Apple Health (Medicaid) drug coverage criteria

• Anti-narcolepsy
• Viloxazine

• 61.40.00
• 61.35.40.AA

• Testosterone Replacement Therapy (TRT)

• 23.10.00

• GLP-1 Receptor Agonists - semaglutide

• 61.25.20.AA

• Anti-IgE antibodies
• IL-5 antagonists

• 44.60.30.AA
• 44.60.40

• Anti-infective agents - Rifaximin
• Inhaled aminoglycosides
• Inhaled Aztreonam

• 16.00.00.49
• 07.00.00
• 16.14.00

• Serotonin modulators

• 58.12.00

• Amylin analogs
• GLP-1 agonists

• 27.15.00
• 27.17.00

• Etranacogene dezaparvovec-drlb

• 85.10.25.AA

• Apolipoprotein B (APOB) synthesis inhibitors - Lomitapide Mesylate
• Icosapent ethyl
• PCSK-9 inhibitors

• 39.48.00
• 39.50.00.AA
• 39.35.00

• Antiprotozoal agents – Nitazoxanide

• 16.40.00.60

• Second generation - cariprazine

• 59.40.00.18

• Hepatitis C treatments

• 12.35.30.99

• Dupilumab
• Topical immunosuppressives
• Crisaborole

• 90.27.30.20
• 90.78.40
• 90.23.00.AA

• Bone Density Regulators

• 30.04.00

• Brands with generic equivalents

• NC-001

• Sinus node inhibitors

• 40.70.00

Chronic GI Motility Agents

• Chronic GI motility agents

• 52.55.00

• Therapies for COVID-19

• 19.50.20

• Deflazacort

• 22.10.00.AA

• Cystic Fibrosis agents

• 45.30.00

• Cytokine and CAM agents

• 66.27.00

• Acne - isotretinoin

• 90.05.00.AA

• Elapegademase-lvlr
• Phenylketonuria (PKU) agents - Pegvaliase-pqpz
• Phenylketonuria (PKU) agents - Sapropterin
• Teprotumumab
• Tripeptidyl Peptidase 1 Deficiency agents - Cerliponase Alfa
• X-Linked Hypophosphatemia (XLH) agents - Burosumab--twza

• 30.90.20.30
• 30.90.85.50
• 30.90.85.65
• 30.19.20.AA
• 30.90.90
• 30.90.95

• Gout Agents

• 68.00.00

• Growth Hormone Agents

• 30.10.00

• Gender Dysphoria

• 24.00.00

• Hereditary Angioedema Agents (HAE) – Acute
• Hereditary Angioedema Agents (HAE) - Prophylaxis

• 85.82.00.AA
• 85.80.20.AA

• Erythropoiesis-stimulating agents (ESAs)
• Granulocyte colony stimulating factors (G-CSF)
• Thrombopoiesis (TPO) stimulating proteins

• 82.40.10
• 82.40.15
• 82.40.50

• Thalidomide analogs

• 99.39.20

• Calcionin gene-related peptide (CGRP) receptor antagonists - acute
• Calcionin gene-related peptide (CGRP) receptor antagonists - preventative

• 67.70.10
• 67.70.20

Medication Treatment for Substance Abuse Disorders (SUDs)

• Buprenorphine containing products
  • Request for Buprenorphine Monotherapy (13-330)
• Naltrexone containing products

• 65.20.00.10
• 93.40.00.20

• Valbenazine

• 62.38.00.AA

• Carisoprodol

• 75.10.00.AA

• ALS - edaravone
• Lupus agents
• SMA - nusinersen
• SMA - risdiplam

• 74.50.90
• 99.40.20
• 74.70.00.AA
• 74.70.65.AA

• Androgen Biosynthesis Inhibitors – abiraterone
• Imidiazotetrazines
• Radiopharmaceuticals - lutetium Lu 177 dotatate
• Tyrosine Kinase Inhibitors (TKI)

• 21.40.60
• 21.10.40
• 21.60.00.45
• 21.53.40

• Methadone
• Opioid Clinical Policy
• Transmucosal Fentanyl Products

• 65.10.00.50
• 65.10.00
• 65.10.00.25

• Cenegermin-bkbj
• Gene Therapy - Voretigene neparvovec-rzyl
• Immunomodulators

• 86.77.00.AA
• 86.37.00
• 86.73.40

Proton Pump Inhibitors (PPIs)

• Proton Pump Inhibitor (PPI) Policy
• Duration of use dose limits for PPIs - Fact sheet

• 49.27.00

• Dalfampridine
• Ocrelizumab

• 62.40.60.30
• 62.40.50.60

• Transthyretin Amyloidosis Agents

• 62.70.00

• Pulmonary Arterial Hypertension (PAH) Agents

• 40.12.00

• Pulmonary Fibrosis Agents

• 45.55.00

• Alpha-Proteinase Inhibitor (Human)

• 45.10.00.00

• tasimelteon

• 60.25.00.AA