Apple Health (Medicaid) drug coverage criteria

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 Aztreonam

• 16.00.00.49
• 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

• Adenosine Triphosphate - Citrate Lyase Inhibitors
• Apolipoprotein B (APOB) synthesis inhibitors - Lomitapide Mesylate
• Icosapent ethyl
• PCSK-9 inhibitors

• 39.38.00
• 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

• Crisaborole

• 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
• Vasoactive Soluble Guanylate Cyclase Stimulators

• 40.70.00
• 40.90.00

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
• IL-36 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.AL
• 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
• Somatostatic Agents
• Teprotumumab
• Tripeptidyl Peptidase 1 Deficiency agents - Cerliponase Alfa
• Urea Cycle Disorder Agents - Oral
• Vasopressin Receptor Antagonists - Oral
• X-Linked Hypophosphatemia (XLH) agents - Burosumab--twza

• 30.90.20.30
• 30.90.85.50
• 30.90.85.65
• 30.17.00
• 30.19.20.AA
• 30.90.90
• 30.90.80
• 30.45.40
• 30.90.95

Gout Agents

• Gout Agents

• 68.00.00

Growth Hormone Agents

• Growth Hormone Agents

• 30.10.00

Hematological Agents

• Hereditary Angioedema Agents (HAE) – Acute
• Hereditary Angioedema Agents (HAE) - Prophylaxis

• 85.82.00.AA
• 85.80.20.AA

Hematopoietic Agents

• Granulocyte colony stimulating factors (G-CSF)
• Sickle Cell Disease Cell and Gene Therapies
• Thrombopoiesis (TPO) stimulating proteins

• 82.40.15
• 82.80.40
• 82.40.50

Immune Modulators

• Thalidomide analogs

• 99.39.20

Medical Necessity

• Medical Necessity

• NC-0002

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
• Antiandrogens - Oral
• Antimetabolites - Oral
• BRAF Kinase Inhibitors - Oral
• Cyclin Dependent Kinase Inhibitors
• Imidiazotetrazines
• Phosphatidylinositol 3-Kinase (PI3K) Inhibitors – Oral
• Radiopharmaceuticals - lutetium Lu 177 dotatate
• Tyrosine Kinase Inhibitors (TKI)

• 21.40.60
• 21.40.24
• 21.30.00
• 21.53.20
• 21.53.10
• 21.10.40
• 21.53.80
• 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