over-the-counter items benefit - new york | wellcare€¦ · over-the-counter items benefit...
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Over-the-Counter Items
Benefit
WellCare provides New York statesponsored health insurance programs. These are free or lowcost.
Want more information about Medicaid Managed Care and Family Health Plus? Call
New York Medicaid Choice at 1-800-505-5678.
You can get your over-the-counter medicines
with a prescription written by your PCP. with a prescription
written by your PCP.
1-800-288-5441 TTY 18772476272
A WellCare representative is waiting to talk to you!
WellCare provides New York statesponsored health insurance programs. These are free or lowcost.
Want more information about Medicaid Managed Care and Family Health Plus? Call New York
Medicaid Choice at 1-800-505-5678.
Generic Name Sample Trade Name Dosage
Form Strength
Additional Coverage Details
ANALGESICS, ANTI-INFLAMMATORY AGENTS AND ANTIPYRETICS
Acetaminophen Children's Silapap, QPap, Mapap, Children's Apap, Children's Pain & Fever
Liquid, Solution
160mg/5mL
Acetaminophen Mapap, Pain & Fever, QPap, QPap Extra Strength, Tactinal
Tabs 325mg QL (279.00 Ea Per 31 Days)
Acetaminophen Mapap, Pain & Fever, QPap, QPap Extra Strength, Tactinal
Tabs 500mg QL (186.00 Ea Per 31 Days)
Aspirin Aspir 81, Aspirin Ec, AspirLow Tabs 81mg
Aspirin Aspirin Childrens Chew 81mg
Aspirin Aspirin Supp 300mg, 600mg
Aspirin Aspirin Tabs 325mg
Ibuprofen Children's Ibuprofen, IbuDrops, Infant's Ibuprofen
Susp 40mg/mL
Ibuprofen Children's Ibuprofen Susp 100mg/5mL
Ibuprofen Ibuprofen Tabs 200mg
ANTIHISTAMINE DRUGS
Chlorpheniramine Maleate Chlorpheniramine Maleate, AllerChlor, Allergy
Tabs 4mg
Diphenhydramine HCl Diphenhydramine HCl, Allergy Relief, Banophen, Diphenhist, QDryl
Caps 25mg/50mg
Diphenhydramine HCl
Diphenhydramine HCl, Banophen, Benadryl Allergy Childrens, Diphenhist, QDryl, Siladryl
Liquid 12.5mg/5mL
Cetirizine HCl Cetirizine HCl Syrup 5mg/5mL QL (300.00 mL Per 31 Days)
Cetirizine HCl Cetirizine HCl Childrens, Children's All Day Allergy, Children's Allergy Relief
Solution 1mg/mL QL (300.00 mL Per 31 Days)
Cetirizine HCl Cetirizine HCl, All Day Allergy Tabs 5mg, 10mg
Fexofenadine HCl Fexofenadine HCl Tabs 60mg, 180mg
Loratadine Allergy Relief, Children's Loratadine, Loratadine Hives Relief, Children's Allergy Relief
Syrup 5mg/5mL QL (300.00 mL Per 31 Days)
Loratadine Loratadine, Allergy, Allergy Relief Tabs 10mg
Loratadine Allergy Tab Rapdis 10mg
OTC Items Benefit | 1 OTC Items Benefit | 2
Generic Name Sample Trade Name Dosage
Form Strength
Additional Coverage Details
ANTHELMINTICS
Pyrantel Pamoate Pinworm Treatment, Pyrantel Pamoate, Reese Pinworm
Susp 144mg/mL
COLD & COUGH PREPARATIONS/EXPECTORANTS - SEE ADDITIONAL LIST BELOW
Pseudoephedrine HCl Pseudoephedrine HCl, Sudogest Tabs 30mg, 60mg
Pseudoephedrine HCl/ Triprolidine HCl
Silafed Syrup 30mg/5mL; 1.25mg/5mL
Pseudoephedrine HCl/ Triprolidine HCl
Actanol, Aprodine, Genac, TriAfed Allergy/Head Cold
Tabs 60mg; 2.5mg
Cetirizine HCl/ Pseudoephedrine HCl ER
CetirizinePseudoephedrine Tab ER 12H 5mg; 120mg
Fexofenadine HCl/ Pseudoephedrine HCl
AllegraD 12 Hour Tab ER 12H 60mg; 120mg
Loratadine/Pseudoephedrine Sulfate
LoratadineD, Allergy ReliefNasal Decongest, Alavert, AllergyCongestion Relief
Tab 12 5mg; 120mg
Loratadine/Pseudoephedrine Sulfate
Allergy Relief And Decogestant, ClearAtadine D
Tab 24 10mg; 240mg
Guaifenesin Guaifenesin, QTussin, Robafen, Siltussin Sa
Syrup 100mg/5mL
Guaifenesin Guaifenesin, Mucus Relief, Chest Congestion Relief
Tabs 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
Children's Cold & Cough, Dimaphen DM, Rynex DM
Solution 1mg 2.5mg
5mg/5mL
Dexchlorpheniramine Maleate / PSE / Chlophed HCl
Vanacof Liquid 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 CoughSinus Oral Susp 5mg 160mg 1mg/5mL
DM / CPM Dimetapp LongActing, Robitussin LongActing
Liquid 7.5mg 1mg/ 5mL
DM / PE / CPM CorfenDM, NohistDM Liquid 15mg 10mg 4mg/5mL
DM / PE / CPM DeChlor DM, TriDex PE Syrup 15mg 10mg
2mg/5 mL
OTC Items Benefit | 3 OTC Items Benefit | 4
Generic Name Sample Trade Name Dosage
Form Strength
Additional Coverage Details
DM / PSE / Brompheniramine Brotapp, QTapp DM Elixir 5mg 15mg
1mg/5mL
DM / PSE / CPM Kidkare, Pedia Relief CoughCold, Pediatric CoughCold
Liquid 5mg 15mg
1mg/5mL
DM / PSE / CPM Mesehist DM Syrup 15mg 15mg
2mg/5mL
Guaifenesin / Codeine Phosphate
Cheratussin Ac, GuaifenesinCodeine, IophenC NR
Liquid 100mg 10mg
/5mL
Guaifenesin / DM
Diabetic SiltussinDM, Iophen DMNR, Siltussin DM Das Cough Formula, Diabetic Tussin DM, Child Mucus Relief Cough, Mucinex FastMax DM Max
Liquid 100mg 10mg
/5mL
Guaifenesin / DM Diabetic Tussin DM, Diabetic Tussin MaxStrength
Liquid 200mg 10mg
/5mL
Guaifenesin / DM
Cough, Extra Action Cough, QTussin DM, RobafenDM Clear, RobitussinCoughChestCong DM, Siltussin DM
Syrup 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, ResconGG Liquid 100mg 5mg
/5mL
PSE / Codeine / CPM Phenylhistine DH Liquid 30mg 10mg
2mg/5mL
PSE / Codeine Phos / Guaifenesin
Cheratussin DAC Syrup 30mg 10mg
100mg/5mL
DIABETIC THERAPY AND SUPPLIES
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 30 unit/mL; 70 unit/mL
QL (60.00 mL Per 31 Days)
NPH, Human Insulin Isophane Humulin 70/30 Pen Insuln Pen 30 unit/mL; 70 unit/mL
QL (60.00 mL Per 31 Days)
NPH, Human Insulin Isophane Humulin N U100 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
Generic Name Sample Trade Name Dosage
Form Strength
Additional Coverage Details
Lancets Lancets Each
Blood Sugar Diagnostic AccuChek [Active, Aviva Plus, Comfort Curve, Smartview] Strips
Strip QL (100.00 Ea Per 31 Days)
Blood Sugar Diagnostic Freestyle Insulinx Blood Glucose Test; Lite Test Strips
Strip QL (100.00 Ea Per 31 Days)
Blood Sugar Diagnostic Precision Xtra Blood Glucose Test Strips
Strip QL (100.00 Ea Per 31 Days)
Blood Sugar Diagnostic, DrumType
AccuChek Compact Strip, AccuChek Compact Drum Strips
Strip QL (100.00 Ea Per 31 Days)
Urine Acetone Test Strips Ketostix Strip QL (100.00 Ea Per 31 Days)
Urine Glucose Test Strips Clinistix, Diastix Strip QL (100.00 Ea Per 31 Days)
BloodGlucose Meter AccuChek Nano Smartview, Freestyle Insulinx Blood Glucose Monitoring System, Precision Xtra
Each QL (2.00 Ea Per 365 Days)
BloodGlucose Meter AccuChek Aviva Plus, Freestyle Freedom Lite, Freestyle Lite Blood Glucose Monitoring System
Kit QL (2.00 Ea Per 365 Days)
BloodGlucose Meter, DrumType
AccuChek Compact Plus Care Kit Kit QL (2.00 Ea Per 365 Days)
BloodGlucose Calib. Control AccuChek Active Glucose Sol, AccuChek Cmfrt Curve Soln, Medisense HML Control Soln
Solution
Blood Glucose Calibration Control High And Low
AccuChek Aviva Each
Blood Glucose Calibration Control Solution, Normal
AccuChek Active Glucose, AccuChek Cmfrt Curve
Combo. Pkg
Blood Glucose Calibration Control Solution, High And
Normal AccuChek Compact Blue Bottle
EENT DRUGS, MISCELLANEOUS
Cromolyn Sodium Cromolyn Sodium Nasal Spray/ Pump
5.2mg/act
Ketotifen Fumarate Ketotifen Fumarate, Alaway, Eye Itch Relief, Zaditor
Ophthalmic Solution
0.025%
Polyvinyl Alcohol Artificial Tears Ophthalmic Solution
1.4% QL (15.00 ML per 31 days)
Sodium Chloride For Inhalation
Broncho Saline Aerosol 0.9%
OTC Items Benefit | 7 OTC Items Benefit | 8
Generic Name Sample Trade Name Dosage
Form Strength
Additional Coverage Details
ELECTROLYTES & MISCELLANEOUS NUTRIENTS
Niacin Niacin Tabs 50mg, 100mg, 250mg, 500mg
Niacin Niacin SR Capsule ER 500mg
Niacin Niacin TR Tablet ER 500mg
Calcium Carbonate Calcium Carbonate Tabs 1250mg, 1500mg,
6500mg
Calcium Carbonate CalLac Caps 500mg
Calcium Carbonate Calcium Carbonate Susp 1250mg/5mL
Calcium Carbonate/ Cholecalciferol (Vitamin D3)
Calcium With Vitamin D Chew 500mg
Calcium Carbonate/ Cholecalciferol (Vitamin D3)
Calcium Carbonate/Vitamin D Tabs 600mg; 400 unit
Calcium Lactate Calcium Lactate Tabs 648mg
Magnesium Oxide Magnesium Oxide Tabs 250mg, 400mg, 420mg, 500mg
Sodium Phos, MBasicDBasic/Potassium Phos,
MBasicDBasic NeutraPhos Powder
250mg/75mL; 278mg/75mL; 164mg/75mL
Zinc Sulfate Zinc Sulfate Tabs 220mg
Electrolyte, Oral Oralyte, Oralyte Freezer Pops Solution 35meq/l; 25gm/l;
20meq/l; 45meq/l; 7.8mg/l
QL (4000.00 mL per 31 days)
GASTROINTESTINAL DRUGS - ANTINAUSEANTS, LAXATIVES, H2-ANTAGONISTS, PROTON-PUMP INHIBITORS
Meclizine HCl Meclizine HCl, Travel Motion Sickness
Tabs 12.5mg
Meclizine HCl Meclizine HCl, MediMeclizine Tabs 25mg
Meclizine HCl Meclizine HCl, Travel Sickness Chew 25mg
Sorbitol Sorbitol Solution 70%
Docusate Calcium Docusate Calcium Caps 240mg
Docusate Sodium DocQLace, Dok, Stool Softener Caps 100mg, 250mg
Docusate Sodium Dok, Stool Softener Tabs 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
Tabs 75mg
OTC Items Benefit | 9 OTC Items Benefit | 10
Generic Name Sample Trade Name Dosage
Form Strength
Additional Coverage Details
Cimetidine Cimetidine Tabs 200mg
Famotidine Famotidine, Acid Controller Tabs 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 Tabs 325mg
Ferrous Sulfate Ferrous Sulfate Tablet DR 324mg, 325mg
Ferrous Sulfate Ferrous Sulfate, Slow Release Iron Tablet ER 160mg
Iron Polysaccharides Complex PolyIron 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 QL (2.00 each per 365 days)
Nebulizer Accessories Optichamber Face Mask Small / Medium / Large
Each QL (2.00 each per 365 days)
Hearing Aid Battery Hearing Aid Battery Misc
MISCELLANEOUS - VAGINALS
Clotrimazole Vaginal Clotrimazole, Clotrimazole 3 Day, GyneLotrimin
Cream 1%, 2%
Miconazole Vaginal GyneStat7, 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 200mg2%
Miconazole Vaginal 3 Day Vaginal, Miconazole 3, Miconazole 3
Cream 4%
Miconazole Vaginal Monistat 7 Combination Pack, MZole Dual Pack
Kit 100mg2%
OTC Items Benefit | 11 OTC Items Benefit | 12
Generic Name Sample Trade Name Dosage
Form Strength
Additional Coverage Details
MISCELLANEOUS - TOPICALS
Terbinafine HCl Topical Terbinafine HCl, Antifungal, Athlete's Foot
Cream 1%
Clotrimazole Topical AntiFungal, Clotrimazole, Lotrimin AF, Mycelex
Solution 1%
Clotrimazole Topical AntiFungal, Athlete's Foot, Athletic Foot Cream
Cream 1%
Miconazole Topical Antifungal Cream, Miconazole Nitrate
Cream 2%
Hydrocortisone
Hydrocortisone Maximum Strength, Hydrocortisone Maximum Strength Plus 12 Moisturizers, Hydroskin
Cream 1%
Hydrocortisone Hydrocortisone 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, OneStep Plantar Wart Remover, OneStep Wart Remover
Pads 40%
Salicylic Acid Compound W, Duofilm Liquid 17%
Salicylic Acid Compound W Maximum
Strength, SalPlant Gel 17%
Salicylic Acid Salactic Film, WartOff 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 12% QL (400.00 gm Per 31 Days)
SLEEP-AIDS
Diphenhydramine HCl Diphenhydramine HCl Tabs 25mg
OTC Items Benefit | 13 OTC Items Benefit | 14
Generic Name Sample Trade Name Dosage
Form Strength
Additional Coverage Details
SMOKING CESSATION AGENTS
Nicotine Nicotine, Nicotine Patch, Nicoderm CQ, NTS
Patch 7mg/24hr, 14mg/24hr, 21mg/24hr
QL (140.00 Ea Per 365 Days)
Nicotine Polacrilex Nicotine Gum, Nicorelief, Nicorette
Gum 2mg, 4mg QL (4032.00 Ea Per 365 Days)
VITAMINS - MULTIIVITAMIN, PEDIATRIC, PRENATAL, SINGLE-ENTITY
Multivitamin Multivitamin Tabs
37.5mg; 20mg; 1mg; 0.1mg; 2mg; 1.5mg; 5000 unit;
400 unit
Multivitamin PolyVitamin Drops Solution
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
Multivitamins with Iron PolyVitamin/Iron Drops Solution
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
Pediatric Multivitamins A,C, & D3 No.21
TriVitamin Solution 35mg/mL;
400 unit/mL; 1500 unit/mL
Pediatric Multivitamins A,C, & D3 No.21
TriVitamin Solution 35mg/mL;
1500 unit/mL; 400 unit/mL
Iron/Vitamins A,C, & D TriViSol/Iron Solution
35mg/mL; 10mg/mL;
1500 unit/mL; 400 unit/mL
OTC Items Benefit | 15 OTC Items Benefit | 16
Generic Name Sample Trade Name Dosage
Form Strength
Additional Coverage Details
Prenatal Vitamins/Ferrous Fumarate/Folic Acid
Prenatal Tabs
100mg; 0; 200mg; 400 unit; 4mcg; 27mg; 0.8mg; 18mg; 2.6mg; 1.7mg; 1.5mg;
4000 unit; 11mg; 25mg
Prenatal Vitamins/Ferrous Fumarate/Folic Acid
Prenavite Tabs
120mg; 0; 200mg; 400 unit; 8mcg; 28mg; 800mcg; 20mg; 2.6mg; 1.7mg; 1.8mg;
30 unit; 4000 unit; 25mg
Vitamin A Vitamin A Caps 8000 unit, 10000 unit
Thiamine Vitamin B1, Thiamine HCl Tabs 50mg, 100mg,
250mg
Thiamine Mononitrate Vitamin B1 Tabs 100mg
Pyridoxine Vitamin B6, Pyridoxine Tabs 25mg, 50mg,
100mg, 250mg,
Pyridoxine Vitamin B6, Pyridoxine Tablet ER 200mg
Vitamin B ComplexC Vitamin B ComplexC Caps 300mg; 10mg; 50mg; 5mg;
10.2mg; 15mg
Folic Acid Folic Acid Tabs 200mcg, 400mcg,
800mcg, 1mg
Cyanocobalamin Vitamin B12 Tabs 1000mcg
OTC Items Benefit | 17 OTC Items Benefit | 18
Notes Notes
110 Fifth Avenue, 3rd FloorNew York, NY 10011
NY020878_CAD_OTC_ENG State Approved 01072013 ©WellCare 2013 NY_11_12
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