TETRACYCLINES | Vendor Drug Program

Brand Name/Generic Name	NDC/Manufacturer	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
DOXYCYCLINE 25 MG/5 ML SUSP doxycycline monohydrate	62135041746 CHARTWELL RX LL	No	No	Medicaid CHIP CSHCN
DOXYCYCLINE 25 MG/5 ML SUSP doxycycline monohydrate	68180065701 LUPIN PHARMACEU	No	No	Medicaid CHIP CSHCN KHC
DOXYCYCLINE HYCLATE 100 MG CAP doxycycline hyclate	62332036350 ALEMBIC PHARMAC	No	No	Medicaid CHIP CSHCN HTW
DOXYCYCLINE HYCLATE 100 MG CAP doxycycline hyclate	62332036371 ALEMBIC PHARMAC	No	No	Medicaid CHIP CSHCN HTW
DOXYCYCLINE HYCLATE 100 MG CAP doxycycline hyclate	72578005505 VIONA PHARMACEU	No	No	Medicaid CHIP CSHCN
DOXYCYCLINE HYCLATE 100 MG CAP doxycycline hyclate	72578005518 VIONA PHARMACEU	No	No	Medicaid CHIP CSHCN
DOXYCYCLINE HYCLATE 100 MG CAP doxycycline hyclate	00143314250 WEST-WARD/HIKMA	No	No	Medicaid CHIP CSHCN HTW KHC
DOXYCYCLINE HYCLATE 100 MG CAP doxycycline hyclate	53489011902 SUN PHARMACEUTI	No	No	Medicaid CHIP CSHCN HTW KHC
DOXYCYCLINE HYCLATE 100 MG CAP doxycycline hyclate	53489011905 SUN PHARMACEUTI	No	No	Medicaid CHIP CSHCN HTW KHC
DOXYCYCLINE HYCLATE 100 MG CAP doxycycline hyclate	00904042804 MAJOR PHARMACEU	No	No	Medicaid CHIP CSHCN HTW KHC