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MassHealth Over-the-Counter Drug List

This page lists the only over-the-counter (OTC) drugs that are covered by MassHealth without prior authorization (PA). All other OTC drugs except insulin vials require PA. Please refer to 130 CMR 406.411(A) and 406.412 (A) (2) for further information on OTC drugs. Insulins that are available without PA are listed in the MassHealth Drug List. All insulins are covered for members at home, in nursing facilities, or in rest homes. The items are listed alphabetically by therapeutic class, then by the generic name of the drug or drug ingredients. In general, MassHealth pays only for generic versions of these OTC drugs, singly or in combination, regardless of strength or dosage form unless otherwise specified. Combination products that contain active ingredients that are not included in this list require PA. Notwithstanding the above, MassHealth may pay for a brand-name OTC product if that product is medically necessary under 130 CMR 450.204. All brand-name OTC products currently covered by MassHealth without prior authorization are listed by brand name, below.

Allergy Agents, Ophthalmic: Antimicrobials, Topical: colloidal oatmeal ketotifen bacitracin cream, lotion, naphazoline gluconate ointment Naphcon-A (naphazoline/ hydrophilic ointment pheniramine) double ointment lanolin Opcon-A (naphazoline/ petrolatum pheniramine) iodine selenium sulfide isopropyl alcohol vitamin A and D ointment : miconazole witch hazel acetaminophen ≤ 4 grams/day zinc oxide povidone aspirin with buffers Gastrointestinal Agents: capsaicin Align (bifidobacterium infantis) triple antibiotic ointment ibuprofen < 19 years naproxen Compounding Agents: aluminum carbonate cherry syrup aluminum hydroxide Anthelmintic Agents: Ora-Plus suspending vehicle bisacodyl Pin-X (pyrantel pamoate) Ora-Sweet oral syrup subsalicylate Reese’s Pinworm (pyrantel Ora-Sweet-SF oral syrup cimetidine pamoate) simple syrup Culturelle (lactobacillus Antihistamines / rhamnosus GG) < 19 years Contraceptives, Oral: Decongestants: dextrin levonorgestrel 1.5 mg tablet cetirizine syrup, tablet docusate sodium cetirizine/pseudoephedrine Contraceptives, Topical: famotidine chlorpheniramine nonoxynol-9 * Florastor (saccharomyces diphenhydramine Dermatologic Agents, boulardii) < 19 years doxylamine Topical: glycerin loratadine tablet, solution benzoyl peroxide < 22 years kaolin/pectin loratadine/pseudoephedrine calamine lotion pseudoephedrine ≤ 240 mg/day magaldrate

* Branded OTC nonoxynol-9 products are covered by MassHealth without prior authorization.

OTC Drug List (Rev. 09/17)

Gastrointestinal Agents Vitamins / Nutrients / (continued): Supplements: meclizine calcium replacement methylcellulose cod liver oil mineral oil coenzyme Q10 < 19 years polyethylene glycol 3350 electrolyte solution, pediatric psyllium ferrous fumarate ranitidine ferrous gluconate sennosides ferrous sulfate simethicone folic acid sodium bicarbonate magnesium salts sodium phosphate melatonin tablet, solution melatonin/pyridoxine tablet Intranasal Sprays: multivitamins nasal spray ≤ 1 niacinamide inhaler/month nicotinic acid Nasacort Allergy 24HR pediatric multivitamins () ≤ 1 Phos-Flur ( oral inhaler/month rinse) Otic Agents: prenatal vitamins carbamide peroxide potassium phosphate Pediculicides/Scabicides: sodium chloride tablet permethrin sodium fluoride chewable tablet, oral solution piperonyl butoxide/pyrethrins vitamin A (retinol) Respiratory Agents: vitamin B-1 (thiamine) sodium chloride for inhalation vitamin B-2 (riboflavin) Smoking Cessation: vitamin B-3 (niacin) nicotine gum, lozenge, patch vitamin B-6 (pyridoxine) vitamin B-12 (cyanocobalamin) Tear/Saliva Replacement vitamin B complex Agents: (ascorbic acid) artificial tears (glycerin/ vitamin D propylene glycol) vitamin E, oral saliva substitute vitamins, multiple Urinary Agents: vitamins, multiple/minerals Oxytrol for Women (oxybutynin) vitamins, pediatric vitamins, prenatal

OTC Drug List (Rev. 09/17)