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Home , Calcium glubionate, Capsule (pharmacy), Magnesium citrate, Nebulizer

Below is a list of over‐the‐counter (OTC) drugs we cover with a prescription from your doctor. OTC drugs should only be prescribed after a clinical evaluation of the member’s necessary medical needs and are not available through the mail order benefit. Generic versions and specifically listed brand name drugs listed are covered while all others are excluded. For applicable co‐payment amounts, please see your Member Handbook (MassHealth members).

Drug Name Dosage Notes Digestive Ulcer Famotidine , Chewable, First line in a step Lansoprazole , DR Capsule therapy program First line medication in a step therapy program Nexium‐24 HR OTC (Esomeprazole) Capsule‐Brand, DR Tab‐Generic Nexium‐60 per 30 days DR Capsule, ER Tab, DR Tab, Omeprazole Suspension Packet First line medication in a step Omeprazole/ Bicarbonate Capsule therapy program Brand‐DR Tab, Generic‐ DR Tab, First line medication in a step Prilosec OTC (Omeprazole) DR Capsule therapy program Ranitidine Tab Digestive Medications + DR Tab, , Enema Tab, Capsule, Docusate/Senna Tab Fleet Enema/Pediatric/Six Pack Enema + Aloe MAX 1 RX PER 365 DAYS Fleet Liquid Glycerin Suppository

Glycerin Suppositories (Pediatric + Adult) Suppository Tab,

Milk of Magnesia () Suspension, Chewable Oil Oil

Miralax OTC ( OTC) Pack, Polycarbophil Tab Powder, Capsules

Senna Tab, Chewable, Capsules, Digestive Medications Antacids Aluminum Hydroxide + Suspension, Chewable Antacid Chewable Antacid Chewable Tab, Chewable, Capsule, Suspension Children's Antacid Chewable Fast Dissolving Chewable Antacid Chewable Tab Rolaids (Calcium Carbonate) Chewable Tab Digestive Medications Anti‐Gas Mylanta (Aluminum hydroxide/Magnesium hydroxide/Simethicone) Suspension Mylanta Gas (Simethicone) Chewable

Simethicone Capsules, Chewable, Suspension

Simethicone with: Aluminum Hydroxide/Magnesium Oxide Aluminum Hydroxide/Magnesium Trisilicate Calcium Carbonate/Magnesium Carbonate Calcium Carbonate/Magnesium Hydroxide Aluminum & Magnesium Oxide/Magnesium Carbonate Aluminum & Magnesium Oxide/Calcium Carbonate Aluminum & Magnesium Oxide/Methylcellulose Aluminum Hydroxide & Magnesium Carbonate/Atropine Aluminum Hydroxide & Magnesium Oxide/Dicyclomine Aluminum & Magnesium Oxides/Dicyclomine/Methylcellulose

Digestive Medications Anti‐Nausea Meclizine Tab Digestive Medications Anti‐Diarrheal Bismuth subsalicylate Chewable Kaolin‐Pectin Liquid Loperamide Tab, Liquid, Suspension Digestive Medications Digestive Health

Acidophilus (lactobacillus acidophilus) ONLY COVERED FOR AGES 18 Culturelle Capsule AND UNDER Lactase Enzyme Tilactase Lactase Tab Lactase Fast Acting Enzyme Tilactase Lactase Tab Digestive Medications Weight Loss Alli Capsule Analgesics Max 200 pills per 365 days Capsule, Tab, CR Tab, Chewable, Max 480ml per 365 days Acetaminophen Liquid, , Dispersible Tab, Chewable, DR Tab, Aspirin Effervescent Tab Max 365 pills per 365 days Aspirin Buffered Tab Max 365 pills per 365 days Capsule, Tab, Chewable, Max 200 pills per 365 days Ibuprofen Suspension Max 480ml per 365 days Naproxen Capsule, Tab Max 200 pills per 365 days Antimicrobials Bacitracin Ointment Bacitracin Ointment Bacitracin//Polymyxin Ointment, Gluconate Solution, Pads, Liquid Hydrogen Peroxide Solution

Neomycin (Single or Triple Combination) Cream Povidone‐ Solution Powder, Spray, Cream, Tolnaftate Solution, Powder Cough and Cold, Allergies Antihistamines/Decongestants Oral Acetaminophen/Diphenhydramine/Phenyl ephrine Tab

Solution/Syrup‐ ONLY COVERED Cetirizine Capsule, Tab, Syrup, Solution FOR AGES 2 AND UNDER Cetirizine/Pseudophedrine ER Tab, ER Capsule Chlorpheniramine Maleate Tab, Syrup, CR Tab Dimenhydramate Tab Elixir, Liquid, Capusles, Tab, Diphenhydramine Chewable, OD Tab Diphenhydramine/Phenylephrine Tab Doxylamine Succinate Tab SUSPENSION‐ ONLY COVERED Fexofenadine Tab, Suspension FOR AGES 2 AND UNDER Fexofenadine/Pseudophedrine ER Tab Tab, Capsule, Chewable, Syrup, Loratadine OD Tab Loratadine/Pseudophedrine Tab, ER Tab 120mg‐Quantity Limit of 60 per 30 days 30mg‐Quantity Limit of 240 per 30 days 60mg‐Quantity Limit of 120 per 30 days 120mg‐Quantity Limit of 60 per 30 days 30mg‐Quantity Limit of 240 per 30 days 60mg‐Quantity Limit of 120 per Pseudophedrine Tab, ER Tab 30 days Cough and Cold, Allergies Nasal Agents

Flonase Sensimist (Fluticasone furoate) (Suspension) Fluticasone Propionate Nasal Spray (Suspension) Nasacort (Triamcinolone Acetonide) Nasal Spray (Suspension) Nasal Spray (Solution) Cough and Cold, Allergies Ophthalmic Agents Ocular Lubricant and Artificial Tears Ointments Ketotifen Fumarate Ophthalmic Solution Dermatological Acne Adapalene Liquid, Gel, Cream, , Bar, Benzoyl Peroxide Foam Dermatological Analgesic Capsaicin Cream, Pads Lidocaine Cream Dermatological Anti‐Dandruff Dermatological Antifungal Clotrimazole Cream, Solution Powder, Aerosol Powder, Spray, Miconazole Cream, Ointment Nizoral A‐D Shampoo Shampoo Terbinafine Cream Dermatological Anti‐Itch Aveeno Smoothing Bath Treatment (Colloidal Oatmeal) Brand‐Pack Calamine Lotion Lotion, Cream, Ointment, Hydrocortisone Solution, Gel Dermatological Diaper Rash A & D Ointment Ointment Ointment, Cream, Vitamin A+D Synthetic Ointment Cream, Ointment Dermatological Lice Permethrin Aerosol Spray, Lotion, Liquid Pyrethins‐Piperonyl Butoxide Shampoo, Liquid, Kit Pyrethrin Kit Dermatological Moisturizing Agent Hydrolatum, Hydrophilic Ointment Brand‐ Ointment, Generic‐Gel, ONLY COVERED FOR AGES 17 (Petrolatum) Ointment AND UNDER ONLY COVERED FOR AGES 17 Lanolin Ointment AND UNDER ONLY COVERED FOR AGES 17 Ammonium Lactate 12% Cream, Lotion AND UNDER Dermatological Warts Salicylic Acid Liquid Vitamins, Nutrients, and Supplements Calcium Supplements Calcium Capsule, Tab, Chewable Calcium Acetate Tab Calcium Carbonate/Vitamin D Tab, Capsule, Chewable Calcium Carbonate/Vitamin D2 (Ergocalciferol) Tab, Chewable Calcium Carbonate/Vitamin D3 (Cholecalciferol) Tab, Chewable, Capsule Capsule, Tab, Granules Calcium Citrate Malate/Vitamin D3 (Cholecalciferol) Tab Calcium Citrate/Vitamin D Tab, Chewable Syrup Capsule, Tab Capsule, Tab Calcium Phosphate/Vitamin D3 (Cholecalciferol) Chewable Calcium/Vitamin D Tab, Capsule Calcium/Vitamin D3 Capsule, Chewable Coral Calcium Capsule, Tab Oyster Shell Calcium Tab Vitamins, Nutrients, and Supplements Supplements Carbonyl Iron Tab, Suspension Ferrous Fumarate Tab Ferrous Gluconate Tab Tab, DR Tab, Solution, Elixir, CR Ferrous Sulfate Tab Ferrous Sulfate Dried CR Tab, Tab Iron Combinations Capsule Iron Heme Polypeptide Tab Iron Succinyl‐Protein Complex Solution Polysaccharide Iron Complex Capsule Vitamins, Nutrients, and Supplements Vitamin B Niacin (Vitamin B3) ER Capsule, Tab Niacin/Inositol/Hexanicotinate Capsule Thiamine HCl (Vitamin B1) Tab Vitamin B Complex Capsule, Tab Tab, CR Tab, Liquid, OD Tab, Vitamin B12 (Cyanocobalamin) Chewable, Lozenge, SL Tab Vitamin B50 Complex CR Tab Vitamin B6 (Pyridoxine) Tab, CR Tab Vitamins, Nutrients, and Supplements Vitamin C Ascorbic Acid Tab Vitamins, Nutrients, and Supplements Vitamin D Tab, Chewable, Liquid, Capsule, Vitamin D Solution Vitamin D2 (Ergocalciferol) Solution

Vitamin D3 (Cholecalciferol) Capsule, Chewable, Liquid, Tab Vitamins, Nutrients, and Supplements Vitamin E Vitamin E Capsule Vitamins, Nutrients, and Supplements Multivitamins Multiple Vitamins with Iron Tab Multivitamins Tab, Capsule Poly‐Vi‐Flor Chewable, Suspension Poly‐Vi‐Flor with Iron Chewable, Suspension Poly‐Vitamin Chewable, Solution (Drops) Poly‐Vitamin with Flouride Chewable, Solution (Drops) Poly‐Vitamin with Iron Solution (Drops) Poly‐Vitamin with Iron/Flouride Solution (Drops) Tri‐Vi‐Flor Suspension Tri‐Vi‐Sol with Iron Solution (Drops) Tri‐Vitamin with Fluoride Solution (Drops) Tri‐Vitamins Solution (Drops) Tri‐Vitamins with Iron/Fluoride Solution (Drops) Vitamins, Nutrients, and Supplements Pediatric Multivitamins ADEKS Chewable AquADEKS Capsule, Chewable, Solution Pediatric Solutions and Freeze Pops Solution, Pack Pediatric Multiple Vitamins with C Solution Pediatric Multiple Vitamins with C/Folic Acid Chewable Pediatric Multiple Vitamins with Extra C/Folic Acid Chewable Pediatric Multiple Vitamins with Iron Chewable, Solution

Pediatric Multiple Vitamins with Minerals Chewable, Solution Pediatric Multivitamins Chewable, Liquid Pediatric Vitamins Chewable Vitamins, Nutrients, and Supplements Prenatal Vitamins Alive Prenatal Chewable Cadeau DHA Capsule Prenatal Vitamins Chewable, Tablets, Gum Theranatal One Capsule Vitamins, Nutrients, and Supplements Omega 3 Equazen Pro Liquid Vitamins, Nutrients, and Supplements Omega 4 Capsule, DR Capsule, Chewable, Omega 3‐Fish Oil Liquid Vitamins, Nutrients, and Supplements Omega 5 Omega‐3 Fatty Acids DR Capsule Vitamins, Nutrients, and Supplements Supplements Coenzyme Q10 Capsule, Tab, Liquid Folic Acid Tab, Capsule Folic Acid/Folate Tab Magnesium Capsule Magnesium Cl/Calcium Carbonate DR Tab Brand‐Tab, Generic‐ Tab, Capsule, OD Tab, Liquid, Chewable, CR ONLY COVERED FOR AGES 17 SM Melatonin Tab, SL Tab AND UNDER Sodium Flouride Chewable, Lozenge, Tab Diabetes Needles 13G, 14G, 15G, 16G, 17G, 18G, 19G, 20G, 21G, 22G, 23G, 24G, Needles (Disposable) 25G, 26G, 27G, 30G 8G, 11G, 13G, 15G, 16G, 17G, 18G, 19G, 20G, 21G, 22G, 23G, Needles (Reusable) 24G, 25G, 26G, 27G, 30G Hypodermic Needles (Disposable) Hypodermic Needles (Reusable) Insulin Pen Needles Diabetes Insulin (Disposable) Insulin Syringe (Reusable) Syringes (Disposable) Syringes (Reusable) Ulticare 0.5mL/31G, 1mL/31G Diabetes Meters Freestyle Freedom Lite Meter Freestyle InsuLinx Meter Kit Freestyle Lite Meter Precision Xtra Meter Diabetes Test Strips Freestyle Test Strips 50ct, 100ct Freestyle Lite Test Strips 50ct, 100ct Freestyle InsuLinx Test Strips 50ct, 100ct Diabetes Beta Ketone Test Strips Precision Xtra Beta Ketone Test Strips 10ct Ketostix Diabetes Misc. Covered Supplies Alcohol Swabs Glucose‐Vitamin C Chewables Glucose Chewables Insulin Lancets 200 per 30 days Glucose Monitoring Kit With or Without Device

Nicotine Patches, Gum, Lozenge Max fill of 180 days per 365 days Contraceptive/ Vaginal Clotrimazole Vaginal Cream Condoms‐Female Contraceptive Sponge Miconazole Nitrate Vaginal Kit, Cream, Suppository Nonoxynol ‐9 Gel Oxytrol (Oxybutynin) Patch Plan B Tab Miscellaneous Artificial Tears Solution Debrox (Carbamide Peroxide) Solution Preparation H Hemorrhoidal Hygiene Pads with Witch Hazel Pads Tuberculin/Allergy Syringes Syringes Medical Devices/ Supplies Humidifier Peak Flow Meter Sodium Chloride Solution for Aerochamber Mini Aerosol Spacers Chamber Vaporizers