IOWA Medicaid Prescription Drug Program Medicare Part D Excluded Drugs Eligible for Coverage under Medicaid (PDL, Dosage Limitations, and PA Requirements still apply) Effective 01-01-14 Drug Cat./Drug Description Exclusion Cat. Drug Cat./Drug Description Exclusion Cat. ANALGESICS – MISC. ELECTROLYTES/ NUTRITIONALS Salicylates Electrolytes Oral Aspirin Chew Tab 81mg OTC Oral Electrolyte Solution OTC Aspirin EC Tab 325mg OTC GI - ANTI - FLATULENTS / GI STIMULANTS Aspirin EC Tab 81mg OTC Stimulant Laxatives Aspirin Tab 325mg OTC Senna Tab 187 MG OTC Aspirin Tab 650mg Tab OTC Sennosides Tab 8.6 MG OTC Aspirin Tab 81mg OTC GI - ANTIDIARRHEAL / ANTACID - MISC. Salicylate Combinations Antacids - Bicarbonate Aspirin Buffered Tab 325mg OTC Sodium Bicarbonate Tab 325 MG OTC Analgesics Other Sodium Bicarbonate Tab 650 MG OTC Acetaminophen Elixir 160mg/5mL OTC Antacids - Magnesium Salts Acetaminophen Soln 100mg/mL OTC Magnesium Oxide Cap 140 MG (85 MG Elemental MG) OTC Acetaminophen Supp. 120mg OTC Magnesium Oxide Tab 400 MG OTC Acetaminophen Tab 325mg OTC GI - ANTIPERISTALTIC AGENTS Acetaminophen Tab 500mg OTC Antiperistaltic Agents Analgesics-Sedatives Loperamide HCl Liq 1 MG/5ML (0.2 MG/ML) OTC Butalbital-Acetaminophen-Caffeine Other Loperamide HCl Tab 2 MG OTC Butalbital-Aspirin-Caffeine Other GI - MISC. ANTIEMETIC – ANTICHOLINERGIC/DOPAMINERGIC Laxatives & DSS Antiemetics - Anticholinergic Magnesium Hydroxide Susp 400MG/5ML OTC Meclizine Chew Tab 25mg OTC Sennosides-Docusate Sodium Tab 8.6-50 MG OTC Meclizine Tab 12.5mg OTC Sennosides Syrup 8.8 MG/5ML OTC Meclizine Tab 25mg OTC MINERALS ANTIHISTAMINES – NON-SEDATING Calcium Antihistamines – Non-Sedating Calcium Carbonate Chew Tab 500 MG OTC Cetirizine 1mg/ml Liquid OTC Calcium Carbonate Chew Tab 750 MG OTC Cetirizine 5mg Tab OTC Calcium Carbonate Chew Tab 1000 MG OTC Cetirizine 10mg Tab OTC Calcium Carbonate Chew Tab 1250 MG (500 MG Loratadine Syrup 10mg/10mL OTC Elemental Ca) OTC Loratadine Tab 10mg OTC Calcium Carbonate Susp 1250 MG/5ML OTC ANTIHISTAMINES - OTHER Calcium Carbonate Tab 600 MG OTC Antihistamines - Alkylamines Calcium Gluconate Tab 650 MG OTC Chlorpheniramine Tab 4mg OTC Calcium Lactate Tab 650 MG OTC Antihistamines - Ethanolamines Calcium Combinations Diphenhydramine HCl Cap 25mg OTC Calcium Carbonate-Vitamin D Tab 500 MG-200 Unit OTC Diphenhydramine HCl Elixir 12.5mg/5mL OTC Calcium Carbonate-Vitamin D Tab 600 MG-200 Unit OTC Diphenhydramine HCl Liquid 12.5mg/5mL OTC Calcium Carbonate-Vitamin D Tab 600 MG-400 Unit OTC Diphenhydramine HCl Syrup 12.5mg/5mL OTC Iron COUGH/COLD - ANTITUSSIVE-EXPECTORANT Ferrous Sulfate Soln 75 MG/0.6ML (15 MG/0.6ML Antitussive-Expectorant Elemental Fe) OTC Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML OTC Ferrous Sulfate Tab 325 MG OTC COUGH/COLD - SYSTEMIC DECONGESTANTS Ferrous Gluconate Tab 325 MG OTC Systemic Decongestants Ferrous Fumarate Tab 325 MG OTC Pseudoephedrine HCl Syrup 30 MG/5ML OTC Magnesium Pseudoephedrine HCl Tab 30 MG OTC Magnesium Chloride Vitamin/Minerals Pseudoephedrine HCl Tab 60 MG OTC Magnesium Sulfate Vitamin/Minerals Drug Cat./Drug Description Exclusion Cat. Drug Cat./Drug Description Exclusion Cat. NICOTINE GUM Scabicide Combinations Smoking Deterents Pyrethrins-Piperonyl Butoxide Liq 0.33-4% OTC Nicotine Polacrilex Gum 2MG OTC Pyrethrins-Piperonyl Butoxide Shampoo 0.3-3% OTC Nicotine Polacrilex Gum 4MG OTC Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4% OTC NICOTINE LOZENGES VAGINAL - ANTI FUNGALS Smoking Deterents Imidazole-Related Antifungals Nicotine Polacrilex Lozenge 2MG OTC Clotrimazole Vaginal Cream 1% OTC Nicotine Polacrilex Lozenge 4MG OTC Miconazole Nitrate Vaginal Cream 2% OTC NICOTINE PATCHES Miconazole Nitrate Vaginal Suppos 100 MG OTC Smoking Deterents VITAMINS Nicotine TD Patch 24HR 7MG/24HR OTC Vitamin B-1 Nicotine TD Patch 24HR 14MG/24HR OTC Thiamine HCl Vitamin/Minerals Nicotine TD Patch 24 HR 21MG/24HR OTC Vitamin B-3 NSAIDS Niacin Tab 100 MG OTC Nonsteroidal Anti-inflammatory Agents (NSAIDs) Niacin Tab 250 MG OTC Ibuprofen Susp 100 MG/5ML OTC Niacin Tab 50 MG OTC Ibuprofen Tab 200 MG OTC Niacin Tab 500 MG OTC OP. MISC Vitamin B-6 Artificial Tears and Lubricants Pyridoxine HCl Vitamin/Minerals Artificial Tear Ophth Solution OTC Vitamin D Artificial Tear Ophth Ointment OTC Ergocalciferol Vitamin/Minerals Ophthalmic Hyperosmolar Products Calcitriol Vitamin/Minerals Sodium Chloride Hypertonic Ophth Oint 5% OTC Dihydrotachysterol Vitamin/Minerals Sodium Chloride Hypertonic Ophth Soln 5% OTC Vitamin K TOPICAL - ACNE PREPARATIONS Acne Products Benzoyl Peroxide Gel 10% OTC Benzoyl Peroxide Gel 5% OTC Benzoyl Peroxide Lotion 10% OTC Benzoyl Peroxide Lotion 5% OTC TOPICAL - ANTIBIOTIC Antibiotics - Topical Bacitracin Oint 500 Unit/GM OTC Antibiotic Mixtures Topical Neomycin-Bacitracin-Polymyxin Oint OTC TOPICAL - ANTIFUNGALS Antifungals - Topical Tolnaftate Cream 1% OTC Tolnaftate Powder 1% OTC Tolnaftate Soln 1% OTC Imidazole-Related Antifungals - Topical Miconazole Nitrate Cream 2% OTC TOPICAL - EMOLLIENTS Emollients Lactic Acid (Ammonium Lactate) Lotion 12% OTC TOPICAL - ENZYMES / KERATOLYTICS / UREA Keratolytic/Antimitotic Agents Salicylic Acid Liquid 17% OTC TOPICAL - SCABICIDES AND PEDICULICIDES Scabicides & Pediculicides Permethrin Lotion 1% OTC