Hawaii OTC Formulary

Summary of Drug Classes
Cough & Cold
Gastrointestinal (H2 & PPI)
Iron Supplement
Miscellaneous, Other
Miscellaneous, Topical
Schedule V OTC Products

Acetaminophen (all forms)
Aspirin (including buffered, enteric coated, chewable
Ibuprofen (all forms)
Phenazopyridine tablets

Antibacterials / Antifungals, Miscellaneous
Bacitracin (all forms)
Clotrimazole 1% cream, solution
Miconazole (all forms)
Polymixin B sulfate, bacitracin zinc, neomycin (single entity and combination/all forms)
Povidone-iodine (all forms)
Terbinafine 1% cream
Tolnaftate (all forms)

Bismuth subsalicylate liquid
Kaolin with pectin liquid
Liquid pediatric electrolyte replacement (i.e., Pedialyte)
Loperamide (all forms)

Hamaelis/glycerin medicated pads (i.e. Tucks)
Hydrocortisone cream
Pramoxine ointment
Shark liver oil combinations (all forms/i.e., Preparation H)

Aluminum hydroxide (all forms)
Magnesium and aluminum hydroxides with/without simethicone (all forms)
Sodium bicarbonate (tablets)

Cough & Cold
Brompheniramine with pseudoephedrine (tablets, liquid)
Chlorpheniramine (all forms)
Diphenhydramine (all forms)
Guaifenesin with/without dextramethorphan (all strengths/liquid)
Loratadine with or without a decongestant (for age 20 years old & younger; for age 61 years old & older; age 21 through 60 continue to require a PA)*
*Effective July 29, 2004, specified age categories for Loratidine will not require a PA.
Zyrtec OTC (see PA criteria)
Meclizine 12.5 and 25 mg tablets
Pseudoephedrine (all forms)

H-2 antagonists (covered without PA if correct diagnosis code entered on claim)
Cimetidine tablets
Famotidine tablets (Pepcid AC--only package sizes of 50 or larger; Mylanta AR--only package sizes of 30 or larger)
Nizatidine (Axid--only 75 mg in package sizes of 30 or larger)
Ranitidine (Zantac--only 75 mg in package sizes of 20 or larger)
Proton Pump Inhibitor
Prilosec OTC**
**Effective February 17, 2004

Iron Supplement
Ferrous sulfate (all forms)

Bisacodyl (all forms)
Bowel Evacuation Kits
Citrate of Magnesia liquid
Docusate calcium or sodium (DSS/all forms)
DSS with casanthranol (all forms)
Glycerin suppositories
Milk of Magnesia (all forms)
Phosphate enema (pediatric, adult)
Psyllium (all forms)
Senna (all forms)
Fleet phosphosoda

Calcium carbonate, all forms (including calcium carbonate + vitamin D)
Magnesium tablets, liquid
Niacin tablets
Phosphate tablets and Neutra-Phos powder
Zinc tablets, capsules

Miscellaneous, Other
Activated charcoal (all forms)
Benzoyl peroxide (all forms)
Contraceptives (all forms)
Gelatin capsules
Glucose tablets (all strengths)
Insulin (all forms)
Ipecac syrup
Permethrin (all forms; i.e., Nix)
Nasalcrom 40 mg/ml nasal spray
Sodium Chloride (for diluting bronchodilator solutions)

Miscellaneous, Topical
Denorex extra-strength shampoo
Denorex shampoo
Estar gel
Hydrocortisone cream, ointment
Sunscreen 8 (PA Required)

Artificial tears ointment (regular or preservative-free)
Artificial tears solution (regular or preservative-free)

Carbamide peroxide

Schedule V OTC Products (Robitussin AC, Dihistine DH, etc.)

Pediatric Multivitamins, including those with fluoride (covered for ages 12 years and younger)
Multivitamins Covered for patients with ESRD**
Multivitamins Covered for pregnant** and lactating** women
Vitamin C (all forms covered for UTI**)
Vitamin B12 (covered for specific deficiencies**)
Long-Term Care Recipients can receive one Multivitamin every day (diagnosis code is not needed for multivitamins for LTC recipients)