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Medicaid-Approved Preferred Drug List

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Medicaid-Approved Preferred Drug List Maryland Medicaid-Approved Preferred Drug List Effective August 15, 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. Drug Name Reference Notes *ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS*** clonidine hcl er oral tablet extended release Kapvay PA; QL 12 hour *ANALEPTICS*** caffeine citrate intravenous solution Cafcit caffeine citrate oral solution *LIPASE INHIBITORS*** ALLI ORAL CAPSULE PA; OTC; QL *ALTERNATIVE MEDICINES* *ALTERNATIVE MEDICINE - ME'S*** cvs melatonin extra strength oral liquid OTC cvs melatonin gummies oral tablet chewable VitaJoy Gummies OTC cvs melatonin oral capsule OTC cvs melatonin oral liquid OTC cvs melatonin oral tablet 3 mg OTC cvs melatonin oral tablet 5 mg OTC; QL cvs melatonin oral tablet dispersible OTC cvs melatonin sublingual tablet sublingual OTC cvs quality sleep oral capsule OTC gnp melatonin maximum strength oral tablet OTC; QL gnp melatonin oral tablet OTC gnp melatonin oral tablet chewable VitaJoy Gummies OTC gnp melatonin sublingual tablet sublingual OTC hm melatonin quick dissolve oral tablet OTC dispersible hm melatonin sublingual tablet sublingual OTC kp melatonin oral tablet OTC max melatonin oral tablet dispersible OTC Zarbees Sleep melatonin childrens oral tablet chewable OTC Child/Melatonin melatonin er oral tablet extended release OTC melatonin extra strength oral liquid OTC melatonin gummies oral tablet chewable VitaJoy Gummies OTC melatonin maximum strength oral tablet 10 OTC mg 2 Drug Name Reference Notes melatonin maximum strength oral tablet 5 OTC; QL mg melatonin oral capsule OTC Zarbees Sleep melatonin oral liquid OTC Child/Melatonin melatonin oral tablet 1 mg, 10 mg, 3 mg, 300 OTC mcg melatonin oral tablet 5 mg OTC; QL melatonin oral tablet chewable VitaJoy Gummies OTC melatonin oral tablet dispersible OTC melatonin quick dissolve sublingual tablet OTC sublingual melatonin sublingual tablet sublingual OTC melatonin tr oral tablet extended release OTC mm melatonin oral tablet extended release OTC qc melatonin max st oral tablet OTC; QL ra melatonin oral tablet 10 mg, 3 mg OTC ra melatonin oral tablet 5 mg OTC; QL sm melatonin oral tablet OTC sm melatonin oral tablet dispersible OTC sv melatonin oral tablet OTC; QL sv melatonin oral tablet dispersible OTC VITAJOY GUMMIES ORAL TABLET OTC CHEWABLE ZARBEES SLEEP CHILD/MELATONIN OTC ORAL LIQUID *AMINOGLYCOSIDES* *AMINOGLYCOSIDES*** neomycin sulfate oral tablet paromomycin sulfate oral capsule Humatin tobramycin inhalation nebulization solution Kitabis Pak SP; QL *ANALGESICS - ANTI- INFLAMMATORY* *ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE PA; SP; QL KIT 3 Drug Name Reference Notes 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 *GOLD COMPOUNDS*** RIDAURA ORAL CAPSULE *NONSTEROIDAL ANTI- INFLAMMATORY AGENTS (NSAIDS)*** ADDAPRIN ORAL TABLET PA; OTC; QL ADVIL JUNIOR STRENGTH ORAL OTC TABLET ADVIL JUNIOR STRENGTH ORAL OTC TABLET CHEWABLE ADVIL LIQUI-GELS MINIS ORAL OTC CAPSULE all day pain relief oral tablet Mediproxen OTC; QL all day relief oral tablet Mediproxen OTC; QL childrens ibuprofen 100 oral suspension Childrens Medi-Profen OTC; QL childrens ibuprofen oral suspension Childrens Medi-Profen OTC; QL CHILDRENS MEDI-PROFEN ORAL OTC; QL SUSPENSION cvs all day pain relief oral tablet Mediproxen OTC; QL cvs childrens ibuprofen oral suspension Childrens Medi-Profen OTC; QL cvs ibuprofen childrens oral suspension Childrens Medi-Profen OTC; QL cvs ibuprofen infants oral suspension Medi-Profen OTC; QL cvs ibuprofen junior strength oral tablet Advil Junior Strength OTC chewable cvs ibuprofen oral capsule Advil Liqui-Gels minis OTC cvs ibuprofen oral tablet Addaprin OTC; QL cvs naproxen sodium oral capsule Aleve OTC cvs naproxen sodium oral tablet Mediproxen OTC; QL 4 Drug Name Reference Notes diclofenac potassium oral tablet Cataflam diclofenac sodium er oral tablet extended PA; QL release 24 hour diclofenac sodium oral tablet delayed QL release eq all day pain relief oral tablet Mediproxen OTC; QL eq ibuprofen childrens oral suspension Childrens Medi-Profen OTC; QL eq ibuprofen junior oral tablet chewable Advil Junior Strength OTC eq ibuprofen oral capsule Advil Liqui-Gels minis OTC eq ibuprofen oral tablet Addaprin PA; OTC; QL eq naproxen sodium oral capsule Aleve OTC eq naproxen sodium oral tablet Mediproxen OTC; QL eql childrens ibuprofen oral suspension Childrens Medi-Profen OTC; QL eql ibuprofen infants oral suspension Medi-Profen OTC; QL eql ibuprofen junior strength oral tablet Advil Junior Strength OTC chewable eql ibuprofen oral capsule Advil Liqui-Gels minis OTC eql ibuprofen oral tablet Addaprin OTC; QL eql naproxen sodium oral capsule Aleve OTC eql naproxen sodium oral tablet Mediproxen OTC; QL etodolac er oral tablet extended release 24 QL hour etodolac oral capsule QL etodolac oral tablet QL fenoprofen calcium oral capsule Nalfon PA fenoprofen calcium oral tablet Nalfon flurbiprofen oral tablet QL gnp childrens ibuprofen oral suspension Childrens Medi-Profen OTC; QL gnp ibuprofen childrens oral tablet chewable Advil Junior Strength OTC gnp ibuprofen infants oral suspension Medi-Profen OTC; QL gnp ibuprofen oral capsule Advil Liqui-Gels minis OTC gnp ibuprofen oral tablet Addaprin OTC; QL gnp naproxen sodium oral capsule Aleve OTC gnp naproxen sodium oral tablet Mediproxen OTC; QL goodsense ibuprofen childrens oral Childrens Medi-Profen OTC; QL suspension goodsense ibuprofen infants oral suspension Medi-Profen OTC; QL goodsense ibuprofen oral capsule Advil Liqui-Gels minis OTC 5 Drug Name Reference Notes goodsense ibuprofen oral tablet Addaprin OTC; QL goodsense naproxen sodium oral tablet Mediproxen OTC; QL hm ibuprofen childrens oral suspension Childrens Medi-Profen OTC; QL hm ibuprofen ib oral tablet Addaprin OTC; QL hm ibuprofen ib oral tablet chewable Advil Junior Strength OTC hm ibuprofen infants oral suspension Medi-Profen OTC; QL hm ibuprofen oral capsule Advil Liqui-Gels minis OTC hm ibuprofen oral tablet Addaprin OTC; QL hm naproxen sodium oral capsule Aleve OTC hm naproxen sodium oral tablet Mediproxen OTC; QL hy-vee all day relief oral tablet Mediproxen OTC; QL HYVEE IBUPROFEN CHILDRENS ORAL OTC; QL SUSPENSION IBU ORAL TABLET QL ibu-200 oral tablet Addaprin PA; OTC; QL ibuprofen 100 junior strength oral tablet Advil Junior Strength OTC chewable ibuprofen childrens oral suspension Childrens Medi-Profen OTC; QL ibuprofen infants oral suspension Medi-Profen OTC; QL ibuprofen junior strength oral tablet Advil Junior Strength OTC chewable ibuprofen oral capsule Advil Liqui-Gels minis OTC ibuprofen oral suspension Childrens Medi-Profen 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 infants ibuprofen oral suspension Medi-Profen OTC; QL 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 kls ibuprofen ib oral tablet Addaprin OTC; QL kls ibuprofen oral tablet Addaprin OTC; QL meclofenamate sodium oral capsule QL 6 Drug Name Reference Notes MEDI-PROFEN ORAL CAPSULE OTC MEDI-PROFEN ORAL SUSPENSION OTC; QL MEDI-PROFEN ORAL TABLET PA; OTC; QL MEDIPROXEN ORAL TABLET OTC; QL mefenamic acid oral capsule PA; QL meijer ibuprofen oral tablet Addaprin OTC; QL meloxicam oral tablet 15 mg Mobic meloxicam oral tablet 7.5 mg Mobic PA MOTRIN IB ORAL CAPSULE OTC MOTRIN IB ORAL TABLET PA; OTC; QL nabumetone oral tablet 500 mg Relafen QL nabumetone oral tablet 750 mg Relafen naproxen oral suspension Naprosyn naproxen oral tablet naproxen sodium oral capsule Aleve OTC naproxen sodium oral tablet 220 mg Mediproxen OTC; QL naproxen sodium oral tablet 275 mg QL naproxen sodium oral tablet 550 mg Anaprox DS QL oxaprozin oral tablet Daypro QL PAMPRIN ALL DAY RELIEF MAX ST OTC; QL ORAL TABLET piroxicam oral capsule Feldene PA; QL px all day relief oral tablet Mediproxen OTC; QL px childrens profen ib oral suspension Childrens Medi-Profen OTC; QL px ibuprofen junior strength oral tablet Advil Junior Strength OTC chewable px ibuprofen oral tablet Addaprin OTC; QL px infants profen ib oral suspension Medi-Profen OTC; QL qc childrens ibuprofen oral suspension Childrens Medi-Profen OTC; QL qc ibuprofen ib oral tablet Addaprin OTC; QL qc ibuprofen oral capsule Advil Liqui-Gels minis OTC qc ibuprofen oral tablet Addaprin OTC; QL qc naproxen sodium
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