March 2, 2018

Beginning Apr. 2, VDP will enhance the restriction on the use of opioid cough and cold products for people enrolled in Medicaid fee-for-service to deny coverage of these products for people less than 18 years of age. This restriction is based on the FDA’s drug safety communication (“FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older”) regarding limiting the use of prescription opioid cough and cold products to adults 18 years of age and older.

Claims will be denied with National Council for Prescription Drug Programs rejection code “60” (“Product/Service Not Covered For Patient Age”) and include the message “Product Not Covered for Under 18 Years of Age” in the “Additional Message Information” field (526-FQ).  These products will also not be allowed in multi-ingredient compound claims for this population. 

Managed care organizations are strongly encouraged to implement this age-based restriction.  Pharmacy staff should contact the person’s managed care organization for claim limitation requirements. The Prescriber MCO Assistance Chart (PDF) identifies the appropriate prior authorization and member call center phone numbers for each MCO.  

The table below is a list of drugs on the Medicaid formulary currently impacted by this change.  This is not a comprehensive list as drug coverage is subject to change daily.

Drug NDC Description
 CODEINE PHOSPHATE/GUAIFENESIN 00121077504 GUAIFEN-CODEINE 100-10 MG/5 ML
CODEINE PHOSPHATE/GUAIFENESIN 00121077516 GUAIFENESIN-CODEINE SYRUP
HYDROCODONE/PSEUDOEPHED/GUAIF 00178329116 HYCOFENIX 2.5-30-200 MG/5 ML
GUAIFENESIN/HYDROCODONE 00178348216 FLOWTUSS 2.5-200 MG/5 ML SOLN
HYDROCODONE BIT/HOMATROP ME-BR 00472103016 HYDROMET SYRUP
HYDROCODONE/CPM/PSEUDOEPHED 00574110316 HYDROCOD-CPM-PSEUDOEP 5-4-60/5
HYDROCODONE BIT/HOMATROP ME-BR 00574110516 HYDROCODONE-HOMATROPINE SOLN
CODEINE PHOSPHATE/GUAIFENESIN 00603107554 CHERATUSSIN AC SYRUP
CODEINE PHOSPHATE/GUAIFENESIN 00603107556 CHERATUSSIN AC SYRUP
CODEINE PHOSPHATE/GUAIFENESIN 00603107558 CHERATUSSIN AC SYRUP
CODEINE PHOSPHATE/GUAIFENESIN 00603132958 IOPHEN-C NR LIQUID
PSEUDOEPHED/COD/CHLORPHENIR 00603152054 PHENYLHISTINE DH LIQUID
PSEUDOEPHED/COD/CHLORPHENIR 00603152058 PHENYLHISTINE DH LIQUID
PROMETHAZINE HCL/CODEINE 00603158554 PROMETHAZINE-CODEINE SYRUP
PROMETHAZINE HCL/CODEINE 00603158558 PROMETHAZINE-CODEINE SYRUP
PROMETHAZINE/PHENYLEPH/CODEINE 00603158854 PROMETHAZINE VC-CODEINE SYRUP
PROMETHAZINE/PHENYLEPH/CODEINE 00603158858 PROMETHAZINE VC-CODEINE SYRUP
HYDROCODONE BIT/HOMATROP ME-BR 10702015016 HYDROCODONE-HOMATROPINE SOLN
CODEINE PHOSPHATE/GUAIFENESIN 16571030216 GUAIFENESIN AC COUGH SYRUP
CODEINE PHOSPHATE/GUAIFENESIN 23359004016 NINJACOF-XG LIQUID
HYDROCODONE/CHLORPHEN P-STIREX 27808008601 HYDROCODONE-CHLORPHEN ER SUSP
HYDROCODONE/CHLORPHEN P-STIREX 27808008602 HYDROCODONE-CHLORPHEN ER SUSP
HYDROCODONE BIT/HOMATROP ME-BR 43386011801 HYDROCODONE-HOMATROPINE 5-1.5
HYDROCODONE BIT/HOMATROP ME-BR 43386011803 HYDROCODONE-HOMATROPINE 5-1.5
HYDROCODONE BIT/HOMATROP ME-BR 50383004316 HYDROCODONE-HOMATROPINE SYRUP
PROMETHAZINE HCL/CODEINE 50383080416 PROMETHAZINE-CODEINE SYRUP
HYDROCODONE/CHLORPHEN P-STIREX 53014054801 TUSSIONEX PENNKINETIC SUSP
CODEINE PHOSPHATE/GUAIFENESIN 58657050004 CODEINE-GUAIFEN 10-100 MG/5 ML
CODEINE PHOSPHATE/GUAIFENESIN 58657050016 CODEINE-GUAIFEN 10-100 MG/5 ML
PROMETHAZINE HCL/CODEINE 60432060616 PROMETHAZINE-CODEINE SYRUP
HYDROCODONE/CHLORPHEN P-STIREX 62175049064 HYDROCODONE-CHLORPHEN ER SUSP
HYDROCODONE/CHLORPHEN P-STIREX 62542030104 HYDROCODONE-CHLORPHEN ER SUSP
HYDROCODONE/CHLORPHEN P-STIREX 62542030117 HYDROCODONE-CHLORPHEN ER SUSP
HYDROCODONE/CPM/PSEUDOEPHED 63717087616 ZUTRIPRO SOLUTION
PROMETHAZINE/PHENYLEPH/CODEINE 65162069486 PROMETHAZINE-PE-CODEINE SYRUP
PROMETHAZINE/PHENYLEPH/CODEINE 65162069490 PROMETHAZINE-PE-CODEINE SYRUP
PSEUDOEPHED/CODEINE/GUAIFEN 69036013016 LORTUSS EX LIQUID
CODEINE PHOSPHATE/GUAIFENESIN 69543025204 VIRTUSSIN AC LIQUID
CODEINE PHOSPHATE/GUAIFENESIN 69543025216 VIRTUSSIN AC LIQUID
PSEUDOEPHED/CODEINE/GUAIFEN 69543025316 VIRTUSSIN DAC LIQUID