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
Artificial Tears
Cetirizine (Zyrtec)
Cetirizine and Pseudoephedrine (Zyrtec-D)
Cherry syrup
Clemastine Fumarate (Tavist Allergy)
Loratadine (Claritin)
Loratadine and Pseudoephedrine (Claritin-D, Alavert)
Diphenhydramine (Benadryl)
Chlorpheniramine (Chlortrimeton)
Dextromethorphan (DM)
Brompheniramine and Phenylephrine (Dimetapp)
Brompheniramine and Phenylephrine (Dimetapp DM)
Guaifenesin (generic for many brands, Mucinex)
Guaifenesin / Codeine Phosphate (Cheratussin AC syrup)
Guaifenesin / Dextromethorphan (Mucinex DM)
Guaifenesin/Dm/Pseudoephedrine (40PSE-400GFN-20DM)
Guaifenesin / Pseudoephedrine HCL (Mucinex D)
Q-Dryl liquid
Saline solution (Ocean Spray)
Dextromethorphan (Benylin, Robitussin)
Ketotifen fumerate / Alaway / Zaditor / Eye itch relief
Naphazoline Hcl/Glycerin (Clear Eyes Redness Relief, Redness Reliever)
Naphazoline Hcl/Pheniramine (Naphcon-A)
Oxymetazoline HCL (nasal decongestant spray, 12 hour nasal sparay)
Phenylephrine/Brompheniramine (Child Wal-Tap Cold-Allergy)
Polyvinyl Alcohol (Artificial Tears)
Pseudoephedrine Hcl (Sudafed, Sudafed 12 Hour, Sudogest, Suphedrin)
Pseudoephedrine / Brompheniramine (Bromaline, Children's Cold & Allergy)
Pseudoephedrine HCL (Sudogest, 12 hour decongestant)
Pseudoephedrine / Triprolidine (Allerfrim)
Pyrilamine/PE/Dextromethorphan (Codal-DM, Codituss DM)
Refresh Lacri-Lube
Thera Tears, Refresh Tears
Topical Preparations – Generics Preferred
Abreva 10% cream
Hydrocortisone 0.5%, 1%, ointment / cream
Triple antibiotic cream / ointment
Bacitracin and Bacitracin Zinc antibiotic ointment
Bacitracin-Polymyxin
Neosporin antibiotic ointment /Antibiotic + pain relief cream (Neosporin + pain relief cream)
Updated 11/1/2014
Quantity Limits
Drug Name
Quantity Limits
Polysporin antibiotic ointment
Triple antibiotic plus ointmnt
Vitamin A & D (A+D ointment)
Iodine (Lugol's Strong Iodine Solution)
Gentian Violet
Salicylic Acid (wart remover)
Benzoyl Peroxide
Zinc Oxide (diaper rash ointment)
Chlorhexidine Gluconate (Periogard)
Other – Generics Preferred
Ammonium Lactate (Amlactin)
Benzoyl Peroxide
Capsaicin (Zostrix Diabetic)
Diphenhydramine HCL
Diphenhydramine HCL/Zinc Acet (anti-itch cream)
Electrolyte replacement fluids (Pedialyte) –
Glycerin
Levonorgestrel
Permethrin (Nix)
Piperonyl Butoxide / Pyrethrins
Sodium Chloride nebulizer solutions
Vaginal Antifungals – Generics Preferred
Clotrimazole (Gyne-Lotrimin)
Miconazole Nitrate (Monistat 7)
Pain Relievers
Acetaminophen, Acetaminophen Extra Strength (Tylenol)
Aspirin
Excedrin Migraine
Ibuprofen (Motrin)
Naproxen (Aleve)
Stomach Problems
Antacids
Acidoph / L.Bulg / Bif.B / S.Thermop (Bacid)
Aluminum Hydroxide gel
Calcium Carbonate (Antacid, Tums, Antacid Extra Strength)
Calcium Polycarbophil (Equalactin, Fibercon, Fiber-Lax, fiber tabs)
Cimetidine (Acid Reducer, Tagamet HB)
Gaviscon
Ranitidine (Zantac) Famotidine
(Pepcid AC) Omeprazole (generic
Prilosec OTC)
Omeprazole / Sodium Bicarbonate (generic Zegerid OTC)
Lansoprazole (generic Prevacid 24 hr)
Loperamide (generic Imodium A-D)
Bismuth Subsalicylate (Pepto-Bismol)
Polyethylene Glycol 3350 oral powder (Miralax)
Updated 11/1/2014
4000ml/30 days
Drug Name
Quantity Limits
Docusate Sodium (Colace)
Psyllium Seed (Metamucil)
Bisacodyl tabs (Ducolax)
Meclizine HCL
Simethicone Drops (Mylicon)
Sennosides (Senna Lax, Senokot, Ex-Lax)
Sennosides/Docusate Sodium (Doc-Q-Lax, Senna Plus, Stool Softener Plus Laxative)
Sodium Bicarbonate
Simethicone chew (Gas-X)
Bisacodyl suppositories (Bisac-Evac)
Glycerin Pediatric suppositories (Fleet Babylax)
Magnesium 250 mg tab, Magnesium Citrate (Citrate Of Magnesia)
Magnesium Hydroxide (Milk Of Magnesia), Epsom Salt
Na Biphosphate / Sodium Phosphate (Fleet Enema)
Topical Antifungals – Generics Preferred
Clotrimazole cream
Ketoconazole (Nizoral A-D shampoo)
Lotrimin AF
Miconazole Nitrate (Micatin)
Mycelex-7 OTC
Tinactin
Lamisil AT
Electrolytes
Oralyte
Magnesium Oxide
Mag 64
Vitamins and Supplements
AquaDEKs (claim to pay if diagnosis for Cystic Fibrosis 277.0 is on Rx claim or on member drug profile)
Calcium Carbonate / Vitamin D3 (Oysco, Oyst-Cal) / Ergocalciferol (Vitamin D2)
Calcium Citrate (Calcitrate)
Complete Formulation
Ferrous Sulfate (Children's Iron), Ferrous Fumarate
Magnesium Oxide (Mag-Ox)
Multivitamin or
Multivitamin with minerals
MVW Complete Formulation (claim to pay if diagnosis for Cystic Fibrosis 277.0 is on Rx claim or on member drug profile)
Pediatric Multiple Vitamin drops (children up to age 5)
Poly-Iron
Prenatal vitamins with folic acid
(see preferred listing on pharmacy PDL)
Niacin
Vitamin B complex
Vitamin D supplement (children up to age 5)
Updated 11/1/2014
Drug Name
Quantity Limits
Miscellaneous Supplies/Accessories
Blood Glucose Meters (Freestyle systems, Accu-chek systems)
1 per year
Accu-chek and Freestyle Blood Glucose Test Strips
Insulin users (100/25 days),
noninsulin users (50/25 days or
100/50 days), members less than
18 years old (200/30 days),
Gestational diabetes – (up to
300/30 days
Updated 11/1/2014
Drug Name
Quantity Limits
Pediatric mask (inhaler, assist device, accessory)
Lancets
200 per month
Lancing device
1 per every 6 months
Tablet cutter
1 per person
Needles, insulin disposable (ReliOn pen needles, Sure-Fine pen needles, Easy Comfort pen
needles, Advocate pen needles)
100 per month
Peak flow meter
Insulin syringes
125 per month
Urine Acetone Test, strips (Ketone Care Test Strips)
200 per month
Keto-Diastix Reagent Strips
200 per month
Urine Glucose Test, strips (Diastix Reagent)
200 per month
Urine Multiple Test (Uristix 4)
200 per month
Smoking Cessation
Nicotine Gum
720/30 days
Nicotine Lozenge
216/30 days
Nicotine Patch
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 1-800-5780603. You may also visit our website at http://www.passporthealthplan.com.
Updated 11/1/2014