Benefit. Over-the-Counter Items. WellCare provides New York state sponsored health insurance programs. These are free or low cost.

Transcription

1 Over-the-Counter Items Benefit WellCare provides New York state sponsored health insurance programs. These are free or low cost. Want more information about Medicaid Managed Care and Family Health Plus? Call New York Medicaid Choice at

2 You can get your overthe-counter medicines with a prescription written by your PCP. with a prescription written by your PCP TTY A WellCare representative is waiting to talk to you! WellCare provides New York state sponsored health insurance programs. These are free or low cost. Want more information about Medicaid Managed Care and Family Health Plus? Call New York Medicaid Choice at

3 ANALGESICS, ANTI-INFLAMMATORY AGENTS AND ANTIPYRETICS Acetaminophen Children's Silapap, Q Pap, Mapap, Children's Apap, Children's Pain & Fever Liquid, Solution 160mg/5mL Acetaminophen Mapap, Pain & Fever, Q Pap, Q Pap Extra, Tactinal 325mg QL ( Ea Per 31 Days) Acetaminophen Mapap, Pain & Fever, Q Pap, Q Pap Extra, Tactinal 500mg QL ( Ea Per 31 Days) Aspirin Aspir 81, Aspirin Ec, Aspir Low 81mg Aspirin Aspirin Childrens Chew 81mg Aspirin Aspirin Supp 300mg, 600mg Aspirin Aspirin 325mg Ibuprofen Children's Ibuprofen, Ibu Drops, Infant's Ibuprofen Susp 40mg/mL Ibuprofen Children's Ibuprofen Susp 100mg/5mL Ibuprofen Ibuprofen 200mg ANTIHISTAMINE DRUGS Chlorpheniramine Maleate Chlorpheniramine Maleate, Aller Chlor, Allergy 4mg Diphenhydramine HCl Diphenhydramine HCl, Allergy Relief, Banophen, Diphenhist, Caps 25mg/50mg Q Dryl Diphenhydramine HCl Diphenhydramine HCl, Banophen, Benadryl Allergy Childrens, Diphenhist, Q Dryl, Liquid 12.5mg/5mL Siladryl Cetirizine HCl Cetirizine HCl Syrup 5mg/5mL QL ( ml Per 31 Days) Cetirizine HCl Cetirizine HCl Childrens, Children's All Day Allergy, Solution 1mg/mL QL ( ml Per 31 Days) Children's Allergy Relief Cetirizine HCl Cetirizine HCl, All Day Allergy 5mg, 10mg Fexofenadine HCl Fexofenadine HCl 60mg, 180mg Loratadine Allergy Relief, Children's Loratadine, Loratadine Hives Syrup 5mg/5mL QL ( ml Per 31 Days) Relief, Children's Allergy Relief Loratadine Loratadine, Allergy, Allergy Relief 10mg Loratadine Allergy Tab Rapdis 10mg OTC Items Benefit 1 OTC Items Benefit 2

4 ANTHELMINTICS Pinworm Treatment, Pyrantel Pyrantel Pamoate Susp 144mg/mL Pamoate, Reese Pinworm COLD & COUGH PREPARATIONS/EXPECTORANTS - SEE ADDITIONAL LIST BELOW Pseudoephedrine HCl Pseudoephedrine HCl, Sudogest 30mg, 60mg Pseudoephedrine HCl/ Triprolidine HCl Pseudoephedrine HCl/ Triprolidine HCl Cetirizine HCl/ Pseudoephedrine HCl ER Fexofenadine HCl/ Pseudoephedrine HCl Loratadine/Pseudoephedrine Sulfate Loratadine/Pseudoephedrine Sulfate Guaifenesin Guaifenesin Silafed Actanol, Aprodine, Genac, Tri Afed Allergy/Head Cold Syrup 30mg/5mL; 1.25mg/5mL 60mg; 2.5mg Cetirizine Pseudoephedrine Tab ER 12H 5mg; 120mg Allegra D 12 Hour Tab ER 12H 60mg; 120mg Loratadine D, Allergy Relief Nasal Decongest, Alavert, Allergy Congestion Relief Allergy Relief And Decogestant, Clear Atadine D Guaifenesin, Q Tussin, Robafen, Siltussin Sa Guaifenesin, Mucus Relief, Chest Congestion Relief Tab 12 Tab 24 Syrup 5mg; 120mg 10mg; 240mg 100mg/5mL 200mg, 400mg COUGH PRODUCTS LIMITED TO THESE TRADE NAMES APAP = Acetaminophen DM = Dextromethorphan HBR PSE = Pseudoephedrine HCl CPM = Chlorpheniramine PE = Phenylephrine HCl Brompheniramine Maleate / PE / DM Dexchlorpheniramine Maleate / PSE / Chlophed HCl Children's Cold & Cough, Dimaphen DM, Rynex DM Vanacof Solution Liquid 1mg 2.5mg 5mg/5mL 1mg 30mg 12.5mg/5mL Dextromethorphan Polistirex Delsym Susp ER 12H 30mg/5mL DM Robitussin Pediatric Cough Syrup 7.5mg/5mL DM / APAP / CPM Children's Mapap Cough Sinus Oral Susp 5mg 160mg 1mg/5mL DM / CPM Dimetapp Long Acting, Robitussin Long Acting Liquid DM / PE / CPM Corfen DM, Nohist DM Liquid DM / PE / CPM De Chlor DM, Tri Dex PE Syrup 7.5mg 1mg/ 5mL 15mg 10mg 4mg/5mL 15mg 10mg 2mg/5 ml OTC Items Benefit 3 OTC Items Benefit 4

5 DM / PSE / Brompheniramine Brotapp, Q Tapp DM Elixir DM / PSE / CPM Kidkare, Pedia Relief Cough Cold, Pediatric Cough Cold Liquid DM / PSE / CPM Mesehist DM Syrup Guaifenesin / Codeine Phosphate Guaifenesin / DM Guaifenesin / DM Guaifenesin / DM Cheratussin Ac, Guaifenesin Codeine, Iophen C NR Diabetic Siltussin DM, Iophen DM NR, Siltussin DM Das Cough ula, Diabetic Tussin DM, Child Mucus Relief Cough, Mucinex Fast Max DM Max Diabetic Tussin DM, Diabetic Tussin Max Cough, Extra Action Cough, Q Tussin DM, Robafen DM Clear, Robitussin Cough Chest Cong DM, Siltussin DM Liquid Liquid Liquid Syrup 5mg 15mg 1mg/5mL 5mg 15mg 1mg/5mL 15mg 15mg 2mg/5mL 100mg 10mg /5mL 100mg 10mg /5mL 200mg 10mg /5mL 100mg 10mg /5mL Guaifenesin / DM Mucosa DM, Refenesen DM Tablet 400mg 20mg Guaifenesin / DM / PE Robafen CF Liquid 100mg 10mg 5mg/5mL Guaifenesin / PE Despec, Rescon GG Liquid 100mg 5mg /5mL PSE / Codeine / CPM Phenylhistine DH Liquid 30mg 10mg 2mg/5mL PSE / Codeine Phos / Cheratussin DAC Guaifenesin DIABETIC THERAPY AND SUPPLIES Syrup 30mg 10mg 100mg/5mL Insulin Regular, Human Humulin R, Novolin R Solution 100 unit/ml QL (60.00 ml Per 31 Days) NPH, Human Insulin Isophane Humulin N, Novolin N Susp 100 unit/ml QL (60.00 ml Per 31 Days) NPH, Human Insulin Isophane/ Insulin Regular, Human Humulin 70/30, Novolin 70/30 Susp NPH, Human Insulin Isophane Humulin 70/30 Pen Insuln Pen 30 unit/ml; 70 unit/ml 30 unit/ml; 70 unit/ml QL (60.00 ml Per 31 Days) QL (60.00 ml Per 31 Days) NPH, Human Insulin Isophane Humulin N U 100 Pen Insuln Pen 100 unit/ml QL (60.00 ml Per 31 Days) Insulin Admin. Supplies Novopen 3 Insuln Pen Dextrose Glucose Chew 4gm Lancing Device Lancing Device Each OTC Items Benefit 5 OTC Items Benefit 6

6 Lancets Lancets Each Blood Sugar Diagnostic Blood Sugar Diagnostic Blood Sugar Diagnostic Blood Sugar Diagnostic, Drum Type Accu Chek [Active, Aviva Plus, Comfort Curve, Smartview] Strips Freestyle Insulinx Blood Glucose Test; Lite Test Strips Precision Xtra Blood Glucose Test Strips Accu Chek Compact Strip, Accu Chek Compact Drum Strips Strip Strip Strip Strip QL ( Ea Per 31 Days) QL ( Ea Per 31 Days) QL ( Ea Per 31 Days) QL ( Ea Per 31 Days) Urine Acetone Test Strips Ketostix Strip QL ( Ea Per 31 Days) Urine Glucose Test Strips Clinistix, Diastix Strip QL ( Ea Per 31 Days) Blood Glucose Meter Accu Chek Nano Smartview, Freestyle Insulinx Blood Glucose Each QL (2.00 Ea Per 365 Days) Monitoring System, Precision Xtra Blood Glucose Meter Accu Chek Aviva Plus, Freestyle Freedom Lite, Freestyle Lite Blood Kit QL (2.00 Ea Per 365 Days) Glucose Monitoring System Blood Glucose Meter, Drum Type Accu Chek Compact Plus Care Kit Kit QL (2.00 Ea Per 365 Days) Blood Glucose Calib. Control Accu Chek Active Glucose Sol, Accu Chek Cmfrt Curve Soln, Solution Medisense H M L Control Soln Blood Glucose Calibration Control High And Low Accu Chek Aviva Each Blood Glucose Calibration Control Solution, Normal Blood Glucose Calibration Control Solution, High And Normal EENT DRUGS, MISCELLANEOUS Cromolyn Sodium Ketotifen Fumarate Polyvinyl Alcohol Sodium Chloride For Inhalation Accu Chek Active Glucose, Accu Chek Cmfrt Curve Accu Chek Compact Blue Cromolyn Sodium Ketotifen Fumarate, Alaway, Eye Itch Relief, Zaditor Artificial Tears Combo. Pkg Bottle Nasal Spray/ Pump Ophthalmic Solution Ophthalmic Solution 5.2mg/act 0.025% Broncho Saline Aerosol 0.9% 1.4% QL (15.00 ML per 31 days) OTC Items Benefit 7 OTC Items Benefit 8

7 ELECTROLYTES & MISCELLANEOUS NUTRIENTS Niacin Niacin 50mg, 100mg, 250mg, 500mg Niacin Niacin SR Capsule ER 500mg Niacin Niacin TR Tablet ER 500mg Calcium Carbonate Calcium Carbonate 1250mg, 1500mg, 6500mg Calcium Carbonate Cal Lac Caps 500mg Calcium Carbonate Calcium Carbonate Susp 1250mg/5mL Calcium Carbonate/ Cholecalciferol (Vitamin D3) Calcium Carbonate/ Cholecalciferol (Vitamin D3) Calcium With Vitamin D Chew 500mg Calcium Carbonate/Vitamin D 600mg; 400 unit Calcium Lactate Calcium Lactate 648mg Magnesium Oxide Magnesium Oxide Sodium Phos, M Basic D Basic/Potassium Phos, M Basic D Basic Neutra Phos Powder 250mg, 400mg, 420mg, 500mg 250mg/75mL; 278mg/75mL; 164mg/75mL Zinc Sulfate Zinc Sulfate 220mg Electrolyte, Oral Oralyte, Oralyte Freezer Pops Solution 35meq/l; 25gm/l; 20meq/l; 45meq/l; 7.8mg/l GASTROINTESTINAL DRUGS - ANTINAUSEANTS, LAXATIVES, H2-ANTAGONISTS, PROTON-PUMP INHIBITORS Meclizine HCl Meclizine HCl, Travel Motion Sickness 12.5mg Meclizine HCl Meclizine HCl, Medi Meclizine 25mg Meclizine HCl Meclizine HCl, Travel Sickness Chew 25mg Sorbitol Sorbitol Solution 70% Docusate Calcium Docusate Calcium Caps 240mg Docusate Sodium Doc Q Lace, Dok, Stool Softener Caps 100mg, 250mg Docusate Sodium Dok, Stool Softener 100mg Psyllium Husk Metamucil Caps 0.52gm Psyllium Seed (With Sugar) Metamucil Wafer Psyllium Seed (With Sugar) Metamucil Smooth Texture, Reguloid Powder 28.3% Ranitidine Ranitidine HCl, Acid Reducer, Acid Control 75mg OTC Items Benefit 9 OTC Items Benefit 10 QL ( ml per 31 days)

8 Cimetidine Cimetidine 200mg Famotidine Famotidine, Acid Controller 10mg Aluminum Hydroxide Aluminum Hydroxide Susp 320mg/5mL Omeprazole Omeprazole Tablet DR 20mg HEMATINICS & BLOOD CELL STIMULATORS Ferrous Sulfate Ferrous Sulfate Elixir 220mg/5mL Ferrous Sulfate Ferrous Sulfate Solution 15mg/mL Ferrous Sulfate Ferrous Sulfate 325mg Ferrous Sulfate Ferrous Sulfate Tablet DR 324mg, 325mg Ferrous Sulfate Ferrous Sulfate, Slow Release Iron Tablet ER 160mg Iron Polysaccharides Complex Poly Iron 150, Polysaccharide Iron Caps 150mg MEDICAL SUPPLIES Peak Flow Meter Peak Flow Meter, Peak Air Adult/ Pediatric, Personal Best Full Range, Personal Best Low Range, Pocket, Pocketpeak Low Range, Pocketpeak /Universal Range Each Nebulizer Accessories Optichamber Face Mask Small / Medium / Large Each Hearing Aid Battery Hearing Aid Battery Misc MISCELLANEOUS - VAGINALS Clotrimazole Vaginal Clotrimazole, Clotrimazole 3 Day, Gyne Lotrimin Cream 1%, 2% Miconazole Vaginal Gyne Stat 7, Miconazole 7, Athletic Foot Cream Cream 2% Miconazole Vaginal Miconazole Nitrate, Miconazole 7, Monistat 7 Supp 100mg Miconazole Vaginal Miconazole 3 Combo Pack, Monistat 3 Combo Pack Kit 200mg 2% Miconazole Vaginal 3 Day Vaginal, Miconazole 3, Miconazole 3 Cream 4% Miconazole Vaginal Monistat 7 Combination Pack, M Zole Dual Pack Kit 100mg 2% QL (2.00 each per 365 days) QL (2.00 each per 365 days) OTC Items Benefit 11 OTC Items Benefit 12

9 MISCELLANEOUS - TOPICALS Terbinafine HCl Topical Clotrimazole Topical Clotrimazole Topical Miconazole Topical Hydrocortisone Hydrocortisone Terbinafine HCl, Antifungal, Athlete's Foot Anti Fungal, Clotrimazole, Lotrimin AF, Mycelex Anti Fungal, Athlete's Foot, Athletic Foot Cream Antifungal Cream, Miconazole Nitrate Hydrocortisone Maximum, Hydrocortisone Maximum Plus 12 Moisturizers, Hydroskin Hydrocortisone Cream 1% Solution 1% Cream 1% Cream 2% Cream 1% Lotion, Ointment 1% Benzoyl Peroxide Benzoyl Peroxide Gel, Lotion 5% Benzoyl Peroxide Benzoyl Peroxide, Acne 10 Gel, Lotion 10% Salicylic Acid Clear Away, Corn Removers, One Step Plantar Wart Remover, One Step Wart Pads 40% Remover Salicylic Acid Compound W, Duofilm Liquid 17% Salicylic Acid Compound W Maximum, Sal Plant Gel 17% Salicylic Acid Salactic Film, Wart Off Solution 17% Salicylic Acid/Collodion, Flexible Freezone Liquid 17.6% Capsaicin Capsaicin Cream 0.025% Chlorhexidine Gluconate Chlorhexidine Gluconate Liquid 4% Permethrin Permethrin, Lice Treatment Lotion 1% QL (60.00 ml Per 31 Days) Ammonium Lactate Ammonium Lactate, Amlactin Lotion, Cream SLEEP-AIDS Diphenhydramine HCl Diphenhydramine HCl 25mg 12% QL ( gm Per 31 Days) OTC Items Benefit 13 OTC Items Benefit 14

10 SMOKING CESSATION AGENTS Nicotine Nicotine, Nicotine Patch, Nicoderm CQ, NTS Nicotine Gum, Nicorelief, Nicotine Polacrilex Nicorette VITAMINS - MULTIIVITAMIN, PEDIATRIC, PRENATAL, SINGLE-ENTITY Patch Multivitamin Multivitamin Multivitamin Poly Vitamin Drops Solution Multivitamins with Iron Poly Vitamin/Iron Drops Solution Pediatric Multivitamins A,C, & D3 No.21 Pediatric Multivitamins A,C, & D3 No.21 Tri Vitamin Tri Vitamin 7mg/24hr, 14mg/24hr, 21mg/24hr QL ( Ea Per 365 Days) Gum 2mg, 4mg QL ( Ea Per 365 Days) Solution Solution Iron/Vitamins A,C, & D Tri Vi Sol/Iron Solution 37.5mg; 20mg; 1mg; 0.1mg; 2mg; 1.5mg; 5000 unit; 400 unit 35mg/mL; 50mcg/mL; 2mcg/mL; 8mg/mL; 3mg/mL; 0.4mg/mL; 0.6mg/mL; 0.5mg/mL; 1500 unit/ml; 400 unit/ml; 5 unit/ml 60mg/mL; 4.5mcg/mL; 10mg/mL; 13.5mg/mL; 1.05mg/mL; 1.2mg/mL; 1.05mg/mL; 2500 unit/ml; 400 unit/ml; 11 unit/ml 35mg/mL; 400 unit/ml; 1500 unit/ml 35mg/mL; 1500 unit/ml; 400 unit/ml 35mg/mL; 10mg/mL; 1500 unit/ml; 400 unit/ml OTC Items Benefit 15 OTC Items Benefit 16

11 Prenatal Vitamins/Ferrous Fumarate/Folic Acid Prenatal Vitamins/Ferrous Fumarate/Folic Acid Prenatal Prenavite Vitamin A Vitamin A Caps Thiamine Vitamin B 1, Thiamine HCl 100mg; 0; 200mg; 400 unit; 4mcg; 27mg; 0.8mg; 18mg; 2.6mg; 1.7mg; 1.5mg; 4000 unit; 11mg; 25mg 120mg; 0; 200mg; 400 unit; 8mcg; 28mg; 800mcg; 20mg; 2.6mg; 1.7mg; 1.8mg; 30 unit; 4000 unit; 25mg 8000 unit, unit 50mg, 100mg, 250mg Thiamine Mononitrate Vitamin B 1 100mg Pyridoxine Vitamin B 6, Pyridoxine 25mg, 50mg, 100mg, 250mg, Pyridoxine Vitamin B 6, Pyridoxine Tablet ER 200mg Vitamin B Complex C Vitamin B Complex C Caps Folic Acid Folic Acid 300mg; 10mg; 50mg; 5mg; 10.2mg; 15mg 200mcg, 400mcg, 800mcg, 1mg Cyanocobalamin Vitamin B mcg OTC Items Benefit 17 OTC Items Benefit 18

12 Notes Notes

13 110 Fifth Avenue, 3rd Floor New York, NY NY020878_CAD_OTC_ENG State Approved WellCare 2013 NY_11_12