OTC Benefit Exclusions
These medications are excluded from coverage because they have a safe and effective over-the-counter equivalent members can purchase without a prescription. Exceptions are not available for these medications.
| Trade Name | Over-the-Counter Alternative |
|---|---|
| Topical Acne Medications: Benzoyl Peroxide Products 10% in strength and less and combinations (e.g. skin cleansers). Examples: Benzac® products, Brevoxyl® products, Desquam® products, Neobenz® products, Oscion® products,Triaz® products |
Benzoyl peroxide - various forms (store brand products) Clearasil® product, Foster® products, Neutrogena®, products Oxo® products, PanOxyl® products, ZAPZYT® products |
| Nasal Steroid Products: Products containing nasal inhaled forms of beclomethasone, budesonide, ciclesonide, flunisolide, fluticasone, mometasone, and triamcinolone alone or in combination with azelastine, such as; Beconase AQ®, Dymista®, Flonase®, Nasacort AQ®, Nasarel®, Nasonex®, Omnaris®, QNASL®, Rhinocort AQ®, Ticanase®, TicaSpray®, Veramyst® and Zetonna® |
Flonase Allergy Relief®, Nasacort Allergy 24HR®, Rhinocort Allergy Spray® and store brand products containing budesonide, fluticasone, and triamcinolone |
| Cough and Cold Products: products containing guaifenesin,chlorpheniramine, pseudoephedrine, phenylephrine,clemastine, dextromethorphan, and pyrilamine in equivalentover the counter doses. These include both single ingredientproducts and combination products. Examples: Ambid®products, Drexophed®products, Guaibid® products, Humibid®products, Tussi-Organidin® products |
Various store brand cough and cold products, Mucinex® products, Bromfed® products, Chlor-Trimeton® products, Drixoral®products, Robitussin® products |
| Non Sedating Antihistamines: products containing citirizine, desloratadine, fexofenadine, levocitirizne, and loratadine, alone or in combination with pseudoephedrine: such as Allegra®, Allegra-D®, Claritin®, Claritin-D®, Clarinex®, Clarinex-D®, Xyzal®, Zyrtec®, and Zyrtec-D® |
Alavert® All Day Allergy® Allegra® Allegra-D® Claritin® Claritin-D® Xyzal® Zyrtec® or; store brand products, containing citirizine, fexofenadine, loratidine, levocitirizine alone or in combination with pseudoephedrine |
| Ammonium lactate 12% cream | Amlactin® 12% cream |
| Antivert® 25mg tablets | Bonine® 25mg tablets |
| Cimetidine 200mg tablets | Tagamet® HB tablets |
| Clotrimazole 1% cream | Lotrimin AF® 1% cream, clotrimazole cream (various store brands) |
| Clotrimazole 1% solution | Clotrimazole solution (various store brands) |
| Diphenhydramine HCL 12.5mg elixir | Benadryl® elixir |
| Diphenhydramine HCL 50mg capsules | Sleepinal® 50mg capsules |
| Diphenhydramine HCL 25mg capsules | Benadryl® capsules, dihyphenhydramine 25mg (various store brands) |
| Dologesic® capsules | Aceta-Gesic® capsules |
| Famotidine 20mg tablets | Pepcid® AC Maximum Strength 20mg tablets |
| GlycoLAX® powder and packets | MiraLAX® powder |
| Hydrocortisone 0.5% cream | Cortaid® cream, hydrocortisone 0.5% (various store brands) |
| Hydrocortisone 1% ointment/cream/lotion | Cortaid® Maximum Strength ointment/cream, hydrocortisone 1% (various store brands) |
| Ibuprofen 100mg/5ml suspension | Childrens Motrin®, Childrens Advil® suspension |
| Ketotifen fumarate eye drops | AlawayTM, Refresh® eye itch relief, Zaditor® |
| Lac-hydrin® 12% cream/lotion | Amlactin® 12% cream lotion |
| Laclotion 12% lotion | Amlactin® 12% lotion |
| Lamisil® 1% solution | Lamisil® AT 1% solution |
| Lansoprazole 15mg capsules | Prevacid® 24HR capsules |
| Loperamide 2mg capsules | Immodium A-D® 2mg tablets, loperamide 2mg tablets (various store brands) |
| Lotrimin® 1% cream | Lotrimin® AF 1% cream, clotrimazole 1% cream (various store brands) |
| Meclizine HCL 12.5mg tablets | Dramamine® |
| Meclizine HCL 25mg tablets | Bonine® 25mg tablets |
| Mentax® 1% cream | Lotrimin® Ultra cream |
| Miconazole 3 200mg suppositories | Monistat-3® suppositories |
| MiraLAX® powder | MiraLAX® powder |
| Monistat 3® 200mg suppositories | Monistat-3® suppositories |
| Monistat Dual-Pak®1200mg | Monistat-1® combination pack |
| Monistat-Derm® 2% cream | Micatin® 2% cream |
| Motrin® 100mg/5ml suspension | Childrens Motrin® Childrens Advil® suspension |
| Mycelex® 1% cream | Lotrimin® AF 1% cream |
| Nasacort AQ® 55mcg/act | Nasacort® Allergy 24HR nasal spray |
| Niacor® 500mg tablets | Niacin 500mg tablets |
| Nexium® 20mg capsules | Nexium® 24HR |
| Oxytrol® 3.9mg/day patch (** Rx excluded for women only) | Oxytrol® For Women |
| Pepcid® 20 mg tablets | Pepcid AC® Maximum Strength 20mg tablets |
| Polyethylene glycol 3350 powder | MiraLAX® powder |
| Prevacid® 15mg capsules | Prevacid® 24HR capsules |
| Procto-Kit® 1% | Cortisone-10® external anal relief cream |
| Procto-Pak® 1% | Cortisone-10® external anal relief cream |
| Proctocort® 1% | Cortisone-10® external anal relief cream |
| Ranitidine 150mg tablets/capsules | Zantac® 150 Maximum Strength |
| Triamcinolone 55mcg/act | Nasacort® Allergy 24HR nasal spray |
| Vertin-32® 25mg tablets | Bonine® 25mg tablets |
| VSL #3® DS packet | VSL #3® DS packet |
| Xenical® 120mg capsules | Alli® 60mg capsules |
| Zaditor® eye drops | AlawayTM, Refresh® eye itch relief, Zaditor® |
| Zantac® 150mg tablets/capsules | Zantac® 150 Maximum Strength |
| Zantac® 150mg EFFER Dose tablets | Zantac® 150 Maximum Strength |
| Zegerid® 20mg capsules | Zegerid OTCTM |
