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 and FAQs	Forms
Androgenic Agents	Testosterone Replacement Therapy (TRT)
Antiasthmatic Monoclonal Antibodies	Anti-IgE Antibodies IL-5 Antagonists
Antibiotics	Inhaled Aminoglycosides Inhaled Aztreonam
Anticonvulsants	Pregabalin Rescue Agents
Antidiabetics	Amylin Analogs
Antihyperlipidemics	Apolipoprotein B (APOB) Synthesis Inhibitors - Lomitapide Mesylate Apolipoprotein B (APOB) Synthesis Inhibitors - Mipomersen Sodium PCSK-9 Inhibitors
Atopic Dermatitis Agents	Topical Immunosuppressives
Cardiovascular Agents	Sinus Node Inhibitors Valsartan-Sacubitril
Chronic GI Motility Agents	Chronic GI Motility Agents
Cytokine and CAM Agents	Cytokine and CAM Agents
Growth Hormone Agents	Growth Hormone Agents
Hepatitis C	Hepatitis C Clinical Policy	13-830A Hepatitis C
Medication Treatment for Substance Abuse Disorders (SUDs)	Buprenorphine Containing Products Naltrexone Containing Products	Request for Buprenorphine Monotherapy (13-330)
Methadone	Methadone
Multiple Sclerosis Agents	Dalfampridine
Opioids	Opioid Clinical Policy Q&A for prescribers (October 18, 2017) Q&A for pharmacies (October 5, 2017) Opioid expedited authorization how-to Patient handout (October 27, 2017) English \| Spanish	Opioid Attestation (13-967)
Ophthalmics	Immunomodulators
Progesterones	Hydroxyprogesterone Caproate
Proton Pump Inhibitors (PPIs)	Proton Pump Inhibitor (PPI) Policy
Pulmonary Arterial Hypertension (PAH) Agents	Pulmonary Arterial Hypertension (PAH) Agents
Pulmonary Fibrosis Agents	Pulmonary Fibrosis Agents
Spinraza	Spinraza Policy