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(HMO SNP) Non-Part D and Over the Counter Medicaid Covered Drugs

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(HMO SNP) Non-Part D and Over the Counter Medicaid Covered Drugs UnitedHealthcare Dual Complete™ ONE (HMO SNP) Non-Part D and Over the Counter Medicaid Covered Drugs PDL CLASS PDL CATEGORY DRUG NAME ANALGESICS ANALGESICS ACETAMINOPHEN ANALGESICS ANALGESICS ACETAMINOPHEN-CAFFEINE-PYRILAMINE TAB ANALGESICS ANALGESICS ACETAMINOPHEN-PAMABROM-PYRILAMINE TAB ANALGESICS NSAIDS ASPIRIN ANALGESICS NSAIDS ASPIRIN BUFFERED (CA CARB-MG CARB-MG OX) TAB ANALGESICS NSAIDS ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB ANALGESICS NSAIDS ASPIRIN-AL HYDRO-MG HYDRO-CA CARB TAB ANALGESICS NSAIDS ASPIRIN-CAFFEINE TAB ANALGESICS NSAIDS IBUPROFEN ANALGESICS NSAIDS MAGNESIUM SALICYLATE TETRAHYDRATE TAB ANALGESICS NSAIDS NAPROXEN SODIUM ANTIHISTAMINES ANTIHISTAMINE CHLORPHENIRAMINE MALEATE ANTIHISTAMINES ANTIHISTAMINES BROMPHENIRAMINE MALEATE LIQUID ANTIHISTAMINES ANTIHISTAMINES CHLORPHENIRAMINE ANTIHISTAMINES ANTIHISTAMINES CLEMASTINE FUMARATE TAB ANTIHISTAMINES ANTIHISTAMINES CYCLIZINE HCL TAB ANTIHISTAMINES ANTIHISTAMINES DEXBROMPHENIRAMINE MALEATE TAB ANTIHISTAMINES ANTIHISTAMINES DIPHENHYDRAMINE ANTIHISTAMINES SECOND GENERATION ANTIHISTAMINES CETIRIZINE ANTIHISTAMINES SECOND GENERATION ANTIHISTAMINES CETIRIZINE-PSEUDOEPHEDRINE TAB SR ANTIHISTAMINES SECOND GENERATION ANTIHISTAMINES FEXOFENADINE ANTIHISTAMINES SECOND GENERATION ANTIHISTAMINES LORATADINE ANTIHISTAMINES SECOND GENERATION ANTIHISTAMINES LORATADINE & PSEUDOEPHEDRINE TAB SR CONTRACEPTIVES CONTRACEPTIVES CONDOMS LATEX LUBRICATED CONTRACEPTIVES CONTRACEPTIVES LEVONORGESTREL TAB CONTRACEPTIVES CONTRACEPTIVES NONOXYNOL-9 GEL Page 1 COUGH AND COLD ALLERGY AND ANTIHISTAMINES CHLORCYCLIZINE & PSEUDOEPHEDRINE LIQUID COUGH AND COLD ALLERGY AND ANTIHISTAMINES CHLORCYCLIZINE HCL TAB COUGH AND COLD ALLERGY AND ANTIHISTAMINES CHLORCYCLIZINE-PHENYLEPHRINE CHEW TAB COUGH AND COLD ALLERGY AND ANTIHISTAMINES CHLORCYCLIZINE-PHENYLEPHRINE SYRUP COUGH AND COLD ALLERGY AND ANTIHISTAMINES CHLORCYCLIZINE-PHENYLEPHRINE TAB COUGH AND COLD ALLERGY AND ANTIHISTAMINES CHLORPHEN TAN-PE TAN-METHSCOPOLAMINE SUSP COUGH AND COLD ALLERGY AND ANTIHISTAMINES CHLORPHEN-PHENYLTOLOX-PE- APAP TAB SR 12HR DIPHENHYDRAMINE HCL-PHENYLEPH HCL TANNATE CHEW COUGH AND COLD ANTIHISTAMINE - ALLERGY DRUGS TAB COUGH AND COLD ANTIHISTAMINE - ALLERGY DRUGS DIPHENHYDRAMINE-ACETAMINOPHEN TAB COUGH AND COLD ANTIHISTAMINE - ALLERGY DRUGS DIPHENHYDRAMINE-PHENYLEPHRINE COUGH AND COLD ANTIHISTAMINE - ALLERGY DRUGS DIPHENHYDRAMINE-PHENYLEPHRINE-APAP COUGH AND COLD ANTIHISTAMINE - ALLERGY DRUGS DOXYLAMINE SUCCINATE CHEW TAB COUGH AND COLD ANTIHISTAMINE - ALLERGY DRUGS DOXYLAMINE-PHENYLEPHRINE-APAP CAP COUGH AND COLD ANTIHISTAMINE - ALLERGY DRUGS DOXYLAMINE-PSEUDOEPHEDRINE LIQUID COUGH AND COLD ANTIHISTAMINE - ALLERGY DRUGS PYRILAMINE-PHENYLEPHRINE TAB COUGH AND COLD ANTIHISTAMINE - ALLERGY DRUGS THONZYLAMINE-CHLOPHEDIANOL LIQUID COUGH AND COLD ANTIHISTAMINE - ALLERGY DRUGS THONZYLAMINE-PHENYLEPHRINE LIQUID COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS BROMPHENIRAMINE & PHENYLEPHRINE COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS BROMPHENIRAMINE & PSEUDOEPHEDRINE COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS CHLORPHENIRAMINE & PHENYLEPHRINE COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS CHLORPHENIRAMINE & PSEUDOEPHEDRINE COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS CHLORPHENIRAMINE-PE-METHSCOPOLAMINE COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS CHLORPHEN-PE-APAP TAB & PE-APAP TAB PACK COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS CHLORPHEN-PE-METHSCOPOLAMINE TAB SR 12HR COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS CHLORPHEN-PHENYLEPHRINE W/ APAP COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS CHLORPHEN-PSE & METHSCOPOLAMINE COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS CHLORPHEN-PSE-ATROPINE-HYOS-SCOPOL TAB SR 12HR COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS DEXBROMPHENIRAMINE & PSEUDOEPHEDRINE TAB COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS DEXBROMPHENIRAMINE-PHENYLEPHRINE TAB COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS DEXCHLORPHENIRAMINE & PSEUDOEPHEDRINE TAB COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS DEXCHLORPHENIRAMINE-PHENYLEPHRINE TAB COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS DEXCHLORPHENIRAMINE-PSEUDOEPHED-APAP TAB COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS DEXCHLORPHEN-PSEUDOEPHED-METHSCOP TAB SR 12HR UnitedHealthcare Dual Complete™ ONE (HMO SNP) Non-Part D and Over the Counter Medicaid Covered Drugs COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS TRIPROLIDINE & PSEUDOEPHEDRINE COUGH AND COLD ANTIHISTAMINE AND DECONGESTANTS TRIPROLIDINE HCL LIQUID COUGH AND COLD ANTITUSSIVES ACETAMINOPHEN W/ DM LIQUID COUGH AND COLD ANTITUSSIVES BENZONATATE CAP COUGH AND COLD ANTITUSSIVES CARBET CIT-CARBET TAN-PE HCL-PE TAN SUS COUGH AND COLD ANTITUSSIVES CARBETAPENTANE CIT-PSEUDOEPH HCL TANNATE SUSP COUGH AND COLD ANTITUSSIVES CHLOPHEDIANOL-CHLORCYCLIZINE COUGH AND COLD ANTITUSSIVES CHLOPHEDIANOL-GUAIFENESIN LIQUID COUGH AND COLD ANTITUSSIVES CHLOPHEDIANOL-PSEUDOEPHEDRINE LIQD COUGH AND COLD ANTITUSSIVES CHLOPHEDIANOL-PYRILAMINE LIQUID COUGH AND COLD ANTITUSSIVES CHLOPHEDIANOL-TRIPROLIDINE LIQUID COUGH AND COLD ANTITUSSIVES CHLORPHEN TANNATE-CARBETAPENTANE TANNATE TAB COUGH AND COLD ANTITUSSIVES CHLORPHENIRAMINE W/ CODEINE COUGH AND COLD ANTITUSSIVES CHLORPHENIRAMINE-DM COUGH AND COLD ANTITUSSIVES CODEINE-CHLORPHENIRAMINE-ACETAMINOPHEN TAB COUGH AND COLD ANTITUSSIVES CODEINE-PHENYLEPHRINE-CHLORCYCLIZINE LIQD COUGH AND COLD ANTITUSSIVES CODEINE-PYRILAMINE SYRUP COUGH AND COLD ANTITUSSIVES DEXTROMETHORPHAN HBR LIQUID COUGH AND COLD ANTITUSSIVES DEXTROMETHORPHAN POLISTIREX LIQUID CR COUGH AND COLD ANTITUSSIVES DEXTROMETHORPHAN-APAP-CHLORPHENIRAMINE COUGH AND COLD ANTITUSSIVES DEXTROMETHORPHAN-DOXYLAMINE-APAP COUGH AND COLD ANTITUSSIVES DEXTROMETHORPHAN-GUAIFENESIN COUGH AND COLD ANTITUSSIVES DEXTROMETHORPHAN-PHENYLEPHRINE-APAP COUGH AND COLD ANTITUSSIVES DIHYDROCODEINE-GUAIFENESIN LIQUID COUGH AND COLD ANTITUSSIVES DOXYLAMINE-DM LIQUID COUGH AND COLD ANTITUSSIVES GUAIFENESIN-CODEINE COUGH AND COLD ANTITUSSIVES HYDROCOD POLST-CHLORPHEN POLST Page 3 COUGH AND COLD ANTITUSSIVES HYDROCODONE W/ HOMATROPINE COUGH AND COLD ANTITUSSIVES HYDROCODONE-CHLORPHENIRAMINE SOLN COUGH AND COLD ANTITUSSIVES PHENYLEPH HCL-PYRIL MAL-DM HBR TANNATE CHEW TAB COUGH AND COLD ANTITUSSIVES PHENYLEPH TAN-PYRILAMINE TAN-DM TAN SUSP COUGH AND COLD ANTITUSSIVES PHENYLEPH-CHLORPHEN-DM W/APAP COUGH AND COLD ANTITUSSIVES PHENYLEPH-DEXCHLORPHEN-PYRIL-DM SYRUP COUGH AND COLD ANTITUSSIVES PHENYLEPH-EPHED-CPM W/ CARBETAPENTANE TAB COUGH AND COLD ANTITUSSIVES PHENYLEPH-PYRILAMINE-CHLOPHEDIANOL LIQD COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE TAN-CARBETAPENTANE TAN SUSP COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE W/ ACETAMINOPHEN COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE W/ CODEINE COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE W/ DM COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-BROMPHEN W/ CODEINE COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-BROMPHEN-CARBETAPENTANE SUSP COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-BROMPHEN-DIHYDROCODEINE LIQD COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-BROMPHENIRAMINE-DM COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-CHLOPHEDIANOL-GG COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-CHLORPHEN W/ CODEINE SYRUP COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-CHLORPHEN-DIHYDROCODEINE COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-CHLORPHEN-DM COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-CODEINE-GUAIFENESIN-APAP COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-DEXBROMPHEN-CHLOPHEDIANOL LIQD COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-DEXCHLORPHENIR-CODEINE LIQUID COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-DIHYDROCODEINE COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-DM SYRUP COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-DM-GG W/ APAP COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-DOXYLAMINE-DM-APAP LIQUID COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-PROMETHAZINE W/ CODEINE SYRUP COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-PYRILAMINE W/ CODEINE SYRUP COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-PYRILAMINE-DIHYDROCOD LIQUID COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-PYRILAMINE-DM COUGH AND COLD ANTITUSSIVES PHENYLEPHRINE-THONZYLAMINE-DM LIQUID COUGH AND COLD ANTITUSSIVES PHENYLEPH-THONZYLAMINE-CHLOPHEDIANOL LIQUID COUGH AND COLD ANTITUSSIVES PHENYLEPH-TRIPROLIDINE-CHLOPHEDIANOL LIQUID UnitedHealthcare Dual Complete™ ONE (HMO SNP) Non-Part D and Over the Counter Medicaid Covered Drugs COUGH AND COLD ANTITUSSIVES PROMETHAZINE W/ CODEINE SYRUP COUGH AND COLD ANTITUSSIVES PROMETHAZINE-DM SYRUP COUGH AND COLD ANTITUSSIVES PSE-CHLORCYCLIZINE-CHLOPHEDIANOL LIQUID COUGH AND COLD ANTITUSSIVES PSEUDOEPH-CHLORPHEN W/ HYDROCODONE COUGH AND COLD ANTITUSSIVES PSEUDOEPH-CHLORPHEN-DM W/ APAP COUGH AND COLD ANTITUSSIVES PSEUDOEPH-DOXYLAMINE-DM W/APAP LIQUID COUGH AND COLD ANTITUSSIVES PSEUDOEPHED TAN-DEXCHLORPHEN TAN-DM TAN SUSP COUGH AND COLD ANTITUSSIVES PSEUDOEPHED-BROMPHEN-DIHYDROCODEINE LIQUID COUGH AND COLD ANTITUSSIVES PSEUDOEPHED-BROMPHEN-DM COUGH AND COLD ANTITUSSIVES PSEUDOEPHED-CHLORPHEN-DIHYDROCODEINE SYRUP COUGH AND COLD ANTITUSSIVES PSEUDOEPHED-CHLORPHEN-DM COUGH AND COLD ANTITUSSIVES PSEUDOEPHED-CODEINE-GUAIFENESIN-APAP COUGH AND COLD ANTITUSSIVES PSEUDOEPHED-DEXBROMPHENIRAMINE-DM LIQUID COUGH AND COLD ANTITUSSIVES PSEUDOEPHED-DEXCHLORPHEN-CHLOPHEDIANOL LIQUID COUGH AND COLD ANTITUSSIVES PSEUDOEPHED-DOXYLAMINE-DM LIQUID COUGH AND COLD ANTITUSSIVES PSEUDOEPHEDRINE TAN-CARBETAPENTANE TAN CHEW TAB COUGH AND COLD ANTITUSSIVES PSEUDOEPHEDRINE W/ APAP-DM COUGH AND COLD ANTITUSSIVES PSEUDOEPHEDRINE W/ CODEINE COUGH AND COLD ANTITUSSIVES PSEUDOEPHEDRINE W/ DM COUGH AND COLD ANTITUSSIVES PSEUDOEPHEDRINE W/ HYDROCODONE SOLN COUGH AND COLD ANTITUSSIVES PSEUDOEPHEDRINE-BROMPHEN-CODEINE LIQUID COUGH
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