Download Medicaid Prescription Drug List for Members Eligible

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Transcript 
June 2009
Medicaid Prescription Drug List
for Members Eligible for Medicare Part D
Brand Name
Generic Name
Coverage
Flag
Central Nervous System Agents
Anticonvulsants
Klonopin
Mebaral
Phenobarbital
clonazepam
mephobarbital
phenobarbital
Generic
Generic
Generic
Anxiolytics, Sedatives and Hypnotics
Ativan
Diastat
Halcion
Librium
Restoril (not 22.5mg)
Serax
Valium
Xanax
lorazepam
diazepam
triazolam
chlordiazepoxide
temazepam
oxazepam
diazepam
alprazolam
Generic
Brand
Generic
Generic
Generic
Generic
Generic
Generic
Fioricet
Fiorinal
apap/butalbital/caffeine
ASA/butalbital/caffeine
Migraine and Headache
Generic
Generic
Gastrointestinal Agents
Ulcer Treatment and Prevention
Prilosec OTC
omeprazole delayed release tabs
Generic
Nutritional Supplements
Vitamins
Adeks
Folic acid
Mephyton
Nephrocaps
Nephro-Vite
multiple vitamins w/minerals chew tab
folic acid
phytonadione
B-Complex w/C & Folic Acid 1mg Cap
B-Complex w/C & Folic Acid 0.8mg Tab
Brand
Generic
Brand
Generic
Generic
Over-the-Counter Analgesics
Aspirin OTC
Tylenol OTC
aspirin
acetaminophen
Generic
Generic
Respiratory Agents
Antihistamines
Claritin OTC
Rondec DM Syrup
loratidine
pseudoephedrine-carbinoxamine-DM
syrup
Page 1 of 2
Generic
Generic
Edits/ Limitations
June 2009
Medicaid Prescription Drug List
for Members Eligible for Medicare Part D
Brand Name
Generic Name
Coverage
Flag
Antitussives, Expectorants and Mucolytics
Histussin HC
Hycodan
Hycotuss Expectorant
Novahistine DH Liquid
Phenergan DM
Phenergan w/Codeine
Promethazine VC/Codeine
Robitussin AC Syrup
Robitussin DAC
Rondec DM Syrup
Tessalon Perles
Tussi-Organidin DM
chlorpheniramine/hydrocodone/
phenylephrine
homatropine/hydrocodone
hydrocodone-guaifenesin syrup
pseudoephedrine-chlorphen w/codeine
liquid 30-2-10mg/5ml
promethazine-DM syrup 6.25-15mg/5ml
promethazine w/codeine
phenylephrine-promethazine w/codeine
syrup
codeine-guaifenesin syrup
pseudoephedrine/codeine/guafenesin
pseudoephedrine-carbinoxamine-DM
syrup
benzonatate
dextromethorpham/guaifenesin
Page 2 of 2
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Edits/ Limitations
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