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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