Over-the-Counter and Medicaid Covered Rx Drug List

Below is a list of over-the-counter (OTC) drugs and we cover with a prescription from your doctor. OTC drugs should only be prescribed after a clinical evaluation of the member’s necessary medical needs and are not available through the mail order benefit. Generic versions and specifically listed brand name drugs listed are covered while all others are excluded. This list also includes some prescription strength products that are covered through the Medicaid portion of your benefit.

Analgesics Laxatives acetaminophen aspirin bisacodyl ± enema docusate products ibuprofen naproxen Fleet Prep Kits ± enema glycerin suppositories magnesium citrate magnesium hydroxide (Milk of Magnesia) Antacid, Anti-Gas, & Anti-Nausea mineral oil Miralax OTC acidophilus (lactobacillus aluminum hydroxide ± polycarbophil psyllium acidophilus) magnesium carbonate methylcellulose senna calcium carbonate magnesium oxide meclizine sodium bicarbonate Ophthalmic & Otic simethicone lactobacillus rhamnosis generic artificial tears carbamide peroxide otic (generic Culturelle) (ocular lubricant solution saccharomyces boulardii Any combinations of the and ointment) (Florastor) above ± simethicone ketotifen naphazoline/pheniramine

Anti-Diarrheals Smoking Cessation Products bismuth subsalicylate kaolin-pectin *Quantity Limits: 90 days/treatment & 2 loperamide treatments/year Generic nicotine products (patches, gum, lozenges) Cough and Cold, Antihistamines loratadine ± cetirizine ± Ulcer Drugs pseudophedrine pseudophedrine omeprazole-OTC 20mg Nexium 24HR OTC fexofenadine ± chlorpheniramine tablet pseudophedrine Zegrid OTC lansoprazole-OTC 15mg dimenhydramine diphenhydramine capsule doxylamine pseudophedrine (≤ ranitidine famotidine 240mg/day) cimetidine

Antiseptics & Disinfectants Nasal Corticosteroids chlorhexidine hydrogen peroxide Nasacort Allergy fluticasone nasal spray povidone iodine isopropyl alcohol

1 Effective 01_2016 Vaginal Products Vitamins, Minerals & Supplements *Only 3 or 7 Day Treatments cranberry coenzyme Q10 clotrimazole miconazole generic calcium ± melatonin nonoxynol 9 (Encare) vitamin D iron supplements RX vitamin C (ascorbic acid) Dermatological multivitamins ± niacin Analgesics (Topical): capsaicin, minerals menthol/methyl salicylate oral electrolyte solution vitamin A (Retinol) Antimicrobials bacitracin, polymyxin-B, omega-3 fish oil vitamin D (calciferol) (Topical): neomycin (single or triple magnesium salts vitamin D RX combination) (ergocalciferol) RX RX Anti-Dandruff: selenium sulfide shampoo All generic B vitamins Reno caps Antifungals (Topical): clotrimazole, miconazole, vitamin E zinc Nizoral A-D Shampoo, terbinafine, tolnaftate Medical Devices and Supplies Anti-Itch: colloidal oatmeal bath, Spacers (i.e. Aerochamber, InspirEase) RX calamine lotion, (*limit 2 per year) hydrocortisone topical Blood glucose meter – FreeStyle Lite® or Precision Lice Treatment: permethrin, piperonyl Xtra® (specific NDCs are covered) butoxide-pyrethrins (*limit 1 per year) Moisturizing Agents: ammonium lactate 12%, Diabetic Preparation/Supplies1: A&D Ointment,  alcohol swabs hydrophilic ointment,  glucose tablets lanolin ointment,  insulin syringe petrolatum ointment, zinc  insulin pen needles oxide, Eucerin  ketostix Wart Removers: salicylic acid  lancets (*limit 200 per 30 days)  test strips (*limit 200 per 30 days) FreeStyle® Miscellaneous or Precision Xtra® lactase sodium chloride for inhalation RX saline (sodium chloride) sodium chloride tablets nasal sprays Saliva substitutes Phenazopyridine (AZO) Compounding Agents RX: Cherry syrup, Ora-Plus, Ora-Sweet, Ora-Sweet SF, simple syrup

Notes: 1 These items may be covered as part of your Medicare Part B benefit, and may be available through mail order

RX These items also include coverage of some prescription strength products BMCHP will not cover unit-dosed packaged products unless unavailable in bulk package form 2 Effective 01_2016