caresource georgia planning for healthy babies – inter

CareSource Georgia Planning for Healthy Babies – Inter-Pregnancy Care Effective 1/1/2022

CareSource Georgia Planning for Healthy Babies – Inter-Pregnancy Care Preferred Drug List (PDL)

Table of Contents

ANTI - INFECTIVES ...............................................................................................................................3 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ........................................................................ 5 CARDIOVASCULAR, HYPERTENSION / LIPIDS................................................................................ 9 DERMATOLOGICALS/TOPICAL THERAPY .................................................................................... 12 DIAGNOSTICS / MISCELLANEOUS AGENTS .................................................................................. 12 ENDOCRINE/DIABETES...................................................................................................................... 12 IMMUNOLOGY, VACCINES / BIOTECHNOLOGY .......................................................................... 14 MUSCULOSKELETAL / RHEUMATOLOGY..................................................................................... 14 OBSTETRICS / GYNECOLOGY .......................................................................................................... 14 OPHTHALMOLOGY............................................................................................................................. 18 RESPIRATORY AND ALLERGY ......................................................................................................... 18 UROLOGICALS..................................................................................................................................... 19 VITAMINS, HEMATINICS / ELECTROLYTES.................................................................................. 19 Index........................................................................................................................................................ 21

1


2

List of Abbreviations

1: Generic

2: Brand

ACA: Affordable Care Act.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service.

OTC: Over the Counter. An OTC drug is a non-prescription drug.

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. https://www.excel-easy.com/examples/read-only-workbook.html

QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.


You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

3

Drug Name Tier / Limits Drug Requirements

ANTI - INFECTIVES ANTIFUNGAL AGENTS clotrimazole mucous membrane

1

fluconazole 1

griseofulvin microsize

1

griseofulvin ultramicrosize

1

ketoconazole oral 1

nystatin oral suspension

1

terbinaf ine hcl oral 1 QL

voriconazole oral 1 PA

ANTIVIRALS acyclovir oral capsule

1

acyclovir oral suspension 200 mg/5 ml

1

acyclovir oral tablet 1

valacyclovir 1

CEPHALOSPORINS cefadroxil oral capsule

1

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

1

cefadroxil oral tablet 1

cefdinir 1

cefprozil 1

cefuroxime axetil 1 oral tablet

cephalexin 1

ERYTHROMYCINS / OTHER MACROLIDES azithromycin oral 1

clarithromycin 1

e.e.s. 400 oral tablet 1

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

1

ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG

2

erythrocin (as stearate) oral tablet 250 mg

1

erythromycin ethylsuccinate oral suspension for reconstitution

1

erythromycin ethylsuccinate oral tablet

1

erythromycin oral capsule,delayed release(dr/ec)

1

erythromycin oral tablet

1

MISCELLANEOUS ANTIINFECTIVES clindamycin hcl 1

clindamycin palmitate hcl

1

clindamycin pediatric

1

dapsone oral 1




4

lansoprazole-amoxicillin-clarithromycin

1

metronidazole oral 1

neomycin 1

PENICILLINS amoxicillin oral capsule

1

amoxicillin oral suspension for reconstitution

1

amoxicillin oral tablet

1

amoxicillin oral tablet,chewable 125 mg, 250 mg

1

amoxicillin-pot clavulanate oral suspension for reconstitution

1

amoxicillin-pot clavulanate oral tablet

1

amoxicillin-pot clavulanate oral tablet,chewable

1

ampicillin oral capsule

1

dicloxacillin 1

penicillin v potassium

1

QUINOLONES CIPRO ORAL SUSPENSION,MIC ROCAPSULE RECON

2

ciprofloxacin 1


ciprofloxacin hcl oral

1

levofloxacin oral 1

ofloxacin oral tablet 300 mg, 400 mg

1 QL

SULFA'S / RELATED A GENTS sulfadiazine 1

sulfamethoxazole-trimethopr im oral

1

sulfatrim 1

TETRACYCLINES avidoxy 1

doxycycl ine hyclate oral capsule

1

doxycycl ine hyclate oral tablet

1

doxycycl ine monohy drate oral capsule

1

doxycycl ine monohy drate oral suspension for reconstitution

1

doxycycl ine monohy drate oral tablet

1

minocycline oral capsule

1

minocycline oral tablet

1

mondox yne nl oral capsule 100 mg, 75 mg

1

morgidox 1

tetracycline 1

URINARY TRACT AGENTS




5

nitrofurantoin 1

nitrofurantoin macrocrystal

1

nitrofurantoin monohy d/m-cryst

1

trimethoprim 1

VANCOMYCIN vancomycin oral capsule

1 PA


AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS BANZEL ORAL SUSPENSION

2

BANZEL ORAL TABLET

2 ST

carbamazepine oral capsule, er multiphase 12 hr

1

carbamazepine oral suspension 100 mg/5 ml

1

carbamazepine oral tablet

1

carbamazepine oral tablet extended release 12 hr

1

carbamazepine oral tablet,chewable

1

CELONTIN ORAL CAPSULE 300 MG

2

clobazam 1 ST

clonazepam oral tablet

1 PA; QL

diazepam rectal kit 1 PA; QL 12.5-15-17.5-20 mg

diazepam rectal kit 2.5 mg, 5-7.5-10 mg

1 PA

DILANTIN 2

divalproex 1

epitol 1

ethosuximide 1

felbamate 1

FYCOMPA ORAL SUSPENSION

2 ST

FYCOMPA ORAL TABLET

2 ST

gabape ntin oral capsule

1 QL

gabape ntin oral solution

1 QL

gabape ntin oral tablet 600 mg, 800 mg

1 QL

lamotrigine oral tablet

1

lamotrigine oral tablet, chewable dispersible

1

levetiracetam oral 1

LYRICA 2 PA; QL

oxcarbazepine 1

OXTELLAR XR 2 PA

PEGANONE 2

phenobarbital 1

phenytoin oral suspension

1

phenytoin oral tablet,chewable

1

phenytoin sodium 1 extended




6

pregabal in oral capsule 200 mg

1 PA; QL

primidone 1

roweepra 1

roweepra xr 1

subvenite 1

tiagabine 1

topiramate oral capsule, sprinkle

1

topiramate oral tablet

1

valproic acid 1

VIMPAT ORAL TABLET

2 ST

zonisamide 1

MUSCLE R ELAXANTS / ANTISPASMODIC T HERAPY pyridostigmine bromide oral syrup

1

pyridostigmine bromide oral tablet 60 mg

1

pyridostigmine bromide oral tablet extended release

1

NON-NARCOTIC AN ALGESICS buprenorphine-naloxone sublingual tablet

1 PA; QL

celecoxib 1 ST

diclofenac potassium 1

diclofenac sodium oral

1

diclofenac- 1 misoprostol


diflunisal 1

ec-naproxen 1

etodolac 1

flurbiprofen oral tablet 100 mg

1

ibu 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

ketoprofen oral capsule 50 mg, 75 mg

1

ketorolac oral 1 QL

meloxicam oral tablet

1

nabumetone 1

naltrexone 1 PA

naproxen oral tablet,delayed release (dr/ec)

1

naproxen sodium oral tablet 275 mg, 550 mg

1

oxaprozin 1

sulindac 1

PSYCHOTHERAPEUTIC DRUGS amitriptyline 1

amitriptyline-chlordiazepoxide

1

amoxapine 1

aripiprazole oral tablet

1 QL

atomoxetine 1 QL

bupropion hcl oral 1 tablet




7

bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg

1 QL

bupropion hcl oral tablet sustained-release 12 hr

1

chlorpromazine oral 1

citalopram oral solution

1

citalopram oral tablet 10 mg

1

citalopram oral tablet 20 mg, 40 mg

1 QL

clomipramine 1

clonidine hcl oral tablet extended release 12 hr

1 QL

clozapine oral tablet 1

desipramine 1

dexmethylphenidate 1 QL

dextroamphetamine oral capsule, extended release

1 QL

dextroamphetamine oral tablet

1 QL

dextroamphetamine-amphetamine

1 QL

doxepin oral capsule 1

doxepin oral concentrate

1

duloxetine 1

escitalopram oxalate oral solution

1

escitalopram oxalate oral tablet 10 mg, 20

1 QL

mg


escitalopram oxalate oral tablet 5 mg

1

fluoxetine oral capsule 10 mg, 40 mg

1

fluoxetine oral capsule 20 mg

1 QL

fluoxetine oral solution

1

fluoxetine oral tablet 1

fluphenazine hcl oral 1

fluvoxamine oral capsule,extended release 24hr

1

fluvoxamine oral tablet 100 mg, 50 mg

1 QL

fluvoxamine oral tablet 25 mg

1

guanf acine oral tablet extended release 24 hr

1 QL

haloperidol 1

haloperidol lactate oral

1

imipramine hcl 1

lithium carbonate 1

lithium citrate oral solution 8 meq/5 ml

1

loxapine succinate 1

methylphenidate hcl oral capsule,er biphas ic 50-50 20 mg, 30 mg, 40 mg

1 QL

methylphenidate hcl oral solution

1 QL

methylphenidate hcl 1 QL oral tablet




8

methylphenidate hcl oral tablet extended release

1 QL

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

1 QL

METHYLPHENID ATE HCL ORAL TABLET EXTENDED RELEASE 24HR 72 MG

2 QL

methylphenidate hcl oral tablet,chewable

1 QL

mirtazapine oral tablet 15 mg, 30 mg, 45 mg

1 QL

mirtazapine oral tablet 7.5 mg

1

mirtazapine oral tablet,disintegrating

1 QL

nefazodone 1 QL

nortriptyline 1

olanzapine oral tablet

1 QL

paliperidone 1 QL

paroxetine hcl oral tablet 10 mg

1

paroxetine hcl oral tablet 20 mg, 30 mg, 40 mg

1 QL

paroxetine hcl oral tablet extended release 24 hr 12.5 mg

1


paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg

1 QL

perphenazine 1

perphenazine-amitriptyline

1

pimozide 1

quetiapine 1 QL

risperidone oral solution

1

risperidone oral tablet

1

sertraline oral concentrate

1

sertraline oral tablet 100 mg, 25 mg

1

sertraline oral tablet 50 mg

1 QL

thioridazine 1

thiothixene 1

tranylcypromine 1

trazodone 1

trifluoperazine 1

trimipramine 1

venlafaxine oral capsule,extended release 24hr 150 mg, 75 mg

1 QL

venlafaxine oral capsule,extended release 24hr 37.5 mg

1

venlafaxine oral tablet

1

ziprasidone hcl 1 QL




9


CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone oral tablet 200 mg

1

disopyramide phosphate oral capsule

1

dofetilide 1

flecainide 1

propaf enone 1

sorine 1

sotalol af 1

sotalol oral 1

ANTIHYPERTENSIVE THERAPY amiloride 1

amiloride-hydrochlorothiazide

1

amlodipine 1

amlodipine-benazepril

1

amlodipine-olmesartan

1

amlodipine-valsartan

1

amlodipine-valsartan-hcthiazid

1

atenolol 1

atenolol-chlorthalidone

1

benazepril 1

benazepril-hydrochlorothiazide

1

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide

1

bumetanide oral 1

candesartan 1

candesartan-hydrochlorothiazid

1

captopril 1

captopril-hydrochlorothiazide

1

cartia xt 1

carvedilol 1

chlorthalidone oral tablet 25 mg, 50 mg

1

clonidine 1

clonidine hcl oral tablet

1 QL

diltiazem hcl oral capsule,ext.rel 24h degradable 180 mg, 240 mg

1

diltiazem hcl oral capsule,extended release 12 hr

1

diltiazem hcl oral capsule,extended release 24 hr

1

diltiazem hcl oral capsule,extended release 24hr

1

diltiazem hcl oral tablet

1

diltiazem hcl oral tablet extended release 24 hr

1

dilt-xr 1

doxazosin 1




10

enalapril maleate 1

enalapril-hydrochlorothiazide

1

eplerenone 1

felodipine 1

fosinopr il 1

fosinopr il-hydrochlorothiazide

1

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

1

furosemide oral tablet

1

guanf acine oral tablet

1

hydralazine oral 1

hydrochlorothiazide 1

indapamide 1

irbesartan 1

irbesartan-hydrochlorothiazide

1

labetalol oral 1

lisinopril 1

lisinopril-hydrochlorothiazide

1

losartan 1

losartan-hydrochlorothiazide

1

matzim la 1

methyldopa 1

metolazone 1

metoprolol succinate 1


metoprolol ta-hydrochlorothiaz

1

metoprolol tartrate oral

1

metyrosine 1

minoxidil oral 1

nadolol 1

nifedipine oral tablet extended release

1

nifedipine oral tablet extended release 24hr

1

olmesartan 1

olmesartan-amlodipin-hcthiazid

1

olmesartan-hydrochlorothiazide

1

propranolol oral 1

quinapr il 1

quinapr il-hydrochlorothiazide

1

ramipril 1

spironolactone 1

spironolacton-hydrochlorothiaz

1

taztia xt 1

telmisartan 1

telmisartan-amlodipine

1

telmisartan-hydrochlorothiazid

1

terazosin 1

torsemide oral 1

trandolapril 1




11

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg

1

triamterene-hydrochlorothiazid oral tablet 37.5-25 mg

1 QL

triamterene-hydrochlorothiazid oral tablet 75-50 mg

1

valsartan 1

valsartan-hydrochlorothiazide

1

verapamil oral capsule,ext rel. pellets 24 hr

1

verapamil oral tablet 120 mg, 80 mg

1

verapamil oral tablet 40 mg

1 QL

verapamil oral tablet extended release

1

CARDIAC GLYCOSIDES digitek 1

digox 1

digoxin oral solution 50 mcg/ml (0.05 mg/ml)

1

digoxin oral tablet 1

COAGULATION THERAPY BRILINTA 2 ST

cilostazol 1

clopidogrel 1

dipyridamole oral 1

ELIQUIS 2


ELIQUIS DVT-PE TREAT 30D START

2

jantoven 1

pentoxifylline 1

prasugrel 1

warfarin 1

XARELTO 2.5 mg 2 ST

XARELTO 10 mg, 15 mg, 20 mg

2

XARELTO DVT-PE TREAT 30D START

2 QL

LIPID/CHOLESTEROL LOWERING AGENTS atorvastatin 1

cholestyramine (with sugar)

1

cholestyramine light 1

colestipol oral tablet 1

ezetimibe 1 ST

fenof ibrate micronized

1

fenof ibrate nanoc rystallized oral tablet 145 mg, 48 mg

1

fenof ibrate oral tablet

1

gemfibrozil 1

lovastatin 1

omega-3 acid ethyl esters

1

pravastatin 1

prevalite 1




12

rosuvastatin 1

simvastatin oral tablet

1

TRIGLIDE ORAL TABLET 160 MG

2

MISCELLANEOUS CARDIOVASCULAR AGENTS ENTRESTO 2 PA

ranolazine 1

NITRATES isosorbide mononi trate

1

nitroglycerin transdermal patch 24 hour

1


DERMATOLOGICALS/TOPICA L THERAPY THERAPY FOR ACNE sulfacetamide sodium-sulfur topical pads, medicated 10-4 %

1

DIAGNOSTICS / MISCELLANEOUS AGENTS MISCELLANEOUS AGENTS midodr ine 1

ENDOCRINE/DIABETES ADRENAL HORMONES hydrocortisone oral 1

methylprednisolone 1

prednisolone oral solution 15 mg/5 ml

1

prednisolone sodium 1 phosphate oral

prednisone 1

prednisone intensol 1

ANTITHYROID A GENTS methimazole oral tablet 10 mg, 5 mg

1

propylthiouracil 1

DIABETES THERAPY acarbose 1

ADMELOG SOLOSTAR U-100 INSULIN

2 QL

ADMELOG U-100 INSULIN LISPRO

2 QL

ALOGLIPTIN 2

ALOGLIPTIN-METFORMIN

2

ALOGLIPTIN-PIOGLITAZONE

2

FREESTYLE INSULINX STRIP

2 PA; OTC; QL

FREESTYLE INSULINX TEST STRIPS

2 PA; OTC; QL

FREESTYLE LIBRE 2 READER

2 PA; QL

FREESTYLE LITE STRIPS

2 PA; OTC; QL

FREESTYLE TEST 2 PA; OTC; QL

glimepiride 1

glipizide 1

glipizide-metformin 1

glyburide 1 QL

glyburide micronized

1 QL

glyburide-metformin 1 QL




13

HUMULIN 70/30 U-100 INSULIN

2 QL

HUMULIN 70/30 U-100 KWIKPEN

2 QL

HUMULIN N NPH INSULIN KWIKPEN

2 QL

HUMULIN N NPH U-100 INSULIN

2 QL

HUMULIN R REGULAR U-100 INSULN

2 QL

HUMULIN R U-500 (CONC) INSULIN

2

HUMULIN R U-500 (CONC) KWIKPEN

2

KETONE URINE TEST

2 OTC; QL

KETOSTIX 2 OTC; QL

LANCETS 2 OTC; QL

metformin oral solution

1

metformin oral tablet

1

metformin oral tablet extended release 24 hr

1

miglitol 1 ST

nateglinide 1

NOVOLIN 70/30 U-100 INSULIN

2 QL

NOVOLIN 70-30 FLEXPEN U-100

2 QL

NOVOLIN N NPH U-100 INSULIN

2 QL


NOVOLIN R REGULAR U-100 INSULN

2 QL

pioglitazone 1

pioglitazone-glimepiride

1 ST

pioglitazone-metformin

1

repaglinide 1

SEMGLEE 100 UNIT/ML VIAL

1 QL

SEMGLEE 100 UNIT/ML PEN

1 QL

STEGLATRO 2 ST; QL

TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML

2 ST; QL

MISCELLANEOUS HORMONES calcitriol oral 1

danaz ol oral capsule 100 mg, 200 mg

1

danaz ol oral capsule 50 mg

1 QL

desmopressin oral 1

THYROID HOR MONES euthyrox 2

levothyroxine oral 1

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

1

liothyronine oral 1




14

SYNTHROID ORAL TABLET 137 MCG

2

unithroid 1


IMMUNOLOGY, VACCINES / BIOTECHNOLOGY VACCINES / MISCELLANEOUS IMMUNOLOGICALS ADACEL(TDAP ADOLESN/ADULT )(PF)

2

BOOSTRIX TDAP 2

ENGERIX-B (P F) 2

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SYRINGE

2

HEPLISAV-B (PF) INTRAMUSCULA R SYRINGE

2

RECOMBIVAX HB (PF)

2

TDVAX 2

TENIVAC (PF) 2

MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY colchicine oral tablet

1 QL

probenecid 1

OSTEOPOROSIS THERAPY alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg

1

ibandr onate oral 1


OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS amabelz 1

camila 1

COMBIPATCH 2

covaryx 1

covaryx h.s. 1

deblitane 1

eemt 1

eemt hs 1

errin 1

estradiol-norethindrone acet

1

estrogens-methyltestosterone

1

fyavolv 1

heather 1

incassia 1

jencycla 1

jinteli 1

lopreeza oral tablet 1-0.5 mg

1

lyza 1

medroxyprogesteron e

1

mimvey 1

nora-be 1

norethindrone (contraceptive)

1

norethindrone acetate

1



15

norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

1

norlyda 1

progesterone micronized

1

sharobel 1

tulana 1

MISCELLANEOUS OB/GYN CLEOCIN VAGINAL SUPPOSITORY

2

clindamycin phosphate vaginal

1

eluryng 1

etonoge strel-ethinyl estradiol

1

metronidazole vaginal

1 QL

terconazole 1

vandaz ole 1 QL

xulane 1

zafemy 1

ORAL CONTRACEPTIVES / RELATED A GENTS afirmelle 1

altavera (28) 1

alyacen 1/35 (28) 1

alyacen 7/7/7 (28) 1

amethia 1 QL

amethia lo 1 QL

amethyst (28) 1 QL

apri 1


aranelle (28) 1

ashlyna 1 QL

aubra 1

aubra eq 1

aurovela 1.5/30 (21) 1

aurovela 1/20 (21) 1

aurovela 24 fe 1

aurovela fe 1.5/30 (28)

1

aurovela fe 1-20 (28)

1

aviane 1

ayuna 1

azurette (28) 1

balziva (28) 1

bekyree (28) 1

blisovi 24 fe 1

blisovi fe 1.5/30 (28) 1

blisovi fe 1/20 (28) 1

briellyn 1

camrese 1 QL

camrese lo 1 QL

caziant (28) 1

chateal (28) 1

chateal eq (28) 1

cryselle (28) 1

cyclafem 1/35 (28) 1

cyclafem 7/7/7 (28) 1

cyred 1

cyred eq 1

dasetta 1/35 (28) 1




16

dasetta 7/7/7 (28) 1

daysee 1 QL

desog-e.estradiol/e.estradio l

1

desogestrel-ethinyl estradiol

1

drospirenone-e.estradiol-lm.fa

1 PA

drospirenone-ethinyl estradiol

1

elinest 1

ELLA 2

emoque tte 1

enpresse 1

enskyce 1

estarylla 1

ethynodiol diac-eth estradiol

1

falmina (28) 1

femynor 1

gianvi (28) 1

hailey 24 fe 1

hailey fe 1.5/30 (28) 1

hailey fe 1/20 (28) 1

introvale 1 QL

isibloom 1

jasmiel (28) 1

jolessa 1 QL

juleber 1

junel 1.5/30 (21) 1

junel 1/20 (21) 1

junel fe 1.5/30 (28) 1


junel fe 1/20 (28) 1

junel fe 24 1

kaitlib fe 1

kariva (28) 1

kelnor 1/35 (28) 1

kelnor 1-50 1

kurvelo (28) 1

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7)

1 QL

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg

1

larin 1.5/30 (21) 1

larin 1/20 (21) 1

larin 24 fe 1

larin fe 1.5/30 (28) 1

larin fe 1/20 (28) 1

larissia 1

layolis fe 1

leena 28 1

lessina 1

levonest (28) 1

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg

1




17

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg (28)

1 QL

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month

1 QL

levonorg-eth estrad triphasic

1

levora-28 1

lillow (28) 1

loryna (28) 1

low-ogestrel (28) 1

lo-zumandimine (28) 1

lutera (28) 1

marlissa (28) 1

microgestin 1.5/30 (21)

1

microgestin 1/20 (21)

1

microgestin fe 1.5/30 (28)

1

microgestin fe 1/20 (28)

1

mili 1

mono-linyah 1

necon 0.5/35 (28) 1

nikki (28) 1

noreth-ethinyl estradiol-iron

1

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg

1


norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7)

1

norgestimate-ethinyl estradiol

1

nortrel 0.5/35 (28) 1

nortrel 1/35 (21) 1

nortrel 1/35 (28) 1

nortrel 7/7/7 (28) 1

ocella 1

orsythia 1

philith 1

pimtrea (28) 1

pirmella 1

portia 28 1

previfem 1

reclipsen (28) 1

setlakin 1 QL

simliya (28) 1

simpesse 1 QL

sprintec (28) 1

sronyx 1

syeda 1

tarina 24 fe 1

tarina fe 1/20 (28) 1

tarina fe 1-20 eq (28)

1

tilia fe 1

tri femynor 1

tri-estarylla 1




18

tri-legest fe 1

tri-linyah 1

tri-lo-estarylla 1

tri-lo-marzia 1

tri-lo-mili 1

tri-lo-sprintec 1

tri-mili 1

tri-previfem (28) 1

tri-sprintec (28) 1

trivora (28) 1

tri-vylibra 1

tri-vylibra lo 1

velivet triphasic regimen (28)

1

vienva 1

viorele (28) 1

vyfemla (28) 1

vylibra 1

wera (28) 1

wymzya fe 1

zarah 1

zovia 1/35e (28) 1

zumandimine (28) 1

OXYTOCICS methergine 1

methylergonov ine oral

1


OPHTHALMOLOGY ANTIBIOTICS moxifloxacin ophthalmic (eye)

1

drops, viscous

NATACYN 2 QL

ORAL DRUGS FOR GLAUCOMA acetazolamide 1

methazolamide 1


RESPIRATORY AND ALLERGY PULMONARY A GENTS albuterol sulfate inhalation

1 QL

albuterol sulfate oral 1

ARNUITY ELLIPTA

2 QL

ATROVENT HFA 2 QL

budesonide inhalation

1 QL

COMBIVENT RESPIMAT

2 QL

cromolyn inhalation 1 QL

DULERA 2 QL

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML

2

FLOVENT DISKUS 2 QL

FLOVENT HFA 2 QL

FLUTICASONE PROPION-SALMETEROL INHALATION AEROSOL POWDR BREATH ACTIVATED

2 QL

fluticasone propion-salmeterol inhalation blister with device

1 QL



19

ipratropium bromide inhalation

1 QL

ipratropium-albuterol

1 QL

LEVALBUTEROL TARTRATE

2 QL

metaproterenol oral syrup

1

montelukast 1

OFEV 2 PA, QL

SEREVENT DISKUS

2 QL

SPIRIVA RESPIMAT

2 QL

STIOLTO RESPIMAT

2 QL

STRIVERDI RESPIMAT

2 QL

terbutaline oral 1

THEO-24 2

theochron oral tablet extended release 12 hr 100 mg, 200 mg

1

theophy lline oral elixir

1

theophy lline oral solution

1

theophy lline oral tablet extended release 12 hr 300 mg, 450 mg

1

theophy lline oral tablet extended release 24 hr

1

TRELEGY ELLIPTA

2 PA, QL

Drug Name Tier / Limits Drug Requirements Drug Name

Tier / Limits Drug Requirements

UROLOGICALS MISCELLANEOUS UROLOGICALS methen-sod phos -meth blue-hyos

1

phosphasal 1

potassium citrate 1

uretron d-s oral tablet 81.6-10.8-40.8 mg

1

urin ds 1

uro-458 1

uryl 1

ustell 1

utira-c 1

vilevev mb 1

URINARY ANESTHETICS phenazopyridine oral tablet 100 mg, 200 mg

1

VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate(phosphat bind)

1

klor-con 10 1

klor-con 8 1

klor-con m10 1

klor-con m15 1

klor-con m20 1

potassium chloride oral capsule, extended release

1



20

potassium chloride oral liquid

1

potassium chloride oral tablet extended release

1

potassium chloride oral tablet,er particles/crystals

1

VITAMINS / HEMATINICS cyanocobalamin (vitamin b-12) injection

1

folic acid oral tablet 1 mg

1

KOSHER PRENATAL PLUS IRON

2

m-natal plus 1

mynatal advance 1

mynatal oral tablet 1


pnv 29-1 1

prenaissance plus 1

prenatabs fa 1

prenatabs rx 1

PRENATAL 19 2

prenatal low iron 1

prenatal plus 1

prenatal plus (calcium carb)

1

prenatal vitamin plus low iron

1

preplus 1

pretab 1

se-natal 19 chewable 1

THRIVITE RX 2

TRICARE 2

trinatal rx 1 1


CareSource Georgia Planning for Healthy Babies – Inter-Pregnancy Care Effective 1/1/2022 Index

A acarbose.............................. 12 acetazolamide ..................... 18 acyclovir ............................... 3 ADACEL(TDAP

ADOLESN/ADULT)(PF) 14 ADMELOG SOLOSTAR U-

100 INSULIN.................. 12 ADMELOG U-100 INSULIN

LISPRO .......................... 12 afirmelle ............................. 15 albuterol sulfate................... 19 alendronate ......................... 14 ALOGLIPTIN..................... 12 ALOGLIPTIN-METFORMIN

....................................... 12 ALOGLIPTIN-

PIOGLITAZONE............ 13 altavera (28) ........................ 15 alyacen 1/35 (28)................. 15 alyacen 7/7/7 (28)................ 15 amabelz .............................. 14 amethia ............................... 15 amethia lo ........................... 15 amethyst (28) ...................... 15 amiloride............................... 9 amiloride-hydrochlorothiazide

......................................... 9 amiodarone ........................... 9 amitriptyline.......................... 7 amitriptyline-chlordiazepoxide

......................................... 7 amlodipine ............................ 9 amlodipine-benazepril ........... 9 amlodipine-olmesartan .......... 9 amlodipine-valsartan ............. 9 amlodipine-valsartan-hcthiazid

......................................... 9 amoxapine ............................ 7 amoxicillin ............................ 4 amoxicillin-pot clavulanate.... 4 ampicillin.............................. 4 apri ..................................... 15 aranelle (28) ........................ 15 aripiprazole ........................... 7

ARNUITY ELLIPTA.......... 19 ashlyna ............................... 15 atenolol................................. 9 atenolol-chlorthalidone .......... 9 atomoxetine .......................... 7 atorvastatin ......................... 11 ATROVENT HFA .............. 19 aubra................................... 15 aubra eq.............................. 15 aurovela 1.5/30 (21) ............ 15 aurovela 1/20 (21) ............... 15 aurovela 24 fe ..................... 15 aurovela fe 1.5/30 (28)......... 15 aurovela fe 1-20 (28) ........... 15 aviane ................................. 16 avidoxy................................. 4 ayuna .................................. 16 azithromycin ......................... 3 azurette (28) ........................ 16 B balziva (28) ......................... 16

benazepril-hydrochlorothiazide

bisoprolol-hydrochlorothiazide

BANZEL.............................. 5 bekyree (28) ........................ 16 benazepril ............................. 9

......................................... 9 bisoprolol fumarate ............... 9

......................................... 9 blisovi 24 fe ........................ 16 blisovi fe 1.5/30 (28) ........... 16 blisovi fe 1/20 (28) .............. 16 BOOSTRIX TDAP ............. 14 briellyn ............................... 16 BRILINTA ......................... 11 budesonide.......................... 19 bumetanide ........................... 9 buprenorphine-naloxone ........ 6 bupropion hcl........................ 7 C calcitriol.............................. 14

....................................... 20 calcium acetate(phosphat bind)

camila ................................. 14 camrese............................... 16

camrese lo........................... 16 candesartan........................... 9 candesartan-hydrochlorothiazid

......................................... 9 captopril................................ 9 captopril-hydrochlorothiazide 9 carbamazepine ...................... 5 cartia xt................................. 9 carvedilol.............................. 9 caziant (28) ......................... 16 cefadroxil.............................. 3 cefdinir ................................. 3 cefprozil................................ 3 cefuroxime axetil................... 3 celecoxib............................... 6 CELONTIN .......................... 5 cephalexin............................. 3 chateal (28) ......................... 16 chateal eq (28)..................... 16 chlorpromazine ..................... 7 chlorthalidone ....................... 9 cholestyramine (with sugar). 11 cholestyramine light ............ 12 cilostazol............................. 11 CIPRO.................................. 4 ciprofloxacin......................... 4 ciprofloxacin hcl ................... 4 citalopram............................. 7 clarithromycin....................... 3 CLEOCIN........................... 15 clindamycin hcl..................... 3 clindamycin palmitate hcl...... 3 clindamycin pediatric ............ 4 clindamycin phosphate ........ 15 clobazam............................... 5 clomipramine ........................ 7 clonazepam........................... 5 clonidine ............................... 9 clonidine hcl 9..................... 7, clopidogrel.......................... 11 clotrimazole .......................... 3 clozapine............................... 7 colchicine ........................... 14 colestipol ............................ 12 COMBIPATCH .................. 14


21

CareSource Georgia Planning for Healthy Babies – Inter-Pregnancy Care Effective 1/1/2022 COMBIVENT RESPIMAT. 19 covaryx............................... 14 covaryx h.s.......................... 14 cromolyn............................. 19 cryselle (28) ........................ 16 cyanocobalamin (vitamin b-12)

....................................... 20 cyclafem 1/35 (28) .............. 16 cyclafem 7/7/7 (28) ............. 16 cyred................................... 16 cyred eq.............................. 16 D danazol ............................... 14 dapsone................................. 4 dasetta 1/35 (28).................. 16 dasetta 7/7/7 (28)................. 16 daysee................................. 16 deblitane ............................. 14 desipramine........................... 7 desmopressin ...................... 14

16desog-e.estradiol/e.estradiol. desogestrel-ethinyl estradiol 16 dexmethylphenidate .............. 7 dextroamphetamine ............... 7 dextroamphetamine-

amphetamine ..................... 7 diazepam............................... 5 diclofenac potassium ............. 6 diclofenac sodium ................. 6 diclofenac-misoprostol .......... 6 dicloxacillin .......................... 4 diflunisal............................... 6 digitek ................................ 11 digox .................................. 11 digoxin ............................... 11 DILANTIN........................... 5 diltiazem hcl 10....................9,dilt-xr.................................. 10 dipyridamole ....................... 11 disopyramide phosphate ........ 9 divalproex............................. 5 dofetilide............................... 9 doxazosin............................ 10 doxepin................................. 7 doxycycline hyclate............... 4 doxycycline monohydrate...... 4

....................................... 16

....................................... 16

drospirenone-e.estradiol-lm.fa

drospirenone-ethinyl estradiol

DULERA............................ 19 duloxetine ............................. 7 E e.e.s. 400............................... 3 ec-naproxen .......................... 6 eemt.................................... 14 eemt hs ............................... 14 elinest ................................. 16 ELIQUIS ............................ 11 ELIQUIS DVT-PE TREAT

30D START .................... 11 ELIXOPHYLLIN................ 19 ELLA ................................. 16 eluryng ............................... 15 emoquette ........................... 16 enalapril maleate ................. 10 enalapril-hydrochlorothiazide

....................................... 10 ENGERIX-B (PF) ............... 14 ENGERIX-B PEDIATRIC

(PF) ................................ 14 enpresse.............................. 16 enskyce............................... 16 ENTRESTO........................ 12 epitol .................................... 5 eplerenone .......................... 10 errin .................................... 14 ery-tab .................................. 3 ERY-TAB............................. 3 erythrocin (as stearate)........... 3 erythromycin......................... 3 erythromycin ethylsuccinate .. 3 escitalopram oxalate .............. 7 estarylla .............................. 16 estradiol-norethindrone acet. 15 estrogens-methyltestosterone 15 ethosuximide......................... 5 ethynodiol diac-eth estradiol 16 etodolac ................................ 6 etonogestrel-ethinyl estradiol15 euthyrox.............................. 14 ezetimibe ............................ 12 F falmina (28) ........................ 16 felbamate .............................. 5 felodipine............................ 10

femynor .............................. 16 fenofibrate .......................... 12 fenofibrate micronized......... 12 fenofibrate nanocrystallized. 12 flecainide .............................. 9 FLOVENT DISKUS ........... 19 FLOVENT HFA ................. 19 fluconazole ........................... 3 fluoxetine.............................. 7 fluphenazine hcl.................... 7 flurbiprofen........................... 6 fluticasone propion-salmeterol

....................................... 19 FLUTICASONE PROPION-

SALMETEROL .............. 19 fluvoxamine .......................... 7 folic acid............................. 20 fosinopril ............................ 10 fosinopril-hydrochlorothiazide

....................................... 10 FREESTYLE INSULINX ... 13 FREESTYLE INSULINX

TEST STRIPS................. 13 FREESTYLE LIBRE 2

READER ........................ 13 FREESTYLE LITE STRIPS 13 FREESTYLE TEST ............ 13 furosemide .......................... 10 fyavolv ............................... 15 FYCOMPA........................... 5 G gabapentin ............................ 5 gemfibrozil ......................... 12 gianvi (28) .......................... 16 glimepiride.......................... 13 glipizide.............................. 13 glipizide-metformin............. 13 glyburide............................. 13 glyburide micronized........... 13 glyburide-metformin ........... 13 griseofulvin microsize ........... 3 griseofulvin ultramicrosize .... 3 guanfacine .......................7, 10 H hailey 24 fe ......................... 16 hailey fe 1.5/30 (28) ............ 16 hailey fe 1/20 (28) ............... 16 haloperidol............................ 7


22

CareSource Georgia Planning for Healthy Babies – Inter-Pregnancy Care Effective 1/1/2022 haloperidol lactate ................. 7 heather................................ 15 HEPLISAV-B (PF) ............. 14 HUMULIN 70/30 U-100

INSULIN ........................ 13 HUMULIN 70/30 U-100

KWIKPEN...................... 13 HUMULIN N NPH INSULIN

KWIKPEN...................... 13 HUMULIN N NPH U-100

INSULIN ........................ 13 HUMULIN R REGULAR U-

100 INSULN................... 13 HUMULIN R U-500 (CONC)

INSULIN ........................ 13 HUMULIN R U-500 (CONC)

KWIKPEN...................... 13 hydralazine ......................... 10 hydrochlorothiazide............. 10 hydrocortisone .................... 12 I ibandronate ......................... 14 ibu ........................................ 6 ibuprofen .............................. 6 imipramine hcl ...................... 7 incassia ............................... 15 indapamide ......................... 10 introvale.............................. 16 ipratropium bromide............ 19 ipratropium-albuterol........... 19 irbesartan............................ 10

....................................... 10 irbesartan-hydrochlorothiazide

isibloom.............................. 16 isosorbide mononitrate ........ 12 J jantoven.............................. 11 jasmiel (28) ......................... 16 jencycla .............................. 15 jinteli .................................. 15 jolessa................................. 16 juleber ................................ 16 junel 1.5/30 (21) .................. 16 junel 1/20 (21)..................... 16 junel fe 1.5/30 (28) .............. 16 junel fe 1/20 (28)................. 16 junel fe 24........................... 16

K kaitlib fe ............................. 16 kariva (28) .......................... 16 kelnor 1/35 (28)................... 16 kelnor 1-50 ......................... 16 ketoconazole ......................... 3 KETONE URINE TEST...... 13 ketoprofen............................. 6 ketorolac ............................... 6 KETOSTIX......................... 13 klor-con 10 ......................... 20 klor-con 8 ........................... 20 klor-con m10....................... 20 klor-con m15....................... 20 klor-con m20....................... 20 KOSHER PRENATAL PLUS

IRON.............................. 20 kurvelo (28) ........................ 16 L l norgest/e.estradiol-e.estrad 17 labetalol .............................. 10 lamotrigine............................ 5 LANCETS.......................... 13 larin 1.5/30 (21) .................. 17 larin 1/20 (21) ..................... 17 larin 24 fe ........................... 17 larin fe 1.5/30 (28)............... 17 larin fe 1/20 (28) ................. 17 larissia ................................ 17 layolis fe ............................. 17 leena 28 .............................. 17 lessina................................. 17 LEVALBUTEROL

TARTRATE.................... 19 levetiracetam......................... 5 levofloxacin .......................... 4 levonest (28) ....................... 17 levonorgestrel-ethinyl estrad 17 levonorg-eth estrad triphasic 17 levora-28............................. 17 levothyroxine ...................... 14 levoxyl................................ 14 lillow (28) ........................... 17 liothyronine......................... 14 lisinopril ............................. 10

....................................... 10 lisinopril-hydrochlorothiazide

lithium carbonate................... 8

lithium citrate........................ 8 lopreeza .............................. 15 loryna (28) .......................... 17 losartan............................... 10 losartan-hydrochlorothiazide 10 lovastatin ............................ 12 low-ogestrel (28) ................. 17 loxapine succinate ................. 8 lo-zumandimine (28) ........... 17 lutera (28) ........................... 17 LYRICA............................... 5 lyza..................................... 15 M marlissa (28) ....................... 17 matzim la ............................ 10 medroxyprogesterone .......... 15 meloxicam ............................ 6 metaproterenol .................... 19 metformin ........................... 13 methazolamide .................... 18 methen-sod phos-meth blue-

hyos ................................ 19 methergine .......................... 18 methimazole........................ 12 methyldopa ......................... 10 methylergonovine................ 18 methylphenidate hcl .............. 8 METHYLPHENIDATE HCL8 methylprednisolone ............. 12 metolazone.......................... 10 metoprolol succinate............ 10 metoprolol ta-hydrochlorothiaz

....................................... 10 metoprolol tartrate............... 10 metronidazole 15..................4,metyrosine .......................... 10 microgestin 1.5/30 (21)........ 17 microgestin 1/20 (21) .......... 17 microgestin fe 1.5/30 (28).... 17 microgestin fe 1/20 (28)....... 17 midodrine ........................... 12 miglitol ............................... 13 mili..................................... 17 mimvey............................... 15 minocycline .......................... 4 minoxidil ............................ 10 mirtazapine ........................... 8 m-natal plus ........................ 20


23

CareSource Georgia Planning for Healthy Babies – Inter-Pregnancy Care Effective 1/1/2022 mondoxyne nl ....................... 5 mono-linyah........................ 17 montelukast......................... 19 morgidox .............................. 5 moxifloxacin....................... 18 mynatal............................... 20 mynatal advance.................. 20 N nabumetone........................... 6 nadolol................................ 10 naltrexone ............................. 6 naproxen............................... 6 naproxen sodium................... 6 NATACYN......................... 18 nateglinide .......................... 13 necon 0.5/35 (28) ................ 17 nefazodone............................ 8 neomycin .............................. 4 nifedipine............................ 10 nikki (28) ............................ 17 nitrofurantoin ........................ 5 nitrofurantoin macrocrystal.... 5 nitrofurantoin monohyd/m-

cryst.................................. 5 nitroglycerin........................ 12 nora-be ............................... 15 noreth-ethinyl estradiol-iron 17 norethindrone (contraceptive)

....................................... 15 norethindrone acetate .......... 15 norethindrone ac-eth estradiol

..................................15, 17 norethindrone-e.estradiol-iron

....................................... 17 norgestimate-ethinyl estradiol

....................................... 17 norlyda ............................... 15 nortrel 0.5/35 (28) ............... 17 nortrel 1/35 (21) .................. 17 nortrel 1/35 (28) .................. 18 nortrel 7/7/7 (28) ................. 18 nortriptyline .......................... 8 NOVOLIN 70/30 U-100

INSULIN ........................ 13 NOVOLIN 70-30 FLEXPEN

U-100.............................. 13 NOVOLIN N NPH U-100

INSULIN ........................ 13

NOVOLIN R REGULAR U-100 INSULN................... 13

nystatin ................................. 3 O ocella .................................. 18 OFEV ................................. 19 ofloxacin............................... 4 olanzapine............................. 8 olmesartan .......................... 10 olmesartan-amlodipin-

hcthiazid ......................... 10 olmesartan-

hydrochlorothiazide ......... 10 omega-3 acid ethyl esters..... 12 orsythia............................... 18 oxaprozin.............................. 6 oxcarbazepine ....................... 5 OXTELLAR XR ................... 5 P paliperidone .......................... 8 paroxetine hcl........................ 8 PEGANONE......................... 6 penicillin v potassium............ 4 pentoxifylline ...................... 11 perphenazine ......................... 8 perphenazine-amitriptyline .... 8 phenazopyridine .................. 20 phenobarbital ........................ 6 phenytoin.............................. 6 phenytoin sodium extended ... 6 philith ................................. 18 phosphasal .......................... 19 pimozide ............................... 8 pimtrea (28) ........................ 18 pioglitazone ........................ 13 pioglitazone-glimepiride...... 13 pioglitazone-metformin ....... 13 pirmella .............................. 18 pnv 29-1 ............................. 20 portia 28 ............................. 18 potassium chloride .............. 20 potassium citrate ................. 20 prasugrel............................. 11 pravastatin .......................... 12 prednisolone........................ 12

....................................... 12 prednisolone sodium phosphate

prednisone .......................... 12

prednisone intensol.............. 12 pregabalin ............................. 6 prenaissance plus................. 20 prenatabs fa......................... 20 prenatabs rx ........................ 20 PRENATAL 19................... 20 prenatal low iron ................. 20 prenatal plus........................ 20 prenatal plus (calcium carb) . 20 prenatal vitamin plus low iron

....................................... 20 preplus ................................ 20 pretab.................................. 20 prevalite.............................. 12 previfem ............................. 18 primidone ............................. 6 probenecid .......................... 14 progesterone micronized...... 15 propafenone .......................... 9 propranolol ......................... 10 propylthiouracil................... 12 pyridostigmine bromide......... 6 Q quetiapine ............................. 8 quinapril ............................. 10 quinapril-hydrochlorothiazide

....................................... 11 R ramipril............................... 11 ranolazine ........................... 12 reclipsen (28) ...................... 18 RECOMBIVAX HB (PF).... 14 repaglinide .......................... 13 risperidone ............................ 8 rosuvastatin ......................... 12 roweepra............................... 6 roweepra xr........................... 6 S se-natal 19 chewable ........... 20 SEREVENT DISKUS ......... 19 sertraline ............................... 8 setlakin ............................... 18 sharobel .............................. 15 simliya (28)......................... 18 simpesse ............................. 18 simvastatin .......................... 12 sorine.................................... 9 sotalol................................... 9


24

CareSource Georgia Planning for Healthy Babies – Inter-Pregnancy Care Effective 1/1/2022 sotalol af ............................... 9 SPIRIVA RESPIMAT......... 19 spironolactone..................... 11

....................................... sprintec (28)

.........................................

11

4

........................ 18 sronyx................................. 18 STEGLATRO ..................... 13 STIOLTO RESPIMAT........ 19 STRIVERDI RESPIMAT.... 19 subvenite............................... 6 sulfacetamide sodium-sulfur 12 sulfadiazine........................... 4

sulfatrim ............................... 4 sulindac ................................ 6 syeda .................................. 18 SYNTHROID ..................... 14

tarina 24 fe.......................... 18 tarina fe 1/20 (28)................ 18 tarina fe 1-20 eq (28) ........... 18 taztia xt ............................... 11 TDVAX.............................. 14 telmisartan .......................... 11 telmisartan-amlodipine ........ 11

....................................... 11 TENIVAC (PF)................... 14 terazosin ............................. 11 terbinafine hcl ....................... 3 terbutaline ........................... 19 terconazole.......................... 15 tetracycline ........................... 5 THEO-24............................ 19 theochron............................ 19 theophylline ........................ 19 thioridazine ........................... 8

spironolacton-hydrochlorothiaz

sulfamethoxazole-trimethoprim

T

telmisartan-hydrochlorothiazid

thiothixene ............................ 8 THRIVITE RX ................... 20 tiagabine ............................... 6 tilia fe ................................. 18 topiramate............................. 6 torsemide ............................ 11 trandolapril ......................... 11 tranylcypromine .................... 8 trazodone .............................. 8 TRELEGY ELLIPTA.......... 19 tri femynor .......................... 18 triamterene-hydrochlorothiazid

....................................... 11 TRICARE........................... 20 tri-estarylla.......................... 18 trifluoperazine....................... 9 TRIGLIDE.......................... 12 tri-legest fe.......................... 18 tri-linyah............................. 18 tri-lo-estarylla ..................... 18 tri-lo-marzia ........................ 18 tri-lo-mili ............................ 18 tri-lo-sprintec ...................... 18 trimethoprim ......................... 5 tri-mili ................................ 18 trimipramine ......................... 9 trinatal rx 1 ......................... 20 tri-previfem (28).................. 18 tri-sprintec (28) ................... 18 trivora (28).......................... 18 tri-vylibra............................ 18 tri-vylibra lo ........................ 18 TRULICITY ....................... 14 tulana.................................. 15 U unithroid ............................. 14 uretron d-s........................... 20 urin ds................................. 20 uro-458 ............................... 20

uryl..................................... 20 ustell................................... 20 utira-c ................................. 20 V valacyclovir .......................... 3 valproic acid ......................... 6 valsartan ............................. 11 valsartan-hydrochlorothiazide

....................................... 11 vancomycin........................... 5 vandazole............................ 15 velivet triphasic regimen (28)

....................................... 18 venlafaxine ........................... 9 verapamil............................ 11 vienva ................................. 18 vilevev mb .......................... 20 VIMPAT .............................. 6 viorele (28) ......................... 18 voriconazole.......................... 3 vyfemla (28) ....................... 18 vylibra ................................ 18 W warfarin .............................. 11 wera (28) ............................ 18 wymzya fe .......................... 18 X XARELTO ......................... 11 XARELTO DVT-PE TREAT

30D START .................... 11 xulane ................................. 15 Z zarah................................... 18 ziprasidone hcl ...................... 9 zonisamide............................ 6 zovia 1/35e (28) .................. 18 zumandimine (28) ............... 18

GA-MMED-1616a-V.7 DCH Approved: 6/18/2020


25

caresource georgia planning for healthy babies – inter

Documents