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Over-the-Counter Items Benefit
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 overthe-counter medicines with a prescription with a prescription written by your PCP. 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 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 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 Tabs 60mg, 180mg Loratadine Allergy Relief, Children's Loratadine, Loratadine Hives Relief, Children's Allergy Relief Syrup 5mg/5mL Loratadine Loratadine, Allergy, Allergy Relief Tabs 10mg Loratadine Allergy Tab Rapdis 10mg 160mg/5mL ANTIHISTAMINE DRUGS Chlorpheniramine Maleate Fexofenadine HCl OTC Items Benefit | 1 QL (300.00 mL Per 31 Days) OTC Items Benefit | 2 Generic Name Sample Trade Name Dosage Form Strength Susp 144mg/mL Additional Coverage Details ANTHELMINTICS Pyrantel Pamoate Pinworm Treatment, Pyrantel Pamoate, Reese Pinworm COLD & COUGH PREPARATIONS/EXPECTORANTS - SEE ADDITIO N AL 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 AllegraD 12 Hour Tab ER 12H 60mg; 120mg LoratadineD, Allergy Relief Loratadine/Pseudoephedrine Nasal Decongest, Alavert, Sulfate AllergyCongestion Relief Tab 12 5mg; 120mg Loratadine/Pseudoephedrine Allergy Relief And Decogestant, Sulfate ClearAtadine D Tab 24 10mg; 240mg Fexofenadine HCl/ Pseudoephedrine HCl 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 Vanacof / PSE / Chlophed HCl Liquid 1mg 30mg 12.5mg/5mL Dextromethorphan Polistirex Delsym Susp ER 12H 30mg/5mL Robitussin Pediatric Cough Syrup 7.5mg/5mL 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 DM DM / APAP / CPM OTC Items Benefit | 3 OTC Items Benefit | 4 Generic Name Sample Trade Name Dosage Form Strength Brotapp, QTapp DM Elixir 5mg 15mg 1mg/5mL DM / PSE / CPM Kidkare, Pedia Relief Cough Cold, Pediatric CoughCold Liquid 5mg 15mg 1mg/5mL DM / PSE / CPM Mesehist DM Syrup 15mg 15mg 2mg/5mL Cheratussin Ac, Guaifenesin Codeine, 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, RobitussinCoughChest Cong DM, Siltussin DM Syrup 100mg 10mg /5mL Guaifenesin / DM Mucosa DM, Refenesen DM Tablet 400mg 20mg Robafen CF Liquid 100mg 10mg 5mg/5mL 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 DM / PSE / Brompheniramine Guaifenesin / Codeine Phosphate Guaifenesin / DM / PE Guaifenesin / PE Additional Coverage Details 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/ Humulin 70/30, Novolin 70/30 Insulin Regular, Human 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) Novopen 3 Insuln Pen Glucose Chew Lancing Device Each Insulin Admin. Supplies Dextrose Lancing Device OTC Items Benefit | 5 4gm OTC Items Benefit | 6 Generic Name Lancets Sample Trade Name Dosage Form Strength Additional Coverage Details 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% Sodium Chloride For Inhalation Broncho Saline Aerosol 0.9% OTC Items Benefit | 7 QL (15.00 ML per 31 days) OTC Items Benefit | 8 Generic Name Sample Trade Name Dosage Form Strength Additional Coverage Details ELECTROLYTES & MISCELLANEOUS NUTRIENTS 50mg, 100mg, 250mg, 500mg Niacin Niacin Tabs Niacin Niacin SR Capsule ER 500mg Niacin Niacin TR Tablet ER 500mg Calcium Carbonate Calcium Carbonate Tabs 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 Tabs 648mg Magnesium Oxide Tabs 250mg, 400mg, 420mg, 500mg Sodium Phos, MBasic DBasic/Potassium Phos, MBasicDBasic NeutraPhos Powder 250mg/75mL; 278mg/75mL; 164mg/75mL Zinc Sulfate Zinc Sulfate Tabs Oralyte, Oralyte Freezer Pops Solution Calcium Lactate Magnesium Oxide Electrolyte, Oral 1250mg, 1500mg, 6500mg 220mg 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 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 Sorbitol OTC Items Benefit | 9 OTC Items Benefit | 10 Generic Name Sample Trade Name Dosage Form Strength Cimetidine Cimetidine Tabs 200mg Famotidine Famotidine, Acid Controller Tabs 10mg Susp 320mg/5mL Aluminum Hydroxide Aluminum Hydroxide Omeprazole Omeprazole Tablet DR Additional Coverage Details 20mg HEMATINICS & BLOOD CELL STIMULATORS Ferrous Sulfate Ferrous Sulfate Elixir Ferrous Sulfate Ferrous Sulfate Solution Ferrous Sulfate Ferrous Sulfate Tabs Ferrous Sulfate Ferrous Sulfate Tablet DR 324mg, 325mg Ferrous Sulfate Ferrous Sulfate, Slow Release Iron Tablet ER 160mg Caps 150mg Iron Polysaccharides Complex PolyIron 150, Polysaccharide Iron 220mg/5mL 15mg/mL 325mg 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 Misc 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 Miconazole Vaginal 3 Day Vaginal, Miconazole 3, Miconazole 3 Cream Miconazole Vaginal Monistat 7 Combination Pack, MZole Dual Pack Kit Hearing Aid Battery MISCELLANEOUS - VAGINALS OTC Items Benefit | 11 200mg2% 4% 100mg2% OTC Items Benefit | 12 Generic Name Sample Trade Name Dosage Form Strength Additional Coverage Details MISCELLANEOUS - TOPICALS 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 Liquid 4% Permethrin, Lice Treatment Lotion 1% QL (60.00 mL Per 31 Days) Ammonium Lactate, Amlactin Lotion, Cream 12% QL (400.00 gm Per 31 Days) Diphenhydramine HCl Tabs Terbinafine HCl Topical Chlorhexidine Gluconate Permethrin Ammonium Lactate SLEEP-AIDS Diphenhydramine HCl OTC Items Benefit | 13 25mg 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) Tabs 37.5mg; 20mg; 1mg; 0.1mg; 2mg; 1.5mg; 5000 unit; 400 unit VITAMINS - MULTIIVITAMIN, PEDIATRIC, PRENATAL, SINGLE-ENTITY Multivitamin Multivitamin 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 Solution 35mg/mL; 10mg/mL; 1500 unit/mL; 400 unit/mL Iron/Vitamins A,C, & D TriViSol/Iron OTC Items Benefit | 15 OTC Items Benefit | 16 Generic Name Prenatal Vitamins/Ferrous Fumarate/Folic Acid Sample Trade Name Prenatal Dosage Form Strength 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 Vitamin B1 Tabs 100mg 25mg, 50mg, 100mg, 250mg, Thiamine Mononitrate Pyridoxine Vitamin B6, Pyridoxine Tabs Pyridoxine Vitamin B6, Pyridoxine Tablet ER Vitamin B ComplexC Caps 300mg; 10mg; 50mg; 5mg; 10.2mg; 15mg Folic Acid Tabs 200mcg, 400mcg, 800mcg, 1mg Vitamin B12 Tabs 1000mcg Vitamin B ComplexC Folic Acid Cyanocobalamin OTC Items Benefit | 17 Additional Coverage Details 200mg OTC Items Benefit | 18 Notes Notes 50007 110 Fifth Avenue, 3rd Floor New York, NY 10011 NY020878_CAD_OTC_ENG State Approved 01072013 ©WellCare 2013 NY_11_12
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