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Florida Medicaid Preferred Drug List (effective 04-01-2022)The Florida Medicaid Preferred Drug List (PDL) is subject to revision following consideration and recommendations by thePharmaceutical and Therapeutics (P&T) Committee and the Agency for Health Care Administration. The quarterly P&T Committeemeeting was held on March 25, 2022.This list is in order by the therapeutic classification. To locate a specific drug or therapeutic class, use the search feature available inAdobe Acrobat Reader. (keyboard shortcut: CTRL F)Phosphate Binders and Prescription Strength Vitamins are covered for dialysis patients.Note: While a product name may be listed on the PDL, a specific NDC may or may not be reimbursable.DEFINITIONS:“Auto PA” System automated criteria looks for specific requirements (e.g., diagnosis, age, previous therapies, etc.). If all requirementsare found, the claims will pay at the pharmacy counter without need of manual prior authorization submission.“Clinical PA Required” These drugs require prior authorization submission that must include clinical documentation. The drugs thatrequire clinical prior authorization review and the prior authorization forms can be found in this link:http://ahca.myflorida.com/medicaid/Prescribed Drug/preferred drug.shtml“Cystic Fib Diag Auto PA” Claims for these products will pay at the pharmacy counter if the diagnosis of cystic fibrosis is found in thesystem.“Requires Med Cert 3” The Food and Drug Administration (FDA) requires participation (by prescribers, pharmacies, and/or patients) incertification, education, training, or agreements prior to dispensing certain drugs. By entering certification code “3”, the dispensingpharmacy is confirming that FDA requirements were met.Auto PA’s in progress:-ENDARI
HIC3A1AA1BA1CA2AHIC3 DESCRIPTIONDIGITALIS GLYCOSIDESXANTHINESINOTROPIC DRUGSANTIARRHYTHMICSLABEL NAMEDIGOXIN 0.05 MG/ML SOLUTIONGeneric nameDIGOXINMEDICAID MIN AGE0MEDICAID MAX AGE999CLINICAL PA REQUIREDNoDIGOXIN 0.25 MG TABLETDIGOXIN0999NoDIGOXIN 125 MCG TABLETDIGOXIN0999NoDIGOXIN 250 MCG TABLETDIGOXIN0999NoCAFFEINE CIT 60 MG/3 ML ORALCAFFEINE CITRATE1999NoCAFFEINE CIT 60 MG/3 ML VIALCAFFEINE CITRATE1999NoTHEO-24 ER 100 MG CAPSULETHEOPHYLLINE ANHYDROUS0999NoTHEO-24 ER 200 MG CAPSULETHEOPHYLLINE ANHYDROUS0999NoTHEO-24 ER 300 MG CAPSULETHEOPHYLLINE ANHYDROUS0999NoTHEO-24 ER 400 MG CAPSULETHEOPHYLLINE ANHYDROUS0999NoTHEOPHYLLINE 80 MG/15 ML SOLNTHEOPHYLLINE ANHYDROUS0999NoTHEOPHYLLINE ER 300 MG TABTHEOPHYLLINE ANHYDROUS0999NoTHEOPHYLLINE ER 400 MG TABLETTHEOPHYLLINE ANHYDROUS0999NoTHEOPHYLLINE ER 450 MG TABTHEOPHYLLINE ANHYDROUS0999NoTHEOPHYLLINE ER 600 MG TABLETTHEOPHYLLINE ANHYDROUS0999NoDOBUTAMINE 1,000 MG/250 ML D5WDOBUTAMINE HCL IN DEXTROSE 5 %0999NoDOBUTAMINE 250 MG/20 ML VIALDOBUTAMINE HCL0999NoDOBUTAMINE 250 MG/250 ML-D5WDOBUTAMINE HCL IN DEXTROSE 5 %0999NoDOBUTAMINE 500 MG/250 ML D5WDOBUTAMINE HCL IN DEXTROSE 5 %0999NoMILRINONE LACT 10 MG/10 ML VLMILRINONE LACTATE0999NoMILRINONE LACT 20 MG/20 ML VLMILRINONE LACTATE0999NoMILRINONE LACT 50 MG/50 ML VLMILRINONE LACTATE0999NoMILRINONE-D5W 20 MG/100 MLMILRINONE LACTATE/D5W0999NoMILRINONE-D5W 40 MG/200 MLMILRINONE LACTATE/D5W0999NoAMIODARONE HCL 100 MG TABLETAMIODARONE HCL0999NoAMIODARONE HCL 200 MG TABLETAMIODARONE HCL0999NoDOFETILIDE 125 MCG CAPSULEDOFETILIDE0999Requires Med Cert 3DOFETILIDE 250 MCG CAPSULEDOFETILIDE0999Requires Med Cert 3DOFETILIDE 500 MCG CAPSULEDOFETILIDE0999Requires Med Cert 3Page 2 of 147
HIC3A2AA2CA4AA4BHIC3 DESCRIPTIONANTIARRHYTHMICSANTIANGINAL, ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMICANTIHYPERTENSIVES, VASODILATORSANTIHYPERTENSIVES, SYMPATHOLYTICLABEL NAMEFLECAINIDE ACETATE 100 MG TABGeneric nameFLECAINIDE ACETATEMEDICAID MIN AGE0MEDICAID MAX AGE999CLINICAL PA REQUIREDNoFLECAINIDE ACETATE 150 MG TABFLECAINIDE ACETATE0999NoFLECAINIDE ACETATE 50 MG TABFLECAINIDE ACETATE0999NoMEXILETINE 150 MG CAPSULEMEXILETINE HCL0999NoMEXILETINE 200 MG CAPSULEMEXILETINE HCL0999NoMEXILETINE 250 MG CAPSULEMEXILETINE HCL0999NoPROPAFENONE HCL 150 MG TABLETPROPAFENONE HCL0999NoPROPAFENONE HCL 225 MG TABPROPAFENONE HCL0999NoPROPAFENONE HCL 300 MG TABPROPAFENONE HCL0999NoQUINIDINE SULFATE 200 MG TABQUINIDINE SULFATE0999NoQUINIDINE SULFATE 300 MG TABQUINIDINE SULFATE0999NoRANOLAZINE ER 1,000 MG TABLETRANOLAZINE0999NoRANOLAZINE ER 500 MG TABLETRANOLAZINE0999NoHYDRALAZINE 10 MG TABLETHYDRALAZINE HCL0999NoHYDRALAZINE 100 MG TABLETHYDRALAZINE HCL0999NoHYDRALAZINE 25 MG TABLETHYDRALAZINE HCL0999NoHYDRALAZINE 50 MG TABLETHYDRALAZINE HCL0999NoMINOXIDIL 10 MG TABLETMINOXIDIL0999NoMINOXIDIL 2.5 MG TABLETMINOXIDIL0999NoCLONIDINE 0.1 MG/DAY PATCHCLONIDINE0999NoCLONIDINE 0.2 MG/DAY PATCHCLONIDINE0999NoCLONIDINE 0.3 MG/DAY PATCHCLONIDINE0999NoCLONIDINE HCL 0.1 MG TABLETCLONIDINE HCL0999NoCLONIDINE HCL 0.2 MG TABLETCLONIDINE HCL0999NoCLONIDINE HCL 0.3 MG TABLETCLONIDINE HCL0999NoGUANFACINE 1 MG TABLETGUANFACINE HCL0999NoGUANFACINE 2 MG TABLETGUANFACINE HCL0999NoMETHYLDOPA 250 MG TABLETMETHYLDOPA0999NoMETHYLDOPA 500 MG TABLETMETHYLDOPA0999NoPage 3 of 147
HIC3A4DA4FHIC3 DESCRIPTIONANTIHYPERTENSIVES, ACE INHIBITORSANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONISTLABEL NAMEBENAZEPRIL HCL 10 MG TABLETGeneric nameBENAZEPRIL HCLMEDICAID MIN AGE0MEDICAID MAX AGE999CLINICAL PA REQUIREDNoBENAZEPRIL HCL 20 MG TABLETBENAZEPRIL HCL0999NoBENAZEPRIL HCL 40 MG TABLETBENAZEPRIL HCL0999NoBENAZEPRIL HCL 5 MG TABLETBENAZEPRIL HCL0999NoENALAPRIL MALEATE 10 MG TABENALAPRIL MALEATE0999NoENALAPRIL MALEATE 2.5 MG TABENALAPRIL MALEATE0999NoENALAPRIL MALEATE 20 MG TABENALAPRIL MALEATE0999NoENALAPRIL MALEATE 5 MG TABLETENALAPRIL MALEATE0999NoFOSINOPRIL SODIUM 10 MG TABFOSINOPRIL SODIUM0999NoFOSINOPRIL SODIUM 20 MG TABFOSINOPRIL SODIUM0999NoFOSINOPRIL SODIUM 40 MG TABFOSINOPRIL SODIUM0999NoLISINOPRIL 10 MG TABLETLISINOPRIL0999NoLISINOPRIL 2.5 MG TABLETLISINOPRIL0999NoLISINOPRIL 20 MG TABLETLISINOPRIL0999NoLISINOPRIL 30 MG TABLETLISINOPRIL0999NoLISINOPRIL 40 MG TABLETLISINOPRIL0999NoLISINOPRIL 5 MG TABLETLISINOPRIL0999NoQUINAPRIL 10 MG TABLETQUINAPRIL HCL0999NoQUINAPRIL 20 MG TABLETQUINAPRIL HCL0999NoQUINAPRIL 40 MG TABLETQUINAPRIL HCL0999NoQUINAPRIL 5 MG TABLETQUINAPRIL HCL0999NoRAMIPRIL 1.25 MG CAPSULERAMIPRIL0999NoRAMIPRIL 10 MG CAPSULERAMIPRIL0999NoRAMIPRIL 2.5 MG CAPSULERAMIPRIL0999NoRAMIPRIL 5 MG CAPSULERAMIPRIL0999NoIRBESARTAN 150 MG TABLETIRBESARTAN0999NoIRBESARTAN 300 MG TABLETIRBESARTAN0999NoIRBESARTAN 75 MG TABLETIRBESARTAN0999NoLOSARTAN POTASSIUM 100 MG TABLOSARTAN POTASSIUM0999NoPage 4 of 147
HIC3A4FA4HA4IHIC3 DESCRIPTIONANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONISTANGIOTENSIN RECEPTOR BLOCKR-CALCIUM CHANNEL BLOCKRANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMBLABEL NAMELOSARTAN POTASSIUM 25 MG TABGeneric nameLOSARTAN POTASSIUMMEDICAID MIN AGE0MEDICAID MAX AGE999CLINICAL PA REQUIREDNoLOSARTAN POTASSIUM 50 MG TABLOSARTAN POTASSIUM0999NoOLMESARTAN MEDOXOMIL 20 MG TABOLMESARTAN MEDOXOMIL0999NoOLMESARTAN MEDOXOMIL 40 MG TABOLMESARTAN MEDOXOMIL0999NoOLMESARTAN MEDOXOMIL 5 MG TABOLMESARTAN MEDOXOMIL0999NoVALSARTAN 160 MG TABLETVALSARTAN1999NoVALSARTAN 320 MG TABLETVALSARTAN1999NoVALSARTAN 40 MG TABLETVALSARTAN1999NoVALSARTAN 80 MG TABLETVALSARTAN1999NoAMLODIPINE-OLMESARTAN 10-20 MGAMLODIPINE BES/OLMESARTAN MED0999NoAMLODIPINE-OLMESARTAN 10-40 MGAMLODIPINE BES/OLMESARTAN MED0999NoAMLODIPINE-OLMESARTAN 5-20 MGAMLODIPINE BES/OLMESARTAN MED0999NoAMLODIPINE-OLMESARTAN 5-40 MGAMLODIPINE BES/OLMESARTAN MED0999NoAMLODIPINE-VALSARTAN 10-160 MGAMLODIPINE BESYLATE/VALSARTAN0999NoAMLODIPINE-VALSARTAN 10-320 MGAMLODIPINE BESYLATE/VALSARTAN0999NoAMLODIPINE-VALSARTAN 5-160 MGAMLODIPINE BESYLATE/VALSARTAN0999NoAMLODIPINE-VALSARTAN 5-320 MGAMLODIPINE BESYLATE/VALSARTAN0999NoIRBESARTAN-HCTZ 150-12.5 MG CTZ 300-12.5 MG Z 100-12.5 MG TABLOSARTAN/HYDROCHLOROTHIAZIDE0999NoLOSARTAN-HCTZ 100-25 MG TABLOSARTAN/HYDROCHLOROTHIAZIDE0999NoLOSARTAN-HCTZ 50-12.5 MG TZ 20-12.5 MG HCTZ 40-12.5 MG HCTZ 40-25 MG CTZ 160-12.5 MG TZ 160-25 MG TZ 320-12.5 MG TZ 320-25 MG TABVALSARTAN/HYDROCHLOROTHIAZIDE0999NoPage 5 of 147
HIC3A4IA4JA4KA4LA7BHIC3 DESCRIPTIONANGIOTENSIN RECEPTOR ANTAG.-THIAZIDE DIURETIC COMBACE INHIBITOR-THIAZIDE OR THIAZIDE-LIKE DIURETICACE INHIBITOR-CALCIUM CHANNEL BLOCKER COMBINATIONANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI)VASODILATORS,CORONARYLABEL NAMEVALSARTAN-HCTZ 80-12.5 MG TABGeneric nameVALSARTAN/HYDROCHLOROTHIAZIDEMEDICAID MIN AGE0MEDICAID MAX AGE999CLINICAL PA REQUIREDNoENALAPRIL-HCTZ 10-25 MG -HCTZ 5-12.5 MG CTZ 10-12.5 MG HCTZ 20-12.5 MG HCTZ 20-25 MG BENAZEPRIL 10-20 MGAMLODIPINE BESYLATE/BENAZEPRIL0999NoAMLODIPINE-BENAZEPRIL 10-40 MGAMLODIPINE BESYLATE/BENAZEPRIL0999NoAMLODIPINE-BENAZEPRIL 2.5-10AMLODIPINE BESYLATE/BENAZEPRIL0999NoAMLODIPINE-BENAZEPRIL 5-10 MGAMLODIPINE BESYLATE/BENAZEPRIL0999NoAMLODIPINE-BENAZEPRIL 5-20 MGAMLODIPINE BESYLATE/BENAZEPRIL0999NoAMLODIPINE-BENAZEPRIL 5-40 MGAMLODIPINE BESYLATE/BENAZEPRIL0999NoENTRESTO 24 MG-26 MG TABLETSACUBITRIL/VALSARTAN0999NoENTRESTO 49 MG-51 MG TABLETSACUBITRIL/VALSARTAN0999NoENTRESTO 97 MG-103 MG TABLETSACUBITRIL/VALSARTAN0999NoISOSORBIDE DINITRATE 10 MG TABISOSORBIDE DINITRATE0999NoISOSORBIDE DINITRATE 20 MG TABISOSORBIDE DINITRATE0999NoISOSORBIDE DINITRATE 30 MG TABISOSORBIDE DINITRATE0999NoISOSORBIDE DINITRATE 40 MG TABISOSORBIDE DINITRATE0999NoISOSORBIDE DINITRATE 5 MG TABISOSORBIDE DINITRATE0999NoISOSORBIDE MONONIT 10 MG TABISOSORBIDE MONONITRATE0999NoISOSORBIDE MONONIT 20 MG TABISOSORBIDE MONONITRATE0999NoISOSORBIDE MONONIT ER 120 MGISOSORBIDE MONONITRATE0999NoISOSORBIDE MONONIT ER 30 MG TBISOSORBIDE MONONITRATE0999NoISOSORBIDE MONONIT ER 60 MG TBISOSORBIDE MONONITRATE0999NoNITROGLYCERIN 0.1 MG/HR PATCHNITROGLYCERIN0999NoNITROGLYCERIN 0.2 MG/HR PATCHNITROGLYCERIN0999NoNITROGLYCERIN 0.3 MG TABLET SLNITROGLYCERIN0999NoNITROGLYCERIN 0.4 MG TABLET SLNITROGLYCERIN0999NoPage 6 of 147
HIC3A7BHIC3 DESCRIPTIONVASODILATORS,CORONARYLABEL NAMENITROGLYCERIN 0.4 MG/HR PATCHGeneric nameNITROGLYCERINMEDICAID MIN AGE0MEDICAID MAX AGE999CLINICAL PA REQUIREDNoNITROGLYCERIN 0.6 MG TABLET SLNITROGLYCERIN0999NoNITROGLYCERIN 0.6 MG/HR PATCHNITROGLYCERIN0999NoA7MBRADYKININ B2 RECEPTOR ANTAGONISTSFIRAZYR 30 MG/3 ML SYRINGEICATIBANT ACETATE18999Auto PAA9ACALCIUM CHANNEL BLOCKING AGENTSAMLODIPINE BESYLATE 10 MG TABAMLODIPINE BESYLATE0999NoAMLODIPINE BESYLATE 2.5 MG TABAMLODIPINE BESYLATE0999NoAMLODIPINE BESYLATE 5 MG TABAMLODIPINE BESYLATE0999NoDILTIAZEM 120 MG TABLETDILTIAZEM HCL0999NoDILTIAZEM 12HR ER 120 MG CAPDILTIAZEM HCL0999NoDILTIAZEM 12HR ER 60 MG CAPDILTIAZEM HCL0999NoDILTIAZEM 12HR ER 90 MG CAPDILTIAZEM HCL0999NoDILTIAZEM 24H ER(CD) 120 MG CPDILTIAZEM HCL0999NoDILTIAZEM 24H ER(CD) 180 MG CPDILTIAZEM HCL0999NoDILTIAZEM 24H ER(CD) 240 MG CPDILTIAZEM HCL0999NoDILTIAZEM 24H ER(CD) 300 MG CPDILTIAZEM HCL0999NoDILTIAZEM 24H ER(CD) 360 MG CPDILTIAZEM HCL0999NoDILTIAZEM 24H ER(XR) 120 MG CPDILTIAZEM HCL0999NoDILTIAZEM 24H ER(XR) 180 MG CPDILTIAZEM HCL0999NoDILTIAZEM 24H ER(XR) 240 MG CPDILTIAZEM HCL0999NoDILTIAZEM 24HR ER 120 MG CAPDILTIAZEM HCL0999NoDILTIAZEM 24HR ER 180 MG CAPDILTIAZEM HCL0999NoDILTIAZEM 24HR ER 240 MG CAPDILTIAZEM HCL0999NoDILTIAZEM 24HR ER 300 MG CAPDILTIAZEM HCL0999NoDILTIAZEM 24HR ER 360 MG CAPDILTIAZEM HCL0999NoDILTIAZEM 24HR ER 420 MG CAPDILTIAZEM HCL0999NoDILTIAZEM 30 MG TABLETDILTIAZEM HCL0999NoDILTIAZEM 60 MG TABLETDILTIAZEM HCL0999NoDILTIAZEM 90 MG TABLETDILTIAZEM HCL0999NoFELODIPINE ER 10 MG TABLETFELODIPINE0999NoPage 7 of 147
HIC3A9AB0AB0DB1BHIC3 DESCRIPTIONCALCIUM CHANNEL BLOCKING AGENTSGENERAL INHALATION AGENTSPULMONARY FIBROSIS - SYSTEMIC ENZYME INHIBITORSPULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONISTLABEL NAMEFELODIPINE ER 2.5 MG TABLETGeneric nameFELODIPINEMEDICAID MIN AGE0MEDICAID MAX AGE999CLINICAL PA REQUIREDNoFELODIPINE ER 5 MG TABLETFELODIPINE0999NoNIFEDIPINE 10 MG CAPSULENIFEDIPINE0999NoNIFEDIPINE 20 MG CAPSULENIFEDIPINE0999NoNIFEDIPINE ER 30 MG TABLETNIFEDIPINE0999NoNIFEDIPINE ER 60 MG TABLETNIFEDIPINE0999NoNIFEDIPINE ER 90 MG TABLETNIFEDIPINE0999NoNIMODIPINE 30 MG CAPSULENIMODIPINE18999NoVERAPAMIL 120 MG TABLETVERAPAMIL HCL0999NoVERAPAMIL 40 MG TABLETVERAPAMIL HCL0999NoVERAPAMIL 80 MG TABLETVERAPAMIL HCL0999NoVERAPAMIL ER 120 MG CAPSULEVERAPAMIL HCL0999NoVERAPAMIL ER 120 MG TABLETVERAPAMIL HCL0999NoVERAPAMIL ER 180 MG CAPSULEVERAPAMIL HCL0999NoVERAPAMIL ER 180 MG TABLETVERAPAMIL HCL0999NoVERAPAMIL ER 240 MG CAPSULEVERAPAMIL HCL0999NoVERAPAMIL ER 240 MG TABLETVERAPAMIL HCL0999NoVERAPAMIL SR 120 MG CAPSULEVERAPAMIL HCL0999NoVERAPAMIL SR 180 MG CAPSULEVERAPAMIL HCL0999NoVERAPAMIL SR 240 MG CAPSULEVERAPAMIL HCL0999NoVERAPAMIL SR 360 MG CAPSULEVERAPAMIL HCL0999NoSODIUM CHLORIDE 0.9% INHAL VLSODIUM CHLORIDE FOR INHALATION0999NoSODIUM CHLORIDE 10% VIALSODIUM CHLORIDE FOR INHALATION0999Auto PAOFEV 100 MG CAPSULENINTEDANIB ESYLATE0999Clinical PA RequiredOFEV 150 MG CAPSULENINTEDANIB ESYLATE0999Clinical PA RequiredAMBRISENTAN 10 MG TABLETAMBRISENTAN0999Clinical PA RequiredAMBRISENTAN 5 MG TABLETAMBRISENTAN0999Clinical PA RequiredTRACLEER 125 MG TABLETBOSENTAN0999Clinical PA RequiredTRACLEER 62.5 MG TABLETBOSENTAN0999Clinical PA RequiredPage 8 of 147
HIC3B1CHIC3 DESCRIPTIONPULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPELABEL NAMEEPOPROSTENOL SODIUM 0.5 MG VLMEDICAID MIN AGE0MEDICAID MAX AGE999CLINICAL PA REQUIREDNoEPOPROSTENOL SODIUM (GLYCINE)0999NoEPOPROSTENOL SODIUM0999NoEPOPROSTENOL SODIUM (GLYCINE)0999NoVENTAVIS 10 MCG/1 ML SOLUTIONILOPROST TROMETHAMINE0999Clinical PA RequiredVENTAVIS 20 MCG/1 ML SOLUTIONILOPROST TROMETHAMINE0999Clinical PA RequiredSILDENAFIL 10 MG/ML ORAL SUSPSILDENAFIL CITRATE0999Clinical PA RequiredSILDENAFIL 20 MG TABLETSILDENAFIL CITRATE0999Clinical PA RequiredTADALAFIL 20 MG TABLETTADALAFIL0999Clinical PA RequiredACETYLCYSTEINE 10% VIALACETYLCYSTEINE0999NoACETYLCYSTEINE 20% VIALACETYLCYSTEINE0999NoPULMOZYME 1 MG/ML AMPULDORNASE ALFA065Auto PACHEST CONGEST RLF 400 MG TABGUAIFENESIN020NoCHEST CONGESTION RELIEF SOLNGUAIFENESIN020NoGNP MUCUS-ER MAX 1,200 MG TABGUAIFENESIN020NoGS TUSSIN MUCUS-CONG 100 MG/5GUAIFENESIN020NoGS TUSSIN MUCUS-CONG 200 MG/10GUAIFENESIN020NoGUAIFENESIN 100 MG/5 ML SOLNGUAIFENESIN020NoGUAIFENESIN 200 MG/10 ML SOLNGUAIFENESIN020NoGUAIFENESIN 300 MG/15 ML SOLNGUAIFENESIN020NoGUAIFENESIN ER 600 MG TABLETGUAIFENESIN020NoHM ADULT TUSSIN CHEST CONG LIQGUAIFENESIN020NoHM CHEST CONGEST RLF 400 MG TBGUAIFENESIN020NoHM MUCUS RELIEF ER 1,200 MG TBGUAIFENESIN020NoHM MUCUS RELIEF ER 600 MG TABGUAIFENESIN020NoLIQUITUSS GG 200 MG/5 ML LIQGUAIFENESIN020NoMUCINEX ER 1,200 MG TABLETGUAIFENESIN020NoMUCINEX ER 600 MG TABLETGUAIFENESIN020NoMUCOSA 400 MG TABLETGUAIFENESIN020NoEPOPROSTENOL SODIUM 1.5 MG VLB1DB3AB3JPULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIBMUCOLYTICSEXPECTORANTSGeneric nameEPOPROSTENOL SODIUMPage 9 of 147
HIC3B3JHIC3 DESCRIPTIONEXPECTORANTSLABEL NAMEMUCUS ER 600 MG TABLETGeneric nameGUAIFENESINMEDICAID MIN AGE0MEDICAID MAX AGE20CLINICAL PA REQUIREDNoMUCUS RELIEF 400 MG TABLETGUAIFENESIN020NoMUCUS RELIEF ER 1,200 MG TABGUAIFENESIN020NoMUCUS RELIEF ER 600 MG TABLETGUAIFENESIN020NoMUCUS-CHEST CONG 200 MG/10 MLGUAIFENESIN020NoQC MUCUS RELIEF 400 MG CAPLETGUAIFENESIN020NoQC MUCUS RELIEF ER 1,200 MG TBGUAIFENESIN020NoQC MUCUS RELIEF ER 600 MG TABGUAIFENESIN020NoQC TUSSIN MUCUS-CONG 200 MG/10GUAIFENESIN020NoROBAFEN 200 MG/10 ML SYRUPGUAIFENESIN020NoSILTUSSIN SA 100 MG/5 ML SYRGUAIFENESIN020NoSM CHEST CONGESTION 400MG CPLTGUAIFENESIN020NoSM MUCUS RELIEF ER 600 MG TABGUAIFENESIN020NoSM MUCUS-ER MAX 1,200 MG TABGUAIFENESIN020NoSM TUSSIN MUCUS-CONG 200 MG/10GUAIFENESIN020NoTUSNEL-EX 100 MG/5 ML LIQUIDGUAIFENESIN0999NoTUSSIN 400 MG TABLETGUAIFENESIN020NoTUSSIN MUCUS-CONG 200 MG/10GUAIFENESIN020NoB3RNON-OPIOID ANTITUS-1ST GEN.ANTIHISTAMINE-DECONGESTBROMPHEN-PSE-DM 2-30-10 IOID ANTITUSSIVE AND EXPECTORANT COMBINATIONCHEST CONG RLF DM 400-20 MG TBGUAIFENESIN/DEXTROMETHORPHAN020NoCHEST CONGESTION RELIEF DM LIQGUAIFENESIN/DEXTROMETHORPHAN020NoCHILD MUCINEX FREEFROM DAY CGHGUAIFENESIN/DEXTROMETHORPHAN020NoCHILD MUCUS-COUGH 5-100 MG/5MLGUAIFENESIN/DEXTROMETHORPHAN020NoCHILD MUCUS-COUGH RELIEF LIQGUAIFENESIN/DEXTROMETHORPHAN020NoCOUGH DM SYRUPGUAIFENESIN/DEXTROMETHORPHAN020NoGNP MUCUS DM MAX ER 1200-60 MGGUAIFENESIN/DEXTROMETHORPHAN020NoGNP MUCUS RELIEF DM MAX LIQUIDGUAIFENESIN/DEXTROMETHORPHAN020NoGNP TUSSIN DM MAX LIQUIDGUAIFENESIN/DEXTROMETHORPHAN020NoGS TUSSIN DM MAX LIQUIDGUAIFENESIN/DEXTROMETHORPHAN020NoPage 10 of 147
HIC3B3TB4CHIC3 DESCRIPTIONNON-OPIOID ANTITUSSIVE AND EXPECTORANT COMBINATIONOPIOID ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONSLABEL NAMEGUAIFENESIN DM SYRUPGeneric nameGUAIFENESIN/DEXTROMETHORPHANMEDICAID MIN AGE0MEDICAID MAX AGE20CLINICAL PA REQUIREDNoGUAIFENESIN-DM 100-10 MG/5 MLGUAIFENESIN/DEXTROMETHORPHAN020NoGUAIFENESIN-DM 200-20 MG/10 MLGUAIFENESIN/DEXTROMETHORPHAN020NoGUAIFENESIN-DM ER 1,200-60 MGGUAIFENESIN/DEXTROMETHORPHAN020NoHM ADT TUSSIN COUGH CONG DM LQGUAIFENESIN/DEXTROMETHORPHAN020NoHM MUCUS DM MAX ER 1200-60 MGGUAIFENESIN/DEXTROMETHORPHAN020NoHM TUSSIN DM 400-20 MG/20 MLGUAIFENESIN/DEXTROMETHORPHAN020NoMUCINEX DM ER 1,200-60 MG TABGUAIFENESIN/DEXTROMETHORPHAN020NoMUCUS DM MAX ER 1,200-60 MG TBGUAIFENESIN/DEXTROMETHORPHAN020NoMUCUS RELIEF DM 20-400 MG TABGUAIFENESIN/DEXTROMETHORPHAN020NoMUCUS RELIEF DM COUGH TABLETGUAIFENESIN/DEXTROMETHORPHAN020NoMUCUS RELIEF DM MAX LIQUIDGUAIFENESIN/DEXTROMETHORPHAN020NoMUCUS RLF DM MAX ER 1200-60 MGGUAIFENESIN/DEXTROMETHORPHAN020NoROBAFEN DM COUGH LIQUIDGUAIFENESIN/DEXTROMETHORPHAN020NoSM TUSSIN DM 400-20 MG/20 MLGUAIFENESIN/DEXTROMETHORPHAN020NoTUSNEL DIABETIC LIQUIDGUAIFENESIN/DEXTROMETHORPHAN020NoTUSSIN DM 400-20 MG/20 ML LIQGUAIFENESIN/DEXTROMETHORPHAN020NoTUSSIN DM LIQUIDGUAIFENESIN/DEXTROMETHORPHAN020NoHYCODAN 5 MG-1.5 MG TABLETHYDROCODONE BIT/HOMATROP ME-BR1820NoHYDROCODONE-HOMATROPINE SOLNHYDROCODONE BIT/HOMATROP ME-BR1820NoHYDROCODONE-HOMATROPINE SYRUPHYDROCODONE BIT/HOMATROP ME-BR1820NoB4ENON-OPIOID ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB.PROMETHAZINE-DM 6.25-15 LINERGICS, ORALLY INHALED SHORT ACTINGATROVENT 17 MCG HFA INHALERIPRATROPIUM BROMIDE0999NoIPRATROPIUM BR 0.02% SOLNIPRATROPIUM BROMIDE0999NoSPIRIVA 18 MCG CP-HANDIHALERTIOTROPIUM BROMIDE18999NoSPIRIVA RESPIMAT 1.25 MCG INHTIOTROPIUM BROMIDE6999NoSPIRIVA RESPIMAT 2.5 MCG INHTIOTROPIUM BROMIDE6999NoANORO ELLIPTA 62.5-25 MCG INHUMECLIDINIUM BRM/VILANTEROL TR18999NoCOMBIVENT RESPIMAT 20-100 MCGIPRATROPIUM/ALBUTEROL SULFATE0999NoB61B62ANTICHOLINERGICS, ORALLY INHALED LONG ACTINGBETA-ADRENERGIC AND ANTICHOLINERGIC COMBO, INHALEDPage 11 of 147
HIC3B62B63B6MB6WHIC3 DESCRIPTIONBETA-ADRENERGIC AND ANTICHOLINERGIC COMBO, INHALEDBETA-ADRENERGIC AND GLUCOCORTICOID COMBO, INHALEDGLUCOCORTICOIDS, ORALLY INHALEDBETA-ADRENERGIC AGENTS, INHALED, SHORT ACTINGLABEL NAMEIPRAT-ALBUT 0.5-3(2.5) MG/3 MLGeneric nameIPRATROPIUM/ALBUTEROL SULFATEMEDICAID MIN AGE0MEDICAID MAX AGE999CLINICAL PA REQUIREDNoSTIOLTO RESPIMAT INHAL SPRAYTIOTROPIUM BR/OLODATEROL HCL0999NoADVAIR 100-50 DISKUSFLUTICASONE PROPION/SALMETEROL4999NoADVAIR 250-50 DISKUSFLUTICASONE PROPION/SALMETEROL4999NoADVAIR 500-50 DISKUSFLUTICASONE PROPION/SALMETEROL4999NoADVAIR HFA 115-21 MCG INHALERFLUTICASONE PROPION/SALMETEROL5999NoADVAIR HFA 230-21 MCG INHALERFLUTICASONE PROPION/SALMETEROL5999NoADVAIR HFA 45-21 MCG INHALERFLUTICASONE PROPION/SALMETEROL5999NoDULERA 100 MCG-5 MCG INHALERMOMETASONE/FORMOTEROL5999NoDULERA 200 MCG-5 MCG INHALERMOMETASONE/FORMOTEROL5999NoDULERA 50 MCG-5 MCG INHALERMOMETASONE/FORMOTEROL5999NoSYMBICORT 160-4.5 MCG INHALERBUDESONIDE/FORMOTEROL FUMARATE5999NoSYMBICORT 80-4.5 MCG INHALERBUDESONIDE/FORMOTEROL FUMARATE5999NoALVESCO 160 MCG INHALERCICLESONIDE5999NoALVESCO 80 MCG INHALERCICLESONIDE5999NoASMANEX TWISTHALER 110 MCG #30MOMETASONE FUROATE4999NoASMANEX TWISTHALER 220 MCG #14MOMETASONE FUROATE4999NoASMANEX TWISTHALER 220 MCG #30MOMETASONE FUROATE4999NoASMANEX TWISTHALER 220 MCG #60MOMETASONE FUROATE4999NoASMANEX TWISTHALR 220 MCG #120MOMETASONE FUROATE4999NoBUDESONIDE 0.25 MG/2 ML SUSPBUDESONIDE18NoBUDESONIDE 0.5 MG/2 ML SUSPBUDESONIDE18NoBUDESONIDE 1 MG/2 ML INH SUSPBUDESONIDE18NoFLOVENT HFA 110 MCG INHALERFLUTICASONE PROPIONATE0999NoFLOVENT HFA 220 MCG INHALERFLUTICASONE PROPIONATE0999NoFLOVENT HFA 44 MCG INHALERFLUTICASONE PROPIONATE0999NoPULMICORT 180 MCG FLEXHALERBUDESONIDE5999NoPULMICORT 90 MCG FLEXHALERBUDESONIDE5999NoALBUTEROL 2.5 MG/0.5 ML SOLALBUTEROL SULFATE0999NoPage 12 of 147
HIC3HIC3 DESCRIPTIONB6WBETA-ADRENERGIC AGENTS, INHALED, SHORT ACTINGLABEL NAMEALBUTEROL 5 MG/ML SOLUTIONGeneric nameALBUTEROL SULFATEMEDICAID MIN AGE0MEDICAID MAX AGE999CLINICAL PA REQUIREDNoALBUTEROL SUL 0.63 MG/3 ML SOLALBUTEROL SULFATE0999NoALBUTEROL SUL 1.25 MG/3 ML SOLALBUTEROL SULFATE0999NoALBUTEROL SUL 2.5 MG/3 ML SOLNALBUTEROL SULFATE0999NoPROAIR HFA 90 MCG INHALERALBUTEROL SULFATE0999NoVENTOLIN HFA 90 MCG INHALERALBUTEROL SULFATE0999NoB6YBETA-ADRENERGIC AGENTS, ORALLY INHALED,LONG ACTINGSEREVENT DISKUS 50 MCGSALMETEROL XINAFOATE4999NoC0BWATERBACTERIOSTATIC WATER VIALWATER FOR RABEN0999NoSTERILE WATER (GRIFOLS FACTOR)WATER FOR INJECTION,STERILE0999NoSTERILE WATER FOR ACTIVASEWATER FOR INJECTION,STERILE0999NoSTERILE WATER FOR BERINERTWATER FOR INJECTION,STERILE0999NoSTERILE WATER FOR GAMMAGARDWATER FOR INJECTION,STERILE0999NoSTERILE WATER FOR HUMATE-PWATER FOR INJECTION,STERILE0999NoSTERILE WATER FOR IC-GREEN AMPWATER FOR INJECTION,STERILE0999NoSTERILE WATER FOR INJECTIONWATER FOR INJECTION,STERILE0999NoSTERILE WATER FOR KCENTRAWATER FOR INJECTION,STERILE0999NoSTERILE WATER FOR TNKASE VIALWATER FOR INJECTION,STERILE0999NoSTERILE WATER FOR ZEMAIRA VIALWATER FOR INJECTION,STERILE0999NoWATER FOR INJECTION VIALWATER FOR INJECTION,STERILE0999NoACAMPROSATE CALC DR 333 MG TABACAMPROSATE CALCIUM0999NoDISULFIRAM 250 MG TABLETDISULFIRAM0999NoDISULFIRAM 500 MG TABLETDISULFIRAM0999NoVIVITROL 380 MG VIALNALTREXONE MICROSPHERES18999Auto PAVIVITROL 380 MG VIAL-DILUENTNALTREXONE MICROSPHERES18999Auto PASODIUM ACETATE 100 MEQ/50 MLSODIUM ACETATE0999NoSODIUM ACETATE 200 MEQ/100 MLSODIUM ACETATE0999NoSODIUM ACETATE 40 MEQ/20 ML VLSODIUM ACETATE0999NoSODIUM ACETATE 400 MEQ/100 MLSODIUM ACETATE0999NoC0DC0KANTI-ALCOHOLIC PREPARATIONSBICARBONATE PRODUCING/CONTAINING AGENTSPage 13 of 147
HIC3C0KC1AC1BHIC3 DESCRIPTIONBICARBONATE PRODUCING/CONTAINING AGENTSELECTROLYTE DEPLETERSSODIUM/SALINE PREPARATIONSLABEL NAMESODIUM BICARBONATE 4.2% VIALGeneric nameSODIUM BICARBONATEMEDICAID MIN AGE0MEDICAID MAX AGE999CLINICAL PA REQUIREDNoSODIUM BICARBONATE 8.4% VIALSODIUM BICARBONATE0999NoCALCIUM ACETATE 667 MG CAPSULECALCIUM ACETATE0999NoCALCIUM ACETATE 667 MG GELCAPCALCIUM ACETATE0999NoLOKELMA 10 GRAM POWDER PACKETSODIUM ZIRCONIUM CYCLOSILICATE18999NoLOKELMA 5 GRAM POWDER PACKETSODIUM ZIRCONIUM CYCLOSILICATE18999NoRENVELA 0.8 GM POWDER PACKETSEVELAMER CARBONATE011NoRENVELA 2.4 GM POWDER PACKETSEVELAMER CARBONATE011NoSEVELAMER CARBONATE 800 MG TABSEVELAMER CARBONATE0999NoSOD POLYSTYREN SULF 15 G/60 MLSODIUM POLYSTYRENE SULFONATE0999NoSODIUM POLYSTYRENE SULF POWDERSODIUM POLYSTYRENE SULFONATE0999NoSPS 15 GM/60 ML SUSPENSIONSODIUM POLYSTYRENE SULFON/SORB0999NoSPS 30 GM/120 ML ENEMA SUSPSODIUM POLYSTYRENE SULFON/SORB0999NoBACTERIOSTATIC SALINE VIALBACTERIOSTATIC SODIUM CHLORIDE0999NoSALINE 0.45% SOLN-EXCEL CONSODIUM CHLORIDE 0.45 %0999NoSODIUM CHLORIDE 0.45% SOLNSODIUM CHLORIDE 0.45 %0999NoSODIUM CHLORIDE 0.9% 1,000 ML0.9 % SODIUM CHLORIDE0999NoSODIUM CHLORIDE 0.9% 100 ML0.9 % SODIUM CHLORIDE0999NoSODIUM CHLORIDE 0.9% 50 ML0.9 % SODIUM CHLORIDE0999NoSODIUM CHLORIDE 0.9% 500 ML0.9 % SODIUM CHLORIDE0999NoSODIUM CHLORIDE 0.9% SOL-EXCEL0.9 % SODIUM CHLORIDE0999NoSODIUM CHLORIDE 0.9% SOLN0.9 % SODIUM CHLORIDE0999NoSODIUM CHLORIDE 0.9% SOLUTION0.9 % SODIUM CHLORIDE0999NoSODIUM CHLORIDE 0.9% VIAL0.9 % SODIUM CHLORIDE0999NoSODIUM CHLORIDE 100 MEQ/40 MLSODIUM CHLORIDE0999NoSODIUM CHLORIDE 120 MEQ/30 MLSODIUM CHLORIDE0999NoSODIUM CHLORIDE 3% IV SOLNSODIUM CHLORIDE 3 %0999NoSODIUM CHLORIDE 4 MEQ/ML VLSODIUM CHLORIDE0999NoSODIUM CHLORIDE 400 MEQ/100 MLSODIUM CHLORIDE0999NoPage 14 of 147
HIC3C1BC1DHIC3 DESCRIPTIONSODIUM/SALINE PREPARATIONSPOTASSIUM REPLACEMENTLABEL NAMESODIUM CHLORIDE 5% IV SOLNGeneric nameSODIUM CHLORIDE 5 %MEDICAID MIN AGE0MEDICAID MAX AGE999CLINICAL PA REQUIREDNoSODIUM CHLORIDE 50 MEQ/20 MLSODIUM CHLORIDE0999NoD5%-1/2NS-KCL 10 MEQ/L IV SOLPOTASSIUM CHLORIDE/D5-0.45NACL0999NoD5%-1/2NS-KCL 30 MEQ/L IV SOLPOTASSIUM CHLORIDE/D5-0.45NACL0999NoD5%-1/2NS-KCL 40 MEQ/L IV SOLPOTASSIUM CHLORIDE/D5-0.45NACL0999NoD5%-1/4NS-KCL 10 MEQ/L IV SOLPOTASSIUM CHLORIDE/D5-0.2%NACL0999NoD5%-1/4NS-KCL 30 MEQ/L IV SOLPOTASSIUM CHLORIDE/D5-0.2%NACL0999NoD5%-1/4NS-KCL 40 MEQ/L IV SOLPOTASSIUM CHLORIDE/D5-0.2%NACL0999NoD5W-KCL 30 MEQ/L IV SOLUTIONPOTASSIUM CHLORIDE IN D5W0999NoEFFER-K 10 MEQ TABLET EFFPOTASSIUM BICARBONATE/CIT AC0999NoEFFER-K 20 MEQ TABLET EFFPOTASSIUM BICARBONATE/CIT AC0999NoEFFER-K 25 MEQ TABLET EFFPOTASSIUM BICARBONATE/CIT AC0999NoKCL 10 MEQ IN D5W-0.225% NACLPOTASSIUM CHLORIDE/D5-0.2%NACL0999NoKCL 10 MEQ IN D5W-0.3% NACLPOTASSIUM CHLORIDE/D5-0.3%NACL0999NoKCL 10 MEQ/500ML-D5W-0.45%NACLPOTASSIUM CHLORIDE/D5-0.45NACL0999NoKCL 20 MEQ IN D5W-0.2% NACLPOTASSIUM CHLORIDE/D5-0.2%NACL0999NoKCL 20 MEQ IN D5W-0.225% NACLPOTASSIUM CHLORIDE/D5-0.2%NACL0999NoKCL 20 MEQ IN D5W-0.3% NACLPOTASSIUM CHLORIDE/D5-0.3%NACL0999NoKCL 20 MEQ IN D5W-0.45% NACLPOTASSIUM CHLORIDE/D5-0.45NACL0999NoKCL 20 MEQ IN D5W-LACT RINGERPOTASSIUM CHLORIDE IN LR-D50999NoKCL 20 MEQ IN D5W-NSPOTASSIUM CHLORIDE/D5-0.9%NACL0999NoKCL 20 MEQ/L IN D5W SOLUTIONPOTASSIUM CHLORIDE IN D5W0999NoKCL 40 MEQ IN D5W SOLUTIONPOTASSIUM CHLORIDE IN D5W0999NoKCL 40 MEQ IN D5W-LACT RINGERPOTASSIUM CHLORIDE IN LR-D50999NoKCL 40 MEQ IN D5W-NACL 0.9%POTASSIUM CHLORIDE/D5-0.9%NACL0999NoKLOR-CON 10 MEQ TABLETPOTASSIUM CHLORIDE0999NoKLOR-CON 20 MEQ PACKETPOTASSIUM CHLORIDE0999NoKLOR-CON 8 MEQ TABLETPOTASSIUM CHLORIDE0999NoKLOR-CON M10 TABLETPOTASSIUM CHLORIDE0999NoPage 15 of 147
HIC3C1DHIC3 DESCRIPTIONPOTASSIUM REPLACEMENTLABEL NAMEKLOR-CON M15 TABLETGeneric namePOTASSIUM CHLORIDEMEDICAID MIN AGE0MEDICAID MAX AGE999CLINICAL PA REQUIREDNoKLOR-CON M20 TABLETPOTASSIUM CHLORIDE0999NoKLOR-CON-EF 25 MEQ TAB EFFPOTASSIUM BICARBONATE/CIT AC0999NoPOTASSIUM ACET 100 MEQ/50 MLPOTASSIUM ACETATE0999NoPOTASSIUM ACET 200 MEQ/100 MLPOTASSIUM ACETATE0999NoPOTASSIUM ACET 40 MEQ/20 ML VLPOTASSIUM ACETATE0999NoPOTASSIUM CL 10 MEQ/100 ML SOLPOTASSIUM CHLORIDE IN WATER0999NoPOTASSIUM CL 10 MEQ/5 ML CONCPOTASSIUM CHLORIDE0999NoPOTASSIUM CL 10 MEQ/50 ML SOLPOTASSIUM CHLORIDE IN WATER0999NoPOTASSIUM CL 10% (20 MEQ/15ML)POTASSIUM CHLORIDE0999NoPOTASSIUM CL 10% (40 MEQ/30ML)POTASSIUM CHLORIDE0999NoPOTASSIUM CL 2 MEQ/ML CONCPOTASSIUM CHLORIDE0999NoPOTASSIUM CL 20 MEQ PACKETPOTASSIUM CHLORIDE0999NoPOTASSIUM CL 20 MEQ/1,000ML-NSPOTASSIUM CHLORIDE IN 0.9%NACL0999NoPOTASSIUM CL 20 MEQ/10 ML CONCPOTASSIUM CHLORIDE0999NoPOTASSIUM CL 20 MEQ/100 ML SOLPOTASSIUM CHLORIDE IN WATER0999NoPOTASSIUM CL 20 MEQ/50 ML SOLPOTASSIUM CHLORIDE IN WATER0999NoPOTASSIUM CL 20 MEQ-0.45% NACLPOTASSIUM CHLORIDE-0.45% NACL0999NoPOTASSIUM CL 20% (40 MEQ/15ML)POTASSIUM CHLORIDE0999NoPOTASSIUM CL 30 MEQ/100 ML SOLPOTASSIUM CHLORIDE IN WATER0999NoPOTASSIUM CL 40 MEQ/1,000ML-NSPOTASSIUM CHLORIDE IN 0.9%NACL0999NoPOTASSIUM CL 40 MEQ/100 ML SOLPOTASSIUM CHLORIDE IN WATER0999NoPOTASSIUM CL 40 MEQ/20 ML CONCPOTASSIUM CHLORIDE0999NoPOTASSIUM CL 60 MEQ/30 ML CONCPOTASSIUM CHLORIDE0999NoPOTASSIUM CL ER 10 MEQ CAPSULEPOTASSIUM CHLORIDE0999NoPOTASSIUM CL ER 10 MEQ TABLETPOTASSIUM CHLORIDE0999NoPOTASSIUM CL ER 20 MEQ TABLETPOTASSIUM CHLORIDE0999NoPOTASSIUM CL ER 8 MEQ CAPSULEPOTASSIUM CHLORIDE0999NoPOTASSIUM CL ER 8 MEQ TABLETPOTASSIUM CHLORIDE0999NoPage 16 of 147
HIC3C1FHIC3 DESCRIPTIONCALCIUM REPLACEMENTLABEL NAMECALCITRATE 200 MG (950 MG) TABGeneric nameCALCIUM CITRATEMEDICAID MIN AGE0MEDICAID MAX AGE999CLINICAL PA REQUIREDNoCALCIUM D SOFT CHEWABLE TABCALCIUM CARB/VITAMIN D3/VIT K10999Cystic Fib Diag Auto PACALCIUM 250-D TABLETCALCIUM CARBONATE/VITAMIN D30999Cystic Fib Diag Auto PACALCIUM 250-VIT D3 125 TABLETCALCIUM CARBONATE/VITAMIN D30999Cystic Fib Diag Auto PACALCIUM 500 MG CHEWABLE TABLETCALCIUM CARBONATE0999NoCALCIUM CARBONATE/VITAMIN D30999Cystic Fib Diag Auto PACALCIUM 500 MG TABLETCALCIUM CARBONATE0999NoCALCIUM 500 MG-VIT D3 5 MCG TBCALCIUM CARBONATE/VITAMIN D30999Cystic Fib Diag Auto PACALCIUM 500 D TABLET CHEWCALCIUM CARBONATE/VITAMIN D30999Cystic Fib Diag Auto PACALCIUM 500MG-VIT D3 10MCG TABCALCIUM CARBONATE/VITAMIN D30999Cystic Fib Diag Auto PACALCIUM 500MG-VIT D3 15MCG TABCALCIUM CARBONATE/VITAMIN D30999Cystic Fib Diag Auto PACALCIUM 500-VIT D3 10 MCG CHEWCALCIUM CARBONATE/VITAMIN D30999Cystic Fib Diag Auto PACALCIUM 500-VIT D3 125 CAPLETCALCIUM CARBONATE/VITAMIN D30999Cystic Fib Diag Auto PACALCIUM 500-VIT D3 200 CAPLETCALCIUM CARBONATE/VITAMIN D30999Cystic Fib Diag Auto PACALCIUM 500-VIT D3 200 TABLETCALCIUM CARBONATE/VITAMIN D30999Cystic Fib Diag Auto PACALCIUM 500-VIT D3 400 TABLETCALCIUM CARBONATE/VITAMIN D30999Cystic Fib Diag Auto PACALCIUM 500-VIT D3 600 CAPLETCALCIUM CARBONATE/VITAMIN D30999Cystic Fib Diag Auto PACALCIUM 500-VIT D3 600 TABLETCALCIUM CARBONATE/VITAMIN D30999Cystic Fib Diag Auto PACALCIUM 600 MG TABLETCALCIUM CARBONATE0999NoCALCIUM ACETATE 668 MG TABLETCALCIUM ACETATE020NoCALCIUM CARB 1,25
The Florida Medicaid Preferred Drug List (PDL) is subject to revision following consideration and recommendations by the Pharmaceutical and Therapeutics (P&T) Committee and the Agency for Health Care Administration. The quarterly P&T Committee meeting was held on March 25, 2022. This list is in order by the therapeutic classification.
