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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