QL dicloxacillin methenamine BETA BLOCKERS and QL fenofibrate QL penicillin VK QL mefloquine COMBINATIONS QL gemfibrozil SULFONAMIDES metronidazole tabs acebutolol QL lovastatin sulfamethoxazole neomycin atenolol QL OTC niacin IR, ER Preferred Drug List /trimethoprim QL nitrofurantoin caps atenolol/chlorthalidone QL pravastatin KEY: TETRACYCLINES praziquantel betaxolol QL simvastatin * age restrictions apply doxycycline monohydrate pyrazinamide bisoprolol, bisoprolol/HCTZ PCSK-9 INHIBITORS PA requires prior (capsules/suspension only) rifabutin carvedilol PA evolocumab authorization minocycline IR rifampin caps labetalol MISCELLANEOUS AGENTS ST requires trial of first step tetracycline rifapentine metoprolol 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 nadolol ALZHEIMER’S DISEASE product QL griseofulvin ACE INHIBITORS and propranolol, QL donepezil OTC over-the-counter available by QL griseofulvin microsize oral COMBINATIONS propranolol ext rel QL galantamine prescription suspension QL benazepril, benazepril/HCTZ sotalol 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 trimipramine QL buspirone bromocriptine 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 hydroxyzine 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 * aripiprazole (tabs only) QL* clonidine ER QL PA triazolam ANTIBACTERIALS QL levetiracetam QL * carbamazepine QL* dexmethylphenidate QL zolpidem OTC chlorhexidine QL oxcarbazepine QL * chlorpromazine QL* dexmethylphenidate ER QL zaleplon mupirocin oint QL phenobarbital QL * clozapine QL* dextroamphetamine, XR silver sulfadiazine QL phenytoin sod ext-rel QL * lithium carbonate QL* methylphenidate, XR COUGH & COLD CORTICOSTEROIDS QL phenytoin tabs, chewableQL QL * lithium carbonate ext rel MIGRAINE benzonatate Products are grouped based upon relative primidone QL* lithium solution QL amitriptyline QL OTC* dextromethorphan syrup potency. QL roweepra QL * loxapine QL butalbital/APAP QL OTC diphenhydramine liquid, LOW QL tiagabine (2mg and 4mg) QL * olanzapine tab QL butalbital/APAP/caff capsules QL RX/OTC hydrocortisone crm, QL topiramate QL * paliperidone ext rel QL* butalbital/APAP/caff/codeine QL OTC* guaifenesin syrup lot, oint QL valproic acid QL * perphenazine QL butalbital/ASA QL* guaifenesin w/codeine OTC QL hydrocortisone-aloe 1% cr QL zonisamide QL* pimozide QL butalbital/ASA/caff syrup MEDIUM ANTIDEPRESSANTS QL* risperidone tab/soln QL* butalbital/ASA/caff/codeine QL* promethazine w/codeine QL betamethasone valerate crm QL amitriptyline QL* quetiapine IR QL naratriptan syrup QL fluticasone propionate crm, QL amitrip/perphenazine QL* thioridazine propranolol, XR QL* promethazine w/DM oint QL amoxapine QL* thiothixene QL sumatriptan tabs syrup QL mometasone furoate crm, QL bupropion, IR, SR, XL QL* trifluoperazine QL ST sumatriptan inj, spray QL * pseudoehedrine syrup, oint, soln QL chlordiazepoxide QL* ziprasidone OPIOID/ALCOHOL DEPENDANCE tablets QL triamcinolone acet crm, /amitriptyline ANTIPSYCHOTICS — injectables QL acamprosate tab QL * saline spray, drops oint QL desipramine * PA aripiprazole (Abilify Maintena) QL buprenorphine DERMATOLOGY HIGH QL doxepin * PA aripiprazole lauroxil (Aristada PA QL buprenorphine/naloxone QL amcinonide oint, lot ACNE ORAL QL imipramine QL* fluphenazine decan, inj SL tabs/film QL betamethasone dipr aug crm PA claravis minocycline IR QL maprotiline QL* haloperidol inj. disulfiram QL betamethasone dipr lotion PA myorisan tetracycline QL mirtazapine *PA olanzapine (Zyprexa Relprevv) naloxone inj syr and vials QL betamethasone valerate oint PA zenatane QL nortriptyline *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 protriptyline *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 trazodone 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 tizanidine (tablets only) oint, soln neomycin/polymyxin B/hc (various) tabloid NSAIDs QL halobetasol propionate crm, QL ofloxacin otic ORAL AGENTS trexall diclofenac oint ANTIHISTAMINES ST empagliflozin GASTROINTESTINAL etodolac FUNGAL INFECTIONS QL azelastine spray 0.1% ST empagliflozin/metformin DIARRHEA ibuprofen OTC butenafine HCL QL cyproheptadine 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* fexofenadine QL glyburide, glyburide EMESIS meloxicam OTC clotrimazole QL OTC loratadine micronized OTC meclizine nabumetone ketoconazole INTRANASAL STEROIDS QL glyburide/metformin metoclopramide naproxen sodium OTC miconazole nitrate QL OTC fluticasone ST linagliptin QL ondansetron ODT piroxicam nystatin QL OTC tiamcinolone ST linagliptin/metformin prochlorperazine 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 esomeprazole leflunomide OTC tolnaftate PA sucroferric oxyhydroxide QL pioglitazone/metformin OTC RX famotidine oral/inj methotrexate SCABIES AND PEDICULOSIS (Velphoro) QL repaglinide OTC QL lansoprazole sulfasalazine QL permethrin 5% cream ST sitagliptin * nizatidine MISC. IMMUNOSUPRRESIVE QL OTC permethrin 1% rinse ENDOCRINOLOGY ST sitagliptin/metformin (XR) OTC QL omeprazole cyclosporine OTC pyrethrins/piperonyl HORMONE THERAPY gengraf ANTIDIABETICS OTC RX ranitidine (tabs, caps, butoxide 4% PA QL testosterone 1% gel mycophenolic acid INJECTABLE AGENTS syrup) spinosad 0.9% topical PA testosterone cyp inj sirolimus ST albiglutide INFLAMMATORY BOWEL DISEASE suspension PA testosterone enan inj tacrolimus QL ST liraglutide