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From benefits to copayments, physician selection to urgent care, find out how to use your health plan.
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Over-the-Counter (OTC) Exclusions

Trade Name OTC Alternative
Topical Acne Medications: Benzoyl Peroxide Products 10% in strength and less and combinations (e.g. skin cleansers). Examples: Benzac® products, Brevoxyl® products, Desquam® products, Neobenz® products, Oscion® products, Triaz® products Benzoyl peroxide – various forms (store brand products)
Clearasil® products
Fostex® products
Neutrogena® products
Oxy® products
PanOxyl® products
ZAPZYT® products
Cough and Cold Products: products containing guaifenesin, chlorpheniramine, pseudoephedrine, phenylephrine, clemastine, dextromethorphan, and pyrilamine in equivalent over the counter doses. These include both single ingredient products and combination products. Examples: Ambid® products, Drexophed® products, Guaibid® products, Humibid® products, Tussi-Organidin® products Various store brand cough and cold products
Bromfed® products
Chlor-Trimeton® products
Drixoral® products
Mucinex® products
Robitussin® products
ammonium lactate 12% cream Amlactin® 12% cream
Antivert® 25mg tablets Bonine® 25mg tablets
cimetidine 200mg tablets Tagamet® HB tablets
clotrimazole 1% cream Lotrimin AF® 1% cream, clotrimazole cream (various store brands)
clotrimazole 1% solution clotrimazole solution (various store brands)
diphenhydramine HCL 12.5mg elixir Benadryl® elixir
diphenhydramine HCL 50mg capsules Sleepinal® 50mg capsules
diphenhydramine HCL 25mg capsules Benadryl® capsules, dihyphenhydramine 25mg (various store brands)
Dologesic ® capsules Aceta-Gesic ® capsules
famotidine 20mg tablets Pepcid® AC Maximum Strength 20mg tablets
GlycoLAX® powder and packets MiraLAX® powder
hydrocortisone 0.5% cream Cortaid® cream, hydrocortisone 0.5% (various store brands)
hydrocortisone 1% ointment/cream/lotion Cortaid® Maximum Strength ointment/cream, hydrocortisone 1% (various store brands)
ibuprofen 100mg/5ml suspension Childrens Motrin®, Childrens Advil® suspension
ketotifen fumarate eye drops AlawayTM, Refresh® eye itch relief, Zaditor®
Lac-hydrin® 12% cream/lotion Amlactin® 12% cream lotion
Laclotion™ 12% lotion Amlactin® 12% lotion
Lamisil® 1% solution Lamisil® AT 1% solution
lansoprazole 15mg capsules Prevacid® 24HR capsules
loperamide 2mg capsules Immodium A-D® 2mg tablets, loperamide 2mg tablets (various store brands)
Lotrimin® 1% cream Lotrimin® AF 1% cream, clotrimazole 1% cream (various store brands)
meclizine HCL 12.5mg tablets Dramamine®
meclizine HCL 25mg tablets Bonine® 25mg tablets
Mentax® 1% cream Lotrimin® Ultra cream
miconazole 3 200mg suppositories Monistat-3® suppositories
MiraLAX® powder MiraLAX® powder
Monistat 3® 200mg suppositories Monistat-3® suppositories
Monistat Dual-Pak® 1200mg Monistat-1® combination pack
Monistat-Derm® 2% cream Micatin® 2% cream
Motrin® 100mg/5ml suspension Childrens Motrin® Childrens Advil® suspension
Mycelex® 1% cream Lotrimin® AF 1% cream
Niacor® 500mg tablets niacin 500mg tablets
Oxytrol® 3.9mg/day patch (** Rx excluded for women only) ® 500mg tablets Oxytrol® For Women
Pepcid® 20 mg tablets Pepcid AC® Maximum Strength 20mg tablets
polyethylene glycol 3350 powder MiraLAX® powder
Prevacid® 15mg capsules Prevacid® 24HR capsules
Procto-Kit® 1% Cortisone-10® external anal relief cream
Procto-Pak® 1% Cortisone-10® external anal relief cream
Proctocort® 1% Cortisone-10® external anal relief cream
Ranitidine 150mg tablets/capsules Zantac® 150 Maximum Strength
Vertin-32® 25mg tablets Bonine® 25mg tablets
VSL #3® DS packet VSL #3® DS packet
Xenical® 120mg capsules Alli® 60mg capsules
Zaditor® eye drops AlawayTM, Refresh® eye itch relief, Zaditor®
Zantac® 150mg  tablets/capsules Zantac® 150 Maxium Strength
Zantac® 150mg  EFFER Dose™ tablets Zantac® 150 Maxium Strength
Zegerid® 20mg capsules Zegerid OTCTM
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