Transcription of Over-the-Counter Drug List
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Over-the-Counter Drug List
Kentucky Medicaid Single MCO PBM OTC List Effective July 1, 2021 1 Copyright 2021 MedImpact Healthcare Systems, Inc. All rights reserved. Allergy, Cough, and Cold Drugs Tablets and Capsules Drug Name Strength Dosage Form All Day Allergy (cetirizine) tablet Cetirizine HCl 5 mg tablet Cetirizine HCl 10 mg tablet Chlorpheniramine maleate 4 mg tablet Chlorpheniramine maleate ER 12 mg tablet Clemastine fumarate mg (1 mg base equiv) tablet Dextromethorphan-guaifenesin 20-400 mg tablet Dextromethorphan-guaifenesin ER 12 hr 30-600 mg tablet Dextromethorphan-guaifenesin ER 12 hr 60-1200 mg tablet Diphenhydramine HCl 25 mg capsule Diphenhydramine HCl 50 mg capsule Diphenhydramine HCl 50 mg tablet Fexofenadine HCl 60 mg tablet Fexofenadine HCl 180 mg tablet Fexofenadine-pseudoephedrine ER 12 hr 60-120 mg tablet Guaifenesin 200 mg tablet Guaifenesin 400 mg tablet Guaifenesin ER 12 hr 600 mg tablet Guaifenesin ER 12 hr 1200 mg tablet Levocetirizine dihydrochloride 5 mg tablet Loratadine 10 mg tablet Loratadine & pseudoephedrine ER 12 hr 5-120 mg tablet Loratadine & pseudoephedrine ER 24 hr 10-240 mg tablet Phenylephrine HCl 10 mg tablet Pseudoephedrine HCl 30 mg tablet Pseudoephedrine HCl ER 12 hr 120 mg tablet Pseudoephedrine-guaifenesin ER 12 hr 60-600 mg tablet Over-the-Counter Drug List Kentucky Single Medicaid MCO PBM Program Effective July 1.
Omeprazole delayed release 20 mg tablet Omeprazole magnesium delayed release 20 mg tablet Psyllium 0.52 gm capsule Sennosides 8.6 mg tablet ... Alum-mag hydroxide-simethicone 400-400-40 mg/5ml suspension ... Tablets and Capsules Drug Name Strength Dosage Form Ascorbic acid 250 mg tablet
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