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
ACETYLCYSTEINE 6 GRAM/30 ML VL acetylcysteine	00574080530		No	No	Medicaid, CHIP, CSHCN
ACID GONE ANTACID LIQUID mag carb/aluminum hydrox/algin	00904772714		No	No	Medicaid, CSHCN
ACID REDUCER 20 MG TABLET famotidine	37205086163		No	No	Medicaid, CSHCN
ACIPHEX DR 20 MG TABLET rabeprazole sodium	62856024330	PROTON PUMP INHIBITORS	No	Yes	Medicaid, CHIP, CSHCN
ACIPHEX SPRINKLE DR 10 MG CAP rabeprazole sodium	13551021001	PROTON PUMP INHIBITORS	No	Yes	Medicaid, CHIP, CSHCN
ACIPHEX SPRINKLE DR 10 MG CAP rabeprazole sodium	23594021001	PROTON PUMP INHIBITORS	No	Yes	Medicaid, CHIP, CSHCN
ACIPHEX SPRINKLE DR 5 MG CAP rabeprazole sodium	13551020501	PROTON PUMP INHIBITORS	No	Yes	Medicaid, CHIP, CSHCN
ACIPHEX SPRINKLE DR 5 MG CAP rabeprazole sodium	23594020501	PROTON PUMP INHIBITORS	No	Yes	Medicaid, CHIP, CSHCN
ACITRETIN 10 MG CAPSULE acitretin	00093113556		No	No	Medicaid, CHIP, CSHCN
ACITRETIN 10 MG CAPSULE acitretin	00115175008		No	No	Medicaid, CHIP, CSHCN
ACITRETIN 10 MG CAPSULE acitretin	00378702093		No	No	Medicaid, CHIP, CSHCN
ACITRETIN 10 MG CAPSULE acitretin	42794008008		No	No	Medicaid, CHIP, CSHCN
ACITRETIN 10 MG CAPSULE acitretin	66993089430		No	No	Medicaid, CHIP, CSHCN
ACITRETIN 17.5 MG CAPSULE acitretin	00093113856		No	No	Medicaid, CHIP, CSHCN
ACITRETIN 17.5 MG CAPSULE acitretin	00115166808		No	No	Medicaid, CHIP, CSHCN
ACITRETIN 17.5 MG CAPSULE acitretin	42794008108		No	No	Medicaid, CHIP, CSHCN
ACITRETIN 25 MG CAPSULE acitretin	00093113656		No	No	Medicaid, CHIP, CSHCN
ACITRETIN 25 MG CAPSULE acitretin	00115166908		No	No	Medicaid, CHIP, CSHCN
ACITRETIN 25 MG CAPSULE acitretin	00115175308		No	No	Medicaid, CHIP, CSHCN
ACITRETIN 25 MG CAPSULE acitretin	00378702393		No	No	Medicaid, CHIP, CSHCN
ACITRETIN 25 MG CAPSULE acitretin	42794008308		No	No	Medicaid, CHIP, CSHCN
ACITRETIN 25 MG CAPSULE acitretin	66993089630		No	No	Medicaid, CHIP, CSHCN
ACNE MEDICATION 10% GEL benzoyl peroxide	00536105656		No	No	Medicaid, CSHCN
ACNE MEDICATION 10% LOTION benzoyl peroxide	00536105875		No	No	Medicaid, CSHCN
ACNE MEDICATION 5% GEL benzoyl peroxide	00536105556		No	No	Medicaid, CSHCN
ACNE MEDICATION 5% LOTION benzoyl peroxide	00536105775		No	No	Medicaid, CSHCN
ACTEMRA 162 MG/0.9 ML SYRINGE tocilizumab	50242013801	CYTOKINE AND CAM ANTAGONISTS	Yes	Yes	Medicaid, CHIP, CSHCN
ACTIDOSE 50 GM LIQUID charcoal/sorbitol solution	00574012008		No	No	Medicaid, CSHCN
ACTIGALL 300 MG CAPSULE ursodiol	52544093001	BILE SALTS	No	Yes	Medicaid, CHIP, CSHCN
ACTIMMUNE 100 MCG/0.5 ML VIAL interferon gamma-1b,recomb.	42238011101		No	No	Medicaid, CHIP, CSHCN
ACTIMMUNE 100 MCG/0.5 ML VIAL interferon gamma-1b,recomb.	42238011112		No	No	Medicaid, CHIP, CSHCN
ACTIMMUNE 100 MCG/0.5 ML VIAL interferon gamma-1b,recomb.	75987011110		No	No	Medicaid, CHIP, CSHCN
ACTIMMUNE 100 MCG/0.5 ML VIAL interferon gamma-1b,recomb.	75987011111		No	No	Medicaid, CHIP, CSHCN
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
ACTONEL 150 MG TABLET risedronate sodium	00430047801	BONE RESORPTION SUPPRESSION AND RELATED AGENTS	No	Yes	Medicaid, CHIP, CSHCN
ACTONEL 150 MG TABLET risedronate sodium	00430047802	BONE RESORPTION SUPPRESSION AND RELATED AGENTS	No	Yes	Medicaid, CHIP, CSHCN
ACTONEL 30 MG TABLET risedronate sodium	00430047015	BONE RESORPTION SUPPRESSION AND RELATED AGENTS	No	Yes	Medicaid, CHIP, CSHCN
ACTONEL 35 MG TABLET risedronate sodium	00430047203	BONE RESORPTION SUPPRESSION AND RELATED AGENTS	No	Yes	Medicaid, CHIP, CSHCN
ACTONEL 5 MG TABLET risedronate sodium	00430047115	BONE RESORPTION SUPPRESSION AND RELATED AGENTS	No	Yes	Medicaid, CHIP, CSHCN
ACTOPLUS MET XR 15-1,000 MG TB pioglitazone HCl/metformin HCl	64764051030	HYPOGLYCEMICS: TZD	Yes	Yes	Medicaid, CHIP, CSHCN
ACTOPLUS MET XR 30-1,000 MG TB pioglitazone HCl/metformin HCl	64764031030	HYPOGLYCEMICS: TZD	Yes	Yes	Medicaid, CHIP, CSHCN
ACULAR 0.5% EYE DROPS ketorolac tromethamine	00023218105	OPHTHALMICS: ANTI-INFLAMMATORIES	No	Yes	Medicaid, CHIP, CSHCN
ACULAR LS 0.4% OPHTH SOL ketorolac tromethamine	00023927705	OPHTHALMICS: ANTI-INFLAMMATORIES	No	Yes	Medicaid, CHIP, CSHCN
ACUVAIL 0.45% OPHTH SOLUTION ketorolac tromethamine/PF	00023350730	OPHTHALMICS: ANTI-INFLAMMATORIES	Yes	Yes	Medicaid, CHIP, CSHCN
ACYCLOVIR 200 MG CAPSULE acyclovir	00093894001	ANTIVIRALS: ORAL	No	No	Medicaid, CHIP, CSHCN, KHC, HTW

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