 Over-The-Counter Medications
Covered for Healthy Options
The following OTC products are covered for Asuris Northwest
Health and Regence BlueShield Healthy Options only. These
medications are benefit exclusions on most other plans.
acetaminophen liquid (limit 480ml)
acetaminophen suppositories
acetaminophen tablets (limit 200)
antacid suspensions
aspirin (limit 200)
bacitracin ointment
brompheniramine
calcium carbonate
calcium gluconate
chlorpheniramine
clotrimazole vaginal cream, vaginal tablets
contraceptive sponges
contraceptive – foam, gel, cream
DELSYM® suspension
dextromethorphan liquid (generic and DELSYM®)
diphenhydramine – capsules, tablets, elixir, syrup
docusate
female condoms – 36 per month
ferrous gluconate
ferrous sulfate
folic acid
generic lacri-lube
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generic pedialyte solution
generic tears
hydrocortisone cream
hypotonic tears
ipecac syrup – 1 bottle per month
loperamide
loratadine
male condoms – 36 per month
miconazole vaginal cream
Nasalcrom® spray
niacin
oxymetazoline nasal spray
parepectolin
pepto-bismol
permethrin (NIX®)
pseudoephedrine/chlorpheniramine
pseudoephedrine/triprolidine 2.5mg only
pyridoxine
sodium chloride solution for nebulizer
triple antibiotic cream
triprolidine with pseudoephedrine
vitamin C |
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