Over-the-Counter Drug List
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- Moris Dwight Maxwell
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1 Over-the-Counter Drug List This list includes some of the over-the-counter drugs covered by Passport Health Plan. To get these covered, you must have a prescription from your doctor. NOTE: Generic is always preferred unless only a brand version exists; brand name given only for informational purposes. DRUG NAME Cough, Cold and Allergy Generics Preferred Artificial Tears Brompheniramine/Phenylephrine/DM HCl (Dimetapp DM) Brompheniramine/Pseudoephedrine HCl drops (Dimetapp) Cetirizine HCl (Zyrtec) Chlorpheniramine maleate (Chlorphen SR) Clemastine fumarate (Dayhist) Dextromethorphan (DM) Diphenhydramine HCl (Benadryl) Fluticasone propionate nasal spray (Flonase) Guaifenesin (generic for many brands, Mucinex) Guaifenesin / Codeine phosphate (Cheratussin AC syrup) Guaifenesin / Dextromethorphan (Mucinex DM) Guaifenesin / Pseudoephedrine HCl (Mucinex D) Guaifenesin/DM/Pseudoephedrine (40PSE-400GFN-20DM) Guaifenesin/Phenylephrine/Acetaminophen (Mucinex Sinus-Max) Hypromellose eye drops (Genteal Mild eye drops) Ketotifen fumarate eye drops (Alaway eye drops) Little Remedies Elderberry Fruit Cough-Immune suspension Little Remedies Honey Cough suspension Loratadine (Claritin) Loratadine/Pseudoephedrine HCl (Claritin-D 24 hour) Lubricant eye drops (Freshkote, Hypotears, Tears Naturale Forte) Mineral Oil/Petrolatum, White (Lubcricant eye ointment) Naphazoline HCl/Glycerin eye drops (Redness Reliever eye drops) Oxymetazoline HCl nasal spray Phenylephrine HCl (Sudafed PE) Pseudophedrine HCl (Sudafed) Refresh eye drops (Classic Eye, Optive Advanced, Optive Sensitive) Sodium chloride nasal spray (Ocean Saline nasal spray) Systane eye drops Triamcinolone acetonide 55mcg/act nasal spray Last Updated: 1/14/16
2 Topical Preparations Generics Preferred Abreva 10% cream Ammonium Lactate lotion (AmLactin) Bacitracin ointment Bacitracin-Polymixin ointment Benzocaine/Resocinol vaginal cream (Vagisil) Benzoyl peroxide wash, foam, cream Calamine/Pramoxine lotion Capsaicin cream, gel, patch DermaCerin cream Diphenhydramine HCl gel, spray (Benadryl) Eucerin cream First Aid antiseptic spray Glycerin shampoo Hydrocortisone cream, lotion, ointment Hydrocortisone/ Aloe Vera/Vit E/Vit A&D cream Hydrocortisone/Aloe Vera cream Hydrocortisone/Oatmeal/Aloe/Vit E cream Lactic Acid liquid Menthol gel (Mineral Ice) Neosporin ointment Permethrin 1% cream, lotion (Lice Treatment) Phenylephrine suppositories Pyrethrin (Lice Treatment) Rid Lice Kits and shampoo Salicylic Acid solution (Wart Remover) Selenium Sulfide 1% shampoo Sodium Hypochlorite solution (Dakin s 0.5%) Vitamin A&D ointment Zinc oxide ointment
3 Topical Antifungals Generics Preferred Butenafine HCl cream Clotrimazole cream Gentian Violet solution Miconazole nitrate spray, cream, ointment Terbinafine HCl cream, spray Tolnaftate powder Vaginal Antifungals Generics Preferred Clotrimazole (Gyne-Lotrimin) Miconazole nitrate (Monistat) Pain Relievers Generics Preferred Acetaminophen (Tylenol) Acentaminophen/Aspirin/Caffeine (Excedrin Migraine) Aspirin Aspirin/Calcium Carbonate/Mag Carb/Mag Ox (Bufferin) Benzocaine/Menthol lozenge, spray (Chloraseptic, Cepacol Sore Throat) Ibuprofen (Motrin, Advil) Menthol cough drops (Halls) Naproxen Sodium (Aleve) Stomach Problems Generics Preferred Antacids Aluminum hydroxide suspension Aluminum hydroxide/magnesium carbonate (Gaviscon) Benefiber packets, powder Bisacodyl (Ducolax) Brewer s Yeast (Fibercel) Bismuth subsalicylate (Pepto-Bismol) Calcium carbonate/magnesium hydroxide/simethicone (Rolaids Advanced, Maalox) Calcium carbonate/simethicone (Gas-X with Maalox Ex St) Castor oil Cellulose Fiber (UniFiber) Cimetidine (Tagamet) Bisacodyl suppositories Docusate Calcium
4 Docusate sodium Docusate sodium/benzocaine enema (Enemeez Mini) Famotidine (Pepcid) Glycerin suppositories (Fleet) Hydrocortisone suppositories Inulin (Fiber Choice gummies) Loperamide/Simethicone (Immodium) Magnesium citrate Magnesium hydroxide (Milk of Magnesia) Magnesium hydroxide/alumninum hydrox/simethicone (MI-ACID) Magnesium oxide (Uro-Mag) Meclizine HCl (Dramamine) Methylcellulose powder (Citrucel) Mineral oil Omeprazole (Prilosec) Polycarbophil (FiberCon) Polyethylene Glycol 3350 oral powder, granules (Miralax) Potassium bitartrate/sodium bicarbonate suppositories (Ceo-Two) Probiotics (see preferred listing on pharmacy PDL) Psyllium (Metamucil) Psyllium/Sennosides (SennaPrompt) Ranitidine HCl (Zantac) Saline solution enema Sennosides tablets, suspension (Senna) Sennosides/Docusate sodium (Doc-Q-Lax, Senokot-S) Simethicone (Gas-X) Simethicone drops (Mylicon) Sodium bicarbonate Sodium phosphate enema (Fleet Enema)
5 Electrolytes Solution Generics Preferred Oralyte solution Pedialyte solution 4000mL/30 days 4000mL/ 30 days Vitamins and Supplements Generics Preferred Calcium ascorbate Calcium carbonate (Tums, Florical) Calcium carbonate/citrate/vit D3 (Citracal+D ER) Calcium carbonate/vit D (Oysco, Oyst-Cal, Caltrate 600+D soft chewables) Calcium carbonate/vit D3/Minerals (Caltrate 600+D3 + Minerals) Calcium formulations (see preferred listing on pharmacy PDL) Carbonyl Iron formulations (see preferred listing on pharmacy PDL) Cyanocobalamin (Vit B-12) Ferrous fumarate Ferrous gluconate Ferrous sulfate ICAPS multivitamin L-Carnitine Levomefolate calcium Multivitamin (see full list on pharmacy PDL) Multivitamin with minerals (see preferred listing on pharmacy PDL) Niacin Poly-Iron (NovaFerrum 50) Poly-Vi-Sol, Poly-Vi-Sol/Iron drops Prenatal vitamins (see preferred listing on pharmacy PDL) Pyridoxine HCl (Vit B-6) Thiamine HCl Vit A Vit B Complex w/vit C Vit C Zinc gluconate Zinc sulfate
6 Other Generics Preferred Dextrose (Glutose 15 gel) Doxylamine succinate (Unisom) Fluoride Sodium solution (Phos-flur oral rinse) Humulin 70/30 Insulin NPH (Humulin N) Insulin Regular (Humulin R) Levonorgestrel Lice Egg Remover Kit Magnesium sulfate crystals (Epsom Salt) Orlistat (Alli) Pyrantel pamoate (Pin-X) Saliva Substitute liquid (Biotene Oral Balance) Miscellaneous Supplies/Accessories Alcohol antiseptic pads Accu-Chek Blood Glucose Meter Accu-Chek Blood Glucose Test Strips 1/365 days Insulin users (100/25 days) Non-insulin users (50/25 days or 100/50 days) 18 years old (200/30 days) Gestational diabetes (300/30 days) Insulin syringes (see preferred listing on pharmacy PDL) Ketone test strips (Keto-Diastix Reagent strips) Lancets Lancing device Peak Flow Meter Pediatric Mask/inhaler assist device Pen needles Urine albumin test kit Urine glucose test strips (Diastix) Urine multiple test (Uristix 4) Tablet cutter 125 / 30 days 200 / 30 days 200 / 30 days 1/180 days 100 / 30 days 200 / 30 days 200 / 30 days 1/lifetime
7 Smoking Cessation Generics Preferred Nicotine Gum Nicotine Lozenge Nicotine Patch 720/30 days 216/30 days 30/30 days Not Covered Alternative and herbal products Cosmetic products Hair growth products Questions? If you have any questions about over-the-counter medicines, please call Member Services at You may also visit our website at
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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,
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How To Pay For Medical Expenses
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Sample eligible expenses Personal Care Account (PCA), Health Savings Account (HSA) and Flexible Spending Account (FSA)
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