Medicaid-Approved Preferred Drug List

1 Georgia Medicaid-Approved Preferred drug List Effective November 1, 2021. Legend In each class, drugs are listed alphabetically by either brand name or generic name. Brand name drug : Uppercase in bold type Generic drug : Lowercase in plain type AL: Age Limit Restrictions DO: Dose Optimization Program GR: Gender Restriction OTC: Over the counter medication available with a prescription. (Prescribers please indicate OTC on the prescription). PA: Prior authorization is required. Prior authorization is the process of obtaining approval of benefits before certain prescriptions are filled. QL: Quantity limits; certain prescription medications have specific quantity limits per prescription or per month. SP: Specialty Pharmacy ST: Step therapy is required. You may need to use one medication before benefits for the use of another medication can be authorized. drug Name Reference Notes *ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS*.

2 *ADHD AGENT - SELECTIVE ALPHA. ADRENERGIC AGONISTS**. clonidine hcl er oral tablet extended release Kapvay AL; QL. 12 hour *ADHD AGENT - SELECTIVE. NOREPINEPHRINE REUPTAKE. INHIBITOR**. atomoxetine hcl oral capsule Strattera DO; AL; QL. *AMPHETAMINE MIXTURES**. amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 5 Adderall XR DO; AL; QL. mg amphetamine-dextroamphet er oral capsule extended release 24 hour 20 mg, 25 mg, 30 Adderall XR AL; QL. mg amphetamine-dextroamphetamine oral Adderall DO; AL; QL. tablet 10 mg, mg, 15 mg, 5 mg, mg amphetamine-dextroamphetamine oral Adderall AL. tablet 20 mg, 30 mg *AMPHETAMINES**. dextroamphetamine sulfate er oral capsule Dexedrine AL; QL. extended release 24 hour dextroamphetamine sulfate oral tablet 10 mg Zenzedi PA; QL. dextroamphetamine sulfate oral tablet 5 mg Zenzedi DO; AL; QL. *ANALEPTICS**. caffeine citrate intravenous solution Cafcit caffeine citrate oral solution *LIPASE INHIBITORS**.

3 ALLI ORAL CAPSULE PA; OTC; QL. *STIMULANTS - MISC.**. dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 Focalin XR DO; AL; QL. mg, 5 mg dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg, 30 mg, 35 Focalin XR AL; QL. mg, 40 mg dexmethylphenidate hcl oral tablet 10 mg Focalin AL; QL. dexmethylphenidate hcl oral tablet mg Focalin DO; AL; QL. 2. drug Name Reference Notes dexmethylphenidate hcl oral tablet 5 mg Focalin PA; DO; QL. methylphenidate hcl er (cd) oral capsule DO; AL; QL. extended release 10 mg, 20 mg, 30 mg methylphenidate hcl er (cd) oral capsule AL; QL. extended release 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule Ritalin LA AL; QL. extended release 24 hour methylphenidate hcl er oral tablet extended DO; AL; QL. release 10 mg methylphenidate hcl er oral tablet extended Concerta DO; AL; QL. release 18 mg, 27 mg methylphenidate hcl er oral tablet extended AL; QL.

4 Release 20 mg methylphenidate hcl er oral tablet extended DO; AL; QL. release 24 hour 18 mg, 27 mg methylphenidate hcl er oral tablet extended AL; QL. release 24 hour 36 mg, 54 mg methylphenidate hcl er oral tablet extended Concerta AL; QL. release 36 mg, 54 mg methylphenidate hcl oral solution Methylin AL. methylphenidate hcl oral tablet 10 mg, 5 mg Ritalin DO; AL; QL. methylphenidate hcl oral tablet 20 mg Ritalin AL. *ALTERNATIVE MEDICINES*. *ALTERNATIVE MEDICINE - ME'S**. cvs melatonin extra strength oral liquid OTC; QL. cvs melatonin gummies oral tablet chewable VitaJoy Gummies OTC; QL. cvs melatonin oral capsule OTC; QL. cvs melatonin oral liquid OTC; QL. cvs melatonin oral tablet OTC; QL. cvs melatonin oral tablet dispersible OTC; QL. cvs melatonin sublingual tablet sublingual OTC; QL. cvs quality sleep oral capsule OTC; QL. gnp melatonin maximum strength oral tablet OTC; QL.

5 Gnp melatonin oral tablet OTC; QL. gnp melatonin oral tablet chewable VitaJoy Gummies OTC; QL. gnp melatonin oral tablet extended release OTC; QL. gnp melatonin sublingual tablet sublingual OTC; QL. hm melatonin quick dissolve oral tablet OTC; QL. dispersible 3. drug Name Reference Notes hm melatonin sublingual tablet sublingual OTC; QL. kp melatonin oral tablet OTC; QL. max melatonin oral tablet dispersible OTC; QL. Zarbees Sleep melatonin childrens oral tablet chewable OTC; QL. Child/Melatonin melatonin er oral tablet extended release OTC; QL. melatonin extra strength oral liquid OTC; QL. melatonin gummies oral tablet chewable VitaJoy Gummies OTC; QL. melatonin maximum strength oral tablet OTC; QL. melatonin oral capsule OTC; QL. Zarbees Sleep melatonin oral liquid OTC; QL. Child/Melatonin melatonin oral tablet OTC; QL. melatonin oral tablet chewable VitaJoy Gummies OTC; QL.

6 Melatonin oral tablet dispersible OTC; QL. melatonin quick dissolve sublingual tablet OTC; QL. sublingual melatonin sublingual tablet sublingual OTC; QL. melatonin tr oral tablet extended release OTC; QL. mm melatonin oral tablet extended release OTC; QL. qc melatonin max st oral tablet OTC; QL. ra melatonin oral tablet OTC; QL. sm melatonin oral tablet OTC; QL. sm melatonin oral tablet dispersible OTC; QL. sv melatonin oral tablet OTC; QL. sv melatonin oral tablet dispersible OTC; QL. VITAJOY GUMMIES ORAL TABLET. OTC; QL. CHEWABLE. ZARBEES SLEEP CHILD/MELATONIN. OTC; QL. ORAL LIQUID. *AMINOGLYCOSIDES*. *AMINOGLYCOSIDES**. neomycin sulfate oral tablet paromomycin sulfate oral capsule Humatin tobramycin inhalation nebulization solution Kitabis Pak SP; QL. 4. drug Name Reference Notes *ANALGESICS - ANTI- INFLAMMATORY*. *ANTI-TNF-ALPHA - MONOCLONAL. ANTIBODIES**. HUMIRA PEDIATRIC CROHNS START.

7 SUBCUTANEOUS PREFILLED SYRINGE PA; SP; QL. KIT. HUMIRA PEN SUBCUTANEOUS PEN- PA; SP; QL. INJECTOR KIT. HUMIRA PEN-CD/UC/HS STARTER. PA; SP; QL. SUBCUTANEOUS PEN-INJECTOR KIT. HUMIRA PEN-PEDIATRIC UC START. PA; SP; QL. SUBCUTANEOUS PEN-INJECTOR KIT. HUMIRA PEN-PS/UV/ADOL HS START. PA; SP; QL. SUBCUTANEOUS PEN-INJECTOR KIT. HUMIRA PEN-PSOR/UVEIT STARTER. PA; SP; QL. SUBCUTANEOUS PEN-INJECTOR KIT. HUMIRA SUBCUTANEOUS PREFILLED. PA; SP; QL. SYRINGE KIT. *GOLD COMPOUNDS**. RIDAURA ORAL CAPSULE. *NONSTEROIDAL ANTI- INFLAMMATORY AGENTS. (NSAIDS)**. ADVIL JUNIOR STRENGTH ORAL. OTC; QL. TABLET. ADVIL JUNIOR STRENGTH ORAL. OTC. TABLET CHEWABLE. ADVIL LIQUI-GELS MINIS ORAL. OTC; QL. CAPSULE. all day pain relief oral tablet Mediproxen OTC; QL. all day relief oral tablet Mediproxen OTC; QL. childrens ibuprofen 100 oral suspension Childrens Medi-Profen OTC; QL. childrens ibuprofen oral suspension Childrens Medi-Profen OTC; QL.

8 CHILDRENS MEDI-PROFEN ORAL. OTC; QL. SUSPENSION. cvs all day pain relief oral tablet Mediproxen OTC; QL. cvs childrens ibuprofen oral suspension Childrens Medi-Profen OTC; QL. cvs ibuprofen childrens oral suspension Childrens Medi-Profen OTC; QL. cvs ibuprofen infants oral suspension Medi-Profen OTC; QL. 5. drug Name Reference Notes cvs ibuprofen junior strength oral tablet Advil Junior Strength OTC. chewable cvs ibuprofen oral capsule Advil Liqui-Gels minis OTC; QL. cvs ibuprofen oral tablet Medi-Profen OTC; QL. cvs naproxen sodium oral capsule Aleve OTC; QL. cvs naproxen sodium oral tablet Mediproxen OTC; QL. diclofenac potassium oral tablet Cataflam diclofenac sodium er oral tablet extended QL. release 24 hour diclofenac sodium oral tablet delayed QL. release eq all day pain relief oral tablet Mediproxen OTC; QL. eq ibuprofen childrens oral suspension Childrens Medi-Profen OTC; QL.

9 Eq ibuprofen junior oral tablet chewable Advil Junior Strength OTC. eq ibuprofen oral capsule Advil Liqui-Gels minis OTC; QL. eq ibuprofen oral tablet Medi-Profen PA; OTC; QL. eq naproxen sodium oral capsule Aleve OTC; QL. eq naproxen sodium oral tablet Mediproxen OTC; QL. eql childrens ibuprofen oral suspension Childrens Medi-Profen OTC; QL. eql ibuprofen infants oral suspension Medi-Profen OTC; QL. eql ibuprofen junior strength oral tablet Advil Junior Strength OTC. chewable eql ibuprofen oral capsule Advil Liqui-Gels minis OTC; QL. eql ibuprofen oral tablet Medi-Profen OTC; QL. eql naproxen sodium oral capsule Aleve OTC; QL. eql naproxen sodium oral tablet Mediproxen OTC; QL. etodolac oral capsule QL. etodolac oral tablet Lodine QL. fenoprofen calcium oral capsule Nalfon PA; QL. fenoprofen calcium oral tablet Nalfon flurbiprofen oral tablet QL. gnp childrens ibuprofen oral suspension Childrens Medi-Profen OTC; QL.

10 Gnp ibuprofen childrens oral tablet chewable Advil Junior Strength OTC. gnp ibuprofen infants oral suspension Medi-Profen OTC; QL. gnp ibuprofen oral capsule Advil Liqui-Gels minis OTC; QL. gnp ibuprofen oral tablet Medi-Profen OTC; QL. gnp naproxen sodium oral capsule Aleve OTC; QL. gnp naproxen sodium oral tablet Mediproxen OTC; QL. 6. drug Name Reference Notes goodsense ibuprofen childrens oral Childrens Medi-Profen OTC; QL. suspension goodsense ibuprofen infants oral suspension Medi-Profen OTC; QL. goodsense ibuprofen oral capsule Advil Liqui-Gels minis OTC; QL. goodsense ibuprofen oral tablet Medi-Profen OTC; QL. goodsense naproxen sodium oral tablet Mediproxen OTC; QL. hm ibuprofen childrens oral suspension Childrens Medi-Profen OTC; QL. hm ibuprofen ib oral tablet Medi-Profen OTC; QL. hm ibuprofen ib oral tablet chewable Advil Junior Strength OTC. hm ibuprofen infants oral suspension Medi-Profen OTC; QL.