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Apple Health (Medicaid) Fee-for-Service
Covered Over-the-Counter Drug List
Effective March 10, 2016
Only generic products are covered unless brand is indicated in parentheses.
Analgesics:
Acetaminophen 80mg dispersible tablet
Acetaminophen 160mg dispersible tablet
Acetaminophen 325mg tablet
Acetaminophen 500mg tablet/capsule
Acetaminophen 650mg CR tablet
Acetaminophen 80mg/0.8ml solution/suspension drops
Acetaminophen 160mg/5ml solution/suspension/elixir
Acetaminophen 80mg suppository
Acetaminophen 120mg suppository
Acetaminophen 325mg suppository
Acetaminophen 650mg suppository
Aspirin 81mg chew tablet
Aspirin 81mg delayed release tablet
Aspirin 325mg delayed release tablet
Aspirin 325mg tablet
Aspirin 325mg tablet, buffered
Ibuprofen 50mg chewable tablet
Ibuprofen 100mg chewable tablet
Ibuprofen 200mg tablet
Ibuprofen 40mg/ml suspension drops
Ibuprofen 100mg/5ml suspension
Naproxen sodium 220mg tablet
Antihistamines:
Chlorpheniramine maleate 4mg tablet
Cetirizine / Pseudoephedrine
Diphenhydramine 25mg tablet/capsule
Diphenhydramine 50mg tablet/capsule
Diphenhydramine 12.5mg/5ml liquid
Fexofenadine / Pseudoephedrine (PA required)
Loratadine / Pseudoephedrine
Newer Antihistamines per Preferred Drug List rules
Cough and Cold:
As listed in our Covered Cough and Cold Product List
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Apple Health (Medicaid) Fee-for-Service
Covered Over-the-Counter Drug List
Effective March 10, 2016
Only generic products are covered unless brand is indicated in parentheses.
Gastrointestinal products (see categories below):
Antacid/acid reducer:
Aluminum and magnesium hydroxides 200mg-200mg/5ml suspension
Calcium carbonate 500mg chewable antacid tablet
Calcium carbonate 648mg chewable antacid tablet
Calcium carbonate 650mg chewable antacid tablet
Calcium carbonate 750mg chewable antacid tablet
Calcium carbonate 1000mg chewable antacid tablet
Famotidine – calcium carbonate – magnesium hydroxide 10-800-165mg chewable tablet
Histamine-2 Receptor Agonists (H2RA) per Preferred Drug List rules
Proton Pump Inhibitors per Preferred Drug List rules
Anti-diarrheal:
Bismuth subsalicylate 262mg tablet/chewable tablet
Bismuth subsalicylate 262mg/15ml suspension
Loperamide 2mg tablet
Loperamide 1mg/5ml liquid
Anti-emetic:
Meclizine 12.5mg tablet
Meclizine 25mg tablet/chewable tablet
Dimenhydrinate 50mg tablet
Anti-gas:
Simethicone 80mg chewable tablet
Simethicone 125mg chewable tablet
Simethicone 125mg capsule
Simethicone 40mg/0.6ml suspension
Emetic:
Ipecac syrup
Laxatives:
Bisacodyl 5mg delayed release tablet
Bisacodyl 10mg suppository
Docusate calcium 240mg capsule
Docusate sodium 100mg capsule/tablet
Docusate sodium 250mg capsule
Docusate sodium 150mg/15ml liquid
Docusate sodium 60mg/15ml syrup
Docusate sodium 283mg enema (Enemeez mini) (requires PA)
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Apple Health (Medicaid) Fee-for-Service
Covered Over-the-Counter Drug List
Effective March 10, 2016
Only generic products are covered unless brand is indicated in parentheses.
Laxatives (cont.):
Docusate sodium-benzocaine 283mg-20mg enema (Enemeez plus) (requires PA)
Glycerin 1gm suppository
Glycerin 1.2gm suppository
Glycerin 1.5gm suppository
Glycerin 2gm suppository
Glycerin 2.1gm suppository
Glycerin 3gm suppository
Glycerin 80.7% suppository
Magnesium citrate solution
Magnesium hydroxide 400mg/5ml suspension
Polyethylene glycol 3350 oral powder
Psyllium powder
Sennosides 8.6mg tablet
Sennosides 8.8mg/5ml syrup
Sodium phosphates oral solution
Sodium phosphates enema
Nasal:
Saline 0.65% nasal spray
Ophthalmic:
Polyvinyl alcohol 1.4% ophthalmic solution
Carboxymethylcellulose sodium 0.5% ophthalmic solution (including preservative free Refresh Plus)
Artificial tear ophthalmic ointment
Ketotifen fumarate 0.025% ophthalmic solution
Naphazoline / pheniramine ophthalmic solution
Otic:
Carbamide peroxide 6.5% otic solution
Topical products (see categories below):
skin protectant cream
hydrophilic ointment
mineral oil-hydrophilic petrolatum ointment
vitamin A and D ointment
Aquabase
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Apple Health (Medicaid) Fee-for-Service
Covered Over-the-Counter Drug List
Effective March 10, 2016
Only generic products are covered unless brand is indicated in parentheses.
Topical products (cont):
Antibiotic:
Bacitracin ointment
Bacitracin/polymyxin B ointment
Antifungal:
Butenafine 1% cream
Clotrimazole 1% topical cream
Clotrimazole 1% vaginal cream
Clotrimazole 2% vaginal cream
Miconazole nitrate topical 2% cream
Miconazole nitrate 2% vaginal cream
Miconazole nitrate 4% vaginal cream
Terbinafine HCl 1% solution
Tolnaftate 1% topical cream
Anti-inflammatory:
Hydrocortisone 0.5% cream/ointment
Hydrocortisone 1% cream/lotion/ointment
Antipruritic
Lactic acid (ammonium lactate) 12% cream/lotion
Pediculicide:
Permethrin 1% cream rinse/lotion
Pyrethrins-piperonyl butoxide 0.3-3% liquid/shampoo
Pyrethrins-piperonyl butoxide 0.33-4% liquid
Vitamins/Minerals:
B-complex with vitamin C and folic acid 0.8mg tablet (requires EA)
Calcium, oyster shell 500mg tablet
Calcium carbonate suspension 1250/5ml
Calcium glubionate syrup 1.8gm/5ml
Calcium carbonate-vitamin D 500mg-200mg tablet
Calcium, oyster shell-vitamin D 500mg-200mg tablet
Calcium carbonate-vitamin D 600mg-200mg tablet
Calcium carbonate-vitamin D 600mg-400mg tablet
Cholecalciferol tablet 1000 unit
Ferrous sulfate 325mg tablet/EC tablet
Ferrous sulfate 220mg/5ml elixir
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Apple Health (Medicaid) Fee-for-Service
Covered Over-the-Counter Drug List
Effective March 10, 2016
Only generic products are covered unless brand is indicated in parentheses.
Vitamins/Minerals (cont.):
Ferrous sulfate 75mg/1ml drops
Ferrous gluconate 324mg tablet
Ferrous gluconate 325mg tablet
Multivitamin and zinc chewable tablets (Aquadeks)
Multivitamin/minerals antioxidant enriched softgel capsule (Aquadeks)
Multivitamin/minerals antioxidant enriched pediatric drops (Aquadeks)
Multivitamin Pediatric ADC 1500U-400U-35mg/ml drops
Multivitamin Pediatric with iron 10mg/ml drops
Niacin 500mg tablet
Niacin 500mg CR capsule / tablet
Niacin 750mg CR tablet
Niacin 1000mg CR tablet
Prenatal Vitamins
Pyridoxine 50mg tablet
Thiamine 100mg tablet (requires PA)
Other:
Artificial saliva solution
Contraceptives -- see the Covered Contraceptives List
Emergency contraceptives
Gelatin capsule (empty)
Glucose 40% gel
Glucose 4 gm chewable tablet
Glycerin liquid
Human insulin 100u/ml
Nicotine Replacement Therapy through 1-800-QUIT-NOW
Oral electrolyte solution
Sodium chloride 0.9% nebulizer solution
Sorbitol solution (bulk)
Pyrantel pamoate chewable tablets / suspension / tablets
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