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Nebraska Medicaid Cough and Cold Covered Products List
Revision Date: January 17, 2013
NEBRASKA MEDICAID
COUGH AND COLD COVERED PRODUCTS LIST
Generic Drug Name
BENZONATATE
CODEINE/PROMETHAZINE HCL
DEXTROMETHORPHAN/PE/BROMPHENIR
D-METHORPHAN HB/P-EPD HCL/BPM
D-METHORPHAN HB/PE/CHLORPHENIR
D-METHORPHAN HB/PROMETH HCL
GUAIFENESIN
GUAIFENESIN
GUAIFENESIN/CODEINE PHOS
GUAIFENESIN/D-METHORPHAN HB
GUAIFENESIN/D-METHORPHAN HB
GUAIFENESIN/DEXTROMETHORPHAN
GUAIFENESIN/D-METHORPHAN HB/PE
GUAIFENESIN/P-EPHED HCL/COD
HYDROCODONE BIT/HOMATROPINE
PHENYLEPHRINE HCL
PHENYLEPHRINE HCL/COD/PROMETH
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/CHLOR-MAL
PSEUDOEPHEDRINE HCL/LORATADINE
* Denotes EAC MARKUP Price instead of MAC Price
Coverage is limited to generic products only
MC6 forms for brand medications will be denied
Proprietary Confidential
© 2013, Magellan Health Services, Inc.
All Rights Reserved.
Strength
100MG
10-6.25/5ML
5-2.5-1/5ML
5-15-1MG/5ML
3-3.5-1/ML
15-6.25/5ML
100MG/5ML
200MG
100-10MG/5ML
100-10MG/5ML
100-10MG/5ML
100-5MG/5ML
100-10-5MG
100-30-10/5ML
5-1.5MG/5ML
10MG
5-10-6.25/5ML
15MG/5ML
30MG/5ML
120MG
30MG
60MG
60MG-4MG
15-1MG/5ML
5-6.26MG/5ML
10MG-4MG
2.5-1MG/5ML
2MG-1MG/ML
240MG-10MG
DESC
Sample Brand Name
CAPSULE
SYRUP
SOLN
ELIXIR
DROPS
SYRUP
LIQUID
TABLET
LIQUID
LIQUID
SYRUP
LIQUID
SYRUP
SYRUP
SYRUP
TABLET
SYRUP
LIQUID
SYRUP
TAB.SR 12H
TABLET
TABLET
TABLET
ELIXIR
SYRUP
TABLET
SOLUTION
DROPS
TABLET
TESSALON PERLE 100 MG CAP
PHENERGAN W/CODEINE SYRUP
DIMETAPP DM COLD & COUGH EL
DIMETAPP DM
CARDEC DM DROPS
PHENERGAN DM SYRUP
ORGANIDIN NR 100 MG/5 ML LIQUID
ORGANIDIN NR 200 MG TABLET
CHERATUSSIN AC LIQUID
CHERACOL D COUGH FORMULA
ROBITUSSIN DM COUGH SYRUP
CHILDREN'S MUCINEX
ROBITUSSIN CF
RYNA-CX 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
SINUS & ALLERGY PE
DIMETAPP
DALLERGY
CLARITIN D 24 HOUR
SMAC
0.09072
0.01533
0.04322
0.02182
2.12435
0.01407
0.00516
0.05816
0.01139
0.01736
0.00648
0.03288
0.01448
0.04765
0.12015
0.03685
0.10578
0.01306
*0.01591
0.44555
0.01413
0.06209
0.13176
0.0105
0.06613
0.2233
0.01608
0.82812
0.58558
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