sign in sign up
<<
Home , Calcium glubionate

FamilyCare Over-the-Counter (OTC) Coverage Guide 2014 Key Therapeutic Drug Categories Effective April 1, 2014

The medications and products listed are This information pertains to: over-the-counter (OTC) items. PHP FamilyCare Prescription ID Card Number: will cover the OTC medication as long as you have a prescription from your doctor. No Benefit Information: co-payment will be due for the OTC prescribed by your doctor. If you do not have a prescription from your doctor, the medication or product will Antivertigo & Antiemetic Agents Keratolytics not be covered. dimenhydrinate (Dimenhydrinate) salicylic acid (Acne Cleansing Pads) The OTC medication or product may work just meclizine HCl (Meclizine HCl) as well as the more expensive prescription drugs Lipid/Cholesterol-Lowering Agents you may be taking. Blood Glucose Monitoring Devices niacin (Niacin) To get one of the OTC medications for a $0 & Supplies co-payment, please follow these steps: Miscellaneous Agents urine acetone test, tablet (Acetest Reagent) • Show this list to your doctor. urine glucose acet comb.tst, strip (Diascreen 9) • Ask whether one of the products would be cough drops (Cough Drops) good for your condition. urine glucose test, tablet (Clinitest Analysis Set) glucosamine HCl/chondro su a • If your doctor agrees, ask him or her to write a urine multiple test (Labstix Reagent) (Glucosamine/Chondroitin) prescription for the OTC version. • Go to a pharmacy in the PHP FC network. Decongestants/Antihistamines oxymetazoline HCl (Nasal Spray) Show your PHP FC card and Medicaid phenylephrine HCl (Nasal Decongestant) MIHEALTH card when you go to the pharmacy. cetirizine HCl/pseudoephedrine (Zyrtec D polysorbates (Tween) OTC) chloride (Saline Nose Spray/Mist) If you have questions about your prescription loratadine/pseudoephedrine (Claritin-D) drug coverage, please call PHP FC Customer sodium Cl irrig soln Service Department at 1 800 661-8299. phenylephrine HCl (Non-Pseudo Sinus Decongestant) ( for Irrigation) phenylephrine HCl/apap (Sinus PE) (Anticavity Fluoride) Antidiarrheals phenylephrine HCl/chlor-mal sorbitol solution (Sorbitol) acidophilus/lactobac spor (Acidophilus) (Sinus & Allergy Decongestant) stannous fluoride gel (Gel-kam) bismuth subsalicylate (Pepto-Bismol) pse/chlor-mal (Cold & Allergy PE) urine albumin test (Micro-Bumintest) kaolin/pectin (Kaolin w/Pectin) pse/loratadine (Allergy Relief And loperamide HCl (Anti-Diarrheal) Decongestant) Miscellaneous Analgesics pse/triprolidine HCl acetaminophen (apap) (Tylenol) Antihistamines (Allergy Relief and Phedrin) apap/caffeine (Excedrin Tension Headache) cetirizine HCl (Zyrtec OTC) pseudoephedrine HCl (pse) (Sudafed) apap/dp-hydramine (Headache Relief PM) chlorpheniramine maleate Diaphragms and Other Non-oral (Chlorpheniramine Maleate) Miscellaneous Dermatologicals clemastine fumarate (Clemastine Fumarate) Contraceptives fexofenadine (Allegra) aluminum acetate (Hydrosal) loratadine (Loratadine) condoms (Condoms) amlactin (Lac-Hydrin) nonoxynol 9 (Nonoxynol 9) Antipsoriatics/Antiseborrheics bismuth formic iodide (Bismuth Formic Iodide) Expectorant Combinations calamine (Calamine) sulfide (Selsun Blue) capsaicin (Capzasin-HP/Zostrix-HP) guaifen (Mucus Relief) Antitussive Combinations guaifen/ephedrine HCl (Bronchial) chlorhexidine gluconate (Hibiclens) colloidal oatmeal (Colloidal Oatmeal) dm hb/pse (Robitussin Maximum) guaifen/phenylephrine HCl (Robitussin PE) colloidal oatmeal/dimethicone dm hb/pse/apap/cp (Severe Cold & Flu) H2 Antagonists dm hb/pse/bpm (Cold & Allergy DM) (Colloidal Oatmeal Lotion) dm hb/pse/cp (Child Cough & Cold) cimetidine, famotidine, ranitidine HCl diphenhydramine HCl (Benadryl) dm hbr (Robitussin DM Cough) (Acid Reducer) lanolin anhydrous ointment (Lanolin) dm hbr/cp (Coricidin HBP) nizatidine (Axid AR) oil (emollients) (Mineral Oil) dm polistirex (Delsym) Insulin Syringes/Miscellaneous mineral oil/pet hy-phl (Aquaphor) dm/apap/cp (Flu Relief BP) mineral oil/pet, white (Eucerin) dm/apap/doxylamn Durable Medical Equipment (Nighttime Cold & Flu Relief) pantothenic acid/aloe vera (Excel-Gel) dm/pse/apap/diphenhydram (Flu Relief ) alcohol swabs (Alcohol Swabs) urea (Carmol 10 and 20/Ureacin) guaifen/dm hb (Robitussin-DM/Mucinex) lancets (Lancets) vitamin e acetate (Vitamin E) guaifen/dm hb/pse (Robitussin CF) test strips (Accu-Chek, OneTouch, Sure Step) oxide () Please note: This member guide does not contain a complete list of formulary drugs. It only lists the top 100 medications. The member must present a prescription to the Pharmacy in order for the over-the-counter product to be billed. The member will not have a co-payment for over-the-counter products that are filled generically. FORM# FF44816E This information is in effect at the time of printing and may be subject to change. (Ed. 3/14) Note: This prescription drug list (PDL) is for Physicians Health Plan FamilyCare, MIChild, MIChild Childrens Special Health Care Services and Healthy Michigan. Miscellaneous Gastrointestinal Agents Other Electrolytes hydrocortisone acetate (Lanacort) bisacodyl (Dulcolax) (Calcium) Topical Scabicides/Pediculicides (Calcium Carbonate) calcium carbonate (Tums) permethrin (Permethrin) calcium carbonate (antacid) (Calcium Antacid) electrolyte,oral (Electrolyte) piperonyl butoxide/pyrethrins (Lice Treatment) calcium polycarbophil (Fibercon) lytes/carboxymethylcellulose (Saliva Substitute) castor oil (Castor Oil) oxide () Urinary Anesthetics dibucaine (Nupercainal) naph,mb-db/k ph,mbdb (Neutra-Phos/Phos-Nak) (Zinc Gluconate) phenazopyridine HCl (Urinary Pain Relief) docusate calcium (Calcium Stool Softener) (Zinc Sulfate) docusate sodium (Docusate Sodium ) Vaginal Antifungals docusate sodium w/casantranol (Docusate Plus) glycerin (Glycerin) clotrimazole (Clotrimazole) hydrocortisone acetate (Anusert HC) potassium (Potassium) miconazole nitrate (Miconazole Nitrate 3 & 7) ipecac (Ipecac) Proton Pump Inhibitors Vasoconstrictor Decongestants mag hydrox/al hydrox/simeth (Antacid Extra Strength) omeprazole OTC (Prilosec OTC naphazoline HCl (Clear Eyes) (Magnesium Citrate) lansoprazole (Prevacid OTC, Susp) naphazoline HCl/phenir mal (Visine-A) magnesium hydroxide (Milk of Magnesia) oxymetazoline (Afrin) magnesium hydroxide/al hydrox (Rulox) Salicylates phenylephrine HCl (Altafrin) (Epsom Salt) asa/apap/caffeine (Pain Reliever Extra Strength) tetrahydrz/dext 70/peg 400/pvp (Eyedrops) melatonin (Meladox) asa/calcium carb/mag/al hydrox (Aspir-Mox IB) Vi tami ns & Hemati ni cs methylcellulose (Citrucel) asa/mag hydrox/al hydrox na phos,m-b/na phos,di-ba (Enema) (Arthritis Pain Formula) ascorbate calcium (Vitamin C) naph,mb-db/pramoxine HCl/gly aspirin (Adult Aspirin) ascorbic acid (Ascorbic Acid) (Fleet P-S Accu-Prep) effervescent antacid (Alka-Seltzer) ascorbic acid/zinc (Zinc) calcium (Calcium) pe/shark liver/gly/pet,wh (Hem-Prep) Smoking Deterrents polyethylene glycol (MiraLax) calcium carb/vit D3/minerals (Calcium Plus D) psyllium seed/dextrose (Natural Psyllium Fiber) nicotine gum (Nicotine Gum) calcium carbonate (Calcium Carbonate) psyllium seed/sucrose (Fiber) nicotine lozenges (Nicorette) calcium carbonate/vit C/vit D3/e/mn nicotine patch (Nicoderm CQ) (Calcium Ultra) sennosides (Senna) calcium carbonate/vitamin D2 sennosides/docusate sodium (Senna S) Therapy For Acne (Oyster Shell Calcium) simethicone (Anti-Gas) with D (Calcium Citrate with D) sodium bicarbonate (Antacid) benzoyl peroxide (Benzoyl Peroxide) salicylic acid/ (Sebasorb) calcium glubionate (Calcionate) Miscellaneous Nutrition Products calcium phosphate/vitamin D3 (Calvite P&D) Topical Anesthetics calcium/mag oxide/vitamin D3 acidophilus/bulgaricus (Floranex) (Coral Calcium Plus) lactase enzyme tablet benzocaine (Orajel) cyanocobalamin (Vitamin B-12) lactobacillus acidophilus (Acidophilus) benzocaine (Sore Throat) cyanocobalamin/fa/pyridoxine (Foltabs 800) medium chain triglycerides (Mct Oil) benzocaine/menthol (Lozenges) ergocalciferol (Calciferol) benzocaine/povidone-/phe ferrous fumarate (Ferrous Fumarate 324) Miscellaneous Ophthalmologics (Oral Anesthetic) ferrous fumarate/docusate na benzocaine/triclosan (Solarcaine) ( with Stool Softner) carboxymethylcellulose sodium (Refresh Tears) dibucaine (Dibucaine) ferrous gluconate (Ferrous Gluconate) dextran 70/hypromellose (Tears Plus) phenol/sodium phenolate (Throat Lozenge) ferrous sulfate (Ferrous Sulfate) hypromellose (Hypromellose) folic acid (Folic Acid) ketotifen fumarate (Zaditor) Topical Antibacterials folic acid/vitamin B comp w-C (Nephro-vite) mineral oil/petrolatum,white (Lubricant Eye) bacitracin (Bacitracin) mag sulf/vitamin B comp w-C/zn (Magan C-7) polyvinyl alcohol (Artificial Tears) bacitracin/polymyxin b sulfate multivitamins (tablet, chew, liquid) sodium chloride (eye preps) (Double Antibiotic) (Multivitamins) (Muro-128/Sodium Chloride Eye Preps) iodine/ (Iodine) multivitamins w/iron (tablet, chew, liquid) neomy sulf/bacitra/polymyxin b (Multivitamins w/iron) Miscellaneous Otic Preparations (Triple Antibiotic/HM Triple Antibiotic/ multivitamins w/minerals (tablet, chew, liquid) carbamide peroxide (Ear Wax Drops) Triple Antibiotic Oint.) (Multivitamins W/minerals) neomy sulf/bacitrac zn/poly (Trisporic) prenatal vitamin (Prenatal Vitamin) Miscellaneous Pulmonary Agents povidone-iodine (Iodex-P) pyridoxine HCl (Vitamin B-6) thiamine HCl (Vitamin B-1) cromolyn sodium (Cromolyn Sodium) Topical Antifungals vitamin A/vit B comp/vitamin E (Apetigen) sodium Cl for inhalation ketoconazole (Nizoral A-d) vitamin A/vit C/vitamin E/zinc (Vi-Zac/Azec) (Sodium Chloride For Inhalation) miconazole nitrate (Lotrimin AF/Neosporin vitamin a/vit c/zinc/propolis (Zinc (Vit. A/ water for inhalation (Sterile Water) AF/Zeasorb-AF) Vit. C/Zinc/Propolis)) terbinafine HCl (Lamisil AT) vitamin A/vitamin D2/cod liver NSAIDs tolnaftate (Antifungal) (Scott's Emulsion) ibuprofen (Motrin) vitamin B complex (Vitamin B Complex) ketoprofen (Orudus) Topical Corticosteroids, Low Potency vitamin E/vitamin B comp w-C naproxen sodium (Aleve) hydrocortisone (Cortizone/cortizone-10/hytone) (Stress Formula w/vitamin C) Please note: This member guide does not contain a complete list of formulary drugs. It only lists the top 100 medications. The member must present a prescription to the Pharmacy in order for the over-the-counter product to be billed. The member will not have a co-payment for over-the-counter products that are filled generically. This information is in effect at the time of printing and may be subject to change. Note: This prescription drug list (PDL) is for Physicians Health Plan FamilyCare, MIChild, MIChild Childrens Special Health Care Services and Healthy Michigan.