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
ADHD/anti-narcolepsy	Anti-narcolepsy Viloxazine	61.40.00 61.35.40.AA
Androgenic Agents	Testosterone Replacement Therapy (TRT)	23.10.00
Anorexiants/Anti-Obesity	GLP-1 Receptor Agonists - semaglutide GLP-1 Receptor Agonists - tirzepatide	61.25.20.AA 61.25.25.AA
Antiasthmatic Monoclonal Antibodies	Anti-IgE antibodies IL-5 antagonists	44.60.30.AA 44.60.40
Antibiotics	Anti-infective agents - Rifaximin Inhaled aminoglycosides Inhaled Aztreonam	16.00.00.49 07.00.00 16.14.00
Antidepressants	Serotonin modulators	58.12.00
Antidiabetics	Amylin analogs GLP-1 agonists	27.15.00 27.17.00
Antihemophilic	Etranacogene dezaparvovec-drlb	85.10.25.AA
Antihyperlipidemics	Apolipoprotein B (APOB) synthesis inhibitors - Lomitapide Mesylate Icosapent ethyl PCSK-9 inhibitors	39.48.00 39.50.00.AA 39.35.00
Antiparasitics	Antiprotozoal agents – Nitazoxanide	16.40.00.60
Antipsychotics	Second generation - cariprazine	59.40.00.18
Antivirals	Hepatitis C treatments	12.35.30.99
Atopic Dermatitis Agents	Topical immunosuppressives Crisaborole	90.78.40 90.23.00.AA
Bone Density Regulators	Calcitonins Parathyroid Hormone Derivatives RANKL Inhibitors Sclerostin Inhibitors	30.04.30 30.04.40 30.04.45 30.04.48
Brands with Biosimilars or A-rated Generics	Brands with Biosimilars or A-rated Generics	NC-001
Cardiovascular Agents	Sinus node inhibitors	40.70.00
Chronic GI Motility Agents	Chronic GI motility agents	52.55.00
COVID-19	Therapies for COVID-19	19.50.20
Corticosteroids	Deflazacort	22.10.00.AA
Cystic Fibrosis Agents	Cystic Fibrosis agents	45.30.00
Cytokine and CAM Antagonists	IL-1 Inhibitors IL-12/IL-23 Inhibitors IL-17 Inhibitors IL-4/IL-13/IL-31 Inhibitors IL-6 Inhibitors Integrin Receptor Antagonists Janus Associated Kinase (JAK) Inhibitors Oral PDE-4 Inhibitors S1-P Receptor Modulators T-Lymphocyte Inhibitors Tumor Necrosis Factor (TNF) Inhibitors	66.27.00.AI 66.27.00.AD 66.27.00.AE 66.27.00.AB 66.27.00.AC 66.27.00.AJ 66.27.00.AH 66.27.00.AF 66.27.00.AK 66.27.00.AG 66.27.00.AA
Dermatologics	Acne - isotretinoin	90.05.00.AA
Endocrine and Metabolic Agents	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	Gout Agents	68.00.00
Growth Hormone Agents	Growth Hormone Agents	30.10.00
Hormone replacement	Gender Dysphoria	24.00.00
Hematological Agents	Hereditary Angioedema Agents (HAE) – Acute Hereditary Angioedema Agents (HAE) - Prophylaxis	85.82.00.AA 85.80.20.AA
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
Immune Modulators	Thalidomide analogs	99.39.20
Migraine Agents	Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists	67.70.10
Movement Disorder Agents	Valbenazine	62.38.00.AA
Multiple Sclerosis Agents	Natalizumab Ozanimod	62.40.50.AA 62.40.70.AA
Musculoskeletal Therapy Agents	Carisoprodol	75.10.00.AA
Neuromuscular Agents	ALS - edaravone Lupus agents SMA - nusinersen SMA - risdiplam	74.50.90 99.40.20 74.70.00.AA 74.70.65.AA
Oncology	Androgen Biosynthesis Inhibitors – abiraterone Cyclin Dependent Kinase Inhibitors Imidiazotetrazines Radiopharmaceuticals - lutetium Lu 177 dotatate Tyrosine Kinase Inhibitors (TKI)	21.40.60 21.53.10 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	Cenegermin-bkbj Gene Therapy - Voretigene neparvovec-rzyl	86.77.00.AA 86.37.00
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
Sleep Disorder Agents	tasimelteon	60.25.00.AA

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Apple Health (Medicaid) drug coverage criteria

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