Apple Health (Medicaid) Preferred Drug List Effective April 1, 2019 (Eff. 4/1/2019) Apple Health PDL APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUS ALLERGY : ALLERGENIC EXTRACTS / BIOLOGICALS MISC ADAGEN SOLN PREFERRED PA REQUIRED ORALAIR SUBL PREFERRED PA REQUIRED ORALAIR ADULT SAMPLE KIT SUBL PREFERRED PA REQUIRED ORALAIR ADULT STARTER PACK SUBL PREFERRED PA REQUIRED ORALAIR CHILDREN/ADOLESCENTS SAMPLE KIT THPK PREFERRED PA REQUIRED ORALAIR CHILDREN/ADOLESCENTS STARTER PACK SUBL PREFERRED PA REQUIRED ALLERGY : ANAPHYLAXIS - VASOPRESSOR SELF-INJECTABLES ADRENALIN SOLN NON-PREFERRED PA REQUIRED EPINEPHRINE SOAJ NON-PREFERRED PA REQUIRED EPINEPHRINE (MYLAN) SOAJ PREFERRED - EPIPEN 2-PAK SOAJ NON-PREFERRED PA REQUIRED EPIPEN-JR 2-PAK SOAJ NON-PREFERRED PA REQUIRED SYMJEPI SOSY PREFERRED - ALLERGY : NASAL ANTIHISTAMINES ASTEPRO SOLN NON-PREFERRED PA REQUIRED AZELASTINE HCL SOLN PREFERRED - AZELASTINE HYDROCHLORIDE SOLN PREFERRED - DYMISTA SUSP NON-PREFERRED - OLOPATADINE HCL SOLN NON-PREFERRED - PATANASE SOLN NON-PREFERRED PA REQUIRED ANALGESICS - ANTIINFLAMMATORY : ANTIRHEUMATIC ANTIMETABOLITES METHOTREXATE SOLN PREFERRED - METHOTREXATE TABS PREFERRED - METHOTREXATE SODIUM SOLN PREFERRED - METHOTREXATE SODIUM SOLR PREFERRED - OTREXUP SOAJ NON-PREFERRED PA REQUIRED The Apple Health Preferred Drug List (PDL) has products listed in groups by drug class. Unless otherwise indicated, the authorization criteria is that the client must have tried and failed, or is intolerant to, at least two preferred drugs within the drug class unless contraindicated, not clinically appropriate, or only one drug is preferred. Drugs may also have additional clinical criteria that is required for approval, these drugs are indicated with PA Required in the PA status column.
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Apple Health (Medicaid) Preferred Drug List · 2019. 7. 5. · Apple Health (Medicaid) Preferred Drug List Effective April 1, 2019 (Eff. 4/1/2019) Apple Health PDL APPLE HEALTH DRUG
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Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSALLERGY : ALLERGENIC EXTRACTS / BIOLOGICALS MISC ADAGEN SOLN PREFERRED PA REQUIRED
ORALAIR SUBL PREFERRED PA REQUIREDORALAIR ADULT SAMPLE KIT SUBL PREFERRED PA REQUIREDORALAIR ADULT STARTER PACK SUBL PREFERRED PA REQUIREDORALAIR CHILDREN/ADOLESCENTS SAMPLE KIT THPK PREFERRED PA REQUIREDORALAIR CHILDREN/ADOLESCENTS STARTER PACK SUBL PREFERRED PA REQUIRED
The Apple Health Preferred Drug List (PDL) has products listed in groups by drug class. Unless otherwise indicated, the authorization criteria is that the client must have tried and failed, or is intolerant to, at least two preferred drugs within the drug class unless contraindicated, not clinically
appropriate, or only one drug is preferred. Drugs may also have additional clinical criteria that is required for approval, these drugs are indicated with PA Required in the PA status column.
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUS
ANALGESICS - OPIOID : LONG ACTING - AGONISTS ARYMO ER TBEA NON-PREFERRED PA REQUIRED
CONZIP CP24 NON-PREFERRED PA REQUIREDDOLOPHINE TABS NON-PREFERRED PA REQUIREDDURAGESIC PT72 NON-PREFERRED PA REQUIREDEMBEDA CPCR NON-PREFERRED PA REQUIREDEXALGO T24A NON-PREFERRED PA REQUIREDFENTANYL PT72 PREFERRED PA REQUIREDFENTANYL 37.5MCG/HR PT72 NON-PREFERRED PA REQUIREDFENTANYL 62.5MCG/HR PT72 NON-PREFERRED PA REQUIREDFENTANYL 87.5MCG/HR PT72 NON-PREFERRED PA REQUIREDHYDROMORPHONE HCL ER T24A NON-PREFERRED PA REQUIREDHYDROMORPHONE HYDROCHLORIDE T24A NON-PREFERRED PA REQUIREDHYDROMORPHONE HYDROCHLORIDE ER T24A NON-PREFERRED PA REQUIREDHYSINGLA ER T24A NON-PREFERRED PA REQUIREDKADIAN CP24 NON-PREFERRED PA REQUIREDMETHADONE HCL CONC NON-PREFERRED PA REQUIREDMETHADONE HCL SOLN NON-PREFERRED PA REQUIREDMETHADONE HCL TABS NON-PREFERRED PA REQUIREDMETHADONE HCL TBSO NON-PREFERRED PA REQUIREDMETHADONE HCL INTENSOL CONC NON-PREFERRED PA REQUIREDMETHADONE HYDROCHLORIDE TABS NON-PREFERRED PA REQUIREDMETHADOSE CONC NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANALGESICS - OPIOID : LONG ACTING - AGONISTS CONT. METHADOSE TBSO NON-PREFERRED PA REQUIRED
METHADOSE SUGAR-FREE CONC NON-PREFERRED PA REQUIREDMORPHABOND ER T12A NON-PREFERRED PA REQUIREDMORPHINE SULFATE ER CP24 NON-PREFERRED PA REQUIREDMORPHINE SULFATE ER TBCR PREFERRED PA REQUIREDMS CONTIN TBCR NON-PREFERRED PA REQUIREDNUCYNTA ER TB12 NON-PREFERRED PA REQUIREDOPANA ER (CRUSH RESISTANT) T12A NON-PREFERRED PA REQUIREDOXYCODONE HCL ER T12A NON-PREFERRED PA REQUIREDOXYCONTIN T12A NON-PREFERRED PA REQUIREDOXYMORPHONE HYDROCHLORIDE ER TB12 PREFERRED PA REQUIREDOXYMORPHONE HYDROCHLORIDE ER 15MG TB12 NON-PREFERRED PA REQUIREDOXYMORPHONE HYDROCHLORIDE ER 7.5MG TB12 NON-PREFERRED PA REQUIREDTRAMADOL HCL ER CP24 NON-PREFERRED PA REQUIREDTRAMADOL HCL ER TB24 PREFERRED PA REQUIREDTRAMADOL HCL ER (BIPHASIC RELEASE) TB24 NON-PREFERRED PA REQUIREDXTAMPZA ER C12A NON-PREFERRED PA REQUIREDZOHYDRO ER C12A NON-PREFERRED PA REQUIRED
ANALGESICS - OPIOID : PARTIAL AGONISTS BELBUCA FILM NON-PREFERRED PA REQUIRED
BUPRENORPHINE PTWK PREFERRED -BUTRANS PTWK NON-PREFERRED PA REQUIRED
ANALGESICS - OPIOID : SHORT ACTING - AGONISTS ABSTRAL SUBL NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANALGESICS - OPIOID : SHORT ACTING - AGONISTS CONT. BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE CAPS PREFERRED -
BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE CAPS PREFERRED -BUTORPHANOL TARTRATE SOLN NON-PREFERRED -CODEINE SULFATE TABS NON-PREFERRED PA REQUIREDCODEINE SULFATE (LANNETT) TABS PREFERRED -DEMEROL TABS NON-PREFERRED PA REQUIREDDILAUDID LIQD NON-PREFERRED PA REQUIREDDILAUDID TABS NON-PREFERRED PA REQUIREDDVORAH TABS NON-PREFERRED -ENDOCET TABS PREFERRED -FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP NON-PREFERRED PA REQUIREDFENTORA TABS NON-PREFERRED PA REQUIREDFIORICET/CODEINE CAPS NON-PREFERRED PA REQUIREDFIORINAL/CODEINE #3 CAPS NON-PREFERRED PA REQUIREDHYDROCODONE BITARTRATE/ACETAMINOPHEN SOLN PREFERRED -HYDROCODONE BITARTRATE/ACETAMINOPHEN TABS PREFERRED -HYDROCODONE/ACETAMINOPHEN TABS PREFERRED -HYDROCODONE/IBUPROFEN TABS PREFERRED -HYDROMORPHONE HCL LIQD NON-PREFERRED -HYDROMORPHONE HCL SUPP PREFERRED -HYDROMORPHONE HCL TABS PREFERRED -IBUDONE TABS NON-PREFERRED PA REQUIREDIONSYS PTCH NON-PREFERRED PA REQUIREDLAZANDA SOLN NON-PREFERRED PA REQUIREDLEVORPHANOL TARTRATE TABS NON-PREFERRED PA REQUIREDLORCET TABS NON-PREFERRED PA REQUIREDLORCET HD TABS PREFERRED -LORCET PLUS TABS NON-PREFERRED PA REQUIREDLORTAB ELIX NON-PREFERRED -MEPERIDINE HCL SOLN NON-PREFERRED PA REQUIREDMEPERIDINE HCL TABS NON-PREFERRED PA REQUIREDMORPHINE SULFATE SOLN NON-PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANALGESICS - OPIOID : SHORT ACTING - AGONISTS CONT. MORPHINE SULFATE SUPP PREFERRED -
MORPHINE SULFATE TABS PREFERRED -NALOCET TABS NON-PREFERRED PA REQUIREDNORCO TABS NON-PREFERRED PA REQUIREDNUCYNTA TABS NON-PREFERRED -OPANA TABS NON-PREFERRED PA REQUIREDOXAYDO TABA NON-PREFERRED -OXYCODONE HCL CAPS NON-PREFERRED -OXYCODONE HCL CONC NON-PREFERRED PA REQUIREDOXYCODONE HCL SOLN PREFERRED -OXYCODONE HCL TABS PREFERRED -OXYCODONE HYDROCHLORIDE CAPS NON-PREFERRED -OXYCODONE HYDROCHLORIDE CONC NON-PREFERRED PA REQUIREDOXYCODONE HYDROCHLORIDE SOLN PREFERRED -OXYCODONE HYDROCHLORIDE TABS PREFERRED -OXYCODONE/ACETAMINOPHEN SOLN NON-PREFERRED PA REQUIREDOXYCODONE/ACETAMINOPHEN TABS PREFERRED -OXYCODONE/ASPIRIN TABS PREFERRED -OXYCODONE/IBUPROFEN TABS NON-PREFERRED -OXYMORPHONE HYDROCHLORIDE TABS NON-PREFERRED -PANLOR TABS NON-PREFERRED -PENTAZOCINE/NALOXONE HCL TABS NON-PREFERRED -PERCOCET TABS NON-PREFERRED PA REQUIREDPRIMLEV TABS NON-PREFERRED PA REQUIREDROXICODONE TABS NON-PREFERRED PA REQUIREDROXYBOND TABA NON-PREFERRED -SUBSYS LIQD NON-PREFERRED PA REQUIREDTRAMADOL HCL TABS PREFERRED -TRAMADOL HYDROCHLORIDE/ACETAMINOPHEN TABS PREFERRED -TYLENOL/CODEINE #3 TABS NON-PREFERRED PA REQUIREDTYLENOL/CODEINE #4 TABS NON-PREFERRED PA REQUIREDULTRACET TABS NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANALGESICS - OPIOID : SHORT ACTING - AGONISTS CONT. ULTRAM TABS NON-PREFERRED PA REQUIRED
VERDROCET TABS NON-PREFERRED -VICODIN TABS NON-PREFERRED PA REQUIREDVICODIN ES TABS NON-PREFERRED PA REQUIREDVICODIN HP TABS NON-PREFERRED PA REQUIRED
ALMOTRIPTAN MALATE TABS NON-PREFERRED -AMERGE TABS NON-PREFERRED PA REQUIREDAXERT TABS NON-PREFERRED PA REQUIREDELETRIPTAN HYDROBROMIDE TABS NON-PREFERRED -FROVA TABS NON-PREFERRED PA REQUIREDFROVATRIPTAN SUCCINATE TABS NON-PREFERRED -IMITREX TABS NON-PREFERRED PA REQUIREDIMITREX INJECTION SOLN NON-PREFERRED PA REQUIREDIMITREX NASAL SPRAY SOLN PREFERRED PA REQUIREDIMITREX STATDOSE REFILL SOCT NON-PREFERRED PA REQUIREDIMITREX STATDOSE SYSTEM SOAJ NON-PREFERRED PA REQUIREDMAXALT TABS NON-PREFERRED PA REQUIREDMAXALT-MLT TBDP NON-PREFERRED PA REQUIREDNARATRIPTAN HCL TABS PREFERRED -ONZETRA XSAIL EXHP NON-PREFERRED PA REQUIREDRELPAX TABS NON-PREFERRED PA REQUIREDRIZATRIPTAN BENZOATE TABS PREFERRED -RIZATRIPTAN BENZOATE ODT TBDP PREFERRED -SUMATRIPTAN SOLN PREFERRED -SUMATRIPTAN SUCCINATE SOAJ PREFERRED -SUMATRIPTAN SUCCINATE SOLN PREFERRED -SUMATRIPTAN SUCCINATE SOSY NON-PREFERRED -SUMATRIPTAN SUCCINATE TABS PREFERRED -SUMATRIPTAN SUCCINATE REFILL SOCT PREFERRED -ZEMBRACE SYMTOUCH SOAJ NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANALGESICS : MIGRAINE AGENTS - 5-HT1 AGONISTS CONT. ZOLMITRIPTAN TABS NON-PREFERRED -
ZOLMITRIPTAN ODT TBDP NON-PREFERRED -ZOMIG SOLN NON-PREFERRED -ZOMIG TABS NON-PREFERRED PA REQUIREDZOMIG ZMT TBDP NON-PREFERRED PA REQUIRED
CAMBIA PACK PREFERRED PA REQUIREDD.H.E. 45 SOLN PREFERRED PA REQUIREDDIHYDROERGOTAMINE MESYLATE SOLN PREFERRED PA REQUIREDERGOMAR SUBL PREFERRED PA REQUIREDISOMETHEPTENE/DICHLORALPHENAZONE/ACETAMINOP CAPS PREFERRED PA REQUIREDMIGERGOT SUPP PREFERRED PA REQUIREDMIGRANAL SOLN PREFERRED PA REQUIREDMIGRANOW THPK PREFERRED PA REQUIREDSUMATRIPTAN/NAPROXEN SODIUM TABS PREFERRED PA REQUIREDTREXIMET TABS PREFERRED PA REQUIRED
ANALPRAM HC CREA NON-PREFERRED PA REQUIREDANALPRAM HC SINGLES CREA NON-PREFERRED PA REQUIREDANALPRAM-HC CREA NON-PREFERRED PA REQUIREDANALPRAM-HC LOTN NON-PREFERRED PA REQUIREDHYDROCORTISONE ACETATE/PRAMOXINE CREA PREFERRED -LIDOCAINE HCL/HYDROCORTISONE ACETATE CREA PREFERRED -LIDOCAINE HCL/HYDROCORTISONE ACETATE KIT NON-PREFERRED PA REQUIREDLIDOCAINE HCL-HYDROCORTISONE ACETATE WITH ALOE GEL NON-PREFERRED PA REQUIREDPRAMCORT CREA NON-PREFERRED PA REQUIREDPROCORT CREA NON-PREFERRED PA REQUIREDPROCTOFOAM HC FOAM NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANORECTAL AGENTS : RECTAL STEROIDS ANUCORT-HC SUPP PREFERRED -
ANUSOL-HC CREA NON-PREFERRED PA REQUIREDANUSOL-HC SUPP PREFERRED -COLOCORT ENEM PREFERRED -CORTENEMA ENEM NON-PREFERRED PA REQUIREDCORTIFOAM FOAM NON-PREFERRED PA REQUIREDHEMMOREX-HC SUPP PREFERRED -HYDROCORTISONE CREA PREFERRED -HYDROCORTISONE ENEM PREFERRED -HYDROCORTISONE ACETATE SUPP PREFERRED -PROCTOCORT CREA NON-PREFERRED PA REQUIREDPROCTOCORT SUPP NON-PREFERRED PA REQUIREDPROCTO-MED HC CREA PREFERRED -PROCTO-PAK CREA PREFERRED -PROCTOSOL HC CREA PREFERRED -PROCTOZONE-HC CREA PREFERRED -UCERIS FOAM NON-PREFERRED PA REQUIRED
ANTIBIOTICS : AMINOGLYCOSIDES - INHALED ARIKAYCE SUSP NON-PREFERRED PA REQUIRED
BETHKIS NEBU PREFERRED PA REQUIREDKITABIS PAK NEBU PREFERRED PA REQUIREDTOBI NEBU NON-PREFERRED PA REQUIREDTOBI PODHALER CAPS PREFERRED PA REQUIREDTOBRAMYCIN NEBU NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIBIOTICS : CEPHALOSPORINS - 3RD GENERATION CONT. CEFTAZIDIME/DEXTROSE SOLR PREFERRED PA REQUIRED
CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE SOLN PREFERRED PA REQUIREDCEFTRIAXONE SODIUM SOLR PREFERRED PA REQUIREDCEFTRIAXONE/DEXTROSE SOLR PREFERRED PA REQUIREDSUPRAX CAPS PREFERRED -SUPRAX CHEW PREFERRED -SUPRAX SUSR NON-PREFERRED -SUPRAX SUSR NON-PREFERRED PA REQUIREDSUPRAX 500MG/5ML SUSR NON-PREFERRED -TAZICEF SOLN PREFERRED PA REQUIREDTAZICEF SOLR PREFERRED PA REQUIRED
CEFEPIME SOLR PREFERRED PA REQUIREDCEFEPIME/DEXTROSE SOLR PREFERRED PA REQUIREDMAXIPIME IV SOLR NON-PREFERRED PA REQUIREDMAXIPIME INJECTION SOLR PREFERRED PA REQUIRED
ANTIBIOTICS : FLUOROQUINOLONES - ORAL AVELOX TABS NON-PREFERRED PA REQUIRED
BAXDELA TABS NON-PREFERRED PA REQUIREDCIPRO SUSR NON-PREFERRED PA REQUIREDCIPRO TABS NON-PREFERRED PA REQUIREDCIPROFLOXACIN SUSR PREFERRED -CIPROFLOXACIN TABS PREFERRED -CIPROFLOXACIN ER TB24 NON-PREFERRED PA REQUIREDCIPROFLOXACIN HCL TABS PREFERRED -CIPROFLOXACIN HYDROCHLORIDE TABS PREFERRED -LEVAQUIN TABS NON-PREFERRED PA REQUIREDLEVOFLOXACIN SOLN NON-PREFERRED -LEVOFLOXACIN TABS PREFERRED -MOXIFLOXACIN HCL TABS NON-PREFERRED -MOXIFLOXACIN HYDROCHLORIDE TABS NON-PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUS
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIBIOTICS : MACROLIDES - ORAL CONT. ERYTHROMYCIN ETHYLSUCCINATE TABS PREFERRED -
PCE TBEC NON-PREFERRED -ZITHROMAX PACK NON-PREFERRED PA REQUIREDZITHROMAX SUSR NON-PREFERRED PA REQUIREDZITHROMAX TABS NON-PREFERRED PA REQUIREDZITHROMAX TRI-PAK TABS NON-PREFERRED PA REQUIREDZITHROMAX Z-PAK TABS NON-PREFERRED PA REQUIRED
ANTIBIOTICS : MONOBACTAMS - INHALED CAYSTON SOLR PREFERRED PA REQUIRED
ANTIBIOTICS : NATURAL PENICILLINS BICILLIN L-A SUSP PREFERRED PA REQUIREDPENICILLIN G POTASSIUM SOLR PREFERRED PA REQUIREDPENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE SOLN PREFERRED PA REQUIREDPENICILLIN G PROCAINE SUSP PREFERRED PA REQUIREDPENICILLIN G SODIUM SOLR PREFERRED PA REQUIREDPENICILLIN V POTASSIUM SOLR PREFERRED -PENICILLIN V POTASSIUM TABS PREFERRED -PFIZERPEN SOLR NON-PREFERRED PA REQUIRED
AMOXICILLIN/CLAVULANATE POTASSIUM SUSR PREFERRED -AMOXICILLIN/CLAVULANATE POTASSIUM TABS PREFERRED -AMOXICILLIN/CLAVULANATE POTASSIUM ER TB12 PREFERRED -AMPICILLIN-SULBACTAM SOLR PREFERRED PA REQUIREDAUGMENTIN SUSR NON-PREFERRED PA REQUIREDAUGMENTIN TABS NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIBIOTICS : PENICILLIN COMBINATIONS CONT. AUGMENTIN 125-31.25MG/5ML SUSR NON-PREFERRED -
AUGMENTIN ES-600 SUSR NON-PREFERRED PA REQUIREDAUGMENTIN XR TB12 NON-PREFERRED PA REQUIREDBICILLIN C-R SUSP PREFERRED PA REQUIREDPIPERACILLIN SODIUM/ TAZOBACTAM SODIUM SOLR PREFERRED PA REQUIREDPIPERACILLIN SODIUM/TAZOBACTAM SODIUM SOLR PREFERRED PA REQUIREDPIPERACILLIN/TAZOBACTAM SOLR PREFERRED PA REQUIREDUNASYN SOLR NON-PREFERRED PA REQUIREDUNASYN BULK PACK SOLR NON-PREFERRED PA REQUIREDZOSYN SOLN PREFERRED PA REQUIREDZOSYN SOLR NON-PREFERRED PA REQUIRED
ANTICOAGULANTS : HEPARINS AND HEPARINOID-LIKE AGENTS ARIXTRA SOLN NON-PREFERRED PA REQUIRED
ENOXAPARIN SODIUM SOLN PREFERRED -FONDAPARINUX SODIUM SOLN NON-PREFERRED -FRAGMIN SOLN NON-PREFERRED -HEPARIN LOCK FLUSH SOLN PREFERRED PA REQUIREDHEPARIN SODIUM SOLN PREFERRED PA REQUIREDHEPARIN SODIUM DCU SOLN PREFERRED PA REQUIREDHEPARIN SODIUM LOCK FLUSH SOLN PREFERRED PA REQUIREDHEPARIN SODIUM/D5W SOLN PREFERRED PA REQUIREDHEPARIN SODIUM/DEXTROSE SOLN PREFERRED PA REQUIREDHEPARIN SODIUM/NACL 0.45% SOLN PREFERRED PA REQUIREDHEPARIN SODIUM/NACL 0.9% SOLN PREFERRED PA REQUIREDHEPARIN SODIUM/SODIUM CHLORIDE SOLN PREFERRED PA REQUIREDHEPARIN SODIUM/SODIUM CHLORIDE 0.9% SOLN PREFERRED PA REQUIREDHEPARIN SODIUM/SODIUM CHLORIDE 0.9% PREMIX SOLN PREFERRED PA REQUIREDLOVENOX SOLN NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTICONVULSANTS : AMPA GLUTAMATE RECEPTOR ANTAGONISTS FYCOMPA SUSP PREFERRED PA REQUIRED
FYCOMPA TABS PREFERRED PA REQUIREDANTICONVULSANTS : BENZODIAZEPINES CLOBAZAM SUSP NON-PREFERRED PA REQUIRED
CLOBAZAM TABS NON-PREFERRED PA REQUIREDCLONAZEPAM TABS PREFERRED -CLONAZEPAM ODT TBDP NON-PREFERRED PA REQUIREDDIASTAT ACUDIAL GEL PREFERRED -DIASTAT PEDIATRIC GEL PREFERRED -DIAZEPAM RECTAL GEL GEL PREFERRED -KLONOPIN TABS NON-PREFERRED PA REQUIREDONFI SUSP NON-PREFERRED PA REQUIREDONFI TABS NON-PREFERRED PA REQUIREDSYMPAZAN FILM NON-PREFERRED PA REQUIRED
ANTICONVULSANTS : CARBAMATES FELBAMATE SUSP PREFERRED PA REQUIREDFELBAMATE TABS PREFERRED PA REQUIREDFELBATOL SUSP NON-PREFERRED PA REQUIREDFELBATOL TABS NON-PREFERRED PA REQUIRED
ANTICONVULSANTS : GABA MODULATORS GABITRIL TABS NON-PREFERRED PA REQUIRED
SABRIL PACK NON-PREFERRED PA REQUIREDSABRIL TABS NON-PREFERRED PA REQUIREDTIAGABINE HYDROCHLORIDE TABS PREFERRED PA REQUIREDVIGABATRIN PACK PREFERRED PA REQUIREDVIGABATRIN TABS PREFERRED PA REQUIREDVIGADRONE PACK PREFERRED PA REQUIRED
ANTICONVULSANTS : HYDANTOINS CEREBYX SOLN PREFERRED PA REQUIREDDILANTIN CAPS PREFERRED -DILANTIN 100MG CAPS NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTICONVULSANTS : HYDANTOINS CONT. DILANTIN INFATABS CHEW NON-PREFERRED PA REQUIRED
DILANTIN-125 SUSP NON-PREFERRED PA REQUIREDFOSPHENYTOIN SODIUM SOLN PREFERRED PA REQUIREDPEGANONE TABS NON-PREFERRED -PHENYTEK CAPS NON-PREFERRED PA REQUIREDPHENYTOIN CHEW PREFERRED -PHENYTOIN SUSP PREFERRED -PHENYTOIN INFATABS CHEW PREFERRED -PHENYTOIN SODIUM SOLN PREFERRED PA REQUIREDPHENYTOIN SODIUM EXTENDED CAPS PREFERRED -
ANTICONVULSANTS : MISC APTIOM TABS NON-PREFERRED PA REQUIREDBANZEL SUSP NON-PREFERRED PA REQUIREDBANZEL TABS NON-PREFERRED PA REQUIREDBRIVIACT SOLN NON-PREFERRED PA REQUIREDBRIVIACT TABS NON-PREFERRED PA REQUIREDBRIVIACT IV SOLN PREFERRED PA REQUIREDCARBAMAZEPINE CHEW PREFERRED -CARBAMAZEPINE SUSP PREFERRED -CARBAMAZEPINE TABS PREFERRED -CARBAMAZEPINE ER CP12 PREFERRED -CARBAMAZEPINE ER TB12 PREFERRED -CARBATROL CP12 NON-PREFERRED PA REQUIREDEPIDIOLEX SOLN NON-PREFERRED PA REQUIREDEPITOL TABS PREFERRED -GABAPENTIN CAPS PREFERRED -GABAPENTIN SOLN PREFERRED -GABAPENTIN TABS PREFERRED -KEPPRA SOLN NON-PREFERRED PA REQUIREDKEPPRA TABS NON-PREFERRED PA REQUIREDKEPPRA XR TB24 NON-PREFERRED PA REQUIREDLAMICTAL TABS NON-PREFERRED PA REQUIREDLAMICTAL CHEWABLE DISPERSIBLE CHEW NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTICONVULSANTS : MISC CONT. LAMICTAL ODT KIT NON-PREFERRED PA REQUIRED
LAMICTAL ODT TBDP NON-PREFERRED PA REQUIREDLAMICTAL STARTER/NOT TAKING CARBAMAZEPINE KIT NON-PREFERRED PA REQUIREDLAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKI KIT NON-PREFERRED PA REQUIREDLAMICTAL STARTER/TAKING VALPROATE KIT NON-PREFERRED PA REQUIREDLAMICTAL XR KIT NON-PREFERRED PA REQUIREDLAMICTAL XR TB24 NON-PREFERRED PA REQUIREDLAMOTRIGINE CHEW NON-PREFERRED PA REQUIREDLAMOTRIGINE TABS PREFERRED -LAMOTRIGINE ER TB24 NON-PREFERRED PA REQUIREDLAMOTRIGINE ODT TBDP NON-PREFERRED PA REQUIREDLAMOTRIGINE STARTER KIT/BLUE KIT NON-PREFERRED PA REQUIREDLAMOTRIGINE STARTER KIT/GREEN KIT NON-PREFERRED PA REQUIREDLAMOTRIGINE STARTER KIT/ORANGE KIT NON-PREFERRED PA REQUIREDLAMOTRIGINE TITRATION KIT NON-PREFERRED PA REQUIREDLEVETIRACETAM TABS PREFERRED -LEVETIRACETAM ER TB24 PREFERRED -LEVETIRACETAM IV & INJECTION SOLN PREFERRED PA REQUIREDLEVETIRACETAM ORAL SOLN PREFERRED -LEVETIRACETAM/SODIUM CHLORIDE SOLN PREFERRED PA REQUIREDLYRICA CAPS NON-PREFERRED PA REQUIREDLYRICA SOLN NON-PREFERRED PA REQUIREDMYSOLINE TABS NON-PREFERRED PA REQUIREDNEURONTIN CAPS NON-PREFERRED PA REQUIREDNEURONTIN SOLN NON-PREFERRED PA REQUIREDNEURONTIN TABS NON-PREFERRED PA REQUIREDOXCARBAZEPINE SUSP PREFERRED -OXCARBAZEPINE TABS PREFERRED -OXTELLAR XR TB24 NON-PREFERRED PA REQUIREDPRIMIDONE TABS PREFERRED -QUDEXY XR CS24 NON-PREFERRED PA REQUIREDROWEEPRA TABS PREFERRED -ROWEEPRA XR TB24 PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTICONVULSANTS : MISC CONT. SPRITAM TB3D NON-PREFERRED PA REQUIRED
SUBVENITE TABS PREFERRED -SUBVENITE STARTER KIT/BLUE KIT NON-PREFERRED PA REQUIREDSUBVENITE STARTER KIT/GREEN KIT NON-PREFERRED PA REQUIREDSUBVENITE STARTER KIT/ORANGE KIT NON-PREFERRED PA REQUIREDTEGRETOL SUSP NON-PREFERRED PA REQUIREDTEGRETOL TABS NON-PREFERRED PA REQUIREDTEGRETOL-XR TB12 NON-PREFERRED PA REQUIREDTOPAMAX TABS NON-PREFERRED PA REQUIREDTOPAMAX SPRINKLE CPSP NON-PREFERRED PA REQUIREDTOPIRAMATE CPSP PREFERRED -TOPIRAMATE TABS PREFERRED -TOPIRAMATE ER CS24 NON-PREFERRED PA REQUIREDTRILEPTAL SUSP NON-PREFERRED PA REQUIREDTRILEPTAL TABS NON-PREFERRED PA REQUIREDTROKENDI XR CP24 PREFERRED -VIMPAT TABS PREFERRED -VIMPAT IV SOLN PREFERRED PA REQUIREDVIMPAT ORAL SOLN PREFERRED -ZONEGRAN CAPS NON-PREFERRED PA REQUIREDZONISAMIDE CAPS PREFERRED -
ANTICONVULSANTS : SUCCUNIMIDES CELONTIN CAPS NON-PREFERRED PA REQUIREDETHOSUXIMIDE CAPS NON-PREFERRED PA REQUIREDETHOSUXIMIDE SOLN NON-PREFERRED PA REQUIREDZARONTIN CAPS NON-PREFERRED PA REQUIREDZARONTIN SOLN NON-PREFERRED PA REQUIRED
ANTICONVULSANTS : VALPROIC ACID DEPACON SOLN NON-PREFERRED PA REQUIREDDEPAKENE CAPS NON-PREFERRED PA REQUIREDDEPAKENE SOLN NON-PREFERRED PA REQUIREDDEPAKOTE TBEC NON-PREFERRED PA REQUIREDDEPAKOTE ER TB24 NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTICONVULSANTS : VALPROIC ACID CONT. DEPAKOTE SPRINKLES CSDR NON-PREFERRED PA REQUIRED
ANTIDEPRESSANTS : NOREPINEPHRINE-DOPAMINE REUPTAKE INHIBITORS APLENZIN TB24 NON-PREFERRED PA REQUIRED
BUPROPION HYDROCHLORIDE TABS PREFERRED -BUPROPION HYDROCHLORIDE ER (SR) TB12 PREFERRED -BUPROPION HYDROCHLORIDE ER (XL) TB24 PREFERRED -FORFIVO XL TB24 NON-PREFERRED PA REQUIREDWELLBUTRIN SR TB12 NON-PREFERRED PA REQUIREDWELLBUTRIN XL TB24 NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIDEPRESSANTS : SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRI) BRISDELLE CAPS NON-PREFERRED PA REQUIRED
CELEXA TABS NON-PREFERRED PA REQUIREDCITALOPRAM SOLN NON-PREFERRED PA REQUIREDCITALOPRAM TABS PREFERRED -CITALOPRAM HYDROBROMIDE SOLN NON-PREFERRED PA REQUIREDCITALOPRAM HYDROBROMIDE TABS PREFERRED -ESCITALOPRAM OXALATE SOLN NON-PREFERRED PA REQUIREDESCITALOPRAM OXALATE TABS PREFERRED -FLUOXETINE (PMDD) CAPS NON-PREFERRED PA REQUIREDFLUOXETINE DR CPDR NON-PREFERRED -FLUOXETINE HCL CAPS PREFERRED -FLUOXETINE HCL SOLN PREFERRED -FLUOXETINE HYDROCHLORIDE SOLN PREFERRED -FLUOXETINE HYDROCHLORIDE TABS NON-PREFERRED -FLUOXETINE HYDROCHLORIDE (PMDD) TABS NON-PREFERRED PA REQUIREDFLUVOXAMINE MALEATE TABS PREFERRED -FLUVOXAMINE MALEATE ER CP24 NON-PREFERRED PA REQUIREDLEXAPRO TABS NON-PREFERRED PA REQUIREDPAROXETINE CAPS NON-PREFERRED PA REQUIREDPAROXETINE HCL TABS PREFERRED -PAROXETINE HCL ER TB24 NON-PREFERRED PA REQUIREDPAROXETINE HYDROCHLORIDE TABS PREFERRED -PAROXETINE HYDROCHLORIDE ER TB24 NON-PREFERRED PA REQUIREDPAXIL SUSP NON-PREFERRED PA REQUIREDPAXIL TABS NON-PREFERRED PA REQUIREDPAXIL CR TB24 NON-PREFERRED PA REQUIREDPEXEVA TABS NON-PREFERRED -PROZAC CAPS NON-PREFERRED PA REQUIREDSARAFEM TABS NON-PREFERRED PA REQUIREDSERTRALINE HCL CONC NON-PREFERRED -SERTRALINE HCL TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIDEPRESSANTS : SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRI) CONT. SERTRALINE HYDROCHLORIDE CONC NON-PREFERRED -
ZOLOFT CONC NON-PREFERRED PA REQUIREDZOLOFT TABS NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIDEPRESSANTS : TRICYCLIC AGENTS CONT. CHLORDIAZEPOXIDE/AMITRIPTYLINE TABS NON-PREFERRED -
GLYSET TABS NON-PREFERRED PA REQUIREDMIGLITOL TABS NON-PREFERRED -PRECOSE TABS NON-PREFERRED PA REQUIRED
ANTIDIABETICS : BIGUANIDES FORTAMET TB24 NON-PREFERRED PA REQUIREDGLUCOPHAGE TABS NON-PREFERRED PA REQUIREDGLUCOPHAGE XR TB24 NON-PREFERRED PA REQUIREDGLUMETZA TB24 NON-PREFERRED PA REQUIREDMETFORMIN HCL TABS PREFERRED -METFORMIN HYDROCHLORIDE TABS PREFERRED -METFORMIN HYDROCHLORIDE ER TB24 PREFERRED -METFORMIN HYDROCHLORIDE ER MODIFIED RELEASE TB24 NON-PREFERRED PA REQUIREDRIOMET SOLN NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIDIABETICS : DOPAMINE RECEPTOR AGONISTS CYCLOSET TABS NON-PREFERRED PA REQUIRED
ANTIDIABETICS : INCRETIN MIMETICS AND ENHANCERS - AMYLIN ANALOGS SYMLINPEN 120 SOPN PREFERRED PA REQUIRED
SYMLINPEN 60 SOPN PREFERRED PA REQUIRED
ANTIDIABETICS : INCRETIN MIMETICS AND ENHANCERS - DPP4 INHIBITOR / SGLT2 INHIBITOR COMBINATIONS GLYXAMBI TABS NON-PREFERRED PA REQUIRED
QTERN TABS NON-PREFERRED PA REQUIREDSTEGLUJAN TABS NON-PREFERRED PA REQUIRED
ANTIDIABETICS : INCRETIN MIMETICS AND ENHANCERS - DPP4 INHIBITOR / TZD COMBINATIONS ALOGLIPTIN/PIOGLITAZONE TABS PREFERRED PA REQUIRED
ANTIDIABETICS : INSULIN - SHORT ACTING AFREZZA POWD NON-PREFERRED PA REQUIRED
HUMULIN R SOLN PREFERRED -HUMULIN R U-500 (CONCENTRATED) SOLN PREFERRED -HUMULIN R U-500 KWIKPEN SOPN PREFERRED -NOVOLIN R SOLN NON-PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIDIABETICS : INSULIN - SHORT ACTING CONT. NOVOLIN R RELION SOLN NON-PREFERRED -
CINVANTI EMUL NON-PREFERRED PA REQUIREDEMEND CAPS NON-PREFERRED PA REQUIREDEMEND SOLR NON-PREFERRED PA REQUIREDEMEND SUSR NON-PREFERRED PA REQUIREDEMEND TRIPACK CAPS NON-PREFERRED PA REQUIREDVARUBI EMUL NON-PREFERRED -VARUBI TABS NON-PREFERRED -
ANTIFUNGALS : INJECTABLES ABELCET SUSP PREFERRED PA REQUIREDAMBISOME SUSR PREFERRED PA REQUIREDAMPHOTERICIN B SOLR PREFERRED PA REQUIREDCANCIDAS SOLR NON-PREFERRED PA REQUIREDCASPOFUNGIN ACETATE SOLR PREFERRED PA REQUIREDCRESEMBA SOLR PREFERRED PA REQUIREDERAXIS SOLR PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUS
ANTIFUNGALS : INJECTABLES CONT. FLUCONAZOLE IN DEXTROSE SOLN PREFERRED PA REQUIREDFLUCONAZOLE IN NACL SOLN PREFERRED PA REQUIREDFLUCONAZOLE IN SODIUM CHLORIDE SOLN PREFERRED PA REQUIREDMYCAMINE SOLR PREFERRED PA REQUIREDNOXAFIL SOLN PREFERRED PA REQUIREDVFEND IV SOLR NON-PREFERRED PA REQUIREDVORICONAZOLE SOLR PREFERRED PA REQUIRED
ANTIFUNGALS : ORAL ANCOBON CAPS NON-PREFERRED PA REQUIREDCLOTRIMAZOLE LOZG PREFERRED -CLOTRIMAZOLE TROC PREFERRED -CRESEMBA CAPS NON-PREFERRED PA REQUIREDDIFLUCAN SUSR NON-PREFERRED PA REQUIREDDIFLUCAN TABS NON-PREFERRED PA REQUIREDFLUCONAZOLE SUSR PREFERRED -FLUCONAZOLE TABS PREFERRED -FLUCYTOSINE CAPS NON-PREFERRED -GRISEOFULVIN MICROSIZE SUSP PREFERRED -GRISEOFULVIN MICROSIZE TABS PREFERRED -GRISEOFULVIN ULTRAMICROSIZE TABS PREFERRED -GRIS-PEG TABS NON-PREFERRED PA REQUIREDITRACONAZOLE CAPS NON-PREFERRED -ITRACONAZOLE SOLN PREFERRED PA REQUIREDKETOCONAZOLE TABS NON-PREFERRED PA REQUIREDLAMISIL TABS NON-PREFERRED PA REQUIREDNOXAFIL SUSP NON-PREFERRED PA REQUIREDNOXAFIL TBEC NON-PREFERRED PA REQUIREDNYSTATIN SUSP PREFERRED -NYSTATIN TABS PREFERRED -ONMEL TABS NON-PREFERRED -SPORANOX CAPS NON-PREFERRED PA REQUIREDSPORANOX SOLN NON-PREFERRED PA REQUIREDSPORANOX PULSEPAK CAPS NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIFUNGALS : ORAL CONT. TERBINAFINE HCL TABS PREFERRED -
TERBINAFINE HYDROCHLORIDE TABS PREFERRED -TOLSURA CAPS NON-PREFERRED PA REQUIREDVFEND SUSR NON-PREFERRED PA REQUIREDVFEND TABS NON-PREFERRED PA REQUIREDVORICONAZOLE SUSR NON-PREFERRED PA REQUIREDVORICONAZOLE TABS NON-PREFERRED PA REQUIRED
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : PROGESTINS-ANTINEOPLASTIC - ORAL MEGACE ES SUSP NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIPARKINSON AGENTS : ANTICHOLINERGICS CONT. TRIHEXYPHENIDYL HCL ELIX PREFERRED -
AMANTADINE HCL SYRP PREFERRED -AMANTADINE HCL TABS NON-PREFERRED -AMANTADINE HYDROCHLORIDE TABS NON-PREFERRED -APOKYN SOCT NON-PREFERRED -BROMOCRIPTINE MESYLATE CAPS NON-PREFERRED -BROMOCRIPTINE MESYLATE TABS NON-PREFERRED -CARBIDOPA TABS PREFERRED -CARBIDOPA/LEVODOPA TABS PREFERRED -CARBIDOPA/LEVODOPA ER TBCR PREFERRED -CARBIDOPA/LEVODOPA ODT TBDP NON-PREFERRED -CARBIDOPA/LEVODOPA/ENTACAPONE TABS NON-PREFERRED -DUOPA SUSP NON-PREFERRED -GOCOVRI CP24 NON-PREFERRED PA REQUIREDLODOSYN TABS NON-PREFERRED PA REQUIREDMIRAPEX TABS NON-PREFERRED PA REQUIREDMIRAPEX ER TB24 NON-PREFERRED PA REQUIREDNEUPRO PT24 NON-PREFERRED -OSMOLEX ER TB24 NON-PREFERRED PA REQUIREDPARLODEL CAPS NON-PREFERRED PA REQUIREDPARLODEL TABS NON-PREFERRED PA REQUIREDPRAMIPEXOLE DIHYDROCHLORIDE TABS PREFERRED -PRAMIPEXOLE DIHYDROCHLORIDE ER TB24 NON-PREFERRED -REQUIP TABS NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIPARKINSON AGENTS : DOPAMINERGICS CONT. REQUIP XL TB24 NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIPSYCHOTICS / ANTIMANIC AGENTS : ANTIPSYCHOTICS - 1ST GENERATION CONT. CHLORPROMAZINE HCL TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIPSYCHOTICS / ANTIMANIC AGENTS : ANTIPSYCHOTICS - 2ND GENERATION CONT. ARIPIPRAZOLE ODT TBDP PREFERRED -
ARISTADA PRSY PREFERRED -ARISTADA INITIO PRSY NON-PREFERRED PA REQUIREDCLOZAPINE TABS PREFERRED -CLOZAPINE ODT TBDP NON-PREFERRED PA REQUIREDCLOZARIL TABS NON-PREFERRED PA REQUIREDFANAPT TABS PREFERRED -FANAPT TITRATION PACK TABS NON-PREFERRED PA REQUIREDFAZACLO TBDP NON-PREFERRED PA REQUIREDGEODON CAPS NON-PREFERRED PA REQUIREDGEODON SOLR PREFERRED -INVEGA TB24 NON-PREFERRED PA REQUIREDINVEGA SUSTENNA SUSP PREFERRED -INVEGA TRINZA SUSP PREFERRED -LATUDA TABS PREFERRED -OLANZAPINE SOLR PREFERRED -OLANZAPINE TABS PREFERRED -OLANZAPINE ODT TBDP PREFERRED -PALIPERIDONE ER TB24 PREFERRED -PERSERIS PRSY NON-PREFERRED PA REQUIREDQUETIAPINE FUMARATE TABS PREFERRED -QUETIAPINE FUMARATE ER TB24 PREFERRED -REXULTI TABS PREFERRED -RISPERDAL SOLN NON-PREFERRED PA REQUIREDRISPERDAL TABS NON-PREFERRED PA REQUIREDRISPERDAL CONSTA SUSR PREFERRED -RISPERDAL M-TAB TBDP NON-PREFERRED PA REQUIREDRISPERIDONE SOLN PREFERRED -RISPERIDONE TABS PREFERRED -RISPERIDONE M-TAB TBDP PREFERRED -RISPERIDONE ODT TBDP PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIPSYCHOTICS / ANTIMANIC AGENTS : ANTIPSYCHOTICS - 2ND GENERATION CONT. SAPHRIS SUBL PREFERRED -
SEROQUEL TABS NON-PREFERRED PA REQUIREDSEROQUEL XR TB24 NON-PREFERRED PA REQUIREDVERSACLOZ SUSP PREFERRED -ZIPRASIDONE HCL CAPS PREFERRED -ZIPRASIDONE HYDROCHLORIDE CAPS PREFERRED -ZYPREXA SOLR NON-PREFERRED PA REQUIREDZYPREXA TABS NON-PREFERRED PA REQUIREDZYPREXA RELPREVV SUSR PREFERRED -ZYPREXA ZYDIS TBDP NON-PREFERRED PA REQUIRED
SYMBYAX CAPS NON-PREFERRED PA REQUIREDANTIPSYCHOTICS / ANTIMANIC AGENTS : ANTIPSYCHOTICS - MISC EQUETRO CP12 PREFERRED PA REQUIRED
NUPLAZID CAPS PREFERRED PA REQUIREDNUPLAZID TABS PREFERRED PA REQUIREDVRAYLAR CAPS PREFERRED PA REQUIREDVRAYLAR CPPK PREFERRED PA REQUIRED
ANTIVIRALS : CMV AGENTS CIDOFOVIR SOLN PREFERRED PA REQUIREDCYTOVENE SOLR NON-PREFERRED PA REQUIREDGANCICLOVIR 500MG/10ML SOLN NON-PREFERRED PA REQUIREDGANCICLOVIR SOLN PREFERRED PA REQUIREDGANCICLOVIR SOLR PREFERRED PA REQUIREDPREVYMIS SOLN PREFERRED PA REQUIREDPREVYMIS TABS PREFERRED PA REQUIREDVALCYTE SOLR NON-PREFERRED PA REQUIREDVALCYTE TABS NON-PREFERRED PA REQUIREDVALGANCICLOVIR TABS PREFERRED -VALGANCICLOVIR HYDROCHLORDE SOLR PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSANTIVIRALS : HEPATITIS B AGENTS ADEFOVIR DIPIVOXIL TABS PREFERRED -
BARACLUDE SOLN NON-PREFERRED -BARACLUDE TABS NON-PREFERRED PA REQUIREDENTECAVIR TABS PREFERRED -EPIVIR HBV SOLN PREFERRED -EPIVIR HBV TABS NON-PREFERRED PA REQUIREDHEPSERA TABS NON-PREFERRED PA REQUIREDLAMIVUDINE TABS PREFERRED -VEMLIDY TABS NON-PREFERRED PA REQUIRED
ANTIVIRALS : HEPATITIS C AGENTS DAKLINZA TABS NON-PREFERRED PA REQUIREDEPCLUSA TABS PREFERRED PA REQUIREDHARVONI TABS NON-PREFERRED PA REQUIREDMAVYRET TABS PREFERRED PA REQUIREDOLYSIO CAPS NON-PREFERRED PA REQUIREDSOVALDI TABS NON-PREFERRED PA REQUIREDTECHNIVIE TABS NON-PREFERRED PA REQUIREDVIEKIRA PAK TBPK NON-PREFERRED PA REQUIREDVIEKIRA XR TB24 NON-PREFERRED PA REQUIREDVOSEVI TABS PREFERRED PA REQUIREDZEPATIER TABS NON-PREFERRED PA REQUIRED
ANTIVIRALS : HERPES AGENTS ACYCLOVIR CAPS PREFERRED -ACYCLOVIR CREA NON-PREFERRED PA REQUIREDACYCLOVIR OINT NON-PREFERRED PA REQUIREDACYCLOVIR SUSP PREFERRED -ACYCLOVIR TABS PREFERRED -ACYCLOVIR SODIUM SOLN PREFERRED PA REQUIREDACYCLOVIR SODIUM SOLR PREFERRED PA REQUIREDDENAVIR CREA NON-PREFERRED PA REQUIREDFAMCICLOVIR TABS PREFERRED -SITAVIG TABS NON-PREFERRED PA REQUIREDVALACYCLOVIR HCL TABS PREFERRED -VALACYCLOVIR HYDROCHLORIDE TABS PREFERRED -VALTREX TABS NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUS
ANTIVIRALS : HERPES AGENTS CONT. XERESE CREA NON-PREFERRED PA REQUIREDZOVIRAX CAPS NON-PREFERRED PA REQUIREDZOVIRAX CREA NON-PREFERRED PA REQUIREDZOVIRAX OINT NON-PREFERRED PA REQUIREDZOVIRAX SUSP NON-PREFERRED PA REQUIREDZOVIRAX TABS NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSASTHMA AND COPD AGENTS : BETA AGONISTS - ORAL CONT. ALBUTEROL SULFATE ER TB12 PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSASTHMA AND COPD AGENTS : INHALED CORTICOSTEROID COMBINATIONS CONT. TRELEGY ELLIPTA AEPB NON-PREFERRED -
ASTHMA AND COPD AGENTS : LEUKOTRIENE MODIFIERS ACCOLATE TABS NON-PREFERRED PA REQUIRED
MONTELUKAST SODIUM CHEW PREFERRED -MONTELUKAST SODIUM PACK PREFERRED -MONTELUKAST SODIUM TABS PREFERRED -SINGULAIR CHEW NON-PREFERRED PA REQUIREDSINGULAIR PACK NON-PREFERRED PA REQUIREDSINGULAIR TABS NON-PREFERRED PA REQUIREDZAFIRLUKAST TABS PREFERRED -ZILEUTON ER TB12 NON-PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSASTHMA AND COPD AGENTS : LEUKOTRIENE MODIFIERS CONT. ZYFLO TABS NON-PREFERRED PA REQUIRED
ZYFLO CR TB12 NON-PREFERRED PA REQUIREDASTHMA AND COPD AGENTS : LONG ACTING MUSCARINIC AGENT / LONG ACTING BETA AGONIST COMBINATIONS ANORO ELLIPTA AEPB NON-PREFERRED -
ASTHMA AND COPD AGENTS : MONOCLONAL ANTIBODIES CINQAIR SOLN PREFERRED PA REQUIRED
DUPIXENT SOSY NON-PREFERRED PA REQUIREDFASENRA SOSY PREFERRED PA REQUIREDNUCALA SOLR PREFERRED PA REQUIREDXOLAIR SOLR PREFERRED PA REQUIREDXOLAIR SOSY PREFERRED PA REQUIRED
ASTHMA AND COPD AGENTS : PHOSPHODIESTERASE 4 INHIBITORS DALIRESP TABS PREFERRED PA REQUIREDASTHMA AND COPD AGENTS : XANTHINES AMINOPHYLLINE SOLN PREFERRED PA REQUIRED
ELIXOPHYLLIN ELIX NON-PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSASTHMA AND COPD AGENTS : XANTHINES CONT. THEO-24 CP24 NON-PREFERRED -
THEOCHRON TB12 PREFERRED -THEOPHYLLINE SOLN PREFERRED -THEOPHYLLINE CR TB12 PREFERRED -THEOPHYLLINE ER TB12 PREFERRED -THEOPHYLLINE ER TB24 PREFERRED -THEOPHYLLINE/D5W SOLN PREFERRED PA REQUIRED
POWD PREFERRED -CHOLESTYRAMINE LIGHT PACK PREFERRED -CHOLESTYRAMINE LIGHT POWD PREFERRED -COLESEVELAM HYDROCHLORIDE PACK NON-PREFERRED -COLESEVELAM HYDROCHLORIDE TABS NON-PREFERRED -COLESTID GRAN NON-PREFERRED PA REQUIREDCOLESTID PACK NON-PREFERRED PA REQUIREDCOLESTID TABS NON-PREFERRED PA REQUIREDCOLESTID FLAVORED GRAN NON-PREFERRED PA REQUIREDCOLESTID FLAVORED PACK NON-PREFERRED PA REQUIREDCOLESTIPOL HCL GRAN NON-PREFERRED -COLESTIPOL HCL PACK NON-PREFERRED -COLESTIPOL HCL TABS PREFERRED -PREVALITE PACK PREFERRED -PREVALITE POWD PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCARDIOVASCULAR AGENTS - ANTIHYPERLIPIDEMICS : BILE ACID SEQUESTRANTS CONT. QUESTRAN PACK NON-PREFERRED PA REQUIRED
QUESTRAN POWD NON-PREFERRED PA REQUIREDQUESTRAN LIGHT POWD NON-PREFERRED PA REQUIREDWELCHOL PACK NON-PREFERRED PA REQUIREDWELCHOL TABS NON-PREFERRED PA REQUIRED
CARDIOVASCULAR AGENTS - ANTIHYPERLIPIDEMICS : FIBRIC ACID DERIVATIVES ANTARA CAPS NON-PREFERRED PA REQUIRED
FENOFIBRATE CAPS NON-PREFERRED PA REQUIREDFENOFIBRATE TABS PREFERRED -FENOFIBRATE MICRONIZED CAPS NON-PREFERRED PA REQUIREDFENOFIBRIC ACID TABS NON-PREFERRED PA REQUIREDFENOFIBRIC ACID DR CPDR NON-PREFERRED PA REQUIREDFENOGLIDE TABS NON-PREFERRED PA REQUIREDFIBRICOR TABS NON-PREFERRED PA REQUIREDGEMFIBROZIL TABS PREFERRED -LIPOFEN CAPS NON-PREFERRED PA REQUIREDLOPID TABS NON-PREFERRED PA REQUIREDTRICOR TABS NON-PREFERRED PA REQUIREDTRIGLIDE TABS NON-PREFERRED PA REQUIREDTRILIPIX CPDR NON-PREFERRED PA REQUIRED
CARDIOVASCULAR AGENTS - ANTIHYPERLIPIDEMICS : HMG COA REDUCTASE INHIBITORS (STATINS) AND COMBINATIONS ALTOPREV TB24 NON-PREFERRED -
ATORVASTATIN CALCIUM TABS PREFERRED -CRESTOR TABS NON-PREFERRED PA REQUIREDEZETIMIBE/SIMVASTATIN TABS NON-PREFERRED PA REQUIREDFLUVASTATIN CAPS NON-PREFERRED -FLUVASTATIN SODIUM ER TB24 NON-PREFERRED -LESCOL XL TB24 NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUS
CARDIOVASCULAR AGENTS - ANTIHYPERLIPIDEMICS : HMG COA REDUCTASE INHIBITORS (STATINS) AND COMBINATIONS CONT. LIPITOR TABS NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN MODULATORS - ACE INHIBITORS CONT. MOEXIPRIL HCL TABS NON-PREFERRED -
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN MODULATORS - ANGIOTENSIN II RECEPTOR BLOCKER COMBINATIONS AMLODIPINE BESYLATE/VALSARTAN TABS PREFERRED PA REQUIRED
AMLODIPINE/OLMESARTAN MEDOXOMIL TABS NON-PREFERRED PA REQUIREDAMLODIPINE/VALSARTAN/HCTZ TABS NON-PREFERRED PA REQUIREDAMLODIPINE/VALSARTAN/HYDROCHLOROTHIAZIDE TABS NON-PREFERRED PA REQUIREDATACAND HCT TABS NON-PREFERRED PA REQUIREDAVALIDE TABS NON-PREFERRED PA REQUIREDAZOR TABS NON-PREFERRED PA REQUIREDBENICAR HCT TABS NON-PREFERRED PA REQUIREDBYVALSON TABS NON-PREFERRED PA REQUIREDCANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE TABS NON-PREFERRED PA REQUIREDDIOVAN HCT TABS NON-PREFERRED PA REQUIREDEDARBYCLOR TABS NON-PREFERRED PA REQUIREDEXFORGE TABS NON-PREFERRED PA REQUIREDEXFORGE HCT TABS NON-PREFERRED PA REQUIREDHYZAAR TABS NON-PREFERRED PA REQUIREDIRBESARTAN/HYDROCHLOROTHIAZIDE TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN MODULATORS - ANGIOTENSIN II RECEPTOR BLOCKER COMBINATIONS CONT. LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS PREFERRED -
MICARDIS HCT TABS NON-PREFERRED PA REQUIREDOLMESARTAN MEDOXOMIL/AMLODIPINE/HYDROCHLOR TABS NON-PREFERRED PA REQUIREDOLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE TABS PREFERRED -TELMISARTAN/AMLODIPINE TABS NON-PREFERRED PA REQUIREDTELMISARTAN/HYDROCHLOROTHIAZIDE TABS NON-PREFERRED PA REQUIREDTRIBENZOR TABS NON-PREFERRED PA REQUIREDTWYNSTA TABS NON-PREFERRED PA REQUIREDVALSARTAN/HYDROCHLOROTHIAZIDE TABS PREFERRED -
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN MODULATORS - ANGIOTENSIN II RECEPTOR BLOCKERS ATACAND TABS NON-PREFERRED PA REQUIRED
AVAPRO TABS NON-PREFERRED PA REQUIREDBENICAR TABS NON-PREFERRED PA REQUIREDCANDESARTAN CILEXETIL TABS NON-PREFERRED -COZAAR TABS NON-PREFERRED PA REQUIREDDIOVAN TABS NON-PREFERRED PA REQUIREDEDARBI TABS NON-PREFERRED -EPROSARTAN MESYLATE TABS NON-PREFERRED -IRBESARTAN TABS PREFERRED -LOSARTAN POTASSIUM TABS PREFERRED -MICARDIS TABS NON-PREFERRED PA REQUIREDOLMESARTAN MEDOXOMIL TABS PREFERRED -TELMISARTAN TABS NON-PREFERRED -VALSARTAN TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUS
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN MODULATORS - DIRECT RENIN INHIBITOR COMBINATIONS TEKTURNA HCT TABS NON-PREFERRED PA REQUIREDCARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN MODULATORS - DIRECT RENIN INHIBITORS TEKTURNA TABS NON-PREFERRED PA REQUIRED
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN MODULATORS - NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMBINATIONS ENTRESTO TABS PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANTIADRENERGICS CONT. METHYLDOPATE HCL SOLN PREFERRED PA REQUIRED
ACEBUTOLOL HYDROCHLORIDE CAPS PREFERRED -ATENOLOL TABS PREFERRED -BETAPACE TABS NON-PREFERRED PA REQUIREDBETAPACE AF TABS NON-PREFERRED PA REQUIREDBETAXOLOL HCL TABS PREFERRED -BISOPROLOL FUMARATE TABS PREFERRED -BREVIBLOC SOLN NON-PREFERRED PA REQUIREDBREVIBLOC PREMIXED SOLN NON-PREFERRED PA REQUIREDBREVIBLOC PREMIXED DOUBLESTRENGTH SOLN NON-PREFERRED PA REQUIREDBYSTOLIC TABS NON-PREFERRED -CARVEDILOL TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : BETA-ADRENERGICS CONT. CARVEDILOL PHOSPHATE CP24 PREFERRED -
COREG TABS NON-PREFERRED PA REQUIREDCOREG CR CP24 NON-PREFERRED PA REQUIREDCORGARD TABS NON-PREFERRED PA REQUIREDESMOLOL HCL SOLN PREFERRED PA REQUIREDESMOLOL HYDROCHLORIDE IN WATER SOLN PREFERRED PA REQUIREDESMOLOL HYDROCHLORIDE IN WATER DOUBLE STRENGT SOLN PREFERRED PA REQUIREDESMOLOL HYDROCHLORIDE/SODIUM CHLORIDE SOLN PREFERRED -HEMANGEOL SOLN NON-PREFERRED -INDERAL LA CP24 NON-PREFERRED PA REQUIREDINDERAL XL CP24 NON-PREFERRED -INNOPRAN XL CP24 NON-PREFERRED -KAPSPARGO SPRINKLE CS24 NON-PREFERRED PA REQUIREDLABETALOL HCL SOLN PREFERRED PA REQUIREDLABETALOL HCL TABS PREFERRED -LABETALOL HYDROCHLORIDE SOLN PREFERRED PA REQUIREDLABETALOL HYDROCHLORIDE TABS PREFERRED -LOPRESSOR TABS NON-PREFERRED PA REQUIREDMETOPROLOL SUCCINATE ER TB24 PREFERRED -METOPROLOL TARTRATE SOCT PREFERRED PA REQUIREDMETOPROLOL TARTRATE SOLN PREFERRED PA REQUIREDMETOPROLOL TARTRATE TABS PREFERRED -METOPROLOL TARTRATE 37.5MG & 75MG TABS NON-PREFERRED PA REQUIREDNADOLOL TABS PREFERRED -PINDOLOL TABS NON-PREFERRED -PROPRANOLOL HCL TABS PREFERRED -PROPRANOLOL HCL ER CP24 PREFERRED -PROPRANOLOL HCL INJECTION SOLN PREFERRED PA REQUIREDPROPRANOLOL HCL ORAL SOLN PREFERRED -PROPRANOLOL HYDROCHLORIDE TABS PREFERRED -SORINE TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : BETA-ADRENERGICS CONT. SOTALOL HCL TABS PREFERRED -
CADUET TABS NON-PREFERRED PA REQUIREDCARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : CALCIUM CHANNEL BLOCKERS ADALAT CC TB24 NON-PREFERRED PA REQUIRED
AFEDITAB CR TB24 PREFERRED -AMLODIPINE BESYLATE TABS PREFERRED -CALAN TABS NON-PREFERRED PA REQUIREDCALAN SR TBCR NON-PREFERRED PA REQUIREDCARDENE IV SOLN PREFERRED PA REQUIREDCARDIZEM TABS NON-PREFERRED PA REQUIREDCARDIZEM CD CP24 NON-PREFERRED PA REQUIREDCARDIZEM LA TB24 NON-PREFERRED PA REQUIREDCARTIA XT CP24 NON-PREFERRED PA REQUIREDCLEVIPREX EMUL PREFERRED PA REQUIREDDILTIAZEM HCL SOLN PREFERRED PA REQUIREDDILTIAZEM HCL SOLR PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : CALCIUM CHANNEL BLOCKERS CONT. DILTIAZEM HCL TABS PREFERRED -
DILTIAZEM HCL CD CP24 PREFERRED -DILTIAZEM HCL ER CP12 PREFERRED -DILTIAZEM HCL ER CP24 PREFERRED -DILTIAZEM HCL ER TB24 NON-PREFERRED -DILTIAZEM HYDROCHLORIDE ER CP24 PREFERRED -DILT-XR CP24 PREFERRED -FELODIPINE ER TB24 PREFERRED -ISRADIPINE CAPS NON-PREFERRED -MATZIM LA TB24 NON-PREFERRED -NICARDIPINE HCL CAPS NON-PREFERRED -NICARDIPINE HCL SOLN PREFERRED PA REQUIREDNIFEDIPINE CAPS PREFERRED -NIFEDIPINE ER TB24 PREFERRED -NIMODIPINE CAPS NON-PREFERRED -NISOLDIPINE ER TB24 NON-PREFERRED -NORVASC TABS NON-PREFERRED PA REQUIREDNYMALIZE SOLN NON-PREFERRED -PROCARDIA CAPS NON-PREFERRED PA REQUIREDPROCARDIA XL TB24 NON-PREFERRED PA REQUIREDSULAR TB24 NON-PREFERRED PA REQUIREDTAZTIA XT CP24 NON-PREFERRED PA REQUIREDTIAZAC CP24 NON-PREFERRED PA REQUIREDVERAPAMIL HCL SOLN PREFERRED PA REQUIREDVERAPAMIL HCL TABS PREFERRED -VERAPAMIL HCL ER CP24 NON-PREFERRED -VERAPAMIL HCL ER TBCR PREFERRED -VERAPAMIL HCL SR CP24 NON-PREFERRED -VERAPAMIL HCL SR 360MG CP24 NON-PREFERRED PA REQUIREDVERAPAMIL HYDROCHLORIDE SOLN PREFERRED PA REQUIREDVERAPAMIL HYDROCHLORIDE TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : CALCIUM CHANNEL BLOCKERS CONT. VERELAN CP24 NON-PREFERRED PA REQUIRED
VERELAN PM CP24 NON-PREFERRED PA REQUIREDCARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : OTHER CORLOPAM SOLN PREFERRED PA REQUIRED
DEMSER CAPS NON-PREFERRED PA REQUIREDEPLERENONE TABS PREFERRED -HYDRALAZINE HCL SOLN PREFERRED PA REQUIREDHYDRALAZINE HCL TABS PREFERRED -HYDRALAZINE HYDROCHLORIDE TABS PREFERRED -INSPRA TABS NON-PREFERRED PA REQUIREDMINOXIDIL TABS PREFERRED -NIPRIDE RTU SOLN PREFERRED PA REQUIREDNITROPRESS SOLN PREFERRED PA REQUIREDPHENOXYBENZAMINE HYDROCHLORIDE CAPS PREFERRED -PHENTOLAMINE MESYLATE SOLR PREFERRED -SODIUM NITROPRUSSIDE SOLN PREFERRED PA REQUIREDVECAMYL TABS NON-PREFERRED PA REQUIRED
DIGOX TABS PREFERRED -DIGOXIN SOLN PREFERRED -DIGOXIN TABS PREFERRED -LANOXIN SOLN NON-PREFERRED PA REQUIREDLANOXIN TABS NON-PREFERRED PA REQUIREDLANOXIN PEDIATRIC SOLN NON-PREFERRED -NITROGLYCERIN IN DEXTROSE 5% SOLN PREFERRED PA REQUIRED
CARDIOVASCULAR AGENTS - CARDIOTONICS : PHOSPHODIESTERASE INHIBITORS MILRINONE IN DEXTROSE SOLN PREFERRED PA REQUIRED
MILRINONE LACTATE SOLN PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCARDIOVASCULAR AGENTS - DIURETICS : CARBONIC ANHYDRASE INHIBITORS ACETAZOLAMIDE TABS PREFERRED -
ACETAZOLAMIDE ER CP12 PREFERRED -ACETAZOLAMIDE SODIUM SOLR PREFERRED PA REQUIREDKEVEYIS TABS NON-PREFERRED -METHAZOLAMIDE TABS PREFERRED -NEPTAZANE TABS NON-PREFERRED PA REQUIRED
BUMETANIDE TABS PREFERRED -DEMADEX TABS NON-PREFERRED PA REQUIREDEDECRIN TABS NON-PREFERRED PA REQUIREDETHACRYNATE SODIUM SOLR PREFERRED -ETHACRYNIC ACID TABS PREFERRED -FUROSEMIDE TABS PREFERRED -FUROSEMIDE INJECTION SOLN PREFERRED PA REQUIREDFUROSEMIDE ORAL SOLN PREFERRED -LASIX TABS NON-PREFERRED PA REQUIREDSODIUM EDECRIN SOLR NON-PREFERRED PA REQUIREDTORSEMIDE TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCARDIOVASCULAR AGENTS - DIURETICS : POTASSIUM SPARING DIURETICS ALDACTONE TABS NON-PREFERRED PA REQUIRED
DILATRATE SR CPCR NON-PREFERRED PA REQUIREDGONITRO PACK NON-PREFERRED -ISORDIL TITRADOSE TABS NON-PREFERRED PA REQUIREDISOSORBIDE DINITRATE TABS PREFERRED -ISOSORBIDE DINITRATE ER TBCR PREFERRED -ISOSORBIDE MONONITRATE TABS PREFERRED -ISOSORBIDE MONONITRATE ER TB24 PREFERRED -MINITRAN PT24 PREFERRED -NITRO-BID OINT PREFERRED -NITRO-DUR PT24 NON-PREFERRED PA REQUIREDNITROGLYCERIN SOLN NON-PREFERRED -NITROGLYCERIN SUBL PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCARDIOVASCULAR AGENTS - MISC : ANTIANGINAL AGENTS - NITRATES CONT. NITROGLYCERIN ER CPCR PREFERRED -
NITROGLYCERIN LINGUAL SOLN NON-PREFERRED PA REQUIREDNITROGLYCERIN TRANSDERMAL PT24 PREFERRED -NITROLINGUAL PUMPSPRAY SOLN NON-PREFERRED PA REQUIREDNITROMIST AERS NON-PREFERRED PA REQUIREDNITROSTAT SUBL NON-PREFERRED PA REQUIREDNITRO-TIME CPCR PREFERRED -
CARDIOVASCULAR AGENTS - MISC : ANTIANGINAL AGENTS - OTHER RANEXA TB12 PREFERRED PA REQUIREDCARDIOVASCULAR AGENTS - MISC : ANTIARRHYTHMICS ADENOCARD SOLN PREFERRED PA REQUIRED
ADENOSINE SOLN PREFERRED PA REQUIREDAMIODARONE HCL SOLN PREFERRED PA REQUIRED
TABS PREFERRED -AMIODARONE HYDROCHLORIDE SOLN PREFERRED PA REQUIREDAMIODARONE HYDROCHLORIDE TABS PREFERRED -CORVERT SOLN PREFERRED PA REQUIREDDISOPYRAMIDE PHOSPHATE CAPS PREFERRED -DOFETILIDE CAPS PREFERRED -FLECAINIDE ACETATE TABS PREFERRED -IBUTILIDE FUMARATE SOLN PREFERRED PA REQUIREDLIDOCAINE HCL SOLN PREFERRED PA REQUIREDLIDOCAINE HCL IN D5W SOLN PREFERRED PA REQUIREDLIDOCAINE HCL/DEXTROSE SOLN PREFERRED PA REQUIREDMEXILETINE HCL CAPS PREFERRED -MULTAQ TABS NON-PREFERRED -NEXTERONE SOLN PREFERRED PA REQUIREDNORPACE CAPS NON-PREFERRED PA REQUIREDNORPACE CR CP12 NON-PREFERRED -PACERONE TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCARDIOVASCULAR AGENTS - MISC : ANTIARRHYTHMICS CONT. PROCAINAMIDE HCL SOLN PREFERRED PA REQUIRED
PROCAINAMIDE HYDROCHLORIDE SOLN PREFERRED PA REQUIREDPROPAFENONE HCL TABS PREFERRED -PROPAFENONE HCL ER CP12 PREFERRED -PROPAFENONE HYDROCHLORIDE ER CP12 PREFERRED -PROPAFENONE HYDROCHLORIDEER CP12 PREFERRED -QUINIDINE GLUCONATE SOLN PREFERRED PA REQUIREDQUINIDINE GLUCONATE CR TBCR PREFERRED -QUINIDINE SULFATE TABS NON-PREFERRED -RYTHMOL SR CP12 NON-PREFERRED PA REQUIREDTIKOSYN CAPS NON-PREFERRED PA REQUIREDXYLOCAINE SOLN PREFERRED PA REQUIRED
ALYQ TABS NON-PREFERRED PA REQUIREDREVATIO SUSR NON-PREFERRED PA REQUIREDREVATIO TABS NON-PREFERRED PA REQUIREDSILDENAFIL TABS PREFERRED PA REQUIREDSILDENAFIL CITRATE TABS PREFERRED PA REQUIREDTADALAFIL TABS NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCARDIOVASCULAR AGENTS - MISC : PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONISTS CONT. UPTRAVI TBPK PREFERRED PA REQUIRED
AMETHIA LO TABS PREFERRED -ASHLYNA TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCONTRACEPTIVES : COMBINATION CONTRACEPTIVES - ORAL, EXTENDED CYCLE CONT. CAMRESE TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCONTRACEPTIVES : COMBINATION CONTRACEPTIVES - ORAL, TRIPHASIC CONT. ORTHO TRI-CYCLEN TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCONTRACEPTIVES : PROGESTIN CONTRACEPTIVES - IMPLANTS NEXPLANON IMPL PREFERRED -CONTRACEPTIVES : PROGESTIN CONTRACEPTIVES - INJECTABLE DEPO-PROVERA CONTRACEPTIVE SUSP PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCORTICOSTEROIDS : GLUCOCORTICOSTEROID COMBINATIONS BETAMETHASONE SODIUM PHOSPHATE/BETAMETHASON SUSP PREFERRED -
CELESTONE-SOLUSPAN SUSP NON-PREFERRED PA REQUIREDDERMACINRX CINLONE-I CPI KIT PREFERRED -
CYTOKINE AND CAM ANTAGONISTS : ACTEMRA SOLN NON-PREFERRED PA REQUIREDACTEMRA SOSY NON-PREFERRED PA REQUIREDACTEMRA ACTPEN SOAJ NON-PREFERRED PA REQUIREDARCALYST SOLR NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCYTOKINE AND CAM ANTAGONISTS : CONT. CIMZIA KIT NON-PREFERRED PA REQUIRED
CIMZIA STARTER KIT KIT NON-PREFERRED PA REQUIREDCOSENTYX SOSY NON-PREFERRED PA REQUIREDCOSENTYX SENSOREADY PEN SOAJ NON-PREFERRED PA REQUIREDENBREL SOLR PREFERRED PA REQUIREDENBREL SOSY PREFERRED PA REQUIREDENBREL MINI SOCT NON-PREFERRED PA REQUIREDENBREL SURECLICK SOAJ PREFERRED PA REQUIREDENTYVIO SOLR NON-PREFERRED PA REQUIREDHUMIRA PSKT PREFERRED PA REQUIREDHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT PREFERRED PA REQUIREDHUMIRA PEN PNKT PREFERRED PA REQUIREDHUMIRA PEN-CD/UC/HS STARTER PNKT PREFERRED PA REQUIREDHUMIRA PEN-PS/UV STARTER PNKT PREFERRED PA REQUIREDILARIS SOLN NON-PREFERRED PA REQUIREDILUMYA SOSY NON-PREFERRED PA REQUIREDINFLECTRA SOLR NON-PREFERRED PA REQUIREDKEVZARA SOAJ NON-PREFERRED PA REQUIREDKEVZARA SOSY NON-PREFERRED PA REQUIREDKINERET SOSY NON-PREFERRED PA REQUIREDOLUMIANT TABS NON-PREFERRED PA REQUIREDORENCIA SOLR NON-PREFERRED PA REQUIREDORENCIA SOSY NON-PREFERRED PA REQUIREDORENCIA CLICKJECT SOAJ NON-PREFERRED PA REQUIREDOTEZLA TABS NON-PREFERRED PA REQUIREDOTEZLA TBPK NON-PREFERRED PA REQUIREDREMICADE SOLR NON-PREFERRED PA REQUIREDRENFLEXIS SOLR NON-PREFERRED PA REQUIREDSILIQ SOSY NON-PREFERRED PA REQUIREDSIMPONI SOAJ NON-PREFERRED PA REQUIREDSIMPONI SOSY NON-PREFERRED PA REQUIREDSIMPONI ARIA SOLN NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSCYTOKINE AND CAM ANTAGONISTS : CONT. STELARA SOLN NON-PREFERRED PA REQUIRED
STELARA SOSY NON-PREFERRED PA REQUIREDTALTZ SOAJ NON-PREFERRED PA REQUIREDTALTZ SOSY NON-PREFERRED PA REQUIREDTREMFYA SOSY NON-PREFERRED PA REQUIREDXELJANZ TABS NON-PREFERRED PA REQUIREDXELJANZ XR TB24 NON-PREFERRED PA REQUIRED
AMNESTEEM CAPS PREFERRED PA REQUIREDCLARAVIS CAPS PREFERRED PA REQUIREDISOTRETINOIN CAPS PREFERRED PA REQUIREDMYORISAN CAPS PREFERRED PA REQUIREDZENATANE CAPS PREFERRED PA REQUIRED
DERMATOLOGICS : AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTS VEREGEN OINT NON-PREFERRED PA REQUIRED
DERMATOLOGICS : ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL AMELUZ GEL PREFERRED PA REQUIRED
CARAC CREA NON-PREFERRED PA REQUIREDDICLOFENAC SODIUM GEL PREFERRED PA REQUIREDEFUDEX CREA NON-PREFERRED PA REQUIREDFLUOROURACIL SOLN PREFERRED PA REQUIREDFLUOROURACIL 0.5% CREA NON-PREFERRED PA REQUIREDFLUOROURACIL 5% CREA PREFERRED -LEVULAN KERASTICK SOLR PREFERRED PA REQUIREDPANRETIN GEL PREFERRED PA REQUIREDPICATO GEL PREFERRED PA REQUIREDTARGRETIN GEL PREFERRED PA REQUIREDTOLAK CREA PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUS
DERMATOLOGICS : ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL CONT. VALCHLOR GEL PREFERRED PA REQUIREDDERMATOLOGICS : ANTIPRURITICS - TOPICAL DOXEPIN HYDROCHLORIDE CREA PREFERRED PA REQUIRED
PRUDOXIN CREA PREFERRED PA REQUIREDZONALON CREA PREFERRED PA REQUIRED
CALCIPOTRIENE OINT PREFERRED -CALCIPOTRIENE SOLN PREFERRED -CALCITRENE OINT PREFERRED -CALCITRIOL OINT NON-PREFERRED -DOVONEX CREA NON-PREFERRED PA REQUIREDSORILUX FOAM NON-PREFERRED PA REQUIREDTAZAROTENE CREA NON-PREFERRED -TAZORAC CREA NON-PREFERRED -TAZORAC CREA NON-PREFERRED PA REQUIREDTAZORAC GEL NON-PREFERRED -VECTICAL OINT NON-PREFERRED -
DERMATOLOGICS : ECZEMA AGENTS DUPIXENT SOSY NON-PREFERRED PA REQUIREDDERMATOLOGICS : ENZYMES - TOPICAL SANTYL OINT NON-PREFERRED PA REQUIREDDERMATOLOGICS : IMMUNOMODULATING AGENTS - TOPICAL ALDARA CREA NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSDERMATOLOGICS : IMMUNOMODULATING AGENTS - TOPICAL CONT. IMIQUIMOD CREA PREFERRED -
IMIQUIMOD PUMP CREA NON-PREFERRED PA REQUIREDZYCLARA CREA NON-PREFERRED PA REQUIREDZYCLARA PUMP CREA NON-PREFERRED PA REQUIRED
DERMATOLOGICS : ROSACEA AGENTS AZELAIC ACID GEL PREFERRED -DOXYCYCLINE CPDR NON-PREFERRED PA REQUIREDFINACEA FOAM PREFERRED -FINACEA GEL PREFERRED -METROCREAM CREA NON-PREFERRED PA REQUIREDMETROGEL GEL NON-PREFERRED PA REQUIREDMETROLOTION LOTN NON-PREFERRED PA REQUIREDMETRONIDAZOLE CREA PREFERRED -METRONIDAZOLE GEL PREFERRED -METRONIDAZOLE LOTN PREFERRED -MIRVASO GEL NON-PREFERRED PA REQUIREDNORITATE CREA NON-PREFERRED PA REQUIREDORACEA CPDR NON-PREFERRED PA REQUIREDRHOFADE CREA NON-PREFERRED PA REQUIREDROSADAN CREA PREFERRED -ROSADAN GEL PREFERRED -ROSADAN KIT KIT NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSDERMATOLOGICS : ROSACEA AGENTS CONT. SOOLANTRA CREA NON-PREFERRED PA REQUIREDDERMATOLOGICS : TOPICAL STEROIDS - HIGH POTENCY AMCINONIDE CREA NON-PREFERRED PA REQUIRED
AMCINONIDE LOTN NON-PREFERRED PA REQUIREDAMCINONIDE OINT NON-PREFERRED PA REQUIREDAPEXICON E CREA NON-PREFERRED PA REQUIREDAUGMENTED BETAMETHASONE DIPROPIONATE CREA NON-PREFERRED PA REQUIREDAUGMENTED BETAMETHASONE DIPROPIONATE GEL NON-PREFERRED PA REQUIREDAUGMENTED BETAMETHASONE DIPROPIONATE LOTN NON-PREFERRED PA REQUIREDAUGMENTED BETAMETHASONE DIPROPIONATE OINT NON-PREFERRED PA REQUIREDBETAMETHASONE DIPROPIONATE CREA NON-PREFERRED PA REQUIREDBETAMETHASONE DIPROPIONATE LOTN NON-PREFERRED PA REQUIREDBETAMETHASONE DIPROPIONATE OINT NON-PREFERRED PA REQUIREDBETAMETHASONE VALERATE CREA PREFERRED -BETAMETHASONE VALERATE FOAM NON-PREFERRED PA REQUIREDBETAMETHASONE VALERATE LOTN NON-PREFERRED PA REQUIREDBETAMETHASONE VALERATE OINT PREFERRED -CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE OINT PREFERRED -CAPEX SHAM NON-PREFERRED PA REQUIREDCLODAN KIT KIT NON-PREFERRED PA REQUIREDDERMA-SMOOTHE/FS BODY OIL NON-PREFERRED PA REQUIREDDERMA-SMOOTHE/FS SCALP OIL NON-PREFERRED PA REQUIREDDERMASORB TA KIT NON-PREFERRED PA REQUIREDDESOXIMETASONE CREA NON-PREFERRED PA REQUIREDDESOXIMETASONE GEL NON-PREFERRED PA REQUIREDDESOXIMETASONE LIQD NON-PREFERRED PA REQUIREDDESOXIMETASONE OINT NON-PREFERRED PA REQUIREDDIFLORASONE DIACETATE CREA NON-PREFERRED PA REQUIREDDIFLORASONE DIACETATE OINT NON-PREFERRED PA REQUIREDDIPROLENE OINT NON-PREFERRED PA REQUIREDDIPROLENE AF CREA NON-PREFERRED PA REQUIREDENSTILAR FOAM NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSDERMATOLOGICS : TOPICAL STEROIDS - HIGH POTENCY CONT. FLUOCINOLONE ACETONIDE CREA NON-PREFERRED PA REQUIRED
FLUOCINOLONE ACETONIDE OINT NON-PREFERRED PA REQUIREDFLUOCINOLONE ACETONIDE SOLN NON-PREFERRED PA REQUIREDFLUOCINOLONE ACETONIDE BODY OIL NON-PREFERRED PA REQUIREDFLUOCINOLONE ACETONIDE SCALP OIL NON-PREFERRED PA REQUIREDFLUOCINONIDE CREA NON-PREFERRED PA REQUIREDFLUOCINONIDE GEL NON-PREFERRED PA REQUIREDFLUOCINONIDE OINT NON-PREFERRED PA REQUIREDFLUOCINONIDE SOLN NON-PREFERRED PA REQUIREDFLUOCINONIDE EMULSIFIED BASE CREA NON-PREFERRED PA REQUIREDFLUOCINONIDE EMULSIFIED BASE CREA NON-PREFERRED PA REQUIREDFLURANDRENOLIDE CREA NON-PREFERRED PA REQUIREDFLURANDRENOLIDE LOTN NON-PREFERRED PA REQUIREDFLURANDRENOLIDE OINT NON-PREFERRED PA REQUIREDHALOG CREA NON-PREFERRED PA REQUIREDHALOG OINT NON-PREFERRED PA REQUIREDKENALOG AERS NON-PREFERRED PA REQUIREDLUXIQ FOAM NON-PREFERRED PA REQUIREDPSORCON CREA NON-PREFERRED PA REQUIREDSERNIVO EMUL NON-PREFERRED PA REQUIREDSYNALAR CREA NON-PREFERRED PA REQUIREDSYNALAR OINT NON-PREFERRED PA REQUIREDSYNALAR SOLN NON-PREFERRED PA REQUIREDSYNALAR CREAM KIT KIT NON-PREFERRED PA REQUIREDSYNALAR OINTMENT KIT KIT NON-PREFERRED PA REQUIREDSYNALAR TS KIT NON-PREFERRED PA REQUIREDTACLONEX OINT NON-PREFERRED PA REQUIREDTACLONEX SUSP NON-PREFERRED PA REQUIREDTOPICORT CREA NON-PREFERRED PA REQUIREDTOPICORT GEL NON-PREFERRED PA REQUIREDTOPICORT LIQD NON-PREFERRED PA REQUIREDTOPICORT OINT NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSDERMATOLOGICS : TOPICAL STEROIDS - HIGH POTENCY CONT. TRIAMCINOLONE ACETONIDE AERS NON-PREFERRED PA REQUIRED
DERMATOLOGICS : TOPICAL STEROIDS - MEDIUM POTENCY CLOCORTOLONE PIVALATE CREA NON-PREFERRED PA REQUIRED
CLOCORTOLONE PIVALATE PUMP CREA NON-PREFERRED PA REQUIREDCLODERM CREA NON-PREFERRED PA REQUIREDCLODERM PUMP CREA NON-PREFERRED PA REQUIREDCUTIVATE LOTN NON-PREFERRED PA REQUIREDDERMASORB HC KIT NON-PREFERRED PA REQUIREDELOCON CREA NON-PREFERRED PA REQUIREDELOCON OINT NON-PREFERRED PA REQUIREDFLUTICASONE PROPIONATE CREA PREFERRED -FLUTICASONE PROPIONATE LOTN NON-PREFERRED PA REQUIREDFLUTICASONE PROPIONATE OINT PREFERRED -HYDROCORTISONE BUTYRATE CREA NON-PREFERRED PA REQUIREDHYDROCORTISONE BUTYRATE LOTN NON-PREFERRED PA REQUIREDHYDROCORTISONE BUTYRATE OINT NON-PREFERRED PA REQUIREDHYDROCORTISONE BUTYRATE SOLN NON-PREFERRED PA REQUIREDHYDROCORTISONE BUTYRATE (LIPID) CREA NON-PREFERRED PA REQUIREDHYDROCORTISONE BUTYRATE (LIPOPHILIC) CREA NON-PREFERRED PA REQUIREDHYDROCORTISONE VALERATE CREA NON-PREFERRED PA REQUIREDHYDROCORTISONE VALERATE OINT NON-PREFERRED PA REQUIREDLOCOID CREA NON-PREFERRED PA REQUIREDLOCOID LOTN NON-PREFERRED PA REQUIREDLOCOID OINT NON-PREFERRED PA REQUIREDLOCOID SOLN NON-PREFERRED PA REQUIREDLOCOID LIPOCREAM CREA NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUS
MOMETASONE FUROATE OINT PREFERRED -MOMETASONE FUROATE SOLN PREFERRED -PANDEL CREA NON-PREFERRED PA REQUIREDPREDNICARBATE CREA NON-PREFERRED PA REQUIREDPREDNICARBATE OINT NON-PREFERRED PA REQUIRED
DERMATOLOGICS : TOPICAL STEROIDS - VERY HIGH POTENCY BRYHALI LOTN NON-PREFERRED PA REQUIRED
CLOBETASOL PROPIONATE CREA PREFERRED -CLOBETASOL PROPIONATE FOAM NON-PREFERRED PA REQUIREDCLOBETASOL PROPIONATE GEL PREFERRED -CLOBETASOL PROPIONATE LIQD NON-PREFERRED PA REQUIREDCLOBETASOL PROPIONATE LOTN NON-PREFERRED PA REQUIREDCLOBETASOL PROPIONATE OINT PREFERRED -CLOBETASOL PROPIONATE SHAM NON-PREFERRED PA REQUIREDCLOBETASOL PROPIONATE SOLN PREFERRED -CLOBETASOL PROPIONATE E CREA NON-PREFERRED PA REQUIREDCLOBETASOL PROPIONATE EMOLLIENT CREA NON-PREFERRED PA REQUIREDCLOBETASOL PROPIONATE EMOLLIENT FOAM NON-PREFERRED PA REQUIREDCLOBEX LIQD NON-PREFERRED PA REQUIREDCLOBEX LOTN NON-PREFERRED PA REQUIREDCLOBEX SHAM NON-PREFERRED PA REQUIREDCLODAN SHAM NON-PREFERRED PA REQUIREDCORDRAN TAPE NON-PREFERRED PA REQUIREDHALAC KIT NON-PREFERRED PA REQUIREDHALOBETASOL PROPIONATE CREA PREFERRED -HALOBETASOL PROPIONATE OINT PREFERRED -OLUX FOAM NON-PREFERRED PA REQUIREDOLUX-E FOAM NON-PREFERRED PA REQUIREDTEMOVATE CREA NON-PREFERRED PA REQUIREDTEMOVATE OINT NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSDERMATOLOGICS : TOPICAL STEROIDS - VERY HIGH POTENCY CONT. ULTRAVATE CREA NON-PREFERRED PA REQUIRED
ULTRAVATE LOTN NON-PREFERRED PA REQUIREDULTRAVATE OINT NON-PREFERRED PA REQUIREDULTRAVATE X KIT NON-PREFERRED PA REQUIRED
DERMATOLOGICS : WOUND CARE PRODUCTS - GROWTH FACTOR AGENTS REGRANEX GEL PREFERRED PA REQUIREDDIGESTIVE AIDS : PANCREATIC ENZYMES CREON CPEP PREFERRED -
ENDOCRINE AND METABOLIC AGENTS : ANDROGENS - OTHER DANAZOL CAPS PREFERRED -ENDOCRINE AND METABOLIC AGENTS : ANDROGENS - TESTOSTERONE ANDRODERM PT24 PREFERRED PA REQUIRED
ANDROGEL GEL NON-PREFERRED PA REQUIREDANDROGEL PUMP GEL NON-PREFERRED PA REQUIREDANDROID CAPS NON-PREFERRED PA REQUIREDAVEED SOLN NON-PREFERRED PA REQUIREDDEPO-TESTOSTERONE SOLN NON-PREFERRED PA REQUIREDFORTESTA GEL NON-PREFERRED PA REQUIREDMETHITEST TABS NON-PREFERRED PA REQUIREDMETHYLTESTOSTERONE CAPS NON-PREFERRED PA REQUIREDSTRIANT MISC NON-PREFERRED PA REQUIREDTESTIM GEL NON-PREFERRED PA REQUIREDTESTOPEL PLLT NON-PREFERRED PA REQUIREDTESTOSTERONE GEL PREFERRED PA REQUIREDTESTOSTERONE SOLN NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSENDOCRINE AND METABOLIC AGENTS : ANDROGENS - TESTOSTERONE CONT. TESTOSTERONE 2% GEL NON-PREFERRED PA REQUIRED
TESTOSTERONE CYPIONATE SOLN PREFERRED -TESTOSTERONE ENANTHATE SOLN PREFERRED -TESTOSTERONE PUMP 20.25MG/ACT (1.62%) GEL NON-PREFERRED PA REQUIREDTESTOSTERONE PUMP GEL PREFERRED PA REQUIREDTESTOSTERONE TOPICAL SOLUTION SOLN NON-PREFERRED PA REQUIREDTESTRED CAPS NON-PREFERRED PA REQUIREDVOGELXO GEL NON-PREFERRED PA REQUIREDVOGELXO PUMP GEL NON-PREFERRED PA REQUIREDXYOSTED SOAJ NON-PREFERRED PA REQUIRED
ENDOCRINE AND METABOLIC AGENTS : BONE DENSITY REGULATORS - BISPHOSPHONATES ACTONEL TABS NON-PREFERRED PA REQUIRED
ALENDRONATE SODIUM SOLN PREFERRED -ALENDRONATE SODIUM TABS PREFERRED -ATELVIA TBEC NON-PREFERRED PA REQUIREDBINOSTO TBEF NON-PREFERRED PA REQUIREDBONIVA SOLN NON-PREFERRED PA REQUIREDBONIVA TABS NON-PREFERRED PA REQUIREDETIDRONATE DISODIUM TABS NON-PREFERRED -FOSAMAX TABS NON-PREFERRED PA REQUIREDFOSAMAX PLUS D TABS NON-PREFERRED PA REQUIREDIBANDRONATE SODIUM SOLN NON-PREFERRED PA REQUIREDIBANDRONATE SODIUM TABS PREFERRED -PAMIDRONATE DISODIUM SOLN NON-PREFERRED PA REQUIREDPAMIDRONATE DISODIUM SOLR NON-PREFERRED PA REQUIREDRECLAST SOLN NON-PREFERRED PA REQUIREDRISEDRONATE SODIUM TABS NON-PREFERRED -RISEDRONATE SODIUM DR TBEC NON-PREFERRED PA REQUIREDZOLEDRONIC ACID CONC PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSENDOCRINE AND METABOLIC AGENTS : BONE DENSITY REGULATORS - BISPHOSPHONATES CONT. ZOLEDRONIC ACID SOLN NON-PREFERRED PA REQUIRED
ZOLEDRONIC ACID SOLN PREFERRED PA REQUIREDZOMETA CONC NON-PREFERRED PA REQUIREDZOMETA SOLN NON-PREFERRED PA REQUIRED
ENDOCRINE AND METABOLIC AGENTS : BONE DENSITY REGULATORS - CALCITONINS CALCITONIN SALMON SOLN PREFERRED -
CALCITONIN-SALMON SOLN PREFERRED -MIACALCIN SOLN PREFERRED PA REQUIRED
ENDOCRINE AND METABOLIC AGENTS : BONE DENSITY REGULATORS - PARATHYROID HORMONE DERIVATIVES FORTEO SOLN PREFERRED PA REQUIRED
NATPARA CART NON-PREFERRED PA REQUIREDTYMLOS SOPN NON-PREFERRED PA REQUIRED
ENDOCRINE AND METABOLIC AGENTS : BONE DENSITY REGULATORS - RANK LIGAND INHIBITORS PROLIA SOLN PREFERRED PA REQUIRED
XGEVA SOLN PREFERRED PA REQUIRED
ENDOCRINE AND METABOLIC AGENTS : BONE DENSITY REGULATORS - SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS) EVISTA TABS NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSENDOCRINE AND METABOLIC AGENTS : ESTROGENS - ORAL ESTRACE TABS NON-PREFERRED PA REQUIRED
ENDOCRINE AND METABOLIC AGENTS : ESTROGENS - TOPICAL ALORA PTTW NON-PREFERRED PA REQUIRED
CLIMARA PTWK NON-PREFERRED PA REQUIREDDIVIGEL GEL NON-PREFERRED -ELESTRIN GEL NON-PREFERRED -ESTRADIOL PTTW PREFERRED -ESTRADIOL PTWK PREFERRED -EVAMIST SOLN NON-PREFERRED -MENOSTAR PTWK NON-PREFERRED -MINIVELLE PTTW NON-PREFERRED PA REQUIREDVIVELLE-DOT PTTW NON-PREFERRED PA REQUIRED
ENDOCRINE AND METABOLIC AGENTS : ESTROGENS - VAGINAL ESTRACE CREA NON-PREFERRED PA REQUIRED
ESTRADIOL CREA PREFERRED -ESTRADIOL TABS PREFERRED -ESTRING RING PREFERRED -FEMRING RING NON-PREFERRED -PREMARIN CREA PREFERRED -VAGIFEM TABS NON-PREFERRED PA REQUIREDYUVAFEM TABS PREFERRED -
ENDOCRINE AND METABOLIC AGENTS : GROWTH HORMONES GENOTROPIN SOLR PREFERRED PA REQUIRED
GENOTROPIN MINIQUICK SOLR PREFERRED PA REQUIREDHUMATROPE SOLR NON-PREFERRED PA REQUIREDHUMATROPE COMBO PACK SOLR NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSENDOCRINE AND METABOLIC AGENTS : GROWTH HORMONES CONT. NORDITROPIN CARTRIDGE SOLN PREFERRED PA REQUIRED
NORDITROPIN FLEXPRO SOLN PREFERRED PA REQUIREDNUTROPIN AQ NUSPIN 10 SOLN NON-PREFERRED PA REQUIREDNUTROPIN AQ NUSPIN 20 SOLN NON-PREFERRED PA REQUIREDNUTROPIN AQ NUSPIN 5 SOLN NON-PREFERRED PA REQUIREDOMNITROPE SOLN NON-PREFERRED PA REQUIREDOMNITROPE SOLR NON-PREFERRED PA REQUIREDSAIZEN SOLR NON-PREFERRED PA REQUIREDSAIZEN CLICK.EASY SOLR NON-PREFERRED PA REQUIREDSAIZENPREP RECONSTITUTIONKIT SOLR NON-PREFERRED PA REQUIREDSEROSTIM SOLR NON-PREFERRED PA REQUIREDZOMACTON SOLR NON-PREFERRED PA REQUIREDZORBTIVE SOLR NON-PREFERRED PA REQUIRED
ENDOCRINE AND METABOLIC AGENTS : PROGESTERONES AYGESTIN TABS NON-PREFERRED PA REQUIRED
HYDROXYPROGESTERONE CAPROATE OIL PREFERRED PA REQUIREDHYDROXYPROGESTERONE CAPROATE SOLN PREFERRED PA REQUIREDMAKENA OIL PREFERRED PA REQUIREDMAKENA SOAJ NON-PREFERRED PA REQUIREDMEDROXYPROGESTERONE ACETATE TABS PREFERRED -NORETHINDRONE ACETATE TABS PREFERRED -PROGESTERONE CAPS PREFERRED -
OIL PREFERRED -PROMETRIUM CAPS NON-PREFERRED PA REQUIREDPROVERA TABS NON-PREFERRED PA REQUIRED
ENDOCRINE AND METABOLIC AGENTS : PROGESTERONES - VAGINAL CRINONE GEL NON-PREFERRED PA REQUIREDENDOCRINE AND METABOLIC AGENTS : THYROID AGENTS - ANTITHYROID AGENTS METHIMAZOLE TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSENDOCRINE AND METABOLIC AGENTS : THYROID AGENTS - ANTITHYROID AGENTS CONT. PROPYLTHIOURACIL TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSGASTROINTESTINAL AGENTS - MISC : GALLSTONE SOLUBILIZING AGENTS CONT. URSO FORTE TABS NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSGENITOURINARY AGENTS - MISC : INTERSTITIAL CYSTITIS AGENTS ELMIRON CAPS PREFERRED PA REQUIRED
CINRYZE SOLR PREFERRED PA REQUIREDFIRAZYR SOLN PREFERRED PA REQUIREDHAEGARDA SOLR PREFERRED PA REQUIREDKALBITOR SOLN PREFERRED PA REQUIREDRUCONEST SOLR PREFERRED PA REQUIREDTAKHZYRO SOLN NON-PREFERRED PA REQUIRED
HEMATOLOGICAL AGENTS - MISC : OTHER ACTIVASE SOLR PREFERRED PA REQUIRED
CATHFLO ACTIVASE SOLR PREFERRED PA REQUIREDCEPROTIN SOLR PREFERRED PA REQUIREDPANHEMATIN SOLR PREFERRED PA REQUIREDPENTOXIFYLLINE ER TBCR PREFERRED -PROTAMINE SULFATE SOLN PREFERRED PA REQUIREDRETAVASE KIT NON-PREFERRED PA REQUIREDRETAVASE HALF-KIT KIT NON-PREFERRED PA REQUIREDSOLIRIS SOLN PREFERRED PA REQUIREDTNKASE KIT PREFERRED PA REQUIREDULTOMIRIS SOLN PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSHEMATOLOGICAL AGENTS - MISC : PLATELET AGGREGATION INHIBITORS CONT. CLOPIDOGREL TABS PREFERRED -
HEMATOPOIETIC AGENTS : AGENTS FOR GAUCHER DISEASE CERDELGA CAPS NON-PREFERRED PA REQUIRED
CEREZYME SOLR NON-PREFERRED PA REQUIREDELELYSO SOLR NON-PREFERRED PA REQUIREDMIGLUSTAT CAPS PREFERRED PA REQUIREDVPRIV SOLR NON-PREFERRED PA REQUIREDZAVESCA CAPS PREFERRED PA REQUIRED
ENDARI PACK NON-PREFERRED PA REQUIREDSIKLOS TABS PREFERRED -
HEMATOPOIETIC AGENTS : ERYTHROPOIESIS-STIMULATING AGENTS (ESAS) ARANESP ALBUMIN FREE SOLN PREFERRED PA REQUIRED
ARANESP ALBUMIN FREE SOSY PREFERRED PA REQUIREDEPOGEN SOLN PREFERRED PA REQUIREDMIRCERA SOSY NON-PREFERRED PA REQUIREDPROCRIT SOLN NON-PREFERRED PA REQUIREDRETACRIT SOLN NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSHEMATOPOIETIC AGENTS : GRANULOCYTE COLONY-STIMULATING FACTORS (G-CSF) CONT. GRANIX SOSY PREFERRED PA REQUIRED
LEUKINE SOLR NON-PREFERRED PA REQUIREDNEULASTA SOSY NON-PREFERRED PA REQUIREDNEULASTA ONPRO KIT PSKT NON-PREFERRED PA REQUIREDNEUPOGEN SOLN PREFERRED PA REQUIREDNEUPOGEN SOSY PREFERRED PA REQUIREDNIVESTYM SOSY NON-PREFERRED PA REQUIREDUDENYCA SOSY NON-PREFERRED PA REQUIREDZARXIO SOSY NON-PREFERRED PA REQUIRED
MULPLETA TABS PREFERRED PA REQUIREDNPLATE SOLR PREFERRED PA REQUIREDPROMACTA PACK PREFERRED PA REQUIREDPROMACTA TABS PREFERRED PA REQUIREDTAVALISSE TABS PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSHYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : BARBITURATE HYPNOTICS CONT. PENTOBARBITAL SODIUM SOLN PREFERRED PA REQUIRED
AMBIEN CR TBCR NON-PREFERRED PA REQUIREDEDLUAR SUBL NON-PREFERRED PA REQUIREDESZOPICLONE TABS NON-PREFERRED PA REQUIREDINTERMEZZO SUBL NON-PREFERRED PA REQUIREDLUNESTA TABS NON-PREFERRED PA REQUIREDSONATA CAPS NON-PREFERRED PA REQUIREDZALEPLON CAPS NON-PREFERRED PA REQUIREDZOLPIDEM TARTRATE SUBL PREFERRED -ZOLPIDEM TARTRATE TABS PREFERRED -ZOLPIDEM TARTRATE ER TBCR PREFERRED -ZOLPIMIST SOLN NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSHYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : SELECTIVE MELATONIN RECEPTOR AGONISTS HETLIOZ CAPS NON-PREFERRED PA REQUIRED
ROZEREM TABS PREFERRED PA REQUIREDHYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : TRICYCLIC AGENTS BELSOMRA TABS NON-PREFERRED PA REQUIRED
SILENOR TABS NON-PREFERRED PA REQUIREDMISCELLANEOUS THERAPEUTIC CLASSES : CHELATING AGENTS CUPRIMINE CAPS PREFERRED PA REQUIRED
DEPEN TITRATABS TABS PREFERRED PA REQUIREDD-PENAMINE TABS NON-PREFERRED PA REQUIREDSYPRINE CAPS NON-PREFERRED PA REQUIREDTRIENTINE HYDROCHLORIDE CAPS PREFERRED PA REQUIRED
BACLOFEN SOLN NON-PREFERRED PA REQUIREDBACLOFEN TABS PREFERRED -BACLOFEN 5MG TABS NON-PREFERRED PA REQUIREDCARISOPRODOL TABS NON-PREFERRED PA REQUIREDCARISOPRODOL/ASPIRIN TABS NON-PREFERRED PA REQUIREDCARISOPRODOL/ASPIRIN/CODEINE TABS NON-PREFERRED PA REQUIREDCHLORZOXAZONE TABS NON-PREFERRED -CYCLOBENZAPRINE HYDROCHLORIDE TABS PREFERRED -DANTRIUM CAPS NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSMUSCULOSKELETAL THERAPY AGENTS : SKELETAL MUSCLE RELAXANTS CONT. DANTRIUM IV SOLR PREFERRED PA REQUIRED
DANTROLENE SODIUM CAPS NON-PREFERRED -FEXMID TABS NON-PREFERRED PA REQUIREDGABLOFEN SOLN NON-PREFERRED PA REQUIREDGABLOFEN SOSY NON-PREFERRED PA REQUIREDLIORESAL INTRATHECAL SOLN NON-PREFERRED PA REQUIREDLORZONE TABS NON-PREFERRED -METAXALL TABS NON-PREFERRED -METAXALONE TABS NON-PREFERRED -METHOCARBAMOL SOLN NON-PREFERRED PA REQUIREDMETHOCARBAMOL TABS PREFERRED -ORPHENADRINE CITRATE SOLN NON-PREFERRED PA REQUIREDORPHENADRINE CITRATE ER TB12 NON-PREFERRED -REVONTO SOLR PREFERRED PA REQUIREDROBAXIN SOLN NON-PREFERRED PA REQUIREDROBAXIN TABS NON-PREFERRED PA REQUIREDROBAXIN-750 TABS NON-PREFERRED PA REQUIREDRYANODEX SUSR PREFERRED PA REQUIREDSKELAXIN TABS NON-PREFERRED PA REQUIREDSOMA TABS NON-PREFERRED PA REQUIREDTIZANIDINE HCL CAPS NON-PREFERRED PA REQUIREDTIZANIDINE HCL TABS PREFERRED -TIZANIDINE HYDROCHLORIDE CAPS NON-PREFERRED PA REQUIREDTIZANIDINE HYDROCHLORIDE TABS PREFERRED -ZANAFLEX CAPS NON-PREFERRED PA REQUIREDZANAFLEX TABS NON-PREFERRED PA REQUIRED
NEUROMUSCULAR AGENTS : ALS AGENTS - BENZATHIAZOLES RILUTEK TABS NON-PREFERRED PA REQUIRED
RILUZOLE TABS PREFERRED -TIGLUTIK SUSP NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSNEUROMUSCULAR AGENTS : ANTIMYASTHENIC/CHOLINERGIC AGENTS ENLON SOLN PREFERRED PA REQUIRED
FIRDAPSE TABS NON-PREFERRED PA REQUIREDGUANIDINE HCL TABS NON-PREFERRED -MESTINON SYRP NON-PREFERRED PA REQUIREDMESTINON TABS NON-PREFERRED PA REQUIREDMESTINON TIMESPAN TBCR NON-PREFERRED PA REQUIREDNEOSTIGMINE METHYLSULFATE SOLN PREFERRED PA REQUIREDPYRIDOSTIGMINE BROMIDE TABS PREFERRED -PYRIDOSTIGMINE BROMIDE ER TBCR PREFERRED -REGONOL SOLN PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSOPHTHALMIC AGENTS : NONSTEROIDAL ANTI-INFLAMMATORY AGENTS ACULAR SOLN NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSOPHTHALMIC AGENTS : OPHTHALMIC ANTIBIOTICS CONT. NEO-POLYCIN OINT NON-PREFERRED -
NEOSPORIN SOLN NON-PREFERRED PA REQUIREDOCUFLOX SOLN NON-PREFERRED PA REQUIREDOFLOXACIN SOLN PREFERRED -POLYCIN OINT NON-PREFERRED -POLYMYXIN B SULFATE/TRIMETHOPRIM SULFATE SOLN PREFERRED -POLYTRIM SOLN NON-PREFERRED PA REQUIREDTOBRAMYCIN SOLN PREFERRED -TOBRAMYCIN SULFATE SOLN PREFERRED -TOBREX OINT NON-PREFERRED -TOBREX SOLN NON-PREFERRED PA REQUIREDTRIMETHOPRIM SULFATE/POLYMYXIN B SULFATE SOLN PREFERRED -VIGAMOX SOLN PREFERRED -ZYMAXID SOLN NON-PREFERRED PA REQUIRED
BLEPHAMIDE S.O.P. OINT NON-PREFERRED PA REQUIREDMAXITROL OINT NON-PREFERRED PA REQUIREDMAXITROL SUSP NON-PREFERRED PA REQUIREDNEOMYCIN/POLYMYXIN/BACITRACIN/HYDROCORTISONEOINT NON-PREFERRED -NEOMYCIN/POLYMYXIN/DEXAMETHASONE OINT PREFERRED -NEOMYCIN/POLYMYXIN/DEXAMETHASONE SUSP PREFERRED -NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP NON-PREFERRED -NEO-POLYCIN HC OINT NON-PREFERRED -PRED-G SUSP NON-PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSOPHTHALMIC AGENTS : OPHTHALMIC ANTIBIOTIC-STEROID COMBINATIONS CONT. PRED-G S.O.P. OINT NON-PREFERRED -
SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSSOLN PREFERRED -TOBRADEX OINT PREFERRED -TOBRADEX SUSP NON-PREFERRED PA REQUIREDTOBRADEX ST SUSP NON-PREFERRED PA REQUIREDTOBRAMYCIN/DEXAMETHASONE SUSP PREFERRED -ZYLET SUSP NON-PREFERRED -
INTUNIV TB24 NON-PREFERRED PA REQUIREDSTRATTERA CAPS NON-PREFERRED PA REQUIRED
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC : ADHD / ANTI-NARCOLEPSY - STIMULANTS - LONG ACTING ADDERALL XR CP24 NON-PREFERRED PA REQUIRED
ADZENYS ER SUER NON-PREFERRED -ADZENYS XR-ODT TBED NON-PREFERRED -AMPHETAMINE/DEXTROAMPHETAMINE CP24 PREFERRED -APTENSIO XR CP24 PREFERRED -CONCERTA TBCR NON-PREFERRED PA REQUIREDCOTEMPLA XR-ODT TBED NON-PREFERRED PA REQUIREDDAYTRANA PTCH NON-PREFERRED PA REQUIREDDEXEDRINE CP24 NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUS
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC : ADHD / ANTI-NARCOLEPSY - STIMULANTS - LONG ACTING CONT. DEXMETHYLPHENIDATE HCL ER CP24 PREFERRED -
DEXMETHYLPHENIDATE HYDROCHLORIDE CP24 PREFERRED -DEXMETHYLPHENIDATE HYDROCHLORIDE ER CP24 PREFERRED -DEXTROAMPHETAMINE SULFATE ER CP24 PREFERRED -DYANAVEL XR SUER NON-PREFERRED -FOCALIN XR CP24 NON-PREFERRED PA REQUIREDMETADATE ER TBCR PREFERRED -METHYLPHENIDATE HYDROCHLORIDE CD CPCR PREFERRED -METHYLPHENIDATE HYDROCHLORIDE ER CP24 PREFERRED -METHYLPHENIDATE HYDROCHLORIDE ER CPCR PREFERRED -METHYLPHENIDATE HYDROCHLORIDE ER TB24 PREFERRED -METHYLPHENIDATE HYDROCHLORIDE ER TBCR PREFERRED -METHYLPHENIDATE HYDROCHLORIDE ER (LA) CP24 PREFERRED -METHYLPHENIDATE HYDROCHLORIDE ER 72MG TBCR NON-PREFERRED -MYDAYIS CP24 NON-PREFERRED -QUILLICHEW ER CHER PREFERRED -QUILLIVANT XR SUSR PREFERRED -RELEXXII TBCR NON-PREFERRED -RITALIN LA CP24 NON-PREFERRED PA REQUIREDVYVANSE CAPS PREFERRED -VYVANSE CHEW PREFERRED -
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC : ADHD / ANTI-NARCOLEPSY - STIMULANTS - MISC ARMODAFINIL TABS PREFERRED PA REQUIRED
DESOXYN TABS NON-PREFERRED PA REQUIREDMETHAMPHETAMINE HCL TABS NON-PREFERRED PA REQUIREDMODAFINIL TABS PREFERRED PA REQUIREDNUVIGIL TABS NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC : ADHD / ANTI-NARCOLEPSY - STIMULANTS - MISC CONT. PROVIGIL TABS NON-PREFERRED PA REQUIREDPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC : ADHD / ANTI-NARCOLEPSY - STIMULANTS - SHORT ACTING ADDERALL TABS NON-PREFERRED PA REQUIRED
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC : OTHER ERGOLOID MESYLATES TABS PREFERRED -
GRALISE TABS NON-PREFERRED PA REQUIREDGRALISE STARTER MISC NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC : OTHER CONT. HORIZANT TBCR NON-PREFERRED PA REQUIRED
LYRICA CR TB24 NON-PREFERRED PA REQUIREDNUEDEXTA CAPS NON-PREFERRED PA REQUIREDORAP TABS NON-PREFERRED PA REQUIREDPIMOZIDE TABS PREFERRED -SAVELLA TABS NON-PREFERRED PA REQUIREDSAVELLA TITRATION PACK MISC NON-PREFERRED PA REQUIREDXYREM SOLN NON-PREFERRED PA REQUIRED
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC : SMOKING DETERRENTS - NICOTINE REPLACEMENT PRODUCTS COMMIT LOZG NON-PREFERRED PA REQUIRED
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC : SMOKING DETERRENTS - OTHER BUPROPION HYDROCHLORIDE ER (SR) TB12 PREFERRED -
CHANTIX TABS PREFERRED -CHANTIX CONTINUING MONTH PAK TABS PREFERRED -CHANTIX STARTING MONTH PAK TABS PREFERRED -
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC : SMOKING DETERRENTS - OTHER CONT. ZYBAN TB12 NON-PREFERRED PA REQUIRED
Apple Health (Medicaid) Preferred Drug ListEffective April 1, 2019
(Eff. 4/1/2019) Apple Health PDL
APPLE HEALTH DRUG CLASS DRUG NAME DOSE FORM PREFERRED STATUS PA STATUSSUBSTANCE USE DISORDER : OPIOID ANTAGONISTS CONT. VIVITROL SUSR PREFERRED -SUBSTANCE USE DISORDER : OPIOID PARTIAL AGONISTS BUNAVAIL FILM NON-PREFERRED PA REQUIRED
BUPRENORPHINE HCL SUBL NON-PREFERRED PA REQUIREDBUPRENORPHINE HCL/NALOXONE HCL SUBL PREFERRED -BUPRENORPHINE HCL/NALOXONE HCL FILM NON-PREFERRED PA REQUIREDPROBUPHINE IMPLANT KIT IMPL NON-PREFERRED PA REQUIREDSUBLOCADE SOSY NON-PREFERRED PA REQUIREDSUBOXONE FILM PREFERRED -ZUBSOLV SUBL NON-PREFERRED PA REQUIRED
SUBSTANCE USE DISORDER : OTHER LUCEMYRA TABS NON-PREFERRED PA REQUIREDVASOPRESSORS : MISC DOBUTAMINE HCL SOLN PREFERRED PA REQUIRED
DOBUTAMINE HCL/D5W SOLN PREFERRED PA REQUIREDDOBUTAMINE HYDROCHLORIDE/DEXTROSE SOLN PREFERRED PA REQUIREDDOBUTAMINE/DEXTROSE 5% SOLN PREFERRED PA REQUIREDDOPAMINE HCL SOLN PREFERRED PA REQUIREDDOPAMINE HYDROCHLORIDE/DEXTROSE SOLN PREFERRED PA REQUIREDDOPAMINE/D5W SOLN PREFERRED PA REQUIREDEPHEDRINE SULFATE SOLN PREFERRED PA REQUIREDEPINEPHRINE HCL SOLN PREFERRED PA REQUIREDEPINEPHRINE HCL SOSY PREFERRED PA REQUIREDLEVOPHED SOLN PREFERRED PA REQUIREDMIDODRINE HCL TABS PREFERRED -MIDODRINE HYDROCHLORIDE TABS PREFERRED -NOREPINEPHRINE BITARTRATE SOLN PREFERRED PA REQUIREDNORTHERA CAPS NON-PREFERRED PA REQUIREDPHENYLEPHRINE HCL SOLN PREFERRED PA REQUIREDPHENYLEPHRINE HYDROCHLORIDE SOLN PREFERRED PA REQUIRED