Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP)

Transcription

1 PAIN RELIEVERS-FEVER REDUCERS acetaminophen Tylenol 325 mg tablets acetaminophen Tylenol Extra Strength 500 mg tablets acetaminophen 500 mg capsules acetaminophen Tylenol Arthritis 650 mg ER tablets acetaminophen 80 mg chewable tablets acetaminophen 160 mg chewable tablets acetaminophen 160 mg/5 ml elixir acetaminophen 160 mg/5 ml liquid acetaminophen Tylenol 160 mg/5 ml suspension acetaminophen 160 mg/5 ml solution acetaminophen Tylenol 80 mg/0.8 ml suspension acetaminophen 100 mg/ml solution (drops) acetaminophen 120 mg suppositories acetaminophen 325 mg suppositories acetaminophen 650 mg suppositories acetaminophen Tylenol Children's Meltaways 80 mg dispersable tablets acetaminophen Tylenol Jr. Meltaways 160 mg dispersable tablets acetaminophen/diphenhydramine Tylenol P.M. 500 mg-25 mg tablets aspirin Bayer Children's 81 mg chewable tablets aspirin 81 mg tablets aspirin 325 mg tablets aspirin Bayer 500 mg tablets aspirin buffered Bufferin 325 mg tablets aspirin buffered Bufferin Extra Strength 500 mg tablets aspirin buffered Ascriptin 325 mg tablets aspirin buffered Ascriptin Maximum Strength 500 mg tablets aspirin enteric-coated Ecotrin 325 mg DR tablets aspirin enteric-coated Ecotrin Maximum Strength 500 mg DR tablets aspirin enteric-coated Bayer Low Dose 81 mg DR tablets PW_2013_026/DHS_Approved_11/15/2012 Page 1 of 13

2 aspirin 300 mg, 600 mg suppositories aspirin Halfprin 162 mg DR tablets aspirin/acetaminophen/caffeine Excedrin Migraine mg tablets ibuprofen Children's Motrin, Children's Advil 100 mg/5 ml suspension ibuprofen Motrin Infants, Children's Advil 40 mg/ml suspension Advil Jr. Strength, Children's Motrin ibuprofen Jr. Strength 100 mg chewable tablets ibuprofen Motrin Jr. Strength 100 mg tablets ibuprofen Advil, Motrin IB 200 mg tablets naproxen sodium Aleve 220 mg tablets FUNGAL INFECTIONS - vaginal clotrimazole Gyne-Lotrimin, Mycelex 7 1% vaginal cream clotrimazole Gyne-Lotrimin 3 2% vaginal cream clotrimazole Gyne-Lotrimin 100 mg vaginal tablets vaginal tablets/ clotrimazole Mycelex-7 Combo Pack 100 mg/1% vaginal cream miconazole Monistat 7 2% vaginal cream miconazole Monistat 3 4% vaginal cream miconazole Monistat mg vaginal tablets miconazole suppository & cream kit Monistat various vaginal tablets & cream kit BIRTH CONTROL condoms all all nonoxynol-9 Conceptrol 4% gel nonoxynol-9 VCF Vaginal Contraceptive Foam 12.5% foam nonoxynol-9 Encare 2.27% suppository nonoxynol-9 Gynol II 2% gel nonoxynol-9 Gynol II Extra Strength 3% gel nonoxynol mg suppository EAR, NOSE, THROAT benzocaine Hurricaine 20% oral solution carbamide peroxide Debrox 6.5% otic solution cromolyn sodium - nasal Nasalcrom 5.2 mg/act nasal aerosol PW_2013_026/DHS_Approved_11/15/2012 Page 2 of 13

3 oxymetazoline Afrin 0.05% nasal spray phenol Chloraseptic Spray 1.40% oral liquid phenylephrine Neo-Synephrine 0.25%, 1% nasal solution sodium chloride Ayr Saline nasal gel sodium chloride Ocean 0.65% nasal spray EYE PRODUCTS artificial tears gel Genteal ophth gel artificial tears solution Tears Naturale ophth solution artificial tears ointment Refresh P.M. ophth ointment carboxymethylcellulose Refresh, Celluvisc ophth solution hypromellose Tearisol, Isopto Tears 0.5%, 1%, 2% ophth solution hypromellose Genteal 0.2%, 0.3%, 0.5% ophth solution ketotifen Zaditor 0.025% ophth solution polyethylene glycol/polyvinyl alcohol Hypotears polyethylene glycol/propylene glycol Systane 0.4%-0.3% ophth solution polyvinyl alcohol Akwa Tears 1.4% ophth solution polyvinyl alcohol/povidone Artificial Tears ophth solution propylene glycol/glycerin Soothe 0.6%-0.6% ophth solution sodium chloride ophthalmic Muro-128 5% ophth ointment sodium chloride ophthalmic Muro-128, AK-NACL 2%, 5% ophth solution white petrolatum-mineral oil Lacri-Lube ophth ointment GASTROINTESTINAL Heartburn, Indigestion aluminum & magnesium hydroxides mg/5ml suspension aluminum & magnesium hydroxides/ mg/5 ml, simethicone Mylanta mg/5 ml suspension aluminum hydroxide gel suspension 320 mg/5 ml suspension aluminum hydroxide gel suspension Alternagel 600 mg/5 ml suspension calcium carbonate Tums Ultra 1000 mg chewable tablets calcium carbonate Childrens Mylanta 400 mg chewable tablets calcium carbonate Tums 500 mg chewable tablets calcium carbonate Maalox 600 mg chewable tablets PW_2013_026/DHS_Approved_11/15/2012 Page 3 of 13

4 calcium carbonate Tums E-X 750 mg chewable tablets cimetidine Tagamet HB 200 mg tablets famotidine Pepcid AC 10 mg tablets, chewable tablets famotidine Pepcid AC Maximum Strength 20 mg tablets, chewable tablets nizatidine Axid AR 75 mg tablets omeprazole delayed-release 20 mg DR tablets omeprazole magnesium delayed-release Prilosec OTC 20 mg DR tablets ranitidine Zantac 75 mg tablets sodium bicarbonate tablets, powder, granules Constipation bisacodyl Dulcolax 5 mg DR tablets bisacodyl Dulcolax 10 mg/30 ml enema bisacodyl Dulcolax 10 mg suppository calcium polycarbophil FiberCon 625 mg caplets cellulose powder Unifiber oral powder docusate sodium Colace 100 mg capsules docusate sodium 250 mg capsules docusate sodium 150 mg/15 ml liquid docusate sodium 50 mg/5 ml liquid docusate sodium Colace 60 mg/15 ml syrup glycerin Fleet Babylax 2.3 g enema glycerin 2.1 g suppository glycerin 1.2 g suppository glycerin 1.5 g suppository glycerin 3 g suppository magnesium citrate oral solution magnesium hydroxide Milk of Magnesia 400 mg/5 ml, 800 mg/5 ml suspension magnesium hydroxide Milk of Magnesia 311 mg chewable tablets methylcellulose Citrucel powder mineral oil oral liquid mineral oil enema enema PEG 3350 oral powder Miralax powder PW_2013_026/DHS_Approved_11/15/2012 Page 4 of 13

5 psyllium powder Metamucil, Fiber-Eze powder senna 187 mg tablets sennosides Ex-Lax 15 mg chewable tablets sennosides Ex-Lax 15 mg tablets sennosides Ex-Lax Maximum Strength 25 mg tablets sennosides Senokot 8.6 mg tablets sennosides/docusate sodium Senokot-S mg tablets sodium phosphates rectal solution Fleets Phospho Soda Enema enema sodium phosphates solution Fleets Phospho Soda oral solution sorbital 70% oral solution sorbital 70% solution Diarrhea bismuth subsalicylate Pepto Bismol various suspension bismuth subsalicylate Pepto Bismol 262 mg tablets loperamide Imodium A-D 2 mg tablets loperamide Imodium A-D 1 mg/5 ml solution simethicone Gas-X 80 mg chewable tablets simethicone Gas-X Extra Strength 125 mg chewable tablets simethicone Phazyme 180 mg capsules Miscellaneous GI lactase Lactaid various capsules, tablets, liquid simethicone Mylicon 40 mg/0.6 ml suspension RESPIRATORY Antihistamines/decongestants brompheniramine/phenylephrine Dimetapp Cold and Allergy 1 mg-2.5 mg/5 ml elixir brompheniramine/pseudoephedrine 1 mg-15 mg/5 ml elixir brompheniramine/pseudoephedrine Lohist PSB 4 mg-20 mg/5 ml liquid cetirizine Zyrtec Children's Allergy 10 mg chewable tablets cetirizine Zyrtec Children's Allergy 5 mg chewable tablets Zyrtec Children's Allergy, Zyrtec cetirizine Children's Hives 5 mg/5 ml syrup cetirizine Zyrtec Allergy, Zyrtec Hives Relief 10 mg tablets PW_2013_026/DHS_Approved_11/15/2012 Page 5 of 13

6 cetirizine 5 mg tablets cetirizine/pseudoephedrine Zyrtec-D 5 mg/120 mg tablets chlorpheniramine Chlor-Trimeton 12 mg CR capsules chlorpheniramine Chlor-Trimeton 2 mg/5 ml syrup chlorpheniramine Chlor-Trimeton 4 mg tablets 1 mg-15 mg/5 ml; 2 mg-30 chlorpheniramine/pseudoephedrine mg/5 ml; 0.8 mg-9 mg/ml liquid CR capsules, chewable chlorpheniramine/pseudoephedrine 8 mg-120 mg; 2 mg-30 mg tablets clemastine fumarate Tavist Allergy 1.34 mg tablets diphenhydramine Benadryl 25 mg, 50 mg capsules chewable tablets, orally diphenhydramine Benadryl 12.5 mg dissolving strips diphenhydramine 12.5 mg/5 ml elixir diphenhydramine Benadryl Allergy 12.5 mg/5 ml liquid diphenhydramine 12.5 mg/5 ml syrup diphenhydramine Benadryl 25 mg tablets diphenhydramine 50 mg tablets diphenhydramine (for sleep) Unisom SleepGels 50 mg capsules diphenhydramine (for sleep) Sominex 25 mg tablets diphenhydramine (for sleep) Nytol Maximum Strength 50 mg tablets doxylamine (for sleep) Unisom 25 mg tablets fexofenadine Allegra Allergy 30 mg/5 ml suspension fexofenadine Allegra Allergy 30 mg, 60 mg, 180 mg tablets loratadine Claritin 5 mg chewable tablets loratadine Claritin Reditablets 10 mg orally disintegrating tablets loratadine Claritin 5 mg/5 ml syrup loratadine Alavert, Claritin 10 mg tablets loratadine/pseudoephedrine Claritin D 24-hour mg ER tablets loratadine/pseudoephedrine Claritin D 12-hour mg ER tablets phenylephrine Sudafed PE 10 mg tablets pseudoephedrine 120 mg ER capsules PW_2013_026/DHS_Approved_11/15/2012 Page 6 of 13

7 pseudoephedrine Sudafed Children's 15 mg/5 ml liquid pseudoephedrine 30 mg/5 ml liquid pseudoephedrine 30 mg/5 ml syrup pseudoephedrine Sudafed 24-hour 240 mg tablets pseudoephedrine Sudafed 12-hour 120 mg tablets pseudoephedrine Sudafed 30 mg tablets pseudoephedrine 60 mg tablets Antitussives and Expectorants brompheniramine/phenylephrine/ dextromethorphan Dimetapp DM 1 mg-2.5 mg-5 mg/5 ml elixir brompheniramine/pseudoephedrine/ 2 mg-30 mg-10 mg/5 ml; dextromethorphan Dimetane DX 4 mg-60 mg-30 mg/5 ml syrup dextromethorphan polistirex Delsym 30 mg/5 ml CR liquid dextromethorphan/guaifensin Cheracol-D 10 mg-100 mg/5 ml liquid dextromethorphan/guaifensin Mucinex Cough-Children's 5 mg-100 mg/5 ml liquid dextromethorphan/guaifensin Mucinex DM Maximum Strength 30mg mg SR tablets dextromethorphan/guaifensin Mucinex DM 30 mg-600 mg SR tablets dextromethorphan/guaifensin Robitussin DM 10 mg-100 mg/5 ml syrup dextromethorphan/guaifenesin/potassium citrate Sorbutuss NR 10 mg-100 mg-85 mg/5 ml liquid guaifenesin Mucinex Cough for Kids 50 mg, 100 mg granules guaifenesin Mucinex for Kids 100 mg/5 ml liquid guaifenesin Mucinex 1200 mg SR tablets guaifenesin Mucinex 600 mg SR tablets guaifenesin Robitussin 100 mg/5 ml syrup guaifenesin 200 mg tablets guaifenesin Liquibid 400 mg tablets guaifenesin/phenylephrine Rescon-GG 100 mg-5 mg/5 ml liquid SKIN Acne benzoyl peroxide 10% cream, lotion, gel benzoyl peroxide 5% gel, lotion salicylic acid Clean & Clear 0.5%, 2%, liquid PW_2013_026/DHS_Approved_11/15/2012 Page 7 of 13

8 Antibacterials-topical bacitracin zinc 500 U/g ointment neomycin/polymyxin B/bacitracin Neosporin, Triple Antibiotic ointment Antifungals-topical clotrimazole Lotrimin AF 1% various ketoconazole Nizoral A-D 1% shampoo miconazole Desenex Spray 2% aerosol miconazole Lotrimin AF 2% aerosol powder miconazole Micatin 2% cream miconazole Desenex Shake Powder 2% powder terbinafine Lamisil AT 1% various tolnaftate Tinactin 1% various Antipruritics colloidal oatmeal Aveeno packets calamine lotion lotion hydrocortisone Hytone 1% cream, lotion, ointment hydrocortisone acetate 1% cream, ointment Pediculosis permethrin Nix Crème Rinse 1% creme rinse permethrin 1% lotion piperonyl butoxide/pyrethrins/permethrin Rid Complete pyrethrins/piperonyl butoxide Tegrin-LT, Pronto shampoo Other Topicals benzocaine Americaine 20% aerosol capsaicin cream Zostrix capsicum 0.025%, 0.075% cream chlorhexidine gluconate Hibiclens 2%, 4% liquid coal tar Ionil-T, T/Gel 1%, 2.5% shampoo coal tar/salicylic acid Tarsum 10%-5% shampoo dibucaine Nupercainal 1% rectal ointment docosanol Abreva 10% topical cream hydroactive dressings Aquaflo Hydrogel, Curafil Hydrogel dressings, pads PW_2013_026/DHS_Approved_11/15/2012 Page 8 of 13

9 hydrocortisone Proctocort 1%, 2.5% rectal cream hydrogen peroxide 3% solution isopropyl alcohol rubbing alcohol 70% solution lactic acid/ammonium lactate Lac-Hydrin 5% povidone-iodine ointment 10% ointment povidone-iodine solution Betadine 7.5%, 10% solution salicylic acid gel Keralyt 3% gel salicylic acid liquid Compound W, DuoFilm 17% liquid salicylic acid patches 40% pad salicylic acid patches Trans-ver-sal Pediapatch 17% patches salicylic acid plaster MediPlast 40% plaster salicylic acid Psoriasis Liquid 3% liquid selenium sulfide Selsun Blue 1%, 3% lotion (shampoo) trolamine salicylate Myoflex, Aspercreme 10% cream, lotion white petrolatum Vaseline gel, ointment wound dressing gel Curafil, Nu-Gel, Curasol gel Balmex, Boudreauox Butt Paste, zinc oxide Desitin various ointment SMOKING CESSATION nicotine gum Nicorette 2 mg, 4 mg gum nicotine oral lozenges Nicorette 2 mg, 4 mg oral lozenges nicotine transdermal patches Nicoderm CQ 7 mg, 14 mg, 21 mg transdermal patches SUPPLEMENTS 15 mg, 30 mg, 10000U, beta carotene 25000U capsules calcium carbonate 1250 mg/5 ml suspension calcium carbonate 1250 mg (500 mg Ca) tablets calcium carbonate Cal-Mint, Os-Cal 500 chewables 500 mg chewable tablets calcium carbonate Caltrate mg (600 mg Ca) tablets calcium carbonate 600 mg tablets tablets, chewable tablets, calcium carbonate/cholecalciferol Os-cal chewables various capsules PW_2013_026/DHS_Approved_11/15/2012 Page 9 of 13

10 calcium carbonate/vitamin D 500 mg-125u tablets calcium carbonate/vitamin D 500 mg-200u tablets calcium carbonate/vitamin D 600 mg-125u tablets calcium carbonate/vitamin D 600 mg-200u tablets calcium carbonate/vitamin D 600 mg-400u tablets calcium carbonate/vitamin D OsCal 500 +D 500 mg-400u chewable tablets 600 mg-400u, calcium carbonate/vitamin D Caltrate 600 +D 1200 mg-1000u chewable tablets calcium carbonate/vitamin D/minerals 600 mg-200u/various tablets calcium citrate 950 mg (200 mg Ca) tablets calcium citrate/vitamin D Citracal +D 315 mg-200u tablets carbonyl iron Icar 15 mg (elemental iron) chewable tablets 15 mg/1.25 ml carbonyl iron Icar (elemental iron) suspension carbonyl iron 25 mg (elemental iron) tablets carbonyl iron Feosol 45 mg (elemental iron) tablets cholecalciferol Vitamin D3 various strengths capsules 1000 mcg, 1500 mcg, cyanocobalamin (Vitamin B12) 2000 mcg CR tablets cyanocobalamin (Vitamin B12) various tablets ergocalciferol Vitamin D U/mL drops ergocalciferol Vitamin D2 400 U tablets ferrous gluconate various tablets ferrous sulfate 220 mg/5 ml elixir ferrous sulfate enteric-coated 325 mg tablets ferrous sulfate 15 mg/ml solution ferrous sulfate various tablets ferrous sulfate, dried Slow Fe 160 mg ER tablets 200 mcg, 400 mcg, folic acid 800 mcg tablets glucosamine sulfate 500 mg, 750 mg, 1000 mg capsules PW_2013_026/DHS_Approved_11/15/2012 Page 10 of 13

11 capsules, tablets, oral glucosamine/chondroitin various liquid iron 66 mg tablets iron 15 mg/1.5 ml suspension iron complex, polysaccharide Iferex mg capsules iron complex, polysaccharide; vitamin B-12; folic acid Irofol 150 mg mg-1 mg tablets levocarnitine levocarnitine 250 mg, 500 mg capsules levocarnitine 250 mg, 330 mg, 500 mg tablets lutein 10 mg tablets lutein-zeaxanthin various capsules, tablets magnesium various strengths capsules, tablets magnesium chloride Slow Mag 535 mg CR tablets magnesium chloride-calcium carbonate Slow Mag 71.5 mg-119 mg tablets magnesium lactate 84 mg tablets magnesium oxide 250 mg, 500 mg tablets magnesium oxide Mag-Ox 400 mg tablets omega-3 fatty acids various capsules niacin 250 mg, 500 mg CR capsules 250 mg, 500 mg, 750 mg, niacin Slo-Niacin 1000 mg ER tablets 50 mg, 100 mg, 250 mg, niacin 500 mg tablets oyster shell calcium Oyst-Cal 500 mg tablets oyster shell calcium/vitamin D 500 mg-200u tablets sodium chloride 1000 mg tablets vitamin A Various capsules vitamin B-1 (Thiamine) 50 mg, 100 mg, 250 mg tablets vitamin B-2 (Riboflavin) 25 mg, 50 mg, 100 mg tablets vitamin B-6 (Pyridoxine) various strengths tablets PW_2013_026/DHS_Approved_11/15/2012 Page 11 of 13

12 100 mg, 250 mg, 500 mg, vitamin C 1000 mg tablets vitamin E various capsules vitamin E 50U/mL solution vitamin K 100 mcg tablets zinc gluconate various tablets zinc sulfate 220 mg capsules Multivitamins B-complex w/c, folic acid Dialyvite, Rena-vite tablets multiple vitamin One-A-Day Essential tablets multiple vitamin with iron tablets multiple vitamins with minerals Ocuvite, Preservision tablets multiple vitamin with minerals Ocuvite, Preservision capsules multiple vitamin with minerals Centrum, Cerovite liquid liquid, chewable tablets, pediatric multiple vitamin Pediavit drops pediatric multiple vitamin with C Poly-Vi-Sol various drops, liquid pediatric multiple vitamin with C and folic acid Fruity chewables, My First Flintstones chewable tablets pediatric multiple vitamin with fluoride 0.25 mg, 0.5 mg, 1 mg chewable tablets pediatric multiple vitamin with fluoride 0.25 mg, 0.5 mg, 1 mg drops pediatric multiple vitamin with fluoride and iron 0.25 mg-10 mg/ml drops pediatric multiple vitamin with iron Flintstones Plus Iron, Centrum Kids chewable tablets pediatric vitamin drops with ADC Tri-Vi-Sol drops pediatric vitamin drops with ADC and iron Tri-Vi-Sol/Iron 10 mg/ml drops prenatal vitamins/folic acid/iron (ferrous fumarate) prenatal vitamins/selenium/folic acid/iron (ferrous fumarate) all tablets OTHER PRODUCTS activated charcoal capsules, tablets, liquid PW_2013_026/DHS_Approved_11/15/2012 Page 12 of 13

13 chewable tablets, dimenhydrinate Dramamine 50 mg tablets various, including hose, elastic bandages and supports T.E.D., Kendall stockings, and wraps glucose tablets, gel meclizine Bonine 25 mg chewable tablets meclizine 12.5 mg, 25 mg tablets oral electrolyte replacement Oralyte, Pedialyte packets, solution various, including drains, caps, belts, pouches, and ostomy supplies, kits Hollister, Kendall, Bard, Convatec skin gel 1 ml, 3 ml, various needle syringe/needles, disposable B-D, Kendall gauges/lengths Key CR = controlled release DR = delayed release ER = extended release SR = sustained release ophth = eye otic = ear U = units PW_2013_026/DHS_Approved_11/15/2012 Page 13 of 13