GA-MED-M-2965031-SPA 2026 GA P4HB_FP

Planificac in familiar-Programa Planning for Healthy Babies (P4HB) Con vigenc ia a partir del 1/1/2026Planificacin familia r-Programa Planning f or Healt hy Babies (P 4HB) de CareSource 1/1/2026 INTRODUCCIN Este es el Formulario o la Lista de medicamentos preferidos (Preferred Drug List, PDL) de Medicaid de CareSource de 2026. Esta lista puede ayudarles a los proveedores en la seleccin de productos clnicamente adecuados y de menor precio. Todos los medicamentos de Medicaid de Georgia estn cubiertos por CareSource. Esta es solo una lista de medicamentos preferidos. Estos medicamentos han sido revisados por el Comit de Farmacia y Teraputica (Pharmacy and Therapeutics, P&T) de CareSource. La lista se encuentra actualiz ada al momento de la revisin. No prometemos la exactitud de los datos. Tampoco pretende ser una lista completa. No sustituy e el c onocimiento, la habilidad y el criterio del proveedor. Todos los datos de la lista constituyen una gua. Los proveedores son totalmente responsables de todas las opciones de medicamentos. La lista est sujeta a las ley es y normas especficas en cada estado. Estas pueden ser, entre otras: l as de la opc in genric a;las listas de sustanc ias c ontroladas;la pref erenc ia por la m arc a;los m edic am entos genric os obligatorios (c uando c orresponda).No asum im os ninguna responsabilidad por las ac c iones o brec has de ningn prov eedor. Deben rev isar los datos de los produc tos del f abric ante de m edic am entos o las ref erenc ias estndar. PREFACIO La lista est ordenada por sec c iones. Cada sec cin se div ide por c lase de m edicamento teraputic o, segn el m todo de ac c in. Los produc tos se m encionan por nom bre genrico. El nom bre de m arc a tam bin f igura en la lista. Esto es solo a f ines inf orm ativ os. A m enos que el m edic am ento sea una iny ec c in o un c aso espec ial, se m enc iona la dosis, las f orm as y las c onc entrac iones. COMIT DE P&T Se usa un Com it nac ional de P&T para aprobar terapias f arm ac olgic as seguras y tiles. Est c om puesto por: los direc tores m dic os del plan;el personal de f arm ac ia;personas de la c om unidad m dic a.DETALLES SOBRE LA COBERTURA DE MEDICAMENTOS Solo se puede c ubrir una c onc entracin, dosif icacin u otra f ormulacin si se inc luy e en la lista. No se c ubr en otras c onc entraciones, dosificaciones ni f orm ulac iones. Por ejem plo: f orm as iny ec tables del produc to. Los produc tos de liberac in prolongada y retardada tienen su propio listado. metformina GlucophageLa lista de produc tos de liberac in inm ediata no tendra el produc to de liberac in ex tendida. metformina ext-rel Glucophage XRUna segunda lista m uestra el produc to de liberac in prolongada. Las f orm as de dosif ic ac in se inc luirn en la sec c in en que se m enc ionan. Neomicina/polimixina B/hidrocortisona Cortisporin Cortisporin solo f igura en la lista de TICOS. Se lim ita a la soluc in y la suspensin. No se puede asum ir que la c rem a f igura en la lista. Debera f orm ar parte de la sec c in DERM ATOLOGA. Autorizacin previa (PA) CareSourc e puede nec esitar que los prov eedores nos inf orm en por qu es nec esario un m edic am ento o una c antidad. Esto se denom ina PA (Prior Authorization). CareSourc e debe autorizar esta solic itud antes de que un af iliado rec iba el m edic am ento. "PA" signif ic a que se nec esita una autorizac in prev ia. Estas son algunas de las razones para una PA: Ex iste un m edic am ento genric o o alternativ o disponible.Podra haber abuso o uso indebido del m edic am ento.El m edic am ento nec esita un m anejo espec ial, superv isin o tiene un env o lim itado.Ex isten otros m edic am entos que se deben probar prim ero.Solicitudes de PA Los asoc iados de salud pueden solic itar una autorizac in prev ia en lnea o por f ax . Obtenga m s inf orm ac in en la pgina de Prov eedores en CareSource.com . Es posible que no aprobem os una solic itud de PA para un m edic am ento. Si no lo hac em os, le direm os al af iliado c m o apelar. Lmites de cantidad Algunos m edic am entos pueden tener lm ites sobre c unto se puede adm inistrar de una v ez. La abreviatura "QL" (Quantity Lim its) se usa para indic ar que hay un lm ite de c antidad. Los QL se basan en la dosis sugerida por los f abric antes de m edic am entos. Tam bin se tiene en c uenta la seguridad del pac iente. La terapia c on analgsic os opioides puede tener lm ites de c antidad. Estos se basan en la dosis rec om endada por los f abric antes de m edic am entos y /o en los reglam entos estatales. Los lm ites de c antidad se enc uentran en la lista a c ontinuac in. Terapia escalonada Es posible que los af iliados deban probar un m edic am ento antes de tom ar otro. Esto se denom i na terapia esc alonada. Se debe probar un m edic am ento antes de que se apruebe el uso de otro. CareSourc e c ubrir c iertos m edic am entos solo si se sigue el protoc olo de terapia esc alonada. Cuando es nec esario, se usa "ST" (Step Therapy ) en la lista. Planificacin familiar-Programa Planning for Healthy Babies (P4HB) Con vigenc ia a partir del 1/1/2026Sustitucin por medicamento genrico e intercambio teraputico La sustituc in por un m edic am ento genric o es una ac c in de la f arm ac ia. Se of rec e una v ersin genri c a en lugar de un produc to de m arc a. La letra c ursiv a signif ic a que ex iste un genric o. No todas las c onc entrac iones o f orm as de dosif ic ac in del genric o pueden estar disponibles c om o genric os. Un m edic am ento de m arc a que c ontenga un produc to genric o no pertenec er al f orm ulario. Se c ubrir el produc to genric o en lugar del produc to de m arc a. La lista est sujeta a los reglam entos estatales y a las norm as sobre la sustituc in por m edic am entos genric os. Los m edic am entos genric os c on f rec uenc ia tienen un prec io m s bajo que los m edic am entos de m arc a. Se deben presc ribir en prim er lugar si se siguen los estndares. Los m edic am entos genric os de v enta c on rec eta estn: Aprobados por la Adm inistrac in de Alim entos y Medic am entos (Food and DrugAdm inistration, FDA) de EE. UU. Esto es por m otiv o de seguridad y ef ic ac ia. Estn f abric ados bajo los m ism os estndares estric tos que los produc tos de m arc a.Se probaron en hum anos. El genric o se debe absorber a la m ism a v eloc idad que el produc to de m arc a. Puede dif erir de la m arc a en el tam ao, el c olor y los ingredientes inac tiv os. Esto no altera su uso.Fabric ados c on la m ism a c onc entrac in y la m ism a f orm a de dosif ic ac in que los m edi c am entos de m arc a.Un m edic am ento genric o tendr el m ism o ef ec to y ser tan seguro c om o el de m arc a. DISEO DEL PLAN La lista m uestra un diseo c errado de plan del f orm ulario. Los m edic am entos inc luidos en la lista est n c ubiertos por el plan segn se m uestra. Ciertos m edic am entos estn c ubiertos si se c um plen c on los estndares de gestin de uso. Puede ser ST, PA y /o QL. Se rev isarn las solic itudes de m edic am entos que no c um plan c on los estndares de la lista. Si un m edic am ento no est en la lista, puede solic itar una ex c epc in al f ormulario para la c obertura. Se rev isarn la nec esidad m dic a o la ex c epc in al f ormulario. Esto se basa en m edidas de PA o los c riterios de presc ripc in estndar que no pertenec en al f ormulario. Un af iliado o un prov eedor pueden solic itar una ex cepcin al f orm ulario. Com plete el f orm ulario que se enc uentra en la pgina de la PDL en CareSource.com . AVISO Los datos de esta lista son priv ados. La inf orm ac in no se puede c opiar en su totalidad o en part e sin una autorizac in por esc rito. 2024. Todos los derec hos reserv ados. Esta lista c ontiene m edic am entos c on rec eta de m arc a que son m arc as c om erc iales o m arc as regi stradas. CareSourc e no opera las organizac iones que se m enc ionan en esta lista. CareSourc e no es responsable de la c onf iabilidad del c ontenido. Estas listas no son una rec om endacin de CareSourc e. Nota: Esta lista se actualiz a peridicamente. Es posible que los cambios aparez can antes de su fecha de entrada en vigencia. Planificacin familiar-Programa Planning for Healthy Babies (P4HB) Con vigenc ia a partir del 1/1/2026List of Abbreviations 1: Pr eferred generic product 2: Pr eferred brand product ACA: A ffordable Care Act AR: A ge Restriction. For certain drugs, the drug may be covered for members in a certain age range without a prior authorization. OTC : Over-the-Counter. An OTC drug is a non-prescription drug. PA: P rior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you dont get approval, we may not cover the drug. QL: Q uantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: S tep Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, we may not cover Drug Bunless you try Drug A first. If Drug A does not work for you, we will then cover Drug B . Georgia P4HB Family PlanningTable of ContentsANESTHETICS……………………………………………………………………………………………………………………………………. 3ANTIARTHRITICS ………………………………………………………………………………………………………………………………… 3ANTIBIOTICS ………………………………………………………………………………………………………………………………………. 3ANTIFUNGALS ……………………………………………………………………………………………………………………………………. 4ANTIVIRALS ……………………………………………………………………………………………………………………………………….. 4BIOLOGICALS …………………………………………………………………………………………………………………………………….. 4CONTRACEPTIVES …………………………………………………………………………………………………………………………….. 4PRE-NATAL VITAMINS ………………………………………………………………………………………………………………………… 62 CURRENT AS OF 1/1/2026Drug NameTierRestrictions / LimitsANESTHETICS phenazopyridine oral tablet 100 mg, 200 mg1ANTIARTHRITICSnaproxen oral tablet,delayed release(dr/ec)1naproxen sodium oral tablet 275 mg, 550 mg1ANTIBIOTICSamoxicillin oral capsule1amoxicillin oral suspension for reconstitution1amoxicillin oral tablet1amoxicillin oral tablet,chewable 125 mg1amoxicillin-pot clavulanate oral suspension for reconstitution1amoxicillin-pot clavulanate oral tablet1amoxicillin-pot clavulanate oral tablet,chewable1ampicillin1AVIDOXY1azithromycin oral1cefadroxil1cefdinir1cefpodoxime1cefprozil1cefuroxime axetil1cephalexin oral capsule250 mg, 500 mg1cephalexin oral suspension for reconstitution1ciprofloxacin hcl oral1 Drug NameTier Restrictions /Limits ciprofloxacin oral suspension,microcapsul e recon 250 mg/5 ml 1 clarithromycin1 clindamycin hcl1 CLINDAMYCINPEDIATRIC1 clindamycin phosphate vaginal1 dicloxacillin1 E.E.S. 4001 ERY-TAB ORALTABLET,DELAYEDRELEASE (DR/EC) 250MG, 333 MG1 ERYTHROCIN (ASSTEARATE)1 erythromycin ethylsuccinate1 erythromycin oral capsule,delayed release(dr/ec)1 erythromycin oral tablet1 erythromycin oral tablet,delayed release(dr/ec) 250 mg1 levofloxacin oral1 metronidazole oral capsule1 metronidazole oral tablet 250 mg, 500 mg1 metronidazole vaginal gel 0.75 % (37.5mg/5gram)1QL (99 GM per99 days)minocycline oral capsule 1 minocycline oral tablet1 MONDOXYNE NL1 MORGIDOX1 neomycin1 nitrofurantoin macrocrystal1GEORGIA P4HB FAMILY PLANNING | Effective 01/01/20263 Drug NameTier Restrictions /Limits nitrofurantoin monohyd/m-cryst 1nitrofurantoin oral suspension 25 mg/5 ml1penicillin v potassium1sulfamethoxazole-trimethoprim oral1SULFATRIM1trimethoprim1URELLE2URETRON D-S1VANDAZOLE1QL (99 GM per99 days)ANTIFUNGALS clotrimazole mucous membrane1fluconazole1griseofulvin microsize1griseofulvin ultramicrosize oral tablet 125 mg, 250 mg1ketoconazole oral1nystatin oral tablet1terbinafine hcl oral1QL (99 EA per99 days)terconazole 1ANTIVIRALSvalacyclovir1BIOLOGICALSADACEL(TDAPADOLESN/ADULT)(PF)2BOOSTRIX TDAP2ENGERIX-B (PF)2ENGERIX-BPEDIATRIC (PF)2HEPLISAV-B (PF)2RECOMBIVAX HB (PF)INTRAMUSCULARSUSPENSION 40MCG/ML, 5 MCG/0.5ML2 Drug NameTier Restrictions /LimitsRECOMBIVAX HB (PF)INTRAMUSCULARSYRINGE 2 TENIVAC (PF)2 CONTRACEPTIVESAFIRMELLE1 ALTAVERA (28)1 ALYACEN 1/35 (28)1 ALYACEN 7/7/7 (28)1 AMETHIA1QL (99 EA per99 days)AMETHYST (28) 1QL (99 EA per99 days)APRI 1 ARANELLE (28)1 ASHLYNA1QL (99 EA per99 days)AUBRA 1 AUBRA EQ1 AUROVELA 1.5/30 (21)1 AUROVELA 1/20 (21)1 AUROVELA 24 FE1 AUROVELA FE 1.5/30(28)1 AUROVELA FE 1-20(28)1 AVIANE1 AYUNA1 AZURETTE (28)1 BALZIVA (28)1 BLISOVI 24 FE1 BLISOVI FE 1.5/30 (28)1 BLISOVI FE 1/20 (28)1 BRIELLYN1 CAMILA1 CAMRESE1QL (99 EA per99 days)CAMRESE LO 1QL (99 EA per99 days)CAZIANT (28) 1GEORGIA P4HB FAMILY PLANNING | Effective 01/01/20264 Drug NameTier Restrictions /LimitsCHATEAL EQ (28) 1CRYSELLE (28)1CYRED1CYRED EQ1DASETTA 1/35 (28)1DASETTA 7/7/7 (28)1DAYSEE1QL (99 EA per99 days)DEBLITANE 1desog-e.estradiol/e.estradiol1drospirenone-ethinyl estradiol1ELINEST1ELURYNG1ENPRESSE1ENSKYCE1ERRIN1ESTARYLLA1ethynodiol diac-eth estradiol1etonogestrel-ethinyl estradiol1FALMINA (28)1HAILEY1HAILEY 24 FE1HEATHER1INCASSIA1ISIBLOOM1JASMIEL (28)1JENCYCLA1JOLESSA1QL (99 EA per99 days)JULEBER 1JUNEL 1.5/30 (21)1JUNEL 1/20 (21)1JUNEL FE 1.5/30 (28)1JUNEL FE 1/20 (28)1JUNEL FE 241 Drug NameTier Restrictions /LimitsKAITLIB FE 1 KALLIGA1 KARIVA (28)1 KELNOR 1/35 (28)1 KURVELO (28)1 l norgest/e.estradiol-e.estrad1QL (99 EA per99 days)LARIN 1.5/30 (21) 1 LARIN 1/20 (21)1 LARIN 24 FE1 LARIN FE 1.5/30 (28)1 LARIN FE 1/20 (28)1 LESSINA1 LEVONEST (28)1 levonorgestrel-ethinyl estrad oral tablet 0.1-20mg-mcg, 0.15-0.03 mg1 levonorgestrel-ethinyl estrad oral tablet 90-20mcg (28)1QL (99 EA per99 days)levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 1QL (99 EA per99 days)levonorg-eth estrad triphasic 1 LEVORA-281 LORYNA (28)1 LOW-OGESTREL (28)1 LO-ZUMANDIMINE (28)1 LUTERA (28)1 LYZA1 MARLISSA (28)1 medroxyprogesterone intramuscular1QL (99 ML per99 days)MICROGESTIN 1.5/30(21) 1 MICROGESTIN 1/20(21)1 MICROGESTIN FE1.5/30 (28)1GEORGIA P4HB FAMILY PLANNING | Effective 01/01/20265 Drug NameTier Restrictions /LimitsMICROGESTIN FE1/20 (28) 1MILI1MONO-LINYAH1NECON 0.5/35 (28)1NIKKI (28)1NORA-BE1noreth-ethinyl estradiol-iron1norethindrone(contraceptive)1norethindrone ac-eth estradiol oral tablet 1-20mg-mcg, 1.5-30 mg-mcg1norethindrone-e.estradiol-iron oral tablet1norgestimate-ethinyl estradiol1NORTREL 0.5/35 (28)1NORTREL 1/35 (21)1NORTREL 1/35 (28)1NORTREL 7/7/7 (28)1OCELLA1PHILITH1PIMTREA (28)1PORTIA 281RECLIPSEN (28)1SETLAKIN1QL (99 EA per99 days)SHAROBEL 1SIMLIYA (28)1SIMPESSE1QL (99 EA per99 days)SPRINTEC (28) 1SRONYX1SYEDA1TARINA 24 FE1TARINA FE 1/20 (28)1 Drug NameTier Restrictions /LimitsTARINA FE 1-20 EQ(28) 1 TILIA FE1 TRI-ESTARYLLA1 TRI-LEGEST FE1 TRI-LINYAH1 TRI-LO-ESTARYLLA1 TRI-LO-MARZIA1 TRI-LO-MILI1 TRI-LO-SPRINTEC1 TRI-MILI1 TRI-SPRINTEC (28)1 TRI-VYLIBRA1 TRI-VYLIBRA LO1 TULANA1 VELIVET TRIPHASICREGIMEN (28)1 VIENVA1 VIORELE (28)1 VYFEMLA (28)1 VYLIBRA1 WERA (28)1 WYMZYA FE1 XULANE1 ZAFEMY1 ZARAH1 ZUMANDIMINE (28)1 PRE-NATALVITAMINSKOSHER PRENATALPLUS IRON2 M-NATAL PLUS1 PRENATABS FA1 PRENATABS RX1 PRENATAL 19 ORALTABLET,CHEWABLE2 PRENATAL PLUS1 PRENATAL PLUS(CALCIUM CARB)1GEORGIA P4HB FAMILY PLANNING | Effective 01/01/20266 Drug NameTier Restrictions /LimitsPRENATAL VITAMINPLUS LOW IRON 1SE-NATAL 19CHEWABLE1THRIVITE RX2TRICARE2TRINATAL RX 11GEORGIA P4HB FAMILY PLANNING | Effective 01/01/20267 IndexADACEL(TDAP ADOLESN/ADULT)(PF)……………4AFIRMELLE …………………………… 4ALTAVERA (28) ……………………… 4ALYACEN 1/35 (28) …………………4ALYACEN 7/7/7 (28) ………………..4AMETHIA ………………………………. 4AMETHYST (28) ……………………..4amoxicillin ………………………………. 3amoxicillin-pot clavulanate ………..3ampicillin ………………………………… 3APRI ……………………………………… 4ARANELLE (28) ……………………… 4ASHLYNA ……………………………… 4AUBRA ………………………………….. 4AUBRA EQ …………………………….. 4AUROVELA 1.5/30 (21) ……………4AUROVELA 1/20 (21) ………………4AUROVELA 24 FE …………………..4AUROVELA FE 1.5/30 (28) ……….4AUROVELA FE 1-20 (28) ………….4AVIANE …………………………………. 4AVIDOXY ………………………………. 3AYUNA ………………………………….. 4azithromycin …………………………… 3AZURETTE (28) ……………………… 4BALZIVA (28) …………………………. 4BLISOVI 24 FE ……………………….. 4BLISOVI FE 1.5/30 (28) ……………4BLISOVI FE 1/20 (28) ………………4BOOSTRIX TDAP ……………………4BRIELLYN ……………………………… 4CAMILA …………………………………. 4CAMRESE ……………………………… 4CAMRESE LO ………………………… 4CAZIANT (28) …………………………. 4cefadroxil ……………………………….. 3cefdinir …………………………………… 3cefpodoxime …………………………… 3cefprozil …………………………………. 3cefuroxime axetil ……………………..3cephalexin ……………………………… 3CHATEAL EQ (28) …………………..5ciprofloxacin …………………………… 3ciprofloxacin hcl ………………………. 3clarithromycin ………………………….3clindamycin hcl ……………………….. 3CLINDAMYCIN PEDIATRIC ……..3clindamycin phosphate ……………..3clotrimazole ……………………………. 4CRYSELLE (28) ……………………… 5CYRED ………………………………….. 5CYRED EQ …………………………….. 5DASETTA 1/35 (28) …………………5DASETTA 7/7/7 (28)………………..5DAYSEE ………………………………… 5DEBLITANE …………………………… 5desog-e.estradiol/e.estradiol ……..5dicloxacillin …………………………….. 3drospirenone-ethinyl estradiol ……5E.E.S. 400 ……………………………… 3ELINEST ……………………………….. 5ELURYNG ……………………………… 5ENGERIX-B (PF) ……………………..4ENGERIX-B PEDIATRIC (PF) …..4ENPRESSE ……………………………. 5ENSKYCE ……………………………… 5ERRIN …………………………………… 5ERY-TAB ……………………………….. 3ERYTHROCIN (AS STEARATE) …………………………… 3erythromycin …………………………… 3erythromycin ethylsuccinate ………3ESTARYLLA ………………………….. 5ethynodiol diac-eth estradiol ………5etonogestrel-ethinyl estradiol …….5FALMINA (28) ………………………… 5fluconazole …………………………….. 4griseofulvin microsize ……………….4griseofulvin ultramicrosize …………4HAILEY …………………………………. 5HAILEY 24 FE ………………………… 5HEATHER ……………………………… 5HEPLISAV-B (PF) ……………………4INCASSIA ……………………………… 5ISIBLOOM ……………………………… 5JASMIEL (28) …………………………. 5JENCYCLA ……………………………..5JOLESSA ………………………………. 5JULEBER ………………………………. 5JUNEL 1.5/30 (21) ……………………5 JUNEL 1/20 (21)………………………5JUNEL FE 1.5/30 (28) ………………5JUNEL FE 1/20 (28) …………………5JUNEL FE 24 …………………………. 5KAITLIB FE ……………………………. 5KALLIGA ……………………………….. 5KARIVA (28) …………………………… 5KELNOR 1/35 (28) …………………..5ketoconazole ………………………….. 4KOSHER PRENATAL PLUS IRON …………………………………….. 6KURVELO (28) ……………………….. 5l norgest/e.estradiol-e.estrad ……..5LARIN 1.5/30 (21) ……………………5LARIN 1/20 (21) ……………………… 5LARIN 24 FE ………………………….. 5LARIN FE 1.5/30 (28) ……………….5LARIN FE 1/20 (28)………………….5LESSINA ……………………………….. 5levofloxacin ……………………………. 3LEVONEST (28) ……………………… 5levonorgestrel-ethinyl estrad ……..5levonorg-eth estrad triphasic ……..5LEVORA-28 …………………………… 5LORYNA (28) …………………………. 5LOW-OGESTREL (28) ……………..5LO-ZUMANDIMINE (28) ……………5LUTERA (28) ………………………….. 5LYZA …………………………………….. 5MARLISSA (28) ………………………. 5medroxyprogesterone ………………5metronidazole …………………………. 3MICROGESTIN 1.5/30 (21) ……….5MICROGESTIN 1/20 (21) ………….5MICROGESTIN FE 1.5/30 (28) ….5MICROGESTIN FE 1/20 (28) …….6MILI ………………………………………. 6minocycline …………………………….. 3M-NATAL PLUS ……………………… 6MONDOXYNE NL ……………………3MONO-LINYAH ………………………. 6MORGIDOX …………………………… 3naproxen ……………………………….. 3naproxen sodium ……………………..3NECON 0.5/35 (28) ………………….6neomycin ……………………………….. 3NIKKI (28) ……………………………… 6nitrofurantoin ………………………….. 4nitrofurantoin macrocrystal ………..3nitrofurantoin monohyd/m-cryst ….4NORA-BE ………………………………. 6noreth-ethinyl estradiol-iron ……….6norethindrone (contraceptive) ……6norethindrone ac-eth estradiol ……6norethindrone-e.estradiol-iron ……6norgestimate-ethinyl estradiol ……6NORTREL 0.5/35 (28) ………………6NORTREL 1/35 (21) …………………6NORTREL 1/35 (28) …………………6NORTREL 7/7/7 (28) ………………..6nystatin ………………………………….. 4OCELLA ………………………………… 6penicillin v potassium ……………….4phenazopyridine ……………………… 3PHILITH ………………………………… 6PIMTREA (28) ………………………… 6PORTIA 28 …………………………….. 6PRENATABS FA ……………………..6PRENATABS RX ……………………..6PRENATAL 19 ……………………….. 6PRENATAL PLUS ……………………68 PRENATAL PLUS (CALCIUM CARB)…………………………………… 6PRENATAL VITAMIN PLUS LOW IRON …………………………….. 7RECLIPSEN (28) ……………………..6RECOMBIVAX HB (PF) ……………4SE-NATAL 19 CHEWABLE ……….7SETLAKIN ……………………………… 6SHAROBEL ……………………………. 6SIMLIYA (28) ………………………….. 6SIMPESSE …………………………….. 6SPRINTEC (28) ………………………. 6SRONYX ……………………………….. 6sulfamethoxazole-trimethoprim ….4SULFATRIM …………………………… 4SYEDA ………………………………….. 6TARINA 24 FE ………………………… 6TARINA FE 1/20 (28) ……………….6TARINA FE 1-20 EQ (28) ………….6TENIVAC (PF) ………………………… 4terbinafine hcl …………………………. 4terconazole …………………………….. 4THRIVITE RX …………………………. 7TILIA FE ………………………………… 6TRICARE ……………………………….. 7TRI-ESTARYLLA ……………………..6TRI-LEGEST FE ………………………6TRI-LINYAH …………………………… 6TRI-LO-ESTARYLLA ………………..6TRI-LO-MARZIA ……………………… 6TRI-LO-MILI …………………………… 6TRI-LO-SPRINTEC ………………….6trimethoprim …………………………… 4TRI-MILI ………………………………… 6TRINATAL RX 1 ……………………… 7TRI-SPRINTEC (28) …………………6TRI-VYLIBRA …………………………. 6TRI-VYLIBRA LO …………………….6TULANA ………………………………… 6URELLE ………………………………… 4URETRON D-S ………………………. 4valacyclovir …………………………….. 4VANDAZOLE ………………………….. 4VELIVET TRIPHASIC REGIMEN (28) ……………………….. 6VIENVA …………………………………. 6VIORELE (28) ………………………… 6VYFEMLA (28) ……………………….. 6VYLIBRA ……………………………….. 6WERA (28) …………………………….. 6WYMZYA FE ………………………….. 6XULANE ………………………………… 6ZAFEMY ………………………………… 6ZARAH ………………………………….. 6ZUMANDIMINE (28) …………………69GA-MED-M-2965031-V.7-SPA Aprobado por DCH: 6/21/2024

GA-MED-M-2964348-SPA 2026 GA IPC

Programa Planning for Healthy Babies (P4HB) – Atencin entre embarazos (IPC) de CareSource con vigencia a partir del 1/1/2026Programa Planning for Healthy Babies (P4HB) – Atencin entre embarazos (IPC) de CareSource 1/1/2026 INTRODUCCIN Este es el Formulario o la Lista de medicamentos preferidos (Preferred Drug List, PDL) de Medicaid de CareSource de 2026. Esta lista puede ayudarles a los proveedores en la seleccin de productos clnicamente adecuados y de menor precio. Todos los medicamentos de Medicaid de Georgia est n cubiertos por CareSource. Esta es solo una lista de medicamentos preferidos. Estos medicamentos han sido revisados por el Comit de Farmacia y Teraputic a (Pharmacy and Therapeutics, P&T) de CareSource. La lista se encuentra actualizad a al momento de la revisin. No prometemos la exactitud de los datos. Tampoc o pretende ser una lista completa. No sustituye el conocimient o, la habilidad y el criterio del proveedor. Todos los datos de la lista constituyen un a gua. Los prov eedores son totalmente responsables de todas las o pciones de medicamentos. La lista est sujeta a las leyes y no rmas espec ficas en cada estado. Estas pueden ser, entre otras : las de la opcin genrica; las listas de sustancias controladas; la preferencia po r la marca; los medicamentos genricos obligatorios (cuando corresponda). No asumimos ninguna responsabilidad por las acciones o brechas de ningn proveedor. Deben revisar los datos de los productos del fabricante de medicamentos o las referencias estndar. PREFACIO La lista est ordenada por secciones. Cada secci n se divide por clase de medicamento terap utico, seg n el m todo de acci n. Los productos se mencionan por nombre gen rico. El nombre de marca tambi n figura en la lista. Esto es solo a fines informativos. A menos que el medicamento sea una inyecci n o un caso especial, se menciona la dosis, las formas y las concentraciones. COMIT DE P&T Se usa un Comit nacional de P&T para aprobar terapias farmacol gicas seguras y tiles . Est compuesto por: los directores mdicos del plan; el personal de farmacia; personas de la comunidad mdica. DETALLES SOBRE LA COBERTURA DE MEDICAMENTOS Solo se puede cubrir una concentraci n, dosificaci n u otra formulaci n si se incluye en la lista. No se cubren otras concentraciones, dosificaciones ni formulaciones. Por ejemplo: formas inyectables del producto. Los productos de liberaci n prolongada y retardada tienen su propio listado. metformina Glucophage La lista de productos de liberaci n inmediata no tendr a el producto de liberaci n extendida. metformina ext-rel Glucophage XR Una segunda lista muestra el producto de liberaci n prolongada. Las formas de dosificaci n se incluir n en la secci n en que se mencionan. neomicina/polimixina B/hidrocortisona Cortisporin Cortisporin solo figura en la lista de TICOS. Se limita a la soluci n y la suspensi n. No se puede asumir que la crema figura en la lista. Deber a formar parte de la secci n DERMATOLOG A. Autorizacin previa (PA) CareSource puede necesitar que los proveedores nos informen por qu es necesario un medicamento o una cantidad. Esto se denomi na PA (Prior Authorization). CareSource debe autorizar esta solicitud antes de que un afiliado reciba el medicamento. "PA" significa que se necesita una autorizacin previa. Estas son algunas de las razones para una PA: Existe un medicamento genrico o alt ernativo disponible. Podra haber abuso o uso indebido del medicamento. El medicamento necesita un manejo especial, supervisin o tiene un envo limitado. Existen otros medicamentos que se deben probar primero. Solicitudes de PA Los asociados de salud pueden solicitar una autorizaci n previa en l nea o por fax. Obtenga m s informaci n en la p gina de Proveedores en CareSource.com . Es posible que no aprobemos una solicitud de PA para un medicamento. Si no lo hacemos, le diremos al afiliado c mo apelar. Lmites de cantidad Algunos medicamentos pueden tener lmites sobre cunto se puede administrar de una vez. La abreviatura "QL" (Quantity Limits) se usa para indicar que hay un lmite de cantidad. Los QL se ba san en la dosis sugerida por los fabricantes de medicamentos. Tambin se tiene en cuenta la seguridad del paciente. La terapia con analgsicos opioides puede tener lmites de cantidad. Estos se basan en la dosis recomendada por los fabricantes de medicamen tos y/o en los reglamentos estatales. Los l mites de cantidad se encuentran en la lista a continuaci n. Terapia escalonada Es posible que los afiliados deban probar un medicamento antes de tomar otro. Esto se denomina terapia escalonada. Se debe probar un medicamento antes de que se apruebe el uso de otro. CareSource cubrir ciertos medicamentos solo si se sigue el protocolo de terapia escalonada. Cuando es necesario, se usa "ST" (Step Therapy) en la lista. Programa Planning for Healthy Babies (P4HB) – Atencin entre embarazos (IPC) de CareSource con vigencia a partir del 1/1/2026 Sustitucin por medicamento genrico e intercambio teraputico La sustituci n por un medicamento gen rico es una acci n de la farmacia. Se ofrece una versi n gen rica en lugar de un producto de marca. La letra cursiva significa que existe un gen rico. No todas las concentraciones o formas de dosificaci n del gen rico pueden estar disponibles como gen ricos. Un medicamento de marca que contenga un producto gen rico no pertenecer al formulario. Se cubrir el producto gen rico en lugar del producto de marca. La lista est sujeta a los reglamentos estatales y las normas espec ficos sobre la sustituci n por medicamentos gen ricos. Los medicamentos gen ricos con frecuencia tienen un precio m s bajo que los medicamentos de marca. Se deben prescribir en primer lugar si se siguen los est ndares. Los medicamentos gen ricos de venta con receta est n: Aprobados por la Administracin de Alimentos y Medicamentos (Food and DrugAdmin istration, FDA) de EE. UU. Esto es por motivo de seguridad y eficacia. Estn fabricados bajo los mismos estndares estrictos que los productos de marca. Probados en humanos. El genrico se debe absorber a la misma velocidad que el producto de marca. Puede diferir de la marca en el tamao, el color y los ingredientes inactivos. Esto no altera su uso. Fabricados con la misma concentracin y la misma forma de dosificacin que los medicamentos de marca. Un medicamento gen rico tendr el mismo efecto y ser tan seguro como el de marca. DISEO DEL PLAN La lista muestra un dise o cerrado de plan del formulario. Los medicamentos incluidos en la lista est n cubiertos por el plan seg n se muestra. Ciertos medicamentos est n cubiertos si se cumplen con los est ndares d e gesti n de uso. Puede ser ST, PA y/o QL. Se revisar n las solicitudes de medicamentos que no cumplan con los est ndares de la lista. Si un medicamento no est en la lista, puede solicitar una excepci n al formulario para la cobertura. Se revisar la nece sidad m dica o la excepci n al formulario. Esto se basa en medidas de PA o los criterios de prescripci n est ndar que no pertenecen al formulario. Un afiliado o un proveedor pueden solicitar una excepci n al formulario. Complete el formulario que se encuen tra en la p gina de la Lista de medicamentos preferidos (PDL) en CareSource.com . AVISO Los datos de esta lista son privados. La informacin no se puede copiar en su totalidad o en parte sin una autorizacin por escrito. 2024. Todos los derechos reservados. Esta lista contiene medicamentos con receta de marca que son marcas comerciales o marcas registradas. CareSource no opera las organizaciones que se mencionan en esta lista. CareSource no es responsable de la confiabilidad del contenido. Estas listas no son una recomendaci n de CareS ource.Nota: Esta lista se actualiza peridicamente. Es posible que los cambios aparezcan antes de su fecha de entrada en vigencia.Programa Planning for Healthy Babies (P4HB) – Atencin entre embarazos (IPC) de CareSource con vigencia a partir del 1/1/2026List of Abbreviations 1: P referred generic product 2: P referred brand product A CA: Affordable Care Act A R: Age Restriction. For certain drugs, the drug may be covered for members in a certain age range without a prior authorization. OT C: Over-the-Counter. An OTC drug is a non-prescription drug. PA : Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you dont get approval, we may not cover the drug. Q L: Quant ity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST : Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, we may not cover Drug Bunless you try Drug A first. If Drug A does not work for you, we will then cover Drug B . Georgia P4HB Inter-Pregnancy Care Table of Contents ANALGESICS ……………………………………………………………………………………………………………………………………… 3 ANESTHETICS ……………………………………………………………………………………………………………………………………. 3 ANTIARTHRITICS ………………………………………………………………………………………………………………………………… 3 ANTIASTHMATICS ………………………………………………………………………………………………………………………………. 3 ANTIBIOTICS ………………………………………………………………………………………………………………………………………. 4 ANTICOAGULANTS …………………………………………………………………………………………………………………………….. 5 ANTIFUNGALS ……………………………………………………………………………………………………………………………………. 5 ANTIHYPERGLYCEMICS ……………………………………………………………………………………………………………………… 5 ANTIINFECTIVES/MISCELLANEOUS ……………………………………………………………………………………………………. 6 ANTINEOPLASTICS …………………………………………………………………………………………………………………………….. 7 ANTIPLATELET DRUGS ………………………………………………………………………………………………………………………. 7 ANTIVIRALS ……………………………………………………………………………………………………………………………………….. 7 AUTONOMIC DRUGS ………………………………………………………………………………………………………………………….. 8 BIOLOGICALS …………………………………………………………………………………………………………………………………….. 8 BLOOD ………………………………………………………………………………………………………………………………………………. 8 CARDIAC DRUGS ……………………………………………………………………………………………………………………………….. 8 CARDIOVASCULAR …………………………………………………………………………………………………………………………….. 9 CNS DRUGS ……………………………………………………………………………………………………………………………………… 10 CONTRACEPTIVES …………………………………………………………………………………………………………………………… 11 DIURETICS ……………………………………………………………………………………………………………………………………….. 14 ELECT/CALORIC/H2O ……………………………………………………………………………………………………………………….. 14 GASTROINTESTINAL ………………………………………………………………………………………………………………………… 15 HORMONES ……………………………………………………………………………………………………………………………………… 15 MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG …………………………………………………………… 15 PRE-NATAL VITAMINS ………………………………………………………………………………………………………………………. 17 PSYCHOTHERAPEUTIC DRUGS ………………………………………………………………………………………………………… 17 SEDATIVE/HYPNOTICS ……………………………………………………………………………………………………………………… 19 THYROID PREPS ………………………………………………………………………………………………………………………………. 19 UNCLASSIFIED DRUG PRODUCTS ……………………………………………………………………………………………………. 19 VITAMINS …………………………………………………………………………………………………………………………………………. 19 2 CURRENT AS OF 1/1/2026 Drug Name Tier Restrictions / Limits ANALGESICSdiclofenac potassium oral tablet 50 mg 1 diflunisal 1 ketorolac oral 1 QL (20 EA per30 days) ANESTHETICSphenazopyridine oral tablet 100 mg, 200 mg 1 ANTIARTHRITICScelecoxib 1 ST colchicine oral tablet 1 QL (1 EA per 1day) diclofenac sodium oral 1 diclofenac-misoprostol 1 etodolac 1 flurbiprofen 1 IBU 1 ibuprofen oral tablet 400mg, 600 mg, 800 mg 1 ketoprofen oral capsule50 mg, 75 mg 1 meloxicam oral tablet 1 nabumetone 1 naproxen oral tablet,delayed release(dr/ec) 1 naproxen sodium oral tablet 275 mg, 550 mg 1 oxaprozin oral tablet 1 probenecid 1 sulindac 1 ANTIASTHMATICSalbuterol sulfate inhalation hfa aerosol inhaler 1 QL (4 GM per90 days) Drug Name Tier Restrictions /Limits albuterol sulfate inhalation solution for nebulization 0.63 mg/3ml, 1.25 mg/3 ml, 2.5mg /3 ml (0.083 %) 1 QL (375 MLper 30 days) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5ml 1 QL (2 EA per 1day) albuterol sulfate inhalation solution for nebulization 5 mg/ml 1 QL (2 ML per 1day) albuterol sulfate oral 1 ARNUITY ELLIPTA 2 QL (1 EA per 1day) ATROVENT HFA 2 QL (65 GM per30 days) budesonide inhalation 1 QL (4 ML per 1day) COMBIVENTRESPIMAT 2 QL (4 GM per30 days) cromolyn inhalation 1 QL (8 ML per 1day) DULERA INHALATIONHFA AEROSOLINHALER 100-5MCG/ACTUATION,200-5MCG/ACTUATION 2 QL (13 GM per30 days) DULERA INHALATIONHFA AEROSOLINHALER 50-5MCG/ACTUATION 2 fluticasone propionate inhalation hfa aerosol inhaler 110mcg/actuation, 220mcg/actuation 2 QL (24 GM per30 days) fluticasone propionate inhalation hfa aerosol inhaler 44mcg/actuation 2 QL (22 GM per30 days) fluticasone propion-salmeterol inhalation aerosol powdr breath activated 2 QL (1 EA per30 days) GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/2026 3 Drug Name Tier Restrictions /Limits fluticasone propion-salmeterol inhalation blister with device 1 QL (2 EA per 1day) ipratropium bromide inhalation 1 QL (10 ML per1 day) ipratropium-albuterol 1 QL (18 ML per1 day) levalbuterol tartrate 2 QL (1 GM per 1day) montelukast 1 SEREVENT DISKUS 2 QL (2 EA per 1day) SPIRIVA RESPIMAT 2 QL (4 GM per30 days) STIOLTO RESPIMAT 2 QL (4 GM per30 days) STRIVERDI RESPIMAT 2 QL (4 GM per30 days) terbutaline oral 1 THEO-24 2 theophylline oral elixir 1 theophylline oral solution 1 theophylline oral tablet extended release 12 hr300 mg, 450 mg 1 theophylline oral tablet extended release 24 hr 1 TRELEGY ELLIPTA 2 PA; QL (1 EAper 28 days) ANTIBIOTICSamoxicillin 1 amoxicillin-pot clavulanate oral suspension for reconstitution 1 amoxicillin-pot clavulanate oral tablet 1 amoxicillin-pot clavulanate oral tablet,chewable 1 ampicillin 1 AVIDOXY 1 Drug Name Tier Restrictions /Limits azithromycin oral 1 cefadroxil 1 cefdinir 1 cefprozil 1 cefuroxime axetil 1 cephalexin 1 ciprofloxacin hcl oral 1 ciprofloxacin oral suspension,microcapsul e recon 250 mg/5 ml 1 clarithromycin 1 CLEOCIN VAGINALSUPPOSITORY 2 clindamycin hcl 1 CLINDAMYCINPEDIATRIC 1 clindamycin phosphate vaginal 1 dapsone oral 1 dicloxacillin 1 doxycycline hyclate oral capsule 1 doxycycline hyclate oral tablet 100 mg, 150 mg,50 mg, 75 mg 1 doxycycline monohydrate oral capsule 1 doxycycline monohydrate oral suspension for reconstitution 1 doxycycline monohydrate oral tablet 1 E.E.S. 400 1 ERY-TAB ORALTABLET,DELAYEDRELEASE (DR/EC) 250MG, 333 MG 1 ERY-TAB ORALTABLET,DELAYEDRELEASE (DR/EC) 500MG 2 GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/20264 Drug NameTier Restrictions /LimitsERYTHROCIN (ASSTEARATE) 1erythromycin ethylsuccinate1erythromycin oral capsule,delayed release(dr/ec)1erythromycin oral tablet1levofloxacin oral1methen-sod phos-meth blue-hyos1metronidazole oral capsule1metronidazole oral tablet 250 mg, 500 mg1metronidazole vaginal gel 0.75 % (37.5mg/5gram)1QL (70 GM per30 days)minocycline oral capsule 1minocycline oral tablet1MONDOXYNE NL1MORGIDOX1moxifloxacin ophthalmic(eye) drops, viscous1neomycin1nitrofurantoin macrocrystal1nitrofurantoin monohyd/m-cryst1ofloxacin oral1QL (2 EA per 1day)penicillin v potassium 1sulfacetamide sodium-sulfur topical pads,medicated1sulfamethoxazole-trimethoprim oral1SULFATRIM1tetracycline oral capsule1trimethoprim1URETRON D-S1 Drug NameTier Restrictions /LimitsURYL 1 vancomycin oral capsule1PAVANDAZOLE 1QL (70 GM per30 days)ANTICOAGULANTS ELIQUIS DVT-PETREAT 30D START2 ELIQUIS ORALTABLET2 enoxaparin1 JANTOVEN1 warfarin1 XARELTO DVT-PETREAT 30D START2QL (51 EA per30 days)XARELTO ORALTABLET 10 MG, 15MG, 20 MG 2 XARELTO ORALTABLET 2.5 MG2STANTIFUNGALS clotrimazole mucous membrane1 fluconazole1 griseofulvin ultramicrosize oral tablet 125 mg, 250 mg1 ketoconazole oral1 NATACYN2QL (15 ML per30 days)nystatin oral suspension 1 terbinafine hcl oral1QL (1 EA per 1day)terconazole 1 voriconazole oral1PAANTIHYPERGLYCEMICS acarbose1 alogliptin2STalogliptin-metformin 2STalogliptin-pioglitazone 2STGEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/2026 5 Drug NameTier Restrictions /Limits dapaglifloz propaned-metformin 1STdapagliflozin propanediol 1STglimepiride oral tablet 1mg, 2 mg, 4 mg 1glipizide oral tablet 10mg, 5 mg1glipizide-metformin1glyburide micronized oral tablet 1.5 mg1QL (8 EA per 1day)glyburide micronized oral tablet 3 mg 1QL (4 EA per 1day)glyburide micronized oral tablet 6 mg 1QL (2 EA per 1day)glyburide oral tablet1.25 mg 1QL (16 EA per1 day)glyburide oral tablet 2.5mg 1QL (8 EA per 1day)glyburide oral tablet 5mg 1QL (4 EA per 1day)glyburide-metformin oral tablet 1.25-250 mg 1QL (260 EA per30 days)glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg 1QL (5 EA per 1day)HUMULIN RU-500(CONC) KWIKPEN 2insulin glargine-yfgn2insulin lispro subcutaneous insulin pen2QL (45 ML per30 days)insulin lispro subcutaneous insulin pen, half-unit 2QL (1 ML per 1day)insulin lispro subcutaneous solution 2QL (45 ML per30 days)INVOKAMET 1STINVOKAMET XR 1metformin oral solution1metformin oral tablet1,000 mg, 500 mg, 850mg1 Drug NameTier Restrictions /Limits metformin oral tablet extended release 24 hr 1 miglitol1STnateglinide 1 pioglitazone1 pioglitazone-glimepiride1STpioglitazone-metformin 1 repaglinide1 RYBELSUS2QL (1 EA per 1day)ANTIINFECTIVES/MISCELLANEOUS CUTTERBACKWOODSOTCQL (1prescription claim per 30days)CUTTERBACKWOODS DRY OTCQL (1prescription claim per 30days)CUTTER LEMONEUCALYPTUS OTCQL (1prescription claim per 30days)CUTTER NATURALINSECT REPELLNT OTCQL (1prescription claim per 30days)CUTTER NATURALREPELLENT2 OTCQL (1prescription claim per 30days)CUTTERSKINSATIONSTOPICAL SPRAY,NON-AEROSOL OTCQL (1prescription claim per 30days)INSECT REPELLENT(DEET) OTCQL (1prescription claim per 30days)INSECT REPELLENT(PICARIDIN) OTCQL (1prescription claim per 30days)GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/20266 Drug Name Tier Restrictions /Limits NATRAPEL TOPICALAEROSOL,SPRAY OTC QL (1prescription claim per 30days) OFF ACTIVE OTC QL (1prescription claim per 30days) OFF DEEP WOODSDRY OTC QL (1prescription claim per 30days) OFF DEEP WOODSSPORTSMEN OTC QL (1prescription claim per 30days) OFF DEEP WOODSTOPICALAEROSOL,SPRAY OTC QL (1prescription claim per 30days) OFF DEEP WOODSTOPICAL SPRAY,NON-AEROSOL OTC QL (1prescription claim per 30days) OFF FAMILYCARE(WITH DEET) OTC QL (1prescription claim per 30days) OFFFAMILYCARE(WITHPICARIDIN) OTC QL (1prescription claim per 30days) RANGER READYREPELLENT OTC QL (1prescription claim per 30days) REPEL 100 OTC QL (1prescription claim per 30days) REPEL FAMILY OTC QL (1prescription claim per 30days) Drug Name Tier Restrictions /Limits REPEL HUNTER'S OTC QL (1prescription claim per 30days) REPEL LEMONEUCALYPTUS OTC QL (1prescription claim per 30days) REPEL SPORTSMEN OTC QL (1prescription claim per 30days) REPEL SPORTSMENDRY OTC QL (1prescription claim per 30days) REPEL SPORTSMENMAX OTC QL (1prescription claim per 30days) REPEL TICKDEFENSE OTC QL (1prescription claim per 30days) TOTAL HOME INSECTREPELLENT OTC QL (1prescription claim per 30days) ULTRATHON OTC QL (1prescription claim per 30days) ANTINEOPLASTICSVOTRIENT 2 ANTIPLATELETDRUGSBRILINTA 2 PA; ST cilostazol 1 clopidogrel 1 dipyridamole oral 1 prasugrel hcl 1 ANTIVIRALSacyclovir oral capsule 1 GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/2026 7 Drug Name Tier Restrictions /Limits acyclovir oral suspension 200 mg/5ml 1 acyclovir oral tablet 1 LAGEVRIO (EUA) 2 valacyclovir 1 AUTONOMICDRUGSdextroamphetamine sulfate oral capsule,extended release 1 QL (2 EA per 1day) dextroamphetamine sulfate oral tablet 10 mg 1 QL (4 EA per 1day) dextroamphetamine sulfate oral tablet 15mg, 20 mg, 30 mg 1 dextroamphetamine sulfate oral tablet 5 mg 1 QL (1 EA per 1day) dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15mg, 5 mg 1 QL (1 EA per 1day) dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25mg, 30 mg 1 QL (2 EA per 1day) dextroamphetamine-amphetamine oral tablet 1 QL (3 EA per 1day) midodrine 1 pyridostigmine bromide oral syrup 1 pyridostigmine bromide oral tablet 60 mg 1 pyridostigmine bromide oral tablet extended release 180 mg 1 BIOLOGICALSADACEL(TDAPADOLESN/ADULT)(PF) 2 BOOSTRIX TDAP 2 ENGERIX-B (PF) 2 Drug Name Tier Restrictions /Limits ENGERIX-BPEDIATRIC (PF) 2 HEPLISAV-B (PF) 2 RECOMBIVAX HB (PF)INTRAMUSCULARSUSPENSION 40MCG/ML, 5 MCG/0.5ML 2 RECOMBIVAX HB (PF)INTRAMUSCULARSYRINGE 2 RHOGAM ULTRA-FILTERED PLUS 2 TENIVAC (PF) 2 BLOODpentoxifylline 1 CARDIAC DRUGSamiodarone oral tablet200 mg 1 amlodipine 1 CARTIA XT 1 DIGITEK 1 digoxin oral solution 1 digoxin oral tablet 125mcg (0.125 mg), 250mcg (0.25 mg) 1 diltiazem hcl oral capsule,ext.rel 24h degradable 1 diltiazem hcl oral capsule,extended release 12 hr 1 diltiazem hcl oral capsule,extended release 24 hr 1 diltiazem hcl oral capsule,extended release 24hr 1 diltiazem hcl oral tablet 1 diltiazem hcl oral tablet extended release 24 hr180 mg, 240 mg, 300mg, 360 mg, 420 mg 1 GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/20268 Drug Name Tier Restrictions /Limits DILT-XR 1 disopyramide phosphate 1 dofetilide 1 felodipine 1 flecainide 1 isosorbide mononitrate 1 MATZIM LA 1 nifedipine oral tablet extended release 1 nitroglycerin transdermal patch 24hour 1 propafenone 1 ranolazine 1 verapamil oral capsule,ext rel. pellets24 hr 1 verapamil oral tablet120 mg, 80 mg 1 verapamil oral tablet 40mg 1 QL (12 EA per1 day) verapamil oral tablet extended release 1 CARDIOVASCULARamlodipine-benazepril 1 amlodipine-olmesartan 1 amlodipine-valsartan 1 amlodipine-valsartan-hcthiazid 1 atenolol 1 atenolol-chlorthalidone 1 atorvastatin 1 benazepril 1 benazepril-hydrochlorothiazide 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 bisoprolol-hydrochlorothiazide 1 candesartan 1 Drug Name Tier Restrictions /Limits candesartan-hydrochlorothiazid 1 captopril 1 captopril-hydrochlorothiazide 1 carvedilol 1 CHOLESTYRAMINELIGHT 1 clonidine 1 colestipol oral tablet 1 doxazosin 1 enalapril maleate oral tablet 1 enalapril-hydrochlorothiazide 1 ENTRESTO 2 PA ezetimibe 1 fenofibrate micronized 1 fosinopril 1 fosinopril-hydrochlorothiazide 1 gemfibrozil 1 guanfacine oral tablet 1 hydralazine oral 1 irbesartan 1 irbesartan-hydrochlorothiazide 1 labetalol oral tablet 100mg, 200 mg, 300 mg 1 lisinopril 1 lisinopril-hydrochlorothiazide 1 losartan 1 losartan-hydrochlorothiazide 1 lovastatin 1 methyldopa 1 metoprolol succinate 1 metoprolol ta-hydrochlorothiaz 1 metoprolol tartrate oral 1 GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/2026 9 Drug Name Tier Restrictions /Limits metyrosine 1 minoxidil oral 1 nadolol 1 olmesartan 1 olmesartan-amlodipin-hcthiazid 1 olmesartan-hydrochlorothiazide 1 pravastatin 1 PREVALITE 1 propranolol oral 1 quinapril 1 quinapril-hydrochlorothiazide 1 ramipril 1 rosuvastatin 1 salmon oil-omega-3fatty acids OTC simvastatin 1 SOTALOL AF 1 sotalol oral 1 telmisartan 1 telmisartan-amlodipine 1 telmisartan-hydrochlorothiazid 1 terazosin 1 trandolapril 1 valsartan oral tablet 1 valsartan-hydrochlorothiazide 1 CNS DRUGScarbamazepine oral capsule, er multiphase12 hr 1 carbamazepine oral suspension 100 mg/5ml 1 carbamazepine oral tablet 1 Drug Name Tier Restrictions /Limits carbamazepine oral tablet extended release12 hr 1 carbamazepine oral tablet,chewable 100 mg 1 CELONTIN 2 clobazam oral suspension 1 ST clobazam oral tablet 1 ST clonazepam oral tablet 1 QL (4 EA per 1day) diazepam rectal 1 DILANTIN 2 DILANTIN EXTENDED 2 divalproex 1 ethosuximide 1 felbamate 1 FYCOMPA 2 ST gabapentin oral capsule100 mg, 400 mg 1 QL (6 EA per 1day) gabapentin oral capsule300 mg 1 QL (9 EA per 1day) gabapentin oral solution 1 QL (72 ML per1 day) gabapentin oral tablet600 mg 1 QL (6 EA per 1day) gabapentin oral tablet800 mg 1 QL (4 EA per 1day) lamotrigine oral tablet 1 lamotrigine oral tablet,chewable dispersible 1 levetiracetam oral solution 1 levetiracetam oral tablet 1 levetiracetam oral tablet extended release 24 hr 1 oxcarbazepine oral suspension 1 oxcarbazepine oral tablet 1 OXTELLAR XR 2 PA phenytoin 1 GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/202610 Drug NameTier Restrictions /Limits phenytoin sodium extended 1pregabalin oral capsule100 mg, 150 mg, 200mg, 25 mg, 50 mg, 75mg1PA; QL (3 EAper 1 day)pregabalin oral capsule225 mg, 300 mg 1PA; QL (2 EAper 1 day)pregabalin oral solution 1PA; QL (30 MLper 1 day)primidone oral tablet250 mg, 50 mg 1ROWEEPRA1SUBVENITE ORALTABLET1tiagabine1topiramate oral capsule,sprinkle 15 mg, 25 mg1topiramate oral tablet1zonisamide1CONTRACEPTIVESAFIRMELLE1ALTAVERA (28)1ALYACEN 1/35 (28)1ALYACEN 7/7/7 (28)1AMETHIA1QL (1 EA per 1day)AMETHYST (28) 1QL (1 EA per 1day)APRI 1ARANELLE (28)1ASHLYNA1QL (1 EA per 1day)AUBRA 1AUBRA EQ1AUROVELA 1.5/30 (21)1AUROVELA 1/20 (21)1AUROVELA 24 FE1AUROVELA FE 1.5/30(28)1 Drug NameTier Restrictions /LimitsAUROVELA FE 1-20(28) 1 AVIANE1 AYUNA1 AZURETTE (28)1 BALZIVA (28)1 BLISOVI 24 FE1 BLISOVI FE 1.5/30 (28)1 BLISOVI FE 1/20 (28)1 BRIELLYN1 CAMILA1 CAMRESE1QL (1 EA per 1day)CAMRESE LO 1QL (1 EA per 1day)CAYA CONTOURED 2QL (2 EA per365 Days)CAZIANT (28) 1 CHATEAL EQ (28)1 CRYSELLE (28)1 CYRED1 CYRED EQ1 DASETTA 1/35 (28)1 DASETTA 7/7/7 (28)1 DAYSEE1QL (1 EA per 1day)DEBLITANE 1 DEPO-SUBQPROVERA 1042 desog-e.estradiol/e.estradiol1 drospirenone-e.estradiol-lm.fa oral tablet 3-0.02-0.451 mg(24) (4)1PAdrospirenone-ethinyl estradiol 1 ELINEST1 ELURYNG1 ENPRESSE1 ENSKYCE1GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/202611 Drug NameTier Restrictions /LimitsERRIN 1ESTARYLLA1ethynodiol diac-eth estradiol1etonogestrel-ethinyl estradiol1FALMINA (28)1FEMCAP2QL (2 EA per365 Days)HAILEY 24 FE 1HAILEY FE 1.5/30 (28)1HAILEY FE 1/20 (28)1HEATHER1INCASSIA1ISIBLOOM1JASMIEL (28)1JENCYCLA1JOLESSA1QL (1 EA per 1day)JULEBER 1JUNEL 1.5/30 (21)1JUNEL 1/20 (21)1JUNEL FE 1.5/30 (28)1JUNEL FE 1/20 (28)1JUNEL FE 241KAITLIB FE1KARIVA (28)1KELNOR 1/35 (28)1KURVELO (28)1l norgest/e.estradiol-e.estrad1QL (1 EA per 1day)LARIN 1.5/30 (21) 1LARIN 1/20 (21)1LARIN 24 FE1LARIN FE 1.5/30 (28)1LARIN FE 1/20 (28)1LESSINA1LEVONEST (28)1 Drug NameTier Restrictions /Limits levonorgestrel-ethinyl estrad oral tablet 0.1-20mg-mcg, 0.15-0.03 mg 1 levonorgestrel-ethinyl estrad oral tablet 90-20mcg (28)1QL (1 EA per 1day)levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 1QL (1 EA per 1day)levonorg-eth estrad triphasic 1 LEVORA-281 LORYNA (28)1 LOW-OGESTREL (28)1 LO-ZUMANDIMINE (28)1 LUTERA (28)1 LYZA1 MARLISSA (28)1 medroxyprogesterone intramuscular1 MICROGESTIN 1.5/30(21)1 MICROGESTIN 1/20(21)1 MICROGESTIN FE1.5/30 (28)1 MICROGESTIN FE1/20 (28)1 MILI1 MONO-LINYAH1 NECON 0.5/35 (28)1 NIKKI (28)1 NORA-BE1 noreth-ethinyl estradiol-iron1 norethindrone(contraceptive)1 norethindrone ac-eth estradiol oral tablet 1-20mg-mcg, 1.5-30 mg-mcg1GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/202612 Drug Name Tier Restrictions /Limits norethindrone-e.estradiol-iron oral tablet 1 norgestimate-ethinyl estradiol 1 NORTREL 0.5/35 (28) 1 NORTREL 1/35 (21) 1 NORTREL 1/35 (28) 1 NORTREL 7/7/7 (28) 1 OCELLA 1 PHILITH 1 PIMTREA (28) 1 PORTIA 28 1 RECLIPSEN (28) 1 SETLAKIN 1 QL (1 EA per 1day) SHAROBEL 1 SIMLIYA (28) 1 SIMPESSE 1 QL (1 EA per 1day) SPRINTEC (28) 1 SRONYX 1 SYEDA 1 TARINA 24 FE 1 TARINA FE 1/20 (28) 1 TARINA FE 1-20 EQ(28) 1 TILIA FE 1 TRI-ESTARYLLA 1 TRI-LEGEST FE 1 TRI-LINYAH 1 TRI-LO-ESTARYLLA 1 TRI-LO-MARZIA 1 TRI-LO-MILI 1 TRI-LO-SPRINTEC 1 TRI-MILI 1 TRI-SPRINTEC (28) 1 TRI-VYLIBRA 1 TRI-VYLIBRA LO 1 Drug Name Tier Restrictions /Limits TULANA 1 VELIVET TRIPHASICREGIMEN (28) 1 VESTURA (28) 1 VIENVA 1 VIORELE (28) 1 VYFEMLA (28) 1 VYLIBRA 1 WERA (28) 1 WIDE-SEALDIAPHRAGM 60 2 QL (2prescription claim(s) per365 days) WIDE-SEALDIAPHRAGM 65 2 QL (2prescription claim(s) per365 days) WIDE-SEALDIAPHRAGM 70 2 QL (2prescription claim(s) per365 days) WIDE-SEALDIAPHRAGM 75 2 QL (2prescription claim(s) per365 days) WIDE-SEALDIAPHRAGM 80 2 QL (2prescription claim(s) per365 days) WIDE-SEALDIAPHRAGM 85 2 QL (2prescription claim(s) per365 days) WIDE-SEALDIAPHRAGM 90 2 QL (2prescription claim(s) per365 days) WIDE-SEALDIAPHRAGM 95 2 QL (2prescription claim(s) per365 days) WYMZYA FE 1 XULANE 1 ZAFEMY 1 GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/2026 13 Drug NameTier Restrictions /LimitsZARAH 1ZOVIA 1-35 (28)1ZUMANDIMINE (28)1DIURETICSacetazolamide1amiloride1amiloride-hydrochlorothiazide1bumetanide oral1chlorthalidone1eplerenone1furosemide oral solution10 mg/ml, 40 mg/5 ml (8mg/ml)1furosemide oral tablet1hydrochlorothiazide1indapamide1methazolamide1metolazone1spironolactone oral tablet1spironolacton-hydrochlorothiaz1torsemide1triamterene-hydrochlorothiazid oral capsule1triamterene-hydrochlorothiazid oral tablet 37.5-25 mg1QL (1 EA per 1day)triamterene-hydrochlorothiazid oral tablet 75-50 mg 1ELECT/CALORIC/H2OCALCIUM 500 + DORAL TABLET 500MG-5 MCG (200 UNIT)OTCCALCIUM 500 WITH DOTCCALCIUM 600 WITHVITAMIN D3 ORALCAPSULEOTC Drug NameTier Restrictions /Limits calcium acetate(phosphat bind) 1 calcium carbonate-vitamin d3 oral capsule600 mg-25 mcg (1,000unit)OTC calcium carbonate-vitamin d3 oral tablet250 mg-3.125 mcg (125unit), 500 mg-10 mcg(400 unit), 500 mg-15mcg (600 unit), 500 mg-3.125 mcg (125 unit),500 mg-5 mcg (200unit), 600 mg-10 mcg(400 unit), 600 mg-20mcg (800 unit), 600 mg-5 mcg (200 unit)OTC CALCIUM WITHVITAMIN DOTC CENTRATEXOTC CHROMAGEN(SUMALATE-QUATREFOLI)OTC DEX4 GLUCOSE ORALTABLET,CHEWABLEOTC DEX4 GLUCOSEPOUCH PACKOTC DEX4 GLUCOSEQUICK DISSOLVEOTC dextrose oral gelOTC fluoride (sodium) oralOTC GLUCOSE GELOTC glucose oral tablet,chewable 4 gramOTC GLUTOSE-15OTC GLUTOSE-45OTC GLUTOSE-5OTC HEMATINIC PLUSVIT/MINERALSOTC HEMATINIC/FOLICACIDOTC HEMATOGEN FORTEOTC HEMOCYTE-PLUSOTC KLOR-CON 101GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/202614 Drug NameTier Restrictions /LimitsKLOR-CON 8 1KLOR-CON M101KLOR-CON M151KLOR-CON M201LIQUID CALCIUMWITH VITAMIN DOTCONEVITE CALCIUM-D3ORAL TABLET 500MG-5 MCG (200 UNIT)OTCOYSCO 500/DOTCOYSTER SHELL + D3OTCOYSTER SHELLCALCIUM-VIT D3OTCpotassium chloride oral capsule, extended release1potassium chloride oral liquid1potassium chloride oral tablet extended release10 meq, 20 meq, 8 meq1potassium chloride oral tablet,er particles/crystals1potassium citrate oral tablet extended release1potassium citrate-citric acidOTCTRICONOTCTRIGELS-F FORTEOTCGASTROINTESTINALamoxicil-clarithromy-lansopraz1omega-3 acid ethyl esters1SUPER OMEGA-3OTCHORMONESCOMBIPATCH2COVARYX1COVARYX H.S.1danazol1 Drug NameTier Restrictions /Limits desmopressin oral 1 EEMT1 EEMT HS1 estradiol-norethindrone acet1 estrogens-methyltestosterone1 FYAVOLV1 hydrocortisone oral1 JINTELI1 medroxyprogesterone oral1 methylergonovine oral1 methylprednisolone1 MIMVEY1 norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg1 prednisolone oral solution1 prednisolone sodium phosphate oral1 prednisone1 PREDNISONEINTENSOL1 progesterone micronized oral1 MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUGAEROCHAMBER MINI2QL (2 EA per365 days)AEROCHAMBER MV 2QL (2 EA per365 days)AEROCHAMBER PLUSFLOW-VU 2QL (2 EA per365 days)AEROCHAMBER PLUSFLOW-VU,L MSK 2QL (2 EA per365 days)GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/2026 15 Drug Name Tier Restrictions /Limits AEROCHAMBER PLUSFLOW-VU,M MSK 2 QL (2 EA per365 days) AEROCHAMBER PLUSFLOW-VU,S MSK 2 QL (2 EA per365 days) AEROCHAMBER PLUS ZSTAT 2 QL (2 EA per365 days) AEROCHAMBER PLUS ZSTAT LG MSK 2 QL (2 EA per365 days) AEROCHAMBER PLUS ZSTAT MD MSK 2 QL (2 EA per365 days) AEROCHAMBER PLUS ZSTAT SM MSK 2 QL (2 EA per365 days) AEROCHAMBER Z-STAT PLUS-FLW SG 2 QL (2 EA per365 days) AEROVENT PLUS 2 QL (2 EA per365 days) BREATHERITE MDISPACER 2 QL (2 EA per365 days) BREATHERITESPACER-MASK, NEO. 2 QL (2 EA per365 days) BREATHERITESPACER-MASK,ADULT 2 QL (2 EA per365 days) BREATHERITESPACER-MASK,CHILD 2 QL (2 EA per365 days) BREATHERITESPACER-MASK,INFANT 2 QL (2 EA per365 days) BREATHERITESPACER-MASK,S.CHLD 2 QL (2 EA per365 days) BREATHERITEVALVED MDICHAMBER 2 QL (2 EA per365 days) BREATHERITEVALVED MDI SPACER 2 QL (2 EA per365 days) CLEVER CHOICECHAMBER-LRG MASK 2 QL (2 EA per365 days) CLEVER CHOICECHAMBER-MED MASK 2 QL (2 EA per365 days) CLEVER CHOICECHAMBER-SM MASK 2 QL (2 EA per365 days) COMPACT SPACECHAMBER 2 QL (2 EA per365 days) Drug Name Tier Restrictions /Limits COMPACT SPACECHAMBER-LRG MASK 2 QL (2 EA per365 days) COMPACT SPACECHAMBER-MED MASK 2 QL (2 EA per365 days) COMPACT SPACECHAMBER-SM MASK 2 QL (2 EA per365 days) EASIVENT HOLDINGCHAMBER 2 QL (2 EA per365 days) EASIVENT MASKLARGE 2 QL (2 EA per365 days) EASIVENT MASKMEDIUM 2 QL (2 EA per365 days) EASIVENT MASKSMALL 2 QL (2 EA per365 days) ECLIPSE SYRINGESYRINGE 3 ML 21GAUGE X 1", 3 ML 25GAUGE X 1" 2 QL (400 EA per30 days) FLEXICHAMBER 2 QL (2 EA per365 days) FREESTYLE LIBRE 14DAY READER 2 PA; QL (1 EAper 1 lifetime) FREESTYLE LIBRE 2READER 2 PA; QL (1 EAper 1 lifetime) insulin syringe-needle u-100 syringe 1 ml 27gauge x 1/2", 1/2 ml 27gauge x 1/2" 2 QL (400 EA per30 days) INTEGRA SYRINGE 2 QL (400 EA per30 days) LITEAIRE MDICHAMBER 2 QL (2 EA per365 days) MICROCHAMBER 2 QL (2 EA per365 days) MICROSPACER 2 QL (2 EA per365 days) MONOJECT INSULINSAFETY SYRINGSYRINGE 0.3 ML 30GAUGE X 5/16", 0.5 ML29 GAUGE X 1/2", 0.5ML 30 GAUGE X 5/16" 2 QL (400 EA per30 days) OPTICHAMBERDIAMOND LG MASK 2 QL (2 EA per365 days) GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/202616 Drug NameTier Restrictions /LimitsOPTICHAMBERDIAMOND VHC 2QL (2 EA per365 days)OPTICHAMBERDIAMOND-MED MSK 2QL (2 EA per365 days)OPTICHAMBERDIAMOND-SML MASK 2QL (2 EA per365 days)PEN NEEDLE NEEDLE30 GAUGE X 5/16" 2QL (400 EA per30 days)POCKET CHAMBER 2QL (2 EA per365 days)PROCHAMBER 2QL (2 EA per365 days)RITEFLOAEROCHAMBER 2QL (2 EA per365 days)V-GO 20 2V-GO 302V-GO 402VORTEX HOLDINGCHAMBER2QL (2 EA per365 days)PRE-NATALVITAMINS COMPLETENATEOTCKOSHER PRENATALPLUS IRON2M-NATAL PLUS1PRENATABS FA1PRENATABS RX1PRENATAL 19 ORALTABLET,CHEWABLEOTCPRENATAL MULTIOTCPRENATAL PLUS1PRENATAL PLUS(CALCIUM CARB)1PRENATAL TABLETOTCPRENATAL VITAMINORAL TABLET 27 MGIRON-0.8 MG, 27 MGIRON-800 MCGOTCPRENATAL VITAMINPLUS LOW IRONOTCPRENATAL VITAMINWITH MINERALSOTC Drug NameTier Restrictions /Limits prenatal vit-iron fum-folic ac OTC SE-NATAL 19CHEWABLE1 THERANATAL ORALTABLETOTC THRIVITE RX2 TRICARE2 TRINATAL RX 11 PSYCHOTHERAPEUTIC DRUGSamitriptyline1 amitriptyline-chlordiazepoxide1 amoxapine1 aripiprazole oral tablet10 mg, 15 mg, 30 mg1QL (1 EA per 1day)aripiprazole oral tablet 2mg, 20 mg 1QL (2 EA per 1day)aripiprazole oral tablet 5mg 1QL (1.5 EA per1 day)atomoxetine oral capsule 10 mg, 18 mg,25 mg, 40 mg 1QL (2 EA per 1day)atomoxetine oral capsule 100 mg, 60 mg,80 mg 1QL (1 EA per 1day)bupropion hcl oral tablet 1 bupropion hcl oral tablet extended release 24 hr150 mg, 300 mg1QL (1 EA per 1day)bupropion hcl oral tablet sustained-release 12 hr 1 chlorpromazine oral tablet1 citalopram oral solution1 citalopram oral tablet1 clomipramine1 clonidine hcl oral tablet extended release 12 hr1QL (4 EA per 1day)clozapine oral tablet 1 desipramine1GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/202617 Drug Name Tier Restrictions /Limits dexmethylphenidate oral capsule,er biphasic50-50 1 QL (1 EA per 1day) dexmethylphenidate oral tablet 10 mg 1 QL (4 EA per 1day) dexmethylphenidate oral tablet 2.5 mg, 5 mg 1 QL (2 EA per 1day) doxepin oral capsule 1 doxepin oral concentrate 1 duloxetine 1 escitalopram oxalate oral solution 1 escitalopram oxalate oral tablet 1 fluoxetine oral capsule 1 fluoxetine oral solution 1 fluoxetine oral tablet 1 fluphenazine hcl oral 1 fluvoxamine 1 guanfacine oral tablet extended release 24 hr 1 QL (1 EA per 1day) haloperidol 1 haloperidol lactate oral 1 imipramine hcl 1 lithium carbonate 1 loxapine succinate 1 methylphenidate hcl oral capsule,er biphasic50-50 20 mg, 40 mg 1 QL (1 EA per 1day) methylphenidate hcl oral capsule,er biphasic50-50 30 mg 1 QL (2 EA per 1day) methylphenidate hcl oral solution 10 mg/5 ml 1 QL (30 ML per1 day) methylphenidate hcl oral solution 5 mg/5 ml 1 QL (60 ML per1 day) methylphenidate hcl oral tablet 1 QL (3 EA per 1day) methylphenidate hcl oral tablet extended release 1 QL (3 EA per 1day) Drug Name Tier Restrictions /Limits methylphenidate hcl oral tablet,chewable 1 QL (3 EA per 1day) mirtazapine 1 nefazodone 1 QL (2 EA per 1day) nortriptyline 1 olanzapine oral tablet10 mg, 15 mg 1 QL (2 EA per 1day) olanzapine oral tablet2.5 mg, 5 mg, 7.5 mg 1 QL (1 EA per 1day) olanzapine oral tablet20 mg 1 QL (3 EA per 1day) paroxetine hcl oral tablet 1 paroxetine hcl oral tablet extended release24 hr 1 perphenazine 1 perphenazine-amitriptyline 1 pimozide 1 quetiapine oral tablet100 mg, 200 mg, 25mg, 50 mg 1 QL (3 EA per 1day) quetiapine oral tablet300 mg, 400 mg 1 QL (4 EA per 1day) quetiapine oral tablet extended release 24 hr150 mg, 200 mg 1 QL (1 EA per 1day) quetiapine oral tablet extended release 24 hr300 mg 1 QL (3 EA per 1day) quetiapine oral tablet extended release 24 hr400 mg, 50 mg 1 QL (2 EA per 1day) risperidone oral solution 1 risperidone oral tablet 1 sertraline oral concentrate 1 sertraline oral tablet 1 thioridazine 1 thiothixene 1 tranylcypromine 1 GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/202618 Drug NameTier Restrictions /Limits trazodone 1trifluoperazine1trimipramine1venlafaxine oral capsule,extended release 24hr1venlafaxine oral tablet1ziprasidone hcl oral capsule 20 mg, 40 mg1QL (2 EA per 1day)ziprasidone hcl oral capsule 60 mg, 80 mg 1QL (3 EA per 1day)SEDATIVE/HYPNOTICS phenobarbital1THYROID PREPSEUTHYROX1levothyroxine oral tablet1LEVOXYL1liothyronine oral1methimazole1propylthiouracil1SYNTHROID2UNITHROID1UNCLASSIFIEDDRUG PRODUCTSAIRBORNE(ASCORBATESODIUM)OTCAIRBORNE (WITHLYSINE ACETATE)OTCalendronate oral tablet1buprenorphine-naloxone sublingual tablet1PA; QL (3 EAper 1 day); ARDIABETIC SUPPORTFORMULA OTCdoxycycline hyclate oral tablet 20 mg1DRY EYE FORMULAOTCHAIR, SKIN ANDNAILS ADVANCEDOTC Drug NameTier Restrictions /LimitsHAIR-SKIN-NAIL(VITA,C-BIOTIN) OTC ibandronate oral1 IMMUNE SUPPORTORALTABLET,CHEWABLEOTC MEGAVITEOTC OFEV2PAOMEGA-3 FISH OILORAL CAPSULE 300-1,000 MG OTC ONE DAILY WOMEN'SMETABOLISMOTC PHYTOMULTIOTC VITAMINS50 PLUS ADULT EYEHEALTHOTC A THRU ZOTC A THRU ZADVANCEDFORMULAOTC A THRU ZHIGHPOTENCYOTC A THRU ZMEN'SULTIMATEOTC A THRU ZSELECTOTC A THRU ZSELECT50PLUS FORMULAOTC A THRU ZSELECTWOMEN'SOTC ADULT MULTIVITAMINGUMMIES ORALTABLET,CHEWABLE200 MCGOTC ADULT ONE DAILYGUMMIESOTC ADULTS 50 PLUSOTC ADULTS' DAILYFORMULAOTC ADULTSMULTIVITAMINOTC ADVANCED MULTI EAOTC ALIVE WOMEN 50 PLSULT POTENCYOTCGEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/202619 Drug Name Tier Restrictions /Limits ALIVE WOMEN'SGUMMY VITAMIN OTC ANTIOXIDANTFORMULA(SELENIUM) OTC BARIATRICMULTIVITAMINS ORALCAPSULE 45 MGIRON-800 MCG-120MCG OTC BIO-35, GLUTEN FREE OTC BODY, HAIR, SKINAND NAILS OTC calcitriol oral 1 CENTRAVITES OTC CENTRAVITES 50PLUS OTC CENTRAVITESADULTS OTC CENTRUMCHEWABLES OTC CENTRUM SILVER OTC CENTRUM SILVERMEN OTC CENTRUM SILVERULTRA MEN'S OTC CENTRUM SILVERWOMEN OTC CENTRUMSPECIALIST HEART OTC CENTRUM WOMEN OTC CENTURY OTC CENTURY MATURE OTC CEROVITE SENIOR OTC CERTA PLUS OTC CERTAVITE SENIOR OTC CERTAVITE-ANTIOXIDANT OTC cholecalciferol (vitamin d3) oral capsule 125mcg (5,000 unit) OTC Drug Name Tier Restrictions /Limits cholecalciferol (vitamin d3) oral tablet 10 mcg(400 unit), 125 mcg(5,000 unit), 25 mcg(1,000 unit), 250 mcg(10,000 unit), 50 mcg(2,000 unit), 75 mcg(3,000 unit) OTC COMPLETEMULTIVITAMIN-MINERAL ORALTABLET OTC cyanocobalamin(vitamin b-12) injection 1 DAILY GUMMIES OTC DAILY MULTIPLE FORWOMEN OTC DAILY MULTIVITAMIN OTC DAILY MULTI-VITAMIN OTC DAILY MULTIVITAMIN-MINERALS OTC DAILY VITAMINFORMULA OTC DAILY VITAMINFORMULA-IRON OTC DAILY VITAMINFORMULA-MINERALS OTC DAILY VITAMIN WITHIRON OTC DAILY VITES/IRON OTC DAILY-VITE OTC DECUBI VITE OTC DEKAS BARIATRIC OTC DEKAS PLUS (FOLICACID) OTC DELTA D3 OTC DIABETES HEALTHFORMULA OTC DIALYVITE 800-ULTRAD OTC EMERGEN-C ORALTABLET,CHEWABLE OTC ENDUR-VM IRON-FREE OTC GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/202620 Drug Name Tier Restrictions /Limits ENDUR-VM WITHIRON OTC ESSENTIA OTC ESSENTIAL MAN OTC ESSENTIAL MAN 50PLUS OTC EYE HEALTH PLUSLUTEIN OTC EYEPROTECT OTC FLORIVA PLUS OTC FOLBEE OTC FOLBIC OTC FOLBIC RF OTC FOLINIC-PLUS OTC FOLTANX OTC FOLTANX RF OTC FOLTX OTC HAIR,SKIN AND NAILS OTC HAIR,SKIN ANDNAILS(FA-BIOTIN)ORAL TABLET 66.7-1,666.7 MCG OTC HAIR-SKIN-NAILS (MV-FA-BIOTIN) OTC HEALTHY EYES OTC HEALTHY EYESSUPERVISION OTC I-VITE OTC K-PAX IMMUNESUPPORT OTC levomefol-b6-meb12-algal oil OTC MACULAR HEALTHFORMULA OTC MACUVITE EYE CARE OTC MEGA MULTI FORWOMEN OTC MEGA MULTIVITAMINFOR MEN OTC MEN 50 PLUSADVANCED ONEDAILY OTC Drug Name Tier Restrictions /Limits MEN 50 PLUSMULTIVITAMIN OTC MEN'S 50 PLUS DAILYFORMULA OTC MEN'S DAILY OTC MEN'S DAILYFORMULA OTC MEN'S DAILYGUMMIES OTC MEN'S MULTIVITAMINGUMMIES ORALTABLET,CHEWABLE200 MCG OTC MEN'S ONE DAILY OTC METANX (ALGAL OIL) OTC MILLTRIUM SENIOR OTC MULTI COMPLETEWITH IRON OTC MULTI FOR HER OTC MULTI FOR HER 50PLUS ORAL CAPSULE OTC MULTIPLE VITAMIN-MINERALS OTC MULTIPLE VITAMINS OTC multivit with min-folic acid oral tablet OTC multivitamin OTC MULTIVITAMIN 50PLUS OTC MULTI-VITAMIN WITHFLUORIDE OTC multivitamin with iron OTC MULTIVITAMINWOMEN 50 PLUS OTC multivit-min-folic acid-lutein OTC multivit-min-iron fum-folic ac OTC MVW COMPLETEFORMUL MULTIVIT OTC MVW COMPLETEFORMULATION D3000ORAL CAPSULE OTC GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/2026 21 Drug Name Tier Restrictions /Limits MVW COMPLETEFORMULATION D5000ORAL CAPSULE OTC MYNEPHROCAPS OTC MYNEPHRON OTC MY-VITALIFE OTC NIVA-FOL OTC NIVA-PLUS OTC OCULAR VITAMINS OTC OCUTABS OTC OCUVITE ADULT 50PLUS OTC OCUVITE EYE PLUSMULTI OTC OCUVITE WITHLUTEIN OTC ONCOVITE OTC ONE DAILY OTC ONE DAILYCALCIUM/IRON OTC ONE DAILYCOMPLETE OTC ONE DAILYESSENTIAL ORALTABLET , 400 MCG OTC ONE DAILY FOR MEN OTC ONE DAILY FOR MEN50 PLUS ADV OTC ONE DAILY FORWOMEN OTC ONE DAILY HEALTHYWEIGHT OTC ONE DAILY MAXIMUMORAL TABLET 18-0.4MG OTC ONE DAILY MEN'S 50PLUS MEMORY OTC ONE DAILY MEN'S 50PLUS W-D3 OTC ONE DAILY MULTI-VITW-MINERAL OTC Drug Name Tier Restrictions /Limits ONE DAILYMULTIVITAMIN OTC ONE DAILYMULTIVITAMIN-IRON OTC ONE DAILY PLUSIRON OTC ONE DAILY WOMEN50 PLUS OTC ONE DAILY WOMEN50 PLUS(VIT K) OTC ONE DAILY WOMENS50 PLUS OTC ONE-A-DAY ENERGY OTC ONE-A-DAY MENVITACRAVES OTC ONE-A-DAYMENOPAUSEFORMULA OTC ONE-A-DAY MEN'S50PLUS(GINKGO) OTC ONE-A-DAY MEN'SMULTIVITAMIN OTC ONE-A-DAYPROACTIVE 65 PLUS OTC ONE-A-DAY TEENADVANTAGE OTC ONE-A-DAY TEENHER VITACRAVES OTC ONE-A-DAY TEEN HIMVITACRAVES OTC ONE-A-DAYVITACRAVES OTC ONE-A-DAYVITACRAVESIMMUNITY OTC ONE-A-DAY WOMENVITACRAVES OTC OPURITYMULTIVITAMIN OTC PRESERVISIONAREDS OTC PRESERVISIONLUTEIN OTC PREVENT OTC GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/202622 Drug Name Tier Restrictions /Limits PROCERV HP OTC PRORENAL OTC PRORENAL QD OTC PROSIGHT OTC PROTECT CARDIO AF OTC PROTECT PLUS SO OTC RENAL CAPS OTC RENAPLEX OTC RENAPLEX-D OTC RENO CAPS OTC SENIOR TABS OTC SENTRY OTC SENTRY SENIOR OTC SOLO OTC SPECTRAVITE ADULT50 PLUS OTC SPECTRAVITE ADULT50 PLUS(LUT) OTC SPECTRAVITEADVANCED FORMULA OTC SPECTRAVITE MEN'S OTC STRESS BWITH ZINC OTC STRESS FORMULA OTC STRESS FORMULAWITH IRON(SULF) OTC SUPER MULTIPLE-LOW IRON OTC SUPER THERA VITE M OTC TAB-A-VITE OTC TAB-A-VITEMULTIVITAMIN W-IRON ORAL TABLET15 MG IRON-400 MCG OTC THERA OTC THERAGRAN-MPREMIER 50 PLUS OTC THERALOGIXCOMPANION OTC THERA-M ORALTABLET 27-0.4 MG OTC THERAPEUTIC-M OTC Drug Name Tier Restrictions /Limits THERA-TABS OTC THERATRUMCOMPLETE 50PLUS/LUT OTC THERATRUMCOMPLETE 50 PLUS-LYC OTC THERATRUMCOMPLETE WITHLUTEIN OTC THEREMSMULTIVITAMIN OTC TRIPHROCAPS OTC VISION FORMULA(WITH LUTEIN) OTC VISION FORMULA(A-C-E-ZN-SE-CU) OTC VISION PLUS LUTEIN OTC VITABEX PLUS OTC VITALEE OTC VITAMIN D3 ORALTABLET OTC VITA-RESPA OTC WESTAB MAX OTC WESTAB ONE OTC WOMEN'S 50 PLUSDAILY FORMULA OTC WOMEN'S DAILYFORMULA OTC WOMENS DAILYGUMMIES OTC WOMEN'SMULTIVITAMIN OTC WOMEN'SMULTIVITAMINGUMMIES ORALTABLET,CHEWABLE200 MCG OTC WOMEN'S ONE DAILYORAL TABLET 18 MGIRON-400 MCG-500MG CA OTC GEORGIA P4HB INTER-PREGNANCY CARE | Effective 01/01/2026 23 Index50 PLUS ADULT EYE HEALTH .19 A THRU Z …………………………….. 19 A THRU ZADVANCED FORMULA ……………………………. 19 A THRU ZHIGH POTENCY …… 19 A THRU ZMEN'S ULTIMATE …. 19 A THRU ZSELECT ……………….. 19 A THRU ZSELECT 50PLUS FORMULA ……………………………. 19 A THRU ZSELECT WOMEN'S .19 acarbose ……………………………….. 5 acetazolamide ………………………. 14 acyclovir …………………………….. 7, 8 ADACEL(TDAP ADOLESN/ADULT)(PF) …………… 8 ADULT MULTIVITAMIN GUMMIES ……………………………. 19 ADULT ONE DAILY GUMMIES .19 ADULTS 50 PLUS …………………. 19 ADULTS' DAILY FORMULA …… 19 ADULTS MULTIVITAMIN ……….. 19 ADVANCED MULTI EA ………….. 19 AEROCHAMBER MINI …………… 15 AEROCHAMBER MV …………….. 15 AEROCHAMBER PLUS FLOW-VU …………………………….. 15 AEROCHAMBER PLUS FLOW-VU,L MSK ………………….. 15 AEROCHAMBER PLUS FLOW-VU,M MSK …………………. 16 AEROCHAMBER PLUS FLOW-VU,S MSK ………………….. 16 AEROCHAMBER PLUS ZSTAT …………………………………… 16 AEROCHAMBER PLUS ZSTAT LG MSK ………………………. 16 AEROCHAMBER PLUS ZSTAT MD MSK ……………………… 16 AEROCHAMBER PLUS ZSTAT SM MSK ……………………… 16 AEROCHAMBER Z-STAT PLUS-FLW SG ……………………… 16 AEROVENT PLUS ………………… 16 AFIRMELLE …………………………. 11 AIRBORNE (ASCORBATE SODIUM) ……………………………… 19 AIRBORNE (WITH LYSINE ACETATE) ……………………………. 19 albuterol sulfate ………………………. 3 alendronate ………………………….. 19 ALIVE WOMEN 50 PLS ULT POTENCY ……………………………. 19 ALIVE WOMEN'S GUMMY VITAMIN ………………………………. 20 alogliptin ………………………………… 5 alogliptin-metformin …………………. 5 alogliptin-pioglitazone ………………. 5 ALTAVERA (28) ……………………. 11 ALYACEN 1/35 (28) ………………. 11 ALYACEN 7/7/7 (28) ……………… 11 AMETHIA …………………………….. 11 AMETHYST (28) …………………… 11 amiloride ………………………………. 14 amiloride-hydrochlorothiazide …. 14 amiodarone ……………………………. 8 amitriptyline ………………………….. 17 amitriptyline-chlordiazepoxide …. 17 amlodipine ……………………………… 8 amlodipine-benazepril ……………… 9 amlodipine-olmesartan …………….. 9 amlodipine-valsartan ……………….. 9 amlodipine-valsartan-hcthiazid ….. 9 amoxapine ……………………………. 17 amoxicil-clarithromy-lansopraz …15 amoxicillin ………………………………. 4 amoxicillin-pot clavulanate ……….. 4 ampicillin ………………………………… 4 ANTIOXIDANT FORMULA (SELENIUM) …………………………. 20 APRI ……………………………………. 11 ARANELLE (28) ……………………. 11 aripiprazole …………………………… 17 ARNUITY ELLIPTA …………………. 3 ASHLYNA ……………………………. 11 atenolol ………………………………….. 9 atenolol-chlorthalidone …………….. 9 atomoxetine ………………………….. 17 atorvastatin …………………………….. 9 ATROVENT HFA …………………….. 3 AUBRA ………………………………… 11 AUBRA EQ …………………………… 11 AUROVELA 1.5/30 (21) …………. 11 AUROVELA 1/20 (21) ……………. 11 AUROVELA 24 FE ………………… 11 AUROVELA FE 1.5/30 (28) …….. 11 AUROVELA FE 1-20 (28) ……….. 11 AVIANE ……………………………….. 11 AVIDOXY ………………………………. 4 AYUNA ………………………………… 11 azithromycin …………………………… 4 AZURETTE (28) ……………………. 11 BALZIVA (28) ……………………….. 11 BARIATRIC MULTIVITAMINS … 20 benazepril ………………………………. 9 benazepril-hydrochlorothiazide …. 9 BIO-35, GLUTEN FREE …………. 20 bisoprolol fumarate ………………….. 9 bisoprolol-hydrochlorothiazide …… 9 BLISOVI 24 FE ……………………… 11 BLISOVI FE 1.5/30 (28) …………. 11 BLISOVI FE 1/20 (28) ……………. 11 BODY, HAIR, SKIN AND NAILS ………………………………….. 20 BOOSTRIX TDAP …………………… 8 BREATHERITE MDI SPACER …16 BREATHERITE SPACER-MASK, NEO. ………………………… 16 BREATHERITE SPACER-MASK,ADULT ………………………. 16 BREATHERITE SPACER-MASK,CHILD ……………………….. 16 BREATHERITE SPACER-MASK,INFANT ……………………… 16 BREATHERITE SPACER-MASK,S.CHLD ……………………… 16 BREATHERITE VALVED MDI CHAMBER …………………………… 16 BREATHERITE VALVED MDI SPACER ……………………………… 16 BRIELLYN ……………………………. 11 BRILINTA ………………………………. 7 budesonide …………………………….. 3 bumetanide ………………………….. 14 buprenorphine-naloxone ………… 19 bupropion hcl ………………………… 17 calcitriol ……………………………….. 20 CALCIUM 500 + D ………………… 14 CALCIUM 500 WITH D ………….. 14 CALCIUM 600 WITH VITAMIN D3 ……………………………………….. 14 calcium acetate(phosphat bind) .14 calcium carbonate-vitamin d3 ….. 14 CALCIUM WITH VITAMIN D …… 14 CAMILA ……………………………….. 11 CAMRESE ……………………………. 11 CAMRESE LO ………………………. 11 candesartan …………………………… 9 candesartan-hydrochlorothiazid … 9 captopril …………………………………. 9 captopril-hydrochlorothiazide ……. 9 carbamazepine ……………………… 10 CARTIA XT …………………………….. 8 carvedilol ……………………………….. 9 CAYA CONTOURED …………….. 11 CAZIANT (28) ……………………….. 11 cefadroxil ……………………………….. 4 cefdinir …………………………………… 4 cefprozil …………………………………. 4 cefuroxime axetil …………………….. 4 celecoxib ……………………………….. 3 CELONTIN …………………………… 10 CENTRATEX ………………………… 14 24 CENTRAVITES …………………….. 20 CENTRAVITES 50 PLUS ……….. 20 CENTRAVITES ADULTS ……….. 20 CENTRUM CHEWABLES ………. 20 CENTRUM SILVER ……………….. 20 CENTRUM SILVER MEN ……….. 20 CENTRUM SILVER ULTRA MEN'S …………………………………. 20 CENTRUM SILVER WOMEN …. 20 CENTRUM SPECIALIST HEART ………………………………… 20 CENTRUM WOMEN ……………… 20 CENTURY ……………………………. 20 CENTURY MATURE ……………… 20 cephalexin ……………………………… 4 CEROVITE SENIOR ……………… 20 CERTA PLUS ……………………….. 20 CERTAVITE SENIOR ……………. 20 CERTAVITE-ANTIOXIDANT …… 20 CHATEAL EQ (28) ………………… 11 chlorpromazine ……………………… 17 chlorthalidone ……………………….. 14 cholecalciferol (vitamin d3) ……… 20 CHOLESTYRAMINE LIGHT …….. 9 CHROMAGEN(SUMALATE-QUATREFOLI) ……………………… 14 cilostazol ……………………………….. 7 ciprofloxacin …………………………… 4 ciprofloxacin hcl ………………………. 4 citalopram …………………………….. 17 clarithromycin …………………………. 4 CLEOCIN ………………………………. 4 CLEVER CHOICE CHAMBER-LRG MASK …………………………… 16 CLEVER CHOICE CHAMBER-MED MASK ………………………….. 16 CLEVER CHOICE CHAMBER-SM MASK …………………………….. 16 clindamycin hcl ……………………….. 4 CLINDAMYCIN PEDIATRIC …….. 4 clindamycin phosphate …………….. 4 clobazam ……………………………… 10 clomipramine ………………………… 17 clonazepam ………………………….. 10 clonidine ………………………………… 9 clonidine hcl …………………………. 17 clopidogrel ……………………………… 7 clotrimazole ……………………………. 5 clozapine ……………………………… 17 colchicine ………………………………. 3 colestipol ……………………………….. 9 COMBIPATCH ……………………… 15 COMBIVENT RESPIMAT …………. 3 COMPACT SPACE CHAMBER .16 COMPACT SPACE CHAMBER-LRG MASK ………….. 16 COMPACT SPACE CHAMBER-MED MASK …………. 16 COMPACT SPACE CHAMBER-SM MASK ……………. 16 COMPLETE MULTIVITAMIN-MINERAL …………………………….. 20 COMPLETENATE …………………. 17 COVARYX ……………………………. 15 COVARYX H.S. …………………….. 15 cromolyn ………………………………… 3 CRYSELLE (28) ……………………. 11 CUTTER BACKWOODS ………….. 6 CUTTER BACKWOODS DRY ….. 6 CUTTER LEMON EUCALYPTUS ……………………….. 6 CUTTER NATURAL INSECT REPELLNT …………………………….. 6 CUTTER NATURAL REPELLENT2 ………………………… 6 CUTTER SKINSATIONS ………….. 6 cyanocobalamin (vitamin b-12) ..20 CYRED ………………………………… 11 CYRED EQ …………………………… 11 DAILY GUMMIES ………………….. 20 DAILY MULTIPLE FOR WOMEN ………………………………. 20 DAILY MULTIVITAMIN …………… 20 DAILY MULTI-VITAMIN …………. 20 DAILY MULTIVITAMIN-MINERALS …………………………… 20 DAILY VITAMIN FORMULA ……. 20 DAILY VITAMIN FORMULA-IRON …………………………………… 20 DAILY VITAMIN FORMULA-MINERALS …………………………… 20 DAILY VITAMIN WITH IRON ….. 20 DAILY VITES/IRON ……………….. 20 DAILY-VITE ………………………….. 20 danazol ………………………………… 15 dapaglifloz propaned-metformin …6 dapagliflozin propanediol ………….. 6 dapsone ………………………………… 4 DASETTA 1/35 (28) ………………. 11 DASETTA 7/7/7 (28) ……………… 11 DAYSEE ………………………………. 11 DEBLITANE …………………………. 11 DECUBI VITE ……………………….. 20 DEKAS BARIATRIC ………………. 20 DEKAS PLUS (FOLIC ACID) ….. 20 DELTA D3 ……………………………. 20 DEPO-SUBQ PROVERA 104 …. 11 desipramine ………………………….. 17 desmopressin ……………………….. 15 desog-e.estradiol/e.estradiol …… 11 DEX4 GLUCOSE ………………….. 14 DEX4 GLUCOSE POUCH PACK ………………………………….. 14 DEX4 GLUCOSE QUICK DISSOLVE …………………………… 14 dexmethylphenidate ………………. 18 dextroamphetamine sulfate ………. 8 dextroamphetamine-amphetamine …………………………. 8 dextrose ………………………………. 14 DIABETES HEALTH FORMULA ……………………………. 20 DIABETIC SUPPORT FORMULA ……………………………. 19 DIALYVITE 800-ULTRA D ……… 20 diazepam ……………………………… 10 diclofenac potassium ……………….. 3 diclofenac sodium ……………………. 3 diclofenac-misoprostol ……………… 3 dicloxacillin …………………………….. 4 diflunisal ………………………………… 3 DIGITEK ………………………………… 8 digoxin …………………………………… 8 DILANTIN …………………………….. 10 DILANTIN EXTENDED ………….. 10 diltiazem hcl ……………………………. 8 DILT-XR ………………………………… 9 dipyridamole …………………………… 7 disopyramide phosphate ………….. 9 divalproex …………………………….. 10 dofetilide ………………………………… 9 doxazosin ………………………………. 9 doxepin ………………………………… 18 doxycycline hyclate ……………. 4, 19 doxycycline monohydrate …………. 4 drospirenone-e.estradiol-lm.fa …. 11 drospirenone-ethinyl estradiol …. 11 DRY EYE FORMULA …………….. 19 DULERA ………………………………… 3 duloxetine …………………………….. 18 E.E.S. 400 ……………………………… 4 EASIVENT HOLDING CHAMBER …………………………… 16 EASIVENT MASK LARGE ……… 16 EASIVENT MASK MEDIUM ……. 16 EASIVENT MASK SMALL ………. 16 ECLIPSE SYRINGE ………………. 16 EEMT ………………………………….. 15 EEMT HS …………………………….. 15 ELINEST ……………………………… 11 ELIQUIS ………………………………… 5 ELIQUIS DVT-PE TREAT 30D START ………………………………….. 5 ELURYNG ……………………………. 1125 EMERGEN-C ……………………….. 20 enalapril maleate …………………….. 9 enalapril-hydrochlorothiazide ……. 9 ENDUR-VM IRON-FREE ……….. 20 ENDUR-VM WITH IRON ………… 21 ENGERIX-B (PF) …………………….. 8 ENGERIX-B PEDIATRIC (PF) ….. 8 enoxaparin …………………………….. 5 ENPRESSE ………………………….. 11 ENSKYCE ……………………………. 11 ENTRESTO ……………………………. 9 eplerenone …………………………… 14 ERRIN …………………………………. 12 ERY-TAB ……………………………….. 4 ERYTHROCIN (AS STEARATE) …………………………… 5 erythromycin …………………………… 5 erythromycin ethylsuccinate ……… 5 escitalopram oxalate ……………… 18 ESSENTIA …………………………… 21 ESSENTIAL MAN ………………….. 21 ESSENTIAL MAN 50 PLUS ……. 21 ESTARYLLA ………………………… 12 estradiol-norethindrone acet ……. 15 estrogens-methyltestosterone …. 15 ethosuximide ………………………… 10 ethynodiol diac-eth estradiol ……. 12 etodolac …………………………………. 3 etonogestrel-ethinyl estradiol ….. 12 EUTHYROX …………………………. 19 EYE HEALTH PLUS LUTEIN ….. 21 EYEPROTECT ……………………… 21 ezetimibe ……………………………….. 9 FALMINA (28) ………………………. 12 felbamate …………………………….. 10 felodipine ……………………………….. 9 FEMCAP ……………………………… 12 fenofibrate micronized ……………… 9 flecainide ……………………………….. 9 FLEXICHAMBER ………………….. 16 FLORIVA PLUS …………………….. 21 fluconazole …………………………….. 5 fluoride (sodium) ……………………. 14 fluoxetine ……………………………… 18 fluphenazine hcl ……………………. 18 flurbiprofen …………………………….. 3 fluticasone propionate ……………… 3 fluticasone propion-salmeterol .3, 4 fluvoxamine ………………………….. 18 FOLBEE ………………………………. 21 FOLBIC ……………………………….. 21 FOLBIC RF …………………………… 21 FOLINIC-PLUS ……………………… 21 FOLTANX …………………………….. 21 FOLTANX RF ……………………….. 21 FOLTX …………………………………. 21 fosinopril ………………………………… 9 fosinopril-hydrochlorothiazide ……. 9 FREESTYLE LIBRE 14 DAY READER ……………………………… 16 FREESTYLE LIBRE 2 READER ……………………………… 16 furosemide …………………………… 14 FYAVOLV …………………………….. 15 FYCOMPA ……………………………. 10 gabapentin …………………………… 10 gemfibrozil ……………………………… 9 glimepiride ……………………………… 6 glipizide …………………………………. 6 glipizide-metformin ………………….. 6 glucose ………………………………… 14 GLUCOSE GEL …………………….. 14 GLUTOSE-15 ……………………….. 14 GLUTOSE-45 ……………………….. 14 GLUTOSE-5 …………………………. 14 glyburide ………………………………… 6 glyburide micronized ……………….. 6 glyburide-metformin …………………. 6 griseofulvin ultramicrosize ………… 5 guanfacine ………………………… 9, 18 HAILEY 24 FE ………………………. 12 HAILEY FE 1.5/30 (28) …………… 12 HAILEY FE 1/20 (28) ……………… 12 HAIR, SKIN AND NAILS ADVANCED …………………………. 19 HAIR,SKIN AND NAILS …………. 21 HAIR,SKIN AND NAILS(FA-BIOTIN) ……………………………….. 21 HAIR-SKIN-NAIL(VIT A,C-BIOTIN) ……………………………….. 19 HAIR-SKIN-NAILS (MV-FA-BIOTIN) ……………………………….. 21 haloperidol ……………………………. 18 haloperidol lactate …………………. 18 HEALTHY EYES …………………… 21 HEALTHY EYES SUPERVISION ……………………… 21 HEATHER ……………………………. 12 HEMATINIC PLUS VIT/MINERALS …………………….. 14 HEMATINIC/FOLIC ACID ………. 14 HEMATOGEN FORTE …………… 14 HEMOCYTE-PLUS ……………….. 14 HEPLISAV-B (PF) …………………… 8 HUMULIN RU-500 (CONC) KWIKPEN ………………………………. 6 hydralazine …………………………….. 9 hydrochlorothiazide ……………….. 14 hydrocortisone ………………………. 15 ibandronate ………………………….. 19 IBU ……………………………………….. 3 ibuprofen ……………………………….. 3 imipramine hcl ………………………. 18 IMMUNE SUPPORT ……………… 19 INCASSIA ……………………………. 12 indapamide …………………………… 14 INSECT REPELLENT (DEET) ….. 6 INSECT REPELLENT (PICARIDIN) …………………………… 6 insulin glargine-yfgn ………………… 6 insulin lispro ……………………………. 6 insulin syringe-needle u-100 …… 16 INTEGRA SYRINGE ……………… 16 INVOKAMET ………………………….. 6 INVOKAMET XR …………………….. 6 ipratropium bromide ………………… 4 ipratropium-albuterol ……………….. 4 irbesartan ………………………………. 9 irbesartan-hydrochlorothiazide ….. 9 ISIBLOOM ……………………………. 12 isosorbide mononitrate …………….. 9 I-VITE ………………………………….. 21 JANTOVEN ……………………………. 5 JASMIEL (28) ……………………….. 12 JENCYCLA …………………………… 12 JINTELI ……………………………….. 15 JOLESSA …………………………….. 12 JULEBER …………………………….. 12 JUNEL 1.5/30 (21) …………………. 12 JUNEL 1/20 (21) ……………………. 12 JUNEL FE 1.5/30 (28) ……………. 12 JUNEL FE 1/20 (28) ………………. 12 JUNEL FE 24 ……………………….. 12 KAITLIB FE ………………………….. 12 KARIVA (28) …………………………. 12 KELNOR 1/35 (28) ………………… 12 ketoconazole ………………………….. 5 ketoprofen ……………………………… 3 ketorolac ………………………………… 3 KLOR-CON 10 ……………………… 14 KLOR-CON 8 ……………………….. 15 KLOR-CON M10 …………………… 15 KLOR-CON M15 …………………… 15 KLOR-CON M20 …………………… 15 KOSHER PRENATAL PLUS IRON …………………………………… 17 K-PAX IMMUNE SUPPORT ……. 21 KURVELO (28) ……………………… 12 l norgest/e.estradiol-e.estrad …… 12 labetalol …………………………………. 9 LAGEVRIO (EUA) …………………… 8 lamotrigine ……………………………. 10 LARIN 1.5/30 (21) …………………. 12 LARIN 1/20 (21) ……………………. 12 LARIN 24 FE ………………………… 12 26 LARIN FE 1.5/30 (28) …………….. 12 LARIN FE 1/20 (28) ……………….. 12 LESSINA ……………………………… 12 levalbuterol tartrate ………………….. 4 levetiracetam ………………………… 10 levofloxacin ……………………………. 5 levomefol-b6-meb12-algal oil ….. 21 LEVONEST (28) ……………………. 12 levonorgestrel-ethinyl estrad …… 12 levonorg-eth estrad triphasic …… 12 LEVORA-28 …………………………. 12 levothyroxine ………………………… 19 LEVOXYL …………………………….. 19 liothyronine …………………………… 19 LIQUID CALCIUM WITH VITAMIN D …………………………… 15 lisinopril …………………………………. 9 lisinopril-hydrochlorothiazide …….. 9 LITEAIRE MDI CHAMBER ……… 16 lithium carbonate …………………… 18 LORYNA (28) ……………………….. 12 losartan …………………………………. 9 losartan-hydrochlorothiazide …….. 9 lovastatin ……………………………….. 9 LOW-OGESTREL (28) …………… 12 loxapine succinate …………………. 18 LO-ZUMANDIMINE (28) …………. 12 LUTERA (28) ………………………… 12 LYZA …………………………………… 12 MACULAR HEALTH FORMULA ……………………………. 21 MACUVITE EYE CARE ………….. 21 MARLISSA (28) …………………….. 12 MATZIM LA ……………………………. 9 medroxyprogesterone ………. 12, 15 MEGA MULTI FOR WOMEN ….. 21 MEGA MULTIVITAMIN FOR MEN ……………………………………. 21 MEGAVITE …………………………… 19 meloxicam ……………………………… 3 MEN 50 PLUS ADVANCED ONE DAILY ………………………….. 21 MEN 50 PLUS MULTIVITAMIN ..21 MEN'S 50 PLUS DAILY FORMULA ……………………………. 21 MEN'S DAILY ……………………….. 21 MEN'S DAILY FORMULA ………. 21 MEN'S DAILY GUMMIES ……….. 21 MEN'S MULTIVITAMIN GUMMIES ……………………………. 21 MEN'S ONE DAILY ……………….. 21 METANX (ALGAL OIL) …………… 21 metformin ………………………………. 6 methazolamide ……………………… 14 methen-sod phos-meth blue-hyos ………………………………………. 5 methimazole …………………………. 19 methyldopa …………………………….. 9 methylergonovine ………………….. 15 methylphenidate hcl ………………. 18 methylprednisolone ……………….. 15 metolazone …………………………… 14 metoprolol succinate ……………….. 9 metoprolol ta-hydrochlorothiaz ….. 9 metoprolol tartrate …………………… 9 metronidazole …………………………. 5 metyrosine ……………………………. 10 MICROCHAMBER ………………… 16 MICROGESTIN 1.5/30 (21) …….. 12 MICROGESTIN 1/20 (21) ……….. 12 MICROGESTIN FE 1.5/30 (28) ..12 MICROGESTIN FE 1/20 (28) ….. 12 MICROSPACER ……………………. 16 midodrine ………………………………. 8 miglitol …………………………………… 6 MILI …………………………………….. 12 MILLTRIUM SENIOR …………….. 21 MIMVEY ………………………………. 15 minocycline …………………………….. 5 minoxidil ………………………………. 10 mirtazapine …………………………… 18 M-NATAL PLUS ……………………. 17 MONDOXYNE NL …………………… 5 MONOJECT INSULIN SAFETY SYRING ………………………………. 16 MONO-LINYAH …………………….. 12 montelukast ……………………………. 4 MORGIDOX …………………………… 5 moxifloxacin ……………………………. 5 MULTI COMPLETE WITH IRON …………………………………… 21 MULTI FOR HER ………………….. 21 MULTI FOR HER 50 PLUS …….. 21 MULTIPLE VITAMIN-MINERALS …………………………… 21 MULTIPLE VITAMINS ……………. 21 multivit with min-folic acid ……….. 21 multivitamin ………………………….. 21 MULTIVITAMIN 50 PLUS ……….. 21 MULTI-VITAMIN WITH FLUORIDE …………………………… 21 multivitamin with iron ……………… 21 MULTIVITAMIN WOMEN 50 PLUS …………………………………… 21 multivit-min-folic acid-lutein …….. 21 multivit-min-iron fum-folic ac ……. 21 MVW COMPLETE FORMUL MULTIVIT …………………………….. 21 MVW COMPLETE FORMULATION D3000 ………….. 21 MVW COMPLETE FORMULATION D5000 ………….. 22 MYNEPHROCAPS ………………… 22 MYNEPHRON ………………………. 22 MY-VITALIFE ……………………….. 22 nabumetone …………………………… 3 nadolol …………………………………. 10 naproxen ……………………………….. 3 naproxen sodium …………………….. 3 NATACYN ……………………………… 5 nateglinide ……………………………… 6 NATRAPEL ……………………………. 7 NECON 0.5/35 (28) ……………….. 12 nefazodone ………………………….. 18 neomycin ……………………………….. 5 nifedipine ……………………………….. 9 NIKKI (28) ……………………………. 12 nitrofurantoin macrocrystal ……….. 5 nitrofurantoin monohyd/m-cryst …. 5 nitroglycerin ……………………………. 9 NIVA-FOL …………………………….. 22 NIVA-PLUS ………………………….. 22 NORA-BE …………………………….. 12 noreth-ethinyl estradiol-iron …….. 12 norethindrone (contraceptive) …. 12 norethindrone ac-eth estradiol………………………………………. 12, 15 norethindrone-e.estradiol-iron …. 13 norgestimate-ethinyl estradiol …. 13 NORTREL 0.5/35 (28) ……………. 13 NORTREL 1/35 (21) ………………. 13 NORTREL 1/35 (28) ………………. 13 NORTREL 7/7/7 (28) ……………… 13 nortriptyline …………………………… 18 nystatin ………………………………….. 5 OCELLA ………………………………. 13 OCULAR VITAMINS ……………… 22 OCUTABS ……………………………. 22 OCUVITE ADULT 50 PLUS ……. 22 OCUVITE EYE PLUS MULTI ….. 22 OCUVITE WITH LUTEIN ……….. 22 OFEV ………………………………….. 19 OFF ACTIVE ………………………….. 7 OFF DEEP WOODS ……………….. 7 OFF DEEP WOODS DRY ………… 7 OFF DEEP WOODS SPORTSMEN …………………………. 7 OFF FAMILYCARE (WITH DEET) …………………………………… 7 OFF FAMILYCARE(WITH PICARIDIN) ……………………………. 7 ofloxacin ………………………………… 5 olanzapine ……………………………. 1827 olmesartan …………………………… 10 olmesartan-amlodipin-hcthiazid ..10 olmesartan-hydrochlorothiazide .10 omega-3 acid ethyl esters ………. 15 OMEGA-3 FISH OIL ………………. 19 ONCOVITE …………………………… 22 ONE DAILY ………………………….. 22 ONE DAILY CALCIUM/IRON ….. 22 ONE DAILY COMPLETE ……….. 22 ONE DAILY ESSENTIAL ……….. 22 ONE DAILY FOR MEN …………… 22 ONE DAILY FOR MEN 50 PLUS ADV …………………………… 22 ONE DAILY FOR WOMEN …….. 22 ONE DAILY HEALTHY WEIGHT ………………………………. 22 ONE DAILY MAXIMUM ………….. 22 ONE DAILY MEN'S 50 PLUS MEMORY …………………………….. 22 ONE DAILY MEN'S 50 PLUS W-D3 …………………………………… 22 ONE DAILY MULTI-VIT W-MINERAL …………………………….. 22 ONE DAILY MULTIVITAMIN …… 22 ONE DAILY MULTIVITAMIN-IRON …………………………………… 22 ONE DAILY PLUS IRON ………… 22 ONE DAILY WOMEN 50 PLUS ..22 ONE DAILY WOMEN 50 PLUS(VIT K) …………………………. 22 ONE DAILY WOMENS 50 PLUS …………………………………… 22 ONE DAILY WOMEN'S METABOLISM ………………………. 19 ONE-A-DAY ENERGY …………… 22 ONE-A-DAY MEN VITACRAVES ……………………….. 22 ONE-A-DAY MENOPAUSE FORMULA ……………………………. 22 ONE-A-DAY MEN'S 50PLUS(GINKGO) ………………… 22 ONE-A-DAY MEN'S MULTIVITAMIN …………………….. 22 ONE-A-DAY PROACTIVE 65 PLUS …………………………………… 22 ONE-A-DAY TEEN ADVANTAGE ……………………….. 22 ONE-A-DAY TEEN HER VITACRAVES ……………………….. 22 ONE-A-DAY TEEN HIM VITACRAVES ……………………….. 22 ONE-A-DAY VITACRAVES …….. 22 ONE-A-DAY VITACRAVES IMMUNITY ……………………………. 22 ONE-A-DAY WOMEN VITACRAVES ……………………….. 22 ONEVITE CALCIUM-D3 …………. 15 OPTICHAMBER DIAMOND LG MASK ………………………………….. 16 OPTICHAMBER DIAMOND VHC …………………………………….. 17 OPTICHAMBER DIAMOND-MED MSK …………………………….. 17 OPTICHAMBER DIAMOND-SML MASK …………………………… 17 OPURITY MULTIVITAMIN ……… 22 oxaprozin ……………………………….. 3 oxcarbazepine ………………………. 10 OXTELLAR XR ……………………… 10 OYSCO 500/D ………………………. 15 OYSTER SHELL + D3 …………… 15 OYSTER SHELL CALCIUM-VIT D3 …………………………………. 15 paroxetine hcl ……………………….. 18 PEN NEEDLE ……………………….. 17 penicillin v potassium ………………. 5 pentoxifylline ………………………….. 8 perphenazine ……………………….. 18 perphenazine-amitriptyline ……… 18 phenazopyridine ……………………… 3 phenobarbital ……………………….. 19 phenytoin ……………………………… 10 phenytoin sodium extended ……. 11 PHILITH ………………………………. 13 PHYTOMULTI ………………………. 19 pimozide ………………………………. 18 PIMTREA (28) ………………………. 13 pioglitazone ……………………………. 6 pioglitazone-glimepiride ……………. 6 pioglitazone-metformin …………….. 6 POCKET CHAMBER ……………… 17 PORTIA 28 …………………………… 13 potassium chloride ………………… 15 potassium citrate …………………… 15 potassium citrate-citric acid …….. 15 prasugrel hcl …………………………… 7 pravastatin ……………………………. 10 prednisolone …………………………. 15 prednisolone sodium phosphate 15 prednisone …………………………… 15 PREDNISONE INTENSOL ……… 15 pregabalin ……………………………. 11 PRENATABS FA …………………… 17 PRENATABS RX …………………… 17 PRENATAL 19 ……………………… 17 PRENATAL MULTI ………………… 17 PRENATAL PLUS …………………. 17 PRENATAL PLUS (CALCIUM CARB) …………………………………. 17 PRENATAL TABLET ……………… 17 PRENATAL VITAMIN …………….. 17 PRENATAL VITAMIN PLUS LOW IRON …………………………… 17 PRENATAL VITAMIN WITH MINERALS …………………………… 17 prenatal vit-iron fum-folic ac ……. 17 PRESERVISION AREDS ……….. 22 PRESERVISION LUTEIN ……….. 22 PREVALITE …………………………. 10 PREVENT ……………………………. 22 primidone …………………………….. 11 probenecid …………………………….. 3 PROCERV HP ………………………. 23 PROCHAMBER …………………….. 17 progesterone micronized ………… 15 propafenone …………………………… 9 propranolol …………………………… 10 propylthiouracil ……………………… 19 PRORENAL ………………………….. 23 PRORENAL QD ……………………. 23 PROSIGHT …………………………… 23 PROTECT CARDIO AF ………….. 23 PROTECT PLUS SO ……………… 23 pyridostigmine bromide ……………. 8 quetiapine …………………………….. 18 quinapril ……………………………….. 10 quinapril-hydrochlorothiazide ….. 10 ramipril …………………………………. 10 RANGER READY REPELLENT …7 ranolazine ………………………………. 9 RECLIPSEN (28) …………………… 13 RECOMBIVAX HB (PF) …………… 8 RENAL CAPS ……………………….. 23 RENAPLEX ………………………….. 23 RENAPLEX-D ………………………. 23 RENO CAPS ………………………… 23 repaglinide ……………………………… 6 REPEL 100 ……………………………. 7 REPEL FAMILY ………………………. 7 REPEL HUNTER'S …………………. 7 REPEL LEMON EUCALYPTUS …7 REPEL SPORTSMEN ……………… 7 REPEL SPORTSMEN DRY ……… 7 REPEL SPORTSMEN MAX ……… 7 REPEL TICK DEFENSE ………….. 7 RHOGAM ULTRA-FILTERED PLUS …………………………………….. 8 risperidone …………………………… 18 RITEFLO AEROCHAMBER ……. 17 rosuvastatin ………………………….. 10 ROWEEPRA ………………………… 11 RYBELSUS ……………………………. 6 salmon oil-omega-3 fatty acids …10 SE-NATAL 19 CHEWABLE …….. 17 28 SENIOR TABS ……………………… 23 SENTRY ………………………………. 23 SENTRY SENIOR …………………. 23 SEREVENT DISKUS ……………….. 4 sertraline ……………………………… 18 SETLAKIN ……………………………. 13 SHAROBEL ………………………….. 13 SIMLIYA (28) ………………………… 13 SIMPESSE …………………………… 13 simvastatin …………………………… 10 SOLO ………………………………….. 23 sotalol ………………………………….. 10 SOTALOL AF ……………………….. 10 SPECTRAVITE ADULT 50 PLUS …………………………………… 23 SPECTRAVITE ADULT 50 PLUS(LUT) …………………………… 23 SPECTRAVITE ADVANCED FORMULA ……………………………. 23 SPECTRAVITE MEN'S ………….. 23 SPIRIVA RESPIMAT ……………….. 4 spironolactone ………………………. 14 spironolacton-hydrochlorothiaz ..14 SPRINTEC (28) …………………….. 13 SRONYX ……………………………… 13 STIOLTO RESPIMAT ………………. 4 STRESS BWITH ZINC ………….. 23 STRESS FORMULA ……………… 23 STRESS FORMULA WITH IRON(SULF) …………………………. 23 STRIVERDI RESPIMAT …………… 4 SUBVENITE …………………………. 11 sulfacetamide sodium-sulfur ……… 5 sulfamethoxazole-trimethoprim …. 5 SULFATRIM …………………………… 5 sulindac …………………………………. 3 SUPER MULTIPLE-LOW IRON …………………………………… 23 SUPER OMEGA-3 ………………… 15 SUPER THERA VITE M …………. 23 SYEDA ………………………………… 13 SYNTHROID ………………………… 19 TAB-A-VITE ………………………….. 23 TAB-A-VITE MULTIVITAMIN W-IRON ……………………………….. 23 TARINA 24 FE ………………………. 13 TARINA FE 1/20 (28) …………….. 13 TARINA FE 1-20 EQ (28) ……….. 13 telmisartan ……………………………. 10 telmisartan-amlodipine …………… 10 telmisartan-hydrochlorothiazid … 10 TENIVAC (PF) ………………………… 8 terazosin ………………………………. 10 terbinafine hcl …………………………. 5 terbutaline ……………………………… 4 terconazole …………………………….. 5 tetracycline …………………………….. 5 THEO-24 ……………………………….. 4 theophylline ……………………………. 4 THERA ………………………………… 23 THERAGRAN-M PREMIER 50 PLUS …………………………………… 23 THERALOGIX COMPANION ….. 23 THERA-M …………………………….. 23 THERANATAL ………………………. 17 THERAPEUTIC-M …………………. 23 THERA-TABS ……………………….. 23 THERATRUM COMPLETE 50 PLUS/LUT ……………………………. 23 THERATRUM COMPLETE 50 PLUS-LYC ……………………………. 23 THERATRUM COMPLETE WITH LUTEIN ………………………. 23 THEREMS MULTIVITAMIN ……. 23 thioridazine …………………………… 18 thiothixene ……………………………. 18 THRIVITE RX ……………………….. 17 tiagabine ………………………………. 11 TILIA FE ………………………………. 13 topiramate ……………………………. 11 torsemide …………………………….. 14 TOTAL HOME INSECT REPELLENT ………………………….. 7 trandolapril …………………………… 10 tranylcypromine …………………….. 18 trazodone …………………………….. 19 TRELEGY ELLIPTA ………………… 4 triamterene-hydrochlorothiazid …14 TRICARE ……………………………… 17 TRICON ……………………………….. 15 TRI-ESTARYLLA …………………… 13 trifluoperazine ……………………….. 19 TRIGELS-F FORTE ………………. 15 TRI-LEGEST FE ……………………. 13 TRI-LINYAH …………………………. 13 TRI-LO-ESTARYLLA ……………… 13 TRI-LO-MARZIA ……………………. 13 TRI-LO-MILI …………………………. 13 TRI-LO-SPRINTEC ……………….. 13 trimethoprim …………………………… 5 TRI-MILI ………………………………. 13 trimipramine ………………………….. 19 TRINATAL RX 1 ……………………. 17 TRIPHROCAPS ……………………. 23 TRI-SPRINTEC (28) ………………. 13 TRI-VYLIBRA ……………………….. 13 TRI-VYLIBRA LO ………………….. 13 TULANA ………………………………. 13 ULTRATHON …………………………. 7 UNITHROID …………………………. 19 URETRON D-S ………………………. 5 URYL …………………………………….. 5 valacyclovir …………………………….. 8 valsartan ………………………………. 10 valsartan-hydrochlorothiazide …. 10 vancomycin ……………………………. 5 VANDAZOLE ………………………….. 5 VELIVET TRIPHASIC REGIMEN (28) ……………………… 13 venlafaxine …………………………… 19 verapamil ……………………………….. 9 VESTURA (28) ……………………… 13 V-GO 20 ………………………………. 17 V-GO 30 ………………………………. 17 V-GO 40 ………………………………. 17 VIENVA ……………………………….. 13 VIORELE (28) ………………………. 13 VISION FORMULA (WITH LUTEIN) ………………………………. 23 VISION FORMULA(A-C-E-ZN-SE-CU) ………………………………… 23 VISION PLUS LUTEIN …………… 23 VITABEX PLUS …………………….. 23 VITALEE ……………………………… 23 VITAMIN D3 …………………………. 23 VITA-RESPA ………………………… 23 voriconazole …………………………… 5 VORTEX HOLDING CHAMBER …………………………… 17 VOTRIENT …………………………….. 7 VYFEMLA (28) ……………………… 13 VYLIBRA ……………………………… 13 warfarin …………………………………. 5 WERA (28) …………………………… 13 WESTAB MAX ……………………… 23 WESTAB ONE ……………………… 23 WIDE-SEAL DIAPHRAGM 60 …. 13 WIDE-SEAL DIAPHRAGM 65 …. 13 WIDE-SEAL DIAPHRAGM 70 …. 13 WIDE-SEAL DIAPHRAGM 75 …. 13 WIDE-SEAL DIAPHRAGM 80 …. 13 WIDE-SEAL DIAPHRAGM 85 …. 13 WIDE-SEAL DIAPHRAGM 90 …. 13 WIDE-SEAL DIAPHRAGM 95 …. 13 WOMEN'S 50 PLUS DAILY FORMULA ……………………………. 23 WOMEN'S DAILY FORMULA …. 23 WOMENS DAILY GUMMIES ….. 23 WOMEN'S MULTIVITAMIN …….. 23 WOMEN'S MULTIVITAMIN GUMMIES ……………………………. 23 WOMEN'S ONE DAILY ………….. 23 WYMZYA FE ………………………… 13 XARELTO ……………………………… 529 XARELTO DVT-PE TREAT 30D START……………………………. 5XULANE ………………………………. 13ZAFEMY ………………………………. 13ZARAH ………………………………… 14ziprasidone hcl ……………………… 19zonisamide …………………………… 11ZOVIA 1-35 (28) …………………….14ZUMANDIMINE (28) ……………….1430 GA-MED-M-2964348-V.7-SPA DCH Approved: 6/21/2024

GA-MED-M-2964344-SPA 2026 GA MCD

Medicaid de Georgia de CareSource 1/1/2026INTRODUCCINEste es el Formulario de Medicaid o la Lista de medicamentos preferidos (Preferred Drug List, PDL) de CareSource de 2026. Esta lista puede ayudar a los proveedores en la seleccin de produc t os c lnic am ente adec uados y de m enor pr ec io. Todos los m edic am entos de Medic aid de Georgia est n c ubiertospor CareSourc e. Esta es solo una lista de m edic am entos pr eferidos. Est os m edic am entos han si do rev isados por el Com it de Farm ac ia y Teraputic a (Pharm ac y and Therapeutic s , P&T) de CareSourc e. La list a se enc uentra ac tualizada al m om ento de la rev isin. No prom etem osl a ex ac titud de l os datos. Tam poc o pretende s er una lista c om pleta. No sustituy e el c onoc im iento, l a habilidad y el c riterio del prov eedor. Todos los dat os de l a lista c onstituy en una gu a. Los pr ov eedores son totalm ente responsabl es de todas las opc i ones de m edic am entos. La lista est sujeta a las l ey es ynorm as es pec fic as en c ada est ado. Estas pueden ser, ent re otras:l as de la opc in genric a;las listas de sustanc ias c ontroladas;la pref erenc ia por la m arc a;los m edic am entos genric os obligatorios (c uando c orresponda).No asum im os ninguna responsabilidad por las ac c iones o brec has de ningn prov eedor. Deben rev i sar los datos de los produc tos del f abric ante de m edic am entos o las ref erenc ias estndar. PREFACIO La lista est ordenada por sec c iones. Cada sec c in se div ide por c lase de m edic am ento teraputic o, segn elm todo de ac c in. Los produc tos se m enc ionan por nom bre genric o. El nom bre de m arc a tam bin f igura en la lista. Esto es solo a f ines inf orm ativ os. A m enos que el m edic am ento sea una iny ec c in o un c aso espec ial, se m enc iona la dosis, las f orm as y las c onc entrac iones. COMIT DE P&T Se usa un Com it nac ional de P&T para aprobar terapias f arm ac olgic as seguras y tiles. Est c om pues to por: los direc tores m dic os del plan; el personal de f arm ac ia;personas de la c om unidad m dic a.DETALLES SOBRE LA COBERTURA DE MEDICAMENTOS Solo se puede c ubrir una c onc entrac in, dosif ic ac in u otra f orm ulac in si se inc luy e en la lista. No se c ubren otras c onc entrac iones, dosif ic ac iones ni f orm ulac iones. Por ejem plo: f orm as iny ec tables del produc to. Los produc tos de liberac in prolongada y r etardada tienen su propio listado. M edic aid de Georgia de CareSourc emetformina Glucophage La lista de produc tos de liberac in inm ediata no tendra el produc to de liberac in ex tendida. metformina ext-rel Glucophage XR Un segundo listado m uestra el produc to de liberac in prolongada. Las f orm as de dosif ic ac in se inc luirn en la sec c in en que se m enc ionan. Neom ic ina/polim ix ina B/hidroc ortisona Cortisporin Cortisporin solo f igura en la lista de TICOS. Se lim ita a la soluc in y la suspensin. No se puede asum i r que la c rem a f igura en la lista. Debera f orm ar parte de la sec c in DERM ATOLOGA. Autorizacin previa (PA) CareSourc e puede nec esitar que los prov eedores nos inf orm en por qu es nec esario un m edicam ento o una c antidad. Esto se denom ina PA (Prior Authorization). CareSourc e debe autorizar esta solic itud antes de que un af iliado rec iba el m edic am ento. "PA" signif ic a que se nec esita una autorizac in prev ia. Estas son algunas de las razones para una PA: Ex iste un m edic am ento genric o o alternativ o disponible.Podra haber abuso o uso indebido del m edic am ento.El m edic am ento nec esita un m anejo espec ial, superv isin o tiene un env o lim itado.Ex isten otros m edic am entos que se deben probar prim ero.Solicitudes de PA Los asoc iados de salud pueden solic itar una autorizac in prev ia en lnea o por f ax . Obtenga m s inf or m ac in en la pgina de Prov eedores en CareSourc e.c om . Es posible que no aprobem os una solic itud de PA para un m edic am ento. Si no lo hac em os, le direm os al af iliado c m o apelar. Lmites de cantidad Al gunos m edic am entos pueden tener lm ites sobre c unto se puede adm inistrar de una v ez. La abrev i atura "QL" (Quantity Lim its) se usa para indic ar que hay un lm ite de c antidad. Los QL se basan en la dosis sugerida por los f abric antes de m edicamentos. Tam bin se tiene en c uenta la seguridad del pac iente. La terapia c on analgsic os opioides puede tener lm ites de c antidad. Estos se basan en la dosis rec om endada por los f abric antes de m edic am entos y /o en los reglam entos estatales. Los lm ites de c antidad se enc uentran en la lista a c ontinuac in. Terapia escalonada Es posible que los af iliados deban probar un m edic am ento antes de tom ar otro. Esto se denom ina terapia esc alonada. Se debe probar un m edic am ento antes de que se apruebe el uso de otro. CareSourc e c ubrir c iertos m edic am entos solo si se sigue el protoc olo de terapia esc alonada. Cuando es nec esario, se usa "ST" (Step Therapy ) en la lista. Sustitucin por medicamento genrico e intercambio teraputico La sustituc in por un m edic am ento genric o es una ac c in de la f arm ac ia. Se of rec e una v ersin genric a en lugar de un produc to de m arc a. La letra c ursiv a signif ic a que ex iste un genric o. No todas las c onc entrac iones o f orm as de dosif ic ac in del genric o pueden estar disponibles c om o genric os. Un m edic am ento de m arc a que tiene un produc to genric o 1/1/2026M edic aid de Georgia de CareSourc epasar a no pertenec er al f orm ulario. Se c ubrir el produc to genric o en lugar del produc to de m arca. La lista est sujeta a los reglam entos estatales y las norm as espec f ic os sobre la sustituc in por m edic am entos genric os. Los m edic am entos genric os c on f rec uenc ia tienen un prec io m s bajo que los m edic am entos de m arc a. Se deben presc ribir en prim er lugar si se siguen los estndares. Los m edic am entos genric os de v enta c on rec eta estn: Aprobados por la Adm inistrac in de Alim entos y Medic am entos (Food and DrugAdm i nistration, FDA) de EE. UU. Esto es por m otiv o de seguridad y ef ic ac ia. Estn f abric ados bajo los m ism os estndares estric tos que los produc tos de m arc a.Probados en hum anos. El genric o se debe absorber a la m ism a v eloc idad que el produc t o de m arc a. Puede dif erir de la m arc a en el tam ao, el c olor y los ingredientes inac tiv os. Esto no altera su uso.Fabric ados c on la m ism a c onc entrac in y la m ism a f orm a de dosif ic ac in que los m edic am entos de m arc a.Un m edic am ento genric o tendr el m ism o ef ec to y ser tan seguro c om o el de m arc a. DISEO DEL PLAN La lista m uestra un diseo c errado de plan del f orm ulario. Los m edic am entos inc luidos en la lista estn c ubiertos por el plan segn se m uestra. Ciertos m edic am entos estn c ubiertos si se c um plen c on los estndares de gestin de uso. Puede ser ST, PA y /o QL. Se rev isarn las solic itudes de m edic am entos que no c um plan c on los estndares de la lista. Si un m edic am ento no est en la lista, puede solic itar una ex c epc in al f orm ulario para la c obertura. Se rev isar la nec esidad m dic a o la ex c epc in al f orm ulario. Esto se basa en m edidas de PA o los c riterios de presc ripc in estndar que no pertenec en al f orm ulario. Un af iliado o un prov eedor pueden solic itar una ex c epc in al f orm ulario. Com plete el f orm ulario que se enc uentra en la pgina de la PDL en CareSource.com . AVISO Los datos de esta lista son priv ados. La inf orm ac in no se puede c opiar en su totalidad o en parte sin una autorizac in por esc rito.2024. Todos los derec hos reserv ados.Esta lista c ontiene m edic am entos c on rec eta de m arc a que son m arc as c om erc iales o m arc as registradas.CareSourc e no opera las organizac iones que se m enc ionan en esta lista. CareSourc e no esrespons able de la c onf iabilidad del c ontenido. Estas listas no son una rec om endac in deCareSourc e.Nota: Esta lista se actualiz a peri dicamente. Es posible que los cambios aparez can antes de su fecha de entrada en vigencia. 1/1/2026List of Abbreviations 1: Pr eferred generic product 2: Pr eferred brand product ACA: A ffordable Care Act AR: A ge Restriction. For certain drugs, the drug may be covered for members in a certain age range without a prior authorization. OTC : Over-the-Counter. An OTC drug is a non-prescription drug. PA: P rior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you dont get approval, we may not cover the drug. QL: Q uantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: S tep Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, we may not cover Drug Bunless you try Drug A first. If Drug A does not work for you, we will then cover Drug B . Georgia Medicaid Preferred Drug List (PDL)Table of ContentsANALGESICS……………………………………………………………………………………………………………………………………… 3ANESTHETICS ……………………………………………………………………………………………………………………………………. 4ANTIALLERGY …………………………………………………………………………………………………………………………………….. 4ANTIARTHRITICS ………………………………………………………………………………………………………………………………… 4ANTIASTHMATICS ………………………………………………………………………………………………………………………………. 5ANTIBIOTICS ………………………………………………………………………………………………………………………………………. 6ANTICOAGULANTS …………………………………………………………………………………………………………………………….. 8ANTIDOTES ………………………………………………………………………………………………………………………………………… 9ANTIFUNGALS ……………………………………………………………………………………………………………………………………. 9ANTIHISTAMINE AND DECONGESTANT COMBINATION ………………………………………………………………………..9ANTIHISTAMINES ……………………………………………………………………………………………………………………………….. 9ANTIHYPERGLYCEMICS ……………………………………………………………………………………………………………………. 10ANTIINFECTIVES/MISCELLANEOUS ………………………………………………………………………………………………….. 10ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS ………………………………………………………….11ANTINEOPLASTICS …………………………………………………………………………………………………………………………… 12ANTIPARASITICS ………………………………………………………………………………………………………………………………. 13ANTIPARKINSON DRUGS ………………………………………………………………………………………………………………….. 13ANTIPLATELET DRUGS …………………………………………………………………………………………………………………….. 13ANTIVIRALS ……………………………………………………………………………………………………………………………………… 13AUTONOMIC DRUGS ………………………………………………………………………………………………………………………… 15BIOLOGICALS …………………………………………………………………………………………………………………………………… 16BLOOD ……………………………………………………………………………………………………………………………………………… 16CARDIAC DRUGS ……………………………………………………………………………………………………………………………… 17CARDIOVASCULAR …………………………………………………………………………………………………………………………… 17CNS DRUGS ……………………………………………………………………………………………………………………………………… 19COLONY STIMULATING FACTORS …………………………………………………………………………………………………….. 21CONTRACEPTIVES …………………………………………………………………………………………………………………………… 21COUGH/COLD PREPARATIONS …………………………………………………………………………………………………………. 23DIURETICS ……………………………………………………………………………………………………………………………………….. 23EENT PREPS …………………………………………………………………………………………………………………………………….. 24ELECT/CALORIC/H2O ……………………………………………………………………………………………………………………….. 24GASTROINTESTINAL ………………………………………………………………………………………………………………………… 27HORMONES ……………………………………………………………………………………………………………………………………… 30IMMUNOSUPPRESSANTS …………………………………………………………………………………………………………………. 31MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ……………………………………………………………32MUSCLE RELAXANTS ……………………………………………………………………………………………………………………….. 35PRE-NATAL VITAMINS ………………………………………………………………………………………………………………………. 35PSYCHOTHERAPEUTIC DRUGS ………………………………………………………………………………………………………… 35SEDATIVE/HYPNOTICS ……………………………………………………………………………………………………………………… 38SKIN PREPS ……………………………………………………………………………………………………………………………………… 38SMOKING DETERRENTS …………………………………………………………………………………………………………………… 41THYROID PREPS ………………………………………………………………………………………………………………………………. 41UNCLASSIFIED DRUG PRODUCTS ……………………………………………………………………………………………………. 41VITAMINS …………………………………………………………………………………………………………………………………………. 432 CURRENT AS OF 1/1/2026Drug NameTierRestrictions / LimitsANALGESICS acetaminophen-codeine oral solution 120 mg-12mg /5 ml (5 ml), 120-12mg/5 ml1PA; QL (125ML per 1 day)acetaminophen-codeine oral solution 300 mg-30mg /12.5 ml 1QL (125 MLper 1 day)acetaminophen-codeine oral tablet 1PA; QL (10 EAper 1 day)AIMOVIGAUTOINJECTOR 2PA; QL (1 MLper 30 days);ARalmotriptan malate 1QL (12 EA per30 days)butalbital-acetaminophen-caff oral capsule 50-325-40 mg 1QL (48 EA per30 days)butalbital-acetaminophen-caff oral tablet 1QL (48 EA per30 days)butalbital-aspirin-caffeine oral capsule 1QL (48 EA per30 days)diclofenac potassium oral tablet 1diflunisal1ELMIRON2EMGALITY PEN2PA; QL (3 MLper 30 days)EMGALITY SYRINGESUBCUTANEOUSSYRINGE 120 MG/ML 2PA; QL (3 MLper 30 days)ENDOCET 1PA; QL (10 EAper 1 day)ergotamine-caffeine 1fentanyl transdermal patch 72 hour 100mcg/hr, 12 mcg/hr, 25mcg/hr, 50 mcg/hr, 75mcg/hr1PA; QL (1 EAper 3 days) Drug NameTier Restrictions /Limits hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml 1PA; QL (125ML per 1 day)hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325mg, 7.5-325 mg 1PA; QL (10 EAper 1 day)hydrocodone-ibuprofen oral tablet 7.5-200 mg 1PA; QL (5 EAper 1 day)hydromorphone oral liquid 1PA; QL (6 MLper 1 day)hydromorphone oral tablet 1PA; QL (6 EAper 1 day)ketorolac oral 1QL (20 EA per30 days)METHADONEINTENSOL 1PAmethadone oral concentrate 1PAmethadone oral solution10 mg/5 ml 1PA; QL (8.67ML per 1 day)methadone oral solution5 mg/5 ml 1PA; QL (20 MLper 1 day)methadone oral tablet10 mg 1PA; QL (2 EAper 1 day)methadone oral tablet 5mg 1PA; QL (4 EAper 1 day)MIGERGOT 1 morphine concentrate oral solution1PA; QL (6 MLper 1 day)morphine oral capsule,extend.release pellets 10 mg, 20 mg,50 mg, 80 mg 1PA; QL (2 EAper 1 day)morphine oral capsule,extend.release pellets 100 mg 1PA; QL (1 EAper 1 day)morphine oral solution 1PA; QL (30 MLper 1 day)morphine oral tablet 1PA; QL (6 EAper 1 day)morphine oral tablet extended release 100mg, 200 mg 1PA; QL (2 EAper 1 day)Georgia Medicaid | Effective 01/01/2026 3 Drug NameTier Restrictions /Limits morphine oral tablet extended release 15mg, 30 mg, 60 mg 1PA; QL (4 EAper 1 day)morphine rectal 1PA; QL (6 EAper 1 day)naratriptan 1QL (9 EA per30 days)oxycodone oral capsule 1PA; QL (6 EAper 1 day)oxycodone oral concentrate 1PA; QL (6 MLper 1 day)oxycodone oral solution 1PA; QL (6 MLper 1 day)oxycodone oral tablet 1PA; QL (6 EAper 1 day)oxycodone-acetaminophen oral solution 1PAoxycodone-acetaminophen oral tablet 10-300 mg, 5-300mg, 7.5-300 mg 1PAoxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg 1PA; QL (10 EAper 1 day)oxycodone-acetaminophen oral tablet 2.5-300 mg 1rizatriptan1QL (12 EA per30 days)sumatriptan 1QL (12 EA per30 days)sumatriptan succinate oral 1QL (12 EA per30 days)sumatriptan succinate subcutaneous cartridge4 mg/0.5 ml 1QL (5 ML per30 days)sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml 1QL (5 ML per30 days)sumatriptan succinate subcutaneous syringe 1QL (5 ML per30 days) Drug NameTier Restrictions /Limits tramadol oral tablet 50mg 1PA; QL (8 EAper 1 day)tramadol-acetaminophen 1PA; QL (40 EAper 25 days)zolmitriptan oral 1QL (12 EA per30 days)ANESTHETICS lidocaine hcl mucous membrane solution 2 %1QL (100 MLper 30 days)lidocaine hcl mucous membrane solution 4 %(40 mg/ml) 1 lidocaine hcl topical cream 3 %1QL (30 GM per30 days)LIDOCAINE VISCOUS 1QL (100 MLper 30 days)lidocaine-prilocaine topical cream 1QL (30 GM per30 days)midazolam (pf) 1ARmidazolam injection 1ARphenazopyridine oral tablet 100 mg, 200 mg 1 ANTIALLERGYcromolyn oral1PAANTIARTHRITICS allopurinol oral tablet100 mg, 300 mg1 celecoxib1STcolchicine oral tablet 1QL (1 EA per 1day)diclofenac sodium oral 1 diclofenac-misoprostol1 etodolac1 flurbiprofen1 IBU1 ibuprofen oral tablet 400mg, 600 mg, 800 mg1 ketoprofen oral capsule50 mg, 75 mg1 ketoprofen oral capsule,ext rel. pellets24 hr1Georgia Medicaid | Effective 01/01/20264 Drug NameTier Restrictions /Limits leflunomide 1meloxicam oral tablet1nabumetone1naproxen oral tablet1naproxen oral tablet,delayed release(dr/ec)1naproxen sodium oral tablet 275 mg, 550 mg1naproxen-esomeprazole1OTEZLA ORALTABLET 20 MG2PAOTEZLA ORALTABLET 30 MG 2PA; QL (2 EAper 1 day)OTEZLA STARTERORAL TABLETS,DOSEPACK 10 MG (4)-20MG (4)-30 MG (47) 2PA; QL (55 EAper 274 days)OTEZLA STARTERORAL TABLETS,DOSEPACK 10 MG (4)-20MG (4)-30 MG(19) 2PAoxaprozin oral tablet 1penicillamine oral tablet1PAprobenecid 1sulindac1XELJANZ ORALTABLET 10 MG2PA; QL (60 EAper 28 days)XELJANZ ORALTABLET 5 MG 2PA; QL (60 EAper 30 days)XELJANZ XR 2PA; QL (30 EAper 30 days)ANTIASTHMATICS albuterol sulfate inhalation hfa aerosol inhaler1QL (4 EA per90 days)albuterol sulfate inhalation solution for nebulization 0.63 mg/3ml, 1.25 mg/3 ml, 2.5mg /3 ml (0.083 %) 1QL (375 MLper 30 days) Drug NameTier Restrictions /Limits albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5ml 1QL (2 EA per 1day)albuterol sulfate inhalation solution for nebulization 5 mg/ml 1QL (2 ML per 1day)albuterol sulfate oral 1 ARNUITY ELLIPTA2QL (1 EA per 1day)ATROVENT HFA 2QL (65 GM per30 days)budesonide inhalation 1QL (4 ML per 1day)COMBIVENTRESPIMAT 2QL (4 GM per30 days)cromolyn inhalation 1QL (8 ML per 1day)DULERA INHALATIONHFA AEROSOLINHALER 100-5MCG/ACTUATION,200-5MCG/ACTUATION 2QL (13 GM per30 days)DULERA INHALATIONHFA AEROSOLINHALER 50-5MCG/ACTUATION 2 fluticasone propionate inhalation hfa aerosol inhaler 110mcg/actuation2QL (12 GM per30 days)fluticasone propionate inhalation hfa aerosol inhaler 220mcg/actuation 2QL (24 GM per30 days)fluticasone propionate inhalation hfa aerosol inhaler 44mcg/actuation 2QL (11 GM per30 days)fluticasone propion-salmeterol inhalation aerosol powdr breath activated 2QL (1 EA per30 days)Georgia Medicaid | Effective 01/01/2026 5 Drug NameTier Restrictions /Limits fluticasone propion-salmeterol inhalation blister with device 1QL (2 EA per 1day)ipratropium bromide inhalation 1QL (10 ML per1 day)ipratropium-albuterol 1QL (18 ML per1 day)levalbuterol tartrate 2QL (1 GM per 1day)montelukast 1QVAR REDIHALER2SEREVENT DISKUS2QL (2 EA per 1day)SPIRIVA RESPIMAT 2QL (4 GM per30 days)STIOLTO RESPIMAT 2QL (4 GM per30 days)STRIVERDI RESPIMAT 2QL (4 GM per30 days)terbutaline oral 1THEO-242theophylline1TRELEGY ELLIPTA2PA; QL (1 unit per 28 days)XOPENEX HFA 2ST; QL (2 EAper 180 days)ANTIBIOTICS amoxicillin1amoxicillin-pot clavulanate1ampicillin1AVAR1QL (341 GMper 30 days)AVAR-E 2AVIDOXY1azithromycin oral1bacitracin ophthalmic(eye)1bacitracin-polymyxin b1BICILLIN L-A2cefadroxil1 Drug NameTier Restrictions /Limits cefdinir 1 cefprozil1 cefuroxime axetil1 CENTANY2QL (22 GM per30 days)cephalexin oral capsule250 mg, 500 mg 1 cephalexin oral suspension for reconstitution1 cephalexin oral tablet250 mg1 CIPRO ORALSUSPENSION,MICROCAPSULE RECON2 ciprofloxacin1 ciprofloxacin hcl1 clarithromycin1 CLEOCIN VAGINALSUPPOSITORY2 clindamycin hcl1 clindamycin palmitate hcl1 CLINDAMYCINPEDIATRIC1 clindamycin phosphate topical gel1 clindamycin phosphate topical gel, once daily1 clindamycin phosphate topical lotion1QL (2 ML per 1day)clindamycin phosphate topical solution 1QL (2 ML per 1day)clindamycin phosphate vaginal 1 dapsone oral1 dicloxacillin1 doxycycline hyclate oral capsule1 doxycycline hyclate oral tablet 100 mg1Georgia Medicaid | Effective 01/01/20266 Drug NameTier Restrictions /Limits doxycycline monohydrate oral capsule 100 mg, 50 mg 1doxycycline monohydrate oral suspension for reconstitution1doxycycline monohydrate oral tablet100 mg, 50 mg1E.E.S. 4001ERY PADS1ERY-TAB ORALTABLET,DELAYEDRELEASE (DR/EC) 250MG, 333 MG1ERY-TAB ORALTABLET,DELAYEDRELEASE (DR/EC) 500MG2ERYTHROCIN (ASSTEARATE)1erythromycin ethylsuccinate1erythromycin ophthalmic (eye)1erythromycin oral capsule,delayed release(dr/ec)1erythromycin oral tablet1erythromycin with ethanol1ethambutol1fidaxomicin1PAFIRVANQ ORALRECON SOLN 25MG/ML 2PAgentamicin ophthalmic(eye) 1gentamicin topical cream1QL (1 GM per 1day)gentamicin topical ointment 1QL (15 GM per30 days)isoniazid oral 1 Drug NameTier Restrictions /Limits levofloxacin oral 1 linezolid1PAmethen-sod phos-meth blue-hyos 1 metronidazole oral capsule1 metronidazole oral tablet 250 mg, 500 mg1 metronidazole vaginal gel 0.75 % (37.5mg/5gram)1QL (70 GM per30 days)minocycline oral capsule 1 minocycline oral tablet1 MONDOXYNE NLORAL CAPSULE 100MG1 MORGIDOX1 moxifloxacin ophthalmic(eye) drops, viscous1 mupirocin1QL (22 GM per30 days)neomycin 1 neomycin-bacitracin-poly-hc1 neomycin-bacitracin-polymyxin1 neomycin-polymyxin b-dexameth1 neomycin-polymyxin-gramicidin1 neomycin-polymyxin-hc1 NEO-POLYCIN1 NEO-POLYCIN HC1 nitrofurantoin macrocrystal1 nitrofurantoin monohyd/m-cryst1 nitrofurantoin oral suspension 25 mg/5 ml1 ofloxacin ophthalmic(eye)1QL (10 ML per30 days)Georgia Medicaid | Effective 01/01/2026 7 Drug NameTier Restrictions /Limits ofloxacin oral 1QL (2 EA per 1day)ofloxacin otic (ear) 1penicillin v potassium1PLEXION TOPICALCLEANSER2PAPOLYCIN 1polymyxin b sulf-trimethoprim1pyrazinamide1rifabutin1rifampin oral1silver sulfadiazine1SSD1SSS 10-5 TOPICALCREAM1sulfacetamide sodium ophthalmic (eye) drops1sulfacetamide sodium-sulfur topical cleanser10-5 % (w/w)1QL (341 GMper 30 days)sulfacetamide sodium-sulfur topical cleanser9-4 % 1STsulfacetamide sodium-sulfur topical cream 10-2 % 1QL (57 GM per30 days)sulfacetamide sodium-sulfur topical cream 10-5 % (w/w) 1sulfacetamide sodium-sulfur topical lotion 10-5% (w/v), 10-5 % (w/w)1sulfacetamide sodium-sulfur topical pads,medicated1STsulfacetamide sodium-sulfur topical suspension 8-4 % 1STsulfacetamide-prednisolone 1SULFACLEANSE 8-41STsulfadiazine 1 Drug NameTier Restrictions /Limits sulfamethoxazole-trimethoprim oral 1 SULFATRIM1 tetracycline oral capsule1 THALOMID2PAtobramycin in 0.225 %nacl 1PA; QL (10 MLper 1 day)tobramycin ophthalmic(eye) 1 tobramycin sulfate injection solution 40mg/ml1PA; ARtobramycin with nebulizer 2QL (10 ML per1 day)tobramycin-dexamethasone 1 trimethoprim1 URETRON D-S1 URYL1 vancomycin oral recon soln 50 mg/ml1PAVANDAZOLE 1QL (70 GM per30 days)ANTICOAGULANTS ELIQUIS DVT-PETREAT 30D START2 ELIQUIS ORALTABLET2 enoxaparin1 heparin (porcine)injection cartridge1 heparin (porcine)injection solution 1,000unit/ml, 5,000 unit/ml1 heparin (porcine)injection syringe1 heparin, porcine (pf)injection solution 1,000unit/ml1 heparin, porcine (pf)injection syringe 5,000unit/ml1 JANTOVEN1Georgia Medicaid | Effective 01/01/20268 Drug NameTier Restrictions /LimitsPRADAXA ORALCAPSULE 2PAwarfarin 1XARELTO DVT-PETREAT 30D START2QL (51 EA per26 days)XARELTO ORALTABLET 10 MG, 15MG, 20 MG 2XARELTO ORALTABLET 2.5 MG2STANTIDOTES KLOXXADO2QL (2 EA per30 days)nalmefene 2QL (2 Units per1 Month)naloxone injection solution 1QL (2 ML per30 days)naloxone injection syringe 1 mg/ml 1naltrexone1OPVEE2QL (2 EA per30 days)ANTIFUNGALS CICLODAN KITTOPICAL SOLUTION1CICLODAN TOPICALCREAM1QL (3 GM per 1day)CICLODAN TOPICALSOLUTION 1QL (6.6 ML per30 days)ciclopirox topical cream 1QL (3 GM per 1day)ciclopirox topical gel 1QL (3 GM per 1day)ciclopirox topical shampoo 1ciclopirox topical solution1QL (6.6 ML per30 days)ciclopirox topical suspension 1QL (3 ML per 1day)clotrimazole mucous membrane 1 Drug NameTier Restrictions /Limits clotrimazole-betamethasone topical cream 1QL (45 GM per30 days)fluconazole 1 griseofulvin microsize1 griseofulvin ultramicrosize oral tablet 125 mg, 250 mg1 ketoconazole oral1 ketoconazole topical cream1QL (2 GM per 1day)ketoconazole topical shampoo 1QL (4 ML per 1day)NATACYN 2QL (15 ML per30 days)NYAMYC 1QL (2 GM per 1day)nystatin oral 1 nystatin topical cream1QL (30 GM per28 days)nystatin topical ointment 1QL (30 GM per28 days)nystatin topical powder 1QL (2 GM per 1day)NYSTOP 1QL (2 GM per 1day)posaconazole oral tablet,delayed release(dr/ec) 1PAterbinafine hcl oral 1QL (1 EA per 1day)terconazole 1 voriconazole oral1PAANTIHISTAMINEANDDECONGESTANTCOMBINATION PROMETHAZINE VC1 promethazine-phenylephrine1 ANTIHISTAMINESazelastine ophthalmic(eye)1Georgia Medicaid | Effective 01/01/20269 Drug NameTier Restrictions /Limits clemastine oral tablet 1cyproheptadine1hydroxyzine hcl oral solution 10 mg/5 ml1hydroxyzine hcl oral tablet1hydroxyzine pamoate1levocetirizine oral solution1promethazine oral1ANTIHYPERGLYCEMICSacarbose1alogliptin2ST; QL (1 EAper 1 day)alogliptin-metformin 2STalogliptin-pioglitazone 2STdapaglifloz propaned-metformin oral tablet, ir-er, biphasic 24hr 10-1,000 mg 1ST; QL (30 EAper 30 days)dapaglifloz propaned-metformin oral tablet, ir-er, biphasic 24hr 5-1,000 mg 1ST; QL (60 EAper 30 days)dapagliflozin propanediol 1ST; QL (30 EAper 30 days)FARXIGA 2PA; QL (30 EAper 30 days)glimepiride oral tablet 1mg, 2 mg, 4 mg 1glipizide oral tablet 10mg, 5 mg1glipizide oral tablet extended release 24hr1glipizide-metformin1glyburide micronized oral tablet 1.5 mg1QL (8 EA per 1day)glyburide micronized oral tablet 3 mg 1QL (4 EA per 1day)glyburide micronized oral tablet 6 mg 1QL (2 EA per 1day) Drug NameTier Restrictions /Limits glyburide oral tablet1.25 mg 1QL (16 EA per1 day)glyburide oral tablet 2.5mg 1QL (8 EA per 1day)glyburide oral tablet 5mg 1QL (4 EA per 1day)glyburide-metformin oral tablet 1.25-250 mg 1QL (260 EA per30 days)glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg 1QL (5 EA per 1day)HUMULIN RU-500(CONC) KWIKPEN 2 insulin glargine-yfgn2 insulin lispro subcutaneous insulin pen2QL (45 ML per30 days)insulin lispro subcutaneous insulin pen, half-unit 2QL (1 ML per 1day)insulin lispro subcutaneous solution 2QL (45 ML per30 days)metformin oral solution 1 metformin oral tablet1,000 mg, 500 mg, 850mg1 metformin oral tablet extended release 24 hr1 miglitol1PA; STnateglinide 1 OZEMPIC2ST; QL (3 MLper 28 days)pioglitazone 1 pioglitazone-metformin1 repaglinide1 RYBELSUS2ST; QL (1 EAper 1 day); ARSOLIQUA 100/33 2ST; QL (6 MLper 30 days)ANTIINFECTIVES/MISCELLANEOUS albendazole1PAatovaquone 1Georgia Medicaid | Effective 01/01/202610 Drug NameTier Restrictions /Limits atovaquone-proguanil 1QL (12 EA per180 days)COARTEM 2QL (24 EA per180 days)CUTTERBACKWOODS 2QL (1 GM per30 days)CUTTERBACKWOODS DRY 2QL (1 GM per30 days)CUTTERSKINSATIONSTOPICAL SPRAY,NON-AEROSOL 2QL (1 ML per30 days)hydroxychloroquine 1INSECT REPELLENT(DEET)2QL (1 GM per30 days)INSECT REPELLENT(PICARIDIN) 2QL (1 ML per30 days)ivermectin oral tablet 3mg 1QL (20 EA per90 days)mefloquine 1QL (6 EA per180 days)OFF ACTIVE 2QL (1 GM per30 days)OFF DEEP WOODSDRY 2QL (1 GM per30 days)OFF DEEP WOODSSPORTSMEN 2QL (1 ML per30 days)OFF DEEP WOODSTOPICALAEROSOL,SPRAY 2QL (1 GM per30 days)OFF DEEP WOODSTOPICAL SPRAY,NON-AEROSOL 2QL (1 ML per30 days)OFF FAMILYCARE(WITH DEET) 2QL (1 ML per30 days)OFFFAMILYCARE(WITHPICARIDIN) 2QL (1 ML per30 days)praziquantel 1PApyrimethamine 1QL (3 EA per 1day)RANGER READYREPELLENT 2QL (1 ML per30 days) Drug NameTier Restrictions /LimitsREPEL 100 2QL (1 ML per30 days)REPEL FAMILY 2QL (1 GM per30 days)REPEL HUNTER'S 2QL (1 GM per30 days)REPEL SPORTSMEN 2QL (1 GM per30 days)REPEL SPORTSMENDRY 2QL (1 GM per30 days)REPEL SPORTSMENMAX TOPICALAEROSOL,SPRAY 2QL (1 GM per30 days)REPEL SPORTSMENMAX TOPICALSPRAY,NON-AEROSOL 2QL (1 ML per30 days)TOTAL HOME INSECTREPELLENT 2QL (1 ML per30 days)ULTRATHON TOPICALAEROSOL,SPRAY 2QL (1 GM per30 days)ANTIINFLAM. TUMOR NECROSIS FACTOR INHIBITING AGENTS adalimumab-adaz subcutaneous pen injector 40 mg/0.4 ml2PAadalimumab-adaz subcutaneous syringe40 mg/0.4 ml 2PAadalimumab-adbm subcutaneous pen injector kit 2PAadalimumab-adbm subcutaneous syringe kit 20 mg/0.4 ml, 40mg/0.4 ml, 40 mg/0.8 ml 2PAadalimumab-adbm(cf)10 mg/0.2 ml syringe 1 adalimumab-adbm(cf)20 mg/0.4 ml syringe2PAadalimumab-adbm(cf)40 mg/0.8 ml syringe 2PAGeorgia Medicaid | Effective 01/01/2026 11 Drug NameTier Restrictions /LimitsENBREL MINI 2PA; QL (4 MLper 28 days)ENBRELSUBCUTANEOUSSOLUTION 2QL (4 ML per28 days)ENBRELSUBCUTANEOUSSYRINGE 2PA; QL (4 MLper 28 days)ENBREL SURECLICK 2PA; QL (4 MLper 28 days)HADLIMA 2PAHADLIMAPUSHTOUCH 2PAHADLIMA(CF) 2PAHADLIMA(CF)PUSHTOUCH 2PAANTINEOPLASTICS abiraterone1PAAFINITOR 2PAAFINITOR DISPERZ 2PAanastrozole 1bexarotene oral1PAbicalutamide 1capecitabine1PACAPRELSA 2PAcyclophosphamide oral capsule 1PAERIVEDGE 2PAerlotinib 1PAetoposide oral 1everolimus(antineoplastic) oral tablet 10 mg1PAeverolimus(antineoplastic) oral tablet for suspension 1PAexemestane 1fluorouracil topical cream 5 %1QL (3 GM per 1day)fluorouracil topical solution 1QL (10 ML per30 days)GILOTRIF 2PA Drug NameTier Restrictions /Limits hydroxyurea 1 IBRANCE2PAimatinib 1PAIMBRUVICA ORALCAPSULE 2PA; QL (1 EAper 1 day); ARIMBRUVICA ORALTABLET 2PA; QL (1 EAper 1 day); ARINLYTA 2PAJAKAFI 2PA; QL (2 EAper 1 day)lapatinib 1PALENVIMA ORALCAPSULE 10 MG/DAY(10 MG X 1), 14MG/DAY(10 MG X 1-4MG X 1), 18 MG/DAY(10 MG X 1-4 MG X2),20 MG/DAY (10 MG X2), 24 MG/DAY(10 MGX 2-4 MG X 1), 8MG/DAY (4 MG X 2) 2PAletrozole 1PALEUKERAN 2PALYSODREN 2 MATULANE2 megestrol oral tablet1 MEKINIST ORALTABLET2PAmercaptopurine oral tablet 1 methotrexate sodium oral1 MYLERAN2PApazopanib oral tablet200 mg 1PAREVLIMID 2PAsorafenib 1PAsunitinib malate 1PASUTENT 2PATAFINLAR ORALCAPSULE 2PAtamoxifen 1Georgia Medicaid | Effective 01/01/202612 Drug NameTier Restrictions /Limits temozolomide 1PAtretinoin (antineoplastic) 1TREXALL2TYKERB2PAVOTRIENT 2ZELBORAF2PAZOLINZA 2PAANTIPARASITICS malathion1QL (59 ML per30 days)permethrin 1QL (2 GM per 1day)spinosad 1PA; QL (4 MLper 1 day)ANTIPARKINSONDRUGS amantadine hcl1benztropine oral1bromocriptine1carbidopa-levodopa oral tablet1carbidopa-levodopa oral tablet extended release1carbidopa-levodopa-entacapone1entacapone1pramipexole oral tablet1pramipexole oral tablet extended release 24 hr0.375 mg, 0.75 mg, 1.5mg, 2.25 mg, 3 mg, 4.5mg1PAropinirole oral tablet 1selegiline hcl1trihexyphenidyl1ANTIPLATELETDRUGSanagrelide1BRILINTA2PA; STcilostazol 1clopidogrel1 Drug NameTier Restrictions /Limits dipyridamole oral 1 prasugrel hcl1 ticagrelor1PA; STANTIVIRALS abacavir oral solution1QL (30 ML per1 day)abacavir oral tablet 1QL (2 EA per 1day)abacavir-lamivudine 1QL (1 EA per 1day)acyclovir oral 1 acyclovir topical ointment1ST; QL (15 GMper 22 days);ARadefovir 1PA; ARAPTIVUS 2QL (4 EA per 1day)atazanavir oral capsule150 mg 1QL (1 EA per 1day)atazanavir oral capsule200 mg 1QL (2 EA per 1day)atazanavir oral capsule300 mg 1 BARACLUDE ORALSOLUTION2PABIKTARVY ORALTABLET 30-120-15 MG 2 BIKTARVY ORALTABLET 50-200-25 MG2QL (1 EA per 1day)COMPLERA 2QL (1 EA per 1day)darunavir oral tablet 600mg 1QL (2 EA per 1day)darunavir oral tablet 800mg 1QL (1 EA per 1day)DELSTRIGO 2QL (1 EA per 1day)DESCOVY 2PADOVATO 2QL (1 EA per 1day)efavirenz 1QL (1 EA per 1day)Georgia Medicaid | Effective 01/01/2026 13 Drug NameTier Restrictions /Limits efavirenz-emtricitabin-tenofov 1QL (1 EA per 1day)efavirenz-lamivu-tenofov disop oral tablet400-300-300 mg 1emtricitabine1QL (1 EA per 1day)emtricitabine-tenofovir(tdf) 1QL (1 EA per 1day)EMTRIVA ORALCAPSULE 2QL (1 EA per 1day)EMTRIVA ORALSOLUTION 2QL (680 MLper 30 days)entecavir 1PAetravirine oral tablet 100mg 1QL (4 EA per 1day)etravirine oral tablet 200mg 1QL (2 EA per 1day)EVOTAZ 2QL (1 EA per 1day)fosamprenavir 1QL (2 EA per 1day)GENVOYA 2QL (1 EA per 1day)ISENTRESS ORALPOWDER IN PACKET 2QL (2 EA per 1day)ISENTRESS ORALTABLET 2QL (4 EA per 1day)ISENTRESS ORALTABLET,CHEWABLE 2QL (6 EA per 1day)JULUCA 2QL (1 EA per 1day)KALETRA ORALTABLET 100-25 MG 2QL (8 EA per 1day)KALETRA ORALTABLET 200-50 MG 2QL (4 EA per 1day)LAGEVRIO (EUA) 2QL (8 units per1 day); ARlamivudine oral solution 1QL (30 ML per1 day)lamivudine oral tablet100 mg 1PAlamivudine oral tablet150 mg 1QL (2 EA per 1day) Drug NameTier Restrictions /Limits lamivudine oral tablet300 mg 1QL (1 EA per 1day)lamivudine-zidovudine 1QL (2 EA per 1day)lopinavir-ritonavir oral tablet 100-25 mg 1QL (8 EA per 1day)lopinavir-ritonavir oral tablet 200-50 mg 1QL (4 EA per 1day)maraviroc oral tablet150 mg 1PA; QL (2 EAper 1 day)maraviroc oral tablet300 mg 1PA; QL (4 EAper 1 day)nevirapine oral suspension 1QL (40 ML per1 day)nevirapine oral tablet 1QL (2 EA per 1day)nevirapine oral tablet extended release 24 hr100 mg 1QL (3 EA per 1day)nevirapine oral tablet extended release 24 hr400 mg 1QL (1 EA per 1day)NORVIR ORALPOWDER IN PACKET 2QL (6 EA per180 days)ODEFSEY 2 oseltamivir oral capsule30 mg1QL (40 EA per365 days)oseltamivir oral capsule45 mg, 75 mg 1QL (20 EA per365 days)oseltamivir oral suspension for reconstitution 1QL (360 MLper 365 days)PAXLOVID ORALTABLETS,DOSE PACK150 MG (10)- 100 MG(10) 2QL (4 EA per 1day); ARPAXLOVID ORALTABLETS,DOSE PACK300 MG (150 MG X 2)-100 MG 2QL (6 EA per 1day); ARPEGASYSSUBCUTANEOUSSOLUTION 2PA; QL (4 MLper 28 days)Georgia Medicaid | Effective 01/01/202614 Drug NameTier Restrictions /LimitsPEGASYSSUBCUTANEOUSSYRINGE 2PA; QL (2 MLper 28 days)penciclovir 1PA; ST; QL (5GM per 30days)PIFELTRO 2QL (1 EA per 1day)PREZCOBIX ORALTABLET 800-150 MG-MG 2QL (1 EA per 1day)PREZISTA ORALSUSPENSION 2QL (1 ML per 1day)PREZISTA ORALTABLET 150 MG 2QL (6 EA per 1day)PREZISTA ORALTABLET 75 MG 2QL (10 EA per1 day)ribavirin oral 1rimantadine1ritonavir1SELZENTRY ORALSOLUTION2PA; QL (1840ML per 25days)sofosbuvir-velpatasvir 2PA; QL (1 EAper 1 day)STRIBILD 2QL (1 EA per 1day)SYMTUZA 2QL (1 EA per 1day)SYNAGIS 2PA; QL (2 MLper 28 days)tenofovir disoproxil fumarate 1QL (1 EA per 1day)TIVICAY 2QL (2 EA per 1day)trifluridine 1TRIUMEQ2QL (1 EA per 1day)TRUVADA 2QL (1 EA per 1day)valacyclovir 1VIRACEPT ORALTABLET 250 MG2QL (10 EA per1 day) Drug NameTier Restrictions /LimitsVIRACEPT ORALTABLET 625 MG 2QL (4 EA per 1day)VIREAD ORALPOWDER 2QL (8 GM per 1day)VIREAD ORAL TABLET150 MG, 200 MG, 250MG 2QL (1 EA per 1day)zidovudine oral capsule 1QL (6 EA per 1day)zidovudine oral syrup 1QL (60 ML per1 day)zidovudine oral tablet 1 AUTONOMICDRUGSbethanechol chloride1 dextroamphetamine sulfate oral capsule,extended release1QL (2 EA per 1day)dextroamphetamine sulfate oral tablet 10 mg 1QL (4 EA per 1day)dextroamphetamine sulfate oral tablet 15mg, 2.5 mg, 5 mg 1QL (1 EA per 1day)dextroamphetamine sulfate oral tablet 20mg, 30 mg, 7.5 mg 1 dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15mg, 5 mg1QL (1 EA per 1day)dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25mg, 30 mg 1QL (2 EA per 1day)dextroamphetamine-amphetamine oral tablet 1QL (3 EA per 1day)donepezil oral tablet 10mg, 5 mg 1 epinephrine injection auto-injector 0.15mg/0.15 ml2QL (4 EA per365 days)Georgia Medicaid | Effective 01/01/2026 15 Drug NameTier Restrictions /Limits epinephrine injection auto-injector 0.15mg/0.3 ml, 0.3 mg/0.3ml 1QL (4 EA per365 days)galantamine 1midodrine1phenoxybenzamine1PApilocarpine hcl oral 1pyridostigmine bromide oral syrup1pyridostigmine bromide oral tablet 60 mg1pyridostigmine bromide oral tablet extended release 180 mg1rivastigmine tartrate1ZENZEDI ORALTABLET 2.5 MG2QL (1 EA per 1day)BIOLOGICALS ABRYSVO (PF)2ARACTHIB (PF) 2ADACEL(TDAPADOLESN/ADULT)(PF)2AREXVY (PF)2BEXSERO2BOOSTRIX TDAP2CAPVAXIVE2DAPTACEL (DTAPPEDIATRIC) (PF)2ENGERIX-B (PF)2ENGERIX-BPEDIATRIC (PF)2GARDASIL 9 (PF)2HAVRIX (PF)2HEPLISAV-B (PF)2HIBERIX (PF)2INFANRIX (DTAP) (PF)2IPOL2JYNNEOS (PF)2KINRIX (PF)2 Drug NameTier Restrictions /LimitsMENVEO A-C-Y-W-135-DIP (PF)INTRAMUSCULAR KIT 2 M-M-R II (PF)2 MRESVIA (PF)1 PEDIARIX (PF)2 PEDVAX HIB (PF)2 PENBRAYA (PF)2 PENTACEL (PF)2 PENTACEL ACTHIBCOMPONENT (PF)2 PNEUMOVAX-232 PROQUAD (PF)2 QUADRACEL (PF)INTRAMUSCULARSUSPENSION2 RECOMBIVAX HB (PF)INTRAMUSCULARSUSPENSION 40MCG/ML, 5 MCG/0.5ML2 RECOMBIVAX HB (PF)INTRAMUSCULARSYRINGE2 RHOGAM ULTRA-FILTERED PLUS2 ROTATEQ VACCINE2 SHINGRIX (PF)2 TENIVAC (PF)2 TRUMENBA2 TWINRIX (PF)2 VAQTA (PF)2 VARIVAX (PF)2 VARIZIG2 BLOODEMPAVELI2PA; QL (8 Vials per 28 days);ARpentoxifylline 1 PYRUKYND2PA; QL (2 EAper 1 day); ARGeorgia Medicaid | Effective 01/01/202616 Drug NameTier Restrictions /LimitsCARDIAC DRUGS amiodarone oral tablet200 mg, 400 mg1amlodipine1CARDIZEM LA ORALTABLET EXTENDEDRELEASE 24 HR 120MG2CARTIA XT1DIGITEK1digoxin oral solution1digoxin oral tablet 125mcg (0.125 mg), 250mcg (0.25 mg)1diltiazem hcl oral1DILT-XR1disopyramide phosphate1dofetilide1felodipine1flecainide1isosorbide dinitrate oral tablet 10 mg, 20 mg, 30mg, 5 mg1isosorbide mononitrate1LANOXIN ORALTABLET 125 MCG(0.125 MG), 250 MCG(0.25 MG)2MATZIM LA1nifedipine oral tablet extended release1nifedipine oral tablet extended release 24hr1NITRO-DUR2nitroglycerin sublingual1nitroglycerin transdermal patch 24hour1nitroglycerin translingual1NITRO-TIME1NORPACE CR2 Drug NameTier Restrictions /LimitsPACERONE ORALTABLET 200 MG 1 propafenone1 ranolazine1 verapamil oral capsule,ext rel. pellets24 hr1 verapamil oral tablet120 mg, 80 mg1 verapamil oral tablet 40mg1QL (12 EA per1 day)verapamil oral tablet extended release 1 CARDIOVASCULARambrisentan1PA; QL (30 EAper 28 days)amlodipine-benazepril 1 amlodipine-olmesartan1 amlodipine-valsartan1 amlodipine-valsartan-hcthiazid1 atenolol1 atenolol-chlorthalidone1 atorvastatin1 benazepril1 benazepril-hydrochlorothiazide1 bisoprolol fumarate oral tablet 10 mg, 5 mg1 bisoprolol-hydrochlorothiazide1 candesartan1 candesartan-hydrochlorothiazid1 captopril1 captopril-hydrochlorothiazide1 carvedilol1 cholestyramine (with sugar)1 CHOLESTYRAMINELIGHT1Georgia Medicaid | Effective 01/01/202617 Drug NameTier Restrictions /Limits clonidine 1clonidine hcl oral tablet0.1 mg1QL (24 EA per1 day)clonidine hcl oral tablet0.2 mg 1QL (12 EA per1 day)clonidine hcl oral tablet0.3 mg 1QL (8 EA per 1day)colestipol oral tablet 1doxazosin1enalapril maleate oral solution1ARenalapril maleate oral tablet 1enalapril-hydrochlorothiazide1ENTRESTO2PA; QL (60 EAper 30 days)EPANED 2ezetimibe1fenofibrate micronized oral capsule 134 mg,200 mg, 67 mg1fenofibrate nanocrystallized1fenofibrate oral tablet160 mg, 54 mg1fosinopril1fosinopril-hydrochlorothiazide1gemfibrozil1guanfacine oral tablet1hydralazine oral1irbesartan1irbesartan-hydrochlorothiazide1labetalol oral tablet 100mg, 200 mg, 300 mg1lisinopril1lisinopril-hydrochlorothiazide1losartan1 Drug NameTier Restrictions /Limits losartan-hydrochlorothiazide 1 lovastatin1 methyldopa1 metoprolol succinate1 metoprolol ta-hydrochlorothiaz1 metoprolol tartrate oral tablet 100 mg, 25 mg,50 mg1 metyrosine1PAminoxidil oral 1 nadolol1 olmesartan1 olmesartan-amlodipin-hcthiazid1 olmesartan-hydrochlorothiazide1 pravastatin1 prazosin1 PRESTALIA ORALTABLET 14-10 MG2PAPREVALITE 1 propranolol oral1 quinapril1 quinapril-hydrochlorothiazide1 ramipril1 REPATHAPUSHTRONEX2PA; QL (3.5 MLper 28 days)REPATHA SURECLICK 2PAREPATHA SYRINGE 2PA; QL (2 MLper 28 days)rosuvastatin 1STsacubitril-valsartan 1PA; QL (60 EAper 30 days)salmon oil-omega-3fatty acids 2 sildenafil(pulm.hypertension) oral tablet1PA; QL (75 EAper 30 days)Georgia Medicaid | Effective 01/01/202618 Drug NameTier Restrictions /Limits simvastatin 1SOTALOL AF1sotalol oral1telmisartan1telmisartan-amlodipine1telmisartan-hydrochlorothiazid1terazosin1trandolapril1valsartan oral tablet1valsartan-hydrochlorothiazide1CNS DRUGSAUSTEDO ORALTABLET 12 MG2PA; QL (4 EAper 1 day)AUSTEDO ORALTABLET 6 MG 2PA; QL (60 EAper 30 days)AUSTEDO ORALTABLET 9 MG 2PA; QL (120EA per 30days)AUSTEDO XR ORALTABLET EXTENDEDRELEASE 24 HR 12MG, 24 MG, 30 MG, 36MG, 42 MG, 48 MG, 6MG 2PA; QL (2 EAper 1 day)AUSTEDO XR ORALTABLET EXTENDEDRELEASE 24 HR 18MG 2AVONEXINTRAMUSCULARPEN INJECTOR KIT2PA; QL (30MCG per 7days)AVONEXINTRAMUSCULARSYRINGE KIT 2PA; QL (4 EAper 30 days)BANZEL ORALSUSPENSION 2PABANZEL ORALTABLET 2PA; STcarbamazepine oral capsule, er multiphase12 hr 1 Drug NameTier Restrictions /Limits carbamazepine oral suspension 100 mg/5ml, 200 mg/10 ml 1 carbamazepine oral tablet1 carbamazepine oral tablet extended release12 hr1 carbamazepine oral tablet,chewable 100 mg1 CARBATROL2 clobazam oral suspension1STclobazam oral tablet 1STclonazepam oral tablet 1QL (4 EA per 1day)diazepam rectal 1 DILANTIN2 DILANTIN EXTENDED2 DILANTIN INFATABS2 DILANTIN-1252 dimethyl fumarate oral capsule,delayed release(dr/ec) 120 mg(14)- 240 mg (46)1PAdimethyl fumarate oral capsule,delayed release(dr/ec) 120 mg,240 mg 1PA; QL (60 EAper 28 days)divalproex 1 EMGALITY SYRINGESUBCUTANEOUSSYRINGE 300 MG/3ML (100 MG/ML X 3)2PA; ARethosuximide 1 felbamate1 fingolimod1PA; QL (1 EAper 1 day)gabapentin oral capsule100 mg, 400 mg 1QL (6 EA per 1day)gabapentin oral capsule300 mg 1QL (12 EA per1 day)Georgia Medicaid | Effective 01/01/2026 19 Drug NameTier Restrictions /Limits gabapentin oral solution 1QL (72 ML per1 day)gabapentin oral tablet600 mg 1QL (6 EA per 1day)gabapentin oral tablet800 mg 1QL (4 EA per 1day)GILENYA ORALCAPSULE 0.25 MG 2PA; QL (1 EAper 1 day); ARglatiramer 1GLATOPA1lacosamide oral tablet1PA; ST; ARlamotrigine oral tablet 1lamotrigine oral tablet,chewable dispersible1levetiracetam oral solution1levetiracetam oral tablet1levetiracetam oral tablet extended release 24 hr1memantine oral solution1memantine oral tablet1memantine oral tablets,dose pack2methsuximide1oxcarbazepine oral suspension1oxcarbazepine oral tablet1OXTELLAR XR2perampanel1STPHENYTEK 2phenytoin1phenytoin sodium extended1pregabalin oral capsule100 mg, 150 mg, 200mg, 25 mg, 50 mg, 75mg1PA; QL (3 EAper 1 day)pregabalin oral capsule225 mg, 300 mg 1PA; QL (2 EAper 1 day)pregabalin oral solution 1PA; QL (30 MLper 1 day) Drug NameTier Restrictions /Limits primidone oral tablet250 mg, 50 mg 1 REBIF (WITHALBUMIN)2PA; QL (6 MLper 30 days)REBIF REBIDOSESUBCUTANEOUS PENINJECTOR 22 MCG/0.5ML, 44 MCG/0.5 ML 2PA; QL (6 MLper 28 days)REBIF REBIDOSESUBCUTANEOUS PENINJECTOR8.8MCG/0.2ML-22MCG/0.5ML (6) 2PA; QL (4.2 MLper 28 days)REBIF TITRATIONPACK 2PA; QL (4.2 MLper 28 days)ROWEEPRA 1 rufinamide oral suspension1PArufinamide oral tablet 1STSUBVENITE ORALTABLET 1 TEGRETOL2 TEGRETOL XR2 teriflunomide1PA; QL (1 EAper 1 day)tiagabine 1 topiramate oral capsule,sprinkle 15 mg, 25 mg1 topiramate oral tablet1 valproic acid1 valproic acid (as sodium salt)1 VUMERITY2PA; QL (4 EAper 1 day)ZEPOSIA 2PA; QL (30 EAper 30 days);ARZEPOSIA STARTERKIT (28-DAY) 2PA; QL (1 EAper 365 days);ARZEPOSIA STARTERPACK (7-DAY) 2PA; QL (1PACK per 365days); ARzonisamide 1Georgia Medicaid | Effective 01/01/202620 Drug NameTier Restrictions /LimitsCOLONYSTIMULATINGFACTORS eltrombopag olamine oral tablet1ZARXIO2PACONTRACEPTIVES AFIRMELLE1ALTAVERA (28)1ALYACEN 1/35 (28)1ALYACEN 7/7/7 (28)1AMETHIA1QL (1 EA per 1day)AMETHYST (28) 1QL (1 EA per 1day)APRI 1ARANELLE (28)1ASHLYNA1QL (1 EA per 1day)AUBRA 1AUBRA EQ1AUROVELA 1.5/30 (21)1AUROVELA 1/20 (21)1AUROVELA 24 FE1AUROVELA FE 1.5/30(28)1AUROVELA FE 1-20(28)1AVIANE1AYUNA1AZURETTE (28)1BALZIVA (28)1BLISOVI 24 FE1BLISOVI FE 1.5/30 (28)1BLISOVI FE 1/20 (28)1BRIELLYN1CAMILA1CAMRESE1QL (1 EA per 1day) Drug NameTier Restrictions /LimitsCAMRESE LO 1QL (1 EA per 1day)CAYA CONTOURED 2QL (1 EA per365 days)CAZIANT (28) 1 CHATEAL EQ (28)1 CRYSELLE (28)1 CYRED1 CYRED EQ1 DASETTA 1/35 (28)1 DASETTA 7/7/7 (28)1 DAYSEE1QL (1 EA per 1day)DEBLITANE 1 DEPO-SUBQPROVERA 1042 desog-e.estradiol/e.estradiol1 drospirenone-e.estradiol-lm.fa oral tablet 3-0.02-0.451 mg(24) (4)1PAdrospirenone-ethinyl estradiol 1 ELINEST1 ELLA2 ELURYNG1 ENPRESSE1 ENSKYCE1 ERRIN1 ESTARYLLA1 ethynodiol diac-eth estradiol1 etonogestrel-ethinyl estradiol1 FALMINA (28)1 FEMCAP2QL (1 EA per365 days)HAILEY 24 FE 1 HAILEY FE 1.5/30 (28)1 HAILEY FE 1/20 (28)1Georgia Medicaid | Effective 01/01/202621 Drug NameTier Restrictions /LimitsHEATHER 1INCASSIA1ISIBLOOM1JASMIEL (28)1JENCYCLA1JOLESSA1QL (1 EA per 1day)JULEBER 1JUNEL 1.5/30 (21)1JUNEL 1/20 (21)1JUNEL FE 1.5/30 (28)1JUNEL FE 1/20 (28)1JUNEL FE 241KAITLIB FE1KARIVA (28)1KELNOR 1/35 (28)1KURVELO (28)1l norgest/e.estradiol-e.estrad1QL (1 EA per 1day)LARIN 1.5/30 (21) 1LARIN 1/20 (21)1LARIN 24 FE1LARIN FE 1.5/30 (28)1LARIN FE 1/20 (28)1LESSINA1LEVONEST (28)1levonorgestrel-ethinyl estrad oral tablet 0.1-20mg-mcg, 0.15-0.03 mg1levonorgestrel-ethinyl estrad oral tablet 90-20mcg (28)1QL (1 EA per 1day)levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 1QL (1 EA per 1day)levonorg-eth estrad triphasic 1LEVORA-281LORYNA (28)1LOW-OGESTREL (28)1 Drug NameTier Restrictions /LimitsLO-ZUMANDIMINE (28) 1 LUTERA (28)1 LYZA1 MARLISSA (28)1 medroxyprogesterone intramuscular1 MICROGESTIN 1.5/30(21)1 MICROGESTIN 1/20(21)1 MICROGESTIN FE1.5/30 (28)1 MICROGESTIN FE1/20 (28)1 MILI1 MONO-LINYAH1 NECON 0.5/35 (28)1 NIKKI (28)1 NORA-BE1 noreth-ethinyl estradiol-iron1 norethindrone(contraceptive)1 norethindrone ac-eth estradiol oral tablet 1-20mg-mcg, 1.5-30 mg-mcg1 norethindrone-e.estradiol-iron oral tablet1 norgestimate-ethinyl estradiol1 NORTREL 0.5/35 (28)1 NORTREL 1/35 (21)1 NORTREL 1/35 (28)1 NORTREL 7/7/7 (28)1 OCELLA1 PHILITH1 PIMTREA (28)1 PORTIA 281 RECLIPSEN (28)1Georgia Medicaid | Effective 01/01/202622 Drug NameTier Restrictions /LimitsSETLAKIN 1QL (1 EA per 1day)SHAROBEL 1SIMLIYA (28)1SIMPESSE1QL (1 EA per 1day)SPRINTEC (28) 1SRONYX1SYEDA1TARINA 24 FE1TARINA FE 1/20 (28)1TARINA FE 1-20 EQ(28)1TILIA FE1TRI-ESTARYLLA1TRI-LEGEST FE1TRI-LINYAH1TRI-LO-ESTARYLLA1TRI-LO-MARZIA1TRI-LO-MILI1TRI-LO-SPRINTEC1TRI-MILI1TRI-SPRINTEC (28)1TRI-VYLIBRA1TRI-VYLIBRA LO1TULANA1VELIVET TRIPHASICREGIMEN (28)1VESTURA (28)1VIENVA1VIORELE (28)1VYFEMLA (28)1VYLIBRA1WERA (28)1WIDE-SEALDIAPHRAGM 602QL (2 EA per365 days)WIDE-SEALDIAPHRAGM 65 2QL (2 EA per365 days)WIDE-SEALDIAPHRAGM 70 2QL (2 EA per365 days) Drug NameTier Restrictions /LimitsWIDE-SEALDIAPHRAGM 75 2QL (2 EA per365 days)WIDE-SEALDIAPHRAGM 80 2QL (2 EA per365 days)WIDE-SEALDIAPHRAGM 85 2QL (2 EA per365 days)WIDE-SEALDIAPHRAGM 90 2QL (2 EA per365 days)WIDE-SEALDIAPHRAGM 95 2QL (2 EA per365 days)WYMZYA FE 1 XULANE1 ZAFEMY1 ZARAH1 ZOVIA 1-35 (28)1 ZUMANDIMINE (28)1 COUGH/COLDPREPARATIONSbenzonatate1QL (4 EA per 1day)BROMFED DM 2 brompheniramine-pseudoeph-dm1 hydrocodone-homatropine oral solution 5-1.5 mg/5 ml1QL (4 ML per 1day); ARhydrocodone-homatropine oral solution 5-1.5 mg/5 ml(5 ml) 1QL (4 ML per 1day)HYDROMET 1QL (4 ML per 1day); ARpromethazine-codeine 1ARpromethazine-dm 1 DIURETICSacetazolamide1 amiloride1 amiloride-hydrochlorothiazide1 bumetanide oral1 chlorthalidone1Georgia Medicaid | Effective 01/01/202623 Drug NameTier Restrictions /Limits furosemide oral solution10 mg/ml, 40 mg/5 ml (8mg/ml) 1furosemide oral tablet1hydrochlorothiazide1indapamide1JYNARQUE ORALTABLET2QL (2 EA per 1day)methazolamide 1metolazone1spironolactone oral tablet1spironolacton-hydrochlorothiaz1tolvaptan oral tablet 15mg1torsemide1triamterene-hydrochlorothiazid oral capsule1triamterene-hydrochlorothiazid oral tablet 37.5-25 mg1QL (1 EA per 1day)triamterene-hydrochlorothiazid oral tablet 75-50 mg 1EENT PREPSacetic acid otic (ear)1atropine ophthalmic(eye) drops 1 %1azelastine-fluticasone1betaxolol ophthalmic(eye)1brimonidine ophthalmic(eye) drops 0.2 %1cromolyn ophthalmic(eye)1cyclopentolate1dexamethasone sodium phosphate ophthalmic(eye)1DEXTENZA1PA Drug NameTier Restrictions /LimitsDEXYCU (PF) 1PA; ARdiclofenac sodium ophthalmic (eye) 1 dorzolamide1 dorzolamide (pf)2 dorzolamide-timolol1 fluorometholone1 HOMATROPAIRE1 hydrocortisone-acetic acid1QL (10 ML per30 days)ipratropium bromide nasal 1QL (4 ML per 1day)ISOPTO ATROPINE 2 ketorolac ophthalmic(eye) drops 0.4 %1QL (5 ML per30 days)ketorolac ophthalmic(eye) drops 0.5 % 1 latanoprost1 levobunolol1 pilocarpine hcl ophthalmic (eye) drops1 %, 2 %, 4 %1 prednisolone acetate1 prednisolone acetate(pf)2 prednisolone sodium phosphate ophthalmic(eye)1 timolol maleate ophthalmic (eye) drops1 timolol maleate ophthalmic (eye) gel forming solution1 TIMOPTIC OCUDOSE(PF) OPHTHALMIC(EYE) DROPPERETTE0.25 %2 tropicamide1 ELECT/CALORIC/H2OACTICAL1 AURYXIA2Georgia Medicaid | Effective 01/01/202624 Drug NameTier Restrictions /LimitsBAQSIMI 2PA; ST; QL (2EA per 365days)BIOCAL 2CALCIUM 5001CALCIUM 500 + D1CALCIUM 500 WITH D1CALCIUM 6001CALCIUM 600 + D(3)ORAL CAPSULE1CALCIUM 600 + D(3)ORAL TABLET 600MG-10 MCG (400UNIT)1CALCIUM 600 WITHVITAMIN D3 ORALTABLET,CHEWABLE1calcium acetate(phosphat bind)1calcium carbonate oral tablet 500 mg calcium(1,250 mg), 600 mg calcium (1,500 mg)1calcium carbonate oral tablet,chewable 500 mg calcium (1,250 mg)1calcium carbonate-vit d3-min1calcium carbonate-vitamin d3 oral capsule600 mg-10 mcg (400unit)1calcium carbonate-vitamin d3 oral tablet250 mg-3 mcg (120unit), 250 mg-3.125mcg (125 unit), 500 mg-10 mcg (400 unit), 500mg-3.125 mcg (125unit), 500 mg-5 mcg(200 unit), 600 mg-10mcg (400 unit), 600 mg-20 mcg (800 unit)1CALCIUM CITRATE +D1 Drug NameTier Restrictions /Limits calcium citrate oral tablet 1 calcium citrate-vitamin d3 oral tablet1 CALCIUM WITHVITAMIN D1 CALTRATE WITHVITAMIN D32 CITRACAL + DMAXIMUM2 CITRACAL REGULAR2 CITRACAL-D3MAXIMUM PLUS2 CITRACAL-D3PETITES2 DENTA 5000 PLUS1 DEX4 GLUCOSE ORALTABLET,CHEWABLE1 DEX4 GLUCOSEPOUCH PACK1 DEX4 GLUCOSEQUICK DISSOLVE1 EFFER-K ORALTABLET,EFFERVESCENT 25MEQ1 electrolytes-dextrose oral solution1 ENFAMIL ENFALYTE2 FEOSOL ORALTABLET 325 MG (65MG IRON)1 FERATE1 FER-IN-SOL2 FEROSUL1 FERREX 1501 FERRIC X-1501 FERROCITE1 FERRO-TIME1 ferrous fumarate oral tablet 324 mg (106 mg iron)1Georgia Medicaid | Effective 01/01/202625 Drug NameTier Restrictions /Limits ferrous gluconate oral tablet 240 mg (27 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron) 1ferrous sulfate oral drops1ferrous sulfate oral elixir1ferrous sulfate oral solution1ferrous sulfate oral tablet1ferrous sulfate oral tablet,delayed release(dr/ec)1fluoride (sodium) oral tablet,chewable1GLUCAGON (HCL)EMERGENCY KIT2GLUCAGONEMERGENCY KIT(HUMAN)2QL (2 EA per30 days)glucose oral tablet,chewable 4 gram 1IFEREX 1501IRON (FERROUSSULFATE)1IRON ORAL TABLET1KIONEX (WITHSORBITOL)1KLOR-CON 101KLOR-CON 81KLOR-CON M101KLOR-CON M151KLOR-CON M201L-GLUTAMINE ORALTABLET 500 MG1LIQUID CALCIUMWITH VITAMIN D2magnesium oxide oral tablet 250 mg magnesium, 400 mg magnesium1 Drug NameTier Restrictions /LimitsMAGOX 2 MGO1 MYFERON 1501 NU-IRON2 ONEVITE CALCIUM-D3ORAL TABLET 500MG-5 MCG (200 UNIT)1 ORALYTE1 OYSCO 500/D1 OYSTER SHELL + D31 OYSTER SHELLCALCIUM1 OYSTER SHELLCALCIUM 5001 OYSTER SHELLCALCIUM-VIT D3ORAL TABLET 250MG-3.125 MCG (125UNIT)2 OYSTER SHELLCALCIUM-VIT D3ORAL TABLET 500MG-10 MCG (400UNIT), 500 MG-5 MCG(200 UNIT)1 PEDIA IRON ORALDROPS1 PEDIALYTEADVANCED CAREOTC PEDIALYTE FREEZERPOPSOTC PEDIALYTE ORALSOLUTIONOTC PEDIALYTE SINGLESOTC PEDIATRICELECTROLYTE ORALSOLUTION1 PHOSPHA 250NEUTRAL1 PHOSPHO-TRIN 250NEUTRAL1 POLY-IRON1 polysaccharide iron complex1Georgia Medicaid | Effective 01/01/202626 Drug NameTier Restrictions /Limits potassium chloride oral capsule, extended release 1potassium chloride oral liquid1potassium chloride oral tablet extended release10 meq, 20 meq, 8 meq1potassium chloride oral tablet,er particles/crystals1potassium citrate oral tablet extended release1potassium iodide oral solution1SF 5000 PLUS1SODIUM FLUORIDE5000 PLUS1sodium polystyrene sulfonate1SPS (WITHSORBITOL)1TRUEPLUS GLUCOSEORALTABLET,CHEWABLE2GASTROINTESTINALACIDOPHILUSPROBIOTIC BLEND2acidophilus-pectin,citrus oral capsule 100million cell-10 mg2ADULT 50 PLUSPROBIOTIC2ADVANCEDPROBIOTIC2ADVANCEDPROBIOTIC-142ALIGN (B.LONGUM)2amoxicil-clarithromy-lansopraz1balsalazide1BIO-K PLUS2 Drug NameTier Restrictions /Limits chlordiazepoxide-clidinium 1 cimetidine hcl1 cimetidine oral tablet300 mg, 400 mg, 800mg1 CONSTULOSE1 CREON2 CULTURELLE KIDSGENTLE-GO2 CULTURELLE KIDSPROBIOTICS ORALPOWDER IN PACKET2 CULTURELLE PRO-WELL 3-IN-12 DAILY PROBIOTIC2 DAILY PROBIOTIC (10STRAINS)2 dicyclomine oral capsule1 dicyclomine oral solution1 dicyclomine oral tablet20 mg1 DIGESTIVEPROBIOTIC ORALCAPSULE 3 BILLIONCELL2 DIGESTIVEPROBIOTIC ORALCAPSULE, SPRINKLE2 diphenoxylate-atropine1 ED-SPAZ1 ENULOSE1 esomeprazole magnesium oral granules dr for susp in packet 10 mg, 20 mg,40 mg1QL (180 EA per365 days)famotidine oral suspension for reconstitution 1ARfamotidine oral tablet 40mg 1Georgia Medicaid | Effective 01/01/202627 Drug NameTier Restrictions /LimitsFISH OIL ORALCAPSULE 1,000 (120-180) MG, 1,200 (144-216) MG, 360-1,200MG, 60-90-500 MG,900 MG-360 MG-455MG-1,000 MG 2FISH OIL ORALCAPSULE 300-1,000MG, 300-500 MG1FISH OIL ORALCAPSULE,DELAYEDRELEASE(DR/EC) 300-1,000 MG1FLORAJENDIGESTION2FLORAJEN KIDS2FLORASTOR1FLORASTORKIDS2GAVILYTE-C1GAVILYTE-G1GAVILYTE-N1GENERLAC1glycopyrrolate oral solution1PAglycopyrrolate oral tablet 1 mg, 2 mg 1granisetron hcl oral1QL (15 EA per30 days)hyoscyamine sulfate oral 1hyoscyamine sulfate sublingual1l.acidoph,saliva-b.bif-s.therm2l.acidophilus-bifido.longum oral capsule,delayed release(dr/ec) 16 mg1lactobac acidoph-fructooligos1LACTO-PECTIN2lactulose oral solution1 Drug NameTier Restrictions /Limits loperamide oral capsule 1QL (2 EA per 1day)lubiprostone 1ST; QL (60 EAper 26 days)MEGA PROBIOTIC 2 mesalamine oral tablet,delayed release(dr/ec)1 mesalamine rectal enema1 metoclopramide hcl oral1 misoprostol1QL (4 EA per 1day)MOOD SUPPORTPROBIOTIC 2 nizatidine1 NULEV2 omega 3-dha-epa-fish oil oral capsule 1,000(120-180) mg, 300-1,000 mg1 omega 3-dha-epa-fish oil oral capsule 1,200(144-216) mg, 200-300-1,000 mg, 300 mg (120mg-180mg)-1,000 mg,60-90-500 mg2 omega 3-dha-epa-fish oil oral capsule,delayed release(dr/ec) 300 mg(120 mg-180mg)-1,000mg, 300-1,000 mg1 omega 3-dha-epa-fish oil oral capsule,delayed release(dr/ec) 600 mg-216 mg-324 mg-1,200mg2 omega-3 acid ethyl esters1 omega-3 fatty acids1 omega-3 fatty acids-fish oil oral capsule 300-1,000 mg1Georgia Medicaid | Effective 01/01/202628 Drug NameTier Restrictions /Limits omega-3s-dha-epa-fish oil oral capsule 300-250-1,000 mg, 600-1,000 mg 2omega-3s-dha-epa-fish oil oral capsule,delayed release(dr/ec) 300-1,000 mg, 720-1,200mg2omeprazole oral capsule,delayed release(dr/ec)1QL (2 EA per 1day)ondansetron hcl oral 1ondansetron oral tablet,disintegrating 4mg, 8 mg1OSCIMIN1OSCIMIN SL1OVEGA-3 ORALCAPSULE 500-270-135MG, 500-320-130 MG2PANCREAZE2pantoprazole oral granules dr for susp in packet1pantoprazole oral tablet,delayed release(dr/ec)1QL (6 EA per 1day)peg 3350-electrolytes 1peg3350-sod sul-nacl-kcl-asb-c1PApeg-electrolyte soln 1PEPCID2PERTZYE ORALCAPSULE,DELAYEDRELEASE(DR/EC)16,000-57,500-60,500UNIT, 8,000-28,750-30,250 UNIT2PAPHILLIPS' COLONHEALTH 2PREORBOTIC2PROBIOTIC 4X1 Drug NameTier Restrictions /LimitsPROBIOTICACIDOPHILUS-PECTIN 2 PROBIOTIC BLEND2 PROBIOTIC COLONSUPPORT ORALCAPSULE 240 MG (3BILLION CELL)2 PROBIOTICDIGESTIVE SYSTEMSUP2 PROBIOTIC ORALCAPSULE 100 BILLIONCELL2 PROBIOTIC ORALCAPSULE 20 BILLIONCELL, 3 BILLION CELL1 PROBIOTIC PEARLS2 PROBIOTIC PEARLSACIDOPHILUS2 PROBIOTIC PEARLSCOMPLETE2 prochlorperazine maleate1 promethazine rectal1 PROMETHEGAN1 PROVAD2 PROVELLA2 RESTORA2 RISA-BID2 RISAQUAD1 RISAQUAD-21 SENIOR PROBIOTIC1 senna leaf extract2 SENNA ORAL SYRUP176 MG/5 ML2 SMART HEARTOMEGA-31 sucralfate oral suspension1 sucralfate oral tablet1QL (4 EA per 1day)sulfasalazine 1Georgia Medicaid | Effective 01/01/202629 Drug NameTier Restrictions /LimitsSUPER DHA GEMS 2SUPER OMEGA-31SYMAX-SR1trimethobenzamide1ULTIMATEPROBIOTIC-102ULTRA FLORA PLUS2ULTRA OMEGA-31ursodiol1VIOKACE2ZELAC2HORMONESbudesonide oral capsule,delayed,extend.release1cabergoline1calcitonin (salmon)nasal1COMBIPATCH2CORTIFOAM2cortisone1COVARYX1COVARYX H.S.1CRINONE VAGINALGEL 4 %2danazol1desmopressin nasal spray with pump1desmopressin oral1DEXAMETHASONEINTENSOL1dexamethasone oral elixir1dexamethasone oral solution1dexamethasone oral tablet1DEXONTO2 Drug NameTier Restrictions /LimitsDOTTITRANSDERMALPATCH SEMIWEEKLY0.025 MG/24 HR, 0.05MG/24 HR, 0.075MG/24 HR, 0.1 MG/24HR 1PAEEMT 1 EEMT HS1 estradiol oral1 estradiol transdermal patch semiweekly 0.025mg/24 hr, 0.05 mg/24hr, 0.075 mg/24 hr, 0.1mg/24 hr1PAestradiol transdermal patch semiweekly0.0375 mg/24 hr 2PAestradiol transdermal patch weekly 1 estradiol vaginal tablet1 estradiol-norethindrone acet1 estrogens-methyltestosterone1 fludrocortisone1 FYAVOLV1 hydrocortisone oral1 hydrocortisone rectal1 INCRELEX2PA; ARJINTELI 1 medroxyprogesterone oral1 melatonin oral capsule2 melatonin oral drops2 melatonin oral liquid 2.5mg/10 ml2 melatonin oral tablet 1mg, 10 mg, 3 mg, 5 mg1 melatonin oral tablet 12mg2Georgia Medicaid | Effective 01/01/202630 Drug NameTier Restrictions /Limits melatonin oral tablet extended release 1 mg,3 mg 1melatonin oral tablet extended release 10 mg2melatonin oral tablet, ir and er, biphasic2melatonin oral tablet,chewable 2.5 mg,5 mg2melatonin oral tablet,disintegrating 1mg, 10 mg, 12 mg, 5mg2melatonin oral tablet,disintegrating 3mg1melatonin-pyridoxine hcl(b6) oral tablet 1-10 mg,3-10 mg1melatonin-pyridoxine hcl(b6) oral tablet, ir and er, biphasic 3-10 mg1methylergonovine oral1methylprednisolone oral tablet 16 mg, 32 mg, 8mg1methylprednisolone oral tablets,dose pack1MIMVEY1NOCDURNA (MEN)2PA; ARNOCDURNA (WOMEN) 2PA; ARnorethindrone acetate 1norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg1OMNITROPESUBCUTANEOUSRECON SOLN2PAORIAHNN 2PA; QL (2 EAper 1 day); ARORILISSA ORALTABLET 150 MG 2PA; QL (1 EAper 1 day); AR Drug NameTier Restrictions /LimitsORILISSA ORALTABLET 200 MG 2PA; QL (2 EAper 1 day); ARprednisolone oral solution 1 prednisolone sodium phosphate oral solution10 mg/5 ml, 20 mg/5 ml(4 mg/ml)1PAprednisolone sodium phosphate oral solution15 mg/5 ml (3 mg/ml),15 mg/5 ml (5 ml), 5 mg base/5 ml (6.7 mg/5 ml) 1 prednisolone sodium phosphate oral tablet,disintegrating1 prednisone1 PREDNISONEINTENSOL1 progesterone micronized oral1 SYNAREL2PAtestosterone transdermal gel 1PAtestosterone transdermal gel in packet 1 % (25mg/2.5gram) 1PAtestosterone transdermal gel in packet 1 % (50 mg/5gram) 1PA; QL (100GM per 30days)VITAJOY MELATONIN 2 IMMUNOSUPPRESSANTSACTEMRA ACTPEN2PAazathioprine oral tablet50 mg 1 cyclosporine modified1 cyclosporine oral1 DUPIXENT PENSUBCUTANEOUS PENINJECTOR 200MG/1.14 ML2PA; QL (2.28ML per 28days)Georgia Medicaid | Effective 01/01/2026 31 Drug NameTier Restrictions /LimitsDUPIXENT PENSUBCUTANEOUS PENINJECTOR 300 MG/2ML 2PA; QL (4 MLper 28 days)DUPIXENT SYRINGESUBCUTANEOUSSYRINGE 200 MG/1.14ML 2PA; QL (2.28ML per 28days)DUPIXENT SYRINGESUBCUTANEOUSSYRINGE 300 MG/2ML 2PA; QL (4 MLper 28 days)ENSPRYNG 2PA; QL (1SYRINGE per28 days); AReverolimus(immunosuppressive)oral tablet 0.25 mg, 0.5mg, 0.75 mg 1GENGRAF1HYFTOR2PA; QL (20 GMper 18 days)mycophenolate mofetil 1mycophenolate sodium1NEORAL2pimecrolimus1PASANDIMMUNE ORAL 2sirolimus oral tablet1STEQEYMA2tacrolimus oral capsule1tacrolimus topical1QL (1 GM per 1day)TYENNEAUTOINJECTOR 2TYENNESUBCUTANEOUS2YESINTEKSUBCUTANEOUS2 Drug NameTier Restrictions /LimitsMISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ACE AEROSOLCLOUD ENHANCER2QL (2 EA per365 days)AEROCHAMBER MINI 2QL (2 EA per365 days)AEROCHAMBER MV 2QL (2 EA per365 days)AEROCHAMBER PLUSFLOW-VU 2QL (2 EA per365 days)AEROCHAMBER PLUSFLOW-VU,L MSK 2QL (2 EA per365 days)AEROCHAMBER PLUSFLOW-VU,M MSK 2QL (2 EA per365 days)AEROCHAMBER PLUSFLOW-VU,S MSK 2QL (2 EA per365 days)AEROCHAMBER PLUS ZSTAT 2QL (2 EA per365 days)AEROCHAMBER PLUS ZSTAT LG MSK 2QL (2 EA per365 days)AEROCHAMBER PLUS ZSTAT MD MSK 2QL (2 EA per365 days)AEROCHAMBER PLUS ZSTAT SM MSK 2QL (2 EA per365 days)AEROCHAMBER Z-STAT PLUS-FLW SG 2QL (2 EA per365 days)AEROTRACH PLUS 2QL (2 EA per365 days)AEROVENT PLUS 2QL (2 EA per365 days)BD ECLIPSE LUER-LOK NEEDLE 30 X 1/2" 2 BD PRECISIONGLIDENEEDLE 27 GAUGE X3/8"2 BD SAFETYGLIDEALLERGIST TRAYSYRINGE 1 ML 27 X1/2"2QL (400 EA per30 days)Georgia Medicaid | Effective 01/01/202632 PAPA Drug NameTier Restrictions /LimitsBREATHERITE MDISPACER 2QL (2 EA per365 days)BREATHERITESPACER-MASK, NEO. 2QL (2 EA per365 days)BREATHERITESPACER-MASK,ADULT 2QL (2 EA per365 days)BREATHERITESPACER-MASK,CHILD 2QL (2 EA per365 days)BREATHERITESPACER-MASK,INFANT 2QL (2 EA per365 days)BREATHERITESPACER-MASK,S.CHLD 2QL (2 EA per365 days)BREATHERITEVALVED MDICHAMBER 2QL (2 EA per365 days)BREATHERITEVALVED MDI SPACER 2QL (2 EA per365 days)CLEVER CHOICECHAMBER-LRG MASK 2QL (2 EA per365 days)CLEVER CHOICECHAMBER-MED MASK 2QL (2 EA per365 days)CLEVER CHOICECHAMBER-SM MASK 2QL (2 EA per365 days)COMPACT SPACECHAMBER 2QL (2 EA per365 days)COMPACT SPACECHAMBER-LRG MASK 2QL (2 EA per365 days)COMPACT SPACECHAMBER-MED MASK 2QL (2 EA per365 days)COMPACT SPACECHAMBER-SM MASK 2QL (2 EA per365 days)DEXCOM G6RECEIVER 2PA; QL (1 EAper 1LIFETIME); ARDEXCOM G6 SENSOR 2PA; QL (3 EAper 28 days);ARDEXCOM G6TRANSMITTER 2PA; QL (1 EAper 90 days);AR Drug NameTier Restrictions /LimitsDEXCOM G7 15 DAYSENSOR 2PA; QL (3 EAper 28 days);ARDEXCOM G7RECEIVER 2PA; QL (1 EAper 1LIFETIME); ARDEXCOM G7 SENSOR 2PA; QL (3 EAper 28 days);AREASIVENT HOLDINGCHAMBER 2QL (2 EA per365 days)EASIVENT MASKLARGE 2QL (2 EA per365 days)EASIVENT MASKMEDIUM 2QL (2 EA per365 days)EASIVENT MASKSMALL 2QL (2 EA per365 days)EASYPOINT NEEDLENEEDLE 25 GAUGE X1 1/2" 2 ECLIPSE NEEDLENEEDLE 23 GAUGE X1", 25 GAUGE X 5/8"2 ECLIPSE SYRINGESYRINGE 3 ML 21GAUGE X 1", 3 ML 25GAUGE X 1"2QL (400 EA per30 days)FLEXICHAMBER 2QL (2 EA per365 days)FLEXICHAMBER-LGCHILD MASK 2QL (2 EA per365 days)FLEXICHAMBER-SMADULT MASK 2QL (2 EA per365 days)FLEXICHAMBER-SMCHILD MASK 2QL (2 EA per365 days)FREESTYLE LIBRE 14DAY READER 2PA; QL (1 EAper 1LIFETIME); ARFREESTYLE LIBRE 14DAY SENSOR 2PA; QL (2 EAper 28 days);ARFREESTYLE LIBRE 2PLUS SENSOR 2ARGeorgia Medicaid | Effective 01/01/2026 33 Drug NameTier Restrictions /LimitsFREESTYLE LIBRE 2READER 2PA; QL (1 EAper 1LIFETIME); ARFREESTYLE LIBRE 2SENSOR 2PA; QL (2 EAper 28 days);ARFREESTYLE LIBRE 3PLUS SENSOR 2ARFREESTYLE LIBRE 3READER 2PA; QL (1 EAper 1LIFETIME); ARFREESTYLE LIBRE 3SENSOR 2PA; QL (2 EAper 28 days);ARinsulin syringe-needle u-100 syringe 1 ml 27gauge x 1/2", 1/2 ml 27gauge x 1/2" 2QL (400 EA per30 days)INSUPEN PENNEEDLE NEEDLE 32GAUGE X 1/4" 2QL (400 EA per30 days)INTEGRA SYRINGE 2QL (400 EA per30 days)LITEAIRE MDICHAMBER 2QL (2 EA per365 days)MAGELLAN INSULINSAFETY SYRNG 2QL (400 EA per30 days)MAGELLAN SYRINGESYRINGE 0.3 ML 30 X5/16", 0.5 ML 30GAUGE X 5/16" 2QL (400 EA per30 days)MICROCHAMBER 2QL (2 EA per365 days)MICROSPACER 2QL (2 EA per365 days)MINI WRIGHT PEAKFLOW METER 2QL (1 EA per365 days)MONOJECT INSULINSAFETY SYRINGSYRINGE 0.3 ML 30GAUGE X 5/16", 0.5 ML29 GAUGE X 1/2", 0.5ML 30 GAUGE X 5/16" 2QL (400 EA per30 days) Drug NameTier Restrictions /LimitsMONOJECTMAGELLAN SAFETYSYRNG SYRINGE 3ML 20 GAUGE X 1" 2QL (400 EA per30 days)MONOJECT SAFETYSYRINGES SYRINGE 3ML 22 GAUGE X 1 1/2" 2QL (400 EA per30 days)MONOJECT SYRINGESYRINGE 1/2 ML 28GAUGE 2QL (400 EA per30 days)OPTICHAMBERADULT MASK-LARGE 2QL (2 EA per365 days)OPTICHAMBERDIAMOND LG MASK 2QL (2 EA per365 days)OPTICHAMBERDIAMOND VHC 2QL (2 EA per365 days)OPTICHAMBERDIAMOND-MED MSK 2QL (2 EA per365 days)OPTICHAMBERDIAMOND-SML MASK 2QL (2 EA per365 days)PEN NEEDLE NEEDLE30 GAUGE X 5/16" 2QL (400 EA per30 days)POCKET CHAMBER 2QL (2 EA per365 days)PROCARE SPACERWITH ADULT MASK 2QL (2 EA per365 days)PROCARE SPACERWITH CHILD MASK 2QL (2 EA per365 days)PROCHAMBER 2QL (2 EA per365 days)RITEFLOAEROCHAMBER 2QL (2 EA per365 days)TRUZONE PEAKFLOW METER 2QL (1 EA per365 days)TUBERCULINSYRINGE SYRINGE 1ML 25 GAUGE X 1" 2QL (400 EA per30 days)ULTICARE SYRINGE 1ML 25 GAUGE X 5/8" 2QL (400 EA per30 days)V-GO 20 2 V-GO 302 V-GO 402 VORTEX HOLDINGCHAMBER2QL (2 EA per365 days)Georgia Medicaid | Effective 01/01/202634 Drug NameTier Restrictions /LimitsMUSCLERELAXANTS baclofen oral tablet 10mg, 20 mg, 5 mg1baclofen oral tablet 15mg2chlorzoxazone oral tablet 500 mg1cyclobenzaprine oral tablet 10 mg, 5 mg1dantrolene oral1methocarbamol oral tablet 500 mg, 750 mg1orphenadrine citrate oral1tizanidine oral tablet1PRE-NATALVITAMINSCOMPLETENATE1KOSHER PRENATALPLUS IRON2KPN2M-NATAL PLUS1ONE A DAY WOMEN'SPRENATAL DHA2pnv no.95-ferrous fumarate-fa1PRENATABS FA1PRENATABS RX1PRENATAL 19 ORALTABLET,CHEWABLE1PRENATAL MULTI2PRENATALMULTIVITAMINS1PRENATAL ONEDAILY1PRENATAL ORALTABLET 28 MG IRON-800 MCG1PRENATAL ORALTABLET 28-800 MG-MCG2 Drug NameTier Restrictions /LimitsPRENATAL PLUS 1 PRENATAL PLUS(CALCIUM CARB)1 PRENATAL TABLET1 prenatal vit no.179-iron-folic1 PRENATAL VITAMINORAL TABLET 27 MGIRON-0.8 MG, 27 MGIRON-800 MCG2 PRENATAL VITAMINPLUS LOW IRON1 PRENATAL VITAMINWITH MINERALS1 prenatal vit-iron fum-folic ac1 SE-NATAL 19CHEWABLE1 THRIVITE RX2 TRICARE2 TRINATAL RX 11 PSYCHOTHERAPEUTIC DRUGSABILIFY MAINTENA2 alprazolam oral tablet1QL (4 EA per 1day)amitriptyline 1 amitriptyline-chlordiazepoxide1 amoxapine1 aripiprazole oral tablet10 mg, 15 mg, 30 mg1QL (1 EA per 1day)aripiprazole oral tablet 2mg, 20 mg 1QL (2 EA per 1day)aripiprazole oral tablet 5mg 1QL (1.5 EA per1 day)ARISTADA INITIO 2QL (3 ML per180 days); ARARISTADAINTRAMUSCULARSUSPENSION,EXTENDED REL SYRING1,064 MG/3.9 ML 2QL (4 ML per60 days)Georgia Medicaid | Effective 01/01/2026 35 Drug NameTier Restrictions /LimitsARISTADAINTRAMUSCULARSUSPENSION,EXTENDED REL SYRING 441MG/1.6 ML 2QL (2 ML per28 days)ARISTADAINTRAMUSCULARSUSPENSION,EXTENDED REL SYRING 662MG/2.4 ML 2QL (3 ML per28 days)ARISTADAINTRAMUSCULARSUSPENSION,EXTENDED REL SYRING 882MG/3.2 ML 2QL (3.2 ML per28 days)atomoxetine oral capsule 10 mg, 18 mg,25 mg, 40 mg 1QL (2 EA per 1day)atomoxetine oral capsule 100 mg, 60 mg,80 mg 1QL (1 EA per 1day)bupropion hcl oral tablet 1bupropion hcl oral tablet extended release 24 hr150 mg, 300 mg1QL (1 EA per 1day)bupropion hcl oral tablet sustained-release 12 hr 1buspirone1chlordiazepoxide hcl1QL (4 EA per 1day)chlorpromazine oral tablet 1citalopram oral solution1citalopram oral tablet1clomipramine1clonidine hcl oral tablet extended release 12 hr1QL (4 EA per 1day)clorazepate dipotassium 1QL (4 EA per 1day)clozapine oral tablet 1desipramine1dexmethylphenidate oral capsule,er biphasic50-501QL (1 EA per 1day) Drug NameTier Restrictions /Limits dexmethylphenidate oral tablet 10 mg 1QL (4 EA per 1day)dexmethylphenidate oral tablet 2.5 mg, 5 mg 1QL (2 EA per 1day)diazepam oral tablet 1QL (4 EA per 1day)doxepin oral capsule 1 doxepin oral concentrate1 duloxetine1 escitalopram oxalate oral solution1 escitalopram oxalate oral tablet1 fluoxetine oral capsule1 fluoxetine oral solution1 fluoxetine oral tablet1 fluphenazine decanoate1 fluphenazine hcl1 fluvoxamine1 guanfacine oral tablet extended release 24 hr1QL (1 EA per 1day)haloperidol 1 haloperidol decanoate1 haloperidol lactate1 imipramine hcl1 imipramine pamoate1 INVEGA HAFYERA2PA; QL (1SYRINGE per180 days); ARINVEGA SUSTENNA 2 INVEGA TRINZAINTRAMUSCULARSYRINGE 273 MG/0.88ML2QL (1 ML per90 days)INVEGA TRINZAINTRAMUSCULARSYRINGE 410 MG/1.32ML, 546 MG/1.75 ML 2QL (2 ML per90 days)Georgia Medicaid | Effective 01/01/202636 Drug NameTier Restrictions /LimitsINVEGA TRINZAINTRAMUSCULARSYRINGE 819 MG/2.63ML 2QL (3 ML per90 days)lithium carbonate 1lithium citrate1LITHOBID2lorazepam oral tablet1QL (3 EA per 1day)loxapine succinate 1methylphenidate hcl oral capsule, er biphasic30-701QL (1 EA per 1day)methylphenidate hcl oral capsule,er biphasic50-50 20 mg, 40 mg 1QL (1 EA per 1day)methylphenidate hcl oral capsule,er biphasic50-50 30 mg 1QL (2 EA per 1day)methylphenidate hcl oral solution 10 mg/5 ml 1QL (30 ML per1 day)methylphenidate hcl oral solution 5 mg/5 ml 1QL (60 ML per1 day)methylphenidate hcl oral tablet 1QL (3 EA per 1day)methylphenidate hcl oral tablet extended release 1QL (3 EA per 1day)methylphenidate hcl oral tablet extended release 24hr 18 mg, 27mg 1QL (1 EA per 1day)methylphenidate hcl oral tablet extended release 24hr 36 mg, 54mg 1QL (2 EA per 1day)methylphenidate hcl oral tablet extended release 24hr 45 mg, 63mg 2methylphenidate hcl oral tablet extended release 24hr 72 mg2QL (1 EA per 1day)methylphenidate hcl oral tablet,chewable 1QL (3 EA per 1day) Drug NameTier Restrictions /Limits mirtazapine 1 nefazodone1QL (2 EA per 1day)nortriptyline 1 olanzapine oral tablet10 mg, 15 mg1QL (2 EA per 1day)olanzapine oral tablet2.5 mg, 5 mg, 7.5 mg 1QL (1 EA per 1day)olanzapine oral tablet20 mg 1QL (3 EA per 1day)oxazepam 1QL (4 EA per 1day)paliperidone oral tablet extended release 24hr1.5 mg, 3 mg, 9 mg 1QL (1 EA per 1day)paliperidone oral tablet extended release 24hr 6mg 1QL (2 EA per 1day)paroxetine hcl oral tablet 1 paroxetine hcl oral tablet extended release24 hr1PA; QL (1 EAper 1 day)perphenazine 1 perphenazine-amitriptyline1 pimozide1 quetiapine oral tablet100 mg, 200 mg, 25mg, 50 mg1QL (3 EA per 1day)quetiapine oral tablet300 mg 1QL (2 EA per 1day)quetiapine oral tablet400 mg 1QL (4 EA per 1day)quetiapine oral tablet extended release 24 hr150 mg, 200 mg 1QL (1 EA per 1day)quetiapine oral tablet extended release 24 hr300 mg 1QL (3 EA per 1day)quetiapine oral tablet extended release 24 hr400 mg, 50 mg 1QL (2 EA per 1day)Georgia Medicaid | Effective 01/01/2026 37 Drug NameTier Restrictions /LimitsRELEXXII ORALTABLET EXTENDEDRELEASE 24HR 18MG, 27 MG, 72 MG 2QL (1 EA per 1day)RELEXXII ORALTABLET EXTENDEDRELEASE 24HR 36MG, 54 MG 2QL (2 EA per 1day)RELEXXII ORALTABLET EXTENDEDRELEASE 24HR 45MG, 63 MG 2RISPERDAL CONSTA2risperidone microspheres1risperidone oral solution1risperidone oral tablet1sertraline oral concentrate1sertraline oral tablet1thioridazine1thiothixene1tranylcypromine1trazodone oral tablet100 mg, 150 mg, 50 mg1trifluoperazine1trimipramine1venlafaxine oral capsule,extended release 24hr1venlafaxine oral tablet1ziprasidone hcl oral capsule 20 mg, 40 mg1QL (2 EA per 1day)ziprasidone hcl oral capsule 60 mg, 80 mg 1QL (3 EA per 1day)SEDATIVE/HYPNOTICS doxepin oral tablet1estazolam1QL (1 EA per 1day)phenobarbital 1triazolam1 Drug NameTier Restrictions /Limits zolpidem oral tablet 1QL (1 EA per 1day)SKIN PREPS ALA-CORT1QL (28.25 GMper 30 days)alclometasone 1QL (2 GM per 1day)AQUA CARE TOPICALCREAM 1 AQUA CARE TOPICALLOTION1QL (16 ML per1 day)AVITA TOPICALCREAM 1QL (45 GM per30 days)AVITA TOPICAL GEL 2QL (45 GM per30 days)BESER 1PA; QL (4 MLper 1 day)betamethasone dipropionate topical cream 1QL (45 GM per30 days)betamethasone dipropionate topical lotion 1QL (2 ML per 1day)betamethasone dipropionate topical ointment 1PA; QL (45 GMper 30 days)betamethasone valerate topical cream 1QL (45 GM per30 days)betamethasone valerate topical lotion 1QL (2 ML per 1day)betamethasone valerate topical ointment 1QL (45 GM per30 days)betamethasone,augmented topical cream 1QL (50 GM per30 days)betamethasone,augmented topical lotion 1QL (2 ML per 1day)betamethasone,augmented topical ointment 1QL (45 GM per30 days)Georgia Medicaid | Effective 01/01/202638 Drug NameTier Restrictions /LimitsBIMZELXAUTOINJECTORSUBCUTANEOUSAUTO-INJECTOR 160MG/ML 2PA; QL (2 MLper 28 days)BIMZELXSUBCUTANEOUSSYRINGE 160 MG/ML 2PA; QL (2 MLper 28 days)calcipotriene scalp 1QL (2 ML per 1day)calcipotriene topical cream 1QL (4 GM per 1day)calcipotriene topical ointment 1QL (4 GM per 1day)clobetasol scalp 1PA; QL (50 MLper 30 days)clobetasol topical cream0.05 % 1PA; QL (2 GMper 1 day)clobetasol topical gel 1PA; QL (2 GMper 1 day)clobetasol topical ointment 1QL (2 GM per 1day)clobetasol topical shampoo 1PA; QL (118ML per 30days)clobetasol-emollient topical cream 1QL (2 GM per 1day)CLODAN 1PA; QL (118ML per 30days)COSENTYX (2SYRINGES) 2PA; QL (2 MLper 28 days)COSENTYX PEN 2PA; QL (1 MLper 28 days)COSENTYX PEN (2PENS) 2PA; QL (2 MLper 28 days)COSENTYXSUBCUTANEOUS 2PA; QL (1 MLper 28 days)COSENTYXUNOREADY PEN 2PAdesonide topical cream 1QL (2 GM per 1day)desonide topical ointment 1QL (2 GM per 1day) Drug NameTier Restrictions /Limits desoximetasone topical cream 0.25 % 1QL (2 GM per 1day)diflorasone 1PA; QL (2 GMper 1 day)DRYSOL 2QL (37.5 MLper 30 days)DRYSOL DAB-O-MATIC 2QL (37.5 MLper 30 days)fluocinolone and shower cap 1QL (1 PACKper 28 days)fluocinolone topical cream 0.01 % 1QL (120 GMper 30 days)fluocinolone topical cream 0.025 % 1QL (2 GM per 1day)fluocinolone topical oil 1QL (120 MLper 30 days)fluocinolone topical ointment 1QL (2 GM per 1day)fluocinolone topical solution 1QL (120 MLper 30 days)fluocinonide topical cream 0.05 % 1PA; QL (2 GMper 1 day)fluocinonide topical gel 1PA; QL (2 GMper 1 day)fluocinonide topical ointment 1PA; QL (2 GMper 1 day)fluocinonide topical solution 1QL (4 ML per 1day)FLUOCINONIDE-E 1QL (2 GM per 1day)fluocinonide-emollient 1QL (120 GMper 30 days)fluticasone propionate topical cream 1QL (2 GM per 1day)fluticasone propionate topical lotion 1PA; QL (4 MLper 1 day)fluticasone propionate topical ointment 1QL (2 GM per 1day)GORMEL 1 GORMEL TEN1QL (16 GM per1 day)hydrocortisone butyrate topical cream 1QL (45 GM per30 days)Georgia Medicaid | Effective 01/01/2026 39 Drug NameTier Restrictions /Limits hydrocortisone butyrate topical ointment 1QL (45 GM per30 days)hydrocortisone butyrate topical solution 1QL (2 ML per 1day)hydrocortisone topical cream 2.5 % 1QL (1 GM per 1day)hydrocortisone topical cream with perineal applicator 1hydrocortisone topical lotion 2 %1hydrocortisone topical lotion 2.5 %1QL (118 MLper 30 days)hydrocortisone topical ointment 2.5 % 1QL (28.25 GMper 30 days)hydrocortisone valerate topical cream 1QL (2 GM per 1day)imiquimod topical cream in packet 3.75 % 1imiquimod topical cream in packet 5 %1PA; QL (24 EAper 28 days)metronidazole topical cream 1QL (45 GM per30 days)metronidazole topical gel 0.75 % 1QL (45 GM per30 days)metronidazole topical lotion 1QL (59 ML per30 days)mometasone topical cream 1QL (45 GM per30 days)mometasone topical ointment 1QL (45 GM per30 days)mometasone topical solution 1QL (2 ML per 1day)podofilox topical solution 1QL (1 PACKper 28 days)PRAMOSONETOPICAL CREAM 2PAPRAMOSONETOPICAL LOTION 2.5-1 % 2PAprednicarbate 1QL (2 GM per 1day)PROCTO-MED HC 1PROCTOSOL HC1 Drug NameTier Restrictions /LimitsPROCTOZONE-HC 1 ROSADAN TOPICALCREAM1QL (45 GM per30 days)ROSADAN TOPICALGEL 1QL (45 GM per30 days)salicylic acid topical cream 1QL (454 GMper 30 days)salicylic acid topical cream,extended release 1QL (454 GMper 30 days)salicylic acid topical lotion 1QL (473 MLper 30 days)salicylic acid topical lotion,extended release 1QL (473 GMper 30 days)salicylic acid topical shampoo 1QL (177 MLper 30 days)SANTYL 2QL (60 GM per28 days)selenium sulfide topical lotion 1 SILIQ2PA; QL (3 MLper 28 days);ARsulfacetamide sodium(acne) 1QL (118 MLper 30 days)tretinoin 1QL (45 GM per30 days); ARtriamcinolone acetonide topical cream 1QL (454 GMper 30 days)triamcinolone acetonide topical lotion 1QL (2 ML per 1day)triamcinolone acetonide topical ointment 0.025%, 0.1 %, 0.5 % 1QL (454 GMper 30 days)triamcinolone acetonide topical ointment 0.05 % 1 TRIDERM1QL (454 GMper 30 days)urea topical cream 10%, 40 % 1 urea topical lotion 10 %1QL (16 ML per1 day)UREACIN-10 2QL (16 ML per1 day)Georgia Medicaid | Effective 01/01/202640 Drug NameTier Restrictions /LimitsSMOKINGDETERRENTS bupropion hcl (smoking deter)1THYROID PREPSEUTHYROX1levothyroxine oral tablet1LEVOXYL1liothyronine oral1methimazole1NP THYROID1propylthiouracil1SYNTHROID2thyroid (pork)1UNITHROID1UNCLASSIFIEDDRUG PRODUCTSacamprosate1AIRBORNE(ASCORBATESODIUM)2AIRBORNE (WITHLYSINE ACETATE)2alendronate oral tablet1alfuzosin1ANTIOXIDANTA/C/E/SELENIUM1BACID WITHLACTOSPORE2BASE, PCCA SYRUPVEHICLE2buprenorphine hcl sublingual1QL (3 EA per 1day); ARbuprenorphine-naloxone sublingual tablet 2-0.5 mg 1PA; QL (1Tablet per 1day); ARbuprenorphine-naloxone sublingual tablet 8-2 mg 1QL (1 Tablet per 1 day); ARcarglumic acid 1PA Drug NameTier Restrictions /Limits chlorhexidine gluconate mucous membrane 1 cpd vehicle susp.sugar-free 122 deferasirox oral tablet,dispersible1PAdisulfiram 1 doxycycline hyclate oral tablet 20 mg1 DRY EYE FORMULA2 E-400 C-500 ANDBETA CAROTENE1 EVRYSDI ORALRECON SOLN2PA; QL (160ML per 21days)finasteride oral tablet 5mg 1 FLAVOR BLEND 2 IN 12 FLAVOR PLUS2 FLAVOR SWEET2 FLAVOR SWEET-SF2 flavoxate1 HAEGARDASUBCUTANEOUSRECON SOLN 2,000UNIT2PA; ARHAEGARDASUBCUTANEOUSRECON SOLN 3,000UNIT 2PAHAIR-SKIN-NAIL(VITA,C-BIOTIN) 2 ibandronate oral1 IMMUNE SUPPORTORALTABLET,CHEWABLE2 KALYDECO ORALGRANULES INPACKET 50 MG, 75MG2PA; QL (56 EAper 30 days);ARKALYDECO ORALTABLET 2PA; QL (60 EAper 30 days);ARleucovorin calcium oral 1Georgia Medicaid | Effective 01/01/202641 Drug NameTier Restrictions /Limits megestrol oral suspension 400 mg/10ml (10 ml), 400 mg/10ml (40 mg/ml) 1megestrol oral suspension 625 mg/5ml (125 mg/ml)1PAMX-SOL 2MX-SOL BLEND2MX-SOL BLEND SF2MX-SOL SUSPEND2NEBUSALINHALATIONSOLUTION FORNEBULIZATION 3 %1OCUVITE LUTEIN ANDZEAXANTHIN2OFEV ORAL CAPSULE100 MG2PA; QL (3 EAper 1 day)OFEV ORAL CAPSULE150 MG 2PA; QL (60 EAper 30 days)OMEGA-3 FISH OILORAL CAPSULE 300-1,000 MG 2ORA-BLEND2ORA-BLEND SF2ORAL MIX2ORAL MIX SF2ORAL SUSPEND2ORAL SYRUP2ORAL SYRUP SF2ORALONE1ORA-PLUS2ORA-SWEET1ORA-SWEET SF2ORKAMBI ORALGRANULES INPACKET 100-125 MG2PA; QL (112EA per 30days); ARORKAMBI ORALGRANULES INPACKET 150-188 MG,75-94 MG 2PA; QL (56 EAper 30 days);AR Drug NameTier Restrictions /LimitsORKAMBI ORALTABLET 2PA; QL (112EA per 30days); ARoxybutynin chloride oral syrup 1 oxybutynin chloride oral tablet 5 mg1 oxybutynin chloride oral tablet extended release24hr1 PAROEX ORAL RINSE1 PCCA-PLUS BASE2 PERIOGARD1 PROBIOTIC (B.COAGULANS) ORALCAPSULE,DELAYEDRELEASE(DR/EC)2 PROXEED PLUS2 PULMOSAL1 PULMOZYME2PA; QL (2.5MG per 1 day);ARraloxifene 1 sapropterin oral powder in packet 500 mg1PAsapropterin oral tablet,soluble 1PAsimple syrup 1 SIMPLYTHICK2 sodium chloride inhalation solution for nebulization 0.9 %, 3 %,7 %1 sodium chloride inhalation solution for nebulization 10 %1QL (4 ML per 1day)SUSPENDRXANHYDROUSSWEETENED 2 SUSPENDRXANHYDROUSUNSWEET2 SWEET-SF2Georgia Medicaid | Effective 01/01/202642 Drug NameTier Restrictions /LimitsSYMDEKO 2PA; QL (56 EAper 30 days);ARSYRPALTA VEHICLE 2SYRSPEND SF LIQUID2SYRUP VEHICLE SF2tamsulosin1tolterodine oral capsule,extended release 24hr1STtolterodine oral tablet 1triamcinolone acetonide dental1TRIKAFTA2PA; QL (84 EAper 28 days);ARtrospium 1STTYBOST 2VERSA FREE2VERSA PLUS2VIVITROL2QL (1 EA per30 days)VITAMINS 50 PLUS ADULT EYEHEALTH2A THRU ZADVANCEDFORMULA1ADULT MULTIVITAMINGUMMIES ORALTABLET,CHEWABLE200 MCG2ADULT ONE DAILYGUMMIES2ADVANCED MULTI EA2ANIMAL CHEWS1APATATE FORTE1ascorbic acid (vitamin c)oral tablet1ascorbic acid (vitamin c)oral tablet,chewable250 mg, 500 mg1 Drug NameTier Restrictions /Limits ascorbic acid-ascorbate sodium oral tablet,chewable 500 mg 1 BCOMPLEX 1 (WITHFOLIC ACID)1 BCOMPLEX PLUSVITAMIN C2 b complex-vitamin c-folic acid oral tablet1 B-12 DOTS1 BABY DDROPS2 BABY VITAMIN D32 BABY'S SUPER DAILYD32 BALANCE B-50 (WITHFOLIC ACID)1 BARIATRICMULTIVITAMINS ORALCAPSULE 45 MGIRON-800 MCG-120MCG2 B-COMPLEX PLUS VITC (CALCIUM)2 b-complex with vitamin c oral tablet1 BIO-35, GLUTEN FREE2 BIO-D-MULSION2 biotin oral capsule 5 mg1 BODY, HAIR, SKINAND NAILS2 CCOMPLEX1 C-10001 C-1000 WITH ROSEHIPS1 C-500 ORAL TABLET1 C-500 ORALTABLET,CHEWABLE1 CALCIDOL1 calcitriol oral1 CENTRUM COMPLETE2 CENTRUM KIDS (VITD3, VIT K)2Georgia Medicaid | Effective 01/01/202643 Drug NameTier Restrictions /LimitsCENTRUM ORALLIQUID 9 MG IRON/15ML 2CENTRUM WOMEN1CENTURY1CEREFOLIN NAC(ALGAL OIL)2CEROVITE JR1CERTAVITE-ANTIOXIDANT1CHILD CHEWABLEVITAMN COMPLETE2CHILD COMPLETEMULTIVITAMIN2CHILD MULTIVITAMINPLUS IRON2CHILDRENMULTIVITAMIN2CHILDREN'S CHEWMULTIVITAMIN1CHILDREN'S CHEWMULTIVIT-IRON2CHILDREN'SCHEWABLEMULTIVITMN1CHILDREN'SCHEWABLE VITAMIN2CHILDREN'SCHEWABLES1CHILDREN'SCHEWABLES EXTRAC1CHILDREN'S MULTI-VIT GUMMIES2CHILDREN'SMULTIVITAMIN2CHILD'S OMEGA-3DHA MULTIVITAM2 Drug NameTier Restrictions /Limits cholecalciferol (vitamin d3) oral capsule 1,250mcg (50,000 unit), 10mcg (400 unit), 125 mcg(5,000 unit), 25 mcg(1,000 unit), 250 mcg(10,000 unit), 50 mcg(2,000 unit) 1 cholecalciferol (vitamin d3) oral drops 10mcg/drop (400unit/drop), 125 mcg/0.5ml (5k unit/0.5ml)2 cholecalciferol (vitamin d3) oral drops 10mcg/ml (400 unit/ml),125 mcg/ml (5,000unit/ml)1 cholecalciferol (vitamin d3) oral tablet 1,250mcg (50,000 unit), 10mcg (400 unit), 125 mcg(5,000 unit), 25 mcg(1,000 unit), 50 mcg(2,000 unit)1 COMPLETEMULTIVITAMIN-MINERAL ORALLIQUID2 COMPLETEMULTIVITAMIN-MINERAL ORALTABLET1 cyanocobalamin(vitamin b-12) injection1 cyanocobalamin(vitamin b-12) oral tablet1,000 mcg, 100 mcg,250 mcg, 500 mcg1 cyanocobalamin(vitamin b-12)sublingual tablet 1,000mcg, 2,500 mcg1 D3 PLUS K2 DOTS2 D3-20001 DAILY GUMMIES2 DAILY MULTIVITAMIN2Georgia Medicaid | Effective 01/01/202644 Drug NameTier Restrictions /LimitsDAILY MULTIVITAMINWITH IRON 1DAILY VITAMINFORMULA-IRON1DAILY VITAMIN WITHIRON1DAILY VITES/IRON1DECARA ORALCAPSULE 1,250 MCG(50,000 UNIT)1DECUBI VITE2DEKAS BARIATRIC2DEKAS PLUS (FOLICACID)2DELTA D31DEPLIN (ALGAL OIL)2DIALYVITE 800 ORALTABLET1DIALYVITE 800 ORALTABLET,CHEWABLE2DIALYVITE ORALTABLET 1-100-300-50MG-MG-MCG-MG1DIALYVITE VITAMIN D1D-VI-SOL1E-2001ELFOLATE1EMERGEN-C2EMERGEN-C IMMUNEPLUS ORAL POWDEREFFERVESCENT INPACKET2EMERGEN-C KIDZDRINK MIX2EMERGEN-C MSMLITE2ENDUR-ACIN1ENDUR-C WITH ROSEHIPS ORAL TABLETEXTENDED RELEASE1,000 MG1ENDUR-VM IRON-FREE2 Drug NameTier Restrictions /LimitsENDUR-VM WITHIRON 2 ergocalciferol (vitamin d2) oral capsule 1,250mcg (50,000 unit)1 ergocalciferol (vitamin d2) oral drops1 ESSENTIA1 FLINTSTONESCOMPLETE2 FLINTSTONESCOMPLETE (FE SULF)2 FLINTSTONESGUMMIES2 FLINTSTONES MULTI-VIT GUMMIES2 FLINTSTONESMULTIVITAMIN ORALTABLET,CHEWABLE300 MCG2 FLINTSTONES SOURGUMMIES2 FLINTSTONES TABCHEW2 FLINTSTONES WITHIRON2 FOLBEE PLUS1 folic acid oral tablet 400mcg, 800 mcg1 FOLTANX RF1 FORTAVIT2 FRUIT C-5001 FULL SPECTRUM B-VITAMIN C1 GUMMI BEARMULTIVITAMIN1 GUMMY DINOS2 HAIR-SKIN-NAILS (MV-FA-BIOTIN)2 HEALTHY EYESSUPERVISION1 HONEY BEARSMULTIVITAMIN1Georgia Medicaid | Effective 01/01/202645 Drug NameTier Restrictions /LimitsK2 PLUS D3 2KIDS' GUMMY2KOBEE1levomefolate calcium1levomefolate-algal oil1levomefol-b6-meb12-algal oil1LITTLE ANIMALS1lmefol ca-acetyl-meb12-algal2L-METHYLFOLATEFORTE1LYSIPLEX PLUS ORALLIQUID1MACULAR HEALTHFORMULA2MAXIMUM D32MEN'S DAILY2MEN'S DAILYGUMMIES2MEN'S MULTIVITAMINGUMMIES ORALTABLET,CHEWABLE200 MCG2MERIBIN2METAFOLBIC PLUS1METAFOLBIC PLUSRF1METANX (ALGAL OIL)2MULTI COMPLETEWITH IRON1MULTI FOR HER 50PLUS ORAL CAPSULE2MULTI FOR HER ORALCAPSULE2MULTI VITAMIN2multivitamin with iron1MULTI-VITE ORALLIQUID 9 MG IRON/15ML2multivit-min-folic acid-lutein2 Drug NameTier Restrictions /LimitsMVW COMPLETEFORMUL MULTIVIT 2 MVW COMPLETEFORMULATION D30002 MVW COMPLETEFORMULATION D50002 MYNEPHROCAPS1 MYNEPHRON1 MY-VITALIFE1 NANOVM T-F2 NEPHRO-VITE2 niacin (inositol niacinate) oral capsule500 mg1 niacin oral tablet 100mg, 250 mg, 50 mg1 niacin oral tablet extended release 1,000mg2 niacin oral tablet extended release 250mg, 500 mg1 niacinamide oral tablet500 mg1 NIVA-PLUS2 NOVAFERRUM YUMPEDIATR MV-IRON2 NOVAMV MMMPEDIATRIC MULTIVIT2 OCUVITE ADULT 50PLUS2 ONCOVITE2 ONE DAILYMULTIVITAMIN ORALTABLET 400 MCG2 ONE DAILYMULTIVITAMIN-IRON2 ONE DAILY MULTIVIT-IRON(FOLIC)1 ONE DAILY PLUSIRON1 ONE DAILY WOMENS50 PLUS1Georgia Medicaid | Effective 01/01/202646 Drug NameTier Restrictions /LimitsONE-A-DAYCHOLESTEROL PLUS 2ONE-A-DAY KID'S2ONE-A-DAY MENVITACRAVES2ONE-A-DAY TEENADVANTAGE ORALTABLET 18-400 MG-MCG1ONE-A-DAY TEENHER VITACRAVES2ONE-A-DAY TEEN HIMVITACRAVES2ONE-A-DAYVITACRAVES2ONE-A-DAYVITACRAVESIMMUNITY2ONE-A-DAY WOMENVITACRAVES2OPURITYMULTIVITAMIN2PEDIA TRI-VITE2phytonadione (vitamin k1) oral tablet 100 mcg2phytonadione (vitamin k1) oral tablet 5 mg1QL (15 EA per28 days)POLY-VI-SOL ORALDROPS 2POLY-VI-SOL WITHIRON2PRESERVISIONAREDS ORALCAPSULE2PREVENT2PRORENAL QD2PROTECT CARDIO AF2PROTECT PLUS SO2pyridoxine (vitamin b6)oral tablet 100 mg, 25mg, 50 mg1pyridoxine (vitamin b6)oral tablet 500 mg2 Drug NameTier Restrictions /LimitsQUINTABS 2 QUINTABS-M IRONFREE1 RENAL CAPS1 RENAL VITAMIN2 RENAL-VITE2 RENA-VITE1 RENO CAPS1 riboflavin (vitamin b2)oral tablet 100 mg, 50mg1 SCOOBY-DOO ONE ADAY2 SCOOBY-DOO ONE ADAY KIDS2 SENTRY1 SLO-NIACIN ORALTABLET EXTENDEDRELEASE 250 MG, 750MG2 SLO-NIACIN ORALTABLET EXTENDEDRELEASE 500 MG1 SPECTRAVITE ADULT50 PLUS(LUT)2 SPECTRAVITEADVANCED FORMULA1 STRAWBERRY C1 STRESS FORMULAWITH IRON(SULF)1 SUPER B/C1 SUPER QUINTS1 SUPER QUINTS B-501 SUPPORT1 SUPPORT-5002 TAB-A-VITEMULTIVITAMIN W-IRON ORAL TABLET15 MG IRON-400 MCG1 THERA1 THERA-D1Georgia Medicaid | Effective 01/01/202647 Drug NameTier Restrictions /LimitsTHERALOGIXCOMPANION 1THERA-TABS1thiamine hcl (vitamin b1) oral tablet1thiamine mononitrate(vit b1) oral tablet 100mg1TRIPHROCAPS1TRI-VI-SOL2TROPICAL LIQUIDNUTRITION2V-C FORTE1VIC-FORTE1VITABEX PLUS2VITALEE1vitamin a oral capsule3,000 mcg (10,000 unit)1vitamin a palmitate oral capsule2vitamin b complex oral capsule1vitamin b complex oral tablet1vitamin b complex-folic acid oral tablet1VITAMIN B-1(MONONITRATE)1VITAMIN B-1 ORALTABLET 100 MG, 50MG1VITAMIN B-12 ORALTABLET 1,000 MCG,100 MCG, 250 MCG,500 MCG1VITAMIN B-12SUBLINGUAL TABLET2,500 MCG1VITAMIN B-2 ORALTABLET 100 MG, 50MG1VITAMIN B-6 ORALTABLET 100 MG, 25MG, 50 MG1 Drug NameTier Restrictions /LimitsVITAMIN CFIZZYDRINK 2 VITAMIN CORALTABLET1 VITAMIN CORALTABLET EXTENDEDRELEASE 1,000 MG1 VITAMIN CORALTABLET,CHEWABLE250 MG, 500 MG1 VITAMIN CWITHROSE HIPS ORALTABLET1 VITAMIN CWITHROSE HIPS ORALTABLET EXTENDEDRELEASE 1,000 MG1 VITAMIN CWITHROSE HIPS ORALTABLET,CHEWABLE2 VITAMIN D21 VITAMIN D3 ORALCAPSULE1 VITAMIN D3 ORALTABLET1 vitamin e (dl, acetate)oral capsule1 vitamin e (dl, acetate)oral drops 22.5 mg (50unit)/ml1 vitamin e acetate1 vitamin e mixed oral capsule1 vitamin e oral capsule1 VITAMINS BCOMPLEX1 WOMENS DAILYGUMMIES2 WOMEN'SMULTIVITAMINGUMMIES ORALTABLET,CHEWABLE200 MCG2 YELETS1Georgia Medicaid | Effective 01/01/202648 Drug NameTier Restrictions /LimitsZOO FRIENDS 2Georgia Medicaid | Effective 01/01/202649 Medical BenefitDrug NameTierRestrictions / LimitsFERRLECIT 2icatibant1PAINFED 2NEULASTA2PA; QL (1.2 MLper 28 days)NEULASTA ONPRO 2PA; QL (1.2 MLper 28 days)VENOFER 2Georgia Medicaid | Effective 01/01/202650 Index50 PLUS ADULT EYE HEALTH.43A THRU ZADVANCED FORMULA ……………………………. 43abacavir ……………………………….. 13abacavir-lamivudine ……………….13ABILIFY MAINTENA ………………35abiraterone …………………………… 12ABRYSVO (PF) …………………….. 16acamprosate ………………………… 41acarbose ……………………………… 10ACE AEROSOL CLOUD ENHANCER …………………………. 32acetaminophen-codeine ……………3acetazolamide ………………………. 23acetic acid ……………………………. 24ACIDOPHILUS PROBIOTIC BLEND ………………………………… 27acidophilus-pectin, citrus …………27ACTEMRA ACTPEN ………………31ACTHIB (PF) ………………………… 16ACTICAL ……………………………… 24acyclovir ………………………………. 13ADACEL(TDAP ADOLESN/ADULT)(PF) ………….16adalimumab-adaz …………………..11adalimumab-adbm ………………….11adefovir ……………………………….. 13ADULT 50 PLUS PROBIOTIC …27ADULT MULTIVITAMIN GUMMIES ……………………………. 43ADULT ONE DAILY GUMMIES .43ADVANCED MULTI EA …………..43ADVANCED PROBIOTIC ………..27ADVANCED PROBIOTIC-14 …..27AEROCHAMBER MINI ……………32AEROCHAMBER MV ……………..32AEROCHAMBER PLUS FLOW-VU …………………………….. 32AEROCHAMBER PLUS FLOW-VU,L MSK …………………..32AEROCHAMBER PLUS FLOW-VU,M MSK ………………….32AEROCHAMBER PLUS FLOW-VU,S MSK …………………..32AEROCHAMBER PLUS ZSTAT …………………………………… 32AEROCHAMBER PLUS ZSTAT LG MSK ………………………. 32AEROCHAMBER PLUS ZSTAT MD MSK ……………………… 32AEROCHAMBER PLUS ZSTAT SM MSK ……………………… 32AEROCHAMBER Z-STAT PLUS-FLW SG……………………… 32AEROTRACH PLUS ………………32AEROVENT PLUS …………………32AFINITOR …………………………….. 12AFINITOR DISPERZ ………………12AFIRMELLE ………………………….21AIMOVIG AUTOINJECTOR ………3AIRBORNE (ASCORBATE SODIUM) ……………………………… 41AIRBORNE (WITH LYSINE ACETATE) ……………………………. 41ALA-CORT …………………………… 38albendazole ………………………….. 10albuterol sulfate ………………………. 5alclometasone ………………………. 38alendronate ………………………….. 41alfuzosin ………………………………. 41ALIGN (B.LONGUM) ………………27allopurinol ………………………………. 4almotriptan malate ……………………3alogliptin ………………………………. 10alogliptin-metformin ………………..10alogliptin-pioglitazone ……………..10alprazolam ……………………………. 35ALTAVERA (28) …………………….21ALYACEN 1/35 (28) ……………….21ALYACEN 7/7/7 (28) ………………21amantadine hcl ……………………… 13ambrisentan …………………………. 17AMETHIA …………………………….. 21AMETHYST (28) ……………………21amiloride ………………………………. 23amiloride-hydrochlorothiazide ….23amiodarone ………………………….. 17amitriptyline ………………………….. 35amitriptyline-chlordiazepoxide ….35amlodipine ……………………………. 17amlodipine-benazepril …………….17amlodipine-olmesartan ……………17amlodipine-valsartan ………………17amlodipine-valsartan-hcthiazid …17amoxapine ……………………………. 35amoxicil-clarithromy-lansopraz …27amoxicillin ………………………………. 6amoxicillin-pot clavulanate ………..6ampicillin ………………………………… 6anagrelide ……………………………. 13anastrozole …………………………… 12ANIMAL CHEWS ……………………43ANTIOXIDANT A/C/E/SELENIUM …………………..41APATATE FORTE ………………….43APRI……………………………………. 21 APTIVUS……………………………… 13AQUA CARE ………………………… 38ARANELLE (28) …………………….21AREXVY (PF) ……………………….. 16aripiprazole …………………………… 35ARISTADA ……………………… 35, 36ARISTADA INITIO ………………….35ARNUITY ELLIPTA ………………….5ascorbic acid (vitamin c) ………….43ascorbic acid-ascorbate sodium .43ASHLYNA ……………………………. 21atazanavir …………………………….. 13atenolol ………………………………… 17atenolol-chlorthalidone ……………17atomoxetine ………………………….. 36atorvastatin …………………………… 17atovaquone ………………………….. 10atovaquone-proguanil …………….11atropine ……………………………….. 24ATROVENT HFA ……………………..5AUBRA ………………………………… 21AUBRA EQ …………………………… 21AUROVELA 1.5/30 (21) ………….21AUROVELA 1/20 (21) …………….21AUROVELA 24 FE …………………21AUROVELA FE 1.5/30 (28) ……..21AUROVELA FE 1-20 (28) ………..21AURYXIA …………………………….. 24AUSTEDO ……………………………. 19AUSTEDO XR ………………………. 19AVAR ……………………………………. 6AVAR-E …………………………………. 6AVIANE ……………………………….. 21AVIDOXY ………………………………. 6AVITA ………………………………….. 38AVONEX ……………………………… 19AYUNA ………………………………… 21azathioprine ………………………….. 31azelastine ………………………………. 9azelastine-fluticasone ……………..24azithromycin …………………………… 6AZURETTE (28) …………………….21 BCOMPLEX 1 (WITH FOLIC ACID) ………………………………….. 43 BCOMPLEX PLUS VITAMIN C .43b complex-vitamin c-folic acid …. 43B-12 DOTS …………………………… 43BABY DDROPS …………………….43BABY VITAMIN D3 …………………43BABY'S SUPER DAILY D3 ……..43BACID WITH LACTOSPORE …..41bacitracin ……………………………….. 6Georgia Medicaid | Effective 01/01/202651bacitracin-polymyxin b………………6baclofen ……………………………….. 35BALANCE B-50 (WITH FOLIC ACID) ………………………………….. 43balsalazide …………………………… 27BALZIVA (28) ……………………….. 21BANZEL ………………………………. 19BAQSIMI ……………………………… 25BARACLUDE ……………………….. 13BARIATRIC MULTIVITAMINS …43BASE, PCCA SYRUP VEHICLE ……………………………… 41B-COMPLEX PLUS VIT C(CALCIUM) …………………………… 43b-complex with vitamin c …………43BD ECLIPSE LUER-LOK ………..32BD PRECISIONGLIDE ……………32BD SAFETYGLIDE ALLERGIST TRAY …………………32benazepril …………………………….. 17benazepril-hydrochlorothiazide ..17benzonatate …………………………. 23benztropine ………………………….. 13BESER ………………………………… 38betamethasone dipropionate ……38betamethasone valerate ………….38betamethasone, augmented ……38betaxolol ………………………………. 24bethanechol chloride ………………15bexarotene …………………………… 12BEXSERO ……………………………. 16bicalutamide …………………………. 12BICILLIN L-A ………………………….. 6BIKTARVY …………………………… 13BIMZELX ……………………………… 39BIMZELX AUTOINJECTOR …….39BIO-35, GLUTEN FREE ………….43BIOCAL ……………………………….. 25BIO-D-MULSION ……………………43BIO-K PLUS …………………………. 27biotin ……………………………………. 43bisoprolol fumarate …………………17bisoprolol-hydrochlorothiazide ….17BLISOVI 24 FE ……………………… 21BLISOVI FE 1.5/30 (28) ………….21BLISOVI FE 1/20 (28) …………….21BODY, HAIR, SKIN AND NAILS ………………………………….. 43BOOSTRIX TDAP ………………….16BREATHERITE MDI SPACER … 33BREATHERITE SPACER-MASK, NEO. ………………………… 33BREATHERITE SPACER-MASK,ADULT ………………………. 33BREATHERITE SPACER-MASK,CHILD……………………….. 33BREATHERITE SPACER-MASK,INFANT ……………………… 33BREATHERITE SPACER-MASK,S.CHLD ……………………… 33BREATHERITE VALVED MDI CHAMBER …………………………… 33BREATHERITE VALVED MDI SPACER ……………………………… 33BRIELLYN ……………………………. 21BRILINTA …………………………….. 13brimonidine …………………………… 24BROMFED DM ……………………… 23bromocriptine ………………………… 13brompheniramine-pseudoeph-dm ………………………………………. 23budesonide ……………………….. 5, 30bumetanide ………………………….. 23buprenorphine hcl ………………….41buprenorphine-naloxone …………41bupropion hcl ………………………… 36bupropion hcl (smoking deter) ….41buspirone …………………………….. 36butalbital-acetaminophen-caff ……3butalbital-aspirin-caffeine ………….3 CCOMPLEX ………………………… 43C-1000 ………………………………… 43C-1000 WITH ROSE HIPS ………43C-500 ………………………………….. 43cabergoline …………………………… 30CALCIDOL …………………………… 43calcipotriene …………………………. 39calcitonin (salmon) …………………30calcitriol ……………………………….. 43CALCIUM 500 ………………………. 25CALCIUM 500 + D …………………25CALCIUM 500 WITH D …………..25CALCIUM 600 ………………………. 25CALCIUM 600 + D(3) ……………..25CALCIUM 600 WITH VITAMIN D3 ……………………………………….. 25calcium acetate(phosphat bind) .25calcium carbonate ………………….25calcium carbonate-vit d3-min …..25calcium carbonate-vitamin d3 …..25calcium citrate ………………………. 25CALCIUM CITRATE + D …………25calcium citrate-vitamin d3 ………..25CALCIUM WITH VITAMIN D ……25CALTRATE WITH VITAMIN D3 .25CAMILA ……………………………….. 21CAMRESE ……………………………. 21CAMRESE LO ………………………. 21candesartan…………………………. 17candesartan-hydrochlorothiazid .17capecitabine …………………………. 12CAPRELSA ………………………….. 12captopril ……………………………….. 17captopril-hydrochlorothiazide …..17CAPVAXIVE …………………………. 16carbamazepine ……………………… 19CARBATROL ……………………….. 19carbidopa-levodopa ………………..13carbidopa-levodopa-entacapone ………………………….. 13CARDIZEM LA ……………………… 17carglumic acid ………………………. 41CARTIA XT …………………………… 17carvedilol ……………………………… 17CAYA CONTOURED ……………..21CAZIANT (28) ……………………….. 21cefadroxil ……………………………….. 6cefdinir …………………………………… 6cefprozil …………………………………. 6cefuroxime axetil ……………………..6celecoxib ……………………………….. 4CENTANY ……………………………… 6CENTRUM …………………………… 44CENTRUM COMPLETE ………….43CENTRUM KIDS (VIT D3, VIT K) ………………………………………… 43CENTRUM WOMEN ………………44CENTURY ……………………………. 44cephalexin ……………………………… 6CEREFOLIN NAC (ALGAL OIL) 44CEROVITE JR ………………………. 44CERTAVITE-ANTIOXIDANT ……44CHATEAL EQ (28) …………………21CHILD CHEWABLE VITAMN COMPLETE …………………………..44CHILD COMPLETE MULTIVITAMIN …………………….. 44CHILD MULTIVITAMIN PLUS IRON …………………………………… 44CHILDREN MULTIVITAMIN …….44CHILDREN'S CHEW MULTIVITAMIN …………………….. 44CHILDREN'S CHEW MULTIVIT-IRON …………………….44CHILDREN'S CHEWABLE MULTIVITMN ……………………….. 44CHILDREN'S CHEWABLE VITAMIN ………………………………. 44CHILDREN'S CHEWABLES ……44CHILDREN'S CHEWABLES EXTRA C ……………………………… 44Georgia Medicaid | Effective 01/01/202652CHILDREN'S MULTI-VIT GUMMIES……………………………. 44CHILDREN'S MULTIVITAMIN …44CHILD'S OMEGA-3 DHA MULTIVITAM ………………………… 44chlordiazepoxide hcl ……………….36chlordiazepoxide-clidinium ………27chlorhexidine gluconate …………..41chlorpromazine ……………………… 36chlorthalidone ……………………….. 23chlorzoxazone ………………………. 35cholecalciferol (vitamin d3) ………44cholestyramine (with sugar) …….17CHOLESTYRAMINE LIGHT ……17CICLODAN …………………………….. 9CICLODAN KIT ………………………. 9ciclopirox ……………………………….. 9cilostazol ……………………………… 13cimetidine …………………………….. 27cimetidine hcl ………………………… 27CIPRO …………………………………… 6ciprofloxacin …………………………… 6ciprofloxacin hcl ………………………. 6citalopram …………………………….. 36CITRACAL + DMAXIMUM ……..25CITRACAL REGULAR ……………25CITRACAL-D3 MAXIMUM PLUS …………………………………… 25CITRACAL-D3 PETITES …………25clarithromycin …………………………. 6clemastine ……………………………. 10CLEOCIN ………………………………. 6CLEVER CHOICE CHAMBER-LRG MASK …………………………… 33CLEVER CHOICE CHAMBER-MED MASK ………………………….. 33CLEVER CHOICE CHAMBER-SM MASK …………………………….. 33clindamycin hcl ……………………….. 6clindamycin palmitate hcl ………….6CLINDAMYCIN PEDIATRIC ……..6clindamycin phosphate ……………..6clobazam ……………………………… 19clobetasol …………………………….. 39clobetasol-emollient ………………..39CLODAN ……………………………… 39clomipramine ………………………… 36clonazepam ………………………….. 19clonidine ………………………………. 18clonidine hcl ……………………. 18, 36clopidogrel ……………………………. 13clorazepate dipotassium ………….36clotrimazole ……………………………. 9clotrimazole-betamethasone ……..9clozapine……………………………… 36COARTEM …………………………… 11colchicine ………………………………. 4colestipol ……………………………… 18COMBIPATCH ……………………… 30COMBIVENT RESPIMAT ………….5COMPACT SPACE CHAMBER .33COMPACT SPACE CHAMBER-LRG MASK …………..33COMPACT SPACE CHAMBER-MED MASK ………….33COMPACT SPACE CHAMBER-SM MASK …………….33COMPLERA …………………………. 13COMPLETE MULTIVITAMIN-MINERAL …………………………….. 44COMPLETENATE ………………….35CONSTULOSE ……………………… 27CORTIFOAM ………………………… 30cortisone ………………………………. 30COSENTYX ………………………….. 39COSENTYX (2 SYRINGES) …….39COSENTYX PEN …………………..39COSENTYX PEN (2 PENS) …….39COSENTYX UNOREADY PEN ..39COVARYX ……………………………. 30COVARYX H.S. …………………….. 30cpd vehicle susp.sugar-free 12 ..41CREON ……………………………….. 27CRINONE …………………………….. 30cromolyn ……………………….. 4, 5, 24CRYSELLE (28) …………………….21CULTURELLE KIDS GENTLE-GO ………………………………………. 27CULTURELLE KIDS PROBIOTICS ……………………….. 27CULTURELLE PRO-WELL 3-IN-1 …………………………………….. 27CUTTER BACKWOODS …………11CUTTER BACKWOODS DRY …11CUTTER SKINSATIONS …………11cyanocobalamin (vitamin b-12) ..44cyclobenzaprine …………………….35cyclopentolate ………………………. 24cyclophosphamide ………………….12cyclosporine …………………………. 31cyclosporine modified ……………..31cyproheptadine ……………………… 10CYRED …………………………………21CYRED EQ …………………………… 21D3 PLUS K2 DOTS ………………..44D3-2000 ………………………………. 44DAILY GUMMIES …………………..44DAILY MULTIVITAMIN ……………44DAILY MULTIVITAMIN WITH IRON…………………………………… 45DAILY PROBIOTIC ………………..27DAILY PROBIOTIC (10 STRAINS) ……………………………..27DAILY VITAMIN FORMULA-IRON …………………………………… 45DAILY VITAMIN WITH IRON …..45DAILY VITES/IRON ………………..45danazol ………………………………… 30dantrolene ……………………………. 35dapaglifloz propaned-metformin .10dapagliflozin propanediol …………10dapsone ………………………………… 6DAPTACEL (DTAP PEDIATRIC) (PF) …………………..16darunavir ……………………………… 13DASETTA 1/35 (28) ……………….21DASETTA 7/7/7 (28) ………………21DAYSEE ………………………………. 21DEBLITANE …………………………. 21DECARA ……………………………… 45DECUBI VITE ……………………….. 45deferasirox …………………………… 41DEKAS BARIATRIC ……………….45DEKAS PLUS (FOLIC ACID) …..45DELSTRIGO ………………………….13DELTA D3 ……………………………. 45DENTA 5000 PLUS ………………..25DEPLIN (ALGAL OIL) ……………..45DEPO-SUBQ PROVERA 104 ….21DESCOVY ……………………………. 13desipramine ………………………….. 36desmopressin ……………………….. 30desog-e.estradiol/e.estradiol ……21desonide ………………………………. 39desoximetasone …………………….39DEX4 GLUCOSE …………………..25DEX4 GLUCOSE POUCH PACK ………………………………….. 25DEX4 GLUCOSE QUICK DISSOLVE …………………………… 25dexamethasone …………………….. 30DEXAMETHASONE INTENSOL …………………………… 30dexamethasone sodium phosphate ……………………………. 24 DEXCOM G6 RECEIVER……….33DEXCOM G6 SENSOR …………..33DEXCOM G6 TRANSMITTER …33DEXCOM G7 15 DAY SENSOR ……………………………… 33DEXCOM G7 RECEIVER ……….33DEXCOM G7 SENSOR …………..33Georgia Medicaid | Effective 01/01/202653dexmethylphenidate……………….36DEXONTO ……………………………. 30DEXTENZA ………………………….. 24dextroamphetamine sulfate ……..15dextroamphetamine-amphetamine ……………………….. 15DEXYCU (PF) ………………………. 24DIALYVITE …………………………… 45DIALYVITE 800 …………………….. 45DIALYVITE VITAMIN D …………..45diazepam ………………………… 19, 36diclofenac potassium ………………..3diclofenac sodium ……………….4, 24diclofenac-misoprostol ………………4dicloxacillin …………………………….. 6dicyclomine …………………………… 27diflorasone ……………………………. 39diflunisal ………………………………… 3DIGESTIVE PROBIOTIC ………..27DIGITEK ………………………………. 17digoxin …………………………………. 17DILANTIN …………………………….. 19DILANTIN EXTENDED …………..19DILANTIN INFATABS …………….19DILANTIN-125 ………………………. 19diltiazem hcl …………………………..17DILT-XR ………………………………. 17dimethyl fumarate …………………..19diphenoxylate-atropine ……………27dipyridamole …………………………. 13disopyramide phosphate …………17disulfiram ……………………………… 41divalproex …………………………….. 19dofetilide ………………………………. 17donepezil ……………………………… 15dorzolamide ………………………….. 24dorzolamide (pf) …………………….24dorzolamide-timolol ………………..24DOTTI …………………………………. 30DOVATO ……………………………… 13doxazosin …………………………….. 18doxepin …………………………… 36, 38doxycycline hyclate …………….6, 41doxycycline monohydrate ………….7drospirenone-e.estradiol-lm.fa ….21drospirenone-ethinyl estradiol …. 21DRY EYE FORMULA ……………..41DRYSOL ……………………………… 39DRYSOL DAB-O-MATIC …………39DULERA ………………………………… 5duloxetine …………………………….. 36DUPIXENT PEN ……………….31, 32DUPIXENT SYRINGE …………….32D-VI-SOL ……………………………… 45E.E.S. 400……………………………… 7E-200 …………………………………… 45E-400 C-500 AND BETA CAROTENE …………………………. 41EASIVENT HOLDING CHAMBER …………………………… 33EASIVENT MASK LARGE ………33EASIVENT MASK MEDIUM …….33EASIVENT MASK SMALL ……….33EASYPOINT NEEDLE ……………33ECLIPSE NEEDLE …………………33ECLIPSE SYRINGE ……………….33ED-SPAZ ……………………………… 27EEMT ………………………………….. 30EEMT HS …………………………….. 30efavirenz ………………………………. 13efavirenz-emtricitabin-tenofov ….14efavirenz-lamivu-tenofov disop …14EFFER-K ……………………………… 25electrolytes-dextrose ………………25ELFOLATE …………………………… 45ELINEST ……………………………… 21ELIQUIS ………………………………… 8ELIQUIS DVT-PE TREAT 30D START ………………………………….. 8ELLA …………………………………… 21ELMIRON ………………………………. 3eltrombopag olamine ………………21ELURYNG ……………………………. 21EMERGEN-C ……………………….. 45EMERGEN-C IMMUNE PLUS …45EMERGEN-C KIDZ DRINK MIX .45EMERGEN-C MSM LITE ………..45EMGALITY PEN ……………………… 3EMGALITY SYRINGE …………3, 19EMPAVELI …………………………… 16emtricitabine …………………………. 14emtricitabine-tenofovir (tdf) ………14EMTRIVA …………………………….. 14enalapril maleate ……………………18enalapril-hydrochlorothiazide …..18ENBREL ………………………………. 12ENBREL MINI ………………………. 12ENBREL SURECLICK ……………12ENDOCET ……………………………… 3ENDUR-ACIN ……………………….. 45ENDUR-C WITH ROSE HIPS ….45ENDUR-VM IRON-FREE ………..45ENDUR-VM WITH IRON …………45ENFAMIL ENFALYTE …………….25ENGERIX-B (PF) ……………………16ENGERIX-B PEDIATRIC (PF) …16enoxaparin …………………………….. 8ENPRESSE ………………………….. 21ENSKYCE……………………………. 21ENSPRYNG …………………………. 32entacapone ………………………….. 13entecavir ………………………………. 14ENTRESTO ………………………….. 18ENULOSE ……………………………. 27EPANED ……………………………… 18epinephrine …………………….. 15, 16ergocalciferol (vitamin d2) ……….45ergotamine-caffeine ………………….3ERIVEDGE …………………………… 12erlotinib ………………………………… 12ERRIN …………………………………. 21ERY PADS …………………………….. 7ERY-TAB ……………………………….. 7ERYTHROCIN (AS STEARATE) …………………………… 7erythromycin …………………………… 7erythromycin ethylsuccinate ………7erythromycin with ethanol ………….7escitalopram oxalate ………………36esomeprazole magnesium ………27ESSENTIA …………………………… 45ESTARYLLA ………………………… 21estazolam …………………………….. 38estradiol ……………………………….. 30estradiol-norethindrone acet …….30estrogens-methyltestosterone ….30ethambutol …………………………….. 7ethosuximide ………………………… 19ethynodiol diac-eth estradiol …….21 etodolac…………………………………. 4etonogestrel-ethinyl estradiol …..21etoposide ……………………………… 12etravirine ……………………………… 14EUTHYROX …………………………. 41everolimus (antineoplastic) ………12everolimus (immunosuppressive) ……………..32EVOTAZ ………………………………. 14EVRYSDI …………………………….. 41exemestane ………………………….. 12ezetimibe ……………………………… 18FALMINA (28) ………………………. 21famotidine …………………………….. 27FARXIGA …………………………….. 10felbamate …………………………….. 19felodipine ……………………………… 17FEMCAP ……………………………… 21fenofibrate ……………………………. 18fenofibrate micronized …………….18fenofibrate nanocrystallized ……..18fentanyl ………………………………….. 3FEOSOL ………………………………. 25Georgia Medicaid | Effective 01/01/202654FERATE………………………………. 25FER-IN-SOL …………………………. 25FEROSUL ……………………………. 25FERREX 150 ………………………… 25FERRIC X-150 ……………………… 25FERRLECIT …………………………. 50FERROCITE …………………………. 25FERRO-TIME ……………………….. 25ferrous fumarate …………………….25ferrous gluconate …………………..26ferrous sulfate ………………………. 26fidaxomicin …………………………….. 7finasteride …………………………….. 41fingolimod …………………………….. 19FIRVANQ ………………………………. 7FISH OIL ……………………………… 28FLAVOR BLEND 2 IN 1 ………….41FLAVOR PLUS ………………………41FLAVOR SWEET …………………..41FLAVOR SWEET-SF ……………..41flavoxate ………………………………. 41flecainide ……………………………… 17FLEXICHAMBER …………………..33FLEXICHAMBER-LG CHILD MASK ………………………………….. 33FLEXICHAMBER-SM ADULT MASK ………………………………….. 33FLEXICHAMBER-SM CHILD MASK ………………………………….. 33FLINTSTONES COMPLETE ……45FLINTSTONES COMPLETE (FE SULF) ……………………………. 45FLINTSTONES GUMMIES ……..45FLINTSTONES MULTI-VIT GUMMIES ……………………………. 45FLINTSTONES MULTIVITAMIN …………………….. 45FLINTSTONES SOUR GUMMIES ……………………………. 45FLINTSTONES TAB CHEW …….45FLINTSTONES WITH IRON ……45FLORAJEN DIGESTION …………28FLORAJEN KIDS …………………..28FLORASTOR ……………………….. 28FLORASTORKIDS …………………28fluconazole …………………………….. 9fludrocortisone ………………………. 30fluocinolone ………………………….. 39fluocinolone and shower cap ……39fluocinonide ………………………….. 39FLUOCINONIDE-E …………………39fluocinonide-emollient …………….. 39fluoride (sodium) …………………….26fluorometholone …………………….24fluorouracil……………………………. 12fluoxetine ……………………………… 36fluphenazine decanoate ………….36fluphenazine hcl …………………….36flurbiprofen …………………………….. 4fluticasone propionate …………5, 39fluticasone propion-salmeterol .5, 6fluvoxamine ………………………….. 36FOLBEE PLUS ……………………… 45folic acid ………………………………. 45FOLTANX RF ……………………….. 45FORTAVIT ……………………………. 45fosamprenavir ……………………….. 14fosinopril ………………………………. 18fosinopril-hydrochlorothiazide …..18FREESTYLE LIBRE 14 DAY READER ……………………………… 33FREESTYLE LIBRE 14 DAY SENSOR ……………………………… 33FREESTYLE LIBRE 2 PLUS SENSOR ……………………………… 33FREESTYLE LIBRE 2 READER ……………………………… 34FREESTYLE LIBRE 2 SENSOR ……………………………… 34FREESTYLE LIBRE 3 PLUS SENSOR ……………………………… 34FREESTYLE LIBRE 3 READER ……………………………… 34FREESTYLE LIBRE 3 SENSOR ……………………………… 34FRUIT C-500 ………………………… 45FULL SPECTRUM B-VITAMIN C …………………………………………. 45furosemide …………………………… 24FYAVOLV …………………………….. 30gabapentin ……………………… 19, 20galantamine ………………………….. 16GARDASIL 9 (PF) ………………….16GAVILYTE-C ………………………… 28GAVILYTE-G ………………………… 28GAVILYTE-N ………………………… 28gemfibrozil ……………………………. 18GENERLAC ………………………….. 28GENGRAF ……………………………. 32gentamicin ……………………………… 7GENVOYA …………………………… 14GILENYA ……………………………… 20GILOTRIF …………………………….. 12glatiramer …………………………….. 20GLATOPA ……………………………. 20glimepiride …………………………….10glipizide ……………………………….. 10glipizide-metformin …………………10GLUCAGON (HCL) EMERGENCY KIT………………….26GLUCAGON EMERGENCY KIT (HUMAN) ……………………….. 26glucose ………………………………… 26glyburide ………………………………. 10glyburide micronized ………………10glyburide-metformin ………………..10glycopyrrolate ……………………….. 28GORMEL ……………………………… 39GORMEL TEN ………………………. 39granisetron hcl ………………………. 28griseofulvin microsize ……………….9griseofulvin ultramicrosize …………9guanfacine ………………………. 18, 36GUMMI BEAR MULTIVITAMIN ..45GUMMY DINOS …………………….45HADLIMA …………………………….. 12HADLIMA PUSHTOUCH …………12HADLIMA(CF) ………………………. 12HADLIMA(CF) PUSHTOUCH ….12HAEGARDA …………………………. 41HAILEY 24 FE ………………………. 21HAILEY FE 1.5/30 (28) ……………21HAILEY FE 1/20 (28) ………………21HAIR-SKIN-NAIL(VIT A,C-BIOTIN) ……………………………….. 41HAIR-SKIN-NAILS (MV-FA-BIOTIN) ……………………………….. 45haloperidol ……………………………. 36haloperidol decanoate …………….36haloperidol lactate ………………….36HAVRIX (PF) ………………………… 16HEALTHY EYES SUPERVISION ……………………… 45HEATHER ……………………………. 22heparin (porcine) ……………………..8heparin, porcine (pf) …………………8HEPLISAV-B (PF) ………………….16HIBERIX (PF) ……………………….. 16HOMATROPAIRE ………………….24HONEY BEARS MULTIVITAMIN …………………….. 45HUMULIN RU-500 (CONC) KWIKPEN …………………………….. 10hydralazine …………………………… 18hydrochlorothiazide ………………..24hydrocodone-acetaminophen …….3hydrocodone-homatropine ………23 hydrocodone-ibuprofen…………….3hydrocortisone ………………….30, 40hydrocortisone butyrate ……..39, 40hydrocortisone valerate …………..40hydrocortisone-acetic acid ……….24Georgia Medicaid | Effective 01/01/202655HYDROMET…………………………. 23hydromorphone ………………………. 3hydroxychloroquine ………………..11hydroxyurea …………………………. 12hydroxyzine hcl ………………………10hydroxyzine pamoate ……………..10HYFTOR ……………………………….32hyoscyamine sulfate ……………….28ibandronate ………………………….. 41IBRANCE …………………………….. 12IBU ……………………………………….. 4ibuprofen ……………………………….. 4icatibant ……………………………….. 50IFEREX 150 …………………………. 26imatinib ………………………………… 12IMBRUVICA …………………………. 12imipramine hcl ………………………. 36imipramine pamoate ……………….36imiquimod …………………………….. 40IMMUNE SUPPORT ………………41INCASSIA ……………………………. 22INCRELEX …………………………… 30indapamide …………………………… 24INFANRIX (DTAP) (PF) …………..16INFED …………………………………. 50INLYTA ………………………………… 12INSECT REPELLENT (DEET) …11INSECT REPELLENT (PICARIDIN) …………………………. 11insulin glargine-yfgn ……………….10insulin lispro …………………………..10insulin syringe-needle u-100 ……34INSUPEN PEN NEEDLE …………34INTEGRA SYRINGE ………………34INVEGA HAFYERA ………………..36INVEGA SUSTENNA ……………..36INVEGA TRINZA ………………36, 37IPOL ……………………………………. 16ipratropium bromide ……………6, 24ipratropium-albuterol ………………..6irbesartan …………………………….. 18irbesartan-hydrochlorothiazide …18IRON …………………………………… 26IRON (FERROUS SULFATE) ….26ISENTRESS …………………………. 14ISIBLOOM ……………………………. 22isoniazid ………………………………… 7ISOPTO ATROPINE ………………24isosorbide dinitrate …………………17isosorbide mononitrate ……………17ivermectin …………………………….. 11JAKAFI ………………………………… 12JANTOVEN ……………………………. 8JASMIEL (28) ……………………….. 22JENCYCLA…………………………… 22JINTELI ……………………………….. 30JOLESSA …………………………….. 22JULEBER …………………………….. 22JULUCA ………………………………. 14JUNEL 1.5/30 (21) ………………….22JUNEL 1/20 (21) …………………….22JUNEL FE 1.5/30 (28) …………….22JUNEL FE 1/20 (28) ……………….22JUNEL FE 24 ……………………….. 22JYNARQUE ………………………….. 24JYNNEOS (PF) …………………….. 16K2 PLUS D3 …………………………. 46KAITLIB FE ………………………….. 22KALETRA …………………………….. 14KALYDECO ………………………….. 41KARIVA (28) …………………………. 22KELNOR 1/35 (28) …………………22ketoconazole ………………………….. 9ketoprofen ……………………………… 4ketorolac …………………………… 3, 24KIDS' GUMMY ……………………… 46KINRIX (PF) …………………………. 16KIONEX (WITH SORBITOL) ……26KLOR-CON 10 ……………………… 26KLOR-CON 8 ……………………….. 26KLOR-CON M10 ……………………26KLOR-CON M15 ……………………26KLOR-CON M20 ……………………26KLOXXADO …………………………… 9KOBEE ………………………………… 46KOSHER PRENATAL PLUS IRON …………………………………… 35KPN …………………………………….. 35KURVELO (28) ……………………… 22l norgest/e.estradiol-e.estrad ……22l.acidoph,saliva-b.bif-s.therm ……28l.acidophilus-bifido.longum ………28labetalol ……………………………….. 18lacosamide …………………………… 20lactobac acidoph-fructooligos …..28LACTO-PECTIN …………………….28lactulose ………………………………. 28LAGEVRIO (EUA) ………………….14lamivudine ……………………………. 14lamivudine-zidovudine …………….14lamotrigine ……………………………. 20LANOXIN …………………………….. 17lapatinib ……………………………….. 12LARIN 1.5/30 (21) ………………….22LARIN 1/20 (21) …………………….22LARIN 24 FE ………………………… 22LARIN FE 1.5/30 (28) ……………..22LARIN FE 1/20 (28) ………………..22latanoprost…………………………… 24leflunomide …………………………….. 5LENVIMA …………………………….. 12LESSINA ……………………………… 22letrozole ……………………………….. 12leucovorin calcium ………………….41LEUKERAN ………………………….. 12levalbuterol tartrate …………………..6levetiracetam ………………………… 20levobunolol …………………………… 24levocetirizine ………………………….10levofloxacin ……………………………. 7levomefolate calcium ………………46levomefolate-algal oil ………………46levomefol-b6-meb12-algal oil …..46LEVONEST (28) …………………….22levonorgestrel-ethinyl estrad ……22levonorg-eth estrad triphasic ……22LEVORA-28 …………………………. 22levothyroxine ………………………… 41LEVOXYL …………………………….. 41L-GLUTAMINE ……………………… 26lidocaine hcl …………………………… 4LIDOCAINE VISCOUS ……………..4lidocaine-prilocaine …………………..4linezolid …………………………………. 7liothyronine …………………………… 41LIQUID CALCIUM WITH VITAMIN D …………………………… 26 lisinopril……………………………….. 18lisinopril-hydrochlorothiazide ……18LITEAIRE MDI CHAMBER ………34lithium carbonate ……………………37lithium citrate ………………………… 37LITHOBID …………………………….. 37LITTLE ANIMALS …………………..46lmefol ca-acetyl-meb12-algal …..46L-METHYLFOLATE FORTE ……46loperamide …………………………… 28lopinavir-ritonavir ……………………14lorazepam ……………………………. 37LORYNA (28) ……………………….. 22losartan ……………………………….. 18losartan-hydrochlorothiazide ……18lovastatin ……………………………… 18LOW-OGESTREL (28) ……………22loxapine succinate ………………….37LO-ZUMANDIMINE (28) ………….22lubiprostone ………………………….. 28LUTERA (28) ………………………… 22LYSIPLEX PLUS ……………………46LYSODREN …………………………..12LYZA …………………………………… 22Georgia Medicaid | Effective 01/01/202656MACULAR HEALTH FORMULA……………………………. 46MAGELLAN INSULIN SAFETY SYRNG ……………………………….. 34MAGELLAN SYRINGE ……………34magnesium oxide …………………..26MAGOX ……………………………….. 26malathion ……………………………… 13maraviroc ………………………………14MARLISSA (28) …………………….. 22MATULANE ………………………….. 12MATZIM LA ………………………….. 17MAXIMUM D3 ………………………. 46medroxyprogesterone ……….22, 30mefloquine ……………………………. 11MEGA PROBIOTIC ………………..28megestrol ……………………….. 12, 42MEKINIST ……………………………. 12melatonin ………………………… 30, 31melatonin-pyridoxine hcl (b6) …..31meloxicam ……………………………… 5memantine …………………………… 20MEN'S DAILY ……………………….. 46MEN'S DAILY GUMMIES ………..46MEN'S MULTIVITAMIN GUMMIES ……………………………. 46MENVEO A-C-Y-W-135-DIP (PF) …………………………………….. 16mercaptopurine …………………….. 12MERIBIN ……………………………… 46mesalamine ………………………….. 28METAFOLBIC PLUS ………………46METAFOLBIC PLUS RF …………46METANX (ALGAL OIL) ……………46metformin …………………………….. 10methadone …………………………….. 3METHADONE INTENSOL ………..3methazolamide ……………………… 24methen-sod phos-meth blue-hyos ………………………………………. 7methimazole …………………………. 41methocarbamol ………………………35methotrexate sodium ………………12methsuximide ……………………….. 20methyldopa …………………………… 18methylergonovine …………………..31methylphenidate hcl ……………….37methylprednisolone ………………..31metoclopramide hcl ………………..28metolazone …………………………… 24metoprolol succinate ………………18metoprolol ta-hydrochlorothiaz …18metoprolol tartrate ………………….18metronidazole ……………………. 7, 40metyrosine……………………………. 18MGO ……………………………………. 26MICROCHAMBER …………………34MICROGESTIN 1.5/30 (21) ……..22MICROGESTIN 1/20 (21) ………..22MICROGESTIN FE 1.5/30 (28) ..22MICROGESTIN FE 1/20 (28) …..22MICROSPACER …………………….34midazolam ……………………………… 4midazolam (pf) ………………………… 4midodrine …………………………….. 16MIGERGOT ……………………………. 3miglitol …………………………………. 10MILI …………………………………….. 22MIMVEY ………………………………. 31MINI WRIGHT PEAK FLOW METER ………………………………… 34minocycline ……………………………..7minoxidil ………………………………. 18mirtazapine …………………………… 37misoprostol …………………………… 28M-M-R II (PF) ……………………….. 16M-NATAL PLUS …………………….35mometasone ………………………… 40MONDOXYNE NL ……………………7MONOJECT INSULIN SAFETY SYRING ………………………………. 34MONOJECT MAGELLAN SAFETY SYRNG ……………………34MONOJECT SAFETY SYRINGES …………………………… 34MONOJECT SYRINGE …………..34MONO-LINYAH …………………….. 22montelukast ……………………………. 6MOOD SUPPORT PROBIOTIC .28MORGIDOX …………………………… 7morphine ……………………………. 3, 4morphine concentrate ……………….3moxifloxacin ……………………………. 7MRESVIA (PF) ……………………… 16MULTI COMPLETE WITH IRON …………………………………… 46MULTI FOR HER …………………..46MULTI FOR HER 50 PLUS ……..46MULTI VITAMIN …………………….46multivitamin with iron ………………46MULTI-VITE …………………………. 46multivit-min-folic acid-lutein ……..46mupirocin ……………………………….. 7MVW COMPLETE FORMUL MULTIVIT …………………………….. 46MVW COMPLETE FORMULATION D3000 …………..46MVW COMPLETE FORMULATION D5000…………..46MX-SOL ………………………………. 42MX-SOL BLEND …………………….42MX-SOL BLEND SF ……………….42MX-SOL SUSPEND ……………….42mycophenolate mofetil ……………32mycophenolate sodium …………..32MYFERON 150 …………………….. 26MYLERAN ……………………………. 12MYNEPHROCAPS …………………46MYNEPHRON ………………………. 46MY-VITALIFE ……………………….. 46nabumetone …………………………… 5nadolol …………………………………. 18nalmefene ……………………………… 9naloxone ………………………………… 9naltrexone ……………………………… 9NANOVM T-F ……………………….. 46naproxen ……………………………….. 5naproxen sodium ……………………..5naproxen-esomeprazole ……………5naratriptan ……………………………… 4NATACYN ……………………………… 9nateglinide ……………………………. 10NEBUSAL ……………………………. 42NECON 0.5/35 (28) ………………..22nefazodone ………………………….. 37neomycin ……………………………….. 7neomycin-bacitracin-poly-hc ………7neomycin-bacitracin-polymyxin ….7neomycin-polymyxin b-dexameth ………………………………. 7neomycin-polymyxin-gramicidin …7neomycin-polymyxin-hc …………….7NEO-POLYCIN ……………………….. 7NEO-POLYCIN HC ………………….7NEORAL ……………………………… 32NEPHRO-VITE ……………………… 46NEULASTA ………………………….. 50NEULASTA ONPRO ………………50 nevirapine…………………………….. 14niacin …………………………………… 46niacin (inositol niacinate) …………46niacinamide ………………………….. 46nifedipine ……………………………… 17NIKKI (28) ……………………………. 22NITRO-DUR …………………………. 17nitrofurantoin ………………………….. 7nitrofurantoin macrocrystal ………..7nitrofurantoin monohyd/m-cryst ….7nitroglycerin ………………………….. 17NITRO-TIME ………………………… 17NIVA-PLUS ………………………….. 46Georgia Medicaid | Effective 01/01/202657nizatidine……………………………… 28NOCDURNA (MEN) ……………….31NOCDURNA (WOMEN) ………….31NORA-BE …………………………….. 22noreth-ethinyl estradiol-iron ……..22norethindrone (contraceptive) ….22norethindrone acetate …………….31norethindrone ac-eth estradiol………………………………………. 22, 31norethindrone-e.estradiol-iron ….22norgestimate-ethinyl estradiol ….22NORPACE CR ……………………… 17NORTREL 0.5/35 (28) …………….22NORTREL 1/35 (21) ……………….22NORTREL 1/35 (28) ……………….22NORTREL 7/7/7 (28) ………………22nortriptyline …………………………… 37NORVIR ………………………………. 14NOVAFERRUM YUM PEDIATR MV-IRON ……………….46NOVAMV MMM PEDIATRIC MULTIVIT …………………………….. 46NP THYROID ……………………….. 41NU-IRON ……………………………… 26NULEV ………………………………… 28NYAMYC ……………………………….. 9nystatin ………………………………….. 9NYSTOP ……………………………….. 9OCELLA ………………………………. 22OCUVITE ADULT 50 PLUS …….46OCUVITE LUTEIN AND ZEAXANTHIN ……………………….. 42ODEFSEY ……………………………. 14OFEV ………………………………….. 42OFF ACTIVE ………………………… 11OFF DEEP WOODS ………………11OFF DEEP WOODS DRY ……….11OFF DEEP WOODS SPORTSMEN ……………………….. 11OFF FAMILYCARE (WITH DEET) …………………………………. 11OFF FAMILYCARE(WITH PICARIDIN) ………………………….. 11ofloxacin …………………………….. 7, 8olanzapine ……………………………. 37olmesartan …………………………… 18olmesartan-amlodipin-hcthiazid ..18olmesartan-hydrochlorothiazide .18omega 3-dha-epa-fish oil …………28omega-3 acid ethyl esters ……….28omega-3 fatty acids ………………..28omega-3 fatty acids-fish oil ……… 28OMEGA-3 FISH OIL ……………….42omega-3s-dha-epa-fish oil ……….29omeprazole………………………….. 29OMNITROPE ………………………… 31ONCOVITE …………………………… 46ondansetron …………………………. 29ondansetron hcl …………………….. 29ONE A DAY WOMEN'S PRENATAL DHA ……………………35ONE DAILY MULTIVITAMIN ……46ONE DAILY MULTIVITAMIN-IRON …………………………………… 46ONE DAILY MULTIVIT-IRON(FOLIC) ……………………….. 46ONE DAILY PLUS IRON …………46ONE DAILY WOMENS 50 PLUS …………………………………… 46ONE-A-DAY CHOLESTEROL PLUS …………………………………… 47ONE-A-DAY KID'S …………………47ONE-A-DAY MEN VITACRAVES ……………………….. 47ONE-A-DAY TEEN ADVANTAGE ……………………….. 47ONE-A-DAY TEEN HER VITACRAVES ……………………….. 47ONE-A-DAY TEEN HIM VITACRAVES ……………………….. 47ONE-A-DAY VITACRAVES ……..47ONE-A-DAY VITACRAVES IMMUNITY ……………………………. 47ONE-A-DAY WOMEN VITACRAVES ……………………….. 47ONEVITE CALCIUM-D3 ………….26OPTICHAMBER ADULT MASK-LARGE ………………………. 34OPTICHAMBER DIAMOND LG MASK ………………………………….. 34OPTICHAMBER DIAMOND VHC …………………………………….. 34OPTICHAMBER DIAMOND-MED MSK …………………………….. 34OPTICHAMBER DIAMOND-SML MASK …………………………… 34OPURITY MULTIVITAMIN ………47OPVEE ………………………………….. 9ORA-BLEND ………………………… 42ORA-BLEND SF …………………….42ORAL MIX ……………………………. 42ORAL MIX SF ……………………….. 42ORAL SUSPEND …………………..42ORAL SYRUP ………………………. 42ORAL SYRUP SF …………………..42ORALONE ……………………………. 42ORALYTE ……………………………. 26ORA-PLUS …………………………… 42ORA-SWEET………………………… 42ORA-SWEET SF ……………………42ORIAHNN …………………………….. 31ORILISSA …………………………….. 31ORKAMBI ……………………………..42orphenadrine citrate ……………….35OSCIMIN ……………………………… 29OSCIMIN SL ………………………….29oseltamivir ……………………………. 14OTEZLA ………………………………… 5OTEZLA STARTER ………………….5OVEGA-3 …………………………….. 29oxaprozin ……………………………….. 5oxazepam …………………………….. 37oxcarbazepine ………………………. 20OXTELLAR XR ………………………20oxybutynin chloride …………………42oxycodone ……………………………… 4oxycodone-acetaminophen ……….4OYSCO 500/D ………………………. 26OYSTER SHELL + D3 ……………26OYSTER SHELL CALCIUM …….26OYSTER SHELL CALCIUM 500 ……………………………………… 26OYSTER SHELL CALCIUM-VIT D3 …………………………………. 26OZEMPIC …………………………….. 10PACERONE …………………………. 17paliperidone ………………………….. 37PANCREAZE ……………………….. 29pantoprazole ………………………… 29PAROEX ORAL RINSE …………..42paroxetine hcl ……………………….. 37PAXLOVID …………………………… 14pazopanib …………………………….. 12PCCA-PLUS BASE ………………..42PEDIA IRON ………………………….26PEDIA TRI-VITE …………………….47PEDIALYTE …………………………. 26PEDIALYTE ADVANCED CARE ………………………………….. 26PEDIALYTE FREEZER POPS …26PEDIALYTE SINGLES ……………26PEDIARIX (PF) ……………………… 16PEDIATRIC ELECTROLYTE …..26PEDVAX HIB (PF) ………………….16peg 3350-electrolytes ……………..29peg3350-sod sul-nacl-kcl-asb-c .29PEGASYS ………………………. 14, 15peg-electrolyte soln ………………..29PEN NEEDLE ……………………….. 34PENBRAYA (PF) ……………………16 penciclovir……………………………. 15penicillamine …………………………… 5Georgia Medicaid | Effective 01/01/202658penicillin v potassium……………….8PENTACEL (PF) ……………………16PENTACEL ACTHIB COMPONENT (PF) ………………..16pentoxifylline ………………………… 16PEPCID ……………………………….. 29perampanel ………………………….. 20PERIOGARD ………………………… 42permethrin ……………………………. 13perphenazine ……………………….. 37perphenazine-amitriptyline ………37PERTZYE …………………………….. 29phenazopyridine ……………………… 4phenobarbital ……………………….. 38phenoxybenzamine ………………..16PHENYTEK ………………………….. 20phenytoin ……………………………… 20phenytoin sodium extended …….20PHILITH ………………………………. 22PHILLIPS' COLON HEALTH ……29PHOSPHA 250 NEUTRAL ………26PHOSPHO-TRIN 250 NEUTRAL …………………………….. 26phytonadione (vitamin k1) ……….47PIFELTRO ……………………………. 15pilocarpine hcl ………………….16, 24pimecrolimus ………………………… 32pimozide ………………………………. 37PIMTREA (28) ………………………. 22pioglitazone ………………………….. 10pioglitazone-metformin ……………10PLEXION ……………………………….. 8PNEUMOVAX-23 …………………..16pnv no.95-ferrous fumarate-fa ….35POCKET CHAMBER ………………34podofilox ………………………………. 40POLYCIN ………………………………. 8POLY-IRON …………………………..26polymyxin b sulf-trimethoprim …….8polysaccharide iron complex ……26POLY-VI-SOL ……………………….. 47POLY-VI-SOL WITH IRON ………47PORTIA 28 …………………………… 22posaconazole …………………………. 9potassium chloride …………………27potassium citrate ……………………27potassium iodide …………………… 27PRADAXA ……………………………… 9pramipexole ………………………….. 13PRAMOSONE ………………………. 40prasugrel hcl …………………………. 13pravastatin ……………………………. 18praziquantel ………………………….. 11prazosin ……………………………….. 18prednicarbate……………………….. 40prednisolone …………………………. 31prednisolone acetate ………………24prednisolone acetate (pf) …………24prednisolone sodium phosphate………………………………………. 24, 31prednisone …………………………… 31PREDNISONE INTENSOL ………31pregabalin ……………………………. 20PRENATABS FA ……………………35PRENATABS RX ……………………35PRENATAL ………………………….. 35PRENATAL 19 ……………………… 35PRENATAL MULTI …………………35PRENATAL MULTIVITAMINS ….35PRENATAL ONE DAILY …………35PRENATAL PLUS ………………….35PRENATAL PLUS (CALCIUM CARB) …………………………………. 35PRENATAL TABLET ………………35prenatal vit no.179-iron-folic …….35PRENATAL VITAMIN ……………..35PRENATAL VITAMIN PLUS LOW IRON …………………………… 35PRENATAL VITAMIN WITH MINERALS …………………………… 35prenatal vit-iron fum-folic ac …….35PREORBOTIC ………………………. 29PRESERVISION AREDS ………..47PRESTALIA …………………………. 18PREVALITE …………………………. 18PREVENT ……………………………. 47PREZCOBIX …………………………. 15PREZISTA ……………………………. 15primidone …………………………….. 20probenecid …………………………….. 5PROBIOTIC ………………………….. 29PROBIOTIC (B. COAGULANS) .42PROBIOTIC 4X …………………….. 29PROBIOTIC ACIDOPHILUS-PECTIN ……………………………….. 29PROBIOTIC BLEND ……………….29PROBIOTIC COLON SUPPORT …………………………….29PROBIOTIC DIGESTIVE SYSTEM SUP ………………………. 29PROBIOTIC PEARLS …………….29PROBIOTIC PEARLS ACIDOPHILUS ……………………… 29PROBIOTIC PEARLS COMPLETE ………………………….. 29PROCARE SPACER WITH ADULT MASK ………………………. 34PROCARE SPACER WITH CHILD MASK……………………….. 34PROCHAMBER ……………………..34prochlorperazine maleate ………..29PROCTO-MED HC …………………40PROCTOSOL HC …………………..40PROCTOZONE-HC ………………..40progesterone micronized …………31promethazine ………………….. 10, 29PROMETHAZINE VC ……………….9promethazine-codeine …………….23promethazine-dm …………………..23promethazine-phenylephrine ……..9PROMETHEGAN …………………..29propafenone …………………………. 17propranolol …………………………… 18propylthiouracil ……………………… 41PROQUAD (PF) …………………….16PRORENAL QD …………………….47PROTECT CARDIO AF …………..47PROTECT PLUS SO ………………47PROVAD ……………………………… 29PROVELLA ………………………….. 29PROXEED PLUS …………………..42PULMOSAL ………………………….. 42PULMOZYME ……………………….. 42pyrazinamide ………………………….. 8pyridostigmine bromide …………..16pyridoxine (vitamin b6) ……………47pyrimethamine ………………………. 11PYRUKYND …………………………. 16QUADRACEL (PF) …………………16quetiapine …………………………….. 37quinapril ……………………………….. 18quinapril-hydrochlorothiazide …..18QUINTABS …………………………… 47QUINTABS-M IRON FREE ……..47QVAR REDIHALER ………………….6raloxifene ……………………………… 42ramipril ………………………………….18 RANGER READY REPELLENT.11ranolazine …………………………….. 17REBIF (WITH ALBUMIN) ………..20REBIF REBIDOSE …………………20REBIF TITRATION PACK ……….20RECLIPSEN (28) ……………………22RECOMBIVAX HB (PF) ………….16RELEXXII …………………………….. 38RENAL CAPS ……………………….. 47RENAL VITAMIN ……………………47RENAL-VITE ………………………… 47RENA-VITE ………………………….. 47RENO CAPS ………………………… 47repaglinide ……………………………. 10Georgia Medicaid | Effective 01/01/202659REPATHA PUSHTRONEX……..18REPATHA SURECLICK ………….18REPATHA SYRINGE ……………..18REPEL 100 ………………………….. 11REPEL FAMILY ……………………..11REPEL HUNTER'S ………………..11REPEL SPORTSMEN …………….11REPEL SPORTSMEN DRY …….11REPEL SPORTSMEN MAX …….11RESTORA ……………………………. 29REVLIMID ……………………………. 12RHOGAM ULTRA-FILTERED PLUS …………………………………… 16ribavirin ………………………………… 15riboflavin (vitamin b2) ……………..47rifabutin …………………………………. 8rifampin …………………………………. 8rimantadine ………………………….. 15RISA-BID ……………………………… 29RISAQUAD …………………………… 29RISAQUAD-2 ……………………….. 29RISPERDAL CONSTA ……………38risperidone …………………………… 38risperidone microspheres ………..38RITEFLO AEROCHAMBER …….34ritonavir ……………………………….. 15rivastigmine tartrate ………………..16rizatriptan ………………………………. 4ropinirole ……………………………… 13ROSADAN ……………………………. 40rosuvastatin ………………………….. 18ROTATEQ VACCINE ……………..16ROWEEPRA ………………………… 20rufinamide ……………………………. 20RYBELSUS ………………………….. 10sacubitril-valsartan …………………18salicylic acid …………………………. 40salmon oil-omega-3 fatty acids …18SANDIMMUNE ……………………… 32SANTYL ………………………………. 40sapropterin …………………………… 42SCOOBY-DOO ONE A DAY ……47SCOOBY-DOO ONE A DAY KIDS ……………………………………. 47selegiline hcl …………………………. 13selenium sulfide ……………………..40SELZENTRY ………………………… 15SE-NATAL 19 CHEWABLE ……..35SENIOR PROBIOTIC ……………..29SENNA ………………………………… 29senna leaf extract …………………..29SENTRY ………………………………. 47SEREVENT DISKUS ………………..6sertraline ……………………………… 38SETLAKIN……………………………. 23SF 5000 PLUS ……………………… 27SHAROBEL ………………………….. 23SHINGRIX (PF) …………………….. 16sildenafil (pulm.hypertension) …..18SILIQ …………………………………… 40silver sulfadiazine …………………….8SIMLIYA (28) ………………………… 23SIMPESSE …………………………… 23simple syrup …………………………. 42SIMPLYTHICK ……………………… 42simvastatin …………………………… 19sirolimus ………………………………. 32SLO-NIACIN …………………………. 47SMART HEART OMEGA-3 ……..29sodium chloride …………………….. 42SODIUM FLUORIDE 5000 PLUS …………………………………… 27sodium polystyrene sulfonate …..27sofosbuvir-velpatasvir ……………..15SOLIQUA 100/33 …………………..10sorafenib ……………………………… 12sotalol ………………………………….. 19SOTALOL AF ……………………….. 19SPECTRAVITE ADULT 50 PLUS(LUT) …………………………… 47SPECTRAVITE ADVANCED FORMULA ……………………………. 47spinosad ………………………………. 13SPIRIVA RESPIMAT ………………..6spironolactone ………………………. 24spironolacton-hydrochlorothiaz ..24SPRINTEC (28) …………………….. 23SPS (WITH SORBITOL) …………27SRONYX ……………………………… 23SSD ………………………………………. 8SSS 10-5 ……………………………….. 8STEQEYMA …………………………. 32STIOLTO RESPIMAT ……………….6STRAWBERRY C ………………….47STRESS FORMULA WITH IRON(SULF) ………………………….47STRIBILD …………………………….. 15STRIVERDI RESPIMAT ……………6SUBVENITE …………………………. 20sucralfate ……………………………… 29sulfacetamide sodium ……………….8sulfacetamide sodium (acne) …..40sulfacetamide sodium-sulfur ………8sulfacetamide-prednisolone ………8SULFACLEANSE 8-4 ……………….8sulfadiazine ……………………………. 8sulfamethoxazole-trimethoprim ….8sulfasalazine ………………………… 29SULFATRIM…………………………… 8sulindac …………………………………. 5sumatriptan ……………………………. 4sumatriptan succinate ………………4sunitinib malate …………………….. 12SUPER B/C ………………………….. 47SUPER DHA GEMS ……………….30SUPER OMEGA-3 …………………30SUPER QUINTS ……………………47SUPER QUINTS B-50 …………….47SUPPORT ……………………………. 47SUPPORT-500 ……………………… 47SUSPENDRX ANHYDROUS SWEETENED ……………………….. 42SUSPENDRX ANHYDROUS UNSWEET …………………………… 42SUTENT ………………………………. 12SWEET-SF …………………………… 42SYEDA ………………………………… 23SYMAX-SR …………………………… 30SYMDEKO …………………………… 43SYMTUZA ……………………………. 15SYNAGIS …………………………….. 15SYNAREL ……………………………. 31SYNTHROID ………………………… 41SYRPALTA VEHICLE …………….43SYRSPEND SF LIQUID ………….43SYRUP VEHICLE SF ……………..43TAB-A-VITE MULTIVITAMIN W-IRON ……………………………….. 47tacrolimus …………………………….. 32TAFINLAR ……………………………. 12tamoxifen ……………………………… 12tamsulosin ……………………………. 43TARINA 24 FE ………………………. 23 TARINA FE 1/20 (28)……………..23TARINA FE 1-20 EQ (28) ………..23TEGRETOL ………………………….. 20TEGRETOL XR …………………….. 20telmisartan ……………………………. 19telmisartan-amlodipine ……………19telmisartan-hydrochlorothiazid …19temozolomide ……………………….. 13TENIVAC (PF) ………………………. 16tenofovir disoproxil fumarate ……15terazosin ………………………………. 19terbinafine hcl …………………………. 9terbutaline ……………………………… 6terconazole …………………………….. 9teriflunomide …………………………. 20testosterone …………………………. 31tetracycline …………………………….. 8THALOMID …………………………….. 8THEO-24 ……………………………….. 6Georgia Medicaid | Effective 01/01/202660theophylline……………………………. 6THERA ………………………………… 47THERA-D …………………………….. 47THERALOGIX COMPANION …..48THERA-TABS ……………………….. 48thiamine hcl (vitamin b1) …………48thiamine mononitrate (vit b1) ……48thioridazine …………………………… 38thiothixene ……………………………. 38THRIVITE RX ……………………….. 35thyroid (pork) ………………………… 41tiagabine ………………………………. 20ticagrelor ……………………………… 13TILIA FE ………………………………. 23timolol maleate ……………………… 24TIMOPTIC OCUDOSE (PF) …….24TIVICAY ………………………………. 15tizanidine ……………………………… 35tobramycin ……………………………… 8tobramycin in 0.225 % nacl ……….8tobramycin sulfate ……………………8tobramycin with nebulizer ………….8tobramycin-dexamethasone ………8tolterodine ……………………………. 43tolvaptan ………………………………. 24topiramate ……………………………. 20torsemide …………………………….. 24TOTAL HOME INSECT REPELLENT ………………………… 11tramadol ………………………………… 4tramadol-acetaminophen …………..4trandolapril …………………………… 19tranylcypromine …………………….. 38trazodone …………………………….. 38TRELEGY ELLIPTA …………………6tretinoin ……………………………….. 40tretinoin (antineoplastic) ………….13TREXALL …………………………….. 13triamcinolone acetonide …….40, 43triamterene-hydrochlorothiazid …24triazolam ………………………………. 38TRICARE ………………………………35TRIDERM …………………………….. 40TRI-ESTARYLLA ……………………23trifluoperazine ……………………….. 38trifluridine ……………………………… 15trihexyphenidyl ……………………… 13TRIKAFTA ……………………………. 43TRI-LEGEST FE …………………….23TRI-LINYAH …………………………. 23TRI-LO-ESTARYLLA ………………23TRI-LO-MARZIA …………………….23TRI-LO-MILI …………………………. 23TRI-LO-SPRINTEC ………………..23trimethobenzamide…………………30trimethoprim …………………………… 8TRI-MILI ………………………………. 23trimipramine ………………………….. 38TRINATAL RX 1 …………………….35TRIPHROCAPS …………………….48TRI-SPRINTEC (28) ……………….23TRIUMEQ …………………………….. 15TRI-VI-SOL …………………………… 48TRI-VYLIBRA ……………………….. 23TRI-VYLIBRA LO …………………..23TROPICAL LIQUID NUTRITION ………………………….. 48tropicamide …………………………… 24trospium ………………………………. 43TRUEPLUS GLUCOSE …………..27TRUMENBA …………………………. 16TRUVADA ……………………………. 15TRUZONE PEAK FLOW METER ………………………………… 34TUBERCULIN SYRINGE ………..34TULANA ………………………………. 23TWINRIX (PF) ………………………. 16TYBOST ………………………………. 43TYENNE ………………………………. 32TYENNE AUTOINJECTOR ……..32TYKERB ………………………………. 13ULTICARE ……………………………. 34ULTIMATE PROBIOTIC-10 ……..30ULTRA FLORA PLUS …………….30ULTRA OMEGA-3 ………………….30ULTRATHON ……………………….. 11UNITHROID …………………………. 41urea …………………………………….. 40UREACIN-10 ………………………… 40URETRON D-S ………………………. 8ursodiol ………………………………… 30URYL …………………………………….. 8valacyclovir ……………………………15valproic acid …………………………. 20valproic acid (as sodium salt) …..20valsartan ………………………………. 19valsartan-hydrochlorothiazide ….19vancomycin ……………………………. 8VANDAZOLE …………………………..8VAQTA (PF) …………………………. 16VARIVAX (PF) ………………………. 16VARIZIG ………………………………. 16V-C FORTE ………………………….. 48VELIVET TRIPHASIC REGIMEN (28) ……………………… 23venlafaxine …………………………… 38VENOFER ……………………………. 50verapamil ……………………………… 17VERSA FREE……………………….. 43VERSA PLUS ……………………….. 43VESTURA (28) ……………………… 23V-GO 20 ………………………………. 34V-GO 30 ………………………………. 34V-GO 40 ………………………………. 34VIC-FORTE ………………………….. 48VIENVA ……………………………….. 23VIOKACE …………………………….. 30VIORELE (28) ………………………. 23VIRACEPT …………………………… 15VIREAD ……………………………….. 15VITABEX PLUS …………………….. 48VITAJOY MELATONIN …………..31VITALEE ……………………………… 48vitamin a ………………………………. 48vitamin a palmitate …………………48vitamin b complex …………………..48vitamin b complex-folic acid …….48VITAMIN B-1 ………………………… 48VITAMIN B-1 (MONONITRATE) ………………….48VITAMIN B-12 ………………………. 48VITAMIN B-2 ………………………… 48VITAMIN B-6 ………………………… 48VITAMIN C …………………………… 48VITAMIN CFIZZY DRINK ……….48VITAMIN CWITH ROSE HIPS ..48VITAMIN D2 …………………………. 48VITAMIN D3 …………………………. 48vitamin e ………………………………. 48 vitamin e (dl, acetate)……………..48vitamin e acetate ……………………48vitamin e mixed …………………….. 48VITAMINS BCOMPLEX …………48VIVITROL …………………………….. 43voriconazole …………………………… 9VORTEX HOLDING CHAMBER …………………………… 34VOTRIENT …………………………… 13VUMERITY …………………………… 20VYFEMLA (28) ……………………… 23VYLIBRA ……………………………… 23warfarin …………………………………. 9WERA (28) …………………………… 23WIDE-SEAL DIAPHRAGM 60 ….23WIDE-SEAL DIAPHRAGM 65 ….23WIDE-SEAL DIAPHRAGM 70 ….23WIDE-SEAL DIAPHRAGM 75 ….23WIDE-SEAL DIAPHRAGM 80 ….23WIDE-SEAL DIAPHRAGM 85 ….23WIDE-SEAL DIAPHRAGM 90 ….23WIDE-SEAL DIAPHRAGM 95 ….23WOMENS DAILY GUMMIES …..48Georgia Medicaid | Effective 01/01/202661WOMEN'S MULTIVITAMIN GUMMIES……………………………. 48WYMZYA FE ………………………… 23XARELTO ……………………………… 9XARELTO DVT-PE TREAT 30D START ……………………………. 9XELJANZ ………………………………. 5XELJANZ XR ………………………….. 5XOPENEX HFA ………………………. 6XULANE ………………………………. 23YELETS ………………………………. 48YESINTEK …………………………… 32ZAFEMY ………………………………. 23ZARAH ………………………………… 23ZARXIO ……………………………….. 21ZELAC …………………………………. 30ZELBORAF ………………………….. 13ZENZEDI ……………………………… 16ZEPOSIA ……………………………… 20ZEPOSIA STARTER KIT (28-DAY) ……………………………………. 20ZEPOSIA STARTER PACK (7-DAY) ……………………………………. 20zidovudine ……………………………. 15ziprasidone hcl ……………………… 38ZOLINZA ……………………………… 13zolmitriptan …………………………….. 4zolpidem ………………………………. 38zonisamide …………………………… 20ZOO FRIENDS ……………………… 49ZOVIA 1-35 (28) …………………….23ZUMANDIMINE (28) ……………….23 Georgia Medicaid | Effective 01/01/2026 62GA-MED-M-2964344-V.7-SPA DCH Approved: 6/21/2024

GA-MMED-1760a-V.22-SPA Member Summary of PDL Changes – GA MCD_508

Asunto: Resumen de los cambios a la PDL en vigor a partir del 1 DE ENERO DE2026 Estimado/a afiliado/a a CareSource: Su atencin mdica es nuestra prioridad. Por este motivo, le escribimos para informarle que el 1 DE ENERO DE 2026, CareSource cambiar la Lista de medicamentos preferidos (PDL). Una PDL es una lista de medicamentos preferidos. LOS SIGUIENTES MEDICAMENTOS SERN NO PREFERIDOS EN LA PDL EN VIGOR A PARTIR DEL 1 DE ENERO DE 2026. Nombre de marca Nombre genrico Dosis Notas Olumiant, comprimido Baricitinib 2 mg LOS SIGUIENTES MEDICAMENTOS TENDRN UN CAMBIO EN SU ESTADO A PARTIR DEL 1 DE ENERO DE 2026. Nombre de marca Nombre genrico Dosis Notas Andembry, autoinyector garadacimab-gxii Todos Se actualiz el lmite de cantidad. Anzupgo, crema delgocitinib Todos Se actualiz el lmite de cantidad. Daybue, solucin oral trofinetida Todos Se actualiz el lmite de cantidad. Egrifta WR, vial, kit de viales acetato de tesamorelina Todos Se actualiz el lmite de cantidad. Ekterly, comprimido sebetralstat Todos Se actualiz el lmite de cantidad. Harliku, comprimido nitisinona Todos Se actualiz el lmite de cantidad. Haegarda, inyectable Inhibidor de C1 esterasa (humano) Todos Se actualizar el cdigo de facturacin de la farmacia por el J0599 Tryptyr, minigotero acoltremn Todos Se actualiz el lmite de cantidad. Widapiki telmisartn-indapamida Todos Se actualiz el lmite de cantidad. Yutrepia, cpsula treprostinil sdico Todos Se actualiz el lmite de cantidad. Zoryve, espuma Roflumilast Todos Se actualiz el lmite de cantidad. Qu debe hacer?En primer lugar, hable con su proveedor de atencin mdica. Es posible que haya otros medicamentos en la PDL que puede tomar en su lugar. Hay varias maneras en que usted o la persona que receta pueden encontrar medicamentos: Puede consultar nuestro sitio web en CareSource.com . En la pgina Afiliados, vaya a Herramientas y recursos y haga clic en Encontrar mis medicamentos con receta. Ollame a nuestro Departamento de Servicios para Afiliados al 1-855-202-0729 (TTY: 1-800-255-0056 o 711). Nuestro horario de atencin es de lunes a viernes, de 7a.m. a 7 p.m. Atentamente, CareSource CareSource cumple las leyes vigentes sobre derecho civil estatales y federales, y no discrimina por motivos de edad, sexo, identidad de gnero, color, raza, discapacidad, nacionalidad, estado civil, preferencia sexual, filiacin religiosa, estado de salud ni estado de asistencia pblica. Si usted o alguien a quien ayuda tienen preguntas sobre CareSource, tiene derecho a recibir esta informacin y ayuda en su propio idioma sin costo. Para hablar con un intrprete, por favor, llame al nmero de Servicios para Afiliados que figura en su tarjeta de identificacin.CareSource ID GA-MMED-1760a-V.22-SPA Aprobado por DCH: 2/21/2019CareSource.com

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AR-PAS-M-1135300-V.17 Sum of Form Changes – AR PASSE_WEB SP

CareSourcePASSE.comAsunto: Resumen de cambios al formulario/a la autorizacin previa en vigor a partir del 1 DE ENERO DE 2026 Su atencin mdica es nuestra prioridad. Por ello, le escribimos para informarle que el 1 DE ENERO DE 2026 habr cambios en la Lista de medicamentos preferidos (Preferred Drug List, PDL) de Medicaid de Arkansas y en la administracin de productos de CareSource PASSE que no estn en la PDL de Medicaid de Arkansas. Una PDL es una lista de medicamentos preferidos. RESUMEN DE CAMBIOS A LA PDL DE MEDICAID DE ARKANSAS EN VIGOR A PARTIR DEL 1 DE ENERO DE 2026: LOS SIGUIENTES MEDICAMENTOS SERN PREFERIDOS EN LA PDL EN VIGOR A PARTIR DEL 1 DE ENERO DE 2026.Nombre del producto Dosis NotasAcetilcistena (genrico de Acetadote ), frasco 6 g/30 ml Se actualiz a preferido, entr en vigor el 10/29/25. Cardizem , comprimidos 30 mg Se actualiz a preferido, entr en vigor el 10/1/25. Diltiazem, 24 h de liberacin prolongada (ER), dosis controlada (CD) (genrico de Cardizem CD ), cpsulas 120 mg Hiclato de doxiciclina (genrico de Acticlate ), comprimidos 75 mg, 150 mg Monohidrato de doxiciclina (genrico de Adoxa ),comprimidos Todas Epoprostenol (genrico de Veletri ), frasco Todas Mesalamina de liberacin prolongada (ER) (genrico de Apriso ) Todas Se actualiz a preferido, entr en vigor el 10/1/25. Pyzchiva (biosimilar a Stelara ), jeringa, frasco 45 mg, 90 mg Se aplica a la jeringa de 45 mg, al frasco y a la jeringa de 90 mg. Preferido con criterios. La marca Stelara ya es no preferida. Steqeyma (biosimilar a Stelara ), jeringa Todas Preferido con criterios. La marca Stelara ya es no preferida. Ticagrelor (genrico de Brilinta ), comprimidos Todas CareSourcePASSE.com Ziac , comprimidos 10/6.25 mg LOS SIGUIENTES MEDICAMENTOS SERN NO PREFERIDOS EN LA PDL EN VIGOR A PARTIR DEL 1 DE ENERO DE 2026. Nombre del producto Dosis Notas Brilinta , comprimidos Todas Centany , ungento 2 % Monohidrato de doxiciclina (genrico de Vibramycin ), suspensin 25 mg/5 ml GoLYTELY , solucin N/C Morgidox , cpsulas 50 mg Enantato de testosterona (genrico de Delatestryl ), frasco 200 mg/ml Tetraciclina (genrico de Sumycin ) Todas Veletri , frasco Todas LOS SIGUIENTES MEDICAMENTOS TIENEN UN CAMBIO EN LA AUTORIZACIN PREVIA/ LOS CRITERIOS PARA LA PDL A PARTIR DEL 1 DE ENERO DE 2026Nombre del producto Dosis NotasAdalimumab-ryvk (CF) (genrico de Simlandi , biosimilar a Humira ), autoinyector 80 mg Se actualiz el lmite de la cantidad y la edad, entr en vigor el 9/5/25. Alosetrn (genrico de Lotronex ), comprimidos Todas Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Amitiza , cpsulas Todas Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Arbli , suspensin 10 mg/ml Se actualiz el lmite de la edad, entr en vigor el 10/1/25. cido azelaico (genrico de Finacea ), gel 15 % Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Bildyos , jeringa 60 mg/ml Se actualiz el lmite de la cantidad el 9/11/25 y el lmite de la edad el 9/29/25. Bilprevda , frasco 120 mg/1.7 ml Se actualiz el lmite de la cantidad y la edad, entr en vigor el 9/11/25. Blujepa , comprimidos 750 mg Se actualiz el lmite de la cantidad y la edad, entr en vigor el 9/8/25. Bosentn (genrico de Tracleer ), comprimidos Todas Se actualiz el lmite de la edad, entr en vigor el 8/20/25. Brekiya , autoinyector 1 mg/ml Se actualiz el lmite de cantidad, entr en vigor el 9/2/25. Brimonidina (genrico de Mirvaso ), gel con dispensador 0.33 % Se actualiz el lmite de la edad, entr en vigor el 10/1/25. CareSourcePASSE.com Nombre del producto Dosis Notas Cresemba , cpsulas Todas Se actualiz el lmite de la edad, entr en vigor el 9/30/25. Dalbavancina y marca Dalvance , frasco Todas Se actualiz el lmite de cantidad, entr en vigor el 11/3/25. Dawnzera , inyectable Todas Se actualiz el lmite de la cantidad y la edad, entr en vigor el 8/21/25. Deflazacort (genrico de Emflaza ), comprimidos Todas Se actualiz el lmite de la edad, entr en vigor el 10/31/25. Dexcom , sensor para 15 das N/C Se actualiz el lmite de cantidad, entr en vigor el 9/1/25. Doptelet , cpsulas dispersables 10 mg Se actualiz el lmite de la edad el 9/22/25 y el lmite de la cantidad el 9/29/25. Eliquis , cpsulas dispersables, comprimidos para suspensin Mltiples Se actualiz el lmite de cantidad para cpsulas dispersables, en vigor desde el 9/10/25, y el lmite de cantidad para comprimidos para suspensin, en vigor desde el 9/11/25. Epsolay , crema con dispensador 5 % Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Escitaloprm, cpsulas 15 mg Se actualizaron los criterios, el lmite de la cantidad y la edad, en vigor desde el 9/29/25. Exxua , comprimidos, paquete de ajuste de dosis (titulacin) de liberacin prolongada (ER) Todas Se actualizaron los criterios, entraron en vigor el 9/29/25. Finacea , espuma, gel 15 % Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Gabapentina de liberacin prolongada (ER) (genrico de Gralise ), comprimidos Todas Se actualiz el lmite de cantidad, entr en vigor el 10/10/25. Ibsrela , comprimidos 50 mg Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Isturisa , comprimidos 1 mg Se actualiz el lmite de la edad, entr en vigor el 11/10/25. Ivermectina y marca Soolantra , crema 1 % Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Jantoven , comprimidos Todas Se actualizaron los criterios, entraron en vigor el 10/1/25. CareSourcePASSE.com Nombre del producto Dosis Notas Jascayd , comprimidos Todas Se actualiz el lmite de la cantidad y la edad, entr en vigor el 10/7/25. Koselugo , cpsulas Todas Se actualiz el lmite de la cantidad y la edad, entr en vigor el 10/17/25 . Kymbee (genrico de Emflaza ), comprimidos Todas Se actualiz el lmite de la edad, entr en vigor el 11/7/25. Leqembi Iqlik, inyectable 360 mg/1.8 ml Se actualiz el lmite de la cantidad y la edad, entr en vigor el 9/8/25. Linezolid, en cloruro de sodio al 0.9 %, bolsa de solucin intravenosa (IV) 600 mg/300 ml Se actualiz el lmite de cantidad, entr en vigor el 11/5/25. Linzess , cpsulas 145 mcg Se actualiz el lmite de la edad, entr en vigor el 11/10/25. Lisdexamfetamina (genrico de Vyvanse ), cpsulas 10 mg, 20 mg Se actualizaron los criterios, entraron en vigor el 9/16/25. Lurasidona (genrico de Latuda ), comprimidos Todas Se actualiz el lmite de la edad, entr en vigor el 8/20/25. Lynkuet , cpsulas Todas Se actualiz el lmite de la cantidad y la edad, entr en vigor el 10/24/25. Lyrica , solucin oral 20 mg/ml Se actualiz el lmite de la edad, entr en vigor el 8/29/25. Mavyret , perlas en paquete, comprimidos Todas Se actualiz el lmite de cantidad, entr en vigor el 10/29/25. Metrocream , crema 0.75 % Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Metrogel , gel tpico 1 % Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Metronidazol y marca MetroLotion , locin tpica 0.75 % Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Minimed , sensor Instinct N/C Se actualiz el lmite de cantidad, entr en vigor el 10/6/25. Mirvaso , gel con dispensador 0.33 % Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Modeyso , cpsulas Todas Se actualiz el lmite de la cantidad y la edad, entr en vigor el 8/11/25. Neurontin , cpsulas 400 mg Se actualiz para quitar criterios; entr en vigor el 10/1/25. Noritate , crema 1 % Se actualiz el lmite de la edad, entr en vigor el 10/1/25. CareSourcePASSE.com Nombre del producto Dosis Notas Nypozi , jeringa 300 mcg/0.5 ml Se actualiz el lmite de cantidad, entr en vigor el 10/20/25. Onapgo , cartucho 98 mg/20 ml Se actualizaron los criterios, entraron en vigor el 7/10/25. OneNatal Rx, comprimidos prenatales Todas Se actualiz el lmite de la edad el 11/5/25 y el lmite de la cantidad el 8/18/25. Orlynvah , comprimidos 500 mg/500 mg Se actualiz el lmite de la edad el 9/12/25 y el lmite de la cantidad el 10/1/25. Oseltamivir (genrico de Tamiflu ), suspensin 6 mg/ml Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Otezla XR, comprimidos 75 mg Se actualiz el lmite de cantidad, entr en vigor el 9/29/25. Otulfi , frasco 45 mg/0.5 ml Se actualiz el lmite de la edad, entr en vigor el 9/18/25. Pazopanib (genrico de Votrient ), comprimidos 400 mg Se actualiz el lmite de cantidad, entr en vigor el 11/5/25. Primacare , cpsulas blandas Todas Se actualiz el lmite de la cantidad el 11/3/25 y el lmite de edad el 11/5/25. Pyquvi , suspensin oral 22.75 mg/ml Se actualiz el lmite de edad, entr en vigor el 9/8/25. Relistor , jeringa, comprimidos, frasco Todas Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Rhapsido , comprimidos Todas Se actualiz el lmite de la cantidad el 10/6/25 y el lmite de la edad el 10/7/25. Rhofade , crema 1 % Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Rosadan , crema, gel 0.75 % Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Emblaveo , frasco 45 mg/0.5 ml Se actualiz el lmite de la edad, entr en vigor el 10/16/25. Simponi , jeringa Todas Se actualiz el lmite de la edad, entr en vigor el 10/10/25. Skytrofa , cartucho Mltiples Se actualizaron el lmite de la cantidad, todas las concentraciones y el lmite de la edad para las concentraciones de 7.6 mg, 9.1 mg, 11 mg y 13.3 mg. Solucin de oxibato de sodio 0.5 mg/ml Se actualiz el lmite de la edad, entr en vigor el 9/18/25. CareSourcePASSE.com Nombre del producto Dosis Notas Sofosbuvir-velpatasvir y marca Epclusa , perlas en paquete, comprimidos Todas Se actualiz el lmite de cantidad, entr en vigor el 10/1/25. Starjemza , jeringa, frasco Todas Se actualiz el lmite de la edad, entr en vigor el 11/10/25. Stoboclo , jeringa 60 mg/ml Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Subvenite , suspensin 10 mg/ml Se actualiz el lmite de la edad, entr en vigor el 11/10/25. Sunosi , comprimidos Todas Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Tonmya , comprimidos sublinguales Todas Se actualiz el lmite de edad, entr en vigor el 10/24/25. Tremfya , jeringa, lapicera, paquete de induccin con pluma Todas Se actualiz el lmite de la edad, entr en vigor el 10/10/25. Tyvaso DPI , polvo para inhalacin 80 mcg Se actualiz el lmite de cantidad, entr en vigor el 11/1/25. Tyzavan , bolsa de solucin intravenosa (IV) Todas Se actualiz el lmite de cantidad, entr en vigor el 10/27/25. Ustekinumab-AAUZ (biosimilar a Otulfi ), jeringa Todas Se actualiz el lmite de la edad, entr en vigor el 11/10/25. Viberzi , comprimidos Todas Se actualiz el lmite de la edad, entr en vigor el 10/1/25. Vyscoxa , suspensin Todas Se actualiz el lmite de cantidad, entr en vigor el 10/31/25. Wakix , comprimidos Todas Se actualiz el lmite de la edad, entr en vigor el 9/18/25. Wayrilz , comprimidos 400 mg Se actualiz el lmite de la cantidad y la edad, entr en vigor el 9/3/25. Xeljanz , comprimidos Todas Se actualiz el lmite de la edad, entr en vigor el 10/31/25. Xerava , frasco Todas Se actualiz el lmite de cantidad, entr en vigor el 10/15/25. Xyrem , solucin oral 500 mg/ml Se actualiz el lmite de la edad, entr en vigor el 9/18/25. Zoryve , crema 0.05 % Se actualiz el lmite de la cantidad el 10/6/25 y el lmite de la edad el 10/17/25. Zurnai , autoinyector 1.5 mg/0.5 ml Se actualiz el lmite de la cantidad y la edad, entr en vigor el 9/8/25. CareSourcePASSE.com Qu debe hacer?Primero, hable con la persona que le receta los medicamentos. Hay distintas formas en que usted y la persona que receta pueden encontrar informacin sobre medicamentos: Puede buscar en nuestro sitio web, en CareSourcePASSE.com . En la pgina Afiliados, vaya a Herramientas y Recursos y haga clic en Encontrar mis medicamentos con receta. Llame a Servicios para Afiliados al 1-833-230-2005 (TDD/TTY: 711) . Estamos aqu para ayudarle. El horario de atencin de Servicios para Afiliados es de lunes a viernes, de 8 a. m. a 5 p. m., hora central (CT). Atentamente, CareSource PASSE. AR-PAS-M-1135300-V.17-SPA Aprobado por DHS: 2/23/2022

N-MED-M-3083118-V.7-SPA-12-1-Member-PDL-Change-Letter-IN-MCD SP

Asunto: Resumen de los cambios en la PDL en vigor a partir del 1 de febrero de 2026 Estimado/a afiliado/a a CareSource: Su atencin mdica es nuestra prioridad. Por este motivo, le escribimos para informarle que el 1 de febrero de 2026, CareSource cambiar la Lista de medicamentos preferidos (Preferred Drug List, PDL). Una PDL es una lista de medicamentos preferidos. Estimado/a afiliado/a a CareSource: Su atencin mdica es nuestra prioridad. Por este motivo, le escribimos para informarle que el 1 de febrero de 2026, CareSource cambiar la Lista de medicamentos preferidos (Preferred Drug List, PDL). Una PDL es una lista de medicamentos preferidos. LOS SIGUIENTES MEDICAMENTOS NO SERN PREFERIDOS EN LA PDL EN VIGOR A PARTIR DEL 1 DE FEBRERO DE 2026 Nombre de marca Nombre genrico Concentracin Notas Aricept Clorhidrato de donepezilo Todas las concentraciones Exelon Rivastigmina Todas las concentraciones Namenda XR Clorhidrato de memantina Todas las concentraciones de las cpsulas Namenda XR Clorhidrato de memantina Paquete de ajuste de dosis (titulacin) de 7/14/21/28 mg Adlarity Clorhidrato de donepezilo Todas las concentraciones Se agreg la terapia escalonada. Clorhidrato de memantina Clorhidrato de donepezilo Todas las concentraciones Se agreg la terapia escalonada. Namzaric Clorhidrato de memantina Clorhidrato de donepezilo Todas las concentraciones Se agreg la terapia escalonada. Zunveyl Gluconato de benzgalantamina Todas las concentraciones Se agreg la terapia escalonada. Ativan Lorazepam Todas las concentraciones de inyeccin Klonopin Clonazepam Todas las concentraciones Valium Diazepam Todas las concentraciones Xanax Alprazolam Todas las concentraciones de los comprimidos de liberacin inmediata Xanax XR Alprazolam Todas las concentraciones CareSource.com Nombre de marca Nombre genrico Concentracin Notas Bucapsol Clorhidrato de buspirona Todas las concentraciones Se agreg la terapia escalonada. Igalmi Clorhidrato de Clorhidrato de metformina Todas las concentraciones Loreev XR Lorazepam Todas las concentraciones Meprobamato Todas las concentraciones Se agreg la terapia escalonada. Celexa Bromhidrato de citalopram Todas las concentraciones Cymbalta Clorhidrato de duloxetina Todas las concentraciones Effexor XR Clorhidrato de venlafaxina Todas las concentraciones Forfivo XL Clorhidrato de bupropin Comprimidos de 450 mg Lexapro Oxalato de escitalopram Todas las concentraciones Paxil Clorhidrato de paroxetina Todas las concentraciones de los comprimidos de liberacin inmediata Paxil CR Clorhidrato de paroxetina Todas las concentraciones Paxil Clorhidrato de paroxetina Suspensin oral de 10 mg/5 ml Anafranil Clorhidrato de clomipramina Todas las concentraciones Nardil Sulfato de fenelzina Comprimidos de 15 mg Fenelzina Comprimidos de 15 mg Se agreg la terapia escalonada. Norpramin Clorhidrato de desipramina Todas las concentraciones Pamelor Clorhidrato de nortriptilina Todas las concentraciones Parnate Sulfato de tranilciapromina Comprimidos de 10 mg Sulfato de tranilciapromina Comprimidos de 10 mg Se agreg la terapia escalonada. Remeron Soltab Mirtazapina Todas las concentraciones Remeron Mirtazapina Todas las concentraciones Wellbutrin SR Clorhidrato de bupropin Todas las concentraciones Emsam Selegilina Todas las concentraciones Se agreg la terapia escalonada. Marplan Isocarboxazid Comprimidos de 10 mg Se agreg la terapia escalonada. CareSource.com Nombre de marca Nombre genrico Concentracin Notas Clorhidrato de bupropin XL (genrico de Forfivo XL) Comprimidos de 450 mg Se agreg la terapia escalonada. Bromhidrato de citalopram Cpsulas de 30 mg Se agreg la terapia escalonada. Drizalma Sprinkle DR Clorhidrato de duloxetina Todas las concentraciones Se agreg la terapia escalonada. Oxalato de escitalopram Cpsulas de 15 mg Se agreg el lmite de cantidad; se agreg terapia escalonada; se agreg la autorizacin previa. Exxua Clorhidrato de gepirona Todas las concentraciones Se agreg el lmite de cantidad; se agreg el lmite de edad; se agreg la terapia escalonada Fluvoxamina ER Todas las concentraciones Se agreg la terapia escalonada. Raldesy Clorhidrato de trazodona Solucin oral de 10 mg/ml Se agreg la terapia escalonada. Sertralina Todas las concentraciones de las cpsulas Se agreg la terapia escalonada. Spravato Clorhidrato de esketamina Todas las concentraciones Maleato de trimipramina Todas las concentraciones Se agreg la terapia escalonada. Abilify Aripiprazol Todas las concentraciones Clozaril Clozapina Todas las concentraciones Geodon Clorhidrato de ziprasidona Todas las concentraciones de las cpsulas Geodon Mesilato de ziprasidona Solucin intramuscular de 20 mg/ml Decanoato de haldol Decanoato de haloperidol Todas las concentraciones de las soluciones intramusculares. Invega Paliperidona Todas las concentraciones de los comprimidos Latuda Clorhidrato de lurasidona Todas las concentraciones Risperdal Risperidona Solucin oral de 1 mg/ml Risperdal Risperidona Todas las concentraciones de los comprimidos CareSource.com Nombre de marca Nombre genrico Concentracin Notas Saphris Maleato de asenapina Todas las concentraciones de los comprimidos sublinguales Seroquel Fumarato de quetiapina Todas las concentraciones de los comprimidos de liberacin inmediata Seroquel XR Fumarato de quetiapina Todas las concentraciones los comprimidos de liberacin prolongada Symbyax Olanzapina/clorhidrato de fluoxetina Todas las concentraciones Zyprexa Olanzapina Vial de 10 mg Zyprexa Olanzapina Todas las concentraciones de los comprimidos Zyprexa Zydis Olanzapina Todas las concentraciones de los comprimidos de desintegracin oral Lithobid Carbonato de litio Comprimidos de liberacin prolongada de 300 mg Cobenfy Tartrato de xanomelina/ Cloruro de trospio Todas las concentraciones Se actualiz la autorizacin previa. Fanapt Iloperidona Todas las concentraciones de los comprimidos Se agreg la terapia escalonada. Fanapt Iloperidona Todas las concentraciones de paquetes de ajuste de dosis (titulacin) Se agreg la terapia escalonada. Nuplazid Tartrato de pimavanserina Todas las concentraciones Se actualiz la autorizacin previa. Opipza Aripiprazol Todas las concentraciones Se agreg la terapia escalonada. Primozida Todas las concentraciones Se agreg la terapia escalonada. Microesferas de risperidona (genrico de Risperdal Consta) Todas las concentraciones Secuado Asenapina Todas las concentraciones Se agreg la terapia escalonada. Versacloz Clozapina Suspensin oral de 50 mg/ml Se agreg la terapia escalonada. Ambien CR Tartrato de zolpidem Todas las concentraciones Ambien Tartrato de zolpidem Todas las concentraciones Doral Quazepam Comprimidos de 15 mg CareSource.com Nombre de marca Nombre genrico Concentracin Notas Halcion Triazolam Comprimidos de 0.25 mg Restoril Temazepam Todas las concentraciones Rozerem Ramelteon Comprimidos de 8 mg Silenor Clorhidrato de doxepina Todas las concentraciones Dayvigo Lemborexant Todas las concentraciones Se agreg la terapia escalonada. Edluar Tartrato de zolpidem Comprimidos sublinguales de 5 mg, 10 mg Se agreg la terapia escalonada. Clorhidrato de flurazepam Todas las concentraciones Se agreg la terapia escalonada. Hetlioz Tasimelteon Cpsulas de 20 mg Se actualiz la autorizacin previa. Hetlioz LQ Tasimelteon Suspensin oral de 4 mg/ml Se actualiz la autorizacin previa. Quazepam Comprimidos de 15 mg Se agreg la terapia escalonada. Quviviq Clorhidrato de daridorexant Todas las concentraciones Se agreg la terapia escalonada. Tasimelteon Cpsulas de 20 mg Se actualiz la autorizacin previa. Tartrato de zolpidem Cpsulas de 7.5 mg Se agreg la terapia escalonada. Tartrato de zolpidem Comprimidos sublinguales de 1.75 mg, 3.5 mg Se agreg la terapia escalonada. Nuvigil Armodafinilo Todas las concentraciones Provigil Modafinilo Todas las concentraciones Sunosi Clorhidrato de solriamfetol Todas las concentraciones Se actualiz la autorizacin previa. Wakix Clorhidrato de pitolisant Todas las concentraciones Se actualiz la autorizacin previa. Oxibato sdico (genrico de Xyrem) Solucin oral de 0.5 mg/ml Se actualiz la autorizacin previa. Xywav Oxibato de calcio/magnesio/ potasio/sodio Solucin oral de 0.5 mg/ml Se actualiz la autorizacin previa. Catapres – TTS Clonidina Todas las concentraciones Intuniv ER Clorhidrato de guanfacina Todas las concentraciones Strattera Clorhidrato de atomoxetina Todas las concentraciones CareSource.com Nombre de marca Nombre genrico Concentracin Notas Adderall Dextroanfetamina/ Anfetamina Todas las concentraciones de los comprimidos de liberacin inmediata Se agreg la terapia escalonada. Adderall XR Dextroanfetamina/ Anfetamina Todas las concentraciones de las cpsulas de liberacin prolongada Se agreg la terapia escalonada. Aptensio XR Clorhidrato de metilfenidato Todas las concentraciones Se agreg la terapia escalonada. Concerta ER Clorhidrato de metilfenidato Todas las concentraciones Se agreg la terapia escalonada. Desoxyn Clorhidrato de metanfetamina Comprimidos de 5 mg Se agreg la terapia escalonada. Dexedrine Spansule Sulfato de dextroanfetamina Todas las concentraciones Se agreg la terapia escalonada. Evekeo Sulfato de anfetamina Todas las concentraciones de los comprimidos Se agreg la terapia escalonada. Focalin Clorhidrato de dexmetilfenidato Todas las concentraciones de los comprimidos de liberacin inmediata Se agreg la terapia escalonada. Focalin XR Clorhidrato de dexmetilfenidato Todas las concentraciones Se agreg la terapia escalonada. Metadate CD Clorhidrato de metilfenidato Todas las concentraciones Se agreg la terapia escalonada. Methylin Clorhidrato de metilfenidato Todas las concentraciones Se agreg la terapia escalonada. Procentra Sulfato de dextroanfetamina Solucin oral de 5 mg/5 ml Se agreg la terapia escalonada. Ritalin Clorhidrato de metilfenidato Todas las concentraciones Se agreg la terapia escalonada. Ritalin LA Clorhidrato de metilfenidato Todas las concentraciones Se agreg la terapia escalonada. Zenzedi Sulfato de dextroanfetamina Todas las concentraciones Se agreg la terapia escalonada. Anfetamina ER ODT (disolucin en la lengua) (genrico de Adzenys XR-ODT) Todas las concentraciones Dextroanfetamina anfetamina ER (genrico de Mydayis ER) Todas las concentraciones Se agreg la terapia escalonada. Mydayis Dextroanfetamina/ Anfetamina Todas las concentraciones Se agreg la terapia escalonada. CareSource.com Nombre de marca Nombre genrico Concentracin Notas Adzenys XR ODT Anfetamina Todas las concentraciones Se agreg la terapia escalonada. Cotempla XR-ODT Metilfenidato Todas las concentraciones Se agreg la terapia escalonada. Dimesilato de lisdexanfetamina Todas las concentraciones de las cpsulas Dimesilato de lisdexanfetamina Todas las concentraciones de los comprimidos masticables Se agreg la terapia escalonada. Clorhidrato de metilfenidato ER (genrico de Aptensio XR) Todas las concentraciones Se agreg la terapia escalonada. Metilfenidato (genrico de Daytrana) Todas las concentraciones Relexxii Clorhidrato de metilfenidato Todas las concentraciones Se agreg la terapia escalonada. Xelstrym Dextroanfetamina Todas las concentraciones Se agreg la terapia escalonada. Depakote DR Divalproato de sodio Todas las concentraciones Depakote ER Divalproato de sodio Todas las concentraciones Solucin de gabapentina Todas las concentraciones Se actualiz la autorizacin previa. Gabarone Gabapentina Todas las concentraciones Se agreg la terapia escalonada. Lamictal Lamotrigina Todas las concentraciones de los comprimidos masticables Se actualiz la autorizacin previa. Lamictal ODT Lamotrigina Todas las concentraciones de los comprimidos de desintegracin oral Lamictal Lamotrigina Todas las concentraciones de los comprimidos de liberacin inmediata, excepto los kits Lamictal XR Lamotrigina Todas las concentraciones de los comprimidos de liberacin prolongada Lamotrigina IR Todas las concentraciones de los kits Se actualiz la autorizacin previa. Lamotrigina ODT Todas las concentraciones de los kits Se actualiz la autorizacin previa. CareSource.com Nombre de marca Nombre genrico Concentracin Notas Keppra Levetiracetam Inyeccin de 500 mg/5 ml Se actualiz la autorizacin previa. Keppra Levetiracetam Solucin oral de 100 mg/ml Se actualiz la autorizacin previa. Keppra Levetiracetam Todas las concentraciones de los comprimidos de liberacin inmediata Se actualiz la autorizacin previa. Keppra XR Levetiracetam Todas las concentraciones los comprimidos de liberacin prolongada Se actualiz la autorizacin previa. Onfi Clobazam Suspensin de 2.5 mg/ml Se actualiz la autorizacin previa. Onfi Clobazam Todas las concentraciones de los comprimidos Se actualiz la autorizacin previa. Oxcarbazepina ER Todas las concentraciones los comprimidos de liberacin prolongada Se actualiz la autorizacin previa. Pregabalina Solucin de 20 mg/ml Se actualiz la autorizacin previa. Subvenite Lamotrigina Todas las concentraciones de los comprimidos Subvenite Lamotrigina Todas las concentraciones de los kits Se actualiz la autorizacin previa. Sympazan Clobazam Todas las concentraciones Se agreg la terapia escalonada. Vyscoxa Celecoxib Suspensin de 10 mg/ml Se agreg la terapia escalonada. Zurnai Clorhidrato de nalmefeno Inyeccin de 1.5 mg/0.5 ml Topamax Sprinkle Topiramato Todas las concentraciones Topamax Topiramato Todas las concentraciones de los comprimidos de liberacin inmediata Topiramato ER (genrico de Trokendi) Todas las concentraciones Topiramato Solucin de 25 mg/ml Trileptal Oxcarbazepina Todas las concentraciones de los comprimidos de liberacin inmediata Se actualiz la autorizacin previa. Trileptal Oxcarbazepina Suspensin de 300 mg/5 ml Se actualiz la autorizacin previa. CareSource.com Nombre de marca Nombre genrico Concentracin Notas Tonmya Clorhidrato de ciclobenzaprina Comprimidos sublinguales de 2.8 mg Se agreg el lmite de cantidad; se agreg la terapia escalonada. Bildyos Denosumab-nxxp Inyeccin de 60 mg/ml Se actualiz la autorizacin previa. Bilprevda Denosumab-nxxp Inyeccin de 120 mg/1.7 ml Se actualiz la autorizacin previa. Bomyntra Denosumab-bnht Inyeccin de 120 mg/1.7 ml Se actualiz la autorizacin previa; se agreg la terapia escalonada. Osenvelt Denosumab-bmwo Inyeccin de 120 mg/1.7 ml Se actualiz la autorizacin previa; se agreg la terapia escalonada. Conexxence Denosumab-bnht Inyeccin de 60 mg/ml Se actualiz la autorizacin previa; se agreg la terapia escalonada. Stoboclo Denosumab-bmwo Inyeccin de 60 mg/ml Se actualiz la autorizacin previa; se agreg la terapia escalonada. Brynovin Clorhidrato de sitagliptina Solucin de 25 mg/ml Se agreg la terapia escalonada. Janumet XR Fosfato de sitagliptina/ Clorhidrato de metformina Todas las concentraciones Se agreg la terapia escalonada. Sogroya Somapacitan-beco Todas las concentraciones Se actualiz la autorizacin previa; se agreg la terapia escalonada. Insulina lispro Vial de 100 unidades/ml Merilog InsulinA aspart-szjj Lapicera y vial de 100 unidades/ml Lynkuet Elinzanetant Cpsulas de 60 mg Se actualiz la autorizacin previa. Andemdbry, autoinyector Garadacimab-gxii Inyeccin de 200 mg/1.2 ml Dawnzera Donidalorsn sdico Inyeccin de 80 mg/0.8 ml Haegarda Inhibidor de C1 esterasa (humano) Todas las concentraciones Nypozi Filgrastim-txid Todas las concentraciones CareSource.com Nombre de marca Nombre genrico Concentracin Notas Ryzneuta Efbecalenograstim alfa-vuwx Inyeccin de 20 mg/ml Tryptyr Acoltremn Gotas para los ojos al 0.003 % Se actualiz la autorizacin previa; se agreg el lmite de cantidad. Natroba Spinosad Suspensin tpica al 0.9 % Pruradik Crotamitn Locin al 10 % Anzupgo Delgocitinib Crema al 2 % Se actualiz la autorizacin previa; se agreg el lmite de cantidad. Zoryve Roflumilast Crema al 0.05 % Se actualiz la autorizacin previa; se agreg el lmite de cantidad; se agreg el lmite de edad. Pristiq ER Succinato de desvenlafaxina Todas las concentraciones Prozac Clorhidrato de fluoxetina Todas las concentraciones Viibryd Clorhidrato de vilazodona Todas las concentraciones Zoloft Clorhidrato de sertralina Todas las concentraciones de los comprimidos Zoloft Clorhidrato de sertralina Concentrado oral de 20 mg/ml LOS SIGUIENTES MEDICAMENTOS SERN PREFERIDOS EN LA PDL EN VIGOR A PARTIR DEL 1 DE FEBRERO DE 2026 Nombre de marca Nombre genrico Concentracin Notas Vtama Tapinarof Crema al 1 % Se actualiz la autorizacin previa. Sitagliptina/ Clorhidrato de metformina (genrico de Zituvimet XR) Todas las concentraciones Se actualiz la autorizacin previa; se agreg la terapia escalonada. Humulin N KwikPen Insulina NPH Kwikpen de 100 unidades/ml Novolog Mix 70/30 Insulina aspart protamina/Insulina aspart Lapicera y vial de 100 unidades/ml CareSource.com Nombre de marca Nombre genrico Concentracin Notas Humalog Insulina lispro Vial de 100 unidades/ml Novolog Insulina aspart Lapicera y vial de 100 unidades/ml Glyxambi Empagliflozina/linagliptina Todas las concentraciones Se retir la terapia escalonada. Eliquis Sprinkle Apixabn Cpsulas de 0.15 mg Se agreg el lmite de cantidad; se agreg la terapia escalonada. Eliquis PKT Apixabn Todas las concentraciones de los comprimidos para suspensin Se agreg el lmite de cantidad; se agreg la terapia escalonada. Cinryze Inhibidor de C1 esterasa (humano) Vial de 500 unidades Orladeyo Clorhidrato de berotralstat Todas las concentraciones Takhzyro Lanadelumab-flyo Todas las concentraciones Spinosad Suspensin tpica al 0.9 % Brixadi Buprenorfina Todas las concentraciones Se actualiz la autorizacin previa. LOS SIGUIENTES MEDICAMENTOS TIENEN UN CAMBIO DE ESTADO EN VIGOR A PARTIR DEL 1 DE FEBRERO DE 2026 Nombre de marca Nombre genrico Concentracin Notas Bromhidrato de citalopram Todas las concentraciones de solucin oral Se agreg la terapia escalonada. Oxalato de escitalopram Todas las concentraciones de solucin oral Se agreg la terapia escalonada. Clorhidrato de fluoxetina Solucin oral de 20 mg/5 ml Se agreg la terapia escalonada. Nortriptilina Solucin oral de 10 mg/5 ml Se agreg la terapia escalonada. Clorhidrato de paroxetina Suspensin oral de 10 mg/5 ml Se agreg la terapia escalonada. Clorhidrato de sertralina Concentrado oral de 20 mg/ml Se agreg la terapia escalonada. CareSource.com Nombre de marca Nombre genrico Concentracin Notas Aripiprazol ODT Todas las concentraciones Se agreg la terapia escalonada. Aripiprazol Solucin de 1 mg/ml Se agreg la terapia escalonada. Clozapina ODT Todas las concentraciones Se agreg la terapia escalonada. Citrato de litio Solucin oral de 8 meq/5 ml Se agreg la terapia escalonada. Risperidona ODT Todas las concentraciones Se agreg la terapia escalonada. Risperidona Solucin oral de 1 mg/ml Se agreg la terapia escalonada. BromHidrato de galantamina Solucin oral de 4 mg/ml Se agreg la terapia escalonada. Qelbree Clorhidrato de viloxazina Todas las concentraciones Se agreg la terapia escalonada. Sulfato de dextroanfetamina Solucin oral de 5 mg/5 ml Se agreg la terapia escalonada. Jornay PM Clorhidrato de metilfenidato Todas las concentraciones Se agreg la terapia escalonada. Vyvanse Dimesilato de lisdexanfetamina Todas las concentraciones de los comprimidos masticables Se agreg la terapia escalonada. Carbaglu cido carglmico Comprimidos de 200 mg Se actualiz la autorizacin previa. cido carglmico Comprimidos de 200 mg Se actualiz la autorizacin previa. Pheburane Fenilbutirato de sodio 483 mg/gramo Se actualiz la autorizacin previa. Fenilbutirato de sodio Todas las concentraciones de los comprimidos y polvos Se actualiz la autorizacin previa. Ravicti Fenilbutirato de glicerol 1.1 gramo/ml Se actualiz la autorizacin previa. Olpruva Fenilbutirato de sodio Todas las concentraciones Se actualiz la autorizacin previa; se actualiz el lmite de edad. Ngenla Somatrogon-ghla Todas las concentraciones Se actualiz la autorizacin previa; se actualiz la terapia escalonada. CareSource.com Nombre de marca Nombre genrico Concentracin Notas Skytrofa Lonapegsomatropina-tcgd Todas las concentraciones Se actualiz la autorizacin previa; se elimin el lmite de edad. Androderm Testosterona Todas las concentraciones Se retir de la Lista de medicamentos preferidos unificada a nivel estatal (Statewide Uniform Preferred Drug List, SUPDL). Eucrisa Crisaborol Ungento al 2 % Se actualiz la autorizacin previa; se agreg el lmite de cantidad. Opzelura Fosfato de ruxolitinib Crema al 1.5 % Se actualiz la autorizacin previa; se agreg el lmite de edad. Zoryve Roflumilast Crema al 0.15 % y 0.3 % Se actualiz la autorizacin previa; se actualiz el lmite de cantidad. Zoryve Roflumilast Espuma al 0.3 % Se actualiz la autorizacin previa; se actualiz el lmite de cantidad. Topiramato ER, dispersable (genrico de Qudexy) Todas las concentraciones Se agreg la terapia escalonada. Anzemet Mesilato de dolasetrn Comprimidos de 50 mg Se agreg la terapia escalonada. Clorhidrato de granisetrn Comprimidos de 1 mg Se agreg la terapia escalonada. Solucin inyectable de clorhidrato de granisetrn Todas las concentraciones Se agreg la terapia escalonada. Clorhidrato de palonosetrn Todas las concentraciones Se agreg la terapia escalonada. Sancuso Granisetrn Parche de 3.1 mg/24 h Se actualiz la terapia escalonada. Sustol Granisetrn Inyeccin de 10 mg/0.4 ml Se agreg la terapia escalonada. Erygel Eritromicina Gel al 2 % Se retir de la SUPDL. CareSource.com Nombre de marca Nombre genrico Concentracin Notas Jubbonti Denosumab-bbdz Inyeccin de 60 mg/ml Se actualiz la autorizacin previa; se agreg la terapia escalonada. Prolia Denosumab Inyeccin de 60 mg/ml Se actualiz la autorizacin previa; se agreg la terapia escalonada. Wyost Denosumab-bbdz Inyeccin de 120 mg/1.7 ml Se actualiz la autorizacin previa; se agreg la terapia escalonada. Xgeva Denosumab Inyeccin de 120 mg/1.7 ml Se actualiz la autorizacin previa; se agreg la terapia escalonada. Estrgenos conjugados (genrico de Premarin) Todas las concentraciones de los comprimidos Se actualiz la autorizacin previa. Estrace Estradiol Todas las concentraciones de los comprimidos Se retir de la SUPDL. Abilify Mycite Aripiprazol Todas las concentraciones Se retir de la SUPDL. Perseris ER Risperidona Todas las concentraciones Se retir de la SUPDL. Rykindo ER Microesferas de risperidona Todas las concentraciones Se retir de la SUPDL. Qtern Dapagliflozina/Clorhidrato de saxagliptina Todas las concentraciones Se actualiz la terapia escalonada. Steglujan Ertuglioflozina/Fosfato de sitagliptina Todas las concentraciones Se actualiz la terapia escalonada. Fenilbutirato de glicerol (genrico de Ravicti) 1.1 gramos/ml Se actualiz la autorizacin previa. Pimecrolimus Crema al 1 % Se actualiz la autorizacin previa. Tacrolimus Todas las concentraciones de los ungentos Se actualiz la autorizacin previa. Enbumyst Bumetanida Aerosol nasal de 0.5 mg Se actualiz la autorizacin previa; se agreg el lmite de cantidad. CareSource.com Nombre de marca Nombre genrico Concentracin Notas Rezdiffra Resmetirom Todas las concentraciones Se actualiz la autorizacin previa. Qu debe hacer? Primero, hable con la persona que le receta los medicamentos. Es posible que haya otros medicamentos en la PDL de CareSource que puede tomar en su lugar. Hay varias maneras en que usted o la persona que receta pueden encontrar medicamentos: Puede consultar nuestro sitio web en CareSource.com/IN . En la pgina Afiliados, vaya a Herramientas y recursos, elija su plan y haga clic en Encontrar mis medicamentos con receta. Obien, llame a Servicios para Afiliados al 1-844-607-2829 (TTY: 1-800-743-3333 o 711). Estamos aqu para ayudarle. El horario de atencin de Servicios para Afiliados es de lunes a viernes, de 8a. m. a 8 p.m, hora del este (ET) y de 7 a.m. a 7 p.m., hora central (CT). Atentamente, CareSource IN-MED-M-3083118-V.7-SPA; Primer uso: 4/29/2025 Aprobado por OMPP: 4/29/2025 CareSource.com

GA-MED-M-4484156-SPA 2025 Member Handbook Update for Dental Grievances

Actualizacin del Manual del Afiliado 2025 La informacin ha cambiado desde que se imprimi y public el Manual del Afiliado 2025 en CareSource.com . Si desea presentar una queja por correo, visite CareSource.com/es/ga/members/tools resour ces/forms/medicaid. Luego, el ija "Formulario de queja/apelacin". Complete e imprima el formulario. El lugar al que lo enve depender del tipo de queja que presente. Existe una nueva direccin para las quejas odontolgicas. Quejas odontolgicas CareSource Attn: Member Appeal and Grievance P.O. Box 1251 Milwaukee, WI 53201 Todas las dems quejas CareSource Attn: Member Grievances P.O. Box 1947 Dayton, OH 45401 Puede presentar una queja en lnea o por telfono. Puede hacerlo para cualquier queja, incluidas las quejas odontolgicas. Llame al: 1-855-202-0729 (TTY : 711) Visite : MyLife.CareSource.com Para obtener ms informacin sobre quejas, consulte las pginas 52 y 53 de su Manual del Afiliado. Tiene preguntas? Llame a Servicios para Afiliados al 1-855-202-0729 (TTY: 711). Nuestro horario de atencin es de lunes a viernes, de 7 a. m. a 7 p. m., hora del este (ET). GA-MED-M-4484156-SPA Aprobado por D CH: 11/17/2025

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