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Apple Health (Medicaid) drug coverage criteria

Use this page to find drug policies and request forms.

For information on billing and rates, the Apple Health preferred drug list, and expedited authorization codes, please visit the Prescription Drug Program on our provider billing guide and rates page.

Coverage for	Policies	Policy Number
Androgenic Agents	Testosterone Replacement Therapy (TRT)	23.10.00
Antiasthmatic Monoclonal Antibodies	Anti-IgE antibodies IL-5 antagonists	44.60.30 44.60.40
Antibiotics	Anti-infective agents - Rifaximin Inhaled aminoglycosides Inhaled Aztreonam	16.00.00.49 07.00.00 16.14.00
Antidiabetics	Amylin analogs	27.15.00
Antihyperlipidemics	Apolipoprotein B (APOB) synthesis inhibitors - Lomitapide Mesylate PCSK-9 inhibitors	39.48.00 39.35.00
Antiparasitics	Antiprotozoal agents – Nitazoxanide	16.40.00.60
Antipsychotics	Second generation - cariprazine	59.40.00.18
Antivirals	Hepatitis C treatments HIV combinations HIV - cabotegravir / rilpivirine HIV - emtricitabine / tenofovir	12.35.30.99 12.10.99 12.10.99.AB 12.10.99.AA
Atopic Dermatitis Agents	Dupilumab Topical immunosuppressives Topical PDE4 Inhibitors	90.27.30.20 90.78.40 90.23.00
Bone Density Regulators	Bone Density Regulators	30.04.00
Brands with Generic Equivalents	Brands with generic equivalents	NC-001
Cardiovascular Agents	Sinus node inhibitors	40.70.00
Chronic GI Motility Agents	Chronic GI motility agents	52.55.00
Cystic Fibrosis Agents	Cystic Fibrosis agents	45.30.00
Cytokine and CAM Agents	Cytokine and CAM agents	66.27.00
Endocrine and Metabolic Agents: Metabolic Modifiers	Elapegademase-lvlr Phenylketonuria (PKU) agents - Pegvaliase-pqpz Phenylketonuria (PKU) agents - Sapropterin Tripeptidyl Peptidase 1 Deficiency agents - Cerliponase Alfa X-Linked Hypohosphatemia (XLH) agents - Burosumab--twza	30.90.20.30 30.90.85.50 30.90.85.65 30.90.90 30.90.95
Gout Agents	Gout Agents	68.00.00
Growth Hormone Agents	Growth Hormone Agents	30.10.00
Hormone replacement	Gender Dysphoria	24.00.00
Hematopoietic Agents	Erythropoiesis-stimulating agents (ESAs) Granulocyte colony stimulating factors (G-CSF) Thrombopoiesis (TPO) stimulating proteins	82.40.10 82.40.15 82.40.50
Migraine Products	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
Monoclonal Antibody Treatment for COVID-19	Monoclonal Antibody Treatment for COVID-19 For general information about COVID-19, see HCA’s Information about novel coronavirus (COVID-19) webpage	19.50.20
Neuromuscular Agents	ALS - edaravone SMA - nusinersen	74.50.90 74.70.00
Oncology	Imidiazotetrazines Radiopharmaceuticals - lutetium Lu 177 dotatate Tyrosine Kinase Inhibitors (TKI)	21.10.40 21.60.00.45 21.53.40
Opioids	Methadone Opioid Clinical Policy Transmucosal Fentanyl Products	65.10.00.50 65.10.00 65.10.00.25
Ophthalmics	Gene Therapy - Voretigene neparvovec-rzyl Immunomodulators	86.37.00 86.73.40
Progesterones	Hydroxyprogesterone Caproate	26.00.00
Proton Pump Inhibitors (PPIs)	Proton Pump Inhibitor (PPI) Policy Duration of use dose limits for PPIs - Fact sheet	49.27.00
Psychotherapeutic and Neurological Agents – MISC : Multiple Sclerosis Agents	Dalfampridine Ocrelizumab	62.40.60.30 62.40.50.60
Psychotherapeutic and Neurological Agents – MISC : Transthyretin Amyloidosis Agents	Transthyretin Amyloidosis Agents	62.70.00
Pulmonary Arterial Hypertension (PAH) Agents	Pulmonary Arterial Hypertension (PAH) Agents	40.12.00
Pulmonary Fibrosis Agents	Pulmonary Fibrosis Agents	45.55.00
Respiratory Agents – MISC	Alpha-Proteinase Inhibitor (Human)	45.10.00.00