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(OTC) Drugs Effective April 1, 2008 Medicaid Covers These Over-The-Counter (OTC) Drugs Pursuant to a Written/Verbal/Electronic Prescription

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(OTC) Drugs Effective April 1, 2008 Medicaid Covers These Over-The-Counter (OTC) Drugs Pursuant to a Written/Verbal/Electronic Prescription MS Medicaid Covered Over-the-Counter (OTC) Drugs Effective April 1, 2008 Medicaid covers these over-the-counter (OTC) drugs pursuant to a written/verbal/electronic prescription. Covered OTC products must be manufactured by pharmaceutical companies participating in the Federal Drug Rebate Program. OTC drug prescriptions are included in the monthly drug benefit limit. * Indicates Limited to beneficiaries up to the age of 21 only ** Indicates Limited to dialysis beneficiaries only, document "For Dialysis Pt" on the front of the Rx. Generic Name Strength Common Brand Name Dosage Form Acetaminophen 100mg/ml Tylenol DropsDrops 120,160, 167, Acetaminophen 500mg/5ml Tylenol Elixir, Liquid Acetaminophen 80,120,325,650mg Feverall SuppositorySuppository Acetaminophen 325, 500 mg Tylenol Tablet Al & Mg Hydroxide Maalox Tablet/Suspension Al & Mg Hydroxide/Simethicone Maalox , Mylanta Tablet/Suspension Ammonium Lactate 12% Amlactin 12% Cream Cream, Lotion Artificial Tears Opthalmic Drops Refresh,Refresh Plus Opthalmic Drops Artificial Tears Opthalmic Ointment Refresh PM Opthalmic Ointment Aspirin 81, 325 mg Various Buff/Chew/E.C. Bacitracin Ointment 500U/Gm Various Topical Ointment Bacitracin/Polymyxin Polysporin Ointment Ointment Benzoyl Peroxide Gel 5%, 10% Benzac AC 5% Gel Gel Brompheniramine/Pseudoephedrine Q-Tapp Liquid, Tablet Brompheniramine/Pseudo/DM Q-Tapp DM Liquid fructan, guar gum, malt soup extract, methylcellulose, Bulk Laxatives * polycarbophil,psyllium Capsule,Powder,Tablet Calcium Carbonate ** 500mg Tablet Calcium Carbonate ** Powder Carboxymethylcellulose Sodium Eye Drops 1% Celluvisc Eye Drops Opthalmic Drops Cetirizine 1mg/ml, 5 mg, 10 mg Zyrtec Chew.Tablet, Tablet, Syrup Cetirizine/Pseudoephedrine 5mg/120mg Zyrtec-D Extended Release Tablet 12Hr Chlorpheniramine 2mg/5ml Chlor-Trimeton Syrup Chlorpheniramine 4, 8, 12 mg Chlor-Trimeton Tablet Clemastine Fumarate 1.34mg Tavist Tablet Clotrimazole Solution 1% Mycelex Solution Solution Clotrimazole Topical 1% Lotrimin AF 1% Cream, Solution Clotrimazole Vaginal 1%, 2% Gyne-Lotrimin, Mycelex 7 Cream Dexbrompheniramine/Pseudoephedrine 6/120mg Drixoral Tabs Tablet Dextromethorphan Polystirex 30mg/5ml Delsym Suspension Dextromethorphan/Pseudoephedrine Dimetapp Syrup Diphenhydramine 12.5mg/5ml Benadryl Elixir, Liquid, Solution Diphenhydramine 25, 50 mg Benadryl Capsule Docusate * All strengths Colace Liquid, Syrup Docusate * 50, 100mg Colace Capsule,Tablet Ferrous Sulfate 75mg/0.6ml Fer-In-Sol Drops Ferrous Sulfate 220mg/5ml, 300mg/5ml Feosol Elixir, Liquid Ferrous Sulfate 325mg Iron Tablet Ferrous Sulfate Slow Release Tab 160mg Slow Fe Tablet Guaifenesin Plain 100mg/5ml Robitussin Plain Liquid Guaifenesin AC 100mg/10mg/5ml Robitussin AC Liquid Guaifenesin DAC 100/30/10mg/5ml Robitussin DAC Liquid Guaifenesin DM 100/10mg/5ml Robitussin DM Liquid Hydrocortione Cream 0.5%, 1% Cortaid Cream Ibuprofen 100mg/5ml Motrin Suspension Insulin (ALL OTC) Loperamide 1mg/5ml Imodium LiquidLiquid Loperamide 2mg Imodium Tablet Loratadine 5mg/5ml Claritin Syrup Syrup Loratadine ODT 5mg Claritin Reditabs ODT Loratadine 10mg Claritin Tablet Loratadine D-12 hr 120/5mg Claritin D-12 Tablet Loratadine D-24 hr 240/10mg Claritin D-24 Tablet Magnesium Chloride SR 64mg Slow-Mag 64 Tablet Magnesium Gluconate 500mg Magtrate Tablet Miconazole Topical 2% Micatin 2% Cream Cream Miconazole Vaginal 2% Monistat Cream Multivitamin and Mineral Supplement * Various Chew.Tablet, Drops, Liquid,Tablet Nicotine Gum Nicorette Gum Nicotine Lozenges Commit Lozenge Lozenge Nicotine Patches Nicorette Patch Oral Electrolyte Replacement Mixtures Oralyte,Pedialyte Freezer Pops, Solution Permethrin Lotion 1% Nix Cream Rinse Rinse Piperonyl/Pyrethrins Lice Treatment, Various Topical Pseudoephedrine 30mg/5ml Sufaded SyrupSyrup Pseudoephedrine 30, 60 mg Sudafed Tablet Pyrantel Pamoate Suspension 144mg/ml Pin X Suspension Renal Vitamins (Dialysis Pts Only)** Allbee Plus Vitamin C Tablet Tolnaftate Cream Tinactin Cream, Powder Triple Antibiotic Ointment Neosporin Ointment Triprolidine/Pseudoephedrine Actifed SyrupSyrup Triprolidine/Pseudoephedrine Actifed TabletTablet Zinc Oxide Ointment * Desitin Ointment List Subject to Revision Last Update 3/28/2008.
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