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Medicaid-Approved Preferred Drug List

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Medicaid-Approved Preferred Drug List New York Medicaid Medicaid-Approved Preferred Drug List Effective August 26, 2021 Legend In each class, drugs are listed alphabetically by either brand name or generic name. Brand name drug: Uppercase in bold type Generic drug: Lowercase in plain type AL: Age Limit Restrictions DO: Dose Optimization Program GR: Gender Restriction OTC: Over the counter medication available with a prescription. (Prescribers please indicate OTC on the prescription) PA: Prior authorization is required. Prior authorization is the process of obtaining approval of benefits before certain prescriptions are filled. QL: Quantity limits; certain prescription medications have specific quantity limits per prescription or per month. SP: Specialty Pharmacy ST: Step therapy is required. You may need to use one medication before benefits for the use of another medication can be authorized. MAT: Medication Assisted Therapy https://newyork.fhsc.com/providers/mat.asp Drug Name Reference Notes *ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 5 Adderall XR DO; AL; QL mg amphetamine-dextroamphet er oral capsule extended release 24 hour 20 mg, 25 mg, 30 Adderall XR AL; QL mg amphetamine-dextroamphetamine oral Adderall DO; AL; QL tablet 10 mg, 12.5 mg, 15 mg, 5 mg, 7.5 mg amphetamine-dextroamphetamine oral Adderall AL tablet 20 mg, 30 mg atomoxetine hcl oral capsule Strattera DO; AL; QL caffeine citrate intravenous solution Cafcit caffeine citrate oral solution clonidine hcl er oral tablet extended release Kapvay AL; QL 12 hour dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 Focalin XR DO; AL; QL mg, 5 mg dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 30 mg, 35 Focalin XR AL; QL mg, 40 mg dexmethylphenidate hcl oral tablet 10 mg Focalin AL; QL dexmethylphenidate hcl oral tablet 2.5 mg Focalin DO; AL; QL dexmethylphenidate hcl oral tablet 5 mg Focalin PA; DO; QL dextroamphetamine sulfate er oral capsule Dexedrine AL; QL extended release 24 hour dextroamphetamine sulfate oral tablet 10 mg Zenzedi PA; QL dextroamphetamine sulfate oral tablet 5 mg Zenzedi PA; DO; QL methylphenidate hcl er (cd) oral capsule DO; AL; QL extended release 10 mg, 20 mg, 30 mg methylphenidate hcl er (cd) oral capsule AL; QL extended release 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule Ritalin LA AL; QL extended release 24 hour methylphenidate hcl er oral tablet extended DO; AL; QL release 10 mg methylphenidate hcl er oral tablet extended Concerta DO; AL; QL release 18 mg, 27 mg 2 Drug Name Reference Notes methylphenidate hcl er oral tablet extended AL; QL release 20 mg methylphenidate hcl er oral tablet extended DO; AL; QL release 24 hour 18 mg, 27 mg methylphenidate hcl er oral tablet extended AL; QL release 24 hour 36 mg, 54 mg methylphenidate hcl er oral tablet extended Concerta AL; QL release 36 mg, 54 mg methylphenidate hcl oral solution Methylin AL methylphenidate hcl oral tablet 10 mg, 5 mg Ritalin DO; AL; QL methylphenidate hcl oral tablet 20 mg Ritalin AL *AMINOGLYCOSIDES* neomycin sulfate oral tablet paromomycin sulfate oral capsule Humatin tobramycin inhalation nebulization solution Kitabis Pak SP; QL *ANALGESICS - ANTI- INFLAMMATORY* childrens ibuprofen oral suspension Childrens Advil OTC; QL diclofenac potassium oral tablet Cataflam diclofenac sodium er oral tablet extended PA; QL release 24 hour diclofenac sodium oral tablet delayed QL release ENBREL MINI SUBCUTANEOUS PA; SP; QL SOLUTION CARTRIDGE ENBREL SUBCUTANEOUS SOLUTION PA; SP; QL ENBREL SUBCUTANEOUS SOLUTION PA; SP; QL PREFILLED SYRINGE ENBREL SUBCUTANEOUS SOLUTION PA; SP; QL RECONSTITUTED ENBREL SURECLICK SUBCUTANEOUS PA; SP; QL SOLUTION AUTO-INJECTOR etodolac er oral tablet extended release 24 QL hour etodolac oral capsule QL etodolac oral tablet Lodine QL fenoprofen calcium oral capsule Nalfon PA fenoprofen calcium oral tablet Nalfon flurbiprofen oral tablet QL gnp childrens ibuprofen oral suspension Childrens Advil OTC; QL 3 Drug Name Reference Notes gnp ibuprofen oral tablet Addaprin OTC; QL goodsense ibuprofen childrens oral Childrens Advil OTC; QL suspension goodsense ibuprofen oral tablet Addaprin OTC; QL hm ibuprofen childrens oral suspension Childrens Advil OTC; QL hm ibuprofen ib oral tablet Addaprin OTC; QL hm ibuprofen oral tablet Addaprin OTC; QL HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE PA; SP; QL KIT HUMIRA PEN SUBCUTANEOUS PEN- PA; SP; QL INJECTOR KIT HUMIRA PEN-CD/UC/HS STARTER PA; SP; QL SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PEDIATRIC UC START PA; SP; QL SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PS/UV/ADOL HS START PA; SP; QL SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA PEN-PSOR/UVEIT STARTER PA; SP; QL SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA SUBCUTANEOUS PREFILLED PA; SP; QL SYRINGE KIT IBU ORAL TABLET QL ibu-200 oral tablet Addaprin OTC; QL ibuprofen childrens oral suspension Childrens Advil OTC; QL ibuprofen oral suspension Childrens Advil QL ibuprofen oral tablet 200 mg Addaprin OTC; QL ibuprofen oral tablet 400 mg, 600 mg, 800 IBU QL mg indomethacin er oral capsule extended release indomethacin oral capsule ketoprofen er oral capsule extended release QL 24 hour ketoprofen oral capsule 50 mg ketoprofen oral capsule 75 mg QL ketorolac tromethamine oral tablet QL leflunomide oral tablet Arava meclofenamate sodium oral capsule QL mefenamic acid oral capsule PA; QL 4 Drug Name Reference Notes meloxicam oral tablet 15 mg Mobic meloxicam oral tablet 7.5 mg Mobic PA nabumetone oral tablet 500 mg Relafen QL nabumetone oral tablet 750 mg Relafen naproxen oral suspension Naprosyn naproxen oral tablet Naprosyn naproxen sodium oral tablet QL OTEZLA ORAL TABLET PA; SP; QL OTEZLA ORAL TABLET THERAPY PACK PA; SP; QL oxaprozin oral tablet Daypro QL piroxicam oral capsule Feldene PA; QL qc childrens ibuprofen oral suspension Childrens Advil OTC; QL RIDAURA ORAL CAPSULE sm childrens ibuprofen oral suspension Childrens Advil OTC; QL sm ibuprofen ib oral tablet Addaprin OTC; QL sulindac oral tablet QL *ANALGESICS - NONNARCOTIC* 8 hour arthritis pain reliever oral tablet Midol OTC; QL extended release 8hr muscle aches & pain oral tablet Midol OTC; QL extended release acetaminophen childrens oral solution OTC; QL acetaminophen childrens oral suspension Panadol Childrens OTC; QL acetaminophen childrens oral tablet Mapap Childrens OTC chewable acetaminophen er oral tablet extended Midol OTC; QL release Healthy Mama Shake acetaminophen extra strength oral tablet OTC; QL That Ache acetaminophen infants oral suspension Panadol Childrens OTC; QL acetaminophen oral liquid Little Remedies for Fever OTC; QL acetaminophen oral solution OTC; QL acetaminophen oral suspension Panadol Childrens OTC; QL acetaminophen oral tablet 325 mg Aphen OTC Healthy Mama Shake acetaminophen oral tablet 500 mg OTC; QL That Ache acetaminophen oral tablet chewable Mapap Childrens OTC acetaminophen rectal suppository FeverAll Adults OTC 5 Drug Name Reference Notes adult aspirin regimen oral tablet delayed Aspir-Low OTC release arthritis pain relief oral tablet extended Midol OTC; QL release aspirin low dose oral tablet chewable Bayer Low Dose OTC; QL aspirin low dose oral tablet delayed release Aspir-Low OTC Bayer Advanced Aspirin aspirin oral tablet OTC Reg St aspirin oral tablet chewable Bayer Low Dose OTC; QL aspirin oral tablet delayed release Bayer Aspirin OTC aspirin rectal suppository OTC ASPIR-LOW ORAL TABLET DELAYED OTC RELEASE BAC ORAL TABLET QL back & body extra strength oral tablet Bayer Back & Body OTC butalbital-acetaminophen oral tablet Tencon QL butalbital-apap-caffeine oral capsule Esgic QL butalbital-apap-caffeine oral tablet Bac QL butalbital-aspirin-caffeine oral capsule QL childrens acetaminophen oral suspension Panadol Childrens OTC; QL childrens silapap oral liquid Little Remedies for Fever OTC; QL diflunisal oral tablet FEVERALL ADULTS RECTAL OTC SUPPOSITORY FEVERALL CHILDRENS RECTAL OTC SUPPOSITORY FEVERALL INFANTS RECTAL OTC SUPPOSITORY FEVERALL JUNIOR STRENGTH RECTAL OTC SUPPOSITORY gnp 8 hour arthritis relief oral tablet extended Midol OTC; QL release gnp 8 hour pain relief oral tablet extended Midol OTC; QL release gnp 8 hour pain reliever oral tablet extended Midol OTC; QL release gnp acetaminophen oral tablet Aphen OTC gnp acetaminophen oral tablet chewable Mapap Childrens OTC gnp adult aspirin low strength oral tablet Bayer Low Dose OTC; QL chewable 6 Drug Name Reference Notes gnp aspirin low dose oral tablet delayed Aspir-Low OTC release gnp aspirin oral tablet delayed release Aspir-Low OTC gnp headache relief extra str oral tablet Bayer Migraine OTC gnp pain & fever childrens oral suspension Panadol Childrens OTC; QL Healthy Mama Shake gnp pain relief extra strength oral tablet OTC; QL That Ache gnp pain relief oral tablet Aphen OTC goodsense arthritis pain oral tablet extended Midol OTC; QL release goodsense aspirin adult low st oral tablet Bayer Low Dose OTC; QL chewable Bayer Advanced Aspirin goodsense aspirin oral tablet OTC Reg St goodsense aspirin oral tablet chewable Bayer Low Dose OTC; QL goodsense migraine formula oral tablet Bayer Migraine OTC goodsense pain & fever child oral Panadol Childrens OTC; QL suspension goodsense pain & fever infants oral Panadol Childrens OTC; QL suspension Healthy Mama Shake goodsense pain relief extra st oral tablet OTC; QL That Ache goodsense pain relief oral tablet Aphen OTC headache relief oral tablet Bayer Migraine OTC hm acetaminophen childrens oral tablet Mapap Childrens OTC chewable hm arthritis pain relief
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