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New York (HARP) Medicaid New York Health and Recovery Plan (HARP) Medicaid-Approved Preferred Drug List Effective February 1, 2020 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* amphetamine-dextroamphet er oral capsule Adderall XR AL; QL extended release 24 hour amphetamine-dextroamphetamine oral Adderall AL tablet atomoxetine hcl oral capsule Strattera 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 Focalin XR AL; QL extended release 24 hour dexmethylphenidate hcl oral tablet 10 mg Focalin AL; QL dexmethylphenidate hcl oral tablet 2.5 mg Focalin AL dexmethylphenidate hcl oral tablet 5 mg Focalin PA; QL dextroamphetamine sulfate er oral capsule Dexedrine AL; QL extended release 24 hour dextroamphetamine sulfate oral tablet Zenzedi AL; QL METADATE ER ORAL TABLET AL; QL EXTENDED RELEASE methylphenidate hcl er (cd) oral capsule AL; QL extended release methylphenidate hcl er (la) oral capsule Ritalin LA AL; QL extended release 24 hour methylphenidate hcl er oral tablet extended AL release 10 mg methylphenidate hcl er oral tablet extended Concerta AL; QL release 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended Metadate ER AL; QL release 20 mg methylphenidate hcl er oral tablet extended AL; QL release 24 hour methylphenidate hcl oral solution Methylin AL methylphenidate hcl oral tablet Ritalin AL *AMINOGLYCOSIDES* neomycin sulfate oral tablet paromomycin sulfate oral capsule tobramycin inhalation nebulization solution Kitabis Pak SP; QL 2 Drug Name Reference Notes *ANALGESICS - ANTI- INFLAMMATORY* ADDAPRIN ORAL TABLET 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 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 oral capsule Medi-Profen OTC cvs ibuprofen oral tablet Addaprin OTC; QL diclofenac potassium oral tablet diclofenac sodium er oral tablet extended PA release 24 hour diclofenac sodium oral tablet delayed release dyspel oral tablet Addaprin OTC; QL ENBREL MINI SUBCUTANEOUS PA; SP; QL SOLUTION CARTRIDGE ENBREL SUBCUTANEOUS SOLUTION PA; SP; QL PREFILLED SYRINGE ENBREL SUBCUTANEOUS SOLUTION PA; SP; QL RECONSTITUTED ENBREL SURECLICK SUBCUTANEOUS PA; SP; QL SOLUTION AUTO-INJECTOR eq ibuprofen childrens oral suspension Childrens Medi-Profen OTC; QL eq ibuprofen infants oral suspension Medi-Profen OTC; QL eq ibuprofen oral capsule Medi-Profen OTC eq ibuprofen oral tablet Addaprin OTC; QL eql childrens ibuprofen oral suspension Childrens Medi-Profen OTC; QL eql ibuprofen infants oral suspension Medi-Profen OTC; QL eql ibuprofen oral capsule Medi-Profen OTC eql ibuprofen oral tablet Addaprin OTC; QL etodolac er oral tablet extended release 24 hour etodolac oral capsule etodolac oral tablet Lodine fenoprofen calcium oral capsule Nalfon 3 Drug Name Reference Notes fenoprofen calcium oral tablet Nalfon QL flurbiprofen oral tablet genpril oral tablet Addaprin OTC; QL gnp childrens ibuprofen oral suspension Childrens Medi-Profen OTC; QL gnp ibuprofen infants oral suspension Medi-Profen OTC; QL gnp ibuprofen oral capsule Medi-Profen OTC gnp ibuprofen oral tablet Addaprin 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 Medi-Profen OTC goodsense ibuprofen oral tablet Addaprin OTC; QL hm ibuprofen childrens oral suspension Childrens Medi-Profen OTC; QL hm ibuprofen ib oral tablet Addaprin OTC; QL hm ibuprofen infants oral suspension Medi-Profen OTC; QL hm ibuprofen oral capsule Medi-Profen OTC 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-PS/UV/ADOL HS START PA; SP; QL SUBCUTANEOUS PEN-INJECTOR KIT HUMIRA SUBCUTANEOUS PREFILLED PA; SP; QL SYRINGE KIT HYVEE IBUPROFEN CHILDRENS ORAL OTC; QL SUSPENSION IBU ORAL TABLET ibu-200 oral tablet Addaprin OTC; QL ibuprofen childrens oral suspension Childrens Medi-Profen OTC; QL ibuprofen infants drops oral suspension Medi-Profen OTC ibuprofen infants oral suspension Medi-Profen OTC; QL ibuprofen oral capsule Medi-Profen OTC ibuprofen oral suspension Childrens Medi-Profen QL ibuprofen oral tablet 200 mg Addaprin OTC; QL 4 Drug Name Reference Notes ibuprofen oral tablet 400 mg, 600 mg, 800 IBU 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 ketorolac tromethamine oral tablet QL kls ibuprofen oral tablet Addaprin OTC; QL ks ibuprofen oral capsule Medi-Profen OTC leflunomide oral tablet Arava meclofenamate sodium oral capsule QL MEDI-PROFEN ORAL CAPSULE OTC MEDI-PROFEN ORAL SUSPENSION OTC; QL MEDI-PROFEN 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 OTC; QL nabumetone oral tablet naproxen oral suspension Naprosyn naproxen oral tablet naproxen sodium oral tablet Anaprox DS oxaprozin oral tablet Daypro piroxicam oral capsule Feldene PA PROVIL ORAL TABLET OTC; QL px childrens profen ib oral suspension Childrens Medi-Profen OTC; QL 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 infants oral suspension Medi-Profen OTC; QL qc ibuprofen oral tablet Addaprin OTC; QL ra ibuprofen childrens oral suspension Childrens Medi-Profen OTC; QL 5 Drug Name Reference Notes ra ibuprofen infants oral suspension Medi-Profen OTC; QL ra ibuprofen oral capsule Medi-Profen OTC ra ibuprofen oral suspension Childrens Medi-Profen OTC; QL ra ibuprofen oral tablet Addaprin OTC; QL ra pain relief ibuprofen oral tablet Addaprin OTC; QL RIDAURA ORAL CAPSULE sb ibuprofen oral tablet Addaprin OTC; QL sb infants ibuprofen oral suspension Medi-Profen OTC; QL sm childrens ibuprofen oral suspension Childrens Medi-Profen OTC; QL sm ibuprofen ib oral tablet Addaprin OTC; QL sm ibuprofen oral capsule Medi-Profen OTC sm ibuprofen oral tablet Addaprin OTC; QL sm infants ibuprofen oral suspension Medi-Profen OTC; QL sulindac oral tablet tgt childrens ibuprofen oral suspension Childrens Medi-Profen OTC; QL tgt ibuprofen childrens oral suspension Childrens Medi-Profen OTC; QL tgt ibuprofen oral capsule Medi-Profen OTC tgt ibuprofen oral tablet Addaprin OTC; QL tgt infants ibuprofen oral suspension Medi-Profen OTC; QL tolmetin sodium oral capsule tolmetin sodium oral tablet WAL-PROFEN ORAL CAPSULE OTC WAL-PROFEN ORAL TABLET OTC; QL *ANALGESICS - NONNARCOTIC* 8 hour arthritis pain reliever oral tablet Midol OTC; QL extended release 8 hour pain reliever oral tablet extended Midol OTC; QL release 8hr muscle aches & pain oral tablet Midol OTC; QL extended release acetaminophen childrens oral solution OTC; QL acetaminophen childrens oral suspension PediaCare Children 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 6 Drug Name Reference Notes acetaminophen infants oral suspension PediaCare Children OTC; QL acetaminophen oral liquid Little Remedies for Fever OTC; QL acetaminophen oral solution OTC; QL acetaminophen oral suspension PediaCare Children OTC; QL acetaminophen oral tablet 325 mg Pharbetol OTC Healthy Mama Shake acetaminophen oral tablet 500 mg OTC; QL That Ache acetaminophen oral tablet chewable 160 mg Mapap Childrens OTC acetaminophen oral tablet chewable 80 mg Childrens Medi-Tabs OTC; QL acetaminophen rectal suppository FeverAll Adults OTC adult aspirin regimen oral tablet delayed Aspir-Low OTC; QL release aminofen oral tablet Pharbetol OTC arthritis pain relief oral tablet extended Midol OTC; QL release arthritis pain reliever oral tablet extended Midol OTC; QL release aspirin 81 oral tablet chewable Bayer Low Dose OTC; QL aspirin 81 oral tablet delayed release Aspir-Low OTC; QL aspirin adult low dose oral tablet delayed Aspir-Low OTC; QL release aspirin adult low strength oral tablet Bayer Low Dose OTC; QL chewable
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