Search Results: Formulary Drugs

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Search results: Formulary Drugs
Brand Name/Generic Name	NDC	PDL Class	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
ACETAMIN-CAFF-DIHYDROCOD 320.5 acetaminophen/caff/dihydrocod	42195084010	ANALGESICS: NARCOTICS SHORT	Yes	Yes	Medicaid, CHIP, CSHCN
ACETAMINOP-CODEINE 120-12 MG/5 acetaminophen with codeine	00121050404	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOP-CODEINE 120-12 MG/5 acetaminophen with codeine	00121050416	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOP-CODEINE 120-12 MG/5 acetaminophen with codeine	50383007916	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN
ACETAMINOP-CODEINE 120-12 MG/5 acetaminophen with codeine	60432024516	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #2 TABLET acetaminophen with codeine	00093005001	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #2 TABLET acetaminophen with codeine	13107005801	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #2 TABLET acetaminophen with codeine	00603233721	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #2 TABLET acetaminophen with codeine	00406048301	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #3 TABLET acetaminophen with codeine	51079016120	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN
ACETAMINOPHEN-COD #3 TABLET acetaminophen with codeine	00406048462	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #3 TABLET acetaminophen with codeine	00093015001	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #3 TABLET acetaminophen with codeine	00093015010	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #3 TABLET acetaminophen with codeine	13107005901	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #3 TABLET acetaminophen with codeine	13107005999	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #3 TABLET acetaminophen with codeine	65162003310	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #3 TABLET acetaminophen with codeine	65162003311	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #3 TABLET acetaminophen with codeine	00603233821	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #3 TABLET acetaminophen with codeine	00603233832	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #3 TABLET acetaminophen with codeine	00406048401	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #3 TABLET acetaminophen with codeine	00406048410	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #4 TABLET acetaminophen with codeine	00406048501	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #4 TABLET acetaminophen with codeine	00406048505	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #4 TABLET acetaminophen with codeine	00093035001	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #4 TABLET acetaminophen with codeine	00093035005	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #4 TABLET acetaminophen with codeine	00093035010	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #4 TABLET acetaminophen with codeine	13107006001	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #4 TABLET acetaminophen with codeine	13107006005	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #4 TABLET acetaminophen with codeine	13107006099	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #4 TABLET acetaminophen with codeine	00603233921	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACETAMINOPHEN-COD #4 TABLET acetaminophen with codeine	00603233928	ANALGESICS: NARCOTICS SHORT	Yes	No	Medicaid, CHIP, CSHCN, KHC
ACTIQ 1,200 MCG LOZENGE fentanyl citrate	63459051230	ANALGESICS: NARCOTICS SHORT	Yes	Yes	Medicaid, CHIP, CSHCN
ACTIQ 1,600 MCG LOZENGE fentanyl citrate	63459051630	ANALGESICS: NARCOTICS SHORT	Yes	Yes	Medicaid, CHIP, CSHCN
ACTIQ 200 MCG LOZENGE fentanyl citrate	63459050230	ANALGESICS: NARCOTICS SHORT	Yes	Yes	Medicaid, CHIP, CSHCN
ACTIQ 400 MCG LOZENGE fentanyl citrate	63459050430	ANALGESICS: NARCOTICS SHORT	Yes	Yes	Medicaid, CHIP, CSHCN
ACTIQ 600 MCG LOZENGE fentanyl citrate	63459050630	ANALGESICS: NARCOTICS SHORT	Yes	Yes	Medicaid, CHIP, CSHCN
ACTIQ 800 MCG LOZENGE fentanyl citrate	63459050830	ANALGESICS: NARCOTICS SHORT	Yes	Yes	Medicaid, CHIP, CSHCN
ALPRAZOLAM 0.25 MG TABLET alprazolam	00378400105		Yes	No	Medicaid, CHIP, CSHCN
ALPRAZOLAM 0.25 MG TABLET alprazolam	59762371901		Yes	No	Medicaid, CHIP, CSHCN
ALPRAZOLAM 0.25 MG TABLET alprazolam	67253090009		Yes	No	Medicaid, CHIP, CSHCN
ALPRAZOLAM 0.25 MG TABLET alprazolam	00781106101		Yes	No	Medicaid, CHIP, CSHCN
ALPRAZOLAM 0.25 MG TABLET alprazolam	59762371903		Yes	No	Medicaid, CHIP, CSHCN
ALPRAZOLAM 0.25 MG TABLET alprazolam	67253090010		Yes	No	Medicaid, CHIP, CSHCN
ALPRAZOLAM 0.25 MG TABLET alprazolam	00781106105		Yes	No	Medicaid, CHIP, CSHCN
ALPRAZOLAM 0.25 MG TABLET alprazolam	59762371904		Yes	No	Medicaid, CHIP, CSHCN
ALPRAZOLAM 0.25 MG TABLET alprazolam	67253090011		Yes	No	Medicaid, CHIP, CSHCN
ALPRAZOLAM 0.25 MG TABLET alprazolam	51991070401		Yes	No	Medicaid, CHIP, CSHCN
ALPRAZOLAM 0.25 MG TABLET alprazolam	00781106110		Yes	No	Medicaid, CHIP, CSHCN
ALPRAZOLAM 0.25 MG TABLET alprazolam	67253090050		Yes	No	Medicaid, CHIP, CSHCN
ALPRAZOLAM 0.25 MG TABLET alprazolam	51991070405		Yes	No	Medicaid, CHIP, CSHCN

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