Search Results: Formulary Drugs

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Search results: Formulary Drugs
Brand Name/Generic Name	NDC/Manufacturer	PDL Class	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
PREGABALIN 150 MG CAPSULE pregabalin	76282057290 EXELAN PHARMACE	NEUROPATHIC PAIN	No	No	Medicaid, CHIP, CSHCN
ANDROGEL 1% (25 MG/2.5 G) PKT testosterone	00051842530 ABBVIE US LLC	ANDROGENIC AGENTS	No	Yes	Medicaid, CHIP, CSHCN
VIREAD 150 MG TABLET tenofovir disoproxil fumarate	61958040401 GILEAD SCIENCES		No	No	Medicaid, CHIP, CSHCN
LANSOPRAZOLE DR 30 MG CAPSULE lansoprazole	00781214892 SANDOZ	PROTON PUMP INHIBITORS	No	Yes	Medicaid, CHIP, CSHCN
RIZATRIPTAN 5 MG TABLET rizatriptan benzoate	67877026118 ASCEND LABORATO	ANTIMIGRAINE AGENTS: TRIPTANS	No	No	Medicaid, CHIP, CSHCN
METFORMIN HCL 1,000 MG TABLET metformin HCl	65862001099 AUROBINDO PHARM		No	No	Medicaid, CHIP, CSHCN, HTW
DULOXETINE HCL DR 60 MG CAP duloxetine HCl	57237001990 RISING PHARM	NEUROPATHIC PAIN	No	No	Medicaid, CHIP, CSHCN
MERCAPTOPURINE 50 MG TABLET mercaptopurine	69076091302 QUINN PHARMACEU		No	No	Medicaid, CHIP, CSHCN
LEVOTHYROXINE 25 MCG TABLET levothyroxine sodium	68180096501 LUPIN PHARMACEU		No	No	Medicaid, CHIP, CSHCN
ANAGRELIDE HCL 1 MG CAPSULE anagrelide HCl	13668046201 TORRENT PHARMAC		No	No	Medicaid, CHIP, CSHCN
PRAZOSIN 5 MG CAPSULE prazosin HCl	70954002120 NOVITIUM PHARMA		No	No	Medicaid, CHIP, CSHCN
CLOBETASOL 0.05% CREAM clobetasol propionate	50383026715 HI-TECH/AKORN C	STEROIDS: TOPICAL VERY HIGH	No	No	Medicaid, CHIP, CSHCN
GLIMEPIRIDE 2 MG TABLET glimepiride	16729000216 ACCORD HEALTHCA		No	No	Medicaid, CHIP, CSHCN, HTW
CEFEPIME HCL 1 GM VIAL cefepime HCl	25021012120 SAGENT PHARMACE		No	No	Medicaid, CHIP, CSHCN
ADAPALENE-BNZYL PEROX 0.1-2.5% adapalene/benzoyl peroxide	00781718270 SANDOZ	ACNE AGENTS: TOPICAL	No	Yes	Medicaid, CHIP, CSHCN
HEMOFIL M 250 UNIT NOMINAL antihemophilic factor, human	00944394002 BAXALTA US INC.		No	No	Medicaid, CHIP
BUPROPION HCL SR 150 MG TABLET bupropion HCl	00185041501 SANDOZ	ANTIDEPRESSANTS: OTHER	No	No	Medicaid, CHIP, CSHCN, HTW
POTASSIUM CL 20 MEQ PACKET potassium chloride	00603155416 QUALITEST/PAR P		No	No	Medicaid, CHIP, CSHCN
CITALOPRAM HBR 40 MG TABLET citalopram hydrobromide	60505252008 APOTEX CORP	ANTIDEPRESSANTS: SSRIs	No	No	Medicaid, CHIP, CSHCN, HTW
TRACLEER 32 MG TABLET FOR SUSP bosentan	66215010356 ACTELION PHARMA	PAH AGENTS: ORAL AND INHALED	No	Yes	Medicaid, CHIP, CSHCN
ONDANSETRON ODT 4 MG TABLET ondansetron	68001024617 BLUEPOINT LABOR	ANTIEMETIC/ANTIVERTIGO AGENTS	No	No	Medicaid, CHIP, CSHCN
FENOFIBRATE 54 MG TABLET fenofibrate	62332053890 ALEMBIC PHARMAC	LIPOTROPICS: OTHER	No	No	Medicaid, CHIP, CSHCN
MOTEGRITY 1 MG TABLET prucalopride succinate	54092054601 SHIRE US INC.	GI MOTILITY: CHRONIC	No	Yes	Medicaid, CHIP, CSHCN
ONDANSETRON HCL 4 MG TABLET ondansetron HCl	63304045830 RANBAXY/SUN PHA	ANTIEMETIC/ANTIVERTIGO AGENTS	No	No	Medicaid, CHIP, CSHCN
PREGABALIN 225 MG CAPSULE pregabalin	64980041609 RISING PHARM	NEUROPATHIC PAIN	No	No	Medicaid, CHIP, CSHCN
SYMTUZA 800-150-200-10 MG TAB darunavir/cob/emtri/tenof alaf	59676080030 JANSSEN PRODUCT		No	No	Medicaid, CHIP, CSHCN
GS ANTACID PLUS ANTI-GAS LIQ mag hydrox/aluminum hyd/simeth	00113035740 PERRIGO/GOODSEN		No	No	Medicaid, CSHCN
NITROGLYCERIN 400 MCG SPRAY nitroglycerin	70003030065 JACKSONVILLE PH		No	No	Medicaid, CHIP, CSHCN
AMOXICILLIN 400 MG/5 ML SUSP amoxicillin	00143988775 WEST-WARD/HIKMA	PENICILLINS	No	No	Medicaid, CHIP, CSHCN, KHC
ATOVAQUONE 750 MG/5 ML SUSP atovaquone	68180028201 LUPIN PHARMACEU		No	No	Medicaid, CHIP, CSHCN
SPIRONOLACTONE 50 MG TABLET spironolactone	68382066101 ZYDUS PHARMACEU		No	No	Medicaid, CHIP, CSHCN
ENALAPRIL MALEATE 20 MG TAB enalapril maleate	16714044501 NORTHSTAR RX LL	ANGIOTENSIN MODULATORS	No	No	Medicaid, CHIP, CSHCN, HTW
METRONIDAZOLE 500 MG TABLET metronidazole	29300022746 UNICHEM PHARMAC	ANTIBIOTICS: GI	No	No	Medicaid, CHIP, CSHCN, KHC, HTW
KLOR-CON M10 TABLET potassium chloride	00245531711 UPSHER-SMITH LA		No	No	Medicaid, CHIP, CSHCN, KHC
VALACYCLOVIR HCL 1 GRAM TABLET valacyclovir HCl	00378427677 MYLAN	ANTIVIRALS: ORAL	No	No	Medicaid, CHIP, CSHCN, KHC, HTW
CLOBETASOL 0.05% TOPICAL LOTN clobetasol propionate	00472040492 ACTAVIS/TEVA	STEROIDS: TOPICAL VERY HIGH	No	Yes	Medicaid, CHIP, CSHCN
GLIPIZIDE 10 MG TABLET glipizide	00591046101 ACTAVIS/TEVA		No	No	Medicaid, CHIP, CSHCN, KHC, HTW
INF GAS REL 20 MG/0.3 ML DROP simethicone	00904589430 MAJOR PHARMACEU		No	No	Medicaid, CSHCN
CIPROFLOX-DEXAMETH OTIC SUSP ciprofloxacin HCl/dexameth	43598032675 DR.REDDY'S LAB	OTIC ANTIBIOTICS	No	Yes	Medicaid, CHIP, CSHCN
CEFACLOR 500 MG CAPSULE cefaclor	61442017230 CARLSBAD TECH	CEPHALOSPORINS AND RELATED ANTIBIOTICS	No	Yes	Medicaid, CHIP, CSHCN
ALUNBRIG 30 MG TABLET brigatinib	63020011330 MILLENNIUM PHAR		No	No	Medicaid, CHIP, CSHCN
DESVENLAFAXINE SUCCNT ER 25 MG desvenlafaxine succinate	59762121003 GREENSTONE LLC.	ANTIDEPRESSANTS: OTHER	No	Yes	Medicaid, CHIP, CSHCN
AMMONIUM LACTATE 12% LOTION ammonium lactate	51672130009 TARO PHARM USA		No	No	Medicaid, CHIP, CSHCN
CLOPIDOGREL 75 MG TABLET clopidogrel bisulfate	65862035730 AUROBINDO PHARM	PLATELET AGGREGATION INHIBITORS	No	No	Medicaid, CHIP, CSHCN, KHC
MEDROXYPROGESTERONE 150 MG/ML medroxyprogesterone acetate	67457088701 MYLAN INSTITUTI		No	No	Medicaid, CSHCN, HTW
PRAZOSIN 1 MG CAPSULE prazosin HCl	00093406701 TEVA USA		No	No	Medicaid, CHIP, CSHCN, KHC
LAMOTRIGINE ER 300 MG TABLET lamotrigine	65162099003 AMNEAL PHARMACE		No	No	Medicaid, CHIP, CSHCN
SENSIPAR 30 MG TABLET cinacalcet HCl	55513007330 AMGEN		No	No	Medicaid, CHIP, CSHCN
PROPRANOLOL ER 60 MG CAPSULE propranolol HCl	51991081701 BRECKENRIDGE	BETA-BLOCKERS	No	Yes	Medicaid, CHIP, CSHCN
ENALAPRIL MALEATE 5 MG TABLET enalapril maleate	68682071110 OCEANSIDE PHARM	ANGIOTENSIN MODULATORS	No	No	Medicaid, CHIP, CSHCN

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