Medicaid-Approved Preferred Drug List

1 Healthy indiana Plan PLUS Medicaid-Approved Preferred drug ListEffective August 1, 2022 Legend In each class, drugs are listed alphabetically by either brand name or generic name. Brand name drug : Uppercase i n 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 i s required. Prior authorization i s the process of obtaining approval of benefits before certain prescriptions are filled.

2 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 t o use one medication before benefits for the use of another medication can be authorized. drug NameReferenceNotes*ADHD/ANTI-NARCOLEPSY/ ANTI-OBESITY/ANOREXIANTS**ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS**clonidine hcl er oral tablet extended release 12 hourKapvayQLguanfacine hcl er oral tablet extended release 24 hourIntunivQL*ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR**atomoxetine hcl oral capsuleStratteraQLQELBREE ORAL CAPSULE EXTENDED RELEASE 24 HOURAL; QL*AMPHETAMINE MIXTURES**amphetamine-dextroamphet er oral capsule extended release 24 hourAdderall XRAL; QLamphetamine-dextroamphetamine oral tabletAdderallAL; QLMYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOURAL.

3 QL*AMPHETAMINES**ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLEAL; QLamphetamine sulfate oral tabletEvekeoAL; QLdextroamphetamine sulfate er oral capsule extended release 24 hourDexedrineAL; QLdextroamphetamine sulfate oral solutionProCentraAL; QLdextroamphetamine sulfate oral tabletZenzediAL; QLDYANAVEL XR ORAL SUSPENSION EXTENDED RELEASEAL; QLEVEKEO ODT ORAL TABLET DISPERSIBLEAL; QLmethamphetamine hcl oral tabletDesoxynALPROCENTRA ORAL SOLUTIONAL; QLVYVANSE ORAL CAPSULEAL; QLVYVANSE ORAL TABLET CHEWABLEAL; QLZENZEDI ORAL TABLETAL; QL*ANALEPTICS**caffeine citrate oral solution2 drug NameReferenceNotes*DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)**SUNOSI ORAL TABLETQL*HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS**WAKIX ORAL TABLET MGPA; SP; QLWAKIX ORAL TABLET MGPA; SP; DO; QL*STIMULANT COMBINATIONS**AZSTARYS ORAL CAPSULEAL; QL*STIMULANTS - MISC.

4 **ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOURAL; QLarmodafinil oral tabletNuvigilPA; QLCOTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLEAL; QLdexmethylphenidate hcl er oral capsule extended release 24 hourFocalin XRAL; QLdexmethylphenidate hcl oral tabletFocalinAL; QLJORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOURAL; QLmethylphenidate hcl er (cd) oral capsule extended releaseAL; QLmethylphenidate hcl er (la) oral capsule extended release 24 hourRitalin LAAL; QLmethylphenidate hcl er (osm) oral tablet extended releaseConcertaAL; QLmethylphenidate hcl er (xr) oral capsule extended release 24 hourAptensio XRAL; QLmethylphenidate hcl er oral tablet extended releaseAL; QLmethylphenidate hcl er oral tablet extended release 24 hourAL; QLmethylphenidate hcl oral solutionMethylinAL; QLmethylphenidate hcl oral tabletRitalinAL; QLmethylphenidate hcl oral tablet chewableAL; QLmethylphenidate transdermal patchDaytranaAL; QLmodafinil oral tablet 100 mgProvigilPA; DO; QLmodafinil oral tablet 200 mgProvigilPA; QLQUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASEAL.

5 QL3 drug NameReferenceNotesQUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ERAL; QLRELEXXII ORAL TABLET EXTENDED RELEASEAL; QLRITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOURAL; QL*ALTERNATIVE MEDICINES**ALTERNATIVE MEDICINE - ME'S**cvs melatonin extra strength oral liquidAL; OTC; QLcvs melatonin gummies oral tablet chewableVitaJoy GummiesOTC; QLcvs melatonin oral capsuleOTC; QLcvs melatonin oral liquidAL; OTC; QLcvs melatonin oral tabletOTC; QLcvs melatonin oral tablet chewableOTC; QLcvs quality sleep oral capsuleOTC; QLgnp melatonin maximum strength oral tabletOTC; QLgnp melatonin oral tabletOTC; QLgnp melatonin oral tablet chewableVitaJoy GummiesOTC; QLkp melatonin oral tabletOTC; QLmelatonin extra strength oral liquidAL; OTC; QLmelatonin extra strength oral tabletOTC; QLmelatonin extra strength oral tablet chewableOTC; QLmelatonin gummies oral tablet chewableVitaJoy GummiesOTC; QLmelatonin maximum strength oral tabletOTC; QLmelatonin oral capsuleOTC; QLmelatonin oral liquid 1 mg/4ml, mg/10mlAL; OTC; QLmelatonin oral liquid 1 mg/mlZarbees Sleep Child/MelatoninAL; OTC; QLmelatonin oral liquid 5 mg/mlOTC; QLmelatonin oral tabletOTC; QLmelatonin oral tablet chewableVitaJoy GummiesOTC.

6 QLqc melatonin max st oral tabletOTC; QLra melatonin oral tabletOTC; QLSLEEP SOUNDLY ORAL LIQUIDOTC; QLsm melatonin oral tabletOTC; QLsv melatonin oral tabletOTC; QL4 drug NameReferenceNotesVITAJOY GUMMIES ORAL TABLET CHEWABLEOTC; QLZARBEES SLEEP CHILD/MELATONIN ORAL LIQUIDAL; OTC; QL*AMINOGLYCOSIDES**AMINOGLYCOSIDES**neo mycin sulfate oral tabletparomomycin sulfate oral capsuleHumatintobramycin inhalation nebulization solutionKitabis PakSP; QL*ANALGESICS - ANTI-INFLAMMATORY**ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES**HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KITPA; SP; QLHUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KITPA; SP; QLHUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KITPA; SP; QLHUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PEN-INJECTOR KITPA; SP; QLHUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KITPA; SP; QLHUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PEN-INJECTOR KITPA; SP; QLHUMIRA SUBCUTANEOUS PREFILLED SYRINGE KITPA; SP; QL*CYCLOOXYGENASE 2 (COX-2) INHIBITORS**celecoxib oral capsuleCeleBREXPA.

7 QL*GOLD COMPOUNDS**RIDAURA ORAL CAPSULE*NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)**ADVIL JUNIOR STRENGTH ORAL TABLET CHEWABLEOTCall day pain relief oral tabletMediproxenOTC; QLall day relief oral tabletMediproxenOTC; QL5 drug NameReferenceNotesCATAFLAM ORAL TABLET childrens ibuprofen 100 oral suspensionChildrens Medi-ProfenOTC; QLchildrens ibuprofen oral suspensionChildrens Medi-ProfenOTC; QLCHILDRENS MEDI-PROFEN ORAL SUSPENSIONOTC; QLcvs all day pain relief oral tabletMediproxenOTC; QLcvs childrens ibuprofen oral suspensionChildrens Medi-ProfenOTC; QLcvs ibuprofen childrens oral suspensionChildrens Medi-ProfenOTC; QLcvs ibuprofen infants oral suspensionMedi-ProfenOTC; QLcvs ibuprofen junior strength oral tablet chewableAdvil Junior StrengthOTCcvs ibuprofen oral tabletMedi-ProfenOTC; QLcvs naproxen sodium oral tabletMediproxenOTC; QLdiclofenac potassium oral tabletCataflamdiclofenac sodium er oral tablet extended release 24 hourQLdiclofenac sodium oral tablet delayed releaseQLeq all day pain relief oral tabletMediproxenOTC; QLeq ibuprofen childrens oral suspensionChildrens Medi-ProfenOTC.

8 QLeq ibuprofen junior oral tablet chewableAdvil Junior StrengthOTCeq ibuprofen oral tabletMedi-ProfenOTC; QLeq naproxen sodium oral tabletMediproxenOTC; QLeql childrens ibuprofen oral suspensionChildrens Medi-ProfenOTC; QLeql ibuprofen infants oral suspensionMedi-ProfenOTC; QLeql ibuprofen oral tabletMedi-ProfenOTC; QLeql naproxen sodium oral tabletMediproxenOTC; QLetodolac er oral tablet extended release 24 hourQLetodolac oral capsuleQLetodolac oral tabletLodineQLflurbiprofen oral tabletQLgnp childrens ibuprofen oral suspensionChildrens Medi-ProfenOTC; QLgnp ibuprofen childrens oral tablet chewableAdvil Junior StrengthOTCgnp ibuprofen infants oral suspensionMedi-ProfenOTC; QLgnp ibuprofen oral tabletMedi-ProfenOTC; QLgnp naproxen sodium oral tabletMediproxenOTC; QL6 drug NameReferenceNotesgoodsense ibuprofen childrens oral suspensionChildrens Medi-ProfenOTC; QLgoodsense ibuprofen infants oral suspensionMedi-ProfenOTC; QLgoodsense ibuprofen oral tabletMedi-ProfenOTC; QLgoodsense naproxen sodium oral tabletMediproxenOTC; QLhm ibuprofen childrens oral suspensionChildrens Medi-ProfenOTC; QLhm ibuprofen ib oral tabletMedi-ProfenOTC.

9 QLhm ibuprofen oral tabletMedi-ProfenOTC; QLhm naproxen sodium oral tabletMediproxenOTC; QLhy-vee all day relief oral tabletMediproxenOTC; QLHYVEE IBUPROFEN CHILDRENS ORAL SUSPENSIONOTC; QLIBU ORAL TABLETQLibu-200 oral tabletMedi-ProfenOTC; QLibuprofen 100 junior strength oral tablet chewableAdvil Junior StrengthOTCibuprofen childrens oral suspensionChildrens Medi-ProfenOTC; QLibuprofen infants oral suspensionMedi-ProfenOTC; QLibuprofen junior strength oral tablet chewableAdvil Junior StrengthOTCibuprofen oral suspensionChildrens Medi-ProfenOTC; QLibuprofen oral tablet 200 mgMedi-ProfenOTC; QLibuprofen oral tablet 400 mg, 600 mg, 800 mgIBUQL indomethacin er oral capsule extended releaseQLindomethacin oral capsuleQLinfants ibuprofen oral suspensionMedi-ProfenOTC; QLketoprofen er oral capsule extended release 24 hourQLketoprofen oral capsuleQLketorolac tromethamine oral tabletQLkls ibuprofen ib oral tabletMedi-ProfenOTC; QLkls ibuprofen oral tabletMedi-ProfenOTC; QLmeclofenamate sodium oral capsuleQLMEDI-PROFEN ORAL SUSPENSIONOTC; QLMEDI-PROFEN ORAL TABLETOTC; QLMEDIPROXEN ORAL TABLETOTC; QLmeijer ibuprofen oral tabletMedi-ProfenOTC; QL7 Dru