Over-the-Counter Drug List - Kentucky

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 Kent

Docusate sodium 50 mg/15ml liquid Docusate sodium 60 mg/15ml syrup Docusate sodium 150 mg/15ml liquid Magnesium citrate solution Magnesium hydroxide 400 mg/5ml suspension Sennosides 8.8 mg/5ml syrup Simethicone 40 mg/0.6ml suspension Powders Drug Name Strength Dosage Form Polyethylene glycol 3350 oral 17 gm packet

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  Liquid, Kentucky, Sodium, Hydroxide

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