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