over-the-counter drug list - passporthealthplan.com

24
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 QUANTITY LIMITS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS ASPIRIN (ASPIR-TRIN EC 325 MG TABLET) ASPIRIN (ECOTRIN EC 325 MG TABLET) ASPIRIN/ACETAMINOPHEN/CAFFEINE (CVS MIGRAINE RELIEF CAPLET) ASPIRIN/ACETAMINOPHEN/CAFFEINE (EXCEDRIN EXTRA STRENGTH CAPLET) ASPIRIN/CALCIUM CARBONATE/MAGNESIUM (ASPIRIN/CALCIUM CARBONATE/MAG 325 MG TABLET) BUFFERIN 325 MG TABLET IBUPROFEN (INFANTS' MOTRIN 50 MG/1.25 ML) IBUPROFEN (WAL-PROFEN 200 MG TABLET) NAPROXEN SODIUM (ALEVE 220 MG GELCAP) NAPROXEN SODIUM (KRO ALL DAY RLF 220 MG CAPLET) PAIN RELIEF TABLET LOCAL ANESTHETICS ASPERCREME LIDOCAINE 4% CREAM BENZOCAINE/RESORCINOL (RA VAGICAINE CREAM) BENZOCAINE/RESORCINOL/ALOE VERA/VITAMIN E ACETATE/VIT A&D (EQ VAGICAINE CREAM) EHA 4% LOTION LIDOCAINE (ANECREAM 4% CREAM) LIDOCAINE HCL/MENTHOL (AFLEXERYL-LC 4%-1% PATCH) LIDOCAINE/TRANSPARENT DRESSING (LIDOCREAM KIT) PV FIRST AID ANTISEPTIC SPRAY PV VAGICREAM SMOKING CESSATION AGENTS NICOTINE (CVS NTS 21 MG/24HR PATCH) max 1 per day NICOTINE POLACRILEX (NICORETTE 2 MG LOZENGE) NICOTINE POLACRILEX (QUIT 2 MG CHEWING GUM) ANTIBACTERIALS, OTHER BACITRACIN (BACITRAYCIN PLUS 500 UNIT/GM) LAST UPDATED 08/2016

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Page 1: Over-the-Counter Drug List - passporthealthplan.com

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 QUANTITY LIMITS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

ASPIRIN (ASPIR-TRIN EC 325 MG TABLET)

ASPIRIN (ECOTRIN EC 325 MG TABLET)

ASPIRIN/ACETAMINOPHEN/CAFFEINE (CVS MIGRAINE RELIEF CAPLET)

ASPIRIN/ACETAMINOPHEN/CAFFEINE (EXCEDRIN EXTRA STRENGTH CAPLET)

ASPIRIN/CALCIUM CARBONATE/MAGNESIUM (ASPIRIN/CALCIUM CARBONATE/MAG325 MG TABLET)

BUFFERIN 325 MG TABLET

IBUPROFEN (INFANTS' MOTRIN 50 MG/1.25 ML)

IBUPROFEN (WAL-PROFEN 200 MG TABLET)

NAPROXEN SODIUM (ALEVE 220 MG GELCAP)

NAPROXEN SODIUM (KRO ALL DAY RLF 220 MG CAPLET)

PAIN RELIEF TABLET

LOCAL ANESTHETICS

ASPERCREME LIDOCAINE 4% CREAM

BENZOCAINE/RESORCINOL (RA VAGICAINE CREAM)

BENZOCAINE/RESORCINOL/ALOE VERA/VITAMIN E ACETATE/VIT A&D (EQ VAGICAINECREAM)

EHA 4% LOTION

LIDOCAINE (ANECREAM 4% CREAM)

LIDOCAINE HCL/MENTHOL (AFLEXERYL-LC 4%-1% PATCH)

LIDOCAINE/TRANSPARENT DRESSING (LIDOCREAM KIT)

PV FIRST AID ANTISEPTIC SPRAY

PV VAGICREAM

SMOKING CESSATION AGENTS

NICOTINE (CVS NTS 21 MG/24HR PATCH) max 1 per day

NICOTINE POLACRILEX (NICORETTE 2 MG LOZENGE)

NICOTINE POLACRILEX (QUIT 2 MG CHEWING GUM)

ANTIBACTERIALS, OTHER

BACITRACIN (BACITRAYCIN PLUS 500 UNIT/GM)

LAST UPDATED 08/2016

Page 2: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

BACITRACIN ZINC (BACITRACIN ZINC 500 UNIT/G OINT. (G))

BACITRACIN/POLYMYXIN B SULFATE (CVS POLY BACITRACIN OINTMNT)

NEOMYCIN SULF/BACITRACIN ZINC/POLYMYXIN B SULF/PRAMOXINE HCL (SM TRIPLEANTIBIOTIC PLUS OINT)

NEOMYCIN SULFATE/BACITRACIN ZINC/POLYMYXIN B (KRO TRIPLE ANTIBIOTICOINTMENT)

NEOMYCIN SULFATE/BACITRACIN ZINC/POLYMYXIN B (NEOSPORIN ANTIBIOTICOINTMENT)

NEOMYCIN SULFATE/POLYMYXIN B SULFATE/PRAMOXINE (ANTIBIOTIC-PRAMOXINECREAM)

NEOSPORIN + PAIN RELIEF CREAM

POLYSPORIN OINTMENT

ANTIEMETICS, OTHER

MECLIZINE HCL (EQL MOTION SICKNESS 25 MG TAB)

meclizine hcl 12.5 mg tablet

MOTION SICKNESS 25 MG TABLET

ANTIFUNGALS

CLOTRIMAZOLE (CLOTRIMAZOLE 2 % CREAM/APPL)

CLOTRIMAZOLE (GYNE-LOTRIMIN-7 1% CREAM)

GENTIAN VIOLET (GENTIAN VIOLET 2 % SOLUTION)

LAMISIL ANTIFUNGAL 1% SPRAY

LAMISIL AT 1% GEL

LOTRIMIN ULTRA 1% CREAM

MICONAZOLE NITRATE (DESENEX 2% SPRAY LIQUID)

MICONAZOLE NITRATE (DESENEX 2% SPRAY POWDER)

miconazole/skin cleanser no.17 1200mg-2% kit

NIZORAL A-D 1% SHAMPOO

TERBINAFINE HCL (PV ATHLETE'S FOOT 1% CREAM)

TOLNAFTATE (TINACTIN JOCK ITCH 1% CREAM)

TOLNAFTATE (TOLNAFTATE 1 % POWDER)

ANTIHELMINTHICS

BEDDING 0.5% SPRAY

PIN-X 250 MG (BASE) TAB CHEW

PV LICE EGG REMOVER GEL KIT

PYRANTEL PAMOATE (PIN-X 144 MG/ML(50 MG/ML BASE))

LAST UPDATED 08/2016

Page 3: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

PEDICULICIDES/SCABICIDES

NIX 1% CREME RINSE LIQUID

PERMETHRIN (HM LICE TREATMENT 1% LOTION)

PYRETHRIN LICE TREATMENT

ANTIHERPETIC AGENTS

ABREVA 10% CREAM

GLYCEMIC AGENTS

DEXTROSE (GLUTOSE 15 GEL)

INSULINS

HUMULIN R 100 UNITS/ML VIAL

INSULIN NPH HUMAN ISOPHANE (HUMULIN N 100 UNITS/ML VIAL)

INSULIN NPH HUMAN ISOPHANE/INSULIN REGULAR, HUMAN (HUMULIN 70/30KWIKPEN)

DYSLIPIDEMICS, OTHER

NIACIN (ENDUR-ACIN SR 250 MG TABLET)

niacin (inositol niacinate) 400(500mg) capsule

niacin (inositol niacinate) 750 mg capsule

NIACIN (SLO-NIACIN 750 MG TABLET)

NIACINAMIDE (NIACINAMIDE 500 MG TABLET)

CENTRAL NERVOUS SYSTEM, OTHER

ACETAMINOPHEN (FEVERALL 80 MG SUPPOSITORY)

ACETAMINOPHEN (RA INFANT FEVER-PAIN REL SUSP)

DENTAL AND ORAL AGENTS

BENZOCAINE/MENTHOL (CVS SORE THROAT LOZENGE)

CEPACOL SORE THROAT LOZENGE

GEL-KAM 0.4% DENTAL GEL

PHENOL (PV SORE THROAT 1.4% SPRAY)

PHOS-FLUR ORAL RINSE

SM COUGH DROPS 5.4 MG

DERMATOLOGICAL AGENTS

ABSORBASE OINTMENT

AMMONIUM LACTATE (AMMONIUM LACTATE 12 % CREAM (G))

BENZOYL PEROXIDE (CVS ACNE 10% CREAM)

LAST UPDATED 08/2016

Page 4: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

BENZOYL PEROXIDE (ON-THE-SPOT 2.5% ACNE CREAM)

CAPSAICIN (ARTHRITIS PAIN RELIEF 0.1% CRM)

CAPSAICIN/MENTHOL (MAC 0.0375%-5% PATCH)

CAPZASIN QUICK RELIEF GEL

CVS ANTI-DANDRUFF 1% SHAMPOO

DERMA-PAX 0.5% LOTION

DIPHENHYDRAMINE HCL (BENADRYL ITCH STOPPING GEL)

DIPHENHYDRAMINE HCL/CALAMINE (CALDYPHEN LOTION)

DIPHENHYDRAMINE HCL/ZINC ACETATE (BENADRYL ITCH COOLING SPRAY)

DIPHENHYDRAMINE HCL/ZINC ACETATE (QC ANTI-ITCH CREAM)

GLYCERIN (NEUTROGENA NORWEGIAN FORMULA)

GLYCERIN/DIMETHICONE/PETROLATUM,WHITE/WATER (STUDIO 35 MOIST SKINCREAM)

IODINE/POTASSIUM IODIDE (IODINE/POTASSIUM IODIDE 5%-10% SOLUTION)

lactic acid 88% to 92% liquid

LANOLIN/MINERAL OIL (EUCERIN ORIGINAL LOTION)

LIDOCAINE (RECTICARE 5% CREAM)

MENTHOL (SM PAIN RELIEF GEL)

MINERAL OIL/ISOPROPYL MYRISTATE/WATER (HYDROCERIN LOTION)

MINERAL OIL/PETROLATUM,WHITE (DERMACERIN CREAM)

PHENYLEPHRINE HCL (RA HEMORRHOID RLF 0.25 % SUPP)

PIPERONYL BUTOXIDE/PYRETHRINS (GNP LICE TREATMENT SHAMPOO)

PIPERONYL BUTOXIDE/PYRETHRINS/PERMETHRIN (EQ COMPLETE LICE TREATMENTKIT)

PIPERONYL BUTOXIDE/PYRETHRINS/PERMETHRIN (RID COMPLETE LICE KIT)

PRAMOXINE HCL/CALAMINE (PV CALAGESIC LOTION)

PV LICE TREATMENT KIT

RID LICE KILLING SHAMPOO

SALICYLIC ACID (SM MAX STRENGTH WART REMOVER)

SALICYLIC ACID/ADHESIVE FOOT CUSHION (LIQUID CORN & CALLUS REMOVER)

SELSUN BLUE 1% SHAMPOO

SELSUN BLUE 1% SHAMPOO

SODIUM CHLORIDE (GNP SALINE WOUND WASH SPRAY)

SODIUM HYPOCHLORITE (ANASEPT 0.057% GEL)

SODIUM HYPOCHLORITE (DAKIN'S 0.5% SOLUTION)

LAST UPDATED 08/2016

Page 5: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

VITAMIN E ACETATE/GLYCERIN/DIMETHICONE/WATER (CETAPHIL MOISTURIZINGLOTION)

ZINC OXIDE (DESITIN RAPID RELIEF 13% CREAM)

ZINC OXIDE (DIAPER RASH 10% OINTMENT)

GASTROINTESTINAL AGENTS, OTHER

ALLI 60 MG CAPSULE

ALUMINUM HYDROXIDE (ALUMINUM HYDROXIDE 600 MG/5ML ORAL SUSP)

BACILLUS COAGULANS/INULIN (PROBIOTIC WITH PREBIOTIC CAPS)

BD LACTINEX

BIFIDOBACTERIUM INFANTIS (ALIGN 4 MG CAPSULE)

BIFIDOBACTERIUM INFANTIS/B ANIMALIS/B LONGUM/B BIFIDUM (RA PROBIOTICDIGESTIVE CARE)

BISMUTH SUBSALICYLATE (PEPTO-BISMOL MAX STR SUSP)

BISMUTH SUBSALICYLATE (SB PEPTIC RELIEF 262 MG/15 ML)

CALCIUM CARBONATE (CALCIUM CARBONATE 260MG(648) TABLET)

CALCIUM CARBONATE (TUMS SMOOTHIES CHEW TABLET)

CALCIUM CARBONATE/MAGNESIUM HYDROXIDE (CVS ANTACID CHEWABLE TABLET)

CALCIUM CARBONATE/SIMETHICONE (GNP ANTACID-ANTIGAS TAB CHEW)

CONTROL DELIVERY PROBIOTC CPLT

CVS ADULT 50 + PROBIOTIC CAPS

CVS ADULT PROBIOTIC 3 BIL CELL

CVS DIGESTIVE PROBIOTIC CAP

CVS PROBIOTIC 20 BIL CELL CAPS

CVS PROBIOTIC 20 BIL CELL CAPS

CVS PROBIOTIC 3 BIL CELL CHEW

CVS PROBIOTIC DR 10 BIL CELL

CVS PROBIOTIC GUMMIES

DIFF-STAT POWDER PACKET

EQ ANTACID MULTI-SYM TAB CHEW

EQ PROBIOTIC 5 BILL CELL CAP

FLORAJEN BIFIDOBLEND CAPSULE

FLORAJEN3 CAPSULE

FLORAJEN4KIDS CAPSULE

FLORAVANCE CAPSULE

GAVISCON 80-14.2 MG TAB CHEW

LAST UPDATED 08/2016

Page 6: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

GAVISCON ES TABLET CHEW

GELUSIL TABLET CHEWABLE

GERBER SOOTHE COLIC DROPS

GNP PROBIOTIC 240 MG CAPSULE

IMODIUM MULTI-SYMPTOM REL CPLT

l. acidophilus/l. bifidus 1b cell wafer

l. acidophilus/lactobac spor 35mm-25mm tablet

l.acidoph,saliva/b.bif/s.therm 175 mg capsule

L.ACIDOPHILUS/S.THERMOPHILUS/L.PARACASEI/BIFIDOBACTERIUM (FLORA-QCAPSULE)

LACTO ACIDOPHILUS/L. BULGARICUS/BIFIDO B/S. THERMOPHILUS (BACID CAPLET)

LACTO-PECTIN CAPSULE

LACTOBACILLUS ACIDOPHILUS (ABATINEX CAPSULE)

LACTOBACILLUS ACIDOPHILUS (LACTOBACILLUS ACIDOPHILUS 100MM CELLCAPSULE)

LACTOBACILLUS ACIDOPHILUS/BIFIDOBACTERIUM ANIMALIS (TRUNATURECHEWABLE PROBIOTIC)

LACTOBACILLUS ACIDOPHILUS/BIFIDOBACTERIUM LONGUM (L. ACIDOPHILUS/BIFIDOLONGUM 16 MG CAPSULE DR)

lactobacillus acidophilus/fos 500mm-50mg tablet

LACTOBACILLUS ACIDOPHILUS/LACTOBACILLUS BULGARICUS (FLORANEXGRANULES PACKET)

LACTOBACILLUS ACIDOPHILUS/PECTIN (KALA TABLET)

LACTOBACILLUS ACIDOPHILUS/PECTIN, CITRUS (L. ACIDOPHILUS/PECTIN, CITRUS25MM-100MG TABLET)

LACTOBACILLUS ACIDOPHILUS/PECTIN, CITRUS (PROBIOTIC ACIDOPHIL-PECTINCAP)

LACTOBACILLUS COMBINATION NO.4 (CVS SENIOR PROBIOTIC CAPSULE)

LACTOBACILLUS GASSERI/BIFIDOBACTERIUM BIFIDUM/BIFIDO LONGUM (PHILLIPS'COLON HEALTH CAPSULE)

LACTOBACILLUS NO.2/S.THERMOPHILUS/BIFIDOBACTERIUM NO.1 (VISBIOME 112.5BILLION CAPSULE)

LACTOBACILLUS NO.2/S.THERMOPHILUS/BIFIDOBACTERIUM NO.1 (VSL#3 CAPSULE)

LACTOBACILLUS REUTERI (FLEET PEDIA-LAX PROBIOTIC YUMS)

LACTOBACILLUS RHAMNOSUS GG (CULTURELLE CAPSULE)

LACTOBACILLUS RHAMNOSUS GG/INULIN (CULTURELLE CAPSULE)

LOPERAMIDE HCL (IMODIUM A-D 1 MG/7.5 ML LIQUID)

LOPERAMIDE HCL (LOPERAMIDE HCL 1 MG/5 ML LIQUID)

LAST UPDATED 08/2016

Page 7: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

MAALOX ADVANCED TAB CHEW

MAGALDRATE/SIMETHICONE (RI MAG PLUS LIQUID)

MAGNESIUM CARBONATE/ALUMINUM HYDROXIDE (PV HEARTBURN ANTACID CHEWTAB)

MAGNESIUM CARBONATE/ALUMINUM HYDROXIDE/ALGINIC ACID (ACID GONEANTACID LIQUID)

MAGNESIUM CARBONATE/ALUMINUM HYDROXIDE/ALGINIC ACID (GAVISCON EXTRASTRENGTH LIQUID)

MAGNESIUM HYDROXIDE/ALUMINUM HYDROXIDE/SIMETHICONE (FLANAX ANTACIDLIQUID)

MAGNESIUM TRISILICATE/AL HYDROX/SOD BICARB/ALGINIC ACID (FOAMINGANTACID TABLET CHEW)

MEGA PROBIOTIC CAPSULE

PRE B2 POWDER PACKET

PREORBOTIC CAPSULE

PROBIOTIC & ACIDOPHILUS CAP

PROBIOTIC 15 BILLION CELL CAP

PROBIOTIC 15 BILLION CELL CAP

PROBIOTIC ACIDOPHILUS BEADS

PROBIOTIC ACIDOPHILUS BIOBEADS

PROBIOTIC COMPLEX TABLET

PROBIOTIC FORMULA CAPSULE

PROVELLA TABLET

RA PROBIOTIC COMPLEX CAPSULE

RA PROBIOTIC COMPLEX TABLET

RA PROBIOTIC DIGESTIVE CARE CP

REZYST 250 MG TABLET CHEW

REZYST IM TABLET CHEW

RI-MAG SUSPENSION

ROLAIDS CHEWABLE TABLET

SACCHAROMYCES BOULARDII (PROBIOTIC 250 MG CAPSULE)

SIMETHICONE (GAS RELIEF 125 MG CHEW TABLET)

SIMETHICONE (GAS-X EX-STR 125 MG TAB CHEW)

SODIUM BICARBONATE (SODIUM BICARBONATE 325 MG TABLET)

TRUNATURE DIGESTIVE PROBIOTIC

UP & UP PROBIOTIC SUPPLEMENT

LAST UPDATED 08/2016

Page 8: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

HISTAMINE2 (H2) RECEPTOR ANTAGONISTS

CIMETIDINE (HEARTBURN RELIEF 200 MG TABLET)

FAMOTIDINE (EQ ACID REDUCER 10 MG TABLET)

FAMOTIDINE/CALCIUM CARBONATE/MAGNESIUM HYDROXIDE (HM COMPLETETABLET CHEW)

PEPCID AC 10 MG TABLET

RANITIDINE HCL (RANITIDINE HCL 150 MG TABLET)

RANITIDINE HCL (ZANTAC 75 MG TABLET)

TAGAMET HB 200 MG TABLET

LAXATIVES

BISACODYL (GNP LAXATIVE EC 5 MG TABLET)

BISACODYL/MAGNESIUM CITRATE (LO-SO LIQUID PREP KIT)

CALCIUM POLYCARBOPHIL (PUB FIBER 625 MG CAPLET)

CASTOR OIL (CASTOR OIL 100 % OIL)

CVS FIBER GUMMIES

DOCUSATE CALCIUM (KAO-TIN 240 MG SOFTGEL)

DOCUSATE SODIUM (DOCUPRENE 100 MG TABLET)

DOCUSATE SODIUM (DOCUSOL MINI-ENEMA)

DOCUSATE SODIUM/BENZOCAINE (DOCUSOL PLUS MINI-ENEMA)

DULCOLAX 10 MG SUPPOSITORY

EVAC POWDER

FIBER 6 TABLET

FIBER CHOICE CHEWABLE TABLET

FIBERCEL POWDER

GLYCERIN (FLEET GLYCERIN LIQUID SUPP)

GLYCERIN (GLYCERIN ADULT SUPP.RECT)

GUAR GUM (BENEFIBER POWDER)

KONDREMUL MICROEMULSION

MAGNESIUM CITRATE (CITROMA SOLUTION)

MAGNESIUM HYDROXIDE (PHILLIPS' MILK OF MAG (CONC))

MAGNESIUM SULFATE (GNP EPSOM SALT GRANULES)

METHYLCELLULOSE (CITRUCEL POWDER S-F)

METHYLCELLULOSE (WITH SUGAR) (FIBER THERAPY POWDER)

MINERAL OIL (RA MINERAL OIL EXTRA HEAVY)

LAST UPDATED 08/2016

Page 9: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

POLYETHYLENE GLYCOL 3350 (HEALTHYLAX POWDER PACKET)

PSYLLIUM HUSK (KONSYL ORIGINAL FIBER POWDER)

PSYLLIUM HUSK (WITH SUGAR) (KONSYL PSYLLIUM FIBER POWDER)

PSYLLIUM HUSK/ASPARTAME (FIBER THERAPY POWDER)

PSYLLIUM HUSK/CALCIUM CARBONATE (WAL-MUCIL PLUS CALCIUM CAPSULE)

PSYLLIUM SEED (HYDROCIL INSTANT POWDER)

PSYLLIUM SEED (WITH DEXTROSE) (NATURAL VEGETABLE POWDER)

PSYLLIUM SEED (WITH SUGAR) (NATURAL FIBER POWDER)

PSYLLIUM SEED/ASPARTAME (NATURAL FIBER POWDER)

SENNA SYRUP

SENNOSIDES (RA LAXATIVE 17.2 MG TABLET)

SENNOSIDES/DOCUSATE SODIUM (STOOL SOFTENER-LAXATIVE TABLET)

SODIUM PHOSPHATE,MONOBASIC/SODIUM PHOSPHATE,DIBASIC (CVS ENEMADISPOSABLE TWIN PACK)

SODIUM PHOSPHATE,MONOBASIC/SODIUM PHOSPHATE,DIBASIC (FLEET PEDIA-LAXENEMA)

UNIFIBER POWDER

WHEAT DEXTRIN (BENEFIBER POWDER)

PROTON PUMP INHIBITORS

ESOMEPRAZOLE MAGNESIUM (NEXIUM 24HR 22.3 MG CAPSULE) max 1 per day

LANSOPRAZOLE (HEARTBURN TREATMNT 24 HR 15 MG) max 1 per day

omeprazole 20 mg tablet dr

omeprazole magnesium 20 mg capsule dr max 2 per day

PRILOSEC OTC 20.6 MG TABLET max 2 per day

ZEGERID OTC 20-1,100 MG CAP max 1 per day

PHOSPHATE BINDERS

calcium acetate 668 mg tablet

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)

HYDROCORTISONE (EQL ANTI-ITCH 1% CREAM)

HYDROCORTISONE ACETATE (HYDROCORTISONE ACETATE 1 % CREAM (G))

HYDROCORTISONE/ALOE VERA (CVS CORTISONE 1% CREAM)

HYDROCORTISONE/ALOE VERA/VITAMIN E ACETATE/VITAMINS A AND D (EQ ANTI-ITCH PLUS 1% CREAM)

HYDROCORTISONE/COLLOIDAL OATMEAL/ALOE/VITAMIN E (ANTI-ITCH 1% CREAM)

LAST UPDATED 08/2016

Page 10: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

ESTROGENS

LEVONORGESTREL (TAKE ACTION 1.5 MG TABLET)

MISCELLANEOUS THERAPEUTIC AGENTS

alcohol antiseptic pads med. pad max 10 per day

arm brace each

blood glucose cntl hi & normal each

blood glucose control high&low each

blood glucose control high&low each

blood sugar diagnostic strip

blood sugar diagnostic, drum strip

blood-glucose calib. control combo. pkg

blood-glucose control, normal each

blood-glucose control, normal each

BLOOD-GLUCOSE METER (BLOOD-GLUCOSE METER KIT)

blood-glucose meter, drum-type kit

castor oil oil

CUTTER LEMON EUCALYPTUS SPRAY

CUTTER NATURAL REPELLENT SPRAY

CVS 12HR COLD RELIEF CAPLET

DIETHYLTOLUAMIDE (REPEL FAMILY 10% SPRAY)

flaxseed/evening prim/bilberry 250-125 mg capsule

GLYCERIN (AQUA GLYCOLIC SHAMPOO)

inhaler,assist device,accesory each

lactic acid 88% to 92% liquid

LANCETS (LANCETS 32 GAUGE EACH)

lancing device each

lancing device/lancets kit

mineral oil oil

MISCELLANEOUS MEDICAL SUPPLY (MISCELLANEOUS MEDICAL SUPPLY EACH)

NASOGASTRIC TUBE (NASOGASTRIC TUBE 12FR-36" EACH)

nebulizer/compressor each

needle clip and storage device each

NEEDLES, REUSABLE (NEEDLES, REUSABLE 18GX2" NEEDLE)

OXYMETAZOLINE HCL (AFRIN NO DRIP PUMP MIST)

LAST UPDATED 08/2016

Page 11: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

OXYMETAZOLINE HCL (SINUS RELIEF 0.05% NASAL SPRAY)

peak flow meter each

PEN NEEDLE, DIABETIC (PEN NEEDLE, DIABETIC 32 GX 1/5" DIS NEEDLE)

PERMETHRIN (LICE BEDDING SPRAY)

PHENYLEPHRINE HCL (NASAL SPRAY 1%)

PHENYLEPHRINE HCL (QC SUPHEDRINE PE 10 MG TABLET)

POLYETHYLENE GLYCOL 3350 (POLYETHYLENE GLYCOL 3350 GRANULES)

PSEUDOEPHEDRINE HCL (CHILDS SUDAFED 15 MG/5 ML LIQ)

PSEUDOEPHEDRINE HCL (QC SUPHEDRINE 30 MG TABLET)

REPEL TICK DEFENSE 15% SPRAY

SM STOOL SOFTENER-LAXATIVE TAB

SODIUM CHLORIDE (OCEAN FOR KIDS 0.65% NASAL SPY)

SODIUM CHLORIDE (RHINARIS 0.2% NASAL GEL)

syr,ndl,insulin,1ml-sharps bin 30gx 5/16" syringe

syr-nd,ins,0.3/container,empty 30gx 5/16" syringe

SYRING W-NDL,DISP,INSUL,0.5 ML/CONTAINER,EMPTY (SYR-ND,INS,0.5/CONTAINER,EMPTY 29 G X1/2" SYRINGE)

syringe reusable syringe

syringe reusable, 0.25 ml syringe

syringe reusable, 1 ml syringe

syringe reusable, 10 ml syringe

syringe reusable, 2 ml syringe

syringe reusable, 20 ml syringe

syringe reusable, 3 ml syringe

syringe reusable, 30 ml syringe

syringe reusable, 5 ml syringe

syringe reusable, 50 ml syringe

SYRINGE W-NEEDLE,DISPOSAB,1 ML (SYRINGE W-NEEDLE,DISPOSAB,1 ML 26GX1/2"DISP SYRIN)

SYRINGE W-NEEDLE,DISPOSAB,3 ML (SYRINGE W-NEEDLE,DISPOSAB,3 ML 21GX11/2" DISP SYRIN)

syringe w-needle,disposable disp syrin

SYRINGE WITH NEEDLE,DISPOSABLE,INSULIN 1 ML (SYRINGE ANDNEEDLE,INSULIN,1ML 28 GAUGE DISP SYRIN)

SYRINGE WITH NEEDLE,INSULIN 0.3 ML (HALF UNIT MARK) (SYRGE-NDL,INS 0.3 MLHALF MARK 29 G X1/2" DISP SYRIN)

SYRINGE WITH NEEDLE,INSULIN DISPOSABLE,0.3 ML (SYRING W-

LAST UPDATED 08/2016

Page 12: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

NDL,DISP,INSUL,0.3ML 29 GAUGE DISP SYRIN)

SYRINGE WITH NEEDLE,INSULIN DISPOSABLE,0.5 ML (SYRING W-NDL,DISP,INSUL,0.5ML 31 GX5/16" DISP SYRIN)

SYRINGE WITH NEEDLE,INSULIN,0.3 ML (SYRING-NEEDL,DISP,INSUL,0.3 ML 29GAUGE DISP SYRIN)

SYRINGE WITH NEEDLE,INSULIN,0.5 ML (SYRINGE-NEEDLE,INSULIN,0.5 ML31GX15/64" DISP SYRIN)

syringe, disposable, 12 ml disp syrin

syringe, disposable, 3 ml disp syrin

syringe, disposable, 30 ml disp syrin

syringe, disposable, 6 ml disp syrin

syringe,needle,insuln,safe,1ml 30gx1/2" disp syrin

syringe,safety needle,12 ml 20gx1 1/2" disp syrin

syringe,safety with needle,1ml 25gx1" syringe

SYRINGE,SAFETY WITH NEEDLE,3 ML (SYRINGE,SAFETY WITH NEEDLE,3ML 21GX11/2" DISP SYRIN)

syringe,safety with needle,3ml 21gx1 1/2" disp syrin

urine acetone test,strips strip

urine acetone test,strips strip

urine acetone test,tablet tablet

urine albumin test strip

urine albumin test strip

urine glucose test strip strip

urine glucose test,strip strip

urine glucose test,tablet tablet

urine glucose-acet test strip strip

urine glucose-acet test strip strip

urine leukocyte test strips strip

urine multiple test strip

urine multiple test strips strip

urine multiple test strips strip

URINE PHENAPHTHAZINE-PH TEST (URINE PHENAPHTHAZINE-PH TEST 15 FEETEACH)

OPHTHALMIC AGENTS, OTHER

CARBOXYMETHYLCELLULOSE SODIUM (GNP LUBRICANT 0.5% EYE DROPS)

CARBOXYMETHYLCELLULOSE SODIUM/GLYCERIN (EQ LUBRICATING EYE DROPS)

LAST UPDATED 08/2016

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DRUG NAME QUANTITY LIMITS

CARBOXYMETHYLCELLULOSE SODIUM/GLYCERIN (REFRESH OPTIVE EYE DROPS)

CARBOXYMETHYLCELLULOSE SODIUM/GLYCERIN/PF (REFRESH OPTIVE SENSITIVEDROPS)

CARBOXYMETHYLCELLULOSE SODIUM/HYPROMELLOSE (CVS LUBRICANT GEL EYEDROPS)

CLEAR EYES REDNESS RELIEF DROP

DEXTRAN 70/HYPROMELLOSE (ARTIFICIAL TEARS EYE DROPS)

DEXTRAN 70/HYPROMELLOSE (NATURE'S TEARS EYE DROPS)

DEXTRAN 70/HYPROMELLOSE/PF (ARTIFICIAL TEARS DROPS)

GLYCERIN/PROPYLENE GLYCOL (ARTIFICIAL TEARS DROPS)

HYPOTEARS EYE DROPS

HYPROMELLOSE (GENTEAL MILD 0.2% EYE DROPS)

LUBRICANT 0.6% EYE DROPS

MINERAL OIL/PETROLATUM,WHITE (LUBRICANT EYE OINTMENT)

MINERAL OIL/PETROLATUM,WHITE (RETAINE PM EYE OINTMENT)

NAPHAZOLINE HCL/GLYCERIN (REDNESS RELIEF EYE DROPS)

POLYETHYLENE GLYCOL 400/HYPROMELLOSE/GLYCERIN (EYE DROP TEARS)

POLYVINYL ALCOHOL (ARTIFICIAL TEARS 1.4 % DROPS)

POLYVINYL ALCOHOL/POVIDONE (ARTIFICIAL TEARS DROPS)

PROPYLENE GLYCOL (CVS LUBRICANT 0.6% EYE DROPS)

PROPYLENE GLYCOL/POLYETHYLENE GLYCOL 400 (SM LUBRICANT EYE DROPS)

PROPYLENE GLYCOL/POLYETHYLENE GLYCOL 400/PF (SYSTANE 0.3-0.4% EYEDROPS)

REFRESH CLASSIC EYE DROPS

REFRESH OPTIVE ADVANCED DROPS

REFRESH OPTIVE ADVANCED DROPS

TEARS NATURALE FORTE DROPS

TEARS NATURALE FREE DROPS

TETRAHYDROZOLINE HCL (SM EYE DROPS)

TETRAHYDROZOLINE HCL/DEXTRAN 70/PEG 400/POVIDONE (ADVANCED FORMULAEYE DROPS)

TETRAHYDROZOLINE HCL/ZINC SULFATE (PV EYE DROPS)

OPHTHALMIC ANTI-ALLERGY AGENTS

KETOTIFEN FUMARATE (ALAWAY 0.025% EYE DROPS)

ZADITOR 0.025% (0.035%) DROPS

ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS

LAST UPDATED 08/2016

Page 14: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

budesonide 32mcg spray/pump

FLUTICASONE PROPIONATE (ALLERGY RELIEF 50 MCG SPRAY) 1.20 pd max

FLUTICASONE PROPIONATE (CHILD FLONASE ALLER RLF 50 MCG) 1.20 pd max

RHINOCORT ALLERGY 32 MCG SPRAY

TRIAMCINOLONE ACETONIDE (CVS NASAL ALLERGY 24HR SPRAY)

ANTIHISTAMINES

CETIRIZINE HCL (HM ALL DAY ALLERGY 10 MG TAB)

CETIRIZINE HCL (ZYRTEC 10 MG TABLET)

CHLORPHENIRAMINE MALEATE (CHLOR-TRIMETON ALLERGY)

CHLORPHENIRAMINE MALEATE (CHLORPHEN SR 12 MG TABLET)

CLEMASTINE FUMARATE (DAYHIST TABLET)

DIPHENHYDRAMINE HCL (BENADRYL 25 MG LIQUI-GELS)

DIPHENHYDRAMINE HCL (EQL ALLERGY 25 MG CAPSULE)

FEXOFENADINE HCL (ALLEGRA ALLERGY 180 MG TABLET)

FEXOFENADINE HCL (CVS CHILD ALLERGY RLF 30 MG/5)

LORATADINE (ALLERCLEAR 10 MG TABLET)

LORATADINE (CLARITIN 10 MG LIQUI-GEL CAP)

RESPIRATORY TRACT AGENTS, OTHER

ALLEGRA-D 24 HOUR TABLET

BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL (COLD & ALLERGY ELIXIR)

BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL (DIMETAPP COLD & ALLERGYELIXIR)

BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL/DEXTROMETHORPHAN(PRESGEN B LIQUID)

BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL/DEXTROMETHORPHAN (RACHILD'S COLD & COUGH ELIXIR)

BROMPHENIRAMINE MALEATE/PSEUDOEPHEDRINE HCL/DEXTROMETHORPHAN (Q-TAPP DM ELIXIR)

CETIRIZINE HCL/PSEUDOEPHEDRINE HCL (CETIRIZINE HCL/PSEUDOEPHEDRINE 5MG-120MG TAB ER 12H)

CHLORPHENIRAMINE MALEATE/PHENYLEPHRINE HCL/DEXTROMETHORPHAN(GENCONTUSS LIQUID)

CODITUSS DM SYRUP

DESGEN DM TABLET

DEXTROMETHORPHAN HBR (CVS TUSSIN COUGH SYRUP)

DEXTROMETHORPHAN HBR (SCOT-TUSSIN DIABETES CF)

LAST UPDATED 08/2016

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DRUG NAME QUANTITY LIMITS

DEXTROMETHORPHAN HBR/ACETAMINOPHEN (COUGH & SORE THROAT LIQUID)

DEXTROMETHORPHAN HBR/ACETAMINOPHEN/DOXYLAMINE (COUGH & SORETHROAT LIQUID)

DEXTROMETHORPHAN HBR/PHENYLEPHRINE HCL/ACETAMINOPHEN (PV DAY-TIMECOLD-FLU LIQUID)

DEXTROMETHORPHAN HBR/PHENYLEPHRINE/ACETAMINOPHEN/DOXYLAMINE(DAYTIME-NIGHTTIME COLD-FLU LIQ)

DEXTROMETHORPHAN HBR/PHENYLEPHRINE/ACETAMINOPHEN/DOXYLAMINE (KROSEVERE SINUS CONGESTION)

DEXTROMETHORPHAN HBR/PSEUDOEPHEDRINE HCL/BROMPHENIRAMINE (D-METHORPHAN HB/P-EPD HCL/BPM 20-20-4/5 LIQUID)

DEXTROMETHORPHAN POLISTIREX (DELSYM 30 MG/5 ML SUSPENSION)

DEXTROMETHORPHAN POLISTIREX (RA COUGH DM ER 30 MG/5 ML SUSP)

DIPHENHYDRAMINE HCL/PHENYLEPHRINE HCL/ACETAMINOPHEN (FLU RELIEFTHERAPY NIGHT LIQ)

DOXYLAMINE/PHENYLEPHRINE/DEXTROMETHORPHAN/ACETAMINOPHEN/GG (VICKSDAYQUIL-NYQUIL SEVERE LQ)

EQL CHLD ALL DAY ALLER 1 MG/ML

EUCALYPTUS OIL/MENTHOL/CAMPHOR (VAPORX BALM OINTMENT)

FEXOFENADINE HCL/PSEUDOEPHEDRINE HCL (WAL-FEX D 24 HOUR 180-240 TAB)

GUAIFENESIN (KID'S MUCINEX MINI-MELTS PACK)

GUAIFENESIN (ROBITUSSIN MUCUS-CHEST CONGEST)

GUAIFENESIN/CODEINE PHOSPHATE (IOPHEN-C NR LIQUID)

GUAIFENESIN/DEXTROMETHORPHAN HBR (PUB TUSSIN DM LIQUID)

GUAIFENESIN/DEXTROMETHORPHAN HBR (TRISPEC DMX LIQUID)

GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE (KRO TUSSIN CFLIQUID)

GUAIFENESIN/DEXTROMETHORPHAN HBR/PSEUDOEPHEDRINE HCL (SM TUSSIN CFSYRUP)

GUAIFENESIN/PHENYLEPHRINE HCL (DESPEC LIQUID)

GUAIFENESIN/PHENYLEPHRINE HCL (ED BRON GP LIQUID)

GUAIFENESIN/PHENYLEPHRINE HCL/ACETAMINOPHEN (SUDAFED PE PRESSURE-PAIN-MUCUS)

GUAIFENESIN/PSEUDOEPHEDRINE HCL (PV TUSSIN COLD CONGES LIQ GLCA)

GUAIFENESIN/PSEUDOEPHEDRINE HCL (RYDEX G TABLET)

LORATADINE/PSEUDOEPHEDRINE SULFATE (CLARITIN-D 12 HOUR TABLET)

LORATADINE/PSEUDOEPHEDRINE SULFATE (WAL-ITIN D 24 HOUR TABLET)

MUCINEX SINUS-MAX NITE CONGEST

PHENYLEPHRINE HCL/ACETAMINOPHEN (KRO SINUS CONGEST-PAIN CAPLET)

LAST UPDATED 08/2016

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DRUG NAME QUANTITY LIMITS

PHENYLEPHRINE HCL/ACETAMINOPHEN/CHLORPHENIRAMINE (GNP PAIN RELIEFALLERGY CAPLET)

PHENYLEPHRINE HCL/BROMPHENIRAMINE MALEATE (COLD & ALLERGY ELIXIR)

PHENYLEPHRINE HCL/DEXTROMETHORPHAN HBR/ACETAMINOPHEN/GUAIFEN (RAMUCUS RELIEF PLUS CAPLET)

PSEUDOEPHEDRINE HCL/CODEINE PHOSPHATE/GUAIFENESIN (GUAIFENESIN DACORAL SOLUTION)

SM NITE TIME COLD-FLU LIQUID

ZYRTEC-D TABLET

SLEEP DISORDERS, OTHER

DIPHENHYDRAMINE HCL (SLEEP AID 25 MG CAPLET)

DIPHENHYDRAMINE HCL (UNISOM 50 MG/30 ML LIQUID)

DOXYLAMINE SUCCINATE (HM SLEEP AID 25 MG TABLET)

SM GAS RELIEF 125 MG SOFTGEL

UNISOM SLEEP AID 25 MG TABLET

ELECTROLYTE/MINERAL REPLACEMENT

calcium carb & citrate/vit d3 600 mg-500 tablet er

calcium carb/mag oxide/cu/znox tablet

CALCIUM CARBONATE (CALCIUM CARBONATE 500(1250) TAB CHEW)

CALCIUM CARBONATE (CALTRATE 600 TABLET)

CALCIUM CARBONATE/CHOLECALCIFEROL (VIT D3)/PHYTONADIONE (CALCIUMCARB/VITAMIN D3/VIT K1 500MG-1000 TAB CHEW)

CALCIUM CARBONATE/CHOLECALCIFEROL (VIT D3)/VITAMIN K2 (CALCIUM PLUSMENAQ7 ADULT TAB)

CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) (CALCIUMCARBONATE/VITAMIN D3 500 MG-600 TABLET)

CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) (CALTRATE 600 + D SOFTCHEW TAB)

CALCIUM CARBONATE/ERGOCALCIFEROL (VITAMIN D2) (CALCIUMCARBONATE/VITAMIN D2 600 MG-125 TABLET)

CALCIUM CARBONATE/VIT D3/MAG OX/ZINC/COPPER/MANGANESE/BORON(CA/D3/MAG OX/ZINC/COP/MANG/BOR 600 MG-800 TABLET)

CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN D3) (CALCIUM CITRATE/VITAMIN D3315 MG-250 TABLET)

CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN D3) (CITRACAL-VIT D 200 MG-250TAB)

calcium citrate/vitamin d2 1500mg-200 tablet

calcium/magnesium/zinc tablet

CALTRATE 600+D PLUS TAB CHEW

LAST UPDATED 08/2016

Page 17: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

CALTRATE GUMMY BITES

CALTRATE+D3 PLUS MINERAL MINIS

CITRACAL + BONE DENSITY TABLET

CITRACAL + D ER TABLET

CITRACAL-VIT D + MAGNESIUM TAB

ELECTROLYTE,ORAL (PEDIATRIC ELECTROLYTE SOLUTION) max 150ml per day

ELECTROLYTES/DEXTROSE (ENFALYTE NURSETTE SOLUTION) max 150ml per day

ELECTROLYTES/DEXTROSE (ORALYTE SOLUTION) max 150ml per day

FERRO-SEQUELS 65-25 MG CAPLET

FERROUS FUMARATE (FERRIMIN 150 TAB)

FERROUS FUMARATE (FERROCITE TABLET)

FERROUS GLUCONATE (FERROUS GLUCONATE 325(36)MG TABLET)

FERROUS SULFATE (FERROUS SULFATE 134MG TABLET)

FERROUS SULFATE (FERROUS SULFATE 140(45)MG TABLET ER)

FERROUS SULFATE, DRIED (FERROUS SULFATE, DRIED 159(45)MG TABLET ER)

IRON POLYSACCHARIDE COMPLEX (FERRIC X-150 CAPSULE)

IRON POLYSACCHARIDE COMPLEX (PRO FE 180 MG CAPSULE)

iron,carbonyl/vit c/fos 30-10-25mg tab chew

magnesium 250 mg tablet

MAGNESIUM CHLORIDE (MAG64 DR 64 MG TABLET)

MAGNESIUM OXIDE (CVS LAX DIETARY 500 MG CAPLET)

MAGNESIUM OXIDE (UROMAG 140 MG CAPSULE)

NOVAFERRUM 125 LIQUID

PEDI ELECTROLYTE FREEZER POP max 150ml per day

SODIUM CHLORIDE (SODIUM CHLORIDE 1000 MG TABLET SOL)

SODIUM FLUORIDE/CALCIUM CARBONATE (FLORICAL CAPSULE)

STRESS FORMULA WITH IRON TAB

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES

ABANEU-SL TABLET SL

acetylcysteine 500 mg capsule

ADULT MULTI + OMEGA-3 GUMMIES

AKEDAMINS TABLET CHEW

ALIVE WOMEN'S ENERGY MV TABLET

LAST UPDATED 08/2016

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DRUG NAME QUANTITY LIMITS

ALIVE WOMEN'S GUMMY VITAMINS

AMINO ACIDS/MULTIVITS,TH W-FE,OTHER MIN (BIOTECT PLUS LIQUID)

AMINO ACIDS/PROTEIN HYDROLYSATE/WHEY PROTEIN ISOLATE (LIQUACEL LIQUIDPROTEIN)

AQUADEKS CHEWABLE TABLET

AQUADEKS PEDIATRIC LIQUID

AQUADEKS SOFTGEL

ascorbic acid 1000 mg tablet

ascorbic acid 125 mg tab chew

B COMPLEX WITH VITAMIN C (VITABEE WITH VIT C CAPLET)

BALANCED B-100 TABLET

BETA-CAROTENE(A) W-C & E/LUTEIN/MINERALS (I-VITE TABLET)

BETA-CAROTENE(A) W-C & E/MINERALS (ANTIOXIDANT FORM SOFTGEL CAP)

BLADDER 2.2 TABLET

CALCIUM COMBINATION NO.1/VITAMIN D3/PYRIDOX HCL/FA/VIT B12 (HEARTBURN &ACID REFLUX TABS)

CENTRUM MULTIGUMMIES

CENTRUM MULTIVIT-MINERAL LIQ

CENTRUM SILVER WOMEN TABLET

CERTA PLUS TABLET

CHILD'S CHEW MULTIVIT W/IRON

CHILD'S CHEW VITAMIN-IRON TAB

CHILD'S OMEGA-3 DHA MULTIVITAM

CHILDREN MULTIVITAMIN GUMMIES

CHILDREN MULTIVITAMIN GUMMIES

CHILDREN MULTIVITAMIN GUMMIES

CHOLECALCIFEROL (VITAMIN D3) (BABY VITAMIN D3 400 UNIT/DROP)

CHOLECALCIFEROL (VITAMIN D3) (CHOLECALCIFEROL (VITAMIN D3) 400 UNITCAPSULE)

CVS GUMMY DINOS GUMMIES

CVS GUMMY DINOS VITAMIN

cyanocobalamin (vitamin b-12) 2500 mcg tab chew

DIALYVITE 800 PLUS D WAFER

ERGOCALCIFEROL (VITAMIN D2) (DRISDOL 8,000 UNITS/ML DROPS)

ERGOCALCIFEROL (VITAMIN D2) (ERGOCALCIFEROL (VITAMIN D2) 400 UNIT TABLET)

ESSENTIAL BALANCE TABLET

LAST UPDATED 08/2016

Page 19: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

EYEPROTECT TABLET

FLINTSTONES + CALCIUM TAB

FLINTSTONES COMPLETE CHEW TAB

FLINTSTONES GUMMIES CHEW TAB

FLINTSTONES MULTI-VIT GUMMIES

FOLIC ACID (FOLIC ACID 0.8 MG CAPSULE)

FOLIC ACID/MULTIVIT WITH FE,OTHER MINERAL (CENTRUM CHEWABLE TABLET)

FOLIC ACID/MULTIVIT WITH FE,OTHER MINERAL (ONE DAILY MAXIMUM TABLET)

FOLIC ACID/MULTIVIT,CALCIUM,IRON,&OTHER MINS/LYCOPENE/LUTEIN (A THRU ZHIGH POTENCY CAPLET)

FOLIC ACID/MULTIVITAMIN WITH MINERALS (ONE DAILY TABLET)

FOLIC ACID/MULTIVITS W-FE,OTHER MIN (ONE DAILY MAXIMUM TABLET)

folic acid/vit bcomp,c 400 mcg tablet

GNP DAILY PRENATAL COMBO PACK

HCU COOLER LIQUID

HM MENS 50+ ADVANCED ONE DAILY

ICAPS MV TABLET

ICAPS TABLET

K-PAX IMMUNE SUPPORT TABLET

KIDS MULTIVIT-MINERALS GUMMIES

KIDS MULTIVITAMIN COMPLETE TAB

LECITHIN/PYRIDOXINE/KELP (KELP-LECITHIN-VIT B-6 TABLET)

LEVOMEFOLATE CALCIUM (LEVOMEFOLATE CALCIUM 7.5 MG TABLET)

levomefolate/b6/b12/algal oil 3-35-2 mg capsule

LITTLE ANIMALS-IRON TAB CHEW

lmfol ca/acetyl/mb12/algal oil 6-600-2 mg tablet

MCT OIL

MEDIUM CHAIN TRIGLYCERIDES (LIQUIGEN EMULSIFIED MCT OIL)

MICROLIPID LIQUID

MTERYTI COMBO PACK

MULTI FOR HER TABLET

MULTI-DAY PLUS MINERALS TABLET

MULTI-DELYN WITH IRON LIQUID

MULTIVIT W-CA, MIN/IRON CHELATE/FA/LUTEIN/HERBAL #179 (MEGA MULTI FORWOMEN TAB)

LAST UPDATED 08/2016

Page 20: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

MULTIVIT WITH CALCIUM, IRON, AND OTHER MINERALS (QC WOMEN'S DAILYMULTIVIT TAB)

MULTIVIT WITH CALCIUM,IRON,MINERALS/FOLIC ACID/PHYTOSTEROL (CENTURYCARDIO TABLET)

MULTIVIT WITH CALCIUM,IRON,MINERALS/FOLIC ACID/PHYTOSTEROL (CVSSPECTRAVITE CARDIO TABLET)

MULTIVIT WITH FE,OTHER MINERAL/GINKGO BILOBA EXTRACT/P.GINSG (EQLCENTRAL-VITE PERFORMANCE)

MULTIVIT WITH FE,OTHER MINERAL/LUTEIN (CENTRUM SILVER ULTRA WOMEN TAB)

MULTIVIT,CALCIUM,IRON,MINERALS/FOLIC ACID/GUARANA, CAFFEINE (CVS DAILYENERGY TABLET)

MULTIVIT,CALCIUM,OTHER MIN/FERROUS FUMARATE/FA/LYCOPENE/LUT (SMCOMPLETE ADVANCED TABLET)

MULTIVIT,TH IRON,OTHER MIN (THERA-M CAPLET)

MULTIVIT,THERAPEUTIC WITH IRON/CALCIUM/FOLIC ACID/MINERALS (SMTHERAPEUTIC M TABLET)

multivit-min/iron fum/folic ac 7.5 mg-400 tablet

MULTIVITAMIN (DAILY VITAMIN FORMULA TABLET)

MULTIVITAMIN (FLINTSTONES TABLET CHEWABLE)

MULTIVITAMIN AND MINERALS COMBINATION NO.55 (CENTRUM FLAVOR BURSTADULT CHW)

MULTIVITAMIN W-CA,IRON,MIN/FOLIC ACID/GUARANA SEED/CAFFEINE (GNP ONEDAILY TABLET)

MULTIVITAMIN W-MINERALS/FOLIC ACID/LYCOPENE/LUTEIN (CENTURY MATUREFORMULA TABLET)

MULTIVITAMIN W-MINERALS/LUTEIN (A THRU Z HIGH POTENCY CAPLET)

MULTIVITAMIN WITH FOLIC ACID (ONE DAILY MULTIVITAMIN TABLET)

MULTIVITAMIN WITH IRON (ONE DAILY MULTIVITAMIN TABLET)

MULTIVITAMIN WITH IRON AND OTHER MINERALS (DINO-LIFE IRON-ZINC TB CHEW)

MULTIVITAMIN WITH IRON AND OTHER MINERALS (PEDIAVIT LIQUID)

MULTIVITAMIN WITH IRON,HEMATINIC (CENTRAL-VITE TABLET)

MULTIVITAMIN WITH MINERALS (RA ONE DAILY ENERGY TABLET)

MULTIVITAMIN WITH MINERALS/FERROUS FUMARAT/FOLIC ACID/LUTEIN (GNPCENTURY ULTIMATE WOMEN TAB)

MULTIVITAMIN WITH MINERALS/FERROUS GLUCONATE (CENTRUM MULTIVIT-MINERAL LIQ)

MULTIVITAMIN WITH MINERALS/FOLIC ACID (HM ONE DAILY ESSENTIAL TABLET)

MULTIVITAMIN WITH MINERALS/FOLIC ACID/CALCIUM CARB/VIT K1 (HM ONE DAILYWOMEN'S 50+)

MULTIVITAMIN WITH MINERALS/FOLIC ACID/GINKGO LEAF EXTRACT (RA ONE DAILY

LAST UPDATED 08/2016

Page 21: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

MEN'S 50+ TABLET)

MULTIVITAMIN WITH MINERALS/FOLIC ACID/LYCOP/LUT/HERBAL 178 (GNP MEGAMULTI FOR MEN TABLET)

MULTIVITAMIN WITH MINERALS/FOLIC ACID/LYCOPENE (ONE DAILY MEN'S HEALTHTABLET)

MULTIVITAMIN WITH MINERALS/FOLIC ACID/LYCOPENE (SM MEN'S ONE DAILYTABLET)

MULTIVITAMIN WITH MINERALS/FOLIC ACID/LYCOPENE/LUTEIN (SENIOR TABS)

MULTIVITAMIN WITH MINERALS/LUTEIN (THERATRUM COMP 50 PLUS TAB)

MULTIVITAMIN, MINERALS, CALCIUM, IRON & AMINO ACIDS (K-PAX SINGLESTRENGTH CAPSULE)

MULTIVITAMIN,STRESS FORMULA (CVS STRESS FORMULA TABLET)

MULTIVITAMIN,STRESS FORMULA/ZINC (STRESS FORMULA-ZINC TABLET)

MULTIVITAMIN,THERAPEUTIC (KENWOOD THERAPEUTIC LIQUID)

MULTIVITAMIN,THERAPEUTIC (THEREMS TABLET)

MULTIVITAMIN,THERAPEUTIC WITH MINERALS (MULTIVITAMIN,THER AND MINERALSTABLET)

MULTIVITAMIN-MINERALS/IRON FUMARATE/FOLIC ACID/PANAX GINSENG (CENTURYENERGY TABLET)

MULTIVITAMIN/FERROUS FUMARATE/FOLIC ACID (CENTRUM COMPLETE MULTIVITTAB)

MULTIVITAMIN/FERROUS FUMARATE/FOLIC ACID (HM COMPLETE WOMEN TABLET)

MULTIVITAMINS W-MINERALS/FOLIC ACID/LYCOPENE/GINKGO LEAF XT (ONE DAILYFOR MEN 50+ ADV TAB)

MULTIVITAMINS WITH IRON (MULTIVITAMINS WITH IRON TABLET)

MULTIVITS W-CA, OTHER MIN/IRON/FOLIC ACID/LYCOPENE (CENTRUM MEN'STABLET)

MULTIVITS W-CA, OTHER MIN/IRON/FOLIC ACID/LYCOPENE (GNP CENTURYULTIMATE MEN'S TAB)

MULTIVITS W-FE,OTHER MIN/GINKGO BILOBA EXTRACT/K.GINSG (RA CENTRAL VITETABLET)

MULTIVITS W-IRON,HEMATINIC (CENTAVITE A-Z W-MINERAL TAB)

MULTIVITS, CA, MINERALS/IRON FUMARATE/FOLIC ACID (GNP ONE DAILY WOMEN'SHLTH TAB)

MULTIVITS, CA, MINERALS/IRON FUMARATE/FOLIC ACID (WOMEN'S DAILY CAPLET)

MULTIVITS,STRESS FORMULA (STRESS 600 TABLET)

MULTIVITS,TH W-CA,FE,OTH MIN (GNP THERAPEUTIC M CAPLET)

MYKIDZ IRON SUSPENSION

NANO VM 1-3 POWDER

NANO VM 4-8 POWDER

LAST UPDATED 08/2016

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DRUG NAME QUANTITY LIMITS

NANO VM 4-8 POWDER

NANO VM T/F LIQUID

NEOCATE NUTRA POWDER

NIACIN (NIACIN 250 MG TABLET)

NUTRITIONAL THERAPY METABOLIC DISORDER,REGULAR (HCU COOLER20 LIQUID)

NUTRIVIT LIQUID

OCUVITE EYE HEALTH GUMMIES

ONE DAILY WOMENS 50 PLUS TAB

ONE-A-DAY MAX FORMULA TAB

ONE-A-DAY MEN'S 50+ TABLET

ONE-A-DAY TEEN HER VITACRAVES

ONE-A-DAY WEIGHTSMART TABLET

ONE-DAILY MULTI-VIT-IRON TAB

OPTISOURCE TABLET CHEW

pediatric multivit comb no.136 tab chew

PEDIATRIC MULTIVIT COMB NO.46/FERROUS SULFATE (POLY-VITA WITH IRONDROPS)

PEDIATRIC MULTIVIT COMB NO.7/FOLIC ACID (FLINTSTONES TAB CHEW)

PEDIATRIC MULTIVITAMIN COMBINATION NO.101 (CVS KIDS' MULTIVITAMIN GUMMY)

PEDIATRIC MULTIVITAMIN COMBINATION NO.23/FOLIC ACID (CHILDREN'SCHEWABLES)

PEDIATRIC MULTIVITAMIN COMBINATION NO.25/FOLIC ACID (ZOO FRIENDS ORIGINALTAB CHEW)

PEDIATRIC MULTIVITAMIN COMBINATION NO.42 (EQ CHILD MULTIVITAMIN GUMMIES)

PEDIATRIC MULTIVITAMIN NO.17/FERROUS SULFATE (CHILDREN'S CHEWABLES)

PEDIATRIC MULTIVITAMIN NO.20 (POLY-VITAMIN DROPS)

PEDIATRIC MULTIVITAMINS A,C,& D3 NO.21 (PEDI MULTIVITS A,C,&D3 NO.21 1500-35/ML DROPS)

pnv103/fa/omega3/dha/fish oil 0.4-32.5mg tab chew

pnv133/ferrous fumarate/fa 28mg-0.8mg tablet

pnv95/ferrous fumarate/fa 28mg-0.8mg tablet

POLY-VI-SOL DROPS

POLY-VI-SOL WITH IRON DROPS

PRENATAL VIT CALC,IRON,FOLIC ACID (LESS THAN 1 MG) (PRENATAL VITCALC,IRON,FOLIC TABLET)

prenatal vit no.124/iron/fa 27mg-0.8mg tablet

prenatal vit/iron fumarate/fa 28mg-0.8mg tablet

LAST UPDATED 08/2016

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DRUG NAME QUANTITY LIMITS

PRENATAL VITAMINS WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID (PRENATALVIT/IRON FUMARATE/FA 27MG-0.8MG TABLET)

prenatal vitamins/fe sulf/fa 27mg-0.8mg tablet

prenatal vits w-ca,fe,fa(<1mg) tablet

PROBARIMIN QT TABLET

PRORENAL QD SOFTGEL

PROSIGHT TABLET

PROTECT PLUS NF LIQUID

PROTEIN SUPPLEMENT (LIQUACEL LIQUID PROTEIN)

PV KIDS VITAMINS CHEW TAB

PV KIDS VITAMINS COMPLETE

PV KIDS VITAMINS+IRON TAB CHEW

PV KIDS VITAMINS+IRON TAB CHEW

PV MULTIVITAL TABLET

PYRIDOXINE HCL (PYRIDOXINE HCL 100 MG TABLET)

QC CHILD COMPLETE VIT CHEW TAB

QC THERIN-M MULTIVT-MINERAL TB

riboflavin 400 mg tablet

SOURCECF PEDIATRIC DROPS

SOURCECF SOFTGEL

STRESS 600 WITH ZINC TAB

STRESS FORMULA WITH IRON TAB

SUNVITE TABLET

THERAPEUTIC M TABLET

THERAPEUTIC VIT-MINERAL CAP

THERAPEUTIC-M CAPLET

THERAPEUTIC-M TABLET

THEREMS-H TABLET

thiamine hcl 100 mg tablet

thiamine mononitrate 100 mg tablet

TOZAL SOFTGEL

TRI-VI-SOL-IRON DROPS

V-R WOMEN'S COMPLEX CAPLET

vit b comp/c/fa/iron/vit e 500-400-18 tablet

VIT B COMPLEX 100 COMBO NO.2 (BALANCED B-100 COMPLEX TAB SA)

LAST UPDATED 08/2016

Page 24: Over-the-Counter Drug List - passporthealthplan.com

DRUG NAME QUANTITY LIMITS

VIT B COMPLEX/VIT C/FOLIC ACID/FERROUS FUMARATE/VIT E ACET (STRESSFORMULA WITH IRON TAB)

VITALETS TABLET CHEWABLE

VITAMIN B COMPLEX (CVS BAL B-50 TABLET)

VITAMIN B COMPLEX/FOLIC ACID (B-STRESS CAPSULES)

vitamins a and d capsule

VITRUM 50+ SENIOR TABLET

WOMEN MULTIVIT W-BIOTIN GUMMY

XAQUIL XR TABLET

ZOO FRIENDS COMPLETE TAB CHEW

ZOO FRIENDS TABLET CHEWABLE

LAST UPDATED 08/2016