Medicaid Covered Over the Counter Drug List by decree

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									                      Medicaid Covered Over the Counter Drug List
                                       Effective April 1, 2010

Only generic products are covered unless brand is indicated in parenthesis.

Analgesics:
Acetaminophen 80mg dispersable tablet
Acetaminophen 160mg dispersable tablet
Acetaminophen 325mg tablet
Acetaminophen 500mg tablet/capsule
Acetaminophen 650mg CR tablet

Acetaminophen 80mg/0.8ml solution/suspension drops
Acetaminophen 160mg/5ml solution/suspension/elixir

Acetaminophen 80mg suppository
Acetaminophen 120mg suppository
Acetaminophen 325mg suppository
Acetaminophen 650mg suppository

Aspirin 81mg chew tablet
Aspirin 81mg delayed release tablet
Aspirin 325mg delayed release tablet
Aspirin 325mg tablet
Aspirin 325mg tablet, buffered

Ibuprofen 100mg chewable tablet
Ibuprofen 200mg tablet (requires EA)

Ibuprofen 40mg/ml suspension drops
Ibuprofen 100mg/5ml suspension

Naproxen sodium 220mg tablet (requires EA)

Gastrointestinal
Antacid/acid reducer
Aluminum and magnesium hydroxides 225mg-200mg/5ml suspension

Calcium carbonate 500mg chewable antacid tablet
Calcium carbonate 650mg chewable antacid tablet
Calcium carbonate 750mg chewable antacid tablet
Calcium carbonate 1000mg chewable antacid tablet

Omeprazole magnesium 20mg (base equiv) delayed release tablet
Omeprazole 20mg delayed release tablet

Ranitidine 75mg tablet
Ranitidine 150mg tablet

Anti-diarrheal
Bismuth subsalicylate 262mg tablet/chewable tablet
Bismuth subsalicylate 300mg chewable tablet
Bismuth subsalicylate 262mg/15ml suspension

Loperamide 2mg tablet
Loperamide 1mg/5ml liquid
Anti-emetic
Meclizine 12.5mg tablet
Meclizine 25mg tablet/chewable tablet

Anti-gas
Simethicone 80mg chewable tablet
Simethicone 125mg chewable tablet
Simethicone 125mg capsule
Simethicone 40mg/0.6ml suspension

Emetic
Ipecac syrup

Laxatives
Bisacodyl 5mg delayed release tablet
Bisacodyl 10mg suppository

Docusate calcium 240mg capsule

Docusate sodium 100mg capsule/tablet
Docusate sodium 250mg capsule
Docusate sodium 150mg/15ml liquid
Docusate sodium 60mg/15ml syrup
docusate sodium 283mg enema (Enemeez mini) (requires PA)
docusate sodium-benzocaine 283mg-20mg enema (Enemeez plus) (requires PA)

glycerin 1.5gm suppository
glycerin 2gm suppository
glycerin 3gm suppository

magnesium citrate solution

Magnesium hydroxide 400mg/5ml suspension

Polyethylene glycol 3350 oral powder (requires EA)

psyllium powder

senna 187mg tablet
sennosides 8.6mg tablet
sennosides 8.8mg/5ml syrup

sodium phosphates oral solution

sodium phosphates enema

Ophthalmic
Polyvinyl alcohol 1.4% ophthalmic solution
Carboxymethylcellulose sodium 0.5% ophthalmic solution (including preservative free Refresh
Plus)

Artificial tear ophthalmic ointment

Ketotifen fumarate 0.025% ophthalmic solution

Otic
Carbamide peroxide 6.5% otic solution
Nasal
Saline 0.65% nasal spray

Antihistamines
Cetirizine 5mg tablet/chewable tablet
Cetirizine 10mg tablet/chewable tablet
Cetirizine 1mg/ml syrup (EA required)

Chlorpheniramine maleate 4mg tablet

Diphenhydramine 25mg tablet/capsule
Diphenhydramine 50mg tablet/capsule
Diphenhydramine 12.5mg/5ml liquid

Loratadine 10mg tablet/disintegrating tablet
Loratadine 5mg/5ml syrup

Topicals
Antibiotic
Bacitracin ointment

Bacitracin/polymyxin B ointment

Antifungal
Clotrimazole 1% topical cream

Clotrimazole 1% vaginal cream
Clotrimazole 2% vaginal cream

Miconazole nitrate topical 2% cream

Miconazole nitrate 2% vaginal cream
Miconazole nitrate 100mg vaginal suppository

Tolnaftate 1% topical cream

Antiinflammatory
Hydrocortisone 0.5% cream/ointment
Hydrocortisone 1% cream/lotion/ointment

Pediculicide
Permethrin 1% cream rinse/lotion

Pyrethrins-piperonyl butoxide 0.3-3% liquid/shampoo
Pyrethrins-piperonyl butoxide 0.3-4% liquid

Antipruritic
Lactic acid (ammonium lactate) 12% cream/lotion

Topicals for use in compounds:
skin protectant cream
hydrophilic ointment
mineral oil-hydrophilic petrolatum ointment
vitamin A and D ointment
Aquabase
Vitamins/Minerals
B-complex with vitamin C and folic acid 0.8mg tablet (requires EA)

Calcium, oyster shell 500mg tablet

Calcium carbonate suspension 1250/5ml

Calcium glubionate syrup 1.8gm/5ml

Calcium carbonate-vitamin D 500mg-200mg tablet
Calcium, oyster shell-vitamin D 500mg-200mg tablet
Calcium carbonate-vitamin D 600mg-200mg tablet
Calcium carbonate-vitamin D 600mg-400mg tablet


Cholecalciferol tablet 1000 unit

Ferrous sulfate 325mg tablet/EC tablet
Ferrous sulfate 220mg/5ml elixir
Ferrous sulfate 75mg/0.6ml drops

Ferrous gluconate 324mg tablet
Ferrous gluconate 325mg tablet

Multivitamin and zinc chewable tablets (Adeks)
Multivitamin/minerals antioxidant enriched softgel capsule (Aquadeks)
Multivitamin/minerals antioxidant enriched pediatric drops (Aquadeks)

Multivitamin Pediatric ADC 1500U-400U-35mg/ml drops
Multivitamin Pediatric with iron 10mg/ml drops

Niacin 500mg tablet

Pyridoxine 50mg tablet

Thiamine 100mg tablet (requires PA)

Other
Artificial saliva solution

Gelatin capsule (empty)

Glucose 40% gel
Glucose 4 gm chewable tablet

Glycerin liquid

Human insulin 100u/ml

Oral electrolyte solution

Potassium and sodium phosphates 278mg-164mg-250mg powder pack (Neutra-Phos)
Potassium and sodium phosphates 280mg-160mg-250mg powder pack (Phos-Nak)

Potassium phosphate 556mg-250mg powder pack (Neutra-Phos K)

Sodium chloride 0.9% nebulizer solution

Sorbitol solution (bulk)

								
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