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1 Department of Human Services Approved PDL for IOWA Medicaid Program Listing Preferred Cough & Cold Drug Products Effective Date: 1/1/2007 Note: Not all 's may be represented and the status of those listed are subject to change without notification. DRUG CATEGORY 12/21/2006 Drug Description Codeine-Guaifenesin Syrup MG/5ML PHARMACEUTICAL ASSOCIATES GG/CODEINE SYP /5 RX PHARMACEUTICAL ASSOCIATES GG/CODEINE SYP /5 RX PHARMACEUTICAL ASSOCIATES GG/CODEINE SYP /5 RX PHARMACEUTICAL ASSOCIATES GG/CODEINE SYP /5 RX IVAX PHARMACEUTICALS, INC GUIATUSS AC SYP /5 OTC IVAX PHARMACEUTICALS, INC GUIATUSS AC SYP /5 RX ACTAVIS MID ATLANTIC GUIATUSS AC SYP /5 OTC ACTAVIS MID ATLANTIC GUIATUSS AC SYP /5 RX ACTAVIS MID ATLANTIC GUIATUSS AC SYP /5 RX QUALITEST CHERATUSSIN SYP AC OTC QUALITEST CHERATUSSIN SYP AC RX QUALITEST CHERATUSSIN SYP AC RX MAJOR PHARMACEUTICALS ROBAFEN AC SYP /5 RX MAJOR PHARMACEUTICALS ROBAFEN AC SYP /5 RX HI-TECH GUAIATUSSIN SYP AC OTC HI-TECH GUAIATUSSIN SYP AC RX MORTON GROVE PHARMACEUTICALS MYTUSSIN AC SYP /5 OTC MORTON GROVE PHARMACEUTICALS MYTUSSIN AC SYP /5 RX WYETH CONSUMER HEALTHCARE Brand ROBITUSSIN SYP DM OTC WYETH CONSUMER HEALTHCARE Brand ROBITUSSIN SYP DM OTC WYETH CONSUMER HEALTHCARE Brand ROBITUSSIN SYP DM OTC WYETH CONSUMER HEALTHCARE Brand ROBITUSSIN SYP DM OTC WYETH CONSUMER HEALTHCARE Brand ROBITUSSIN SYP SUGAR FR OTC PERRIGO TUSSIN DM SYP /5 OTC PERRIGO TUSSIN DM SYP /5 OTC PERRIGO TUSSIN DM SYP /5 OTC PHARMACEUTICAL ASSOCIATES GUAIFENESIN SYP DM OTC PHARMACEUTICAL ASSOCIATES GUAIFENESIN SYP DM OTC PHARMACEUTICAL ASSOCIATES GUAIFENESIN SYP DM OTC PHARMACEUTICAL ASSOCIATES GUAIFENESIN SYP DM OTC PHARMACEUTICAL ASSOCIATES GUAIFENESIN SYP DM OTC IVAX PHARMACEUTICALS, INC GENATUSS DM SYP /5 OTC IVAX PHARMACEUTICALS, INC GUIATUSS DM SYP /5 OTC IVAX PHARMACEUTICALS, INC GUIATUSS DM SYP /5 OTC Page 1 of 5
2 Drug Description IVAX PHARMACEUTICALS, INC GUIATUSS DM SYP /5 OTC ACTAVIS MID ATLANTIC GUIATUSS DM SYP /5 OTC ACTAVIS MID ATLANTIC GUIATUSS DM SYP /5 OTC ACTAVIS MID ATLANTIC GUIATUSS DM SYP /5 OTC ACTAVIS MID ATLANTIC GUIATUSS DM SYP /5 OTC ACTAVIS MID ATLANTIC GUIATUSS DM SYP /5 OTC RUGBY GG/DM SYP /5 OTC RUGBY GG/DM SYP /5 OTC QUALITEST Q-TUSSIN SYP DM OTC QUALITEST Q-TUSSIN SYP DM OTC QUALITEST Q-TUSSIN SYP DM OTC QUALITEST Q-TUSSIN SYP DM OTC QUALITEST Q-TUSSIN SYP DM OTC MAJOR PHARMACEUTICALS ROBAFEN DM SYP /5 OTC MAJOR PHARMACEUTICALS ROBAFEN DM SYP /5 OTC MAJOR PHARMACEUTICALS ROBAFEN DM SYP /5 OTC MAJOR PHARMACEUTICALS ROBAFEN DM SYP /5 OTC MAJOR PHARMACEUTICALS ROBAFEN DM SYP /5 OTC MAJOR PHARMACEUTICALS ROBAFEN DM SYP /5 OTC SELECT BRAND COUGH CONTRO SYP DM OTC SELECT BRAND COUGH CONTRO SYP DM OTC BERGEN BRUNSWIG TUSSIN DM SYP /5 OTC BERGEN BRUNSWIG TUSSIN DM SYP /5 OTC BERGEN BRUNSWIG TUSSIN DM SYP CLEAR OTC LEADER BRAND PRODUCTS TUSSIN DM SYP /5 OTC LEADER BRAND PRODUCTS TUSSIN DM SYP /5 OTC MCKESSON VALU-RITE EXPECTORANT SYP DM OTC MCKESSON VALU-RITE EXPECTORANT SYP DM OTC MCKESSON VALU-RITE SM TUSSIN SYP DM CLEAR OTC MCKESSON VALU-RITE SM TUSSIN SYP DM CLEAR OTC MEDICINE SHOPPE MEDI-TUSSIN SYP DM OTC HI-TECH GUAIATUSSIN SYP DM OTC HI-TECH GUAIATUSSIN SYP DM OTC MCKESSON/HEALTH MART TUSSID DM SYP /5 OTC MCKESSON/HEALTH MART TUSSID DM SYP /5 OTC SILARX SILTUSSIN-DM SYP ALC FREE OTC SILARX SILTUSSIN-DM SYP ALC FREE OTC SILARX SILTUSSIN-DM SYP ALC FREE OTC ALTAIRE ALTARUSSIN SYP DM OTC ALTAIRE ALTARUSSIN SYP DM OTC ALTAIRE ALTARUSSIN SYP DM OTC ALTAIRE ALTARUSSIN SYP DM OTC ALTAIRE ALTARUSSIN SYP DM OTC ALTAIRE ALTARUSSIN SYP DM OTC ALTAIRE ALTARUSSIN SYP DM OTC Page 2 of 5
3 Drug Description AMKAS LABORATORIES GUAIFENESIN SYP DM OTC AMKAS LABORATORIES GUAIFENESIN SYP DM OTC CHAIN DRUG MARKETING ASSOC TUSSIN DM SYP /5 OTC CHAIN DRUG MARKETING ASSOC TUSSIN DM SYP /5 OTC WALSH DISTRIBUTION, INC HCA TUSSIN SYP DM OTC WALSH DISTRIBUTION, INC HCA TUSSIN SYP DM OTC Hydrocodone-Pot Guaiaco Syrup MG/5ML PRO-PHARMA LLC Brand PRO-CLEAR SYP RX S-DECONGESTANT Pseudoephedrine w/ DM-GG Syrup MG/5ML URL PSE/DM/GG SYP RX BRECKENRIDGE COLDMIST DM SYP RX ETHEX TRI-VENT DM SYP RX BOCA PHARMACAL PSE/DM/GG SYP RX COUGH/COLD - NARCOTIC ANTITUSSIVE-DECONGESTANT Phenyleph-Hydrocodone Liq MG/5ML BLANSETT PHARMACAL Brand NALEX DH LIQ 5-2.5/5M RX BRECKENRIDGE RHINACON DH LIQ RX BOCA PHARMACAL PHENYLEPHRIN LIQ HD RX Pseudoephedrine w/ Hydrocodone Soln 60-5 MG/5ML SANOFI PHARMACEUTICALS HISTUSSIN D SOL 60-5/5ML RX QUALITEST Brand HC TUSSIVE-D SOL 60-5/5ML RX MAJOR PHARMACEUTICALS DETUSSIN SOL 60-5/5ML RX COUGH/COLD - NON-NARC ANTITUSSIVE-DECONGESTANT Pseudoephedrine-DM Liqd MG/5ML WYETH CONSUMER HEALTHCARE Brand ROBITUSS PED LIQ CGH/COLD OTC WYETH CONSUMER HEALTHCARE Brand ROBITUSS PED LIQ CGH/COLD OTC NOVARTIS TRIAMINIC AM LIQ CGH/DEC OTC NOVARTIS TRIAMINIC LIQ ALLERGY OTC NOVARTIS TRIAMINIC LIQ CGH/NASL OTC PERRIGO TUSSIN PED LIQ CGH/COLD OTC BERGEN BRUNSWIG TUSSIN CG&CD LIQ PEDIATRI OTC Pseudoephedrine-DM Liqd MG/5ML FAMILY PHARMACY FORMULA D LIQ OTC Pseudoephedrine-DM Liqd MG/5ML PERRIGO Brand TUSSIN COUGH LIQ COLD OTC Pseudoephedrine-DM Elixir MG/5ML PERRIGO COUGH FORMUL ELX RELIEF D OTC P & G HEALTH Brand VICKS FORM ELX 44D CGH OTC P & G HEALTH Brand VICKS FORM ELX 44D CGH OTC LEADER BRAND PRODUCTS DECONGESTANT ELX D OTC Page 3 of 5
4 Drug Description COUGH/COLD - NON-NARC ANTITUSSIVE-DECONGESTANT Pseudoephedrine-DM Elixir MG/5ML ALTAIRE DEXATREX D ELX CF-NASAL OTC Pseudoephedrine-DM Syrup MG/5ML WYETH CONSUMER HEALTHCARE Brand DIMETAPP SYP CGH/COLD OTC Pseudoephedrine-DM Syrup MG/5ML WYETH CONSUMER HEALTHCARE Brand ROBITUSSIN SYP MAX/CGH OTC WYETH CONSUMER HEALTHCARE Brand ROBITUSSIN SYP MAX/CGH OTC MCKESSON VALU-RITE SM TUSSIN SYP CGH/COLD OTC Pseudoephedrine-DM Soln MG/0.8ML PFIZER CONS HEALTH Brand PEDIACARE SOL DCON/CGH OTC WYETH CONSUMER HEALTHCARE Brand DIMETAPP SOL DCON/CGH OTC PERRIGO PEDIA RELIEF DRO INFANT OTC PFIZER CONS HEALTH Brand PEDIACARE DRO DCON/CGH OTC MAJOR PHARMACEUTICALS PEDIA RELIEF DRO INFANT OTC MCKESSON VALU-RITE PEDIA RELIEF DRO INFANT OTC COUGH/COLD - SYSTEMIC DECONGESTANTS Pseudoephedrine HCl Tab 30 MG ROXANE PSEUDOEPHEDR TAB 30MG OTC GOLDLINE GENAPHED TAB 30MG OTC IVAX PHARMACEUTICALS, INC GENAPHED TAB 30MG OTC RUGBY PSEUDOEPHEDR TAB 30MG OTC RUGBY PSEUDOEPHEDR TAB 30MG OTC SANDOZ PSEUDOEPHEDR TAB 30MG OTC MAJOR PHARMACEUTICALS SUDOGEST TAB 30MG OTC MAJOR PHARMACEUTICALS SUDOGEST TAB 30MG OTC BERGEN BRUNSWIG SUPHEDRIN TAB 30MG OTC BERGEN BRUNSWIG SUPHEDRIN TAB 30MG OTC LEADER BRAND PRODUCTS PSEUDOEPHEDR TAB 30MG OTC LEADER BRAND PRODUCTS PSEUDOEPHEDR TAB 30MG OTC MCKESSON VALU-RITE SM SUPHEDRIN TAB 30MG OTC MCKESSON VALU-RITE SM SUPHEDRIN TAB 30MG OTC MCKESSON VALU-RITE SUPHEDRINE TAB 30MG OTC TIME-CAP LABS PSEUDOEPHEDR TAB 30MG OTC TIME-CAP LABS PSEUDOEPHEDR TAB 30MG OTC TIME-CAP LABS PSEUDOEPHEDR TAB 30MG OTC MEDICINE SHOPPE MEDI-PHEDRIN TAB 30MG OTC MEDICINE SHOPPE MEDI-PHEDRIN TAB 30MG OTC MEDICINE SHOPPE MEDI-PHEDRIN TAB 30MG OTC MCNEIL CONSUMER SIMPLY STUFF TAB 30MG OTC MCNEIL CONSUMER SIMPLY STUFF TAB 30MG OTC RICHMOND PHARMACEUTICALS PSEUDOEPHEDR TAB 30MG OTC RICHMOND PHARMACEUTICALS PSEUDOEPHEDR TAB 30MG OTC PRIME MARKETING SUDOPHED TAB 30MG OTC PRIME MARKETING SUDOPHED TAB 30MG OTC Page 4 of 5
5 Drug Description COUGH/COLD - SYSTEMIC DECONGESTANTS Pseudoephedrine HCl Tab 30 MG CHAIN DRUG MARKETING ASSOC SUPHEDRINE TAB 30MG OTC CHAIN DRUG MARKETING ASSOC SUPHEDRINE TAB 30MG OTC Pseudoephedrine HCl Tab 60 MG ROXANE PSEUDOEPHEDR TAB 60MG OTC SANDOZ PSEUDOEPHEDR TAB 60MG OTC MAJOR PHARMACEUTICALS SUDOGEST TAB 60MG OTC MAJOR PHARMACEUTICALS SUDOGEST TAB 60MG OTC INTERPHARM PSEUDOEPHEDR TAB 60MG OTC INTERPHARM PSEUDOEPHEDR TAB 60MG OTC INTERPHARM PSEUDOEPHEDR TAB 60MG OTC RICHMOND PHARMACEUTICALS PSEUDOEPHEDR TAB 60MG OTC Pseudoephedrine HCl Syrup 30 MG/5ML PHARMACEUTICAL ASSOCIATES PSEUDOEPHEDR SYP 30MG/5ML OTC ALPHARMA DECOFED SYP 30MG/5ML OTC ALPHARMA DECOFED SYP 30MG/5ML OTC ALPHARMA DECOFED SYP 30MG/5ML OTC RUGBY PSEUDOEPHEDR SYP 30MG/5ML OTC RUGBY PSEUDOEPHEDR SYP 30MG/5ML OTC Page 5 of 5
Ohio Medicaid Fee-For-Service Cough and Cold Drug List Effective October 1, 2013 $ 2 Co-Pay May Apply
NDC ANALGESICS Label Name Generic Drug Name Drug Strength Dosage Form 00713011801 ACEPHEN 120 MG SUPPOSITORY ACETAMINOPHEN 120 MG SUPP.RECT 45802073233 ACETAMINOPHEN 120 MG SUPPOSITORY ACETAMINOPHEN 120
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