Preferred Drug List - Amerigroup

Preferred drug ListVersion Date: 2/1/2018 WEBMGA-0242-17 Applies to Medicaid market- Georgia KEY: *age restrictions applyPA requires prior authorization ST requires trial of first step product QL daily dosage limits apply RX legend prescription product OTC over-the-counter available by prescription ANTIBACTERIALS ANTIBIOTICS CEPHALOSPORINS First Generation QL cefadroxil QL cephalexin Second Generation QL cefaclor QL cefprozil QL cefuroxime axetil Third Generation QL cefdinir QL cefpodoxime FLUOROQUINOLONES QL* ciprofloxacin tabs *ofloxacinMACROLIDES QL azithromycin QL clarithromycin QL erythromycin (all salt forms) PENICILLINS QL amoxicillin QL amoxicillin/clavulanate QL ampicillin QL dicloxacillin QL penicillin VK SULFONAMIDES sulfamethoxazole /trimethoprim TETRACYCLINES doxycycline monohydrate (capsules/suspension only) minocycline IR tetracycline ANTIFUNGALS QL clotrimazole troches QL fluconazole QL griseofulvin QL griseofulvin microsize oral suspension QL ketoconazole cream, shampoo QL nystatin QL OTC terbinafine ANTIVIRALS HEPATITIS C PA QL elbasiv/grazoprevir (Zepatier) PA glecaprevir/pibrentasvir (Mavyret) PA peginterferon alfa 2a PA peginterferon alfa 2b ribavirin PA QL sofosbuvir (Sovaldi) ANTIVIRALS acyclovir QL famciclovir QL valacyclovir HIV/AIDS Please see Amerigroup formulary for covered agents.

QL dorzolamide/timolol . QL latanoprost . QL levobunolol . metipranolol . QL pilocarpine . QL timolol gel-solution . QL timolol maleate (solution only) INFECTIONS QL bacitracin QL bacitracin/polymyxin B oint . QL ciprofloxacin . QL erythromycin . gatifloxacin 0.5% drops . QL gentamicin . levofloxacin 0.5% drops . moxifloxacin 0.5% drops ...

Loading..

Tags:

  Drug, Preferred, Lists, Preferred drug list, Timolol, Latanoprost

Information

Related search queries