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Medicaid-Approved Preferred Drug List

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Medicaid-Approved Preferred Drug List Georgia 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 AL; QL 12 hour *ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR*** atomoxetine hcl oral capsule Strattera DO; AL; QL *AMPHETAMINE MIXTURES*** 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 *AMPHETAMINES*** 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 DO; AL; QL *ANALEPTICS*** caffeine citrate intravenous solution Cafcit caffeine citrate oral solution *LIPASE INHIBITORS*** ALLI ORAL CAPSULE PA; OTC; QL *STIMULANTS - MISC.*** 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 2 Drug Name Reference Notes dexmethylphenidate hcl oral tablet 5 mg Focalin 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 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 *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 3 Drug Name Reference Notes 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 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 4 Drug Name Reference Notes 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 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 5 Drug Name Reference Notes 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 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 oral capsule QL etodolac oral tablet Lodine QL fenoprofen calcium oral capsule Nalfon PA; QL 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 6 Drug Name Reference Notes 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 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 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
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