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Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description PAIN RELIEVERS-FEVER REDUCERS acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen/caffeine acetaminophen/caffeine/pyrilamine PW_12-13_1049/DHS_Approved_01/24/2014 Brand Examples Strengths Dosage Forms Tylenol Tylenol Extra Strength 325 mg 500 mg 650 mg 500 mg 650 mg 80 mg 160 mg 500 mg 160 mg/5 mL 160 mg/5 mL 167 mg/5 mL 500 mg/5 mL 160 mg/5 mL 160 mg/5 mL 325 mg/5 mL 160 mg/5 mL 80 mg/0.8 mL 100 mg/mL 80 mg 120 mg 325 mg 650 mg 80 mg 160 mg 500 mg 500 mg-65 mg 500 mg-60 mg-15 mg tablets tablets tablets capsules tablets, ER chewable tablets chewable tablets chewable tablets elixir liquid liquid liquid suspension solution solution syrup suspension solution (drops) suppositories suppositories suppositories suppositories dispersable tablets dispersable tablets dispersable tablets tablets tablets Tylenol Arthritis Tylenol Go Tylenol Tylenol Triaminic Fever Reducer Tylenol Feverall Tylenol Children's Meltaways Tylenol Jr. Meltaways Excedrin Tension Headache Midol Complete Page 1 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description acetaminophen/diphenhydramine acetaminophen/ diphenhydramine acetaminophen/ diphenhydramine acetaminophen/ diphenhydramine aspirin aspirin aspirin aspirin aspirin aspirin buffered aspirin buffered aspirin buffered aspirin buffered aspirin buffered aspirin enteric-coated aspirin enteric-coated aspirin enteric-coated aspirin aspirin aspirin aspirin enteric-coated aspirin/acetaminophen/ caffeine aspirin/caffeine ibuprofen ibuprofen ibuprofen ibuprofen naproxen sodium PW_12-13_1049/DHS_Approved_01/24/2014 Brand Examples Tylenol PM Excedrin PM Unisom PM Pain Tylenol PM St. Joseph Bayer Chewable Low Dose Bayer Advanced Bufferin Low Dose Bufferin Bufferin Extra Strength Ascriptin Ascriptin Maximum Strength Ecotrin Ecotrin Maximum Strength Bayer Low Dose Halfprin Excedrin Migraine Children's Motrin, Children's Advil Motrin Infants, Children's Advil Advil Jr. Strength, Children's Motrin Jr. Strength Advil, Motrin IB Aleve Strengths 500 mg-25 mg 500 mg-38 mg 325 mg-50 mg 1000 mg-50 mg/30 mL 75 mg 81 mg 81 mg 325 mg 500 mg 81 mg 325 mg 500 mg 325 mg 500 mg 325 mg 500 mg 81 mg 81 mg 300 mg, 600 mg 60 mg, 120 mg, 200 mg 162 mg Dosage Forms tablets tablets tablets liquid chewable tablets chewable tablets tablets tablets tablets tablets tablets tablets tablets tablets tablets, DR tablets, DR tablets, DR dispersable tablets suppositories suppositories tablets, DR 250-250-65 mg 400 mg-32 mg, 500 mg32.5 mg 100 mg/5 mL 40 mg/mL tablets 100 mg 200 mg 220 mg chewable tablets tablets tablets tablets suspension suspension Page 2 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description FUNGAL INFECTIONS - vaginal clotrimazole clotrimazole miconazole miconazole miconazole miconazole suppository & cream kit BIRTH CONTROL condoms Conceptrol (nonoxynol-9) nonoxynol-9 nonoxynol-9 nonoxynol-9 Gynol II (nonoxynol-9) levonorgestrel levonorgestrel nonoxynol-9 EAR, NOSE, THROAT benzocaine carbamide peroxide cromolyn sodium - nasal oxymetazoline phenol phenylephrine sodium chloride sodium chloride sodium chloride sodium chloride sodium chloride PW_12-13_1049/DHS_Approved_01/24/2014 Brand Examples Strengths Dosage Forms Gyne-Lotrimin Gyne-Lotrimin 3 1% 2% 2% 4% 100 mg vaginal cream vaginal cream vaginal cream vaginal cream vaginal tablets various vaginal tablets & cream kit all 4% 12.5% 28% 2% 3% 0.75 mg 1.5 mg 100 mg all gel foam film gel gel tablets tablets suppository 20% 6.5% 5.2 mg/act 0.05% 1.4% 0.25%, 1% oral solution otic solution nasal aerosol nasal spray oral liquid nasal spray nasal gel nasal spray nasal spray nasal solution nasal solution VCF Vaginal Contraceptive Foam VCF Vaginal Contraceptive Film Shur-seal Plan B Plan B Encare Hurricaine Debrox Nasalcrom Afrin Chloraseptic Spray Neo-Synephrine Ayr Saline Ocean Rhinaris Ayr Nasal Nasadrops 0.65% 0.2% 0.65% 0.9% Page 3 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description sodium chloride EYE PRODUCTS artificial tears gel artificial tears solution artificial tears ointment carboxymethylcellulose hypromellose hypromellose ketotifen polyethylene glycol/polyvinyl alcohol polyethylene glycol/propylene glycol polyvinyl alcohol polyvinyl alcohol polyvinyl alcohol/povidone propylene glycol/glycerin propylene glycol/glycerin sodium chloride ophthalmic sodium chloride ophthalmic white petrolatum-mineral oil GASTROINTESTINAL Heartburn, Indigestion aluminum & magnesium hydroxides aluminum & magnesium hydroxides/simethicone aluminum & magnesium hydroxides/simethicone aluminum hydroxide gel suspension calcium carbonate calcium carbonate calcium carbonate PW_12-13_1049/DHS_Approved_01/24/2014 Brand Examples Ayr Allergy and Sinus Genteal, Systane Tears Naturale Refresh P.M. Refresh Tearisol, Isopto Tears Genteal Zaditor Hypotears Systane Nutratear Akwa Tears artificial tears Soothe artificial tears Muro-128 Muro-128 Genteal PM, Systane Mylanta Tums Ultra Children's Mylanta Tums Strengths 2.65% Dosage Forms nasal solution 0.4%, 0.5%, 2% 0.2%, 0.3% 0.025% ophth gel ophth solution ophth ointment ophth solution ophth solution ophth solution ophth solution 0.4%-0.3% 0.6% 1.4% 0.6%/0.6% 1%/0.3% 5% 2%, 5% ophth solution ophth solution ophth solution ophth solution ophth solution ophth solution ophth ointment ophth solution ophth ointment 225-200 mg/5mL suspension 200-200-20 mg/5 mL, 400400-40 mg/5 mL suspension 200-200-20 mg, 200-20025 mg chewable tablets 320 mg/5mL 1000 mg 400 mg 500 mg suspension chewable tablets chewable tablets chewable tablets Page 4 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description calcium carbonate calcium carbonate calcium carbonate cimetidine famotidine famotidine nizatidine omeprazole delayed-release omeprazole magnesium delayed-release ranitidine sodium bicarbonate Constipation bisacodyl bisacodyl bisacodyl calcium polycarbophil calcium polycarbophil docusate sodium docusate sodium docusate sodium docusate sodium docusate sodium docusate sodium docusate sodium glycerin glycerin glycerin glycerin glycerin glycerin PW_12-13_1049/DHS_Approved_01/24/2014 Brand Examples Maalox Tums E-X Tagamet HB Pepcid AC Pepcid AC Maximum Strength Axid AR Prilosec OTC Zantac Dulcolax Fleet Bisacodyl Dulcolax FiberCon Equalactin Colace Pedia-Lax Fleet Strengths 600 mg 750 mg 420 mg, 1177 mg 200 mg 10 mg 20 mg 75 mg 20 mg 20 mg 75 mg Dosage Forms chewable tablets chewable tablets chewable tablets tablets chewable tablets, tablets chewable tablets tablets tablets, DR tablets, DR tablets tablets, powder 5 mg 10 mg/30 mL 10 mg 625 mg 625 mg 50 mg, 100 mg 250 mg 150 mg/15 mL 50 mg/15 mL 60 mg/15 mL 100 mg 283 mg 5.6 g 2.1 g 1.2 g 1.5 g 2g 3g tablets, DR enema suppository caplets chewable tablets capsules capsules liquid liquid syrup tablets enema enema suppository suppository suppository suppository suppository Page 5 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description glycerin glycerin magnesium citrate Brand Examples Pedia-Lax magnesium hydroxide magnesium hydroxide magnesium hydroxide magnesium hydroxide methylcellulose methylcellulose mineral oil mineral oil enema PEG 3350 oral powder psyllium powder psyllium psyllium senna senna Milk of Magnesia Milk of Magnesia Milk of Magnesia Pedia-Lax Citrucel Citrucel sennosides sennosides sennosides sennosides sennosides sennosides sennosides sennosides sennosides sennosides-docusate sodium sodium phosphates rectal solution sodium phosphates solution PW_12-13_1049/DHS_Approved_01/24/2014 Miralax Metamucil, Fiber-Eze Metamucil Metamucil Ex-Lax Ex-Lax Ex-Lax Maximum Strength Senokot Senokot Xtra Senokot-S Fleet Enema Strengths 1 g, 2.8 g 80.7% 400 mg/5 mL, 800 mg/5 mL 2400 mg/10 mL 311 mg 400 mg 500 mg 0.52 g 1.7 g 187 mg 25 mg/15 mL, 8.8 mg/mL 8.8 mg/5 mL 8.6 mg 10 mg 15 mg 15 mg 25 mg 8.6 mg 17.2 mg 8.6-50 mg Dosage Forms suppository suppository oral solution suspension concentrate chewable tablets chewable tablets powder tablets oral liquid enema powder powder capsules wafers tablets powder, syrup liquid syrup capsules chewable tablets chewable tablets tablets tablets tablets tablets tablets enema oral solution Page 6 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description sorbitol Diarrhea bismuth subsalicylate bismuth subsalicylate loperamide loperamide loperamide loperamide simethicone simethicone simethicone simethicone simethicone simethicone simethicone simethicone simethicone Miscellaneous GI lactase RESPIRATORY Antihistamines/decongestants brompheniramine/ phenylephrine brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine brompheniramine/ pseudoephedrine PW_12-13_1049/DHS_Approved_01/24/2014 Brand Examples Strengths 70% Dosage Forms oral solution Pepto Bismol Pepto Bismol various 262 mg 2 mg 2 mg 1 mg/7.5 mL 1 mg/5 mL 80 mg 125 mg 125 mg 180 mg 40 mg/0.6 mL 40 mg 62.5 mg 40 mg/0.6 mL 80 mg, 125 mg suspension chewable tablets, tablets capsules chewable tablets, tablets solution solution chewable tablets chewable tablets capsules capsules liquid oral strips oral strips suspension tablets Lactaid various capsules, chewable tablets, tablets Dimetapp Cold and Allergy 1-2.5mg/5mL elixir 4-60 mg capsules 1 mg-15 mg/5 mL elixir 1-7.5 mg/mL liquid 4 mg-20 mg/5 mL liquid Imodium A-D Imodium A-D Gas-X Gas-X Extra Strength Mylanta Gas Phazyme Gas-X Infant Gas-X Children's Gas-X Extra Strength Mylicon Page 7 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description cetirizine cetirizine cetirizine cetirizine cetirizine cetirizine/ pseudoephedrine chlorpheniramine chlorpheniramine chlorpheniramine chlorpheniramine/pseudoephedrine chlorpheniramine/pseudoephedrine chlorpheniramine/pseudoephedrine chlorpheniramine/pseudoephedrine chlorpheniramine/pseudoephedrine clemastine fumarate diphenhydramine diphenhydramine diphenhydramine diphenhydramine diphenhydramine diphenhydramine diphenhydramine diphenhydramine diphenhydramine diphenhydramine (for sleep) diphenhydramine (for sleep) diphenhydramine (for sleep) diphenhydramine (for sleep) PW_12-13_1049/DHS_Approved_01/24/2014 Brand Examples Zyrtec Children's Allergy Zyrtec Children's Allergy Zyrtec Children's Allergy, Zyrtec Children's Hives Zyrtec Allergy, Zyrtec Hives Relief Zyrtec-D Chlor-Trimeton Chlor-Trimeton Chlor-Trimeton Tavist Allergy Benadryl Benadryl Benadryl Allergy Triaminic Allergy Benadryl ZZZquil Unisom SleepGels Unisom SleepMelts ZZZquil Strengths 10 mg 5 mg Dosage Forms chewable tablets chewable tablets 5 mg/5 mL 10 mg 5 mg syrup tablets tablets 5 mg/120 mg 12 mg 2 mg/5 mL 4 mg 2 mg-30 mg/5 mL 2 mg-30 mg 0.8 mg-9 mg/mL 1-15 mg/5 mL 4 mg-60 mg 1.34 mg 25 mg 12.5 mg tablets, ER capsules, ER syrup tablets liquid chewable tablets drops syrup tablets tablets capsules dispersable tablets 12.5 mg 12.5 mg/5 mL 12.5 mg/5 mL 12.5 mg 12.5 mg/5 mL 25 mg 50 mg 25 mg 50 mg 25 mg 50 mg/30 mL chewable tablets, orally dissolving strips elixir liquid orally dissolving strips syrup tablets capsules, tablets capsules capsules dispersable tablets liquid Page 8 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description diphenhydramine (for sleep) diphenhydramine (for sleep) fexofenadine fexofenadine fexofenadine fexofenadine/pseudoephedrine fexofenadine/pseudoephedrine loratadine loratadine loratadine loratadine loratadine loratadine loratadine/pseudoephedrine loratadine/pseudoephedrine phenylephrine Brand Examples Sominex Nytol Maximum Strength Allegra Allergy Allegra Allergy Allegra Allergy Allegra-D 12 HR Allegra-D 24 HR Claritin Claritin Claritin Reditablets Claritin Reditablets Claritin Alavert, Claritin Claritin-D 24 HR Claritin-D 12 HR Little Colds Strengths 25 mg 50 mg 30 mg/5 mL 30 mg 30 mg, 60 mg, 180 mg 60-120 mg 180-240 mg 10 mg 5 mg 5 mg 10 mg 5 mg/5mL 10 mg 10-240 mg 5-120 mg 2.5 mg/mL Dosage Forms tablets tablets suspension orally disintegrating tablets tablets tablets, ER tablets, ER capsules chewable tablets orally disintegrating tablets orally disintegrating tablets syrup tablets tablets, ER tablets, ER liquid phenylephrine phenylephrine phenylephrine pseudoephedrine pseudoephedrine pseudoephedrine pseudoephedrine pseudoephedrine pseudoephedrine pseudoephedrine Antitussives and Expectorants brompheniramine/ phenylephrine/dextromethorphan Pediacare Children's Decongestant 2.5 mg/5 mL 5 mg 10 mg 15 mg/5 mL 30 mg/5 mL 30 mg/5 mL 120 mg 240 mg 30 mg 60 mg oral solution tablets tablets liquid liquid syrup tablets, ER tablets, ER tablets tablets 1-2.5-5 mg/5mL elixir PW_12-13_1049/DHS_Approved_01/24/2014 Sudafed PE Sudafed Children's Sudafed 12 HR Sudafed 24 HR Sudafed Dimetapp DM Page 9 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description brompheniramine/ pseudoephedrine/ dextromethorphan brompheniramine/ pseudoephedrine/ dextromethorphan dextromethorphan polistirex dextromethorphan/guaifensin dextromethorphan/guaifensin dextromethorphan/guaifensin dextromethorphan/guaifensin Brand Examples Strengths Dosage Forms Dimetane DX 2 mg-30 mg-10 mg/5 mL syrup 3 mg-50 mg-30 mg/5 mL 30 mg/5 mL 10 mg-200 mg 5-100 mg 10-100 mg/5 mL 5-100 mg/5 mL syrup liquid, ER capsules granules liquid liquid dextromethorphan/guaifensin dextromethorphan/guaifensin Neo DM Delsym Coricidin HBP Mucinex Cough for Kids Cheracol-D Mucinex Cough-Children's Robitussin Cough & Congestion DM Max Vicks Dayquil Mucus Control DM dextromethorphan/guaifensin dextromethorphan/guaifensin dextromethorphan/guaifensin dextromethorphan/guaifensin Mucinex DM Maximum Strength Mucinex DM Robitussin DM dextromethorphan/ guaifensin dextromethorphan/guaifensin dextromethorphan/guaifensin dextromethorphan-guaifenesin-potassium citrate guaifenesin Sorbutuss NR Mucinex for Kids PW_12-13_1049/DHS_Approved_01/24/2014 10 -200 mg/5 mL liquid 10-200 mg/15 mL liquid 15-25 mg/5 mL, 15-125 mg/5 mL, 15-200 mg/5 mL, 20-200 mg/30 mL, 20300 mg/5 mL, 20-400 mg/5 mL, 30-200 mg/5 mL liquid 60 mg-1200 mg tablets, ER 30-600 mg tablets, ER 10-100 mg/5 mL syrup 3.33-33.3 mg/5 mL, 20200 mg/15 mL, 20-400 mg/5 mL syrup 15 mg-400 mg tablets 20 mg-400 mg tablets 10-100-85 mg/5 mL 50 mg, 100 mg liquid granules Page 10 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description guaifenesin guaifenesin guaifenesin guaifenesin guaifenesin guaifenesin guaifenesin guaifenesin guaifenesin/phenylephrine Peak Flow Meters ASSESS ASSESS ASSESS ASSESS ASSESS ASSESS AsthmaMentor AsthmaMentor Peak Air Personal Personal Personal PocketPeak SKIN Acne benzoyl peroxide benzoyl peroxide benzoyl peroxide benzoyl peroxide PW_12-13_1049/DHS_Approved_01/24/2014 Brand Examples Mucinex for Kids Strengths 100 mg/5 mL Dosage Forms liquid Mucinex Mucinex Robitussin 100 mg/6.25 mL, 150 mg/15 mL, 200 mg/5 mL 50 mg/5 mL 1200 mg 600 mg 100 mg/5 mL 200 mg 400 mg 100 mg-5 mg/5 mL liquid oral solution tablets, ER tablets, ER syrup tablets tablets liquid 10% 2.5% 5% 2.5%, 7% cream, lotion, gel cream, lotion gel, lotion gel Liquibid Rescon GG Page 11 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description benzoyl peroxide benzoyl peroxide salicylic acid salicylic acid Antibacterials-topical bacitracin zinc neomycin/polymyxin B/bacitracin Antifungals-topical clotrimazole ketoconazole miconazole miconazole miconazole miconazole miconazole miconazole terbinafine tolnaftate Antipruritics collodial oatmeal calamine lotion hydrocortisone hydrocortisone hydrocortisone acetate Pediculosis permethrin permethrin permethrin piperonyl butoxide/ pyrethrins/permethrin PW_12-13_1049/DHS_Approved_01/24/2014 Brand Examples Panoxyl Clean & Clear Clean & Clear Strengths 4%, 8% 3.5%, 5.25% 0.5%, 2%, 21% Dosage Forms lotion lotion cream, gel, liquid, lotion ointment 500U/g ointment ointment 1% 1% 2% 2% 2% 2% 2% 2% 1% 1% various shampoo aerosol aerosol powder cream lotion, solution ointment powder various various 0.5% 1% 1% packets lotion cream, ointment cream, lotion, ointment, solution cream, ointment 1% 1% 0.5% creme rinse lotion aerosol Neosporin, Triple Antibiotic Lotrimin AF Nizoral A-D Desenex Spray Lotrimin AF Micatin Aloe Vesta Antifungal Desenex Shake Powder Lamisil AT Tinactin Aveeno Hytone Rid Rid Complete shampoo Page 12 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description pyrethrins/piperonyl butoxide Other Topicals capsaicin capsicum chlorhexidine gluconate coal tar coal tar coal tar coal tar/salicylic acid dibucaine docosanol ethyl alcohol hydroactive dressings hydrocortisone hydrogen peroxide isopropyl alcohol lactic acid/ammonium lactate lactic acid/ammonium lactate menthol/zinc oxide povidone/iodine povidone/iodine povidone/iodine povidone/iodine povidone/iodine salicylic acid gel salicylic acid liquid salicylic acid patches salicylic acid patches salicylic acid plaster salicylic acid PW_12-13_1049/DHS_Approved_01/24/2014 Brand Examples Tegrin-LT, Pronto Strengths Zostrix Hibiclens Ionil-T, T/Gel Tarsum Nupercainal Abreva Rubbing alcohol Curafil Hydrogel Proctocort Rubbing alcohol Lac-Hydrin Lac-Hydrin Calmoseptine Betadine Keralyt Compound W, DuoFilm Trans-ver-sal Pediapatch MediPlast Psoriasis Liquid 0.025%, 0.075% 2%, 4% 1%, 5%, 10% 0.5%, 1%, 2.5% 2.8%, 3%, 10% 10%-5% 1% 10% 70%, 95% 1%, 2.5% 3% 70% 5% 12% 0.44-20.625% 10% 7.5%, 10% 0.75%, 1%, 5% 1%, 10% 7.5%, 10% 3% 17% 40% 15% 40% 3% Dosage Forms shampoo cream, gel, liquid, lotion, pad cream liquid lotion shampoo shampoo shampoo rectal ointment topical cream solution dressings, pads rectal cream solution solution lotion lotion ointment ointment solution solution gel swabs gel liquid pad patches plaster liquid Page 13 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description selenium sulfide trolamine salicylate trolamine salicylate white petrolatum wound dressing gel zinc oxide SMOKING CESSATION nicotine gum nicotine oral lozenges nicotine transdermal patches SUPPLEMENTS Brand Examples Selsun Blue Myoflex, Aspercreme Strengths 1% 10% 10% Vaseline Curafil, Nu-Gel, Curasol Balmex, Boudreaux's Butt Paste, Desitin Dosage Forms lotion (shampoo) cream, lotion aerosol gel, ointment gel various cream, ointment, paste, powder, stick Nicorette Nicorette Nicoderm CQ 2 mg, 4 mg 2 mg, 4 mg 7 mg, 14 mg, 21 mg gum oral lozenges transdermal patches beta carotene calcium carbonate calcium carbonate calcium carbonate calcium carbonate calcium carbonate calcium carbonate calcium carbonate/cholecalciferol calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/vitamin D PW_12-13_1049/DHS_Approved_01/24/2014 Cal-Mint, Os-Cal 500 Chewables Caltrate 600 Os-Cal chews 15 mg, 30 mg, 10000U, 25000U 200 mg, 1250 mg (500 mg Ca) 1250 mg/5 mL 1250 mg (500 mg Ca) 260 mg, 500 mg 1500 mg (600 mg Ca) 600 mg various 300 mg-100U, 500 mg50U 600 mg-200U 250 mg-125U 500 mg/125U 500 mg/200U 500 mg/400U 600 mg/125U 600 mg/200U capsules capsules suspension tablets chewable tablets tablets tablets tablets, chewable tablets, capsules capsules capsules tablets tablets tablets tablets tablets tablets Page 14 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description calcium carbonate/vitamin D calcium carbonate/vitamin D calcium carbonate/ vitamin D/minerals calcium citrate Brand Examples Caltrate 600 +D calcium citrate calcium citrate calcium citrate/vitamin D calcium citrate/vitamin D calcium citrate/vitamin D calcium citrate/vitamin D carbonyl iron Citracal +D Icar carbonyl iron carbonyl iron carbonyl iron Icar cholecalciferol cyanocobalamin (Vitamin B12) cyanocobalamin (Vitamin B12) cyanocobalamin (Vitamin B12) ergocalciferol ergocalciferol ferrous gluconate Vitamin D3 PW_12-13_1049/DHS_Approved_01/24/2014 Feosol Vitamin D2 Vitamin D2 Strengths 600 mg-400U 600 mg-400U 600 mg-200U, 600 mg400U/various 950 mg (200 mg Ca) 150 mg, 200 mg, 250 mg, 1040 mg 760 mg/3.5 g 315mg/200U 200 mg-250U, 250 mg200U, 315 mg-250U 200 mg-125U, 250 mg50U, 250 mg-100U 500 mg-400U 15 mg (elemental iron) 15 mg/1.25 mL (elemental iron) 25 mg (elemental iron) 45 mg (elemental iron) various strengths 1000 mcg, 1500 mcg, 2000 mcg various 500 mcg, 1000 mcg, 2500 mcg 8000U/mL 400U, 2000U various Dosage Forms tablets chewable tablets tablets, chewable tablets tablets tablets granules tablets tablets tablets chewable tablets chewable tablets suspension tablets tablets capsules, chewable tablets, liquid, orally disintegrating tablets, tablets, wafers tablets, ER tablets sublingual tablets drops tablets tablets Page 15 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description ferrous sulfate ferrous sulfate ferrous sulfate ferrous sulfate ferrous sulfate ferrous sulfate ferrous sulfate, dried ferrous sulfate, dried ferrous sulfate, dried folic acid iron Brand Examples Feosol Slow Fe iron complex, polysaccharide iron complex, polysaccharide iron complex, polysaccharide; vitamin B-12; folic acid iron complex, polysaccharide; vitamin B-12; folic acid levocarnitine lutein lutein/zeaxanthin magnesium magnesium chloride magnesium chloride/calcium carbonate magnesium lactate magnesium oxide magnesium oxide magnesium oxide niacin PW_12-13_1049/DHS_Approved_01/24/2014 Strengths 220 mg/5 mL 324 mg, 325 mg 15 mg/mL 300 mg/5 mL various various 200 mg 143 mg 160 mg 400 mcg, 800 mcg 15 mg/1.5 mL 50 mg, 150 mg, 180 mg, 200 mg Dosage Forms elixir enteric-coated tablets solution syrup tablets tablets, ER tablets tablets, ER tablets, ER tablets suspension capsules 15 mg/0.5 mL, 15 mg/mL liquid Irofol 150 mg-0.025-1 mg tablets Hematron 15 mg-0.008 mg-4 mg/mL 250 mg, 500 mg 10 mg various various strengths 535 mg 71.5 mg/119 mg 84 mg 400 mg, 500 mg 250 mg, 500 mg 400 mg 250 mg, 500 mg liquid capsules, tablets tablets capsules, tablets capsules, tablets tablets, ER tablets, DR tablets, ER capsules tablets tablets capsules, ER Slow Mag Mag-Ox Page 16 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description Brand Examples niacin Slo-Niacin niacin oyster shell calcium oyster shell calcium/vitamin D sodium chloride vitamin A vitamin B-1 (Thiamine) vitamin B-2 (Riboflavin) vitamin B-6 (Pyridoxine) vitamin B-6 (Pyridoxine) vitamin C vitamin C vitamin C vitamin E vitamin E vitamin K zinc gluconate zinc gluconate zinc sulfate Multivitamins B-complex w/C, folic acid B-complex w/C, folic acid multiple vitamin multiple vitamin multiple vitamin with iron multiple vitamins with minerals PW_12-13_1049/DHS_Approved_01/24/2014 Dialyvite, Rena-vite Nephrocaps One-A-Day Essential Ocuvite, Preservision Strengths 250 mg, 500 mg, 750 mg, 1000 mg 50 mg, 100 mg, 250 mg, 500 mg 500 mg 500 mg, 600 mg 1000 mg various 50 mg, 100 mg, 250 mg 25 mg, 50 mg, 100 mg, 400 mg various strengths 200 mg 100 mg, 250 mg, 500 mg, 1000 mg 500 mg 500 mg, 1000 mg, 1500 mg various 50U/mL 100 mcg various 10 mg, 13.3 mg 220 mg Dosage Forms tablets, ER tablets tablets tablets tablets capsules, tablets tablets capsules, tablets tablets tablets, ER chewable tablets, tablets capsules, ER tablets, ER capsules, chewable tablets, tablets solution tablets tablets lozenges capsules tablets capsules tablets capsules, chewable tablets, liquid tablets tablets Page 17 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description multiple vitamin with minerals multiple vitamin with minerals pediatric multiple vitamin pediatric multiple vitamin with C Brand Examples Ocuvite, Preservision Centrum, Cerovite Pediavit Poly-Vi-Sol Fruity Chewables, My First pediatric multiple vitamin with C and folic acid Flintstones pediatric multiple vitamin with fluoride pediatric multiple vitamin with fluoride pediatric multiple vitamin with fluoride and iron pediatric multiple vitamin with iron pediatric vitamin drops with ADC prenatal vitamins/folic acid/iron (ferrous fumarate) prenatal vitamins/selenium/folic acid/iron (ferrous fumarate) OTHER PRODUCTS Strengths various Dosage Forms capsules liquid liquid, chewable tablets, drops drops, liquid 0.25 mg, 0.5 mg, 1 mg 0.25 mg, 0.5 mg chewable tablets chewable tablets drops 0.25 mg-10 mg/mL drops Flintstones Plus Iron, Centrum Kids Tri-Vi-Sol chewable tablets drops all activated charcoal dimenhydrinate Dramamine elastic bandages and supports glucose ipecac meclizine meclizine oral electrolyte replacement T.E.D, Kendall, J&J ostomy supplies, kits Hollister, Kendall, Bard, Convatec PW_12-13_1049/DHS_Approved_01/24/2014 50 mg 25 mg 12.5 mg, 25 mg, 32 mg Oralyte, Pedialyte tablets capsules, tablets, liquid, for suspension chewable tablets, tablets various, including hose, stockings, wraps chewable tablets, gel, liquid syrup chewable tablets tablets packets, solution various, including drains, caps, belts, pouches, skin gel Page 18 of 19 Medicaid-Covered, Over-the-Counter Drug List for PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete (HMO SNP) Note: Abbreviation Key is provided on the last page of this document Generic Description Brand Examples Strengths 1 mL, 3 mL, various needle gauges/lengths Dosage Forms syringes/needles, disposable OTHER PRESCRIPTION PRODUCTS Cough and Cold Products codeine/guaifenesin B-D, Kendall 10-100 mg/5 mL solution pseudoephedrine/chlorpheniramine-codeine Prescription Supplements calcitriol cyanocobalamin (Vitamin B12) cyanocobalamin (Vitamin B12) ergocalciferol folic acid vitamin K (phytonadione) vitamin K (phytonadione) Phenylhistine DH 30-2-10 mg/5 mL solution Rocaltrol 1 mcg/mL 1000 mcg/mL 500 mcg/0.1 mL 50,000U 1 mg 5 mg 2 mg/mL, 10 mg/mL oral solution injectable solution nasal solution capsules tablets tablets injectable solution Nascobal Drisdol Mephyton Key CR = controlled release DR = delayed release ER = extended release SR = sustained release ophth = eye otic = ear U = units PW_12-13_1049/DHS_Approved_01/24/2014 Page 19 of 19
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