Over-the-Counter Drug List

1 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.

2 2021 This list applies only to Kentucky Medicaid Managed Care Organizations (MCO). For Fee-for-Service refer to the OTC list on the Magellan Medicaid Administration website: Inclusion in this list does not guarantee coverage. Quantity, cost, and other limits may apply. Kentucky Medicaid Single MCO PBM OTC List Effective July 1, 2021 2 Copyright 2021 MedImpact Healthcare Systems, Inc. All rights reserved. Liquids Drug Name Strength Dosage Form Cetirizine HCl 1 mg/ml (5 mg/5ml) syrup Chlorpheniramine maleate 2 mg/5ml syrup Dextromethorphan polistirex ER 30 mg/5ml suspension Dextromethorphan-guaifenesin 5-100 mg/5ml liquid Dextromethorphan-guaifenesin 10-100 mg/5ml liquid Dextromethorphan-guaifenesin 10-100 mg/5ml syrup Dextromethorphan-guaifenesin 10-200 mg/5ml liquid Diphenhydramine HCl mg/5ml elixir Diphenhydramine HCl mg/5ml liquid Guaifenesin 100 mg/5ml liquid Guaifenesin 100 mg/5ml syrup Guaifenesin-codeine 100-10 mg/5ml solution Loratadine 5 mg/5ml syrup Phenylephrine-brompheniramine-DM mg/5ml elixir Phenylephrine-brompheniramine-DM mg/5ml liquid Pseudoephed-bromphen-DM 15-1-5 mg/5ml elixir Pseudoephed-bromphen-DM 30-2-10 mg/5ml syrup Pseudoephedrine HCl 15 mg/5ml liquid Chewable Tablets Drug Name Strength Dosage Form Diphenhydramine HCl mg chewable tablet Loratadine 5 mg chewable tablet Drugs for Acne, Skin.

3 And Warts Creams and Lotions for the Skin Drug Name Strength Dosage Form Benzoyl peroxide 5% lotion Benzoyl peroxide 10% cream Benzoyl peroxide 10% lotion Hydrocortisone cream Hydrocortisone 1% lotion Lactic acid (ammonium lactate) 12% cream Lactic acid (ammonium lactate) 12% lotion Selenium sulfide 1% lotion Urea 10% cream Urea 20% cream Urea 30% cream Urea 40% cream Kentucky Medicaid Single MCO PBM OTC List Effective July 1, 2021 3 Copyright 2021 MedImpact Healthcare Systems, Inc. All rights reserved. Ointments for the Skin Drug Name Strength Dosage Form Hydrocortisone ointment Zinc oxide 20% ointment Liquids for the Skin Drug Name Strength Dosage Form Benzoyl peroxide liquid Benzoyl peroxide 4% liquid Benzoyl peroxide 5% liquid Benzoyl peroxide 6% liquid Benzoyl peroxide 10% liquid Salicylic acid 17% liquid Gels for the Skin Drug Name Strength Dosage Form Benzoyl peroxide gel Benzoyl peroxide 5% gel Benzoyl peroxide 10% gel Birth Control Condoms Drug Name Strength Dosage Form Condoms latex lubricated Condoms latex non-lubricated Emergency Contraceptives Drug Name Strength Dosage Form Levonorgestrel mg tablet Women s Health Vaginal Creams Drug Name Strength Dosage Form Clotrimazole vaginal 1% cream Clotrimazole vaginal 2% cream Miconazole vaginal 2% cream Miconazole vaginal 4% cream Kentucky Medicaid Single MCO PBM OTC List Effective July 1.

4 2021 4 Copyright 2021 MedImpact Healthcare Systems, Inc. All rights reserved. Kits Drug Name Strength Dosage Form Miconazole vaginal 2% applicator and cream kit Miconazole vaginal 2% suppository and cream kit Vaginal Suppositories Drug Name Strength Dosage Form Miconazole vaginal 100 mg suppository Tablets Drug Name Strength Dosage Form Phenazopyridine HCl 95 mg tablet Diabetes Drugs Insulins Drug Name Strength Dosage Form Humulin N NPH U-100 vial Humulin N NPH U-100 KwikPen Glucose Drug Name Strength Dosage Form Glucose 4 gm chewable tablet Metabolic Aids Drug Name Strength Dosage Form Levocarnitine 1 gm/10ml (10%) solution Levocarnitine 330 mg tablet Ear, Eye, Mouth, and Nose Drugs Ear Drops Drug Name Strength Dosage Form Carbamide peroxide otic solution Kentucky Medicaid Single MCO PBM OTC List Effective July 1, 2021 5 Copyright 2021 MedImpact Healthcare Systems, Inc.

5 All rights reserved. Eye Drops Drug Name Strength Dosage Form Artificial tears ophthalmic solution Carboxymethylcellulose sodium ophthalmic solution Dextran 70-hypromellose ophthalmic solution Ketotifen fumarate (base equiv) ophthalmic solution Polyethylene gly-propylene gly ophthalmic solution Polyvinyl alcohol ophthalmic solution Mouth Drug Name Strength Dosage Form Benzocaine-menthol mg lozenge Chlorhexidine gluconate 4% liquid Sodium fluoride cream Sodium fluoride ( f) gel Nose Sprays Drug Name Strength Dosage Form Budesonide 32 mcg/act nasal spray Cromolyn sodium mg/act (4%) nasal spray Oxymetazoline nasal spray Saline nasal spray Triamcinolone acetonide 55 mcg/act nasal spray Digestive and Laxative Drugs Tablets and Capsules Drug Name Strength Dosage Form Bisacodyl delayed release 5 mg tablet Bismuth subsalicylate 262 mg tablet Calcium polycarbophil 625 mg tablet Docusate calcium 240 mg capsule Docusate sodium 100 mg capsule Docusate sodium 100 mg tablet Docusate sodium 250 mg capsule Lactobacillus-inulin capsule Loperamide HCl 2 mg tablet Magnesium oxide 400 mg tablet Magnesium oxide 420 mg tablet omeprazole delayed release 20 mg tablet omeprazole magnesium delayed release 20 mg tablet Psyllium gm capsule Sennosides mg tablet Continued on next page Kentucky Medicaid Single MCO PBM OTC List Effective July 1, 2021 6 Copyright 2021 MedImpact Healthcare Systems, Inc.

6 All rights reserved. Digestive and Laxative Drugs, Continued Sennosides 25 mg tablet Sennosides-docusate sodium mg tablet Simethicone 125 mg capsule Simethicone 180 mg capsule Sodium bicarbonate 325 mg tablet Sodium bicarbonate 650 mg tablet Chewable Tablets Drug Name Strength Dosage Form Alum hydroxide-magnesium carb 160-105 mg chewable tablet Alum hydroxide-magnesium trisilicate 80- 20 mg chewable tablet Alum-mag hydroxide-simethicone 200-200-25 mg chewable tablet Bismuth subsalicylate 262 mg chewable tablet Calcium carbonate (antacid) 648 mg chewable tablet Calcium carbonate (antacid) 500 mg chewable tablet Calcium carbonate (antacid) 750 mg chewable tablet Calcium carbonate (antacid) 1000 mg chewable tablet Meclizine HCl 25 mg chewable tablet Simethicone 80 mg chewable tablet Simethicone 125 mg chewable tablet Liquids Drug Name Strength Dosage Form Alum hydroxide-magnesium carb 95-358 mg/15ml suspension Alum-mag hydroxide-simethicone 200-200- 20 mg /5ml suspension Alum-mag hydroxide-simethicone 400-400- 40 mg /5ml suspension Bismuth subsalicylate 262 mg/15ml suspension Bismuth subsalicylate 525 mg/15ml suspension Calcium carbonate (antacid)

7 1250 mg/5ml suspension 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 mg/5ml syrup Simethicone 40 suspension Powders Drug Name Strength Dosage Form Polyethylene glycol 3350 oral 17 gm packet Polyethylene glycol 3350 oral 17 gm/scoop powder Psyllium powder Psyllium powder Psyllium 33% powder Psyllium powder Psyllium powder Psyllium 95% powder Kentucky Medicaid Single MCO PBM OTC List Effective July 1, 2021 7 Copyright 2021 MedImpact Healthcare Systems, Inc. All rights reserved. Enemas and Suppositories Drug Name Strength Dosage Form Bisacodyl 10 mg suppository Glycerin gm suppository Glycerin 2 gm suppository Sodium phosphates enema Vitamins Tablets and Capsules Drug Name Strength Dosage Form Ascorbic acid 250 mg tablet Ascorbic acid 500 mg tablet B-complex w/ C & folic acid mg tablet Calcium carbonate 600 mg tablet Calcium carbonate 1250 mg (500 mg elemtl Ca) tablet Calcium carbonate 1500 mg (600 mg elemtl Ca)

8 Tablet Calcium carbonate-cholecalciferol 250 mg-125 unit tablet Calcium carbonate-cholecalciferol 500 mg-200 unit tablet Calcium carbonate-cholecalciferol 500 mg-400 unit tablet Calcium carbonate-cholecalciferol 600 mg-200 unit tablet Calcium carbonate-cholecalciferol 600 mg-400 unit tablet Calcium carbonate-cholecalciferol 600 mg-800 unit tablet Calcium carbonate-ergocalciferol 500mg-200 unit tablet Calcium carbonate-vitamin D 250 mg-125 unit tablet Calcium carbonate-vitamin D 500 mg-125 unit tablet Calcium carbonate-vitamin D 500 mg-200 unit tablet Calcium carbonate-vitamin D 500 mg-400 unit tablet Calcium carbonate-vitamin D 600 mg-200 unit tablet Calcium carbonate-vitamin D 600 mg-400 unit tablet Calcium citrate 950 mg (200 mg elemtl Ca) tablet Calcium citrate-vitamin d 315 mg-200 unit (elemtl Ca) tablet Calcium cit-vitamin d 315 mg-250 unit (elemtl Ca) tablet Cholecalciferol mg (50000 unit) capsule Cholecalciferol 10 mcg (400 unit) tablet Cholecalciferol 25 mcg (1000 unit) capsule Cholecalciferol 25 mcg (1000 unit) tablet Cholecalciferol 50 mcg (2000 unit) capsule Cholecalciferol 50 mcg (2000 unit) tablet Cholecalciferol 125 mcg (5000 unit) capsule Cholecalciferol 125 mcg (5000 unit) tablet Cyanocobalamin 250 mcg tablet Cyanocobalamin 500 mcg tablet Cyanocobalamin ER 1000 mcg tablet Ferrous fum 324 mg (106 mg elem fe) tablet Ferrous fum 325 mg (106 mg elem fe) tablet Continued on next page Kentucky Medicaid Single MCO PBM OTC List Effective July 1, 2021 8 Copyright 2021 MedImpact Healthcare Systems, Inc.

9 All rights reserved. Vitamins, Continued Ferrous gluc 240 mg (27 mg elem fe) tablet Ferrous gluc 324 mg (38 mg elemtl Fe) tablet Ferrous gluc 324 mg ( mg elemtl Fe) tablet Ferrous sulf 325 mg (65 mg elemtl Fe) tablet Ferrous sulf EC 324 mg (65 mg Fe eq) tablet Ferrous sulf EC 325 mg (65 mg Fe eq) tablet Ferrous sulf dried ER 160 mg (50 mg Fe eq) tablet Ferrous sulf dried 200 mg (65 mg elemtl Fe) tablet Folic acid 1 mg tablet Folic acid 400 mcg tablet Folic acid 800 mcg tablet Magnesium oxide 250 mg (Mg supplement) tablet Magnesium oxide 400 mg (240 mg elemtl Mg) tablet Magnesium oxide 400 mg ( mg elemtl Mg) tablet Magnesium oxide 500 mg (Mg supplement) tablet Multiple vitamin tablet Multiple vitamins w/ iron tablet Multiple vitamins w/ minerals tablet Multiple vitamins w/ minerals tablet Multiple vitamins w/ minerals & fa 1 mg tablet Niacin 50 mg tablet Niacin 100 mg tablet Niacin ER 250 mg capsule Niacin ER 250 mg tablet Niacin ER 500 mg capsule Niacin ER 500 mg tablet Niacin ER 750 mg tablet Omega-3 fatty acids 500 mg capsule Omega-3 fatty acids 1000 mg capsule Oyster shell calcium 500 mg tablet Polysaccharide iron complex 150 mg (Fe eq) capsule Sodium chloride 1 gm tablet Thiamine HCl 50 mg tablet Thiamine HCl 100 mg tablet Vinate one tablet Vitamin A 3 mg (10000 unit) capsule Chewable Tablets Drug Name Strength Dosage Form Calcium carb 1250 mg (500 mg elemtl Ca) chewable tablet Calcium carb-vit D-minerals 600 mg-400 unit chewable tablet Cholecalciferol 10 mcg (400 unit)

10 Chewable tablet Multiple vitamins w/ minerals chewable tablet Pediatric multi vit w/ C & FA chewable tablet Pediatric multi vitamin w/ extra C & FA chewable tablet Pediatric multi vitamin w/ minerals & C chewable tablet Pediatric multi vitamins w/ iron 15 mg chewable tablet Pediatric multi vitamins w/ iron 18 mg chewable tablet Kentucky Medicaid Single MCO PBM OTC List Effective July 1, 2021 9 Copyright 2021 MedImpact Healthcare Systems, Inc. All rights reserved. Liquids Drug Name Strength Dosage Form Cholecalciferol oral 10 mcg/ml (400 unit/ml) liquid Ergocalciferol 200 mcg/ml (8000 unit/ml) solution Ferrous sulf 75 mg/ml (15 mg elemtl Fe) solution Ferrous sulf 220 mg/5ml (44 mg elemtl Fe) elixir Ferrous sulf 220 mg/5ml (44 mg elemtl Fe) liquid Multiple vitamins w/ minerals liquid Prenatal Vitamins Drug Name Strength Dosage Form Prenatal vit w/ Fe fumarate-FA mg capsule Prenatal vit w/ Fe fumarate- FA 15-1 mg tablet Prenatal vit w/ Fe fumarate- FA mg tablet Prenatal vit w/ Fe fumarate- FA 27-1 mg tablet Prenatal vit w/ Fe fumarate- FA 75-1 mg tablet Prenat-Fe-FA-Omega 3 mg tablet Prenatal multivit-minerals-Fe-FA mg tablet Prenatal vit w/ Fe fum-FA mg tablet Prenatal vit w/ Fe fumarate- FA mg tablet Prenatal vit w/ Fe fumarate- FA 28-1 mg tablet Prenatal vit w/ Fe fum-FA 35-5 mg tablet Pain Medications Tablets and Capsules Drug Name Strength Dosage Form Acetaminophen 325 mg tablet Acetaminophen 500 mg capsule Acetaminophen 500 mg tablet Acetaminophen ER 650 mg tablet Aspirin delayed release 81 mg tablet Aspirin delayed release 325 mg tablet Ibuprofen 200 mg tablet Chewable and Disintegrating Tablets Drug Name