Subtitle header text Over-the-Counter Drug List

Subtitle header text

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

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

Liquids

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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.

Subtitle header text

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

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Kits

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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

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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

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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

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