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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