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All managed care plans and the fee-for-service program serving Apple Health clients use the Apple Health Preferred Drug List (PDL).
See what drugs are preferred and whether they need a prior authorization (PA).
Preferred drugs within a chosen therapeutic class are selected based on clinical evidence of safety, efficacy, and effectiveness. The drugs within a chosen therapeutic class are evaluated by the Drug Use Review Board, which makes recommendations to HCA regarding the selection of the preferred drugs.
The Apple Health PDL has products listed in groups by drug class. To obtain authorization for a nonpreferred drug, a client must have tried and failed, or is intolerant to, a designated number of preferred drugs within the drug class unless contraindicated or not clinically appropriate. The designated number of preferred drugs is listed on the Apple Health PDL.
In addition to approval criteria for nonpreferred products, some drugs have additional criteria that must be met. The requirement for additional criteria is noted in the columns on the Apple Health PDL.
For continuity of care
All plans will use the same PA criteria, step therapy edits, and quantity limits developed by HCA.
The Apple Health (Medicaid) Fee-For-Service Preferred Drug List no longer applies. All PDL products are on HCA’s Apple Health Preferred Drug List that is used by managed care plans and the fee-for-service program.
If you can't find the versions you're looking for, email Apple Health Pharmacy Policy.
The therapeutic interchange program (TIP) will apply only to drug classes included in both the Washington PDL and the Apple Health PDL. Therapeutic interchange is a service for Endorsing Practitioners of the Washington PDL.
Prescription drug billing, rate, PDL, and authorization information
For information on billing and rates, the Apple Health PDL, and expedited authorization codes, please visit the Prescription Drug Program on our provider billing guide and rates webpage.