OVER-THE-COUNTER DRUG LIST
The following over-the-counter (OTC) items are a covered benefit of the Health Plan and are also subject to the generic mandate policy. All OTC prescriptions will require a prescription from a licensed prescriber to be considered a covered benefit of the pharmacy program. Only those items listed are considered a covered benefit.
|
BRAND (TRADE) NAME |
DRUG NAME & STRENGTH |
|
|
|
|
1. ACTIFED TAB |
TRIPROLIDINE/PSEUDOEPHEDRINE TAB |
|
2. ACTIFED SYRUP |
TRIPROLIDINE/PSEUDOEPHEDRINE SYRUP |
|
3.
AMPHOJEL |
ALUM. HYDROXIDE
4% GEL |
|
4. ASPIRIN TAB |
ASPIRIN 325MG TAB |
|
5. BABY ASPIRIN CHEW TAB |
ASPIRIN 81MG TAB |
|
6. BACIGUENT |
BACITRACIN 500U/GM OINT |
|
7. BENADRYL CAP |
DIPHENHYDRAMINE 25MG CAP |
|
8. BENADRYL ELIXIR |
DIPHENHYDRAMINE 12.5MG/5ML ELXIR |
|
9.
BENYLIN
SYRUP |
DIPHENHYDRAMINE
CMPD SYRUP |
|
10. BETADINE OINT |
POVIDONE IODINE |
|
11. BETADINE SOLN |
POVIDONE IODINE |
|
12. BUFFERIN TAB |
ASPIRIN (BUFFERED) 325MG TAB |
|
13. CENTRUM JR Prior Authorization Required – Lead Poisoning Only |
MULTIVITAMINS W/IRON |
|
14. CHILDRENS MOTRIN SUSP |
IBUPROFEN 100MG/5ML SUSP |
|
15. CHLOR-TRIMETON TAB |
CHLORPHENARAMINE MALEATE 4MG TAB |
|
16. CHLOR-TRIMETON TAB |
CHLORPHENARAMINE MALEATE 8MG CAP |
|
17. CHLOR-TRIMETON |
CHLORPHENARAMINE MALEATE 12MG CAP |
|
18. CLARITIN 10MG TAB/ REDITAB |
LORATADINE TAB |
|
19. CLARITIN 5MG/5ML SYRUP |
LORTATADINE SYRUP |
|
20. CLARITIN D –24 HR |
LORATADINE/PSEU TAB |
|
21. COLACE CAP |
DOCUSATE SODIUM 100MG CAP |
|
22. COLACE CAP |
DOCUSATE SODIUM 250MG CAP |
|
23. DELFIN FOAM |
CONTRACEPTIVE FOAM |
|
24. DIMETANE TAB |
BROMPHENIRAMINE 8MG TAB |
|
25. DIMETANE TAB |
BROMPHENIRAMINE 12MG TAB |
|
26. DIMETANE TAP |
BROMPHENIRAMINE 4MG TAB |
|
27. DIMETAPP TAB |
BROMPHENIRAMINE/PHENYLEPH. TAB |
|
28. DIMETAPP LIQ |
BROMPHENIRAMINE/PHENYLEPH LIQ |
|
29. DULCOLAX TAB |
BISACODYL 5MG TAB |
|
30. DULCOLAX SUPPOSITORY |
BISACODYL 10MG SUPP |
|
31. ECOTRIN TAB |
ASPIRIN EC 500MG TAB |
|
32. ECOTRIN TAB |
ASPIRIN EC 325MG TAB |
|
33. EMKO FOAM |
CONTRACEPTIVE FOAM |
|
34. FEOSOL TAB |
FERROUS SULFATE 325MG TAB |
|
35. FEOSOL ELIXIR |
FERROUS SULFATE 220MG/5ML ELIXIR |
|
36. FER-IN-SOL |
FERROUS SULFATE DROPS |
|
37. GYNE-LOTRIMIN CR |
CLOTRIMAZOLE VAGINAL 1% CR |
|
38. GYNE-LOTRIMIN TAB |
CLOTRIMAZOLE 100MG VAGINAL TAB |
|
39. CORTAID |
HYDROCORTISONE 0.5% |
|
40. HYTONE |
HYDROCORTISONE 1% CR |
|
41. INTERCEPT CR |
CONTRACEPTIVE CREAM |
|
42. KAOPECTATE SUSP |
KAOLIN/PECTIN SUSP |
|
43. KOROMEX II GEL |
CONTRACEPTIVE GEL |
|
44. LACRI-LUBE OPHTH OINT |
OPHTH. LUBRICANT OINT |
|
45. LATEX CONDOM (MALE) |
LATEX CONDOM
(MALE) |
|
46. LOTRIMIN CR |
CLOTRIMAZOLE 1%
CR |
|
47. MAALOX
TAB |
ALUMIN/MAG-OH
TAB |
|
48. MAALOX SUSP |
ALUMIN/MAG-OH
SUSP |
|
49. METAMUCIL POWDER |
PSYLLIUM POWDER |
|
50. MOISTUREL |
|
|
51. MONISTAT CR |
MICONAZOLE
VAGINAL 2% CR |
|
52. MOTRIN TAB |
IBUPROFEN 200MG TAB |
|
53. MYLANTA SUSP |
|
|
54. NEOSPORIN OINT |
TRIPLE ANTIBIOTIC OINT |
|
55. NIX SHAMPOO |
NIX |
|
56. ONE-A-DAY TAB |
MULTI-VITAMIN (ADULT) TAB |
|
57. ORTHO CR |
CONTRACEPTIVE CR |
|
58. ORTHO GYNOL CR |
CONTRACEPTIVE CR |
|
59. OSCAL TAB |
OYSTER SHELL CALCIUM W/VITAMIN D TAB |
|
60. PEDIALYTE |
PEDIATRIC ELECTROLYTES |
|
61. PEPTO BISMOL SUSP |
PINK BISMUTH SUSP |
|
62. PERI-COLACE CAP |
DOCUSATE
Na/CASANTHR CAP |
|
63. POLY-VI-SOL CHEW TAB |
MULTI-VITAMIN (CHILDRENS) CHEW TAB |
|
64. RAMSES GEL |
CONTRACEPTIVE GEL |
|
65. ROBITUSSIN SYRUP |
GUAIFENSESIN SYRUP |
|
66. ROBITUSSIN DM SYRUP |
GUAIFENESIN W/DM SYRUP |
|
67. SEMICID INSERT |
CONTRACEPTIVE SUPP |
|
68. SUDAFED TAB |
PSEUDOEPHEDRINE 30MG TAB |
|
69. SUDAFED TAB |
PSEUDOEPHEDRINE 60MG TAB |
|
70. TAVIST TAB |
CLEMASTINE 1.34MG TAB |
|
71. TEARS-NATURALLE |
METHYLCELLULOSE OPHTH DROPS |
|
72. TINACTIN CR |
TOLNAFTATE 1% CR |
|
73. TUMS |
CALCIUM CARBONATE |
|
74. TYLENOL DROPS |
ACETAMINOPHEN 100MG/ML DROPS |
|
75. TYLENOL ELIXIR |
ACETAMINOPHEN ELIXIR |
|
76. TYLENOL TAB/CAP |
ACETAMINOPHEN 325MG TAB/CAP |
|
77. TYLENOL CHEW TAB |
ACETAMINOPHEN 80MG CHEW TAB |
|
78. TYLENOL XS TAB/CAP |
ACETAMINOPHEN 500MG TAB/CAP |
|
79. VITAMIN B-1 TAB |
THIAMINE 100MG TAB |
|
80. VITAMIN B-6 TAB |
PYRIDOXINE 100MG TAB |