Download Generic Drug Name Strength DESC Sample Brand Name SMAC

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NEBRASKA MEDICAID COUGH AND COLD COVERED PRODUCTS LIST
Generic Drug Name
Strength
DESC
Sample Brand Name
BENZONATATE
CODEINE/PROMETHAZINE HCL
DEXTROMETHORPHAN/PE/BROMPHENIR
D-METHORPHAN HB/PE/CHLORPHENIR
D-METHORPHAN HB/PE/CHLORPHENIR
D-METHORPHAN HB/P-EPD HCL/BPM
D-METHORPHAN HB/PROMETH HCL
GUAIFEN/DM HB/P-EPHEDRINE
GUAIFENESIN
GUAIFENESIN
GUAIFENESIN/CODEINE PHOS
GUAIFENESIN/D-METHORPHAN HB
GUAIFENESIN/D-METHORPHAN HB
GUAIFENESIN/D-METHORPHAN HB
GUAIFENESIN/D-METHORPHAN HB/PE
GUAIFENESIN/P-EPHED HCL/COD
GUAIFENESIN/PHENYLEPHRINE HCL
HYDROCODONE BIT/HOMATROPINE
PHENYLEPHRINE HCL
PHENYLEPHRINE HCL/COD/PROMETH
PHENYLEPHRINE/CHLOR-MAL/SCOP
PHENYLEPHRINE/CHLOR-MAL/SCOP
PHENYLEPHRINE/DHCODEINE BT/CP
PSEUDOEPHEDRINE HCL
PSEUDOEPHEDRINE HCL
PSEUDOEPHEDRINE HCL
PSEUDOEPHEDRINE HCL
PSEUDOEPHEDRINE HCL
PSEUDOEPHEDRINE HCL/CHLOR-MAL
PSEUDOEPHEDRINE HCL/BROMPHENIRAMINE
PHENYLEPHRINE HCL/PROMETH HCL
PHENYLEPHRINE/CHLOR-MAL
PHENYLEPHRINE/BROMPHENIRAMINE
PHENYLEPHRINE/BROMPHENIRAMINE
PHENYLEPHRINE/CHLOR-MAL
PSEUDOEPHEDRINE HCL/LORATADINE
*coverage is limited to generic products only
100MG
10-6.25/5ML
5-2.5-1/5ML
3-3.5-1/ML
15-12.5-4/5ML
15-45-4/5ML
15-6.25/5ML
100-10-30/5ML
100MG/5ML
200MG
100-10MG/5ML
100-10MG/5ML
200-20/5ML
100-10MG/5ML
100-10-5MG
100-30-10/5ML
100-7.5/5/ML
5-1.5MG/5ML
10MG
5-10-6.25/5ML
10-2-1.25/5ML
10-2-0.625/5ML
7.5-3-2/5ML
15MG/5ML
30MG/5ML
120MG
30MG
60MG
60MG-4MG
15-1MG/5ML
5-6.26MG/5ML
10MG-4MG
2.5-1MG/5ML
2.5-1MG/5ML
2MG-1MG/ML
240MG-10MG
CAPSULE
SYRUP
SOLUTION
DROPS
SYRUP
SYRUP
SYRUP
SYRUP
LIQUID
TABLET
LIQUID
LIQUID
ELIXIR
SYRUP
SYRUP
SYRUP
SYRUP
SYRUP
TABLET
SYRUP
SYRUP
SYRUP
SYRUP
LIQUID
SYRUP
TAB.SR 12H
TABLET
TABLET
TABLET
ELIXIR
SYRUP
TABLET
SOLUTION
TAB CHEW
DROPS
TABLET
TESSALON PERLE 100 MG CAP
PHENERGAN W/CODEINE SYRUP
DIMETAPP DM COLD & COUGH EL
CARDEC DM DROPS
CARDEC DM SYRUP
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
DURATUSS DM ELIXIR
ROBITUSSIN DM COUGH SYRUP
ROBITUSSIN CF
RYNA-CX LIQUID
QUINTEX LIQUID
HYCODAN SYRUP
SUDAFED PE 10MG
PHENERGAN VC W/CODEINE SYRUP
DURADRYL SYRUP
DALLERGY SYRUP
PANCOF PD 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
SINUS & ALLERGY PE
DIMETAPP
DIMETAPP
DALLERGY
CLARITIN D 24 HOUR
MC6 forms for brand medications will be denied
SMAC
0.30000
0.07500
0.03750
0.75000
0.22500
0.03000
0.03000
0.02700
0.02100
0.07500
0.11250
0.02670
0.04500
0.02670
0.03000
0.07500
0.15000
0.15000
0.07500
0.12000
0.07500
0.07500
0.13500
0.03000
0.02250
0.28000
0.05100
0.05250
0.02750
0.01800
0.06500
0.07500
0.02000
0.20000
0.55000
0.60000
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