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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

ADHD/anti-narcolepsy
  • 61.40.00.AA
Androgenic Agents
  • 23.10.00
Antiasthmatic Monoclonal Antibodies
  • 44.60.30
  • 44.60.40
Antibiotics
  • 16.00.00.49
  • 07.00.00
  • 16.14.00
Antidepressants
  • 58.12.00
Antidiabetics
  • 27.15.00
  • 27.17.00
Antihyperlipidemics
  • 39.48.00
  • 39.35.00
Antiparasitics
  • 16.40.00.60
Antipsychotics
  • 59.40.00.18
Antivirals
  • 12.35.30.99
  • 12.10.99
  • 12.10.99.AB
  • 12.10.99.AA
  • 12.10.90.AA
Atopic Dermatitis Agents
  • 90.27.30.20
  • 90.78.40
  • 90.23.00.AA
Bone Density Regulators
  • 30.04.00
Brands with Generic Equivalents
  • NC-001
Cardiovascular Agents
  • 40.70.00

Chronic GI Motility Agents

  • 52.55.00
COVID-19
  • 19.50.20
Cystic Fibrosis Agents
  • 45.30.00
Cytokine and CAM Agents
  • 66.27.00
Dermatologics
  • 90.05.00.AA
Endocrine and Metabolic Agents: Metabolic Modifiers
  • 30.90.20.30
  • 30.90.85.50
  • 30.90.85.65
  • 30.90.90
  • 30.90.95
Gout Agents
  • 68.00.00
Growth Hormone Agents
  • 30.10.00
Hormone replacement
  • 24.00.00
Hematopoietic Agents
  • 82.40.10
  • 82.40.15
  • 82.40.50
Migraine Products
  • 67.70.10
  • 67.70.20

Medication Treatment for Substance Abuse Disorders (SUDs)

  • 65.20.00.10
  • 93.40.00.20
Neuromuscular Agents
  • 74.50.90
  • 74.70.00.AA
  • 74.70.65.AA
Oncology
  • 21.10.40
  • 21.60.00.45
  • 21.53.40
Opioids
  • 65.10.00.50
  • 65.10.00
  • 65.10.00.25
Ophthalmics
  • 86.37.00
  • 86.73.40
Progesterones
  • 26.00.00

Proton Pump Inhibitors (PPIs)

  • 49.27.00
Psychotherapeutic and Neurological Agents – MISC : Multiple Sclerosis Agents
  • 62.40.60.30
  • 62.40.50.60
Psychotherapeutic and Neurological Agents – MISC : Transthyretin Amyloidosis Agents
  • 62.70.00
Pulmonary Arterial Hypertension (PAH) Agents
  • 40.12.00
Pulmonary Fibrosis Agents
  • 45.55.00
Respiratory Agents – MISC
  • 45.10.00.00