Download Over-the-counter drug coverage

Over-the-counter drug coverage
March 2014
Network Health pharmacy benefits cover the over-the-counter (OTC) drugs and products below for members with a prescription,
and when dispensed as a prescription at a pharmacy.
Generic vs. brand names:
Generic drugs have the same active ingredients and work the same as brand-name drugs. We cover brand-name drugs only when a
generic drug is not available.
Co-payments for generic drugs:
• Network Health Together ® (MassHealth), Network Health Forward ® (Commonwealth Care) Plan Type I, and
Network Health Extend™ Plan Type I members pay $0 – $3.65 for up to a 30-day supply.
• Network Health Forward (Commonwealth Care) Plan Type II and III and Network Health Extend Plan Type II and III members
pay up to $12.50 for up to a 30-day supply.
• Network Health Direct (individual and small-group plan) members pay a Tier 1 co-payment for up to a 30-day supply unless otherwise
indicated.
Category
Generic name
(What your doctor should prescribe)
Example of brand name
Acne products
Benzoyl peroxide 5% and 10%
Benzac W 5
Allergy/antihistamines
Cetirizine
Cetirizine/pseudoephedrine
Chlorpheniramine
Diphenhydramine
Loratadine
Loratadine/pseudoephedrine
Zyrtec OTC
Zyrtec-D OTC
Chlor-trimeton
Benadryl
Alavert, Claritin
Alavert-D, Claritin-D
Analgesic/pain drugs
Acetaminophen (quantity limit 4 gm/day)
Aspirin
Ibuprofen
Naproxen
Tylenol
Bayer
Advil
Aleve
Antacids, antigas, and antinausea
Aluminum hydroxide
Aluminum hydroxide/magnesium hydroxide
Aluminum hydroxide/magnesium hydroxide/simethicone
Magaldrate, Magaldrate/simethicone
Meclizine
Simethicone
Alternagel
Maalox
Mylanta
Riopan
Dramamine
Mylicon
Antidandruff
Selenium sulfide topical
Selsun Blue
Antidiarrheals
Acidophilus, Lactobacillus (age 18 and under)
Bismuth subsalicylate, Attapulgite
Loperamide
Culturelle, Probiotic, Acidophilus
Pepto-Bismol, Kaopectate
Imodium AD
Antifungal drugs
Clotrimazole 1% topical
Clotrimazole 1% vaginal
Miconazole topical
Miconazole vaginal
Tolnaftate
Lotrimin
Gyne-Lotrimin
Monistat-Derm
Monistat
Tinactin
Antiulcer drugs
Cimetidine
Famotidine
Rantidine
Tagamet
Pepcid AC
Zantac
Contraceptive agents
Levonorgestrel
Nonoxynol-9
Plan B
Conceptrol, Emko
Cough/cold products
Brompheniramine/phenylephrine
Guaifenesin
Guaifenesin DM
Pseudoephedrine
Dimetapp
Robitussin
Robitussin DM
Sudafed
Counterirritants
Capsaicin
Zostrix
Diabetes drugs
Glucose tablets and gel
Glucose
Dry skin preparations
Ammonium lactate topical
White petrolatum
Amlactin
Hydrolatum
Ear drops
Carbamide peroxide
Debrox
Electrolyte solution
Electrolyte solution
Pedialyte
First aid/antiseptics/disinfectants
Bacitracin topical
Bacitracin/Polymyxin B
Chlorhexidine gluconate
Hydrogen peroxide
Iodine
Isopropyl alcohol
Povidone
Triple antibiotic ointment, Neomycin/Bacitracin/Polymyxin B
Bacitracin topical
Double antibiotic
Hibiclens
Hydrogen peroxide
Iodine
Isopropyl alcohol
Betadine
Neosporin
($0 co-payment for all plans)
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Category
Generic name
(What your doctor should prescribe)
Example of brand name
Laxative/stool softeners
Bisacodyl
Cascara
Docusate sodium, Docusate calcium
Docusate sodium with casanthranol
Glycerin suppositories
Magnesium citrate
Magnesium hydroxide
Methylcellulose
Mineral oil
Psyllium
Senna
Sennosides/Docusate sodium
Sodium phosphate
Dulcolax
Nature’s Remedy
Colace, Surfak
Docusate sodium with casanthranol
Glycerin suppositories
Citrate of Magnesia
Milk of Magnesia
Citrucel
Mineral oil
Metamucil
Senokot
Doc-Q-Lax
Fleet Enema
Lice treatments
Permethrin
Pyrethin/piperonyl butoxide
NIX
RID
Nasal sprays
Cromolyn
Oxymetazoline nasal spray
Sodium chloride nasal spray
Nasalcrom
Afrin
Ocean
Ophthalmic/eye drugs
Ocular lubricant
Ketotifen fumarate
Naphazoline
Naphazoline/pheniramine
Sodium chloride 5% drops
Tetrahydrozoline
Artificial Tears
Alaway, Zaditor
Naphcon
Naphcon-A, Opcon-A, Visine-A
Muro-128 drops
Visine
Poison ivy/rash treatments
Calamine lotion
Colloidal oatmeal
Hydrocortisone topical
Zinc oxide topical
Calamine lotion
Aveeno Oatmeal Bath
Anusol-HC
Balmex
Sleep aids
Melatonin 1 mg, 3 mg, 5 mg (age 18 and under)
Melatonin
Smoking deterrents
Nicotine gum
Nicotine lozenges
Nicotine patch
Nicorette, Nicorette DS
Commit
Nicoderm
Calcium carbonate
Calcium carbonate with vitamin D
Calcium citrate
Calcium citrate with vitamin D
Calcium with vitamin D
Co-enzyme Q10 (age 18 and under)
Ferrous fumarate
Ferrous gluconate
Ferrous sulfate
Fish oil
Folic acid
Magnesium gluconate
Magnesium oxide
Multivitamins
Multivitamins with minerals
Niacin
Niacinamide
Nicotinic acid
Omega-3 fish oil
Potassium phosphate
Prenatal vitamins (without DHA)
Vitamin A
Vitamin B
Vitamin B-12
Vitamin C
Vitamin D
Vitamin E
Oscal
Oscal + D
Citracal
Citracal + D
Calcium with vitamin D
Co-enzyme Q10
Femiron
Fergon
Feosol
Fish oil
Folvite
Magonate
Uro-Mag
Multivitamins
Multivitamins with minerals
Niacin
Niacinamide
Niaspan ER
Omega-3 fish oil
Neutra-Phos, Neutra-Phos K
Prenatal vitamins (without DHA)
Vitamin A
Vitamin B
Vitamin B-12
Vitamin C
Vitamin D
Vitamin E
(90-day supply per every 180 days)
Vitamins/minerals/supplements
Supplies
$0 co-payment for Network Health Together, Network Health Forward Plan Type I and II, and Network Health Extend Plan Type I and II
10% co-payment for Network Health Forward Plan Type III and Network Health Extend Plan Type III
20% co-payment for Network Health Direct
Asthma supplies
Peak flow meters
Spacers for asthma inhalers (up to two per year)
Sodium chloride for inhalation
Diabetes testing supplies
Blood glucose meters (up to two per year; Abbott exclusive)
Blood glucose test strips (up to 150 per 30 days; Abbott exclusive)
Humidifiers/vaporizers (covered for
Network Health Together only)
Humidifiers/vaporizers (one per year)
Co-payments and covered drugs are subject to change.
We’re here to help. Please call our member services team at 888-257-1985 or visit Network-Health.org.
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Questions about our OTC drug coverage?
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