Over-the-Counter Drug List

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

1,200 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

1034169KYMENABS 06/21

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 1,000 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 Vit B-complex w/vit 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 citrate-vitamin D

Cholecalciferol

Cholecalciferol

Cholecalciferol

Cholecalciferol

Cholecalciferol

Cholecalciferol

Cholecalciferol

Cholecalciferol

Cyanocobalamin

Cyanocobalamin

Cyanocobalamin ER

Ferrous fum

Ferrous fum

Continued on next page

Strength 250 mg 500 mg

0.8 mg

600 mg 1,250 mg (500 mg elemtl Ca) 1,500 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 (50,000 unit) 10 mcg (400 unit) 25 mcg (1,000 unit) 25 mcg (1,000 unit)

50 mcg (2,000 unit) 50 mcg (2,000 unit)

125 mcg (5,000 unit) 125 mcg (5,000 unit)

250 mcg

500 mcg

1,000 mcg 324 mg (106 mg elem fe)

325 mg (106 mg elem fe)

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 & folic acid 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 multivitamin w/ C & FA Pediatric multivitamin w/ extra C & FA Pediatric multivitamin w/minerals & C Pediatric multivitamins w/ iron Pediatric multivitamins 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

1,000 mg

500 mg

150 mg (Fe eq)

1 gm

50 mg

100 mg

3 mg (10,000 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 1,250 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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