Medicaid-Approved Preferred Drug List - MMIT

1 VA Anthem Common Core FormularyMedicaid- approved Preferred drug ListEffective February 1, 2022 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.

2 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 NameReferenceNotes*ADHD/ANTI-NARCOLEPSY/ ANTI-OBESITY/ANOREXIANTS**ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS**clonidine hcl er oral tablet extended release 12 hourKapvayguanfacine hcl er oral tablet extended release 24 hourIntunivAL*ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR**atomoxetine hcl oral capsuleStratteraAL; QL*AMPHETAMINE MIXTURES**ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOURPA; ALamphetamine-dextroamphetamine oral tabletAdderallAL*AMPHETAMINES**dextroamp hetamine sulfate oral tablet 10 mg, 5 mgZenzediALdextroamphetamine sulfate oral tablet 15 mg, 20 mg, 30 mgZenzediPA.

3 ALVYVANSE ORAL CAPSULEALVYVANSE ORAL TABLET CHEWABLEAL*ANALEPTICS**caffeine citrate intravenous solutionCafcitcaffeine citrate oral solution*STIMULANTS - MISC.**CONCERTA ORAL TABLET EXTENDED RELEASEALDAYTRANA TRANSDERMAL PATCHALFOCALIN ORAL TABLETALFOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOURAL methylphenidate hcl oral tabletRitalinAL*ALTERNATIVE MEDICINES**ALTERNATIVE MEDICINE - KR'S**krill oil oral capsuleSM MegaKrillOTCmaximum red krill oral capsuleSM MegaKrillOTC2 drug NameReferenceNotesomega-3 krill oil oral capsuleSM MegaKrillOTCSM MEGAKRILL ORAL CAPSULEOTC*ALTERNATIVE MEDICINE - ME'S**cvs melatonin extra strength oral liquidOTC; QLcvs melatonin gummies oral tablet chewableVitaJoy GummiesOTC; QLcvs melatonin oral capsuleOTC; QLcvs melatonin oral liquidOTC; QLcvs melatonin oral tabletOTC.

4 QLcvs melatonin oral tablet dispersibleOTCcvs melatonin sublingual tablet sublingual 10 mgOTCcvs melatonin sublingual tablet sublingual 5 mgOTC; QLcvs quality sleep oral capsuleOTC; QLgnp melatonin maximum strength oral tabletOTC; QLgnp melatonin oral tabletOTC; QLgnp melatonin oral tablet chewableVitaJoy GummiesOTC; QLgnp melatonin oral tablet extended releaseOTCgnp melatonin sublingual tablet sublingualOTChm melatonin oral tablet extended releaseOTChm melatonin quick dissolve oral tablet dispersibleOTChm melatonin sublingual tablet sublingualOTCkp melatonin oral tabletOTC; QLmax melatonin oral tablet dispersibleOTCmelatonin childrens oral tablet chewableZarbees Sleep Child/MelatoninOTC; QLmelatonin er oral tablet extended releaseOTCmelatonin extra strength oral liquidOTC; QLmelatonin extra strength oral tabletOTCmelatonin gummies oral tablet chewableVitaJoy GummiesOTC; QLmelatonin maximum strength oral tablet 10 mgOTCmelatonin maximum strength oral tablet 5 mgOTC; QLmelatonin oral capsuleOTC; QLmelatonin oral liquidZarbees Sleep Child/MelatoninOTC3 drug NameReferenceNotesmelatonin oral tablet 1 mg, 3 mg, 300 mcg, 5 mgOTC; QLmelatonin oral tablet 10 mgOTCmelatonin oral tablet chewableVitaJoy GummiesOTC; QLmelatonin oral tablet dispersible 10 mgOTCmelatonin oral tablet dispersible 12 mgOTCmelatonin oral tablet dispersible 3 mg, 5 mgOTC.

5 QLmelatonin quick dissolve sublingual tablet sublingualOTCmelatonin sublingual tablet sublingual 10 mgOTCmelatonin sublingual tablet sublingual 5 mgOTC; QLmelatonin tr oral tablet extended releaseOTCmm melatonin oral tablet extended releaseOTCqc melatonin max st oral tabletOTC; QLra melatonin oral tablet 10 mgOTCra melatonin oral tablet 3 mg, 5 mgOTC; QLsm melatonin oral tabletOTC; QLsm melatonin oral tablet dispersibleOTC; QLsv melatonin oral tabletOTC; QLsv melatonin oral tablet dispersibleOTC; QLVITAJOY GUMMIES ORAL TABLET CHEWABLEOTC; QLZARBEES SLEEP CHILD/MELATONIN ORAL LIQUIDOTC*ALTERNATIVE MEDICINE COMBINATIONS - THREE INGREDIENTS**flax + dha oral capsuleSuper Omega-3 OTComega 3-6-9 complex oral capsuleSuper Omega-3 OTComega 3-6-9 oral capsuleSuper Omega-3 OTComega-3-6-9 oral capsuleSuper Omega-3 OTCra omega 3-6-9 oral capsuleSuper Omega-3 OTCsm omega-3 oral capsuleSuper Omega-3 OTCsm omega-3-6-9 fatty acids oral capsuleSuper Omega-3 OTCSUPER OMEGA-3 ORAL CAPSULEOTC triple omega-3-6-9 oral capsuleSuper Omega-3 OTC4 drug NameReferenceNotes*ALTERNATIVE MEDICINE COMBINATIONS - TWO INGREDIENTS**eql glucosamine chondroitin oral tabletOTCglucosamine-chondroitin oral tabletOTCkp glucosamine chondroitin oral tabletOTCra

6 Glucosamine-chondroitin oral tabletOTC*AMINOGLYCOSIDES**AMINOGLYCOSID ES**BETHKIS INHALATION NEBULIZATION SOLUTIONSP; AL; QLKITABIS PAK INHALATION NEBULIZATION SOLUTIONSP; AL; QLTOBI PODHALER INHALATION CAPSULEPA; SP; QL*ANALGESICS - ANTI-INFLAMMATORY**ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES**HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KITSP; ALHUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KITSP; ALHUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KITSP; ALHUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS PEN-INJECTOR KITSP; ALHUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KITSP; ALHUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PEN-INJECTOR KITSP; ALHUMIRA SUBCUTANEOUS PREFILLED SYRINGE KITSP; AL*GOLD COMPOUNDS**RIDAURA ORAL CAPSULE*NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)**ADVIL JUNIOR STRENGTH ORAL TABLETPA; OTC5 drug NameReferenceNotesADVIL LIQUI-GELS MINIS ORAL CAPSULEPA.

7 OTCall day pain relief oral tabletMediproxenOTCall day relief oral tabletMediproxenOTCchildrens ibuprofen 100 oral suspensionChildrens Medi-ProfenOTCchildrens ibuprofen oral suspensionChildrens Medi-ProfenOTCCHILDRENS MEDI-PROFEN ORAL SUSPENSIONOTCcvs all day pain relief oral tabletMediproxenOTCcvs childrens ibuprofen oral suspensionChildrens Medi-ProfenOTCcvs ibuprofen childrens oral suspensionChildrens Medi-ProfenOTCcvs ibuprofen infants oral suspensionMedi-ProfenOTC; QLcvs ibuprofen oral capsuleAdvil Liqui-Gels minisOTCcvs ibuprofen oral tabletMedi-ProfenOTC; QLcvs naproxen sodium oral capsuleAleveOTCcvs naproxen sodium oral tabletMediproxenOTCdiclofenac sodium oral tablet delayed releaseec-naproxen oral tablet delayed releaseEC-Naprosyneq all day pain relief oral tabletMediproxenOTCeq ibuprofen childrens oral suspensionChildrens Medi-ProfenOTCeq ibuprofen oral capsuleAdvil Liqui-Gels minisOTCeq ibuprofen oral tabletMedi-ProfenOTC; QLeq naproxen sodium oral capsuleAleveOTCeq naproxen sodium oral tabletMediproxenOTCeql childrens ibuprofen oral suspensionChildrens Medi-ProfenOTCeql ibuprofen infants oral suspensionMedi-ProfenOTC; QLeql ibuprofen oral capsuleAdvil Liqui-Gels minisOTCeql ibuprofen oral tabletMedi-ProfenOTC.

8 QLeql naproxen sodium oral tabletMediproxenOTCgnp childrens ibuprofen oral suspensionChildrens Medi-ProfenOTCgnp ibuprofen infants oral suspensionMedi-ProfenOTC; QLgnp ibuprofen oral capsuleAdvil Liqui-Gels minisOTCgnp ibuprofen oral tabletMedi-ProfenOTC; QLgnp naproxen sodium oral capsuleAleveOTCgnp naproxen sodium oral tabletMediproxenOTCgoodsense ibuprofen childrens oral suspensionChildrens Medi-ProfenOTC6 drug NameReferenceNotesgoodsense ibuprofen infants oral suspensionMedi-ProfenOTC; QLgoodsense ibuprofen oral capsuleAdvil Liqui-Gels minisOTCgoodsense ibuprofen oral tabletMedi-ProfenOTC; QLgoodsense naproxen sodium oral tabletMediproxenOTChm ibuprofen childrens oral suspensionChildrens Medi-ProfenOTChm ibuprofen ib oral tabletMedi-ProfenOTC; QLhm ibuprofen infants oral suspensionMedi-ProfenOTC; QLhm ibuprofen oral capsuleAdvil Liqui-Gels minisOTChm ibuprofen oral tabletMedi-ProfenOTC; QLhm naproxen sodium oral capsuleAleveOTChm naproxen sodium oral tabletMediproxenOTChy-vee all day relief oral tabletMediproxenOTCHYVEE IBUPROFEN CHILDRENS ORAL SUSPENSIONOTCIBU ORAL TABLETibu-200 oral tabletMedi-ProfenOTC; QLibuprofen childrens oral suspensionChildrens Medi-ProfenOTCibuprofen infants oral suspensionMedi-ProfenOTC.

9 QLibuprofen oral capsuleAdvil Liqui-Gels minisOTCibuprofen oral suspensionChildrens Medi-ProfenQLibuprofen oral tablet 200 mgMedi-ProfenOTC; QLibuprofen oral tablet 400 mg, 600 mg, 800 mgIBUindomethacin sodium intravenous solution reconstitutedPAinfants ibuprofen oral suspensionMedi-ProfenOTC; QLkls ibuprofen ib oral tabletMedi-ProfenOTC; QLkls ibuprofen oral tabletMedi-ProfenOTC; QLMEDI-PROFEN ORAL CAPSULEOTCMEDI-PROFEN ORAL SUSPENSIONOTC; QLMEDI-PROFEN ORAL TABLETOTC; QLMEDIPROXEN ORAL TABLETOTC meijer ibuprofen oral tabletMedi-ProfenOTC; QLmeloxicam oral tabletMobicMOTRIN IB ORAL CAPSULEOTCMOTRIN IB ORAL TABLETOTC; QLnaproxen oral tabletNaprosynnaproxen oral tablet delayed releaseEC-Naprosyn7 drug NameReferenceNotesnaproxen sodium oral capsuleAleveOTCnaproxen sodium oral tablet 220 mgMediproxenOTCnaproxen sodium oral tablet 550 mgAnaprox DSPAPAMPRIN ALL DAY RELIEF MAX ST ORAL TABLETOTCpx all day relief oral tabletMediproxenOTCpx childrens profen ib oral suspensionChildrens Medi-ProfenOTCpx ibuprofen oral tabletMedi-ProfenOTC; QLpx infants profen ib oral suspensionMedi-ProfenOTC; QLqc childrens ibuprofen oral suspensionChildrens Medi-ProfenOTCqc ibuprofen ib oral tabletMedi-ProfenOTC; QLqc ibuprofen oral capsuleAdvil Liqui-Gels minisOTCqc ibuprofen oral tabletMedi-ProfenOTC.

10 QLqc naproxen sodium oral tabletMediproxenOTCra ibuprofen childrens oral suspensionChildrens Medi-ProfenOTCra ibuprofen infants oral suspensionMedi-ProfenOTC; QLra ibuprofen oral capsuleAdvil Liqui-Gels minisOTCra ibuprofen oral tabletMedi-ProfenOTC; QLra naproxen sodium oral tabletMediproxenOTCra pain relief ibuprofen oral tabletMedi-ProfenOTC; QLsb ibuprofen oral tabletMedi-ProfenOTC; QLsb infants ibuprofen oral suspensionMedi-ProfenOTC; QLsb naproxen sodium oral tabletMediproxenOTCsm childrens ibuprofen oral suspensionChildrens Medi-ProfenOTCsm ibuprofen ib oral tabletMedi-ProfenOTC; QLsm ibuprofen jr oral tabletAdvil Junior StrengthOTCsm ibuprofen oral capsuleAdvil Liqui-Gels minisOTCsm ibuprofen oral tabletMedi-ProfenOTC; QLsm infants ibuprofen oral suspensionMedi-ProfenOTC; QLsm naproxen sodium oral tabletMediproxenOTCsulindac oral tabletWAL-PROFEN ORAL CAPSULEOTCWAL-PROFEN ORAL TABLETOTC.