Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MASSHEALTH
TRANSMITTAL LETTER OPD-51
June 2003
TO:      Outpatient Hospitals Participating in MassHealth

FROM:      Douglas S. Brown, Acting Commissioner.
RE:      Outpatient Hospital Manual (Revised Nonlegend Drug List)
This letter transmits a revised Appendix M of the Outpatient Manual. Appendix M, which lists all generic nonlegend drugs that are covered by MassHealth, has been revised to include generic, nonlegend versions of loratadine.
This revised appendix is effective July 1, 2003.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Outpatient Hospital Manual
Pages M-1 and M-2
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Outpatient Hospital Manual
Pages M-1 and M-2 — transmitted by Transmittal Letter OPD-48

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
OUTPATIENT HOSPITAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX M: NONLEGEND DRUGS	PAGE
M-1	

	TRANSMITTAL LETTER
OPD-51	DATE
07/01/03	
This appendix lists the only nonlegend drugs, with the exception of insulins, that are covered by the Division without prior authorization. All other nonlegend drugs require prior authorization. Please refer to 130 CMR 406.411(A) and 406.412(B) 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. The Division will pay 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 Division’s Web site at www.mass.gov/dma.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
OUTPATIENT HOSPITAL MANUAL	SUBCHAPTER NUMBER AND TITLE
APPENDIX M: NONLEGEND DRUGS	PAGE
M-2	

	TRANSMITTAL LETTER
OPD-51	DATE
07/01/03	

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
nizatidine
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