Example: tourism industry
Run Date: 01/09/22 Monthly Maximum Allowable Cost (MAC ...
acarbose 25 mg tablet oral 01/12/2021 0.22780 acebutolol hcl 200 mg capsule oral 09/07/2021 0.88574 acebutolol hcl 400 mg capsule oral 10/26/2021 0.95381 acetaminophen 500 mg capsule oral 06/02/2020 0.04047 acetaminophen 160 mg/5ml oral susp oral 11/09/2021 0.02222
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Kentucky Medicaid Pharmacy Preferred Drug List
kyportal.magellanmedicaid.comBevespi Aerosphere™ QL Combivent® Respimat® QL CC, QL ipratropium inhalation solution QL Spiriva Handihaler® QL Stiolto™ Respimat® QL Breztri Aerosphere™ Daliresp™ CC, QL Duaklir® Pressair® Incruse® Ellipta®QL Lonhala™ Magnair™ Seebri Neohaler® CC, QL Spiriva® Respimat®QL Trelegy Ellipta CC, QL Tudorza® QLPressair™
Kentucky Medicaid External Clinical Criteria
kyportal.magellanmedicaid.comKentucky Medicaid Single PDL Prior Authorization (PA) Criteria Effective March 3, 2022 BETA BLOCKERS + DIURETIC COMBINATIONS Preferred Agents Non-Preferred Agents atenolol/chlorthalidone Lopressor® HCT bisoprolol/HCTZ metoprolol tartrate/HCTZ nadolol/bendroflumethiazide propranolol/HCTZ
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