OVER-THE-COUNTER (OTC) MEDICATION AVAILABLE THROUGH THE COMMISSARY

Ammonium lactate lotion/cream

1. Requests to improve the appearance of the skin will be disapproved.
2. Indigent Patient AND treatment is medically necessary. Orders are limited to 30 days in duration when approved on the basis of indigent status alone. If renewed, the indigent status will be reassessed.

 

Analgesics Topical – capsaicin cream, diclofenac 1% (Voltaren®), salicylate/menthol (Bengay®)

1. A failed 30-day trial of oral NSAIDs or NSAIDs is contraindicated AND
2. Documented improvement in functional status (required for renewals) OR
3. Indigent Patient AND treatment is medically necessary. Orders are limited to 30 days in duration when approved on the basis of indigent status alone. If renewed, the indigent status will be reassessed.
4. Diclofenac gel 3% will not be approved without sufficient justification as to why 1% cannot be used.

Artificial tears – solution and ointment (various OTC formulations)

1. Initiated by an optometrist or ophthalmologist with ongoing evaluation and

2. Failure of commissary alternatives or Indigent Patients AND treatment is medically necessary. Orders are limited to 30 days.

 

Benzoyl peroxide washes/soaps

1. Chronic cystic scarring acne and/or causing secondary bacterial infections OR
2. Indigent Patient – treatment is medically necessary. Orders are limited to 30 days in duration when approved on the basis of indigent status alone. If renewed, indigent status will be reassessed.

Bismuth Subsalicylate (Pepto Bismol®)

1. Indigent Patient: treatment is medically necessary AND has failed OTC Indigent program alternatives. Orders are limited to 30 days in duration.

Calcium carbonate (Tums®)

1. Indigent Patient: treatment is medically necessary AND has failed OTC Indigent program alternatives. Orders are limited to 30 days in duration.

Carbamide peroxide 6.5% ear drops (Debrox®)

1. Indigent Patient – treatment is medically necessary. Orders are limited to 10 days in duration when approved on the basis of indigent status alone. If renewed, indigent status will be reassessed.

Coal Tar shampoo/gel/solution

1. Documented failure of OTC commissary selenium or coal tar shampoo OR
2. Indigent Patient, treatment medically necessary AND has failed OTC Indigent Program alternatives (ex: Selenium 1% Shampoo). Orders are limited to 30 days in duration when approved on the basis of indigent status alone. If renewed, indigent status will be reassessed
3. For Psoriasis, lesions interfere with function.
4. For Psoriasis: Psoriasis affects >10% of BSA (refer patients to the commissary for mild psoriasis) OR crucial body areas (hands, feet, fact, etc.)

• • Selenium shampoo/lotion
  • Documented failure of OTC commissary selenium or coal tar shampoo OR
  • The patient is indigent, treatment medically necessary, AND has failed OTC Indigent Program alternatives (ex: Selenium Shampoo 1%Shampoo). Orders are limited to 30 days in duration when approved based on indigent status alone. If renewed, the indigent status will be reassessed.

Hemorrhoidal cream/ointment- (Preparation H®, Anusol ®, others), dibucaine ointment

1. Pending hemorrhoid surgery or 30 days (or less) post-hemorrhoid surgery OR
2. For indigent Patients, treatment is medically necessary. Orders are limited to 30 days in duration when approved based on indigent status alone. If renewed, the indigent status will be reassessed.

Loperamide (Immodium®)

1. For Indigent Patients, treatment is medically necessary. OTC has failed Indigent program alternatives. Orders are limited to 30 days in duration.

Magnesium/aluminum/simethicone-containing products (Maalox®/Mylanta®/Gaviscon®, Milk of Magnesia®, etc.)

1. For Indigent Patients, treatment is medically necessary. OTC has failed Indigent program alternatives. Orders are limited to 30 days in duration.

Moisturizers topical (all formulations except Vitamin A&D)

1. Failed a 30-day trial of two commissary moisturizers OR
2. Indigent Patients, and treatment are medically necessary. Orders are limited to 30 days in duration when approved based on indigent status alone. If renewed, the indigent status will be reassessed.

Naphazoline-pheniramine Ophthalmic drops (Visine-A®, Opcon A®)

1. Initiated by an optometrist or ophthalmologist with ongoing evaluation and
2. Failure of commissary alternatives or
3. Indigent Patients, and treatment are medically necessary. Orders are limited to 3 days.

Simethicone tablets/capsules (Gas-X®)

1. Indigent Patients, and treatment are medically necessary. Orders are limited to 30 days in duration when approved based on indigent status alone. If renewed, the indigent status will be reassessed.

Sunscreens (various formulations)

1. Prescribed an essential medication causing documented photosensitivity OR
2. For indigent Patients, treatment is medically necessary. Orders are limited to 30 days in duration when approved based on indigent status alone. If renewed, the indigent status will be reassessed.
3. Requests due to the unavailability of protective clothing will be disapproved.
4. Approvals will be for SPF 30 products only.

Vitamin A&D Ointment

1. Diabetes with Neuropathy OR
2. Circulatory disorder evidenced by the absence of pedal pulses and/or extremity hair loss due to poor circulation or abnormal monofilament exam demonstrating loss of sensation OR
3. Indigent Patients, and treatments are medically necessary. Orders are limited to 30 days in duration when approved based on indigent status alone. If renewed, the indigent status will be reassessed.

Witch hazel & glycerin pads topical (Tucks® Pads)

1. Pending hemorrhoid surgery or 30 days (or less) post-hemorrhoid surgery OR
2. Indigent Patients, AND treatment are medically necessary. Orders are limited to 30 days in duration when approved based on indigent status alone. If renewed, the indigent status will be reassessed.

The administration of that dose must be recorded on a Medication Administration Record (MAR’s) by the employee.

Risk Evaluation and Mitigation Strategies (REMS)