. This list is not all-inclusive and does not guarantee coverage. You need a prescription from a Medica participating provider to get an OTC medication covered by Medica. Also, you must take the prescription to a pharmacy in the Medica network. Pharmacies will dispense the generic version of the prescribed product whenever possible. Please refer to your benefit information for your copayment information or contact Medicas Customer Service at the number on the back of your Medica ID card (TTY/TDD: please call 711).

When a generic drug is available, the brand name is listed as a reference only.

The list is subject to change. Visit our Web site at www.medica.com for updated OTC Drug List information.

2017 Medica. Medica is a registered service mark of Medica Health Plans. Medica refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured, and Medica Health Management, LLC.

Last updated November 2016

http:www.medica.com

TABLE OF CONTENTS

OTC Category See Page ACNE PRODUCTS .................................................................................... 3 ALTERNATIVE MEDICINES........................................................................ 3 ANALGESIC COMBINATIONS ..................................................................... 3 ANTACIDS ............................................................................................. 4 ANTIBIOTICS ......................................................................................... 6 ANTIDIARRHEALS................................................................................... 6 ANTIDOTES ........................................................................................... 6 ANTIEMETICS - ANTICHOLINERGIC............................................................. 7 ANTIFLATULENTS................................................................................... 7 ANTIFUNGALS ....................................................................................... 7 ANTIHISTAMINES .................................................................................. 8 ANTITUSSIVES ....................................................................................... 8 ARTIFICIAL TEARS .................................................................................. 9 ASTRINGENTS .......................................................................................10 B-COMPLEX VITAMINS............................................................................10 CALCIUM .............................................................................................10 CARDIOVASCULAR AGENTS - MISC............................................................11 CHEMICALS ..........................................................................................11 CHLORINE ANTISEPTICS..........................................................................11 COBALAMINS .......................................................................................12 CONTRACEPTIVES .................................................................................12 DECONGESTANT ANTIHISTAMINE .............................................................12 DERMATOLOGICALS ..............................................................................18 DIABETIC OTHER ...................................................................................19 DIGESTIVE ENZYMES..............................................................................19 EXPECTORANTS ....................................................................................20 FLUORIDE DENTAL PRODUCTS .................................................................20 FOLIC ACID/FOLATES .............................................................................20 GASTROINTESTINAL...............................................................................20 GENITOURINARY ...................................................................................21 H-2 ANTAGONISTS .................................................................................21 HEMATOPOIETIC AGENTS........................................................................21 IMIDAZOLE-RELATED ANTIFUNGALS.........................................................22 IODINE ANTISEPTICS ..............................................................................22 IRON ...................................................................................................22 KERATOLYTIC/ANTIMITOTIC AGENTS........................................................24 LAXATIVES ..........................................................................................24 LOCAL ANESTHETICS - TOPICAL ...............................................................26

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Please Note: This drug list is subject to change. Generic medications are covered as listed. Last updated November 2016

LUBRICANT LAXATIVES..........................................................................26 MINERALS ELECTROLYTES ....................................................................26 MISC. RESPIRATORY INHALANTS ..............................................................30 MISC. TOPICAL ......................................................................................30 MOUTH/THROAT/DENTAL AGENTS ............................................................30 MULTIVITAMINS ...................................................................................31 NASAL AGENTS .....................................................................................31 OPHTHALMIC........................................................................................32 OTIC AGENTS........................................................................................33 PEDIATRIC MULTIPLE VITAMINS...............................................................33 PHARMACEUTICAL ADJUVANTS ...............................................................33 PRENATAL MV MIN W/FE-FA ....................................................................34 RECTAL COMBINATIONS - MISC. ...............................................................36 RESPIRATORY .......................................................................................36 SALICYLATE COMBINATIONS...................................................................37 SALICYLATES .......................................................................................37 SALINE LAXATIVES................................................................................38 SCABICIDE COMBINATIONS .....................................................................38 SEMI SOLID VEHICLES ............................................................................38 SMOKING DETERRENTS ..........................................................................39 SURFACTANT LAXATIVES .......................................................................39 SYSTEMIC DECONGESTANTS....................................................................39 TOPICAL ..............................................................................................40 ULCER DRUGS.......................................................................................41 VITAMINS ............................................................................................41

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Please Note: This drug list is subject to change. Generic medications are covered as listed. Last updated November 2016

ACNE PRODUCTS benzoyl per liq 5% wash benzoyl per liq 10% wash

benzoyl peroxide bar 10% BENZOYL PEROXIDE BAR 5%

benzoyl peroxide cream 2.5% benzoyl peroxide cream 10%

BENZOYL PEROXIDE CLEANSER 3.5%

BENZOYL PEROXIDE ER LIQD CLEANSER 4.4% BENZOYL PEROXIDE FOAM 10% BENZOYL PEROXIDE GEL 2.5% BENZOYL PEROXIDE GEL 3%

BENZOYL PEROXIDE GEL 5.5% benzoyl peroxide gel 5%

benzoyl peroxide gel 10% benzoyl peroxide liq 4% benzoyl peroxide liq 5.25%

BENZOYL PEROXIDE GEL 7%

BENZOYL PEROXIDE LIQ 8% BENZOYL PEROXIDE LOTION 3% BENZOYL PEROXIDE LOTION 4% BENZOYL PEROXIDE LOTION 5% BENZOYL PEROXIDE LOTION 9% BENZOYL PEROXIDE LOTION 10% BENZOYL PEROXIDE SOLUTION 5.5%

ALTERNATIVE MEDICINES

LUTEIN ESTERS CAP 18.6 MG

lutein cap 6 mg lutein cap 20 mg lutein cap 40 mg

lutein tab 10 mg lutein tab 20 mg

LUTEIN TAB 6 MG

ANALGESIC COMBINATIONS

ASPIRIN-ACETAMINOPHEN-CAFFEINE (BUFFERED) TAB 227-194-33 MG

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Please Note: This drug list is subject to change. Generic medications are covered as listed. Last updated November 2016

ASPIRIN-ACETAMINOPHEN-CAFFEINE POWD PACK 500-325-65 MG ASPIRIN-ACETAMINOPHEN-CAFFEINE POWD PACK 520-260-32.5 MG

aspirin-acetaminophen-caffeine tab 250-250-65 mg bayer tab migraine

ADVIL JR ST TAB 100MG NSAIDS

ADVIL JR STR CHW 100MG ibu-drops dro 50/1.25 ibuprofen cap 200mg ibuprofen chew tab 100 mg ibuprofen susp 40 mg/ml ibuprofen tab 100 mg ibuprofen tab 200mg MOTRIN IB TAB 200MG naproxen sodium tab 220 mg

ANALGESICS OTHER acetaminophen cap 500 mg acetaminophen tab 325 mg acetaminophen tab 500 mg acetaminophen tab cr 650 mg

ANTACID SIMETHICONE alum & mag hydroxide-simethicone susp 400-400-40 mg/5ml antacid sus ultra st maalox advan sus max st

ANTACIDS

AntacidsAluminum Salts ALUM HYDROX SUS 320/5ML

ANTACIDS - BICARBONATE SODIUM & POTASSIUM BICARBONATE EFFER TAB SODIUM & POTASSIUM BICARBONATE TAB 360-180 MG

sodium bicarbonate tab 325 mg

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Please Note: This drug list is subject to change. Generic medications are covered as listed. Last updated November 2016

sodium bicarbonate tab 650 mg SODIUM BICARBONATE-CITRATE EFFER GRANULES 0.78-1.82 GM/DOSE SODIUM BICARBONATE-CITRIC ACID EFFER TAB 1940-1000 MG

ANTACIDS - CALCIUM SALTS ANTACID CHW

antacid chw 420mg antacid chw 500mg antacid chw 550-110 antacid chw 750mg antacid chw 1000mg antacid chw dbl st antacid extr chw 675-135

calcium carbonate (antacid) ANTACID ULTR CHW 1000-200

calcium carbonate (antacid) chew tab 400 mg calcium carbonate (antacid) chew tab 420 mg calcium carbonate (antacid) chew tab 600 mg calcium carbonate (antacid) chew tab 750 mg calcium carbonate (antacid) chew tab 1000 mg

calcium carbonate (antacid) tab 648 mg

CALCIUM CARBONATE (ANTACID) CHEW TAB 1177 MG (471 MG CA)

calcium carbonate-mag hydroxide susp 400-135 mg/5ml

maalox child chw MAALOX

MAGNESIUM CAPS MAGNESIUM CARBONATE GRAN MAGNESIUM OXIDE CAPS

URO-MAG

magnesium oxide TABS naproxen sodium cap 220 mg

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Please Note: This drug list is subject to change. Generic medications are covered as listed. Last updated November 2016

http:0.78-1.82

ANTIBIOTIC MIXTURES TOPICAL bacitracin-polymyxin b oint

double antib oin BAND-AID PLS PAD ANTIBIOT

neomycin-bacitracin-polymyxin-pra moxine oint 1% neosporin+pn oin relf max

ANTIBIOTICS - TOPICAL bacitracin oint 500 unit/gm bacitracin zinc oint 500 unit/gm

ANTIDIARRHEAL AGENTS - MISC. pink bismuth chw 262mg pink bismuth sus 262/15ml pink bismuth sus 525/15ml pink bismuth tab 262mg

ANTIDIARRHEALS

Antidiarrheal Combinations LOPERAMIDE-SIMETHICONE CHEW TAB 2-125 MG

loperamide-simethicone tab 2-125 mg

actidose-aq liq 50/240ml ANTIDOTES

charcoal activated cap 260 mg charcoal activated for oral susp charcoal activated liq

Topical Antidotes CALGONATE

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Please Note: This drug list is subject to change. Generic medications are covered as listed. Last updated November 2016

ANTIEMETICS - ANTICHOLINERGIC dimenhydrinate tab 50 mg motion sick tab 50mg

gas relief chw 80mg gas relief chw 125mg gas relief dro 20/0.3ml gas-x cap 125mg gas-x cap 180mg gas-x infant dro simethicone cap 125 mg simethicone cap 180 mg

ANTIFLATULENTS

SIMETHICONE CAP 250 MG simethicone chew tab 80 mg simethicone chew tab 125 mg

simethicone liquid 40 mg/0.6ml SIMETHICONE LIQUID

simethicone susp 40 mg/0.6ml

SIMETHICONE ORAL STRIP 40 MG SIMETHICONE ORAL STRIP 62.5 MG

SIMETHICONE TAB 80 MG SIMETHICONE TAB 125 MG

ANTIFUNGALS - TOPICAL anti-fungal pow 1% antifungal aer 1% antifungal cre 1% ath foot spr aer 1% athlete foot aer 1% athlete foot cre 1% lamisil af aer 1% terbinafine hcl cream 1%

ANTIFUNGALS - TOPICAL COMBINATIONS clotrimazole cream 1% clotrimazole soln 1%

GENTIAN VIOLET SOLN 1% GENTIAN VIOLET SOLN 2% KETOCONAZOLE SHAMPOO 1%

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Please Note: This drug list is subject to change. Generic medications are covered as listed. Last updated November 2016

undecylenic acid liqd 25% TERBINAFINE HCL SOLN 1%

UNDECYLENIC ACID SOLN 25% undecylenic acid-zinc undecylenate oint 5-20%

ANTIHISTAMINES - ALKYLAMINES CHLORPHENIRAMINE MALEATE LIQUID 2 MG/ML

chlorpheniramine maleate syrup 2 mg/5ml chlorpheniramine maleate tab 4 mg chlorpheniramine maleate tab cr 12 mg

ANTIHISTAMINES - ETHANOLAMINES clemastine fumarate tab 1.34 mg (1 mg base equiv)

ANTIHISTAMINES - NON-SEDATING ALLEGRA ALRG TAB 30MG FEXOFENADINE HCL ORALLY DISINTEGRATING TAB 30 MG FEXOFENADINE HCL TAB 30 MG

fexofenadine hcl tab 60 mg fexofenadine hcl tab 180 mg fexofenadine sus 30mg/5ml mucinex allr tab 180mg

ANTISEPTICS DISINFECTANTS

Antiseptics Disinfectants hydrogen peroxide soln 3%

Chlorine Antiseptics CHLORHEXIDINE GLUCONATE LIQUID 2%

ANTITUSSIVE - NONNARCOTIC cough dm liq 30mg/5ml dextromethorphan hbr cap 15 mg

DEXTROMETHORPHAN HBR CHEW TAB 7.5 MG

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Please Note: This drug list is subject to change. Generic medications are covered as listed. Last updated November 2016

DEXTROMETHORPHAN HBR GEL SYRUP 7.5 MG/5ML

dextromethorphan hbr liquid 7.5 mg/5ml

DEXTROMETHORPHAN HBR LIQUID 7.5 MG/ML DEXTROMETHORPHAN HBR LIQUID 10 MG/5ML DEXTROMETHORPHAN HBR LIQUID 12.5 MG/5ML DEXTROMETHORPHAN HBR LOZENGE 7.5 MG

DEXTROMETHORPHAN HBR SYRUP 10 MG/15ML

dextromethorphan hbr syrup 5 mg/5ml dextromethorphan hbr syrup 7.5 mg/5ml dextromethorphan hbr syrup 10 mg/5ml

dextromethorphan hbr syrup 15 mg/5ml

tussin cough cap 15mg

DEXTROMETHORPHAN HBR SYRUP 20 MG/15ML

tussin cough liq 15mg/5ml tussin cough syp 15mg/5ml

ANTITUSSIVE-EXPECTORANT dextromethorphan-guaifenesin liquid 10-100 mg/5ml dextromethorphan-guaifenesin liquid 30-200 mg/5ml dextromethorphan-guaifenesin syrup 10-100 mg/5ml tussin dm liq 100-10/5 tussin dm syp 100-10/5

ARTIFICIAL TEAR OINTMENTS artificial tear ophth ointment refresh p.m. oin op

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Please Note: This drug list is subject to change. Generic medications are covered as listed. Last updated November 2016

ARTIFICIAL TEAR SOLUTIONS artificial tear ophth solution

ASTRINGENTS aluminum sulfate & calcium acetate powd pack

zinc oxide oint 10% ZINC OXIDE OINT 12.8% ZINC OXIDE OINT 16%

zinc oxide oint 20%

CALAMINE LOTION ZINC OXIDE OINT 9.38%

ZINC OXIDE OINT 25% zinc oxide oint 30% zinc oxide oint 40%

b-complex vitamin cap B-COMPLEX VITAMINS

B-COMPLEX VITAMIN ELIXIR b-complex vitamin sublingual liquid b-complex vitamin tab b-complex vitamin tab cr

B-COMPLEX W/ C FOLIC ACID B-COMPLEX W/ C & FOLIC ACID LIQUID 0.9 MG/15ML

b-complex w/ c & folic acid tab b-complex w/ c & folic acid tab 0.8 mg

calcium chw 500mg

B-COMPLEX W/ C & FOLIC ACID TAB CR

CALCIUM

CALCIUM COMBINATIONS calc cit+d3 tab 250-200 calc citr+d3 tab 200-250 calcium 500 tab +d calcium 600 chw w/vit d

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Please Note: This drug list is subject to change. Generic medications are covered as listed. Last updated November 2016

calcium 600 tab +d3 calcium carbonate-cholecalciferol tab 500 mg-125 unit calcium carbonate-vitamin d cap 600 mg-200 unit calcium carbonate-vitamin d tab 250 mg-125 unit calcium cit/ tab vit d calcium tab 500/d calcium+d3 tab 315-250 calcium/d3 tab 600-400 calcium/d tab 500-200 calcium/d tab 600-400 calcium/d tab 600mg calcium/vitd cap 600-500 calcium/vitd tab 500-400 calcium/vt d tab 600-125 caltrate 600 chw +d os-cal chw oys shell+d chw 500-400 oyst shell/d tab 500-125 oyst shell/d tab 500mg

CARDIOVASCULAR AGENTS - MISC.

Peripheral Vasodilators niacin cap 500mg

NIACIN CAP 590MG NIACIN FLUSH CAP FREE

CHEMICALS

Liquids ALCOHOL, USP 70%

isopropyl alcohol, rubbing 70%

CHLORINE ANTISEPTICS CHLORHEXIDINE GLUCONATE LIQUID 4%

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Please Note: This drug list is subject to change. Generic medications are covered as listed. Last updated November 2016

COBALAMINS B-12 CAP 1000MCG B-12 CAP 3000MCG B-12 LIQ 5000/ML

B-12 TAB 2500MCG b-12 sub 3000mcg

cyanocobalamin chew tab 2500 mcg CYANOCOBALAMIN CAP 5000 MCG

CYANOCOBALAMIN LIQUID 200 MCG/SPRAY

liquid b12 liq 1000/15

vitamin b12 tab 1000mcg VITAMIN B12 DRO 3000/ML

vitamin b-12 sub 500mcg vitamin b-12 sub 1000mcg vitamin b-12 sub 2500mcg vitamin b-12 sub 5000mcg

VITAMIN B-12 LIQ 1000MCG

VITAMIN B-12 SUB 6000MCG vitamin b-12 tab 50mcg vitamin b-12 tab 100mcg vitamin b-12 tab 250mcg vitamin b-12 tab 500mcg vitamin b-12 tab 1000mcg vitamin b-12 tab 1500 tr vitamin b-12 tab 2000mcg

levonorgestrel tab 1.5 mg

CONTRACEPTIVES

Emergency Contraceptives

DECONGESTANT ANTIHISTAMINE BROMPHENIRAMINE & PHENYLEPHRINE CHEW TAB 1-2.5 MG

brompheniramine & phenylephrine elixir 1-2.5 mg/5ml

BROMPHENIRAMINE & PHENYLEPHRINE LIQD 2-5 MG/ML

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Please Note: This drug list is subject to change. Generic medications are covered as listed. Last updated November 2016

brompheniramine & phenylephrine liqd 4-10 mg/5ml brompheniramine & phenylephrine susp 6-10 mg/5ml

BROMPHENIRAMINE & PHENYLEPHRINE SYRUP 1-2.5 MG/5ML BROMPHENIRAMINE & PHENYLEPHRINE TAB 4-10 MG

CHLORPHEN-PHENYLEPHRINE W/ APAP TAB 2-5-162 MG

cetirizine-pseudoephedrine tab sr 12hr 5-120 mg chlorphen-phenylephrine w/ apap effer tab 2-5-250 mg

chlorphen-phenylephrine w/ apap tab 2-5-325 mg

chlorphen-phenylephrine w/ apap tab 4-10-650 mg

CHLORPHEN-PHENYLEPHRINE W/ APAP TAB 2-5-500 MG CHLORPHEN-PHENYLEPHRINE W/ APAP TAB 4-10-325 MG

CHLORPHENIRAMINE & PHENYLEPHRINE LIQUID 1-2 MG/ML CHLORPHENIRAMINE & PHENYLEPHRINE LIQUID 1-2.5 MG/5ML

CHLORPHENIRAMINE & PHENYLEPHRINE LIQUID 2-5 MG/ML

chlorpheniramine & phenylephrine liquid 1-2.5 mg/ml chlorpheniramine & phenylephrine liquid 1-3.5 mg/ml

chlorpheniramine & phenylephrine liquid 4-10 mg/5ml

chlorpheniramine & phenylephrine tab 4-10 mg

CHLORPHENIRAMINE & PHENYLEPHRINE SYRUP 1-2.5 MG/5ML CHLORPHENIRAMINE & PHENYLEPHRINE TAB 3.5-10 MG

chlorpheniramine-dm DEXTROMETHORPHAN-APAP-CHLORPHEN LIQUID 7.5-160-1 MG/5ML DEXTROMETHORPHAN-APAP-CHLORPHE N SYRUP 7.5-160-1 MG/5ML DEXTROMETHORPHAN-APAP-CHLORPHE NIRAMINE CAP 15-325-4 MG

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Please Note: This drug list is subject to change. Generic medications are covered as listed. Last updated November 2016

DEXTROMETHORPHAN-APAP-CHLORPHE NIRAMINE LIQD 30-650-4 MG/30ML

dextromethorphan-apap-chlorphenir amine susp 5-160-1 mg/5ml dextromethorphan-apap-chlorphenir amine tab 15-500-2 mg dextromethorphan-guaifenesin cap 10-200 mg

dextromethorphan-guaifenesin liquid 5-50 mg/ml

DEXTROMETHORPHAN-GUAIFENESIN GRANULES PACKET 5-100 MG

DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-187 MG/5ML DEXTROMETHORPHAN-GUAIFENESIN LIQUID 15-25 MG/5ML DEXTROMETHORPHAN-GUAIFENESIN LIQUID 15-125 MG/5ML DEXTROMETHORPHAN-GUAIFENESIN LIQUID 15-200 MG/5ML DEXTROMETHORPHAN-GUAIFENESIN LIQUID 20-200 MG/30ML

DEXTROMETHORPHAN-GUAIFENESIN LIQUID 20-400 MG/5ML

dextromethorphan-guaifenesin liquid 20-300 mg/5ml

dextromethorphan-guaifenesin tab 20-400 mg dextromethorphan-guaifenesin tab sr 12hr 30-600 mg dextromethorphan-guaifenesin tab sr 12hr 60-1200 mg

DEXTROMETHORPHAN-GUAIFENESIN SYRUP 5-100 MG/5ML DEXTROMETHORPHAN-GUAIFENESIN SYRUP 20-400 MG/5ML DEXTROMETHORPHAN-GUAIFENESIN TAB 15-400 MG

DEXTROMETHORPHAN-PHENYLEPHRINEAPAP LIQD 2.5-1.25-80 MG/ML

dextromethorphan-phenylephrine-ap ap liqd 10-5-325 mg/15ml dextromethorphan-phenylephrine-ap ap powd pack 20-10-650 mg dextromethorphan-phenylephrine-ap ap tab 10-5-325 mg

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Please Note: This drug list is subject to change. Generic medications are covered as listed. Last updated November 2016

DEXTROMETHORPHAN-PHENYLEPHRINEAPAP TAB 15-5-325 MG DIMETAPP LONG ACTING COUG

loratadine & pseudoephedrine tab sr 24hr 10-240 mg loratadine-d tab 5-120mg

pe-dm-apap & pe-cpm-dm-apap tab day/night therapy pack

MUCINEX FAST TAB 5-10-200

phenylephrine w/ acetaminophen cap 5-325 mg phenylephrine w/ acetaminophen powd pack 10-650 mg phenylephrine w/ acetaminophen tab 5-325 mg phenylephrine w/ acetaminophen tab 5-500 mg

phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml

PHENYLEPHRINE W/ DM-GG LIQD 2.5-5-50 MG/5ML

phenylephrine w/ dm-gg liqd 2.5-5-75 mg/5ml phenylephrine w/ dm-gg liqd 2.5-5-100 mg/5ml

phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml

PHENYLEPHRINE W/ DM-GG LIQD 2.5-5-100 MG/ML PHENYLEPHRINE W/ DM-GG LIQD 7.5-30-200 MG/5ML

PHENYLEPHRINE W/ DM-GG LIQD 10-18-200 MG/15ML

PHENYLEPHRINE W/ DM-GG LIQD 10-29-390 MG/5ML

phenylephrine w/ dm-gg liqd 10-28-388 mg/5ml

PHENYLEPHRINE W/ DM-GG LIQD 10-30-200 MG/5ML

PHENYLEPHRINE W/ DM-GG LIQUID 10-20-200 MG/5ML

phenylephrine w/ dm-gg liquid 10-15-350 mg/5ml

PHENYLEPHRINE W/ DM-GG LIQUID 10-20-400 MG/5ML

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Please Note: This drug list is subject to change. Generic medications are covered as listed.

PHENYLEPHRINE W/ DM-GG SUSP 10-40-400 MG/10ML

phenylephrine w/ dm-gg syrup 5-10-100 mg/5ml

phenylephrine w/ dm-gg tab 10-15-380 mg

PHENYLEPHRINE W/ DM-GG SYRUP 5-15-100 MG/5ML PHENYLEPHRINE W/ DM-GG SYRUP 10-15-350 MG/5ML

PHENYLEPHRINE W/ DM-GG SYRUP 10-20-100 MG/5ML

PHENYLEPHRINE W/ DM-GG TAB 10-15-395 MG

phenylephrine w/ dm-gg tab 10-20-400 mg phenylephrine-brompheniramine-dm elixir 2.5-1-5 mg/5ml phenylephrine-brompheniramine-dm liquid 2.5-1-5 mg/5ml phenylephrine-brompheniramine-dm liquid 7.5-4-15 mg/5ml phenylephrine-brompheniramine-dm liquid 10-4-20 mg/5ml

PHENYLEPHRINE W/ DM-GG TAB 10-15-400 MG

PHENYLEPHRINE-GUAIFENESIN LIQD 2.5-50 MG/5ML

phenylephrine-guaifenesin liqd 2.5-100 mg/5ml phenylephrine-guaifenesin liqd 5-100 mg/5ml phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml)

phenylephrine-guaifenesin tab 5-200 mg

PHENYLEPHRINE-GUAIFENESIN LIQD 7.5-200 MG/5ML PHENYLEPHRINE-GUAIFENESIN LIQD 10-100 MG/5ML

phenylephrine-guaifenesin tab 10-380 mg

phenylephrine-guaifenesin tab 10-400 mg

PHENYLEPHRINE-GUAIFENESIN TAB 10-395 MG

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Please Note: This drug list is subject to change. Generic medications are covered as listed.

pseudoephed-chlorphen-dm liq 15-1-5 mg/5ml pseudoephed-chlorphen-dm liq 15-1-7.5 mg/5ml pseudoephed-chlorphen-dm liq 15-2-15 mg/5ml

pseudoephedrine-guaifenesin cap 30-200 mg

PSEUDOEPHED-CHLORPHEN-DM SUSP 30-4-30 MG/5ML PSEUDOEPHED-CHLORPHEN-DM SYRUP 15-1-7.5 MG/5ML PSEUDOEPHED-CHLORPHEN-DM SYRUP 30-2-10 MG/5ML PSEUDOEPHEDRINE-GUAIFENESIN CAP 30-150 MG

PSEUDOEPHEDRINE-GUAIFENESIN LIQD 7.5-50 MG/ML

PSEUDOEPHEDRINE-GUAIFENESIN TAB 30-190 MG

pseudoephedrine-guaifenesin syrup 30-100 mg/5ml

PSEUDOEPHEDRINE-GUAIFENESIN TAB 30-200 MG PSEUDOEPHEDRINE-GUAIFENESIN TAB 38.5-398 MG

PSEUDOEPHEDRINE-GUAIFENESIN TAB 45-400 MG

pseudoephedrine-guaifenesin tab 40-400 mg

PSEUDOEPHEDRINE-GUAIFENESIN TAB 60-375 MG PSEUDOEPHEDRINE-GUAIFENESIN TAB 60-380 MG

ROBITUSSIN NIGHTTIME COUG

pseudoephedrine-guaifenesin tab 60-400 mg pseudoephedrine-guaifenesin tab sr 12hr 60-600 mg pseudoephedrine-guaifenesin tab sr 12hr 120-1200 mg robitussin cap cold+flu robitussin liq robitussin liq ms max

sudafed pe tab 4-10mg TRIAMINIC COUGH & RUNNY N

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Please Note: This drug list is subject to change. Generic medications are covered as listed.

triprolidine & pseudoephedrine liquid 0.938-10 mg/ml triprolidine & pseudoephedrine tab 2.5-60 mg tussin cf liq cgh/cold tussin dm liq 10-200/5 tusslin liq pediatri tylenol cold tab multi-s vcks dayquil liq mucus dm vick dayquil liq cold/flu

VICKS NYQUIL CHILDRENS CO

DERMATOLOGICALS

Antihistamines-Topical diphenhydramine hcl cream 2% diphenhydramine hcl soln 2% diphenhydramine-zinc acetate cream 1-0.1% diphenhydramine-zinc acetate cream 2-0.1% diphenhydramine-zinc acetate liquid 2-0.1%

DIPHENHYDRAMINE-ZINC ACETATE STICK 2-0.1%

Antivirals - Topical DOCOSANOL CREAM 10%

Emollient/Keratolytic Agents

UREA CREAM 20% urea cream 10%

UREA CREAM 30% UREA LOTION 5%

UREA LOTION 15% urea lotion 10%

urea lotion 25% UREA LOTION 20%

UREA OINTMENT 10% UREA OINTMENT 20% UREA OINTMENT 22%

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Please Note: This drug list is subject to change. Generic medications are covered as listed.

Keratolytic/Antimitotic Agents SALICYLIC ACID CREAM 0.5% SALICYLIC ACID CREAM 2% SALICYLIC ACID FOAM 2%

salicylic acid gel 2%

salicylic acid lotion 2%

SALICYLIC ACID LIQUID 0.5% SALICYLIC ACID LIQUID 17.6% SALICYLIC ACID LOTION 0.6%

SALICYLIC ACID PAD 0.5% SALICYLIC ACID PLASTER 40% SALICYLIC ACID SHAMPOO 2% SALICYLIC ACID SHAMPOO 3%

Liniments CAPSICUM OLEORESIN CREAM 0.025%

Tar Products

trolamine salicylate cream 10%

coal tar shampoo 0.5% coal tar shampoo 1% coal tar shampoo 2.5%

coal tar shampoo 4% COAL TAR SHAMPOO 3%

COAL TAR SHAMPOO 10% COAL TAR SHAMPOO 15% COAL TAR-SALICYLIC ACID SHAMP 10-5%

DIABETIC OTHER GLUCOSE CHEW TAB 1 GM GLUCOSE CHEW TAB 4 GM GLUCOSE CHEW TAB 5 GM GLUCOSE GEL 15 GM/33GM

GLUCOSE GEL 77.4% glucose gel 40%

glucose oral liquid 15 gm/59ml

DIGESTIVE ENZYMES LACTASE CAP 250 MG LACTASE CHEW TAB 3000 UNIT LACTASE CHEW TAB 4500 UNIT

lactase chew tab 9000 unit lactase tab 9000 unit

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Please Note: This drug list is subject to change. Generic medications are covered as listed.

EXPECTORANTS GUAIFENESIN GRANULES PACKET 50 MG GUAIFENESIN GRANULES PACKET 100 MG GUAIFENESIN LIQUID 150 MG/15ML

GUAIFENESIN SOLN 50 MG/5ML guaifenesin liquid 200 mg/5ml

guaifenesin syrup 100 mg/5ml guaifenesin tab 200 mg guaifenesin tab 400 mg guaifenesin tab sr 12hr 600 mg

tussin adult liq 100/5ml GUAIFENESIN TAB SR 12HR 1200 MG

tussin syp 100/5ml

FLUORIDE DENTAL PRODUCTS sodium fluoride rinse 0.05% stannous fluoride gel 0.4%

FOLIC ACID/FOLATES FOLIC ACID CAP 0.8 MG FOLIC ACID CAP 5 MG FOLIC ACID CAP 20 MG

GASTROINTESTINAL

ANTIEMETICS

folic acid tab 400 mcg folic acid tab 800 mcg

DIMENHYDRINATE CHEW TAB 25 MG DIMENHYDRINATE CHEW TAB 50 MG

meclizine hcl chew tab 25 mg meclizine hcl tab 12.5 mg meclizine hcl tab 25 mg meclizine hcl tab 32 mg

H2-RECEPTOR ANTAGONISTS famotidine tab 10 mg famotidine tab 20 mg ranitidine hcl tab 150 mg

LAXATIVES Page 20 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

peg 3350 pow

LOPERAMIDE CAP 2MG

MISCELLANEOUS IMODIUM A-D CHW 2MG

loperamide hcl tab 2 mg loperamide liq 1mg/5ml loperamide sus 1mg/7.5

oral electrolyte solution ORAL ELECTROLYTE - PACKET

oral electrolyte tab

PROTON PUMP INHIBITORS lansoprazole cap delayed release 15 mg

omeprazole magnesium cap dr 20.6 mg (20 mg base equiv)

NEXIUM 24HR TAB 20MG

PRILOSEC OTC TAB 20MG

GENITOURINARY

VAGINAL ANTI-INFECTIVES 3 day vagnal cre 4% miconazole 3 kit combo pk miconazole 7 cre 2% miconazole 7 sup 100mg monistat 7 kit combo pk

H-2 ANTAGONISTS cimetidine tab 200 mg

FAMOTIDINE CHEW TAB 10 MG ranitidine hcl tab 75 mg

HEMATOPOIETIC AGENTS

Hematopoietic Mixtures FERRO-SEQUELS FERROUS FUMARATE W/ DSS TAB

folic acid-vitamin b6-vitamin b12 iron-vitamin c

VITRON-C

Page 21 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

IMIDAZOLE-RELATED ANTIFUNGALS clotrimazole vaginal cream 1% clotrimazole vaginal cream 2% 3 day vaginl cre 2% miconazole 1 kit

tioconazole vaginal oint 6.5%

MICONAZOLE 1 KIT COMBO MONISTAT 3 KIT COMBO PK MONISTAT 7 KIT COMPLETE

IMIDAZOLE-RELATED ANTIFUNGALS - TOPICAL lotrimin af aer 2% miconazole aer 2% miconazole nitrate aerosol 2% miconazole nitrate cream 2%

IODINE ANTISEPTICS POVIDONE-IODINE AEROSOL SOLN 5%

povidone-iodine oint 10% POVIDONE-IODINE SOLN 0.75% POVIDONE-IODINE SOLN 1% POVIDONE-IODINE SOLN 5%

povidone-iodine soln 7.5% povidone-iodine soln 10%

POVIDONE-IODINE SWABS 7.5% povidone-iodine swabs 10%

IRON CARBONYL IRON CHEW TAB 15 MG (ELEMENTAL IRON) CARBONYL IRON CHEW TAB 18 MG (ELEMENTAL IRON) FERROUS FUMARATE TAB 29 MG (FE EQUIVALENT) FERROUS FUMARATE TAB 63 MG (20 MG ELEMENTAL FE) FERROUS FUMARATE TAB 90 MG (29.5 MG ELEMENTAL FE) FERROUS FUMARATE TAB 150 MG (FE EQUIVALENT)

Page 22 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

ferrous fumarate tab 324 mg (106 mg elemental fe) ferrous fumarate tab 325 mg (106 mg elemental fe)

ferrous gluconate tab 240 mg (27 mg elemental fe) ferrous gluconate tab 324 mg (37.5 mg elemental iron)

FERROUS GLUCONATE TAB 225 MG (27 MG FE EQUIVALENT)

FERROUS GLUCONATE TAB 324 MG (38 MG ELEMENTAL IRON)

ferrous gluconate tab 325 mg (36 mg elemental fe)

ferrous sulfate dried tab 200 mg (65 mg elemental fe)

FERROUS SULF TAB 140MG

ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe)

FERROUS SULFATE LIQUID 5 MG/20ML (ELEMENTAL IRON) FERROUS SULFATE LIQUID 220 MG/5ML (44 MG/5ML ELEMENTAL FE)

FERROUS SULFATE SYRUP 300 MG/5ML (60 MG/5ML ELEMENTAL FE)

ferrous sulfate tab 27 mg (elemental fe)

ferrous sulfate tab 134 mg (27 mg elemental fe)

FERROUS SULFATE TAB 90 MG (18 MG ELEMENTAL FE)

ferrous sulfate tab cr 47.5 mg (elemental fe) ferrous sulfate tab cr 50 mg (elemental fe) ferrous sulfate tab cr 142 mg (45 mg fe equivalent)

ferrous sulfate tab ec 325 mg (65 mg fe equivalent)

FERROUS SULFATE TAB CR 143 MG (45 MG FE EQUIVALENT) FERROUS SULFATE TAB EC 324 MG (65 MG FE EQUIVALENT)

IRON HIGH CAP POTENCY iron slow tab 45mg

IRON TAB 18MG CR

Page 23 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

iron tab 27mg IRON TAB 28MG IRON TAB 28MG iron tab 325mg

POLYSACCHARIDE IRON COMPLEX CAP 50 MG (IRON EQUIVALENT)

polysaccharide iron complex cap 150 mg (iron equivalent)

polysaccharide iron complex cap 434.8 mg (200 mg elem fe)

POLYSACCHARIDE IRON COMPLEX CAP 391.3 MG (180 MG ELEM FE)

POLYSACCHARIDE IRON COMPLEX LIQUID 15 MG/0.5ML (FE EQUIV) POLYSACCHARIDE IRON COMPLEX LIQUID 15 MG/ML (FE EQUIV) SLOW REL FE TAB 143MG CR

slow rel fe tab 160mg cr

KERATOLYTIC/ANTIMITOTIC AGENTS clean&clear liq 2% clean&clear lot acne salicylic acid liquid 2% salicylic acid liquid 3% salicylic acid liquid 17% salicylic acid lotion 0.5% salicylic acid pad 2% salicylic acid soln 17% wart remover liq 17%

calcium polycarbophil tab 625 mg

LAXATIVES

Bulk Laxatives BENEFIBER PAK CALCIUM POLYCARBOPHIL CHEW TAB 625 MG

CELLULOSE POWDER FIBER CHW METAMUCIL POW 55.46%

METAMUCIL POW 58.12% metamucil pow 58.6%org

METAMUCIL POW 63% METAMUCIL WAF

methylcellulose powder laxative

Page 24 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

METHYLCELLULOSE POWDER PACKET LAXATIVE

NUTRISOURCE POW FIBER methylcellulose tab 500 mg

psyllium cap 0.52 gm PSYLLIUM CAP 400 MG PSYLLIUM CAP 500 MG

PSYLLIUM POWDER 52.3%

psyllium powder 28.3% psyllium powder 30% psyllium powder 30.9% psyllium powder 33% psyllium powder 48.57% psyllium powder 49%

PSYLLIUM POWDER 60.3%

PSYLLIUM POWDER 71.67% psyllium powder 68%

PSYLLIUM POWDER 92%

PSYLLIUM POWDER PACKET 28%

psyllium powder 95% psyllium powder 100%

PSYLLIUM POWDER PACKET 28.3% PSYLLIUM POWDER PACKET 58.6% PSYLLIUM POWDER PACKET 60.3% PSYLLIUM POWDER PACKET 95% PSYLLIUM POWDER PACKET 100%

Stimulant Laxatives NAT SENNA TAB LAXATIVE SENNA LEAVES MIS SENNA SYRUP 176 MG/5ML SENNA TEA BAG 30 MG

LAXATIVES - MISCELLANEOUS GLYCERIN LIQUID SUPPOS 2.8 GM (2.7 ML)

glycerin suppos 1 gm glycerin suppos 1.2 gm glycerin suppos 2 gm glycerin suppos 2.1 gm glycerin suppos 80.7% polyethylene glycol 3350 oral packet

SORBITOL ORAL SOLUTION 70% SORBITOL RECTAL SOLUTION 70%

Page 25 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

LOCAL ANESTHETICS - TOPICAL calamine med lot 1-8% capsaicin cream 0.1% capsaicin cream 0.025%

capsaicin cream 0.075% CAPSAICIN CREAM 0.035%

CAPSAICIN GEL 0.05% CAPSAICIN GEL 0.025% CAPSAICIN GEL 0.075% CAPSAICIN LIQUID 0.15% CAPSAICIN LOTION 0.035%

CAPSAICIN PLASTER 0.15% capsaicin pad 0.025%

CAPSAICIN STICK 0.075% PRAMOXINE-CALAMINE CREAM 1-3%

PRAMOXINE-ZINC OXIDE-CALAMINE LIQUID 1-0.4-0.4%

pramoxine-calamine lotion 1-8%

LUBRICANT LAXATIVES MINERAL OIL

MINERALS ELECTROLYTES

Calcium

mineral oil enema

CA GLUCONATE TAB 50MG CAL-LAC CALCI-CHEW CALCIUM CAPS

CALCIUM ACETATE TABS 668mg

calcium TABS calcium 600 tab vit d/mi

CALCIUM ASPARTATE CALCIUM CARB CHW 260MG CALCIUM CARB POW 800/2GM

CALCIUM CARB-CHOLECALCIFEROL TAB SR 24HR 600 MG-500 UNIT

calcium carb sus 1250/5ml

calcium carb-vit d w/ minerals chew tab 600 mg-400 unit

Page 26 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

calcium carb-vit d w/ minerals chew tab 600 mg-800 unit calcium carb-vit d w/ minerals chew tab 1200 mg-1000 unit

calcium carb-vit d w/ minerals tabs 600 mg-400 unit calcium carb-vit d w/ minerals tabs 600 mg-800 unit calcium carbonate SUSP; TABS

CALCIUM CARB-VIT D W/ MINERALS TABS 300 MG-800 UNIT

CALCIUM CARBONATE CAP 1250 MG (500 MG ELEMENTAL CA) CALCIUM CARBONATE CHEW TAB 1250 MG (500 MG ELEMENTAL CA) CALCIUM CARBONATE CHEWABLE WAFER 500 MG (200 MG CALCIUM) CALCIUM CARBONATE-CHOLECALCIFEROL CAP 600 MG-100 UNIT CALCIUM CARBONATE-CHOLECALCIFEROL CAP 600 MG-400 UNIT CALCIUM CARBONATE-CHOLECALCIFEROL CAP 600 MG-1000 UNIT CALCIUM CARBONATE-CHOLECALCIFEROL CHEW TAB 600 MG-400 UNIT CALCIUM CARBONATE-CHOLECALCIFEROL LIQUID 500-400 MG-UNIT/5ML CALCIUM CARBONATE-CHOLECALCIFEROL TAB 90 MG-400 UNIT

CALCIUM CARBONATE-CHOLECALCIFEROL TAB 250 MG-250 UNIT

calcium carbonate-cholecalciferol tab 250 mg-125 unit

CALCIUM CARBONATE-CHOLECALCIFEROL TAB 333 MG-133 UNIT

calcium carbonate-cholecalciferol tab 500 mg-600 unit

Page 27 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

CALCIUM CARBONATE-CHOLECALCIFEROL TAB 600 MG-1000 UNIT CALCIUM CARBONATE-CHOLECALCIFEROL TAB 1000 MG-800 UNIT CALCIUM CARBONATE-ERGOCALCIFEROL TAB 250 MG-125 UNIT CALCIUM CARBONATE-VITAMIN D CAP 300 MG-100 UNIT CALCIUM CARBONATE-VITAMIN D CAP 500 MG-50 UNIT (BASE EQUIV)

CALCIUM CITRATE CAP 150 MG

calcium chw 500mg 500mg calcium cit tab 200mg calcium citrate TABS

CALCIUM CITRATE TAB 250 MG

CALCIUM CITRATE TAB 1040 MG CALCIUM CITRATE-VIT D LIQD 1000 MG/30ML-400 UNIT/30ML CALCIUM CITRATE-VIT D ORAL POWD 500 MG/5GM-500 UNIT/5GM CALCIUM CITRATE-VITAMIN D CHEW TAB 500 MG-400 UNIT CALCIUM CITRATE-VITAMIN D CHEW TAB 500 MG-500 UNIT CALCIUM CITRATE-VITAMIN D TAB 200 MG-125 UNIT (ELEMENTAL CA) CALCIUM CITRATE-VITAMIN D TAB 250 MG-50 UNIT (ELEMENTAL CA) CALCIUM CITRATE-VITAMIN D TAB 250 MG-100 UNIT (ELEMENTAL CA) CALCIUM GLUBIONATE SYRUP 1.8 GM/5ML CALCIUM GLUCONATE CAP 500 MG CALCIUM GLUCONATE TAB 500 MG CALCIUM GRA CITRATE CALCIUM LACTATE

CHELATED CALCIUM

calcium tab 500mg calcium tab 600mg

CORAL CALCIUM CAPS; TABS ELITE CALCIUM OSTIGEN

Page 28 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

oyster shell SM CORAL CALCIUM

Magnesium CVS TRIPLE MAGNESIUM COMP

mag oxide tab 400mg

magnesium TABS 100mg, 200mg, 250mg

MAG-TAB SR MAGINEX MAGINEX DS

magnesium cap 100 mg

MAGNESIUM TABS 200mg MAGNESIUM CAP 70 MG

MAGNESIUM CAP 300 MG

magnesium cap 500mg magnesium chloride TBCR magnesium chloride tab cr 535 mg (64 mg elemental mg) magnesium chloride-calcium tab dr 64-106 mg (base equiv)

MAGNESIUM CAP 400MG

MAGNESIUM CITRATE TAB 100 MG magnesium gl tab 500mg

magnesium gluconate TABS

MAGNESIUM GL TAB 550MG

MAGNESIUM GLUCONATE LIQUID 1000 MG/5ML (54 MG/5ML MAGNESIUM)

MAGNESIUM GLUCONATE TAB 30 MG

MAGNESIUM GLUCONATE TAB 250 MG

MAGNESIUM GLUCONATE TAB 500 MG

MAGNESIUM OXIDE POWDER (MG SUPPLEMENT)

magnesium oxide (mg supplement)

MAGNESIUM OXIDE TAB 200 MG (ELEMENTAL MG)

MAGNESIUM TAB 30 MG

Page 29 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

MAGNESIUM TAB 65 MG

MAGNESIUM TAB 80 MG

magnesium tab 100 mg magnesium tab 200 mg magnesium tab 250mg magnesium tab 400mg

magnesium tab 500mg MAGNESIUM TAB 500 MG

magnesium-ox tab 400mg magonate tab 500mg

MISC. RESPIRATORY INHALANTS nasal mist aer 0.9%

witch hazel pad MISC. TOPICAL

MOUTH/THROAT/DENTAL AGENTS

Anti-infectives - Throat CARBAMIDE PEROXIDE SOLN 20% HYDROGEN PEROXIDE GEL 1.5%

Dental Products SODIUM FLUORIDE MOUTHWASH 2.1 MG/10ML SODIUM FLUORIDE RINSE 0.02% SODIUM FLUORIDE RINSE 0.044%

sodium fluoride rinse 0.0221% (0.01% f)

benzocaine lozenge 10 mg Lozenges

benzocaine lozenge 15 mg CEPACOL HYDR LOZ 3MG CEPACOL WARM LOZ 4MG

Throat Products - Misc. ARTIFICIAL SALIVA - GEL

ARTIFICIAL SALIVA - GUM

Page 30 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

artificial saliva - lozenge

ARTIFICIAL SALIVA - KIT

ARTIFICIAL SALIVA - SOLUTION

MULTIPLE VITAMINS W/ IRON MULTIPLE VITAMINS W/ IRON CAP

multiple vitamins w/ iron tab

MULTIPLE VITAMINS W/ MINERALS multiple vitamins w/ minerals cap

multiple vitamins w/ minerals effer tab

MULTIPLE VITAMINS W/ MINERALS CAP CR

MULTIPLE VITAMINS W/ MINERALS CHEW TAB

MULTIPLE VITAMINS W/ MINERALS EC TAB

multiple vitamins w/ minerals elixir

multiple vitamins w/ minerals tab

MULTIPLE VITAMINS W/ MINERALS PACK

MULTIPLE VITAMINS W/ MINERALS POWDER

MULTIPLE VITAMINS W/ MINERALS SYRUP

multivitamin liq

multiple vitamin tab MULTIVITAMINS

multivitamin cap one daily tab

niacin cap 400mg Vitamin Mixtures

NASAL AGENTS - MISC. SALINE NASAL AEROSOL SOLN

Page 31 of 47

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SALINE NASAL AEROSOL SOLN 0.9%

SALINE NASAL SPRAY 0.2%

saline nasal spray 0.65%

NASAL AGENTS - SYSTEMIC AND TOPICAL

Nasal Agent Combinations OXYMETAZOLINE HCL W/ MENTHOL NASAL SOLN 0.05%

Nasal Antiallergy cromolyn sod spr 5.2/act

triple antib oin

OPHTHALMIC

ANTI-INFECTIVES

OPHTHALMIC ANTIALLERGIC KETOTIFEN FUMARATE OPHTH SOLN 0.025% (BASE EQUIV) zyrtec itchy dro 0.025%op

OPHTHALMIC DECONGESTANT COMBINATIONS naphazoline w/ pheniramine ophth soln 0.025-0.3% naphazoline w/ pheniramine ophth soln 0.027-0.315%

TETRAHYDROZ-POLYVIN ALC-POVIDONE OPHTH SOLN 0.05-0.5-0.6 %

tetrahydrozoline hcl ophth soln 0.05% tetrahydrozoline w/ polyethylene glycol ophth soln 0.05-1% tetrahydrozoline w/ zinc sulfate ophth soln 0.05-0.25% visine-a sol op

Page 32 of 47

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http:0.05-0.25

OPHTHALMIC HYPEROSMOLAR PRODUCTS SODIUM CHLORIDE HYPERTONIC OPHTH SOLN 2%

sodium chloride hypertonic ophth soln 5%

OTIC AGENTS

Otic Agents - Miscellaneous carbamide peroxide 6.5% otic soln ear wax remv sol 6.5% ot

PEDIATRIC MULTIPLE VITAMINS PEDIATRIC MULTIPLE VITAMIN CHEW TAB

pediatric multiple vitamin liq

PEDIATRIC MULTIPLE VITAMINS W/ C pediatric multiple vitamin w/ c soln 35 mg/ml

PEDIATRIC MULTIPLE VITAMINS W/ EXTRA C FA PEDIATRIC MULTIPLE VITAMIN W/ C CHEW TAB

pediatric multiple vitamin w/ extra c & fa chew tab

PHARMACEUTICAL ADJUVANTS

Internal Vehicle Ingredients/Agents STARCH ORAL THICKENING LIQUID

STARCH ORAL THICKENING POWDER

STARCH ORAL THICKENING POWDER PACKET

Semi Solid Vehicles white petrolatum topical gel

Page 33 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

PRENATAL MV MIN W/FE-FA ONE A DAY CAP PRENATAL PRENAT W/ FE FUM-FA TAB 28-0.8 MG & OMEGA 3 CAP 440 MG PAK PRENAT W/FE CARBONYL-FA TAB 33-0.8 MG & DHA CAP 350 MG PAK

PRENAT W/FE FUM-METHYLFOL-FA-DHA CAP 29-0.4-0.8-375 MG

PRENAT W/FEBISGLY-FA TAB 28-0.8 MG & OMEGA 3 CAP DR 450 MG

PRENAT W/FECBN-FA-DSS TAB 29-1 MG & OMEGA 3 CAP 387 MG PAK

PRENAT W/O A W/ FE BISGLY-FA-DHA TAB & DHA CAP 300 MG PAK

PRENATAL CAP OMEGA-3

PRENATAL MULTIVITAMINS & MINERALS W/ FE & FA TAB 0.25 MG

PRENATAL MULTIVITAMINS & MINERALS W/IRON & FA TAB 0.1 MG

PRENATAL MULTIVITAMINS & MINERALS W/IRON & FA TAB 0.8 MG

PRENATAL MV & MIN W/FE CARBONYL-FA-DHA CAP 27-0.8-200 MG

PRENATAL MV & MIN W/FE CARBONYL-FA-DHA TAB 7-0.4-100 MG

PRENATAL MV & MIN W/FE FUM-FA-DHA CAP 30-0.975-200 MG

PRENATAL TAB

PRENATAL TAB FORMULA

Page 34 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

PRENATAL VIT & MIN W/ FA-FISH OIL CHEW TAB 0.4-113.5 MG

PRENATAL VIT W/ DSS-IRON

CARBONYL-FA TAB 29-1 MG

PRENATAL VIT W/ FE FUM-FA-OMEGA 3 CAP 27-0.8-228 MG

PRENATAL VIT W/ FE FUM-FA-OMEGA 3 CAP 28-0.8-235 MG

PRENATAL VIT W/ FE FUMARATE-FA CAP 13.5-0.4 MG

PRENATAL VIT W/ FE FUMARATE-FA TAB 14-0.4 MG

PRENATAL VIT W/ FE FUMARATE-FA TAB 27-0.8 MG

PRENATAL VIT W/ FE FUMARATE-FA TAB 28-0.8 MG

PRENATAL VIT W/ FE FUMARATE-FA TAB THERAPY PAK 35-1.1 MG

PRENATAL VIT W/ FE FUMARATE-FA TAB THERAPY PAK 35-5 MG

PRENATAL VIT W/ FE GLUCONATE-FA TAB 30-0.4 MG

PRENATAL VIT W/ FE GLUCONATE-FA TAB 30-0.8 MG

PRENATAL VIT W/ FE SUCCINATE-FA TAB 7.5-0.2 MG

PRENATAL W/FE FUM-FA TAB 27-0.8 MG & DHA CAP 200 MG PACK

PRENATAL W/FE FUM-FA TAB 27-1 MG & VIT-DHA CAP 300 MG PAK

Page 35 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

PRENATAL W/FE FUM-FA TAB 28-0.8 MG & DHA CAP 200 MG PACK

PRENATAL W/FE FUM-FA TAB 28-0.975 MG & DHA CAP 200 MG PACK

PRENATAL W/O A VIT W/ FE CARBONYL-FA CHEW TAB 18-0.8 MG

PRENATAL W/O VIT A W/ FE FUMARATE-FA-DHA CAP 27-1-300 MG

PRENATAL W/O VIT A W/ FE POLYSAC CMPLX-FA CAP 155-1 MG

PRENATL MULT CAP + DHA

RECTAL COMBINATIONS - MISC. hemorrhoidal oin hemorrhoidal sup hemorrhoidal sup 0.25%

cetirizine chw 5mg

PHENYLEPHRINE-COCOA BUTTER SUPPOS 0.25-85.39%

RESPIRATORY

ANTIHISTAMINES

cetirizine chw 10mg CETIRIZINE HCL CAP 10 MG

cetirizine sol 5mg/5ml

CETIRIZINE HCL ORALLY DISINTEGRATING TAB 10 MG

cetirizine tab 5mg cetirizine tab 10mg

diphenhydramine hcl cap 25 mg

CLARITIN CAP 10MG CLARITIN CHW 5MG

diphenhydramine hcl cap 50 mg diphenhydramine hcl chew tab 12.5 mg diphenhydramine hcl liquid 12.5 mg/5ml

Page 36 of 47

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http:0.25-85.39

DIPHENHYDRAMINE HCL ORAL STRIP 12.5 MG

diphenhydramine hcl oral strip 25 mg diphenhydramine hcl tab 25 mg

diphenhydramine hcl tab disp 12.5 mg

DIPHENHYDRAMINE HCL TAB 50 MG

LORATADINE CAP 10 MG LORATADINE ORALLY DISINTEGRATING TAB 5 MG

ZYRTEC CHILD TAB 10MG

loratadine syrup 5 mg/5ml loratadine tab 10 mg loratadine tab 10mg

SALICYLATE COMBINATIONS ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 81 MG ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB 500 MG

aspirin effer tab 325 mg

aspirin suppos 300 mg

ASPIRIN EFFER TAB 500 MG ASPIRIN SUPPOS 120 MG ASPIRIN SUPPOS 200 MG

aspirin suppos 600 mg

buffered asa tab 325mg

ASPIRIN-AL HYDRO-MG HYDRO-CA CARB TAB 325 MG ASPIRIN-AL HYDRO-MG HYDRO-CA CARB TAB 500-33-33-237 MG

BACKACHE RELIEF EXTRA STR

BAYER PLUS TAB 500MG

BAYER WOMENS TAB 81-300MG

magnesium salicylate magnesium salicylate tetrahydrate

SALICYLATES aspirin chw 81mg

Page 37 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

ASPIRIN TAB 81 MG aspirin tab 81mg ec aspirin tab 325 mg aspirin tab 325mg ec aspirin tab 500 mg bayer asa tab 325mg bayer asa tab 500mg bayer low chw 81mg bayer low tab 81mg ec

SALINE LAXATIVE MIXTURES enema ene

SALINE LAXATIVES EPSOM SALT GRAN

magnesium citrate SOLN magnesium citrate soln magnesium hydroxide SUSP magnesium hydroxide chew tab 311 mg

MAGNESIUM HYDROXIDE CHEW TAB 400 MG

magnesium hydroxide susp 400 mg/5ml magnesium oxide (laxative) magnesium sulfate (laxative)

MILK OF MAGN SUS 800/5ML MILK OF MAGN SUS 2400MG

milk of magn sus mint

SCABICIDE COMBINATIONS lice killing sha 0.33-4% pyrethrins-piperonyl butoxide liq 0.3-3% pyrethrins-piperonyl butoxide liq 0.33-4%

SEMI SOLID VEHICLES PETROLEUM GEL VASELINE PUR GEL ULT WHTE

Page 38 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

Last updated November 2016

SMOKING DETERRENTS NICOTINE DIS 7MG/24HR nicotine dis 14mg/24h NICOTINE DIS 21MG/24H nicotine pol loz 2mg mint nicotine pol loz 4mg mint

sm nicotine gum 2mg

NICOTINE TD PATCH 24 HR KIT 21-14-7 MG/24HR

sm nicotine gum 4mg

bisacodyl suppos 10 mg bisacodyl tab delayed release 5 mg laxative tab 5mg ec

SURFACTANT LAXATIVES docusate calcium cap 240 mg docusate sodium cap 100 mg docusate sodium enema 100 mg/5ml docusate sodium enema 283 mg

DOCUSATE SODIUM LIQUID 50 MG/15ML docusate sodium liquid 150 mg/15ml docusate sodium tab 100 mg stool softnr cap 100mg stool softnr syp 60/15ml stool softnr tab 100mg

SYSTEMIC DECONGESTANTS

nasal sinus spr 0.05% oxymetazoline hcl nasal soln 0.05%

PHENYLEPHRINE HCL NASAL SOLN 0.5% phenylephrine hcl nasal soln 0.25%

PHENYLEPHRINE HCL NASAL SOLN 0.125% phenylephrine hcl nasal soln 1%

PHENYLEPHRINE HCL TAB 5 MG phenylephrine hcl tab 10 mg

PSEUDOEPHEDRINE HCL CAP 30 MG PSEUDOEPHEDRINE HCL GEL SYRUP 15 MG/5ML

pseudoephedrine hcl liq 15 mg/5ml

Page 39 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

PSEUDOEPHEDRINE HCL LIQ 30 MG/5ML pseudoephedrine hcl syrup 30 mg/5ml pseudoephedrine hcl tab 30 mg pseudoephedrine hcl tab 60 mg pseudoephedrine hcl tab abuse deter 30 mg pseudoephedrine hcl tab sr 12hr 120 mg sudafed 12hr tab 120mg cr

SUDAFED 24HR TAB 240MG XYLOMETAZOLINE HCL NASAL SOLN 0.05%

TOPICAL

DERMATOLOGY, CORTICOSTEROIDS hydrocortisone cream 0.5% hydrocortisone cream 1% hydrocortisone lotion 1% hydrocortisone soln 1%

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lac cre 12%

LACTIC ACID (AMMONIUM LACTATE) CREAM 10%

DERMATOLOGY, SCABICIDES AND PEDICULIDES lice trtmnt liq 1% permethrin creme rinse 1% permethrin spray & pyrethins-piperonyl butoxide shamp kit

PYRETH-PIPER BUT SPRAY & PYRETH-PIPER BUT SHAMP KIT

pyreth-piperonyl butox sham-permeth aero-nit remover gel kit

PYRETHRINS-PIPERONYL BUTOXIDE FOAM 0.33-4% PYRETHRINS-PIPERONYL BUTOXIDE GEL 0.33-4%

PYRETHRINS-PIPERONYL BUTOXIDE GEL KIT 0.33-4%

Page 40 of 47

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PYRETHRINS-PIPERONYL BUTOXIDE LIQ 0.18-2.2%

PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO KIT 0.33-4%

ULCER DRUGS

Ulcer Therapy Combinations famotidine-ca carbonate-mag hydroxide chew tab 10-800-165 mg

beta carotene cap 15 mg VITAMIN A

BETA CAROTENE CAP 30 MG

BETA CAROTENE CAP 10000 UNIT

VITAMIN A CAP 7500 UNIT

beta carotene cap 25000 unit

vitamin a cap 8000unit

vitamin a cap 10000unt

vitamin a tab 10000unt

VITAMIN A CAP 25000 UNIT

VITAMIN A TAB

VITAMIN A TAB 8000 UNIT

VITAMIN A TAB 15000UNT

VITAMIN A-BETA CAROTENE TAB 15000-10000 UNIT

VITAMIN B-1 B-1 TAB 500MG

vitamin b-1 tab 50mg

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Please Note: This drug list is subject to change. Generic medications are covered as listed.

vitamin b-1 tab 100mg vitamin b-1 tab 250mg

VITAMIN B-2 RIBOFLAVIN CAP 50 MG

RIBOFLAVIN CAP 100 MG

RIBOFLAVIN CAP 400 MG

VITAMIN B-3

vitamin b-2 tab 25mg vitamin b-2 tab 50mg vitamin b-2 tab 100mg

niacin er cap 250mg niacin er cap 500mg niacin tab 50mg niacin tab 100mg niacin tab 250mg niacin tab 250mg tr niacin tab 500mg niacin tab 500mg tr niacin tab 750mg tr

niacinamide tab 100mg NIACIN TR TAB 1000MG

VITAMIN B-6 CALCIUM PANTOTHENATE TABS 100mg, 200mg

calcium pantothenate TABS 500mg

pantothenic acid tab 500 mg

NIACINAMIDE TAB CR 500 MG

PANTOTHENIC ACID CAP 250 MG

PYRIDOXINE HCL CAP 250 MG

RIBOFLAVIN TAB 400 MG

THIAMINE MONONITRATE TAB 250 MG

vitamin b6 tab 200mg vitamin b-6 tab 25mg

Page 42 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

vitamin b-6 tab 50mg vitamin b-6 tab 100mg vitamin b-6 tab 200mg tr vitamin b-6 tab 250mg vitamin b-6 tab 500mg

calcium ascorbate TABS

VITAMIN C ASCORBIC ACID SYRUP 500 MG/15ML

vitachew vit chw c 125mg

vitamin c cap 500mg tr VITAMIN C CAP 500MG

vitamin c chw 100mg vitamin c chw 250mg

vitamin c chw 500mg VITAMIN C CHW 300MG

vitamin c liq 500/5ml vitamin c syp 500/5ml vitamin c tab 100mg vitamin c tab 250mg vitamin c tab 500mg vitamin c tab 500mg tr vitamin c tab 1000mg vitamin c tr tab 1000mg vitamin c tr tab 1500mg

VITAMIN C CHW 1000MG VITAMIN C CHW GUMMIE

VITAMIN D

cholecalciferol drops 400 unit/0.03ml (per drop)

CHOLECALCIFEROL CAP 14000 UNIT

CHOLECALCIFEROL CAP 25000 UNIT

CHOLECALCIFEROL CHEWABLE WAFER 14000 UNIT

CHOLECALCIFEROL CHEWABLE WAFER 50000 UNIT

CHOLECALCIFEROL DROPS 400 UNIT/0.028ML (PER DROP)

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Please Note: This drug list is subject to change. Generic medications are covered as listed.

CHOLECALCIFEROL DROPS 600 UNIT/0.028ML (PER DROP)

cholecalciferol drops 2000 unit/0.03ml (per drop)

CHOLECALCIFEROL DROPS 1000 UNIT/0.028ML (PER DROP)

CHOLECALCIFEROL DROPS 2000 UNIT/0.028ML (PER DROP)

CHOLECALCIFEROL ORALLY DISINTEGRATING TAB 1000 UNIT

CHOLECALCIFEROL ORALLY DISINTEGRATING TAB 2000 UNIT

DAILY D3 DRO 1000UNIT

VITAMIN D2 TAB 400UNIT ergocalcifer dro 8000/ml

vitamin d3 cap 400unit

VITAMIN D2 TAB 2000UNIT

VITAMIN D3 CAP 4000UNIT vitamin d3 cap 5000unit vitamin d3 cap 10000unt vitamin d3 cap 50000unt vitamin d3 chw 400unit vitamin d3 chw 1000unit vitamin d3 chw 2000unit vitamin d3 chw 5000unit vitamin d3 dro 400unit vitamin d3 dro 5000unit

vitamin d3 tab 400unit

VITAMIN D3 LIQ 1000UNIT VITAMIN D3 LIQ 1200UNIT VITAMIN D3 SPR 1000UNIT

VITAMIN D3 TAB 3000UNIT VITAMIN D3 TAB 50000UNT

vitamin d-3 cap 1000unit vitamin d-3 cap 2000unit vitamin d-3 tab 1000unit vitamin d-3 tab 2000unit vitamin d-3 tab 5000unit

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Please Note: This drug list is subject to change. Generic medications are covered as listed.

VITAMIN E vitamin e cap 100unit vitamin e cap 200unit vitamin e cap 400unit vitamin e cap 600unit vitamin e cap 1000unit VITAMIN E CHEW TAB 400 UNIT2 vitamin e dro 15/0.3ml vitamin e liquid 400 unit/15ml (26.6 unit/ml) vitamin e oil 100unit

vitamin e tab 400 unit

VITAMIN E TAB 100 UNIT VITAMIN E TAB 200 UNIT

VITAMIN K VITAMIN K2 CAP 100MCG VITAMIN K2 TAB

vitamin k tab 100mcg ZINC

ELITE ZINC

MEGA ZINC TAB 100MG CR

ZINC CAPS

ZINC LOZG 10mg

ZINC TABS 100mg

zinc LOZG 23mg zinc TABS 25mg, 50mg

zinc gluconate LOZG; TABS

ZINC ASPARTATE ZINC CHELATED

ZINC GLUCONATE CAP 50 MG (ELEMENTAL ZN)

zinc gluconate tab 15 mg (elemental zn) zinc gluconate tab 30 mg

ZINC METHIONATE

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Please Note: This drug list is subject to change. Generic medications are covered as listed.

zinc sulfate CAPS; TABS

zinc sulfate cap 220mg

ZINC SULFATE TAB

zinc sulfate tab 220mg

zinc tab 50mg

zinc tab 100mg

ZINC SULFATE TAB 66 MG (15 MG ELEMENTAL ZN)

ZINC SULFATE TAB 110 MG (25 MG ELEMENTAL ZN)

ZINC TAB 220MG

Page 46 of 47

Please Note: This drug list is subject to change. Generic medications are covered as listed.

OTC Category See PageACNE PRODUCTSALTERNATIVE MEDICINESANALGESIC COMBINATIONSNSAIDSANALGESICS OTHER

ANTACID SIMETHICONEANTACIDSAntacidsAluminum Salts

ANTACIDS - BICARBONATEANTACIDS - CALCIUM SALTSANTIBIOTIC MIXTURES TOPICALANTIBIOTICS - TOPICALANTIDIARRHEAL AGENTS - MISC.ANTIDIARRHEALSAntidiarrheal Combinations

ANTIDOTESTopical Antidotes

ANTIEMETICS - ANTICHOLINERGICANTIFLATULENTSANTIFUNGALS - TOPICALANTIFUNGALS - TOPICAL COMBINATIONSANTIHISTAMINES - ALKYLAMINESANTIHISTAMINES - ETHANOLAMINESANTIHISTAMINES - NON-SEDATINGAntiseptics DisinfectantsChlorine Antiseptics

ANTITUSSIVE - NONNARCOTICANTITUSSIVE-EXPECTORANTARTIFICIAL TEAR OINTMENTSARTIFICIAL TEAR SOLUTIONSASTRINGENTSB-COMPLEX VITAMINSB-COMPLEX W/ C FOLIC ACIDCALCIUMCALCIUM COMBINATIONSCARDIOVASCULAR AGENTS - MISC.Peripheral Vasodilators

CHEMICALSLiquids

CHLORINE ANTISEPTICSCOBALAMINSCONTRACEPTIVESEmergency Contraceptives

DECONGESTANT ANTIHISTAMINEDERMATOLOGICALSAntihistamines-TopicalAntivirals - TopicalEmollient/Keratolytic AgentsKeratolytic/Antimitotic AgentsLinimentsTar Products

DIABETIC OTHERDIGESTIVE ENZYMESEXPECTORANTSFLUORIDE DENTAL PRODUCTSFOLIC ACID/FOLATESGASTROINTESTINALANTIEMETICSH2-RECEPTOR ANTAGONISTSLAXATIVESMISCELLANEOUSPROTON PUMP INHIBITORS

GENITOURINARYVAGINAL ANTI-INFECTIVES

H-2 ANTAGONISTSHEMATOPOIETIC AGENTSHematopoietic Mixtures

IMIDAZOLE-RELATED ANTIFUNGALSIMIDAZOLE-RELATED ANTIFUNGALS - TOPICALIODINE ANTISEPTICSIRONKERATOLYTIC/ANTIMITOTIC AGENTSLAXATIVESBulk LaxativesStimulant Laxatives

LAXATIVES - MISCELLANEOUSLOCAL ANESTHETICS - TOPICALLUBRICANT LAXATIVESMINERALS ELECTROLYTESCalciumMagnesium

MISC. RESPIRATORY INHALANTSMISC. TOPICALMOUTH/THROAT/DENTAL AGENTSAnti-infectives - ThroatLozengesThroat Products - Misc.

MULTIPLE VITAMINS W/ IRONMULTIPLE VITAMINS W/ MINERALSMULTIVITAMINSVitamin Mixtures

NASAL AGENTS - MISC.NASAL AGENTS - SYSTEMIC AND TOPICALNasal Agent CombinationsNasal Antiallergy

OPHTHALMICANTI-INFECTIVES

OPHTHALMIC ANTIALLERGICOPHTHALMIC DECONGESTANT COMBINATIONSOPHTHALMIC HYPEROSMOLAR PRODUCTSOTIC AGENTSOtic Agents - Miscellaneous

PEDIATRIC MULTIPLE VITAMINSPEDIATRIC MULTIPLE VITAMINS W/ CPEDIATRIC MULTIPLE VITAMINS W/ EXTRA C FAPHARMACEUTICAL ADJUVANTSInternal Vehicle Ingredients/AgentsSemi Solid Vehicles

PRENATAL MV MIN W/FE-FARECTAL COMBINATIONS - MISC.RESPIRATORYANTIHISTAMINES

SALICYLATE COMBINATIONSSALICYLATESSALINE LAXATIVE MIXTURESSALINE LAXATIVESSCABICIDE COMBINATIONSSEMI SOLID VEHICLESSMOKING DETERRENTSSURFACTANT LAXATIVESSYSTEMIC DECONGESTANTSTOPICALDERMATOLOGY, CORTICOSTEROIDSDERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANEDERMATOLOGY, SCABICIDES AND PEDICULIDES

ULCER DRUGSUlcer Therapy Combinations

VITAMIN AVITAMIN B-1VITAMIN B-2VITAMIN B-3VITAMIN B-6VITAMIN CVITAMIN DVITAMIN EVITAMIN K