Drugs Covered Under Medicaid 3-9-12 Appendix A

AMENDEDAppendix

5101:3-9-125101:3-9-12 Appendix A Page 1 of 61

DR

UG

CL

AS

S AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

A1A-DIGITALIS GLYCOSIDESDIGOXIN 0.05MG/ML PED ELIXIR 0 NDIGOXIN 0.125MG, 0.25MG, 0.5MG 0 NDIGOXIN 0.25MG/ML INJ 0 NLANOXICAPS 0.1MG, 0.2MG 2 NLANOXIN 0.05MG/ML PED ELIXIR 2 NLANOXIN 0.125MG, 0.25MG 2 NLANOXIN 0.25MG/ML INJ 2 N

A1B-XANTHINESAMINOPHYLLINE 100MG, 200MG TAB 0 NAMINOPHYLLINE 105MG/5ML LIQUID 0 NAMINOPHYLLINE 500MG/20ML INJ 0 NCAFCIT 20MG/ML 2 NCAFFEINE CITRATE 20MG/ML 0 NDILOR 200MG, 400MG 2 NDYPHYLLINE 100MG/15ML 2 NELIXOPHYLLIN ELIXIR 80MG/15ML 2 NTHEO-24 100MG, 200MG, 300MG, 400MG 2 NTHEOPHYLLINE ANHYDROUS CAPS 100MG, 125MG, 200MG, 300MG 0 NTHEOPHYLLINE LIQUID 80MG/15ML 0 NTHEOPHYLLINE SR TAB 100MG, 200MG, 300MG, 450MG 0 NUNIPHYL 400MG, 600MG 2 N

A1D-GENERAL BRONCHODILATOR AGENTSATROVENT HFA 2 NATROVENT INH, REF 18MCG 2 NIPRATROPIUM 0.2MG/ML 0 NKIE LIQUID 2 NSPIRIVA INHALER 18MCG 2 N

A2A-ANTIARRHYTHMICSAMIODARONE 200MG 0 NCORDARONE IV 50MG/ML 2 NDISOPYRAMIDE CR 150MG 0 NDISOPYRAMIDE PHOSPHATE 100MG, 150MG 0 NETHMOZINE 200MG, 250MG, 300MG 2 NFLECAINIDE ACETATE 50MG, 100MG, 150MG 0 NMEXILITENE HCL 150MG, 200MG, 250MG 0 NNORPACE CR 100MG, 150MG 2 NPACERONE 200MG 0 NPROCAINAMIDE HCL 250MG, 500MG 0 NPROCAINAMIDE HCL INJ 100MG/ML, 500MG/ML 0 NPROCAINAMIDE HCL SR 500MG 0 NPROCAINAMIDE HCL SR 750MG, 1000MG 0 NPROCANBID 500MG, 1000MG 2 NPRONESTYL 250MG, 500MG 2 NPROPAFENONE 150MG, 225MG 0 NQUINIDINE GLUCONATE 324MG 0 N

Effective October 1, 2007 March 20, 2008

APPENDIX p(31979) pa(40321) d(168211) ra(140269) print date: 02/19/2008 10:36 AM

5101:3-9-12 Appendix A Page 2 of 61D

RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

QUINIDINE SULFATE 200MG, 300MG 0 NQUINIDINE SULFATE SR 300MG 0 NRYTHMOL 150MG, 225MG 2 NRYTHMOL 300MG 0 NRYTHMOL SR 225MG, 325MG, 425MG 2 NTAMBOCOR 50MG, 100MG, 150MG 2 NTIKOSYN 0.125MG, 0.25MG, 0.5MG 2 N

A2C-ANTI-ANGINAL AND ANTI-ISCHEMIC AGENTS, NON-HEMODYNAMICRANEXA 500MG 2 N

A4A-HYPOTENSIVES, VASODILATORSDOXAZOSIN MESYLATE 1MG, 2MG, 4MG, 8MG 0 NHYDRALAZINE HCL 10MG, 25MG, 50MG, 100MG 0 NHYDRALAZINE INJ 20MG/ML 0 NHYDRALAZINE/HCTZ 25/25, 50/50, 100/50 0 NHYDRALAZINE/HCTZ/RESERPINE 25-0.1-15 0 NMINOXIDIL 2.5MG, 10MG 0 NPRAZOSIN HCL 1MG, 2MG, 5MG 0 NTERAZOSIN HCL 1MG, 2MG, 5MG, 10MG 0 N

A4B-HYPOTENSIVES, SYMPATHOLYTICCATAPRES-TTS 0.1MG, 0.2MG, 0.3MG 2 NCLONIDINE HCL 0.1MG, 0.2MG, 0.3MG 0 NCLORPRES 0.1/15, 0.2/15, 0.3/15 2 NENDURONYL FORTE 0.5/5 2 NGUANABENZ 4MG, 8MG 0 NGUANFACINE 1MG, 2MG 0 NHYDROCHLOROTHIAZIDE/RESERPINE 50/0.125 0 NISMELIN 10MG, 25MG 2 NMETHYLDOPA 250MG, 500MG 0 NMETHYLDOPA/HCTZ 250/15, 250/25, 500/30 0 NRESERPINE 0.1MG, 0.25MG 0 NSALUTENSIN 0.125MG/50MG 2 NSALUTENSIN-DEMI 0.125MG/25MG 2 N

A4C-HYPOTENSIVES, GANGLIONIC BLOCKERSINVERSINE 2.5MG 2 N

A4D-HYPOTENSIVES, ACE INHIBITORSBENAZEPRIL 5MG, 10MG, 20MG, 40MG 0 NBENAZEPRIL/HCTZ 5-6.25MG, 10-12.5MG, 20-12.5MG, 20-25MG 0 NCAPTOPRIL 12.5MG, 25MG, 50MG, 100MG 0 NCAPTOPRIL/HCTZ 25/15, 25/25, 50/15, 50/25 0 NENALAPRIL 2.5MG, 5MG, 10MG, 20MG 0 NENALAPRIL/HCTZ 5/12.5, 10/25 0 NLISINOPRIL 2.5MG, 5MG, 10MG, 20MG, 30MG, 40MG 0 NLISINOPRIL/HCTZ 10/12.5, 20/12.5, 20/25 0 N

A4F-HYPOTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONISTAVALIDE 12.5-150, 12.5-300, 300-25 2 NAVAPRO 75MG, 150MG, 300MG 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

BENICAR 5MG, 20MG, 40MG 2 NBENICAR HCT 20/12.5, 40/12.5, 40/25 2 NCOZAAR 25MG, 50MG, 100MG 2 NDIOVAN 40MG, 80MG, 160MG, 320MG 2 NDIOVAN HCT 80/12.5, 160/12.5, 160/25, 320/12.5, 320/25 2 NHYZAAR 50/12.5, 100/12.5, 100/25 2 NMICARDIS 20MG, 40MG, 80MG 2 NMICARDIS HCT 40-12.5, 80-12.5, 80-25 2 N

A4H-ANGIOTENSIN RECEPTOR ANTAGONIST & CALCIUM CHANNEL BLOCKER COMBINATION EXFORGE TABLET 5MG-160MG, 10MG-160MG, 5MG-320MG, 10MG-320MG 2 N

A4K-ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONLOTREL 10/2.5, 10/5, 10/20, 20/5, 40/5, 40/10 2 NTARKA 2/180, 1/240, 2/240, 4/240 2 N

A4Y-HYPOTENSIVES,MISCATENOLOL/CHLORTHALIDONE 25/50, 25/100 0 NBISOPROLOL FUMARATE/HCTZ 6.25/2.5, 6.25/5, 6.25/10 0 NDEMSER 250MG 2 NPROPRANOL/HCTZ 25/40, 25/80 0 NTIMOLIDE 10/25 2 N

A7B-CORONARY VASODILATORSDILATRATE SR 40MG 2 NDIPYRIDAMOLE 25MG, 50MG, 75MG 0 NIMDUR 120MG 0 NISOSORBIDE DINITRATE ORAL 5MG, 10MG, 20MG, 30MG 0 NISOSORBIDE DINITRATE SL 2.5MG, 5MG 0 NISOSORBIDE DINITRATE SR 40MG 0 NISOSORBIDE MONONITRATE 10MG, 20MG, 30MG, 60MG 0 NMINITRAN 0.1MG/HR, 0.2MG/HR, 0.4MG/HR, 0.6MG/HR 2 NNITROBID OINT 2% 2 NNITRO-DUR 0.1MG/HR, 0.3MG/HR, 0.8MG/HR 2 NNITRO-DUR II 0.1MG/HR, 0.2MG/HR, 0.3MG/HR 2 NNITRO-DUR II 0.4MG/HR, 0.6MG/HR 2 NNITROGLYCERIN ORAL 2.5MG, 6.5MG, 9MG 0 NNITROGLYCERIN PATCHES 0.1MG/HR, 0.2MG/HR, 0.4MG/HR, 0.6MG/HR 0 NNITROGLYCERIN SL 0.3, 0.4, 0.6 0 NNITROLINGUAL SPRAY 0.4MG/DOSE 2 NNITROQUICK 0.3MG, 0.4MG, 0.6MG 0 NNITROSTAT 0.3MG, 0.4MG, 0.6MG 2 N

A7C-PERIPHERAL VASODILATORSERGOT ALKALOIDS ORAL 1MG 0 NPAPAVERINE HCL 150MG 0 N

A9A-CALCIUM CHANNEL BLOCKERSAMLODIPINE 2.5MG, 5MG, 10MG 0 NDILTIAZEM 30MG, 60MG, 90MG, 120MG 0 NDILTIAZEM CD 120MG, 180MG, 240MG, 300MG, 360MG 0 NDILTIAZEM INJ 5MG/ML 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

DILTIAZEM SR 60MG, 90MG, 120MG 0 NDILTIAZEM XR 120MG, 180MG, 240MG, 0 NDYNACIRC 2.5MG, 5MG 0 NDYNACIRC CR 5MG, 10MG 2 NFELODIPINE ER 2.5MG, 5MG, 10MG 0 NNICARDIPINE HCL 20MG, 30MG 0 NNIPEDIPINE ER 30MG, 60MG, 90MG 0 NSULAR 10MG, 20MG, 30MG, 40MG 2 NTAZTIA XT 120MG, 180MG, 240MG, 300MG, 360MG 0 NVERAPAMIL HCL 40MG, 80MG, 120MG 0 NVERAPAMIL SR 120MG, 180MG, 240MG, 360MG 0 N

B0A-GENERAL INHALATION AGENTSDEY-PAK 10% 2 NDEY-PAK 3% 0 NSODIUM CHLORIDE FOR INHALATION 0.9% 0 N

B3A-MUCOLYTICSACETYLCYSTEINE SOLN 10%, 20% 0 NPULMOZYME 2.5MG 2 N

B3J-EXPECTORANTS (cough suppressants may be covered for dual eligible)BRONTEX LIQUID 0 YBRONTEX TABS 0 YDE-CHLOR G 100-10-2/5ML 2 YGDP-EX 200-300-10 0 YGUAIFENESIN 200MG, 400MG, 600MG, 1200MG 0 NGUAIFENESIN CODEINE 300/10MG TABS, 150-5/10ML 0 YGUAIFENESIN CODEINE SYRUP 100-10/5 ML, 150-5/10ML 0 YGUAIFENESIN DM 600/30 TABS 0 YGUAIFENESIN DM SYRUP 100-10/5ML, 100-15/5ML, 200-10/5ML, 200-30/5ML 0 YGUAIFENESIN PE SYRUP 100-30/5ML 0 NGUAIFENESIN PE/HC SYRUP 50-7.5-2.5/5ML 0 YGUAIFENESIN SYRUP 100MG/5ML 0 YGUAIFENESIN/DM/PE 200-30-10/5ML 0 YGUAIFENESIN/PHENYLEPH/HCOD 100-10-2MG/5ML 0 YGUAIFENESIN/PSEUDOEPHEDRINE 100-30/5ML 0 NGUAIFENESIN/PSEUDOEPHEDRINE 250/120, 300/60 0 NGUAIFENESIN/PSEUDOEPHEDRINE 50-15/5ML 0 NGUAIFENESIN/PSEUDOEPHEDRINE 600/120, 600/60 0 NGUAIFENESIN/PSEUDOEPHEDRINE/CODEINE 100-30-10/5 0 YGUAIFENESIN/PSEUDOEPHEDRINE/DEXTROMETHORPHAN LIQ 100-10-30/5ML 0 YGUAIFENESIN/PSEUDOEPHEDRINE/DEXTROMETHORPHAN TAB 600-60-30 0 YGUAITUSS CF (GUAIFENESIN/DEXTROMETHORPHAN/PSE 100-10-30) 0 YHCA COUGH FORMULA 200-30/5ML 2 YHUMIBID LA 600-300 2 NHYDROCODONE/GUAI/PSEUDO 5-200-60/5ML, 100-15-3/5ML 0 YHYDROCODONE/GUAIFENESIN SYRUP 5MG-100MG/5ML 0 YHYDRON EX 120-2.5MG/5ML 2 Y



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

HYDRO-TUSSIN XP 2 YINTENSE COUGH RELIEVER SYRUP 2 YMINTUSS G 100-10-2/5ML 2 YMUCINEX TABLET 600MG, 1200MG 2 YPOT GUAIACO-HYDROCOD 120-2.5MG/5ML 0 YPRO-CLEAR 350-3MG/5ML 2 YPRO-COF 300MG-5MG/5ML 2 YROBITUSSIN DM 200-10MG/5ML 2 YROBITUSSIN DM INFANT DROPS 100-5/2.5ML 2 Y

B3K-COUGH AND/OR COLD PREPARATIONS (cough suppressants may be covered for dual eligible)AMERITUSS AD 15-10-3/5ML 2 YATUSS HC 10-2.5-2MG/5ML 2 YBROMAXEFED RF 45-4/5ML 0 NBROMODIPHENHYDRAMINE/CODEINE 12.5-10/5ML 0 YBROMPLEX DM 30-60-4MG/5ML 2 YCARBINOXAMINE/PSEUDO 4MG/60MG, 8MG/120MG 0 NCARBINOXAMINE/PSEUDO DROPS, SYRUP 15-1/1ML, 15-2/1ML, 60-4/5ML 0 NCARBINOXAMINE/PSEUDO/DM DROPS, SYRUP 4-15-1/1ML, 4-15-2/1ML 0 YCHILDS ALLERGY 5-15-1MG/5ML 2 YCHLORPHEN/P-EPH/HC 2-2-5/5 0 YCHLORPHEN/P-EPH/PHENYLTOX 4/20/50 0 NCHLORPHEN/PSEUDO 4MG/60MG, 8MG/120MG 0 NCHLORPHEN/PSEUDO SYRUP 2MG-30MG/5ML, 1-15/5ML 0 NCHLORPHEN/PSEUDO/ACETA 4/60/650 0 NCLORFED 60-4MG 2 NCOLDCOUGH HC 15-3-2/5ML 2 YDEXBROMPHENIRAMINE/PSEUDO 6/120 0 NDEXTROMETHORPHAN/PSEUDOEPHEDRINE/CHRLORPHENIRAMINE 5-15-1/5ML 0 YDIHISTINE DH (PSEUDO/CPM/COD) 0 YDM TAN/P-EPH TAN-CP TAN 25MG-75MG-4.5MG/5ML 0 YDM/PE/CHLORPHEN 15-10-2MG/5ML, 15-6-2/5ML 0 YDUOTAN PD 75-2.5MG/5ML 2 NHISTADE 120MG-12MG 2 NHYDROCODONE/HOMATRO 5/1.5 TAB, SYRUP 0 YHYDROCODONE/PSEUDO LIQUID 5MG-60MG/5ML 0 YHYDRON CP 10-5-2MG/5ML 2 YNOVAHISTINE DH 2 YPEDIA COUGH-COLD 5-15-1MG/5ML 2 YPEDIACARE 7.5-15MG CHEW 2 YPHENYLEPH/HCOD BT/CP 5-2.5-2/5ML, 10-5-2/5ML, 5-5-2/5ML, 10-2.5-2/5ML 0 YPHENYLEPH/PYRIL/DM 5-8.33-10/5ML 0 YPHENYLEPH/PYRIL/HCOD 7.5-15/5 0 YPHENYLEPHRINE/PYRILAMINE TANNATE 5-30/5ML 0 NPROMETHAZINE CODEINE SYRUP 10-6.25/5ML 0 YPROMETHAZINE VC CODEINE SYRUP 0 YPROMETHAZINE VC SYRUP 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

PRO-RED 5-2-8.33/5ML 2 YPSE-BROM 30-60-4/5ML 2 YPSEUDO/BROM MAL 15-1/5ML,60-4/5ML 0 NPSEUDO/BROM MAL DM 15-1-5/ML,60-4-15/5ML 0 YPSEUDO/BROMPHEN/DM 45-4-15/5ML, 10-30-2/5ML, 30-60-4/5 0 YPSEUDO/CARB MAL 15-2/ML 0 NPSEUDO/HC/CTM 15-3-2/5ML 0 YPSEUDOEPHEDRINE/CHLORPHENIRAMINE/CODEINE 30-10-2/5ML 0 YRELACON HC 10-3.5-2.5MG/5ML 2 YROBITUSSIN 10MG-30MG-2MG/5ML 0 YROBITUSSIN PM 7.5MG-15MG-1MG/5ML 2 YR-TANNIC-S 5-30MG/ML 0 NRU-TUSS A 15-10-2MG/5ML 0 YTRIACTING COLD & ALLERGY 0 NTRIACTING COLD/COUGH 5-15-1/5ML 0 YTRIACTING SORE THROAT 7.5-15-160MG/5ML 2 YTRIAMINIC COUGH 5-15 MG/5ML 2 YTRIAMINIC COUGH/SORE THROAT 7.5-15-160/5ML 2 YTRIPROLIDINE/PSEUDO 2.5/60 TAB 0 NTRIPROLIDINE/PSEUDO LIQUID 1.25-30/5ML 0 NTRIPROLIDINE/PSEUDO/CODEINE SYRUP 0 YTUSSIN PEDIATRIC COUGH-COLD 7.5-15MG/5ML 2 YUNI-TUSS DM 15-5-2/5 2 Y

B3P-NON-NARC ANTITUS-1ST GEN ANTIHIST-DECON-ANALGES CB (cough suppressants may becovered for dual eligible)

DIMETAPP 5-15-160-1 2 YTRIAMINIC COLD/COUGH/FEVER 2 Y

B3Q-NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST (cough suppressants may be covered for dual eligible)

BROMPHENIRAMINE-HYDROCOD-PSE 30-2.5-3MG/5ML 0 YBROVEX HC 2 YHYDRO-TUSSIN HC 15-3-2/5ML 2 YPHENYLEPHRINE-HYDROCODONE-CP 5-5-2MG/5ML 0 Y

B3R-NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST (cough suppressants may becovered for dual eligible)

CODIMAL DM SYRUP 2 YDEXTROMETHORPHAN/PHENYLEPHRIN/BROMPHENIRAMINE 5-2.5-1/5 0 YDEXTROMETHORPHAN/PHENYLEPHRINE/CHLORPHENIRAMINE 15-12.5-4, 3-3.5-1/ML, 15-10-2/5ML 0 YDIMETAPP DM 2 YPE-HIST DM 15-5-2MG/5ML 2 YRESCON DM 10MG-30MG, 10-30-2/5 2 YTANACOF-DM 25-75-2.5/5ML 2 YTRIAMINIC COLD & COUGH 5-15-1MG/5ML 2 YTRIAMINIC NIGHT TIME 2 Y



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

B3T-NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB (cough suppressants may be coveredfor dual eligible)

GUAIFENESIN/DEXTROMETHORPHAN 100-5MG/5, 400-20MG TAB 0 YHCA COUGH FORMULA (WALSH) 300-20/5ML 2 Y

B4A-NON-NARCOTIC ANTITUSSIVE-ANALGESIC COMBINATIONS (cough suppressants may be coveredfor dual eligible)

DEXTROMETHORPHAN/ACETAMINOPHEN 30-1000/30, 7.5-160/5 0 YB4D-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE

COTAB AX 4-20MG 2 YB4E-NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB (cough suppressants may be coveredfor dual eligible)

DEXTROMETHORPHAN/CHLORPHENIRAMINE 7.5-1MG/5ML 0 YPROMETHAZINE DM SYRUP 15-6.25/5 0 YROBITUSSIN COUGH-COLD LIQUID 7.5MG-1MG/5ML 0 Y

B4K-NARCOTIC ANTITUSSIVE-DECONGESTANT COMBINATIONS (cough suppressants may be coveredfor dual eligible)

HISTUSSIN D 60-5MG/5ML 2 YPANCOF HC 15-3/5ML 2 Y

B4M-NON-NARCOTIC ANTITUSSIVE-DECONGESTANT-ANALGESIC CB (cough suppressants may be covered for dual eligible)

D-METHORPHAN/PE/ACETAMINOPHEN 5-325MG/15 0 YB4P-NON-NARC ANTITUSS-DECONGESTANT-ANALGESIC-EXPECT CB (cough suppressants may becovered for dual eligible)

HCA COUGH AND COLD RELIEVER (WALSH) 10-5-325/5ML 2 YB4Q-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT COMB (cough suppressants may becovered for dual eligible)

DONATUSSIN DC SYR 2 YB4R-NON-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT CMB (cough suppressants may becovered for dual eligible)

GUAIFENISEN/DEXTROMETHORPHAN/PHENYLEPHRINE 100-10-5/5ML 0 YTUSNEL PEDIATRIC LIQUID 50-5-15/5ML 2 Y

B4S-NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION (cough suppressants may be covered fordual eligible)

EXECOF-XP 90-3/5ML 2 YGUAIFENESIN W/CODEINE SYRUP 100-10MG/5 0 YM-CLEAR 400-5/5ML 2 YPANCOF XP 90-3/5ML 2 Y

B4W-DECONGESTANT-EXPECTORANT COMBINATIONSMARDROPS-EX 50-15/1ML 2 NRESCON GG 100-5/5ML 2 NRESPAIRE SR 200/60 2 NROBITUSSIN PE 2 NTRIACTING CHEST CONGESTION 0 NTRIAMINIC CHEST CONGESTION 50-15MG/5ML 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

C0B-WATERSTERILE WATER FOR INHALATION 0 NSTERILE WATER FOR INJECTION 0 N

C0C-DRUGS USED TO TREAT ACIDOSISLACTATED RINGERS SOLN 0 N

C0D-ANTI-ALCOHOLIC PREPARATIONSANTABUSE 250MG, 500MG 2 NCAMPRAL 333MG 2 N

C0K-BICARBONATE PRODUCING/CONTAINING AGENTSSODIUM ACETATE 2MEQ/ML, 4MEQ/ML 0 NSODIUM LACTATE 5MEQ/ML 0 N

C1A-ELECTROLYTE DEPLETERSFOSRENOL 250MG, 500MG, 750MG, 1000MG 2 NKAYEXALATE POWDER 2 NKIONEX PDR 0 NMAGNEBIND 450/200, 300/300, 200/400 2 NPHOSLO 667MG 2 NRENAGEL 400MG, 800MG 2 NSODIUM POLYSTYRENE SULFONATE 15GM/60ML 0 N

C1B-SODIUM/SALINE PREPARATIONSSODIUM CHLORIDE SOLUTION 0.45%, 0.9%, 5%, 2.5 MEQ/ML, 4MEQ/ML 0 N

C1D POTASSIUM REPLACEMENTDEXTROSE 10% - 1/4NS-KCL 0 NDEXTROSE 5% - 1/4NS-KCL 1 NDEXTROSE 5% - 1/2NS-KCL 2 NDEXTROSE 5% - KCL 0 NDEXTROSE 5% - LACT RING-KCL 0 NEFFER-K TABLETS 10MEQ, 20MEQ 2 NKAON 20MEQ/15ML 2 NKAON-CL 10MEQ 2 NKLOR-CON 10, 10MEQ 2 NKLOR-CON 25 EFFERVESCENT 0 NKLOR-CON 25, 25MEQ 2 NKLOTRIX 10MEQ 2 NK-TAB 10MEQ 2 NMICRO-K EXTENCAPS 8MEQ 2 NPOTASSIUM CHLORIDE 10 MEQ, 20MEQ 0 NPOTASSIUM CHLORIDE 8MEQ, 10MEQ 0 NPOTASSIUM CHLORIDE EFF PKTS 25MEQ 0 NPOTASSIUM CHLORIDE INJ 20MEQ, 40MEQ 0 NPOTASSIUM CHLORIDE ORAL LIQ 10%, 20% 0 NPOTASSIUM CHLORIDE PACKETS 20MEQ 0 NPOTASSIUM GLUCONATE ELIXIR 4.68GM/15ML 0 NTRAVERT 10%-1/2NS KCL 40MEQ 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

C1F-CALCIUM REPLACEMENT (may be covered for dual eligible)CALCI-MIX 1.25GM 2 YCALCIUM CARBONATE 1.25 GM 0 YCALCIUM CARBONATE 10GR 0 YCALCIUM CITRATE 950MG, 1040MG 0 YCALCIUM GLUBIONATE 1.8GM/5ML 0 YCALCIUM GLUCONATE 10% 0 YCALCIUM GLUCONATE 10GR 0 YCALCIUM LACTATE 10GR 0 YCITRACAL 950MG 2 YNEPHRO CALCI 1500MG 2 YOYSTER SHELL CALC W/D 250MG/125U, 500MG/125U, 500MG/200U 0 YOYSTER SHELL CALCIUM 500MG 0 Y

C1H-MAGNESIUM SALTS REPLACEMENT (may be covered for dual eligible)MAG DELAY 64MG 0 YMAGNESIUM GLUCONATE 500MG 0 YMAGNESIUM OXIDE 400MG 0 YMAGNESIUM SULFATE 4MEQ/ML 0 YMAGNESIUM SULFATE/DEX 1%, 2% 2 YMAGONATE 1GM/5ML ORAL 2 YMAGTAB SR 84MG 2 YSLOW MAG 64MG 2 YURO-MAG 140MG 2 Y

C1P-PHOSPHATE REPLACEMENT (may be covered for dual eligible)NEUTRA-PHOS 2 YNEUTRA-PHOS-K 2 YPHOS-NAK 2 YPOTASSIUM PHOS 3MM/ML 0 YSODIUM PHOS 3MM/ML 0 Y

C1W-ELECTROLYTE MAINTENANCEDEXTROSE 10% - ELECTROLYE #48 2 NDEXTROSE 5% - ELECTROLYE #48, #75 2 NFRUCTOSE 10% ELECTROLYTE #48 2 NFRUCTOSE 5% ELECTROLYTE #48, #75 2 NM.T.E. 2 NM.T.E. -4, -5, -6, -7 2 NMULTITRACE-4, -5 2 NP.T.E. -4, -5 2 NPEDTRACE-4 2 NPLASMA-LYTE 2 NTRAVERT - ELECTROLYTES #1, #2, #3, #4 2 N

C1Z-ELECTROLYTE REPLACEMENTNORMOSOL-M AND DEXTROSE 5% 2 NORAL ELECTROLYTES 0 YPARENTERAL ELECTROLYTES 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

PARENTERAL ELECTROLYTES W/DEXTROSE 2 NPEDIAPOP 0 Y

C3B-IRON REPLACEMENT (may be covered for dual eligible)B-COMPLEX PLUS IRON 0 YCHROMAGEN FA 70-150-1 2 YCHROMAGEN FORTE 151-60-1 2 YCORVITE 150 2 YCORVITE FREE 2 YDEXFERRUM 50MG/ML 2 YFEFUM/C/B12/IF/FA 0.5MG 0 YFEOGEN FORTE 460/60MG 0 YFERROGELS FORTE 460/60MG 0 YFERROUS FUM/C/B-12 0 YFERROUS FUM/C/B-12/FA 0 YFERROUS FUMARATE 325MG 0 YFERROUS GLUCONATE EC 5GR, 240MG 0 YFERROUS SULFATE 5GR 0 YFERROUS SULFATE DROPS, ELIXIR 75MG/0.6ML, 220MG/5ML 0 YFERROUS/FA/B&C 0 YHEMATOGEN 0 YHEMATOGEN FA 200-250MG 0 YHEMATOGEN FORTE 460-60MG 0 YINFED INJ 100MG/2ML 2 YMYKIDZ IRON 10 SUSPENSION 15MG/1.5ML 0 YNEPHRON FA 2 YNIFEREX 100MG/5ML ELIXIR 2 YNIFEREX 150 FORTE 2 YPOLYSACCARIDE 150 FORTE 0 YPOLYSACCARIDE FORTE ELIXIR 0 YPOLYSACCARIDE IRON 150MG 0 YRE DUALVIT F 106-1MG 2 YRE DUALVIT PLUS 106-1MG 2 YREOCYTE PLUS 106-1MG 2 YSTRESS FORMULA + IRON 0 Y

C3C-ZINC REPLACEMENT (may be covered for dual eligible)ZINC SULFATE 220MG 2 Y

C3H-IODINE CONTAINING AGENTS (may be covered for dual eligible)POTASSIUM IODIDE 1GM/ML 0 Y

C3M-MISC MINERAL REPLACEMENT (may be covered for dual eligible)MOLYPEN 25MCG/ML 2 Y

C4F-ANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDE COMB.JANUMET 50-500, 50-1000 2 N

C4G-INSULINSLANTUS 100U/ML 2 NNOVOLIN 70/30 100U/ML, 150U/1.5ML, 70-30U/ML 2 NNOVOLIN N 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

NOVOLIN R 2 NNOVOLOG 100U/ML 2 NNOVOLOG MIX 70/30 2 N

C4H-ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPESYMLIN 0.6MG/ML 2 N

C4I-ANTIHYPERGLYCEMIC, INCRETIN MIMETIC(GLP-1 RECEPTOR AGONIST)BYETTA 5MCG/0.02, 10MCG/0.04 2 N

C4J-ANTIHYPERGLYCEMIC, DPP-4 INHIBITORSJANUVIA 25MG, 50MG, 100MG 2 N

C4K-HYPOGLYCEMICS, INSULIN-RELEASE STIMULANT TYPEACETOHEXAMIDE 250MG,500MG 0 NCHLORPROPAMIDE 100MG, 250MG 0 NGLIMEPIRIDE 1MG, 2MG, 4MG 0 NGLIPIZIDE 5MG,10MG 0 NGLIPIZIDE ER 2.5MG,5MG,10MG 0 NGLYBURIDE 1.25MG,2.5MG,5MG 0 NGLYBURIDE MICRONIZED 1.5MG,3MG,6MG 0 NSTARLIX 60MG,120MG 2 NTOLAZAMIDE 100MG,250MG,500MG 0 NTOLBUTAMIDE 500MG 0 NTOLINASE 100MG 2 N

C4L-HYPOGLYCEMICS, BIGUANIDE TYPE (NON-SULFONYLUREAS)METFORMIN 500MG, 850MG, 1000MG 0 NMETFORMIN HCL ER 500MG, 750MG 0 N

C4M-HYPOGLYCEM, ALPHA-GLUCOSIDASE INHIB TYPE (N-S)GLYSET 25MG,50MG,100MG 2 NPRECOSE 25MG,50MG,100MG 2 N

C4N-HYPOGLYCEMICS, INSULIN-RESPONSE ENHANCER (N-S)ACTOPLUS MET 15-500, 15-850 2 NACTOS 15MG, 30MG, 45MG 2 NAVANDIA 2MG,4MG,8MG 2 N

C4R-HYPOGLYCEMICS, INSULIN-RESPONSE & INSULIN RELEASE COMBINATIONAVANDARYL 4-1, 4-2, 4-4, 8-2, 8-4 2 NDUETACT 30-2, 30-4 2 N

C4S-HYPOGLY, INSULIN-REL STIM. & BIGUANIDE (N-S) COMB.GLYBURIDE-METFORMIN 1.25-250, 2.5-500, 5-500 0 N

C4T-HYPOGLY, INSUL-RESP. ENHANCER & BIGUANIDE COMB.AVANDAMET 1-500, 2-500, 4-500, 2-1000, 4-1000 2 N

C5A-CARBOHYDRATESTRAVERT IN NORMAL SALINE 2 N

C5B-PROTEIN REPLACEMENTNOVAMINE 15% 2 NPREMASOL 6%, 10% 2 NPROSOL 20% INJECTION 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

C5F-DIETARY SUPPLEMENTS, MISC (may be covered for dual eligible)CO ENZYME Q10 0 YLIQ10 50MG/5ML 0 YQ-GEL MEGA 100MG 0 Y

C5H-VITAMINS INJ (may be covered for dual eligible)M.V.I. PED, 12 2 Y

C5J-IV SOLNS DEXTROSE/WATERDEXTROSE 5% W/POTASSIUM CHLORIDE 10MEQ/L, 20MEQ/L, 30MEQ/L, 40MEQ/L 0 NDEXTROSE/WATER 5%, 10%, 50%, 70% 0 N

C5K-IV SOLNS DEXTROSE/SALINE/KCLDEXTROSE 5%/0.25%NS/KCL 10MEQ/L, 20MEQ/L, 30MEQ/L, 40MEQ/L 0 NDEXTROSE 5%/0.33%NS/KCL 10MEQ/L, 20MEQ/L, 30MEQ/L, 40MEQ/L 0 NDEXTROSE 5%/0.45%NS/KCL 10MEQ/L, 20MEQ/L, 30MEQ/L, 40MEQ/L 0 NDEXTROSE/NACL 2%/0.45%, 5%/0.2%, 5%/0.33%, 5%/0.45%, 5%/0.9% 0 NDEXTROSE/NS/KCL 10MEQ/L, 20MEQ/L,30MEQ/L,40MEQ/L 0 N

C5M-IV SOLNS DEXTROSE/LACT RINGERSDEXTROSE 5%/LACTATED RINGERS 0 N

C5N-PROTEIN REPLACEMENTAMINESS 5.2% 2 NAMINOSYN 5%, 5.2%, 7%, 8.5%, 10% 2 NAMINOSYN II 4.25%, 5%, 7%, 8.5%, 10% 2 NAMINOSYN-HBC 7% 2 NAMINOSYN-HF 8% 2 NAMINOSYN-PF 7%, 10% 2 NCLINIMIX 2.75%,4.25%,5% 2 NCLINIMIX-E 2.75/5, 2.75/10, 4.25/5, 4.25/10, 4.25/25, 5/15, 5/20, 5/25 2 NCLINISOL 15% 2 NFREAMINE III 8.5%, 10% 2 NFREAMINE HBC 6.9% 2 NHEPATAMINE 8% 2 NHEPATASOL 8% 2 NPROCALAMINE 3% 2 NQUICK MIX W/LYTES 2.75%, 4.25% 2 NRENAMIN 6.5% 2 NTRAVASOL 5.5%, 8.5%, 10% 2 NTRAVASOL/DEXTROSE 5.5%, 8.5% 2 NTRAVASOL/ELECTROLYTES 5.5%, 8.5% 2 NTROPHAMINE 6%, 10% 2 N

C5O-SOLNS MISCELLANEOUSDILUENT 2 NELLIOTTS B 2 N

C6B-VITAMIN B PREPARATIONS (may be covered for dual eligible)ALLANTEX 2 YCEREFOLIN 1-5-50-5MG 2 YCEREFOLIN NAC 2 YDEXFOL 5MG 2 Y



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

DIALYVITE 3000 2 YDIATX 2 YDIATX ZN 5-1.5-25MG 2 YFOLAMIN 2-2.5-25MG 2 YFOLBALIN 1-2.5-25MG 2 YFOLBALIN PLUS 2-2.5-25 2 YFOLBEE 1-2.5-25MG 2 YFOLBEE PLUS 2 YFOLBIC 2-2.5-25MG 2 YFOLEVE TABLET 2 YFOLGARD RX 0.5-2.2-25, 1-2.2-25 2 YFOLNATE TABLET 2 YFOLNATE PLUS TABLET 2 YFOLTX 2-2.5-25 2 YMETANX 2-2.8-25MG 2 YNEPHPLEX RX 2 YNEPHROCAPS 2 YNEPHRONEX 1MG 2 YNEPHRO-VITE RX 2 YRENAL CAPS 1MG 2 YRENAPHRO 1MG 0 YRENA-VITE 0 YRENA-VITE RX 0 Y

C6D-VITAMIN D PREPARATIONS (may be covered for dual eligible)CALCIFEROL LIQ 8,000U/ML 2 YCALCITRIOL 0.25MCG, 0.5MCG 0 YDHT 0.125MG, 0.2MG, 0.4MG 2 YDHT INTENSOL 0.2MG/ML 2 YDRISDOL 8000 IU/ML 2 YROCALTROL 0.25MCG, 0.5MCG 2 YROCALTROL 1MCG/ML 0 YVITAMIN D 50,000U 0 Y

C6E-VITAMIN E PREPARATIONS (may be covered for dual eligible)AQUAVIT-E 50U/ML 0 Y

C6F-PRENATAL VITAMINS (family planning)ANEMAGEN OB 0 NCARENATE 600 0 NCENOGEN OB 0 NCENOGEN ULTRA 0 NCHROMAGEN OB 0 NCITRACAL PRENATAL RX 27-1-50MG 0 NCITRANATAL RX 27-1-50 0 NCO-NATAL FA 0 NDUET 0 NDUET DHA STUARTNATAL 0 NDUET DHA EC STUARTNATAL 29-1-400 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

DUET STUARTNATAL 0 NEMBREX-600 0 NGENERIC PRENATALS 0 NICAR PRENATAL 0 NINATAL ADVANCE 90-1MG 0 NINATAL GT 90-1MG 0 NINATAL ULTRA 90-1MG 0 NMARNATAL-F PLUS 60-1MG 0 NMATERNA 0 NNATACAPS 106-1MG 0 NNATACHEW 0 NNATAFOLIC-OB 0 NNATAFORT 0 NNATALCARE PLUS 0 NNATALCARE THREE 0 NNATALVIT 0 NNATATAB 0 NNATATAB CFE 0 NNATELLE 27-1MG 0 NNATELLE PREFER 0 NNESTABS CBF 0 NNESTABS FA 0 NNESTABS RX 0 NNIFEREX PN FORTE 0 NNU-NATAL ADVANCED 0 NOBEGYN 0 NO-CAL PRENATAL 0 NPOLY IRON PN 60-1MG 0 NPOLY IRON PN FORTE 60-1MG 0 NPRECARE 0 NPRECARE CONCEIVE 0 NPREMESIS RX 0 NPRENAFIRST 0 NPRENATABS CBF 0 NPRENATABS FA 0 NPRENATABS OBN 29-1MG 0 NPRENATABS RX 0 NPRENATAL 19 0 NPRENATAL AD 0 NPRENATAL FORMULA 0 NPRENATAL H 0 NPRENATAL MR 90 FE 0 NPRENATAL MTR 0 NPRENATAL PC 40 0 NPRENATAL START 0 NPRENATAL-U 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

PRIMACARE 30-300-1MG 0 NRE DUALVIT OB 0 NSTUART PRENATAL 0 NSTUARTNATAL PLUS 3 0 NTANDEM OB 0 NTRINATE 0 NULTRA-NATAL 0 NULTRANATAL CARE 0 NUNI-REX 600 0 NVEROTIN-BY 0 NVEROTIN-GR 0 NVINATAL 0 NVINATAL FORTE 0 NVINATE ADVANCED 0 NVINATE AZ 27-1 0 NVINATE AZ EXTRA 0 NVINATE M 0 NVINATE PRENATAL 0 NVINATE-90 0 NZENATE 0 N

C6G-GERIATRIC VITAMIN PREPARATIONS (may be covered for dual eligible)GERIATRIC VITAMINS (COMPARE TO CENTRUM, GEVRABON, ZYMASYRUP) 0 Y

C6H-PEDIATRIC VITAMINS (may be covered for dual eligible)CHEWABLES AND LIQUID DROPS GENERICS 0 YCHEWABLES W/FLUORIDE AND LIQUID DROPS W/FLUORIDE 0 YCHEWABLES WITH IRON AND FLUORIDE GENERICS 0 YCHEWABLES WITH IRON AND LIQUID DROPS WITH IRON GENERICS 0 YINFUVITE 0 YLIQUID DROPS WITH IRON AND FLUORIDE GENERICS 0 Y

C6K-VITAMIN K PREPARATIONS (may be covered for dual eligible)MEPHYTON 5MG 0 YVITAMIN K 10MG/ML INJ 0 Y

C6L-VITAMIN B-12 PREPARATIONS (may be covered for dual eligible)CYANOCOBALAMIN INJ 1000MG/ML 0 YFOLCAPS 0.5-2.2-25MG 2 YFOLPLEX 2.2MG 2 YNUFOL 1-2.5-25MG 2 Y

C6M-FOLIC ACID PREPARATIONS (may be covered for dual eligible)DIALYVITE 0 YFOLIC ACID 1MG 0 YFOLIC ACID INJ 5MG/ML 2 YLEUCOVORIN CALCIUM PDR FOR INJ 50MG,100MG,200MG 0 YLEUCOVORIN CALCIUM TABS 5MG 0 Y

C6N-NIACIN PREPARATIONS (may be covered for dual eligible)NIACIN SR 125MG,250MG,500MG 0 YSLO-NIACIN 250,500,750MG 2 Y



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

C6T-VITAMIN B1 PREPARATIONS (may be covered for dual eligible)THIAMINE HCL INJ 100MG/ML 0 Y

C6Z-MULTIVITAMIN PREPARATIONS (may be covered for dual eligible)GENERIC EQUIVALENTS TO: 0 Y

ALLBEE C 0 YBEROCCA PLUS 0 YCENTRUM 0 YONE-A-DAY & ONE-A-DAY W/IRON 0 YSTRESSTAB 600 FORMULA, WITH IRON AND WITH ZINC 0 YTHERAGRAN, THERAGRAN M & THERAGRAN H 0 YUNICAP, UNICAP W/IRON, UNICAP M 0 Y

CERNEVIT 2 YDAILY VITAMIN FORMULA 0 YDEXTROSE W/VITAMINS 2 YINFUVITE 2 YINFUVITE ADULT INJ 2 YRENAX 2 YTHERAPEUTIC M 0 YTHERAPEUTIC M 27-0,4MG 0 YVITAMIN B COMPLEX INJ 0 YVITAMINS FOR INFUSION 2 Y

C7A-HYPERURICEMIA TX - PURINE INHIBITORSALLOPURINOL 100MG,300MG 0 N

C7B-DECARBOXYLASE INHIBITORS (SEE ALSO H6A)CARBIDOPA/LEVODOPA 10/100,25/100,25/250 0 N

C7D-METABOLIC DEFICIENCY AGENTSCYSTADANE 1GM/1.7ML 2 N

C7F-APPETITE STIMULANTS FOR ANOREXIA, CACHEXIA, WASTING SYNDROMEMEGACE ES 625MG/5ML 2 N

C8A-METALLIC POISON ANTIDOTESCHEMET 100MG 2 NDEFEROXAMINE MESYLATE 500MG,2GM 0 NDESFERAL INJ 500MG,2GM 2 NEXJADE 125MG, 250MG, 500MG 2 NGALZIN 25MG, 50MG 2 NSYPRINE 250MG 2 N

D1D-DENTAL AIDS & PREPARATIONSCHLORHEXIDINE GLUCONATE SOLN 0 NTRIAMCINOLONE DENTAL PASTE 0 N

D2A-FLUORIDE PREPARATIONSSODIUM FLUORIDE 2.2MG TABS (1MG FLUORIDE) 0 NSODIUM FLUORIDE DROPS 0.125MG/ML, 0.5MG/ML 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

D4B-ANTACIDS (may be covered for dual eligible if available over the counter)GENERIC EQUIVALENTS OF:

GAVISCON 358-95/15ML, 237.5-254, 20-80 0 YMAALOX 400-400-30, 400-400-40, 200-225-25, 450-500-40, 200-225 0 YMYLANTA 400-400-30, 200-200-20, 400-400-40 0 YRIOPAN 540MG/5ML 0 Y

ALU-CAPS 475MG 2 YALUMINUM HYDROXIDE 600MG/5ML, 320MG/5ML 0 YALU-TAB 600MG 2 YCALCIUM CARBONATE 500MG/5ML 0 YSODIUM BICARBONATE 5GR, 10GR 0 Y

D4E-ANTIULCER PREPARATIONSCARAFATE 1GM/10ML 2 NCYTOTEC 100MCG, 200MCG 0 NSUCRALFATE 1GM 0 N

D4F-ANTI-ULCER-H.PYLORI AGENTSHELIDAC 2 NPREVPAC 30/500/500 2 NPYLERA 125-125 2 N

D4G-GASTRIC ENZYMESLACTRASE 250MG 2 NSUCRAID 8.5MU/ML 2 N

D4I-ORAL MUCOSITIS/STOMATITIS ANTI-INFLAMMATORY AGENTAPHTHASOL PASTE 5% 2 N

D4K-GASTRIC ACID SECRETION REDUCERSNEXIUM 20MG, 40MG CAPS 0 NPREVACID 15MG,30MG 0 NPREVACID SOLUTAB 15MG, 30MG (AGES 0-6) * N

D4N-ANTIFLATULENTS (may be covered for dual eligible if available over the counter)SIMETHICONE 80MG TABS 0 YSIMETHICONE DROPS 40MG/0.6ML 0 Y

D5P-INTESTINAL ADSORBENTS AND PROTECTIVES (may be covered for dual eligible if available over the counter)

ACIDOPHILUS W/PECTIN LIQ 0 YKAOLIN-PECTIN (ATTAPULGITE) SUSP 750MG/15ML 0 Y

D6C-IRRITABLE BOWEL SYNDROME AGENT,5HT-3 ANTAGONIST-TYPELOTRONEX 0.5MG, 1MG 2 N

D6D-ANTIDIARRHEALS (may be covered for dual eligible if available over the counter)BISMUTH SUSPENSION 525MG/15ML 0 YDIPHENOXYLATE/ATROPINE SULFATE TABS, LIQUID 0 NLOPERAMIDE HCL 2MG TABS, 1MG/5ML SOLN 0 NMOTOFEN TABS 2 NPAREGORIC 0 N

D6F-DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLATEASACOL 400MG 2 NCOLAZAL 750MG 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

DIPENTUM 250MG 2 NLIALDA 1.2G 2 NPENTASA 250MG, 500MG 2 N

D6S-LAXATIVES & CATHARTICS (may be covered for dual eligible if available over the counter)AMITIZA 24MG 2 NBISACODYL 10MG SUPPS, 5MG TABS 0 YCOLYTE 2 NDOCUSATE CALCIUM 240MG 0 YDOCUSATE SODIUM DROPS, LIQUID, SYRUP 150MG/15ML, 60MG/15ML 0 YDOCUSATE SODIUM CAPS 100MG, 250MG 0 YDOCUSATE SODIUM/CASANTHRANOL SYRUP, CAPS 300-100/5ML, 300-100 0 YFIBER LAXATIVE TABS 500MG, 625MG 0 YGLYCOLAX POWDER 2 NGOLYTELY SOLUTION 2 NLACTULOSE SYRUP 10GM/15ML 0 NMILK OF MAGNESIA 400MG/5ML, 800MG/5ML 0 YMIRALAX 2 NNULYTELY SOLUTION 2 NOCL 2 NPEG-3350 0 NPOLYCARBOPHYL 625MG 0 YPOLYETHYLENE GLYCOL GRAN 0 NPSYLLIUM PREPARATIONS/VEGETABLE LAXATIVES 0 YSENNA CONCENTRATES 8.6MG 0 YSENNA LIQUID 8.8MG/5ML 0 YSENNA W/DOCUSATE 8.6MG-50MG 0 YTRILYTE 2 N

D7A-BILE SALTSACTIGALL 300MG 2 NURSO 250MG 2 NURSODIOL 300MG 0 N

D7L-BILE SALT SEQUESTRANTSCHOLESTYRAMINE LIGHT BULK 0 NCHOLESTYRAMINE POWDER 378GM 0 NCOLESTID GRANULES, 1GM TABS 2 NPREVALITE POWDER 0 NQUESTRAN BULK POWDER 2 NQUESTRAN LIGHT BULK POWDER 2 NWELCHOL 625 MG 2 N

D8A-PANCREATIC ENZYMESAMYLASE/LIPASE/PROTEASE 33.2-10-38, 60-16-60 0 NAMYLASE/LIPASE/PROTEASE 39/12/39, 59/18/59, 65/20/65 0 NAMYLASE/LIPASE/PROTEASE 48-16-48 0 NAMYLASE/LIPASE/PROTEASE 66.4-20-75 0 NCOTAZYM S 5000U 2 NCREON 16.6-5-19, 33.2-10-38, 66.4-20-75 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

DYGASE 30-2.4-30 2 NKUTRASE 30-2.4-30 2 NKU-ZYME 15-1.2-15 2 NKU-ZYME HP 2 NLAPASE 15-1.2-15 2 NLIPRAM-PN20 56/20/44 0 NPANCREASE MT-4, MT-10, MT-16, MT-20 2 NPANCREATIC ENZYMES 20-4-25, 20-4.5-25, 30-8-30, 30-10-30 0 NPANCRECARB MS-4 (25-4-25), MS-8 (40-8-45), MS-16 (52-16-52) 2 NULTRASE 4000U, 25-5-20 2 NULTRASE MT-6, MT-12, MT-18, MT-20 2 NVIOKASE 60-16-60 2 NVIOKASE 8000U 2 NVIOKASE POWDER 2 NZYMASE 5000U 2 N

D9A-AMMONIA INHIBITORBUPHENYL POWDER 500MG 2 NLACTULOSE 10GM/15ML 0 NLITHOSTAT 250MG 2 N

F1A-ANDROGENIC AGENTSANDRODERM 2.5MG/24H, 5MG/24H 2 NANDROGEL 12.5MG, 25MG, 50MG 2 NDELATESTRYL 200MG/ML 2 NDEPOTESTOSTERONE INJ 200MG/ML 2 NFLUOXYMESTERONE 10MG 0 NMETHITEST 10MG 2 NNANDROLONE DECANOATE INJ 100MG 0 NTESTIM 1% (50MG) 2 NTESTOSTERONE PROPIONATE INJ 100MG/ML 0 N

G1A-ESTROGENIC AGENTSACTIVELLA 1-0.5MG 2 NALORA 0.025MG/24HR, 0.05MG/24HR, 0.075MG/24HR, 0.1MG/24HR 2 NCENESTIN 0.3MG, 0.45MG, 0.625MG, 0.9MG, 1.25MG 2 NCLIMARA 0.025MG/24 HR, 0.075MG/24 HR 0 NCLIMARA 0.0375MG/24HR, 0.06MG/24HR 2 NCLIMARA 3.9MG, 7.8MG 0 NCLIMARA PRO 45-15/24H 2 NCOMBIPATCH 0.05-0.14/24 HR, 0.05-0.25/24 HR 2 NDELESTROGEN INJ 40MG/ML 2 NDEPOESTRADIOL INJ 5MG/ML 2 NELESTRIN 0.06% GEL 2 NENJUVIA TABLET 0.3MG, 0.45MG, 0.625MG, 0.9MG, 1.25MG 2 NESTRADERM PATCH 0.05MG, 0.1MG 2 NESTRADIOL 0.5MG, 1MG, 2MG 0 NESTRADIOL CYPIONATE INJ 5MG/ML 0 NESTRADIOL VALERATE INJ 40MG/ML 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

ESTRASORB 2.5/G-1.74 2 NESTRATAB 0.625MG 2 NESTROGEL 0.75/1.25G 2 NESTROPIPATE 0.625MG, 0.75MG, 1.25MG, 2.5MG, 3MG 0 NFEMHRT 1-0.005MG, 2.5MCG-0.5 2 NFEMPATCH 0.025MG/24HR 2 NFEMTRACE 0.45MG, 0.9MG, 1.8MG 2 NGYNODIOL 0.5MG, 1.5MG, 2MG 0 NMENEST 0.3MG, 0.625MG, 1.25MG, 2.5MG 2 NORTHO-PREFEST 1-1-0.09MG 2 NPREMARIN 0.3MG, 0.45MG, 0.625MG, 0.9MG, 1.25MG, 2.5MG 2 NPREMPHASE 0.625/5 2 NPREMPRO 0.3-1.5MG, 0.625/2.5, 0.625/5 2 NPREMPRO LOW DOSE 0.45MG-1.5MG 2 NSTILPHOSTROL INJ 50MG/ML 2 NVIVELLE 0.025MG/24 HR DOT, PATCH 2 NVIVELLE, DOT, PATCH 0.0375/24HR, 0.075/24HR, 0.05/24HR, 0.1/24HR 2 N

G1D-ESTROGEN & PROGESTIN WITH ANTIMINERALOCORTICOID CBANGELIQ 0.5 MG/1 MG TABLET 2 N

G2A-PROGESTATIONAL AGENTSAYGESTIN 5MG 2 NDEPOPROVERA INJ 400MG/ML 2 NMEDROXYPROGESTERONE ACETATE 2.5MG, 5MG, 10MG 0 NNORETHINDRONE ACETATE 5MG 0 NPROGESTERONE INJ 50MG/ML 0 NPROMETRIUM 100MG, 200MG 2 N

G3A-OXYTOCICS (family planning)METHERGINE 0.2MG 0 N

G8A-CONTRACEPTIVES, ORAL (family planning)ALESSE 0.1-0.02 0 NAPRI 0.15-0.03 0 NARANELLE 7/9/5 0 NAVIANE 0.1-0.002 0 NBALZIVA 28 TABLET 0 NBREVICON 0.5-0.035MG 0 NCAMILA 0.35MG 0 NCESIA 7 DAYSX3 0 NCRYSELLE 0.3-0.03MG 0 NCYCLESSA 7-7-7 0 NDEMULEN 1/0.035MG, 1/0.050MG 0 NDESOGEN 0.15/0.3 0 NENPRESSE 6-5-10 0 NERRIN 0.35MG 0 NESTROSTEP 5-7-9-7 0 NETHINYL ESTRADIOL/NORETHINDRONE 10/11 0 NETHINYL ESTRADIOL/NORETHINDRONE 35MCG/0.5MG 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

ETHINYL ESTRADIOL/NORETHINDRONE 35MCG/1MG 0 NETHYNODIOL DIACET/ETH ESTRA 1/0.035, 1/0.05 0 NJENEST-28 0 NJOLESSA 0.15 MG/0.03 MG TAB 0 NJOLIVETTE 0.35MG 0 NJUNEL 1-0.02MG, 1.5-0.03MG 0 NJUNEL FE 1.5-0.03MG, 1-0.02MG 0 NKARIVA 21-5 0 NLEENA 7-9-5 0 NLESSINA 0.1-0.02 0 NLEVLEN 0.15/0.03 0 NLEVLITE 0.1-0.02 0 NLEVONORGESTROL/ETH ESTRADIOL 6-5-10 0 NLEVORA 0.15/0.03 0 NLO/OVRAL 0.3/0.03 0 NLOESTRIN 1.5/0.03, 1/0.02 0 NLOESTRIN 24 FE 0 NLOESTRIN FE 1.5/30, 1/20 0 NLUTERA 0.1-0.02 0 NMESTRANOL/NORETHINDRONE 50MCG/1MG 0 NMICROGESTIN 1.0-02MG, 1.5-0.03MG 0 NMICROGESTIN FE 1.5-0.035, 1.0-0.02 0 NMICRONOR 0.35MG 0 NMIRCETTE 21-2-5 0 NNECON 10/11 0 NNECON 7 DAYS X 3 0 NNORA-BE 0.35MG 0 NNORDETTE 0.15/0.03 0 NNORGESTIMATE/ETHINYL ESTRADIOL 0.25/0.035 0 NNORGESTREL/ETHINYL ESTRADIOL 0.3/0.03 0 NNORTREL 7 DAYS X 3 0 NNOTREL 0.5-0.035,1.0-0.035 0 NOGESTREL 0.5-0.05MG 0 NORTHO NOVUM 1/35, 1/50, 10/11, 7/7/7 0 NORTHO-CEPT 0.15/30 0 NORTHO-TRICYCLEN 0 NORTHO-TRICYCLEN LO 7-7-7-LOW 1 0 NOVCON 1/0.05, 0.4/0.035 0 NOVRAL 0.5/0.05 0 NOVRETTE 0 NPLAN B 0 NPORTIA 0.15-0.03 0 NQUASENSE 0.15/0.03 MG 0 NRECLIPSEN 0 NSEASONALE 0 NSEASONIQUE 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

SOLIA 0.15-0.03 0 NSPRINTEC 0.25-0.035MG 0 NSPRONYX 0 NTILIA FE 5-7-9-7 0 NTRI-LEVLEN 6-5-10 0 NTRINESSA 7DAYS X 3 0 NTRI-NORINYL 7-9-5 0 NTRIPHASIL 6-5-10 0 NTRI-LEGEST FE 5-7-9-7 0 NTRI-PREVIFEM 7 DAYS X 3 0 NTRI-SPRINTEC 7 DAYS X 3 0 NVELIVET 7 DAYS X 3 0 NYASMIN 28 0 NYAZ 0 NZENCHENT 0.4-0.035 0 NZOVIA 1/0.05MG, 1/0.035MG 0 N

G8F-CONTRACEPTIVE, TRANSDERMAL (family planning)ORTHO-EVRA 20-150/24HR 0 N

G9A-CONTRACEPTIVES, INTRAVAGINAL (family planning)BECAUSE 0 NCONCEPTROL GEL, INSERTS 0 NDELFEN FOAM 0 NEMKO FOAM 0 NGYNOL II 0 NSEMICID 0 N

G9B- CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC (family planning)NUVA RING 0.12-0.015 0 N

H0B-LOCAL ANESTHETICSLIDOCAINE GEL 2% 0 NLIDOCAINE INJ 1% 0 NLIDOCAINE VISCOUS 2% 0 N

H0E-AGENTS TO TREAT MULTIPLE SCLEROSISAVONEX 30MCG 2 NBETASERON 0.3MG 2 NCOPAXONE 20MG 2 NREBIF 22MCG/0.5ML,44MCG/0.5ML, TITRATION PACK (8.8MCG AND 22MCG) 2 N

H1A-ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTSNAMENDA 5MG, 10MG, 5-10MG, 10MG/5ML 2 N

H2A-CNS STIMULANTSCYLERT 18.75MG, 75MG 0 NCYLERT 37.5MG 0 NCYLERT CHEWABLE 37.5MG 0 NPEMOLINE 37.5MG, 75MG 0 N

H2D-BARBITURATES (may be covered for dual eligible)BUTISOL SODIUM ELIXIR 30MG/5ML 2 YBUTISOL SODIUM TABS 15MG, 30MG, 50MG, 100MG 2 Y



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

LUMINAL INJ 60MG/ML 0 YPHENOBARBITAL 1/4GR, 1/2GR, 1GR, 1-1/2GR 0 YPHENOBARBITAL ELIXIR 20MG/5ML 0 YPHENOBARBITAL INJ 30MG/ML, 60MG/ML, 65MG/ML, 130MG/ML 0 YSECONAL SODIUM 100MG 2 Y

H2E-NON-BARB SEDATIVE-HYPNOTIC (benzodiazepines may be covered for dual eligible)AQUACHLORAL SUPPS 324MG, 648MG 2 NATIVAN INJ 2MG/ML, 4MG/ML 2 YCHLORAL HYDRATE SUPPS 500MG 0 NCHLORAL HYDRATE SYRUP 500MG/5ML 0 NESTAZOLAM 1MG, 2MG 0 YFLURAZEPAM 15MG, 30MG 0 YLORAZEPAM INJ 2MG/ML, 4MG/ML 0 YLUNESTA 1MG, 2MG, 3MG 2 NMIDAZOLAM HCL SYRUP 2MG/ML 0 YTEMAZEPAM 15MG,30MG 0 YZOLPIDEM 5MG, 10MG 0 NTRIAZOLAM 0.125MG,0.25MG 0 Y

H2F-ANTI-ANXIETY DRUGS (benzodiazepines may be covered for dual eligible)ALPRAZOLAM 0.25MG, 0.5MG, 1MG, 2MG 0 YBUSPIRONE 5MG, 7.5MG, 10MG, 15MG, 30MG 0 NCHLORDIAZEPOXIDE HCL 5MG, 10MG, 25MG 0 YCLORAZEPATE 3.75MG, 7.5MG, 15MG 0 YDIAZEPAM 2MG, 5MG, 10MG 0 YDIAZEPAM INJ 5MG/ML 0 YDIAZEPAM ORAL SOLN 5MG/ML, 5MG/5ML 0 YLORAZEPAM 0.5MG, 1MG, 2MG 0 YLORAZEPAM INTENSOL SOLN 2MG/ML 0 YMEPROBAMATE 200MG, 400MG 0 NOXAZEPAM 10MG, 15MG, 30MG 0 Y

H2G-ANTI-PSYCHOTICS PHENOTHIAZINES (SEE ALSO H6J)CHLORPROMAZINE 10MG, 25MG, 50MG, 100MG, 200MG 0 NCHLORPROMAZINE CONC SOLN 30MG/ML, 100MG/ML 0 NCHLORPROMAZINE INJ 25MG/ML 0 NFLUPHENAZINE DECANOATE INJ 25MG/ML 0 NFLUPHENAZINE HCL 1MG, 2.5MG, 5MG, 10MG 0 NFLUPHENAZINE INJ 2.5MG/ML 0 NFLUPHENAZINE SOLN 2.5MG/5ML, 5MG/ML 0 NPERPHENAZINE 2MG, 4MG, 8MG, 16MG 0 NTHIORIDAZINE 10MG, 15MG, 25MG, 50MG, 100MG, 150MG, 200MG 0 NTHIORIDAZINE 30MG/ML, 100MG/ML SOLN 0 NTRIFLUOPERAZINE HCL 1MG, 2MG, 5MG, 10MG 0 N

H2H-MONOAMINEOXIDASE INHIBITORS (SEE ALSO H6A)EMSAM 6MG/24H, 9MG/24H, 12MG/24H 2 NSELEGILINE HCL 5MG 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

H2J-ANTIDEPRESSANTSAMITRIPTYLINE HCL 10MG, 25MG, 50MG, 75MG, 100MG, 150MG 0 NAMOXAPINE 25MG, 50MG, 100MG, 150MG 0 NDESIPRAMINE 10MG, 25MG, 50MG, 75MG, 100MG, 150MG 0 NDESYREL DIVIDOSE 300MG 0 NDOXEPIN HCL 10MG, 25MG, 50MG, 75MG, 100MG, 150MG 0 NDOXEPIN HCL ORAL CONC 10MG/ML 0 NIMIPRAMINE HCL 10MG, 25MG, 50MG 0 NMAPROTILINE 25MG, 50MG, 75MG 0 NNORTRIPTYLINE 10MG, 25MG, 50MG, 75MG, 10MG/5ML ORAL 0 NPAMELOR SOLN 10MG/5ML 2 NTRAZODONE HCL 50MG, 100MG, 150MG 0 N

H2K-ANTIDEPRESSANT COMBINATIONSAMITRIPTYLINE/CHLORDIAZEPOXIDE 12.5/5, 25/10 0 NAMITRIPTYLINE/PERPHENAZINE 10/2, 10/4, 25/2, 25/4, 50/4 0 N

H2L-ANTIPSYCHOTIC, NON-PHENOTHIAZINELOXAPINE SUCCINATE 5MG, 10MG, 25MG, 50MG 0 NTHIOTHIXENE 1MG, 2MG, 5MG, 10MG, 5MG/ML ORAL CONC 0 N

H2M-ANTI-MANIA DRUGSESKALITH CR 450MG 2 NLITHIUM CARBONATE 150MG, 300MG, 600MG 0 NLITHIUM CARBONATE SR 300MG, 450MG 0 NLITHIUM CITRATE SYRUP 8MEQ/5ML 0 NLITHOBID 300MG 2 N

H2R-ANTIPRURITICS (SYSTEMIC)CYPROHEPTADINE 4MG 0 NCYPROHEPTADINE SYRUP 2MG/5ML 0 N

H2S-SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS)CITALOPRAM 10MG/5ML 0 NCITALOPRAM HBR 10MG, 20MG, 40MG 0 NFLUOXETINE 10MG TABS 0 NFLUOXETINE 10MG, 20MG CAPS, 20MG/5ML 0 NFLUVOXAMINE MALEATE 25MG, 50MG, 100MG 0 NLEXAPRO 5MG, 20MG, 5MG/5ML 2 NPAROXETINE HCL 10MG, 20MG, 30MG, 40MG 0 NPAXIL CR 12.5MG, 25MG, 37.5MG 2 NPAXIL LIQUID 10MG/5ML 2 NPEXEVA 10MG, 20MG, 30MG, 40MG 2 NPROZAC WEEKLY 90MG 2 NSERTRALINE 25MG, 50MG, 100MG, 20MG/ML 0 N

H2U-TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIBCLOMIPRAMINE 25MG, 50MG, 75MG 0 NPROTRIPTYLINE 5MG 0 NSURMONTIL 25MG, 50MG, 100MG 2 NTOFRANIL PM 75MG, 100MG, 125MG, 150MG 2 NVIVACTIL 5MG, 10MG 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

H2V-TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSYCONCERTA 18MG, 27MG, 36MG, 54MG (AGE 6 AND OVER) 2 NFOCALIN 2.5MG, 5MG, 10MG (AGE 6 AND OVER) 2 NFOCALIN XR 5MG, 10MG, 15MG, 20MG (AGE 6 AND OVER) 2 NMETADATE CD 10MG, 20MG, 30MG, 40MG, 50MG, 60MG (AGE 5 AND OVER) 2 NMETADATE ER 10MG (AGE 5 AND OVER) 2 NMETHYLIN 5MG/5ML, 10MG/5ML (AGE 5 AND OVER) 2 NMETHYLIN ER 10MG (AGE 5 AND OVER) 2 NMETHYLPHENIDATE HCL 5MG, 10MG, 20MG (AGE 5 AND OVER) 0 NMETHYLPHENIDATE SR 20MG (AGE 5 AND OVER) 0 N

H3A-NARCOTIC ANALGESICSACETAMINOPHEN/CODEINE 15-300, 30-300, 60-300 0 NACETAMINOPHEN/CODEINE ELIXIR 120-12MG/5ML 0 NASPIRIN/CODEINE 30-325, 60-325 0 NASTROMORPH 4MG/ML 2 NB&O SUPRETTES 15-A,16-A 2 NBELLADONNA/OPIUM SUPPS 30-16.2MG 0 NCODEINE PHOSPHATE 1/2GR, 1GR 0 NCODEINE PHOSPHATE INJ 15MG/ML, 30MG/ML 0 NCODEINE SULFATE 1/4GR, 1/2GR, 1GR 0 NDEMEROL INJ 25MG/ML, 50MG/ML, 75MG/ML, 75MG/1.5ML, 100MG/ML 2 NDILAUDID 3MG SUPPS 2 NDILAUDID INJ 1MG/ML, 2MG/ML, 4MG/ML, 10MG/ML 2 NDILAUDID-5 1MG/ML ORAL 2 NDURAGESIC PATCH 12MCG 2 NDURAGESIC PATCH 25MCG, 50MCG, 75MCG, 100MCG 0 NHYDROCODONE/ACETA 10MG/325MG 0 NHYDROCODONE/ACETA 2.5-167/5ML 0 NHYDROCODONE/ACETA 5MG/500MG, 7.5MG/500MG, 7.5MG/750MG, 10MG/500MG 0 NHYDROMORPHONE HCL 2MG, 4MG, 8MG 0 NHYDROMORPHONE HCL ORAL LIQ 1MG/ML 0 NHYDROMORPHONE INJ 2MG/ML, 4MG/ML, 10MG/ML 0 NHYDROMORPHONE SUPPS 3MG 0 NKADIAN 20MG, 30MG, 50MG, 60MG, 80MG, 100MG, 200MG 2 NLEVO-DROMERAN INJ 2MG/ML 2 NMEPERIDINE 50MG, 100MG 0 NMEPERIDINE HCL INJ 10MG/ML, 25MG/ML, 50MG/ML, 75MG/ML, 100MG/ML 0 NMEPERIDINE SYRUP 50MG/5ML 0 NMETHADONE 10MG/5ML 2 NMETHADONE 5MG, 10MG, 40MG 0 NMETHADONE SOLN 5MG/5ML, 10MG/ML CONC SOLN 0 NMETHADOSE 10MG/ML 0 NMORPHINE SULFATE SOLN, ELIXIR 20MG/ML 0 NMORPHINE SULFATE 10MG, 15MG, 30MG 0 NMORPHINE SULFATE ER 15MG, 30MG, 60MG, 100MG, 200MG 0 NMORPHINE SULFATE INJ 8MG/ML, 10MG/ML, 15MG/ML, 25MG/ML, 50MG/ML 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

MORPHINE SULFATE INJ 0.5MG/ML, 1MG/ML, 2MG/ML, 4MG/ML, 5MG/ML 0 NMORPHINE SULFATE SOLN 10MG/5ML, 20MG/5ML 0 NMORPHINE SULFATE SUPPS 5MG, 10MG, 20MG, 30MG 0 NOXYCODONE ER 10MG, 20MG, 40MG, 80MG 0 NOXYCODONE HCL 5MG, 15MG, 30MG 0 NOXYCODONE HCL 5MG/5ML, 20MG/ML 0 NOXYCODONE HCL/ACETA 5-325, 5-500, 7.5-325, 7.5-500, 10-325, 10-650 0 NOXYCODONE HCL/OXY T/ASA 4.5/0.38/325 0 NROXICET ORAL SOLN 5MG/325MG 2 NROXICODONE 5MG/5ML 2 NSUBOXONE 2MG-0.5MG, 8MG-2MG 2 NSUBUTEX 2MG, 8MG 2 N

H3B-ANALGESICSBUTORPHANOL INJ 2MG/ML 0 NBUTORPHANOL NS 10MG/ML 0 NSTADOL INJ 2MG/ML 2 NTRAMADOL 50MG 0 N

H3C-ANALGESICS, NON-NARCOTICSPROPOXYPENE NAPSYLATE/ACETA 100/650 0 NPROPOXYPHENE CPD 65 0 NPROPOXYPHENE HCL 65MG 0 NPROPOXYPHENE/ACETA 65/650 0 N

H3D-ANALGESIC/ANTIPYRETICS, SALICYLATES (may be covered for dual eligible if available over the counter)

ANABAR 200-300-20 2 NASPIRIN 800MG 0 NASPIRIN 975MG 0 NASPIRIN EC 81MG, 325MG, 650MG 0 YBE-FLEX PLUS 200-300-20 2 NCETAZONE-T 2 NCHOLINE MAGNESIUM TRISALICYLATE 500MG, 750MG, 1000MG 0 NCHOLINE MAGNESIUM TRISALICYLATE LIQUID 500MG/5ML 0 NED-FLEX 200-300-20 2 NSALSALATE 500MG, 750MG 0 NZORPRIN 800MG 2 N

H3E-ANALGESIC, ANTIPYRETIC-NON-SAL (may be covered for dual eligible if available over the counteror contains barbiturate)

ACETAMINOPHEN SUPPOSITORIES 120MG, 325MG, 650MG 0 YACETAMINOPHEN/BUTALBITAL 325MG/50MG, 650MG/50MG 0 YBUTALBITAL/ACETAMINOPHEN/CAFFEINE 325/40/50 CAP, TAB 0 YBUTALBITAL/ACETAMINOPHEN/CAFFEINE 500-40-50 TAB 0 YDOLGIC LIQUID 325-40-50/5ML 2 YDOLOGESIC 500-30MG 2 NPHRENILIN 2 YPHRENILIN FORTE 2 Y



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

H3F-ANTIMIGRAINE PREPARATIONSAMERGE 1MG, 2.5MG 2 NAXERT 6.25MG, 12.5MG 2 NCAFERGOT 1-100MG 2 NCAFERGOT SUPPOSITORIES 2 NCAFFEINE-ERGOTAMINE SUPPOSITORIES 0 NERGOTAMINE/CAFFEINE TABS 1-100MG 0 NFROVA 2.5MG 2 NIMITREX INJ 4MG/0.5ML, 6MG/0.5ML 2 NIMITREX NASAL 5MG, 20MG 2 NIMITREX TAB 25MG, 50MG, 100MG 2 NMAXALT 5MG, 10MG 2 NMAXALT MLT 5MG, 10MG 2 NMIGRANAL NASAL 4MG/ML, 0.5MG/SPRAY 2 NRELPAX 20MG, 40MG 2 N

H3T-NARCOTIC ANTAGONISTSNALTREXONE HCL 50MG 0 N

H4B-ANTICONVULSANTS (benzodiazepines and barbiturates may be covered for dual eligible)CARBAMAZEPINE 100MG, 200MG, 100MG/5ML 0 NCARBATROL 100MG, 200MG, 300MG 2 NCELONTIN 150MG, 300MG 2 NCLONAZEPAM 0.5MG, 1MG, 2MG 0 YDEPAKENE 250MG (BMN ONLY) 2 NDEPAKENE SYRUP 250MG/5ML (BMN ONLY) 2 NDEPAKOTE 125MG, 250MG, 500MG 2 NDEPAKOTE ER 250MG, 500MG 2 NDEPAKOTE SPRINKLE 125MG 2 NDIASTAT 2.5MG, 5MG, 10MG, 20MG 2 YDIASTAT ACUDIAL 10, 20 2 YDILANTIN 30MG, 50MG CHEWABLE, 100MG 2 NDILANTIN SUSP 125MG/5ML 2 NETHOSUXIMIDE SYRUP 250MG/5ML 0 NEQUETRO 100MG, 200MG, 300MG 2 NFELBATOL 400MG, 600MG 2 NFELBATOL SUSP 600MG/5ML 2 NGABAPENTIN 100MG, 300MG, 400MG, 600MG, 800MG 0 NLAMICTAL 5MG 0 NLAMICTAL 25MG, 100MG, 150MG, 200MG, 25-100 2 NMEBARAL 32MG, 50MG, 100MG 2 YMEPHOBARBITAL 32MG, 50MG, 100MG 0 YMYSOLINE 250MG (BMN ONLY) 2 NMYSOLINE 50MG 2 NMYSOLINE SUSP 250MG/5ML 2 NNEURONTIN 250MG/5ML 2 NPEGANONE 250MG 2 NPHENYTEK 200MG, 300MG 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

PHENYTOIN SODIUM 100MG, ER100MG 0 NPHENYTOIN SODIUM INJ 50MG/ML 0 NPHENYTOIN SUSP 125MG/5ML 0 NPRIMIDONE 250MG 0 NPRIMIDONE 50MG 0 NTEGRETOL 100MG, 200MG (BMN ONLY) 2 NTEGRETOL SUSP 100MG/5ML 2 NTEGRETOL XR 100MG, 200MG, 400MG 2 NTOPAMAX 15MG, 25MG, 50MG, 100MG, 200MG 2 NTRILEPTAL 150MG, 300MG, 600MG, 300MG/5ML 2 NVALPROIC ACID 250MG 0 NVALPROIC ACID SYRUP 250MG/5ML 0 NZARONTIN 250MG 0 NZARONTIN SYRUP 250MG/5ML 2 N

H4C-ANTICONVULSANTSGABITRIL 2MG, 4MG, 12MG, 16MG 2 NKEPPRA 100MG/ML 2 NKEPPRA 250MG, 500MG, 750MG, 1000MG 2 NLYRICA 25MG, 50MG, 75MG, 100MG, 150MG, 200MG, 225MG, 300MG 2 NZONISAMIDE 25MG, 50MG, 100MG 0 N

H6A-ANTIPARKINSON DRUGS, OTHER (SEE ALSO C7B, H2H)AMANTADINE HCL 100MG 0 NAMANTADINE SYRUP 50MG/5ML 0 NAPOKYN 10MG/ML 2 NAZILECT 0.5MG, 1MG 2 NBROMOCRIPTINE 2.5MG, 5MG 0 NCARBIDOPA/LEVODOPA 10/100, 25/100, 25/250 0 NCARBIDOPA/LEVODOPA CR 25/100, 50/200 0 NCOMTAN 200MG 2 NLARODOPA 100MG, 250MG, 500MG 2 NMIRAPEX 0.125MG, 0.25MG, 0.5MG, 0.75MG, 1MG, 1.5MG 2 NNEUPRO PATCH 2MG/24HR, 4MG/24HR, 6MG/24HR 2 NPARLODEL 2.5MG, 5MG 2 NPERGOLIDE 0.05MG, 0.25MG, 1MG 0 NPERMAX 0.05MG, 0.25MG, 1MG 2 NREQUIP 0.25MG, 0.5MG, 1MG, 2MG, 3MG, 4MG, 5MG 2 NSELEGILINE HCL 5MG 0 NSTALEVO 12.5/50/200, 25/100/200, 37.5/150/200, 50/200/200 2 NTASMAR 100MG, 200MG 2 NZELAPAR 1.25MG 2 N

H6B-ANTIPARKINSONISM DRUGS,ANTICHOLINERGICAKINETON 2MG 2 NBENZTROPINE 0.5MG, 1MG, 2MG 0 NCOGENTIN INJ 1MG/ML 2 NKEMADRIN 5MG 2 NTRIHEXIPHENIDYL HCL 2MG, 5MG, 2MG/5ML 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

H6C-ANTITUSSIVE NON-NARC (may be covered for dual eligible)BENZONATATE 100MG 0 YDELSYM 30MG/5ML 2 YDEXTROMETHORPHAN HBR 15MG/5ML 0 YELIXSURE COUGH 7.5MG/5ML (DM) 2 YROBITUSSIN PEDIATRIC 7.5MG/5ML 2 Y

H6H-SKELETAL MUSCLE RELAXANTSBACLOFEN 10MG, 20MG 0 NCHLORZOXAZONE 250MG, 500MG 0 NCYCLOBENZAPRINE 5MG, 10MG 0 NMETHOCARBAMOL 500MG, 750MG 0 NMETHOCARBAMOL WITH ASPIRIN 400/325 0 NNORFLEX 30MG/ML INJ 2 NORPHENADRINE CITRATE 100MG 0 NORPHENADRINE CITRATE INJ 30MG/ML 0 NORPHENADRINE CPD 385/30/25 0 NORPHENADRINE CPD 770/60/50 0 NROBAXIN INJ 100MG/ML 2 NTIZANIDINE HCL 2MG, 4MG 0 N

H6J-ANTIEMETIC/ANTIVERTIGO AGENTS (SEE ALSO H2G)ANTI-NAUSEA LIQUID 0 NCESAMET 1MG 2 NCOLA SYRUP 0 NCOMPAZINE INJ 5MG/ML 2 NDIMENHYDRINATE 50MG 0 NDIMENHYDRINATE 50MG/ML 0 NEMEND 40MG, 80MG, 125MG, 125-80 2 NMARINOL 2.5MG, 5MG, 10MG 2 NMECLIZINE 12.5MG, 25MG CHEWABLE, 25MG 0 NNAUSETROL SOLN 0 NONDANSETRON 4MG, 8MG, 24MG 0 NONDANSETRON ODT 4MG, 8MG 0 NONDANSETRON ORAL SOLUTION 4MG/5ML 0 NPROCHLORPERAZINE EDISYLATE INJ 5MG/ML 0 NPROCHLORPERAZINE MALEATE 5MG, 10MG 0 NPROCHLORPERAZINE MALEATE SUPP 25MG 0 NPROMETHAZINE SUPPS, 12.5MG, 25MG, 50MG 0 NSCOPACE 0.4MG 2 NTIGAN INJ 100MG/ML 2 NTORECAN 10MG, 5MG/ML INJ 2 NTRANSDERM SCOP PATCH 1.5MG/72HRS 2 NTRIMETHOBENZAMIDE HCL 300MG 0 NTRIMETHOBENZAMIDE INJ 100MG/ML 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

H7B-ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTSMIRTAZAPINE 7.5MG, 15MG, 30MG, 45MG, SOL-TABS 0 NMIRTAZAPINE RAPID DISSOLVE TABLET 15MG, 30MG, 45MG 0 NREMERON SOL-TABS 15MG, 30MG, 45MG 2 N

H7C-SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)CYMBALTA 20MG, 30MG, 60MG 2 NEFFEXOR 25MG, 37.5MG, 50MG, 75MG, 100MG 2 NEFFEXOR XR 37.5MG, 75MG, 150MG 2 NVENLAFAXINE HCL 25MG, 37.5MG, 50MG, 75MG, 100MG TABS 0 N

H7D-NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS)BUPROPION HCL 75MG, 100MG 0 NBUPROPION SR 100MG, 150MG, 200MG 0 NWELLBUTRIN SR 100MG, 150MG, 200MG 2 NWELLBUTRIN XL 150MG, 300MG 2 N

H7E-SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS)NEFAZODONE HCL 50MG, 100MG, 150MG, 200MG, 250MG 0 N

H7J-MAOIS - NON-SELECTIVE & IRREVERSIBLENARDIL 15MG 2 NPARNATE 10MG 2 N

H7O-ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONESHALDOL INJ 5MG/ML 0 NHALOPERIDOL 0.5MG, 1MG, 2MG, 5MG, 20MG 0 NHALOPERIDOL DECANOATE 50MG/ML, 100MG/ML 0 NHALOPERIDOL LACTATE CONC LIQUID 2MG/ML 0 N

H7R-ANTIPSYCH, DOPAMINE ANTAGONIST, DIPHENYLBUTYLPIPERIDINESORAP 1MG, 2MG 2 N

H7S-ANTIPSYCHOTICS, DOPAMINE ANTAGONIST, DIHYDROINDOLONESMOBAN 5MG, 10MG, 25MG, 50MG 2 N

H7T-ANTIPSYCHOTICS, ATYPICAL,DOPAMINE,& SEROTONIN ANTAGCLOZAPINE 12.5MG, 25MG, 50MG, 100MG, 200MG 0 NCLOZARIL 25MG, 100MG (BMN ONLY) 2 NFAZACLO TABLET 12.5M G , 25MG, 100MG 2 NGEODON 20MG, 40MG, 60MG, 80MG 2 NRISPERDAL 0.25MG, 0.5MG, 1MG, 2MG, 3MG, 4MG 2 NRISPERDAL M 0.5MG, 1MG, 2MG, 3MG, 4MG 2 NRISPERDAL SOLN 1MG/ML 2 NSEROQUEL 25MG, 50MG, 100MG, 200MG, 300MG, 400MG 2 NSEROQUEL XR 200MG, 300MG, 400MG 2 NZYPREXA 2.5MG, 5MG, 7.5MG, 10MG, 15MG, 20MG 2 NZYPREXA ZYDIS 5MG, 10MG, 15MG, 20MG 2 N

H7X-ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXEDABILIFY 2MG, 5MG, 10MG, 15MG, 20MG, 30MG 2 NABILIFY 5MG/5ML 2 NABILIFY DISCMELT 10MG, 15MG 2 NABILIFY INJ 9.75MG/1.3ML 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

H7Y-TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPESTRATTERA 10MG, 18MG, 25MG, 40MG, 60MG, 80MG, 100MG (AGE 6 AND OLDER) 2 N

H7Z-SSRI &ANTIPSYCH, ATYP, DOPAMINE & SEROTONIN ANTAG COMBSYMBYAX 3MG-25M G , 6MG-25MG, 6MG-50MG, 12MG-25MG, 12MG-50MG 2 N

H8B-HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTSROZEREM 8MG 2 N

J1A-PARASYMPATHETIC AGENTSBETHANECHOL CHLORIDE 5MG, 10MG, 25MG, 50MG 0 NEVOXAC 30MG 2 NGUANIDINE HCL 125MG 2 NPILOCARPINE HCL 5MG 0 NSALAGEN 5MG 2 N

J1B-CHOLINESTERASE INHIBITORSARICEPT 5MG,10MG 2 NARICEPT ODT 5MG, 10MG 2 NCOGNEX 10MG, 20MG, 30MG, 40MG 2 NEXELON 1.5MG, 3MG, 4.5MG, 6MG, 2MG/ML 2 NEXELON PATCH 4.6MG/24HR, 9.5MG/24HR 2 NMESTINON 180MG 2 NMESTINON 60MG/5ML LIQUID 2 NMYTELASE 10MG 2 NPROSTIGMIN 15MG 2 NPYRIDOSTIGMINE BROMIDE 60MG 0 NRAZADYNE 4MG, 8MG, 12MG, 4MG/ML 2 NRAZADYNE ER 8MG, 16MG, 24MG 2 N

J2A-BELLADONNA ALKALOIDSATROPINE INJ 1MG/ML 0 NCOLYTROL 0.031MG/ML 2 NCOLYTROL LIQ, PED DROPS, TABS 2 NCYSTOSPAZ 0.15MG 2 NHYOSCYAMINE 0.125MG, 0.15MG 0 NHYOSCYAMINE 0.125MG/ML, 0.125MG/5ML 0 NHYOSCYAMINE 0.375MG 0 NHYOSCYAMINE SULFATE 0.25MG 0 NPAMINE 2.5MG 2 NPAMINE FORTE 5MG 2 NSAL-TROPINE 0.4MG 2 NSYMAX 0.125MG 2 N

J2B-ANTICHOLINERGIC, QUATERNARY AMMONIUMCANTIL 25MG 2 NGLYCOPYRROLATE 1MG, 2MG 0 NPROPANTHELINE 15MG 0 NROBINUL 1MG 2 NROBINUL FORTE 2MG 2 NROBINUL INJ 0.2MG/ML 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

J2D-ANTICHOLINERGIC ANTISPASMODICSBENTYL 10MG/5ML 0 NDICYCLOMINE HCL 10MG, 20MG 0 NDICYCLOMINE HCL INJ 10MG/ML 0 NOXYBUTYNIN CHLORIDE 5MG 0 NOXYBUTYNIN CHLORIDE 5MG/5ML 0 N

J3A-SMOKING DETERRENT AGENTS (GANGLIONIC STIM, OTHERS)COMMIT 2MG, 4MG 2 NNICODERM CQ PATCH 7MG/24HR, 14MG/24HR, 21MG/24HR 0 NNICORETTE GUM 2MG, 4MG 2 NNICOTINE GUM 2MG, 4MG 0 NNICOTROL INHALER 2 NNICOTROL NASAL SPRAY 2 NZYBAN 150MG 2 N

J3C-SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONISTCHANTIX 0.5MG, 1MG, MONTH PAK 2 N

J5A-ADRENERGIC AGENTS, CATECHOLAMINESADRENALIN CHLORIDE 1MG/ML 2 NEPINEPHRINE 0.1MG/ML 0 NEPINEPHRINE 1MG/ML 0 NISOETHARINE HCL 1% 0 N

J5B-ADRENERGICS, AROMATIC, NON-CATECHOLAMINEADDERALL 5MG, 10MG, 20MG, 30MG 2 NADDERALL 7.5MG, 12.5MG, 15MG 0 NADDERALL XR 5MG, 10MG, 15MG, 20MG, 25MG, 30MG 2 NAMPHETAMINE SALT COMBO 5MG, 10MG, 20MG, 30MG 0 NVYVANSE 30MG, 50MG, 70MG 2 N

J5D-BETA ADRENERGIC AGENTSALBUTEROL 2MG, 4MG 0 NACCUNEB (AGE 0 TO 12 ONLY) 0.21MG/ML, 0.42MG/ML * NALBUTEROL 0.83MG/ML SOLN FOR INH 0 NALBUTEROL 2MG/5ML SYRUP 0 NALBUTEROL 5MG/ML SOLN FOR INH 0 NALBUTEROL 90MCG INH, REF 0 NBRETHINE 1MG/ML INJ 2 NBRETHINE 2.5MG, 5MG 2 NCOMBIVENT 103-18MCG 2 NMAXAIR AUTOHALER 2 NMETAPROTERENOL 10MG, 20MG 0 NMETAPROTERENOL 10MG/5ML SYRUP 0 NMETAPROTERENOL SOLN FOR INH 0.4%, 0.6% 0 NPROAIR HFA (FORMERLY ALBUTEROL SULFATE HFA) 0 NTERBUTALINE SO4 2.5MG, 5MG 0 NVENTOLIN HFA 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

VOSPIRE ER 4MG, 8MG 2 NXOPENEX 0.63MG/3ML, 1.25MG/3ML, 0.31MG/3ML 2 NXOPENEX HFA 2 N

J5E-SYMPATHOMIMETIC AGENTSCHILDRENS NASAL DECONGESTANT 15MG/5ML (PSEUDO) 0 NEPHEDRINE SULFATE 25MG 0 NPHENYLEPHRINE HCL 10MG 0 NPSEUDOEPHEDRINE HCL 30MG, 60MG 0 NPSEUDOEPHEDRINE HCL 30MG/5ML 0 N

J5F-ANAPHYLAXIS THERAPY AGENTSEPIPEN, EPIPEN JR 0.15MG 2 N

J5H-ADRENERGIC VASOPRESSOR AGENTSMIDODRINE HCL 2.5MG, 5MG, 10MG 0 NPROAMATINE 2.5MG, 5MG, 10MG 2 N

J7A-ALPHA/BETA-ADRENERGIC BLOCKING AGENTSCARVEDILOL TABLETS 3.125MG, 6.25MG, 12.5MG, 25MG 0 NCOREG 3.125MG, 6.25MG, 12.5MG, 25MG 2 NCOREG CR 10MG, 20MG, 40MG, 80MG 2 NLABETALOL 100MG, 200MG, 300MG 0 N

J7C-BETA ADRENERGIC BLOCKERSACEBUTOLOL 200MG, 400MG 0 NATENOLOL 25MG, 50MG, 100MG 0 NBETAXOLOL HCL 10MG, 20MG 0 NBISOPROLOL FUM 5MG, 10MG 0 NINDERAL LA 60MG, 80MG, 120MG, 160MG 2 NMETOPROLOL TARTRATE 25MG, 50MG, 100MG 0 NNADOLOL 20MG, 40MG, 80MG, 120MG, 160MG 0 NPINDOLOL 5MG, 10MG 0 NPROPRANOLOL 20MG/5ML, 40MG/5ML SOLN 2 NPROPRANOLOL HCL 10MG, 20MG, 40MG, 60MG, 80MG, 90MG 0 NPROPRANOLOL LA 60MG, 80MG, 120MG, 160MG 0 NSOTALOL 80MG, 120MG, 160MG, 240MG 0 NTIMOLOL MALEATE 5MG, 10MG, 20MG 0 NTOPROL XL 50MG, 100MG, 200MG 2 NTOPROL XL 25MG 0 N

J9A-INTESTINAL MOTILITY STIMULANTSMETOCLOPRAMIDE HCL 10MG 0 NMETOCLOPRAMIDE HCL 5MG/5ML ORAL SOLN 0 NMETOCLOPRAMIDE HCL 5MG/ML INJ 0 N

L0B-TOPICAL/MUCOUS MEMBRANE/SUBCUTANEOUS ENZYMEACCUZYME 0.83MMU SPRAY 2 NACCUZYME 0.83MMU/GM, OINT 2 NACCUZYME SE SPRAY EMULSION 2 NETHEZYME 0.83MMU/G, 1.1MMU/G 2 NGLADASE 0.83MMU/GM 2 NGLADASE-C 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

KOVIA OINT 0 NPANAFIL 10%, SPRAY 521700-10 2 NPANAFIL SE SPRAY EMULSION 2 NPAPAIN-UREA-CHLOROPHYLLIN 1.1MMU/G 0 NPAP-UREA 830000 U/G 2 NPAPTASE FOAM 83000-10 2 NSANTYL 2 NZIOX 405 2 N

L1A-ANTIPSORIATIC AGENTS,SYSTEMICSORIATANE 10MG, 25MG 2 NSORIATANE CK KIT 10MG, 25MG 2 N

L2A-EMOLLIENTSAMLACTIN CREAM 12% 2 NAMMONIUM LACTATE 12% CREAM 0 NKERI SENSITIVE SKIN LOTION 2 NLAC-HYDRIN CREAM 2 NRESURFIX 2 N

L3A-PROTECTIVES (may be covered for dual eligible if available over the counter)ALOE VESTA 2 YBAZA PROTECT 2 YCRITIC-AID CLEAR OINT 2 YDERMAMED OINT, SPRAY 2 YPELEVERUS 2 YREMEDY SKIN REPAIR CREAM 1.5% 2 Y

L3B - PROTECTIVES (may be covered for dual eligible if available over the counter)SENSI-CARE 2 Y

L3P-ANTIPRURITICS TOPICALAMLACTIN AP 1% 2 NDIPHENHYDRAMINE 2% CREAM 0 NPRUDOXIN 5% 2 NZONALON 5% 2 N

L5A-KERATOLYTICSAMLACTIN LOTION 12% 2 NAMMONIUM LACTATE LOTION 12% 0 NBENZAC AC 2.5% 2 NBENZOYL PEROXIDE GEL 2.5%, 5%, 10% 0 NBENZOYL PEROXIDE LOTION 5%, 10% 0 NBENZOYL PEROXIDE WASH 2.5%, 5%, 10% 0 NBREVOXYL CLEANSING LOTION 4% 2 NBREVOXYL CREAMY WASH 4%, 8% 2 NBREVOXYL GEL 4%, 8% 2 NBREVOXYL-8 LOTION 8% 2 NCONDYLOX GEL 0.5% 2 NCONDYLOX TOP SOLN 0.5% 0 NDESQUAM-E 2.5% 2 NHYDRISALIC CREAM 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

KEROL 42% REDI-CLOTHS 2 NLACTINOL 10% 2 NMECTALYTE TOPICAL SUSP 40% 2 NNEOBENZ MICRO CREAM 3.5%, 5.5%, 8.5% 2 NOSCION CLEANSER 3%, 6%, 9% 2 NSALAC 2% 2 NSALACTIC FILM 16.7% 2 NSAL-PLANT GEL 17% 2 NSALICYLIC ACID 6% SHAMPOO 0 NTRIAZ 3%, 6%, 9% GEL 2 NTRIAZ CLEANSING LOTION 3%, 6%, 10% 2 NUREA GEL 40% 0 NUREA LOTION 35%, 40% 0 NUREALAC 50% NAIL STICK 2 NVANAMIDE 40% 2 NZACLIR 4%, 8% 2 N

L5E-ANTISEBORRHEIC AGENTSCARMOL SCALP TREATMENT KIT 10-10% 2 NCARMOL SCALP TREATMENT LOTION 10% 2 N

L5F-ANTIPSORIATICSANTHRALIN 1% 0 NDOVONEX CREAM, OINT, SOLN 0.005% 2 NPSORIATEC 1% 2 NTAZORAC GEL 0.05%, 0.1%(AGES 0-23) 2 N

L5G-ROSACEA AGENTS, TOPICALFINACEA 15% 2 NMETROGEL 0.75% 0 NMETROGEL 1% 2 NMETROLOTION 0.75% 2 NMETRONIDAZOLE 0.75% TOPICAL GEL 0 NNORITATE 1% 2 NROZEX 0.75% 2 N

L5H-ACNE AGENTS, TOPICALAZELEX 20% (AGES 0-23) 2 NBENZACLIN 1-5% 2 NDUAC 1-5% 2 NZIANA GEL 1.2-0.025% (AGES 0-23) 2 N

L6A-IRRITANTS/COUNTER-IRRITANTSCAPSAGEL 0.05% 2 NCAPSAICIN 0.025%, 0.05%, 0.075% CREAM, LOTION 0 NZIKS OINT 2 N

L9A-MISC TOPICAL AGENTSATRAC-TAIN 10% 2 NCARA-KLENZ 2 NCARMOL 40 CREAM 2 NCARMOL 40% LOTION, GEL 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

RE UREA 40 0 NSELENIUM SULFIDE 2.5% 0 NUREA CREAM, LOTION 40% 0 NWOUN'DRES 2 N

L9B-VITAMIN A DERIVATIVESAVITA CREAM, GEL 0.025% (AGES 0-23) 2 NDIFFERIN CREAM, GEL, SOLN 0.1% (AGES 0-23) 2 NRENOVA EMOLLIENT 0.05% (AGES 0-23) 2 NRETIN A CREAM 0.025%, 0.05%, 0.1% (AGES 0-23) 0 NRETIN A GEL 0.01%, 0.025% (AGES 0-23) 0 NRETIN A MICRO 0.04%, 0.1% (AGES 0-23) 2 N

M0D-PLASMA EXPANDERSDEXTRAN75/DEXTROSE 5% 2 N

M0E-ANTIHEMOPHILIC FACTORSADVATE 250, 500, 1000, 1500, 1800-2200 (+/-)U 2 NADVATE H 1000 (+/-)U 2 NADVATE L 250 (+/-)U 2 NADVATE M 500 (+/-)U 2 NADVATE SH 1500 (+/-)U 2 NADVATE UH 2000 (+/-)U 2 NALPHANATE 250-500, 1000-1500 (+/-)U 2 NANTIHEMOPHILIC FACTOR 2 NBIOCLATE 1020 2 NFEIBA VH IMMUNO 490U, 400-650U, 1750-3250U 2 NHELIXATE FS 250, 500, 1000 (+/-)U 2 NHEMOFIL-M 220-400, 401-800, 801-1700, 1701-2000 (+/-)U 2 NHEMOFIL-T 30 1000U 2 NHUMATE-P 250-600U, 500-1200U, 1000-2400U 2 NKOATE-DVI 250U, 500U, 1000U 2 NKOGENATE FS 250U, 500U, 1000U 2 NMONOCLATE-P 250U, 500U, 1000U 2 NNOVOSEVEN 1200MCG, 2400MCG, 4800MCG 2 NRECOMBINATE 310AHFU, 407AHFU, 600AHFU 2 NREFACTO 250U, 500U, 1000U, 2000U 2 N

M0F-FACTOR IX PREPARATIONSALPHANINE 375U, 800U 2 NBEBULIN VH IMMUNO 700U 2 NBENEFIX 250U, 500U, 1000U 2 NMONONINE 250U, 500U, 1000U 2 NPROFILNINE SD 500U, 1250U 2 NPROPLEX SX 300-1200U 2 NPROPLEX T 300-1200U 2 N

M4B-IV FAT EMULSIONSFAT EMULSION 10%, 20% 2 NINTRALIPID 10%, 20%, 30% 2 NLIPOSYN II 10%, 20% 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

LIPOSYN III 10%, 20%, 30% 2 NTRAVAMULSION 10%, 20% 2 N

M4E-LIPOTROPICSADVICOR 20-500MG, 20-750MG, 20-1000MG, 40-1000 2 NGEMFIBROZIL 600MG 0 NLOVASTATIN 10MG, 20MG, 40MG 0 NNIASPAN 500MG, 750MG, 1000MG 2 NPRAVASTATIN 10MG, 20MG, 40MG, 80MG 0 NSIMVASTATIN 5MG, 10MG, 20MG, 40MG, 80MG 0 NTRICOR 48MG, 54MG, 145MG, 160MG 2 N

M4F-LIPOTROPICSCRESTOR 5MG, 10MG, 20MG, 40MG 2 NLESCOL 20MG, 40MG 2 NLESCOL XL 80MG 2 NLIPITOR 10MG, 20MG, 40MG, 80MG 2 NVYTORIN 10-10, 10-20, 10-40, 10-80MG 2 NZETIA 10MG 2 N

M4G-HYPERGLYCEMICSGLUCACON 1MG, EMERGENCY KIT 1MG 2 NGLUTOSE 40% 2 NPROGLYCEM 50MG/ML 2 N

M4I-LIPOTROPICS-CALCIUM CHANNEL BLOCKER COMBINATIONCADUET 2.5-10, 2.5-20, 2.5-40, 5-10, 5-20, 5-40, 5-80, 10-10, 10-40, 10-80 2 N

M9D-ANTIFIBRINOLYTIC AGENTSAMICAR 250MG/ML INJ 2 NAMICAR 250MG/ML SYRUP 0 NAMICAR 500MG, 1000MG 2 NCYKLOKAPRON 100MG/ML INJ 2 N

M9K-HEPARIN AND RELATED PREPARATIONSARIXTRA 2.5MG/0.5ML, 5MG/0.5ML, 7.5MG/0.6ML, 10MG/0.8ML 2 NFRAGMIN 2500U/0.2ML, 5000U/0.2ML 2 NFRAGMIN 7500U/0.3ML, 10000U/ML, 25000U/ML 2 NHEPARIN 10U/ML, 100U/ML, 1000U/ML 0 NHEPARIN 5000U/ML, 7500U/ML, 10000U/ML, 20000U/ML 0 NINNOHEP 20MU/ML 2 NLOVENOX 30MG, 40MG, 60MG, 80MG, 100MG, 120MG, 150MG INJ 2 N

M9L-ANTICOAGULANTS, COUMARIN TYPEWARFARIN SODIUM 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 0 N

M9P-PLATELET AGGREGATE INHIBAGGRENOX 25-200MG 2 NCILOSTAZOL 50MG, 100MG 0 NPLAVIX 75MG 2 NTICLOPIDINE 250MG 0 N

M9S-HEMORRHEOLOGIC AGENTSPENTOXIFYLLINE 400MG 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

N1C-LEUKOCYTE STIMULANTSLEUKINE 250MCG, 500MCG INJ 2 NNEULASTA 6MG/0.6ML 2 NNEUPOGEN 300MCG/ML INJ 2 N

N1D-PLATELET REDUCING AGENTSANAGRELIDE HCL 0.5MG, 1MG 0 N

N1E-PLATELET PROLIFERATION STIMULANTSNEUMEGA 5MG INJ 2 N

P1B-SOMATOSTATIC AGENTSSANDOSTATIN 0.05MG/ML, 0.1MG/ML, 0.2MG/ML 0 NSANDOSTATIN 0.5MG/ML, 1MG/ML 0 N

P1C-LUTEINIZING HORMONESLUPRON DEPOT 3.75MG, 7.5MG 2 N

P1E-ADRENOCORTICOTROPHIC HORMACTHAR HP 80U 2 N

P1F-PITUITARY SUPPRESSIVE AGENTSCABERGOLINE 0.5MG 0 NDANAZOL 50MG, 100MG, 200MG 0 NDANOCRINE 50MG, 100MG, 200MG 2 NDOSTINEX 0.5MG 2 NSYNAREL 2MG/ML NASAL SOLN 2 N

P1G-ADRENAL STEROID INHIBITORSCYTADREN 250MG 2 N

P2B-ANTIDIURETIC AND VASOPRESSOR HORMONESDDAVP 0.1MG, 0.2MG 2 NDDAVP 4MCG/ML INJ 2 NDDAVP NASAL 0.01%, SPRAY PUMP 10MCG/DOSE 2 NDESMOPRESSIN ACETATE INJ 4MCG/ML 0 NDESMOPRESSIN ACETATE NASAL 0.1MG/ML 0 N

P3A-THYROID HORMONESARMOUR THYROID 15MG, 30MG, 60MG, 100MG, 120MG, 180MG, 240MG, 300MG 2 NCYTOMEL 5MCG, 25MCG, 50MCG 2 NLEVOTHROID 0.0137 0 NLEVOTHYROXINE SODIUM 0.025, 0.05, 0.075, 0.88, 0.1, 0.112, 0.125MG 0 NLEVOTHYROXINE SODIUM 0.137, 0.15, 0.175, 0.2, 0.3MG 0 NLEVOXYL 0.137 2 NSYNTHROID 0.137MG 2 NTHYROID 30MG, 60MG, 120MG, 180MG 0 NWESTHROID 120MG 2 N

P3L-ANTITHYROIDSMETHIMAZOLE 5MG, 10MG, 20MG 0 NPROPYLTHIOURACIL 50MG 0 N

P4D - HYPERPARATHYROID VITAMIN D ANALOGHECTOROL 0.5MG, 2.5MG 2 NZEMPLAR 1MCG, 2MCG, 4MCG 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

P4L-BONE RESORPTION INHIBITORSACTONEL 5MG, 30MG, 70MG 2 NBONIVA 2.5MG, 150MG 2 NDIDRONEL 200MG, 400MG, 50MG/ML 2 NETIDRONATE 200MG, 400MG 0 NEVISTA 60MG 2 NFOSAMAX 5MG, 10MG, 35MG, 40MG, 70MG, 70MG/75ML 2 NMIACALCIN 200U/ML INJ, NASAL SOLN 200U/DOSE 2 N

P4N-BONE OSSIFICATION SUPPRESSION RESORPTION INHIBITOR & VITAMIN D COMBINATIONSFOSAMAX PLUS D 70MG-2800, 70MG-5600 2 N

P5A-GLUCOCORTICOIDSCORTEF 5MG, 10MG 2 NCORTISONE ACETATE 25MG 0 NDELTASONE 2.5MG 2 NHYDROCORTISONE 10MG, 20MG 0 NHYDROCORTISONE SODIUM SUCCINATE 100MG INJ 0 NHYDROCORTONE 10MG 2 NMEDROL 2MG, 16MG 2 NMEDROL 8MG 0 NMETHYLPREDNISOLONE TABLET 4MG, 16MG, 32MG 0 NMETHYLPREDNISOLONE ACETATE INJ 40MG/ML, 80MG/ML 0 NORAPRED 15MG/5ML 2 NORAPRED ODT TAB 10MG, 15MG, 30MG 2 NPEDIAPRED LIQUID 6.7MG/5ML 2 NPREDNISOLONE 5MG 0 NPREDNISOLONE ORAL SOLN 15MG/5ML, 5MG/5ML 0 NPREDNISOLONE SOD PHOS 5MG/5ML, 15MG/5ML 0 NPREDNISONE 1MG, 2.5MG, 5MG, 10MG, 20MG, 50MG 0 NSOLU-CORTEF INJ 100MG 2 NSOLU-MEDROL INJ 125MG 2 NTRIAMCINOLONE ACETONIDE INJ 40MG/ML 0 N

P5B-GLUCOCORTICOIDS, SYSTEMICCELESTONE 0.6MG/5ML SOLN 2 NCELESTONE SOLUSPAN INJ 6MG/ML 2 NDECADRON 0.5MG, 0.75MG 2 NDEXAMETHASONE 0.5MG, 0.75MG, 1.5MG, 4MG, 6MG 0 NDEXAMETHASONE 0.5MG/5ML 0 NDEXAMETHASONE ACETATE INJ 8MG/ML 0 NDEXAMETHASONE SODIUM PHOSPHATE INJ 4MG/ML 0 NDEXPAK 1.5MG 2 NENTOCORT EC 3MG 2 NPULMICORT 0.25MG/2ML, 0.5MG/2ML 2 NQVAR INH 0.04MG, 0.08MG PER ACTUATION 2 NTRIAMCINOLONE DIACETATE INJ 40MG/ML 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

P5C-GLUCOCORTICOIDS, TOPICALAEROBID, AEROBID-M 2 NARISTOCORT 4MG 2 NASMANEX 2 NAZMACORT INH 100MCG/ACTUATION 2 NFLOVENT DISKUS 50MCG 2 NFLOVENT HFA SPRAY 44MCG, 110MCG, 220MCG 2 NKENALOG 40 INJ 40MG/ML 2 N

P5S-MINERALOCORTICOIDSFLORINEF ACETATE 0.1MG 2 NFLUDROCORTISONE 0.1MG 0 N

Q2C-OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPERESTASIS 0.05% 2 N

Q3A-RECTAL PREPSANUSOL HC 2.5% CREAM 2 NHYDROCORTISONE CREAM 2.5% 0 NPROCTOCORT 1% 2 NPROCTOCREAM HC 2.5% 2 NPROCTOSOL HC 2.5% 2 NPROCTOZONE HC 2.5% 2 N

Q3B-RECTAL/LOWER BOWEL PREP.,GLUCOCORTICOID (NON-HEMORRHOID)HYDROCORTISONE ENEMA 100MG 0 N

Q3D-HEMORRHOIDAL PREPSHEMORRHOIDAL CREAM, OINT, SUPP 0 N

Q3E - CHRONIC INFLAMMATORY COLON DX, 5-A-SALICYLAT,RECTAL TXCANASA 500MG, 1000MG 2 NROWASA ENEMA 4GM/60ML 2 N

Q3S-LAXATIVES, LOCAL/RECTAL (may be covered for dual eligible if available over the counter)DOCUSOL MINI ENEMA 2 YENEMEEZ MINI ENEMA 2 YENEMEEZ PLUS MINI ENEMA 2 Y

Q4A-VAGINAL MISCAMINO ACID CERVICAL 0 N

Q4B-VAGINAL ANTISEPTICSACID JELLY 0 N

Q4F-VAGINAL ANTIFUNGALSCLOTRIMAZOLE VAG CREAM, SUPPS 0 NGYNAZOLE-1 2 NMICONAZOLE NITRATE VAG CREAM 2% 0 NMICONAZOLE VAG SUPPS 100MG, 200MG 0 NMICONAZOLE VAGINAL COMBO PAK 200MG-2% CREAM 0 NMONISTAT 1 COMBINATION PACK 2 NMONISTAT 3 VAG SUPPS 2 NMONISTAT COMBO PAK 100MG SUPP-2% CREAM 2 NNYSTATIN 100000U VAG TABS 0 NTERAZOL 3 VAG CREAM 0.8% 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

TERAZOL 3 VAG TABS 2 NTERAZOL 7 VAG CREAM 0.4% 0 NTICONAZOLE-1 6.5% 0 N

Q4K-VAGINAL ESTROGENS (SEE ALSO G1A)ESTRING 7.5MCG/24HR 2 NESTRACE VAG CREAM 0.01% 2 NFEMRING 0.05MG/24HR 2 NPREMARIN VAG CREAM 0.625MG/GM 2 NVAGIFEM 25MCG 2 N

Q4S-VAGINAL SULFONAMIDESAVC 15% VAG CREAM 2 N

Q4W-VAGINAL ANTIBIOTICSCLEOCIN VAG CREAM 2% 0 NCLEOCIN VAG TAB 100MG 2 NCLINDESSE 2% 2 NMETROGEL VAG CREAM 0.75% 0 N

Q5A-TOPICAL PREPS, MISC (may be covered for dual eligible if available over the counter)DERMAGRAN OINT, SPRAY 2 YNAIL SCRUB 2 Y

Q5B-TOPICAL ANTIBACTERIALSCAPITROL 2% 2 NFINEVIN 20% (AGES 0-23) 2 NNITROFURAZONE 0 NPHISOHEX 3% 2 NPOVIDONE-IODINE OINT, SCRUB, SOLN 0 N

Q5F-TOPICAL ANTIFUNGALSCLOTRIM/BETAMETH CRM 0 NCLOTRIMAZOLE CREAM 1%, AF CREAM 0 NCICLOPIROX 8% SOLUTION 0 NDERMA FUNGAL 2% 0 NFUNGOID TR 2 NKETOCONAZOLE 2% 0 NKETOCONAZOLE SHAMPOO 2% 0 NLOPROX CREAM, SUSP 0.77% 0 NLOPROX SHAMPOO 1%, GEL 0.77% 2 NMICONAZOLE NITRATE CREAM, POWDER 2% 0 NMPM ANTIFUNGAL CREAM 1% 2 NNAFTIN CREAM, GEL 1% 2 NNYSTATIN CREAM, OINT, PDR 100000U/GM 0 NNYSTATIN TRIAMCINOLONE CREAM, OINT 0 NOXISTAT CREAM, LOTION 1% 2 NPEDI-DRI 100MU/GM 2 NPENLAC 8% 2 NTOLNAFTATE CREAM, POWDER, SOLN 1% 0 NVUSION OINT 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

Q5H-TOPICAL LOCAL ANESTHETICSELA-MAX 4% 2 NELA-MAX PLUS 4% 2 NEMLA CREAM 2.5%/2.5% 2 NEXACTACAIN SPRAY 2-14-2% 2 NL.M.X.4 4% 2 NL.M.X.4 PLUS 4% 2 NLIDA MANTLE 3% 2 NLIDA MANTLE HC 0.5-3% 2 NLIDOCAINE OINT 5% 0 NLIDOCAINE-HC 0.5-3% 0 NLIDOCAINE-PRILOCAINE 2.5-2.5% 0 NLIDOCAINE 3%, 4% CREAM 0 NLIDODERM 5% 2 NMPM REGENECARE 2 N

Q5K-TOPICAL-IMMUNOSUPPRESSIVE AGENTSELIDEL 1% 2 NPROTOPIC 0.03%, 0.1% 2 N

Q5N-TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGENTSCARAC 0.5% 2 NEFUDEX CREAM 5%, SOLN 2%, 5% 2 NFLUOROPLEX CREAM 1% 2 NSOLARAZE 3% 2 N

Q5P-TOPICAL ANTI-INFLAMMATORY STEROIDALACLOVATE CREAM, OINT 0.05% 0 NAMCINONIDE 0.1% LOTION, CREAM 0 NBETAMETHASONE DIPROPIONATE CRM, GEL, OINT, LOT 0.05% 0 NBETAMETHASONE DP AUGMENTED 0 NBETAMETHASONE VALERATE CREAM, OINT, LOT 0.1% 0 NCAPEX SHAMPOO 0.01% 2 NCARMOL HC 1% 2 NCLOBETASOL E CREAM 0.05% 0 NCLOBETASOL PROPIONATE OINT, CREAM, GEL, SCALP 0.05% 0 NCLOBEX 0.05% LIQ 2 NCLODERM 0.1% 2 NCORDRAN OINT 0.05% 2 NCORDRAN LOTION 0.05% 2 NCORDRAN TAPE 4MCG/SQC 2 NCYCLOCORT CREAM, OINT 0.1% 0 NCYCLOCORT LOT 0.1% 2 NDERMA-SMOOTHE/FS OIL 0.01% 2 NDERMATOP 0.1% CREAM, OINT 2 NDESONIDE CREAM, OINT, LOTION 0.05% 0 NDESOXIMETASONE CREAM, OINT 0.05%, 0.25% 0 NDESOXIMETASONE GEL 0.05% 0 NDIFLORASONE DIACETATE CREAM, OINT 0.05% 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

DIPROLENE AF CREAM 0 NDIPROLENE LOTION 0.05% 2 NELOCON CREAM, OINT, LOT 0.1% 0 NFLUOCINOLONE ACETONIDE CREAM, OINT 0.025% 0 NFLUOCINOLONE ACETONIDE CREAM, SOLN 0.01% 0 NFLUOCINONIDE CREAM, OINT, SOLN, GEL 0.05% 0 NFLUOCINONIDE E CREAM 0.05% 0 NFLUTICASONE PROPIONATE CRM 0.05% 0 NFLUTICASONE PROPIONATE OINT 0.005% 0 NHALOBETASOL PROPIONATE 0.05% CREAM 0 NHALOG CREAM, OINT, SOLN 0.1% 2 NHYDROCORTISONE ACETATE W/UREA 1% 0 NHYDROCORTISONE BUTYRATE CREAM, SOLN, OINT 0.1% 0 NHYDROCORTISONE CREAM, OINT, 0.5%, 1%, 2.5% 0 NHYDROCORTISONE LOT 1%, 2.5% 0 NHYDROCORTISONE VALERATE 0.2% CREAM 0 NKENALOG AEROSOL 2 NKERATOL HC 1% CREAM 2 NLOCOID CREAM, OINT, LOT, LIPOCREAM 0.1% 2 NLUXIQ 0.12% 2 NMAXIFLOR CREAM, OINT 0.05% 2 NMOMETASONE FUROATE OINT 0.1% 0 NNUTRACORT LOTION 2.5% 2 NOLUX 2 NOLUX-E 2 NPANDEL CREAM 1% 2 NPSORCON E CREAM, OINT 0.05% 2 NTEMOVATE EMOLLIENT CREAM 0.05% 2 NTEXACORT 1%, 2.5% 2 NTOPICORT OINT 0.25%, GEL 0.05% 2 NTRIAMCINOLONE CREAM, OINT 0.025%, 0.1%, 0.5% 0 NTRIAMCINOLONE LOT 0.025%, 0.1% 0 NULTRAVATE CREAM, OINT 0.05% 0 NVANOS 0.1% 2 N

Q5R-TOPICAL ANTIPARISITICSELIMITE CREAM 5% 2 NEURAX CREAM, LOTION 10% 2 NLINDANE LOTION, SHAMPOO 0 NOVIDE 0.5% 2 NPERMETHRIN 1% LIQUID, 5% CREAM 0 NPYRINYL/LICE TREATMENT LIQUID 0 N

Q5S-TOPICAL SULFONAMIDESAVAR 10%/5% 2 NCLENIA 10%/5% 2 NNICOSYN 10%/5% 2 NPLEXION 10/5% 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

PRASCION 10-5% (W/W) 2 NROSADERM 10-5% 2 NROSANIL 10-5% 2 NROSULA 10%/5% 0 NSILVER SULFADIAZINE 1% 0 NSODIUM SULFACETAMIDE/SULFUR LOTION 10%/5% 0 NSULFACET-R LOTION 2 NSULFAMYLON 8.5% 2 NSULFATOL, SULFATOL-M 10%/5% 2 NZETACET 10-5% 2 N

Q5V-TOPICAL ANTIVIRALSDENAVIR CREAM 1% 2 NZOVIRAX OINT 5% 2 N

Q5W-TOPICAL ANTIBIOTICS (may be covered for dual eligible if available over the counter)BACITRACIN TOPICAL 500U/GM 0 YBACITRACIN/POLYMYXIN OINT 500U/GM/10MU/GM 0 YBACTROBAN CREAM, OINT 2% 0 2 NBENZAMYCIN GEL 30MG/50MG 0 2 NCENTANY 2% 0 NCLEOCIN T GEL 0 NCLINDAGEL 1% 2 NCLINDAMYCIN TOP SOLN 1% 0 NERYTHROMYCIN GEL, SOLN, PADS 2% 0 NERYTHROMYCIN-BENZOYL PEROXIDE GEL 3%-5% 0 NGENTAMICIN SULFATE CREAM, OINT 0.1% 0 NMUPIROCIN OINT 2% 0 NPOLYSPORIN TOPICAL POWDER 2 NTRIPLE ANTIBIOTIC OINT 0 Y

Q5X-TOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDALCORTISPORIN OINT 1% 2 N

Q6A-EYE PREPS MISCALTACHLORE OINT, SOLN 5% 2 NFML-S SUSP 10%/0.1% 2 NMURO 128 SOLN, OINT 5% 2 NSODIUM CHLORIDE SOLN, OINT 5% 0 N

Q6C-EYE VASOCONSTRICTORS RXNAPHAZOLINE SOLN 0.1% 0 NNEO-SYNEPHRINE SOLN 2.5%, 10% 2 NPHENYLEPHRINE SOLN 2.5%, 10% 0 N

Q6D-EYE VASOCONSTRICTORS OTCTETRAHYDROZOLINE/ZINC 0.5-0.25% 0 NVASOCON A 0.05%/0.5% 2 N

Q6G-MIOTICS/OTHER INTRAOC. PRESSURE REDUCERSALPHAGAN P SOLN 0.15% 2 NAZOPT SOLN 1% 2 NBETAXOLOL HCL 0.5% 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

BETIMOL SOLN 0.25%, 0.5% 2 NBRIMONIDINE TARTRATE 0.2% 0 NCARTEOLOL HCL 1% 0 NCOMBIGAN 0.2-0.5% 2 NCOSOPT PLUS 2-0.5% 2 NCOSOPT SOLN 2%/0.5% 2 NEPINAL 1% 2 NISOPTO CARBACHOL SOLN 1.5%, 3% 2 NISOPTO CARPINE SOLN 8%, 10% 2 NLEVOBUNOLOL SOLN 0.25%, 0.5% 0 NMETIPRANOLOL 0.3% 0 NPHOSPHOLINE IODIDE SOLN 0.125% 2 NPILOCARPINE SOLN 0.5%, 1%, 2%, 3%, 4%, 5%, 6% 0 NPILOPINE HS GEL 4% 2 NTIMOLOL MALEATE SOL 0.25%, 0.5% 0 NTIMOLOL MALEATE SOLN XE 0.25%, 0.5% 0 NTRAVATAN 0.004% 2 NTRAVATAN Z 0.004% 2 NTRUSOPT 2% 2 NXALATAN 0.005% 2 N

Q6H-EYE LOCAL ANESTHETICSFLUORACAINE 0.5-0.25% 2 NPROPARICAINE HCL SOLN 0.5% 0 NTETRACAINE HCL SOLN 0.5% 0 N

Q6I- EYE ANTIBIOTIC-CORTICOID COMBINATIONSCORTISPORIN SUSP 2 NNEOMYCIN/POLYMYXIN/HC SUSP 0 NPOLYPRED SUSP 2 NPRED G SUSP, OINT 2 NTOBRADEX SUSP, OINT 0.3%/0.1% 2 NZYLET EYE DROPS 0.3%-0.5% 2 N

Q6J-MYDRIATICSAK-PENTOLATE SOLN 2% 0 NATROPINE SULFATE SOLN, OINT 1% 0 NCYCLOGYL 0.5%, 1%, 2% 2 NCYCLOMYDRIL SOLN 0.2%/1% 2 NCYCLOPENTOLATE SOLN 1% 0 NDIPIVEFRIN SOLN 0.1% 0 NISOPTO ATROPINE SOLN 1% 2 NISOPTO HOMATROPINE SOLN 2%, 5% 2 NISOPTO HYOSCINE SOLN 0.25% 2 NTROPICAMIDE SOLN 0.5%, 1% 0 N

Q6P-EYE ANTIINFLAMMATORY AGENTSACULAR LS 0.4% 2 NACULAR SOLN 0.5% 2 NALREX SOLN 0.2% 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

DEXAMETHASONE SOD PHOSPHATE OINT 0.05%, SOLN 0.1% 0 NECONOPRED 0.125% 2 NFLUOROMETHOLONE SOLN 0.1% 0 NFLURBIPROFEN SODIUM 0.03% 0 NFML FORTE SOLN 0.25% 2 NFML SOP OINT 0.1% 2 NHMS LIQUIFILM SOLN 1% 2 NINFLAMASE MILD 0.125% 2 NLOTEMAX SOLN 0.5% 2 NMAXIDEX SOLN 0.1% 2 NNEVANAC 0.1% 2 NPRED MILD SOLN 0.12% 2 NPREDNISOLONE ACETATE SOLN 1% 0 NPREDNISOLONE SOD PHOSPHATE SOLN 0.125%, 1% 0 NVEXOL SOLN 1% 2 NVOLTAREN SOLN 0.1% 2 N

Q6R-EYE ANTIHISTAMINEALAWAY 0.025% 2 NOPTIVAR 0.05% 2 NPATADAY 0.2% 2 NPATANOL 0.1% 2 NZADITOR 0.025% 2 N

Q6S-EYE SULFONAMIDESBLEPHAMIDE OINT, SOLN 0.2% 2 NPREDNISOLONE/SULFACETAMIDE SOLN 0.25%-10% 0 NSULFACETAMIDE OINT 10% 0 NSULFACETAMIDE SODIUM, SOLN 10%, 30% 0 N

Q6T-EYE LUBRICANTS/TEARS (may be covered for dual eligible if available over the counter)ARTIFICIAL TEARS 0.5%, 1.4%, 1.4%/0.6% 0 YFRESHKOTE 2 NGENTEAL MILD 2% 2 YHYPOTEARS OINT, SOLN 2 YLUBRICANTS, DRY EYES, REFRESH 0 YTEARS NATURALE FORTE 2 YTEARS NATURALE PM 0 Y

Q6U-EYE MAST CELL STABILIZERSALOCRIL 2% 2 NALOMIDE SOLN 0.1% 2 NCROMOLYN SODIUM SOLN 4% 0 N

Q6V-EYE ANTIVIRALSTRIFLURIDINE SOLN 1% 0 NVIROPTIC SOLN 1% 2 N

Q6W-EYE ANTIBIOTICSAKTETRA 2 NAZASITE 1% EYE DROPS 2 NBACITRACIN OINT 500U/GM 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

BACITRACIN/NEOMYCIN/POLYMYXIN/HC OINT 0 NBACITRACIN/POLYMYXIN OINT 0 NCILOXAN OINT 0.3% 2 NCIPROFLOXACIN 0.3% 0 NDEXAMETHASONE/NEOMYCIN/POLYMYXIN OINT, SOLN 0 NERYTHROMYCIN OINT 5MG/GM 0 NGENTAMICIN SOLN 3MG/ML, OINT 3MG/GM 0 NIQUIX 1.5% 2 NNATACYN 5% 2 NNEOMYCIN/POLYMYXIN/BACITRACIN OINT 0 NNEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN 0 NPOLYMYXIN/TRIMETHOPRIM SOLN 0 NTOBRAMYCIN SOLN 0.3% 0 NTOBREX 0.3% OINT 2 NVIGAMOX 0.5% 2 NZYMAR 0.3% SOLN 2 N

Q6Y-EYE PREP, MISC (may be covered for dual eligible)ALTALUBE OPH OINT 0 Y

Q7A-NOSE PREPARATIONS, MISCELLANEOUS (RX)IPRATROPIUM BR 21MCG, 42MCG NS 0 N

Q7C-NASAL VASOCONSTRICTORS RXTYZINE 0.05%, 0.1% 2 N

Q7D-NASAL VASOCONSTRICTORS OTCOXYMETAZOLINE HCL 0.05% 0 NPHENYLEPHRINE HCL 0.125%, 1% 0 N

Q7E-NASAL ANTIHISTAMINEASTELIN NASAL SPRAY 137MCG 2 N

Q7H-NASAL MAST CELL STABILIZERS AGENTS (may be covered for dual eligible if available over thecounter)

CROMOLYN SODIUM 40MG/ML 0 YNASALCROM 40MG/ML 2 Y

Q7P-NASAL, ANTI-INFLAMMATORY STEROIDSFLONASE AQ 0.05% 0 NNASACORT AQ 2 NNASONEX 50MCG 2 N

Q7W-NASAL ANTIBIOTICSBACTROBAN NASAL 2% 2 N

Q7Y-NASAL OTC MISC (may be covered for dual eligible if available over the counter)SODIUM CHLORIDE (SALINE) NASAL SPRAY 0.65% 0 Y

Q8B-EAR PREPS, MISC ANTI-INFECTIVEACETIC ACID HC OTIC 2% 0 NACETIC ACID OTIC 2% 0 NACETIC ACID/ ALUMINUM ACETATE 0 NAERO OTIC HC 2 N

Q8F-OTIC PREPARATIONS, ANTI-INFLAMMATORY-ANTIBIOTICSCIPRO HC OTIC 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

CIPRODEX 0.3-0.1% 2 NQ8H-EAR PREPS, LOCAL ANESTHETIC

ANTIPYRINE/BENZOCAINE 0 NOTICAINE 20% 2 NOTIGESIC 0 NOTOCAIN 20% 2 NTYMPAGESIC 2 N

Q8R-EAR WAX REMOVAL PREPS (may be covered for dual eligible if available over the counter)CARBAMIDE PEROXIDE 6.5% 0 Y

Q8W-EAR ANTIBIOTICSCOLYMYCIN-S 2 NCORTISPORIN-TC SUSP 2 NFLOXIN OTIC 2 NNEOMYCIN/POLYMYXIN/HC SUSP, SOLN 0 NPEDIOTIC 2 N

Q9B-BPH/MICTURITION AGENTSAVODART 0.5MG 2 NFINASTERIDE 5MG 0 NFLOMAX 0.4MG 2 N

RIA-URINARY TRACT ANTISPASMODICS/ANTIINCONTINENCE AGENTDETROL LA 2MG, 4MG 2 NFLAVOXATE 100MG 0 N

R1E-CARBONIC ANHYDRASE INHIBITORSACETAZOLAMIDE 125MG, 250MG 0 NDIAMOX SEQUELS 500MG 2 NMETHAZOLAMIDE 25MG, 50MG 0 N

R1F-THIAZIDE DIURETIC&RELCHLOROTHIAZIDE 250MG, 500MG 0 NCHLORTHALIDONE 25MG, 50MG, 100MG 0 NDIURIL 250MG/5ML 2 NHYDROCHLOROTHIAZIDE 25MG, 50MG, 100MG 0 NINDAPAMIDE 1.25MG, 2.5MG 0 NMETHYCLOTHIAZIDE 2.5MG, 5MG 0 NMETOLAZONE 2.5MG, 5MG, 10MG 0 NSALURON 50MG 2 N

R1H-POTASSIUM SPARING DIURETICS (SEE ALSO P5T)AMILORIDE HCL 5MG 0 NALDACTONE 25MG, 50MG, 100MG 2 NINSPRA 25MG, 50MG 2 NSPIRONOLACTONE 25MG, 50MG, 100MG 0 N

R1I-TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG.ENABLEX 7.5MG, 15MG 2 NVESICARE 5MG, 10MG 2 N

R1K-DIURETICS,MISCELLANEOUSISMOTIC 45% 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

R1L-POTASSIUM SPARING DIURETICS IN COMBINATIONAMILORIDE/HCTZ 5/50 0 NSPIRONOLACTONE/HCTZ 25/25 0 NTRIAMTERENE HCTZ 25/50, 25/37.5, 50/75 0 N

R1M-LOOP DIURETICSBUMETANIDE 0.5MG, 1MG, 2MG 0 NBUMETANIDE INJ 0.25MG/ML 0 NDEMADEX 5MG, 10MG, 20MG, 10MG/ML 0 NEDECRIN 25MG, 50MG 2 NFUROSEMIDE 10MG/ML INJ 0 NFUROSEMIDE 10MG/ML ORAL, 40MG/5ML ORAL 0 NFUROSEMIDE 20MG, 40MG, 80MG 0 NTORSEMIDE 5MG, 10MG, 20MG, 100MG 0 N

R1R-URICOSURIC AGENTSPROBENECID 500MG 0 NSULFINPYRAZONE 100MG 0 N

R1S-URINARY PH MODIFIERSBICITRA SOLN 2 NCITRIC ACID/SODIUM CITRATE 334-500MG 0 NCITROLITH 2 NCYTRA-2 SOLN 0 NCYTRA-3 SOLN 0 NCYTRA-K SOLN 0 NK-PHOS M.F., #2 2 NK-PHOS NEUTRAL 250MG 2 NK-PHOS ORIGINAL 2 NPEDAMETH 15MG/ML 2 NPEDAMETH 200MG 2 NPHOSPHA 250 NEUTRAL 250 MG 2 YPOLYCITRA LC SOLN 2 NPOLYCITRA SYRUP 2 NPOLYCITRA-K SOLN 2 NPOTASSIUM CITRATE/CITRIC ACID 0 NRENACIDIN SOLN 0 NUROCIT-K 540MG, 750MG 2 NUROQID-ACID NO.2 2 NVIS-PHOS N 250MG TABLET 2 N

R4A-KIDNEY STONE AGENTSCALCIBIND 2 NCYSTAGON 50MG, 150MG 2 NTHIOLA 2 N

R5A-URINARY TRACT ANESTHETIC/ANALGESIC AGENTSAZO 95MG 2 NPHENAZOPYRIDINE 100MG, 200MG 0 NPHENAZOPYRIDINE PLUS 150-0.3-15 0 NPYRIDIUM PLUS 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

R5B-URINARY ANALGESICSELMIRON 100MG 2 N

S2A-COLCHICINESCOLCHICINE 0.6MG 0 NPROBENECID W/ COLCHICINE 500MG/0.5MG 0 N

S2B-NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPEADVIL 40MG/ML, 100MG/5ML 0 NADVIL 50MG, 100MG 2 NCELEBREX 50MG, 100MG, 200MG, 400MG (AGE 60+) 2 NDICLOFENAC POTASSIUM 50MG 0 NDICLOFENAC SODIUM 25MG, 50MG, 75MG, 100MG 0 NELIXSURE IB 10MG/5ML 0 NETODOLAC 200MG, 300MG, 400MG, 500MG 0 NETODOLAC XL 400MG, 500MG, 600MG 0 NFENOPROFEN CALCIUM 600MG 0 NFLURBIPROFEN 50MG, 100MG 0 NIBUPROFEN 100MG, 200MG, 400MG, 600MG, 800MG 0 NIBUPROFEN 100MG/5ML SUSP, 40MG/ML DROPS 0 NINDOCIN SUSP 25MG/5ML 2 NINDOMETHACIN 25MG, 50MG 0 NKETOPROFEN 100MG, 200MG SR 0 NKETOPROFEN 25MG, 50MG, 75MG 0 NKETOROLAC TROMETHAMINE 10MG, INJ 15MG/ML, 30MG/ML 0 NMECLOFENAMATE SODIUM 50MG, 100MG 0 NMELOXICAM 7.5MG, 15MG 0 NMOTRIN 40MG/ML, 100MG/5ML 0 NMOTRIN 50MG, 100MG 2 NNABUMETONE 500MG, 750MG 0 NNAPROSYN 125MG/5ML 2 NNAPROXEN 250MG, 375MG, 500MG, 125MG/5ML 0 NNAPROXEN EC 375MG, 500MG 0 NNAPROXEN SODIUM 220MG, 275MG, 550MG 0 NORUDIS KT 12.5MG 2 NPIROXICAM 10MG, 20MG 0 NSULINDAC 150MG, 200MG 0 NTORADOL INJ 15MG/ML 2 N

S2C-GOLD SALTSRIDAURA 3MG 2 N

S2D-ANTI-INFLAMMATORY AGENTSOXAPROZIN 600MG 0 N

S2I-ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITORLEFLUNOMIDE 10MG, 20MG 0 N

S2K-ANTI-ARTHRITIC AND CHELATING AGENTS 2 NCUPRIMINE 250MG 2 NDEPEN 250MG 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

U6E-OINTMENT-CREAM BASESHYDROPHILIC PETROLATUM 2 N

U6F-HYDROPHILIC CREAM/OINTMENT BASESHYDROPHILIC 2 NTRIAD 2 N

U6N-VEHICLESORA-BLEND SF 2 NORA-SWEET 2 NORA-SWEET SF 2 N

U6W-BULK CHEMICALSCLORPACTIN WCS-90 2 NHYDROUS EMULSIFIED BASE 0 NL-GLUTAMINE PDR 2 NORA-PLUS 2 NZINC SULFATE PDR 2 N

V1A-ALKYLATING AGENTSALKERAN 2MG, INJ 50MG 2 NCARBOPLATIN INJ 50MG, 150MG, 450MG 0 NCEENU 10MG, 40MG, 100MG, DOSEPAK 2 NCISPLATIN INJ 1MG/ML 0 NCYTOXAN 25MG, 50MG 0 NCYTOXAN LYOPHILIZED INJ 500MG, 1GM, 2GM 0 NDROXIA 200MG, 300MG, 400MG 2 NHYDROXYUREA 500MG 0 NIFEX-MESNEX 1GM/1GM, 1GM/3GM 2 NLEUKERAN 2MG 2 NMUSTARGEN INJ 10MG 2 NMYLERAN 2MG 2 NPARAPLATIN INJ 50MG, 150MG, 450MG 2 NTEMODAR 5MG, 20MG, 100MG, 140MG, 180MG, 250MG 2 N

V1B-ANTIMETABOLITESCYTARABINE INJ 1GM, 2GM, 100MG, 500MG 0 NFLUOROURACIL INJ 50MG/ML 0 NGEMZAR INJ 200MG, 1GM 2 NMERCAPTOPURINE 50MG 0 NMETHOTREXATE INJ 25MG/ML, TAB 2.5MG 0 NMETHOTREXATE LPF INJ 25MG/ML 0 NPURINETHOL 50MG 2 NTHIOGUANINE 40MG 2 NXELODA 150MG, 500MG 2 N

V1C-VINCA ALKALOIDSNAVELBINE INJ 10MG/ML 2 NVINBLASTINE INJ 10MG 0 NVINORELBINE INJ 10MG/ML 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

V1D-ANTIBIOTIC ANTINEOPLASTICSBLENOXANE INJ 15U, 30U 2 NBLEOMYCIN SULFATE INJ 15U, 30U 0 NCOSMEGEN INJ 0.5MG 2 NMITHRACIN 2500MCG 2 N

V1E-STEROID ANTINEOPLASTICSEMCYT 140MG 2 NMEGESTROL ACETATE 20MG, 40MG, 40MG/ML 0 NTESLAC 50MG 2 N

V1F-MISC ANTINEOPLASTICSARIMIDEX 1MG 2 NETOPOSIDE 20MG. 0 NLYSODREN 500MG 2 NMATULANE 50MG 2 NMITOXANTRONE 2MG/ML 0 NNOVANTRONE INJ 2MG/ML 2 NVEPESID 50MG CAP 0 NVESANOID 10MG CAP 2 N

V1H-ANTINEOPLASTIC-BREAST CANCERAROMASIN 25MG 2 NFEMARA 2.5MG 2 N

V1I-CHEMOTHERAPY RESCUE/ANTIDOTE AGENTSMESNEX 100MG/ML 2 N

V1J-ANTIANDROGENIC AGENTSCASODEX 50MG 2 NEULEXIN 125MG 2 NFLUTAMIDE 125MG 0 NNILANDRON 150MG 2 N

V1O-ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR.TRELSTAR DEPOT 3.75MG 2 N

V1Q-ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORSGLEEVEC 100MG, 400MG 2 NIRESSA 250MG 2 NNEXAVAR 200MG 2 NSUTENT 12.5MG, 25MG, 50MG 2 NTARCEVA 25MG, 100MG, 150MG 2 NTASIGNA 200MG 2 NTYKERB 250MG 2 N

V1T-SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM)FARESTON 60MG 2 NTAMOXIFEN CITRATE 10MG, 20MG 0 N

W1A-PENICILLINSAMOX TR/POTASSIUM CLAV 200-28.5/5, 400-57/5, 600-42.9/5ML 0 NAMOX TR/POTASSIUM CLAV 500-125MG, 875-125MG 0 NAMOX TR/POTASSIUM CLAV CHEW TAB 200-28.5, 400-57 0 NAMOXICILLIN 250MG, 500MG, 875MG, 125MG/5ML, 250MG/5ML 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

AMOXICILLIN 200MG/5ML, 400MG/5ML 0 NAMOXICILLIN CHEWABLE 125MG, 200MG, 250MG, 400MG 0 NAMOXICILLIN PED DROPS 50MG/ML 0 NAMOXIL 875MG 0 NAMPICILLIN 250MG, 500MG 0 NAMPICILLIN SUSP 125MG/5ML, 250MG/5ML 0 NAMPICILLIN VIAL 250MG, 500MG, 1GM, 2GM 0 NAMPICILLIN/SULBACTAM INJ 1.5GM, 3GM 0 NAUGMENTIN CHEWABLES 125/31.25, 250/62.5 0 NAUGMENTIN CHEWABLES 200/28.5, 400/56 2 NAUGMENTIN ES 600 SUSP 2 NAUGMENTIN SUSP 125-31.25/5ML 0 NAUGMENTIN SUSP 250-62.5/5ML 0 NAUGMENTIN TABS 250/125, 500/125, 875/125 0 NAUGMENTIN XR 1000-62.5 2 NBACTOCILL INJ 500MG, 1GM 2 NBICILLIN CR INJ 150/150, 600MU/ML, 1.2MMU/2ML 2 NBICILLIN L-A INJ 600, 1.2MMU/2ML, 2.4MMU/4ML 2 NDICLOXACILLIN 250MG, 500MG 0 NGEOCILLIN 382MG 2 NNAFCILLIN SODIUM INJ 500MG, 2GM 0 NPENICILLIN G POTASSIUM INJ 1MMU, 5MMU, 20MMU 0 NPENICILLIN G PROCAINE 600000U, 1200000U 0 NPENICILLIN VK 250MG, 500MG, 125MG/5ML, 250MG/5ML 0 NTICAR INJ 1GM, 3GM 2 NTIMENTIN INJ 3.1GM/100ML 2 NTOTACILLIN N INJ 2GM 2 NUNASYN INJ 1.5GM, 3GM 2 NZOSYN 2.25G/50ML, 3.375G/50ML, 4.5G/100ML 2 NZOSYN INJ 2/0.25, 3/0.375, 4/0.5, 36/4.5 2 N

W1C-TETRACYCLINESDOXYCYCLINE HYCLATE 50MG, 100MG 0 NMINOCYCLINE HCL 50MG, 100MG 0 NSUMYCIN 125MG/5ML 2 NTETRACYCLINE HCL 250MG, 500MG 0 NVIBRAMYCIN 25MG/5ML SUSP 2 NVIBRAMYCIN CALCIUM 50MG/5ML SYRUP 2 N

W1D-MACROLIDESAZITHROMYCIN 250MG, 500MG, 600MG 0 NAZITHROMYCIN IV 500MG 0 NAZITHROMYCIN PACKETS 1GM 0 NAZITHROMYCIN SUSP 100MG/5ML, 200MG/5ML 0 NCLARITHROMYCIN 250MG, 500MG 0 NCLARITHROMYCIN ER 500MG 0 NCLARITHROMYCIN SUSP 125MG/5ML, 250MG/5ML 0 NERYPED DROPS 40MG/ML 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

ERYTHROMYCIN 250MG 0 NERYTHROMYCIN 333MG 0 NERYTHROMYCIN 500MG 0 NERYTHROMYCIN ESTOLATE 125MG/5ML, 250MG/5ML 0 NERYTHROMYCIN ETHYLSUCCINATE 400MG, 200MG/5ML, 400MG/5ML 0 NERYTHROMYCIN LACTOBIONATE INJ 500MG/1GM 0 NERYTHROMYCIN STEARATE 250MG, 500MG 0 NERYTHROMYCIN W/ SULFISOXAZOLE 200/600 SUSP 0 NZMAX 2GM/60ML 2 N

W1F-AMINOGLYCOSIDESAMIKACIN SULFATE INJ 50MG/ML, 250MG/ML 0 NGENTAMICIN INJ 10MG/ML, 40MG/ML 0 NNEO-FRADIN 125MG/5ML 2 NNEOMYCIN SULFATE 500MG 0 NTOBI 300MG/5ML 2 NTOBRAMYCIN SULFATE 10MG/ML, 40MG/ML 0 N

W1G-ANTITUBERCULAR ANTIBIOTICSRIFADIN 150MG 0 NRIFAMPIN 300MG 0 NRIFATER 120/50/300 2 N

W1H-AMINOCYCLITOLSTROBICIN W/DILUENT 2GM 2 N

W1J-VANCOMYCIN AND DERIVATIVESVANCOCIN 125MG, 250MG 2 NVANCOCIN INJ 1GM 2 NVANCOMYCIN 500MG, 1GM 0 N

W1K-LINCOSAMIDESCLEOCIN 300MG 0 NCLEOCIN 75MG, 75MG/5ML 2 NCLEOCIN PHOSPHATE INJ 150MG/ML 2 NCLINDAMYCIN HCL 150MG, 300MG 0 NCLINDAMYCIN PHOSPHATE INJ 150MG/ML 0 NLINCOCIN INJ 300MG/ML 2 N

W1N-POLYMYXIN AND DERIVATIVESCOLISTIMETHATE NA 150MG 0 NCOLY-MYCIN M INJ 150MG 2 N

W1P-BETA LACTAMSAZACTAM INJ 500MG, 1GM, 2GM 2 N

W1Q-QUINOLONESAVELOX 400MG 2 NCIPRO SUSP (AGES 0-12) * NCIPROFLOXACIN 250MG, 500MG, 750MG 0 N

W1S-CARBAPENEMS (THIENAMYCINS)PRIMAXIN IM/IV 250MG, 500MG 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

W1W-CEPHALOSPORINS - 1ST GENERATIONCEFADROXIL MONOHYDRATE 500MG 0 NCEFAZOLIN SODIUM INJ 500MG, 1GM, 10GM 0 NCEPHALEXIN 250MG, 500MG, 125MG/5ML, 250MG/5ML 0 NDURICEF 250MG/5ML, 500MG/5ML 0 N

W1X-CEPHALOSPORINS - 2ND GENERATIONCEFACLOR 250MG, 500MG 0 NCEFACLOR SUSP 125/5, 187/5, 250/5, 375/5ML 0 NCEFTIN SUSPENSION (AGE 0 THROUGH 12) * NCEFUROXIME 250MG, 500MG 0 NCEFUROXIME SODIUM INJ 750MG, 1.5GM 0 NZINACEF INJ 750MG, 1.5GM 2 N

W1Y-CEPHALOSPORINS - 3RD GENERATIONCEDAX 400MG, 90MG/5ML SUSP 2 NCEFOTAXIME INJ 1GM 0 NCEFTRIAXONE 250MG, 500MG, 1GM, 2GM, 10GM 0 NCLAFORAN IM/IV 500MG, 1GM, 2GM 0 NFORTAZ INJ 500MG, 1GM, 2GM, 6GM 2 NOMNICEF 125MG/5ML, 250MG/5ML 0 NOMNICEF 300MG 0 NROCEPHIN INJ 250MG, 500MG, 1GM, 2GM, 10GM 2 NTAZICEF INJ 1GM, 2GM, 6GM 2 N

W1Z-CEPHALOSPORINS - 4TH GENERATIONMAXIPIME INJ 500MG, 1GM, 2GM 2 N

W2A-ABSORBABLE SULFONAMIDESAZULFIDINE ENTABS 500MG 2 NGANTRISIN SUSP 500MG/5ML 2 NSEPTRA IV 400/80 2 NSULFADIAZINE 500MG 0 NSULFAMETHOXAZOLE/TRIMETHOPRIM INJ 400/80 0 NSULFAMETHOXAZOLE/TRIMETHOPRIM SUSP 200&40/5 0 NSULFAMETHOXAZOLE/TRIMETHOPRIM TAB 400/80, 800/160 0 NSULFASALAZINE 500MG, EC500MG 0 NSULFISOXAZOLE 500MG 0 N

W2E-ANTI-MYCOBACTERIUM AGENTSETHAMBUTOL HCL 400MG 0 NISONIAZID 100MG, 300MG, 50MG/5ML 0 NMYAMBUTOL 100MG, 400MG 2 NMYCOBUTIN 150MG 2 NPASER 4GM 2 NPYRAZINAMIDE 500MG 0 NTRECATOR-SC 250MG 2 N

W2F-NITROFURAN DERIVATIVESFURADANTIN 25MG/5ML ORAL SUSP 2 NFUROXONE 100MG, 50MG/15ML LIQUID 2 NMACROBID 100MG 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

MACRODANTIN 25MG, 50MG, 100MG 0 NNITROFURANTOIN MONOHYDRATE MACRO 100MG 0 N

W2G-CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC.HIPREX 1GM 2 NMETHENAMINE HIPPURATE 1GM 0 NMETHENAMINE MANDELATE 500MG, 1GM 0 NMONUROL 3GM 2 NPRIMSOL 50MG/5ML 2 NPROLOPRIM 100MG 2 NTRIMETHOPRIM 100MG 0 NUREX 1GM 2 NURINARY ANTISEPTIC VARIOUS 0 NURISED 2 NURITACT DS 81.6MG 2 NUTA 120-0.12MG 2 NUTIRA 81.6-0.12MG 2 N

W3A-ANTIFUNGAL ANTIBIOTICSFULVICIN U/F 250MG 2 NGRIFULVIN V 500MG 2 NGRISEOFULVIN 125MG/5ML 0 NGRIS-PEG 125MG, 250MG 2 NNYSTATIN SUSP 100000U/ML, TAB 500,000U 0 N

W3B-ANTIFUNGALSANCOBON 250MG, 500MG 2 NKETOCONAZOLE 200MG 0 NMYCELEX 10MG TROCHE 0 N

W3C-ANTIFUNGALSDIFLUCAN IN DEXTROSE 200MG/100ML, 400MG/200ML 2 NDIFLUCAN IN SALINE 200MG/100ML, 400MG/200ML 2 NDIFLUCAN SUSP 50/5, 200/5 0 NFLUCONAZOLE 50MG, 100MG, 150MG, 200MG 0 NFLUCONAZOLE IN DEXTROSE 200MG/100ML, 400MG/200ML 0 NFLUCONAZOLE IN SALINE 200MG/100ML, 400MG/200ML 0 NLAMISIL 250MG 2 NTERBINAFINE HCL 250MG TABLET 0 N

W4A-ANTIMALARIALSARALEN PHOSPHATE 500MG 2 NCHLOROQUINE PHOSPHATE 250MG,500MG 0 NDARAPRIM 25MG 2 NFANSIDAR 500/25 2 NHYDROXYCHLOROQUINE SULFATE 200MG 0 NMALARONE 62.5/25MG,250/100MG 2 NMEFLOQUINE 250MG 0 NPRIMAQUINE PHOSPHATE 26.3MG 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

QUALAQUIN 324MG 2 NQUININE SULFATE 260MG 0 NQUININE SULFATE 325MG 0 N

W4C-AMEBACIDESHUMATIN 250MG 2 NPAROMOMYCIN 250 MG 0 NTINDAMAX 250MG, 500MG 2 N

W4E-ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTSFLAGYL ER 750MG 0 NMETRONIDAZOLE 250MG, 500MG 0 N

W4K-MISC ANTI-PROTOZOALSMEPRON 750MG/5ML 2 NNEBUPENT AEROSOL 2 NNEUTREXIN INJ 25MG 2 NPENTAMIDINE ISOETHIONATE 300MG INJ 0 N

W4L-ANTHELMINTICSALBENZA 200MG 2 NMEBENDAZOLE 100MG 0 NMINTEZOL 500MG, 500MG/5ML 2 NSTROMECTOL 3MG 2 N

W4M-ANTIPARASITICSALINIA 100MG/5ML 2 NALINIA 500MG 2 N

W4O-MISC ANTI-INFECTIVESBILTRICIDE 600MG 2 N

W4P-ANTI-LEPROTICSDAPSONE 25MG, 100MG 2 N

W5A-ANTIVIRALS, GENERALACYCLOVIR 200MG, 400MG, 800MG, 200MG/5ML 0 NACYCLOVIR SODIUM 500MG, 1000MG 0 NCYTOVENE 500MG 2 NCYTOVENE INJ 500MG/10ML 2 NFLUMADINE 50MG/5ML SYRUP 2 NFOSCARNET SODIUM 24MG/ML 0 NFOSCAVIR INJ 24MG/ML 2 NGANCICLOVIR 250MG, 500MG 0 NRELENZA 5MG 2 NRIMANTADINE 100MG 0 NTAMIFLU 12MG/ML 2 NTAMIFLU 30MG, 45MG, 75MG 2 NVALCYTE 450MG 2 NVALTREX 500MG, 1000MG 2 N

W5C-ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORSAGENERASE 15MG/ML 2 NAGENERASE 50MG, 150MG 2 NCRIXIVAN 100MG, 200MG, 333MG, 400MG 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

INVIRASE 200MG, 500MG 2 NLEXIVA 700MG TABLET, 50MG/ML SUSPENSION 2 NNORVIR 100MG, 80MG/ML SOLN 2 NREYATAZ 100MG, 150MG, 200MG, 300MG 2 NVIRACEPT 250MG, 625MG, PED ORAL PDR 50MG/GM 2 N

W5F-HEPATITIS B TREATMENT AGENTSBARACLUDE 0.05MG/ML 2 NBARACLUDE 0.5MG, 1MG 2 NEPIVIR HBV 100MG, 25MG/5ML 2 NHEPSERA 10MG 2 NTYZEKA 600MG 2 N

W5G-HEPATITIS C TREATMENTSINFERGEN 9MCG/0.3ML, 15MCG/0.5ML 2 NPEGASYS 180MCG/ML 2 NPEGASYS SYRINGE 180MCG/ML 2 NPEG-INTRON 100MCG, 160MCG, 240MCG 2 NPEG-INTRON REDIPEN 120MCG/0.5, 150MCG/0.5 2 NPEG-INTRON REDIPEN 50MCG/0.5, 80MCG/0.5 2 NREBETOL 200MG 0 NREBETOL 40MG/ML 2 N

W5I-ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTIVIREAD 300MG 2 N

W5J-ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTIDIDANOSINE 200MG, 250MG, 400MG 0 NEMTRIVA 200MG 2 NEPIVIR 150MG, 300MG, 10MG/ML ORAL SOLN 2 NHIVID 0.375MG, 0.75MG 2 NRETROVIR 100MG, 10MG/ML SYRUP 2 NRETROVIR IV 10MG/ML 2 NVIDEX 25MG, 50MG, 100MG, 150MG, 200MG 2 NVIDEX EC 125MG, 200MG, 250MG, 400MG 2 NVIDEX PACKET 167MG, 250MG 2 NVIDEX PED SUSP 2GM/120MG, 4GM/240ML 2 NZERIT 15MG, 20MG, 30MG, 40MG, 1MG/ML ORAL 2 NZIAGEN 20MG/ML 2 NZIAGEN 300MG 2 NZIDOVUDINE 100MG, 300MG, 10MG/ML 0 N

W5K-ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTIRESCRIPTOR 100MG, 200MG 2 NSUSTIVA 50MG, 100MG, 200MG, 600MG 2 NVIRAMUNE 200MG, 50ML/5ML 2 N

W5L-ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMBOCOMBIVIR 150MG/300MG 2 NEPZICOM 600-300MG 2 NTRIZIVIR 300-150MG 2 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

W5M-ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMBOKALETRA 25-10 0 , 133.3-33.3, 500-200 2 NKALETRA 400-100/5ML 2 N

W5N-ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORSFUZEON 90MG/ML 2 N

W5O-ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOGTRUVADA 200MG-300MG 2 N

W5P-ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIBAPTIVUS 250MG 2 NPREZISTA 300MG 2 N

W5Q-ANTIRETROVIRAL COMB NUCLEOSIDE, NUCLEOTIDE, & NON-NUCLEOSIDE RTIATRIPLA 600-200 2 N

W5T-ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAGONITSTS SELZENTRY TABLET 150MG, 300MG 2 N

W5U-ANTIVIRALS, HIV-1 INTEGRASE STRAND TRANSFER INHIBITOR ISENTRESS 400MG 2 N

W8F-IRRIGANTSACETIC ACID SOLN 0.25% 0 NNEOSPORIN G.U. IRRIGANT 2 NSEA-CLENS 2 NSODIUM CHLORIDE SOLN 0.45%,0.9% 0 NSORBITOL SOLN 70% 0 NSORBITOL UROLOGIC IRRIGATION 3%,3.3% 0 NWATER FOR IRRIGATION, STERILE 0 N

W8J-MISC ANTIBACTERIAL IRRIGANTSAMINOACETIC ACID IRRIGATION 1.5% 0 NGLYCINE 0 N

W9A-KETOLIDESKETEK 300MG, 400MG 2 N

Z2A-ANTIHISTAMINES (oral diphenhydramine may be available for dual eligible)A.R.M. 60-4MG 2 NCARBINOXAMINE DROPS, SYRUP 4MG/5ML 0 NCARBINOXAMINE/PSEUDO 4-60/5ML, 4/60, 8/120 0 NCHLORPHENIRAMINE 4MG, 8MGTR, 12MGTR 0 NDEXCHLORPHENIRAMINE MALEATE 4MG, 6MG, 2MG/5ML 0 NDIPHENHYDRAMINE 25MG, 50MG, 12.5MG/5ML 0 YDIPHENHYDRAMINE INJ 10MG/ML, 50MG/ML 0 NMINTEX 30-2MG/5ML 2 NPROMETHAZINE 6.25MG/5ML, 12.5MG, 25MG, 50MG 0 NPSE 15/CPM 2 15-2MG CHEWABLE 0 NPSEUDO TAN/CHLORPHEN TAN 75-4.5/5ML 0 NSILDEC DROPS 15-1/ML 0 NSILDEC LIQ 45-4/5ML 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

Z2D-HISTAMINE 2 INHIBITORSCIMETIDINE 200MG, 300MG, 400MG, 800MG, 300MG/5ML 0 NCIMETIDINE INJ 150MG/ML 0 NFAMOTIDINE 10MG 0 NFAMOTIDINE 20MG, 40MG, 10MG/ML INJ, 20MG/50ML INJ 0 NRANITIDINE 150MG, 300MG 0 NZANTAC 150MG/10ML SYRUP, 15MG/ML ORAL SOLN (0-12 YRS) * NZANTAC INJ 25MG/ML 2 N

Z2E-IMMUNOSUPPRESSIVESAZASAN 75MG, 100MG 2 NAZATHIOPRINE 50MG 0 NCELLCEPT 200MG/ML 2 NCELLCEPT 250MG, 500MG 2 NCYCLOSPORINE 25MG, 50MG, 100MG, 100MG/ML 0 NGENGRAF 25MG, 100MG, 100MG/ML 2 NMYFORTIC 180MG, 360MG 2 NNEORAL 100MG/ML ORAL 2 NNEORAL 25MG, 100MG 2 NPROGRAF 0.5MG, 1MG, 5MG 2 NRAPAMUNE 1MG, 2MG 2 NRAPAMUNE 1MG/ML 2 NSANDIMMUNE 100MG/ML INJ 2 NSANDIMMUNE 25MG, 100MG 2 N

Z2F-MAST CELL STABILIZERSCROMOLYN SODIUM 10MG/ML INH SOLN 0 NGASTROCOM 20MG/ML 2 NINTAL 800MCG INH 112 SPRAY, 200 SPRAY 2 NTILADE 1.75MG AEROSOL 2 N

Z2G-IMMUNOMODULATORSINTRON A 6MMU, 10MMU, 18MMU, 50MMU 2 NINTRON A PEN DELIVERY SYSTEMS 3MMU, 5MMU, 10MMU 2 N

Z2N-1ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONSBROVEX ADT 2 NHISDEC 30-2/5 2 NHISTEX 30MG-2MG/5ML 2 NHYDRO-TUSSIN CBX 2 NNALEX A 5-7.5-2.5MG/5ML 2 NPEDIOX 15-2MG 2 NPHENYLEPHRINE/BROMPHENIRAMINE 2.5-1MG/5 0 NPHENYLEPHRINE/CHLORPHENIRAMINE 12.5-4MG/5ML, 3.5-1MG/ML 0 NRHINACON A 5-7.5-2.5MG/5ML 2 NSUPHEDRINE COLD & ALLERGY 60MG-4MG 2 NTRIAMINIC COLD & ALLERGY 15-1MG/5ML 2 N

Z2O-2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONSALAVERT 120-5MG 2 NALLERGY AND CONGESTION RELIEF 240-10MG (PSE-LORAT) 0 N



RU

G C

LA

SS AMEND

DRUG NAME CO

-PA

YM

EN

T

CO

VE

RE

D

FO

R D

UA

L

EL

IGIB

LE

ALLERGY RELIEF D 240-10MG 0 NLORATADINE D 240-10MG 0 NSEMPREX-D 60/8 2 N

Z2P-ANTIHISTAMINES - 1ST GENERATIONBROMPHENIRAMINE 6MG 0 NBROVEX 12MG/5ML 2 NB-VEX 12MG/5ML 2 NCLEMASTINE 1.34MG, 2.68MG, 0.67MG/5ML 0 NHISTEX PD 12 2MG-6MG/5ML 2 NHYDROXYZINE HCL 10MG, 25MG, 50MG 0 NHYDROXYZINE HCL INJ 25MG/ML, 50MG/ML 0 NHYDROXYZINE HCL SYRUP 10MG/5ML 0 NHYDROXYZINE PAMOATE 25MG, 50MG, 100MG 0 NLODRANE 6MG (BROMPHENIRAMINE) 2 NLODRANE XR 8MG/5ML 2 NNOLAHIST 25MG 2 NPALGIC 4MG, 4MG/5ML 2 NPHENERGAN 25MG 2 NPROMETHAZINE HCL 12.5MG, 25MG, 50MG TAB 0 NPROMETHAZINE HCL INJ 25MG/ML, 50MG/ML 0 NPROMETHAZINE SYRUP 6.25MG/5ML 0 NTANACOF XR 8MG/5ML 0 NVAZOL 2MG/5ML 2 NVISTARIL 25MG/5ML 2 NZYMINE 1.25MG/5ML 2 N

Z2Q-ANTIHISTAMINES - 2ND GENERATIONALAVERT 10MG 2 NALLERGY RELIEF 5MG/5ML (LORATADINE) 0 NLORATADINE 10MG 0 NZYRTEC CHEW 5MG, 10MG (AGES 0-6) * NZYRTEC SYRUP (AGES 0-6) * N

Z4B-LEUKOTRIENE RECEPTOR ANTAGONISTSACCOLATE 10MG, 20MG 2 NSINGULAIR 4MG, 5MG, 10MG 2 NSINGULAIR ORAL GRANULES 4MG 2 N


Documents

Drugs Covered Under Medicaid 3-9-12 Appendix A