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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

capsules . QL OTC* guaifenesin syrup . QL* guaifenesin w/codeine . syrup QL* promethazine w/codeine syrup . QL* promethazine w/DM syrup . QL * pseudoehedrine syrup, ... (5mg and 10mg only) chlorzoxazone . dantrolene . QL methocarbamol . orphenadrine . QL tizanidine (tablets only) NSAIDs diclofenac . etodolac . ibuprofen .

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