Over-the-Counter Drug List - Kentucky

Over-the-Counter Drug List

Kentucky Single Medicaid MCO PBM Program

Effective July 1, 2021

This list applies only to Kentucky Medicaid Managed Care Organizations (MCO). For Fee-for-Service refer to the OTC list on the Magellan Medicaid Administration website: . Inclusion in this list does not guarantee coverage. Quantity, cost, and other limits may apply.

Allergy, Cough, and Cold Drugs

Tablets and Capsules

Drug Name All Day Allergy (cetirizine) Cetirizine HCl Cetirizine HCl Chlorpheniramine maleate Chlorpheniramine maleate ER Clemastine fumarate Dextromethorphan-guaifenesin Dextromethorphan-guaifenesin ER 12 hr Dextromethorphan-guaifenesin ER 12 hr Diphenhydramine HCl Diphenhydramine HCl Diphenhydramine HCl Fexofenadine HCl Fexofenadine HCl Fexofenadine-pseudoephedrine ER 12 hr Guaifenesin Guaifenesin Guaifenesin ER 12 hr Guaifenesin ER 12 hr Levocetirizine dihydrochloride Loratadine Loratadine & pseudoephedrine ER 12 hr Loratadine & pseudoephedrine ER 24 hr Phenylephrine HCl Pseudoephedrine HCl Pseudoephedrine HCl ER 12 hr Pseudoephedrine-guaifenesin ER 12 hr

Strength

5 mg 10 mg 4 mg 12 mg 1.34 mg (1 mg base equiv) 20-400 mg 30-600 mg 60-1200 mg 25 mg 50 mg 50 mg 60 mg 180 mg 60-120 mg 200 mg 400 mg 600 mg 1200 mg 5 mg 10 mg 5-120 mg 10-240 mg 10 mg 30 mg 120 mg 60-600 mg

Dosage Form tablet tablet tablet tablet tablet tablet tablet tablet tablet capsule capsule tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet

Kentucky Medicaid Single MCO PBM OTC List

Effective July 1, 2021

1

Copyright ? 2021 MedImpact Healthcare Systems, Inc. All rights reserved.

Liquids

Drug Name Cetirizine HCl Chlorpheniramine maleate Dextromethorphan polistirex ER Dextromethorphan-guaifenesin Dextromethorphan-guaifenesin Dextromethorphan-guaifenesin Dextromethorphan-guaifenesin Diphenhydramine HCl Diphenhydramine HCl Guaifenesin Guaifenesin Guaifenesin-codeine Loratadine Phenylephrine-brompheniramine-DM Phenylephrine-brompheniramine-DM Pseudoephed-bromphen-DM Pseudoephed-bromphen-DM Pseudoephedrine HCl

Chewable Tablets

Drug Name Diphenhydramine HCl Loratadine

Strength 1 mg/ml (5 mg/5ml)

2 mg/5ml 30 mg/5ml 5-100 mg/5ml 10-100 mg/5ml 10-100 mg/5ml 10-200 mg/5ml 12.5 mg/5ml 12.5 mg/5ml 100 mg/5ml 100 mg/5ml 100-10 mg/5ml 5 mg/5ml 2.5-1-5 mg/5ml 2.5-1-5 mg/5ml 15-1-5 mg/5ml 30-2-10 mg/5ml 15 mg/5ml

Strength 12.5 mg

5 mg

Drugs for Acne, Skin, and Warts

Creams and Lotions for the Skin

Drug Name Benzoyl peroxide Benzoyl peroxide Benzoyl peroxide Hydrocortisone Hydrocortisone Lactic acid (ammonium lactate) Lactic acid (ammonium lactate) Selenium sulfide Urea Urea Urea Urea

Strength 5% 10% 10% 0.5% 1% 12% 12% 1% 10% 20% 30% 40%

Dosage Form syrup syrup

suspension liquid liquid syrup liquid elixir liquid liquid syrup

solution syrup elixir liquid elixir syrup liquid

Dosage Form chewable tablet chewable tablet

Dosage Form lotion cream lotion cream lotion cream lotion lotion cream cream cream cream

Kentucky Medicaid Single MCO PBM OTC List

Effective July 1, 2021

2

Copyright ? 2021 MedImpact Healthcare Systems, Inc. All rights reserved.

Ointments for the Skin

Hydrocortisone Zinc oxide

Drug Name

Liquids for the Skin

Benzoyl peroxide Benzoyl peroxide Benzoyl peroxide Benzoyl peroxide Benzoyl peroxide Salicylic acid

Drug Name

Gels for the Skin

Benzoyl peroxide Benzoyl peroxide Benzoyl peroxide

Drug Name

Birth Control

Condoms

Drug Name Condoms latex lubricated Condoms latex non-lubricated

Emergency Contraceptives

Levonorgestrel

Drug Name

Women's Health

Vaginal Creams

Drug Name Clotrimazole vaginal Clotrimazole vaginal Miconazole vaginal Miconazole vaginal

Strength 0.5% 20%

Strength 2.5% 4% 5% 6% 10% 17%

Strength 2.5% 5% 10%

Strength

Strength 1.5 mg

Strength 1% 2% 2% 4%

Kentucky Medicaid Single MCO PBM OTC List

Effective July 1, 2021

Copyright ? 2021 MedImpact Healthcare Systems, Inc. All rights reserved.

Dosage Form ointment ointment

Dosage Form liquid liquid liquid liquid liquid liquid

Dosage Form gel gel gel

Dosage Form

Dosage Form tablet

Dosage Form cream cream cream cream

3

Kits

Drug Name Miconazole vaginal Miconazole vaginal

Vaginal Suppositories

Drug Name Miconazole vaginal

Tablets

Drug Name Phenazopyridine HCl

Strength 2% 2%

Strength 100 mg

Strength 95 mg

Diabetes Drugs

Insulins

Humulin N NPH Humulin N NPH

Glucose

Glucose

Drug Name Drug Name

Metabolic Aids

Levocarnitine Levocarnitine

Drug Name

Strength U-100 U-100

Strength 4 gm

Strength 1 gm/10ml (10%)

330 mg

Ear, Eye, Mouth, and Nose Drugs

Ear Drops

Drug Name Carbamide peroxide

Strength 6.5%

Dosage Form applicator and cream kit suppository and cream kit

Dosage Form suppository

Dosage Form tablet

Dosage Form vial

KwikPen

Dosage Form chewable tablet

Dosage Form solution tablet

Dosage Form otic solution

Kentucky Medicaid Single MCO PBM OTC List

Effective July 1, 2021

4

Copyright ? 2021 MedImpact Healthcare Systems, Inc. All rights reserved.

Eye Drops

Drug Name Artificial tears Carboxymethylcellulose sodium Dextran 70-hypromellose Ketotifen fumarate Polyethylene gly-propylene gly Polyvinyl alcohol

Mouth

Drug Name Benzocaine-menthol Chlorhexidine gluconate Sodium fluoride Sodium fluoride

Nose Sprays

Drug Name Budesonide Cromolyn sodium Oxymetazoline Saline Triamcinolone acetonide

Strength

0.5% 0.1-0.3% 0.025% (base equiv) 0.4-0.3%

1.4%

Strength 15-3.6 mg

4% 1.1% 1.1% (0.5% f)

Strength 32 mcg/act 5.2 mg/act (4%)

0.05% 0.65% 55 mcg/act

Digestive and Laxative Drugs

Tablets and Capsules

Drug Name Bisacodyl delayed release Bismuth subsalicylate Calcium polycarbophil Docusate calcium Docusate sodium Docusate sodium Docusate sodium Lactobacillus-inulin Loperamide HCl Magnesium oxide Magnesium oxide Omeprazole delayed release Omeprazole magnesium delayed release Psyllium Sennosides

Continued on next page

Strength 5 mg

262 mg 625 mg 240 mg 100 mg 100 mg 250 mg

2 mg 400 mg 420 mg 20 mg 20 mg 0.52 gm 8.6 mg

Kentucky Medicaid Single MCO PBM OTC List

Effective July 1, 2021

Copyright ? 2021 MedImpact Healthcare Systems, Inc. All rights reserved.

Dosage Form ophthalmic solution ophthalmic solution ophthalmic solution ophthalmic solution ophthalmic solution ophthalmic solution

Dosage Form lozenge liquid cream gel

Dosage Form nasal spray nasal spray nasal spray nasal spray nasal spray

Dosage Form tablet tablet tablet capsule capsule tablet capsule capsule tablet tablet tablet tablet tablet capsule tablet

5

Digestive and Laxative Drugs, Continued Sennosides Sennosides-docusate sodium Simethicone Simethicone Sodium bicarbonate Sodium bicarbonate

Chewable Tablets

Drug Name Alum hydroxide-magnesium carb Alum hydroxide-magnesium trisilicate Alum-mag hydroxide-simethicone Bismuth subsalicylate Calcium carbonate (antacid) Calcium carbonate (antacid) Calcium carbonate (antacid) Calcium carbonate (antacid) Meclizine HCl Simethicone Simethicone

Liquids

Drug Name Alum hydroxide-magnesium carb Alum-mag hydroxide-simethicone Alum-mag hydroxide-simethicone Bismuth subsalicylate Bismuth subsalicylate Calcium carbonate (antacid) Docusate sodium Docusate sodium Docusate sodium Magnesium citrate Magnesium hydroxide Sennosides Simethicone

Powders

Drug Name Polyethylene glycol 3350 oral Polyethylene glycol 3350 oral Psyllium Psyllium Psyllium Psyllium Psyllium Psyllium

25 mg 8.6-50 mg

125 mg 180 mg 325 mg 650 mg

Strength 160-105 mg

80-20 mg 200-200-25 mg

262 mg 648 mg 500 mg 750 mg 1000 mg 25 mg 80 mg 125 mg

Strength 95-358 mg/15ml 200-200-20 mg/5ml 400-400-40 mg/5ml

262 mg/15ml 525 mg/15ml 1250 mg/5ml 50 mg/15ml 60 mg/15ml 150 mg/15ml

400 mg/5ml 8.8 mg/5ml 40 mg/0.6ml

Strength 17 gm

17 gm/scoop 28.3% 30.9% 33% 48.57% 58.6% 95%

Kentucky Medicaid Single MCO PBM OTC List

Effective July 1, 2021

Copyright ? 2021 MedImpact Healthcare Systems, Inc. All rights reserved.

tablet tablet capsule capsule tablet tablet

Dosage Form chewable tablet chewable tablet chewable tablet chewable tablet chewable tablet chewable tablet chewable tablet chewable tablet chewable tablet chewable tablet chewable tablet

Dosage Form suspension suspension suspension suspension suspension suspension liquid syrup liquid solution suspension syrup suspension

Dosage Form packet powder powder powder powder powder powder powder

6

Enemas and Suppositories

Drug Name Bisacodyl Glycerin Glycerin Sodium phosphates

Strength 10 mg 1.2 gm 2 gm

Vitamins

Tablets and Capsules

Drug Name Ascorbic acid Ascorbic acid B-complex w/ C & folic acid Calcium carbonate Calcium carbonate Calcium carbonate Calcium carbonate-cholecalciferol Calcium carbonate-cholecalciferol Calcium carbonate-cholecalciferol Calcium carbonate-cholecalciferol Calcium carbonate-cholecalciferol Calcium carbonate-cholecalciferol Calcium carbonate-ergocalciferol Calcium carbonate-vitamin D Calcium carbonate-vitamin D Calcium carbonate-vitamin D Calcium carbonate-vitamin D Calcium carbonate-vitamin D Calcium carbonate-vitamin D Calcium citrate Calcium citrate-vitamin d Calcium cit-vitamin d Cholecalciferol Cholecalciferol Cholecalciferol Cholecalciferol Cholecalciferol Cholecalciferol Cholecalciferol Cholecalciferol Cyanocobalamin Cyanocobalamin Cyanocobalamin ER Ferrous fum Ferrous fum

Strength 250 mg 500 mg 0.8 mg 600 mg

1250 mg (500 mg elemtl Ca) 1500 mg (600 mg elemtl Ca)

250 mg-125 unit 500 mg-200 unit 500 mg-400 unit 600 mg-200 unit 600 mg-400 unit 600 mg-800 unit 500mg-200 unit 250 mg-125 unit 500 mg-125 unit 500 mg-200 unit 500 mg-400 unit 600 mg-200 unit 600 mg-400 unit 950 mg (200 mg elemtl Ca) 315 mg-200 unit (elemtl Ca) 315 mg-250 unit (elemtl Ca) 1.25 mg (50000 unit) 10 mcg (400 unit) 25 mcg (1000 unit) 25 mcg (1000 unit) 50 mcg (2000 unit) 50 mcg (2000 unit) 125 mcg (5000 unit) 125 mcg (5000 unit)

250 mcg 500 mcg 1000 mcg 324 mg (106 mg elem fe) 325 mg (106 mg elem fe)

Continued on next page

Kentucky Medicaid Single MCO PBM OTC List

Effective July 1, 2021

Copyright ? 2021 MedImpact Healthcare Systems, Inc. All rights reserved.

Dosage Form suppository suppository suppository enema

Dosage Form tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet capsule tablet capsule tablet capsule tablet capsule tablet tablet tablet tablet tablet tablet

7

Vitamins, Continued

Ferrous gluc Ferrous gluc Ferrous gluc Ferrous sulf Ferrous sulf EC Ferrous sulf EC Ferrous sulf dried ER Ferrous sulf dried Folic acid Folic acid Folic acid Magnesium oxide Magnesium oxide Magnesium oxide Magnesium oxide Multiple vitamin Multiple vitamins w/ iron Multiple vitamins w/ minerals Multiple vitamins w/ minerals Multiple vitamins w/ minerals & fa Niacin Niacin Niacin ER Niacin ER Niacin ER Niacin ER Niacin ER Omega-3 fatty acids Omega-3 fatty acids Oyster shell calcium Polysaccharide iron complex Sodium chloride Thiamine HCl Thiamine HCl Vinate one Vitamin A

Chewable Tablets

Drug Name Calcium carb Calcium carb-vit D-minerals Cholecalciferol Multiple vitamins w/ minerals Pediatric multi vit w/ C & FA Pediatric multi vitamin w/ extra C & FA Pediatric multi vitamin w/ minerals & C Pediatric multi vitamins w/ iron Pediatric multi vitamins w/ iron

240 mg (27 mg elem fe) 324 mg (38 mg elemtl Fe) 324 mg (37.5 mg elemtl Fe) 325 mg (65 mg elemtl Fe)

324 mg (65 mg Fe eq) 325 mg (65 mg Fe eq) 160 mg (50 mg Fe eq) 200 mg (65 mg elemtl Fe)

1 mg 400 mcg 800 mcg 250 mg (Mg supplement) 400 mg (240 mg elemtl Mg) 400 mg (241.3 mg elemtl Mg) 500 mg (Mg supplement)

1 mg 50 mg 100 mg 250 mg 250 mg 500 mg 500 mg 750 mg 500 mg 1000 mg 500 mg 150 mg (Fe eq) 1 gm 50 mg 100 mg

3 mg (10000 unit)

tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet tablet capsule tablet capsule tablet tablet capsule capsule tablet capsule tablet tablet tablet tablet capsule

Strength 1250 mg (500 mg elemtl Ca)

600 mg-400 unit 10 mcg (400 unit)

15 mg 18 mg

Dosage Form chewable tablet chewable tablet chewable tablet chewable tablet chewable tablet chewable tablet chewable tablet chewable tablet chewable tablet

Kentucky Medicaid Single MCO PBM OTC List

Effective July 1, 2021

8

Copyright ? 2021 MedImpact Healthcare Systems, Inc. All rights reserved.

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