Obsolete 0718 - Table III - Covered Medications

Effective April 1, 2004 - June 30, 2018 (This table is obsolete as of July 1, 2018)

 

Services covered by Medicaid vary based on the benefit package for which the individual qualifies.  Refer to the Current Benefits Chart sent out by Health Care Financing to decide if a service is covered by Traditional Medicaid, Non-Traditional Medicaid, or the Primary Care Network.  This Table describes in general, what pharmacy benefits Medicaid covers and lists covered over-the-counter medications.

 

Pharmacy (Drugs)

Most prescribed drugs, including some prescribed over-the-counter medications can be covered by Medicaid.  Generic substitution of prescription drugs will be made.  Quantities may be limited.

Medicaid does not cover most prescriptions for individuals who are eligible to receive Medicare.  Medicaid will still cover benzodiazapines, barbiturates, and prescribed over-the-counter medications covered by Medicaid for Medicare eligibles.

1.  Prior approval required for: Lactulose, amphetamines, Ritalin, nutrients and food supplements.

 

2.  "Desi" drugs are not covered.  (These are drugs whose effectiveness for the stated purpose has not been determined.)

 

3.  Vitamins restricted to prenatal vitamins with folic acid for pregnant women and supplements with fluoride for children through age 5.

 

A utilization review committee may review the medical necessity of a person's prescriptions when the person has a large number of prescriptions.

 

4.  When some prescriptions are denied by Medicaid

     because a utilization review determines the prescriptions are not medically necessary, clients cannot use the costs against spenddown if they purchase them privately.  Contact Program Specialist if you have questions.

 

Co-pays apply based on benefit package. Certain groups are exempt from copays under Traditional and Non-Traditional Medicaid.   More limits on available drugs may apply to non-Traditional recipients.

 

5.  PCN enrollees limited to four prescriptions a month.  No exemptions to copays apply for PCN.

Prescribed over-the-counter medications (OTCs) are limited to the following lists.  There is a list for Traditional Medicaid and for Non-Traditional Medicaid.  On the Non-Traditional table, a few items are available to PCN enrollees.  These are marked by two pound signs (##).  Even when prescribed, other OTCs are not covered nor can they be used to meet a Medicaid spenddown.  Medicaid does not cover smoking cessation medications.  The individual may call 1-800 567-TRUTH for help to pay for such medications.

COVERED MEDICATIONS

MEDICAID-COVERED OVER-THE-COUNTER (OTC) DRUGS

Traditional Medicaid Recipients

(When prescribed)

Previous Table

Effective April 1, 2004

 

Limitations:  Brand Name Products are only payable when marked with an *.   Manufacturers who have not entered the federal rebate program will not have their products covered; this includes almost all house-brand (store-brand) products. 

Maximums and minimum limits may apply and are indicted below.

Acetaminophen

Not in N.H.

Acetone tests (e.g. Acetest*)

Not in N.H.

Alcohol Swabs

Not in N.H.

Antacid Liquid and Tablets (Tums rolls covered. Tums -500, E-X, & Ultra NOT covered. Mylanta NOT covered.)

Not in N.H.

Aspirin including enteric coated, buffered

Not in N.H.

AxidAR (package size > 30 tablets)

 

Benadryl (generic equivalent only)

 

Benylin (generic equivalent only)

 

Benadryl Allergy Decongestant*

 

Bisacodyl Tablets and Suppositories

 

Chlorpheniramine

 

Citrate of Magnesia 600ml, maximum

 

Codimal DM* (alcohol, dye, and sugar free)

 

Contraceptive Creams, Foams, Tablets, Sponges and Condoms

Not in N.H.

Dramamine (generic equivalent only)

 

DSS Caps Liquid and Syrup and Concentrate Drops 5% (Na+ or Ca++ salt)

Not in N.H.

Ferrous Gluconate 325mg - sulfate tabs 325mg/elixir 220mg/5cc

 

Glucose Blood Tests  (e.g., Chemstrip* BG, One-touch*, Ultra*, etc.)

Not in N.H.

Glutose*

 

Gyne-Lotrimin (generic equivalent only)

 

Hydrocortisone Cream, Ointment

 

Ibuprofen

Not in N.H.

Imodium AD (generic equivalent only)

Not in N.H.

Insulin Syringe with needle-disposable (100/month max.)

Not in N.H.

Insulin

 

Kaolin w/pectin suspension

Not in N.H.

Lancets (100/month max.)

Not in N.H.

Lotrimin, Lotrimin AF (generic equivalent only)

 

Maalox* suspension

Not in N.H.

MAG-CARB

 

Milk-of-Magnesia

 

Monistat-7 (generic equivalent only)

 

Motrin oral susp  NDC 00045018404

 

Motrin drops  NDC 50580010015

 

Mycelex OTC (generic equivalent only)

 

Niacin 250mg, 500mg for hyperlipidemia only (SR, LA forms not covered)

 

Nix and generic equivalent  should this have an asterisk?

 

Pediacare Cough-Cold*

 

Pedialyte* liquid and generic equivalent (only children age 0-10)

 

Pepcid AC (package size > 50)  should this have an asterisk?

 

Pepto-Bismol* and generic equivalent

 

Poly Vi Sol* and generic equivalents (not iron)

 

Prophylactics - male, female  (Trojan, Ramses, etc.)

Not in N.H.

Pseudoephedrine HCL 30mg, 60mg

 

PsylliumMuciloid Powder

 

Rid* and generic equivalents

 

Robitussin (generic equivalent only)

 

Robitussin DM (generic equivalent only)

 

Senokot 8.6mg tab. (generic equivalent only)

 

Tagamet HB and generic equivalent (package size > 30)

 

Tavist-1 (generic equivalent only)

 

Triaminic - only the following: Triaminic AM cough and decongestant, Triaminic cold and cough, Triaminic night-time, Triaminic sore throat formula and generic equivalents   should this have an asterisk?

 

Triple Antibiotic Ointment 15mg

 

Tri Vi Sol and generic equivalents

 

Urine Tests (e.g., Clinistix, Clinitest*, Diastix* Ketostix)

Not in N.H.

Zantac 75 (package size > 20)

 

 

Non-Traditional Medicaid Recipients

(When prescribed)

 

Items marked by two pound signs ## are covered by the PCN program.

Acetaminophen

Not in N.H.

Antacid liquid and tablets  (Tums rolls covered.  Tums - 500, E-X, and Ultra NOT covered.  Mylanta NOT covered.)

Not in N.H.

Aspirin including enteric coated, buffered

Not in N.H.

Benadryl (generic equivalent only)

 

 

Bisacodyl Tablets and suppositories

Not in N.H.

Contraceptive creams, foams, tablets, sponges, and condoms.  ##

???

DSS caps, liquid, and syrup and concentrate drops 5%

Not in N.H.

Glucose blood tests.  ##  (e.g., Chemstrip BG*, One-touch*, Ultra*, etc.)

 

Gyne-lotrimin (generic equivalent only)

 

Hydrocortisone cream, ointment

 

Ibuprofen

Not in N.H.

Imodium AD (generic equivalent only)

Not in N.H.

Insulin  ##

 

Insulin syringes  ##

 

Lancets  ##

 

Lotrimin, Lotrimin AF (generic equivalent only)

 

Milk of Magnesia

Not in N.H.

Monistat-7 (generic equivalent only)

 

Nix and generic equivalent

 

Pepcid AC (package size > 50)

 

Pseudoephedrine HCL 30 mg, 60 mg

 

psylliummuciloid powder

 

Rid* and generic equivalents

 

Robitussin and Robitussin DM (generic equivalent only)

 

Tagamet HB and generic equivalent (package size > 30)

 

Triaminic (only the following are covered):  Triaminic AM cough and decongestant, Triaminic cold and cough, Triaminic night time, Triaminic sore throat formula, and generic equivalents

 

Triple antibiotic ointment 15 mg

 

Zantac 75 (package size > 20)