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Home | Provider | Health Care/Medical Assistance | Medicare Part D - Prescription Drug Coverage | Helpful Guidelines for MA Coverage of Over-the-Counter Drugs

Helpful Guidelines for MA Coverage of Over-the-Counter Drugs

1. Recipient must obtain a prescription from his physician.
2. Manufacturer of the product must be a rebate labeler.
3. Product must be included in the list of covered products per 1121.53(d). Payment for prescribed non-legend drugs shall be limited to drugs and dosage forms listed in the following categories:
   1. Analgesics except long acting products.
      • Acetaminophen and acetaminophen combinations in the form of tablets, capsules, suppositories, liquids and drops.
      • Aspirin and aspirin combinations in the form of tablets, capsules and suppositories.
      • Salicylates in the form of tablets, capsules and liquids.
      • Ibuprofen in its available dosage forms.
   2. Antacids.
   3. Antidiarrheals.
      • Kaolin-pectin combinations.
      • Loperamide in its available dosage forms.
   4. Antiflatulents.
      • Simethicone.
      • Simethicone combined with antacid.
   5. Antinauseants.
      • Concentrated balanced solutions of sugar and orthophosphoric acid.
      • Cyclizine lactate.
      • Dimenhydrinate.
      • Meclizine hydrochloride.
   6. Bronchodilators.
   7. Cough—cold preparations, not including mouthwashes, lozenges, troches, throat sprays or rubs, only when prescribed for MA recipients under 21 years of age.
   8. Contraceptives.
   9. Hematinics, not including long acting products.
      • Ferrous fumarate.
      • Ferrous gluconate.
      • Ferrous sulfate.
   10. Insulin and disposable insulin syringes.
   11. Laxatives and stool softeners.
   12. Nasal preparations.
       • Oxymetazoline.
       • Phenylephrine.
       • Xylometazoline.
       • Naphazoline.
   13. Ophthalmic preparations.
       • Ocular lubricants containing polyvinyl alcohol or cellulose derivatives.
       • Phenylephrine in all ophthalmic forms.
       • Sodium chloride in strengths of 2% or greater in ophthalmic forms.
   14. Topical products containing one or more of the following active ingredients:
       • Anesthetics.
         1. Benzocaine.
         2. Cyclomethycaine.
         3. Dibucaine.
         4. Lidocaine.
         5. Pramoxine.
         6. Tetracaine.
       • Antibacterials.
         1. Bacitracin.
         2. Neomycin.
         3. Polymyxin.
         4. Povidone-iodine.
         5. Tetracycline.
       • Dermatological baths.
         1. Colloidal oatmeal and combinations.
         2. Soya protein complex and combinations.
       • Fungicidals.
         1. Iodochlorhydroxyquin (clioquinol).
         2. Miconazole nitrate.
         3. Salicylanilide.
         4. Salicylic acid.
         5. Sodium caprylate.
         6. Sodium proprionate.
         7. Triacetin (glyceryl triacetate).
         8. Tolnaftate.
         9. Undecylenic acid, esters and salts.
       • Rectal preparations.
         1. Bismuth subgallate.
         2. Yeast.
         3. Zinc oxide.
       • Tar preparations, not including soaps and cleansing agents.
       • Wet dressings.
         1. Aluminum acetate.
         2. Aluminum sulfate.
         3. Calcium sulfate.
         4. Zinc sulfate.
   15. Vitamins and minerals.
       • Single entity and multiple vitamins with or without fluoride for children under 3 years of age.
       • Single entity and multiple vitamins when prescribed for prenatal use.
       • Nicotinic acid and its amides.
       • Calcium salts.
   16. Diagnostic agents.
   17. Quinine.
4. When a recipient’s location is long term care, reimbursement is not made for the following over-the counter products (1121.54) (17)(111):
   1. Analgesics.
   2. Antacids.
   3. Antacids with simethicone.
   4. Cough—cold preparations.
   5. Contraceptives.
   6. Laxative and stool softeners.
   7. Ophthalmic preparations.
   8. Diagnostic agents
5. For GA recipients, coverage of OTC drugs is limited to insulin and drugs that the Department has identified as the preferred drug in a therapeutic class. (1121.11)