Florida Medicaid Preferred Drug List (updated
The Florida Medicaid Preferred Drug List (PDL) is subject to revision following consideration and recommendations by the Pharmaceutical and Therapeutics (P&T) Committee and the Agency for Health Care Administration. The quarterly P&T Committee meeting was held on September 28, 2018.
This list is in order by the therapeutic classification. To locate a specific drug or therapeutic class, use the search feature available in Adobe Acrobat Reader. (keyboard shortcut: CTRL+F)
Phosphate Binders and Prescription Strength Vitamins are covered for dialysis patients.
Note: While a product name may be listed on the PDL, a specific NDC may or may not be reimbursable.
DEFINITIONS:
“Auto PA” = System automated criteria looks for specific requirements (e.g., diagnosis, age, previous therapies, etc.). If all requirements are found, the claims will pay at the pharmacy counter without need of manual prior authorization submission.
“Clinical PA Required” = These drugs require prior authorization submission that must include clinical documentation. The drugs that require clinical prior authorization review and the prior authorization forms can be found in this link: http://ahca.myflorida.com/medicaid/Prescribed_Drug/preferred_drug.shtml
“Cystic Fib Diag Auto PA” = Claims for these products will pay at the pharmacy counter if the diagnosis of cystic fibrosis is found in the system.
“Requires Med Cert 3” = The Food and Drug Administration (FDA) requires participation (by prescribers, pharmacies, and/or patients) in certification, education, training, or agreements prior to dispensing certain drugs. By entering certification code “3”, the dispensing pharmacy is confirming that FDA requirements were met.
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
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Min Age |
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Max Age |
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Thursday, October 25, 2018 |
Page 1 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
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|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
A1A |
DIGITALIS GLYCOSIDES |
|
|
|
|
|
|
|
|
|
|
A1A |
|
DIGOXIN 0.125 MG TABLET |
DIGOXIN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1A |
|
DIGOXIN 0.25 MG TABLET |
DIGOXIN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1A |
|
DIGOXIN 125 MCG TABLET |
DIGOXIN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1A |
|
DIGOXIN 250 MCG TABLET |
DIGOXIN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1A |
|
DIGOXIN 50 MCG/ML SOLUTION |
DIGOXIN |
0 |
999 |
|
No |
|
||||
|
|
|
A1B |
XANTHINES |
|
|
|
|
|
|
|
|
|
|
A1B |
|
CAFFEINE CIT 20 MG/ML ORAL SOL |
CAFFEINE CITRATE |
|
11 mos |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
CAFFEINE CIT 60 MG/3 ML ORAL |
CAFFEINE CITRATE |
11 mos |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
CAFFEINE CIT 60 MG/3 ML VIAL |
CAFFEINE CITRATE |
11 mos |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
CAFFEINE CITRATE 20 MG/ML VIAL |
CAFFEINE CITRATE |
11 mos |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
CAFFEINE CITRATE 60 MG/3 ML VL |
CAFFEINE CITRATE |
11 mos |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
ELIXOPHYLLIN 80 MG/15 ML ELIX |
THEOPHYLLINE ANHYDROUS |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
THEOPHYLLINE ANHYDROUS |
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
THEOPHYLLINE ANHYDROUS |
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
THEOPHYLLINE ANHYDROUS |
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
THEOPHYLLINE ANHYDROUS |
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
THEOPHYLLINE 100 MG TAB SA |
THEOPHYLLINE ANHYDROUS |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
THEOPHYLLINE 200 MG TAB SA |
THEOPHYLLINE ANHYDROUS |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
THEOPHYLLINE 300 MG TAB SA |
THEOPHYLLINE ANHYDROUS |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
THEOPHYLLINE 450 MG TAB SA |
THEOPHYLLINE ANHYDROUS |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
THEOPHYLLINE 80 MG/15 ML SOLN |
THEOPHYLLINE ANHYDROUS |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
THEOPHYLLINE ER 300 MG TAB |
THEOPHYLLINE ANHYDROUS |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
THEOPHYLLINE ER 400 MG TABLET |
THEOPHYLLINE ANHYDROUS |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A1B |
|
THEOPHYLLINE ER 450 MG TAB |
THEOPHYLLINE ANHYDROUS |
0 |
999 |
|
No |
|
||||
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Thursday, October 25, 2018 |
Page 2 of 204 |
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Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
A1B |
|
THEOPHYLLINE ER 600 MG TABLET |
THEOPHYLLINE ANHYDROUS |
0 |
999 |
|
No |
|
|||
|
|
|
A1C |
INOTROPIC DRUGS |
|
|
|
|
|
|
|
|
|
A1C |
|
DOBUTAMINE 1 GM/D5W 250 ML |
DOBUTAMINE HCL IN DEXTROSE 5 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A1C |
|
DOBUTAMINE 12.5 MG/ML VIAL |
DOBUTAMINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A1C |
|
DOBUTAMINE 250 MG/20 ML VIAL |
DOBUTAMINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A1C |
|
DOBUTAMINE 250 MG/D5W 250 ML |
DOBUTAMINE HCL IN DEXTROSE 5 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A1C |
|
DOBUTAMINE 500 MG/D5W 250 ML |
DOBUTAMINE HCL IN DEXTROSE 5 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A1C |
|
MILRINONE 0.2 MG/ML IN D5W |
MILRINONE LACTATE/D5W |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A1C |
|
MILRINONE LACT 10 MG/10 ML VL |
MILRINONE LACTATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A1C |
|
MILRINONE LACT 20 MG/20 ML VL |
MILRINONE LACTATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A1C |
|
MILRINONE LACT 50 MG/50 ML VL |
MILRINONE LACTATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A1C |
|
MILRINONE LACTATE 1 MG/ML VL |
MILRINONE LACTATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A1C |
|
MILRINONE LACTATE/D5W |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
A1C |
|
MILRINONE LACTATE/D5W |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A2A |
ANTIARRHYTHMICS |
|
|
|
|
|
|
|
|
|
A2A |
|
AMIODARONE HCL 100 MG TABLET |
AMIODARONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A2A |
|
AMIODARONE HCL 200 MG TABLET |
AMIODARONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A2A |
|
DISOPYRAMIDE 100 MG CAPSULE |
DISOPYRAMIDE PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A2A |
|
DISOPYRAMIDE 150 MG CAPSULE |
DISOPYRAMIDE PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A2A |
|
FLECAIDIDE ACETATE 150 MG TAB |
FLECAINIDE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A2A |
|
FLECAINIDE ACETATE 100 MG TAB |
FLECAINIDE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A2A |
|
FLECAINIDE ACETATE 100 MG TB |
FLECAINIDE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A2A |
|
FLECAINIDE ACETATE 150 MG TAB |
FLECAINIDE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A2A |
|
FLECAINIDE ACETATE 150 MG TB |
FLECAINIDE ACETATE |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 3 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A2A |
|
FLECAINIDE ACETATE 50 MG TAB |
|
|
FLECAINIDE ACETATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A2A |
|
MEXILETINE 150 MG CAPSULE |
|
|
MEXILETINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A2A |
|
MEXILETINE 200 MG CAPSULE |
|
|
MEXILETINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A2A |
|
MEXILETINE 250 MG CAPSULE |
|
|
MEXILETINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A2A |
|
PROPAFENONE HCL 150 MG TAB |
|
|
PROPAFENONE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
A2A |
|
PROPAFENONE HCL 150 MG TABLET |
PROPAFENONE HCL |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A2A |
|
PROPAFENONE HCL 225 MG TAB |
|
|
PROPAFENONE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A2A |
|
PROPAFENONE HCL 300 MG TAB |
|
|
PROPAFENONE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
A2A |
|
PROPAFENONE HCL ER 225 MG CAP |
PROPAFENONE HCL |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A2A |
|
PROPAFENONE HCL ER 325 MG CAP |
PROPAFENONE HCL |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A2A |
|
PROPAFENONE HCL ER 425 MG CAP |
PROPAFENONE HCL |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A2A |
|
QUINIDINE GLUC 324 MG TAB SA |
|
|
QUINIDINE GLUCONATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A2A |
|
QUINIDINE SULFATE 200 MG TAB |
|
|
QUINIDINE SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A2A |
|
QUINIDINE SULFATE 300 MG TAB |
|
|
QUINIDINE SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A2A |
|
TIKOSYN 125 MCG CAPSULE |
|
|
DOFETILIDE |
0 |
999 |
|
Requires Med Cert 3 |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A2A |
|
TIKOSYN 250 MCG CAPSULE |
|
|
DOFETILIDE |
0 |
999 |
|
Requires Med Cert 3 |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A2A |
|
TIKOSYN 500 MCG CAPSULE |
|
|
DOFETILIDE |
0 |
999 |
|
Requires Med Cert 3 |
|
||
|
|
|
|
|
|
|
|
||||||
|
|
|
A2C |
ANTIANGINAL, |
|
|
|
||||||
|
A2C |
|
RANEXA ER 1,000 MG TABLET |
|
|
RANOLAZINE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A2C |
|
RANEXA ER 500 MG TABLET |
|
|
RANOLAZINE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4A |
|
|
ANTIHYPERTENSIVES, VASODILATORS |
|
|
|
|
|
|
|
|
A4A |
|
HYDRALAZINE 10 MG TABLET |
|
|
HYDRALAZINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4A |
|
HYDRALAZINE 100 MG TABLET |
|
|
HYDRALAZINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4A |
|
HYDRALAZINE 25 MG TABLET |
|
|
HYDRALAZINE HCL |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 4 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
A4A |
|
HYDRALAZINE 50 MG TABLET |
HYDRALAZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4A |
|
HYDRALAZINE HCL 100 MG TABLET |
HYDRALAZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4A |
|
HYDRALAZINE HCL 25 MG TABLET |
HYDRALAZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4A |
|
MINOXIDIL 10 MG TABLET |
MINOXIDIL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4A |
|
MINOXIDIL 2.5 MG TABLET |
MINOXIDIL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4B |
ANTIHYPERTENSIVES, SYMPATHOLYTIC |
|
|
|
|
|
|
|
|
|
A4B |
|
CLONIDINE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
A4B |
|
CLONIDINE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
A4B |
|
CLONIDINE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
A4B |
|
CLONIDINE HCL 0.1 MG TABLET |
CLONIDINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4B |
|
CLONIDINE HCL 0.2 MG TABLET |
CLONIDINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4B |
|
CLONIDINE HCL 0.3 MG TABLET |
CLONIDINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4B |
|
GUANFACINE 1 MG TABLET |
GUANFACINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4B |
|
GUANFACINE 2 MG TABLET |
GUANFACINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4B |
|
METHYLDOPA 250 MG TABLET |
METHYLDOPA |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4B |
|
METHYLDOPA 500 MG TABLET |
METHYLDOPA |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4D |
ANTIHYPERTENSIVES, ACE INHIBITORS |
|
|
|
|
|
|
|
|
|
A4D |
|
BENAZEPRIL HCL 10 MG TABLET |
BENAZEPRIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4D |
|
BENAZEPRIL HCL 20 MG TABLET |
BENAZEPRIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4D |
|
BENAZEPRIL HCL 40 MG TABLET |
BENAZEPRIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4D |
|
BENAZEPRIL HCL 5 MG TABLET |
BENAZEPRIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4D |
|
ENALAPRIL MALEATE 10 MG TAB |
ENALAPRIL MALEATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4D |
|
ENALAPRIL MALEATE 10 MG TABLET |
ENALAPRIL MALEATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4D |
|
ENALAPRIL MALEATE 2.5 MG TAB |
ENALAPRIL MALEATE |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 5 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
ENALAPRIL MALEATE 20 MG TAB |
|
|
ENALAPRIL MALEATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
A4D |
|
ENALAPRIL MALEATE 20 MG TABLET |
ENALAPRIL MALEATE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
ENALAPRIL MALEATE 5 MG TAB |
|
|
ENALAPRIL MALEATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
ENALAPRIL MALEATE 5 MG TABLET |
|
|
ENALAPRIL MALEATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
FOSINOPRIL SODIUM 10 MG TAB |
|
|
FOSINOPRIL SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
FOSINOPRIL SODIUM 20 MG TAB |
|
|
FOSINOPRIL SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
FOSINOPRIL SODIUM 40 MG TAB |
|
|
FOSINOPRIL SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
LISINOPRIL 10 MG TABLET |
|
|
LISINOPRIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
LISINOPRIL 2.5 MG TABLET |
|
|
LISINOPRIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
LISINOPRIL 20 MG TABLET |
|
|
LISINOPRIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
LISINOPRIL 30 MG TABLET |
|
|
LISINOPRIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
LISINOPRIL 40 MG TABLET |
|
|
LISINOPRIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
LISINOPRIL 5 MG TABLET |
|
|
LISINOPRIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
QUINAPRIL 10 MG TABLET |
|
|
QUINAPRIL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
QUINAPRIL 20 MG TABLET |
|
|
QUINAPRIL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
QUINAPRIL 40 MG TABLET |
|
|
QUINAPRIL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
QUINAPRIL 5 MG TABLET |
|
|
QUINAPRIL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
QUINAPRIL HCL 10 MG TABLET |
|
|
QUINAPRIL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
QUINAPRIL HCL 5 MG TABLET |
|
|
QUINAPRIL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
RAMIPRIL 1.25 MG CAPSULE |
|
|
RAMIPRIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
RAMIPRIL 10 MG CAPSULE |
|
|
RAMIPRIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
RAMIPRIL 2.5 MG CAPSULE |
|
|
RAMIPRIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4D |
|
RAMIPRIL 5 MG CAPSULE |
|
|
RAMIPRIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
||||||
|
|
|
A4F |
ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST |
|
|
|
Thursday, October 25, 2018 |
Page 6 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
A4F |
|
IRBESARTAN 150 MG TABLET |
|
|
IRBESARTAN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4F |
|
IRBESARTAN 300 MG TABLET |
|
|
IRBESARTAN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4F |
|
IRBESARTAN 75 MG TABLET |
|
|
IRBESARTAN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
A4F |
|
LOSARTAN POTASSIUM 100 MG TAB |
LOSARTAN POTASSIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A4F |
|
LOSARTAN POTASSIUM 25 MG TAB |
LOSARTAN POTASSIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
A4F |
|
LOSARTAN POTASSIUM 50 MG TAB |
LOSARTAN POTASSIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4F |
|
MICARDIS 20 MG TABLET |
|
|
TELMISARTAN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4F |
|
MICARDIS 40 MG TABLET |
|
|
TELMISARTAN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4F |
|
MICARDIS 80 MG TABLET |
|
|
TELMISARTAN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4F |
|
VALSARTAN 160 MG TABLET |
|
|
VALSARTAN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4F |
|
VALSARTAN 320 MG TABLET |
|
|
VALSARTAN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4F |
|
VALSARTAN 40 MG TABLET |
|
|
VALSARTAN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4F |
|
VALSARTAN 80 MG TABLET |
|
|
VALSARTAN |
0 |
999 |
|
No |
|
||
|
|
|
A4H |
ANGIOTENSIN RECEPTOR |
|
|
|
||||||
|
A4H |
|
AMLODIPINE BES/OLMESARTAN MED |
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
A4H |
|
AMLODIPINE BES/OLMESARTAN MED |
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
A4H |
|
AMLODIPINE BES/OLMESARTAN MED |
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
A4H |
|
AMLODIPINE BES/OLMESARTAN MED |
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
A4H |
|
AMLODIPINE BESYLATE/VALSARTAN |
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
A4H |
|
AMLODIPINE BESYLATE/VALSARTAN |
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
A4H |
|
AMLODIPINE BESYLATE/VALSARTAN |
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
A4H |
|
AMLODIPINE BESYLATE/VALSARTAN |
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
||||||
|
|
|
A4I |
ANGIOTENSIN RECEPTOR |
|
|
|
||||||
|
A4I |
|
|
|
LOSARTAN/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 7 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4I |
|
|
|
LOSARTAN/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4I |
|
|
|
LOSARTAN/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4I |
|
|
|
LOSARTAN/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4I |
|
MICARDIS HCT 40/12.5 MG TAB |
|
|
TELMISARTAN/HYDROCHLOROTHIAZID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4I |
|
MICARDIS HCT 80/12.5 MG TAB |
|
|
TELMISARTAN/HYDROCHLOROTHIAZID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4I |
|
MICARDIS HCT 80/25 MG TABLET |
|
|
TELMISARTAN/HYDROCHLOROTHIAZID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4I |
|
|
|
VALSARTAN/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4I |
|
|
|
VALSARTAN/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4I |
|
|
|
VALSARTAN/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4I |
|
|
|
VALSARTAN/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4I |
|
|
|
VALSARTAN/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
A4J |
ACE |
|
|
|
|
|
||||
|
A4J |
|
ENALAPRIL/HCTZ |
|
|
ENALAPRIL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4J |
|
ENALAPRIL/HCTZ |
|
|
ENALAPRIL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4J |
|
|
|
ENALAPRIL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4J |
|
|
|
ENALAPRIL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4J |
|
|
|
ENALAPRIL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4J |
|
|
|
ENALAPRIL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4J |
|
|
|
FOSINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4J |
|
|
|
FOSINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4J |
|
|
|
LISINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4J |
|
|
|
LISINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4J |
|
|
|
LISINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4J |
|
|
|
LISINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 8 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
A4J |
|
|
|
|
LISINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4J |
|
|
|
|
LISINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4J |
|
|
|
|
LISINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4J |
|
|
|
|
LISINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4J |
|
|
|
|
LISINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4J |
|
|
|
|
LISINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4J |
|
|
|
|
LISINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4J |
|
|
|
|
LISINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4J |
|
|
|
|
LISINOPRIL/HYDROCHLOROTHIAZIDE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4J |
|
|
|
|
QUINAPRIL/HYDROCHLOROTHIAZIDE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4J |
|
|
|
|
QUINAPRIL/HYDROCHLOROTHIAZIDE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4J |
|
|
|
|
QUINAPRIL/HYDROCHLOROTHIAZIDE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|||||||
|
|
|
A4K |
ACE |
|
|
|
|||||||
|
A4K |
|
|
|
AMLODIPINE BESYLATE/BENAZEPRIL |
0 |
|
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4K |
|
|
|
AMLODIPINE BESYLATE/BENAZEPRIL |
0 |
|
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
A4K |
|
|
|
AMLODIPINE BESYLATE/BENAZEPRIL |
0 |
|
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4K |
|
|
|
|
AMLODIPINE BESYLATE/BENAZEPRIL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4K |
|
|
|
|
AMLODIPINE BESYLATE/BENAZEPRIL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4K |
|
|
|
|
AMLODIPINE BESYLATE/BENAZEPRIL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4K |
|
|
|
|
AMLODIPINE BESYLATE/BENAZEPRIL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4K |
|
|
|
|
AMLODIPINE BESYLATE/BENAZEPRIL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4K |
|
|
|
|
AMLODIPINE BESYLATE/BENAZEPRIL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
A4K |
|
|
|
|
AMLODIPINE BESYLATE/BENAZEPRIL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
A4L |
|
ANGIOTENSIN |
|
|
|
|
Thursday, October 25, 2018 |
Page 9 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
A4L |
|
ENTRESTO 24 |
SACUBITRIL/VALSARTAN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4L |
|
ENTRESTO 49 |
SACUBITRIL/VALSARTAN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A4L |
|
ENTRESTO 97 |
SACUBITRIL/VALSARTAN |
0 |
999 |
|
No |
|
|||
|
|
|
A7B |
VASODILATORS,CORONARY |
|
|
|
|
|
|
|
|
|
A7B |
|
ISOSORBIDE DINITRATE 10 MG TAB |
ISOSORBIDE DINITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE DINITRATE 20 MG TAB |
ISOSORBIDE DINITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE DN 10 MG TABLET |
ISOSORBIDE DINITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE DN 20 MG TABLET |
ISOSORBIDE DINITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE DN 30 MG TABLET |
ISOSORBIDE DINITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE DN 5 MG TABLET |
ISOSORBIDE DINITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE MN 10 MG TABLET |
ISOSORBIDE MONONITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE MN 120 MG TAB SA |
ISOSORBIDE MONONITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE MN 20 MG TABLET |
ISOSORBIDE MONONITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE MN 30 MG TAB SA |
ISOSORBIDE MONONITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE MN 30 MG TABLET ER |
ISOSORBIDE MONONITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE MN 60 MG TAB ER |
ISOSORBIDE MONONITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE MN 60 MG TAB SA |
ISOSORBIDE MONONITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE MN 60 MG TABLET ER |
ISOSORBIDE MONONITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE MN ER 120 MG TAB |
ISOSORBIDE MONONITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE MN ER 30 MG TABLET |
ISOSORBIDE MONONITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
ISOSORBIDE MN ER 60 MG TABLET |
ISOSORBIDE MONONITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
NITROGLYCERIN 0.1 MG/HR PATCH |
NITROGLYCERIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
NITROGLYCERIN 0.1 MG/HR PTCH |
NITROGLYCERIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
NITROGLYCERIN 0.2 MG/HR PATCH |
NITROGLYCERIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 10 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
A7B |
|
NITROGLYCERIN 0.2 MG/HR PTCH |
NITROGLYCERIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
NITROGLYCERIN 0.3 MG TABLET SL |
NITROGLYCERIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
NITROGLYCERIN 0.4 MG TABLET SL |
NITROGLYCERIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
NITROGLYCERIN 0.4 MG/HR PATCH |
NITROGLYCERIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
NITROGLYCERIN 0.4 MG/HR PTCH |
NITROGLYCERIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
NITROGLYCERIN 0.6 MG TABLET SL |
NITROGLYCERIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
NITROGLYCERIN 0.6 MG/HR PATCH |
NITROGLYCERIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
NITROGLYCERIN 0.6 MG/HR PTCH |
NITROGLYCERIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
NITROSTAT 0.3 MG TABLET SL |
NITROGLYCERIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
NITROSTAT 0.4 MG TABLET SL |
NITROGLYCERIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A7B |
|
NITROSTAT 0.6 MG TABLET SL |
NITROGLYCERIN |
0 |
999 |
|
No |
|
|||
|
|
|
A7M |
BRADYKININ B2 RECEPTOR ANTAGONISTS |
|
|
|
|
|
|||
|
A7M |
|
FIRAZYR 30 MG/3 ML SYRINGE |
ICATIBANT ACETATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
A9A |
CALCIUM CHANNEL BLOCKING AGENTS |
|
|
|
|
|
|
|
|
|
A9A |
|
AMLODIPINE BESYLATE 10 MG TAB |
AMLODIPINE BESYLATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
AMLODIPINE BESYLATE 2.5 MG TAB |
AMLODIPINE BESYLATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
AMLODIPINE BESYLATE 5 MG TAB |
AMLODIPINE BESYLATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM 120 MG CAPSULE SA |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM 120 MG TABLET |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM 24HR CD 360 MG CAP |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM 24HR ER 120 MG CAP |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM 24HR ER 180 MG CAP |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM 24HR ER 240 MG CAP |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM 24HR ER 300 MG CAP |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 11 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
A9A |
|
DILTIAZEM 24HR ER 360 MG CAP |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM 30 MG TABLET |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM 60 MG CAPSULE SA |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM 60 MG TABLET |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM 90 MG CAPSULE SA |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM 90 MG TABLET |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM ER 120 MG CAP SA |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM ER 120 MG CAP SA |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM ER 120 MG CAPSULE |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM ER 120 MG CAPSULE |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM ER 180 MG CAP SA |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM ER 180 MG CAPSULE |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM ER 180 MG CAPSULE |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM ER 240 MG CAP SA |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM ER 240 MG CAPSULE |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM ER 60 MG CAP SA |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM ER 90 MG CAP SA |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM HCL 120 MG CAP SA |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM HCL ER 120 MG CAP |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM HCL ER 180 MG CAP |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM HCL ER 240 MG CAP |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM HCL ER 300 MG CAP |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM HCL ER 360 MG CAP |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
DILTIAZEM HCL ER 420 MG CAP |
DILTIAZEM HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 12 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
A9A |
|
FELODIPINE ER 10 MG TABLET |
FELODIPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
FELODIPINE ER 2.5 MG TABLET |
FELODIPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
FELODIPINE ER 5 MG TABLET |
FELODIPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
NIFEDIPINE 10 MG CAPSULE |
NIFEDIPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
NIFEDIPINE 20 MG CAPSULE |
NIFEDIPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
NIFEDIPINE ER 30 MG TABLET |
NIFEDIPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
NIFEDIPINE ER 60 MG TABLET |
NIFEDIPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
NIFEDIPINE ER 90 MG TABLET |
NIFEDIPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
NIMODIPINE 30 MG CAPSULE |
NIMODIPINE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL 120 MG CAP PELLET |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL 120 MG CAP PELLET |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL 120 MG TABLET |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL 120 MG TABLET SA |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL 180 MG CAP PELLET |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL 180 MG CAP PELLET |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL 180 MG TABLET SA |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL 240 MG CAP PELLET |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL 240 MG CAP PELLET |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL 240 MG TABLET SA |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL 360 MG CAP PELLET |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL 40 MG TABLET |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL 80 MG TABLET |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL ER 120 MG TABLET |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
A9A |
|
VERAPAMIL ER 180 MG TABLET |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 13 of 204 |
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
A9A |
|
VERAPAMIL ER 240 MG TABLET |
VERAPAMIL HCL |
0 |
999 |
|
No |
|
B0A |
|
GENERAL INHALATION AGENTS |
|
|
B0A |
SODIUM CHLORIDE 0.9% VIAL |
|
SODIUM CHLORIDE FOR INHALATION |
0 |
999 |
B0A |
SODIUM CHLORIDE 10% VIAL |
|
SODIUM CHLORIDE FOR INHALATION |
0 |
999 |
B0A |
SODIUM CHLORIDE 3% VIAL |
|
SODIUM CHLORIDE FOR INHALATION |
0 |
999 |
|
B0D |
|
PULMONARY FIBROSIS - SYSTEMIC ENZYME INHIBITORS |
|
|
B0D |
OFEV 100 MG CAPSULE |
|
NINTEDANIB ESYLATE |
0 |
999 |
B0D |
OFEV 150 MG CAPSULE |
|
NINTEDANIB ESYLATE |
0 |
999 |
|
B1B |
PULMONARY |
|||
B1B |
LETAIRIS 10 MG TABLET |
|
AMBRISENTAN |
0 |
999 |
B1B |
LETAIRIS 5 MG TABLET |
|
AMBRISENTAN |
0 |
999 |
B1B |
TRACLEER 125 MG TABLET |
|
BOSENTAN |
0 |
999 |
B1B |
TRACLEER 62.5 MG TABLET |
|
BOSENTAN |
0 |
999 |
|
B1C |
|
PULMONARY ANTIHYPERTENSIVES, |
|
|
B1C |
EPOPROSTENOL SODIUM 0.5 MG VL |
EPOPROSTENOL SODIUM (GLYCINE) |
0 |
999 |
|
B1C |
EPOPROSTENOL SODIUM 1.5 MG VL |
EPOPROSTENOL SODIUM (GLYCINE) |
0 |
999 |
|
B1C |
VENTAVIS 10 MCG/1 ML SOLUTION |
ILOPROST TROMETHAMINE |
0 |
999 |
|
B1C |
VENTAVIS 20 MCG/1 ML SOLUTION |
ILOPROST TROMETHAMINE |
0 |
999 |
|
|
B1D |
|
|||
B1D |
SILDENAFIL 20 MG TABLET |
|
SILDENAFIL CITRATE |
0 |
999 |
No
Auto PA
Auto PA
Clinical PA Required
Clinical PA Required
Clinical PA Required
Clinical PA Required
Clinical PA Required
Clinical PA Required
No
No
Clinical PA Required
Clinical PA Required
Clinical PA Required
|
B3A |
MUCOLYTICS |
|
|
|
B3A |
ACETYLCYSTEINE 10% VIAL |
ACETYLCYSTEINE |
0 |
999 |
No |
|
|
|
|
|
|
B3A |
ACETYLCYSTEINE 20% VIAL |
ACETYLCYSTEINE |
0 |
999 |
No |
|
|
|
|
|
|
B3A |
PULMOZYME 1 MG/ML AMPUL |
DORNASE ALFA |
0 |
65 |
Auto PA |
|
B3J |
EXPECTORANTS |
|
|
|
B3J |
CHL MUCINEX CHEST CONGEST LIQ |
GUAIFENESIN |
0 |
999 |
No |
Thursday, October 25, 2018 |
Page 14 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B3J |
|
GUAIFENESIN 100 MG/5 ML SOLN |
|
|
|
GUAIFENESIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
B3J |
|
GUAIFENESIN 100 MG/5 ML SYRUP |
|
|
GUAIFENESIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
B3J |
|
GUAIFENESIN 200 MG/10 ML SOLN |
|
|
GUAIFENESIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
B3J |
|
GUAIFENESIN 300 MG/15 ML SOLN |
|
|
GUAIFENESIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
B3J |
|
GUAIFENESIN ER 1,200 MG TABLET |
|
|
GUAIFENESIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B3J |
|
KID'S MUCINEX |
|
|
|
GUAIFENESIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B3J |
|
MUCINEX 600 MG TABLET |
|
|
|
GUAIFENESIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B3J |
|
MUCINEX ER 1,200 MG TABLET |
|
|
|
GUAIFENESIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B3J |
|
MUCINEX ER 600 MG TABLET |
|
|
|
GUAIFENESIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|||||||
|
|
|
B3R |
|
|
|
||||||||
|
B3R |
|
|
|
BROMPHENIRAMINE/PSEUDOEPHED/DM |
0 |
20 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
B3R |
|
|
|
BROMPHENIRAMINE/PSEUDOEPHED/DM |
0 |
20 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|||||||
|
|
|
B3T |
|
|
|
||||||||
|
B3T |
|
GUAIFENESIN DM SYRUP |
|
|
|
GUAIFENESIN/DEXTROMETHORPHAN |
0 |
20 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B3T |
|
|
|
|
GUAIFENESIN/DEXTROMETHORPHAN |
0 |
20 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
B4C |
OPIOID |
|
|
|
|
|
|||||
|
B4C |
|
HYDROCODONE COMPOUND SYRUP |
|
|
HYDROCODONE BIT/HOMATROP |
18 |
20 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
B4C |
|
|
|
HYDROCODONE BIT/HOMATROP |
18 |
20 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
B4C |
|
|
|
HYDROCODONE BIT/HOMATROP |
18 |
20 |
|
No |
|
||||
|
|
|
B4E |
|
|
|
||||||||
|
B4E |
|
PROMETHAZINE DM SYRUP |
|
|
|
PROMETHAZINE/DEXTROMETHORPHAN |
0 |
20 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B4E |
|
PROMETHAZINE W/DM SYRUP |
|
|
|
PROMETHAZINE/DEXTROMETHORPHAN |
0 |
20 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
B60 |
|
ANTICHOLINERGICS, ORALLY INHALED SHORT ACTING |
|
|
|
|
|
||||
|
B60 |
|
ATROVENT HFA INHALER |
|
|
|
IPRATROPIUM BROMIDE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B60 |
|
IPRATROPIUM BR 0.02% SOLN |
|
|
|
IPRATROPIUM BROMIDE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
B61 |
|
ANTICHOLINERGICS, ORALLY INHALED LONG ACTING |
|
|
|
|
|
Thursday, October 25, 2018 |
Page 15 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
B61 |
|
SPIRIVA 18 MCG |
|
|
TIOTROPIUM BROMIDE |
18 |
999 |
|
No |
|
||
|
|
|
B62 |
|
|
|
|||||||
|
B62 |
|
BEVESPI AEROSPHERE INHALER |
|
|
GLYCOPYRROLATE/FORMOTEROL FUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B62 |
|
|
|
IPRATROPIUM/ALBUTEROL SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
||||
|
B62 |
|
IPRATROPIUM/ALBUTEROL SULFATE |
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B62 |
|
STIOLTO RESPIMAT INHAL SPRAY |
|
|
TIOTROPIUM BR/OLODATEROL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
B62 |
|
UTIBRON NEOHALER |
INDACATEROL/GLYCOPYRROLATE |
0 |
999 |
|
No |
|
||||
|
|
|
B63 |
|
|
|
|||||||
|
B63 |
|
ADVAIR 100/50 DISKUS |
|
|
FLUTICASONE/SALMETEROL |
4 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B63 |
|
ADVAIR |
|
|
FLUTICASONE/SALMETEROL |
4 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B63 |
|
ADVAIR 250/50 DISKUS |
|
|
FLUTICASONE/SALMETEROL |
4 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B63 |
|
ADVAIR |
|
|
FLUTICASONE/SALMETEROL |
4 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B63 |
|
ADVAIR 500/50 DISKUS |
|
|
FLUTICASONE/SALMETEROL |
4 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B63 |
|
ADVAIR |
|
|
FLUTICASONE/SALMETEROL |
4 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B63 |
|
ADVAIR HFA |
|
|
FLUTICASONE/SALMETEROL |
5 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B63 |
|
ADVAIR HFA |
|
|
FLUTICASONE/SALMETEROL |
5 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B63 |
|
ADVAIR HFA |
|
|
FLUTICASONE/SALMETEROL |
5 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B63 |
|
DULERA 100 MCG/5 MCG INHALER |
|
|
MOMETASONE/FORMOTEROL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B63 |
|
DULERA 200 MCG/5 MCG INHALER |
|
|
MOMETASONE/FORMOTEROL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B63 |
|
SYMBICORT 160/4.5 MCG INHALER |
|
|
BUDESONIDE/FORMOTEROL FUMARATE |
5 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B63 |
|
SYMBICORT 80/4.5 MCG INHALER |
|
|
BUDESONIDE/FORMOTEROL FUMARATE |
5 |
999 |
|
No |
|
||
|
|
|
B6M |
|
|
GLUCOCORTICOIDS, ORALLY INHALED |
|
|
|
|
|
|
|
|
B6M |
|
ASMANEX TWISTHALER 110 MCG #30 |
MOMETASONE FUROATE |
4 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
B6M |
|
ASMANEX TWISTHALER 220 MCG #14 |
MOMETASONE FUROATE |
4 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
B6M |
|
ASMANEX TWISTHALER 220 MCG #30 |
MOMETASONE FUROATE |
4 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 16 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
B6M |
|
ASMANEX TWISTHALER 220 MCG #60 |
|
|
MOMETASONE FUROATE |
4 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
B6M |
|
ASMANEX TWISTHALR 220 MCG #120 |
|
|
MOMETASONE FUROATE |
4 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B6M |
|
FLOVENT HFA 110 MCG INHALER |
|
|
|
FLUTICASONE PROPIONATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B6M |
|
FLOVENT HFA 220 MCG INHALER |
|
|
|
FLUTICASONE PROPIONATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B6M |
|
FLOVENT HFA 44 MCG INHALER |
|
|
|
FLUTICASONE PROPIONATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B6M |
|
PULMICORT 0.25 MG/2 ML RESPUL |
|
|
|
BUDESONIDE |
1 |
8 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B6M |
|
PULMICORT 0.5 MG/2 ML RESPULE |
|
|
|
BUDESONIDE |
1 |
8 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B6M |
|
PULMICORT 1 MG/2 ML RESPULE |
|
|
|
BUDESONIDE |
1 |
8 |
|
No |
|
||
|
|
|
B6W |
|
|
|
|
|
|
|||||
|
B6W |
|
ALBUTEROL 0.083% INHAL SOLN |
|
|
|
ALBUTEROL SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B6W |
|
ALBUTEROL 0.83 MG/ML SOLUTION |
|
|
|
ALBUTEROL SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B6W |
|
ALBUTEROL 5 MG/ML SOLUTION |
|
|
|
ALBUTEROL SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B6W |
|
ALBUTEROL SUL 0.63 MG/3 ML SOL |
|
|
|
ALBUTEROL SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B6W |
|
ALBUTEROL SUL 1.25 MG/3 ML SOL |
|
|
|
ALBUTEROL SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B6W |
|
ALBUTEROL SUL 2.5 MG/3 ML SOLN |
|
|
|
ALBUTEROL SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B6W |
|
PROAIR HFA 90 MCG INHALER |
|
|
|
ALBUTEROL SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
B6W |
|
PROVENTIL HFA 90 MCG INHALER |
|
|
|
ALBUTEROL SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|||||||
|
|
|
B6Y |
|
|
|
||||||||
|
B6Y |
|
SEREVENT DISKUS 50 MCG |
|
|
|
SALMETEROL XINAFOATE |
4 |
999 |
|
No |
|
||
|
|
|
C0D |
|
|
|
|
|
|
|
|
|
|
|
|
C0D |
|
ACAMPROSATE CALC DR 333 MG TAB |
|
|
ACAMPROSATE CALCIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C0D |
|
DISULFIRAM 250 MG TABLET |
|
|
|
DISULFIRAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C0D |
|
DISULFIRAM 500 MG TABLET |
|
|
|
DISULFIRAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C0D |
|
VIVITROL 380 MG VIAL |
|
|
|
NALTREXONE MICROSPHERES |
18 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C0D |
|
VIVITROL INJECTABLE SUSPENSION |
|
|
|
NALTREXONE MICROSPHERES |
18 |
999 |
|
Auto PA |
|
Thursday, October 25, 2018 |
Page 17 of 204 |
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C0K |
BICARBONATE PRODUCING/CONTAINING AGENTS |
|
|
|
C0K |
SODIUM ACETATE 100 MEQ/50 ML |
SODIUM ACETATE |
0 |
999 |
No |
|
|
|
|
|
|
C0K |
SODIUM ACETATE 2 MEQ/ML VIAL |
SODIUM ACETATE |
0 |
999 |
No |
|
|
|
|
|
|
C0K |
SODIUM ACETATE 200 MEQ/100 ML |
SODIUM ACETATE |
0 |
999 |
No |
|
|
|
|
|
|
C0K |
SODIUM ACETATE 4 MEQ/ML VIAL |
SODIUM ACETATE |
0 |
999 |
No |
|
|
|
|
|
|
C0K |
SODIUM ACETATE 40 MEQ/20 ML VL |
SODIUM ACETATE |
0 |
999 |
No |
|
|
|
|
|
|
C0K |
SODIUM BICARB 4.2% VIAL |
SODIUM BICARBONATE |
0 |
999 |
No |
|
|
|
|
|
|
C0K |
SODIUM BICARB 8.4% VIAL |
SODIUM BICARBONATE |
0 |
999 |
No |
|
|
|
|
|
|
C0K |
SODIUM LACTATE 5 MEQ/ML VIAL |
SODIUM LACTATE |
0 |
999 |
No |
|
|
|
|
|
|
|
C1A |
ELECTROLYTE DEPLETERS |
|
|
|
C1A |
CALCIUM ACETATE 667 MG CAPSULE |
CALCIUM ACETATE |
0 |
999 |
No |
|
|
|
|
|
|
C1A |
CALCIUM ACETATE 667 MG GELCAP |
CALCIUM ACETATE |
0 |
999 |
No |
|
|
|
|
|
|
C1A |
CALCIUM ACETATE 668 MG TABLET |
CALCIUM ACETATE |
0 |
999 |
No |
|
|
|
|
|
|
C1A |
RENAGEL 400 MG TABLET |
SEVELAMER HCL |
0 |
999 |
No |
|
|
|
|
|
|
C1A |
RENAGEL 800 MG TABLET |
SEVELAMER HCL |
0 |
999 |
No |
|
|
|
|
|
|
C1A |
RENVELA 0.8 GM POWDER PACKET |
SEVELAMER CARBONATE |
0 |
11 |
No |
|
|
|
|
|
|
C1A |
RENVELA 2.4 GM POWDER PACKET |
SEVELAMER CARBONATE |
0 |
11 |
No |
|
|
|
|
|
|
C1A |
SOD POLYSTYREN SULF 15 G/60 ML |
SODIUM POLYSTYRENE SULFONATE |
0 |
999 |
No |
|
|
|
|
|
|
C1A |
SODIUM POLYSTYRENE SULF POWDER |
SODIUM POLYSTYRENE SULFONATE |
0 |
999 |
No |
|
|
|
|
|
|
C1A |
SODIUM POLYSTYRENE SULF PWD |
SODIUM POLYSTYRENE SULFONATE |
0 |
999 |
No |
|
|
|
|
|
|
C1A |
SPS 15 GM/60 ML SUSPENSION |
SODIUM POLYSTYRENE SULFON/SORB |
0 |
999 |
No |
|
|
|
|
|
|
C1A |
SPS 15 GM/60 ML SUSPENSION |
SODIUM POLYSTYRENE SULFONATE |
0 |
999 |
No |
|
|
|
|
|
|
C1A |
SPS 30 GM/120 ML ENEMA |
SODIUM POLYSTYRENE SULFON/SORB |
0 |
999 |
No |
|
|
|
|
|
|
C1A |
SPS 30 GM/120 ML ENEMA |
SODIUM POLYSTYRENE SULFONATE |
0 |
999 |
No |
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 18 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C1A |
|
SPS 50 GM/200 ML ENEMA |
SODIUM POLYSTYRENE SULFONATE |
0 |
999 |
|
No |
|
|||
|
|
|
C1D |
POTASSIUM REPLACEMENT |
|
|
|
|
|
|
|
|
|
C1D |
|
POTASSIUM BICARBONATE/CIT AC |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM BICARBONATE/CIT AC |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM BICARBONATE/CIT AC |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
K EFFERVESCENT 25 MEQ TABLET |
POTASSIUM BICARBONATE/CIT AC |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM BICARBONATE/CIT AC |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM 25 MEQ TABLET EFF |
POTASSIUM BICARBONATE/CIT AC |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM ACET 100 MEQ/50 ML |
POTASSIUM ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM ACET 2 MEQ/ML VIAL |
POTASSIUM ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM ACET 40 MEQ/20 ML VL |
POTASSIUM ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CHLORIDE 10% LIQUID |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM |
POTASSIUM CHLORIDE IN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 10 MEQ CAP SA |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 10 MEQ TAB SA |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 19 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C1D |
|
POTASSIUM CL 10 MEQ TABLET ER |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 10 MEQ/100 ML SOL |
POTASSIUM CHLORIDE IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 10 MEQ/5 ML CONC |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 10 MEQ/50 ML SOL |
POTASSIUM CHLORIDE IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 10% (20 MEQ/15 ML |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 10% (20 MEQ/15ML) |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 10% (40 MEQ/30 ML |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 2 MEQ/ML VIAL |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 20 MEQ PACKET |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 20 MEQ TAB ER |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 20 MEQ TABLET ER |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 20 MEQ/10 ML CONC |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 20 MEQ/100 ML SOL |
POTASSIUM CHLORIDE IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 20 MEQ/50 ML SOL |
POTASSIUM CHLORIDE IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 20% (40 MEQ/15 ML |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 20% (40 MEQ/15ML) |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 25 MEQ TAB EFF |
POT CHLORIDE/POT BICARB/CIT AC |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 30 MEQ/100 ML SOL |
POTASSIUM CHLORIDE IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 40 MEQ/100 ML SOL |
POTASSIUM CHLORIDE IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 40 MEQ/20 ML CONC |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 8 MEQ CAP SA |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL 8 MEQ TABLET SA |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL ER 10 MEQ CAPSULE |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL ER 10 MEQ TABLET |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 20 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C1D |
|
POTASSIUM CL ER 20 MEQ TABLET |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL ER 8 MEQ CAPSULE |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1D |
|
POTASSIUM CL ER 8 MEQ TABLET |
POTASSIUM CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
C1F |
CALCIUM REPLACEMENT |
|
|
|
|
|
|
|
|
|
C1F |
|
CALCIUM + D SOFT CHEWABLE TAB |
CALCIUM CARB/VITAMIN D3/VIT K1 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM + VIT D & K CHEW TAB |
CALCIUM CARB/VITAMIN D3/VIT K1 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM 250+D TABLET |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM 500 + D TABLET |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM 500 + VIT D 200 CAPLET |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM 500 + VIT D 400 TABLET |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM 500 + VIT D3 400 TAB |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM 500 + VIT D3 TABLET |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM 500+D CAPLET |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM 500+D TABLET |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM 500+VIT D 400 TAB |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM CARB 500 MG TAB CHEW |
CALCIUM CARBONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM CARB 500 MG TAB CHEW |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM CARB 500 TAB CHEW |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM CARBONATE 500 MG TAB |
CALCIUM CARBONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM CARBONATE 500 MG TAB |
CALCIUM CARBONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM CARBONATE 600 MG TAB |
CALCIUM CARBONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM CIT |
CALCIUM CITRATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 21 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C1F |
|
CALCIUM FOR WOMEN CHEWABLE TAB |
CALCIUM CARB/VITAMIN D3/VIT K1 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM OYS SHELL 250 MG TAB |
CALCIUM CARBONATE/VITAMIN D2 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALCIUM W/VITAMIN D TABLET |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CALICUM 500+D TABLET CHEW |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
CHEWABLE CALCIUM TAB CHEW |
CALCIUM CARB/VITAMIN D3/VIT K1 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
NATURAL CALCIUM 500 MG TABLET |
CALCIUM CARBONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1F |
|
OYSTER SHELL 250 MG + VIT D TB |
CALCIUM CARBONATE/VITAMIN D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
C1H |
MAGNESIUM SALTS REPLACEMENT |
|
|
|
|
|
|
|
|
|
C1H |
|
MAGNESIUM 250 MG TABLET |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM 250 MG TABLET |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM 400 MG CAPS |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM 400 MG SOFTGEL |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM 400 MG TABLET |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM 500 MG SOFTGEL |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM 500 MG TABLET |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM OXIDE 250 MG CAPLET |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM OXIDE 250 MG TABLET |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM OXIDE 400 MG TAB |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM OXIDE 400 MG TABLET |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM OXIDE 420 MG TAB |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM OXIDE 420 MG TABLET |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM OXIDE 500 MG CAPSULE |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM OXIDE 500 MG TAB |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1H |
|
MAGNESIUM OXIDE 500 MG TABLET |
MAGNESIUM OXIDE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 22 of 204 |
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C1P |
PHOSPHATE REPLACEMENT |
|
|
|
C1P |
POTASSIUM PH 3MM/ML VIAL |
POTASSIUM |
0 |
999 |
No |
|
|
|
|
|
|
C1P |
POTASSIUM PHOSP 45 MMOL/15 ML |
POTASSIUM |
0 |
999 |
No |
|
|
|
|
|
|
C1P |
SODIUM PHOSPHATE 3MM/ML VIAL |
SOD |
0 |
999 |
No |
|
|
|
|
|
|
C1P |
SODIUM PHOSPHATE 45 MMOL/15 ML |
SOD |
0 |
999 |
No |
|
|
|
|
|
|
|
C1W |
ELECTROLYTE MAINTENANCE |
|
|
|
C1W |
DEXTROSE |
0 |
999 |
No |
|
|
|
|
|
|
|
C1W |
HYPERLYTE CR VIAL |
SODIUM/POT/MAG/CALC/CHLOR/ACET |
0 |
999 |
No |
|
|
|
|
|
|
C1W |
IONOSOL B/D5W IV SOLUTION |
0 |
999 |
No |
|
|
|
|
|
|
|
C1W |
IONOSOL MB IN 5% DEXTROSE |
0 |
999 |
No |
|
|
|
|
|
|
|
C1W |
IONOSOL MB/D5W IV SOLUTION |
0 |
999 |
No |
|
|
|
|
|
|
|
C1W |
ISOLYTE P/DEXTROSE 5% SOLN |
0 |
999 |
No |
|
|
|
|
|
|
|
C1W |
ISOLYTE S IV SOLN PH7.4 |
0 |
999 |
No |
|
|
|
|
|
|
|
C1W |
ISOLYTE S IV SOLUTION/EXCEL |
0 |
999 |
No |
|
|
|
|
|
|
|
C1W |
LACTATED RINGERS INJ/EXCEL |
RINGER'S SOLUTION,LACTATED |
0 |
999 |
No |
|
|
|
|
|
|
C1W |
LACTATED RINGERS INJECTION |
RINGER'S SOLUTION,LACTATED |
0 |
999 |
No |
|
|
|
|
|
|
C1W |
0 |
999 |
No |
||
|
|
|
|
|
|
C1W |
0 |
999 |
No |
||
|
|
|
|
|
|
C1W |
0 |
999 |
No |
||
|
|
|
|
|
|
C1W |
0 |
999 |
No |
||
|
|
|
|
|
|
C1W |
0 |
999 |
No |
||
|
|
|
|
|
|
C1W |
0 |
999 |
No |
||
|
|
|
|
|
|
C1W |
NUTRILYTE VIAL |
SOD/POT/MAG/CAL/CL/ACET/GLUCON |
0 |
999 |
No |
|
|
|
|
|
|
C1W |
0 |
999 |
No |
||
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 23 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C1W |
|
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
C1W |
|
RINGERS INJECTION |
RINGER'S SOLUTION |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1W |
|
RINGER'S INJECTION IV SOLN |
RINGER'S SOLUTION |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1W |
|
TPN ELECTROLYTES II IV SOLN |
SODIUM/POT/MAG/CALC/CHLOR/ACET |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C1W |
|
TPN ELECTROLYTES VIAL |
SODIUM/POT/MAG/CALC/CHLOR/ACET |
0 |
999 |
|
No |
|
|||
|
|
|
C3B |
IRON REPLACEMENT |
|
|
|
|
|
|
|
|
|
C3B |
|
FERATE 27 MG TABLET |
FERROUS GLUCONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS SULFATE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FEROSUL 325 MG TABLET |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERRALET 90 TABLET |
IRON CARB,GL/FA/B12/C/DOCUSATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERRAPLUS 90 TABLET |
IRON/FOLIC ACID/B12/C/DOCUSATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERREX 150 CAPSULE |
IRON POLYSACCHARIDE COMPLEX |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERREX 150 FORTE CAPSULE |
IRON PS COMPLEX/B12/FOLIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERREX 150 FORTE PLUS CAPSULE |
IRON ASPGLY,PS/C/B12/FA/CA/SUC |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERREX 150 PLUS CAPSULE |
IRON ASPGLY,PS/C/SUCCINIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERREX 28 TABLET |
IRON/C/FOLIC ACD/MV CMB11/CALC |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
IRON POLYSACCHARIDE COMPLEX |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERRIC |
IRON POLYSACCHARIDE COMPLEX |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERRIMIN 150 TAB |
FERROUS FUMARATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERRLECIT 62.5 MG/5 ML VIAL |
SODIUM FERRIC GLUCONAT/SUCROSE |
0 |
18 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS SULFATE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS FUMARATE 324 MG TAB |
FERROUS FUMARATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS GLUCONATE 324 MG TAB |
FERROUS GLUCONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS GLUCONATE 325 MG TAB |
FERROUS GLUCONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 24 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C3B |
|
FERROUS SULF 15 MG IRON/ML DRP |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS SULF 220 MG/5 ML ELIX |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS SULF 220 MG/5 ML ELIX |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS SULF 300 MG/5 ML LIQ |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS SULF 324 MG TAB EC |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS SULF 325 MG TAB EC |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS SULFATE 15 MG/ML DROPS |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS SULFATE 15 MG/ML DROPS |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS SULFATE 325 MG TAB |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS SULFATE 325 MG TAB |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS SULFATE 325 MG TABLET |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS SULFATE ER 140 MG TAB |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUS SULFATE ER 140MG TAB |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FERROUSUL 325 MG TABLET |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
IRON FUM,PS/FOLIC ACID/VITC/B3 |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
FUSION PLUS CAPSULE |
IRON,FM,PS/FOLIC/B,C18/L.CASEI |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
HEMATOGEN FA SOFTGEL |
IRON FUMARATE/VIT C/VIT B12/FA |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
HEMOCYTE PLUS CAPSULE |
IRON FUM/FOLIC ACID/MV,MIN 15 |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
HEMOCYTE TABLET |
FERROUS FUMARATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
HM SLOW RELEASE IRON TABLET |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
IFEREX 150 CAPSULE |
IRON POLYSACCHARIDE COMPLEX |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
IFEREX 150 FORTE CAPSULE |
IRON PS COMPLEX/B12/FOLIC ACID |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
IFEREX 150 FORTE CAPSULE |
IRON PS COMPLEX/B12/FOLIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
INTEGRA F CAPSULE |
IRON FUM,PS/FOLIC ACID/VITC/B3 |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 25 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C3B |
|
INTEGRA PLUS CAPSULE |
IRON FUM,PS/FOLIC/BCOMP,C NO.9 |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
IRON 27 MG TABLET |
FERROUS GLUCONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
IRON 325 MG TABLET |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
IRON 45 MG TABLET |
FERROUS SULFATE, DRIED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
IRON 65 MG TABLET |
FERROUS SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
MYFERON 150 CAPSULE |
IRON POLYSACCHARIDE COMPLEX |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
IRON PS COMPLEX/B12/FOLIC ACID |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
IRON POLYSACCHARIDE COMPLEX |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
IRON PS COMPLEX/B12/FOLIC ACID |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
IRON POLYSACCHARIDE COMPLEX |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
PUREVIT DUALFE PLUS CAPSULE |
IRON FM,PS NO.1/FOLIC/MV NO.18 |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
IRON FM,PS NO.1/FOLIC/MV NO.18 |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
TANDEM PLUS CAPSULE |
IRON FM,PS NO.1/FOLIC/MV NO.18 |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
TARON FORTE CAPSULE |
IRON BG,PS/VITC/B12/FA/CALCIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
TL ICON CAPSULE |
FERROUS FUM/VIT |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
TRICON CAPSULE |
FERROUS FUM/VIT |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3B |
|
WEE CARE 15 MG/1.25 ML SUSP |
IRON,CARBONYL |
0 |
999 |
|
No |
|
|||
|
|
|
C3C |
ZINC REPLACEMENT |
|
|
|
|
|
|
|
|
|
C3C |
|
ZINC CHLORIDE 1 MG/ML VIAL |
ZINC CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3C |
|
ZINC SULFATE 5 MG/ML VIAL |
ZINC SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C3H |
IODINE CONTAINING AGENTS |
|
|
|
|
|
|
|
|
|
C3H |
|
IODOPEN 100 MCG/ML VIAL |
SODIUM IODIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C3H |
|
SSKI 1 GM/ML SOLUTION |
POTASSIUM IODIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
C3M |
MINERAL REPLACEMENT, MISCELLANEOUS |
|
|
|
|
|
|||
|
C3M |
|
CHROMIUM 4 MCG/ML VIAL |
CHROMIC CHLORIDE |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 26 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
C3M |
|
CHROMIUM CL 40 MCG/10 ML VIAL |
|
|
CHROMIC CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C3M |
|
COPPER CHLORIDE 0.4 MG/ML VL |
|
|
|
CUPRIC CHLORIDE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C3M |
|
MANGANESE 0.1 MG/ML VIAL |
|
|
|
MANGANESE CHLORIDE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C3M |
|
|
|
|
ZINC/COPPER/MANGAN/CHROMIC CHL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C3M |
|
|
|
|
ZINC/COPPER/MANGAN/CHROMIC CHL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C3M |
|
|
|
|
ZINC/COPPER/MANGAN/CHROM/SELEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C3M |
|
|
|
|
ZINC/COPPER/MANGAN/CHROM/SELEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C3M |
|
SELENIUM 40 MCG/ML VIAL |
|
|
|
SELENIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C3M |
|
TRACE |
|
|
|
ZINC/COPPER/MANGAN/CHROMIC CHL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|||||||
|
|
|
C4D |
|
|
|
||||||||
|
C4D |
|
FARXIGA 10 MG TABLET |
|
|
|
DAPAGLIFLOZIN PROPANEDIOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4D |
|
FARXIGA 5 MG TABLET |
|
|
|
DAPAGLIFLOZIN PROPANEDIOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4D |
|
INVOKANA 100 MG TABLET |
|
|
|
CANAGLIFLOZIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4D |
|
INVOKANA 300 MG TABLET |
|
|
|
CANAGLIFLOZIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4D |
|
JARDIANCE 10 MG TABLET |
|
|
|
EMPAGLIFLOZIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4D |
|
JARDIANCE 25 MG TABLET |
|
|
|
EMPAGLIFLOZIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
||||||
|
|
|
C4E |
|
|
|
|
|||||||
|
C4E |
|
INVOKAMET |
|
|
CANAGLIFLOZIN/METFORMIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4E |
|
INVOKAMET |
|
|
|
CANAGLIFLOZIN/METFORMIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4E |
|
INVOKAMET |
|
|
|
CANAGLIFLOZIN/METFORMIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4E |
|
INVOKAMET |
|
|
|
CANAGLIFLOZIN/METFORMIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4E |
|
SYNJARDY |
|
|
|
EMPAGLIFLOZIN/METFORMIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4E |
|
SYNJARDY |
|
|
|
EMPAGLIFLOZIN/METFORMIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4E |
|
SYNJARDY |
|
|
|
EMPAGLIFLOZIN/METFORMIN HCL |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 27 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4E |
|
SYNJARDY |
|
|
EMPAGLIFLOZIN/METFORMIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4E |
|
XIGDUO XR 10 |
|
|
DAPAGLIFLOZIN/METFORMIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4E |
|
XIGDUO XR 10 |
|
|
DAPAGLIFLOZIN/METFORMIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4E |
|
XIGDUO XR 2.5 |
|
|
DAPAGLIFLOZIN/METFORMIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4E |
|
XIGDUO XR 5 |
|
|
DAPAGLIFLOZIN/METFORMIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4E |
|
XIGDUO XR 5 |
|
|
DAPAGLIFLOZIN/METFORMIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
C4F |
|
|
|
|||||||
|
C4F |
|
JANUMET |
|
|
SITAGLIPTIN PHOS/METFORMIN HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4F |
|
JANUMET |
|
|
SITAGLIPTIN PHOS/METFORMIN HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4F |
|
JANUMET XR |
|
|
SITAGLIPTIN PHOS/METFORMIN HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4F |
|
JANUMET XR |
|
|
SITAGLIPTIN PHOS/METFORMIN HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4F |
|
JANUMET XR |
|
|
SITAGLIPTIN PHOS/METFORMIN HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4F |
|
JENTADUETO 2.5 |
|
|
LINAGLIPTIN/METFORMIN HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4F |
|
JENTADUETO 2.5 |
|
|
LINAGLIPTIN/METFORMIN HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4F |
|
JENTADUETO 2.5 |
|
|
LINAGLIPTIN/METFORMIN HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4F |
|
KOMBIGLYZE XR |
|
|
SAXAGLIPTIN HCL/METFORMIN HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4F |
|
KOMBIGLYZE XR |
|
|
SAXAGLIPTIN HCL/METFORMIN HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4F |
|
KOMBIGLYZE XR |
|
|
SAXAGLIPTIN HCL/METFORMIN HCL |
18 |
999 |
|
No |
|
||
|
|
|
C4G |
|
|
INSULINS |
|
|
|
|
|
|
|
|
C4G |
|
HUMALOG 100 UNITS/ML CARTRIDGE |
INSULIN LISPRO |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4G |
|
HUMALOG 100 UNITS/ML KWIKPEN |
|
|
INSULIN LISPRO |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4G |
|
HUMALOG 100 UNITS/ML VIAL |
|
|
INSULIN LISPRO |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4G |
|
HUMALOG MIX 50/50 KWIKPEN |
|
|
INSULIN LISPRO PROTAMIN/LISPRO |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4G |
|
HUMALOG MIX 50/50 VIAL |
|
|
INSULIN LISPRO PROTAMIN/LISPRO |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 28 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
HUMALOG MIX |
INSULIN LISPRO PROTAMIN/LISPRO |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
HUMALOG MIX 75/25 KWIKPEN |
INSULIN LISPRO PROTAMIN/LISPRO |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
HUMALOG MIX 75/25 VIAL |
INSULIN LISPRO PROTAMIN/LISPRO |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
HUMALOG MIX |
INSULIN LISPRO PROTAMIN/LISPRO |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
HUMULIN 70/30 VIAL |
INSULIN NPH HUM/REG INSULIN HM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
HUMULIN |
INSULIN NPH HUM/REG INSULIN HM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
HUMULIN N 100 UNITS/ML VIAL |
INSULIN NPH HUMAN ISOPHANE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
HUMULIN R 100 UNITS/ML VIAL |
INSULIN REGULAR, HUMAN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
LANTUS 100 UNIT/ML VIAL |
INSULIN GLARGINE,HUM.REC.ANLOG |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
LANTUS 100 UNITS/ML VIAL |
INSULIN GLARGINE,HUM.REC.ANLOG |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
LANTUS SOLOSTAR 100 UNIT/ML |
INSULIN GLARGINE,HUM.REC.ANLOG |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
LANTUS SOLOSTAR 100 UNITS/ML |
INSULIN GLARGINE,HUM.REC.ANLOG |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
LEVEMIR 100 UNITS/ML VIAL |
INSULIN DETEMIR |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
LEVEMIR FLEXTOUCH 100 UNITS/ML |
INSULIN DETEMIR |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
NOVOLIN 70/30 100 UNITS/ML VIA |
INSULIN NPH HUM/REG INSULIN HM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
NOVOLIN N 100 UNITS/ML VIAL |
INSULIN NPH HUMAN ISOPHANE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
NOVOLIN R 100 UNITS/ML VIAL |
INSULIN REGULAR, HUMAN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
NOVOLOG 100 UNITS/ML CARTRIDGE |
INSULIN ASPART |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
NOVOLOG 100 UNITS/ML VIAL |
INSULIN ASPART |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
NOVOLOG FLEXPEN SYRINGE |
INSULIN ASPART |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
NOVOLOG MIX 70/30 FLEXPEN SYRN |
INSULIN ASPART PROT/INSULN ASP |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
NOVOLOG MIX 70/30 VIAL |
INSULIN ASPART PROT/INSULN ASP |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
RELION NOVOLIN |
INSULIN NPH HUM/REG INSULIN HM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4G |
|
RELION NOVOLIN N 100 UNIT/ML |
INSULIN NPH HUMAN ISOPHANE |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 29 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4G |
|
RELION NOVOLIN R 100 UNIT/ML |
|
|
INSULIN REGULAR, HUMAN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
C4H |
ANTIHYPERGLYCEMIC, AMYLIN |
|
|
|
|
|||||
|
C4H |
|
SYMLINPEN 120 PEN INJECTOR |
|
|
PRAMLINTIDE ACETATE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4H |
|
SYMLINPEN 60 PEN INJECTOR |
|
|
PRAMLINTIDE ACETATE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
C4I |
ANTIHYPERGLY,INCRETIN |
|
|
|
|
|||||
|
C4I |
|
BYDUREON 2 MG VIAL |
|
|
EXENATIDE MICROSPHERES |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4I |
|
BYETTA 10 MCG DOSE PEN INJ |
|
|
EXENATIDE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4I |
|
BYETTA 5 MCG DOSE PEN INJ |
|
|
EXENATIDE |
0 |
|
999 |
|
No |
|
|
|
|
|
C4J |
|
|
ANTIHYPERGLYCEMIC, |
|
|
|
|
|
|
|
|
C4J |
|
JANUVIA 100 MG TABLET |
|
|
SITAGLIPTIN PHOSPHATE |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4J |
|
JANUVIA 25 MG TABLET |
|
|
SITAGLIPTIN PHOSPHATE |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4J |
|
JANUVIA 50 MG TABLET |
|
|
SITAGLIPTIN PHOSPHATE |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4J |
|
ONGLYZA 2.5 MG TABLET |
|
|
SAXAGLIPTIN HCL |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4J |
|
ONGLYZA 5 MG TABLET |
|
|
SAXAGLIPTIN HCL |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4J |
|
TRADJENTA 5 MG TABLET |
|
|
LINAGLIPTIN |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
C4K |
ANTIHYPERGLYCEMIC, |
|
|
|
|
|||||
|
C4K |
|
CHLORPROPAMIDE 100 MG TABLET |
|
|
CHLORPROPAMIDE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4K |
|
CHLORPROPAMIDE 250 MG TABLET |
|
|
CHLORPROPAMIDE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4K |
|
GLIMEPIRIDE 1 MG TABLET |
|
|
GLIMEPIRIDE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4K |
|
GLIMEPIRIDE 2 MG TABLET |
|
|
GLIMEPIRIDE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4K |
|
GLIMEPIRIDE 4 MG TABLET |
|
|
GLIMEPIRIDE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4K |
|
GLIPIZIDE 10 MG TABLET |
|
|
GLIPIZIDE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4K |
|
GLIPIZIDE 5 MG TABLET |
|
|
GLIPIZIDE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4K |
|
GLIPIZIDE ER 10 MG TABLET |
|
|
GLIPIZIDE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4K |
|
GLIPIZIDE ER 2.5 MG TABLET |
|
|
GLIPIZIDE |
0 |
|
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 30 of 204 |
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Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
GLIPIZIDE ER 5 MG TABLET |
GLIPIZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
GLIPIZIDE XL 10 MG TABLET |
GLIPIZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
GLIPIZIDE XL 2.5 MG TABLET |
GLIPIZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
GLIPIZIDE XL 5 MG TABLET |
GLIPIZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
GLYBURIDE 1.25 MG TABLET |
GLYBURIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
GLYBURIDE 2.5 MG TABLET |
GLYBURIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
GLYBURIDE 5 MG TABLET |
GLYBURIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
GLYBURIDE MICRO 1.5 MG TAB |
GLYBURIDE,MICRONIZED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
GLYBURIDE MICRO 3 MG TAB |
GLYBURIDE,MICRONIZED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
GLYBURIDE MICRO 3 MG TABLET |
GLYBURIDE,MICRONIZED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
GLYBURIDE MICRO 6 MG TAB |
GLYBURIDE,MICRONIZED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
GLYBURIDE MICRO 6 MG TABLET |
GLYBURIDE,MICRONIZED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
REPAGLINIDE 0.5 MG TABLET |
REPAGLINIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
REPAGLINIDE 1 MG TABLET |
REPAGLINIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
REPAGLINIDE 2 MG TABLET |
REPAGLINIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
TOLAZAMIDE 250 MG TABLET |
TOLAZAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
TOLAZAMIDE 500 MG TABLET |
TOLAZAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4K |
|
TOLBUTAMIDE 500 MG TABLET |
TOLBUTAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
C4L |
ANTIHYPERGLYCEMIC, BIGUANIDE TYPE |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4L |
|
METFORMIN HCL 1,000 MG TABLET |
METFORMIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
||
|
C4L |
|
METFORMIN HCL 500 MG TABLET |
METFORMIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|||
|
C4L |
|
METFORMIN HCL 750 MG ER TABLET |
METFORMIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C4L |
|
METFORMIN HCL 850 MG TABLET |
METFORMIN HCL |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 31 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4L |
|
METFORMIN HCL ER 500 MG TAB |
|
|
|
|
METFORMIN HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4L |
|
METFORMIN HCL ER 500 MG TABLET |
|
|
|
METFORMIN HCL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4L |
|
METFORMIN HCL ER 750 MG TABLET |
|
|
|
METFORMIN HCL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
C4M |
|
|
ANTIHYPERGLYCEMIC, |
|
|
|
|
|||||
|
C4M |
|
ACARBOSE 100 MG TABLET |
|
|
|
|
ACARBOSE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4M |
|
ACARBOSE 25 MG TABLET |
|
|
|
|
ACARBOSE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4M |
|
ACARBOSE 50 MG TABLET |
|
|
|
|
ACARBOSE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4M |
|
GLYSET 100 MG TABLET |
|
|
|
|
MIGLITOL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4M |
|
GLYSET 25 MG TABLET |
|
|
|
|
MIGLITOL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4M |
|
GLYSET 50 MG TABLET |
|
|
|
|
MIGLITOL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
||||||||
|
|
|
C4N |
ANTIHYPERGLYCEMIC,THIAZOLIDINEDIONE(PPARG AGONIST) |
|
|
|
||||||||
|
C4N |
|
PIOGLITAZONE 15 MG TABLET |
|
|
|
|
PIOGLITAZONE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4N |
|
PIOGLITAZONE 30 MG TABLET |
|
|
|
|
PIOGLITAZONE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4N |
|
PIOGLITAZONE 45 MG TABLET |
|
|
|
|
PIOGLITAZONE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4N |
|
PIOGLITAZONE HCL 15 MG TABLET |
|
|
|
|
PIOGLITAZONE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4N |
|
PIOGLITAZONE HCL 30 MG TABLET |
|
|
|
|
PIOGLITAZONE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4N |
|
PIOGLITAZONE HCL 45 MG TABLET |
|
|
|
|
PIOGLITAZONE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
C4S |
|
|
|
|
|
|||||||
|
C4S |
|
|
|
|
GLIPIZIDE/METFORMIN HCL |
0 |
|
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C4S |
|
|
|
|
GLIPIZIDE/METFORMIN HCL |
0 |
|
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4S |
|
|
|
|
|
GLIPIZIDE/METFORMIN HCL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4S |
|
|
|
|
|
GLIPIZIDE/METFORMIN HCL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4S |
|
|
|
|
|
GLIPIZIDE/METFORMIN HCL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4S |
|
|
|
|
|
GLIPIZIDE/METFORMIN HCL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
C4S |
|
|
|
GLYBURIDE/METFORMIN HCL |
0 |
|
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 32 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
C4S |
|
GLYBURIDE/METFORMIN HCL |
0 |
|
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4S |
|
|
|
GLYBURIDE/METFORMIN HCL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4S |
|
|
|
GLYBURIDE/METFORMIN HCL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|||
|
C4S |
|
GLYBURIDE/METFORMIN HCL |
0 |
|
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|||
|
C4S |
|
GLYBURIDE/METFORMIN HCL |
0 |
|
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|||
|
C4S |
|
GLYBURIDE/METFORMIN HCL |
0 |
|
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4S |
|
|
|
GLYBURIDE/METFORMIN HCL |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
||||||
|
|
|
C4T |
ANTIHYPERGLYCEMIC, THIAZOLIDINEDIONE AND BIGUANIDE |
|
|
|
||||||
|
C4T |
|
PIOGLITAZONE HCL/METFORMIN HCL |
0 |
|
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|||
|
C4T |
|
PIOGLITAZONE HCL/METFORMIN HCL |
0 |
|
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|||||
|
|
|
C4W |
ANTIHYPERGLYCEMIC, |
|
|
|
|
|||||
|
C4W |
|
GLYXAMBI 10 |
|
|
EMPAGLIFLOZIN/LINAGLIPTIN |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C4W |
|
GLYXAMBI 25 |
|
|
EMPAGLIFLOZIN/LINAGLIPTIN |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C5B |
C5B |
AMINOSYN |
C5B |
AMINOSYN 8.5% IV SOLUTION |
C5B |
AMINOSYN II 8.5% ELECTROLYT |
C5B |
AMINOSYN M 3.5% IV SOLUTION |
C5B |
|
C5B |
CLINIMIX 2.75/5 SOLUTION |
C5B |
CLINIMIX 4.25%/10 SOLUTION |
C5B |
CLINIMIX 4.25%/20 SOLUTION |
C5B |
CLINIMIX 4.25%/25 SOLUTION |
C5B |
CLINIMIX 4.25/20 SOLUTION |
C5B |
CLINIMIX 4.25/5 SOLUTION |
PROTEIN REPLACEMENT
AMINO ACIDS 7 %/ELECTROLYTES |
0 |
999 |
No |
AMINO ACIDS 8.5 %/ELECTROLYTES |
0 |
999 |
No |
AMINO ACIDS 8.5 %/ELECTROLYTES |
0 |
999 |
No |
AMINO ACIDS 3.5%/ELECTROLYTE M |
0 |
999 |
No |
AMINO ACIDS 7 % |
0 |
999 |
No |
AMINO ACIDS 2.75 %/D5W |
0 |
999 |
No |
AMINO ACIDS 4.25%/DEXTROSE 10% |
0 |
999 |
No |
AMINO ACIDS 4.25%/DEXTROSE 20% |
0 |
999 |
No |
AMINO ACID 4.25 %/DEXTROSE 25% |
0 |
999 |
No |
AMINO ACIDS 4.25%/DEXTROSE 20% |
0 |
999 |
No |
AMINO ACIDS 4.25 %/DEXTROSE 5% |
0 |
999 |
No |
Thursday, October 25, 2018 |
Page 33 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
CLINIMIX 5/15 SOLUTION |
AMINO ACIDS 5 %/DEXTROSE 15 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
CLINIMIX 5/20 SOLUTION |
AMINO ACIDS 5 %/DEXTROSE 20 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
CLINIMIX 5/25 SOLUTION |
AMINO ACIDS 5 %/DEXTROSE 25 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
CLINIMIX E 2.75/5 SOLUTION |
AA 2.75 %/CALCIUM/LYTES/D5W |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
CLINIMIX E 4.25/10 SOLUTION |
AA 4.25%/CALCIUM/LYTES/DEX 10% |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
CLINIMIX E 4.25/25 SOLUTION |
AA 4.25 %/CALCIUM/LYTES/D25W |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
CLINIMIX E 4.25/5 SOLUTION |
AA 4.25 %/CALCIUM/LYTES/D5W |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
CLINIMIX E 5/20 SOLUTION |
AA 5 %/CALCIUM/LYTES/DEXT 20 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
CLINIMIX E 5/25 SOLUTION |
AA 5 %/CALCIUM/LYTES/DEXT 25 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
FREAMINE HBC 6.9% IV SOLN |
AMINO ACIDS 6.9 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
HEPATAMINE 8% IV SOLUTION |
AMINO ACIDS 8 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
CYSTEINE HCL |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
NEPHRAMINE 5.4% IV SOLUTION |
AMINO ACIDS 5.4 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
PROCALAMINE IV SOLUTION |
AMINO AC 3%/ELECTROLYTE/GLYCER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
TROPHAMINE 10% IV SOLUTION |
AMINO ACIDS 10 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5B |
|
TROPHAMINE 6% IV SOLUTION |
AMINO ACIDS 6 % |
0 |
999 |
|
No |
|
|||
|
|
|
C5F |
DIETARY SUPPLEMENT, MISCELLANEOUS |
|
|
|
|
|
|
||
|
C5F |
|
COCONUT OIL 1,000 MG SOFTGEL |
COCONUT OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5F |
|
EQL COCONUT OIL 1,000 MG SFTGL |
COCONUT OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5F |
|
OMEGA3/DHA/EPA/FISH OIL/VIT D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C5F |
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||||
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
C5J |
IV SOLUTIONS: |
|
|
|
|
|
|
||
|
C5J |
|
DEXTROSE 10% WATER IV SOLN. |
DEXTROSE 10 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 10%/H2O/EXCEL CONT |
DEXTROSE 10 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 34 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C5J |
|
DEXTROSE 10%/WATER IV SOLN |
DEXTROSE 10 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 10%/WATER IV SOLN. |
DEXTROSE 10 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE |
DEXTROSE 10 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 20%/WATER IV SOLN |
DEXTROSE 20 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 25%/WATER SYRINGE |
DEXTROSE 25 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 30%/WATER IV SOLN. |
DEXTROSE 30 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 40%/WATER IV SOLN |
DEXTROSE 40 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 5%/WATER IV SOLN |
DEXTROSE 5 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 5%/WATER IV SOLN. |
DEXTROSE 5 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 5%/WATER VIAL |
DEXTROSE 5 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 5%/WATER/EXCEL CON |
DEXTROSE 5 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE |
DEXTROSE 5 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE |
DEXTROSE 5 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE |
DEXTROSE 5 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE |
DEXTROSE 5 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE |
DEXTROSE 5 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 50%/WATER ABBOJECT |
DEXTROSE 50 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 50%/WATER IV SOLN |
DEXTROSE 50 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 50%/WATER SYRINGE |
DEXTROSE 50 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 50%/WATER VIAL |
DEXTROSE 50 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 70%/WATER IV SOLN |
DEXTROSE 70 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE 70%/WATER IV SOLN. |
DEXTROSE 70 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
DEXTROSE |
DEXTROSE 70 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C5J |
|
GLUCOSE |
DEXTROSE 5 % IN WATER |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 35 of 204 |
Class |
Medicaid Drug Name |
|
|
C5J |
GLUCOSE |
|
C5K |
C5K |
|
C5K |
|
C5K |
|
C5K |
|
C5K |
DEXTROSE |
C5K |
DEXTROSE |
C5K |
DEXTROSE |
C5K |
DEXTROSE |
C5K |
DEXTROSE |
C5K |
DEXTROSE |
C5K |
DEXTROSE |
C5K |
DEXTROSE |
C5K |
DEXTROSE |
C5K |
DEXTROSE |
C5K |
DEXTROSE |
|
C5M |
C5M |
DEXTROSE |
C5M |
DEXTROSE |
|
C6A |
C6A |
CVS VITAMIN A 8,000 UNIT SFTGL |
C6A |
GNP VITAMIN A 10,000 UNIT SFGL |
C6A |
RA VITAMIN A 10,000 UNIT SFTGL |
C6A |
VITAMIN A 10,000 UNITS CAP |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
Min Age |
|
Max Age |
|
|
|
DEXTROSE 5 % IN WATER |
0 |
999 |
|
No |
||
|
IV SOLUTIONS: |
|
|
|
|
|
|
|
DEXTROSE 10 % AND 0.45 % NACL |
0 |
999 |
|
No |
||
|
DEXTROSE 5 |
0 |
999 |
|
No |
||
|
DEXTROSE 5 % AND 0.3 % NACL |
0 |
999 |
|
No |
||
|
DEXTROSE 5 |
0 |
999 |
|
No |
||
|
DEXTROSE 10 % AND 0.2 % NACL |
0 |
999 |
|
No |
||
|
DEXTROSE 2.5 % AND 0.45 % NACL |
0 |
999 |
|
No |
||
|
DEXTROSE 5 |
0 |
999 |
|
No |
||
|
DEXTROSE 5 |
0 |
999 |
|
No |
||
|
DEXTROSE 5 % AND 0.3 % NACL |
0 |
999 |
|
No |
||
|
DEXTROSE 5 % AND 0.3 % NACL |
0 |
999 |
|
No |
||
|
DEXTROSE 5 % AND 0.3 % NACL |
0 |
999 |
|
No |
||
|
DEXTROSE 5 |
0 |
999 |
|
No |
||
|
DEXTROSE 5 |
0 |
999 |
|
No |
||
|
DEXTROSE 5 |
0 |
999 |
|
No |
||
|
DEXTROSE 5 % AND 0.9 % NACL |
0 |
999 |
|
No |
||
IV SOLUTIONS: DEXTROSE AND LACTATED RINGERS |
|
|
|
|
|||
|
DEXTROSE |
0 |
999 |
|
No |
||
|
DEXTROSE |
0 |
999 |
|
No |
||
|
VITAMIN A PREPARATIONS |
|
|
|
|
|
|
|
VITAMIN A |
0 |
999 |
|
Cystic Fib Diag Auto PA |
||
|
VITAMIN A |
0 |
999 |
|
Cystic Fib Diag Auto PA |
||
|
VITAMIN A |
0 |
999 |
|
Cystic Fib Diag Auto PA |
||
|
VITAMIN A |
0 |
999 |
|
Cystic Fib Diag Auto PA |
Thursday, October 25, 2018 |
Page 36 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C6A |
|
VITAMIN A 10,000 UNITS CAPSULE |
VITAMIN A |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6A |
|
VITAMIN A 10,000 UNITS SOFTGEL |
VITAMIN A |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6A |
|
VITAMIN A 25,000 UNITS CAPSULE |
VITAMIN A |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6A |
|
VITAMIN A 8,000 UNITS CAPSULE |
VITAMIN A |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6A |
|
VITAMIN A 8,000 UNITS SOFTGELS |
VITAMIN A |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
C6B |
VITAMIN B PREPARATIONS |
|
|
|
|
|
|
|
|
|
C6B |
|
DIALYVITE 3,000 TABLET |
FOLIC ACID/B CPLX/C/SELEN/ZINC |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6B |
|
DIALYVITE 5000 TABLET |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6B |
|
DIALYVITE SUPREME D TABLET |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6B |
|
DIALYVITE TABLET |
FOLIC ACID/VIT B COMPLEX AND C |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6B |
|
DIALYVITE WITH ZINC TABLET |
B COMPLEX 11/FOLIC/C/BIOT/ZINC |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6B |
|
NEPHPLEX RX TABLET |
B COMP NO3/FOLIC/C/BIOTIN/ZINC |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6B |
|
VIT B COMP NO.3/FOLIC/C/BIOTIN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6B |
|
TL GARD RX TABLET |
CYANOCOBALAMIN/FOLIC AC/VIT B6 |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6B |
|
FOLIC ACID/B COMPLEX C NO.17 |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6B |
|
B CMPLX 4/VIT D3/C/FOLIC/ZINC |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6B |
|
VIT B COMP NO.3/FOLIC/C/BIOTIN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6B |
|
VIT B COMP NO.3/FOLIC/C/BIOTIN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6C |
VITAMIN C PREPARATIONS |
|
|
|
|
|
|
|
|
|
C6C |
|
ACEROLA C 500 MG TABLET CHEW |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ACEROLA C 500 MG WAFER |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ASCORBIC ACID 250 MG TABLET |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ASCORBIC ACID 500 MG TABLET |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ASCORBIC ACID 500 MG TABLET |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
Thursday, October 25, 2018 |
Page 37 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ASCORBIC ACID 500 MG/5 ML SYR |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ASCORBIC ACID GRANULAR |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ASCORBIC ACID W/RH 500 MG TB |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
CALCIUM ASCORBATE 500 MG TAB |
ASCORBATE CALCIUM |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
VITAMIN C 1,000 MG CAPLET |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
VITAMIN C 1,000 MG TABLET |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
VITAMIN C 125 MG GUMMIES |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
VITAMIN C 125 MG GUMMY |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
VITAMIN C 250 MG TABLET |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
VITAMIN C 500 MG CAPLET |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
VITAMIN C 500 MG CHEW TABLET |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
VITAMIN C 500 MG TABLET |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6C |
|
VITAMIN C 500 MG TABLET CHEW |
ASCORBIC ACID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6D |
VITAMIN D PREPARATIONS |
|
|
|
|
|
|
|
|
|
C6D |
|
BABY VITAMIN D3 400 UNIT/DROP |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
CALCITRIOL 0.25 MCG CAPSULE |
CALCITRIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 38 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C6D |
|
CALCITRIOL 0.5 MCG CAPSULE |
CALCITRIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
CALCITRIOL 1 MCG/ML AMPUL |
CALCITRIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
CALCITRIOL 1 MCG/ML SOLUTION |
CALCITRIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
KIDS VITAMIN D3 TAB CHEW |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VIT D2 1.25 MG (50,000 UNIT) |
ERGOCALCIFEROL (VITAMIN D2) |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VIT D3 5,000 UNIT FAST DISSOLV |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 1,000 UNIT TAB |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 1,000 UNIT TABLET |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 1,000 UNITS SOFTGEL |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 1,000 UNITS TAB |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 1,000 UNITS TABLET |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 10,000 UNIT SOFTGEL |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 2,000 UNIT SOFTGEL |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 2,000 UNIT TABLET |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 2,000 UNITS SOFTGEL |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 2000 SOFTGEL |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 400 UNIT SOFTGEL |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 400 UNIT TABLET |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 400 UNIT/ML DROP |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 400 UNITS TABLET |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 5,000 UNIT CAPSULE |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 5,000 UNIT TABLET |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 50,000 UNIT CAPSULE |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D 50,000 UNITS CAPSULE |
ERGOCALCIFEROL (VITAMIN D2) |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 39 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C6D |
|
VITAMIN D2 2,000 UNIT TABLET |
ERGOCALCIFEROL (VITAMIN D2) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D2 400 UNIT TABLET |
ERGOCALCIFEROL (VITAMIN D2) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 1,000 UNIT GUMMIES |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 1,000 UNIT SOFTGEL |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 1,000 UNIT TAB |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 1,000 UNIT TAB CHEW |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 1,000 UNIT TABLET |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 1,000 UNIT/10 ML LQ |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 1,000 UNITS SOFTGEL |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 1,000 UNITS TABLET |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 10,000 UNIT SOFTGEL |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 10,000 UNIT TABLET |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 2,000 UNIT SOFTGEL |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 2,000 UNIT SPRAY |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 2,000 UNIT TAB CHEW |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 2,000 UNIT TABLET |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 2,000 UNITS SOFTGEL |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 3,000 UNIT TABLET |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 400 UNIT SOFTGEL |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 400 UNIT TAB CHEW |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 40 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C6D |
|
VITAMIN D3 400 UNIT TABLET |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 400 UNIT/5 ML LIQ |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 400 UNIT/ML DROP |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 5,000 UNIT CAPSULE |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 5,000 UNIT SOFTGEL |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 5,000 UNIT TABLET |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 5,000 UNIT/ML DROPS |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 5,000 UNITS SOFTGEL |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 5,000 UNITS/ML DRPS |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN D3 50,000 UNITS CAPS |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6D |
|
VITAMIN |
CHOLECALCIFEROL (VITAMIN D3) |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
C6F |
PRENATAL VITAMIN PREPARATIONS |
|
|
|
|
|
|
|
|
|
C6F |
|
PNV, CALCIUM 70/IRON/FOLIC/DHA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
CITRANATAL 90 DHA COMBO PACK |
PNV72/IRON,GLUC/FOLIC/DSS/DHA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
CITRANATAL ASSURE COMBO PACK |
PNV73/IRON,GLUC/FOLIC/DSS/DHA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
CITRANATAL |
PRENATAL 48/IRON/FOLIC ACID/B6 |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
CITRANATAL DHA PACK |
PNV 76/IRON,GLUC/FOLIC/DSS/DHA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
CITRANATAL HARMONY CAPSULE |
PNV59/IRON,CARB,FUM/FA/DSS/DHA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PNV 11/IRON FUM/FOLIC ACID/OM3 |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
COMPLETE NATAL DHA |
PRENATAL 2/IRON/FOLIC ACID/OM3 |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
COMPLETENATE TABLET CHEW |
PRENATAL VIT 14/IRON FUM/FOLIC |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
CONCEPT DHA CAPSULE |
PNV 16/IRON |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
CONCEPT OB CAPSULE |
PNV 15/IRON FUM,PS/FOLIC ACID |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL NO.123/IRON/FOLIC AC |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 41 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C6F |
|
PNV 15/IRON FUM,PS/FOLIC ACID |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
OB COMPLETE CAPLET |
PRENATAL NO.123/IRON/FOLIC AC |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PNV OB+DHA COMBO PACK |
PNV 22/IRON,GLUC/FOLIC/DSS/DHA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PNV 66/IRON/FOLIC/DOCUSATE/DHA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENAT 115/IRON FUM/FOLIC/DSS |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL 68/IRON/FOLIC NO1/DHA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PNV NO.5/FERROUS FUM/FOLIC AC |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PREFERA OB TABLET |
PNV 21/IRON PS,HEME PPEP/FOLIC |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENAISSANCE CAPSULE |
PNV 80/IRON FUM/FOLIC/DSS/DHA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENAISSANCE PLUS SOFTGEL |
PNV 69/IRON/FOLIC/DOCUSATE/DHA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL PLUS TABLET |
PNV,CALCIUM 72/IRON/FOLIC ACID |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL VITAMIN PLUS LOW IRON |
PNV,CALCIUM 72/IRON/FOLIC ACID |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PREPLUS |
PNV,CALCIUM 72/IRON/FOLIC ACID |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PREPLUS TABLET |
PNV,CALCIUM 72/IRON/FOLIC ACID |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PROVIDA OB CAPSULE |
PRENATAL VIT 65/IRON FUM,PS/FA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
RULAVITE DHA SOFTGEL |
PRENATAL 47/IRON/FOLATE 1/DHA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL VIT 33/IRON/FOLIC/DHA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL VIT128/IRON/FOLIC ACD |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL NO13/IRON PS/FOLATE 1 |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PNV NO.118/IRON FUMARATE/FA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PNV119/IRON FUM/FOLIC/DOCUSATE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
TARON PRENATAL DHA CAPSULE |
PNV 39/IRON/FOLIC/DOCUSATE/DHA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PNV 16/IRON |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
TRINATAL RX 1 TABLET |
PRENATAL VIT27,CALCIUM/IRON/FA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 42 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C6F |
|
PRENATAL 53/IRON/FOLIC AC/OMG3 |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
TRUST NATAL DHA |
PRENATAL 2/IRON/FOLIC ACID/OM3 |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
ULTIMATECARE ONE CAPSULE |
PNV,CALCIUM37/IRON/FOLIC/OMEG3 |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PNV 66/IRON/FOLIC/DOCUSATE/DHA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL VITS15/IRON/FOLIC/DSS |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PNV 16/IRON |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PNV 11/IRON FUM/FOLIC ACID/OM3 |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL 47/IRON/FOLATE 1/DHA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL 68/IRON/FOLIC NO1/DHA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL,CALC.40/IRON/FOLATE 1 |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
VIRTPREX CAPSULE |
PNV 66/IRON/FOLIC/DOCUSATE/DHA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PNV 80/IRON FUM/FOLIC/DSS/DHA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL VITS16/IRON/FOLIC/DSS |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
VITAFOL FE+ DOCUSATE COMBO PCK |
PNV 102/IRON/FOLATE 1/DSS/DHA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
VITAFOL GUMMIES |
PNV 112/IRON/FOLIC/OM3/DHA/EPA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
VITAFOL NANO TABLET |
PRENATAL NO.75/IRON/FOLATE NO1 |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
VITAFOL ULTRA SOFTGEL |
PNV 67/IRON PS/FOLATE NO.1/DHA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL VIT 10/IRON FUM/FOLIC |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL VIT 10/IRON/FOLIC/DHA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL 26/IRON PS/FOLIC/DHA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL 34/IRON/FOLIC/DSS/DHA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PNV 21/IRON PS,HEME PPEP/FOLIC |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL 47/IRON/FOLATE 1/DHA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
C6F |
|
PRENATAL 68/IRON/FOLIC NO1/DHA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 43 of 204 |
Class Medicaid Drug Name
|
C6H |
C6H |
AQUADEKS PEDIATRIC LIQUID |
C6H |
COMPLETE FORMULATION D3000 CAP |
C6H |
COMPLETE FORMULATION D3000 CHW |
C6H |
COMPLETE FORMULATION D5000 CAP |
C6H |
COMPLETE FORMULATION MULTIVIT |
C6H |
COMPLETE FORMULATION MULTIVIT |
C6H |
COMPLETE FORMULATION PEDIATRIC |
C6H |
DEKAS PLUS LIQUID |
C6H |
INFUVITE PEDIATRIC VIAL |
C6H |
M.V.I. PEDIATRIC VIAL |
C6H |
|
C6H |
|
C6H |
|
C6H |
|
C6H |
|
C6H |
|
C6H |
|
C6H |
MULTIVITS W/F 0.25 MG/ML DRP |
C6H |
MULTIVITS W/F 0.5 MG/ML DROP |
C6H |
MVW COMPLETE FORM MULTIVIT CHW |
C6H |
|
C6H |
|
C6H |
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
PEDIATRIC VITAMIN PREPARATIONS
PEDI MULTIVIT 40/PHYTONADIONE |
0 |
3 |
No |
PEDIATRIC MULTIVIT 61/D3/VIT K |
0 |
999 |
Cystic Fib Diag Auto PA |
PEDI MULTIVIT 22/VIT D3/VIT K |
0 |
999 |
Cystic Fib Diag Auto PA |
PEDIATRIC MULTIVIT 61/D3/VIT K |
0 |
999 |
Cystic Fib Diag Auto PA |
PEDI MULTIVIT 22/VIT D3/VIT K |
0 |
999 |
Cystic Fib Diag Auto PA |
PEDIATRIC MULTIVIT 61/D3/VIT K |
0 |
999 |
Cystic Fib Diag Auto PA |
PEDI MULTIVIT 77/VIT D3/VIT K |
0 |
999 |
Cystic Fib Diag Auto PA |
PEDI MULTIVIT NO.128/VITAMIN K |
0 |
999 |
Cystic Fib Diag Auto PA |
MULTIVIT INFUSION,PEDI 1,VIT K |
0 |
999 |
No |
MULTIVIT INFUSION,PEDI 2,VIT K |
0 |
999 |
No |
PEDI MULTIVIT 75/FLUORIDE/IRON |
0 |
12 |
No |
PEDI MULTIVIT NO.17 |
0 |
12 |
No |
PEDI MULTIVIT NO.17 |
0 |
12 |
No |
PEDI MULTIVIT NO.17 |
0 |
12 |
No |
PEDI MULTIVIT NO.17 |
0 |
12 |
No |
PEDI MULTIVIT NO.17 |
0 |
12 |
No |
PEDI MULTIVIT NO.17 |
0 |
12 |
No |
PEDI MULTIVIT NO.82 |
0 |
12 |
No |
PEDI MULTIVIT NO.82 |
0 |
12 |
No |
PEDI MULTIVIT 22/VIT D3/VIT K |
0 |
999 |
Cystic Fib Diag Auto PA |
PEDI MULTIVIT NO.37 |
0 |
12 |
No |
PEDI MULTIVIT NO.33/FLUORIDE |
0 |
12 |
No |
PEDI MULTIVIT NO.33/FLUORIDE |
0 |
12 |
No |
Thursday, October 25, 2018 |
Page 44 of 204 |
Class |
|
Medicaid Drug Name |
|
|
|
C6H |
|
|
C6H |
|
|
C6H |
|
|
C6H |
|
|
C6H |
|
|
C6H |
|
|
C6H |
|
|
|
|
C6K |
C6K |
|
MEPHYTON 5 MG TABLET |
C6K |
|
PHYTONADIONE 1 MG/0.5 ML SYR |
C6K |
|
VITAMIN K 1 MG/0.5 ML AMPUL |
C6K |
|
VITAMIN K 10 MG/ML AMPUL |
C6K |
|
VITAMIN |
C6K |
|
VITAMIN |
|
|
C6L |
C6L |
|
CYANOCOBALAMIN 1,000 MCG/ML |
C6L |
|
CYANOCOBALAMIN 10,000 MCG/10 |
C6L |
|
CYANOCOBALAMIN 30,000 MCG/30 |
C6L |
|
FOLTRATE TABLET |
|
|
C6M |
C6M |
|
FOLIC ACID 1 MG TABLET |
C6M |
|
FOLIC ACID 5 MG/ML VIAL |
|
|
C6Q |
C6Q |
|
PYRIDOXINE 100 MG/ML VIAL |
|
|
C6T |
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
Min Age |
|
Max Age |
|
|
PEDI MULTIVIT NO.33/FLUORIDE |
0 |
12 |
|
No |
||
PEDI MULTIVIT 37/FLUORIDE/IRON |
0 |
12 |
|
No |
||
PEDI MULTIVIT 33/FLUORIDE/IRON |
0 |
12 |
|
No |
||
PED MVIT A,C,D3 NO.38/FLUORIDE |
0 |
12 |
|
No |
||
PED MVIT A,C,D3 NO.38/FLUORIDE |
0 |
12 |
|
No |
||
PED MVIT A,C,D3 NO.21/FLUORIDE |
0 |
12 |
|
No |
||
PED MVIT A,C,D3 NO.21/FLUORIDE |
0 |
12 |
|
No |
||
VITAMIN K PREPARATIONS |
|
|
|
|
|
|
PHYTONADIONE (VIT K1) |
0 |
999 |
|
No |
||
PHYTONADIONE (VIT K1) |
0 |
999 |
|
No |
||
PHYTONADIONE (VIT K1) |
0 |
999 |
|
No |
||
PHYTONADIONE (VIT K1) |
0 |
999 |
|
No |
||
PHYTONADIONE (VIT K1) |
0 |
999 |
|
No |
||
PHYTONADIONE (VIT K1) |
0 |
999 |
|
No |
||
VITAMIN B12 PREPARATIONS |
|
|
|
|
|
|
CYANOCOBALAMIN (VITAMIN |
0 |
999 |
|
No |
||
CYANOCOBALAMIN (VITAMIN |
0 |
999 |
|
No |
||
CYANOCOBALAMIN (VITAMIN |
0 |
999 |
|
No |
||
CYANOCOBALAMIN/FOLIC ACID |
0 |
999 |
|
No |
||
FOLIC ACID PREPARATIONS |
|
|
|
|
|
|
FOLIC ACID |
0 |
999 |
|
No |
||
FOLIC ACID |
0 |
999 |
|
No |
||
VITAMIN B6 PREPARATIONS |
|
|
|
|
|
|
PYRIDOXINE HCL (VITAMIN B6) |
0 |
999 |
|
No |
VITAMIN B1 PREPARATIONS
Thursday, October 25, 2018 |
Page 45 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
C6T |
|
THIAMINE 100 MG/ML VIAL |
|
|
|
THIAMINE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6T |
|
THIAMINE 200 MG/2 ML VIAL |
|
|
|
THIAMINE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6Z |
|
|
|
MULTIVITAMIN PREPARATIONS |
|
|
|
|
|
|
|
|
C6Z |
|
AQUADEKS CHEWABLE TABLET |
|
|
|
4 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6Z |
|
BACMIN CAPLET |
|
|
|
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6Z |
|
CORVITA TABLET |
|
|
|
FOLIC/MVI |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6Z |
|
DEKAS ESSENTIAL CAPSULE |
|
|
|
VIT A/VIT D3/E/TOCOPHERSOLAN/K |
0 |
|
999 |
|
Cystic Fib Diag Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6Z |
|
DEKAS ESSENTIAL LIQUID |
|
|
|
VIT A/D3/TOCOPHERSOLAN/VIT K |
0 |
|
999 |
|
Cystic Fib Diag Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6Z |
|
DEKAS PLUS CHEWABLE TABLET |
|
|
|
0 |
|
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6Z |
|
DEKAS PLUS SOFTGEL |
|
|
|
0 |
|
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6Z |
|
DIALYVITE 800 WITH IRON TAB |
|
|
|
FERROUS FUM/FOLIC ACID/BCOMP,C |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6Z |
|
INFUVITE ADULT VIAL |
|
|
|
MULTIVIT INFUSN,ADULT 4,VIT K |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6Z |
|
M.V.I. ADULT VIAL |
|
|
|
MULTIVIT INFUSN,ADULT 1,VIT K |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6Z |
|
|
|
|
12 |
|
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6Z |
|
THRIVITE 19 TABLET |
|
|
|
MV, MIN 59/IRON/FOLIC/DOCUSATE |
12 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C6Z |
|
|
|
|
12 |
|
999 |
|
No |
|
|||
|
|
|
C7A |
|
HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS |
|
|
|
|
|||||
|
C7A |
|
ALLOPURINOL 100 MG TABLET |
|
|
|
ALLOPURINOL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C7A |
|
ALLOPURINOL 300 MG TABLET |
|
|
|
ALLOPURINOL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C7D |
|
|
|
METABOLIC DEFICIENCY AGENTS |
|
|
|
|
|
|
|
|
C7D |
|
CYSTADANE 1 GRAM/1.7 ML POWDER |
|
|
BETAINE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C7D |
|
LEVOCARNITINE 100 MG/ML SOLN |
|
|
|
LEVOCARNITINE (WITH SUGAR) |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C7D |
|
LEVOCARNITINE 330 MG TABLET |
|
|
|
LEVOCARNITINE |
0 |
|
999 |
|
No |
|
|
|
|
|
C7F |
APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND. |
|
|
|
|
||||||
|
C7F |
|
MEGESTROL 625 MG/5 ML SUSP |
|
|
|
MEGESTROL ACETATE |
0 |
|
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 46 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C7F |
|
MEGESTROL ACET 40 MG/ML SUSP |
|
|
MEGESTROL ACETATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C7F |
|
MEGESTROL ACET 400 MG/10 ML |
|
|
MEGESTROL ACETATE |
0 |
999 |
|
No |
|
||
|
|
|
C7I |
|
|
CYTOCHROME P450 INHIBITORS |
|
|
|
|
|
|
|
|
C7I |
|
TYBOST 150 MG TABLET |
|
|
COBICISTAT |
18 |
999 |
|
Auto PA |
|
||
|
|
|
C8A |
|
|
METALLIC POISON,AGENTS TO TREAT |
|
|
|
|
|
|
|
|
C8A |
|
DEFEROXAMINE 2 GRAM VIAL |
|
|
DEFEROXAMINE MESYLATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C8A |
|
DEFEROXAMINE 500 MG VIAL |
|
|
DEFEROXAMINE MESYLATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
C8E |
|
|
ANTIDOTES,MISCELLANEOUS |
|
|
|
|
|
|
|
|
C8E |
|
ACETYLCYSTEINE 200 MG/ML VIAL |
|
|
ACETYLCYSTEINE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C8E |
|
ACETYLCYSTEINE 6 GRAM/30 ML VL |
|
|
ACETYLCYSTEINE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
||||||
|
|
|
C9C |
PARENTERAL AMINO ACID SOLUTIONS AND COMBINATIONS |
|
|
|
||||||
|
C9C |
|
AMINO ACIDS 15% SOLUTION |
|
|
PARENTERAL AMINO ACID 15% NO.1 |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C9C |
|
AMINOSYN 10% IV SOLUTION |
|
|
PARENTERAL AMINO ACID 10% NO.2 |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C9C |
|
AMINOSYN 8.5% IV SOLUTION |
|
|
PARENT. AMINO ACID 8.5 % NO.2 |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C9C |
|
AMINOSYN II 10% IV SOLUTION |
|
|
PARENTERAL AMINO ACID 10% NO.1 |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C9C |
|
AMINOSYN II 15% IV SOLUTION |
|
|
PARENTERAL AMINO ACID 15% NO.2 |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C9C |
|
AMINOSYN II 7% IV SOLUTION |
|
|
PARENTERAL AMINO ACID 7 % NO.2 |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C9C |
|
AMINOSYN II 8.5% ELECTROLYT |
|
|
PARENT. AMINO ACID 8.5 % NO.3 |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C9C |
|
|
|
PARENT.AMINO ACID 10% NO5(PED) |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C9C |
|
|
|
PARENT.AMINO ACID 7 % NO1(PED) |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C9C |
|
|
|
PARENT AMINO AC 5.2 % (RENAL) |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C9C |
|
CLINIMIX E 2.75/10 SOLUTION |
|
|
AMINO AC 2.75%/DEX 10%/LYTE 29 |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C9C |
|
CLINIMIX E 5/15 SOLUTION |
|
|
AA 5%/D15W/ELECTROLYTES |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C9C |
|
CLINIMIX N14G30E |
|
|
AA 4.25%/D15W/ELECTROLYTES 25 |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
C9C |
|
CLINIMIX N9G15E |
|
|
AA 2.75%/D7.5%W/ELECTROLYTES12 |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 47 of 204 |
Class |
Medicaid Drug Name |
|
|
C9C |
CLINIMIX N9G20E |
C9C |
CLINISOL 15% SOLUTION |
C9C |
FREAMINE III 10% IV SOLN. |
C9C |
KABIVEN IV EMULSION |
C9C |
PERIKABIVEN IV EMULSION |
C9C |
PREMASOL 10% IV SOLUTION |
C9C |
PREMASOL 6% IV SOLUTION |
C9C |
PROSOL 20% INJECTION |
C9C |
SYNTHAMIN 17 WITHOUT ELYTE 10% |
C9C |
TRAVASOL 10% SOLN VIAFLEX |
|
D1A |
D1A |
DOXYCYCLINE 20 MG TABLET |
D1A |
DOXYCYCLINE HYCLATE 20 MG TAB |
|
D1D |
D1D |
CHLORHEXIDINE 0.12% RINSE |
D1D |
TRIAMCINOLONE 0.1% PASTE |
|
D2A |
D2A |
FLUORIDE 0.25 MG TABLET CHEW |
D2A |
FLUORIDE 0.5 MG TABLET CHEW |
D2A |
FLUORIDE 1 MG TABLET CHEWABLE |
D2A |
SODIUM FLUORIDE 0.5 MG/ML DROP |
|
D4D |
D4D |
PROBIOTIC & ACIDOPHILUS CAP |
D4D |
PROBIOTIC 10 BILLION CELL CAP |
D4D |
PROBIOTIC 15 BILLION CELL CAP |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
Min Age |
|
Max Age |
|
|
|
AMINO AC 2.75%/DEX 10%/LYTE 29 |
0 |
999 |
|
No |
||
|
PARENTERAL AMINO ACID 15% NO.5 |
0 |
999 |
|
No |
||
|
PARENTERAL AMINO ACID 10% NO.4 |
0 |
999 |
|
No |
||
|
AA 3.31 |
0 |
999 |
|
No |
||
|
AA |
0 |
999 |
|
No |
||
|
PARENTERAL AMINO ACID 10% NO.7 |
0 |
999 |
|
No |
||
|
PARENTERAL AMINO ACID 6 % NO.1 |
0 |
999 |
|
No |
||
|
PARENTERAL AMINO ACID 20% NO.1 |
0 |
999 |
|
No |
||
|
PARENTERAL AMINO ACID 10% NO.6 |
0 |
999 |
|
No |
||
|
PARENTERAL AMINO ACID 10% NO.6 |
0 |
999 |
|
No |
||
|
PERIODONTAL COLLAGENASE INHIBITORS |
|
|
|
|
||
|
DOXYCYCLINE HYCLATE |
0 |
999 |
|
No |
||
|
DOXYCYCLINE HYCLATE |
0 |
999 |
|
No |
||
|
DENTAL AIDS AND PREPARATIONS |
|
|
|
|
|
|
|
CHLORHEXIDINE GLUCONATE |
0 |
999 |
|
No |
||
|
TRIAMCINOLONE ACETONIDE |
0 |
999 |
|
No |
||
|
FLUORIDE PREPARATIONS |
|
|
|
|
|
|
|
FLUORIDE (SODIUM) |
0 |
999 |
|
No |
||
|
FLUORIDE (SODIUM) |
0 |
999 |
|
No |
||
|
FLUORIDE (SODIUM) |
0 |
999 |
|
No |
||
|
FLUORIDE (SODIUM) |
0 |
999 |
|
No |
||
ANTIDIARRHEAL MICROORGANISMS AGENTS |
|
|
|
|
|||
|
LACTOBACILLUS 3/FOS/PANTETHINE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
||
|
L.ACIDOPH,PARACASEI, B.LACTIS |
0 |
999 |
|
Cystic Fib Diag Auto PA |
||
|
L. ACIDOPHILUS/L. RHAMNOSUS |
0 |
999 |
|
Cystic Fib Diag Auto PA |
Thursday, October 25, 2018 |
Page 48 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC 15 BILLION CELL CAP |
LACTOBACILLUS COMBO NO.11 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC 250 MG CAPSULE |
SACCHAROMYCES BOULARDII |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC 4X CAPLET |
B INFANTIS/B ANI/B LON/B BIFID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC 5 BILLION CELL CAP |
L. ACIDOPHILUS/BIFID. ANIMALIS |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC |
L. ACIDOPHILUS/PECTIN, CITRUS |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC ACIDOPHILUS 250 MILL |
LACTOBACILLUS ACIDOPHILUS |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC ACIDOPHILUS BEADS |
L.ACIDOPH/B.LONG/L.PLANT/B.LAC |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC ACIDOPHILUS BIOBEADS |
L.ACIDOPH/L.RHAMN/B.BIF/B.LONG |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC BLEND CAPSULE |
L.ACID/L.CASEI/B.BIF/B.LON/FOS |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC FORMULA CAPSULE |
BACILLUS COAGULANS/INULIN |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC GOLD ACIDOPHILUS CAP |
LACTOBACILLUS ACIDOPHILUS |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC PEARLS COMPLETE SFGL |
LACTOBACILLUS COMBO NO.13 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC PLUS COLOSTRUM POWD |
LACTOBAC 42/BIFID 8/COLOST/FOS |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC SOFTGEL |
LACTOBACILLUS ACIDOPHILUS |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
PROBIOTIC WITH PREBIOTIC CAPS |
BACILLUS COAGULANS/INULIN |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
LACTOBAC NO.41/BIFIDOBACT NO.7 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
D4D |
|
L. ACIDOPHILUS/DIG ENZ CMB 5 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
D4E |
|
|
|
|
|
|
|
||
|
D4E |
|
MISOPROSTOL 100 MCG TABLET |
MISOPROSTOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4E |
|
MISOPROSTOL 200 MCG TABLET |
MISOPROSTOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D4E |
|
SUCRALFATE 1 GM TABLET |
SUCRALFATE |
0 |
999 |
|
No |
|
|||
|
|
|
D4F |
|
|
|
|
|
|
|
||
|
D4F |
|
PYLERA CAPSULE |
BISMUTH/METRONID/TETRACYCLINE |
0 |
999 |
|
No |
|
|||
|
|
|
D4J |
|
|
|
|
|
|
|
||
|
D4J |
|
NEXIUM 10 MG PACKET |
ESOMEPRAZOLE MAGNESIUM |
0 |
11 |
|
No |
|
Thursday, October 25, 2018 |
Page 49 of 204 |
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Class |
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Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
NEXIUM 20 MG PACKET |
|
|
ESOMEPRAZOLE MAGNESIUM |
0 |
11 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
NEXIUM 40 MG PACKET |
|
|
ESOMEPRAZOLE MAGNESIUM |
0 |
11 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
NEXIUM DR 2.5 MG PACKET |
|
|
ESOMEPRAZOLE MAGNESIUM |
0 |
11 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
NEXIUM DR 5 MG PACKET |
|
|
ESOMEPRAZOLE MAGNESIUM |
0 |
11 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
OMEPRAZOLE 10 MG CAPSULE DR |
|
|
OMEPRAZOLE |
1 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
OMEPRAZOLE 20 MG CAPSULE DR |
|
|
OMEPRAZOLE |
1 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
OMEPRAZOLE 40 MG CAPSULE DR |
|
|
OMEPRAZOLE |
1 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
OMEPRAZOLE DR 10 MG CAPSULE |
|
|
OMEPRAZOLE |
1 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
OMEPRAZOLE DR 20 MG CAPSULE |
|
|
OMEPRAZOLE |
1 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
OMEPRAZOLE DR 40 MG CAPSULE |
|
|
OMEPRAZOLE |
1 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
OMEPRAZOLE MAG DR 20 MG CAP |
|
|
OMEPRAZOLE MAGNESIUM |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
D4J |
|
OMEPRAZOLE MAG DR 20.6 MG CAP |
OMEPRAZOLE MAGNESIUM |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
PANTOPRAZOLE SOD 20 MG TAB EC |
|
|
PANTOPRAZOLE SODIUM |
5 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
PANTOPRAZOLE SOD 40 MG TAB EC |
|
|
PANTOPRAZOLE SODIUM |
5 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
PANTOPRAZOLE SOD DR 20 MG TAB |
|
|
PANTOPRAZOLE SODIUM |
5 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
PANTOPRAZOLE SOD DR 40 MG TAB |
|
|
PANTOPRAZOLE SODIUM |
5 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
PREVACID 15 MG SOLUTAB |
|
|
LANSOPRAZOLE |
1 |
11 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
PREVACID 30 MG SOLUTAB |
|
|
LANSOPRAZOLE |
1 |
11 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D4J |
|
PROTONIX 40 MG SUSPENSION |
|
|
PANTOPRAZOLE SODIUM |
5 |
11 |
|
No |
|
||
|
|
|
|
|
|
|
|
||||||
|
|
|
D6C |
IRRITABLE BOWEL SYNDROME AGENTS, |
|
|
|
||||||
|
D6C |
|
ALOSETRON HCL 0.5 MG TABLET |
|
|
ALOSETRON HCL |
0 |
999 |
|
Requires Med Cert 3 |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D6C |
|
ALOSETRON HCL 1 MG TABLET |
|
|
ALOSETRON HCL |
0 |
999 |
|
Requires Med Cert 3 |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D6C |
|
LOTRONEX 0.5 MG TABLET |
|
|
ALOSETRON HCL |
0 |
999 |
|
Requires Med Cert 3 |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D6C |
|
LOTRONEX 1 MG TABLET |
|
|
ALOSETRON HCL |
0 |
999 |
|
Requires Med Cert 3 |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 50 of 204 |
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
D6D |
|
ANTIDIARRHEALS |
|
|
|
D6D |
DIPHENOXYLATE/ATROPINE TAB |
|
DIPHENOXYLATE HCL/ATROPINE |
0 |
999 |
No |
|
|
|
|
|
|
|
D6D |
|
DIPHENOXYLATE HCL/ATROPINE |
0 |
999 |
No |
|
|
|
|
|
|
|
|
D6D |
|
DIPHENOXYLATE HCL/ATROPINE |
0 |
999 |
No |
|
|
|
|
|
|
|
|
D6D |
LOPERAMIDE 2 MG CAPSULE |
|
LOPERAMIDE HCL |
0 |
999 |
No |
|
|
|
|
|
||
|
D6F |
DRUG |
|
|
||
D6F |
APRISO 0.375 GM CAPSULE ER |
|
MESALAMINE |
0 |
999 |
No |
|
|
|
|
|
|
|
D6F |
DELZICOL DR 400 MG CAPSULE |
|
MESALAMINE |
0 |
999 |
No |
|
|
|
|
|
|
|
D6F |
SULFASALAZINE 500 MG TABLET |
|
SULFASALAZINE |
0 |
999 |
No |
|
|
|
|
|
|
|
D6F |
SULFASALAZINE DR 500 MG TAB |
|
SULFASALAZINE |
0 |
999 |
No |
|
|
|
|
|
|
|
|
D6G |
|
|
|
||
D6G |
LINZESS 145 MCG CAPSULE |
|
LINACLOTIDE |
18 |
999 |
Auto PA |
|
|
|
|
|
|
|
D6G |
LINZESS 290 MCG CAPSULE |
|
LINACLOTIDE |
18 |
999 |
Auto PA |
|
|
|
|
|
|
|
D6G |
LINZESS 72 MCG CAPSULE |
|
LINACLOTIDE |
18 |
999 |
Auto PA |
|
D6S |
|
LAXATIVES AND CATHARTICS |
|
|
|
D6S |
GOLYTELY PACKET |
|
PEG3350/SOD SULF,BICARB,CL/KCL |
0 |
999 |
No |
|
|
|
|
|
|
|
D6S |
GOLYTELY SOLUTION |
|
PEG3350/SOD SULF,BICARB,CL/KCL |
0 |
999 |
No |
|
|
|
|
|
|
|
D6S |
LACTULOSE 10 GM/15 ML SOLN |
|
LACTULOSE |
0 |
999 |
No |
|
|
|
|
|
|
|
D6S |
LACTULOSE 10 GM/15 ML SOLUTION |
LACTULOSE |
0 |
999 |
No |
|
|
|
|
|
|
|
|
D6S |
LACTULOSE 20 GM/30 ML SOLUTION |
LACTULOSE |
0 |
999 |
No |
|
|
|
|
|
|
|
|
D6S |
PEG 3350/ELECTROLYTE SOLN |
|
PEG3350/SOD SULF,BICARB,CL/KCL |
0 |
999 |
No |
|
|
|
|
|
|
|
D6S |
PEG |
|
SODIUM CHLORIDE/NAHCO3/KCL/PEG |
0 |
999 |
No |
|
|
|
|
|
|
|
D6S |
|
PEG3350/SOD SULF,BICARB,CL/KCL |
0 |
999 |
No |
|
|
|
|
|
|
|
|
D6S |
PEG3350 POWDER |
|
POLYETHYLENE GLYCOL 3350 |
0 |
999 |
No |
|
|
|
|
|
|
|
D6S |
|
SODIUM CHLORIDE/NAHCO3/KCL/PEG |
0 |
999 |
No |
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 51 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
D6S |
|
POLYETHYLENE GLYCOL 3350 POWD |
|
|
POLYETHYLENE GLYCOL 3350 |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D6S |
|
TRILYTE WITH FLAVOR PACKETS |
|
|
SODIUM CHLORIDE/NAHCO3/KCL/PEG |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
D7A |
|
|
BILE SALTS |
|
|
|
|
|
|
|
|
D7A |
|
URSODIOL 250 MG TABLET |
|
|
URSODIOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D7A |
|
URSODIOL 300 MG CAPSULE |
|
|
URSODIOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D7A |
|
URSODIOL 500 MG TABLET |
|
|
URSODIOL |
0 |
999 |
|
No |
|
||
|
|
|
D7D |
DRUGS TO TREAT HEREDITARY TYROSINEMIA |
|
|
|
|
|
||||
|
D7D |
|
NITYR 10 MG TABLET |
|
|
NITISINONE |
0 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D7D |
|
NITYR 2 MG TABLET |
|
|
NITISINONE |
0 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D7D |
|
NITYR 5 MG TABLET |
|
|
NITISINONE |
0 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D7D |
|
ORFADIN 10 MG CAPSULE |
|
|
NITISINONE |
0 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D7D |
|
ORFADIN 2 MG CAPSULE |
|
|
NITISINONE |
0 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D7D |
|
ORFADIN 20 MG CAPSULE |
|
|
NITISINONE |
0 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D7D |
|
ORFADIN 4 MG/ML SUSPENSION |
|
|
NITISINONE |
0 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D7D |
|
ORFADIN 5 MG CAPSULE |
|
|
NITISINONE |
0 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
D7L |
|
|
BILE SALT SEQUESTRANTS |
|
|
|
|
|
|
|
|
D7L |
|
CHOLESTYRAMINE LIGHT PACKET |
|
|
CHOLESTYRAMINE/ASPARTAME |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D7L |
|
CHOLESTYRAMINE LIGHT POWDER |
|
|
CHOLESTYRAMINE/ASPARTAME |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D7L |
|
CHOLESTYRAMINE PACKET |
|
|
CHOLESTYRAMINE (WITH SUGAR) |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D7L |
|
CHOLESTYRAMINE POWDER |
|
|
CHOLESTYRAMINE (WITH SUGAR) |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D7L |
|
COLESTIPOL HCL 1 GM TABLET |
|
|
COLESTIPOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
D8A |
|
|
PANCREATIC ENZYMES |
|
|
|
|
|
|
|
|
D8A |
|
CREON DR 12,000 UNITS CAPSULE |
|
|
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D8A |
|
CREON DR 24,000 UNITS CAPSULE |
|
|
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D8A |
|
CREON DR 3,000 UNITS CAPSULE |
|
|
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 52 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
CREON DR 36,000 UNITS CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
CREON DR 6,000 UNITS CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
PANCREAZE 10,500 UNIT CAP DR |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
PANCREAZE 16,800 UNIT CAP DR |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
PANCREAZE 21,000 UNIT CAP DR |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
PANCREAZE 4,200 UNIT CAP DR |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
PANCREAZE DR 2,600 UNIT CAP |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
PERTZYE DR 16,000 UNITS CAPS |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
PERTZYE DR 24,000 UNIT CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
PERTZYE DR 4,000 UNIT CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
PERTZYE DR 8,000 UNITS CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
VIOKACE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
VIOKACE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
ZENPEP DR 10,000 UNIT CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
ZENPEP DR 10,000 UNITS CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
ZENPEP DR 15,000 UNIT CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
ZENPEP DR 15,000 UNITS CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
ZENPEP DR 20,000 UNIT CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
ZENPEP DR 20,000 UNITS CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
ZENPEP DR 25,000 UNIT CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
ZENPEP DR 25,000 UNITS CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
ZENPEP DR 3,000 UNIT CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
ZENPEP DR 3,000 UNITS CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
D8A |
|
ZENPEP DR 40,000 UNIT CAPSULE |
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 53 of 204 |
|
Class |
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Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
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|
|
|
|
||
|
D8A |
|
ZENPEP DR 40,000 UNITS CAPSULE |
|
|
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D8A |
|
ZENPEP DR 5,000 UNIT CAPSULE |
|
|
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
D8A |
|
ZENPEP DR 5,000 UNITS CAPSULE |
|
|
LIPASE/PROTEASE/AMYLASE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
D9A |
|
|
AMMONIA INHIBITORS |
|
|
|
|
|
|
|
|
D9A |
|
LACTULOSE 10 GM/15 ML SOLUTION |
|
|
LACTULOSE |
0 |
999 |
|
No |
|
||
|
|
|
E0G |
PRENATAL VITAMINS WITH LOW OR NO IRON |
|
|
|
|
|
||||
|
E0G |
|
|
|
PNV/FOLIC AC/B6/CALCIUM/GINGER |
12 |
999 |
|
No |
|
|||
|
|
|
F1A |
|
|
ANDROGENIC AGENTS |
|
|
|
|
|
|
|
|
F1A |
|
ANDROGEL 1% GEL PUMP |
|
|
TESTOSTERONE |
18 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
F1A |
|
ANDROGEL 1%(2.5G) GEL PACKET |
|
|
TESTOSTERONE |
18 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
F1A |
|
ANDROGEL 1%(5G) GEL PACKET |
|
|
TESTOSTERONE |
18 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
F1A |
|
ANDROGEL 1.62% GEL PUMP |
|
|
TESTOSTERONE |
18 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
F1A |
|
ANDROGEL 1.62%(1.25G) GEL PCKT |
|
|
TESTOSTERONE |
18 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
F1A |
|
ANDROGEL 1.62%(2.5G) GEL PCKT |
|
|
TESTOSTERONE |
18 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
F1A |
|
TESTOSTERON CYP 1,000 MG/10 ML |
|
|
TESTOSTERONE CYPIONATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
F1A |
|
TESTOSTERON CYP 2,000 MG/10 ML |
|
|
TESTOSTERONE CYPIONATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
F1A |
|
TESTOSTERON ENAN 1,000 MG/5 ML |
|
|
TESTOSTERONE ENANTHATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
F1A |
|
TESTOSTERONE CYP 100 MG/ML |
|
|
TESTOSTERONE CYPIONATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
F1A |
|
TESTOSTERONE CYP 200 MG/ML |
|
|
TESTOSTERONE CYPIONATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
F1A |
|
TESTOSTERONE ENAN 200 MG/ML |
|
|
TESTOSTERONE ENANTHATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
G1A |
|
|
ESTROGENIC AGENTS |
|
|
|
|
|
|
|
|
G1A |
|
CLIMARA PRO PATCH |
|
|
ESTRADIOL/LEVONORGESTREL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G1A |
|
COMBIPATCH |
|
|
ESTRADIOL/NORETHINDRONE ACET |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G1A |
|
COMBIPATCH |
|
|
ESTRADIOL/NORETHINDRONE ACET |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G1A |
|
ESTRADIOL 0.025 MG/DAY PATCH |
|
|
ESTRADIOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 54 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
G1A |
|
ESTRADIOL 0.0375 MG/DAY PATCH |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL 0.05 MG/DAY PATCH |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL 0.06 MG/DAY PATCH |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL 0.075 MG/DAY PATCH |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL 0.1 MG/DAY PATCH |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL 0.5 MG TABLET |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL 1 MG TABLET |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL 2 MG TABLET |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL TDS 0.025 MG/DAY |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL TDS 0.0375 MG/DAY |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL TDS 0.05 MG/DAY |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL TDS 0.06 MG/DAY |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL TDS 0.075 MG/DAY |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL TDS 0.1 MG/DAY |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL VALERATE 20 MG/ML VL |
ESTRADIOL VALERATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL VALERATE 40 MG/ML VL |
ESTRADIOL VALERATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL/NORETHINDRONE ACET |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL/NORETHINDRONE ACET |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTRADIOL/NORETHINDRONE ACET |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTROPIPATE 0.625(0.75 MG) TAB |
ESTROPIPATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTROPIPATE 1.25(1.5 MG) TAB |
ESTROPIPATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
ESTROPIPATE 2.5(3 MG) TAB |
ESTROPIPATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
FEMHRT 0.5 MG/2.5 MCG TABLET |
NORETHINDRONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G1A |
|
NORETHINDRONE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 55 of 204 |
Class |
|
Medicaid Drug Name |
|
|
|
G1A |
|
|
G1A |
|
PREMARIN 0.3 MG TABLET |
G1A |
|
PREMARIN 0.45 MG TABLET |
G1A |
|
PREMARIN 0.625 MG TABLET |
G1A |
|
PREMARIN 0.9 MG TABLET |
G1A |
|
PREMARIN 1.25 MG TABLET |
G1A |
|
PREMPHASE |
G1A |
|
PREMPRO 0.3 |
G1A |
|
PREMPRO |
G1A |
|
PREMPRO |
G1A |
|
PREMPRO |
|
|
G1B |
G1B |
|
|
G1B |
|
|
|
|
G2A |
G2A |
|
MEDROXYPROGESTERONE 10 MG TB |
G2A |
|
MEDROXYPROGESTERONE 2.5 MG |
G2A |
|
MEDROXYPROGESTERONE 2.5 MG TAB |
G2A |
|
MEDROXYPROGESTERONE 5 MG TAB |
G2A |
|
NORETHINDRN 5 MG TB (LUPANETA) |
G2A |
|
NORETHINDRONE 5 MG TABLET |
G2A |
|
PROGESTERONE 100 MG CAPSULE |
G2A |
|
PROGESTERONE 200 MG CAPSULE |
G2A |
|
PROGESTERONE OIL 50 MG/ML VL |
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
Min Age |
|
Max Age |
|
|
NORETHINDRONE |
0 |
999 |
|
No |
||
ESTROGENS, CONJUGATED |
0 |
999 |
|
No |
||
ESTROGENS, CONJUGATED |
0 |
999 |
|
No |
||
ESTROGENS, CONJUGATED |
0 |
999 |
|
No |
||
ESTROGENS, CONJUGATED |
0 |
999 |
|
No |
||
ESTROGENS, CONJUGATED |
0 |
999 |
|
No |
||
0 |
999 |
|
No |
|||
0 |
999 |
|
No |
|||
0 |
999 |
|
No |
|||
0 |
999 |
|
No |
|||
0 |
999 |
|
No |
|||
ESTROGEN/ANDROGEN COMBINATIONS |
|
|
|
|
|
|
0 |
999 |
|
No |
|||
0 |
999 |
|
No |
|||
PROGESTATIONAL AGENTS |
|
|
|
|
|
|
MEDROXYPROGESTERONE ACETATE |
0 |
999 |
|
No |
||
MEDROXYPROGESTERONE ACETATE |
0 |
999 |
|
No |
||
MEDROXYPROGESTERONE ACETATE |
0 |
999 |
|
No |
||
MEDROXYPROGESTERONE ACETATE |
0 |
999 |
|
No |
||
NORETHINDRONE ACETATE |
18 |
999 |
|
No |
||
NORETHINDRONE ACETATE |
0 |
999 |
|
No |
||
PROGESTERONE, MICRONIZED |
0 |
999 |
|
No |
||
PROGESTERONE, MICRONIZED |
0 |
999 |
|
No |
||
PROGESTERONE |
0 |
999 |
|
No |
Thursday, October 25, 2018 |
Page 56 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
G2A |
|
PROGESTERONE OIL 50 MG/ML VL |
PROGESTERONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G2A |
|
PROMETRIUM 100 MG CAPSULE |
PROGESTERONE, MICRONIZED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G2A |
|
PROMETRIUM 200 MG CAPSULE |
PROGESTERONE, MICRONIZED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
G3A |
OXYTOCICS |
|
|
|
|
|
|
|
|
|
G3A |
|
METHYLERGONOVINE 0.2 MG TABLET |
METHYLERGONOVINE MALEATE |
0 |
999 |
|
No |
|
|||
|
|
|
G8A |
CONTRACEPTIVES,ORAL |
|
|
|
|
|
|
|
|
|
G8A |
|
AFTERA 1.5 MG TABLET |
LEVONORGESTREL |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ALYACEN |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ALYACEN |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
AMETHIA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
AMETHIA LO TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
AMETHYST |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
APRI 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ARANELLE 28 TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ASHLYNA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
AUBRA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
AZURETTE 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
BALCOLTRA TABLET |
LEVONORGEST/ETH.ESTRADIOL/IRON |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
BALZIVA 28 TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
BEKYREE 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
BEYAZ 28 TABLET |
DROSPIR/ETH ESTRA/LEVOMEFOL CA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 57 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
G8A |
|
BLISOVI 24 FE TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
BLISOVI FE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
BLISOVI FE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
BRIELLYN TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
CAMILA 0.35 MG TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
CAMRESE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
CAMRESE LO TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
CAZIANT 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
CHATEAL |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
CYCLAFEM |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
CYCLAFEM |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
CYCLESSA 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
CYRED 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
DASETTA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
DASETTA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
DAYSEE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
DEBLITANE 0.35 MG TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
DROSPIR/ETH ESTRA/LEVOMEFOL CA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
DROSPIR/ETH ESTRA/LEVOMEFOL CA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ETHINYL ESTRADIOL/DROSPIRENONE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 58 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
G8A |
|
ETHINYL ESTRADIOL/DROSPIRENONE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ETHINYL ESTRADIOL/DROSPIRENONE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ECONTRA EZ 1.5 MG TABLET |
LEVONORGESTREL |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ECONTRA |
LEVONORGESTREL |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ELLA 30 MG TABLET |
ULIPRISTAL ACETATE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
EMOQUETTE 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ENSKYCE 28 TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ERRIN 0.35 MG TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ESTARYLLA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ESTROSTEP |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ETHYNODIOL |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ETHYNODIOL |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
FALLBACK SOLO 1.5 MG TABLET |
LEVONORGESTREL |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
FAYOSIM TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
FEMYNOR 28 TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
GENERESS FE CHEWABLE TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
GIANVI 3 |
ETHINYL ESTRADIOL/DROSPIRENONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
GILDAGIA 0.4 |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
HEATHER TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
INCASSIA 0.35 MG TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
INTROVALE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 59 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
G8A |
|
ISIBLOOM 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
JENCYCLA 0.35 MG TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
JOLESSA 0.15 MG/0.03 MG TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
JOLIVETTE TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
JULEBER 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
JUNEL 1.5/30 TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
JUNEL 1/20 TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
JUNEL FE 1.5/30 TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
JUNEL FE 1/20 TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
JUNEL FE 24 TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
KAITLIB FE CHEWABLE TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
KARIVA 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
KELNOR 1/35 28 TABLET |
ETHYNODIOL |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
KELNOR |
ETHYNODIOL |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
KELNOR |
ETHYNODIOL |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
KIMIDESS 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
KURVELO TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LARIN 1.5 |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LARIN 21 |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LARIN 24 FE 1 |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LARIN FE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LARIN FE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LAYOLIS FE CHEWABLE TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 60 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
G8A |
|
LEENA 28 TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LEVONORG |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LO LOESTRIN FE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LOESTRIN 21 |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LOESTRIN 21 |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LOESTRIN FE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LOESTRIN FE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LOMEDIA 24 FE 1 |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LORYNA 3 |
ETHINYL ESTRADIOL/DROSPIRENONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
LOSEASONIQUE TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 61 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
G8A |
|
LYZA 0.35 MG TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
MELODETTA 24 FE CHEWABLE TAB |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
MIBELAS 24 FE CHEWABLE TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
MICROGESTIN 21 |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
MICROGESTIN 21 |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
MICROGESTIN 24 FE 1 |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
MICROGESTIN FE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
MICROGESTIN FE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
MICRONOR 0.35 MG TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
MILI |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
MINASTRIN 24 FE CHEWABLE TAB |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
MIRCETTE 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
MONONESSA 28 TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
MY CHOICE 1.5 MG TABLET |
LEVONORGESTREL |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
MY WAY 1.5 MG TABLET |
LEVONORGESTREL |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NATAZIA 28 TABLET |
ESTRADIOL VALERATE/DIENOGEST |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NECON |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NECON |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NECON |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NEW DAY 1.5 MG TABLET |
LEVONORGESTREL |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NIKKI 3 |
ETHINYL ESTRADIOL/DROSPIRENONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 62 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
G8A |
|
NORETHINDRONE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NORETHINDRONE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NORETHINDRONE 0.35 MG TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NORINYL |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NORLYDA 0.35 MG TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NORTREL 0.5/35 TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NORTREL |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NORTREL 1/35 TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NORTREL |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NORTREL |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NORTREL |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
NORTREL |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
OCELLA TABLET |
ETHINYL ESTRADIOL/DROSPIRENONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
OGESTREL TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
OPCICON |
LEVONORGESTREL |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 63 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
G8A |
|
ORTHO MICRONOR 0.35 MG TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ORTHO |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
ORTHO |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
PHILITH |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
PIMTREA 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
PIRMELLA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
PIRMELLA |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
PLAN B |
LEVONORGESTREL |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
PREVIFEM TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
QUARTETTE TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
QUASENSE 0.15/0.03 MG TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
RAJANI 28 TABLET |
DROSPIR/ETH ESTRA/LEVOMEFOL CA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
RECLIPSEN 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
RIVELSA TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
SAFYRAL TABLET |
DROSPIR/ETH ESTRA/LEVOMEFOL CA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
SEASONIQUE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
SETLAKIN 0.15 |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
SHAROBEL 0.35 MG TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
SPRINTEC 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
SRONYX |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 64 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
G8A |
|
SYEDA 28 TABLET |
ETHINYL ESTRADIOL/DROSPIRENONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
TAKE ACTION 1.5 MG TABLET |
LEVONORGESTREL |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
TARINA FE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
TAYTULLA 1 |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
TILIA FE 28 TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
TRI FEMYNOR 28 TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
TRINESSA LO TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
TRINESSA TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
12 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
TULANA 0.35 MG TABLET |
NORETHINDRONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
TYDEMY TABLET |
DROSPIR/ETH ESTRA/LEVOMEFOL CA |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
VELIVET 28 DAY TABLET |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
G8A |
|
VESTURA 3 |
ETHINYL ESTRADIOL/DROSPIRENONE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 65 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
G8A |
|
|
|
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G8A |
|
VIORELE 28 DAY TABLET |
|
|
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G8A |
|
VYFEMLA 28 TABLET |
|
|
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G8A |
|
VYLIBRA 28 TABLET |
|
|
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G8A |
|
WERA 0.5/0.035 MG 28 TABLET |
|
|
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G8A |
|
WYMZYA FE CHEWABLE TABLET |
|
|
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G8A |
|
YASMIN 28 TABLET |
|
|
ETHINYL ESTRADIOL/DROSPIRENONE |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G8A |
|
YAZ 28 TABLET |
|
|
ETHINYL ESTRADIOL/DROSPIRENONE |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G8A |
|
ZARAH TABLET |
|
|
ETHINYL ESTRADIOL/DROSPIRENONE |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G8A |
|
ZENCHENT 0.4 |
|
|
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G8A |
|
ZOVIA 1/50E TABLET |
|
|
ETHYNODIOL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G8A |
|
ZOVIA |
|
|
ETHYNODIOL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
G8C |
|
|
CONTRACEPTIVES,INJECTABLE |
|
|
|
|
|
|
|
|
G8C |
|
|
|
MEDROXYPROGESTERONE ACETATE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
G8C |
|
MEDROXYPROGESTERONE 150 MG/ML |
|
|
MEDROXYPROGESTERONE ACETATE |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
G8F |
|
|
CONTRACEPTIVES,TRANSDERMAL |
|
|
|
|
|
|
|
|
G8F |
|
XULANE PATCH |
|
|
NORELGESTROMIN/ETHIN.ESTRADIOL |
12 |
999 |
|
No |
|
||
|
|
|
G9B |
CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC |
|
|
|
|
|
||||
|
G9B |
|
NUVARING VAGINAL RING |
|
|
ETONOGESTREL/ETHINYL ESTRADIOL |
12 |
999 |
|
No |
|
||
|
|
|
H0A |
|
|
LOCAL ANESTHETICS |
|
|
|
|
|
|
|
|
H0A |
|
BUPIVACAINE 0.25% VIAL |
|
|
BUPIVACAINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0A |
|
BUPIVACAINE 0.25% VIAL |
|
|
BUPIVACAINE HCL/PF |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0A |
|
BUPIVACAINE |
|
|
BUPIVACAINE HCL/EPINEPHRINE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0A |
|
BUPIVACAINE |
|
|
BUPIVACAINE HCL/EPINEPHRINE/PF |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0A |
|
BUPIVACAINE 0.5% VIAL |
|
|
BUPIVACAINE HCL |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 66 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
BUPIVACAINE 0.5% VIAL |
BUPIVACAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
BUPIVACAINE |
BUPIVACAINE HCL/EPINEPHRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
BUPIVACAINE |
BUPIVACAINE HCL/EPINEPHRINE/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
BUPIVACAINE 0.75% AMPUL |
BUPIVACAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
BUPIVACAINE 0.75% VIAL |
BUPIVACAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
BUPIVACAINE/DEXTR 0.75% AMP |
BUPIVACAINE HCL IN DEXTROSE/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
BUPIVACAINE/EPI 0.25%/0.0005 |
BUPIVACAINE HCL/EPINEPHRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
BUPIVACAINE/EPI 0.25%/0.0005 |
BUPIVACAINE HCL/EPINEPHRINE/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
BUPIVACAINE/EPI 0.5%/0.0005 |
BUPIVACAINE HCL/EPINEPHRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
BUPIVACAINE/EPI 0.5%/0.0005 |
BUPIVACAINE HCL/EPINEPHRINE BI |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
BUPIVACAINE/EPI 0.5%/0.0005 |
BUPIVACAINE HCL/EPINEPHRINE/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
BUPIVACAINE HCL/EPINEPHRINE/PF |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
BUPIVACAINE HCL/EPINEPHRINE/PF |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE 0.5%/EPI 1:200,000 |
LIDOCAINE HCL/EPINEPHRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE 1%/EPI 1:100,000 |
LIDOCAINE HCL/EPINEPHRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE |
LIDOCAINE HCL/EPINEPHRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE 1.5%/EPI 1:200,000 |
LIDOCAINE HCL/EPINEPHRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE |
LIDOCAINE HCL/EPINEPHRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE 2% - EPI 1:100,000 |
LIDOCAINE HCL/EPINEPHRINE BIT |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE 2% - EPI 1:50,000 |
LIDOCAINE HCL/EPINEPHRINE BIT |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE 2% VISCOUS SOLN |
LIDOCAINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE 2%/EPI 1:100,000 |
LIDOCAINE HCL/EPINEPHRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE 2%/EPI 1:200,000 |
LIDOCAINE HCL/EPINEPHRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE 5% IN D7.5W AMPUL |
LIDOCAINE HCL/DEXTROSE 7.5%/PF |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 67 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 0.5% VIAL |
LIDOCAINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 0.5% VIAL |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 1% 20 MG/2 ML |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 1% 20 MG/2 ML VL |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 1% 300 MG/30 ML |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 1% 50 MG/5 ML |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 1% 50 MG/5 ML VL |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 1% AMPUL |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 1% VIAL |
LIDOCAINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 1% VIAL |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 1.5% AMPUL |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 2% 100 MG/5 ML |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 2% 40 MG/2 ML |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 2% 40 MG/2 ML VL |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 2% AMPUL |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 2% JELLY |
LIDOCAINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 2% VIAL |
LIDOCAINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 2% VIAL |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 4% AMPUL |
LIDOCAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
LIDOCAINE HCL 4% SOLUTION |
LIDOCAINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0A |
|
MEPIVACAINE HCL 3% CARTRIDGE |
MEPIVACAINE HCL/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H0E |
AGENTS TO TREAT MULTIPLE SCLEROSIS |
|
|
|
|
|
|
|
|
|
H0E |
|
AUBAGIO 14 MG TABLET |
TERIFLUNOMIDE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H0E |
|
AUBAGIO 7 MG TABLET |
TERIFLUNOMIDE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 68 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H0E |
|
AVONEX ADMIN PACK 30 MCG VL |
|
|
INTERFERON |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0E |
|
AVONEX PEN 30 MCG/0.5 ML KIT |
|
|
INTERFERON |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0E |
|
AVONEX PREFILLED SYR 30 MCG KT |
|
|
INTERFERON |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0E |
|
BETASERON 0.3 MG KIT |
|
|
INTERFERON |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0E |
|
BETASERON 0.3 MG VIAL |
|
|
INTERFERON |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0E |
|
COPAXONE 20 MG INJECTION KIT |
|
|
GLATIRAMER ACETATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0E |
|
GILENYA 0.25 MG CAPSULE |
|
|
FINGOLIMOD HCL |
10 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0E |
|
GILENYA 0.5 MG CAPSULE |
|
|
FINGOLIMOD HCL |
10 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0E |
|
REBIF 22 MCG/0.5 ML SYRINGE |
|
|
INTERFERON |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0E |
|
REBIF 44 MCG/0.5 ML SYRINGE |
|
|
INTERFERON |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0E |
|
REBIF REBIDOSE 22 MCG/0.5 ML |
|
|
INTERFERON |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0E |
|
REBIF REBIDOSE 44 MCG/0.5 ML |
|
|
INTERFERON |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0E |
|
REBIF REBIDOSE TITRATION PACK |
|
|
INTERFERON |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H0E |
|
REBIF TITRATION PACK |
|
|
INTERFERON |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
H1A |
ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS |
|
|
|
|
|
||||
|
H1A |
|
MEMANTINE |
|
|
MEMANTINE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H1A |
|
MEMANTINE HCL 10 MG TABLET |
|
|
MEMANTINE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
H1A |
|
MEMANTINE HCL 2 MG/ML SOLUTION |
MEMANTINE HCL |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H1A |
|
MEMANTINE HCL 5 MG TABLET |
|
|
MEMANTINE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H20 |
|
|
|
|
|
|
|
|
|
|
|
H20 |
|
ALPRAZOLAM 0.25 MG TABLET |
|
|
ALPRAZOLAM |
7 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H20 |
|
ALPRAZOLAM 0.5 MG TABLET |
|
|
ALPRAZOLAM |
7 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H20 |
|
ALPRAZOLAM 1 MG TABLET |
|
|
ALPRAZOLAM |
7 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H20 |
|
ALPRAZOLAM 2 MG TABLET |
|
|
ALPRAZOLAM |
7 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 69 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H20 |
|
CHLORDIAZEPOXIDE 10 MG CAP |
CHLORDIAZEPOXIDE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
CHLORDIAZEPOXIDE 10 MG CAPSULE |
CHLORDIAZEPOXIDE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
CHLORDIAZEPOXIDE 25 MG CAP |
CHLORDIAZEPOXIDE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
CHLORDIAZEPOXIDE 25 MG CAPSULE |
CHLORDIAZEPOXIDE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
CHLORDIAZEPOXIDE 5 MG CAP |
CHLORDIAZEPOXIDE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
CHLORDIAZEPOXIDE 5 MG CAPSULE |
CHLORDIAZEPOXIDE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
CLORAZEPATE 15 MG TABLET |
CLORAZEPATE DIPOTASSIUM |
9 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
CLORAZEPATE 3.75 MG TABLET |
CLORAZEPATE DIPOTASSIUM |
9 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
CLORAZEPATE 7.5 MG TABLET |
CLORAZEPATE DIPOTASSIUM |
9 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
DIAZEPAM 10 MG TABLET |
DIAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
DIAZEPAM 2 MG TABLET |
DIAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
DIAZEPAM 5 MG TABLET |
DIAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
DIAZEPAM 5 MG/5 ML SOLUTION |
DIAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
LORAZEPAM 0.5 MG TABLET |
LORAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
LORAZEPAM 1 MG TABLET |
LORAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
LORAZEPAM 2 MG TABLET |
LORAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
LORAZEPAM 2 MG/ML ORAL CONCENT |
LORAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
LORAZEPAM INTENSOL 2 MG/ML |
LORAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
OXAZEPAM 10 MG CAPSULE |
OXAZEPAM |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
OXAZEPAM 15 MG CAPSULE |
OXAZEPAM |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H20 |
|
OXAZEPAM 30 MG CAPSULE |
OXAZEPAM |
6 |
999 |
|
No |
|
|||
|
|
|
H21 |
|
|
|
|
|
||||
|
H21 |
|
LORAZEPAM 2 MG/ML CARPUJECT |
LORAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H21 |
|
LORAZEPAM 2 MG/ML VIAL |
LORAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 70 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H21 |
|
LORAZEPAM 20 MG/10 ML VIAL |
LORAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H21 |
|
LORAZEPAM 4 MG/ML CARPUJECT |
LORAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H21 |
|
LORAZEPAM 4 MG/ML VIAL |
LORAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H21 |
|
LORAZEPAM 40 MG/10 ML VIAL |
LORAZEPAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H21 |
|
TEMAZEPAM 15 MG CAPSULE |
TEMAZEPAM |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H21 |
|
TEMAZEPAM 30 MG CAPSULE |
TEMAZEPAM |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H2D |
BARBITURATES |
|
|
|
|
|
|
|
|
|
H2D |
|
PHENOBARBITAL 100 MG TABLET |
PHENOBARBITAL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2D |
|
PHENOBARBITAL 15 MG TABLET |
PHENOBARBITAL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2D |
|
PHENOBARBITAL 16.2 MG TABLET |
PHENOBARBITAL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2D |
|
PHENOBARBITAL 20 MG/5 ML ELIX |
PHENOBARBITAL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2D |
|
PHENOBARBITAL 20 MG/5 ML SOLN |
PHENOBARBITAL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2D |
|
PHENOBARBITAL 30 MG TABLET |
PHENOBARBITAL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2D |
|
PHENOBARBITAL 32.4 MG TABLET |
PHENOBARBITAL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2D |
|
PHENOBARBITAL 60 MG TABLET |
PHENOBARBITAL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2D |
|
PHENOBARBITAL 64.8 MG TABLET |
PHENOBARBITAL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2D |
|
PHENOBARBITAL 97.2 MG TABLET |
PHENOBARBITAL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
H2E |
|
|
|
|
|
||||
|
H2E |
|
ZOLPIDEM TARTRATE 10 MG TAB |
ZOLPIDEM TARTRATE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2E |
|
ZOLPIDEM TARTRATE 10 MG TABLET |
ZOLPIDEM TARTRATE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2E |
|
ZOLPIDEM TARTRATE 5 MG TABLET |
ZOLPIDEM TARTRATE |
18 |
999 |
|
No |
|
|||
|
|
|
H2F |
|
|
|
|
|
|
|
||
|
H2F |
|
BUSPIRONE HCL 10 MG TABLET |
BUSPIRONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2F |
|
BUSPIRONE HCL 15 MG TABLET |
BUSPIRONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2F |
|
BUSPIRONE HCL 30 MG TABLET |
BUSPIRONE HCL |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 71 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
H2F |
|
BUSPIRONE HCL 5 MG TABLET |
BUSPIRONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2F |
|
BUSPIRONE HCL 7.5 MG TABLET |
BUSPIRONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
H2G |
ANTIPSYCHOTICS,PHENOTHIAZINES |
|
|
|
|
|
|
|
|
|
H2G |
|
CHLORPROMAZINE 10 MG TABLET |
CHLORPROMAZINE HCL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
CHLORPROMAZINE 100 MG TABLET |
CHLORPROMAZINE HCL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
CHLORPROMAZINE 200 MG TABLET |
CHLORPROMAZINE HCL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
CHLORPROMAZINE 25 MG TABLET |
CHLORPROMAZINE HCL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
CHLORPROMAZINE 25 MG/ML AMP |
CHLORPROMAZINE HCL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
CHLORPROMAZINE 50 MG TABLET |
CHLORPROMAZINE HCL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
FLUPHENAZINE 1 MG TABLET |
FLUPHENAZINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
FLUPHENAZINE 10 MG TABLET |
FLUPHENAZINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
FLUPHENAZINE 2.5 MG TABLET |
FLUPHENAZINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
FLUPHENAZINE 2.5 MG/5 ML ELIX |
FLUPHENAZINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
FLUPHENAZINE 2.5 MG/ML VIAL |
FLUPHENAZINE HCL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
FLUPHENAZINE 5 MG TABLET |
FLUPHENAZINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
FLUPHENAZINE 5 MG/ML CONC |
FLUPHENAZINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
FLUPHENAZINE DEC 125 MG/5 ML |
FLUPHENAZINE DECANOATE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
FLUPHENAZINE DEC 25 MG/ML VL |
FLUPHENAZINE DECANOATE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
PERPHENAZINE 16 MG TABLET |
PERPHENAZINE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
PERPHENAZINE 2 MG TABLET |
PERPHENAZINE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
PERPHENAZINE 4 MG TABLET |
PERPHENAZINE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
PERPHENAZINE 8 MG TABLET |
PERPHENAZINE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
THIORIDAZINE 10 MG TABLET |
THIORIDAZINE HCL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2G |
|
THIORIDAZINE 100 MG TABLET |
THIORIDAZINE HCL |
18 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 72 of 204 |
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Class |
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Medicaid Drug Name |
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|
Generic Name |
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Medicaid |
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Medicaid |
|
Clinical PA Required |
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|
|
|
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|
|
Min Age |
|
Max Age |
|
|
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|
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|
|
|
|
||
|
H2G |
|
THIORIDAZINE 25 MG TABLET |
|
|
THIORIDAZINE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2G |
|
THIORIDAZINE 50 MG TABLET |
|
|
THIORIDAZINE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2G |
|
TRIFLUOPERAZINE 1 MG TABLET |
|
|
TRIFLUOPERAZINE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2G |
|
TRIFLUOPERAZINE 10 MG TABLET |
|
|
TRIFLUOPERAZINE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2G |
|
TRIFLUOPERAZINE 2 MG TABLET |
|
|
TRIFLUOPERAZINE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2G |
|
TRIFLUOPERAZINE 5 MG TABLET |
|
|
TRIFLUOPERAZINE HCL |
18 |
999 |
|
No |
|
||
|
|
|
H2M |
|
|
BIPOLAR DISORDER DRUGS |
|
|
|
|
|
|
|
|
H2M |
|
EQUETRO 100 MG CAPSULE |
|
|
CARBAMAZEPINE |
6 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2M |
|
EQUETRO 200 MG CAPSULE |
|
|
CARBAMAZEPINE |
6 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2M |
|
EQUETRO 300 MG CAPSULE |
|
|
CARBAMAZEPINE |
6 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2M |
|
LITHIUM CARBONATE 150 MG CAP |
|
|
LITHIUM CARBONATE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2M |
|
LITHIUM CARBONATE 300 MG CAP |
|
|
LITHIUM CARBONATE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2M |
|
LITHIUM CARBONATE 300 MG TAB |
|
|
LITHIUM CARBONATE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2M |
|
LITHIUM CARBONATE 600 MG CAP |
|
|
LITHIUM CARBONATE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2M |
|
LITHIUM CARBONATE ER 300 MG TB |
|
|
LITHIUM CARBONATE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2M |
|
LITHIUM CARBONATE ER 450 MG TB |
|
|
LITHIUM CARBONATE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2M |
|
LITHIUM CITRATE 8 MEQ/5 ML SOL |
|
|
LITHIUM CITRATE |
6 |
11 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2M |
|
LITHIUM ER 450 MG TABLET |
|
|
LITHIUM CARBONATE |
6 |
999 |
|
No |
|
||
|
|
|
H2S |
SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) |
|
|
|
|
|
||||
|
H2S |
|
CITALOPRAM 10 MG/5 ML SOLUTION |
|
|
CITALOPRAM HYDROBROMIDE |
6 |
11 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2S |
|
CITALOPRAM HBR 10 MG TABLET |
|
|
CITALOPRAM HYDROBROMIDE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2S |
|
CITALOPRAM HBR 10 MG/5 ML SOLN |
|
|
CITALOPRAM HYDROBROMIDE |
6 |
11 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2S |
|
CITALOPRAM HBR 20 MG TABLET |
|
|
CITALOPRAM HYDROBROMIDE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2S |
|
CITALOPRAM HBR 40 MG TABLET |
|
|
CITALOPRAM HYDROBROMIDE |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 73 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
CITALOPRAM HBR 40 MG TABLET |
CITALOPRAM HYDROBROMIDE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
ESCITALOPRAM 10 MG TABLET |
ESCITALOPRAM OXALATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
ESCITALOPRAM 20 MG TABLET |
ESCITALOPRAM OXALATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
ESCITALOPRAM 5 MG TABLET |
ESCITALOPRAM OXALATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
FLUOXETINE 10 MG CAPSULE |
FLUOXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
FLUOXETINE 20 MG CAPSULE |
FLUOXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
FLUOXETINE 20 MG/5 ML SOLN |
FLUOXETINE HCL |
6 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
FLUOXETINE 20 MG/5 ML SOLUTION |
FLUOXETINE HCL |
6 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
FLUOXETINE 40 MG CAPSULE |
FLUOXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
FLUOXETINE HCL 10 MG CAPSULE |
FLUOXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
FLUOXETINE HCL 20 MG CAPSULE |
FLUOXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
FLUOXETINE HCL 40 MG CAPSULE |
FLUOXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
FLUVOXAMINE MAL 100 MG TAB |
FLUVOXAMINE MALEATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
FLUVOXAMINE MALEATE 100 MG TAB |
FLUVOXAMINE MALEATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
FLUVOXAMINE MALEATE 25 MG TAB |
FLUVOXAMINE MALEATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
FLUVOXAMINE MALEATE 25 MG TB |
FLUVOXAMINE MALEATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
FLUVOXAMINE MALEATE 50 MG TAB |
FLUVOXAMINE MALEATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
FLUVOXAMINE MALEATE 50 MG TB |
FLUVOXAMINE MALEATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
PAROXETINE HCL 10 MG TABLET |
PAROXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
PAROXETINE HCL 20 MG TABLET |
PAROXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
PAROXETINE HCL 30 MG TABLET |
PAROXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
PAROXETINE HCL 40 MG TABLET |
PAROXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
SERTRALINE 20 MG/ML ORAL CONC |
SERTRALINE HCL |
6 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2S |
|
SERTRALINE 20 MG/ML ORAL SOLN |
SERTRALINE HCL |
6 |
11 |
|
No |
|
Thursday, October 25, 2018 |
Page 74 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2S |
|
SERTRALINE HCL 100 MG TABLET |
|
|
SERTRALINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2S |
|
SERTRALINE HCL 25 MG TABLET |
|
|
SERTRALINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2S |
|
SERTRALINE HCL 50 MG TABLET |
|
|
SERTRALINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
H2U |
TRICYCLIC |
|
|
|
|
|
||||
|
H2U |
|
AMITRIPTYLINE HCL 10 MG TAB |
|
|
AMITRIPTYLINE HCL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
AMITRIPTYLINE HCL 100 MG TAB |
|
|
AMITRIPTYLINE HCL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
AMITRIPTYLINE HCL 150 MG TAB |
|
|
AMITRIPTYLINE HCL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
AMITRIPTYLINE HCL 25 MG TAB |
|
|
AMITRIPTYLINE HCL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
AMITRIPTYLINE HCL 50 MG TAB |
|
|
AMITRIPTYLINE HCL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
AMITRIPTYLINE HCL 75 MG TAB |
|
|
AMITRIPTYLINE HCL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
AMOXAPINE 100 MG TABLET |
|
|
AMOXAPINE |
16 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
AMOXAPINE 150 MG TABLET |
|
|
AMOXAPINE |
16 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
AMOXAPINE 25 MG TABLET |
|
|
AMOXAPINE |
16 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
AMOXAPINE 50 MG TABLET |
|
|
AMOXAPINE |
16 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
CLOMIPRAMINE 25 MG CAPSULE |
|
|
CLOMIPRAMINE HCL |
10 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
CLOMIPRAMINE 50 MG CAPSULE |
|
|
CLOMIPRAMINE HCL |
10 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
CLOMIPRAMINE 75 MG CAPSULE |
|
|
CLOMIPRAMINE HCL |
10 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
DESIPRAMINE 10 MG TABLET |
|
|
DESIPRAMINE HCL |
13 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
DESIPRAMINE 100 MG TABLET |
|
|
DESIPRAMINE HCL |
13 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
DESIPRAMINE 150 MG TABLET |
|
|
DESIPRAMINE HCL |
13 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
DESIPRAMINE 25 MG TABLET |
|
|
DESIPRAMINE HCL |
13 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
DESIPRAMINE 50 MG TABLET |
|
|
DESIPRAMINE HCL |
13 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
DESIPRAMINE 75 MG TABLET |
|
|
DESIPRAMINE HCL |
13 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
DOXEPIN 10 MG CAPSULE |
|
|
DOXEPIN HCL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 75 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H2U |
|
DOXEPIN 10 MG/ML ORAL CONC |
|
|
DOXEPIN HCL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
DOXEPIN 100 MG CAPSULE |
|
|
DOXEPIN HCL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
DOXEPIN 150 MG CAPSULE |
|
|
DOXEPIN HCL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
DOXEPIN 25 MG CAPSULE |
|
|
DOXEPIN HCL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
DOXEPIN 50 MG CAPSULE |
|
|
DOXEPIN HCL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
DOXEPIN 75 MG CAPSULE |
|
|
DOXEPIN HCL |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
IMIPRAMINE HCL 10 MG TABLET |
|
|
IMIPRAMINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
IMIPRAMINE HCL 25 MG TABLET |
|
|
IMIPRAMINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
IMIPRAMINE HCL 50 MG TABLET |
|
|
IMIPRAMINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
NORTRIPTYLINE 10 MG/5 ML SOL |
|
|
NORTRIPTYLINE HCL |
13 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
NORTRIPTYLINE HCL 10 MG CAP |
|
|
NORTRIPTYLINE HCL |
13 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
NORTRIPTYLINE HCL 25 MG CAP |
|
|
NORTRIPTYLINE HCL |
13 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
NORTRIPTYLINE HCL 50 MG CAP |
|
|
NORTRIPTYLINE HCL |
13 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2U |
|
NORTRIPTYLINE HCL 75 MG CAP |
|
|
NORTRIPTYLINE HCL |
13 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
||||||
|
|
|
H2V |
TX FOR ATTENTION |
|
|
|
||||||
|
H2V |
|
APTENSIO XR 10 MG CAPSULE |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
APTENSIO XR 15 MG CAPSULE |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
APTENSIO XR 20 MG CAPSULE |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
APTENSIO XR 30 MG CAPSULE |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
APTENSIO XR 40 MG CAPSULE |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
APTENSIO XR 50 MG CAPSULE |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
APTENSIO XR 60 MG CAPSULE |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
DAYTRANA 10 MG/9 HR PATCH |
|
|
METHYLPHENIDATE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
DAYTRANA 15 MG/9 HR PATCH |
|
|
METHYLPHENIDATE |
6 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 76 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
DAYTRANA 20 MG/9 HOUR PATCH |
METHYLPHENIDATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
DAYTRANA 30 MG/9 HOUR PATCH |
METHYLPHENIDATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
DEXMETHYLPHENIDATE 10 MG TAB |
DEXMETHYLPHENIDATE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
DEXMETHYLPHENIDATE 2.5 MG TAB |
DEXMETHYLPHENIDATE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
DEXMETHYLPHENIDATE 5 MG TAB |
DEXMETHYLPHENIDATE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
FOCALIN XR 10 MG CAPSULE |
DEXMETHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
FOCALIN XR 15 MG CAPSULE |
DEXMETHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
FOCALIN XR 20 MG CAPSULE |
DEXMETHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
FOCALIN XR 25 MG CAPSULE |
DEXMETHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
FOCALIN XR 30 MG CAPSULE |
DEXMETHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
FOCALIN XR 35 MG CAPSULE |
DEXMETHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
FOCALIN XR 40 MG CAPSULE |
DEXMETHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
FOCALIN XR 5 MG CAPSULE |
DEXMETHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
METHYLPHENIDATE 10 MG CHEW TAB |
METHYLPHENIDATE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
METHYLPHENIDATE 10 MG TABLET |
METHYLPHENIDATE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
METHYLPHENIDATE 2.5 MG CHEW TB |
METHYLPHENIDATE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
METHYLPHENIDATE 20 MG TABLET |
METHYLPHENIDATE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
METHYLPHENIDATE 5 MG CHEW TAB |
METHYLPHENIDATE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
METHYLPHENIDATE 5 MG TABLET |
METHYLPHENIDATE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
METHYLPHENIDATE CD 10 MG CAP |
METHYLPHENIDATE HCL |
6 |
999 |
|
No (Generic Metadate CD) |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
METHYLPHENIDATE CD 20 MG CAP |
METHYLPHENIDATE HCL |
6 |
999 |
|
No (Generic Metadate CD) |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
METHYLPHENIDATE CD 30 MG CAP |
METHYLPHENIDATE HCL |
6 |
999 |
|
No (Generic Metadate CD) |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
METHYLPHENIDATE CD 40 MG CAP |
METHYLPHENIDATE HCL |
6 |
999 |
|
No (Generic Metadate CD) |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H2V |
|
METHYLPHENIDATE CD 50 MG CAP |
METHYLPHENIDATE HCL |
6 |
999 |
|
No (Generic Metadate CD) |
|
Thursday, October 25, 2018 |
Page 77 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
METHYLPHENIDATE CD 60 MG CAP |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No (Generic Metadate CD) |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
METHYLPHENIDATE ER 10 MG CAP |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No (Generic Metadate CD) |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
METHYLPHENIDATE ER 10 MG TAB |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No (Generic Metadate CD) |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
METHYLPHENIDATE ER 20 MG CAP |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No (Generic Metadate CD) |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
METHYLPHENIDATE ER 20 MG TAB |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No (Generic Metadate CD) |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
METHYLPHENIDATE ER 30 MG CAP |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No (Generic Metadate CD) |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
METHYLPHENIDATE ER 40 MG CAP |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No (Generic Metadate CD) |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
METHYLPHENIDATE ER 50 MG CAP |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No (Generic Metadate CD) |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
METHYLPHENIDATE ER 60 MG CAP |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No (Generic Metadate CD) |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
QUILLICHEW ER 20 MG CHEW TAB |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
QUILLICHEW ER 30 MG CHEW TAB |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
QUILLICHEW ER 40 MG CHEW TAB |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2V |
|
QUILLIVANT XR 25 MG/5 ML SUSP |
|
|
METHYLPHENIDATE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
||||||
|
|
|
H2W |
TRICYCLIC |
|
|
|
||||||
|
H2W |
|
PERPHENAZINE/AMITRIPTYLINE HCL |
18 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
H2W |
|
PERPHENAZINE/AMITRIPTYLINE HCL |
18 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
H2W |
|
PERPHENAZINE/AMITRIPTYLINE HCL |
18 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
H2W |
|
PERPHENAZINE/AMITRIPTYLINE HCL |
18 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
||||
|
H2W |
|
PERPHENAZINE/AMITRIPTYLINE HCL |
18 |
999 |
|
No |
|
|||||
|
|
|
H2X |
TRICYCLIC |
|
|
|
||||||
|
H2X |
|
AMITRIP/CDP |
|
|
AMITRIPTYLINE/CHLORDIAZEPOXIDE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H2X |
|
AMITRIP/CDP |
|
|
AMITRIPTYLINE/CHLORDIAZEPOXIDE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3A |
|
|
OPIOID ANALGESICS |
|
|
|
|
|
|
|
|
H3A |
|
ARYMO ER 15 MG TABLET |
|
|
MORPHINE SULFATE |
18 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3A |
|
ARYMO ER 30 MG TABLET |
|
|
MORPHINE SULFATE |
18 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 78 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H3A |
|
ARYMO ER 60 MG TABLET |
MORPHINE SULFATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
BELLADONNA & OPIUM SUPPOS |
OPIUM/BELLADONNA ALKALOIDS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
CODEINE SULFATE 15 MG TABLET |
CODEINE SULFATE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
CODEINE SULFATE 30 MG TABLET |
CODEINE SULFATE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
CODEINE SULFATE 60 MG TABLET |
CODEINE SULFATE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
EMBEDA ER |
MORPHINE SULFATE/NALTREXONE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
EMBEDA ER |
MORPHINE SULFATE/NALTREXONE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
EMBEDA ER |
MORPHINE SULFATE/NALTREXONE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
EMBEDA ER |
MORPHINE SULFATE/NALTREXONE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
EMBEDA ER |
MORPHINE SULFATE/NALTREXONE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
EMBEDA ER |
MORPHINE SULFATE/NALTREXONE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
FENTANYL 100 MCG/HR PATCH |
FENTANYL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
FENTANYL 12 MCG/HR PATCH |
FENTANYL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
FENTANYL 25 MCG/HR PATCH |
FENTANYL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
FENTANYL 50 MCG/HR PATCH |
FENTANYL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
FENTANYL 75 MCG/HR PATCH |
FENTANYL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
HYDROMORPHONE 0.5 MG/0.5 ML |
HYDROMORPHONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
HYDROMORPHONE 2 MG TABLET |
HYDROMORPHONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
HYDROMORPHONE 4 MG TABLET |
HYDROMORPHONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
HYDROMORPHONE 8 MG TABLET |
HYDROMORPHONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
HYDROMORPHONE HCL 8 MG TAB |
HYDROMORPHONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
HYSINGLA ER 100 MG TABLET |
HYDROCODONE BITARTRATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
HYSINGLA ER 120 MG TABLET |
HYDROCODONE BITARTRATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
HYSINGLA ER 20 MG TABLET |
HYDROCODONE BITARTRATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 79 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H3A |
|
HYSINGLA ER 30 MG TABLET |
HYDROCODONE BITARTRATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
HYSINGLA ER 40 MG TABLET |
HYDROCODONE BITARTRATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
HYSINGLA ER 60 MG TABLET |
HYDROCODONE BITARTRATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
HYSINGLA ER 80 MG TABLET |
HYDROCODONE BITARTRATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
MORPHABOND ER 100 MG TABLET |
MORPHINE SULFATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
MORPHABOND ER 15 MG TABLET |
MORPHINE SULFATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
MORPHABOND ER 30 MG TABLET |
MORPHINE SULFATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
MORPHABOND ER 60 MG TABLET |
MORPHINE SULFATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
MORPHINE SULF 10 MG/5 ML SOLN |
MORPHINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
MORPHINE SULF 100 MG/5 ML SOLN |
MORPHINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
MORPHINE SULF 20 MG/5 ML SOLN |
MORPHINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
MORPHINE SULFATE 15 MG TABLET |
MORPHINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
MORPHINE SULFATE 20 MG/ML SOLN |
MORPHINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
MORPHINE SULFATE 30 MG TABLET |
MORPHINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
OXYCODONE HCL 10 MG TABLET |
OXYCODONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
OXYCODONE HCL 15 MG TABLET |
OXYCODONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
OXYCODONE HCL 20 MG TABLET |
OXYCODONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
OXYCODONE HCL 30 MG TABLET |
OXYCODONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
OXYCODONE HCL 5 MG TABLET |
OXYCODONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
OXYCODONE HCL 5 MG/5 ML SOL |
OXYCODONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
OXYCODONE HCL 5 MG/5 ML SOLN |
OXYCODONE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
TRAMADOL HCL 50 MG TABLET |
TRAMADOL HCL |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
XTAMPZA ER 13.5 MG CAPSULE |
OXYCODONE MYRISTATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3A |
|
XTAMPZA ER 18 MG CAPSULE |
OXYCODONE MYRISTATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 80 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H3A |
|
XTAMPZA ER 27 MG CAPSULE |
|
OXYCODONE MYRISTATE |
18 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3A |
|
XTAMPZA ER 36 MG CAPSULE |
|
OXYCODONE MYRISTATE |
18 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3A |
|
XTAMPZA ER 9 MG CAPSULE |
|
OXYCODONE MYRISTATE |
18 |
999 |
|
Auto PA |
|
||
|
|
|
H3D |
|
ANALGESIC/ANTIPYRETICS, SALICYLATES |
|
|
|
|
|
|
|
|
H3D |
|
ASPIRIN 325 MG TABLET |
|
ASPIRIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3D |
|
ASPIRIN EC 325 MG TABLET |
|
ASPIRIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3D |
|
HM ASPIRIN 325 MG TABLET |
|
ASPIRIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3D |
|
SALSALATE 500 MG TABLET |
|
SALSALATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3D |
|
SALSALATE 750 MG TABLET |
|
SALSALATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3D |
|
SB ASPIRIN 325 MG TABLET |
|
ASPIRIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
H3E |
|
|
|
|
|
||||
|
H3E |
|
8 HOUR ER 650 MG CAPLET |
|
ACETAMINOPHEN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3E |
|
8HR ARTHRITIS PAIN ER 650 MG |
|
ACETAMINOPHEN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3E |
|
8HR MUSCLE |
|
ACETAMINOPHEN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3E |
|
ACETAMINOPHEN 160 MG/5 ML ELX |
|
ACETAMINOPHEN |
0 |
6 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3E |
|
ACETAMINOPHEN 160 MG/5 ML LIQ |
|
ACETAMINOPHEN |
0 |
6 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3E |
|
APAP CHILDRENS SUSPENSION |
|
ACETAMINOPHEN |
0 |
6 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3E |
|
ARTHRITIS PAIN ER 650 MG CAPLT |
|
ACETAMINOPHEN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3E |
|
CHILD PAIN & FEVER 160 MG/5 ML |
|
ACETAMINOPHEN |
0 |
6 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3E |
|
CHILD |
|
ACETAMINOPHEN |
0 |
6 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3E |
|
CHILDREN'S PAIN RELIEF SUSP |
|
ACETAMINOPHEN |
0 |
6 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3E |
|
CHILDREN'S SILAPAP ELIXIR |
|
ACETAMINOPHEN |
0 |
6 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3E |
|
CHILD'S PAIN RELIEVER SUSP |
|
ACETAMINOPHEN |
0 |
6 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H3E |
|
CHLD ACETAMINOPHEN 160 MG/5 ML |
|
ACETAMINOPHEN |
0 |
6 |
|
No |
|
||
|
|
|
H3F |
|
ANTIMIGRAINE PREPARATIONS |
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 81 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H3F |
|
RIZATRIPTAN 10 MG ODT |
|
|
RIZATRIPTAN BENZOATE |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3F |
|
RIZATRIPTAN 10 MG TABLET |
|
|
RIZATRIPTAN BENZOATE |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3F |
|
RIZATRIPTAN 5 MG ODT |
|
|
RIZATRIPTAN BENZOATE |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3F |
|
RIZATRIPTAN 5 MG TABLET |
|
|
RIZATRIPTAN BENZOATE |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
H3F |
|
SUMATRIPTAN 20 MG NASAL SPRAY |
SUMATRIPTAN |
18 |
|
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3F |
|
SUMATRIPTAN 5 MG NASAL SPRAY |
|
|
SUMATRIPTAN |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
H3F |
|
SUMATRIPTAN SUCC 100 MG TABLET |
SUMATRIPTAN SUCCINATE |
18 |
|
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|||
|
H3F |
|
SUMATRIPTAN SUCC 25 MG TABLET |
SUMATRIPTAN SUCCINATE |
18 |
|
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|||
|
H3F |
|
SUMATRIPTAN SUCC 50 MG TABLET |
SUMATRIPTAN SUCCINATE |
18 |
|
999 |
|
No |
|
|||
|
|
|
H3K |
ANALGESIC, |
|
|
|
||||||
|
H3K |
|
APAP/BUTALBITAL 325/50 TAB |
|
|
BUTALBITAL/ACETAMINOPHEN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
H3K |
|
BUTALBITAL/ACETAMINOPHEN |
0 |
|
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|||
|
H3K |
|
BUTALBITAL/ACETAMINOPHEN |
0 |
|
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|||
|
H3K |
|
BUTALBITAL/ACETAMINOPHEN |
0 |
|
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
||||||
|
|
|
H3L |
|
|
|
|||||||
|
H3L |
|
BUTALB/ACETAMINOPHEN/CAFFEINE |
0 |
|
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|||
|
H3L |
|
BUTALB/ACETAMINOPHEN/CAFFEINE |
0 |
|
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3L |
|
|
|
BUTALB/ACETAMINOPHEN/CAFFEINE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|||
|
H3L |
|
BUTALB/ACETAMINOPHEN/CAFFEINE |
0 |
|
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3L |
|
BUTALBITAL/APAP/CAFFEINE TAB |
|
|
BUTALB/ACETAMINOPHEN/CAFFEINE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3L |
|
BUTALBITAL/APAP/CAFFEINE TB |
|
|
BUTALB/ACETAMINOPHEN/CAFFEINE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3L |
|
|
|
BUTALB/ACETAMINOPHEN/CAFFEINE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3L |
|
|
|
BUTALB/ACETAMINOPHEN/CAFFEINE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|||||
|
|
|
H3M |
|
|
|
|
||||||
|
H3M |
|
BUTALBITAL/CAFF/APAP/COD CP |
|
|
BUTALBIT/ACETAMIN/CAFF/CODEINE |
12 |
|
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 82 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3M |
|
|
|
|
BUTALBIT/ACETAMIN/CAFF/CODEINE |
12 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3M |
|
|
|
|
BUTALBIT/ACETAMIN/CAFF/CODEINE |
12 |
|
999 |
|
No |
|
||
|
|
|
H3N |
|
OPIOID ANALGESIC AND NSAID COMBINATION |
|
|
|
|
|||||
|
H3N |
|
HYDROCODONE |
|
|
|
HYDROCODONE/IBUPROFEN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3N |
|
HYDROCODONE |
|
|
|
HYDROCODONE/IBUPROFEN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3N |
|
HYDROCODONE |
|
|
|
HYDROCODONE/IBUPROFEN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3N |
|
|
|
|
HYDROCODONE/IBUPROFEN |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3N |
|
|
|
HYDROCODONE/IBUPROFEN |
0 |
|
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3N |
|
|
|
|
HYDROCODONE/IBUPROFEN |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
||||||
|
|
|
H3O |
ANALGESIC, SALICYLATE, BARBITURATE, XANTHINE COMB. |
|
|
|
|
||||||
|
H3O |
|
|
|
|
BUTALBITAL/ASPIRIN/CAFFEINE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3O |
|
BUTALBITAL COMPOUND CAPSULE |
|
|
|
BUTALBITAL/ASPIRIN/CAFFEINE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3O |
|
|
|
|
BUTALBITAL/ASPIRIN/CAFFEINE |
0 |
|
999 |
|
No |
|
||
|
|
|
H3T |
|
|
|
OPIOID ANTAGONISTS |
|
|
|
|
|
|
|
|
H3T |
|
NALOXONE 0.4 MG/ML CARPUJECT |
|
|
|
NALOXONE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3T |
|
NALOXONE 0.4 MG/ML SYRINGE |
|
|
|
NALOXONE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3T |
|
NALOXONE 0.4 MG/ML VIAL |
|
|
|
NALOXONE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3T |
|
NALOXONE 2 MG/2 ML SYRINGE |
|
|
|
NALOXONE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3T |
|
NALOXONE 4 MG/10 ML VIAL |
|
|
|
NALOXONE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3T |
|
NALTREXONE 50 MG TABLET |
|
|
|
NALTREXONE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3T |
|
NARCAN 2 MG NASAL SPRAY |
|
|
|
NALOXONE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H3T |
|
NARCAN 4 MG NASAL SPRAY |
|
|
|
NALOXONE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
H3U |
|
OPIOID ANALGESIC AND |
|
|
|
|
|||||
|
H3U |
|
|
|
|
ACETAMINOPHEN WITH CODEINE |
12 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
|
|
ACETAMINOPHEN WITH CODEINE |
12 |
|
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 83 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H3U |
|
ACETAMINOPHEN/COD #2 TABLET |
ACETAMINOPHEN WITH CODEINE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
ACETAMINOPHEN/COD #3 TABLET |
ACETAMINOPHEN WITH CODEINE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
ACETAMINOPHEN/COD #4 TABLET |
ACETAMINOPHEN WITH CODEINE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
ACETAMINOPHEN/COD ELIXIR |
ACETAMINOPHEN WITH CODEINE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
ACETAMINOPHEN WITH CODEINE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
ACETAMINOPHEN WITH CODEINE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
ACETAMINOPHEN WITH CODEINE |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H3U |
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 84 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H3U |
|
|
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
|
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
|
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
|
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
|
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
|
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
NORCO |
|
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
NORCO |
|
|
HYDROCODONE/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
OXYCODON |
|
|
OXYCODONE HCL/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
|
|
OXYCODONE HCL/ACETAMINOPHEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
|
|
OXYCODONE HCL/ACETAMINOPHEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
OXYCODONE W/APAP 5/325 TAB |
|
|
OXYCODONE HCL/ACETAMINOPHEN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
|
|
OXYCODONE HCL/ACETAMINOPHEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
|
|
OXYCODONE HCL/ACETAMINOPHEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
|
|
OXYCODONE HCL/ACETAMINOPHEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
|
|
OXYCODONE HCL/ACETAMINOPHEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
|
|
OXYCODONE HCL/ACETAMINOPHEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3U |
|
|
|
OXYCODONE HCL/ACETAMINOPHEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
H3W |
OPIOID WITHDRAWAL THERAPY AGENTS, |
|
|
|
|
|
||||
|
H3W |
|
BUPRENORPHINE 2 MG TABLET SL |
|
|
BUPRENORPHINE HCL |
16 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3W |
|
BUPRENORPHINE 8 MG TABLET SL |
|
|
BUPRENORPHINE HCL |
16 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3W |
|
SUBLOCADE 100 MG/0.5 ML SYRING |
|
|
BUPRENORPHINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3W |
|
SUBLOCADE 300 MG/1.5 ML SYRING |
|
|
BUPRENORPHINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3W |
|
SUBOXONE 12 |
|
|
BUPRENORPHINE HCL/NALOXONE HCL |
16 |
999 |
|
Clinical PA Required |
|
Thursday, October 25, 2018 |
Page 85 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3W |
|
SUBOXONE 2 |
|
|
BUPRENORPHINE HCL/NALOXONE HCL |
16 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3W |
|
SUBOXONE 4 |
|
|
BUPRENORPHINE HCL/NALOXONE HCL |
16 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3W |
|
SUBOXONE 8 |
|
|
BUPRENORPHINE HCL/NALOXONE HCL |
16 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
||||||
|
|
|
H3Y |
|
|
|
|||||||
|
H3Y |
|
MOVANTIK 12.5 MG TABLET |
|
|
NALOXEGOL OXALATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H3Y |
|
MOVANTIK 25 MG TABLET |
|
|
NALOXEGOL OXALATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
H4A |
|
ANTICONVULSANT - BENZODIAZEPINE TYPE |
|
|
|
|
|
|||
|
H4A |
|
CLONAZEPAM 0.125 MG DIS TAB |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
CLONAZEPAM 0.125 MG ODT |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
CLONAZEPAM 0.25 MG DIS TAB |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
CLONAZEPAM 0.25 MG DIS TABLET |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
CLONAZEPAM 0.25 MG ODT |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
CLONAZEPAM 0.5 MG DIS TAB |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
CLONAZEPAM 0.5 MG DIS TABLET |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
CLONAZEPAM 0.5 MG ODT |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
CLONAZEPAM 0.5 MG TABLET |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
CLONAZEPAM 1 MG DIS TABLET |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
CLONAZEPAM 1 MG ODT |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
CLONAZEPAM 1 MG TABLET |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
CLONAZEPAM 2 MG DIS TABLET |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
CLONAZEPAM 2 MG ODT |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
CLONAZEPAM 2 MG TABLET |
|
|
CLONAZEPAM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
DIASTAT 2.5 MG PEDI SYSTEM |
|
|
DIAZEPAM |
0 |
18 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H4A |
|
DIASTAT ACUDIAL |
|
|
DIAZEPAM |
0 |
18 |
|
Auto PA |
|
Thursday, October 25, 2018 |
Page 86 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
H4A |
|
DIASTAT ACUDIAL |
DIAZEPAM |
0 |
18 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4A |
|
DIAZEPAM 10 MG RECTAL GEL |
DIAZEPAM |
0 |
18 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4A |
|
DIAZEPAM 10 MG RECTAL GEL SYST |
DIAZEPAM |
0 |
18 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4A |
|
DIAZEPAM 2.5 MG RECTAL GEL |
DIAZEPAM |
0 |
18 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4A |
|
DIAZEPAM 2.5 MG RECTAL GEL SYS |
DIAZEPAM |
0 |
18 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4A |
|
DIAZEPAM 20 MG RECTAL GEL |
DIAZEPAM |
0 |
18 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4A |
|
DIAZEPAM 20 MG RECTAL GEL SYST |
DIAZEPAM |
0 |
18 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4A |
|
KLONOPIN 0.5 MG TABLET |
CLONAZEPAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4A |
|
KLONOPIN 1 MG TABLET |
CLONAZEPAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4A |
|
KLONOPIN 2 MG TABLET |
CLONAZEPAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4A |
|
ONFI 10 MG TABLET |
CLOBAZAM |
2 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4A |
|
ONFI 2.5 MG/ML SUSPENSION |
CLOBAZAM |
2 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4A |
|
ONFI 20 MG TABLET |
CLOBAZAM |
2 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H4B |
ANTICONVULSANTS |
|
|
|
|
|
|
|
|
|
H4B |
|
APTIOM 200 MG TABLET |
ESLICARBAZEPINE ACETATE |
4 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
APTIOM 400 MG TABLET |
ESLICARBAZEPINE ACETATE |
4 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
APTIOM 600 MG TABLET |
ESLICARBAZEPINE ACETATE |
4 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
APTIOM 800 MG TABLET |
ESLICARBAZEPINE ACETATE |
4 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
BANZEL 200 MG TABLET |
RUFINAMIDE |
1 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
BANZEL 40 MG/ML SUSPENSION |
RUFINAMIDE |
1 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
BANZEL 400 MG TABLET |
RUFINAMIDE |
1 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
BRIVIACT 10 MG TABLET |
BRIVARACETAM |
4 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
BRIVIACT 10 MG/ML ORAL SOLN |
BRIVARACETAM |
4 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
BRIVIACT 100 MG TABLET |
BRIVARACETAM |
4 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 87 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H4B |
|
BRIVIACT 25 MG TABLET |
BRIVARACETAM |
4 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
BRIVIACT 50 MG TABLET |
BRIVARACETAM |
4 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
BRIVIACT 50 MG/5 ML VIAL |
BRIVARACETAM |
16 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
BRIVIACT 75 MG TABLET |
BRIVARACETAM |
4 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBAMAZEPINE 100 MG TAB CHEW |
CARBAMAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBAMAZEPINE 100 MG TAB CHW |
CARBAMAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBAMAZEPINE 100 MG/5 ML SUS |
CARBAMAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBAMAZEPINE 200 MG TABLET |
CARBAMAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBAMAZEPINE ER 100 MG CAP |
CARBAMAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBAMAZEPINE ER 100 MG TABLET |
CARBAMAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBAMAZEPINE ER 200 MG CAP |
CARBAMAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBAMAZEPINE ER 200 MG TABLET |
CARBAMAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBAMAZEPINE ER 300 MG CAP |
CARBAMAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBAMAZEPINE ER 400 MG TABLET |
CARBAMAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBAMAZEPINE XR 200 MG TABLET |
CARBAMAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBAMAZEPINE XR 400 MG TABLET |
CARBAMAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBATROL 100 MG CAPSULE SA |
CARBAMAZEPINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBATROL 200 MG CAPSULE SA |
CARBAMAZEPINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
CARBATROL 300 MG CAPSULE SA |
CARBAMAZEPINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DEPAKENE 250 MG CAPSULE |
VALPROIC ACID |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DEPAKENE 250 MG/5 ML SYRUP |
VALPROIC ACID (AS SODIUM SALT) |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DEPAKOTE 125 MG SPRINKLE CAP |
DIVALPROEX SODIUM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DEPAKOTE 125 MG TABLET EC |
DIVALPROEX SODIUM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DEPAKOTE 250 MG TABLET EC |
DIVALPROEX SODIUM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 88 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H4B |
|
DEPAKOTE 500 MG TABLET EC |
DIVALPROEX SODIUM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DEPAKOTE ER 250 MG TAB SA |
DIVALPROEX SODIUM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DEPAKOTE ER 250 MG TABLET |
DIVALPROEX SODIUM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DEPAKOTE ER 500 MG TAB SA |
DIVALPROEX SODIUM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DILANTIN 100 MG CAPSULE |
PHENYTOIN SODIUM EXTENDED |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DILANTIN 125 MG/5 ML SUSP |
PHENYTOIN |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DILANTIN 30 MG CAPSULE |
PHENYTOIN SODIUM EXTENDED |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DILANTIN 50 MG INFATAB |
PHENYTOIN |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DIVALPROEX SOD 125 MG TAB EC |
DIVALPROEX SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DIVALPROEX SOD 250 MG TAB EC |
DIVALPROEX SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DIVALPROEX SOD 250 MG TAB ER |
DIVALPROEX SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DIVALPROEX SOD 500 MG TAB EC |
DIVALPROEX SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DIVALPROEX SOD 500 MG TAB ER |
DIVALPROEX SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DIVALPROEX SOD DR 125 MG TAB |
DIVALPROEX SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DIVALPROEX SOD DR 250 MG TAB |
DIVALPROEX SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DIVALPROEX SOD DR 500 MG TAB |
DIVALPROEX SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DIVALPROEX SOD ER 250 MG TAB |
DIVALPROEX SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DIVALPROEX SOD ER 500 MG TAB |
DIVALPROEX SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
DIVALPROEX SODIUM 125 MG CAP |
DIVALPROEX SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
EPITOL 200 MG TABLET |
CARBAMAZEPINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ETHOSUXIMIDE 250 MG CAPSULE |
ETHOSUXIMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ETHOSUXIMIDE 250 MG/5 ML SOLN |
ETHOSUXIMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ETHOSUXIMIDE 250 MG/5 ML SYRP |
ETHOSUXIMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
FELBAMATE 400 MG TABLET |
FELBAMATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 89 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H4B |
|
FELBAMATE 600 MG TABLET |
FELBAMATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
FELBAMATE 600 MG/5 ML SUSP |
FELBAMATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
FELBATOL 400 MG TABLET |
FELBAMATE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
FELBATOL 600 MG TABLET |
FELBAMATE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
FELBATOL 600 MG/5 ML SUSP |
FELBAMATE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
FYCOMPA 0.5 MG/ML ORAL SUSP |
PERAMPANEL |
12 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
FYCOMPA 10 MG TABLET |
PERAMPANEL |
12 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
FYCOMPA 12 MG TABLET |
PERAMPANEL |
12 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
FYCOMPA 2 MG TABLET |
PERAMPANEL |
12 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
FYCOMPA 4 MG TABLET |
PERAMPANEL |
12 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
FYCOMPA 6 MG TABLET |
PERAMPANEL |
12 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
FYCOMPA 8 MG TABLET |
PERAMPANEL |
12 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
GABAPENTIN 100 MG CAPSULE |
GABAPENTIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
GABAPENTIN 250 MG/5 ML SOLN |
GABAPENTIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
GABAPENTIN 300 MG CAPSULE |
GABAPENTIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
GABAPENTIN 300 MG/6 ML SOLN |
GABAPENTIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
GABAPENTIN 400 MG CAPSULE |
GABAPENTIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
GABAPENTIN 600 MG TABLET |
GABAPENTIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
GABAPENTIN 800 MG TABLET |
GABAPENTIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
GABITRIL 12 MG TABLET |
TIAGABINE HCL |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
GABITRIL 16 MG TABLET |
TIAGABINE HCL |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
GABITRIL 2 MG TABLET |
TIAGABINE HCL |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
GABITRIL 4 MG TABLET |
TIAGABINE HCL |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
KEPPRA 1,000 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 90 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H4B |
|
KEPPRA 100 MG/ML ORAL SOLN |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
KEPPRA 250 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
KEPPRA 500 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
KEPPRA 750 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
KEPPRA XR 500 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
KEPPRA XR 750 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL 100 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL 150 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL 200 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL 25 MG DISPER TABLET |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL 25 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL 5 MG DISPER TABLET |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL ODT 100 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL ODT 200 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL ODT 25 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL ODT 50 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL ODT START KIT (BLUE) |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL ODT START KIT (GREEN) |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL ODT START KT (ORANGE) |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL TAB START KIT (BLUE) |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL TAB START KIT (GREEN) |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL TB START KIT (ORANGE) |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL XR 100 MG TABLET |
LAMOTRIGINE |
13 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL XR 200 MG TABLET |
LAMOTRIGINE |
13 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 91 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H4B |
|
LAMICTAL XR 25 MG TABLET |
LAMOTRIGINE |
13 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL XR 250 MG TABLET |
LAMOTRIGINE |
13 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL XR 300 MG TABLET |
LAMOTRIGINE |
13 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL XR 50 MG TABLET |
LAMOTRIGINE |
13 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL XR START KIT (BLUE) |
LAMOTRIGINE |
13 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL XR START KIT (GREEN) |
LAMOTRIGINE |
13 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMICTAL XR START KIT (ORANGE) |
LAMOTRIGINE |
13 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE 100 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE 150 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE 200 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE 25 MG DISPER TAB |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE 25 MG DISPER TABS |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE 25 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE 5 MG DISPER TABLET |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ER 100 MG TABLET |
LAMOTRIGINE |
13 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ER 100 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ER 200 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ER 200 MG TABLET |
LAMOTRIGINE |
13 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ER 25 MG TABLET |
LAMOTRIGINE |
13 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ER 25 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ER 250 MG TABLET |
LAMOTRIGINE |
13 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ER 300 MG TABLET |
LAMOTRIGINE |
13 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ER 300 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ER 50 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 92 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H4B |
|
LAMOTRIGINE ER 50 MG TABLET |
LAMOTRIGINE |
13 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ODT 100 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ODT 200 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ODT 25 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ODT 50 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ODT KIT (BLUE) |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ODT KIT (GREEN) |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE ODT KIT (ORANGE) |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE TAB START |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE TAB START |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LAMOTRIGINE TAB START |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LEVETIRACETAM 1,000 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LEVETIRACETAM 100 MG/ML SOLN |
LEVETIRACETAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LEVETIRACETAM 250 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LEVETIRACETAM 500 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LEVETIRACETAM 500 MG/5 ML SOLN |
LEVETIRACETAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LEVETIRACETAM 500 MG/5 ML VIAL |
LEVETIRACETAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LEVETIRACETAM 750 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LEVETIRACETAM ER 500 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LEVETIRACETAM ER 750 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LYRICA 100 MG CAPSULE |
PREGABALIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LYRICA 150 MG CAPSULE |
PREGABALIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LYRICA 200 MG CAPSULE |
PREGABALIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LYRICA 225 MG CAPSULE |
PREGABALIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 93 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H4B |
|
LYRICA 25 MG CAPSULE |
PREGABALIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LYRICA 300 MG CAPSULE |
PREGABALIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LYRICA 50 MG CAPSULE |
PREGABALIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
LYRICA 75 MG CAPSULE |
PREGABALIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
MYSOLINE 250 MG TABLET |
PRIMIDONE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
MYSOLINE 50 MG TABLET |
PRIMIDONE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
NEURONTIN 100 MG CAPSULE |
GABAPENTIN |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
NEURONTIN 250 MG/5 ML SOLN |
GABAPENTIN |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
NEURONTIN 300 MG CAPSULE |
GABAPENTIN |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
NEURONTIN 400 MG CAPSULE |
GABAPENTIN |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
NEURONTIN 600 MG TABLET |
GABAPENTIN |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
NEURONTIN 800 MG TABLET |
GABAPENTIN |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
OXCARBAZEPINE 150 MG TABLET |
OXCARBAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
OXCARBAZEPINE 300 MG TABLET |
OXCARBAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
OXCARBAZEPINE 300 MG/5 ML SUSP |
OXCARBAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
OXCARBAZEPINE 600 MG TABLET |
OXCARBAZEPINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
OXTELLAR XR 150 MG TABLET |
OXCARBAZEPINE |
6 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
OXTELLAR XR 300 MG TABLET |
OXCARBAZEPINE |
6 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
OXTELLAR XR 600 MG TABLET |
OXCARBAZEPINE |
6 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
PHENYTEK 200 MG CAPSULE |
PHENYTOIN SODIUM EXTENDED |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
PHENYTEK 300 MG CAPSULE |
PHENYTOIN SODIUM EXTENDED |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
PHENYTOIN 125 MG/5 ML SUSP |
PHENYTOIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
PHENYTOIN 125 MG/5 ML SUSPEN |
PHENYTOIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
PHENYTOIN 50 MG INFATAB |
PHENYTOIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 94 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H4B |
|
PHENYTOIN 50 MG TABLET CHEW |
PHENYTOIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
PHENYTOIN SOD EXT 100 MG CAP |
PHENYTOIN SODIUM EXTENDED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
PHENYTOIN SOD EXT 200 MG CAP |
PHENYTOIN SODIUM EXTENDED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
PHENYTOIN SOD EXT 300 MG CAP |
PHENYTOIN SODIUM EXTENDED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
PRIMIDONE 250 MG TABLET |
PRIMIDONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
PRIMIDONE 50 MG TABLET |
PRIMIDONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
QUDEXY XR 100 MG CAPSULE |
TOPIRAMATE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
QUDEXY XR 150 MG CAPSULE |
TOPIRAMATE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
QUDEXY XR 200 MG CAPSULE |
TOPIRAMATE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
QUDEXY XR 25 MG CAPSULE |
TOPIRAMATE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
QUDEXY XR 50 MG CAPSULE |
TOPIRAMATE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ROWEEPRA 1,000 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ROWEEPRA 500 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ROWEEPRA 750 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ROWEEPRA XR 500 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ROWEEPRA XR 750 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
SABRIL 500 MG POWDER PACKET |
VIGABATRIN |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
SABRIL 500 MG TABLET |
VIGABATRIN |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
SPRITAM 1000 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
SPRITAM 250 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
SPRITAM 500 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
SPRITAM 750 MG TABLET |
LEVETIRACETAM |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
SUBVENITE 100 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
SUBVENITE 150 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 95 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H4B |
|
SUBVENITE 200 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
SUBVENITE 25 MG TABLET |
LAMOTRIGINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
SUBVENITE TAB START KIT (BLUE) |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
SUBVENITE TAB START KIT(GREEN) |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
SUBVENITE TAB START KT(ORANGE) |
LAMOTRIGINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TEGRETOL 100 MG/5 ML SUSP |
CARBAMAZEPINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TEGRETOL 200 MG TABLET |
CARBAMAZEPINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TEGRETOL XR 100 MG TABLET SA |
CARBAMAZEPINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TEGRETOL XR 200 MG TABLET SA |
CARBAMAZEPINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TEGRETOL XR 400 MG TABLET SA |
CARBAMAZEPINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TIAGABINE HCL 12 MG TABLET |
TIAGABINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TIAGABINE HCL 16 MG TABLET |
TIAGABINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TIAGABINE HCL 2 MG TABLET |
TIAGABINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TIAGABINE HCL 4 MG TABLET |
TIAGABINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPAMAX 100 MG TABLET |
TOPIRAMATE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPAMAX 15 MG SPRINKLE CAP |
TOPIRAMATE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPAMAX 200 MG TABLET |
TOPIRAMATE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPAMAX 25 MG SPRINKLE CAP |
TOPIRAMATE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPAMAX 25 MG TABLET |
TOPIRAMATE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPAMAX 50 MG TABLET |
TOPIRAMATE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPIRAMATE 100 MG TABLET |
TOPIRAMATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPIRAMATE 15 MG SPRINKLE CAP |
TOPIRAMATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPIRAMATE 200 MG TABLET |
TOPIRAMATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPIRAMATE 25 MG SPRINKLE CAP |
TOPIRAMATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 96 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H4B |
|
TOPIRAMATE 25 MG TABLET |
TOPIRAMATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPIRAMATE 50 MG TABLET |
TOPIRAMATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPIRAMATE ER 100 MG CAPSULE |
TOPIRAMATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPIRAMATE ER 150 MG CAPSULE |
TOPIRAMATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPIRAMATE ER 200 MG CAPSULE |
TOPIRAMATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPIRAMATE ER 25 MG CAPSULE |
TOPIRAMATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TOPIRAMATE ER 50 MG CAPSULE |
TOPIRAMATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TRILEPTAL 150 MG TABLET |
OXCARBAZEPINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TRILEPTAL 300 MG TABLET |
OXCARBAZEPINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TRILEPTAL 300 MG/5 ML SUSP |
OXCARBAZEPINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TRILEPTAL 600 MG TABLET |
OXCARBAZEPINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TROKENDI XR 100 MG CAPSULE |
TOPIRAMATE |
6 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TROKENDI XR 200 MG CAPSULE |
TOPIRAMATE |
6 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TROKENDI XR 25 MG CAPSULE |
TOPIRAMATE |
6 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
TROKENDI XR 50 MG CAPSULE |
TOPIRAMATE |
6 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
VALPROIC ACID 250 MG CAPSULE |
VALPROIC ACID |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
VALPROIC ACID 250 MG/5 ML SOL |
VALPROIC ACID (AS SODIUM SALT) |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
VALPROIC ACID 250 MG/5 ML SOLN |
VALPROIC ACID (AS SODIUM SALT) |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
VALPROIC ACID 250 MG/5 ML SYR |
VALPROIC ACID (AS SODIUM SALT) |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
VALPROIC ACID 500 MG/10 ML SOL |
VALPROIC ACID (AS SODIUM SALT) |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
VIGABATRIN 500 MG POWDER PACKT |
VIGABATRIN |
0 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
VIGADRONE 500 MG POWDER PACKET |
VIGABATRIN |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
VIMPAT 10 MG/ML SOLUTION |
LACOSAMIDE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
VIMPAT 100 MG TABLET |
LACOSAMIDE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 97 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H4B |
|
VIMPAT 150 MG TABLET |
LACOSAMIDE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
VIMPAT 200 MG TABLET |
LACOSAMIDE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
VIMPAT 50 MG TABLET |
LACOSAMIDE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
VIMPAT STARTER KIT |
LACOSAMIDE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ZARONTIN 250 MG CAPSULE |
ETHOSUXIMIDE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ZARONTIN 250 MG/5 ML SYRUP |
ETHOSUXIMIDE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ZONEGRAN 100 MG CAPSULE |
ZONISAMIDE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ZONEGRAN 25 MG CAPSULE |
ZONISAMIDE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ZONISAMIDE 100 MG CAPSULE |
ZONISAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ZONISAMIDE 25 MG CAPSULE |
ZONISAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H4B |
|
ZONISAMIDE 50 MG CAPSULE |
ZONISAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
H6A |
ANTIPARKINSONISM DRUGS,OTHER |
|
|
|
|
|
|
|
|
|
H6A |
|
AMANTADINE 100 MG CAPSULE |
AMANTADINE HCL |
1 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
AMANTADINE 100 MG TABLET |
AMANTADINE HCL |
1 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
AMANTADINE 100 MG/10 ML SOLN |
AMANTADINE HCL |
1 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
AMANTADINE 50 MG/5 ML SYRUP |
AMANTADINE HCL |
1 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVO 10/100 TAB |
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVO 25/100 TAB |
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVO 25/100 TAB |
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVO 25/100 TABLET |
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVO 25/100 TB SA |
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVO 25/250 TAB |
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVO 25/250 TABLET |
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVO 50/200 TB SA |
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 98 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H6A |
|
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA/ENTACAPONE |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA/ENTACAPONE |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA/ENTACAPONE |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA/ENTACAPONE |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA/ENTACAPONE |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
CARBIDOPA/LEVODOPA/ENTACAPONE |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
PRAMIPEXOLE 0.125 MG TABLET |
PRAMIPEXOLE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
PRAMIPEXOLE 0.25 MG TABLET |
PRAMIPEXOLE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
PRAMIPEXOLE 0.5 MG TABLET |
PRAMIPEXOLE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H6A |
|
PRAMIPEXOLE 0.75 MG TABLET |
PRAMIPEXOLE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 99 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H6A |
|
PRAMIPEXOLE 1 MG TABLET |
|
|
PRAMIPEXOLE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6A |
|
PRAMIPEXOLE 1.5 MG TABLET |
|
|
PRAMIPEXOLE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6A |
|
ROPINIROLE HCL 0.25 MG TABLET |
|
|
ROPINIROLE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6A |
|
ROPINIROLE HCL 0.5 MG TABLET |
|
|
ROPINIROLE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6A |
|
ROPINIROLE HCL 1 MG TABLET |
|
|
ROPINIROLE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6A |
|
ROPINIROLE HCL 2 MG TABLET |
|
|
ROPINIROLE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6A |
|
ROPINIROLE HCL 3 MG TABLET |
|
|
ROPINIROLE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6A |
|
ROPINIROLE HCL 4 MG TABLET |
|
|
ROPINIROLE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6A |
|
ROPINIROLE HCL 5 MG TABLET |
|
|
ROPINIROLE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6A |
|
SELEGILINE HCL 5 MG CAPSULE |
|
|
SELEGILINE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6A |
|
SELEGILINE HCL 5 MG TABLET |
|
|
SELEGILINE HCL |
18 |
999 |
|
No |
|
||
|
|
|
H6B |
ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC |
|
|
|
|
|
||||
|
H6B |
|
BENZTROPINE MES 0.5 MG TAB |
|
|
BENZTROPINE MESYLATE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6B |
|
BENZTROPINE MES 1 MG TABLET |
|
|
BENZTROPINE MESYLATE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6B |
|
BENZTROPINE MES 2 MG TABLET |
|
|
BENZTROPINE MESYLATE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6B |
|
TRIHEXYPHENIDYL 2 MG TABLET |
|
|
TRIHEXYPHENIDYL HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6B |
|
TRIHEXYPHENIDYL 2 MG/5 ML ELX |
|
|
TRIHEXYPHENIDYL HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6B |
|
TRIHEXYPHENIDYL 5 MG TABLET |
|
|
TRIHEXYPHENIDYL HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H6C |
|
|
ANTITUSSIVES, |
|
|
|
|
|
|
|
|
H6C |
|
BENZONATATE 100 MG CAPSULE |
|
|
BENZONATATE |
0 |
20 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6C |
|
BENZONATATE 150 MG CAPSULE |
|
|
BENZONATATE |
0 |
20 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6C |
|
BENZONATATE 200 MG CAPSULE |
|
|
BENZONATATE |
0 |
20 |
|
No |
|
||
|
|
|
H6H |
|
|
SKELETAL MUSCLE RELAXANTS |
|
|
|
|
|
|
|
|
H6H |
|
BACLOFEN 10 MG TABLET |
|
|
BACLOFEN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6H |
|
BACLOFEN 20 MG TABLET |
|
|
BACLOFEN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 100 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H6H |
|
BACLOFEN 5 MG TABLET |
|
BACLOFEN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6H |
|
CHLORZOXAZONE 500 MG TABLET |
|
CHLORZOXAZONE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6H |
|
CYCLOBENZAPRINE 10 MG TABLET |
|
CYCLOBENZAPRINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6H |
|
CYCLOBENZAPRINE 5 MG TABLET |
|
CYCLOBENZAPRINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6H |
|
CYCLOBENZAPRINE 7.5 MG TABLET |
|
CYCLOBENZAPRINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6H |
|
METHOCARBAMOL 500 MG TABLET |
|
METHOCARBAMOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6H |
|
METHOCARBAMOL 750 MG TABLET |
|
METHOCARBAMOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6H |
|
TIZANIDINE HCL 2 MG TABLET |
|
TIZANIDINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6H |
|
TIZANIDINE HCL 4 MG TABLET |
|
TIZANIDINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
H6I |
AMYOTROPHIC LATERAL SCLEROSIS AGENTS |
|
|
|
|
|
|||
|
H6I |
|
RILUZOLE 50 MG TABLET |
|
RILUZOLE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6I |
|
RILUZOLE 50MG TABLET |
|
RILUZOLE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H6J |
|
ANTIEMETIC/ANTIVERTIGO AGENTS |
|
|
|
|
|
|
|
|
H6J |
|
DICLEGIS DR |
|
DOXYLAMINE SUCCINATE/VIT B6 |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
EMEND 125 MG CAPSULE |
|
APREPITANT |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
EMEND 40 MG CAPSULE |
|
APREPITANT |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
EMEND 80 MG CAPSULE |
|
APREPITANT |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
GRANISETRON HCL 1 MG TABLET |
|
GRANISETRON HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
MECLIZINE 12.5 MG TABLET |
|
MECLIZINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
MECLIZINE 25 MG TABLET |
|
MECLIZINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
ONDANSETRON 4 MG TABLET |
|
ONDANSETRON HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
ONDANSETRON 4 MG/2 ML ISECURE |
|
ONDANSETRON HCL/PF |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
ONDANSETRON 4 MG/5 ML SOLN |
|
ONDANSETRON HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
ONDANSETRON 4 MG/5 ML SOLUTION |
|
ONDANSETRON HCL |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 101 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
ONDANSETRON 40 MG/20 ML VIAL |
|
|
ONDANSETRON HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
ONDANSETRON 8 MG TABLET |
|
|
ONDANSETRON HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
ONDANSETRON HCL |
|
|
ONDANSETRON HCL/PF |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
ONDANSETRON HCL 2 MG/ML VIAL |
|
|
ONDANSETRON HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
ONDANSETRON HCL 4 MG TABLET |
|
|
ONDANSETRON HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
ONDANSETRON HCL 4 MG/2 ML SYR |
|
|
ONDANSETRON HCL/PF |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
ONDANSETRON HCL 4 MG/2 ML VIAL |
|
|
ONDANSETRON HCL/PF |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
ONDANSETRON HCL 8 MG TABLET |
|
|
ONDANSETRON HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
ONDANSETRON ODT 4 MG TABLET |
|
|
ONDANSETRON |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
ONDANSETRON ODT 8 MG TABLET |
|
|
ONDANSETRON |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
PROCHLORPERAZINE 10 MG TAB |
|
|
PROCHLORPERAZINE MALEATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
PROCHLORPERAZINE 5 MG TABLET |
|
|
PROCHLORPERAZINE MALEATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
PROMETHAZINE 12.5 MG SUPPOS |
|
|
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
PROMETHAZINE 25 MG SUPPOS |
|
|
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
PROMETHAZINE 25 MG SUPPOSITORY |
|
|
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
PROMETHEGAN 12.5 MG SUPPOS |
|
|
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
PROMETHEGAN 25 MG SUPPOSITORY |
|
|
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
PROMETHEGAN 50 MG SUPPOS |
|
|
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
PROMETHEGAN 50 MG SUPPOSITORY |
|
|
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H6J |
|
|
|
SCOPOLAMINE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
H7B |
|
|
|
|
|
|||||
|
H7B |
|
MIRTAZAPINE 15 MG ODT |
|
|
MIRTAZAPINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7B |
|
MIRTAZAPINE 15 MG RPD DISLV TB |
|
|
MIRTAZAPINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7B |
|
MIRTAZAPINE 15 MG TABLET |
|
|
MIRTAZAPINE |
6 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 102 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7B |
|
MIRTAZAPINE 30 MG ODT |
|
|
MIRTAZAPINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7B |
|
MIRTAZAPINE 30 MG RPD DISLV TB |
|
|
MIRTAZAPINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7B |
|
MIRTAZAPINE 30 MG TABLET |
|
|
MIRTAZAPINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7B |
|
MIRTAZAPINE 45 MG ODT |
|
|
MIRTAZAPINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7B |
|
MIRTAZAPINE 45 MG RPD DISLV TB |
|
|
MIRTAZAPINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7B |
|
MIRTAZAPINE 45 MG TABLET |
|
|
MIRTAZAPINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7B |
|
MIRTAZAPINE 7.5 MG TABLET |
|
|
MIRTAZAPINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
H7C |
|
|
|
|
|
|||||
|
H7C |
|
DESVENLAFAXINE SUC ER 100 MG |
|
|
DESVENLAFAXINE SUCCINATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7C |
|
DESVENLAFAXINE SUC ER 25 MG TB |
|
|
DESVENLAFAXINE SUCCINATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7C |
|
DESVENLAFAXINE SUC ER 50 MG TB |
|
|
DESVENLAFAXINE SUCCINATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7C |
|
DULOXETINE HCL DR 20 MG CAP |
|
|
DULOXETINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7C |
|
DULOXETINE HCL DR 30 MG CAP |
|
|
DULOXETINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7C |
|
DULOXETINE HCL DR 40 MG CAP |
|
|
DULOXETINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7C |
|
DULOXETINE HCL DR 60 MG CAP |
|
|
DULOXETINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7C |
|
VENLAFAXINE HCL 100 MG TABLET |
|
|
VENLAFAXINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7C |
|
VENLAFAXINE HCL 25 MG TABLET |
|
|
VENLAFAXINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7C |
|
VENLAFAXINE HCL 37.5 MG TABLET |
|
|
VENLAFAXINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7C |
|
VENLAFAXINE HCL 50 MG TABLET |
|
|
VENLAFAXINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7C |
|
VENLAFAXINE HCL 75 MG TABLET |
|
|
VENLAFAXINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7C |
|
VENLAFAXINE HCL ER 150 MG CAP |
|
|
VENLAFAXINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7C |
|
VENLAFAXINE HCL ER 37.5 MG CAP |
|
|
VENLAFAXINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7C |
|
VENLAFAXINE HCL ER 75 MG CAP |
|
|
VENLAFAXINE HCL |
6 |
999 |
|
No |
|
||
|
|
|
H7D |
NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) |
|
|
|
Thursday, October 25, 2018 |
Page 103 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H7D |
|
BUPROPION HCL 100 MG TABLET |
|
|
|
BUPROPION HCL |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7D |
|
BUPROPION HCL 75 MG TABLET |
|
|
|
BUPROPION HCL |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7D |
|
BUPROPION HCL ER 100 MG TAB |
|
|
|
BUPROPION HCL |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7D |
|
BUPROPION HCL ER 200 MG TAB |
|
|
|
BUPROPION HCL |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7D |
|
BUPROPION HCL SR 100 MG TAB |
|
|
|
BUPROPION HCL |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7D |
|
BUPROPION HCL SR 100 MG TABLET |
|
|
BUPROPION HCL |
6 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7D |
|
BUPROPION HCL SR 150 MG TABLET |
|
|
BUPROPION HCL |
6 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7D |
|
BUPROPION HCL SR 200 MG TAB |
|
|
|
BUPROPION HCL |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7D |
|
BUPROPION HCL SR 200 MG TABLET |
|
|
BUPROPION HCL |
6 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7D |
|
BUPROPION HCL XL 150 MG TABLET |
|
|
BUPROPION HCL |
6 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7D |
|
BUPROPION HCL XL 300 MG TABLET |
|
|
BUPROPION HCL |
6 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7D |
|
BUPROPION SR 150 MG TABLET |
|
|
|
BUPROPION HCL |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
H7E |
|
|
|
|
|
||||||
|
H7E |
|
TRAZODONE 100 MG TABLET |
|
|
|
TRAZODONE HCL |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7E |
|
TRAZODONE 150 MG TABLET |
|
|
|
TRAZODONE HCL |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7E |
|
TRAZODONE 300 MG TABLET |
|
|
|
TRAZODONE HCL |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7E |
|
TRAZODONE 50 MG TABLET |
|
|
|
TRAZODONE HCL |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7N |
|
|
|
SMOKING DETERRENTS, OTHER |
|
|
|
|
|
|
|
|
H7N |
|
BUPROPION SR 150 MG TABLET |
|
|
|
BUPROPION HCL |
18 |
|
999 |
|
No |
|
|
|
|
|
H7O |
ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES |
|
|
|
|||||||
|
H7O |
|
DROPERIDOL 2.5 MG/ML AMPUL |
|
|
|
DROPERIDOL |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7O |
|
DROPERIDOL 2.5 MG/ML VIAL |
|
|
|
DROPERIDOL |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7O |
|
HALOPERIDOL 0.5 MG TABLET |
|
|
|
HALOPERIDOL |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7O |
|
HALOPERIDOL 1 MG TABLET |
|
|
|
HALOPERIDOL |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7O |
|
HALOPERIDOL 10 MG TABLET |
|
|
|
HALOPERIDOL |
6 |
|
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 104 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7O |
|
HALOPERIDOL 2 MG TABLET |
|
|
HALOPERIDOL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7O |
|
HALOPERIDOL 20 MG TABLET |
|
|
HALOPERIDOL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7O |
|
HALOPERIDOL 5 MG TABLET |
|
|
HALOPERIDOL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7O |
|
HALOPERIDOL 5 MG/ML AMPUL |
|
|
HALOPERIDOL LACTATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
H7O |
|
HALOPERIDOL DEC 100 MG/ML AMP |
HALOPERIDOL DECANOATE |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
H7O |
|
HALOPERIDOL DEC 100 MG/ML VIAL |
HALOPERIDOL DECANOATE |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7O |
|
HALOPERIDOL DEC 100 MG/ML VL |
|
|
HALOPERIDOL DECANOATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
H7O |
|
HALOPERIDOL DEC 50 MG/ML VIAL |
HALOPERIDOL DECANOATE |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7O |
|
HALOPERIDOL DEC 50 MG/ML VL |
|
|
HALOPERIDOL DECANOATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
H7O |
|
HALOPERIDOL DEC 500 MG/5 ML VL |
HALOPERIDOL DECANOATE |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
H7O |
|
HALOPERIDOL DECAN 50 MG/ML AMP |
HALOPERIDOL DECANOATE |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
H7O |
|
HALOPERIDOL LAC 2 MG/ML CONC |
HALOPERIDOL LACTATE |
6 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7O |
|
HALOPERIDOL LAC 5 MG/ML VIAL |
|
|
HALOPERIDOL LACTATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
H7O |
|
HALOPERIDOL LAC 50 MG/10 ML VL |
HALOPERIDOL LACTATE |
18 |
999 |
|
No |
|
||||
|
|
|
H7P |
ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENES |
|
|
|
||||||
|
H7P |
|
THIOTHIXENE 1 MG CAPSULE |
|
|
THIOTHIXENE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7P |
|
THIOTHIXENE 10 MG CAPSULE |
|
|
THIOTHIXENE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7P |
|
THIOTHIXENE 2 MG CAPSULE |
|
|
THIOTHIXENE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7P |
|
THIOTHIXENE 5 MG CAPSULE |
|
|
THIOTHIXENE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
||||||
|
|
|
H7R |
ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINES |
|
|
|
||||||
|
H7R |
|
PIMOZIDE 1 MG TABLET |
|
|
PIMOZIDE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7R |
|
PIMOZIDE 2 MG TABLET |
|
|
PIMOZIDE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
||||||
|
|
|
H7T |
ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST |
|
|
|
||||||
|
H7T |
|
CLOZAPINE 100 MG TABLET |
|
|
CLOZAPINE |
6 |
999 |
|
Requires Med Cert 3 |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
CLOZAPINE 200 MG TABLET |
|
|
CLOZAPINE |
6 |
999 |
|
Requires Med Cert 3 |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 105 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H7T |
|
CLOZAPINE 25 MG TABLET |
CLOZAPINE |
6 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
CLOZAPINE 50 MG TABLET |
CLOZAPINE |
6 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
CLOZAPINE ODT 100 MG TABLET |
CLOZAPINE |
6 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
CLOZAPINE ODT 12.5 MG TABLET |
CLOZAPINE |
6 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
CLOZAPINE ODT 150 MG TABLET |
CLOZAPINE |
6 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
CLOZAPINE ODT 200 MG TABLET |
CLOZAPINE |
6 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
CLOZAPINE ODT 25 MG TABLET |
CLOZAPINE |
6 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
CLOZARIL 100 MG TABLET |
CLOZAPINE |
6 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
CLOZARIL 25 MG TABLET |
CLOZAPINE |
6 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
INVEGA SUSTENNA 117 MG PREF SY |
PALIPERIDONE PALMITATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
INVEGA SUSTENNA 156 MG PREF SY |
PALIPERIDONE PALMITATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
INVEGA SUSTENNA 156 MG/ML SYRG |
PALIPERIDONE PALMITATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
INVEGA SUSTENNA 234 MG PREF SY |
PALIPERIDONE PALMITATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
INVEGA SUSTENNA 39 MG PREF SYR |
PALIPERIDONE PALMITATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
INVEGA SUSTENNA 78 MG PREF SYR |
PALIPERIDONE PALMITATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
INVEGA TRINZA 273 MG/0.875 ML |
PALIPERIDONE PALMITATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
INVEGA TRINZA 410 MG/1.315 ML |
PALIPERIDONE PALMITATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
INVEGA TRINZA 546 MG/1.75 ML |
PALIPERIDONE PALMITATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
INVEGA TRINZA 819 MG/2.625 ML |
PALIPERIDONE PALMITATE |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
LATUDA 120 MG TABLET |
LURASIDONE HCL |
10 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
LATUDA 20 MG TABLET |
LURASIDONE HCL |
10 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
LATUDA 40 MG TABLET |
LURASIDONE HCL |
10 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
LATUDA 60 MG TABLET |
LURASIDONE HCL |
10 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
LATUDA 80 MG TABLET |
LURASIDONE HCL |
10 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 106 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H7T |
|
OLANZAPINE 10 MG TABLET |
OLANZAPINE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
OLANZAPINE 15 MG TABLET |
OLANZAPINE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
OLANZAPINE 2.5 MG TABLET |
OLANZAPINE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
OLANZAPINE 20 MG TABLET |
OLANZAPINE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
OLANZAPINE 5 MG TABLET |
OLANZAPINE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
OLANZAPINE 7.5 MG TABLET |
OLANZAPINE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
OLANZAPINE ODT 10 MG TABLET |
OLANZAPINE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
OLANZAPINE ODT 15 MG TABLET |
OLANZAPINE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
OLANZAPINE ODT 20 MG TABLET |
OLANZAPINE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
OLANZAPINE ODT 5 MG TABLET |
OLANZAPINE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
QUETIAPINE ER 150 MG TABLET |
QUETIAPINE FUMARATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
QUETIAPINE ER 200 MG TABLET |
QUETIAPINE FUMARATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
QUETIAPINE ER 300 MG TABLET |
QUETIAPINE FUMARATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
QUETIAPINE ER 400 MG TABLET |
QUETIAPINE FUMARATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
QUETIAPINE ER 50 MG TABLET |
QUETIAPINE FUMARATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
QUETIAPINE FUMARATE 100 MG TAB |
QUETIAPINE FUMARATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
QUETIAPINE FUMARATE 200 MG TAB |
QUETIAPINE FUMARATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
QUETIAPINE FUMARATE 25 MG TAB |
QUETIAPINE FUMARATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
QUETIAPINE FUMARATE 300 MG TAB |
QUETIAPINE FUMARATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
QUETIAPINE FUMARATE 400 MG TAB |
QUETIAPINE FUMARATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
QUETIAPINE FUMARATE 50 MG TAB |
QUETIAPINE FUMARATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
RISPERDAL CONSTA 12.5 MG SYR |
RISPERIDONE MICROSPHERES |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
RISPERDAL CONSTA 25 MG SYR |
RISPERIDONE MICROSPHERES |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
H7T |
|
RISPERDAL CONSTA 37.5 MG SYR |
RISPERIDONE MICROSPHERES |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 107 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H7T |
|
RISPERDAL CONSTA 50 MG SYR |
|
|
RISPERIDONE MICROSPHERES |
18 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
RISPERIDONE 0.25 MG ODT |
|
|
RISPERIDONE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
RISPERIDONE 0.25 MG TABLET |
|
|
RISPERIDONE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
RISPERIDONE 0.5 MG ODT |
|
|
RISPERIDONE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
RISPERIDONE 0.5 MG TABLET |
|
|
RISPERIDONE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
RISPERIDONE 1 MG ODT |
|
|
RISPERIDONE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
RISPERIDONE 1 MG TABLET |
|
|
RISPERIDONE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
RISPERIDONE 1 MG/ML SOLUTION |
|
|
RISPERIDONE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
RISPERIDONE 2 MG ODT |
|
|
RISPERIDONE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
RISPERIDONE 2 MG TABLET |
|
|
RISPERIDONE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
RISPERIDONE 3 MG ODT |
|
|
RISPERIDONE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
RISPERIDONE 3 MG TABLET |
|
|
RISPERIDONE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
RISPERIDONE 4 MG ODT |
|
|
RISPERIDONE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
RISPERIDONE 4 MG TABLET |
|
|
RISPERIDONE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
ZIPRASIDONE HCL 20 MG CAPSULE |
|
|
ZIPRASIDONE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
ZIPRASIDONE HCL 40 MG CAPSULE |
|
|
ZIPRASIDONE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
ZIPRASIDONE HCL 60 MG CAPSULE |
|
|
ZIPRASIDONE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7T |
|
ZIPRASIDONE HCL 80 MG CAPSULE |
|
|
ZIPRASIDONE HCL |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
||||||
|
|
|
H7U |
ANTIPSYCHOTICS, DOPAMINE AND SEROTONIN ANTAGONISTS |
|
|
|
||||||
|
H7U |
|
LOXAPINE 10 MG CAPSULE |
|
|
LOXAPINE SUCCINATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7U |
|
LOXAPINE 25 MG CAPSULE |
|
|
LOXAPINE SUCCINATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7U |
|
LOXAPINE 5 MG CAPSULE |
|
|
LOXAPINE SUCCINATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7U |
|
LOXAPINE 50 MG CAPSULE |
|
|
LOXAPINE SUCCINATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7U |
|
LOXAPINE SUCCINATE 10 MG CAP |
|
|
LOXAPINE SUCCINATE |
18 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 108 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7U |
|
LOXAPINE SUCCINATE 25 MG CAP |
|
|
|
LOXAPINE SUCCINATE |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7U |
|
LOXAPINE SUCCINATE 5 MG CAP |
|
|
|
LOXAPINE SUCCINATE |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7U |
|
LOXAPINE SUCCINATE 50 MG CAP |
|
|
|
LOXAPINE SUCCINATE |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
H7X |
ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED |
|
|
|
|
||||||
|
H7X |
|
ABILIFY MAINTENA ER 300 MG SYR |
|
|
|
ARIPIPRAZOLE |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ABILIFY MAINTENA ER 300 MG VL |
|
|
|
ARIPIPRAZOLE |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ABILIFY MAINTENA ER 400 MG SYR |
|
|
|
ARIPIPRAZOLE |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ABILIFY MAINTENA ER 400 MG VL |
|
|
|
ARIPIPRAZOLE |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ARIPIPRAZOLE 1 MG/ML SOLUTION |
|
|
|
ARIPIPRAZOLE |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ARIPIPRAZOLE 10 MG TABLET |
|
|
|
ARIPIPRAZOLE |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ARIPIPRAZOLE 15 MG TABLET |
|
|
|
ARIPIPRAZOLE |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ARIPIPRAZOLE 2 MG TABLET |
|
|
|
ARIPIPRAZOLE |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ARIPIPRAZOLE 20 MG TABLET |
|
|
|
ARIPIPRAZOLE |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ARIPIPRAZOLE 30 MG TABLET |
|
|
|
ARIPIPRAZOLE |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ARIPIPRAZOLE 5 MG TABLET |
|
|
|
ARIPIPRAZOLE |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ARIPIPRAZOLE ODT 10 MG TABLET |
|
|
|
ARIPIPRAZOLE |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ARIPIPRAZOLE ODT 15 MG TABLET |
|
|
|
ARIPIPRAZOLE |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ARISTADA ER 1064 MG/3.9 ML SYR |
|
|
|
ARIPIPRAZOLE LAUROXIL |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ARISTADA ER 441 MG/1.6 ML SYRN |
|
|
|
ARIPIPRAZOLE LAUROXIL |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ARISTADA ER 662 MG/2.4 ML SYRN |
|
|
|
ARIPIPRAZOLE LAUROXIL |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
H7X |
|
ARISTADA ER 882 MG/3.2 ML SYRN |
|
|
|
ARIPIPRAZOLE LAUROXIL |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
H7Y |
|
TX FOR ATTENTION |
|
|
|
|
|||||
|
H7Y |
|
ATOMOXETINE HCL 10 MG CAPSULE |
|
|
|
ATOMOXETINE HCL |
6 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H7Y |
|
ATOMOXETINE HCL 100 MG CAPSULE |
|
|
ATOMOXETINE HCL |
6 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 109 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
H7Y |
|
ATOMOXETINE HCL 18 MG CAPSULE |
|
|
ATOMOXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
H7Y |
|
ATOMOXETINE HCL 25 MG CAPSULE |
|
|
ATOMOXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
H7Y |
|
ATOMOXETINE HCL 40 MG CAPSULE |
|
|
ATOMOXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
H7Y |
|
ATOMOXETINE HCL 60 MG CAPSULE |
|
|
ATOMOXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
H7Y |
|
ATOMOXETINE HCL 80 MG CAPSULE |
|
|
ATOMOXETINE HCL |
6 |
999 |
|
No |
|
|||
|
|
|
H8B |
|
HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTS |
|
|
|
|
|
||||
|
H8B |
|
ROZEREM 8 MG TABLET |
|
|
|
RAMELTEON |
65 |
999 |
|
No |
|
||
|
|
|
H8M |
|
TX FOR ADHD - SELECTIVE |
|
|
|
|
|
||||
|
H8M |
|
GUANFACINE HCL ER 1 MG TABLET |
|
|
|
GUANFACINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H8M |
|
GUANFACINE HCL ER 2 MG TABLET |
|
|
|
GUANFACINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H8M |
|
GUANFACINE HCL ER 3 MG TABLET |
|
|
|
GUANFACINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H8M |
|
GUANFACINE HCL ER 4 MG TABLET |
|
|
|
GUANFACINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
H8P |
|
SSRI AND 5HT1A PARTIAL AGONIST ANTIDEPRESSANTS |
|
|
|
|
|
||||
|
H8P |
|
VIIBRYD 10 MG TABLET |
|
|
|
VILAZODONE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H8P |
|
VIIBRYD 20 MG TABLET |
|
|
|
VILAZODONE HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H8P |
|
VIIBRYD 40 MG TABLET |
|
|
|
VILAZODONE HCL |
18 |
999 |
|
No |
|
||
|
|
|
H8Q |
|
NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS |
|
|
|
|
|
||||
|
H8Q |
|
MODAFINIL 100 MG TABLET |
|
|
|
MODAFINIL |
18 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H8Q |
|
MODAFINIL 200 MG TABLET |
|
|
|
MODAFINIL |
18 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|||||||
|
|
|
H8T |
SSRI, SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANTS |
|
|
|
|||||||
|
H8T |
|
TRINTELLIX 10 MG TABLET |
|
|
|
VORTIOXETINE HYDROBROMIDE |
18 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H8T |
|
TRINTELLIX 20 MG TABLET |
|
|
|
VORTIOXETINE HYDROBROMIDE |
18 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
H8T |
|
TRINTELLIX 5 MG TABLET |
|
|
|
VORTIOXETINE HYDROBROMIDE |
18 |
999 |
|
Auto PA |
|
||
|
|
|
J1A |
|
|
|
PARASYMPATHETIC AGENTS |
|
|
|
|
|
|
|
|
J1A |
|
BETHANECHOL 10 MG TABLET |
|
|
|
BETHANECHOL CHLORIDE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J1A |
|
BETHANECHOL 25 MG TABLET |
|
|
|
BETHANECHOL CHLORIDE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 110 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
J1A |
|
BETHANECHOL 5 MG TABLET |
BETHANECHOL CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J1A |
|
BETHANECHOL 50 MG TABLET |
BETHANECHOL CHLORIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J1A |
|
GUANIDINE HCL 125 MG TABLET |
GUANIDINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J1A |
|
PILOCARPINE HCL 5 MG TABLET |
PILOCARPINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J1A |
|
PILOCARPINE HCL 7.5 MG TABLET |
PILOCARPINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
J1B |
CHOLINESTERASE INHIBITORS |
|
|
|
|
|
|
|
|
|
J1B |
|
DONEPEZIL HCL 10 MG TABLET |
DONEPEZIL HCL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J1B |
|
DONEPEZIL HCL 5 MG TABLET |
DONEPEZIL HCL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J1B |
|
DONEPEZIL HCL ODT 10 MG TABLET |
DONEPEZIL HCL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J1B |
|
DONEPEZIL HCL ODT 5 MG TABLET |
DONEPEZIL HCL |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J1B |
|
EXELON 13.3 MG/24HR PATCH |
RIVASTIGMINE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J1B |
|
EXELON 4.6 MG/24HR PATCH |
RIVASTIGMINE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J1B |
|
EXELON 9.5 MG/24HR PATCH |
RIVASTIGMINE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J1B |
|
MESTINON 60 MG/5 ML SYRUP |
PYRIDOSTIGMINE BROMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J1B |
|
PYRIDOSTIGMINE BR 60 MG TAB |
PYRIDOSTIGMINE BROMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J1B |
|
PYRIDOSTIGMINE BR 60 MG TABLET |
PYRIDOSTIGMINE BROMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J1B |
|
PYRIDOSTIGMINE ER 180 MG TAB |
PYRIDOSTIGMINE BROMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
J2A |
BELLADONNA ALKALOIDS |
|
|
|
|
|
|
|
|
|
J2A |
|
BELLADONNA/PHENOBARB TABLET |
PHENOBARB/HYOSCY/ATROPINE/SCOP |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J2A |
|
PHENOBARB/HYOSCY/ATROPINE/SCOP |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
J2A |
|
HYOSCYAMINE 0.125 MG ODT |
HYOSCYAMINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J2A |
|
HYOSCYAMINE 0.125 MG TAB SL |
HYOSCYAMINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J2A |
|
HYOSCYAMINE 0.125 MG/ML DROP |
HYOSCYAMINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J2A |
|
HYOSCYAMINE 125 MCG/5 ML ELIX |
HYOSCYAMINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 111 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
J2A |
|
HYOSCYAMINE ER 0.375 MG TAB |
|
|
|
HYOSCYAMINE SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J2A |
|
HYOSCYAMINE SULF 0.125 MG TAB |
|
|
|
HYOSCYAMINE SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
J2B |
|
ANTICHOLINERGICS,QUATERNARY AMMONIUM |
|
|
|
|
|
||||
|
J2B |
|
CUVPOSA 1 MG/5 ML SOLUTION |
|
|
|
GLYCOPYRROLATE |
3 |
16 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J2B |
|
GLYCOPYRROLATE 0.2 MG/ML VIAL |
|
|
|
GLYCOPYRROLATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J2B |
|
GLYCOPYRROLATE 0.2 MG/ML VL |
|
|
|
GLYCOPYRROLATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J2B |
|
GLYCOPYRROLATE 0.4 MG/2 ML VL |
|
|
|
GLYCOPYRROLATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J2B |
|
GLYCOPYRROLATE 1 MG TABLET |
|
|
|
GLYCOPYRROLATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J2B |
|
GLYCOPYRROLATE 1 MG/5 ML VIAL |
|
|
|
GLYCOPYRROLATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J2B |
|
GLYCOPYRROLATE 2 MG TABLET |
|
|
|
GLYCOPYRROLATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
J2B |
|
GLYCOPYRROLATE 4 MG/20 ML VIAL |
|
|
GLYCOPYRROLATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J2B |
|
PROPANTHELINE 15 MG TABLET |
|
|
|
PROPANTHELINE BROMIDE |
0 |
999 |
|
No |
|
||
|
|
|
J2D |
|
|
|
ANTICHOLINERGICS/ANTISPASMODICS |
|
|
|
|
|
|
|
|
J2D |
|
DICYCLOMINE 10 MG CAPSULE |
|
|
|
DICYCLOMINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J2D |
|
DICYCLOMINE 10 MG/5 ML SYRUP |
|
|
|
DICYCLOMINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J2D |
|
DICYCLOMINE 20 MG TABLET |
|
|
|
DICYCLOMINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
J3A |
SMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS) |
|
|
|
|||||||
|
J3A |
|
HM NICOTINE 14 MG/24HR PATCH |
|
|
|
NICOTINE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
HM NICOTINE 2 MG CHEWING GUM |
|
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
HM NICOTINE 2 MG LOZENGE |
|
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
HM NICOTINE 21 MG/24HR PATCH |
|
|
|
NICOTINE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
HM NICOTINE 4 MG CHEWING GUM |
|
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
HM NICOTINE 4 MG LOZENGE |
|
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
HM NICOTINE 7 MG/24HR PATCH |
|
|
|
NICOTINE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE 14 MG/24 HR PATCH |
|
|
|
NICOTINE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 112 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
J3A |
|
NICOTINE 14 MG/24HR PATCH |
|
|
NICOTINE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE 2 MG CHEWING GUM |
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE 2 MG GUM |
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE 2 MG LOZENGE |
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE 2 MG MINI LOZENGE |
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE 21 MG/24 HR PATCH |
|
|
NICOTINE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE 21 MG/24HR PATCH |
|
|
NICOTINE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE 4 MG CHEWING GUM |
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE 4 MG GUM |
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE 4 MG LOZENGE |
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE 4 MG MINI LOZENGE |
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE 7 MG/24 HR PATCH |
|
|
NICOTINE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE 7 MG/24HR PATCH |
|
|
NICOTINE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE POLACRILEX 2 MG GUM |
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE POLACRILEX 4 MG GUM |
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
NICOTINE TRANSDERMAL SYSTEM |
|
|
NICOTINE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
SM NICOTINE 14 MG/24HR PATCH |
|
|
NICOTINE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
SM NICOTINE 2 MG LOZENGE |
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
SM NICOTINE 21 MG/24HR PATCH |
|
|
NICOTINE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
SM NICOTINE 4 MG LOZENGE |
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
SM NICOTINE 7 MG/24HR PATCH |
|
|
NICOTINE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
SUNMARK NICOTINE 2 MG GUM |
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3A |
|
SUNMARK NICOTINE 4 MG GUM |
|
|
NICOTINE POLACRILEX |
18 |
999 |
|
No |
|
||
|
|
|
J3C |
SMOKING |
|
|
|
Thursday, October 25, 2018 |
Page 113 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
J3C |
|
CHANTIX 0.5 MG TABLET |
|
|
VARENICLINE TARTRATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3C |
|
CHANTIX 1 MG CONT MONTH BOX |
|
|
VARENICLINE TARTRATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3C |
|
CHANTIX 1 MG TABLET |
|
|
VARENICLINE TARTRATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J3C |
|
CHANTIX STARTING MONTH BOX |
|
|
VARENICLINE TARTRATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
J5B |
ADRENERGICS, AROMATIC, |
|
|
|
|
|
||||
|
J5B |
|
ADZENYS |
|
|
AMPHETAMINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
ADZENYS |
|
|
AMPHETAMINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
ADZENYS |
|
|
AMPHETAMINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
ADZENYS |
|
|
AMPHETAMINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
ADZENYS |
|
|
AMPHETAMINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
ADZENYS |
|
|
AMPHETAMINE |
6 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
AMPHETAMINE SALTS 10 MG TAB |
|
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
AMPHETAMINE SALTS 10 MG TABLET |
|
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
AMPHETAMINE SALTS 12.5 MG TAB |
|
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
AMPHETAMINE SALTS 12.5 MG TB |
|
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
AMPHETAMINE SALTS 15 MG TAB |
|
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
AMPHETAMINE SALTS 15 MG TABLET |
|
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
AMPHETAMINE SALTS 20 MG TAB |
|
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
AMPHETAMINE SALTS 20 MG TABLET |
|
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
AMPHETAMINE SALTS 30 MG TAB |
|
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
AMPHETAMINE SALTS 30 MG TABLET |
|
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
AMPHETAMINE SALTS 5 MG TAB |
|
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
AMPHETAMINE SALTS 5 MG TABLET |
|
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5B |
|
AMPHETAMINE SALTS 7.5 MG TAB |
|
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 114 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
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Medicaid |
|
Clinical PA Required |
|
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|
|
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|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
DEXTROAMPHETAMINE/AMPHETAMINE |
3 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
DEXTROAMPHETAMINE 10 MG TAB |
DEXTROAMPHETAMINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
DEXTROAMPHETAMINE 5 MG TAB |
DEXTROAMPHETAMINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
DEXTROAMPHETAMINE ER 5 MG CAP |
DEXTROAMPHETAMINE SULFATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
VYVANSE 10 MG CAPSULE |
LISDEXAMFETAMINE DIMESYLATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
VYVANSE 10 MG CHEWABLE TABLET |
LISDEXAMFETAMINE DIMESYLATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
VYVANSE 20 MG CAPSULE |
LISDEXAMFETAMINE DIMESYLATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
VYVANSE 20 MG CHEWABLE TABLET |
LISDEXAMFETAMINE DIMESYLATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
VYVANSE 30 MG CAPSULE |
LISDEXAMFETAMINE DIMESYLATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
VYVANSE 30 MG CHEWABLE TABLET |
LISDEXAMFETAMINE DIMESYLATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
VYVANSE 40 MG CAPSULE |
LISDEXAMFETAMINE DIMESYLATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
VYVANSE 40 MG CHEWABLE TABLET |
LISDEXAMFETAMINE DIMESYLATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
VYVANSE 50 MG CAPSULE |
LISDEXAMFETAMINE DIMESYLATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
VYVANSE 50 MG CHEWABLE TABLET |
LISDEXAMFETAMINE DIMESYLATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
VYVANSE 60 MG CAPSULE |
LISDEXAMFETAMINE DIMESYLATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
VYVANSE 60 MG CHEWABLE TABLET |
LISDEXAMFETAMINE DIMESYLATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J5B |
|
VYVANSE 70 MG CAPSULE |
LISDEXAMFETAMINE DIMESYLATE |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
J5D |
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 115 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
J5D |
|
ALBUTEROL SULF 2 MG/5 ML SYRP |
|
|
ALBUTEROL SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5D |
|
ALBUTEROL SULF 2 MG/5 ML SYRUP |
|
|
ALBUTEROL SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5D |
|
TERBUTALINE SULF 1 MG/ML VIAL |
|
|
TERBUTALINE SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
J5F |
|
|
ANAPHYLAXIS THERAPY AGENTS |
|
|
|
|
|
|
|
|
J5F |
|
EPINEPHRINE 0.15 MG |
|
|
EPINEPHRINE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5F |
|
EPINEPHRINE 0.3 MG |
|
|
EPINEPHRINE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
J5H |
|
|
ADRENERGIC VASOPRESSOR AGENTS |
|
|
|
|
|
|
|
|
J5H |
|
MIDODRINE HCL 10 MG TABLET |
|
|
MIDODRINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5H |
|
MIDODRINE HCL 2.5 MG TABLET |
|
|
MIDODRINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J5H |
|
MIDODRINE HCL 5 MG TABLET |
|
|
MIDODRINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
J7A |
|
|
|
|
|
|||||
|
J7A |
|
CARVEDILOL 12.5 MG TABLET |
|
|
CARVEDILOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7A |
|
CARVEDILOL 25 MG TABLET |
|
|
CARVEDILOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7A |
|
CARVEDILOL 3.125 MG TABLET |
|
|
CARVEDILOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7A |
|
CARVEDILOL 6.25 MG TABLET |
|
|
CARVEDILOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7A |
|
LABETALOL HCL 100 MG TABLET |
|
|
LABETALOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7A |
|
LABETALOL HCL 200 MG TABLET |
|
|
LABETALOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7A |
|
LABETALOL HCL 300 MG TABLET |
|
|
LABETALOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
J7B |
|
|
|
|
|
|
|
|
|
|
|
J7B |
|
DOXAZOSIN MESYLATE 1 MG TAB |
|
|
DOXAZOSIN MESYLATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7B |
|
DOXAZOSIN MESYLATE 2 MG TAB |
|
|
DOXAZOSIN MESYLATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7B |
|
DOXAZOSIN MESYLATE 4 MG TAB |
|
|
DOXAZOSIN MESYLATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7B |
|
DOXAZOSIN MESYLATE 8 MG TAB |
|
|
DOXAZOSIN MESYLATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7B |
|
PRAZOSIN 1 MG CAPSULE |
|
|
PRAZOSIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7B |
|
PRAZOSIN 2 MG CAPSULE |
|
|
PRAZOSIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 116 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
J7B |
|
PRAZOSIN 5 MG CAPSULE |
PRAZOSIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7B |
|
PRAZOSIN HCL 1 MG CAPSULE |
PRAZOSIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7B |
|
PRAZOSIN HCL 2 MG CAPSULE |
PRAZOSIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7B |
|
PRAZOSIN HCL 5 MG CAPSULE |
PRAZOSIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7B |
|
TERAZOSIN 1 MG CAPSULE |
TERAZOSIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7B |
|
TERAZOSIN 10 MG CAPSULE |
TERAZOSIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7B |
|
TERAZOSIN 2 MG CAPSULE |
TERAZOSIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7B |
|
TERAZOSIN 5 MG CAPSULE |
TERAZOSIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
J7C |
|
|
|
|
|
|
|
||
|
J7C |
|
ACEBUTOLOL 200 MG CAPSULE |
ACEBUTOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
ACEBUTOLOL 400 MG CAPSULE |
ACEBUTOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
ATENOLOL 100 MG TABLET |
ATENOLOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
ATENOLOL 25 MG TABLET |
ATENOLOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
ATENOLOL 50 MG TABLET |
ATENOLOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
BETAPACE AF 120 MG TABLET |
SOTALOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
BISOPROLOL FUMARATE 10 MG TAB |
BISOPROLOL FUMARATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
BISOPROLOL FUMARATE 10 MG TB |
BISOPROLOL FUMARATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
BISOPROLOL FUMARATE 5 MG TAB |
BISOPROLOL FUMARATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
METOPROLOL 100 MG TABLET |
METOPROLOL TARTRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
METOPROLOL 25 MG TABLET |
METOPROLOL TARTRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
METOPROLOL 50 MG TABLET |
METOPROLOL TARTRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
METOPROLOL SUCC ER 100 MG TAB |
METOPROLOL SUCCINATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
METOPROLOL SUCC ER 200 MG TAB |
METOPROLOL SUCCINATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
METOPROLOL SUCC ER 25 MG TAB |
METOPROLOL SUCCINATE |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 117 of 204 |
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Class |
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Medicaid Drug Name |
|
Generic Name |
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Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
METOPROLOL SUCC ER 50 MG TAB |
METOPROLOL SUCCINATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
METOPROLOL TARTRATE 100 MG TAB |
METOPROLOL TARTRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
METOPROLOL TARTRATE 25 MG TAB |
METOPROLOL TARTRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
METOPROLOL TARTRATE 50 MG TAB |
METOPROLOL TARTRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 10 MG TABLET |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 120 MG CAPSULE ER |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 120 MG CAPSULE SA |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 160 MG CAPSULE ER |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 160 MG CAPSULE SA |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 20 MG TABLET |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 20 MG/5 ML SOLN |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 40 MG TABLET |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 40 MG/5 ML SOLN |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 60 MG CAPSULE ER |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 60 MG CAPSULE SA |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 60 MG TABLET |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 80 MG CAPSULE ER |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 80 MG CAPSULE SA |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL 80 MG TABLET |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL ER 120 MG CAPSULE |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL ER 160 MG CAPSULE |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL ER 60 MG CAPSULE |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
PROPRANOLOL ER 80 MG CAPSULE |
PROPRANOLOL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
J7C |
|
SOTALOL 120 MG TABLET |
SOTALOL HCL |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 118 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7C |
|
SOTALOL 160 MG TABLET |
|
|
SOTALOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7C |
|
SOTALOL 240 MG TABLET |
|
|
SOTALOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7C |
|
SOTALOL 80 MG TABLET |
|
|
SOTALOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7C |
|
SOTALOL AF 120 MG TABLET |
|
|
SOTALOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7C |
|
SOTALOL AF 160 MG TABLET |
|
|
SOTALOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7C |
|
SOTALOL AF 80 MG TABLET |
|
|
SOTALOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7C |
|
SOTALOL HCL 120 MG TABLET |
|
|
SOTALOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7C |
|
SOTALOL HCL 160 MG TABLET |
|
|
SOTALOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7C |
|
SOTALOL HCL 240 MG TABLET |
|
|
SOTALOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7C |
|
SOTALOL HCL 80 MG TABLET |
|
|
SOTALOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
J7H |
|
|
|
|
|
|||||
|
J7H |
|
ATENOLOL/CHLORTHAL 100/25 |
|
|
ATENOLOL/CHLORTHALIDONE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7H |
|
ATENOLOL/CHLORTHAL 50/25 |
|
|
ATENOLOL/CHLORTHALIDONE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7H |
|
ATENOLOL/CHLORTHAL 50/25 TB |
|
|
ATENOLOL/CHLORTHALIDONE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7H |
|
BISOPROLOL/HCTZ 10/6.25 TAB |
|
|
BISOPROLOL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7H |
|
BISOPROLOL/HCTZ 2.5/6.25 TB |
|
|
BISOPROLOL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7H |
|
BISOPROLOL/HCTZ 5/6.25 TAB |
|
|
BISOPROLOL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7H |
|
|
|
BISOPROLOL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7H |
|
|
|
BISOPROLOL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7H |
|
|
|
BISOPROLOL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7H |
|
|
|
BISOPROLOL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7H |
|
|
|
BISOPROLOL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7H |
|
|
|
BISOPROLOL/HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7H |
|
PROPRANOLOL/HCTZ 40/25 TAB |
|
|
PROPRANOLOL/HYDROCHLOROTHIAZID |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 119 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J7H |
|
PROPRANOLOL/HCTZ 80/25 TAB |
|
|
PROPRANOLOL/HYDROCHLOROTHIAZID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
J9A |
|
|
INTESTINAL MOTILITY STIMULANTS |
|
|
|
|
|
|
|
|
J9A |
|
METOCLOPRAMIDE 10 MG TABLET |
|
|
METOCLOPRAMIDE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J9A |
|
METOCLOPRAMIDE 5 MG TABLET |
|
|
METOCLOPRAMIDE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J9A |
|
METOCLOPRAMIDE 5 MG/5 ML SOLN |
|
|
METOCLOPRAMIDE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J9A |
|
METOCLOPRAMIDE 5 MG/5 ML SYRP |
|
|
METOCLOPRAMIDE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
J9A |
|
METOCLOPRAMIDE 5 MG/5 ML SYRUP |
|
|
METOCLOPRAMIDE HCL |
0 |
999 |
|
No |
|
||
|
|
|
L0B |
TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMES |
|
|
|
|
|
||||
|
L0B |
|
HYQVIA HY CMPNT 1,600 UNIT/10 |
|
|
HYALURONIDASE, HUMAN RECOMB. |
0 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
L0B |
|
HYQVIA HY CMPNT 2,400 UNIT/15 |
|
|
HYALURONIDASE, HUMAN RECOMB. |
0 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
L0B |
|
HYQVIA HY CMPNT 200 UNIT/1.25 |
|
|
HYALURONIDASE, HUMAN RECOMB. |
0 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
L0B |
|
HYQVIA HY CMPNT 400 UNIT/2.5 |
|
|
HYALURONIDASE, HUMAN RECOMB. |
0 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
L0B |
|
HYQVIA HY CMPNT 800 UNIT/5 ML |
|
|
HYALURONIDASE, HUMAN RECOMB. |
0 |
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
L0B |
|
SANTYL OINTMENT |
|
|
COLLAGENASE CLOSTRIDIUM HIST. |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
L1A |
|
|
ANTIPSORIATIC AGENTS,SYSTEMIC |
|
|
|
|
|
|
|
|
L1A |
|
ACITRETIN 10 MG CAPSULE |
|
|
ACITRETIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
L1A |
|
ACITRETIN 17.5 MG CAPSULE |
|
|
ACITRETIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
L1A |
|
ACITRETIN 25 MG CAPSULE |
|
|
ACITRETIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
L1A |
|
COSENTYX 150 MG/ML PEN INJECT |
|
|
SECUKINUMAB |
18 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
L1A |
|
COSENTYX 150 MG/ML SYRINGE |
|
|
SECUKINUMAB |
18 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
L1A |
|
COSENTYX 300 MG/ML PEN INJECT (2 PENS) |
SECUKINUMAB |
18 |
999 |
|
Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
L1A |
|
COSENTYX 300 MG/ML SYRINGE (2 SYRINGES |
SECUKINUMAB |
18 |
999 |
|
Auto PA |
|
||||
|
|
|
L1B |
|
|
ACNE AGENTS,SYSTEMIC |
|
|
|
|
|
|
|
|
L1B |
|
AMNESTEEM 10 MG CAPSULE |
|
|
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
L1B |
|
AMNESTEEM 20 MG CAPSULE |
|
|
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 120 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
L1B |
|
AMNESTEEM 40 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
CLARAVIS 10 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
CLARAVIS 20 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
CLARAVIS 30 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
CLARAVIS 40 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
ISOTRETINOIN 10 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
ISOTRETINOIN 20 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
ISOTRETINOIN 30 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
ISOTRETINOIN 40 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
MYORISAN 10 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
MYORISAN 20 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
MYORISAN 30 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
MYORISAN 40 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
MYORISAN 40 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
ZENATANE 10 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
ZENATANE 20 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
ZENATANE 30 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L1B |
|
ZENATANE 40 MG CAPSULE |
ISOTRETINOIN |
12 |
999 |
|
Requires Med Cert 3 |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
L2A |
EMOLLIENTS |
|
|
|
|
|
|
|
|
|
L2A |
|
AMMONIUM LACTATE 12% CREAM |
AMMONIUM LACTATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L2A |
|
AMMONIUM LACTATE 12% LOTION |
AMMONIUM LACTATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
L3P |
ANTIPRURITICS,TOPICAL |
|
|
|
|
|
|
|
|
|
L3P |
|
DOXEPIN 5% CREAM |
DOXEPIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
L5A |
KERATOLYTICS |
|
|
|
|
|
|
|
|
|
L5A |
|
PODOFILOX 0.5% TOPICAL SOLN |
PODOFILOX |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 121 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
L5A |
|
SALICYLIC ACID 6% CREAM |
SALICYLIC ACID |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L5A |
|
UREA 40% CREAM |
UREA |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L5A |
|
UREA 40% LOTION |
UREA |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L5A |
|
UREA 45% LOTION |
UREA |
0 |
999 |
|
No |
|
|||
|
|
|
L5E |
ANTISEBORRHEIC AGENTS |
|
|
|
|
|
|
|
|
|
L5E |
|
SELENIUM 2.5% LOTION/SHAMPOO |
SELENIUM SULFIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L5E |
|
SELENIUM SULF 2.5% SHAMPOO |
SELENIUM SULFIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L5E |
|
SELENIUM SULFIDE 2.25% SHAMPOO |
SELENIUM SULFIDE |
0 |
999 |
|
No |
|
|||
|
|
|
L5F |
ANTIPSORIATICS AGENTS |
|
|
|
|
|
|
|
|
|
L5F |
|
CALCIPOTRIENE 0.005% CREAM |
CALCIPOTRIENE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L5F |
|
CALCIPOTRIENE 0.005% OINTMENT |
CALCIPOTRIENE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L5F |
|
CALCITRIOL 3 MCG/G OINTMENT |
CALCITRIOL |
0 |
999 |
|
No |
|
|||
|
|
|
L5G |
ROSACEA AGENTS, TOPICAL |
|
|
|
|
|
|
|
|
|
L5G |
|
FINACEA 15% GEL |
AZELAIC ACID |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L5G |
|
METRONIDAZOLE 0.75% CREAM |
METRONIDAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L5G |
|
METRONIDAZOLE TOP 0.75% GEL |
METRONIDAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L5G |
|
METRONIDAZOLE TOP 1% GEL PUMP |
METRONIDAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L5G |
|
METRONIDAZOLE TOPICAL 0.75% GL |
METRONIDAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L5G |
|
METRONIDAZOLE TOPICAL 1% GEL |
METRONIDAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
L5H |
ACNE AGENTS,TOPICAL |
|
|
|
|
|
|
|
|
|
L5H |
|
AZELEX 20% CREAM |
AZELAIC ACID |
12 |
999 |
|
No |
|
|||
|
|
|
L9B |
VITAMIN A DERIVATIVES |
|
|
|
|
|
|
|
|
|
L9B |
|
AVITA 0.025% CREAM |
TRETINOIN |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L9B |
|
DIFFERIN 0.1% CREAM |
ADAPALENE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
L9B |
|
DIFFERIN 0.1% LOTION |
ADAPALENE |
12 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 122 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
L9B |
|
TRETINOIN |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
L9B |
|
TRETINOIN |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
L9B |
|
TRETINOIN |
12 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M0B |
PLASMA PROTEINS |
|
|
|
|
|
|
|
|
|
M0B |
|
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
ALBUMIN (HUMAN) 25% IV SOLN |
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
ALBUMIN (HUMAN) 5% IV SOLUTION |
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
ALBURX (HUMAN) 25% VIAL |
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
ALBURX (HUMAN) 5% VIAL |
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
ALBUTEIN 25% VIAL |
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
ALBUTEIN 5% IV SOLUTION |
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
ALBUTEIN 5% VIAL |
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
BUMINATE 5% IV SOLUTION |
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
FLEXBUMIN 25% IV SOLUTION |
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
FLEXBUMIN 5% IV SOLUTION |
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
KEDBUMIN 25% VIAL |
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
ALBUMIN HUMAN |
0 |
999 |
|
Clinical PA Required |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M0B |
|
PLASMANATE 5% IV SOLUTION |
PLASMA PROTEIN FRACTION |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M0N |
C1 ESTERASE INHIBITORS |
|
|
|
|
|
|
|
|
|
M0N |
|
BERINERT 500 UNIT KIT |
C1 ESTERASE INHIBITOR |
12 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M0N |
|
BERINERT 500 UNIT VIAL |
C1 ESTERASE INHIBITOR |
12 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M0N |
|
CINRYZE 500 UNIT VIAL |
C1 ESTERASE INHIBITOR |
6 |
999 |
|
Auto PA |
|
Thursday, October 25, 2018 |
Page 123 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M0N |
|
RUCONEST 2,100 UNIT VIAL |
|
|
C1 ESTERASE INHIBITOR, RECOMB |
12 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4B |
|
|
IV FAT EMULSIONS |
|
|
|
|
|
|
|
|
M4B |
|
INTRALIPID 20% IV FAT EMUL |
|
|
FAT EMULSIONS |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4B |
|
INTRALIPID 30% IV FAT EMUL |
|
|
FAT EMULSIONS |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
M4D |
ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS |
|
|
|
|
|||||
|
M4D |
|
ATORVASTATIN 10 MG TABLET |
|
|
ATORVASTATIN CALCIUM |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
ATORVASTATIN 20 MG TABLET |
|
|
ATORVASTATIN CALCIUM |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
ATORVASTATIN 40 MG TABLET |
|
|
ATORVASTATIN CALCIUM |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
ATORVASTATIN 80 MG TABLET |
|
|
ATORVASTATIN CALCIUM |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
LOVASTATIN 10 MG TABLET |
|
|
LOVASTATIN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
LOVASTATIN 20 MG TABLET |
|
|
LOVASTATIN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
LOVASTATIN 40 MG TABLET |
|
|
LOVASTATIN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
PRAVASTATIN SODIUM 10 MG TAB |
|
|
PRAVASTATIN SODIUM |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
PRAVASTATIN SODIUM 20 MG TAB |
|
|
PRAVASTATIN SODIUM |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
PRAVASTATIN SODIUM 40 MG TAB |
|
|
PRAVASTATIN SODIUM |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
PRAVASTATIN SODIUM 80 MG TAB |
|
|
PRAVASTATIN SODIUM |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
ROSUVASTATIN CALCIUM 10 MG TAB |
|
|
ROSUVASTATIN CALCIUM |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
ROSUVASTATIN CALCIUM 20 MG TAB |
|
|
ROSUVASTATIN CALCIUM |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
ROSUVASTATIN CALCIUM 40 MG TAB |
|
|
ROSUVASTATIN CALCIUM |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
ROSUVASTATIN CALCIUM 5 MG TAB |
|
|
ROSUVASTATIN CALCIUM |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
SIMVASTATIN 10 MG TABLET |
|
|
SIMVASTATIN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
SIMVASTATIN 20 MG TABLET |
|
|
SIMVASTATIN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
SIMVASTATIN 40 MG TABLET |
|
|
SIMVASTATIN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4D |
|
SIMVASTATIN 5 MG TABLET |
|
|
SIMVASTATIN |
0 |
|
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 124 of 204 |
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Medicaid Drug Name |
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Generic Name |
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Medicaid |
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Medicaid |
|
Clinical PA Required |
|
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|
|
|
Min Age |
|
Max Age |
|
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|||
|
M4D |
|
SIMVASTATIN 80 MG TABLET |
SIMVASTATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M4E |
LIPOTROPICS |
|
|
|
|
|
|
|
|
|
M4E |
|
EZETIMIBE 10 MG TABLET |
EZETIMIBE |
10 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FENOFIBRATE 145 MG TABLET |
FENOFIBRATE NANOCRYSTALLIZED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FENOFIBRATE 48 MG TABLET |
FENOFIBRATE NANOCRYSTALLIZED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 1,000 MG CAPSULE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 1,000 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 1,000 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 1,000 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 1,000 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 1,000 MG SOFTGEL DR |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 1,000 MG SOFTGEL DR |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 1,200 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 1,200 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 1,200 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 1,200 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 1,360 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 1,400 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 1,600 MG/5 ML LIQUID |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL 500 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL CONC 1,000 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL CONC 1,000 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL CONCENTRATE SOFTGEL |
DOCOSAHEXANOIC ACID/EPA |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL CONCETRATE SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 125 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
M4E |
|
FISH OIL DR 1,000 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL EC 1,000 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL EC 1,200 MG SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL GUMMIES |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
FISH |
OMEGA3/DHA/EPA/FISH OIL/VIT D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
GEMFIBROZIL 600 MG TABLET |
GEMFIBROZIL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
NIACIN ER 1,000 MG TABLET |
NIACIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
NIACIN ER 500 MG TABLET |
NIACIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
NIACIN ER 750 MG TABLET |
NIACIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
NIACOR 500 MG TABLET |
NIACIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
OMEGA 3 500 SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
OMEGA 3 FISH OIL 1,000 MG CAP |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
OMEGA 3 FISH OIL SOFTGEL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||||
|
|
|
|
|
|
|
|
|
|
|||
|
M4E |
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 126 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
M4E |
|
|
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M4E |
|
|
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M4E |
|
|
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M4E |
|
|
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M4E |
|
|
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M4E |
|
|
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M4E |
|
|
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M4E |
|
|
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M4E |
|
|
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M4E |
|
|
|
OMEGA3/DHA/EPA/FISH OIL/VIT D3 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M4E |
|
|
|
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
M4G |
AGENTS TO TREAT HYPOGLYCEMIA (HYPERGLYCEMICS) |
|
|
|
|
|
||||
|
M4G |
|
GLUCAGEN 1 MG HYPOKIT |
|
|
GLUCAGON,HUMAN RECOMBINANT |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M4G |
|
GLUCAGON 1 MG EMERGENCY KIT |
|
|
GLUCAGON,HUMAN RECOMBINANT |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M4G |
|
PROGLYCEM 50 MG/ML ORAL SUSP |
|
|
DIAZOXIDE |
0 |
999 |
|
No |
|
||
|
|
|
M9D |
|
|
ANTIFIBRINOLYTIC AGENTS |
|
|
|
|
|
|
|
|
M9D |
|
AMICAR 0.25 GRAM/ML ORAL SOLN |
|
|
AMINOCAPROIC ACID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9D |
|
AMICAR 1,000 MG TABLET |
|
|
AMINOCAPROIC ACID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9D |
|
AMICAR 500 MG TABLET |
|
|
AMINOCAPROIC ACID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9D |
|
AMINOCAPROIC ACID 250 MG/ML |
|
|
AMINOCAPROIC ACID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9D |
|
AMINOCAPROIC ACID 5 G/20 ML VL |
|
|
AMINOCAPROIC ACID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9D |
|
TRANEXAMIC ACID 1,000 MG/10 ML |
|
|
TRANEXAMIC ACID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9D |
|
TRANEXAMIC ACID 1000 MG/10 ML |
|
|
TRANEXAMIC ACID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9D |
|
TRANEXAMIC ACID 650 MG TABLET |
|
|
TRANEXAMIC ACID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M9F |
|
|
THROMBOLYTIC ENZYMES |
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 127 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
M9F |
|
CATHFLO ACTIVASE 2 MG VIAL |
ALTEPLASE |
0 |
999 |
|
No |
|
|||
|
|
|
M9K |
HEPARIN AND RELATED PREPARATIONS |
|
|
|
|
|
|
|
|
|
M9K |
|
ENOXAPARIN 100 MG/ML SYR |
ENOXAPARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9K |
|
ENOXAPARIN 100 MG/ML SYRINGE |
ENOXAPARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9K |
|
ENOXAPARIN 120 MG/0.8 ML SYR |
ENOXAPARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9K |
|
ENOXAPARIN 150 MG/ML SYR |
ENOXAPARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9K |
|
ENOXAPARIN 150 MG/ML SYRINGE |
ENOXAPARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9K |
|
ENOXAPARIN 30 MG/0.3 ML SYR |
ENOXAPARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9K |
|
ENOXAPARIN 300 MG/3 ML VIAL |
ENOXAPARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9K |
|
ENOXAPARIN 40 MG/0.4 ML SYR |
ENOXAPARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9K |
|
ENOXAPARIN 60 MG/0.6 ML SYR |
ENOXAPARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9K |
|
ENOXAPARIN 80 MG/0.8 ML SYR |
ENOXAPARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M9L |
ANTICOAGULANTS,COUMARIN TYPE |
|
|
|
|
|
|
|
|
|
M9L |
|
COUMADIN 1 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
COUMADIN 10 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
COUMADIN 2 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
COUMADIN 2.5 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
COUMADIN 3 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
COUMADIN 4 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
COUMADIN 5 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
COUMADIN 6 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
COUMADIN 7.5 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
JANTOVEN 1 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
JANTOVEN 10 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 128 of 204 |
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Class |
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Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
JANTOVEN 2 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
JANTOVEN 2.5 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
JANTOVEN 3 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
JANTOVEN 4 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
JANTOVEN 5 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
JANTOVEN 6 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
JANTOVEN 7.5 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
WARFARIN SODIUM 1 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
WARFARIN SODIUM 10 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
WARFARIN SODIUM 2 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
WARFARIN SODIUM 2.5 MG TAB |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
WARFARIN SODIUM 2.5 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
WARFARIN SODIUM 3 MG TAB |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
WARFARIN SODIUM 3 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
WARFARIN SODIUM 4 MG TAB |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
WARFARIN SODIUM 4 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
WARFARIN SODIUM 5 MG TAB |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
WARFARIN SODIUM 5 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
WARFARIN SODIUM 6 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
WARFARIN SODIUM 7.5 MG TAB |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9L |
|
WARFARIN SODIUM 7.5 MG TABLET |
WARFARIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M9P |
PLATELET AGGREGATION INHIBITORS |
|
|
|
|
|
|
|
|
|
M9P |
|
ADULT ASPIRIN CHEW TABLET |
ASPIRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
ADULT ASPIRIN EC 81 MG TABLET |
ASPIRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 129 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
M9P |
|
ADULT ASPIRIN REGIMEN EC 81 MG |
ASPIRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
AGGRENOX CAPSULE SA |
ASPIRIN/DIPYRIDAMOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
ASPIRIN 81 MG CHEW TABLET |
ASPIRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
ASPIRIN 81 MG CHEWABLE TABLET |
ASPIRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
ASPIRIN 81 MG TABLET CHEW |
ASPIRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
ASPIRIN ADULT 81 MG TAB CHEW |
ASPIRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
ASPIRIN CHILD 81 MG TAB CHEW |
ASPIRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
ASPIRIN CHILD 81 MG TAB CHEW |
ASPIRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
ASPIRIN EC 81 MG TABLET |
ASPIRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
BRILINTA 60 MG TABLET |
TICAGRELOR |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
BRILINTA 90 MG TABLET |
TICAGRELOR |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
CHILDREN'S CHEW ASPIRIN TAB |
ASPIRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
CILOSTAZOL 100 MG TABLET |
CILOSTAZOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
CILOSTAZOL 50 MG TABLET |
CILOSTAZOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
CLOPIDOGREL 75 MG TABLET |
CLOPIDOGREL BISULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
CLOPIDOGREL BISULFATE 75 MG TB |
CLOPIDOGREL BISULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
DIPYRIDAMOLE 25 MG TABLET |
DIPYRIDAMOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
DIPYRIDAMOLE 50 MG TABLET |
DIPYRIDAMOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
DIPYRIDAMOLE 75 MG TABLET |
DIPYRIDAMOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
HM ASPIRIN 81 MG CHEWABLE TAB |
ASPIRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
HM ASPIRIN EC 81 MG TABLET |
ASPIRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
PRASUGREL 10 MG TABLET |
PRASUGREL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
PRASUGREL 5 MG TABLET |
PRASUGREL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
M9P |
|
QC ASPIRIN 81 MG CHEWABLE TAB |
ASPIRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 130 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
M9P |
|
QC ASPIRIN EC 81 MG TABLET |
|
|
ASPIRIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9P |
|
SB ASPIRIN EC 81 MG TABLET |
|
|
ASPIRIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9P |
|
SM ASPIRIN 81 MG TABLET CHEW |
|
|
ASPIRIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9P |
|
SM ASPIRIN 81 MG TABLET CHEW |
|
|
ASPIRIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9P |
|
SM ASPIRIN CHLD 81 MG TB CHW |
|
|
ASPIRIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9P |
|
ST. JOSEPH ASPIRIN EC 81 MG TB |
|
|
ASPIRIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
M9S |
|
|
HEMORRHEOLOGIC AGENTS |
|
|
|
|
|
|
|
|
M9S |
|
PENTOXIFYLLINE 400 MG TAB SA |
|
|
PENTOXIFYLLINE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9S |
|
PENTOXIFYLLINE ER 400 MG TAB |
|
|
PENTOXIFYLLINE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
M9T |
THROMBIN INHIBITORS, SELECTIVE, DIRECT, REVERSIBLE |
|
|
|
|
|
||||
|
M9T |
|
PRADAXA 110 MG CAPSULE |
|
|
DABIGATRAN ETEXILATE MESYLATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9T |
|
PRADAXA 150 MG CAPSULE |
|
|
DABIGATRAN ETEXILATE MESYLATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9T |
|
PRADAXA 75 MG CAPSULE |
|
|
DABIGATRAN ETEXILATE MESYLATE |
18 |
999 |
|
No |
|
||
|
|
|
M9V |
|
|
DIRECT FACTOR XA INHIBITORS |
|
|
|
|
|
|
|
|
M9V |
|
ELIQUIS 2.5 MG TABLET |
|
|
APIXABAN |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9V |
|
ELIQUIS 5 MG STARTER PACK |
|
|
APIXABAN |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9V |
|
ELIQUIS 5 MG TABLET |
|
|
APIXABAN |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9V |
|
SAVAYSA 15 MG TABLET |
|
|
EDOXABAN TOSYLATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9V |
|
SAVAYSA 30 MG TABLET |
|
|
EDOXABAN TOSYLATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9V |
|
SAVAYSA 60 MG TABLET |
|
|
EDOXABAN TOSYLATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9V |
|
XARELTO 10 MG TABLET |
|
|
RIVAROXABAN |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9V |
|
XARELTO 15 MG TABLET |
|
|
RIVAROXABAN |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
M9V |
|
XARELTO 20 MG TABLET |
|
|
RIVAROXABAN |
18 |
999 |
|
No |
|
||
|
|
|
N1B |
|
|
|
|
|
|
|
|
||
|
N1B |
|
ARANESP 10 MCG/0.4 ML SYRINGE |
|
|
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
|
Thursday, October 25, 2018 |
Page 131 of 204 |
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Class |
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Medicaid Drug Name |
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Generic Name |
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Medicaid |
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Medicaid |
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Clinical PA Required |
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Min Age |
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Max Age |
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|||
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N1B |
|
ARANESP 100 MCG/0.5 ML SYRINGE |
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
|
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|||
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N1B |
|
ARANESP 100 MCG/ML VIAL |
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
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|||
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N1B |
|
ARANESP 150 MCG/0.3 ML SYRINGE |
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
|
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|||
|
N1B |
|
ARANESP 200 MCG/0.4 ML SYRINGE |
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
|
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N1B |
|
ARANESP 200 MCG/ML VIAL |
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
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N1B |
|
ARANESP 25 MCG/0.42 ML SYRING |
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
|
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N1B |
|
ARANESP 25 MCG/ML VIAL |
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
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N1B |
|
ARANESP 300 MCG/0.6 ML SYRINGE |
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
|
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|||
|
N1B |
|
ARANESP 300 MCG/ML VIAL |
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
|
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|||
|
N1B |
|
ARANESP 40 MCG/0.4 ML SYRINGE |
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
|
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N1B |
|
ARANESP 40 MCG/ML VIAL |
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
|
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|||
|
N1B |
|
ARANESP 500 MCG/1 ML SYRINGE |
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
|
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|||
|
N1B |
|
ARANESP 60 MCG/0.3 ML SYRINGE |
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
|
|||
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|
|||
|
N1B |
|
ARANESP 60 MCG/ML VIAL |
DARBEPOETIN ALFA IN POLYSORBAT |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
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|
|
|
|
|
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|
|||
|
N1B |
|
EPOGEN 10,000 UNITS/ML VIAL |
EPOETIN ALFA |
0 |
999 |
|
Auto PA |
|
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|||
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N1B |
|
EPOGEN 2,000 UNITS/ML VIAL |
EPOETIN ALFA |
0 |
999 |
|
Auto PA |
|
|||
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|||
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N1B |
|
EPOGEN 20,000 UNITS/ML VIAL |
EPOETIN ALFA |
0 |
999 |
|
Auto PA |
|
|||
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|||
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N1B |
|
EPOGEN 3,000 UNITS/ML VIAL |
EPOETIN ALFA |
0 |
999 |
|
Auto PA |
|
|||
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|||
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N1B |
|
EPOGEN 4,000 UNITS/ML VIAL |
EPOETIN ALFA |
0 |
999 |
|
Auto PA |
|
|||
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|||
|
N1B |
|
RETACRIT 10,000 UNIT/ML VIAL |
EPOETIN |
0 |
999 |
|
No |
|
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N1B |
|
RETACRIT 2,000 UNIT/ML VIAL |
EPOETIN |
0 |
999 |
|
No |
|
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N1B |
|
RETACRIT 3,000 UNIT/ML VIAL |
EPOETIN |
0 |
999 |
|
No |
|
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N1B |
|
RETACRIT 4,000 UNIT/ML VIAL |
EPOETIN |
0 |
999 |
|
No |
|
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N1B |
|
RETACRIT 40,000 UNIT/ML VIAL |
EPOETIN |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 132 of 204 |
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
Min Age |
|
Max Age |
|
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N1C |
LEUKOCYTE (WBC) STIMULANTS |
|
|
|
N1C |
GRANIX 300 MCG/0.5 ML SAFE SYR |
0 |
999 |
Clinical PA Required |
|
|
|
|
|
|
|
N1C |
GRANIX 300 MCG/0.5 ML SYRINGE |
0 |
999 |
Clinical PA Required |
|
|
|
|
|
|
|
N1C |
GRANIX 480 MCG/0.8 ML SAFE SYR |
0 |
999 |
Clinical PA Required |
|
|
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|
|
|
|
N1C |
GRANIX 480 MCG/0.8 ML SYRINGE |
0 |
999 |
Clinical PA Required |
|
|
|
|
|
|
|
N1C |
LEUKINE 250 MCG VIAL |
SARGRAMOSTIM |
0 |
999 |
Clinical PA Required |
|
|
|
|
|
|
N1C |
NEULASTA 6 MG/0.6 ML DLVRY KIT |
PEGFILGRASTIM |
0 |
999 |
Clinical PA Required |
|
|
|
|
|
|
N1C |
NEULASTA 6 MG/0.6 ML SYRINGE |
PEGFILGRASTIM |
0 |
999 |
Clinical PA Required |
|
|
|
|
|
|
N1C |
NEUPOGEN 300 MCG/0.5 ML SYR |
FILGRASTIM |
0 |
999 |
Clinical PA Required |
|
|
|
|
|
|
N1C |
NEUPOGEN 300 MCG/ML VIAL |
FILGRASTIM |
0 |
999 |
Clinical PA Required |
|
|
|
|
|
|
N1C |
NEUPOGEN 480 MCG/0.8 ML SYR |
FILGRASTIM |
0 |
999 |
Clinical PA Required |
|
|
|
|
|
|
N1C |
NEUPOGEN 480 MCG/1.6 ML VIAL |
FILGRASTIM |
0 |
999 |
Clinical PA Required |
|
|
|
|
|
|
N1C |
ZARXIO 300 MCG/0.5 ML SYRINGE |
0 |
999 |
Clinical PA Required |
|
|
|
|
|
|
|
N1C |
ZARXIO 480 MCG/0.8 ML SYRINGE |
0 |
999 |
Clinical PA Required |
|
|
N1D |
PLATELET REDUCING AGENTS |
|
|
|
N1D |
ANAGRELIDE HCL 0.5 MG CAPSULE |
ANAGRELIDE HCL |
0 |
999 |
No |
|
|
|
|
|
|
N1D |
ANAGRELIDE HCL 1 MG CAPSULE |
ANAGRELIDE HCL |
0 |
999 |
No |
|
|
|
|
|
|
|
N1G |
CXCR4 CHEMOKINE RECEPTOR ANTAGONIST |
|
|
|
N1G |
MOZOBIL 24 MG/1.2 ML VIAL |
PLERIXAFOR |
0 |
999 |
Clinical PA Required |
|
P0G |
PREGNANCY MAINTAINING AGENT,HORMONAL |
|
|
|
P0G |
MAKENA 250 MG/ML VIAL |
HYDROXYPROGESTERONE CAPROAT/PF |
16 |
999 |
Clinical PA Required |
|
|
|
|
|
|
P0G |
MAKENA 275 MG/1.1 ML AUTOINJCT |
HYDROXYPROGESTERONE CAPROAT/PF |
16 |
999 |
Clinical PA Required |
|
|
|
|
|
|
|
P1A |
GROWTH HORMONES |
|
|
|
P1A |
GENOTROPIN 12 MG CARTRIDGE |
SOMATROPIN |
0 |
16 |
Clinical PA Required |
|
|
|
|
|
|
P1A |
GENOTROPIN 5 MG CARTRIDGE |
SOMATROPIN |
0 |
16 |
Clinical PA Required |
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 133 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
P1A |
|
GENOTROPIN MINIQUICK 0.2 MG |
SOMATROPIN |
0 |
16 |
|
Clinical PA Required |
|
|||
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|
|||
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P1A |
|
GENOTROPIN MINIQUICK 0.4 MG |
SOMATROPIN |
0 |
16 |
|
Clinical PA Required |
|
|||
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|
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|
|||
|
P1A |
|
GENOTROPIN MINIQUICK 0.6 MG |
SOMATROPIN |
0 |
16 |
|
Clinical PA Required |
|
|||
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|
|
|
|
|
|
|
|
|
|||
|
P1A |
|
GENOTROPIN MINIQUICK 0.8 MG |
SOMATROPIN |
0 |
16 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1A |
|
GENOTROPIN MINIQUICK 1 MG |
SOMATROPIN |
0 |
16 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1A |
|
GENOTROPIN MINIQUICK 1.2 MG |
SOMATROPIN |
0 |
16 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1A |
|
GENOTROPIN MINIQUICK 1.4 MG |
SOMATROPIN |
0 |
16 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1A |
|
GENOTROPIN MINIQUICK 1.6 MG |
SOMATROPIN |
0 |
16 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1A |
|
GENOTROPIN MINIQUICK 1.8 MG |
SOMATROPIN |
0 |
16 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1A |
|
GENOTROPIN MINIQUICK 2 MG |
SOMATROPIN |
0 |
16 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1A |
|
NORDITROPIN FLEXPRO 10 MG/1.5 |
SOMATROPIN |
0 |
16 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1A |
|
NORDITROPIN FLEXPRO 15 MG/1.5 |
SOMATROPIN |
0 |
16 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1A |
|
NORDITROPIN FLEXPRO 30 MG/3 ML |
SOMATROPIN |
0 |
16 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1A |
|
NORDITROPIN FLEXPRO 5 MG/1.5 |
SOMATROPIN |
0 |
16 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1A |
|
SEROSTIM 4 MG VIAL |
SOMATROPIN |
18 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1A |
|
SEROSTIM 5 MG VIAL |
SOMATROPIN |
18 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1A |
|
SEROSTIM 6 MG VIAL |
SOMATROPIN |
18 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
P1B |
SOMATOSTATIC AGENTS |
|
|
|
|
|
|
|
|
|
P1B |
|
OCTREOTIDE 1,000 MCG/ML VIAL |
OCTREOTIDE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1B |
|
OCTREOTIDE 1,000 MCG/5 ML VIAL |
OCTREOTIDE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1B |
|
OCTREOTIDE 5,000 MCG/5 ML VIAL |
OCTREOTIDE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1B |
|
OCTREOTIDE ACET 0.05 MG/ML VL |
OCTREOTIDE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1B |
|
OCTREOTIDE ACET 100 MCG/ML VL |
OCTREOTIDE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P1B |
|
OCTREOTIDE ACET 200 MCG/ML VL |
OCTREOTIDE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 134 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
P1B |
|
OCTREOTIDE ACET 50 MCG/ML VIAL |
|
|
OCTREOTIDE ACETATE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P1B |
|
OCTREOTIDE ACET 500 MCG/ML VL |
|
|
|
OCTREOTIDE ACETATE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P1E |
|
|
|
ADRENOCORTICOTROPHIC HORMONES |
|
|
|
|
|
|
|
|
P1E |
|
HP ACTHAR GEL 80 UNIT/ML VIAL |
|
|
|
CORTICOTROPIN |
0 |
|
999 |
|
Clinical PA Required |
|
|
|
|
|
P1F |
|
|
|
PITUITARY SUPPRESSIVE AGENTS |
|
|
|
|
|
|
|
|
P1F |
|
CABERGOLINE 0.5 MG TABLET |
|
|
|
CABERGOLINE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P1F |
|
DANAZOL 100 MG CAPSULE |
|
|
|
DANAZOL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P1F |
|
DANAZOL 200 MG CAPSULE |
|
|
|
DANAZOL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P1F |
|
DANAZOL 50 MG CAPSULE |
|
|
|
DANAZOL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
P1M |
LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS |
|
|
|
|
||||||
|
P1M |
|
LUPRON DEPO 11.25MG (LUPANETA) |
|
|
LEUPROLIDE ACETATE |
18 |
|
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P1M |
|
LUPRON DEPOT 11.25 MG 3MO KIT |
|
|
|
LEUPROLIDE ACETATE |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P1M |
|
LUPRON DEPOT 3.75 MG KIT |
|
|
|
LEUPROLIDE ACETATE |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P1M |
|
LUPRON DEPOT 3.75MG (LUPANETA) |
|
|
LEUPROLIDE ACETATE |
18 |
|
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P1M |
|
SYNAREL 2 MG/ML NASAL SPRAY |
|
|
|
NAFARELIN ACETATE |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
P1O |
|
LHRH (GNRH) AGONIST ANALOG AND PROGESTIN COMB |
|
|
|
|
|||||
|
P1O |
|
LUPANETA PK |
|
|
|
LEUPROLIDE/NORETHINDRONE ACET |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P1O |
|
LUPANETA PK |
|
|
|
LEUPROLIDE/NORETHINDRONE ACET |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
P1P |
LHRH(GNRH)AGNST |
|
|
|
|||||||
|
P1P |
|
LUPRON DEPOT 11.25 MG 3MO KIT |
|
|
|
LEUPROLIDE ACETATE |
2 |
|
12 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P1P |
|
LUPRON |
|
|
|
LEUPROLIDE ACETATE |
2 |
|
12 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P1P |
|
LUPRON |
|
|
|
LEUPROLIDE ACETATE |
2 |
|
12 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P1P |
|
LUPRON |
|
|
LEUPROLIDE ACETATE |
2 |
|
12 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P1P |
|
LUPRON |
|
|
|
LEUPROLIDE ACETATE |
2 |
|
12 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P1P |
|
TRIPTODUR 22.5 MG KIT |
|
|
|
TRIPTORELIN PAMOATE |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 135 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
P1P |
|
TRIPTODUR 22.5 MG VIAL |
|
|
TRIPTORELIN PAMOATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
P2B |
ANTIDIURETIC AND VASOPRESSOR HORMONES |
|
|
|
|
|
||||
|
P2B |
|
DESMOPRESSIN 10 MCG/0.1 ML SPR |
|
|
DESMOPRESSIN (NONREFRIGERATED) |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P2B |
|
DESMOPRESSIN 40 MCG/10 ML VIAL |
|
|
DESMOPRESSIN ACETATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P2B |
|
DESMOPRESSIN AC 4 MCG/ML AMP |
|
|
DESMOPRESSIN ACETATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P2B |
|
DESMOPRESSIN AC 4 MCG/ML AMPUL |
|
|
DESMOPRESSIN ACETATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P2B |
|
DESMOPRESSIN AC 4 MCG/ML VIAL |
|
|
DESMOPRESSIN ACETATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P2B |
|
DESMOPRESSIN AC 4 MCG/ML VL |
|
|
DESMOPRESSIN ACETATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P2B |
|
DESMOPRESSIN ACETATE 0.1 MG TB |
|
|
DESMOPRESSIN ACETATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P2B |
|
DESMOPRESSIN ACETATE 0.2 MG TB |
|
|
DESMOPRESSIN ACETATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P2B |
|
STIMATE 1.5 MG/ML NASAL SPRAY |
|
|
DESMOPRESSIN ACETATE |
0 |
999 |
|
No |
|
||
|
|
|
P3A |
|
|
THYROID HORMONES |
|
|
|
|
|
|
|
|
P3A |
|
ARMOUR THYROID 120 MG TABLET |
|
|
THYROID,PORK |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3A |
|
ARMOUR THYROID 15 MG TABLET |
|
|
THYROID,PORK |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3A |
|
ARMOUR THYROID 180 MG TABLET |
|
|
THYROID,PORK |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3A |
|
ARMOUR THYROID 240 MG TABLET |
|
|
THYROID,PORK |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3A |
|
ARMOUR THYROID 30 MG TABLET |
|
|
THYROID,PORK |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3A |
|
ARMOUR THYROID 300 MG TABLET |
|
|
THYROID,PORK |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3A |
|
ARMOUR THYROID 60 MG TABLET |
|
|
THYROID,PORK |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3A |
|
ARMOUR THYROID 90 MG TABLET |
|
|
THYROID,PORK |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3A |
|
|
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3A |
|
|
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3A |
|
|
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3A |
|
|
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 136 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
P3A |
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 100 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 112 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 125 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 137 MCG TAB |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 137 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 150 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 175 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 200 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 25 MCG TAB |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 25 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 300 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 50 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 75 MCG TAB |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 75 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOTHYROXINE 88 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOXYL 100 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 137 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
P3A |
|
LEVOXYL 112 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOXYL 125 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOXYL 137 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOXYL 150 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOXYL 175 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOXYL 200 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOXYL 25 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOXYL 50 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOXYL 75 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LEVOXYL 88 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LIOTHYRONINE SOD 25 MCG TAB |
LIOTHYRONINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LIOTHYRONINE SOD 5 MCG TAB |
LIOTHYRONINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LIOTHYRONINE SOD 50 MCG TAB |
LIOTHYRONINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
NP THYROID 120 MG TABLET |
THYROID,PORK |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
NP THYROID 15 MG TABLET |
THYROID,PORK |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
NP THYROID 30 MG TABLET |
THYROID,PORK |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
NP THYROID 60 MG TABLET |
THYROID,PORK |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
NP THYROID 90 MG TABLET |
THYROID,PORK |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
SYNTHROID 100 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
SYNTHROID 112 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
SYNTHROID 125 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
SYNTHROID 137 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
SYNTHROID 150 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
SYNTHROID 175 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 138 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
P3A |
|
SYNTHROID 200 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
SYNTHROID 25 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
SYNTHROID 300 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
SYNTHROID 50 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
SYNTHROID 75 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
SYNTHROID 88 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
THYROID 120 MG TABLET |
THYROID,PORK |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
THYROID 15 MG TABLET |
THYROID,PORK |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
THYROID 30 MG TABLET |
THYROID,PORK |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
THYROID 60 MG TABLET |
THYROID,PORK |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
THYROID 90 MG TABLET |
THYROID,PORK |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LIOTRIX |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LIOTRIX |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LIOTRIX |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LIOTRIX |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
LIOTRIX |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
UNITHROID 100 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
UNITHROID 112 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
UNITHROID 125 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
UNITHROID 137 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
UNITHROID 150 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
UNITHROID 175 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
UNITHROID 200 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P3A |
|
UNITHROID 25 MCG TABLET |
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 139 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
P3A |
|
UNITHROID 300 MCG TABLET |
|
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3A |
|
UNITHROID 50 MCG TABLET |
|
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3A |
|
UNITHROID 75 MCG TABLET |
|
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3A |
|
UNITHROID 88 MCG TABLET |
|
|
LEVOTHYROXINE SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P3L |
|
|
ANTITHYROID PREPARATIONS |
|
|
|
|
|
|
|
|
P3L |
|
METHIMAZOLE 10 MG TABLET |
|
|
METHIMAZOLE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3L |
|
METHIMAZOLE 5 MG TABLET |
|
|
METHIMAZOLE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3L |
|
PROPYLTHIOURACIL 50 MG TABLET |
|
|
PROPYLTHIOURACIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P3L |
|
PROPYLTHIOURACIL 50 MG TABS |
|
|
PROPYLTHIOURACIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
||||||
|
|
|
P4D |
HYPERPARATHYROID TX AGENTS - VITAMIN D |
|
|
|
||||||
|
P4D |
|
DOXERCALCIFEROL 0.5 MCG CAP |
|
|
DOXERCALCIFEROL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P4D |
|
DOXERCALCIFEROL 1 MCG CAPSULE |
|
|
DOXERCALCIFEROL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P4D |
|
DOXERCALCIFEROL 2.5 MCG CAP |
|
|
DOXERCALCIFEROL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P4D |
|
PARICALCITOL 1 MCG CAPSULE |
|
|
PARICALCITOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P4D |
|
PARICALCITOL 10 MCG/2 ML VIAL |
|
|
PARICALCITOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P4D |
|
PARICALCITOL 2 MCG CAPSULE |
|
|
PARICALCITOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P4D |
|
PARICALCITOL 2 MCG/ML VIAL |
|
|
PARICALCITOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P4D |
|
PARICALCITOL 4 MCG CAPSULE |
|
|
PARICALCITOL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
P4D |
|
PARICALCITOL 5 MCG/ML VIAL |
|
|
PARICALCITOL |
0 |
999 |
|
No |
|
||
|
|
|
P4L |
|
|
BONE RESORPTION INHIBITORS |
|
|
|
|
|
|
|
|
P4L |
|
ALENDRONATE SODIUM 10 MG TAB |
ALENDRONATE SODIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
P4L |
|
ALENDRONATE SODIUM 35 MG TAB |
ALENDRONATE SODIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
P4L |
|
ALENDRONATE SODIUM 40 MG TAB |
ALENDRONATE SODIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
P4L |
|
ALENDRONATE SODIUM 5 MG TABLET |
ALENDRONATE SODIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
P4L |
|
ALENDRONATE SODIUM 70 MG TAB |
ALENDRONATE SODIUM |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 140 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
P4L |
|
CALCITONIN,SALMON,SYNTHETIC |
18 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P4L |
|
PAMIDRONATE 30 MG/10 ML VIAL |
PAMIDRONATE DISODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P4L |
|
PAMIDRONATE 60 MG/10 ML VIAL |
PAMIDRONATE DISODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P4L |
|
PAMIDRONATE 90 MG/10 ML VIAL |
PAMIDRONATE DISODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P4L |
|
PAMIDRONATE DISOD 30 MG VIAL |
PAMIDRONATE DISODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P4L |
|
PAMIDRONATE DISOD 90 MG VIAL |
PAMIDRONATE DISODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P4L |
|
ZOLEDRONIC ACID 4 MG VIAL |
ZOLEDRONIC ACID |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P4L |
|
ZOLEDRONIC ACID 4 MG/100 ML |
ZOLEDRONIC AC/MANNITOL/0.9NACL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P4L |
|
ZOLEDRONIC ACID 4 MG/5 ML VIAL |
ZOLEDRONIC ACID |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P4L |
|
ZOLEDRONIC ACID 5 MG/100 ML |
ZOLEDRONIC |
0 |
999 |
|
No |
|
|||
|
|
|
P5A |
GLUCOCORTICOIDS |
|
|
|
|
|
|
|
|
|
P5A |
|
BETAMETHASONE |
BETAMETHASONE ACETATE,SOD PHOS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
BUDESONIDE EC 3 MG CAPSULE |
BUDESONIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
CELESTONE SOLUSPAN 30 MG/5 ML |
BETAMETHASONE ACETATE,SOD PHOS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 0.5 MG TABLET |
DEXAMETHASONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 0.5 MG/0.5 ML |
DEXAMETHASONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 0.5 MG/5 ML ELX |
DEXAMETHASONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 0.5 MG/5 ML LIQ |
DEXAMETHASONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 0.75 MG TABLET |
DEXAMETHASONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 1 MG TABLET |
DEXAMETHASONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 1.5 MG TABLET |
DEXAMETHASONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 10 MG/ML VIAL |
DEXAMETHASONE SODIUM PHOSP/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 10 MG/ML VIAL |
DEXAMETHASONE SODIUM PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 100 MG/10 ML VL |
DEXAMETHASONE SODIUM PHOSPHATE |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 141 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 120 MG/30 ML VL |
DEXAMETHASONE SODIUM PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 2 MG TABLET |
DEXAMETHASONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 20 MG/5 ML VIAL |
DEXAMETHASONE SODIUM PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 4 MG TABLET |
DEXAMETHASONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 4 MG/ML SYRINGE |
DEXAMETHASONE SODIUM PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 4 MG/ML VIAL |
DEXAMETHASONE SODIUM PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
DEXAMETHASONE 6 MG TABLET |
DEXAMETHASONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
HYDROCORTISONE 10 MG TABLET |
HYDROCORTISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
HYDROCORTISONE 20 MG TABLET |
HYDROCORTISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
HYDROCORTISONE 5 MG TABLET |
HYDROCORTISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
METHYLPRED SS 125 MG VIAL |
METHYLPREDNISOLONE SOD SUCC |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
METHYLPREDNISOLONE 1 GM VIAL |
METHYLPREDNISOLONE SOD SUCC |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
METHYLPREDNISOLONE 16 MG TAB |
METHYLPREDNISOLONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
METHYLPREDNISOLONE 32 MG TAB |
METHYLPREDNISOLONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
METHYLPREDNISOLONE 4 MG DOSEPK |
METHYLPREDNISOLONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
METHYLPREDNISOLONE 4 MG TAB |
METHYLPREDNISOLONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
METHYLPREDNISOLONE 4 MG TABLET |
METHYLPREDNISOLONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
METHYLPREDNISOLONE 40 MG VIAL |
METHYLPREDNISOLONE SOD SUCC |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
METHYLPREDNISOLONE 40 MG/ML VL |
METHYLPREDNISOLONE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
METHYLPREDNISOLONE 8 MG TAB |
METHYLPREDNISOLONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
METHYLPREDNISOLONE 80 MG/ML VL |
METHYLPREDNISOLONE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
METHYLPREDNISOLONE SS 1 GM VL |
METHYLPREDNISOLONE SOD SUCC |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
METHYLPREDNISOLONE SS 125 MG |
METHYLPREDNISOLONE SOD SUCC |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
METHYLPREDNISOLONE SS 40 MG VL |
METHYLPREDNISOLONE SOD SUCC |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 142 of 204 |
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Medicaid Drug Name |
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Generic Name |
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Medicaid |
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Medicaid |
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Clinical PA Required |
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Min Age |
|
Max Age |
|
|
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|
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P5A |
|
ORAPRED ODT 10 MG TABLET |
PREDNISOLONE SOD PHOSPHATE |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
ORAPRED ODT 15 MG TABLET |
PREDNISOLONE SOD PHOSPHATE |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
ORAPRED ODT 30 MG TABLET |
PREDNISOLONE SOD PHOSPHATE |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISOLONE 10 MG/5 ML SOLN |
PREDNISOLONE SOD PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISOLONE 15 MG/5 ML SOLN |
PREDNISOLONE SOD PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISOLONE 15 MG/5 ML SYRUP |
PREDNISOLONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISOLONE 20 MG/5 ML SOLN |
PREDNISOLONE SOD PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISOLONE 5 MG/5 ML SOLN |
PREDNISOLONE SOD PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISOLONE SOD PH 25 MG/5 ML |
PREDNISOLONE SOD PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISONE 1 MG TABLET |
PREDNISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISONE 10 MG TAB DOSE PACK |
PREDNISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISONE 10 MG TABLET |
PREDNISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISONE 2.5 MG TABLET |
PREDNISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISONE 20 MG TABLET |
PREDNISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISONE 5 MG TAB DOSE PACK |
PREDNISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISONE 5 MG TABLET |
PREDNISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISONE 5 MG/5 ML SOLUTION |
PREDNISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
PREDNISONE 50 MG TABLET |
PREDNISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
HYDROCORTISONE SODIUM SUCC/PF |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
HYDROCORTISONE SODIUM SUCC/PF |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
HYDROCORTISONE SOD SUCCINATE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
HYDROCORTISONE SODIUM SUCC/PF |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
P5A |
|
HYDROCORTISONE SODIUM SUCC/PF |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
P5S |
MINERALOCORTICOIDS |
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 143 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
P5S |
|
FLUDROCORTISONE 0.1 MG TAB |
|
|
|
FLUDROCORTISONE ACETATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
P5S |
|
FLUDROCORTISONE 0.1 MG TABLET |
|
|
FLUDROCORTISONE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|||||||
|
|
|
Q2C |
OPHTHALMIC |
|
|
|
|||||||
|
Q2C |
|
RESTASIS 0.05% EYE EMULSION |
|
|
|
CYCLOSPORINE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q2C |
|
RESTASIS MULTIDOSE 0.05% EYE |
|
|
|
CYCLOSPORINE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
Q2L |
|
|
|
OPHTHALMIC CYSTINE DEPLETING AGENTS |
|
|
|
|
|
||
|
Q2L |
|
CYSTARAN 0.44% EYE DROPS |
|
|
|
CYSTEAMINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
Q3B |
RECTAL/LOWER BOWEL PREP.,GLUCOCORT. |
|
|
|
|||||||
|
Q3B |
|
HYDROCORTISONE 100 MG/60 ML |
|
|
HYDROCORTISONE |
0 |
999 |
|
No |
|
|||
|
|
|
Q3E |
|
CHRONIC INFLAM. COLON DX, |
|
|
|
|
|
||||
|
Q3E |
|
MESALAMINE 4 GM/60 ML ENEMA |
|
|
MESALAMINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
Q3E |
|
MESALAMINE 4G/60 ML RECTL SUSP |
|
|
MESALAMINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|||||||
|
|
|
Q3I |
HEMORRHOID |
|
|
|
|||||||
|
Q3I |
|
|
|
|
HYDROCORTISONE/LIDOCAINE/ALOE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q3I |
|
|
|
|
HYDROCORTISONE/LIDOCAINE/ALOE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q3I |
|
|
|
|
HYDROCORTISONE/LIDOCAINE/ALOE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q3I |
|
|
|
|
HYDROCORTISONE/PRAMOXINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q4F |
|
|
|
VAGINAL ANTIFUNGALS |
|
|
|
|
|
|
|
|
Q4F |
|
3 DAY VAGINAL 2% CREAM |
|
|
|
CLOTRIMAZOLE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q4F |
|
|
|
|
CLOTRIMAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q4F |
|
CLOTRIM 1% VAGINAL CREAM |
|
|
|
CLOTRIMAZOLE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q4F |
|
CLOTRIMAZOLE 1% CREAM |
|
|
|
CLOTRIMAZOLE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q4F |
|
CLOTRIMAZOLE 3 DAY CREAM |
|
|
|
CLOTRIMAZOLE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q4F |
|
GYNAZOLE 1 2% CREAM |
|
|
|
BUTOCONAZOLE NITRATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
MICONAZOLE 1 COMBINATION PACK |
|
|
MICONAZOLE NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
MICONAZOLE 100 MG VAG SUPP |
|
|
MICONAZOLE NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 144 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
Q4F |
|
MICONAZOLE 3 200 MG VAG SUPP |
MICONAZOLE NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
MICONAZOLE 3 4% CREAM |
MICONAZOLE NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
MICONAZOLE 7 100 MG VAG SUPP |
MICONAZOLE NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
MICONAZOLE 7 CREAM |
MICONAZOLE NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
MICONAZOLE NITRATE 2% CREAM |
MICONAZOLE NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
QC 3 DAY VAGINAL 4% CREAM |
MICONAZOLE NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
QC MICONAZOLE 7 CREAM |
MICONAZOLE NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
SM CLOTRIMAZOLE 1% CREAM |
CLOTRIMAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
SM MICONAZOLE 7 100 MG VAG SUP |
MICONAZOLE NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
SM MICONAZOLE NITRATE 2% CREAM |
MICONAZOLE NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
SM |
TIOCONAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
SUNMARK |
CLOTRIMAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
SUNMARK MICONAZOLE 7 CREAM |
MICONAZOLE NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
TERCONAZOLE 0.4% CREAM |
TERCONAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
TERCONAZOLE 0.8% VAGINAL CR |
TERCONAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4F |
|
TERCONAZOLE 80 MG SUPPOSITORY |
TERCONAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q4K |
VAGINAL ESTROGEN PREPARATIONS |
|
|
|
|
|
|
|
|
|
Q4K |
|
ESTRING 2 MG VAGINAL RING |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4K |
|
PREMARIN VAGINAL |
ESTROGENS, CONJUGATED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4K |
|
VAGIFEM 10 MCG VAGINAL TAB |
ESTRADIOL |
0 |
999 |
|
No |
|
|||
|
|
|
Q4W |
VAGINAL ANTIBIOTICS |
|
|
|
|
|
|
|
|
|
Q4W |
|
CLEOCIN 100 MG VAGINAL OVULE |
CLINDAMYCIN PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4W |
|
CLINDESSE 2% VAGINAL CREAM |
CLINDAMYCIN PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q4W |
|
NUVESSA VAGINAL 1.3% GEL |
METRONIDAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
Q5B |
TOPICAL PREPARATIONS,ANTIBACTERIALS |
|
|
|
|
|
Thursday, October 25, 2018 |
Page 145 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
Q5B |
|
SILVER NITRATE 0.5% SOLN |
SILVER NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
Q5E |
TOPICAL |
|
|
|
|
|
|
||
|
Q5E |
|
VOLTAREN 1% GEL |
DICLOFENAC SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
Q5F |
TOPICAL ANTIFUNGALS |
|
|
|
|
|
|
||
|
Q5F |
|
CICLOPIROX 0.77% CREAM |
CICLOPIROX OLAMINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5F |
|
CICLOPIROX 0.77% TOPICAL SUSP |
CICLOPIROX OLAMINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5F |
|
CICLOPIROX 8% SOLUTION |
CICLOPIROX |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5F |
|
CICLOPIROX OLAMINE 0.77% CREAM |
CICLOPIROX OLAMINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5F |
|
CLOTRIMAZOLE 1% CREAM |
CLOTRIMAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5F |
|
CLOTRIMAZOLE 1% SOLUTION |
CLOTRIMAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5F |
|
ECONAZOLE NITRATE 1% CREAM |
ECONAZOLE NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5F |
|
KETOCONAZOLE 2% CREAM |
KETOCONAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5F |
|
KETOCONAZOLE 2% SHAMPOO |
KETOCONAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5F |
|
MICONAZOLE NITRATE 2% CREAM |
MICONAZOLE NITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5F |
|
NYSTATIN 100,000 UNIT/GM CREAM |
NYSTATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5F |
|
NYSTATIN 100,000 UNIT/GM POWD |
NYSTATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5F |
|
NYSTATIN 100,000 UNITS/GM OINT |
NYSTATIN |
0 |
999 |
|
No |
|
|||
|
|
|
Q5H |
TOPICAL LOCAL ANESTHETICS |
|
|
|
|
|
|
||
|
Q5H |
|
LIDOCAINE 3% CREAM |
LIDOCAINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5H |
|
LIDOCAINE 5% PATCH |
LIDOCAINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5H |
|
LIDOCAINE/PRILOCAINE |
0 |
999 |
|
No |
|
||||
|
|
|
Q5K |
TOPICAL IMMUNOSUPPRESSIVE AGENTS |
|
|
|
|
|
|
||
|
Q5K |
|
ELIDEL 1% CREAM |
PIMECROLIMUS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5K |
|
PROTOPIC 0.03% OINTMENT |
TACROLIMUS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5K |
|
PROTOPIC 0.1% OINTMENT |
TACROLIMUS |
16 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 146 of 204 |
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q5M |
TOPICAL |
|
|||
Q5M |
CLOTRIMAZOLE/BETAMETH CREAM |
CLOTRIMAZOLE/BETAMETHASONE DIP |
0 |
999 |
No |
|
|
|
|
|
|
|
|
Q5M |
CLOTRIMAZOLE/BETAMETHASONE DIP |
0 |
999 |
No |
||
|
|
|
|
|
|
|
Q5M |
CLOTRIMAZOLE/BETAMETHASONE DIP |
0 |
999 |
No |
||
|
Q5N |
TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTS |
|
|
||
Q5N |
DICLOFENAC SODIUM 3% GEL |
|
DICLOFENAC SODIUM |
18 |
999 |
Auto PA |
|
|
|
|
|
|
|
Q5N |
FLUOROURACIL 0.5% CREAM |
|
FLUOROURACIL |
0 |
999 |
No |
|
|
|
|
|
|
|
Q5N |
FLUOROURACIL 2% SOLUTION |
|
FLUOROURACIL |
0 |
999 |
No |
|
|
|
|
|
|
|
Q5N |
FLUOROURACIL 5% CREAM |
|
FLUOROURACIL |
0 |
999 |
No |
|
|
|
|
|
|
|
Q5N |
FLUOROURACIL 5% SOLUTION |
|
FLUOROURACIL |
0 |
999 |
No |
|
|
|
|
|
|
|
Q5N |
PANRETIN 0.1% GEL |
|
ALITRETINOIN |
0 |
999 |
Clinical PA Required |
|
|
|
|
|
|
|
|
Q5P |
|
TOPICAL |
|
|
|
Q5P |
ALCLOMETASONE DIP 0.05% OINT |
|
ALCLOMETASONE DIPROPIONATE |
0 |
999 |
No |
|
|
|
|
|
|
|
Q5P |
ALCLOMETASONE DIPR 0.05% OINT |
ALCLOMETASONE DIPROPIONATE |
0 |
999 |
No |
|
|
|
|
|
|
|
|
Q5P |
|
HYDROCORTISONE |
0 |
999 |
No |
|
|
|
|
|
|
|
|
Q5P |
BETAMETHASONE DP 0.05% CRM |
|
BETAMETHASONE/PROPYLENE GLYC |
0 |
999 |
No |
|
|
|
|
|
|
|
Q5P |
BETAMETHASONE DP AUG 0.05% CRM |
BETAMETHASONE/PROPYLENE GLYC |
0 |
999 |
No |
|
|
|
|
|
|
|
|
Q5P |
BETAMETHASONE VA 0.1% CREAM |
BETAMETHASONE VALERATE |
0 |
999 |
No |
|
|
|
|
|
|
|
|
Q5P |
CLOBETASOL 0.05% CREAM |
|
CLOBETASOL PROPIONATE |
0 |
999 |
No |
|
|
|
|
|
|
|
Q5P |
CLOBETASOL 0.05% CREAM |
|
CLOBETASOL PROPIONATE/EMOLL |
0 |
999 |
No |
|
|
|
|
|
|
|
Q5P |
CLOBETASOL 0.05% GEL |
|
CLOBETASOL PROPIONATE |
0 |
999 |
No |
|
|
|
|
|
|
|
Q5P |
CLOBETASOL 0.05% SOLUTION |
|
CLOBETASOL PROPIONATE |
0 |
999 |
No |
|
|
|
|
|
|
|
Q5P |
CLOBETASOL EMOLLIENT 0.05% CRM |
CLOBETASOL PROPIONATE/EMOLL |
0 |
999 |
No |
|
|
|
|
|
|
|
|
Q5P |
|
FLUOCINOLONE ACETONIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
|
Q5P |
|
FLUOCINOLONE/SHOWER CAP |
0 |
999 |
No |
Thursday, October 25, 2018 |
Page 147 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
FLUTICASONE PROP 0.005% OINT |
FLUTICASONE PROPIONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
FLUTICASONE PROP 0.05% CREAM |
FLUTICASONE PROPIONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
HALOBETASOL PROP 0.05% CREAM |
HALOBETASOL PROPIONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
HALOBETASOL PROP 0.05% OINT |
HALOBETASOL PROPIONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
HALOBETASOL PROP 0.05% OINTMNT |
HALOBETASOL PROPIONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
HYDROCORTISONE 1% CREAM |
HYDROCORTISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
HYDROCORTISONE 1% OINTMENT |
HYDROCORTISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
HYDROCORTISONE 2.5% CREAM |
HYDROCORTISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
HYDROCORTISONE 2.5% OINT |
HYDROCORTISONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
MOMETASONE FUROATE 0.1% CREAM |
MOMETASONE FUROATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
MOMETASONE FUROATE 0.1% OINT |
MOMETASONE FUROATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
MOMETASONE FUROATE 0.1% ONT |
MOMETASONE FUROATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
MOMETASONE FUROATE 0.1% SOLN |
MOMETASONE FUROATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
HYDROCORTISONE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
HYDROCORTISONE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
TRIAMCINOLONE 0.025% CREAM |
TRIAMCINOLONE ACETONIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
TRIAMCINOLONE 0.025% OINT |
TRIAMCINOLONE ACETONIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
TRIAMCINOLONE 0.1% CREAM |
TRIAMCINOLONE ACETONIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
TRIAMCINOLONE 0.1% OINTMENT |
TRIAMCINOLONE ACETONIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
TRIAMCINOLONE 0.5% CREAM |
TRIAMCINOLONE ACETONIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5P |
|
TRIAMCINOLONE 0.5% OINTMENT |
TRIAMCINOLONE ACETONIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q5R |
TOPICAL ANTIPARASITICS |
|
|
|
|
|
|
|
|
|
Q5R |
|
HM LICE KILLING SHAMPOO |
PIPERONYL BUTOXIDE/PYRETHRINS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5R |
|
HM LICE TREATMENT 1% CRM RINSE |
PERMETHRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 148 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
Q5R |
|
LICE KILLING SHAMPOO |
PIPERONYL BUTOXIDE/PYRETHRINS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5R |
|
LICE SOLUTION KIT |
PIPERONYL BUTOX/PYRETHR/PERMET |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5R |
|
LICE TREATMENT 1% CREME RINSE |
PERMETHRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5R |
|
LICE TREATMENT SHAMPOO |
PIPERONYL BUTOXIDE/PYRETHRINS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5R |
|
NATROBA 0.9% TOPICAL SUSP |
SPINOSAD |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5R |
|
PERMETHRIN 5% CREAM |
PERMETHRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5R |
|
SB LICE KILLING SHAMPOO |
PIPERONYL BUTOXIDE/PYRETHRINS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5R |
|
SKLICE 0.5% LOTION |
IVERMECTIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5R |
|
SM LICE TREATMENT 1% CRM RINSE |
PERMETHRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5R |
|
SUNMARK LICE KILLING SHAMPO |
PERMETHRIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5R |
|
SUNMARK LICE KILLING TREATM |
PIPERONYL BUTOXIDE/PYRETHRINS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5R |
|
SUNMARK LICE SOLUTION KIT |
PIPERONYL BUTOX/PYRETHR/PERMET |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q5S |
TOPICAL SULFONAMIDES |
|
|
|
|
|
|
|
|
|
Q5S |
|
SILVER SULFADIAZINE 1% CREAM |
SILVER SULFADIAZINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5S |
|
SILVER SULFADIAZINE 1% CRM |
SILVER SULFADIAZINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5S |
|
SULFAMYLON 8.5% CREAM |
MAFENIDE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
Q5V |
TOPICAL ANTIVIRALS |
|
|
|
|
|
|
|
|
|
Q5V |
|
DENAVIR 1% CREAM |
PENCICLOVIR |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5V |
|
ZOVIRAX 5% CREAM |
ACYCLOVIR |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5V |
|
ZOVIRAX 5% OINTMENT |
ACYCLOVIR |
12 |
999 |
|
No |
|
|||
|
|
|
Q5W |
TOPICAL ANTIBIOTICS |
|
|
|
|
|
|
|
|
|
Q5W |
|
CLINDAMYCIN PH 1% SOLUTION |
CLINDAMYCIN PHOSPHATE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5W |
|
CLINDAMYCIN PHOS 1% PLEDGET |
CLINDAMYCIN PHOSPHATE |
12 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5W |
|
GENTAMICIN 0.1% CREAM |
GENTAMICIN SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q5W |
|
MUPIROCIN 2% OINTMENT |
MUPIROCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 149 of 204 |
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q5X |
TOPICAL ANTIBIOTIC AND |
|
|
|
Q5X |
CORTISPORIN CREAM |
NEOMYCIN/POLYMYXIN B/HYDROCORT |
0 |
999 |
No |
|
|
|
|
|
|
Q5X |
CORTISPORIN OINTMENT |
NEOMYC/BACIT/POLYMYX/HYDROCORT |
0 |
999 |
No |
|
|
|
|
|
|
|
Q6C |
EYE VASOCONSTRICTORS |
|
|
|
Q6C |
PHENYLEPHRINE 10% EYE DROPS |
PHENYLEPHRINE HCL |
0 |
999 |
No |
|
|
|
|
|
|
Q6C |
PHENYLEPHRINE 2.5% EYE DROP |
PHENYLEPHRINE HCL |
0 |
999 |
No |
|
|
|
|
|
|
|
Q6E |
EYE IRRIGATIONS |
|
|
|
Q6E |
BALANCED SALT SOLUTION |
BALANCED SALT IRRIG SOLN NO.2 |
0 |
999 |
No |
|
Q6G |
MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERS |
|
|
|
Q6G |
AZOPT 1% EYE DROPS |
BRINZOLAMIDE |
0 |
999 |
No |
|
|
|
|
|
|
Q6G |
BRIMONIDINE 0.2% EYE DROP |
BRIMONIDINE TARTRATE |
0 |
999 |
No |
|
|
|
|
|
|
Q6G |
BRIMONIDINE 0.2% EYE DROPS |
BRIMONIDINE TARTRATE |
0 |
999 |
No |
|
|
|
|
|
|
Q6G |
CARTEOLOL HCL 1% EYE DROPS |
CARTEOLOL HCL |
0 |
999 |
No |
|
|
|
|
|
|
Q6G |
COMBIGAN |
BRIMONIDINE TARTRATE/TIMOLOL |
0 |
999 |
No |
|
|
|
|
|
|
Q6G |
COMBIGAN EYE DROPS |
BRIMONIDINE TARTRATE/TIMOLOL |
0 |
999 |
No |
|
|
|
|
|
|
Q6G |
DORZOLAMIDE HCL 2% EYE DROPS |
DORZOLAMIDE HCL |
0 |
999 |
No |
|
|
|
|
|
|
Q6G |
DORZOLAMIDE HCL/TIMOLOL MALEAT |
0 |
999 |
No |
|
|
|
|
|
|
|
Q6G |
LATANOPROST 0.005% EYE DROPS |
LATANOPROST |
0 |
999 |
No |
|
|
|
|
|
|
Q6G |
LEVOBUNOLOL 0.5% EYE DROPS |
LEVOBUNOLOL HCL |
0 |
999 |
No |
|
|
|
|
|
|
Q6G |
SIMBRINZA |
BRINZOLAMIDE/BRIMONIDINE TART |
0 |
999 |
No |
|
|
|
|
|
|
Q6G |
TIMOLOL 0.25% EYE DROPS |
TIMOLOL MALEATE |
0 |
999 |
No |
|
|
|
|
|
|
Q6G |
TIMOLOL 0.25% GEL /SOLUTION |
TIMOLOL MALEATE |
0 |
999 |
No |
|
|
|
|
|
|
Q6G |
TIMOLOL 0.25% |
TIMOLOL MALEATE |
0 |
999 |
No |
|
|
|
|
|
|
Q6G |
TIMOLOL 0.5% EYE DROP |
TIMOLOL MALEATE |
0 |
999 |
No |
|
|
|
|
|
|
Q6G |
TIMOLOL 0.5% EYE DROPS |
TIMOLOL MALEATE |
0 |
999 |
No |
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 150 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
Q6G |
|
TIMOLOL 0.5% GEL/SOLUTION |
|
|
TIMOLOL MALEATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6G |
|
TIMOLOL 0.5% |
|
|
TIMOLOL MALEATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6G |
|
TRAVATAN Z 0.004% EYE DROP |
|
|
TRAVOPROST |
0 |
999 |
|
No |
|
||
|
|
|
Q6I |
EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONS |
|
|
|
|
|
||||
|
Q6I |
|
NEO/BACIT/POLY/HC EYE OINT |
|
|
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6I |
|
NEO/POLY/DEXAMET EYE OINT |
|
|
NEOMYCIN/POLYMYXIN B/DEXAMETHA |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6I |
|
NEO/POLYMYXIN/DEXAMETH DROP |
|
|
NEOMYCIN/POLYMYXIN B/DEXAMETHA |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6I |
|
|
|
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
Q6I |
|
NEOMYCIN/POLYMYXIN B/DEXAMETHA |
0 |
999 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6I |
|
TOBRADEX EYE DROPS |
|
|
TOBRAMYCIN/DEXAMETHASONE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6I |
|
TOBRADEX EYE OINTMENT |
|
|
TOBRAMYCIN/DEXAMETHASONE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6I |
|
ZYLET EYE DROPS |
|
|
TOBRAMYCIN/LOTEPRED ETAB |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q6J |
|
|
MYDRIATICS |
|
|
|
|
|
|
|
|
Q6J |
|
ATROPINE 1% EYE DROPS |
|
|
ATROPINE SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6J |
|
ATROPINE 1% EYE OINTMENT |
|
|
ATROPINE SULFATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q6P |
|
|
EYE |
|
|
|
|
|
|
|
|
Q6P |
|
ALREX 0.2% EYE DROPS |
|
|
LOTEPREDNOL ETABONATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6P |
|
DEXAMETHASONE 0.1% EYE DROP |
|
|
DEXAMETHASONE SODIUM PHOSPHATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6P |
|
DICLOFENAC 0.1% EYE DROPS |
|
|
DICLOFENAC SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6P |
|
DICLOFENAC SODIUM 0.1 % SOLN |
|
|
DICLOFENAC SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6P |
|
DUREZOL 0.05% EYE DROPS |
|
|
DIFLUPREDNATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6P |
|
FLAREX 0.1% EYE DROPS |
|
|
FLUOROMETHOLONE ACETATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6P |
|
FLURBIPROFEN 0.03% EYE DROP |
|
|
FLURBIPROFEN SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6P |
|
FML FORTE 0.25% EYE DROPS |
|
|
FLUOROMETHOLONE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6P |
|
FML S.O.P. 0.1% OINTMENT |
|
|
FLUOROMETHOLONE |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 151 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
Q6P |
|
ILEVRO 0.3% OPHTH DROPS |
NEPAFENAC |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q6P |
|
KETOROLAC 0.5% OPHTH SOLUTION |
KETOROLAC TROMETHAMINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q6P |
|
LOTEMAX 0.5% EYE DROPS |
LOTEPREDNOL ETABONATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q6P |
|
MAXIDEX 0.1% EYE DROPS |
DEXAMETHASONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Q6P |
|
PREDNISOLONE AC 1% EYE DROP |
PREDNISOLONE ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q6R |
EYE ANTIHISTAMINES |
|
|
Q6R |
OLOPATADINE HCL 0.1% EYE DROPS |
OLOPATADINE HCL |
0 |
999 |
Q6R |
PAZEO 0.7% EYE DROPS |
OLOPATADINE HCL |
0 |
999 |
|
Q6S |
EYE SULFONAMIDES |
|
|
Q6S |
SULFACETAMIDE/PREDNISOLONE SP |
0 |
999 |
|
|
Q6U |
EYE MAST CELL STABILIZERS |
|
|
Q6U |
CROMOLYN 4% EYE DROPS |
CROMOLYN SODIUM |
0 |
999 |
Q6U |
CROMOLYN SODIUM 4% EYE DROP |
CROMOLYN SODIUM |
0 |
999 |
|
Q6V |
EYE ANTIVIRALS |
|
|
Q6V |
TRIFLURIDINE 1% OPHTHAL SOLN |
TRIFLURIDINE |
0 |
999 |
|
Q6W |
OPHTHALMIC ANTIBIOTICS |
|
|
Q6W |
BACIT/POLYMYXIN EYE OINT |
BACITRACIN/POLYMYXIN B SULFATE |
0 |
999 |
Q6W |
CIPROFLOXACIN 0.3% EYE DROP |
CIPROFLOXACIN HCL |
0 |
999 |
Q6W |
ERYTHROMYCIN 0.5% EYE OINTMENT |
ERYTHROMYCIN BASE |
0 |
999 |
Q6W |
ERYTHROMYCIN EYE OINTMENT |
ERYTHROMYCIN BASE |
0 |
999 |
Q6W |
GENTAMICIN 3 MG/ML EYE DROPS |
GENTAMICIN SULFATE |
0 |
999 |
Q6W |
MOXEZA 0.5% EYE DROPS |
MOXIFLOXACIN HCL |
0 |
999 |
Q6W |
MOXIFLOXACIN 0.5% EYE DROPS |
MOXIFLOXACIN HCL |
0 |
999 |
Q6W |
NEO/BACIT/POLY EYE OINTMENT |
NEOMYCIN SULF/BACITRACIN/POLY |
0 |
999 |
Q6W |
NEOMYCIN SULF/BACITRACIN/POLY |
0 |
999 |
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Thursday, October 25, 2018 |
Page 152 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6W |
|
OFLOXACIN 0.3% EYE DROPS |
|
|
OFLOXACIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6W |
|
POLYMYXIN B/TMP EYE DROPS |
|
|
POLYMYXIN B SULF/TRIMETHOPRIM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q6W |
|
TOBRAMYCIN 0.3% EYE DROPS |
|
|
TOBRAMYCIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q7E |
|
|
NASAL ANTIHISTAMINE |
|
|
|
|
|
|
|
|
Q7E |
|
AZELASTINE 0.1% (137 MCG) SPRY |
|
|
AZELASTINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q7E |
|
AZELASTINE 0.15% NASAL SPRAY |
|
|
AZELASTINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q7E |
|
AZELASTINE 137 MCG NASAL SPRAY |
|
|
AZELASTINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q7E |
|
AZELASTINE HCL 0.1% NASAL SPRY |
|
|
AZELASTINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q7E |
|
AZELASTINE HCL 137 MCG SPRAY |
|
|
AZELASTINE HCL |
0 |
999 |
|
No |
|
||
|
|
|
Q7P |
|
|
NASAL |
|
|
|
|
|
|
|
|
Q7P |
|
FLUTICASONE 50 MCG NASAL SPRAY |
|
|
FLUTICASONE PROPIONATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q7P |
|
FLUTICASONE PROP 50 MCG SPRAY |
|
|
FLUTICASONE PROPIONATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|||
|
Q7P |
|
MOMETASONE FUROATE 50 MCG SPRY |
|
MOMETASONE FUROATE |
0 |
999 |
|
No |
|
|||
|
|
|
Q7W |
|
|
NOSE PREPARATIONS ANTIBIOTICS |
|
|
|
|
|
|
|
|
Q7W |
|
BACTROBAN NASAL 2% OINTMENT |
|
|
MUPIROCIN CALCIUM |
0 |
999 |
|
No |
|
||
|
|
|
Q8B |
|
EAR PREPARATIONS, MISC. |
|
|
|
|
|
|||
|
Q8B |
|
ACETIC ACID 2% EAR SOLUTION |
|
|
ACETIC ACID |
0 |
999 |
|
No |
|
||
|
|
|
Q8F |
OTIC |
|
|
|
|
|
||||
|
Q8F |
|
CIPRODEX OTIC SUSPENSION |
|
|
CIPROFLOXACIN HCL/DEXAMETH |
0 |
999 |
|
No |
|
||
|
|
|
Q8P |
|
EAR PREPARATIONS |
|
|
|
|
|
|||
|
Q8P |
|
FLUOCINOLONE OIL 0.01% EAR DRP |
|
|
FLUOCINOLONE ACETONIDE OIL |
0 |
999 |
|
No |
|
||
|
|
|
Q8W |
|
|
EAR PREPARATIONS,ANTIBIOTICS |
|
|
|
|
|
|
|
|
Q8W |
|
NEO/POLYMYXIN/HC EAR SOLN |
|
|
NEOMYCIN/POLYMYXIN B/HYDROCORT |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q8W |
|
NEO/POLYMYXIN/HC EAR SUSP |
|
|
NEOMYCIN/POLYMYXIN B/HYDROCORT |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q8W |
|
|
|
NEOMYCIN/POLYMYXIN B/HYDROCORT |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Q8W |
|
OFLOXACIN 0.3% EAR DROPS |
|
|
OFLOXACIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 153 of 204 |
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Q9B |
|
BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS |
|
|
|
Q9B |
ALFUZOSIN HCL ER 10 MG TABLET |
|
ALFUZOSIN HCL |
0 |
999 |
No |
|
|
|
|
|
|
|
Q9B |
DUTASTERIDE 0.5 MG CAPSULE |
|
DUTASTERIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
Q9B |
FINASTERIDE 5 MG TABLET |
|
FINASTERIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
Q9B |
TAMSULOSIN HCL 0.4 MG CAPSULE |
TAMSULOSIN HCL |
0 |
999 |
No |
|
|
|
|
|
|||
|
R1A |
URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT |
|
|||
R1A |
OXYBUTYNIN 5 MG TABLET |
|
OXYBUTYNIN CHLORIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
R1A |
OXYBUTYNIN 5 MG/5 ML SYRUP |
|
OXYBUTYNIN CHLORIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
R1A |
OXYBUTYNIN CL ER 10 MG TABLET |
|
OXYBUTYNIN CHLORIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
R1A |
OXYBUTYNIN CL ER 15 MG TABLET |
|
OXYBUTYNIN CHLORIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
R1A |
OXYBUTYNIN CL ER 5 MG TABLET |
|
OXYBUTYNIN CHLORIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
R1A |
TOVIAZ 4 MG ER TABLET |
|
FESOTERODINE FUMARATE |
18 |
999 |
No |
|
|
|
|
|
|
|
R1A |
TOVIAZ 8 MG ER TABLET |
|
FESOTERODINE FUMARATE |
18 |
999 |
No |
|
R1E |
|
CARBONIC ANHYDRASE INHIBITORS |
|
|
|
R1E |
ACETAZOLAMIDE 125 MG TABLET |
|
ACETAZOLAMIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
R1E |
ACETAZOLAMIDE 250 MG TABLET |
|
ACETAZOLAMIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
R1E |
ACETAZOLAMIDE ER 500 MG CAP |
|
ACETAZOLAMIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
R1E |
METHAZOLAMIDE 25 MG TABLET |
|
METHAZOLAMIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
R1E |
METHAZOLAMIDE 50 MG TABLET |
|
METHAZOLAMIDE |
0 |
999 |
No |
|
R1F |
|
THIAZIDE AND RELATED DIURETICS |
|
|
|
R1F |
CHLOROTHIAZIDE 250 MG TABLET |
|
CHLOROTHIAZIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
R1F |
CHLOROTHIAZIDE 500 MG TABLET |
|
CHLOROTHIAZIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
R1F |
CHLORTHALIDONE 25 MG TABLET |
|
CHLORTHALIDONE |
0 |
999 |
No |
|
|
|
|
|
|
|
R1F |
CHLORTHALIDONE 50 MG TABLET |
|
CHLORTHALIDONE |
0 |
999 |
No |
|
|
|
|
|
|
|
R1F |
DIURIL 250 MG/5 ML ORAL SUSP |
|
CHLOROTHIAZIDE |
0 |
11 |
No |
Thursday, October 25, 2018 |
Page 154 of 204 |
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Generic Name |
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Medicaid |
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Medicaid |
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Clinical PA Required |
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Min Age |
|
Max Age |
|
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|
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|
|||
|
R1F |
|
HYDROCHLOROTHIAZIDE 12.5 MG |
HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1F |
|
HYDROCHLOROTHIAZIDE 12.5 MG CP |
HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1F |
|
HYDROCHLOROTHIAZIDE 12.5 MG TB |
HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1F |
|
HYDROCHLOROTHIAZIDE 25 MG TAB |
HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1F |
|
HYDROCHLOROTHIAZIDE 25 MG TB |
HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1F |
|
HYDROCHLOROTHIAZIDE 50 MG TAB |
HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1F |
|
HYDROCHLOROTHIAZIDE 50 MG TB |
HYDROCHLOROTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1F |
|
INDAPAMIDE 1.25 MG TABLET |
INDAPAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1F |
|
INDAPAMIDE 2.5 MG TABLET |
INDAPAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1F |
|
METHYCLOTHIAZIDE 5 MG TABLET |
METHYCLOTHIAZIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1F |
|
METOLAZONE 10 MG TABLET |
METOLAZONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1F |
|
METOLAZONE 2.5 MG TABLET |
METOLAZONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1F |
|
METOLAZONE 5 MG TABLET |
METOLAZONE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R1H |
POTASSIUM SPARING DIURETICS |
|
|
R1H |
AMILORIDE HCL 5 MG TABLET |
AMILORIDE HCL |
0 |
999 |
R1H |
SPIRONOLACTONE 100 MG TABLET |
SPIRONOLACTONE |
0 |
999 |
R1H |
SPIRONOLACTONE 25 MG TABLET |
SPIRONOLACTONE |
0 |
999 |
R1H |
SPIRONOLACTONE 50 MG TABLET |
SPIRONOLACTONE |
0 |
999 |
|
R1I |
URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG. |
|
|
R1I |
VESICARE 10 MG TABLET |
SOLIFENACIN SUCCINATE |
18 |
999 |
R1I |
VESICARE 5 MG TABLET |
SOLIFENACIN SUCCINATE |
18 |
999 |
|
R1L |
POTASSIUM SPARING DIURETICS IN COMBINATION |
|
|
R1L |
AMILORIDE HCL/HCTZ 5/50 TAB |
AMILORIDE/HYDROCHLOROTHIAZIDE |
0 |
999 |
R1L |
SPIRONOLACT/HCTZ 25/25 TAB |
SPIRONOLACT/HYDROCHLOROTHIAZID |
0 |
999 |
R1L |
SPIRONOLACT/HYDROCHLOROTHIAZID |
0 |
999 |
No No
No
No
No
No
No
No
No
Thursday, October 25, 2018 |
Page 155 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
R1L |
|
TRIAMTERENE/HCTZ 37.5/25 CP |
TRIAMTERENE/HYDROCHLOROTHIAZID |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1L |
|
TRIAMTERENE/HCTZ 37.5/25 TB |
TRIAMTERENE/HYDROCHLOROTHIAZID |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1L |
|
TRIAMTERENE/HCTZ 50/25 CAP |
TRIAMTERENE/HYDROCHLOROTHIAZID |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1L |
|
TRIAMTERENE/HCTZ 75/50 TAB |
TRIAMTERENE/HYDROCHLOROTHIAZID |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1L |
|
TRIAMTERENE/HYDROCHLOROTHIAZID |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
R1L |
|
TRIAMTERENE/HYDROCHLOROTHIAZID |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
R1L |
|
TRIAMTERENE/HYDROCHLOROTHIAZID |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
R1L |
|
TRIAMTERENE/HYDROCHLOROTHIAZID |
0 |
999 |
|
No |
|
||||
|
|
|
R1M |
LOOP DIURETICS |
|
|
|
|
|
|
|
|
|
R1M |
|
BUMETANIDE 0.25 MG/ML VIAL |
BUMETANIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
BUMETANIDE 0.5 MG TABLET |
BUMETANIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
BUMETANIDE 1 MG TABLET |
BUMETANIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
BUMETANIDE 1 MG/4 ML VIAL |
BUMETANIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
BUMETANIDE 2 MG TABLET |
BUMETANIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
BUMETANIDE 2.5 MG/10 ML VIAL |
BUMETANIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
FUROSEMIDE 10 MG/ML SOLUTION |
FUROSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
FUROSEMIDE 10 MG/ML SYRINGE |
FUROSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
FUROSEMIDE 10 MG/ML VIAL |
FUROSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
FUROSEMIDE 100 MG/10 ML SYRING |
FUROSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
FUROSEMIDE 100 MG/10 ML VIAL |
FUROSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
FUROSEMIDE 20 MG TABLET |
FUROSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
FUROSEMIDE 20 MG/2 ML VIAL |
FUROSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
FUROSEMIDE 40 MG TABLET |
FUROSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
FUROSEMIDE 40 MG/4 ML SYRINGE |
FUROSEMIDE |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 156 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
FUROSEMIDE 40 MG/4 ML VIAL |
FUROSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
FUROSEMIDE 40 MG/5 ML SOLN |
FUROSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
FUROSEMIDE 80 MG TABLET |
FUROSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
TORSEMIDE 10 MG TABLET |
TORSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
TORSEMIDE 100 MG TABLET |
TORSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
TORSEMIDE 20 MG TABLET |
TORSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1M |
|
TORSEMIDE 5 MG TABLET |
TORSEMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R1R |
URICOSURIC AGENTS |
|
|
|
|
|
|
|
|
|
R1R |
|
PROBENECID 500 MG TABLET |
PROBENECID |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1R |
|
PROBENECID/COLCHICINE TABS |
PROBENECID/COLCHICINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1R |
|
PROBENECID/COLCHICINE |
0 |
999 |
|
No |
|
||||
|
|
|
R1S |
URINARY PH MODIFIERS |
|
|
|
|
|
|
|
|
|
R1S |
|
SOD |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
R1S |
|
SOD PHOS DI, MONO/K PHOS MONO |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
R1S |
|
POTASSIUM PHOSPHATE,MONOBASIC |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
R1S |
|
ORACIT ORAL SOLUTION |
CITRIC ACID/SODIUM CITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1S |
|
ORACIT SOLUTION 15 ML |
CITRIC ACID/SODIUM CITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1S |
|
ORACIT SOLUTION 30 ML |
CITRIC ACID/SODIUM CITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1S |
|
PHOSPHA 250 NEUTRAL TABLET |
SOD PHOS DI, MONO/K PHOS MONO |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1S |
|
POT |
POTASSIUM CITRATE/CITRIC ACID |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1S |
|
POTASS |
SOD/POT/K CIT/SOD CIT/CIT ACID |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1S |
|
POTASSIUM |
POTASSIUM CITRATE/CITRIC ACID |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1S |
|
POTASSIUM CITRATE 10 MEQ TABLE |
POTASSIUM CITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
R1S |
|
POTASSIUM CITRATE 5 MEQ TABLET |
POTASSIUM CITRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 157 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
R1S |
|
POTASSIUM CITRATE ER 10 MEQ TB |
|
|
POTASSIUM CITRATE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R1S |
|
POTASSIUM CITRATE ER 15 MEQ TB |
|
|
POTASSIUM CITRATE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R1S |
|
POTASSIUM CITRATE ER 5 MEQ TAB |
|
|
POTASSIUM CITRATE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R1S |
|
RENACIDIN IRRIGATION SOLUTION |
|
|
CITRIC AC/GLUCONOLACT/MAG CARB |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R1S |
|
SOD CITRATE/CITRIC ACID SOL |
|
|
CITRIC ACID/SODIUM CITRATE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R1S |
|
SOD |
|
|
CITRIC ACID/SODIUM CITRATE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R1S |
|
TRICITRATES SOLUTION |
|
|
SOD/POT/K CIT/SOD CIT/CIT ACID |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R1S |
|
|
|
SOD PHOS DI, MONO/K PHOS MONO |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R1S |
|
|
|
CITRIC ACID/SODIUM CITRATE |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R1S |
|
|
|
SOD/POT/K CIT/SOD CIT/CIT ACID |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R1S |
|
|
|
POTASSIUM CITRATE/CITRIC ACID |
0 |
|
999 |
|
No |
|
||
|
|
|
R1W |
|
|
|
|
||||||
|
R1W |
|
CYSTAGON 150 MG CAPSULE |
|
|
CYSTEAMINE BITARTRATE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R1W |
|
CYSTAGON 50 MG CAPSULE |
|
|
CYSTEAMINE BITARTRATE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R4A |
|
|
KIDNEY STONE AGENTS |
|
|
|
|
|
|
|
|
R4A |
|
THIOLA 100 MG TABLET |
|
|
TIOPRONIN |
0 |
|
999 |
|
No |
|
|
|
|
|
R5A |
URINARY TRACT ANESTHETIC/ANALGESIC AGNT |
|
|
|
|
|||||
|
R5A |
|
PHENAZOPYRIDINE 100 MG TAB |
|
|
PHENAZOPYRIDINE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
R5A |
|
PHENAZOPYRIDINE 200 MG TAB |
|
|
PHENAZOPYRIDINE HCL |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2A |
|
|
COLCHICINE |
|
|
|
|
|
|
|
|
S2A |
|
COLCHICINE 0.6 MG CAPSULE |
|
|
COLCHICINE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2A |
|
COLCHICINE 0.6 MG TABLET |
|
|
COLCHICINE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2A |
|
COLCHICINE 0.6 MG TABLET |
|
|
COLCHICINE |
4 |
|
999 |
|
No |
|
|
|
|
|
S2B |
NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS |
|
|
|
|
|||||
|
S2B |
|
DICLOFENAC POT 50 MG TABLET |
|
|
DICLOFENAC POTASSIUM |
0 |
|
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 158 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
DICLOFENAC SOD 100 MG TAB SA |
DICLOFENAC SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
DICLOFENAC SOD 50 MG TAB EC |
DICLOFENAC SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
DICLOFENAC SOD 75 MG TAB EC |
DICLOFENAC SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
DICLOFENAC SOD DR 25 MG TAB |
DICLOFENAC SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
DICLOFENAC SOD DR 50 MG TAB |
DICLOFENAC SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
DICLOFENAC SOD DR 75 MG TAB |
DICLOFENAC SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
DICLOFENAC SOD EC 25 MG TAB |
DICLOFENAC SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
DICLOFENAC SOD EC 50 MG TAB |
DICLOFENAC SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
DICLOFENAC SOD EC 75 MG TAB |
DICLOFENAC SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
DICLOFENAC SOD ER 100 MG TAB |
DICLOFENAC SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
IBUPROFEN 100 MG/5 ML SUSP |
IBUPROFEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
IBUPROFEN 400 MG TABLET |
IBUPROFEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
IBUPROFEN 400 MG TABLET |
IBUPROFEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
IBUPROFEN 600 MG TABLET |
IBUPROFEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
IBUPROFEN 600 MG TABLET |
IBUPROFEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
IBUPROFEN 800 MG TABLET |
IBUPROFEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
IBUPROFEN 800 MG TABLET |
IBUPROFEN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
INDOMETHACIN 25 MG CAPSULE |
INDOMETHACIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
INDOMETHACIN 50 MG CAPSULE |
INDOMETHACIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
KETOROLAC 10 MG TABLET |
KETOROLAC TROMETHAMINE |
17 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
KETOROLAC 15 MG/ML CARPUJECT |
KETOROLAC TROMETHAMINE |
17 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
KETOROLAC 15 MG/ML SYRINGE |
KETOROLAC TROMETHAMINE |
17 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
KETOROLAC 15 MG/ML VIAL |
KETOROLAC TROMETHAMINE |
17 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
S2B |
|
KETOROLAC 30 MG/ML CARPUJECT |
KETOROLAC TROMETHAMINE |
17 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 159 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
S2B |
|
KETOROLAC 30 MG/ML ISECURE SYR |
|
|
KETOROLAC TROMETHAMINE |
17 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
KETOROLAC 30 MG/ML SYRINGE |
|
|
|
KETOROLAC TROMETHAMINE |
17 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
KETOROLAC 30 MG/ML VIAL |
|
|
|
KETOROLAC TROMETHAMINE |
17 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
KETOROLAC 60 MG/2 ML SYRINGE |
|
|
|
KETOROLAC TROMETHAMINE |
17 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
KETOROLAC 60 MG/2 ML VIAL |
|
|
|
KETOROLAC TROMETHAMINE |
17 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
MELOXICAM 15 MG TABLET |
|
|
|
MELOXICAM |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
MELOXICAM 7.5 MG TABLET |
|
|
|
MELOXICAM |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
NABUMETONE 500 MG TABLET |
|
|
|
NABUMETONE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
NABUMETONE 750 MG TABLET |
|
|
|
NABUMETONE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
NAPROXEN 250 MG TABLET |
|
|
|
NAPROXEN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
NAPROXEN 375 MG TABLET |
|
|
|
NAPROXEN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
NAPROXEN 375 MG TABLET EC |
|
|
|
NAPROXEN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
NAPROXEN 500 MG TABLET |
|
|
|
NAPROXEN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
NAPROXEN 500 MG TABLET EC |
|
|
|
NAPROXEN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
NAPROXEN DR 375 MG TABLET |
|
|
|
NAPROXEN |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2B |
|
NAPROXEN DR 500 MG TABLET |
|
|
|
NAPROXEN |
0 |
|
999 |
|
No |
|
|
|
|
|
S2I |
|
|
|
|
|
||||||
|
S2I |
|
LEFLUNOMIDE 10 MG TABLET |
|
|
|
LEFLUNOMIDE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2I |
|
LEFLUNOMIDE 20 MG TABLET |
|
|
|
LEFLUNOMIDE |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
S2J |
|
|
|
||||||||
|
S2J |
|
ENBREL 25 MG KIT |
|
|
|
ETANERCEPT |
2 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2J |
|
ENBREL 25 MG/0.5 ML SYRINGE |
|
|
|
ETANERCEPT |
2 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
S2J |
|
ENBREL 50 MG/ML MINI CARTRIDGE |
|
|
ETANERCEPT |
2 |
|
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2J |
|
ENBREL 50 MG/ML SURECLICK SYR |
|
|
|
ETANERCEPT |
2 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 160 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
S2J |
|
ENBREL 50 MG/ML SYRINGE |
|
|
ETANERCEPT |
2 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2J |
|
HUMIRA 10 MG/0.1 ML SYRINGE |
|
|
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2J |
|
HUMIRA 10 MG/0.2 ML SYRINGE |
|
|
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2J |
|
HUMIRA 20 MG/0.2 ML SYRINGE |
|
|
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2J |
|
HUMIRA 20 MG/0.4 ML SYRINGE |
|
|
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2J |
|
HUMIRA 40 MG/0.4 ML PEN |
|
|
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2J |
|
HUMIRA 40 MG/0.4 ML SYRINGE |
|
|
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2J |
|
HUMIRA 40 MG/0.8 ML PEN |
|
|
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2J |
|
HUMIRA 40 MG/0.8 ML SYRINGE |
|
|
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2J |
|
HUMIRA CROHN'S STARTER PACK |
|
|
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
S2J |
|
HUMIRA PED CROHN'S 40 MG/0.8 ML |
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|||
|
S2J |
|
HUMIRA PED CROHNS 80 MG/0.8 ML |
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|||
|
S2J |
|
HUMIRA PED CROHN'S STARTER PK |
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|||
|
S2J |
|
HUMIRA PEDIATR CROHN'S |
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|||
|
S2J |
|
HUMIRA PEN |
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|||
|
S2J |
|
HUMIRA PEN |
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2J |
|
HUMIRA PSORIASIS STARTER PACK |
|
|
ADALIMUMAB |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
S2L |
|
|
|
|
||||||
|
S2L |
|
CELECOXIB 100 MG CAPSULE |
|
|
CELECOXIB |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2L |
|
CELECOXIB 200 MG CAPSULE |
|
|
CELECOXIB |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2L |
|
CELECOXIB 400 MG CAPSULE |
|
|
CELECOXIB |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
S2L |
|
CELECOXIB 50 MG CAPSULE |
|
|
CELECOXIB |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
S2T |
NSAIDS(COX |
|
|
|
||||||
|
S2T |
|
DICLOFENAC SODIUM/MISOPROSTOL |
0 |
|
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 161 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
S2T |
|
|
|
DICLOFENAC SODIUM/MISOPROSTOL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
T0I |
TOP. |
|
|
|
|
|
||||
|
T0I |
|
EUCRISA 2% OINTMENT |
|
|
CRISABOROLE |
0 |
999 |
|
No |
|
||
|
|
|
U5B |
|
|
HERBAL DRUGS |
|
|
|
|
|
|
|
|
U5B |
|
ALOE VERA 5,000 CONC SOFTGEL |
|
|
ALOE VERA |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
ALOE VERA 5,000 MG SOFTGEL |
|
|
ALOE VERA |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
CVS FLAXSEED OIL 1,000 MG CAPS |
|
|
FLAXSEED OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
FLAX SEED OIL 1,000 MG SFTG |
|
|
FLAXSEED OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
FLAX SEED OIL 1,000 MG SOFTGEL |
|
|
FLAXSEED OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
FLAX SEED OIL 1,000 MG SOFTGEL |
|
|
FLAXSEED OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
FLAXSEED OIL 1,000 MG CAP |
|
|
FLAXSEED OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
FLAXSEED OIL 1,000 MG SOFTGEL |
|
|
FLAXSEED OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
GNP FLAXSEED 1,000 MG SOFTGEL |
|
|
FLAXSEED OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
HM FLAXSEED OIL 1,000 MG SFTGL |
|
|
FLAXSEED OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
MILK THISTLE 140 MG CAPSULE |
|
|
MILK THISTLE SEED EXTRACT |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
MILK THISTLE 175 MG CAPSULE |
|
|
MILK THISTLE SEED EXTRACT |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
MILK THISTLE 175 MG TABLET |
|
|
MILK THISTLE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
MILK THISTLE 300 MG CAPSULE |
|
|
MILK THISTLE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
MILK THISTLE 500 MG CAPSULE |
|
|
MILK THISTLE |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
MILK THISTLE EXTRACT CAPSULE |
|
|
MILK THISTLE SEED EXTRACT |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
|
|
FLAXSEED OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
PROBIOTIC PLUS & CRANBERRY CAP |
|
|
CRAN/C/B.COAG/FOS/L.ACID/L.RHA |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
RA FLAXSEED OIL 1,000 MG SFTGL |
|
|
FLAXSEED OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
U5B |
|
SM FLAX OIL 1,000 MG SFTGL |
|
|
FLAXSEED OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 162 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
U5B |
|
SM FLAXSEED OIL 1,000 MG SFTGL |
FLAXSEED OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
U5B |
|
SPIRULINA 500 MG TABLET |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
U5B |
|
SV ALOE VERA 25 MG SOFTGEL |
ALOE VERA |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
U5B |
|
SV FLAXSEED OIL 1,000 MG SFTGL |
FLAXSEED OIL |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
U5B |
|
SV FLAXSEED OIL 1,300 MG SFTGL |
FLAXSEED OIL/OMEGA 3,6,9 |
0 |
999 |
|
Cystic Fib Diag Auto PA |
|
|||
|
|
|
V1A |
ANTINEOPLASTIC - ALKYLATING AGENTS |
|
|
|
|
|
|
||
|
V1A |
|
ALKERAN 2 MG TABLET |
MELPHALAN |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
BICNU 100 MG VIAL |
CARMUSTINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
BUSULFEX 6 MG/ML VIAL |
BUSULFAN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
BUSULFEX 60 MG/10 ML VIAL |
BUSULFAN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
CARBOPLATIN 150 MG/15 ML VIAL |
CARBOPLATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
CARBOPLATIN 450 MG/45 ML VIAL |
CARBOPLATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
CARBOPLATIN 50 MG/5 ML VIAL |
CARBOPLATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
CARBOPLATIN 600 MG/60 ML VIAL |
CARBOPLATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
CISPLATIN 1 MG/ML VIAL |
CISPLATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
CISPLATIN 100 MG/100 ML VIAL |
CISPLATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
CISPLATIN 200 MG/200 ML VIAL |
CISPLATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
CISPLATIN 50 MG/50 ML VIAL |
CISPLATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
CISPLATIN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
CYCLOPHOSPHAMIDE 1 GM VIAL |
CYCLOPHOSPHAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
CYCLOPHOSPHAMIDE 2 GM VIAL |
CYCLOPHOSPHAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
CYCLOPHOSPHAMIDE 25 MG CAPSULE |
CYCLOPHOSPHAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
CYCLOPHOSPHAMIDE 50 MG CAPSULE |
CYCLOPHOSPHAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
CYCLOPHOSPHAMIDE 500 MG VIAL |
CYCLOPHOSPHAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 163 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
V1A |
|
HYDROXYUREA 500 MG CAPSULE |
HYDROXYUREA |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
IFOSFAMIDE 1 GM VIAL |
IFOSFAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
IFOSFAMIDE 1 GM/ 20 ML VIAL |
IFOSFAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
IFOSFAMIDE 1 GM/20 ML VIAL |
IFOSFAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
IFOSFAMIDE 3 GM VIAL |
IFOSFAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
IFOSFAMIDE 3 GM/ 60 ML VIAL |
IFOSFAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
IFOSFAMIDE 3 GM/60 ML VIAL |
IFOSFAMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
IFOSFAMIDE/MESNA KIT |
IFOSFAMIDE/MESNA |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
LEUKERAN 2 MG TABLET |
CHLORAMBUCIL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
MELPHALAN 2 MG TABLET |
MELPHALAN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
MELPHALAN 50 MG VIAL |
MELPHALAN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
MELPHALAN HCL 50 MG VIAL |
MELPHALAN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
MYLERAN 2 MG TABLET |
BUSULFAN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
OXALIPLATIN 100 MG VIAL |
OXALIPLATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
OXALIPLATIN 100 MG/20 ML |
OXALIPLATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
OXALIPLATIN 100 MG/20 ML VIAL |
OXALIPLATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
OXALIPLATIN 50 MG VIAL |
OXALIPLATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
OXALIPLATIN 50 MG/10 ML VIAL |
OXALIPLATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
TEMODAR 100 MG VIAL |
TEMOZOLOMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
TEMOZOLOMIDE 100 MG CAPSULE |
TEMOZOLOMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
TEMOZOLOMIDE 140 MG CAPSULE |
TEMOZOLOMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
TEMOZOLOMIDE 180 MG CAPSULE |
TEMOZOLOMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
TEMOZOLOMIDE 20 MG CAPSULE |
TEMOZOLOMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
TEMOZOLOMIDE 250 MG CAPSULE |
TEMOZOLOMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 164 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
V1A |
|
TEMOZOLOMIDE 5 MG CAPSULE |
TEMOZOLOMIDE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
THIOTEPA 15 MG VIAL |
THIOTEPA |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
TREANDA 100 MG VIAL |
BENDAMUSTINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1A |
|
TREANDA 25 MG VIAL |
BENDAMUSTINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1B |
ANTINEOPLASTIC - ANTIMETABOLITES |
|
|
|
|
|
|
|
|
|
V1B |
|
ALIMTA 100 MG VIAL |
PEMETREXED DISODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
ALIMTA 500 MG VIAL |
PEMETREXED DISODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
AZACITIDINE 100 MG VIAL |
AZACITIDINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
CLADRIBINE 1 MG/ML VIAL |
CLADRIBINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
CLADRIBINE 10 MG/10 ML VIAL |
CLADRIBINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
CYTARABINE 100 MG/5 ML VIAL |
CYTARABINE/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
CYTARABINE 100 MG/ML VIAL |
CYTARABINE/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
CYTARABINE 1000 MG/50 ML VIAL |
CYTARABINE/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
CYTARABINE 2 G/20 ML VIAL |
CYTARABINE/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
CYTARABINE 20 MG/ML VIAL |
CYTARABINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
CYTARABINE 20 MG/ML VIAL |
CYTARABINE/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
DECITABINE 50 MG VIAL |
DECITABINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
FLOXURIDINE 500 MG VIAL |
FLOXURIDINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
FLUDARABINE 50 MG VIAL |
FLUDARABINE PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
FLUDARABINE 50 MG/2 ML VIAL |
FLUDARABINE PHOSPHATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
FLUOROURACIL 1,000 MG/20 ML VL |
FLUOROURACIL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
FLUOROURACIL 2,500 MG/50 ML VL |
FLUOROURACIL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
FLUOROURACIL 2.5 GM/50 ML BTL |
FLUOROURACIL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
FLUOROURACIL 2.5 GM/50 ML VIAL |
FLUOROURACIL |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 165 of 204 |
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Medicaid Drug Name |
|
Generic Name |
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Medicaid |
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Medicaid |
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Clinical PA Required |
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|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
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|
|
|
|
|||
|
V1B |
|
FLUOROURACIL 5 GM/100 ML BTL |
FLUOROURACIL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
FLUOROURACIL 5 GM/100 ML VIAL |
FLUOROURACIL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
FLUOROURACIL 5,000 MG/100 ML |
FLUOROURACIL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
FLUOROURACIL 50 MG/ML VIAL |
FLUOROURACIL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
FLUOROURACIL 500 MG/10 ML VIAL |
FLUOROURACIL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
GEMCITABINE 1 GRAM/26.3 ML VL |
GEMCITABINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
GEMCITABINE 2 GRAM/52.6 ML VL |
GEMCITABINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
GEMCITABINE 200 MG/5.26 ML VL |
GEMCITABINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
GEMCITABINE HCL 1 GRAM VIAL |
GEMCITABINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
GEMCITABINE HCL 1 GRAM/10 ML |
GEMCITABINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
GEMCITABINE HCL 1.5 GRAM/15 ML |
GEMCITABINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
GEMCITABINE HCL 2 GRAM VIAL |
GEMCITABINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
GEMCITABINE HCL 2 GRAM/20 ML |
GEMCITABINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
GEMCITABINE HCL 200 MG VIAL |
GEMCITABINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
GEMCITABINE HCL 200 MG/2 ML VL |
GEMCITABINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
MERCAPTOPURINE 50 MG TABLET |
MERCAPTOPURINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
METHOTREXATE 1 GM VIAL |
METHOTREXATE SODIUM/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
METHOTREXATE 1 GRAM/40 ML VIAL |
METHOTREXATE SODIUM/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
METHOTREXATE 100 MG/4 ML VIAL |
METHOTREXATE SODIUM/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
METHOTREXATE 2.5 MG TABLET |
METHOTREXATE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
METHOTREXATE 200 MG/8 ML VIAL |
METHOTREXATE SODIUM/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
METHOTREXATE 25 MG/ML VIAL |
METHOTREXATE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
METHOTREXATE 25 MG/ML VIAL |
METHOTREXATE SODIUM/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
METHOTREXATE 250 MG/10 ML VIAL |
METHOTREXATE SODIUM/PF |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 166 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
METHOTREXATE 50 MG/2 ML VIAL |
METHOTREXATE SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
METHOTREXATE 50 MG/2 ML VIAL |
METHOTREXATE SODIUM/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
XELODA 150 MG TABLET |
CAPECITABINE |
18 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1B |
|
XELODA 500 MG TABLET |
CAPECITABINE |
18 |
999 |
|
No |
|
|||
|
|
|
V1C |
ANTINEOPLASTIC - VINCA ALKALOIDS |
|
|
|
|
|
|
|
|
|
V1C |
|
VINBLASTINE 1 MG/ML VIAL |
VINBLASTINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1C |
|
VINCRISTINE 1 MG/ML VIAL |
VINCRISTINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1C |
|
VINCRISTINE 2 MG/2 ML VIAL |
VINCRISTINE SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1C |
|
VINORELBINE 10 MG/ML VIAL |
VINORELBINE TARTRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1C |
|
VINORELBINE 50 MG/5 ML VIAL |
VINORELBINE TARTRATE |
0 |
999 |
|
No |
|
|||
|
|
|
V1D |
ANTIBIOTIC ANTINEOPLASTICS |
|
|
|
|
|
|
|
|
|
V1D |
|
BLEOMYCIN SULFATE 15 UNIT VIAL |
BLEOMYCIN SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
BLEOMYCIN SULFATE 15 UNITS VIA |
BLEOMYCIN SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
BLEOMYCIN SULFATE 30 UNIT VIAL |
BLEOMYCIN SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
BLEOMYCIN SULFATE 30 UNITS VIA |
BLEOMYCIN SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DAUNORUBICIN 20 MG VIAL |
DAUNORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DAUNORUBICIN 20 MG/4 ML VIAL |
DAUNORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DAUNORUBICIN 50 MG/10 ML VIAL |
DAUNORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DAUNORUBICIN HCL 20 MG VIAL |
DAUNORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DOXORUBICIN 10 MG VIAL |
DOXORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DOXORUBICIN 10 MG/5 ML VIAL |
DOXORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DOXORUBICIN 150 MG/75 ML VIAL |
DOXORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DOXORUBICIN 2 MG/ML VIAL |
DOXORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DOXORUBICIN 20 MG/10 ML VIAL |
DOXORUBICIN HCL |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 167 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DOXORUBICIN 20 MG/10 ML VIAL |
DOXORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DOXORUBICIN 200 MG/100 ML VIAL |
DOXORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DOXORUBICIN 50 MG VIAL |
DOXORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DOXORUBICIN 50 MG/25 ML VIAL |
DOXORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DOXORUBICIN 50 MG/25 ML VIAL |
DOXORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DOXORUBICIN LIPOSOME 20MG/10ML |
DOXORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
DOXORUBICIN LIPOSOME 50MG/25ML |
DOXORUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
EPIRUBICIN 200 MG/100 ML VIAL |
EPIRUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
EPIRUBICIN 50 MG/25 ML VIAL |
EPIRUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
EPIRUBICIN HCL 200 MG VIAL |
EPIRUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
IDARUBICIN HCL 1 MG/ML VIAL |
IDARUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
IDARUBICIN HCL 10 MG/10 ML VL |
IDARUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
IDARUBICIN HCL 20 MG/20 ML VL |
IDARUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
IDARUBICIN HCL 5 MG/5 ML VIAL |
IDARUBICIN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
MITOMYCIN 20 MG VIAL |
MITOMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
MITOMYCIN 40 MG VIAL |
MITOMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
MITOMYCIN 5 MG VIAL |
MITOMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
MUTAMYCIN 20 MG VIAL |
MITOMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
MUTAMYCIN 40 MG VIAL |
MITOMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
MUTAMYCIN 5 MG VIAL |
MITOMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1D |
|
VALSTAR 40 MG/ML VIAL |
VALRUBICIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1E |
STEROID ANTINEOPLASTICS |
|
|
|
|
|
|
|
|
|
V1E |
|
MEGESTROL 20 MG TABLET |
MEGESTROL ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V1E |
|
MEGESTROL 40 MG TABLET |
MEGESTROL ACETATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
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Thursday, October 25, 2018 |
Page 168 of 204 |
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1F |
ANTINEOPLASTICS,MISCELLANEOUS |
|
|
|
V1F |
DACARBAZINE 100 MG VIAL |
DACARBAZINE |
0 |
999 |
No |
|
|
|
|
|
|
V1F |
DACARBAZINE 200 MG VIAL |
DACARBAZINE |
0 |
999 |
No |
|
|
|
|
|
|
V1F |
DOCETAXEL 160 MG/16 ML VIAL |
DOCETAXEL |
18 |
999 |
No |
|
|
|
|
|
|
V1F |
DOCETAXEL 160 MG/8 ML VIAL |
DOCETAXEL |
18 |
999 |
No |
|
|
|
|
|
|
V1F |
DOCETAXEL 20 MG/2 ML VIAL |
DOCETAXEL |
18 |
999 |
No |
|
|
|
|
|
|
V1F |
DOCETAXEL 20 MG/ML VIAL |
DOCETAXEL |
18 |
999 |
No |
|
|
|
|
|
|
V1F |
DOCETAXEL 200 MG/10 ML VIAL |
DOCETAXEL |
18 |
999 |
No |
|
|
|
|
|
|
V1F |
DOCETAXEL 80 MG/4 ML VIAL |
DOCETAXEL |
18 |
999 |
No |
|
|
|
|
|
|
V1F |
DOCETAXEL 80 MG/8 ML VIAL |
DOCETAXEL |
18 |
999 |
No |
|
|
|
|
|
|
V1F |
ETOPOSIDE 1,000 MG/50 ML VIAL |
ETOPOSIDE |
0 |
999 |
No |
|
|
|
|
|
|
V1F |
ETOPOSIDE 100 MG/5 ML VIAL |
ETOPOSIDE |
0 |
999 |
No |
|
|
|
|
|
|
V1F |
ETOPOSIDE 20 MG/ML VIAL |
ETOPOSIDE |
0 |
999 |
No |
|
|
|
|
|
|
V1F |
ETOPOSIDE 500 MG/25 ML VIAL |
ETOPOSIDE |
0 |
999 |
No |
|
|
|
|
|
|
V1F |
MATULANE 50 MG CAPSULE |
PROCARBAZINE HCL |
0 |
999 |
No |
|
|
|
|
|
|
V1F |
MITOXANTRONE 20 MG/10 ML VIAL |
MITOXANTRONE HCL |
18 |
999 |
No |
|
|
|
|
|
|
V1F |
MITOXANTRONE 20 MG/10 ML VL |
MITOXANTRONE HCL |
18 |
999 |
No |
|
|
|
|
|
|
V1F |
MITOXANTRONE 25 MG/12.5 ML VL |
MITOXANTRONE HCL |
18 |
999 |
No |
|
|
|
|
|
|
V1F |
MITOXANTRONE 30 MG/15 ML VIAL |
MITOXANTRONE HCL |
18 |
999 |
No |
|
|
|
|
|
|
V1F |
MITOXANTRONE 30 MG/15 ML VL |
MITOXANTRONE HCL |
18 |
999 |
No |
|
|
|
|
|
|
V1F |
ONCASPAR 3,750 UNIT/5 ML VIAL |
PEGASPARGASE |
0 |
999 |
No |
|
|
|
|
|
|
V1F |
PACLITAXEL 100 MG/16.7 ML VIAL |
PACLITAXEL |
0 |
999 |
No |
|
|
|
|
|
|
V1F |
PACLITAXEL 150 MG/25 ML VIAL |
PACLITAXEL |
0 |
999 |
No |
|
|
|
|
|
|
V1F |
PACLITAXEL 30 MG/5 ML VIAL |
PACLITAXEL |
0 |
999 |
No |
Thursday, October 25, 2018 |
Page 169 of 204 |
|
Class |
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Medicaid Drug Name |
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Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
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|
Min Age |
|
Max Age |
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||
|
V1F |
|
PACLITAXEL 300 MG/50 ML VIAL |
|
|
PACLITAXEL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1F |
|
PACLITAXEL 6 MG/ML VIAL |
|
|
PACLITAXEL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1F |
|
TRETINOIN 10 MG CAPSULE |
|
|
TRETINOIN |
1 |
999 |
|
No |
|
||
|
|
|
|
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|
|
|
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|
|
||
|
V1F |
|
TRISENOX 10 MG/10 ML AMPULE |
|
|
ARSENIC TRIOXIDE |
0 |
999 |
|
No |
|
||
|
|
|
V1I |
CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS |
|
|
|
|
|
||||
|
V1I |
|
AMIFOSTINE 500 MG VIAL |
|
|
AMIFOSTINE CRYSTALLINE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
DEXRAZOXANE 250 MG VIAL |
|
|
DEXRAZOXANE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
DEXRAZOXANE 500 MG VIAL |
|
|
DEXRAZOXANE HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
LEUCOVORIN CALCIUM 10 MG TAB |
|
|
LEUCOVORIN CALCIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
LEUCOVORIN CALCIUM 100 MG VIAL |
|
|
LEUCOVORIN CALCIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
LEUCOVORIN CALCIUM 100 MG VL |
|
|
LEUCOVORIN CALCIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
LEUCOVORIN CALCIUM 15 MG TAB |
|
|
LEUCOVORIN CALCIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
LEUCOVORIN CALCIUM 200 MG VIAL |
|
|
LEUCOVORIN CALCIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
LEUCOVORIN CALCIUM 25 MG TAB |
|
|
LEUCOVORIN CALCIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
LEUCOVORIN CALCIUM 350 MG VIAL |
|
|
LEUCOVORIN CALCIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
LEUCOVORIN CALCIUM 350 MG VL |
|
|
LEUCOVORIN CALCIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
LEUCOVORIN CALCIUM 5 MG TAB |
|
|
LEUCOVORIN CALCIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
LEUCOVORIN CALCIUM 50 MG VIAL |
|
|
LEUCOVORIN CALCIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
LEUCOVORIN CALCIUM 500 MG VL |
|
|
LEUCOVORIN CALCIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
MESNA 1 GRAM/10 ML VIAL |
|
|
MESNA |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1I |
|
MESNA 100 MG/ML VIAL |
|
|
MESNA |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
V1J |
ANTINEOPLASTIC - ANTIANDROGENIC AGENTS |
|
|
|
|
|
||||
|
V1J |
|
BICALUTAMIDE 50 MG TABLET |
|
|
BICALUTAMIDE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1J |
|
FLUTAMIDE 125 MG CAPSULE |
|
|
FLUTAMIDE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
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|
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|
Thursday, October 25, 2018 |
Page 170 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
V1J |
|
NILUTAMIDE 150 MG TABLET |
|
|
NILUTAMIDE |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1J |
|
XTANDI 40 MG CAPSULE |
|
|
ENZALUTAMIDE |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1J |
|
ZYTIGA 250 MG TABLET |
|
|
ABIRATERONE ACETATE |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1J |
|
ZYTIGA 500 MG TABLET |
|
|
ABIRATERONE ACETATE |
18 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
V1K |
ANTINEOPLASTICS |
|
|
|
||||||
|
V1K |
|
CAMPATH 30 MG/ML VIAL |
|
|
ALEMTUZUMAB |
0 |
|
999 |
|
No |
|
|
|
|
|
V1M |
ANTINEOPLASTIC IMMUNOMODULATOR AGENTS |
|
|
|
|
|||||
|
V1M |
|
POMALYST 1 MG CAPSULE |
|
|
POMALIDOMIDE |
18 |
|
999 |
|
Requires Med Cert 3 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1M |
|
POMALYST 2 MG CAPSULE |
|
|
POMALIDOMIDE |
18 |
|
999 |
|
Requires Med Cert 3 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1M |
|
POMALYST 3 MG CAPSULE |
|
|
POMALIDOMIDE |
18 |
|
999 |
|
Requires Med Cert 3 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1M |
|
POMALYST 4 MG CAPSULE |
|
|
POMALIDOMIDE |
18 |
|
999 |
|
Requires Med Cert 3 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1M |
|
REVLIMID 10 MG CAPSULE |
|
|
LENALIDOMIDE |
18 |
|
999 |
|
Requires Med Cert 3 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1M |
|
REVLIMID 15 MG CAPSULE |
|
|
LENALIDOMIDE |
18 |
|
999 |
|
Requires Med Cert 3 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1M |
|
REVLIMID 2.5 MG CAPSULE |
|
|
LENALIDOMIDE |
18 |
|
999 |
|
Requires Med Cert 3 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1M |
|
REVLIMID 20 MG CAPSULE |
|
|
LENALIDOMIDE |
18 |
|
999 |
|
Requires Med Cert 3 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1M |
|
REVLIMID 25 MG CAPSULE |
|
|
LENALIDOMIDE |
18 |
|
999 |
|
Requires Med Cert 3 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1M |
|
REVLIMID 5 MG CAPSULE |
|
|
LENALIDOMIDE |
18 |
|
999 |
|
Requires Med Cert 3 |
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
V1O |
ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. |
|
|
|
|
|||||
|
V1O |
|
LEUPROLIDE 2WK 1 MG/0.2 ML KIT |
|
|
LEUPROLIDE ACETATE |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1O |
|
LEUPROLIDE 2WK 14 MG/2.8 ML VL |
|
|
LEUPROLIDE ACETATE |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1O |
|
LUPRON DEPOT 22.5 MG 3MO KIT |
|
|
LEUPROLIDE ACETATE |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1O |
|
LUPRON DEPOT 45 MG 6MO KIT |
|
|
LEUPROLIDE ACETATE |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1O |
|
LUPRON DEPOT 7.5 MG KIT |
|
|
LEUPROLIDE ACETATE |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1O |
|
LUPRON |
|
|
LEUPROLIDE ACETATE |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
V1O |
|
ZOLADEX 10.8 MG IMPLANT SYRN |
|
|
GOSERELIN ACETATE |
18 |
|
999 |
|
Auto PA |
|
Thursday, October 25, 2018 |
Page 171 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1O |
|
ZOLADEX 3.6 MG IMPLANT SYRN |
|
|
GOSERELIN ACETATE |
18 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
V1Q |
ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS |
|
|
|
|
|
||||
|
V1Q |
|
CAPRELSA 100 MG TABLET |
|
|
VANDETANIB |
18 |
999 |
|
Requires Med Cert 3 |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1Q |
|
CAPRELSA 300 MG TABLET |
|
|
VANDETANIB |
18 |
999 |
|
Requires Med Cert 3 |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1Q |
|
GLEEVEC 100 MG TABLET |
|
|
IMATINIB MESYLATE |
1 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1Q |
|
GLEEVEC 400 MG TABLET |
|
|
IMATINIB MESYLATE |
1 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1Q |
|
IRESSA 250 MG TABLET |
|
|
GEFITINIB |
18 |
999 |
|
Requires Med Cert 3 |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1Q |
|
NEXAVAR 200 MG TABLET |
|
|
SORAFENIB TOSYLATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1Q |
|
SUTENT 12.5 MG CAPSULE |
|
|
SUNITINIB MALATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1Q |
|
SUTENT 25 MG CAPSULE |
|
|
SUNITINIB MALATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1Q |
|
SUTENT 37.5 MG CAPSULE |
|
|
SUNITINIB MALATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1Q |
|
SUTENT 50 MG CAPSULE |
|
|
SUNITINIB MALATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1Q |
|
VELCADE 3.5 MG VIAL |
|
|
BORTEZOMIB |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1Q |
|
VOTRIENT 200 MG TABLET |
|
|
PAZOPANIB HCL |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
V1T |
SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS) |
|
|
|
|
|
||||
|
V1T |
|
SOLTAMOX 20 MG/10 ML SOLN |
|
|
TAMOXIFEN CITRATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1T |
|
TAMOXIFEN 10 MG TABLET |
|
|
TAMOXIFEN CITRATE |
18 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V1T |
|
TAMOXIFEN 20 MG TABLET |
|
|
TAMOXIFEN CITRATE |
18 |
999 |
|
No |
|
||
|
|
|
V3C |
ANTINEOPLASTIC - MTOR KINASE INHIBITORS |
|
|
|
|
|
||||
|
V3C |
|
TEMSIROLIMUS 25 MG VIAL |
|
|
TEMSIROLIMUS |
0 |
999 |
|
No |
|
||
|
|
|
V3E |
ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS |
|
|
|
|
|
||||
|
V3E |
|
IRINOTECAN HCL 100 MG/5 ML VL |
|
|
IRINOTECAN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V3E |
|
IRINOTECAN HCL 20 MG/ML VIAL |
|
|
IRINOTECAN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V3E |
|
IRINOTECAN HCL 40 MG/2 ML VIAL |
|
|
IRINOTECAN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
V3E |
|
IRINOTECAN HCL 500 MG/25 ML VL |
|
|
IRINOTECAN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 172 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
V3E |
|
TOPOTECAN HCL 4 MG VIAL |
TOPOTECAN HCL |
6 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V3E |
|
TOPOTECAN HCL 4 MG VIAL |
TOPOTECAN HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
V3E |
|
TOPOTECAN HCL 4 MG/4 ML VIAL |
TOPOTECAN HCL |
0 |
999 |
|
No |
|
|
V3F |
ANTINEOPLASTIC - AROMATASE INHIBITORS |
|
|
V3F |
ANASTROZOLE 1 MG TABLET |
ANASTROZOLE |
18 |
999 |
V3F |
EXEMESTANE 25 MG TABLET |
EXEMESTANE |
18 |
999 |
V3F |
LETROZOLE 2.5 MG TABLET |
LETROZOLE |
18 |
999 |
|
V3I |
ANTINEOPLASTIC - HALICHONDRIN B ANALOGS |
|
|
V3I |
HALAVEN 1 MG/2 ML VIAL |
ERIBULIN MESYLATE |
0 |
999 |
|
W0E |
HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMB |
|
|
W0E |
MAVYRET |
GLECAPREVIR/PIBRENTASVIR |
18 |
999 |
|
W0G |
HEP C - NS5A, NS3/4A, NUCLEOTIDE NS5B INHIB COMBO |
|
|
W0G |
VOSEVI |
SOFOSBUVIR/VELPATAS/VOXILAPREV |
18 |
999 |
|
W0H |
|||
W0H |
SYMTUZA |
DARUNAVIR/COB/EMTRI/TENOF ALAF |
0 |
999 |
|
W0I |
|||
W0I |
JULUCA |
DOLUTEGRAVIR/RILPIVIRINE |
18 |
999 |
|
W0J |
ANTIRETROVIRAL - |
|
|
W0J |
TROGARZO 200 MG/1.33 ML VIAL |
18 |
999 |
|
|
W1A |
PENICILLIN ANTIBIOTICS |
|
|
W1A |
AMOX |
AMOXICILLIN/POTASSIUM CLAV |
0 |
999 |
W1A |
AMOX |
AMOXICILLIN/POTASSIUM CLAV |
0 |
999 |
W1A |
AMOX |
AMOXICILLIN/POTASSIUM CLAV |
0 |
999 |
W1A |
AMOX |
AMOXICILLIN/POTASSIUM CLAV |
0 |
999 |
W1A |
AMOX |
AMOXICILLIN/POTASSIUM CLAV |
0 |
999 |
W1A |
AMOX |
AMOXICILLIN/POTASSIUM CLAV |
0 |
999 |
No
No
No
No
Clinical PA Required
Clinical PA Required
Auto PA
Auto PA
Clinical PA Required
No
No
No
No
No
No
Thursday, October 25, 2018 |
Page 173 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
W1A |
|
AMOX |
AMOXICILLIN/POTASSIUM CLAV |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMOXICILLIN/POTASSIUM CLAV |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMOXICILLIN/POTASSIUM CLAV |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMOXICILLIN/POTASSIUM CLAV |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMOXICILLIN 125 MG TAB CHEW |
AMOXICILLIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMOXICILLIN 125 MG/5 ML SUSP |
AMOXICILLIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMOXICILLIN 200 MG/5 ML SUSP |
AMOXICILLIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMOXICILLIN 250 MG CAPSULE |
AMOXICILLIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMOXICILLIN 250 MG TAB CHEW |
AMOXICILLIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMOXICILLIN 250 MG/ 5 ML SUSP |
AMOXICILLIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMOXICILLIN 250 MG/5 ML SUSP |
AMOXICILLIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMOXICILLIN 400 MG/5 ML SUSP |
AMOXICILLIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMOXICILLIN 500 MG CAPSULE |
AMOXICILLIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMOXICILLIN 500 MG TABLET |
AMOXICILLIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMOXICILLIN 875 MG TABLET |
AMOXICILLIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN 1 GM A/V VIAL |
AMPICILLIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN 1 GM |
AMPICILLIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN 1 GM VIAL |
AMPICILLIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN 10 GM BOTTLE |
AMPICILLIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN 10 GM VIAL |
AMPICILLIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN 125 MG VIAL |
AMPICILLIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN 2 GM A/V VIAL |
AMPICILLIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN 2 GM |
AMPICILLIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN 2 GM |
AMPICILLIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 174 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
W1A |
|
AMPICILLIN 2 GM VIAL |
AMPICILLIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN 250 MG VIAL |
AMPICILLIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN 500 MG VIAL |
AMPICILLIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN TR 500 MG CAPSULE |
AMPICILLIN TRIHYDRATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN SODIUM/SULBACTAM NA |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN SODIUM/SULBACTAM NA |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN SODIUM/SULBACTAM NA |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
AMPICILLIN SODIUM/SULBACTAM NA |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
BICILLIN |
PEN G BENZ/PEN G PROCAINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
BICILLIN |
PEN G BENZ/PEN G PROCAINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
BICILLIN |
PEN G BENZ/PEN G PROCAINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
BICILLIN |
PEN G BENZ/PEN G PROCAINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
BICILLIN LA 1,200,000 UNITS |
PENICILLIN G BENZATHINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
BICILLIN |
PENICILLIN G BENZATHINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
BICILLIN LA 2,400,000 UNITS |
PENICILLIN G BENZATHINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
BICILLIN |
PENICILLIN G BENZATHINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
BICILLIN LA 600,000 UNIT/ML |
PENICILLIN G BENZATHINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
BICILLIN |
PENICILLIN G BENZATHINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
DICLOXACILLIN 250 MG CAPSULE |
DICLOXACILLIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
DICLOXACILLIN 500 MG CAPSULE |
DICLOXACILLIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
PEN G 1.2 MILLION UNIT/2 ML |
PENICILLIN G PROCAINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
PENICILLIN G 1.2MM UNITS/2 ML |
PENICILLIN G PROCAINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
PENICILLIN G 600,000 UNIT/1 ML |
PENICILLIN G PROCAINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
PENICILLIN G 600M UNITS/1 ML |
PENICILLIN G PROCAINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 175 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
W1A |
|
PENICILLIN G SOD 5MM UNITS VIA |
PENICILLIN G SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
PENICILLIN G SOD 5MM UNITS VL |
PENICILLIN G SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
PENICILLIN VK 125 MG/5 ML LIQ |
PENICILLIN V POTASSIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
PENICILLIN VK 250 MG TABLET |
PENICILLIN V POTASSIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
PENICILLIN VK 250 MG/5 ML LIQ |
PENICILLIN V POTASSIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
PENICILLIN VK 500 MG TABLET |
PENICILLIN V POTASSIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
PIPERACILLIN SODIUM/TAZOBACTAM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
PIPERACILLIN SODIUM/TAZOBACTAM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
PIPERACILLIN SODIUM/TAZOBACTAM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
PIPERACILLIN SODIUM/TAZOBACTAM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W1A |
|
PIPERACILLIN SODIUM/TAZOBACTAM |
0 |
999 |
|
No |
|
||||
|
|
|
W1C |
TETRACYCLINE ANTIBIOTICS |
|
|
|
|
|
|
|
|
|
W1C |
|
DOXYCYCLINE 100 MG CAPSULE |
DOXYCYCLINE HYCLATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1C |
|
DOXYCYCLINE 100 MG TABLET |
DOXYCYCLINE HYCLATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1C |
|
DOXYCYCLINE 50 MG CAPSULE |
DOXYCYCLINE HYCLATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1C |
|
DOXYCYCLINE HYC DR 200 MG TAB |
DOXYCYCLINE HYCLATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1C |
|
DOXYCYCLINE HYC DR 50 MG TAB |
DOXYCYCLINE HYCLATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1C |
|
DOXYCYCLINE HYCLATE 100 MG CAP |
DOXYCYCLINE HYCLATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1C |
|
DOXYCYCLINE HYCLATE 100 MG TAB |
DOXYCYCLINE HYCLATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1C |
|
DOXYCYCLINE HYCLATE 50 MG CAP |
DOXYCYCLINE HYCLATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1C |
|
MINOCYCLINE 100 MG CAPSULE |
MINOCYCLINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1C |
|
MINOCYCLINE 50 MG CAPSULE |
MINOCYCLINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1C |
|
MINOCYCLINE 75 MG CAPSULE |
MINOCYCLINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1C |
|
TETRACYCLINE 250 MG CAPSULE |
TETRACYCLINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 176 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
W1C |
|
TETRACYCLINE 500 MG CAPSULE |
TETRACYCLINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
W1D |
MACROLIDE ANTIBIOTICS |
|
|
|
|
|
|
|
|
|
W1D |
|
AZITHROMYCIN 1 GM PWD PACKET |
AZITHROMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1D |
|
AZITHROMYCIN 100 MG/5 ML SUSP |
AZITHROMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1D |
|
AZITHROMYCIN 200 MG/5 ML SUSP |
AZITHROMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1D |
|
AZITHROMYCIN 250 MG TABLET |
AZITHROMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1D |
|
AZITHROMYCIN 500 MG TABLET |
AZITHROMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1D |
|
AZITHROMYCIN 600 MG TABLET |
AZITHROMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1D |
|
AZITHROMYCIN I.V. 500 MG VIAL |
AZITHROMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1D |
|
CLARITHROMYCIN 125 MG/5 ML SUS |
CLARITHROMYCIN |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1D |
|
CLARITHROMYCIN 250 MG TABLET |
CLARITHROMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1D |
|
CLARITHROMYCIN 250 MG/5 ML SUS |
CLARITHROMYCIN |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1D |
|
CLARITHROMYCIN 500 MG TABLET |
CLARITHROMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1D |
|
CLARITHROMYCIN ER 500 MG TAB |
CLARITHROMYCIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1D |
|
E.E.S. 200 MG/5 ML GRANULES |
ERYTHROMYCIN ETHYLSUCCINATE |
0 |
999 |
|
No |
|
|||
|
|
|
W1F |
AMINOGLYCOSIDE ANTIBIOTICS |
|
|
|
|
|
|
|
|
|
W1F |
|
GENTAMICIN 40 MG/ML VIAL |
GENTAMICIN SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1F |
|
GENTAMICIN 70 MG/NS 50 ML PB |
GENTAMICIN IN NACL, |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1F |
|
GENTAMICIN 80 MG/2 ML VIAL |
GENTAMICIN SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1F |
|
GENTAMICIN 800 MG/20 ML VIAL |
GENTAMICIN SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1F |
|
GENTAMICIN PED 10 MG/ML VIAL |
GENTAMICIN SULFATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1F |
|
GENTAMICIN PED 10 MG/ML VIAL |
GENTAMICIN SULFATE/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1F |
|
GENTAMICIN PED 20 MG/2 ML VIAL |
GENTAMICIN SULFATE/PF |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W1F |
|
ISO GENTAMICIN 100 MG/100 ML |
GENTAMICIN IN NACL, |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 177 of 204 |
Class |
Medicaid Drug Name |
|
|
W1F |
ISO GENTAMICIN 120 MG/100 ML |
W1F |
ISOTON GENTAMICIN 100 MG/50 ML |
W1F |
ISOTON GENTAMICIN 60 MG/50 ML |
W1F |
ISOTON GENTAMICIN 80 MG/100 ML |
W1F |
ISOTON GENTAMICIN 80 MG/50 ML |
W1F |
KITABIS PAK 300 MG/5 ML |
W1F |
NEOMYCIN 500 MG TABLET |
W1F |
TOBI 300 MG/5 ML SOLUTION |
W1F |
TOBRAMYCIN 10 MG/ML VIAL |
W1F |
TOBRAMYCIN 40 MG/ML VIAL |
W1F |
TOBRAMYCIN 80 MG/2 ML VIAL |
|
W1G |
W1G |
RIFAMPIN 150 MG CAPSULE |
W1G |
RIFAMPIN 300 MG CAPSULE |
W1G |
RIFAMPIN IV 600 MG VIAL |
|
W1J |
W1J |
VANCOMYCIN 1 GM |
W1J |
VANCOMYCIN 1 GM VIAL |
W1J |
VANCOMYCIN 5 GM VIAL |
W1J |
VANCOMYCIN 500 MG A/V VIAL |
W1J |
VANCOMYCIN 500 MG VIAL |
W1J |
VANCOMYCIN 750 MG VIAL |
W1J |
VANCOMYCIN HCL 1 GM VIAL |
W1J |
VANCOMYCIN HCL 10 GM VIAL |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
Min Age |
|
Max Age |
|
|
|
GENTAMICIN IN NACL, |
0 |
999 |
|
No |
||
|
GENTAMICIN IN NACL, |
0 |
999 |
|
No |
||
|
GENTAMICIN IN NACL, |
0 |
999 |
|
No |
||
|
GENTAMICIN IN NACL, |
0 |
999 |
|
No |
||
|
GENTAMICIN IN NACL, |
0 |
999 |
|
No |
||
|
TOBRAMYCIN/NEBULIZER |
0 |
999 |
|
Auto PA |
||
|
NEOMYCIN SULFATE |
0 |
999 |
|
No |
||
|
TOBRAMYCIN IN 0.225% SOD CHLOR |
0 |
999 |
|
Auto PA |
||
|
TOBRAMYCIN SULFATE |
0 |
999 |
|
No |
||
|
TOBRAMYCIN SULFATE |
0 |
999 |
|
No |
||
|
TOBRAMYCIN SULFATE |
0 |
999 |
|
No |
||
|
ANTITUBERCULAR ANTIBIOTICS |
|
|
|
|
|
|
|
RIFAMPIN |
0 |
999 |
|
No |
||
|
RIFAMPIN |
0 |
999 |
|
No |
||
|
RIFAMPIN |
0 |
999 |
|
No |
||
VANCOMYCIN ANTIBIOTICS AND DERIVATIVES |
|
|
|
|
|||
|
VANCOMYCIN HCL |
0 |
999 |
|
No |
||
|
VANCOMYCIN HCL |
0 |
999 |
|
No |
||
|
VANCOMYCIN HCL |
0 |
999 |
|
No |
||
|
VANCOMYCIN HCL |
0 |
999 |
|
No |
||
|
VANCOMYCIN HCL |
0 |
999 |
|
No |
||
|
VANCOMYCIN HCL |
0 |
999 |
|
No |
||
|
VANCOMYCIN HCL |
0 |
999 |
|
No |
||
|
VANCOMYCIN HCL |
0 |
999 |
|
No |
Thursday, October 25, 2018 |
Page 178 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
W1J |
|
VANCOMYCIN HCL 125 MG CAPSULE |
|
VANCOMYCIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1J |
|
VANCOMYCIN HCL 250 MG CAPSULE |
|
VANCOMYCIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1J |
|
VANCOMYCIN HCL 250 MG VIAL |
|
VANCOMYCIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1J |
|
VANCOMYCIN HCL 5 GM VIAL |
|
VANCOMYCIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1J |
|
VANCOMYCIN HCL 750 MG VIAL |
|
VANCOMYCIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
W1K |
|
LINCOSAMIDE ANTIBIOTICS |
|
|
|
|
|
|
|
|
W1K |
|
CLINDAMYCIN 300 MG/2 ML ADDVAN |
|
CLINDAMYCIN PHOSPHATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN 600 MG/4 ML ADDVAN |
|
CLINDAMYCIN PHOSPHATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN 75 MG/5 ML SOLN |
|
CLINDAMYCIN PALMITATE HCL |
0 |
11 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN 900 MG/6 ML ADDVAN |
|
CLINDAMYCIN PHOSPHATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN HCL 150 MG CAP |
|
CLINDAMYCIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN HCL 150 MG CAPS |
|
CLINDAMYCIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN HCL 150 MG CAPSULE |
|
CLINDAMYCIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN HCL 300 MG CAPS |
|
CLINDAMYCIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN HCL 300 MG CAPSULE |
|
CLINDAMYCIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN HCL 75 MG CAPSULE |
|
CLINDAMYCIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN PEDIATR 75 MG/5 ML |
|
CLINDAMYCIN PALMITATE HCL |
0 |
11 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN PH 150 MG/ML VIAL |
|
CLINDAMYCIN PHOSPHATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN PH 300 MG/2 ML VL |
|
CLINDAMYCIN PHOSPHATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN PH 600 MG/4 ML VL |
|
CLINDAMYCIN PHOSPHATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN PH 9 G/60 ML VIAL |
|
CLINDAMYCIN PHOSPHATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
CLINDAMYCIN PH 900 MG/6 ML VL |
|
CLINDAMYCIN PHOSPHATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
||
|
W1K |
|
LINCOCIN 300 MG/ML VIAL |
|
LINCOMYCIN HCL |
0 |
999 |
|
No |
|
||
|
|
|
W1N |
POLYMYXIN ANTIBIOTICS AND DERIVATIVES |
|
|
|
|
|
Thursday, October 25, 2018 |
Page 179 of 204 |
Class |
|
Medicaid Drug Name |
|
|
|
W1N |
|
COLISTIMETHATE 150 MG VIAL |
W1N |
|
POLYMYXIN B SULFATE VIAL |
|
|
W1P |
W1P |
|
AZACTAM 1 GM VIAL |
W1P |
|
AZACTAM 2 GM VIAL |
W1P |
|
|
W1P |
|
|
|
|
W1Q |
W1Q |
|
CIPRO 10% SUSPENSION |
W1Q |
|
CIPRO 5% SUSPENSION |
W1Q |
|
CIPROFLOXACIN 10 MG/ML VIAL |
W1Q |
|
CIPROFLOXACIN 200 MG/100 ML |
W1Q |
|
CIPROFLOXACIN 400 MG/200 ML |
W1Q |
|
CIPROFLOXACIN 500 MG TABLET |
W1Q |
|
CIPROFLOXACIN HCL 100 MG TAB |
W1Q |
|
CIPROFLOXACIN HCL 250 MG TAB |
W1Q |
|
CIPROFLOXACIN HCL 500 MG TAB |
W1Q |
|
CIPROFLOXACIN HCL 750 MG TAB |
W1Q |
|
|
W1Q |
|
LEVOFLOXACIN 250 MG TABLET |
W1Q |
|
LEVOFLOXACIN 250 MG/50 |
W1Q |
|
LEVOFLOXACIN 500 MG TABLET |
W1Q |
|
LEVOFLOXACIN 500 MG/100 |
W1Q |
|
LEVOFLOXACIN 750 MG TABLET |
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
Min Age |
|
Max Age |
|
|
COLISTIN (COLISTIMETHATE NA) |
0 |
999 |
|
No |
||
POLYMYXIN B SULFATE |
0 |
999 |
|
No |
||
BETALACTAMS |
|
|
|
|
|
|
AZTREONAM |
0 |
999 |
|
No |
||
AZTREONAM |
0 |
999 |
|
No |
||
0 |
999 |
|
No |
|||
0 |
999 |
|
No |
|||
QUINOLONE ANTIBIOTICS |
|
|
|
|
|
|
CIPROFLOXACIN |
0 |
11 |
|
No |
||
CIPROFLOXACIN |
0 |
11 |
|
No |
||
CIPROFLOXACIN LACTATE |
0 |
999 |
|
No |
||
CIPROFLOXACIN IN 5 % DEXTROSE |
0 |
999 |
|
No |
||
CIPROFLOXACIN IN 5 % DEXTROSE |
0 |
999 |
|
No |
||
CIPROFLOXACIN HCL |
12 |
999 |
|
No |
||
CIPROFLOXACIN HCL |
12 |
999 |
|
No |
||
CIPROFLOXACIN HCL |
12 |
999 |
|
No |
||
CIPROFLOXACIN HCL |
12 |
999 |
|
No |
||
CIPROFLOXACIN HCL |
12 |
999 |
|
No |
||
CIPROFLOXACIN IN 5 % DEXTROSE |
0 |
999 |
|
No |
||
LEVOFLOXACIN |
12 |
999 |
|
No |
||
LEVOFLOXACIN IN DEXTROSE 5 % |
0 |
999 |
|
No |
||
LEVOFLOXACIN |
12 |
999 |
|
No |
||
LEVOFLOXACIN IN DEXTROSE 5 % |
0 |
999 |
|
No |
||
LEVOFLOXACIN |
12 |
999 |
|
No |
Thursday, October 25, 2018 |
Page 180 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
W1Q |
|
LEVOFLOXACIN 750 MG/150 |
|
|
LEVOFLOXACIN IN DEXTROSE 5 % |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Q |
|
|
|
LEVOFLOXACIN IN DEXTROSE 5 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Q |
|
|
|
LEVOFLOXACIN IN DEXTROSE 5 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Q |
|
|
|
LEVOFLOXACIN IN DEXTROSE 5 % |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
W1S |
CARBAPENEM ANTIBIOTICS (THIENAMYCINS) |
|
|
|
|
|
||||
|
W1S |
|
|
|
IMIPENEM/CILASTATIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1S |
|
|
|
IMIPENEM/CILASTATIN SODIUM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1S |
|
MEROPENEM IV 1 GM VIAL |
|
|
MEROPENEM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1S |
|
MEROPENEM IV 500 MG VIAL |
|
|
MEROPENEM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
W1W |
CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION |
|
|
|
|
|
||||
|
W1W |
|
CEFADROXIL 500 MG CAPSULE |
|
|
CEFADROXIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1W |
|
CEFAZOLIN 1 GM |
|
|
CEFAZOLIN SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1W |
|
CEFAZOLIN 1 GM VIAL |
|
|
CEFAZOLIN SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1W |
|
CEFAZOLIN 10 GM BULK VIAL |
|
|
CEFAZOLIN SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1W |
|
CEFAZOLIN 10 GM VIAL |
|
|
CEFAZOLIN SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1W |
|
CEFAZOLIN 20 GM BULK VIAL |
|
|
CEFAZOLIN SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1W |
|
CEFAZOLIN 500 MG VIAL |
|
|
CEFAZOLIN SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1W |
|
CEPHALEXIN 125 MG/5 ML SUSP |
|
|
CEPHALEXIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1W |
|
CEPHALEXIN 125 MG/5 ML SUSPEN |
|
|
CEPHALEXIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1W |
|
CEPHALEXIN 250 MG CAPSULE |
|
|
CEPHALEXIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1W |
|
CEPHALEXIN 250 MG/5 ML SUSP |
|
|
CEPHALEXIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1W |
|
CEPHALEXIN 250 MG/5 ML SUSPEN |
|
|
CEPHALEXIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1W |
|
CEPHALEXIN 500 MG CAPSULE |
|
|
CEPHALEXIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1W |
|
CEPHALEXIN 750 MG CAPSULE |
|
|
CEPHALEXIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
W1X |
CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION |
|
|
|
|
|
Thursday, October 25, 2018 |
Page 181 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
W1X |
|
CEFACLOR 250 MG CAPSULE |
|
|
CEFACLOR |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFACLOR 500 MG CAPSULE |
|
|
CEFACLOR |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFOTETAN 1 GM VIAL |
|
|
CEFOTETAN DISODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFOTETAN 10 GM VIAL |
|
|
CEFOTETAN DISODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFOTETAN 2 GM VIAL |
|
|
CEFOTETAN DISODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
|
|
CEFOTETAN DISOD/ISOSM DEXTROSE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
|
|
CEFOTETAN DISOD/ISOSM DEXTROSE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFOXITIN 1 GM PIGGYBACK BAG |
|
|
CEFOXITIN SODIUM/DEXTROSE,ISO |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFOXITIN 1 GM VIAL |
|
|
CEFOXITIN SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFOXITIN 10 GM VIAL |
|
|
CEFOXITIN SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFOXITIN 2 GM PIGGYBACK BAG |
|
|
CEFOXITIN SODIUM/DEXTROSE,ISO |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFOXITIN 2 GM VIAL |
|
|
CEFOXITIN SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFPROZIL 125 MG/5 ML SUSP |
|
|
CEFPROZIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFPROZIL 250 MG TABLET |
|
|
CEFPROZIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFPROZIL 250 MG/5 ML SUSP |
|
|
CEFPROZIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFPROZIL 500 MG TABLET |
|
|
CEFPROZIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFUROXIME AXETIL 250 MG TAB |
|
|
CEFUROXIME AXETIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFUROXIME AXETIL 500 MG TAB |
|
|
CEFUROXIME AXETIL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFUROXIME SOD 1.5 GM VIAL |
|
|
CEFUROXIME SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFUROXIME SOD 7.5 GM VIAL |
|
|
CEFUROXIME SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1X |
|
CEFUROXIME SOD 750 MG VIAL |
|
|
CEFUROXIME SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
W1Y |
CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION |
|
|
|
|
|
||||
|
W1Y |
|
CEFDINIR 125 MG/5 ML SUSP |
|
|
CEFDINIR |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFDINIR 250 MG/5 ML SUSP |
|
|
CEFDINIR |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 182 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
W1Y |
|
CEFDINIR 300 MG CAPSULE |
|
|
CEFDINIR |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFOTAXIME SODIUM 1 GM VIAL |
|
|
CEFOTAXIME SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFOTAXIME SODIUM 10 GM VIAL |
|
|
CEFOTAXIME SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFOTAXIME SODIUM 2 GM VIAL |
|
|
CEFOTAXIME SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFOTAXIME SODIUM 500 MG VIAL |
|
|
CEFOTAXIME SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFTAZIDIME 1 GM VIAL |
|
|
CEFTAZIDIME |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFTAZIDIME 2 GM VIAL |
|
|
CEFTAZIDIME |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFTAZIDIME 6 GM VIAL |
|
|
CEFTAZIDIME |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFTRIAXONE 1 GM PIGGYBACK |
|
|
CEFTRIAXONE IN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFTRIAXONE 1 GM VIAL |
|
|
CEFTRIAXONE SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFTRIAXONE 1 GM/D5W BAG |
|
|
CEFTRIAXONE IN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFTRIAXONE 10 GM VIAL |
|
|
CEFTRIAXONE SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFTRIAXONE 2 GM PIGGYBACK |
|
|
CEFTRIAXONE IN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFTRIAXONE 2 GM VIAL |
|
|
CEFTRIAXONE SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFTRIAXONE 2 GM/D5W BAG |
|
|
CEFTRIAXONE IN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFTRIAXONE 250 MG VIAL |
|
|
CEFTRIAXONE SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
CEFTRIAXONE 500 MG VIAL |
|
|
CEFTRIAXONE SODIUM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Y |
|
SUPRAX 400 MG CAPSULE |
|
|
CEFIXIME |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
W1Z |
CEPHALOSPORIN ANTIBIOTICS - 4TH GENERATION |
|
|
|
|
|
||||
|
W1Z |
|
CEFEPIME HCL 1 GM VIAL |
|
|
CEFEPIME HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Z |
|
CEFEPIME HCL 1 GRAM VIAL |
|
|
CEFEPIME HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W1Z |
|
CEFEPIME HCL 2 GRAM VIAL |
|
|
CEFEPIME HCL |
0 |
999 |
|
No |
|
||
|
|
|
W2A |
ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTS |
|
|
|
|
|
||||
|
W2A |
|
SULFADIAZINE 500 MG TABLET |
|
|
SULFADIAZINE |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 183 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2A |
|
SULFAMETHOXAZOLE W/TMP SUSP |
|
|
SULFAMETHOXAZOLE/TRIMETHOPRIM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2A |
|
SULFAMETHOXAZOLE/TMP DS TAB |
|
|
SULFAMETHOXAZOLE/TRIMETHOPRIM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2A |
|
SULFAMETHOXAZOLE/TMP SS TAB |
|
|
SULFAMETHOXAZOLE/TRIMETHOPRIM |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2A |
|
|
|
SULFAMETHOXAZOLE/TRIMETHOPRIM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2A |
|
|
|
SULFAMETHOXAZOLE/TRIMETHOPRIM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2A |
|
|
|
SULFAMETHOXAZOLE/TRIMETHOPRIM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2A |
|
|
|
SULFAMETHOXAZOLE/TRIMETHOPRIM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W2E |
|
|
|
|
|
|
|
|
|
|
|
W2E |
|
ETHAMBUTOL HCL 100 MG TABLET |
|
|
ETHAMBUTOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2E |
|
ETHAMBUTOL HCL 400 MG TABLET |
|
|
ETHAMBUTOL HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2E |
|
ISONIAZID 100 MG TABLET |
|
|
ISONIAZID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2E |
|
ISONIAZID 300 MG TABLET |
|
|
ISONIAZID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2E |
|
ISONIAZID 50 MG/5 ML SYRUP |
|
|
ISONIAZID |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2E |
|
PYRAZINAMIDE 500 MG TABLET |
|
|
PYRAZINAMIDE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2E |
|
RIFABUTIN 150 MG CAPSULE |
|
|
RIFABUTIN |
0 |
999 |
|
No |
|
||
|
|
|
W2F |
NITROFURAN DERIVATIVES ANTIBACTERIAL AGENTS |
|
|
|
|
|
||||
|
W2F |
|
NITROFURANTOIN 25 MG/5 ML SUSP |
|
|
NITROFURANTOIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2F |
|
NITROFURANTOIN MCR 100 MG CAP |
|
|
NITROFURANTOIN MACROCRYSTAL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2F |
|
NITROFURANTOIN MCR 100 MG CP |
|
|
NITROFURANTOIN MACROCRYSTAL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2F |
|
NITROFURANTOIN MCR 25 MG CAP |
|
|
NITROFURANTOIN MACROCRYSTAL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2F |
|
NITROFURANTOIN MCR 50 MG CAP |
|
|
NITROFURANTOIN MACROCRYSTAL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2F |
|
NITROFURANTOIN |
|
|
NITROFURANTOIN |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W2F |
|
|
|
NITROFURANTOIN |
0 |
999 |
|
No |
|
|||
|
|
|
W2G |
CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC. |
|
|
|
|
|
||||
|
W2G |
|
METHENAMINE HIPP 1 GM TABLET |
|
|
METHENAMINE HIPPURATE |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 184 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
W2G |
|
METHENAMINE MD 1 GM TABLET |
METHENAMINE MANDELATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W2G |
|
METHENAMINE MD 500 MG TABLET |
METHENAMINE MANDELATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W2G |
|
TRIMETHOPRIM 100 MG TABLET |
TRIMETHOPRIM |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W2G |
|
METH/MEBLUE/SOD PHOS/PSAL/HYOS |
0 |
999 |
|
No |
|
||||
|
|
|
W3A |
ANTIFUNGAL ANTIBIOTICS |
|
|
|
|
|
|
|
|
|
W3A |
|
AMPHOTERICIN B 50 MG VIAL |
AMPHOTERICIN B |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3A |
|
ERAXIS(WATER DIL) 100 MG VIAL |
ANIDULAFUNGIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3A |
|
ERAXIS(WATER DIL) 50 MG VIAL |
ANIDULAFUNGIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3A |
|
GRISEOFULVIN 125 MG/5 ML SUSP |
GRISEOFULVIN, MICROSIZE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3A |
|
NYSTATIN 100,000 UNIT/ML SUSP |
NYSTATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3A |
|
NYSTATIN 100,000 UNITS/ML SUSP |
NYSTATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3A |
|
NYSTATIN 500,000 UNIT ORAL TAB |
NYSTATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3A |
|
NYSTATIN 500,000 UNIT/5 ML SUS |
NYSTATIN |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3A |
|
NYSTATIN 500,000 UNITS/5 ML |
NYSTATIN |
0 |
999 |
|
No |
|
|||
|
|
|
W3B |
ANTIFUNGAL AGENTS |
|
|
|
|
|
|
|
|
|
W3B |
|
CLOTRIMAZOLE 10 MG TROCHE |
CLOTRIMAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3B |
|
FLUCONAZOLE 10 MG/ML SUSP |
FLUCONAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3B |
|
FLUCONAZOLE 100 MG TABLET |
FLUCONAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3B |
|
FLUCONAZOLE 150 MG TABLET |
FLUCONAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3B |
|
FLUCONAZOLE 200 MG TABLET |
FLUCONAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3B |
|
FLUCONAZOLE 40 MG/ML SUSP |
FLUCONAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3B |
|
FLUCONAZOLE 50 MG TABLET |
FLUCONAZOLE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W3B |
|
FLUCONAZOLE IN |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W3B |
|
FLUCONAZOLE IN |
0 |
999 |
|
No |
|
Thursday, October 25, 2018 |
Page 185 of 204 |
Class |
|
Medicaid Drug Name |
|
|
|
W3B |
|
|
W3B |
|
|
W3B |
|
|
W3B |
|
|
W3B |
|
|
W3B |
|
|
W3B |
|
TERBINAFINE HCL 250 MG TABLET |
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
Min Age |
|
Max Age |
|
|
FLUCONAZOLE IN |
0 |
999 |
|
No |
||
FLUCONAZOLE IN |
0 |
999 |
|
No |
||
FLUCONAZOLE IN |
0 |
999 |
|
No |
||
FLUCONAZOLE IN |
0 |
999 |
|
No |
||
FLUCONAZOLE IN |
0 |
999 |
|
No |
||
FLUCONAZOLE IN |
0 |
999 |
|
No |
||
TERBINAFINE HCL |
0 |
999 |
|
No |
|
W4A |
ANTIMALARIAL DRUGS |
|
|
|
W4A |
CHLOROQUINE PH 250 MG TABLET |
CHLOROQUINE PHOSPHATE |
0 |
999 |
No |
|
|
|
|
|
|
W4A |
CHLOROQUINE PH 500 MG TABLET |
CHLOROQUINE PHOSPHATE |
0 |
999 |
No |
|
|
|
|
|
|
W4A |
HYDROXYCHLOROQUINE 200 MG TAB |
HYDROXYCHLOROQUINE SULFATE |
0 |
999 |
No |
|
|
|
|
|
|
W4A |
HYDROXYCHLOROQUINE 200 MG TB |
HYDROXYCHLOROQUINE SULFATE |
0 |
999 |
No |
|
|
|
|
|
|
W4A |
MEFLOQUINE HCL 250 MG TABLET |
MEFLOQUINE HCL |
0 |
999 |
No |
|
|
|
|
|
|
W4A |
PRIMAQUINE 26.3 MG TABLET |
PRIMAQUINE PHOSPHATE |
0 |
999 |
No |
|
|
|
|
|
|
|
W4E |
ANAEROBIC |
|
|
|
W4E |
METRONIDAZOLE 250 MG TABLET |
METRONIDAZOLE |
0 |
999 |
No |
|
|
|
|
|
|
W4E |
METRONIDAZOLE 500 MG TABLET |
METRONIDAZOLE |
0 |
999 |
No |
|
|
|
|
|
|
W4E |
METRONIDAZOLE 500 MG/100 ML |
METRONIDAZOLE/SODIUM CHLORIDE |
0 |
999 |
No |
|
|
|
|
|
|
W4E |
METRONIDAZOLE 500 MG/100 ML BG |
METRONIDAZOLE/SODIUM CHLORIDE |
0 |
999 |
No |
|
|
|
|
|
|
|
W4G |
2ND GEN. ANAEROBIC |
|
|
|
W4G |
TINIDAZOLE 250 MG TABLET |
TINIDAZOLE |
0 |
999 |
No |
|
|
|
|
|
|
W4G |
TINIDAZOLE 500 MG TABLET |
TINIDAZOLE |
0 |
999 |
No |
|
|
|
|
|
|
|
W4K |
ANTIPROTOZOAL DRUGS,MISCELLANEOUS |
|
|
|
W4K |
ATOVAQUONE 750 MG/5 ML SUSP |
ATOVAQUONE |
0 |
999 |
No |
|
|
|
|
|
|
W4K |
NEBUPENT 300 MG INHAL POWDER |
PENTAMIDINE ISETHIONATE |
0 |
999 |
No |
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 186 of 204 |
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W4L |
ANTHELMINTICS |
|
|
|
W4L |
ALBENZA 200 MG TABLET |
ALBENDAZOLE |
0 |
999 |
No |
|
|
|
|
|
|
W4L |
BILTRICIDE 600 MG TABLET |
PRAZIQUANTEL |
0 |
999 |
No |
|
|
|
|
|
|
W4L |
IVERMECTIN 3 MG TABLET |
IVERMECTIN |
0 |
999 |
No |
|
W4P |
ANTILEPROTICS |
|
|
|
W4P |
DAPSONE 100 MG TABLET |
DAPSONE |
0 |
999 |
No |
|
|
|
|
|
|
W4P |
DAPSONE 25 MG TABLET |
DAPSONE |
0 |
999 |
No |
|
|
|
|
|
|
W4P |
THALOMID 100 MG CAPSULE |
THALIDOMIDE |
0 |
999 |
Requires Med Cert 3 |
|
|
|
|
|
|
W4P |
THALOMID 150 MG CAPSULE |
THALIDOMIDE |
0 |
999 |
Requires Med Cert 3 |
|
|
|
|
|
|
W4P |
THALOMID 200 MG CAPSULE |
THALIDOMIDE |
0 |
999 |
Requires Med Cert 3 |
|
|
|
|
|
|
W4P |
THALOMID 50 MG CAPSULE |
THALIDOMIDE |
0 |
999 |
Requires Med Cert 3 |
|
|
|
|
|
|
|
W5A |
ANTIVIRALS, GENERAL |
|
|
|
W5A |
ACYCLOVIR 200 MG CAPSULE |
ACYCLOVIR |
0 |
999 |
No |
|
|
|
|
|
|
W5A |
ACYCLOVIR 200 MG/5 ML SUSP |
ACYCLOVIR |
0 |
17 |
No |
|
|
|
|
|
|
W5A |
ACYCLOVIR 400 MG TABLET |
ACYCLOVIR |
0 |
999 |
No |
|
|
|
|
|
|
W5A |
ACYCLOVIR 800 MG TABLET |
ACYCLOVIR |
0 |
999 |
No |
|
|
|
|
|
|
W5A |
GANCICLOVIR 500 MG VIAL |
GANCICLOVIR SODIUM |
0 |
999 |
No |
|
|
|
|
|
|
W5A |
GANCICLOVIR 500 MG/10 ML VIAL |
GANCICLOVIR SODIUM |
0 |
999 |
No |
|
|
|
|
|
|
W5A |
RELENZA 5 MG DISKHALER |
ZANAMIVIR |
6 |
999 |
No |
|
|
|
|
|
|
W5A |
RIBAVIRIN 6 GM INHALATION VIAL |
RIBAVIRIN |
5 |
999 |
Auto PA |
|
|
|
|
|
|
W5A |
TAMIFLU 30 MG GELCAP |
OSELTAMIVIR PHOSPHATE |
0 |
999 |
No |
|
|
|
|
|
|
W5A |
TAMIFLU 45 MG GELCAP |
OSELTAMIVIR PHOSPHATE |
0 |
999 |
No |
|
|
|
|
|
|
W5A |
TAMIFLU 6 MG/ML SUSPENSION |
OSELTAMIVIR PHOSPHATE |
0 |
12 |
No |
|
|
|
|
|
|
W5A |
TAMIFLU 75 MG GELCAP |
OSELTAMIVIR PHOSPHATE |
0 |
999 |
No |
|
|
|
|
|
|
W5A |
VALACYCLOVIR HCL 1 GRAM TABLET |
VALACYCLOVIR HCL |
0 |
999 |
No |
Thursday, October 25, 2018 |
Page 187 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5A |
|
VALACYCLOVIR HCL 500 MG TABLET |
|
|
VALACYCLOVIR HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5A |
|
VALCYTE 450 MG TABLET |
|
|
VALGANCICLOVIR HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5A |
|
VALCYTE 50 MG/ML SOLUTION |
|
|
VALGANCICLOVIR HCL |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
W5C |
ANTIVIRALS, |
|
|
|
|
|
||||
|
W5C |
|
CRIXIVAN 200 MG CAPSULE |
|
|
INDINAVIR SULFATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5C |
|
CRIXIVAN 400 MG CAPSULE |
|
|
INDINAVIR SULFATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5C |
|
EVOTAZ 300 |
|
|
ATAZANAVIR SULFATE/COBICISTAT |
18 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5C |
|
INVIRASE 500 MG TABLET |
|
|
SAQUINAVIR MESYLATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5C |
|
LEXIVA 50 MG/ML SUSPENSION |
|
|
FOSAMPRENAVIR CALCIUM |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5C |
|
LEXIVA 700 MG TABLET |
|
|
FOSAMPRENAVIR CALCIUM |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5C |
|
NORVIR 100 MG POWDER PACKET |
|
|
RITONAVIR |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5C |
|
NORVIR 100 MG TABLET |
|
|
RITONAVIR |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5C |
|
NORVIR 80 MG/ML SOLUTION |
|
|
RITONAVIR |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5C |
|
REYATAZ 150 MG CAPSULE |
|
|
ATAZANAVIR SULFATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5C |
|
REYATAZ 200 MG CAPSULE |
|
|
ATAZANAVIR SULFATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5C |
|
REYATAZ 300 MG CAPSULE |
|
|
ATAZANAVIR SULFATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5C |
|
REYATAZ 50 MG POWDER PACKET |
|
|
ATAZANAVIR SULFATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5C |
|
VIRACEPT 250 MG TABLET |
|
|
NELFINAVIR MESYLATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5C |
|
VIRACEPT 625 MG TABLET |
|
|
NELFINAVIR MESYLATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
W5F |
|
|
HEPATITIS B TREATMENT AGENTS |
|
|
|
|
|
|
|
|
W5F |
|
BARACLUDE 0.05 MG/ML SOLUTION |
|
|
ENTECAVIR |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5F |
|
ENTECAVIR 0.5 MG TABLET |
|
|
ENTECAVIR |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5F |
|
ENTECAVIR 1 MG TABLET |
|
|
ENTECAVIR |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5F |
|
EPIVIR HBV 25 MG/5 ML SOLN |
|
|
LAMIVUDINE |
0 |
11 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
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|
|
Thursday, October 25, 2018 |
Page 188 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
W5F |
|
LAMIVUDINE 100 MG TABLET |
LAMIVUDINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5F |
|
LAMIVUDINE 100 MG TABLET |
LAMIVUDINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5F |
|
LAMIVUDINE HBV 100 MG TABLET |
LAMIVUDINE |
0 |
999 |
|
No |
|
|||
|
|
|
W5G |
HEPATITIS C TREATMENT AGENTS |
|
|
|
|
|
|
|
|
|
W5G |
|
MODERIBA 200 MG TABLET |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
MODERIBA |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
MODERIBA |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
MODERIBA |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
MODERIBA |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
PEGASYS 180 MCG/0.5 ML SYRINGE |
PEGINTERFERON |
3 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
PEGASYS 180 MCG/ML VIAL |
PEGINTERFERON |
3 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
PEGASYS PROCLICK 135 MCG/0.5 |
PEGINTERFERON |
3 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
PEGASYS PROCLICK 180 MCG/0.5 |
PEGINTERFERON |
3 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
PEGINTRON 50 MCG KIT |
PEGINTERFERON |
3 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
REBETOL 40 MG/ML SOLUTION |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
RIBAPAK |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
RIBAPAK |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
RIBAPAK |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
RIBAPAK |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
RIBASPHERE 200 MG CAPSULE |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
RIBASPHERE 200 MG TABLET |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
RIBASPHERE 400 MG TABLET |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
RIBASPHERE 600 MG TABLET |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W5G |
|
RIBAVIRIN 200 MG CAPSULE |
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 189 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
W5G |
|
RIBAVIRIN 200 MG TABLET |
|
|
RIBAVIRIN |
5 |
999 |
|
Auto PA |
|
||
|
|
|
W5I |
ANTIVIRALS, |
|
|
|
|
|
||||
|
W5I |
|
VIREAD 150 MG TABLET |
|
|
TENOFOVIR DISOPROXIL FUMARATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5I |
|
VIREAD 200 MG TABLET |
|
|
TENOFOVIR DISOPROXIL FUMARATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5I |
|
VIREAD 250 MG TABLET |
|
|
TENOFOVIR DISOPROXIL FUMARATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5I |
|
VIREAD 300 MG TABLET |
|
|
TENOFOVIR DISOPROXIL FUMARATE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5I |
|
VIREAD POWDER |
|
|
TENOFOVIR DISOPROXIL FUMARATE |
0 |
999 |
|
No |
|
||
|
|
|
W5J |
ANTIVIRALS, |
|
|
|
|
|
||||
|
W5J |
|
ABACAVIR 300 MG TABLET |
|
|
ABACAVIR SULFATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
DIDANOSINE 200 MG DR CAPSULE |
|
|
DIDANOSINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
DIDANOSINE 250 MG DR CAPSULE |
|
|
DIDANOSINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
DIDANOSINE 400 MG DR CAPSULE |
|
|
DIDANOSINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
EMTRIVA 10 MG/ML SOLUTION |
|
|
EMTRICITABINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
EMTRIVA 200 MG CAPSULE |
|
|
EMTRICITABINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
EPIVIR 10 MG/ML ORAL SOLN |
|
|
LAMIVUDINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
LAMIVUDINE 10 MG/ML ORAL SOLN |
|
|
LAMIVUDINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
LAMIVUDINE 150 MG TABLET |
|
|
LAMIVUDINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
LAMIVUDINE 300 MG TABLET |
|
|
LAMIVUDINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
RETROVIR 200 MG/20 ML VIAL |
|
|
ZIDOVUDINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
STAVUDINE 15 MG CAPSULE |
|
|
STAVUDINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
STAVUDINE 20 MG CAPSULE |
|
|
STAVUDINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
STAVUDINE 30 MG CAPSULE |
|
|
STAVUDINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
STAVUDINE 40 MG CAPSULE |
|
|
STAVUDINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
VIDEX 2 GM PEDIATRIC SOLN |
|
|
DIDANOSINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 190 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
W5J |
|
VIDEX 4 GM PEDIATRIC SOLN |
|
|
DIDANOSINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
ZIAGEN 20 MG/ML SOLUTION |
|
|
ABACAVIR SULFATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
ZIDOVUDINE 100 MG CAPSULE |
|
|
ZIDOVUDINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
ZIDOVUDINE 300 MG TABLET |
|
|
ZIDOVUDINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5J |
|
ZIDOVUDINE 50 MG/5 ML SYRUP |
|
|
ZIDOVUDINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
W5K |
ANTIVIRALS, |
|
|
|
|
|
||||
|
W5K |
|
EDURANT 25 MG TABLET |
|
|
RILPIVIRINE HCL |
12 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5K |
|
INTELENCE 100 MG TABLET |
|
|
ETRAVIRINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5K |
|
INTELENCE 200 MG TABLET |
|
|
ETRAVIRINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5K |
|
INTELENCE 25 MG TABLET |
|
|
ETRAVIRINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5K |
|
NEVIRAPINE 200 MG TABLET |
|
|
NEVIRAPINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5K |
|
NEVIRAPINE 50 MG/5 ML SUSP |
|
|
NEVIRAPINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5K |
|
NEVIRAPINE ER 100 MG TABLET |
|
|
NEVIRAPINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5K |
|
NEVIRAPINE ER 400 MG TABLET |
|
|
NEVIRAPINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5K |
|
RESCRIPTOR 100 MG TABLET |
|
|
DELAVIRDINE MESYLATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5K |
|
RESCRIPTOR 200 MG TABLET |
|
|
DELAVIRDINE MESYLATE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5K |
|
SUSTIVA 200 MG CAPSULE |
|
|
EFAVIRENZ |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5K |
|
SUSTIVA 50 MG CAPSULE |
|
|
EFAVIRENZ |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5K |
|
SUSTIVA 600 MG TABLET |
|
|
EFAVIRENZ |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5K |
|
VIRAMUNE 50 MG/5 ML SUSP |
|
|
NEVIRAPINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
W5L |
ANTIVIRALS, |
|
|
|
|
|
||||
|
W5L |
|
EPZICOM TABLET |
|
|
ABACAVIR SULFATE/LAMIVUDINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5L |
|
|
|
LAMIVUDINE/ZIDOVUDINE |
0 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5L |
|
TRIZIVIR TABLET |
|
|
ABACAVIR/LAMIVUDINE/ZIDOVUDINE |
0 |
999 |
|
Auto PA |
|
||
|
|
|
W5M |
ANTIVIRALS, |
|
|
|
|
|
Thursday, October 25, 2018 |
Page 191 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
W5M |
|
KALETRA |
|
|
LOPINAVIR/RITONAVIR |
0 |
|
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5M |
|
KALETRA |
|
|
|
LOPINAVIR/RITONAVIR |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5M |
|
KALETRA |
|
|
|
LOPINAVIR/RITONAVIR |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
W5N |
|
ANTIVIRALS, |
|
|
|
|
|||||
|
W5N |
|
FUZEON CONVENIENCE KIT |
|
|
|
ENFUVIRTIDE |
6 |
|
999 |
|
Clinical PA Required |
|
|
|
|
|
W5O |
|
ANTIVIRALS, |
|
|
|
|
|||||
|
W5O |
|
CIMDUO |
|
|
|
LAMIVUDINE/TENOFOVIR DISOP FUM |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5O |
|
DESCOVY |
|
|
|
EMTRICITABINE/TENOFOV ALAFENAM |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5O |
|
TRUVADA 100 |
|
|
|
EMTRICITABINE/TENOFOVIR (TDF) |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5O |
|
TRUVADA 133 |
|
|
|
EMTRICITABINE/TENOFOVIR (TDF) |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5O |
|
TRUVADA 167 |
|
|
|
EMTRICITABINE/TENOFOVIR (TDF) |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5O |
|
TRUVADA TABLET |
|
|
|
EMTRICITABINE/TENOFOVIR (TDF) |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
W5P |
|
ANTIVIRALS, |
|
|
|
|
|||||
|
W5P |
|
APTIVUS 100 MG/ML SOLUTION |
|
|
|
TIPRANAVIR/VITAMIN E TPGS |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5P |
|
APTIVUS 250 MG CAPSULE |
|
|
|
TIPRANAVIR |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
W5P |
|
PREZCOBIX 800 |
|
|
DARUNAVIR/COBICISTAT |
18 |
|
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5P |
|
PREZISTA 100 MG/ML SUSPENSION |
|
|
|
DARUNAVIR ETHANOLATE |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5P |
|
PREZISTA 150 MG TABLET |
|
|
|
DARUNAVIR ETHANOLATE |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5P |
|
PREZISTA 600 MG TABLET |
|
|
|
DARUNAVIR ETHANOLATE |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5P |
|
PREZISTA 75 MG TABLET |
|
|
|
DARUNAVIR ETHANOLATE |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5P |
|
PREZISTA 800 MG TABLET |
|
|
|
DARUNAVIR ETHANOLATE |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
W5Q |
ARTV |
|
|
|
|||||||
|
W5Q |
|
ATRIPLA TABLET |
|
|
|
EFAVIRENZ/EMTRICIT/TENOFOVR DF |
12 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5Q |
|
COMPLERA TABLET |
|
|
|
EMTRICITA/RILPIVIRINE/TENOF DF |
12 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5Q |
|
ODEFSEY TABLET |
|
|
|
EMTRICITAB/RILPIVIRI/TENOF ALA |
12 |
|
999 |
|
Auto PA |
|
Thursday, October 25, 2018 |
Page 192 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5Q |
|
SYMFI |
|
|
|
EFAVIRENZ/LAMIVU/TENOFOV DISOP |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5Q |
|
SYMFI LO |
|
|
|
EFAVIRENZ/LAMIVU/TENOFOV DISOP |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
W5T |
|
ANTIVIRALS, |
|
|
|
|
|||||
|
W5T |
|
SELZENTRY 150 MG TABLET |
|
|
|
MARAVIROC |
16 |
|
999 |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5T |
|
SELZENTRY 20 MG/ML ORAL SOLN |
|
|
|
MARAVIROC |
16 |
|
999 |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5T |
|
SELZENTRY 25 MG TABLET |
|
|
|
MARAVIROC |
16 |
|
999 |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5T |
|
SELZENTRY 300 MG TABLET |
|
|
|
MARAVIROC |
16 |
|
999 |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5T |
|
SELZENTRY 75 MG TABLET |
|
|
|
MARAVIROC |
16 |
|
999 |
|
Clinical PA Required |
|
|
|
|
|
W5U |
|
|
|
|
|
||||||
|
W5U |
|
ISENTRESS 100 MG POWDER PACKET |
|
|
RALTEGRAVIR POTASSIUM |
0 |
|
999 |
|
Auto PA |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5U |
|
ISENTRESS 100 MG TABLET CHEW |
|
|
|
RALTEGRAVIR POTASSIUM |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5U |
|
ISENTRESS 25 MG TABLET CHEW |
|
|
|
RALTEGRAVIR POTASSIUM |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5U |
|
ISENTRESS 400 MG TABLET |
|
|
|
RALTEGRAVIR POTASSIUM |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5U |
|
ISENTRESS HD 600 MG TABLET |
|
|
|
RALTEGRAVIR POTASSIUM |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5U |
|
TIVICAY 10 MG TABLET |
|
|
|
DOLUTEGRAVIR SODIUM |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5U |
|
TIVICAY 25 MG TABLET |
|
|
|
DOLUTEGRAVIR SODIUM |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5U |
|
TIVICAY 50 MG TABLET |
|
|
|
DOLUTEGRAVIR SODIUM |
0 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
W5X |
|
|
|
|
|
||||||
|
W5X |
|
BIKTARVY |
|
|
|
BICTEGRAV/EMTRICIT/TENOFOV ALA |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5X |
|
GENVOYA TABLET |
|
|
|
ELVITEG/COB/EMTRI/TENOF ALAFEN |
12 |
|
999 |
|
Auto PA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W5X |
|
STRIBILD TABLET |
|
|
|
ELVITEG/COB/EMTRI/TENOFO DISOP |
12 |
|
999 |
|
Auto PA |
|
|
|
|
|
W5Z |
|
|
|
||||||||
|
W5Z |
|
TRIUMEQ TABLET |
|
|
|
ABACAVIR/DOLUTEGRAVIR/LAMIVUDI |
18 |
|
999 |
|
Auto PA |
|
|
|
|
|
W7K |
|
|
|
ANTISERA |
|
|
|
|
|
|
|
|
W7K |
|
ATGAM 50 MG/ML AMPUL |
|
|
|
LYMPHOCYTE IG,ANTITHYMOCYT,EQU |
0 |
|
999 |
|
Clinical PA Required |
|
Thursday, October 25, 2018 |
Page 193 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
BIVIGAM LIQUID 10% VIAL |
IMMUN GLOB G(IGG)/GLY/IGA OV50 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
CARIMUNE NF 12 GM VIAL |
IMMUN GLOBG(IGG)/SUCR/IGA OV50 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
CARIMUNE NF 6 GM VIAL |
IMMUN GLOBG(IGG)/SUCR/IGA OV50 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
CUVITRU 1 GRAM/5 ML VIAL |
IMMUN GLOB G(IGG)/GLY/IGA OV50 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
CUVITRU 2 GRAM/10 ML VIAL |
IMMUN GLOB G(IGG)/GLY/IGA OV50 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
CUVITRU 4 GRAM/20 ML VIAL |
IMMUN GLOB G(IGG)/GLY/IGA OV50 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
CUVITRU 8 GRAM/ 40 ML VIAL |
IMMUN GLOB G(IGG)/GLY/IGA OV50 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
CYTOGAM 2.5 GM/50 ML VIAL |
CYTOMEGALOVIRUS IMMUNE GLOBULN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
FLEBOGAMMA DIF 10% VIAL |
IMM GLOB G (IGG)/SORB/IGA |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
FLEBOGAMMA DIF 5% VIAL |
IMM GLOB G (IGG)/SORB/IGA |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
GAMASTAN S/D VIAL |
IMMUNE GLOBUL G (IGG)/GLYCINE |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
GAMASTAN |
IMMUNE GLOBUL G (IGG)/GLYCINE |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
GAMMAGARD LIQUID 10% VIAL |
IMMUN GLOB G(IGG)/GLY/IGA OV50 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
GAMMAGARD |
IMMUN GLOB G/GLY/GLUC/IGA |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
GAMMAGARD |
IMMUN GLOB G/GLY/GLUC/IGA |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
GAMMAKED 1 GRAM/10 ML VIAL |
IMMUNE GLOBUL G/GLY/IGA AVG 46 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
GAMMAKED 10 GRAM/100 ML VIAL |
IMMUNE GLOBUL G/GLY/IGA AVG 46 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
GAMMAKED 2.5 GRAM/25 ML VIAL |
IMMUNE GLOBUL G/GLY/IGA AVG 46 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
GAMMAKED 20 GRAM/200 ML VIAL |
IMMUNE GLOBUL G/GLY/IGA AVG 46 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
GAMMAKED 5 GRAM/50 ML VIAL |
IMMUNE GLOBUL G/GLY/IGA AVG 46 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
GAMMAPLEX 10 GRAM/100 ML VIAL |
IMMUN GLOB G(IGG)/GLY/IGA |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
GAMMAPLEX 20 GRAM/200 ML VIAL |
IMMUN GLOB G(IGG)/GLY/IGA |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
GAMMAPLEX 5 GRAM/50 ML VIAL |
IMMUN GLOB G(IGG)/GLY/IGA |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
GAMMAPLEX 5% VIAL |
IMMUN GLOB G/SORB/GLY/IGA |
0 |
999 |
|
Clinical PA Required |
|
Thursday, October 25, 2018 |
Page 194 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
IMMUNE GLOBUL G/GLY/IGA AVG 46 |
0 |
999 |
|
Clinical PA Required |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
IMMUNE GLOBUL G/GLY/IGA AVG 46 |
0 |
999 |
|
Clinical PA Required |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
IMMUNE GLOBUL G/GLY/IGA AVG 46 |
0 |
999 |
|
Clinical PA Required |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
IMMUNE GLOBUL G/GLY/IGA AVG 46 |
0 |
999 |
|
Clinical PA Required |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
IMMUNE GLOBUL G/GLY/IGA AVG 46 |
0 |
999 |
|
Clinical PA Required |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
IMMUNE GLOBUL G/GLY/IGA AVG 46 |
0 |
999 |
|
Clinical PA Required |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HIZENTRA 1 GRAM/5 ML VIAL |
IMMUN GLOB G(IGG)/PRO/IGA |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HIZENTRA 10 GRAM/ 50 ML VIAL |
IMMUN GLOB G(IGG)/PRO/IGA |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HIZENTRA 10 GRAM/50 ML VIAL |
IMMUN GLOB G(IGG)/PRO/IGA |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HIZENTRA 2 GRAM/10 ML VIAL |
IMMUN GLOB G(IGG)/PRO/IGA |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HIZENTRA 4 GRAM/20 ML VIAL |
IMMUN GLOB G(IGG)/PRO/IGA |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HYPERHEP B S/D NEONATAL SYRIN. |
HEPATITIS B IMMUNE GLOBULIN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HYPERHEP B S/D SYRINGE |
HEPATITIS B IMMUNE GLOBULIN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HYPERHEP B S/D VIAL |
HEPATITIS B IMMUNE GLOBULIN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HYPERHEP B |
HEPATITIS B IMMUNE GLOBULIN |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HYQVIA 10 GM/800 UNIT VIAL |
IGG/HYALURONIDASE,RECOMBINANT |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HYQVIA 2.5 GM/200 UNIT VIAL |
IGG/HYALURONIDASE,RECOMBINANT |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HYQVIA 20 GM/1,600 UNIT VIAL |
IGG/HYALURONIDASE,RECOMBINANT |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HYQVIA 30 GM/2,400 UNIT VIAL |
IGG/HYALURONIDASE,RECOMBINANT |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HYQVIA 5 GM/400 UNIT VIAL |
IGG/HYALURONIDASE,RECOMBINANT |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HYQVIA IG CMPNT 10 GM/100 ML |
IMMUN GLOB G(IGG)/GLY/IGA OV50 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HYQVIA IG CMPNT 2.5 GM/25 ML |
IMMUN GLOB G(IGG)/GLY/IGA OV50 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HYQVIA IG CMPNT 20 GM/200 ML |
IMMUN GLOB G(IGG)/GLY/IGA OV50 |
0 |
999 |
|
Clinical PA Required |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
W7K |
|
HYQVIA IG CMPNT 30 GM/300 ML |
IMMUN GLOB G(IGG)/GLY/IGA OV50 |
0 |
999 |
|
Clinical PA Required |
|
Thursday, October 25, 2018 |
Page 195 of 204 |
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Generic Name |
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Medicaid |
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Medicaid |
|
Clinical PA Required |
|
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|
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|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
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|
|
|
|
|
|
|
W7K |
|
HYQVIA IG CMPNT 5 GM/50 ML |
|
|
IMMUN GLOB G(IGG)/GLY/IGA OV50 |
0 |
|
999 |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W7K |
|
|
|
HEPATITIS B IMMUNE GLOBULIN |
0 |
|
999 |
|
Clinical PA Required |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W7K |
|
OCTAGAM 10% VIAL |
|
|
IMMUN GLOBG(IGG)/MALT/IGA OV50 |
0 |
|
999 |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W7K |
|
OCTAGAM 5% VIAL |
|
|
IMMUN GLOBG(IGG)/MALT/IGA OV50 |
0 |
|
999 |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W7K |
|
PRIVIGEN 10% VIAL |
|
|
IMMUN GLOB G(IGG)/PRO/IGA |
0 |
|
999 |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W7K |
|
THYMOGLOBULIN 25 MG VIAL |
|
|
0 |
|
999 |
|
Clinical PA Required |
|
||
|
|
|
W8F |
|
|
IRRIGANTS |
|
|
|
|
|
|
|
|
W8F |
|
ACETIC ACID 0.25% IRRIG SOLN |
|
|
ACETIC ACID |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W8F |
|
ACETIC ACID 0.25% IRRIG. |
|
|
ACETIC ACID |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W8F |
|
LACTATED RINGERS IRRIGATION |
|
|
RINGER'S SOLUTION,LACTATED |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
W8F |
|
NEOMYCIN SULF/POLYMYXIN B SULF |
0 |
|
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W8F |
|
|
|
NEOMYCIN SULF/POLYMYXIN B SULF |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W8F |
|
RINGERS IRRIGATION |
|
|
RINGER'S SOLUTION |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W8F |
|
RINGERS IRRIGATION SOLUTION |
|
|
RINGER'S SOLUTION |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W8F |
|
RINGER'S LACTATED IRRIG SOL |
|
|
RINGER'S SOLUTION,LACTATED |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W8F |
|
SODIUM CHLORIDE 0.9% IRRIG |
|
|
SODIUM CHLORIDE IRRIG SOLUTION |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W8F |
|
SODIUM CHLORIDE 0.9% IRRIG. |
|
|
SODIUM CHLORIDE IRRIG SOLUTION |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W8F |
|
SODIUM CHLORIDE 0.9% IRRIGAT |
|
|
SODIUM CHLORIDE IRRIG SOLUTION |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W8F |
|
SORBITOL 3% UROLOGIC IRRIG |
|
|
SORBITOL SOLUTION |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W8F |
|
SORBITOL 3.3% UROLOGIC SOLN |
|
|
SORBITOL SOLUTION |
0 |
|
999 |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W8F |
|
|
|
MANNITOL/SORBITOL SOLUTION |
0 |
|
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
W8F |
|
STERILE WATER FOR IRRIGATION |
|
|
WATER FOR IRRIGATION,STERILE |
0 |
|
999 |
|
No |
|
|
|
|
|
Z1G |
DRUGS TO TX GAUCHER |
|
|
|
|
|||||
|
Z1G |
|
CERDELGA 84 MG CAPSULE |
|
|
ELIGLUSTAT TARTRATE |
18 |
|
999 |
|
Auto PA |
|
Thursday, October 25, 2018 |
Page 196 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
Z1G |
|
ZAVESCA 100 MG CAPSULE |
MIGLUSTAT |
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Z1H |
|
METABOLIC DISEASE ENZYME REPLACEMENT, FABRY'S DX |
|
|
Z1H |
FABRAZYME 35 MG VIAL |
|
AGALSIDASE BETA |
8 |
999 |
Z1H |
FABRAZYME 5 MG VIAL |
|
AGALSIDASE BETA |
8 |
999 |
|
Z1I |
|
METABOLIC DISEASE ENZYME REPLACEMENT, GAUCHER'S DX |
||
Z1I |
CEREZYME 400 UNITS VIAL |
|
IMIGLUCERASE |
2 |
999 |
Z1I |
ELELYSO 200 UNITS VIAL |
|
TALIGLUCERASE ALFA |
4 |
999 |
Z1I |
VPRIV 400 UNITS VIAL |
|
VELAGLUCERASE ALFA |
4 |
999 |
|
Z1K |
METABOLIC DX ENZYME REPLACEMT,SEV.COMB.IMMUNE DEF. |
|||
Z1K |
ADAGEN 250 UNITS/ML VIAL |
|
PEGADEMASE BOVINE |
0 |
999 |
|
Z21 |
|
MAST CELL STABILIZERS, ORALLY INHALED |
|
|
Z21 |
CROMOLYN 20 MG/2 ML NEB SOLN |
CROMOLYN SODIUM |
0 |
999 |
|
Z21 |
CROMOLYN NEBULIZER SOLUTION |
|
CROMOLYN SODIUM |
0 |
999 |
Auto PA
Auto PA
Auto PA
Auto PA
Auto PA
No
No
No
|
Z2D |
HISTAMINE |
|
|
|
Z2D |
FAMOTIDINE 10 MG/ML VIAL |
FAMOTIDINE |
0 |
999 |
No |
|
|
|
|
|
|
Z2D |
FAMOTIDINE 20 MG PIGGYBACK |
FAMOTIDINE IN |
0 |
999 |
No |
|
|
|
|
|
|
Z2D |
FAMOTIDINE 20 MG TABLET |
FAMOTIDINE |
0 |
999 |
No |
|
|
|
|
|
|
Z2D |
FAMOTIDINE 20 MG/2 ML VIAL |
FAMOTIDINE/PF |
0 |
999 |
No |
|
|
|
|
|
|
Z2D |
FAMOTIDINE 200 MG/20 ML VIAL |
FAMOTIDINE |
0 |
999 |
No |
|
|
|
|
|
|
Z2D |
FAMOTIDINE 40 MG TABLET |
FAMOTIDINE |
0 |
999 |
No |
|
|
|
|
|
|
Z2D |
FAMOTIDINE 40 MG/4 ML VIAL |
FAMOTIDINE |
0 |
999 |
No |
|
|
|
|
|
|
Z2D |
RANITIDINE 15 MG/ML SYRUP |
RANITIDINE HCL |
0 |
999 |
No |
|
|
|
|
|
|
Z2D |
RANITIDINE 150 MG TABLET |
RANITIDINE HCL |
0 |
999 |
No |
|
|
|
|
|
|
Z2D |
RANITIDINE 150 MG/10 ML SYRUP |
RANITIDINE HCL |
0 |
999 |
No |
|
|
|
|
|
|
Z2D |
RANITIDINE 300 MG TABLET |
RANITIDINE HCL |
0 |
999 |
No |
|
Z2E |
IMMUNOSUPPRESSIVES |
|
|
|
Thursday, October 25, 2018 |
Page 197 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
Z2E |
|
AZATHIOPRINE 50 MG TABLET |
AZATHIOPRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
CELLCEPT 200 MG/ML ORAL SUSP |
MYCOPHENOLATE MOFETIL |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
CELLCEPT 500 MG VIAL |
MYCOPHENOLATE MOFETIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
CYCLOSPORINE 50 MG/ML AMP |
CYCLOSPORINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
CYCLOSPORINE MODIFIED 100 MG |
CYCLOSPORINE, MODIFIED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
CYCLOSPORINE MODIFIED 25 MG |
CYCLOSPORINE, MODIFIED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
CYCLOSPORINE MODIFIED 50 MG |
CYCLOSPORINE, MODIFIED |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
MYCOPHENOLATE 250 MG CAPSULE |
MYCOPHENOLATE MOFETIL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
MYCOPHENOLATE 500 MG TABLET |
MYCOPHENOLATE MOFETIL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
MYCOPHENOLATE 500 MG VIAL |
MYCOPHENOLATE MOFETIL HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
RAPAMUNE 1 MG/ML ORAL SOLN |
SIROLIMUS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
SANDIMMUNE 100 MG/ML SOLN |
CYCLOSPORINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
SANDIMMUNE 50 MG/ML AMPUL |
CYCLOSPORINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
SIROLIMUS 0.5 MG TABLET |
SIROLIMUS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
SIROLIMUS 1 MG TABLET |
SIROLIMUS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
SIROLIMUS 2 MG TABLET |
SIROLIMUS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
TACROLIMUS 0.5 MG CAPSULE |
TACROLIMUS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
TACROLIMUS 0.5 MG CAPSULES |
TACROLIMUS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
TACROLIMUS 1 MG CAPSULE |
TACROLIMUS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
TACROLIMUS 5 MG CAPSULE |
TACROLIMUS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
TACROLIMUS ANHYDROUS 0.5MG CAP |
TACROLIMUS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
TACROLIMUS ANHYDROUS 1 MG CAP |
TACROLIMUS |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2E |
|
TACROLIMUS ANHYDROUS 5 MG CAP |
TACROLIMUS |
0 |
999 |
|
No |
|
|||
|
|
|
Z2F |
MAST CELL STABILIZERS |
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 198 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
Z2F |
|
CROMOLYN 100 MG/5 ML ORAL CONC |
CROMOLYN SODIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
||||
|
Z2F |
|
CROMOLYN SODIUM 100 MG/5 ML |
CROMOLYN SODIUM |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Z2G |
|
|
IMMUNOMODULATORS |
|
|
|
|
|
|
|
|
Z2G |
|
ACTIMMUNE 100 MCG/0.5 ML VIAL |
INTERFERON |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Z2G |
|
IMIQUIMOD 5% CREAM |
|
|
IMIQUIMOD |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Z2G |
|
IMIQUIMOD 5% CREAM PACKET |
|
|
IMIQUIMOD |
12 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Z2G |
|
INTRON A 10 MILLION UNITS VIAL |
|
|
INTERFERON |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Z2G |
|
INTRON A 10MM UNITS/ML VIAL |
|
|
INTERFERON |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Z2G |
|
INTRON A 18 MILLION UNITS VIAL |
|
|
INTERFERON |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Z2G |
|
INTRON A 50 MILLION UNITS VIAL |
|
|
INTERFERON |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Z2G |
|
INTRON A 6MM UNITS/ML VIAL |
|
|
INTERFERON |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
Z2G |
|
PROLEUKIN 22 MILLION UNIT VIAL |
ALDESLEUKIN |
0 |
999 |
|
Clinical PA Required |
|
||||
|
|
|
Z2H |
|
|
SYSTEMIC ENZYME INHIBITORS |
|
|
|
|
|
|
|
|
Z2H |
|
ARALAST NP 1,000 MG VIAL |
|
|
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Z2H |
|
ARALAST NP 500 MG VIAL |
|
|
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Z2H |
|
GLASSIA 1 GM/50 ML VIAL |
|
|
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Z2H |
|
PROLASTIN C 1,000 MG VIAL |
|
|
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Z2H |
|
|
|
18 |
999 |
|
Auto PA |
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Z2H |
|
ZEMAIRA 1,000 MG VIAL |
|
|
18 |
999 |
|
Auto PA |
|
|||
|
|
|
|
|
|
|
|
||||||
|
|
|
Z2N |
1ST GEN ANTIHISTAMINE AND DECONGESTANT COMBINATION |
|
|
|
||||||
|
Z2N |
|
PROMETHAZINE VC SYRUP |
|
|
PHENYLEPHRINE HCL/PROMETH HCL |
0 |
20 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
||||
|
Z2N |
|
PHENYLEPHRINE HCL/PROMETH HCL |
0 |
20 |
|
No |
|
|||||
|
|
|
|
|
|
|
|
||||||
|
|
|
Z2O |
2ND GEN ANTIHISTAMINE AND DECONGESTANT COMBINATION |
|
|
|
||||||
|
Z2O |
|
ALL DAY |
|
|
CETIRIZINE HCL/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
||
|
Z2O |
|
ALLERGY & CONGESTION RLF TAB |
|
|
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 199 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
Z2O |
|
ALLERGY RELIEF & NASAL DECO TB |
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
ALLERGY RELIEF |
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
ALLERGY RELIEF |
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
CETIRIZINE HCL/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
CETIRIZINE HCL/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
CETIRIZINE HCL/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
HM ALLERGY & CONGESTION TABLET |
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
HM ALLERGY |
CETIRIZINE HCL/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
HM ALLERGY |
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
||||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
QC |
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
SM ALL DAY |
CETIRIZINE HCL/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
SM LORATADINE D 12 HOUR TABLET |
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
SM |
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2O |
|
SUNMARK |
LORATADINE/PSEUDOEPHEDRINE |
0 |
999 |
|
No |
|
|||
|
|
|
Z2P |
ANTIHISTAMINES - 1ST GENERATION |
|
|
|
|
|
|
|
|
|
Z2P |
|
CARBINOXAMINE 4 MG/5 ML LIQUID |
CARBINOXAMINE MALEATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
CARBINOXAMINE MALEATE 4 MG TAB |
CARBINOXAMINE MALEATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
CLEMASTINE FUM 2.68 MG TAB |
CLEMASTINE FUMARATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
CYPROHEPTADINE 2 MG/5 ML SYRUP |
CYPROHEPTADINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 200 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
Z2P |
|
CYPROHEPTADINE 4 MG TABLET |
CYPROHEPTADINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
CYPROHEPTADINE 4 MG/10 ML SYRP |
CYPROHEPTADINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
DIPHENHYDRAMINE 12.5 MG/5 ML |
DIPHENHYDRAMINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
DIPHENHYDRAMINE 25 MG/10 ML |
DIPHENHYDRAMINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
DIPHENHYDRAMINE 50 MG/ML SYN |
DIPHENHYDRAMINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
DIPHENHYDRAMINE 50 MG/ML SYRNG |
DIPHENHYDRAMINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
DIPHENHYDRAMINE 50 MG/ML VIAL |
DIPHENHYDRAMINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
DIPHENHYDRAMINE 50 MG/ML VL |
DIPHENHYDRAMINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
DIPHENHYDRAMINE ELIXIR |
DIPHENHYDRAMINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
DIPHENHYDRAMINE HCL 50 MG/ML |
DIPHENHYDRAMINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
HYDROXYZINE 10 MG/5 ML SYRUP |
HYDROXYZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
HYDROXYZINE HCL 10 MG TABLET |
HYDROXYZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
HYDROXYZINE HCL 25 MG TABLET |
HYDROXYZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
HYDROXYZINE HCL 50 MG TABLET |
HYDROXYZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
HYDROXYZINE PAM 100 MG CAP |
HYDROXYZINE PAMOATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
HYDROXYZINE PAM 25 MG CAP |
HYDROXYZINE PAMOATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
HYDROXYZINE PAM 50 MG CAP |
HYDROXYZINE PAMOATE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
PROMETHAZINE 12.5 MG TABLET |
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
PROMETHAZINE 25 MG TABLET |
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
PROMETHAZINE 25 MG/ML AMPUL |
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
PROMETHAZINE 25 MG/ML VIAL |
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
PROMETHAZINE 50 MG TABLET |
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
PROMETHAZINE 50 MG/ML AMPUL |
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
PROMETHAZINE 50 MG/ML VIAL |
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
Thursday, October 25, 2018 |
Page 201 of 204 |
|
Class |
|
Medicaid Drug Name |
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
|
|
|
|
Z2P |
|
PROMETHAZINE 6.25 MG/5 ML SYR |
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
PROMETHAZINE 6.25 MG/5 ML SYRP |
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2P |
|
PROMETHAZINE HCL 25MG TABLETS |
PROMETHAZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
Z2Q |
ANTIHISTAMINES - 2ND GENERATION |
|
|
|
|
|
|
|
|
|
Z2Q |
|
ALL DAY ALLERGY 10 MG TABLET |
CETIRIZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
ALL DAY ALLERGY 10 MG TABLET |
CETIRIZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
ALLERGY 10 MG TABLET |
LORATADINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
ALLERGY RELIEF 10 MG ODT |
LORATADINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
ALLERGY RELIEF 10 MG TABLET |
LORATADINE |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
ALLERGY RELIEF 5 MG/5 ML SOLN |
LORATADINE |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
CETIRIZINE HCL 1 MG/1 ML SOLN |
CETIRIZINE HCL |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
CETIRIZINE HCL 1 MG/ML SOLN |
CETIRIZINE HCL |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
CETIRIZINE HCL 1 MG/ML SYRUP |
CETIRIZINE HCL |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
CETIRIZINE HCL 10 MG CHEW TAB |
CETIRIZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
CETIRIZINE HCL 10 MG TABLET |
CETIRIZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
CETIRIZINE HCL 5 MG CHEW TAB |
CETIRIZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
CETIRIZINE HCL 5 MG TABLET |
CETIRIZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
CHILD ALL DAY ALLERGY 1 MG/ML |
CETIRIZINE HCL |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
CHILD CETIRIZINE 10 MG CHEW TB |
CETIRIZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
CHILD CETIRIZINE 5 MG CHEW TAB |
CETIRIZINE HCL |
0 |
999 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
CHILD CETIRIZINE HCL 1 MG/ML |
CETIRIZINE HCL |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
CHILD LORATADINE 5 MG/5 ML SOL |
LORATADINE |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
CHILD LORATADINE 5 MG/5 ML SYR |
LORATADINE |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
|
|
|
|
|||
|
Z2Q |
|
CHILDREN'S ALL DAY ALLERGY SOL |
CETIRIZINE HCL |
0 |
11 |
|
No |
|
|||
|
|
|
|
|
|
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Thursday, October 25, 2018 |
Page 202 of 204 |
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Class |
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Medicaid Drug Name |
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Generic Name |
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Medicaid |
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Medicaid |
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Clinical PA Required |
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Min Age |
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Max Age |
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Z2Q |
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CHILDS ALL DAY ALLERGY SOLU |
CETIRIZINE HCL |
0 |
11 |
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No |
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Z2Q |
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LORATADINE |
0 |
999 |
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No |
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||||
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Z2Q |
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LORATADINE |
0 |
999 |
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No |
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Z2Q |
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FEXOFENADINE HCL 180 MG TABLET |
FEXOFENADINE HCL |
0 |
999 |
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Cystic Fib Diag Auto PA |
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Z2Q |
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FEXOFENADINE HCL 30 MG/5 ML |
FEXOFENADINE HCL |
0 |
999 |
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Cystic Fib Diag Auto PA |
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Z2Q |
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FEXOFENADINE HCL 60 MG TABLET |
FEXOFENADINE HCL |
0 |
999 |
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Cystic Fib Diag Auto PA |
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Z2Q |
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HM ALL DAY ALLERGY 10 MG TAB |
CETIRIZINE HCL |
0 |
999 |
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No |
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Z2Q |
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HM CHILD CETIRIZINE 1 MG/ML |
CETIRIZINE HCL |
0 |
11 |
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No |
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Z2Q |
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HM CHILD LORATADINE 5 MG/5 ML |
LORATADINE |
0 |
11 |
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No |
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Z2Q |
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HM FEXOFENADINE HCL 180 MG TAB |
FEXOFENADINE HCL |
0 |
999 |
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Cystic Fib Diag Auto PA |
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Z2Q |
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HM FEXOFENADINE HCL 60 MG TAB |
FEXOFENADINE HCL |
0 |
999 |
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Cystic Fib Diag Auto PA |
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Z2Q |
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HM LORATADINE 10 MG TABLET |
LORATADINE |
0 |
999 |
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No |
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Z2Q |
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LEVOCETIRIZINE 2.5 MG/5 ML SOL |
LEVOCETIRIZINE DIHYDROCHLORIDE |
0 |
999 |
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Cystic Fib Diag Auto PA |
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Z2Q |
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LEVOCETIRIZINE 5 MG TABLET |
LEVOCETIRIZINE DIHYDROCHLORIDE |
0 |
999 |
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No |
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Z2Q |
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LORATADINE 10 MG TABLET |
LORATADINE |
0 |
999 |
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No |
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Z2Q |
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LORATADINE 10 MG TABLET |
LORATADINE |
0 |
999 |
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No |
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Z2Q |
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LORATADINE 5 MG/5 ML SOLN |
LORATADINE |
0 |
11 |
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No |
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Z2Q |
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LORATADINE 5 MG/5 ML SYRUP |
LORATADINE |
0 |
11 |
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No |
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Z2Q |
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LORATADINE ALLERGY 5 MG/5 ML |
LORATADINE |
0 |
11 |
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No |
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Z2Q |
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LORATADINE HIVES 5 MG/5 ML |
LORATADINE |
0 |
11 |
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No |
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Z2Q |
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QC ALL DAY ALLERGY 10 MG TAB |
CETIRIZINE HCL |
0 |
999 |
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No |
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Z2Q |
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QC FEXOFENADINE HCL 180 MG TAB |
FEXOFENADINE HCL |
0 |
999 |
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Cystic Fib Diag Auto PA |
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Z2Q |
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QC LORATADINE 10 MG TABLET |
LORATADINE |
0 |
999 |
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No |
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Z2Q |
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SB ALLERGY 10 MG TABLET |
CETIRIZINE HCL |
0 |
999 |
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No |
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Thursday, October 25, 2018 |
Page 203 of 204 |
|
Class |
|
Medicaid Drug Name |
|
|
Generic Name |
|
Medicaid |
|
Medicaid |
|
Clinical PA Required |
|
|
|
|
|
|
|
|
|
Min Age |
|
Max Age |
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|
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|
Z2Q |
|
SB LORATADINE 10 MG TABLET |
|
|
LORATADINE |
0 |
999 |
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No |
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Z2Q |
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SM ALL DAY ALLERGY 10 MG TAB |
|
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CETIRIZINE HCL |
0 |
999 |
|
No |
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Z2Q |
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SM ALLERGY RELIEF 10 MG TB |
|
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LORATADINE |
0 |
999 |
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No |
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Z2Q |
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SM CHILD ALL DAY ALLER 1 MG/ML |
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CETIRIZINE HCL |
0 |
11 |
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No |
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Z2Q |
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SM CHILD LORATADINE 5 MG/5 ML |
|
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LORATADINE |
0 |
11 |
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No |
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Z2Q |
|
SM CHILDREN'S ALL DAY ALLERGY |
|
|
CETIRIZINE HCL |
0 |
999 |
|
No |
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Z2Q |
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SM FEXOFENADINE HCL 180 MG TAB |
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FEXOFENADINE HCL |
0 |
999 |
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Cystic Fib Diag Auto PA |
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Z2Q |
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SM FEXOFENADINE HCL 60 MG TAB |
|
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FEXOFENADINE HCL |
0 |
999 |
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Cystic Fib Diag Auto PA |
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Z2Q |
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SM LORATADINE 10 MG TABLET |
|
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LORATADINE |
0 |
999 |
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No |
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Z2Q |
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SM LORATADINE 5 MG/5 ML SYRUP |
|
|
LORATADINE |
0 |
11 |
|
No |
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||||
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Z2W |
|
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|||||
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Z2W |
|
ARZERRA 1,000 MG/50 ML VIAL |
|
|
OFATUMUMAB |
0 |
999 |
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No |
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Z2W |
|
ARZERRA 100 MG/5 ML VIAL |
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OFATUMUMAB |
0 |
999 |
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No |
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Z2W |
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RITUXAN 10 MG/ML VIAL |
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RITUXIMAB |
0 |
999 |
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No |
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Z2Z |
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JANUS KINASE (JAK) INHIBITORS |
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Z2Z |
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XELJANZ 10 MG TABLET |
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TOFACITINIB CITRATE |
18 |
999 |
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Auto PA |
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Z2Z |
|
XELJANZ 5 MG TABLET |
|
|
TOFACITINIB CITRATE |
18 |
999 |
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Auto PA |
|
||
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Z2Z |
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XELJANZ XR 11 MG TABLET |
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TOFACITINIB CITRATE |
18 |
999 |
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Auto PA |
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Z4B |
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LEUKOTRIENE RECEPTOR ANTAGONISTS |
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Z4B |
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MONTELUKAST SOD 10 MG TABLET |
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MONTELUKAST SODIUM |
0 |
999 |
|
No |
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Z4B |
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MONTELUKAST SOD 4 MG TAB CHEW |
|
|
MONTELUKAST SODIUM |
0 |
999 |
|
No |
|
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Z4B |
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MONTELUKAST SOD 5 MG TAB CHEW |
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MONTELUKAST SODIUM |
0 |
999 |
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No |
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Z9D |
DIAGNOSTIC PREPARATIONS,MISCELLANEOUS |
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Z9D |
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GLUCAGEN DIAGNOSTIC 1 MG VIAL |
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GLUCAGON,HUMAN RECOMBINANT |
0 |
999 |
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No |
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Z9D |
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GLUCAGON 1 MG VIAL |
|
|
GLUCAGON HCL |
0 |
999 |
|
No |
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Thursday, October 25, 2018 |
Page 204 of 204 |