IOWA Medicaid Prescription Drug Program Medicare Part D Excluded Drugs Eligible for Coverage under Medicaid

Based on Utilization: DOS 7/1/2005 - present

These drugs will maintain the current IA Medicaid Formulary with enforcement of its existing edits: PDL, Dosage Limitations, PA Requirements.

Drug CAT / Drug Description Exclusion Cat Drug CAT / Drug Description Exclusion Cat ANALGESICS - MISC. Benzodiazepines

Salicylates Alprazolam Benzodiazepines Aspirin Chew Tab 81 MG OTC Chlordiazepoxide HCl Benzodiazepines Aspirin EC Tab 325 MG OTC Clorazepate Dipotassium Benzodiazepines Aspirin EC Tab 81 MG OTC Diazepam Benzodiazepines Aspirin Tab 325 MG OTC Lorazepam Benzodiazepines Aspirin Tab 650 MG OTC Oxazepam Benzodiazepines Aspirin Tab 81 MG OTC ANXIOLYTICS - LONG ACTING

Salicylate Combinations Benzodiazepines

Aspirin Buffered Tab 325 MG OTC Alprazolam Benzodiazepines COUGH/COLD Analgesics Other

Acetaminophen Elixir 160 MG/5ML OTC Antitussive - Opioid Acetaminophen Soln 100 MG/ML OTC Hydrocodone Bitartrate (Antitussive) Cough and Cold Acetaminophen Suppos 120 MG OTC Decongestant-Antihistamine-Anticholinergic Acetaminophen Tab 325 MG OTC Chlorpheniramine Tannate-Phenylephrine Tan- Cough and Cold Acetaminophen Tab 500 MG OTC Methscopalamine

Analgesics-Sedatives Opioid Antitussive-Decongestant

Butalbital-Acetaminophen-Caffeine Other Excluded Pseudoephedrine w/ Hydrocodone Cough and Cold Butalbital-Aspirin-Caffeine Other Excluded Opioid Antitussive-Decongestant-Antihistamine ANTIASTHMATIC - MISC. RESPIRATORY INHALANTS Pseudoephedrine-Brompheniramine-Hydrocodone Cough and Cold Misc. Respiratory Inhalants

Sodium Chloride Aero Soln 0.9% OTC Non-Narc Antitussive-Decongestant ANTICONVULSANTS Phenylephrine Tannate-Carbetapentane Tannate Cough and Cold Carbetapentane Citrate-Pseudoephedrine HCl Tannate Cough and Cold Anticonvulsants - Benzodiazepines Pseudoephedrine-DM Elixir 20-10 MG/5ML OTC Clonazepam Benzodiazepines Pseudoephedrine-DM Liqd 15-7.5 MG/5ML OTC Diazepam (Anticonvulsant) Benzodiazepines Pseudoephedrine-DM Liqd 20-10 MG/5ML OTC ANTIEMETIC - ANTICHOLINERGIC / DOPAMINERGIC Pseudoephedrine-DM Liqd 30-15 MG/5ML OTC Pseudoephedrine-DM Soln 7.5-2.5 MG/0.8ML OTC Antiemetics - Anticholinergic Pseudoephedrine-DM Syrup 15-5 MG/5ML OTC Meclizine HCl Chew Tab 25 MG OTC Pseudoephedrine-DM Syrup 15-7.5 MG/5ML OTC Meclizine HCl Tab 12.5 MG OTC Pseudoephedrine-DM Syrup 30-15 MG/5ML OTC Meclizine HCl Tab 25 MG OTC ANTIHISTAMINES - NON-SEDATING Non-Narc Antitussive-Decongestant-Antihistamine Phenyleph Tannate-Bromphen Tannate- Cough and Cold Antihistamines - Non-Sedating Dextromethorphan Tannate Loratadine Syrup 10 MG/10ML OTC Phenylephrine-Chlorphen-DM Cough and Cold Loratadine Tab 10 MG OTC Phenyleph Tannate-Pyrilamine Tannate- Cough and Cold Carbetapentane Tannate ANTIHISTAMINES - OTHER Pseudoephed-Bromphen-DM Cough and Cold Antihistamines - Alkylamines Pseudoephedrine Tan-Dexchlorphen Tan- Cough and Cold Dextromethorphan Tan Chlorpheniramine Maleate Tab 4 MG OTC Phenyleph Tannate-Diphenhyd Tannate- Cough and Cold Carbetapentane Tannate Antihistamines - Ethanolamines Decongestant w/ Expectorant Diphenhydramine HCl Cap 25 MG OTC Phenylephrine-Guaifenesin Cough and Cold Diphenhydramine HCl Elixir 12.5 MG/5ML OTC Pseudoephedrine-Guaifenesin Cough and Cold Diphenhydramine HCl Liquid 12.5 MG/5ML OTC

Diphenhydramine HCl Syrup 12.5 MG/5ML OTC Decongestant-Antihistamine w/ Expectorant

ANXIOLYTICS - BENZODIAZEPINES Phenylephrine-Chlorphen-GG Cough and Cold rt6287_medicare part d vers A_05/18/2006 Page 1 of 4 Drug CAT / Drug Description Exclusion Cat Drug CAT / Drug Description Exclusion Cat COUGH/COLD COUGH/COLD - EXPECTORANT MIXTURES

Antitussive-Expectorant Expectorant Mixtures

Carbetapentane-Guaifenesin Cough and Cold Guaifenesin-Potassium Guaiacolsulfonate Cough and Cold Dextromethorphan-Guaifenesin Cough and Cold COUGH/COLD - EXPECTORANTS Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML OTC Expectorants Hydrocodone-Guaifenesin Cough and Cold Guaifenesin Tabs Cough and Cold Antitussive-Expectorants-Decongestant COUGH/COLD - NARCOTIC ANTITUSSIVE-ANTIHISTAMINE Phenylephrine w/ DM-GG Cough and Cold Opioid Antitussive-Antihistamine Phenylephrine w/Hydrocodone-GG Cough and Cold Chlorpheniramine w/Hydrocodone Cough and Cold Pseudoeph w/Hydrocodone-GG Cough and Cold Promethazine w/Codeine Cough and Cold Antitussive-Expectorant - Decongest-Antihist COUGH/COLD - NARCOTIC ANTITUSSIVE-DECONGESTANT Phenylephrine-Chlorpheniramine w/ DM-GG Cough and Cold Opioid Antitussive-Decongestant

Antitussive-Expectorant - Decongest-Analgesic Phenyleph-Hydrocodone Cough and Cold Pseudoephedrine-DM-GG w/ APAP Cough and Cold Pseudoephedrine w/ Hydrocodone Cough and Cold COUGH/COLD - ANTITUSSIVE - NARCOTIC Pseudoephedrine Tannate-Hydrocodone Tannate Cough and Cold COUGH/COLD - NARCOTIC ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE Antitussive - Opioid

Hydrocodone w/ Homatropine Cough and Cold Opioid Antitussive-Decongestant-Antihistamine COUGH/COLD - ANTITUSSIVE - NONNARCOTIC Phenyleph-Promethazine w/ Cod Cough and Cold Phenylephrine-Chlorpheniramine-Dihydrocodeine Cough and Cold Antitussive - Nonnarcotic Pseudoeph-Chlorphen w/ Cod Cough and Cold Benzonatate Cough and Cold Phenyleph-CPM w/ Hydrocod Cough and Cold COUGH/COLD - ANTITUSSIVE-EXPECTORANT Phenyleph-Pyril w/ Hydrocod Cough and Cold

Antitussive-Expectorant Pseudoephedrine-Brompheniramine-Hydrocodone Cough and Cold Pseudoephed-CPM w/ Hydrocod Cough and Cold Codeine-Guaifenesin Cough and Cold Pseudoephedrine-Chlorpheniramine-Dihydrocodeine Cough and Cold Dextromethorphan-Guaifenesin Cough and Cold Pseudoephedrine-Carbinoxamine w/ Hydrocodone Cough and Cold Hydrocodone-Guaifenesin Cough and Cold Hydrocodone-Potassium Guaiacolsulfonate Cough and Cold COUGH/COLD - NON-NARC ANTITUSSIVE-ANTIHISTAMINE Guaifenesin-Potassium Guaiacolsulfonate- Cough and Cold Non-Narc Antitussive-Antihistamine Dextromethorphan COUGH/COLD - ANTITUSSIVE-EXPECTORANT - DECONGEST-ANTIHIST Chlorpheniramine Tannate-Carbetapentane Tannate Cough and Cold Promethazine-DM Cough and Cold Antitussive-Expectorant - Decongest-Antihist COUGH/COLD - NON-NARC ANTITUSSIVE-DECONGESTANT pseudoephed-bromphen-dm-gg syrup 30-2-5-50 mg/5 Cough and Cold ml Non-Narc Antitussive-Decongestant

COUGH/COLD - ANTITUSSIVE-EXPECTORANTS-DECONGESTANT Carbetapentane Citrate-Pseudoephedrine HCl Tannate Cough and Cold Antitussive-Expectorants-Decongestant COUGH/COLD - NON-NARC ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE

Phenylephrine w/Hydrocodone-GG Cough and Cold Non-Narc Antitussive-Decongestant-Antihistamine Pseudoephedrine w/ Codeine-GG Cough and Cold Phenylephrine-Chlorphen-DM Cough and Cold Pseudoephedrine w/ DM-GG Cough and Cold Phenyleph Tannate-Chlorphen Tannate- Cough and Cold Pseudoephedrine-Dihydrocodeine-Guaifenesin Cough and Cold Carbetapentane Tannate Pseudoeph w/Hydrocodone-GG Cough and Cold Phenylephrine-Pyrilamine-DM Cough and Cold Phenylephrine-Carbetapentane-Guaifenesin Cough and Cold Phenyleph Tannate-Pyrilamine Tannate- Cough and Cold Carbetapentane Tannate COUGH/COLD - DECONGESTANT & ANTICHOLINERGIC Pseudoephedrine Tan-Chlorphen Tan- Cough and Cold Dextromethorphan Tan Decongestant & Anticholinergic Pseudoephed-Bromphen-DM Cough and Cold pseudoephedrine-methscopolamine Cough and Cold Pseudoephedrine Tan-Dexchlorphen Tan- Cough and Cold COUGH/COLD - DECONGESTANT W/ EXPECTORANT Dextromethorphan Tan Pseudoephed-Carbinox-DM Cough and Cold Decongestant w/ Expectorant Phenylephrine-Ephedrine-Chlorpheniramine w/ Cough and Cold Carbetapentane Phenylephrine-Guaifenesin Cough and Cold COUGH/COLD - SYSTEMIC DECONGESTANTS Pseudoephedrine-Guaifenesin Cough and Cold COUGH/COLD - DECONGESTANT-ANTIHISTAMINE W/ EXPECTORANT Systemic Decongestants Pseudoephedrine HCl Syrup 30 MG/5ML OTC Decongestant-Antihistamine w/ Expectorant Pseudoephedrine HCl Tab 30 MG OTC RYNA-12X Cough and Cold Pseudoephedrine HCl Tab 60 MG OTC COUGH/COLD - DECONGESTANT-ANTIHISTAMINE-ANTICHOLINERGIC COUGH/COLD - TOPICAL DECONGESTANTS Decongestant-Antihistamine-Anticholinergic Topical Decongestants Carbinoxamine-Pseudoephedrine-Methscopolamine Cough and Cold ADRENALIN Cough and Cold Chlorpheniramine-Pseudoephedrine & Cough and Cold TYZINE Cough and Cold Methscopolamine Chlorpheniramine-Phenylephrine-Methscopolamine Cough and Cold ELECTROLYTES/ NUTRITIONALS rt6287_medicare part d vers A_05/18/2006 Page 2 of 4 Drug CAT / Drug Description Exclusion Cat Drug CAT / Drug Description Exclusion Cat ELECTROLYTES/ NUTRITIONALS Artificial Tears and Lubricants

Electrolytes Oral *Artificial Tear Ophth Ointment*** OTC *Oral Electrolyte Solution*** OTC Ophthalmic Hyperosmolar Products GI - ANTI - FLATULENTS / GI STIMULANTS Sodium Chloride Hypertonic Ophth Oint 5% OTC Stimulant Laxatives Sodium Chloride Hypertonic Ophth Soln 5% OTC Senna Tab 187 MG OTC SEDATIVE/HYPNOTICS - BARBITURATE Sennosides Granules 15 MG/TSP (15 MG/3GM) OTC Barbiturate Hypnotics Sennosides Tab 8.6 MG OTC Butabarbital Sodium Barbiturates GI - ANTIDIARRHEAL / ANTACID - MISC. Mephobarbital Barbiturates Antacids - Bicarbonate Pentobarbital Sodium Barbiturates Sodium Bicarbonate Tab 325 MG OTC Phenobarbital Barbiturates Sodium Bicarbonate Tab 650 MG OTC Phenobarbital Sodium Barbiturates Secobarbital Sodium Barbiturates Antacids - Magnesium Salts SEDATIVE/HYPNOTICS - BENZODIAZEPINES Magnesium Oxide Cap 140 MG (85 MG Elemental MG) OTC Magnesium Oxide Tab 400 MG OTC Benzodiazepine Hypnotics GI - ANTIPERISTALTIC AGENTS Estazolam Benzodiazepines Flurazepam HCl Benzodiazepines Antiperistaltic Agents Midazolam HCl Benzodiazepines Loperamide HCl Liq 1 MG/5ML (0.2 MG/ML) OTC Quazepam Benzodiazepines Loperamide HCl Tab 2 MG OTC Temazepam Benzodiazepines GI - MISC. Triazolam Benzodiazepines

Laxatives & DSS TOPICAL - ACNE PREPARATIONS

Sennosides-Docusate Sodium Tab 8.6-50 MG OTC Acne Products

GI - PROTON PUMP INHIBITOR Benzoyl Peroxide Gel 10% OTC

Proton Pump Inhibitors Benzoyl Peroxide Gel 5% OTC Benzoyl Peroxide Liq 10% OTC Omeprazole Magnesium Delayed Release Tab 20 MG ( OTC Base Equiv) Benzoyl Peroxide Lotion 10% OTC MINERALS Benzoyl Peroxide Lotion 5% OTC

Calcium TOPICAL - ANTIBIOTIC Calcium Carbonate Chew Tab 1250 MG (500 MG OTC Antibiotics - Topical Elemental Ca) Bacitracin Oint 500 Unit/GM OTC Calcium Carbonate Susp 1250 MG/5ML OTC

Calcium Carbonate Tab 600 MG OTC Antibiotic Mixtures Topical Calcium Gluconate Vitamins and Minerals *Neomycin-Bacitracin-Polymyxin Oint*** OTC Calcium Gluconate Tab 650 MG OTC TOPICAL - ANTIFUNGALS Calcium Lactate Tab 650 MG OTC Antifungals - Topical Calcium Combinations Tolnaftate Cream 1% OTC Calcium Carbonate-Vitamin D Tab 500 MG-200 Unit OTC Tolnaftate Powder 1% OTC Calcium Carbonate-Vitamin D Tab 600 MG-200 Unit OTC Tolnaftate Soln 1% OTC Magnesium Imidazole-Related Antifungals - Topical Magnesium Chloride Vitamins and Minerals Miconazole Nitrate Cream 2% OTC Magnesium Sulfate Vitamins and Minerals TOPICAL - EMOLLIENTS Iron Emollients Ferrous Sulfate Elixir 220 MG/5ML OTC Lactic Acid (Ammonium Lactate) Lotion 12% OTC Ferrous Sulfate Soln 75 MG/0.6ML (15 MG/0.6ML OTC Elemental Fe) TOPICAL - ENZYMES / KERATOLYTICS / UREA Ferrous Sulfate Tab 300 MG OTC Keratolytic/Antimitotic Agents Ferrous Sulfate Tab 325 MG OTC Salicylic Acid Liquid 17% OTC Ferrous Gluconate Tab 325 MG OTC Ferrous Fumarate Tab 325 MG OTC TOPICAL - SCABICIDES AND PEDICULICIDES NSAIDS Scabicides & Pediculicides

Nonsteroidal Anti-inflammatory Agents (NSAIDs) Permethrin Creme Rinse 1% OTC

Ibuprofen Susp 100 MG/5ML OTC Scabicide Combinations Ibuprofen Tab 200 MG OTC Pyrethrins-Piperonyl Butoxide Liq 0.33-4% OTC OP. MISC Pyrethrins-Piperonyl Butoxide Shampoo 0.3-3% OTC

Artificial Tears and Lubricants Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4% OTC

*Artificial Tear Ophth Solution*** OTC VAGINAL - ANTI FUNGALS

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Imidazole-Related Antifungals

Clotrimazole Vaginal Cream 1% OTC Miconazole Nitrate Vaginal Cream 2% OTC Miconazole Nitrate Vaginal Suppos 100 MG OTC VITAMINS

Vitamin B-1

Thiamine HCl Vitamins and Minerals

Vitamin B-3

Niacin Tab 100 MG OTC Niacin Tab 250 MG OTC Niacin Tab 50 MG OTC Niacin Tab 500 MG OTC

Vitamin B-6

Pyridoxine HCl Vitamins and Minerals

Vitamin D

Ergocalciferol Vitamins and Minerals Calcitriol Vitamins and Minerals Dihydrotachysterol Vitamins and Minerals

Vitamin K

Phytonadione Vitamins and Minerals WEIGHT LOSS

Fat Absorption Decreasing Agents

Orlistat Anorexia, Weight Loss, and Weight Gain

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