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

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