Medicaid Cough and Cold Quick List - School of Pharmacy

Medicaid Cough and Cold Quick List

Medicaid covers these over-the-counter (OTC) drugs pursuant to a written/verbal/electronic prescription. This list is subject to revision

Current DOM OTC NDC list for covered products:

1st Generation Antihistamines and

Combinations

2nd Generation Antihistamine Combinations

Antitussive s &

Combinati ons

Class

Generic

Strength

Common Names

Brompheniramine/Phenylephrine Brompheniramine/Phenylephrine/ DM Brompheniramine/ Pseudoephedrine Brompheniramine/ Pseudoephedrine/ DM Chlorpheniramine Chlorpheniramine/phenylephrine Clemastine Fumarate

Diphenhydramine

Triprolidine/ Pseudoephedrine Cetirizine

1-2.5mg/ 5mL 1-2.5-5mg/ 5mL 1-15mg/5mL 1-15-5mg/ 5mL 2mg/5mL, 4mg 4mg/10mg 1.34mg

Rynex PE Rynex DM Q-Tapp, Rynex PSE Q-Tapp DM Aller-Chlor Syrup,ED Chlorped Jr Ed A-HIst, Allerest PE, Nasohist Ped Tavist

12.5mg/5mL,25mg, 50mg Benadryl

1.25-30mg/ 5mL, 2.5-60mg Aprodine

1mg/mL, 5mg, 10mg

Zyrtec

Dosage Form

Liquid Liquid Liquid Liquid Syrup, Tablets Liquid Tablet Capsule, Elixir, Liquid, Solution Syrup, Tablet Chewable Tab, Tablets, Syrup

Age

Rx/OTC

4 OTC

>4 OTC

OTC OTC OTC

OTC

OTC

Decong estant s

Phenylephrine Oral

2.5mg/5mL, 10mg

Children's Sudafed PE, Contact D Cold

Liquid, Tablet

>4 OTC

Nasal Solutions

Pseudoephedrine Oxymetazoline Nasal Solution Phenylephrine Nasal Solution Sodium Chloride Nasal Solution

15mg/5mL, 30mg/5mL, 30mg 0.05%

0.125%, 0.25%, 0.5%, 1%

0.2%, 0.65%, 0.9%

Children's Sudafed Syrup, Sudagest, Sudafed

Afrin, Sinex 12 hour Decongestant

Little Noses Decongestant, NeoSynephrine Mild Nasal, 4 Way

Ayr, Ocean

Syrup, Tablet Spray Drops, Spray Drops, Spray

>4 OTC OTC

OTC OTC

Classified as Schedule III controlled substance in MS. Federally classified as OTC product and remains covered, pursuant to a prescription.

Version 2: September 10, 2015

Classified as Schedule V controlled substance in MS. Federally classified as OTC product and remains covered, pursuant to a prescription.

Reflects medically-accepted indications as determined by drug compendia and clinical literature, and not exclusively for FDA-approved ages. Use clinical judgment.



Expectorants &

combination

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