April 2017
Family Health Network Over-The-Counter Drug List
The Family Health Network Over-The-Counter Drug List is a guide to non-prescription medications that are covered by your plan. This
list can help your doctor choose the medicines that are right for you. If an over-the-counter medicine that you use is not on this list, it may
still be covered if your doctor asks for you to get it. Over-the-counter drug coverage requires a valid prescription.
This list is not an all-inclusive list and does not guarantee coverage.
Illinois Client Enrollment Services will send you information about your health plan choices when it is time for you to make a health plan
choice and during your Open Enrollment period.
Community Care Alliance of Illinois complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex.
PRODUCT NAME
BRAND NAME EXAMPLES
acetaminophen QL
TYLENOL
acetic acid soln
alcohol swabs QL
alumina-magnesia
MAALOX
alumina-magnesia-simethicone
MAALOX
alumina-magnesia-simethicone
MYLANTA
aluminum hydroxide 320 mg/5 mL
ammonium lactate 12%
LAC-HYDRIN
artificial tears oint, soln
ARTIFICIAL TEARS
ascorbic acid
aspirin
bacitracin
bacitracin-polymyxin B
POLYSPORIN
benzoyl peroxide
benzoyl peroxide gel 2.5%
bisacodyl
DULCOLAX
bismuth subsalicylate
PEPTO-BISMOL
blood glucose monitoring kits, test strips QL
FREESTYLE FREEDOM LITE KITS AND TEST STRIPS,
FREESTYLE INSULINX KITS AND TEST STRIPS,
FREESTYLE LITE KITS AND TEST STRIPS,
PRECISION XTRA KITS AND TEST STRIPS
budesonide spray - Rhinocort Allergy QL
calamine lotion
calcium
calcium carbonate
calcium polycarbophil
calcium-vitamin D
capsaicin gel 0.025%
CAPSAGEL
cetirizine
ZYRTEC
LEGEND
QL: Quantity Limit
PRODUCT NAME
BRAND NAME EXAMPLES
cetirizine-pseudoephedrine ext-rel
ZYRTEC-D 12 HOUR
chlorpheniramine
chlorpheniramine ext-rel
cholecalciferol (D3)
VITAMIN D
cimetidine
TAGAMET HB
clemastine
clotrimazole
codeine-guaifenesin liquid
codeine-guaifenesin-pseudoephedrine
condoms, female QL
FC2 FEMALE CONDOM
condoms, male QL
cromolyn sodium nasal spray
NASALCROM
dextran 70-hypromellose
dextromethorphan
dextromethorphan-guaifenesin ext-rel
MUCINEX DM
dextromethorphan-guaifenesin liq, soln, syp
dextromethorphan-guaifenesin-pseudoephedrine liq 10 mg/100 mg/30 mg/5 mL
dextrose gel 40%
dextrose tabs
dextrose-fructose-phosphoric acid
dibucaine
dimenhydrinate
dimethicone 1% crm
PROSHIELD PLUS
dimethicone-zinc oxide
diphenhydramine
BENADRYL
docosanol
ABREVA
docusate calcium
docusate sodium
COLACE
doxylamine
UNISOM
electrolyte soln, oral
PEDIALYTE
esomeprazole magnesium delayed-rel QL
NEXIUM 24HR
famotidine
PEPCID AC
ferrous fumarate
ferrous gluconate
FERGON
ferrous sulfate
FEOSOL
fexofenadine
ALLEGRA
fexofenadine-pseudoephedrine ext-rel
ALLEGRA-D
fluticasone spray QL
FLONASE ALLERGY RELIEF
folic acid
glycerin rectal suppository, pediatric
guaifenesin ext-rel
MUCINEX
guaifenesin liq
DIABETIC TUSSIN
guaifenesin liq, syp, tabs
hydrocortisone crm, gel, lotion, oint, soln 1%
CORTIZONE-10
hydrocortisone oint 0.5%
hydrocortisone-aloe vera crm 0.5%, 1%
hypromellose
ADVIL
ibuprofen
LEGEND
QL: Quantity Limit
PRODUCT NAME
BRAND NAME EXAMPLES
insulin human
HUMULIN R
insulin human
NOVOLIN R
insulin isophane human
HUMULIN N
insulin isophane human
NOVOLIN N
insulin isophane human 70%-regular 30%
HUMULIN 70/30
insulin isophane human 70%-regular 30%
NOVOLIN 70/30
insulin syringes, needles
BD ULTRAFINE INSULIN SYRINGES AND NEEDLES
iron polysaccharides complex
ZADITOR
ketotifen
lactase
lancets
lanolin-mineral oil-petrolatum
lansoprazole delayed-rel QL
PREVACID 24HR
lidocaine-benzalkonium chloride
BACTINE
loperamide
loperamide-simethicone
IMODIUM
loratadine
CLARITIN
loratadine-pseudoephedrine ext-rel
CLARITIN-D
magnesium hydroxide
MILK OF MAGNESIA
magnesium oxide 400 mg tabs
mask QL
meclizine
methylcellulose powder
miconazole
multiple urine test products QL
KETO-DIASTIX
multiple urine test products QL
MULTISTIX
multivitamins
multivitamins drops
POLY-VI-SOL
multivitamins-iron drops
POLY-VI-SOL WITH IRON
multivitamins-minerals
AQUADEKS
naproxen sodium
ALEVE
nebulizer QL
neomycin-bacitracin-polymyxin B
NEOSPORIN
niacin
niacin ext-rel
nicotine polacrilex gum
NICORETTE
nicotine transdermal
nonoxynol-9
GYNOL II
omega-3 fatty acids
FISH OIL
omega-3 fatty acids-vitamin E
FISH OIL
omeprazole delayed-rel tabs QL
omeprazole magnesium delayed-rel QL
PRILOSEC OTC
omeprazole magnesium delayed-rel caps QL
omeprazole-sodium bicarbonate QL
ZEGERID OTC
oxybutynin transdermal * gender restriction - coverage for females
OXYTROL FOR WOMEN
peak flow meter QL
permethrin
petrolatum-mineral oil
LEGEND
QL: Quantity Limit
PRODUCT NAME
BRAND NAME EXAMPLES
phenylephrine supp
piperonyl butoxide-pyrethrin
MIRALAX
polyethylene glycol 3350
polyvinyl alcohol
polyvinyl alcohol-povidone
povidone-iodine
BETADINE
prenatal vitamins-ferrous fumarate-folic acid QL
PRENATAL 27-0.8 MG
prenatal vitamins-ferrous fumarate-folic acid QL
PRENATAL 28-0.8 MG
prenatal vitamins-ferrous fumarate-folic acid-DHA QL
PRENATAL + DHA
pseudoephedrine
SUDAFED
pseudoephedrine ext-rel QL
SUDAFED
pseudoephedrine-guaifenesin ext-rel
MUCINEX D
pseudoephedrine-guaifenesin syp 30 mg/100 mg/5 mL
psyllium
pyrantel
PIN-X
pyridoxine 50 mg
VITAMIN B6
ranitidine
ZANTAC
salicylic acid
SELSUN BLUE
selenium sulfide shampoo 1%
senna
sennosides
SENOKOT
sennosides-docusate sodium
SENNA PLUS
simethicone
sodium bicarbonate tabs
sodium chloride 1 gm tab
sodium chloride for inhalation
OCEAN
sodium chloride nasal spray
sodium chloride ophth oint 5%
sodium fluoride
spacer QL
AEROCHAMBER
stannous fluoride
terbinafine
tolnaftate
TINACTIN
triamcinolone acetonide spray QL
NASACORT ALLERGY 24HR
triprolidine-pseudoephedrine liq, syp
vaporizer QL
vitamin A & D oint
vitamin D2 drops
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LEGEND
QL: Quantity Limit
106-1050245-040117 v2