Acetaminophen 80mg/0.8mL Suspension Drops Acetaminophen 120mg Suppository Acetaminophen 160mg/5mL Suspension Acetaminophen 325mg Suppository Acetaminophen 325mg Tablet, Caplet, or Capsule Acetaminophen 500mg Tablet, Caplet, or Capsule Acetaminophen 650mg Suppository Acetaminophen 80mg Suppository Acetaminophen 80mg Chewable Tablet Aspirin 325mg Tablet Aspirin 325mg Tablet EC Aspirin 81mg Tablet Chew Aspirin 81mg Tablet EC Aspirin Buffered 5 grains Ibuprofen 200mg Tablet Ibuprofen Children s Susp. Naproxen 220mg Tablet Office of Medicaid Policy and Planning ANALGESICS Aluminum Hydroxide Gel Magnesium Carbonate/Aluminum Hydroxide/AA Magnesium Hydroxide/Aluminum Hydroxide/Simethicone Magnesium Hydroxide/Aluminum Hydroxide/Simethicone EX Sodium Bicarbonate 325mg Tablet Sodium Bicarbonate 650mg Tablet ANTACIDS Simethicone 40mg/0.6mL Drops ANTI-FLATULENTS 1
Hemorrhoidal Preparation Ointment Hemorrhoidal Preparation Suppository Nupercainal 1% Ointment ANTI-HEMORRHOIDALS CALCIUM SUPPLEMENTS Calcium Carbonate 1.25gm Tablet Calcium Carbonate 1000mg Tablet Chewable/Non-chewable Calcium Carbonate 500mg Tablet Chewable/Non-chewable Calcium Carbonate 750mg Tablet Chewable/Non-chewable Calcium Carbonate Liquid 1.25gm/5mL A & D Preventative Ointment Corn starch powder Dimethicone cream/lotion Povidone-iodine 10% solution Vitamin A & D cream/ointment COMPOUNDING AGENTS 2
Chlorpheniramine Maleate 2mg/5mL Syrup Chlorpheniramine Maleate 4mg Tablet Delsym 30mg/5mL liquid Diphenhydramine 12.5mg/mL Syrup Diphenhydramine 25mg Capsule/Caplet/Tablet Diphenhydramine 50mg Capsule Guaifenesin 100mg/5mL Liquid Guaifenesin 100mg/5mL Syrup Guaifenesin/D-Methorphan Syrup Guaifenesin/D-Methorphan Tablet Pseudoephedrine HCL 120mg Tablet Pseudoephedrine HCL 15mg/5mL Liquid Pseudoephedrine HCL 30mg Tablet Pseudoephedrine HCL 30mg/5mL Liquid Pseudoephedrine HCL 60mg Tablet Pseudoephedrine HCL 15mg/5mL Elixir Artificial Tears Ophthalmic Ointment Artificial Tears Ophthalmic Ointment, PF Artificial Tears Ophthalmic Solution Artificial Tears Ophthalmic Solution, PF Ketotifen Fumerate 0.025% Eye Drops Naphazoline 0.012% Eye Drops Naphazoline/Pheniramine 0.025%/0.3% Eye Drops COUGH AND COLD PRODUCTS Age 4 years and older Age 4 years and older Age 4 years and older EYE PRODUCTS 3
Bisacodyl 5mg Tablet EC Bisacodyl Suppository Bismuth Subsalicylate 262mg Tab Chew Bismuth Subsalicylate 262mg Tablet Bismuth Subsalicylate Suspension Docusate Calcium 240mg Capsule Docusate Sodium 100mg Capsule/Caplet Docusate Sodium 100mg Tablet Docusate Sodium 150mg/15mL Liquid Docusate Sodium 50mg Capsule/Caplet/Tablet Docusate Sodium 60mg/15mL Syrup Glycerin Adult Suppository Glycerin Pediatric Suppository Loperamide HCl 1mg/5mL Liquid Loperamide HCL 2mg Capsule/Tablet Magnesium Citrate Solution Milk of Magnesia Suspension Polyethylene Glycol 3350 Powder Psyllium Mucilloid Powder Psyllium Mucilloid Powder Packet Senna Syrup Senna Tablet Sodium Phosphate/NA Biphos Adult/Pediatric Enema Sodium Phosphate/NA Biphos Pediatric Enema Office of Medicaid Policy and Planning GASTRO-INTESTINAL PRODUCTS Quantity limit of 120 ml/14 days Quantity limit of 12 caps or tabs/14 days 4
Cimetidine 200mg Tablet Famotidine 10mg Tablet Ranitidine 75mg Tablet H2 ANTAGONISTS 60 tabs per 30 days 60 tabs per 30 days 60 tabs per 30 days Meclizine HCL 25mg Tablet Meclizine HCL 25mg Chew Tab Cromolyn Sodium 4% Spray Allegra 30mg/5mL Suspension Cetirizine 10mg Tablet Cetirizine 1mg/mL Syrup Cetirizine 5mg Tablet Fexofenadine 180mg Tablet Fexofenadine 60mg Tablet Loratadine 10mg Tablet Loratadine 10mg Tablet ODT Loratadine Syrup Loratadine/Pseudoephedrine 10/240mg Tablet Loratadine/Pseudoephedrine 5/120mg Tablet Carbamide Peroxide 6.5% Drops MOTION SICKNESS PRODUCTS NASAL PRODUCTS NON-SEDATING ANTIHISTAMINES ; QL 10mls/day; trial and failure of both cetirizine & loratadine syrup within past 90 days ; QL 10mls/day Trial & failure of both cetirizine & loratadine within past 90 days Trial & failure of both cetirizine & loratadine within past 90 days ; QL 10mls/day OTIC PRODUCTS 5
Nicoderm Topical Patch 7mg/24hr Nicoderm Topical Patch 14mg/24hr Nicoderm Topical Patch 21mg/24hr Nicorette Chewing Gum 2mg Nicorette Chewing Gum 4mg Nicorette Lozenge 2mg Nicorette Lozenge 4mg Nicotine Chewing Gum 2mg Nicotine Chewing Gum 4mg Nicotine Lozenge 2mg Nicotine Lozenge 4mg Nicotine Topical Patch 7mg/24hr Nicotine Topical Patch 14mg/24hr Nicotine Topical Patch 21mg/24hr Capsaicin 0.025% Cream Capsaicin 0.075% Cream SMOKING CESSATION PRODUCTS TOPICAL ANALGESICS 6
Abreva 10% Cream Ammonium Lactate 12% Lotion Bacitracin 500 units/gm Ointment Bacitracin/Polymixin B Sulfate Ointment Benzoyl Peroxide 10% Cream/Oint. Benzoyl Peroxide 10% Gel Benzoyl Peroxide 5% Gel/Oint./Cream Benzoyl Peroxide Cleanser Benzoyl Peroxide Creamy Wash Benzoyl Peroxide Wash Benzoyl Peroxide Wash Kit BPO 10 Wash Clotrimazole 1% Cream Dibucaine 1% Ointment Hydrocortisone Acetate 0.5% Ointment/Cream Hydrocortisone Acetate 1% Ointment/Cream Miconazole Nitrate 2% Cream Permethrin 1% Liquid Pyrethrin Liquid Pyrethrin Shampoo Selenium Sulfide Shampoo Triple Antibiotic Neo/Poly/Bac TOPICAL PRODUCTS Requires 14-day trial of 2 preferred agents listed on the Preferred Drug List Age under 26 years Age under 26 years Age under 26 years Requires 14-day trial of 2 preferred agents listed on the Preferred Drug List Quantity limit of one bottle or one tube per claim Quantity limit of one bottle or one tube per claim Quantity limit of one bottle or one tube per claim 7
Clotrimazole 1% Cream Clotrimazole 2% Cream Miconazole Nitrate Dual Pak Miconazole Suppository Miconazole Nitrate 2% Cream Tioconazole 6.5% Ointment VAGINAL AGENTS Magnebind 300mg Tablet VITAMINS 8