TennCare Over-the-Counter (OTC) List:

TennCare Over-the-Counter (OTC) List:
Eligible Children Younger than 21 Years Old
July 24, 2014
ASTHMA SUPPLIES
Spacers QL
Sodium Chloride (saline) for Inhalation Peak Flow Meters
Peak Flow Meters QL
COUGH/COLD
Abreva® (Docosanol)
Fexofenadine/Pseudoephedrine PA, QL
cetirizine chewable PA, QL
Guaifenesin DM
Brompheniramine/Pseudoephedrine
Guaifenesin
cetirizine tabs QL and syrup
Loratadine QL
cetirizine/PSE QL
loratadine RDT PA, QL
Chlorpheniramine Maleate
Loratadine-D QL
Dextromethorphan
Phenylephrine Oral Formulations
Diphenhydramine HCl caps, liquid and tabs
Diphenhydramine HCl chewables, strips, and disp tabs PA
Fexofenadine PA, QL
Pseudoephedrine 30 mg tabs QL
Saline Nasal Drops
DIABETES
Alcohol Pads
Ketone Testing Strips QL (i.e., Ketostix®)
Blood Glucose Test Strips QL
Pen Needles – Syringe Needles
Blood Glucose Meters QL
Lancets
Glucose Control Solution
Insulins
Select Insulin Syringes
GASTROINTESTINALS
Aluminum Carbonate Capsule/Suspension
Magnesium Hydroxide Suspension
Bisacodyl Suppositories/Tablet
Magnesium Hydroxide/Aluminum
Aluminum Hydroxide Capsule/Tablet/Suspension
Docusate Calcium Capsules
Docusate Sodium Capsule/Liquid/Syrup/Enema
Glycerin Suppositories
Loperamide
Proprietary & Confidential
© 2014, Magellan Health Services, Inc. All Rights Reserved.
Magnesium Hydroxide/Aluminum Hydroxide
Hydroxide/Simethicone
Polyethylene Glycol
Psyllium Agents
Sorbitol
Magellan Health Services
TennCare OTC List: Eligible Children Younger than 21 Years Old
MISCELLANEOUS
Betaine Tablet
Ointments and Drops used as Saliva Substitutes
Meclizine
Phenylketonuria (PKU) Agents
Caffeine Citrate Powder
ketotifen ophthalmic drops QL
Nasacort®
Ointments and Drops used for Eye Lubricants
(i.e., Artificial Tears)
Sodium Benzoate Powder
PAIN/FEVER
Acetaminophen liquid and tablets
Ibuprofen chewables PA
Aspirin
Naproxen Sodium OTC
Acetaminophen chewables and disp tabs PA
Buffered Aspirin
Arginine
Ibuprofen liquid and tablets
PROTEIN REPLACEMENT
Levocarnitine Capsule/Tablet
SMOKING CESSATION AGENTS
Commit®
nicotine polacrilex gum
Nicorette® gum
nicotine transdermal patch
Nicoderm®
nicotine polacrilex lozenge
TOPICAL AGENTS AND INTRAVAGINALS
Ammonium Lactate 5%, 12% Cream, Ointment, Lotion
Hydrocortisone 1% Cream
Benzocaine Dental Ointment
Miconazole Cream/Ointment/Lotion/Intravaginal
Products
Bacitracin Zinc
Benzocaine Ointment/Cream
Benzoyl Peroxide
Clotrimazole Cream/Ointment/Lotion and Intravaginal
Suppositories/Creams
Diphenhydramine Ointment
Proprietary & Confidential
Ketoconazole 1% Shampoo
Mineral Oil/Petrolatum Ointment
Permethrin 1% Liquid
Povidone–Iodine Topical Solution
Triple Antibiotic Ointment
Page 2
Revision Date: July 24, 2014
Magellan Health Services
TennCare OTC List: Eligible Children Younger than 21 Years Old
VITAMINS/ELECTROLYTES
Biotin Tablet/Capsules
Folic Acid/Vitamin B-Complex with C
Calcium Carbonate with Vitamin D
Multivitamins and Multivitamins with Iron
Calcium Carbonate
Calcium Lactate
Cyanocobalamin (vitamin B12) PA
Ferrous gluconate 324 mg and 325 mg tabs
Ferrous sulfate drops (ages 6 and younger)
Ferrous sulfate elixir
Magnesium Salts
Multivitamins (Prenatal-Pediatric)
Potassium Phosphate (Mono- and Di-Basic)
Sodium Bicarbonate Tablets
Vitamin A, Bs, B-Complex, C, D, and E
Ferrous sulfate 324 mg and 325 mg tabs
Proprietary & Confidential
Page 3
Revision Date: July 24, 2014

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