Covered Over-the-Counter Products 

In accordance with Federal Law, a prescription is required for coverage of these non-prescription products. To see a complete list of products in each group, click on the heading.

Antihistamines (Covered for members 0-20)
CETIRIZINE HCL ORAL 1 MG/ML SOLUTION                          
CETIRIZINE HCL ORAL 10 MG TABLET                              
CETIRIZINE HCL ORAL 5 MG TABLET                               
CETIRIZINE HCL ORAL 5 MG/5 ML  SOLUTION  
LORATADINE ORAL 10 MG TAB RAPDIS                              
LORATADINE ORAL 10 MG TABLET                                  
LORATADINE ORAL 5 MG/5 ML  SOLUTION       

Calcium / Vitamin D 
CALCIUM CARBONATE/VITAMIN D3 ORAL                            

Family Planning
CONDOMS, FEMALE
CONDOMS, LATEX, LUBRICATED
CONDOMS, LATEX, NON-LUBRICATED
CONDOMS, NON-LATEX, LUBRICATED
CONDOMS, NON-LATEX, NON-LUBRI 
LEVONORGESTREL ORAL 1.5 MG TABLET  (PLAN B)                            
NONOXYNOL 9 VAGINAL 1000 MG CON.SPONGE                        
NONOXYNOL 9 VAGINAL 12.5% FOAM/APPL                           
NONOXYNOL 9 VAGINAL 2.2 % JELLY                               
NONOXYNOL 9 VAGINAL 28 % FILM                                 
NONOXYNOL 9 VAGINAL 3.5 % GEL/PF APP

Laxatives (Covered for members 0-20) 
POLYETHLYENE GLYCOL (PEG-3350)

Lice Treatment  (Covered for members 0-20)
PERMETHRIN TOPICAL 1 % LIQUID                      

Ophthalmic allergy (Covered for members 0-20)
KETOTIFEN FUMARATE OPHTHALMIC 0.025 % DROPS                   

Smoking Cessation
NICOTINE POLACRILEX BUCCAL 2 MG GUM                           
NICOTINE POLACRILEX BUCCAL 2 MG LOZENGE                       
NICOTINE POLACRILEX BUCCAL 4 MG GUM                           
NICOTINE POLACRILEX BUCCAL 4 MG LOZENGE                       
NICOTINE TRANSDERM  14MG/24HR  PATCH TD24                     
NICOTINE TRANSDERM  21 MG/24HR PATCH TD24                     
NICOTINE TRANSDERM  21-14-7MG  PATCH DYSQ                     
NICOTINE TRANSDERM  7MG/24HR PATCH TD24      

Topical Anti-Fungal (Covered for members 0-20)
CLOTRIMAZOLE TOPICAL 1 % CREAM (G)                            
TERBINAFINE HCL TOPICAL 1 % CREAM (G)                         
TOLNAFTATE TOPICAL 1 % CREAM (G)                                

PKU Supplements