GATEWAY HEALTH Plan^® OTC FORMULARY

This medication coverage applies only to Gateway Health Plan^® members
(for coverage, drugs must be written as a prescription)

Drugs are listed alphabetically by category. Specific OTC drugs are Listed as examples and are not inclusive of all covered products.

Analgesic

Acetaminophen
Acetaminophen combination
Aspirin
Aspirin combination
Nonsteroidal anti-inflammatory agent
Salicylate

Dermatologicals/Topical Therapy

Acne (benzoyl peroxide)
Anesthetics (benzocaine, dibucaine, lidocaine,
cyclomethycaine, pramoxine, tetracaine)
Antibacterials (bacitracin, neomycin, triple
antibiotic preparation, povidone-iodine,
tetracycline)
Anti-inflammatory agents (hydrocortisone 1%)
Dermatological baths (colloidal oatmeal)
Fungicides (clotrimazole, miconazole, tolnaftate,
terbinafine, undecylenic acid, clioquinol,
salicyclic acid, triacetin)
Tar preparations (not including soaps and
cleansing agents)
Wet dressings (aluminum acetate)
Scabicides/pediculicide (permethrin, RID)

Endocrine/Diabetes

Insulin
Insulin needles and syringe
Diagnostic device
Diabetic supplies (lancets, alcohol swabs)

Gastroenterology

Antacid
Antidiarrheals (kaolin-pectin combinations,
loperamide)
Antiflatulents (simethicone)
Antinauseants (cyclizine, meclizine,
dimenhydrinate)
Laxatives and stool softener
Histamine-2 receptor antagonist
Prilosec OTC

Obstetrics & Gynecology

Contraceptives (condoms, contraceptive jellies)
Contraceptive device
Pregnancy Test Kits
Vaginal fungicide

Ophthalmic Preparation

Ocular lubricants (polyvinyl alcohol or cellulose
derivatives)
Decongestants (Naphcon, Visine)
Phenylephrine 0.12%
Sodium chloride

Respiratory, Allergy, Cough & Cold

Antihistamines (diphenhydramine, loratadine)
Bronchodilator
Cough and cold product
Nasal preparations (naphazoline, xylometazoline,
oxymetazoline, phenylephrine, saline)
Saline for inhalation

Smoking Cessation Product

Nicotine replacement

Vitamins, Hematinics & Electrolyte

Vitamin
Prenatal vitamin
Calcium salt
Iron products (not including long-acting products)
Nicotinic acid
Oral electrolyte mixture

Medical Supplies

Please check with Gateway Health Plan^® for coverage