Kentucky Medicaid Pharmacy Preferred Drug List

2021 Magellan Health, Inc. All rights reserved. Magellan Medicaid Administration, part of the Magellan Rx Management division of Magellan Health, Inc. Kentucky Medicaid Pharmacy Program Single Preferred drug List (PDL) Effective: December 14, 2021 GENERAL DEFINITION OF TERMS Clinical Criteria (CC) Due to the nature of some medications, prior authorization (PA) is required for the medication to be covered. Medications with this indicator may require prior use of a different medication or drug product, a qualifying diagnosis to be reported and/or appropriate clinical criteria to be satisfied before prior authorization is approved. Prescriptions exceeding plan limitations such as a Quantity Limit (QL), Maximum Duration (MD), or Age Edit (AE), in addition to those subject to Clinical Criteria (CC), will require additional approval.

The following classes are examples of common maintenance drugs. Maintenance drugs, as determined by First Databank (FDB) or Medi-Span, can be processed for up to a 92 day s’ supply for KY Medicaid recipients.

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