“auto pa” = system automated criteria looks for specific ... · florida medicaid preferred drug...
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Florida Medicaid Preferred Drug List (updated 05-14-2019)
The Florida Medicaid Preferred Drug List (PDL) is subject to revision following consideration and recommendations by the
Pharmaceutical and Therapeutics (PT) Committee and the Agency for Health Care Administration. The quarterly PT Committee
meeting was held on March 22, 2019.
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.
Tuesday, May 14, 2019 Page 1 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
A1A DIGITALIS GLYCOSIDESA1A DIGOXIN 0 999DIGOXIN 0.125 MG TABLET No
A1A DIGOXIN 0 999DIGOXIN 0.25 MG TABLET No
A1A DIGOXIN 0 999DIGOXIN 125 MCG TABLET No
A1A DIGOXIN 0 999DIGOXIN 250 MCG TABLET No
A1A DIGOXIN 0 999DIGOXIN 50 MCG/ML SOLUTION No
A1B XANTHINESA1B CAFFEINE CITRATE 1 999CAFFEINE CIT 20 MG/ML ORAL SOL No
A1B CAFFEINE CITRATE 1 999CAFFEINE CIT 60 MG/3 ML ORAL No
A1B CAFFEINE CITRATE 1 999CAFFEINE CIT 60 MG/3 ML VIAL No
A1B CAFFEINE CITRATE 1 999CAFFEINE CITRATE 20 MG/ML VIAL No
A1B CAFFEINE CITRATE 1 999CAFFEINE CITRATE 60 MG/3 ML VL No
A1B THEOPHYLLINE ANHYDROUS 0 999ELIXOPHYLLIN 80 MG/15 ML ELIX No
A1B THEOPHYLLINE ANHYDROUS 0 999THEO-24 ER 100 MG CAPSULE No
A1B THEOPHYLLINE ANHYDROUS 0 999THEO-24 ER 200 MG CAPSULE No
A1B THEOPHYLLINE ANHYDROUS 0 999THEO-24 ER 300 MG CAPSULE No
A1B THEOPHYLLINE ANHYDROUS 0 999THEO-24 ER 400 MG CAPSULE No
A1B THEOPHYLLINE ANHYDROUS 0 999THEOPHYLLINE 100 MG TAB SA No
A1B THEOPHYLLINE ANHYDROUS 0 999THEOPHYLLINE 200 MG TAB SA No
A1B THEOPHYLLINE ANHYDROUS 0 999THEOPHYLLINE 300 MG TAB SA No
Tuesday, May 14, 2019 Page 2 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
A1B THEOPHYLLINE ANHYDROUS 0 999THEOPHYLLINE 450 MG TAB SA No
A1B THEOPHYLLINE ANHYDROUS 0 999THEOPHYLLINE 80 MG/15 ML SOLN No
A1B THEOPHYLLINE ANHYDROUS 0 999THEOPHYLLINE ER 300 MG TAB No
A1B THEOPHYLLINE ANHYDROUS 0 999THEOPHYLLINE ER 400 MG TABLET No
A1B THEOPHYLLINE ANHYDROUS 0 999THEOPHYLLINE ER 450 MG TAB No
A1B THEOPHYLLINE ANHYDROUS 0 999THEOPHYLLINE ER 600 MG TABLET No
A1C INOTROPIC DRUGSA1C DOBUTAMINE HCL IN DEXTROSE 5 % 0 999DOBUTAMINE 1 GM/D5W 250 ML No
A1C DOBUTAMINE HCL 0 999DOBUTAMINE 12.5 MG/ML VIAL No
A1C DOBUTAMINE HCL 0 999DOBUTAMINE 250 MG/20 ML VIAL No
A1C DOBUTAMINE HCL IN DEXTROSE 5 % 0 999DOBUTAMINE 250 MG/D5W 250 ML No
A1C DOBUTAMINE HCL IN DEXTROSE 5 % 0 999DOBUTAMINE 500 MG/D5W 250 ML No
A1C MILRINONE LACTATE/D5W 0 999MILRINONE 0.2 MG/ML IN D5W No
A1C MILRINONE LACTATE 0 999MILRINONE LACT 10 MG/10 ML VL No
A1C MILRINONE LACTATE 0 999MILRINONE LACT 20 MG/20 ML VL No
A1C MILRINONE LACTATE 0 999MILRINONE LACT 50 MG/50 ML VL No
A1C MILRINONE LACTATE 0 999MILRINONE LACTATE 1 MG/ML VL No
A1C MILRINONE LACTATE/D5W 0 999MILRINONE-D5W 20 MG/100 ML No
A1C MILRINONE LACTATE/D5W 0 999MILRINONE-D5W 40 MG/200 ML No
A2A ANTIARRHYTHMICSA2A AMIODARONE HCL 0 999AMIODARONE HCL 100 MG TABLET No
A2A AMIODARONE HCL 0 999AMIODARONE HCL 200 MG TABLET No
A2A DISOPYRAMIDE PHOSPHATE 0 999DISOPYRAMIDE 100 MG CAPSULE No
A2A DISOPYRAMIDE PHOSPHATE 0 999DISOPYRAMIDE 150 MG CAPSULE No
Tuesday, May 14, 2019 Page 3 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
A2A FLECAINIDE ACETATE 0 999FLECAIDIDE ACETATE 150 MG TAB No
A2A FLECAINIDE ACETATE 0 999FLECAINIDE ACETATE 100 MG TAB No
A2A FLECAINIDE ACETATE 0 999FLECAINIDE ACETATE 100 MG TB No
A2A FLECAINIDE ACETATE 0 999FLECAINIDE ACETATE 150 MG TAB No
A2A FLECAINIDE ACETATE 0 999FLECAINIDE ACETATE 150 MG TB No
A2A FLECAINIDE ACETATE 0 999FLECAINIDE ACETATE 50 MG TAB No
A2A MEXILETINE HCL 0 999MEXILETINE 150 MG CAPSULE No
A2A MEXILETINE HCL 0 999MEXILETINE 200 MG CAPSULE No
A2A MEXILETINE HCL 0 999MEXILETINE 250 MG CAPSULE No
A2A PROPAFENONE HCL 0 999PROPAFENONE HCL 150 MG TAB No
A2A PROPAFENONE HCL 0 999PROPAFENONE HCL 150 MG TABLET No
A2A PROPAFENONE HCL 0 999PROPAFENONE HCL 225 MG TAB No
A2A PROPAFENONE HCL 0 999PROPAFENONE HCL 300 MG TAB No
A2A QUINIDINE GLUCONATE 0 999QUINIDINE GLUC 324 MG TAB SA No
A2A QUINIDINE SULFATE 0 999QUINIDINE SULFATE 200 MG TAB No
A2A QUINIDINE SULFATE 0 999QUINIDINE SULFATE 300 MG TAB No
A2A DOFETILIDE 0 999TIKOSYN 125 MCG CAPSULE Requires Med Cert 3
A2A DOFETILIDE 0 999TIKOSYN 250 MCG CAPSULE Requires Med Cert 3
A2A DOFETILIDE 0 999TIKOSYN 500 MCG CAPSULE Requires Med Cert 3
A2C ANTIANGINAL, ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMICA2C RANOLAZINE 0 999RANEXA ER 1,000 MG TABLET No
A2C RANOLAZINE 0 999RANEXA ER 500 MG TABLET No
A4A ANTIHYPERTENSIVES, VASODILATORSA4A HYDRALAZINE HCL 0 999HYDRALAZINE 10 MG TABLET No
Tuesday, May 14, 2019 Page 4 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
A4A HYDRALAZINE HCL 0 999HYDRALAZINE 100 MG TABLET No
A4A HYDRALAZINE HCL 0 999HYDRALAZINE 25 MG TABLET No
A4A HYDRALAZINE HCL 0 999HYDRALAZINE 50 MG TABLET No
A4A MINOXIDIL 0 999MINOXIDIL 10 MG TABLET No
A4A MINOXIDIL 0 999MINOXIDIL 2.5 MG TABLET No
A4B ANTIHYPERTENSIVES, SYMPATHOLYTICA4B CLONIDINE 0 999CATAPRES-TTS 1 PATCH No
A4B CLONIDINE 0 999CATAPRES-TTS 2 PATCH No
A4B CLONIDINE 0 999CATAPRES-TTS 3 PATCH No
A4B CLONIDINE HCL 0 999CLONIDINE HCL 0.1 MG TABLET No
A4B CLONIDINE HCL 0 999CLONIDINE HCL 0.2 MG TABLET No
A4B CLONIDINE HCL 0 999CLONIDINE HCL 0.3 MG TABLET No
A4B GUANFACINE HCL 0 999GUANFACINE 1 MG TABLET No
A4B GUANFACINE HCL 0 999GUANFACINE 2 MG TABLET No
A4B METHYLDOPA 0 999METHYLDOPA 250 MG TABLET No
A4B METHYLDOPA 0 999METHYLDOPA 500 MG TABLET No
A4D ANTIHYPERTENSIVES, ACE INHIBITORSA4D BENAZEPRIL HCL 0 999BENAZEPRIL HCL 10 MG TABLET No
A4D BENAZEPRIL HCL 0 999BENAZEPRIL HCL 20 MG TABLET No
A4D BENAZEPRIL HCL 0 999BENAZEPRIL HCL 40 MG TABLET No
A4D BENAZEPRIL HCL 0 999BENAZEPRIL HCL 5 MG TABLET No
A4D ENALAPRIL MALEATE 0 999ENALAPRIL MALEATE 10 MG TAB No
A4D ENALAPRIL MALEATE 0 999ENALAPRIL MALEATE 10 MG TABLET No
A4D ENALAPRIL MALEATE 0 999ENALAPRIL MALEATE 2.5 MG TAB No
Tuesday, May 14, 2019 Page 5 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
A4D ENALAPRIL MALEATE 0 999ENALAPRIL MALEATE 20 MG TAB No
A4D ENALAPRIL MALEATE 0 999ENALAPRIL MALEATE 20 MG TABLET No
A4D ENALAPRIL MALEATE 0 999ENALAPRIL MALEATE 5 MG TAB No
A4D ENALAPRIL MALEATE 0 999ENALAPRIL MALEATE 5 MG TABLET No
A4D FOSINOPRIL SODIUM 0 999FOSINOPRIL SODIUM 10 MG TAB No
A4D FOSINOPRIL SODIUM 0 999FOSINOPRIL SODIUM 20 MG TAB No
A4D FOSINOPRIL SODIUM 0 999FOSINOPRIL SODIUM 40 MG TAB No
A4D LISINOPRIL 0 999LISINOPRIL 10 MG TABLET No
A4D LISINOPRIL 0 999LISINOPRIL 2.5 MG TABLET No
A4D LISINOPRIL 0 999LISINOPRIL 20 MG TABLET No
A4D LISINOPRIL 0 999LISINOPRIL 30 MG TABLET No
A4D LISINOPRIL 0 999LISINOPRIL 40 MG TABLET No
A4D LISINOPRIL 0 999LISINOPRIL 5 MG TABLET No
A4D QUINAPRIL HCL 0 999QUINAPRIL 10 MG TABLET No
A4D QUINAPRIL HCL 0 999QUINAPRIL 20 MG TABLET No
A4D QUINAPRIL HCL 0 999QUINAPRIL 40 MG TABLET No
A4D QUINAPRIL HCL 0 999QUINAPRIL 5 MG TABLET No
A4D QUINAPRIL HCL 0 999QUINAPRIL HCL 10 MG TABLET No
A4D QUINAPRIL HCL 0 999QUINAPRIL HCL 5 MG TABLET No
A4D RAMIPRIL 0 999RAMIPRIL 1.25 MG CAPSULE No
A4D RAMIPRIL 0 999RAMIPRIL 10 MG CAPSULE No
A4D RAMIPRIL 0 999RAMIPRIL 2.5 MG CAPSULE No
A4D RAMIPRIL 0 999RAMIPRIL 5 MG CAPSULE No
A4F ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST
Tuesday, May 14, 2019 Page 6 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
A4F IRBESARTAN 0 999IRBESARTAN 150 MG TABLET No
A4F IRBESARTAN 0 999IRBESARTAN 300 MG TABLET No
A4F IRBESARTAN 0 999IRBESARTAN 75 MG TABLET No
A4F LOSARTAN POTASSIUM 0 999LOSARTAN POTASSIUM 100 MG TAB No
A4F LOSARTAN POTASSIUM 0 999LOSARTAN POTASSIUM 25 MG TAB No
A4F LOSARTAN POTASSIUM 0 999LOSARTAN POTASSIUM 50 MG TAB No
A4F OLMESARTAN MEDOXOMIL 0 999OLMESARTAN MEDOXOMIL 20 MG TAB No
A4F OLMESARTAN MEDOXOMIL 0 999OLMESARTAN MEDOXOMIL 40 MG TAB No
A4F OLMESARTAN MEDOXOMIL 0 999OLMESARTAN MEDOXOMIL 5 MG TAB No
A4H ANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKRA4H AMLODIPINE BES/OLMESARTAN MED 0 999AMLODIPINE-OLMESARTAN 10-20 MG No
A4H AMLODIPINE BES/OLMESARTAN MED 0 999AMLODIPINE-OLMESARTAN 10-40 MG No
A4H AMLODIPINE BES/OLMESARTAN MED 0 999AMLODIPINE-OLMESARTAN 5-20 MG No
A4H AMLODIPINE BES/OLMESARTAN MED 0 999AMLODIPINE-OLMESARTAN 5-40 MG No
A4H AMLODIPINE BESYLATE/VALSARTAN 0 999AMLODIPINE-VALSARTAN 10-160 MG No
A4H AMLODIPINE BESYLATE/VALSARTAN 0 999AMLODIPINE-VALSARTAN 10-320 MG No
A4H AMLODIPINE BESYLATE/VALSARTAN 0 999AMLODIPINE-VALSARTAN 5-160 MG No
A4H AMLODIPINE BESYLATE/VALSARTAN 0 999AMLODIPINE-VALSARTAN 5-320 MG No
A4I ANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMBA4I LOSARTAN/HYDROCHLOROTHIAZIDE 0 999LOSARTAN-HCTZ 100-12.5 MG TAB No
A4I LOSARTAN/HYDROCHLOROTHIAZIDE 0 999LOSARTAN-HCTZ 100-25 MG TAB No
A4I LOSARTAN/HYDROCHLOROTHIAZIDE 0 999LOSARTAN-HCTZ 100-25 MG TABLET No
A4I LOSARTAN/HYDROCHLOROTHIAZIDE 0 999LOSARTAN-HCTZ 50-12.5 MG TAB No
A4J ACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETICA4J ENALAPRIL/HYDROCHLOROTHIAZIDE 0 999ENALAPRIL/HCTZ 10-25MG TAB No
Tuesday, May 14, 2019 Page 7 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
A4J ENALAPRIL/HYDROCHLOROTHIAZIDE 0 999ENALAPRIL/HCTZ 5-12.5MG TAB No
A4J ENALAPRIL/HYDROCHLOROTHIAZIDE 0 999ENALAPRIL-HCTZ 10-25 MG TAB No
A4J ENALAPRIL/HYDROCHLOROTHIAZIDE 0 999ENALAPRIL-HCTZ 10-25 MG TABLET No
A4J ENALAPRIL/HYDROCHLOROTHIAZIDE 0 999ENALAPRIL-HCTZ 5-12.5 MG TAB No
A4J ENALAPRIL/HYDROCHLOROTHIAZIDE 0 999ENALAPRIL-HCTZ 5-12.5MG TAB No
A4J FOSINOPRIL/HYDROCHLOROTHIAZIDE 0 999FOSINOPRIL-HCTZ 10-12.5 MG TAB No
A4J FOSINOPRIL/HYDROCHLOROTHIAZIDE 0 999FOSINOPRIL-HCTZ 20-12.5 MG TAB No
A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 10/12.5 TAB No
A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 10/12.5 TB No
A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 10-12.5 MG TAB No
A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 10-12.5 TAB No
A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 20/12.5 TAB No
A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 20/12.5 TB No
A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 20/25 TAB No
A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 20/25MG TB No
A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 20-12.5 MG TAB No
A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 20-12.5 TAB No
A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 20-25 MG TAB No
A4J LISINOPRIL/HYDROCHLOROTHIAZIDE 0 999LISINOPRIL-HCTZ 20-25 TAB No
A4J QUINAPRIL/HYDROCHLOROTHIAZIDE 0 999QUINAPRIL-HCTZ 10-12.5 MG TAB No
A4J QUINAPRIL/HYDROCHLOROTHIAZIDE 0 999QUINAPRIL-HCTZ 20-12.5 MG TAB No
A4J QUINAPRIL/HYDROCHLOROTHIAZIDE 0 999QUINAPRIL-HCTZ 20-25 MG TAB No
A4K ACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATIONA4K AMLODIPINE BESYLATE/BENAZEPRIL 0 999AMLODIPINE-BENAZEPRIL 10/20 MG No
Tuesday, May 14, 2019 Page 8 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
A4K AMLODIPINE BESYLATE/BENAZEPRIL 0 999AMLODIPINE-BENAZEPRIL 10-20 MG No
A4K AMLODIPINE BESYLATE/BENAZEPRIL 0 999AMLODIPINE-BENAZEPRIL 10-40 MG No
A4K AMLODIPINE BESYLATE/BENAZEPRIL 0 999AMLODIPINE-BENAZEPRIL 2.5/10 No
A4K AMLODIPINE BESYLATE/BENAZEPRIL 0 999AMLODIPINE-BENAZEPRIL 2.5-10 No
A4K AMLODIPINE BESYLATE/BENAZEPRIL 0 999AMLODIPINE-BENAZEPRIL 5/10 MG No
A4K AMLODIPINE BESYLATE/BENAZEPRIL 0 999AMLODIPINE-BENAZEPRIL 5/20 MG No
A4K AMLODIPINE BESYLATE/BENAZEPRIL 0 999AMLODIPINE-BENAZEPRIL 5-10 MG No
A4K AMLODIPINE BESYLATE/BENAZEPRIL 0 999AMLODIPINE-BENAZEPRIL 5-20 MG No
A4K AMLODIPINE BESYLATE/BENAZEPRIL 0 999AMLODIPINE-BENAZEPRIL 5-40 MG No
A4L ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI)A4L SACUBITRIL/VALSARTAN 0 999ENTRESTO 24 MG-26 MG TABLET No
A4L SACUBITRIL/VALSARTAN 0 999ENTRESTO 49 MG-51 MG TABLET No
A4L SACUBITRIL/VALSARTAN 0 999ENTRESTO 97 MG-103 MG TABLET No
A7B VASODILATORS,CORONARYA7B ISOSORBIDE DINITRATE 0 999ISOSORBIDE DINITRATE 10 MG TAB No
A7B ISOSORBIDE DINITRATE 0 999ISOSORBIDE DINITRATE 20 MG TAB No
A7B ISOSORBIDE DINITRATE 0 999ISOSORBIDE DINITRATE 5 MG TAB No
A7B ISOSORBIDE DINITRATE 0 999ISOSORBIDE DN 10 MG TABLET No
A7B ISOSORBIDE DINITRATE 0 999ISOSORBIDE DN 20 MG TABLET No
A7B ISOSORBIDE DINITRATE 0 999ISOSORBIDE DN 30 MG TABLET No
A7B ISOSORBIDE DINITRATE 0 999ISOSORBIDE DN 5 MG TABLET No
A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MN 10 MG TABLET No
A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MN 120 MG TAB SA No
A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MN 20 MG TABLET No
Tuesday, May 14, 2019 Page 9 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MN 30 MG TAB SA No
A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MN 30 MG TABLET ER No
A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MN 60 MG TAB ER No
A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MN 60 MG TAB SA No
A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MN 60 MG TABLET ER No
A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MN ER 120 MG TAB No
A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MN ER 30 MG TABLET No
A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MN ER 60 MG TABLET No
A7B ISOSORBIDE MONONITRATE 0 999ISOSORBIDE MONONIT ER 120 MG No
A7B NITROGLYCERIN 0 999NITROGLYCERIN 0.1 MG/HR PATCH No
A7B NITROGLYCERIN 0 999NITROGLYCERIN 0.1 MG/HR PTCH No
A7B NITROGLYCERIN 0 999NITROGLYCERIN 0.2 MG/HR PATCH No
A7B NITROGLYCERIN 0 999NITROGLYCERIN 0.2 MG/HR PTCH No
A7B NITROGLYCERIN 0 999NITROGLYCERIN 0.3 MG TABLET SL No
A7B NITROGLYCERIN 0 999NITROGLYCERIN 0.4 MG TABLET SL No
A7B NITROGLYCERIN 0 999NITROGLYCERIN 0.4 MG/HR PATCH No
A7B NITROGLYCERIN 0 999NITROGLYCERIN 0.4 MG/HR PTCH No
A7B NITROGLYCERIN 0 999NITROGLYCERIN 0.6 MG TABLET SL No
A7B NITROGLYCERIN 0 999NITROGLYCERIN 0.6 MG/HR PATCH No
A7B NITROGLYCERIN 0 999NITROGLYCERIN 0.6 MG/HR PTCH No
A7M BRADYKININ B2 RECEPTOR ANTAGONISTSA7M ICATIBANT ACETATE 18 999FIRAZYR 30 MG/3 ML SYRINGE Auto PA
A9A CALCIUM CHANNEL BLOCKING AGENTSA9A AMLODIPINE BESYLATE 0 999AMLODIPINE BESYLATE 10 MG TAB No
Tuesday, May 14, 2019 Page 10 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
A9A AMLODIPINE BESYLATE 0 999AMLODIPINE BESYLATE 2.5 MG TAB No
A9A AMLODIPINE BESYLATE 0 999AMLODIPINE BESYLATE 5 MG TAB No
A9A DILTIAZEM HCL 0 999DILTIAZEM 120 MG CAPSULE SA No
A9A DILTIAZEM HCL 0 999DILTIAZEM 120 MG TABLET No
A9A DILTIAZEM HCL 0 999DILTIAZEM 24HR CD 360 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM 24HR ER 120 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM 24HR ER 120 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM 24HR ER 180 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM 24HR ER 180 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM 24HR ER 240 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM 24HR ER 240 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM 24HR ER 300 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM 24HR ER 300 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM 24HR ER 360 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM 24HR ER 360 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM 30 MG TABLET No
A9A DILTIAZEM HCL 0 999DILTIAZEM 60 MG CAPSULE SA No
A9A DILTIAZEM HCL 0 999DILTIAZEM 60 MG TABLET No
A9A DILTIAZEM HCL 0 999DILTIAZEM 90 MG CAPSULE SA No
A9A DILTIAZEM HCL 0 999DILTIAZEM 90 MG TABLET No
A9A DILTIAZEM HCL 0 999DILTIAZEM ER 120 MG CAP SA No
A9A DILTIAZEM HCL 0 999DILTIAZEM ER 120 MG CAP SA No
A9A DILTIAZEM HCL 0 999DILTIAZEM ER 120 MG CAPSULE No
A9A DILTIAZEM HCL 0 999DILTIAZEM ER 120 MG CAPSULE No
Tuesday, May 14, 2019 Page 11 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
A9A DILTIAZEM HCL 0 999DILTIAZEM ER 180 MG CAP SA No
A9A DILTIAZEM HCL 0 999DILTIAZEM ER 180 MG CAPSULE No
A9A DILTIAZEM HCL 0 999DILTIAZEM ER 240 MG CAP SA No
A9A DILTIAZEM HCL 0 999DILTIAZEM ER 60 MG CAP SA No
A9A DILTIAZEM HCL 0 999DILTIAZEM ER 90 MG CAP SA No
A9A DILTIAZEM HCL 0 999DILTIAZEM HCL ER 120 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM HCL ER 180 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM HCL ER 240 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM HCL ER 300 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM HCL ER 360 MG CAP No
A9A DILTIAZEM HCL 0 999DILTIAZEM HCL ER 420 MG CAP No
A9A FELODIPINE 0 999FELODIPINE ER 10 MG TABLET No
A9A FELODIPINE 0 999FELODIPINE ER 2.5 MG TABLET No
A9A FELODIPINE 0 999FELODIPINE ER 5 MG TABLET No
A9A NIFEDIPINE 0 999NIFEDIPINE 10 MG CAPSULE No
A9A NIFEDIPINE 0 999NIFEDIPINE 20 MG CAPSULE No
A9A NIFEDIPINE 0 999NIFEDIPINE ER 30 MG TABLET No
A9A NIFEDIPINE 0 999NIFEDIPINE ER 60 MG TABLET No
A9A NIFEDIPINE 0 999NIFEDIPINE ER 90 MG TABLET No
A9A NIMODIPINE 18 999NIMODIPINE 30 MG CAPSULE No
A9A VERAPAMIL HCL 0 999VERAPAMIL 120 MG CAP PELLET No
A9A VERAPAMIL HCL 0 999VERAPAMIL 120 MG CAP PELLET No
A9A VERAPAMIL HCL 0 999VERAPAMIL 120 MG TABLET No
A9A VERAPAMIL HCL 0 999VERAPAMIL 120 MG TABLET SA No
Tuesday, May 14, 2019 Page 12 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
A9A VERAPAMIL HCL 0 999VERAPAMIL 180 MG CAP PELLET No
A9A VERAPAMIL HCL 0 999VERAPAMIL 180 MG CAP PELLET No
A9A VERAPAMIL HCL 0 999VERAPAMIL 180 MG TABLET SA No
A9A VERAPAMIL HCL 0 999VERAPAMIL 240 MG CAP PELLET No
A9A VERAPAMIL HCL 0 999VERAPAMIL 240 MG CAP PELLET No
A9A VERAPAMIL HCL 0 999VERAPAMIL 240 MG TABLET SA No
A9A VERAPAMIL HCL 0 999VERAPAMIL 360 MG CAP PELLET No
A9A VERAPAMIL HCL 0 999VERAPAMIL 40 MG TABLET No
A9A VERAPAMIL HCL 0 999VERAPAMIL 80 MG TABLET No
A9A VERAPAMIL HCL 0 999VERAPAMIL ER 120 MG TABLET No
A9A VERAPAMIL HCL 0 999VERAPAMIL ER 180 MG TABLET No
A9A VERAPAMIL HCL 0 999VERAPAMIL ER 240 MG TABLET No
B0A GENERAL INHALATION AGENTSB0A SODIUM CHLORIDE FOR INHALATION 0 999SODIUM CHLORIDE 0.9% VIAL No
B0A SODIUM CHLORIDE FOR INHALATION 0 999SODIUM CHLORIDE 10% VIAL Auto PA
B1B PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONISTB1B AMBRISENTAN 0 999LETAIRIS 10 MG TABLET Clinical PA Required
B1B AMBRISENTAN 0 999LETAIRIS 5 MG TABLET Clinical PA Required
B1B BOSENTAN 0 999TRACLEER 125 MG TABLET Clinical PA Required
B1B BOSENTAN 0 999TRACLEER 62.5 MG TABLET Clinical PA Required
B1C PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPEB1C EPOPROSTENOL SODIUM (GLYCINE) 0 999EPOPROSTENOL SODIUM 0.5 MG VL No
B1C EPOPROSTENOL SODIUM (GLYCINE) 0 999EPOPROSTENOL SODIUM 1.5 MG VL No
B1C ILOPROST TROMETHAMINE 0 999VENTAVIS 10 MCG/1 ML SOLUTION Clinical PA Required
B1C ILOPROST TROMETHAMINE 0 999VENTAVIS 20 MCG/1 ML SOLUTION Clinical PA Required
Tuesday, May 14, 2019 Page 13 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
B1D PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIBB1D SILDENAFIL CITRATE 0 999SILDENAFIL 20 MG TABLET Clinical PA Required
B3A MUCOLYTICSB3A ACETYLCYSTEINE 0 999ACETYLCYSTEINE 10% VIAL No
B3A ACETYLCYSTEINE 0 999ACETYLCYSTEINE 20% VIAL No
B3A DORNASE ALFA 0 65PULMOZYME 1 MG/ML AMPUL Auto PA
B3J EXPECTORANTSB3J GUAIFENESIN 0 999CHL MUCINEX CHEST CONGEST LIQ No
B3J GUAIFENESIN 0 999GUAIFENESIN 100 MG/5 ML SOLN No
B3J GUAIFENESIN 0 999GUAIFENESIN 100 MG/5 ML SYRUP No
B3J GUAIFENESIN 0 999GUAIFENESIN 200 MG/10 ML SOLN No
B3J GUAIFENESIN 0 999GUAIFENESIN 300 MG/15 ML SOLN No
B3J GUAIFENESIN 0 999GUAIFENESIN ER 1,200 MG TABLET No
B3J GUAIFENESIN 0 999KID'S MUCINEX MINI-MELTS PACK No
B3J GUAIFENESIN 0 999MUCINEX 600 MG TABLET No
B3J GUAIFENESIN 0 999MUCINEX ER 1,200 MG TABLET No
B3J GUAIFENESIN 0 999MUCINEX ER 600 MG TABLET No
B3R NON-OPIOID ANTITUS-1ST GEN.ANTIHISTAMINE-DECONGESTB3R BROMPHENIRAMINE/PSEUDOEPHED/DM 0 20BROMIPHENIR-PSEUDOEPHED-DM SYR No
B3R BROMPHENIRAMINE/PSEUDOEPHED/DM 0 20BROMPHENIR-PSEUDOEPHED-DM SYR No
B3T NON-OPIOID ANTITUSSIVE AND EXPECTORANT COMBINATIONB3T GUAIFENESIN/DEXTROMETHORPHAN 0 20GUAIFENESIN DM SYRUP No
B3T GUAIFENESIN/DEXTROMETHORPHAN 0 20GUAIFENESIN-DM ER 1,200-60 MG No
B4C OPIOID ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONSB4C HYDROCODONE BIT/HOMATROP ME-BR 18 20HYDROCODONE COMPOUND SYRUP No
B4C HYDROCODONE BIT/HOMATROP ME-BR 18 20HYDROCODONE-HOMATROPINE SOLN No
Tuesday, May 14, 2019 Page 14 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
B4C HYDROCODONE BIT/HOMATROP ME-BR 18 20HYDROCODONE-HOMATROPINE SYRUP No
B4E NON-OPIOID ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB.B4E PROMETHAZINE/DEXTROMETHORPHAN 0 20PROMETHAZINE DM SYRUP No
B4E PROMETHAZINE/DEXTROMETHORPHAN 0 20PROMETHAZINE W/DM SYRUP No
B60 ANTICHOLINERGICS, ORALLY INHALED SHORT ACTINGB60 IPRATROPIUM BROMIDE 0 999ATROVENT HFA INHALER No
B60 IPRATROPIUM BROMIDE 0 999IPRATROPIUM BR 0.02% SOLN No
B61 ANTICHOLINERGICS, ORALLY INHALED LONG ACTINGB61 TIOTROPIUM BROMIDE 18 999SPIRIVA 18 MCG CP-HANDIHALER No
B62 BETA-ADRENERGIC AND ANTICHOLINERGIC COMBO, INHALEDB62 GLYCOPYRROLATE/FORMOTEROL FUM 0 999BEVESPI AEROSPHERE INHALER No
B62 IPRATROPIUM/ALBUTEROL SULFATE 0 999COMBIVENT RESPIMAT INHAL SPRAY No
B62 IPRATROPIUM/ALBUTEROL SULFATE 0 999IPRAT-ALBUT 0.5-3(2.5) MG/3 ML No
B62 IPRATROPIUM/ALBUTEROL SULFATE 0 999IPRATR-ALBUTEROL 0.5-3 MG/3 ML No
B62 TIOTROPIUM BR/OLODATEROL HCL 0 999STIOLTO RESPIMAT INHAL SPRAY No
B62 INDACATEROL/GLYCOPYRROLATE 0 999UTIBRON NEOHALER 27.5-15.6 MCG No
B63 BETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALEDB63 FLUTICASONE PROPION/SALMETEROL 4 999ADVAIR 100/50 DISKUS No
B63 FLUTICASONE PROPION/SALMETEROL 4 999ADVAIR 100-50 DISKUS No
B63 FLUTICASONE PROPION/SALMETEROL 4 999ADVAIR 250/50 DISKUS No
B63 FLUTICASONE PROPION/SALMETEROL 4 999ADVAIR 250-50 DISKUS No
B63 FLUTICASONE PROPION/SALMETEROL 4 999ADVAIR 500/50 DISKUS No
B63 FLUTICASONE PROPION/SALMETEROL 4 999ADVAIR 500-50 DISKUS No
B63 FLUTICASONE PROPION/SALMETEROL 5 999ADVAIR HFA 115-21 MCG INHALER No
B63 FLUTICASONE PROPION/SALMETEROL 5 999ADVAIR HFA 230-21 MCG INHALER No
Tuesday, May 14, 2019 Page 15 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
B63 FLUTICASONE PROPION/SALMETEROL 5 999ADVAIR HFA 45-21 MCG INHALER No
B63 MOMETASONE/FORMOTEROL 12 999DULERA 100 MCG/5 MCG INHALER No
B63 MOMETASONE/FORMOTEROL 12 999DULERA 200 MCG/5 MCG INHALER No
B63 BUDESONIDE/FORMOTEROL FUMARATE 5 999SYMBICORT 160/4.5 MCG INHALER No
B63 BUDESONIDE/FORMOTEROL FUMARATE 5 999SYMBICORT 80/4.5 MCG INHALER No
B6M GLUCOCORTICOIDS, ORALLY INHALEDB6M MOMETASONE FUROATE 4 999ASMANEX TWISTHALER 110 MCG #30 No
B6M MOMETASONE FUROATE 4 999ASMANEX TWISTHALER 220 MCG #14 No
B6M MOMETASONE FUROATE 4 999ASMANEX TWISTHALER 220 MCG #30 No
B6M MOMETASONE FUROATE 4 999ASMANEX TWISTHALER 220 MCG #60 No
B6M MOMETASONE FUROATE 4 999ASMANEX TWISTHALR 220 MCG #120 No
B6M BUDESONIDE 1 8BUDESONIDE 0.25 MG/2 ML SUSP No
B6M BUDESONIDE 1 8BUDESONIDE 0.5 MG/2 ML SUSP No
B6M BUDESONIDE 1 8BUDESONIDE 1 MG/2 ML INH SUSP No
B6M FLUTICASONE PROPIONATE 0 999FLOVENT HFA 110 MCG INHALER No
B6M FLUTICASONE PROPIONATE 0 999FLOVENT HFA 220 MCG INHALER No
B6M FLUTICASONE PROPIONATE 0 999FLOVENT HFA 44 MCG INHALER No
B6W BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTINGB6W ALBUTEROL SULFATE 0 999ALBUTEROL 0.083% INHAL SOLN No
B6W ALBUTEROL SULFATE 0 999ALBUTEROL 0.83 MG/ML SOLUTION No
B6W ALBUTEROL SULFATE 0 999ALBUTEROL 5 MG/ML SOLUTION No
B6W ALBUTEROL SULFATE 0 999ALBUTEROL SUL 0.63 MG/3 ML SOL No
B6W ALBUTEROL SULFATE 0 999ALBUTEROL SUL 1.25 MG/3 ML SOL No
B6W ALBUTEROL SULFATE 0 999ALBUTEROL SUL 2.5 MG/3 ML SOLN No
Tuesday, May 14, 2019 Page 16 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
B6W ALBUTEROL SULFATE 0 999PROAIR HFA 90 MCG INHALER No
B6W ALBUTEROL SULFATE 0 999PROVENTIL HFA 90 MCG INHALER No
B6Y BETA-ADRENERGIC AGENTS, ORALLY INHALED,LONG ACTINGB6Y SALMETEROL XINAFOATE 4 999SEREVENT DISKUS 50 MCG No
C0B WATERC0B WATER FOR INJ.,BACTERIOSTATIC 0 999BACTERIOSTATIC WATER VIAL No
C0B WATER/ME-PARABEN/PROPYLPARABEN 0 999BACTERIOSTATIC WATER VIAL No
C0B WATER FOR INJECTION,STERILE 0 999STERILE WATER FOR INJECTION No
C0B WATER FOR INJECTION,STERILE 0 999STERILE WATER FOR KCENTRA No
C0B WATER FOR INJECTION,STERILE 0 999WATER FOR INJECTION FLIPTOP No
C0B WATER FOR INJECTION,STERILE 0 999WATER FOR INJECTION VIAL No
C0D ANTI-ALCOHOLIC PREPARATIONSC0D ACAMPROSATE CALCIUM 0 999ACAMPROSATE CALC DR 333 MG TAB No
C0D DISULFIRAM 0 999DISULFIRAM 250 MG TABLET No
C0D DISULFIRAM 0 999DISULFIRAM 500 MG TABLET No
C0D NALTREXONE MICROSPHERES 18 999VIVITROL 380 MG VIAL Auto PA
C0D NALTREXONE MICROSPHERES 18 999VIVITROL INJECTABLE SUSPENSION Auto PA
C0K BICARBONATE PRODUCING/CONTAINING AGENTSC0K SODIUM ACETATE 0 999SODIUM ACETATE 100 MEQ/50 ML No
C0K SODIUM ACETATE 0 999SODIUM ACETATE 2 MEQ/ML VIAL No
C0K SODIUM ACETATE 0 999SODIUM ACETATE 200 MEQ/100 ML No
C0K SODIUM ACETATE 0 999SODIUM ACETATE 4 MEQ/ML VIAL No
C0K SODIUM ACETATE 0 999SODIUM ACETATE 40 MEQ/20 ML VL No
C0K SODIUM BICARBONATE 0 999SODIUM BICARB 4.2% VIAL No
C0K SODIUM BICARBONATE 0 999SODIUM BICARB 8.4% VIAL No
Tuesday, May 14, 2019 Page 17 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C0K SODIUM LACTATE 0 999SODIUM LACTATE 5 MEQ/ML VIAL No
C1A ELECTROLYTE DEPLETERSC1A CALCIUM ACETATE 0 999CALCIUM ACETATE 667 MG CAPSULE No
C1A CALCIUM ACETATE 0 999CALCIUM ACETATE 667 MG GELCAP No
C1A CALCIUM ACETATE 0 999CALCIUM ACETATE 668 MG TABLET No
C1A SEVELAMER HCL 0 999RENAGEL 400 MG TABLET No
C1A SEVELAMER HCL 0 999RENAGEL 800 MG TABLET No
C1A SEVELAMER CARBONATE 0 11RENVELA 0.8 GM POWDER PACKET No
C1A SEVELAMER CARBONATE 0 11RENVELA 2.4 GM POWDER PACKET No
C1A SODIUM POLYSTYRENE SULFONATE 0 999SOD POLYSTYREN SULF 15 G/60 ML No
C1A SODIUM POLYSTYRENE SULFONATE 0 999SODIUM POLYSTYRENE SULF POWDER No
C1A SODIUM POLYSTYRENE SULFONATE 0 999SODIUM POLYSTYRENE SULF PWD No
C1A SODIUM POLYSTYRENE SULFON/SORB 0 999SPS 15 GM/60 ML SUSPENSION No
C1A SODIUM POLYSTYRENE SULFONATE 0 999SPS 15 GM/60 ML SUSPENSION No
C1A SODIUM POLYSTYRENE SULFON/SORB 0 999SPS 30 GM/120 ML ENEMA No
C1A SODIUM POLYSTYRENE SULFONATE 0 999SPS 30 GM/120 ML ENEMA No
C1A SODIUM POLYSTYRENE SULFONATE 0 999SPS 50 GM/200 ML ENEMA No
C1B SODIUM/SALINE PREPARATIONSC1B BACTERIOSTATIC SODIUM CHLORIDE 0 999BACTERIOSTATIC SALINE VIAL No
C1B SODIUM CHLORIDE 0.45 % 0 999SALINE 0.45% SOLN/EXCEL CON No
C1B 0.9 % SODIUM CHLORIDE 0 999SALINE 0.9% SOLN/EXCEL CONT No
C1B SODIUM CHLORIDE 0 999SOD CHLORIDE 4 MEQ/ML VIAL No
C1B SODIUM CHLORIDE 0 999SODIUM CHL 2.5 MEQ/ML VIAL No
C1B SODIUM CHLORIDE 0.45 % 0 999SODIUM CHLORIDE 0.45% SOLN No
Tuesday, May 14, 2019 Page 18 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C1B SODIUM CHLORIDE 0.45 % 0 999SODIUM CHLORIDE 0.45% SOLUTION No
C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% 1,000 ML No
C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% 100 ML No
C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% 1000 ML No
C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% 250 ML No
C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% 50 ML No
C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% 500 ML No
C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% SOLN No
C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% SOLN. No
C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% SOLUTION No
C1B 0.9 % SODIUM CHLORIDE 0 999SODIUM CHLORIDE 0.9% VIAL No
C1B SODIUM CHLORIDE 0 999SODIUM CHLORIDE 100 MEQ/40 ML No
C1B SODIUM CHLORIDE 3 % 0 999SODIUM CHLORIDE 3% IV SOLN No
C1B SODIUM CHLORIDE 0 999SODIUM CHLORIDE 4 MEQ/ML VL No
C1B SODIUM CHLORIDE 5 % 0 999SODIUM CHLORIDE 5% IV SOLN No
C1B SODIUM CHLORIDE 0 999SODIUM CL 2.5 MEQ/ML VIAL No
C1D POTASSIUM REPLACEMENTC1D POTASSIUM CHLORIDE/D5-0.45NACL 0 999D5-1/2NS/KCL 10 MEQ/L IV SOL No
C1D POTASSIUM CHLORIDE/D5-0.45NACL 0 999D5-1/2NS/KCL 10 MEQ-L IV SOL No
C1D POTASSIUM CHLORIDE/D5-0.45NACL 0 999D5-1/2NS/KCL 20 MEQ/L IV SOL No
C1D POTASSIUM CHLORIDE/D5-0.45NACL 0 999D5-1/2NS/KCL 30 MEQ/L IV SOL No
C1D POTASSIUM CHLORIDE/D5-0.45NACL 0 999D5-1/2NS/KCL 40 MEQ/L IV SOL No
C1D POTASSIUM CHLORIDE/D5-0.3%NACL 0 999D5-1/3NS/KCL 20 MEQ/L IV SOL No
C1D POTASSIUM CHLORIDE/D5-0.2%NACL 0 999D5-1/4NS/KCL 10 MEQ-L IV SOL No
Tuesday, May 14, 2019 Page 19 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C1D POTASSIUM CHLORIDE/D5-0.2%NACL 0 999D5-1/4NS/KCL 20 MEQ/L IV SOL No
C1D POTASSIUM CHLORIDE/D5-0.2%NACL 0 999D5-1/4NS/KCL 30 MEQ/L IV SOL No
C1D POTASSIUM CHLORIDE/D5-0.2%NACL 0 999D5-1/4NS/KCL 40 MEQ/L IV SOL No
C1D POTASSIUM CHLORIDE/D5-0.9%NACL 0 999D5NS W/KCL 20 MEQ/L IV SOLN No
C1D POTASSIUM CHLORIDE IN D5W 0 999D5W/KCL 20 MEQ/L IV SOLUTION No
C1D POTASSIUM CHLORIDE IN D5W 0 999D5W/KCL 30 MEQ/L IV SOLUTION No
C1D POTASSIUM CHLORIDE IN D5W 0 999D5W/KCL 40 MEQ/L IV SOLUTION No
C1D POTASSIUM CHLORIDE IN D5W 0 999DEXTROSE 5%/KCL 20 MEQ/L SOL No
C1D POTASSIUM BICARBONATE/CIT AC 0 999EFFER-K 10 MEQ TABLET EFF No
C1D POTASSIUM BICARBONATE/CIT AC 0 999EFFER-K 20 MEQ TABLET EFF No
C1D POTASSIUM BICARBONATE/CIT AC 0 999EFFER-K 25 MEQ TABLET EFF No
C1D POTASSIUM BICARBONATE/CIT AC 0 999K EFFERVESCENT 25 MEQ TABLET No
C1D POTASSIUM CHLORIDE/D5-0.3%NACL 0 999KCL 10 MEQ IN D5W/0.3% NACL No
C1D POTASSIUM CHLORIDE/D5-0.2%NACL 0 999KCL 10 MEQ IN D5W/NACL 0.225% No
C1D POTASSIUM CHLORIDE/D5-0.45NACL 0 999KCL 10 MEQ IN D5W/NACL 0.45% No
C1D POTASSIUM CHLORIDE IN LR-D5 0 999KCL 20 MEQ IN D5W & LACT RNG No
C1D POTASSIUM CHLORIDE/D5-0.2%NACL 0 999KCL 20 MEQ IN D5W/NACL 0.225% No
C1D POTASSIUM CHLORIDE/D5-0.9%NACL 0 999KCL 20 MEQ IN D5W/NACL 0.9% No
C1D POTASSIUM CHLORIDE-0.45% NACL 0 999KCL 20 MEQ/0.5 NS 1,000 ML SOL No
C1D POTASSIUM CHLORIDE IN 0.9%NACL 0 999KCL 20 MEQ/NS 1,000 ML IV SOLN No
C1D POTASSIUM CHLORIDE IN LR-D5 0 999KCL 40 MEQ IN D5W & LACT RNG No
C1D POTASSIUM CHLORIDE/D5-0.9%NACL 0 999KCL 40 MEQ IN D5W/NACL 0.9% No
C1D POTASSIUM CHLORIDE IN 0.9%NACL 0 999KCL 40 MEQ/NS 1,000 ML IV No
C1D POTASSIUM CHLORIDE IN 0.9%NACL 0 999KCL 40 MEQ/NS 1,000 ML IV SOLN No
Tuesday, May 14, 2019 Page 20 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C1D POTASSIUM CHLORIDE 0 999KLOR-CON 10 MEQ TABLET No
C1D POTASSIUM CHLORIDE 0 999KLOR-CON 20 MEQ PACKET No
C1D POTASSIUM CHLORIDE 0 999KLOR-CON 25 MEQ PACKET No
C1D POTASSIUM CHLORIDE 0 999KLOR-CON 8 MEQ TABLET No
C1D POTASSIUM CHLORIDE 0 999KLOR-CON M10 TABLET No
C1D POTASSIUM CHLORIDE 0 999KLOR-CON M15 TABLET No
C1D POTASSIUM CHLORIDE 0 999KLOR-CON M20 TABLET No
C1D POTASSIUM CHLORIDE 0 999KLOR-CON SPRINKLE ER 10 MEQ CP No
C1D POTASSIUM CHLORIDE 0 999KLOR-CON SPRINKLE ER 8 MEQ CAP No
C1D POTASSIUM BICARBONATE/CIT AC 0 999KLOR-CON-EF 25 MEQ TAB EFF No
C1D POTASSIUM BICARBONATE/CIT AC 0 999POTASSIUM 25 MEQ TABLET EFF No
C1D POTASSIUM ACETATE 0 999POTASSIUM ACET 100 MEQ/50 ML No
C1D POTASSIUM ACETATE 0 999POTASSIUM ACET 2 MEQ/ML VIAL No
C1D POTASSIUM ACETATE 0 999POTASSIUM ACET 40 MEQ/20 ML VL No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CHLORIDE 10% LIQUID No
C1D POTASSIUM CHLORIDE IN LR-D5 0 999POTASSIUM CHLORIDE-DW5-LR SOLN No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 10 MEQ CAP SA No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 10 MEQ TAB SA No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 10 MEQ TABLET ER No
C1D POTASSIUM CHLORIDE IN WATER 0 999POTASSIUM CL 10 MEQ/100 ML SOL No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 10 MEQ/5 ML CONC No
C1D POTASSIUM CHLORIDE IN WATER 0 999POTASSIUM CL 10 MEQ/50 ML SOL No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 10% (20 MEQ/15 ML No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 10% (20 MEQ/15ML) No
Tuesday, May 14, 2019 Page 21 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 10% (40 MEQ/30 ML No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 2 MEQ/ML VIAL No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 20 MEQ PACKET No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 20 MEQ TAB ER No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 20 MEQ TABLET ER No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 20 MEQ/10 ML CONC No
C1D POTASSIUM CHLORIDE IN WATER 0 999POTASSIUM CL 20 MEQ/100 ML SOL No
C1D POTASSIUM CHLORIDE IN WATER 0 999POTASSIUM CL 20 MEQ/50 ML SOL No
C1D POTASSIUM CHLORIDE-0.45% NACL 0 999POTASSIUM CL 20 MEQ-0.45% NACL No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 20% (40 MEQ/15 ML No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 20% (40 MEQ/15ML) No
C1D POT CHLORIDE/POT BICARB/CIT AC 0 999POTASSIUM CL 25 MEQ TAB EFF No
C1D POTASSIUM CHLORIDE IN WATER 0 999POTASSIUM CL 30 MEQ/100 ML SOL No
C1D POTASSIUM CHLORIDE IN WATER 0 999POTASSIUM CL 40 MEQ/100 ML SOL No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 40 MEQ/20 ML CONC No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 8 MEQ CAP SA No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL 8 MEQ TABLET SA No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL ER 10 MEQ CAPSULE No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL ER 10 MEQ TABLET No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL ER 20 MEQ TABLET No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL ER 8 MEQ CAPSULE No
C1D POTASSIUM CHLORIDE 0 999POTASSIUM CL ER 8 MEQ TABLET No
C1F CALCIUM REPLACEMENTC1F CALCIUM CITRATE 0 999CALCITRATE 950 MG TABLET No
Tuesday, May 14, 2019 Page 22 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C1F CALCIUM CITRATE/VITAMIN D3 0 999CALCITRATE CAPLET Cystic Fib Diag Auto PA
C1F CALCIUM CARB/VITAMIN D3/VIT K1 0 999CALCIUM + D SOFT CHEWABLE TAB Cystic Fib Diag Auto PA
C1F CALCIUM CARB/VITAMIN D3/VIT K1 0 999CALCIUM + VIT D & K CHEW TAB Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 250+D TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500 + D TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500 + D3 TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500 + VIT D 200 CAPLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500 + VIT D 400 TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500 + VIT D3 400 TAB Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500 + VIT D3 TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE 0 999CALCIUM 500 MG CHEWABLE TABLET No
C1F CALCIUM CARBONATE 0 999CALCIUM 500 MG TABLET No
C1F CALCIUM CARBONATE 0 999CALCIUM 500 MG TABLET No
C1F CALCIUM CARBONATE 0 999CALCIUM 500 MG TABLET No
C1F CALCIUM CARBONATE 0 999CALCIUM 500 MG TABLET CHEW No
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500 WITH VITAMIN D TAB Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500+D CAPLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500+D TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500+VIT D 400 TAB Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500-VIT D3 600 CAPLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM 500-VIT D3 600 TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE 0 999CALCIUM 600 MG TABLET No
C1F CALCIUM CARBONATE 0 999CALCIUM CARB 1,250 MG/5 ML SUS No
C1F CALCIUM CARBONATE 0 999CALCIUM CARB 500 MG TAB CHEW No
Tuesday, May 14, 2019 Page 23 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM CARB 500 MG TAB CHEW Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM CARB 500 TAB CHEW Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE 0 999CALCIUM CARBONATE 1,250 MG TAB No
C1F CALCIUM CARBONATE 0 999CALCIUM CARBONATE 1.25 GM TB No
C1F CALCIUM CARBONATE 0 999CALCIUM CARBONATE 500 MG TAB No
C1F CALCIUM CARBONATE 0 999CALCIUM CARBONATE 600 MG TAB No
C1F CALCIUM CHLORIDE 0 999CALCIUM CHLORIDE 10% VIAL No
C1F CALCIUM CITRATE/VITAMIN D3 0 999CALCIUM CIT 315-VIT D3 250 TAB Cystic Fib Diag Auto PA
C1F CALCIUM CARB/VITAMIN D3/VIT K1 0 999CALCIUM FOR WOMEN CHEWABLE TAB Cystic Fib Diag Auto PA
C1F CALCIUM GLUCONATE 0 999CALCIUM GLUC 1,000 MG/10 ML VL No
C1F CALCIUM GLUCONATE 0 999CALCIUM GLUC 10,000 MG/100 ML No
C1F CALCIUM GLUCONATE 0 999CALCIUM GLUC 5,000 MG/50 ML VL No
C1F CALCIUM GLUCONATE 0 999CALCIUM GLUCONATE 10% VIAL No
C1F CALCIUM GLUCONATE 0 999CALCIUM GLUCONATE 500 MG TAB No
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALCIUM W/VITAMIN D TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALICUM 500+D TABLET CHEW Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CALICUM 500+D TABLET CHEW Cystic Fib Diag Auto PA
C1F CALCIUM CARB/VITAMIN D3/VIT K1 0 999CHEWABLE CALCIUM TAB CHEW Cystic Fib Diag Auto PA
C1F CALCIUM CARB, CITRATE/VIT D3 0 999CITRACAL + D ER TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CITRATE/VITAMIN D3 0 999CITRACAL + D MAXIMUM CAPLET Cystic Fib Diag Auto PA
C1F CALCIUM PHOSPHATE TRIB/VIT D3 0 999CITRACAL + D3 GUMMIES Cystic Fib Diag Auto PA
C1F CALCIUM CITRATE/VITAMIN D3 0 999CITRACAL-VIT D 250 MG-200 TAB Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999CVS CALCIUM 500 + VIT D TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARB/VITAMIN D3/VIT K1 0 999CVS CALCIUM SOFT CHEW Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 24 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C1F CALCIUM CARBONATE 0 999ELEMENTAL CALCIUM 600 MG TAB No
C1F CALCIUM CARBONATE/VITAMIN D3 0 999EQ CALCIUM 500 + VIT D TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999GNP CALCIUM 500+VIT D 400 TAB Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999HM CALCIUM 500 + VIT D 200 CPT Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999HM CALCIUM 500-VIT D3 200 CPLT Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE 0 999NATURAL CALCIUM 500 MG TABLET No
C1F CALCIUM CARBONATE 0 999OYSCO-500 TABLET No
C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL 250 MG + VIT D TB Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL 500 MG + VIT D TB Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE 0 999OYSTER SHELL 500 MG TABLET No
C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL 500-VIT D3 200 TB Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE 0 999OYSTER SHELL CAL 500 MG TAB No
C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL CALCIUM + D CPLT Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL CALCIUM + D TAB Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL CALCIUM +D TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE 0 999OYSTER SHELL CALCIUM 500 MG No
C1F CALCIUM CARBONATE 0 999OYSTER SHELL CALCIUM 500 MG TB No
C1F CALCIUM CARBONATE 0 999OYSTER SHELL CALCIUM TABLET No
C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL CALCIUM-VIT D TAB Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL CALCIUM-VIT D TAB Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D2 0 999OYSTER SHELL W/VIT D TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL W/VIT D TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL W/VIT D TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL W/VIT D TABLET Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 25 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL W/VIT D TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999OYSTER SHELL+D 250 MG TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/BORON GLUC 0 999RA CALCIUM W/BORON TABLET Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999RA OYSTER SHELL W/VIT D TAB Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999SM CALCIUM 500 + VIT D 200 CPT Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999SM CALCIUM 500 MG WITH D TAB Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE 0 999SM CALCIUM 500 TABLET No
C1F CALCIUM CARB/VITAMIN D3/VIT K1 0 999SM CALCIUM SOFT TAB CHEW Cystic Fib Diag Auto PA
C1F CALCIUM CARBONATE/VITAMIN D3 0 999SUNMARK CALCIUM 500 WITH D TAB Cystic Fib Diag Auto PA
C1F CALCIUM CARB/VITAMIN D3/VIT K1 0 999SUNMARK CALCIUM SOFT TAB CHEW Cystic Fib Diag Auto PA
C1F CALCIUM/MAG/D3/B12/FA/B6/BORON 0 999TL G-FOL OS TABLET No
C1H MAGNESIUM SALTS REPLACEMENTC1H MAGNESIUM OXIDE 0 999CVS MAGNESIUM 500 MG TABLET Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999GNP MAGNESIUM 250 MG TABLET Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999HM MAGNESIUM 400 MG CAPLET Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM 250 MG TABLET Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM 250 MG TABLET Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM 400 MG CAPS Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM 400 MG SOFTGEL Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM 400 MG TABLET Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM 500 MG SOFTGEL Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM 500 MG TABLET Cystic Fib Diag Auto PA
C1H MAGNESIUM CHLORIDE 0 999MAGNESIUM CHL 200 MG/ML VIAL No
C1H MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 250 MG CAPLET Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 26 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C1H MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 250 MG TABLET Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 400 MG TAB Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 400 MG TABLET Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 400 MG TABLET Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 420 MG TAB Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 420 MG TABLET Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 500 MG CAPSULE Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 500 MG TAB Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 500 MG TABLET Cystic Fib Diag Auto PA
C1H MAGNESIUM SULFATE IN WATER 0 999MAGNESIUM SULF 2 G/50 ML BAG No
C1H MAGNESIUM SULFATE IN WATER 0 999MAGNESIUM SULF 20 G/500 ML BAG No
C1H MAGNESIUM SULFATE IN WATER 0 999MAGNESIUM SULF 4 G/100 ML BAG No
C1H MAGNESIUM SULFATE IN WATER 0 999MAGNESIUM SULF 4 G/50 ML BAG No
C1H MAGNESIUM SULFATE IN WATER 0 999MAGNESIUM SULF 40 G/1,000 ML No
C1H MAGNESIUM SULFATE 0 999MAGNESIUM SULFATE 50% VIAL No
C1H MAGNESIUM OXIDE 0 999MAGNESIUM-OXIDE 400 MG TAB Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAG-OXIDE 200 MG TAB Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999MAG-OXIDE 400 MG TABLET Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999RA MAGNESIUM 500 MG CAPSULE Cystic Fib Diag Auto PA
C1H MAGNESIUM OXIDE 0 999SV MAGNESIUM OXIDE 400 MG TAB Cystic Fib Diag Auto PA
C1P PHOSPHATE REPLACEMENTC1P POTASSIUM PHOS,M-BASIC-D-BASIC 0 999POTASSIUM PH 3MM/ML VIAL No
C1P POTASSIUM PHOS,M-BASIC-D-BASIC 0 999POTASSIUM PHOSP 45 MMOL/15 ML No
C1P SOD PHOSPHATE,MONOBASIC-DIBAS 0 999SODIUM PHOSPHATE 3MM/ML VIAL No
Tuesday, May 14, 2019 Page 27 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C1P SOD PHOSPHATE,MONOBASIC-DIBAS 0 999SODIUM PHOSPHATE 45 MMOL/15 ML No
C1W ELECTROLYTE MAINTENANCEC1W ELECTROLYTE-48 SOLUTION/D5W 0 999DEXTROSE 5%-ELECTROLYTE 48 No
C1W SODIUM/POT/MAG/CALC/CHLOR/ACET 0 999HYPERLYTE CR VIAL No
C1W ELECTROLYTE-B SOLUTION/D5W 0 999IONOSOL B/D5W IV SOLUTION No
C1W ELECTROLYTE-MB SOLUTION/D5W 0 999IONOSOL MB IN 5% DEXTROSE No
C1W ELECTROLYTE-MB SOLUTION/D5W 0 999IONOSOL MB/D5W IV SOLUTION No
C1W ELECTROLYTE-P SOLUTION/D5W 0 999ISOLYTE P/DEXTROSE 5% SOLN No
C1W ELECTROLYTE-S (PH 7.4) 0 999ISOLYTE S IV SOLN PH7.4 No
C1W ELECTROLYTE-S SOLUTION 0 999ISOLYTE S IV SOLUTION/EXCEL No
C1W RINGER'S SOLUTION,LACTATED 0 999LACTATED RINGERS INJ/EXCEL No
C1W RINGER'S SOLUTION,LACTATED 0 999LACTATED RINGERS INJECTION No
C1W ELECTROLYTE-M SOLUTION/D5W 0 999NORMOSOL-M AND DEXTROSE 5% No
C1W ELECTROLYTE-M SOLUTION/D5W 0 999NORMOSOL-M/DEXTROSE 5% No
C1W ELECTROLYTE-R SOLUTION 0 999NORMOSOL-R IV SOLUTION No
C1W ELECTROLYTE-R (PH 7.4) 0 999NORMOSOL-R PH 7.4 IV SOLN. No
C1W ELECTROLYTE-R (PH 7.4) 0 999NORMOSOL-R PH 7.4 IV SOLUTION No
C1W ELECTROLYTE-R SOLUTION/D5W 0 999NORMOSOL-R/DEXTROSE 5% IV SOLN No
C1W SOD/POT/MAG/CAL/CL/ACET/GLUCON 0 999NUTRILYTE VIAL No
C1W ELECTROLYTE-148 SOLUTION 0 999PLASMA-LYTE 148 IV SOLUTION No
C1W ELECTROLYTE-A SOLUTION 0 999PLASMA-LYTE A PH 7.4 SOLN. No
C1W RINGER'S SOLUTION 0 999RINGERS INJECTION No
C1W RINGER'S SOLUTION 0 999RINGER'S INJECTION IV SOLN No
C1W SODIUM/POT/MAG/CALC/CHLOR/ACET 0 999TPN ELECTROLYTES II IV SOLN No
Tuesday, May 14, 2019 Page 28 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C1W SODIUM/POT/MAG/CALC/CHLOR/ACET 0 999TPN ELECTROLYTES VIAL No
C3B IRON REPLACEMENTC3B IRON,CARBONYL 0 999FEOSOL 45 MG CAPLET No
C3B FERROUS SULFATE 0 999FEOSOL 65 MG TABLET No
C3B FERROUS GLUCONATE 0 999FERATE 27 MG TABLET No
C3B FERROUS SULFATE 0 999FER-IN-SOL 75 MG/0.6 ML DROPS No
C3B FERROUS SULFATE 0 999FEROSUL 325 MG TABLET No
C3B IRON CARB,GL/FA/B12/C/DOCUSATE 0 999FERRALET 90 TABLET No
C3B IRON/FOLIC ACID/B12/C/DOCUSATE 0 999FERRAPLUS 90 TABLET No
C3B IRON POLYSACCHARIDE COMPLEX 0 999FERREX 150 CAPSULE Cystic Fib Diag Auto PA
C3B IRON PS COMPLEX/B12/FOLIC ACID 0 999FERREX 150 FORTE CAPSULE Cystic Fib Diag Auto PA
C3B IRON ASPGLY,PS/C/B12/FA/CA/SUC 0 999FERREX 150 FORTE PLUS CAPSULE Cystic Fib Diag Auto PA
C3B IRON ASPGLY,PS/C/SUCCINIC ACID 0 999FERREX 150 PLUS CAPSULE Cystic Fib Diag Auto PA
C3B IRON/C/FOLIC ACD/MV CMB11/CALC 0 999FERREX 28 TABLET Cystic Fib Diag Auto PA
C3B IRON POLYSACCHARIDE COMPLEX 0 999FERREX-150 CAPSULE Cystic Fib Diag Auto PA
C3B IRON POLYSACCHARIDE COMPLEX 0 999FERRIC X-150 CAPSULE Cystic Fib Diag Auto PA
C3B FERROUS FUMARATE 0 999FERRIMIN 150 TAB No
C3B FERROUS SULFATE 0 999FERRO-TIME 325 MG TABLET No
C3B FERROUS FUMARATE 0 999FERROUS FUMARATE 324 MG TAB No
C3B FERROUS GLUCONATE 0 999FERROUS GLUCONATE 324 MG TAB No
C3B FERROUS GLUCONATE 0 999FERROUS GLUCONATE 325 MG TAB No
C3B FERROUS SULFATE 0 999FERROUS SULF 15 MG IRON/ML DRP No
C3B FERROUS SULFATE 0 999FERROUS SULF 220 MG/5 ML ELIX No
C3B FERROUS SULFATE 0 999FERROUS SULF 220 MG/5 ML ELIX No
Tuesday, May 14, 2019 Page 29 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C3B FERROUS SULFATE 0 999FERROUS SULF 300 MG/5 ML LIQ No
C3B FERROUS SULFATE 0 999FERROUS SULF 324 MG TAB EC No
C3B FERROUS SULFATE 0 999FERROUS SULF 325 MG TAB EC No
C3B FERROUS SULFATE 0 999FERROUS SULF 44 MG IRON/5ML LQ No
C3B FERROUS SULFATE 0 999FERROUS SULFATE 15 MG/ML DROPS No
C3B FERROUS SULFATE 0 999FERROUS SULFATE 325 MG TAB No
C3B FERROUS SULFATE 0 999FERROUS SULFATE 325 MG TAB No
C3B FERROUS SULFATE 0 999FERROUS SULFATE 325 MG TABLET No
C3B FERROUS SULFATE 0 999FERROUS SULFATE ER 140 MG TAB No
C3B FERROUS SULFATE 0 999FERROUS SULFATE ER 140MG TAB No
C3B FERROUS SULFATE 0 999FERROUSUL 325 MG TABLET No
C3B IRON FUM,PS/FOLIC ACID/VITC/B3 0 999FOLIVANE-F CAPSULE No
C3B IRON,FM,PS/FOLIC/B,C18/L.CASEI 0 999FUSION PLUS CAPSULE No
C3B IRON FUMARATE/VIT C/VIT B12/FA 0 999HEMATOGEN FA SOFTGEL No
C3B IRON FUM/FOLIC ACID/MV,MIN 15 0 999HEMOCYTE PLUS CAPSULE No
C3B FERROUS FUMARATE 0 999HEMOCYTE TABLET No
C3B FERROUS FUMARATE/FOLIC ACID 0 999HEMOCYTE-F TABLET No
C3B FERROUS SULFATE 0 999HM SLOW RELEASE IRON TABLET No
C3B IRON POLYSACCHARIDE COMPLEX 0 999IFEREX 150 CAPSULE Cystic Fib Diag Auto PA
C3B IRON PS COMPLEX/B12/FOLIC ACID 0 999IFEREX 150 FORTE CAPSULE Cystic Fib Diag Auto PA
C3B IRON PS COMPLEX/B12/FOLIC ACID 0 999IFEREX 150 FORTE CAPSULE No
C3B IRON FUM,PS/FOLIC ACID/VITC/B3 0 999INTEGRA F CAPSULE No
C3B IRON FUM,PS/FOLIC/BCOMP,C NO.9 0 999INTEGRA PLUS CAPSULE No
C3B FERROUS SULFATE, DRIED 0 999IRON 45 MG TABLET No
Tuesday, May 14, 2019 Page 30 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C3B FERROUS SULFATE 0 999IRON 65 MG TABLET No
C3B IRON POLYSACCHARIDE COMPLEX 0 999MYFERON 150 CAPSULE Cystic Fib Diag Auto PA
C3B IRON PS COMPLEX/B12/FOLIC ACID 0 999MYFERON-150 FORTE CAPSULE No
C3B IRON POLYSACCHARIDE COMPLEX 0 999NU-IRON 150 CAPSULE Cystic Fib Diag Auto PA
C3B IRON PS COMPLEX/B12/FOLIC ACID 0 999POLY-IRON 150 FORTE CAPSULE No
C3B IRON POLYSACCHARIDE COMPLEX 0 999POLY-IRON 150 MG CAPSULE Cystic Fib Diag Auto PA
C3B IRON FM,PS NO.1/FOLIC/MV NO.18 0 999PUREVIT DUALFE PLUS CAPSULE No
C3B IRON FM,PS NO.1/FOLIC/MV NO.18 0 999SE-TAN PLUS CAPSULE No
C3B IRON FM,PS NO.1/FOLIC/MV NO.18 0 999TANDEM PLUS CAPSULE No
C3B IRON BG,PS/VITC/B12/FA/CALCIUM 0 999TARON FORTE CAPSULE No
C3B FERROUS FUM/VIT C/B12-IF/FOLIC 0 999TL ICON CAPSULE No
C3B FERROUS FUM/VIT C/B12-IF/FOLIC 0 999TRICON CAPSULE No
C3C ZINC REPLACEMENTC3C ZINC CHLORIDE 0 999ZINC CHLORIDE 1 MG/ML VIAL No
C3C ZINC SULFATE 0 999ZINC SULFATE 5 MG/ML VIAL No
C3H IODINE CONTAINING AGENTSC3H SODIUM IODIDE 0 999IODOPEN 100 MCG/ML VIAL No
C3H POTASSIUM IODIDE 0 999SSKI 1 GM/ML SOLUTION No
C3M MINERAL REPLACEMENT, MISCELLANEOUSC3M CHROMIC CHLORIDE 0 999CHROMIUM 4 MCG/ML VIAL No
C3M CHROMIC CHLORIDE 0 999CHROMIUM CL 40 MCG/10 ML VIAL No
C3M CUPRIC CHLORIDE 0 999COPPER CHLORIDE 0.4 MG/ML VL No
C3M MANGANESE CHLORIDE 0 999MANGANESE 0.1 MG/ML VIAL No
C3M ZINC/COPPER/MANGAN/CHROMIC CHL 0 999MULTITRACE-4 CONC VIAL No
C3M ZINC/COPPER/MANGAN/CHROMIC CHL 0 999MULTITRACE-4 VIAL No
Tuesday, May 14, 2019 Page 31 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C3M ZINC/COPPER/MANGAN/CHROM/SELEN 0 999MULTITRACE-5 CONC VIAL No
C3M ZINC/COPPER/MANGAN/CHROM/SELEN 0 999MULTITRACE-5 VIAL No
C3M SELENIUM 0 999SELENIUM 40 MCG/ML VIAL No
C3M ZINC/COPPER/MANGAN/CHROMIC CHL 0 999TRACE ELEMENTS-4 VIAL No
C4D ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIBC4D DAPAGLIFLOZIN PROPANEDIOL 0 999FARXIGA 10 MG TABLET No
C4D DAPAGLIFLOZIN PROPANEDIOL 0 999FARXIGA 5 MG TABLET No
C4D CANAGLIFLOZIN 0 999INVOKANA 100 MG TABLET No
C4D CANAGLIFLOZIN 0 999INVOKANA 300 MG TABLET No
C4D EMPAGLIFLOZIN 0 999JARDIANCE 10 MG TABLET No
C4D EMPAGLIFLOZIN 0 999JARDIANCE 25 MG TABLET No
C4E ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR-BIGUANIDE COMBS.C4E CANAGLIFLOZIN/METFORMIN HCL 0 999INVOKAMET 150-1,000 MG TABLET No
C4E CANAGLIFLOZIN/METFORMIN HCL 0 999INVOKAMET 150-500 MG TABLET No
C4E CANAGLIFLOZIN/METFORMIN HCL 0 999INVOKAMET 50-1,000 MG TABLET No
C4E CANAGLIFLOZIN/METFORMIN HCL 0 999INVOKAMET 50-500 MG TABLET No
C4E EMPAGLIFLOZIN/METFORMIN HCL 0 999SYNJARDY 12.5-1,000 MG TABLET No
C4E EMPAGLIFLOZIN/METFORMIN HCL 0 999SYNJARDY 12.5-500 MG TABLET No
C4E EMPAGLIFLOZIN/METFORMIN HCL 0 999SYNJARDY 5-1,000 MG TABLET No
C4E EMPAGLIFLOZIN/METFORMIN HCL 0 999SYNJARDY 5-500 MG TABLET No
C4E DAPAGLIFLOZIN/METFORMIN HCL 0 999XIGDUO XR 10 MG-1,000 MG TAB No
C4E DAPAGLIFLOZIN/METFORMIN HCL 0 999XIGDUO XR 10 MG-500 MG TABLET No
C4E DAPAGLIFLOZIN/METFORMIN HCL 0 999XIGDUO XR 2.5 MG-1,000 MG TAB No
C4E DAPAGLIFLOZIN/METFORMIN HCL 0 999XIGDUO XR 5 MG-1,000 MG TABLET No
Tuesday, May 14, 2019 Page 32 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C4E DAPAGLIFLOZIN/METFORMIN HCL 0 999XIGDUO XR 5 MG-500 MG TABLET No
C4F ANTIHYPERGLYCEMIC,DPP-4 INHIBITOR-BIGUANIDE COMBS.C4F SITAGLIPTIN PHOS/METFORMIN HCL 18 999JANUMET 50-1,000 MG TABLET No
C4F SITAGLIPTIN PHOS/METFORMIN HCL 18 999JANUMET 50-500 MG TABLET No
C4F SITAGLIPTIN PHOS/METFORMIN HCL 18 999JANUMET XR 100-1,000 MG TABLET No
C4F SITAGLIPTIN PHOS/METFORMIN HCL 18 999JANUMET XR 50-1,000 MG TABLET No
C4F SITAGLIPTIN PHOS/METFORMIN HCL 18 999JANUMET XR 50-500 MG TABLET No
C4F LINAGLIPTIN/METFORMIN HCL 18 999JENTADUETO 2.5 MG-1000 MG TAB No
C4F LINAGLIPTIN/METFORMIN HCL 18 999JENTADUETO 2.5 MG-500 MG TAB No
C4F LINAGLIPTIN/METFORMIN HCL 18 999JENTADUETO 2.5 MG-850 MG TAB No
C4F SAXAGLIPTIN HCL/METFORMIN HCL 18 999KOMBIGLYZE XR 2.5-1,000 MG TAB No
C4F SAXAGLIPTIN HCL/METFORMIN HCL 18 999KOMBIGLYZE XR 5-1,000 MG TAB No
C4F SAXAGLIPTIN HCL/METFORMIN HCL 18 999KOMBIGLYZE XR 5-500 MG TABLET No
C4G INSULINSC4G INSULIN LISPRO 0 999HUMALOG 100 UNITS/ML CARTRIDGE No
C4G INSULIN LISPRO 0 999HUMALOG 100 UNITS/ML VIAL No
C4G INSULIN LISPRO PROTAMIN/LISPRO 0 999HUMALOG MIX 50/50 KWIKPEN No
C4G INSULIN LISPRO PROTAMIN/LISPRO 0 999HUMALOG MIX 50/50 VIAL No
C4G INSULIN LISPRO PROTAMIN/LISPRO 0 999HUMALOG MIX 50-50 KWIKPEN No
C4G INSULIN LISPRO PROTAMIN/LISPRO 0 999HUMALOG MIX 75/25 KWIKPEN No
C4G INSULIN LISPRO PROTAMIN/LISPRO 0 999HUMALOG MIX 75/25 VIAL No
C4G INSULIN LISPRO PROTAMIN/LISPRO 0 999HUMALOG MIX 75-25 KWIKPEN No
C4G INSULIN NPH HUM/REG INSULIN HM 0 999HUMULIN 70/30 VIAL No
C4G INSULIN NPH HUM/REG INSULIN HM 0 999HUMULIN 70-30 VIAL No
Tuesday, May 14, 2019 Page 33 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C4G INSULIN NPH HUMAN ISOPHANE 0 999HUMULIN N 100 UNITS/ML VIAL No
C4G INSULIN REGULAR, HUMAN 0 999HUMULIN R 100 UNITS/ML VIAL No
C4G INSULIN GLARGINE,HUM.REC.ANLOG 0 999LANTUS 100 UNIT/ML VIAL No
C4G INSULIN GLARGINE,HUM.REC.ANLOG 0 999LANTUS 100 UNITS/ML VIAL No
C4G INSULIN GLARGINE,HUM.REC.ANLOG 0 999LANTUS SOLOSTAR 100 UNIT/ML No
C4G INSULIN GLARGINE,HUM.REC.ANLOG 0 999LANTUS SOLOSTAR 100 UNITS/ML No
C4G INSULIN DETEMIR 0 999LEVEMIR 100 UNITS/ML VIAL No
C4G INSULIN DETEMIR 0 999LEVEMIR FLEXTOUCH 100 UNITS/ML No
C4G INSULIN NPH HUMAN ISOPHANE 0 999NOVOLIN N 100 UNITS/ML VIAL No
C4G INSULIN REGULAR, HUMAN 0 999NOVOLIN R 100 UNITS/ML VIAL No
C4G INSULIN ASPART 0 999NOVOLOG 100 UNITS/ML CARTRIDGE No
C4G INSULIN ASPART 0 999NOVOLOG 100 UNITS/ML VIAL No
C4G INSULIN ASPART 0 999NOVOLOG FLEXPEN SYRINGE No
C4G INSULIN ASPART PROT/INSULN ASP 0 999NOVOLOG MIX 70/30 FLEXPEN SYRN No
C4G INSULIN ASPART PROT/INSULN ASP 0 999NOVOLOG MIX 70/30 VIAL No
C4G INSULIN NPH HUMAN ISOPHANE 0 999RELION NOVOLIN N 100 UNIT/ML No
C4G INSULIN REGULAR, HUMAN 0 999RELION NOVOLIN R 100 UNIT/ML No
C4H ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPEC4H PRAMLINTIDE ACETATE 0 999SYMLINPEN 120 PEN INJECTOR No
C4H PRAMLINTIDE ACETATE 0 999SYMLINPEN 60 PEN INJECTOR No
C4I ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST)C4I EXENATIDE MICROSPHERES 0 999BYDUREON 2 MG PEN INJECT No
C4I EXENATIDE MICROSPHERES 0 999BYDUREON 2 MG VIAL No
C4I EXENATIDE 0 999BYETTA 10 MCG DOSE PEN INJ No
Tuesday, May 14, 2019 Page 34 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C4I EXENATIDE 0 999BYETTA 5 MCG DOSE PEN INJ No
C4J ANTIHYPERGLYCEMIC, DPP-4 INHIBITORSC4J SITAGLIPTIN PHOSPHATE 18 999JANUVIA 100 MG TABLET No
C4J SITAGLIPTIN PHOSPHATE 18 999JANUVIA 25 MG TABLET No
C4J SITAGLIPTIN PHOSPHATE 18 999JANUVIA 50 MG TABLET No
C4J SAXAGLIPTIN HCL 18 999ONGLYZA 2.5 MG TABLET No
C4J SAXAGLIPTIN HCL 18 999ONGLYZA 5 MG TABLET No
C4J LINAGLIPTIN 18 999TRADJENTA 5 MG TABLET No
C4K ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPEC4K CHLORPROPAMIDE 0 999CHLORPROPAMIDE 100 MG TABLET No
C4K CHLORPROPAMIDE 0 999CHLORPROPAMIDE 250 MG TABLET No
C4K GLIMEPIRIDE 0 999GLIMEPIRIDE 1 MG TABLET No
C4K GLIMEPIRIDE 0 999GLIMEPIRIDE 2 MG TABLET No
C4K GLIMEPIRIDE 0 999GLIMEPIRIDE 4 MG TABLET No
C4K GLIPIZIDE 0 999GLIPIZIDE 10 MG TABLET No
C4K GLIPIZIDE 0 999GLIPIZIDE 5 MG TABLET No
C4K GLIPIZIDE 0 999GLIPIZIDE ER 10 MG TABLET No
C4K GLIPIZIDE 0 999GLIPIZIDE ER 2.5 MG TABLET No
C4K GLIPIZIDE 0 999GLIPIZIDE ER 5 MG TABLET No
C4K GLIPIZIDE 0 999GLIPIZIDE XL 10 MG TABLET No
C4K GLIPIZIDE 0 999GLIPIZIDE XL 2.5 MG TABLET No
C4K GLIPIZIDE 0 999GLIPIZIDE XL 5 MG TABLET No
C4K GLYBURIDE 0 999GLYBURIDE 1.25 MG TABLET No
C4K GLYBURIDE 0 999GLYBURIDE 2.5 MG TABLET No
Tuesday, May 14, 2019 Page 35 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C4K GLYBURIDE 0 999GLYBURIDE 5 MG TABLET No
C4K GLYBURIDE,MICRONIZED 0 999GLYBURIDE MICRO 1.5 MG TAB No
C4K GLYBURIDE,MICRONIZED 0 999GLYBURIDE MICRO 3 MG TAB No
C4K GLYBURIDE,MICRONIZED 0 999GLYBURIDE MICRO 3 MG TABLET No
C4K GLYBURIDE,MICRONIZED 0 999GLYBURIDE MICRO 6 MG TAB No
C4K GLYBURIDE,MICRONIZED 0 999GLYBURIDE MICRO 6 MG TABLET No
C4K REPAGLINIDE 0 999REPAGLINIDE 0.5 MG TABLET No
C4K REPAGLINIDE 0 999REPAGLINIDE 1 MG TABLET No
C4K REPAGLINIDE 0 999REPAGLINIDE 2 MG TABLET No
C4K TOLAZAMIDE 0 999TOLAZAMIDE 250 MG TABLET No
C4K TOLAZAMIDE 0 999TOLAZAMIDE 500 MG TABLET No
C4K TOLBUTAMIDE 0 999TOLBUTAMIDE 500 MG TABLET No
C4L ANTIHYPERGLYCEMIC, BIGUANIDE TYPEC4L METFORMIN HCL 0 999METFORMIN HCL 1,000 MG TABLET No
C4L METFORMIN HCL 0 999METFORMIN HCL 500 MG TABLET No
C4L METFORMIN HCL 0 999METFORMIN HCL 750 MG ER TABLET No
C4L METFORMIN HCL 0 999METFORMIN HCL 850 MG TABLET No
C4L METFORMIN HCL 0 999METFORMIN HCL ER 500 MG TAB No
C4L METFORMIN HCL 0 999METFORMIN HCL ER 500 MG TABLET No
C4L METFORMIN HCL 0 999METFORMIN HCL ER 750 MG TABLET No
C4M ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIBITORSC4M ACARBOSE 0 999ACARBOSE 100 MG TABLET No
C4M ACARBOSE 0 999ACARBOSE 25 MG TABLET No
C4M ACARBOSE 0 999ACARBOSE 50 MG TABLET No
Tuesday, May 14, 2019 Page 36 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C4M MIGLITOL 0 999GLYSET 100 MG TABLET No
C4M MIGLITOL 0 999GLYSET 25 MG TABLET No
C4M MIGLITOL 0 999GLYSET 50 MG TABLET No
C4N ANTIHYPERGLYCEMIC,THIAZOLIDINEDIONE(PPARG AGONIST)C4N PIOGLITAZONE HCL 0 999PIOGLITAZONE 15 MG TABLET No
C4N PIOGLITAZONE HCL 0 999PIOGLITAZONE 30 MG TABLET No
C4N PIOGLITAZONE HCL 0 999PIOGLITAZONE 45 MG TABLET No
C4N PIOGLITAZONE HCL 0 999PIOGLITAZONE HCL 15 MG TABLET No
C4N PIOGLITAZONE HCL 0 999PIOGLITAZONE HCL 30 MG TABLET No
C4N PIOGLITAZONE HCL 0 999PIOGLITAZONE HCL 45 MG TABLET No
C4S ANTIHYPERGLYCEMIC,INSULIN-RELEASE STIM.-BIGUANIDEC4S GLIPIZIDE/METFORMIN HCL 0 999GLIPIZIDE-METFORMIN 2.5/250 MG No
C4S GLIPIZIDE/METFORMIN HCL 0 999GLIPIZIDE-METFORMIN 2.5/500 MG No
C4S GLIPIZIDE/METFORMIN HCL 0 999GLIPIZIDE-METFORMIN 2.5-250 MG No
C4S GLIPIZIDE/METFORMIN HCL 0 999GLIPIZIDE-METFORMIN 2.5-500 MG No
C4S GLIPIZIDE/METFORMIN HCL 0 999GLIPIZIDE-METFORMIN 5/500 MG No
C4S GLIPIZIDE/METFORMIN HCL 0 999GLIPIZIDE-METFORMIN 5-500 MG No
C4S GLYBURIDE/METFORMIN HCL 0 999GLYBURIDE-METFORMIN 2.5/500 MG No
C4S GLYBURIDE/METFORMIN HCL 0 999GLYBURIDE-METFORMIN 2.5-500 MG No
C4S GLYBURIDE/METFORMIN HCL 0 999GLYBURIDE-METFORMIN 5/500 MG No
C4S GLYBURIDE/METFORMIN HCL 0 999GLYBURIDE-METFORMIN 5-500 MG No
C4S GLYBURIDE/METFORMIN HCL 0 999GLYBURID-METFORMIN 1.25/250 MG No
C4S GLYBURIDE/METFORMIN HCL 0 999GLYBURID-METFORMIN 1.25-250 MG No
C4S GLYBURIDE/METFORMIN HCL 0 999GLYBURID-METFORMIN 2.5-500 MG No
Tuesday, May 14, 2019 Page 37 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C4S GLYBURIDE/METFORMIN HCL 0 999GLYBURID-METFORMIN 5-500 MG No
C4T ANTIHYPERGLYCEMIC, THIAZOLIDINEDIONE AND BIGUANIDEC4T PIOGLITAZONE HCL/METFORMIN HCL 0 999PIOGLITAZONE-METFORMIN 15-500 No
C4T PIOGLITAZONE HCL/METFORMIN HCL 0 999PIOGLITAZONE-METFORMIN 15-850 No
C4W ANTIHYPERGLYCEMIC, SGLT-2 AND DPP-4 INHIBITOR COMBC4W EMPAGLIFLOZIN/LINAGLIPTIN 18 999GLYXAMBI 10 MG-5 MG TABLET No
C4W EMPAGLIFLOZIN/LINAGLIPTIN 18 999GLYXAMBI 25 MG-5 MG TABLET No
C5B PROTEIN REPLACEMENTC5B CYSTEINE HCL 0 999L-CYSTEINE 50 MG/ML VIAL No
C5F DIETARY SUPPLEMENT, MISCELLANEOUSC5F COCONUT OIL 0 999COCONUT OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
C5F COCONUT OIL 0 999EQL COCONUT OIL 1,000 MG SFTGL Cystic Fib Diag Auto PA
C5F OMEGA3/DHA/EPA/FISH OIL/VIT D3 0 999OMEGA-3 + VITAMIN D3 TAB CHEW Cystic Fib Diag Auto PA
C5F OMEGA-3S/DHA/EPA/FISH OIL 0 999OMEGA-3 GUMMIES Cystic Fib Diag Auto PA
C5J IV SOLUTIONS: DEXTROSE-WATERC5J DEXTROSE 10 % IN WATER 0 999DEXTROSE 10% WATER IV SOLN. No
C5J DEXTROSE 10 % IN WATER 0 999DEXTROSE 10%/H2O/EXCEL CONT No
C5J DEXTROSE 10 % IN WATER 0 999DEXTROSE 10%/WATER IV SOLN No
C5J DEXTROSE 10 % IN WATER 0 999DEXTROSE 10%/WATER IV SOLN. No
C5J DEXTROSE 10 % IN WATER 0 999DEXTROSE 10%-WATER IV SOLUTION No
C5J DEXTROSE 20 % IN WATER 0 999DEXTROSE 20%/WATER IV SOLN No
C5J DEXTROSE 25 % IN WATER 0 999DEXTROSE 25%/WATER SYRINGE No
C5J DEXTROSE 30 % IN WATER 0 999DEXTROSE 30%/WATER IV SOLN. No
C5J DEXTROSE 40 % IN WATER 0 999DEXTROSE 40%/WATER IV SOLN No
C5J DEXTROSE 5 % IN WATER 0 999DEXTROSE 5%/WATER IV SOLN No
Tuesday, May 14, 2019 Page 38 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C5J DEXTROSE 5 % IN WATER 0 999DEXTROSE 5%/WATER IV SOLN. No
C5J DEXTROSE 5 % IN WATER 0 999DEXTROSE 5%/WATER VIAL No
C5J DEXTROSE 5 % IN WATER 0 999DEXTROSE 5%/WATER/EXCEL CON No
C5J DEXTROSE 5 % IN WATER 0 999DEXTROSE 5%-MULTI-PACK No
C5J DEXTROSE 5 % IN WATER 0 999DEXTROSE 5%-WATER 100 ML No
C5J DEXTROSE 5 % IN WATER 0 999DEXTROSE 5%-WATER 50 ML No
C5J DEXTROSE 5 % IN WATER 0 999DEXTROSE 5%-WATER IV SOLN No
C5J DEXTROSE 5 % IN WATER 0 999DEXTROSE 5%-WATER IV SOLUTION No
C5J DEXTROSE 50 % IN WATER 0 999DEXTROSE 50%/WATER ABBOJECT No
C5J DEXTROSE 50 % IN WATER 0 999DEXTROSE 50%/WATER IV SOLN No
C5J DEXTROSE 50 % IN WATER 0 999DEXTROSE 50%/WATER SYRINGE No
C5J DEXTROSE 50 % IN WATER 0 999DEXTROSE 50%/WATER VIAL No
C5J DEXTROSE 70 % IN WATER 0 999DEXTROSE 70%/WATER IV SOLN No
C5J DEXTROSE 70 % IN WATER 0 999DEXTROSE 70%/WATER IV SOLN. No
C5J DEXTROSE 70 % IN WATER 0 999DEXTROSE 70%-WATER IV SOLN No
C5J DEXTROSE 5 % IN WATER 0 999GLUCOSE 5%-WATER 100 ML No
C5J DEXTROSE 5 % IN WATER 0 999GLUCOSE 5%-WATER 50 ML No
C5K IV SOLUTIONS: DEXTROSE-SALINEC5K DEXTROSE 10 % AND 0.45 % NACL 0 999D10%-1/2NS SOLN/EXCEL CONT No
C5K DEXTROSE 5 %-0.45 % SOD CHLORD 0 999D5%-1/2NS SOLN/EXCEL CONT No
C5K DEXTROSE 5 % AND 0.3 % NACL 0 999D5%-1/3NS SOLN/EXCEL CONT No
C5K DEXTROSE 5 %-0.2 % SOD CHLORID 0 999D5%-1/4NS SOLN/EXCEL CONT No
C5K DEXTROSE 10 % AND 0.2 % NACL 0 999DEXTROSE 10%-1/4NS IV SOLN No
C5K DEXTROSE 2.5 % AND 0.45 % NACL 0 999DEXTROSE 2.5%-1/2NS IV SOLN No
Tuesday, May 14, 2019 Page 39 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C5K DEXTROSE 5 %-0.45 % SOD CHLORD 0 999DEXTROSE 5%-1/2NS IV SOLN No
C5K DEXTROSE 5 %-0.45 % SOD CHLORD 0 999DEXTROSE 5%-1/2NS IV SOLN. No
C5K DEXTROSE 5 % AND 0.3 % NACL 0 999DEXTROSE 5%-1/3NS IV SOLN No
C5K DEXTROSE 5 % AND 0.3 % NACL 0 999DEXTROSE 5%-1/3NS IV SOLN. No
C5K DEXTROSE 5 % AND 0.3 % NACL 0 999DEXTROSE 5%-1/3NS IV SOLN. No
C5K DEXTROSE 5 %-0.2 % SOD CHLORID 0 999DEXTROSE 5%-1/4NS IV SOLN No
C5K DEXTROSE 5 %-0.2 % SOD CHLORID 0 999DEXTROSE 5%-1/4NS IV SOLN. No
C5K DEXTROSE 5 %-0.2 % SOD CHLORID 0 999DEXTROSE 5%-1/4NS IV SOLN. No
C5K DEXTROSE 5 % AND 0.9 % NACL 0 999DEXTROSE 5%-NS IV SOLUTION No
C5M IV SOLUTIONS: DEXTROSE AND LACTATED RINGERSC5M DEXTROSE 5%-LACTATED RINGERS 0 999DEXTROSE 5%-LR IV SOLUTION No
C5M DEXTROSE 5%-LACTATED RINGERS 0 999DEXTROSE 5%-LR SOLN/EXCEL No
C6A VITAMIN A PREPARATIONSC6A VITAMIN A 0 999CVS VITAMIN A 8,000 UNIT SFTGL Cystic Fib Diag Auto PA
C6A VITAMIN A 0 999GNP VITAMIN A 10,000 UNIT SFGL Cystic Fib Diag Auto PA
C6A VITAMIN A 0 999RA VITAMIN A 10,000 UNIT SFTGL Cystic Fib Diag Auto PA
C6A VITAMIN A 0 999VITAMIN A 10,000 UNITS CAP Cystic Fib Diag Auto PA
C6A VITAMIN A 0 999VITAMIN A 10,000 UNITS CAPSULE Cystic Fib Diag Auto PA
C6A VITAMIN A 0 999VITAMIN A 10,000 UNITS SOFTGEL Cystic Fib Diag Auto PA
C6A VITAMIN A 0 999VITAMIN A 8,000 UNITS CAPSULE Cystic Fib Diag Auto PA
C6A VITAMIN A 0 999VITAMIN A 8,000 UNITS SOFTGELS Cystic Fib Diag Auto PA
C6B VITAMIN B PREPARATIONSC6B FOLIC ACID/B CPLX/C/SELEN/ZINC 0 999DIALYVITE 3,000 TABLET No
C6B MULTIVIT-MINS NO.11/FOLIC ACID 0 999DIALYVITE 5000 TABLET No
C6B MULTIVIT-MINS 25/FOLIC ACID/D3 0 999DIALYVITE SUPREME D TABLET No
Tuesday, May 14, 2019 Page 40 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C6B FOLIC ACID/VIT B COMPLEX AND C 0 999DIALYVITE TABLET No
C6B B COMPLEX 11/FOLIC/C/BIOT/ZINC 0 999DIALYVITE WITH ZINC TABLET No
C6B B COMP NO3/FOLIC/C/BIOTIN/ZINC 0 999NEPHPLEX RX TABLET No
C6B VIT B COMP NO.3/FOLIC/C/BIOTIN 0 999NEPHRO-VITE RX TABLET No
C6B CYANOCOBALAMIN/FOLIC AC/VIT B6 0 999TL GARD RX TABLET No
C6B FOLIC ACID/B COMPLEX C NO.17 0 999VIRT-VITE PLUS TABLET No
C6B B CMPLX 4/VIT D3/C/FOLIC/ZINC 0 999VITAL-D RX TABLET No
C6B VIT B COMP NO.3/FOLIC/C/BIOTIN 0 999VOL-CARE RX TABLET No
C6B VIT B COMP NO.3/FOLIC/C/BIOTIN 0 999VP-VITE RX TABLET No
C6C VITAMIN C PREPARATIONSC6C ASCORBIC ACID 0 999ACEROLA C 500 MG TABLET CHEW Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999ACEROLA C 500 MG WAFER Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999ASCORBIC ACID 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999ASCORBIC ACID 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999ASCORBIC ACID 500 MG/ML VIAL No
C6C ASCORBIC ACID 0 999ASCORBIC ACID 500 MG-ML VIAL No
C6C ASCORBIC ACID 0 999ASCORBIC ACID GRANULAR Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999C-1,000 MG TABLET SA Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999C-1000 ER CAPLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999C-1000 MG W/ ROSE HIPS TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999C-1000 MG W/ROSE HIPS CAPLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999C-1000 TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999C-500 ER TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999C-500 MG TABLET Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 41 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C6C ASCORBIC ACID 0 999C-500 TABLET CHEWABLE Cystic Fib Diag Auto PA
C6C ASCORBATE CALCIUM 0 999CALCIUM ASCORBATE 500 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999CVS VITAMIN C 1,000 MG CAPLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999CVS VITAMIN C 250 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999CVS VITAMIN C 500 MG CAPLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999CVS VITAMIN C 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999EQL VIT C W/RH 1,000 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999EQL VIT C-ROSE HIPS 500 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999EQL VITAMIN C 1,000 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999EQL VITAMIN C 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999GNP VIT C-ROSE HIPS 500 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999GNP VITAMIN C 1,000 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999GNP VITAMIN C 250 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999GNP VITAMIN C 500 MG TAB CHEW Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999GNP VITAMIN C 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999GNP VITAMIN C DROPS Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999GNP VITAMIN C ER 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999HM VIT C-ROSE HIP 1,000 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999HM VIT C-ROSE HIPS 500 MG CPLT Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999HM VITAMIN C 1,000 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999HM VITAMIN C 500 MG CAPLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999HM VITAMIN C 500 MG TAB CHEW Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999HM VITAMIN C TR 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999RA VIT C 500 MG CAPLET SA Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 42 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C6C ASCORBIC ACID 0 999RA VITAMIN C 1,000 MG TAB SA Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999RA VITAMIN C 1,000 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999RA VITAMIN C 250 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999RA VITAMIN C 500 MG TAB CHEW Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999RA VITAMIN C 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999RA VITAMIN C W/RH 500 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SB C-500 TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SM VIT C 500 MG TABLET CHEW Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SM VITAMIN C 1,000 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SM VITAMIN C 1,000 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SM VITAMIN C 250 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SM VITAMIN C 500 MG CAPLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SM VITAMIN C 500 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SM VITAMIN C 500 MG TAB SA Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SM VITAMIN C 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SM VITAMIN C DROPS Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SM VITAMIN C TR 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SM VITAMIN C W/RH 500 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SUNMARK VITAMIN C 500 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SUNMARK VITAMIN C W-ROSE HIPS Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SUNMARK VITAMIN C W-ROSE HIPS Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SV VIT C-ROSE HIP 1,000 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SV VIT C-ROSE HIPS 1,000 MG TB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SV VIT C-ROSE HIPS 500 MG TAB Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 43 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C6C ASCORBIC ACID 0 999SV VITAMIN C 500 MG TAB CHEW Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999SV VITAMIN C TR 1,000 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VIT C-ROSE HIPS 1,000 MG CPLT Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VIT C-ROSE HIPS 1,000 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VIT C-ROSE HIPS 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VIT C-ROSE HIPS TR 1,000 MG Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VIT C-ROSE HIPS TR 500 MG CPLT Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VIT C-ROSE HIPS TR 500 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C 1,000 MG CAPLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C 1,000 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C 1,500 MG TABLET SA Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C 100 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C 125 MG GUMMIES Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C 125 MG GUMMY Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C 250 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C 250 MG TABLET CHEW Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C 500 MG CAPSULE SA Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C 500 MG CHEW TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C 500 MG SOFTGEL Cystic Fib Diag Auto PA
C6C ASCORBATE CALCIUM 0 999VITAMIN C 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C 500 MG TABLET CHEW Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C DROPS Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 44 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C6C ASCORBIC ACID 0 999VITAMIN C ER 500 MG CAPSULE Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C TR 1,000 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C TR 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C W/RH 1,000 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C W/RH 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C/RH 500 MG TABLET Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C-500 MG TR CAPSULE Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VITAMIN C-ROSE HIPS 500 MG CPT Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999VIT-C + ROSE HIPS 1,000 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999V-R VIT C 250 MG TABLET CHEW Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999V-R VIT C 500 MG TABLET CHEW Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999V-R VITAMIN C 1,000 MG TAB Cystic Fib Diag Auto PA
C6C ASCORBIC ACID 0 999V-R VITAMIN C 500 MG TAB Cystic Fib Diag Auto PA
C6D VITAMIN D PREPARATIONSC6D CHOLECALCIFEROL (VITAMIN D3) 0 999BABY VITAMIN D3 400 UNIT/DROP Cystic Fib Diag Auto PA
C6D CALCITRIOL 0 999CALCITRIOL 0.25 MCG CAPSULE No
C6D CALCITRIOL 0 999CALCITRIOL 0.5 MCG CAPSULE No
C6D CALCITRIOL 0 999CALCITRIOL 1 MCG/ML AMPUL No
C6D CALCITRIOL 0 999CALCITRIOL 1 MCG/ML SOLUTION No
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VIT D3 1,000 UNIT GUMMIES Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VIT D3 1,000 UNIT GUMMIES Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VIT D3 1,000 UNIT SOFT CHW Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VIT D3 1,000 UNIT TAB CHEW Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VITAMIN D 1,000 UNIT SFTGL Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 45 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VITAMIN D3 1,000 UNIT SFGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VITAMIN D3 2,000 UNIT SFGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VITAMIN D3 400 UNIT SFTGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VITAMIN D3 400 UNIT/DROP Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999CVS VITAMIN D3 5,000 UNIT SFGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999D3-50 50,000 UNITS CAPSULE Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999EQL VITAMIN D3 1,000 UNIT SFGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999EQL VITAMIN D3 2,000 UNIT SFGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999EQL VITAMIN D3 400 UNIT SFTGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999EQL VITAMIN D3 5,000 UNIT SFGL Cystic Fib Diag Auto PA
C6D ERGOCALCIFEROL (VITAMIN D2) 0 999ERGOCALCIFEROL 8,000 UNITS/ML Cystic Fib Diag Auto PA
C6D ERGOCALCIFEROL (VITAMIN D2) 0 999ERGOCALCIFEROL ORAL SOLUTION Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999GNP VIT D3 400 UNIT TAB CHEW Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999GNP VITAMIN D 1,000 UNIT TAB Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999GNP VITAMIN D 2,000 UNIT TAB Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999GNP VITAMIN D 400 UNIT TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999GNP VITAMIN D 5,000 UNIT TAB Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999HM VITAMIN D 1,000 UNIT TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999HM VITAMIN D 400 UNIT TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999HM VITAMIN D3 2,000 UNIT SFTGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999HM VITAMIN D3 4,000 UNIT SFTGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999KIDS VITAMIN D3 TAB CHEW Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999RA VITAMIN D 2,000 UNIT SFTGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999RA VITAMIN D3 1,000 UNIT TAB Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 46 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999RA VITAMIN D-3 2,000 UNIT SFTG Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999RA VITAMIN D3 5,000 UNIT SFTGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999REPLESTA 50,000 UNITS WAFER Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999REPLESTA NX 14,000 UNITS WAFER Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999SM VITAMIN D3 1,000 UNIT TAB Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999SM VITAMIN D3 1,000 UNITS TAB Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999SM VITAMIN D3 2,000 UNIT SFTGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999SM VITAMIN D3 4,000 UNIT SFTGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999SV VITAMIN D3 1,000 UNITS SFGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999SV VITAMIN D3 2,000 UNIT SFTGL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999SV VITAMIN D3 400 UNIT SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999SV VITAMIN D3 5,000 UNIT SFTGL Cystic Fib Diag Auto PA
C6D ERGOCALCIFEROL (VITAMIN D2) 0 999VIT D2 1.25 MG (50,000 UNIT) No
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VIT D3 5,000 UNIT FAST DISSOLV Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 1,000 UNIT TAB Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 1,000 UNIT TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 1,000 UNITS SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 1,000 UNITS TAB Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 1,000 UNITS TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 10,000 UNIT SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 2,000 UNIT SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 2,000 UNIT TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 2,000 UNITS SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 2000 SOFTGEL Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 47 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 400 UNIT SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 400 UNIT TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 400 UNIT/ML DROP Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 400 UNITS TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 5,000 UNIT CAPSULE Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D 50,000 UNIT CAPSULE Cystic Fib Diag Auto PA
C6D ERGOCALCIFEROL (VITAMIN D2) 0 999VITAMIN D 50,000 UNITS CAPSULE No
C6D ERGOCALCIFEROL (VITAMIN D2) 0 999VITAMIN D2 2,000 UNIT TABLET Cystic Fib Diag Auto PA
C6D ERGOCALCIFEROL (VITAMIN D2) 0 999VITAMIN D2 400 UNIT TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 1,000 UNIT GUMMIES Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 1,000 UNIT SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 1,000 UNIT TAB Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 1,000 UNIT TAB CHEW Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 1,000 UNIT TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 1,000 UNIT/10 ML LQ Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 1,000 UNITS SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 1,000 UNITS TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 10,000 UNIT SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 10,000 UNIT TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 2,000 UNIT SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D-3 2,000 UNIT SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 2,000 UNIT SPRAY Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 2,000 UNIT TAB CHEW Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 2,000 UNIT TABLET Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 48 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D-3 2,000 UNIT TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 2,000 UNITS SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D-3 2,000 UNITS TAB Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D-3 2,000 UNITS TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 3,000 UNIT TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 400 UNIT SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 400 UNIT TAB CHEW Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 400 UNIT TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 400 UNIT/5 ML LIQ Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 400 UNIT/ML DROP Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 5,000 UNIT CAPSULE Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 5,000 UNIT SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 5,000 UNIT TABLET Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 5,000 UNIT/ML DROPS Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 5,000 UNITS SOFTGEL Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 5,000 UNITS/ML DRPS Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D3 50,000 UNITS CAPS Cystic Fib Diag Auto PA
C6D CHOLECALCIFEROL (VITAMIN D3) 0 999VITAMIN D-400 TABLET Cystic Fib Diag Auto PA
C6F PRENATAL VITAMIN PREPARATIONSC6F PNV, CALCIUM 70/IRON/FOLIC/DHA 12 999CALCIUM-PNV 28-1-250 MG SFTGL No
C6F PNV72/IRON,GLUC/FOLIC/DSS/DHA 12 999CITRANATAL 90 DHA COMBO PACK No
C6F PNV73/IRON,GLUC/FOLIC/DSS/DHA 12 999CITRANATAL ASSURE COMBO PACK No
C6F PRENATAL 48/IRON/FOLIC ACID/B6 12 999CITRANATAL B-CALM COMBO PACK No
C6F PNV 76/IRON,GLUC/FOLIC/DSS/DHA 12 999CITRANATAL DHA PACK No
Tuesday, May 14, 2019 Page 49 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C6F PNV59/IRON,CARB,FUM/FA/DSS/DHA 12 999CITRANATAL HARMONY CAPSULE No
C6F PNV 11/IRON FUM/FOLIC ACID/OM3 12 999C-NATE DHA SOFTGEL No
C6F PRENATAL 2/IRON/FOLIC ACID/OM3 12 999COMPLETE NATAL DHA No
C6F PRENATAL VIT 14/IRON FUM/FOLIC 12 999COMPLETENATE TABLET CHEW No
C6F PNV 16/IRON FUM,PS/FOLIC/OM-3 12 999CONCEPT DHA CAPSULE No
C6F PNV 15/IRON FUM,PS/FOLIC ACID 12 999CONCEPT OB CAPSULE No
C6F PRENATAL NO.123/IRON/FOLIC AC 12 999ELITE-OB CAPLET No
C6F PNV 15/IRON FUM,PS/FOLIC ACID 12 999FOLIVANE-OB CAPSULE No
C6F PRENATAL NO.123/IRON/FOLIC AC 12 999OB COMPLETE CAPLET No
C6F PNV 22/IRON,GLUC/FOLIC/DSS/DHA 12 999PNV OB+DHA COMBO PACK No
C6F PNV 66/IRON/FOLIC/DOCUSATE/DHA 12 999PNV-DHA + DOCUSATE SOFTGEL No
C6F PRENAT 115/IRON FUM/FOLIC/DSS 12 999PNV-FERROUS FUMARATE-DOCU-FA No
C6F PRENATAL 68/IRON/FOLIC NO1/DHA 12 999PNV-OMEGA SOFTGEL No
C6F PNV NO.5/FERROUS FUM/FOLIC AC 12 999PNV-VP-U CAPSULE No
C6F PNV 21/IRON PS,HEME PPEP/FOLIC 12 999PREFERA OB TABLET No
C6F PNV 80/IRON FUM/FOLIC/DSS/DHA 12 999PRENAISSANCE CAPSULE No
C6F PNV 69/IRON/FOLIC/DOCUSATE/DHA 12 999PRENAISSANCE PLUS SOFTGEL No
C6F PNV,CALCIUM 72/IRON/FOLIC ACID 12 999PRENATAL PLUS TABLET No
C6F PNV,CALCIUM 72/IRON/FOLIC ACID 12 999PRENATAL VITAMIN PLUS LOW IRON No
C6F PNV,CALCIUM 72/IRON/FOLIC ACID 12 999PREPLUS CA-FE 27 MG-FA 1 MG TB No
C6F PNV,CALCIUM 72/IRON/FOLIC ACID 12 999PREPLUS TABLET No
C6F PRENATAL VIT 65/IRON FUM,PS/FA 12 999PROVIDA OB CAPSULE No
C6F PRENATAL VIT 33/IRON/FOLIC/DHA 12 999SELECT-OB + DHA PACK No
C6F PRENATAL VIT128/IRON/FOLIC ACD 12 999SELECT-OB CAPLET No
Tuesday, May 14, 2019 Page 50 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C6F PRENATAL NO13/IRON PS/FOLATE 1 12 999SELECT-OB CHEWABLE CAPLET No
C6F PNV NO.118/IRON FUMARATE/FA 12 999SE-NATAL 19 CHEWABLE TABLET No
C6F PNV119/IRON FUM/FOLIC/DOCUSATE 12 999SE-NATAL 19 TABLET No
C6F PNV 39/IRON/FOLIC/DOCUSATE/DHA 12 999TARON PRENATAL DHA CAPSULE No
C6F PNV 16/IRON FUM,PS/FOLIC/OM-3 12 999TARON-C DHA CAPSULE No
C6F PRENATAL VIT27,CALCIUM/IRON/FA 12 999TRINATAL RX 1 TABLET No
C6F PRENATAL 53/IRON/FOLIC AC/OMG3 12 999TRIVEEN-DUO DHA COMBO PACK No
C6F PRENATAL 2/IRON/FOLIC ACID/OM3 12 999TRUST NATAL DHA No
C6F PRENATAL VITS15/IRON/FOLIC/DSS 12 999VIRT-ADVANCE TABLET No
C6F PNV 16/IRON FUM,PS/FOLIC/OM-3 12 999VIRT-C DHA SOFTGEL No
C6F PNV 11/IRON FUM/FOLIC ACID/OM3 12 999VIRT-NATE DHA SOFTGEL No
C6F PRENATAL 47/IRON/FOLATE 1/DHA 12 999VIRT-PN DHA SOFTGEL No
C6F PRENATAL 68/IRON/FOLIC NO1/DHA 12 999VIRT-PN PLUS SOFTGEL No
C6F PRENATAL,CALC.40/IRON/FOLATE 1 12 999VIRT-PN TABLET No
C6F PNV 66/IRON/FOLIC/DOCUSATE/DHA 12 999VIRTPREX CAPSULE No
C6F PNV 80/IRON FUM/FOLIC/DSS/DHA 12 999VIRT-SELECT CAPSULE No
C6F PRENATAL VITS16/IRON/FOLIC/DSS 12 999VIRT-VITE GT TABLET No
C6F PNV 102/IRON/FOLATE 1/DSS/DHA 12 999VITAFOL FE+ DOCUSATE COMBO PCK No
C6F PNV 112/IRON/FOLIC/OM3/DHA/EPA 12 999VITAFOL GUMMIES No
C6F PRENATAL NO.75/IRON/FOLATE NO1 12 999VITAFOL NANO TABLET No
C6F PNV 67/IRON PS/FOLATE NO.1/DHA 12 999VITAFOL ULTRA SOFTGEL No
C6F PRENATAL VIT 10/IRON FUM/FOLIC 12 999VITAFOL-OB CAPLET No
C6F PRENATAL VIT 10/IRON/FOLIC/DHA 12 999VITAFOL-OB+DHA COMBO PACK No
C6F PRENATAL 26/IRON PS/FOLIC/DHA 12 999VITAFOL-ONE CAPSULE No
Tuesday, May 14, 2019 Page 51 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C6F PRENATAL 34/IRON/FOLIC/DSS/DHA 12 999VP-CH-PNV PRENATAL SOFTGEL No
C6F PNV 21/IRON PS,HEME PPEP/FOLIC 12 999VP-HEME OB TABLET No
C6F PRENATAL 47/IRON/FOLATE 1/DHA 12 999ZATEAN-PN DHA CAPSULE No
C6F PRENATAL 68/IRON/FOLIC NO1/DHA 12 999ZATEAN-PN PLUS SOFTGEL No
C6H PEDIATRIC VITAMIN PREPARATIONSC6H PEDI MULTIVIT 40/PHYTONADIONE 0 3AQUADEKS PEDIATRIC LIQUID No
C6H PEDIATRIC MULTIVIT 61/D3/VIT K 0 999COMPLETE FORMULATION D3000 CAP Cystic Fib Diag Auto PA
C6H PEDI MULTIVIT 22/VIT D3/VIT K 0 999COMPLETE FORMULATION D3000 CHW Cystic Fib Diag Auto PA
C6H PEDIATRIC MULTIVIT 61/D3/VIT K 0 999COMPLETE FORMULATION D5000 CAP Cystic Fib Diag Auto PA
C6H PEDI MULTIVIT 22/VIT D3/VIT K 0 999COMPLETE FORMULATION MULTIVIT Cystic Fib Diag Auto PA
C6H PEDIATRIC MULTIVIT 61/D3/VIT K 0 999COMPLETE FORMULATION MULTIVIT Cystic Fib Diag Auto PA
C6H PEDI MULTIVIT 77/VIT D3/VIT K 0 999COMPLETE FORMULATION PEDIATRIC Cystic Fib Diag Auto PA
C6H PEDI MULTIVIT NO.128/VITAMIN K 0 999DEKAS PLUS LIQUID Cystic Fib Diag Auto PA
C6H MULTIVIT INFUSION,PEDI 1,VIT K 0 999INFUVITE PEDIATRIC VIAL No
C6H MULTIVIT INFUSION,PEDI 2,VIT K 0 999M.V.I. PEDIATRIC VIAL No
C6H PEDI MULTIVIT NO.17 W-FLUORIDE 0 12MULTIVIT-FLUOR 0.25 MG TAB CHW No
C6H PEDI MULTIVIT NO.17 W-FLUORIDE 0 12MULTIVIT-FLUOR 0.25 MG TAB CHW No
C6H PEDI MULTIVIT NO.17 W-FLUORIDE 0 12MULTIVIT-FLUOR 0.5 MG TAB CHEW No
C6H PEDI MULTIVIT NO.17 W-FLUORIDE 0 12MULTIVIT-FLUOR 0.5 MG TAB CHW No
C6H PEDI MULTIVIT NO.17 W-FLUORIDE 0 12MULTIVIT-FLUORIDE 1 MG TAB CHW No
C6H PEDI MULTIVIT NO.17 W-FLUORIDE 0 12MULTIVIT-FLUORIDE 1 MG TAB CHW No
C6H PEDI MULTIVIT 22/VIT D3/VIT K 0 999MVW COMPLETE FORM MULTIVIT CHW Cystic Fib Diag Auto PA
C6H PEDI MULTIVIT NO.37 W-FLUORIDE 0 12POLY-VI-FLOR 0.25 MG DROPS No
C6H PEDI MULTIVIT NO.33/FLUORIDE 0 12POLY-VI-FLOR 0.25 MG TAB CHEW No
Tuesday, May 14, 2019 Page 52 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C6H PEDI MULTIVIT NO.33/FLUORIDE 0 12POLY-VI-FLOR 0.5 MG TAB CHEW No
C6H PEDI MULTIVIT NO.33/FLUORIDE 0 12POLY-VI-FLOR 1 MG TAB CHEW No
C6H PEDI MULTIVIT 37/FLUORIDE/IRON 0 12POLY-VI-FLOR WITH IRON 0.25 MG No
C6H PEDI MULTIVIT 33/FLUORIDE/IRON 0 12POLY-VI-FLOR WITH IRON 0.5 MG No
C6H PED MVIT A,C,D3 NO.38/FLUORIDE 0 12TRI-VI-FLOR 0.25 MG DROPS No
C6H PED MVIT A,C,D3 NO.38/FLUORIDE 0 12TRI-VI-FLOR 0.5 MG DROPS No
C6K VITAMIN K PREPARATIONSC6K PHYTONADIONE (VIT K1) 0 999MEPHYTON 5 MG TABLET No
C6K PHYTONADIONE (VIT K1) 0 999PHYTONADIONE 1 MG/0.5 ML SYR No
C6K PHYTONADIONE (VIT K1) 0 999VITAMIN K 1 MG/0.5 ML AMPUL No
C6K PHYTONADIONE (VIT K1) 0 999VITAMIN K 10 MG/ML AMPUL No
C6K PHYTONADIONE (VIT K1) 0 999VITAMIN K-1 1 MG/0.5 ML AMPUL No
C6K PHYTONADIONE (VIT K1) 0 999VITAMIN K-1 10 MG/ML AMPUL No
C6L VITAMIN B12 PREPARATIONSC6L CYANOCOBALAMIN (VITAMIN B-12) 0 999CYANOCOBALAMIN 1,000 MCG/ML No
C6L CYANOCOBALAMIN (VITAMIN B-12) 0 999CYANOCOBALAMIN 10,000 MCG/10 No
C6L CYANOCOBALAMIN (VITAMIN B-12) 0 999CYANOCOBALAMIN 30,000 MCG/30 No
C6L CYANOCOBALAMIN/FOLIC ACID 0 999FOLTRATE TABLET No
C6M FOLIC ACID PREPARATIONSC6M FOLIC ACID 0 999FOLIC ACID 1 MG TABLET No
C6M FOLIC ACID 0 999FOLIC ACID 5 MG/ML VIAL No
C6Q VITAMIN B6 PREPARATIONSC6Q PYRIDOXINE HCL (VITAMIN B6) 0 999PYRIDOXINE 100 MG/ML VIAL No
C6T VITAMIN B1 PREPARATIONSC6T THIAMINE HCL 0 999THIAMINE 100 MG/ML VIAL No
Tuesday, May 14, 2019 Page 53 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C6T THIAMINE HCL 0 999THIAMINE 200 MG/2 ML VIAL No
C6Z MULTIVITAMIN PREPARATIONSC6Z MV-MIN 51/FOLIC ACID/VIT K/UBI 4 999AQUADEKS CHEWABLE TABLET No
C6Z MULTIVIT-MINS NO.20/IRON/FOLIC 0 999BACMIN CAPLET No
C6Z FOLIC/MVI THER-MIN/LYCOP/LUT 0 999CORVITA TABLET No
C6Z VIT A/VIT D3/E/TOCOPHERSOLAN/K 0 999DEKAS ESSENTIAL CAPSULE Cystic Fib Diag Auto PA
C6Z VIT A/D3/TOCOPHERSOLAN/VIT K 0 999DEKAS ESSENTIAL LIQUID Cystic Fib Diag Auto PA
C6Z MULTIVIT-MINS 56/FOLIC/K/COQ10 0 999DEKAS PLUS CHEWABLE TABLET Cystic Fib Diag Auto PA
C6Z MULTIVIT-MINS 53/FOLIC/K/COQ10 0 999DEKAS PLUS SOFTGEL Cystic Fib Diag Auto PA
C6Z MULTIVIT INFUSN,ADULT 4,VIT K 0 999INFUVITE ADULT VIAL No
C6Z MULTIVIT INFUSN,ADULT 1,VIT K 0 999M.V.I. ADULT VIAL No
C6Z MULTIVIT-MINS60/IRON FUM/FOLIC 12 999NIVA-PLUS TABLET No
C6Z MV,MIN10/FOLIC ACID/D3/ALA/LUT 0 999STROVITE ONE CAPLET No
C6Z MV, MIN 59/IRON/FOLIC/DOCUSATE 12 999THRIVITE 19 TABLET No
C6Z MULTIVIT-MINS60/IRON FUM/FOLIC 12 999VOL-PLUS TABLET No
C7A HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORSC7A ALLOPURINOL 0 999ALLOPURINOL 100 MG TABLET No
C7A ALLOPURINOL 0 999ALLOPURINOL 300 MG TABLET No
C7D METABOLIC DEFICIENCY AGENTSC7D BETAINE 0 999CYSTADANE 1 GRAM/1.7 ML POWDER No
C7D LEVOCARNITINE (WITH SUGAR) 0 999LEVOCARNITINE 100 MG/ML SOLN No
C7D LEVOCARNITINE 0 999LEVOCARNITINE 330 MG TABLET No
C7F APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND.C7F MEGESTROL ACETATE 0 999MEGESTROL 625 MG/5 ML SUSP No
C7F MEGESTROL ACETATE 0 999MEGESTROL ACET 40 MG/ML SUSP No
Tuesday, May 14, 2019 Page 54 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C7F MEGESTROL ACETATE 0 999MEGESTROL ACET 400 MG/10 ML No
C7I CYTOCHROME P450 INHIBITORSC7I COBICISTAT 18 999TYBOST 150 MG TABLET Auto PA
C8A METALLIC POISON,AGENTS TO TREATC8A DEFEROXAMINE MESYLATE 0 999DEFEROXAMINE 2 GRAM VIAL No
C8A DEFEROXAMINE MESYLATE 0 999DEFEROXAMINE 500 MG VIAL No
C8E ANTIDOTES,MISCELLANEOUSC8E ACETYLCYSTEINE 0 999ACETYLCYSTEINE 200 MG/ML VIAL No
C8E ACETYLCYSTEINE 0 999ACETYLCYSTEINE 6 GRAM/30 ML VL No
C9C PARENTERAL AMINO ACID SOLUTIONS AND COMBINATIONSC9C PARENTERAL AMINO ACID 15% NO.1 0 999AMINO ACIDS 15% SOLUTION No
C9C PARENTERAL AMINO ACID 10% NO.2 0 999AMINOSYN 10% IV SOLUTION No
C9C AMINO ACIDS 7 %/ELECTROLYTES 0 999AMINOSYN 7%-ELECTROLYTE SOL No
C9C AMINO ACIDS 8.5 %/ELECTROLYTES 0 999AMINOSYN 8.5% IV SOLUTION No
C9C PARENT. AMINO ACID 8.5 % NO.2 0 999AMINOSYN 8.5% IV SOLUTION No
C9C PARENTERAL AMINO ACID 10% NO.1 0 999AMINOSYN II 10% IV SOLUTION No
C9C PARENTERAL AMINO ACID 15% NO.2 0 999AMINOSYN II 15% IV SOLUTION No
C9C PARENTERAL AMINO ACID 7 % NO.2 0 999AMINOSYN II 7% IV SOLUTION No
C9C AMINO ACIDS 8.5 %/ELECTROLYTES 0 999AMINOSYN II 8.5% ELECTROLYT No
C9C PARENT. AMINO ACID 8.5 % NO.3 0 999AMINOSYN II 8.5% ELECTROLYT No
C9C AMINO ACIDS 3.5%/ELECTROLYTE M 0 999AMINOSYN M 3.5% IV SOLUTION No
C9C AMINO ACIDS 7 % 0 999AMINOSYN-HBC 7% IV SOLUTION No
C9C PARENT.AMINO ACID 10% NO5(PED) 0 999AMINOSYN-PF 10% IV SOLUTION No
C9C PARENT.AMINO ACID 7 % NO1(PED) 0 999AMINOSYN-PF 7% IV SOLUTION No
C9C PARENT AMINO AC 5.2 % (RENAL) 0 999AMINOSYN-RF IV SOLUTION No
Tuesday, May 14, 2019 Page 55 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C9C AMINO ACIDS 4.25%/DEXTROSE 10% 0 999CLINIMIX 4.25%/10 SOLUTION No
C9C AMINO ACIDS 4.25%/DEXTROSE 20% 0 999CLINIMIX 4.25%/20 SOLUTION No
C9C AMINO ACID 4.25 %/DEXTROSE 25% 0 999CLINIMIX 4.25%/25 SOLUTION No
C9C AMINO ACIDS 4.25 %/DEXTROSE 5% 0 999CLINIMIX 4.25/5 SOLUTION No
C9C AMINO ACIDS 5 %/DEXTROSE 15 % 0 999CLINIMIX 5/15 SOLUTION No
C9C AMINO ACIDS 5 %/DEXTROSE 20 % 0 999CLINIMIX 5/20 SOLUTION No
C9C AMINO ACIDS 5 %/DEXTROSE 25 % 0 999CLINIMIX 5/25 SOLUTION No
C9C AMINO AC 2.75%/DEX 10%/LYTE 29 0 999CLINIMIX E 2.75/10 SOLUTION No
C9C AA 2.75 %/CALCIUM/LYTES/D5W 0 999CLINIMIX E 2.75/5 SOLUTION No
C9C AA 4.25%/CALCIUM/LYTES/DEX 10% 0 999CLINIMIX E 4.25/10 SOLUTION No
C9C AA 4.25 %/CALCIUM/LYTES/D25W 0 999CLINIMIX E 4.25/25 SOLUTION No
C9C AA 4.25 %/CALCIUM/LYTES/D5W 0 999CLINIMIX E 4.25/5 SOLUTION No
C9C AA 5%/D15W/ELECTROLYTES 0 999CLINIMIX E 5/15 SOLUTION No
C9C AA 5 %/CALCIUM/LYTES/DEXT 20 % 0 999CLINIMIX E 5/20 SOLUTION No
C9C AA 5 %/CALCIUM/LYTES/DEXT 25 % 0 999CLINIMIX E 5/25 SOLUTION No
C9C AA 4.25%/D15W/ELECTROLYTES 25 0 999CLINIMIX N14G30E 4.25%-D15W No
C9C AA 2.75%/D7.5%W/ELECTROLYTES12 0 999CLINIMIX N9G15E 2.75%-D7.5W No
C9C AMINO AC 2.75%/DEX 10%/LYTE 29 0 999CLINIMIX N9G20E 2.75%-D10W SOL No
C9C PARENTERAL AMINO ACID 15% NO.5 0 999CLINISOL 15% SOLUTION No
C9C AMINO ACIDS 6.9 % 0 999FREAMINE HBC 6.9% IV SOLN No
C9C PARENTERAL AMINO ACID 10% NO.4 0 999FREAMINE III 10% IV SOLN. No
C9C AMINO ACIDS 8 % 0 999HEPATAMINE 8% IV SOLUTION No
C9C AA 3.31 %/D9.8W/FAT/E-LYTES 10 0 999KABIVEN IV EMULSION No
C9C AMINO ACIDS 5.4 % 0 999NEPHRAMINE 5.4% IV SOLUTION No
Tuesday, May 14, 2019 Page 56 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
C9C AA 2.36%/D6.8W/FAT/E-LYTES NO9 0 999PERIKABIVEN IV EMULSION No
C9C PARENTERAL AMINO ACID 10% NO.7 0 999PREMASOL 10% IV SOLUTION No
C9C PARENTERAL AMINO ACID 6 % NO.1 0 999PREMASOL 6% IV SOLUTION No
C9C AMINO AC 3%/ELECTROLYTE/GLYCER 0 999PROCALAMINE IV SOLUTION No
C9C PARENTERAL AMINO ACID 20% NO.1 0 999PROSOL 20% INJECTION No
C9C PARENTERAL AMINO ACID 10% NO.6 0 999SYNTHAMIN 17 WITHOUT ELYTE 10% No
C9C PARENTERAL AMINO ACID 10% NO.6 0 999TRAVASOL 10% SOLN VIAFLEX No
C9C AMINO ACIDS 10 % 0 999TROPHAMINE 10% IV SOLUTION No
C9C AMINO ACIDS 6 % 0 999TROPHAMINE 6% IV SOLUTION No
D1A PERIODONTAL COLLAGENASE INHIBITORSD1A DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE 20 MG TABLET No
D1A DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE HYCLATE 20 MG TAB No
D1D DENTAL AIDS AND PREPARATIONSD1D CHLORHEXIDINE GLUCONATE 0 999CHLORHEXIDINE 0.12% RINSE No
D1D TRIAMCINOLONE ACETONIDE 0 999TRIAMCINOLONE 0.1% PASTE No
D2A FLUORIDE PREPARATIONSD2A FLUORIDE (SODIUM) 0 999FLUORIDE 0.25 MG TABLET CHEW No
D2A FLUORIDE (SODIUM) 0 999FLUORIDE 0.5 MG TABLET CHEW No
D2A FLUORIDE (SODIUM) 0 999FLUORIDE 1 MG TABLET CHEWABLE No
D2A FLUORIDE (SODIUM) 0 999SODIUM FLUORIDE 0.5 MG/ML DROP No
D4B ANTACIDSD4B CALCIUM CARBONATE 0 999ANTACID 750 MG CHEWABLE TABLET No
D4B CALCIUM CARBONATE 0 999ANTACID CALCIUM 500 MG CHW TAB No
D4B CALCIUM CARBONATE 0 999ANTACID EX-STR TABLET CHEW No
D4B CALCIUM CARBONATE 0 999ANTACID EX-STR TABLET CHEW No
Tuesday, May 14, 2019 Page 57 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
D4B CALCIUM CARBONATE 0 999ANTACID EX-STRN TABLET CHEW No
D4B CALCIUM CARBONATE 0 999ANTACID EXTRA STRENGTH CHEW TB No
D4B CALCIUM CARBONATE 0 999ANTACID TABLET CHEW No
D4B CALCIUM CARBONATE 0 999ANTACID TABLET CHEWABLE No
D4B CALCIUM CARBONATE 0 999CALCIUM ANTACID 1,000 MG TAB No
D4B CALCIUM CARBONATE 0 999CALCIUM ANTACID 500 MG CHW TAB No
D4B CALCIUM CARBONATE 0 999CALCIUM ANTACID 500 MG TAB CHW No
D4B CALCIUM CARBONATE 0 999CALCIUM ANTACID 750 MG TB CHEW No
D4B CALCIUM CARBONATE 0 999CALCIUM ANTACID EX-STR TABLET No
D4B CALCIUM CARBONATE 0 999CALCIUM ANTACID TABLET CHEW No
D4B CALCIUM CARBONATE 0 999CALCIUM CARBONATE 648 MG TAB No
D4B CALCIUM CARBONATE 0 999CAL-GEST 500 MG TABLET CHEW No
D4B CALCIUM CARBONATE 0 999GS CAL ANTACID 750 MG CHEW TAB No
D4B CALCIUM CARBONATE 0 999HM CAL ANTACID 1000 MG CHEW TB No
D4B CALCIUM CARBONATE 0 999HM CAL ANTACID 750 MG CHEW TAB No
D4B MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 400 MG TAB Cystic Fib Diag Auto PA
D4B MAGNESIUM OXIDE 0 999MAGNESIUM OXIDE 400 MG TABLET Cystic Fib Diag Auto PA
D4B CALCIUM CARBONATE 0 999SM CAL ANTACID 500 MG CHEW TAB No
D4B CALCIUM CARBONATE 0 999SM CALCIUM ANTACID 750 MG TB No
D4B CALCIUM CARBONATE 0 999SM CALCIUM ANTACID TAB CHEW No
D4B CALCIUM CARBONATE 0 999SM CALCIUM ANTACID TABLET No
D4D ANTIDIARRHEAL MICROORGANISMS AGENTSD4D B INFANTIS/B ANI/B LON/B BIFID 0 999GLUCOSAMINE-CHONDR CAPLET Cystic Fib Diag Auto PA
D4D LACTOBACILLUS 3/FOS/PANTETHINE 0 999PROBIOTIC & ACIDOPHILUS CAP Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 58 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
D4D L.ACIDOPH,PARACASEI, B.LACTIS 0 999PROBIOTIC 10 BILLION CELL CAP Cystic Fib Diag Auto PA
D4D L. ACIDOPHILUS/L. RHAMNOSUS 0 999PROBIOTIC 15 BILLION CELL CAP Cystic Fib Diag Auto PA
D4D LACTOBACILLUS COMBO NO.11 0 999PROBIOTIC 15 BILLION CELL CAP Cystic Fib Diag Auto PA
D4D SACCHAROMYCES BOULARDII 0 999PROBIOTIC 250 MG CAPSULE Cystic Fib Diag Auto PA
D4D B INFANTIS/B ANI/B LON/B BIFID 0 999PROBIOTIC 4X CAPLET Cystic Fib Diag Auto PA
D4D L. ACIDOPHILUS/BIFID. ANIMALIS 0 999PROBIOTIC 5 BILLION CELL CAP Cystic Fib Diag Auto PA
D4D L. ACIDOPHILUS/PECTIN, CITRUS 0 999PROBIOTIC ACIDOPHIL-PECTIN CAP Cystic Fib Diag Auto PA
D4D LACTOBACILLUS ACIDOPHILUS 0 999PROBIOTIC ACIDOPHILUS 250 MILL Cystic Fib Diag Auto PA
D4D L.ACIDOPH/B.LONG/L.PLANT/B.LAC 0 999PROBIOTIC ACIDOPHILUS BEADS Cystic Fib Diag Auto PA
D4D L.ACIDOPH/L.RHAMN/B.BIF/B.LONG 0 999PROBIOTIC ACIDOPHILUS BIOBEADS Cystic Fib Diag Auto PA
D4D L.ACID/L.CASEI/B.BIF/B.LON/FOS 0 999PROBIOTIC BLEND CAPSULE Cystic Fib Diag Auto PA
D4D BACILLUS COAGULANS/INULIN 0 999PROBIOTIC FORMULA CAPSULE Cystic Fib Diag Auto PA
D4D LACTOBACILLUS ACIDOPHILUS 0 999PROBIOTIC GOLD ACIDOPHILUS CAP Cystic Fib Diag Auto PA
D4D LACTOBACILLUS COMBO NO.13 0 999PROBIOTIC PEARLS COMPLETE SFGL Cystic Fib Diag Auto PA
D4D LACTOBAC 42/BIFID 8/COLOST/FOS 0 999PROBIOTIC PLUS COLOSTRUM POWD Cystic Fib Diag Auto PA
D4D LACTOBACILLUS ACIDOPHILUS 0 999PROBIOTIC SOFTGEL Cystic Fib Diag Auto PA
D4D BACILLUS COAGULANS/INULIN 0 999PROBIOTIC WITH PREBIOTIC CAPS Cystic Fib Diag Auto PA
D4D LACTOBAC NO.41/BIFIDOBACT NO.7 0 999PROBIOTIC-10 3 BILLION CELL CP Cystic Fib Diag Auto PA
D4D L. ACIDOPHILUS/DIG ENZ CMB 5 0 999PROBIOTIC-DIGESTIVE ENZYMES Cystic Fib Diag Auto PA
D4D L GASSERI/B BIFIDUM/B LONGUM 0 999RA PROBIOTIC COLON CARE CAP Cystic Fib Diag Auto PA
D4D L.ACID/B.BIFIDUM/B.ANIMAL/FOS 0 999RA PROBIOTIC COMPLEX CAPSULE Cystic Fib Diag Auto PA
D4D LACTOBACILLUS RHAMNOSUS R0011 0 999RA PROBIOTIC DIGESTIVE CARE CP Cystic Fib Diag Auto PA
D4D BACILLUS COAGULANS 0 999RA PROBIOTIC GUMMIES Cystic Fib Diag Auto PA
D4D B INFANTIS/B ANI/B LON/B BIFID 0 999SM PROBIOTIC 4X CAPLET Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 59 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
D4D LACTOBACILLUS ACIDOPHILUS 0 999SV PROBIOTIC ACIDOPHILUS CPLT Cystic Fib Diag Auto PA
D4D LACTOBAC NO.21/BIFIDOBACT NO.6 0 999UP & UP PROBIOTIC SUPPLEMENT Cystic Fib Diag Auto PA
D4E ANTI-ULCER PREPARATIONSD4E MISOPROSTOL 0 999MISOPROSTOL 100 MCG TABLET No
D4E MISOPROSTOL 0 999MISOPROSTOL 200 MCG TABLET No
D4E SUCRALFATE 0 999SUCRALFATE 1 GM TABLET No
D4F ANTI-ULCER-H.PYLORI AGENTSD4F BISMUTH/METRONID/TETRACYCLINE 0 999PYLERA CAPSULE No
D4J PROTON-PUMP INHIBITORSD4J OMEPRAZOLE MAGNESIUM 0 999ACID REDUCER DR 20 MG CAP Cystic Fib Diag Auto PA
D4J OMEPRAZOLE MAGNESIUM 0 999CVS OMEPRAZOLE DR 20 MG CAP Cystic Fib Diag Auto PA
D4J OMEPRAZOLE MAGNESIUM 0 999CVS OMEPRAZOLE MAG DR 20.6 MG Cystic Fib Diag Auto PA
D4J OMEPRAZOLE MAGNESIUM 0 999EQ OMEPRAZOLE MAG DR 20.6 MG Cystic Fib Diag Auto PA
D4J OMEPRAZOLE MAGNESIUM 0 999KRO OMEPRAZOLE MAG DR 20.6 MG Cystic Fib Diag Auto PA
D4J ESOMEPRAZOLE MAGNESIUM 0 11NEXIUM 10 MG PACKET No
D4J ESOMEPRAZOLE MAGNESIUM 0 11NEXIUM 20 MG PACKET No
D4J ESOMEPRAZOLE MAGNESIUM 0 11NEXIUM 40 MG PACKET No
D4J ESOMEPRAZOLE MAGNESIUM 0 11NEXIUM DR 2.5 MG PACKET No
D4J ESOMEPRAZOLE MAGNESIUM 0 11NEXIUM DR 5 MG PACKET No
D4J OMEPRAZOLE 1 999OMEPRAZOLE 10 MG CAPSULE DR No
D4J OMEPRAZOLE 1 999OMEPRAZOLE 20 MG CAPSULE DR No
D4J OMEPRAZOLE 1 999OMEPRAZOLE 40 MG CAPSULE DR No
D4J OMEPRAZOLE 1 999OMEPRAZOLE DR 10 MG CAPSULE No
D4J OMEPRAZOLE 1 999OMEPRAZOLE DR 20 MG CAPSULE No
D4J OMEPRAZOLE 1 999OMEPRAZOLE DR 40 MG CAPSULE No
Tuesday, May 14, 2019 Page 60 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
D4J OMEPRAZOLE MAGNESIUM 0 999OMEPRAZOLE MAG DR 20 MG CAP Cystic Fib Diag Auto PA
D4J OMEPRAZOLE MAGNESIUM 0 999OMEPRAZOLE MAG DR 20.6 MG CAP Cystic Fib Diag Auto PA
D4J PANTOPRAZOLE SODIUM 5 999PANTOPRAZOLE SOD 20 MG TAB EC No
D4J PANTOPRAZOLE SODIUM 5 999PANTOPRAZOLE SOD 40 MG TAB EC No
D4J PANTOPRAZOLE SODIUM 5 999PANTOPRAZOLE SOD DR 20 MG TAB No
D4J PANTOPRAZOLE SODIUM 5 999PANTOPRAZOLE SOD DR 40 MG TAB No
D4J LANSOPRAZOLE 1 11PERVACID 15 MG SOLUTAB No
D4J LANSOPRAZOLE 1 11PREVACID 15 MG SOLUTAB No
D4J LANSOPRAZOLE 1 11PREVACID 30 MG SOLUTAB No
D4J PANTOPRAZOLE SODIUM 5 11PROTONIX 40 MG SUSPENSION No
D4J OMEPRAZOLE MAGNESIUM 0 999QC OMEPRAZOLE MAG DR 20.6 MG Cystic Fib Diag Auto PA
D6C IRRITABLE BOWEL SYNDROME AGENTS, 5-HT3 ANTAGONISTD6C ALOSETRON HCL 0 999ALOSETRON HCL 0.5 MG TABLET Requires Med Cert 3
D6C ALOSETRON HCL 0 999ALOSETRON HCL 1 MG TABLET Requires Med Cert 3
D6C ALOSETRON HCL 0 999LOTRONEX 0.5 MG TABLET Requires Med Cert 3
D6C ALOSETRON HCL 0 999LOTRONEX 1 MG TABLET Requires Med Cert 3
D6D ANTIDIARRHEALSD6D DIPHENOXYLATE HCL/ATROPINE 0 999DIPHENOXYLATE/ATROPINE TAB No
D6D DIPHENOXYLATE HCL/ATROPINE 0 999DIPHENOXYLATE-ATROP 2.5-0.025 No
D6D DIPHENOXYLATE HCL/ATROPINE 0 999DIPHENOXYLATE-ATROPINE TABLET No
D6D LOPERAMIDE HCL 0 999LOPERAMIDE 2 MG CAPSULE No
D6F DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLATD6F MESALAMINE 0 999APRISO 0.375 GM CAPSULE ER No
D6F MESALAMINE 0 999DELZICOL DR 400 MG CAPSULE No
D6F SULFASALAZINE 0 999SULFASALAZINE 500 MG TABLET No
Tuesday, May 14, 2019 Page 61 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
D6F SULFASALAZINE 0 999SULFASALAZINE DR 500 MG TAB No
D6G IBS-C/CIC AGENTS, GUANYLATE CYCLASE-C AGONISTD6G LINACLOTIDE 18 999LINZESS 145 MCG CAPSULE Auto PA
D6G LINACLOTIDE 18 999LINZESS 290 MCG CAPSULE Auto PA
D6G LINACLOTIDE 18 999LINZESS 72 MCG CAPSULE Auto PA
D6S LAXATIVES AND CATHARTICSD6S PEG3350/SOD SULF,BICARB,CL/KCL 0 999GOLYTELY PACKET No
D6S PEG3350/SOD SULF,BICARB,CL/KCL 0 999GOLYTELY SOLUTION No
D6S LACTULOSE 0 999LACTULOSE 10 GM/15 ML SOLN No
D6S LACTULOSE 0 999LACTULOSE 10 GM/15 ML SOLUTION No
D6S LACTULOSE 0 999LACTULOSE 20 GM/30 ML SOLUTION No
D6S PEG3350/SOD SULF,BICARB,CL/KCL 0 999PEG 3350/ELECTROLYTE SOLN No
D6S SODIUM CHLORIDE/NAHCO3/KCL/PEG 0 999PEG 3350-ELECTROLYTE SOLUTION No
D6S PEG3350/SOD SULF,BICARB,CL/KCL 0 999PEG-3350 AND ELECTROLYTES SOLN No
D6S POLYETHYLENE GLYCOL 3350 0 999PEG3350 POWDER No
D6S SODIUM CHLORIDE/NAHCO3/KCL/PEG 0 999PEG-3350 SOLUTION No
D6S POLYETHYLENE GLYCOL 3350 0 999POLYETHYLENE GLYCOL 3350 POWD No
D6S SODIUM CHLORIDE/NAHCO3/KCL/PEG 0 999TRILYTE WITH FLAVOR PACKETS No
D7A BILE SALTSD7A URSODIOL 0 999URSODIOL 250 MG TABLET No
D7A URSODIOL 0 999URSODIOL 300 MG CAPSULE No
D7A URSODIOL 0 999URSODIOL 500 MG TABLET No
D7D DRUGS TO TREAT HEREDITARY TYROSINEMIAD7D NITISINONE 0 999NITYR 10 MG TABLET Clinical PA Required
D7D NITISINONE 0 999NITYR 2 MG TABLET Clinical PA Required
Tuesday, May 14, 2019 Page 62 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
D7D NITISINONE 0 999NITYR 5 MG TABLET Clinical PA Required
D7D NITISINONE 0 999ORFADIN 10 MG CAPSULE Clinical PA Required
D7D NITISINONE 0 999ORFADIN 2 MG CAPSULE Clinical PA Required
D7D NITISINONE 0 999ORFADIN 20 MG CAPSULE Clinical PA Required
D7D NITISINONE 0 999ORFADIN 4 MG/ML SUSPENSION Clinical PA Required
D7D NITISINONE 0 999ORFADIN 5 MG CAPSULE Clinical PA Required
D7L BILE SALT SEQUESTRANTSD7L CHOLESTYRAMINE/ASPARTAME 0 999CHOLESTYRAMINE LIGHT PACKET No
D7L CHOLESTYRAMINE/ASPARTAME 0 999CHOLESTYRAMINE LIGHT POWDER No
D7L CHOLESTYRAMINE (WITH SUGAR) 0 999CHOLESTYRAMINE PACKET No
D7L CHOLESTYRAMINE (WITH SUGAR) 0 999CHOLESTYRAMINE POWDER No
D7L COLESTIPOL HCL 0 999COLESTIPOL HCL 1 GM TABLET No
D8A PANCREATIC ENZYMESD8A LIPASE/PROTEASE/AMYLASE 0 999CREON DR 12,000 UNITS CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999CREON DR 24,000 UNITS CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999CREON DR 3,000 UNITS CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999CREON DR 36,000 UNITS CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999CREON DR 6,000 UNITS CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999PANCREAZE 10,500 UNIT CAP DR No
D8A LIPASE/PROTEASE/AMYLASE 0 999PANCREAZE 16,800 UNIT CAP DR No
D8A LIPASE/PROTEASE/AMYLASE 0 999PANCREAZE 21,000 UNIT CAP DR No
D8A LIPASE/PROTEASE/AMYLASE 0 999PANCREAZE 4,200 UNIT CAP DR No
D8A LIPASE/PROTEASE/AMYLASE 0 999PANCREAZE DR 10,500 UNIT CAP No
D8A LIPASE/PROTEASE/AMYLASE 0 999PANCREAZE DR 16,800 UNIT CAP No
Tuesday, May 14, 2019 Page 63 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
D8A LIPASE/PROTEASE/AMYLASE 0 999PANCREAZE DR 2,600 UNIT CAP No
D8A LIPASE/PROTEASE/AMYLASE 0 999PANCREAZE DR 21,000 UNIT CAP No
D8A LIPASE/PROTEASE/AMYLASE 0 999PANCREAZE DR 4,200 UNIT CAP No
D8A LIPASE/PROTEASE/AMYLASE 0 999PERTZYE DR 16,000 UNITS CAPS No
D8A LIPASE/PROTEASE/AMYLASE 0 999PERTZYE DR 24,000 UNIT CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999PERTZYE DR 4,000 UNIT CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999PERTZYE DR 8,000 UNITS CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999VIOKACE 10,440-39,150 UNITS TB No
D8A LIPASE/PROTEASE/AMYLASE 0 999VIOKACE 20,880-78,300 UNITS TB No
D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 10,000 UNIT CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 10,000 UNITS CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 15,000 UNIT CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 15,000 UNITS CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 20,000 UNIT CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 20,000 UNITS CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 25,000 UNIT CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 25,000 UNITS CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 3,000 UNIT CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 3,000 UNITS CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 40,000 UNIT CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 40,000 UNITS CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 5,000 UNIT CAPSULE No
D8A LIPASE/PROTEASE/AMYLASE 0 999ZENPEP DR 5,000 UNITS CAPSULE No
D9A AMMONIA INHIBITORS
Tuesday, May 14, 2019 Page 64 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
D9A LACTULOSE 0 999LACTULOSE 10 GM/15 ML SOLUTION No
E0G PRENATAL VITAMINS WITH LOW OR NO IRONE0G PNV/FOLIC AC/B6/CALCIUM/GINGER 12 999VP-GGR-B6 TABLET No
F1A ANDROGENIC AGENTSF1A TESTOSTERONE 18 999ANDRODERM 2 MG/24HR PATCH Clinical PA Required
F1A TESTOSTERONE 18 999ANDRODERM 4 MG/24HR PATCH Clinical PA Required
F1A TESTOSTERONE 18 999ANDROGEL 1%(2.5G) GEL PACKET Clinical PA Required
F1A TESTOSTERONE 18 999ANDROGEL 1%(5G) GEL PACKET Clinical PA Required
F1A TESTOSTERONE 18 999ANDROGEL 1.62% GEL PUMP Clinical PA Required
F1A TESTOSTERONE 18 999ANDROGEL 1.62%(1.25G) GEL PCKT Clinical PA Required
F1A TESTOSTERONE 18 999ANDROGEL 1.62%(2.5G) GEL PCKT Clinical PA Required
F1A TESTOSTERONE CYPIONATE 0 999TESTOSTERON CYP 1,000 MG/10 ML No
F1A TESTOSTERONE CYPIONATE 0 999TESTOSTERON CYP 2,000 MG/10 ML No
F1A TESTOSTERONE ENANTHATE 0 999TESTOSTERON ENAN 1,000 MG/5 ML No
F1A TESTOSTERONE CYPIONATE 0 999TESTOSTERONE CYP 100 MG/ML No
F1A TESTOSTERONE CYPIONATE 0 999TESTOSTERONE CYP 200 MG/ML No
F1A TESTOSTERONE ENANTHATE 0 999TESTOSTERONE ENAN 200 MG/ML No
G1A ESTROGENIC AGENTSG1A ESTRADIOL/LEVONORGESTREL 0 999CLIMARA PRO PATCH No
G1A ESTRADIOL/NORETHINDRONE ACET 0 999COMBIPATCH 0.05-0.14 MG PTCH No
G1A ESTRADIOL/NORETHINDRONE ACET 0 999COMBIPATCH 0.05-0.25 MG PTCH No
G1A ESTRADIOL 0 999ESTRADIOL 0.025 MG/DAY PATCH No
G1A ESTRADIOL 0 999ESTRADIOL 0.0375 MG/DAY PATCH No
G1A ESTRADIOL 0 999ESTRADIOL 0.05 MG/DAY PATCH No
G1A ESTRADIOL 0 999ESTRADIOL 0.06 MG/DAY PATCH No
Tuesday, May 14, 2019 Page 65 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
G1A ESTRADIOL 0 999ESTRADIOL 0.075 MG/DAY PATCH No
G1A ESTRADIOL 0 999ESTRADIOL 0.1 MG/DAY PATCH No
G1A ESTRADIOL 0 999ESTRADIOL 0.5 MG TABLET No
G1A ESTRADIOL 0 999ESTRADIOL 1 MG TABLET No
G1A ESTRADIOL 0 999ESTRADIOL 2 MG TABLET No
G1A ESTRADIOL 0 999ESTRADIOL TDS 0.025 MG/DAY No
G1A ESTRADIOL 0 999ESTRADIOL TDS 0.0375 MG/DAY No
G1A ESTRADIOL 0 999ESTRADIOL TDS 0.05 MG/DAY No
G1A ESTRADIOL 0 999ESTRADIOL TDS 0.06 MG/DAY No
G1A ESTRADIOL 0 999ESTRADIOL TDS 0.075 MG/DAY No
G1A ESTRADIOL 0 999ESTRADIOL TDS 0.1 MG/DAY No
G1A ESTRADIOL VALERATE 0 999ESTRADIOL VALERATE 20 MG/ML VL No
G1A ESTRADIOL VALERATE 0 999ESTRADIOL VALERATE 40 MG/ML VL No
G1A ESTRADIOL/NORETHINDRONE ACET 0 999ESTRADIOL-NORETH 0.5-0.1 MG TB No
G1A ESTRADIOL/NORETHINDRONE ACET 0 999ESTRADIOL-NORETH 1-0.5 MG TAB No
G1A ESTRADIOL/NORETHINDRONE ACET 0 999ESTRADIOL-NORETHINDRONE TAB No
G1A ESTROPIPATE 0 999ESTROPIPATE 0.625(0.75 MG) TAB No
G1A ESTROPIPATE 0 999ESTROPIPATE 1.25(1.5 MG) TAB No
G1A ESTROPIPATE 0 999ESTROPIPATE 2.5(3 MG) TAB No
G1A NORETHINDRONE AC-ETH ESTRADIOL 0 999FEMHRT 0.5 MG/2.5 MCG TABLET No
G1A NORETHINDRONE AC-ETH ESTRADIOL 0 999NORETHIND-ETH ESTRAD 0.5-2.5 No
G1A NORETHINDRONE AC-ETH ESTRADIOL 0 999NORETHIN-ETH ESTRAD 1 MG-5 MCG No
G1A ESTROGENS, CONJUGATED 0 999PREMARIN 0.3 MG TABLET No
G1A ESTROGENS, CONJUGATED 0 999PREMARIN 0.45 MG TABLET No
Tuesday, May 14, 2019 Page 66 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
G1A ESTROGENS, CONJUGATED 0 999PREMARIN 0.625 MG TABLET No
G1A ESTROGENS, CONJUGATED 0 999PREMARIN 0.9 MG TABLET No
G1A ESTROGENS, CONJUGATED 0 999PREMARIN 1.25 MG TABLET No
G1A ESTROGEN,CON/M-PROGEST ACET 0 999PREMPHASE 0.625-5 MG TABLET No
G1A ESTROGEN,CON/M-PROGEST ACET 0 999PREMPRO 0.3 MG-1.5 MG TABLET No
G1A ESTROGEN,CON/M-PROGEST ACET 0 999PREMPRO 0.45-1.5 MG TABLET No
G1A ESTROGEN,CON/M-PROGEST ACET 0 999PREMPRO 0.625-2.5 MG TABLET No
G1A ESTROGEN,CON/M-PROGEST ACET 0 999PREMPRO 0.625-5 MG TABLET No
G1B ESTROGEN/ANDROGEN COMBINATIONSG1B ESTROGEN,ESTER/ME-TESTOSTERONE 0 999ESTROGEN-METHYLTESTOS F.S. TAB No
G1B ESTROGEN,ESTER/ME-TESTOSTERONE 0 999ESTROGEN-METHYLTESTOS H.S. TAB No
G2A PROGESTATIONAL AGENTSG2A MEDROXYPROGESTERONE ACETATE 0 999MEDROXYPROGESTERONE 10 MG TB No
G2A MEDROXYPROGESTERONE ACETATE 0 999MEDROXYPROGESTERONE 2.5 MG No
G2A MEDROXYPROGESTERONE ACETATE 0 999MEDROXYPROGESTERONE 2.5 MG TAB No
G2A MEDROXYPROGESTERONE ACETATE 0 999MEDROXYPROGESTERONE 5 MG TAB No
G2A NORETHINDRONE ACETATE 18 999NORETHINDRN 5 MG TB (LUPANETA) No
G2A NORETHINDRONE ACETATE 0 999NORETHINDRONE 5 MG TABLET No
G2A PROGESTERONE, MICRONIZED 0 999PROGESTERONE 100 MG CAPSULE No
G2A PROGESTERONE, MICRONIZED 0 999PROGESTERONE 200 MG CAPSULE No
G2A PROGESTERONE 0 999PROGESTERONE OIL 50 MG/ML VL No
G2A PROGESTERONE, MICRONIZED 0 999PROMETRIUM 100 MG CAPSULE No
G2A PROGESTERONE, MICRONIZED 0 999PROMETRIUM 200 MG CAPSULE No
G3A OXYTOCICSG3A METHYLERGONOVINE MALEATE 0 999METHYLERGONOVINE 0.2 MG TABLET No
Tuesday, May 14, 2019 Page 67 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
G8A CONTRACEPTIVES,ORALG8A LEVONORGESTREL 12 999AFTERA 1.5 MG TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999ALTAVERA-28 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999ALYACEN 1-35-28 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999ALYACEN 7-7-7-28 TABLET No
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999AMETHIA 0.15-0.03-0.01 MG TAB No
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999AMETHIA LO TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999AMETHYST 90-20 MCG TABLET No
G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999APRI 28 DAY TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999ARANELLE 28 TABLET No
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999ASHLYNA 0.15-0.03-0.01 MG TAB No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999AUBRA EQ-28 TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999AUBRA-28 TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999AVIANE-28 TABLET No
G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999AZURETTE 28 DAY TABLET No
G8A LEVONORGEST/ETH.ESTRADIOL/IRON 12 999BALCOLTRA TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999BALZIVA 28 TABLET No
G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999BEKYREE 28 DAY TABLET No
G8A DROSPIR/ETH ESTRA/LEVOMEFOL CA 12 999BEYAZ 28 TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999BLISOVI 24 FE TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999BLISOVI FE 1.5-30 TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999BLISOVI FE 1-20 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999BRIELLYN TABLET No
G8A NORETHINDRONE 12 999CAMILA 0.35 MG TABLET No
Tuesday, May 14, 2019 Page 68 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999CAMRESE 0.15-0.03-0.01 MG TAB No
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999CAMRESE LO TABLET No
G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999CAZIANT 28 DAY TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999CHATEAL EQ-28 TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999CHATEAL-28 TABLET No
G8A NORGESTREL-ETHINYL ESTRADIOL 12 999CRYSELLE-28 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999CYCLAFEM 1-35-28 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999CYCLAFEM 7-7-7-28 TABLET No
G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999CYCLESSA 28 DAY TABLET No
G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999CYRED 28 DAY TABLET No
G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999CYRED EQ 28 DAY TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999DASETTA 1-35-28 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999DASETTA 7/7/7-28 TABLET No
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999DAYSEE 0.15-0.03-0.01 MG TAB No
G8A NORETHINDRONE 12 999DEBLITANE 0.35 MG TABLET No
G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999DESOGEST-ETH ESTRA 0.15-0.03MG No
G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999DESOGESTR-ETH ESTRAD ETH ESTRA No
G8A DROSPIR/ETH ESTRA/LEVOMEFOL CA 12 999DROSP-EE-LEVOMEF 3-0.02-0.451 No
G8A DROSPIR/ETH ESTRA/LEVOMEFOL CA 12 999DROSP-EE-LEVOMEF 3-0.03-0.451 No
G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999DROSPIRENONE-EE 3-0.02 MG TAB No
G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999DROSPIRENONE-EE 3-0.03 MG TAB No
G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999DROSPIRENONE-ETH ESTRADIOL TAB No
G8A LEVONORGESTREL 12 999ECONTRA EZ 1.5 MG TABLET No
G8A LEVONORGESTREL 12 999ECONTRA ONE-STEP 1.5 MG TABLET No
Tuesday, May 14, 2019 Page 69 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
G8A NORGESTREL-ETHINYL ESTRADIOL 12 999ELINEST-28 TABLET No
G8A ULIPRISTAL ACETATE 12 999ELLA 30 MG TABLET No
G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999EMOQUETTE 28 DAY TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999ENPRESSE-28 TABLET No
G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999ENSKYCE 28 TABLET No
G8A NORETHINDRONE 12 999ERRIN 0.35 MG TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999ESTARYLLA 0.25-0.035 MG TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999ESTROSTEP FE-28 TABLET No
G8A ETHYNODIOL D-ETHINYL ESTRADIOL 12 999ETHYNODIOL-ETH ESTRA 1MG-35MCG No
G8A ETHYNODIOL D-ETHINYL ESTRADIOL 12 999ETHYNODIOL-ETH ESTRA 1MG-50MCG No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999FALMINA-28 TABLET No
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999FAYOSIM TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999FEMYNOR 28 TABLET No
G8A NORETH-ETHINYL ESTRADIOL/IRON 12 999GENERESS FE CHEWABLE TABLET No
G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999GIANVI 3 MG-0.02 MG TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999GILDAGIA 0.4 MG-0.035 MG TAB No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999HAILEY 24 FE 1 MG-20 MCG TAB No
G8A NORETHINDRONE 12 999HEATHER TABLET No
G8A NORETHINDRONE 12 999INCASSIA 0.35 MG TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999INTROVALE 0.15-0.03 MG TABLET No
G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999ISIBLOOM 28 DAY TABLET No
G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999JASMIEL 3 MG-0.02 MG TABLET No
G8A NORETHINDRONE 12 999JENCYCLA 0.35 MG TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999JOLESSA 0.15 MG/0.03 MG TABLET No
Tuesday, May 14, 2019 Page 70 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
G8A NORETHINDRONE 12 999JOLIVETTE TABLET No
G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999JULEBER 28 DAY TABLET No
G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999JUNEL 1.5/30 TABLET No
G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999JUNEL 1/20 TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999JUNEL FE 1.5/30 TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999JUNEL FE 1/20 TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999JUNEL FE 24 TABLET No
G8A NORETH-ETHINYL ESTRADIOL/IRON 12 999KAITLIB FE CHEWABLE TABLET No
G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999KARIVA 28 DAY TABLET No
G8A ETHYNODIOL D-ETHINYL ESTRADIOL 12 999KELNOR 1/35 28 TABLET No
G8A ETHYNODIOL D-ETHINYL ESTRADIOL 12 999KELNOR 1-35 28 TABLET No
G8A ETHYNODIOL D-ETHINYL ESTRADIOL 12 999KELNOR 1-50 TABLET No
G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999KIMIDESS 28 DAY TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999KURVELO TABLET No
G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999LARIN 1.5 MG-30 MCG TABLET No
G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999LARIN 21 1-20 TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999LARIN 24 FE 1 MG-20 MCG TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999LARIN FE 1.5-30 TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999LARIN FE 1-20 TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LARISSIA-28 TABLET No
G8A NORETH-ETHINYL ESTRADIOL/IRON 12 999LAYOLIS FE CHEWABLE TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999LEENA 28 TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LESSINA-28 TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LEVONEST-28 TABLET No
Tuesday, May 14, 2019 Page 71 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999LEVONO-E ESTRAD 0.10-0.02-0.01 No
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999LEVONO-E ESTRAD 0.15-0.03-0.01 No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LEVONOR-ETH ESTRA 0.09-0.02 MG No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LEVONOR-ETH ESTRAD 0.1-0.02 MG No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LEVONOR-ETH ESTRAD 0.15-0.03 No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LEVONOR-ETH ESTRAD TRIPHASIC No
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999LEVONORG 0.15MG-EE 20-25-30MCG No
G8A LEVONORGESTREL 12 999LEVONORGESTREL 1.5 MG TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LEVONORGESTREL-ETH ESTRAD TAB No
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999LEVONORG-ETH ESTRAD ETH ESTRAD No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LEVORA-28 TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LILLOW-28 TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999LO LOESTRIN FE 1-10 TABLET No
G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999LOESTRIN 21 1.5-30 TABLET No
G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999LOESTRIN 21 1-20 TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999LOESTRIN FE 1.5-30 TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999LOESTRIN FE 1-20 TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999LOMEDIA 24 FE 1 MG-20 MCG TAB No
G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999LORYNA 3 MG-0.02 MG TABLET No
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999LOSEASONIQUE TABLET No
G8A NORGESTREL-ETHINYL ESTRADIOL 12 999LOW-OGESTREL-28 TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999LUTERA-28 TABLET No
G8A NORETHINDRONE 12 999LYZA 0.35 MG TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999MARLISSA-28 TABLET No
Tuesday, May 14, 2019 Page 72 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999MELODETTA 24 FE CHEWABLE TAB No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999MIBELAS 24 FE CHEWABLE TABLET No
G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999MICROGESTIN 21 1.5-30 TAB No
G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999MICROGESTIN 21 1-20 TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999MICROGESTIN 24 FE 1 MG-20 MCG No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999MICROGESTIN FE 1.5-30 TAB No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999MICROGESTIN FE 1-20 TABLET No
G8A NORETHINDRONE 12 999MICRONOR 0.35 MG TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999MILI 0.25-0.035 MG TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999MINASTRIN 24 FE CHEWABLE TAB No
G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999MIRCETTE 28 DAY TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999MONO-LINYAH 28 TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999MONONESSA 28 TABLET No
G8A LEVONORGESTREL 12 999MY CHOICE 1.5 MG TABLET No
G8A LEVONORGESTREL 12 999MY WAY 1.5 MG TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999MYZILRA-28 TABLET No
G8A ESTRADIOL VALERATE/DIENOGEST 12 999NATAZIA 28 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999NECON 0.5-35-28 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999NECON 7-7-7-28 TABLET No
G8A LEVONORGESTREL 12 999NEW DAY 1.5 MG TABLET No
G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999NIKKI 3 MG-0.02 MG TABLET No
G8A NORETHINDRONE 12 999NORA-BE TABLET No
G8A NORETH-ETHINYL ESTRADIOL/IRON 12 999NORET-ESTR-FE 0.4-0.035(21)-75 No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999NORETH-ESTRAD-FE 1-0.02(24)-75 No
Tuesday, May 14, 2019 Page 73 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
G8A NORETHINDRONE AC-ETH ESTRADIOL 12 999NORETHIND-ETH ESTRAD 1-0.02 MG No
G8A NORETHINDRONE 12 999NORETHINDRONE 0.35 MG TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999NORETHIN-ESTRAD-FERR 1-0.02 MG No
G8A NORETH-ETHINYL ESTRADIOL/IRON 12 999NORETHIN-ESTRA-FE 0.8-0.025 MG No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999NORG-EE 0.18-0.215-0.25/0.025 No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999NORG-EE 0.18-0.215-0.25/0.035 No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999NORGESTIMAT-E ESTRADIOL 28 TAB No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999NORG-ETHIN ESTRA 0.25-0.035 MG No
G8A NORETHINDRONE 12 999NORLYDA 0.35 MG TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999NORTREL 0.5/35 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999NORTREL 0.5-35-28 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999NORTREL 1/35 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999NORTREL 1-35 21 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999NORTREL 1-35 28 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999NORTREL 7/7/7-28 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999NORTREL 7-7-7-28 TABLET No
G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999OCELLA TABLET No
G8A NORGESTREL-ETHINYL ESTRADIOL 12 999OGESTREL TABLET No
G8A LEVONORGESTREL 12 999OPCICON ONE-STEP 1.5 MG TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999ORSYTHIA-28 TABLET No
G8A NORETHINDRONE 12 999ORTHO MICRONOR 0.35 MG TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999ORTHO TRI-CYCLEN 28 TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999ORTHO TRI-CYCLEN LO TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999ORTHO-CYCLEN 28 TABLET No
Tuesday, May 14, 2019 Page 74 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999ORTHO-NOVUM 1-35-28 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999ORTHO-NOVUM 7-7-7-28 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999PHILITH 0.4-0.035 MG TABLET No
G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999PIMTREA 28 DAY TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999PIRMELLA 1-35-28 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999PIRMELLA 7-7-7-28 TABLET No
G8A LEVONORGESTREL 12 999PLAN B ONE-STEP 1.5 MG TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999PORTIA-28 TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999PREVIFEM TABLET No
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999QUARTETTE TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999QUASENSE 0.15/0.03 MG TABLET No
G8A DROSPIR/ETH ESTRA/LEVOMEFOL CA 12 999RAJANI 28 TABLET No
G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999RECLIPSEN 28 DAY TABLET No
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999RIVELSA TABLET No
G8A DROSPIR/ETH ESTRA/LEVOMEFOL CA 12 999SAFYRAL TABLET No
G8A L-NORGEST/E.ESTRADIOL-E.ESTRAD 12 999SEASONIQUE 0.15/0.03-0.01 TAB No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999SETLAKIN 0.15 MG-0.03 MG TAB No
G8A NORETHINDRONE 12 999SHAROBEL 0.35 MG TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999SPRINTEC 28 DAY TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999SRONYX 0.10-0.02 MG TABLET No
G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999SYEDA 28 TABLET No
G8A LEVONORGESTREL 12 999TAKE ACTION 1.5 MG TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999TARINA 24 FE 1 MG-20 MCG TAB No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999TARINA FE 1-20 EQ TABLET No
Tuesday, May 14, 2019 Page 75 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999TARINA FE 1-20 TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999TAYTULLA 1 MG-20 MCG CAPSULE No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999TILIA FE 28 TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI FEMYNOR 28 TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-ESTARYLLA TABLET No
G8A NORETHINDRONE-E.ESTRADIOL-IRON 12 999TRI-LEGEST FE-28 DAY TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-LINYAH TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-LO-ESTARYLLA TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-LO-MARZIA TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-LO-SPRINTEC TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-MILI 28 TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRINESSA LO TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRINESSA TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999TRI-NORINYL 28 TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-PREVIFEM TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-SPRINTEC TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999TRIVORA-28 TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-VYLIBRA 28 TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999TRI-VYLIBRA LO TABLET No
G8A NORETHINDRONE 12 999TULANA 0.35 MG TABLET No
G8A DROSPIR/ETH ESTRA/LEVOMEFOL CA 12 999TYDEMY TABLET No
G8A DESOGESTREL-ETHINYL ESTRADIOL 12 999VELIVET 28 DAY TABLET No
G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999VESTURA 3 MG-0.02 MG TABLET No
G8A LEVONORGESTREL-ETHIN ESTRADIOL 12 999VIENVA-28 TABLET No
Tuesday, May 14, 2019 Page 76 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
G8A DESOG-E.ESTRADIOL/E.ESTRADIOL 12 999VIORELE 28 DAY TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999VYFEMLA 28 TABLET No
G8A NORGESTIMATE-ETHINYL ESTRADIOL 12 999VYLIBRA 28 TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999WERA 0.5/0.035 MG 28 TABLET No
G8A NORETH-ETHINYL ESTRADIOL/IRON 12 999WYMZYA FE CHEWABLE TABLET No
G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999YASMIN 28 TABLET No
G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999YAZ 28 TABLET No
G8A ETHINYL ESTRADIOL/DROSPIRENONE 12 999ZARAH TABLET No
G8A NORETHINDRONE-ETHINYL ESTRAD 12 999ZENCHENT 0.4 MG-35 MCG TABLET No
G8A ETHYNODIOL D-ETHINYL ESTRADIOL 12 999ZOVIA 1/50E TABLET No
G8A ETHYNODIOL D-ETHINYL ESTRADIOL 12 999ZOVIA 1-35E TABLET No
G8C CONTRACEPTIVES,INJECTABLEG8C MEDROXYPROGESTERONE ACETATE 12 999DEPO-SUBQ PROVERA 104 SYRINGE No
G8C MEDROXYPROGESTERONE ACETATE 12 999MEDROXYPROGESTERONE 150 MG/ML No
G8F CONTRACEPTIVES,TRANSDERMALG8F NORELGESTROMIN/ETHIN.ESTRADIOL 12 999XULANE PATCH No
G9B CONTRACEPTIVES, INTRAVAGINAL, SYSTEMICG9B ETONOGESTREL/ETHINYL ESTRADIOL 12 999NUVARING VAGINAL RING No
H0A LOCAL ANESTHETICSH0A BUPIVACAINE HCL 0 999BUPIVACAINE 0.25% VIAL No
H0A BUPIVACAINE HCL/PF 0 999BUPIVACAINE 0.25% VIAL No
H0A BUPIVACAINE HCL/EPINEPHRINE 0 999BUPIVACAINE 0.25%-EPI 1:200000 No
H0A BUPIVACAINE HCL/EPINEPHRINE/PF 0 999BUPIVACAINE 0.25%-EPI 1:200000 No
H0A BUPIVACAINE HCL 0 999BUPIVACAINE 0.5% VIAL No
H0A BUPIVACAINE HCL/PF 0 999BUPIVACAINE 0.5% VIAL No
Tuesday, May 14, 2019 Page 77 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H0A BUPIVACAINE HCL/EPINEPHRINE 0 999BUPIVACAINE 0.5%-EPI 1:200,000 No
H0A BUPIVACAINE HCL/EPINEPHRINE/PF 0 999BUPIVACAINE 0.5%-EPI 1:200,000 No
H0A BUPIVACAINE HCL/PF 0 999BUPIVACAINE 0.75% AMPUL No
H0A BUPIVACAINE HCL/PF 0 999BUPIVACAINE 0.75% VIAL No
H0A BUPIVACAINE HCL IN DEXTROSE/PF 0 999BUPIVACAINE/DEXTR 0.75% AMP No
H0A BUPIVACAINE HCL/EPINEPHRINE 0 999BUPIVACAINE/EPI 0.25%/0.0005 No
H0A BUPIVACAINE HCL/EPINEPHRINE/PF 0 999BUPIVACAINE/EPI 0.25%/0.0005 No
H0A BUPIVACAINE HCL/EPINEPHRINE 0 999BUPIVACAINE/EPI 0.5%/0.0005 No
H0A BUPIVACAINE HCL/EPINEPHRINE BI 0 999BUPIVACAINE/EPI 0.5%/0.0005 No
H0A BUPIVACAINE HCL/EPINEPHRINE/PF 0 999BUPIVACAINE/EPI 0.5%/0.0005 No
H0A BUPIVACAINE HCL/EPINEPHRINE/PF 0 999BUPIVACAINE-EPI 0.25%-0.0005 No
H0A BUPIVACAINE HCL/EPINEPHRINE/PF 0 999BUPIVACAINE-EPI 0.5%-0.0005 No
H0A LIDOCAINE HCL/EPINEPHRINE 0 999LIDOCAINE 0.5%/EPI 1:200,000 No
H0A LIDOCAINE HCL/EPINEPHRINE 0 999LIDOCAINE 1%/EPI 1:100,000 No
H0A LIDOCAINE HCL/EPINEPHRINE 0 999LIDOCAINE 1%-EPI 1:100,000 No
H0A LIDOCAINE HCL/EPINEPHRINE 0 999LIDOCAINE 1.5%/EPI 1:200,000 No
H0A LIDOCAINE HCL/EPINEPHRINE 0 999LIDOCAINE 1.5%-EPI 1:200,000 No
H0A LIDOCAINE HCL/EPINEPHRINE BIT 0 999LIDOCAINE 2% - EPI 1:100,000 No
H0A LIDOCAINE HCL/EPINEPHRINE BIT 0 999LIDOCAINE 2% - EPI 1:50,000 No
H0A LIDOCAINE HCL 0 999LIDOCAINE 2% VISCOUS SOLN No
H0A LIDOCAINE HCL/EPINEPHRINE 0 999LIDOCAINE 2%/EPI 1:100,000 No
H0A LIDOCAINE HCL/EPINEPHRINE 0 999LIDOCAINE 2%/EPI 1:200,000 No
H0A LIDOCAINE HCL/DEXTROSE 7.5%/PF 0 999LIDOCAINE 5% IN D7.5W AMPUL No
H0A LIDOCAINE HCL 0 999LIDOCAINE HCL 0.5% VIAL No
Tuesday, May 14, 2019 Page 78 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 0.5% VIAL No
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 1% 20 MG/2 ML No
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 1% 20 MG/2 ML VL No
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 1% 300 MG/30 ML No
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 1% 50 MG/5 ML No
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 1% 50 MG/5 ML VL No
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 1% AMPUL No
H0A LIDOCAINE HCL 0 999LIDOCAINE HCL 1% VIAL No
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 1% VIAL No
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 1.5% AMPUL No
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 2% 100 MG/5 ML No
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 2% 40 MG/2 ML No
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 2% 40 MG/2 ML VL No
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 2% AMPUL No
H0A LIDOCAINE HCL 0 999LIDOCAINE HCL 2% JELLY No
H0A LIDOCAINE HCL 0 999LIDOCAINE HCL 2% VIAL No
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 2% VIAL No
H0A LIDOCAINE HCL/PF 0 999LIDOCAINE HCL 4% AMPUL No
H0A LIDOCAINE HCL 0 999LIDOCAINE HCL 4% SOLUTION No
H0A MEPIVACAINE HCL/PF 0 999MEPIVACAINE HCL 3% CARTRIDGE No
H0E AGENTS TO TREAT MULTIPLE SCLEROSISH0E TERIFLUNOMIDE 18 999AUBAGIO 14 MG TABLET No
H0E TERIFLUNOMIDE 18 999AUBAGIO 7 MG TABLET No
H0E INTERFERON BETA-1A/ALBUMIN 18 999AVONEX ADMIN PACK 30 MCG VL No
Tuesday, May 14, 2019 Page 79 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H0E INTERFERON BETA-1A 18 999AVONEX PEN 30 MCG/0.5 ML KIT No
H0E INTERFERON BETA-1A 18 999AVONEX PREFILLED SYR 30 MCG KT No
H0E INTERFERON BETA-1B 18 999BETASERON 0.3 MG KIT No
H0E INTERFERON BETA-1B 18 999BETASERON 0.3 MG VIAL No
H0E GLATIRAMER ACETATE 18 999COPAXONE 20 MG INJECTION KIT No
H0E FINGOLIMOD HCL 10 999GILENYA 0.25 MG CAPSULE No
H0E FINGOLIMOD HCL 10 999GILENYA 0.5 MG CAPSULE No
H0E INTERFERON BETA-1A/ALBUMIN 0 999REBIF 22 MCG/0.5 ML SYRINGE No
H0E INTERFERON BETA-1A/ALBUMIN 0 999REBIF 44 MCG/0.5 ML SYRINGE No
H0E INTERFERON BETA-1A/ALBUMIN 0 999REBIF REBIDOSE 22 MCG/0.5 ML No
H0E INTERFERON BETA-1A/ALBUMIN 0 999REBIF REBIDOSE 44 MCG/0.5 ML No
H0E INTERFERON BETA-1A/ALBUMIN 0 999REBIF REBIDOSE TITRATION PACK No
H0E INTERFERON BETA-1A/ALBUMIN 0 999REBIF TITRATION PACK No
H1A ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTSH1A MEMANTINE HCL 18 999MEMANTINE 5-10 MG TITRATION PK No
H1A MEMANTINE HCL 18 999MEMANTINE HCL 10 MG TABLET No
H1A MEMANTINE HCL 18 999MEMANTINE HCL 2 MG/ML SOLUTION No
H1A MEMANTINE HCL 18 999MEMANTINE HCL 5 MG TABLET No
H20 ANTI-ANXIETY - BENZODIAZEPINESH20 ALPRAZOLAM 7 999ALPRAZOLAM 0.25 MG TABLET No
H20 ALPRAZOLAM 7 999ALPRAZOLAM 0.5 MG TABLET No
H20 ALPRAZOLAM 7 999ALPRAZOLAM 1 MG TABLET No
H20 ALPRAZOLAM 7 999ALPRAZOLAM 2 MG TABLET No
H20 CHLORDIAZEPOXIDE HCL 6 999CHLORDIAZEPOXIDE 10 MG CAP No
Tuesday, May 14, 2019 Page 80 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H20 CHLORDIAZEPOXIDE HCL 6 999CHLORDIAZEPOXIDE 10 MG CAPSULE No
H20 CHLORDIAZEPOXIDE HCL 6 999CHLORDIAZEPOXIDE 25 MG CAP No
H20 CHLORDIAZEPOXIDE HCL 6 999CHLORDIAZEPOXIDE 25 MG CAPSULE No
H20 CHLORDIAZEPOXIDE HCL 6 999CHLORDIAZEPOXIDE 5 MG CAP No
H20 CHLORDIAZEPOXIDE HCL 6 999CHLORDIAZEPOXIDE 5 MG CAPSULE No
H20 CLORAZEPATE DIPOTASSIUM 9 999CLORAZEPATE 15 MG TABLET No
H20 CLORAZEPATE DIPOTASSIUM 9 999CLORAZEPATE 3.75 MG TABLET No
H20 CLORAZEPATE DIPOTASSIUM 9 999CLORAZEPATE 7.5 MG TABLET No
H20 DIAZEPAM 0 999DIAZEPAM 10 MG TABLET No
H20 DIAZEPAM 0 999DIAZEPAM 2 MG TABLET No
H20 DIAZEPAM 0 999DIAZEPAM 5 MG TABLET No
H20 DIAZEPAM 0 999DIAZEPAM 5 MG/5 ML SOLUTION No
H20 LORAZEPAM 0 999LORAZEPAM 0.5 MG TABLET No
H20 LORAZEPAM 0 999LORAZEPAM 1 MG TABLET No
H20 LORAZEPAM 0 999LORAZEPAM 2 MG TABLET No
H20 LORAZEPAM 0 999LORAZEPAM 2 MG/ML ORAL CONCENT No
H20 LORAZEPAM 0 999LORAZEPAM INTENSOL 2 MG/ML No
H20 OXAZEPAM 6 999OXAZEPAM 10 MG CAPSULE No
H20 OXAZEPAM 6 999OXAZEPAM 15 MG CAPSULE No
H20 OXAZEPAM 6 999OXAZEPAM 30 MG CAPSULE No
H21 SEDATIVE-HYPNOTICS - BENZODIAZEPINESH21 LORAZEPAM 0 999LORAZEPAM 2 MG/ML CARPUJECT No
H21 LORAZEPAM 0 999LORAZEPAM 2 MG/ML VIAL No
H21 LORAZEPAM 0 999LORAZEPAM 20 MG/10 ML VIAL No
Tuesday, May 14, 2019 Page 81 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H21 LORAZEPAM 0 999LORAZEPAM 4 MG/ML CARPUJECT No
H21 LORAZEPAM 0 999LORAZEPAM 4 MG/ML VIAL No
H21 LORAZEPAM 0 999LORAZEPAM 40 MG/10 ML VIAL No
H21 TEMAZEPAM 18 999TEMAZEPAM 15 MG CAPSULE No
H21 TEMAZEPAM 18 999TEMAZEPAM 30 MG CAPSULE No
H2D BARBITURATESH2D PHENOBARBITAL 0 999PHENOBARBITAL 100 MG TABLET No
H2D PHENOBARBITAL 0 999PHENOBARBITAL 15 MG TABLET No
H2D PHENOBARBITAL 0 999PHENOBARBITAL 16.2 MG TABLET No
H2D PHENOBARBITAL 0 999PHENOBARBITAL 20 MG/5 ML ELIX No
H2D PHENOBARBITAL 0 999PHENOBARBITAL 20 MG/5 ML SOLN No
H2D PHENOBARBITAL 0 999PHENOBARBITAL 30 MG TABLET No
H2D PHENOBARBITAL 0 999PHENOBARBITAL 32.4 MG TABLET No
H2D PHENOBARBITAL 0 999PHENOBARBITAL 60 MG TABLET No
H2D PHENOBARBITAL 0 999PHENOBARBITAL 64.8 MG TABLET No
H2D PHENOBARBITAL 0 999PHENOBARBITAL 97.2 MG TABLET No
H2E SEDATIVE-HYPNOTICS,NON-BARBITURATEH2E ZALEPLON 18 999ZALEPLON 10 MG CAPSULE No
H2E ZALEPLON 18 999ZALEPLON 5 MG CAPSULE No
H2E ZOLPIDEM TARTRATE 18 999ZOLPIDEM TARTRATE 10 MG TAB Auto PA
H2E ZOLPIDEM TARTRATE 18 999ZOLPIDEM TARTRATE 10 MG TABLET Auto PA
H2E ZOLPIDEM TARTRATE 18 999ZOLPIDEM TARTRATE 5 MG TABLET No
H2F ANTI-ANXIETY DRUGSH2F BUSPIRONE HCL 0 999BUSPIRONE HCL 10 MG TABLET No
H2F BUSPIRONE HCL 0 999BUSPIRONE HCL 15 MG TABLET No
Tuesday, May 14, 2019 Page 82 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H2F BUSPIRONE HCL 0 999BUSPIRONE HCL 30 MG TABLET No
H2F BUSPIRONE HCL 0 999BUSPIRONE HCL 5 MG TABLET No
H2F BUSPIRONE HCL 0 999BUSPIRONE HCL 7.5 MG TABLET No
H2G ANTIPSYCHOTICS,PHENOTHIAZINESH2G CHLORPROMAZINE HCL 18 999CHLORPROMAZINE 10 MG TABLET No
H2G CHLORPROMAZINE HCL 18 999CHLORPROMAZINE 100 MG TABLET No
H2G CHLORPROMAZINE HCL 18 999CHLORPROMAZINE 200 MG TABLET No
H2G CHLORPROMAZINE HCL 18 999CHLORPROMAZINE 25 MG TABLET No
H2G CHLORPROMAZINE HCL 18 999CHLORPROMAZINE 25 MG/ML AMP No
H2G CHLORPROMAZINE HCL 18 999CHLORPROMAZINE 50 MG TABLET No
H2G FLUPHENAZINE HCL 6 999FLUPHENAZINE 1 MG TABLET No
H2G FLUPHENAZINE HCL 6 999FLUPHENAZINE 10 MG TABLET No
H2G FLUPHENAZINE HCL 6 999FLUPHENAZINE 2.5 MG TABLET No
H2G FLUPHENAZINE HCL 6 999FLUPHENAZINE 2.5 MG/5 ML ELIX No
H2G FLUPHENAZINE HCL 18 999FLUPHENAZINE 2.5 MG/ML VIAL No
H2G FLUPHENAZINE HCL 6 999FLUPHENAZINE 5 MG TABLET No
H2G FLUPHENAZINE HCL 6 999FLUPHENAZINE 5 MG/ML CONC No
H2G FLUPHENAZINE DECANOATE 18 999FLUPHENAZINE DEC 125 MG/5 ML No
H2G FLUPHENAZINE DECANOATE 18 999FLUPHENAZINE DEC 25 MG/ML VL No
H2G PERPHENAZINE 6 999PERPHENAZINE 16 MG TABLET No
H2G PERPHENAZINE 6 999PERPHENAZINE 2 MG TABLET No
H2G PERPHENAZINE 6 999PERPHENAZINE 4 MG TABLET No
H2G PERPHENAZINE 6 999PERPHENAZINE 8 MG TABLET No
H2G THIORIDAZINE HCL 18 999THIORIDAZINE 10 MG TABLET No
Tuesday, May 14, 2019 Page 83 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H2G THIORIDAZINE HCL 18 999THIORIDAZINE 100 MG TABLET No
H2G THIORIDAZINE HCL 18 999THIORIDAZINE 25 MG TABLET No
H2G THIORIDAZINE HCL 18 999THIORIDAZINE 50 MG TABLET No
H2G TRIFLUOPERAZINE HCL 18 999TRIFLUOPERAZINE 1 MG TABLET No
H2G TRIFLUOPERAZINE HCL 18 999TRIFLUOPERAZINE 10 MG TABLET No
H2G TRIFLUOPERAZINE HCL 18 999TRIFLUOPERAZINE 2 MG TABLET No
H2G TRIFLUOPERAZINE HCL 18 999TRIFLUOPERAZINE 5 MG TABLET No
H2M BIPOLAR DISORDER DRUGSH2M CARBAMAZEPINE 6 999EQUETRO 100 MG CAPSULE Auto PA
H2M CARBAMAZEPINE 6 999EQUETRO 200 MG CAPSULE Auto PA
H2M CARBAMAZEPINE 6 999EQUETRO 300 MG CAPSULE Auto PA
H2M LITHIUM CARBONATE 6 999LITHIUM CARBONATE 150 MG CAP No
H2M LITHIUM CARBONATE 6 999LITHIUM CARBONATE 300 MG CAP No
H2M LITHIUM CARBONATE 6 999LITHIUM CARBONATE 300 MG TAB No
H2M LITHIUM CARBONATE 6 999LITHIUM CARBONATE 600 MG CAP No
H2M LITHIUM CARBONATE 6 999LITHIUM CARBONATE ER 300 MG TB No
H2M LITHIUM CARBONATE 6 999LITHIUM CARBONATE ER 450 MG TB No
H2M LITHIUM CITRATE 6 11LITHIUM CITRATE 8 MEQ/5 ML SOL No
H2M LITHIUM CARBONATE 6 999LITHIUM ER 450 MG TABLET No
H2S SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS)H2S CITALOPRAM HYDROBROMIDE 6 11CITALOPRAM 10 MG/5 ML SOLUTION No
H2S CITALOPRAM HYDROBROMIDE 6 999CITALOPRAM HBR 10 MG TABLET No
H2S CITALOPRAM HYDROBROMIDE 6 11CITALOPRAM HBR 10 MG/5 ML SOLN No
H2S CITALOPRAM HYDROBROMIDE 6 999CITALOPRAM HBR 20 MG TABLET No
Tuesday, May 14, 2019 Page 84 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H2S CITALOPRAM HYDROBROMIDE 0 999CITALOPRAM HBR 40 MG TABLET No
H2S CITALOPRAM HYDROBROMIDE 6 999CITALOPRAM HBR 40 MG TABLET No
H2S ESCITALOPRAM OXALATE 6 999ESCITALOPRAM 10 MG TABLET No
H2S ESCITALOPRAM OXALATE 6 999ESCITALOPRAM 20 MG TABLET No
H2S ESCITALOPRAM OXALATE 6 999ESCITALOPRAM 5 MG TABLET No
H2S FLUOXETINE HCL 6 999FLUOXETINE 10 MG CAPSULE No
H2S FLUOXETINE HCL 6 999FLUOXETINE 20 MG CAPSULE No
H2S FLUOXETINE HCL 6 11FLUOXETINE 20 MG/5 ML SOLN No
H2S FLUOXETINE HCL 6 11FLUOXETINE 20 MG/5 ML SOLUTION No
H2S FLUOXETINE HCL 6 999FLUOXETINE 40 MG CAPSULE No
H2S FLUOXETINE HCL 6 999FLUOXETINE HCL 10 MG CAPSULE No
H2S FLUOXETINE HCL 6 999FLUOXETINE HCL 20 MG CAPSULE No
H2S FLUOXETINE HCL 6 999FLUOXETINE HCL 40 MG CAPSULE No
H2S FLUVOXAMINE MALEATE 6 999FLUVOXAMINE MAL 100 MG TAB No
H2S FLUVOXAMINE MALEATE 6 999FLUVOXAMINE MALEATE 100 MG TAB No
H2S FLUVOXAMINE MALEATE 6 999FLUVOXAMINE MALEATE 25 MG TAB No
H2S FLUVOXAMINE MALEATE 6 999FLUVOXAMINE MALEATE 25 MG TB No
H2S FLUVOXAMINE MALEATE 6 999FLUVOXAMINE MALEATE 50 MG TAB No
H2S FLUVOXAMINE MALEATE 6 999FLUVOXAMINE MALEATE 50 MG TB No
H2S PAROXETINE HCL 6 999PAROXETINE HCL 10 MG TABLET No
H2S PAROXETINE HCL 6 999PAROXETINE HCL 20 MG TABLET No
H2S PAROXETINE HCL 6 999PAROXETINE HCL 30 MG TABLET No
H2S PAROXETINE HCL 6 999PAROXETINE HCL 40 MG TABLET No
H2S SERTRALINE HCL 6 11SERTRALINE 20 MG/ML ORAL CONC No
Tuesday, May 14, 2019 Page 85 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H2S SERTRALINE HCL 6 11SERTRALINE 20 MG/ML ORAL SOLN No
H2S SERTRALINE HCL 6 999SERTRALINE HCL 100 MG TABLET No
H2S SERTRALINE HCL 6 999SERTRALINE HCL 25 MG TABLET No
H2S SERTRALINE HCL 6 999SERTRALINE HCL 50 MG TABLET No
H2U TRICYCLIC ANTIDEPRESSANTS,REL.NON-SEL.REUPT-INHIBH2U AMITRIPTYLINE HCL 12 999AMITRIPTYLINE HCL 10 MG TAB No
H2U AMITRIPTYLINE HCL 12 999AMITRIPTYLINE HCL 100 MG TAB No
H2U AMITRIPTYLINE HCL 12 999AMITRIPTYLINE HCL 150 MG TAB No
H2U AMITRIPTYLINE HCL 12 999AMITRIPTYLINE HCL 25 MG TAB No
H2U AMITRIPTYLINE HCL 12 999AMITRIPTYLINE HCL 50 MG TAB No
H2U AMITRIPTYLINE HCL 12 999AMITRIPTYLINE HCL 75 MG TAB No
H2U AMOXAPINE 16 999AMOXAPINE 100 MG TABLET No
H2U AMOXAPINE 16 999AMOXAPINE 150 MG TABLET No
H2U AMOXAPINE 16 999AMOXAPINE 25 MG TABLET No
H2U AMOXAPINE 16 999AMOXAPINE 50 MG TABLET No
H2U CLOMIPRAMINE HCL 10 999CLOMIPRAMINE 25 MG CAPSULE Auto PA
H2U CLOMIPRAMINE HCL 10 999CLOMIPRAMINE 50 MG CAPSULE Auto PA
H2U CLOMIPRAMINE HCL 10 999CLOMIPRAMINE 75 MG CAPSULE Auto PA
H2U DESIPRAMINE HCL 13 999DESIPRAMINE 10 MG TABLET No
H2U DESIPRAMINE HCL 13 999DESIPRAMINE 100 MG TABLET No
H2U DESIPRAMINE HCL 13 999DESIPRAMINE 150 MG TABLET No
H2U DESIPRAMINE HCL 13 999DESIPRAMINE 25 MG TABLET No
H2U DESIPRAMINE HCL 13 999DESIPRAMINE 50 MG TABLET No
H2U DESIPRAMINE HCL 13 999DESIPRAMINE 75 MG TABLET No
Tuesday, May 14, 2019 Page 86 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H2U DOXEPIN HCL 12 999DOXEPIN 10 MG CAPSULE No
H2U DOXEPIN HCL 12 999DOXEPIN 10 MG/ML ORAL CONC No
H2U DOXEPIN HCL 12 999DOXEPIN 100 MG CAPSULE No
H2U DOXEPIN HCL 12 999DOXEPIN 150 MG CAPSULE No
H2U DOXEPIN HCL 12 999DOXEPIN 25 MG CAPSULE No
H2U DOXEPIN HCL 12 999DOXEPIN 50 MG CAPSULE No
H2U DOXEPIN HCL 12 999DOXEPIN 75 MG CAPSULE No
H2U IMIPRAMINE HCL 6 999IMIPRAMINE HCL 10 MG TABLET No
H2U IMIPRAMINE HCL 6 999IMIPRAMINE HCL 25 MG TABLET No
H2U IMIPRAMINE HCL 6 999IMIPRAMINE HCL 50 MG TABLET No
H2U NORTRIPTYLINE HCL 13 999NORTRIPTYLINE 10 MG/5 ML SOL No
H2U NORTRIPTYLINE HCL 13 999NORTRIPTYLINE HCL 10 MG CAP No
H2U NORTRIPTYLINE HCL 13 999NORTRIPTYLINE HCL 25 MG CAP No
H2U NORTRIPTYLINE HCL 13 999NORTRIPTYLINE HCL 50 MG CAP No
H2U NORTRIPTYLINE HCL 13 999NORTRIPTYLINE HCL 75 MG CAP No
H2V TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSYH2V METHYLPHENIDATE HCL 6 999APTENSIO XR 10 MG CAPSULE No
H2V METHYLPHENIDATE HCL 6 999APTENSIO XR 15 MG CAPSULE No
H2V METHYLPHENIDATE HCL 6 999APTENSIO XR 20 MG CAPSULE No
H2V METHYLPHENIDATE HCL 6 999APTENSIO XR 30 MG CAPSULE No
H2V METHYLPHENIDATE HCL 6 999APTENSIO XR 40 MG CAPSULE No
H2V METHYLPHENIDATE HCL 6 999APTENSIO XR 50 MG CAPSULE No
H2V METHYLPHENIDATE HCL 6 999APTENSIO XR 60 MG CAPSULE No
H2V METHYLPHENIDATE 6 999DAYTRANA 10 MG/9 HR PATCH No
Tuesday, May 14, 2019 Page 87 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H2V METHYLPHENIDATE 6 999DAYTRANA 15 MG/9 HR PATCH No
H2V METHYLPHENIDATE 6 999DAYTRANA 20 MG/9 HOUR PATCH No
H2V METHYLPHENIDATE 6 999DAYTRANA 30 MG/9 HOUR PATCH No
H2V DEXMETHYLPHENIDATE HCL 0 999DEXMETHYLPHENIDATE 10 MG TAB No
H2V DEXMETHYLPHENIDATE HCL 0 999DEXMETHYLPHENIDATE 2.5 MG TAB No
H2V DEXMETHYLPHENIDATE HCL 0 999DEXMETHYLPHENIDATE 5 MG TAB No
H2V DEXMETHYLPHENIDATE HCL 6 999FOCALIN XR 10 MG CAPSULE No
H2V DEXMETHYLPHENIDATE HCL 6 999FOCALIN XR 15 MG CAPSULE No
H2V DEXMETHYLPHENIDATE HCL 6 999FOCALIN XR 20 MG CAPSULE No
H2V DEXMETHYLPHENIDATE HCL 6 999FOCALIN XR 25 MG CAPSULE No
H2V DEXMETHYLPHENIDATE HCL 6 999FOCALIN XR 30 MG CAPSULE No
H2V DEXMETHYLPHENIDATE HCL 6 999FOCALIN XR 35 MG CAPSULE No
H2V DEXMETHYLPHENIDATE HCL 6 999FOCALIN XR 40 MG CAPSULE No
H2V DEXMETHYLPHENIDATE HCL 6 999FOCALIN XR 5 MG CAPSULE No
H2V METHYLPHENIDATE HCL 0 999METHYLPHENIDATE 10 MG CHEW TAB No
H2V METHYLPHENIDATE HCL 0 999METHYLPHENIDATE 10 MG TABLET No
H2V METHYLPHENIDATE HCL 0 999METHYLPHENIDATE 2.5 MG CHEW TB No
H2V METHYLPHENIDATE HCL 0 999METHYLPHENIDATE 20 MG TABLET No
H2V METHYLPHENIDATE HCL 0 999METHYLPHENIDATE 5 MG CHEW TAB No
H2V METHYLPHENIDATE HCL 0 999METHYLPHENIDATE 5 MG TABLET No
H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE CD 10 MG CAP No(generic metadateCD)
H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE CD 20 MG CAP No(generic metadateCD)
H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE CD 30 MG CAP No(generic metadateCD)
H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE CD 40 MG CAP No(generic metadateCD)
Tuesday, May 14, 2019 Page 88 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE CD 50 MG CAP No(generic metadateCD)
H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE CD 60 MG CAP No(generic metadateCD)
H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE ER 10 MG CAP No(generic metadateCD)
H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE ER 10 MG TAB No(generic metadateER)
H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE ER 20 MG CAP No(generic metadateCD)
H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE ER 20 MG TAB No(generic metadateER)
H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE ER 30 MG CAP No(generic metadateCD)
H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE ER 40 MG CAP No(generic metadateCD)
H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE ER 50 MG CAP No(generic metadateCD)
H2V METHYLPHENIDATE HCL 6 999METHYLPHENIDATE ER 60 MG CAP No(generic metadateCD)
H2V METHYLPHENIDATE HCL 6 999QUILLICHEW ER 20 MG CHEW TAB No
H2V METHYLPHENIDATE HCL 6 999QUILLICHEW ER 30 MG CHEW TAB No
H2V METHYLPHENIDATE HCL 6 999QUILLICHEW ER 40 MG CHEW TAB No
H2V METHYLPHENIDATE HCL 6 999QUILLIVANT XR 25 MG/5 ML SUSP No
H2W TRICYCLIC ANTIDEPRESSANT-PHENOTHIAZINE COMBINATNSH2W PERPHENAZINE/AMITRIPTYLINE HCL 18 999PERPHEN-AMITRIP 2 MG-10 MG TAB No
H2W PERPHENAZINE/AMITRIPTYLINE HCL 18 999PERPHEN-AMITRIP 2 MG-25 MG TAB No
H2W PERPHENAZINE/AMITRIPTYLINE HCL 18 999PERPHEN-AMITRIP 4 MG-10 MG TAB No
H2W PERPHENAZINE/AMITRIPTYLINE HCL 18 999PERPHEN-AMITRIP 4 MG-25 MG TAB No
H2W PERPHENAZINE/AMITRIPTYLINE HCL 18 999PERPHEN-AMITRIP 4 MG-50 MG TAB No
H2X TRICYCLIC ANTIDEPRESSANT-BENZODIAZEPINE COMBINATNSH2X AMITRIPTYLINE/CHLORDIAZEPOXIDE 18 999AMITRIP/CDP 12.5-5 TABLET No
H2X AMITRIPTYLINE/CHLORDIAZEPOXIDE 18 999AMITRIP/CDP 25-10 TABLET No
H3A OPIOID ANALGESICSH3A MORPHINE SULFATE 18 999ARYMO ER 15 MG TABLET Auto PA
Tuesday, May 14, 2019 Page 89 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H3A MORPHINE SULFATE 18 999ARYMO ER 30 MG TABLET Auto PA
H3A MORPHINE SULFATE 18 999ARYMO ER 60 MG TABLET Auto PA
H3A OPIUM/BELLADONNA ALKALOIDS 0 999BELLADONNA & OPIUM SUPPOS No
H3A OPIUM/BELLADONNA ALKALOIDS 0 999BELLADONNA-OPIUM 16.2-30 SUPP No
H3A OPIUM/BELLADONNA ALKALOIDS 0 999BELLADONNA-OPIUM 16.2-60 SUPP No
H3A CODEINE SULFATE 12 999CODEINE SULFATE 15 MG TABLET No
H3A CODEINE SULFATE 12 999CODEINE SULFATE 30 MG TABLET No
H3A CODEINE SULFATE 12 999CODEINE SULFATE 60 MG TABLET No
H3A MORPHINE SULFATE/NALTREXONE 18 999EMBEDA ER 100-4 MG CAPSULE No
H3A MORPHINE SULFATE/NALTREXONE 18 999EMBEDA ER 20-0.8 MG CAPSULE No
H3A MORPHINE SULFATE/NALTREXONE 18 999EMBEDA ER 30-1.2 MG CAPSULE No
H3A MORPHINE SULFATE/NALTREXONE 18 999EMBEDA ER 50-2 MG CAPSULE No
H3A MORPHINE SULFATE/NALTREXONE 18 999EMBEDA ER 60-2.4 MG CAPSULE No
H3A MORPHINE SULFATE/NALTREXONE 18 999EMBEDA ER 80-3.2 MG CAPSULE No
H3A FENTANYL 18 999FENTANYL 100 MCG/HR PATCH No
H3A FENTANYL 18 999FENTANYL 12 MCG/HR PATCH No
H3A FENTANYL 18 999FENTANYL 25 MCG/HR PATCH No
H3A FENTANYL 18 999FENTANYL 50 MCG/HR PATCH No
H3A FENTANYL 18 999FENTANYL 75 MCG/HR PATCH No
H3A HYDROMORPHONE HCL 0 999HYDROMORPHONE 0.5 MG/0.5 ML No
H3A HYDROMORPHONE HCL 0 999HYDROMORPHONE 2 MG TABLET No
H3A HYDROMORPHONE HCL 0 999HYDROMORPHONE 4 MG TABLET No
H3A HYDROMORPHONE HCL 0 999HYDROMORPHONE 8 MG TABLET No
H3A HYDROMORPHONE HCL 0 999HYDROMORPHONE HCL 8 MG TAB No
Tuesday, May 14, 2019 Page 90 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H3A HYDROCODONE BITARTRATE 18 999HYSINGLA ER 100 MG TABLET Auto PA
H3A HYDROCODONE BITARTRATE 18 999HYSINGLA ER 120 MG TABLET Auto PA
H3A HYDROCODONE BITARTRATE 18 999HYSINGLA ER 20 MG TABLET Auto PA
H3A HYDROCODONE BITARTRATE 18 999HYSINGLA ER 30 MG TABLET Auto PA
H3A HYDROCODONE BITARTRATE 18 999HYSINGLA ER 40 MG TABLET Auto PA
H3A HYDROCODONE BITARTRATE 18 999HYSINGLA ER 60 MG TABLET Auto PA
H3A HYDROCODONE BITARTRATE 18 999HYSINGLA ER 80 MG TABLET Auto PA
H3A MORPHINE SULFATE 18 999MORPHABOND ER 100 MG TABLET Auto PA
H3A MORPHINE SULFATE 18 999MORPHABOND ER 15 MG TABLET Auto PA
H3A MORPHINE SULFATE 18 999MORPHABOND ER 30 MG TABLET Auto PA
H3A MORPHINE SULFATE 18 999MORPHABOND ER 60 MG TABLET Auto PA
H3A MORPHINE SULFATE 0 999MORPHINE SULF 10 MG/5 ML SOLN No
H3A MORPHINE SULFATE 0 999MORPHINE SULF 100 MG/5 ML SOLN No
H3A MORPHINE SULFATE 0 999MORPHINE SULF 20 MG/5 ML SOLN No
H3A MORPHINE SULFATE 0 999MORPHINE SULFATE 15 MG TABLET No
H3A MORPHINE SULFATE 0 999MORPHINE SULFATE 20 MG/ML SOLN No
H3A MORPHINE SULFATE 0 999MORPHINE SULFATE 30 MG TABLET No
H3A OXYCODONE HCL 0 999OXYCODONE HCL 10 MG TABLET No
H3A OXYCODONE HCL 0 999OXYCODONE HCL 15 MG TABLET No
H3A OXYCODONE HCL 0 999OXYCODONE HCL 20 MG TABLET No
H3A OXYCODONE HCL 0 999OXYCODONE HCL 30 MG TABLET No
H3A OXYCODONE HCL 0 999OXYCODONE HCL 5 MG TABLET No
H3A OXYCODONE HCL 0 999OXYCODONE HCL 5 MG/5 ML SOL No
H3A OXYCODONE HCL 0 999OXYCODONE HCL 5 MG/5 ML SOLN No
Tuesday, May 14, 2019 Page 91 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H3A TRAMADOL HCL 12 999TRAMADOL HCL 50 MG TABLET No
H3A OXYCODONE MYRISTATE 18 999XTAMPZA ER 13.5 MG CAPSULE Auto PA
H3A OXYCODONE MYRISTATE 18 999XTAMPZA ER 18 MG CAPSULE Auto PA
H3A OXYCODONE MYRISTATE 18 999XTAMPZA ER 27 MG CAPSULE Auto PA
H3A OXYCODONE MYRISTATE 18 999XTAMPZA ER 36 MG CAPSULE Auto PA
H3A OXYCODONE MYRISTATE 18 999XTAMPZA ER 9 MG CAPSULE Auto PA
H3D ANALGESIC/ANTIPYRETICS, SALICYLATESH3D ASPIRIN 0 999ASPIRIN 325 MG TABLET No
H3D ASPIRIN 0 999ASPIRIN EC 325 MG TABLET No
H3D ASPIRIN 0 999HM ASPIRIN 325 MG TABLET No
H3D SALSALATE 0 999SALSALATE 500 MG TABLET No
H3D SALSALATE 0 999SALSALATE 750 MG TABLET No
H3D ASPIRIN 0 999SB ASPIRIN 325 MG TABLET No
H3E ANALGESIC/ANTIPYRETICS,NON-SALICYLATEH3E ACETAMINOPHEN 0 9998 HOUR ER 650 MG CAPLET No
H3E ACETAMINOPHEN 0 9998HR ARTHRITIS PAIN ER 650 MG No
H3E ACETAMINOPHEN 0 9998HR MUSCLE ACHE-PAIN ER 650 MG No
H3E ACETAMINOPHEN 0 6ACETAMINOPHEN 160 MG/5 ML ELX No
H3E ACETAMINOPHEN 0 6ACETAMINOPHEN 160 MG/5 ML LIQ No
H3E ACETAMINOPHEN 0 6APAP CHILDRENS SUSPENSION No
H3E ACETAMINOPHEN 0 999ARTHRITIS PAIN ER 650 MG CAPLT No
H3E ACETAMINOPHEN 0 6CHILD ACETAMINOPHEN 160 MG No
H3E ACETAMINOPHEN 0 6CHILD PAIN & FEVER 160 MG/5 ML No
H3E ACETAMINOPHEN 0 6CHILD PAIN-FEVER 160 MG/5 ML No
Tuesday, May 14, 2019 Page 92 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H3E ACETAMINOPHEN 0 6CHILDREN'S PAIN RELIEF SUSP No
H3E ACETAMINOPHEN 0 6CHILDREN'S SILAPAP ELIXIR No
H3E ACETAMINOPHEN 0 6CHILD'S MAPAP 160 MG TAB CHEW No
H3E ACETAMINOPHEN 0 6CHILD'S PAIN RELIEVER SUSP No
H3E ACETAMINOPHEN 0 6CHLD ACETAMINOPHEN 160 MG/5 ML No
H3E ACETAMINOPHEN 0 6ED-APAP 160 MG/5 ML LIQUID No
H3E ACETAMINOPHEN 0 6GS CHLD PAIN-FEVER 160 MG/5 ML No
H3E ACETAMINOPHEN 0 6GS INFANT PAIN-FEVER 160 MG/5 No
H3E ACETAMINOPHEN 0 999HM ARTHRIT PAIN RLF ER 650 MG No
H3E ACETAMINOPHEN 0 999HM ARTHRITIS PAIN ER 650 MG No
H3E ACETAMINOPHEN 0 6HM CHILD ACETAMINOPHEN 160 MG No
H3E ACETAMINOPHEN 0 6HM CHLD PAIN-FEVER 160 MG/5 ML No
H3E ACETAMINOPHEN 0 6HM INFNT PAIN & FEVER 160 MG/5 No
H3E ACETAMINOPHEN 0 6INF ACETAMINOPHEN 160 MG/5 ML No
H3E ACETAMINOPHEN 0 6INFANT PAIN & FEVER SUSP No
H3E ACETAMINOPHEN 0 6INFANT PAIN & FEVER SUSPENSION No
H3E ACETAMINOPHEN 0 6INFANT PAIN RELIEF 160 MG/5 ML No
H3E ACETAMINOPHEN 0 6INFANT PAIN-FEVER 160 MG/5 ML No
H3E ACETAMINOPHEN 0 6INFANTS' PAIN & FEVER SUSP No
H3E ACETAMINOPHEN 0 6MAPAP 160 MG/5 ML ELIXIR No
H3E ACETAMINOPHEN 0 6NON-ASPIRIN CHILDREN'S SUSP No
H3E ACETAMINOPHEN 0 6QC CHILD PAIN RLF 160 MG/5 ML No
H3E ACETAMINOPHEN 0 6QC INFANT PAIN RLF 160 MG/5 ML No
H3E ACETAMINOPHEN 0 6QC INFNT PAIN RLF 160 MG/5 ML No
Tuesday, May 14, 2019 Page 93 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H3E ACETAMINOPHEN 0 6QC JR. NON-ASPIRIN 160 MG TAB No
H3E ACETAMINOPHEN 0 6QC NON-ASPIRIN 160 MG/5 ML No
H3E ACETAMINOPHEN 0 999SB ARTHRITIS PAIN ER 650 MG No
H3E ACETAMINOPHEN 0 999SM ARTHRIT PAIN RLF ER 650 MG No
H3E ACETAMINOPHEN 0 6SM CHILD PAIN & FEVER 160 MG/5 No
H3E ACETAMINOPHEN 0 6SM INFANT PAIN-FEVER 160 MG/5 No
H3E ACETAMINOPHEN 0 6SM PAIN REL JR STR TAB CHEW No
H3F ANTIMIGRAINE PREPARATIONSH3F GALCANEZUMAB-GNLM 18 999EMGALITY 120 MG/ML PEN No
H3F RIZATRIPTAN BENZOATE 6 999RIZATRIPTAN 10 MG ODT No
H3F RIZATRIPTAN BENZOATE 6 999RIZATRIPTAN 10 MG TABLET No
H3F RIZATRIPTAN BENZOATE 6 999RIZATRIPTAN 5 MG ODT No
H3F RIZATRIPTAN BENZOATE 6 999RIZATRIPTAN 5 MG TABLET No
H3F SUMATRIPTAN 18 999SUMATRIPTAN 20 MG NASAL SPRAY No
H3F SUMATRIPTAN 18 999SUMATRIPTAN 5 MG NASAL SPRAY No
H3F SUMATRIPTAN SUCCINATE 18 999SUMATRIPTAN SUCC 100 MG TABLET No
H3F SUMATRIPTAN SUCCINATE 18 999SUMATRIPTAN SUCC 25 MG TABLET No
H3F SUMATRIPTAN SUCCINATE 18 999SUMATRIPTAN SUCC 50 MG TABLET No
H3K ANALGESIC, NON-SALICYLATE AND BARBITURATE COMBINATH3K BUTALBITAL/ACETAMINOPHEN 0 999APAP/BUTALBITAL 325/50 TAB No
H3K BUTALBITAL/ACETAMINOPHEN 0 999BUTALBITAL-ACETAMIN 50-300 TAB No
H3K BUTALBITAL/ACETAMINOPHEN 0 999BUTALBITAL-ACETAMINOPHN 50-300 No
H3K BUTALBITAL/ACETAMINOPHEN 0 999BUTALBITAL-ACETAMINOPHN 50-325 No
H3L ANALGESIC,NON-SALICYLATE,BARBITURATE,XANTHINE COMBH3L BUTALB/ACETAMINOPHEN/CAFFEINE 0 999BUTALB-ACETAMIN-CAFF 50-300-40 No
Tuesday, May 14, 2019 Page 94 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H3L BUTALB/ACETAMINOPHEN/CAFFEINE 0 999BUTALB-ACETAMIN-CAFF 50-325-40 No
H3L BUTALB/ACETAMINOPHEN/CAFFEINE 0 999BUTALB-APAP-CAFF 50-325-40 TAB No
H3L BUTALB/ACETAMINOPHEN/CAFFEINE 0 999BUTALBIT-ACETAMINOPHEN-CAFF CP No
H3L BUTALB/ACETAMINOPHEN/CAFFEINE 0 999BUTALBITAL/APAP/CAFFEINE TAB No
H3L BUTALB/ACETAMINOPHEN/CAFFEINE 0 999BUTALBITAL/APAP/CAFFEINE TB No
H3L BUTALB/ACETAMINOPHEN/CAFFEINE 0 999BUTALBITAL-APAP-CAFFEINE TAB No
H3L BUTALB/ACETAMINOPHEN/CAFFEINE 0 999BUTALBITAL-APAP-CAFFEINE TB No
H3M OPIOID,NON-SALICYL.ANALGESIC,BARBITURATE,XANTHINEH3M BUTALBIT/ACETAMIN/CAFF/CODEINE 12 999BUTALBITAL/CAFF/APAP/COD CP No
H3M BUTALBIT/ACETAMIN/CAFF/CODEINE 12 999BUTALBITAL-CAFF-APAP-COD CAP No
H3M BUTALBIT/ACETAMIN/CAFF/CODEINE 12 999BUTALBITAL-CAFF-APAP-COD CP No
H3N OPIOID ANALGESIC AND NSAID COMBINATIONH3N HYDROCODONE/IBUPROFEN 0 999HYDROCODONE BIT-IBUPROFEN TAB No
H3N HYDROCODONE/IBUPROFEN 0 999HYDROCODONE BT-IBUPROFEN TAB No
H3N HYDROCODONE/IBUPROFEN 0 999HYDROCODONE BT-IBUPROFEN TB No
H3N HYDROCODONE/IBUPROFEN 0 999HYDROCODONE-IBUPROFEN 10-200 No
H3N HYDROCODONE/IBUPROFEN 0 999HYDROCODONE-IBUPROFEN 5-200 MG No
H3N HYDROCODONE/IBUPROFEN 0 999HYDROCODONE-IBUPROFEN 7.5-200 No
H3O ANALGESIC, SALICYLATE, BARBITURATE, XANTHINE COMB.H3O BUTALBITAL/ASPIRIN/CAFFEINE 0 999BUTALB-ASPIRIN-CAFFE 50-325-40 No
H3O BUTALBITAL/ASPIRIN/CAFFEINE 0 999BUTALBITAL COMPOUND CAPSULE No
H3O BUTALBITAL/ASPIRIN/CAFFEINE 0 999BUTALBITAL-ASP-CAFFEINE CAP No
H3T OPIOID ANTAGONISTSH3T NALOXONE HCL 0 999NALOXONE 0.4 MG/ML CARPUJECT No
H3T NALOXONE HCL 0 999NALOXONE 0.4 MG/ML SYRINGE No
Tuesday, May 14, 2019 Page 95 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H3T NALOXONE HCL 0 999NALOXONE 0.4 MG/ML VIAL No
H3T NALOXONE HCL 0 999NALOXONE 2 MG/2 ML SYRINGE No
H3T NALOXONE HCL 0 999NALOXONE 4 MG/10 ML VIAL No
H3T NALTREXONE HCL 0 999NALTREXONE 50 MG TABLET No
H3T NALOXONE HCL 0 999NARCAN 4 MG NASAL SPRAY No
H3U OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICSH3U ACETAMINOPHEN WITH CODEINE 12 999ACETAMIN-CODEIN 300-30 MG/12.5 No
H3U ACETAMINOPHEN WITH CODEINE 12 999ACETAMINOP-CODEINE 120-12 MG/5 No
H3U ACETAMINOPHEN WITH CODEINE 12 999ACETAMINOPHEN/COD #2 TABLET No
H3U ACETAMINOPHEN WITH CODEINE 12 999ACETAMINOPHEN/COD #3 TABLET No
H3U ACETAMINOPHEN WITH CODEINE 12 999ACETAMINOPHEN/COD #4 TABLET No
H3U ACETAMINOPHEN WITH CODEINE 12 999ACETAMINOPHEN/COD ELIXIR No
H3U ACETAMINOPHEN WITH CODEINE 12 999ACETAMINOPHEN-COD #2 TABLET No
H3U ACETAMINOPHEN WITH CODEINE 12 999ACETAMINOPHEN-COD #3 TABLET No
H3U ACETAMINOPHEN WITH CODEINE 12 999ACETAMINOPHEN-COD #4 TABLET No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODON-ACETAMIN 7.5-325/15 No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODON-ACETAMINOPH 2.5-325 No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODON-ACETAMINOPH 7.5-300 No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODON-ACETAMINOPH 7.5-325 No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODON-ACETAMINOPHEN 5-300 No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODON-ACETAMINOPHEN 5-325 No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODON-ACETAMINOPHN 10-300 No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODON-ACETAMINOPHN 10-325 No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMIN 10-300 MG No
Tuesday, May 14, 2019 Page 96 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMIN 10-325 MG No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMIN 2.5-108/5 No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMIN 5-217/10 No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMIN 5-300 MG No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMIN 5-325 MG No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMIN 7.5-300 No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMIN 7.5-325 No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-ACETAMINOPHEN SOLN No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-APAP 10/325 MG TAB No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-APAP 10-325 TABLET No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-APAP 5/325 MG TAB No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-APAP 5-325 TABLET No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-APAP 7.5/325 MG TB No
H3U HYDROCODONE/ACETAMINOPHEN 0 999HYDROCODONE-APAP 7.5-325 TAB No
H3U OXYCODONE HCL/ACETAMINOPHEN 0 999OXYCODON HCL-APAP 10/325 MG TB No
H3U OXYCODONE HCL/ACETAMINOPHEN 0 999OXYCODON-ACETAMINOPHEN 2.5-325 No
H3U OXYCODONE HCL/ACETAMINOPHEN 0 999OXYCODON-ACETAMINOPHEN 7.5-325 No
H3U OXYCODONE HCL/ACETAMINOPHEN 0 999OXYCODONE W/APAP 5/325 TAB No
H3U OXYCODONE HCL/ACETAMINOPHEN 0 999OXYCODONE-ACETAMINOPHEN 10-325 No
H3U OXYCODONE HCL/ACETAMINOPHEN 0 999OXYCODONE-ACETAMINOPHEN 5-325 No
H3U OXYCODONE HCL/ACETAMINOPHEN 0 999OXYCODONE-APAP 10-325 TABLET No
H3U OXYCODONE HCL/ACETAMINOPHEN 0 999OXYCODONE-APAP 5-325 MG TAB No
H3U OXYCODONE HCL/ACETAMINOPHEN 0 999OXYCODONE-APAP 5-325 TABLET No
H3U OXYCODONE HCL/ACETAMINOPHEN 0 999OXYCODONE-APAP 7.5/325 MG TAB No
Tuesday, May 14, 2019 Page 97 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H3W OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPEH3W BUPRENORPHINE HCL 16 999BUPRENORPHINE 2 MG TABLET SL Clinical PA Required
H3W BUPRENORPHINE HCL 16 999BUPRENORPHINE 8 MG TABLET SL Clinical PA Required
H3W BUPRENORPHINE 18 999SUBLOCADE 100 MG/0.5 ML SYRING Auto PA
H3W BUPRENORPHINE 18 999SUBLOCADE 300 MG/1.5 ML SYRING Auto PA
H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999SUBOXONE 12 MG-3 MG SL FILM Clinical PA Required
H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999SUBOXONE 2 MG-0.5 MG SL FILM Clinical PA Required
H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999SUBOXONE 4 MG-1 MG SL FILM Clinical PA Required
H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999SUBOXONE 8 MG-2 MG SL FILM Clinical PA Required
H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999ZUBSOLV 0.7-0.18 MG TABLET SL Clinical PA Required
H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999ZUBSOLV 1.4-0.36 MG TABLET SL Clinical PA Required
H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999ZUBSOLV 11.4-2.9 MG TABLET SL Clinical PA Required
H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999ZUBSOLV 2.9-0.71 MG TABLET SL Clinical PA Required
H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999ZUBSOLV 5.7-1.4 MG TABLET SL Clinical PA Required
H3W BUPRENORPHINE HCL/NALOXONE HCL 16 999ZUBSOLV 8.6-2.1 MG TABLET SL Clinical PA Required
H3Y MU-OPIOID RECEPTOR ANTAGONISTS,PERIPHERALLY-ACTINGH3Y NALOXEGOL OXALATE 0 999MOVANTIK 12.5 MG TABLET Auto PA
H3Y NALOXEGOL OXALATE 0 999MOVANTIK 25 MG TABLET Auto PA
H4A ANTICONVULSANT - BENZODIAZEPINE TYPEH4A CLOBAZAM 2 999CLOBAZAM 10 MG TABLET No
H4A CLOBAZAM 2 999CLOBAZAM 2.5 MG/ML SUSPENSION No
H4A CLOBAZAM 2 999CLOBAZAM 20 MG TABLET No
H4A CLONAZEPAM 0 999CLONAZEPAM 0.125 MG DIS TAB No
H4A CLONAZEPAM 0 999CLONAZEPAM 0.125 MG ODT No
H4A CLONAZEPAM 0 999CLONAZEPAM 0.25 MG DIS TAB No
Tuesday, May 14, 2019 Page 98 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H4A CLONAZEPAM 0 999CLONAZEPAM 0.25 MG DIS TABLET No
H4A CLONAZEPAM 0 999CLONAZEPAM 0.25 MG ODT No
H4A CLONAZEPAM 0 999CLONAZEPAM 0.5 MG DIS TAB No
H4A CLONAZEPAM 0 999CLONAZEPAM 0.5 MG DIS TABLET No
H4A CLONAZEPAM 0 999CLONAZEPAM 0.5 MG ODT No
H4A CLONAZEPAM 0 999CLONAZEPAM 0.5 MG TABLET No
H4A CLONAZEPAM 0 999CLONAZEPAM 1 MG DIS TABLET No
H4A CLONAZEPAM 0 999CLONAZEPAM 1 MG ODT No
H4A CLONAZEPAM 0 999CLONAZEPAM 1 MG TABLET No
H4A CLONAZEPAM 0 999CLONAZEPAM 2 MG DIS TABLET No
H4A CLONAZEPAM 0 999CLONAZEPAM 2 MG ODT No
H4A CLONAZEPAM 0 999CLONAZEPAM 2 MG TABLET No
H4A DIAZEPAM 0 18DIASTAT 2.5 MG PEDI SYSTEM Auto PA
H4A DIAZEPAM 0 18DIASTAT ACUDIAL 12.5-15-20 MG Auto PA
H4A DIAZEPAM 0 18DIASTAT ACUDIAL 5-7.5-10 MG KT Auto PA
H4A DIAZEPAM 0 18DIAZEPAM 10 MG RECTAL GEL SYST No
H4A DIAZEPAM 0 18DIAZEPAM 2.5 MG RECTAL GEL SYS No
H4A DIAZEPAM 0 18DIAZEPAM 20 MG RECTAL GEL SYST No
H4A CLONAZEPAM 0 999KLONOPIN 0.5 MG TABLET Auto PA
H4A CLONAZEPAM 0 999KLONOPIN 1 MG TABLET Auto PA
H4A CLONAZEPAM 0 999KLONOPIN 2 MG TABLET Auto PA
H4A CLOBAZAM 2 999ONFI 10 MG TABLET Auto PA
H4A CLOBAZAM 2 999ONFI 2.5 MG/ML SUSPENSION Auto PA
H4A CLOBAZAM 2 999ONFI 20 MG TABLET Auto PA
Tuesday, May 14, 2019 Page 99 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H4B ANTICONVULSANTSH4B ESLICARBAZEPINE ACETATE 4 999APTIOM 200 MG TABLET Auto PA
H4B ESLICARBAZEPINE ACETATE 4 999APTIOM 400 MG TABLET Auto PA
H4B ESLICARBAZEPINE ACETATE 4 999APTIOM 600 MG TABLET Auto PA
H4B ESLICARBAZEPINE ACETATE 4 999APTIOM 800 MG TABLET Auto PA
H4B RUFINAMIDE 1 999BANZEL 200 MG TABLET Auto PA
H4B RUFINAMIDE 1 999BANZEL 40 MG/ML SUSPENSION Auto PA
H4B RUFINAMIDE 1 999BANZEL 400 MG TABLET Auto PA
H4B BRIVARACETAM 4 999BRIVIACT 10 MG TABLET Auto PA
H4B BRIVARACETAM 4 999BRIVIACT 10 MG/ML ORAL SOLN Auto PA
H4B BRIVARACETAM 4 999BRIVIACT 100 MG TABLET Auto PA
H4B BRIVARACETAM 4 999BRIVIACT 25 MG TABLET Auto PA
H4B BRIVARACETAM 4 999BRIVIACT 50 MG TABLET Auto PA
H4B BRIVARACETAM 16 999BRIVIACT 50 MG/5 ML VIAL Auto PA
H4B BRIVARACETAM 4 999BRIVIACT 75 MG TABLET Auto PA
H4B CARBAMAZEPINE 0 999CARBAMAZEPINE 100 MG TAB CHEW No
H4B CARBAMAZEPINE 0 999CARBAMAZEPINE 100 MG TAB CHW No
H4B CARBAMAZEPINE 0 999CARBAMAZEPINE 100 MG/5 ML SUS No
H4B CARBAMAZEPINE 0 999CARBAMAZEPINE 200 MG TABLET No
H4B CARBAMAZEPINE 0 999CARBAMAZEPINE ER 100 MG CAP No
H4B CARBAMAZEPINE 0 999CARBAMAZEPINE ER 100 MG TABLET No
H4B CARBAMAZEPINE 0 999CARBAMAZEPINE ER 200 MG CAP No
H4B CARBAMAZEPINE 0 999CARBAMAZEPINE ER 200 MG TABLET No
H4B CARBAMAZEPINE 0 999CARBAMAZEPINE ER 300 MG CAP No
Tuesday, May 14, 2019 Page 100 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H4B CARBAMAZEPINE 0 999CARBAMAZEPINE ER 400 MG TABLET No
H4B CARBAMAZEPINE 0 999CARBAMAZEPINE XR 200 MG TABLET No
H4B CARBAMAZEPINE 0 999CARBAMAZEPINE XR 400 MG TABLET No
H4B CARBAMAZEPINE 0 999CARBATROL 100 MG CAPSULE SA Auto PA
H4B CARBAMAZEPINE 0 999CARBATROL 200 MG CAPSULE SA Auto PA
H4B CARBAMAZEPINE 0 999CARBATROL 300 MG CAPSULE SA Auto PA
H4B VALPROIC ACID 0 999DEPAKENE 250 MG CAPSULE Auto PA
H4B VALPROIC ACID (AS SODIUM SALT) 0 999DEPAKENE 250 MG/5 ML SYRUP Auto PA
H4B DIVALPROEX SODIUM 0 999DEPAKOTE 125 MG SPRINKLE CAP Auto PA
H4B DIVALPROEX SODIUM 0 999DEPAKOTE 125 MG TABLET EC Auto PA
H4B DIVALPROEX SODIUM 0 999DEPAKOTE 250 MG TABLET EC Auto PA
H4B DIVALPROEX SODIUM 0 999DEPAKOTE 500 MG TABLET EC Auto PA
H4B DIVALPROEX SODIUM 0 999DEPAKOTE ER 250 MG TAB SA Auto PA
H4B DIVALPROEX SODIUM 0 999DEPAKOTE ER 250 MG TABLET Auto PA
H4B DIVALPROEX SODIUM 0 999DEPAKOTE ER 500 MG TAB SA Auto PA
H4B PHENYTOIN SODIUM EXTENDED 0 999DILANTIN 100 MG CAPSULE Auto PA
H4B PHENYTOIN 0 999DILANTIN 125 MG/5 ML SUSP Auto PA
H4B PHENYTOIN SODIUM EXTENDED 0 999DILANTIN 30 MG CAPSULE Auto PA
H4B PHENYTOIN 0 999DILANTIN 50 MG INFATAB Auto PA
H4B DIVALPROEX SODIUM 0 999DIVALPROEX DR 125 MG CAP SPRNK No
H4B DIVALPROEX SODIUM 0 999DIVALPROEX SOD 125 MG TAB EC No
H4B DIVALPROEX SODIUM 0 999DIVALPROEX SOD 250 MG TAB EC No
H4B DIVALPROEX SODIUM 0 999DIVALPROEX SOD 250 MG TAB ER No
H4B DIVALPROEX SODIUM 0 999DIVALPROEX SOD 500 MG TAB EC No
Tuesday, May 14, 2019 Page 101 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H4B DIVALPROEX SODIUM 0 999DIVALPROEX SOD 500 MG TAB ER No
H4B DIVALPROEX SODIUM 0 999DIVALPROEX SOD DR 125 MG TAB No
H4B DIVALPROEX SODIUM 0 999DIVALPROEX SOD DR 250 MG TAB No
H4B DIVALPROEX SODIUM 0 999DIVALPROEX SOD DR 500 MG TAB No
H4B DIVALPROEX SODIUM 0 999DIVALPROEX SOD ER 250 MG TAB No
H4B DIVALPROEX SODIUM 0 999DIVALPROEX SOD ER 500 MG TAB No
H4B DIVALPROEX SODIUM 0 999DIVALPROEX SODIUM 125 MG CAP No
H4B CARBAMAZEPINE 0 999EPITOL 200 MG TABLET Auto PA
H4B ETHOSUXIMIDE 0 999ETHOSUXIMIDE 250 MG CAPSULE No
H4B ETHOSUXIMIDE 0 999ETHOSUXIMIDE 250 MG/5 ML SOLN No
H4B ETHOSUXIMIDE 0 999ETHOSUXIMIDE 250 MG/5 ML SYRP No
H4B FELBAMATE 0 999FELBAMATE 400 MG TABLET No
H4B FELBAMATE 0 999FELBAMATE 600 MG TABLET No
H4B FELBAMATE 0 999FELBAMATE 600 MG/5 ML SUSP No
H4B FELBAMATE 0 999FELBATOL 400 MG TABLET Auto PA
H4B FELBAMATE 0 999FELBATOL 600 MG TABLET Auto PA
H4B FELBAMATE 0 999FELBATOL 600 MG/5 ML SUSP Auto PA
H4B PERAMPANEL 4 999FYCOMPA 0.5 MG/ML ORAL SUSP Auto PA
H4B PERAMPANEL 4 999FYCOMPA 10 MG TABLET Auto PA
H4B PERAMPANEL 4 999FYCOMPA 12 MG TABLET Auto PA
H4B PERAMPANEL 4 999FYCOMPA 2 MG TABLET Auto PA
H4B PERAMPANEL 4 999FYCOMPA 4 MG TABLET Auto PA
H4B PERAMPANEL 4 999FYCOMPA 6 MG TABLET Auto PA
H4B PERAMPANEL 4 999FYCOMPA 8 MG TABLET Auto PA
Tuesday, May 14, 2019 Page 102 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H4B GABAPENTIN 0 999GABAPENTIN 100 MG CAPSULE No
H4B GABAPENTIN 0 999GABAPENTIN 250 MG/5 ML SOLN No
H4B GABAPENTIN 0 999GABAPENTIN 300 MG CAPSULE No
H4B GABAPENTIN 0 999GABAPENTIN 300 MG/6 ML SOLN No
H4B GABAPENTIN 0 999GABAPENTIN 400 MG CAPSULE No
H4B GABAPENTIN 0 999GABAPENTIN 600 MG TABLET No
H4B GABAPENTIN 0 999GABAPENTIN 800 MG TABLET No
H4B TIAGABINE HCL 0 999GABITRIL 12 MG TABLET Auto PA
H4B TIAGABINE HCL 0 999GABITRIL 16 MG TABLET Auto PA
H4B TIAGABINE HCL 0 999GABITRIL 2 MG TABLET Auto PA
H4B TIAGABINE HCL 0 999GABITRIL 4 MG TABLET Auto PA
H4B LEVETIRACETAM 0 999KEPPRA 1,000 MG TABLET Auto PA
H4B LEVETIRACETAM 0 999KEPPRA 100 MG/ML ORAL SOLN Auto PA
H4B LEVETIRACETAM 0 999KEPPRA 250 MG TABLET Auto PA
H4B LEVETIRACETAM 0 999KEPPRA 500 MG TABLET Auto PA
H4B LEVETIRACETAM 0 999KEPPRA 750 MG TABLET Auto PA
H4B LEVETIRACETAM 0 999KEPPRA XR 500 MG TABLET Auto PA
H4B LEVETIRACETAM 0 999KEPPRA XR 750 MG TABLET Auto PA
H4B LAMOTRIGINE 0 999LAMICTAL 100 MG TABLET Auto PA
H4B LAMOTRIGINE 0 999LAMICTAL 150 MG TABLET Auto PA
H4B LAMOTRIGINE 0 999LAMICTAL 200 MG TABLET Auto PA
H4B LAMOTRIGINE 0 999LAMICTAL 25 MG DISPER TABLET Auto PA
H4B LAMOTRIGINE 0 999LAMICTAL 25 MG TABLET Auto PA
H4B LAMOTRIGINE 0 999LAMICTAL 5 MG DISPER TABLET Auto PA
Tuesday, May 14, 2019 Page 103 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H4B LAMOTRIGINE 0 999LAMICTAL ODT 100 MG TABLET No
H4B LAMOTRIGINE 0 999LAMICTAL ODT 200 MG TABLET No
H4B LAMOTRIGINE 0 999LAMICTAL ODT 25 MG TABLET No
H4B LAMOTRIGINE 0 999LAMICTAL ODT 50 MG TABLET No
H4B LAMOTRIGINE 0 999LAMICTAL ODT START KIT (BLUE) Auto PA
H4B LAMOTRIGINE 0 999LAMICTAL ODT START KIT (GREEN) Auto PA
H4B LAMOTRIGINE 0 999LAMICTAL ODT START KT (ORANGE) Auto PA
H4B LAMOTRIGINE 0 999LAMICTAL TAB START KIT (BLUE) No
H4B LAMOTRIGINE 0 999LAMICTAL TAB START KIT (GREEN) No
H4B LAMOTRIGINE 0 999LAMICTAL TB START KIT (ORANGE) No
H4B LAMOTRIGINE 13 999LAMICTAL XR 100 MG TABLET Auto PA
H4B LAMOTRIGINE 13 999LAMICTAL XR 200 MG TABLET Auto PA
H4B LAMOTRIGINE 13 999LAMICTAL XR 25 MG TABLET Auto PA
H4B LAMOTRIGINE 13 999LAMICTAL XR 250 MG TABLET Auto PA
H4B LAMOTRIGINE 13 999LAMICTAL XR 300 MG TABLET Auto PA
H4B LAMOTRIGINE 13 999LAMICTAL XR 50 MG TABLET Auto PA
H4B LAMOTRIGINE 13 999LAMICTAL XR START KIT (BLUE) Auto PA
H4B LAMOTRIGINE 13 999LAMICTAL XR START KIT (GREEN) Auto PA
H4B LAMOTRIGINE 13 999LAMICTAL XR START KIT (ORANGE) Auto PA
H4B LAMOTRIGINE 0 999LAMOTRIGINE 100 MG TABLET No
H4B LAMOTRIGINE 0 999LAMOTRIGINE 150 MG TABLET No
H4B LAMOTRIGINE 0 999LAMOTRIGINE 200 MG TABLET No
H4B LAMOTRIGINE 0 999LAMOTRIGINE 25 MG DISPER TAB No
H4B LAMOTRIGINE 0 999LAMOTRIGINE 25 MG DISPER TABS No
Tuesday, May 14, 2019 Page 104 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H4B LAMOTRIGINE 0 999LAMOTRIGINE 25 MG TABLET No
H4B LAMOTRIGINE 0 999LAMOTRIGINE 5 MG DISPER TABLET No
H4B LAMOTRIGINE 0 999LAMOTRIGINE ER 100 MG TABLET No
H4B LAMOTRIGINE 13 999LAMOTRIGINE ER 100 MG TABLET No
H4B LAMOTRIGINE 0 999LAMOTRIGINE ER 200 MG TABLET No
H4B LAMOTRIGINE 13 999LAMOTRIGINE ER 200 MG TABLET No
H4B LAMOTRIGINE 13 999LAMOTRIGINE ER 25 MG TABLET No
H4B LAMOTRIGINE 0 999LAMOTRIGINE ER 25 MG TABLET No
H4B LAMOTRIGINE 13 999LAMOTRIGINE ER 250 MG TABLET No
H4B LAMOTRIGINE 0 999LAMOTRIGINE ER 300 MG TABLET No
H4B LAMOTRIGINE 13 999LAMOTRIGINE ER 300 MG TABLET No
H4B LAMOTRIGINE 0 999LAMOTRIGINE ER 50 MG TABLET No
H4B LAMOTRIGINE 13 999LAMOTRIGINE ER 50 MG TABLET No
H4B LAMOTRIGINE 0 999LAMOTRIGINE ODT 100 MG TABLET Auto PA
H4B LAMOTRIGINE 0 999LAMOTRIGINE ODT 200 MG TABLET Auto PA
H4B LAMOTRIGINE 0 999LAMOTRIGINE ODT 25 MG TABLET Auto PA
H4B LAMOTRIGINE 0 999LAMOTRIGINE ODT 50 MG TABLET Auto PA
H4B LAMOTRIGINE 0 999LAMOTRIGINE ODT KIT (BLUE) No
H4B LAMOTRIGINE 0 999LAMOTRIGINE ODT KIT (GREEN) No
H4B LAMOTRIGINE 0 999LAMOTRIGINE ODT KIT (ORANGE) No
H4B LAMOTRIGINE 0 999LAMOTRIGINE TAB START KIT-BLUE Auto PA
H4B LAMOTRIGINE 0 999LAMOTRIGINE TAB START KT-GREEN Auto PA
H4B LAMOTRIGINE 0 999LAMOTRIGINE TAB START KT-ORANG Auto PA
H4B LEVETIRACETAM 0 999LEVETIRACETAM 1,000 MG TABLET No
Tuesday, May 14, 2019 Page 105 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H4B LEVETIRACETAM 0 999LEVETIRACETAM 100 MG/ML SOLN No
H4B LEVETIRACETAM 0 999LEVETIRACETAM 250 MG TABLET No
H4B LEVETIRACETAM 0 999LEVETIRACETAM 500 MG TABLET No
H4B LEVETIRACETAM 0 999LEVETIRACETAM 500 MG/5 ML SOLN No
H4B LEVETIRACETAM 0 999LEVETIRACETAM 500 MG/5 ML VIAL No
H4B LEVETIRACETAM 0 999LEVETIRACETAM 750 MG TABLET No
H4B LEVETIRACETAM 0 999LEVETIRACETAM ER 500 MG TABLET No
H4B LEVETIRACETAM 0 999LEVETIRACETAM ER 750 MG TABLET No
H4B PREGABALIN 0 999LYRICA 100 MG CAPSULE No
H4B PREGABALIN 0 999LYRICA 150 MG CAPSULE No
H4B PREGABALIN 0 999LYRICA 200 MG CAPSULE No
H4B PREGABALIN 0 999LYRICA 225 MG CAPSULE No
H4B PREGABALIN 0 999LYRICA 25 MG CAPSULE No
H4B PREGABALIN 0 999LYRICA 300 MG CAPSULE No
H4B PREGABALIN 0 999LYRICA 50 MG CAPSULE No
H4B PREGABALIN 0 999LYRICA 75 MG CAPSULE No
H4B PRIMIDONE 0 999MYSOLINE 250 MG TABLET Auto PA
H4B PRIMIDONE 0 999MYSOLINE 50 MG TABLET Auto PA
H4B GABAPENTIN 0 999NEURONTIN 100 MG CAPSULE Auto PA
H4B GABAPENTIN 0 999NEURONTIN 250 MG/5 ML SOLN Auto PA
H4B GABAPENTIN 0 999NEURONTIN 300 MG CAPSULE Auto PA
H4B GABAPENTIN 0 999NEURONTIN 400 MG CAPSULE Auto PA
H4B GABAPENTIN 0 999NEURONTIN 600 MG TABLET Auto PA
H4B GABAPENTIN 0 999NEURONTIN 800 MG TABLET Auto PA
Tuesday, May 14, 2019 Page 106 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H4B OXCARBAZEPINE 0 999OXCARBAZEPINE 150 MG TABLET No
H4B OXCARBAZEPINE 0 999OXCARBAZEPINE 300 MG TABLET No
H4B OXCARBAZEPINE 0 999OXCARBAZEPINE 300 MG/5 ML SUSP No
H4B OXCARBAZEPINE 0 999OXCARBAZEPINE 600 MG TABLET No
H4B OXCARBAZEPINE 6 999OXTELLAR XR 150 MG TABLET Auto PA
H4B OXCARBAZEPINE 6 999OXTELLAR XR 300 MG TABLET Auto PA
H4B OXCARBAZEPINE 6 999OXTELLAR XR 600 MG TABLET Auto PA
H4B PHENYTOIN SODIUM EXTENDED 0 999PHENYTEK 200 MG CAPSULE Auto PA
H4B PHENYTOIN SODIUM EXTENDED 0 999PHENYTEK 300 MG CAPSULE Auto PA
H4B PHENYTOIN 0 999PHENYTOIN 125 MG/5 ML SUSP No
H4B PHENYTOIN 0 999PHENYTOIN 125 MG/5 ML SUSPEN No
H4B PHENYTOIN 0 999PHENYTOIN 50 MG INFATAB No
H4B PHENYTOIN 0 999PHENYTOIN 50 MG TABLET CHEW No
H4B PHENYTOIN SODIUM EXTENDED 0 999PHENYTOIN SOD EXT 100 MG CAP No
H4B PHENYTOIN SODIUM EXTENDED 0 999PHENYTOIN SOD EXT 200 MG CAP No
H4B PHENYTOIN SODIUM EXTENDED 0 999PHENYTOIN SOD EXT 300 MG CAP No
H4B PRIMIDONE 0 999PRIMIDONE 250 MG TABLET No
H4B PRIMIDONE 0 999PRIMIDONE 50 MG TABLET No
H4B TOPIRAMATE 0 999QUDEXY XR 100 MG CAPSULE Auto PA
H4B TOPIRAMATE 0 999QUDEXY XR 150 MG CAPSULE Auto PA
H4B TOPIRAMATE 0 999QUDEXY XR 200 MG CAPSULE Auto PA
H4B TOPIRAMATE 0 999QUDEXY XR 25 MG CAPSULE Auto PA
H4B TOPIRAMATE 0 999QUDEXY XR 50 MG CAPSULE Auto PA
H4B LEVETIRACETAM 0 999ROWEEPRA 1,000 MG TABLET Auto PA
Tuesday, May 14, 2019 Page 107 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H4B LEVETIRACETAM 0 999ROWEEPRA 500 MG TABLET Auto PA
H4B LEVETIRACETAM 0 999ROWEEPRA 750 MG TABLET Auto PA
H4B LEVETIRACETAM 0 999ROWEEPRA XR 500 MG TABLET Auto PA
H4B LEVETIRACETAM 0 999ROWEEPRA XR 750 MG TABLET Auto PA
H4B VIGABATRIN 0 999SABRIL 500 MG POWDER PACKET Auto PA
H4B VIGABATRIN 0 999SABRIL 500 MG TABLET Auto PA
H4B LEVETIRACETAM 0 999SPRITAM 1000 MG TABLET Auto PA
H4B LEVETIRACETAM 0 999SPRITAM 250 MG TABLET Auto PA
H4B LEVETIRACETAM 0 999SPRITAM 500 MG TABLET Auto PA
H4B LEVETIRACETAM 0 999SPRITAM 750 MG TABLET Auto PA
H4B LAMOTRIGINE 0 999SUBVENITE 100 MG TABLET Auto PA
H4B LAMOTRIGINE 0 999SUBVENITE 150 MG TABLET Auto PA
H4B LAMOTRIGINE 0 999SUBVENITE 200 MG TABLET Auto PA
H4B LAMOTRIGINE 0 999SUBVENITE 25 MG TABLET Auto PA
H4B LAMOTRIGINE 0 999SUBVENITE TAB START KIT (BLUE) Auto PA
H4B LAMOTRIGINE 0 999SUBVENITE TAB START KIT(GREEN) Auto PA
H4B LAMOTRIGINE 0 999SUBVENITE TAB START KT(ORANGE) Auto PA
H4B CARBAMAZEPINE 0 999TEGRETOL 100 MG/5 ML SUSP Auto PA
H4B CARBAMAZEPINE 0 999TEGRETOL 200 MG TABLET Auto PA
H4B CARBAMAZEPINE 0 999TEGRETOL XR 100 MG TABLET SA Auto PA
H4B CARBAMAZEPINE 0 999TEGRETOL XR 200 MG TABLET SA Auto PA
H4B CARBAMAZEPINE 0 999TEGRETOL XR 400 MG TABLET SA Auto PA
H4B TIAGABINE HCL 0 999TIAGABINE HCL 12 MG TABLET No
H4B TIAGABINE HCL 0 999TIAGABINE HCL 16 MG TABLET No
Tuesday, May 14, 2019 Page 108 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H4B TIAGABINE HCL 0 999TIAGABINE HCL 2 MG TABLET No
H4B TIAGABINE HCL 0 999TIAGABINE HCL 4 MG TABLET No
H4B TOPIRAMATE 0 999TOPAMAX 100 MG TABLET Auto PA
H4B TOPIRAMATE 0 999TOPAMAX 15 MG SPRINKLE CAP Auto PA
H4B TOPIRAMATE 0 999TOPAMAX 200 MG TABLET Auto PA
H4B TOPIRAMATE 0 999TOPAMAX 25 MG SPRINKLE CAP Auto PA
H4B TOPIRAMATE 0 999TOPAMAX 25 MG TABLET Auto PA
H4B TOPIRAMATE 0 999TOPAMAX 50 MG TABLET Auto PA
H4B TOPIRAMATE 0 999TOPIRAMATE 100 MG TABLET No
H4B TOPIRAMATE 0 999TOPIRAMATE 15 MG SPRINKLE CAP No
H4B TOPIRAMATE 0 999TOPIRAMATE 200 MG TABLET No
H4B TOPIRAMATE 0 999TOPIRAMATE 25 MG SPRINKLE CAP No
H4B TOPIRAMATE 0 999TOPIRAMATE 25 MG TABLET No
H4B TOPIRAMATE 0 999TOPIRAMATE 50 MG TABLET No
H4B TOPIRAMATE 0 999TOPIRAMATE ER 100 MG CAPSULE No
H4B TOPIRAMATE 0 999TOPIRAMATE ER 150 MG CAPSULE No
H4B TOPIRAMATE 0 999TOPIRAMATE ER 200 MG CAPSULE No
H4B TOPIRAMATE 0 999TOPIRAMATE ER 25 MG CAPSULE No
H4B TOPIRAMATE 0 999TOPIRAMATE ER 50 MG CAPSULE No
H4B OXCARBAZEPINE 0 999TRILEPTAL 150 MG TABLET Auto PA
H4B OXCARBAZEPINE 0 999TRILEPTAL 300 MG TABLET Auto PA
H4B OXCARBAZEPINE 0 999TRILEPTAL 300 MG/5 ML SUSP Auto PA
H4B OXCARBAZEPINE 0 999TRILEPTAL 600 MG TABLET Auto PA
H4B TOPIRAMATE 6 999TROKENDI XR 100 MG CAPSULE Auto PA
Tuesday, May 14, 2019 Page 109 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H4B TOPIRAMATE 6 999TROKENDI XR 200 MG CAPSULE Auto PA
H4B TOPIRAMATE 6 999TROKENDI XR 25 MG CAPSULE Auto PA
H4B TOPIRAMATE 6 999TROKENDI XR 50 MG CAPSULE Auto PA
H4B VALPROIC ACID 0 999VALPROIC ACID 250 MG CAPSULE No
H4B VALPROIC ACID (AS SODIUM SALT) 0 999VALPROIC ACID 250 MG/5 ML SOL No
H4B VALPROIC ACID (AS SODIUM SALT) 0 999VALPROIC ACID 250 MG/5 ML SOLN No
H4B VALPROIC ACID (AS SODIUM SALT) 0 999VALPROIC ACID 250 MG/5 ML SYR No
H4B VALPROIC ACID (AS SODIUM SALT) 0 999VALPROIC ACID 500 MG/10 ML SOL No
H4B VIGABATRIN 0 999VIGABATRIN 500 MG POWDER PACKT Requires Med Cert 3
H4B VIGABATRIN 0 999VIGABATRIN 500 MG TABLET Requires Med Cert 3
H4B VIGABATRIN 0 999VIGADRONE 500 MG POWDER PACKET Auto PA
H4B LACOSAMIDE 0 999VIMPAT 10 MG/ML SOLUTION Auto PA
H4B LACOSAMIDE 0 999VIMPAT 100 MG TABLET Auto PA
H4B LACOSAMIDE 0 999VIMPAT 150 MG TABLET Auto PA
H4B LACOSAMIDE 0 999VIMPAT 200 MG TABLET Auto PA
H4B LACOSAMIDE 0 999VIMPAT 50 MG TABLET Auto PA
H4B LACOSAMIDE 0 999VIMPAT STARTER KIT Auto PA
H4B ETHOSUXIMIDE 0 999ZARONTIN 250 MG CAPSULE Auto PA
H4B ETHOSUXIMIDE 0 999ZARONTIN 250 MG/5 ML SYRUP Auto PA
H4B ZONISAMIDE 0 999ZONISAMIDE 100 MG CAPSULE No
H4B ZONISAMIDE 0 999ZONISAMIDE 25 MG CAPSULE No
H4B ZONISAMIDE 0 999ZONISAMIDE 50 MG CAPSULE No
H6A ANTIPARKINSONISM DRUGS,OTHERH6A AMANTADINE HCL 1 999AMANTADINE 100 MG CAPSULE No
Tuesday, May 14, 2019 Page 110 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H6A AMANTADINE HCL 1 999AMANTADINE 100 MG TABLET No
H6A AMANTADINE HCL 1 999AMANTADINE 100 MG/10 ML SOLN No
H6A AMANTADINE HCL 1 999AMANTADINE 50 MG/5 ML SYRUP No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA/LEVO 10/100 TAB No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA/LEVO 25/100 TAB No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA/LEVO 25/100 TAB No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA/LEVO 25/100 TABLET No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA/LEVO 25/100 TB SA No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA/LEVO 25/250 TAB No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA/LEVO 25/250 TABLET No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA/LEVO 50/200 TB SA No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVO 10-100 MG ODT No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVO 10-100 TAB No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVO 25-100 ER TAB No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVO 25-100 MG ODT No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVO 25-100 TAB No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVO 25-100 TAB SA No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVO 25-250 TAB No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVO 50-200 ER TAB No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVO 50-200 TAB SA No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVO ER 25-100 TAB No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVO ER 50-200 TAB No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVODOPA 10-100 TAB No
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVODOPA 25-100 TAB No
Tuesday, May 14, 2019 Page 111 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H6A CARBIDOPA/LEVODOPA 18 999CARBIDOPA-LEVODOPA 25-250 TAB No
H6A CARBIDOPA/LEVODOPA/ENTACAPONE 18 999CARBIDOPA-LEVODOPA-ENTA 100 MG No
H6A CARBIDOPA/LEVODOPA/ENTACAPONE 18 999CARBIDOPA-LEVODOPA-ENTA 125 MG No
H6A CARBIDOPA/LEVODOPA/ENTACAPONE 18 999CARBIDOPA-LEVODOPA-ENTA 150 MG No
H6A CARBIDOPA/LEVODOPA/ENTACAPONE 18 999CARBIDOPA-LEVODOPA-ENTA 200 MG No
H6A CARBIDOPA/LEVODOPA/ENTACAPONE 18 999CARBIDOPA-LEVODOPA-ENTA 50 MG No
H6A CARBIDOPA/LEVODOPA/ENTACAPONE 18 999CARBIDOPA-LEVODOPA-ENTA 75 MG No
H6A PRAMIPEXOLE DI-HCL 18 999PRAMIPEXOLE 0.125 MG TABLET No
H6A PRAMIPEXOLE DI-HCL 18 999PRAMIPEXOLE 0.25 MG TABLET No
H6A PRAMIPEXOLE DI-HCL 18 999PRAMIPEXOLE 0.5 MG TABLET No
H6A PRAMIPEXOLE DI-HCL 18 999PRAMIPEXOLE 0.75 MG TABLET No
H6A PRAMIPEXOLE DI-HCL 18 999PRAMIPEXOLE 1 MG TABLET No
H6A PRAMIPEXOLE DI-HCL 18 999PRAMIPEXOLE 1.5 MG TABLET No
H6A ROPINIROLE HCL 18 999ROPINIROLE HCL 0.25 MG TABLET No
H6A ROPINIROLE HCL 18 999ROPINIROLE HCL 0.5 MG TABLET No
H6A ROPINIROLE HCL 18 999ROPINIROLE HCL 1 MG TABLET No
H6A ROPINIROLE HCL 18 999ROPINIROLE HCL 2 MG TABLET No
H6A ROPINIROLE HCL 18 999ROPINIROLE HCL 3 MG TABLET No
H6A ROPINIROLE HCL 18 999ROPINIROLE HCL 4 MG TABLET No
H6A ROPINIROLE HCL 18 999ROPINIROLE HCL 5 MG TABLET No
H6A SELEGILINE HCL 18 999SELEGILINE HCL 5 MG CAPSULE No
H6A SELEGILINE HCL 18 999SELEGILINE HCL 5 MG TABLET No
H6B ANTIPARKINSONISM DRUGS,ANTICHOLINERGICH6B BENZTROPINE MESYLATE 3 999BENZTROPINE MES 0.5 MG TAB No
Tuesday, May 14, 2019 Page 112 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H6B BENZTROPINE MESYLATE 3 999BENZTROPINE MES 1 MG TABLET No
H6B BENZTROPINE MESYLATE 3 999BENZTROPINE MES 2 MG TABLET No
H6B TRIHEXYPHENIDYL HCL 18 999TRIHEXYPHENIDYL 2 MG TABLET No
H6B TRIHEXYPHENIDYL HCL 18 999TRIHEXYPHENIDYL 2 MG/5 ML ELX No
H6B TRIHEXYPHENIDYL HCL 18 999TRIHEXYPHENIDYL 5 MG TABLET No
H6C ANTITUSSIVES, NON-OPIOIDH6C BENZONATATE 0 20BENZONATATE 100 MG CAPSULE No
H6C BENZONATATE 0 20BENZONATATE 150 MG CAPSULE No
H6C BENZONATATE 0 20BENZONATATE 200 MG CAPSULE No
H6H SKELETAL MUSCLE RELAXANTSH6H BACLOFEN 0 999BACLOFEN 10 MG TABLET No
H6H BACLOFEN 0 999BACLOFEN 20 MG TABLET No
H6H BACLOFEN 0 999BACLOFEN 5 MG TABLET No
H6H CHLORZOXAZONE 0 999CHLORZOXAZONE 500 MG TABLET No
H6H CYCLOBENZAPRINE HCL 0 999CYCLOBENZAPRINE 10 MG TABLET No
H6H CYCLOBENZAPRINE HCL 0 999CYCLOBENZAPRINE 5 MG TABLET No
H6H CYCLOBENZAPRINE HCL 0 999CYCLOBENZAPRINE 7.5 MG TABLET No
H6H METHOCARBAMOL 0 999METHOCARBAMOL 500 MG TABLET No
H6H METHOCARBAMOL 0 999METHOCARBAMOL 750 MG TABLET No
H6H TIZANIDINE HCL 0 999TIZANIDINE HCL 2 MG TABLET No
H6H TIZANIDINE HCL 0 999TIZANIDINE HCL 4 MG TABLET No
H6I AMYOTROPHIC LATERAL SCLEROSIS AGENTSH6I RILUZOLE 0 999RILUZOLE 50 MG TABLET No
H6I RILUZOLE 0 999RILUZOLE 50MG TABLET No
H6J ANTIEMETIC/ANTIVERTIGO AGENTS
Tuesday, May 14, 2019 Page 113 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H6J DOXYLAMINE SUCCINATE/VIT B6 18 999DICLEGIS DR 10-10 MG TABLET No
H6J APREPITANT 0 999EMEND 125 MG CAPSULE No
H6J APREPITANT 0 999EMEND 40 MG CAPSULE No
H6J APREPITANT 0 999EMEND 80 MG CAPSULE No
H6J GRANISETRON HCL 0 999GRANISETRON HCL 1 MG TABLET No
H6J MECLIZINE HCL 0 999MECLIZINE 12.5 MG TABLET No
H6J MECLIZINE HCL 0 999MECLIZINE 25 MG TABLET No
H6J ONDANSETRON HCL 0 999ONDANSETRON 4 MG TABLET No
H6J ONDANSETRON HCL/PF 0 999ONDANSETRON 4 MG/2 ML ISECURE No
H6J ONDANSETRON HCL 0 999ONDANSETRON 4 MG/5 ML SOLN No
H6J ONDANSETRON HCL 0 999ONDANSETRON 4 MG/5 ML SOLUTION No
H6J ONDANSETRON HCL 0 999ONDANSETRON 40 MG/20 ML VIAL No
H6J ONDANSETRON HCL 0 999ONDANSETRON 8 MG TABLET No
H6J ONDANSETRON HCL/PF 0 999ONDANSETRON HCL No
H6J ONDANSETRON HCL 0 999ONDANSETRON HCL 2 MG/ML VIAL No
H6J ONDANSETRON HCL 0 999ONDANSETRON HCL 4 MG TABLET No
H6J ONDANSETRON HCL/PF 0 999ONDANSETRON HCL 4 MG/2 ML SYR No
H6J ONDANSETRON HCL/PF 0 999ONDANSETRON HCL 4 MG/2 ML VIAL No
H6J ONDANSETRON HCL 0 999ONDANSETRON HCL 8 MG TABLET No
H6J ONDANSETRON 0 999ONDANSETRON ODT 4 MG TABLET No
H6J ONDANSETRON 0 999ONDANSETRON ODT 8 MG TABLET No
H6J PROCHLORPERAZINE MALEATE 0 999PROCHLORPERAZINE 10 MG TAB No
H6J PROCHLORPERAZINE MALEATE 0 999PROCHLORPERAZINE 5 MG TABLET No
H6J PROMETHAZINE HCL 0 999PROMETHAZINE 12.5 MG SUPPOS No
Tuesday, May 14, 2019 Page 114 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H6J PROMETHAZINE HCL 0 999PROMETHAZINE 25 MG SUPPOS No
H6J PROMETHAZINE HCL 0 999PROMETHAZINE 25 MG SUPPOSITORY No
H6J PROMETHAZINE HCL 0 999PROMETHEGAN 12.5 MG SUPPOS No
H6J PROMETHAZINE HCL 0 999PROMETHEGAN 25 MG SUPPOSITORY No
H6J PROMETHAZINE HCL 0 999PROMETHEGAN 50 MG SUPPOS No
H6J PROMETHAZINE HCL 0 999PROMETHEGAN 50 MG SUPPOSITORY No
H6J SCOPOLAMINE 18 999TRANSDERM-SCOP 1.5 MG/3 DAY Auto PA
H6L DRUGS TO TREAT MOVEMENT DISORDERSH6L DEUTETRABENAZINE 18 999AUSTEDO 12 MG TABLET Auto PA
H6L DEUTETRABENAZINE 18 999AUSTEDO 6 MG TABLET Auto PA
H6L DEUTETRABENAZINE 18 999AUSTEDO 9 MG TABLET Auto PA
H6L TETRABENAZINE 18 999TETRABENAZINE 12.5 MG TABLET Auto PA
H6L TETRABENAZINE 18 999TETRABENAZINE 25 MG TABLET Auto PA
H7B ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTSH7B MIRTAZAPINE 6 999MIRTAZAPINE 15 MG ODT No
H7B MIRTAZAPINE 6 999MIRTAZAPINE 15 MG RPD DISLV TB No
H7B MIRTAZAPINE 6 999MIRTAZAPINE 15 MG TABLET No
H7B MIRTAZAPINE 6 999MIRTAZAPINE 30 MG ODT No
H7B MIRTAZAPINE 6 999MIRTAZAPINE 30 MG RPD DISLV TB No
H7B MIRTAZAPINE 6 999MIRTAZAPINE 30 MG TABLET No
H7B MIRTAZAPINE 6 999MIRTAZAPINE 45 MG ODT No
H7B MIRTAZAPINE 6 999MIRTAZAPINE 45 MG RPD DISLV TB No
H7B MIRTAZAPINE 6 999MIRTAZAPINE 45 MG TABLET No
H7B MIRTAZAPINE 6 999MIRTAZAPINE 7.5 MG TABLET No
H7C SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)
Tuesday, May 14, 2019 Page 115 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H7C DESVENLAFAXINE SUCCINATE 18 999DESVENLAFAXINE SUC ER 100 MG No
H7C DESVENLAFAXINE SUCCINATE 18 999DESVENLAFAXINE SUC ER 25 MG TB No
H7C DESVENLAFAXINE SUCCINATE 18 999DESVENLAFAXINE SUC ER 50 MG TB No
H7C DULOXETINE HCL 6 999DULOXETINE HCL DR 20 MG CAP No
H7C DULOXETINE HCL 6 999DULOXETINE HCL DR 30 MG CAP No
H7C DULOXETINE HCL 6 999DULOXETINE HCL DR 40 MG CAP No
H7C DULOXETINE HCL 6 999DULOXETINE HCL DR 60 MG CAP No
H7C VENLAFAXINE HCL 6 999VENLAFAXINE HCL 100 MG TABLET No
H7C VENLAFAXINE HCL 6 999VENLAFAXINE HCL 25 MG TABLET No
H7C VENLAFAXINE HCL 6 999VENLAFAXINE HCL 37.5 MG TABLET No
H7C VENLAFAXINE HCL 6 999VENLAFAXINE HCL 50 MG TABLET No
H7C VENLAFAXINE HCL 6 999VENLAFAXINE HCL 75 MG TABLET No
H7C VENLAFAXINE HCL 6 999VENLAFAXINE HCL ER 150 MG CAP No
H7C VENLAFAXINE HCL 6 999VENLAFAXINE HCL ER 37.5 MG CAP No
H7C VENLAFAXINE HCL 6 999VENLAFAXINE HCL ER 75 MG CAP No
H7D NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS)H7D BUPROPION HCL 6 999BUPROPION HCL 100 MG TABLET No
H7D BUPROPION HCL 6 999BUPROPION HCL 75 MG TABLET No
H7D BUPROPION HCL 6 999BUPROPION HCL ER 100 MG TAB No
H7D BUPROPION HCL 6 999BUPROPION HCL ER 200 MG TAB No
H7D BUPROPION HCL 6 999BUPROPION HCL SR 100 MG TAB No
H7D BUPROPION HCL 6 999BUPROPION HCL SR 100 MG TABLET No
H7D BUPROPION HCL 6 999BUPROPION HCL SR 150 MG TABLET No
H7D BUPROPION HCL 6 999BUPROPION HCL SR 200 MG TAB No
Tuesday, May 14, 2019 Page 116 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H7D BUPROPION HCL 6 999BUPROPION HCL SR 200 MG TABLET No
H7D BUPROPION HCL 6 999BUPROPION HCL XL 150 MG TABLET No
H7D BUPROPION HCL 6 999BUPROPION HCL XL 300 MG TABLET No
H7D BUPROPION HCL 18 999BUPROPION HCL XL 450 MG TABLET No
H7D BUPROPION HCL 6 999BUPROPION SR 150 MG TABLET No
H7E SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS)H7E TRAZODONE HCL 6 999TRAZODONE 100 MG TABLET No
H7E TRAZODONE HCL 6 999TRAZODONE 150 MG TABLET No
H7E TRAZODONE HCL 6 999TRAZODONE 300 MG TABLET No
H7E TRAZODONE HCL 6 999TRAZODONE 50 MG TABLET No
H7N SMOKING DETERRENTS, OTHERH7N BUPROPION HCL 18 999BUPROPION SR 150 MG TABLET No
H7O ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONESH7O DROPERIDOL 18 999DROPERIDOL 2.5 MG/ML AMPUL No
H7O DROPERIDOL 18 999DROPERIDOL 2.5 MG/ML VIAL No
H7O HALOPERIDOL 6 999HALOPERIDOL 0.5 MG TABLET No
H7O HALOPERIDOL 6 999HALOPERIDOL 1 MG TABLET No
H7O HALOPERIDOL 6 999HALOPERIDOL 10 MG TABLET No
H7O HALOPERIDOL 6 999HALOPERIDOL 2 MG TABLET No
H7O HALOPERIDOL 6 999HALOPERIDOL 20 MG TABLET No
H7O HALOPERIDOL 6 999HALOPERIDOL 5 MG TABLET No
H7O HALOPERIDOL LACTATE 18 999HALOPERIDOL 5 MG/ML AMPUL No
H7O HALOPERIDOL DECANOATE 18 999HALOPERIDOL DEC 100 MG/ML AMP No
H7O HALOPERIDOL DECANOATE 18 999HALOPERIDOL DEC 100 MG/ML AMP No
H7O HALOPERIDOL DECANOATE 18 999HALOPERIDOL DEC 100 MG/ML VIAL No
Tuesday, May 14, 2019 Page 117 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H7O HALOPERIDOL DECANOATE 18 999HALOPERIDOL DEC 100 MG/ML VL No
H7O HALOPERIDOL DECANOATE 18 999HALOPERIDOL DEC 50 MG/ML VIAL No
H7O HALOPERIDOL DECANOATE 18 999HALOPERIDOL DEC 50 MG/ML VL No
H7O HALOPERIDOL DECANOATE 18 999HALOPERIDOL DEC 500 MG/5 ML VL No
H7O HALOPERIDOL DECANOATE 18 999HALOPERIDOL DECAN 50 MG/ML AMP No
H7O HALOPERIDOL LACTATE 6 999HALOPERIDOL LAC 2 MG/ML CONC No
H7O HALOPERIDOL LACTATE 18 999HALOPERIDOL LAC 5 MG/ML VIAL No
H7O HALOPERIDOL LACTATE 18 999HALOPERIDOL LAC 50 MG/10 ML VL No
H7P ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENESH7P THIOTHIXENE 18 999THIOTHIXENE 1 MG CAPSULE No
H7P THIOTHIXENE 18 999THIOTHIXENE 10 MG CAPSULE No
H7P THIOTHIXENE 18 999THIOTHIXENE 2 MG CAPSULE No
H7P THIOTHIXENE 18 999THIOTHIXENE 5 MG CAPSULE No
H7R ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINESH7R PIMOZIDE 18 999PIMOZIDE 1 MG TABLET No
H7R PIMOZIDE 18 999PIMOZIDE 2 MG TABLET No
H7T ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNSTH7T CLOZAPINE 6 999CLOZAPINE 100 MG TABLET Requires Med Cert 3
H7T CLOZAPINE 6 999CLOZAPINE 200 MG TABLET Requires Med Cert 3
H7T CLOZAPINE 6 999CLOZAPINE 25 MG TABLET Requires Med Cert 3
H7T CLOZAPINE 6 999CLOZAPINE 50 MG TABLET Requires Med Cert 3
H7T CLOZAPINE 6 999CLOZAPINE ODT 100 MG TABLET Requires Med Cert 3
H7T CLOZAPINE 6 999CLOZAPINE ODT 12.5 MG TABLET Requires Med Cert 3
H7T CLOZAPINE 6 999CLOZAPINE ODT 150 MG TABLET Requires Med Cert 3
H7T CLOZAPINE 6 999CLOZAPINE ODT 200 MG TABLET Requires Med Cert 3
Tuesday, May 14, 2019 Page 118 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H7T CLOZAPINE 6 999CLOZAPINE ODT 25 MG TABLET Requires Med Cert 3
H7T CLOZAPINE 6 999CLOZARIL 100 MG TABLET Requires Med Cert 3
H7T CLOZAPINE 6 999CLOZARIL 25 MG TABLET Requires Med Cert 3
H7T PALIPERIDONE PALMITATE 18 999INVEGA SUSTENNA 117 MG PREF SY Auto PA
H7T PALIPERIDONE PALMITATE 18 999INVEGA SUSTENNA 156 MG PREF SY Auto PA
H7T PALIPERIDONE PALMITATE 18 999INVEGA SUSTENNA 156 MG/ML SYRG Auto PA
H7T PALIPERIDONE PALMITATE 18 999INVEGA SUSTENNA 234 MG PREF SY Auto PA
H7T PALIPERIDONE PALMITATE 18 999INVEGA SUSTENNA 39 MG PREF SYR Auto PA
H7T PALIPERIDONE PALMITATE 18 999INVEGA SUSTENNA 78 MG PREF SYR Auto PA
H7T PALIPERIDONE PALMITATE 18 999INVEGA TRINZA 273 MG/0.875 ML Auto PA
H7T PALIPERIDONE PALMITATE 18 999INVEGA TRINZA 410 MG/1.315 ML Auto PA
H7T PALIPERIDONE PALMITATE 18 999INVEGA TRINZA 546 MG/1.75 ML Auto PA
H7T PALIPERIDONE PALMITATE 18 999INVEGA TRINZA 819 MG/2.625 ML Auto PA
H7T LURASIDONE HCL 10 999LATUDA 120 MG TABLET No
H7T LURASIDONE HCL 10 999LATUDA 20 MG TABLET No
H7T LURASIDONE HCL 10 999LATUDA 40 MG TABLET No
H7T LURASIDONE HCL 10 999LATUDA 60 MG TABLET No
H7T LURASIDONE HCL 10 999LATUDA 80 MG TABLET No
H7T OLANZAPINE 6 999OLANZAPINE 10 MG TABLET No
H7T OLANZAPINE 6 999OLANZAPINE 15 MG TABLET No
H7T OLANZAPINE 6 999OLANZAPINE 2.5 MG TABLET No
H7T OLANZAPINE 6 999OLANZAPINE 20 MG TABLET No
H7T OLANZAPINE 6 999OLANZAPINE 5 MG TABLET No
H7T OLANZAPINE 6 999OLANZAPINE 7.5 MG TABLET No
Tuesday, May 14, 2019 Page 119 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H7T OLANZAPINE 6 999OLANZAPINE ODT 10 MG TABLET No
H7T OLANZAPINE 6 999OLANZAPINE ODT 15 MG TABLET No
H7T OLANZAPINE 6 999OLANZAPINE ODT 20 MG TABLET No
H7T OLANZAPINE 6 999OLANZAPINE ODT 5 MG TABLET No
H7T RISPERIDONE 18 999PERSERIS ER 120 MG SYRINGE KIT Auto PA
H7T RISPERIDONE 18 999PERSERIS ER 90 MG SYRINGE KIT Auto PA
H7T QUETIAPINE FUMARATE 6 999QUETIAPINE ER 150 MG TABLET No
H7T QUETIAPINE FUMARATE 6 999QUETIAPINE ER 200 MG TABLET No
H7T QUETIAPINE FUMARATE 6 999QUETIAPINE ER 300 MG TABLET No
H7T QUETIAPINE FUMARATE 6 999QUETIAPINE ER 400 MG TABLET No
H7T QUETIAPINE FUMARATE 6 999QUETIAPINE ER 50 MG TABLET No
H7T QUETIAPINE FUMARATE 6 999QUETIAPINE FUMARATE 100 MG TAB No
H7T QUETIAPINE FUMARATE 6 999QUETIAPINE FUMARATE 200 MG TAB No
H7T QUETIAPINE FUMARATE 6 999QUETIAPINE FUMARATE 25 MG TAB No
H7T QUETIAPINE FUMARATE 6 999QUETIAPINE FUMARATE 300 MG TAB No
H7T QUETIAPINE FUMARATE 6 999QUETIAPINE FUMARATE 400 MG TAB No
H7T QUETIAPINE FUMARATE 6 999QUETIAPINE FUMARATE 50 MG TAB No
H7T RISPERIDONE MICROSPHERES 18 999RISPERDAL CONSTA 12.5 MG SYR Auto PA
H7T RISPERIDONE MICROSPHERES 18 999RISPERDAL CONSTA 25 MG SYR Auto PA
H7T RISPERIDONE MICROSPHERES 18 999RISPERDAL CONSTA 37.5 MG SYR Auto PA
H7T RISPERIDONE MICROSPHERES 18 999RISPERDAL CONSTA 50 MG SYR Auto PA
H7T RISPERIDONE 6 999RISPERIDONE 0.25 MG ODT No
H7T RISPERIDONE 6 999RISPERIDONE 0.25 MG TABLET No
H7T RISPERIDONE 6 999RISPERIDONE 0.5 MG ODT No
Tuesday, May 14, 2019 Page 120 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H7T RISPERIDONE 6 999RISPERIDONE 0.5 MG TABLET No
H7T RISPERIDONE 6 999RISPERIDONE 1 MG ODT No
H7T RISPERIDONE 6 999RISPERIDONE 1 MG TABLET No
H7T RISPERIDONE 6 999RISPERIDONE 1 MG/ML SOLUTION No
H7T RISPERIDONE 6 999RISPERIDONE 2 MG ODT No
H7T RISPERIDONE 6 999RISPERIDONE 2 MG TABLET No
H7T RISPERIDONE 6 999RISPERIDONE 3 MG ODT No
H7T RISPERIDONE 6 999RISPERIDONE 3 MG TABLET No
H7T RISPERIDONE 6 999RISPERIDONE 4 MG ODT No
H7T RISPERIDONE 6 999RISPERIDONE 4 MG TABLET No
H7T ZIPRASIDONE HCL 6 999ZIPRASIDONE HCL 20 MG CAPSULE No
H7T ZIPRASIDONE HCL 6 999ZIPRASIDONE HCL 40 MG CAPSULE No
H7T ZIPRASIDONE HCL 6 999ZIPRASIDONE HCL 60 MG CAPSULE No
H7T ZIPRASIDONE HCL 6 999ZIPRASIDONE HCL 80 MG CAPSULE No
H7U ANTIPSYCHOTICS, DOPAMINE AND SEROTONIN ANTAGONISTSH7U LOXAPINE SUCCINATE 18 999LOXAPINE 10 MG CAPSULE No
H7U LOXAPINE SUCCINATE 18 999LOXAPINE 25 MG CAPSULE No
H7U LOXAPINE SUCCINATE 18 999LOXAPINE 5 MG CAPSULE No
H7U LOXAPINE SUCCINATE 18 999LOXAPINE 50 MG CAPSULE No
H7U LOXAPINE SUCCINATE 18 999LOXAPINE SUCCINATE 10 MG CAP No
H7U LOXAPINE SUCCINATE 18 999LOXAPINE SUCCINATE 25 MG CAP No
H7U LOXAPINE SUCCINATE 18 999LOXAPINE SUCCINATE 5 MG CAP No
H7U LOXAPINE SUCCINATE 18 999LOXAPINE SUCCINATE 50 MG CAP No
H7X ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED
Tuesday, May 14, 2019 Page 121 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H7X ARIPIPRAZOLE 18 999ABILIFY MAINTENA ER 300 MG SYR Auto PA
H7X ARIPIPRAZOLE 18 999ABILIFY MAINTENA ER 300 MG VL Auto PA
H7X ARIPIPRAZOLE 18 999ABILIFY MAINTENA ER 400 MG SYR Auto PA
H7X ARIPIPRAZOLE 18 999ABILIFY MAINTENA ER 400 MG VL Auto PA
H7X ARIPIPRAZOLE 6 999ARIPIPRAZOLE 1 MG/ML SOLUTION No
H7X ARIPIPRAZOLE 6 999ARIPIPRAZOLE 10 MG TABLET No
H7X ARIPIPRAZOLE 6 999ARIPIPRAZOLE 15 MG TABLET No
H7X ARIPIPRAZOLE 6 999ARIPIPRAZOLE 2 MG TABLET No
H7X ARIPIPRAZOLE 6 999ARIPIPRAZOLE 20 MG TABLET No
H7X ARIPIPRAZOLE 6 999ARIPIPRAZOLE 30 MG TABLET No
H7X ARIPIPRAZOLE 6 999ARIPIPRAZOLE 5 MG TABLET No
H7X ARIPIPRAZOLE 6 999ARIPIPRAZOLE ODT 10 MG TABLET No
H7X ARIPIPRAZOLE 6 999ARIPIPRAZOLE ODT 15 MG TABLET No
H7X ARIPIPRAZOLE LAUROXIL 18 999ARISTADA ER 1064 MG/3.9 ML SYR Auto PA
H7X ARIPIPRAZOLE LAUROXIL 18 999ARISTADA ER 441 MG/1.6 ML SYRN Auto PA
H7X ARIPIPRAZOLE LAUROXIL 18 999ARISTADA ER 662 MG/2.4 ML SYRN Auto PA
H7X ARIPIPRAZOLE LAUROXIL 18 999ARISTADA ER 882 MG/3.2 ML SYRN Auto PA
H7Y TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPEH7Y ATOMOXETINE HCL 6 999ATOMOXETINE HCL 10 MG CAPSULE No
H7Y ATOMOXETINE HCL 6 999ATOMOXETINE HCL 100 MG CAPSULE No
H7Y ATOMOXETINE HCL 6 999ATOMOXETINE HCL 18 MG CAPSULE No
H7Y ATOMOXETINE HCL 6 999ATOMOXETINE HCL 25 MG CAPSULE No
H7Y ATOMOXETINE HCL 6 999ATOMOXETINE HCL 40 MG CAPSULE No
H7Y ATOMOXETINE HCL 6 999ATOMOXETINE HCL 60 MG CAPSULE No
Tuesday, May 14, 2019 Page 122 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
H7Y ATOMOXETINE HCL 6 999ATOMOXETINE HCL 80 MG CAPSULE No
H8B HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTSH8B RAMELTEON 65 999ROZEREM 8 MG TABLET No
H8M TX FOR ADHD - SELECTIVE ALPHA-2 RECEPTOR AGONISTH8M GUANFACINE HCL 0 999GUANFACINE HCL ER 1 MG TABLET No
H8M GUANFACINE HCL 0 999GUANFACINE HCL ER 2 MG TABLET No
H8M GUANFACINE HCL 0 999GUANFACINE HCL ER 3 MG TABLET No
H8M GUANFACINE HCL 0 999GUANFACINE HCL ER 4 MG TABLET No
H8P SSRI AND 5HT1A PARTIAL AGONIST ANTIDEPRESSANTSH8P VILAZODONE HCL 18 999VIIBRYD 10 MG TABLET No
H8P VILAZODONE HCL 18 999VIIBRYD 20 MG TABLET No
H8P VILAZODONE HCL 18 999VIIBRYD 40 MG TABLET No
H8Q NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTSH8Q MODAFINIL 18 999MODAFINIL 100 MG TABLET Auto PA
H8Q MODAFINIL 18 999MODAFINIL 200 MG TABLET Auto PA
H8T SSRI, SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANTSH8T VORTIOXETINE HYDROBROMIDE 18 999TRINTELLIX 10 MG TABLET Auto PA
H8T VORTIOXETINE HYDROBROMIDE 18 999TRINTELLIX 20 MG TABLET Auto PA
H8T VORTIOXETINE HYDROBROMIDE 18 999TRINTELLIX 5 MG TABLET Auto PA
J1A PARASYMPATHETIC AGENTSJ1A BETHANECHOL CHLORIDE 0 999BETHANECHOL 10 MG TABLET No
J1A BETHANECHOL CHLORIDE 0 999BETHANECHOL 25 MG TABLET No
J1A BETHANECHOL CHLORIDE 0 999BETHANECHOL 5 MG TABLET No
J1A BETHANECHOL CHLORIDE 0 999BETHANECHOL 50 MG TABLET No
J1A GUANIDINE HCL 0 999GUANIDINE HCL 125 MG TABLET No
J1A PILOCARPINE HCL 0 999PILOCARPINE HCL 5 MG TABLET No
Tuesday, May 14, 2019 Page 123 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
J1A PILOCARPINE HCL 0 999PILOCARPINE HCL 7.5 MG TABLET No
J1B CHOLINESTERASE INHIBITORSJ1B DONEPEZIL HCL 18 999DONEPEZIL HCL 10 MG TABLET No
J1B DONEPEZIL HCL 18 999DONEPEZIL HCL 5 MG TABLET No
J1B DONEPEZIL HCL 18 999DONEPEZIL HCL ODT 10 MG TABLET No
J1B DONEPEZIL HCL 18 999DONEPEZIL HCL ODT 5 MG TABLET No
J1B RIVASTIGMINE 18 999EXELON 13.3 MG/24HR PATCH No
J1B RIVASTIGMINE 18 999EXELON 4.6 MG/24HR PATCH No
J1B RIVASTIGMINE 18 999EXELON 9.5 MG/24HR PATCH No
J1B PYRIDOSTIGMINE BROMIDE 0 999MESTINON 60 MG/5 ML SYRUP No
J1B PYRIDOSTIGMINE BROMIDE 0 999PYRIDOSTIGMINE 60 MG/5 ML SOLN No
J1B PYRIDOSTIGMINE BROMIDE 0 999PYRIDOSTIGMINE BR 60 MG TAB No
J1B PYRIDOSTIGMINE BROMIDE 0 999PYRIDOSTIGMINE BR 60 MG TABLET No
J1B PYRIDOSTIGMINE BROMIDE 0 999PYRIDOSTIGMINE ER 180 MG TAB No
J2A BELLADONNA ALKALOIDSJ2A PHENOBARB/HYOSCY/ATROPINE/SCOP 0 999BELLADONNA/PHENOBARB TABLET No
J2A PHENOBARB/HYOSCY/ATROPINE/SCOP 0 999BELLADONNA-PHENOBARBITAL TAB No
J2A HYOSCYAMINE SULFATE 0 999HYOSCYAMINE 0.125 MG ODT No
J2A HYOSCYAMINE SULFATE 0 999HYOSCYAMINE 0.125 MG TAB SL No
J2A HYOSCYAMINE SULFATE 0 999HYOSCYAMINE 0.125 MG/ML DROP No
J2A HYOSCYAMINE SULFATE 0 999HYOSCYAMINE 125 MCG/5 ML ELIX No
J2A HYOSCYAMINE SULFATE 0 999HYOSCYAMINE ER 0.375 MG TAB No
J2A HYOSCYAMINE SULFATE 0 999HYOSCYAMINE SULF 0.125 MG TAB No
J2B ANTICHOLINERGICS,QUATERNARY AMMONIUMJ2B GLYCOPYRROLATE 0 999GLYCOPYRROLATE 1 MG TABLET No
Tuesday, May 14, 2019 Page 124 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
J2B GLYCOPYRROLATE 0 999GLYCOPYRROLATE 2 MG TABLET No
J2B GLYCOPYRROLATE/PF 0 999GLYRX-PF 0.2 MG/ML VIAL No
J2B GLYCOPYRROLATE/PF 0 999GLYRX-PF 0.4 MG/2 ML VIAL No
J2B PROPANTHELINE BROMIDE 0 999PROPANTHELINE 15 MG TABLET No
J2D ANTICHOLINERGICS/ANTISPASMODICSJ2D DICYCLOMINE HCL 0 999DICYCLOMINE 10 MG CAPSULE No
J2D DICYCLOMINE HCL 0 999DICYCLOMINE 10 MG/5 ML SYRUP No
J2D DICYCLOMINE HCL 0 999DICYCLOMINE 20 MG TABLET No
J3A SMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS)J3A NICOTINE 18 999HM NICOTINE 14 MG/24HR PATCH No
J3A NICOTINE POLACRILEX 18 999HM NICOTINE 2 MG CHEWING GUM No
J3A NICOTINE POLACRILEX 18 999HM NICOTINE 2 MG LOZENGE No
J3A NICOTINE 18 999HM NICOTINE 21 MG/24HR PATCH No
J3A NICOTINE POLACRILEX 18 999HM NICOTINE 4 MG CHEWING GUM No
J3A NICOTINE POLACRILEX 18 999HM NICOTINE 4 MG LOZENGE No
J3A NICOTINE 18 999HM NICOTINE 7 MG/24HR PATCH No
J3A NICOTINE 18 999NICOTINE 14 MG/24 HR PATCH No
J3A NICOTINE 18 999NICOTINE 14 MG/24HR PATCH No
J3A NICOTINE POLACRILEX 18 999NICOTINE 2 MG CHEWING GUM No
J3A NICOTINE POLACRILEX 18 999NICOTINE 2 MG GUM No
J3A NICOTINE POLACRILEX 18 999NICOTINE 2 MG LOZENGE No
J3A NICOTINE POLACRILEX 18 999NICOTINE 2 MG MINI LOZENGE No
J3A NICOTINE 18 999NICOTINE 21 MG/24 HR PATCH No
J3A NICOTINE 18 999NICOTINE 21 MG/24HR PATCH No
Tuesday, May 14, 2019 Page 125 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
J3A NICOTINE POLACRILEX 18 999NICOTINE 4 MG CHEWING GUM No
J3A NICOTINE POLACRILEX 18 999NICOTINE 4 MG GUM No
J3A NICOTINE POLACRILEX 18 999NICOTINE 4 MG LOZENGE No
J3A NICOTINE POLACRILEX 18 999NICOTINE 4 MG MINI LOZENGE No
J3A NICOTINE 18 999NICOTINE 7 MG/24 HR PATCH No
J3A NICOTINE 18 999NICOTINE 7 MG/24HR PATCH No
J3A NICOTINE POLACRILEX 18 999NICOTINE POLACRILEX 2 MG GUM No
J3A NICOTINE POLACRILEX 18 999NICOTINE POLACRILEX 4 MG GUM No
J3A NICOTINE 18 999NICOTINE TRANSDERMAL SYSTEM No
J3A NICOTINE 18 999SM NICOTINE 14 MG/24HR PATCH No
J3A NICOTINE POLACRILEX 18 999SM NICOTINE 2 MG LOZENGE No
J3A NICOTINE 18 999SM NICOTINE 21 MG/24HR PATCH No
J3A NICOTINE POLACRILEX 18 999SM NICOTINE 4 MG LOZENGE No
J3A NICOTINE 18 999SM NICOTINE 7 MG/24HR PATCH No
J3A NICOTINE POLACRILEX 18 999SUNMARK NICOTINE 2 MG GUM No
J3A NICOTINE POLACRILEX 18 999SUNMARK NICOTINE 4 MG GUM No
J3C SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONISTJ3C VARENICLINE TARTRATE 18 999CHANTIX 0.5 MG TABLET No
J3C VARENICLINE TARTRATE 18 999CHANTIX 1 MG CONT MONTH BOX No
J3C VARENICLINE TARTRATE 18 999CHANTIX 1 MG TABLET No
J3C VARENICLINE TARTRATE 18 999CHANTIX STARTING MONTH BOX No
J5B ADRENERGICS, AROMATIC, NON-CATECHOLAMINEJ5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999AMPHETAMINE SALTS 10 MG TAB No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999AMPHETAMINE SALTS 10 MG TABLET No
Tuesday, May 14, 2019 Page 126 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999AMPHETAMINE SALTS 12.5 MG TAB No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999AMPHETAMINE SALTS 12.5 MG TB No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999AMPHETAMINE SALTS 15 MG TAB No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999AMPHETAMINE SALTS 15 MG TABLET No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999AMPHETAMINE SALTS 20 MG TAB No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999AMPHETAMINE SALTS 20 MG TABLET No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999AMPHETAMINE SALTS 30 MG TAB No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999AMPHETAMINE SALTS 30 MG TABLET No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999AMPHETAMINE SALTS 5 MG TAB No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999AMPHETAMINE SALTS 5 MG TABLET No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999AMPHETAMINE SALTS 7.5 MG TAB No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 6 999DEXTROAMP-AMPHET ER 10 MG CAP No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 6 999DEXTROAMP-AMPHET ER 15 MG CAP No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 6 999DEXTROAMP-AMPHET ER 20 MG CAP No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 6 999DEXTROAMP-AMPHET ER 25 MG CAP No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 6 999DEXTROAMP-AMPHET ER 30 MG CAP No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 6 999DEXTROAMP-AMPHET ER 5 MG CAP No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999DEXTROAMP-AMPHETAM 12.5 MG TAB No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999DEXTROAMP-AMPHETAM 7.5 MG TAB No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999DEXTROAMP-AMPHETAMIN 10 MG TAB No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999DEXTROAMP-AMPHETAMIN 15 MG TAB No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999DEXTROAMP-AMPHETAMIN 20 MG TAB No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999DEXTROAMP-AMPHETAMIN 30 MG TAB No
J5B DEXTROAMPHETAMINE/AMPHETAMINE 3 999DEXTROAMP-AMPHETAMINE 5 MG TAB No
Tuesday, May 14, 2019 Page 127 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
J5B DEXTROAMPHETAMINE SULFATE 0 999DEXTROAMPHETAMINE 10 MG TAB No
J5B DEXTROAMPHETAMINE SULFATE 0 999DEXTROAMPHETAMINE 5 MG TAB No
J5B DEXTROAMPHETAMINE SULFATE 6 999DEXTROAMPHETAMINE ER 5 MG CAP No
J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 10 MG CAPSULE No
J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 10 MG CHEWABLE TABLET No
J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 20 MG CAPSULE No
J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 20 MG CHEWABLE TABLET No
J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 30 MG CAPSULE No
J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 30 MG CHEWABLE TABLET No
J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 40 MG CAPSULE No
J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 40 MG CHEWABLE TABLET No
J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 50 MG CAPSULE No
J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 50 MG CHEWABLE TABLET No
J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 60 MG CAPSULE No
J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 60 MG CHEWABLE TABLET No
J5B LISDEXAMFETAMINE DIMESYLATE 6 999VYVANSE 70 MG CAPSULE No
J5D BETA-ADRENERGIC AGENTSJ5D ALBUTEROL SULFATE 0 999ALBUTEROL SULF 2 MG/5 ML SYRP No
J5D ALBUTEROL SULFATE 0 999ALBUTEROL SULF 2 MG/5 ML SYRUP No
J5D TERBUTALINE SULFATE 0 999TERBUTALINE SULF 1 MG/ML VIAL No
J5F ANAPHYLAXIS THERAPY AGENTSJ5F EPINEPHRINE 0 999EPINEPHRINE 0.15 MG AUTO-INJCT No
J5F EPINEPHRINE 0 999EPINEPHRINE 0.3 MG AUTO-INJECT No
J5H ADRENERGIC VASOPRESSOR AGENTSJ5H MIDODRINE HCL 0 999MIDODRINE HCL 10 MG TABLET No
Tuesday, May 14, 2019 Page 128 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
J5H MIDODRINE HCL 0 999MIDODRINE HCL 2.5 MG TABLET No
J5H MIDODRINE HCL 0 999MIDODRINE HCL 5 MG TABLET No
J7A ALPHA/BETA-ADRENERGIC BLOCKING AGENTSJ7A CARVEDILOL 0 999CARVEDILOL 12.5 MG TABLET No
J7A CARVEDILOL 0 999CARVEDILOL 25 MG TABLET No
J7A CARVEDILOL 0 999CARVEDILOL 3.125 MG TABLET No
J7A CARVEDILOL 0 999CARVEDILOL 6.25 MG TABLET No
J7A LABETALOL HCL 0 999LABETALOL HCL 100 MG TABLET No
J7A LABETALOL HCL 0 999LABETALOL HCL 200 MG TABLET No
J7A LABETALOL HCL 0 999LABETALOL HCL 300 MG TABLET No
J7B ALPHA-ADRENERGIC BLOCKING AGENTSJ7B DOXAZOSIN MESYLATE 0 999DOXAZOSIN MESYLATE 1 MG TAB No
J7B DOXAZOSIN MESYLATE 0 999DOXAZOSIN MESYLATE 2 MG TAB No
J7B DOXAZOSIN MESYLATE 0 999DOXAZOSIN MESYLATE 4 MG TAB No
J7B DOXAZOSIN MESYLATE 0 999DOXAZOSIN MESYLATE 8 MG TAB No
J7B PRAZOSIN HCL 0 999PRAZOSIN 1 MG CAPSULE No
J7B PRAZOSIN HCL 0 999PRAZOSIN 2 MG CAPSULE No
J7B PRAZOSIN HCL 0 999PRAZOSIN 5 MG CAPSULE No
J7B PRAZOSIN HCL 0 999PRAZOSIN HCL 1 MG CAPSULE No
J7B PRAZOSIN HCL 0 999PRAZOSIN HCL 2 MG CAPSULE No
J7B PRAZOSIN HCL 0 999PRAZOSIN HCL 5 MG CAPSULE No
J7B TERAZOSIN HCL 0 999TERAZOSIN 1 MG CAPSULE No
J7B TERAZOSIN HCL 0 999TERAZOSIN 10 MG CAPSULE No
J7B TERAZOSIN HCL 0 999TERAZOSIN 2 MG CAPSULE No
Tuesday, May 14, 2019 Page 129 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
J7B TERAZOSIN HCL 0 999TERAZOSIN 5 MG CAPSULE No
J7C BETA-ADRENERGIC BLOCKING AGENTSJ7C ACEBUTOLOL HCL 0 999ACEBUTOLOL 200 MG CAPSULE No
J7C ACEBUTOLOL HCL 0 999ACEBUTOLOL 400 MG CAPSULE No
J7C ATENOLOL 0 999ATENOLOL 100 MG TABLET No
J7C ATENOLOL 0 999ATENOLOL 25 MG TABLET No
J7C ATENOLOL 0 999ATENOLOL 50 MG TABLET No
J7C SOTALOL HCL 0 999BETAPACE AF 120 MG TABLET No
J7C BISOPROLOL FUMARATE 0 999BISOPROLOL FUMARATE 10 MG TAB No
J7C BISOPROLOL FUMARATE 0 999BISOPROLOL FUMARATE 10 MG TB No
J7C BISOPROLOL FUMARATE 0 999BISOPROLOL FUMARATE 5 MG TAB No
J7C METOPROLOL TARTRATE 0 999METOPROLOL 100 MG TABLET No
J7C METOPROLOL TARTRATE 0 999METOPROLOL 25 MG TABLET No
J7C METOPROLOL TARTRATE 0 999METOPROLOL 50 MG TABLET No
J7C METOPROLOL SUCCINATE 0 999METOPROLOL SUCC ER 100 MG TAB No
J7C METOPROLOL SUCCINATE 0 999METOPROLOL SUCC ER 200 MG TAB No
J7C METOPROLOL SUCCINATE 0 999METOPROLOL SUCC ER 25 MG TAB No
J7C METOPROLOL SUCCINATE 0 999METOPROLOL SUCC ER 50 MG TAB No
J7C METOPROLOL TARTRATE 0 999METOPROLOL TARTRATE 100 MG TAB No
J7C METOPROLOL TARTRATE 0 999METOPROLOL TARTRATE 25 MG TAB No
J7C METOPROLOL TARTRATE 0 999METOPROLOL TARTRATE 50 MG TAB No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 10 MG TABLET No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 120 MG CAPSULE ER No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 120 MG CAPSULE SA No
Tuesday, May 14, 2019 Page 130 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 160 MG CAPSULE ER No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 160 MG CAPSULE SA No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 20 MG TABLET No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 20 MG/5 ML SOLN No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 40 MG TABLET No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 40 MG/5 ML SOLN No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 60 MG CAPSULE ER No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 60 MG CAPSULE SA No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 60 MG TABLET No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 80 MG CAPSULE ER No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 80 MG CAPSULE SA No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL 80 MG TABLET No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL ER 120 MG CAPSULE No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL ER 160 MG CAPSULE No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL ER 60 MG CAPSULE No
J7C PROPRANOLOL HCL 0 999PROPRANOLOL ER 80 MG CAPSULE No
J7C SOTALOL HCL 0 999SOTALOL 120 MG TABLET No
J7C SOTALOL HCL 0 999SOTALOL 160 MG TABLET No
J7C SOTALOL HCL 0 999SOTALOL 240 MG TABLET No
J7C SOTALOL HCL 0 999SOTALOL 80 MG TABLET No
J7C SOTALOL HCL 0 999SOTALOL AF 120 MG TABLET No
J7C SOTALOL HCL 0 999SOTALOL AF 160 MG TABLET No
J7C SOTALOL HCL 0 999SOTALOL AF 80 MG TABLET No
J7C SOTALOL HCL 0 999SOTALOL HCL 120 MG TABLET No
Tuesday, May 14, 2019 Page 131 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
J7C SOTALOL HCL 0 999SOTALOL HCL 160 MG TABLET No
J7C SOTALOL HCL 0 999SOTALOL HCL 240 MG TABLET No
J7C SOTALOL HCL 0 999SOTALOL HCL 80 MG TABLET No
J7H BETA-BLOCKERS AND THIAZIDE,THIAZIDE-LIKE DIURETICSJ7H ATENOLOL/CHLORTHALIDONE 0 999ATENOLOL/CHLORTHAL 100/25 No
J7H ATENOLOL/CHLORTHALIDONE 0 999ATENOLOL/CHLORTHAL 50/25 No
J7H ATENOLOL/CHLORTHALIDONE 0 999ATENOLOL/CHLORTHAL 50/25 TB No
J7H BISOPROLOL/HYDROCHLOROTHIAZIDE 0 999BISOPROLOL/HCTZ 10/6.25 TAB No
J7H BISOPROLOL/HYDROCHLOROTHIAZIDE 0 999BISOPROLOL/HCTZ 2.5/6.25 TB No
J7H BISOPROLOL/HYDROCHLOROTHIAZIDE 0 999BISOPROLOL/HCTZ 5/6.25 TAB No
J7H BISOPROLOL/HYDROCHLOROTHIAZIDE 0 999BISOPROLOL-HCTZ 10/6.25MG TAB No
J7H BISOPROLOL/HYDROCHLOROTHIAZIDE 0 999BISOPROLOL-HCTZ 10-6.25 MG TAB No
J7H BISOPROLOL/HYDROCHLOROTHIAZIDE 0 999BISOPROLOL-HCTZ 2.5/6.25MG TAB No
J7H BISOPROLOL/HYDROCHLOROTHIAZIDE 0 999BISOPROLOL-HCTZ 2.5-6.25 MG TB No
J7H BISOPROLOL/HYDROCHLOROTHIAZIDE 0 999BISOPROLOL-HCTZ 5/6.25MG TAB No
J7H BISOPROLOL/HYDROCHLOROTHIAZIDE 0 999BISOPROLOL-HCTZ 5-6.25 MG TAB No
J7H PROPRANOLOL/HYDROCHLOROTHIAZID 0 999PROPRANOLOL/HCTZ 40/25 TAB No
J7H PROPRANOLOL/HYDROCHLOROTHIAZID 0 999PROPRANOLOL/HCTZ 80/25 TAB No
J9A INTESTINAL MOTILITY STIMULANTSJ9A METOCLOPRAMIDE HCL 0 999METOCLOPRAMIDE 10 MG TABLET No
J9A METOCLOPRAMIDE HCL 0 999METOCLOPRAMIDE 5 MG TABLET No
J9A METOCLOPRAMIDE HCL 0 999METOCLOPRAMIDE 5 MG/5 ML SOLN No
J9A METOCLOPRAMIDE HCL 0 999METOCLOPRAMIDE 5 MG/5 ML SYRP No
J9A METOCLOPRAMIDE HCL 0 999METOCLOPRAMIDE 5 MG/5 ML SYRUP No
L0B TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMES
Tuesday, May 14, 2019 Page 132 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
L0B HYALURONIDASE, HUMAN RECOMB. 0 999HYQVIA HY CMPNT 1,600 UNIT/10 Clinical PA Required
L0B HYALURONIDASE, HUMAN RECOMB. 0 999HYQVIA HY CMPNT 2,400 UNIT/15 Clinical PA Required
L0B HYALURONIDASE, HUMAN RECOMB. 0 999HYQVIA HY CMPNT 200 UNIT/1.25 Clinical PA Required
L0B HYALURONIDASE, HUMAN RECOMB. 0 999HYQVIA HY CMPNT 400 UNIT/2.5 Clinical PA Required
L0B HYALURONIDASE, HUMAN RECOMB. 0 999HYQVIA HY CMPNT 800 UNIT/5 ML Clinical PA Required
L0B COLLAGENASE CLOSTRIDIUM HIST. 0 999SANTYL OINTMENT No
L1A ANTIPSORIATIC AGENTS,SYSTEMICL1A ACITRETIN 0 999ACITRETIN 10 MG CAPSULE No
L1A ACITRETIN 0 999ACITRETIN 17.5 MG CAPSULE No
L1A ACITRETIN 0 999ACITRETIN 25 MG CAPSULE No
L1A SECUKINUMAB 18 999COSENTYX 150 MG/ML PEN INJECT Auto PA
L1A SECUKINUMAB 18 999COSENTYX 150 MG/ML SYRINGE Auto PA
L1A SECUKINUMAB 18 999COSENTYX 300 MG (2 PENS) INJECT Auto PA
L1A SECUKINUMAB 18 999COSENTYX 300 MG (2 SYRINGES) Auto PA
L1B ACNE AGENTS,SYSTEMICL1B ISOTRETINOIN 12 999AMNESTEEM 10 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999AMNESTEEM 20 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999AMNESTEEM 40 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999CLARAVIS 10 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999CLARAVIS 20 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999CLARAVIS 30 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999CLARAVIS 40 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999ISOTRETINOIN 10 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999ISOTRETINOIN 20 MG CAPSULE Requires Med Cert 3
Tuesday, May 14, 2019 Page 133 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
L1B ISOTRETINOIN 12 999ISOTRETINOIN 30 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999ISOTRETINOIN 40 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999MYORISAN 10 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999MYORISAN 20 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999MYORISAN 30 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999MYORISAN 40 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999ZENATANE 10 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999ZENATANE 20 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999ZENATANE 30 MG CAPSULE Requires Med Cert 3
L1B ISOTRETINOIN 12 999ZENATANE 40 MG CAPSULE Requires Med Cert 3
L2A EMOLLIENTSL2A AMMONIUM LACTATE 0 999AMMONIUM LACTATE 12% CREAM No
L2A AMMONIUM LACTATE 0 999AMMONIUM LACTATE 12% LOTION No
L3P ANTIPRURITICS,TOPICALL3P DOXEPIN HCL 0 999DOXEPIN 5% CREAM No
L5A KERATOLYTICSL5A PODOFILOX 0 999PODOFILOX 0.5% TOPICAL SOLN No
L5A SALICYLIC ACID 0 999SALICYLIC ACID 6% CREAM No
L5A UREA 0 999UREA 40% CREAM No
L5A UREA 0 999UREA 40% LOTION No
L5E ANTISEBORRHEIC AGENTSL5E SELENIUM SULFIDE 0 999SELENIUM 2.5% LOTION/SHAMPOO No
L5E SELENIUM SULFIDE 0 999SELENIUM SULF 2.5% SHAMPOO No
L5E SELENIUM SULFIDE 0 999SELENIUM SULFIDE 2.25% SHAMPOO No
L5F ANTIPSORIATICS AGENTS
Tuesday, May 14, 2019 Page 134 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
L5F CALCIPOTRIENE 0 999CALCIPOTRIENE 0.005% CREAM No
L5F CALCIPOTRIENE 0 999CALCIPOTRIENE 0.005% OINTMENT No
L5F CALCITRIOL 0 999CALCITRIOL 3 MCG/G OINTMENT No
L5G ROSACEA AGENTS, TOPICALL5G AZELAIC ACID 0 999FINACEA 15% GEL No
L5G METRONIDAZOLE 0 999METRONIDAZOLE 0.75% CREAM No
L5G METRONIDAZOLE 0 999METRONIDAZOLE TOP 0.75% GEL No
L5G METRONIDAZOLE 0 999METRONIDAZOLE TOP 1% GEL PUMP No
L5G METRONIDAZOLE 0 999METRONIDAZOLE TOPICAL 0.75% GL No
L5G METRONIDAZOLE 0 999METRONIDAZOLE TOPICAL 1% GEL No
L5H ACNE AGENTS,TOPICALL5H AZELAIC ACID 12 999AZELEX 20% CREAM No
L5H CLINDAMYCIN PHOS/BENZOYL PEROX 12 999CLINDA-BENZOYL PEROX 1-5% PUMP No
L9B VITAMIN A DERIVATIVESL9B TRETINOIN 12 999AVITA 0.025% CREAM No
L9B ADAPALENE 12 999DIFFERIN 0.1% CREAM No
L9B ADAPALENE 12 999DIFFERIN 0.1% LOTION No
L9B TRETINOIN 12 999RETIN-A 0.025% CREAM No
L9B TRETINOIN 12 999RETIN-A 0.05% CREAM No
L9B TRETINOIN 12 999RETIN-A 0.1% CREAM No
M0B PLASMA PROTEINSM0B ALBUMIN HUMAN 0 999ALBUKED-25 VIAL Clinical PA Required
M0B ALBUMIN HUMAN 0 999ALBUKED-5 VIAL Clinical PA Required
M0B ALBUMIN HUMAN 0 999ALBUMIN (HUMAN) 25% IV SOLN Clinical PA Required
M0B ALBUMIN HUMAN 0 999ALBUMIN (HUMAN) 5% IV SOLUTION Clinical PA Required
Tuesday, May 14, 2019 Page 135 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
M0B ALBUMIN HUMAN-KJDA 0 999ALBUMINEX 25% VIAL Clinical PA Required
M0B ALBUMIN HUMAN-KJDA 0 999ALBUMINEX 5% VIAL Clinical PA Required
M0B ALBUMIN HUMAN 0 999ALBURX (HUMAN) 25% VIAL Clinical PA Required
M0B ALBUMIN HUMAN 0 999ALBURX (HUMAN) 5% VIAL Clinical PA Required
M0B ALBUMIN HUMAN 0 999ALBUTEIN 25% VIAL Clinical PA Required
M0B ALBUMIN HUMAN 0 999ALBUTEIN 5% IV SOLUTION Clinical PA Required
M0B ALBUMIN HUMAN 0 999ALBUTEIN 5% VIAL Clinical PA Required
M0B ALBUMIN HUMAN 0 999BUMINATE 5% IV SOLUTION Clinical PA Required
M0B ALBUMIN HUMAN 0 999FLEXBUMIN 25% IV SOLUTION Clinical PA Required
M0B ALBUMIN HUMAN 0 999FLEXBUMIN 5% IV SOLUTION Clinical PA Required
M0B ALBUMIN HUMAN 0 999KEDBUMIN 25% VIAL Clinical PA Required
M0B ALBUMIN HUMAN 0 999PLASBUMIN-25 IV SOLUTION Clinical PA Required
M0B ALBUMIN HUMAN 0 999PLASBUMIN-5 IV SOLUTION Clinical PA Required
M0B PLASMA PROTEIN FRACTION 0 999PLASMANATE 5% IV SOLUTION Clinical PA Required
M0N C1 ESTERASE INHIBITORSM0N C1 ESTERASE INHIBITOR 12 999BERINERT 500 UNIT KIT Auto PA
M0N C1 ESTERASE INHIBITOR 12 999BERINERT 500 UNIT VIAL Auto PA
M4B IV FAT EMULSIONSM4B FAT EMULSIONS 0 999INTRALIPID 20% IV FAT EMUL No
M4B FAT EMULSIONS 0 999INTRALIPID 30% IV FAT EMUL No
M4D ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS)M4D ATORVASTATIN CALCIUM 0 999ATORVASTATIN 10 MG TABLET No
M4D ATORVASTATIN CALCIUM 0 999ATORVASTATIN 20 MG TABLET No
M4D ATORVASTATIN CALCIUM 0 999ATORVASTATIN 40 MG TABLET No
M4D ATORVASTATIN CALCIUM 0 999ATORVASTATIN 80 MG TABLET No
Tuesday, May 14, 2019 Page 136 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
M4D LOVASTATIN 0 999LOVASTATIN 10 MG TABLET No
M4D LOVASTATIN 0 999LOVASTATIN 20 MG TABLET No
M4D LOVASTATIN 0 999LOVASTATIN 40 MG TABLET No
M4D PRAVASTATIN SODIUM 0 999PRAVASTATIN SODIUM 10 MG TAB No
M4D PRAVASTATIN SODIUM 0 999PRAVASTATIN SODIUM 20 MG TAB No
M4D PRAVASTATIN SODIUM 0 999PRAVASTATIN SODIUM 40 MG TAB No
M4D PRAVASTATIN SODIUM 0 999PRAVASTATIN SODIUM 80 MG TAB No
M4D ROSUVASTATIN CALCIUM 0 999ROSUVASTATIN CALCIUM 10 MG TAB No
M4D ROSUVASTATIN CALCIUM 0 999ROSUVASTATIN CALCIUM 20 MG TAB No
M4D ROSUVASTATIN CALCIUM 0 999ROSUVASTATIN CALCIUM 40 MG TAB No
M4D ROSUVASTATIN CALCIUM 0 999ROSUVASTATIN CALCIUM 5 MG TAB No
M4D SIMVASTATIN 0 999SIMVASTATIN 10 MG TABLET No
M4D SIMVASTATIN 0 999SIMVASTATIN 20 MG TABLET No
M4D SIMVASTATIN 0 999SIMVASTATIN 40 MG TABLET No
M4D SIMVASTATIN 0 999SIMVASTATIN 5 MG TABLET No
M4D SIMVASTATIN 0 999SIMVASTATIN 80 MG TABLET No
M4E LIPOTROPICSM4E EZETIMIBE 10 999EZETIMIBE 10 MG TABLET No
M4E FENOFIBRATE NANOCRYSTALLIZED 0 999FENOFIBRATE 145 MG TABLET No
M4E FENOFIBRATE NANOCRYSTALLIZED 0 999FENOFIBRATE 48 MG TABLET No
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999FISH OIL 1,000 MG CAPSULE Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999FISH OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999FISH OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 137 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
M4E OMEGA-3S/DHA/EPA/FISH OIL 0 999FISH OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999FISH OIL 1,000 MG SOFTGEL DR Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL 1,000 MG SOFTGEL DR Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999FISH OIL 1,200 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999FISH OIL 1,200 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL 1,200 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3S/DHA/EPA/FISH OIL 0 999FISH OIL 1,200 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL 1,360 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL 1,400 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL 1,600 MG/5 ML LIQUID Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL 500 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999FISH OIL CONC 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999FISH OIL CONC 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
M4E DOCOSAHEXANOIC ACID/EPA 0 999FISH OIL CONCENTRATE SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999FISH OIL CONCETRATE SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3S/DHA/EPA/FISH OIL 0 999FISH OIL DR 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL EC 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL EC 1,200 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL GUMMIES Cystic Fib Diag Auto PA
M4E OMEGA-3S/DHA/EPA/FISH OIL 0 999FISH OIL OMEGA-3 1,360 MG SFGL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999FISH OIL OMEGA-3 EC 1,200 MG Cystic Fib Diag Auto PA
M4E OMEGA-3S/DHA/EPA/FISH OIL/D3 0 999FISH OIL-OMEGA-3-VIT D SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA3/DHA/EPA/FISH OIL/VIT D3 0 999FISH OIL-VIT D3 SOFTGEL Cystic Fib Diag Auto PA
M4E GEMFIBROZIL 0 999GEMFIBROZIL 600 MG TABLET No
Tuesday, May 14, 2019 Page 138 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999MAXEPA 1,000 MG CAPSULE Cystic Fib Diag Auto PA
M4E NIACIN 0 999NIACIN ER 1,000 MG TABLET No
M4E NIACIN 0 999NIACIN ER 500 MG TABLET No
M4E NIACIN 0 999NIACIN ER 750 MG TABLET No
M4E NIACIN 0 999NIACOR 500 MG TABLET No
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA 3 500 SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999OMEGA 3 FISH OIL 1,000 MG CAP Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999OMEGA 3 FISH OIL SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS 0 999OMEGA-3 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999OMEGA-3 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 EC SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999OMEGA-3 FISH OIL 1,000 MG SFGL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL 1,000 MG SFGL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL 1,000 MG SFTG Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL 1,000MG SFTGL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL 1,200 MG SFGL Cystic Fib Diag Auto PA
M4E OMEGA-3S/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL 1,200 MG SFGL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999OMEGA-3 FISH OIL 1,200 MG STGL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL 1,400 MG SFGL Cystic Fib Diag Auto PA
M4E OMEGA-3S/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL 1,400 MG SFGL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999OMEGA-3 FISH OIL 1,760 MG STGL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL EC 1,000 MG Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL SOFTGEL Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 139 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGA-3 FISH OIL SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA3/DHA/EPA/FISH OIL/VIT D3 0 999OMEGA-3-FISH OIL-VIT D3 SFTGL Cystic Fib Diag Auto PA
M4E OMEGA-3S/DHA/EPA/FISH OIL/D3 0 999OMEGA-3-FISH OIL-VIT D3 SFTGL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999OMEGAMINT FISH OIL 750 MG SFGL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999RA FISH OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999RA FISH OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
M4E DOCOSAHEXANOIC ACID/EPA 0 999RA FISH OIL 120/180 SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999SM FISH OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999SM FISH OIL 1,200 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS/FISH OIL 0 999SM FISH OIL 1,200 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3/DHA/EPA/FISH OIL 0 999SM FISH OIL 554 MG SOFTGEL Cystic Fib Diag Auto PA
M4E OMEGA-3 FATTY ACIDS 0 999SM FISH OIL CONCENTRATE SFG Cystic Fib Diag Auto PA
M4G AGENTS TO TREAT HYPOGLYCEMIA (HYPERGLYCEMICS)M4G GLUCAGON,HUMAN RECOMBINANT 0 999GLUCAGEN 1 MG HYPOKIT No
M4G GLUCAGON,HUMAN RECOMBINANT 0 999GLUCAGON 1 MG EMERGENCY KIT No
M4G DIAZOXIDE 0 999PROGLYCEM 50 MG/ML ORAL SUSP No
M9D ANTIFIBRINOLYTIC AGENTSM9D AMINOCAPROIC ACID 0 999AMICAR 0.25 GRAM/ML ORAL SOLN No
M9D AMINOCAPROIC ACID 0 999AMICAR 1,000 MG TABLET No
M9D AMINOCAPROIC ACID 0 999AMICAR 500 MG TABLET No
M9D AMINOCAPROIC ACID 0 999AMINOCAPROIC ACID 250 MG/ML No
M9D AMINOCAPROIC ACID 0 999AMINOCAPROIC ACID 5 G/20 ML VL No
M9D TRANEXAMIC ACID 0 999TRANEXAMIC ACID 1,000 MG/10 ML No
M9D TRANEXAMIC ACID 0 999TRANEXAMIC ACID 1000 MG/10 ML No
Tuesday, May 14, 2019 Page 140 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
M9D TRANEXAMIC ACID 0 999TRANEXAMIC ACID 650 MG TABLET No
M9F THROMBOLYTIC ENZYMESM9F ALTEPLASE 0 999CATHFLO ACTIVASE 2 MG VIAL No
M9K HEPARIN AND RELATED PREPARATIONSM9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 100 MG/ML SYR No
M9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 100 MG/ML SYRINGE No
M9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 120 MG/0.8 ML SYR No
M9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 150 MG/ML SYR No
M9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 150 MG/ML SYRINGE No
M9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 30 MG/0.3 ML SYR No
M9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 300 MG/3 ML VIAL No
M9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 40 MG/0.4 ML SYR No
M9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 60 MG/0.6 ML SYR No
M9K ENOXAPARIN SODIUM 0 999ENOXAPARIN 80 MG/0.8 ML SYR No
M9L ANTICOAGULANTS,COUMARIN TYPEM9L WARFARIN SODIUM 0 999COUMADIN 1 MG TABLET No
M9L WARFARIN SODIUM 0 999COUMADIN 10 MG TABLET No
M9L WARFARIN SODIUM 0 999COUMADIN 2 MG TABLET No
M9L WARFARIN SODIUM 0 999COUMADIN 2.5 MG TABLET No
M9L WARFARIN SODIUM 0 999COUMADIN 3 MG TABLET No
M9L WARFARIN SODIUM 0 999COUMADIN 4 MG TABLET No
M9L WARFARIN SODIUM 0 999COUMADIN 5 MG TABLET No
M9L WARFARIN SODIUM 0 999COUMADIN 6 MG TABLET No
M9L WARFARIN SODIUM 0 999COUMADIN 7.5 MG TABLET No
M9L WARFARIN SODIUM 0 999JANTOVEN 1 MG TABLET No
Tuesday, May 14, 2019 Page 141 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
M9L WARFARIN SODIUM 0 999JANTOVEN 10 MG TABLET No
M9L WARFARIN SODIUM 0 999JANTOVEN 2 MG TABLET No
M9L WARFARIN SODIUM 0 999JANTOVEN 2.5 MG TABLET No
M9L WARFARIN SODIUM 0 999JANTOVEN 3 MG TABLET No
M9L WARFARIN SODIUM 0 999JANTOVEN 4 MG TABLET No
M9L WARFARIN SODIUM 0 999JANTOVEN 5 MG TABLET No
M9L WARFARIN SODIUM 0 999JANTOVEN 6 MG TABLET No
M9L WARFARIN SODIUM 0 999JANTOVEN 7.5 MG TABLET No
M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 1 MG TABLET No
M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 10 MG TABLET No
M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 2 MG TABLET No
M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 2.5 MG TAB No
M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 2.5 MG TABLET No
M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 3 MG TAB No
M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 3 MG TABLET No
M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 4 MG TAB No
M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 4 MG TABLET No
M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 5 MG TAB No
M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 5 MG TABLET No
M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 6 MG TABLET No
M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 7.5 MG TAB No
M9L WARFARIN SODIUM 0 999WARFARIN SODIUM 7.5 MG TABLET No
M9P PLATELET AGGREGATION INHIBITORSM9P ASPIRIN 0 999ADULT ASPIRIN CHEW TABLET No
Tuesday, May 14, 2019 Page 142 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
M9P ASPIRIN 0 999ADULT ASPIRIN EC 81 MG TABLET No
M9P ASPIRIN 0 999ADULT ASPIRIN REGIMEN EC 81 MG No
M9P ASPIRIN/DIPYRIDAMOLE 0 999AGGRENOX CAPSULE SA No
M9P ASPIRIN 0 999ASPIRIN 81 MG CHEW TABLET No
M9P ASPIRIN 0 999ASPIRIN 81 MG CHEWABLE TABLET No
M9P ASPIRIN 0 999ASPIRIN 81 MG TABLET CHEW No
M9P ASPIRIN 0 999ASPIRIN ADULT 81 MG TAB CHEW No
M9P ASPIRIN 0 999ASPIRIN CHILD 81 MG TAB CHEW No
M9P ASPIRIN 0 999ASPIRIN CHILD 81 MG TAB CHEW No
M9P ASPIRIN 0 999ASPIRIN EC 81 MG TABLET No
M9P TICAGRELOR 0 999BRILINTA 60 MG TABLET No
M9P TICAGRELOR 0 999BRILINTA 90 MG TABLET No
M9P ASPIRIN 0 999CHILDREN'S CHEW ASPIRIN TAB No
M9P CILOSTAZOL 0 999CILOSTAZOL 100 MG TABLET No
M9P CILOSTAZOL 0 999CILOSTAZOL 50 MG TABLET No
M9P CLOPIDOGREL BISULFATE 0 999CLOPIDOGREL 75 MG TABLET No
M9P CLOPIDOGREL BISULFATE 0 999CLOPIDOGREL BISULFATE 75 MG TB No
M9P DIPYRIDAMOLE 0 999DIPYRIDAMOLE 25 MG TABLET No
M9P DIPYRIDAMOLE 0 999DIPYRIDAMOLE 50 MG TABLET No
M9P DIPYRIDAMOLE 0 999DIPYRIDAMOLE 75 MG TABLET No
M9P ASPIRIN 0 999HM ASPIRIN 81 MG CHEWABLE TAB No
M9P ASPIRIN 0 999HM ASPIRIN EC 81 MG TABLET No
M9P PRASUGREL HCL 0 999PRASUGREL 10 MG TABLET No
M9P PRASUGREL HCL 0 999PRASUGREL 5 MG TABLET No
Tuesday, May 14, 2019 Page 143 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
M9P ASPIRIN 0 999QC ASPIRIN 81 MG CHEWABLE TAB No
M9P ASPIRIN 0 999QC ASPIRIN EC 81 MG TABLET No
M9P ASPIRIN 0 999SB ASPIRIN EC 81 MG TABLET No
M9P ASPIRIN 0 999SM ASPIRIN 81 MG TABLET CHEW No
M9P ASPIRIN 0 999SM ASPIRIN 81 MG TABLET CHEW No
M9P ASPIRIN 0 999SM ASPIRIN CHLD 81 MG TB CHW No
M9P ASPIRIN 0 999ST. JOSEPH ASPIRIN 81 MG CHEW No
M9P ASPIRIN 0 999ST. JOSEPH ASPIRIN EC 81 MG TB No
M9S HEMORRHEOLOGIC AGENTSM9S PENTOXIFYLLINE 0 999PENTOXIFYLLINE 400 MG TAB SA No
M9S PENTOXIFYLLINE 0 999PENTOXIFYLLINE ER 400 MG TAB No
M9T THROMBIN INHIBITORS, SELECTIVE, DIRECT, REVERSIBLEM9T DABIGATRAN ETEXILATE MESYLATE 18 999PRADAXA 110 MG CAPSULE No
M9T DABIGATRAN ETEXILATE MESYLATE 18 999PRADAXA 150 MG CAPSULE No
M9T DABIGATRAN ETEXILATE MESYLATE 18 999PRADAXA 75 MG CAPSULE No
M9V DIRECT FACTOR XA INHIBITORSM9V APIXABAN 18 999ELIQUIS 2.5 MG TABLET No
M9V APIXABAN 18 999ELIQUIS 5 MG STARTER PACK No
M9V APIXABAN 18 999ELIQUIS 5 MG TABLET No
M9V RIVAROXABAN 18 999XARELTO 10 MG TABLET No
M9V RIVAROXABAN 18 999XARELTO 15 MG TABLET No
M9V RIVAROXABAN 18 999XARELTO 2.5 MG TABLET No
M9V RIVAROXABAN 18 999XARELTO 20 MG TABLET No
M9V RIVAROXABAN 18 999XARELTO STARTER PACK No
N1B ERYTHROPOIESIS-STIMULATING AGENTS
Tuesday, May 14, 2019 Page 144 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 10 MCG/0.4 ML SYRINGE Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 100 MCG/0.5 ML SYRINGE Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 100 MCG/ML VIAL Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 150 MCG/0.3 ML SYRINGE Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 200 MCG/0.4 ML SYRINGE Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 200 MCG/ML VIAL Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 25 MCG/0.42 ML SYRING Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 25 MCG/ML VIAL Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 300 MCG/0.6 ML SYRINGE Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 300 MCG/ML VIAL Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 40 MCG/0.4 ML SYRINGE Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 40 MCG/ML VIAL Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 500 MCG/1 ML SYRINGE Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 60 MCG/0.3 ML SYRINGE Clinical PA Required
N1B DARBEPOETIN ALFA IN POLYSORBAT 0 999ARANESP 60 MCG/ML VIAL Clinical PA Required
N1B EPOETIN ALFA 0 999EPOGEN 10,000 UNITS/ML VIAL Auto PA
N1B EPOETIN ALFA 0 999EPOGEN 2,000 UNITS/ML VIAL Auto PA
N1B EPOETIN ALFA 0 999EPOGEN 20,000 UNITS/ML VIAL Auto PA
N1B EPOETIN ALFA 0 999EPOGEN 3,000 UNITS/ML VIAL Auto PA
N1B EPOETIN ALFA 0 999EPOGEN 4,000 UNITS/ML VIAL Auto PA
N1B EPOETIN ALFA-EPBX 0 999RETACRIT 10,000 UNIT/ML VIAL No
N1B EPOETIN ALFA-EPBX 0 999RETACRIT 2,000 UNIT/ML VIAL No
N1B EPOETIN ALFA-EPBX 0 999RETACRIT 3,000 UNIT/ML VIAL No
N1B EPOETIN ALFA-EPBX 0 999RETACRIT 4,000 UNIT/ML VIAL No
Tuesday, May 14, 2019 Page 145 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
N1B EPOETIN ALFA-EPBX 0 999RETACRIT 40,000 UNIT/ML VIAL No
N1C LEUKOCYTE (WBC) STIMULANTSN1C TBO-FILGRASTIM 0 999GRANIX 300 MCG/0.5 ML SAFE SYR Clinical PA Required
N1C TBO-FILGRASTIM 0 999GRANIX 300 MCG/0.5 ML SYRINGE Clinical PA Required
N1C TBO-FILGRASTIM 0 999GRANIX 300 MCG/ML VIAL Clinical PA Required
N1C TBO-FILGRASTIM 0 999GRANIX 480 MCG/0.8 ML SAFE SYR Clinical PA Required
N1C TBO-FILGRASTIM 0 999GRANIX 480 MCG/0.8 ML SYRINGE Clinical PA Required
N1C TBO-FILGRASTIM 0 999GRANIX 480 MCG/1.6 ML VIAL Clinical PA Required
N1C SARGRAMOSTIM 0 999LEUKINE 250 MCG VIAL Clinical PA Required
N1C PEGFILGRASTIM 0 999NEULASTA 6 MG/0.6 ML DLVRY KIT Clinical PA Required
N1C PEGFILGRASTIM 0 999NEULASTA 6 MG/0.6 ML SYRINGE Clinical PA Required
N1C FILGRASTIM 0 999NEUPOGEN 300 MCG/0.5 ML SYR Clinical PA Required
N1C FILGRASTIM 0 999NEUPOGEN 300 MCG/ML VIAL Clinical PA Required
N1C FILGRASTIM 0 999NEUPOGEN 480 MCG/0.8 ML SYR Clinical PA Required
N1C FILGRASTIM 0 999NEUPOGEN 480 MCG/1.6 ML VIAL Clinical PA Required
N1D PLATELET REDUCING AGENTSN1D ANAGRELIDE HCL 0 999ANAGRELIDE HCL 0.5 MG CAPSULE No
N1D ANAGRELIDE HCL 0 999ANAGRELIDE HCL 1 MG CAPSULE No
N1G CXCR4 CHEMOKINE RECEPTOR ANTAGONISTN1G PLERIXAFOR 0 999MOZOBIL 24 MG/1.2 ML VIAL Clinical PA Required
P0G PREGNANCY MAINTAINING AGENT,HORMONALP0G HYDROXYPROGESTERONE CAPROAT/PF 16 999MAKENA 250 MG/ML VIAL Clinical PA Required
P0G HYDROXYPROGESTERONE CAPROAT/PF 16 999MAKENA 275 MG/1.1 ML AUTOINJCT Clinical PA Required
P1A GROWTH HORMONESP1A SOMATROPIN 0 16GENOTROPIN 12 MG CARTRIDGE Clinical PA Required
Tuesday, May 14, 2019 Page 146 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
P1A SOMATROPIN 0 16GENOTROPIN 5 MG CARTRIDGE Clinical PA Required
P1A SOMATROPIN 0 16GENOTROPIN MINIQUICK 0.2 MG Clinical PA Required
P1A SOMATROPIN 0 16GENOTROPIN MINIQUICK 0.4 MG Clinical PA Required
P1A SOMATROPIN 0 16GENOTROPIN MINIQUICK 0.6 MG Clinical PA Required
P1A SOMATROPIN 0 16GENOTROPIN MINIQUICK 0.8 MG Clinical PA Required
P1A SOMATROPIN 0 16GENOTROPIN MINIQUICK 1 MG Clinical PA Required
P1A SOMATROPIN 0 16GENOTROPIN MINIQUICK 1.2 MG Clinical PA Required
P1A SOMATROPIN 0 16GENOTROPIN MINIQUICK 1.4 MG Clinical PA Required
P1A SOMATROPIN 0 16GENOTROPIN MINIQUICK 1.6 MG Clinical PA Required
P1A SOMATROPIN 0 16GENOTROPIN MINIQUICK 1.8 MG Clinical PA Required
P1A SOMATROPIN 0 16GENOTROPIN MINIQUICK 2 MG Clinical PA Required
P1A SOMATROPIN 0 16NORDITROPIN FLEXPRO 10 MG/1.5 Clinical PA Required
P1A SOMATROPIN 0 16NORDITROPIN FLEXPRO 15 MG/1.5 Clinical PA Required
P1A SOMATROPIN 0 16NORDITROPIN FLEXPRO 30 MG/3 ML Clinical PA Required
P1A SOMATROPIN 0 16NORDITROPIN FLEXPRO 5 MG/1.5 Clinical PA Required
P1A SOMATROPIN 18 999SEROSTIM 4 MG VIAL Clinical PA Required
P1A SOMATROPIN 18 999SEROSTIM 5 MG VIAL Clinical PA Required
P1A SOMATROPIN 18 999SEROSTIM 6 MG VIAL Clinical PA Required
P1B SOMATOSTATIC AGENTSP1B OCTREOTIDE ACETATE 0 999OCTREOTIDE 1,000 MCG/ML VIAL No
P1B OCTREOTIDE ACETATE 0 999OCTREOTIDE 1,000 MCG/5 ML VIAL No
P1B OCTREOTIDE ACETATE 0 999OCTREOTIDE 5,000 MCG/5 ML VIAL No
P1B OCTREOTIDE ACETATE 0 999OCTREOTIDE ACET 0.05 MG/ML VL No
P1B OCTREOTIDE ACETATE 0 999OCTREOTIDE ACET 100 MCG/ML VL No
Tuesday, May 14, 2019 Page 147 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
P1B OCTREOTIDE ACETATE 0 999OCTREOTIDE ACET 200 MCG/ML VL No
P1B OCTREOTIDE ACETATE 0 999OCTREOTIDE ACET 50 MCG/ML VIAL No
P1B OCTREOTIDE ACETATE 0 999OCTREOTIDE ACET 500 MCG/ML VL No
P1E ADRENOCORTICOTROPHIC HORMONESP1E CORTICOTROPIN 0 999HP ACTHAR GEL 80 UNIT/ML VIAL Clinical PA Required
P1F PITUITARY SUPPRESSIVE AGENTSP1F CABERGOLINE 0 999CABERGOLINE 0.5 MG TABLET No
P1F DANAZOL 0 999DANAZOL 100 MG CAPSULE No
P1F DANAZOL 0 999DANAZOL 200 MG CAPSULE No
P1F DANAZOL 0 999DANAZOL 50 MG CAPSULE No
P1M LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTSP1M LEUPROLIDE ACETATE 18 999LUPRON DEPO 11.25MG (LUPANETA) Auto PA
P1M LEUPROLIDE ACETATE 18 999LUPRON DEPOT 11.25 MG 3MO KIT Auto PA
P1M LEUPROLIDE ACETATE 18 999LUPRON DEPOT 3.75 MG KIT Auto PA
P1M LEUPROLIDE ACETATE 18 999LUPRON DEPOT 3.75MG (LUPANETA) Auto PA
P1M NAFARELIN ACETATE 0 999SYNAREL 2 MG/ML NASAL SPRAY Auto PA
P1N LHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTSP1N ELAGOLIX SODIUM 0 999ORILISSA 150 MG TABLET Clinical PA Required
P1N ELAGOLIX SODIUM 0 999ORILISSA 200 MG TABLET Clinical PA Required
P1O LHRH (GNRH) AGONIST ANALOG AND PROGESTIN COMBP1O LEUPROLIDE/NORETHINDRONE ACET 18 999LUPANETA PK 11.25-5 MG 3MO KIT Auto PA
P1O LEUPROLIDE/NORETHINDRONE ACET 18 999LUPANETA PK 3.75-5 MG 1MO KIT Auto PA
P1P LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTYP1P LEUPROLIDE ACETATE 2 12LUPRON DEPOT 11.25 MG 3MO KIT Auto PA
P1P LEUPROLIDE ACETATE 2 12LUPRON DEPOT-PED 11.25 MG KIT Auto PA
P1P LEUPROLIDE ACETATE 2 12LUPRON DEPOT-PED 15 MG KIT Auto PA
Tuesday, May 14, 2019 Page 148 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
P1P LEUPROLIDE ACETATE 2 12LUPRON DEPOT-PED 30 MG 3MO KIT Auto PA
P1P LEUPROLIDE ACETATE 2 12LUPRON DEPOT-PED 7.5 MG KIT Auto PA
P1P TRIPTORELIN PAMOATE 0 999TRIPTODUR 22.5 MG KIT Auto PA
P1P TRIPTORELIN PAMOATE 0 999TRIPTODUR 22.5 MG VIAL Auto PA
P2B ANTIDIURETIC AND VASOPRESSOR HORMONESP2B DESMOPRESSIN (NONREFRIGERATED) 0 999DESMOPRESSIN 10 MCG/0.1 ML SPR No
P2B DESMOPRESSIN ACETATE 0 999DESMOPRESSIN 40 MCG/10 ML VIAL No
P2B DESMOPRESSIN ACETATE 0 999DESMOPRESSIN AC 4 MCG/ML AMP No
P2B DESMOPRESSIN ACETATE 0 999DESMOPRESSIN AC 4 MCG/ML AMPUL No
P2B DESMOPRESSIN ACETATE 0 999DESMOPRESSIN AC 4 MCG/ML VIAL No
P2B DESMOPRESSIN ACETATE 0 999DESMOPRESSIN AC 4 MCG/ML VL No
P2B DESMOPRESSIN ACETATE 0 999DESMOPRESSIN ACETATE 0.1 MG TB No
P2B DESMOPRESSIN ACETATE 0 999DESMOPRESSIN ACETATE 0.2 MG TB No
P3A THYROID HORMONESP3A THYROID,PORK 0 999ARMOUR THYROID 120 MG TABLET No
P3A THYROID,PORK 0 999ARMOUR THYROID 15 MG TABLET No
P3A THYROID,PORK 0 999ARMOUR THYROID 180 MG TABLET No
P3A THYROID,PORK 0 999ARMOUR THYROID 240 MG TABLET No
P3A THYROID,PORK 0 999ARMOUR THYROID 30 MG TABLET No
P3A THYROID,PORK 0 999ARMOUR THYROID 300 MG TABLET No
P3A THYROID,PORK 0 999ARMOUR THYROID 60 MG TABLET No
P3A THYROID,PORK 0 999ARMOUR THYROID 90 MG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 100 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 112 MCG TABLET No
Tuesday, May 14, 2019 Page 149 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 125 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 137 MCG TAB No
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 137 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 150 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 175 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 200 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 25 MCG TAB No
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 25 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 300 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 50 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 75 MCG TAB No
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 75 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOTHYROXINE 88 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOXYL 100 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOXYL 112 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOXYL 125 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOXYL 137 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOXYL 150 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOXYL 175 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOXYL 200 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOXYL 25 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOXYL 50 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOXYL 75 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999LEVOXYL 88 MCG TABLET No
Tuesday, May 14, 2019 Page 150 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
P3A LIOTHYRONINE SODIUM 0 999LIOTHYRONINE SOD 25 MCG TAB No
P3A LIOTHYRONINE SODIUM 0 999LIOTHYRONINE SOD 5 MCG TAB No
P3A LIOTHYRONINE SODIUM 0 999LIOTHYRONINE SOD 50 MCG TAB No
P3A THYROID,PORK 0 999NP THYROID 120 MG TABLET No
P3A THYROID,PORK 0 999NP THYROID 15 MG TABLET No
P3A THYROID,PORK 0 999NP THYROID 30 MG TABLET No
P3A THYROID,PORK 0 999NP THYROID 60 MG TABLET No
P3A THYROID,PORK 0 999NP THYROID 90 MG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999SYNTHROID 100 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999SYNTHROID 112 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999SYNTHROID 125 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999SYNTHROID 137 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999SYNTHROID 150 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999SYNTHROID 175 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999SYNTHROID 200 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999SYNTHROID 25 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999SYNTHROID 300 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999SYNTHROID 50 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999SYNTHROID 75 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999SYNTHROID 88 MCG TABLET No
P3A THYROID,PORK 0 999THYROID 120 MG TABLET No
P3A THYROID,PORK 0 999THYROID 15 MG TABLET No
P3A THYROID,PORK 0 999THYROID 30 MG TABLET No
P3A THYROID,PORK 0 999THYROID 60 MG TABLET No
Tuesday, May 14, 2019 Page 151 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
P3A THYROID,PORK 0 999THYROID 90 MG TABLET No
P3A LIOTRIX 0 999THYROLAR-1 STRENGTH TABLET No
P3A LIOTRIX 0 999THYROLAR-1/2 STRENGTH TAB No
P3A LIOTRIX 0 999THYROLAR-1/4 STRENGTH TAB No
P3A LIOTRIX 0 999THYROLAR-2 STRENGTH TABLET No
P3A LIOTRIX 0 999THYROLAR-3 STRENGTH TABLET No
P3A LEVOTHYROXINE SODIUM 0 999UNITHROID 100 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999UNITHROID 112 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999UNITHROID 125 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999UNITHROID 137 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999UNITHROID 150 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999UNITHROID 175 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999UNITHROID 200 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999UNITHROID 25 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999UNITHROID 300 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999UNITHROID 50 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999UNITHROID 75 MCG TABLET No
P3A LEVOTHYROXINE SODIUM 0 999UNITHROID 88 MCG TABLET No
P3L ANTITHYROID PREPARATIONSP3L METHIMAZOLE 0 999METHIMAZOLE 10 MG TABLET No
P3L METHIMAZOLE 0 999METHIMAZOLE 5 MG TABLET No
P3L PROPYLTHIOURACIL 0 999PROPYLTHIOURACIL 50 MG TABLET No
P3L PROPYLTHIOURACIL 0 999PROPYLTHIOURACIL 50 MG TABS No
P4D HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPE
Tuesday, May 14, 2019 Page 152 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
P4D DOXERCALCIFEROL 0 999DOXERCALCIFEROL 0.5 MCG CAP No
P4D DOXERCALCIFEROL 0 999DOXERCALCIFEROL 1 MCG CAPSULE No
P4D DOXERCALCIFEROL 0 999DOXERCALCIFEROL 2.5 MCG CAP No
P4D PARICALCITOL 0 999PARICALCITOL 1 MCG CAPSULE No
P4D PARICALCITOL 0 999PARICALCITOL 10 MCG/2 ML VIAL No
P4D PARICALCITOL 0 999PARICALCITOL 2 MCG CAPSULE No
P4D PARICALCITOL 0 999PARICALCITOL 2 MCG/ML VIAL No
P4D PARICALCITOL 0 999PARICALCITOL 4 MCG CAPSULE No
P4D PARICALCITOL 0 999PARICALCITOL 5 MCG/ML VIAL No
P4L BONE RESORPTION INHIBITORSP4L ALENDRONATE SODIUM 0 999ALENDRONATE SODIUM 10 MG TAB No
P4L ALENDRONATE SODIUM 0 999ALENDRONATE SODIUM 35 MG TAB No
P4L ALENDRONATE SODIUM 0 999ALENDRONATE SODIUM 40 MG TAB No
P4L ALENDRONATE SODIUM 0 999ALENDRONATE SODIUM 5 MG TABLET No
P4L ALENDRONATE SODIUM 0 999ALENDRONATE SODIUM 70 MG TAB No
P4L CALCITONIN,SALMON,SYNTHETIC 18 999CALCITONIN-SALMON 200 UNITS SP No
P4L PAMIDRONATE DISODIUM 0 999PAMIDRONATE 30 MG/10 ML VIAL No
P4L PAMIDRONATE DISODIUM 0 999PAMIDRONATE 60 MG/10 ML VIAL No
P4L PAMIDRONATE DISODIUM 0 999PAMIDRONATE 90 MG/10 ML VIAL No
P4L PAMIDRONATE DISODIUM 0 999PAMIDRONATE DISOD 30 MG VIAL No
P4L PAMIDRONATE DISODIUM 0 999PAMIDRONATE DISOD 90 MG VIAL No
P4L ZOLEDRONIC ACID 0 999ZOLEDRONIC ACID 4 MG VIAL No
P4L ZOLEDRONIC AC/MANNITOL/0.9NACL 0 999ZOLEDRONIC ACID 4 MG/100 ML No
P4L ZOLEDRONIC ACID 0 999ZOLEDRONIC ACID 4 MG/5 ML VIAL No
Tuesday, May 14, 2019 Page 153 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
P4L ZOLEDRONIC ACID/MANNITOL-WATER 0 999ZOLEDRONIC ACID 5 MG/100 ML No
P5A GLUCOCORTICOIDSP5A BETAMETHASONE ACETATE,SOD PHOS 0 999BETAMETHASONE AC-SP 6 MG/ML VL No
P5A BETAMETHASONE ACETATE,SOD PHOS 0 999BETAMETHASONE SP-AC 30 MG/5 ML No
P5A BUDESONIDE 0 999BUDESONIDE EC 3 MG CAPSULE No
P5A BETAMETHASONE ACETATE,SOD PHOS 0 999CELESTONE SOLUSPAN 30 MG/5 ML No
P5A DEXAMETHASONE 0 999DEXAMETHASONE 0.5 MG TABLET No
P5A DEXAMETHASONE 0 999DEXAMETHASONE 0.5 MG/0.5 ML No
P5A DEXAMETHASONE 0 999DEXAMETHASONE 0.5 MG/5 ML ELX No
P5A DEXAMETHASONE 0 999DEXAMETHASONE 0.5 MG/5 ML LIQ No
P5A DEXAMETHASONE 0 999DEXAMETHASONE 0.75 MG TABLET No
P5A DEXAMETHASONE 0 999DEXAMETHASONE 1 MG TABLET No
P5A DEXAMETHASONE 0 999DEXAMETHASONE 1.5 MG TABLET No
P5A DEXAMETHASONE SODIUM PHOSP/PF 0 999DEXAMETHASONE 10 MG/ML VIAL No
P5A DEXAMETHASONE SODIUM PHOSPHATE 0 999DEXAMETHASONE 10 MG/ML VIAL No
P5A DEXAMETHASONE SODIUM PHOSPHATE 0 999DEXAMETHASONE 100 MG/10 ML VL No
P5A DEXAMETHASONE SODIUM PHOSPHATE 0 999DEXAMETHASONE 120 MG/30 ML VL No
P5A DEXAMETHASONE 0 999DEXAMETHASONE 2 MG TABLET No
P5A DEXAMETHASONE SODIUM PHOSPHATE 0 999DEXAMETHASONE 20 MG/5 ML VIAL No
P5A DEXAMETHASONE 0 999DEXAMETHASONE 4 MG TABLET No
P5A DEXAMETHASONE SODIUM PHOSPHATE 0 999DEXAMETHASONE 4 MG/ML SYRINGE No
P5A DEXAMETHASONE SODIUM PHOSPHATE 0 999DEXAMETHASONE 4 MG/ML VIAL No
P5A DEXAMETHASONE 0 999DEXAMETHASONE 6 MG TABLET No
P5A HYDROCORTISONE 0 999HYDROCORTISONE 10 MG TABLET No
Tuesday, May 14, 2019 Page 154 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
P5A HYDROCORTISONE 0 999HYDROCORTISONE 20 MG TABLET No
P5A HYDROCORTISONE 0 999HYDROCORTISONE 5 MG TABLET No
P5A METHYLPREDNISOLONE SOD SUCC 0 999METHYLPRED SS 125 MG VIAL No
P5A METHYLPREDNISOLONE SOD SUCC 0 999METHYLPREDNISOLONE 1 GM VIAL No
P5A METHYLPREDNISOLONE 0 999METHYLPREDNISOLONE 16 MG TAB No
P5A METHYLPREDNISOLONE 0 999METHYLPREDNISOLONE 32 MG TAB No
P5A METHYLPREDNISOLONE 0 999METHYLPREDNISOLONE 4 MG DOSEPK No
P5A METHYLPREDNISOLONE 0 999METHYLPREDNISOLONE 4 MG TAB No
P5A METHYLPREDNISOLONE 0 999METHYLPREDNISOLONE 4 MG TABLET No
P5A METHYLPREDNISOLONE SOD SUCC 0 999METHYLPREDNISOLONE 40 MG VIAL No
P5A METHYLPREDNISOLONE ACETATE 0 999METHYLPREDNISOLONE 40 MG/ML VL No
P5A METHYLPREDNISOLONE 0 999METHYLPREDNISOLONE 8 MG TAB No
P5A METHYLPREDNISOLONE ACETATE 0 999METHYLPREDNISOLONE 80 MG/ML VL No
P5A METHYLPREDNISOLONE SOD SUCC 0 999METHYLPREDNISOLONE SS 1 GM VL No
P5A METHYLPREDNISOLONE SOD SUCC 0 999METHYLPREDNISOLONE SS 125 MG No
P5A METHYLPREDNISOLONE SOD SUCC 0 999METHYLPREDNISOLONE SS 40 MG VL No
P5A PREDNISOLONE SODIUM PHOSPHATE 0 999PREDNISOLONE 10 MG/5 ML SOLN No
P5A PREDNISOLONE SODIUM PHOSPHATE 0 999PREDNISOLONE 15 MG/5 ML SOLN No
P5A PREDNISOLONE 0 999PREDNISOLONE 15 MG/5 ML SYRUP No
P5A PREDNISOLONE SODIUM PHOSPHATE 0 999PREDNISOLONE 20 MG/5 ML SOLN No
P5A PREDNISOLONE SODIUM PHOSPHATE 0 999PREDNISOLONE 5 MG/5 ML SOLN No
P5A PREDNISOLONE SODIUM PHOSPHATE 0 999PREDNISOLONE SOD PH 25 MG/5 ML No
P5A PREDNISONE 0 999PREDNISONE 1 MG TABLET No
P5A PREDNISONE 0 999PREDNISONE 10 MG TAB DOSE PACK No
Tuesday, May 14, 2019 Page 155 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
P5A PREDNISONE 0 999PREDNISONE 10 MG TABLET No
P5A PREDNISONE 0 999PREDNISONE 2.5 MG TABLET No
P5A PREDNISONE 0 999PREDNISONE 20 MG TABLET No
P5A PREDNISONE 0 999PREDNISONE 5 MG TAB DOSE PACK No
P5A PREDNISONE 0 999PREDNISONE 5 MG TABLET No
P5A PREDNISONE 0 999PREDNISONE 5 MG/5 ML SOLUTION No
P5A PREDNISONE 0 999PREDNISONE 50 MG TABLET No
P5A HYDROCORTISONE SODIUM SUCC/PF 0 999SOLU-CORTEF (PF) 1,000 MG VIAL No
P5A HYDROCORTISONE SODIUM SUCC/PF 0 999SOLU-CORTEF 100 MG ACT-O-VIAL No
P5A HYDROCORTISONE SOD SUCCINATE 0 999SOLU-CORTEF 100 MG VIAL No
P5A HYDROCORTISONE SODIUM SUCC/PF 0 999SOLU-CORTEF 250 MG ACT-O-VIAL No
P5A HYDROCORTISONE SODIUM SUCC/PF 0 999SOLU-CORTEF 500 MG ACT-O-VIAL No
P5S MINERALOCORTICOIDSP5S FLUDROCORTISONE ACETATE 0 999FLUDROCORTISONE 0.1 MG TAB No
P5S FLUDROCORTISONE ACETATE 0 999FLUDROCORTISONE 0.1 MG TABLET No
Q2C OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPEQ2C CYCLOSPORINE 0 999RESTASIS 0.05% EYE EMULSION No
Q2C CYCLOSPORINE 0 999RESTASIS MULTIDOSE 0.05% EYE No
Q2L OPHTHALMIC CYSTINE DEPLETING AGENTSQ2L CYSTEAMINE HCL 0 999CYSTARAN 0.44% EYE DROPS No
Q3B RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR)Q3B HYDROCORTISONE 0 999HYDROCORTISONE 100 MG/60 ML No
Q3E CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TXQ3E MESALAMINE 0 999CANASA 1,000 MG SUPP PAC No
Q3E MESALAMINE 0 999CANASA 1,000 MG SUPPOSITORY No
Q3I HEMORRHOID PREP,ANTI-INFLAM STEROID-LOCAL ANESTHET
Tuesday, May 14, 2019 Page 156 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Q3I HYDROCORTISONE/LIDOCAINE/ALOE 0 999LIDOCAINE-HC 2.8-0.55% GEL No
Q3I LIDOCAINE/HYDROCORTISONE AC 0 999LIDOCAINE-HC 3-0.5% CREAM No
Q3I HYDROCORTISONE/LIDOCAINE/ALOE 0 999LIDOCAINE-HC 3-2.5% GEL KIT No
Q3I HYDROCORTISONE/PRAMOXINE 0 999PROCTOFOAM-HC 1%-1% FOAM No
Q4F VAGINAL ANTIFUNGALSQ4F CLOTRIMAZOLE 0 9993 DAY VAGINAL 2% CREAM No
Q4F CLOTRIMAZOLE 0 9993-DAY VAGINAL CREAM No
Q4F CLOTRIMAZOLE 0 999CLOTRIM 1% VAGINAL CREAM No
Q4F CLOTRIMAZOLE 0 999CLOTRIMAZOLE 1% CREAM No
Q4F CLOTRIMAZOLE 0 999CLOTRIMAZOLE 3 DAY CREAM No
Q4F BUTOCONAZOLE NITRATE 0 999GYNAZOLE 1 2% CREAM No
Q4F MICONAZOLE NITRATE 0 999MICONAZOLE 1 COMBINATION PACK No
Q4F MICONAZOLE NITRATE 0 999MICONAZOLE 100 MG VAG SUPP No
Q4F MICONAZOLE NITRATE 0 999MICONAZOLE 3 200 MG VAG SUPP No
Q4F MICONAZOLE NITRATE 0 999MICONAZOLE 3 4% CREAM No
Q4F MICONAZOLE NITRATE 0 999MICONAZOLE 7 100 MG VAG SUPP No
Q4F MICONAZOLE NITRATE 0 999MICONAZOLE 7 CREAM No
Q4F MICONAZOLE NITRATE 0 999MICONAZOLE NITRATE 2% CREAM No
Q4F MICONAZOLE NITRATE 0 999QC 3 DAY VAGINAL 4% CREAM No
Q4F MICONAZOLE NITRATE 0 999QC MICONAZOLE 7 CREAM No
Q4F CLOTRIMAZOLE 0 999SM CLOTRIMAZOLE 1% CREAM No
Q4F MICONAZOLE NITRATE 0 999SM MICONAZOLE 7 100 MG VAG SUP No
Q4F MICONAZOLE NITRATE 0 999SM MICONAZOLE NITRATE 2% CREAM No
Q4F TIOCONAZOLE 0 999SM TIOCONAZOLE-1 6.5% OINTMENT No
Tuesday, May 14, 2019 Page 157 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Q4F CLOTRIMAZOLE 0 999SUNMARK 3-DAY VAGINAL CREAM No
Q4F MICONAZOLE NITRATE 0 999SUNMARK MICONAZOLE 7 CREAM No
Q4F TERCONAZOLE 0 999TERCONAZOLE 0.4% CREAM No
Q4F TERCONAZOLE 0 999TERCONAZOLE 0.8% VAGINAL CR No
Q4K VAGINAL ESTROGEN PREPARATIONSQ4K ESTRADIOL 0 999ESTRING 2 MG VAGINAL RING No
Q4K ESTROGENS, CONJUGATED 0 999PREMARIN VAGINAL CREAM-APPL No
Q4K ESTRADIOL 0 999VAGIFEM 10 MCG VAGINAL TAB No
Q4W VAGINAL ANTIBIOTICSQ4W CLINDAMYCIN PHOSPHATE 0 999CLEOCIN 100 MG VAGINAL OVULE No
Q4W CLINDAMYCIN PHOSPHATE 0 999CLINDESSE 2% VAGINAL CREAM No
Q4W METRONIDAZOLE 0 999NUVESSA VAGINAL 1.3% GEL No
Q5B TOPICAL PREPARATIONS,ANTIBACTERIALSQ5B HYDROCORTISONE/IODOQUINOL 0 999HYDROCORTISONE-IODOQUINOL CRM No
Q5B SILVER NITRATE 0 999SILVER NITRATE 0.5% SOLN No
Q5E TOPICAL ANTI-INFLAMMATORY, NSAIDSQ5E DICLOFENAC SODIUM 0 999VOLTAREN 1% GEL No
Q5F TOPICAL ANTIFUNGALSQ5F CICLOPIROX OLAMINE 0 999CICLOPIROX 0.77% CREAM No
Q5F CICLOPIROX OLAMINE 0 999CICLOPIROX 0.77% TOPICAL SUSP No
Q5F CICLOPIROX 0 999CICLOPIROX 8% SOLUTION No
Q5F CICLOPIROX OLAMINE 0 999CICLOPIROX OLAMINE 0.77% CREAM No
Q5F CLOTRIMAZOLE 0 999CLOTRIMAZOLE 1% CREAM No
Q5F CLOTRIMAZOLE 0 999CLOTRIMAZOLE 1% SOLUTION No
Q5F ECONAZOLE NITRATE 0 999ECONAZOLE NITRATE 1% CREAM No
Tuesday, May 14, 2019 Page 158 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Q5F KETOCONAZOLE 0 999KETOCONAZOLE 2% CREAM No
Q5F KETOCONAZOLE 0 999KETOCONAZOLE 2% SHAMPOO No
Q5F MICONAZOLE NITRATE 0 999MICONAZOLE NITRATE 2% CREAM No
Q5F NYSTATIN 0 999NYSTATIN 100,000 UNIT/GM CREAM No
Q5F NYSTATIN 0 999NYSTATIN 100,000 UNIT/GM OINT No
Q5F NYSTATIN 0 999NYSTATIN 100,000 UNIT/GM POWD No
Q5F NYSTATIN 0 999NYSTATIN 100,000 UNITS/GM OINT No
Q5H TOPICAL LOCAL ANESTHETICSQ5H LIDOCAINE HCL 0 999LIDOCAINE 3% CREAM No
Q5H LIDOCAINE 0 999LIDOCAINE 5% OINTMENT No
Q5H LIDOCAINE 0 999LIDOCAINE 5% PATCH Auto PA
Q5H LIDOCAINE/PRILOCAINE 0 999LIDOCAINE-PRILOCAINE CREAM No
Q5K TOPICAL IMMUNOSUPPRESSIVE AGENTSQ5K PIMECROLIMUS 0 999ELIDEL 1% CREAM No
Q5K TACROLIMUS 0 999PROTOPIC 0.03% OINTMENT No
Q5K TACROLIMUS 16 999PROTOPIC 0.1% OINTMENT No
Q5M TOPICAL ANTIFUNGAL/ANTI-INFLAMMATORY,STEROID AGENTQ5M CLOTRIMAZOLE/BETAMETHASONE DIP 0 999CLOTRIMAZOLE/BETAMETH CREAM No
Q5M CLOTRIMAZOLE/BETAMETHASONE DIP 0 999CLOTRIMAZOLE-BETAMETH CREAM No
Q5M CLOTRIMAZOLE/BETAMETHASONE DIP 0 999CLOTRIMAZOLE-BETAMETHASONE CRM No
Q5N TOPICAL ANTINEOPLASTIC PREMALIGNANT LESION AGENTSQ5N DICLOFENAC SODIUM 18 999DICLOFENAC SODIUM 3% GEL Auto PA
Q5N FLUOROURACIL 0 999FLUOROURACIL 0.5% CREAM No
Q5N FLUOROURACIL 0 999FLUOROURACIL 2% SOLUTION No
Q5N FLUOROURACIL 0 999FLUOROURACIL 5% CREAM No
Tuesday, May 14, 2019 Page 159 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Q5N FLUOROURACIL 0 999FLUOROURACIL 5% SOLUTION No
Q5N ALITRETINOIN 0 999PANRETIN 0.1% GEL Clinical PA Required
Q5P TOPICAL ANTI-INFLAMMATORY STEROIDALQ5P HYDROCORTISONE 0 999ANUSOL-HC 2.5% CREAM No
Q5P BETAMETHASONE/PROPYLENE GLYC 0 999BETAMETHASONE DP 0.05% CRM No
Q5P BETAMETHASONE/PROPYLENE GLYC 0 999BETAMETHASONE DP AUG 0.05% CRM No
Q5P BETAMETHASONE VALERATE 0 999BETAMETHASONE VA 0.1% CREAM No
Q5P CLOBETASOL PROPIONATE 0 999CLOBETASOL 0.05% CREAM No
Q5P CLOBETASOL PROPIONATE/EMOLL 0 999CLOBETASOL 0.05% CREAM No
Q5P CLOBETASOL PROPIONATE 0 999CLOBETASOL 0.05% GEL No
Q5P CLOBETASOL PROPIONATE 0 999CLOBETASOL 0.05% OINTMENT No
Q5P CLOBETASOL PROPIONATE 0 999CLOBETASOL 0.05% SOLUTION No
Q5P CLOBETASOL PROPIONATE/EMOLL 0 999CLOBETASOL EMOLLIENT 0.05% CRM No
Q5P FLUOCINOLONE ACETONIDE 0 999DERMA-SMOOTHE-FS BODY OIL No
Q5P FLUOCINOLONE/SHOWER CAP 0 999DERMA-SMOOTHE-FS SCALP OIL No
Q5P FLUTICASONE PROPIONATE 0 999FLUTICASONE PROP 0.005% OINT No
Q5P FLUTICASONE PROPIONATE 0 999FLUTICASONE PROP 0.05% CREAM No
Q5P HALOBETASOL PROPIONATE 0 999HALOBETASOL PROP 0.05% CREAM No
Q5P HALOBETASOL PROPIONATE 0 999HALOBETASOL PROP 0.05% OINT No
Q5P HALOBETASOL PROPIONATE 0 999HALOBETASOL PROP 0.05% OINTMNT No
Q5P HYDROCORTISONE 0 999HYDROCORTISONE 1% CREAM No
Q5P HYDROCORTISONE 0 999HYDROCORTISONE 1% OINTMENT No
Q5P HYDROCORTISONE 0 999HYDROCORTISONE 2.5% CREAM No
Q5P HYDROCORTISONE 0 999HYDROCORTISONE 2.5% OINT No
Tuesday, May 14, 2019 Page 160 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Q5P MOMETASONE FUROATE 0 999MOMETASONE FUROATE 0.1% CREAM No
Q5P MOMETASONE FUROATE 0 999MOMETASONE FUROATE 0.1% OINT No
Q5P MOMETASONE FUROATE 0 999MOMETASONE FUROATE 0.1% ONT No
Q5P MOMETASONE FUROATE 0 999MOMETASONE FUROATE 0.1% SOLN No
Q5P HYDROCORTISONE 0 999PROCTOSOL-HC 2.5% CREAM No
Q5P HYDROCORTISONE 0 999PROCTOZONE-HC 2.5% CREAM No
Q5P TRIAMCINOLONE ACETONIDE 0 999TRIAMCINOLONE 0.025% CREAM No
Q5P TRIAMCINOLONE ACETONIDE 0 999TRIAMCINOLONE 0.025% OINT No
Q5P TRIAMCINOLONE ACETONIDE 0 999TRIAMCINOLONE 0.1% CREAM No
Q5P TRIAMCINOLONE ACETONIDE 0 999TRIAMCINOLONE 0.1% OINTMENT No
Q5P TRIAMCINOLONE ACETONIDE 0 999TRIAMCINOLONE 0.5% CREAM No
Q5P TRIAMCINOLONE ACETONIDE 0 999TRIAMCINOLONE 0.5% OINTMENT No
Q5R TOPICAL ANTIPARASITICSQ5R SPINOSAD 0 999NATROBA 0.9% TOPICAL SUSP No
Q5R PERMETHRIN 0 999PERMETHRIN 5% CREAM No
Q5R IVERMECTIN 0 999SKLICE 0.5% LOTION No
Q5S TOPICAL SULFONAMIDESQ5S SILVER SULFADIAZINE 0 999SILVER SULFADIAZINE 1% CREAM No
Q5S SILVER SULFADIAZINE 0 999SILVER SULFADIAZINE 1% CRM No
Q5V TOPICAL ANTIVIRALSQ5V PENCICLOVIR 0 999DENAVIR 1% CREAM No
Q5V ACYCLOVIR 12 999ZOVIRAX 5% CREAM No
Q5V ACYCLOVIR 12 999ZOVIRAX 5% OINTMENT No
Q5W TOPICAL ANTIBIOTICSQ5W CLINDAMYCIN PHOSPHATE 12 999CLINDAMYCIN PH 1% SOLUTION No
Tuesday, May 14, 2019 Page 161 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Q5W CLINDAMYCIN PHOSPHATE 12 999CLINDAMYCIN PHOS 1% PLEDGET No
Q5W GENTAMICIN SULFATE 0 999GENTAMICIN 0.1% CREAM No
Q5W MUPIROCIN 0 999MUPIROCIN 2% OINTMENT No
Q5X TOPICAL ANTIBIOTIC AND ANTI-INFLAMMATORY STEROIDQ5X NEOMYCIN/POLYMYXIN B/HYDROCORT 0 999CORTISPORIN CREAM No
Q5X NEOMYC/BACIT/POLYMYX/HYDROCORT 0 999CORTISPORIN OINTMENT No
Q6C EYE VASOCONSTRICTORSQ6C PHENYLEPHRINE HCL 0 999PHENYLEPHRINE 10% EYE DROPS No
Q6C PHENYLEPHRINE HCL 0 999PHENYLEPHRINE 2.5% EYE DROP No
Q6E EYE IRRIGATIONSQ6E BALANCED SALT IRRIG SOLN NO.2 0 999BALANCED SALT SOLUTION No
Q6G MIOTICS AND OTHER INTRAOCULAR PRESSURE REDUCERSQ6G BRINZOLAMIDE 0 999AZOPT 1% EYE DROPS No
Q6G BRIMONIDINE TARTRATE 0 999BRIMONIDINE 0.2% EYE DROP No
Q6G BRIMONIDINE TARTRATE 0 999BRIMONIDINE 0.2% EYE DROPS No
Q6G CARTEOLOL HCL 0 999CARTEOLOL HCL 1% EYE DROPS No
Q6G BRIMONIDINE TARTRATE/TIMOLOL 0 999COMBIGAN 0.2%-0.5% EYE DROPS No
Q6G BRIMONIDINE TARTRATE/TIMOLOL 0 999COMBIGAN EYE DROPS No
Q6G DORZOLAMIDE HCL 0 999DORZOLAMIDE HCL 2% EYE DROPS No
Q6G DORZOLAMIDE HCL/TIMOLOL MALEAT 0 999DORZOLAMIDE-TIMOLOL EYE DROPS No
Q6G LATANOPROST 0 999LATANOPROST 0.005% EYE DROPS No
Q6G LEVOBUNOLOL HCL 0 999LEVOBUNOLOL 0.5% EYE DROPS No
Q6G NETARSUDIL MESYLATE 18 999RHOPRESSA 0.02% OPHTH SOLUTION Auto PA
Q6G BRINZOLAMIDE/BRIMONIDINE TART 0 999SIMBRINZA 1%-0.2% EYE DROPS No
Q6G TIMOLOL MALEATE 0 999TIMOLOL 0.25% EYE DROPS No
Tuesday, May 14, 2019 Page 162 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Q6G TIMOLOL MALEATE 0 999TIMOLOL 0.25% GEL /SOLUTION No
Q6G TIMOLOL MALEATE 0 999TIMOLOL 0.25% GEL-SOLUTION No
Q6G TIMOLOL MALEATE 0 999TIMOLOL 0.5% EYE DROP No
Q6G TIMOLOL MALEATE 0 999TIMOLOL 0.5% EYE DROPS No
Q6G TIMOLOL MALEATE 0 999TIMOLOL 0.5% GEL/SOLUTION No
Q6G TIMOLOL MALEATE 0 999TIMOLOL 0.5% GEL-SOLUTION No
Q6G TRAVOPROST 0 999TRAVATAN Z 0.004% EYE DROP No
Q6I EYE ANTIBIOTIC AND GLUCOCORTICOID COMBINATIONSQ6I NEOMYCIN/BACIT/P-MYX/HYDROCORT 0 999NEO/BACIT/POLY/HC EYE OINT No
Q6I NEOMYCIN/POLYMYXIN B/DEXAMETHA 0 999NEO/POLY/DEXAMET EYE OINT No
Q6I NEOMYCIN/POLYMYXIN B/DEXAMETHA 0 999NEO/POLYMYXIN/DEXAMETH DROP No
Q6I NEOMYCIN/BACIT/P-MYX/HYDROCORT 0 999NEO-BACIT-POLY-HC EYE OINTMENT No
Q6I NEOMYCIN/POLYMYXIN B/DEXAMETHA 0 999NEOMYC-POLYM-DEXAMET EYE OINTM No
Q6I TOBRAMYCIN/DEXAMETHASONE 0 999TOBRADEX EYE DROPS No
Q6I TOBRAMYCIN/DEXAMETHASONE 0 999TOBRADEX EYE OINTMENT No
Q6I TOBRAMYCIN/LOTEPRED ETAB 0 999ZYLET EYE DROPS No
Q6J MYDRIATICSQ6J ATROPINE SULFATE 0 999ATROPINE 1% EYE DROPS No
Q6J ATROPINE SULFATE 0 999ATROPINE 1% EYE OINTMENT No
Q6J CYCLOPENTOLATE HCL 0 999CYCLOPENTOLATE 0.5% EYE DROPS No
Q6J CYCLOPENTOLATE HCL 0 999CYCLOPENTOLATE 1% EYE DROPS No
Q6J CYCLOPENTOLATE HCL 0 999CYCLOPENTOLATE HCL 2% DROPS No
Q6P EYE ANTI-INFLAMMATORY AGENTSQ6P LOTEPREDNOL ETABONATE 0 999ALREX 0.2% EYE DROPS No
Q6P DEXAMETHASONE SODIUM PHOSPHATE 0 999DEXAMETHASONE 0.1% EYE DROP No
Tuesday, May 14, 2019 Page 163 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Q6P DICLOFENAC SODIUM 0 999DICLOFENAC 0.1% EYE DROPS No
Q6P DICLOFENAC SODIUM 0 999DICLOFENAC SODIUM 0.1 % SOLN No
Q6P DIFLUPREDNATE 0 999DUREZOL 0.05% EYE DROPS No
Q6P FLUOROMETHOLONE ACETATE 0 999FLAREX 0.1% EYE DROPS No
Q6P FLURBIPROFEN SODIUM 0 999FLURBIPROFEN 0.03% EYE DROP No
Q6P FLUOROMETHOLONE 0 999FML FORTE 0.25% EYE DROPS No
Q6P FLUOROMETHOLONE 0 999FML S.O.P. 0.1% OINTMENT No
Q6P NEPAFENAC 0 999ILEVRO 0.3% OPHTH DROPS No
Q6P KETOROLAC TROMETHAMINE 0 999KETOROLAC 0.5% OPHTH SOLUTION No
Q6P LOTEPREDNOL ETABONATE 0 999LOTEMAX 0.5% EYE DROPS No
Q6P DEXAMETHASONE 0 999MAXIDEX 0.1% EYE DROPS No
Q6P PREDNISOLONE ACETATE 0 999PREDNISOLONE AC 1% EYE DROP No
Q6R EYE ANTIHISTAMINESQ6R OLOPATADINE HCL 0 999OLOPATADINE HCL 0.1% EYE DROPS No
Q6R OLOPATADINE HCL 0 999PAZEO 0.7% EYE DROPS No
Q6S EYE SULFONAMIDESQ6S SULFACETAMIDE/PREDNISOLONE SP 0 999SULF-PRED 0.25% EYE DROPS No
Q6U EYE MAST CELL STABILIZERSQ6U CROMOLYN SODIUM 0 999CROMOLYN 4% EYE DROPS No
Q6U CROMOLYN SODIUM 0 999CROMOLYN SODIUM 4% EYE DROP No
Q6V EYE ANTIVIRALSQ6V TRIFLURIDINE 0 999TRIFLURIDINE 1% OPHTHAL SOLN No
Q6W OPHTHALMIC ANTIBIOTICSQ6W BACITRACIN/POLYMYXIN B SULFATE 0 999BACIT/POLYMYXIN EYE OINT No
Q6W CIPROFLOXACIN HCL 0 999CIPROFLOXACIN 0.3% EYE DROP No
Tuesday, May 14, 2019 Page 164 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Q6W ERYTHROMYCIN BASE 0 999ERYTHROMYCIN 0.5% EYE OINTMENT No
Q6W ERYTHROMYCIN BASE 0 999ERYTHROMYCIN EYE OINTMENT No
Q6W GENTAMICIN SULFATE 0 999GENTAMICIN 3 MG/ML EYE DROPS No
Q6W MOXIFLOXACIN HCL 0 999MOXEZA 0.5% EYE DROPS No
Q6W MOXIFLOXACIN HCL 0 999MOXIFLOXACIN 0.5% EYE DROP No
Q6W MOXIFLOXACIN HCL 0 999MOXIFLOXACIN 0.5% EYE DROPS No
Q6W NEOMYCIN SULF/BACITRACIN/POLY 0 999NEO/BACIT/POLY EYE OINTMENT No
Q6W NEOMYCIN SULF/BACITRACIN/POLY 0 999NEOMYC-BACIT-POLYMIX EYE OINT No
Q6W OFLOXACIN 0 999OFLOXACIN 0.3% EYE DROPS No
Q6W POLYMYXIN B SULF/TRIMETHOPRIM 0 999POLYMYXIN B/TMP EYE DROPS No
Q6W TOBRAMYCIN 0 999TOBRAMYCIN 0.3% EYE DROPS No
Q7E NASAL ANTIHISTAMINEQ7E AZELASTINE HCL 0 999AZELASTINE 0.1% (137 MCG) SPRY No
Q7E AZELASTINE HCL 0 999AZELASTINE 0.15% NASAL SPRAY No
Q7E AZELASTINE HCL 0 999AZELASTINE 137 MCG NASAL SPRAY No
Q7E AZELASTINE HCL 0 999AZELASTINE HCL 0.1% NASAL SPRY No
Q7E AZELASTINE HCL 0 999AZELASTINE HCL 137 MCG SPRAY No
Q7P NASAL ANTI-INFLAMMATORY STEROIDSQ7P FLUTICASONE PROPIONATE 0 999FLUTICASONE 50 MCG NASAL SPRAY No
Q7P FLUTICASONE PROPIONATE 0 999FLUTICASONE PROP 50 MCG SPRAY No
Q7P MOMETASONE FUROATE 0 999MOMETASONE FUROATE 50 MCG SPRY No
Q7W NOSE PREPARATIONS ANTIBIOTICSQ7W MUPIROCIN CALCIUM 0 999BACTROBAN NASAL 2% OINTMENT No
Q8B EAR PREPARATIONS, MISC. ANTI-INFECTIVESQ8B ACETIC ACID 0 999ACETIC ACID 2% EAR SOLUTION No
Tuesday, May 14, 2019 Page 165 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Q8F OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICSQ8F CIPROFLOXACIN HCL/DEXAMETH 0 999CIPRODEX OTIC SUSPENSION No
Q8P EAR PREPARATIONS ANTI-INFLAMMATORYQ8P FLUOCINOLONE ACETONIDE OIL 0 999FLUOCINOLONE OIL 0.01% EAR DRP No
Q8W EAR PREPARATIONS,ANTIBIOTICSQ8W NEOMYCIN/POLYMYXIN B/HYDROCORT 0 999NEO/POLYMYXIN/HC EAR SOLN No
Q8W NEOMYCIN/POLYMYXIN B/HYDROCORT 0 999NEO/POLYMYXIN/HC EAR SUSP No
Q8W NEOMYCIN/POLYMYXIN B/HYDROCORT 0 999NEO-POLYMYXIN-HC EAR SUSP No
Q8W OFLOXACIN 0 999OFLOXACIN 0.3% EAR DROPS No
Q9B BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTSQ9B ALFUZOSIN HCL 0 999ALFUZOSIN HCL ER 10 MG TABLET No
Q9B DUTASTERIDE 0 999DUTASTERIDE 0.5 MG CAPSULE No
Q9B FINASTERIDE 0 999FINASTERIDE 5 MG TABLET No
Q9B TAMSULOSIN HCL 0 999TAMSULOSIN HCL 0.4 MG CAPSULE No
R1A URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENTR1A OXYBUTYNIN CHLORIDE 0 999OXYBUTYNIN 5 MG TABLET No
R1A OXYBUTYNIN CHLORIDE 0 999OXYBUTYNIN 5 MG/5 ML SYRUP No
R1A OXYBUTYNIN CHLORIDE 0 999OXYBUTYNIN CL ER 10 MG TABLET No
R1A OXYBUTYNIN CHLORIDE 0 999OXYBUTYNIN CL ER 15 MG TABLET No
R1A OXYBUTYNIN CHLORIDE 0 999OXYBUTYNIN CL ER 5 MG TABLET No
R1A FESOTERODINE FUMARATE 18 999TOVIAZ 4 MG ER TABLET No
R1A FESOTERODINE FUMARATE 18 999TOVIAZ 8 MG ER TABLET No
R1E CARBONIC ANHYDRASE INHIBITORSR1E ACETAZOLAMIDE 0 999ACETAZOLAMIDE 125 MG TABLET No
R1E ACETAZOLAMIDE 0 999ACETAZOLAMIDE 250 MG TABLET No
R1E ACETAZOLAMIDE 0 999ACETAZOLAMIDE ER 500 MG CAP No
Tuesday, May 14, 2019 Page 166 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
R1E METHAZOLAMIDE 0 999METHAZOLAMIDE 25 MG TABLET No
R1E METHAZOLAMIDE 0 999METHAZOLAMIDE 50 MG TABLET No
R1F THIAZIDE AND RELATED DIURETICSR1F CHLOROTHIAZIDE 0 999CHLOROTHIAZIDE 250 MG TABLET No
R1F CHLOROTHIAZIDE 0 999CHLOROTHIAZIDE 500 MG TABLET No
R1F CHLORTHALIDONE 0 999CHLORTHALIDONE 25 MG TABLET No
R1F CHLORTHALIDONE 0 999CHLORTHALIDONE 50 MG TABLET No
R1F CHLOROTHIAZIDE 0 11DIURIL 250 MG/5 ML ORAL SUSP No
R1F HYDROCHLOROTHIAZIDE 0 999HYDROCHLOROTHIAZIDE 12.5 MG No
R1F HYDROCHLOROTHIAZIDE 0 999HYDROCHLOROTHIAZIDE 12.5 MG CP No
R1F HYDROCHLOROTHIAZIDE 0 999HYDROCHLOROTHIAZIDE 12.5 MG TB No
R1F HYDROCHLOROTHIAZIDE 0 999HYDROCHLOROTHIAZIDE 25 MG TAB No
R1F HYDROCHLOROTHIAZIDE 0 999HYDROCHLOROTHIAZIDE 25 MG TB No
R1F HYDROCHLOROTHIAZIDE 0 999HYDROCHLOROTHIAZIDE 50 MG TAB No
R1F HYDROCHLOROTHIAZIDE 0 999HYDROCHLOROTHIAZIDE 50 MG TB No
R1F INDAPAMIDE 0 999INDAPAMIDE 1.25 MG TABLET No
R1F INDAPAMIDE 0 999INDAPAMIDE 2.5 MG TABLET No
R1F METOLAZONE 0 999METOLAZONE 10 MG TABLET No
R1F METOLAZONE 0 999METOLAZONE 2.5 MG TABLET No
R1F METOLAZONE 0 999METOLAZONE 5 MG TABLET No
R1H POTASSIUM SPARING DIURETICSR1H AMILORIDE HCL 0 999AMILORIDE HCL 5 MG TABLET No
R1H EPLERENONE 0 999EPLERENONE 25 MG TABLET No
R1H EPLERENONE 0 999EPLERENONE 50 MG TABLET No
Tuesday, May 14, 2019 Page 167 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
R1H SPIRONOLACTONE 0 999SPIRONOLACTONE 100 MG TABLET No
R1H SPIRONOLACTONE 0 999SPIRONOLACTONE 25 MG TABLET No
R1H SPIRONOLACTONE 0 999SPIRONOLACTONE 50 MG TABLET No
R1I URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG.R1I SOLIFENACIN SUCCINATE 18 999VESICARE 10 MG TABLET No
R1I SOLIFENACIN SUCCINATE 18 999VESICARE 5 MG TABLET No
R1L POTASSIUM SPARING DIURETICS IN COMBINATIONR1L AMILORIDE/HYDROCHLOROTHIAZIDE 0 999AMILORIDE HCL/HCTZ 5/50 TAB No
R1L SPIRONOLACT/HYDROCHLOROTHIAZID 0 999SPIRONOLACT/HCTZ 25/25 TAB No
R1L SPIRONOLACT/HYDROCHLOROTHIAZID 0 999SPIRONOLACTONE-HCTZ 25-25 TAB No
R1L TRIAMTERENE/HYDROCHLOROTHIAZID 0 999TRIAMTERENE/HCTZ 37.5/25 CP No
R1L TRIAMTERENE/HYDROCHLOROTHIAZID 0 999TRIAMTERENE/HCTZ 37.5/25 TB No
R1L TRIAMTERENE/HYDROCHLOROTHIAZID 0 999TRIAMTERENE/HCTZ 50/25 CAP No
R1L TRIAMTERENE/HYDROCHLOROTHIAZID 0 999TRIAMTERENE/HCTZ 75/50 TAB No
R1L TRIAMTERENE/HYDROCHLOROTHIAZID 0 999TRIAMTERENE-HCTZ 37.5-25 MG CP No
R1L TRIAMTERENE/HYDROCHLOROTHIAZID 0 999TRIAMTERENE-HCTZ 37.5-25 MG TB No
R1L TRIAMTERENE/HYDROCHLOROTHIAZID 0 999TRIAMTERENE-HCTZ 75/50 TAB No
R1L TRIAMTERENE/HYDROCHLOROTHIAZID 0 999TRIAMTERENE-HCTZ 75-50 MG TAB No
R1M LOOP DIURETICSR1M BUMETANIDE 0 999BUMETANIDE 0.25 MG/ML VIAL No
R1M BUMETANIDE 0 999BUMETANIDE 0.5 MG TABLET No
R1M BUMETANIDE 0 999BUMETANIDE 1 MG TABLET No
R1M BUMETANIDE 0 999BUMETANIDE 1 MG/4 ML VIAL No
R1M BUMETANIDE 0 999BUMETANIDE 2 MG TABLET No
R1M BUMETANIDE 0 999BUMETANIDE 2.5 MG/10 ML VIAL No
Tuesday, May 14, 2019 Page 168 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
R1M FUROSEMIDE 0 999FUROSEMIDE 10 MG/ML SOLUTION No
R1M FUROSEMIDE 0 999FUROSEMIDE 10 MG/ML SYRINGE No
R1M FUROSEMIDE 0 999FUROSEMIDE 10 MG/ML VIAL No
R1M FUROSEMIDE 0 999FUROSEMIDE 100 MG/10 ML SYRING No
R1M FUROSEMIDE 0 999FUROSEMIDE 100 MG/10 ML VIAL No
R1M FUROSEMIDE 0 999FUROSEMIDE 20 MG TABLET No
R1M FUROSEMIDE 0 999FUROSEMIDE 20 MG/2 ML VIAL No
R1M FUROSEMIDE 0 999FUROSEMIDE 40 MG TABLET No
R1M FUROSEMIDE 0 999FUROSEMIDE 40 MG/4 ML SYRINGE No
R1M FUROSEMIDE 0 999FUROSEMIDE 40 MG/4 ML VIAL No
R1M FUROSEMIDE 0 999FUROSEMIDE 40 MG/5 ML SOLN No
R1M FUROSEMIDE 0 999FUROSEMIDE 80 MG TABLET No
R1M TORSEMIDE 0 999TORSEMIDE 10 MG TABLET No
R1M TORSEMIDE 0 999TORSEMIDE 100 MG TABLET No
R1M TORSEMIDE 0 999TORSEMIDE 20 MG TABLET No
R1M TORSEMIDE 0 999TORSEMIDE 5 MG TABLET No
R1R URICOSURIC AGENTSR1R PROBENECID 0 999PROBENECID 500 MG TABLET No
R1R PROBENECID/COLCHICINE 0 999PROBENECID/COLCHICINE TABS No
R1R PROBENECID/COLCHICINE 0 999PROBENECID-COLCHICINE TABS No
R1S URINARY PH MODIFIERSR1S SOD PHOS,M-B/K PHOS,MONOB 0 999K-PHOS #2 TABLET No
R1S SOD PHOS DI, MONO/K PHOS MONO 0 999K-PHOS NEUTRAL TABLET No
R1S POTASSIUM PHOSPHATE,MONOBASIC 0 999K-PHOS ORIGINAL TABLET No
Tuesday, May 14, 2019 Page 169 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
R1S CITRIC ACID/SODIUM CITRATE 0 999ORACIT ORAL SOLUTION No
R1S CITRIC ACID/SODIUM CITRATE 0 999ORACIT SOLUTION 15 ML No
R1S CITRIC ACID/SODIUM CITRATE 0 999ORACIT SOLUTION 30 ML No
R1S SOD PHOS DI, MONO/K PHOS MONO 0 999PHOSPHA 250 NEUTRAL TABLET No
R1S POTASSIUM CITRATE/CITRIC ACID 0 999POT CITRATE-CITRIC ACID PACKET No
R1S SOD/POT/K CIT/SOD CIT/CIT ACID 0 999POTASS CIT-SOD CIT-CITRIC SOLN No
R1S POTASSIUM CITRATE/CITRIC ACID 0 999POTASSIUM CIT-CITRIC ACID SOLN No
R1S POTASSIUM CITRATE 0 999POTASSIUM CITRATE 10 MEQ TABLE No
R1S POTASSIUM CITRATE 0 999POTASSIUM CITRATE 5 MEQ TABLET No
R1S POTASSIUM CITRATE 0 999POTASSIUM CITRATE ER 10 MEQ TB No
R1S POTASSIUM CITRATE 0 999POTASSIUM CITRATE ER 15 MEQ TB No
R1S POTASSIUM CITRATE 0 999POTASSIUM CITRATE ER 5 MEQ TAB No
R1S CITRIC AC/GLUCONOLACT/MAG CARB 0 999RENACIDIN IRRIGATION SOLUTION No
R1S CITRIC ACID/SODIUM CITRATE 0 999SOD CITRATE/CITRIC ACID SOL No
R1S CITRIC ACID/SODIUM CITRATE 0 999SOD CITRATE-CITRIC ACID SOLN No
R1S SOD/POT/K CIT/SOD CIT/CIT ACID 0 999TRICITRATES SOLUTION No
R1S SOD PHOS DI, MONO/K PHOS MONO 0 999VIRT-PHOS 250 NEUTRAL TABLET No
R1S CITRIC ACID/SODIUM CITRATE 0 999VIRTRATE-2 SOLUTION No
R1S SOD/POT/K CIT/SOD CIT/CIT ACID 0 999VIRTRATE-3 SOLUTION No
R1S POTASSIUM CITRATE/CITRIC ACID 0 999VIRTRATE-K SOLUTION No
R1W CYSTINE-DEPLETING AGENTS, NEPHROPATHIC CYSTINOSISR1W CYSTEAMINE BITARTRATE 0 999CYSTAGON 150 MG CAPSULE No
R1W CYSTEAMINE BITARTRATE 0 999CYSTAGON 50 MG CAPSULE No
R4A KIDNEY STONE AGENTS
Tuesday, May 14, 2019 Page 170 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
R4A TIOPRONIN 0 999THIOLA 100 MG TABLET No
R5A URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE)R5A PHENAZOPYRIDINE HCL 0 999PHENAZOPYRIDINE 100 MG TAB No
R5A PHENAZOPYRIDINE HCL 0 999PHENAZOPYRIDINE 200 MG TAB No
S2A COLCHICINES2A COLCHICINE 18 999COLCHICINE 0.6 MG CAPSULE No
S2A COLCHICINE 4 999COLCHICINE 0.6 MG TABLET No
S2B NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICSS2B DICLOFENAC POTASSIUM 0 999DICLOFENAC POT 50 MG TABLET No
S2B DICLOFENAC SODIUM 0 999DICLOFENAC SOD 50 MG TAB EC No
S2B DICLOFENAC SODIUM 0 999DICLOFENAC SOD 75 MG TAB EC No
S2B DICLOFENAC SODIUM 0 999DICLOFENAC SOD DR 25 MG TAB No
S2B DICLOFENAC SODIUM 0 999DICLOFENAC SOD DR 50 MG TAB No
S2B DICLOFENAC SODIUM 0 999DICLOFENAC SOD DR 75 MG TAB No
S2B DICLOFENAC SODIUM 0 999DICLOFENAC SOD EC 25 MG TAB No
S2B DICLOFENAC SODIUM 0 999DICLOFENAC SOD EC 50 MG TAB No
S2B DICLOFENAC SODIUM 0 999DICLOFENAC SOD EC 75 MG TAB No
S2B DICLOFENAC SODIUM 0 999DICLOFENAC SOD ER 100 MG TAB No
S2B NAPROXEN 0 999EC-NAPROXEN DR 375 MG TABLET No
S2B NAPROXEN 0 999EC-NAPROXEN DR 500 MG TABLET No
S2B IBUPROFEN 0 999IBUPROFEN 100 MG/5 ML SUSP No
S2B IBUPROFEN 0 999IBUPROFEN 400 MG TABLET No
S2B IBUPROFEN 0 999IBUPROFEN 400 MG TABLET No
S2B IBUPROFEN 0 999IBUPROFEN 600 MG TABLET No
S2B IBUPROFEN 0 999IBUPROFEN 600 MG TABLET No
Tuesday, May 14, 2019 Page 171 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
S2B IBUPROFEN 0 999IBUPROFEN 800 MG TABLET No
S2B IBUPROFEN 0 999IBUPROFEN 800 MG TABLET No
S2B INDOMETHACIN 0 999INDOMETHACIN 25 MG CAPSULE No
S2B INDOMETHACIN 0 999INDOMETHACIN 50 MG CAPSULE No
S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 10 MG TABLET No
S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 15 MG/ML CARPUJECT No
S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 15 MG/ML SYRINGE No
S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 15 MG/ML VIAL No
S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 30 MG/ML CARPUJECT No
S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 30 MG/ML ISECURE SYR No
S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 30 MG/ML SYRINGE No
S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 30 MG/ML VIAL No
S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 60 MG/2 ML SYRINGE No
S2B KETOROLAC TROMETHAMINE 17 999KETOROLAC 60 MG/2 ML VIAL No
S2B MELOXICAM 0 999MELOXICAM 15 MG TABLET No
S2B MELOXICAM 0 999MELOXICAM 7.5 MG TABLET No
S2B NABUMETONE 0 999NABUMETONE 500 MG TABLET No
S2B NABUMETONE 0 999NABUMETONE 750 MG TABLET No
S2B NAPROXEN 0 999NAPROXEN 250 MG TABLET No
S2B NAPROXEN 0 999NAPROXEN 375 MG TABLET No
S2B NAPROXEN 0 999NAPROXEN 375 MG TABLET EC No
S2B NAPROXEN 0 999NAPROXEN 500 MG TABLET No
S2B NAPROXEN 0 999NAPROXEN 500 MG TABLET EC No
S2B NAPROXEN 0 999NAPROXEN DR 375 MG TABLET No
Tuesday, May 14, 2019 Page 172 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
S2B NAPROXEN 0 999NAPROXEN DR 500 MG TABLET No
S2I ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITORS2I LEFLUNOMIDE 0 999LEFLUNOMIDE 10 MG TABLET No
S2I LEFLUNOMIDE 0 999LEFLUNOMIDE 20 MG TABLET No
S2J ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITORS2J ETANERCEPT 2 999ENBREL 25 MG KIT Auto PA
S2J ETANERCEPT 2 999ENBREL 25 MG/0.5 ML SYRINGE Auto PA
S2J ETANERCEPT 2 999ENBREL 50 MG/ML MINI CARTRIDGE Auto PA
S2J ETANERCEPT 2 999ENBREL 50 MG/ML SURECLICK SYR Auto PA
S2J ETANERCEPT 2 999ENBREL 50 MG/ML SYRINGE Auto PA
S2J ADALIMUMAB 0 999HUMIRA 10 MG/0.1 ML SYRINGE Auto PA
S2J ADALIMUMAB 0 999HUMIRA 10 MG/0.2 ML SYRINGE Auto PA
S2J ADALIMUMAB 0 999HUMIRA 20 MG/0.2 ML SYRINGE Auto PA
S2J ADALIMUMAB 0 999HUMIRA 20 MG/0.4 ML SYRINGE Auto PA
S2J ADALIMUMAB 0 999HUMIRA 40 MG/0.4 ML PEN Auto PA
S2J ADALIMUMAB 0 999HUMIRA 40 MG/0.4 ML SYRINGE Auto PA
S2J ADALIMUMAB 0 999HUMIRA 40 MG/0.8 ML PEN Auto PA
S2J ADALIMUMAB 0 999HUMIRA 40 MG/0.8 ML SYRINGE Auto PA
S2J ADALIMUMAB 0 999HUMIRA CROHN'S STARTER PACK Auto PA
S2J ADALIMUMAB 0 999HUMIRA PED CROHNS 80 MG/0.8 ML Auto PA
S2J ADALIMUMAB 0 999HUMIRA PED CROHN'S STARTER PK Auto PA
S2J ADALIMUMAB 0 999HUMIRA PEDIATR CROHN'S 80-40MG Auto PA
S2J ADALIMUMAB 0 999HUMIRA PEN CROHN-UC-HS 80 MG Auto PA
S2J ADALIMUMAB 0 999HUMIRA PEN PSOR-UVEI 80MG-40MG Auto PA
Tuesday, May 14, 2019 Page 173 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
S2J ADALIMUMAB 0 999HUMIRA PSORIASIS STARTER PACK Auto PA
S2J ADALIMUMAB 0 999HUMIRA(CF) PEN 80 MG/0.8 ML Auto PA
S2L NSAIDS,CYCLOOXYGENASE-2(COX-2) SELECTIVE INHIBITORS2L CELECOXIB 0 999CELECOXIB 100 MG CAPSULE No
S2L CELECOXIB 0 999CELECOXIB 200 MG CAPSULE No
S2L CELECOXIB 0 999CELECOXIB 400 MG CAPSULE No
S2L CELECOXIB 0 999CELECOXIB 50 MG CAPSULE No
T0I TOP. ANTI-INFLAM.,PHOSPHODIESTERASE-4 (PDE4) INHIBT0I CRISABOROLE 0 999EUCRISA 2% OINTMENT No
U5B HERBAL DRUGSU5B ALOE VERA 0 999ALOE VERA 5,000 CONC SOFTGEL Cystic Fib Diag Auto PA
U5B ALOE VERA 0 999ALOE VERA 5,000 MG SOFTGEL Cystic Fib Diag Auto PA
U5B FLAXSEED OIL 0 999CVS FLAXSEED OIL 1,000 MG CAPS Cystic Fib Diag Auto PA
U5B FLAXSEED OIL 0 999FLAX SEED OIL 1,000 MG SFTG Cystic Fib Diag Auto PA
U5B FLAXSEED OIL 0 999FLAX SEED OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
U5B FLAXSEED OIL 0 999FLAX SEED OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
U5B FLAXSEED OIL 0 999FLAXSEED OIL 1,000 MG CAP Cystic Fib Diag Auto PA
U5B FLAXSEED OIL 0 999FLAXSEED OIL 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
U5B FLAXSEED OIL 0 999GNP FLAXSEED 1,000 MG SOFTGEL Cystic Fib Diag Auto PA
U5B FLAXSEED OIL 0 999HM FLAXSEED OIL 1,000 MG SFTGL Cystic Fib Diag Auto PA
U5B MILK THISTLE SEED EXTRACT 0 999MILK THISTLE 140 MG CAPSULE Cystic Fib Diag Auto PA
U5B MILK THISTLE SEED EXTRACT 0 999MILK THISTLE 175 MG CAPSULE Cystic Fib Diag Auto PA
U5B MILK THISTLE 0 999MILK THISTLE 175 MG TABLET Cystic Fib Diag Auto PA
U5B MILK THISTLE 0 999MILK THISTLE 300 MG CAPSULE Cystic Fib Diag Auto PA
U5B MILK THISTLE 0 999MILK THISTLE 500 MG CAPSULE Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 174 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
U5B MILK THISTLE SEED EXTRACT 0 999MILK THISTLE EXTRACT CAPSULE Cystic Fib Diag Auto PA
U5B FLAXSEED OIL 0 999OMEGA-3 FLAXSEED OIL 1,000 MG Cystic Fib Diag Auto PA
U5B CRAN/C/B.COAG/FOS/L.ACID/L.RHA 0 999PROBIOTIC PLUS & CRANBERRY CAP Cystic Fib Diag Auto PA
U5B FLAXSEED OIL 0 999RA FLAXSEED OIL 1,000 MG SFTGL Cystic Fib Diag Auto PA
U5B FLAXSEED OIL 0 999SM FLAX OIL 1,000 MG SFTGL Cystic Fib Diag Auto PA
U5B FLAXSEED OIL 0 999SM FLAXSEED OIL 1,000 MG SFTGL Cystic Fib Diag Auto PA
U5B BLUE-GREEN ALGAE 0 999SPIRULINA 500 MG TABLET Cystic Fib Diag Auto PA
U5B ALOE VERA 0 999SV ALOE VERA 25 MG SOFTGEL Cystic Fib Diag Auto PA
U5B FLAXSEED OIL 0 999SV FLAXSEED OIL 1,000 MG SFTGL Cystic Fib Diag Auto PA
U5B FLAXSEED OIL/OMEGA 3,6,9 0 999SV FLAXSEED OIL 1,300 MG SFTGL Cystic Fib Diag Auto PA
V1A ANTINEOPLASTIC - ALKYLATING AGENTSV1A MELPHALAN 18 999ALKERAN 2 MG TABLET No
V1A CARMUSTINE 0 999BICNU 100 MG VIAL No
V1A BUSULFAN 0 999BUSULFEX 6 MG/ML VIAL No
V1A BUSULFAN 0 999BUSULFEX 60 MG/10 ML VIAL No
V1A CARBOPLATIN 0 999CARBOPLATIN 150 MG/15 ML VIAL No
V1A CARBOPLATIN 0 999CARBOPLATIN 450 MG/45 ML VIAL No
V1A CARBOPLATIN 0 999CARBOPLATIN 50 MG/5 ML VIAL No
V1A CARBOPLATIN 0 999CARBOPLATIN 600 MG/60 ML VIAL No
V1A CISPLATIN 0 999CISPLATIN 1 MG/ML VIAL No
V1A CISPLATIN 0 999CISPLATIN 100 MG/100 ML VIAL No
V1A CISPLATIN 0 999CISPLATIN 200 MG/200 ML VIAL No
V1A CISPLATIN 0 999CISPLATIN 50 MG/50 ML VIAL No
V1A CISPLATIN 0 999CISPLATIN-AQ 1 MG/ML VIAL No
Tuesday, May 14, 2019 Page 175 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
V1A CYCLOPHOSPHAMIDE 0 999CYCLOPHOSPHAMIDE 1 GM VIAL No
V1A CYCLOPHOSPHAMIDE 0 999CYCLOPHOSPHAMIDE 2 GM VIAL No
V1A CYCLOPHOSPHAMIDE 0 999CYCLOPHOSPHAMIDE 25 MG CAPSULE No
V1A CYCLOPHOSPHAMIDE 0 999CYCLOPHOSPHAMIDE 50 MG CAPSULE No
V1A CYCLOPHOSPHAMIDE 0 999CYCLOPHOSPHAMIDE 500 MG VIAL No
V1A HYDROXYUREA 0 999HYDROXYUREA 500 MG CAPSULE No
V1A IFOSFAMIDE 0 999IFOSFAMIDE 1 GM VIAL No
V1A IFOSFAMIDE 0 999IFOSFAMIDE 1 GM/ 20 ML VIAL No
V1A IFOSFAMIDE 0 999IFOSFAMIDE 1 GM/20 ML VIAL No
V1A IFOSFAMIDE 0 999IFOSFAMIDE 3 GM VIAL No
V1A IFOSFAMIDE 0 999IFOSFAMIDE 3 GM/ 60 ML VIAL No
V1A IFOSFAMIDE 0 999IFOSFAMIDE 3 GM/60 ML VIAL No
V1A IFOSFAMIDE/MESNA 0 999IFOSFAMIDE/MESNA KIT No
V1A CHLORAMBUCIL 0 999LEUKERAN 2 MG TABLET No
V1A MELPHALAN 0 999MELPHALAN 2 MG TABLET No
V1A MELPHALAN HCL 0 999MELPHALAN 50 MG VIAL W-DILUENT No
V1A MELPHALAN HCL 0 999MELPHALAN HCL 50 MG VIAL No
V1A BUSULFAN 0 999MYLERAN 2 MG TABLET No
V1A OXALIPLATIN 0 999OXALIPLATIN 100 MG VIAL No
V1A OXALIPLATIN 0 999OXALIPLATIN 100 MG/20 ML No
V1A OXALIPLATIN 0 999OXALIPLATIN 100 MG/20 ML VIAL No
V1A OXALIPLATIN 0 999OXALIPLATIN 50 MG VIAL No
V1A OXALIPLATIN 0 999OXALIPLATIN 50 MG/10 ML VIAL No
V1A TEMOZOLOMIDE 0 999TEMODAR 100 MG VIAL No
Tuesday, May 14, 2019 Page 176 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
V1A TEMOZOLOMIDE 0 999TEMOZOLOMIDE 100 MG CAPSULE No
V1A TEMOZOLOMIDE 0 999TEMOZOLOMIDE 140 MG CAPSULE No
V1A TEMOZOLOMIDE 0 999TEMOZOLOMIDE 180 MG CAPSULE No
V1A TEMOZOLOMIDE 0 999TEMOZOLOMIDE 20 MG CAPSULE No
V1A TEMOZOLOMIDE 0 999TEMOZOLOMIDE 250 MG CAPSULE No
V1A TEMOZOLOMIDE 0 999TEMOZOLOMIDE 5 MG CAPSULE No
V1A THIOTEPA 0 999THIOTEPA 15 MG VIAL No
V1A BENDAMUSTINE HCL 0 999TREANDA 100 MG VIAL No
V1A BENDAMUSTINE HCL 0 999TREANDA 25 MG VIAL No
V1B ANTINEOPLASTIC - ANTIMETABOLITESV1B PEMETREXED DISODIUM 0 999ALIMTA 100 MG VIAL No
V1B PEMETREXED DISODIUM 0 999ALIMTA 500 MG VIAL No
V1B AZACITIDINE 0 999AZACITIDINE 100 MG VIAL No
V1B CLADRIBINE 0 999CLADRIBINE 1 MG/ML VIAL No
V1B CLADRIBINE 0 999CLADRIBINE 10 MG/10 ML VIAL No
V1B CYTARABINE/PF 0 999CYTARABINE 100 MG/5 ML VIAL No
V1B CYTARABINE/PF 0 999CYTARABINE 100 MG/ML VIAL No
V1B CYTARABINE/PF 0 999CYTARABINE 1000 MG/50 ML VIAL No
V1B CYTARABINE/PF 0 999CYTARABINE 2 G/20 ML VIAL No
V1B CYTARABINE 0 999CYTARABINE 20 MG/ML VIAL No
V1B CYTARABINE/PF 0 999CYTARABINE 20 MG/ML VIAL No
V1B DECITABINE 0 999DECITABINE 50 MG VIAL No
V1B FLOXURIDINE 0 999FLOXURIDINE 500 MG VIAL No
V1B FLUDARABINE PHOSPHATE 0 999FLUDARABINE 50 MG VIAL No
Tuesday, May 14, 2019 Page 177 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
V1B FLUDARABINE PHOSPHATE 0 999FLUDARABINE 50 MG/2 ML VIAL No
V1B FLUOROURACIL 0 999FLUOROURACIL 1,000 MG/20 ML VL No
V1B FLUOROURACIL 0 999FLUOROURACIL 2,500 MG/50 ML VL No
V1B FLUOROURACIL 0 999FLUOROURACIL 2.5 GM/50 ML BTL No
V1B FLUOROURACIL 0 999FLUOROURACIL 2.5 GM/50 ML VIAL No
V1B FLUOROURACIL 0 999FLUOROURACIL 5 GM/100 ML BTL No
V1B FLUOROURACIL 0 999FLUOROURACIL 5 GM/100 ML VIAL No
V1B FLUOROURACIL 0 999FLUOROURACIL 5,000 MG/100 ML No
V1B FLUOROURACIL 0 999FLUOROURACIL 50 MG/ML VIAL No
V1B FLUOROURACIL 0 999FLUOROURACIL 500 MG/10 ML VIAL No
V1B GEMCITABINE HCL 0 999GEMCITABINE 1 GRAM/26.3 ML VL No
V1B GEMCITABINE HCL 0 999GEMCITABINE 2 GRAM/52.6 ML VL No
V1B GEMCITABINE HCL 0 999GEMCITABINE 200 MG/5.26 ML VL No
V1B GEMCITABINE HCL 0 999GEMCITABINE HCL 1 GRAM VIAL No
V1B GEMCITABINE HCL 0 999GEMCITABINE HCL 1 GRAM/10 ML No
V1B GEMCITABINE HCL 0 999GEMCITABINE HCL 1.5 GRAM/15 ML No
V1B GEMCITABINE HCL 0 999GEMCITABINE HCL 2 GRAM VIAL No
V1B GEMCITABINE HCL 0 999GEMCITABINE HCL 2 GRAM/20 ML No
V1B GEMCITABINE HCL 0 999GEMCITABINE HCL 200 MG VIAL No
V1B GEMCITABINE HCL 0 999GEMCITABINE HCL 200 MG/2 ML VL No
V1B MERCAPTOPURINE 0 999MERCAPTOPURINE 50 MG TABLET No
V1B METHOTREXATE SODIUM/PF 0 999METHOTREXATE 1 GM VIAL No
V1B METHOTREXATE SODIUM/PF 0 999METHOTREXATE 1 GRAM/40 ML VIAL No
V1B METHOTREXATE SODIUM/PF 0 999METHOTREXATE 100 MG/4 ML VIAL No
Tuesday, May 14, 2019 Page 178 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
V1B METHOTREXATE SODIUM 0 999METHOTREXATE 2.5 MG TABLET No
V1B METHOTREXATE SODIUM/PF 0 999METHOTREXATE 200 MG/8 ML VIAL No
V1B METHOTREXATE SODIUM 0 999METHOTREXATE 25 MG/ML VIAL No
V1B METHOTREXATE SODIUM/PF 0 999METHOTREXATE 25 MG/ML VIAL No
V1B METHOTREXATE SODIUM/PF 0 999METHOTREXATE 250 MG/10 ML VIAL No
V1B METHOTREXATE SODIUM 0 999METHOTREXATE 50 MG/2 ML VIAL No
V1B METHOTREXATE SODIUM/PF 0 999METHOTREXATE 50 MG/2 ML VIAL No
V1B CAPECITABINE 18 999XELODA 150 MG TABLET No
V1B CAPECITABINE 18 999XELODA 500 MG TABLET No
V1C ANTINEOPLASTIC - VINCA ALKALOIDSV1C VINBLASTINE SULFATE 0 999VINBLASTINE 1 MG/ML VIAL No
V1C VINCRISTINE SULFATE 0 999VINCRISTINE 1 MG/ML VIAL No
V1C VINCRISTINE SULFATE 0 999VINCRISTINE 2 MG/2 ML VIAL No
V1C VINORELBINE TARTRATE 0 999VINORELBINE 10 MG/ML VIAL No
V1C VINORELBINE TARTRATE 0 999VINORELBINE 50 MG/5 ML VIAL No
V1D ANTIBIOTIC ANTINEOPLASTICSV1D BLEOMYCIN SULFATE 0 999BLEOMYCIN SULFATE 15 UNIT VIAL No
V1D BLEOMYCIN SULFATE 0 999BLEOMYCIN SULFATE 15 UNITS VIA No
V1D BLEOMYCIN SULFATE 0 999BLEOMYCIN SULFATE 30 UNIT VIAL No
V1D BLEOMYCIN SULFATE 0 999BLEOMYCIN SULFATE 30 UNITS VIA No
V1D DAUNORUBICIN HCL 0 999DAUNORUBICIN 20 MG VIAL No
V1D DAUNORUBICIN HCL 0 999DAUNORUBICIN 20 MG/4 ML VIAL No
V1D DAUNORUBICIN HCL 0 999DAUNORUBICIN 50 MG/10 ML VIAL No
V1D DAUNORUBICIN HCL 0 999DAUNORUBICIN HCL 20 MG VIAL No
Tuesday, May 14, 2019 Page 179 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
V1D DOXORUBICIN HCL 0 999DOXORUBICIN 10 MG VIAL No
V1D DOXORUBICIN HCL 0 999DOXORUBICIN 10 MG/5 ML VIAL No
V1D DOXORUBICIN HCL 0 999DOXORUBICIN 150 MG/75 ML VIAL No
V1D DOXORUBICIN HCL 0 999DOXORUBICIN 2 MG/ML VIAL No
V1D DOXORUBICIN HCL 0 999DOXORUBICIN 20 MG/10 ML VIAL No
V1D DOXORUBICIN HCL PEG-LIPOSOMAL 0 999DOXORUBICIN 20 MG/10 ML VIAL No
V1D DOXORUBICIN HCL 0 999DOXORUBICIN 200 MG/100 ML VIAL No
V1D DOXORUBICIN HCL 0 999DOXORUBICIN 50 MG VIAL No
V1D DOXORUBICIN HCL 0 999DOXORUBICIN 50 MG/25 ML VIAL No
V1D DOXORUBICIN HCL PEG-LIPOSOMAL 0 999DOXORUBICIN 50 MG/25 ML VIAL No
V1D DOXORUBICIN HCL PEG-LIPOSOMAL 0 999DOXORUBICIN LIPOSOME 20MG/10ML No
V1D DOXORUBICIN HCL PEG-LIPOSOMAL 0 999DOXORUBICIN LIPOSOME 50MG/25ML No
V1D EPIRUBICIN HCL 0 999EPIRUBICIN 200 MG/100 ML VIAL No
V1D EPIRUBICIN HCL 0 999EPIRUBICIN 50 MG/25 ML VIAL No
V1D EPIRUBICIN HCL 0 999EPIRUBICIN HCL 200 MG VIAL No
V1D IDARUBICIN HCL 0 999IDARUBICIN HCL 1 MG/ML VIAL No
V1D IDARUBICIN HCL 0 999IDARUBICIN HCL 10 MG/10 ML VL No
V1D IDARUBICIN HCL 0 999IDARUBICIN HCL 20 MG/20 ML VL No
V1D IDARUBICIN HCL 0 999IDARUBICIN HCL 5 MG/5 ML VIAL No
V1D MITOMYCIN 0 999MITOMYCIN 20 MG VIAL No
V1D MITOMYCIN 0 999MITOMYCIN 40 MG VIAL No
V1D MITOMYCIN 0 999MITOMYCIN 5 MG VIAL No
V1D MITOMYCIN 0 999MUTAMYCIN 20 MG VIAL No
V1D MITOMYCIN 0 999MUTAMYCIN 40 MG VIAL No
Tuesday, May 14, 2019 Page 180 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
V1D MITOMYCIN 0 999MUTAMYCIN 5 MG VIAL No
V1D VALRUBICIN 0 999VALSTAR 40 MG/ML VIAL No
V1E STEROID ANTINEOPLASTICSV1E MEGESTROL ACETATE 0 999MEGESTROL 20 MG TABLET No
V1E MEGESTROL ACETATE 0 999MEGESTROL 40 MG TABLET No
V1F ANTINEOPLASTICS,MISCELLANEOUSV1F DACARBAZINE 0 999DACARBAZINE 100 MG VIAL No
V1F DACARBAZINE 0 999DACARBAZINE 200 MG VIAL No
V1F DOCETAXEL 18 999DOCETAXEL 160 MG/16 ML VIAL No
V1F DOCETAXEL 18 999DOCETAXEL 160 MG/8 ML VIAL No
V1F DOCETAXEL 18 999DOCETAXEL 20 MG/2 ML VIAL No
V1F DOCETAXEL 18 999DOCETAXEL 20 MG/ML VIAL No
V1F DOCETAXEL 18 999DOCETAXEL 200 MG/10 ML VIAL No
V1F DOCETAXEL 18 999DOCETAXEL 80 MG/4 ML VIAL No
V1F DOCETAXEL 18 999DOCETAXEL 80 MG/8 ML VIAL No
V1F ETOPOSIDE 0 999ETOPOSIDE 1,000 MG/50 ML VIAL No
V1F ETOPOSIDE 0 999ETOPOSIDE 100 MG/5 ML VIAL No
V1F ETOPOSIDE 0 999ETOPOSIDE 20 MG/ML VIAL No
V1F ETOPOSIDE 0 999ETOPOSIDE 500 MG/25 ML VIAL No
V1F PROCARBAZINE HCL 0 999MATULANE 50 MG CAPSULE No
V1F MITOXANTRONE HCL 18 999MITOXANTRONE 20 MG/10 ML VIAL No
V1F MITOXANTRONE HCL 18 999MITOXANTRONE 20 MG/10 ML VL No
V1F MITOXANTRONE HCL 18 999MITOXANTRONE 25 MG/12.5 ML VL No
V1F MITOXANTRONE HCL 18 999MITOXANTRONE 30 MG/15 ML VIAL No
Tuesday, May 14, 2019 Page 181 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
V1F MITOXANTRONE HCL 18 999MITOXANTRONE 30 MG/15 ML VL No
V1F PEGASPARGASE 0 999ONCASPAR 3,750 UNIT/5 ML VIAL No
V1F PACLITAXEL 0 999PACLITAXEL 100 MG/16.7 ML VIAL No
V1F PACLITAXEL 0 999PACLITAXEL 150 MG/25 ML VIAL No
V1F PACLITAXEL 0 999PACLITAXEL 30 MG/5 ML VIAL No
V1F PACLITAXEL 0 999PACLITAXEL 300 MG/50 ML VIAL No
V1F PACLITAXEL 0 999PACLITAXEL 6 MG/ML VIAL No
V1F TRETINOIN 1 999TRETINOIN 10 MG CAPSULE No
V1F ARSENIC TRIOXIDE 0 999TRISENOX 10 MG/10 ML AMPULE No
V1I CHEMOTHERAPY RESCUE/ANTIDOTE AGENTSV1I AMIFOSTINE CRYSTALLINE 0 999AMIFOSTINE 500 MG VIAL No
V1I DEXRAZOXANE HCL 0 999DEXRAZOXANE 250 MG VIAL No
V1I DEXRAZOXANE HCL 0 999DEXRAZOXANE 500 MG VIAL No
V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CAL 100 MG/10 ML VL No
V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CAL 500 MG/50 ML VL No
V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CALCIUM 10 MG TAB No
V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CALCIUM 100 MG VIAL No
V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CALCIUM 100 MG VL No
V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CALCIUM 15 MG TAB No
V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CALCIUM 200 MG VIAL No
V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CALCIUM 25 MG TAB No
V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CALCIUM 350 MG VIAL No
V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CALCIUM 350 MG VL No
V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CALCIUM 5 MG TAB No
Tuesday, May 14, 2019 Page 182 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CALCIUM 50 MG VIAL No
V1I LEUCOVORIN CALCIUM 0 999LEUCOVORIN CALCIUM 500 MG VL No
V1I MESNA 0 999MESNA 1 GRAM/10 ML VIAL No
V1I MESNA 0 999MESNA 100 MG/ML VIAL No
V1J ANTINEOPLASTIC - ANTIANDROGENIC AGENTSV1J BICALUTAMIDE 18 999BICALUTAMIDE 50 MG TABLET No
V1J FLUTAMIDE 18 999FLUTAMIDE 125 MG CAPSULE No
V1J NILUTAMIDE 18 999NILUTAMIDE 150 MG TABLET No
V1J ENZALUTAMIDE 18 999XTANDI 40 MG CAPSULE No
V1J ABIRATERONE ACETATE 18 999ZYTIGA 250 MG TABLET No
V1J ABIRATERONE ACETATE 18 999ZYTIGA 500 MG TABLET No
V1K ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXESV1K ALEMTUZUMAB 0 999CAMPATH 30 MG/ML VIAL No
V1M ANTINEOPLASTIC IMMUNOMODULATOR AGENTSV1M POMALIDOMIDE 18 999POMALYST 1 MG CAPSULE Requires Med Cert 3
V1M POMALIDOMIDE 18 999POMALYST 2 MG CAPSULE Requires Med Cert 3
V1M POMALIDOMIDE 18 999POMALYST 3 MG CAPSULE Requires Med Cert 3
V1M POMALIDOMIDE 18 999POMALYST 4 MG CAPSULE Requires Med Cert 3
V1M LENALIDOMIDE 18 999REVLIMID 10 MG CAPSULE Requires Med Cert 3
V1M LENALIDOMIDE 18 999REVLIMID 15 MG CAPSULE Requires Med Cert 3
V1M LENALIDOMIDE 18 999REVLIMID 2.5 MG CAPSULE Requires Med Cert 3
V1M LENALIDOMIDE 18 999REVLIMID 20 MG CAPSULE Requires Med Cert 3
V1M LENALIDOMIDE 18 999REVLIMID 25 MG CAPSULE Requires Med Cert 3
V1M LENALIDOMIDE 18 999REVLIMID 5 MG CAPSULE Requires Med Cert 3
V1O ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR.
Tuesday, May 14, 2019 Page 183 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
V1O LEUPROLIDE ACETATE 0 999LEUPROLIDE 2WK 1 MG/0.2 ML KIT Auto PA
V1O LEUPROLIDE ACETATE 0 999LEUPROLIDE 2WK 14 MG/2.8 ML VL Auto PA
V1O LEUPROLIDE ACETATE 18 999LUPRON DEPOT 22.5 MG 3MO KIT Auto PA
V1O LEUPROLIDE ACETATE 18 999LUPRON DEPOT 45 MG 6MO KIT Auto PA
V1O LEUPROLIDE ACETATE 18 999LUPRON DEPOT 7.5 MG KIT Auto PA
V1O LEUPROLIDE ACETATE 18 999LUPRON DEPOT-4 MONTH KIT Auto PA
V1O GOSERELIN ACETATE 18 999ZOLADEX 10.8 MG IMPLANT SYRN Auto PA
V1O GOSERELIN ACETATE 18 999ZOLADEX 3.6 MG IMPLANT SYRN Auto PA
V1Q ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORSV1Q VANDETANIB 18 999CAPRELSA 100 MG TABLET Requires Med Cert 3
V1Q VANDETANIB 18 999CAPRELSA 300 MG TABLET Requires Med Cert 3
V1Q IMATINIB MESYLATE 1 999GLEEVEC 100 MG TABLET No
V1Q IMATINIB MESYLATE 1 999GLEEVEC 400 MG TABLET No
V1Q GEFITINIB 18 999IRESSA 250 MG TABLET Requires Med Cert 3
V1Q SORAFENIB TOSYLATE 18 999NEXAVAR 200 MG TABLET No
V1Q SUNITINIB MALATE 18 999SUTENT 12.5 MG CAPSULE No
V1Q SUNITINIB MALATE 18 999SUTENT 25 MG CAPSULE No
V1Q SUNITINIB MALATE 18 999SUTENT 37.5 MG CAPSULE No
V1Q SUNITINIB MALATE 18 999SUTENT 50 MG CAPSULE No
V1Q BORTEZOMIB 0 999VELCADE 3.5 MG VIAL No
V1Q PAZOPANIB HCL 18 999VOTRIENT 200 MG TABLET No
V1T SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)V1T TAMOXIFEN CITRATE 18 999SOLTAMOX 20 MG/10 ML SOLN No
V1T TAMOXIFEN CITRATE 18 999TAMOXIFEN 10 MG TABLET No
Tuesday, May 14, 2019 Page 184 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
V1T TAMOXIFEN CITRATE 18 999TAMOXIFEN 20 MG TABLET No
V3C ANTINEOPLASTIC - MTOR KINASE INHIBITORSV3C TEMSIROLIMUS 0 999TEMSIROLIMUS 25 MG VIAL No
V3E ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORSV3E IRINOTECAN HCL 0 999IRINOTECAN HCL 100 MG/5 ML VL No
V3E IRINOTECAN HCL 0 999IRINOTECAN HCL 20 MG/ML VIAL No
V3E IRINOTECAN HCL 0 999IRINOTECAN HCL 40 MG/2 ML VIAL No
V3E IRINOTECAN HCL 0 999IRINOTECAN HCL 500 MG/25 ML VL No
V3E TOPOTECAN HCL 0 999TOPOTECAN HCL 4 MG VIAL No
V3E TOPOTECAN HCL 6 999TOPOTECAN HCL 4 MG VIAL No
V3E TOPOTECAN HCL 0 999TOPOTECAN HCL 4 MG/4 ML VIAL No
V3F ANTINEOPLASTIC - AROMATASE INHIBITORSV3F ANASTROZOLE 18 999ANASTROZOLE 1 MG TABLET No
V3F EXEMESTANE 18 999EXEMESTANE 25 MG TABLET No
V3F LETROZOLE 18 999LETROZOLE 2.5 MG TABLET No
V3I ANTINEOPLASTIC - HALICHONDRIN B ANALOGSV3I ERIBULIN MESYLATE 0 999HALAVEN 1 MG/2 ML VIAL No
W0E HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMBW0E GLECAPREVIR/PIBRENTASVIR 18 999MAVYRET 100-40 MG TABLET Clinical PA Required
W0G HEP C - NS5A, NS3/4A, NUCLEOTIDE NS5B INHIB COMBOW0G SOFOSBUVIR/VELPATAS/VOXILAPREV 18 999VOSEVI 400-100-100 MG TABLET Clinical PA Required
W0H ANTIRETROVIRAL-NUCLEOSIDE,NUCLEOTIDE,PROTEASE INH.W0H DARUNAVIR/COB/EMTRI/TENOF ALAF 0 999SYMTUZA 800-150-200-10 MG TAB Auto PA
W0I ANTIRETROVIRAL-INTEGRASE INHIBITOR AND NNRTI COMB.W0I DOLUTEGRAVIR/RILPIVIRINE 18 999JULUCA 50-25 MG TABLET Auto PA
W0J ANTIRETROVIRAL - ANTI-CD4 DOMAIN 2 MONOCLONAL AB
Tuesday, May 14, 2019 Page 185 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W0J IBALIZUMAB-UIYK 18 999TROGARZO 200 MG/1.33 ML VIAL Clinical PA Required
W0K ANTIRETROVIRAL - INTEGRASE INHIBITOR AND NRTI COMB.W0K DOLUTEGRAVIR SODIUM/LAMIVUDINE 0 999DOVATO 50-300 MG TABLET Auto PA
W1A PENICILLIN ANTIBIOTICSW1A AMOXICILLIN/POTASSIUM CLAV 0 999AMOX TR-K CLV 200-28.5/5 SUSP No
W1A AMOXICILLIN/POTASSIUM CLAV 0 999AMOX TR-K CLV 250-125 MG TAB No
W1A AMOXICILLIN/POTASSIUM CLAV 0 999AMOX TR-K CLV 250-62.5/5 SUSP No
W1A AMOXICILLIN/POTASSIUM CLAV 0 999AMOX TR-K CLV 400-57/5 SUSP No
W1A AMOXICILLIN/POTASSIUM CLAV 0 999AMOX TR-K CLV 500-125 MG TAB No
W1A AMOXICILLIN/POTASSIUM CLAV 0 999AMOX TR-K CLV 600-42.9/5 SUSP No
W1A AMOXICILLIN/POTASSIUM CLAV 0 999AMOX TR-K CLV 875-125 MG TAB No
W1A AMOXICILLIN/POTASSIUM CLAV 0 999AMOX-CLAV 250-125 MG TABLET No
W1A AMOXICILLIN/POTASSIUM CLAV 0 999AMOX-CLAV 500-125 MG TABLET No
W1A AMOXICILLIN/POTASSIUM CLAV 0 999AMOX-CLAV 875-125 MG TABLET No
W1A AMOXICILLIN 0 999AMOXICILLIN 125 MG TAB CHEW No
W1A AMOXICILLIN 0 999AMOXICILLIN 125 MG/5 ML SUSP No
W1A AMOXICILLIN 0 999AMOXICILLIN 200 MG/5 ML SUSP No
W1A AMOXICILLIN 0 999AMOXICILLIN 250 MG CAPSULE No
W1A AMOXICILLIN 0 999AMOXICILLIN 250 MG TAB CHEW No
W1A AMOXICILLIN 0 999AMOXICILLIN 250 MG/ 5 ML SUSP No
W1A AMOXICILLIN 0 999AMOXICILLIN 250 MG/5 ML SUSP No
W1A AMOXICILLIN 0 999AMOXICILLIN 400 MG/5 ML SUSP No
W1A AMOXICILLIN 0 999AMOXICILLIN 500 MG CAPSULE No
W1A AMOXICILLIN 0 999AMOXICILLIN 500 MG TABLET No
Tuesday, May 14, 2019 Page 186 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W1A AMOXICILLIN 0 999AMOXICILLIN 875 MG TABLET No
W1A AMPICILLIN SODIUM 0 999AMPICILLIN 1 GM A/V VIAL No
W1A AMPICILLIN SODIUM 0 999AMPICILLIN 1 GM ADD-VANTAGE VL No
W1A AMPICILLIN SODIUM 0 999AMPICILLIN 1 GM A-V VIAL No
W1A AMPICILLIN SODIUM 0 999AMPICILLIN 1 GM VIAL No
W1A AMPICILLIN SODIUM 0 999AMPICILLIN 10 GM BOTTLE No
W1A AMPICILLIN SODIUM 0 999AMPICILLIN 10 GM VIAL No
W1A AMPICILLIN SODIUM 0 999AMPICILLIN 125 MG VIAL No
W1A AMPICILLIN SODIUM 0 999AMPICILLIN 2 GM A/V VIAL No
W1A AMPICILLIN SODIUM 0 999AMPICILLIN 2 GM ADD-VANTAGE VL No
W1A AMPICILLIN SODIUM 0 999AMPICILLIN 2 GM A-V VIAL No
W1A AMPICILLIN SODIUM 0 999AMPICILLIN 2 GM VIAL No
W1A AMPICILLIN SODIUM 0 999AMPICILLIN 250 MG VIAL No
W1A AMPICILLIN SODIUM 0 999AMPICILLIN 500 MG VIAL No
W1A AMPICILLIN TRIHYDRATE 0 999AMPICILLIN TR 500 MG CAPSULE No
W1A AMPICILLIN SODIUM/SULBACTAM NA 0 999AMPICILLIN-SULB 1.5 G ADD VIAL No
W1A AMPICILLIN SODIUM/SULBACTAM NA 0 999AMPICILLIN-SULB 3 GM ADD VIAL No
W1A AMPICILLIN SODIUM/SULBACTAM NA 0 999AMPICILLIN-SULBACTAM 1.5 GM VL No
W1A AMPICILLIN SODIUM/SULBACTAM NA 0 999AMPICILLIN-SULBACTAM 15 GM VL No
W1A AMPICILLIN SODIUM/SULBACTAM NA 0 999AMPICILLIN-SULBACTAM 3 GM VIAL No
W1A AMPICILLIN SODIUM/SULBACTAM NA 0 999AMPICILLIN-SULBACTAM 3 GM VL No
W1A PEN G BENZ/PEN G PROCAINE 0 999BICILLIN C-R 1.2 MILLION UNIT No
W1A PEN G BENZ/PEN G PROCAINE 0 999BICILLIN C-R 1.2MM UNITS SYR No
W1A PEN G BENZ/PEN G PROCAINE 0 999BICILLIN C-R 900/300 SYRINGE No
Tuesday, May 14, 2019 Page 187 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W1A PEN G BENZ/PEN G PROCAINE 0 999BICILLIN C-R 900-300 SYRINGE No
W1A PENICILLIN G BENZATHINE 0 999BICILLIN LA 1,200,000 UNITS No
W1A PENICILLIN G BENZATHINE 0 999BICILLIN L-A 1,200,000 UNITS No
W1A PENICILLIN G BENZATHINE 0 999BICILLIN LA 2,400,000 UNITS No
W1A PENICILLIN G BENZATHINE 0 999BICILLIN L-A 2,400,000 UNITS No
W1A PENICILLIN G BENZATHINE 0 999BICILLIN LA 600,000 UNIT/ML No
W1A PENICILLIN G BENZATHINE 0 999BICILLIN L-A 600,000 UNIT/ML No
W1A DICLOXACILLIN SODIUM 0 999DICLOXACILLIN 250 MG CAPSULE No
W1A DICLOXACILLIN SODIUM 0 999DICLOXACILLIN 500 MG CAPSULE No
W1A PENICILLIN G PROCAINE 0 999PEN G 1.2 MILLION UNIT/2 ML No
W1A PENICILLIN G PROCAINE 0 999PENICILLIN G 1.2MM UNITS/2 ML No
W1A PENICILLIN G PROCAINE 0 999PENICILLIN G 600,000 UNIT/1 ML No
W1A PENICILLIN G PROCAINE 0 999PENICILLIN G 600M UNITS/1 ML No
W1A PENICILLIN G SODIUM 0 999PENICILLIN G SOD 5MM UNITS VIA No
W1A PENICILLIN G SODIUM 0 999PENICILLIN G SOD 5MM UNITS VL No
W1A PENICILLIN V POTASSIUM 0 999PENICILLIN VK 125 MG/5 ML LIQ No
W1A PENICILLIN V POTASSIUM 0 999PENICILLIN VK 250 MG TABLET No
W1A PENICILLIN V POTASSIUM 0 999PENICILLIN VK 250 MG/5 ML LIQ No
W1A PENICILLIN V POTASSIUM 0 999PENICILLIN VK 500 MG TABLET No
W1A PIPERACILLIN SODIUM/TAZOBACTAM 0 999PIPERACIL-TAZOBACT 13.5 GM VL No
W1A PIPERACILLIN SODIUM/TAZOBACTAM 0 999PIPERACIL-TAZOBACT 2.25 GM VL No
W1A PIPERACILLIN SODIUM/TAZOBACTAM 0 999PIPERACIL-TAZOBACT 3.375 GM VL No
W1A PIPERACILLIN SODIUM/TAZOBACTAM 0 999PIPERACIL-TAZOBACT 4.5 GM VIAL No
W1A PIPERACILLIN SODIUM/TAZOBACTAM 0 999PIPERACIL-TAZOBACT 40.5 GRAM No
Tuesday, May 14, 2019 Page 188 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W1C TETRACYCLINE ANTIBIOTICSW1C DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE 100 MG CAPSULE No
W1C DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE 100 MG TABLET No
W1C DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE 50 MG CAPSULE No
W1C DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE HYCLATE 100 MG CAP No
W1C DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE HYCLATE 100 MG TAB No
W1C DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE HYCLATE 150 MG TAB No
W1C DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE HYCLATE 50 MG CAP No
W1C DOXYCYCLINE HYCLATE 0 999DOXYCYCLINE HYCLATE 75 MG TAB No
W1C MINOCYCLINE HCL 0 999MINOCYCLINE 100 MG CAPSULE No
W1C MINOCYCLINE HCL 0 999MINOCYCLINE 50 MG CAPSULE No
W1C MINOCYCLINE HCL 0 999MINOCYCLINE 75 MG CAPSULE No
W1D MACROLIDE ANTIBIOTICSW1D AZITHROMYCIN 0 999AZITHROMYCIN 1 GM PWD PACKET No
W1D AZITHROMYCIN 0 999AZITHROMYCIN 100 MG/5 ML SUSP No
W1D AZITHROMYCIN 0 999AZITHROMYCIN 200 MG/5 ML SUSP No
W1D AZITHROMYCIN 0 999AZITHROMYCIN 250 MG TABLET No
W1D AZITHROMYCIN 0 999AZITHROMYCIN 500 MG TABLET No
W1D AZITHROMYCIN 0 999AZITHROMYCIN 600 MG TABLET No
W1D AZITHROMYCIN 0 999AZITHROMYCIN I.V. 500 MG VIAL No
W1D CLARITHROMYCIN 0 11CLARITHROMYCIN 125 MG/5 ML SUS No
W1D CLARITHROMYCIN 0 999CLARITHROMYCIN 250 MG TABLET No
W1D CLARITHROMYCIN 0 11CLARITHROMYCIN 250 MG/5 ML SUS No
W1D CLARITHROMYCIN 0 999CLARITHROMYCIN 500 MG TABLET No
Tuesday, May 14, 2019 Page 189 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W1D CLARITHROMYCIN 0 999CLARITHROMYCIN ER 500 MG TAB No
W1D ERYTHROMYCIN ETHYLSUCCINATE 0 999E.E.S. 200 MG/5 ML GRANULES No
W1F AMINOGLYCOSIDE ANTIBIOTICSW1F GENTAMICIN SULFATE 0 999GENTAMICIN 40 MG/ML VIAL No
W1F GENTAMICIN IN NACL, ISO-OSM 0 999GENTAMICIN 70 MG/NS 50 ML PB No
W1F GENTAMICIN SULFATE 0 999GENTAMICIN 80 MG/2 ML VIAL No
W1F GENTAMICIN SULFATE 0 999GENTAMICIN 800 MG/20 ML VIAL No
W1F GENTAMICIN SULFATE 0 999GENTAMICIN PED 10 MG/ML VIAL No
W1F GENTAMICIN SULFATE/PF 0 999GENTAMICIN PED 10 MG/ML VIAL No
W1F GENTAMICIN SULFATE/PF 0 999GENTAMICIN PED 20 MG/2 ML VIAL No
W1F GENTAMICIN IN NACL, ISO-OSM 0 999ISO GENTAMICIN 100 MG/100 ML No
W1F GENTAMICIN IN NACL, ISO-OSM 0 999ISO GENTAMICIN 120 MG/100 ML No
W1F GENTAMICIN IN NACL, ISO-OSM 0 999ISOTON GENTAMICIN 100 MG/50 ML No
W1F GENTAMICIN IN NACL, ISO-OSM 0 999ISOTON GENTAMICIN 60 MG/50 ML No
W1F GENTAMICIN IN NACL, ISO-OSM 0 999ISOTON GENTAMICIN 80 MG/100 ML No
W1F GENTAMICIN IN NACL, ISO-OSM 0 999ISOTON GENTAMICIN 80 MG/50 ML No
W1F TOBRAMYCIN/NEBULIZER 0 999KITABIS PAK 300 MG/5 ML Auto PA
W1F NEOMYCIN SULFATE 0 999NEOMYCIN 500 MG TABLET No
W1F TOBRAMYCIN IN 0.225% SOD CHLOR 0 999TOBI 300 MG/5 ML SOLUTION Auto PA
W1F TOBRAMYCIN SULFATE 0 999TOBRAMYCIN 10 MG/ML VIAL No
W1F TOBRAMYCIN SULFATE 0 999TOBRAMYCIN 40 MG/ML VIAL No
W1F TOBRAMYCIN SULFATE 0 999TOBRAMYCIN 80 MG/2 ML VIAL No
W1G ANTITUBERCULAR ANTIBIOTICSW1G RIFAMPIN 0 999RIFAMPIN 150 MG CAPSULE No
Tuesday, May 14, 2019 Page 190 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W1G RIFAMPIN 0 999RIFAMPIN 300 MG CAPSULE No
W1G RIFAMPIN 0 999RIFAMPIN IV 600 MG VIAL No
W1J VANCOMYCIN ANTIBIOTICS AND DERIVATIVESW1J VANCOMYCIN/0.9 % SOD CHLORIDE 0 999VANCO 500 MG/100 ML-0.9% NACL No
W1J VANCOMYCIN/0.9 % SOD CHLORIDE 0 999VANCO 750 MG/150 ML-0.9% NACL No
W1J VANCOMYCIN HCL IN 5 % DEXTROSE 0 999VANCOCIN HCL 500 MG/100 ML No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN 1 GM ADD-VAN VIAL No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN 1 GM VIAL No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN 5 GM VIAL No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN 500 MG A/V VIAL No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN 500 MG VIAL No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN 750 MG VIAL No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 1 GM VIAL No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 1.25 GRAM VIAL No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 1.5 GRAM VIAL No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 10 GM VIAL No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 125 MG CAPSULE No
W1J VANCOMYCIN/0.9 % SOD CHLORIDE 0 999VANCOMYCIN HCL 1G/200 ML BAG No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 250 MG CAPSULE No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 250 MG VIAL No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 5 GM VIAL No
W1J VANCOMYCIN HCL 0 999VANCOMYCIN HCL 750 MG VIAL No
W1K LINCOSAMIDE ANTIBIOTICSW1K CLINDAMYCIN PHOSPHATE 0 999CLINDAMYCIN 300 MG/2 ML ADDVAN No
Tuesday, May 14, 2019 Page 191 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W1K CLINDAMYCIN PHOSPHATE 0 999CLINDAMYCIN 600 MG/4 ML ADDVAN No
W1K CLINDAMYCIN PALMITATE HCL 0 11CLINDAMYCIN 75 MG/5 ML SOLN No
W1K CLINDAMYCIN PHOSPHATE 0 999CLINDAMYCIN 900 MG/6 ML ADDVAN No
W1K CLINDAMYCIN HCL 0 999CLINDAMYCIN HCL 150 MG CAP No
W1K CLINDAMYCIN HCL 0 999CLINDAMYCIN HCL 150 MG CAPS No
W1K CLINDAMYCIN HCL 0 999CLINDAMYCIN HCL 150 MG CAPSULE No
W1K CLINDAMYCIN HCL 0 999CLINDAMYCIN HCL 300 MG CAPS No
W1K CLINDAMYCIN HCL 0 999CLINDAMYCIN HCL 300 MG CAPSULE No
W1K CLINDAMYCIN HCL 0 999CLINDAMYCIN HCL 75 MG CAPSULE No
W1K CLINDAMYCIN PALMITATE HCL 0 11CLINDAMYCIN PEDIATR 75 MG/5 ML No
W1K CLINDAMYCIN PHOSPHATE 0 999CLINDAMYCIN PH 150 MG/ML VIAL No
W1K CLINDAMYCIN PHOSPHATE 0 999CLINDAMYCIN PH 300 MG/2 ML VL No
W1K CLINDAMYCIN PHOSPHATE 0 999CLINDAMYCIN PH 600 MG/4 ML VL No
W1K CLINDAMYCIN PHOSPHATE 0 999CLINDAMYCIN PH 9 G/60 ML VIAL No
W1K CLINDAMYCIN PHOSPHATE 0 999CLINDAMYCIN PH 900 MG/6 ML VL No
W1K LINCOMYCIN HCL 0 999LINCOMYCIN HCL 3 GM/10 ML VIAL No
W1K LINCOMYCIN HCL 0 999LINCOMYCIN HCL 600 MG/2 ML VL No
W1N POLYMYXIN ANTIBIOTICS AND DERIVATIVESW1N COLISTIN (COLISTIMETHATE NA) 0 999COLISTIMETHATE 150 MG VIAL No
W1N POLYMYXIN B SULFATE 0 999POLYMYXIN B SULFATE VIAL No
W1O OXAZOLIDINONE ANTIBIOTICSW1O LINEZOLID 0 999LINEZOLID 600 MG TABLET No
W1P BETALACTAMSW1P AZTREONAM 0 999AZACTAM 1 GM VIAL No
W1P AZTREONAM 0 999AZACTAM 2 GM VIAL No
Tuesday, May 14, 2019 Page 192 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W1P AZTREONAM/DEXTROSE-WATER 0 999AZACTAM-ISO-OSMOT 1 GM/50 ML No
W1P AZTREONAM/DEXTROSE-WATER 0 999AZACTAM-ISO-OSMOT 2 GM/50 ML No
W1Q QUINOLONE ANTIBIOTICSW1Q CIPROFLOXACIN 0 11CIPRO 10% SUSPENSION No
W1Q CIPROFLOXACIN 0 11CIPRO 5% SUSPENSION No
W1Q CIPROFLOXACIN LACTATE 0 999CIPROFLOXACIN 10 MG/ML VIAL No
W1Q CIPROFLOXACIN IN 5 % DEXTROSE 0 999CIPROFLOXACIN 200 MG/100 ML No
W1Q CIPROFLOXACIN IN 5 % DEXTROSE 0 999CIPROFLOXACIN 400 MG/200 ML No
W1Q CIPROFLOXACIN HCL 12 999CIPROFLOXACIN 500 MG TABLET No
W1Q CIPROFLOXACIN HCL 12 999CIPROFLOXACIN HCL 100 MG TAB No
W1Q CIPROFLOXACIN HCL 12 999CIPROFLOXACIN HCL 250 MG TAB No
W1Q CIPROFLOXACIN HCL 12 999CIPROFLOXACIN HCL 500 MG TAB No
W1Q CIPROFLOXACIN HCL 12 999CIPROFLOXACIN HCL 750 MG TAB No
W1Q LEVOFLOXACIN 12 999LEVOFLOXACIN 250 MG TABLET No
W1Q LEVOFLOXACIN IN DEXTROSE 5 % 0 999LEVOFLOXACIN 250 MG/50 ML-D5W No
W1Q LEVOFLOXACIN 12 999LEVOFLOXACIN 500 MG TABLET No
W1Q LEVOFLOXACIN IN DEXTROSE 5 % 0 999LEVOFLOXACIN 500 MG/100 ML-D5W No
W1Q LEVOFLOXACIN 12 999LEVOFLOXACIN 750 MG TABLET No
W1Q LEVOFLOXACIN IN DEXTROSE 5 % 0 999LEVOFLOXACIN 750 MG/150 ML-D5W No
W1Q LEVOFLOXACIN IN DEXTROSE 5 % 0 999LEVOFLOXACIN-D5W 250 MG/50 ML No
W1Q LEVOFLOXACIN IN DEXTROSE 5 % 0 999LEVOFLOXACIN-D5W 500 MG/100 ML No
W1Q LEVOFLOXACIN IN DEXTROSE 5 % 0 999LEVOFLOXACIN-D5W 750 MG/150 ML No
W1S CARBAPENEM ANTIBIOTICS (THIENAMYCINS)W1S IMIPENEM/CILASTATIN SODIUM 0 999IMIPENEM-CILASTATIN 250 MG VL No
Tuesday, May 14, 2019 Page 193 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W1S IMIPENEM/CILASTATIN SODIUM 0 999IMIPENEM-CILASTATIN 500 MG VL No
W1S MEROPENEM 0 999MEROPENEM IV 1 GM VIAL No
W1S MEROPENEM 0 999MEROPENEM IV 500 MG VIAL No
W1S MEROPENEM-0.9% SODIUM CHLORIDE 0 999MEROPENEM-0.9% NACL 1 GRAM/50 No
W1S MEROPENEM-0.9% SODIUM CHLORIDE 0 999MEROPENEM-0.9% NACL 500 MG/50 No
W1W CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATIONW1W CEFADROXIL 0 999CEFADROXIL 500 MG CAPSULE No
W1W CEFAZOLIN SODIUM 0 999CEFAZOLIN 1 GM ADD-VAN VIAL No
W1W CEFAZOLIN SODIUM 0 999CEFAZOLIN 1 GM VIAL No
W1W CEFAZOLIN SODIUM 0 999CEFAZOLIN 10 GM BULK VIAL No
W1W CEFAZOLIN SODIUM 0 999CEFAZOLIN 10 GM VIAL No
W1W CEFAZOLIN SODIUM 0 999CEFAZOLIN 20 GM BULK VIAL No
W1W CEFAZOLIN SODIUM 0 999CEFAZOLIN 500 MG VIAL No
W1W CEPHALEXIN 0 999CEPHALEXIN 125 MG/5 ML SUSP No
W1W CEPHALEXIN 0 999CEPHALEXIN 125 MG/5 ML SUSPEN No
W1W CEPHALEXIN 0 999CEPHALEXIN 250 MG CAPSULE No
W1W CEPHALEXIN 0 999CEPHALEXIN 250 MG/5 ML SUSP No
W1W CEPHALEXIN 0 999CEPHALEXIN 250 MG/5 ML SUSPEN No
W1W CEPHALEXIN 0 999CEPHALEXIN 500 MG CAPSULE No
W1W CEPHALEXIN 0 999CEPHALEXIN 750 MG CAPSULE No
W1X CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATIONW1X CEFACLOR 0 999CEFACLOR 250 MG CAPSULE No
W1X CEFACLOR 0 999CEFACLOR 500 MG CAPSULE No
W1X CEFOTETAN DISODIUM 0 999CEFOTETAN 1 GM VIAL No
Tuesday, May 14, 2019 Page 194 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W1X CEFOTETAN DISODIUM 0 999CEFOTETAN 10 GM VIAL No
W1X CEFOTETAN DISODIUM 0 999CEFOTETAN 2 GM VIAL No
W1X CEFOTETAN DISOD/ISOSM DEXTROSE 0 999CEFOTETAN-DEXTR 1 G DUPLEX BAG No
W1X CEFOTETAN DISOD/ISOSM DEXTROSE 0 999CEFOTETAN-DEXTR 2 G DUPLEX BAG No
W1X CEFOXITIN SODIUM/DEXTROSE,ISO 0 999CEFOXITIN 1 GM PIGGYBACK BAG No
W1X CEFOXITIN SODIUM 0 999CEFOXITIN 1 GM VIAL No
W1X CEFOXITIN SODIUM 0 999CEFOXITIN 10 GM VIAL No
W1X CEFOXITIN SODIUM/DEXTROSE,ISO 0 999CEFOXITIN 2 GM PIGGYBACK BAG No
W1X CEFOXITIN SODIUM 0 999CEFOXITIN 2 GM VIAL No
W1X CEFPROZIL 0 999CEFPROZIL 125 MG/5 ML SUSP No
W1X CEFPROZIL 0 999CEFPROZIL 250 MG TABLET No
W1X CEFPROZIL 0 999CEFPROZIL 250 MG/5 ML SUSP No
W1X CEFPROZIL 0 999CEFPROZIL 500 MG TABLET No
W1X CEFUROXIME AXETIL 0 999CEFUROXIME AXETIL 250 MG TAB No
W1X CEFUROXIME AXETIL 0 999CEFUROXIME AXETIL 500 MG TAB No
W1X CEFUROXIME SODIUM 0 999CEFUROXIME SOD 1.5 GM VIAL No
W1X CEFUROXIME SODIUM 0 999CEFUROXIME SOD 7.5 GM VIAL No
W1X CEFUROXIME SODIUM 0 999CEFUROXIME SOD 750 MG VIAL No
W1Y CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATIONW1Y CEFDINIR 0 999CEFDINIR 125 MG/5 ML SUSP No
W1Y CEFDINIR 0 999CEFDINIR 250 MG/5 ML SUSP No
W1Y CEFDINIR 0 999CEFDINIR 300 MG CAPSULE No
W1Y CEFOTAXIME SODIUM 0 999CEFOTAXIME SODIUM 1 GM VIAL No
W1Y CEFOTAXIME SODIUM 0 999CEFOTAXIME SODIUM 2 GM VIAL No
Tuesday, May 14, 2019 Page 195 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W1Y CEFOTAXIME SODIUM 0 999CEFOTAXIME SODIUM 500 MG VIAL No
W1Y CEFTAZIDIME 0 999CEFTAZIDIME 1 GM VIAL No
W1Y CEFTAZIDIME 0 999CEFTAZIDIME 2 GM VIAL No
W1Y CEFTAZIDIME 0 999CEFTAZIDIME 6 GM VIAL No
W1Y CEFTRIAXONE IN IS-OSM DEXTROSE 0 999CEFTRIAXONE 1 GM PIGGYBACK No
W1Y CEFTRIAXONE SODIUM 0 999CEFTRIAXONE 1 GM VIAL No
W1Y CEFTRIAXONE IN IS-OSM DEXTROSE 0 999CEFTRIAXONE 1 GM/D5W BAG No
W1Y CEFTRIAXONE SODIUM 0 999CEFTRIAXONE 10 GM VIAL No
W1Y CEFTRIAXONE IN IS-OSM DEXTROSE 0 999CEFTRIAXONE 2 GM PIGGYBACK No
W1Y CEFTRIAXONE SODIUM 0 999CEFTRIAXONE 2 GM VIAL No
W1Y CEFTRIAXONE IN IS-OSM DEXTROSE 0 999CEFTRIAXONE 2 GM/D5W BAG No
W1Y CEFTRIAXONE SODIUM 0 999CEFTRIAXONE 250 MG VIAL No
W1Y CEFTRIAXONE SODIUM 0 999CEFTRIAXONE 500 MG VIAL No
W1Y CEFIXIME 0 999SUPRAX 400 MG CAPSULE No
W1Z CEPHALOSPORIN ANTIBIOTICS - 4TH GENERATIONW1Z CEFEPIME HCL 0 999CEFEPIME HCL 1 GM VIAL No
W1Z CEFEPIME HCL 0 999CEFEPIME HCL 1 GRAM VIAL No
W1Z CEFEPIME HCL 0 999CEFEPIME HCL 2 GRAM VIAL No
W2A ABSORBABLE SULFONAMIDE ANTIBACTERIAL AGENTSW2A SULFADIAZINE 0 999SULFADIAZINE 500 MG TABLET No
W2A SULFAMETHOXAZOLE/TRIMETHOPRIM 0 999SULFAMETHOXAZOLE/TMP DS TAB No
W2A SULFAMETHOXAZOLE/TRIMETHOPRIM 0 999SULFAMETHOXAZOLE/TMP SS TAB No
W2A SULFAMETHOXAZOLE/TRIMETHOPRIM 0 999SULFAMETHOXAZOLE-TMP DS TAB No
W2A SULFAMETHOXAZOLE/TRIMETHOPRIM 0 999SULFAMETHOXAZOLE-TMP DS TABLET No
Tuesday, May 14, 2019 Page 196 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W2A SULFAMETHOXAZOLE/TRIMETHOPRIM 0 999SULFAMETHOXAZOLE-TMP SS TABLET No
W2A SULFAMETHOXAZOLE/TRIMETHOPRIM 0 999SULFAMETHOXAZOLE-TMP SUSP No
W2E ANTI-MYCOBACTERIUM AGENTSW2E ETHAMBUTOL HCL 0 999ETHAMBUTOL HCL 100 MG TABLET No
W2E ETHAMBUTOL HCL 0 999ETHAMBUTOL HCL 400 MG TABLET No
W2E ISONIAZID 0 999ISONIAZID 100 MG TABLET No
W2E ISONIAZID 0 999ISONIAZID 300 MG TABLET No
W2E ISONIAZID 0 999ISONIAZID 50 MG/5 ML SYRUP No
W2E PYRAZINAMIDE 0 999PYRAZINAMIDE 500 MG TABLET No
W2E RIFABUTIN 0 999RIFABUTIN 150 MG CAPSULE No
W2F NITROFURAN DERIVATIVES ANTIBACTERIAL AGENTSW2F NITROFURANTOIN 0 999NITROFURANTOIN 25 MG/5 ML SUSP No
W2F NITROFURANTOIN MACROCRYSTAL 0 999NITROFURANTOIN MCR 100 MG CAP No
W2F NITROFURANTOIN MACROCRYSTAL 0 999NITROFURANTOIN MCR 100 MG CP No
W2F NITROFURANTOIN MACROCRYSTAL 0 999NITROFURANTOIN MCR 25 MG CAP No
W2F NITROFURANTOIN MACROCRYSTAL 0 999NITROFURANTOIN MCR 50 MG CAP No
W2F NITROFURANTOIN MONOHYD/M-CRYST 0 999NITROFURANTOIN MONO-MCR 100 MG No
W2F NITROFURANTOIN MONOHYD/M-CRYST 0 999NITROFURANTOIN-MACRO 100 MG No
W2G CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC.W2G METHENAMINE HIPPURATE 0 999METHENAMINE HIPP 1 GM TABLET No
W2G METHENAMINE MANDELATE 0 999METHENAMINE MD 1 GM TABLET No
W2G METHENAMINE MANDELATE 0 999METHENAMINE MD 500 MG TABLET No
W2G TRIMETHOPRIM 0 999TRIMETHOPRIM 100 MG TABLET No
W2G METH/MEBLUE/SOD PHOS/PSAL/HYOS 0 999UTIRA-C TABLET No
W3A ANTIFUNGAL ANTIBIOTICS
Tuesday, May 14, 2019 Page 197 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W3A AMPHOTERICIN B 0 999AMPHOTERICIN B 50 MG VIAL No
W3A ANIDULAFUNGIN 0 999ERAXIS(WATER DIL) 100 MG VIAL No
W3A ANIDULAFUNGIN 0 999ERAXIS(WATER DIL) 50 MG VIAL No
W3A GRISEOFULVIN, MICROSIZE 0 999GRISEOFULVIN 125 MG/5 ML SUSP No
W3A NYSTATIN 0 999NYSTATIN 100,000 UNIT/ML SUSP No
W3A NYSTATIN 0 999NYSTATIN 100,000 UNITS/ML SUSP No
W3A NYSTATIN 0 999NYSTATIN 500,000 UNIT ORAL TAB No
W3A NYSTATIN 0 999NYSTATIN 500,000 UNIT/5 ML SUS No
W3A NYSTATIN 0 999NYSTATIN 500,000 UNITS/5 ML No
W3B ANTIFUNGAL AGENTSW3B CLOTRIMAZOLE 0 999CLOTRIMAZOLE 10 MG TROCHE No
W3B FLUCONAZOLE 0 999FLUCONAZOLE 10 MG/ML SUSP No
W3B FLUCONAZOLE 0 999FLUCONAZOLE 100 MG TABLET No
W3B FLUCONAZOLE 0 999FLUCONAZOLE 150 MG TABLET No
W3B FLUCONAZOLE 0 999FLUCONAZOLE 200 MG TABLET No
W3B FLUCONAZOLE 0 999FLUCONAZOLE 40 MG/ML SUSP No
W3B FLUCONAZOLE 0 999FLUCONAZOLE 50 MG TABLET No
W3B FLUCONAZOLE IN DEXTROSE,ISO-OS 0 999FLUCONAZOLE-DEXT 200 MG/100 ML No
W3B FLUCONAZOLE IN DEXTROSE,ISO-OS 0 999FLUCONAZOLE-DEXT 400 MG/200 ML No
W3B FLUCONAZOLE IN NACL,ISO-OSM 0 999FLUCONAZOLE-NACL 100 MG/50 ML No
W3B FLUCONAZOLE IN NACL,ISO-OSM 0 999FLUCONAZOLE-NACL 200 MG/100 ML No
W3B FLUCONAZOLE IN NACL,ISO-OSM 0 999FLUCONAZOLE-NACL 400 MG/200 ML No
W3B FLUCONAZOLE IN NACL,ISO-OSM 0 999FLUCONAZOLE-NS 200 MG/100 ML No
W3B FLUCONAZOLE IN NACL,ISO-OSM 0 999FLUCONAZOLE-NS 200 MG/100 ML No
Tuesday, May 14, 2019 Page 198 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W3B FLUCONAZOLE IN NACL,ISO-OSM 0 999FLUCONAZOLE-NS 400 MG/200 ML No
W3B TERBINAFINE HCL 0 999TERBINAFINE HCL 250 MG TABLET No
W4A ANTIMALARIAL DRUGSW4A CHLOROQUINE PHOSPHATE 0 999CHLOROQUINE PH 250 MG TABLET No
W4A CHLOROQUINE PHOSPHATE 0 999CHLOROQUINE PH 500 MG TABLET No
W4A HYDROXYCHLOROQUINE SULFATE 0 999HYDROXYCHLOROQUINE 200 MG TAB No
W4A HYDROXYCHLOROQUINE SULFATE 0 999HYDROXYCHLOROQUINE 200 MG TB No
W4A MEFLOQUINE HCL 0 999MEFLOQUINE HCL 250 MG TABLET No
W4A PRIMAQUINE PHOSPHATE 0 999PRIMAQUINE 26.3 MG TABLET No
W4E ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTSW4E METRONIDAZOLE 0 999METRONIDAZOLE 250 MG TABLET No
W4E METRONIDAZOLE 0 999METRONIDAZOLE 500 MG TABLET No
W4E METRONIDAZOLE/SODIUM CHLORIDE 0 999METRONIDAZOLE 500 MG/100 ML No
W4E METRONIDAZOLE/SODIUM CHLORIDE 0 999METRONIDAZOLE 500 MG/100 ML BG No
W4G 2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIALW4G TINIDAZOLE 0 999TINIDAZOLE 250 MG TABLET No
W4G TINIDAZOLE 0 999TINIDAZOLE 500 MG TABLET No
W4K ANTIPROTOZOAL DRUGS,MISCELLANEOUSW4K ATOVAQUONE 0 999ATOVAQUONE 750 MG/5 ML SUSP No
W4K PENTAMIDINE ISETHIONATE 0 999NEBUPENT 300 MG INHAL POWDER No
W4L ANTHELMINTICSW4L ALBENDAZOLE 0 999ALBENZA 200 MG TABLET No
W4L PRAZIQUANTEL 0 999BILTRICIDE 600 MG TABLET No
W4L IVERMECTIN 0 999IVERMECTIN 3 MG TABLET No
W4P ANTILEPROTICSW4P DAPSONE 0 999DAPSONE 100 MG TABLET No
Tuesday, May 14, 2019 Page 199 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W4P DAPSONE 0 999DAPSONE 25 MG TABLET No
W4P THALIDOMIDE 0 999THALOMID 100 MG CAPSULE Requires Med Cert 3
W4P THALIDOMIDE 0 999THALOMID 150 MG CAPSULE Requires Med Cert 3
W4P THALIDOMIDE 0 999THALOMID 200 MG CAPSULE Requires Med Cert 3
W4P THALIDOMIDE 0 999THALOMID 50 MG CAPSULE Requires Med Cert 3
W5A ANTIVIRALS, GENERALW5A ACYCLOVIR 0 999ACYCLOVIR 200 MG CAPSULE No
W5A ACYCLOVIR 0 17ACYCLOVIR 200 MG/5 ML SUSP No
W5A ACYCLOVIR 0 999ACYCLOVIR 400 MG TABLET No
W5A ACYCLOVIR 0 999ACYCLOVIR 800 MG TABLET No
W5A GANCICLOVIR SODIUM 0 999GANCICLOVIR 500 MG VIAL No
W5A GANCICLOVIR SODIUM 0 999GANCICLOVIR 500 MG/10 ML VIAL No
W5A ZANAMIVIR 6 999RELENZA 5 MG DISKHALER No
W5A RIBAVIRIN 5 999RIBAVIRIN 6 GM INHALATION VIAL Auto PA
W5A OSELTAMIVIR PHOSPHATE 0 999TAMIFLU 30 MG GELCAP No
W5A OSELTAMIVIR PHOSPHATE 0 999TAMIFLU 45 MG GELCAP No
W5A OSELTAMIVIR PHOSPHATE 0 12TAMIFLU 6 MG/ML SUSPENSION No
W5A OSELTAMIVIR PHOSPHATE 0 999TAMIFLU 75 MG GELCAP No
W5A VALACYCLOVIR HCL 0 999VALACYCLOVIR HCL 1 GRAM TABLET No
W5A VALACYCLOVIR HCL 0 999VALACYCLOVIR HCL 500 MG TABLET No
W5A VALGANCICLOVIR HCL 0 999VALGANCICLOVIR 450 MG TABLET No
W5A VALGANCICLOVIR HCL 0 999VALGANCICLOVIR HCL 50 MG/ML No
W5C ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORSW5C INDINAVIR SULFATE 0 999CRIXIVAN 200 MG CAPSULE Auto PA
Tuesday, May 14, 2019 Page 200 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W5C INDINAVIR SULFATE 0 999CRIXIVAN 400 MG CAPSULE Auto PA
W5C ATAZANAVIR SULFATE/COBICISTAT 18 999EVOTAZ 300 MG-150 MG TABLET Auto PA
W5C SAQUINAVIR MESYLATE 0 999INVIRASE 500 MG TABLET Auto PA
W5C FOSAMPRENAVIR CALCIUM 0 999LEXIVA 50 MG/ML SUSPENSION Auto PA
W5C FOSAMPRENAVIR CALCIUM 0 999LEXIVA 700 MG TABLET Auto PA
W5C RITONAVIR 0 999NORVIR 100 MG POWDER PACKET Auto PA
W5C RITONAVIR 0 999NORVIR 100 MG TABLET Auto PA
W5C RITONAVIR 0 999NORVIR 80 MG/ML SOLUTION Auto PA
W5C ATAZANAVIR SULFATE 0 999REYATAZ 150 MG CAPSULE Auto PA
W5C ATAZANAVIR SULFATE 0 999REYATAZ 200 MG CAPSULE Auto PA
W5C ATAZANAVIR SULFATE 0 999REYATAZ 300 MG CAPSULE Auto PA
W5C ATAZANAVIR SULFATE 0 999REYATAZ 50 MG POWDER PACKET Auto PA
W5C NELFINAVIR MESYLATE 0 999VIRACEPT 250 MG TABLET Auto PA
W5C NELFINAVIR MESYLATE 0 999VIRACEPT 625 MG TABLET Auto PA
W5F HEPATITIS B TREATMENT AGENTSW5F ENTECAVIR 0 999BARACLUDE 0.05 MG/ML SOLUTION No
W5F ENTECAVIR 0 999ENTECAVIR 0.5 MG TABLET No
W5F ENTECAVIR 0 999ENTECAVIR 1 MG TABLET No
W5F LAMIVUDINE 0 11EPIVIR HBV 25 MG/5 ML SOLN No
W5F LAMIVUDINE 0 999LAMIVUDINE 100 MG TABLET No
W5F LAMIVUDINE 0 999LAMIVUDINE HBV 100 MG TABLET No
W5G HEPATITIS C TREATMENT AGENTSW5G RIBAVIRIN 5 999MODERIBA 200 MG TABLET Auto PA
W5G RIBAVIRIN 5 999MODERIBA 200-400 MG DOSEPACK Auto PA
Tuesday, May 14, 2019 Page 201 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W5G RIBAVIRIN 5 999MODERIBA 400-400 MG DOSEPACK Auto PA
W5G RIBAVIRIN 5 999MODERIBA 600-400 MG DOSEPACK Auto PA
W5G RIBAVIRIN 5 999MODERIBA 600-600 MG DOSEPACK Auto PA
W5G PEGINTERFERON ALFA-2A 3 999PEGASYS 180 MCG/0.5 ML SYRINGE Auto PA
W5G PEGINTERFERON ALFA-2A 3 999PEGASYS 180 MCG/ML VIAL Auto PA
W5G PEGINTERFERON ALFA-2A 3 999PEGASYS PROCLICK 180 MCG/0.5 Auto PA
W5G PEGINTERFERON ALFA-2B 3 999PEGINTRON 50 MCG KIT Auto PA
W5G RIBAVIRIN 5 999REBETOL 40 MG/ML SOLUTION Auto PA
W5G RIBAVIRIN 5 999RIBAPAK 200-600 MG DOSEPACK Auto PA
W5G RIBAVIRIN 5 999RIBAPAK 400-400 MG DOSEPACK Auto PA
W5G RIBAVIRIN 5 999RIBAPAK 400-600 MG DOSEPACK Auto PA
W5G RIBAVIRIN 5 999RIBAPAK 600-600 MG DOSEPACK Auto PA
W5G RIBAVIRIN 5 999RIBASPHERE 200 MG CAPSULE Auto PA
W5G RIBAVIRIN 5 999RIBASPHERE 200 MG TABLET Auto PA
W5G RIBAVIRIN 5 999RIBASPHERE 400 MG TABLET Auto PA
W5G RIBAVIRIN 5 999RIBASPHERE 600 MG TABLET Auto PA
W5G RIBAVIRIN 5 999RIBAVIRIN 200 MG CAPSULE Auto PA
W5G RIBAVIRIN 5 999RIBAVIRIN 200 MG TABLET Auto PA
W5I ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTIW5I TENOFOVIR DISOPROXIL FUMARATE 0 999TENOFOVIR DISOP FUM 300 MG TB No
W5I TENOFOVIR DISOPROXIL FUMARATE 0 999VIREAD 150 MG TABLET No
W5I TENOFOVIR DISOPROXIL FUMARATE 0 999VIREAD 200 MG TABLET No
W5I TENOFOVIR DISOPROXIL FUMARATE 0 999VIREAD 250 MG TABLET No
W5I TENOFOVIR DISOPROXIL FUMARATE 0 999VIREAD POWDER No
Tuesday, May 14, 2019 Page 202 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W5J ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTIW5J ABACAVIR SULFATE 0 999ABACAVIR 300 MG TABLET Auto PA
W5J DIDANOSINE 0 999DIDANOSINE 250 MG DR CAPSULE Auto PA
W5J DIDANOSINE 0 999DIDANOSINE 400 MG DR CAPSULE Auto PA
W5J EMTRICITABINE 0 999EMTRIVA 10 MG/ML SOLUTION Auto PA
W5J EMTRICITABINE 0 999EMTRIVA 200 MG CAPSULE Auto PA
W5J LAMIVUDINE 0 999EPIVIR 10 MG/ML ORAL SOLN Auto PA
W5J LAMIVUDINE 0 999LAMIVUDINE 10 MG/ML ORAL SOLN Auto PA
W5J LAMIVUDINE 0 999LAMIVUDINE 150 MG TABLET Auto PA
W5J LAMIVUDINE 0 999LAMIVUDINE 300 MG TABLET Auto PA
W5J ZIDOVUDINE 0 999RETROVIR 200 MG/20 ML VIAL Auto PA
W5J STAVUDINE 0 999STAVUDINE 15 MG CAPSULE Auto PA
W5J STAVUDINE 0 999STAVUDINE 20 MG CAPSULE Auto PA
W5J STAVUDINE 0 999STAVUDINE 30 MG CAPSULE Auto PA
W5J STAVUDINE 0 999STAVUDINE 40 MG CAPSULE Auto PA
W5J DIDANOSINE 0 999VIDEX 2 GM PEDIATRIC SOLN Auto PA
W5J DIDANOSINE 0 999VIDEX 4 GM PEDIATRIC SOLN Auto PA
W5J ABACAVIR SULFATE 0 999ZIAGEN 20 MG/ML SOLUTION Auto PA
W5J ZIDOVUDINE 0 999ZIDOVUDINE 100 MG CAPSULE Auto PA
W5J ZIDOVUDINE 0 999ZIDOVUDINE 300 MG TABLET Auto PA
W5J ZIDOVUDINE 0 999ZIDOVUDINE 50 MG/5 ML SYRUP Auto PA
W5K ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTIW5K RILPIVIRINE HCL 12 999EDURANT 25 MG TABLET Auto PA
W5K ETRAVIRINE 0 999INTELENCE 100 MG TABLET Auto PA
Tuesday, May 14, 2019 Page 203 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W5K ETRAVIRINE 0 999INTELENCE 200 MG TABLET Auto PA
W5K ETRAVIRINE 0 999INTELENCE 25 MG TABLET Auto PA
W5K NEVIRAPINE 0 999NEVIRAPINE 200 MG TABLET Auto PA
W5K NEVIRAPINE 0 999NEVIRAPINE 50 MG/5 ML SUSP Auto PA
W5K NEVIRAPINE 0 999NEVIRAPINE ER 100 MG TABLET Auto PA
W5K NEVIRAPINE 0 999NEVIRAPINE ER 400 MG TABLET Auto PA
W5K DORAVIRINE 18 999PIFELTRO 100 MG TABLET Auto PA
W5K DELAVIRDINE MESYLATE 0 999RESCRIPTOR 100 MG TABLET Auto PA
W5K DELAVIRDINE MESYLATE 0 999RESCRIPTOR 200 MG TABLET Auto PA
W5K EFAVIRENZ 0 999SUSTIVA 200 MG CAPSULE Auto PA
W5K EFAVIRENZ 0 999SUSTIVA 50 MG CAPSULE Auto PA
W5K EFAVIRENZ 0 999SUSTIVA 600 MG TABLET Auto PA
W5K NEVIRAPINE 0 999VIRAMUNE 50 MG/5 ML SUSP Auto PA
W5L ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMBW5L ABACAVIR SULFATE/LAMIVUDINE 0 999ABACAVIR-LAMIVUDINE 600-300 MG Auto PA
W5L LAMIVUDINE/ZIDOVUDINE 0 999LAMIVUDINE-ZIDOVUDINE TABLET Auto PA
W5L ABACAVIR/LAMIVUDINE/ZIDOVUDINE 0 999TRIZIVIR TABLET Auto PA
W5M ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMBW5M LOPINAVIR/RITONAVIR 0 999KALETRA 100-400/5 ML ORAL SOLU Auto PA
W5M LOPINAVIR/RITONAVIR 0 999KALETRA 25-100 MG TABLET Auto PA
W5M LOPINAVIR/RITONAVIR 0 999KALETRA 50-200 MG TABLET Auto PA
W5N ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORSW5N ENFUVIRTIDE 6 999FUZEON CONVENIENCE KIT Clinical PA Required
W5O ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOGW5O LAMIVUDINE/TENOFOVIR DISOP FUM 0 999CIMDUO 300-300 MG TABLET Auto PA
Tuesday, May 14, 2019 Page 204 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W5O EMTRICITABINE/TENOFOV ALAFENAM 0 999DESCOVY 200-25 MG TABLET Auto PA
W5O EMTRICITABINE/TENOFOVIR (TDF) 0 999TRUVADA 100 MG-150 MG TABLET Auto PA
W5O EMTRICITABINE/TENOFOVIR (TDF) 0 999TRUVADA 133 MG-200 MG TABLET Auto PA
W5O EMTRICITABINE/TENOFOVIR (TDF) 0 999TRUVADA 167 MG-250 MG TABLET Auto PA
W5O EMTRICITABINE/TENOFOVIR (TDF) 0 999TRUVADA TABLET Auto PA
W5P ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIBW5P TIPRANAVIR/VITAMIN E TPGS 0 999APTIVUS 100 MG/ML SOLUTION Auto PA
W5P TIPRANAVIR 0 999APTIVUS 250 MG CAPSULE Auto PA
W5P DARUNAVIR/COBICISTAT 18 999PREZCOBIX 800 MG-150 MG TABLET Auto PA
W5P DARUNAVIR ETHANOLATE 0 999PREZISTA 100 MG/ML SUSPENSION Auto PA
W5P DARUNAVIR ETHANOLATE 0 999PREZISTA 150 MG TABLET Auto PA
W5P DARUNAVIR ETHANOLATE 0 999PREZISTA 600 MG TABLET Auto PA
W5P DARUNAVIR ETHANOLATE 0 999PREZISTA 75 MG TABLET Auto PA
W5P DARUNAVIR ETHANOLATE 0 999PREZISTA 800 MG TABLET Auto PA
W5Q ARTV NUCLEOSIDE,NUCLEOTIDE,NON-NUCLEOSIDE RTI COMBW5Q EFAVIRENZ/EMTRICIT/TENOFOVR DF 12 999ATRIPLA TABLET Auto PA
W5Q EMTRICITA/RILPIVIRINE/TENOF DF 12 999COMPLERA TABLET Auto PA
W5Q DORAVIRINE/LAMIVU/TENOFOV DISO 18 999DELSTRIGO 100-300-300 MG TAB Auto PA
W5Q EMTRICITAB/RILPIVIRI/TENOF ALA 12 999ODEFSEY TABLET Auto PA
W5Q EFAVIRENZ/LAMIVU/TENOFOV DISOP 0 999SYMFI 600-300-300 MG TABLET Auto PA
W5Q EFAVIRENZ/LAMIVU/TENOFOV DISOP 0 999SYMFI LO 400-300-300 MG TABLET Auto PA
W5T ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG.W5T MARAVIROC 16 999SELZENTRY 150 MG TABLET Clinical PA Required
W5T MARAVIROC 16 999SELZENTRY 20 MG/ML ORAL SOLN Clinical PA Required
W5T MARAVIROC 16 999SELZENTRY 25 MG TABLET Clinical PA Required
Tuesday, May 14, 2019 Page 205 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W5T MARAVIROC 16 999SELZENTRY 300 MG TABLET Clinical PA Required
W5T MARAVIROC 16 999SELZENTRY 75 MG TABLET Clinical PA Required
W5U ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTRW5U RALTEGRAVIR POTASSIUM 0 999ISENTRESS 100 MG POWDER PACKET Auto PA
W5U RALTEGRAVIR POTASSIUM 0 999ISENTRESS 100 MG TABLET CHEW Auto PA
W5U RALTEGRAVIR POTASSIUM 0 999ISENTRESS 25 MG TABLET CHEW Auto PA
W5U RALTEGRAVIR POTASSIUM 0 999ISENTRESS 400 MG TABLET Auto PA
W5U RALTEGRAVIR POTASSIUM 0 999ISENTRESS HD 600 MG TABLET Auto PA
W5U DOLUTEGRAVIR SODIUM 0 999TIVICAY 10 MG TABLET Auto PA
W5U DOLUTEGRAVIR SODIUM 0 999TIVICAY 25 MG TABLET Auto PA
W5U DOLUTEGRAVIR SODIUM 0 999TIVICAY 50 MG TABLET Auto PA
W5X ARV-NUCLEOSIDE,NUCLEOTIDE RTI,INTEGRASE INHIBITORSW5X BICTEGRAV/EMTRICIT/TENOFOV ALA 18 999BIKTARVY 50-200-25 MG TABLET Auto PA
W5X ELVITEG/COB/EMTRI/TENOF ALAFEN 12 999GENVOYA TABLET Auto PA
W5X ELVITEG/COB/EMTRI/TENOFO DISOP 12 999STRIBILD TABLET Auto PA
W5Z ANTIRETROVIRAL-NRTIS AND INTEGRASE INHIBITORS COMBW5Z ABACAVIR/DOLUTEGRAVIR/LAMIVUDI 18 999TRIUMEQ TABLET Auto PA
W7K ANTISERAW7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999BIVIGAM LIQUID 10% VIAL Clinical PA Required
W7K IMMUN GLOBG(IGG)/SUCR/IGA OV50 0 999CARIMUNE NF 12 GM VIAL Clinical PA Required
W7K IMMUN GLOBG(IGG)/SUCR/IGA OV50 0 999CARIMUNE NF 6 GM VIAL Clinical PA Required
W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999CUVITRU 1 GRAM/5 ML VIAL Clinical PA Required
W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999CUVITRU 2 GRAM/10 ML VIAL Clinical PA Required
W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999CUVITRU 4 GRAM/20 ML VIAL Clinical PA Required
W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999CUVITRU 8 GRAM/ 40 ML VIAL Clinical PA Required
Tuesday, May 14, 2019 Page 206 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W7K CYTOMEGALOVIRUS IMMUNE GLOBULN 0 999CYTOGAM 2.5 GM/50 ML VIAL Clinical PA Required
W7K IMM GLOB G (IGG)/SORB/IGA 0-50 0 999FLEBOGAMMA DIF 10% VIAL Clinical PA Required
W7K IMM GLOB G (IGG)/SORB/IGA 0-50 0 999FLEBOGAMMA DIF 5% VIAL Clinical PA Required
W7K IMMUNE GLOBUL G (IGG)/GLYCINE 0 999GAMASTAN S/D VIAL Clinical PA Required
W7K IMMUNE GLOBUL G (IGG)/GLYCINE 0 999GAMASTAN S-D VIAL Clinical PA Required
W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999GAMMAGARD LIQUID 10% VIAL Clinical PA Required
W7K IMMUN GLOB G/GLY/GLUC/IGA 0-50 0 999GAMMAGARD S-D 10 G (IGA<1) SOL Clinical PA Required
W7K IMMUN GLOB G/GLY/GLUC/IGA 0-50 0 999GAMMAGARD S-D 5 G (IGA<1) SOLN Clinical PA Required
W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMMAKED 1 GRAM/10 ML VIAL Clinical PA Required
W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMMAKED 10 GRAM/100 ML VIAL Clinical PA Required
W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMMAKED 2.5 GRAM/25 ML VIAL Clinical PA Required
W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMMAKED 20 GRAM/200 ML VIAL Clinical PA Required
W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMMAKED 5 GRAM/50 ML VIAL Clinical PA Required
W7K IMMUN GLOB G(IGG)/GLY/IGA 0-50 0 999GAMMAPLEX 10 GRAM/100 ML VIAL Clinical PA Required
W7K IMMUN GLOB G(IGG)/GLY/IGA 0-50 0 999GAMMAPLEX 20 GRAM/200 ML VIAL Clinical PA Required
W7K IMMUN GLOB G(IGG)/GLY/IGA 0-50 0 999GAMMAPLEX 5 GRAM/50 ML VIAL Clinical PA Required
W7K IMMUN GLOB G/SORB/GLY/IGA 0-50 0 999GAMMAPLEX 5% VIAL Clinical PA Required
W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMUNEX-C 1 GRAM/10 ML VIAL Clinical PA Required
W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMUNEX-C 10 GRAM/100 ML VIAL Clinical PA Required
W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMUNEX-C 2.5 GRAM/25 ML VIAL Clinical PA Required
W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMUNEX-C 20 GRAM/200 ML VIAL Clinical PA Required
W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMUNEX-C 40 GRAM/400 ML VIAL Clinical PA Required
W7K IMMUNE GLOBUL G/GLY/IGA AVG 46 0 999GAMUNEX-C 5 GRAM/50 ML VIAL Clinical PA Required
W7K IMMUN GLOB G(IGG)/PRO/IGA 0-50 0 999HIZENTRA 1 GRAM/5 ML VIAL Clinical PA Required
Tuesday, May 14, 2019 Page 207 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W7K IMMUN GLOB G(IGG)/PRO/IGA 0-50 0 999HIZENTRA 10 GRAM/ 50 ML VIAL Clinical PA Required
W7K IMMUN GLOB G(IGG)/PRO/IGA 0-50 0 999HIZENTRA 10 GRAM/50 ML VIAL Clinical PA Required
W7K IMMUN GLOB G(IGG)/PRO/IGA 0-50 0 999HIZENTRA 2 GRAM/10 ML VIAL Clinical PA Required
W7K IMMUN GLOB G(IGG)/PRO/IGA 0-50 0 999HIZENTRA 4 GRAM/20 ML VIAL Clinical PA Required
W7K HEPATITIS B IMMUNE GLOBULIN 0 999HYPERHEP B S/D NEONATAL SYRIN. Clinical PA Required
W7K HEPATITIS B IMMUNE GLOBULIN 0 999HYPERHEP B S/D SYRINGE Clinical PA Required
W7K HEPATITIS B IMMUNE GLOBULIN 0 999HYPERHEP B S/D VIAL Clinical PA Required
W7K HEPATITIS B IMMUNE GLOBULIN 0 999HYPERHEP B S-D VIAL Clinical PA Required
W7K IGG/HYALURONIDASE,RECOMBINANT 0 999HYQVIA 10 GM/800 UNIT VIAL Clinical PA Required
W7K IGG/HYALURONIDASE,RECOMBINANT 0 999HYQVIA 2.5 GM/200 UNIT VIAL Clinical PA Required
W7K IGG/HYALURONIDASE,RECOMBINANT 0 999HYQVIA 20 GM/1,600 UNIT VIAL Clinical PA Required
W7K IGG/HYALURONIDASE,RECOMBINANT 0 999HYQVIA 30 GM/2,400 UNIT VIAL Clinical PA Required
W7K IGG/HYALURONIDASE,RECOMBINANT 0 999HYQVIA 5 GM/400 UNIT VIAL Clinical PA Required
W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999HYQVIA IG CMPNT 10 GM/100 ML Clinical PA Required
W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999HYQVIA IG CMPNT 2.5 GM/25 ML Clinical PA Required
W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999HYQVIA IG CMPNT 20 GM/200 ML Clinical PA Required
W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999HYQVIA IG CMPNT 30 GM/300 ML Clinical PA Required
W7K IMMUN GLOB G(IGG)/GLY/IGA OV50 0 999HYQVIA IG CMPNT 5 GM/50 ML Clinical PA Required
W7K HEPATITIS B IMMUNE GLOBULIN 0 999NABI-HB VIAL Clinical PA Required
W7K IMMUN GLOBG(IGG)/MALT/IGA OV50 0 999OCTAGAM 10% VIAL Clinical PA Required
W7K IMMUN GLOBG(IGG)/MALT/IGA OV50 0 999OCTAGAM 5% VIAL Clinical PA Required
W7K IMMUN GLOB G(IGG)/PRO/IGA 0-50 0 999PRIVIGEN 10% VIAL Clinical PA Required
W8F IRRIGANTSW8F ACETIC ACID 0 999ACETIC ACID 0.25% IRRIG SOLN No
Tuesday, May 14, 2019 Page 208 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
W8F ACETIC ACID 0 999ACETIC ACID 0.25% IRRIG. No
W8F RINGER'S SOLUTION,LACTATED 0 999LACTATED RINGERS IRRIGATION No
W8F NEOMYCIN SULF/POLYMYXIN B SULF 0 999NEOMY-POLYMYXIN B 40 MG/ML AMP No
W8F NEOMYCIN SULF/POLYMYXIN B SULF 0 999NEOMY-POLYMYXIN B 40 MG/ML VL No
W8F RINGER'S SOLUTION 0 999RINGERS IRRIGATION No
W8F RINGER'S SOLUTION 0 999RINGERS IRRIGATION SOLUTION No
W8F RINGER'S SOLUTION,LACTATED 0 999RINGER'S LACTATED IRRIG SOL No
W8F SODIUM CHLORIDE IRRIG SOLUTION 0 999SODIUM CHLORIDE 0.9% IRRIG No
W8F SODIUM CHLORIDE IRRIG SOLUTION 0 999SODIUM CHLORIDE 0.9% IRRIG. No
W8F SODIUM CHLORIDE IRRIG SOLUTION 0 999SODIUM CHLORIDE 0.9% IRRIGAT No
W8F SORBITOL SOLUTION 0 999SORBITOL 3% UROLOGIC IRRIG No
W8F SORBITOL SOLUTION 0 999SORBITOL 3.3% UROLOGIC SOLN No
W8F MANNITOL/SORBITOL SOLUTION 0 999SORBITOL-MANNITOL IRRIG No
W8F WATER FOR IRRIGATION,STERILE 0 999STERILE WATER FOR IRRIGATION No
Z1G DRUGS TO TX GAUCHER DX-TYPE 1, SUBSTRATE REDUCINGZ1G ELIGLUSTAT TARTRATE 18 999CERDELGA 84 MG CAPSULE Auto PA
Z1G MIGLUSTAT 18 999ZAVESCA 100 MG CAPSULE Auto PA
Z1H METABOLIC DISEASE ENZYME REPLACEMENT, FABRY'S DXZ1H AGALSIDASE BETA 8 999FABRAZYME 35 MG VIAL Auto PA
Z1H AGALSIDASE BETA 8 999FABRAZYME 5 MG VIAL Auto PA
Z1I METABOLIC DISEASE ENZYME REPLACEMENT, GAUCHER'S DXZ1I TALIGLUCERASE ALFA 4 999ELELYSO 200 UNITS VIAL Auto PA
Z1K METABOLIC DX ENZYME REPLACEMT,SEV.COMB.IMMUNE DEF.Z1K PEGADEMASE BOVINE 0 999ADAGEN 250 UNITS/ML VIAL No
Z21 MAST CELL STABILIZERS, ORALLY INHALED
Tuesday, May 14, 2019 Page 209 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Z21 CROMOLYN SODIUM 0 999CROMOLYN 20 MG/2 ML NEB SOLN No
Z21 CROMOLYN SODIUM 0 999CROMOLYN NEBULIZER SOLUTION No
Z2D HISTAMINE H2-RECEPTOR INHIBITORSZ2D FAMOTIDINE 0 999FAMOTIDINE 10 MG/ML VIAL No
Z2D FAMOTIDINE IN NACL,ISO-OSM/PF 0 999FAMOTIDINE 20 MG PIGGYBACK No
Z2D FAMOTIDINE 0 999FAMOTIDINE 20 MG TABLET No
Z2D FAMOTIDINE/PF 0 999FAMOTIDINE 20 MG/2 ML VIAL No
Z2D FAMOTIDINE 0 999FAMOTIDINE 200 MG/20 ML VIAL No
Z2D FAMOTIDINE 0 999FAMOTIDINE 40 MG TABLET No
Z2D FAMOTIDINE 0 999FAMOTIDINE 40 MG/4 ML VIAL No
Z2D RANITIDINE HCL 0 999RANITIDINE 15 MG/ML SYRUP No
Z2D RANITIDINE HCL 0 999RANITIDINE 150 MG TABLET No
Z2D RANITIDINE HCL 0 999RANITIDINE 150 MG/10 ML SYRUP No
Z2D RANITIDINE HCL 0 999RANITIDINE 300 MG TABLET No
Z2E IMMUNOSUPPRESSIVESZ2E LYMPHOCYTE IG,ANTITHYMOCYT,EQU 0 999ATGAM 50 MG/ML AMPUL Clinical PA Required
Z2E AZATHIOPRINE 0 999AZATHIOPRINE 50 MG TABLET No
Z2E MYCOPHENOLATE MOFETIL 0 11CELLCEPT 200 MG/ML ORAL SUSP No
Z2E MYCOPHENOLATE MOFETIL HCL 0 999CELLCEPT 500 MG VIAL No
Z2E CYCLOSPORINE 0 999CYCLOSPORINE 50 MG/ML AMP No
Z2E CYCLOSPORINE, MODIFIED 0 999CYCLOSPORINE MODIFIED 100 MG No
Z2E CYCLOSPORINE, MODIFIED 0 999CYCLOSPORINE MODIFIED 25 MG No
Z2E CYCLOSPORINE, MODIFIED 0 999CYCLOSPORINE MODIFIED 50 MG No
Z2E MYCOPHENOLATE MOFETIL 0 999MYCOPHENOLATE 250 MG CAPSULE No
Tuesday, May 14, 2019 Page 210 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Z2E MYCOPHENOLATE MOFETIL 0 999MYCOPHENOLATE 500 MG TABLET No
Z2E MYCOPHENOLATE MOFETIL HCL 0 999MYCOPHENOLATE 500 MG VIAL No
Z2E SIROLIMUS 0 999RAPAMUNE 1 MG/ML ORAL SOLN No
Z2E CYCLOSPORINE 0 999SANDIMMUNE 100 MG/ML SOLN No
Z2E CYCLOSPORINE 0 999SANDIMMUNE 50 MG/ML AMPUL No
Z2E SIROLIMUS 0 999SIROLIMUS 0.5 MG TABLET No
Z2E SIROLIMUS 0 999SIROLIMUS 1 MG TABLET No
Z2E SIROLIMUS 0 999SIROLIMUS 2 MG TABLET No
Z2E TACROLIMUS 0 999TACROLIMUS 0.5 MG CAPSULE No
Z2E TACROLIMUS 0 999TACROLIMUS 0.5 MG CAPSULES No
Z2E TACROLIMUS 0 999TACROLIMUS 1 MG CAPSULE No
Z2E TACROLIMUS 0 999TACROLIMUS 5 MG CAPSULE No
Z2E TACROLIMUS 0 999TACROLIMUS ANHYDROUS 0.5MG CAP No
Z2E TACROLIMUS 0 999TACROLIMUS ANHYDROUS 1 MG CAP No
Z2E TACROLIMUS 0 999TACROLIMUS ANHYDROUS 5 MG CAP No
Z2E ANTI-THYMOCYTE GLOBULIN,RABBIT 0 999THYMOGLOBULIN 25 MG VIAL Clinical PA Required
Z2F MAST CELL STABILIZERSZ2F CROMOLYN SODIUM 0 999CROMOLYN 100 MG/5 ML ORAL CONC No
Z2F CROMOLYN SODIUM 0 999CROMOLYN SODIUM 100 MG/5 ML No
Z2G IMMUNOMODULATORSZ2G INTERFERON GAMMA-1B,RECOMB. 0 999ACTIMMUNE 100 MCG/0.5 ML VIAL No
Z2G IMIQUIMOD 12 999IMIQUIMOD 5% CREAM No
Z2G IMIQUIMOD 12 999IMIQUIMOD 5% CREAM PACKET No
Z2G INTERFERON ALFA-2B,RECOMB. 0 999INTRON A 10 MILLION UNITS VIAL No
Tuesday, May 14, 2019 Page 211 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Z2G INTERFERON ALFA-2B,RECOMB. 0 999INTRON A 10MM UNITS/ML VIAL No
Z2G INTERFERON ALFA-2B,RECOMB. 0 999INTRON A 18 MILLION UNITS VIAL No
Z2G INTERFERON ALFA-2B,RECOMB. 0 999INTRON A 50 MILLION UNITS VIAL No
Z2G INTERFERON ALFA-2B,RECOMB. 0 999INTRON A 6MM UNITS/ML VIAL No
Z2G ALDESLEUKIN 0 999PROLEUKIN 22 MILLION UNIT VIAL Clinical PA Required
Z2H SYSTEMIC ENZYME INHIBITORSZ2H ALPHA-1-PROTEINASE INHIBITOR 18 999ARALAST NP 1,000 MG VIAL Auto PA
Z2H ALPHA-1-PROTEINASE INHIBITOR 18 999ARALAST NP 500 MG VIAL Auto PA
Z2H ALPHA-1-PROTEINASE INHIBITOR 18 999GLASSIA 1 GM/50 ML VIAL Auto PA
Z2H ALPHA-1-PROTEINASE INHIBITOR 18 999PROLASTIN C 1,000 MG VIAL Auto PA
Z2H ALPHA-1-PROTEINASE INHIBITOR 18 999PROLASTIN-C 1,000 MG/20 ML VL Auto PA
Z2H ALPHA-1-PROTEINASE INHIBITOR 18 999ZEMAIRA 1,000 MG VIAL Auto PA
Z2N 1ST GEN ANTIHISTAMINE AND DECONGESTANT COMBINATIONZ2N PHENYLEPHRINE HCL/PROMETH HCL 0 20PROMETHAZINE VC SYRUP No
Z2N PHENYLEPHRINE HCL/PROMETH HCL 0 20PROMETHAZINE-PHENYLEPHRINE SYR No
Z2O 2ND GEN ANTIHISTAMINE AND DECONGESTANT COMBINATIONZ2O CETIRIZINE HCL/PSEUDOEPHEDRINE 0 999ALL DAY ALLERGY-D TABLET No
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999ALLERGY & CONGESTION RLF TAB No
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999ALLERGY RELIEF & NASAL DECO TB No
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999ALLERGY RELIEF D-24 TABLET No
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999ALLERGY RELIEF D-24HR TABLET No
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999ALLERGY-CONGES RELF ER TABLET No
Z2O CETIRIZINE HCL/PSEUDOEPHEDRINE 0 999ALLER-TEC D 5-120 MG TABLET No
Z2O CETIRIZINE HCL/PSEUDOEPHEDRINE 0 999CETIRIZINE-PSE 5-120 MG TAB No
Z2O CETIRIZINE HCL/PSEUDOEPHEDRINE 0 999CETIRIZINE-PSE ER 5-120 MG TAB No
Tuesday, May 14, 2019 Page 212 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999HM ALLERGY & CONGESTION TABLET No
Z2O CETIRIZINE HCL/PSEUDOEPHEDRINE 0 999HM ALLERGY COMPLETE-D TABLET No
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999HM ALLERGY RLF-NASAL DECONG TB No
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999LORATADINE-D 12 HOUR TABLET No
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999LORATADINE-D 24HR TAB No
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999LORATADINE-D 24HR TABLET No
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999LORATADINE-D TABLET No
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999QC LORATADINE-D TABLET No
Z2O CETIRIZINE HCL/PSEUDOEPHEDRINE 0 999SM ALL DAY ALLERGY-D TABLET No
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999SM LORATADINE D 12 HOUR TABLET No
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999SM LORATADINE-D 12 HOUR TABLET No
Z2O LORATADINE/PSEUDOEPHEDRINE 0 999SUNMARK LORATA-DINE D TABLET No
Z2P ANTIHISTAMINES - 1ST GENERATIONZ2P CARBINOXAMINE MALEATE 0 999CARBINOXAMINE 4 MG/5 ML LIQUID No
Z2P CARBINOXAMINE MALEATE 0 999CARBINOXAMINE MALEATE 4 MG TAB No
Z2P CLEMASTINE FUMARATE 0 999CLEMASTINE FUM 2.68 MG TAB No
Z2P CYPROHEPTADINE HCL 0 999CYPROHEPTADINE 2 MG/5 ML SYRUP No
Z2P CYPROHEPTADINE HCL 0 999CYPROHEPTADINE 4 MG TABLET No
Z2P CYPROHEPTADINE HCL 0 999CYPROHEPTADINE 4 MG/10 ML SYRP No
Z2P DIPHENHYDRAMINE HCL 0 999DIPHENHYDRAMINE 12.5 MG/5 ML No
Z2P DIPHENHYDRAMINE HCL 0 999DIPHENHYDRAMINE 25 MG/10 ML No
Z2P DIPHENHYDRAMINE HCL 0 999DIPHENHYDRAMINE 50 MG/ML SYN No
Z2P DIPHENHYDRAMINE HCL 0 999DIPHENHYDRAMINE 50 MG/ML SYRNG No
Z2P DIPHENHYDRAMINE HCL 0 999DIPHENHYDRAMINE 50 MG/ML VIAL No
Tuesday, May 14, 2019 Page 213 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Z2P DIPHENHYDRAMINE HCL 0 999DIPHENHYDRAMINE 50 MG/ML VL No
Z2P DIPHENHYDRAMINE HCL 0 999DIPHENHYDRAMINE ELIXIR No
Z2P DIPHENHYDRAMINE HCL 0 999DIPHENHYDRAMINE HCL 50 MG/ML No
Z2P HYDROXYZINE HCL 0 999HYDROXYZINE 10 MG/5 ML SYRUP No
Z2P HYDROXYZINE HCL 0 999HYDROXYZINE HCL 10 MG TABLET No
Z2P HYDROXYZINE HCL 0 999HYDROXYZINE HCL 25 MG TABLET No
Z2P HYDROXYZINE HCL 0 999HYDROXYZINE HCL 50 MG TABLET No
Z2P HYDROXYZINE PAMOATE 0 999HYDROXYZINE PAM 100 MG CAP No
Z2P HYDROXYZINE PAMOATE 0 999HYDROXYZINE PAM 25 MG CAP No
Z2P HYDROXYZINE PAMOATE 0 999HYDROXYZINE PAM 50 MG CAP No
Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 12.5 MG TABLET No
Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 25 MG TABLET No
Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 25 MG/ML AMPUL No
Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 25 MG/ML VIAL No
Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 50 MG TABLET No
Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 50 MG/ML AMPUL No
Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 50 MG/ML VIAL No
Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 6.25 MG/5 ML SYR No
Z2P PROMETHAZINE HCL 0 999PROMETHAZINE 6.25 MG/5 ML SYRP No
Z2P PROMETHAZINE HCL 0 999PROMETHAZINE HCL 25MG TABLETS No
Z2Q ANTIHISTAMINES - 2ND GENERATIONZ2Q CETIRIZINE HCL 0 999ALL DAY ALLERGY 10 MG TABLET No
Z2Q CETIRIZINE HCL 0 999ALL DAY ALLERGY 10 MG TABLET No
Z2Q LORATADINE 0 999ALLERGY (LORATADINE) 10 MG TAB No
Tuesday, May 14, 2019 Page 214 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Z2Q LORATADINE 0 999ALLERGY 10 MG TABLET No
Z2Q LORATADINE 0 999ALLERGY RELIEF 10 MG ODT No
Z2Q LORATADINE 0 999ALLERGY RELIEF 10 MG TABLET No
Z2Q LORATADINE 0 11ALLERGY RELIEF 5 MG/5 ML SOLN No
Z2Q CETIRIZINE HCL 0 11CETIRIZINE HCL 1 MG/1 ML SOLN No
Z2Q CETIRIZINE HCL 0 11CETIRIZINE HCL 1 MG/ML SOLN No
Z2Q CETIRIZINE HCL 0 11CETIRIZINE HCL 1 MG/ML SYRUP No
Z2Q CETIRIZINE HCL 0 999CETIRIZINE HCL 10 MG CHEW TAB No
Z2Q CETIRIZINE HCL 0 999CETIRIZINE HCL 10 MG TABLET No
Z2Q CETIRIZINE HCL 0 999CETIRIZINE HCL 5 MG CHEW TAB No
Z2Q CETIRIZINE HCL 0 999CETIRIZINE HCL 5 MG TABLET No
Z2Q CETIRIZINE HCL 0 11CHILD ALL DAY ALLERGY 1 MG/ML No
Z2Q CETIRIZINE HCL 0 999CHILD CETIRIZINE 10 MG CHEW TB No
Z2Q CETIRIZINE HCL 0 999CHILD CETIRIZINE 5 MG CHEW TAB No
Z2Q CETIRIZINE HCL 0 11CHILD CETIRIZINE HCL 1 MG/ML No
Z2Q LORATADINE 0 11CHILD LORATADINE 5 MG/5 ML SOL No
Z2Q LORATADINE 0 11CHILD LORATADINE 5 MG/5 ML SYR No
Z2Q CETIRIZINE HCL 0 11CHILDREN'S ALL DAY ALLERGY SOL No
Z2Q CETIRIZINE HCL 0 11CHILDS ALL DAY ALLERGY SOLU No
Z2Q LORATADINE 0 999CLEAR-ATADINE 10 MG TABLET No
Z2Q LORATADINE 0 999CLEAR-ATADINE 10 MG TABLET No
Z2Q FEXOFENADINE HCL 0 999FEXOFENADINE HCL 180 MG TABLET Cystic Fib Diag Auto PA
Z2Q FEXOFENADINE HCL 0 999FEXOFENADINE HCL 30 MG/5 ML Cystic Fib Diag Auto PA
Z2Q FEXOFENADINE HCL 0 999FEXOFENADINE HCL 60 MG TABLET Cystic Fib Diag Auto PA
Tuesday, May 14, 2019 Page 215 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Z2Q CETIRIZINE HCL 0 999HM ALL DAY ALLERGY 10 MG TAB No
Z2Q CETIRIZINE HCL 0 11HM CHILD ALL DAY ALLER 1 MG/ML No
Z2Q CETIRIZINE HCL 0 11HM CHILD CETIRIZINE 1 MG/ML No
Z2Q LORATADINE 0 11HM CHILD LORATADINE 5 MG/5 ML No
Z2Q FEXOFENADINE HCL 0 999HM FEXOFENADINE HCL 180 MG TAB Cystic Fib Diag Auto PA
Z2Q FEXOFENADINE HCL 0 999HM FEXOFENADINE HCL 60 MG TAB Cystic Fib Diag Auto PA
Z2Q LORATADINE 0 999HM LORATADINE 10 MG TABLET No
Z2Q LEVOCETIRIZINE DIHYDROCHLORIDE 0 999LEVOCETIRIZINE 2.5 MG/5 ML SOL Cystic Fib Diag Auto PA
Z2Q LEVOCETIRIZINE DIHYDROCHLORIDE 0 999LEVOCETIRIZINE 5 MG TABLET Cystic Fib Diag Auto PA
Z2Q LORATADINE 0 999LORATADINE 10 MG TABLET No
Z2Q LORATADINE 0 999LORATADINE 10 MG TABLET No
Z2Q LORATADINE 0 11LORATADINE 5 MG/5 ML SOLN No
Z2Q LORATADINE 0 11LORATADINE 5 MG/5 ML SYRUP No
Z2Q LORATADINE 0 11LORATADINE ALLERGY 5 MG/5 ML No
Z2Q LORATADINE 0 11LORATADINE HIVES 5 MG/5 ML No
Z2Q CETIRIZINE HCL 0 999QC ALL DAY ALLERGY 10 MG TAB No
Z2Q CETIRIZINE HCL 0 11QC CHILDREN'S ALLERGY 1 MG/ML No
Z2Q FEXOFENADINE HCL 0 999QC FEXOFENADINE HCL 180 MG TAB Cystic Fib Diag Auto PA
Z2Q LORATADINE 0 999QC LORATADINE 10 MG TABLET No
Z2Q CETIRIZINE HCL 0 999SB ALLERGY 10 MG TABLET No
Z2Q LORATADINE 0 999SB LORATADINE 10 MG TABLET No
Z2Q CETIRIZINE HCL 0 999SM ALL DAY ALLERGY 10 MG TAB No
Z2Q LORATADINE 0 999SM ALLERGY RELIEF 10 MG TB No
Z2Q CETIRIZINE HCL 0 11SM CHILD ALL DAY ALLER 1 MG/ML No
Tuesday, May 14, 2019 Page 216 of 217
Class Generic Name Medicaid Min Age
Medicaid Max Age
Medicaid Drug Name Clinical PA Required
Z2Q LORATADINE 0 11SM CHILD ALLERGY 5 MG/5 ML SOL No
Z2Q LORATADINE 0 11SM CHILD LORATADINE 5 MG/5 ML No
Z2Q CETIRIZINE HCL 0 999SM CHILDREN'S ALL DAY ALLERGY No
Z2Q FEXOFENADINE HCL 0 999SM FEXOFENADINE HCL 180 MG TAB Cystic Fib Diag Auto PA
Z2Q FEXOFENADINE HCL 0 999SM FEXOFENADINE HCL 60 MG TAB Cystic Fib Diag Auto PA
Z2Q LORATADINE 0 999SM LORATADINE 10 MG TABLET No
Z2Q LORATADINE 0 11SM LORATADINE 5 MG/5 ML SYRUP No
Z2W ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODYZ2W OFATUMUMAB 0 999ARZERRA 1,000 MG/50 ML VIAL No
Z2W OFATUMUMAB 0 999ARZERRA 100 MG/5 ML VIAL No
Z2W RITUXIMAB 0 999RITUXAN 10 MG/ML VIAL No
Z2Z JANUS KINASE (JAK) INHIBITORSZ2Z TOFACITINIB CITRATE 18 999XELJANZ 10 MG TABLET Auto PA
Z2Z TOFACITINIB CITRATE 18 999XELJANZ 5 MG TABLET Auto PA
Z2Z TOFACITINIB CITRATE 18 999XELJANZ XR 11 MG TABLET Auto PA
Z4B LEUKOTRIENE RECEPTOR ANTAGONISTSZ4B MONTELUKAST SODIUM 0 999MONTELUKAST SOD 10 MG TABLET No
Z4B MONTELUKAST SODIUM 0 999MONTELUKAST SOD 4 MG TAB CHEW No
Z4B MONTELUKAST SODIUM 0 999MONTELUKAST SOD 5 MG TAB CHEW No
Z9D DIAGNOSTIC PREPARATIONS,MISCELLANEOUSZ9D GLUCAGON,HUMAN RECOMBINANT 0 999GLUCAGEN DIAGNOSTIC 1 MG VIAL No
Z9D GLUCAGON HCL 0 999GLUCAGON 1 MG VIAL No
Tuesday, May 14, 2019 Page 217 of 217