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Medallion 4.0 Formulary (Current) VIRGINIA PREMIER HEALTH PLAN MEDICAID FORMULARY PLEASE NOTE: Check your benefit materials for the specific drugs covered and the copayments for your prescription drug program. For specific questions about your coverage, please call the phone number printed on your ID card. The list may not be all- inclusive. THIS LIST IS SUBJECT TO CHANGE. For the member: Generic medications contain the same active ingredients as their corresponding brand-name medications, although they may look different in color or shape. They have been FDA-approved under strict standards. For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you. CURRENT AS OF 9/1/2021 Requirements/Limits AGE = Age limit requirement Custom = Drug has unique restrictions OTC = Over the Counter PA = Prior Authorization required QL = Quantity Level Limit lowercase italics = Generic Formulary SP = Specialty Drug. Preferred Specialty drugs Pharmacy will be listed if applicable UPPERCASE = Brand name Formulary Formulary Status ST = Step Therapy may apply to some or all drugs Formulary = Covered strengths of the drug Drug Name Formulary Status Requirements/Limits 1st relief spray external liquid 4-1 % Formulary OTC 1st tier unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 Formulary OTC; QL (200 EA per 30 days) mm , 31g x 8 mm , 32g x 4 mm 1st tier unilet comfortouch Formulary OTC; QL (150 EA per 30 days) 50+ adult eye health oral capsule Formulary OTC A & D ZINC OXIDE EXTERNAL CREAM Formulary OTC a thru z advanced oral tablet Formulary OTC a thru z advantage oral tablet Formulary OTC a thru z select oral tablet chewable Formulary OTC A+D CRACKED SKIN RELIEF EXTERNAL CREAM 2- Formulary OTC 0.13 % a1c test at-home in vitro kit Formulary OTC a-25 oral capsule 25000 unit Formulary OTC abacavir sulfate oral solution 20 mg/ml Formulary abacavir sulfate oral tablet 300 mg Formulary abacavir sulfate-lamivudine oral tablet 600-300 mg Formulary abacavir-lamivudine-zidovudine oral tablet 300-150-300 Formulary mg ABANATUSS PED ORAL LIQUID 15-0.5-6.25 MG/ML, Formulary OTC 60-2-25 MG/5ML ABATRACE ORAL CAPSULE Formulary OTC ABATREX ORAL TABLET 8-200-4-100-600 MG Formulary OTC ABATRON AF ORAL TABLET 150-1 MG Formulary OTC ABATRON ORAL LIQUID Formulary OTC ABATUSS DMX ORAL LIQUID 30-1-15 MG/5ML Formulary OTC ABILIFY MAINTENA INTRAMUSCULAR PREFILLED Formulary AGE (Min 18 Years) SYRINGE 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR Formulary AGE (Min 18 Years) SUSPENSION RECONSTITUTED ER 300 MG, 400 MG abiraterone acetate oral tablet 250 mg Formulary ABRAXANE INTRAVENOUS SUSPENSION Formulary RECONSTITUTED 100 MG ABREVA EXTERNAL CREAM 10 % Formulary OTC acamprosate calcium oral tablet delayed release 333 mg Formulary acarbose oral tablet 100 mg, 25 mg, 50 mg Formulary ACCU-CHEK FASTCLIX LANCET KIT Formulary OTC 1 Drug Name Formulary Status Requirements/Limits ACCU-CHEK SOFT TOUCH LANCETS Formulary OTC; QL (150 EA per 30 days) ACCU-CHEK SOFTCLIX LANCETS Formulary OTC; QL (150 EA per 30 days) ACCUTANE ORAL CAPSULE 20 MG, 30 MG, 40 MG Formulary ACCUTREND CHOLESTEROL CONTROL IN VITRO Formulary OTC SOLUTION ACCUTREND CHOLESTEROL IN VITRO STRIP Formulary OTC ACCUTREND PLUS DEVICE Formulary OTC ACE AEROSOL CLOUD ENHANCER Formulary QL (2 EA per 365 days) ACE KNEE BRACE W/STABILIZERS Formulary OTC acebutolol hcl oral capsule 200 mg, 400 mg Formulary ACEROLA C 500 ORAL WAFER 500 MG Formulary OTC ACETA-GESIC ORAL TABLET 12.5-325 MG Formulary OTC acetaminophen oral liquid 160 mg/5ml Formulary OTC acetaminophen oral solution 160 mg/5ml Formulary OTC acetaminophen oral tablet 325 mg Formulary OTC acetaminophen-codeine #2 oral tablet 300-15 mg Formulary PA; QL (280 EA per 7 days) acetaminophen-codeine #3 oral tablet 300-30 mg Formulary PA; QL (140 EA per 7 days) acetaminophen-codeine #4 oral tablet 300-60 mg Formulary PA; QL (70 EA per 7 days) acetaminophen-codeine oral solution 120-12 mg/5ml Formulary PA; QL (1750 ML per 7 days) ACETASOL HC OTIC SOLUTION 2-1 % Formulary acetazolamide er oral capsule extended release 12 hour 500 Formulary mg acetazolamide oral tablet 250 mg Formulary acetic acid irrigation solution 0.25 % Formulary acetic acid otic solution 2 % Formulary acetylcysteine inhalation solution 10 %, 20 % Formulary ACID GONE ORAL SUSPENSION 95-358 MG/15ML Formulary OTC acid reducer maximum strength oral tablet 20 mg Formulary OTC acidophilus oral capsule Formulary OTC acidophilus probiotic oral tablet 10 mg Formulary OTC acidophilus/bifidus oral tablet chewable Formulary OTC acidophilus/citrus pectin oral tablet Formulary OTC acidophilus/pectin oral capsule Formulary OTC acitretin oral capsule 10 mg, 17.5 mg, 25 mg Formulary PA; QL (68 EA per 34 days) acne medication 10 external gel 10 % Formulary OTC; AGE (Max 18 Years) acne medication 10 external lotion 10 % Formulary OTC; AGE (Max 18 Years) acne medication 5 external gel 5 % Formulary AGE (Max 18 Years) acne medication 5 external lotion 5 % Formulary OTC; AGE (Max 18 Years) acne treatment external bar 10 % Formulary OTC; AGE (Max 18 Years) ACNEFREE ACNE CLEARING SYSTEM EXTERNAL Formulary OTC KIT 2.5 & 3.7 % ACNEFREE SEVERE CLEARING SYST EXTERNAL Formulary OTC KIT 2.5 & 10 % ACT TOTAL CARE MOUTH/THROAT SOLUTION 0.05 Formulary OTC % 2 Drug Name Formulary Status Requirements/Limits ACTHIB INTRAMUSCULAR SOLUTION Formulary AGE (Min 19 Years) RECONSTITUTED ACTICARNITINE SF ORAL SOLUTION 1 GM/10ML Formulary OTC ACTICON ORAL SOLUTION 1-30 MG/5ML Formulary OTC ACTICON ORAL TABLET 2-60 MG Formulary OTC actidom dmx oral liquid 10-30-200 mg/5ml Formulary OTC ACTIDOSE WITH SORBITOL ORAL LIQUID 50 Formulary OTC GM/240ML actidose-aqua oral liquid 15 gm/72ml Formulary OTC ACTIFLOVIT EAR HEALTH ORAL TABLET Formulary OTC ACTIFOAM COLLAGEN SPONGE EXTERNAL Formulary acti-lance lite lancets 28g Formulary OTC; QL (150 EA per 30 days) acti-lance special lancets 17g Formulary OTC; QL (150 EA per 30 days) acti-lance universal 23g Formulary OTC; QL (150 EA per 30 days) ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 Formulary UNIT/0.5ML ACTINEL ORAL LIQUID 30-15-200 MG/5ML Formulary OTC ACTISEP MOUTH/THROAT SOLUTION 2-0.5-0.1 % Formulary OTC ACTITROM ORAL CAPSULE Formulary OTC ACTIVE Q MAXIMUM STRENGTH ORAL CAPSULE Formulary OTC 300 MG ACTIVE Q ORAL SYRUP 100 MG/5ML Formulary OTC ACTIVE-Q EXTRA STRENGTH ORAL CAPSULE 200 Formulary OTC MG ACTIVE-Q ORAL CAPSULE 200-30 MG Formulary OTC ACTIVITE EC ORAL TABLET 1 MG Formulary OTC ACTIVON ARTHRITIS ULTRA ST EXTERNAL STICK Formulary OTC 0.028-4.574 % acyclovir external ointment 5 % Formulary acyclovir oral capsule 200 mg Formulary acyclovir oral suspension 200 mg/5ml Formulary acyclovir oral tablet 400 mg, 800 mg Formulary ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 Formulary LF-MCG/0.5 ADAGEN INTRAMUSCULAR SOLUTION 250 Formulary PA UNIT/ML adapalene external cream 0.1 % Formulary AGE (Max 18 Years) adapalene external gel 0.1 %, 0.3 % Formulary AGE (Max 18 Years) ADDERALL XR ORAL CAPSULE EXTENDED QL (30 EA per 30 days); AGE (Min 4 Formulary RELEASE 24 HOUR 10 MG, 15 MG, 5 MG Years and Max 17 Years) ADDERALL XR ORAL CAPSULE EXTENDED QL (60 EA per 30 days); AGE (Min 4 Formulary RELEASE 24 HOUR 20 MG, 25 MG, 30 MG Years and Max 17 Years) adefovir dipivoxil oral tablet 10 mg Formulary adhesive bandages sheer Formulary OTC adjustable lancing device Formulary OTC; QL (1 EA per 365 days) ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION Formulary PEN-INJECTOR 100 UNIT/ML 3 Drug Name Formulary Status Requirements/Limits ADMELOG SUBCUTANEOUS SOLUTION 100 Formulary UNIT/ML ADRENAL C FORMULA ORAL TABLET Formulary ADRENALIN INJECTION SOLUTION 1 MG/ML, 30 Formulary MG/30ML ADRUCIL INTRAVENOUS SOLUTION 2.5 GM/50ML, 5 Formulary GM/100ML, 500 MG/10ML adult gummy oral tablet chewable Formulary OTC adult mask device Formulary QL (2 EA per 365 days) adult wash cloths with aloe external 3 % Formulary OTC adult-lock weekly pill remind Formulary OTC ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 Formulary MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION AEROSOL 115-21 Formulary MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT advanced acne wash external liquid extended release 4.4 % Formulary OTC ADVANCED CALCIUM/D/MAGNESIUM ORAL Formulary OTC TABLET advanced hand sanitizer external liquid 70 % Formulary OTC ADVIL ALLERGY & CONGESTION ORAL TABLET 4- Formulary OTC 10-200 MG ADVIL ALLERGY SINUS ORAL TABLET 2-30-200 MG Formulary OTC ADVIL COLD & SINUS LIQUI-GELS ORAL CAPSULE Formulary OTC 30-200 MG ADVIL COLD/SINUS ORAL TABLET 30-200 MG Formulary OTC ADVIL ORAL CAPSULE 200 MG Formulary OTC ADVIL ORAL TABLET 200 MG Formulary OTC ADVIL PM ORAL CAPSULE 200-25 MG Formulary OTC ADVIL PM ORAL TABLET 200-38 MG Formulary OTC ADVIL SINUS CONGESTION & PAIN ORAL TABLET Formulary OTC 10-200 MG ADVOCATE INSULIN SYRINGE 29G X 1/2" 0.5 ML Formulary OTC 29G X 1/2" 0.5 ML ADVOCATE INSULIN SYRINGE 30G X 5/16" 0.3 ML Formulary OTC 30G X 5/16" 0.3 ML ADVOCATE INSULIN SYRINGE 30G X 5/16" 1 ML 30G Formulary OTC X 5/16" 1 ML ADVOCATE INSULIN SYRINGE 31G X 5/16" 1 ML 31G Formulary OTC X 5/16" 1 ML AEROCHAMBER PLUS FLO-VU Formulary QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU LARGE Formulary QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU SMALL Formulary QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU W/MASK Formulary QL (2 EA per 365 days) AFEDITAB CR ORAL TABLET EXTENDED RELEASE Formulary 24 HOUR 30 MG, 60 MG AFLURIA INTRAMUSCULAR SUSPENSION Formulary AGE (Min 19 Years) 4 Drug Name Formulary Status Requirements/Limits AFLURIA PRESERVATIVE FREE INTRAMUSCULAR Formulary AGE (Min 19 Years) SUSPENSION PREFILLED
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