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MEDEL: Medicare Part D Excluded Drugs MEDEL Medicare Part D Excluded Drugs Eligible for Coverage under MEDEL Only drugs provided by MEDEL participating manufacturers will be eligible for coverage. These drugs will maintain the current MEDEL Formulary with enforcement of its existing edits: PDL, Dosage Limitations, etc. Drug Categories / Drug Description Exclusion Cat Drug Categories / Drug Description Exclusion Cat ANALGESICS - MISC. Antidiarrheal Agents - Misc. Salicylates Bismuth Subsalicylate OTC Aspirin OTC Antacids - Aluminum Salts Analgesics Other Aluminum Hydroxide Gel OTC Acetaminophen OTC Antacids - Bicarbonate ANTIASTHMATIC - NASAL MISC. Sodium Bicarbonate (Antacid) OTC Nasal Agents - Misc. Antacids - Calcium Salts Saline OTC ANTICONVULSANTS Calcium Carbonate (Antacid) OTC Anticonvulsants - Benzodiazepines Antacids - Magnesium Salts Clonazepam Benzodiazepines Magnesium Oxide OTC Diazepam (Anticonvulsant) Benzodiazepines Antacid Combinations ANTIHISTAMINES - NON-SEDATING Aluminum & Magnesium Hydroxide OTC Antihistamines - Non-Sedating GI - ANTIPERISTALTIC AGENTS CLARITIN OTC Antiperistaltic Agents loratadine OTC ANXIOLYTICS - BENZODIAZEPINES Loperamide HCl OTC GI - DIGESTIVE ENZYMES Benzodiazepines Digestive Enzymes Alprazolam Benzodiazepines Chlordiazepoxide HCl Benzodiazepines Lactase OTC Clorazepate Dipotassium Benzodiazepines GI - H2-ANTAGONISTS Diazepam Benzodiazepines Lorazepam Benzodiazepines H-2 Antagonists Oxazepam Benzodiazepines Cimetidine OTC COUGH/COLD Famotidine OTC Ranitidine HCl OTC Systemic Decongestants GI - MISC. Pseudoephedrine HCl OTC Saline Laxatives Topical Decongestants Magnesium Citrate OTC Oxymetazoline HCl OTC Magnesium Hydroxide OTC Antitussive-Expectorant Saline Laxative Mixtures ROBITUSSIN DM OTC FLEET ENEMA OTC ROBITUSSIN SUGAR FREE OTC FLEET PEDIATRIC OTC EAR FLEET PHOSPHO SODA OTC sodium phosphates OTC Otic Agents - Miscellaneous Stimulant Laxatives Carbamide Peroxide (Otic) OTC GI - ANTI - FLATULENTS / GI STIMULANTS Bisacodyl OTC Senna OTC Antiflatulents Sennosides OTC Simethicone OTC Bulk Laxatives GI - ANTIDIARRHEAL / ANTACID - MISC. Cellulose OTC rt5377_verb_III_c_STATE Page 1 of 3 Drug Categories / Drug Description Exclusion Cat Drug Categories / Drug Description Exclusion Cat GI - MISC. Zinc Bulk Laxatives Zinc OTC Guar Gum OTC Zinc Gluconate OTC Methylcellulose (Laxative) OTC Zinc Sulfate OTC Polycarbophil Calcium OTC Iron Psyllium OTC Ferrous Fumarate OTC Surfactant Laxatives Ferrous Gluconate OTC Docusate Sodium OTC Ferrous Sulfate OTC Ferrous Sulfate Dried OTC Laxative Combinations Iron OTC Senna-Psyllium OTC Polysaccharide Iron Complex OTC NICOTINE PATCHES / TABLETS Laxatives & DSS Smoking Deterrents Sennosides-Docusate Sodium OTC NICODERM CQ OTC Antacid & Simethicone NICOTINE REPLACEMENT - OTHER Alum & Mag Hydrox-Simethicone OTC Smoking Deterrents Oral Vehicles Nicotine Polacrilex OTC Sorbitol OTC NSAIDS GI - PROTON PUMP INHIBITOR Nonsteroidal Anti-inflammatory Agents (NSAIDs) Proton Pump Inhibitors Ibuprofen OTC PRILOSEC OTC OTC Naproxen Sodium OTC MISCELLANEOUS OP. ARTIFICIAL TEARS AND LUBRICANTS Antihistamines - Ethanolamines Artificial Tears and Lubricants Clemastine Fumarate OTC Carboxymethylcellulose Sodium (Ophth) OTC Diphenhydramine HCl OTC Hydroxypropyl Methylcellulose (Ophth) OTC Methylcellulose (Ophth) OTC Liniments Polyvinyl Alcohol OTC Capsicum Oleoresin OTC Artificial Tear Gels Thickening Agents Artificial Tear Gel OTC DIAFOODS THICK-IT OTC OP. MISC DIAFOODS THICK-IT #2 OTC Ophthalmic Hyperosmolar Products DIAFOODS THICK-IT ORIGINA OTC MINERALS Sodium Chloride Hypertonic OTC Other Antihistamines Calcium Antihistamines - Alkylamines Calcium Carbonate OTC Calcium Citrate OTC Chlorpheniramine Maleate OTC Calcium Glubionate OTC Antihistamines - Ethanolamines Calcium Gluconate OTC Calcium Lactate OTC Clemastine Fumarate OTC Oyster Shell OTC Diphenhydramine HCl OTC Calcium Combinations Antihistamines - Non-Sedating Calcium Carbonate-Cholecalciferol OTC loratadine OTC Calcium Carbonate-Vit D-Vit C-Vit E w/ Minerals OTC SEDATIVE/HYPNOTICS - BARBITURATE Calcium Carbonate-Vitamin D OTC Barbiturate Hypnotics Calcium Carbonate-Vitamin D w/ Minerals OTC Calcium Citrate-Vitamin D OTC Butabarbital Sodium Barbiturates Calcium w/ Vitamin D OTC Mephobarbital Barbiturates Calcium w/ Vitamins D & K OTC Phenobarbital Barbiturates Secobarbital Sodium Barbiturates Magnesium SEDATIVE/HYPNOTICS - BENZODIAZEPINES Magnesium OTC Benzodiazepine Hypnotics Magnesium Chloride OTC Magnesium Gluconate OTC Estazolam Benzodiazepines Magnesium Oxide (Mg Supplement) OTC Flurazepam HCl Benzodiazepines rt5377_verb_III_c_STATE Page 2 of 3 Drug Categories / Drug Description Exclusion Cat Drug Categories / Drug Description Exclusion Cat SEDATIVE/HYPNOTICS - BENZODIAZEPINES Folic Acid/Folates Benzodiazepine Hypnotics Folic Acid OTC Midazolam HCl Benzodiazepines VITAMINS - MISC. Quazepam Benzodiazepines B-Complex Vitamins OTC Temazepam Benzodiazepines B-Complex w/ C & Folic Acid Vitamins and Minerals Triazolam Benzodiazepines B-Complex w/ C-Zn & Folic Acid Vitamins and Minerals TOPICAL - ANTIFUNGALS Multiple Vitamin OTC Multiple Vitamins w/ Iron OTC Antifungals - Topical Multiple Vitamins w/ Minerals OTC Tolnaftate OTC Imidazole-Related Antifungals - Topical Clotrimazole (Topical) OTC Ketoconazole (Topical) OTC Miconazole Nitrate (Topical) OTC TOPICAL - CORTICOSTEROIDS Corticosteroids - Topical Hydrocortisone (Topical) OTC Hydrocortisone Acetate (Topical) OTC TOPICAL - LOCAL ANESTHETICS Local Anesthetics - Topical Capsaicin OTC Dibucaine OTC Lidocaine OTC Topical Anesthetic Combinations Lidocaine-Transparent Dressing OTC VITAMINS Vitamin B-1 Thiamine HCl OTC Vitamin B-2 Riboflavin OTC Vitamin B-3 Niacin OTC Vitamin B-6 Pyridoxine HCl OTC Vitamin C Ascorbic Acid OTC Vitamin D: Oral Only Calcitriol Vitamins and Minerals Cholecalciferol OTC Dihydrotachysterol Vitamins and Minerals Ergocalciferol Vitamins and Minerals Vitamin D OTC Vitamin E Vitamin E OTC Vitamin K: Oral Only Phytonadione Vitamins and Minerals Cobalamins Cyanocobalamin OTC rt5377_verb_III_c_STATE Page 3 of 3.
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