Over-the-Counter Drug List

Kentucky Single Medicaid MCO PBM Program

Effective July 1, 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: https://kentucky.magellanmedicaid.com/kentucky/source/index.asp.
Inclusion in this list does not guarantee coverage. Quantity, cost, and other limits may apply.

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 1.34 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

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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 12.5 mg/5ml elixir
Diphenhydramine HCl 12.5 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 2.5-1-5 mg/5ml elixir
Phenylephrine-brompheniramine-DM 2.5-1-5 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 12.5 mg chewable tablet
Loratadine 5 mg chewable tablet

Drugs for Acne, Skin, 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 0.5% 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

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Ointments for the Skin
Drug Name Strength Dosage Form
Hydrocortisone 0.5% ointment
Zinc oxide 20% ointment

Liquids for the Skin

Drug Name Strength Dosage Form
Benzoyl peroxide 2.5% 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 2.5% 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 1.5 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

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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 6.5% otic solution

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Eye Drops
Drug Name Strength Dosage Form
Artificial tears ophthalmic solution
Carboxymethylcellulose sodium 0.5% ophthalmic solution
Dextran 70-hypromellose 0.1-0.3% ophthalmic solution
Ketotifen fumarate 0.025% (base equiv) ophthalmic solution
Polyethylene gly-propylene gly 0.4-0.3% ophthalmic solution
Polyvinyl alcohol 1.4% ophthalmic solution

Mouth
Drug Name Strength Dosage Form
Benzocaine-menthol 15-3.6 mg lozenge
Chlorhexidine gluconate 4% liquid
Sodium fluoride 1.1% cream
Sodium fluoride 1.1% (0.5% f) gel

Nose Sprays
Drug Name Strength Dosage Form
Budesonide 32 mcg/act nasal spray
Cromolyn sodium 5.2 mg/act (4%) nasal spray
Oxymetazoline 0.05% nasal spray
Saline 0.65% 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 0.52 gm capsule
Sennosides 8.6 mg tablet

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Digestive and Laxative Drugs, Continued
Sennosides 25 mg tablet
Sennosides-docusate sodium 8.6-50 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) 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 8.8 mg/5ml syrup
Simethicone 40 mg/0.6ml suspension

Powders
Drug Name Strength Dosage Form
Polyethylene glycol 3350 oral 17 gm packet
Polyethylene glycol 3350 oral 17 gm/scoop powder
Psyllium 28.3% powder
Psyllium 30.9% powder
Psyllium 33% powder
Psyllium 48.57% powder
Psyllium 58.6% powder
Psyllium 95% powder

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Enemas and Suppositories
Drug Name Strength Dosage Form
Bisacodyl 10 mg suppository
Glycerin 1.2 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 0.8 mg tablet
Calcium carbonate 600 mg tablet
Calcium carbonate 1250 mg (500 mg elemtl Ca) tablet
Calcium carbonate 1500 mg (600 mg elemtl Ca) 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 1.25 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

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Vitamins, Continued

Ferrous gluc 240 mg (27 mg elem fe) tablet

Ferrous gluc 324 mg (38 mg elemtl Fe) tablet
Ferrous gluc 324 mg (37.5 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 (241.3 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) 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

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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 13.5-0.4 mg capsule
Prenatal vit w/ Fe fumarate- FA 15-1 mg tablet
Prenatal vit w/ Fe fumarate- FA 27-0.8 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 28-0.8-440 mg tablet
Prenatal multivit-minerals-Fe-FA 0.8 mg tablet
Prenatal vit w/ Fe fum-FA 35-1.1 mg tablet
Prenatal vit w/ Fe fumarate- FA 28-0.8 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 Strength Dosage Form
Acetaminophen 80 mg chewable tablet
Acetaminophen 160 mg chewable tablet
Acetaminophen 160 mg disintegrating tablet
Aspirin 81 mg chewable tablet

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Liquids
Drug Name Strength Dosage Form
Acetaminophen 160 mg/5ml liquid
Acetaminophen 160 mg/5ml solution
Acetaminophen 160 mg/5ml suspension
Acetaminophen 167 mg/5ml liquid
Ibuprofen 40 mg/ml suspension
Ibuprofen 100 mg/5ml suspension

Suppositories
Drug Name Strength Dosage Form
Acetaminophen 80 mg suppository
Acetaminophen 120 mg suppository
Acetaminophen 325 mg suppository
Acetaminophen 650 mg suppository
Aspirin 600 mg suppository

Medications to put on the Skin

Drug Name Strength Dosage Form
Capsaicin 0.025% cream
Capsaicin 0.035% cream
Capsaicin 0.035% lotion
Lidocaine 3% cream
Lidocaine 4% cream
Lidocaine 4% patch
Lidocaine HCl 2% gel
Lidocaine HCl 3% cream
Lidocaine HCl 4% cream

Sleep Aids

Drug Name Strength Dosage Form

Doxylamine succinate (sleep) 25 mg tablet
Melatonin 3 mg tablet
Melatonin 5 mg tablet

Drugs for Parasite and Fungal Infections of Skin and Hair

Creams and Lotions for the Skin

Drug Name Strength Dosage Form
Permethrin 1% lotion
Terbinafine HCl 1% cream

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Ointments for the Skin
Drug Name Strength Dosage Form
Bacitracin-polymyxin B ointment
Antifungal (clotrimazole) ointment
Bacitracin 500 unit/gm ointment
Bacitracin zinc 500 unit/gm ointment
Neomycin-bacitracin-polymyxin ointment
Neomycin-bacitracin-polymyxin-pramoxine 1% ointment

Liquids for the Skin and Hair

Drug Name Strength Dosage Form
Pyrantel pamoate 144 mg/ml (50 mg/ml base eq) suspension
Pyrethrins-piperonyl butoxide 0.33-4% liquid

Liquids for the Hair

Drug Name Strength Dosage Form
Permethrin 1% creme rinse
Neomycin-bacitracin-polymyxin-pramoxine 1% ointment
Pyrethrins-piperonyl butoxide 0.33-4% shampoo
Terbinafine HCl 1% cream

Skin Protectants

Drug Name Strength Dosage Form

Cream base
Emollient - cream
Emollient - gel
Emollient - kit
Emollient - liquid
Emollient - lotion
Emollient - miscellaneous
Emollient - oil
Emollient - ointment
Emollient - pads
Glycerin liquid

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 Medical Supplies

Drug Name Strength Dosage Form

Accu-chek softclix lancets
Acetone (urine) test strip
Alcohol swabs
Blood glucose calibration - liquid
Nebulizers
Peak flow meter
Spacer/aerosol-holding chambers
Urine glucose-ketones test strips

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