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 QLLANTIINFECTIVESANTIBACTERIAL DRUGS amoxicillin 775mg generic NP PA QLLamox/clavulanate IR tabs, susp generic P QLLamox/clavulanate chew tabs NP PA QLLamox/clavulanate 250-125mg tabs generic NP PAamox/clavulanate ER tabs generic NP PA QLLamox/clavulanate 250-62.5mg/5ml susp generic NP PA QLLampicillin/sulbactam inj. generic PARIKAYCE P PA QLLAUGMENTIN 125mg/5ml SUSPENSION NP PA QLLAVYCAZ NP PA QLLAZACTAM NP PAazithromycin generic P QLLaztreonam generic P PABETHKIS P QLLCAYSTON P QLLcefaclor er generic NP PA QLLcefaclor caps generic P QLLcefaclor oral suspension generic NP PA QLLcefadroxil caps, suspension generic P QLLcefadroxil tabs generic NP PA QLLcefazolin iv generic Pcefdinir P QLLcefixime suspension generic NP PA QLLceftriaxone generic Pcefpodoxime generic NP PA QLLcefprozil generic P QLLcefuroxime generic tabs P QLLcefuroxime generic susp P QLLcephalexin 250mg, 500mg caps generic P QLLcephalexin tabs generic NP PA QLLcephalexin 750mg generic NP PA QLLCIPRO SUSPENSION P QLLciprofloxacin/SR generic P QLLciprofloxacin suspension generic P QLLclarithromycin/ER generic P QLLclarithromycin susp. P QLLCLEOCIN 75MG CAPS Pclindamycin caps generic Pclindamycin for oral solution generic P QLLclindamycin in D5W injection generic P

Georgia Medicaid/PeachCare Preferred Drug ListEffective January 1, 2021

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, 2021

clindamycin in NaCl 0.9% injection generic Pclindamycin injection 150MG/ML (900MG/6ML) generic PDIFICID NP PA QLLDORYX, -MPC NP PA QLLdoxycycline hyclate 20mg, 100mg generic Pdoxycycline hyclate 75mg, 150mg generic NP PAdoxycycline hyclate delayed release tabs NP PA QLLdoxycycline monohydrate 50mg, 100mg caps, 75mg, 100mg, 150mg tabs generic Pdoxycycline monohydrate 75mg, 150mg caps generic NP PAdoxycycline suspension generic PDYNAPEN SUSP PERYPED 400mg/5ml suspension NP PA QLLERY-TAB NP PA QLLERYTHROCIN NP PA QLLerythromycin cap, tab generic NP PA QLLerythromycin ethylsuccinate susp. 200mg/5ml generic NP PA QLLerythromycin ethylsuccinate/E.E.S. 400mg tab generic NP PA QLLFLAGYL CAPS NP PAGANTRISIN PEDIATRIC PKEFLEX 750mg P QLLKITABIS PAK P QLLlevofloxacin injection 25mg/ml generic NP PA QLLlevofloxacin in D5W (generic Levaquin Premix) Plevofloxacin solution generic NP PA QLLlevofloxacin tabs generic P QLLLINCOCIN Pmetronidazole IR tabs generic Pmetronidazole caps generic NP PAminocycline caps generic Pminocycline IR, SR tab generic NP PA QLLMINOLIRA NP PA QLLMORGIDOX KIT NP PA QLLMOXATAG NP PA QLLmoxifloxacin generic P QLLnitrofurantoin caps generic Pnitrofurantoin suspension generic NP PA QLLNUZYRA INJ. NP PANUZYRA TABS NP PA QLLofloxacin generic P QLLparomomycin generic NP PAPCE 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, 2021

piperacillin generic Ppiperacillin sodium-tazobactam sodium generic NP PASOLODYN NP PA QLLSOLOSEC NP PASPECTRACEF NP PA QLLstreptomycin inj. generic P QLLsulfadiazine tab generic NP PAsulfamethoxazole-trimethoprim susp. 200mg-40mg/5ml generic (except 00121-0853-**) PSUPRAX CAPS NP PA QLLSUPRAX 500MG/5ML SUSP., CHEW TABS NP PA QLLTOBI PODHALER NP PA QLLtobramycin 40mg/ml inj. generic P QLLtobramycin nebulizer generic NP PA QLLUNASYN 15GM NP PAVIBRAMYCIN SYRUP PXENLETA inj., tab NP PA QLLZERBAXA NP PAZOSYN P

TOPICAL ANTIBACTERIAL DRUGS CORTISPORIN CREAM, -OINT. P QLLgentamicin cream, -oint. generic Pmupirocin cream generic NP PAmupirocin ointment generic PXEPI NP PA QLL

ANTIMYCOBACTERIAL DRUGS cycloserine generic Pethambutol generic Pisoniazid generic PPRETOMANID P PAPRIFTIN Ppyrazinamide generic PRIFAMATE Prifampin generic PRIFATER PSIRTURO P PA QLLTRECATOR P

ANTIFUNGAL DRUGS AMBISOME INJ. 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, 2021

CANCIDAS INJ. NP PAclotrimazole troche generic PCRESEMBA CAPS NP PA QLLfluconazole generic Pfluconazole/nacl inj. generic P PAfluconazole 150mg tab generic P QLLflucytosine generic NP PAgriseofulvin oral susp generic P PAgriseofulvin microsize tab generic NP PA QLLgriseofulvin ultramicrosize tab generic NP PA QLLitraconazole generic P PA QLLMYCAMINE P QLLNOXAFIL NP PA QLLONMEL NP PA QLLORAVIG NP PA QLLSPORANOX ORAL SOLUTION P PA QLLterbinafine tab generic PVFEND SUSP NP PAvoriconazole generic NP PA

TOPICAL ANTIFUNGALS BENSAL HP NP PAciclopirox 0.77% cream, suspension generic Pciclopirox gel/shampoo generic NP PAciclopirox nail lacquer P PAciclopirox 8% and vitamin E 5% kit NP PAclotrimazole/betamethasone lotion generic NP PAeconazole generic P QLLERTACZO NPEXELDERM NPEXTINA NP PA QLLGYNAZOLE PJUBLIA SOLN. 10% NP PA QLLKERYDIN NP PA QLLketoconazole aer 2% foam generic NP PAketoconazole cream, shampoo Pketocon plus kit generic NP PA QLLLOPROX KIT NP PA QLLLUZU NP PA QLLMENTAX NPmiconazole generic P QLLMONISTAT 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, 2021

naftifine cream generic NP PA QLLNAFTIN GEL NP PAnystatin cream Pnystatin/triamcinolone cream generic NP PAnystatin/triamcinolone ointment generic POXISTAT NPPEDIADERM AF KIT COMPLETE (covered < 21 yrs old) NP PA QLLterconazole generic P QLL

ANTIRETROVIRALS & PROTEASE INHIBITORS abacavir tabs generic P QLLabacavir/lamivudine generic Pabacavir/lamivudine/zidovudine generic NP PA QLLAPTIVUS NP PAatazanavir generic PATRIPLA PBIKTARVY P QLLCIMDUO P QLLCOMPLERA NP PA QLLCRIXIVAN NP PADELSTRIGO NP PADESCOVY P QLLDOVATO P QLLEDURANT P PA QLLEMTRIVA PEPIVIR SOLN P QLLEVOTAZ P PA QLLFUZEON NP PA QLLGENVOYA P QLLINTELENCE NP PA QLLINVIRASE NP PAISENTRESS, -HD P PA QLLJULUCA P QLLKALETRA P QLLlamivudine soln. generic P QLLlamivudine generic P QLLlamivudine/zidovudine generic P QLLLEXIVA NP PAnevirapine suspension generic NP PA QLLnevirapine tabs generic P QLLnevirapine er generic NP PA QLLNORVIR POWDER PACKETS 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, 2021

NORVIR SOLN, TABS PODEFSEY P PA QLLPIFELTRO NP PAPREZCOBIX P PA QLLPREZISTA P PARESCRIPTOR PREYATAZ POWDER PACKET NP PAritonavir tabs generic NP PASELZENTRY NP PAstavudine NPSTRIBILD NP PA QLLSUSTIVA PSYMFI NP PA QLLSYMFI LO NP PA QLLSYMTUZA P QLLTEMIXYS NP PA QLLtenofovir disoproxil fumarate 300mg tabs P QLLTIVICAY P QLLTIVICAY PD P PA (>12 years) QLLTRIUMEQ P QLLTRIZIVIR P QLLTRUVADA P QLLTYBOST P PA QLLVIDEX SOLN. NP PAVIDEX EC PVIRACEPT PVIRAMUNE SUSPENSION P QLLVIREAD POWDER, 150mg, 200mg, 250mg TABS P QLLVITEKTA NP PA QLLZIAGEN SOLN. Pzidovudine generic P HEPATITIS AGENTSadefovir generic NP PA QLLBARACLUDE SOLN. P QLLentecavir generic P QLLEPCLUSA P PA QLLHARVONI NP PA QLLHEPSERA P QLLMAVYRET P PA QLLMODERIBA NP PAPEGASYS, -PROCLICK 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, 2021

PEG-INTRON P QLLREBETOL ORAL SOLUTION PRIBAPAK NP PARIBASPHERE NP PAribavirin 200mg generic PSOVALDI NP PA QLLVEMLIDY NP PA QLLVOSEVI P PA QLLZEPATIER NP PA QLL

OTHER ANTIVIRAL DRUGS acyclovir generic PCYTOVENE P PAlamivudine HBV generic P QLLfamciclovir generic P QLLganciclovir caps generic Pganciclovir inj generic NP PAoseltamivir generic P QLLPREVYMIS NP PA QLLRELENZA P QLLrimantadine generic NPSITAVIG NP PA QLLvalacyclovir generic P QLLvalganciclovir soln. generic NP PA QLLvalganciclovir tabs generic P QLLVALCYTE SOLN P PA (>17 yrs) QLLXOFLUZA NP PA TOPICAL ANTIVIRAL DRUGS acyclovir ointment generic NP PA QLLDENAVIR CREAM NP PAVEREGEN OINTMENT NP PAXERESE CREAM NP PA QLLZOVIRAX CREAM P QLL ANTIINFECTIVES SPECIALIZED INDICATIONS albendazole generic P PAatovaquone generic Patovaquone-proguanil generic NP PABAXDELA NP PA QLLbenznidazole generic P PA QLLchloroquine phosphate 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, 2021

COARTEM NP PA QLLCUBICIN P PADALVANCE NP PA QLLDAPSONE Pdaptomycin iv soln. 350mg generic P PADARAPRIM P PADORIBAX NP PA QLLEMVERM NP PAFIRVANQ NP PAhydroxychloroquine sulfate generic Pimipenem-cilastatin generic NP PAINVANZ P PAivermectin generic P QLLKRINTAFEL P PA QLLlinezolid iv soln., suspension generic NP PA QLLlinezolid tabs generic P PA QLLMALARONE NP PA QLLmefloquine hydrochloride generic Pmeropenem generic P PAmeropenem/sodium chloride IV soln. generic NP PAMINTEZOL PNEBUPENT P QLLPRIMAXIN P PAQUALAQUIN NP PA QLLquinine sulfate generic NP PArifabutin generic P QLLSIVEXTRO NP PA QLLSTROMECTOL NP PA QLLTEFLARO NP PA QLLtinidazole generic NP PATYGACIL NP PAvancomycin generic P QLLVIBATIV NP PAXIFAXAN NP PA QLLZYVOX IV SOLN., ORAL SUSP. P PA QLL

ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGSabiraterone generic (except Patriot) P PA QLLAFINITOR P PA QLLAFINITOR DISPERZ P PA QLLAGRYLIN 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, 2021

ALECENSA P PA QLLALKERAN tablets PALUNBRIG P PA QLLanastrozole generic P QLLARCALYST P PA QLLASTAGRAF XL NP PA QLLAYVAKIT P PA QLLBALVERSA P PA QLLBYNFEZIA NP PAbexarotene generic NP PA QLLbicalutamide P QLLBOSULIF P PA QLLBRAFTOVI P PA QLLBRUKINSA P PA QLLCABOMETYX P PA QLLCALQUENCE P PA QLLcapecitabine generic NP PACAPRELSA NP PA QLLCELLCEPT IV INJ PCELLCEPT SUSPENSION P PA (>18 years)CIMZIA NP PA QLLCOMETRIQ P PA QLLCOPIKTRA P PA QLLCOTELLIC P PA QLLcyclophosphamide generic Pcyclosporine generic PDEPO-PROVERA 400mg/ml PDAURISMO P PA QLLELIGARD PEMCYT PENBREL (all formulations except vial) P PA QLLENBREL 25mg/0.5ml VIAL NP PA QLLERLEADA P PA QLLERIVEDGE P PA QLLETOPOPHOS P PAetoposide capsules generic Petoposide inj. generic P PAENVARSUS XR NP PAexemestane generic P QLLFARESTON PFARYDAK P PA QLLFENSOLVI 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, 2021

FIRMAGON P PA QLLGILOTRIF P PA QLLHUMIRA P PA QLLHYCAMTIN PIBRANCE CAPS P PA QLLICLUSIG P PA QLLIDHIFA P PA QLLILARIS P PA QLLimatinib generic P QLLIMBRUVICA P PA QLLINQOVI P PA QLLINREBIC P PA QLLINLYTA P PA QLLIRESSA P PA QLLJAKAFI P QLLKEVZARA NP PA QLLKINERET NP PA QLLKISQALI P PA QLLKISQALI 200 PAK FEMARA P PA QLLKOSELUGO P PA QLLleflunomide generic P QLLLENVIMA P PA QLLletrozole generic P QLLLEUKERAN Pleuprolide 1mg/0.2ml (5mg/ml) injection generic PLORBRENA P PA QLLLONSURF P PA QLLLUPRON DEPOT 3.75MG, 7.5MG, 11.25MG, 22.5MG, 30MG P QLLLUPRON DEPOT 45MG NP PA QLLLUPRON DEPOT PEDIATRIC 7.5MG, 15MG P QLLLUPRON DEPOT PEDIATRIC 11.25MG, 30MG NP PA QLLLYNPARZA P PA QLLLYSODREN PMATULANE PMEKINIST P PA QLLMEKTOVI P PA QLLMYCAPSSA NP PA QLLmycophenolate mofetil caps, tabs generic Pmycophenolate mofetil suspension generic NP PAmycophenolic tab generic P QLLMYLERAN PNERLYNX 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, 2021

NEXAVAR P PA QLLNILANDRON PNINLARO P PA QLLNUBEQA P PA QLLoctreotide generic P PAODOMZO P PA QLLORENCIA 50mg/0.4ml, 87.5mg/0.7ml, 125MG/ML, CLICKJECT NP PA QLLPEMAZYRE P PA QLLPHESGO P PA QLLPIQRAY P PA QLLPOMALYST P PA QLLPROGRAF GRANULES NP PAPURINETHOL PPURIXAN NP PA QLLQINLOCK P PA QLLRAPAMUNE SOLN. P QLLRETEVMO P PA QLLREVLIMID P QLLRIDAURA PRINVOQ ER NP PA QLLROZLYTREK P PA QLLRUBRACA P PA QLLRYDAPT P PA QLLSANDOSTATIN LAR P PASILIQ NP PASIMPONI NP PA QLLsirolimus tabs generic PSOMATULINE DEPOT NP PASOMAVERT NP PA QLLSPRYCEL P PA QLLSYNRIBO P PA QLLSUTENT P PA QLLSTIVARGA P PA QLLTABRECTA P PA QLLtacrolimus generic PTAFINLAR P PA QLLTAGRISSO P PA QLLTALZENNA P PA QLLTALTZ NP PA QLLTARCEVA P PA QLLTARGRETIN CAP 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, 2021

TARGRETIN GEL P QLLTASIGNA P PA QLLTAZVERIK P PA QLLtemozolomide generic P PA QLLTHALOMID P QLLTHIOGUANINE PTIBSOVO P PA QLLTOPOSAR P PATRELSTAR LA/-DEPOT P PA QLLTREMFYA NP PA QLLtretinoin caps generic PTUKYSA P PA QLLTURALIO P PA QLLTYKERB P QLLUCERIS NP PA QLLVENCLEXTA P PA QLLVERZENIO P PA QLLVITRAKVI P PA QLLVIZIMPRO P PA QLLVOTRIENT P PA QLLXALKORI P PA QLLXELODA P QLLXOSPATA P PA QLLXPOVIO PAK P PA QLLXTANDI P PA QLLYONSA NP PA QLLZEJULA P PA QLLZELBORAF P PA QLLZOLINZA P PAZORTRESS NP PA QLLZYDELIG P PA QLLZYKADIA P PA QLLZYTIGA 250mg P PA QLLZYTIGA 500mg NP PA QLL CARDIOVASCULAR MEDICATIONS CALCIUM ANTAGONISTS afeditab cr generic P QLLamlodipine P QLLCARDIZEM LA 120mg P QLLdiltiazem (generic Cardizem) P QLLdiltiazem cd/er 360mg (generic Cardizem CD) 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, 2021

diltiazem cd/er,cartia xt, dilt-cd (generic Cardizem CD-all strengths except 360mg) P QLLdiltiazem er,diltzac,taztia xt caps (generic Tiazac) P QLLdiltiazem er, dilt-xr (generic Dilacor XR) P QLLfelodipine er generic P QLLisradipine generic NP PA QLLKATERZIA NP PA QLLmatzim la (generic Cardizem LA) NP PA QLLnicardipine generic P QLLnifedical xl generic P QLLnifedipine er generic P QLLnifedipine ir generic P QLLnifedipine sa generic P QLLNYMALIZE NP PA QLLnisoldipine sr generic NP PA QLLverapamil generic P QLLverapamil er caps 100mg, 200mg, 300mg (generic Verelan PM) NP PA QLL

CARDIAC GLYCOSIDES digoxin generic PLANOXIN 0.0625MG, 0.1875MG NP PALANOXIN INJ P BETA-ADRENERGIC ANTAGONIST DRUGS all beta-adrenergic antagonists generics are preferred P QLLBYSTOLIC NP PA QLLCOREG CR NP PA QLLCORZIDE NP PA QLLDUTOPROL P QLLHEMANGEOL (covered 5 weeks-12 months old) PINNOPRAN XL NP PA QLLmetoprolol HCTZ generic NP PA QLLmetoprolol succinate ER generic P QLLnadolol generic P QLLSOTYLIZE NP PA QLLtimolol tabs generic NP PA QLL CENTRALLY ACTING ANTIHYPERTENSIVES CATAPRES-TTS P QLLclonidine patch 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, 2021

ANGIOTENSIN CONVERTING ENZYME INHIBITORS & COMBOS benazepril generic P QLLbenazepril HCTZ generic P QLLcaptopril generic P QLLcaptopril HCTZ generic P QLLenalapril generic P QLLenalapril HCTZ generic P QLLenalaprilat generic P QLLEPANED P PA (>12 years) QLLfosinopril generic P QLLfosinopril HCTZ generic P QLLlisinopril generic P QLLlisinopril HCTZ generic P QLLmoexipril generic P QLLmoexipril HCTZ generic P QLLperindopril generic NP PA QLLQBRELIS P PA (>12 years) QLLquinapril generic P QLLquinapril HCTZ generic P QLLramipril caps generic P QLLtrandolapril generic P QLL

ANGIOTENSIN II RECEPTOR ANTAGONISTS & COMBOS amlodipine/olmesartan NP PA QLLamlodipine/valsartan generic P PA QLLamlodipine/valsartan/hctz generic P PA QLLcandesartan generic NP PA QLLcandesartan/hctz generic NP PA QLLEDARBI NP PA QLLEDARBYCLOR NP PA QLLENTRESTO P PA QLLeprosartan generic NP PA QLLirbesartan generic P QLLirbesartan/HCTZ generic P QLLlosartan generic P QLLlosartan/HCTZ generic P QLLMICARDIS NP PA QLLMICARDIS HCT NP PA QLLolmesartan generic P QLLolmesartan/hctz generic P QLLtelmisartan generic NP PA QLLtelmisartan/HCTZ 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, 2021

telmisartan/amlodipine generic NP PA QLLTRIBENZOR NP PA QLLTWYNSTA NP PA QLLvalsartan generic P QLLvalsartan/hctz generic P QLL OTHER ANTIHYPERTENSIVES amlodipine/benazepril generic P QLLchlorthalidone generic Pchlorothiazide 500mg injection generic Phydrochlorothiazide generic Pphenoxybenzamine generic NP PAPRESTALIA NP PA QLLTEKTURNA NP PA QLLTEKTURNA HCT NP PA QLLtrandolapril/verapamil generic (except Greenstone) P QLLtrandolapril/verapamil (Greenstone generic) NP PA QLLVECAMYL NP PA QLL

NITRATES GONITRO POWDER NP PA QLLisosorbide generic Pnitroglycerin patches generic P QLLnitroglycerin lingual spray soln (generic Nitrolingual) NP PA QLLnitroglycerin sublingual tabs generic PNITROMIST SPRAY NP PA QLLNITROSTAT SL TABS P ANTIDYSRHYTHMIC DRUGS amiodarone/pacerone generic Pdofetilide generic PMULTAQ NP PA QLLpropafenone er generic P QLL

ANTILIPIDEMIC DRUGS ALTOPREV NP PA QLLamlodipine/atorvastatin generic NP PA QLLatorvastatin generic P QLLCOLESTID NP PAcolestipol generic NP PAcholestyramine/cholestyramine lite packets generic NP PAcholestyramine/cholestyramine lite powder 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, 2021

EZALLOR SPRINKLE NP PA QLLezetimibe generic P QLLfluvastatin generic NP PA QLLfluvastatin er generic NP PA QLLJUXTAPID NP PA QLLLIVALO NP PA QLLlovastatin generic P QLLNEXLETOL NP PA QLLNEXLIZET NP PA QLLniacin er generic P QLLomega-3-acid generic NP PA QLLPRALUENT NP PA QLLpravastatin generic P QLLPREVALITE PACKETS NP PAPREVALITE POWDER PREPATHA NP PA QLLREPATHA PUSH INJ. NP PA QLLrosuvastatin generic P QLLsimvastatin 5mg, 10mg, 20mg, 40mg generic P QLLsimvastatin 80mg generic P PA QLLVASCEPA NP PA QLLVYTORIN (except 10-80mg) P QLLVYTORIN 10-80mg P PA QLLWELCHOL NP PAXENICAL (covered 12 - 20 yrs old) P PA (12 yrs-20 yrs)ZYPITAMAG NP PA QLL

FIBRIC ACID DERIVATIVESANTARA NP PA QLLfenofibrate caps generic NP PA QLLfenofibrate tabs generic P QLLfenofibrate tab (generic Fenoglide) NP PA QLLfenofibric acid generic NP PA QLLFENOGLIDE NP PA QLLgemfibrozil generic P QLLTRIGLIDE NP PA QLL

OTHER CARDIOVASCULAR DRUGS BIDIL NP PA QLLbumetanide generic NP PACAROSPIR NP PA QLLCORLANOR 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, 2021

eplerenone generic NP PA QLLethacrynic acid generic NP PAmethyclothiazide generic NP PAmidodrine generic Pmilrinone generic P PANORTHERA NP PA QLLPROAMATINE Pranolazine generic P PAspironolactone generic P QLLtriamterene generic NP PAVYNDAMAX P PA QLLVYNDAQEL P PA QLL

DRUGS FOR PULMONARY HYPERTENSIONADEMPAS NP PA QLLambrisentan generic P QLLepoprostenol PFLOLAN NP PAOPSUMIT NP PA QLLORENITRAM NP PA QLLREMODULIN NP PAREVATIO SUSPENSION NP PA QLLsildenafil generic P PA QLLtadalafil (generic Adcirca) P PA QLLTRACLEER P QLLTRACLEER 32mg TAB FOR ORAL SUSP NP PATYVASO NP PA QLLUPTRAVI NP PA QLLVELETRI NP PAVENTAVIS P PA QLL DRUGS FOR PHEOCHROMOCYTOMA DEMSER P

AUTONOMIC AND CNS MEDICATIONSNARCOTIC ANALGESICS ACTIQ NP PA QLLARYMO ER NP PA QLLBELBUCA NP PA QLLbenzhydrocodone/acetaminophen NP PAbutalbital/acetaminophen 300mg/caffeine/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, 2021

butalbital/acetaminophen 325mg/caffeine/codeine generic P QLLbutalbital/aspirin/caffeine/codeine cap generic NP PAbutorphanol nasal generic P QLLBUTRANS P QLLcodeine tab generic NP PAdihydrocodeine compound cap (acetaminophen/caffeine/dihydrocodeine) generic Pdihydrocodeine compound tab (acetaminophen/caffeine/dihydrocodeine) generic NP PADILAUDID 1mg/ml NP PAfentanyl citrate generic (generic Actiq) NP PA QLLfentanyl patch generic (generic Duragesic)-12-, 25-, 50-, 75-, 100 mcg/hr P QLLfentanyl patch generic (generic Duragesic)- 37.5-, 62.5-, 87.5 mcg/hr NP PA QLLFENTORA NP PA QLLHYCET NP PA QLLhydrocodone-APAP 7.5mg/325mg/15mL soln. generic P QLLhydrocodone-APAP 10mg/325mg/15mL soln. generic NP PA QLLhydrocodone-APAP 5-300mg, 10-300mg, 7.5-300mg tab generic P QLLhydrocodone/ibuprofen 2.5-200mg, 5-200mg, 10-200mg generic NP PAhydrocodone/ibuprofen 7.5-200mg generic Phydromorphone er tabs generic NP PA QLLhydromorphone ir tabs generic Phydromorphone suppositories generic NP PAHYSINGLA ER NP PA QLLIBUDONE NP PAKADIAN NP PA QLLLAZANDA NP PAlevorphanol generic NP PA QLLLORTAB ELIXIR P QLLmeperidine solution generic NP PAmeperidine tabs generic NP PAMORPHABOND ER NP PA QLLmorphine ir generic Pmorphine sulfate sa caps (generic Kadian) NP PA QLLmorphine sulfate er caps (generic Avinza) NP PA QLLmorphine sulfate sa tabs generic P QLLmorphine sulfate suppositories generic NP PANALOCET 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, 2021

NUCYNTA NP PA QLLNUCYNTA ER NP PA QLLOXAYDO NP PAoxycodone concentrate generic NP PAoxycodone ir generic P QLLoxycodone/aspirin tabs generic NP PAoxycodone/ibuprofen 5/400mg generic NP PA QLLoxymorphone/er generic NP PA QLLOXYCONTIN NP PA QLLpentazocine/naloxone tabs generic NP PAPRIMLEV NP PASUBSYS NP PA QLLXTAMPZA ER NP PA QLLZOHYDRO ER NP PA QLL

OTHER ANALGESICSBUPAP (butalbital-acetaminophen tabs 50-300mg) NP PAbutalbital-acetaminophen tabs 50-325mg generic Pbutalbital-acetaminophen caps 50-300mg generic NP PAbutalbital-acetaminophen-caffeine capsule generic NP PAbutalbital-acetaminophen-caffeine tabs generic Pbutalbital-aspirin-caffeine capsule PCONZIP NP PA QLLGRALISE NP PA QLLlidocaine 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 QLLPRIZOTRAL KIT NP PA QLLSAVELLA NP PA QLLtramadol generic (except 100mg tab) P QLLtramadol/acetaminophen generic P QLLtramadol er (generic Conzip, Ultram ER, Ryzolt) NP PA QLLZEBUTAL NP PAZTLIDO P PA QLL DRUGS TO PREVENT AND TREAT HEADACHES AIMOVIG NP PA QLLAJOVY P PA QLLalmotriptan generic NP PA QLLCAMBIA 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, 2021

dihydroergotamine spray generic NP PA QLLeletriptan generic NP PA QLLEMGALITY 100mg NP PA QLLEMGALITY 120mg P PA QLLERGOMAR NP PAFROVA NP PA QLLMIGERGOT NP PAMIGRANAL NS NP PA QLLnaratriptan generic NP PA QLLNURTEC ODT NP PA QLLONZETRA XSAIL NP PA QLLREYVOW NP PArizatriptan odt generic P QLLrizatriptan tab generic P QLLsumatriptan injection NP PA QLLsumatriptan nasal spray generic P QLLsumatriptan tabs generic P QLLTOSYMRA NP PA QLLTREXIMET NP PA QLLUBRELVY P PAZEMBRACE SYMTOUCH INJ. NP PA QLLzolmitriptan, -odt generic NP PA QLLZOMIG NASAL SPRAY P QLLZOMIG, -ZMT NP PA QLL

ANXIOLYTICS alprazolam generic P QLLalprazolam er, odt generic NP PA buspirone generic Pchlordiazepoxide generic P QLLclorazepate dipotassium generic P QLLdiazepam generic P QLLlorazepam generic P QLLmeprobamate generic NP PA oxazepam generic P QLL SEDATIVE/HYPNOTIC DRUGS AMBIEN NP PA QLLAMBIEN CR NP PA QLLBELSOMRA NP PA QLLDORAL NP PA EDLUAR 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, 2021

eszopiclone generic NP PA QLLHETLIOZ NP PA QLLLUNESTA NP PA QLLmidazolam generic NP PA ROZEREM NP PA QLLphenobarbital generic PSECONAL NP PA QLLSILENOR NP PA QLLSONATA NP PA QLLtemazepam 7.5mg, 22.5mg NP PA temazepam 15mg, 30mg generic P QLLtriazolam P QLLzaleplon generic P QLLzolpidem generic P QLLzolpidem er generic NP PA QLLzolpidem sl tab generic NP PA QLL

ANTIMANIA DRUGS lithium carbonate generic P

ANTICONVULSANT DRUGS APTIOM NP PA QLLBANZEL TABS NP PA QLLBANZEL SUSPENSION NP PA QLLBRIVIACT NP PA QLLcarbamazepine ir generic Pcarbamazepine er/sr 200mg, 400mg generic P QLLcarbamazepine sr 12 hr (generic Carbatrol) PCELONTIN Pclobazam suspension generic NP PA QLLclobazam tabs generic P QLLclonazepam generic P QLLclonazepam odt generic NP PADIACOMIT P PA QLLdiazepam rectal gel generic P PA (> 21 yrs) QLLdivalproex sprinkles generic Pdivalproex DR, -ER generic PEPIDIOLEX P PA QLLfelbamate generic NP PA QLLfelbamate suspension generic NP PAFYCOMPA NP PA QLLgabapentin caps 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, 2021

gabapentin solution generic Pgabapentin tabs generic PGABITRIL NP PA QLLLAMICTAL KITS (immediate release) NP PALAMICTAL ODT TABS, KITS NP PA LAMICTAL XR KITS NP PA lamotrigine chewable dispersable tab generic P QLLlamotrigine kits (immediate release and odt) NP PA QLLlamotrigine odt generic NP PAlamotrigine tabs generic P QLLlamotrigine er tabs generic NP PAlevetiracetam solution/tabs generic Plevetiracetam tabs er generic NP PA QLLlevetiracetam injection generic P QLLLYRICA P QLLLYRICA CR NP PA QLLNAYZILAM NP PA QLLoxcarbazepine susp., tabs generic P QLLOXTELLAR XR NP PA QLLPEGANONE PPHENYTEK NPphenytoin generic Pprimidone generic PQUDEXY XR NP PA QLLSABRIL NP PA QLLSTAVZOR NP PASYMPAZAN NP PA QLLTEGRETOL XR 100mg P QLLtiagabine generic NP PAtopiramate sprinkles generic P QLLtopiramate er sprinkles generic P PA QLLtopiramate tabs generic P QLLTROKENDI XR NP PA QLLvalproic acid caps NP PAvalproic acid syrup PVALTOCO NP PA QLLVIMPAT P QLLVIMPAT INJ. P PA QLLXCOPRI NP PA QLLzonisamide generic P

SELECTIVE SEROTONIN REUPTAKE INHIBITORS

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, 2021

citalopram generic P QLLescitalopram tabs generic P QLLescitalopram soln. generic NP PA QLLfluoxetine generic P QLLfluoxetine 90mg caps generic NP PA QLLfluoxetine 10mg, 20mg tabs generic NP PA QLLfluoxetine 60mg tab generic NPfluoxetine (pmdd) caps generic NP PA QLLfluvoxamine generic P QLLfluvoxamine er generic NP PA QLLparoxetine generic P QLLparoxetine er NP PA QLLPAXIL SUSP. NP PAPEXEVA NP PA QLLSARAFEM NP PA QLLsertraline generic P QLL

SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS desvenlafaxine er tabs (generic Khedezla) NP PA QLLdesvenlafaxine succinate er tabs (generic Pristiq) P QLLDRIZALMA NP PA QLLduloxetine 20mg, 30mg, 60mg generic P QLLduloxetine 40mg generic NP PA QLLFETZIMA NP PA QLLvenlafaxine generic P QLLvenlafaxine ER tabs generic NP PA QLLvenlafaxine ER caps generic P QLL

MODIFIED CYCLICSnefazodone generic NP PA QLLtrazodone 50mg, 100mg, 150mg generic P QLLtrazodone 300mg generic NP PA QLLTRINTELLIX P PA QLLVIIBRYD NP PA QLL

MAO INHIBITORS EMSAM NP PA QLLMARPLAN NP PAphenelzine generic NP PA QLLtranylcypromine generic NP PA

TRICYCLIC ANTIDEPRESSANTS

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, 2021

amitriptyline generic Pamoxapine generic Pclomipramine authorized generic (Mallinckrodt) Pdesimpramine generic Pdoxepin generic Pimipramine tabs generic Pimipramine caps generic NP PAnortriptyline generic Pprotriptyline generic NP PAtrimipramine generic NP PA ALPHA-2 RECEPTOR ANTAGONISTSmirtazapine, -odt generic P QLL

MISCELLANEOUS ANTIDEPRESSANTSAPLENZIN NP PA QLLbupropion IR generic P QLLbupropion ER & SR 100mg, 150mg generic P QLLbupropion SR 200mg generic P QLLFORFIVO XL NP PA QLLmaprotiline generic NP PA QLLSPRAVATO NP PA

ANTIVERTIGO AND ANTIEMETIC DRUGSAKYNZEO NP PA QLLANZEMET TABS NP PA QLLANZEMET INJECTION NP PACESAMET NP PA QLLCOMPRO (RECTAL) SUPPOSITORY NP PADICLEGIS P QLLdimenhydrinate inj. generic NP PAdoxylamine/pyridoxine generic (Analog Pharma only) P QLLdronabinol generic P PAEMEND CAPS P QLLEMEND SUSP NP PA QLLgranisetron generic NP PA QLLmeclizine generic Ppromethazine generic Ppromethazine 50mg rectal suppository generic NP PAondansetron generic P QLLondansetron inj. generic P PASANCUSO 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, 2021

SYNDROS NP PA QLLTRANSDERM-SCOP Ptrimethobenzamide generic NP PAVARUBI NP PA QLLZUPLENZ NP PA QLL

ANTIPARKINSON DRUGS APOKYN NP PAAZILECT NPbromocriptine generic Pcarbidopa generic P QLLcarbidopa/levodopa generic Pcarbidopa/levodopa disintegrating tablets generic NP PAcarbidopa/levodopa/entacapone generic PDUOPA NP PAentacapone generic PINBRIJA NP PAKYNMOBI NP PA QLLMIRAPEX ER NP PA QLLNEUPRO NP PA QLLNOURIANZ NP PA QLLpramipexole generic P QLLpramipexole er generic NP PA QLLREQUIP XL NP PA QLLropinirole generic Propinirole er generic NP PA QLLRYTARY NP PA QLLselegiline generic Ptolcapone generic NP PAXADAGO NP PAZELAPAR NP PA ATYPICAL ANTIPSYCHOTIC DRUGS ABILIFY MYCITE NP PA QLLaripiprazole odt generic NP PA QLLaripiprazole tabs generic P PA (<10 years) QLLaripiprazole oral soln. generic NP PA QLLCAPLYTA NP PA QLLclozapine generic P PA (<18 years) QLLclozapine odt generic NP PA (<18 years) QLLFANAPT NP PA QLLGEODON inj 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, 2021

LATUDA P PA** QLLNUPLAZID NP PA QLLolanzapine, -odt generic P PA (<13 years) QLLolanzapine inj. (short-acting) generic NP PAolanzapine/fluoxetine generic NP PA QLLpaliperidone er generic NP PA QLLquetiapine generic 25mg, 50mg P PA***/PA (<10 years) QLLquetiapine generic 100mg, 200mg, 300mg, 400mg P PA (<10 years) QLLquetiapine er generic P PA (<10 years) QLLREXULTI NP PA QLLrisperidone generic P PA (<10 years) QLLrisperidone orally disintegrating tab generic P PA (<10 years) QLLSAPHRIS NP PA QLLSECUADO NP PA QLLVERSACLOZ SUSPENSION NP PA QLLVRAYLAR NP PA QLLziprasidone caps generic P PA (<18 years) QLLZYPREXA INJECTABLE NP

ATYPICAL ANTIPSYCHOTIC LONG ACTING INJECTABLES ABILIFY MAINTENA P PA QLLARISTADA P PA QLLARISTADA INITIO P PA QLLINVEGA SUSTENNA, -TRINZA P PA QLLPERSERIS NP PA QLLRISPERDAL CONSTA P PA QLLZYPREXA RELPREVV P PA QLL

OTHER ANTIPSYCHOTIC DRUGSEQUETRO NP PAfluphenazine decanoate vial generic P QLLhaloperidol decanoate vial generic P QLLmolindone generic P

CNS STIMULANT DRUGS ADDERALL XR P PA (> 21 years) QLLADHANSIA XR NP PA QLLADZENYS XR NP PA QLLamphetamine er susp generic NP PAamphetamine salt combination generic P PA (> 21 years) QLLAPTENSIO XR NP PA QLLarmodafinil generic 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, 2021

atomoxetine generic P PA (> 21 years) QLLCONCERTA P PA (> 21 years) QLLCOTEMPLA NP PA QLLDAYTRANA NP PA QLLDESOXYN NP PA QLLdexmethylphenidate generic P PA (> 21 years) QLLdexmethylphenidate er generic NP PA QLLdextroamphetamine generic P PA (> 21 years) QLLdextroamphetamine er generic NP PA QLLdextroamphetamine soln. generic NP PA QLLDYANAVEL XR SUSP. NP PA QLLEVEKEO, -ODT NP PA QLLFOCALIN XR P PA (> 21 years) QLLJORNAY PM NP PA QLLmethamphetamine generic NP PA QLLmethylphenidate generic P PA (> 21 years) QLLmethylphenidate cd generic P PA (> 21 years) QLLmethylphenidate chew tabs generic NP PA QLLmethylphenidate 10mg er (generic for Metadate ER) P PA (> 21 years) QLLmethylphenidate/metadate 20mg er/sr (generic for Ritalin SR) P PA (> 21 years) QLLmethylphenidate er (generic for Ritalin LA) NP PA QLLmethylphenidate sa osm (generic for Concerta) NP PA QLLmethylphenidate osm 72mg generic NP PA QLLmethylphenidate solution generic P PA (> 21 years) QLLmodafinil generic P PA (> 21 years) QLLMYDAYIS NP PA QLLQUILLICHEW ER NP PA QLLQUILLIVANT SUSP XR NP PA QLLRITALIN LA 10mg NP PA QLLSUNOSI NP PA QLLVYVANSE P PA (> 21 years) QLLWAKIX NP PA QLLZENZEDI 2.5mg, 7.5mg, 15mg, 20mg, 30mg NP PA QLL OTHER CNS/AUTONOMIC DRUGS BUNAVAIL NP PA QLLbuprenorphine generic P QLLbuprenorphine/naloxone sl tabs generic NP PA QLLcaffeine citrate injection 60mg/3ml generic Pclonidine 0.1mg er generic NP PA QLLFIRDAPSE P PA QLLguanfacine er generic 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, 2021

HORIZANT NP PA QLLMESTINON P QLLnaloxone injection generic PNARCAN SPRAY P PAnimodipine generic P QLLNYMALIZE P PA QLLpimozide generic Ppyridostigmine generic NP PA QLLRUZURGI P PA QLLSUBOXONE P QLLTEGSEDI NP PA QLLVIVITROL P QLLXYREM NP PA QLLZUBSOLV NP PA QLL

ANTIDEMENTIA DRUGS donepezil, -ODT generic P QLLdonepezil 23mg generic NP PA QLLEXELON PATCH P QLLgalantamine , -er generic Pmemantine soln. generic NP PA QLLmemantine tabs, titration pak generic P QLLmemantine er caps generic NP PA QLLNAMZARIC NP PA QLLrivastigmine caps generic P DRUGS TO TREAT MULTIPLE SCLEROSIS AUBAGIO P QLLAVONEX P QLLBAFIERTAM NP PA QLLBETASERON NP PA QLLCOPAXONE KIT 20MG/ML P QLLCOPAXONE 40MG/ML NP PA QLLdalfampridine generic P PA QLLEXTAVIA NP PA QLLGILENYA 0.5mg P QLLGLATOPA NP PA QLLMAVENCLAD NP PA QLLMAYZENT NP PA QLLPLEGRIDY NP PA QLLREBIF, REBIDOSE P QLLTECFIDERA 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, 2021

VUMERITY NP PA QLL

SMOKING CESSATION DRUGSbuproban/bupropion sr 150mg (generic Zyban) P PA QLLCHANTIX P QLLnicotine gum, lozenge, patch generic P QLLNICOTROL INHALER, NASAL SPRAY NP PA QLL

MISCELLANEOUSacamprosate generic P QLLACTHAR HP P PA (> 2 years) QLLAMPHADASE P PAAUSTEDO P PA QLLBRISDELLE NP PA QLLCUVPOSA NP PA QLLdisulfiram generic P QLLGOCOVRI NP PA QLLHYLENEX P PAINGREZZA NP PA QLLLUCEMYRA NP PANUEDEXTA NP PA QLLtetrabenazine generic P PA QLLVITRASE P PA

DERMATOLOGICAL MEDICATIONS TOPICAL CORTICOSTEROID all topical corticosteroid generics (unless listed otherwise) Palclometasone cream/oint. generic NP PAamcinonide cream, lotion, ointment generic NP PAAPEXICON E CREAM NP PABESER KIT NP PA QLLbetamethasone dipropionate gel, ointment generic NP PAbetamethasone dipropionate (augmented) cream, lotion, ointment generic NP PAbetamethasone valerate aerosol foam 0.12%, lotion generic NP PACAPEX SHAMPOO NP PAclobetasol emulsion foam (generic OLUX-E) NP PA QLLclobetasol emollient cream NP PAclobetasol foam (generic OLUX) NP PA QLLclobetasol cream, lotion, shampoo generic NP PAclobetasol spray 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, 2021

CLOBEX LOTION, -SHAMPOO NP PACLODAN KIT NP PA QLLCLODERM NP PA QLLclocortolone generic NP PA QLLCORDRAN TAPE NP PA QLLCUTIVATE CREAM, OINT. NP PADERMA-SMOOTHE FS PDESONATE NP PAdesonide cream, lotion, ointment generic NP PAdesoximetasone cream, gel, ointment generic NP PA QLLdiflorasone diacetate cream and ointment generic NP PAfluocinolone acetonide cream, ointment, solution generic NP PAfluocinolone acetonide scalp/body oil generic NP PAfluocinonide cream 0.1% generic NP PA QLLfluocinonide 0.05% cream, e cream, gel, oint., soln. generic NP PAflurandrenolide cream, lotion, ointment generic NP PAfluticasone cream, ointment generic Pfluticasone lotion generic NP PABRYHALI NP PA QLLhalobetasol aerosol 0.05% generic NP PAHALOG, -E NP PAhydrocortisone acetate gel generic Phydrocortisone butyrate cream, lipophilic cream, ointment, solution generic NP PAhydrocortisone valerate cream, ointment generic NP PAKENALOG AEROSOL NP PAKENALOG-10,40, 80 INJ PLUXIQ NP PA QLLNEO-SYNALAR KIT NP PA QLLOLUX-E NP PA QLLPANDEL NP PAprednicarbate cream, ointment generic NP PAPSORCON E NP PASERNIVO SPRAY NP PASYNALAR OINTMENT NP PASYNALAR TS KITS NP PA QLLTEXACORT SOLN NP PATOPICORT 0.05% OINTMENT, SPRAY NP PA QLLtriamcinolone acetonide spray generic NP PATRIANEX OINTMENT NP PA QLLULTRAVATE X KIT 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, 2021

ULTRAVATE LOTION NP PA

TOPICAL ANTIACNE DRUGS ACANYA GEL NP PA QLLACZONE GEL NP PAadapalene gel, cream generic NP PA QLLAKLIEF NP PA QLLAMZEEQ NP PA QLLALTRENO LOTION NP PA QLLARAZLO NP PA QLLAZELEX P PA (> 21 years)AVITA P PA (> 21 years) QLLBENZEFOAM NP PA QLLBP 10-1 emulsion generic NP PACLINDACIN KIT PAC 1% NP PA QLLclindamycin aer 1% generic NP PAclindamycin 1% gel, lotion, topical solution generic Pclindamycin pads/swabs generic Pclindamycin-benzoyl peroxide gel 1-5% (generic for Benzaclin) NP PA QLLclindamycin-benzoyl peroxide gel 1.2-5% (generic for Duac) PDIFFERIN NP PA (> 21 years) QLLEPIDUO P PA (> 21 years) QLLEPIDUO FORTE NP PA QLLERY PAD 2% NP PAerythromycin pads generic NP PAerythromycin/benzoyl peroxide gel (generic Benzamycin) NP PAEVOCLIN NP PAFABIOR AER 0.1% NP PA QLLFINACEA NP PA QLLINOVA KITS NP PA QLLmetronidazole cream, 1% gel, lotion generic NP PAMETROGEL P QLLMETROGEL PUMP NP PA QLLNORITATE NPNEUAC Gel, KIT NP PA QLLONEXTON NP PA QLLOSCION NP PARETIN-A MICRO NP PA QLLROSADAN KIT NP PA QLLsodium sulfacetamide/sulfur 10-5% aerosol, cream, emulsion 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, 2021

sodium sulfacetamide/sulfur 10-4% pads generic NP PASulfacetamide sodium/sulfur in urea emulsion 10-5% generic NP PAsulfacetamide sodium 10% lotion/wash generic NP PASUMAXIN PADS NP PA QLLSUMAXIN WASH NP PA QLLTAZORAC P PA (> 30 years) QLLtretinoin cream generic P PA (> 21 years) QLLtretinoin gel 0.01%, 0.025% generic P PA (> 21 years) QLLtretinoin gel 0.05% generic NP PA QLLtretinoin microsphere gel/gel pump generic NP PA QLLVELTIN NP PA QLLZIANA NP PA QLL ORAL ANTIACNE DRUGSABSORICA, -LD NP PA QLLisotretinoin generics P PA QLL

ANTIPSORIASIS AND ANTIECZEMA DRUGS acitretin generic P QLLcalcipotriene cream generic P QLLcalcipotriene oint. generic NP PAcalcipotriene scalp soln. generic Pcalcitriol ointment generic NP PA QLLcalcipotriene-betamethasone ointment generic NP PA QLLCOSENTYX NP PA QLLENSTILAR NP PA QLLmethoxsalen generic NP PAOXSORALEN-UL PSKYRIZI NP PA QLLSORILUX NP PA QLLSTELARA 90mg/ml NP PA QLLTACLONEX NP PA QLLVECTICAL NP PA QLL

OTHER TOPICAL DERMATOLOGICAL DRUGS CARAC P QLLCONDYLOX GEL Pdiclofenac gel generic P QLLdoxepin 5% cream generic NP PA QLLDUPIXENT NP PA QLLEFUDEX PELIDEL 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, 2021

EUCRISA P QLLfluorouracil 5% inj., soln. generic Pimiquimod 5% generic Platrix xm generic NP PA QLLLICART NP PA QLLKERAFOAM NP PAPANRETIN P PAPICATO NP PA QLLpodofilox soln. generic NP PAPRUDOXIN NP PA QLLPROTOPIC P QLLQBREXZA NP PA QLLREGRANEX P PA QLLSANTYL NP PAtacrolimus ointment generic NP PA QLLTOLAK P QLLUMECTA PD NP PA QLLURAMAXIN NP PAurea cream/lotion/ointment generic Purea gel/emulsion generic NP PAurea nail kit generic NP PA QLLVALCHLOR GEL P PA QLLVUSION NP PAZONALON NP PA QLLZYCLARA NP PA PEDICULOCIDES and SCABICIDES EURAX CREAM NP PA QLLEURAX LOTION NP PA QLLLINDANE LOTION, SHAMPOO NP PA QLLmalathion lotion NP PA QLLNATROBA NP PA QLLOVIDE NP PA QLLpermethrin 1% lotion P QLLpermethrin 5% cream generic P QLLSKLICE NP PA QLLspinosad generic NP PA QLL

ROSACEA AGENTSdoxycycline (rosacea) 40mg cap generic NP PA QLLORACEA NP PA QLLFINACEA 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, 2021

SOOLANTRA NP PA QLLZILXI NP PA QLL

EAR-NOSE-THROAT MEDICATIONS DRUGS AFFECTING THE EAR CERUMENEX PCIPRODEX P QLLCIPRO HC Pciprofloxacin otic generic NP PA DERMOTIC Pneomycin/polymyxin/hc generic P QLLofloxacin otic generic POTOVEL NP PA QLL DRUGS AFFECTING THE NOSE azelastine 137mcg (0.1%) generic P QLLazelastine 0.15% generic NP PA QLLBECONASE AQ NP PA QLLbudesonide nasal susp. generic NP PA QLLDYMISTA NP PA QLLflunisolide generic NP PA QLLfluticasone generic P QLLipratropium nasal spray generic P QLLmometasone nasal spray generic NP PA QLLolopatadine generic NP PA QLLOMNARIS NP PA QLLQNASL NP PA QLLXHANCE NP PA QLLZETONNA NP PA QLL DRUGS AFFECTING THE THROAT AND MOUTH cevimeline generic Ppilocarpine tabs generic PRADIACARE PSALAGEN P

ENDOCRINE MEDICATIONS BONE OSSIFICATION AGENTS ACTONEL 5mg, 30mg NP PA QLLalendronate generic P QLLalendronate oral soln generic NP PA QLLATELVIA 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, 2021

BINOSTO NP PA QLLcalcitonin nasal solution generic P QLLetidronate disodium generic P QLLFORTEO NP PAFOSAMAX-D NP PA QLLFOSAMAX SOLUTION NP PA QLLibandronate -inj., -tabs generic NP PA QLLMIACALCIN INJECTION NP PA QLLrisedronate, -dr generic NP PA QLLTYMLOS NP PA

INSULIN AFREZZA NP PAAPIDRA NP PA QLLAPIDRA SOLOSTAR NP PA QLLBASAGLAR NP PA QLLFIASP NP PA QLLHUMALOG P QLLHUMALOG KWIKPEN 200 units/ml NP PA QLLHUMALOG pens and cartridges P PA (> 21 years) QLLHUMALOG MIX 50/50 P QLLHUMALOG MIX 75/25 P QLLHUMULIN 70/30 P QLLHUMULIN N P QLLHUMULIN R U-100 P QLLHUMULIN R U-500 vial P QLLHUMULIN R U-500 pen P PA (> 21 years) QLLHUMULIN pens P PA (> 21 years) QLLLANTUS P QLLLANTUS SOLOSTAR P QLLLEVEMIR P QLLLEVEMIR FLEXTOUCH P QLLLYUMJEV NP PA QLLNOVOLIN NP PA QLLNOVOLIN 70/30 FLEXPEN NP PA QLLNOVOLIN R PEN NP PA QLLNOVOLOG P QLLNOVOLOG MIX pen P PA (> 21 years) QLLNOVOLOG MIX vial P QLLNOVOLOG pens and cartridges P PA (> 21 years) QLLTOUJEO NP PA QLLTRESIBA FLEX, -INJ. 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, 2021

XULTOPHY NP PA QLL

ORAL ANTIDIABETIC AGENTS acarbose PACTOPLUS MET XR NP PA QLLalogliptin 6.25mg, 12.5mg generic NP PA QLLalogliptin-metformin generic NP PA QLLalogliptin-pioglitazone generic NP PA QLLAVANDIA NP PA QLLAVANDAMET NP PA QLLchlorpropamide generic NP PACYCLOSET NP PA QLLFARXIGA P QLLFORTAMET ER NP PA QLLglimepiride generic Pglipizide, XL Pglipizide/metformin generic P QLLGLUMETZA ER NP PA QLLglyburide generic P QLLglyburide/metformin generic P QLLGLYSET PGLYXAMBI NP PA QLLINVOKANA P QLLINVOKAMET P QLLINVOKAMET XR NP PA QLLJANUMET P QLLJANUMET XR NP PA QLLJANUVIA P QLLJARDIANCE P QLLJENTADUETO P QLLJENTADUETO XR NP PA QLLKOMBIGLYZE P QLLmetformin generic P QLLmetformin er (generic for Glucophage XR) Pmetformin er (generic for Glumetza) P QLLmetformin er osmotic (generic for Fortamet ER) NP PA QLLnateglinide generic P QLLNESINA 25mg NP PA QLLONGLYZA P QLLpioglitazone generic P QLLpioglitazone/glimepiride generic NP PA QLLpioglitazone/metformin 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, 2021

PRANDIMET NP PA QLLQTERN NP PA QLLrepaglinide generic P QLLrepaglinide-metformin generic NP PA QLLRIOMET P QLLRIOMET ER NP PA QLLSEGLUROMET NP PA QLLSTEGLATRO NP PA QLLSTEGLUJAN NP PA QLLSYNJARDY, -XR NP PA QLLtolazamide generic NP PAtolbutamide generic NP PATRADJENTA P QLLTRIJARDY XR NP PA QLLXIGDUO XR P QLL

MISC. ANTIDIABETIC AGENTSADLYXIN NP PA QLLBYDUREON P PA QLLBYDUREON BCISE NP PA QLLBYETTA P PA QLLOZEMPIC NP PA QLLRYBELSUS NP PA QLLSOLIQUA NP PA QLLSYMLINPEN P PA QLLTANZEUM NP PA QLLTRULICITY NP PA QLLVICTOZA P PA QLL

THYROID SUPPLEMENTS ARMOUR THYROID Plevothyroxine tabs generic Plevothyroxine inj. generic P PA QLLliothyronine inj. generic P PAliothyronine tabs generic Pnp thyroid 30mg, 60mg 90mg tab generic PTIROSINT NP PA MISC. ENDOCRINE DRUGS BAQSIMI NP PA QLLBUPHENYL P QLLCEREZYME 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, 2021

cortisone generic PCERDELGA P PA QLLCRYSVITA NP PADDAVP NASAL Pdesmopressin generic Pdexamethasone generic PDEXPAK NP PADOSTINEX P QLLELELYSO P PAEMFLAZA NP PA QLLFLO-PRED SUSPENSION NP PAGALAFOLD P PA QLLGVOKE PFS, -HYPO NP PA QLLhydrocortisone generic PISTURISA P PA QLLKORLYM P PA QLLMEDROL 2mg Pmethylprednisolone generic PMILLIPRED ORAL SOLN., TABS NP PAMYALEPT P PA QLLNATPARA NP PA QLLORAPRED ODT NP PAORFADIN PORFADIN SUSP. P PAprednisolone oral soln. 10mg/5ml NP PAprednisolone oral soln. 15mg/5ml generic Pprednisolone oral soln. 20mg/5ml NP PAprednisolone oral soln. 25mg/5ml generic Pprednisolone odt generic NP PAprednisone generic Praloxifene generic P QLLRAVICTI NP PA QLLRAYOS NP PA QLLREVCOVI NP PASIGNIFOR, -LAR NP PA QLLsodium phenylbutyrate generic NP PA QLLSTRENSIQ P PATAPERDEX NP PA QLLVERIPRED 20 SOL 20MG/5ML NP PAVIMIZIM P PAVPRIV P PAZAVESCA 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, 2021

ANABOLIC STEROIDSANADROL-50 P PAoxandrolone P PA QLL

GASTROINTESTINAL MEDICATIONS ANTIULCER DRUGS cimetidine generic P QLLfamotidine inj., tab generic P QLLfamotidine suspension generic NP PA QLLnizatidine caps, solution generic NP PA QLL PROTON PUMP INHIBITORS (PPI) ACIPHEX SPRINKLES NP PA QLLDEXILANT NP PA QLLesomeprazole inj. generic NP PA QLLesomeprazole magnesium cap (generic Nexium) NP PA QLLesomeprazole strontium cap generic NP PA QLLlansoprazole generic NP PA QLLNEXIUM GRANULES/SUSPENSION P QLLomeprazole generic P QLLomeprazole/sodium bicarbonate caps generic NP PA QLLpantoprazole generic P QLLpantoprazole inj. generic NP PA QLLPREVACID SOLUTAB NP PA QLLPRILOSEC POWDER NP PA QLLPROTONIX PAK NP PA QLLrabeprazole tabs generic NP PA QLLZEGERID POWDER NP PA QLL

HELICOBACTER PYLORI DRUGS HELIDAC NP PA QLLlansoprazole/amoxicillin/clarithromycin generic NP PA QLLOMECLAMOX-PAK NP PA QLLPYLERA P PA QLLTALICIA NP PA QLL

OTHER GI DRUGS ACTIGALL Palosetron 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, 2021

AMITIZA P PA QLLANALPRAM-HC 1-1% CREAM NP PAAPRISO Pbalsalazide generic Pbudesonide SR caps generic P QLLCHENODAL NP PAchlordiazepoxide-clidinium generic NP PACHOLBAM P PA QLLCLENPIQ NP PACOLYTE P QLLCORTIFOAM PCREON P QLLcromolyn sodium oral conc. 100mg/5ml generic PDELZICOL P QLLdiphenoxylate-atropine generic PFULYZAQ NP PA QLLGATTEX NP PA QLLGAVILYTE-H KIT NP PA QLLGIAZO NP PA QLLGOLYTELY P QLLGLYCATE NP PA QLLglycopyrrolate tab generic Pglycopyrrolate injection, -PF generic NP PA QLLGLYRX-PF Phc pramoxine cream 1-1% generic NP PAhydrocortisone acetate cream generic P QLLKRISTALOSE NP PA QLLlactulose generic P LIALDA PLINZESS P PA QLLLOTRONEX NP QLLmesalamine enema generic NP PAmesalamine kit generic NP PA QLLmesalamine suppositories generic Pmesalamine tab generic NP PAmethscopolamine generic NP PAmetoclopramide generic Pmetoclopramide odt generic NP PA QLLMOTEGRITY NP PA QLLMOTOFEN NP PAMOVANTIK P PA QLLMOVIPREP 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, 2021

MYTESI NP PA QLLNULYTELY P QLLOCALIVA P PAOPIUM TINCTURE NP PAORTIKOS NP PA QLLPANCREAZE NP PA QLLPENTASA PPERTZYE NP PAPLENVU NP PA QLLpramcort cream 1-1% generic PPRAMOSONE CREAM 1% PPREPOPIK NP PA QLLPROCORT NP PAPROCTOFOAM-HC Ppropantheline generic NP PARECTIV OINT 0.4% NP PA QLLRELISTOR NP PA QLLSFROWASA NP PASUCLEAR P QLLsulfasalazine generic PSUPREP NP PA QLLSYMPROIC NP PATRULANCE NP PA QLLursodiol caps generic NP PAursodiol tabs generic PVIBERZI NP PA QLLVIOKACE NP PAXERMELO P PA QLLZENPEP P QLLz-pram cream generic (hydrocortisone acetate w/pramoxine 2.35-1%) NP PA QLL

IMMUNOLOGICALS ACTIMMUNE P QLLALFERON N PARANESP NP PA QLLBENLYSTA SUBCUTANEOUS SOLN. P PABIVIGAM NP PACARIMUNE NF NP PACUTAQUIG NP PACUVITRU NP PACYTOGAM 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, 2021

DOPTELET P PAEPOGEN P PAFLEBOGAMMA/DIF NP PAFULPHILA P PA QLLGAMASTAN, -S/D NP PAGAMMAGARD/SD P PAGAMMAKED NP PAGAMMAPLEX NP PAGAMUNEX-C P PAGRANIX 300mcg/0.5ml, 480mcg/0.8ml syringes (non-needle guard) NP PA QLLHEPAGAM B NP PAHIZENTRA P PAHYQVIA NP PAINTRON A P QLLLEUKINE P PA QLLMIRCERA NP PA QLLMOZOBIL P PAMULPLETA P PANEULASTA NP PA QLLNEUPOGEN P PA QLLNIVESTYM NP PA QLLNPLATE NP PAOCTAGAM NP PAPANZYGA NP PAPRIVIGEN NP PAPROCRIT P PAPROLEUKIN PPROMACTA P PA QLLRETACRIT NP PASYLATRON P PASYNAGIS P PA QLLTAVALISSE P PA QLLUDENYCA P PA QLLXEMBIFY NP PAZARXIO NP PA QLLZIEXTENZO NP PA

GROWTH HORMONESEGRIFTA SV P PA QLLGENOTROPIN P PAHUMATROPE NP PANORDITROPIN 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, 2021

NUTROPIN AQ P PAOMNITROPE NP PASAIZEN NP PASEROSTIM NP PAZOMACTON NP PAZORBTIVE NP PA

GROWTH FACTORSINCRELEX NP PA

MUSCULOSKELETAL MEDICATIONS NON-STEROIDAL ANTIINFLAMMATORY AGENTS celecoxib generic NP PA QLLdiclofenac w/misoprostol generic NP PA QLLdiclofenac epolamine patch 1.3% generic NP PAdiclofenac sodium er tab generic NP PAdiclofenac solution 1.5% NP PA QLLdiflunisal generic NP PADUEXIS NP PA QLLetodolac er tab generic NP PAfenoprofen calcium cap, tab generic NP PA QLLgeneric NSAIDs (unless listed otherwise) P QLLindomethacin er cap generic NP PAindomethacin IR generic Pketoprofen, -er generic NP PAmeclofenamate sodium cap generic NP PAmefenamic acid generic NP PA QLLmeloxicam suspension generic NP PA QLLmeloxicam tablets generic P QLLNAPRELAN NP PA QLLnaproxen dr tab generic NP PAnaproxen sodium cr tab (generic for Naprelan) NP PA QLLnaproxen suspension generic Poxaprozin tab generic NP PAPENNSAID NP PA QLLRELAFEN DS NP PA QLLsalsalate generic NP PASPRIX NP PA QLLTIVORBEX NP PA QLLtolmetin sodium generic NP PAVIMOVO 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, 2021

VIVLODEX NP PA QLLVOLTAREN GEL PZIPSOR NP PA QLLZORVOLEX NP PA QLL OTHER DRUGS FOR ARTHRITIS ACTEMRA NP PA QLLCUPRIMINE POLUMIANT NP PA QLLOTEZLA NP PA QLLOTREXUP NP PA QLLRASUVO NP PA QLLXATMEP NP PA QLLXELJANZ IR (5MG, 10MG) P PA QLLXELJANZ XR - requires LOMN after at least a 30-day trial of Xeljanz (IR-5MG) P PA QLL

DRUGS FOR GOUTallopurinol generic Pcolchicine cap generic P QLLcolchicine tab generic NP PA QLLfebuxostat generic NP PA QLLGLOPERBA NP PA QLLMITIGARE P QLLprobenecid generic Pprobenecid/colchicine generic P

SKELETAL MUSCLE RELAXANTS AMRIX NP PA QLLbaclofen 10mg, 20mg generic Pcarisoprodol 250mg generic NP PA QLLcarisoprodol 350mg generic P QLLcarisoprodol w/aspirin generic Pcarisoprodol w/aspirin and codeine generic NP PAchlorzoxazone generic Pcyclobenzaprine 5mg, 10mg generic P QLLcyclobenzaprine 7.5mg generic NP PA QLLdantrolene sodium (Par generic only) PFEXMID NP PA QLLGABLOFEN INJ. P QLLLIORESAL INJ. PLORZONE NP PA QLLmetaxalone generic 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, 2021

methocarbamol generic Porphenadrine generic Porphenadrine/aspirin/caffeine generic PTHERABENZAPR PAK -60 Ptizanidine caps generic NP PAtizanidine tabs generic PZANAFLEX CAPS NP PA

NEUROMUSCULAR AGENTSriluzole generic P QLLTIGLUTIK NP PA QLL

NUTRITION / BLOOD MODIFIERS / ELECTROLYTES END STAGE RENAL DISEASEaluminum hydroxide generic P PAAURYXIA NP PA QLLcalcitriol generic Pcalcium acetate caps Pcalcium acetate tabs NP PAcalcium carbonate generic P PAcalcium carbonate/glycine generic P PAcalcium lactate P PADIALYVITE/ZINC P PADIALYVITE SUPREME D NP PAdocusate sodium/calcium P PADOJOLVI NP PAdoxercalciferol generic NP PAergocalciferol generic PFERAHEME NP PAFERRETTES FE CHEW TABS Pferric gluconate injection generic NP PAfolic acid 1mg generic P QLLHECTOROL NP PAINFED P PAINJECTAFER NP PA QLLINTRALIPID NP PAKABIVEN NP PAlanthanum chew tab generic NP PAlevocarnitine generic Pmagnesium carbonate generic P PAMAGNEBIND P PANEPHPLEX RX 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, 2021

NEPHRON FA P PAniacin generic P PANUTRALIPID POMEGAVEN P PAparicalcitol 1mcg, 2mcg generic Pparicalcitol 4mcg generic NP PAPERIKABIVEN NP PAPHOSLYRA NP PApyridoxine (vitamin B-6) inj. generic P PARAYALDEE NP PA QLLRENAGEL P QLLRENVELA TAB NP PA QLLROCALTROL PSENSIPAR NP PAsevelamer 400mg generic NP PAsevelamer powder packet generic NP PA QLLSMOFLIPID NP PAsodium bicarbonate generic P PAthiamine (vitamin B-1) generic P PATRALEMENT PVELPHORO NP PA QLLVENOFER P PAvitamin B complex generic P PAvitamin B-12 injection generic P ORAL ANTICOAGULANTS, VITAMIN K BEVYXXA NP PA QLLCOUMADIN TABS PCOUMADIN INJ PELIQUIS P QLLMEPHYTON P QLLPRADAXA P QLLSAVAYSA NP PA QLLwarfarin sodium generic PXARELTO P QLL HEPARIN AND HEPARIN ANTAGONISTS enoxaparin syringe generic (Winthrop/Fresenius) P QLLenoxaparin vial generic (Winthrop/Fresenius) P QLLfondaparinux generic NP PA QLLFRAGMIN SYRINGE NP PA QLLheparin 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, 2021

ANTIPLATELET DRUGS AGGRENOX Paspirin (enteric coated) Paspirin/dipyridamole generic (Slate Run) Paspirin/dipyridamole generic (all generics except Slate Run) NP PABRILINTA P QLLcilostazol generic Pclopidogrel 75mg generic P QLLclopidogrel 300mg generic NP PA QLLdipyridamole generic Pticlopidine generic PPLAVIX 300mg P QLLprasugrel generic P QLLYOSPRALA NP PA QLLZONTIVITY NP PA QLL

CHELATING AGENTdeferasorox generic NP PA QLLDEPEN TITRATABS P PAEXJADE P QLLFERPRX 2-DAY NP PA QLLFERRIPROX NP PA QLLJADENU TABS NP PA QLLSYPRINE P

ANTIHEMOPHILIC FACTOR DRUGS ADVATE PADYNOVATE NP PAAFSTYLA PALPHANATE PALPHANINE PALPROLIX NP PABEBULINE PBENEFIX PELOCTATE NP PAESPEROCT NP PAFEIBA NP PAHEMLIBRA NP PA QLLHEMOFIL PHUMATE-P NP PAIDELVION 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, 2021

IXINITY NP PAJIVI NP PAKOGENATE FS PKOVALTRY NP PAMONONINE PNOVOEIGHT PNOVOSEVEN RT NP PANUWIQ PPROFILNINE PREBINYN NP PARECOMBINATE NP PARIXUBIS NP PATRETTEN NP PAVONVENDI NP PAWILATE PXYNTHA P

PRENATAL VITAMINSCITRANATAL 90 DHA PCITRANATAL ASSURE PCITRANATAL B-CALM PCITRANATAL DHA PCITRANATAL HARMONY PCONCEPT DHA Pprenatal brands/generics with DHA Pprenatal brand/generics (without DHA) PSELECT-OB + DHA PTRICARE PVITAFOL FE+ PVITAFOL NANO PVITAFOL TAB CHEW PVITAFOL ULTRA PVITAFOL-OB PVITAFOL-OB+DHA PVITAFOL-ONE PVITAFOL STRIPS P

VITAMIN AND MINERAL PRODUCTS (covered <21 years old)corvita 150 generic PFERIVA PFERIVA 21-7 NP PAFERIVA FA 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, 2021

FERRALET 90 PFUSION PLUS, -SPRINKLE PHEMOCYTE-F PHEMOCYTE PLS PINTEGRA F PINTEGRA PLUS PMAXARON FORTE PTANDEM PLUS P

OTHERAMICAR P QLLaminocaproic acid tabs generic P QLLBERINERT PCABLIVI NP PACARBAGLU P PACATHFLO ACTIVASE P QLLCINRYZE NP PADROXIA PENDARI P PA QLLFIRAZYR P QLLHAEGARDA Phydroxyurea generic Picatibant generic P QLLJYNARQUE P PA QLLKALBITOR NPKEVEYIS P PA QLLKLOR-CON PKUVAN P QLLLOKELMA NP PAOXBRYTA NP PA QLLPALYNZIQ P PA QLLpentoxifylline generic Ppotassium chloride generic Ppotassium citrate 5meq, 10meq generic P QLLpotassium citrate 15meq generic NP PA QLLRUCONEST NP PASAMSCA P QLLSIKLOS NP PA QLLTAKHZYRO NP PAtranexamic acid inj. NP PAUROCIT-K 15 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, 2021

OBSTETRICAL & GYNECOLOGICAL MEDICATIONS MISCELLANEOUS OB/GYN DRUGS CLEOCIN SUPPOSITORY NP PAclindamycin 2% cream generic NP PACLINDESSE P QLLINTRAROSA NP PAmethylergonovine generic P QLLNUVESSA P QLLORILISSA P PAOSPHENA NP PASYNAREL Ptranexamic acid tab generic NP PA QLL ANDROGEN DRUGS ANADROL-50 P PAANDRODERM PATCH P PA QLLdanazol P PADELATESTRYL P PADEPO-TESTOSTERONE P PAJATENZO NP PA QLLMETHITEST P PAmethyltestosterone cap generic NP PA QLLoxandrolone generic P PA QLLNATESTO NP PA QLLSTRIANT NP PA QLLtestosterone gel generic NP PA QLLtestosterone gel packets (Actavis NDCs-00591-3216** and 00591-3217** and Perrigo NDCs 45802-0366-** and 45802-0754-** generics) P PA QLLtestosterone gel packets (all generics except Actavis NDCs-00591-3216** and 00591-3217** and Perrigo NDCs 45802-0366-** and 45802-0754-**) NP PA QLLtestosterone gel pump (Upsher-Smith generic for Vogelxo) P PA QLLtestosterone gel pump (all generics except Upsher-Smith generic for Vogelxo) NP PA QLLtestosterone injection generic P PAtestosterone topical soln. generic NP PA QLLXYOSTED NP PA QLL

ESTROGEN DRUGS ALORA P QLLDIVIGEL NP PA QLLELESTRIN 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, 2021

ESTRACE CREAM P QLLestradiol patch generic P QLLestradiol tabs generic PESTRASORB NP PAEVAMIST PIMVEXXY NP PAMENEST PMINIVELLE NP PAPREMARIN P QLLVIVELLE DOT P QLLyuvafem (estradiol) vaginal tab generic P

ESTROGEN COMBINATIONS ANGELIQ P QLLBIJUVA NP PA QLLCLIMARA PRO PATCH P QLLCOMBIPATCH PDUAVEE NP PA QLLestradiol/norethindrone generic P QLLFEMHRT P QLLFEMRING NP QLLjinteli (norethindrone/estradiol 1mg-5mcg) generic Pnorethindrone/estradiol 0.5mg-2.5mcg generic NP PA QLLPREFEST PPREMPHASE P QLLPREMPRO P QLL PROGESTIN DRUGS CRINONE GEL NP PAMAKENA AUTO-INJECTOR P PA QLLMEGACE ES NP PAmegestrol 40mg/ml susp generic Pmegestrol 625mg/5ml susp generic NP PAprogesterone caps generic P CONTRACEPTIVES amethia, -lo generic NP PA QLLamethyst generic NP PA QLLANNOVERA NP PA QLLaranelle (generic Tri-Norinyl) NP PABALCOLTRA NP PA QLLcamrese, -lo 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, 2021

DEPO-SQ PROVERA 104 NP QLLdrospirenone/ethinyl estradiol/levomefolate generic NP PA QLLELLA P QLLgildess 24 fe generic Pgianvi (drospirenone/ethinyl estradiol) generic NP PA QLLjolessa generic P QLLjunel fe 24 generic Plarin 24 fe generic Pleena (generic Tri-Norinyl) NP PAlevonorgestrel/ethinyl estradiol (generic LoSeasonique) NP PA QLLLO LOESTRIN FE NP PA QLLlomedia 24 fe generic PLO MINASTRIN FE NP PA QLLLOSEASONIQUE P QLLmedroxyprogesterone 150mg/ml generic P QLLMINASTRIN 24 CHW FE NP PA QLLNATAZIA NP PA QLLNECON 1/50 NP PAnext choice 0.75mg generic (covered < 17 yrs old) P QLLnext choice 1.5mg generic (covered < 17 yrs old) P QLLnorethindrone 0.35mg generic Pnorethindrone/ethinyl estradiol-fe chew tabs (generic for Generess Fe Chew) NP PA QLLnorethindrone/ethinyl estradiol 7/7/7, alyacen, cyclafem, dasetta, necon, notrel, pirmella, etc. (generic for Ortho-Novum 7/7/7) Pnorgestimate/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 PANUVARING Pocella generic NP PAPLAN B ONE STEP (covered < 17 yrs old) P QLLQUARTETTE NP PA QLLquasense generic P QLLSAFYRAL NP PA QLLSEASONIQUE P QLLSLYND NP PA QLLtri-legest/tilia fe generic Ptrinessa lo generic P QLLwymza fe chew (generic for Femcon FE Chew) 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, 2021

xulane (norelgestromin-ethinyl estradiol) generic NP PA QLLzarah generic NP PAzenchent fe chew (generic for Femcon FE Chew) NP PA QLLzeosa chew generic NP PAzovia 1/50e (ethynodiol) generic NP PA

OPHTHALMIC MEDICATIONS OPHTHALMIC QUINOLONES BESIVANCE NP PA QLLCILOXAN ophth. oint. Pciprofloxacin HCL drops P QLLgatifloxacin ophth. soln. generic NP PA QLLlevofloxacin 0.5% ophth generic NP PA QLLMOXEZA P QLLmoxifloxacin ophthalmic soln. 0.5% generic P QLLofloxacin drops generic NP PA QLLZYMAXID NP PA QLL OPHTHALMIC CORTICOSTEROID DRUGS ALREX P QLLDUREZOL P QLLFML-FORTE P QLLLOTEMAX, -SM GEL NP PA QLLLOTEMAX OINT P QLLloteprednol 0.5% ophth. susp. (Oceanside generic) P QLLVEXOL P QLL

OPHTHALMIC COMBINATIONS BLEPHAMIDE S.O.P. NP PAneomycin/polymyxin/bacitracin/hc ophth. oint. generic NP PAneomycin/polymyxin/hc ophth. susp. generic NP PA QLLneomycin/polymyxin B sulfate/dexamethasone ophth. susp. generic PTOBRADEX P QLLTOBRADEX ST NP PA QLLtobramycin/dexamethasone generic NP PA QLLZYLET P

ORAL ANTIGLAUCOMA DRUGS acetazolamide ir generic Pacetazolamide sr 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, 2021

TOPICAL ANTIGLAUCOMA DRUGS ALPHAGAN-P 0.1% P QLLALPHAGAN-P 0.15% P QLLapraclonidine generic NP PAAZOPT NP PAbetaxolol generic PBETOPTIC S Pbimatoprost generic NP PA QLLbrimonidine 0.2% generic Pbrimonidine 0.15% generic NP PA QLLcarteolol hcl generic PCOMBIGAN 5ml P QLLCOMBIGAN 10ml NP PA QLLCOSOPT PF NP PA QLLdorzolamide generic Pdorzolamide/timolol generic PIOPIDINE 1% PISOPTO CARBACHOL PISTALOL NP PAlatanoprost generic P QLLlevobunolol hcl generic PLUMIGAN P QLLPHOSPHOLINE IODIDE Ppilocarpine ophthalmic generic NP PAPILOPINE H.S. PRHOPRESSA P PA QLLROCKLATAN P PASIMBRINZA NP PA QLLtimolol maleate generic PTIMOPTIC OCUDOSE NP PATRAVATAN Z P QLLVYZULTA NP PA QLLXELPROS NP PA QLLZIOPTAN NP PA QLL

OPHTHALMIC ANTIHISTAMINESazelastine ophth. generic NP PA QLLBEPREVE P QLLepinastine generic NP PA QLLLASTACAFT NP PA QLLolopatadine 0.1% soln. generic NP PA QLLPATADAY 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, 2021

PAZEO P QLLZERVIATE NP PA QLL

OPHTHALMIC MAST CELL STABILIZERSALOCRIL NP PA QLLALOMIDE NP PA QLLcromolyn sodium generic P QLL OTHER OPHTHALMIC DRUGS ACUVAIL NP PA QLLatropine sulfate ophthalmic soln. generic PAZASITE NP PAbacitracin ophthalmic oint. generic NP PAbromfenac ophth soln generic NP PA QLLBROMSITE NP PACEQUA NP PACYCLOGYL 0.5% PCYCLOGYL 2% NP PAcyclopentol 1%, 2% ophth soln generic PCYSTARAN P QLLdiclofenac ophth soln generic Pflurbiprofen ophth susp generic PILEVRO P QLLketorolac ophthalmic generic P QLLNATACYN NP PAneomycin/polymyxin/gramicidin ophthalmic soln. generic NP PANEVANAC NP PAOXERVATE P PA QLLpolymyxin/bacitracin ophthalmic ointment generic Ppolymyxin/trimethoprim ophthalmic drops generic PPROLENSA NP PA QLLRESTASIS MULTIDOSE NP PA QLLRESTASIS single dose vials P QLLsulfacetamide ophthalmic ointment generic NPsulfacetamide ophthalmic drops generic Ptobramycin ophthalmic generic Ptrifluridine generic PXIIDRA PZIRGAN NP PA QLL

RESPIRATORY MEDICATIONS

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, 2021

BRONCHODILATORS AND RELATED DRUGS albuterol for nebulization generic 2.5mg/3ml, 5mg/ml P QLLalbuterol for nebulization generic 0.63mg/3ml, 1.25mg/3ml

NP PA QLL

albuterol sulfate ir, er tabs generic NP PABROVANA NP PAELIXOPHYLLIN ELIXIR Plevalbuterol neb generic NP PA (> 8 years) QLLmetaproterenol syrup, tabs generic NP PAPERFOROMIST NP PA QLLPROAIR DIGIHALER NP PA QLLPROAIR HFA P QLLSEREVENT DISKUS P QLLSTRIVERDI RESPIMAT NP PA QLLterbutaline tabs generic NP PAtheophylline generic PXOPENEX HFA NP PA QLL

COPD ANTICHOLINERGICSalbuterol/ipratropium neb soln generic P QLLANORO ELLIPTA P QLLATROVENT HFA P QLLBEVESPI NP PA QLLBREZTRI NP PA QLLCOMBIVENT RESPIMAT P QLLDUAKLIR NP PA QLLINCRUSE ELLIPTA NP PA QLLipratropium inhalation solution generic P QLLLONHALA MAGNAIR NP PA QLLSPIRIVA HANDIHALER P QLLSPIRIVA RESPIMAT NP PA QLLSTIOLTO RESPIMAT P QLLTRELEGY ELLIPTA NP PA QLLTUDORZA NP PA QLLYUPELRI NP PA QLL

INHALED STEROIDS/PULMONARY ANTIINFLAMMATORY DRUGS ADVAIR HFA P QLLADVAIR DISKUS P QLLAIRDUO RESPICLICK, -DIGIHALER NP PA QLLALVESCO NP PA QLLARMONAIR, -DIGIHALER 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, 2021

ARNUITY ELLIPTA NP PA QLLASMANEX HFA (except 50mcg) NP PA QLLASMANEX TWISTHALER 110mcg P PA (> 12 years) QLLASMANEX TWISTHALER 220mcg P QLLBREO ELLIPTA NP PA QLLbudesonide inhalation susp P QLLDULERA (except 50-5mcg) P QLLFLOVENT DISKUS/HFA P QLLfluticasone/salmeterol inhaler (generic AIRDUO) NP PAPULMICORT FLEXHALER P QLLQVAR P QLLQVAR REDIHALER NP PA QLLSYMBICORT P QLL LEUKOTRIENE MODIFIERS montelukast chewables, tabs generic P QLLmontelukast granules generic P PA QLLzafirlukast generic NP PA QLLzileuton er generic NP PA QLLZYFLO IR NP PA QLL ANTIHISTAMINE AND DECONGESTANT DRUGS carbinoxamine generic Pcetirizine syrup generic Rx/OTC P QLLcetirizine tabs generic OTC P QLLCLARINEX-D NP PA QLLCLARINEX SYRUP NP PA QLLdesloratadine tab generic NP PA QLLdesloratadine ODT generic NP PA QLLKARBINAL ER NP PA QLLlevocetirizine syrup generic NP PA QLLlevocetirizine tab generic P QLLloratadine, -D generic OTC P QLLRYVENT NP PA QLLSEMPREX-D P ALPHA-1 PROTEINASE INHIBITORSARALAST-NP P PAGLASSIA P PAPROLASTIN-C P PAZEMAIRA 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, 2021

OTHER RESPIRATORY DRUGS ALLFEN PDALIRESP NP PA QLLEPIPEN, -JR. NP PA QLLepinephrine 0.15mg, 0.3mg injection generic NP PA QLL brand) P QLLESBRIET NP PA QLLFASENRA PEN NP PA QLLGRASTEK NP PA QLLKALYDECO P PA QLLNUCALA AUTO-INJECTOR NP PAOFEV P PA QLLORALAIR NP PA QLLORKAMBI P PA QLLPALFORZIA NP PAPULMOZYME P QLLRAGWITEK NP PA QLLSYMDEKO P PA QLLSYMJEPI NP PA QLLTRIKAFTA P PA QLL

UROLOGICAL/RENAL MEDICATIONSCALCIBIND PCYSTAGON PELMIRON PENABLEX NP PA QLLflavoxate generic NP PA QLLGELNIQUE NP PA QLLmethenamine generic Pmethenamine hippurate generic NP PAMONUROL PMYRBETRIQ NP PA QLLoxybutynin generic P QLLoxybutynin ER generic P QLLOXYTROL P QLLPROCYSBI NP PA QLLsolifenacin generic P QLLTHIOLA EC P PA QLLtolterodine, -er generic NP PA QLLTOVIAZ P QLLtrospium generic NP PA QLLtrospium 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, 2021

URIMAR-T NP PAURIN D/S PUROGESIC BLUE NP PA QLL

DRUGS FOR BPH alfuzosin generic P QLLCARDURA XL NP PACIALIS 2.5MG, 5MG NP PA QLLdutasteride generic P QLLdutasteride-tamsulosin generic NP PA QLLfinasteride generic P QLLJALYN NP PA QLLRAPAFLO NP PA QLLtamsulosin generic P QLL

DIABETIC SUPPLIES METERS-Abbott select brands are covered through manufacturer n/a n/a n/a n/aTEST 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/a

VACCINES For a complete list of covered vaccines, please refer to www.mmis.georgia.gov → Pharmacy → Other Documents → Covered Vaccines n/a n/a n/a n/a

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