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Cough and Cold Drugs
Per Section 1927(d) of the Social Security Act, agents used for the symptomatic relief of cough and colds are optional for coverage by Medicaid
and are exempt from coverage under the Medicare Modernization Act.
The following excluded drugs [per Section 1927(d)] are covered by Arkansas Medicaid.
This reference list includes drugs covered for Arkansas Medicaid beneficiaries and dual eligible Medicare/Arkansas Medicaid beneficiaries.
Cough and Cold products are restricted to beneficiaries under the age of 21 and to beneficaries with Long Term Care Coverage.
OTC Medications in this list are only covered pursuant to a valid prescription, but are not covered for Long Term Care beneficiaries.
Inclusion on this list does not guarantee market availability and products must have a rebate agreement with the Centers for Medicare and
Medicaid Services (CMS) to be covered by Arkansas Medicaid.
Pharmacy Quantity of Claim Edits may apply. Arkansas Medicaid Pharmacy Claim Edits
Pharmacy Prior Authorization or Clinical Criteria may apply. Arkansas Medicaid Pharmacy Prior Authorization Criteria
The Labeler Code and Label Name are supplied for provider reference. For questions about a specific NDC or for further information, please call the
AR Pharmacy Help Desk at TOLL FREE (800) 424-7895.
Updated 10/24/2013
LABELER CODE DRUG STRENGTH DOSE FORM ROUTE LABEL NAME MANUFACTURER
67877 BENZONATATE 100 MG CAPSULE ORAL BENZONATATE 100 MG CAPSULE ASCEND LABS
68084 BENZONATATE 100 MG CAPSULE ORAL BENZONATATE 100 MG CAPSULE AHP
00069 BENZONATATE 100 MG CAPSULE ORAL TESSALON PERLE 100 MG CAP PFIZER
00904 BENZONATATE 100 MG CAPSULE ORAL BENZONATATE 100 MG CAPSULE MAJOR
50111 BENZONATATE 100 MG CAPSULE ORAL BENZONATATE 100 MG CAPSULE PLIVA
57664 BENZONATATE 100 MG CAPSULE ORAL BENZONATATE 100 MG CAPSULE CARACO PHARM
65162 BENZONATATE 100 MG CAPSULE ORAL BENZONATATE 100 MG CAPSULE AMNEAL PHARM
68382 BENZONATATE 100 MG CAPSULE ORAL BENZONATATE 100 MG CAPSULE ZYDUS PHARM
00603 DEXTROMETHORPHAN-PROMETHAZINE 15-6.25 MG/5 ML SYRUP ORAL PROMETHAZINE-DM SYRUP QUALITEST
50383 DEXTROMETHORPHAN-PROMETHAZINE 15-6.25 MG/5 ML SYRUP ORAL PROMETHAZINE-DM SYRUP HI-TECH PHARM
60432 DEXTROMETHORPHAN-PROMETHAZINE 15-6.25 MG/5 ML SYRUP ORAL PROMETHAZINE-DM SYRUP MORTON GROVE
00031 GUAIFENESIN 100 MG/5 ML LIQUID ORAL ROBITUSSIN MUCUS-CHEST CONGEST WYETH CONSUMER
00113 GUAIFENESIN 100 MG/5 ML LIQUID ORAL CHILDREN'S MUCUS RELIEF LIQ PERRIGO
00113 GUAIFENESIN 100 MG/5 ML LIQUID ORAL TUSSIN MUCUS-CONGEST 100 MG/5 PERRIGO
00121 GUAIFENESIN 100 MG/5 ML SYRUP ORAL GUAIFENESIN 100 MG/5 ML LIQUID PHARMACEU ASSOC
Arkansas Medicaid Pharmacy Program
TOLL FREE (800) 424-7895
www.medicaid.state.ar.us
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LABELER CODE DRUG STRENGTH DOSE FORM ROUTE LABEL NAME MANUFACTURER
00536 GUAIFENESIN 100 MG/5 ML LIQUID ORAL COUGH SYRUP 100 MG/5 ML RUGBY
00536 GUAIFENESIN 100 MG/5 ML LIQUID ORAL GUAIFENESIN 100 MG/5 ML SYRUP RUGBY
00603 GUAIFENESIN 100 MG/5 ML LIQUID ORAL IOPHEN NR LIQUID QUALITEST
00603 GUAIFENESIN 100 MG/5 ML LIQUID ORAL Q-TUSSIN 100 MG/5 ML SOLUTION QUALITEST
00904 GUAIFENESIN 100 MG/5 ML SYRUP ORAL ROBAFEN 100 MG/5 ML SYRUP MAJOR
15127 GUAIFENESIN 100 MG/5 ML SYRUP ORAL SB COUGH CONTROL SYRUP SELECT BRAND
24385 GUAIFENESIN 100 MG/5 ML LIQUID ORAL TUSSIN 100 MG/5 ML SYRUP AMERISOURCEBERG
36800 GUAIFENESIN 100 MG/5 ML LIQUID ORAL CHILDREN'S MUCUS RELIEF LIQ TOPCO
36800 GUAIFENESIN 100 MG/5 ML LIQUID ORAL TUSSIN CHEST CONGESTION LIQUID TOPCO
37205 GUAIFENESIN 100 MG/5 ML LIQUID ORAL TUSSIN MUCUS-CONGEST 100 MG/5 LEADER
49348 GUAIFENESIN 100 MG/5 ML LIQUID ORAL SM TUSSIN 100 MG/5 ML LIQUID SUNMARK
49348 GUAIFENESIN 100 MG/5 ML SYRUP ORAL TUSSIN HONEY SYRUP SUNMARK
49614 GUAIFENESIN 100 MG/5 ML SYRUP ORAL MEDI-TUSSIN 100 MG/5 ML SYRUP MEDICINE SHOP
50383 GUAIFENESIN 100 MG/5 ML LIQUID ORAL GUAIFENESIN 100 MG/5 ML SOLN HI-TECH PHARM
54838 GUAIFENESIN 100 MG/5 ML LIQUID ORAL DIABETIC SILTUSSIN DAS-NA LIQ SILARX PHARM
54838 GUAIFENESIN 100 MG/5 ML SYRUP ORAL SILTUSSIN SA 100 MG/5 ML SYR SILARX PHARM
62011 GUAIFENESIN 100 MG/5 ML SYRUP ORAL HM ADULT TUSSIN CHEST CONG LIQ HEALTH MART
63868 GUAIFENESIN 100 MG/5 ML LIQUID ORAL QC MEDIFIN EXP MUCUS RLF LIQ CHAIN DRUG
63868 GUAIFENESIN 100 MG/5 ML SYRUP ORAL QC TUSSIN 100 MG/5 ML LIQUID CHAIN DRUG
00904 GUAIFENESIN 600 MG TABLET ER ORAL MUCUS ER 600 MG TABLET MAJOR
37205 GUAIFENESIN 600 MG TABLET ER ORAL MUCUS ER 600 MG TABLET LEADER
45802 GUAIFENESIN 600 MG TABLET ER ORAL GUAIFENESIN ER 600 MG TABLET PERRIGO
46122 GUAIFENESIN 600 MG TABLET ER ORAL MUCUS ER 600 MG TABLET AMERISOURCEBERG
49348 GUAIFENESIN 600 MG TABLET ER ORAL SM MUCUS ER 600 MG TABLET SUNMARK
63824 GUAIFENESIN 600 MG TABLET ER ORAL MUCINEX ER 600 MG TABLET RECKITT BENCKIS
00121 GUAIFENESIN-CODEINE 100-10 MG/5 ML SYRUP ORAL GUAIFENESIN-CODEINE SYRUP PHARMACEU ASSOC
00603 GUAIFENESIN-CODEINE 100-10 MG/5 ML SYRUP ORAL CHERATUSSIN AC SYRUP QUALITEST
00603 GUAIFENESIN-CODEINE 100-10 MG/5 ML LIQUID ORAL IOPHEN-C NR LIQUID QUALITEST
16571 GUAIFENESIN-CODEINE 100-10 MG/5 ML LIQUID ORAL GUAIFENESIN AC COUGH SYRUP PACK PHARM
50383 GUAIFENESIN-CODEINE 100-10 MG/5 ML LIQUID ORAL GUAIATUSSIN AC LIQUID HI-TECH PHARM
00113 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL TUSSIN DM CLEAR LIQUID PERRIGO
00113 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL TUSSIN DM COUGH & CHEST LIQUID PERRIGO
00113 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL TUSSIN DM COUGH SYRUP PERRIGO
00536 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL COUGH SYRUP RUGBY
00536 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL EXTRA ACTION COUGH SYRUP RUGBY
00603 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML LIQUID ORAL IOPHEN DM-NR LIQUID QUALITEST
00603 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL Q-TUSSIN DM SYRUP QUALITEST
00904 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL ROBAFEN-DM SYRUP MAJOR
15127 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL SB COUGH CONTROL DM SYRUP SELECT BRAND
24385 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL TUSSIN DM CLEAR SYRUP AMERISOURCEBERG
24385 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL TUSSIN DM SYRUP AMERISOURCEBERG
37205 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML LIQUID ORAL TUSSIN DM LIQUID LEADER
Arkansas Medicaid Pharmacy Program TOLL FREE (800) 424-7895
www.medicaid.state.ar.us
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LABELER CODE DRUG STRENGTH DOSE FORM ROUTE LABEL NAME MANUFACTURER
49348 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL SM TUSSIN DM SYRUP SUNMARK
49614 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML LIQUID ORAL MEDI-TUSSIN DM DIABETIC LIQ MEDICINE SHOP
49614 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL MEDI-TUSSIN DM SYRUP MEDICINE SHOP
49614 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL TUSSIN DM COUGH SYRUP MEDICINE SHOP
54838 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL SILTUSSIN DM COUGH SYRUP SILARX PHARM
54838 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML LIQUID ORAL SILTUSSIN DM DAS LIQUID SILARX PHARM
63868 GUAIFENESIN-DEXTROMETHORPHAN 100-10 MG/5 ML SYRUP ORAL QC TUSSIN DM SYRUP CHAIN DRUG
00603 PHENYLEPHRINE-CODEINE-PROMETH 5-10-6.25 MG/5 ML SYRUP ORAL PROMETHAZINE VC-CODEINE SYRUP QUALITEST
50383 PROMETHAZINE-CODEINE 6.25-10 MG/5 ML SYRUP ORAL PROMETHAZINE-CODEINE SYRUP HI-TECH PHARM
00472 PROMETHAZINE-CODEINE 6.25-10 MG/5 ML SYRUP ORAL PROMETHAZINE-CODEINE SYRUP ACTAVIS
00603 PROMETHAZINE-CODEINE 6.25-10 MG/5 ML SYRUP ORAL PROMETHAZINE-CODEINE SYRUP QUALITEST
57664 PROMETHAZINE-CODEINE 6.25-10 MG/5 ML SYRUP ORAL PROMETHAZINE-CODEINE SYRUP CARACO PHARM
60432 PROMETHAZINE-CODEINE 6.25-10 MG/5 ML SYRUP ORAL PROMETHAZINE-CODEINE SYRUP MORTON GROVE
00603 PSE-CODEINE-CHLORPHENIRAMINE 30-10-2 MG/5 ML LIQUID ORAL PHENYLHISTINE DH LIQUID QUALITEST
00603 PSE-CODEINE-GUAIFENESIN 30-10-100 MG/5 ML SYRUP ORAL CHERATUSSIN DAC SYRUP QUALITEST
16571 PSE-CODEINE-GUAIFENESIN 30-10-100 MG/5 ML SYRUP ORAL GUAIFENESIN DAC ORAL SOLUTION PACK PHARM
54859 PSE-CODEINE-GUAIFENESIN 30-10-100 MG/5 ML SYRUP ORAL TUSNEL C SYRUP LLORENS PHARM
Arkansas Medicaid Pharmacy Program
www.medicaid.state.ar.us TOLL FREE (800) 424-7895
