PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLLabacavir tabs generic P QLLabacavir/lamivudine/zidovudine generic NP PA QLLABILIFY MAINTENA P PA QLLABSORICA NP PA QLLABSTRAL NP PA QLLacamprosate generic P QLLACANYA GEL NP PA QLLacarbose PACCOLATE P PA QLLacetazolamide ir generic Pacetazolamide sr generic P QLLACIPHEX TABS, SPRINKLES NP PA QLLacitretin generic NP PA QLLACTEMRA NP PA QLLACTHAR HP P PAACTIGALL PACTIMMUNE PACTIQ NP PA QLLACTIVELLA P QLLACTONEL NP PA QLLACTOPLUS MET XR NP PA QLLACULAR NP QLLACULAR LS NP QLLACUVAIL NP PA QLLacyclovir generic Pacyclovir ointment generic NP PA QLLACZONE GEL NP PAADALAT CC NP QLLadapalene gel, cream, lotion generic NP PA QLLADCIRCA NP PA QLLADDERALL XR NP PA QLLadefovir generic NP PA QLLADEMPAS NP PA QLLADRENACLICK NP PA QLLADVAIR DISKUS P QLLADVAIR HFA NP PA QLLADVATE PADVICOR NP PA QLLADYNOVATE NP PAADZENYS XR NP PA QLLAEROSPAN P QLLafeditab cr generic P QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

AFINITOR P PA QLLAFINITOR DISPERZ P PA QLLAFREZZA NP PAAFSTYLA NP PAAGGRENOX PAGRYLIN PAKYNZEO NP PA QLLALBENZA P PAalbuterol for nebulization generic 0.63mg/3ml, 1.25mg/3ml

NP PA QLL

albuterol for nebulization generic 2.5mg/3ml, 5mg/mlP QLL

albuterol sulfate tabs generic NP PAalbuterol/ipratropium neb soln generic P QLLalclometasone cream/oint. generic NP PAALDARA PALECENSA P PA QLLalendronate generic P QLLalendronate oral soln generic NP PA QLLALFERON N Palfuzosin generic P QLLALINIA P QLLALKERAN tablets Pall beta-adrenergic antagonists generics are preferred P QLLall topical corticosteroid generics (unless listed otherwise) PALLFEN Pallopurinol generic Palmotriptan generic NP PA QLLALOCRIL NP PA QLLalogliptin 6.25mg, 12.5mg generic NP PA QLLalogliptin-metformin generic NP PA QLLalogliptin-pioglitazone generic NP PA QLLALOMIDE NP PA QLLALORA P QLLalosetron generic NP PA QLLALPHAGAN-P 0.1% P QLLALPHAGAN-P 0.15% P QLLALPHANATE NP PAALPHANINE Palprazolam er, odt generic NP PA alprazolam generic P QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

ALPROLIX NP PAALREX P QLLALTABAX NP PA QLLALTOPREV NP PA QLLaluminum hydroxide generic P PAALVESCO NP PA QLLAMBIEN NP PA QLLAMBIEN CR NP PA QLLAMBISOME INJ. NP PAamcinonide lotion, ointment generic NP PAAMERGE NP PA QLLamethia, -lo generic NP PA QLLamethyst generic NP PA QLLAMICAR Paminocaproic acid tabs generic Pamiodarone/pacerone generic PAMITIZA NP PA QLLamitriptyline generic Pamlodipine P QLLamlodipine/atorvastatin generic NP PA QLLamlodipine/benazepril generic P QLLamlodipine/valsartan generic NP PA QLLamlodipine/valsartan/hctz generic NP PA QLLamox/clavulanate 250-125mg tabs generic NP PAamox/clavulanate 250-62.5mg/5ml susp generic NP PA QLL

amox/clavulanate chew tabs, IR tabs, susp generic P QLLamox/clavulanate ER tabs generic NP PA QLLamoxapine generic Pamoxicillin 775mg generic NP PA QLLAMPHADASE P PAamphetamine salt combination ER generic NP PA QLLamphetamine salt combination generic P PA (> 21 years) QLLampicillin/sulbactam inj. generic PAMPYRA P PA QLLAMRIX NP PA QLLAMTURNIDE NP PA QLLANADROL-50 P PAANADROL-50 P PAanastrozole generic P QLLANDRODERM PATCH P PA QLLANDROGEL GEL, PACKETS 1.62%, PUMP P PA QLLANDROID NP PA

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

ANDROXY P PAANGELIQ P QLLANORO ELLIPTA NP PA QLLANTARA NP PA QLLANZEMET INJECTION NP PAANZEMET TABS NP PA QLLAPEXICON E CREAM NP PAAPIDRA NP PA QLLAPIDRA SOLOSTAR NP PA QLLAPLENZIN NP PA QLLAPOKYN Papraclonidine 0.5% NP PAAPRISO PAPTENSIO XR NP PA QLLAPTIOM NP PA QLLAPTIVUS NP PAARALAST-NP P PAaranelle (generic Tri-Norinyl) NP PAARANESP NP PA QLLARAVA NP QLLARBINOXA NP PAARCALYST P PA QLLARCAPTA NP PA QLLARICEPT 23MG NP PA QLLARICEPT, -ODT 5MG, 10MG NP QLLARIMIDEX NP QLLaripiprazole odt generic NP PA QLLaripiprazole oral soln. generic NP PA QLLaripiprazole tabs generic P PA QLLARISTADA P PA QLLARMOUR THYROID PARNUITY ELLIPTA NP PA QLLAROMASIN NP QLLARTHROTEC NP PA QLLASACOL HD NP PAASMANEX HFA NP PA QLLASMANEX TWISTHALER 110mcg P PA (> 12 years) QLLASMANEX TWISTHALER 220mcg P QLLaspirin (enteric coated) Paspirin/dipyridamole generic NP PAASTAGRAF XL NP PA QLLASTEPRO 0.15% NP PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

ATACAND NP PA QLLATACAND HCT NP PA QLLATELVIA NP PA QLLatorvastatin generic P QLLatovaquone generic NP PAatovaquone-proguanil generic NP PAATRALIN GEL P PA (> 21 years) QLLATRIPLA Patropine sulfate ophthalmic soln. generic PATROVENT HFA P QLLAUBAGIO P QLLAUGMENTIN 250/5ML SUSP NP PA QLLAUGMENTIN XR NP PA QLLAURYXIA NP PA QLLAUVI-Q NP PA QLLAVANDAMET NP PA QLLAVANDIA NP PA QLLAVELOX NP PA QLLAVELOX ABC NP PA QLLAVINZA NP PA QLLAVITA P PA (> 21 years) QLLAVODART NP PA QLLAVONEX P QLLAVYCAZ NP PA QLLAXERT NP PA QLLAXIRON NP PA QLLAZACTAM NP PAAZASITE NP PAazelastine 137mcg (0.1%) generic P QLLazelastine 0.15% generic NP PA QLLazelastine ophth. generic NP PA QLLAZELEX P PA (> 21 years)AZILECT NPazithromycin generic P QLLAZOPT PAZOR P PA QLLaztreonam generic P PAAZULFIDINE EN-TAB Pbaclofen generic PBACTROBAN CREAM P QLLBACTROBAN NASAL P QLLBACTROBAN OINTMENT NP QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

balsalazide generic PBANZEL SUSPENSION NP PA QLLBANZEL TABS P PA QLLBARACLUDE P QLLBEBULINE PBECONASE AQ NP PA QLLBELBUCA NP PA QLLBELSOMRA NP PA QLLbenazepril generic P QLLbenazepril HCTZ generic P QLLBENEFIX PBENICAR P QLLBENICAR HCT P QLLBENZACLIN P QLLBENZAMYCIN PAK NP PABENZEFOAM NP PA QLLbenzoyl peroxide cleanser generic Pbenzoyl peroxide cream 5.5% generic NP PA QLLbenzoyl peroxide pads generic NP PABEPREVE P QLLBERINERT PBESIVANCE NP PA QLLBETAGAN NPbetamethasone dipropionate (augmented) cream, lotion, ointment generic NP PA

betamethasone dipropionate gel, ointment generic NP PAbetamethasone valerate aerosol foam 0.12%, lotion generic NP PABETAPACE, -AF NP QLLBETASERON P QLLbetaxolol generic PBETHKIS NP PA QLLBETIMOL NP PABETOPTIC S Pbexarotene generic NP PA QLLBIAXIN NP QLLBIAXIN SUSPENSION NP QLLBIAXIN XL NP QLLbicalutamide P QLLBIDIL NP PA QLLbimatoprost generic NP PA QLLBINOSTO NP PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

BIVIGAM P PABOSULIF P PA QLLbpo, se bpo cloths generic NP PA QLLBPS gel PBREO ELLIPTA NP PA QLLBRILINTA P QLLbrimonidine 0.15% generic NP PA QLLbrimonidine 0.2% generic PBRISDELLE NP PA QLLBRIVIACT NP PA QLLbromfenac ophth soln generic NP PA QLLbromocriptine generic PBROVANA P budeprion XL P QLLbudesonide inhalation susp NP PA QLLbudesonide nasal susp. generic NP PA QLLbudesonide SR caps generic P QLLBUNAVAIL NP PA QLLBUPAP NP PABUPHENYL P QLLbuprenorphine generic P PA QLLbuprenorphine/naloxone sl tabs generic NP PA QLLbuproban/bupropion sr 150mg (generic Zyban) P PA QLLbupropion ER & SR 100mg, 150mg generic P QLLbupropion IR generic P QLLbupropion SR 200mg generic P QLLbuspirone generic P generic NP PAbutalbital/acetaminophen 325mg/caffeine/codeine generic P QLLbutalbital-acetaminophen tabs generic Pbutalbital-acetaminophen-caffeine capsule generic NP PAbutalbital-acetaminophen-caffeine tabs generic Pbutalbital-aspirin-caffeine capsule NP PAbutorphanol nasal generic P QLLBUTRANS P QLLBYDUREON P PA QLLBYETTA NP PA QLLBYSTOLIC NP PA QLLCABOMETYX P PA QLLcaffeine citrate injection 60mg/3ml generic PCALAN NP QLLCALAN SR NP QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

CALCIBIND Pcalcipotriene cream generic P QLLcalcipotriene oint. generic NP PAcalcipotriene scalp soln. generic Pcalcipotriene-betamethasone ointment generic NP PA QLLcalcitonin nasal solution generic P QLLcalcitriol generic Pcalcitriol ointment generic NP PA QLLcalcium acetate caps NP PAcalcium acetate tabs Pcalcium carbonate generic P PAcalcium carbonate/glycine generic P PAcalcium lactate P PACAMBIA NP PA QLLcamrese, -lo generic NP PA QLLCANASA PCANCIDAS INJ. NP PAcandesartan generic NP PA QLLcandesartan/hctz generic NP PA QLLcapecitabine generic NP PACAPEX SHAMPOO NP PACAPRELSA NP PA QLLcaptopril generic P QLLcaptopril HCTZ generic P QLLCARAC P QLLCARBAGLU P PAcarbamazepine er/sr 200mg, 400mg generic P QLLcarbamazepine ir generic Pcarbamazepine sr 12 hr (generic Carbatrol) NP PACARBATROL Pcarbidopa generic P QLLcarbidopa/levodopa disintegrating tablets generic NP PAcarbidopa/levodopa generic Pcarbidopa/levodopa/entacapone generic NP PAcarbinoxamine generic PCARDENE SR NP PA QLLCARDIZEM LA 120mg P QLLCARDURA XL NP PACARIMUNE NF P PAcarisoprodol 250mg generic NP PA QLLcarisoprodol 350mg generic P QLLcarisoprodol w/aspirin and codeine generic NP PA

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

carisoprodol w/aspirin generic Pcarteolol hcl generic PCASODEX NP QLLCATAPRES-TTS P QLLCAYSTON P QLLCEDAX NP PA QLLcefaclor caps generic P QLLcefaclor er generic P QLLcefaclor oral suspension generic NP PA QLLcefadroxil generic P QLLcefazolin iv generic Pcefdinir P QLLcefditoren generic P QLLcefixime suspension generic NP PA QLLcefpodoxime generic P QLLcefprozil generic P QLLceftibuten generic NP PA QLLCEFTIN SUSPENSION P QLLceftriaxone generic Pcefuroxime generic susp P QLLcefuroxime generic tabs P QLLcelecoxib generic NP PA QLLCELLCEPT IV INJ PCELLCEPT SUSPENSION P PA (>18 years)CELONTIN Pcephalexin 250mg, 500mg caps generic P QLLcephalexin 750mg generic NP PA QLLcephalexin tabs generic NP PA QLLCERDELGA P PA QLLCEREZYME P PACERUMENEX PCESAMET NP PA QLLcetirizine syrup generic Rx/OTC P QLLcetirizine tabs generic OTC P QLLcevimeline generic PCHANTIX NP PA QLLCHENODAL NP PAchlordiazepoxide generic P QLLchloroquine phosphate generic Pchlorothiazide 500mg injection generic Pchlorpropamide generic NP PAchlorthalidone generic P

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

chlorzoxazone generic PCHOLBAM P PA QLL

cholestyramine/cholestyramine lite packets generic NP PA

cholestyramine/cholestyramine lite powder generic PCIALIS 2.5MG, 5MG NP PA QLLCICLODAN KIT NP PA QLLciclopirox 0.77% cream, suspension generic Pciclopirox 8% and vitamin E 5% kit NP PAciclopirox gel/shampoo generic NP PAciclopirox nail lacquer P PAcilostazol generic PCILOXAN ophth. oint. Pcimetidine generic P QLLCIMZIA NP PA QLLCINRYZE PCIPRO HC PCIPRO SUSPENSION P QLLCIPRODEX P QLLciprofloxacin HCL drops P QLLciprofloxacin otic generic NP PA ciprofloxacin suspension generic NP PA QLLciprofloxacin/SR generic P QLLcitalopram generic P QLLCLARINEX SYRUP NP PA QLLCLARINEX-D P PA QLLclarithromycin susp. P QLLclarithromycin/ER generic P QLLCLEOCIN 75MG CAPS PCLEOCIN SUPPOSITORY NP PACLEOCIN/D5W INJ. PCLIMARA P QLLCLIMARA PRO PATCH P QLLCLINDACIN KIT PAC 1% NP PA QLLCLINDAGEL NP PAclindamycin 1% gel, lotion, topical solution generic Pclindamycin 2% cream generic Pclindamycin aer 1% generic NP PAclindamycin caps generic Pclindamycin for oral solution generic P QLLclindamycin in D5W injection generic NP PA

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

clindamycin injection 150MG/ML (900MG/6ML) generic Pclindamycin pads/swabs generic NP PAclindamycin-benzoyl peroxide gel 1.2-5% (generic for Duac) NP PAclindamycin-benzoyl peroxide gel 1-5% (generic for Benzaclin) NP PA QLLCLINDESSE NP PA QLLclobetasol cream, lotion, shampoo generic NP PAclobetasol emollient cream NP PAclobetasol emulsion foam (generic OLUX-E) NP PA QLLclobetasol foam (generic OLUX) NP PA QLLclobetasol spray generic NP PA QLLCLOBEX LOTION, -SHAMPOO NP PACLOBEX SPRAY NP PA QLLclocortolone generic NP PA QLLCLODAN KIT NP PA QLLCLODERM NP PA QLLclomipramine generic Pclonazepam generic P QLLclonazepam odt generic NP PAclonidine 0.1mg er generic NP PA QLLclonidine patch NP PA QLLclopidogrel 300mg generic NP PA QLLclopidogrel 75mg generic P QLLclorazepate dipotassium generic P QLLclotrimazole troche generic Pclozapine generic P PA (<18 years) QLLclozapine odt generic NP PA QLLCNL8 NAIL KIT NP PA QLLCOARTEM NP PA QLLcolchicine generic P QLLCOLCRYS NP PA QLLCOLESTID NP PAcolestipol generic NP PACOLYTE P QLLCOMBIGAN 10ml NP PA QLLCOMBIGAN 5ml P QLLCOMBIPATCH PCOMBIVENT RESPIMAT P QLLCOMETRIQ P PA QLLCOMPLERA NP PA QLLCOMTAN P QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

CONDYLOX GEL PCONZIP NP PA QLLCOPAXONE 40MG/ML NP PA QLLCOPAXONE KIT 20MG/ML P QLLCOPEGUS NP PACORDRAN NP PA QLLCOREG NP QLLCOREG CR NP PA QLLCORLANOR NP PA QLLCORTIFOAM Pcortisone generic Pcorvita generic NP PA QLLCORVITE P QLLCORZIDE P QLLCOSENTYX P PA QLLCOSOPT NP QLLCOSOPT PF NP PA QLLCOTELLIC P PA QLLCOUMADIN INJ PCOUMADIN TABS PCREON P QLLCRESEMBA CAPS NP PA QLLCRESTOR NP PA QLLCRINONE GEL NP PACRIXIVAN NP PACROLOM NP QLLcromolyn sodium generic P QLLcromolyn sodium oral conc. 100mg/5ml generic PCUBICIN P PACUPRIMINE PCUTIVATE CREAM, OINT. NP PACUVITRU P PACUVPOSA NP PA QLLCYCLESSA NPcyclobenzaprine 5mg, 10mg generic P QLLcyclobenzaprine 7.5mg generic NP PA QLLCYCLOGYL 0.5%, 2% PCYCLOGYL 1% NPcyclopentol 1% ophth soln generic Pcyclopentol 2% ophth soln generic NP PAcyclophosphamide generic Pcycloserine generic P

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

CYCLOSET NP PA QLLcyclosporine generic PCYKLOKAPRON NP PACYSTAGON PCYSTARAN P QLLCYTOGAM P PACYTOMEL PCYTOVENE P PADAKLINZA NP PA QLLDALIRESP NP PA QLLDALVANCE NP PA QLLdanazol P PAdantrolene sodium generic PDAPSONE PDARAPRIM P PADAYTRANA NP PA QLLDDAVP NASAL PDDAVP TAB NPDELATESTRYL P PADELZICOL P QLLDEMSER PDENAVIR CREAM NP PADEPAKOTE sprinkles PDEPO-PROVERA 400mg/ml PDEPO-SQ PROVERA 104 NP QLLDEPO-TESTOSTERONE P PADERMOTIC NP PADESCOVY P QLLdesimpramine generic Pdesloratadine ODT generic P PA QLLdesloratadine tab generic NP PA QLLdesmopressin generic PDESONATE NP PAdesoximetasone cream, gel, ointment generic NP PA QLLDESOXYN NP PA QLLdesvenlafaxine er tabs generic NP PA QLLdexamethasone generic PDEXEDRINE CAPS NP PA QLLDEXILANT NP PA QLLdexmethylphenidate, -er generic NP PA QLLDEXPAK NP PAdextroamphetamine er generic NP PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

dextroamphetamine generic P PA (> 21 years) QLLdextroamphetamine soln. generic NP PA QLLDIALYVITE SUPREME D NP PADIALYVITE/ZINC P PADIAMOX SEQUELS NP QLLDIASTAT P PA (> 21 yrs) QLLdiazepam generic P QLLdiazepam rectal gel generic NP PA QLLDICLEGIS NP QLLdiclofenac gel generic NP PA QLLdiclofenac ophth soln generic NP PAdiclofenac sodium er tab generic NP PAdiclofenac solution 1.5% NP PA QLLdiclofenac w/misoprostol generic NP PA QLLdidanosine delayed-release caps generic PDIFFERIN NP PA (> 21 years) QLLDIFICID NP PA QLLdiflorasone diacetate cream and ointment generic NP PADIFLUCAN NPDIFLUCAN 150MG TAB NP QLLdigoxin generic P

dihydrocodeine compound cap (acetaminophen/caffeine/dihydrocodeine) generic Pdihydrocodeine/aspirin/caffeine cap (generic Synalgos-DC) NP PA QLLdihydroergotamine spray generic NP PA QLLDILACOR XR NP QLLDILANTIN NPDILANTIN INFATAB NP DILAUDID-5 1mg/ml Pdiltiazem (generic Cardizem) P QLLdiltiazem cd/er 360mg (generic Cardizem CD) NP PA QLLdiltiazem cd/er,cartia xt, dilt-cd (generic Cardizem CD-all strengths except 360mg) P QLLdiltiazem er, dilt-xr (generic Dilacor XR) P QLL

diltiazem er,diltzac,taztia xt caps (generic Tiazac) NP PA QLLdiphenoxylate-atropine generic PDIPROLENE AF NPDIPROLENE LOTION NP PADIPROLENE OINT NPdipyridamole generic P

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

disulfiram generic P QLLDITROPAN TABS/SYRUP NPdivalproex DR, -ER generic Pdivalproex sprinkles generic NP PADIVIGEL NP PAdocusate sodium/calcium P PAdonepezil 23mg generic NP PA QLLdonepezil, -ODT generic P QLLDORAL NP PA DORIBAX NP PA QLLDORYX, -MPC NP PA QLLdorzolamide generic Pdorzolamide/timolol generic PDOSTINEX P QLLdoxepin generic Pdoxercalciferol generic NP PAdoxycycline (rosacea) 40mg cap generic NP PA QLLdoxycycline hyclate delayed release tabs NP PA QLLdoxycycline hyclate generic Pdoxycycline monohydrate 50mg, 100mg, 150mg caps, 75mg, 100mg, 150mg tabs generic Pdoxycycline monohydrate 75 mg caps, 50 mg tabs generic NP PAdoxycycline suspension generic NP PAdronabinol generic P PA

drospirenone/ethinyl estradiol/levomefolate generic NP PA QLLDUAC P QLLDUAVEE NP PA QLLDUETACT NP PA QLLDUEXIS NP PA QLL

DULERA P QLL

duloxetine 20mg, 30mg, 60mg generic P QLLduloxetine 40mg generic NP PA QLLDUOPA PDURAGESIC NP QLLDUREZOL P QLLDURLAZA NP PA QLLdutasteride generic NP PA QLLdutasteride-tamsulosin generic NP PA QLLDUTOPROL P QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

DYANAVEL XR SUSP. NP PA QLLDYMISTA NP PA QLLDYNACIRC CR P QLLDYNAPEN SUSP PE.E.S. 400 TAB NP PA QLLE.E.S. GRANULES SUSPENSION NP PA QLLeconazole generic PEDARBI NP PA QLLEDARBYCLOR NP PA QLLEDLUAR NP PA QLLEDURANT P PA QLLEFFIENT NP PA QLLEFUDEX NPEGRIFTA NP PA QLLELAPRASE P PAELELYSO P PAELESTAT NP PA QLLELESTRIN NP PAELIDEL P PA QLLELIGARD PELIQUIS P QLLELIXOPHYLLIN ELIXIR PELLA P QLLELMIRON PELOCON NP QLLELOCTATE NP PAEMADINE NP PA QLLEMBEDA P QLLEMCYT PEMEND CAPS NP QLLEMEND SUSP NP PA QLLEMSAM NP PA QLLEMTRIVA PEMVERM NP PAENABLEX NP PA QLLenalapril generic P QLLenalapril HCTZ generic P QLLenalaprilat generic P QLLENBREL P PA QLLENJUVIA P QLLenoxaparin generic P QLLENSTILAR NP PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

entacapone generic NP PAentecavir generic NP PAENTOCORT EC NP QLLENTRESTO NP PA QLLENVARSUS XR NP PAEPANED P PA (>12 years) QLLEPCLUSA P PA QLLEPIDUO P PA (> 21 years) QLLEPIDUO FORTE NP PA QLLepinastine generic NP PA QLLepinephrine 0.15mg, 0.3mg injection generic P QLLEPIPEN P QLLEPIVIR HBV PEPIVIR SOLN P QLLeplerenone generic NP PA QLLEPOGEN P PAepoprostenol Peprosartan generic NP PA QLLEPZICOM PEQUETRO Pergocalciferol generic PERIVEDGE P PA QLLERTACZO NPERY PAD 2% NP PAERYPED NP PA QLLERY-TAB NP PA QLLERYTHROCIN NP PA QLLerythromycin cap, tab generic NP PA QLLerythromycin ethyl succinate 400mg tab generic P QLLerythromycin ethyl succinate suspension generic P PA (>12 yrs) QLLerythromycin pads generic NP PAerythromycin/benzoyl peroxide gel (generic Benzamycin) PESBRIET NP PA QLLescitalopram soln., tabs generic P QLLesomeprazole inj. generic NP PA QLLesomeprazole magnesium cap (generic Nexium) NP PA QLLesomeprazole strontium cap generic NP PA QLLestazolam generic P QLLESTRACE CREAM P QLLestradiol patch generic NP PA QLLestradiol tabs generic Pestradiol/norethindrone generic NP PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

ESTRASORB NP PAESTROGEL NP PA QLLESTROSTEP FE Peszopiclone generic NP PA QLLethambutol generic Petidronate disodium generic P QLLetodolac er tab generic NP PAetoposide capsules generic PEURAX LOTION NP PA QLLEURAX CREAM NP PA QLLEVAMIST NP PAEVEKEO NP PA QLLEVOCLIN NP PAEVOTAZ P PA QLLEVZIO NP PA QLLEXALGO NP PA QLLEXELDERM NPEXELON PATCHES P QLLexemestane generic P QLLEXFORGE P PA QLLEXFORGE HCT P PA QLLEXJADE P EXTAVIA NP PA QLLEXTINA NP PA QLLFABIOR AER 0.1% NP PA QLLfamciclovir generic P QLLfamotidine suspension generic NP PA QLLfamotidine tab generic P QLLFAMVIR NP QLLFANAPT NP PA QLLFARESTON PFARXIGA NP PA QLLFARYDAK P PA QLLFAZACLO NP PA (<18 years) QLLfelbamate generic NP PA QLLfelbamate suspension generic NP PAFELBATOL NP PA QLLfelodipine er generic NP PA QLLFEMARA P QLLFEMCON FE CHEW P QLLFEMHRT P QLLFEMRING NP QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

fenofibrate generic P QLLfenofibrate tab (generic Fenoglide) NP PA QLLfenofibric acid generic NP PA QLLFENOGLIDE NP PA QLLfenoprofen calcium cap, tab generic NP PA QLLfentanyl citrate generic (generic Actiq) NP PA QLLfentanyl patch generic (generic Duragesic)- 37.5-, 62.5-, 87.5 mcg/hr NP PA QLLfentanyl patch generic (generic Duragesic)-12-, 25-, 50-, 75-, 100 mcg/hr P QLLFENTORA NP PA QLLFERAHEME NP PAFERIVA PFERRALET 90 PFERRETTES FE CHEW TABS Pferric gluconate injection generic NP PAFERRIPROX NP PA QLLFETZIMA NP PA QLLFEXMID NP PA QLLFIBRICOR NP PA QLLFINACEA NP PA QLLFINACEA NP PAFINACEA KIT NP PA QLLfinasteride generic P QLLFIORICET (300mg APAP) NP PA QLLFIORICET W/CODEINE (300mg APAP) NP PA QLLFIRAZYR P QLLFIRMAGON P PA QLLFLAGYL CAPS NP PAFLAGYL ER NP PA QLLflavoxate generic P QLLFLEBOGAMMA/DIF P PAFLECTOR PAD NP PAFLOLAN NP PAFLOMAX NP QLLFLO-PRED SUSPENSION NP PAFLOVENT DISKUS/HFA P QLLfluconazole 150mg tab generic P QLLfluconazole generic Pflucytosine generic Pflunisolide generic NP PA QLLfluocinolone (otic) oil 0.01% P

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

fluocinolone acetonide cream, ointment, scalp/body oil, solution generic NP PAfluocinonide cream 0.1% generic P QLLfluocinonide ointment generic NP PAfluorouracil 0.5% cream generic NP PAfluorouracil 5% cream, inj., soln. generic Pfluoxetine 10mg, 20mg tabs generic NP PA QLLfluoxetine 60mg tab generic NPfluoxetine 90mg caps generic NP PA QLLfluoxetine generic P QLLfluphenazine decanoate vial generic P QLLflurazepam generic P QLLflurbiprofen ophth susp generic Pfluticasone cream, lotion, ointment generic NP PAfluticasone generic P QLLfluvastatin er generic NP PA QLLfluvastatin generic NP PA QLLfluvoxamine er generic NP PA QLLfluvoxamine generic P QLLFML-FORTE P QLLFML-S PFOCALIN P PA (> 21 years) QLLFOCALIN XR P PA (> 21 years) QLLfolic acid 1mg generic P QLLfondaparinux generic NP PA QLLFORADIL P QLLFORFIVO XL NP PA QLLFORTAMET ER NP PA QLLFORTEO NP PAFORTEO NP PAFORTESTA GEL NP PA QLLFORTICAL NP PA QLLFOSAMAX SOLUTION NP PA QLLFOSAMAX-D NP PA QLLfosinopril generic P QLLfosinopril HCTZ generic P QLLFOSRENOL NP PAFRAGMIN P QLLFROVA NP PA QLLFULYZAQ NP PA QLLFUSION PLUS PFUZEON NP PA QLLFYCOMPA NP PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

gabapentin caps generic Pgabapentin solution generic Pgabapentin tabs generic NP PAGABITRIL NP PA QLLGABLOFEN INJ. Pgalantamine , -er generic Pgalantamine soln. generic NP PAGAMASTAN P PAGAMMAGARD/SD P PAGAMMAKED P PAGAMMAPLEX P PAGAMUNEX-C P PAganciclovir caps generic Pganciclovir inj generic NP PAGANTRISIN PEDIATRIC Pgatifloxacin ophth. soln. generic NP PA QLLGATTEX NP PA QLLGELNIQUE NP PA QLLgemfibrozil generic P QLLGENERESS FE CHEW NP PA QLLgeneric NSAIDs (unless listed otherwise) P QLLGENOTROPIN P PAGENVOYA P QLLGEODON inj Pgianvi generic NP PA QLLGIAZO NP PA QLLgildess 24 fe generic PGILENYA P QLLGILOTRIF P PA QLLGLASSIA P PAGLATOPA NP PA QLLGLEEVEC PGLEOSTINE Pglimepiride generic Pglipizide, XL Pglipizide/metformin generic P QLLGLUMETZA ER NP PA QLLglyburide generic P QLLglyburide/metformin generic P QLLGLYCATE NP PA QLLglycopyrrolate generic PGLYSET P

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

GLYXAMBI NP PA QLLGOLYTELY P QLLGONITRO POWDER NP PAGRALISE NP PA QLLgranisetron generic NP PA QLLGRANIX NP PA QLLGRASTEK NP PA QLLgriseofulvin microsize tab generic NP PA QLLgriseofulvin oral susp generic Pgriseofulvin ultramicrosize tab generic P QLLguanfacine er generic NP PA QLLGYNAZOLE PHALOG, -E NP PAHALONATE KIT NP PA QLLhaloperidol decanoate vial generic P QLLHARVONI P PA QLLHECTOROL NP PAHELIDAC NP PA QLLHELIXATE PHEMANGEOL (covered 5 weeks-12 months old) PHEMOCYTE PLS PHEMOCYTE-F PHEMOFIL PHEPAGAM B NP PAheparin generic PHEPSERA P QLLHETLIOZ NP PA QLLHIZENTRA P PAHORIZANT NP PA QLLHUMALOG P QLLHUMALOG KWIKPEN 200 units/ml NP PA QLLHUMALOG MIX 50/50 P QLLHUMALOG MIX 75/25 P QLLHUMALOG pens and cartridges P PA (> 21 years) QLLHUMATE-P NP PAHUMATROPE NP PAHUMIRA P PA QLLHUMULIN 70/30 P QLLHUMULIN N P QLLHUMULIN pens and cartridges P PA (> 21 years) QLLHUMULIN R 100, U-500 P QLLHYCAMTIN P

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

HYCET NP PA QLLhydrochlorothiazide generic Phydrocodone/ibuprofen 2.5-200mg, 5-200mg, 10-200mg generic NP PAhydrocodone/ibuprofen 7.5-200mg generic Phydrocodone-APAP 10mg/325mg/15mL soln. generic NP PA QLLhydrocodone-APAP 5-300mg, 10-300mg, 7.5-300mg tab generic P QLLhydrocodone-APAP 7.5mg/325mg/15mL soln. generic P QLLhydrocortisone acetate cream generic P QLLhydrocortisone acetate gel generic Phydrocortisone butyrate cream generic NP PAhydrocortisone generic Phydrocortisone valerate cream, ointment generic NP PAhydromorphone er tabs generic NP PA QLLhydromorphone ir generic Phydromorphone liquid 1mg/ml generic NP PAhydroxychloroquine sulfate generic PHYLENEX P PAHYQVIA P PAHYSINGLA ER NP PA QLLIB STAT ORAL SPRAY NP QLLibandronate -inj., -tabs generic NP PA QLLIBRANCE P PA QLLibudone generic PICLUSIG P PA QLLIDELVION NP PAILARIS P PA QLLILEVRO P QLLIMBRUVICA P PA QLLimipenem-cilastatin generic NP PAimipramine caps generic NP PAimipramine tabs generic Pimiquimod 5% generic PIMITREX INJECTION P QLLIMITREX NASAL SPRAY P QLLIMITREX tabs NP QLLINCRELEX NP PAINCRUSE ELLIPTA NP PA QLLindomethacin er cap generic NP PAindomethacin IR generic P

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

INFED P PAINJECTAFER NP PA QLLINLYTA P PA QLLINNOPRAN XL NP PA QLLINOVA KITS NP PA QLLINTEGRA F PINTEGRA PLUS PINTELENCE NP PA QLLINTRON A PINTUNIV P PA (> 21 years) QLLINVANZ P PAINVEGA NP PA QLLINVEGA SUSTENNA, -TRINZA P PA QLLINVIRASE NP PAINVOKAMET, -XR NP PA QLLINVOKANA NP PA QLLIOPIDINE Pipratropium inhalation solution generic P QLLipratropium nasal spray generic P QLLirbesartan generic P QLLirbesartan/HCTZ generic P QLLIRENKA NP PA QLLIRESSA P PA QLLISENTRESS P PA QLLisoniazid generic PISOPTIN SR NP QLLISOPTO CARBACHOL Pisosorbide generic Pisotretinoin generics P PA QLLisradipine generic NP PA QLLISTALOL NP PAitraconazole generic P PA QLLivermectin generic NP PAIXINITY NP PAJADENU NP PA QLLJAKAFI P QLLJALYN NP PA QLLJANUMET NP PA QLLJANUMET XR NP PA QLLJANUVIA NP PA QLLJARDIANCE NP PA QLLJENTADUETO P PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

JENTADUETO XR NP PA QLLjinteli (norethindrone/estradiol 1mg-5mcg) generic Pjolessa generic P QLLJUBLIA SOLN. 10% NP PA QLLjunel fe 24 generic NP PAJUXTAPID NP PA QLLKABIVEN NP PAKADIAN 10MG, 20MG, 30MG, 50MG, 60MG, 100MG P QLLKADIAN 40MG, 70MG, 80MG, 130MG, 150MG, 200MG NP PA QLLKALBITOR NPKALETRA P QLLKALYDECO P PA QLLKAPVAY P PA (> 21 years) QLLKARBINAL ER NP PA QLLKEFLEX 750mg P QLLKENALOG AEROSOL NP PAKENALOG-10,40 INJ PKEPPRA INJECTION NP QLLKEPPRA TABS NPKERAFOAM NP PAKERYDIN NP PA QLLKETEK NP PA QLLketocon plus kit generic NP PA QLLketoconazole aer 2% foam generic NP PAketoconazole cream, shampoo PKETODAN KIT NP PA QLLketoprofen, -er generic NP PAketorolac ophthalmic generic P QLLKEVEYIS P PA QLLKHEDEZLA NP PA QLLKINERET NP PA QLLKITABIS PAK P QLLKLARON PKLOR-CON PKOATE PKOGENATE NP PAKOMBIGLYZE P PA QLLKORLYM P PA QLLKOVALTRY NP PAKRISTALOSE NP PA QLLKUVAN P

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

KYNAMRO NP PA QLLlactulose generic P LAMICTAL KITS (immediate release) NP PALAMICTAL ODT TABS, KITS NP PA LAMICTAL XR KITS NP PA LAMISIL SOLUTION NPlamivudine generic P QLLlamivudine HBV generic NP PA QLLlamivudine soln. generic NP PA QLLlamivudine/zidovudine generic P QLLlamotrigine chewable dispersable tab generic Plamotrigine er tabs generic NP PAlamotrigine kits (immediate release and odt) NP PA QLLlamotrigine odt generic NP PAlamotrigine tabs generic PLANOXIN 0.0625MG, 0.1875MG NP PALANOXIN INJ Plansoprazole generic NP PA QLLlansoprazole/amoxicillin/clarithromycin generic NP PA QLLLANTUS P QLLLANTUS pens and cartridges P PA (> 21 years) QLLlarin 24 fe generic PLASTACAFT NP PA QLLlatanoprost generic P QLLlatrix xm generic NP PA QLLLATUDA P PA** QLLLAZANDA NP PAleena (generic Tri-Norinyl) NP PAleflunomide generic P QLLLENVIMA P PA QLLLESCOL, -XL P QLLLETAIRIS P QLLletrozole generic NP PA QLLLEUKERAN PLEUKINE P PA QLLleuprolide 1mg/0.2ml (5mg/ml) injection generic Plevalbuterol neb generic NP PA QLLLEVAQUIN TABS NP QLLLEVATOL P QLLLEVEMIR P QLLLEVEMIR FLEXPEN P PA (> 21 years) QLLlevetiracetam injection generic P QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

levetiracetam solution/tabs generic Plevetiracetam tabs er generic NP PA QLLlevobunolol hcl generic Plevocarnitine generic Plevocetirizine syrup generic NP PA QLLlevocetirizine tab generic P QLLlevofloxacin 0.5% ophth generic NP PA QLLlevofloxacin in D5W (generic Levaquin Premix) Plevofloxacin injection 25mg/ml generic NP PA QLLlevofloxacin solution generic NP PA QLLlevofloxacin tabs generic P QLLlevonorgestrel/ethinyl estradiol (generic LoSeasonique) NP PA QLLlevothyroxine inj. generic P PA QLLlevothyroxine tabs generic PLEXIVA NP PALIALDA NP PAlidocaine cream, lotion 3% generic Plidocaine gel 2%, jelly 2%, soln. 4% generic Plidocaine ointment 5% generic NP PAlidocaine pad 5% generic NP PA QLLLIDODERM NP PA QLLLINCOCIN PLINDANE LOTION, SHAMPOO NP PA QLLlinezolid iv soln., suspension generic NP PA QLLlinezolid tabs generic P PA QLLLINZESS NP PA QLLLIORESAL INJ. Pliothyronine tabs generic NP PALIPITOR NP QLLLIPOFEN NP PA QLLLIPTRUZET NP PA QLLlisinopril generic P QLLlisinopril HCTZ generic P QLLlithium carbonate generic PLIVALO NP PA QLLLO LOESTRIN FE NP PA QLLLO MINASTRIN FE NP PA QLLLOESTRIN 24 FE Plomedia 24 fe generic NP PALONSURF P PA QLLLOPROX SHAMPOO NP PAloratadine, -D generic OTC P QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

lorazepam generic P QLLLORTAB ELIXIR P QLLLORZONE NP PA QLLlosartan generic P QLLlosartan/HCTZ generic P QLLLOSEASONIQUE P QLLLOTEMAX GEL P QLLLOTEMAX OINT P QLLLOTEMAX SUSP P QLLLOTRONEX NP QLLlovastatin generic P QLLLOVAZA NP PA QLLLOVAZA (formerly OMACOR) NP PALUMIGAN P QLLLUNESTA NP PA QLLLUPRON DEPOT 3.75MG, 7.5MG, 11.25MG, 22.5MG, 30MG P QLLLUPRON DEPOT 45MG NP PA QLLLUPRON DEPOT PEDIATRIC 11.25MG, 30MG NP PA QLLLUPRON DEPOT PEDIATRIC 7.5MG, 15MG PLUVOX CR NP PA QLLLUXIQ NP PA QLLLUZU NP PA QLLLYNPARZA P PA QLLLYRICA P QLLLYRICA SOLN. NP PA QLLLYSODREN PMACRODANTIN 25mg PMAGNEBIND P PAmagnesium carbonate generic P PAMAKENA P PA QLLMALARONE NP PA QLLmalathion lotion NP PA QLLmaprotiline generic P QLLMARPLAN PMATULANE Pmatzim la (generic Cardizem LA) P QLLMAXARON FORTE PMAXITROL SUSP. Pmeclizine generic Pmeclofenamate sodium cap generic NP PAMEDROL 2mg Pmedroxyprogesterone 150mg/ml generic P QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

mefenamic acid generic NP PA QLLmefloquine hydrochloride generic PMEGACE ES NP PAmegestrol 40mg/ml susp generic Pmegestrol 625mg/5ml susp generic NP PAMEKINIST P PA QLLmeloxicam suspension generic NP PA QLLmeloxicam tablets generic P QLLmemantine soln., titration pak generic NP PA QLLmemantine tabs generic P QLLMENEST PMENTAX NPmeperidine generic PMEPHYTON PMEPRON P QLLmeropenem generic P PAmeropenem/sodium chloride IV soln. generic NP PAmesalamine enema generic Pmesalamine kit generic P QLLMESTINON PMETADATE CD P PA (> 21 years) QLLMETADATE ER P PA (> 21 years) QLLmetaxalone generic NP QLLMETERS-Abbott select brands are covered through manufacturer n/a n/a n/a n/ametformin er (generic for Glucophage XR) Pmetformin er osmotic (generic for Fortamet ER) NP PA QLLmetformin generic P QLLmethamphetamine generic NP PA QLLmethenamine generic Pmethenamine hippurate generic NP PAMETHITEST P PAmethocarbamol generic Pmethoxsalen generic NP PAmethylergonovine generic P QLLMETHYLIN CHEW TABS P PA (> 21 years) QLLMETHYLIN ER P PA (> 21 years) QLLMETHYLIN SOLN P PA (> 21 years) QLLMETHYLIN TABS P PA (> 21 years) QLLmethylphenidate cd (generic for Metadate CD) NP PAmethylphenidate chew tabs generic NP PA QLLmethylphenidate er (generic for Ritalin LA) P PA (> 21 years) QLLmethylphenidate er/sr (generic for Ritalin SR) P PA (> 21 years) QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

methylphenidate generic P PA (> 21 years) QLLmethylphenidate sa osm (generic for Concerta; preferred manufacturer: Actavis/Watson) P PA (> 21 years) QLLmethylphenidate solution generic NP PA QLLmethylprednisolone generic Pmethyltestosterone cap generic NP PA QLLmetipranolol generic Pmetoclopramide generic Pmetoclopramide odt generic NP PA QLLmetoprolol HCTZ generic NP PA QLLmetoprolol succinate ER generic P QLLMETOZOLV NP PA QLLMETROCREAM NPMETROGEL P QLLMETROGEL PUMP NP PA QLLMETROLOTION NPmetronidazole caps generic NP PAmetronidazole cream, 1% gel, lotion generic NP PAmetronidazole IR tabs generic PMEVACOR NP QLLMIACALCIN INJECTION NP PA QLLMICARDIS P QLLMICARDIS HCT P QLLmiconazole generic P QLLmidazolam generic NP PA MIGRANAL NS NP PA QLLMILLIPRED ORAL SOLN., TABS NP PAmilrinone generic P PAMINASTRIN 24 CHW FE NP PA QLLMINIVELLE NP PAminocycline caps generic Pminocycline IR, SR tab generic NP PA QLLMINTEZOL PMIRAPEX ER NP PA QLLmirtazapine, -odt generic P QLLMITIGARE NP PA QLLMOBIC SUSPENSION NP PA QLLmodafinil generic NP PA QLLMODERIBA NP PAmoexipril generic P QLLmoexipril HCTZ generic P QLLmolindone generic PMONISTAT 1 P QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

MONOCLATE PMONONINE Pmontelukast generic P PA QLLMONUROL PMORGIDOX KIT NP PA QLLmorphine ir generic Pmorphine sulfate er caps (generic Avinza) NP PA QLLmorphine sulfate sa caps (generic Kadian) NP PA QLLmorphine sulfate sa tabs generic P QLLMOVANTIK NP PA QLLMOVIPREP P QLLMOXATAG NP PA QLLMOXEZA P QLLmoxifloxacin generic NP PA QLLMOZOBIL P PAMS CONTIN NP QLLMULTAQ NP PA QLLmupirocin cream generic NP PAmupirocin ointment generic PMYALEPT P PA QLLmycophenolate mofetil caps, tabs generic Pmycophenolate mofetil suspension generic NP PAmycophenolic tab generic NP PA QLLMYFORTIC P QLLMYLERAN PMYRBETRIQ NP PA QLLMYTESI NP PAnadolol generic Pnadolol/bendroflumethiazide generic NP PA QLLnaftifine generic NP PA QLLNAFTIN NP PA QLLNALFON NP PA QLLnaloxone injection generic PNAMENDA SOLN., TITRATION PAK P QLLNAMENDA XR NP PA QLLNAMZARIC NP PA QLLNAPRELAN NP PA QLLnaproxen dr tab generic NP PAnaproxen sodium cr tab (generic for Naprelan) NP PA QLLnaproxen suspension generic Pnaratriptan generic P QLLNARCAN SPRAY P PA

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

NASONEX P QLLNATAZIA NP PA QLLnateglinide generic NP PA QLLNATESTO NP PA QLLNATPARA NP PA QLLNATROBA P QLLNEBUPENT P QLLNECON 1/50 NP PAnefazodone generic P QLLneomycin/polymyxin/hc generic P QLLneomycin/polymyxin/hc ophth. susp. generic P QLLNEO-SYNALAR KIT NP PA QLLNEPHPLEX RX NP PANEPHROCAPS QT P PA QLLNEPHRON FA P PANESINA 25mg NP PA QLLNEUAC KIT NP PA QLLNEULASTA P PA QLLNEUMEGA P QLLNEUPOGEN P PA QLLNEUPRO NP PA QLLNEURONTIN SOLN. NPNEURONTIN TABS/CAPS NPNEVANAC NP PAnevirapine er generic NP PA QLLnevirapine suspension generic NP PA QLLnevirapine tabs generic P QLLNEXAVAR P QLLNEXIUM NP PA QLLNEXIUM INJ NP PA QLL

next choice 0.75mg generic (covered < 17 yrs old) P QLL

next choice 1.5mg generic (covered < 17 yrs old) P QLLniacin er generic P QLLniacin generic P PANIACOR NP PAnicardipine generic NP PA QLLnicotine gum, lozenge, patch generic P QLLNICOTROL INHALER, NASAL SPRAY NP PA QLLnifediac cc generic P QLLnifedical xl generic P QLLnifedipine er generic P QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

nifedipine ir generic P QLLnifedipine sa generic P QLLNILANDRON Pnimodipine generic P QLLNINLARO P PA QLLnisoldipine sr generic NP PA QLLNITRATES nitrofurantoin 25mg cap generic NP PAnitrofurantoin generic P

nitroglycerin lingual spray aerosol (generic Nitromist) P QLL

nitroglycerin lingual spray soln (generic Nitrolingual) NP QLLnitroglycerin patches generic P QLLNITROLINGUAL SPRAY P QLLNITROMIST SPRAY NP PA QLLNITROSTAT SL TABS Pnizatidine caps, solution generic NP PA QLLNORDITROPIN, -FLEXPRO P PAnorethindrone 0.35mg generic Pnorethindrone/estradiol 0.5mg-2.5mcg generic NP PA QLLnorethindrone/ethinyl estradiol 7/7/7, alyacen, cyclafem, dasetta, necon, notrel, pirmella, etc. (generic for Ortho-Novum 7/7/7) Pnorethindrone/ethinyl estradiol-fe chew tabs (generic for Generess Fe Chew) NP PA QLLnorgestimate/ethinyl estradiol, tri-estaryll, tri-linyah, trinessa, tri-previfem, tri-sprintec, etc. (generic for Ortho Tri-Cyclen) Pnorgestimate/ethinyl estradiol, tri-lo estaryll, tri-lo marzia, tri-lo sprintec, etc., except for trinessa lo, (generic for Ortho Tri-cyclen Lo) NP PA QLLNORINYL 1+50 NP PANORITATE NPNOR-QD PNORTHERA NP PA QLLnortriptyline generic PNORVASC NP QLLNORVIR CAPS, SOLN, TABS PNOVOEIGHT PNOVOLIN NP PA QLLNOVOLOG NP PA QLLNOVOLOG MIX NP PA QLLNOVOLOG pens and cartridges NP PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

NOXAFIL NP PA QLLnp thyroid 30mg, 60mg 90mg tab generic PNPLATE NP PANUCYNTA NP PA QLLNUCYNTA ER NP PA QLLNUEDEXTA NP PA QLLNULYTELY P QLLNUTROPIN, -AQ, -NUSPIN P PANUVARING PNUVESSA NP PA QLLNUVIGIL NP PA QLLNUWIQ NP PANYMALIZE P PA QLLnystatin cream Pnystatin/triamcinolone cream, ointment generic NP PAOCALIVA P PAocella generic NP PAOCTAGAM P PAoctreotide generic P PAODEFSEY NP PA QLLODOMZO P PA QLLOFEV NP PA QLLofloxacin drops generic P QLLofloxacin generic P QLLofloxacin otic Polanzapine inj. (short-acting) generic NP PAolanzapine, -odt generic P PA (<13 years) QLLolanzapine/fluoxetine generic NP PA QLLOLEPTRO NP PA QLLolopatadine 0.1% soln. generic NP PA QLLolopatadine generic NP PA QLLOLUX NP QLLOLUX-E NP PA QLLOLYSIO NP PA QLLOMECLAMOX-PAK NP PA QLLomega-3-acid generic NP PA QLLomeprazole generic P PA QLLomeprazole/sodium bicarbonate caps generic NP PA QLLOMNARIS NP PA QLLOMNICEF NP QLLOMNICEF SUSPENSION NP QLLOMNITROPE NP PA

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

ondansetron generic P QLLondansetron inj. generic P PAONEXTON NP PA QLLONFI NP PA QLLONFI SUSPENSION NP PA QLLONGLYZA P PA QLLONMEL NP PA QLLONSOLIS NP PA QLLOPANA/ER NP PA QLLOPSUMIT NP PA QLLORACEA NP PA QLLORALAIR NP PA QLLORAP PORAPRED ODT NP PAORAVIG NP PA QLLORENCIA 125MG/ML, CLICKJECT NP PA QLLORENITRAM NP PA QLLORFADIN PORFADIN SUSP. P PAORKAMBI P PA QLLorphenadrine generic Porphenadrine/aspirin/caffeine generic PORTHO-EVRA NP PA QLLOSCION NP PAOTEZLA NP PA QLLOTOVEL NP PAOTREXUP NP PA QLLOVCON-35 NPOVIDE NP PA QLLoxandrolone P PA QLLoxandrolone generic P PA QLLoxaprozin tab generic NP PAoxazepam generic P QLLoxcarbazepine susp., tabs generic P QLLOXISTAT NPOXSORALEN-UL POXTELLAR XR P PA** QLLoxybutynin ER generic P QLLoxybutynin generic P QLLoxycodone er generic NP PA QLLoxycodone ir generic P QLLoxycodone/ibuprofen 5/400mg generic NP PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

OXYCONTIN NP PA QLLoxymorphone/er generic NP PA QLLOXYTROL P QLLpaliperidone er generic NP PA QLLPANCREAZE NP PA QLLpancrelipase generic P QLLPANDEL NP PAPANRETIN P PApantoprazole generic P PA QLLpantoprazole inj. generic NP PA QLLparicalcitol generic NP PAPARNATE Pparoxetine er NP PA QLLparoxetine generic P QLLPATADAY P QLLPATANASE NP PA QLLPATANOL P QLLPAZEO P QLLPCE NP PA QLLPEDIADERM AF KIT COMPLETE (covered < 21 yrs old) NP PA QLLPEDIADERM HC KIT (covered < 21 yrs old) NP PA QLLPEDIADERM TA KIT (covered < 21 yrs old) NP PA QLLPEDIPIROX-4 KIT NAIL NP PA QLLPEGANONE PPEGASYS, -PROCLICK P QLLPEG-INTRON P QLLPENNSAID NP PA QLLPENTASA PPERFOROMIST NP PA QLLPERIKABIVEN NP PAperindopril generic NP PA QLLpermethrin 1% lotion P QLLpermethrin 5% cream generic P QLLPERTZYE NP PAPEXEVA NP PA QLLphenelzine generic P QLLphenobarbital generic Pphenoxybenzamine generic NP PAPHENYTEK NPphenytoin generic PPHOSLYRA PPHOSPHOLINE IODIDE P

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

PICATO NP PA QLLpilocarpine ophthalmic generic Ppilocarpine tabs generic PPILOPINE H.S. Ppimozide generic NP PApioglitazone generic P QLLpioglitazone/glimepiride generic NP PA QLLpioglitazone/metformin generic NP PA QLLpiperacillin generic Ppiperacillin sodium-tazobactam sodium generic NP PAPLAN B ONE STEP (covered < 17 yrs old) P QLLPLAVIX 300mg P QLLPLAVIX 75mg NP QLLPLEGRIDY NP PA QLLpodofilox soln. generic Ppolyethylene glycol generic P QLLpolymyxin/bacitracin ophthalmic ointment generic Ppolymyxin/trimethoprim ophthalmic drops generic PPOMALYST P PA QLLpotassium chloride generic Ppotassium citrate 15meq generic NP PA QLLpotassium citrate 5meq, 10meq generic P QLLPOTIGA NP PA QLLPRADAXA P QLLPRALUENT NP PA QLLpramcort cream 1-1% generic NP PApramipexole er generic NP PA QLLpramipexole generic P QLLPRAMOSONE CREAM 1% NP PAPRANDIMET NP PA QLLPRANDIN P QLLPRAVACHOL NP QLLpravastatin generic P QLLprednicarbate ointment generic NP PAprednisolone odt generic NP PAprednisolone oral soln. 15mg/5ml generic Pprednisolone oral soln. 25mg/5ml generic Pprednisone generic PPREFEST PPREMARIN P QLLPREMPHASE P QLLPREMPRO P QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

prenatal brand/generics (without DHA) Pprenatal brands/generics with DHA PPREPOPIK P QLLPRESTALIA NP PA QLLPREVACID SOLUTAB NP PA QLLPREVALITE PACKETS NP PAPREVALITE POWDER PPREZCOBIX P PA QLLPREZISTA P PAPRIFTIN PPRIMAXIN P PAprimidone generic PPRIMLEV NP PAPRISTIQ NP PA QLLPRIVIGEN P PAPROAIR HFA NP PA QLLPROAIR RESPICLICK NP PA QLLPROAMATINE Pprobenecid generic Pprobenecid/colchicine generic PPROCARDIA, -XL NP QLLPROCENTRA NP PA QLLPROCRIT P PAPROCTOFOAM-HC PPROCYSBI NP PAPROFILNINE Pprogesterone caps generic PPROGRAF NPPROLASTIN-C P PAPROLENSA NP PA QLLPROLEUKIN PPROMACTA P PA QLLpromethazine generic Ppropafenone er generic NP PAPROSCAR NP QLLPROTONIX INJ NP PA QLLPROTONIX PAK NP PA QLLPROTOPIC P PA QLLprotriptyline generic NP PAPROVENTIL FOR NEBULIZATION NP QLLPROVENTIL HFA P QLLPROVIGIL NP PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

PROZAC WEEKLY NP PA QLLPSORCON E NP PAPULMICORT FLEXHALER P QLLPULMICORT RESPULES P QLLPURINETHOL PPURIXAN P PA (> 12 years) QLLPYLERA P PA QLLpyrazinamide generic Ppyridostigmine generic NP PApyridoxine (vitamin B-6) generic P PAQBRELIS P PA (>12 years)QNASL NP PA QLLQUALAQUIN NP PA QLLQUARTETTE NP PA QLLquasense generic P QLLQUDEXY XR P PA QLL

quetiapine generic 100mg, 200mg, 300mg, 400mg P PA (<10 years) QLLquetiapine generic 25mg, 50mg P PA***/PA (<10 years) QLLQUILLICHEW ER P PA (> 21 years) QLLQUILLIVANT SUSP XR P PA (> 21 years) QLLquinapril generic P QLLquinapril HCTZ generic P QLLquinine sulfate generic NP PAQVAR P QLLrabeprazole tabs generic NP PA QLLRADIACARE PRAGWITEK NP PA QLLraloxifene generic P QLLramipril caps generic P QLLRANEXA NP PAranitidine cap generic NP PA QLLranitidine syrup, tab generic P QLLRAPAFLO NP PA QLLRASUVO NP PA QLLRAVICTI NP PA QLLRAYOS NP PA QLLRAZADYNE SOLN. PRAZADYNE, ER NPREBETOL NPREBETOL ORAL SOLUTION PREBIF, REBIDOSE P QLLRECOMBINATE NP PA

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

RECTIV OINT 0.4% NP PA QLLREGRANEX P PA QLLRELENZA P QLLRELISTOR NP PA QLLRELPAX P QLLREMODULIN NP PARENAGEL P QLLRENVELA PAK, TAB NP PA QLLrepaglinide generic NP PA QLLrepaglinide-metformin generic NP PA QLLREPATHA NP PA QLLREPATHA PUSH INJ. NP PA QLLREPREXAIN NP PAREQUIP XL NP PA QLLRESCRIPTOR PRESTASIS P QLLRETIN-A GEL P PA (> 21 years) QLLRETIN-A MICRO NP PA QLLRETROVIR NPREVATIO SUSPENSION NP PA QLLREVLIMID P QLL

REXULTIstatus based on

diagnosisstatus based on

diagnosis PA** QLLREYATAZ PRIBAPAK NP PARIBASPHERE 400MG, 600MG NP PAribavirin 200mg generic PRIDAURA Prifabutin generic P QLLRIFAMATE Prifampin generic PRIFATER Priluzole generic P QLLrimantadine generic NPRIOMET P QLLrisedronate, -dr generic NP PA QLLRISPERDAL CONSTA P PA QLLrisperidone generic P PA (<10 years) QLLrisperidone orally disintegrating tab generic P PA (<10 years) QLLRITALIN LA 10mg, 60mg NP PA QLLrivastigmine caps generic Privastigmine patches generic NP PA QLLRIXUBIS NP PA

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

rizatriptan odt generic P QLLrizatriptan tab generic P QLLROCALTROL Propinirole er generic NP PA QLLropinirole generic PROSADAN KIT NP PA QLLROSANIL NP PAROZEREM NP PA QLLRYTARY NP PA QLLRYTHMOL SR P QLLSABRIL NP PA QLLSAFYRAL NP PA QLLSAIZEN NP PASALAGEN PSAMSCA P QLLSANCUSO NP PA QLLSANDOSTATIN LAR P PASANTYL NP PASAPHRIS NP PA QLLSARAFEM NP PA QLLSAVAYSA NP PA QLLSAVELLA NP PA QLLSEASONALE NP QLLSEASONIQUE P QLLSECONAL NP PA QLLselegiline generic PSELZENTRY NP PASEMPREX-D PSENSIPAR NP PASEREVENT DISKUS P QLLSEROQUEL XR NP PA QLLSEROSTIM NP PAsertraline generic P QLLsevelamer generic NP PA QLLSFROWASA NP PASIGNIFOR, -LAR NP PA QLLsildenafil generic P PA QLLSILENOR NP PA QLLSIMBRINZA P QLLSIMCOR P QLLSIMPONI NP PA QLLsimvastatin 5mg, 10mg, 20mg, 40mg generic P QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

simvastatin 80mg generic P PA QLLsirolimus generic PSIRTURO P PA QLLSITAVIG NP PA QLLSIVEXTRO NP PA QLLSKELID NPSKLICE P QLLsodium bicarbonate generic P PAsodium phenylbutyrate generic NP PA QLLSOLARAZE NP QLLSOLODYN NP PA QLLSOMA 250mg NP PA QLLSOMATULINE DEPOT NP PASOMAVERT NP PA QLLSONATA NP PA QLLSOOLANTRA NP PA QLLSORIATANE P QLLSORILUX NP PA QLLSOTYLIZE P PA (>12 years) QLLSOVALDI NP PA QLLSPECTRACEF NP PA QLLspinosad generic NP PA QLLSPIRIVA HANDIHALER P QLLSPIRIVA RESPIMAT NP PA QLLspironolactone generic P QLLSPORANOX ORAL SOLUTION P PA QLLSPRIX NP PA QLLSPRYCEL P PA QLLSTALEVO PSTARLIX P QLLstavudine PSTAVZOR NP PASTELARA NP PA QLLSTIOLTO RESPIMAT NP PA QLLSTIVARGA P PA QLLSTRATTERA P PA (> 21 years) QLLSTRENSIQ P PASTRIANT NP PA QLLSTRIBILD NP PA QLLSTRIVERDI RESPIMAT NP PA QLLSTROMECTOL P QLLSUBOXONE P PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

SUBSYS NP PA QLLSUCLEAR P QLLsulfacetamide ophthalmic drops generic Psulfacetamide ophthalmic ointment generic NPsulfacetamide sodium lotion/suspension generic NP PAsulfasalazine generic Psumatriptan injection NP PA QLLsumatriptan nasal spray generic NP PA QLLsumatriptan tabs generic P QLLSUMAVEL DOSEPRO NP PA QLLSUMAXIN PADS NP PA QLLSUMAXIN WASH NP PA QLLSUPRAX 500MG/5ML SUSP., CHEW TABS NP PA QLLSUPRAX CAPS P PA QLLSUPREP P QLLSURMONTIL PSUSTIVA PSUTENT P PA QLLSYLATRON P PASYMBICORT P QLLSYMBYAX NP PA QLLSYMLINPEN P PA QLLSYNAGIS P PA QLLSYNALAR OINTMENT NP PASYNALAR TS KITS NP PA QLLSYNALGOS-DC NP PA QLLSYNAREL PSYNJARDY NP PA QLLSYNRIBO P PA QLLSYNTHROID NPSYPRINE PTACLONEX NP PA QLLtacrolimus generic Ptacrolimus ointment generic NP PA QLLTAFINLAR P PA QLLTAGRISSO P PA QLLTAMIFLU P QLLtamsulosin generic P QLLTANZEUM NP PA QLLTARCEVA P PA QLLTARGRETIN CAP P QLLTARGRETIN GEL P QLLTASIGNA P PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

TASMAR PTAZORAC P PA (> 30 years) QLLTECFIDERA P QLLTECHNIVIE P PA QLLTEFLARO NP PA QLLTEGRETOL NPTEGRETOL XR 100mg P QLLTEGRETOL XR 200mg, 400mg NP QLLTEKAMLO NP PA QLLTEKTURNA NP PA QLLTEKTURNA HCT NP PA QLLtelmisartan generic NP PA QLLtelmisartan/amlodipine generic NP PA QLLtelmisartan/HCTZ generic NP PA QLLtemazepam 15mg, 30mg generic P QLLtemazepam 7.5mg, 22.5mg NP PA temozolomide generic P PA QLLterbinafine tab generic PTERBINEX KIT NP PA QLLterconazole generic P QLLTEST STRIPS, LANCETS, PEN NEEDLES, INSULIN SYRINGES -for a complete list of covered diabetic supplies, please refer to www.mmis.georgia.gov → Pharmacy → Other Documents → Covered Diabetic Supplies n/a n/a n/a n/aTESTIM NP PA QLLtestosterone gel generic NP PA QLLtestosterone injection generic P PATESTRED NP PAtetrabenazine (all generics except oceanside) NP PA QLLtetrabenazine (oceanside) generic P PA QLLTEVETEN NP PA QLLTEVETEN HCT NP PA QLLTEV-TROPIN NP PATEXACORT SOLN NP PATHALOMID Ptheophylline elixir generic NPtheophylline generic PTHERABENZAPR PAK -60 Pthiamine (vitamin B-1) generic P PATHIOGUANINE PTHYROLAR Ptiagabine generic NP PA

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

TIAZAC P QLLticlopidine generic PTIKOSYN Ptimolol maleate generic PTIMOPTIC OCUDOSE NP PATIMOPTIC/XE NPTINDAMAX NP PAtinidazole generic NP PATIROSINT NP PATIVICAY P QLLTIVORBEX NP PA QLLtizanidine caps generic NP PAtizanidine tabs generic PTOBI PODHALER NP PA QLLTOBRADEX P QLLTOBRADEX ST P QLLtobramycin nebulizer generic NP PA QLLtobramycin ophthalmic generic Ptobramycin/dexamethasone generic NP PA QLLTOLAK P QLLtolazamide generic NP PAtolbutamide generic NP PAtolcapone generic NP PAtolmetin sodium generic NP PAtolterodine, -er generic NP PA QLLTONOCARD PTOPAMAX sprinkles NP QLLTOPAMAX tabs NP QLLTOPICORT 0.05% OINTMENT, SPRAY NP PA QLLtopiramate er sprinkles generic P PA QLLtopiramate sprinkles generic P QLLtopiramate tabs generic P QLLTOPROL XL NP QLLTOUJEO NP PA QLLTOVIAZ P QLLTRACLEER NP PA QLLTRADJENTA P PA QLLtramadol er (generic Conzip, Ultram ER, Ryzolt) NP PA QLLtramadol generic P QLLtramadol/acetaminophen generic P QLLtrandolapril generic P QLLtrandolapril/verapamil generic P QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

tranexamic acid inj. NP PAtranexamic acid tab generic NP PA QLLTRANSDERM-SCOP Ptranylcypromine generic Ptranylcypromine generic NP PATRAVATAN Z P QLLtravoprost generic NP PAtrazodone 300mg generic NP PA QLLtrazodone 50mg, 100mg, 150mg generic P QLLTRECATOR PTRELSTAR LA/-DEPOT P PA QLLTRESIBA FLEX NP PA QLLtretinoin caps generic Ptretinoin cream generic P PA (> 21 years) QLLtretinoin gel generic NP PA QLLtretinoin microsphere gel/gel pump generic NP PA QLLTREXIMET NP PA QLLtriamcinolone acetonide spray generic NP PATRIANEX OINTMENT NP PA QLLtriazolam P QLLTRIBENZOR P PA QLLtrifluridine generic PTRIGLIDE P QLLtri-legest/tilia fe generic NP PAtrimethobenzamide generic Ptrinessa lo generic P QLLTRINTELLIX P PA QLLTRIUMEQ P QLLTRIZIVIR P QLLTROKENDI XR NP PA QLLtrospium er generic NP PA QLLtrospium generic NP PA QLLTROVAN NPTRULICITY NP PA QLLTRUSOPT NPTRUVADA PTUDORZA NP PA QLLTWYNSTA NP PA QLLTYBOST P PA QLLTYGACIL NP PATYKERB PTYVASO NP PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

TYZEKA NPUCERIS NP PA QLLU-CORT NP PAULESFIA NP PA QLLULORIC NP PA QLLULTRACET NP QLLULTRAVATE X KIT NP PA QLLULTRESA NP PAUMECTA PD NP PA QLLUNASYN 15GM NP PAUNIPHYL NP UPTRAVI NP PA QLLUR N-C NP PAURAMAXIN NP PAURAMAXIN 45% CREAM NPurea cream/lotion/ointment generic Purea gel/emulsion generic NP PAurea nail kit generic NP PA QLLURELLE NP PAURIMAR-T NP PAURIN D/S PUROCIT-K 15 NP PA QLLUROGESIC BLUE NP PA QLLURSO, -FORTE Pursodiol generic NP PAvalacyclovir generic P QLLVALCHLOR GEL P PA QLLVALCYTE SOLN P PA (>17 yrs) QLLVALCYTE TABS Pvalganciclovir generic NP PAvalproic acid caps NP PAvalproic acid syrup Pvalsartan generic P QLLvalsartan/hctz generic P QLLvancomycin generic P QLLVARUBI NP PA QLLVASCEPA NP PA QLLVECAMYL NP PA QLLVECTICAL NP PA QLLVELETRI NP PAVELPHORO NP PA QLLVELTASSA NP PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

VELTIN NP PA QLLVENCLEXTA P PA QLLvenlafaxine ER caps generic P QLLvenlafaxine ER tabs generic NP PA QLLvenlafaxine generic P QLLVENOFER P PAVENTAVIS P PA QLLVENTOLIN HFA NP PA QLLVERAMYST NP PA QLLverapamil er caps 100mg, 200mg, 300mg (generic Verelan PM) NP PA QLLverapamil generic P QLLVERDESO NP PAVEREGEN OINTMENT NP PAVERIPRED 20 SOL 20MG/5ML NP PAVERSACLOZ SUSPENSION NP PA QLLVESICARE P QLLVEXOL P QLLVFEND IV, SUSP NP PAVIBATIV NP PAVIBERZI NP PAVIBRAMYCIN SYRUP, SUSPENSION PVICTOZA NP PA QLLVIDEX PVIDEX EC NPVIEKIRA PAK, -XR P PA QLLVIGAMOX P QLLVIIBRYD NP PA QLLVIMIZIM P PAVIMOVO NP PA QLLVIMPAT P QLLVIMPAT INJ. P PA QLLVIOKACE NP PAVIRACEPT PVIRAMUNE SUSPENSION P QLLVIRAMUNE TABS NP QLLVIRAMUNE XR NP PA QLLVIREAD P QLLvitamin B complex generic P PAvitamin B-12 injection generic PVITEKTA NP PA QLLVITRASE P PAVIVELLE DOT P QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

VIVITROL P PA QLLVIVLODEX NP PA QLLVOGELXO NP PA QLLVOLTAREN GEL NP PAVONVENDI NP PAvoriconazole generic NP PAVOTRIENT P PA QLLVPRIV P PAVRAYLAR NP PA QLLVUSION NP PAVYTORIN (except 10-80mg) P QLLVYTORIN 10-80mg P PA QLLVYVANSE P PA (> 21 years) QLLwarfarin sodium generic PWELCHOL NP PAWILATE Pwymza fe chew (generic for Femcon FE Chew) NP PA QLLXALATAN NP QLLXALKORI P PA QLLXARELTO P QLLXARTEMIS XR NP PA QLLXELJANZ, -XR NP PA QLLXELODA PXENICAL (covered < 21 yrs old) P PA (< 21 yrs)XERESE CREAM NP PA QLLXIFAXAN NP PA QLLXIGDUO XR NP PA QLLXODOL NP QLLXOPENEX NP PA (> 8 years) QLLXOPENEX HFA NP PA QLLXTANDI P PA QLLxulane (norelgestromin-ethinyl estradiol) generic NP PA QLLXYNTHA NP PAXYREM NP PA QLLXYZAL SYRUP NP QLLYASMIN NP PAYAZ NP PA QLLyuvafem (estradiol) vaginal tab generic Pzafirlukast generic NP PA QLLzaleplon generic P QLLZAMICET NP PA QLLZANAFLEX CAPS NP PA

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

zarah generic NP PAZARXIO NP PA QLLZAVESCA P QLLZEBUTAL NP PAZEGERID Rx CAP, -POWDER NP PA QLLZELAPAR NP PAZELBORAF P PA QLLZEMAIRA P PAZEMBRACE SYMTOUCH INJ. NP PA QLLZEMPLAR CAPS NP PAzenchent fe chew (generic for Femcon FE Chew) NP PA QLLZENPEP NP PA QLLZENZEDI 2.5mg, 7.5mg, 15mg, 20mg, 30mg NP PA QLLzeosa chew generic NP PAZEPATIER P PA QLLZERBAXA NP PAZERIT NPZETIA NP PA QLLZETONNA NP PA QLLZIAGEN SOLN. PZIANA P PA (> 21 years) QLLzidovudine generic PZINBRYTA NP PA QLLZIOPTAN P QLLziprasidone caps generic P PA (<18 years) QLLZIPSOR NP PA QLLZIRGAN NP PA QLLZITHROMAX SUSPENSION NP QLLZITHROMAX TABLETS NP QLLZMAX NP PA QLLZOCOR NP QLLZOHYDRO ER NP PA QLLZOLINZA P PAzolmitriptan, -odt generic NP PA QLLzolpidem er generic NP PA QLLzolpidem generic P QLLzolpidem sl tab generic NP PA QLLZOMIG NASAL SPRAY P PA ≥18 years QLLZOMIG, -ZMT NP PA QLLZONEGRAN NPzonisamide generic PZONTIVITY NP PA QLL

PA** Requires PA if automated protocols not metPA*** Requires PA based on dose

This Preferred Drug List is subject to change without notice. Generics are considered preferred unless noted.This list does not include all drugs covered under the Georgia Medicaid/PeachCare for Kids outpatient pharmacy program. KEY: Preferred / P: medications associated with a lower member copayment; Non-Preferred / NP: medications associated with a higher member copayment; PA: prior authorization required; QLL: quantity ortherapy limits apply. The QLL listing and therapy limitation description are located in Part II of the Policies and Procedures for Pharmacy Services Manual located on the web portal, under Provider Manuals.

Preferred Non-Preferred PA QLL

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2017 (rev. 1/5/17)

ZORBTIVE NP PAZORTRESS NP PA QLLZORVOLEX NP PA QLLZOSYN PZOVIA 1/50E NP PAZOVIRAX CREAM P QLLz-pram cream generic (hydrocortisone acetate w/pramoxine 2.35-1%) NP PA QLLZUBSOLV NP PA QLLZUPLENZ NP PA QLLZYCLARA NP PAZYDELIG P PA QLLZYFLO CR, IR NP PA QLLZYKADIA P PA QLLZYLET PZYMAXID P QLLZYPREXA INJECTABLE NP ZYPREXA RELPREVV P PA QLLZYTIGA P PA QLLZYVOX IV SOLN., ORAL SUSP. P PA QLL