Download 2015 OVER-THE-COUNTER DRUG LIST

HAP - Midwest Health Plan
2015 OVER-THE-COUNTER DRUG LIST
The following Over-the-Counter (OTC) items are a covered benefit of the health plan. They are subject to the generic mandate
policy. To obtain these products the member must obtain a prescription from a licensed prescriber to be considered a covered
benefit of the pharmacy program.
SYMPTOM
Pain Relief
Laxatives
Anti-Diarrheal
Stool Softener
Antacids
Cough & Cold
Vaginal Agents
Condoms
BRAND NAME
Ecotrin EC Low
Baby Aspirin
Ecotrin
Motrin
Motrin Liquid
Tylenol Elixir
Tylenol Tabs
Tylenol Caps
Tylenol Chewable Tabs
Tylenol Suppositories
Dulcolax Tabs
Dulcolax Suppository
MiraLax
Metamucil Powder
Peri-Colace Caps
Senokot tabs
Immodium 2mg caps / tabs
Kaopectate Liquid
Pepto-Bismol Liquid
Colace 100mg caps
Amphojel Liquid
Maalox Liquid
Mylanta Liquid
Tums Chewable Tablets
Mylicon Drops
Robitussin Syrup
Robitussin – DM Syrup
Actifed tabs
Benadryl caps / tabs
Benadryl Liquid
Claritin Tabs
Claritin Liquid
Sudafed Tabs
Zyrtec Tabs
Zyrtec Syrup
Gyne-Lotrimin Cream
Gynol II Foam
Monistat Cream
Latex Condom (Male)
GENERIC NAME
Aspirin 81mg Enteric Coated
Aspirin 81mg
Aspirin 325mg Enteric Coated
Ibuprofen 200mg
Ibuprofen 100mg/5ml
Acetaminophen 160mg/5ml
Acetaminophen 325mg tabs
Acetaminophen 325mg caps
Acetaminophen 80mg chew tab
Acetaminophen 120mg
Bisacodyl 5mg tabs
Bisacodyl 10mg suppository
Polyethylene Glycol 17gm packet
Psyllium powder
Docusate Na/Senna caps
Senna 8.6mg tabs
Loperamide 2mg caps / tabs
Kaolin / Pectin suspension
Pink Bismuth Suspension
Docusate 100mg caps
Aluminum Hydroxide 4% Gel
Aluminum / Magnesium Hydroxide
suspension
Simethicone 20mg suspension
Calcium Carbonate Chewable
Simethicone 40mg/0.6ml drops
Guaifenesin Syrup
Guaifenesin w/DM Syrup
Triprolidine & pseudoephedrine tab
Diphenhydramine 25mg caps / tabs
Diphenhydramine 12.5mg liquid
Loratidine 10mg tabs
Loratidine syrup
Pseudoephedrine 30mg tabs
Cetirizine
Cetirizine
Clotrimazole vaginal cream 1%
Nonoxynol-9 Gel 2%
Miconazole 2% vaginal cream
Latex Condom
HAP - Midwest Health Plan
2015 OVER-THE-COUNTER DRUG LIST
Vitamins
Creams &
Ointments
Miscellaneous
Feosol
Fer-In-Sol
One-A-Day Vitamin
Os-Cal 500 + D
Poly-Vi-Sol Chew Tab
Vitamin B-1
Vitamin B-6
Bacitracin Ointment
Betadine Ointment
Hytone 1% Cream
Lotrimin 1% Cream
Neosporin Ointment
Nix
Unisom Sleep Aid Tablet
Ferrous Sulfate 200mg
Ferrous Sulfate Drops
Multivitamin (adult) tab
Calcium Carbonate w/Vitamin D
500mg/125mg
Multivitamin (Childrens) Chew tab
Thiamine HCl 100mg tab
Pyridoxine 100mg tab
Bacitracin Ointment
Povidone Iodine Ointment
Hydrocortisone 1% Cream
Clotrimazole 1% Cream
Triple Antibiotic Ointment
Permethrin 1% Lotion
Doxylamine Succinate 25mg tab
Approved by Pharmacy & Therapeutics Committee: 1/20/2015