PDF Generic Name Strength Common Brand Name - Medicaid

MS Medicaid Covered Over-the-Counter (OTC) Dr Effective January 1, 2013 Medicaid covers these over-the-counter (OTC) drugs pursuant to a written/verbal/electronic prescri Covered OTC products must be manufactured by pharmaceutical companies participating in the Fe OTC prescriptions are included in the monthly drug benefit limit but all count as generics. Nonrebated OTCs & OTC products not listed may be covered for beneficiaries under 21 with a 'Ch as part of the expanded EPSDT coverage.

Generic Name Acetaminophen

Acetaminophen Acetaminophen Acetaminophen Al & Mg Hydroxide Al & Mg Hydroxide/Simethicone Ammonium Lactate 12%

Artificial Tears Opthalmic Aspirin Bacitracin Topical Bacitracin/Polymyxin Benzoyl Peroxide *

Brompheniramine/Phenylephrine Brompheniramine/Phenylephrine/Dextromethorphan Brompheniramine/Pseudoephedrine***

Strength 100mg/ml 120,160, 167, 500mg/5ml 80,120,325,650mg 325, 500 mg

81, 325 mg 500U/Gm

2.5%, 5%, 10% 1-2.5mg/5ml 1-2.5-5mg/5ml 1-15mg/5ml

Common Brand Name Tylenol Drops

Tylenol Feverall Suppository Tylenol Maalox Maalox , Mylanta Amlactin 12% Cream Refresh,Refresh Plus, Refresh PM Various Various Polysporin Ointment Acneclear, Panoxyl Dimetapp Cold & Allergy Elixir Dimetapp DM Cold & Cough Elixir Q-Tapp

Brompheniramine/Pseudoephedrine/DM*** 1-15-5mg/5ml

Bulk Laxatives * Calcium Carbonate ** Calcium Carbonate **

500mg

Q-Tapp DM

fructan, guar gum, malt soup extract, methylcellulose, polycarbophil,psyllium

Carboxymethylcellulose Sodium Eye Drops Cetirizine Cetirizine/Pseudoephedrine*** Chlorpheniramine Clemastine Fumarate

Clotrimazole Topical Clotrimazole Vaginal

Dextromethorphan HBr

1% 1mg/ml, 5 mg, 10 mg 5mg/120mg 2mg/5ml, 4 mg 1.34mg

1% 1%, 2%

7.5mg/5ml, 15mg/5ml

Celluvisc Eye Drops Zyrtec Zyrtec-D 12 Hour Aller-Chlor Syrup, Tabs Tavist Lotrimin AF, Mycelex Solution Gyne-Lotrimin, Mycelex 7 Robitussin Pediatric Cough, Tussin Liquid

Dextromethorphan HBr /Phenylephrine

5-2.5 mg/5ml

Triaminic Cold & Cough Liquid

Dextromethorphan HBr /Pseudoephedrine*** 7.5-15mg/5ml

Triaminic Cough-Nasal Congestion

Dextromethorphan Polystirex

30mg/5ml

Delsym

Diphenhydramine

12.5mg/5ml, 25 mg, 50

mg

Benadryl

Docusate * Ferrous Sulfate

Ferrous Sulfate Ferrous Sulfate Ferrous Sulfate Slow Release Tab

Guaifenesin Plain

Guaifenesin/Codeine

Guaifenesin/Dextromethorphan

Guaifenesin/Phenylephrine Guaifenesin/Pseudoephedrine/Codeine*** Hydrocortisone Topical Ibuprofen Insulin (ALL OTC) Ketotifen Fumarate 0.025% Eye Drop Loperamide

50mg/5ml, 50mg/15ml,

60mg/15ml, 50 mg,

100 mg

Colace

75mg/0.6ml

Fer-In-Sol

220mg/5ml, 300mg/5ml

Feosol

325mg

Iron

160mg

Slow Fe

100mg/5ml, 200mg/5ml

Robitussin Plain ,Diabetic Tussin Mucous Relief

100mg/10mg/5ml

Guaifenesin AC Cough Syrup

100-10mg, 20010mg/5ml

Robitussin DM, Robitussin DM Max

Rescon GG,Triaminic 50-2.5, 100-5mg/5ml Chest-Nasal Congestion

100/30/10mg/5ml

Cheratussin DAC Syrup

0.5%, 1%

Cortaid

100mg/5ml

Motrin

0.025% 1mg/5ml, 2mg

Eye Itch Relief, Zaditor Imodium A-D

Loratadine Loratadine/Pseudoephedrine*** Magnesium Chloride SR Magnesium Gluconate Magnesium Oxide Miconazole Topical Miconazole Vaginal Multivitamin and Mineral Supplement *

5 mg/5ml, 5 mg, 10 mg Claritin

5-120mg, 10-240mg Claritin D 12 & 24 Hour

64mg

Slow-Mag 64

500mg

Magtrate

All Strengths

MagOx

2%

Micatin 2% Cream

2%

Monistat

Various

Nicotine Oral Electrolyte Replacement Mixtures

Oxymetazoline Nasal Solution Permethrin Lotion

All Strengths

0.05% 1%

Phenylephrine Nasal Solution

0.5%, 1%

Commit Lozenge, Nicorette Oralyte,Pedialyte Afrin, Sinex 12 Hr.Decongestant Nix Cream Rinse

4 Way, Sinex 12-Hr Decongestant Ultrafine Mist

Phenylephrine Oral Piperonyl/Pyrethrins

2.5 mg/5ml, 10 mg

Children's Sudafed PE, Contac D Cold

Lice Treatment, Various

Pseudoephedrine*** Renal Vitamins (Dialysis Pts Only)** Sodium Chloride Nasal Solution Tablet Splitters Terbinafine Topical Tolnaftate Triple Antibiotic Ointment

Triprolidine/Pseudoephedrine***

Vitamin D2 and D3 Zinc Oxide Ointment *

15mg/5ml, 30mg/5ml, 30 mg

0.2%,0.65%,0.9%

Children's Sufaded Syrup, Sudagest, Sudafed Allbee Plus Vitamin C Ayr, Ocean

1% 1%

1.25-30mg /5ml, 2.560mg

All Strengths

Lamisil AT Tinactin Neosporin

Aprodine Ergocalciferol, Cholecalciferol Desitin

* Limited to beneficiaries up to the age of 21 only ** Limited to dialysis beneficiaries only, document "For Dialysis Pt" on the front of the Rx

*** Effective 7-1-10, Classified as a Schedule III controlled substance in MS. Federally classified a

covered, pursuant to a prescription,for MS Medicaid beneficiaries.

Denotes additions since previous list

List Subject to Revision

rugs

ption. ederal Drug Rebate Program.

hildren's Medical Necessity' Prior Authorization

Drops

Dosage Form

Elixir, Liquid Suppository Tablet Tablet/Suspension Tablet/Suspension Cream, Lotion

Drops, Ointment Buff/Chew/E.C. Ointment Ointment Bar, Cream, Gel, Lotion, Wash

Liquid

Liquid Liquid

Liquid

Capsule,Powder,Tablet Powder Tablet

Opthalmic Drops ChewableTablet, Tablet, Syrup Extended Release Tablet Syrup, Tablet Tablet

Cream, Solution Cream

Liquid

Liquid

Syrup Suspension

Capsule, Elixir, Liquid, Solution

Capsule, Liquid, Syrup, Tablet Drops

Elixir, Liquid Tablet Tablet

Liquid

Liquid

Liquid

Liquid Liquid Cream, Lotion, Ointment Suspension See Preferred Drug List for preferred products Solution Liquid, Tablet

Chewable Tablet, Syrup, Reditab, Tablet Extended Release Tablet Tablet Tablet Tablet Cream Cream Chew.Tablet, Drops, Liquid,Tablet

Gum, Lozenge, Patch Freezer Pops, Solution

Spray Rinse

Drops, Spray

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