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Drug Categories with Limited Coverage

Revised: 09-20-2011

MHCP has limitations on some drug categories. Use this information with NDC Search to determine specific drug coverage. MHCP reserves the right to reimburse only for the least expensive alternative within a therapeutic area.

Category

Coverage Policy

Agents used for cosmetic purpose or hair growth

Not covered

Agents used for plantar warts

Covered:

  • • Salicylic Acid 17%
  • Agents used to promote smoking cessation

    All smoking cessation products are covered.

    Analgesics – OTC

    Covered:

  • • Acetaminophen
  • • Aspirin
  • • Aspirin with buffers
  • • Capsaicin cream: 0.025% and 0.075%
  • • Ibuprofen
  • • Naproxen
  • Antacids and antigas – OTC

    Covered:

  • • Aluminum hydroxide
  • • Aluminum & magnesium hydroxide
  • • Aluminum & magnesium hydroxides plus simethicone
  • • Aluminum carbonate gel, basic
  • • Calcium carbonate
  • • Milk of Magnesia
  • • Simethicone
  • Antidiarrheal – OTC

    Covered:

  • • Activated attapulgite
  • • Bismuth subsalicylate: regular & extra strength tablets & liquid
  • • Loperamide
  • Antihistamine and decongestant combinations

    Covered:

  • • Pseudoephedrine/brompheniramine
  • • Pseudoephedrine/chlorpheniramine
  • • Pseudoephedrine/loratadine
  • • Pseudoephedrine/cetirizine
  • Antihistamines (OTC)

    Covered:

  • • Cetirizine
  • • Chlorpheniramine
  • • Clemastine
  • • Diphenhydramine
  • • Loratadine
  • • Meclizine
  • Antiseptics

    Covered:

  • • Chlorhexidine gluconate 3% or 4%
  • • Povidone-iodine
  • • Triple antibiotic ointment: polymyxin, neomycin and bacitracin
  • Barbiturates

    Covered

    Benzodiazepines

    Covered

    DESI and IRS drugs
    Product case examples:
    Midrin
    Estratest

    DESI and IRS drugs are FDA designations related to “substantial evidence” of effectiveness. MHCP does not cover designation values 4 and 5.

    Drugs used to promote weight loss

    Not covered

    Eye – Ear – Nose – Mouth

    Covered:

  • • 0.65% saline nose spray
  • • Artificial tears: liquid and ointment
  • • Carbamide peroxide otic drops
  • • Chlorhexidine gluconate
  • • Cromolyn sodium
  • • Hypertonic saline (covered by HCPCS code A9999)
  • • Naphazoline/antazoline
  • • Naphazoline/pheniramine maleate
  • • Oxymetazoline HCL nasal spray
  • • Refresh Plus & Celluvisc
  • • Ocular ketotifen
  • Laxatives

    Covered:

  • • Bisacodyl
  • • Casanthranol and docusate sodium
  • • Docusate sodium
  • • Evac-Q-Kwik
  • • Glycerin suppository and enemas
  • • Lactulose
  • • Magnesium citrate
  • • Milk of Magnesia
  • • Mineral oil
  • • Natural vegetable laxative (psyllium)
  • • Phosphate enemas
  • • Senna
  • • Senokot-S
  • • Sorbitol 70% (may be repackaged from gallons to pints)
  • • Theravac
  • • Unifiber
  • Miscellaneous – OTC

    Covered:

  • • Activated charcoal
  • • Activated charcoal/sorbitol solution
  • • Ipecac syrup
  • • Insulin: all types
  • • Lactase, for lactose intolerance
  • Pediculocides

    Covered:

  • • Lindane
  • • Malathion
  • • Permethrin
  • • Pyrethrins
  • Symptomatic relief of cough and colds

    Legend and OTC drugs listed in Pharmacy Services are covered.
    Covered:

  • • Guaifenesin & dextromethorphan
  • • Guaifenesin tablets
  • • Guaifenesin and codeine
  • • Guaifenesin syrup
  • • Guaifenesin with hydrocodone syrup
  • Topical and vaginal antifungals

    Covered:

  • • Butoconazole nitrate
  • • Clotrimazole
  • • Ketoconazole shampoo 2% (OTC 1% ketoconazole is not covered)
  • • Miconazole
  • • Tolnaftate
  • Topicals, misc.

    Covered:

  • • Dimethicone & dimethicone/ZnO (Proshield Plus, Baza Pro)
  • • Coal tar shampoo
  • • Hydrocortisone 1% cream and ointment
  • • Salicylic acid/coal tar/sulfur shampoo (Sebutone)
  • Vitamins, minerals and electrolytes
    (Some specific brands may not be covered)

    Coverage limitations:
    MHCP covers vitamins only:

  • • When the manufacturer has signed a rebate agreement for coverage
  • • For children under age 7 years
  • • Prescription strength prenatal vitamin products for use during pregnancy and the breast-feeding period
  • • Products are FDA approved and not just simply marketed as a health food or nutritional product
  • • All other requirements for drug coverage are met
  • • Covered:
  • • Beta carotene/vitamins C and E/minerals (generics for Ocuvite)
  • • Calcium carbonate
  • • Calcium acetate
  • • Calcium with vitamin D preparations
  • • Ferrous gluconate and sulfate
  • • Iron polysaccharides complex
  • • Levocarnitine: (L-carnitine)
  • • Magnesium oxide
  • • Niacin (vitamin B3): for the treatment of hyperlipidemia
  • • Oral electrolytes: Pedialyte and Ricelyte
  • • Fluoride: legend preparations
  • • Sodium bicarbonate: tablet
  • • Vitamin D (limited rebating manufacturers)
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