01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION AA 2.75%/CALCIUM/LYTES/D10W AA 2.75%/CALCIUM/LYTES/D5W AA 3.5 %/CALC/LYTES/DEXT 25 % AA 3.5 %/LYTES/DEXTROSE 5 % AA 3.5%/CALCIUM/LYTES/D25W AA 3.5%/ELECTROLYTE-TPN SOLN AA 3.5%/ELECTROLYTE-TPN/D5W AA 3%/ELECTROLYTE-TPN SOLN AA 3%/ELECTROLYTE-TPN SOLN/GLY AA 4.25%/CALCIUM/LYTES/D10W AA 4.25%/CALCIUM/LYTES/D20W AA 4.25%/CALCIUM/LYTES/D25W AA 4.25%/CALCIUM/LYTES/D5W AA 4.25%/ELECTROLYTE-TPN/D10W AA 4.25%/ELECTROLYTE-TPN/D25W AA 4.25%/ELECTROLYTE-TPN/D5W AA 5 %/ELECTROLYTE-TPN/D25W AA 5.5%/ELECTROLYTE-TPN SOLN AA 5.5%/ELECTROLYTE-TPN/D50W AA 5%/CAL/ELECTROLYTE-TPN/D15W AA 5%/CAL/ELECTROLYTE-TPN/D20W AA 5%/CAL/ELECTROLYTE-TPN/D25W AA 5%/ELECTROLYTE-TPN/D25W AA 8.5 %/ELECTROLYTE/DEXT 50 % AA 8.5%/ELECTROLYTE-TPN SOLN AA/PROT/ARGININE/C/ZINC/COPPER AA/PROT/FRUC/C/ZN/COPPER/ARGIN AA/PROT/LYSINE/METHIO/VIT C/B6 AA8/A-CARNITIN/GRP/COCOA/HC126 AA9/A-CARNITIN/DEX/COCOA/HC127 AA9/A-CARNITIN/DEX/COCOA/HC128 ABACAVIR SULFATE ABACAVIR SULFATE ABACAVIR SULFATE/LAMIVUDINE ABACAVIR/DOLUTEGRAVIR/LAMIVUDI ABACAVIR/LAMIVUDINE/ZIDOVUDINE ABATACEPT ABATACEPT/MALTOSE ABIRATERONE ACETATE ABOBOTULINUMTOXINA ACACIA/INULIN/C-LOSE/MV-MN/FA ACAMPROSATE CALCIUM ACARBOSE ACARBOSE ACARBOSE ACEBUTOLOL HCL DOSAGE IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN KIT IV SOLN LIQUID LIQUID TABLET CAPSULE CAPSULE CAPSULE SOLUTION TABLET TABLET TABLET TABLET SYRINGE VIAL TABLET VIAL TAB CHEW TABLET DR TABLET TABLET TABLET CAPSULE STRENGTH 2.75% 2.75% 3.5 % 3.5 % 3.5 % 3.5 % 3.5 % 3 % 3 % 4.25 % 4.25 % 4.25 % 4.25 % 4.25 % 4.25 % 4.25 % 5 % 5.5 % 5.5 % 5 % 5 % 5 % 5 % 8.5 % 8.5 % 15G-100/30 17G-100/30 50-12.5 MG 343-20-10 290-40-35 290-40-15 20 MG/ML 300 MG 600-300MG 600-50-300 150-300MG 125 MG/ML 250 MG 250 MG 500 UNIT 2G-200MCG 333 MG 100 MG 25 MG 50 MG 200 MG NOTE APPENDIX A PAGE 1 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ACEBUTOLOL HCL ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN WITH CODEINE ACETAMINOPHEN/PHENYLTOLX ACETAZOLAMIDE ACETAZOLAMIDE ACETAZOLAMIDE ACETAZOLAMIDE SODIUM ACETIC ACID ACETIC ACID ACETIC ACID/ALUMINUM ACETATE ACETIC ACID/HYDROCORTISONE ACETOHYDROXAMIC ACID ACETYL/METHYL-B12/LMEFOLATE CA ACETYLCARNITINE ACETYLCARNITINE HCL ACETYLCARNITINE HCL/ALIP ACID ACETYLCYSTEINE ACETYLCYSTEINE ACETYLCYSTEINE ACETYLCYSTEINE ACETYLCYSTEINE ACITRETIN ACITRETIN ACITRETIN ACLIDINIUM BROMIDE ACYCLOVIR ACYCLOVIR ACYCLOVIR ACYCLOVIR ACYCLOVIR ACYCLOVIR ACYCLOVIR SODIUM ACYCLOVIR SODIUM ACYCLOVIR/HYDROCORTISONE ADALIMUMAB ADALIMUMAB ADALIMUMAB ADAPALENE ADAPALENE ADAPALENE ADAPALENE ADEFOVIR DIPIVOXIL DOSAGE CAPSULE ORAL SUSP SOLUTION TABLET TABLET TABLET TABLET CAPSULE ER TABLET TABLET VIAL IRRIG SOLN SOLUTION DROPS DROPS TABLET TABLET CAPSULE CAPSULE CAPSULE CAPSULE VIAL VIAL VIAL VIAL CAPSULE CAPSULE CAPSULE AER POW BA CAPSULE CREAM (G) OINT. (G) ORAL SUSP TABLET TABLET VIAL VIAL CREAM (G) PEN IJ KIT SYRINGEKIT SYRINGEKIT CREAM (G) GEL (GRAM) GEL W/PUMP LOTION TABLET STRENGTH 400 MG 120-12MG/5 120-12MG/5 300MG-15MG 300MG-30MG 300MG-60MG 500MG-30MG 500 MG 125 MG 250 MG 500 MG 0.25 % 2 % 2 % 2 %-1 % 250 MG 600-2-6 MG 500 MG 250 MG 400-200 MG 600 MG 100 MG/ML 100 MG/ML 200 MG/ML 200 MG/ML 10 MG 17.5 MG 25 MG 400 MCG 200 MG 5 % 5 % 200 MG/5ML 400 MG 800 MG 50 MG/ML 500 MG 5 %-1 % 40MG/0.8ML 20MG/0.4ML 40MG/0.8ML 0.1 % 0.1 % 0.3 % 0.1 % 10 MG NOTE 10ML 10ML APPENDIX A PAGE 2 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ADENOSINE ADENOSINE ADENOSINE TRIPHOSPHATE ADENOSINE TRIPHOSPHATE ADO-TRASTUZUMAB EMTANSINE ADO-TRASTUZUMAB EMTANSINE ADULT NUTRITIONAL AFATINIB DIMALEATE AFLIBERCEPT AGALSIDASE BETA AGALSIDASE BETA ALANINE ALANINE/GLUTAMIC ACID/GLYCINE ALBENDAZOLE ALBIGLUTIDE ALBIGLUTIDE ALBUMEN (ALBUMIN) ALBUMIN HUMAN ALBUMIN HUMAN ALBUMIN HUMAN ALBUMIN HUMAN ALBUTEROL SULFATE ALBUTEROL SULFATE ALBUTEROL SULFATE ALBUTEROL SULFATE ALBUTEROL SULFATE ALBUTEROL SULFATE ALBUTEROL SULFATE ALBUTEROL SULFATE ALBUTEROL SULFATE ALBUTEROL SULFATE ALBUTEROL SULFATE ALCAFTADINE ALCLOMETASONE DIPROPIONATE ALCLOMETASONE DIPROPIONATE ALENDRONATE SODIUM ALENDRONATE SODIUM ALENDRONATE SODIUM ALENDRONATE SODIUM ALENDRONATE SODIUM ALENDRONATE SODIUM ALENDRONATE SODIUM/VITAMIN D3 ALENDRONATE SODIUM/VITAMIN D3 ALFENTANIL HCL ALFUZOSIN HCL ALGLUCOSIDASE ALFA DOSAGE SYRINGE VIAL TABLET DR TABLET DR VIAL VIAL CAN TABLET VIAL VIAL VIAL POWD PACK TABLET TABLET PEN INJCTR PEN INJCTR POWDER IV SOLN IV SOLN VIAL VIAL HFA AER AD SOLUTION SYRUP TAB ER 12H TAB ER 12H TABLET TABLET VIAL-NEB VIAL-NEB VIAL-NEB VIAL-NEB DROPS CREAM (G) OINT. (G) TABLET TABLET TABLET TABLET TABLET TABLET EFF TABLET TABLET AMPUL TAB ER 24H VIAL STRENGTH 3 MG/ML 3 MG/ML 20 MG 25 MG 100 MG 160 MG 0.07G-1.5 40 MG 2MG/0.05ML 35 MG 5 MG 1000 MG 200-200 MG 200 MG 30MG/0.5ML 50MG/0.5ML 25 % 5 % 25 % 5 % 90 MCG 5 MG/ML 2 MG/5 ML 4 MG 8 MG 2 MG 4 MG 0.63MG/3ML 1.25MG/3ML 2.5 MG/0.5 2.5 MG/3ML 0.25 % 0.05 % 0.05 % 10 MG 35 MG 40 MG 5 MG 70 MG 70 MG 70 MG-2800 70 MG-5600 500 MCG/ML 10 MG 50 MG NOTE APPENDIX A PAGE 3 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 4 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ALIP ACID/BIOTIN/MIN 16/HRB91 ALIP ACID/CAL PHOS/CR/FENUGR ALISKIREN HEMIFUMARATE ALISKIREN HEMIFUMARATE ALISKIREN/AMLODIPIN/HCTHIAZIDE ALISKIREN/AMLODIPIN/HCTHIAZIDE ALISKIREN/AMLODIPIN/HCTHIAZIDE ALISKIREN/AMLODIPIN/HCTHIAZIDE ALISKIREN/AMLODIPIN/HCTHIAZIDE ALISKIREN/AMLODIPINE BESYLATE ALISKIREN/AMLODIPINE BESYLATE ALISKIREN/AMLODIPINE BESYLATE ALISKIREN/AMLODIPINE BESYLATE ALISKIREN/HYDROCHLOROTHIAZIDE ALISKIREN/HYDROCHLOROTHIAZIDE ALISKIREN/HYDROCHLOROTHIAZIDE ALISKIREN/HYDROCHLOROTHIAZIDE ALITRETINOIN ALLOPURINOL ALLOPURINOL ALMOTRIPTAN MALATE ALMOTRIPTAN MALATE ALOGLIPTIN BENZ/PIOGLITAZONE ALOGLIPTIN BENZ/PIOGLITAZONE ALOGLIPTIN BENZ/PIOGLITAZONE ALOGLIPTIN BENZ/PIOGLITAZONE ALOGLIPTIN BENZOATE ALOSETRON HCL ALOSETRON HCL ALPHA LIPOIC ACID/ACETYLCARN ALPHA-1-PROTEINASE INHIBITOR ALPHA-1-PROTEINASE INHIBITOR ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM ALPROSTADIL DOSAGE TABLET TABLET ER TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET GEL (GRAM) TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET CAPSULE VIAL VIAL ORAL CONC TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB RAPDIS TAB RAPDIS TAB RAPDIS TAB RAPDIS TABLET TABLET TABLET TABLET AMPUL STRENGTH 75 MG-300 50-118-500 150 MG 300 MG 150-5-12.5 300-10-25 300-5-12.5 300-5-25MG 300MG-10MG 150 MG-5MG 150MG-10MG 300MG-10MG 300MG-5MG 150-12.5MG 150MG-25MG 300-12.5MG 300MG-25MG 0.1 % 100 MG 300 MG 12.5 MG 6.25 MG 12.5-15 MG 12.5-30 MG 25 MG-15MG 25 MG-30MG 25 MG 0.5 MG 1 MG 200-500MG 1000 MG 500 MG 1 MG/ML 0.5 MG 1 MG 2 MG 3 MG 0.25 MG 0.5 MG 1 MG 2 MG 0.25 MG 0.5 MG 1 MG 2 MG 500 MCG/ML NOTE FOR MALES ONLY 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ALTEPLASE ALTEPLASE ALTRETAMINE AM AC/E AC SUCC/ZN/PROST/HERB9 AMANTADINE HCL AMANTADINE HCL AMANTADINE HCL AMBRISENTAN AMBRISENTAN AMCINONIDE AMCINONIDE AMCINONIDE AMIFOSTINE CRYSTALLINE AMIKACIN SULFATE AMIKACIN SULFATE AMILORIDE HCL AMILORIDE/HYDROCHLOROTHIAZIDE AMINO AC 2.75 %/LYTES/DEXT 10% AMINO AC 7%/LYTES/DEXTROSE 50% AMINO AC/MULTIVITS-MIN/HC 139 AMINO AC/PROTEIN HYDR/WHEY PRO AMINO AC/PROTEIN HYDR/WHEY PRO AMINO AC/WHEY PROT CON & ISOL AMINO AC/WHEY PROT CON & ISOL AMINO AC/WHEY PROT CON & ISOL AMINO ACID/PROTEIN/VIT C/ZINC AMINO ACIDS AMINO ACIDS AMINO ACIDS AMINO ACIDS AMINO ACIDS AMINO ACIDS AMINO ACIDS AMINO ACIDS AMINO ACIDS AMINO ACIDS AMINO ACIDS AMINO ACIDS 10 % AMINO ACIDS 11.4 % AMINO ACIDS 15 % AMINO ACIDS 2.75 %/D5W AMINO ACIDS 2.75%/D5W AMINO ACIDS 3.5 % AMINO ACIDS 3.5 %/DEXTROSE 25% AMINO ACIDS 3.5 %/DEXTROSE 5 % AMINO ACIDS 3.5%/D25W DOSAGE VIAL VIAL CAPSULE TABLET CAPSULE SYRUP TABLET TABLET TABLET CREAM (G) LOTION OINT. (G) VIAL VIAL VIAL TABLET TABLET IV SOLN KIT POWDER LIQUID PKT LIQUID PKT POWDER POWDER POWDER LIQUID CAN CAPSULE PACKET POWDER POWDER POWDER POWDER POWDER TAB CHEW TABLET TABLET IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN STRENGTH 2 MG 50 MG 50 MG 100 MG 50 MG/5 ML 100 MG 10 MG 5 MG 0.1 % 0.1 % 0.1 % 500 MG 1000MG/4ML 500 MG/2ML 5 MG 5MG-50MG 2.75% 7 %-50 % 20G-400MCG 11G-40/45 15G-100/30 25G-140/34 25G-140/36 26G-150/39 17 G-70/30 14.3 G-469 14.3 G-469 14.5G-475 3.1 G/100 82G-328 500 MG 10 % 11.4 % 15 % 2.75% 2.75% 3.5 % 3.5 % 3.5 % 3.5 % NOTE APPENDIX A PAGE 5 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO AMINO ACIDS 3.5%/D5W ACIDS 3.5%/ELECTROLYTE M ACIDS 3.5%/ELECTROLYTE-M ACIDS 4.25%/D10W ACIDS 4.25%/D20W ACIDS 4.25%/D25W ACIDS 4.25%/D5W ACIDS 5 %/CAL/LYTES/D35W ACIDS 5.2% ACIDS 5.2%/HISTIDINE HCL ACIDS 5.4 % ACIDS 5.5% ACIDS 5.5%/D10W ACIDS 5.5%/D20W ACIDS 5.5%/D50W ACIDS 5% ACIDS 5%/D15W ACIDS 5%/D20W ACIDS 5%/D25W ACIDS 6 % ACIDS 6.5 % ACIDS 6.9 % ACIDS 7 % ACIDS 7 %/DEXTROSE 50 % ACIDS 7 %/ELECTROLYTES ACIDS 7% ACIDS 7%/ELECTROLYTE-TPN ACIDS 8 % ACIDS 8.5 % ACIDS 8.5 % ACIDS 8.5 %/DEXTROSE 10% ACIDS 8.5 %/DEXTROSE 20% ACIDS 8.5 %/DEXTRSOE 50% ACIDS 8.5 %/DEXTRSOE 50% ACIDS 8.5 %/ELECTROLYTES ACIDS 8.5% ACIDS 8% ACIDS/CHROMIUM ACIDS/GLYCINE/GLUT ACID ACIDS/MAGNESIUM SULFATE ACIDS/MINERALS ACIDS/MULTIVITS-MIN ACIDS/MULTIVITS-MIN ACIDS/PROTEIN HYDR/FIBER ACIDS/PROTEIN HYDR/FIBER ACIDS/PROTEIN HYDROLYS DOSAGE IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN KIT IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN KIT IV SOLN IV SOLN IV SOLN KIT IV SOLN IV SOLN IV SOLN TABLET CAPSULE TABLET TABLET CAPSULE POWDER LIQUID LIQUID PKT LIQUID STRENGTH 3.5 % 3.5 % 3.5 % 4.25 % 4.25 % 4.25 % 4.25 % 5 % 5.2 % 5.2 % 5.4% 5.5 % 5.5 % 5.5 % 5.5 % 5 % 5 % 5 % 5 % 6 % 6.5 % 6.9% 7 % 7 %-50 % 7 % 7 % 7 % 8 % 8.5 % 8.5 % 8.5 % 8.5 % 8.5 % 8.5 % 8.5 % 8.5 % 8 % 24G-240/65 15-90/30 15-90/30 10G-100/30 NOTE APPENDIX A PAGE 6 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION AMINO ACIDS/PROTEIN HYDROLYS AMINO ACIDS/PROTEIN HYDROLYS AMINO ACIDS/PROTEIN HYDROLYS AMINO ACIDS/PROTEIN HYDROLYS AMINO ACIDS/PROTEIN HYDROLYS AMINO ACIDS/PROTEIN HYDROLYS AMINO ACIDS/PROTEIN HYDROLYS AMINO ACIDS/PROTEIN HYDROLYS AMINO ACIDS/PROTEIN HYDROLYS AMINO ACIDS/PROTEIN HYDROLYS AMINO ACIDS/PROTEIN HYDROLYS AMINO ACIDS/PROTEIN HYDROLYS AMINO ACIDS/PROTEIN HYDROLYS AMINO ACIDS/PROTEIN HYDROLYS AMINO ACIDS/PROTEIN SUPPLEMENT AMINO ACIDS/PROTEIN SUPPLEMENT AMINO ACIDS/PROTEIN/FRUCTOSE AMINOCAPROIC ACID AMINOCAPROIC ACID AMINOCAPROIC ACID AMINOCAPROIC ACID AMINOHIPPURATE SODIUM AMINOPHYLLINE AMINOPHYLLINE AMIODARONE HCL AMIODARONE HCL AMIODARONE HCL AMIODARONE HCL AMIODARONE HCL AMITRIP HCL/CHLORDIAZEPOXIDE AMITRIP HCL/CHLORDIAZEPOXIDE AMITRIPTYLINE HCL AMITRIPTYLINE HCL AMITRIPTYLINE HCL AMITRIPTYLINE HCL AMITRIPTYLINE HCL AMITRIPTYLINE HCL AMLODIPINE BES/OLMESARTAN MED AMLODIPINE BES/OLMESARTAN MED AMLODIPINE BES/OLMESARTAN MED AMLODIPINE BES/OLMESARTAN MED AMLODIPINE BESYLATE AMLODIPINE BESYLATE AMLODIPINE BESYLATE AMLODIPINE BESYLATE/BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL DOSAGE LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID PKT LIQUID PKT LIQUID PKT POWD PACK TABLET LIQUID SOLUTION TABLET TABLET VIAL VIAL VIAL VIAL AMPUL TABLET TABLET TABLET VIAL TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET CAPSULE CAPSULE STRENGTH 11.3-86/30 11-80/30ML 15 G-60/30 15 G-72/30 15G-100/30 15G-101/30 15G-105/30 17G-100/30 18 G-72/30 18G-100/30 20 G-80/30 11-80/30ML 15 G-60/30 15G-100/30 15 G-12.3G 15G-100/30 250 MG/ML 1000 MG 500 MG 250 MG/ML 20 % 250MG/10ML 500MG/20ML 50 MG/ML 100 MG 200 MG 400 MG 50 MG/ML 12.5MG-5MG 25 MG-10MG 10 MG 100 MG 150 MG 25 MG 50 MG 75 MG 10 MG-20MG 10 MG-40MG 5 MG-20 MG 5 MG-40 MG 10 MG 2.5 MG 5 MG 10 MG-20MG 10 MG-40MG NOTE APPENDIX A PAGE 7 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION AMLODIPINE BESYLATE/BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL AMLODIPINE BESYLATE/BENAZEPRIL AMLODIPINE/ATORVASTATIN AMLODIPINE/ATORVASTATIN AMLODIPINE/ATORVASTATIN AMLODIPINE/ATORVASTATIN AMLODIPINE/ATORVASTATIN AMLODIPINE/ATORVASTATIN AMLODIPINE/ATORVASTATIN AMLODIPINE/ATORVASTATIN AMLODIPINE/ATORVASTATIN AMLODIPINE/ATORVASTATIN AMLODIPINE/ATORVASTATIN AMLODIPINE/VALSARTAN AMLODIPINE/VALSARTAN AMLODIPINE/VALSARTAN AMLODIPINE/VALSARTAN AMLODIPINE/VALSARTAN/HCTHIAZID AMLODIPINE/VALSARTAN/HCTHIAZID AMLODIPINE/VALSARTAN/HCTHIAZID AMLODIPINE/VALSARTAN/HCTHIAZID AMLODIPINE/VALSARTAN/HCTHIAZID AMMONIUM LACTATE AMMONIUM LACTATE AMOXAPINE AMOXAPINE AMOXAPINE AMOXAPINE AMOXICILLIN AMOXICILLIN AMOXICILLIN AMOXICILLIN AMOXICILLIN AMOXICILLIN AMOXICILLIN AMOXICILLIN AMOXICILLIN AMOXICILLIN AMOXICILLIN/POTASSIUM CLAV AMOXICILLIN/POTASSIUM CLAV AMOXICILLIN/POTASSIUM CLAV AMOXICILLIN/POTASSIUM CLAV AMOXICILLIN/POTASSIUM CLAV AMOXICILLIN/POTASSIUM CLAV DOSAGE CAPSULE CAPSULE CAPSULE CAPSULE TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET CREAM (G) LOTION TABLET TABLET TABLET TABLET CAPSULE CAPSULE SUSP RECON SUSP RECON SUSP RECON SUSP RECON TAB CHEW TAB CHEW TABLET TABLET SUSP RECON SUSP RECON SUSP RECON SUSP RECON SUSP RECON TAB CHEW STRENGTH 2.5MG-10MG 5 MG-10 MG 5 MG-20 MG 5 MG-40 MG 10 MG-10MG 10 MG-20MG 10 MG-40MG 10 MG-80MG 2.5MG-10MG 2.5MG-20MG 2.5MG-40MG 5 MG-10 MG 5 MG-20 MG 5 MG-40 MG 5 MG-80 MG 10MG-160MG 10MG-320MG 5MG-160MG 5MG-320MG 10-160-25 10-320-25 10MG-160MG 5-160-12.5 5-160-25MG 12 % 12 % 100 MG 150 MG 25 MG 50 MG 250 MG 500 MG 125 MG/5ML 200 MG/5ML 250 MG/5ML 400 MG/5ML 125 MG 250 MG 500 MG 875 MG 125-31.25/ 200-28.5/5 250-62.5/5 400-57MG/5 600-42.9/5 200-28.5MG NOTE APPENDIX A PAGE 8 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION AMOXICILLIN/POTASSIUM CLAV AMOXICILLIN/POTASSIUM CLAV AMOXICILLIN/POTASSIUM CLAV AMOXICILLIN/POTASSIUM CLAV AMOXICILLIN/POTASSIUM CLAV AMPHOTERICIN B AMPHOTERICIN B LIPID COMPLEX AMPHOTERICIN B LIPOSOME AMPICILLIN SODIUM AMPICILLIN SODIUM AMPICILLIN SODIUM AMPICILLIN SODIUM AMPICILLIN SODIUM AMPICILLIN SODIUM AMPICILLIN SODIUM AMPICILLIN SODIUM AMPICILLIN SODIUM/SULBACTAM NA AMPICILLIN SODIUM/SULBACTAM NA AMPICILLIN SODIUM/SULBACTAM NA AMPICILLIN SODIUM/SULBACTAM NA AMPICILLIN SODIUM/SULBACTAM NA AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE ANAGRELIDE HCL ANAGRELIDE HCL ANAKINRA ANASTROZOLE ANIDULAFUNGIN ANIDULAFUNGIN ANTI-INHIBITOR COAGULANT COMP. ANTI-INHIBITOR COAGULANT COMP. ANTI-INHIBITOR COAGULANT COMP. ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII PLAS/ALB FREE DOSAGE TAB CHEW TAB ER 12H TABLET TABLET TABLET VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL PORT VIAL PORT VIAL VIAL VIAL VIAL PORT VIAL PORT CAPSULE CAPSULE SUSP RECON SUSP RECON CAPSULE CAPSULE SYRINGE TABLET VIAL VIAL VIAL VIAL VIAL KIT KIT KIT KIT SYRINGEKIT SYRINGEKIT SYRINGEKIT SYRINGEKIT SYRINGEKIT VIAL VIAL VIAL STRENGTH 400-57MG 1000-62.5 250-125 MG 500-125 MG 875-125 MG 50 MG 5 MG/ML 50 MG 1 G 10 G 125 MG 2 G 250 MG 500 MG 1 G 2 G 1.5 G 15 G 3 G 1.5 G 3 G 250 MG 500 MG 125 MG/5ML 250 MG/5ML 0.5 MG 1 MG 100MG/0.67 1 MG 100 MG 50 MG 1750-3250 400-650 651-1200 1000 (+/-) 2000 (+/-) 250 (+/-) 500 (+/-) 1000 (+/-) 2000 (+/-) 250 (+/-) 3000 (+/-) 500 (+/-) 1000 (+/-) 1500 (+/-) 2000 (+/-) NOTE APPENDIX A PAGE 9 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII PLAS/ALB FREE ANTIHEMOPH.FVIII REC,FC FUSION ANTIHEMOPH.FVIII REC,FC FUSION ANTIHEMOPH.FVIII REC,FC FUSION ANTIHEMOPH.FVIII REC,FC FUSION ANTIHEMOPH.FVIII REC,FC FUSION ANTIHEMOPH.FVIII REC,FC FUSION ANTIHEMOPH.FVIII REC,FC FUSION ANTIHEMOPHILIC FACTOR/VWF ANTIHEMOPHILIC FACTOR/VWF ANTIHEMOPHILIC FACTOR/VWF ANTIHEMOPHILIC FACTOR/VWF ANTIHEMOPHILIC FACTOR/VWF ANTIHEMOPHILIC FACTOR/VWF ANTIHEMOPHILIC FACTOR/VWF ANTIHEMOPHILIC FACTOR/VWF ANTIHEMOPHILIC FACTOR, HUM REC ANTIHEMOPHILIC FACTOR, HUM REC ANTIHEMOPHILIC FACTOR, HUM REC ANTIHEMOPHILIC FACTOR, HUM REC ANTIHEMOPHILIC FACTOR, HUM REC ANTIHEMOPHILIC FACTOR, HUM REC ANTIHEMOPHILIC FACTOR, HUM REC ANTIHEMOPHILIC FACTOR, HUM REC ANTIHEMOPHILIC FACTOR, HUM REC ANTIHEMOPHILIC FACTOR, HUM REC ANTIHEMOPHILIC FACTOR, HUM REC ANTIHEMOPHILIC FACTOR, HUMAN ANTIHEMOPHILIC FACTOR, HUMAN ANTIHEMOPHILIC FACTOR, HUMAN ANTIHEMOPHILIC FACTOR, HUMAN ANTIHEMOPHILIC FACTOR, HUMAN ANTIHEMOPHILIC FACTOR, HUMAN ANTIPYRINE/BENZOCAINE ANTIPYRINE/BENZOCAINE ANTITHROMBIN III (HUM PLAS) APIXABAN APIXABAN APPLE JUICE APRACLONIDINE HCL APRACLONIDINE HCL APREMILAST APREMILAST DOSAGE VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL KIT KIT KIT VIAL VIAL VIAL VIAL VIAL KIT KIT KIT KIT KIT VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL DROPS DROPS VIAL TABLET TABLET LIQUID DROPERETTE DROPS TAB DS PK TABLET STRENGTH 250 (+/-) 3000 (+/-) 4000 (+/-) 500 (+/-) 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT 750 UNIT 1000-2400 250-600 500-1200 1000 (400) 1500 (600) 2000 (800) 250 (100) 500 (200) 1000 (+/-) 2000 (+/-) 250 (+/-) 3000 (+/-) 500 (+/-) 1000 (+/-) 1500 (+/-) 2000 (+/-) 250 (+/-) 3000 (+/-) 500 (+/-) 1000 (+/-) 1501-2000 220-400 250 (+/-) 401-800 801-1500 5.4 %-1.4% 5.5 %-1.4% 500 (+/-) 2.5 MG 5 MG 1 % 0.5 % 10-20-30MG 30 MG NOTE APPENDIX A PAGE 10 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION APREPITANT APREPITANT APREPITANT APREPITANT ARFORMOTEROL TARTRATE ARG/NIA/YHBK/GIN/GNK/DAM/SCHIS ARG/ORN/LYS/GLU/COL,BOV/ORN/GL ARGATROBAN ARGINAID CHERRY - 9.2G - 56 PA ARGINAID LEMON - 9.2G - 56 PAC ARGINAID ORANGE - 9.2G - 56 P ARGINARD EXTRA ORANGE BURST ARGINARD EXTRA WILDBERRY - 8 ARGININE ARGININE ARGININE ARGININE ARGININE ARGININE HCL ARGININE/ASCORBATE SOD/VITE AC ARGININE/CA CARB/GNK/DAM/K.GIN ARGININE/CALCIUM CARBONATE ARGININE/GLUTAMINE ARGININE/GLUTAMINE/CALCIUM HMB ARGININE/ORNITHINE/LYSINE ARGNIN/HIST/E/GNK/K.GIN/HRB50 ARIPIPRAZOLE ARIPIPRAZOLE ARIPIPRAZOLE ARIPIPRAZOLE ARIPIPRAZOLE ARIPIPRAZOLE ARIPIPRAZOLE ARIPIPRAZOLE ARIPIPRAZOLE ARIPIPRAZOLE ARIPIPRAZOLE ARIPIPRAZOLE ARMODAFINIL ARMODAFINIL ARMODAFINIL ARMODAFINIL ARSENIC TRIOXIDE ASCORBATE CALCIUM/B5/QUERCETIN ASCORBIC ACID ASCORBIC ACID DOSAGE CAP DS PK CAPSULE CAPSULE CAPSULE VIAL-NEB TABLET CAPSULE VIAL PACKET PACKET PACKET PACKET PACKET CAPSULE CAPSULE POWD PACK POWD PACK TABLET TABLET POWD PACK TABLET CAPSULE PACKET POWD PACK TABLET CAPSULE SOLUTION SUSER VIAL SUSER VIAL TAB RAPDIS TAB RAPDIS TABLET TABLET TABLET TABLET TABLET TABLET VIAL TABLET TABLET TABLET TABLET AMPUL TABLET UNIT VIAL STRENGTH 125MG-80MG 125 MG 40 MG 80 MG 15MCG/2ML 200-150 MG 100 MG/ML 500 MG 700 MG 2000 MG 500 MG 500 MG 1000 MG 4.5 G/9.2G 625-125MG 1000-25MG 7.5G-10G 7G-7G-1.5G 250MG-25MG 1 MG/ML 300 MG 400 MG 10 MG 15 MG 10 MG 15 MG 2 MG 20 MG 30 MG 5 MG 9.75MG/1.3 150 MG 200 MG 250 MG 50 MG 10 MG/10ML 100-100-50 100 % 500 MG/ML NOTE APPENDIX A PAGE 11 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ASCORBIC ACID/VITAMIN E/BIOTIN ASENAPINE MALEATE ASENAPINE MALEATE ASPARAGINASE ASPARAGINASE (ERWINIA CHRYSAN) ASPARTIC ACID ASPIRIN/DIPYRIDAMOLE ASTAXANTHIN ATAZANAVIR SULFATE ATAZANAVIR SULFATE ATAZANAVIR SULFATE ATENOLOL ATENOLOL ATENOLOL ATENOLOL/CHLORTHALIDONE ATENOLOL/CHLORTHALIDONE ATOMOXETINE HCL ATOMOXETINE HCL ATOMOXETINE HCL ATOMOXETINE HCL ATOMOXETINE HCL ATOMOXETINE HCL ATOMOXETINE HCL ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM ATORVASTATIN CALCIUM ATOVAQUONE ATOVAQUONE/PROGUANIL HCL ATOVAQUONE/PROGUANIL HCL ATROPINE SULFATE ATROPINE SULFATE ATROPINE SULFATE ATROPINE SULFATE ATROPINE SULFATE ATROPINE SULFATE ATTAPULGITE ATTAPULGITE ATTAPULGITE ATTAPULGITE ATTAPULGITE AURANOFIN AXITINIB AXITINIB AZACITIDINE AZATHIOPRINE DOSAGE TAB CHEW TAB SUBL TAB SUBL VIAL VIAL CAPSULE CPMP 12HR CAPSULE CAPSULE CAPSULE CAPSULE TABLET TABLET TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE TABLET TABLET TABLET TABLET ORAL SUSP TABLET TABLET DROPS OINT. (G) SYRINGE SYRINGE VIAL VIAL LIQUID ORAL SUSP ORAL SUSP ORAL SUSP TABLET CAPSULE TABLET TABLET VIAL TABLET STRENGTH 7.5MG-1250 10 MG 5 MG 10000 UNIT 10000 UNIT 600 MG 25MG-200MG 4 MG 150 MG 200 MG 300 MG 100 MG 25 MG 50 MG 100MG-25MG 50 MG-25MG 10 MG 100 MG 18 MG 25 MG 40 MG 60 MG 80 MG 10 MG 20 MG 40 MG 80 MG 750 MG/5ML 250-100 MG 62.5-25 MG 1 % 1 % 0.05MG/ML 0.1 MG/ML 0.4 MG/ML 1 MG/ML 600MG/15ML 600MG/15ML 750 MG/5ML 750MG/15ML 600 MG 3 MG 1 MG 5 MG 100 MG 100 MG NOTE APPENDIX A PAGE 12 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 13 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION AZATHIOPRINE AZATHIOPRINE AZELASTINE HCL AZELASTINE HCL AZELASTINE HCL AZELASTINE/FLUTICASONE AZILSARTAN MED/CHLORTHALIDONE AZILSARTAN MED/CHLORTHALIDONE AZILSARTAN MEDOXOMIL AZILSARTAN MEDOXOMIL AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZITHROMYCIN AZTREONAM AZTREONAM AZTREONAM LYSINE AZTREONAM/DEXTROSE-WATER AZTREONAM/DEXTROSE-WATER B CMPLX 4/VIT D3/C/FA/ZINC OX B COMP/VIT E AC/MINERAL 3/SOYB B COMPLEX & C NO.20/FOLIC ACID B COMPLEX & C NO.20/FOLIC ACID B-SIT/M-19/DR BT-ORG PEEL/GR T B/E AC/FA/MIN CMB NO.26/SOYB B/E AC/FA/MIN CMB NO.35/SOYB BACITRACIN BACITRACIN BACITRACIN/POLYMYXIN B SULFATE BACLOFEN BACLOFEN BACLOFEN BACLOFEN BACLOFEN BACTERIOSTATIC SODIUM CHLORIDE BAICALIN/CATECHIN BAICALIN/CATECHIN BAICALIN/CATECHIN/CITRATED ZNC BAICALIN/CATECHIN/CITRATED ZNC BAICALIN/CATECHIN/CITRATED ZNC BALANCED SALT IRRIG SOLN NO.1 DOSAGE TABLET TABLET DROPS SPRAY/PUMP SPRAY/PUMP SPRAY/PUMP TABLET TABLET TABLET TABLET DROPS PACKET SUS ER REC SUSP RECON SUSP RECON TABLET TABLET TABLET VIAL VIAL VIAL VIAL-NEB FROZ.PIGGY FROZ.PIGGY TABLET TABLET CAPSULE CAPSULE CAPSULE TABLET TABLET OINT. (G) VIAL OINT. (G) AMPUL AMPUL AMPUL TABLET TABLET VIAL CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE IRRIG SOLN STRENGTH 50 MG 75 MG 0.05 % 137 MCG 205.5MCG 137-50 MCG 40 MG-25MG 40-12.5 MG 40 MG 80 MG 1 % 1 G 2 G/60 ML 100 MG/5ML 200 MG/5ML 250 MG 500 MG 600 MG 500 MG 1 G 2 G 75 MG/ML 1 G/50 ML 2 G/50 ML 1750-60-1 30 U-55MG 1 MG 1 MG 3MG-42MG 15-200-40 30-400-80 500 UNIT/G 50000 UNIT 500-10K/G 2000MCG/ML 50 MCG/ML 500 MCG/ML 10 MG 20 MG 0.9 % 250 MG 500 MG 250MG-50MG 500MG-50MG 525MG-50MG NOTE (RX ONLY) OPHTH ONLY 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION BALANCED SALT IRRIG SOLN NO.2 BALSALAZIDE DISODIUM BASILIXIMAB BASILIXIMAB BCG LIVE BECAPLERMIN BECLOMETHASONE DIPROPIONATE BECLOMETHASONE DIPROPIONATE BECLOMETHASONE DIPROPIONATE BECLOMETHASONE DIPROPIONATE BEE POLLEN BEE POLLEN BEE POLLEN BEE POLLEN BEE POLLEN BEEF,IRON & WINE BELATACEPT BELIMUMAB BELIMUMAB BENAZEPRIL HCL BENAZEPRIL HCL BENAZEPRIL HCL BENAZEPRIL HCL BENAZEPRIL/HYDROCHLOROTHIAZIDE BENAZEPRIL/HYDROCHLOROTHIAZIDE BENAZEPRIL/HYDROCHLOROTHIAZIDE BENAZEPRIL/HYDROCHLOROTHIAZIDE BENDAMUSTINE HCL BENDAMUSTINE HCL BENECALORIE 1.5 FL OZ CUPS BENEPROTEIN 7G PKTS BENEPROTEIN 8 OZ CANISTER BENZOCAINE BENZTROPINE MESYLATE BENZTROPINE MESYLATE BENZTROPINE MESYLATE BENZTROPINE MESYLATE BENZTROPINE MESYLATE BENZYL ALCOHOL BEPOTASTINE BESILATE BESIFLOXACIN HCL BETAINE BETAINE HCL BETAMET ACET/BETAMET NA PH BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE DOSAGE IRRIG SOLN CAPSULE VIAL VIAL VIAL GEL (GRAM) AER W/ADAP AER W/ADAP HFA AER AD SPRAY CAPSULE CAPSULE TAB CHEW TAB CHEW TABLET ELIXIR VIAL VIAL VIAL TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET VIAL VIAL UNIT PACKET CAN DROPS AMPUL TABLET TABLET TABLET VIAL LOTION DROPS DROPS SUSP POWDER TABLET VIAL CREAM (G) GEL (GRAM) STRENGTH 750 MG 10 MG 20 MG 50 MG 0.01 % 40 MCG 80 MCG 80 MCG 42MCG 550 MG 580MG 1000 MG 500 MG 500 MG 250 MG 120 MG 400 MG 10 MG 20 MG 40 MG 5 MG 10-12.5MG 20-12.5 MG 20-25MG 5-6.25MG 100 MG 25 MG 7.5KCAL/ML 20 % 2 MG/2 ML 0.5 MG 1 MG 2 MG 2 MG/2 ML 5 % 1.5 % 0.6 % 1 G/1.7 ML 300 MG 6 MG/ML 0.05 % 0.05 % NOTE APPENDIX A PAGE 14 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE BETAMETHASONE VALERATE BETAMETHASONE VALERATE BETAMETHASONE VALERATE BETAMETHASONE VALERATE BETAMETHASONE/PROPYLENE GLYC BETAMETHASONE/PROPYLENE GLYC BETAMETHASONE/PROPYLENE GLYC BETAXOLOL HCL BETAXOLOL HCL BETAXOLOL HCL BETAXOLOL HCL BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE BETHANECHOL CHLORIDE BEVACIZUMAB BEXAROTENE BEXAROTENE BICALUTAMIDE BIMATOPROST BIOFLAV/FA/MV/DIET7/BEE POLL BIOTIN/CALCIUM CARBONATE BISAC/NACL/NAHCO3/KCL/PEG 3350 BISACODYL BISACODYL BISACODYL/MAGNESIUM CITRATE BISMUTH/METRONID/TETRACYCLINE BISOPROLOL FUMARATE BISOPROLOL FUMARATE BISOPROLOL FUMARATE/HCTZ BISOPROLOL FUMARATE/HCTZ BISOPROLOL FUMARATE/HCTZ BLEOMYCIN SULFATE BLEOMYCIN SULFATE BLOOD KETONE TEST,STRIPS BLOOD SUGAR DIAGNOSTIC BLOOD SUGAR DIAGNOSTIC, DISC BLOOD SUGAR DIAGNOSTIC, DRUM BOCEPREVIR BOOST CHOC - 8 OZ BTL - 24/CAS BOOST GLUCOSE CONTROL CHOC - 8 BOOST GLUCOSE CONTROL STRAWBER BOOST GLUCOSE CONTROL VANILLA BOOST HIGH PROTEIN VANILLA - 8 DOSAGE LOTION OINT. (G) CREAM (G) FOAM LOTION OINT. (G) CREAM (G) LOTION OINT. (G) DROPS DROPS SUSP TABLET TABLET TABLET TABLET TABLET TABLET VIAL CAPSULE GEL (GRAM) TABLET DROPS CAPSULE TABLET KIT TABLET TABLET DR COMBO. PKG CAPSULE TABLET TABLET TABLET TABLET TABLET VIAL VIAL STRIP STRIP STRIP STRIP CAPSULE BOTTLE UNIT UNIT UNIT BOTTLE STRENGTH 0.05 % 0.05 % 0.1 % 0.12 % 0.1 % 0.1 % 0.05 % 0.05 % 0.05 % 0.5 % 0.25 % 10 MG 20 MG 10 MG 25 MG 5 MG 50 MG 25 MG/ML 75 MG 1 % 50 MG 0.01 % 3MG-67MCG 800MCG-195 5 MG-210 G 5 MG 5 MG 125-125 MG 10 MG 5 MG 10-6.25MG 2.5-6.25MG 5-6.25MG 15 UNIT 30 UNIT 200 MG NOTE APPENDIX A PAGE 15 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION BOOST KID ESSENTIALS CHOC - 8 BOOST KID ESSENTIALS CHOC - 8. BOOST KID ESSENTIALS CHOC 1.5 BOOST KID ESSENTIALS STRAWBERR BOOST KID ESSENTIALS VANILLA BOOST KID ESSENTIALS VANILLA 8 BOOST KID ESSENTIALS W/FIBER V BOOST KID ESSENTIALS 1.5 VANIL BOOST KID 1.5 ESSENTIALS STRAW BOOST PLUS CHOC - 8 OZ BTL - 2 BOOST PLUS STRAWBERRY - 8 OZ B BOOST PLUS VANILLA - 8 OZ BTL BOOST PUDDING BUTTERSCOTCH - 5 BOOST PUDDING CHOC - 5 OZ CAN BOOST PUDDING VANILLA - 5 OZ C BOOST STRAWBERRY - 8 OZ BTL BOOST VANILLA - 8 OZ BTL - 24/ BORAGE &FISH OIL/FRUCT/SOY LEC BORTEZOMIB BOSENTAN BOSENTAN BOSUTINIB BOSUTINIB BRAN BRENTUXIMAB VEDOTIN BRIGHT BEGINNING SOY - 8 OZ CA BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE BRIMONIDINE TARTRATE/TIMOLOL BRINZOLAMIDE BRINZOLAMIDE/BRIMONIDINE TART BROMFENAC SODIUM BROMFENAC SODIUM BROMOCRIPTINE MESYLATE BROMOCRIPTINE MESYLATE BROMPHENIRAMINE MALEATE BUDESONIDE BUDESONIDE BUDESONIDE BUDESONIDE BUDESONIDE BUDESONIDE BUDESONIDE BUDESONIDE BUDESONIDE/FORMOTEROL FUMARATE DOSAGE BRIK BRIK BRIK BRIK BRIK BRIK BRIK BRIK BRIK UNIT UNIT UNIT CAN CAN CAN BOTTLE BOTTLE EMULSION VIAL TABLET TABLET TABLET TABLET TABLET VIAL CAN DROPS DROPS DROPS DROPS DROPS SUSP DROPS SUSP DROPS DROPS CAPSULE TABLET DROPS AER POW BA AER POW BA AMPUL-NEB AMPUL-NEB AMPUL-NEB CAPDR - ER SPRAY/PUMP TABDR & ER HFA AER AD STRENGTH 1 G/ML 3.5 MG 125 MG 62.5 MG 100 MG 500 MG 500 MG 50 MG 0.03G-1/ML 0.1 % 0.15 % 0.2 % 0.2%-0.5% 1 % 1 %-0.2 % 0.07 % 0.09% 5 MG 2.5 MG 1 MG/ML 180 MCG 90 MCG 0.25MG/2ML 0.5 MG/2ML 1 MG/2 ML 3 MG 32MCG 9 MG 160-4.5MCG NOTE APPENDIX A PAGE 16 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION BUDESONIDE/FORMOTEROL FUMARATE BUMETANIDE BUMETANIDE BUMETANIDE BUMETANIDE BUPIVACAINE HCL BUPIVACAINE HCL BUPIVACAINE HCL BUPIVACAINE HCL/DEX-WATER/PF BUPIVACAINE HCL/EPINEPHRINE BUPIVACAINE HCL/EPINEPHRINE BUPIVACAINE HCL/EPINEPHRINE BUPIVACAINE HCL/EPINEPHRINE/PF BUPIVACAINE HCL/EPINEPHRINE/PF BUPIVACAINE HCL/PF BUPIVACAINE HCL/PF BUPIVACAINE HCL/PF BUPIVACAINE HCL/PF BUPRENORPHINE BUPRENORPHINE BUPRENORPHINE BUPRENORPHINE BUPRENORPHINE BUPRENORPHINE HCL BUPRENORPHINE HCL BUPRENORPHINE HCL BUPRENORPHINE HCL BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE HCL/NALOXONE HCL BUPRENORPHINE HCL/NALOXONE HCL BUPROPION HBR BUPROPION HBR BUPROPION HCL BUPROPION HCL BUPROPION HCL BUPROPION HCL BUPROPION HCL BUPROPION HCL DOSAGE HFA AER AD TABLET TABLET TABLET VIAL POWDER VIAL VIAL AMPUL VIAL VIAL VIAL VIAL VIAL AMPUL VIAL VIAL VIAL PATCH TDWK PATCH TDWK PATCH TDWK PATCH TDWK PATCH TDWK AMPUL SYRINGE TAB SUBL TAB SUBL FILM FILM FILM FILM FILM FILM FILM TAB SUBL TAB SUBL TAB SUBL TAB SUBL TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TABLET TABLET TABLET ER STRENGTH 80-4.5 MCG 0.5 MG 1 MG 2 MG 0.25 MG/ML 100 % 2.5 MG/ML 5 MG/ML 0.75 % 0.25-.0005 0.5-1:200K 0.5-1:200K 0.25-.0005 0.5-1:200K 2.5 MG/ML 2.5 MG/ML 5 MG/ML 7.5 MG/ML 10 MCG/HR 15 MCG/HR 20 MCG/HR 5 MCG/HR 7.5 MCG/HR 0.3 MG/ML 0.3 MG/ML 2 MG 8 MG 12 MG-3 MG 2 MG-0.5MG 2.1-0.3 MG 4.2-0.7 MG 4MG-1MG 6.3MG-1MG 8 MG-2 MG 1.4-0.36MG 2 MG-0.5MG 5.7-1.4 MG 8 MG-2 MG 174MG 348MG 150 MG 300 MG 450 MG 100 MG 75 MG 100 MG NOTE 50ML APPENDIX A PAGE 17 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION BUPROPION HCL BUPROPION HCL BUSPIRONE HCL BUSPIRONE HCL BUSPIRONE HCL BUSPIRONE HCL BUSPIRONE HCL BUSULFAN BUTABARBITAL SODIUM BUTABARBITAL SODIUM BUTABARBITAL SODIUM BUTALB/ACETAMINOPHEN/CAFFEINE BUTALB/ACETAMINOPHEN/CAFFEINE BUTALB/ACETAMINOPHEN/CAFFEINE BUTALB/ACETAMINOPHEN/CAFFEINE BUTALBIT/ACETAMIN/CAFF/CODEINE BUTALBIT/ACETAMIN/CAFF/CODEINE BUTALBITAL/ACETAMINOPHEN BUTALBITAL/ACETAMINOPHEN BUTALBITAL/ASPIRIN/CAFFEINE BUTENAFINE HCL BUTORPHANOL TARTRATE BUTORPHANOL TARTRATE BUTORPHANOL TARTRATE B2/MAG CIT & OX/FEVERFEW B3/AZEL AC/ZINC/B6/COPPER/FA B3/AZEL/QUER/TUR/FA/B6/ZN/COPP B3/B6/C/FA/COPPR/MG/ZN/ALIP AC B6/FA/B12/CO Q10/HERB NO.225 C/B-6/NIACIN/FA/B12/HERB#192 C/CHROMIUM/CHITOS/BRIN/HERB188 C/D3/E/FA/ZN/SELEN/LYC/L-CARNI C/E/FA/ZINC/SELEN/LEVOCAR/LYCO C/E/FA/ZINC/SELENIUM/LYCOPENE C/ECH/ST.JHNWT/ELD/SGIN/HRB30 C/HESP METH CHAL/DIOSM/BUTC BR C/NIAC/CHROM POLYNICOTIN/OAT/P CA CARB/CA CIT/MG-ZN/D3/HC122 CA CARB/D3/GLUC/CHNDR/SY IS/BR CA CARB/D3/SOY/HORSET/LACTOBAC CA CARB/MAGNESIUM/CAPS/GINGER CA CARB/SOYB XT/FLAX/BLK COH CA CITRATE/VIT D3/ISOFLAVON #2 CA PH TRI/E AC SUCC/HERB23 CA PHOS/CRANBERRY/MILK THISTLE CABAZITAXEL DOSAGE TABLET ER TABLET ER TABLET TABLET TABLET TABLET TABLET TABLET ELIXIR TABLET TABLET CAPSULE CAPSULE SOLUTION TABLET CAPSULE CAPSULE TABLET TABLET CAPSULE CREAM (G) SPRAY VIAL VIAL TABLET TABLET TABLET TABLET TABLET CAPSULE TABLET COMBO. PKG TABLET TABLET CAPSULE TABLET TABLET TABLET TABLET TABLET TABLET TABLET ER TABLET TABLET CAPSULE VIAL STRENGTH 150 MG 200 MG 10 MG 15 MG 30 MG 5 MG 7.5 MG 2 MG 30 MG/5 ML 30 MG 50 MG 50-300-40 50-325-40 50-325/15 50-325-40 50-300-30 50-325-30 50MG-300MG 50MG-325MG 50-325-40 1 % 10 MG/ML 1 MG/ML 2 MG/ML 200-180-50 600-5-500 700 MG-500 800-10-100 100-0.8MG 60-5-2.5MG 100-67-333 250 MG-500 125MG-100 250 MG-200 150-150MG 75-12.5-50 250 MG-100 335-80-170 141MG-5-60 100-40-100 186-100-40 100MG-1000 FNL10MG/ML NOTE APPENDIX A PAGE 18 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION CABERGOLINE CAF/CHOL BTT/AA COMB.NO7/HC125 CAFF/CHOLINE/AA COMB.NO7/HC125 CAFF/CHOLINE/AA COMB.NO7/HC125 CAFFEIN/AA COMB13/CINN/HC135 CAFFEIN/CHOL BITART/AA11/HC130 CAFFEIN/CHOL/AA COMB12/HC131 CAFFEIN/CHOLINE BIT/AA11/HC130 CAFFEINE CITRATED CAFFEINE CITRATED CAFFEINE/NIA/VIT B6/HRB CB133 CAFFEINE/PRAST (DHEA)/B6/HC132 CAL CARB/MGOX/D3/B12/FA/B6/BOR CAL LAC/MAG CIT/PASS FLW/VALER CAL PHOS/BRINDAL BERRY CAL PHOS/CHROM/BRINDAL BERRY CALC/MAG/CHON/BR/HB#180/MIN#36 CALCIPOTRIENE CALCIPOTRIENE CALCIPOTRIENE CALCIPOTRIENE CALCIPOTRIENE/BETAMETHASONE CALCIPOTRIENE/BETAMETHASONE CALCITONIN,SALMON,SYNTHETIC CALCITONIN,SALMON,SYNTHETIC CALCITRIOL CALCITRIOL CALCITRIOL CALCITRIOL CALCIUM ACETATE CALCIUM ACETATE CALCIUM ACETATE CALCIUM CARBONATE CALCIUM CARBONATE CALCIUM CARBONATE/MAG CARB CALCIUM CARBONATE/MAG CARB/FA CALCIUM CASEINATE/WHEY CALCIUM CHLORIDE CALCIUM CHLORIDE CALCIUM GLUBIONATE CALCIUM GLUCONATE CALCIUM GLUCONATE CALCIUM POLYCARBOPHIL CALCIUM PYRUVATE CALCIUM/FOLIC ACID/MIN/SOYBEAN CALCIUM/MAGNESIUM/HERBA1 #180 DOSAGE TABLET CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE SOLUTION VIAL CAPSULE CAPSULE TABLET TABLET TABLET TABLET TABLET CREAM (G) FOAM OINT. (G) SOLUTION OINT. (G) SUSPENSION SPRAY/PUMP VIAL CAPSULE CAPSULE OINT. (G) SOLUTION CAPSULE SOLUTION TABLET ORAL SUSP TABLET TABLET TABLET PACKET SYRINGE VIAL SYRUP TABLET VIAL TABLET CAPSULE POWDER TABLET STRENGTH 0.5 MG 40MG-101MG 40.5-101MG 40MG-101MG 6.25-162.5 37.5-125MG 6.5-125MG 14 MG-47MG 60 MG/3 ML 60 MG/3 ML 25-5-0.5MG 24.5-6.25 500-1.1MG 25-50-20MG 250-115MG 500-75-200 167-65-50 0.005 % 0.005 % 0.005 % 0.005 % 0.005-.064 0.005-.064 200/SPRAY 200/ML 0.25 MCG 0.5 MCG 3 MCG/G 1 MCG/ML 667 MG 667 MG/5ML 667 MG 500 MG/5ML 500(1250) 250-300MG 200-400-1 7.5G 100 MG/ML 100 MG/ML 115MG/5ML 45(500) MG 100 MG/ML 625 MG 750 MG 350-46MG 167-65-200 NOTE APPENDIX A PAGE 19 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION CALCIUM/PHOS/GENIST/D3/ZN/K CALORIC SUPPLEMENT CALORIC SUPPLEMENT CALORIC SUPPLEMENT CALORIC SUPPLEMENT CANAGLIFLOZIN CANAGLIFLOZIN CANAKINUMAB/PF CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL CANDESARTAN CILEXETIL CANDESARTAN/HYDROCHLOROTHIAZID CANDESARTAN/HYDROCHLOROTHIAZID CANDESARTAN/HYDROCHLOROTHIAZID CAPECITABINE CAPECITABINE CAPSAICIN/SKIN CLEANSER CAPTOPRIL CAPTOPRIL CAPTOPRIL CAPTOPRIL CAPTOPRIL PWD CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE CARBACHOL CARBAMAZEPINE CARBAMAZEPINE CARBAMAZEPINE CARBAMAZEPINE CARBAMAZEPINE CARBAMAZEPINE CARBAMAZEPINE CARBAMAZEPINE CARBAMAZEPINE CARBAMAZEPINE CARBIDOPA CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA DOSAGE CAPSULE LIQUID LIQUID POWDER POWDER TABLET TABLET VIAL TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET KIT TABLET TABLET TABLET TABLET UNIT TABLET TABLET TABLET TABLET VIAL CPMP 12HR CPMP 12HR CPMP 12HR ORAL SUSP ORAL SUSP TAB CHEW TAB ER 12H TAB ER 12H TAB ER 12H TABLET TABLET TAB RAPDIS TAB RAPDIS TAB RAPDIS TABLET TABLET TABLET TABLET ER STRENGTH 500MG-70MG 7.5KCAL/ML 96 G-384 100 MG 300 MG 180 MG/1.2 16 MG 32 MG 4 MG 8 MG 16-12.5MG 32-12.5MG 32MG-25MG 150 MG 500 MG 8 % 100 MG 12.5 MG 25 MG 50 MG 100 % 25 MG-15MG 25 MG-25MG 50 MG-15MG 50 MG-25MG 0.01 % 100 MG 200 MG 300 MG 100 MG/5ML 200MG/10ML 100 MG 100 MG 200 MG 400 MG 200 MG 25 MG 10MG-100MG 25MG-100MG 25MG-250MG 10MG-100MG 25MG-100MG 25MG-250MG 25MG-100MG NOTE APPENDIX A PAGE 20 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA/LEVODOPA/ENTACAPONE CARBIDOPA/LEVODOPA/ENTACAPONE CARBINOXAMINE MALEATE CARBINOXAMINE MALEATE CARBOPLATIN CARBOPLATIN CARDIOPLEGIC SOLUTION NO.1 CARGLUMIC ACID CARISOPRODOL CARISOPRODOL CARISOPRODOL/ASPIRIN CARNATION INSTANT BREAKFAST L CARNATION INSTANT BREAKFAST LF CARNATION INSTANT BREAKFAST LF CARTEOLOL HCL CARVEDILOL CARVEDILOL CARVEDILOL CARVEDILOL CARVEDILOL PHOSPHATE CARVEDILOL PHOSPHATE CARVEDILOL PHOSPHATE CARVEDILOL PHOSPHATE CARVEDILOL TABS CASANTHRANOL/DOSS POTASSIUM CASCARA SAGRADA CASCARA SAGRADA CASEIN CASEIN/MILK, NF, SKIM/PALM OIL CASEIN/MILK, NF, SKIM/PALM OIL CASPOFUNGIN ACETATE CASPOFUNGIN ACETATE CASTOR OIL CEFACLOR CEFACLOR CEFACLOR CEFACLOR CEFADROXIL CEFADROXIL CEFADROXIL CEFADROXIL DOSAGE TABLET ER TABLET TABLET TABLET TABLET TABLET TABLET LIQUID TABLET VIAL VIAL PLST BG PF TAB DISPER TABLET TABLET TABLET UNIT UNIT UNIT DROPS TABLET TABLET TABLET TABLET CPMP 24HR CPMP 24HR CPMP 24HR CPMP 24HR UNIT CAPSULE CAPSULE ORAL SUSP POWDER POWD PACK POWDER VIAL VIAL OIL CAPSULE CAPSULE SUSP RECON TAB ER 12H CAPSULE SUSP RECON SUSP RECON TABLET STRENGTH 50MG-200MG 12.5-50 MG 18.75-75MG 25-100-200 31.25-125 37.5-150MG 50-200-200 4 MG/5 ML 4 MG 10 MG/ML 150 MG K+=16MEQ/L 200 MG 250 MG 350 MG 200-325 MG 22.5G-560 1 % 12.5 MG 25 MG 3.125 MG 6.25 MG 10 MG 20 MG 40 MG 80 MG 12.5 MG 30MG-100MG 450 MG 50 MG/15ML 2 G-100/15 13.6G-667 50 MG 70 MG 250 500 250 500 500 250 500 1 G MG MG MG/5ML MG MG MG/5ML MG/5ML NOTE APPENDIX A PAGE 21 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION CEFAZOLIN SODIUM CEFAZOLIN SODIUM CEFAZOLIN SODIUM CEFAZOLIN SODIUM CEFAZOLIN SODIUM/DEXTROSE,ISO CEFAZOLIN SODIUM/DEXTROSE,ISO CEFDINIR CEFDINIR CEFDINIR CEFDITOREN PIVOXIL CEFEPIME HCL CEFEPIME HCL CEFEPIME HCL/DEXTROSE, ISO-OSM CEFEPIME HCL/DEXTROSE, ISO-OSM CEFIXIME CEFIXIME CEFIXIME CEFIXIME CEFIXIME CEFOTAXIME SODIUM CEFOTAXIME SODIUM CEFOTAXIME SODIUM CEFOTAXIME SODIUM CEFOTAXIME SODIUM CEFOTAXIME SODIUM CEFOTETAN DISOD/DEXTROSE,ISO CEFOTETAN DISOD/DEXTROSE,ISO CEFOTETAN DISODIUM CEFOTETAN DISODIUM CEFOTETAN DISODIUM CEFOXITIN SODIUM CEFOXITIN SODIUM CEFOXITIN SODIUM CEFOXITIN SODIUM/DEXTROSE,ISO CEFOXITIN SODIUM/DEXTROSE,ISO CEFPODOXIME PROXETIL CEFPODOXIME PROXETIL CEFPODOXIME PROXETIL CEFPODOXIME PROXETIL CEFPROZIL CEFPROZIL CEFPROZIL CEFPROZIL CEFTAROLINE FOSAMIL ACETATE CEFTAROLINE FOSAMIL ACETATE CEFTAZIDIME NA/DEXTROSE,ISO DOSAGE VIAL VIAL VIAL VIAL PORT PIGGYBACK PIGGYBACK CAPSULE SUSP RECON SUSP RECON TABLET VIAL VIAL FROZ.PIGGY FROZ.PIGGY CAPSULE SUSP RECON SUSP RECON TAB CHEW TAB CHEW VIAL VIAL VIAL VIAL VIAL PORT VIAL PORT PIGGYBACK PIGGYBACK VIAL VIAL VIAL VIAL VIAL VIAL PIGGYBACK PIGGYBACK SUSP RECON SUSP RECON TABLET TABLET SUSP RECON SUSP RECON TABLET TABLET VIAL VIAL FROZ.PIGGY STRENGTH 1 G 10 G 500 MG 1 G 1 G/50 ML 2 G/50 ML 300 MG 125 MG/5ML 250 MG/5ML 400 MG 1 G 2 G 1 G/50 ML 2 G/100 ML 400 MG 100 MG/5ML 200 MG/5ML 100 MG 200 MG 1 G 10 G 2 G 500 MG 1 G 2 G 1 G/50 ML 2 G/50 ML 1 G 10 G 2 G 1 G 10 G 2 G 1 G/50 ML 2 G/50 ML 100 MG/5ML 50 MG/5 ML 100 MG 200 MG 125 MG/5ML 250 MG/5ML 250 MG 500 MG 400 MG 600 MG 2 G/50 ML NOTE APPENDIX A PAGE 22 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION CEFTAZIDIME PENTAHYDRATE CEFTAZIDIME PENTAHYDRATE CEFTAZIDIME PENTAHYDRATE CEFTAZIDIME PENTAHYDRATE CEFTAZIDIME PENTAHYDRATE CEFTAZIDIME PENTAHYDRATE/D5W CEFTAZIDIME PENTAHYDRATE/D5W CEFTIBUTEN DIHYDRATE CEFTIBUTEN DIHYDRATE CEFTRIAXONE NA/DEXTROSE,ISO CEFTRIAXONE NA/DEXTROSE,ISO CEFTRIAXONE NA/DEXTROSE,ISO CEFTRIAXONE NA/DEXTROSE,ISO CEFTRIAXONE SODIUM CEFTRIAXONE SODIUM CEFTRIAXONE SODIUM CEFTRIAXONE SODIUM CEFTRIAXONE SODIUM CEFTRIAXONE SODIUM CEFTRIAXONE SODIUM CEFUROXIME AXETIL CEFUROXIME AXETIL CEFUROXIME AXETIL CEFUROXIME AXETIL CEFUROXIME SODIUM CEFUROXIME SODIUM CEFUROXIME SODIUM CEFUROXIME SODIUM CEFUROXIME SODIUM CELECOXIB CELECOXIB CELECOXIB CELECOXIB CELLULOSE GUM CELLULOSE GUM CEPHALEXIN CEPHALEXIN CEPHALEXIN CEPHALEXIN CEPHALEXIN CEPHALEXIN CEPHALEXIN CERTOLIZUMAB PEGOL CERTOLIZUMAB PEGOL CETIRIZINE HCL CETIRIZINE HCL DOSAGE VIAL VIAL VIAL VIAL PORT VIAL PORT PIGGYBACK PIGGYBACK CAPSULE SUSP RECON FROZ.PIGGY FROZ.PIGGY PIGGYBACK PIGGYBACK VIAL VIAL VIAL VIAL VIAL VIAL PORT VIAL PORT SUSP RECON SUSP RECON TABLET TABLET VIAL VIAL VIAL VIAL PORT VIAL PORT CAPSULE CAPSULE CAPSULE CAPSULE PACKET POWDER CAPSULE CAPSULE CAPSULE SUSP RECON SUSP RECON TABLET TABLET KIT SYRINGEKIT SOLUTION TAB CHEW STRENGTH 1 G 2 G 6G 1 G 2 G 1 G/50 ML 2 G/50 ML 400 MG 180 MG/5ML 1 G/50 ML 2 G/50 ML 1 G/50 ML 2 G/50 ML 1 G 10 G 2 G 250 MG 500 MG 1 G 2 G 125 MG/5ML 250 MG/5ML 250 MG 500 MG 1.5 G 7.5G 750 MG 1.5 G 750 MG 100 MG 200 MG 400 MG 50 MG 250 MG 500 MG 750 MG 125 MG/5ML 250 MG/5ML 250 MG 500 MG 400 MG 400MG/2ML 1 MG/ML 10 MG NOTE APPENDIX A PAGE 23 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION CETIRIZINE HCL CETIRIZINE HCL CETIRIZINE HCL CETIRIZINE HCL/PSEUDOEPHEDRINE CETUXIMAB CETUXIMAB CEVIMELINE HCL CH/GL/CAR/PID/TY/DMAE/DHA/H151 CHENODIOL CHIA SEED/ALA/LINOLEIC/OLEIC CHITOSAN CHLORAMBUCIL CHLORAMPHENICOL SOD SUCC CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL CHLOREL/CHLOROPH/D3/B2/FA/IRON CHLORHEXIDINE GLUCONATE CHLOROQUINE PHOSPHATE CHLOROQUINE PHOSPHATE CHLOROTHIAZIDE CHLOROTHIAZIDE CHLOROTHIAZIDE CHLOROTHIAZIDE SODIUM CHLORPROMAZINE HCL CHLORPROMAZINE HCL CHLORPROMAZINE HCL CHLORPROMAZINE HCL CHLORPROMAZINE HCL CHLORPROMAZINE HCL CHLORPROPAMIDE CHLORPROPAMIDE CHLORTHALIDONE CHLORTHALIDONE CHLORZOXAZONE CHLORZOXAZONE CHLORZOXAZONE CHO/AA21/GABA/INO/GRIF/GLU/CRE CHOL BITART/AA COMB.NO7/HC125 CHOL BITART/AA10/GABA/HC129 CHOL/AA10/GABA/HERB129/PRT/LEC CHOL/GL/SER/RNA/PHEN/PRG/HB150 CHOLECALCIFEROL (VITAMIN D3) CHOLESTEROL/SOYBEAN OIL/C/E CHOLESTYRAMINE (WITH SUGAR) CHOLESTYRAMINE (WITH SUGAR) DOSAGE TAB CHEW TABLET TABLET TAB ER 12H VIAL VIAL CAPSULE TABLET TABLET CAPSULE CAPSULE TABLET VIAL CAPSULE CAPSULE CAPSULE CAPSULE MOUTHWASH TABLET TABLET ORAL SUSP TABLET TABLET VIAL AMPUL TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE POWD PACK TABLET CAPSULE POWDER POWD PACK POWDER STRENGTH 5 MG 10 MG 5 MG 5 MG-120MG 100MG/50ML 200MG/0.1L 30 MG 40-125-125 250 MG 1000 MG 500 MG 2 MG 1 G 10 MG 25 MG 5 MG 0.45 G-67 0.12 % 250 MG 500 MG 250 MG/5ML 250 MG 500 MG 500 MG 25 MG/ML 10 MG 100 MG 200 MG 25 MG 50 MG 100 MG 250 MG 25 MG 50 MG 375 MG 500 MG 750 MG 35.2-10.2 383.5-41MG 101.5MG 62.5-100-9 250-250 MG 50000 UNIT 60-200-80 4 G 4 G NOTE APPENDIX A PAGE 24 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION CHOLESTYRAMINE/ASPARTAME CHOLESTYRAMINE/ASPARTAME CHOLINE BIT/AA COMB.NO7/HC125 CHOLINE BIT/AA COMB.NO7/HC125 CHOLINE BIT/AA10/GABA/HC129 CHOLINE BIT/AA10/GABA/HC129 CHOLINE DIHYDROGEN CITRATE CHONDRO SU A/VIT C/MANGANESE CHONDROITIN SUL A NA CHONDROITIN SULFATE A SODIUM CHORIONIC GONADOTROPIN, HUMAN CHRM/CIDER/DR BT-ORG PEEL/GR T CHRM/CIDER/DR BT-ORG PEEL/GR T CHROMIC CHLORIDE CHROMIUM CHLORIDE/BEAN POD EXT CHROMIUM PICOLINATE/CHITOSAN CHROMIUM PICOLINATE/VITAMIN D3 CHROMIUM/HERBAL COMPLEX NO.238 CHROMIUM/VIT B #13/FA/DHA/EPA CICLESONIDE CICLESONIDE CICLESONIDE CICLESONIDE CICLOPIROX CICLOPIROX CICLOPIROX CICLOPIROX OLAMINE CICLOPIROX OLAMINE CICLOPIROX/NAIL LACQUER REMOVR CIDER VINEGAR CIDER VINEGAR CIDER/AP PECTIN/GYM LF/B6/MC32 CIDOFOVIR CILOSTAZOL CILOSTAZOL CIMETIDINE CIMETIDINE CIMETIDINE CIMETIDINE CIMETIDINE HCL CINACALCET HCL CINACALCET HCL CINACALCET HCL CINNAMON BARK/CHROMIUM/ALA CIPROFLOXACIN CIPROFLOXACIN DOSAGE POWD PACK POWDER CAPSULE CAPSULE CAPSULE CAPSULE TABLET CAPSULE CAPSULE CAPSULE VIAL TABLET TABLET VIAL CAPSULE TABLET TABLET TABLET CAPSULE HFA AER AD HFA AER AD HFA AER AD SPRAY/PUMP GEL (GRAM) SHAMPOO SOLUTION CREAM (G) SUSPENSION KIT CAPSULE TABLET TABLET VIAL TABLET TABLET TABLET TABLET TABLET TABLET SOLUTION TABLET TABLET TABLET CAPSULE SUS MC REC SUS MC REC STRENGTH 4 G 4 G 101 MG 383.5-41MG 101.5MG 62.5-100MG 650 MG 400-60-2.5 400 MG 400 MG 10000 UNIT 500-133MG 500-300-60 4MCG/ML 20 MCG-500 0.05-500MG 1000-400 250MCG-775 1000-1-300 160 MCG 37 MCG 80 MCG 50 MCG 0.77 % 1 % 8 % 0.77 % 0.77 % 8 % 600 MG 300 MG 300-50-200 75 MG/ML 100 MG 50 MG 200 MG 300 MG 400 MG 800 MG 300 MG/5ML 30 MG 60 MG 90 MG 500-0.1 MG 250 MG/5ML 500 MG/5ML NOTE APPENDIX A PAGE 25 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION CIPROFLOXACIN HCL CIPROFLOXACIN HCL CIPROFLOXACIN HCL CIPROFLOXACIN HCL CIPROFLOXACIN HCL CIPROFLOXACIN HCL CIPROFLOXACIN HCL CIPROFLOXACIN HCL/DEXAMETH CIPROFLOXACIN LACTATE CIPROFLOXACIN LACTATE CIPROFLOXACIN LACTATE/D5W CIPROFLOXACIN LACTATE/D5W CIPROFLOXACIN/CIPROFLOXA HCL CIPROFLOXACIN/CIPROFLOXA HCL CIPROFLOXACIN/HYDROCORTISONE CISPLATIN CITALOPRAM HYDROBROMIDE CITALOPRAM HYDROBROMIDE CITALOPRAM HYDROBROMIDE CITALOPRAM HYDROBROMIDE CITICOLINE SODIUM CITICOLINE SODIUM CITICOLINE SODIUM CITRIC ACID/G-LACTONE/MAG CARB CITRIC ACID/SODIUM CITRATE CITRIC ACID/SODIUM CITRATE CITRULLINE CITRULLINE CITRULLINE CITRULLINE CITRULLINE CLARITHROMYCIN CLARITHROMYCIN CLARITHROMYCIN CLARITHROMYCIN CLARITHROMYCIN CLEMASTINE FUMARATE CLINDAMYCIN HCL CLINDAMYCIN HCL CLINDAMYCIN HCL CLINDAMYCIN PALMITATE HCL CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE DOSAGE DROPERETTE DROPS OINT. (G) TABLET TABLET TABLET TABLET DROPS SUSP VIAL VIAL PIGGYBACK PIGGYBACK TBMP 24HR TBMP 24HR DROPS SUSP VIAL SOLUTION TABLET TABLET TABLET SOLN PK ML TABLET TABLET IRRIG SOLN SOLUTION SOLUTION CAPSULE CAPSULE POWD PACK POWD PACK POWDER SUSP RECON SUSP RECON TAB ER 24H TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE SOLN RECON CREAM/APPL CRM ER (G) FOAM SUPP.VAG VIAL STRENGTH 0.2 % 0.3 % 0.3 % 100 MG 250 MG 500 MG 750 MG 0.3 %-0.1% 200MG/20ML 400MG/40ML 200MG/0.1L 400MG/0.2L 1000 MG 500 MG 0.2 %-1 % 1 MG/ML 10 MG/5 ML 10 MG 20 MG 40 MG 1000 MG/10 1000 MG 500 MG 6.602G/100 334-500MG 640-490MG 400 MG 600 MG 1 G/4 G 200 MG/4 G 125 MG/5ML 250 MG/5ML 500 MG 250 MG 500 MG 2.68 MG 150 MG 300 MG 75 MG 75 MG/5 ML 2 % 2 % 1 % 100 MG 150 MG/ML NOTE APPENDIX A PAGE 26 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE/D5W CLINDAMYCIN PHOSPHATE/D5W CLINDAMYCIN PHOSPHATE/D5W CLOBAZAM CLOBAZAM CLOBAZAM CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE/EMOLL CLOBETASOL PROPIONATE/EMOLL CLOCORTOLONE PIVALATE CLOMIPRAMINE HCL CLOMIPRAMINE HCL CLOMIPRAMINE HCL CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONIDINE CLONIDINE CLONIDINE CLONIDINE HCL CLONIDINE HCL CLONIDINE HCL CLONIDINE HCL CLOPIDOGREL BISULFATE CLOPIDOGREL BISULFATE CLORAZEPATE DIPOTASSIUM CLORAZEPATE DIPOTASSIUM CLORAZEPATE DIPOTASSIUM CLOTRIMAZOLE CLOTRIMAZOLE CLOTRIMAZOLE DOSAGE VIAL PORT VIAL PORT VIAL PORT PIGGYBACK PIGGYBACK PIGGYBACK ORAL SUSP TABLET TABLET CREAM (G) FOAM GEL (GRAM) LOTION OINT. (G) SHAMPOO SOLUTION SPRAY CREAM (G) FOAM CREAM (G) CAPSULE CAPSULE CAPSULE TAB RAPDIS TAB RAPDIS TAB RAPDIS TAB RAPDIS TAB RAPDIS TABLET TABLET TABLET PATCH TDWK PATCH TDWK PATCH TDWK TAB ER 12H TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET CREAM (G) SOLUTION TROCHE STRENGTH 300 MG/2ML 600 MG/4ML 900MG/6ML 300MG/50ML 600MG/50ML 900MG/50ML 2.5 MG/ML 10 MG 20 MG 0.05 % 0.05 % 0.05 % 0.05 % 0.05 % 0.05 % 0.05 % 0.05 % 0.05 % 0.05 % 0.1 % 25 MG 50 MG 75 MG 0.125 MG 0.25 MG 0.5 MG 1 MG 2 MG 0.5 MG 1 MG 2 MG 0.1MG/24HR 0.2MG/24HR 0.3MG/24HR 0.1 MG 0.1 MG 0.2 MG 0.3 MG 300 MG 75 MG 15 MG 3.75 MG 7.5 MG 1 % 1 % 10 MG NOTE APPENDIX A PAGE 27 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION CLOTRIMAZOLE/BETAMETHASONE DIP CLOTRIMAZOLE/BETAMETHASONE DIP CLOZAPINE CLOZAPINE CLOZAPINE CLOZAPINE CLOZAPINE CLOZAPINE CLOZAPINE CLOZAPINE CLOZAPINE CLOZAPINE CLYTROL VANILLA 250 ML COAGULATION FACTOR VIIA,RECOMB COAGULATION FACTOR VIIA,RECOMB COAGULATION FACTOR VIIA,RECOMB COAGULATION FACTOR VIIA,RECOMB COBICISTAT COCAINE HCL COCAINE HCL COCONUT OIL CODEINE SULFATE CODEINE SULFATE CODEINE SULFATE CODEINE/BUTALBITAL/ASA/CAFFEIN CODEINE/CARISOPRODOL/ASPIRIN COENZYME Q10-L-CARNITINE-VIT E COENZYME Q10-L-CARNITINE-VIT E COENZYME Q10/L-CARNITINE COLCHICINE COLCHICINE/PROBENECID COLESEVELAM HCL COLESEVELAM HCL COLESTIPOL HCL COLESTIPOL HCL COLESTIPOL HCL COLESTIPOL HCL COLISTIN (COLISTIMETHATE NA) COLLAGENASE CLOSTRIDIUM HIST. COLLAGENASE CLOSTRIDIUM HIST. COLOSTRUM/SE/GR TEA/MUSH CMB1 COLOSTRUM, BOVINE COMPLEAT CLOSED SYSTEM CONTAIN COMPLEAT PEDIATRIC UNFLAVORED COMPLEAT UNFLAVORED - 250ML CA CONDOMS, LATEX, LUBRICATED DOSAGE CREAM (G) LOTION ORAL SUSP TAB RAPDIS TAB RAPDIS TAB RAPDIS TAB RAPDIS TAB RAPDIS TABLET TABLET TABLET TABLET UNIT VIAL VIAL VIAL VIAL TABLET SOLUTION SOLUTION CAPSULE TABLET TABLET TABLET CAPSULE TABLET CAPSULE CAPSULE CAPSULE TABLET TABLET POWD PACK TABLET GRANULES PACKET PACKET TABLET VIAL OINT. (G) VIAL TABLET CAPSULE UNIT UNIT UNIT EACH STRENGTH 1 %-0.05 % 1 %-0.05 % 50 MG/ML 100 MG 12.5 MG 150 MG 200 MG 25 MG 100 MG 200 MG 25 MG 50 MG 1 MG 2 MG 5 MG 8 MG 150 MG 10 % 4 % 1000 MG 15 MG 30 MG 60 MG 30-50-325 16-200-325 25-50-30 30-250-75 100MG-20MG 0.6 MG 0.5-500MG 3.75 G 625 MG 5 G 5 G 7.5G 1 G 150 MG 250 UNIT/G 0.9 MG 300-0.1MG 500 MG NOTE APPENDIX A PAGE 28 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION CONDOMS, LATEX, NON-LUBRICATED COPPER CORN STARCH CORN STARCH CORN STARCH CORTICOTROPIN CORTISONE ACETATE COSYNTROPIN COSYNTROPIN CR NICOTIN/GLUCO/BN/CHIT/H102 CRAN/VITC/MANNOSE/FOS/BROMELN CRAN/VITC/MANNOSE/FOS/BROMELN CRANBERRY EXTRACT/MULTIVITAMIN CRANBERRY JUICE CREATINE MONOHYDRATE CREATINE MONOHYDRATE CRIZOTINIB CRIZOTINIB CROFELEMER CROMOLYN SODIUM CROMOLYN SODIUM CROMOLYN SODIUM CROTAMITON CROTAMITON CRUICAL ULTRAPAK SYSTEM - 1000 CRUICAL UNFLAVORED - 250ML CAN CUPRIC CHLORIDE CYANOCOBALAMIN (VITAMIN B-12) CYANOCOBALAMIN (VITAMIN B-12) CYANOCOBALAMIN/FA/PYRIDOXINE CYANOCOBALAMIN/FA/PYRIDOXINE CYANOCOBALAMIN/FA/PYRIDOXINE CYANOCOBALAMIN/FA/PYRIDOXINE CYCLOBENZAPRINE HCL CYCLOBENZAPRINE HCL CYCLOBENZAPRINE HCL CYCLOBENZAPRINE HCL CYCLOPENTOLATE HCL CYCLOPENTOLATE HCL CYCLOPENTOLATE HCL CYCLOPENTOLATE/PHENYLEPHRINE CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE CYCLOSPORINE DOSAGE EACH IUD LIQUID PACKET POWDER VIAL TABLET VIAL VIAL CAPSULE LIQUID LIQUID POWD PACK LIQUID POWD PACK POWDER CAPSULE CAPSULE TABLET DR AMPUL-NEB DROPS SOLUTION CREAM (G) LOTION UNIT UNIT VIAL SPRAY VIAL TABLET TABLET TABLET TABLET CAP ER 24H CAP ER 24H TABLET TABLET DROPS DROPS DROPS DROPS CAPSULE VIAL VIAL VIAL AMPUL STRENGTH 380 SQ MM 80 UNIT/ML 25 MG 0.25 MG 0.25 MG/ML 75-200-200 1937 MG/15 3875MG/30 500 MG/5 G 5000 MG 200 MG 250 MG 125 MG 20 MG/2 ML 4 % 20 MG/ML 10 % 10 % 0.4 MG/ML 500MCG/SPR 1000MCG/ML 0.5-2.2-25 1-2.2-25MG 1-2.5-25MG 2-2.5-25MG 15 MG 30 MG 10 MG 5 MG 0.5 % 1 % 2 % 0.2 %-1 % 25 MG 1 G 2 G 500 MG 250 MG/5ML NOTE APPENDIX A PAGE 29 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION CYCLOSPORINE CYCLOSPORINE CYCLOSPORINE CYCLOSPORINE CYCLOSPORINE, MODIFIED CYCLOSPORINE, MODIFIED CYCLOSPORINE, MODIFIED CYCLOSPORINE, MODIFIED CYPROHEPTADINE HCL CYPROHEPTADINE HCL CYSTEAMINE BITARTRATE CYSTEAMINE BITARTRATE CYSTEAMINE BITARTRATE CYSTEAMINE BITARTRATE CYSTEINE HCL CYSTEINE HCL CYSTEINE HCL CYSTEINE HCL CYSTEINE HCL CYSTINE CYTARABINE CYTARABINE LIPOSOME/PF CYTARABINE/PF CYTOMEGALOVIRUS IMMUNE GLOBULN C1 ESTERASE INHIBITOR C1 ESTERASE INHIBITOR D-MANNOSE D-XYLITOL 300 DABIGATRAN ETEXILATE MESYLATE DABIGATRAN ETEXILATE MESYLATE DABRAFENIB MESYLATE DABRAFENIB MESYLATE DACARBAZINE DACARBAZINE DACTINOMYCIN DALFAMPRIDINE DALTEPARIN SODIUM,PORCINE DALTEPARIN SODIUM,PORCINE DALTEPARIN SODIUM,PORCINE DALTEPARIN SODIUM,PORCINE DALTEPARIN SODIUM,PORCINE DALTEPARIN SODIUM,PORCINE DALTEPARIN SODIUM,PORCINE DANAZOL DANAZOL DANAZOL DOSAGE CAPSULE CAPSULE DROPERETTE SOLUTION CAPSULE CAPSULE CAPSULE SOLUTION SYRUP TABLET CAP DR SPR CAP DR SPR CAPSULE CAPSULE CAPSULE CAPSULE DISP SYRIN SYRINGE VIAL PACKET VIAL VIAL VIAL VIAL KIT VIAL POWDER SOLUTION CAPSULE CAPSULE CAPSULE CAPSULE VIAL VIAL VIAL TAB ER 12H SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE CAPSULE CAPSULE CAPSULE STRENGTH 100 MG 25 MG 0.05 % 100 MG/ML 100 MG 25 MG 50 MG 100 MG/ML 2 MG/5 ML 4 MG 25 MG 75 MG 150 MG 50 MG 500 MG 750 MG 50 MG/ML 50 MG/ML 50 MG/ML 0.5G-15/4G 20 MG/ML 50 MG/5 ML 100 MG/5ML 50 MG/ML 500(10 ML) 500 (5 ML) 3.3G/5ML 150 MG 75 MG 50 MG 75 MG 100 MG 200 MG 0.5 MG 10 MG 10000/ML 12500/0.5 15000/0.6 18000/0.72 2500/0.2ML 5000/0.2ML 7500/0.3ML 100 MG 200 MG 50 MG NOTE APPENDIX A PAGE 30 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION DANTROLENE SODIUM DANTROLENE SODIUM DANTROLENE SODIUM DANTROLENE SODIUM DAPAGLIFLOZIN PROPANEDIOL DAPAGLIFLOZIN PROPANEDIOL DAPAGLIFLOZIN/METFORMIN HCL DAPAGLIFLOZIN/METFORMIN HCL DAPAGLIFLOZIN/METFORMIN HCL DAPAGLIFLOZIN/METFORMIN HCL DAPSONE DAPTOMYCIN DARBEPOETIN ALFA IN POLYSORBAT DARBEPOETIN ALFA IN POLYSORBAT DARBEPOETIN ALFA IN POLYSORBAT DARBEPOETIN ALFA IN POLYSORBAT DARBEPOETIN ALFA IN POLYSORBAT DARBEPOETIN ALFA IN POLYSORBAT DARBEPOETIN ALFA IN POLYSORBAT DARBEPOETIN ALFA IN POLYSORBAT DARBEPOETIN ALFA IN POLYSORBAT DARBEPOETIN ALFA IN POLYSORBAT DARBEPOETIN ALFA IN POLYSORBAT DARBEPOETIN ALFA IN POLYSORBAT DARBEPOETIN ALFA IN POLYSORBAT DARBEPOETIN ALFA IN POLYSORBAT DARBEPOETIN ALFA IN POLYSORBAT DARIFENACIN HYDROBROMIDE DARIFENACIN HYDROBROMIDE DARUNAVIR ETHANOLATE DARUNAVIR ETHANOLATE DARUNAVIR ETHANOLATE DARUNAVIR ETHANOLATE DARUNAVIR ETHANOLATE DARUNAVIR ETHANOLATE DASATINIB DASATINIB DASATINIB DASATINIB DASATINIB DASATINIB DECITABINE DEFERASIROX DEFERASIROX DEFERASIROX DEFERIPRONE DOSAGE CAPSULE CAPSULE CAPSULE VIAL TABLET TABLET TAB BP 24H TAB BP 24H TAB BP 24H TAB BP 24H TABLET VIAL SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE VIAL VIAL VIAL VIAL VIAL VIAL VIAL TAB ER 24H TAB ER 24H ORAL SUSP TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET VIAL TAB DISPER TAB DISPER TAB DISPER TABLET STRENGTH 100 MG 25 MG 50 MG 20 MG 10 MG 5 MG 10-1000 MG 10MG-500MG 5 MG-500MG 5MG-1000MG 25 MG 500 MG 100MCG/0.5 150MCG/0.3 200MCG/0.4 25MCG/0.42 300MCG/0.6 40 MCG/0.4 500 MCG/ML 60MCG/0.3 100 MCG/ML 150MCG/.75 200 MCG/ML 25 MCG/ML 300 MCG/ML 40 MCG/ML 60MCG/ML 15 MG 7.5 MG 100 MG/ML 150 MG 400 MG 600 MG 75 MG 800 MG 100 MG 140 MG 20 MG 50 MG 70 MG 80 MG 50 MG 125 MG 250 MG 500 MG 500 MG NOTE APPENDIX A PAGE 31 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION DEFEROXAMINE MESYLATE DEFEROXAMINE MESYLATE DEGARELIX ACETATE DEGARELIX ACETATE DELAVIRDINE MESYLATE DEMECLOCYCLINE HCL DEMECLOCYCLINE HCL DENOSUMAB DENOSUMAB DESIPRAMINE HCL DESIPRAMINE HCL DESIPRAMINE HCL DESIPRAMINE HCL DESIPRAMINE HCL DESIPRAMINE HCL DESLORATADINE DESLORATADINE DESLORATADINE DESLORATADINE DESLORATADINE/PSEUDOEPHEDRINE DESMOPRESSIN (NONREFRIGERATED) DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE DESOG-E.ESTRADIOL/E.ESTRADIOL DESOGESTREL-ETHINYL ESTRADIOL DESOGESTREL-ETHINYL ESTRADIOL DESONIDE DESONIDE DESONIDE DESONIDE DESOXIMETASONE DESOXIMETASONE DESOXIMETASONE DESOXIMETASONE DESOXIMETASONE DESVENLAFAXINE SUCCINATE DESVENLAFAXINE SUCCINATE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DOSAGE VIAL VIAL VIAL VIAL TAB DISPER TABLET TABLET SYRINGE VIAL TABLET TABLET TABLET TABLET TABLET TABLET SYRUP TAB RAPDIS TAB RAPDIS TABLET TBMP 12HR SPRAY/PUMP AMPUL SOLUTION SPRAY/PUMP SPRAY/PUMP TABLET TABLET VIAL TABLET TABLET TABLET CREAM (G) GEL (GRAM) LOTION OINT. (G) CREAM (G) CREAM (G) GEL (GRAM) OINT. (G) OINT. (G) TAB ER 24H TAB ER 24H DROPS DROPS SUSP ELIXIR IMPLANT STRENGTH 2 G 500 MG 120 MG 80 MG 100 MG 150 MG 300 MG 60 MG/ML 120 MG/1.7 10 MG 100 MG 150 MG 25 MG 50 MG 75 MG 2.5 MG/5ML 2.5 MG 5 MG 5 MG 2.5-120 MG 10/SPRAY 4MCG/ML 0.1 MG/ML 10/SPRAY 150/SPRAY 0.1 MG 0.2 MG 4MCG/ML 21-5 0.15-0.03 7 DAYS X 3 0.05 % 0.05 % 0.05 % 0.05 % 0.05 % 0.25 % 0.05 % 0.05 % 0.25 % 100 MG 50 MG 1 MG/ML 0.1 % 0.5 MG/5ML 0.7 MG NOTE APPENDIX A PAGE 32 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE DEXAMETHASONE SOD PHOSPHATE DEXAMETHASONE SOD PHOSPHATE DEXAMETHASONE SOD PHOSPHATE DEXAMETHASONE SOD PHOSPHATE DEXAMETHASONE SOD PHOSPHATE/PF DEXLANSOPRAZOLE DEXLANSOPRAZOLE DEXMEDETOMIDINE HCL DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL DEXMETHYLPHENIDATE HCL DEXRAZOXANE HCL DEXRAZOXANE HCL DEXTRAN 40 IN 0.9 % NACL DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE SULFATE DEXTROAMPHETAMINE/AMPHETAMINE DEXTROAMPHETAMINE/AMPHETAMINE DEXTROAMPHETAMINE/AMPHETAMINE DEXTROAMPHETAMINE/AMPHETAMINE DOSAGE SOLUTION TAB DS PK TAB DS PK TAB DS PK TABLET TABLET TABLET TABLET TABLET TABLET TABLET DROPS POWDER VIAL VIAL VIAL CAP DR BP CAP DR BP VIAL CPBP 50-50 CPBP 50-50 CPBP 50-50 CPBP 50-50 CPBP 50-50 CPBP 50-50 CPBP 50-50 CPBP 50-50 TABLET TABLET TABLET VIAL VIAL IV SOLN CAPSULE ER CAPSULE ER CAPSULE ER SOLUTION TABLET TABLET TABLET TABLET TABLET CAP ER 24H CAP ER 24H CAP ER 24H CAP ER 24H STRENGTH 0.5 MG/5ML 1.5MG (21) 1.5MG (35) 1.5MG (51) 0.5 MG 0.75 MG 1 MG 1.5 MG 2 MG 4 MG 6 MG 0.1 % 100 % 10 MG/ML 4 MG/ML 10 MG/ML 30 MG 60 MG 200MCG/2ML 10 MG 15 MG 20 MG 25 MG 30 MG 35 MG 40 MG 5 MG 10 MG 2.5 MG 5 MG 250 MG 500 MG 10 % 10 MG 15 MG 5 MG 5 MG/5 ML 10 MG 15 MG 2.5 MG 5 MG 7.5 MG 10 MG 15 MG 20 MG 25 MG NOTE APPENDIX A PAGE 33 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION DEXTROAMPHETAMINE/AMPHETAMINE DEXTROAMPHETAMINE/AMPHETAMINE DEXTROAMPHETAMINE/AMPHETAMINE DEXTROAMPHETAMINE/AMPHETAMINE DEXTROAMPHETAMINE/AMPHETAMINE DEXTROAMPHETAMINE/AMPHETAMINE DEXTROAMPHETAMINE/AMPHETAMINE DEXTROAMPHETAMINE/AMPHETAMINE DEXTROAMPHETAMINE/AMPHETAMINE DEXTROMETHORPHAN HBR/QUINIDINE DEXTROSE 10 % AND 0.2 % NACL DEXTROSE 10 % AND 0.45 % NACL DEXTROSE 10 % IN WATER DEXTROSE 10 % IN WATER DEXTROSE 2.5 % AND 0.45 % NACL DEXTROSE 20 % IN WATER DEXTROSE 30 % IN WATER DEXTROSE 40 % IN WATER DEXTROSE 5 % AND 0.3 % NACL DEXTROSE 5 % AND 0.9 % NACL DEXTROSE 5 % IN WATER DEXTROSE 5 % IN WATER DEXTROSE 5 % IN WATER DEXTROSE 5 % IN WATER DEXTROSE 5 %-0.2 % NACL DEXTROSE 5 %-0.45 % NACL DEXTROSE 5%-LACTATED RINGERS DEXTROSE 70 % IN WATER DHA/CALCIUM CARBONATE DHA/EPA/POLICOS/B6/B12/FA/PHYT DHA/PHOSPHATIDYLSERINE DHA/PHOSPHOLIPIDS,PORCINE DIABETISOURCE AC CLOSED SYSTEM DIABETISOURCE AC UNFLAVORED DIALYSIS SOLUTIONS DIALYSIS SOLUTIONS DIALYSIS SOLUTIONS DIALYSIS SOLUTIONS DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DOSAGE CAP ER 24H CAP ER 24H TABLET TABLET TABLET TABLET TABLET TABLET TABLET CAPSULE DEHP FR BG IV SOLN DEHP FR BG IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN PGGYBK PRT PGY VL PRT VIAL IV SOLN IV SOLN IV SOLN IV SOLN CAPSULE CAPSULE CAPSULE CAPSULE UNIT UNIT IP SOLN IP SOLN IP SOLN IP SOLN KIT KIT KIT ORAL CONC SOLUTION SYRINGE TABLET TABLET STRENGTH 30 MG 5 MG 10 MG 12.5 MG 15 MG 20 MG 30 MG 5 MG 7.5 MG 20 MG-10MG 10 %-0.2 % 10%-0.45% 10 % 10 % 2.5%-0.45% 20 % 30 % 40 % 5 %-0.3 % 5 %-0.9 % 5 % 5 % 5 %-0.2 % 5 %-0.45 % 5 % 70 % 100-200 MG 100-150-5 150MG-50MG 40 MG-50MG 0.06G-1.2 346MOSM/L 347MOSM/L 386MOSM/L 486MOSM/L 12.5-15-20 2.5 MG 5-7.5-10MG 5 MG/ML 5 MG/5 ML 5 MG/ML 10 MG 2 MG NOTE APPENDIX A PAGE 34 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION DIAZEPAM DIAZEPAM DIAZOXIDE DICLOFENAC EPOLAMINE DICLOFENAC POTASSIUM DICLOFENAC POTASSIUM DICLOFENAC POTASSIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM/MISOPROSTOL DICLOFENAC SODIUM/MISOPROSTOL DICLOFENAC SUBMICRONIZED DICLOFENAC SUBMICRONIZED DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM DICYCLOMINE HCL DICYCLOMINE HCL DICYCLOMINE HCL DICYCLOMINE HCL DIDANOSINE DIDANOSINE DIDANOSINE DIDANOSINE DIDANOSINE DIET SUPP#21/CALCIUM PHOSPHATE DIETARY SUPP CMB.20/FOLIC ACID DIETARY SUPPLEMENT DIETARY SUPPLEMENT DIETARY SUPPLEMENT DIETARY SUPPLEMENT DIETARY SUPPLEMENT,MISC COMB14 DIFENOXIN HCL/ATROPINE SULFATE DIFLORASONE DIACETATE DIFLORASONE DIACETATE DIFLUNISAL DIFLUPREDNATE DIGOXIN DIGOXIN DIGOXIN DOSAGE TABLET VIAL ORAL SUSP PATCH TD12 CAPSULE POWD PACK TABLET DROPS DROPS GEL (GRAM) GEL (GRAM) SOL MD PMP TAB ER 24H TABLET DR TABLET DR TABLET DR TAB IR DR TAB IR DR CAPSULE CAPSULE CAPSULE CAPSULE AMPUL CAPSULE SOLUTION TABLET CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR SOLN RECON TABLET TABLET BAR CAPSULE PACKET POWDER CAPSULE TABLET CREAM (G) OINT. (G) TABLET DROPS AMPUL SOLUTION TABLET STRENGTH 5 MG 5 MG/ML 50 MG/ML 1.3 % 25 MG 50 MG 50 MG 0.1 % 1.5 % 1 % 3 % 20MG/G(2%) 100 MG 25 MG 50 MG 75 MG 50 MG-200 75 MG-200 18 MG 35 MG 250 MG 500 MG 10 MG/ML 10 MG 10 MG/5 ML 20 MG 125 MG 200 MG 250 MG 400 MG FNL10MG/ML 190MG-85MG 400 MCG 24MG-21MG 1-0.025MG 0.05 % 0.05 % 500 MG 0.05 % 250 MCG/ML 50 MCG/ML 125 MCG NOTE APPENDIX A PAGE 35 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION DIGOXIN DIHYDROERGOTAMINE MESYLATE DIHYDROERGOTAMINE MESYLATE DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DILTIAZEM HCL DIMENHYDRINATE DIMETHYL FUMARATE DIMETHYL FUMARATE DIMETHYL FUMARATE DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL DIPHENOXYLATE HCL/ATROPINE DIPHENOXYLATE HCL/ATROPINE DIPYRIDAMOLE DIPYRIDAMOLE DOSAGE TABLET AMPUL SPRAY/PUMP CAP ER DEG CAP ER DEG CAP ER DEG CAP ER 12H CAP ER 12H CAP ER 12H CAP ER 24H CAP ER 24H CAP ER 24H CAP ER 24H CAP ER 24H CAPSULE ER CAPSULE ER CAPSULE ER CAPSULE ER CAPSULE ER CAPSULE ER TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TABLET TABLET TABLET TABLET VIAL VIAL PORT VIAL CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE CAPSULE CAPSULE CAPSULE LIQUID VIAL LIQUID TABLET TABLET TABLET STRENGTH 250 MCG 1 MG/ML 0.5MG/SPRY 120 MG 180 MG 240 MG 120 MG 60 MG 90 MG 120 MG 180 MG 240 MG 300 MG 360 MG 120 MG 180 MG 240 MG 300 MG 360 MG 420MG 120 MG 180 MG 240 MG 300 MG 360 MG 420MG 120 MG 30 MG 60 MG 90 MG 5 MG/ML 100 MG 50 MG/ML 120 MG 120-240 MG 240 MG 25 MG 25MG 50 MG 50MG 12.5MG/5ML 50 MG/ML 2.5-.025/5 2.5-.025MG 25 MG 50 MG NOTE APPENDIX A PAGE 36 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION DIPYRIDAMOLE DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE DISULFIRAM DISULFIRAM DIVALPROEX SODIUM DIVALPROEX SODIUM DIVALPROEX SODIUM DIVALPROEX SODIUM DIVALPROEX SODIUM DIVALPROEX SODIUM DOBUTAMINE HCL DOBUTAMINE HCL DOBUTAMINE HCL/D5W DOBUTAMINE HCL/D5W DOBUTAMINE HCL/D5W DOCETAXEL DOCETAXEL DOCETAXEL DOCETAXEL DOCUSATE CALCIUM DOCUSATE POTASSIUM DOCUSATE POTASSIUM DOCUSATE SODIUM DOCUSATE SODIUM DOCUSATE SODIUM DOCUSATE SODIUM DOCUSATE SODIUM DOFETILIDE DOFETILIDE DOFETILIDE DOLASETRON MESYLATE DOLASETRON MESYLATE DOLASETRON MESYLATE DOLASETRON MESYLATE DOLUTEGRAVIR SODIUM DONEPEZIL HCL DONEPEZIL HCL DONEPEZIL HCL DONEPEZIL HCL DONEPEZIL HCL DOPAMINE HCL DOPAMINE HCL/D5W DOPAMINE HCL/D5W DOSAGE TABLET CAPSULE CAPSULE CAPSULE ER CAPSULE ER TABLET TABLET CAP SPRINK TAB ER 24H TAB ER 24H TABLET DR TABLET DR TABLET DR VIAL VIAL IV SOLN IV SOLN IV SOLN VIAL VIAL VIAL VIAL CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE LIQUID SYRUP CAPSULE CAPSULE CAPSULE TABLET TABLET VIAL VIAL TABLET TAB RAPDIS TAB RAPDIS TABLET TABLET TABLET VIAL PLAST. BAG PLAST. BAG STRENGTH 75 MG 100 MG 150 MG 100 MG 150 MG 250 MG 500 MG 125 MG 250 MG 500 MG 125 MG 250 MG 500 MG 250MG/20ML 500MG/40ML 1000MG/250 250MG/250 500MG/250 20 MG 20MG/ML(1) 80 MG 80 MG/4 ML 240 MG 100 MG 240 MG 100 MG 250 MG 50 MG 50 MG/5 ML 60 MG/15ML 125 MCG 250 MCG 500 MCG 100 MG 50 MG 100 MG/5ML 12.5/0.625 50 MG 10 MG 5 MG 10 MG 23 MG 5 MG 400MG/10ML 800MG/.25L 800MG/0.5L NOTE APPENDIX A PAGE 37 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION DORIPENEM DORIPENEM DORNASE ALFA DORZOLAMIDE HCL DORZOLAMIDE HCL/TIMOLOL MALEAT DORZOLAMIDE/TIMOLOL/PF DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE DOXEPIN HCL DOXEPIN HCL DOXEPIN HCL DOXEPIN HCL DOXEPIN HCL DOXEPIN HCL DOXEPIN HCL DOXEPIN HCL DOXEPIN HCL DOXEPIN HCL DOXERCALCIFEROL DOXERCALCIFEROL DOXERCALCIFEROL DOXERCALCIFEROL DOXERCALCIFEROL DOXORUBICIN HCL DOXORUBICIN HCL DOXORUBICIN HCL DOXORUBICIN HCL DOXORUBICIN HCL DOXORUBICIN HCL PEG-LIPOSOMAL DOXYCYCLINE CALCIUM DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE DOSAGE VIAL VIAL SOLUTION DROPS DROPS DROPERETTE TAB ER 24 TAB ER 24 TABLET TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CREAM (G) ORAL CONC TABLET TABLET CAPSULE CAPSULE CAPSULE VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL SYRUP CAPSULE CAPSULE TABLET TABLET TABLET DR TABLET DR TABLET DR TABLET DR VIAL CAP IR DR CAPSULE CAPSULE STRENGTH 250 MG 500 MG 1 MG/ML 2 % 2 %-0.5 % 2 %-0.5 % 4 MG 8 MG 1 MG 2 MG 4 MG 8 MG 10 MG 100 MG 150 MG 25 MG 50 MG 75 MG 5 % 10 MG/ML 3 MG 6 MG 0.5 MCG 1 MCG 2.5 MCG 2MCG/ML(1) 4MCG/2ML 10 MG 10 MG/5 ML 2 MG/ML 20 MG/10ML 50 MG/25ML 2 MG/ML 50 MG/5 ML 100 MG 50 MG 100 MG 20 MG 100 MG 150 MG 200 MG 75 MG 100 MG 40 MG 100 MG 150 MG NOTE APPENDIX A PAGE 38 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE DOXYLAMINE/PYRIDOXINE HCL DRONABINOL DRONABINOL DRONABINOL DRONEDARONE HCL DROPERIDOL DROPERIDOL DROSPIR/ETH ESTRA/LEVOMEFOL CA DROSPIR/ETH ESTRA/LEVOMEFOL CA DROSPIRENONE/ESTRADIOL DROSPIRENONE/ESTRADIOL DULOXETINE HCL DULOXETINE HCL DULOXETINE HCL DUTASTERIDE DUTASTERIDE/TAMSULOSIN HCL DYPHYLLINE DYPHYLLINE D3/E/SE/SOY ISOFL/TOCOPH/LYCOP D3/RED WINE/RESVERATROL/MALT E AC/RUT/HESPER/BIO/B&C/HC111 ECALLANTIDE ECHOTHIOPHATE IODIDE ECONAZOLE NITRATE ECULIZUMAB EFAVIRENZ EFAVIRENZ EFAVIRENZ EFAVIRENZ/EMTRICITAB/TENOFOVIR EFINACONAZOLE ELECARE UNFLAVORED POWDER - 14 ELECARE VANILLA POWDER - 14.1 ELECARE WITH DHA & ARA POWDER ELECTROLYTE SOLUTION ELECTROLYTE SOLUTION ELECTROLYTE SOLUTION,INJ ELECTROLYTE SOLUTION,INJ/D50W ELECTROLYTE-A SOLUTION ELECTROLYTE-B SOLUTION/D5W ELECTROLYTE-H SOLUTION/D5W DOSAGE CAPSULE SUSP RECON TABLET TABLET TABLET TABLET TABLET DR CAPSULE CAPSULE CAPSULE TABLET AMPUL VIAL TABLET TABLET TABLET TABLET CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE CPMP 24HR TABLET TABLET CAPSULE CAPSULE TABLET VIAL DROPS CREAM (G) VIAL CAPSULE CAPSULE TABLET TABLET SOL W/APPL CAN CAN UNIT SYRINGE VIAL SYRINGE IV SOLN IV SOLN IV SOLN IV SOLN STRENGTH 50 MG 25 MG/5 ML 100 MG 150 MG 50 MG 75 MG 10 MG-10MG 10 MG 2.5 MG 5 MG 400 MG 2.5 MG/ML 2.5 MG/ML 3-0.02(24) 3-0.03(21) 0.25-0.5MG 0.5 MG-1MG 20 MG 30 MG 60 MG 0.5 MG 0.5-0.4 MG 200 MG 400 MG 1200-15-35 5000-200 25-40MG-25 10MG/ML(1) 0.125 % 1 % 300MG/30ML 200 MG 50 MG 600 MG 600-200MG 10 % 3.1 G/100 14.5G-475 3.1 G/100 50 % 5 % 5 % NOTE APPENDIX A PAGE 39 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ELECTROLYTE-M SOLUTION/D5W ELECTROLYTE-MB SOLUTION/D5W ELECTROLYTE-P SOLUTION/D5W ELECTROLYTE-R (PH 7.4) ELECTROLYTE-R SOLUTION ELECTROLYTE-R SOLUTION/D5W ELECTROLYTE-S (PH 7.4) ELECTROLYTE-S IN 5 % DEXTROSE ELECTROLYTE-S SOLUTION ELECTROLYTE-S SOLUTION/D5W ELECTROLYTE-T SOLUTION/D5W ELECTROLYTE-148 IN 5% DEXTROSE ELECTROLYTE-148 SOLN ELECTROLYTE-148 SOLUTION ELECTROLYTE-48 SOLUTION/D5W ELECTROLYTE-48/FRUCTOSE 10 % ELECTROLYTE-48/FRUCTOSE 5 % ELECTROLYTE-56 SOLUTION/D5W ELECTROLYTE-75/FRUCTOSE 5 % ELECTROLYTE,ORAL ELECTROLYTE,ORAL ELETRIPTAN HBR ELETRIPTAN HBR ELOSULFASE ALFA ELTROMBOPAG OLAMINE ELTROMBOPAG OLAMINE ELTROMBOPAG OLAMINE ELTROMBOPAG OLAMINE ELVITEGR/COBICIST/EMTRIC/TENOF EM#53/NAMGF/CYC/PHOS/NAHC/NACL EMEDASTINE DIFUMARATE EMOLLIENT COMBINATION NO. 25 EMOLLIENT COMBINATION NO.53 EMPAGLIFLOZIN EMPAGLIFLOZIN EMTRICITAB/RILPIVIRINE/TENOFOV EMTRICITABINE EMTRICITABINE EMTRICITABINE/TENOFOVIR ENALAPRIL MALEATE ENALAPRIL MALEATE ENALAPRIL MALEATE ENALAPRIL MALEATE ENALAPRIL MALEATE ENALAPRIL/HYDROCHLOROTHIAZIDE ENALAPRIL/HYDROCHLOROTHIAZIDE DOSAGE IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN PACKET SOLUTION TABLET TABLET VIAL TABLET TABLET TABLET TABLET TABLET KT CRM GEL DROPS CREAM (G) CREAM (G) TABLET TABLET TABLET CAPSULE SOLUTION TABLET SOLN RECON TABLET TABLET TABLET TABLET TABLET TABLET STRENGTH 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 5 % 10 % 5 % 5 % 5 % 20 MG 40 MG 5 MG/5 ML 12.5 MG 25 MG 50 MG 75 MG 150-200 MG 0.05 % 10 MG 25 MG 200-25-300 200 MG 10 MG/ML 200-300 MG 1 MG/ML 10 MG 2.5 MG 20 MG 5 MG 10 MG-25MG 5MG-12.5MG NOTE APPENDIX A PAGE 40 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ENALAPRILAT DIHYDRATE ENFAGROW SOY TODDLER - 24 OZ C ENFAMIL A.R. LIPIL LIQUID RTU ENFAMIL A.R. LIPIL POWDER - 12 ENFAMIL A.R. LIPIL POWDER - 24 ENFAMIL ENFACARE LIQUID-32 OZ ENFAMIL ENFACARE POWDER - 12.8 ENFAMIL ENFACARE RTU - 2 OZ BO ENFAMIL GENTLEASE LIPIL POWDER ENFAMIL GENTLEASE POWDER - 22. ENFAMIL GENTLEASE POWDER - 33. ENFAMIL GENTLEASE RTU - 32 OZ ENFAMIL LIPIL CONC - 13 OZ CAN ENFAMIL LIPIL PACKET - 16 STIC ENFAMIL LIPIL POWDER - 12.9 OZ ENFAMIL LIPIL POWDER - 25.7 OZ ENFAMIL LIPIL RTF - 2 OZ BOTTL ENFAMIL LIPIL RTU - 32 OZ CAN ENFAMIL LIPIL RTU - 4 - 8 OZ C ENFAMIL LIPIL RTU - 6 OZ BOTTL ENFAMIL LIPIL RTU 20 CAL - 2 O ENFAMIL LIQUID - 8 OZ CAN - 24 ENFAMIL ORAL CONC - 13 OZ CAN ENFAMIL PACKET - 17.4G - 16/CA ENFAMIL POWDER - 12.5 OZ CAN ENFAMIL POWDER - 23.4 OZ CAN ENFAMIL PREMATURE LIPIL IRON F ENFAMIL PREMIUM NEWBORN POWDER ENFAMIL PROSOBEE LIPIL CONC ENFAMIL PROSOBEE LIPIL POWDER ENFAMIL PROSOBEE LIPIL RTU - 2 ENFAMIL PROSOBEE RTU - 4 - 8 O ENFAMIL PROSOBEE RTU 32 OZ CAN ENFAMIL W/LOW IRON - 17.6G PAC ENFUVIRTIDE ENLIVE APPLE - 8.1 OZ BRIK ENLIVE MIXED BERRY - 8.1 OZ BR ENOXAPARIN SODIUM ENOXAPARIN SODIUM ENOXAPARIN SODIUM ENOXAPARIN SODIUM ENOXAPARIN SODIUM ENOXAPARIN SODIUM ENOXAPARIN SODIUM ENOXAPARIN SODIUM ENSURE BUTTER PECAN IMMUNE HEA DOSAGE VIAL CAN CAN CAN CAN CAN CAN CAN CAN CAN CAN CAN CAN CAN CAN CAN BOTTLE UNIT UNIT CAN CAN CAN CAN PACKET CAN UNIT BTL CAN CAN CAN CAN CAN CAN PACKET VIAL BRIK BRIK SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE VIAL UNIT STRENGTH 1.25 MG/ML 2.3 G/100 2.3 G/100 2.3 G/100 2.1 G/100 90 MG 0.037-1.04 0.037-1.04 100 MG/ML 120MG/.8ML 150 MG/ML 30MG/0.3ML 40MG/0.4ML 60MG/0.6ML 80MG/0.8ML 300MG/3ML 0.04G-1.05 NOTE APPENDIX A PAGE 41 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ENSURE CLEAR - APPLE ENSURE CLEAR - MIXED BERRY ENSURE COFFEE LATTE INSTITUTIO ENSURE COMPLETE READY TO DRINK ENSURE CREAMY MILK CHOC IMMUNE ENSURE CREAMY MILK CHOC INSTIT ENSURE HIGH CALCUIM CREAMY MIL ENSURE HIGH CALCUIM HOMEMADE V ENSURE HIGH PROTEIN CREAMY MIL ENSURE HIGH PROTEIN HOMEMADE V ENSURE HIGH PROTEIN WILD BERRY ENSURE HOMEMADE VANILLA IMMUNE ENSURE HOMEMADE VANILLA INSTIT ENSURE PLUS BUTTER PECAN - 8 O ENSURE PLUS COFFEE LATTE - 8 O ENSURE PLUS CREAMY MILK CHOC ENSURE PLUS CREAMY MILK CHOC ENSURE PLUS HOMEMADE VANILLA ENSURE PLUS STRAWBERRIES & CRE ENSURE POWDER HOMEMADE VANILL ENSURE PUDDING BUTTERSCOTCH DE ENSURE PUDDING CREAMY MILK CHO ENSURE PUDDING HOMEMADE VANILL ENSURE STRAWBERRIES & CREAM IM ENTACAPONE ENTECAVIR ENTECAVIR ENTECAVIR ENZALUTAMIDE EPHEDRINE SULFATE EPINASTINE HCL EPINEPHRINE EPINEPHRINE EPINEPHRINE EPINEPHRINE EPINEPHRINE EPINEPHRINE EPINEPHRINE EPINEPHRINE HCL/PF EPIRUBICIN HCL EPIRUBICIN HCL EPIRUBICIN HCL EPIRUBICIN HCL EPLERENONE EPLERENONE EPOETIN ALFA DOSAGE BRIK BRIK UNIT BOTTLE UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT CAN CAN CAN UNIT TABLET SOLUTION TABLET TABLET CAPSULE VIAL DROPS AMPUL AUTO INJCT AUTO INJCT AUTO INJCT SYRINGE VIAL VIAL AMPUL VIAL VIAL VIAL VIAL TABLET TABLET VIAL STRENGTH 0.035-1/ML 0.035-1/ML 0.05 G-1.5 0.04G-1.05 0.04G-1.05 0.04G-1.05 0.04G-1.05 0.05 G-1.5 0.05 G-1.5 0.05 G-1.5 0.05 G-1.5 0.05 G-1.5 0.05 G-1.5 0.04G-1.05 200 MG 0.05MG/ML 0.5 MG 1 MG 40 MG 50 MG/ML 0.05 % 1 MG/ML(1) 0.15/0.15 0.15MG/0.3 0.3MG/0.3 0.1 MG/ML 1 MG/ML 1 MG/ML(1) 1 MG/ML(1) 200 MG 200MG/0.1L 50 MG 50 MG/25ML 25 MG 50 MG 10000/ML NOTE APPENDIX A PAGE 42 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION EPOETIN ALFA EPOETIN ALFA EPOETIN ALFA EPOETIN ALFA EPOETIN ALFA EPOETIN ALFA EPOPROSTENOL SODIUM (ARGININE) EPOPROSTENOL SODIUM (ARGININE) EPOPROSTENOL SODIUM (GLYCINE) EPOPROSTENOL SODIUM (GLYCINE) EPROSARTAN MESYLATE EPROSARTAN/HYDROCHLOROTHIAZIDE EPROSARTAN/HYDROCHLOROTHIAZIDE EPTIFIBATIDE EPTIFIBATIDE ERGOCALCIFEROL ERGOCALCIFEROL (VITAMIN D2) ERGOCALCIFEROL(VITAMIN D2 ERGOLOID MESYLATES ERGOTAMINE TARTRATE/CAFFEINE ERIBULIN MESYLATE ERLOTINIB HCL ERLOTINIB HCL ERLOTINIB HCL ERTAPENEM SODIUM ERTAPENEM SODIUM ERYTHROMYCIN BASE ERYTHROMYCIN BASE ERYTHROMYCIN BASE ERYTHROMYCIN BASE ERYTHROMYCIN BASE ERYTHROMYCIN BASE ERYTHROMYCIN BASE ERYTHROMYCIN BASE ERYTHROMYCIN BASE ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN LACTOBIONATE ERYTHROMYCIN LACTOBIONATE ERYTHROMYCIN STEARATE ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE ESLICARBAZEPINE ACETATE DOSAGE VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL TABLET TABLET TABLET VIAL VIAL DROPS CAPSULE DROPS TABLET TABLET VIAL TABLET TABLET TABLET VIAL VIAL PORT CAPSULE DR OINT. (G) TAB PART TAB PART TABLET TABLET TABLET DR TABLET DR TABLET DR SUSP RECON SUSP RECON TABLET VIAL VIAL PORT TABLET SOLUTION TABLET TABLET TABLET TABLET STRENGTH 2000/ML 20000/ML 20000/2ML 3000/ML 4000/ML 40000/ML 0.5 MG 1.5 MG 0.5 MG 1.5 MG 600 MG 600-12.5MG 600-25MG 0.75MG/ML 2 MG/ML 8000 U/ML 50000 UNIT 80000 UNIT 1 MG 1 MG-100MG 1 MG/2 ML 100 MG 150 MG 25 MG 1 G 1 G 250 MG 5 MG/G 333 MG 500 MG 250 MG 500 MG 250 MG 333 MG 500 MG 200 MG/5ML 400 MG/5ML 400 MG 500 MG 500 MG 250 MG 5 MG/5 ML 10 MG 20 MG 5 MG 200 MG NOTE APPENDIX A PAGE 43 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ESLICARBAZEPINE ACETATE ESLICARBAZEPINE ACETATE ESLICARBAZEPINE ACETATE ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE MAGNESIUM ESOMEPRAZOLE SODIUM ESOMEPRAZOLE SODIUM ESOMEPRAZOLE STRONTIUM ESTAZOLAM ESTAZOLAM ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ESTRADIOL ACETATE ESTRADIOL ACETATE ESTRADIOL CYPIONATE ESTRADIOL VALERATE ESTRADIOL VALERATE ESTRADIOL VALERATE ESTRADIOL VALERATE/DIENOGEST ESTRADIOL/LEVONORGESTREL DOSAGE TABLET TABLET TABLET CAPSULE DR CAPSULE DR SUSPDR PKT SUSPDR PKT SUSPDR PKT SUSPDR PKT SUSPDR PKT VIAL VIAL CAPSULE DR TABLET TABLET CREAM/APPL GEL MD PMP GEL PACKET GEL PACKET GEL PACKET PATCH TDSW PATCH TDSW PATCH TDSW PATCH TDSW PATCH TDSW PATCH TDWK PATCH TDWK PATCH TDWK PATCH TDWK PATCH TDWK PATCH TDWK PATCH TDWK SPRAY TABLET TABLET TABLET TABLET VAG RING VAG RING VAG RING VIAL VIAL VIAL VIAL TABLET PATCH TDWK STRENGTH 400 MG 600 MG 800 MG 20 MG 40 MG 10 MG 2.5 MG 20 MG 40 MG 5 MG 20 MG 40 MG 49.3 MG 1 MG 2 MG 0.01 % 0.87G 0.25(0.1%) 0.5MG(0.1) 1MG(0.1%) .025MG/24H .0375MG/24 .075MG/24H 0.05MG/24H 0.1MG/24HR .025MG/24H .0375MG/24 .075MG/24H 0.05MG/24H 0.06MG/24H 0.1MG/24HR 14MCG/24HR 1.53/SPRAY 0.5 MG 1 MG 10 MCG 2 MG 7.5MCG/24H 0.05MG/24H 0.1MG/24HR 5 MG/ML 10 MG/ML 20 MG/ML 40 MG/ML 3-2-1(28) 45-15/24H NOTE APPENDIX A PAGE 44 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ESTRADIOL/NORETHINDRONE ACET ESTRADIOL/NORETHINDRONE ACET ESTRADIOL/NORETHINDRONE ACET ESTRADIOL/NORETHINDRONE ACET ESTRADIOL/NORGESTIMATE ESTRAMUSTINE PHOSPHATE SODIUM ESTROGEN,CON/M-PROGEST ACET ESTROGEN,CON/M-PROGEST ACET ESTROGEN,CON/M-PROGEST ACET ESTROGEN,CON/M-PROGEST ACET ESTROGENS, CONJUGATED ESTROGENS, CONJUGATED ESTROGENS, CONJUGATED ESTROGENS, CONJUGATED ESTROGENS, CONJUGATED ESTROGENS, CONJUGATED ESTROGENS, CONJUGATED ESTROGENS,CONJ.,SYNTHETIC B ESTROGENS,CONJ.,SYNTHETIC B ESTROGENS,CONJ.,SYNTHETIC B ESTROGENS,CONJ.,SYNTHETIC B ESTROGENS,CONJ.,SYNTHETIC B ESTROGENS,ESTERIFIED ESTROGENS,ESTERIFIED ESTROGENS,ESTERIFIED ESTROGENS,ESTERIFIED ESTROPIPATE ESTROPIPATE ESTROPIPATE ESZOPICLONE ESZOPICLONE ESZOPICLONE ETANERCEPT ETANERCEPT ETANERCEPT ETANERCEPT ETHACRYNIC ACID ETHAMBUTOL HCL ETHAMBUTOL HCL ETHINYL ESTRADIOL/DROSPIRENONE ETHINYL ESTRADIOL/DROSPIRENONE ETHIONAMIDE ETHOSUXIMIDE ETHOSUXIMIDE ETHOTOIN ETHYL ALCOHOL DOSAGE PATCH TDSW PATCH TDSW TABLET TABLET TABLET CAPSULE TABLET TABLET TABLET TABLET CREAM/APPL TABLET TABLET TABLET TABLET TABLET VIAL TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET PEN INJCTR SYRINGE SYRINGE VIAL TABLET TABLET TABLET TABLET TABLET TABLET CAPSULE SOLUTION TABLET AMPUL STRENGTH .05-.14/24 .05-.25/24 0.5-0.1MG 1 MG-0.5MG 1-1-0.09MG 140 MG 0.3-1.5MG 0.45-1.5MG 0.625-2.5 0.625-5 MG 0.625 MG/G 0.3 MG 0.45MG 0.625 MG 0.9 MG 1.25 MG 25 MG 0.3 MG 0.45MG 0.625 MG 0.9 MG 1.25 MG 0.3 MG 0.625 MG 1.25 MG 2.5 MG 0.75 MG 1.5 MG 3 MG 1 MG 2 MG 3 MG 50 MG/ML 25MG/0.5ML 50 MG/ML 25 MG 25 MG 100 MG 400 MG 0.02-3(24) 0.03-3MG 250 MG 250 MG 250 MG/5ML 250 MG 98 % NOTE APPENDIX A PAGE 45 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ETHYL ALCOHOL ETHYNODIOL D-ETHINYL ESTRADIOL ETHYNODIOL D-ETHINYL ESTRADIOL ETIDRONATE DISODIUM ETIDRONATE DISODIUM ETODOLAC ETODOLAC ETODOLAC ETODOLAC ETODOLAC ETODOLAC ETODOLAC ETONOGESTREL ETONOGESTREL/ETHINYL ESTRADIOL ETOPOSIDE ETOPOSIDE ETRAVIRINE ETRAVIRINE EVEROLIMUS EVEROLIMUS EVEROLIMUS EVEROLIMUS EVEROLIMUS EVEROLIMUS EVEROLIMUS EVEROLIMUS EXEMESTANE EXENATIDE EXENATIDE EXENATIDE MICROSPHERES EXENATIDE MICROSPHERES EZETIMIBE EZETIMIBE/ATORVASTATIN CALCIUM EZETIMIBE/ATORVASTATIN CALCIUM EZETIMIBE/ATORVASTATIN CALCIUM EZETIMIBE/ATORVASTATIN CALCIUM EZETIMIBE/SIMVASTATIN EZETIMIBE/SIMVASTATIN EZETIMIBE/SIMVASTATIN EZETIMIBE/SIMVASTATIN EZOGABINE EZOGABINE EZOGABINE EZOGABINE E028 GRAPE SPLASH - 8 OZ BOX 2 E028 ORANGE-PINEAPPLE SPLASH - DOSAGE VIAL TABLET TABLET TABLET TABLET CAPSULE CAPSULE TAB ER 24H TAB ER 24H TAB ER 24H TABLET TABLET IMPLANT VAG RING CAPSULE VIAL TABLET TABLET TAB SUSP TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET PEN INJCTR PEN INJCTR PEN INJCTR VIAL TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET BRIK BRIK STRENGTH 98 % 1 MG-35MCG 1 MG-50MCG 200 MG 400 MG 200 MG 300 MG 400 MG 500 MG 600 MG 400 MG 500 MG 68 MG .12-.015MG 50 MG 20 MG/ML 100 MG 200 MG 3 MG 0.25 MG 0.5 MG 0.75 MG 10 MG 2.5 MG 5 MG 7.5 MG 25 MG 10MCG/0.04 5MCG/0.02 2MG/0.65ML 2 MG 10 MG 10 MG-10MG 10 MG-20MG 10 MG-40MG 10 MG-80MG 10 MG-10MG 10 MG-20MG 10 MG-40MG 10 MG-80MG 200 MG 300 MG 400 MG 50 MG 0.025-1/ML NOTE APPENDIX A PAGE 46 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 47 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION E028 TROPICAL FRUIT - 8 OZ BOX FA/MU-VITS-MIN TH/LYCOPENE/LUT FA/MV,CA,IRON/POLLEN/HERB#101 FA/OMEGA-3/DHA/EPA/ST.JOHN FA/VIT BCOMP&C/SE/MIN AA/ZN FACTOR IX FACTOR IX FACTOR IX FACTOR IX COMPLEX (PCC) COMB.6 FACTOR IX COMPLEX HUMAN FACTOR IX COMPLEX HUMAN FACTOR IX COMPLEX HUMAN FACTOR IX HUMAN RECOMBINANT FACTOR IX HUMAN RECOMBINANT FACTOR IX HUMAN RECOMBINANT FACTOR IX HUMAN RECOMBINANT FACTOR IX HUMAN RECOMBINANT FACTOR IX HUMAN RECOMBINANT FACTOR IX HUMAN RECOMBINANT FACTOR IX HUMAN RECOMBINANT FACTOR IX HUMAN RECOMBINANT FACTOR IX HUMAN RECOMBINANT FACTOR IX REC, FC FUSION PROTN FACTOR IX REC, FC FUSION PROTN FACTOR IX REC, FC FUSION PROTN FACTOR IX REC, FC FUSION PROTN FACTOR XIII FAMCICLOVIR FAMCICLOVIR FAMCICLOVIR FAMOTIDINE FAMOTIDINE FAMOTIDINE FAMOTIDINE FAMOTIDINE/PF FAT EMULSIONS FE FUMARATE/CAL/E/FA/MULTIVIT FE FUMARATE/DOSS/FA/BCOMP&C FE FUMARATE/FA/MV, MIN COMB#15 FE FUMARATE/FA/VIT BCOMP&C FE FUMARATE/VIT C/B12-IF/FA FEBUXOSTAT FEBUXOSTAT FELBAMATE FELBAMATE FELBAMATE DOSAGE CAN TABLET TABLET CAPSULE TABLET VIAL VIAL VIAL VIAL VIAL VIAL VIAL KIT KIT KIT KIT KIT VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL KIT TABLET TABLET TABLET ORAL SUSP TABLET TABLET VIAL VIAL EMULSION TABLET TABLET CAPSULE TABLET CAPSULE TABLET TABLET ORAL SUSP TABLET TABLET STRENGTH 0.025-1/ML 1.25-2.5MG 5MG-133MCG 200MCG-167 3MG-15MG 1000 (+/-) 1500 (+/-) 500 (+/-) 700 (+/-) 1000 (+/-) 1500 (+/-) 500 (+/-) 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT 1000 UNIT 2000 UNIT 250 UNIT 3000 UNIT 500 UNIT 1000 UNIT 2000 UNIT 3000 UNIT 500 UNIT 1000-1600 125 MG 250 MG 500 MG 40MG/5ML 20 MG 40 MG 10 MG/ML 20 MG/2 ML 50 % 65 MG-1 MG 66.6-1MG 106 MG-1MG 29MG-0.8MG 110-0.5MG 40 MG 80 MG 600 MG/5ML 400 MG 600 MG NOTE (RX ONLY) 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION FELODIPINE FELODIPINE FELODIPINE FENOFIBRATE FENOFIBRATE FENOFIBRATE FENOFIBRATE FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE,MICRONIZED FENOFIBRATE,MICRONIZED FENOFIBRATE,MICRONIZED FENOFIBRATE,MICRONIZED FENOFIBRATE,MICRONIZED FENOFIBRATE,MICRONIZED FENOFIBRATE,MICRONIZED FENOFIBRIC ACID FENOFIBRIC ACID FENOFIBRIC ACID (CHOLINE) FENOFIBRIC ACID (CHOLINE) FENOLDOPAM MESYLATE FENOLDOPAM MESYLATE FENOPROFEN CALCIUM FENOPROFEN CALCIUM FENTANYL FENTANYL FENTANYL FENTANYL FENTANYL FENTANYL FENTANYL FENTANYL FENTANYL FENTANYL CITRATE FENTANYL CITRATE FENTANYL CITRATE FENTANYL CITRATE FENTANYL CITRATE FENTANYL CITRATE FENTANYL CITRATE FENTANYL CITRATE FENTANYL CITRATE FENTANYL CITRATE FENTANYL CITRATE FENTANYL CITRATE DOSAGE TAB ER 24H TAB ER 24H TAB ER 24H CAPSULE CAPSULE TABLET TABLET TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE TABLET TABLET CAPSULE DR CAPSULE DR AMPUL VIAL CAPSULE TABLET PATCH TD72 PATCH TD72 PATCH TD72 PATCH TD72 PATCH TD72 SPRAY SPRAY SPRAY SPRAY LOZENGE HD LOZENGE HD LOZENGE HD LOZENGE HD LOZENGE HD LOZENGE HD SPRAY/PUMP TABLET EFF TABLET EFF TABLET EFF TABLET EFF TABLET EFF STRENGTH 10 MG 2.5 MG 5 MG 150 MG 50 MG 160 MG 54 MG 145MG 160 MG 48 MG 130 MG 134MG 200 MG 30 MG 43 MG 67 MG 90 MG 105 MG 35 MG 135 MG 45 MG 10 MG/ML 10 MG/ML 400 MG 600 MG 100 MCG/HR 12 MCG/HR 25MCG/HR 50MCG/HR 75MCG/HR 100MCG/SPR 200 MCG 400MCG/SPR 800 MCG 1200 MCG 1600 MCG 200 MCG 400 MCG 600 MCG 800 MCG 100MCG/SPR 100 MCG 200 MCG 400 MCG 600 MCG 800 MCG NOTE APPENDIX A PAGE 48 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION FENTANYL CITRATE/PF FENTANYL CITRATE/PF FERRIC CARBOXYMALTOSE FERROUS FUMARATE FERROUS FUMARATE/FOLIC ACID FERROUS FUMARATE/IRON PS CPLX FERROUS GLUCONATE FERROUS GLUCONATE FERROUS GLUCONATE FERROUS SULFATE FERROUS SULFATE FERROUS SULFATE FERROUS SULFATE FERROUS SULFATE FERROUS SULFATE FERROUS SULFATE FERUMOXYTOL FESOTERODINE FUMARATE FESOTERODINE FUMARATE FEXOFENADINE HCL FEXOFENADINE HCL FEXOFENADINE HCL FIBER FIBERSOURCE - 1000ML - 6/CASE FIBERSOURCE - 1500ML - 6/CASE FIBERSOURCE HN UNFLAVORED - 25 FIBRINOGEN FIDAXOMICIN FILGRASTIM FILGRASTIM FILGRASTIM FILGRASTIM FINASTERIDE FINGOLIMOD HCL FISH OIL/FAT NO.8/HRB COMB.137 FISH OIL/OMEGA-3/VIT C/VIT E FISH OIL/OMEGA-3/VITAMIN E FISH OIL/VIT E/FAT NO.5/HC137 FLAVOXATE HCL FLECAINIDE ACETATE FLECAINIDE ACETATE FLECAINIDE ACETATE FLUCONAZOLE FLUCONAZOLE FLUCONAZOLE FLUCONAZOLE DOSAGE AMPUL VIAL VIAL TABLET TABLET CAPSULE TABLET TABLET TABLET DROPS LIQUID ORAL SUSP SOLUTION TABLET TABLET DR TABLET DR VIAL TAB ER 24H TAB ER 24H ORAL SUSP TABLET TABLET TABLET UNIT UNIT UNIT EACH TABLET SYRINGE SYRINGE VIAL VIAL TABLET CAPSULE CAPSULE EMUL PACKT CAPSULE CAPSULE TABLET TABLET TABLET TABLET SUSP RECON SUSP RECON TABLET TABLET STRENGTH 50 MCG/ML 50 MCG/ML 750MG/15ML 324(106)MG 106 MG-1MG 106 MG 240(27)MG 324(37.5) 324(38)MG 15 MG/ML 300 MG/5ML 15MG/1.5ML 220(44)/5 325(65) MG 324(65)MG 325(65) MG 510MG/17ML 4 MG 8 MG 30 MG/5 ML 180 MG 60 MG 900-1300MG 200 MG 300MCG/0.5 480MCG/0.8 300 MCG/ML 480MCG/1.6 5 MG 0.5 MG 1200 MG 2000-3/2.5 1100-700MG 400 MG-5 100 MG 100 MG 150 MG 50 MG 10 MG/ML 40 MG/ML 100 MG 150 MG NOTE APPENDIX A PAGE 49 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 50 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION FLUCONAZOLE FLUCONAZOLE FLUCONAZOLE IN DEXTROSE,ISO-OS FLUCONAZOLE IN DEXTROSE,ISO-OS FLUCONAZOLE IN NACL,ISO-OSM FLUCONAZOLE IN NACL,ISO-OSM FLUCYTOSINE FLUCYTOSINE FLUDARABINE PHOSPHATE FLUDARABINE PHOSPHATE FLUDROCORTISONE ACETATE FLUNISOLIDE FLUNISOLIDE FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE OIL FLUOCINOLONE/SHOWER CAP FLUOCINONIDE FLUOCINONIDE FLUOCINONIDE FLUOCINONIDE FLUOCINONIDE FLUOCINONIDE/EMOLLIENT BASE FLUORESCEIN SODIUM FLUORIDE/IRON/VIT A,C&D FLUOROMETHOLONE FLUOROMETHOLONE FLUOROMETHOLONE FLUOROMETHOLONE ACETATE FLUOROURACIL FLUOROURACIL FLUOROURACIL FLUOROURACIL FLUOROURACIL FLUOROURACIL FLUOROURACIL FLUOROURACIL FLUOXETINE HCL FLUOXETINE HCL FLUOXETINE HCL FLUOXETINE HCL FLUOXETINE HCL DOSAGE TABLET TABLET PIGGYBACK PIGGYBACK PIGGYBACK PIGGYBACK CAPSULE CAPSULE VIAL VIAL TABLET HFA AER AD SPRAY CREAM (G) CREAM (G) OIL OINT. (G) SHAMPOO SOLUTION DROPS OIL CREAM (G) CREAM (G) GEL (GRAM) OINT. (G) SOLUTION CREAM (G) VIAL DROPS DROPS SUSP DROPS SUSP OINT. (G) DROPS SUSP CREAM (G) CREAM (G) SOLUTION SOLUTION VIAL VIAL VIAL VIAL CAPSULE CAPSULE CAPSULE CAPSULE DR SOLUTION STRENGTH 200 MG 50 MG 200MG/0.1L 400MG/0.2L 200MG/0.1L 400MG/0.2L 250 MG 500 MG 50 MG 50 MG/2 ML 0.1 MG 80 MCG 25 MCG 0.01 % 0.025 % 0.01 % 0.025 % 0.01 % 0.01 % 0.01 % 0.01 % 0.05 % 0.1 % 0.05 % 0.05 % 0.05 % 0.05 % 500 MG/5ML 0.25 MG/ML 0.1 % 0.25 % 0.1 % 0.1 % 0.5 % 5 % 2 % 5 % 1 G/20 ML 2.5 G/50ML 5 G/100 ML 500MG/10ML 10 MG 20 MG 40 MG 90 MG 20 MG/5 ML NOTE OPHTH ONLY 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION FLUOXETINE HCL FLUOXETINE HCL FLUOXETINE HCL FLUPHENAZINE DECANOATE FLUPHENAZINE HCL FLUPHENAZINE HCL FLUPHENAZINE HCL FLUPHENAZINE HCL FLUPHENAZINE HCL FLUPHENAZINE HCL FLUPHENAZINE HCL FLURANDRENOLIDE FLURAZEPAM HCL FLURAZEPAM HCL FLURBIPROFEN FLURBIPROFEN FLURBIPROFEN SODIUM FLUTAMIDE FLUTICASONE FUROATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE PROPIONATE FLUTICASONE/SALMETEROL FLUTICASONE/SALMETEROL FLUTICASONE/SALMETEROL FLUTICASONE/SALMETEROL FLUTICASONE/SALMETEROL FLUTICASONE/SALMETEROL FLUTICASONE/VILANTEROL FLUVASTATIN SODIUM FLUVASTATIN SODIUM FLUVASTATIN SODIUM FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE FOLIC ACID FOLIC ACID DOSAGE TABLET TABLET TABLET VIAL ELIXIR ORAL CONC TABLET TABLET TABLET TABLET VIAL MED. TAPE CAPSULE CAPSULE TABLET TABLET DROPS CAPSULE SPRAY SUSP AER W/ADAP AER W/ADAP AER W/ADAP BLST W/DEV BLST W/DEV BLST W/DEV CREAM (G) LOTION OINT. (G) SPRAY SUSP BLST W/DEV BLST W/DEV BLST W/DEV HFA AER AD HFA AER AD HFA AER AD BLST W/DEV CAPSULE CAPSULE TAB ER 24H CAP ER 24H CAP ER 24H TABLET TABLET TABLET TABLET VIAL STRENGTH 10 MG 20 MG 60 MG 25 MG/ML 2.5 MG/5ML 5 MG/ML 1 MG 10 MG 2.5 MG 5 MG 2.5 MG/ML 4MCG/SQ CM 15 MG 30 MG 100 MG 50 MG 0.03 % 125 MG 27.5 MCG 110 MCG 220 MCG 44 MCG 100 MCG 250 MCG 50 MCG 0.05 % 0.05 % 0.005 % 50 MCG 100-50 MCG 250-50 MCG 500-50 MCG 115-21MCG 230-21MCG 45-21MCG 100-25MCG 20 MG 40 MG 80 MG 100 MG 150 MG 100 MG 25 MG 50 MG 1 MG 5 MG/ML NOTE APPENDIX A PAGE 51 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 52 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION FOLIC ACID/INOSITOL FOLIC ACID/VIT BCOMP&C/CU/ZNOX FOLIC ACID/VITAMIN B COMP W-C FOLIC ACID/VITAMIN B COMP W-C FOLIC ACID/VITAMIN B COMP W-C FONDAPARINUX SODIUM FONDAPARINUX SODIUM FONDAPARINUX SODIUM FONDAPARINUX SODIUM FORMOTEROL FUMARATE FORMOTEROL FUMARATE FOS/INULIN/NUTRIT SUPP/FIBER FOS/INULIN/NUTRIT SUPP/FIBER FOSAMPRENAVIR CALCIUM FOSAMPRENAVIR CALCIUM FOSAPREPITANT DIMEGLUMINE FOSFOMYCIN TROMETHAMINE FOSINOPRIL SODIUM FOSINOPRIL SODIUM FOSINOPRIL SODIUM FOSINOPRIL/HYDROCHLOROTHIAZIDE FOSINOPRIL/HYDROCHLOROTHIAZIDE FOSPHENYTOIN SODIUM FOSPHENYTOIN SODIUM FROVATRIPTAN SUCCINATE FULVESTRANT FUROSEMIDE FUROSEMIDE FUROSEMIDE FUROSEMIDE FUROSEMIDE FUROSEMIDE FUROSEMIDE GABAPENTIN GABAPENTIN GABAPENTIN GABAPENTIN GABAPENTIN GABAPENTIN GABAPENTIN GABAPENTIN GABAPENTIN GABAPENTIN ENACARBIL GALANTAMINE HBR GALANTAMINE HBR GALANTAMINE HBR DOSAGE POWD PACK TABLET TABLET TABLET TABLET SYRINGE SYRINGE SYRINGE SYRINGE CAP W/DEV VIAL-NEB ORAL SUSP ORAL SUSP ORAL SUSP TABLET VIAL PACKET TABLET TABLET TABLET TABLET TABLET VIAL VIAL TABLET SYRINGE SOLUTION SOLUTION SYRINGE TABLET TABLET TABLET VIAL CAPSULE CAPSULE CAPSULE SOLUTION TAB ER 24H TAB ER 24H TAB ER 24H TABLET TABLET TABLET ER CAP24H PEL CAP24H PEL CAP24H PEL STRENGTH 200-2000MG 5-1.5-25MG 0.8 MG 1 MG-100MG 5 MG 10MG/0.8ML 2.5 MG/0.5 5MG/0.4ML 7.5MG/0.6 12 MCG 20 MCG/2ML 0.03G-1/ML 0.06G-1.5 50 MG/ML 700 MG 150 MG 3 G 10 MG 20 MG 40 MG 10-12.5MG 20-12.5 MG 100MG PE/2 500 PE/10 2.5 MG 250 MG/5ML 10 MG/ML 40MG/5ML 10 MG/ML 20 MG 40 MG 80 MG 10 MG/ML 100 MG 300 MG 400 MG 250 MG/5ML 300 MG 300-600 MG 600 MG 600 MG 800 MG 600 MG 16 MG 24 MG 8 MG NOTE (RX ONLY) (RX ONLY) 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION GALANTAMINE HBR GALANTAMINE HBR GALANTAMINE HBR GALSULFASE GANCICLOVIR GANCICLOVIR SODIUM GASTRIC NO.3/HERBAL NO.212 GATIFLOXACIN GEMCITABINE HCL GEMCITABINE HCL GEMCITABINE HCL GEMFIBROZIL GENISTEIN GENISTEIN/CIT ZN BISGLY/VIT D3 GENTAMICIN IN NACL, ISO-OSM GENTAMICIN IN NACL, ISO-OSM GENTAMICIN IN NACL, ISO-OSM GENTAMICIN IN NACL, ISO-OSM GENTAMICIN SULFATE GENTAMICIN SULFATE GENTAMICIN SULFATE GENTAMICIN SULFATE GENTAMICIN SULFATE GENTAMICIN SULFATE GENTAMICIN SULFATE/PF GENTAMICIN/PREDNISOL AC GENTAMICIN/PREDNISOL AC GENTLEASE LIPIL POWDER - 12.4 GINGER ROOT XT/FENNEL SD XT GLATIRAMER ACETATE GLATIRAMER ACETATE GLIMEPIRIDE GLIMEPIRIDE GLIMEPIRIDE GLIPIZIDE GLIPIZIDE GLIPIZIDE GLIPIZIDE GLIPIZIDE GLIPIZIDE/METFORMIN HCL GLIPIZIDE/METFORMIN HCL GLIPIZIDE/METFORMIN HCL GLUCAGON,HUMAN RECOMBINANT GLUCAGON,HUMAN RECOMBINANT GLUCAGON,HUMAN RECOMBINANT GLUCERNA BUTTER PECAN SHAKE RT DOSAGE TABLET TABLET TABLET VIAL GEL (GRAM) VIAL CAPSULE DROPS VIAL VIAL VIAL TABLET TABLET CAPSULE PIGGYBACK PIGGYBACK PIGGYBACK PIGGYBACK CREAM (G) DROPS OINT. (G) OINT. (G) VIAL VIAL VIAL DROPS SUSP OINT. (G) CAN LIQUID SYRINGE SYRINGE TABLET TABLET TABLET TAB ER 24 TAB ER 24 TAB ER 24 TABLET TABLET TABLET TABLET TABLET KIT VIAL VIAL UNIT STRENGTH 12 MG 4 MG 8 MG 5 MG/5 ML 0.15 % 500 MG 204.5-190 0.5 % 1 G 2 G 200 MG 600 MG 30 MG 27-20-200 100MG/0.1L 60 MG/50ML 80 MG/50ML 80MG/100ML 0.1 % 0.3 % 0.1 % 0.3 % 20 MG/2 ML 40 MG/ML 20 MG/2 ML 0.3%-1% 0.3-0.6% 5MG-4MG/5 20 MG/ML 40 MG/ML 1 MG 2 MG 4 MG 10 MG 2.5 MG 5 MG 10 MG 5 MG 2.5-250 MG 2.5-500 MG 5 MG-500MG 1 MG 1 MG 1 MG/ML NOTE APPENDIX A PAGE 53 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION GLUCERNA HOMEMADE VANILLA SHAK GLUCERNA RTD RICH CHOC SHAKE I GLUCERNA RTD RICH CREAMY STRAW GLUCERNA 1.0 CAL RTD VANILLA I GLUCERNA 1.2 CAL RTD VANILLA I GLUCERNA 1.5 CAL RTD VANILLA I GLUCOSE POLYMERS GLUCOSE POLYMERS GLUT/LYSINE HC/C/MV-MN/HC124 GLUTAMINE GLUTAMINE GLUTAMINE GLUTAMINE GLUTAMINE GLUTAMINE GLYBURIDE GLYBURIDE GLYBURIDE GLYBURIDE/METFORMIN HCL GLYBURIDE/METFORMIN HCL GLYBURIDE/METFORMIN HCL GLYBURIDE,MICRONIZED GLYBURIDE,MICRONIZED GLYBURIDE,MICRONIZED GLYCEROL PHENYLBUTYRATE GLYCINE GLYCINE GLYCINE GLYCINE GLYCINE UROLOGIC SOLUTION GLYCINE/SOD/WATER/SOD HYDROX GLYCOPYRROLATE GLYCOPYRROLATE GLYCOPYRROLATE GLYCOPYRROLATE GLYTROL SPIKERIGHT PLUS ULTRAP GOLIMUMAB GOLIMUMAB GOOD START CONC GENTLE PLUS GOOD START GENTLE PLUS POWDER GOOD START GENTLE PLUS RTF - 3 GOOD START ORAL CONC - 32 OZ C GOOD START ORAL SUSP - 32 OZ C GOOD START POWDER - 24 OZ CAN GOOD START POWDER - 24 OZ CAN GOOD START PROTECT PLUS POWDER DOSAGE UNIT UNIT UNIT UNIT UNIT UNIT LIQUID POWDER TABLET EFF CAPSULE PACKET POWD PACK POWD PACK POWDER TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET LIQUID CAPSULE CAPSULE POWD PACK POWDER IRRIG SOLN VIAL SOLUTION TABLET TABLET VIAL UNIT PEN INJCTR SYRINGE CAN CAN CAN CAN CAN CAN CAN CAN STRENGTH 384/100G 1000-50 MG 500 MG 10 G 10 G 15 G 100 % 500 MG 1.25 MG 2.5 MG 5 MG 1.25-250MG 2.5-500 MG 5 MG-500MG 1.5 MG 3 MG 6 MG 1.1GRAM/ML 500 MG 600 MG 500 MG 1.5 % 1 MG/5 ML 1 MG 2 MG 0.2 MG/ML 50MG/0.5ML 50MG/0.5ML 2.2 G/100 2.2 G/100 2.2 G/100 2.2 G/100 2.2 G/100 2.2 G/100 2.2 G/100 NOTE APPENDIX A PAGE 54 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION GOOD START SOY PLUS CONC - 13 GOOD START SOY PLUS POWDER - 1 GOOD START SOY PLUS POWDER - 2 GOOD START SOY PLUS RTF - 32 O GOOD START SUPREME POWDER - 25 GOOD START W/IRON LIQUID - 24 GOOD START W/IRON ORAL CONC GOOD START W/IRON POWDER - 24 GOOD START 2 SUPREME POWDER GOSERELIN ACETATE GOSERELIN ACETATE GRANISETRON GRANISETRON HCL GRANISETRON HCL GRANISETRON HCL GRANISETRON HCL/PF GRANISETRON HCL/PF GRASS POLLEN-TIMOTHY, STD GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN, MICROSIZE GRISEOFULVIN, MICROSIZE GUAIFENESIN/PHENYLEPHRINE HCL GUAIFENESIN/PHENYLEPHRINE HCL GUANFACINE HCL GUANFACINE HCL GUANFACINE HCL GUANFACINE HCL GUANFACINE HCL GUANFACINE HCL GUAR GUM GUAR/CHRM/DR BT-ORG PEEL/HC109 GUARA XT/AA COMB 2/CA/BEE POLL GUARA/M-18/YHBK/K.GINSG/MACA GUARANA/CR/VANAD/S.GINSG/HRB40 GUARANA/SGINRT/GINSENG/K.GINSG GUARANA/SGINRT/MA-HUNG/K.GINSG H-IMMU COL,BOV/A-CAR/ARA/HC112 HALCINONIDE HALCINONIDE HALOBETASOL PROPIONATE HALOBETASOL PROPIONATE HALOPERIDOL HALOPERIDOL HALOPERIDOL HALOPERIDOL DOSAGE CAN CAN CAN CAN CAN CAN CAN CAN CAN IMPLANT IMPLANT PATCH TDWK TABLET VIAL VIAL VIAL VIAL TAB SUBL TABLET TABLET ORAL SUSP TABLET SYRUP TABLET TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TABLET TABLET POWDER CAPSULE TABLET TABLET TABLET CAPSULE TABLET CAPSULE CREAM (G) OINT. (G) CREAM (G) OINT. (G) TABLET TABLET TABLET TABLET STRENGTH 11.6 G/100 2.8 G/100 10.8MG 3.6 MG 3.1MG/24HR 1 MG 1 MG/ML 1 MG/ML(1) 1 MG/ML(1) 100 MCG/ML 2800 BAU 125 MG 250 MG 125 MG/5ML 500 MG 200-5MG/5 400MG-10MG 1 MG 2 MG 3 MG 4 MG 1 MG 2 MG 100MG-200 200 MG 125-85MG 500 MG 0.1 % 0.1 % 0.05 % 0.05 % 0.5 MG 1 MG 10 MG 2 MG NOTE APPENDIX A PAGE 55 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION HALOPERIDOL HALOPERIDOL HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE HALOPERIDOL LACTATE HALOPERIDOL LACTATE HALOPERIDOL LACTATE HEPARIN SOD,PORK IN 0.45% NACL HEPARIN SODIUM,PORCINE HEPARIN SODIUM,PORCINE HEPARIN SODIUM,PORCINE HEPARIN SODIUM,PORCINE HEPARIN SODIUM,PORCINE HEPARIN SODIUM,PORCINE HEPARIN SODIUM,PORCINE HEPARIN SODIUM,PORCINE/D5W HEPARIN SODIUM,PORCINE/D5W HEPARIN SODIUM,PORCINE/D5W HEPARIN SODIUM,PORCINE/NS/PF HEPARIN SODIUM,PORCINE/PF HEPARIN SODIUM,PORCINE/PF HEPARIN SODIUM,PORCINE/PF HEPARIN SODIUM,PORCINE/PF HEPARIN SODIUM,PORCINE/PF HEPARIN SODIUM,PORCINE/PF HEPARIN SODIUM,PORCINE/PF HEPARIN SODIUM,PORCINE/PF HEPARIN SODIUM,PORCINE/PF HEPATITIS B IMMUNE GLOBULIN HEPATITIS B IMMUNE GLOBULIN HEPATITIS B IMMUNE GLOBULIN HEPATITIS B IMMUNE GLOBULIN HEPATITIS B IMMUNE GLOBULIN HESP METH CHAL/RUS ACU XT/ROSE HESP/DIOSM HYD/CA DOBE/DIOSMIN HETASTARCH IN 0.9 % NACL HI-CAL VANILLA - 1 LTR BOTTLE HISTIDINE HCL HISTRELIN AC HUM INSULIN NPH/REG INSULIN HM HUM INSULIN NPH/REG INSULIN HM HYALUR AC/CHOND SUL/COLG II/AA HYALURONATE SODIUM HYALURONATE SODIUM/VIT C DOSAGE TABLET TABLET AMPUL AMPUL VIAL VIAL AMPUL ORAL CONC VIAL IV SOLN CARTRIDGE VIAL VIAL VIAL VIAL VIAL VIAL IV SOLN IV SOLN IV SOLN IV SOLN DISP SYRIN DISP SYRIN SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE VIAL VIAL SYRINGE VIAL VIAL VIAL VIAL CAPSULE TABLET PLAST. BAG UNIT CAPSULE KIT INSULN PEN VIAL CAPSULE CAPSULE CAPSULE STRENGTH 20 MG 5 MG 100 MG/ML 50 MG/ML 100 MG/ML 50 MG/ML 5 MG/ML 2 MG/ML 5 MG/ML 12500/250 5000/ML(1) 100/ML 1000/ML 10000/ML 20000/ML 5000/ML 5000/ML 20K/500ML 25000/250 25000/500 1000/500ML 300/3 ML 500/5 ML 10 UNIT/ML 1000/10 ML 200/2 ML 300/3 ML 500/5 ML 1000/ML 5000/0.5ML 110/0.5ML >1560/5ML >312/ML 220 UNIT/1 220/ML (5) 150-150MG 200-500MG 6 %-0.9 % 600 MG 50 MG 70-30/ML 70-30/ML 40-80-400 20 MG 20 MG-60MG NOTE 10ML APPENDIX A PAGE 56 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION HYDRALAZINE HCL HYDRALAZINE HCL HYDRALAZINE HCL HYDRALAZINE HCL HYDRALAZINE HCL HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE HYDROCODONE BITARTRATE HYDROCODONE BITARTRATE HYDROCODONE BITARTRATE HYDROCODONE BITARTRATE HYDROCODONE BITARTRATE HYDROCODONE BITARTRATE HYDROCODONE/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN HYDROCODONE/ACETAMINOPHEN HYDROCODONE/IBUPROFEN HYDROCODONE/IBUPROFEN HYDROCODONE/IBUPROFEN HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE HYDROCORTISONE AC/LIDOCAINE HYDROCORTISONE AC/LIDOCAINE HYDROCORTISONE AC/LIDOCAINE HYDROCORTISONE AC/LIDOCAINE DOSAGE TABLET TABLET TABLET TABLET VIAL CAPSULE TABLET TABLET TABLET CAP ER 12H CAP ER 12H CAP ER 12H CAP ER 12H CAP ER 12H CAP ER 12H SOLUTION SOLUTION SOLUTION SOLUTION TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET CREAM (G) CREAM (G) CREAM/APPL ENEMA LOTION LOTION OINT. (G) OINT. (G) POWDER SOLUTION TABLET TABLET TABLET CREAM (G) CREAM/APPL CREAM/APPL KIT STRENGTH 10 MG 100 MG 25 MG 50 MG 20 MG/ML 12.5 MG 12.5 MG 25 MG 50 MG 10 MG 15 MG 20 MG 30 MG 40 MG 50 MG 10-300/15 10-325/15 2.5-167/5 7.5-325/15 10MG-300MG 10MG-325MG 10MG-500MG 5MG-300MG 5MG-325MG 7.5-300MG 7.5-325MG 10MG-200MG 5MG-200MG 7.5-200 MG 1 % 2.5 % 2.5 % 100MG/60ML 1 % 2.5 % 1 % 2.5 % 2.5 % 10 MG 20 MG 5 MG 0.5 %-3 % 0.5 %-3 % 1%-3%(7G) 0.5 %-3 % NOTE APPENDIX A PAGE 57 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION HYDROCORTISONE AC/LIDOCAINE HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE/UREA HYDROCORTISONE BUTYRATE HYDROCORTISONE BUTYRATE HYDROCORTISONE BUTYRATE HYDROCORTISONE PROBUTATE HYDROCORTISONE SOD SUCC/PF HYDROCORTISONE SOD SUCC/PF HYDROCORTISONE SOD SUCC/PF HYDROCORTISONE SOD SUCC/PF HYDROCORTISONE SOD SUCCINATE HYDROCORTISONE VALERATE HYDROCORTISONE VALERATE HYDROCORTISONE/EMOL NO.45 HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL/PF HYDROMORPHONE HCL/PF HYDROMORPHONE HCL/PF HYDROMORPHONE HCL/PF HYDROMORPHONE HCL/PF HYDROMORPHONE HCL/PF HYDROXOCOBALAMIN HYDROXYCHLOROQUINE SULFATE HYDROXYPROGESTERONE CAPROATE HYDROXYPROPYL CELLULOSE HYDROXYUREA HYDROXYUREA HYDROXYUREA HYDROXYUREA HYDROXYZINE HCL HYDROXYZINE HCL HYDROXYZINE HCL HYDROXYZINE HCL DOSAGE KIT FOAM/APPL CREAM (G) CREAM (G) OINT. (G) SOLUTION CREAM (G) VIAL VIAL VIAL VIAL VIAL CREAM (G) OINT. (G) KT LOTN CE LIQUID SUPP.RECT SYRINGE SYRINGE SYRINGE TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TABLET TABLET TABLET VIAL AMPUL AMPUL AMPUL AMPUL VIAL VIAL VIAL TABLET VIAL INSERT CAPSULE CAPSULE CAPSULE CAPSULE SYRUP TABLET TABLET TABLET STRENGTH 1%-3%(7G) 10 % 1 %-10 % 0.1 % 0.1 % 0.1 % 0.1 % 100 MG/2ML 1000MG/8ML 250 MG/2ML 500 MG/4ML 100 MG 0.2 % 0.2 % 2 % 1 MG/ML 3 MG 1 MG/ML 2 MG/ML 4 MG/ML 12 MG 16 MG 32 MG 8 MG 2 MG 4 MG 8 MG 2 MG/ML 1 MG/ML 10 MG/ML 2 MG/ML 4 MG/ML 10 MG/ML 250 MG 1000MCG/ML 200 MG 250 MG/ML 5 MG 200 MG 300 MG 400 MG 500 MG 10 MG/5 ML 10 MG 25 MG 50 MG NOTE APPENDIX A PAGE 58 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION HYDROXYZINE HCL HYDROXYZINE HCL HYDROXYZINE PAMOATE HYDROXYZINE PAMOATE HYDROXYZINE PAMOATE HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE HYOSCYAMINE/CHASTE/AMER GINS IBANDRONATE SODIUM IBANDRONATE SODIUM IBRUTINIB IBUPROFEN IBUPROFEN IBUPROFEN IBUPROFEN IBUPROFEN/FAMOTIDINE IBUPROFEN/OXYCODONE HCL IBUTILIDE FUMARATE ICATIBANT ACETATE ICOSAPENT ETHYL IDELALISIB IDELALISIB IDURSULFASE IFOSFAMIDE IFOSFAMIDE IFOSFAMIDE IFOSFAMIDE IGG/HYALURONIDASE,RECOMBINANT IGG/HYALURONIDASE,RECOMBINANT IGG/HYALURONIDASE,RECOMBINANT IGG/HYALURONIDASE,RECOMBINANT IGG/HYALURONIDASE,RECOMBINANT ILOPERIDONE ILOPERIDONE ILOPERIDONE ILOPERIDONE ILOPERIDONE ILOPERIDONE ILOPERIDONE ILOPERIDONE ILOPROST TROMETHAMINE ILOPROST TROMETHAMINE IMATINIB MESYLATE DOSAGE VIAL VIAL CAPSULE CAPSULE CAPSULE ELIXIR TAB ER 12H TAB RAPDIS TAB SUBL TABLET TABLET SYRINGE TABLET CAPSULE ORAL SUSP TABLET TABLET TABLET TABLET TABLET VIAL SYRINGE CAPSULE TABLET TABLET VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL TAB DS PK TABLET TABLET TABLET TABLET TABLET TABLET TABLET AMPUL-NEB AMPUL-NEB TABLET STRENGTH 25 MG/ML 50 MG/ML 100 MG 25 MG 50 MG 125MCG/5ML 0.375 MG 0.125 MG 0.125 MG 0.125 MG 3 MG/3 ML 150 MG 140 MG 100 MG/5ML 400 MG 600 MG 800 MG 800-26.6MG 400MG-5MG 0.1 MG/ML 30 MG/3 ML 1 G 100 MG 150 MG 6 MG/3 ML 1 G 1 G/20 ML 3 G 3G/60ML 10 G/100ML 2.5G/25ML 20 G/200ML 30 G/300ML 5 G/50 ML 1-2-4-6MG 1 MG 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG 10 MCG/ML 20 MCG/ML 100 MG NOTE APPENDIX A PAGE 59 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION IMATINIB MESYLATE IMIGLUCERASE IMIPENEM/CILASTATIN SODIUM IMIPENEM/CILASTATIN SODIUM IMIPENEM/CILASTATIN SODIUM IMIPENEM/CILASTATIN SODIUM IMIPRAMINE HCL IMIPRAMINE HCL IMIPRAMINE HCL IMIPRAMINE PAMOATE IMIPRAMINE PAMOATE IMIPRAMINE PAMOATE IMIPRAMINE PAMOATE IMIQUIMOD IMIQUIMOD IMIQUIMOD IMIQUIMOD IMMUNE GLOB/PLASMA FRA BOVINE IMMUNE GLOB,GAM CAPRYLATE(IGG) IMMUNE GLOB,GAM CAPRYLATE(IGG) IMMUNE GLOB,GAM CAPRYLATE(IGG) IMMUNE GLOB,GAM CAPRYLATE(IGG) IMMUNE GLOB,GAM CAPRYLATE(IGG) IMMUNE GLOBULIN,GAMMA(IGG) IMMUNE GLOBULIN,GAMMA(IGG) IMMUNE GLOBULIN,GAMMA(IGG) IMMUNE GLOBULIN,GAMMA(IGG) IMMUNE GLOBULIN,GAMMA(IGG) IMMUNE GLOBULIN,GAMMA(IGG) IMMUNE GLOBULIN,GAMMA(IGG) IMMUNE GLOBULIN,GAMMA(IGG) IMMUNE GLOBULIN,GAMMA(IGG) IMMUNE GLOBULIN,GAMMA(IGG) IMMUNE GLOBULIN,GAMMA(IGG) IMPACT ADVANCED RECOVERY CHOC IMPACT ADVANCED RECOVERY VANIL IMPACT CLOSED SYSTEM - 1000ML IMPACT GLUTAMINE UNFLAVORED IMPACT GLUTAMINE UNFLAVORED CL IMPACT UNFLAVORED - 250 ML CAN IMPACT UNFLAVORED W/FIBER - 25 IMPACT UNFLAVORED W/FIBER CLOS IMPACT UNFLAVORED 1.5 CAL - 25 INCOBOTULINUMTOXINA INCOBOTULINUMTOXINA INDAPAMIDE DOSAGE TABLET VIAL VIAL VIAL VIAL PORT VIAL PORT TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE CAPSULE CREAM PACK CREAM PACK CRM MD PMP CRM MD PMP POWD PACK VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT VIAL VIAL TABLET STRENGTH 400 MG 400 UNIT 250 MG 500 MG 250 MG 500 MG 10 MG 25 MG 50 MG 100 MG 125 MG 150 MG 75 MG 3.75 % 5 % 2.5 % 3.75 % 5 G 1 G/10 ML 10 G/100ML 2.5G/25ML 20 G/200ML 5 G/50 ML 1 G/5 ML 10 % 10 G 10 G/50 ML 12G 15%-18% 2 G/10 ML 4 G/20 ML 5 % 5 G 6G 0.08G-1.4 0.08G-1.4 0.08G-1.3 0.06G-1/ML 0.06G-1/ML 0.08G-1.5 100 UNIT 50 UNIT 1.25 MG NOTE APPENDIX A PAGE 60 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION INDAPAMIDE INDINAVIR SULFATE INDINAVIR SULFATE INDOMETHACIN INDOMETHACIN INDOMETHACIN INDOMETHACIN INDOMETHACIN INDOMETHACIN SODIUM INF FORM FE LF/DHA/ARACHID AC INF FORM FE LF/DHA/ARACHID AC INF FORM FE LF/DHA/ARACHID AC INF FORM FOR TYROSINEMIA, IRON INF FORM FOR TYROSINEMIA, IRON INF FORM LACT.RED,IRON,DHA/ARA INF FORM LACT.RED,IRON,DHA/ARA INF FORM.W-IRON/DHA/ARA/B.ANIM INF FORM/IRON/AMINO AC/DHA/ARA INF FORM/IRON/DHA/ARA/L.REUTER INF FORM, GLUTARIC ACIDURIA I INF FORM,IRON/DHA/ARA/POLY/GOS INF FORM,IRON/DHA/ARA/POLY/GOS INF FORM,SOY,IRON,LF/DHA/ARA INF FORM,SOY,IRON,LF/DHA/ARA INF FORM,SOY,IRON,LF/DHA/ARA INF FORM,SOY,IRON,LF/DHA/ARA INF FORM,SOY,IRON,LF/DHA/ARA INF FORM,SOY,IRON,LF/DHA/ARA INF FORM,SOY,IRON,LF/DHA/ARA INF FORM,SOY,IRON,LF/DHA/ARA INF FORM,SP.MET,IRON/LACT RHAM INF FORM,SP.MET,IRON/LACT RHAM INF FORM,SP.MET,LF,IRON/AA INF FORMULA,SP.MET,LAC FR,IRON INF FORMULA,SP.MET,LAC FR,IRON INF. FORM, ISOVALERIC ACIDEMIA INF. FORM, ISOVALERIC ACIDEMIA INF.FORM,METAB,IRON METHION-FR INF.FORM,METAB,IRON METHION-FR INFANT FORM. W-IRON LF/DHA/ARA INFANT FORM. W-IRON LF/DHA/ARA INFANT FORM. W-IRON LF/DHA/ARA INFANT FORM. W-IRON LF/DHA/ARA INFANT FORM.IRON, LACTOSE FREE INFANT FORM.IRON,HUMAN MILK FT INFANT FORM.IRON,HUMAN MILK FT DOSAGE TABLET CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE ER ORAL SUSP SUPP.RECT VIAL ORAL SUSP ORAL SUSP POWDER POWDER POWDER LIQUID POWDER POWDER POWDER POWDER POWDER LIQUID POWDER LIQUID LIQUID ORAL CONC ORAL SUSP ORAL SUSP POWDER POWDER POWDER POWDER POWDER POWDER LIQUID ORAL CONC POWDER POWDER POWDER POWDER ORAL SUSP ORAL SUSP POWDER POWDER LIQUID LIQUID PKT POWD PACK STRENGTH 2.5 MG 200 MG 400 MG 25 MG 50 MG 75 MG 25 MG/5 ML 50 MG 1 MG 2.14G/100 2.75G/100 2.14G/100 13G-475 16.7G-500 2.14G/100 2.14G/100 2.2 G/100 2.8 G/100 2.2 G/100 13G-475 2.3 G/100 2.3 G/100 2.45 G/100 2.5 G-5.3G 2.5 G/100 2.45 G/100 2.5 G/100 2.45 G/100 2.5 G/100 2.8 G/100 2.5 G/100 2.8 G/100 2.8 G/100 2.8 G/100 2.8 G/100 13G-475 15G-480 13G-475 15G-480 2.14G/100 2.75G/100 2.75G/100 3.1 G/100 2.14G/100 0.349G/5ML 0.275/0.71 NOTE APPENDIX A PAGE 61 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT INFANT FORM, METAB, METHION-FR FORM, METAB, METHION-FR FORM, W/IRON,SULFITE OX FORM, W/IRON,SULFITE OX FORM,FE,LAC-FR,HYPOALR1 FORM,IRON/SOY/DHA/ARA FORM,IRON/SOY/DHA/ARA FORM,PROPIONIC ACIDEMIA FORM,PROPIONIC ACIDEMIA FORM,PROPIONIC ACIDEMIA FORMULA W-IRON FORMULA W-IRON FORMULA W-IRON FORMULA W-IRON FORMULA W-IRON FORMULA W-IRON FORMULA W-IRON FORMULA W-IRON FORMULA WITH IRON FORMULA WITH IRON FORMULA WITH IRON FORMULA WITH IRON FORMULA WITH IRON FORMULA WITH IRON FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA FORMULA, IRON/DHA/ARA DOSAGE POWDER POWDER POWDER POWDER POWDER POWDER POWDER POWDER POWDER POWDER CAN LIQUID LIQUID ORAL SUSP PACKET POWDER POWDER POWDER LIQUID LIQUID LIQUID ORAL CONC PACKET POWDER LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID ORAL CONC ORAL CONC ORAL SUSP ORAL SUSP ORAL SUSP ORAL SUSP ORAL SUSP STRENGTH 13G-475 16.2G-500 13G-475 25G-309 22-33-14.8 2.6 G/100 3G/100KCAL 13G-475 15.7G-500 15G-480 2.6 G/100 2.71G/100 2.07G/100 2.6 G/100 2.07G/100 2.3 G/100 2.07G/100 2.1 G/100 2.14G/100 2.3 G/100 2.32 G/100 2.5 G-5.1G 2.8 G-5.2G 2.8 G-5.3G 2-5.3G/100 3.3 G/100 3.5 G-5.1G 3.6 G-5.2G 3-5.1G/100 3-5.2G/100 3G/100KCAL 11.6 G/100 2-5.3G/100 11.6 G/100 2.07G/100 2.1 G/100 2.3 G/100 3G/100KCAL NOTE APPENDIX A PAGE 62 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, IRON/DHA/ARA INFANT FORMULA, METABOLIC,IRON INFANT FORMULA, METABOLIC,IRON INFANT FORMULA, METABOLIC,IRON INFANT FORMULA, UREA CYCLE DIS INFANT FORMULA, UREA CYCLE DIS INFANT FORMULA,REGULAR INFANT FORMULA,SOY-FE LAC-FREE INFANT FORMULA,SOY-FE LAC-FREE INFANT FORMULA,SOY-FE LAC-FREE INFANT FORMULA,SOY-FE LAC-FREE INFANT FORMULA,SOY-FE LAC-FREE INFANT FORMULA,SOY,W-IRON,LF INFANT FORMULA,SOY,W-IRON,LF INFANT FORMULA,SOY,W-IRON,LF INFANT FORMULA,SOY,W-IRON,LF INFANT FORMULA,SPEC. METABOLIC INFANT FORMULA,SPEC.METAB MSUD INFANT FORMULA,SPEC.METAB MSUD INFANT FORMULA,SPEC.METAB MSUD INFLIXIMAB INHALER, ASSIST DEVICES INHALER,ASSIST DEVICE,ACCESORY INOSITOL/D-CHIRO-INOSITOL INOSITOL/MV COMB 1/SE/BETAINE INSULIN ASPART INSULIN ASPART INSULIN ASPART INSULIN DETEMIR INSULIN DETEMIR INSULIN GLARGINE,HUM.REC.ANLOG INSULIN GLARGINE,HUM.REC.ANLOG DOSAGE POWD PACK POWD PACK POWDER POWDER POWDER POWDER POWDER POWDER POWDER POWDER POWDER POWDER POWDER POWDER POWDER LIQUID POWDER POWDER POWDER POWDER PACKET CAN LIQUID ORAL CONC POWDER POWDER LIQUID ORAL CONC PACKET POWDER POWDER POWDER POWDER POWDER VIAL SPACER EACH POWD PACK CAPSULE CARTRIDGE INSULN PEN VIAL INSULN PEN VIAL INSULN PEN VIAL STRENGTH 2.3 G/100 2-5.3G/100 11.6 G/100 2.07G/100 2.1 G/100 2.2 G/100 2.3 G/100 2.32 G/100 2.5 G/100 2.6 G/100 2.8 G-5.1G 2.8 G-5.2G 2.8 G-5.3G 2.8 G/100 2-5.3G/100 3.5G/100 530/100G 6.5G-500 7.5G-510 2.8 G/100 13G-475 15G-480 16.2G-500 100 MG 2000-50MG 100/ML 100/ML 100/ML 100/ML (3) 100/ML 100/ML (3) 100/ML NOTE APPENDIX A PAGE 63 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION INSULIN GLULISINE INSULIN GLULISINE INSULIN LISPRO INSULIN LISPRO INSULIN LISPRO INSULIN NPL/INSULIN LISPRO INSULIN NPL/INSULIN LISPRO INSULIN NPL/INSULIN LISPRO INSULIN NPL/INSULIN LISPRO INSULIN REGULAR, HUMAN INSULIN REGULAR, HUMAN INSULN ASP PRT/INSULIN ASPART INSULN ASP PRT/INSULIN ASPART INTERFERON ALFA-2B,RECOMB. INTERFERON ALFA-2B,RECOMB. INTERFERON ALFA-2B,RECOMB. INTERFERON ALFA-2B,RECOMB. INTERFERON ALFA-2B,RECOMB. INTERFERON BETA-1A INTERFERON BETA-1A INTERFERON BETA-1A INTERFERON BETA-1A/ALBUMIN INTERFERON BETA-1A/ALBUMIN INTERFERON BETA-1A/ALBUMIN INTERFERON BETA-1A/ALBUMIN INTERFERON BETA-1A/ALBUMIN INTERFERON BETA-1A/ALBUMIN INTERFERON BETA-1A/ALBUMIN INTERFERON BETA-1B INTERFERON GAMMA-1B,RECOMB. INULIN/SORBITOL IPILIMUMAB IPILIMUMAB IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE IPRATROPIUM/ALBUTEROL SULFATE IPRATROPIUM/ALBUTEROL SULFATE IRBESARTAN IRBESARTAN IRBESARTAN IRBESARTAN/HYDROCHLOROTHIAZIDE IRBESARTAN/HYDROCHLOROTHIAZIDE IRINOTECAN HCL IRINOTECAN HCL DOSAGE INSULN PEN VIAL CARTRIDGE INSULN PEN VIAL INSULN PEN INSULN PEN VIAL VIAL VIAL VIAL INSULN PEN VIAL VIAL VIAL VIAL VIAL VIAL PEN IJ KIT SYRINGE SYRINGEKIT KIT PEN INJCTR PEN INJCTR PEN INJCTR SYRINGE SYRINGE SYRINGE KIT VIAL TAB CHEW VIAL VIAL HFA AER AD SOLUTION SPRAY SPRAY AMPUL-NEB MIST INHAL TABLET TABLET TABLET TABLET TABLET VIAL VIAL STRENGTH 100/ML 100/ML 100/ML 100/ML 100/ML 50-50/ML 75-25/ML 50-50/ML 75-25/ML 100/ML 500/ML 70-30/ML 70-30/ML 10MM UNIT 10MM/ML 18MM UNIT 50MM UNIT 6MMUNIT/ML 30MCG/.5ML 30MCG/.5ML 30MCG/.5ML 30 MCG 22MCG/.5ML 44MCG/.5ML 8.8-22(6) 22MCG/.5ML 44MCG/.5ML 8.8-22(6) 0.3 MG 100MCG/0.5 2 G 200MG/40ML 50 MG/10ML 17MCG 0.2 MG/ML 21 MCG 42MCG 0.5-3MG/3 20-100 MCG 150 MG 300 MG 75 MG 150-12.5MG 300-12.5MG 100 MG/5ML 300MG/15ML NOTE APPENDIX A PAGE 64 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION IRINOTECAN HCL IRINOTECAN HCL IRON AG&FUM/C/FA/MV CMB11/CA-T IRON AG/C/B12/CA/SUC.ACID/STOM IRON ASPGLY&PS CMPLX/C/SUCAC IRON ASPGLY&PS/C/B12/FA/CA/SUC IRON ASPGLY/C/B12/FA/CA-TH/SUC IRON BG&PS/VIT C/B12/FA/CA THR IRON BISGLY & PS/FA/B&C#12/SUC IRON DEXTRAN COMPLEX IRON DEXTRAN COMPLEX IRON FUM & AG/C/B12/FA/CA/SUCC IRON FUM & P/FA/VIT B & C NO.9 IRON FUM & PS CMP/FA/VIT C/B3 IRON FUM & PS CMP/VIT C & B IRON FUM&POLYSAC#1/FA/MV NO.18 IRON FUMARATE/VIT C/VIT B12/FA IRON GLY&FUM/C/B12/ME-THFOLATE IRON POLYSACCHARIDE COMPLEX IRON POLYSACCHARIDE COMPLEX IRON POLYSACCHARIDE COMPLEX IRON POLYSACCHARIDE COMPLEX IRON POLYSACCHARIDE COMPLEX/D3 IRON PS CMPLX/VIT B12/FA IRON PS/IRON HEM POLY/FA/B12 IRON SUCROSE COMPLEX IRON SUCROSE COMPLEX IRON SUCROSE COMPLEX IRON/FA/B12/C/DOCUSATE SODIUM IRON/FA/VITAMIN B COMP W-C/MIN IRON/FLUORIDE/VITS A, C, & D3 IRON, CARB & GLUC/FA/B12/C/DSS IRON, CARBONYL/FA/C/B-6/B12/ZN IRON,CARB/FA#6/MV, MIN NO.40 IRON,CARB/FA#6/MV, MIN NO.41 IRON,CARBONYL IRON,CARBONYL IRON,CARBONYL/ASCORBIC ACID IRON,CARBONYL/FA/MULTIVITS-MIN IRON,CARBONYL/FA/MULTIVITS-MIN IRON,CARBONYL/VIT C/VIT B12/FA IRON,FUM&PS/FA/VIT B&C#18/L.CA ISOCARBOXAZID ISOLEUCINE ISOLEUCINE/CARBOHYDRATE SUPPL ISOLEUCINE/CARBOHYDRATE SUPPL DOSAGE VIAL VIAL TABLET TABLET CAPSULE CAPSULE TABLET CAPSULE TABLET VIAL VIAL TABLET CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE TABLET CAPSULE CAPSULE CAPSULE DROPS LIQUID CAPSULE TABLET VIAL VIAL VIAL TABLET TABLET ORAL SUSP TABLET TABLET TABLET TABLET ORAL SUSP TAB CHEW TABLET TABLET TABLET TABLET CAPSULE TABLET CAPSULE POWD PACK POWD PACK STRENGTH 40 MG/2 ML 500MG/25ML 151-200-1 70-150-10 150-50-50 150-25-1 70-150-1MG 150-60-1 65-1MG(24) 100 MG/2ML 50MG/ML(1) 151-60-1MG 125MG-1MG 125-1-40-3 125-40-3MG 106 MG-1MG 460-60MG 150-200 MG 150 MG 200 MG 50 MG 15 MG/ML 125 MG/5ML 150-25-1 22-6-1-25 100 MG/5ML 200MG/10ML 50MG/2.5ML 90-1-50 MG 106 MG-1MG 10-0.25/2 90-1-50 MG 150-1.25MG 150 MG-1MG 150 MG-1MG 15MG/1.25 15 MG 100-250MG 50-1.25MG 75-1.25 MG 100-250-1 130-1.25MG 10 MG 600 MG 1 G/4 G 50 MG/4 G NOTE APPENDIX A PAGE 65 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 66 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ISONIAZID ISONIAZID ISONIAZID ISONIAZID ISOPROTERENOL HCL ISOSORB DINIT/HYDRALAZINE HCL ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ISOSOURCE CLOSED SYSTEM - 1000 ISOSOURCE CLOSED SYSTEM - 1500 ISOSOURCE HN CLOSED SYSTEM - 1 ISOSOURCE HN UNFLAVORED - 250 ISOSOURCE VANILLA 1.5 CAL-250M ISOTRETINOIN ISOTRETINOIN ISOTRETINOIN ISOTRETINOIN ISOTRETINOIN ISOTRETINOIN ISOTRETINOIN ISRADIPINE ISRADIPINE ITRACONAZOLE ITRACONAZOLE IVACAFTOR IVERMECTIN IVERMECTIN IXABEPILONE IXABEPILONE JEVITY 1.0 CAL RTH - 1000ML C JEVITY 1.0 CAL RTH - 1500ML C JEVITY 1.0 CAL UNFLAVORED - 8 JEVITY 1.2 CAL RTH - 1000ML CO JEVITY 1.2 CAL RTH - 1500ML CO JEVITY 1.2 CAL UNFLAVORED - 8 JEVITY 1.5 CAL RTH 1000ML CONT DOSAGE SOLUTION TABLET TABLET VIAL AMPUL TABLET CAPSULE ER TABLET TABLET TABLET TABLET TABLET TABLET ER TAB ER 24H TAB ER 24H TAB ER 24H TABLET TABLET UNIT UNIT UNIT UNIT UNIT CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE SOLUTION TABLET LOTION TABLET VIAL VIAL UNIT UNIT UNIT UNIT UNIT UNIT UNIT STRENGTH NOTE 50 MG/5 ML 100 MG 300 MG 100 MG/ML 0.2 MG/ML 20-37.5MG 40 MG 10 MG 20 MG 30 MG 40 MG 5 MG 40 MG 120 MG 30 MG 60 MG 10 MG 20 MG 10 MG 10 MG 20 MG 20 MG 30 MG 40 MG 40 MG 2.5 MG 5 MG 100 MG 10 MG/ML 150 MG 0.5 % 3 MG 15 MG 45 MG 0.06G-1.5 NO REFILLS NO REFILLS NO REFILLS 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION JEVITY 1.5 CAL RTH 1500ML CONT JEVITY 1.5 CAL UNFLAVORED - 8 JUVEN GRAPE - CARTON - 1 CART JUVEN GRAPE - 0.85 OZ PACKET JUVEN ORANGE - CARTON - 1 CART JUVEN ORANGE - 0.85 OZ PACKET JUVEN UNFLAVORED - CARTON - 1 JUVEN UNFLAVORED - 0.85 OZ PAC KAOLIN/PECTIN KETOCAL POWDER 3:1 - 11 OZ CAN KETOCAL POWDER 4:1 VANILLA - 1 KETOCONAZOLE KETOCONAZOLE KETOCONAZOLE KETOCONAZOLE KETOPROFEN KETOPROFEN KETOPROFEN KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE/PF L. RHAMNOSUS/L. REUTERI L-CARNITINE FUMARATE L-CARNITINE/ACETYLCARN/FRUC/CA L-NORGEST-ETH ESTR/ETHIN ESTRA L-NORGEST-ETH ESTR/ETHIN ESTRA L-NORGEST-ETH ESTR/ETHIN ESTRA LABETALOL HCL LABETALOL HCL LABETALOL HCL LABETALOL HCL LACOSAMIDE LACOSAMIDE LACOSAMIDE LACOSAMIDE LACOSAMIDE LACOSAMIDE LACTALBUMINS, HYDROLYZATES/CYS LACTOSE-FREE FOOD DOSAGE UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT ORAL SUSP CAN CAN CREAM (G) FOAM SHAMPOO TABLET CAPSULE CAPSULE CAP24H PEL CARTRIDGE CARTRIDGE DROPS DROPS SPRAY TABLET VIAL VIAL VIAL DROPERETTE CAPSULE CAPSULE PACKET TBDSPK 3MO TBDSPK 3MO TBDSPK 3MO TABLET TABLET TABLET VIAL SOLUTION TABLET TABLET TABLET TABLET VIAL TABLET LIQUID STRENGTH 0.06G-1.5 0.06G-1.5 7G-7G-1.5G 7G-7G-1.5G 7G-7G-1.5G 7G-7G-1.5G 7G-7G-1.5G 7G-7G-1.5G 15.3G-699 14.4 G-701 2 % 2 % 2 % 200 MG 50 MG 75 MG 200 MG 15 MG/ML 30 MG/ML 0.4 % 0.5 % 15.75 MG 10 MG 15 MG/ML 30MG/ML(1) 60 MG/2 ML 0.45 % 2.5B-2.5B 200 MG 0.15MG(84) 100-20(84) 150-30(84) 100 MG 200 MG 300 MG 5 MG/ML 10 MG/ML 100 MG 150 MG 200 MG 50 MG 200MG/20ML 750MG-20MG NOTE APPENDIX A PAGE 67 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION LACTOSE-FREE FOOD LACTOSE-FREE FOOD LACTOSE-FREE FOOD LACTOSE-FREE FOOD LACTOSE-FREE FOOD LACTOSE-FREE FOOD LACTOSE-FREE FOOD/FIBER LACTOSE-FREE FOOD/FIBER LACTULOSE LACTULOSE LACTULOSE LACTULOSE LAMIVUDINE LAMIVUDINE LAMIVUDINE LAMIVUDINE LAMIVUDINE LAMIVUDINE/ZIDOVUDINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LAMOTRIGINE LANCETS LANCETS LANCETS DOSAGE LIQUID LIQUID LIQUID LIQUID PACKET POWDER LIQUID LIQUID PACKET PACKET SOLUTION SOLUTION SOLUTION SOLUTION TABLET TABLET TABLET TABLET TAB DS PK TAB DS PK TAB DS PK TAB ER 24 TAB ER 24 TAB ER 24 TAB ER 24 TAB ER 24 TAB ER 24 TAB RAPDIS TAB RAPDIS TAB RAPDIS TAB RAPDIS TABLET TABLET TABLET TABLET TB CHW DSP TB CHW DSP TB ER DSPK TB ER DSPK TB ER DSPK TB RD DSPK TB RD DSPK TB RD DSPK EACH EACH EACH STRENGTH 0.04G-0.93 0.04G-1.05 0.05 G-1.5 0.05G-1.05 0.06G-1.5 10 G 20 G 10 G/15 ML 20 G/30 ML 10 MG/ML 25 MG/5 ML 100 MG 150 MG 300 MG 150-300MG 25(42)-100 25(84)-100 25MG (35) 100 MG 200 MG 25 MG 250 MG 300 MG 50 MG 100 MG 200 MG 25 MG 50 MG 100 MG 150 MG 200 MG 25 MG 25 MG 5 MG 25(21)-50 25-50-100 50-100-200 25(21)-50 25-50-100 50(42)-100 21 GAUGE 23 GAUGE NOTE APPENDIX A PAGE 68 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION LANCETS LANCETS LANCETS LANCETS LANCETS LANCETS LANCING DEVICE/LANCETS LANREOTIDE ACETATE LANREOTIDE ACETATE LANSOPRAZOLE LANSOPRAZOLE LANSOPRAZOLE LANSOPRAZOLE LANSOPRAZOLE/AMOXICILN/CLARITH LANTHANUM CARBONATE LANTHANUM CARBONATE LANTHANUM CARBONATE LAPATINIB DITOSYLATE LARONIDASE LATANOPROST LECITH/FA/VIT BCOMP&C/HERB10 LECITH/PYRIDOX HCL/I2/CIDER LECITH/TAUR/ARGNIN/KAV/HRB58 LECITH/VIT B6/GRAPEFRUIT/KELP LECITHIN/B6/IODINE/CIDERVINEGR LEDIPASVIR/SOFOSBUVIR LEFLUNOMIDE LEFLUNOMIDE LENALIDOMIDE LENALIDOMIDE LENALIDOMIDE LENALIDOMIDE LENALIDOMIDE LETROZOLE LEUCINE LEUCINE/ISOLEUCINE/VALINE/SOY LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM LEUPROLIDE ACETATE LEUPROLIDE ACETATE DOSAGE EACH EACH EACH EACH EACH EACH KIT SYRINGE SYRINGE CAPSULE DR CAPSULE DR TAB RAP DR TAB RAP DR COMBO. PKG TAB CHEW TAB CHEW TAB CHEW TABLET VIAL DROPS TABLET TABLET CAPSULE TABLET CAPSULE TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE TABLET POWD PACK POWD PACK TABLET TABLET TABLET TABLET VIAL VIAL VIAL VIAL KIT KIT STRENGTH 25 26 28 30 32 33 GAUGE GAUGE GAUGE GAUGE GAUGE GAUGE 120MG/0.5 90MG/0.3ML 15 MG 30 MG 15 MG 30 MG 30-500-500 1000 MG 500 MG 750 MG 250 MG 2.9 MG/5ML 0.005 % 200-5-75 50MG-100MG 200-5-75 90MG-400MG 10 MG 20 MG 10 MG 15 MG 2.5 MG 25 MG 5 MG 2.5 MG 0.1G-15/4G 2.5-1.24/5 10 MG 15 MG 25 MG 5 MG 100 MG 200 MG 350 MG 50 MG 1 MG/0.2ML 11.25 MG NOTE APPENDIX A PAGE 69 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION LEUPROLIDE ACETATE LEUPROLIDE ACETATE LEUPROLIDE ACETATE LEUPROLIDE ACETATE LEUPROLIDE ACETATE LEUPROLIDE ACETATE LEUPROLIDE ACETATE LEUPROLIDE ACETATE LEUPROLIDE ACETATE LEUPROLIDE ACETATE LEUPROLIDE ACETATE LEUPROLIDE/NORETHINDRONE ACET LEUPROLIDE/NORETHINDRONE ACET LEVALBUTEROL HCL LEVALBUTEROL HCL LEVALBUTEROL HCL LEVALBUTEROL HCL LEVALBUTEROL TARTRATE LEVETIRACETAM LEVETIRACETAM LEVETIRACETAM LEVETIRACETAM LEVETIRACETAM LEVETIRACETAM LEVETIRACETAM LEVETIRACETAM LEVOBUNOLOL HCL LEVOCARNITINE LEVOCARNITINE LEVOCARNITINE LEVOCARNITINE LEVOCARNITINE LEVOCARNITINE LEVOCARNITINE LEVOCARNITINE (WITH SUGAR) LEVOCARNITINE TARTRATE LEVOCARNITINE TARTRATE LEVOCETIRIZINE DIHYDROCHLORIDE LEVOCETIRIZINE DIHYDROCHLORIDE LEVOFLOXACIN LEVOFLOXACIN LEVOFLOXACIN LEVOFLOXACIN LEVOFLOXACIN LEVOFLOXACIN LEVOFLOXACIN/D5W DOSAGE KIT KIT SYRINGE SYRINGE SYRINGE SYRINGEKIT SYRINGEKIT SYRINGEKIT SYRINGEKIT SYRINGEKIT SYRINGEKIT KT SYR TAB KT SYR TAB VIAL-NEB VIAL-NEB VIAL-NEB VIAL-NEB HFA AER AD SOLUTION TAB ER 24H TAB ER 24H TABLET TABLET TABLET TABLET VIAL DROPS CAPSULE SOLUTION SOLUTION TABLET TABLET TABLET VIAL SOLUTION CAPSULE CAPSULE SOLUTION TABLET DROPS SOLUTION TABLET TABLET TABLET VIAL PIGGYBACK STRENGTH 15 MG 7.5 MG 22.5 MG 30 MG 45 MG 11.25 MG 22.5 MG 3.75 MG 30 MG 45 MG 7.5 MG 11.25-5 MG 3.75MG-5MG 0.31MG/3ML 0.63MG/3ML 1.25MG/0.5 1.25MG/3ML 45 MCG 100 MG/ML 500 MG 750 MG 1000 MG 250 MG 500 MG 750 MG 500 MG/5ML 0.5 % 250 MG 1 G/10 ML 100 MG/ML 250 MG 330 MG 500 MG 200 MG/ML 100 MG/ML 250 MG 500 MG 2.5 MG/5ML 5 MG 0.5 % 250MG/10ML 250 MG 500 MG 750 MG 25 MG/ML 500MG/0.1L NOTE APPENDIX A PAGE 70 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION LEVOFLOXACIN/D5W LEVOLEUCOVORIN CALCIUM LEVOMEFOLATE CALCIUM LEVOMEFOLATE CALCIUM LEVOMEFOLATE/ALGAL OIL LEVOMEFOLATE/ALGAL OIL LEVOMEFOLATE/B6/B12/ALGAL OIL LEVOMILNACIPRAN HYDROCHLORIDE LEVOMILNACIPRAN HYDROCHLORIDE LEVOMILNACIPRAN HYDROCHLORIDE LEVOMILNACIPRAN HYDROCHLORIDE LEVOMILNACIPRAN HYDROCHLORIDE LEVONORGESTREL LEVONORGESTREL LEVONORGESTREL LEVONORGESTREL-ETHIN ESTRADIOL LEVONORGESTREL-ETHIN ESTRADIOL LEVONORGESTREL-ETHIN ESTRADIOL LEVONORGESTREL-ETHIN ESTRADIOL LEVONORGESTREL-ETHIN ESTRADIOL LEVORPHANOL TARTRATE LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM LIDOCAINE LIDOCAINE DOSAGE PIGGYBACK VIAL TABLET TABLET CAPSULE CAPSULE CAPSULE CAP SA 24H CAP SA 24H CAP SA 24H CAP SA 24H CAP24HDSPK IUD IUD TABLET TABLET TABLET TABLET TABLET TBDSPK 3MO TABLET CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET VIAL ADH. PATCH OINT. (G) STRENGTH 750MG/.15L 50 MG 15 MG 7.5 MG 15-90.314 7.5-90.314 3-35-2 MG 120 MG 20 MG 40 MG 80 MG 20-40MG 14MCG/24HR 20MCG/24HR 1.5 MG 0.1-0.02 0.15-0.03 6-5-10 90-20MCG 0.15-0.03 2 MG 100 MCG 112 MCG 125 MCG 13 MCG 137 MCG 150 MCG 25 MCG 50 MCG 75 MCG 88 MCG 100 MCG 112 MCG 125 MCG 137 MCG 150 MCG 175MCG 200 MCG 25 MCG 300 MCG 50 MCG 75 MCG 88 MCG 100 MCG 5%(700MG) 5 % NOTE APPENDIX A PAGE 71 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION LIDOCAINE HCL LIDOCAINE HCL LIDOCAINE HCL LIDOCAINE HCL LIDOCAINE HCL LIDOCAINE HCL LIDOCAINE HCL LIDOCAINE HCL/D5W/PF LIDOCAINE HCL/D5W/PF LIDOCAINE HCL/D7.5W/PF LIDOCAINE HCL/EPINEPHRINE LIDOCAINE HCL/EPINEPHRINE LIDOCAINE HCL/EPINEPHRINE LIDOCAINE HCL/EPINEPHRINE/PF LIDOCAINE HCL/EPINEPHRINE/PF LIDOCAINE HCL/EPINEPHRINE/PF LIDOCAINE HCL/PF LIDOCAINE HCL/PF LIDOCAINE HCL/PF LIDOCAINE HCL/PF LIDOCAINE HCL/PF LIDOCAINE HCL/PF LIDOCAINE HCL/PF LIDOCAINE HCL/PF LIDOCAINE HCL/PF LIDOCAINE/PRILOCAINE LIDOCAINE/PRILOCAINE LINACLOTIDE LINACLOTIDE LINAGLIPTIN LINAGLIPTIN/METFORMIN HCL LINAGLIPTIN/METFORMIN HCL LINAGLIPTIN/METFORMIN HCL LINCOMYCIN HCL LINDANE LINDANE LINEZOLID LINEZOLID LINEZOLID LINEZOLID LINOLEIC ACID, CONJUGATED LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM LIOTHYRONINE SODIUM LIOTRIX LIOTRIX DOSAGE AMPUL JEL (ML) JEL/PF APP SOLUTION SOLUTION VIAL VIAL IV SOLN IV SOLN AMPUL VIAL VIAL VIAL VIAL VIAL VIAL AMPUL AMPUL AMPUL AMPUL LUER SYRINGE SYRINGE VIAL VIAL VIAL CREAM (G) KIT CAPSULE CAPSULE TABLET TABLET TABLET TABLET VIAL LOTION SHAMPOO IV SOLN IV SOLN SUSP RECON TABLET CAPSULE TABLET TABLET TABLET TABLET TABLET STRENGTH 15 MG/ML 2 % 2 % 2 % 40 MG/ML 10 MG/ML 20 MG/ML 4 MG/ML 8 MG/ML 5 % 0.5-1:200K 1%-1:100K 2 %-1:100K 1 %-1:200K 1.5-1:200K 2%-1:200K 10 MG/ML 15 MG/ML 40 MG/ML 20 MG/ML 100 MG/5ML 50 MG/5 ML 10 MG/ML 20 MG/ML 5 MG/ML 2.5 %-2.5% 2.5 %-2.5% 145 MCG 290 MCG 5 MG 2.5-1000MG 2.5-500 MG 2.5-850 MG 300 MG/ML 1 % 1 % 200MG/0.1L 600MG/300 100 MG/5ML 600 MG 1000 MG 25 MCG 5 MCG 50 MCG 12.5-50MCG 25-100MCG NOTE APPENDIX A PAGE 72 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION LIOTRIX LIOTRIX LIOTRIX LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPASE/PROTEASE/AMYLASE LIPISTART - 400G CAN - 6/CASE LIPOSOMAL UBIQUINOL LIPOSOMAL UBIQUINOL LIPOSOMAL UBIQUINOL LIRAGLUTIDE LISDEXAMFETAMINE DIMESYLATE LISDEXAMFETAMINE DIMESYLATE LISDEXAMFETAMINE DIMESYLATE LISDEXAMFETAMINE DIMESYLATE LISDEXAMFETAMINE DIMESYLATE LISDEXAMFETAMINE DIMESYLATE LISINOPRIL LISINOPRIL LISINOPRIL LISINOPRIL LISINOPRIL LISINOPRIL LISINOPRIL/HYDROCHLOROTHIAZIDE LISINOPRIL/HYDROCHLOROTHIAZIDE LISINOPRIL/HYDROCHLOROTHIAZIDE LITHIUM ASPARTATE LITHIUM ASPARTATE LITHIUM CARBONATE DOSAGE TABLET TABLET TABLET CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR CAPSULE DR TABLET TABLET TABLET CAN AMPUL LIQUID LIQUID PEN INJCTR CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE STRENGTH 3.1-12.5 37.5-150 6.25-25MCG 10.5K-25K 10-34-55K 12K-38K-60 15-51-82K 16.8-40-70 16K-57.5K 20-68-109K 21-37-61K 24-76-120K 25-85-136K 3-9.5-15K 3K-10K-16K 36-114-180 4.2K-10K 5K-17K-27K 6K-19K-30K 8K-28.75K 16-60-60K 20.9-78.3K 8K-30K-30K 80 MG/10ML 100 MG/ML 8 MG/ML 0.6MG/0.1 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG 10 MG 2.5 MG 20 MG 30 MG 40 MG 5 MG 10-12.5MG 20-12.5 MG 20-25MG 20 MG 5 MG 150 MG NOTE APPENDIX A PAGE 73 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION LITHIUM CARBONATE LITHIUM CARBONATE LITHIUM CARBONATE LITHIUM CARBONATE LITHIUM CARBONATE LITHIUM CITRATE LODOXAMIDE TROMETHAMINE LOMITAPIDE MESYLATE LOMITAPIDE MESYLATE LOMITAPIDE MESYLATE LOMUSTINE LOMUSTINE LOMUSTINE LOPERAMIDE HCL LOPINAVIR/RITONAVIR LOPINAVIR/RITONAVIR LOPINAVIR/RITONAVIR LORATADINE LORATADINE LORATADINE LORATADINE/PSEUDOEPHEDRINE LORATADINE/PSEUDOEPHEDRINE LORAZEPAM LORAZEPAM LORAZEPAM LORAZEPAM LORAZEPAM LORAZEPAM LORAZEPAM LORAZEPAM LOSARTAN POTASSIUM LOSARTAN POTASSIUM LOSARTAN POTASSIUM LOSARTAN/HYDROCHLOROTHIAZIDE LOSARTAN/HYDROCHLOROTHIAZIDE LOSARTAN/HYDROCHLOROTHIAZIDE LOTEPREDNOL ETABONATE LOTEPREDNOL ETABONATE LOTEPREDNOL ETABONATE LOTEPREDNOL ETABONATE LOVASTATIN LOVASTATIN LOVASTATIN LOVASTATIN LOVASTATIN LOVASTATIN DOSAGE CAPSULE CAPSULE TABLET TABLET ER TABLET ER SOLUTION DROPS CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE SOLUTION TABLET TABLET SOLUTION TAB RAPDIS TABLET TAB ER 12H TAB ER 24H ORAL CONC SYRINGE SYRINGE TABLET TABLET TABLET VIAL VIAL TABLET TABLET TABLET TABLET TABLET TABLET DROPS GEL DROPS SUSP DROPS SUSP OINT. (G) TAB ER 24H TAB ER 24H TAB ER 24H TABLET TABLET TABLET STRENGTH 300 MG 600 MG 300 MG 300 MG 450 MG 8 MEQ/5 ML 0.1 % 10 MG 20 MG 5 MG 10 MG 100 MG 40 MG 2 MG 400-100/5 100MG-25MG 200MG-50MG 5 MG/5 ML 10 MG 10 MG 5 MG-120MG 10MG-240MG 2 MG/ML 2 MG/ML 4 MG/ML 0.5 MG 1 MG 2 MG 2 MG/ML 4 MG/ML 100 MG 25 MG 50 MG 100-12.5MG 100MG-25MG 50-12.5 MG 0.5 % 0.2 % 0.5 % 0.5 % 20 MG 40 MG 60 MG 10 MG 20 MG 40 MG NOTE APPENDIX A PAGE 74 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION LOXAPINE SUCCINATE LOXAPINE SUCCINATE LOXAPINE SUCCINATE LOXAPINE SUCCINATE LUBIPROSTONE LUBIPROSTONE LUBIPROSTONE LULICONAZOLE LURASIDONE HCL LURASIDONE HCL LURASIDONE HCL LURASIDONE HCL LURASIDONE HCL LYCOPENE/LUT XT/FRUIT EXTRACTS LYMPHOCYTE IMMUNE GLOBULIN LYSINE LYSINE LYSINE LYSINE LYSINE LYSINE ACETATE LYSINE HCL LYSINE HCL LYSINE HCL/VIT B COMP/FA/ZINC LYSINE/VIT E/FA/VIT BCOMP&C/ZN LYTES/CARBOXYMETHYLCELLULOSE LYTES/CARBOXYMETHYLCELLULOSE LYTES/CARBOXYMETHYLCELLULOSE LYTES/CARBOXYMETHYLCELLULOSE LYTES/CARBOXYMETHYLCELLULOSE LYTES/YERBA SANTA MACITENTAN MAFENIDE ACETATE MAFENIDE ACETATE MAG OX/CALCIUM/POTASSIUM/E/BIL MAG OXIDE/VIT D3/TUMERIC RT XT MAGNESIUM ASPARTATE HCL MAGNESIUM CITRATE MAGNESIUM GLUCONATE MAGNESIUM HYDROXIDE MAGNESIUM SULFATE MAGNESIUM SULFATE MAGNESIUM SULFATE MAGNESIUM SULFATE IN WATER MAGNESIUM SULFATE IN WATER MAGNESIUM SULFATE IN WATER DOSAGE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CREAM (G) TABLET TABLET TABLET TABLET TABLET CAPSULE AMPUL CAPSULE TABLET TABLET TABLET TABLET ER POWD PACK TABLET TABLET LIQUID TABLET AEROSOL MED. SWAB SOLUTION SPRAY SPRAY/PUMP SPRAY TABLET CREAM (G) PACKET ORAL SUSP CAPSULE POWD PACK SOLUTION TABLET ORAL SUSP GRANULES SYRINGE VIAL IV SOLN IV SOLN PIGGYBACK STRENGTH 10 MG 25 MG 5 MG 50 MG 24MCG 8 MCG 8MCG 1 % 120 MG 20 MG 40 MG 60 MG 80 MG 5-6-150MG 50 MG/ML 500 MG 1000 MG 500 MG 600 MG 1000 MG 4000 MG 1000 MG 500 MG 1000-800 10 MG 8.5 % 50 G 300-600/15 500MG-3000 122(1230) 27MG 400 MG/5ML 4 MEQ/ML 4 MEQ/ML 20 G/500ML 40G/1000ML 2 G/50 ML NOTE APPENDIX A PAGE 75 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION MAGNESIUM SULFATE IN WATER MAGNESIUM SULFATE IN WATER MAGNESIUM SULFATE/D5W MALATHION MALIC ACID MALTODEXTRIN MANGANESE CHLORIDE MANNITOL MANNITOL MANNITOL/SORBITOL SOLUTION MAPROTILINE HCL MAPROTILINE HCL MAPROTILINE HCL MARAVIROC MARAVIROC ME-THFOLATE GLUC/B12/HERB #236 MECASERMIN MECHLORETHAMINE HCL MECHLORETHAMINE HCL MECLIZINE HCL MECLIZINE HCL MECLIZINE HCL MECLOFENAMATE SODIUM MECLOFENAMATE SODIUM MEDIUM CHAIN TRIGLYCERIDES (MC MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE MEFENAMIC ACID MEFLOQUINE HCL MEGESTROL ACETATE MEGESTROL ACETATE MEGESTROL ACETATE MEGESTROL ACETATE MEGESTROL ACETATE MELOXICAM MELOXICAM MELOXICAM MELPHALAN MELPHALAN HCL MEMANTINE HCL MEMANTINE HCL DOSAGE PIGGYBACK PIGGYBACK PIGGYBACK LOTION TABLET POWDER VIAL IRRIG SOLN IV SOLN IRRIG SOLN TABLET TABLET TABLET TABLET TABLET CAPSULE VIAL GEL (GRAM) VIAL TAB CHEW TABLET TABLET CAPSULE CAPSULE UNIT SYRINGE SYRINGE TABLET TABLET TABLET VIAL VIAL CAPSULE TABLET ORAL SUSP ORAL SUSP ORAL SUSP TABLET TABLET ORAL SUSP TABLET TABLET TABLET VIAL CAP SPR 24 CAP SPR 24 STRENGTH 4 G/100 ML 4 G/50 ML 1 G/100 ML 0.5 % 800 MG 94.5G-376 0.1 MG/ML 5 % 20 % 0.54G-2.7G 25 MG 50 MG 75 MG 150 MG 300 MG 1-1-500 MG 10 MG/ML 0.016 % 10 MG 25MG 12.5 MG 25 MG 100 MG 50 MG 7.7KCAL/ML 104MG/0.65 150 MG/ML 10 MG 2.5 MG 5 MG 150 MG/ML 400 MG/ML 250 MG 250 MG 400MG/10ML 625MG/5ML 800MG/20ML 20 MG 40 MG 7.5 MG/5ML 15 MG 7.5 MG 2 MG 50 MG 14 MG 21 MG NOTE APPENDIX A PAGE 76 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION MEMANTINE HCL MEMANTINE HCL MEMANTINE HCL MEMANTINE HCL MEMANTINE HCL MEMANTINE HCL MEMANTINE HCL MEPENZOLATE BROMIDE MEPERIDINE HCL MEPERIDINE HCL MEPERIDINE HCL MEPERIDINE HCL MEPERIDINE HCL MEPERIDINE HCL MEPERIDINE HCL/PF MEPERIDINE HCL/PF MEPERIDINE HCL/PF MEPERIDINE HCL/PF MEPERIDINE HCL/PF MEPERIDINE HCL/PF MEPERIDINE HCL/PF MEPERIDINE HCL/PF MEPERIDINE HCL/PF MEPIVACAINE HCL MEPIVACAINE HCL MEPIVACAINE HCL/PF MEPIVACAINE HCL/PF MEPROBAMATE MEPROBAMATE MERCAPTOPURINE MEROPENEM MEROPENEM MESALAMINE MESALAMINE MESALAMINE MESALAMINE MESALAMINE MESALAMINE MESALAMINE MESALAMINE MESALAMINE W/CLEANSING WIPES MESNA MESNA METAPROTERENOL SULFATE METAPROTERENOL SULFATE METAPROTERENOL SULFATE DOSAGE CAP SPR 24 CAP SPR 24 CAP24 DSPK SOLUTION TAB DS PK TABLET TABLET TABLET CARTRIDGE SOLUTION TABLET TABLET VIAL VIAL AMPUL AMPUL AMPUL AMPUL AMPUL SYRINGE SYRINGE SYRINGE SYRINGE VIAL VIAL VIAL VIAL TABLET TABLET TABLET VIAL VIAL CAP ER 24H CAPSULE DR CAPSULE ER CAPSULE ER ENEMA SUPP.RECT TABLET DR TABLET DR ENEMA KIT TABLET VIAL SYRUP TABLET TABLET STRENGTH 28 MG 7 MG 7-14-21-28 10 MG/5 ML 5 MG-10 MG 10 MG 5 MG 25 MG 10 MG/ML 50 MG/5 ML 100 MG 50 MG 100 MG/ML 50 MG/ML 100 MG/ML 100 MG/2ML 25MG/0.5ML 50 MG/ML 75MG/1.5ML 100 MG/ML 25 MG/ML 50 MG/ML 75 MG/ML 10 MG/ML 20 MG/ML 15 MG/ML 20 MG/ML 200 MG 400 MG 50 MG 1 G 500 MG 0.375G 400 MG 250 MG 500 MG 4 G/60 ML 1000 MG 1.2 G 800 MG 4 G/60 ML 400 MG 100 MG/ML 10 MG/5 ML 10 MG 20 MG NOTE APPENDIX A PAGE 77 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION METAXALONE METFORMIN HCL METFORMIN HCL METFORMIN HCL METFORMIN HCL METFORMIN HCL METFORMIN HCL METFORMIN HCL METFORMIN HCL METFORMIN HCL METFORMIN HCL METHADONE HCL METHADONE HCL METHADONE HCL METHADONE HCL METHADONE HCL METHAMPHETAMINE HCL METHAZOLAMIDE METHAZOLAMIDE METHEN/M-BLUE/SAL/NA PHOS/HYOS METHEN/SOD PHOS/METH BLUE/HYOS METHENAMINE HIPPURATE METHENAMINE MANDELATE METHIMAZOLE METHIMAZOLE METHIONIN/LYSIN/CYST/SUPOX/CAT METHIONINE/CARBOHYDRATE SUPPL METHOCARBAMOL METHOCARBAMOL METHOHEXITAL SODIUM METHOHEXITAL SODIUM METHOTREXATE SODIUM METHOTREXATE SODIUM METHOTREXATE SODIUM METHOTREXATE SODIUM METHOTREXATE SODIUM METHOTREXATE SODIUM METHOTREXATE SODIUM METHOTREXATE SODIUM/PF METHOXSALEN, RAPID METHSCOPOLAMINE BROMIDE METHSCOPOLAMINE BROMIDE METHSUXIMIDE METHYCLOTHIAZIDE METHYL-B12/L-MEFOLATE/B6 PHOS METHYLCELLULOSE DOSAGE TABLET SOLUTION TAB ER 24 TAB ER 24 TAB ER 24H TAB ER 24H TABERGR24H TABERGR24H TABLET TABLET TABLET ORAL CONC SOLUTION SOLUTION TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET CAPSULE POWD PACK TABLET TABLET VIAL VIAL TAB DS PK TABLET TABLET TABLET TABLET TABLET VIAL VIAL CAPSULE TABLET TABLET CAPSULE TABLET TABLET POWDER STRENGTH 800 MG 500 MG/5ML 1000 MG 500 MG 500 MG 750 MG 1000 MG 500 MG 1000 MG 500 MG 850 MG 10 MG/ML 10 MG/5 ML 5 MG/5 ML 10 MG 5 MG 5 MG 25 MG 50 MG 120-0.12MG 81.6-.12MG 1 G 1 G 10 MG 5 MG 200-20-5MG 100 MG/4 G 500 MG 750 MG 2.5 G 500 MG 2.5 MG 10 MG 15 MG 2.5 MG 5 MG 7.5 MG 25 MG/ML 25 MG/ML 10 MG 2.5 MG 5 MG 300 MG 5 MG 2-3-35 MG NOTE APPENDIX A PAGE 78 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION METHYLCELLULOSE METHYLCELLULOSE (WITH SUGAR) METHYLDOPA METHYLDOPA METHYLDOPA/HYDROCHLOROTHIAZIDE METHYLDOPA/HYDROCHLOROTHIAZIDE METHYLERGONOVINE MALEATE METHYLNALTREXONE BROMIDE METHYLNALTREXONE BROMIDE METHYLNALTREXONE BROMIDE METHYLPHENIDATE METHYLPHENIDATE METHYLPHENIDATE METHYLPHENIDATE METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPHENIDATE HCL METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE METHYLPREDNISOLONE ACETATE DOSAGE TABLET POWDER TABLET TABLET TABLET TABLET TABLET SYRINGE SYRINGE VIAL PATCH TD24 PATCH TD24 PATCH TD24 PATCH TD24 CPBP 30-70 CPBP 30-70 CPBP 30-70 CPBP 30-70 CPBP 30-70 CPBP 30-70 CPBP 50-50 CPBP 50-50 CPBP 50-50 CPBP 50-50 SOLUTION SOLUTION SU ER RC24 TAB CHEW TAB CHEW TAB CHEW TAB ER 24 TAB ER 24 TAB ER 24 TAB ER 24 TABLET TABLET TABLET TABLET ER TABLET ER TAB DS PK TABLET TABLET TABLET TABLET TABLET VIAL STRENGTH 500 MG 250 MG 500 MG 250MG-15MG 250MG-25MG 0.2 MG 12MG/0.6ML 8 MG/0.4ML 12MG/0.6ML 10MG/9HR 15MG/9HR 20 MG/9 HR 30MG/9HR 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 10 MG 20 MG 30 MG 40 MG 10 MG/5 ML 5 MG/5 ML 5 MG/ML 10 MG 2.5 MG 5 MG 18 MG 27 MG 36 MG 54 MG 10 MG 20 MG 5 MG 10 MG 20 MG 4 MG 16 MG 2 MG 32 MG 4 MG 8 MG 20 MG/ML NOTE APPENDIX A PAGE 79 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE SOD SUCC METHYLPREDNISOLONE SOD SUCC METHYLPREDNISOLONE SOD SUCC METHYLPREDNISOLONE SOD SUCC METHYLPREDNISOLONE SOD SUCC METHYLPREDNISOLONE SOD SUCC/PF METHYLPREDNISOLONE SOD SUCC/PF METHYLPREDNISOLONE SOD SUCC/PF METHYLPREDNISOLONE SOD SUCC/PF METHYLSULFONYLMETHANE METHYLSULFONYLMETHANE METHYLSULFONYLMETHANE METHYLSULFONYLMETHANE METHYLTESTOSTERONE METHYLTESTOSTERONE METIPRANOLOL METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL METOLAZONE METOLAZONE METOLAZONE METOPROLOL SUCCINATE METOPROLOL SUCCINATE METOPROLOL SUCCINATE METOPROLOL SUCCINATE METOPROLOL SUCCINATE/HCTZ METOPROLOL SUCCINATE/HCTZ METOPROLOL SUCCINATE/HCTZ METOPROLOL TARTRATE METOPROLOL TARTRATE METOPROLOL TARTRATE METOPROLOL TARTRATE METOPROLOL TARTRATE METOPROLOL TARTRATE METOPROLOL/HYDROCHLOROTHIAZIDE METOPROLOL/HYDROCHLOROTHIAZIDE METOPROLOL/HYDROCHLOROTHIAZIDE METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE DOSAGE VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL CAPSULE CAPSULE TABLET TABLET CAPSULE TABLET DROPS SOLUTION SOLUTION TAB RAPDIS TABLET TABLET VIAL TABLET TABLET TABLET TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H AMPUL SYRINGE TABLET TABLET TABLET VIAL TABLET TABLET TABLET CAPSULE CREAM (G) CREAM (G) STRENGTH 40 MG/ML 80 MG/ML 1000 MG 125 MG 2 G 40 MG 500 MG 1000MG/8ML 125 MG/2ML 40 MG/ML 500 MG/4ML 1000 MG 500 MG 1000 MG 1500 MG 10 MG 10 MG 0.3 % 10 MG/10ML 5 MG/5 ML 5 MG 10 MG 5 MG 5 MG/ML 10 MG 2.5 MG 5 MG 100 MG 200 MG 25 MG 50 MG 100-12.5MG 25-12.5 MG 50-12.5 MG 5 MG/5 ML 5 MG/5 ML 100 MG 25 MG 50 MG 5 MG/5 ML 100MG-25MG 100MG-50MG 50 MG-25MG 375 MG 0.75 % 1 % NOTE APPENDIX A PAGE 80 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE METRONIDAZOLE/SODIUM CHLORIDE MEXILETINE HCL MEXILETINE HCL MEXILETINE HCL MICAFUNGIN SODIUM MICAFUNGIN SODIUM MICONAZOLE MICONAZOLE NITRATE MICONAZOLE NITRATE MICONAZOLE NITRATE/ZINC OX/PET MICROSLIPID UNFLAVORED - 3 OZ MIDAZOLAM HCL MIDAZOLAM HCL MIDAZOLAM HCL MIDAZOLAM HCL MIDAZOLAM HCL MIDAZOLAM HCL/PF MIDAZOLAM HCL/PF MIDAZOLAM HCL/PF MIDAZOLAM HCL/PF MIDAZOLAM HCL/PF MIDAZOLAM HCL/PF MIDODRINE HCL MIDODRINE HCL MIDODRINE HCL MIGLITOL MIGLITOL MIGLITOL MILK BASED FORMULA MILK BASED FORMULA/CORN STARCH MILK PROT/TURMER/PEPPER/PINEAP MILK PROT/TURMER/PEPPER/PINEAP MILNACIPRAN HCL MILNACIPRAN HCL MILNACIPRAN HCL MILNACIPRAN HCL MILNACIPRAN HCL MILRINONE LACTATE DOSAGE GEL (GRAM) GEL (GRAM) GEL W/APPL GEL W/PUMP LOTION TABLET TABLET TABLET ER PIGGYBACK CAPSULE CAPSULE CAPSULE VIAL VIAL MA BUC TAB SUPP.VAG TINCTURE OINT. (G) UNIT SYRUP VIAL VIAL VIAL VIAL CARTRIDGE SYRINGE VIAL VIAL VIAL VIAL TABLET TABLET TABLET TABLET TABLET TABLET LIQUID LIQUID CAPSULE TABLET TAB DS PK TABLET TABLET TABLET TABLET VIAL STRENGTH 0.75 % 1 % 0.75 % 1 % 0.75 % 250 MG 500 MG 750 MG 500MG/0.1L 150 MG 200 MG 250 MG 100 MG 50 MG 50 MG 200 MG 2% 0.25 %-15% 50 % 2 MG/ML 10 MG/10ML 10 MG/2 ML 2 MG/2 ML 5 MG/ML 2 MG/2 ML 2 MG/2 ML 10 MG/2 ML 2 MG/2 ML 5 MG/ML(1) 5 MG/5 ML 10 MG 2.5 MG 5 MG 100 MG 25 MG 50 MG 0.03 G-0.7 640 MG 1280 MG 12.5-25-50 100 MG 12.5 MG 25 MG 50 MG 1 MG/ML NOTE APPENDIX A PAGE 81 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION MILRINONE LACTATE/D5W MILRINONE LACTATE/D5W MINERAL OIL MINOCYCLINE HCL MINOCYCLINE HCL MINOCYCLINE HCL MINOCYCLINE HCL MINOCYCLINE HCL MINOCYCLINE HCL MINOCYCLINE HCL MINOCYCLINE HCL MINOCYCLINE HCL MINOXIDIL MINOXIDIL MIRABEGRON MIRABEGRON MIRTAZAPINE MIRTAZAPINE MIRTAZAPINE MIRTAZAPINE MIRTAZAPINE MIRTAZAPINE MIRTAZAPINE MISOPROSTOL MISOPROSTOL MITOMYCIN MITOMYCIN MITOTANE MITOXANTRONE HCL MODAFINIL MODAFINIL MOEXIPRIL HCL MOEXIPRIL HCL MOEXIPRIL/HYDROCHLOROTHIAZIDE MOEXIPRIL/HYDROCHLOROTHIAZIDE MOEXIPRIL/HYDROCHLOROTHIAZIDE MOMETASONE FUROATE MOMETASONE FUROATE MOMETASONE FUROATE MOMETASONE FUROATE MOMETASONE FUROATE MOMETASONE FUROATE MOMETASONE FUROATE MOMETASONE FUROATE MOMETASONE FUROATE MOMETASONE FUROATE DOSAGE PIGGYBACK PIGGYBACK OIL CAPSULE CAPSULE CAPSULE TAB ER 24H TAB ER 24H TAB ER 24H TABLET TABLET TABLET TABLET TABLET TAB ER 24H TAB ER 24H TAB RAPDIS TAB RAPDIS TAB RAPDIS TABLET TABLET TABLET TABLET TABLET TABLET VIAL VIAL TABLET VIAL TABLET TABLET TABLET TABLET TABLET TABLET TABLET AER POW BA AER POW BA AER POW BA AER POW BA AER POW BA AER POW BA CREAM (G) OINT. (G) SOLUTION SPRAY/PUMP STRENGTH 20MG/100ML 40MG/200ML 100 MG 50 MG 75 MG 135 MG 45 MG 90 MG 100 MG 50 MG 75 MG 10 MG 2.5 MG 25 MG 50 MG 15 MG 30 MG 45 MG 15 MG 30 MG 45 MG 7.5 MG 100 MCG 200 MCG 20 MG 5 MG 500 MG 2 MG/ML 100 MG 200 MG 15 MG 7.5 MG 15-12.5MG 15-25MG 7.5-12.5MG 110 MCG(7) 110MCG(30) 220MCG 120 220MCG(14) 220MCG(30) 220MCG(60) 0.1 % 0.1 % 0.1 % 50 MCG NOTE APPENDIX A PAGE 82 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION MOMETASONE/FORMOTEROL MOMETASONE/FORMOTEROL MONTELUKAST SODIUM MONTELUKAST SODIUM MONTELUKAST SODIUM MONTELUKAST SODIUM MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE/PF MORPHINE SULFATE/PF MORPHINE SULFATE/PF MORPHINE SULFATE/PF MOXIFLOXACIN HCL MOXIFLOXACIN HCL MOXIFLOXACIN HCL MOXIFLOXACIN IN NACL (ISO-OSM) DOSAGE HFA AER AD HFA AER AD GRAN PACK TAB CHEW TAB CHEW TABLET CAP ER PEL CAP ER PEL CAP ER PEL CAP ER PEL CAP ER PEL CAP ER PEL CAP ER PEL CAP ER PEL CPMP 24HR CPMP 24HR CPMP 24HR CPMP 24HR CPMP 24HR CPMP 24HR SOLUTION SOLUTION SOLUTION SUPP.RECT SUPP.RECT SUPP.RECT SUPP.RECT SYRINGE TABLET TABLET TABLET ER TABLET ER TABLET ER TABLET ER TABLET ER VIAL VIAL VIAL PORT PCA VIAL PCA VIAL VIAL VIAL DROPS DROPS VISC TABLET PIGGYBACK STRENGTH 100-5 MCG 200-5 MCG 4 MG 4 MG 5 MG 10 MG 10 MG 100 MG 20 MG 200 MG 30 MG 50 MG 60 MG 80 MG 120 MG 30 MG 45 MG 60 MG 75 MG 90 MG 10 MG/5 ML 100 MG/5ML 20 MG/5 ML 10 MG 20 MG 30 MG 5 MG 20 MG/ML 15 MG 30 MG 100 MG 15 MG 200 MG 30 MG 60 MG 25 MG/ML 50 MG/ML 250MG/10ML 150MG/30ML 30 MG/30ML 0.5 MG/ML 1 MG/ML 0.5 % 0.5 % 400 MG 400MG/.25L NOTE APPENDIX A PAGE 83 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 84 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION MSM/COLL HY/CO Q10/HERB NO.226 MTH/ME BLUE/SOD PHOS/PHEN/HYOS MTH/ME BLUE/SOD PHOS/PHEN/HYOS MULTIVIT, IRON, MIN #5, FA MULTIVIT, MIN CMB#20/IRON/FA MULTIVIT, MINCMB#11/FOLIC ACID MULTIVIT,CA,MIN/D3/HERBAL #161 MULTIVIT,IRON,MN/AMINO ACID#20 MULTIVITAMIN MULTIVITAMIN, MIN CMB#25/FA/D3 MULTIVITAMINS WITH MIN NO.7/FA MULTIVITAMINS/MINERALS/UBIDECA MULTIVITS MIN/IRON/FA/HERB#186 MULTIVITS&MINS/FA/COENZYME Q10 MULTIVITS&MINS/FA/COENZYME Q10 MULTIVITS-MIN/HRB CB121 MUPIROCIN MUPIROCIN MUPIROCIN CALCIUM MUPIROCIN CALCIUM MV-MIN/FA/C/GLU/LYS HCL/HC124 MV-MIN/FA/LEVOCAR/CHOL/INOSIT MV-MIN/VIT C/GLU/LYS HCL/HC124 MV-MIN/VIT C/GLU/LYS HCL/HC124 MV-MIN/VIT C/GLU/LYS HCL/HC124 MV-MIN/VIT C/GLUT/LYS AC/HC124 MV-MN/BIOTIN/HERBAL COMP #194 MV-MN/FA/HERBS190&215/DIGEST#4 MV-MN/FA/L-CAR/A-CAR/CIT/COQ10 MV-MN/FA/LYCOPENE/LUT/HB#185 MV-MN/HERB#208/BETA-SITOSTEROL MV-MN/HERBAL COMPLEX NO.217 MV-MN/IRON/FA/HERBAL CMPLX#190 MV-MN/LYCOP/LUT/HERBAL COMP219 MV-MN/VITC/ASBNA/GLU/LYS/HC124 MV-MN/VITC/ASBNA/GLU/LYS/HC124 MV-MN/VITC/ASBNA/GLU/LYS/HC124 MV/FA/DHA/EPA/COQ10/CA/D3/CRAN MV/FA/DHA/EPA/COQ10/SAW/HRB177 MV/FA/DHA/EPA/FISH OIL/SAW/GNK MV/FA/DHA/EPA/FISH/CAL/D3/GINK MV/FA/D3/K/LYCOP/LUT/HERB#220 MV/FA/D3/K2/LYCOP/HERB#222 MV/FA/D3/OM3/FISH/SAW PAL/ARG MV, MIN CMB #6/FA/LUT/LYCO/Q10 MV, MIN CMB#16/FA/LUTEIN/LYCOP DOSAGE TABLET CAPSULE TABLET TABLET TABLET TABLET TABLET POWDER DROPS TABLET CAPSULE DROPS SUSP TABLET CAPSULE TAB CHEW CAPSULE KIT OINT. (G) CREAM (G) OINT. (G) POWD PACK POWD PACK EFFPOWDPKT POWD PACK TAB CHEW TAB CHEW CAPSULE TABLET POWD PACK TABLET TABLET CAPSULE TABLET TABLET LOZENGE TAB CHEW TAB CHEW COMBO. PKG COMBO. PKG COMBO. PKG COMBO. PKG TABLET TABLET COMBO. PKG TABLET TABLET STRENGTH 100-100 MG 118-10-36 81.6-10.8 10 MG-1 MG 27 MG-1 MG 5 MG 1000 UNIT 3 MG-2000 1 MG 2MG/ML 3.3 MG-25 0.1MG-10MG 100MCG-5MG 20-8.5-5 2 % 2 % 2 % 2 % 0.4-1000MG 0.5-270 MG 1000-50 MG 1000-50 MG 250-12.5MG 250-12.5MG 300 MCG 800-150-25 200-1-0.5 167-100-83 100 MG 18-800-150 3-3-200 MG 250-1.25MG 333-1.7 MG 334-1.7 MG 400MCG-240 200MCG-240 400MCG-200 400MCG-200 500-20-400 200-300-20 200-1600 1.25-35MG 200MCG-1.5 NOTE (RX ONLY) (RX ONLY) 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 85 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION MV, MIN CMB#22/LUT/OM3/DHA/EPA MV, MIN CMB#43/LUT/OM3/DHA/EPA MV,CA,FE,MIN/FA/GUARANA/CAFF MV,CA,MIN/FA/HERBAL COMP #223 MV,CA,MIN/FA/HERBAL NO.157 MV,CA,MIN/FA/HERBAL NO.158 MV,CA,MIN/FA/HERBAL NO.160 MV,CA,MIN/FA/HERBAL NO.176 MV,CA,MIN/FA/HERBAL NO.187 MVI-MIN-INOSIT/CHOLI/BIOFLAVON MVI, ADULT NO.1 WITH VIT K MVI, ADULT NO.2 WITHOUT VIT K MVI, ADULT NO.4 WITH VIT K MVI, ADULT NO.4 WITH VIT K MVI, PEDI NO.1 WITH VIT K MVI, PEDI NO.1 WITH VIT K MVI, PEDI NO.2 WITH VIT K MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL HCL MYCOPHENOLATE SODIUM MYCOPHENOLATE SODIUM NA PHOS,M-B/K PHOS,MONOB NA PHOS,M-B/NA PHOS,DI-BA NA PHOS,M-B/NA PHOS,DI-BA NABUMETONE NABUMETONE NACL/POT CHL/SOD CIT/RICE SYR NACL/POT CHL/SOD CIT/RICE SYR NACL/POT CHL/SOD CIT/RICE SYR NACL/POT CHL/SOD CIT/RICE SYR NACL/POT CHL/SOD CIT/RICE SYR NACL/POT CHL/SOD CIT/RICE SYR NACL/POT CHL/SOD CIT/RICE SYR NACL/POT CHL/SOD CIT/RICE SYR NACL/POT CHL/SOD CIT/RICE SYR NACL/POT CHL/SOD CIT/RICE SYR NACL/POT CHL/SOD CIT/RICE SYR NACL/POT CHLORIDE/SOD CIT/MV NADOLOL NADOLOL NADOLOL NADOLOL/BENDROFLUMETHIAZIDE NADOLOL/BENDROFLUMETHIAZIDE NAFARELIN ACETATE DOSAGE CAPSULE CAPSULE TABLET TABLET TABLET CAPSULE TABLET TABLET TABLET TABLET VIAL VIAL VIAL VIAL VIAL VIAL VIAL CAPSULE SUSP RECON TABLET VIAL TABLET DR TABLET DR TABLET LIQUID SOLUTION TABLET TABLET LIQUID LIQUID ORAL CONC POWD PACK POWD PACK POWD PACK POWD PACK POWD PACK POWD PACK SOLUTION SOLUTION POWD PACK TABLET TABLET TABLET TABLET TABLET SPRAY STRENGTH 3.33-200MG 3.33-200MG 300-18-0.4 400 MCG 400 MCG 400 MCG 100 MCG 200 MCG 200 MCG 111-100 MG 200-150/10 200-600/10 200-150/10 200-150/10 400-200/5 400-200/5 400-200 250 MG 200 MG/ML 500 MG 500 MG 180 MG 360 MG 700-305MG 7.2-2.7/15 500 MG 750 MG 115-40-40 200-100-20 115-40-40 2.3-1.5/50 2.6-1.5/34 200-75-80 240-300-32 400-200 MG 440-300-32 140-51-69 374-254-80 40-20/2.5 20 MG 40 MG 80 MG 40 MG-5 MG 80 MG-5 MG 2 MG/ML NOTE (RX ONLY) (RX ONLY) SEE PACS MIXED F 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION NAFCILLIN IN DEXTROSE,ISO-OSM NAFCILLIN SODIUM NAFCILLIN SODIUM NAFCILLIN SODIUM NAFCILLIN SODIUM NAFCILLIN SODIUM NAFTIFINE HCL NAFTIFINE HCL NAFTIFINE HCL NALBUPHINE HCL NALBUPHINE HCL NALBUPHINE HCL NALBUPHINE HCL NALOXONE HCL NALTREXONE HCL NALTREXONE MICROSPHERES NAPHAZOLINE HCL NAPHOS M-B M-H/NA PHOS,DI-BA NAPROXEN NAPROXEN NAPROXEN NAPROXEN NAPROXEN NAPROXEN NAPROXEN SODIUM NAPROXEN SODIUM NAPROXEN SODIUM NAPROXEN SODIUM NAPROXEN SODIUM NAPROXEN/ESOMEPRAZOLE MAG NAPROXEN/ESOMEPRAZOLE MAG NARATRIPTAN HCL NARATRIPTAN HCL NATALIZUMAB NATAMYCIN NATEGLINIDE NATEGLINIDE NEBIVOLOL HCL NEBIVOLOL HCL NEBIVOLOL HCL NEBIVOLOL HCL NEDOCROMIL SODIUM NEEDLES, INSULIN DISP., SAFETY NEEDLES, INSULIN DISP., SAFETY NEEDLES, INSULIN DISP., SAFETY NEEDLES, INSULIN DISPOSABLE DOSAGE FROZ.PIGGY VIAL VIAL VIAL VIAL PORT VIAL PORT CREAM (G) CREAM (G) GEL (GRAM) AMPUL AMPUL VIAL VIAL VIAL TABLET SUS ER REC DROPS TABLET ORAL SUSP TABLET TABLET TABLET TABLET DR TABLET DR TABLET TABLET TBMP 24HR TBMP 24HR TBMP 24HR TAB IR DR TAB IR DR TABLET TABLET VIAL DROPS SUSP TABLET TABLET TABLET TABLET TABLET TABLET DROPS DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE STRENGTH 2 G/100 ML 1 G 10 G 2 G 1 G 2 G 1 % 2 % 1 % 10 MG/ML 20 MG/ML 10 MG/ML 20 MG/ML 0.4 MG/ML 50 MG 380MG 0.1 % 1.5 G 125 MG/5ML 250 MG 375 MG 500 MG 375 MG 500 MG 275 MG 550 MG 375 MG 500 MG 750 MG 375MG-20MG 500MG-20MG 1 MG 2.5 MG 300MG/15ML 5 % 120 MG 60 MG 10 MG 2.5 MG 20 MG 5 MG 2 % 29GX3/16" 29GX5/16" 30GX1/3" 29 GAUGE NOTE APPENDIX A PAGE 86 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEEDLES, INSULIN DISPOSABLE NEFAZODONE HCL NEFAZODONE HCL NEFAZODONE HCL NEFAZODONE HCL NEFAZODONE HCL NELARABINE NELFINAVIR MESYLATE NELFINAVIR MESYLATE NEO/POLYMYX B SULF/DEXAMETH NEO/POLYMYX B SULF/DEXAMETH NEOCATE INFANT POWDER - 14 OZ NEOCATE INFANT POWDER WITH DHA NEOCATE JUNIOR CHOC POWDER - 1 NEOCATE JUNIOR TROPICAL POWDER NEOCATE JUNIOR UNFLAVORED POWD NEOCATE ONE PLUS - 2.1 OZ PACK NEOMY SULF/BACITRA/POLYMYXIN B NEOMY SULF/BACITRAC ZN/POLY/HC NEOMY SULF/COLIST SUL/HC/THONZ NEOMY SULF/POLYMYXIN B SULFATE NEOMY SULF/POLYMYXIN B SULFATE NEOMYCIN SULFATE NEOMYCIN/BACITRA/POLYMYXIN/HC NEOMYCIN/POLYMYXIN B SULF/HC NEOMYCIN/POLYMYXIN B SULF/HC NEOMYCIN/POLYMYXIN B SULF/HC NEOMYCIN/POLYMYXIN B SULF/HC NEOMYCIN/POLYMYXN B/GRAMICIDIN DOSAGE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE DIS NEEDLE TABLET TABLET TABLET TABLET TABLET VIAL TABLET TABLET DROPS SUSP OINT. (G) CAN CAN CAN CAN CAN PACKET OINT. (G) OINT. (G) DROPS SUSP AMPUL VIAL TABLET OINT. (G) DROPS SUSP DROPS SUSP DROPS SUSP SOLUTION DROPS STRENGTH 29GX1/2" 29GX5/16" 30GX1/3" 30GX5/16" 31 GAUGE 31GX1/4" 31GX3/16" 31GX5/16" 32 GX 1/6" 32 GX0.2" 32GX 5/32" 32GX0.25" 32GX3/16" 32GX5/16" 33GX 0.25" 33GX 3/16" 33GX 5/16" 33GX 5/32" 100 MG 150 MG 200 MG 250 MG 50 MG 250MG/50ML 250 MG 625 MG 0.1 % 3.5-10K-.1 13G-421 3.1 G/100 16G-451 16G-451 16G-478 10G-400 3.5MG-400 3.5-10K-1 3.3-3-10/1 40-200K/ML 40-200K/ML 500 MG 1 % 3.5-10K-1 3.5-10K-1 3.5-10K-10 3.5-10K-1 1.75MG-10K NOTE OTIC APPENDIX A PAGE 87 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 88 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION NEOSTIGMINE METHYLSULFATE NEPAFENAC NEPAFENAC NEPRO BUTTER PECAN 8 OZ BOTTL NEPRO HOMEMADE VANILLA - 8 OZ NEPRO MIXED BERRY - 8 OZ BOTTL NEPRO W/CARB STEADY RTD BUTTER NEPRO W/CARB STEADY RTD MIXED NEPRO W/CARB STEADY RTD VANILL NEVIRAPINE NEVIRAPINE NEVIRAPINE NIA#1/FA/B12/FE/ZN/CHR/INO/ACY NIACIN NIACIN NIACIN NIACIN NIACIN NIACIN NIACIN NIACIN NIACIN NIACIN NIACIN/LOVASTATIN NIACIN/LOVASTATIN NIACIN/LOVASTATIN NIACIN/LOVASTATIN NIACIN/POLIC/GUG/PLANT/CAY/GAR NIACIN/SIMVASTATIN NIACIN/SIMVASTATIN NIACIN/SIMVASTATIN NIACIN/SIMVASTATIN NIACIN/SIMVASTATIN NIACINAMIDE NIACINAMIDE NICARDIPINE HCL NICARDIPINE HCL NICARDIPINE HCL NICOTINE NICOTINE NICOTINE NICOTINE NICOTINE NICOTINE NICOTINE NICOTINE DOSAGE VIAL DROPS SUSP DROPS SUSP UNIT UNIT UNIT CAN CAN CAN ORAL SUSP TAB ER 24H TABLET TAB IR DR CAPSULE ER CAPSULE ER TAB ER 24H TAB ER 24H TAB ER 24H TABLET TABLET TABLET TABLET ER TABLET ER TBMP 24HR TBMP 24HR TBMP 24HR TBMP 24HR CAPSULE TBMP 24HR TBMP 24HR TBMP 24HR TBMP 24HR TBMP 24HR TABLET TABLET CAPSULE CAPSULE VIAL CARTRIDGE PATCH DYSQ PATCH TD24 PATCH TD24 PATCH TD24 PATCH TD24 PATCH TD24 SPRAY STRENGTH 1:1000 0.1 % 0.3 % 0.08G-1.80 0.08G-1.80 0.08G-1.80 0.08G-1.80 0.08G-1.80 0.08G-1.80 50 MG/5 ML 400 MG 200 MG 760-500-15 250 MG 500 MG 1000 MG 500 MG 750 MG 100 MG 50 MG 500 MG 250 MG 500 MG 1000-20MG 1000-40 MG 500MG-20MG 750MG-20MG 25-5-50 MG 1000-20MG 1000-40 MG 500MG-20MG 500MG-40MG 750MG-20MG 100 MG 500 MG 20 MG 30 MG 25 MG/10ML 10 MG 21-14-7MG 14MG/24HR 14MG/24HR 21 MG/24HR 21 MG/24HR 7MG/24HR 10 MG/ML NOTE NO REFILLS NO REFILLS 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION NICOTINE POLACRILEX NICOTINE POLACRILEX NICOTINE POLACRILEX NICOTINE POLACRILEX NIFEDIPINE NIFEDIPINE NIFEDIPINE NIFEDIPINE NIFEDIPINE NIFEDIPINE NIFEDIPINE NIFEDIPINE NILOTINIB HCL NILOTINIB HCL NILUTAMIDE NIMODIPINE NISOLDIPINE NISOLDIPINE NISOLDIPINE NISOLDIPINE NISOLDIPINE NISOLDIPINE NISOLDIPINE NITAZOXANIDE NITAZOXANIDE NITISINONE NITISINONE NITISINONE NITROFURANTOIN NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN MONOHYD/M-CRYST NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN DOSAGE GUM GUM LOZENGE LOZENGE CAPSULE CAPSULE TAB ER 24 TAB ER 24 TAB ER 24 TABLET ER TABLET ER TABLET ER CAPSULE CAPSULE TABLET CAPSULE TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H SUSP RECON TABLET CAPSULE CAPSULE CAPSULE ORAL SUSP CAPSULE CAPSULE CAPSULE CAPSULE OINT. (G) OINT. (G) PATCH TD24 PATCH TD24 PATCH TD24 PATCH TD24 PATCH TD24 PATCH TD24 PATCH TD24 PATCH TD24 PATCH TD24 SPRAY TAB SUBL STRENGTH 2 MG 4 MG 2 MG 4 MG 10 MG 20 MG 30 MG 60 MG 90 MG 30 MG 60 MG 90 MG 150 MG 200 MG 150 MG 30 MG 17 MG 20 MG 25.5 MG 30 MG 34 MG 40 MG 8.5MG 100 MG/5ML 500 MG 10 MG 2 MG 5 MG 25 MG/5 ML 100 MG 25 MG 50 MG 100 MG 0.4% (W/W) 2 % 0.1MG/HR 0.2MG/HR 0.2MG/HR 0.3 MG/HR 0.4MG/HR 0.4MG/HR 0.6MG/HR 0.6MG/HR 0.8MG/HR 400MCG/SPR 0.3 MG NOTE 30'S 30'S 30'S APPENDIX A PAGE 89 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN/D5W NITROGLYCERIN/D5W NITROGLYCERIN/D5W NITROPRUSSIDE SODIUM NIZATIDINE NIZATIDINE NIZATIDINE NORELGESTROMIN/ETHIN.ESTRADIOL NOREPINEPHRINE BITARTRATE NOREPINEPHRINE BITARTRATE NORETH-ETHINYL ESTRADIOL/IRON NORETH-ETHINYL ESTRADIOL/IRON NORETHINDRONE NORETHINDRONE AC-ETH ESTRADIOL NORETHINDRONE AC-ETH ESTRADIOL NORETHINDRONE AC-ETH ESTRADIOL NORETHINDRONE AC-ETH ESTRADIOL NORETHINDRONE ACETATE NORETHINDRONE-E.ESTRADIOL-IRON NORETHINDRONE-E.ESTRADIOL-IRON NORETHINDRONE-E.ESTRADIOL-IRON NORETHINDRONE-E.ESTRADIOL-IRON NORETHINDRONE-E.ESTRADIOL-IRON NORETHINDRONE-E.ESTRADIOL-IRON NORETHINDRONE-ETHINYL ESTRAD NORETHINDRONE-ETHINYL ESTRAD NORETHINDRONE-ETHINYL ESTRAD NORETHINDRONE-ETHINYL ESTRAD NORETHINDRONE-ETHINYL ESTRAD NORETHINDRONE-ETHINYL ESTRAD NORETHINDRONE-MESTRANOL NORGESTIMATE-ETHINYL ESTRADIOL NORGESTIMATE-ETHINYL ESTRADIOL NORGESTIMATE-ETHINYL ESTRADIOL NORGESTREL-ETHINYL ESTRADIOL NORGESTREL-ETHINYL ESTRADIOL NORTRIPTYLINE HCL NORTRIPTYLINE HCL NORTRIPTYLINE HCL NORTRIPTYLINE HCL NORTRIPTYLINE HCL NOVASOURCE RENAL VANILLA 8 OZ NPH, HUMAN INSULIN ISOPHANE NPH, HUMAN INSULIN ISOPHANE DOSAGE TAB SUBL TAB SUBL INFUS. BTL INFUS. BTL INFUS. BTL VIAL CAPSULE CAPSULE SOLUTION PATCH TDWK AMPUL VIAL TAB CHEW TAB CHEW TABLET TABLET TABLET TABLET TABLET TABLET TAB CHEW TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE CAPSULE SOLUTION UNIT INSULN PEN VIAL STRENGTH 0.4 MG 0.6 MG 100MG/250 25MG/250ML 50MG/250ML 25 MG/ML 150 MG 300 MG 150MG/10ML 150-35/24H 1 MG/ML 1 MG/ML 0.4-35(21) 0.8-25(24) 0.35 MG 0.5MG-2.5 1.5-0.03MG 1MG-20MCG 1MG-5MCG 5 MG 1MG-20(24) 1.5-30(21) 1MG-10(24) 1MG-20(21) 1MG-20(24) 5-7-9-7 0.4-0.035 0.5-0.035 1 MG-35MCG 10-11 7 DAYS X 3 7-9-5 1 MG-50MCG 0.25-0.035 7DAYSX3 LO 7DAYSX3 28 0.3-0.03MG 0.5 MG-50 10 MG 25 MG 50 MG 75 MG 10 MG/5 ML 100/ML (3) 100/ML NOTE APPENDIX A PAGE 90 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION NS COMB1/FOS/INULIN NUT SUP, GLUCOSE INTOLERANT #1 NUT TX FOR ISOVALERIC ACIDEMIA NUT TX FOR ISOVALERIC ACIDEMIA NUT TX FOR ISOVALERIC ACIDEMIA NUT TX FOR ISOVALERIC ACIDEMIA NUT TX FOR TYROSINEMIA W-IRON NUT TX FOR TYROSINEMIA W-IRON NUT TX FOR TYROSINEMIA W-IRON NUT TX FOR TYROSINEMIA W-IRON NUT TX IMP.DIGEST FXN,SOY&FIB1 NUT TX IMP.DIGEST FXN,SOY&FIB2 NUT TX, GA 1/FLAXSEED/FIBER NUT TX, LACT-REDUCED, IRON NUT TX, LACT-REDUCED, IRON NUT TX, MILK PROT, SP. FORMULA NUT TX, MILK PROT,SP. FORMULA NUT TX,UREA CYCLE DIS W-O IRON NUT. THERAPY FOR GSD NUT. TX FOR PKU WITH IRON #9 NUT. TX FOR PROPIONIC ACIDEMIA NUT. TX FOR PROPIONIC ACIDEMIA NUT. TX FOR PROPIONIC ACIDEMIA NUT. TX FOR PROPIONIC ACIDEMIA NUT. TX FOR PROPIONIC ACIDEMIA NUT. TX FOR PROPIONIC ACIDEMIA NUT. TX FOR PROPIONIC ACIDEMIA NUT. TX FOR PROPIONIC ACIDEMIA NUT. TX FOR PROPIONIC ACIDEMIA NUT. TX, ATOPIC DISORDERS/FOS NUT. TX, GLUTARIC ACIDURIA I NUT. TX, GLUTARIC ACIDURIA I NUT. TX, GLUTARIC ACIDURIA I NUT. TX, GLUTARIC ACIDURIA I NUT. TX, GLUTARIC ACIDURIA I NUT. TX, GLUTARIC ACIDURIA I NUT. TX, GLUTARIC ACIDURIA I NUT. TX, GLUTARIC ACIDURIA I NUT. TX, GLUTARIC ACIDURIA 1 NUT. TX, GLUTARIC ACIDURIA 1 NUT. TX, MET DIS, MVI, MIN #3 NUT. TX, MET DIS, MVI, MIN #4 NUT. TX, MOVEMENT DISORDER,SOY NUT. TX,IMP. RENAL FXN, WHEY NUT. TX,IMP. RENAL FXN, WHEY NUT. TX,IMP. RENAL FXN, WHEY DOSAGE ORAL SUSP LIQUID POWDER POWDER POWDER POWDER LIQUID POWD PACK POWDER POWDER LIQUID LIQUID POWDER BRIK LIQUID LIQUID LIQUID POWDER POWD PACK POWDER LIQUID POWD PACK POWD PACK POWD PACK POWDER POWDER POWDER POWDER POWDER POWDER POWD PACK POWD PACK POWDER POWDER POWDER POWDER POWDER POWDER POWDER POWDER POWDER POWDER PACKET PACKET POWDER SUSP RECON STRENGTH 0.0756-1.2 3G-2.7-60 16.2G-500 25G-324 30G-410 40G-305 6 G-80/100 60 G-297 28 G-385 63G-295 0.05G-1/ML 0.03G-1/ML 25 G-385 0.09G-2.25 0.07 G-0.8 12-100/118 12-100/118 79G-316 0.3 G-214 22G-410 11.5 G-79 41.7 G-338 42G-342 60 G-302 21 G-410 25G-324 30G-410 40G-305 56G-300 8G-120/30G 41.7 G-338 60 G-297 10 G-410 15.1G-500 25G-324 30G-410 40G-305 81 G-324 25G-324 40G-305 15G-120 15G-200 9.75G 7.5 G-494 10G-235 NOTE APPENDIX A PAGE 91 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION NUT.SOY,LACFREE/FOS/DHA/EPA/IN NUT.SUP,SPEC.FRM,L-FR,IRON/FOS NUT.TX MSUD, IRON/FLAXSEED OIL NUT.TX. METABOLIC DISORDER,REG NUT.TX. METABOLIC DISORDER,REG NUT.TX. METABOLIC DISORDER,REG NUT.TX. METABOLIC DISORDER,REG NUT.TX. METABOLIC DISORDER,REG NUT.TX. METABOLIC DISORDER,REG NUT.TX. METABOLIC DISORDER,SOY NUT.TX. METABOLIC DISORDER,SOY NUT.TX. METABOLIC DISORDER,SOY NUT.TX., UREA CYCLE DISORDER NUT.TX., UREA CYCLE DISORDER NUT.TX., UREA CYCLE DISORDER NUT.TX., UREA CYCLE DISORDER NUT.TX.,ELEMENTAL,LAC-FREE/MCT NUT.TX.COMP. IMMUNE SYSTM,REG NUT.TX.COMP. IMMUNE SYSTM,REG NUT.TX.COMP. IMMUNE SYSTM,REG NUT.TX.COMP. IMMUNE SYSTM,REG NUT.TX.COMP. IMMUNE SYSTM,REG NUT.TX.COMP. IMMUNE SYSTM,REG NUT.TX.COMP. IMMUNE SYSTM,REG NUT.TX.COMP. IMMUNE SYSTM,REG NUT.TX.COMP. IMMUNE SYSTM,REG NUT.TX.COMP. IMMUNE SYSTM,SOY NUT.TX.COMP.IMMUNE SYS/SOY FIB NUT.TX.COMP.IMMUNE SYS/SOY FIB NUT.TX.COMP.IMMUNE SYS,L-F,SOY NUT.TX.GLU INT/FOS/DHA NUT.TX.GLUC.INTOLER,LAC-FR,REG NUT.TX.GLUC.INTOLER,LAC-FR,SOY NUT.TX.GLUC.INTOLER,LAC-FR,SOY NUT.TX.GLUCOSE INTOL,SOY/FIBER NUT.TX.GLUCOSE INTOLERANCE,SOY NUT.TX.GLUCOSE INTOLERANCE,SOY NUT.TX.GLUCOSE INTOLERANCE,SOY NUT.TX.GLUCOSE INTOLERANCE,SOY NUT.TX.GLUCOSE INTOLERANCE,SOY NUT.TX.IMP.RENAL FXN,LAC-FREE NUT.TX.IMP.RENAL FXN,LAC-FREE NUT.TX.IMP.RENAL FXN,LAC-FREE NUT.TX.IMP.RENAL FXN,LAC-FREE NUT.TX.IMPAIRED DIGEST FXN NUT.TX.IMPAIRED DIGEST FXN DOSAGE LIQUID LIQUID POWDER LIQUID ORAL SUSP POWD PACK POWD PACK POWD PACK POWD PACK LIQUID POWDER POWDER POWDER POWDER POWDER POWDER LIQUID PKT LIQUID LIQUID LIQUID LIQUID PACKET PACKET PACKET PACKET SUSP RECON LIQUID LIQUID LIQUID PACKET ORAL SUSP LIQUID LIQUID POWD PACK LIQUID BAR BAR BAR BAR LIQUID LIQUID LIQUID LIQUID LIQUID PKT CAN LIQUID STRENGTH 0.09G-1/ML 0.08G-2/ML 13 G-496 0.115G-.71 118KCAL/31 160KCAL/42 198KCAL/52 80KCAL/21G 0.067G-1.3 400/100G 12 G-385 15 G-393 15G-440 8.2G-410 14G-230/45 0.06G-1/ML 0.08G-1.4 0.09 G-1.5 12G-90KCAL 15G-350 21 G-400 0.06G-1/ML 0.08G-1.3 0.042-0.8 14G-120/PK 0.06G-1.2 10G-140/40 10G-150/40 3 G-80/20G 0.08G-2/ML 0.5 G-2.4 0.5 G-2.4 8.2G-472 0.03G-1/ML NOTE APPENDIX A PAGE 92 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION NUT.TX.IMPAIRED DIGEST FXN NUT.TX.IMPAIRED DIGEST FXN NUT.TX.IMPAIRED DIGEST FXN NUT.TX.IMPAIRED DIGEST FXN NUT.TX.IMPAIRED DIGEST FXN NUT.TX.IMPAIRED DIGEST FXN NUT.TX.IMPAIRED DIGEST FXN NUT.TX.IMPAIRED DIGEST FXN NUT.TX.IMPAIRED DIGEST FXN NUT.TX.IMPAIRED DIGEST FXN,SOY NUT.TX.IMPAIRED DIGEST FXN,SOY NUT.TX.IMPAIRED DIGEST FXN,SOY NUT.TX.IMPAIRED DIGEST FXN,SOY NUT.TX.IMPAIRED DIGEST FXN,SOY NUT.TX.IMPAIRED DIGEST/FIBER NUT.TX.IMPAIRED DIGEST/FIBER NUT.TX.IMPAIRED DIGEST/FIBER NUT.TX.IMPAIRED DIGEST/FIBER NUT.TX.IMPAIRED DIGEST/FIBER NUT.TX.IMPAIRED DIGEST/FIBER NUT.TX.IMPAIRED HEPATIC FXN NUT.TX.IMPAIRED RENAL FXN,SOY NUT.TX.IMPAIRED RENAL FXN,SOY NUT.TX.IMPAIRED RENAL FXN,SOY NUT.TX.PULM.DISORD.REG,LAC-FR NUT.TX.PULM.DISORD.REG,LAC-FR NUT.TX.PULM.DISORD.SOY,LAC-FR NUT.TX, METAB.DIS, MV & MIN #2 NUT.TX, METAB.DIS, MV,MIN NO.6 NUT.TX,METAB.DIS,LEUCINE-FREE NUT.TX,METABOLIC DIS,METHIO-FR NUT.TX,METABOLIC DIS,METHIO-FR NUT.TX,METABOLIC DIS,METHIO-FR NUT.TX,METABOLIC DIS,METHIO-FR NUT.TX,METABOLIC DIS,METHIO-FR NUT.TX,METABOLIC DIS,METHIO-FR NUT.TX,METABOLIC DIS,METHIO-FR NUT.TX,METABOLIC DIS,METHIO-FR NUT.TX,METABOLIC DIS,METHIO-FR NUT.TX,METABOLIC DIS,METHIO-FR NUT.TX,METABOLIC DIS,METHIO-FR NUT.TX,TYROSINEM. WITHOUT IRON NUTRA BALANCE HI PROTEIN COOKI NUTRA BALANCE NO SUGAR ADDED C NUTRA BALANCE POWDER UNFLAVORE NUTRA BALANCE REGEN HI PROTEIN DOSAGE LIQUID LIQUID PACKET POWD PACK POWD PACK POWD PACK POWD PACK POWDER POWDER LIQUID LIQUID LIQUID POWD PACK POWDER LIQUID LIQUID LIQUID POWDER POWDER POWDER LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID LIQUID POWD PACK POWD PACK LIQUID LIQUID PKT ORAL SUSP POWD PACK POWD PACK POWD PACK POWD PACK POWDER POWDER POWDER POWDER POWDER LIQUID EACH EACH CAN EACH STRENGTH 0.035-1/ML 0.08G-1/ML 11.5 G-300 13.5 G-300 6.2-300/80 6-200/48.5 8.2G-472 0.03G-1/ML 0.05G-1/ML 0.07G-1.5 7.4G-240 0.04G-1/ML 0.07G-1.5 0.08 G-1.2 16 G-459 16 G-469 16G-478 0.04G-1.5 0.04G-1.79 0.08G-1.80 0.06G-1.5 20GRAM/40 46KCAL/100 11.5 G-79 20-120/125 0.115G-.71 41.7 G-338 42G-342 60 G-297 60 G-302 22G-410 25G-324 30G-410 40G-305 69G-290 2 G-34/100 NOTE APPENDIX A PAGE 93 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION NUTRA BALANCE REGEN STRAWBERRY NUTRA BALANCE REGEN VANILLA LI NUTRA BALANCE THIK & CLEAR HON NUTRA BALANCE THIK & CLEAR NEC NUTRAMIGEN AA LIPIL POWDER - 1 NUTRAMIGEN ENFLORA-LGG POWDER NUTRAMIGEN LIPIL CONC - 13 OZ NUTRAMIGEN LIPIL POWDER - 1 LB NUTRAMIGEN LIPIL RTU - 2 OZ BO NUTRAMIGEN LIPIL RTU - 32 OZ C NUTRAMIGEN LIPIL RTU - 6 OZ BO NUTRAMINE T-UNFLAVORED-PACKETNUTRAMINE-UNFLAVORED-PACKET-42 NUTREN JUNIOR ULTRAPAK SYSTEM NUTREN JUNIOR VANILLA -250ML C NUTREN JUNIOR VANILLA W/FIBER NUTREN PULMONARY ULTRAPAK SYST NUTREN PULMONARY VANILLA - 250 NUTREN REPLETE W/FIBER ULTRAPA NUTREN VANILLA 1.0 - 250ML CAN NUTREN VANILLA 1.0 FIBER W/PRE NUTREN VANILLA 1.5 - 250ML CAN NUTREN VANILLA 2.0 - 250ML CAN NUTREN 2.0 ULTRAPAK SYSTEM - 1 NUTREN1.5 ULTRAPAK SYSTEM - 10 NUTRESTORE POWDER - PACK NUTRIHEP UNFLAVORED - 250ML CA NUTRISOURCE FIBER POWDER, 4G P NUTRISOURCE FIBER POWDER, 7.2 NUTRIT SUPP/INULIN/FOS/FIBER NUTRIT SUPP/INULIN/FOS/FIBER NUTRIT. TX, MSUD WITHOUT IRON NUTRIT. TX, MSUD WITHOUT IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON DOSAGE BRIK BRIK PACKET PACKET CAN CAN CAN CAN BTL CAN BTL UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT CAN PACKET CAN LIQUID LIQUID BAR POWDER LIQUID PKT LIQUID PKT ORAL SUSP ORAL SUSP POWD PACK POWD PACK POWD PACK POWDER POWDER POWDER POWDER POWDER POWDER STRENGTH 2.8 2.8 2.8 2.8 2.8 2.8 2.8 G/100 G/100 G/100 G/100 G/100 G/100 G/100 0.03G-1/ML 0.04G-1/ML 5 G 0.16G-1.5 0.03G-1/ML 0.04G-1/ML 10G-270 10G-42/13G 15-140/140 20-120/125 0.11G-1.06 0.115G-.71 41.7 G-338 42G-342 60 G-297 10G-164 16.2G-500 20G-395 24G-410 25 G-380 25G-324 NOTE APPENDIX A PAGE 94 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRIT.THERAPY, MSUD WITH IRON NUTRITIONAL SUPP/INULIN/FOS NUTRITIONAL SUPPLEMENT NUTRITIONAL SUPPLEMENT NUTRITIONAL SUPPLEMENT NUTRITIONAL SUPPLEMENT NUTRITIONAL SUPPLEMENT NUTRITIONAL SUPPLEMENT NUTRITIONAL SUPPLEMENT NUTRITIONAL SUPPLEMENT NUTRITIONAL SUPPLEMENT NUTRITIONAL SUPPLEMENT NUTRITIONAL SUPPLEMENT PEDIASU NUTRITIONAL SUPPLEMENT/ALBUMEN NUTRITIONAL SUPPLEMENT/FIBER NUTRITIONAL SUPPLEMENT/FIBER NUTRITIONAL SUPPLEMENT/FIBER NUTRITIONAL SUPPLEMENT/MCT NUTRITIONAL TX FOR TYROSINEMIA NUTRITIONAL TX FOR TYROSINEMIA NUTRITIONAL TX FOR TYROSINEMIA NUTRITIONAL TX FOR TYROSINEMIA NUTRITIONAL TX FOR TYROSINEMIA NUTRITIONAL TX FOR TYROSINEMIA NUTRITIONAL TX FOR TYROSINEMIA NUTRITIONAL TX, KETOGENIC/LCT NUTRITIONAL TX, KETOGENIC/MCT NUTRITIONAL TX, KETOGENIC, SOY NUTRITIONAL TX, KETOGENIC, SOY NUTRITIONAL TX, KETOGENIC, SOY NUTRITIONAL TX, KETOGENIC,WHEY NUTRITIONAL TX, KETOGENIC,WHEY NYSTATIN NYSTATIN NYSTATIN NYSTATIN NYSTATIN NYSTATIN/EMOLLIENT COMBO NO.54 NYSTATIN/TRIAMCIN NYSTATIN/TRIAMCIN OBINUTUZUMAB OCTREOTIDE ACETATE DOSAGE POWDER POWDER POWDER POWDER POWDER LIQUID BOTTLE LIQUID LIQUID LIQUID ORAL SUSP ORAL SUSP PACKET POWDER POWDER POWDER BOTTLE LIQUID EACH LIQUID LIQUID POWDER LIQUID PKT POWD PACK POWD PACK POWD PACK POWDER POWDER POWDER EMULSION EMULSION LIQUID POWDER POWDER POWDER POWDER CREAM (G) OINT. (G) ORAL SUSP POWDER TABLET CREAM (G) CREAM (G) OINT. (G) VIAL AMPUL STRENGTH 30G-410 40G-305 54G-300 60 G-297 60G-250 0.03G-1/ML 0.03G-1/ML 0.04G-1.05 41-240/237 0.03G-1/ML 0.045G-1.5 2.6 G/100 6G-160/36G 0.045G-1.5 0.04G-1/ML 20-120/125 41.7 G-338 42G-342 60 G-297 22G-410 25G-324 30G-410 20 G-180 21 G-189 3.09 G-150 14.4 G-701 15G-720 14.5 G-686 14.5 G-712 100000/G 100000/G 100000/ML 100000/G 500K UNIT 100000/G 100000-0.1 100000-0.1 1000 MG/40 100 MCG/ML NOTE APPENDIX A PAGE 95 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OFATUMUMAB OFATUMUMAB OFLOXACIN OLANZAPINE OLANZAPINE OLANZAPINE OLANZAPINE OLANZAPINE OLANZAPINE OLANZAPINE OLANZAPINE OLANZAPINE OLANZAPINE OLANZAPINE OLANZAPINE/FLUOXETINE HCL OLANZAPINE/FLUOXETINE HCL OLANZAPINE/FLUOXETINE HCL OLANZAPINE/FLUOXETINE HCL OLANZAPINE/FLUOXETINE HCL OLMESARTAN MEDOXOMIL OLMESARTAN MEDOXOMIL OLMESARTAN MEDOXOMIL OLMESARTAN/AMLODIPIN/HCTHIAZID OLMESARTAN/AMLODIPIN/HCTHIAZID OLMESARTAN/AMLODIPIN/HCTHIAZID OLMESARTAN/AMLODIPIN/HCTHIAZID OLMESARTAN/AMLODIPIN/HCTHIAZID OLMESARTAN/HYDROCHLOROTHIAZIDE OLMESARTAN/HYDROCHLOROTHIAZIDE OLMESARTAN/HYDROCHLOROTHIAZIDE OLOPATADINE HCL OLOPATADINE HCL OLOPATADINE HCL OM-3/DHA/EPA/FISH OIL/VIT D3 OM-3/DHA/EPA/FISH OIL/VIT D3 OM-3/DHA/EPA/FISH OIL/VIT D3 DOSAGE AMPUL AMPUL KIT KIT KIT VIAL VIAL VIAL VIAL VIAL VIAL VIAL DROPS TAB RAPDIS TAB RAPDIS TAB RAPDIS TAB RAPDIS TABLET TABLET TABLET TABLET TABLET TABLET VIAL CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET DROPS DROPS SPRAY/PUMP CAPSULE EMUL PACKT TAB CHEW STRENGTH 50 MCG/ML 500 MCG/ML 10 MG 20 MG 30 MG 100 MCG/ML 1000MCG/ML 200 MCG/ML 50 MCG/ML 500 MCG/ML 100 MG/5ML 1000 MG/50 0.3 % 10 MG 15 MG 20 MG 5 MG 10 MG 15 MG 2.5 MG 20 MG 5 MG 7.5 MG 10 MG 12MG-25MG 12MG-50MG 3 MG-25 MG 6MG-25MG 6MG-50MG 20 MG 40 MG 5 MG 20-5-12.5 40-10-12.5 40-10-25MG 40-5-12.5 40-5-25 MG 20-12.5 MG 40 MG-25MG 40-12.5 MG 0.1 % 0.2 % 0.6 % 666.66MG 650MG-1000 31.25-117 NOTE APPENDIX A PAGE 96 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION OM-3/DHA/EPA/TUNA OIL OM-3/EPA/DHA/FISH OIL/FLAX/E OMALIZUMAB OMEGA-3 ACID ETHYL ESTERS OMEGA-3/B12/FA/B-6/PHYTOSTEROL OMEGA-3/DHA/ARA/CARBOHYDRATE OMEGA-3/DHA/CARBOHYDRATE SUPP OMEGA-3/DHA/EPA/FISH OIL/Q-10 OMEGA-3/DHA/EPA/LUT/ZEAXANTHIN OMEGA-3/DHA/EPA/LUT/ZEAXANTHIN OMEGA-3/DHA/EPA/LUT/ZEAXANTHIN OMEGA-3/DHA/EPA/TUNA OIL OMEGA-3/DHA/EPA/VIT E OMEGA-3/VIT B12/FA/PYRIDOXINE OMEGA-3S/DHA/EPA/FISH OIL OMEGA-3S/DHA/EPA/FISH OIL OMEGA-3S/DHA/EPA/FISH OIL/D3 OMEGA-3S/DHA/EPA/FISH OIL/D3 OMEGA-3S/DHA/EPA/FISH OIL/D3 OMEGA-3S/DHA/EPA/FISH OIL/D3 OMEPRAZOLE OMEPRAZOLE OMEPRAZOLE OMEPRAZOLE MAGNESIUM OMEPRAZOLE MAGNESIUM OMEPRAZOLE/CLARITH/AMOXICILLIN OMEPRAZOLE/SODIUM BICARBONATE OMEPRAZOLE/SODIUM BICARBONATE OM3-DHA/EPA/D3/LUTEIN/ZEAZANTH OM3/DHA/EPA/OTHER OM3/EVE/BIL OM3,6,9#4/FSH&FL/UB/FA/B6,12/E ONABOTULINUMTOXINA ONABOTULINUMTOXINA ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON ONDANSETRON HCL ONDANSETRON HCL ONDANSETRON HCL ONDANSETRON HCL ONDANSETRON HCL/PF ONDANSETRON HCL/PF OPIUM TINCTURE OPIUM/BELLADONNA ALKALOIDS OPIUM/BELLADONNA ALKALOIDS DOSAGE TAB CHEW CAPSULE VIAL CAPSULE CAPSULE POWD PACK POWD PACK EMUL PACKT CAPSULE CAPSULE CAPSULE TAB CHEW CAPSULE CAPSULE CAP CHEW CAPSULE CAPSULE CAPSULE CAPSULE LIQUID CAPSULE DR CAPSULE DR CAPSULE DR SUSPDR PKT SUSPDR PKT COMBO. PKG CAPSULE CAPSULE CAPSULE CAPSULE COMBO. PKG VIAL VIAL FILM FILM TAB RAPDIS TAB RAPDIS SOLUTION TABLET TABLET VIAL AMPUL VIAL TINCTURE SUPP.RECT SUPP.RECT STRENGTH 25-5-113.5 150-100 MG 150 MG 1 G 500-0.5-1 100-200/4G 0.1-200/4G 1900MG/2.5 250-2.5 MG 500-5-1 MG 800-10-2MG 25-5-113.5 500-139 MG 0.5-1-12.5 135-33.8MG 300-1000MG 350MG-1000 667 MG-250 667-280 MG 1150-1000 10 MG 20 MG 40 MG 10 MG 2.5 MG 20(20)-500 20MG-1.1G 40MG-1.1G 550 MG-250 650-150-20 1000-1000 100 UNIT 200 UNIT 4 MG 8 MG 4 MG 8 MG 4 MG/5 ML 4 MG 8 MG 2 MG/ML 4 MG/2 ML 4 MG/2 ML 10 MG/ML 30-16.2MG 60-16.2MG NOTE APPENDIX A PAGE 97 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION OPRELVEKIN OPTIMENTAL RTH - 1000ML CONTA OPTIMENTAL VANILLA - 8 OZ CAN OPTISOURCE CARAMEL HIGH PROTE OPTISOURCE STRAWBERRY - HIGH P ORA SWEET SF ORA-PLUS ORANGE JUICE ORLISTAT ORNITHINE ORNITHINE ORNITHINE ORPHENADRINE CITRATE ORPHENADRINE CITRATE ORPHENADRINE CITRATE OSELTAMIVIR PHOSPHATE OSELTAMIVIR PHOSPHATE OSELTAMIVIR PHOSPHATE OSELTAMIVIR PHOSPHATE OSMOLITE UNFLAVORED 1.0 CAL OSMOLITE UNFLAVORED 1.2 CAL OSMOLITE UNFLAVORED 1.5 CAL OSMOLITE 1.0 CAL RTH -1000ML C OSMOLITE 1.0 CAL RTH -1500ML C OSMOLITE 1.2 CAL RTH -1000ML C OSMOLITE 1.2 CAL RTH -1500ML C OSMOLITE 1.5 CAL RTH -1000ML C OSPEMIFENE OXACILLIN SODIUM OXACILLIN SODIUM OXACILLIN SODIUM OXACILLIN SODIUM OXACILLIN SODIUM OXACILLIN SODIUM/DEXTROSE,ISO OXALIPLATIN OXALIPLATIN OXALIPLATIN OXALIPLATIN OXANDROLONE OXANDROLONE OXAPROZIN OXAZEPAM OXAZEPAM OXAZEPAM OXCARBAZEPINE OXCARBAZEPINE DOSAGE VIAL UNIT CAN UNIT UNIT UNIT UNIT LIQUID CAPSULE CAPSULE CAPSULE CAPSULE AMPUL TABLET ER VIAL CAPSULE CAPSULE CAPSULE SUSP RECON UNIT UNIT UNIT UNIT UNIT UNIT UNIT UNIT TABLET VIAL VIAL VIAL VIAL PORT VIAL PORT FROZ.PIGGY VIAL VIAL VIAL VIAL TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE ORAL SUSP TAB ER 24H STRENGTH 5 MG 120 MG 300 MG 500 MG 600 MG 30 MG/ML 100 MG 30 MG/ML 30 MG 45 MG 75 MG 6 MG/ML 60 MG 1 G 10 G 2 G 1 G 2 G 2 G/50 ML 100 MG 100MG/20ML 50 MG 50 MG/10ML 10 MG 2.5 MG 600 MG 10 MG 15 MG 30 MG 300 MG/5ML 150 MG NOTE APPENDIX A PAGE 98 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION OXCARBAZEPINE OXCARBAZEPINE OXCARBAZEPINE OXCARBAZEPINE OXCARBAZEPINE OXEPA UNFLAVORED - 8 OZ CAN OXEPA UNFLAVORED RTH -1000ML C OXICONAZOLE NITRATE OXICONAZOLE NITRATE OXYBUTYNIN OXYBUTYNIN OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL/ACETAMINOPHEN OXYCODONE HCL/ACETAMINOPHEN OXYCODONE HCL/ACETAMINOPHEN OXYCODONE HCL/ACETAMINOPHEN OXYCODONE HCL/ACETAMINOPHEN OXYCODONE HCL/ACETAMINOPHEN OXYCODONE HCL/ASPIRIN OXYMETHOLONE OXYMORPHONE HCL OXYMORPHONE HCL OXYMORPHONE HCL OXYMORPHONE HCL DOSAGE TAB ER 24H TAB ER 24H TABLET TABLET TABLET UNIT UNIT CREAM (G) LOTION GEL MD PMP PATCH TDSW GEL PACKET SYRUP TAB ER 24 TAB ER 24 TAB ER 24 TABLET CAPSULE ORAL CONC SOLUTION TAB ER 12H TAB ER 12H TAB ER 12H TAB ER 12H TAB ER 12H TAB ER 12H TAB ER 12H TABLET TABLET TABLET TABLET TABLET TABLET ORL TABLET ORL SOLUTION TAB IR ERO TABLET TABLET TABLET TABLET TABLET TABLET AMPUL TAB ER 12H TAB ER 12H TAB ER 12H STRENGTH 300 MG 600 MG 150 MG 300 MG 600 MG 0.06G-1.5 0.06G-1.5 1 % 1 % 28MG/0.92G 3.9MG/24HR 10 % 5 MG/5 ML 10 MG 15 MG 5 MG 5 MG 5 MG 20 MG/ML 5 MG/5 ML 10 MG 15 MG 20 MG 30 MG 40 MG 60 MG 80 MG 10 MG 15 MG 20 MG 30 MG 5 MG 5 MG 7.5 MG 5-325/5ML 7.5-325MG 10MG-325MG 2.5-325MG 5MG-325MG 7.5-325MG 4.8355-325 50 MG 1 MG/ML 10 MG 15 MG 20 MG NOTE APPENDIX A PAGE 99 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 100 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION OXYMORPHONE HCL OXYMORPHONE HCL OXYMORPHONE HCL OXYMORPHONE HCL OXYMORPHONE HCL OXYMORPHONE HCL P-EPHED HCL/BROMPHENIRAMIN P-EPHED HCL/TRIPROLIDINE HCL PACLITAXEL PACLITAXEL PROTEIN-BOUND PALIFERMIN PALIPERIDONE PALIPERIDONE PALIPERIDONE PALIPERIDONE PALIPERIDONE PALMITATE PALIPERIDONE PALMITATE PALIPERIDONE PALMITATE PALIPERIDONE PALMITATE PALIPERIDONE PALMITATE PALIVIZUMAB PALIVIZUMAB PALONOSETRON HCL PAMIDRONATE DISODIUM PAMIDRONATE DISODIUM PAMIDRONATE DISODIUM PANCREAT/BET HCL/PEP/BROM/PAP PANCURONIUM BROMIDE PANITUMUMAB PANITUMUMAB PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM PANTOPRAZOLE SODIUM PAPAIN PARENTERAL AMINO ACID 15% NO.1 PARICALCITOL PARICALCITOL PARICALCITOL PARICALCITOL PARICALCITOL PAROMOMYCIN SULFATE PAROXETINE HCL PAROXETINE HCL PAROXETINE HCL PAROXETINE HCL DOSAGE TAB ER 12H TAB ER 12H TAB ER 12H TAB ER 12H TABLET TABLET DROPS LIQUID VIAL VIAL VIAL TAB ER 24 TAB ER 24 TAB ER 24 TAB ER 24 SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE VIAL VIAL VIAL VIAL VIAL VIAL CAPSULE VIAL VIAL VIAL GRANPKT DR TABLET DR TABLET DR VIAL TABLET IV SOLN CAPSULE CAPSULE CAPSULE VIAL VIAL CAPSULE ORAL SUSP TAB ER 24H TAB ER 24H TAB ER 24H STRENGTH 30 MG 40 MG 5 MG 7.5 MG 10 MG 5 MG 7.5-1MG/ML 10-0.938/1 6 MG/ML 100 MG 6.25 MG 1.5 MG 3 MG 6 MG 9 MG 117MG/0.75 156 MG/ML 234MG/1.5 39MG/0.25 78MG/0.5ML 100 MG/ML 50MG/0.5ML 0.25MG/5ML 30MG/10ML 60 MG/10ML 90 MG/10ML 250-162 MG 1 MG/ML 100 MG/5ML 400MG/20ML 40 MG 20 MG 40 MG 40 MG 100 MG 15 % 1 MCG 2 MCG 4MCG 2 MCG/ML 5 MCG/ML 250 MG 10 MG/5 ML 12.5 MG 25 MG 37.5 MG NOTE ONLY CLINISOL PA 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION PAROXETINE HCL PAROXETINE HCL PAROXETINE HCL PAROXETINE HCL PAROXETINE MESYLATE PAROXETINE MESYLATE PAROXETINE MESYLATE PAROXETINE MESYLATE PAROXETINE MESYLATE PAZOPANIB HCL PEAK FLOW METER PECT/B-6/MIN COMBO NO.4/CIDER PED MULTIVIT #46/IRON SULFATE PED MV A,C,D3 #21 W-FLUORIDE PED MV A,C,D3 #21 W-FLUORIDE PED MV A,C,D3 #38 W-FLUORIDE PED.NUTRIT.,SOY,IRON,LACT FREE PEDI M.VIT NO.17 WITH FLUORIDE PEDI M.VIT NO.17 WITH FLUORIDE PEDI M.VIT NO.17 WITH FLUORIDE PEDI MULTIVIT #37 W-FLUORIDE PEDI MULTIVIT #47/IRON/FLUORID PEDI MULTIVIT #63 W-FLUORIDE PEDI MULTIVIT #63 W-FLUORIDE PEDI MULTIVIT #63 W-FLUORIDE PEDI MULTIVIT NO.2 W-FLUORIDE PEDI MULTIVIT NO.2 W-FLUORIDE PEDI MV #37 W-FLUORIDE & IRON PEDI MV #45/FLUORIDE/IRON PEDI MV #75/FLUORIDE/IRON PEDI MVI NO.12/SODIUM FLUORIDE PEDI MVI NO.16 WITH FLUORIDE PEDI MVI NO.16 WITH FLUORIDE PEDI MVI NO.16 WITH FLUORIDE PEDI MVI NO.33 WITH FLUORIDE PEDI MVI NO.33 WITH FLUORIDE PEDI MVI NO.33 WITH FLUORIDE PEDI MVI NO.82 WITH FLUORIDE PEDI MVI NO.82 WITH FLUORIDE PEDI NUTRIT.,SOY,IRON,LF/FIBER PEDIALYTE APPLE - 8 OZ BOTTLE PEDIALYTE BUBBLE GUM-1 LTR BOT PEDIALYTE CHERRY - 8 OZ BOTTLE PEDIALYTE FROZEN POPS - 2.1 OZ PEDIALYTE FRUIT-1 LTR BOTTLE-8 PEDIALYTE GRAPE-1 LTR BOTTLE-8 DOSAGE TABLET TABLET TABLET TABLET CAPSULE TABLET TABLET TABLET TABLET TABLET EACH TABLET DROPS DROPS DROPS DRPS SP BP POWDER TAB CHEW TAB CHEW TAB CHEW DRPS SP BP TAB CHEW TAB CHEW TAB CHEW TAB CHEW DROPS DROPS DRPS SP BP DROPS DROPS TAB CHEW TAB CHEW TAB CHEW TAB CHEW TAB CHEW TAB CHEW TAB CHEW DROPS DROPS POWDER BOTTLE BOTTLE BOTTLE EACH BOTTLE BOTTLE STRENGTH 10 MG 20 MG 30 MG 40 MG 7.5 MG 10 MG 20 MG 30 MG 40 MG 200 MG 8.3-300MG 1500-10/ML 0.25 MG/ML 0.5 MG/ML 0.25 MG/ML 2G-80/17.5 0.25 MG 0.5 MG 1 MG 0.25 MG/ML 7.5-0.25MG 0.25(0.55) 0.5(1.1)MG 1MG(2.2MG) 0.25 MG/ML 0.5 MG/ML 0.25-7MG/1 0.25-10/ML 0.25-10/ML 0.5 MG 0.25 MG 0.5 MG 1 MG 0.25 MG 0.5 MG 1 MG 0.25 MG/ML 0.5 MG/ML 7G-237/52G NOTE APPENDIX A PAGE 101 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION PEDIALYTE UNFLAVORED-1 LTR BOT PEDIASURE BANANA CREAM - 8 OZ PEDIASURE CHOC - 8 OZ BOTTLE PEDIASURE CHOC - 8 OZ BOTTLE PEDIASURE ENTERAL FORMULA VANI PEDIASURE ENTERANL FORMULA WIT PEDIASURE SIDEKICKS 0.63 CAL R PEDIASURE STRAWBERRY - 8 OZ BO PEDIASURE VANILLA - 8 OZ BOTTL PEDIASURE VANILLA W/FIBER - 8 PEDIASURE VANILLA W/FIBER - 8 PEDIASURE 1.5 CAL VANILLA - 8 PEDIASURE 1.5 CAL W/FIBER VANI PEDIATRIC MV #33 W-FLUORIDE&FE PEDIATRIC NUT, MILK, IRON/DHA PEDIATRIC NUT, MILK, IRON/DHA PEDIATRIC NUT,MILK BASED,IRON PEDIATRIC NUT,MILK BASED,IRON PEDIATRIC NUT,MILK BASED,IRON PEDIATRIC NUTRIT,IRON,LF&FIBER PEDIATRIC NUTRIT,IRON,LF&FIBER PEDIATRIC NUTRIT,IRON,LF&FIBER PEDIATRIC NUTRIT,IRON,LF&FIBER PEDIATRIC NUTRITION, IRON, LF PEDIATRIC NUTRITION, IRON, LF PEDIATRIC NUTRITION, IRON, LF PEDIATRIC NUTRITION, IRON, LF PEDIATRIC NUTRITIONAL PEDISURE BANANA CREAM - 8 OZ C PEDISURE BERRY CREAM - 8 OZ CA PEDISURE CHOC - 8 OZ CAN - 24/ PEDISURE STRAWBERRY - 8 OZ CAN PEDISURE VANILLA - 8 OZ CAN PEG 3350/NA SULF,BICARB,CL/KCL PEG 3350/NA SULF,BICARB,CL/KCL PEG 3350/NA SULF,BICARB,CL/KCL PEG 3350/NA SULF,BICARB,CL/KCL PEGADEMASE BOVINE PEGASPARGASE PEGFILGRASTIM PEGINTERFERON ALFA-2A PEGINTERFERON ALFA-2A PEGINTERFERON ALFA-2A PEGINTERFERON ALFA-2A PEGINTERFERON ALFA-2B PEGINTERFERON ALFA-2B DOSAGE BOTTLE BOTTLE BOTTLE BOTTLE BOTTLE CAN BOTTLE BOTTLE BOTTLE BOTTLE CAN CAN CAN TAB CHEW LIQUID POWDER LIQUID POWDER POWDER LIQUID LIQUID LIQUID LIQUID BRIKID LIQUID LIQUID POWDER __________ CAN CAN CAN CAN CAN POWD PACK SOLN RECON SOLN RECON SOLN RECON VIAL VIAL SYRINGE PEN INJCTR PEN INJCTR SYRINGE VIAL KIT KIT STRENGTH 0.03G-1/ML 0.03G-1/ML 0.03G-1/ML 0.03G-1/ML 0.03 G-0.6 0.03G-1/ML 0.03G-1/ML 0.03G-1/ML 0.03G-1/ML 0.06G-1.5 0.06G-1.5 0.5MG-10MG 0.03 G-0.5 6G-160/36G 0.03 G-0.6 2 G-80/17G 6 G-170/38 0.03 G-0.6 0.03G-1/ML 0.04G-1.5 0.06G-1.5 0.03G-1/ML 0.03G-1/ML 0.04G-1.5 2 G-80/17G 0.03G-1/ML 0.03G-1/ML 0.03G-1/ML 0.03G-1/ML 0.03G-1/ML 227.1-21.5 227.1-21.5 236-22.74G 240-22.72G 250 UNIT/1 750/ML 6MG/0.6ML 135MCG/0.5 180MCG/0.5 180MCG/0.5 180MCG/ML 120MCG/0.5 150MCG/0.5 NOTE APPENDIX A PAGE 102 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION PEGINTERFERON ALFA-2B PEGINTERFERON ALFA-2B PEGINTERFERON ALFA-2B PEGINTERFERON ALFA-2B PEGINTERFERON ALFA-2B PEGINTERFERON ALFA-2B PEGINTERFERON ALFA-2B PEGINTERFERON ALFA-2B PEGINTERFERON ALFA-2B PEGINTERFERON BETA-1A PEGVISOMANT PEGVISOMANT PEGVISOMANT PEG3350/SOD SUL/NACL/ASB/C/KCL PEMBROLIZUMAB PEMETREXED DISODIUM PEMETREXED DISODIUM PEN G BENZ/PEN G PROCAINE PEN G BENZ/PEN G PROCAINE PEN G POT/DEXTROSE-WATER PEN G POT/DEXTROSE-WATER PENBUTOLOL SULFATE PENCICLOVIR PENICILLAMINE PENICILLAMINE PENICILLIN G BENZATHINE PENICILLIN G BENZATHINE PENICILLIN G BENZATHINE PENICILLIN G POTASSIUM PENICILLIN G POTASSIUM PENICILLIN G PROCAINE PENICILLIN G PROCAINE PENICILLIN G SODIUM PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM PENTAMIDINE ISETHIONATE PENTAMIDINE ISETHIONATE PENTAZOCINE HCL/NALOXONE HCL PENTAZOCINE LACTATE PENTOSAN POLYSULFATE SODIUM PENTOXIFYLLINE PEPTAMEN AF UNFLAVORED - 250ML PEPTAMEN JUNIOR CHOC - 250ML PEPTAMEN JUNIOR STRAWBERRY - 2 DOSAGE KIT KIT KIT KIT KIT PEN IJ KIT PEN IJ KIT PEN IJ KIT PEN IJ KIT PEN INJCTR VIAL VIAL VIAL POWD PACK VIAL VIAL VIAL SYRINGE SYRINGE FROZ.PIGGY FROZ.PIGGY TABLET CREAM (G) CAPSULE TABLET SYRINGE SYRINGE SYRINGE VIAL VIAL SYRINGE SYRINGE VIAL SOLN RECON SOLN RECON TABLET TABLET VIAL VIAL-NEB TABLET AMPUL CAPSULE TABLET ER UNIT UNIT UNIT STRENGTH 200 MCG 300 MCG 50 MCG/0.5 600 MCG 80MCG/0.5 120MCG/0.5 150MCG/0.5 50 MCG/0.5 80MCG/0.5 125MCG/0.5 10 MG 15 MG 20 MG 7.5-2.691G 50 MG 100 MG 500 MG 1.2MM/2 ML 900-300/2 2MM/50ML 3MM/50ML 20 MG 1 % 250 MG 250 MG 1.2MM/2 ML 2.4MM/4ML 600000/ML 20MM UNIT 5MM UNIT 1.2MM/2 ML 600000/ML 5MM UNIT 125 MG/5ML 250 MG/5ML 250 MG 500 MG 300 MG 300 MG 50MG-0.5MG 30 MG/ML 100 MG 400 MG 0.0756-1.2 0.03G-1/ML 0.03G-1/ML NOTE APPENDIX A PAGE 103 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION PEPTAMEN JUNIOR UNFLAVORED - 2 PEPTAMEN JUNIOR VANILLA - 250M PEPTAMEN OS CREAMY VANILLA - 8 PEPTAMEN OS RICH CHOC - 8 OZ B PEPTAMEN OS 1.5 VANILLA-8 OZ B PEPTAMEN UNFLAVORED - 250ML CA PEPTAMEN VANILLA - 250ML CAN PEPTAMEN VANILLA W/PREBIO - 25 PEPTAMEN 1.5 UNFLAVORED-250ML PEPTAMEN 1.5 VANILLA-250ML CAN PEPTAMIN JUNIOR VANILLA W/FIBE PEPTAMIN JUNIOR VANILLA W/PREB PEPTAMIN JUNIOR 1.5 UNFLAVORED PEPTINEX 1.0 - 8 OZ CAN - 24/C PEPTINEX 1.5 - 8 OZ CAN - 24/C PERAMPANEL PERAMPANEL PERAMPANEL PERAMPANEL PERATIVE UNFLAVORED - 8 OZ CAN PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE PERMETHRIN PERPHENAZINE PERPHENAZINE PERPHENAZINE PERPHENAZINE PERPHENAZINE/AMITRIPTYLINE HCL PERPHENAZINE/AMITRIPTYLINE HCL PERPHENAZINE/AMITRIPTYLINE HCL PERPHENAZINE/AMITRIPTYLINE HCL PERPHENAZINE/AMITRIPTYLINE HCL PERTUZUMAB PHENAZOPYRIDINE HCL PHENAZOPYRIDINE HCL PHENELZINE SULFATE PHENOBARBITAL PHENOBARBITAL PHENOBARBITAL PHENOBARBITAL PHENOBARBITAL PHENOBARBITAL PHENOBARBITAL PHENOBARBITAL PHENOBARBITAL DOSAGE UNIT UNIT UNIT UNIT BRIK/CAN UNIT UNIT UNIT CAN CAN UNIT UNIT UNIT UNIT UNIT TABLET TABLET TABLET TABLET UNIT TABLET TABLET TABLET CREAM (G) TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET VIAL TABLET TABLET TABLET ELIXIR TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET STRENGTH 0.03G-1/ML 0.03G-1/ML 2 MG 4 MG 6 MG 8 MG 0.067G-1.3 2 MG 4 MG 8 MG 5 % 16 MG 2 MG 4 MG 8 MG 2 MG-10 MG 2 MG-25 MG 4 MG-25 MG 4MG-10MG 4MG-50MG 420MG/14ML 100 MG 200 MG 15 MG 20 MG/5 ML 100 MG 15 MG 16.2 MG 30 MG 32.4 MG 60 MG 64.8 MG 97.2MG NOTE APPENDIX A PAGE 104 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION PHENOBARBITAL SODIUM PHENOBARBITAL SODIUM PHENYLALANINE PHENYLALANINE PHENYLALANINE PHENYLEPHRINE HCL PHENYLEPHRINE HCL PHENYLEPHRINE HCL PHENYLEPHRINE/DP-HYDRAM TAN PHENYTOIN PHENYTOIN PHENYTOIN PHENYTOIN SODIUM PHENYTOIN SODIUM PHENYTOIN SODIUM EXTENDED PHENYTOIN SODIUM EXTENDED PHENYTOIN SODIUM EXTENDED PHENYTOIN SODIUM EXTENDED PHOSPHORUS #1 PHOSPSERIN/OMEGA-3/DHA/EPA PHOSPSERIN/OMEGA-3/DHA/EPA PHYSIOLOGICAL IRRIG SOL CMB #1 PHYTONADIONE PHYTONADIONE PHYTONADIONE PHYTOSTEROL PHYTOSTEROL/OM-3/DHA/EPA/FISH PHYTOSTEROL/VIT D3/ FISH OIL PILOCARPINE HCL PILOCARPINE HCL PILOCARPINE HCL PILOCARPINE HCL PILOCARPINE HCL PIMECROLIMUS PIMOZIDE PIMOZIDE PINDOLOL PINDOLOL PIOGLITAZONE HCL PIOGLITAZONE HCL PIOGLITAZONE HCL PIOGLITAZONE HCL/GLIMEPIRIDE PIOGLITAZONE HCL/GLIMEPIRIDE PIOGLITAZONE HCL/METFORMIN HCL PIOGLITAZONE HCL/METFORMIN HCL PIOGLITAZONE HCL/METFORMIN HCL DOSAGE VIAL VIAL CAPSULE POWD PACK TABLET DROPS DROPS VIAL TAB CHEW ORAL SUSP ORAL SUSP TAB CHEW AMPUL VIAL CAPSULE CAPSULE CAPSULE CAPSULE TABLET CAPSULE CAPSULE IRRIG SOLN AMPUL AMPUL TABLET TABLET CAPSULE CAPSULE DROPS DROPS DROPS TABLET TABLET CREAM (G) TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TBMP 24HR STRENGTH 130MG/ML 65 MG/ML 600 MG 50 MG 500 MG 10 % 2.5 % 10 MG/ML 5MG-12.5MG 100 MG/4ML 125 MG/5ML 50 MG 50 MG/ML 50 MG/ML 100 MG 200 MG 30 MG 300 MG 250 MG 100-19.5MG 75MG-8.5MG 140-5-3-98 1MG/0.5ML 10 MG/ML 5 MG 400 MG 0.63-232.5 650MG-400 1 % 2 % 4 % 5 MG 7.5 MG 1 % 1 MG 2 MG 10 MG 5 MG 15 MG 30 MG 45 MG 30 MG-2 MG 30 MG-4 MG 15MG-500MG 15MG-850MG 15-1000 MG NOTE APPENDIX A PAGE 105 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION PIOGLITAZONE HCL/METFORMIN HCL PIPERACILLIN SODIUM/TAZOBACTAM PIPERACILLIN SODIUM/TAZOBACTAM PIPERACILLIN SODIUM/TAZOBACTAM PIPERACILLIN SODIUM/TAZOBACTAM PIPERACILLIN SODIUM/TAZOBACTAM PIPERACILLIN SODIUM/TAZOBACTAM PIPERACILLIN SODIUM/TAZOBACTAM PIPERACILLIN-TAZO-DEXTROSE,ISO PIPERACILLIN-TAZO-DEXTROSE,ISO PIPERACILLIN-TAZO-DEXTROSE,ISO PIROXICAM PIROXICAM PITAVASTATIN CALCIUM PITAVASTATIN CALCIUM PITAVASTATIN CALCIUM PIVOT UNFLAVORED 1.5 CAL- 8 OZ PLERIXAFOR PN W-CA64/IRON CB&GL/FA/DSS/DH PNV #14/FERROUS FUM/FOLIC ACID PNV #35/IRON/FA #6/DHA PNV #56/IRON CARB&ASPG/FA/DHA PNV #78/IRON ASP GLY/FA#1/DHA PNV #8/IRON PS CMP&ASPG/FA/DHA PNV #87/IRON BISGLY/FA/DHA PNV COMB NO.3/IRON FUM&GLUC/FA PNV COMBO #19/IRON/FOL AC/DHA PNV COMBO #22/IRON/FA/OM3/DHA PNV COMBO#47/IRON/FA #1/DHA PNV NO.118/IRON FUMARATE/FA PNV NO.15/IRON FUM & PS CMP/FA PNV NO.22/IRON CBN&GLUC/FA/DSS PNV NO.23-IRON PS COMPLEX-FA PNV NO.66/IRON,CARBONYL/FA/DHA PNV W-CA #40/IRON FUM/FA CMB#1 PNV W-O IRON/FA/CALCIUM/B6/B12 PNV WITH CA #68/IRON/FA#1/DHA PNV WITH CA NO.65/IRON POLY/FA PNV WITH CA,NO.70/IRON/FA/DHA PNV WITH CA,NO.71/IRON/FA PNV WITH CA,NO.72/IRON/FA PNV WITH CA,NO63/IRON/FA/B6 PNV 11-IRON FUM-FOLIC ACID-OM3 PNV 18/FE,CARB/FA/DSS/UBI/DHA PNV/FERROUS FUMARATE/FA/SE PNV/IRON,CARBONYL/DOCUSATE/FA DOSAGE TBMP 24HR VIAL VIAL VIAL VIAL VIAL PORT VIAL PORT VIAL PORT FROZ.PIGGY FROZ.PIGGY FROZ.PIGGY CAPSULE CAPSULE TABLET TABLET TABLET CAN VIAL COMBO. PKG TAB CHEW CAPSULE CAPSULE CAPSULE COMBO. PKG COMBO. PKG TABLET CAPSULE COMBO. PKG CAPSULE TAB CHEW CAPSULE TABLET CAPSULE CAPSULE TABLET TBMP 24HR CAPSULE CAPSULE CAPSULE TABLET TABLET TABLET SEQ CAPSULE TABLET TABLET TABLET STRENGTH 30-1000 MG 2.25 G 3.375 G 4.5 G 40.5 G 2.25 G 3.375 G 4.5 G 2.25G/50ML 3.375G/50 4.5G/100ML 10 MG 20 MG 1 MG 2 MG 4 MG 24MG/1.2ML 90-1-300MG 29 MG-1 MG 29-1-300MG 35-5-1 MG 18-1-300MG 22-6-1-200 32-1-230MG 20MG-0.8MG 22-6-1-200 28-6-1-203 27-1-300MG 29 MG-1 MG 85 MG-1 MG 27-1-50 MG 155 MG-1MG 20-1-320MG 27 MG-1 MG 1-200-75 28-1-300MG 60 MG-1 MG 28-1-250MG 27 MG-1 MG 27 MG-1 MG 20-1-25 MG 28-1-200MG 15-0.5-25 27 MG-1 MG 90-50-1MG NOTE APPENDIX A PAGE 106 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION PNV#16/IRON FUM & PS/FA/OM-3 PNV#20/IRON/FA/DS/FISH/DHA/EPA PNV#26/IRON POLY/FA/DHA PNV#67/IRON PS/FA CMB#1/DHA PNV#79/IRON/FA/LMFOLATE CA/DHA PNV119/IRON FUMARATE/FA/DSS PNV17/IRON/FA/FISH OIL/DHA/OM PNV2/IRON B-G SUC-P/FA/OMEGA-3 PNV22/IRON CBN&GLUC/FA/DSS/DHA PNV34/IRON,CARBONYL/FA/DSS/DHA PNV38/IRON CBN&GLUC/FA/DSS/DHA PNV39/IRON FUMARATE/FA/DSS/DHA PNV53/IRON FUM/FA/DOCUSATE/DHA PNV59/IRON,CARB&FUM/FA/DSS/DHA PNV59/IRON,CARBONYL/FA/DSS/DHA PNV66/IRON FUMARATE/FA/DSS/DHA PNV66/IRON FUMARATE/FA/DSS/DHA PNV69/IRON,CARBONYL/FA/DSS/DHA PNV69/IRON,CARBONYL/FA/DSS/DHA PNV72/IRON,CARB&GLU/FA/DSS/DHA PNV73/IRON,CARB&GLU/FA/DSS/DHA PNV76/IRON,CARB&GLU/FA/DSS/DHA PNV80/IRON FUMARATE/FA/DSS/DHA PNV81/SOD IRON EDTA& PS/FA/OM3 PNV83/IRON,CARB/IRON ASP GL/FA PN85/IRON CB&ASP G/FA/DHA/FISH PODOFILOX PODOFILOX PODOPHYLLUM RESIN POLYCOSE POWDER UNFLAVORED - 1 POLYETHYLENE GLYCOL 3350 POLYETHYLENE GLYCOL 3350 POLYMYXIN B SULF/TRIMETHOPRIM POLYMYXIN B SULFATE POLYPODIUM LEUCOTOMOS EXTRACT POMALIDOMIDE POMALIDOMIDE POMALIDOMIDE POMALIDOMIDE PORACTANT ALFA PORTAGEN - 1 LB CAN - 6/CASE POSACONAZOLE POSACONAZOLE POT CHLORIDE/POT BICARB/CIT AC POTASSIUM ACETATE POTASSIUM BICARBONATE/CIT AC DOSAGE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE TABLET CAPSULE COMBO. PKG COMBO. PKG CAPSULE COMBO. PKG CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE COMBO. PKG COMBO. PKG COMBO. PKG CAPSULE CMBPKGDRCP TABLET CAPSULE GEL (GRAM) SOLUTION LIQUID CAN POWD PACK POWDER DROPS VIAL CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE VIAL CAN ORAL SUSP TABLET DR TABLET EFF VIAL TABLET EFF STRENGTH 35-1-200MG 27-1-500MG 29-1-200MG 29-1-200MG 27-1.13 MG 29-1-25 MG 35-5-1.2MG 29-1-250MG 27-1-50 MG 30-1-50 MG 35-1-50 MG 30-1.2-55 29-1.25-55 27-1-50 MG 29-1-50 MG 26-1.2-55 27-1.25-55 27-1-50 MG 28-1-50 MG 90-1-300MG 35-1-50 MG 27-1-50 MG 29-1.25-55 27-1-430MG 30-20-1 MG 40-10-1 MG 0.5 % 0.5 % 25 % 380/100 G 17G 17G/DOSE 10000-1/ML 500K UNIT 240 MG 1 MG 2 MG 3 MG 4 MG 240 MG/3ML 200 MG/5ML 100 MG 25 MEQ 2 MEQ/ML 25 MEQ NOTE APPENDIX A PAGE 107 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE POTASSIUM CHLORIDE IN LR-D5 POTASSIUM CHLORIDE IN 0.9%NACL POTASSIUM CHLORIDE IN 0.9%NACL POTASSIUM CHLORIDE-0.45% NACL POTASSIUM CHLORIDE/D5-0.2%NACL POTASSIUM CHLORIDE/D5-0.45NACL POTASSIUM CHLORIDE/D5-0.45NACL POTASSIUM CHLORIDE/D5-0.45NACL POTASSIUM CHLORIDE/D5-0.45NACL POTASSIUM CHLORIDE/D5-0.9%NACL POTASSIUM CITRATE POTASSIUM CITRATE POTASSIUM CITRATE POTASSIUM CITRATE/CITRIC ACID POTASSIUM CITRATE/CITRIC ACID POTASSIUM IODIDE POTASSIUM PHOS,M-BASIC-D-BASIC POTASSIUM PHOSPHATE,MONOBASIC PRALATREXATE PRALATREXATE PRAMIPEXOLE DI-HCL PRAMIPEXOLE DI-HCL PRAMIPEXOLE DI-HCL PRAMIPEXOLE DI-HCL PRAMIPEXOLE DI-HCL PRAMIPEXOLE DI-HCL PRAMIPEXOLE DI-HCL PRAMIPEXOLE DI-HCL DOSAGE CAPSULE ER CAPSULE ER IV SOLN LIQUID LIQUID PACKET PACKET PIGGYBACK PIGGYBACK PIGGYBACK PIGGYBACK TAB ER PRT TAB ER PRT TAB ER PRT TABLET ER TABLET ER TABLET ER VIAL IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN IV SOLN TABLET ER TABLET ER TABLET ER PACKET SOLUTION SOLUTION VIAL TABLET SOL VIAL VIAL TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TABLET STRENGTH 10 MEQ 8 MEQ 2 MEQ/ML 20MEQ/15ML 40MEQ/15ML 20 MEQ 25 MEQ 10MEQ/0.1L 20MEQ/0.1L 20MEQ/50ML 40MEQ/0.1L 10 MEQ 15 MEQ 20 MEQ 10 MEQ 20 MEQ 8 MEQ 2 MEQ/ML 20 MEQ/L 20 MEQ/L 40 MEQ/L 20 MEQ/L 20 MEQ/L 10 MEQ/L 20 MEQ/L 30 MEQ/L 40 MEQ/L 40 MEQ/L 10 MEQ 15 MEQ 5 MEQ 3300-1002 1100-334/5 1 G/ML 3MMOL/ML 500 MG 20MG/ML(1) 40 MG/2 ML 0.375 MG 0.75 MG 1.5 MG 2.25 MG 3 MG 3.75 MG 4.5 MG 0.125 MG NOTE APPENDIX A PAGE 108 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 109 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION PRAMIPEXOLE DI-HCL PRAMIPEXOLE DI-HCL PRAMIPEXOLE DI-HCL PRAMIPEXOLE DI-HCL PRAMIPEXOLE DI-HCL PRAMLINTIDE ACETATE PRAST (DHEA)/VIT BCOMP&C/HC134 PRASTERONE (DHEA)/CALCIUM CARB PRASTERONE (DHEA)/CALCIUM CARB PRASTERONE (DHEA)/CALCIUM CARB PRASUGREL HCL PRASUGREL HCL PRAVASTATIN SODIUM PRAVASTATIN SODIUM PRAVASTATIN SODIUM PRAVASTATIN SODIUM PRAZIQUANTEL PRAZOSIN HCL PRAZOSIN HCL PRAZOSIN HCL PREDNICARBATE PREDNICARBATE PREDNISOLONE PREDNISOLONE PREDNISOLONE PREDNISOLONE ACETATE PREDNISOLONE ACETATE PREDNISOLONE ACETATE PREDNISOLONE ACETATE PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SOD PHOSPHATE PREDNISONE PREDNISONE PREDNISONE PREDNISONE PREDNISONE PREDNISONE PREDNISONE PREDNISONE DOSAGE TABLET TABLET TABLET TABLET TABLET PEN INJCTR CAPSULE TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE CREAM (G) OINT. (G) SOLUTION TAB DS PK TABLET DROPS SUSP DROPS SUSP DROPS SUSP ORAL SUSP DROPS SOLUTION SOLUTION SOLUTION SOLUTION SOLUTION TAB RAPDIS TAB RAPDIS TAB RAPDIS ORAL CONC SOLUTION TAB DS PK TAB DS PK TABLET TABLET TABLET TABLET STRENGTH 0.25 MG 0.5 MG 0.75 MG 1 MG 1.5 MG 2700/2.7ML 83.25-91.4 10 MG-47MG 25-52MG 50 MG-60MG 10 MG 5 MG 10 MG 20 MG 40 MG 80 MG 600 MG 1 MG 2 MG 5 MG 0.1 % 0.1 % 15 MG/5 ML 5 MG (21) 5 MG 0.12 % 1 % 1 % 15 MG/5 ML 1 % 10 MG/5 ML 15 MG/5 ML 20 MG/5 ML 25 MG/5 ML 5 MG/5 ML 10 MG 15 MG 30 MG 5 MG/ML 5 MG/5 ML 10 MG 5 MG 1 MG 10 MG 10 MG 2.5 MG NOTE SEE PACS MIXED F NOT DS PK 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION PREDNISONE PREDNISONE PREDNISONE PREGABALIN PREGABALIN PREGABALIN PREGABALIN PREGABALIN PREGABALIN PREGABALIN PREGABALIN PREGABALIN PREGESTIMIL POWDER - 1 LB CAN PREGESTIMIL 20 CAL RTF 2 OZ BO PREGESTIMIL 24 CAL RTF 2 OZ BO PRENAT VIT COMB.10/IRON/FA/DHA PRENATAL #103/IRON FUMARATE/FA PRENATAL #48/IRON CB&GLU/FA/B6 PRENATAL #57/IRON/FA/DSS/DHA PRENATAL NO.13/IRON PS/FA CB#1 PRENATAL NO.75/IRON/FOLATE #1 PRENATAL VIT COMB.10/IRON/FA PRENATAL VIT NO.109/IRON/FA PRENATAL VIT NO.112/FOLIC ACID PRENATAL VIT NO.114/FA/GINGER PRENATAL VIT NO.44/IRON/FA/DHA PRENATAL VIT NO.73/IRON/FA PRENATAL VIT NO.87/IRON/FA/DHA PRENATAL VIT 16/IRON CB/FA/DSS PRENATAL VIT 18/IRON CB/FA/DSS PRENATAL VIT/IRON BISGLYCIN/FA PRENATAL VIT/IRON FUMARATE/FA PRENATAL VIT/IRON FUMARATE/FA PRENATAL VIT#65/IRON FUM&PS/FA PRENATAL VIT#86/IRON BISGLY/FA PRENATAL VITAMINS#21, IRON, FA PRENATAL VITS #33/IRON/FA/DHA PRENATAL VIT27&CALCIUM/IRON/FA PRENATAL VIT37/IRON/FOLIC ACID PRIMAQUINE PHOSPHATE PRIMIDONE PRIMIDONE PRO-PHREE 14.1 OZ CAN-6 CAN/CA PROBENECID PROCAINAMIDE HCL PROCAINAMIDE HCL DOSAGE TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE SOLUTION CAN BOTTLE BOTTLE COMBO. PKG TABLET TABLET SEQ CAPSULE TAB CHEW TABLET TABLET TAB CHEW TAB CHEW TABLET CAPSULE TABLET CAPSULE TABLET TABLET TABLET TABLET TABLET CAPSULE TABLET TABLET COMBO. PKG TABLET TAB CHEW TABLET TABLET TABLET CAN TABLET VIAL VIAL STRENGTH 20 MG 5 MG 50 MG 100 MG 150 MG 200 MG 225 MG 25 MG 300 MG 50 MG 75 MG 20 MG/ML 65-1-250MG 27 MG-1 MG 20-1-25 MG 29-1.25-55 29 MG-1 MG 18 MG-1 MG 65 MG-1 MG 40-1MG 1 MG 1MG-500MG 29-1-350MG 28 MG-1 MG 18-1-350MG 90-1-50 MG 90-1-50 MG 29 MG-1 MG 15-1MG 66-1MG 40-1.25 MG 32 MG-1 MG 28-6-1 MG 29-1-250MG 60 MG-1 MG 29 MG-1 MG 26.3 MG 250 MG 50 MG 500 MG 100 MG/ML 500 MG/ML NOTE APPENDIX A PAGE 110 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION PROCARBAZINE HCL PROCEL PROTEIN POWDER - 10 OZ PROCEL PROTEIN POWDER - 30 SER PROCHLORPERAZINE EDISYLATE PROCHLORPERAZINE MALEATE PROCHLORPERAZINE MALEATE PROCHLORPERAZINE MALEATE PROCYAN OLIG/UBI/VIT A/HB#155 PROGESTERONE PROGESTERONE PROGESTERONE PROGESTERONE PROGESTERONE PROGESTERONE PROGESTERONE,MICRONIZED PROGESTERONE,MICRONIZED PROMETHAZINE HCL PROMETHAZINE HCL PROMETHAZINE HCL PROMETHAZINE HCL PROMETHAZINE HCL PROMETHAZINE HCL PROMETHAZINE HCL PROMETHAZINE HCL PROMETHAZINE HCL PROMETHAZINE HCL PROMETHAZINE HCL PROMOD FRUIT PUNCH - 32 OZ BOT PROMOTE VANILLA - 8 OZ CAN PROMOTE VANILLA W/FIBER - 8 OZ PROMOTE VANILLA W/FIBER RTH PROPAFENONE HCL PROPAFENONE HCL PROPAFENONE HCL PROPAFENONE HCL PROPAFENONE HCL PROPAFENONE HCL PROPANTHELINE BROMIDE PROPARACAINE HCL PROPRANOLOL HCL PROPRANOLOL HCL PROPRANOLOL HCL PROPRANOLOL HCL PROPRANOLOL HCL PROPRANOLOL HCL PROPRANOLOL HCL DOSAGE CAPSULE UNIT UNIT VIAL SUPP.RECT TABLET TABLET TABLET SUPP.VAG SUPP.VAG SUPP.VAG SUPP.VAG SUPP.VAG VIAL CAPSULE CAPSULE AMPUL AMPUL SUPP.RECT SUPP.RECT SUPP.RECT SYRUP TABLET TABLET TABLET VIAL VIAL UNIT UNIT UNIT UNIT CAP ER 12H CAP ER 12H CAP ER 12H TABLET TABLET TABLET TABLET DROPS CAP ER 24H CAP ER 24H CAP SA 24H CAP SA 24H CAP SA 24H CAP SA 24H SOLUTION STRENGTH 50 MG 10 MG/2 ML 25 MG 10 MG 5 MG 8 MG-3 MG 100 MG 200 MG 25 MG 400 MG 50 MG 50 MG/ML 100 MG 200 MG 25 MG/ML 50 MG/ML 12.5 MG 25 MG 50 MG 6.25MG/5ML 12.5 MG 25 MG 50 MG 25 MG/ML 50 MG/ML 225 MG 325 MG 425 MG 150 MG 225 MG 300 MG 15 MG 0.5 % 120 MG 80 MG 120 MG 160 MG 60 MG 80 MG 20 MG/5 ML NOTE APPENDIX A PAGE 111 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION PROPRANOLOL HCL PROPRANOLOL HCL PROPRANOLOL HCL PROPRANOLOL HCL PROPRANOLOL HCL PROPRANOLOL HCL PROPRANOLOL HCL PROPRANOLOL/HYDROCHLOROTHIAZID PROPRANOLOL/HYDROCHLOROTHIAZID PROPYLTHIOURACIL PROTAMINE SULFATE PROTEIN HYDROLYSATE,MILK PROTEIN HYDROLYSATE,MILK PROTEIN SUPP/AMINO ACIDS/MIN PROTEIN SUPPLEMENT PROTEIN SUPPLEMENT PROTEIN SUPPLEMENT PROTEIN SUPPLEMENT PROTEIN SUPPLEMENT PROTEIN SUPPLEMENT PROTEIN SUPPLEMENT PROTEIN SUPPLEMENT/COPPER PROTEIN SUPPLEMENT/SELENIUM PROTEINEX LIQUID 16 OZ BTL PROTRIPTYLINE HCL PROTRIPTYLINE HCL PSEUDOEPHEDRINE HCL/CHLOR-MAL PSYLLIUM HUSK PSYLLIUM HUSK/SUCROSE PSYLLIUM SEED PSYLLIUM SEED PSYLLIUM SEED PSYLLIUM SEED/ASPARTAME PSYLLIUM SEED/DEXTROSE PSYLLIUM SEED/DEXTROSE PSYLLIUM SEED/SUCROSE PSYLLIUM SEED/SUCROSE PSYLLIUM/MV CMB 12/GING/CIT AC PULMOCARE VANILLA - 8 OZ CAN PULMOCARE VANILLA RTH - 1000ML PURAMINO DHA & ARA - 14.1 OZ C PV W-O CAL/FERROUS FUMARATE/FA PV W-O VIT A/FE FUMARATE/FA PYCNOGN/GRPSDXT/GKBLFXT/GRTLFX PYRAZINAMIDE PYRIDOSTIGMINE BROMIDE DOSAGE SOLUTION TABLET TABLET TABLET TABLET TABLET VIAL TABLET TABLET TABLET VIAL LIQUID POWDER POWDER LIQUID LIQUID LIQUID PACKET POWDER TABLET TABLET TABLET TABLET UNIT TABLET TABLET LIQUID CAPSULE POWDER PACKET POWDER POWDER POWDER POWDER POWDER POWDER WAFER POWDER UNIT UNIT CAN TABLET TABLET TABLET TABLET SYRUP STRENGTH 40MG/5ML 10 MG 20 MG 40 MG 60 MG 80 MG 1 MG/ML 40 MG-25MG 80 MG-25MG 50 MG 10 MG/ML 1G-4KCAL/6 75G-390 7G 15 G-60/30 16 G-60/70 975 MG 15 G-60/30 10 MG 5 MG 30-2MG/5ML 0.52G 3.4 G/7 G 3.4G/5.8G 3.4 G/7 G 30MG-72MG 27 MG-1 MG 40-1MG 10-50-20MG 500 MG 60 MG/5 ML NOTE APPENDIX A PAGE 112 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMINE BROMIDE PYRIDOXINE HCL PYRIMETHAMINE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUETIAPINE FUMARATE QUINAPRIL HCL QUINAPRIL HCL QUINAPRIL HCL QUINAPRIL HCL QUINAPRIL/HYDROCHLOROTHIAZIDE QUINAPRIL/HYDROCHLOROTHIAZIDE QUINAPRIL/HYDROCHLOROTHIAZIDE QUINIDINE GLUCONATE QUINIDINE SULFATE QUINIDINE SULFATE QUINIDINE SULFATE QUININE SULFATE QUINUPRISTIN/DALFOPRISTIN RABEPRAZOLE SODIUM RABIES IMMUNE GLOBULIN/PF RABIES VACC, HUMAN DIPLOID/PF RABIES VACCINE (PCEC)/PF RACEPINEPHRINE HCL RALOXIFENE HCL RALTEGRAVIR POTASSIUM RALTEGRAVIR POTASSIUM RALTEGRAVIR POTASSIUM RAMELTEON RAMIPRIL RAMIPRIL RAMIPRIL RAMIPRIL RANIBIZUMAB RANITIDINE HCL RANITIDINE HCL RANITIDINE HCL DOSAGE TABLET TABLET ER VIAL TABLET TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET ER TABLET TABLET TABLET ER CAPSULE VIAL TABLET DR VIAL VIAL VIAL VIAL-NEB TABLET TAB CHEW TAB CHEW TABLET TABLET CAPSULE CAPSULE CAPSULE CAPSULE VIAL CAPSULE CAPSULE SYRUP STRENGTH 60 MG 180 MG 100 MG/ML 25 MG 150 MG 200 MG 300 MG 400 MG 50 MG 100 MG 200 MG 25 MG 300 MG 400 MG 50 MG 10 MG 20 MG 40 MG 5 MG 10-12.5MG 20-12.5 MG 20-25MG 324 MG 200 MG 300 MG 300 MG 324 MG 500 MG 20 MG 150 UNIT/1 2.5 UNIT 2.5 UNIT 2.25% 60 MG 100 MG 25 MG 400 MG 8 MG 1.25 MG 10 MG 2.5 MG 5 MG 0.5MG/0.05 150 MG 300 MG 15 MG/ML NOTE APPENDIX A PAGE 113 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION RANITIDINE HCL RANITIDINE HCL RANITIDINE HCL RANITIDINE HCL RANOLAZINE RANOLAZINE RASAGILINE MESYLATE RASAGILINE MESYLATE RCF SOY FORMULA CONC CARB FREE REGORAFENIB REMIFENTANIL HCL REMIFENTANIL HCL REMIFENTANIL HCL RENA START 100 GM PACKETS-10 P RENALCAL UNFLAVORED - 250ML CA REPAGLINIDE REPAGLINIDE REPAGLINIDE REPAGLINIDE/METFORMIN HCL REPAGLINIDE/METFORMIN HCL REPLETE FIBER SPIKERIGHT PLUS REPLETE FIBER VANILLA 250 ML REPLETE SPIKERIGHT PLUS ULTRA REPLETE SPIKERIGHT PLUS ULTRAP REPLETE VANILLA 250 ML RESERPINE RESERPINE RESOURCE BENEFIBER UNFLAVORED RESOURCE BENEFIBER UNFLAVORED RESOURCE BREEZE ORANGE - 8 OZ RESOURCE BREEZE PEACH - 8 OZ B RESOURCE BREEZE VARIETY - 8 OZ RESOURCE BREEZE WILDBERRY - 8 RESOURCE DIABETISHIELD MIXED B RESOURCE DIABETISHIELD ORANGE RESOURCE VANILLA 2.0 - 32 OZ B RESOURCE VANILLA 2.0 - 8 OZ BR RESVER/WINE/BFL/GRPSD/PC/C/GRP RESVER/WINE/BFL/GRPSD/PC/C/POM RESVERATROL/QUERCETIN RETAPAMULIN RHO(D) IMMUNE GLOBULIN RIBAVIRIN RIBAVIRIN RIBAVIRIN RIBAVIRIN DOSAGE TABLET TABLET VIAL VIAL TAB ER 12H TAB ER 12H TABLET TABLET CAN TABLET VIAL VIAL VIAL UNIT UNIT TABLET TABLET TABLET TABLET TABLET UNIT UNIT UNIT UNIT UNIT TABLET TABLET CAN PACKET BRIK BRIK BRIK BRIK UNIT UNIT UNIT UNIT CAPSULE CAPSULE TABLET OINT. (G) SYRINGE CAPSULE SOLUTION TAB DS PK TAB DS PK STRENGTH 150 MG 300 MG 25 MG/ML 50 MG/2 ML 1000 MG 500 MG 0.5 MG 1 MG 40 MG 1 MG 2 MG 5 MG 7.5 G-494 0.14G-2 0.5 MG 1 MG 2 MG 1MG-500MG 2 MG-500MG 0.1 MG 0.25 MG 3G-2.7-60 3G-2.7-60 200MG-60MG 200MG-60MG 100-100 MG 1 % 1500 UNIT 200 MG 40 MG/ML 400-400 MG 400-400(7) NOTE APPENDIX A PAGE 114 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION RIBAVIRIN RIBAVIRIN RIBAVIRIN RIBAVIRIN RIBAVIRIN RIBAVIRIN RIFABUTIN RIFAMP/ISONIAZID/PYRAZINAMIDE RIFAMPIN RIFAMPIN RIFAMPIN RIFAMPIN/ISONIAZID RIFAPENTINE RIFAXIMIN RIFAXIMIN RILPIVIRINE HCL RILUZOLE RIMABOTULINUMTOXINB RIMABOTULINUMTOXINB RIMABOTULINUMTOXINB RIMANTADINE HCL RIMEXOLONE RINGERS SOLUTION RINGERS SOLUTION RINGERS SOLUTION,LACTATED RINGERS SOLUTION,LACTATED RIOCIGUAT RIOCIGUAT RIOCIGUAT RIOCIGUAT RIOCIGUAT RISEDRONATE SODIUM RISEDRONATE SODIUM RISEDRONATE SODIUM RISEDRONATE SODIUM RISEDRONATE SODIUM RISPERIDONE RISPERIDONE RISPERIDONE RISPERIDONE RISPERIDONE RISPERIDONE RISPERIDONE RISPERIDONE RISPERIDONE RISPERIDONE DOSAGE TAB DS PK TAB DS PK TAB DS PK TAB DS PK TABLET VIAL-NEB CAPSULE TABLET CAPSULE CAPSULE VIAL CAPSULE TABLET TABLET TABLET TABLET TABLET VIAL VIAL VIAL TABLET DROPS SUSP IRRIG SOLN IV SOLN IRRIG SOLN IV SOLN TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET DR SOLUTION TAB RAPDIS TAB RAPDIS TAB RAPDIS TAB RAPDIS TAB RAPDIS TAB RAPDIS TABLET TABLET TABLET STRENGTH 600-400 MG 600-400(7) 600-600 MG 600-600(7) 200 MG 6G 150 MG 120-50-300 150 MG 300 MG 600 MG 300-150 MG 150 MG 200 MG 550 MG 25 MG 50 MG 10000/2ML 2500/0.5ML 5000/ML 100 MG 1 % 0.5 MG 1 MG 1.5 MG 2 MG 2.5 MG 150 MG 30 MG 35 MG 5 MG 35 MG 1 MG/ML 0.25 MG 0.5 MG 1 MG 2 MG 3 MG 4 MG 0.25 MG 0.5 MG 1 MG NOTE APPENDIX A PAGE 115 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION RISPERIDONE RISPERIDONE RISPERIDONE RISPERIDONE MICROSPHERES RISPERIDONE MICROSPHERES RISPERIDONE MICROSPHERES RISPERIDONE MICROSPHERES RITONAVIR RITONAVIR RITONAVIR RITUXIMAB RIVAROXABAN RIVAROXABAN RIVAROXABAN RIVASTIGMINE RIVASTIGMINE RIVASTIGMINE RIVASTIGMINE TARTRATE RIVASTIGMINE TARTRATE RIVASTIGMINE TARTRATE RIVASTIGMINE TARTRATE RIZATRIPTAN BENZOATE RIZATRIPTAN BENZOATE RIZATRIPTAN BENZOATE RIZATRIPTAN BENZOATE ROFLUMILAST ROMIPLOSTIM ROMIPLOSTIM ROPINIROLE HCL ROPINIROLE HCL ROPINIROLE HCL ROPINIROLE HCL ROPINIROLE HCL ROPINIROLE HCL ROPINIROLE HCL ROPINIROLE HCL ROPINIROLE HCL ROPINIROLE HCL ROPINIROLE HCL ROPINIROLE HCL ROPIVACAINE HCL/PF ROPIVACAINE HCL/PF ROPIVACAINE HCL/PF ROPIVACAINE HCL/PF ROSIGLITAZONE MALEATE ROSIGLITAZONE MALEATE DOSAGE TABLET TABLET TABLET SYRINGE SYRINGE SYRINGE SYRINGE CAPSULE SOLUTION TABLET VIAL TABLET TABLET TABLET PATCH TD24 PATCH TD24 PATCH TD24 CAPSULE CAPSULE CAPSULE CAPSULE TAB RAPDIS TAB RAPDIS TABLET TABLET TABLET VIAL VIAL TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TAB ER 24H TABLET TABLET TABLET TABLET TABLET TABLET TABLET AMPUL AMPUL INFUS. BTL VIAL TABLET TABLET STRENGTH 2 MG 3 MG 4 MG 12.5MG/2ML 25 MG/2 ML 37.5MG/2ML 50 MG/2 ML 100 MG 80 MG/ML 100 MG 10 MG/ML 10 MG 15 MG 20 MG 13.3MG/24H 4.6MG/24HR 9.5MG/24HR 1.5 MG 3 MG 4.5 MG 6 MG 10 MG 5 MG 10 MG 5 MG 500 MCG 250 MCG 500 MCG 12 MG 2 MG 4 MG 6 MG 8 MG 0.25 MG 0.5 MG 1 MG 2 MG 3 MG 4 MG 5 MG 10 MG/ML 2 MG/ML 2 MG/ML 5 MG/ML 2 MG 4 MG NOTE APPENDIX A PAGE 116 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ROSIGLITAZONE MALEATE ROSIGLITAZONE/GLIMEPIRIDE ROSIGLITAZONE/GLIMEPIRIDE ROSIGLITAZONE/GLIMEPIRIDE ROSIGLITAZONE/METFORMIN HCL ROSIGLITAZONE/METFORMIN HCL ROSIGLITAZONE/METFORMIN HCL ROSUVASTATIN CALCIUM ROSUVASTATIN CALCIUM ROSUVASTATIN CALCIUM ROSUVASTATIN CALCIUM ROTIGOTINE ROTIGOTINE ROTIGOTINE ROTIGOTINE ROTIGOTINE ROTIGOTINE ROYAL JELLY ROYAL JELLY RUFINAMIDE RUFINAMIDE RUFINAMIDE RUTIN/HESP CM/BIOFL/ROSE/HC111 RUTIN/HESP/BIOFLAV/C/HERB#196 RUTIN/HESP/BIOFLAV/C/HERB#196 RUTIN/QUERCETIN/BIOFLAV/BILBER RUXOLITINIB PHOSPHATE S-ADENOSYLMET/VIT B12/FA/B6 S-ADENOSYLMETHIONINE SUL TOSYL S-ADENOSYLMETHIONINE SUL TOSYL S-ADENOSYLMETHIONINE SUL TOSYL S-ADENOSYLMETHIONINE SUL TOSYL SAFFLOWER OIL/LINOLEIC ACID,CO SALICYLIC ACID SALICYLIC ACID SALICYLIC ACID SALICYLIC ACID SALM OIL/VIT E MIX/SOY/FAT 3 SALMETEROL XINAFOATE SALMON OIL/OMEGA-3 FATTY ACIDS SALSALATE SALSALATE SAPROPTERIN DIHYDROCHLORIDE SAPROPTERIN DIHYDROCHLORIDE SAQUINAVIR MESYLATE SAQUINAVIR MESYLATE DOSAGE TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET PATCH TD24 PATCH TD24 PATCH TD24 PATCH TD24 PATCH TD24 PATCH TD24 CAPSULE CAPSULE ORAL SUSP TABLET TABLET TABLET CAPSULE TABLET CAPSULE TABLET TABLET DR TABLET TABLET TABLET DR TABLET DR CAPSULE CREAM (G) GEL (GRAM) LIQ-FILM LIQUID CAPSULE BLST W/DEV CAPSULE TABLET TABLET POWD PACK TABLET SOL CAPSULE TABLET STRENGTH 8 MG 4MG-1MG 4MG-2MG 8MG-4MG 2 MG-500MG 2-1000MG 4-500MG 10 MG 20 MG 40 MG 5 MG 1 MG/24 HR 2 MG/24 HR 3 MG/24 HR 4 MG/24 HR 6 MG/24 HR 8 MG/24 HR 250 MG 500 MG 40 MG/ML 200 MG 400 MG 40-25-50MG 40-25-50MG 40-25-50MG 25MG-40MG 20 MG 100-3-200 200 MG 400 MG 200 MG 400 MG 1000 MG 6 % 6 % 27.5 % 26 % 50 MCG 500-100 MG 500 MG 750 MG 100 MG 100 MG 200 MG 500 MG NOTE APPENDIX A PAGE 117 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION SARGRAMOSTIM SAW PALMETTO/PUMPKIN/PYG/ZN/B6 SAW/VIT E/SOD SEL/LYC/BETA/PYG SAXAGLIPTIN HCL SAXAGLIPTIN HCL SAXAGLIPTIN HCL/METFORMIN HCL SAXAGLIPTIN HCL/METFORMIN HCL SCANDICAL CALORIE BOOSTER - 8 SCANDISHAKE CHOC - 3 OZ PACK SCANDISHAKE CHOC WITH ASPERTIO SCANDISHAKE LF CHOC - 3 OZ PAC SCANDISHAKE LF VANILLA - 3 OZ SCANDISHAKE STRAWBERRY - 3 OZ SCANDISHAKE VANILLA - 3 OZ PAC SCANDISHAKE VANILLA WITH ASPER SCOPOLAMINE SCOPOLAMINE HYDROBROMIDE SECOBARBITAL SODIUM SELEGILINE SELEGILINE SELEGILINE SELEGILINE HCL SELEGILINE HCL SELEGILINE HCL SELENIUM SELENIUM SULFIDE SELENIUM SULFIDE SENNOSIDES SENNOSIDES SENNOSIDES SENNOSIDES SENNOSIDES SENNOSIDES/DOCUSATE SODIUM SERTACONAZOLE NITRATE SERTRALINE HCL SERTRALINE HCL SERTRALINE HCL SERTRALINE HCL SEVELAMER CARBONATE SEVELAMER CARBONATE SEVELAMER CARBONATE SEVELAMER HCL SEVELAMER HCL SHARK CARTILAGE SHARK CARTILAGE SHARK CARTILAGE DOSAGE VIAL CAPSULE TABLET TABLET TABLET TBMP 24HR TBMP 24HR UNIT PACKET PACKET PACKET PACKET PACKET PACKET PACKET PATCH TD72 VIAL CAPSULE PATCH TD24 PATCH TD24 PATCH TD24 CAPSULE TAB RAPDIS TABLET VIAL SHAMPOO SUSPENSION CAPSULE SYRUP TABLET TABLET TABLET TABLET CREAM (G) ORAL CONC TABLET TABLET TABLET POWD PACK POWD PACK TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE STRENGTH 250 MCG 320-40-10 160-100 2.5 MG 5 MG 2.5-1000MG 5MG-1000MG 1.5MG/72HR 0.4 MG/ML 100 MG 12MG/24HR 6 MG/24 HR 9 MG/24 HR 5 MG 1.25 MG 5 MG 40 MCG/ML 2.25 % 2.5 % 8.6 MG 8.8MG/5ML 17.2MG 25 MG 8.6 MG 8.6MG-50MG 2 % 20 MG/ML 100 MG 25 MG 50 MG 0.8 G 2.4 G 800 MG 400 MG 800 MG 500 MG 700 MG 750 MG NOTE APPENDIX A PAGE 118 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION SILDENAFIL CITRATE SILDENAFIL CITRATE SILDENAFIL CITRATE SILODOSIN SILODOSIN SILVER SULFADIAZINE SIMEPREVIR SODIUM SIMILAC SIMILAC - 12.9 OZ CAN - 6/CASE SIMILAC - 12.9 OZ CAN - 6/CASE SIMILAC ADVANCE - 1 LB CAN - 6 SIMILAC ADVANCE CONC - 13 OZ C SIMILAC ADVANCE EARLY SHIELD P SIMILAC ADVANCE EARLY SHIELD R SIMILAC ADVANCE NEWBORN EARLY SIMILAC ADVANCE POWDER EARLY S SIMILAC ADVANCE RTF - 1 QT BOT SIMILAC ALIMENTUM - 1 LB CAN SIMILAC ALIMENTUM - 1 LB CAN SIMILAC ALIMENTUM EXPERT CARE SIMILAC EXPERT CARE NEOSURE PO SIMILAC FOR SPIT-UP POWDER - 1 SIMILAC HUMAN MILK FORTIFIER P SIMILAC ISOMIL ADVANCE SOY - 1 SIMILAC ISOMIL ADVANCE SOY RTF SIMILAC ISOMIL DF RTF - 32 OZ SIMILAC ISOMIL POWDER SOY - 12 SIMILAC ISOMIL SOY SIMILAC LACTOSE FREE POWDER SIMILAC LACTOSE FREE SOY - 12. SIMILAC LOW IRON POWDER -13.1 SIMILAC NEOSURE ADVANCE EXPERT SIMILAC NEOSURE LIQUID - 1 QT SIMILAC NEOSURE POWDER - 13.1 SIMILAC ORAL CONC - 1000ML BTL SIMILAC ORGANIC POWDER - 12.9 SIMILAC ORGANIC POWDER - 13.1 SIMILAC PM 60/40 - 1000ML BTL SIMILAC PM 60/40 POWDER - 14.1 SIMILAC POWDER - 1 LB CAN - 6 SIMILAC SENSITIVE FORTIFIER SIMILAC SENSITIVE ISOMIL ADVAN SIMILAC SENSITIVE LACTOSE FREE SIMILAC SENSITIVE POWDER - 12. SIMILAC SENSITIVE R. S. SPIT U SIMILAC SENSITIVE R. S. SPIT U DOSAGE SUSP RECON TABLET VIAL CAPSULE CAPSULE CREAM (G) CAPSULE CAN CAN CAN CAN CAN CAN CAN CAN PACKET CAN CAN CAN CAN CAN CAN PACKET CAN CAN CAN CAN CAN CAN CAN CAN CAN CAN CAN UNIT CAN CAN UNIT CAN CAN CAN CAN CAN CAN CAN PACKET STRENGTH 10 MG/ML 20 MG 10 MG/12.5 4 MG 8 MG 1 % 150 MG 2.07G/100 2.07G/100 2.07G/100 2.07G/100 2.07G/100 2.75G/100 2.75G/100 2.8 G/100 2.14G/100 0.25G/0.9G 2.45 G/100 2.45 G/100 2.14G/100 2.14G/100 NOTE APPENDIX A PAGE 119 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION SIMILAC SENSITIVE R.S. SPIT UP SIMILAC SOY ISOMIL CONCENTRATE SIMILAC SOY ISOMIL POWDER/1.45 SIMILAC SOY ISOMIL READY TO FE SIMILAC SPECIAL CARE SIMILAC SPECIAL CARE W/IRON SIMILAC SPECIAL CARE 24 W/IRON SIMILAC W/IRON - 1000ML BTL SIMILAC W/IRON ORAL CONC - 100 SIMILAC W/IRON POWDER - 1 LB C SIMILAC 2 POWDER - 1 LB CAN SIMILAC 2 POWDER - 1.45 LB CAN SIMILAC 2 W/IRON POWDER - 1 LB SIMILACE SPECIAL CARE 30 WITH SIMPLE SYRUP SIMPLY THICK HONEY INDIVIDUAL SIMPLY THICK NECTAR INDIVIDUAL SIMVASTATIN SIMVASTATIN SIMVASTATIN SIMVASTATIN SIMVASTATIN SINECATECHINS SIPULEUCEL-T/LACTATED RINGERS SIROLIMUS SIROLIMUS SIROLIMUS SIROLIMUS SITAGLIPTIN PHOS/METFORMIN HCL SITAGLIPTIN PHOS/METFORMIN HCL SITAGLIPTIN PHOS/METFORMIN HCL SITAGLIPTIN PHOS/METFORMIN HCL SITAGLIPTIN PHOS/METFORMIN HCL SITAGLIPTIN PHOSPHATE SITAGLIPTIN PHOSPHATE SITAGLIPTIN PHOSPHATE SOD BIC/GINGER/FENNEL/CHAMOM SOD CHLORIDE/NAHCO3/KCL/PEGS SOD CIT/POT CL/POT CIT/CALC CL SOD/POT/K CIT/SOD CIT/CIT ACID SOD/POT/MAG/CAL/CHLO/ACE/GLUC SOD/POTASS/CHLOR/ZINC/DEX/FRUC SODISMUT/GLUTA/CYST/GLYC/GLUT SODIUM ACETATE SODIUM ACETATE SODIUM BICARBONATE DOSAGE BOTTLE CAN EACH BOTTLE CAN BOTTLE CAN UNIT UNIT CAN CAN CAN CAN BOTTLE UNIT PACKET PACKET TABLET TABLET TABLET TABLET TABLET OINT. (G) PLAST. BAG SOLUTION TABLET TABLET TABLET TABLET TABLET TBMP 24HR TBMP 24HR TBMP 24HR TABLET TABLET TABLET LIQUID SOLN RECON POWD PACK SOLUTION VIAL CONCSOLPKT TABLET DR VIAL VIAL SYRINGE STRENGTH 2.14G/100 2.45 G/100 2.45 G/100 3G/100KCAL 30G 15 G 10 MG 20 MG 40 MG 5 MG 80 MG 15 % 50 MM/250 1 MG/ML 0.5 MG 1 MG 2 MG 50-1000 MG 50MG-500MG 100-1000MG 50-1000 MG 50MG-500MG 100 MG 25 MG 50 MG 14-2.5-2/5 420G 11.25-5MEQ 500-550/5 25-40.6MEQ 5.3-2.35 500-50-50 2 MEQ/ML 4 MEQ/ML 0.5MEQ/ML NOTE APPENDIX A PAGE 120 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION SODIUM BICARBONATE SODIUM BICARBONATE SODIUM BICARBONATE SODIUM BICARBONATE SODIUM BICARBONATE SODIUM BICARBONATE SODIUM CHLORIDE SODIUM CHLORIDE SODIUM CHLORIDE FOR INHALATION SODIUM CHLORIDE FOR INHALATION SODIUM CHLORIDE FOR INHALATION SODIUM CHLORIDE IRRIG SOLUTION SODIUM CHLORIDE 0.45 % SODIUM CHLORIDE 0.45 % SODIUM CHLORIDE 5 % SODIUM CHLORIDE/NAHCO3/KCL/PEG SODIUM CL/POTASSIUM CHLORIDE SODIUM CL/POTASSIUM CHLORIDE SODIUM FERRIC GLUCONAT/SUCROSE SODIUM FLUORIDE SODIUM FLUORIDE SODIUM FLUORIDE SODIUM FLUORIDE SODIUM FLUORIDE SODIUM FLUORIDE SODIUM FLUORIDE SODIUM FLUORIDE SODIUM FLUORIDE/XYLITOL SODIUM FLUORIDE/XYLITOL SODIUM FLUORIDE/XYLITOL SODIUM LACTATE SODIUM OXYBATE SODIUM PHENYLBUTYRATE SODIUM PHENYLBUTYRATE SODIUM PHOS,M-BASIC-D-BASIC SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE SODIUM/CHLORIDE/POTASS/CITRATE SODIUM/CHLORIDE/POTASS/CITRATE SODIUM/CHLORIDE/POTASS/CITRATE SODIUM/CHLORIDE/POTASS/CITRATE SODIUM/CL/POT/CITRAT/DEXTROSE SODIUM/K+/MAG/CA/CHLOR/ACETATE SODIUM/K+/MAG/CA/CHLOR/ACETATE SODIUM/K+/MAG/CA/CHLOR/ACETATE DOSAGE SYRINGE SYRINGE SYRINGE VIAL VIAL VIAL VIAL VIAL VIAL-NEB VIAL-NEB VIAL-NEB IRRIG SOLN IV SOLN PGGYBK PRT IV SOLN SOLN RECON STRIP TABLET VIAL CREAM (G) DROPS DROPS GEL (GRAM) SOLUTION TAB CHEW TAB CHEW TAB CHEW TAB CHEW TAB CHEW TAB CHEW VIAL SOLUTION POWDER TABLET VIAL ENEMA ORAL SUSP POWDER ORAL SUSP PACKET PACKET PACKET PACKET VIAL VIAL VIAL STRENGTH 0.9MEQ/ML 1 MEQ/ML 10MEQ/10ML 0.48MEQ/ML 0.5MEQ/ML 1 MEQ/ML 2.5 MEQ/ML 4 MEQ/ML 0.9 % 3 % 7 % 0.9 % 0.45 % 5 % 420G 6MG-2MG 287-180-15 62.5MG/5ML 1.1 % 0.5 MG/ML 2.5 MG/ML 1.1 % 0.2 % 0.25(0.55) 0.5(1.1)MG 1MG(2.2MG) 0.25(0.55) 0.5(1.1)MG 1MG(2.2MG) 5 MEQ/ML 500 MG/ML 0.94 G/G 500 MG 3MMOL/ML 30G/120ML 15G/60ML 70-60MEQ/L 50-40MEQ 70-60MEQ 90-80MEQ 367-828MG 18-18-5MEQ 25-20-5/20 35-20-5MEQ NOTE APPENDIX A PAGE 121 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 122 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION SODIUM/POTASS/CHLORIDE/DEXTROS SODIUM,POTASSIUM,&MAG SULFATES SOFOSBUVIR SOLIFENACIN SUCCINATE SOLIFENACIN SUCCINATE SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SOMATROPIN SORAFENIB TOSYLATE SORBITOL SOLUTION SOTALOL HCL SOTALOL HCL SOTALOL HCL SOTALOL HCL SOTALOL HCL SOY ISOFLAVONE DOSAGE POWD PACK SOLN RECON TABLET TABLET TABLET CARTRIDGE CARTRIDGE CARTRIDGE CARTRIDGE CARTRIDGE CARTRIDGE CARTRIDGE CARTRIDGE CARTRIDGE CARTRIDGE CARTRIDGE PEN INJCTR PEN INJCTR PEN INJCTR PEN INJCTR SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE SYRINGE VIAL VIAL VIAL VIAL VIAL VIAL VIAL VIAL TABLET IRRIG SOLN TABLET TABLET TABLET TABLET VIAL CAPSULE STRENGTH 10.6-4.7 17.5-3.13G 400 MG 10 MG 5 MG 10 MG/2 ML 10MG/1.5ML 12 MG 12 MG/ML 20 MG/2 ML 24 MG 5 MG/ML 5 MG/1.5ML 5 MG/2 ML 6 MG 8.8 MG/1.5 10MG/1.5ML 15MG/1.5ML 30 MG/3 ML 5 MG/1.5ML 0.2MG/0.25 0.4MG/0.25 0.6MG/0.25 0.8MG/0.25 1.2MG/0.25 1.4MG/0.25 1.6MG/0.25 1.8MG/0.25 1MG/0.25ML 2MG/0.25ML 4 MG 4 MG 5 MG 5 MG 5.8 MG 6 MG 6 MG 8.8 MG 200 MG 3.3% 120 MG 160 MG 240 MG 80 MG 150MG/10ML 100 MG NOTE PRICED/EA PRICED/EA PRICED/EA PRICED/EA 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 123 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION SOY ISOFLAVONE SOY ISOFLAVONE SOY ISOFLAVONE SOY ISOFLAVONE/SOYBEAN EXTRACT SOY PROTEIN SPINOSAD SPIROMETERS AND ACCESSORIES SPIRONOLACT/HYDROCHLOROTHIAZID SPIRONOLACT/HYDROCHLOROTHIAZID SPIRONOLACTONE SPIRONOLACTONE SPIRONOLACTONE STANNOUS FLUORIDE STARCH STARCH STARCH STAVUDINE STAVUDINE STAVUDINE STAVUDINE STAVUDINE STEVIO/REB A&B/STEVIOL/STEV/D3 STREPTOMYCIN SULFATE STREPTOZOCIN STRONTIUM GLUCONATE/B6-B12-FA SUCCIMER SUCCINYLCHOLINE CHLORIDE SUCRALFATE SUCRALFATE SUCROFERRIC OXYHYDROXIDE SUFENTANIL CITRATE SUFENTANIL CITRATE SULCONAZOLE NITRATE SULCONAZOLE NITRATE SULFACETAMIDE SODIUM SULFACETAMIDE SODIUM SULFACETAMIDE SODIUM SULFACETAMIDE SODIUM SULFACETAMIDE/PREDNISOLONE SP SULFACETM NA/PREDNISOL AC SULFACETM NA/PREDNISOL AC SULFADIAZINE SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM DOSAGE CAPSULE TABLET TABLET TABLET POWDER SUSPENSION EACH TABLET TABLET TABLET TABLET TABLET SOLN(GRAM) PACKET POWD PACK POWDER CAPSULE CAPSULE CAPSULE CAPSULE SOLN RECON CAPSULE VIAL VIAL TABLET CAPSULE VIAL ORAL SUSP TABLET TAB CHEW AMPUL VIAL CREAM (G) SOLUTION DROPS OINT. (G) SHAMPOO SUSPENSION DROPS DROPS SUSP OINT. (G) TABLET ORAL SUSP TABLET TABLET VIAL STRENGTH NOTE 50 MG 40 MG 55 MG 65MG-325MG 0.9 % 25 MG-25MG 50 MG-50MG 100 MG 25 MG 50 MG 0.63% 15 MG 20 MG 30 MG 40 MG 1 MG/ML 113 MG 1 G 1 G 680MG-30MG 100 MG 20 MG/ML 1 G/10 ML 1 G 500MG IRON 50 MCG/ML 50 MCG/ML 1 % 1 % 10 % 10 % 10 % 10 % 10 %-0.23% 10 %-0.2 % 10 %-0.2 % 500 MG 200-40MG/5 400MG-80MG 800-160 MG 80-16MG/ML OPHTH ONLY 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION SULFANILAMIDE SULFASALAZINE SULFASALAZINE SULINDAC SULINDAC SUMATRIPTAN SUMATRIPTAN SUMATRIPTAN SUCC/NAPROXEN SOD SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE SUMATRIPTAN SUCCINATE SUNITINIB MALATE SUNITINIB MALATE SUNITINIB MALATE SUNITINIB MALATE SUPER SOLUBLE DUOCAL POWDER SUPER SOLUBLE DUOCAL POWDER 14 SUPLENA VANILLA - 8 OZ BOTTLE SUPLENA VANILLA W/CARB STEADY SUVOREXANT SUVOREXANT SUVOREXANT SUVOREXANT SYR W-NDL,INS 0.3 ML HALF MARK SYR W-NDL,INS 0.3 ML HALF MARK SYR W-NDL,INS 0.3 ML HALF MARK SYR W-NDL,INS 0.3 ML HALF MARK SYR-ND,INS,0.3/CONTAINER,EMPTY SYR-ND,INS,0.3/CONTAINER,EMPTY SYR-ND,INS,0.5/CONTAINER,EMPTY SYR-ND,INS,0.5/CONTAINER,EMPTY SYRING W-NDL,DISP,INSUL,0.3 ML SYRING W-NDL,DISP,INSUL,0.3 ML SYRING W-NDL,DISP,INSUL,0.3 ML SYRING W-NDL,DISP,INSUL,0.3 ML SYRING W-NDL,DISP,INSUL,0.3 ML SYRING W-NDL,DISP,INSUL,0.3 ML SYRING W-NDL,DISP,INSUL,0.3 ML SYRING W-NDL,DISP,INSUL,0.3 ML SYRING W-NDL,DISP,INSUL,0.3 ML DOSAGE CREAM/APPL TABLET TABLET DR TABLET TABLET SPRAY SPRAY TABLET CARTRIDGE CARTRIDGE NDL FR INJ PEN INJCTR PEN INJCTR TABLET TABLET TABLET VIAL CAPSULE CAPSULE CAPSULE CAPSULE CAN CAN UNIT CAN TABLET TABLET TABLET TABLET DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN SYRINGE SYRINGE SYRINGE SYRINGE DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN STRENGTH 15 % 500 MG 500 MG 150 MG 200 MG 20 MG 5 MG 85MG-500MG 4 MG/0.5ML 6 MG/0.5ML 6 MG/0.5ML 4 MG/0.5ML 6 MG/0.5ML 100 MG 25 MG 50 MG 6 MG/0.5ML 12.5 MG 25 MG 37.5 MG 50 MG 0.04G-1.79 10 MG 15 MG 20 MG 5 MG 29GX1/2" 30GX5/16" 31GX15/64" 31GX5/16" 29GX1/2" 30GX5/16" 29GX1/2" 30GX5/16" 28 GAUGE 28GX1/2" 29 GAUGE 29GX1/2" 30 GAUGE 30GX1/2" 30GX3/8" 30GX5/16" 31GX15/64" NOTE APPENDIX A PAGE 124 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION SYRING W-NDL,DISP,INSUL,0.3 ML SYRING W-NDL,DISP,INSUL,0.3 ML SYRING W-NDL,DISP,INSUL,0.5 ML SYRING W-NDL,DISP,INSUL,0.5 ML SYRING W-NDL,DISP,INSUL,0.5 ML SYRING W-NDL,DISP,INSUL,0.5 ML SYRING W-NDL,DISP,INSUL,0.5 ML SYRING W-NDL,DISP,INSUL,0.5 ML SYRING W-NDL,DISP,INSUL,0.5 ML SYRING W-NDL,DISP,INSUL,0.5 ML SYRING W-NDL,DISP,INSUL,0.5 ML SYRING W-NDL,DISP,INSUL,0.5 ML SYRING W-NDL,DISP,INSUL,0.5 ML SYRING W-NDL,DISP,INSUL,0.5 ML SYRING W-NDL,DISP,INSUL,0.5 ML SYRING W-NDL,DISP,INSUL,0.5ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE & NEEDLE,INSULIN,1 ML SYRINGE W-NDL, DISP., INSULIN SYRINGE W-NDL, DISP., INSULIN SYRINGE W-NDL, DISP,INSUL,1ML SYRINGE W-NDL, DISP,INSUL,1ML SYRINGE W-NEEDLE,DISPOSAB,1ML SYRINGE W-NEEDLE,DISPOSABLE SYRINGE W-NEEDLE,DISPOSB,0.5ML SYRINGE-NDL,INS DISPOSABLE SYRINGE, DISPOSABLE, 1ML SYRINGE,SAFETY W-NDL,1ML SYRNGE&NEEDLE,INSLN,1ML&SHARPS SYRNGE&NEEDLE,INSLN,1ML&SHARPS TACROLIMUS TACROLIMUS TACROLIMUS DOSAGE DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN DISP SYRIN SYRINGE SYRINGE CAPSULE CAPSULE CAPSULE STRENGTH 31GX3/8" 31GX5/16" 27GX1/2" 28 GAUGE 28GX1/2" 29 GAUGE 29GX1/2" 30 GAUGE 30GX1/2" 30GX3/8" 30GX5/16" 31GX15/64" 31GX3/8" 31GX5/16" 29GX1/2" 27GX1/2" 27GX5/8" 28 GAUGE 28GX1/2" 29 GAUGE 29GX1/2" 29GX7/16" 30 GAUGE 30GX1/2" 30GX3/8" 30GX5/16" 31GX15/64" 31GX3/8" 31GX5/16" 29GX1/2" 28GX1/2" 29GX1/2" 28GX1/2" 23GX1" 29GX1/2" 30GX5/16" 0.5 MG 1 MG 5 MG NOTE APPENDIX A PAGE 125 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 126 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION TACROLIMUS TACROLIMUS TADALAFIL TAFLUPROST/PF TALIGLUCERASE ALFA TAMOXIFEN CITRATE TAMOXIFEN CITRATE TAMSULOSIN HCL TAPENTADOL HCL TAPENTADOL HCL TAPENTADOL HCL TAPENTADOL HCL TAPENTADOL HCL TAPENTADOL HCL TAPENTADOL HCL TAPENTADOL HCL TASIMELTEON TAURINE TAURINE TAZAROTENE TAZAROTENE TAZAROTENE TAZAROTENE TBO-FILGRASTIM TBO-FILGRASTIM TELAPREVIR TELAVANCIN HCL TELBIVUDINE TELITHROMYCIN TELMISARTAN TELMISARTAN TELMISARTAN TELMISARTAN/AMLODIPINE TELMISARTAN/AMLODIPINE TELMISARTAN/AMLODIPINE TELMISARTAN/AMLODIPINE TELMISARTAN/HYDROCHLOROTHIAZID TELMISARTAN/HYDROCHLOROTHIAZID TELMISARTAN/HYDROCHLOROTHIAZID TEMAZEPAM TEMAZEPAM TEMAZEPAM TEMAZEPAM TEMOZOLOMIDE TEMOZOLOMIDE TEMOZOLOMIDE DOSAGE OINT. (G) OINT. (G) TABLET DROPERETTE VIAL TABLET TABLET CAP ER 24H TAB ER 12H TAB ER 12H TAB ER 12H TAB ER 12H TAB ER 12H TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE CREAM (G) CREAM (G) GEL (GRAM) GEL (GRAM) SYRINGE SYRINGE TABLET VIAL TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE STRENGTH 0.03 % 0.1 % 20 MG 0.0015 % 200 UNIT 10 MG 20 MG 0.4 MG 100 MG 150 MG 200 MG 250 MG 50 MG 100 MG 50 MG 75 MG 20 MG 1000 MG 500 MG 0.05 % 0.1 % 0.05 % 0.1 % 300MCG/0.5 480MCG/0.8 375 MG 750 MG 600 MG 400 MG 20 MG 40 MG 80 MG 40 MG-5 MG 40MG-10MG 80 MG-10MG 80 MG-5 MG 40-12.5 MG 80 MG-25MG 80-12.5MG 15 MG 22.5 MG 30 MG 7.5 MG 100 MG 140 MG 180 MG NOTE MIN AGE:18 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION TEMOZOLOMIDE TEMOZOLOMIDE TEMOZOLOMIDE TEMSIROLIMUS TENOFOVIR DISOPROXIL FUMARATE TENOFOVIR DISOPROXIL FUMARATE TENOFOVIR DISOPROXIL FUMARATE TENOFOVIR DISOPROXIL FUMARATE TENOFOVIR DISOPROXIL FUMARATE TERAZOSIN HCL TERAZOSIN HCL TERAZOSIN HCL TERAZOSIN HCL TERBINAFINE HCL TERBINAFINE HCL TERBINAFINE HCL TERBUTALINE SULFATE TERBUTALINE SULFATE TERBUTALINE SULFATE TERCONAZOLE TERCONAZOLE TERCONAZOLE TERIFLUNOMIDE TERIFLUNOMIDE TERIPARATIDE TESTOSTERONE TESTOSTERONE TESTOSTERONE TESTOSTERONE TESTOSTERONE TESTOSTERONE TESTOSTERONE TESTOSTERONE TESTOSTERONE TESTOSTERONE TESTOSTERONE TESTOSTERONE CYPIONATE TESTOSTERONE CYPIONATE TESTOSTERONE ENANTHATE TETANUS IMMUNE GLOBULIN/PF TETRABENAZINE TETRABENAZINE TETRACAINE HCL TETRACYCLINE HCL TETRACYCLINE HCL TETRAHYDROZOLINE HCL DOSAGE CAPSULE CAPSULE CAPSULE VIAL POWDER TABLET TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE CAPSULE GRAN PACK GRAN PACK TABLET TABLET TABLET VIAL CREAM/APPL CREAM/APPL SUPP.VAG TABLET TABLET PEN INJCTR GEL (GRAM) GEL MD PMP GEL MD PMP GEL MD PMP GEL PACKET GEL PACKET GEL PACKET GEL PACKET PATCH TD24 PATCH TD24 SOL MD PMP VIAL VIAL VIAL SYRINGE TABLET TABLET DROPS CAPSULE CAPSULE DROPS STRENGTH 20 MG 250 MG 5 MG FNL 30MG/3 40MG/SCOOP 150 MG 200 MG 250 MG 300 MG 1 MG 10 MG 2 MG 5 MG 125 MG 187.5MG 250 MG 2.5 MG 5 MG 1 MG/ML 0.4 % 0.8 % 80 MG 14 MG 7 MG 20MCG/DOSE 50 MG (1%) 1.25G (1%) 10 MG (2%) 20.25/1.25 1.25G-1.62 2.5G-1.62% 25MG(1%) 50 MG (1%) 2 MG/24 HR 4 MG/24 HR 30MG/1.5ML 100 MG/ML 200 MG/ML 200 MG/ML 250 UNIT 12.5 MG 25 MG 0.5 % 250 MG 500 MG 0.05 % NOTE APPENDIX A PAGE 127 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION THALIDOMIDE THALIDOMIDE THALIDOMIDE THALIDOMIDE THEANINE THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS THEOPHYLLINE/D5W THIAMINE HCL THICK-IT POWDER - 36 OZ CAN THICK-IT 2 - 8 OZ CAN THIOGUANINE THIORIDAZINE HCL THIORIDAZINE HCL THIORIDAZINE HCL THIORIDAZINE HCL THIOTHIXENE THIOTHIXENE THIOTHIXENE THIOTHIXENE THREONINE THREONINE THYROID,PORK THYROID,PORK THYROID,PORK THYROID,PORK THYROID,PORK THYROID,PORK THYROID,PORK THYROID,PORK THYROTROPIN ALFA TIAGABINE HCL TIAGABINE HCL TIAGABINE HCL TIAGABINE HCL TICAGRELOR DOSAGE CAPSULE CAPSULE CAPSULE CAPSULE TAB RAPDIS CAP ER 24H CAP ER 24H CAP ER 24H CAP ER 24H ELIXIR SOLUTION TAB ER 12H TAB ER 12H TAB ER 12H TAB ER 12H TABLET ER TABLET ER IV SOLN VIAL CAN CAN TABLET TABLET TABLET TABLET TABLET CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET VIAL TABLET TABLET TABLET TABLET TABLET STRENGTH 100 MG 150 MG 200 MG 50 MG 50 MG 100 MG 200 MG 300 MG 400 MG 80 MG/15ML 80 MG/15ML 100 MG 200 MG 300 MG 450 MG 400 MG 600 MG 400MG/0.5L 100 MG/ML 40 MG 10 MG 100 MG 25 MG 50 MG 1 MG 10 MG 2 MG 5 MG 500 MG 500 MG 120 MG 15 MG 180 MG 240 MG 30 MG 300 MG 60 MG 90 MG 1.1 MG 12 MG 16 MG 2 MG 4 MG 90 MG NOTE APPENDIX A PAGE 128 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION DOSAGE TICARCILLIN/K CLAVULANATE VIAL TICLOPIDINE HCL TABLET TIGECYCLINE VIAL TIMOLOL MALEATE DROP DAILY TIMOLOL MALEATE DROPS TIMOLOL MALEATE DROPS TIMOLOL MALEATE SOL-GEL TIMOLOL MALEATE SOL-GEL TIMOLOL MALEATE TABLET TIMOLOL MALEATE TABLET TIMOLOL MALEATE/PF DROPERETTE TIMOLOL MALEATE/PF DROPERETTE TINIDAZOLE TABLET TINIDAZOLE TABLET TIOPRONIN TABLET TIOTROPIUM BROMIDE CAP W/DEV TIPRANAVIR CAPSULE TIZANIDINE HCL CAPSULE TIZANIDINE HCL CAPSULE TIZANIDINE HCL CAPSULE TIZANIDINE HCL TABLET TIZANIDINE HCL TABLET TOBRAMYCIN AMPUL-NEB TOBRAMYCIN CAP W/DEV TOBRAMYCIN DROPS TOBRAMYCIN OINT. (G) TOBRAMYCIN IN 0.225% NACL AMPUL-NEB TOBRAMYCIN SULFATE VIAL TOBRAMYCIN SULFATE VIAL TOBRAMYCIN/DEXAMETHASONE DROPS SUSP TOBRAMYCIN/DEXAMETHASONE DROPS SUSP TOBRAMYCIN/DEXAMETHASONE OINT. (G) TOBRAMYCIN/LOTEPRED ETAB DROPS SUSP TOBRAMYCIN/SODIUM CHLORIDE PIGGYBACK TOCILIZUMAB VIAL TOCILIZUMAB VIAL TOCILIZUMAB VIAL TOFACITINIB CITRATE TABLET TOLAZAMIDE TABLET TOLAZAMIDE TABLET TOLBUTAMIDE TABLET TOLCAPONE TABLET TOLEREX UNFLAVORED - 2.82 OZ P PACKET TOLMETIN SODIUM CAPSULE TOLMETIN SODIUM TABLET TOLMETIN SODIUM TABLET STRENGTH 31G 250 MG 50 MG 0.5 % 0.25 % 0.5 % 0.25 % 0.5 % 10 MG 20 MG 0.25 % 0.5 % 250 MG 500 MG 100 MG 18 MCG 250 MG 2 MG 4 MG 6 MG 2 MG 4 MG 300 MG/4ML 28 MG 0.3 % 0.3 % 300 MG/5ML 1.2 G 40 MG/ML 0.3 %-0.1% 0.3%-0.05% 0.3 %-0.1% 0.3%-0.5% 80MG/100ML 200MG/10ML 400MG/20ML 80 MG/4 ML 5 MG 250 MG 500 MG 500 MG 100 MG 400 MG 200 MG 600 MG NOTE APPENDIX A PAGE 129 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION TOLTERODINE TARTRATE TOLTERODINE TARTRATE TOLTERODINE TARTRATE TOLTERODINE TARTRATE TOLVAPTAN TOLVAPTAN TOPIRAMATE TOPIRAMATE TOPIRAMATE TOPIRAMATE TOPIRAMATE TOPIRAMATE TOPIRAMATE TOPIRAMATE TOPIRAMATE TOPIRAMATE TOPIRAMATE TOPIRAMATE TOPOTECAN HCL TOPOTECAN HCL TOPOTECAN HCL TORSEMIDE TORSEMIDE TORSEMIDE TORSEMIDE TRACE METALS TRAMADOL HCL TRAMADOL HCL TRAMADOL HCL TRAMADOL HCL TRAMADOL HCL TRAMADOL HCL TRAMADOL HCL TRAMADOL HCL TRAMADOL HCL TRAMADOL HCL TRAMADOL HCL/ACETAMINOPHEN TRAMETINIB DIMETHYL SULFOXIDE TRAMETINIB DIMETHYL SULFOXIDE TRANDOLAPRIL TRANDOLAPRIL TRANDOLAPRIL TRANDOLAPRIL/VERAPAMIL HCL TRANDOLAPRIL/VERAPAMIL HCL TRANDOLAPRIL/VERAPAMIL HCL TRANDOLAPRIL/VERAPAMIL HCL DOSAGE CAP ER 24H CAP ER 24H TABLET TABLET TABLET TABLET CAP ER 24H CAP ER 24H CAP ER 24H CAP ER 24H CAP SPR 24 CAP SPR 24 CAP SPRINK CAP SPRINK TABLET TABLET TABLET TABLET CAPSULE CAPSULE VIAL TABLET TABLET TABLET TABLET VIAL CPBP 17-83 CPBP 25-75 CPBP 25-75 TAB ER 24H TAB ER 24H TAB ER 24H TABLET TBMP 24HR TBMP 24HR TBMP 24HR TABLET TABLET TABLET TABLET TABLET TABLET TBMP 24HR TBMP 24HR TBMP 24HR TBMP 24HR STRENGTH 2 MG 4 MG 1 MG 2 MG 15 MG 30 MG 100 MG 200 MG 25 MG 50 MG 100 MG 50 MG 15 MG 25 MG 100 MG 200 MG 25 MG 50 MG 0.25 MG 1 MG 4 MG 10 MG 100 MG 20 MG 5 MG 100MCG-1MG 300 MG 100 MG 200 MG 100 MG 200 MG 300 MG 50 MG 100 MG 200 MG 300 MG 37.5-325MG 0.5 MG 2 MG 1 MG 2 MG 4 MG 1-240MG 2 MG-180MG 2-240MG 4-240MG NOTE APPENDIX A PAGE 130 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION TRANEXAMIC ACID TRANEXAMIC ACID TRANYLCYPROMINE SULFATE TRASTUZUMAB TRAVOPROST TRAZODONE HCL TRAZODONE HCL TRAZODONE HCL TRAZODONE HCL TRAZODONE HCL TRAZODONE HCL TREPROSTINIL TREPROSTINIL SODIUM TREPROSTINIL SODIUM TREPROSTINIL SODIUM TREPROSTINIL SODIUM TREPROSTINIL/NEB ACCESSORIES TREPROSTINIL/NEBULIZER/ACCESOR TRETINOIN TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE/PF TRIAMCINOLONE HEXACETONIDE TRIAMCINOLONE/EMOLLIENT CMB#45 TRIAMTERENE/HYDROCHLOROTHIAZID TRIAMTERENE/HYDROCHLOROTHIAZID TRIAMTERENE/HYDROCHLOROTHIAZID TRIAMTERENE/HYDROCHLOROTHIAZID TRIAZOLAM TRIAZOLAM TRIENTINE HCL TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL DOSAGE AMPUL TABLET TABLET VIAL DROPS TAB ER 24H TAB ER 24H TABLET TABLET TABLET TABLET AMPUL-NEB VIAL VIAL VIAL VIAL AMPUL-NEB AMPUL-NEB CAPSULE AEROSOL CREAM (G) CREAM (G) CREAM (G) LOTION LOTION OINT. (G) OINT. (G) OINT. (G) OINT. (G) PASTE (G) SPRAY VIAL VIAL VIAL VIAL CREAM (G) CAPSULE CAPSULE TABLET TABLET TABLET TABLET CAPSULE TABLET TABLET TABLET STRENGTH 1000 MG/10 650 MG 10 MG 440 MG 0.004 % 150 MG 300 MG 100 MG 150 MG 300 MG 50 MG 1.74MG/2.9 1 MG/ML 10 MG/ML 2.5 MG/ML 5 MG/ML 1.74MG/2.9 1.74MG/2.9 10 MG 0.147MG/G 0.025 % 0.1 % 0.5 % 0.025 % 0.1 % 0.025 % 0.05 % 0.1 % 0.5 % 0.1 % 55 MCG 10 MG/ML 40 MG/ML 40 MG/ML 20 MG/ML 0.1 % 37.5-25 MG 50 MG-25MG 37.5-25 MG 75 MG-50MG 0.125 MG 0.25 MG 250 MG 1 MG 10 MG 2 MG NOTE APPENDIX A PAGE 131 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION TRIFLUOPERAZINE HCL TRIFLURIDINE TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL TRIMETHOBENZAMIDE HCL TRIMETHOPRIM TRIMETHOPRIM TRIMIPRAMINE MALEATE TRIMIPRAMINE MALEATE TRIMIPRAMINE MALEATE TRIPTORELIN PAMOATE TRIPTORELIN PAMOATE TRIPTORELIN PAMOATE TRIPTORELIN PAMOATE TRIPTORELIN PAMOATE TROPICAMIDE TROPICAMIDE TROSPIUM CHLORIDE TROSPIUM CHLORIDE TWO CAL HN BUTTER PECAN - 8 O TWO CAL HN VANILLA - 8 OZ CAN TWO CAL HN VANILLA RTH - 1000M TYROSINE TYROSINE TYROSINE UBIDECAR/OCTACOS/VIT B12/HERB7 UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE UBIDECARENONE DOSAGE TABLET DROPS ELIXIR TABLET TABLET CAPSULE SOLUTION TABLET CAPSULE CAPSULE CAPSULE SYRINGE SYRINGE VIAL VIAL VIAL DROPS DROPS CAP ER 24H TABLET UNIT UNIT CAN CAPSULE CAPSULE PACKET TABLET CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE EMUL PACKT LIQUID LIQUID POWDER TAB CHEW TAB CHEW TAB ER 24H TABLET STRENGTH 5 MG 1 % 2 MG/5 ML 2 MG 5 MG 300 MG 50 MG/5 ML 100 MG 100 MG 25 MG 50 MG 11.25/2ML 3.75MG/2ML 11.25 MG 22.5 MG 3.75 MG 0.5 % 1 % 60 MG 20 MG 0.08G-2/ML 0.08G-2/ML 0.08G-2/ML 500 MG 800 MG 1 G-15/4 G 10 MG 100 MG 125 MG 150 MG 200 MG 30 MG 300 MG 400 MG 50 MG 60 MG 75 MG 50 MG 100 MG/ML 30 MG/5 ML 200 MG/G 200 MG 50 MG 100 MG 100 MG NOTE APPENDIX A PAGE 132 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION UBIDECARENONE UBIDECARENONE UBIDECARENONE/OMEGA-3/VIT E UBIDECARENONE/RED YEAST RICE UBIDECARENONE/VIT E ACETATE UBIDECARENONE/VITAMIN E UBIDECARENONE/VITAMIN E UBIDECARENONE/VITAMIN E UBIDECARENONE/VITAMIN E MIXED UBIQUINOL UBIQUINOL UBIQUINONE UBIQUINONE UCD 2 450 G TIN - 2 TINS/BOX ULIPRISTAL ACETATE UMECLIDINIUM BRM/VILANTEROL TR UREA UREA UREA UREA UREA UREA UREA UREA/LACTIC ACID/SALICYL ACID URINE ACETONE TEST,STRIPS URINE GLUC-ACET COMB.TST,STRIP URINE GLUCOSE TEST,STRIP URINE GLUCOSE TEST,TABLET URINE MULTIPLE TEST URINE MULTIPLE TEST UROFOLLITROPIN URSODIOL URSODIOL URSODIOL USTEKINUMAB USTEKINUMAB VALACYCLOVIR HCL VALACYCLOVIR HCL VALGANCICLOVIR HCL VALGANCICLOVIR HCL VALINE VALINE/CARBOHYDRATE SUPPLEMENT VALINE/CARBOHYDRATE SUPPLEMENT VALPROIC ACID VALPROIC ACID VALPROIC ACID (AS SODIUM SALT) DOSAGE TABLET TABLET CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE LIQUID CAPSULE CAPSULE CAPSULE CAPSULE TAB RAPDIS UNIT TABLET BLST W/DEV CREAM (G) CREAM (G) CREAM (G) FOAM GEL (ML) GEL (ML) NL FM SUSP SUSPENSION STRIP STRIP STRIP TABLET MISCELL STRIP VIAL CAPSULE TABLET TABLET SYRINGE SYRINGE TABLET TABLET SOLN RECON TABLET CAPSULE PACKET POWD PACK CAPSULE CAPSULE DR SOLUTION STRENGTH 50 MG 60 MG 50-300-30 25MG-600MG 100MG-5 150 MG 50 MG-5 30 MG-15 100MG-100 100 MG 200 MG 75 MG 90 MG 67G-290 30 MG 62.5-25MCG 40 % 45 % 50 % 40 % 40 % 45 % 40 % 50 % 75 UNIT 300 MG 250 MG 500 MG 45MG/0.5ML 90 MG/ML 1000 MG 500 MG 50 MG/ML 450 MG 600 MG 50 MG/4 G 1 G/4 G 250 MG 250 MG 250 MG/5ML NOTE APPENDIX A PAGE 133 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION VALPROIC ACID (AS SODIUM SALT) VALPROIC ACID (AS SODIUM SALT) VALRUBICIN VALSARTAN VALSARTAN VALSARTAN VALSARTAN VALSARTAN/HYDROCHLOROTHIAZIDE VALSARTAN/HYDROCHLOROTHIAZIDE VALSARTAN/HYDROCHLOROTHIAZIDE VALSARTAN/HYDROCHLOROTHIAZIDE VALSARTAN/HYDROCHLOROTHIAZIDE VANCOMYCIN HCL VANCOMYCIN HCL VANCOMYCIN HCL VANCOMYCIN HCL VANCOMYCIN HCL VANCOMYCIN HCL VANCOMYCIN HCL VANCOMYCIN HCL VANCOMYCIN HCL VANCOMYCIN HCL/D5W VANCOMYCIN HCL/D5W VARENICLINE TARTRATE VARENICLINE TARTRATE VARENICLINE TARTRATE VASOPRESSIN VEDOLIZUMAB VELAGLUCERASE ALFA VEMURAFENIB VENLAFAXINE HCL VENLAFAXINE HCL VENLAFAXINE HCL VENLAFAXINE HCL VENLAFAXINE HCL VENLAFAXINE HCL VENLAFAXINE HCL VENLAFAXINE HCL VENLAFAXINE HCL VENLAFAXINE HCL VENLAFAXINE HCL VENLAFAXINE HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL DOSAGE SOLUTION VIAL VIAL TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET CAPSULE CAPSULE VIAL VIAL VIAL VIAL VIAL VIAL PORT VIAL PORT FROZ.PIGGY FROZ.PIGGY TAB DS PK TABLET TABLET VIAL VIAL VIAL TABLET CAP ER 24H CAP ER 24H CAP ER 24H TAB ER 24 TAB ER 24 TAB ER 24 TAB ER 24 TABLET TABLET TABLET TABLET TABLET AMPUL CAP24H PCT CAP24H PCT CAP24H PCT STRENGTH 500MG/10ML 500 MG/5ML 40 MG/ML 160 MG 320 MG 40 MG 80 MG 160-12.5MG 160-25MG 320-12.5MG 320MG-25MG 80-12.5MG 125 MG 250 MG 1 G 10 G 5 G 500 MG 750 MG 1 G 500 MG 1G/200ML 500MG/0.1L 0.5(11)-1 0.5 MG 1 MG 20 UNIT/ML 300 MG 400 UNIT 240 MG 150 MG 37.5 MG 75 MG 150 MG 225 MG 37.5 MG 75 MG 100 MG 25 MG 37.5 MG 50 MG 75 MG 2.5 MG/ML 100 MG 200 MG 300 MG NOTE APPENDIX A PAGE 134 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT APPENDIX A PAGE 135 ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL VIGABATRIN VIGABATRIN VILAZODONE HYDROCHLORIDE VILAZODONE HYDROCHLORIDE VILAZODONE HYDROCHLORIDE VILAZODONE HYDROCHLORIDE VINBLASTINE SULFATE VINCRISTINE SULFATE VINCRISTINE SULFATE VINCRISTINE SULFATE LIPOSOMAL VINORELBINE TARTRATE VINORELBINE TARTRATE VINP/HUPE/GINK/A-CYST/PHOS/ACE VISMODEGIB VIT A,C,& E/DIETARY SUPP NO.12 VIT A,C,E/B6/B12/ZINC/HERB 148 VIT A,C,E/MIN/HERBAL COMP 147 VIT A,C,E/MIN/HERBAL COMP#221 VIT B CMPLX NO3/FA/C/BIOT/ZINC VIT B CMPLX 3/FA/VIT C/BIOTIN VIT B COMP/E AC SUCC/FA/HC 105 VIT B COMP/E/FA/SOY ISO/HB 143 VIT B COMP/E/FA/SOYBEAN/HB 143 VIT B COMPLEX/MIN/HOPS/BERB CL VIT B CPLX #11/FA/C/BIOT/ZN OX VIT B12/IOD/MG/ZN/SE/HERB#193 VIT B12/LIVER EXT/DNA/RNA VIT B12/LMEFOLATE CA/VIT B6/B2 VIT B6/MAG CIT & OX/POTASS CIT VIT C/B6/B5/MAGNESIUM/HERB#173 VIT C/CHROMIUM/BRINDALL BERRY VIT C/DIOS/RUT/BIOFLAV/BUTC BR VIT C/E/MAG AA CHELATE/HB#189 VIT C/RUT/HESPER/BIOFL/BUTC BR DOSAGE CAP24H PEL CAP24H PEL CAP24H PEL CAP24H PEL SYRINGE TABLET TABLET TABLET TABLET ER TABLET ER TABLET ER VIAL POWD PACK TABLET TAB DS PK TABLET TABLET TABLET VIAL VIAL VIAL KIT VIAL VIAL TABLET ER CAPSULE TABLET EFF TABLET TABLET EFF TABLET EFF TABLET TABLET TABLET TABLET TABLET TABLET TABLET CAPSULE TABLET TABLET TABLET ER CAPSULE CAPSULE CAPSULE CAPSULE CAPSULE STRENGTH 120 MG 180 MG 240 MG 360 MG 2.5 MG/ML 120 MG 40 MG 80 MG 120 MG 180 MG 240 MG 2.5 MG/ML 500 MG 500 MG 10-20-40MG 10 MG 20 MG 40 MG 1 MG/ML 1 MG/ML 2 MG/2 ML FNL 5MG/31 10 MG/ML 50 MG/5 ML 10-100-65 150 MG 5K-1000-30 250-7.5MG 5K-1000-30 2K-1000-30 1MG-60MG 1MG-60MG 30-400 15UNIT-0.2 15UNIT-0.2 100-100 MG 1 MG-100MG 50-75 MCG 1-6-50-5MG 3.75-45-45 50-5-6-5MG 10-25-500 75MG-375MG 60MG-15-70 150-150MG NOTE (RX ONLY) (RX ONLY) (RX ONLY) 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION VIT C/RUT/HESPER/BIOFLAV/HC122 VIT C/VIT E/SELENIUM/HERB#191 VIT C/ZINC CITRATE/HERBAL #163 VIT D3 & K/BERBERINE HCL/HOPS VIT E AC/MIN/BOV CPLX/HRB38 VIT E/TOCOTRIENOL GAM,ALPH,DEL VITAL AF 1.2 CAL RTD - 8 OZ CA VITAL HN POWDER VANILLA - 2.7 VITAL JR STRAWBERRY FLAVOR 8 O VITAL JR VANILLA FLAVOR 8 OZ B VITAL JUNIOR STRAWBERRY - 8 OZ VITAL JUNIOR UNFLAVORED - 8 OZ VITAL JUNIOR VANILLA - 8 OZ CA VITAL 1.0 CAL - 8 OZ CAN VITAMIN A PALMITATE VITAMIN B COMP W-C/FA/ZN CIT VITAMIN E VITAMIN E VITAMINS A,C AND D VITE AC/GRAPE/HYALURONIC ACID VIVONEX CLOSED SYSTEM - 1000ML VIVONEX CLOSED SYSTEM - 1500ML VIVONEX PEDIATRIC UNFLAVORED VIVONEX PLUS UNFLAVORED - 2.8 VIVONEX T.E.N. UNFLAVORED - 2 VIVONEX UNFLAVORED RTF - 250 M VORAPAXAR SULFATE VORICONAZOLE VORICONAZOLE VORICONAZOLE VORICONAZOLE VORINOSTAT VORTIOXETINE HYDROBROMIDE VORTIOXETINE HYDROBROMIDE VORTIOXETINE HYDROBROMIDE WARFARIN SODIUM WARFARIN SODIUM WARFARIN SODIUM WARFARIN SODIUM WARFARIN SODIUM WARFARIN SODIUM WARFARIN SODIUM WARFARIN SODIUM WARFARIN SODIUM WATER FOR INJECTION,STERILE WATER FOR INJECTION,STERILE DOSAGE TABLET CAPSULE LOZENGE TABLET TABLET CAPSULE CAN UNIT LIQUID BOTTLE CAN CAN CAN CAN VIAL TABLET CAPSULE DROPS DROPS CREAM (G) UNIT UNIT UNIT UNIT UNIT UNIT TABLET SUSP RECON TABLET TABLET VIAL CAPSULE TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET TABLET IV SOLN VIAL STRENGTH 500-2.5-25 15-15-10 300MG-7MG 500-500-90 50 UNIT-50 0.08 G-1.2 0.04G-1/ML 50000/ML 0.8MG-15MG 400 UNIT 50 UNIT/ML 1500 U-35 0.05G-1/ML 2.08 MG 200 MG/5ML 200 MG 50 MG 200 MG 100 MG 10 MG 20 MG 5 MG 1 MG 10 MG 2 MG 2.5 MG 3 MG 4 MG 5 MG 6 MG 7.5 MG NOTE APPENDIX A PAGE 136 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION WATER FOR IRRIGATION,STERILE WEED POLLEN-SHORT RAGWEED WHEAT DEXTRIN/CA #15/ASPARTAME WHEY WHEY WHEY PROT/ARG/GLU/C/ZN/COP/TOS WHEY PROTEIN CONCEN/AMINO ACID WHEY PROTEIN ISOLAT/AMINO ACID WHEY PROTEIN ISOLAT/AMINO ACID WHEY PROTEIN ISOLATE WHEY PROTEIN ISOLATE WHEY PROTEIN ISOLATE WHEY PROTEIN ISOLATE WHEY PROTEIN ISOLATE WHEY PROTEIN-ARGININ-GLUT-FLAX WHEY PROTEIN/ARGININE/C/E/ZINC WHEY/ARGNIN/VIT C/E/MALIC/CA XANTHAN GUM XANTHAN GUM XANTHAN GUM XANTHAN GUM XANTHAN GUM XANTHAN GUM XANTHAN GUM XANTHAN GUM ZAFIRLUKAST ZAFIRLUKAST ZALEPLON ZALEPLON ZANAMIVIR ZIDOVUDINE ZIDOVUDINE ZIDOVUDINE ZILEUTON ZILEUTON ZINC ACETATE ZINC ACETATE ZINC CHLORIDE ZINC CITRATE/PHYTASE ZINC MTH/COPPER/SAW PALM/GNSG ZINC SULFATE ZINC SULFATE ZIPRASIDONE HCL ZIPRASIDONE HCL ZIPRASIDONE HCL ZIPRASIDONE HCL DOSAGE IRRIG SOLN TAB SUBL POWDER PACKET POWDER POWD PACK POWDER POWD PACK POWDER POWD PACK POWD PACK POWDER POWDER POWDER POWDER LIQUID PACKET GEL (GRAM) GEL MD PMP GEL PACKET GEL PACKET GEL PACKET GEL PACKET GEL PACKET GEL PACKET TABLET TABLET CAPSULE CAPSULE BLST W/DEV CAPSULE SYRUP TABLET TABLET TBMP 12HR CAPSULE CAPSULE VIAL CAPSULE CAPSULE VIAL VIAL CAPSULE CAPSULE CAPSULE CAPSULE STRENGTH 12 UNIT 3 G-200/6G 9G 10-7/42.75 24G-120/30 6 G-25/7.4 6 G-25/7.4 21G-100/27 6 G-25/7 G 21 G-90/24 21G-100/27 6 G-25/7 G 5 G-35/8 G 6G-4.5-250 5G-4.5G 15 G 7G 12G 120G 15 G 240 G 26G 30G 10 MG 20 MG 10 MG 5 MG 5 MG 100 MG 10 MG/ML 300 MG 600 MG 600 MG 25 MG 50 MG 1 MG/ML 25MG-500MG 15-2-160MG 1 MG/ML 5 MG/ML 20 MG 40 MG 60 MG 80 MG NOTE APPENDIX A PAGE 137 01/01/15 LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEM DEPT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES FINANCING LOUISIANA MEDICAID PHARMACY BENEFITS MANAGEMENT UNIT ONLY THESE DOSAGE FORMS ARE COVERED AND ONLY IF FROM VENDOR LISTED IN APPENDIX C LIST OF DRUG PAYABLE ON DRUG FILE GENERIC DESCRIPTION ZIPRASIDONE MESYLATE ZN GLUC/PUMP SEED OIL/SAW PAL ZN/COL/EGG/HB#232/PLY#1/THY/AC ZNSO4/CUSO4/MANG SU/CHROMIC CL ZOLEDRONIC ACID ZOLEDRONIC ACID/MANNITOL&WATER ZOLEDRONIC ACID/MANNITOL&WATER ZOLEDRONIC ACID/MANNITOL&WATER ZOLMITRIPTAN ZOLMITRIPTAN ZOLMITRIPTAN ZOLMITRIPTAN ZOLMITRIPTAN ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE ZONISAMIDE ZONISAMIDE ZONISAMIDE 0.9 % SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 0.9 % SODIUM CHLORIDE 5-HYDROXYTRYPTOPHAN 5-HYDROXYTRYPTOPHAN DOSAGE VIAL CAPSULE CAPSULE VIAL VIAL INFUS. BTL INFUS. BTL PIGGYBACK SPRAY SPRAY TAB RAPDIS TABLET TABLET SPRAY/PUMP TAB MPHASE TAB MPHASE TAB SUBL TAB SUBL TAB SUBL TAB SUBL TABLET TABLET CAPSULE CAPSULE CAPSULE IV SOLN PGGYBK PRT PGY VL PRT SYRINGE VIAL CAPSULE CAPSULE STRENGTH FNL 20MG/1 7.5-40-160 15-330-650 5-1-0.5-10 4 MG/5 ML 4 MG/100ML 5 MG/100ML 5 MG/100ML 2.5 MG 5 MG 5 MG 2.5 MG 5 MG 5 MG/SPRAY 12.5 MG 6.25 MG 1.75 MG 10 MG 3.5 MG 5 MG 10 MG 5 MG 100 MG 25 MG 50 MG 0.9 % 0.9 % 0.9 % 100 MG 50 MG NOTE APPENDIX A PAGE 138
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