Drug name

COVERED OTC DRUG
REFERENCE DRUG
REQUIREMENTS/LIMITS
TOPICAL ANTIBACTERIAL/ANTIFUNAL OTC DRUGS
OTC bacitracin topical ointment
OTC clotrimazole (vaginal use)
OTC clotrimazole (topical use)
OTC miconazole 2% ointment
OTC miconazole vaginal suppositories,
cream
OTC tolnaftate
OTC triple antibiotic cream
PAIN RELIEVER OTC DRUGS
OTC acetaminophen tablets, capsules,
suppositories, liquids, drops
OTC EC aspirin 81 mg, 325 mg,
OTC aspirin 325 mg
OTC ibuprofen
OTC naproxen
SMOKING CESSATION OTC DRUGS
OTC nicotine patch
TOPICAL DERMATOLOGICAL (“SKIN/SCALP”) OTC DRUGS
OTC capsaicin
OTC DOAK TAR DISTILLATE, OIL
hydrocortisone
(prescription and OTC forms covered)
OTC permethrin 1% lotion
OTC Pyrethrin 0.33%
OTC zinc oxide ointment
DIABETES OTC DRUGS
INSULIN OTC VIALS
OTC HUMULIN 50/50 VIAL
OTC HUMULIN N
OTC HUMULIN R (100 U/ML VIAL)
OTC HUMULIN 70/30 VIAL
OTC NOVOLIN 70/30 VIAL
OTC NOVOLIN R VIAL
OTC NOVOLIN N VIAL
OTHER OTC DRUGS FOR DIABETES
OTC glucose chewable tablets
DIGESTION OTC DRUGS
ANTIDIARRHEAL DRUGS
OTC loperamide
ANTI-HEMORRHOIDAL DRUGS
OTC hemorrhoidal cream
ANTIULCER DRUGS
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COVERED OTC DRUG
REFERENCE DRUG
REQUIREMENTS/LIMITS
OTC cimetidine
OTC famotidine
OTC nizatidine
OTC ranitidine
PROTON PUMP INHIBITORS (“PPI”)
OTC omeprazole
LAXATIVES AND CATHARTICS
OTC bisacodyl
OTC docusate
OTC glycerin
OTC MIRALAX
OTC psyllium
OTC SENOKOT (brand and generic
dosage forms covered)
OTC SORBITOL 70% ORAL SOLN
OTHER DIGESTION DRUGS
OTC acidophilus
OTC aluminum hydroxide gel
OTC antacid liquid, suspension
OTC calcium antacid tablet
OTC effervescent pain relief
OTC simethicone drops
OTC VITAMINS
OTC calciferol, OTC ergocalciferol drops
OTC calcium carbonate,
OTC calcium carbonate 600 mg + D
OTC calcium citrate
OTC ferrous fumerate
OTC ferrous gluconate
OTC ferrous sulfate
OTC magnesium oxide
OTC multivitamins (generic, adult
multivitamins)
OTC niacin
OTC pyridoxine (vitamin B6)
OTC SLO NIACIN
OTC sodium bicarbonate
OTC vitamin C 500, 1000 mg
OTC vitamin D
OTC thiamine (vitamin B1)
FAMILY PLANNING OTC DRUGS
OTC levonorgestrel
OTC PLAN B ONE STEP
OTC NEXT CHOICE
EYE CARE OTC DRUGS
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COVERED OTC DRUG
REFERENCE DRUG
REQUIREMENTS/LIMITS
OTC artificial tears
OTC REFRESH TEARS, LIQUIGEL
(15 ML AND 30 ML BOTTLE ONLY)
OTC sodium chloride 5% drops,
ointment
OTC SYSTANE
(15 ML AND 30 ML BOTTLE ONLY)
OTC ZADITOR
COUGH/COLD/ALLERGY OTC DRUGS
ANTIHISTAMINES
cetirizine OTC tablets,
cetirizine-D OTC tablets,
cetirizine solution, Syrup
OTC diphenhydramine
OTC loratadine,
OTC loratadine-D
ANTIHISTAMINE/DECONGESTANT COMBINATIONS
OTC brompheniramine-pseudoephedrine
elixir
ANTITUSSIVE AND EXPECTORANT DRUGS
OTC CHERATUSSIN AC
OTC MUCINEX, DM
OTC tussin syrup, softgel, liquicap
OTC tussin DM
OTHER DRUGS FOR COUGH/COLD ALERGY
OTC nasal spray
OTC pseudoephedrine (all generic
dosage forms covered)
DIABETIC OTC SUPPLIES
(GLUCOMETERS, INSULIN SYRINGES, TEST STRIPS, LANCETS)
ACCU-CHEK ACTIVE
GLUCOMETER/TEST STRIPS
ACCU-CHEK ADVANTAGE
GLUCOMETER/TEST STRIPS
ACCU-CHEK AVIVA GLUCOMETER/TEST
ACCU-CHEK COMPACT
GLUCOMETER/TEST STRIPS
ACCU-CHEK COMPLETE GLUCOMETER
ACCU-CHEK SIMPLICITY
ACCU-CHEK COMFORT CURVE TEST
ACCU-CHEK MULTICLIX LANCET
DEVICE/LANCETS
ACCU-CHEK SOFTCLIX LANCET
DEVICE/LANCETS
MICROLET LANCING DEVICE/LANCETS
AUTOJECT 2 INJECTION DEVICE
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COVERED OTC DRUG
REFERENCE DRUG
REQUIREMENTS/LIMITS
insulin syringes
ONE TOUCH ULTRA2, UKTRALINK,
ULTRAMINI, ULTRASMART
ONE TOUCH SELECT
ONE TOUCH TEST STRIPS, CONTROL
SOLUTION
SOFT TOUCH
SOFTCLIX
CHEMSTRIP
KETOSTIX
ASTHMA OTC SUPPLIES (PEAK FLOW METERS, SPACERS)
AEROCHAMBER, MICROCHAMBER
ASSESS PEAK FLOW METER
MICROCHAMBER PEAK FLOW METER
PERSONAL BEST PEAK FLOW METER
OTHER OTC DRUGS
sodium chloride 0.9%
nebulizer solution OTC
Page 4

Source: http://www.majestacare.com/assets/pdf/providers/pharmacy/OTC-List-VA.pdf