| Document Date: 2014-03-04 12:44:54
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Company Caplet SA / / Organization office of Medicaid Policy / / Product Iron 150mg Capsule / Selenium Sulfide / Miconazole Nitrate / Bacitracin / Docusate Sodium 150mg/15mL Liquid Docusate Sodium 50mg Capsule / Loratadine / Calcium Citrate 950mg Tablet / Acetaminophen / IU Tablet / Miconazole / Planning Over-the-Counter Drug Formulary DRUG CRITERIA MOTION SICKNESS PRODUCTS Meclizine HCL 25mg Tablet / Ranitidine / Ibuprofen / Suspension Cetirizine 10mg Tablet Cetirizine 1mg/mL Syrup Cetirizine 5mg Tablet / Hydrocortisone Acetate / Tablet Docusate Sodium 60mg/15mL Syrup Glycerin Adult Suppository Glycerin Pediatric Suppository Loperamide HCl 1mg/5mL Liquid Loperamide HCL 2mg Capsules / Sodium Chloride / MAGNESIUM Magnesium 64mg Tablet ER Magnesium Oxide 400mg Tablet / Clotrimazole / Pseudoephedrine HCL 15mg/5mL Liquid Pseudoephedrine HCL 30mg Tablet Pseudoephedrine HCL 30mg/5mL Liquid Pseudoephedrine HCL 60mg Tablet / Minerals Tablet / Ointment CALCIUM SUPPLEMENTS Calcium 500mg Tablet Calcium Carbonate 1.25gm Tab Chew Calcium Carbonate 1.25gm Tablet Calcium Carbonate 1000mg Tablet / Famotidine / Cromolyn Sodium / Senna Syrup Senna Tablet / Pyridoxine HCL 500mg Tablet Pyridoxine HCL 50mg Tablet Riboflavin 100mg Tablet Riboflavin 50mg Tablet / Magnebind 300mg Tablet Pyridoxine HCL 100mg Tablet Pyridoxine HCL 250mg Tablet Pyridoxine HCL 25mg Tablet / NIACIN / Magnesia Suspension / IRON PRODUCTS Ferrous Sulfate 220mg/5mL Elixir Ferrous Sulfate 220mg/5mL Liquid Ferrous Sulfate 325mg Tablet Ferrous Sulfate 325mg Tablet / Planning Over-the-Counter Drug Formulary DRUG CRITERIA ZINC Zinc 200mg Tablet Zinc 220mg Capsule / Minerals Capsule / Sodium Bicarbonate / Chewable/Non-chewable Calcium Carbonate 500mg Tablet Calcium Carbonate 750mg Tablet / Tioconazole / DEXTROSE / IU Capsule / Chewable Tablet Aspirin 325mg Tablet Aspirin 325mg Tablet EC Aspirin 81mg Tablet Chew Aspirin 81mg Tablet / Tablet Diphenhydramine 12.5mg/mL Syrup Diphenhydramine 25mg Capsule/Caplet/Tablet Diphenhydramine 50mg Capsule / Abreva / Vitamin D / SORBITOL / Guifenesin 100mg/5mL Liquid Guaifenesin 100mg/5mL Syrup Guaifensesin/D-Methorphan Capsule Guaifenesin/D-Methorphan Syrup Guaifenesin/D-Methorphan Tablet Guaifenesin/pseudoephedrine Syrup Pseudoephedrine HCL 120mg Tablet / URINARY ANALGESICS Phenazopyridine 95mg Tablet / GASTRO-INTESTINAL PRODUCTS Bisacodyl 5mg Tablet EC Bisacodyl Suppository Bismuth Subsalicylate 262mg Tab Chew Bismuth Subsalicylate 262mg Tablet / Allegra / Ammonium Lactate / Capsule Acetaminophen 500mg Tablet / Thiamine 100mg Tablet Thiamine 250mg Tablet / Permethrin / Cimetidine / Nicorette / Naproxen / Fexofenadine / Bismuth Subsalicylate Suspension Docusate Calcium 240mg Capsule Docusate Sodium 100mg Capsule/Caplet Docusate Sodium 100mg Tablet / Chlorpheniramine Maleate / Ketotifen / Zaditor / Nicotine / Nizatidine / Caplet SA Ascorbic Acid 250mg Tablet Ascorbic Acid 500mg Tablet Ascorbic Acid 500mg/5mL Syrup Ascorbic Acid Powder Biotin 5mg Capsule / / ProgrammingLanguage EC / / ProvinceOrState Indiana / /
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Office of Medicaid Policy and Planning Over-the-Counter Drug Formulary DRUG CRITERIA ANALGESICS