ADDITIONAL DRUG LISTING FOR MEDICARE & MEDI-CAL MEMBERS

Transcription

1 MEDICARE & MEDICAL MEMBERS! Please read carefully! The following pages include additional drugs which may be covered for you with your doctor s prescription by MediCal (Medicaid). These drugs CANNOT be ordered via the SCAN OTC Call Center, online, or using the OTC order form. You must take your prescription to a SCAN network pharmacy to obtain these additional products which may be available under your MediCal (Medicaid) benefit. DO NOT mail your prescription to the OTC Center. To find a network pharmacy please check your SCAN Provider & Pharmacy directory at or contact your SCAN PAL at the number below. For questions or assistance please contact your SCAN PAL at: (TTY users: 711) October 1 to March 31 8 a.m. to 8 p.m., 7 days a week April 1 to September 30 8 a.m. to 8 p.m., Monday through Friday Messages received on holidays and outside of our business hours will be returned within one business day. 1

2 MEDICARE & MEDICAL MEMBERS Allergy, Cold, Flu, Decongestant & Sinus Sodium Chloride Nasal Spray 0.65% Benzonatate Benzonatate Chlorpheniramine Maleate 4 mg Sodium Chloride Nasal Spray 0.90% Sodium Chloride Nasal Spray 2.65% Antacids & Acid Reducers 6.3 / Aluminum And Magnesium Hydroxide 10 / 10 / 8 / Aluminum Hydroxide, Magnesium Hydroxide And Simethicone Aluminum Hydroxide, Magnesium Hydroxide And Simethicone Cromolyn Sodium Spray 20 / 10 ml 5.2 mg Cimetidine Famotidine 10 mg Fluticasone Propionate Spray 50 mcg Famotidine 20 mg Loratadine Loratadine Pseudoephedrine Extended Release 5 mg / 10 mg 120 mg Omeprazole Enteric Coated Ranitidine Ranitidine 20 mg 75 mg 150 mg Pseudoephedrine Pseudoephedrine Pseudoephedrine Pseudoephedrine Sodium Chloride / Aloe Vera Nasal Spray 15 mg / 30 mg / 30 mg 60 mg Anthelmintic Pyrantel Pamoate Anticandidal (yeast) Clotrimazole Vaginal Cream 1% Miconazole Vaginal Cream 2% Sodium Chloride Nasal 0.65% Miconazole Vaginal Suppositories 2

3 MEDICARE & MEDICAL MEMBERS Antidiarrheal, Laxatives & Digestive Health Sennosides Bisacodyl Enteric Coated Bisacodyl Suppositories Bisacodyl Bismuth Subsalicylate Chewable Bismuth Subsalicylate 5 mg 10 mg 5 mg 262 mg 262 mg / 1 Simethicone Chewable Simethicone Simethicone Simethicone Chewable Simethicone Suspension Antifungal 80 mg mg 1 40 mg / 0.6 ml Bismuth Subsalicylate Bismuth Subsalicylate Docusate Sodium Docusate Sodium Docusate Sodium Docusate Sodium Syrup Docusate Sodium Syrup Docusate Sodium 5 / mg 50 mg / 50 mg / 15ml 60 mg / 15ml Magnesium Citrate Oral Solution Psyllium Husk Psyllium Husk Psyllium Husk Powder 0.4 g 0.52 g 3.4 g / 5.4 g Clotrimazole Topical Cream 1% Miconazole Topical Cream 2% Tolnaftate Cream 1% Tolnaftate Solution 1% Antiitch Hydrocortisone Cream 0.5% Hydrocortisone Cream 1% Hydrocortisone Lotion 1% Hydrocortisone Ointment 0.5% Hydrocortisone Ointment 1% Cold Sore & Medicated Lip Products Docosanol Cream 10% Psyllium Husk Powder Sennosides / Docusate Sodium Sennosides Syrup Sennosides 6 g / 6 g mg 8.8 mg / 8.6 mg Contraceptives Levonorgestrel 1.5 mg Nonoxynol 9 Foam 12.50% Nonoxynol 9 Gel 4% 3

4 MEDICARE & MEDICAL MEMBERS Ear Care Pain Relievers & Fever Reducers Carbamide Peroxide Otic 6.50% Electrolytes Electrolytes (Pedialyte) Eye Care Eye Wash Solution Ketotifen Fumarate Ophthalmic Propylene Glycol Ophthalmic 0.03% Acetaminophen Aspirin Enteric Coated Low Dose Aspirin Enteric Coated Aspirin Ibuprofen Ibuprofen Suspension Ibuprofen 160 mg / 81 mg 3 3 / Sodium Chloride Ophthalmic Sodium Chloride Ophthalmic Sodium Chloride Ophthalmic Ointment First Aid 2% 5% 5% Naproxen Sodium Naproxen Sodium Pediculicide (lice treatment) 220 mg 220 mg Permethrin Lice Treatment 1% Piperonyl Butoxide / Pyrethrins Lice Killing Shampoo Bacitracin Ointment Bacitracin Zinc Ointment Personal Care Benzoyl Peroxide Acne Gel 5% Polymixin B Sulfate and Bacitracin Zinc Ointment Meclizine Chewable Meclizine Motion Sickness 12.5 mg Benzoyl Peroxide Acne Gel 10% Smoking Cessation Nicotine Gum 2 mg Nicotine Gum 4 mg Nicotine Lozenge 2 mg Meclizine Nicotine Lozenge 4 mg 4

5 MEDICARE & MEDICAL MEMBERS Nicotine Patch 7 mg / 24 hr Calcium Carbonate 1 Nicotine Patch Nicotine Patch Therapeutic Skin Care 14 mg / 24 hr 21 mg / 24 hr Calamine Lotion Ascorbic Acid Chewable Ascorbic Acid Chewable Vitamins & Minerals Ascorbic Acid Crystals Ascorbic Acid Extended Release Ascorbic Acid Extended Release Ascorbic Acid Extended Release Ascorbic Acid Lozenge 1000 mg 60 mg Ascorbic Acid Powder Ascorbic Acid Syrup Ascorbic Acid Ascorbic Acid Ascorbic Acid Ascorbic Acid Ascorbic Acid Wafer BetaCarotene Calcium Carbonate / 1000 mg unit 600 mg Calcium Gluconate Extended Release Extended Release Lozenge Lozenge Lozenge Sublingual Sublingual Sublingual Sublingual 648 mg 3000 mcg / ml 2000 mcg / mcg 500 mcg 500 mcg 2500 mcg 5000 mcg 50 mcg 100 mcg 5

6 MEDICARE & MEDICAL MEMBERS 250 mcg 500 mcg Niacin Extended Release Niacin Niacin 750 mg 50 mg Ergocalciferol (Vitamin D2) Ergocalciferol (Vitamin D2) Ergocalciferol (Vitamin D2) Ferrous Sulfate Iron Supplement Ferrous Sulfate Iron Supplement Ferrous Sulfate Iron Supplement Folic Acid Magnesium 2500 mcg 8000 unit / ml 400 unit 2000 unit 15 mg / ml mcg 30 mg Niacin Niacin Omega3 Fatty Acids / DHA / EPA Omega3 Fatty Acids / Fish Oil Omega3 Fatty Acids / Fish Oil Omega3 Fatty Acids / Fish Oil Omega3 Fatty Acids / Fish Oil Omega3 Fatty Acids / Fish Oil Omega3 Fatty Acids / Fish Oil Omega3 Fatty Acids / Fish Oil mg mg mg mg mg mg Magnesium Omega3 Fatty Acids 1000 mg Magnesium Niacin Extended Release Niacin Extended Release Phytonadione (Vitamin K1) Phytonadione (Vitamin K1) 100 mcg 5 mg Prenatal Vitamins Niacin Extended Release Pyridoxine (Vitamin B6) Niacin Extended Release Pyridoxine (Vitamin B6) 50 mg 6

7 MEDICARE & MEDICAL MEMBERS Pyridoxine (Vitamin B6) Riboflavin (Vitamin B2) Riboflavin (Vitamin B2) 50 mg Vitamin A Palmitate / BCarotene Vitamin A Palmitate / Vitamin D unit unit Riboflavin (Vitamin B2) Vitamin A Palmitate unit Thiamine 50 mg Vitamin A Palmitate unit Thiamine Vitamin E 100 unit Thiamine Vitamin E 200 unit Vitamin A / Vitamin C / Vitamin E / Selenium Vitamin A / Vitamin C / Zinc / Propolis Lozenge 15 mg Vitamin E Vitamin E Weight Loss 400 unit 1000 unit Vitamin A / Vitamin D2 Vitamin A unit 8000 unit Lorcaserin (Belviq) Lorcaserin (Belviq XR) 10 mg 20 mg Vitamin A unit 7

8 MEDICARE & MEDICAL MEMBERS 3 Additional products (listed on pages 2 7) may be covered for you under your MediCal (Medicaid) benefits with your doctor s prescription at our network pharmacies. Limitations/restrictions may apply. Select products or manufacturers may be covered. Please contact your SCAN PAL (phone number listed below) or visit for additional information regarding which products are covered for you under your MediCal (Medicaid) benefit. The drug listing is current as of October 2018 and is subject to change. For more recent information or other questions please contact your SCAN PAL at: (TTY users: 711) October 1 to March 31 8 a.m. to 8 p.m., 7 days a week April 1 to September 30 8 a.m. to 8 p.m., Monday through Friday Messages received on holidays and outside of our business hours will be returned within one business day. 8