MS Medicaid Covered Over-the-Counter (OTC) Drugs
MS Medicaid Covered Over-the-Counter (OTC) Drugs
Medicaid covers these over-the-counter (OTC) drugs pursuant to a written/verbal/electronic prescription. Covered OTC products must be manufactured by pharmaceutical companies participating in the Federal Drug Rebate Program. 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 'Children's Medical Necessity' Prior Authorization as part of the expanded EPSDT coverage.
Generic Name Acetaminophen
100mg/ml
Strength
Common Brand Name Tylenol Drops
Acetaminophen
120,160, 167, 500mg/5ml
Tylenol
Acetaminophen Acetaminophen Al & Mg Hydroxide
80,120,325,650mg 325, 500 mg
Feverall Suppository Tylenol Maalox
Al & Mg Hydroxide/Simethicone
Maalox , Mylanta
Ammonium Lactate 12% Artificial Tears Opthalmic Aspirin Bacitracin Topical Bacitracin/Polymyxin
Benzoyl Peroxide *
Amlactin 12% Cream
Refresh,Refresh Plus, Refresh PM
81, 325 mg See Preferred Drug List for preferred or non-preferred products See Preferred Drug List for preferred or non-preferred products
Various
See Preferred Drug List for preferred or non-preferred products
Brompheniramine/Phenylephrine
1-2.5mg/5ml
Brompheniramine/Phenylephrine/Dextro-
methorphan
1-2.5-5mg/5ml
Dimetapp Cold & Allergy Elixir Dimetapp DM Cold & Cough Elixir
Brompheniramine/Pseudoephedrine*** 1-15mg/5ml
Brompheniramine/Pseudoephedrine/DM
***
1-15-5mg/5ml
Q-Tapp Q-Tapp DM
Dosage Form Drops Elixir, Liquid Suppository Tablet, Gelcap Tablet/Suspension Tablet/Suspension Cream, Lotion Drops, Ointment Buff/Chew/E.C.
Liquid Liquid Liquid Liquid
Bulk Laxatives *
fructan, guar gum, malt soup extract, methylcellulose, polycarbophil,psyllium Capsule,Powder,Tablet
Calcium Carbonate **
Calcium Carbonate ** Carboxymethylcellulose Sodium Eye Drops
500mg 1%
Celluvisc Eye Drops
Powder Tablet
Opthalmic Drops
Cetirizine Cetirizine/Pseudoephedrine***
See Preferred Drug List for preferred or non-preferred products
See Preferred Drug List for preferred or non-preferred products
Chlorpheniramine Clemastine Fumarate
Clotrimazole Topical
2mg/5ml, 4 mg
1.34mg See Preferred Drug List for preferred or non-preferred products
Aller-Chlor Syrup, Tabs Tavist
Syrup, Tablet Tablet
Clotrimazole Vaginal
See Preferred Drug List for preferred or non-preferred products
Dextromethorphan HBr
7.5mg/5ml, 15mg/5ml
Dextromethorphan HBr /Phenylephrine 5-2.5 mg/5ml
Dextromethorphan HBr /Pseudoephedrine***
Dextromethorphan Polystirex
Diethyltoluamide
7.5-15mg/5ml 30mg/5ml 7%,10%,15%,25%
Robitussin Pediatric Cough, Tussin Liquid
Triaminic Cold & Cough Liquid
Liquid Liquid
Triaminic Cough-Nasal Congestion Delsym Off Deep Woods Spray
Syrup Suspension Spray
Diphenhydramine Docusate * Doxylamine Succinate # Ferrous Sulfate Ferrous Sulfate Ferrous Sulfate Ferrous Sulfate Slow Release Tab
Guaifenesin Plain
12.5mg/5ml, 25 mg, 50 mg 50mg/5ml, 50mg/15ml, 60mg/15ml, 50 mg, 100 mg 25mg 75mg/0.6ml 220mg/5ml, 300mg/5ml 325mg 160mg
100mg/5ml, 200mg/5ml
Benadryl Colace Unisom Fer-In-Sol Feosol Iron Slow Fe Robitussin Plain ,Diabetic Tussin Mucous Relief
Capsule, Elixir, Liquid, Solution Capsule, Liquid, Syrup, Tablet Tablet Drops Elixir, Liquid Tablet Tablet
Liquid
Guaifenesin/Codeine Guaifenesin/Dextromethorphan
100mg/10mg/5ml 100-10mg, 200-10mg/5ml
Guaifenesin AC Cough Syrup Robitussin DM, Robitussin DM Max
Guaifenesin/Phenylephrine
50-2.5, 100-5mg/5ml
Rescon GG,Triaminic Chest-Nasal Congestion
Guaifenesin/Pseudoephedrine/Codeine*
**
100/30/10mg/5ml
Cheratussin DAC Syrup
Hydrocortisone Topical
See Preferred Drug List for preferred or non-preferred products
Ibuprofen
See Preferred Drug List for preferred or non-preferred products
Liquid Liquid
Liquid Liquid
Icaridin Insulin (ALL OTC)
2%
Ranger Ready Repellent
See Preferred Drug List for preferred or non-preferred products
Iron Chews 15mg Tablet
15mg
ICar 15mg Chewable
Ketotifen Fumarate 0.025% Eye Drop Loperamide
Loratadine
0.025%
Eye Itch Relief, Zaditor
1mg/5ml, 2mg
Imodium A-D
See Preferred Drug List for preferred or non-preferred products
Loratadine/Pseudoephedrine*** Magnesium Chloride SR Magnesium Gluconate Magnesium Oxide
See Preferred Drug List for preferred or non-preferred products 64mg
500mg All Strengths
Slow-Mag 64 Magtrate MagOx
Miconazole Topical
Miconazole Vaginal Select Multivitamin and Mineral Supplement *
Nicotine
See Preferred Drug List for preferred or non-preferred products
See Preferred Drug List for preferred or non-preferred products
See Preferred Drug List for preferred or non-preferred products
Various
Oral Electrolyte Replacement Mixtures
Oralyte,Pedialyte
Chewable tablet Solution Liquid, Tablet
Tablet Tablet Tablet
Chew.Tablet, Drops, Liquid,Tablet
Freezer Pops, Solution
Oxymetazoline Nasal Solution
Permethrin Lotion
Phenylephrine Nasal Solution Phenylephrine Oral Piperonyl/Pyrethrins Polyethylene glycol 3350
Pseudoephedrine*** Pyrantel Pamoate Pyridoxine # 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 *
0.05%
Afrin, Sinex 12 Hr.Decongestant
Spray
See Preferred Drug List for preferred or non-preferred products
4 Way, Sinex 12-Hr Decongestant Ultrafine Mist
Drops, Spray
2.5 mg/5ml, 10 mg
Children's Sudafed PE, Contac D Cold Liquid, Tablet
Lice Treatment, Various
Topical
gram 15mg/5ml, 30mg/5ml, 30 mg
Miralax
Children's Sufaded Syrup, Sudagest, Sudafed
Powder - Bottles, Jars Syrup, Tablet
50mg/ml, 250mg
Pin-X
Suspension, Chew.Tablet
25mg 0.2%,0.65%,0.9%
Vitamin B6 Allbee Plus Vitamin C, Dialyvite Ayr, Ocean
Tablet Tablet Drops, Spray
See Preferred Drug List for preferred or non-preferred products
See Preferred Drug List for preferred or non-preferred products
See Preferred Drug List for preferred or non-preferred products
1.25-30mg /5ml, 2.5-60mg All Strengths
Aprodine Ergocalciferol, Cholecalciferol Desitin
Syrup, Tablet All Dosage Forms Ointment
* 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 as an OTC product & remains
covered, pursuant to a prescription,for MS Medicaid beneficiaries. # Treatment of nausea & vomiting of pregnancy- for women of childbearing age only Denotes additions and changes since previous list
Note- A complete NDC listing of covered OTC products can be found on the Conduent Webportal at this link:
Revised 7/30/2020
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- hay fever sufferers prefer prescription medication but use over the
- patient advice hay fever
- princeton charter school authorization for administration of non
- over the counter non prescription medications and your kidneys bc renal
- management of seasonal allergic rhinitis hay fever res systems
- standing orders for otc medications ariel clinical services
- over the counter medications for upper respiratory infection
- hay fever frequently asked question for patients
- over the counter otc form girlscoutsla
- guide to over the counter medications for people with chronic kidney
Related searches
- best over the counter erectile dysfunction medication
- pink eye over the counter medication
- over the counter erectile dysfunction pills
- over the counter pink eye drops
- best over the counter ed pills
- over the counter ed pills for men
- over the counter ed remedies
- over the counter erectile pills at walgreens
- conjunctivitis over the counter treatment
- best over the counter erectile pill
- over the counter conjunctivitis medication
- over the counter eye drops for conjunctivitis