Download Generic Drug Name Strength DESC Sample Brand Name SMAC

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Transcript 
NEBRASKA MEDICAID
COUGH AND COLD COVERED PRODUCTS LIST
Generic Drug Name
Strength
DESC
Sample Brand Name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
BENZONATATE
100MG
CODEINE/PROMETHAZINE HCL
10-6.25/5ML
DEXTROMETHORPHAN/PE/BROMPHENIR
5-2.5-1/5ML
D-METHORPHAN HB/PE/CHLORPHENIR
3-3.5-1/ML
D-METHORPHAN HB/P-EPD HCL/BPM
15-45-4/5ML
D-METHORPHAN HB/PROMETH HCL
15-6.25/5ML
GUAIFEN/DM HB/P-EPHEDRINE
100-10-30/5ML
GUAIFENESIN
100MG/5ML
GUAIFENESIN
200MG
GUAIFENESIN/CODEINE PHOS
100-10MG/5ML
GUAIFENESIN/D-METHORPHAN HB
100-10MG/5ML
GUAIFENESIN/D-METHORPHAN HB
100-10MG/5ML
GUAIFENESIN/D-METHORPHAN HB/PE
100-10-5MG
GUAIFENESIN/P-EPHED HCL/COD
100-30-10/5ML
GUAIFENESIN/PHENYLEPHRINE HCL
100-7.5/5/ML
HYDROCODONE BIT/HOMATROPINE
5-1.5MG/5ML
PHENYLEPHRINE HCL
10MG
PHENYLEPHRINE HCL/COD/PROMETH
5-10-6.25/5ML
PSEUDOEPHEDRINE HCL
15MG/5ML
PSEUDOEPHEDRINE HCL
30MG/5ML
PSEUDOEPHEDRINE HCL
120MG
PSEUDOEPHEDRINE HCL
30MG
PSEUDOEPHEDRINE HCL
60MG
PSEUDOEPHEDRINE HCL/CHLOR-MAL
60MG-4MG
PSEUDOEPHEDRINE HCL/BROMPHENIRAMINE
15-1MG/5ML
PHENYLEPHRINE HCL/PROMETH HCL
5-6.26MG/5ML
PHENYLEPHRINE/CHLOR-TAN
25-9MG
PHENYLEPHRINE/CHLOR-MAL
10MG-4MG
PHENYLEPHRINE/BROMPHENIRAMINE
2.5-1MG/5ML
PHENYLEPHRINE/CHLOR-MAL
2MG-1MG/ML
PSEUDOEPHEDRINE HCL/LORATADINE
240MG-10MG
*coverage is limited to generic products only
MC6 forms for brand medications will be denied
CAPSULE
SYRUP
SOLUTION
DROPS
SYRUP
SYRUP
SYRUP
LIQUID
TABLET
LIQUID
LIQUID
SYRUP
SYRUP
SYRUP
SYRUP
SYRUP
TABLET
SYRUP
LIQUID
SYRUP
TAB.SR 12H
TABLET
TABLET
TABLET
ELIXIR
SYRUP
TABLET
TABLET
SOLUTION
DROPS
TABLET
TESSALON PERLE 100 MG CAP
PHENERGAN W/CODEINE SYRUP
DIMETAPP DM COLD & COUGH EL
CARDEC DM DROPS
CARBOFED DM SYRUP
PHENERGAN DM SYRUP
ROBAFEN CF SYRUP
ORGANIDIN NR 100 MG/5 ML LIQUID
ORGANIDIN NR 200 MG TABLET
CHERATUSSIN AC LIQUID
CHERACOL D COUGH FORMULA
ROBITUSSIN DM COUGH SYRUP
ROBITUSSIN CF
RYNA-CX LIQUID
QUINTEX LIQUID
HYCODAN SYRUP
SUDAFED PE 10MG
PHENERGAN VC W/CODEINE SYRUP
CHILDS SUDAFED 15MG/5 ML LIQU
SUDAFED 30MG/5 ML SYRUP
SUDAFED 12 HOUR 120 MG CAPLT
SUDAFED 30MG TABLET
SUDAFED 60MG TABLET
SUDAFED PLUS
DIMETAPP
PHENERGAN VC
RYNATAN
SINUS & ALLERGY PE
DIMETAPP
DALLERGY
CLARITIN D 24 HOUR
SMAC
0.30000
0.07500
0.03750
0.75000
0.03000
0.03000
0.02700
0.02100
0.07500
0.11250
0.02670
0.02670
0.03000
0.07500
0.15000
0.15000
0.07500
0.12000
0.03000
0.02250
0.28000
0.05100
0.05250
0.02750
0.01800
0.06500
0.70000
0.07500
0.02000
0.55000
0.60000
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