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Mainecare Medicare Part D Excluded Drugs Eligible for Coverage Under Mainecare

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