Florida Medicaid Preferred Drug List (updated 1 08-2018) T ...

1 Florida Medicaid Preferred drug List ( updated 06-10-2020)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 May 8, l ist 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 = Syste m automated criteri a look s for specific requirements ( , diagnosis, age, previous therapies, etc.). If all requirements are found, the claims will pay at the pharmacy counter without need of manual prior authorization submission. Clinical PA Required = These drug s require prior authorization submission that mus t inclu de clin ical documentation.

2 The drugs that require clinical prior authorization review and the prior authorization forms can be found in this link: Cysti c Fib Diag Auto PA = Claims for these products will pay at the pharmacy coun ter if the diagnosis of cystic fibros is is fou nd in the system. Requires Med Cert 3 = The Food and drug Administration (FDA ) requir es participation (by prescribers, pharmacies, and/or patients) in certification, education, training, or agreements prior to dispensing certain drugs. By entering certification code 3 , the dispensing pharmacy is confirming that FDA requirements were PA in Process:-Nayzilam nasalThursday, June 4, 2020 Page 1 of 187 ClassGeneric NameMedicaid Min AgeMedicaid Max AgeLabel NameClinical PA RequiredA1 ADIGITALIS GLYCOSIDESA1 ADIGOXIN0999 DIGOXIN MG TABLETNoA1 ADIGOXIN0999 DIGOXIN MG TABLETNoA1 ADIGOXIN0999 DIGOXIN 125 MCG TABLETNoA1 ADIGOXIN0999 DIGOXIN 250 MCG TABLETNoA1 ADIGOXIN0999 DIGOXIN MG/ML SOLUTIONNoA1 BXANTHINESA1 BCAFFEINE CITRATE1999 CAFFEINE CIT 60 MG/3 ML ORALNoA1 BCAFFEINE CITRATE1999 CAFFEINE CIT 60 MG/3 ML VIALNoA1 BTHEOPHYLLINE ANHYDROUS0999 THEO-24 ER 300 MG CAPSULENoA1 BTHEOPHYLLINE ANHYDROUS0999 THEOPHYLLINE ER 450 MG TABNoA1 BTHEOPHYLLINE ANHYDROUS0999 THEOPHYLLINE ER 300 MG TABNoA1 BTHEOPHYLLINE ANHYDROUS0999 THEOPHYLLINE ER 200 MG TABLETNoA1 BTHEOPHYLLINE ANHYDROUS0999 THEOPHYLLINE ER 100 MG TABLETNoA1 BTHEOPHYLLINE ANHYDROUS0999 THEOPHYLLINE ER 600 MG TABLETNoA1 BTHEOPHYLLINE ANHYDROUS0999 THEOPHYLLINE ER 400 MG TABLETNoA1 BTHEOPHYLLINE ANHYDROUS0999 THEO-24 ER 400 MG CAPSULENoA1 BTHEOPHYLLINE ANHYDROUS0999 THEO-24 ER 200 MG CAPSULENoA1

3 BTHEOPHYLLINE ANHYDROUS0999 THEO-24 ER 100 MG CAPSULENoA1 BTHEOPHYLLINE ANHYDROUS0999 THEOPHYLLINE 80 MG/15 ML SOLNNoThursday, June 4, 2020 Page 2 of 187 ClassGeneric NameMedicaid Min AgeMedicaid Max AgeLabel NameClinical PA RequiredA1 CINOTROPIC DRUGSA1 CDOBUTAMINE HCL0999 DOBUTAMINE 250 MG/20 ML VIALNoA1 CDOBUTAMINE HCL0999 DOBUTAMINE MG/ML VIALNoA1 CDOBUTAMINE HCL IN DEXTROSE 5 %0999 DOBUTAMINE 500 MG/250 ML D5 WNoA1 CDOBUTAMINE HCL IN DEXTROSE 5 %0999 DOBUTAMINE 1,000 MG/250 ML D5 WNoA1 CDOBUTAMINE HCL IN DEXTROSE 5 %0999 DOBUTAMINE 250 MG/250 ML-D5 WNoA1 CMILRINONE LACTATE0999 MILRINONE LACT 10 MG/10 ML VLNoA1 CMILRINONE LACTATE0999 MILRINONE LACT 20 MG/20 ML VLNoA1 CMILRINONE LACTATE0999 MILRINONE LACT 50 MG/50 ML VLNoA1 CMILRINONE LACTATE/D5W0999 MILRINONE-D5W 20 MG/100 MLNoA1 CMILRINONE LACTATE/D5W0999 MILRINONE-D5W 40 MG/200 MLNoA2 AANTIARRHYTHMICSA2 AAMIODARONE HCL0999 AMIODARONE HCL 200 MG TABLETNoA2 AAMIODARONE HCL0999 AMIODARONE HCL 100 MG TABLETNoA2 ADOFETILIDE0999 DOFETILIDE 500 MCG CAPSULER equires Med Cert 3A2 ADOFETILIDE0999 DOFETILIDE 125 MCG CAPSULER equires Med Cert 3A2 ADOFETILIDE0999 DOFETILIDE 250 MCG CAPSULER equires Med Cert 3A2 AFLECAINIDE ACETATE0999 FLECAINIDE ACETATE 100 MG TABNoA2 AFLECAINIDE ACETATE0999 FLECAINIDE ACETATE 150 MG TABNoA2 AFLECAINIDE ACETATE0999 FLECAINIDE ACETATE 50 MG TABNoA2 AMEXILETINE HCL0999 MEXILETINE 150 MG CAPSULENoA2 AMEXILETINE HCL0999 MEXILETINE 200 MG CAPSULENoA2 AMEXILETINE HCL0999

4 MEXILETINE 250 MG CAPSULENoA2 APROPAFENONE HCL0999 PROPAFENONE HCL 150 MG TABLETNoThursday, June 4, 2020 Page 3 of 187 ClassGeneric NameMedicaid Min AgeMedicaid Max AgeLabel NameClinical PA RequiredA2 APROPAFENONE HCL0999 PROPAFENONE HCL 300 MG TABNoA2 APROPAFENONE HCL0999 PROPAFENONE HCL 225 MG TABNoA2 AQUINIDINE SULFATE0999 QUINIDINE SULFATE 200 MG TABNoA2 AQUINIDINE SULFATE0999 QUINIDINE SULFATE 300 MG TABNoA2 CANTIANGINAL, ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMICA2 CRANOLAZINE0999 RANEXA ER 1,000 MG TABLETNoA2 CRANOLAZINE0999 RANEXA ER 500 MG TABLETNoA4 AANTIHYPERTENSIVES, VASODILATORSA4 AHYDRALAZINE HCL0999 HYDRALAZINE 50 MG TABLETNoA4 AHYDRALAZINE HCL0999 HYDRALAZINE 10 MG TABLETNoA4 AHYDRALAZINE HCL0999 HYDRALAZINE 100 MG TABLETNoA4 AHYDRALAZINE HCL0999 HYDRALAZINE 25 MG TABLETNoA4 AMINOXIDIL0999 MINOXIDIL 10 MG TABLETNoA4 AMINOXIDIL0999 MINOXIDIL MG TABLETNoA4 BANTIHYPERTENSIVES, SYMPATHOLYTICA4 BCLONIDINE0999 CATAPRES-TTS 1 PATCHNoA4 BCLONIDINE0999 CATAPRES-TTS 2 PATCHNoA4 BCLONIDINE0999 CATAPRES-TTS 3 PATCHNoA4 BCLONIDINE HCL0999 CLONIDINE HCL MG TABLETNoA4 BCLONIDINE HCL0999 CLONIDINE HCL MG TABLETNoA4 BCLONIDINE HCL0999 CLONIDINE HCL MG TABLETNoA4 BGUANFACINE HCL0999 GUANFACINE 2 MG TABLETNoA4 BGUANFACINE HCL0999 GUANFACINE 1 MG TABLETNoA4 BMETHYLDOPA0999 METHYLDOPA 250 MG TABLETNoA4 BMETHYLDOPA0999 METHYLDOPA 500 MG TABLETNoThursday, June 4, 2020 Page 4 of 187 ClassGeneric NameMedicaid Min AgeMedicaid Max AgeLabel NameClinical PA RequiredA4 DANTIHYPERTENSIVES.

5 ACE INHIBITORSA4 DBENAZEPRIL HCL0999 BENAZEPRIL HCL 10 MG TABLETNoA4 DBENAZEPRIL HCL0999 BENAZEPRIL HCL 20 MG TABLETNoA4 DBENAZEPRIL HCL0999 BENAZEPRIL HCL 40 MG TABLETNoA4 DBENAZEPRIL HCL0999 BENAZEPRIL HCL 5 MG TABLETNoA4 DENALAPRIL MALEATE0999 ENALAPRIL MALEATE 5 MG TABLETNoA4 DENALAPRIL MALEATE0999 ENALAPRIL MALEATE 10 MG TABNoA4 DENALAPRIL MALEATE0999 ENALAPRIL MALEATE MG TABNoA4 DENALAPRIL MALEATE0999 ENALAPRIL MALEATE 20 MG TABNoA4 DFOSINOPRIL SODIUM0999 FOSINOPRIL SODIUM 40 MG TABNoA4 DFOSINOPRIL SODIUM0999 FOSINOPRIL SODIUM 10 MG TABNoA4 DFOSINOPRIL SODIUM0999 FOSINOPRIL SODIUM 20 MG TABNoA4 DLISINOPRIL0999 LISINOPRIL 5 MG TABLETNoA4 DLISINOPRIL0999 LISINOPRIL 10 MG TABLETNoA4 DLISINOPRIL0999 LISINOPRIL MG TABLETNoA4 DLISINOPRIL0999 LISINOPRIL 20 MG TABLETNoA4 DLISINOPRIL0999 LISINOPRIL 30 MG TABLETNoA4 DLISINOPRIL0999 LISINOPRIL 40 MG TABLETNoA4 DQUINAPRIL HCL0999 QUINAPRIL 5 MG TABLETNoA4 DQUINAPRIL HCL0999 QUINAPRIL 40 MG TABLETNoA4 DQUINAPRIL HCL0999 QUINAPRIL 20 MG TABLETNoA4 DQUINAPRIL HCL0999 QUINAPRIL 10 MG TABLETNoA4 DRAMIPRIL0999 RAMIPRIL MG CAPSULENoA4 DRAMIPRIL0999 RAMIPRIL 10 MG CAPSULENoThursday, June 4, 2020 Page 5 of 187 ClassGeneric NameMedicaid Min AgeMedicaid Max AgeLabel NameClinical PA RequiredA4 DRAMIPRIL0999 RAMIPRIL MG CAPSULENoA4 DRAMIPRIL0999 RAMIPRIL 5 MG CAPSULENoA4 FANTIHYPERTENSIVES.

6 ANGIOTENSIN RECEPTOR ANTAGONISTA4 FIRBESARTAN0999 IRBESARTAN 150 MG TABLETNoA4 FIRBESARTAN0999 IRBESARTAN 300 MG TABLETNoA4 FIRBESARTAN0999 IRBESARTAN 75 MG TABLETNoA4 FLOSARTAN POTASSIUM0999 LOSARTAN POTASSIUM 100 MG TABNoA4 FLOSARTAN POTASSIUM0999 LOSARTAN POTASSIUM 25 MG TABNoA4 FLOSARTAN POTASSIUM0999 LOSARTAN POTASSIUM 50 MG TABNoA4 FOLMESARTAN MEDOXOMIL0999 OLMESARTAN MEDOXOMIL 20 MG TABNoA4 FOLMESARTAN MEDOXOMIL0999 OLMESARTAN MEDOXOMIL 40 MG TABNoA4 FOLMESARTAN MEDOXOMIL0999 OLMESARTAN MEDOXOMIL 5 MG TABNoA4 HANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKRA4 HAMLODIPINE BES/OLMESARTAN MED0999 AMLODIPINE-OLMESARTAN 10-20 MGNoA4 HAMLODIPINE BES/OLMESARTAN MED0999 AMLODIPINE-OLMESARTAN 10-40 MGNoA4 HAMLODIPINE BES/OLMESARTAN MED0999 AMLODIPINE-OLMESARTAN 5-20 MGNoA4 HAMLODIPINE BES/OLMESARTAN MED0999 AMLODIPINE-OLMESARTAN 5-40 MGNoA4 HAMLODIPINE BESYLATE/VALSARTAN0999 AMLODIPINE-VALSARTAN 5-160 MGNoA4 HAMLODIPINE BESYLATE/VALSARTAN0999 AMLODIPINE-VALSARTAN 10-320 MGNoA4 HAMLODIPINE BESYLATE/VALSARTAN0999 AMLODIPINE-VALSARTAN 10-160 MGNoA4 HAMLODIPINE BESYLATE/VALSARTAN0999 AMLODIPINE-VALSARTAN 5-320 MGNoA4 IANGIOTENSIN RECEPTOR DIURETIC COMBA4 IIRBESARTAN/HYDROCHLOROTHIAZIDE0999 IRBESARTAN-HCTZ MG TBNoA4 IIRBESARTAN/HYDROCHLOROTHIAZIDE0999 IRBESARTAN-HCTZ MG TBNoA4 ILOSARTAN/HYDROCHLOROTHIAZIDE0999 LOSARTAN-HCTZ MG TABNoThursday, June 4.

7 2020 Page 6 of 187 ClassGeneric NameMedicaid Min AgeMedicaid Max AgeLabel NameClinical PA RequiredA4 ILOSARTAN/HYDROCHLOROTHIAZIDE0999 LOSARTAN-HCTZ 100-25 MG TABNoA4 ILOSARTAN/HYDROCHLOROTHIAZIDE0999 LOSARTAN-HCTZ MG TABNoA4 IOLMESARTAN/HYDROCHLOROTHIAZIDE0999 OLMESARTAN-HCTZ 40-25 MG TABNoA4 IOLMESARTAN/HYDROCHLOROTHIAZIDE0999 OLMESARTAN-HCTZ MG TABNoA4 IOLMESARTAN/HYDROCHLOROTHIAZIDE0999 OLMESARTAN-HCTZ MG TABNoA4 JACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETICA4 JENALAPRIL/HYDROCHLOROTHIAZIDE0999 ENALAPRIL-HCTZ 10-25 MG TABLETNoA4 JENALAPRIL/HYDROCHLOROTHIAZIDE0999 ENALAPRIL-HCTZ MG TABNoA4 JLISINOPRIL/HYDROCHLOROTHIAZIDE0999 LISINOPRIL-HCTZ MG TABNoA4 JLISINOPRIL/HYDROCHLOROTHIAZIDE0999 LISINOPRIL-HCTZ MG TABNoA4 JLISINOPRIL/HYDROCHLOROTHIAZIDE0999 LISINOPRIL-HCTZ 20-25 MG TABNoA4 JQUINAPRIL/HYDROCHLOROTHIAZIDE0999 QUINAPRIL-HCTZ 20-25 MG TABNoA4 JQUINAPRIL/HYDROCHLOROTHIAZIDE0999 QUINAPRIL-HCTZ MG TABNoA4 JQUINAPRIL/HYDROCHLOROTHIAZIDE0999 QUINAPRIL-HCTZ MG TABNoA4 KACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATIONA4 KAMLODIPINE BESYLATE/BENAZEPRIL0999 AMLODIPINE-BENAZEPRIL 5-10 MGNoA4 KAMLODIPINE BESYLATE/BENAZEPRIL0999 AMLODIPINE-BENAZEPRIL 5-20 MGNoA4 KAMLODIPINE BESYLATE/BENAZEPRIL0999 AMLODIPINE-BENAZEPRIL 5-40 MGNoA4 KAMLODIPINE BESYLATE/BENAZEPRIL0999 AMLODIPINE-BENAZEPRIL 10-20 MGNoA4 KAMLODIPINE BESYLATE/BENAZEPRIL0999 AMLODIPINE-BENAZEPRIL BESYLATE/BENAZEPRIL0999 AMLODIPINE-BENAZEPRIL 10-40 MGNoA4 LANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI)

8 A4 LSACUBITRIL/VALSARTAN0999 ENTRESTO 24 MG-26 MG TABLETNoA4 LSACUBITRIL/VALSARTAN0999 ENTRESTO 49 MG-51 MG TABLETNoA4 LSACUBITRIL/VALSARTAN0999 ENTRESTO 97 MG-103 MG TABLETNoThursday, June 4, 2020 Page 7 of 187 ClassGeneric NameMedicaid Min AgeMedicaid Max AgeLabel NameClinical PA RequiredA7 BVASODILATORS,CORONARYA7 BISOSORBIDE DINITRATE0999 ISOSORBIDE DINITRATE 40 MG TABNoA7 BISOSORBIDE DINITRATE0999 ISOSORBIDE DINITRATE 5 MG TABNoA7 BISOSORBIDE DINITRATE0999 ISOSORBIDE DINITRATE 30 MG TABNoA7 BISOSORBIDE DINITRATE0999 ISOSORBIDE DINITRATE 20 MG TABNoA7 BISOSORBIDE DINITRATE0999 ISOSORBIDE DINITRATE 10 MG TABNoA7 BISOSORBIDE MONONITRATE0999 ISOSORBIDE MONONIT 20 MG TABNoA7 BISOSORBIDE MONONITRATE0999 ISOSORBIDE MONONIT ER 120 MGNoA7 BISOSORBIDE MONONITRATE0999 ISOSORBIDE MONONIT ER 30 MG TBNoA7 BISOSORBIDE MONONITRATE0999 ISOSORBIDE MONONIT ER 60 MG TBNoA7 BISOSORBIDE MONONITRATE0999 ISOSORBIDE MONONIT 10 MG TABNoA7 BNITROGLYCERIN0999 NITROGLYCERIN MG TABLET SLNoA7 BNITROGLYCERIN0999 NITROGLYCERIN MG/HR PATCHNoA7 BNITROGLYCERIN0999 NITROGLYCERIN MG/HR PATCHNoA7 BNITROGLYCERIN0999 NITROGLYCERIN MG/HR PATCHNoA7 BNITROGLYCERIN0999 NITROGLYCERIN MG TABLET SLNoA7 BNITROGLYCERIN0999 NITROGLYCERIN MG TABLET SLNoA7 BNITROGLYCERIN0999 NITROGLYCERIN MG/HR PATCHNoA7 MBRADYKININ

9 B2 RECEPTOR ANTAGONISTSA7 MICATIBANT ACETATE18999 FIRAZYR 30 MG/3 ML SYRINGEAuto PAA9 ACALCIUM CHANNEL BLOCKING AGENTSA9 AAMLODIPINE BESYLATE0999 AMLODIPINE BESYLATE 10 MG TABNoA9 AAMLODIPINE BESYLATE0999 AMLODIPINE BESYLATE MG TABNoA9 AAMLODIPINE BESYLATE0999 AMLODIPINE BESYLATE 5 MG TABNoA9 ADILTIAZEM HCL0999 DILTIAZEM 90 MG TABLETNoThursday, June 4, 2020 Page 8 of 187 ClassGeneric NameMedicaid Min AgeMedicaid Max AgeLabel NameClinical PA RequiredA9 ADILTIAZEM HCL0999 DILTIAZEM 24H ER(CD) 180 MG CPNoA9 ADILTIAZEM HCL0999 DILTIAZEM 24H ER(CD) 240 MG CPNoA9 ADILTIAZEM HCL0999 DILTIAZEM 24H ER(CD) 300 MG CPNoA9 ADILTIAZEM HCL0999 DILTIAZEM 24H ER(CD) 360 MG CPNoA9 ADILTIAZEM HCL0999 DILTIAZEM 120 MG TABLETNoA9 ADILTIAZEM HCL0999 DILTIAZEM 60 MG TABLETNoA9 ADILTIAZEM HCL0999 DILTIAZEM 24HR ER 360 MG CAPNoA9 ADILTIAZEM HCL0999 DILTIAZEM 30 MG TABLETNoA9 ADILTIAZEM HCL0999 DILTIAZEM 24HR ER 420 MG CAPNoA9 ADILTIAZEM HCL0999 DILTIAZEM 24HR ER 300 MG CAPNoA9 ADILTIAZEM HCL0999 DILTIAZEM 24HR ER 240 MG CAPNoA9 ADILTIAZEM HCL0999 DILTIAZEM 24HR ER 180 MG CAPNoA9 ADILTIAZEM HCL0999 DILTIAZEM 24HR ER 120 MG CAPNoA9 ADILTIAZEM HCL0999 DILTIAZEM 12HR ER 90 MG CAPNoA9 ADILTIAZEM HCL0999 DILTIAZEM 12HR ER 60 MG CAPNoA9 ADILTIAZEM HCL0999 DILTIAZEM 12HR ER 120 MG CAPNoA9 ADILTIAZEM HCL0999 DILTIAZEM 24H ER(CD)

10 120 MG CPNoA9 AFELODIPINE0999 FELODIPINE ER 10 MG TABLETNoA9 AFELODIPINE0999 FELODIPINE ER MG TABLETNoA9 AFELODIPINE0999 FELODIPINE ER 5 MG TABLETNoA9 ANIFEDIPINE0999 NIFEDIPINE ER 60 MG TABLETNoA9 ANIFEDIPINE0999 NIFEDIPINE ER 90 MG TABLETNoA9 ANIFEDIPINE0999 NIFEDIPINE 20 MG CAPSULENoA9 ANIFEDIPINE0999 NIFEDIPINE 10 MG CAPSULENoThursday, June 4, 2020 Page 9 of 187 ClassGeneric NameMedicaid Min AgeMedicaid Max AgeLabel NameClinical PA RequiredA9 ANIFEDIPINE0999 NIFEDIPINE ER 30 MG TABLETNoA9 ANIMODIPINE18999 NIMODIPINE 30 MG CAPSULENoA9 AVERAPAMIL HCL0999 VERAPAMIL ER 240 MG CAPSULENoA9 AVERAPAMIL HCL0999 VERAPAMIL SR 240 MG CAPSULENoA9 AVERAPAMIL HCL0999 VERAPAMIL SR 180 MG CAPSULENoA9 AVERAPAMIL HCL0999 VERAPAMIL SR 120 MG CAPSULENoA9 AVERAPAMIL HCL0999 VERAPAMIL 80 MG TABLETNoA9 AVERAPAMIL HCL0999 VERAPAMIL 40 MG TABLETNoA9 AVERAPAMIL HCL0999 VERAPAMIL 360 MG CAP PELLETNoA9 AVERAPAMIL HCL0999 VERAPAMIL ER 240 MG TABLETNoA9 AVERAPAMIL HCL0999 VERAPAMIL ER 180 MG TABLETNoA9 AVERAPAMIL HCL0999 VERAPAMIL ER 180 MG CAPSULENoA9 AVERAPAMIL HCL0999 VERAPAMIL ER 120 MG TABLETNoA9 AVERAPAMIL HCL0999 VERAPAMIL ER 120 MG CAPSULENoA9 AVERAPAMIL HCL0999 VERAPAMIL 120 MG TABLETNoB0 AGENERAL INHALATION AGENTSB0 ASODIUM CHLORIDE FOR INHALATION0999 SODIUM CHLORIDE 10% VIALAuto PAB0 ASODIUM CHLORIDE FOR INHALATION0999 SODIUM CHLORIDE