Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 
600 Washington Street
Boston, MA  02111 
www.mass.gov/masshealth


MASSHEALTH TRANSMITTAL LETTER DEN-67 June 2004 
TO: Dental Providers Participating in MassHealth 
FROM: Beth Waldman, Medicaid Director 

RE: Dental Manual (Revised Nonlegend Drug List) 
This letter transmits a revised Appendix I of the Dental Manual. Appendix I, which lists all generic nonlegend drugs that are covered by MassHealth, has been revised to delete nizatidine. This revision reflects changes issued with the April 15, 2004, MassHealth Drug List. 
These changes were effective April 15, 2004. 
NEW MATERIAL (The pages listed here contain new or revised language.) Dental Manual 
Pages I-1 and I-2 
OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Dental Manual 
Pages I-1 and I-2 — transmitted by Transmittal Letter DEN-65 
Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series  SUBCHAPTER NUMBER AND TITLE APPENDIX I:  NONLEGEND DRUGS  PAGE I-1  
DENTAL MANUAL  TRANSMITTAL LETTER DEN-67  DATE 04/15/04  

This appendix lists the only nonlegend drugs, with the exception of insulins, that are covered by MassHealth without prior authorization.  All other nonlegend drugs require prior authorization.  Please refer to 130 CMR 406.411(A) and 406.412(A)(2) for further information on nonlegend drugs.  All insulins are covered for members at home, in nursing facilities, or in rest homes.   
The items in this appendix are listed alphabetically by therapeutic class, then by the generic name of the drug or drug ingredients.  MassHealth pays for generic, nonlegend drugs on this list, singly or in combination, regardless of strength or dosage form.  Combination products that contain active ingredients not included in this list require prior authorization.  
This list of nonlegend drugs is also located on the MassHealth Web site at www.mass.gov/masshealth. 
Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series  SUBCHAPTER NUMBER AND TITLE APPENDIX I:  NONLEGEND DRUGS  PAGE I-2  
DENTAL MANUAL  TRANSMITTAL LETTER DEN-67  DATE 04/15/04  

Analgesics: 
acetaminophen aspirin aspirin with buffers capsaicin ibuprofen ketoprofen naproxen 

Antihistamines/ Decongestants: 
brompheniramine chlorpheniramine diphenhydramine loratadine pseudoephedrine 

Antimicrobials, Topical: 
bacitracin chlorhexidine gluconate clotrimazole hydrogen peroxide iodine isopropyl alcohol miconazole neomycin polymixin B povidone tolnaftate 

Contraceptives, Topical: 
nonoxynol-9 

Gastrointestinal Products: 
aluminum carbonate aluminum hydroxide bisacodyl bismuth subsalicylate calcium carbonate casanthranol cimetidine cod liver oil docusate sodium famotidine kaolin/pectin loperamide magaldrate magnesium citrate magnesium hydroxide magnesium trisalicylate meclizine mineral oil psyllium ranitidine senna simethicone sodium bicarbonate 


Vitamins and Nutrients: 
ascorbic acid calcium carbonate calcium citrate calcium glubionate calcium gluconate calcium phosphate cyanocobalamin electrolyte solution (pediatric) ferrous fumarate ferrous gluconate ferrous sulfate folic acid magnesium gluconate multivitamins, N.F. multivitamins with minerals niacin niacinamide nicotinic acid pediatric vitamins prenatal vitamins pyridoxine (vitamin B6) retinol (vitamin A) riboflavin thiamine vitamin B complex vitamin D 

Miscellaneous Products: 
A&D ointment artificial tears benzoyl peroxide calamine lotion carbamide peroxide colloidal oatmeal hydrocortisone lanolin permethrin petrolatum selenium sulfide sodium chloride solution 
for inhalation water for inhalation witch hazel zinc oxide