Fee-For Service Pharmacy Over-The-Counter (OTC) Covered Drug List Effective 09/02/2015 Unless otherwise noted, only generic versions of the following products are covered. GENERAL DEFINITION OF TERMS Quantity Limits (QL) – Quantity limits have been placed on medications to be consistent with the maximum dosage that the Food and Drug Administration (FDA) has approved to be both safe and effective. Step Therapy (ST) – Step therapy is an electronic prior authorization (PA) process that takes place at the time the pharmacy submits the claim. Maximum Duration (MD) – Medications indicated will be available for a defined period of days per rolling year (365 days) before requiring a new or additional PA. Age Edit (AE) – Medications indicated are available for members above or below XX age without PA. ANALGESICS acetaminophen (QL) ibuprofen aspirin with buffer ketoprofen aspirin naproxen aspirin / calcium / Mg COLD AND COUGH / ANTIHISTAMINES aspirin / chlorphenerimine diphenhydramine HCl brompheniramine doxylamine succinate brompheniramine / pseudoephedrine guaifenesin cetirizine tablets, capsules, 1 mg/mL solution, 5 mg/5 guaifenesin / dextromethorphan mL syrup, ODT cetirizine / pseudoephedrine loratadine chlorpheniramine loratadine / pseudoephedrine clemastine pseudoephedrine dextromethorphan salaine nasal drops diphenhydramine citrate TOPICALS ammonium lactate miconazole bacitracin neomycin / bacitracin / polymyxin bacitracin zinc neomycin / polymyxin B bacitracin zinc / polymyxin neomycin / bacit / polymyxin bacitracin / polymyxin B permethrin benzoyl peroxide piperonly clotrimazole (vaginal) salicylic acid diphenhydramine HCl terbinafine (topical) docosanol [brand] tolnaftate hydrocortisone vitamin A & D ointment lanolin zinc oxide lanolin bases Proprietary Confidential © 2015 Magellan Health, Inc. Fee-For Service Pharmacy Over-The-Counter (OTC) Covered Drug List Effective 09/02/2015 VITAMINS biotin ferrous sulfate calcium carbonate ferrous fumarate calcium carbonate / vitamin D2 ferrous gluconate calcium carbonate / vitamin D3 fish oil calcium acetate folic acid calcium citrate magnesium chloride calcium citrate / vitamin D magnesium calcium glubionate magnesium gluconate calcium gluconate magnesium oxide calcium gluconate / vitamin D multivitamin with Iron drops (AE) calcium lactate niacin and nicotinic acid calcium phosphate niacinamide cholecalciferol (vitamin D3) prenatal vitamins ferrous fumarate / docusate pyridoxine HCl GI Products aluminum hydroxide magnesium hydroxide bisacodyl magnesium hydroxide / aluminum hydroxide bisacodyl / magnesium citrate meclizine calcium carbonate methylcellulose calcium carbonate / magnesium carbonate methylcellulose with sugar calcium carbonate / magnesium hydroxide mineral oil calcium polycarbophil mineral oil / magnesium hydroxide casanthranol / docusate nizatadine cellulose polyethylene glycol docusate calcium psyllium docusate potassium psyllium seed docusate sodium psyllium seed (SF) famotidine psyllium seed / dextrose famotidine calcium psyllium seed / sucrose glycerin ranitidine loperamide senna magnesium citrate senna leaf extract magnesium carbonate / aluminum hydroxide / alginic sennosides acid magaldrate simethicone magnesium carbonate / aluminum hydroxide sorbitol MISCELLANEOUS instant dextrose NaCl for Nebulization insulins (brand and generic) polyvinyl alcohol ketotifen (branded Alaway OTC, Zaditor OTC) Water for Inhalation levonorgestrel Water for Nebulization 2 of 2.