This list represents the OTC formulary for MA. Please use the NDC search tool to verify formulary status of any particular NDC.
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1 INCLUDED IN MHCP OTC FORMULARY Updated June 2016 Important Notes * Individual product NDCs are only covered if the manufacturer participates in the federal CMS rebate program TherapeuticClassDesc GenericName Strength DoseForm Allylamines TERBINAFINE HCL 0.01 cream Alpha and Beta Adrenergic Agonists PSEUDOEPHEDRINE HCL 120 MG 30 MG 30 MG/5 ML liquid Antacids and Adsorbents ACTIVATED CHARCOAL 15G/72ML oral suspension 25 G oral suspension 25G/120ML oral suspension 50G/240ML oral suspension ALUMINUM HYDROXIDE 320MG/5ML oral suspension CALCIUM CARBONATE 400 MG chewable 300MG(750) chewable 320MG(750) chewable 500 MG chewable 600 MG chewable CALCIUM CARBONATE/MAG HYDROX /5 oral suspension MG chewable CHARCOAL/SORBITOL SOLUTION 25G/120ML oral suspension 50G/240ML oral suspension MAG HYDROX/AL HYDROX/SIMETH oral suspension chewable chewable oral suspension MAGNESIUM CARBONATE/AL HYDROX MG chewable MAGNESIUM OXIDE 400 MG SODIUM BICARBONATE 325 MG
2 650 MG Anti-allergic Agents KETOTIFEN FUMARATE drops Antibacterials BACITRACIN 500 UNIT/G ointment BACITRACIN ZINC 500 UNIT/G ointment NEOMY SULF/BACITRAC ZN/POLY K ointment Antidiarrhea Agents BISMUTH SUBSALICYLATE 262 MG chewable 262MG/15ML oral suspension 525MG/15ML oral suspension LOPERAMIDE HCL 1 MG/5 ML liquid 1MG/7.5ML liquid 2 MG capsule 2 MG Antiflatulents SIMETHICONE 125 MG 125 MG capsule 40MG/0.6ML drops susp. 80 MG chewable Antihistamines MECLIZINE HCL 12.5 MG 25 MG chewable Anti-inflammatory Agents HYDROCORTISONE 0.5 ointment 1% cream 1% ointment 1% lotion HYDROCORTISONE ACETATE 1% cream Antitussives DEXTROMETHORPHAN HBR 30 MG/5 ML suspension, 12Hr DEXTROMETHORPHAN POLISTIREX MG/5 liquid GUAIFENESIN/CODEINE PHOS /5ML syrup GUAIFENESIN/D-METHORPHAN HB MG/5 liquid 400MG-20MG Topical Antifungals CLOTRIMAZOLE 1% cream 2% cream w/applicator 1% cream w/applicator 200MG-1% combo pkg.
3 MICONAZOLE NITRATE 2% spray 1% cream w/applicator 2% cream 2% powder 2% tincture 100 MG suppository, vag. 200 MG-2 % combo pkg. TIOCONAZOLE ointment Basic Lotions and Liniments AMMONIUM LACTATE 0.12 lotion 0.12 cream Basic Ointments and Protectants DIMETHICONE 0.01 cream DIMETHICONE/ZINC OXIDE cream Caloric Agents DEXTROSE 0.4 gel Cariostatic Agents SODIUM FLUORIDE powder solution Cathartics and Laxatives BISACODYL 10 MG suppository, rectal 10MG/30ML enema 5 MG 5MG delayed release CALCIUM POLYCARBOPHIL 625 MG DOCUSATE SODIUM 100 MG capsule 250 MG capsule 283 MG enema (ea) 283 MG/5 ML enema (ml) 50 MG/5 ML liquid 60 MG/15ML syrup GLYCERIN 2.8G/2.7ML solution w/applicator ADULT suppository, rectal PEDIATRIC suppository, rectal METHYLCELLULOSE (blank) powder MINERAL OIL enema oil
4 NA PHOS,M-B/NA PHOS,DI-BA 19G-7G/118 enema /59 enema PSYLLIUM 0.52G capsule PSYLLIUM HUSK 3.4G/5.8G powder PSYLLIUM HUSK/SUCROSE 3.4G/7G powder 3.4G/11G-12G powder PSYLLIUM SEED (blank) powder PSYLLIUM SEED/ASPARTAME (blank) powder PSYLLIUM SEED/DEXTROSE (blank) powder PSYLLIUM SEED/SUGAR packet powder SENNOSIDES/DOCUSATE SODIUM 8.6 MG 8.8MG/5ML syrup 25MG 8.6MG-50MG SORBITOL SOLUTION 0.7 solution Diabetic Supplies Blood-Glucose Meter each Blood Sugar Diagnositc strip Lancing Devices each Lancets kit Blood Glucose Control Solution each Digestants LACTASE 3000 UNIT 250 MG capsule Ethanolamine Derivatives CLEMASTINE FUMARATE 1.34 MG DIPHENHYDRAMINE HCL 12.5MG/5ML liquid 25 MG capsule 25 MG Expectorants GUAIFENESIN 100 MG/5ML liquid 1200 MG 12hr 400 MG Iron Preparations FERROUS FUMARATE 325(106)MG FERROUS GLUCONATE 240(27)MG
5 324(38)MG FERROUS SULFATE 15 MG/ML drops 220(44)/5 solution 300MG/5ML liquid 324(65)MG delayed release 325(65) MG 325(65) MG delayed release IRON POLYSACCHARIDES COMPLEX 150 MG capsule Keratolytic Agents BENZOYL PEROXIDE 0.05 gel 0.1 gel 0.1 cleanser 0.5 cleanser 4.25 cleanser 4.25 cleanser.8-.5 kit SALICYLIC ACID 0.4 adhesive patch (blank) powder 0.17 liquid Keratoplastic Agents COAL TAR shampoo 0.2 solution Miscellaneous Analgesics and Antipyretics ACETAMINOPHEN 100 MG/ML drops 100% powder 120 MG suppository, rectal 160 MG, rapid dissolve 160 MG/5ML elixir liquid oral suspension 160MG/5ML elixir 325 MG suppository, rectal 500 MG
6 80MG/0.8ML drops 500MG 650 MG suppository, rectal 80MG chewable, rapid dissolve 80MG/0.8ML drops Miscellaneous Antilipemic Agents NIACIN 1000 MG 250 MG ER 50 MG 500 MG capsule 750 MG ER 100 MG Miscellaneous Autonomic Drugs NICOTINE 21 MG/24HR patch TD24 14 MG/24HR patch TD24 7MG/24HR patch TD24 15MG/16HR patch TD24 NICOTINE POLACRILEX 2 MG gum lozenge 4 MG gum lozenge Miscellaneous Local Anti-infectives CHLORHEXIDINE GLUCONATE 0.04 liquid POVIDONE-IODINE 10% ointment 10% solution Mouthwashes and Gargles HYDROGEN PEROXIDE 0.03 solution Multivitamin Preparations BETA-CAROTENE(A) W-C & E (blank) BETA-CAROTENE(A) W-C & E/ZN/CU (blank) FOLIC ACID/MV,FE,OTHER MIN 0.4MG-18MG chewable 10MG-400/2 oral suspension MULTIVITAMIN chewable
7 chewable MULTIVITAMINS W-IRON (blank) chewable MULTIVITAMINS W-MINERALS MULTIVITAMINS W-MINERALS/LUT (blank) MULTIVITAMINS/IRON/FOLIC ACID 18MG-0.4MG MULTIVITS W-FE,OTHER MIN chewable chewable MULTIVITS W-IRON,HEMATINIC 27MG-0.4MG MULTIVITS,STRESS FORMULA/ZINC (blank) PRENATAL VIT/FE FUMARATE/FA MG MG PV W-O CAL/FE GLUCONATE/FA VITAMINS A,C,AND D 1500 U-35 drops 5-HYDROXYTRYPTOPHAN 50 MG capsule CREATINE MONOHYDRATE (blank) powder SODIUM CHLORIDE 1000 MG, soluble 0.65% spray Other Nonsteroidal Anti-inflammatory Agents IBUPROFEN 100 MG/5ML oral suspension 200 MG capsule 50 MG/1.25 drops NAPROXEN SODIUM 220MG Replacement Preparations CALCIUM CARBONATE 500(1250) chewable 600 MG 500MG/5ML oral suspension 648MG CALCIUM CARBONATE/VITAMIN D2 500MG MG-125 CALCIUM CARBONATE/VITAMIN D3 500 MG-200
8 500 MG-400 chewable 500MG-100 chewable 600 MG MG MG MG-400 CALCIUM CITRATE 200MG-250 CALCIUM CITRATE/VITAMIN D3 315MG MG-250 CALCIUM LACTATE CALCIUM/MULTIVITAMINS W-IRON (blank) solution ELECTROLYTE,ORAL 250 MG SODIUM CHLORIDE vial-nebulizer Salicylates ASPIRIN 300 MG suppository, rectal 325 MG, delayed release 81 MG, delayed release 81MG chewable ASPIRIN/ACETAMINOPHEN/CAFFEINE ASPIRIN/CALCIUM CARBONATE/MAG 325 MG Scabicides and Pediculicides PERMETHRIN 0.01 liquid PIP BUTOX/PYRETHRINS/PERMETH % kit 4%-0.33% liquid shampoo Second Generation Antihistamines CETIRIZINE HCL 1 MG/ML solution 10 MG chewable 5 MG chewable CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG, 12HR LORATADINE 10 MG, rapid dissolve
9 5 MG/5 ML solution LORATADINE/PSEUDOEPHEDRINE SUL 10MG-240MG 24H 5 MG-120MG, 12HR Skin and Mucous Membrane Agents, Misc CAPSAICIN cream cream Thiocarbamates TOLNAFTATE 0.01 aerosol, powder 0.01 cream 0.01 solution Vasoconstrictors NAPHAZOLINE HCL/PHENIR MAL % drops Vitamin A BETA-CAROTENE UNIT capsule VITAMIN A UNIT capsule 8000 UNIT capsule Vitamin B Complex CYANOCOBALAMIN 100 MCG 1000 MCG extended release 250 MCG 500 MCG FOLIC ACID 100% powder 0.4 MG 0.8MG NIACINAMIDE 100 MG PYRIDOXINE HCL 100 MG 25 MG 50 MG THIAMINE HCL 100 MG 50 MG (blank) powder Vitamin C ASCORBIC ACID 1000 MG, Sustained Action Vitamin C 250 MG chewable 500 MG chewable
10 sustained action 500 MG/5ML syrup Vitamin D CHOLECALCIFEROL 1000 UNIT 2000 UNIT capsule 400 UNIT 400/ML drops 2000 UNIT 5000 UNIT capsule Vitamin E VITAMIN E 1000 UNIT capsule 200 UNIT capsule 100 UNIT capsule 400 UNIT capsule ERGOCALCIFEROL 200 UNIT capsule
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