OTC DRUG LIST

E ffective M ay 2 0 1 2
The following is a partial listing of NDCs for OTCs covered by Passport Health Plan. There may be other NDCs covered, such as store brands for the generic products listed. However, the NDC must be loaded into the First Data Bank System. Listing subject to change. Check the Passport Health Plan website for updates. Generic Drug Description Common Brand Name**
(if available)

Brand/Generic

NDC

Manufacturer

COUGH, COLD & ALLERGY

Antihistamine Diphenhydramine 25mg caps Benadryl, Q-DRYL Generic Generic Generic Generic Diphenhydramine 50mg caps Benadryl Generic Generic Generic Diphenhydramine 12.5mg/5ml elixir Chlorpheniramine 4mg tablet Chlorpheniramine 2mg/5ml syrup Loratidine tablet Loratadine rapid disintegrting tablet Loratidine syrup Benadryl Chlor-trimeton Aller-chlor Claritin, Allergy Relief Alavert Claritin, Allergy Relief Generic Generic Generic Generic Generic Brand Generic Generic Generic Cetirizine tablet Zyrtec Generic Generic Generic Cetirizine syrup Zyrtec Generic Generic 00536359401 00603024118 00185064801 00185064810 00185064901 00603334032 65162051810 00182616840 00182047110 00485009804 00113031152 37205038167 00573262048 24385053126 51672207308 24385053126 00378363701 45802091987 60505263301 45802097426 51672208808 RUGBY QUALITEST EON LABS EON LABS EON LABS QUALITEST AKYMA PHARMACEU IVAX PHARMACEUT IVAX PHARMACEUT EDWARDS PHARMACY PERRIGO CO. LEADER WYETH CONSUMER BERGEN BRUNSWIG TARO PHARM USA BERGEN BRUNSWIG MYLAN PERRIGO CO. APOTEX CORP PERRIGO CO. TARO PHARM USA

**Generics preferred when available. Unit dose only long-term care setting.

The following is a partial listing of NDCs for OTCs covered by Passport Health Plan. There may be other NDCs covered, such as store brands for the generic products listed. However, the NDC must be loaded into the First Data Bank System. Listing subject to change. Check the Passport Health Plan website for updates. Generic Drug Description
Antihistamine-Decongestant Combinations Pseudoephedrine Hcl/Brompheniramine Pseudoephedrine Hcl/Triprolidine Hcl Phenylephrine/Brompheniramine Loratadine/Pseudoephedrine Cetirizine/Pseudoephedrine Decongestant Pseudoephedrine Hcl Tablet, Syrup Pseudoephedrine Hcl Syrup Decongestant-Expectorant Combinations Guaifenesin/Pseudoephedrine Hcl Expectorant Guaifenesin tab CR 600 mg Guaifenesin 100mg/5ml Mucinex Robitussin, Guiatuss, Q-Tussin Brand Generic Generic Generic Nasal - Decongestant Oxymetazoline Afrin Generic Generic Generic Nasal - Misc Sodium Chloride Spray 0.65% Sea Soft/Deep Sea Generic Generic Generic 00603038046 87701055205 00182613577 QUALITEST GOOD NEIGHBOR IVAX 00904571135 51672203003 49348002827 MAJOR PHARM. TARO PHARM USA SUNMARK 63824000810 00536082597 00113031026 00603085781 ADAMS LABS RUGBY PERRIGO QUALITEST Mucinex D Brand 63824005718 ADAMS LABS Sudafed Childrens Sudafed Generic Generic Generic 00121042104 00536185085 54838010440 PHARMACEU ASSOC RUGBY SILARX PHARM Dimetapp, Q-Tapp Elixir Bromaline Solution Aprodine Dimetapp Solution Claritin D Zyrtec D Generic Generic Generic Generic Generic Generic Generic Generic 00603085194 00536088097 00904025059 00904578109 24385035152 51660072411 45802072162 001130117662 QUALITEST RUGBY MAJOR PHARM. MAJOR PHARM. BERGEN BRUNSWIG OHM LABS. PERRIGO CO. PERRIGO CO.

Common Brand Name**

(if available)

Brand/Generic

NDC

Manufacturer

**Generics preferred when available. Unit dose only long-term care setting.

The following is a partial listing of NDCs for OTCs covered by Passport Health Plan. There may be other NDCs covered, such as store brands for the generic products listed. However, the NDC must be loaded into the First Data Bank System. Listing subject to change. Check the Passport Health Plan website for updates. Generic Drug Description
Opthalmic Antihistamine Ketotifen Fumarate Opthalmic - Vasoconstrictors Naphazoline Hcl/Pheniramine Naphazoline Hcl Opthalmic - Misc Polyvinyl Alcohol Drops Mineral Oil/ White Petrolatum ointment Antitussives (Non-Narcotic) Dextromethorphan Polistirex Dextromethorphan HBR (pediatric) Delsym susp Robitussin Pediatric, Pediacare Brand Brand Brand Antitussive-1st Gen. Antihistamine-Decongestant (Non-Narcotic) Dextromethorphan/pseudoephedrine/ brompheniramine Pyrilamine/Phenylephrine/ Dextromethorphan Guaifenesin/Dextromethorphan Dimetapp DM/Q-Tapp DM Elixir Generic Generic Codituss DM Syrup Robitussin DM Syrup Diabetic Tussin DM Mucinex DM Tablets Guaifenesin/Dextromethorphan/ Phenylephrine Antitussive-Expectorant Combination (Narcotic) Guaifenesin/codeine phos Cheratussin AC Brand 00603107558 QUALITEST Robitussin Cough & Cold CF Generic Generic Generic Brand Brand Generic Brand Antitussive and Expectorant Combination (Non-Narcotic) 00536097097 00603085558 61787006204 63824005620 63824005640 00031861614 RUGBY QUALITEST HI-TECH CARE ADAMS LABS ADAMS LABS WYETH 00536136085 00603085254 60258077116 RUGBY QUALITEST CYPRESS PHARM. 63824017663 00031869412 00501242204 RECKITT BENCKIS WYETH CONSUMER PFIZER CONS.HLT Akwa Tears Lacri-Lube S.O.P. Generic Generic Brand 00536197072 00904501735 00023031204 RUGBY MAJOR PHARM. ALLERGAN INC. Naphcon-A Naphcon Brand Brand 42002020005 00998007815 J&J ALCON LABS. Zaditor/Alaway Generic Brand 17478071710 00078047661 AKORN INC. NOVARTIS

Common Brand Name**

(if available)

Brand/Generic

NDC

Manufacturer

**Generics preferred when available. Unit dose only long-term care setting.

The following is a partial listing of NDCs for OTCs covered by Passport Health Plan. There may be other NDCs covered, such as store brands for the generic products listed. However, the NDC must be loaded into the First Data Bank System. Listing subject to change. Check the Passport Health Plan website for updates. Generic Drug Description Common Brand Name**
(if available) Antitussive-Decongestant-Expectorant Comb (Narcotic) Pseudoephedrine Hcl/Codeine/Guaifenesin Acid reducers - Antacids Aluminum Hydroxide Aluminum/Magnesium Hydroxide/simethicone Magnesium Hydroxide Calcium Carbonate tabs Acid reducers - H2blockers & PPIs Cimetidine 200mg tablet Famotidine 10mg Famotidine 20mg Ranitidine 75mg Ranitidine 150mg Omeprazole 20mg Prilosec OTC Tagamet HB Pepcid AC Pepcid AC Zantac Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Antidiarrheals Loperamide Hcl caplet Loperamide Hcl 1mg/5ml liquid Bismuth Subsalicylate chew tabs Bismuth Subsalicylate suspension Antiflatulents Simethicone Drops Mylicon Generic Generic 00603089450 00904506730 QUALITEST MAJOR PHARM. Pepto-Bismol Pepto-Bismol Imodium A-D Generic Generic Generic Generic 49348008304 00113037726 00603023516 00182181144 SUNMARK PERRIGO CO. QUALITEST IVAX PHARMACEUT 00113002239 00113020789 00182266222 00172572860 00904539952 37205053165 00172435749 49348084661 37205083706 45802088830 PERRIGO CO. PERRIGO CO. IVAX PHARMACEUT IVAX PHARMACEUT MAJOR PHARM. LEADER IVAX PHARMACEUT SUNMARK LEADER PERRIGO CO. Alternagel Mylanta/Maalox MOM Tums Brand Generic Generic Generic Generic Generic Generic 53807013201 70030013055 00904000414 00536247083 00182083339 00904125892 00182113920 RIJ PHARM PERRIGO CO. MAJOR PHARM. RUGBY IVAX PHARMACEUT MAJOR PHARM. IVAX PHARMACEUT Cheratussin DAC Brand 00603107858 QUALITEST

Brand/Generic

NDC

Manufacturer

GASTROINTESTINAL (STOMACH) AGENTS

**Generics preferred when available. Unit dose only long-term care setting.

The following is a partial listing of NDCs for OTCs covered by Passport Health Plan. There may be other NDCs covered, such as store brands for the generic products listed. However, the NDC must be loaded into the First Data Bank System. Listing subject to change. Check the Passport Health Plan website for updates. Generic Drug Description
Simethicone Chew tabs Laxatives Polyethylene glycol 3350 oral powder Docusate sodium cap 100mg Sennosides Sennosides/Docusate Sodium Bisacodyl tabs Calcium Polycarbophil Psyllium Seed Magnesium Citrate Laxatives, Local/Rectal Bisacodyl Supp Glycerin Pediatric Supp Na biphosphate/sodium phosphate Bisac-Evac Fleet Babylax Fleet Enema Generic Generic Brand Brand Generic 00536135501 45802071030 00132019012 00132020140 24385003928 00603002632 00182106107 00904404073 00182142095 RUGBY PERRIGO FLEET,C.B. CO. FLEET,C.B. CO. BERGEN BRUNSWIG QUALITEST IVAX PHARMACEUT MAJOR PHARM. IVAX PHARMACEUT Miralax Colace Senokot Senna-S Dulcolax Fiber-Lax Metamucil/Natural fiber Citrate of Magnesia Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic 00574041202 00603014521 5363755601 00603028221 00182109301 00182111301 00182111310 00113008663 00603248321 49348075913 00603018102 00904519965 00536444454 00869066738 24385067510 PADDOCK LABS QUALITEST RUGBY QUALITEST IVAX PHARMACEUT IVAX PHARMACEUT IVAX PHARMACEUT PERRIGO CO. QUALITEST SUNMARK QUALITEST MAJOR PHARM. RUGBY VI JON INC BERGEN BRUNSWIG

Common Brand Name**

(if available) Gas-X

Brand/Generic
Generic Generic

NDC
65162044310 00536453301

Manufacturer
AKYMA PHARMACEU RUGBY

PA I N R E L I E V E R S
Aspirin 81mg EC Aspirin 81mg Chewable Ecotrin Bayer Childrens Aspirin Generic Generic Generic Generic

**Generics preferred when available. Unit dose only long-term care setting.

The following is a partial listing of NDCs for OTCs covered by Passport Health Plan. There may be other NDCs covered, such as store brands for the generic products listed. However, the NDC must be loaded into the First Data Bank System. Listing subject to change. Check the Passport Health Plan website for updates. Generic Drug Description
Aspirin EC 325mg Tablet APAP 100mg/ml Drops APAP 160mg/5ml Solution APAP 325mg Tablet APAP 500mg Tablet APAP 80mg Chewable Tablet APAP 120mg Supp APAP 325mg Supp Aspirin/APAP/Caffeine Ibuprofen 200m Tablet Ibuprofen 100mg/5ml Suspension Naproxen 220mg Tablet

Common Brand Name**

(if available) Ecotrin Q-PAP Drops Q-Pap Solution Tylenol Tylenol Extra Strength Childrens Tylenol Feverall, Acephen Feverall, Acephen Excedrin Migraine Motrin Childrens Motrin Aleve

Brand/Generic
Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Brand Generic Generic Generic Generic Generic Generic Generic

NDC
00536331301 00603016921 00603083873 00472141799 00603083958 00182147340 00603026321 00904198280 10135015210 00603026821 00536323307 00536323307 00472120106 00182166211 00713016412 00536132012 00067203991 00904513559 00182103901 00904791540 24385090526 00113089726 00904523059 00113036878

Manufacturer
RUGBY QUALITEST QUALITEST ACTAVIS MID ATL QUALITEST IVAX PHARMACEUT QUALITEST MAJOR PHARM. MARLEX PHARM. QUALITEST RUGBY RUGBY ACTAVIS MID ATL IVAX PHARMACEUT G & W LABS. RUGBY NOVARTIS CONSUM MAJOR PHARM. IVAX PHARMACEUT MAJOR PHARM. BERGEN BRUNSWIG PERRIGO CO. MAJOR PHARM. PERRIGO CO.

TOPICALS
Topical Anti-infective viral Docosanol Terbinafine Abreva Lamisil AT Brand Generic Generic 00135020001 24385052403 51672208002 GSK CONSUMER AMERISOURCEBERGEN TARO PHARM USA

**Generics preferred when available. Unit dose only long-term care setting.

The following is a partial listing of NDCs for OTCs covered by Passport Health Plan. There may be other NDCs covered, such as store brands for the generic products listed. However, the NDC must be loaded into the First Data Bank System. Listing subject to change. Check the Passport Health Plan website for updates. Generic Drug Description
Topical - Anti-Infective Polymyxin B, neomycin, bacitracin Triple Antibiotic Ointment Generic Generic Generic Topical-Anti-Parasites Permethrin 1% Topical Steroid Low Potency Hydrocortisone 0.5% cream Hydrocortisone 0.5% ointment Hydrocortisone 1% cream Hydrocortisone 1% lotion Hydrocortisone 1% ointment Hydrocortisone acetate 0.5% cream Hydrocortisone acetate 1.0% cream Hydrocortisone acetate 1.0% ointment Topical Antifungal Clotrimazole cream 1% Miconazole Nitrate 2% Cream Ketoconazole 1% Shampoo Lotrimin-AF Baza Antifungal Nizoral A-D Generic Generic Generic Generic Brand 45802043411 51672200202 00472073041 00472073514 50580089504 PERRIGO CO. TARO PHARM USA ACTAVIS MID ATL ACTAVIS MID ATL MC NEIL CONS. Dermolate Cortizone-5 Cortaid HydroSkin Cortizone-10 Lanacort-5 Creme Lanacort 10 Creme Max strength Cortaid Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic 00168001431 49348002172 00168001631 45802043803 00168015431 00536510597 45802028306 00472034556 00168002031 24385019003 24385027403 00603053450 45802027603 FOUGERA SUNMARK FOUGERA PERRIGO CO. FOUGERA RUGBY PERRIGO CO. ACTAVIS MID ATL FOUGERA BERGEN BRUNSWIG BERGEN BRUNSWIG QUALITEST PERRIGO CO. Nix Generic Generic 00472524267 49348046030 ACTAVIS MID ATL SUNMARK 00603064450 51672201602 00168001231 QUALITEST TARO PHARM USA FOUGERA

Common Brand Name**

(if available)

Brand/Generic

NDC

Manufacturer

**Generics preferred when available. Unit dose only long-term care setting.

The following is a partial listing of NDCs for OTCs covered by Passport Health Plan. There may be other NDCs covered, such as store brands for the generic products listed. However, the NDC must be loaded into the First Data Bank System. Listing subject to change. Check the Passport Health Plan website for updates. Generic Drug Description
Topical Protectives Zinc oxide 20% Zinc oxide 40% Vitamin A&D Vaginal Clotrimazole vaginal cream 1% Miconazole nitrate vaginal cream 2% Miconazole nitrate 100mg vaginal supp Miconazole 200mg-2% Combo Pack Benzoyl Peroxide 10% Gel Benzoyl Peroxide 5% Gel Gyne-lotrimin Monistat 7 Monistat 7 supp Monistat 3 Combo pack Benzac AC 10% Benzac AC 5& Generic Generic Generic Generic Generic Generic Generic Generic Generic 51672200306 00472022063 70030013252 00472073041 00713019757 00472173607 00904541501 00536409256 00536408956 TARO PHARM USA ACTAVIS MID ATL PERRIGO CO. ACTAVIS MID ATL G & W LABS. ACTAVIS MID ATL MAJOR PHARM. RUGBY RUGBY Vitamin A&D Zinc Oxide Generic Generic Generic 00085009601 SCHERING PLOUGH 00168006202 FOUGERA

Common Brand Name**

(if available)

Brand/Generic

NDC

Manufacturer

V I TA M I N S / M I N E R A L S
Calcium Replacement Calcium Carbonate/Vitamin D3 500-200 Calcium Carbonate/Vitamin D3 600-400 Calcium Carbonate/Vitamin D2 500-125 Calcium Carbonate 500mg Calcium Carb 1250mg/5 ml Suspension Calcium Citrate 200mg Calcium Citrate/Vitamin D3 315-200 Calcitrate Citrus Calcium with Vit D Oyst-Cal-500 Oysco-500 Oysco 500+D Oyst-Cal-D 500 Calcarb 600 with Vitamin D Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic 00536781708 00182443910 00182414126 00904323352 37205008378 00182157626 00536410608 00121076616 00054311763 00904506260 00536322408 RUGBY IVAX PHARMACEUT IVAX PHARMACEUT MAJOR PHARM. LEADER IVAX PHARMACEUT RUGBY PHARMACEU ASSOC ROXANNE LAB MAJOR RUGBY

**Generics preferred when available. Unit dose only long-term care setting.

The following is a partial listing of NDCs for OTCs covered by Passport Health Plan. There may be other NDCs covered, such as store brands for the generic products listed. However, the NDC must be loaded into the First Data Bank System. Listing subject to change. Check the Passport Health Plan website for updates. Generic Drug Description
Magnesium Salts Replacement Magnesium Oxide 400mg Mag-ox Generic Generic Generic Iron Replacement Ferrous Sulfate 325mg tabs Generic Generic Generic Ferrous Sulfate 324mg tabs Ferrous Sulfate 15mg/0.6 ml drop Generic Generic Generic Generic Ferrous Sulfate 220mg/5ml elixir Poly-Iron 150mg Capsule Pediatric Vitamin Preparations (up to age 5) Multivitamin drops Multivitamin chew tabs Multivitamins with iron drops Multivitamins W-Iron chew tabs Vitamin D drops Multivitamin Preparations Multivitamins Multivitamins, therapeutic Vigran Thera Generic Generic Generic Generic 00536404610 00182442810 00182451810 00904053980 RUGBY IVAX PHARMACEUT IVAX PHARMACEUT MAJOR PHARM. Poly-vitamin Flinstone chewable Poly-vi-sol with iron Flintstones with Iron D-Vi-Sol Generic Generic Generic Generic Generic Generic Generic Brand Generic 50383062550 00536845080 00182431401 00904262170 50383063250 00536853080 00182431501 00904053660 00087086644 54838000650 HI-TECH PHARM. RUGBY IVAX PHARMACEUT MAJOR PHARM. HI-TECH PHARM. RUGBY IVAX PHARMACEUT MAJOR PHARM. MJ NUTRITIONAL SILARX Poly-iron Generic Generic 65162040611 00677007001 00182402901 00574060801 54838001150 00536071080 00603076247 00536065085 60258018501 AMNEAL PHARMACEU URL PHARMA IVAX PHARMACEUT PADDOCK LABS SILARX RUGBY QUALITEST RUGBY CYPRESS PHARM. 60258017101 68549010012 68585000612 CYPRESS PHARM. BLAINE PHARMACE RISING PHARM

Common Brand Name**

(if available)

Brand/Generic

NDC

Manufacturer

**Generics preferred when available. Unit dose only long-term care setting.

The following is a partial listing of NDCs for OTCs covered by Passport Health Plan. There may be other NDCs covered, such as store brands for the generic products listed. However, the NDC must be loaded into the First Data Bank System. Listing subject to change. Check the Passport Health Plan website for updates. Generic Drug Description
Multivitamins, therapeutic with minerals

Common Brand Name**

(if available) Thera-M

Brand/Generic
Generic Generic

NDC
10939026011 37205018581

Manufacturer
MCKESSON LEADER

**Generics preferred when available. Unit dose only long-term care setting.

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