Over-the-Counter (OTC) Applies to: Tufts Health RITogether and Tufts Health Together*

As communicated in the November 1, 2018 Provider Update, the following changes are effective for fill dates on or after January 1, 2019. As a result of this change, some OTC medications will require prior authorization in certain circumstances as outlined below:

Brand-Name OTC Has a Covered Interchangeable Generic Version Available

Afrin No Drip Advil capsule Advil tablet Advil PM tablet Afrin Nasal Spray Original nasal solution

Afrin No Drip Oatmeal Severe nasal Aleve tablet Baciguent ointment capsule Bath Pak Treatment solution

Benadryl Benadryl Allergy Benadryl Allergy Benadryl Extra Benefiber powder tablet capsule Liquid Strength cream

Caltrate 600 +D Centrum Silver Betadine Swabstick Caltrate + D tablet Centrum liquid Plus Minerals tablet tablet

Centrum Silver Centrum Ultra Men’s Children’s Advil Centrum tablet Cheracol-D syrup Adult 50+ tablet tablet suspension

Children’s Benadryl Citracal Calcium + Children’s Benadryl Children’s Chlor-Trimeton Allergy chewable D Slow Release Allergy liquid suspension syrup tablet tablet

Citrucel Fiber Claritin-D 12 hour Claritin-D 24 hour Clear Cough Liquid Citrucel tablet powder tablet tablet PM

Dimetapp DM Dex4 Fast Acting Dimetapp Cold and Colace capsule Conceptrol 4% gel Cough and Cold Glucose liquid Allergy elixir elixir

Dristan nasal spray Dulcolax tablet D-Vi-Sol liquid Ecotrin tablet Evac powder

Ex-Lax chewable Gas-X chewable Feosol tablet Fer-In-Sol solution Fleet enema tablet tablet

Gas-X Extra Gaviscon Extra Genteal Mild to Gelusil chewable Strength chewable Strength chewable Genteal Gel Moderate tablet tablet tablet ophthalmic solution

Geritol Complete Glycerin Adult Gonak ophthalmic Gyne-Lotrimin 1% Gyne-Lotrimin 3 tablet suppository solution vaginal cream cream

Hydrocil Instant Icar Pediatric Hemocyte tablet Hibiclens liquid Imodium A-D liquid packet Suspension

Maalox Advanced Infants’ Tylenol Imodium A-D tablet Konsyl powder Lotrimin AF cream Maximum strength Suspension tablet

Monistat 3 Combo Monistat 3 Magox tablet Monistat 1 Monistat-3 cream Pack Combination pack

Monistat Soothing Muro 128 Monistat 7 Motrin Infant Drops Care Itch Relief Mucinex-DM tablet ophthalmic cream ointment

Muro 128 DS Naphcon-A Mylanta suspension Nasalcrom spray ophthalmic solution suspension ophthalmic solution

Revised 10/2018 1 Over-the-Counter (OTC) Medications – Tufts Health RITogether and Tufts Health Together

Brand-Name OTC Medication Has a Covered Interchangeable Generic Version Available

Neosporin Plus Pain Neosporin Original One-A-Day Men’s Relief Maximum Nicoderm CQ patch Ocean Nasal Spray ointment tablet Strength

One-A-Day One-A-Day One-A-Day Scooby Vitacraves Gummies Opcon-A ophthalmic Pedia-Lax Women’s Formula Chewables + Omega 3 DHA solution suppository tablet chewable tablet

Pedialyte Advanced Pedialyte Electrolyte Pedialyte Freezer Pepcid AC Maximum Pedialyte solution Care solution Singles Pops Strength tablet

Pepto-Bismol Pepto-Bismol Refresh Plus Pepto-Bismol tablet Phillips tablet chewable tablet suspension ophthalmic solution

Refresh Tears Sudafed Congestion Rid Aerosol Senokot-S tablet Slo-Niacin tablet ophthalmic solution tablet

Tums Lasting Tinactin 1% aerosol Tums chewable Tagamet HB tablet Tinactin 1% aerosol Effects chewable powder tablet tablet

Tylenol Children’s Tylenol Children’s Tylenol tablet Tylenol Arthritis Tylenol 8 Hour Pain and Fever Chewable tablet Chewable tablet

Tylenol Infants Tylenol Cough Sore Tylenol Extra Tylenol PM Extra Fever and Pain Unisom tablet Throat liquid Strength tablet Strength tablet suspension

Vick’s Sinex 12 Advanced Visine ophthalmic Visine Extra Vitacraves + Omega Hour Relief ophthalmic solution ophthalmic solution 3 Chews solution solution

Zantac 150 Zaditor ophthalmic Zyrtec Allergy Zantac 75 tablet Maximum Strength Zyrtec Allergy tablet solution capsule tablet

Zyrtec Children’s Zyrtec-D Allergy/ Zyrtec tablet ZZZquil liquid Allergy oral solution Congestion tablet

Brand-Name OTC Medication Does Not Have an Interchangeable Generic Version Available and Requires Prior Authorization

Allergy Multi Pak Antacid Soft chews Aquaphor Advanced Aquadeks Aquaphor Day/Night tablet Therapy

Ayr Nasal Drops Baridium tablet Benefiber Drink Mix Brotapp DM elixir Cerave cream

Centravites Adults Centrum Silver Ultra Centrum Silver Ultra Centrum Silver Centrum Ultra tablet Men’s tablet Women’s tablet Women’s tablet Women’s tablet

Children’s Zyrtec Cerovite Advanced Certavite Senior Children’s Claritin Claritin chewable Allergy orally Formula liquid tablet chewable tablet tablet disintegrating tablet

Eq Sinus Relief Clean & Clear Eq One Daily Men’s Eq One Daily Claritin Reditabs Maximum Strength Advantage lotion tablet Women’s tablet tablet

Freshkote Isopto Tears Histex Liquid Hydralyte solution Lohist-D liquid ophthalmic solution ophthalmic solution

Revised 10/2018 2 Over-the-Counter (OTC) Medications – Tufts Health RITogether and Tufts Health Together

Brand-Name OTC Medication Does Not Have an Interchangeable Generic Version Available and Requires Prior Authorization

Metamucil Fiber Metamucil Metamucil Smooth Miconazole 1 kit Mucinex tablet Singles Multihealth Fiber Texture packet Combo

Nexafed Sinus Multivitamin Adults Multivitamin Men’s Multi-Delyn liquid Multi Prenatal tablet Pressure and Pain tablet tablet tablet

Non-Drying Sinus Nortemp Infants Pedia-Lax chewable Prenatal One Daily Oncovite tablet PE tablet suspension tablet tablet

Refresh Optive Prenatal RA APAP Flu Severe Refresh Liquigel Prilosec OTC tablets Advanced tablet Cold tablet ophthalmic solution ophthalmic solution

Refresh Optive Spectravite Senior Right Step Prenatal Spectravite Adult Spectravite Adult Sensitive Ultra Women’s Vitamin tablet 50+ tablet gummies ophthalmic solution tablet

Spectravite Ultra Spectravite Ultra Spectravite Ultra Sudafed Severe Women’s Health Thera-M tablet Men's tablet Men’s 50+ tablet Cold tablet tablet

Theranatal Lactation Tums Chewy Thera M Plus tablet Thera-Tabs M tablet Therems-M tablet One tablet Delights tablet

Tylenol Allergy Pack Tylenol Sinus MS Unicomplex-M tablet Vanicream Multi Symptom tablet

Brand-Name and Generic Versions of the Same OTC Medication Require Prior Authorization

Clear Eyes Redness Robitussin Pediatric Delsym suspension Fibercon tablet Lamisil AT cream Relief solution syrup

Thick-It Vivarin tablet

*Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans (ACPPs)

Revised 10/2018 3 Over-the-Counter (OTC) Medications – Tufts Health RITogether and Tufts Health Together