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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 Page 1 of 5 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) Page 2 of 5 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 Page 3 of 5 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 Page 4 of 5 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 Page 5 of 5