2018 CHP+/MEDICAID CHOICE OVER-THE-COUNTER (OTC) LIST

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1 2018 CHP+/MEDICAID CHOICE OVER-THE-COUNTER (OTC) LIST Note: Prescriptions for OTCs must be written by a Denver Health provider and filled at a Denver Health Pharmacy Drug Name Strength Dosage Form 80mg-160mg, 100mg/ml, 160mg/5ml, 200mg/2ml, 500mg/15ml, 80mg/0.8ml ACETAMINOPHEN ALCOHOL ANTISEPTIC PADS AMMONIUM LACTATE 12% lotion ASA/CALCIUM CARB/MAG/AL HYDROX 325mg, 500mg, tab chew, tab rapids, SA, ER, capsule, supp rect, elixir, liquid, oral susp, disp syrin, drops, drops susp ASCORBIC ACID 100mg, 250mg, 500mg, 1000mg tab chew,, ER, DR, capsule ER, ASPIRIN 81mg, 162mg, 325mg, 500mg DR,, tab chew BACITRACIN BENZOYL PEROXIDE 2.5%, 3%, 5%, 6%, 8%, 10% cleanser, cream, gel BISACODYL BISMUTH SUBSALICYLATE 262mg, 525mg/15ml tab chew,, oral susp BUDESONIDE (RHINOCORT) 32mcg nasal spray BUTOCONAZOLE NITRATE 2 % CRM/PF APP CA CARBONATE/VITAMIN D3/ VIT K CA CITRATE/MGOX/VIT D3/B6/ MIN, tab chew CALCIUM CARB & LACT/ VITAMIN D3, tab chew CALCIUM CARB&CIT/D3/ PHYTOSTROL, tab chew CALCIUM CARB&CIT/MAG12/VIT D3 CALCIUM CARB/MAG OXIDE/ VIT D3 400mg-133, , tab chew CALCIUM CARB/MAGNESIUM CMB #10, tab chew CALCIUM CARB/VIT D3/MAG11/ ZINC

2 CALCIUM CARB/VIT D3/ MINERALS CALCIUM CARBONATE 200(500)mg, 300mg(750), 400(1000), 500(1250), 600mg, 650mg500mg/5ml tab chew,, oral susp CALCIUM CARBONATE/MAG CARB/FA CALCIUM CARBONATE/ CALCIUM CARBONATE/ 250 MG-125, 500mg-125, 250mg- 125, 500mg-200, 500mg-400, 500mg-600, 600mg-200, CALCIUM CARBONATE/VITAMIN 1000mg-800, 500mg-100, D 600mg-500, tab chew CALCIUM CIT, CALCIUM CARB, CALCIUM PHOS, CALCIUM/MAG , 300MG-200, 100MG- AND VARIATIONS 100, 105MG-120, tab chew CAPSAICIN 0.025%, 0.075% cream CETIRIZINE HCL 1mg/ml, 10mg, 20mg solution,, tab chew, SA, capsules SA, oral CHLORPHENIRAMINE MALEATE 4mg, 8mg, 12mg, 4mg/5ml susp 400 unit, 1000 unit, 2000 unit, 2500 unit, 3000 unit, 4000 unit, CHOLECALCIFEROL (VITAMIN 5000 unit, unit, 2000 unit/, tab chew, capsule, drops, D3) drop, 400 unit/5ml, 400 unit/ml liquid CIMETIDINE 200mg CLEMASTINE FUMARATE 1.34mg CLOTRIMAZOLE 1%, 100mg, 100mg-1%, 200mg-1% cream, solution, cream/appl,, combo pkg CROMOLYN SODIUM 5.2mg spray/pump nasal CYANOCOBALAMIN (VITAMIN B-12) 500mcg, 1000mcg DEXTROSE 40% gel DIPHENHYDRAMINE HCL 12.5mg, 12.5mg/5ml, 25mg, 50mg, tab chew, capsule, elixir, syrup, liquid, prfl spoon DOCUSATE CALCIUM 240mg capsule DOCUSATE SODIUM 50mg, 100mg, 250mg, 50mg/15ml, 60mg/15ml, capsule, syrup, liquid DOXYLAMINE SUCCINATE 25mg ERGOCALCIFEROL (VITAMIN D2) 400unit

3 236(27)mg, 246(28)mg, 324(36) mg, 324(37.5)mg, 324(38), FERROUS GLUCONATE 325mg, 325(36)mg FERROUS SULFATE, tabler ER, capsule ER, liquid, elixir, solution, drops FEXOFENADINE HCL 30mg, 60mg, 180mg FOLIC ACID 0.4mg, 0.8mg FOLIC ACID/MULTIVITS-MIN, tab chew GUAIFEN/DM HB/P-EPHEDRINE ml, drops, liquid GUAIFENESIN 100mg/5ml, 1200mg, 200mg, 400mg, 50mg/5ml, 600mg, tab er 12, liquid, syrup GUAIFENESIN/ DEXTROMETHORPHAN multiple strengths liquid, syrup, gran pack, tbmp 12hr, liquid pkt, capsule,, ER 12 hr, elixir, GUAIFENESIN/DM/ PSEUDOEPHEDRINE multiple strengths syrup, liquid, oral susp, solution GUAIFENESIN/D-METHORPHAN HB mg/5 syrup HYDROCORT/PRAMOXIN/ EMOL/PRAM# %(4g) KT Crm TWL HYDROCORTISONE 0.5%, 1%, cream, oint, lotion, solution HYDROCORTISONE/ALOE VERA HYDROGEN PEROXIDE 3% solution IBUPROFEN 50mg, 100mg, 200mg, 100mg/5ml, 50mg/1.25ml, tab chew, capsule, oral susp, drops susp IRON/VITAMIN B COMP W-C IRON/VITAMINS A,C,AND D (TRI-VI-SOL WITH IRON) drops LOPERAMIDE HCL 1mg/5ml liquid LORATADINE 5mg, 10mg, 5mg/5ml, tab chew, capsule, tab rapids, soln MAG HYDROX/AL HYDROX/ SIMETH oral susp, tab chew MAGNESIUM HYDROXIDE 400meq/5ml, 80meq/30ml oral susp MAGNESIUM HYDROXIDE/AL HYDROX tab chew, oral susp MECLIZINE HCL 12.5mg, 25mg, tab chew MELATONIN 1mg, 3mg, 5mg, 10mg, capsule, oral disintegrating MICONAZOLE NITRATE 2%, 200mg, 200mg-2% cream, oint, cream/appl, supp vag, combo pkg multiple strengths, tab chew, ER, capsule, liquid, drops

4 NAPROXEN SODIUM 220mg, capsule NEOMY SULF/BACITRA/ POLYMYXIN B (TRIPLE ANTIBIOTIC) ointment NICOTINE (ORAL) 2mg, 4mg gum, lozenge NICOTINE PATCHES 7mg/24h, 14mg/24h, 21mg/24h patches NIACIN 50mg, 500mg, tabler ER OMEGA-3 FATTY ACIDS/FISH OIL (FISH OIL) mg, mg, 1000mg capsule PECTIN/BENZOCAINE/CME- CELL SOD (ORAHEAL) 20% paste PEDI MULTIVIT 9/IRON/FA (KIDS VITAMINS) multiple strengths tab chew PEG 400/HYPROMELLOSE/ GLYCERIN (DRY EYE RELIEF) % drops P-EPHED HCL/TRIPROLIDINE HCL mg PERMETHRIN 1% liquid PHENYLEPHRINE HCL (HEMORRHOIDAL) 0.25% supp rect PHENYLEPHRINE HCL (ORAL TABLET) 10mg PNV CMB#95/FERROUS FUMARATE/FA (PRENATAL VITAMINS) multiple strengths POLYVINYL ALCOHOL (LIQUITEARS) 1.4% drops POVIDONE-IODINE 10% solution PSEUDOEPHEDRINE HCL 30mg, 60mg, 120mg, 9.4mg/ml, 15mg/5ml, 30mg/5ml, ER, capsule ER, liquid, syrup, drops PSYLLIUM 100%, 0.52g capsule, powder 25mg, 50mg, 100mg, 200mg,, ER, lozenge, lozenge PYRIDOXINE HCL (VITAMIN B-6) 250mg, 500mg HD SENNOSIDES, liquid, syrup, SENNOSIDES/DOCUSATE SODIUM 8.6MG-50MG SENNOSIDES/PSYLLIUM 9MG-500MG capsule SIMETHICONE 80mg, 125mg, 166mg, 180mg, 40mg/0.6ml, tab chew, capsule, liquid, drops, drops susp SODIUM FLUORIDE tab chew, drops TERBINAFINE HCL 1% cream THIAMINE HCL 25mg, 50mg, 100mg, 250mg, 500mg

5 TOLNAFTATE (LAMISIL) 1% cream, powder URINE ACETONE TEST,STRIPS strip VITAMIN E 100u, 200u, 400u, 600u, 800u, 1000u, tab chew, capsule VITAMINS A,C,AND D (TRI-VI- SOL) drops Last Updated: November 2017

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