MI Medicaid Maintenance Drug List

A maximum days supply of 102 days is allowed for drugs in the following therapeutic classes

TC TC DESCRIPTION HIC3 HIC3_DESCRIPTION PDL CLASS 05 BILE THERAPY D7A BILE SALTS YES D7B CHOLERETICS NO D7E FARNESOID X RECEPTOR (FXR) AGONIST, BILE AC ANALOG NO

09 ANTIPARKINSON AGENTS C7B DECARBOXYLASE INHIBITORS YES H6A ANTIPARKINSONISM DRUGS,OTHER YES H6B ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC YES

11 PSYCHOSTIMULANTS‐ANTIDEPRESSANTS H24 ANTIDEPRESSANT ‐ POSTPARTUM DEPRESSION (PPD) NO H2H MONOAMINE OXIDASE (MAO) INHIBITOR ANTIDEPRESSANTS NO H2M BIPOLAR DISORDER DRUGS YES H2S SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) NO H2U TRICYCLIC ANTIDEPRESSANTS,REL.NON‐SEL.REUPT‐INHIB NO H2W TRICYCLIC ANTIDEPRESSANT‐PHENOTHIAZINE COMBINATNS NO H2X TRICYCLIC ANTIDEPRESSANT‐BENZODIAZEPINE COMBINATNS NO H7B ALPHA‐2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS NO H7C SEROTONIN‐NOREPINEPHRINE REUPTAKE‐INHIB (SNRIS) YES H7D NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) NO H7E SEROTONIN‐2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) NO H7J MAOIS ‐NON‐SELECTIVE,IRREVERSIBLE ANTIDEPRESSANTS NO H7Y TX FOR ATTENTION DEFICIT‐HYPERACT.(ADHD), NRI‐TYPE YES H7Z SSRI‐ANTIPSYCH, ATYPICAL,DOPAMINE,SEROTONIN ANTAG YES H8M TX FOR ADHD ‐ SELECTIVE ALPHA‐2 RECEPTOR AGONIST YES H8P SSRI AND 5HT1A PARTIAL AGONIST ANTIDEPRESSANTS NO H8Q NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS NO H8T SSRI, SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANTS NO H8Z ANTIDEPRESSANT ‐ NMDA RECEPTOR ANTAGONIST NO

15 BRONCHODILATORS A1D GENERAL BRONCHODILATOR AGENTS NO B60 ANTICHOLINERGICS, ORALLY INHALED SHORT ACTING YES B61 ANTICHOLINERGICS, ORALLY INHALED LONG ACTING YES B62 BETA‐ADRENERGIC AND ANTICHOLINERGIC COMBO, INHALED YES B63 BETA‐ADRENERGIC AND GLUCOCORTICOID COMBO, INHALED YES B64 BETA‐ADRENERGIC‐ANTICHOLINERGIC‐GLUCOCORT, INHALED YES B6W BETA‐ADRENERGIC AGENTS, INHALED, SHORT ACTING YES B6Y BETA‐ADRENERGIC AGENTS, ORALLY INHALED,LONG ACTING YES B6Z BETA‐ADRENERGIC AGENTS, INHALED, ULTRA‐LONG ACTING YES J5D BETA‐ADRENERGIC AGENTS NO Z21 MAST CELL STABILIZERS, ORALLY INHALED NO Z4B LEUKOTRIENE RECEPTOR ANTAGONISTS YES Z4E 5‐LIPOXYGENASE INHIBITORS YES

32 ANTIMALARIALS W4A ANTIMALARIAL DRUGS NO

33 ANTIVIRALS Q5V TOPICAL ANTIVIRALS YES T0C TOPICAL GENITAL WART‐HPV TREATMENT AGENTS NO T0E TOPICAL ANTIVIRAL AND ANTI‐INFLAMMATORY STEROID YES W0A HEPATITIS C VIRUS ‐ NS5A REPLICATION COMPLEX INHIB YES W0B HEP C VIRUS‐NS5B POLYMERASE AND NS5A INHIB. COMBO. YES W0D HEP C ‐ NS5A, NS3/4A, NON‐NUCLEO.NS5B INHIB COMB. YES W0E HEPATITIS C VIRUS‐ NS5A AND NS3/4A INHIBITOR COMB YES W0G HEP C ‐ NS5A, NS3/4A, NUCLEOTIDE NS5B INHIB COMBO YES W0H ANTIRETROVIRAL‐NUCLEOSIDE,NUCLEOTIDE,PROTEASE INH. NO W0I ANTIRETROVIRAL‐INTEGRASE INHIBITOR AND NNRTI COMB. NO W0K ANTIRETROVIRAL‐INTEGRASE INHIBITOR AND NRTI COMB. NO W50 ANTIVIRALS, HIV‐SPECIFIC, CD4 ATTACHMENT INHIBITOR NO W5A ANTIVIRALS, GENERAL YES W5C ANTIVIRALS, HIV‐SPECIFIC, PROTEASE INHIBITORS NO W5D ANTIVIRAL MONOCLONAL ANTIBODIES NO

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TC TC DESCRIPTION HIC3 HIC3_DESCRIPTION PDL CLASS W5F HEPATITIS B TREATMENT AGENTS NO W5G HEPATITIS C TREATMENT AGENTS YES W5I ANTIVIRALS, HIV‐SPECIFIC, NUCLEOTIDE ANALOG, RTI NO W5J ANTIVIRALS, HIV‐SPECIFIC, NUCLEOSIDE ANALOG, RTI NO W5K ANTIVIRALS, HIV‐SPECIFIC, NON‐NUCLEOSIDE, RTI NO W5L ANTIVIRALS, HIV‐SPEC., NUCLEOSIDE ANALOG, RTI COMB NO W5M ANTIVIRALS, HIV‐SPECIFIC, PROTEASE INHIBITOR COMB NO W5N ANTIVIRALS, HIV‐SPECIFIC, FUSION INHIBITORS NO W5O ANTIVIRALS, HIV‐SPEC, NUCLEOSIDE‐NUCLEOTIDE ANALOG NO W5P ANTIVIRALS, HIV‐SPEC, NON‐PEPTIDIC PROTEASE INHIB NO W5Q ARTV NUCLEOSIDE,NUCLEOTIDE,NON‐NUCLEOSIDE RTI COMB NO W5T ANTIVIRALS, HIV‐SPECIFIC, CCR5 CO‐RECEPTOR ANTAG. NO W5U ANTIVIRALS,HIV‐1 INTEGRASE STRAND TRANSFER INHIBTR NO W5V HEPATITIS C VIRUS NS3/4A SERINE PROTEASE INHIB. YES W5X ARV‐NUCLEOSIDE,NUCLEOTIDE RTI,INTEGRASE INHIBITORS NO W5Y HEP C VIRUS,NUCLEOTIDE ANALOG NS5B POLYMERASE INH YES W5Z ANTIRETROVIRAL‐NRTIS AND INTEGRASE INHIBITORS COMB NO

34 TB PREPARATIONS W1G ANTITUBERCULAR ANTIBIOTICS NO W2E ANTI‐MYCOBACTERIUM AGENTS NO

38 GENERAL ANTIBACTERIALS AND ANTISEPTICS W8E ANTISEPTICS,GENERAL NO

41 NON‐OPIOID ANALGESICS HSN 044923 AIMOVIG (ERENUMAB‐AOOE) YES (MIGRAINE PREVENTION) HSN 045236 AJOVY (FREMANEZUMAB‐VFRM) YES HSN 045281 EMGALITY (GALCANEZUMAB‐GNLM) YES

48 ANTICONVULSANTS H4A ANTICONVULSANT ‐ BENZODIAZEPINE TYPE YES H4B ANTICONVULSANTS YES

52 MINERALOCORTICOIDS P5S MINERALOCORTICOIDS NO

53 ALDOSTERONE ANTAGONISTS R1H POTASSIUM SPARING DIURETICS NO

55 THYROID PREPS P3A THYROID HORMONES NO

56 ANTITHYROID PREPS P3L ANTITHYROID PREPARATIONS NO

58 DIABETIC THERAPY C4B ANTIHYPERGLYCEMIC‐GLUCOCORTICOID RECEPTOR BLOCKER YES C4C ANTIHYPERGLY,DPP‐4 ENZYME INHIB.‐THIAZOLIDINEDIONE YES C4D ANTIHYPERGLYCEMC‐SOD/GLUC COTRANSPORT2(SGLT2)INHIB YES C4E ANTIHYPERGLYCEMIC‐SGLT2 INHIBITOR‐BIGUANIDE COMBS. YES C4F ANTIHYPERGLYCEMIC,DPP‐4 INHIBITOR‐BIGUANIDE COMBS. YES C4G INSULINS YES C4H ANTIHYPERGLYCEMIC, AMYLIN ANALOG‐TYPE YES C4I ANTIHYPERGLY,INCRETIN MIMETIC(GLP‐1 RECEP.AGONIST) YES C4J ANTIHYPERGLYCEMIC, DPP‐4 INHIBITORS YES C4K ANTIHYPERGLYCEMIC, INSULIN‐RELEASE STIMULANT TYPE YES C4L ANTIHYPERGLYCEMIC, BIGUANIDE TYPE YES C4M ANTIHYPERGLYCEMIC, ALPHA‐GLUCOSIDASE INHIBITORS YES C4N ANTIHYPERGLYCEMIC,THIAZOLIDINEDIONE(PPARG AGONIST) YES C4R ANTIHYPERGLYCEMIC, THIAZOLIDINEDIONE‐SULFONYLUREA YES C4S ANTIHYPERGLYCEMIC,INSULIN‐RELEASE STIM.‐BIGUANIDE YES C4T ANTIHYPERGLYCEMIC, THIAZOLIDINEDIONE AND BIGUANIDE YES C4V ANTIHYPERGLYCEMIC ‐ DOPAMINE RECEPTOR AGONISTS YES C4W ANTIHYPERGLYCEMIC, SGLT‐2 AND DPP‐4 INHIBITOR COMB YES C4X ANTIHYPERGLY,INSULIN,LONG ACT‐GLP‐1 RECEPT.AGONIST YES C4Y ANTIHYPERGLY‐SGLT‐2 INHIB,DPP‐4 INHIB,BIGUANIDE CB YES M4G AGENTS TO TREAT HYPOGLYCEMIA (HYPERGLYCEMICS) NO

61 ESTROGENS G1A ESTROGENIC AGENTS NO

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TC TC DESCRIPTION HIC3 HIC3_DESCRIPTION PDL CLASS G1B ESTROGEN/ANDROGEN COMBINATIONS NO G1D ESTROGEN‐PROGESTIN WITH ANTIMINERALOCORTICOID COMB NO G1F ESTROGEN AND PROGESTIN COMBINATIONS NO G1G ESTROGEN‐SELECTIVE ESTROGEN RECEPTOR MOD(SERM)COMB NO Q4D VAGINAL ESTROGEN FOR SEXUAL DYSFUNCTION NO Q4K VAGINAL ESTROGEN PREPARATIONS NO

62 PROGESTERONE G2A PROGESTATIONAL AGENTS YES

63 SYSTEMIC CONTRACEPTIVES G8A CONTRACEPTIVES,ORAL NO G8B CONTRACEPTIVES,IMPLANTABLE NO G8C CONTRACEPTIVES,INJECTABLE NO G8F CONTRACEPTIVES,TRANSDERMAL NO G9B CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC NO

66 CHOLESTEROL REDUCERS D7L BILE SALT SEQUESTRANTS YES

67 DIGESTANTS D4A ACID REPLACEMENT NO D4G GASTRIC ENZYMES NO

69 ENZYMES C7K PKU TREATMENT AGENTS ‐ PHENYLALANINE AMMONIA LYASE NO D8A PANCREATIC ENZYMES YES L0B TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMES NO

71 OTHER ANTIHYPERTENSIVES A4A ANTIHYPERTENSIVES, VASODILATORS NO A4B ANTIHYPERTENSIVES, SYMPATHOLYTIC YES A4C ANTIHYPERTENSIVES, GANGLIONIC BLOCKERS NO A4D ANTIHYPERTENSIVES, ACE INHIBITORS YES A4F ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST YES A4H ANGIOTENSIN RECEPTOR BLOCKR‐CALCIUM CHANNEL BLOCKR YES A4I ANGIOTENSIN RECEPTOR ANTAG.‐THIAZIDE DIURETIC COMB YES A4J ACE INHIBITOR‐THIAZIDE OR THIAZIDE‐LIKE DIURETIC YES A4K ACE INHIBITOR‐CALCIUM CHANNEL BLOCKER COMBINATION YES A4N ANGIOTENSIN II RECEPTOR BLOCKER‐BETA BLOCKER COMB. YES A4T RENIN INHIBITOR, DIRECT YES A4U RENIN INHIBITOR,DIRECT AND THIAZIDE DIURETIC COMB YES A4V ANGIOTEN.RECEPTR ANTAG‐CALCIUM CHANL BLKR‐THIAZIDE YES A4Y ANTIHYPERTENSIVES, MISCELLANEOUS NO A7J VASODILATORS, COMBINATION NO B1B PULMONARY ANTI‐HTN, ENDOTHELIN RECEPTOR ANTAGONIST YES B1C PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN‐TYPE YES B1D PULM.ANTI‐HTN,SEL.C‐GMP PHOSPHODIESTERASE T5 INHIB YES B1F PULM ANTI‐HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR YES J7B ALPHA‐ADRENERGIC BLOCKING AGENTS YES

72 VASODILATORS CORONARY A7B VASODILATORS,CORONARY NO Z1Z SOLUBLE GUANYLATE CYCLASE (SGC) STIMULATOR NO

73 VASODILATORS PERIPHERAL A7C VASODILATORS,PERIPHERAL NO

74 DIGITALIS PREPARATIONS A1A DIGITALIS GLYCOSIDES NO

75 XANTHINE DERIVATIVES A1B XANTHINES NO

76 OTHER CARDIOVASCULAR PREPS A1C INOTROPIC DRUGS NO A2A ANTIARRHYTHMICS NO A2B HEART RATE REDUCING,SA SELECTIVE I(F) CURRENT INH. NO A2C ANTIANGINAL, ANTI‐ISCHEMIC AGENTS,NON‐HEMODYNAMIC NO A4L ANGIOTENSIN RECEPT‐NEPRILYSIN INHIBITOR COMB(ARNI) YES A5A PATENT DUCTUS ARTERIOSUS TREAT. AGENTS, NSAID‐TYPE NO A9A CALCIUM CHANNEL BLOCKING AGENTS YES

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TC TC DESCRIPTION HIC3 HIC3_DESCRIPTION PDL CLASS J7A ALPHA/BETA‐ADRENERGIC BLOCKING AGENTS YES J7B ALPHA‐ADRENERGIC BLOCKING AGENTS NO J7C BETA‐ADRENERGIC BLOCKING AGENTS YES J7H BETA‐BLOCKERS AND THIAZIDE,THIAZIDE‐LIKE DIURETICS YES M4I ANTIHYPERLIPID‐ HMG‐COA RI‐CALCIUM CHANNEL BLOCKER YES M9F THROMBOLYTIC ENZYMES NO M9S HEMORRHEOLOGIC AGENTS NO M9U THROMBOLYTIC ‐ NUCLEOTIDE TYPE NO

77 ANTICOAGULANTS M9K HEPARIN AND RELATED PREPARATIONS YES M9L ANTICOAGULANTS,COUMARIN TYPE YES M9P PLATELET AGGREGATION INHIBITORS YES M9T THROMBIN INHIBITORS, SELECTIVE, DIRECT, REVERSIBLE YES M9V DIRECT FACTOR XA INHIBITORS YES

79 DIURETICS R1E CARBONIC ANHYDRASE INHIBITORS NO R1F THIAZIDE AND RELATED DIURETICS NO R1H POTASSIUM SPARING DIURETICS NO R1K DIURETICS,MISCELLANEOUS NO R1L POTASSIUM SPARING DIURETICS IN COMBINATION NO R1M LOOP DIURETICS NO R1N ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS NO R1O POLYCYSTIC KIDNEY DISEASE AGENT, AVP RECEP. ANTAG NO

80 FAT SOLUBLE VITAMINS C6D VITAMIN D PREPARATIONS NO C6E VITAMIN E PREPARATIONS NO

81 WATER SOLUBLE VITAMINS C6B VITAMIN B PREPARATIONS NO C6L VITAMIN B12 PREPARATIONS NO C6N NIACIN PREPARATIONS YES C6Q VITAMIN B6 PREPARATIONS NO C6T VITAMIN B1 PREPARATIONS NO

82 MULTIVITAMINS C6F PRENATAL VITAMIN PREPARATIONS NO C6H PEDIATRIC VITAMIN PREPARATIONS NO C6Z MULTIVITAMIN PREPARATIONS NO

83 FOLIC ACID PREPARATIONS C6M FOLIC ACID PREPARATIONS NO

84 B COMPLEX WITH VITAMIN C C6Z MULTIVITAMIN PREPARATIONS NO

87 ELECTROLYTES & MISCELLANEOUS NUTRIENTS C0D ANTI‐ALCOHOLIC PREPARATIONS YES C0K BICARBONATE PRODUCING/CONTAINING AGENTS NO C1A ELECTROLYTE DEPLETERS YES C1B SODIUM/SALINE PREPARATIONS NO C1D POTASSIUM REPLACEMENT NO C1F CALCIUM REPLACEMENT NO C1H MAGNESIUM SALTS REPLACEMENT NO C1P PHOSPHATE REPLACEMENT NO C1W ELECTROLYTE MAINTENANCE NO C5J IV SOLUTIONS: DEXTROSE‐WATER NO C5K IV SOLUTIONS: DEXTROSE‐SALINE NO C5L IV SOLUTIONS: DEXTROSE AND RINGERS NO C5M IV SOLUTIONS: DEXTROSE AND LACTATED RINGERS NO

88 HEMATINICS & BLOOD CELL STIMULATORS C3B IRON REPLACEMENT NO

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