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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