Florida Medicaid Preferred Drug List (effective 10-01-2021)

1 Florida Medicaid Preferred Drug List (effective 01-01-2022)The Florida Medicaid Preferred Drug List (PDL) is subject to revision following consideration and recommendations by the Pharmaceutical and Therapeutics (P&T) Committee and the Agency for Health Care Administration. The quarterly P&T Committee meeting was held on December 10, list is in order by the therapeutic classification. To locate a specific drug or therapeutic class, use the search feature available in Adobe Acrobat Reader. (keyboard shortcut: CTRL+F)Phosphate Binders and Prescription Strength Vitamins are covered for dialysis : While a product name may be listed on the PDL, a specific NDC may or may not be : Auto PA = System automated criteria looks for specific requirements ( , diagnosis, age, previous therapies, etc.)

2 If all requirements are found, the claims will pay at the pharmacy counter without need of manual prior authorization submission. Clinical PA Required = These drugs require prior authorization submission that must include clinical documentation. The drugs that require clinical prior authorization review and the prior authorization forms can be found in this link: Cystic Fib Diag Auto PA = Claims for these products will pay at the pharmacy counter if the diagnosis of cystic fibrosis is found in the system. Requires Med Cert 3 = The Food and Drug Administration (FDA) requires participation (by prescribers, pharmacies, and/or patients) in certification, education, training, or agreements prior to dispensing certain drugs.

3 By entering certification code 3 , the dispensing pharmacy is confirming that FDA requirements were DESCRIPTIONLABEL NAMEG eneric nameMEDICAID MIN AGEMEDICAID MAX AGECLINICAL PA REQUIREDA1 ADIGITALIS GLYCOSIDESDIGOXIN MG/ML SOLUTIONDIGOXIN0999 NoDIGOXIN MG TABLETDIGOXIN0999 NoDIGOXIN MG TABLETDIGOXIN0999 NoDIGOXIN 125 MCG TABLETDIGOXIN0999 NoDIGOXIN 250 MCG TABLETDIGOXIN0999 NoA1 BXANTHINESCAFFEINE CIT 60 MG/3 ML ORALCAFFEINE CITRATE1999 NoCAFFEINE CIT 60 MG/3 ML VIALCAFFEINE CITRATE1999 NoTHEO-24 ER 100 MG CAPSULETHEOPHYLLINE ANHYDROUS0999 NoTHEO-24 ER 200 MG CAPSULETHEOPHYLLINE ANHYDROUS0999 NoTHEO-24 ER 300 MG CAPSULETHEOPHYLLINE ANHYDROUS0999 NoTHEO-24 ER 400 MG CAPSULETHEOPHYLLINE ANHYDROUS0999 NoTHEOPHYLLINE 80 MG/15 ML SOLNTHEOPHYLLINE

4 ANHYDROUS0999 NoTHEOPHYLLINE ER 100 MG TABLETTHEOPHYLLINE ANHYDROUS0999 NoTHEOPHYLLINE ER 200 MG TABLETTHEOPHYLLINE ANHYDROUS0999 NoTHEOPHYLLINE ER 300 MG TABTHEOPHYLLINE ANHYDROUS0999 NoTHEOPHYLLINE ER 400 MG TABLETTHEOPHYLLINE ANHYDROUS0999 NoTHEOPHYLLINE ER 450 MG TABTHEOPHYLLINE ANHYDROUS0999 NoTHEOPHYLLINE ER 600 MG TABLETTHEOPHYLLINE ANHYDROUS0999 NoA1 CINOTROPIC DRUGSDOBUTAMINE 1,000 MG/250 ML D5 WDOBUTAMINE HCL IN DEXTROSE 5 %0999 NoDOBUTAMINE 250 MG/20 ML VIALDOBUTAMINE HCL0999 NoDOBUTAMINE 250 MG/250 ML-D5 WDOBUTAMINE HCL IN DEXTROSE 5 %0999 NoDOBUTAMINE 500 MG/250 ML D5 WDOBUTAMINE HCL IN DEXTROSE 5 %0999 NoMILRINONE LACT 10 MG/10 ML VLMILRINONE LACTATE0999 NoMILRINONE LACT 20 MG/20 ML VLMILRINONE LACTATE0999 NoMILRINONE LACT 50 MG/50 ML VLMILRINONE LACTATE0999 NoMILRINONE-D5W 20 MG/100 MLMILRINONE LACTATE/D5W0999 NoMILRINONE-D5W 40 MG/200 MLMILRINONE LACTATE/D5W0999 NoA2 AANTIARRHYTHMICSAMIODARONE HCL 100 MG TABLETAMIODARONE HCL0999 NoAMIODARONE HCL 200 MG TABLETAMIODARONE HCL0999 NoPage 2 of 145 HIC3 HIC3 DESCRIPTIONLABEL NAMEG eneric nameMEDICAID MIN AGEMEDICAID MAX AGECLINICAL PA REQUIREDA2

5 AANTIARRHYTHMICSDOFETILIDE 125 MCG CAPSULEDOFETILIDE0999 Requires Med Cert 3 DOFETILIDE 250 MCG CAPSULEDOFETILIDE0999 Requires Med Cert 3 DOFETILIDE 500 MCG CAPSULEDOFETILIDE0999 Requires Med Cert 3 FLECAINIDE ACETATE 100 MG TABFLECAINIDE ACETATE0999 NoFLECAINIDE ACETATE 150 MG TABFLECAINIDE ACETATE0999 NoFLECAINIDE ACETATE 50 MG TABFLECAINIDE ACETATE0999 NoMEXILETINE 150 MG CAPSULEMEXILETINE HCL0999 NoMEXILETINE 200 MG CAPSULEMEXILETINE HCL0999 NoMEXILETINE 250 MG CAPSULEMEXILETINE HCL0999 NoPROPAFENONE HCL 150 MG TABLETPROPAFENONE HCL0999 NoPROPAFENONE HCL 225 MG TABPROPAFENONE HCL0999 NoPROPAFENONE HCL 300 MG TABPROPAFENONE HCL0999 NoQUINIDINE SULFATE 200 MG TABQUINIDINE SULFATE0999 NoQUINIDINE SULFATE 300 MG TABQUINIDINE SULFATE0999 NoA2 CANTIANGINAL, ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMICRANOLAZINE ER 1,000 MG TABLETRANOLAZINE0999 NoRANOLAZINE ER 500 MG TABLETRANOLAZINE0999 NoA4 AANTIHYPERTENSIVES, VASODILATORSHYDRALAZINE 10 MG TABLETHYDRALAZINE HCL0999 NoHYDRALAZINE 100 MG TABLETHYDRALAZINE HCL0999 NoHYDRALAZINE 25 MG TABLETHYDRALAZINE HCL0999 NoHYDRALAZINE 50 MG TABLETHYDRALAZINE HCL0999 NoMINOXIDIL 10 MG TABLETMINOXIDIL0999 NoMINOXIDIL MG TABLETMINOXIDIL0999 NoA4 BANTIHYPERTENSIVES.

6 SYMPATHOLYTICCLONIDINE MG/DAY PATCHCLONIDINE0999 NoCLONIDINE MG/DAY PATCHCLONIDINE0999 NoCLONIDINE MG/DAY PATCHCLONIDINE0999 NoCLONIDINE HCL MG TABLETCLONIDINE HCL0999 NoCLONIDINE HCL MG TABLETCLONIDINE HCL0999 NoCLONIDINE HCL MG TABLETCLONIDINE HCL0999 NoGUANFACINE 1 MG TABLETGUANFACINE HCL0999 NoPage 3 of 145 HIC3 HIC3 DESCRIPTIONLABEL NAMEG eneric nameMEDICAID MIN AGEMEDICAID MAX AGECLINICAL PA REQUIREDA4 BANTIHYPERTENSIVES, SYMPATHOLYTICGUANFACINE 2 MG TABLETGUANFACINE HCL0999 NoMETHYLDOPA 250 MG TABLETMETHYLDOPA0999 NoMETHYLDOPA 500 MG TABLETMETHYLDOPA0999 NoA4 DANTIHYPERTENSIVES, ACE INHIBITORSBENAZEPRIL HCL 10 MG TABLETBENAZEPRIL HCL0999 NoBENAZEPRIL HCL 20 MG TABLETBENAZEPRIL HCL0999 NoBENAZEPRIL HCL 40 MG TABLETBENAZEPRIL HCL0999 NoBENAZEPRIL HCL 5 MG TABLETBENAZEPRIL HCL0999 NoENALAPRIL MALEATE 10 MG TABENALAPRIL MALEATE0999 NoENALAPRIL MALEATE MG TABENALAPRIL MALEATE0999 NoENALAPRIL MALEATE 20 MG TABENALAPRIL MALEATE0999 NoENALAPRIL MALEATE 5 MG TABLETENALAPRIL MALEATE0999 NoFOSINOPRIL SODIUM 10 MG TABFOSINOPRIL SODIUM0999 NoFOSINOPRIL SODIUM 20 MG TABFOSINOPRIL SODIUM0999 NoFOSINOPRIL SODIUM 40 MG TABFOSINOPRIL SODIUM0999 NoLISINOPRIL 10 MG TABLETLISINOPRIL0999 NoLISINOPRIL MG TABLETLISINOPRIL0999 NoLISINOPRIL 20 MG TABLETLISINOPRIL0999 NoLISINOPRIL 30 MG TABLETLISINOPRIL0999 NoLISINOPRIL

7 40 MG TABLETLISINOPRIL0999 NoLISINOPRIL 5 MG TABLETLISINOPRIL0999 NoQUINAPRIL 10 MG TABLETQUINAPRIL HCL0999 NoQUINAPRIL 20 MG TABLETQUINAPRIL HCL0999 NoQUINAPRIL 40 MG TABLETQUINAPRIL HCL0999 NoQUINAPRIL 5 MG TABLETQUINAPRIL HCL0999 NoRAMIPRIL MG CAPSULERAMIPRIL0999 NoRAMIPRIL 10 MG CAPSULERAMIPRIL0999 NoRAMIPRIL MG CAPSULERAMIPRIL0999 NoRAMIPRIL 5 MG CAPSULERAMIPRIL0999 NoA4 FANTIHYPERTENSIVES, angiotensin RECEPTOR ANTAGONISTIRBESARTAN 150 MG TABLETIRBESARTAN0999 NoPage 4 of 145 HIC3 HIC3 DESCRIPTIONLABEL NAMEG eneric nameMEDICAID MIN AGEMEDICAID MAX AGECLINICAL PA REQUIREDA4 FANTIHYPERTENSIVES, angiotensin RECEPTOR ANTAGONISTIRBESARTAN 300 MG TABLETIRBESARTAN0999 NoIRBESARTAN 75 MG TABLETIRBESARTAN0999 NoLOSARTAN POTASSIUM 100 MG TABLOSARTAN POTASSIUM0999 NoLOSARTAN POTASSIUM 25 MG TABLOSARTAN POTASSIUM0999 NoLOSARTAN POTASSIUM 50 MG TABLOSARTAN POTASSIUM0999 NoOLMESARTAN MEDOXOMIL 20 MG TABOLMESARTAN MEDOXOMIL0999 NoOLMESARTAN MEDOXOMIL 40 MG TABOLMESARTAN MEDOXOMIL0999 NoOLMESARTAN MEDOXOMIL 5 MG TABOLMESARTAN MEDOXOMIL0999 NoA4 HANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKRAMLODIPINE-OLMESARTAN 10-20 MGAMLODIPINE BES/OLMESARTAN MED0999 NoAMLODIPINE-OLMESARTAN 10-40 MGAMLODIPINE BES/OLMESARTAN MED0999 NoAMLODIPINE-OLMESARTAN 5-20 MGAMLODIPINE BES/OLMESARTAN MED0999 NoAMLODIPINE-OLMESARTAN 5-40 MGAMLODIPINE

8 BES/OLMESARTAN MED0999 NoAMLODIPINE-VALSARTAN 10-160 MGAMLODIPINE BESYLATE/VALSARTAN0999 NoAMLODIPINE-VALSARTAN 10-320 MGAMLODIPINE BESYLATE/VALSARTAN0999 NoAMLODIPINE-VALSARTAN 5-160 MGAMLODIPINE BESYLATE/VALSARTAN0999 NoAMLODIPINE-VALSARTAN 5-320 MGAMLODIPINE BESYLATE/VALSARTAN0999 NoA4 IANGIOTENSIN RECEPTOR DIURETIC COMBIRBESARTAN-HCTZ MG TBIRBESARTAN/HYDROCHLOROTHIAZIDE0999 NoIRBESARTAN-HCTZ MG TBIRBESARTAN/HYDROCHLOROTHIAZIDE0999 NoLOSARTAN-HCTZ MG TABLOSARTAN/HYDROCHLOROTHIAZIDE0999 NoLOSARTAN-HCTZ 100-25 MG TABLOSARTAN/HYDROCHLOROTHIAZIDE0999 NoLOSARTAN-HCTZ MG TABLOSARTAN/HYDROCHLOROTHIAZIDE0999 NoOLMESARTAN-HCTZ MG TABOLMESARTAN/HYDROCHLOROTHIAZIDE0999 NoOLMESARTAN-HCTZ MG TABOLMESARTAN/HYDROCHLOROTHIAZIDE0999 NoOLMESARTAN-HCTZ 40-25 MG TABOLMESARTAN/HYDROCHLOROTHIAZIDE0999 NoA4 JACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETICENALAPRIL-HCTZ 10-25 MG TABLETENALAPRIL/HYDROCHLOROTHIAZIDE0999 NoENALAPRIL-HCTZ MG TABENALAPRIL/HYDROCHLOROTHIAZIDE0999 NoLISINOPRIL-HCTZ MG TABLISINOPRIL/HYDROCHLOROTHIAZIDE0999 NoLISINOPRIL-HCTZ MG TABLISINOPRIL/HYDROCHLOROTHIAZIDE0999 NoLISINOPRIL-HCTZ 20-25 MG TABLISINOPRIL/HYDROCHLOROTHIAZIDE0999 NoPage 5 of 145 HIC3 HIC3 DESCRIPTIONLABEL NAMEG eneric nameMEDICAID MIN AGEMEDICAID MAX AGECLINICAL PA REQUIREDA4 JACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETICQUINAPRIL-HCTZ MG TABQUINAPRIL/HYDROCHLOROTHIAZIDE0999 NoQUINAPRIL-HCTZ MG

9 TABQUINAPRIL/HYDROCHLOROTHIAZIDE0999 NoQUINAPRIL-HCTZ 20-25 MG TABQUINAPRIL/HYDROCHLOROTHIAZIDE0999 NoA4 KACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATIONAMLODIPINE-BENAZEPRIL 10-20 MGAMLODIPINE BESYLATE/BENAZEPRIL0999 NoAMLODIPINE-BENAZEPRIL 10-40 MGAMLODIPINE BESYLATE/BENAZEPRIL0999 NoAMLODIPINE-BENAZEPRIL BESYLATE/BENAZEPRIL0999 NoAMLODIPINE-BENAZEPRIL 5-10 MGAMLODIPINE BESYLATE/BENAZEPRIL0999 NoAMLODIPINE-BENAZEPRIL 5-20 MGAMLODIPINE BESYLATE/BENAZEPRIL0999 NoAMLODIPINE-BENAZEPRIL 5-40 MGAMLODIPINE BESYLATE/BENAZEPRIL0999 NoA4 LANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI)ENTRESTO 24 MG-26 MG TABLETSACUBITRIL/VALSARTAN0999 NoENTRESTO 49 MG-51 MG TABLETSACUBITRIL/VALSARTAN0999 NoENTRESTO 97 MG-103 MG TABLETSACUBITRIL/VALSARTAN0999 NoA7 BVASODILATORS.

10 CORONARYISOSORBIDE DINITRATE 10 MG TABISOSORBIDE DINITRATE0999 NoISOSORBIDE DINITRATE 20 MG TABISOSORBIDE DINITRATE0999 NoISOSORBIDE DINITRATE 30 MG TABISOSORBIDE DINITRATE0999 NoISOSORBIDE DINITRATE 40 MG TABISOSORBIDE DINITRATE0999 NoISOSORBIDE DINITRATE 5 MG TABISOSORBIDE DINITRATE0999 NoISOSORBIDE MONONIT 10 MG TABISOSORBIDE MONONITRATE0999 NoISOSORBIDE MONONIT 20 MG TABISOSORBIDE MONONITRATE0999 NoISOSORBIDE MONONIT ER 120 MGISOSORBIDE MONONITRATE0999 NoISOSORBIDE MONONIT ER 30 MG TBISOSORBIDE MONONITRATE0999 NoISOSORBIDE MONONIT ER 60 MG TBISOSORBIDE MONONITRATE0999 NoNITROGLYCERIN MG/HR PATCHNITROGLYCERIN0999 NoNITROGLYCERIN MG/HR PATCHNITROGLYCERIN0999 NoNITROGLYCERIN MG TABLET SLNITROGLYCERIN0999 NoNITROGLYCERIN MG TABLET SLNITROGLYCERIN0999 NoNITROGLYCERIN MG/HR PATCHNITROGLYCERIN0999 NoNITROGLYCERIN MG TABLET SLNITROGLYCERIN0999 NoNITROGLYCERIN MG/HR PATCHNITROGLYCERIN0999 NoPage 6 of 145 HIC3 HIC3 DESCRIPTIONLABEL NAMEG eneric nameMEDICAID MIN AGEMEDICAID MAX AGECLINICAL PA REQUIREDA7 MBRADYKININ B2 RECEPTOR ANTAGONISTSFIRAZYR 30 MG/3 ML SYRINGEICATIBANT ACETATE18999 Auto PAA9 ACALCIUM CHANNEL BLOCKING AGENTSAMLODIPINE BESYLATE 10 MG TABAMLODIPINE BESYLATE0999 NoAMLODIPINE BESYLATE MG TABAMLODIPINE BESYLATE0999 NoAMLODIPINE BESYLATE 5 MG TABAMLODIPINE BESYLATE0999 NoDILTIAZEM 120 MG TABLETDILTIAZEM HCL0999 NoDILTIAZEM 12HR ER 120 MG CAPDILTIAZEM HCL0999 NoDILTIAZEM 12HR ER 60 MG CAPDILTIAZEM HCL0999