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Home , Lifitegrast, Naphazoline, Nizatidine

QL dicloxacillin methenamine BETA BLOCKERS and QL fenofibrate QL penicillin VK QL mefloquine COMBINATIONS QL gemfibrozil SULFONAMIDES metronidazole tabs QL lovastatin sulfamethoxazole QL OTC niacin IR, ER Preferred Drug List /trimethoprim QL nitrofurantoin caps atenolol/chlorthalidone QL pravastatin KEY: TETRACYCLINES praziquantel QL simvastatin * age restrictions apply doxycycline monohydrate pyrazinamide , bisoprolol/HCTZ PCSK-9 INHIBITORS PA requires prior (capsules/suspension only) rifabutin PA evolocumab authorization minocycline IR rifampin caps MISCELLANEOUS AGENTS ST requires trial of first step tetracycline rifapentine digoxin tab/soln product ANTIFUNGALS rifater QL metoprolol HCTZ QL daily dosage limits apply QL clotrimazole troches metoprolol ext rel CENTRAL NERVOUS SYSTEM RX legend prescription QL fluconazole CARDIOVASCULAR AGENTS ALZHEIMER’S DISEASE product QL griseofulvin ACE INHIBITORS and , QL donepezil OTC over-the-counter available by QL griseofulvin microsize oral COMBINATIONS propranolol ext rel QL galantamine prescription suspension QL benazepril, benazepril/HCTZ QL galantamine ER QL ketoconazole cream, shampoo captopril, captopril/HCTZ CALCIUM CHANNEL BLOCKERS ANALGESICS ANTIBACTERIALS QL nystatin enalapril, enalapril/HCTZ QL amlodipine QL* codeine/APAP ANTIBIOTICS QL OTC terbinafine QL fosinopril, fosinopril/HCTZ QL diltiazem ext-rel QL PA fentanyl citrate lozenge CEPHALOSPORINS ANTIVIRALS — HEPATITIS C QL lisinopril, lisinopril/HCTZ QL felodipine ext-rel QL PA fentanyl transdermal First Generation PA QL elbasiv/grazoprevir moexipril, moexipril/HCTZ QL isradipine QL hydrocodone/acetaminophen QL cefadroxil (Zepatier) quinapril, quinapril/HCTZ QL nifedipine ext-rel QL hydromorphone QL cephalexin PA glecaprevir/pibrentasvir ANGIOTENSIN II RECEPTOR QL nicardipine QL meperidine Second Generation (Mavyret) BLOCKERS QL verapamil ext-rel QL PA methadone QL cefaclor PA peginterferon alfa 2a QL candesartan, DIURETICS QL morphine tab, soln, suppository QL cefprozil PA peginterferon alfa 2b candesartan/HCTZ amiloride QL morphine ER tab QL cefuroxime axetil ribavirin QL irbesartan, irbesartan/HCTZ amiloride/HCTZ QL oxycodone, oxycodone/APAP Third Generation PA QL sofosbuvir (Sovaldi) QL losartan, losartan/HCTZ bumetanide HYLAURONICS QL cefdinir ANTIVIRALS QL valsartan, valsartan/HCTZ chlorthalidone PA hyaluronate sodium (Euflexxa) QL cefpodoxime acyclovir ANTICOAGULANTS furosemide PA hyaluronate sodium (Gelsyn) FLUOROQUINOLONES QL famciclovir apixaban hydrochlorothiazide PA hyaluronate sodium (Supartz QL* ciprofloxacin tabs QL valacyclovir PA QL enoxaparin indapamide FX) * ofloxacin HIV/AIDS jantoven metolazone MISCELLANEOUS MACROLIDES Please see Amerigroup formulary for QL rivaroxaban spironolactone QL lidocaine crm/HC covered agents. QL azithromycin warfarin spironolactone/HCTZ lidocaine jelly, gel MISCELLANEOUS QL clarithromycin ANTIPLATELET AGENTS (25/25mg only) QL lidocaine sol albendazole QL erythromycin (all salt forms) QL OTC aspirin torsemide lidocaine/pramoxine crm atovaquone-proquanil PENICILLINS cilostazol triamterene/HCTZ (without applicator) clindamycin QL amoxicillin QL clopidogrel LIPID LOWERING AGENTS QL PA lidocaine topical patch ethambutol QL amoxicillin/clavulanate QL dipyridamole QL cholestyramine QL tramadol; tramadol/APAP isoniazid QL ampicillin colestipol ivermectin Version Date: 2/1/2018 WEBMGA-0242-17 Applies to Medicaid market- Georgia QL QL 1.2- 5% gel ANTICONVULSANTS SNRIs QL chlordiazepoxide carbidopa/levodopa OTC Differin 0.1% gel QL carbamazepine QL venlafaxine QL clonazepam carbidopa/levodopa XR erythromycin 2% pad, soln QL clonazepam tabs QL venlafaxine XR QL clorazepate QL carbidopa/entacapone metronidazole 0.75% cream, lotion, QL diazepam rectal gel SSRIs QL diazepam /levodopa gel QL divalproex DR, ER, QL citalopram QL hcl, pamoate pramipexole metronidazole 1% gel, gel pump sprinkle QL escitalopram QL lorazepam ropinirole rosadan 0.75% cream, gel QL epitol QL fluoxetine (except 60mg) QL oxazepam selegiline caps, tabs * tretinoin gel (0.01%, 0.025%) QL ethosuximide QL fluvoxamine ATTENTION DEFICIT HYPERACTIVITY trihexyphenidyl * tretinoin gel micro 0.1% tube QL felbamate QL paroxetine hcl DISORDER SEDATIVE/HYPNOTICS * tretinoin cream (0.025%, QL gabapentin QL sertraline QL* amphet/dextroamph, ER QL estazolam 0.05%, 0.1%) QL lamotrigine disper tab, ER, ANTIPSYCHOTICS — oral QL* atomoxetine QL temazepam (15/30mg only) * tretinoin emollient crm 0.05% ODT QL * (tabs only) QL* ER QL PA triazolam ANTIBACTERIALS QL levetiracetam QL * carbamazepine QL* dexmethylphenidate QL zolpidem OTC chlorhexidine QL oxcarbazepine QL * QL* dexmethylphenidate ER QL zaleplon oint QL phenobarbital QL * QL* dextroamphetamine, XR silver sulfadiazine QL phenytoin sod ext-rel QL * lithium carbonate QL* methylphenidate, XR COUGH & COLD QL phenytoin tabs, chewableQL QL * lithium carbonate ext rel MIGRAINE benzonatate Products are grouped based upon relative primidone QL* lithium solution QL QL OTC* dextromethorphan syrup potency. QL roweepra QL * QL butalbital/APAP QL OTC liquid, LOW QL tiagabine (2mg and 4mg) QL * tab QL butalbital/APAP/caff capsules QL RX/OTC hydrocortisone crm, QL topiramate QL * ext rel QL* butalbital/APAP/caff/codeine QL OTC* guaifenesin syrup lot, oint QL valproic acid QL * QL butalbital/ASA QL* guaifenesin w/codeine OTC QL hydrocortisone-aloe 1% cr QL zonisamide QL* pimozide QL butalbital/ASA/caff syrup MEDIUM QL* tab/soln QL* butalbital/ASA/caff/codeine QL* w/codeine QL valerate crm QL amitriptyline QL* IR QL naratriptan syrup QL propionate crm, QL amitrip/perphenazine QL* propranolol, XR QL* promethazine w/DM oint QL QL* thiothixene QL sumatriptan tabs syrup QL furoate crm, QL bupropion, IR, SR, XL QL* QL ST sumatriptan inj, spray QL * pseudoehedrine syrup, oint, soln QL chlordiazepoxide QL* OPIOID/ALCOHOL DEPENDANCE tablets QL acet crm, /amitriptyline ANTIPSYCHOTICS — injectables QL acamprosate tab QL * spray, drops oint QL * PA aripiprazole (Abilify Maintena) QL buprenorphine DERMATOLOGY HIGH QL * PA (Aristada PA QL buprenorphine/naloxone QL amcinonide oint, lot ACNE ORAL QL QL* decan, inj SL tabs/film QL betamethasone dipr aug crm PA claravis minocycline IR QL QL* inj. disulfiram QL betamethasone dipr lotion PA myorisan tetracycline QL *PA olanzapine (Zyprexa Relprevv) naloxone inj syr and vials QL betamethasone valerate oint PA zenatane QL *PA paliperidone(InvegaSustenna) QL naloxone nasal spray QL diflorasone diacetate crm ACNE TOPICAL QL phenelzine *PA paliperidone (Invega Trinza) naltrexone tab QL fluocinonide E cream PA adapalene cream, gel QL *PA risperidone (Risperdal Consta) PARKINSON’S DISEASE QL triamcinolone acet crm, oint QL OTC benzoyl peroxide QL tranylcypromine ANXIETY QL amantadine (tablets only) VERY HIGH clindamycin 1% gel, pad, soln QL QL alprazolam benztropine QL clobetasol E propionate crm clindamycin-benzoyl peroxide

Version Date: 2/1/2018 WEBMGA-0242-17 Applies to Medicaid market- Georgia

QL clobetasol propionate crm, gel, ciprofloxacin 0.2% otic sol QL alcohol prep pads octreotide QL (tablets only) oint, soln neomycin/polymyxin B/hc (various) tabloid NSAIDs QL halobetasol propionate crm, QL ofloxacin otic ORAL AGENTS trexall diclofenac oint ST empagliflozin GASTROINTESTINAL etodolac FUNGAL INFECTIONS QL spray 0.1% ST empagliflozin/metformin DIARRHEA ibuprofen OTC butenafine HCL QL glimepiride diphenoxylate/atropine indomethacin QL PA ciclodan 8% soln QL OTC diphenhydramine glipizide, glipizide ext-rel OTC QL loperamide (tabs only) ketorolac tromethamine QL PA ciclopirox 8% soln QL OTC* QL glyburide, glyburide EMESIS meloxicam OTC clotrimazole QL OTC micronized OTC nabumetone ketoconazole INTRANASAL STEROIDS QL glyburide/metformin naproxen sodium OTC miconazole nitrate QL OTC fluticasone ST linagliptin QL ondansetron ODT piroxicam nystatin QL OTC tiamcinolone ST linagliptin/metformin sulindac OTC generic terbinafine HCL QL metformin, metformin XR promethazine MISC. ANTIRHEUMATIC cream ELECTROLYTIC AND RENAL AGENTS QL nateglinide GERD/HEARTBURN/ULCERS azathioprine terbinafine tab calcium acetate QL pioglitazone/glimeperide OTC QL leflunomide OTC tolnaftate PA sucroferric oxyhydroxide QL pioglitazone/metformin OTC RX oral/inj methotrexate SCABIES AND PEDICULOSIS (Velphoro) QL repaglinide OTC QL sulfasalazine QL permethrin 5% cream ST sitagliptin * nizatidine MISC. IMMUNOSUPRRESIVE QL OTC permethrin 1% rinse ENDOCRINOLOGY ST sitagliptin/metformin (XR) OTC QL cyclosporine OTC pyrethrins/piperonyl HORMONE THERAPY gengraf ANTIDIABETICS OTC RX (tabs, caps, butoxide 4% PA QL testosterone 1% gel mycophenolic acid INJECTABLE AGENTS syrup) spinosad 0.9% topical PA testosterone cyp inj ST INFLAMMATORY BOWEL DISEASE suspension PA testosterone enan inj tacrolimus QL ST balsalazide VIRAL INFECTIONS HUMAN CHELATING AGENTS (Wilson’s disease) QL hydrocortisone QL acyclovir ointment PA somatropin (Zomacton) PA Depen QL aspart/insulin QL mesalamine ER (Apriso) QL docosanol topical OSTEOPOROSIS/PAGETS PA Syprine aspart protamine QL sulfasalazine podofilox QL alendronate (Novolog Mix) PANCREATIC ENZYMES QL OTC salicylic acid 17% THYROID DISEASE QL PA (Levemir) QL pancrelipase OB/GYN MISCELLANEOUS QL levothyroxine QL (Basaglar CONTRACEPTIVES QL ammonium lactate 12% levoxyl Kwikpen) RHEUMATOLOGY and All generic oral contraceptives are QL emollient oint liothyronine QL (Apidra) MUSCULOSKELETAL covered. (hydrolatum) nature-throid QL insulin isophane & regular MUSCLE RELAXANTS *QL EE/norelgestromin patch QL selen sul shampoo 2.5% NP thyroid (Humulin, Novolin) QL baclofen *QL EE/norgestimate QL ST tacrolimus oint unithroid QL /insulin lispro carisoprodol *QL /norethindrone acet QL urea crm/gel 40% westhroid protamine (Humalog Mix) carisoprodol/ASA *QL etonogestrel /EE vag ring ANTINEOPLASTIC MONITORING STRIPS AND IR (5mg Today Contraceptive Sponge alkeran EAR, NOSE & THROAT KITS/DIABETIC SUPPLIES and 10mg only) EMERGENCY CONTRACEPTIVES cyclophosphamide QL acetic acid/aluminum QL True Metrix (Trividia) chlorzoxazone ulipristal acetate (Ella) etoposide acetate QL lancets, select syringes, dantrolene levonorgestrel 1.5 mg tab leukeran benzocaine/antipyrine and needles QL methocarbamol HORMONE THERAPY mercaptopurine OTC carbamide peroxide 6.5% QL True Metrix control sol estradiol tabs

Version Date: 2/1/2018 WEBMGA-0242-17 Applies to Medicaid market- Georgia

ethinyl estradiol/ betaxolol HCL 0.5% QL tabs QL Pocket Chamber norethindrone QL CORTICOSTEROIDS QL Primeaire Chamber PA estradiol patch QL (Aerospan) QL Prochamber Holding Chamber estropipate QL dorzolamide QL (Arnuity QL Riteflo Spacer PA hydroxyprogesterone QL dorzolamide/ Ellipta) QL Vortex Holding Chamber PA Makena vial QL latanoprost QL ST fluticasone/ (Breo QL Vortex VHC Frog Child Mask medroxyprogesterone acetate QL Ellipta) QL Vortex VHC Ladybug Toddler norethindrone QL ST mometasone/ QL Watchhaler Spacer Yuvafem vaginal insert QL pilocarpine (Dulera) VAGINAL INFECTIONS QL timolol gel-solution LEUKOTRIENE MODIFIERS SMOKING DETERRENTS clindamycin crm QL timolol maleate (solution only) QL montelukast QL bupropion IR, XL, SR OTC clotrimazole crm INFECTIONS QL zafirlukast OTC QL nicotine patch/gum/loz fluconazole tabs QL bacitracin NEBULIZER INHALATIONS metronidazole tabs QL bacitracin/polymyxin B oint QL albuterol soln UROLOGICAL metronidazole vaginal gel QL ciprofloxacin QL * susp OTC miconazole QL erythromycin QL cromolyn soln bethanechol terconazole gatifloxacin 0.5% drops QL ipratropium soln darifenacin tioconazole oint QL gentamicin QL ipratropium/albuterol soln levofloxacin 0.5% drops XANTHINES finasteride OPHTHALMIC moxifloxacin 0.5% drops theophylline ER tabs QL oxybutynin, oxybutynin ext-rel ALLERGY neomycin/polymyxin theophylline soln/elixir OTC oxytrol for women patch QL cromolyn sodium B/gramicidin OTHERS QL OTC ofloxacin QL AL albuterol; ipratropium MDI ANTI-INFLAMMATORIES polymyxin B/trimethoprim QL ipratropium HFA tolterodine, tolterodine ER sodium phos sulfacetamide 10% QL tiotropium (Spiriva Respimat) trospium, trospium ER QL diclofenac 0.1% drops tobramycin QL umeclidinium/vilanterol QL trifluridine (Anoro Ellipta) fluorometholone 0.1% drops MISCELLANEOUS VASOCONSTRICTOR PULMONARY ARTERIAL QL neomycin/polymyxinB/HC sol ANAPHYLAXIS THERAPY AGENTS HYPERTENSION AGENTS neomycin/polymyxin/dexa- QL epinephrine 0.15 mg Auto- OTC artificial tears PA methasone oint Inject (generic)naphazoline 0.1 % eye SPACER DEVICES acetate 1% QL epinephrine 0.3 mg Auto- dops QL Ace Aerosol Cloud Enhancer drops Inject 2.5% eye drops QL Aerotrach Holding Chamber prednisolone sod 1% drops epinephrine 0.1 mg/mL phenylephrine 10% eye drops QL Aerovent Plus Holding Chamber sulfacetamide/prednisolone Syringe QL Breatherite Spacer drops epinephrine 1 mg/mL Vial QL Breathrite Chamber tobramycin/dexameth ophth RESPIRATORY DRUGS METABOLIC DEFICIENCY AGENTS QL Compact Space Chamber susp BETA AGONISTS levocarnitine 330mg tab DRY EYE QL albuterol tabs, syrup QL Liteaire OTC artificial tears drops/ointment QL albuterol sulfate (Ventolin QL Microchamber PA Xiidra 5% (lifitegrast) HFA) QL Microspacer GLAUCOMA QL metaproterenol syrup QL Optichamber Diamond

Version Date: 2/1/2018 WEBMGA-0242-17 Applies to Medicaid market- Georgia