maintenance drug pharmacy program - caresource

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Maintenance Drug Pharmacy Program CareSource offers a 90-day supply of certain maintenance medications as part of our pharmacy program. Maintenance medications are used to treat long-term conditions or chronic illness. It is important to take maintenance medications regularly and as prescribed. Related to the Coronavirus (COVID-19) pandemic, all CareSource Ohio Medicaid members are eligible for 90-day supplies of the medications listed below. Please note that utilization edits will apply (dose and quantity limits and other safety edits) and some medications may require Prior Authorization or Step before a 90-day supply will process. 1ST TIER UNIFINE PENTP 5MM 31G 1ST TIER UNIFINE PNTIP 4MM 32G 1ST TIER UNIFINE PNTIP 6MM 31G 1ST TIER UNIFINE PNTIP 8MM 31G 1ST TIER UNIFINE PNTP 12MM 29G 1ST TIER UNIFINE PNTP 29GX1/2" 1ST TIER UNIFINE PNTP 31GX1/4" 1ST TIER UNIFINE PNTIP 8MM 31G 1ST TIER UNIFINE PNTP 31GX3/16 1ST TIER UNIFINE PNTP 31GX5/16 1ST TIER UNIFINE PNTP 32GX5/32 1ST TIER COMFORTOUCH 28G LANCT 1ST TIER COMFORTOUCH 30G LANCT 24HR ALLERGY(LEVOCETIRZN) 5 MG RELION 2-IN-1 LANCET DEVICE 2TEK CONTROL SOLUTION 2TEK GLUCOSE-WRIST MONITOR KIT 50 PLUS ADULT EYE HEALTH SFTGL A THRU Z ADVANCED FORMULA TAB A THRU Z MEN'S ULTIMATE TABLET A THRU Z ADVANCED FORMULA TAB A THRU Z ADVANCED FORMULA TAB A THRU Z SELECT TABLET A THRU Z SELECT WOMEN'S TABLET A THRU Z SELECT MEN 50+ TABLET A THRU Z SELECT MULTIVIT TAB A THRU Z SELECT TABLET A THRU Z SELECT 50 PLUS TABLET ABACAVIR 20 MG/ML SOLUTION ABACAVIR 300 MG TABLET ABACAVIR-LAMIVUDINE 600-300 MG ABACAVIR-LAMIVUDINE-ZIDOV TAB ABC PLUS TABLET ABDEK MULTIVITAMIN SOFTGEL ABDEK MULTIVITAMIN DROP ABDEK MULTIVITAMIN CHEW TAB ABILIFY 10 MG TABLET ABILIFY 15 MG TABLET OHIO MEDICAID Effective April 1, 2020

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Maintenance Drug Pharmacy Program CareSource offers a 90-day supply of certain maintenance medications as part of our pharmacy

program. Maintenance medications are used to treat long-term conditions or chronic illness. It is

important to take maintenance medications regularly and as prescribed.

Related to the Coronavirus (COVID-19) pandemic, all CareSource Ohio Medicaid

members are eligible for 90-day supplies of the medications listed below. Please note that

utilization edits will apply (dose and quantity limits and other safety edits) and some medications

may require Prior Authorization or Step before a 90-day supply will process.

1ST TIER UNIFINE PENTP 5MM 31G

1ST TIER UNIFINE PNTIP 4MM 32G

1ST TIER UNIFINE PNTIP 6MM 31G

1ST TIER UNIFINE PNTIP 8MM 31G

1ST TIER UNIFINE PNTP 12MM 29G

1ST TIER UNIFINE PNTP 29GX1/2"

1ST TIER UNIFINE PNTP 31GX1/4"

1ST TIER UNIFINE PNTIP 8MM 31G

1ST TIER UNIFINE PNTP 31GX3/16

1ST TIER UNIFINE PNTP 31GX5/16

1ST TIER UNIFINE PNTP 32GX5/32

1ST TIER COMFORTOUCH 28G LANCT

1ST TIER COMFORTOUCH 30G LANCT

24HR ALLERGY(LEVOCETIRZN) 5 MG

RELION 2-IN-1 LANCET DEVICE

2TEK CONTROL SOLUTION

2TEK GLUCOSE-WRIST MONITOR KIT

50 PLUS ADULT EYE HEALTH SFTGL

A THRU Z ADVANCED FORMULA TAB

A THRU Z MEN'S ULTIMATE TABLET

A THRU Z ADVANCED FORMULA TAB

A THRU Z ADVANCED FORMULA TAB

A THRU Z SELECT TABLET

A THRU Z SELECT WOMEN'S TABLET

A THRU Z SELECT MEN 50+ TABLET

A THRU Z SELECT MULTIVIT TAB

A THRU Z SELECT TABLET

A THRU Z SELECT 50 PLUS TABLET

ABACAVIR 20 MG/ML SOLUTION

ABACAVIR 300 MG TABLET

ABACAVIR-LAMIVUDINE 600-300 MG

ABACAVIR-LAMIVUDINE-ZIDOV TAB

ABC PLUS TABLET

ABDEK MULTIVITAMIN SOFTGEL

ABDEK MULTIVITAMIN DROP

ABDEK MULTIVITAMIN CHEW TAB

ABILIFY 10 MG TABLET

ABILIFY 15 MG TABLET

OHIO MEDICAID Effective April 1, 2020

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ABILIFY 2 MG TABLET

ABILIFY 20 MG TABLET

ABILIFY 30 MG TABLET

ABILIFY 5 MG TABLET

ABILIFY MAINTENA ER 300 MG SYR

ABILIFY MAINTENA ER 300 MG VL

ABILIFY MAINTENA ER 400 MG SYR

ABILIFY MAINTENA ER 400 MG VL

ABILIFY MYCITE 10 MG KIT

ABILIFY MYCITE 15 MG KIT

ABILIFY MYCITE 2 MG KIT

ABILIFY MYCITE 20 MG KIT

ABILIFY MYCITE 30 MG KIT

ABILIFY MYCITE 5 MG KIT

ABIRATERONE ACETATE 250 MG TAB

ABOUTTIME PEN NEEDLE 30G X 8MM

ABOUTTTIME PEN NEEDLE 31G X 5MM

ABOUTTIME PEN NEEDLE 31G X 8MM

ABOUTTIME PEN NEEDLE 32G X 4MM

ACACIA 1:20 (W/V) VIAL

ACAMPROSATE CALC DR 333 MG TAB

ACARBOSE 100 MG TABLET

ACARBOSE 25 MG TABLET

ACARBOSE 50 MG TABLET

ACCOLATE 10 MG TABLET

ACCOLATE 20 MG TABLET

ACCU-CHEK AVIVA SOLUTION

ACCU-CHEK COMPACT PLUS KIT

ACCU-CHEK COMBO SYSTEM

ACCU-CHEK MULTICLIX LANCETS

ACCU-CHEK MULTICLIX LANCET KIT

ACCU-CHEK AVIVA CONNECT METER

ACCU-CHEK AVIVA PLUS TEST STRP

ACCU-CHEK AVIVA PLUS METER

ACCU-CHEK COMPACT PLUS CONTROL

ACCU-CHEK COMPACT PLUS STRIPS

ACCU-CHEK FASTCLIX LANCET DRUM

ACCU-CHEK FASTCLIX LANCING DEV

ACCU-CHEK GUIDE L1-L2 CTRL SOL

ACCU-CHEK GUIDE ME GLUCOSE MTR

ACCU-CHEK GUIDE MONITOR SYSTEM

ACCU-CHEK GUIDE TEST STRIP

ACCU-CHEK NANO SMARTVIEW METER

ACCU-CHEK SAFE-T-PRO 23G LANCT

ACCU-CHEK SAFE-T-PRO PLUS 23G

ACCU-CHEK SMARTVIEW TEST STRIP

ACCU-CHEK SMARTVIEW CONTRL SOL

ACCU-CHEK SOFTCLIX LANCETS

ACCU-CHEK SOFTCLIX LANCET KIT

ACCUPRIL 10 MG TABLET

ACCUPRIL 20 MG TABLET

ACCUPRIL 40 MG TABLET

ACCUPRIL 5 MG TABLET

ACCURETIC 10-12.5 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ACCURETIC 20-12.5 MG TABLET

ACCURETIC 20-25 MG TABLET

ACCUTREND CHOLESTEROL CONTROL

ACCUTREND GLUCOSE CONTROL

ACCUTREND GLUCOSE TEST STRIP

ACCUTREND PLUS METER

ACEBUTOLOL 200 MG CAPSULE

ACEBUTOLOL 400 MG CAPSULE

ACETAZOLAMIDE 125 MG TABLET

ACETAZOLAMIDE 250 MG TABLET

ACETAZOLAMIDE ER 500 MG CAP

ACID CONTROL 150 MG TABLET

ACID CONTROL 75 MG TABLET

GNP ACID CONTROL 150 MG TABLET

ACID CONTROLLER 10 MG TABLET

ACID CONTROLLER 20 MG TABLET

CVS ACID CONTROLLER 10 MG TAB

CVS ACID CONTROLLER 20 MG TAB

QC ACID CONTROLLER 10 MG TAB

ACID REDUCER 200 MG TABLET

EQ ACID REDUCER 200 MG TABLET

SM ACID REDUCER 200 MG TABLET

ACID REDUCER 10 MG TABLET

ACID REDUCER 20 MG TABLET

EQ ACID REDUCER 10 MG TABLET

EQ ACID REDUCER 20 MG TABLET

GNP ACID REDUCER 10 MG TABLET

GNP ACID REDUCER 20 MG TABLET

PUB ACID REDUCER 10 MG TABLET

RA ACID REDUCER 10 MG TABLET

RA ACID REDUCER 20 MG TABLET

SM ACID REDUCER 10 MG TABLET

SM ACID REDUCER 20 MG TABLET

ACID REDUCER DR 20 MG CAP

ACID REDUCER 150 MG TABLET

ACID REDUCER 75 MG TABLET

CVS ACID REDUCER 150 MG TABLET

CVS ACID REDUCER 75 MG TABLET

EQ ACID REDUCER 150 MG TABLET

EQL ACID REDUCER 150 MG TABLET

EQL ACID REDUCER 75 MG TABLET

GNP ACID REDUCER 75 MG TABLET

GS ACID REDUCER 150 MG TABLET

GS ACID REDUCER 75 MG TABLET

HM ACID REDUCER 150 MG TABLET

HM ACID REDUCER 75 MG TABLET

RA ACID REDUCER 150 MG TABLET

SB ACID REDUCER 150 MG TABLET

SM ACID REDUCER 150 MG TABLET

SM ACID REDUCER 75 MG TABLET

SW ACID REDUCER 150 MG TABLET

ACIPHEX DR 20 MG TABLET

ACIPHEX SPRINKLE DR 10 MG CAP

ACIPHEX SPRINKLE DR 5 MG CAP

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ACITRETIN 10 MG CAPSULE

ACITRETIN 17.5 MG CAPSULE

ACITRETIN 25 MG CAPSULE

ACREMONIUM 20,000 PNU/ML

ACTEMRA 162 MG/0.9 ML SYRINGE

ACTEMRA 200 MG/10 ML VIAL

ACTEMRA 400 MG/20 ML VIAL

ACTEMRA 80 MG/4 ML VIAL

ACTEMRA ACTPEN 162 MG/0.9 ML

ACTIGALL 300 MG CAPSULE

ACTI-LANCE LITE 28G LANCETS

ACTI-LANCE SPECIAL 17G LANCETS

ACTI-LANCE UNIVERS 23G LANCETS

ACTIMMUNE 100 MCG/0.5 ML VIAL

ACTIVE OB SOFTGEL

ACTIVELLA 0.5-0.1 MG TABLET

ACTIVELLA 1 MG-0.5 MG TABLET

ACTIVITE TABLET

ACTONEL 150 MG TABLET

ACTONEL 35 MG TABLET

ACTONEL 5 MG TABLET

ACTOPLUS MET 15 MG-500 MG TAB

ACTOPLUS MET 15 MG-850 MG TAB

ACTOPLUS MET XR 15-1,000 MG TB

ACTOPLUS MET XR 30-1,000 MG TB

ACTOS 15 MG TABLET

ACTOS 30 MG TABLET

ACTOS 45 MG TABLET

ACYCLOVIR 200 MG CAPSULE

ACYCLOVIR 200 MG/5 ML SUSP

ACYCLOVIR 400 MG TABLET

ACYCLOVIR 800 MG TABLET

ADAGEN 250 UNIT/ML VIAL

ADAKVEO 100 MG/10 ML VIAL

ADALAT CC 30 MG TABLET

ADALAT CC 60 MG TABLET

ADALAT CC 90 MG TABLET

ADCIRCA 20 MG TABLET

ADDAPRIN 200 MG TABLET

ADDERALL 10 MG TABLET

ADDERALL 12.5 MG TABLET

ADDERALL 15 MG TABLET

ADDERALL 20 MG TABLET

ADDERALL 30 MG TABLET

ADDERALL 5 MG TABLET

ADDERALL 7.5 MG TABLET

ADDERALL XR 10 MG CAPSULE

ADDERALL XR 15 MG CAPSULE

ADDERALL XR 20 MG CAPSULE

ADDERALL XR 25 MG CAPSULE

ADDERALL XR 30 MG CAPSULE

ADDERALL XR 5 MG CAPSULE

ADEMPAS 0.5 MG TABLET

ADEMPAS 1 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ADEMPAS 1.5 MG TABLET

ADEMPAS 2 MG TABLET

ADEMPAS 2.5 MG TABLET

ADHANSIA XR 25 MG CAPSULE

ADHANSIA XR 35 MG CAPSULE

ADHANSIA XR 45 MG CAPSULE

ADHANSIA XR 55 MG CAPSULE

ADHANSIA XR 70 MG CAPSULE

ADHANSIA XR 85 MG CAPSULE

ADLYXIN 20 MCG MAINTENANCE PK

ADMELOG 100 UNIT/ML VIAL

ADMELOG SOLOSTAR 100 UNIT/ML

ADULT ASPIRIN REGIMEN EC 81 MG

ADULT MULTI + OMEGA-3 GUMMIES

ADULT MULTI GUMMIES

ADULT MULTIVITAMIN EXTRA D3

ADULT MULTIVITAMIN GUMMIES

ADULT ONE DAILY GUMMIES

ADULT ONE DAILY MULTIVIT TAB

ADULTS 50 PLUS DAILY FORMULA

ADULTS 50 PLUS MULTIVITAMIN

ADULTS 50 PLUS MULTIVITAMIN TB

ADULTS' DAILY FORMULA TABLET

ADULTS MULTIVITAMIN CAPLET

ADULTS MULTIVITAMIN TABLET

ADVAIR 100-50 DISKUS

ADVAIR 250-50 DISKUS

ADVAIR 500-50 DISKUS

ADVAIR HFA 115-21 MCG INHALER

ADVAIR HFA 230-21 MCG INHALER

ADVAIR HFA 45-21 MCG INHALER

CVS ADVANCED GLUCOSE METER

CVS ADVANCED GLUCOSE TEST STR

CVS ADVANCED GLUCOSE TEST STR

ADVANCED LANCING DEVICE

PUB ADVANCED LANCING DEVICE

ADVANCED MULTI EA CHEW TABLET

ADVANCED TRAVEL 28G LANCETS

ADVANCED TRAVEL 30G LANCETS

ADVATE 1,201-1,800 UNIT VIAL

ADVATE 1,801-2,400 UNIT VIAL

ADVATE 2,401-3,600 UNIT VIAL

ADVATE 200-400 UNIT VIAL

ADVATE 3,601-4,800 UNIT VIAL

ADVATE 401-800 UNIT VIAL

ADVATE 801-1,200 UNIT VIAL

ADVIL 100 MG TABLET

ADVIL 200 MG CAPLET

ADVIL 200 MG GEL CAPLET

ADVIL 200 MG LIQUI-GEL CAPSULE

ADVIL 200 MG TABLET

ADVIL JR STR 100 MG TAB CHEW

ADVIL LIQUI-GELS 200 MG CAP

ADVIL MIGRAINE 200 MG CAPS

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ADVOCATE BLOOD GLUCOSE MONITOR

ADVOCATE CONTROL SOLUTION HIGH

ADVOCATE CONTROL SOLUTION LOW

ADVOCATE DUO GLU-WRIST MONITOR

ADVOCATE 26G LANCETS

ADVOCATE 30G LANCETS

ADVOCATE 26G LANCETS

ADVOCATE PEN NEEDLE 4MM 33G

ADVOCATE PEN NDL 12.7MM 29G

ADVOCATE PEN NEEDLES 5MM 31G

ADVOCATE PEN NEEDLES 8MM 31G

ADVOCATE REDI-CODE TEST STRIP

ADVOCATE REDI-CODE GLU METER

ADVOCATE REDI-CODE GLU MONITOR

ADVOCATE REDI-CODE PLUS METER

ADVOCATE REDI-CODE+ TEST STRIP

ADVOCATE REDI-CODE+ CTRL SOLN

ADVOCATE REDI-CODE+ CTRL SOLN

ADVOCATE INS 1 ML 31GX5/16"

ADVOCATE INS SYR 1 ML 29GX1/2"

ADVOCATE INS SYR 1 ML 30GX5/16

ADVOCATE INS 0.5 ML 30GX5/16"

ADVOCATE INS 0.5 ML 31GX5/16"

ADVOCATE INS SYR 0.5ML 29GX1/2

ADVOCATE INS 0.3 ML 30GX5/16"

ADVOCATE INS 0.3 ML 31GX5/16"

ADVOCATE INS SYR 0.3ML 29GX1/2

ADVOCATE TEST STRIP

ADYNOVATE 1,251-2,500 UNIT VL

ADYNOVATE 1,500 UNIT VIAL

ADYNOVATE 200-400 UNIT VIAL

ADYNOVATE 3,000 UNIT VIAL

ADYNOVATE 401-800 UNIT VIAL

ADYNOVATE 750 UNIT VIAL

ADYNOVATE 801-1,250 UNIT VIAL

ADZENYS ER 1.25 MG/ML SUSP

ADZENYS XR-ODT 12.5 MG TABLET

ADZENYS XR-ODT 15.7 MG TABLET

ADZENYS XR-ODT 18.8 MG TABLET

ADZENYS XR-ODT 3.1 MG TABLET

ADZENYS XR-ODT 6.3 MG TABLET

ADZENYS XR-ODT 9.4 MG TABLET

AEROSPAN 80 MCG INHALER

AFEDITAB CR 30 MG TABLET

AFEDITAB CR 60 MG TABLET

AFINITOR 10 MG TABLET

AFINITOR 2.5 MG TABLET

AFINITOR 5 MG TABLET

AFINITOR 7.5 MG TABLET

AFINITOR DISPERZ 2 MG TABLET

AFINITOR DISPERZ 3 MG TABLET

AFINITOR DISPERZ 5 MG TABLET

AFIRMELLE-28 TABLET

AFREZZA 12 UNIT CARTRIDGE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

AFREZZA 30-4 UNIT / 60-8 UNIT

AFREZZA 4 UNIT CARTRIDGE

AFREZZA 4 UNIT/8 UNIT/12 UNIT

AFREZZA 60-4 UNIT / 30-8 UNIT

AFREZZA 60-8 UNIT / 30-12 UNIT

AFREZZA 8 UNIT CARTRIDGE

AFREZZA 90-4 UNIT / 90-8 UNIT

AFREZZA 90-8 UNIT / 90-12 UNIT

AFSTYLA 1,000 UNIT VIAL

AFSTYLA 1,500 UNIT RANGE VIAL

AFSTYLA 2,000 UNIT VIAL

AFSTYLA 2,500 UNIT RANGE VIAL

AFSTYLA 250 UNIT VIAL

AFSTYLA 3,000 UNIT VIAL

AFSTYLA 500 UNIT VIAL

AGAMATRIX AMP TEST STRIPS

AGAMATRIX AMP GLUC MONITOR SYS

AGAMATRIX NORM-HI CONTROL SOLN

AGAMATRIX HIGH CONTROL SOLN

AGGRENOX 25 MG-200 MG CAPSULE

AGRYLIN 0.5 MG CAPSULE

AIMOVIG 140 MG/ML AUTOINJECTOR

AIMOVIG 70 MG/ML AUTOINJECTOR

AIMOVIG 140 MG DOSE-2 AUTOINJ

AIRDUO RESPICLICK 113-14 MCG

AIRDUO RESPICLICK 232-14 MCG

AIRDUO RESPICLICK 55-14 MCG

AJOVY 225 MG/1.5 ML SYRINGE

ALBA-LYBE LIQUID

ALBUTEROL 2.5 MG/0.5 ML SOL

ALBUTEROL 5 MG/ML SOLUTION

ALBUTEROL SUL 0.63 MG/3 ML SOL

ALBUTEROL SUL 1.25 MG/3 ML SOL

ALBUTEROL SUL 2.5 MG/3 ML SOLN

ALBUTEROL SULF 2 MG/5 ML SYRUP

ALBUTEROL SULFATE 2 MG TAB

ALBUTEROL SULFATE 4 MG TAB

ALBUTEROL SULFATE ER 4 MG TAB

ALBUTEROL SULFATE ER 8 MG TAB

ALBUTEROL HFA 90 MCG INHALER

ALDACTAZIDE 25-25 TABLET

ALDACTAZIDE 50-50 TABLET

ALDACTONE 100 MG TABLET

ALDACTONE 25 MG TABLET

ALDACTONE 50 MG TABLET

ALDER 1:20 (W/V) VIAL

ALDURAZYME 2.9 MG/5 ML VIAL

ALECENSA 150 MG CAPSULE

ALENDRONATE SOD 70 MG/75 ML

ALENDRONATE SODIUM 10 MG TAB

ALENDRONATE SODIUM 35 MG TAB

ALENDRONATE SODIUM 40 MG TAB

ALENDRONATE SODIUM 5 MG TABLET

ALENDRONATE SODIUM 70 MG TAB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ALEVE 220 MG CAPLET

ALEVE 220 MG GELCAP

ALEVE 220 MG LIQUID GEL CAP

ALEVE 220 MG TABLET

ALFUZOSIN HCL ER 10 MG TABLET

ALIQOPA 60 MG VIAL

ALISKIREN 150 MG TABLET

ALISKIREN 300 MG TABLET

ALIVE ONCE DAILY WOMEN 50 PLUS

ALIVE PRENATAL GUMMY

ALIVE WOMEN'S 50 PLUS TABLET

ALIVE WOMEN'S ENERGY MV TABLET

ALIVE WOMEN'S GUMMY VITAMIN

ALL DAY PAIN RELIEF 220 MG TAB

ALL DAY PAIN RLF 220 MG CAPLET

CVS ALL DAY PAIN RLF 220 MG TB

GNP ALL DAY PAIN RLF 220 MG TB

SM ALL DAY RELIEF 220 MG CAPLT

ALL DAY RELIEF 220 MG CAPLET

ALL DAY RELIEF 220 MG TABLET

PUB ALL DAY RELIEF 220 MG TAB

PUB ALL DAY RLF 220 MG CAPLET

CVS ALLERGY RELIEF 5 MG TABLET

ALLOPURINOL 100 MG TABLET

ALLOPURINOL 300 MG TABLET

ALOGLIPTIN 12.5 MG TABLET

ALOGLIPTIN 25 MG TABLET

ALOGLIPTIN 6.25 MG TABLET

ALOGLIPTIN-METFORMIN 12.5-1000

ALOGLIPTIN-METFORMIN 12.5-500

ALOGLIPTIN-PIOGLIT 12.5-15 MG

ALOGLIPTIN-PIOGLIT 12.5-30 MG

ALOGLIPTIN-PIOGLIT 12.5-45 MG

ALOGLIPTIN-PIOGLIT 25-15 MG TB

ALOGLIPTIN-PIOGLIT 25-30 MG TB

ALOGLIPTIN-PIOGLIT 25-45 MG TB

ALORA 0.025 MG PATCH

ALORA 0.05 MG PATCH

ALORA 0.075 MG PATCH

ALORA 0.1 MG PATCH

ALPHAGAN P 0.1% DROPS

ALPHAGAN P 0.15% EYE DROPS

ALPHANATE 1,000-400 UNIT VIAL

ALPHANATE 1,500-600 UNIT VIAL

ALPHANATE 2,000-800 UNIT VIAL

ALPHANATE 250-100 UNIT VIAL

ALPHANATE 500-200 UNIT VIAL

ALPHANINE SD 1,000 UNIT VIAL

ALPHANINE SD 1,500 UNIT VIAL

ALPHANINE SD 500 UNIT VIAL

ALPROLIX 1,000 UNIT NOMINAL

ALPROLIX 2,000 UNIT NOMINAL

ALPROLIX 250 UNIT NOMINAL

ALPROLIX 3,000 UNIT NOMINAL

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ALPROLIX 4,000 UNIT NOMINAL

ALPROLIX 500 UNIT NOMINAL

ALTACE 1.25 MG CAPSULE

ALTACE 10 MG CAPSULE

ALTACE 2.5 MG CAPSULE

ALTACE 5 MG CAPSULE

ALTACHLORE 5% OINTMENT

ALTACHLORE 5% OPHTH SOLN

ALTAVERA-28 TABLET

ALTERNARIA 20,000 PNU/ML VIAL

ALTERNATE SITE 26G LANCETS

ALTOPREV 20 MG TABLET

ALTOPREV 40 MG TABLET

ALTOPREV 60 MG TABLET

ALUNBRIG 180 MG TABLET

ALUNBRIG 30 MG TABLET

ALUNBRIG 90 MG TABLET

ALVESCO 160 MCG INHALER

ALVESCO 80 MCG INHALER

ALYACEN 1-35 28 TABLET

ALYACEN 7-7-7-28 TABLET

ALYQ 20 MG TABLET

AMABELZ 0.5 MG-0.1 MG TABLET

AMABELZ 1 MG-0.5 MG TABLET

AMANTADINE 100 MG CAPSULE

AMANTADINE 100 MG TABLET

AMANTADINE 100 MG/10 ML SOLN

AMANTADINE 50 MG/5 ML SOLUTION

AMARYL 1 MG TABLET

AMARYL 2 MG TABLET

AMARYL 4 MG TABLET

AMBRISENTAN 10 MG TABLET

AMBRISENTAN 5 MG TABLET

AMERICAN BEECH 1:20 W/V VIAL

AMERICAN COCKROACH 1:20 (W/V)

AMERICAN ELM 1:20 (W/V) VIAL

AMERICAN SYCAMORE 1:20 (W/V)

AMETHIA 0.15-0.03-0.01 MG TAB

AMETHIA LO TABLET

AMETHYST 90-20 MCG TABLET

AMILORIDE HCL 5 MG TABLET

AMILORIDE HCL-HCTZ 5-50 MG TAB

AMIODARONE HCL 100 MG TABLET

AMIODARONE HCL 200 MG TABLET

AMIODARONE HCL 400 MG TABLET

AMITIZA 24 MCG CAPSULES

AMITIZA 8 MCG CAPSULE

AMITRIPTYLINE HCL 10 MG TAB

AMITRIPTYLINE HCL 100 MG TAB

AMITRIPTYLINE HCL 150 MG TAB

AMITRIPTYLINE HCL 25 MG TAB

AMITRIPTYLINE HCL 50 MG TAB

AMITRIPTYLINE HCL 75 MG TAB

AMLODIPINE BESYLATE 10 MG TAB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

AMLODIPINE BESYLATE 2.5 MG TAB

AMLODIPINE BESYLATE 5 MG TAB

AMLODIPINE-BENAZEPRIL 10-20 MG

AMLODIPINE-BENAZEPRIL 10-40 MG

AMLODIPINE-BENAZEPRIL 2.5-10

AMLODIPINE-BENAZEPRIL 5-10 MG

AMLODIPINE-BENAZEPRIL 5-20 MG

AMLODIPINE-BENAZEPRIL 5-40 MG

AMLODIPINE-ATORVAST 10-10 MG

AMLODIPINE-ATORVAST 10-20 MG

AMLODIPINE-ATORVAST 10-40 MG

AMLODIPINE-ATORVAST 10-80 MG

AMLODIPINE-ATORVAST 2.5-10 MG

AMLODIPINE-ATORVAST 2.5-20 MG

AMLODIPINE-ATORVAST 2.5-40 MG

AMLODIPINE-ATORVAST 5-10 MG

AMLODIPINE-ATORVAST 5-20 MG

AMLODIPINE-ATORVAST 5-40 MG

AMLODIPINE-ATORVAST 5-80 MG

AMLODIPINE-OLMESARTAN 10-20 MG

AMLODIPINE-OLMESARTAN 10-40 MG

AMLODIPINE-OLMESARTAN 5-20 MG

AMLODIPINE-OLMESARTAN 5-40 MG

AMLODIPINE-VALSARTAN 10-160 MG

AMLODIPINE-VALSARTAN 10-320 MG

AMLODIPINE-VALSARTAN 5-160 MG

AMLODIPINE-VALSARTAN 5-320 MG

AMLOD-VALSA-HCTZ 10-160-12.5MG

AMLOD-VALSA-HCTZ 10-160-25 MG

AMLOD-VALSA-HCTZ 10-320-25 MG

AMLOD-VALSA-HCTZ 5-160-12.5 MG

AMLOD-VALSA-HCTZ 5-160-25 MG

AMOXAPINE 100 MG TABLET

AMOXAPINE 150 MG TABLET

AMOXAPINE 25 MG TABLET

AMOXAPINE 50 MG TABLET

AMPHETAMINE ER 1.25 MG/ML SUSP

AMPHETAMINE SULFATE 10 MG TAB

AMPHETAMINE SULFATE 5 MG TAB

AMPYRA ER 10 MG TABLET

ANADROL-50 TABLET

ANAFRANIL 25 MG CAPSULE

ANAFRANIL 50 MG CAPSULE

ANAFRANIL 75 MG CAPSULE

ANAGRELIDE HCL 0.5 MG CAPSULE

ANAGRELIDE HCL 1 MG CAPSULE

ANAPROX DS 550 MG TABLET

ANASPAZ 0.125 MG TABLET ODT

ANASTROZOLE 1 MG TABLET

ANDRODERM 2 MG/24HR PATCH

ANDRODERM 4 MG/24HR PATCH

ANDROGEL 1% GEL PUMP

ANDROGEL 1%(2.5G) GEL PACKET

ANDROGEL 1%(5G) GEL PACKET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ANDROGEL 1.62% GEL PUMP

ANDROGEL 1.62%(1.25G) GEL PCKT

ANDROGEL 1.62%(2.5G) GEL PCKT

ANDROID 10 MG CAPSULE

ANDROXY 10 MG TABLET

ANGELIQ 0.25 MG-0.5 MG TABLET

ANGELIQ 0.5 MG-1 MG TABLET

ANIMAL CHEWS TABLET

ANIMAL SHAPES CHEWABLE TABLET

SM ANIMAL SHAPES COMPLETE CHEW

HM ANIMAL SHAPES COMPLETE CHEW

ANIMAS VIBE INSULIN PUMP-CGM

ANIMI-3 CAPSULE

ANNOVERA VAGINAL RING

ANORO ELLIPTA 62.5-25 MCG INH

ANTABUSE 250 MG TABLET

ANTABUSE 500 MG TABLET

ANTARA 30 MG CAPSULE

ANTARA 90 MG CAPSULE

SB ANTI-DIARRHEA 2 MG CAPLET

ANTI-DIARRHEAL 1 MG/7.5 ML SOL

ANTI-DIARRHEAL 2 MG CAPLET

ANTI-DIARRHEAL 2 MG SOFTGEL

ANTI-DIARRHEAL 2 MG TABLET

CVS ANTI-DIARRHEAL 2 MG CAPLET

CVS ANTI-DIARRHEAL 2 MG SFTGEL

EQ ANTI-DIARRHEAL 2 MG CAPLET

EQ ANTI-DIARRHEAL 2 MG SFTGEL

EQL ANTI-DIARRHEAL 2 MG CAPLET

GNP ANTI-DIARRHEAL 2 MG CAPLET

GS ANTI-DIARRHEAL 2 MG CAPLET

HM ANTI-DIARRHEAL 2 MG CAPLET

QC ANTI-DIARRHEAL 2 MG CAPLET

QC ANTI-DIARRHEAL 2 MG SOFTGEL

RA ANTI-DIARRHEAL 2 MG CAPLET

RA ANTI-DIARRHEAL 2 MG SOFTGEL

SM ANTI-DIARRHEAL 1 MG/7.5 ML

SM ANTI-DIARRHEAL 2 MG CAPLET

SM ANTI-DIARRHEAL 2 MG SOFTGEL

ANTIOXIDANT FORMULA TABLET

HM ANTIOXIDANT VITAMINS TABLET

SM ANTIOXIDANT VITAMINS TABLET

APATATE FORTE LIQUID

APIDRA 100 UNITS/ML VIAL

APIDRA SOLOSTAR 100 UNITS/ML

APLENZIN ER 174 MG TABLET

APLENZIN ER 348 MG TABLET

APLENZIN ER 522 MG TABLET

APOKYN 30 MG/3 ML CARTRIDGE

APRI 28 DAY TABLET

APRISO ER 0.375 GRAM CAPSULE

APTENSIO XR 10 MG CAPSULE

APTENSIO XR 15 MG CAPSULE

APTENSIO XR 20 MG CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

APTENSIO XR 30 MG CAPSULE

APTENSIO XR 40 MG CAPSULE

APTENSIO XR 50 MG CAPSULE

APTENSIO XR 60 MG CAPSULE

APTIOM 200 MG TABLET

APTIOM 400 MG TABLET

APTIOM 600 MG TABLET

APTIOM 800 MG TABLET

APTIVUS 250 MG CAPSULE

APTIVUS 100 MG/ML SOLUTION

AQUADEKS CHEWABLE TABLET

AQUADEKS PEDIATRIC LIQUID

ARALAST NP 1,000 MG VIAL

ARALAST NP 500 MG VIAL

ARANELLE 28 TABLET

ARANESP 10 MCG/0.4 ML SYRINGE

ARANESP 100 MCG/0.5 ML SYRINGE

ARANESP 100 MCG/ML VIAL

ARANESP 150 MCG/0.3 ML SYRINGE

ARANESP 150 MCG/0.75 ML VIAL

ARANESP 200 MCG/0.4 ML SYRINGE

ARANESP 200 MCG/ML VIAL

ARANESP 25 MCG/0.42 ML SYRING

ARANESP 25 MCG/ML VIAL

ARANESP 300 MCG/0.6 ML SYRINGE

ARANESP 300 MCG/ML VIAL

ARANESP 40 MCG/0.4 ML SYRINGE

ARANESP 40 MCG/ML VIAL

ARANESP 500 MCG/1 ML SYRINGE

ARANESP 60 MCG/0.3 ML SYRINGE

ARANESP 60 MCG/ML VIAL

ARAVA 10 MG TABLET

ARAVA 20 MG TABLET

ARCALYST 220 MG INJECTION

ARCAPTA NEOHALER 75 MCG CAP

ARICEPT 10 MG TABLET

ARICEPT 23 MG TABLET

ARICEPT 5 MG TABLET

ARIMIDEX 1 MG TABLET

ARIPIPRAZOLE 1 MG/ML SOLUTION

ARIPIPRAZOLE 10 MG TABLET

ARIPIPRAZOLE 15 MG TABLET

ARIPIPRAZOLE 2 MG TABLET

ARIPIPRAZOLE 20 MG TABLET

ARIPIPRAZOLE 30 MG TABLET

ARIPIPRAZOLE 5 MG TABLET

ARIPIPRAZOLE ODT 10 MG TABLET

ARIPIPRAZOLE ODT 15 MG TABLET

ARISTADA ER 1064 MG/3.9 ML SYR

ARISTADA ER 441 MG/1.6 ML SYRN

ARISTADA ER 662 MG/2.4 ML SYRN

ARISTADA ER 882 MG/3.2 ML SYRN

ARIZONA CYPRESS 1:20 (W/V) VL

ARMODAFINIL 150 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ARMODAFINIL 200 MG TABLET

ARMODAFINIL 250 MG TABLET

ARMODAFINIL 50 MG TABLET

ARMONAIR RESPICLICK 113 MCG

ARMONAIR RESPICLICK 232 MCG

ARMONAIR RESPICLICK 55 MCG

ARMOUR THYROID 120 MG TABLET

ARMOUR THYROID 15 MG TABLET

ARMOUR THYROID 180 MG TABLET

ARMOUR THYROID 240 MG TABLET

ARMOUR THYROID 30 MG TABLET

ARMOUR THYROID 300 MG TABLET

ARMOUR THYROID 60 MG TABLET

ARMOUR THYROID 90 MG TABLET

ARNUITY ELLIPTA 100 MCG INH

ARNUITY ELLIPTA 200 MCG INH

ARNUITY ELLIPTA 50 MCG INH

AROMASIN 25 MG TABLET

ARTHROTEC 50 MG-200 MCG TAB

ARTHROTEC 75 MG-200 MCG TAB

ASACOL HD DR 800 MG TABLET

ASCENIV 10% VIAL

ASHLYNA 0.15-0.03-0.01 MG TAB

ASMANEX TWISTHALER 110 MCG #30

ASMANEX TWISTHALER 110 MCG #7

ASMANEX TWISTHALER 220 MCG #14

ASMANEX TWISTHALER 220 MCG #30

ASMANEX TWISTHALER 220 MCG #60

ASMANEX TWISTHALR 220 MCG #120

ASMANEX HFA 100 MCG INHALER

ASMANEX HFA 200 MCG INHALER

ASMANEX HFA 50 MCG INHALER

ASPERGILLUS FUMIGATUS 10000/ML

ASPERGILLUS FUMIGATUS 20000/ML

ASPIR EC 81 MG TABLET

ASPIRIN 325 MG TABLET

ASPIRIN 81 MG CHEWABLE TABLET

BAYER ASPIRIN 325 MG CAPLET

BAYER ASPIRIN 325 MG TABLET

CVS ASPIRIN 325 MG CAPLET

CVS ASPIRIN 325 MG TABLET

CVS ASPIRIN 81 MG CHEWABLE TAB

EQ ASPIRIN 325 MG TABLET

EQ ASPIRIN 81 MG CHEWABLE TAB

EQL ASPIRIN 325 MG TABLET

EQL ASPIRIN 81 MG CHEWABLE TAB

GNP ASPIRIN 325 MG TABLET

GNP ASPIRIN 81 MG CHEWABLE TAB

GS ASPIRIN 325 MG TABLET

GS ASPIRIN 81 MG CHEWABLE TAB

HM ASPIRIN 325 MG TABLET

HM ASPIRIN 81 MG CHEWABLE TAB

KRO ASPIRIN 325 MG TABLET

KRO ASPIRIN 81 MG CHEWABLE TAB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

PUB ASPIRIN 325 MG TABLET

PUB ASPIRIN 81 MG CHEWABLE TAB

QC ASPIRIN 325 MG TABLET

QC ASPIRIN 81 MG CHEWABLE TAB

RA ASPIRIN 325 MG TABLET

RA ASPIRIN 81 MG CHEWABLE TAB

SB ASPIRIN 325 MG TABLET

SM ASPIRIN 325 MG TABLET

SM ASPIRIN 81 MG CHEWABLE TAB

ASPIRIN EC 325 MG TABLET

ASPIRIN EC 81 MG TABLET

CVS ASPIRIN EC 325 MG TABLET

CVS ASPIRIN EC 81 MG TABLET

EQ ASPIRIN EC 325 MG TABLET

EQ ASPIRIN EC 81 MG TABLET

EQL ASPIRIN EC 325 MG TABLET

EQL ASPIRIN EC 81 MG TABLET

GNP ASPIRIN EC 325 MG TABLET

GNP ASPIRIN EC 81 MG TABLET

GS ASPIRIN EC 325 MG TABLET

GS ASPIRIN EC 81 MG TABLET

HM ASPIRIN EC 325 MG TABLET

HM ASPIRIN EC 81 MG TABLET

QC ASPIRIN EC 325 MG TABLET

QC ASPIRIN EC 81 MG TABLET

RA ASPIRIN EC 325 MG TABLET

RA ASPIRIN EC 81 MG TABLET

SB ASPIRIN EC 81 MG TABLET

SM ASPIRIN EC 325 MG TABLET

SM ASPIRIN EC 81 MG TABLET

ASPIRIN-DIPYRIDAM ER 25-200 MG

ASPIRIN-OMEPRAZOL DR 325-40 MG

ASPIRIN-OMEPRAZOLE DR 81-40 MG

ASPIR-LOW EC 81 MG TABLET

ASPIR-TRIN EC 325 MG TABLET

ASSURE 4 TEST STRIPS

ASSURE 4 CONTROL SOLUTION

ASSURE DOSE CONTROL SOLUTION

ASSURE DOSE CONTROL SOLUTION

ASSURE HAEMOLANCE PLUS BLADE

ASSURE HAEMOLANCE PLUS 18G

ASSURE HAEMOLANCE PLUS 21G

ASSURE HAEMOLANCE PLUS 25G

ASSURE HAEMOLANCE PLUS 28G

ASSURE ID SYR 1 ML 29GX1/2"

ASSURE ID SYR 0.5 ML 29GX1/2"

ASSURE ID PEN NEEDLE 30GX3/16"

ASSURE ID PEN NEEDLE 30GX5/16"

ASSURE ID PEN NEEDLE 31GX3/16"

ASSURE LANCE 25G LANCETS

ASSURE LANCE 28G LANCETS

ASSURE LANCE 28G SAFETY LANCET

ASSURE LANCE PLUS 21G LANCETS

ASSURE LANCE PLUS 25G LANCETS

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ASSURE LANCE PLUS 30G LANCETS

ASSURE PLATINUM TEST STRIPS

ASSURE PLATINUM GLUCOSE METER

ASSURE PLATINUM TEST STRIP

ASSURE PRISM CONTROL SOLUTION

ASSURE PRISM MULTI TEST STRIPS

ASSURE PRISM MULTI METER

ASTAGRAF XL 0.5 MG CAPSULE

ASTAGRAF XL 1 MG CAPSULE

ASTAGRAF XL 5 MG CAPSULE

ASTEPRO 0.15% NASAL SPRAY

CVS AT HOME A1C TEST KIT

ATABEX EC CAPLET

ATACAND 16 MG TABLET

ATACAND 32 MG TABLET

ATACAND 4 MG TABLET

ATACAND 8 MG TABLET

ATACAND HCT 16-12.5 MG TAB

ATACAND HCT 32-12.5 MG TAB

ATACAND HCT 32-25 MG TABLET

ATAZANAVIR SULFATE 150 MG CAP

ATAZANAVIR SULFATE 200 MG CAP

ATAZANAVIR SULFATE 300 MG CAP

ATELVIA DR 35 MG TABLET

ATENOLOL 100 MG TABLET

ATENOLOL 25 MG TABLET

ATENOLOL 50 MG TABLET

ATENOLOL-CHLORTHALIDONE 100-25

ATENOLOL-CHLORTHALIDONE 50-25

ATOMOXETINE HCL 10 MG CAPSULE

ATOMOXETINE HCL 100 MG CAPSULE

ATOMOXETINE HCL 18 MG CAPSULE

ATOMOXETINE HCL 25 MG CAPSULE

ATOMOXETINE HCL 40 MG CAPSULE

ATOMOXETINE HCL 60 MG CAPSULE

ATOMOXETINE HCL 80 MG CAPSULE

ATORVASTATIN 10 MG TABLET

ATORVASTATIN 20 MG TABLET

ATORVASTATIN 40 MG TABLET

ATORVASTATIN 80 MG TABLET

ATRIPLA TABLET

ATROPINE 1% EYE DROPS

ATROPINE 1% EYE OINTMENT

ATROVENT 17 MCG HFA INHALER

AUBAGIO 14 MG TABLET

AUBAGIO 7 MG TABLET

AUBRA-28 TABLET

AUBRA EQ-28 TABLET

AUREOBASIDIUM 10,000 PNU/ML VL

AUREOBASIDIUM 20,000 PNU/ML VL

AUROVELA 1 MG-20 MCG TABLET

AUROVELA 21 1.5-30 TABLET

AUROVELA 24 FE 1 MG-20 MCG TAB

AUROVELA FE 1.5 MG-30 MCG TAB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

AUROVELA FE 1-20 TABLET

AURYXIA 210 MG TABLET

AUSTEDO 12 MG TABLET

AUSTEDO 6 MG TABLET

AUSTEDO 9 MG TABLET

AUSTRALIAN PINE 1:20 (W/V) VL

AUTOJECT 2 INJECTION DEVICE

AUTOLET IMPRESS LANCING DEVICE

AUTOPEN 1 TO 21 UNITS

AUTOPEN 2 TO 42 UNITS

BD AUTOSHIELD DUO NDL 5MMX30G

BD AUTOSHIELD NEEDLE 5MMX29G

BD AUTOSHIELD NEEDLE 8MMX29G

AUTOSOFT 30 INFUS SET 23" 13MM

AUTOSOFT 30 INFUS SET 43" 13MM

AUTOSOFT 90 INFUSN SET 23" 6MM

AUTOSOFT 90 INFUSN SET 23" 9MM

AUTOSOFT 90 INFUSN SET 43" 6MM

AUTOSOFT 90 INFUSN SET 43" 9MM

AUTOSOFT XC INFUSN SET 23" 6MM

AUTOSOFT XC INFUSN SET 23" 9MM

AUTOSOFT XC INFUSN SET 32" 6MM

AUTOSOFT XC INFUSN SET 43" 6MM

AUTOSOFT XC INFUSN SET 43" 9MM

AVALIDE 150-12.5 MG TABLET

AVALIDE 300-12.5 MG TABLET

AVANDAMET 2 MG-1,000 MG TAB

AVANDAMET 2 MG-500 MG TABLET

AVANDIA 2 MG TABLET

AVANDIA 4 MG TABLET

AVAPRO 150 MG TABLET

AVAPRO 300 MG TABLET

AVAPRO 75 MG TABLET

AVEED 750 MG/3 ML VIAL

AVIANE-28 TABLET

AVODART 0.5 MG SOFTGEL

AVONEX PREFILLED SYR 30 MCG

AVONEX PREFILLED SYR 30 MCG KT

AVONEX 30 MCG VIAL KIT

AVONEX PEN 30 MCG/0.5 ML KIT

AV-VITE FB TABLET

AV-VITE FB FORTE TABLET

AXIRON 30 MG/ACTUATION SOLN

AYGESTIN 5 MG TABLET

AYUNA-28 TABLET

AYVAKIT 100 MG TABLET

AYVAKIT 200 MG TABLET

AYVAKIT 300 MG TABLET

AZASAN 100 MG TABLET

AZASAN 75 MG TABLET

AZATHIOPRINE 50 MG TABLET

AZELASTINE 0.1% (137 MCG) SPRY

AZELASTINE 0.15% NASAL SPRAY

AZESCO TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

AZILECT 0.5 MG TABLET

AZILECT 1 MG TABLET

AZOPT 1% EYE DROPS

AZOR 10-20 MG TABLET

AZOR 10-40 MG TABLET

AZOR 5-20 MG TABLET

AZOR 5-40 MG TABLET

AZULFIDINE 500 MG TABLET

AZULFIDINE ENTAB 500 MG

AZURETTE 28 DAY TABLET

RA B-COMPLEX TABLET

B COMPLEX FORMULA #1 TABLET

B COMPLEX WITH VITAMIN C CAP

B COMPLEX-FOLIC ACID TABLET

BABY IRON-MULTIVITAMIN DROP

BACLOFEN 10 MG TABLET

BACLOFEN 10 MG/20 ML VIAL

BACLOFEN 20 MG TABLET

BACLOFEN 20,000 MCG/20 ML VIAL

BACLOFEN 40 MG/20 ML VIAL

BACLOFEN 5 MG TABLET

BACMIN CAPLET

BAHIA 1:20 (W/V) VIAL

CVS BAL B-100 TABLET

CVS BAL B-50 TABLET

BALANCE B-100 TABLET

BALANCE B-50 TABLET

RA BALANCED B-100 TABLET

BALANCED B-50 TABLET

RA BALANCED B-50 TABLET

BAL-CARE DHA COMBO PACK

BAL-CARE DHA ESSENTIAL PACK

BALCOLTRA TABLET

BALD CYPRESS 1:20 (W/V) VIAL

BALVERSA 3 MG TABLET

BALVERSA 4 MG TABLET

BALVERSA 5 MG TABLET

BALZIVA 28 TABLET

BANZEL 200 MG TABLET

BANZEL 40 MG/ML SUSPENSION

BANZEL 400 MG TABLET

BARACLUDE 0.05 MG/ML SOLUTION

BARACLUDE 0.5 MG TABLET

BARACLUDE 1 MG TABLET

BARIATRIC MV-IRON 45 MG CAP

BASAGLAR 100 UNIT/ML KWIKPEN

BAVENCIO 200 MG/10 ML VIAL

BAYBERRY 1:20 (W/V) VIAL

BAYER ASPIRIN 81 MG CHEW TAB

B-COMPLEX TABLET

B-COMPLEX PLUS VITAMIN C CPLT

B-COMPLEX PLUS VITAMIN C CPLT

GNP B-COMPLEX PLUS VIT C TAB

B-COMPLEX WITH C TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

SM B COMPLEX WITH VIT C TABLET

BD MICROTAINER 21G LANCETS

BD MICROTAINER 30G LANCETS

BD ULTRA-FINE 33G LANCETS

BD ULTRA-FINE II 30G LANCETS

BEBULIN 200-1,200 UNITS VIAL

BECONASE AQ 0.042% SPRAY

BEE-ZEE TABLET

BEKYREE 28 DAY TABLET

BELEODAQ 500 MG VIAL

BELLADONNA-PHENOBARBITAL TAB

BELVIQ 10 MG TABLET

BELVIQ XR 20 MG TABLET

BENAZEPRIL HCL 10 MG TABLET

BENAZEPRIL HCL 20 MG TABLET

BENAZEPRIL HCL 40 MG TABLET

BENAZEPRIL HCL 5 MG TABLET

BENAZEPRIL-HCTZ 10-12.5 MG TAB

BENAZEPRIL-HCTZ 20-12.5 MG TAB

BENAZEPRIL-HCTZ 20-25 MG TAB

BENAZEPRIL-HCTZ 5-6.25 MG TAB

BENEFIX 1,000 UNIT RANGE

BENEFIX 2,000 UNIT RANGE

BENEFIX 250 UNIT RANGE

BENEFIX 3,000 UNIT RANGE

BENEFIX 500 UNIT RANGE

BENICAR 20 MG TABLET

BENICAR 40 MG TABLET

BENICAR 5 MG TABLET

BENICAR HCT 20-12.5 MG TABLET

BENICAR HCT 40-12.5 MG TABLET

BENICAR HCT 40-25 MG TABLET

BENLYSTA 120 MG VIAL

BENLYSTA 200 MG/ML AUTOINJECT

BENLYSTA 200 MG/ML SYRINGE

BENLYSTA 400 MG VIAL

BENTYL 10 MG CAPSULE

BENZTROPINE MES 0.5 MG TAB

BENZTROPINE MES 1 MG TABLET

BENZTROPINE MES 2 MG TABLET

BEOVU 6 MG/0.05 ML VIAL

BERINERT 500 UNIT KIT

BEROCCA EFFERVESCENT TABLET

BETAGAN 0.5% EYE DROPS

BETAPACE 120 MG TABLET

BETAPACE 160 MG TABLET

BETAPACE 240 MG TABLET

BETAPACE 80 MG TABLET

BETAPACE AF 120 MG TABLET

BETAPACE AF 160 MG TABLET

BETAPACE AF 80 MG TABLET

BETASERON 0.3 MG KIT

BETAXOLOL 10 MG TABLET

BETAXOLOL 20 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

BETAXOLOL HCL 0.5% EYE DROP

BETHANECHOL 10 MG TABLET

BETHANECHOL 25 MG TABLET

BETHANECHOL 5 MG TABLET

BETHANECHOL 50 MG TABLET

BETHKIS 300 MG/4 ML AMPULE

BETIMOL 0.25% EYE DROPS

BETIMOL 0.5% EYE DROPS

BETOPTIC S 0.25% EYE DROPS

BEVESPI AEROSPHERE INHALER

BEXAROTENE 75 MG CAPSULE

BEYAZ 28 TABLET

BICALUTAMIDE 50 MG TABLET

BIDIL TABLET

BIJUVA 1 MG-100 MG CAPSULE

BIKTARVY 50-200-25 MG TABLET

BIMATOPROST 0.03% EYE DROPS

BINOSTO 70 MG EFFERVESCENT TAB

BINOSTO 70 MG TABLET EFF

BIO-35 SOFTGEL

BIOCEL TABLET

BIOSUPP LIQUID

BIOTECT PLUS LIQUID

BIOTIN 1,000 MCG GUMMIES

BIOTIN 1,000 MCG TABLET

BIOTIN 10 MG TABLET

BIOTIN 10,000 MCG SOFTGEL

BIOTIN 10,000 MCG TABLET

BIOTIN 2,500 MCG SOFTGEL

BIOTIN 300 MCG TABLET

BIOTIN 5 MG TABLET

BIOTIN 5,000 MCG CAPSULE

BIOTIN 5,000 MCG FAST DISSOLVE

BIOTIN 5,000 MCG QUICK DISSOLV

BIOTIN 5,000 MCG SOFTGEL

BIOTIN 5,000 MCG TABLET

BIOTIN 800 MCG TABLET

CVS BIOTIN 1,000 MCG TABLET

CVS BIOTIN 10,000 MCG SOFTGEL

CVS BIOTIN 5,000 MCG CAPSULE

GNP BIOTIN 5,000 MCG CAPSULE

HM BIOTIN 10,000 MCG TABLET

HM BIOTIN 5,000 MCG CAPSULE

RA BIOTIN 2,500 MCG CAPSULE

SM BIOTIN 5,000 MCG CAPSULE

SM BIOTIN 5,000 MCG TABLET

SV BIOTIN 1,000 MCG SOFTGEL

SV BIOTIN 5,000 MCG SOFTGEL

BIOTIN FORTE 3 MG TABLET

BIOTIN FORTE 5 MG TABLET

BIOTIN PLUS-CALCIUM & VIT D3

BIOVOL SYRUP

BISOPROLOL FUMARATE 10 MG TAB

BISOPROLOL FUMARATE 5 MG TAB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

BISOPROLOL-HCTZ 10-6.25 MG TAB

BISOPROLOL-HCTZ 2.5-6.25 MG TB

BISOPROLOL-HCTZ 5-6.25 MG TAB

BIVIGAM 10% VIAL

BIVIGAM LIQUID 10% VIAL

BLACK WALNUT POLLEN 1:20 (W/V)

BLACK WILLOW 1:20 (W/V) VIAL

BLADDER 2.2 TABLET

BLISOVI 24 FE TABLET

BLISOVI FE 1.5-30 TABLET

BLISOVI FE 1-20 TABLET

BLOOD GLUCOSE CONTROL SOLUTION

GLUCOCOM BLOOD GLUCOSE METER

BLOOD GLUCOSE MONITORING SYST

CAREONE GLUCOSE MONITORING SYS

GS BLOOD GLUCOSE MONITOR SYS

REXALL GLUCOSE MONITORING SYS

UP & UP BLOOD MONITORING SYST

BLOOD GLUCOSE TEST STRIP

CAREONE BLOOD GLUCOSE TST STRP

EQ BLOOD GLUCOSE TEST STRIP

GHT BLOOD GLUCOSE TEST STRIP

GS BLOOD GLUCOSE TEST STRIP

REXALL BLOOD GLUCOSE TEST STRP

UP & UP BLOOD GLUCOSE TST STRP

BLOOD KETONE TEST STRIP

BLOOD LANCETS 30G

GLUCOSE CONTROL SOLUTION

FIFTY50 2.0 GLUCOSE METER

BODY, HAIR, SKIN AND NAILS CAP

BONIVA 150 MG TABLET

BONIVA 3 MG/3 ML SYRINGE

BOSENTAN 125 MG TABLET

BOSENTAN 62.5 MG TABLET

BOSULIF 100 MG TABLET

BOSULIF 400 MG TABLET

BOSULIF 500 MG TABLET

BOX ELDER 1:20 (W/V) VIAL

BRAFTOVI 50 MG CAPSULE

BRAFTOVI 75 MG CAPSULE

BRAINSTRONG PRENATAL COMBO PAC

BREEZE 2 DISC TEST STRIP

BREEZE 2 SOLUTION

BREEZE 2 SOLUTION

BREEZE 2 SOLUTION

BREO ELLIPTA 100-25 MCG INH

BREO ELLIPTA 200-25 MCG INH

BREVICON 28 TABLET

BRIELLYN TABLET

BRILINTA 60 MG TABLET

BRILINTA 90 MG TABLET

BRIMONIDINE 0.2% EYE DROP

BRIMONIDINE TARTRATE 0.15% DRP

BRIMONIDINE 0.15%-DORZOLAM 2%

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

BRINEURA 2X150MG/5ML-ELYTE KIT

BRISDELLE 7.5 MG CAPSULE

BRIVIACT 10 MG TABLET

BRIVIACT 10 MG/ML ORAL SOLN

BRIVIACT 100 MG TABLET

BRIVIACT 25 MG TABLET

BRIVIACT 50 MG TABLET

BRIVIACT 75 MG TABLET

BROME 1:20 W/V VIAL

BROMOCRIPTINE 2.5 MG TABLET

BROMOCRIPTINE 5 MG CAPSULE

BROVANA 15 MCG/2 ML SOLUTION

BRUKINSA 80 MG CAPSULE

BUDESONIDE 0.25 MG/2 ML SUSP

BUDESONIDE 0.5 MG/2 ML SUSP

BUDESONIDE 1 MG/2 ML INH SUSP

BUDESONIDE 32 MCG NASAL SPRAY

BUDESONIDE-FORMOTEROL 160-4.5

BUDESONIDE-FORMOTEROL 80-4.5

BUFFERED ASPIRIN 325 MG TB

CVS BUFFERED ASPIRIN 325 MG TB

BUFFERIN 325 MG TABLET

BULLSEYE MINI SAFETY 21G

BULLSEYE MINI SAFETY 25G LANCT

BULLSEYE MINI SAFETY 28G LANCT

BUMETANIDE 0.5 MG TABLET

BUMETANIDE 1 MG TABLET

BUMETANIDE 2 MG TABLET

BUNAVAIL 2.1-0.3 MG FILM

BUNAVAIL 4.2-0.7 MG FILM

BUNAVAIL 6.3-1 MG FILM

BUPHENYL 500 MG TABLET

BUPHENYL POWDER

BUPRENO-NALOX 2-0.5 MG SL FILM

BUPRENOR-NALOX 12-3 MG SL FILM

BUPRENORPHIN-NALOXON 8-2 MG SL

BUPRENORPHN-NALOXN 2-0.5 MG SL

BUPRENORP-NALOX 4-1 MG SL FILM

BUPRENORP-NALOX 8-2 MG SL FILM

BUPROPION HCL 100 MG TABLET

BUPROPION HCL 75 MG TABLET

BUPROPION HCL ER 200 MG TABLET

BUPROPION HCL SR 100 MG TABLET

BUPROPION HCL SR 150 MG TABLET

BUPROPION HCL SR 200 MG TABLET

BUPROPION HCL XL 150 MG TABLET

BUPROPION HCL XL 300 MG TABLET

BUPROPION HCL XL 450 MG TABLET

BUSPIRONE HCL 10 MG TABLET

BUSPIRONE HCL 15 MG TABLET

BUSPIRONE HCL 30 MG TABLET

BUSPIRONE HCL 5 MG TABLET

BUSPIRONE HCL 7.5 MG TABLET

BYDUREON 2 MG VIAL

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

BYDUREON BCISE 2 MG AUTOINJECT

BYDUREON 2 MG PEN INJECT

BYETTA 10 MCG DOSE PEN INJ

BYETTA 5 MCG DOSE PEN INJ

BYSTOLIC 10 MG TABLET

BYSTOLIC 2.5 MG TABLET

BYSTOLIC 20 MG TABLET

BYSTOLIC 5 MG TABLET

BYVALSON 5 MG-80 MG TABLET

CABERGOLINE 0.5 MG TABLET

CABOMETYX 20 MG TABLET

CABOMETYX 40 MG TABLET

CABOMETYX 60 MG TABLET

CADEAU DHA SOFTGEL

CADUET 10 MG-10 MG TABLET

CADUET 10 MG-20 MG TABLET

CADUET 10 MG-40 MG TABLET

CADUET 10 MG-80 MG TABLET

CADUET 2.5 MG-10 MG TABLET

CADUET 2.5 MG-20 MG TABLET

CADUET 2.5 MG-40 MG TABLET

CADUET 5 MG-10 MG TABLET

CADUET 5 MG-20 MG TABLET

CADUET 5 MG-40 MG TABLET

CADUET 5 MG-80 MG TABLET

CALAN 120 MG TABLET

CALAN 80 MG TABLET

CALAN SR 120 MG CAPLET

CALAN SR 180 MG CAPLET

CALAN SR 240 MG CAPLET

CALCITONIN-SALMON 200 UNITS SP

CALCITRIOL 0.25 MCG CAPSULE

CALCITRIOL 0.5 MCG CAPSULE

CALCITRIOL 1 MCG/ML SOLUTION

CVS CALCIUM CHEWABLES PLUS TAB

CALCIUM ACETATE 667 MG CAPSULE

CALCIUM ACETATE 667 MG GELCAP

CALCIUM ACETATE 667 MG TABLET

CAL PEPPER TREE 1:20 (W/V)

CALQUENCE 100 MG CAPSULE

CAMILA 0.35 MG TABLET

CAMRESE 0.15-0.03-0.01 MG TAB

CAMRESE LO TABLET

CANASA 1,000 MG SUPPOSITORY

CANDESARTAN CILEXETIL 16 MG TB

CANDESARTAN CILEXETIL 32 MG TB

CANDESARTAN CILEXETIL 4 MG TAB

CANDESARTAN CILEXETIL 8 MG TAB

CANDESARTAN-HCTZ 16-12.5 MG TB

CANDESARTAN-HCTZ 32-12.5 MG TB

CANDESARTAN-HCTZ 32-25 MG TAB

CANDIDA ALBICANS 10,000 PNU/ML

CANDIDA ALBICANS 20,000 PNU/ML

CAPLYTA 42 MG CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

CAPRELSA 100 MG TABLET

CAPRELSA 300 MG TABLET

CAPTOPRIL 100 MG TABLET

CAPTOPRIL 12.5 MG TABLET

CAPTOPRIL 25 MG TABLET

CAPTOPRIL 50 MG TABLET

CAPTOPRIL-HCTZ 25-15 MG TABLET

CAPTOPRIL-HCTZ 25-25 MG TABLET

CAPTOPRIL-HCTZ 50-15 MG TABLET

CAPTOPRIL-HCTZ 50-25 MG TABLET

CARAFATE 1 GM TABLET

CARAFATE 1 GM/10 ML SUSP

CARBAGLU 200 MG DISPER TABLET

CARBAMAZEPINE 100 MG TAB CHEW

CARBAMAZEPINE 100 MG/5 ML SUSP

CARBAMAZEPINE 200 MG TABLET

CARBAMAZEPINE 200 MG/10 ML LIQ

CARBAMAZEPINE 200 MG/10ML SUSP

CARBAMAZEPINE ER 100 MG CAP

CARBAMAZEPINE ER 100 MG TABLET

CARBAMAZEPINE ER 200 MG CAP

CARBAMAZEPINE ER 200 MG TABLET

CARBAMAZEPINE ER 300 MG CAP

CARBAMAZEPINE ER 400 MG TABLET

CARBATROL ER 100 MG CAPSULE

CARBATROL ER 200 MG CAPSULE

CARBATROL ER 300 MG CAPSULE

CARBIDOPA 25 MG TABLET

CARBIDOPA-LEVO 10-100 MG ODT

CARBIDOPA-LEVO 25-100 MG ODT

CARBIDOPA-LEVO 25-250 MG ODT

CARBIDOPA-LEVODOPA 10-100 TAB

CARBIDOPA-LEVODOPA 25-100 TAB

CARBIDOPA-LEVODOPA 25-250 TAB

CARBIDOPA-LEVO ER 25-100 TAB

CARBIDOPA-LEVO ER 50-200 TAB

CARBIDOPA-LEVODOPA 100 MG-ENTA

CARBIDOPA-LEVODOPA 125 MG-ENTA

CARBIDOPA-LEVODOPA 150 MG-ENTA

CARBIDOPA-LEVODOPA 200 MG-ENTA

CARBIDOPA-LEVODOPA 50 MG-ENTA

CARBIDOPA-LEVODOPA 75 MG-ENTA

CARDIZEM 120 MG TABLET

CARDIZEM 30 MG TABLET

CARDIZEM 60 MG TABLET

CARDIZEM CD 120 MG CAPSULE

CARDIZEM CD 180 MG CAPSULE

CARDIZEM CD 240 MG CAPSULE

CARDIZEM CD 300 MG CAPSULE

CARDIZEM CD 360 MG CAPSULE

CARDIZEM LA 120 MG TABLET

CARDIZEM LA 180 MG TABLET

CARDIZEM LA 240 MG TABLET

CARDIZEM LA 300 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

CARDIZEM LA 360 MG TABLET

CARDIZEM LA 420 MG TABLET

CARDURA 1 MG TABLET

CARDURA 2 MG TABLET

CARDURA 4 MG TABLET

CARDURA 8 MG TABLET

CARDURA XL 4 MG TABLET

CARDURA XL 8 MG TABLET

CAREFINE PEN NEEDLE 12.7MM 29G

CAREFINE PEN NEEDLE 4MM 32G

CAREFINE PEN NEEDLE 5MM 32G

CAREFINE PEN NEEDLE 6MM 31G

CAREFINE PEN NEEDLE 8MM 30G

CAREFINE PEN NEEDLES 6MM 32G

CAREFINE PEN NEEDLES 8MM 31G

CAREONE ULTRA THIN LANCET

CARESENS CONTROL SOLUTION

CARESENS N TEST STRIPS

CARESENS N BLOOD GLUCOSE SYST

CARESENS N VOICE GLUCOSE METER

CARETOUCH GLUCOSE MONITOR SYS

CARETOUCH SYR 1 ML 28GX5/16"

CARETOUCH SYR 1 ML 29GX5/16"

CARETOUCH PEN NEEDLE 31GX1/4"

CARETOUCH PEN NEEDLE 31GX3/16"

CARETOUCH PEN NEEDLE 31GX5/16"

CARETOUCH PEN NEEDLE 32GX3/16"

CARETOUCH PEN NEEDLE 32GX5/32"

CARETOUCH TEST STRIP

CARETOUCH TWIST 28G LANCET

CARETOUCH TWIST 30G LANCET

CARETOUCH TWIST 33G LANCET

CARIMUNE NF 12 GM VIAL

CARIMUNE NF 6 GM VIAL

CARNITOR 330 MG TABLET

CARNITOR 100 MG/ML ORAL SOLN

CARNITOR SF 100 MG/ML ORAL SOL

CAROSPIR 25 MG/5 ML SUSPENSION

CARTEOLOL HCL 1% EYE DROPS

CARTIA XT 120 MG CAPSULE

CARTIA XT 180 MG CAPSULE

CARTIA XT 240 MG CAPSULE

CARTIA XT 300 MG CAPSULE

CARTRIDGE STAMPED IR 1200

CARVEDILOL 12.5 MG TABLET

CARVEDILOL 25 MG TABLET

CARVEDILOL 3.125 MG TABLET

CARVEDILOL 6.25 MG TABLET

CARVEDILOL ER 10 MG CAPSULE

CARVEDILOL ER 20 MG CAPSULE

CARVEDILOL ER 40 MG CAPSULE

CARVEDILOL ER 80 MG CAPSULE

CASODEX 50 MG TABLET

CATAPRES 0.1 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

CATAPRES 0.2 MG TABLET

CATAPRES 0.3 MG TABLET

CATAPRES-TTS 1 PATCH

CATAPRES-TTS 2 PATCH

CATAPRES-TTS 3 PATCH

CATTLE EPITHELIUM 1:20 VIAL

CAVERJECT 20 MCG VIAL

CAVERJECT 40 MCG VIAL

CAVERJECT IMPULSE 10 MCG KIT

CAVERJECT IMPULSE 10 MCG SYRNG

CAVERJECT IMPULSE 20 MCG KIT

CAVERJECT IMPULSE 20 MCG SYRNG

CAZIANT 28 DAY TABLET

CEDAR ELM 1:20 (W/V) VIAL

CELEBREX 100 MG CAPSULE

CELEBREX 200 MG CAPSULE

CELEBREX 400 MG CAPSULE

CELEBREX 50 MG CAPSULE

CELECOXIB 100 MG CAPSULE

CELECOXIB 200 MG CAPSULE

CELECOXIB 400 MG CAPSULE

CELECOXIB 50 MG CAPSULE

CELEXA 10 MG TABLET

CELEXA 20 MG TABLET

CELEXA 40 MG TABLET

CELLCEPT 200 MG/ML ORAL SUSP

CELLCEPT 250 MG CAPSULE

CELLCEPT 500 MG TABLET

CELONTIN 300 MG KAPSEAL

CENTAMIN LIQUID

RA CENTRAL-VITE TABLET

RA CENTRAL-VITE TABLET

RA CENTRAL-VITE SENIOR TABLET

RA CENTRAL-VITE WOMEN'S TABLET

CENTRAM-CARE MULTIVIT-MIN LIQ

CENTRAVITES TABLET

CENTRAVITES 50 PLUS TABLET

CENTRAVITES 50 PLUS TABLET

CENTRAVITES ADULTS TABLET

CENTRUM MULTIVIT-MINERAL LIQ

CENTRUM CHEWABLES ADULTS TAB

CENTRUM COMPLETE MULTIVIT TAB

CENTRUM FLAVOR BURST ADULT CHW

CENTRUM FLAVOR BURST KIDS CHEW

CENTRUM KIDS CHEWABLE TABLET

CENTRUM MEN'S TABLET

CENTRUM MULTIGUMMIES

CENTRUM SILVER CHEWABLE TABLET

CENTRUM SILVER TABLET

CENTRUM SILVER MEN TABLET

CENTRUM SILVER ULTRA MEN'S TAB

CENTRUM SILVER WOMEN TABLET

CENTRUM SPECIALIST ENERGY TAB

CENTRUM SPECIALIST HEART TAB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

CENTRUM SPECIALIST PRENATAL

CENTRUM ULTRA MEN'S TABLET

CENTRUM WOMEN TABLET

CENTURY TABLET

GNP CENTURY TABLET

CENTURY ADULTS 50 PLUS TABLET

CENTURY CARDIO TABLET

GNP CENTURY CARDIO TABLET

GNP CENTURY MATURE TABLET

EQL CENTURY MATURE TABLET

EQL CENTURY MEN'S TABLET

CENTURY ULTIMATE MEN'S TABLET

CENTURY ULTIMATE MEN'S TABLET

CENTURY ULTIMATE WOMEN'S TAB

CENTURY ULTIMATE WOMEN'S TAB

CEPROTIN 400-600 UNITS VIAL

CEPROTIN 800-1,200 UNITS VIAL

CEQUA 0.09% SOLUTION

CEQUR SIMPLICITY 2 UNIT PATCH

CERDELGA 84 MG CAPSULE

CEREFOLIN CAPLET

CEREZYME 400 UNIT VIAL

CEROVITE LIQUID

CEROVITE ADVANCED FORM TAB

CEROVITE JR TABLET CHEW

CEROVITE SENIOR TABLET

CERTA PLUS TABLET

CERTA VITE LIQUID

CERTAVITE SR-ANTIOXIDANT TAB

CERTAVITE-ANTIOXIDANT TABLET

CERTAVITE-ANTIOXIDANT LIQUID

CEVIMELINE HCL 30 MG CAPSULE

CHATEAL-28 TABLET

CHATEAL EQ-28 TABLET

CHEMSTRIP K

CHEMSTRIP UGK

CHEWABLE-VITE TABLET

CHEW-VITES-IRON TABLET CHEW

CHILD CHEW + IRON TAB CHEW

CVS CHILD CHEW VITAMN COMPLETE

RA CHILD COMPLETE CHEWABLE VIT

EQ CHILD COMPLETE CHEW TABLET

CHILD IBUPROFEN 100 MG/5 ML

LITTLE ANIMALS CHILD TB CHW

CHILD MULTIVITAMIN PLUS IRON

CHILD MULTIVITAMINS TAB CHEW

CVS CHILD VIT-MINERAL TAB

CHILDREN MULTIVITAMIN GUMMIES

CHILDREN'S ADVIL 100 MG/5 ML

CHILD ASPIRIN 81 MG CHEW TAB

CHILD ASPIRIN 81 MG TAB CHEW

CVS CHILD ASPIRIN CHEW TAB

RA CHILD ASPIRIN 81 MG CHW TAB

SB CHILD ASPIRIN 81 MG CHW TAB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

SM CHILD ASPIRIN 81 MG CHW TAB

CHILDREN'S CHEW MULTIVITAMIN

CHILD'S CHEW MULTIVIT W/IRON

CHILD'S CHEW VITAMIN-IRON TAB

CHILDREN'S CHEWABLES

GNP CHILDREN'S CHEWABLES

CHILD'S CHEWABLE MULTIVIT TAB

CHILDRENS CHEW VITAMIN TAB

CHILDREN'S CHEWABLE VITAMIN

CHILD'S CHEWABLE VITAMIN TAB

CHILDREN'S CHEWABLES

GNP CHILDREN'S CHEWABLES

CHILDREN'S CHEWABLES

GNP CHILDREN'S CHEWABLES

CHILDREN'S CHEWABLES

GNP CHILDREN'S CHEWABLES

CHILDREN IBUPROFEN 100 MG/5 ML

CVS CHLD IBUPROFEN 100 MG/5 ML

EQ CHILD IBUPROFEN 100 MG/5 ML

EQL CHLD IBUPROFEN 100 MG/5 ML

GNP CHLD IBUPROFEN 100 MG/5 ML

GS CHILD IBUPROFEN 100 MG/5 ML

HM CHILD IBUPROFEN 100 MG/5 ML

KRO CHLD IBUPROFEN 100 MG/5 ML

QC CHILD IBUPROFEN 100 MG/5 ML

RA CHILD IBUPROFEN 100 MG/5 ML

SB CHILD IBUPROFEN 100 MG/5 ML

CHILDREN'S MOTRIN 100 MG/5 ML

CHILDREN'S MULTI-VIT GUMMIES

CHILDREN MULTIVITAMIN CHEW TAB

CHILDREN MULTIVITAMIN GUMMIES

CHILDREN MULTIVITAMIN GUMMIES

CHILDREN MULTIVITAMIN GUMMIES

CHILDREN MULTIVITAMIN CHEW TAB

EQ CHILD MULTIVITAMIN GUMMIES

CHILDREN MULTIVITAMIN GUMMIES

PUB CHILDREN'S PROFEN IB SUSP

PUB CHILDREN'S PROFENIB SUSP

CHILD VITAMIN-IRON TAB CHEW

CHILD'S OMEGA-3 DHA MULTIVITAM

CVS CHILD'S VITAMIN-IRON TB

CHLORDIAZEPO-AMITRIPTYL 5-12.5

CHLORDIAZEPOX-AMITRIPTYL 10-25

CHLORDIAZEPOXIDE-CLIDINIUM CAP

CHLOROTHIAZIDE 250 MG TABLET

CHLOROTHIAZIDE 500 MG TABLET

CHLORPROMAZINE 10 MG TABLET

CHLORPROMAZINE 100 MG TABLET

CHLORPROMAZINE 200 MG TABLET

CHLORPROMAZINE 25 MG TABLET

CHLORPROMAZINE 50 MG TABLET

CHLORPROPAMIDE 100 MG TABLET

CHLORPROPAMIDE 250 MG TABLET

CHLORTHALIDONE 25 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

CHLORTHALIDONE 50 MG TABLET

CHOLBAM 250 MG CAPSULE

CHOLBAM 50 MG CAPSULE

CHOLESTYRAMINE PACKET

CHOLESTYRAMINE POWDER

CHOLESTYRAMINE LIGHT PACKET

CHOLESTYRAMINE LIGHT POWDER

CHOLINE MAG TRISAL LIQUID

CIALIS 10 MG TABLET

CIALIS 2.5 MG TABLET

CIALIS 20 MG TABLET

CIALIS 5 MG TABLET

CILOSTAZOL 100 MG TABLET

CILOSTAZOL 50 MG TABLET

CIMDUO 300-300 MG TABLET

CIMETIDINE 200 MG TABLET

CIMETIDINE 300 MG TABLET

CIMETIDINE 400 MG TABLET

CIMETIDINE 800 MG TABLET

CVS CIMETIDINE 200 MG TABLET

GNP CIMETIDINE 200 MG TABLET

CIMETIDINE 300 MG/5 ML SOLN

CIMZIA 200 MG VIAL KIT

CIMZIA 2X200 MG/ML SYRINGE KIT

CIMZIA 2X200 MG/ML(X3)START KT

CINACALCET HCL 30 MG TABLET

CINACALCET HCL 60 MG TABLET

CINACALCET HCL 90 MG TABLET

CINQAIR 100 MG/10 ML VIAL

CINRYZE 500 UNIT VIAL

CITALOPRAM HBR 10 MG TABLET

CITALOPRAM HBR 10 MG/5 ML SOLN

CITALOPRAM HBR 20 MG TABLET

CITALOPRAM HBR 20 MG/10 ML SOL

CITALOPRAM HBR 40 MG TABLET

CITRANATAL 90 DHA COMBO PACK

CITRANATAL ASSURE COMBO PACK

CITRANATAL B-CALM COMBO PACK

CITRANATAL DHA PACK

CITRANATAL HARMONY CAPSULE

CITRANATAL RX TABLET

C. CLADOSPORIOIDES 10,000/ML

C. CLADOSPORIOIDES 20,000/ML

C. SPHAEROSPERMUM 20,000/ML

CLARINEX 0.5 MG/ML (2.5 MG/5)

CLARINEX 5 MG TABLET

CLASSIC PRENATAL TABLET

CLEO 90 INFUSION SET 24" 6MM

CLEO 90 INFUSION SET 24" 9MM

CLEO 90 INFUSION SET 31" 6MM

CLEO 90 INFUSION SET 31" 9MM

CLEVER CHEK BLOOD GLUCOSE SYST

CLEVER CHEK ULTRA THIN 30G

CLEVER CHOICE GLUCOSE MONITOR

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

CLEVER CHOICE BLOOD GLUCOS SYS

CLEVER CHOICE LVL 3 CONTRL SOL

CLEVER CHOICE LVL 1 CONTRL SOL

CLEVER CHOICE LVL 2 CONTRL SOL

CLEVER CHOICE HD GLUCOSE SYST

CLEVER CHOICE MICRO MONITOR

CLEVER CHOICE MICRO TEST STRIP

CLEVER CHOICE PRO TEST STRIP

CLEVER CHOICE PRO GLUCOSE MTR

CLEVER CHOICE TALK TEST STRIPS

CLEVER CHOICE TALK GLUCOSE SYS

CLEVER CHOICE TEST STRIPS

CLEVER CHOICE VOICE+ TST STRIP

CLICKFINE 31G X 1/4" NEEDLES

CLICKFINE 31G X 5/16" NEEDLES

CLICKFINE PEN NEEDLE 32GX5/32"

CLICKFINE UNIVERSAL 31G X 1/4"

CLICKFINE UNIVERSAL 31GX5/16"

GNP CLICKFINE 31G X 1/4" NDL

GNP CLICKFINE 31G X 5/16" NDL

CLIMARA 0.025 MG/DAY PATCH

CLIMARA 0.0375 MG/DAY PATCH

CLIMARA 0.05 MG/DAY PATCH

CLIMARA 0.06 MG/DAY PATCH

CLIMARA 0.075 MG/DAY PATCH

CLIMARA 0.1 MG/DAY PATCH

CLIMARA PRO PATCH

CLINPRO 5000 1.1% TOOTHPASTE

CLOBAZAM 10 MG TABLET

CLOBAZAM 2.5 MG/ML SUSPENSION

CLOBAZAM 20 MG TABLET

CLOMIPRAMINE 25 MG CAPSULE

CLOMIPRAMINE 50 MG CAPSULE

CLOMIPRAMINE 75 MG CAPSULE

CLONAZEPAM 0.125 MG DIS TAB

CLONAZEPAM 0.125 MG ODT

CLONAZEPAM 0.25 MG ODT

CLONAZEPAM 0.5 MG DIS TABLET

CLONAZEPAM 0.5 MG ODT

CLONAZEPAM 0.5 MG TABLET

CLONAZEPAM 1 MG DIS TABLET

CLONAZEPAM 1 MG ODT

CLONAZEPAM 1 MG TABLET

CLONAZEPAM 2 MG ODT

CLONAZEPAM 2 MG TABLET

CLONIDINE 0.1 MG/DAY PATCH

CLONIDINE 0.2 MG/DAY PATCH

CLONIDINE 0.3 MG/DAY PATCH

CLONIDINE HCL 0.1 MG TABLET

CLONIDINE HCL 0.2 MG TABLET

CLONIDINE HCL 0.3 MG TABLET

CLONIDINE HCL ER 0.1 MG TABLET

CLOPIDOGREL 75 MG TABLET

CLOZAPINE 100 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

CLOZAPINE 200 MG TABLET

CLOZAPINE 25 MG TABLET

CLOZAPINE 50 MG TABLET

CLOZAPINE ODT 100 MG TABLET

CLOZAPINE ODT 12.5 MG TABLET

CLOZAPINE ODT 150 MG TABLET

CLOZAPINE ODT 200 MG TABLET

CLOZAPINE ODT 25 MG TABLET

CLOZARIL 100 MG TABLET

CLOZARIL 200 MG TABLET

CLOZARIL 25 MG TABLET

CLOZARIL 50 MG TABLET

C-NATE DHA SOFTGEL

COAGUCHEK LANCETS

COAGUCHEK PT TEST STRIPS

COAGUCHEK XS PT TEST STRIPS

COCKLEBUR 1:20 (W/V) VIAL

COLCHICINE 0.6 MG CAPSULE

COLCHICINE 0.6 MG TABLET

COLCRYS 0.6 MG TABLET

COLESEVELAM 625 MG TABLET

COLESEVELAM HCL 3.75 G PACKET

COLESTID 1 GM TABLET

COLESTID FLAVORED GRANULES

COLESTID GRANULES

COLESTID GRANULES PACKET

COLESTIPOL HCL 1 GM TABLET

COLESTIPOL HCL GRANULES

COLESTIPOL HCL GRANULES PACKET

COLESTIPOL MICRONIZED 1 GM TAB

SM COLOR LANCETS 21G

COMBIGAN 0.2%-0.5% EYE DROPS

COMBIPATCH 0.05-0.14 MG PTCH

COMBIPATCH 0.05-0.25 MG PTCH

COMBIVENT RESPIMAT 20-100 MCG

COMBIVIR TABLET

COMETRIQ 100 MG DAILY-DOSE PK

COMETRIQ 140 MG DAILY-DOSE PK

COMETRIQ 60 MG DAILY-DOSE PACK

COMFORT INFUSION SET 23" 17MM

COMFORT INFUSION SET 31" 17MM

COMFORT INFUSION SET 32" 17MM

COMFORT INFUSION SET 43" 17MM

COMFORT EZ SAFETY 23G LANCETS

COMFORT EZ SAFETY 28G LANCETS

COMFORT EZ INS 1 ML 31GX5/16"

COMFORT EZ SYR 1 ML 28GX1/2"

COMFORT EZ SYR 1 ML 29GX1/2"

COMFORT EZ SYR 1 ML 30GX1/2"

COMFORT EZ SYR 1 ML 30GX5/16"

COMFORT EZ INS 0.5ML 31GX5/16"

COMFORT EZ INSULIN SYR 0.5 ML

COMFORT EZ SYR 0.5 ML 28GX1/2"

COMFORT EZ SYR 0.5 ML 29GX1/2"

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

COMFORT EZ SYR 0.5 ML 30GX1/2"

COMFORT EZ INS 0.3ML 30GX1/2"

COMFORT EZ INS 0.3ML 30GX5/16"

COMFORT EZ INSULIN SYR 0.3 ML

COMFORT EZ SYR 0.3 ML 29GX1/2"

COMFORT EZ PEN NEEDLE 12MM 29G

COMFORT EZ PEN NEEDLES 4MM 32G

COMFORT EZ PEN NEEDLES 4MM 33G

COMFORT EZ PEN NEEDLES 5MM 31G

COMFORT EZ PEN NEEDLES 5MM 32G

COMFORT EZ PEN NEEDLES 5MM 33G

COMFORT EZ PEN NEEDLES 6MM 31G

COMFORT EZ PEN NEEDLES 6MM 32G

COMFORT EZ PEN NEEDLES 6MM 33G

COMFORT EZ PEN NEEDLES 8MM 31G

COMFORT EZ PEN NEEDLES 8MM 32G

COMFORT EZ PEN NEEDLES 8MM 33G

COMFORT LANCETS

COMFORT SHORT INFUSION SET 23"

COMFORT SHORT INFUSION SET 31"

COMFORT SHORT INFUSION SET 32"

COMFORT SHORT INFUSION SET 43"

COMPANION TABLET

COMPLERA TABLET

SM COMPLETE ADVANCED TABLET

HM COMPLETE 50 PLUS TABLET

SM COMPLETE 50 PLUS TABLET

HM COMPLETE MEN TABLET

HM COMPLETE MEN 50 PLUS TABLET

COMPLETE MULTI TABLET

COMPLETE MULTI 50+ TABLET

COMPLETE MULTIVITAMIN TAB

EQ COMPLETE MULTIVITAMIN TAB

COMPLETE MULTIVIT-MINERAL LIQ

HM COMPLETE MULTI-VIT-MINERAL

SM COMPLETE MULTI-VIT-MINERAL

EQ COMPLETE MV ADLT 50 PLUS TB

COMPLETE NATAL DHA

SM COMPLETE PREMIUM VITAMIN TB

COMPLETE SENIOR TABLET

SM COMPLETE SENIOR FORMULA TAB

SM COMPLETE SENIOR FORMULA TAB

HM COMPLETE WOMEN TABLET

COMPLETENATE TABLET CHEW

COMPLEX B-100 TABLET SA

COMPLEX B-50 TABLET

COMTAN 200 MG TABLET

CONCEPT DHA CAPSULE

CONCEPT OB CAPSULE

CONCERTA ER 18 MG TABLET

CONCERTA ER 27 MG TABLET

CONCERTA ER 36 MG TABLET

CONCERTA ER 54 MG TABLET

CONSENSI 10-200 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

CONSENSI 2.5-200 MG TABLET

CONSENSI 5-200 MG TABLET

CONSTULOSE 10 GM/15 ML SOLN

CONTACT DETACH INFUSN SET 23"

CONTACT DETACH INFUSN SET 32"

CONTACT DETACH INFUSN SET 43"

CONTOUR SOLUTION

CONTOUR SOLUTION

CONTOUR SOLUTION

CONTOUR METER

CONTOUR LINK METER

CONTOUR NEXT METER

CONTOUR NEXT LEV 1 CONTROL SOL

CONTOUR NEXT LEV 2 CONTROL SOL

CONTOUR NEXT EZ METER

CONTOUR NEXT LINK METER

CONTOUR NEXT LINK 2.4 METER KT

CONTOUR NEXT ONE METER

CONTOUR NEXT TEST STRIP

CONTOUR TEST STRIP

CONTRAVE ER 8-90 MG TABLET

CONTROL AST MONITORING SYSTEM

CONTROL AST TEST STRIP

FORA HIGH CONTROL SOLUTION

PRODIGY CONTROL SOLUTION

FORA LOW CONTROL SOLUTION

MEDPOINT CONTROL SOLUTION

COOL BLOOD GLUCOSE METER KIT

COOL BLOOD GLUCOSE METER

COOL CONTROL B SOLUTION

COOL CONTROL A SOLUTION

COOL GLUCOSE TEST STRIP

COPAXONE 20 MG/ML SYRINGE

COPAXONE 40 MG/ML SYRINGE

COPIKTRA 15 MG CAPSULE

COPIKTRA 25 MG CAPSULE

COREG 12.5 MG TABLET

COREG 25 MG TABLET

COREG 3.125 MG TABLET

COREG 6.25 MG TABLET

COREG CR 10 MG CAPSULE

COREG CR 20 MG CAPSULE

COREG CR 40 MG CAPSULE

COREG CR 80 MG CAPSULE

CORGARD 20 MG TABLET

CORGARD 40 MG TABLET

CORGARD 80 MG TABLET

CORIFACT KIT

CORLANOR 5 MG TABLET

CORLANOR 5 MG/5 ML ORAL SOLN

CORLANOR 7.5 MG TABLET

CORN POLLEN 1:20 W/V VIAL

CORTEF 10 MG TABLET

CORTEF 20 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

CORTEF 5 MG TABLET

CORVITA TABLET

CORVITE TABLET

CORVITE FREE TABLET

CORZIDE 40-5 TABLET

CORZIDE 80-5 TABLET

COSENTYX 300 MG DOSE-2 SYRINGE

COSENTYX 150 MG/ML PEN INJECT

COSENTYX 300 MG DOSE-2 PENS

COSENTYX 150 MG/ML SYRINGE

COSOPT EYE DROPS

COSOPT PF EYE DROPS

COTELLIC 20 MG TABLET

COTEMPLA XR-ODT 17.3 MG TABLET

COTEMPLA XR-ODT 25.9 MG TABLET

COTEMPLA XR-ODT 8.6 MG TABLET

COUMADIN 1 MG TABLET

COUMADIN 10 MG TABLET

COUMADIN 2 MG TABLET

COUMADIN 2.5 MG TABLET

COUMADIN 3 MG TABLET

COUMADIN 4 MG TABLET

COUMADIN 5 MG TABLET

COUMADIN 6 MG TABLET

COUMADIN 7.5 MG TABLET

COVARYX TABLET

COVARYX H.S. TABLET

COZAAR 100 MG TABLET

COZAAR 25 MG TABLET

COZAAR 50 MG TABLET

CREON DR 12,000 UNITS CAPSULE

CREON DR 24,000 UNITS CAPSULE

CREON DR 3,000 UNITS CAPSULE

CREON DR 36,000 UNITS CAPSULE

CREON DR 6,000 UNITS CAPSULE

CRESTOR 10 MG TABLET

CRESTOR 20 MG TABLET

CRESTOR 40 MG TABLET

CRESTOR 5 MG TABLET

CRIXIVAN 200 MG CAPSULE

CRIXIVAN 400 MG CAPSULE

CROMOLYN 100 MG/5 ML ORAL CONC

CROMOLYN 20 MG/2 ML NEB SOLN

CRYSELLE-28 TABLET

CRYSVITA 10 MG/ML VIAL

CRYSVITA 20 MG/ML VIAL

CRYSVITA 30 MG/ML VIAL

CULTURELLE KIDS COMPLET MV CHW

CUPRIMINE 250 MG CAPSULE

CURVULARIA 20,000 PNU/ML VIAL

CUTAQUIG 16.5% (1 G/6 ML) VIAL

CUTAQUIG 16.5% (1.65 G/10 ML)

CUTAQUIG 16.5% (2 G/12 ML) VL

CUTAQUIG 16.5% (3.3 G/20 ML)

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

CUTAQUIG 16.5% (4 G/24 ML) VL

CUTAQUIG 16.5% (8 G/48 ML) VL

CUVITRU 1 GRAM/5 ML VIAL

CUVITRU 10 GRAM/50 ML VIAL

CUVITRU 2 GRAM/10 ML VIAL

CUVITRU 4 GRAM/20 ML VIAL

CUVITRU 8 GRAM/ 40 ML VIAL

CUVPOSA 1 MG/5 ML SOLUTION

CYANOCOBALAMIN 1,000 MCG/ML

CYANOCOBALAMIN 10,000 MCG/10

CYANOCOBALAMIN 30,000 MCG/30

CYCLAFEM 1-35-28 TABLET

CYCLAFEM 7-7-7-28 TABLET

CYCLESSA 28 DAY TABLET

CYCLOSET 0.8 MG TABLET

CYCLOSPORINE 100 MG CAPSULE

CYCLOSPORINE 25 MG CAPSULE

CYCLOSPORINE 0.1% IN KLARITY

CYCLOSPORINE MODIFIED 100 MG

CYCLOSPORINE MODIFIED 100MG/ML

CYCLOSPORINE MODIFIED 25 MG

CYCLOSPORINE MODIFIED 50 MG

CYMBALTA 20 MG CAPSULE

CYMBALTA 30 MG CAPSULE

CYMBALTA 60 MG CAPSULE

CYRAMZA 100 MG/10 ML VIAL

CYRAMZA 500 MG/50 ML VIAL

CYRED 28 DAY TABLET

CYRED EQ 28 DAY TABLET

CYSTADANE 1 GRAM/1.7 ML POWDER

CYSTAGON 150 MG CAPSULE

CYSTAGON 50 MG CAPSULE

CYSTARAN 0.44% EYE DROPS

CYTO B7 5 MG/ML LIQUID

CYTOMEL 25 MCG TABLET

CYTOMEL 5 MCG TABLET

CYTOMEL 50 MCG TABLET

CYTOTEC 100 MCG TABLET

CYTOTEC 200 MCG TABLET

STD D.FARINAE 10,000 AU/ML

STD MITE D.PTERONYS 10,000/ML

CVS DAILY GUMMIES

CVS DAILY MULTIPLE TABLET

DAILY MULTIPLE TABLET

CVS DAILY MULTIPLE TABLET

CVS DAILY MULTIPLE TABLET

CVS DAILY MULTIPLE VITAMIN TAB

CVS DAILY MULTIPLE TABLET

DAILY MULTIPLE VITAMIN TAB

DAILY MULTIPLE VITAMIN TABLET

DAILY MULTIVITAMIN CAPSULE

DAILY MULTIVITAMIN-IRON TABLET

DAILY PRENATAL COMBO PACK

GNP DAILY PRENATAL COMBO PACK

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

DAILY VALUE MULTIVITAMIN TAB

DAILY VITAMIN + IRON TABLET

DAILY VITAMIN FORMULA TABLET

DAILY VITAMIN FORMULA-IRON TAB

DAILY VITAMIN FORMULA TABLET

DAILY VITE TABLET

DAILY-VITE TABLET

DAILY VITE WITH IRON TABLET

DAILY-VITES WITH IRON TABLET

DALFAMPRIDINE ER 10 MG TABLET

DALIRESP 250 MCG TABLET

DALIRESP 500 MCG TABLET

DANTRIUM 25 MG CAPSULE

DANTRIUM 50 MG CAPSULE

DANTROLENE SODIUM 100 MG CAP

DANTROLENE SODIUM 25 MG CAP

DANTROLENE SODIUM 50 MG CAP

DAPSONE 100 MG TABLET

DAPSONE 25 MG TABLET

DARIFENACIN ER 15 MG TABLET

DARIFENACIN ER 7.5 MG TABLET

DASETTA 1-35-28 TABLET

DASETTA 7/7/7-28 TABLET

DAURISMO 100 MG TABLET

DAURISMO 25 MG TABLET

DAYPRO 600 MG CAPLET

DAYSEE 0.15-0.03-0.01 MG TAB

DAYTRANA 10 MG/9 HR PATCH

DAYTRANA 15 MG/9 HR PATCH

DAYTRANA 20 MG/9 HOUR PATCH

DAYTRANA 30 MG/9 HOUR PATCH

DDAVP 0.01% NASAL SPRAY

DDAVP 0.1 MG TABLET

DDAVP 0.2 MG TABLET

DDAVP 10 MCG/0.1 ML SOLUTION

DEBLITANE 0.35 MG TABLET

DECUBI VITE CAPSULE

DEFERASIROX 125 MG TB FOR SUSP

DEFERASIROX 180 MG TABLET

DEFERASIROX 250 MG TB FOR SUSP

DEFERASIROX 360 MG TABLET

DEFERASIROX 500 MG TB FOR SUSP

DEFERASIROX 90 MG TABLET

DEKAS BARIATRIC CHEW TABLET

DEKAS ESSENTIAL LIQUID

DEKAS ESSENTIAL CAPSULE

DEKAS PLUS SOFTGEL

DEKAS PLUS CHEWABLE TABLET

DEKAS PLUS LIQUID

DELESTROGEN 10 MG/ML VIAL

DELESTROGEN 20 MG/ML VIAL

DELESTROGEN 40 MG/ML VIAL

DELSTRIGO 100-300-300 MG TAB

DELYLA-28 TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

DELZICOL DR 400 MG CAPSULE

DEMADEX 10 MG TABLET

DEMADEX 20 MG TABLET

DEMSER 250 MG CAPSULE

DENTA 5000 PLUS CREAM

DENTAGEL 1.1% GEL

DEPAKENE 250 MG CAPSULE

DEPAKENE 250 MG/5 ML SOLUTION

DEPAKOTE DR 125 MG TABLET

DEPAKOTE DR 250 MG TABLET

DEPAKOTE DR 500 MG TABLET

DEPAKOTE EC 125 MG TABLET

DEPAKOTE EC 250 MG TABLET

DEPAKOTE ER 250 MG TABLET

DEPAKOTE ER 500 MG TABLET

DEPAKOTE DR 125 MG SPRINKLE CP

DEPEN 250 MG TITRATAB

DEPO-ESTRADIOL 5 MG/ML VIAL

DEPO-PROVERA 150 MG/ML SYRINGE

DEPO-PROVERA 150 MG/ML VIAL

DEPO-PROVERA 400 MG/ML VIAL

DEPO-SUBQ PROVERA 104 SYRINGE

DEPO-TESTOSTERONE 100 MG/ML VL

DEPO-TESTOSTERONE 200 MG/ML

DEPO-TESTOSTERONE 200 MG/ML VL

DESCOVY 200-25 MG TABLET

DESIPRAMINE 10 MG TABLET

DESIPRAMINE 100 MG TABLET

DESIPRAMINE 150 MG TABLET

DESIPRAMINE 25 MG TABLET

DESIPRAMINE 50 MG TABLET

DESIPRAMINE 75 MG TABLET

DESLORATADINE 2.5 MG ODT

DESLORATADINE 5 MG ODT

DESLORATADINE 5 MG TABLET

DESMOPRESSIN 10 MCG/0.1 ML SPR

DESMOPRESSIN 0.01% SOLUTION

DESMOPRESSIN 0.01% SPRAY

DESMOPRESSIN ACETATE 0.1 MG TB

DESMOPRESSIN ACETATE 0.2 MG TB

DESOGEN 28 DAY TABLET

DESOGEST-ETH ESTRA 0.15-0.03MG

DESOGESTREL-ETHINYL ESTRAD TAB

DESOGESTR-ETH ESTRAD ETH ESTRA

DESOXYN 5 MG TABLET

DESVENLAFAXINE ER 100 MG TAB

DESVENLAFAXINE ER 50 MG TAB

DESVENLAFAXINE ER 50 MG TABLET

DESVENLAFAXINE FUM ER 100 MG

DESVENLAFAXINE FUM ER 50 MG

DESVENLAFAXINE SUC ER 100 MG

DESVENLAFAXINE SUC ER 25 MG TB

DESVENLAFAXINE SUC ER 50 MG TB

DETROL 1 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

DETROL 2 MG TABLET

DETROL LA 2 MG CAPSULE

DETROL LA 4 MG CAPSULE

DEXCOM RECEIVER KIT

DEXCOM G4 (PED) RECEIVER KIT

DEXCOM G4 RECEIVER KIT

DEXCOM G4 RECEIVER-SHARE (PED)

DEXCOM G4 RECEIVER-SHARE KIT

DEXCOM G4 TRANSMITTER KIT

DEXCOM G5 RECEIVER KIT

DEXCOM G5 TRANSMITTER KIT

DEXCOM G5-G4 SENSOR KIT

DEXCOM G6 RECEIVER

DEXCOM G6 SENSOR

DEXCOM G6 TRANSMITTER

DEXEDRINE SPANSULE 10 MG

DEXEDRINE SPANSULE 15 MG

DEXEDRINE SPANSULE 5 MG

DEXILANT DR 30 MG CAPSULE

DEXILANT DR 60 MG CAPSULE

DEXMETHYLPHENIDATE 10 MG TAB

DEXMETHYLPHENIDATE 2.5 MG TAB

DEXMETHYLPHENIDATE 5 MG TAB

DEXMETHYLPHENIDATE ER 10 MG CP

DEXMETHYLPHENIDATE ER 15 MG CP

DEXMETHYLPHENIDATE ER 20 MG CP

DEXMETHYLPHENIDATE ER 25 MG CP

DEXMETHYLPHENIDATE ER 30 MG CP

DEXMETHYLPHENIDATE ER 35 MG CP

DEXMETHYLPHENIDATE ER 40 MG CP

DEXMETHYLPHENIDATE ER 5 MG CAP

DEXTROAMPHETAMINE 10 MG TAB

DEXTROAMPHETAMINE 5 MG TAB

DEXTROAMPHETAMINE 5 MG/5 ML

DEXTROAMPHETAMINE ER 10 MG CAP

DEXTROAMPHETAMINE ER 15 MG CAP

DEXTROAMPHETAMINE ER 5 MG CAP

DEXTROAMP-AMPHET ER 10 MG CAP

DEXTROAMP-AMPHET ER 15 MG CAP

DEXTROAMP-AMPHET ER 20 MG CAP

DEXTROAMP-AMPHET ER 25 MG CAP

DEXTROAMP-AMPHET ER 30 MG CAP

DEXTROAMP-AMPHET ER 5 MG CAP

DEXTROAMP-AMPHETAM 12.5 MG TAB

DEXTROAMP-AMPHETAM 7.5 MG TAB

DEXTROAMP-AMPHETAMIN 10 MG TAB

DEXTROAMP-AMPHETAMIN 15 MG TAB

DEXTROAMP-AMPHETAMIN 20 MG TAB

DEXTROAMP-AMPHETAMIN 30 MG TAB

DEXTROAMP-AMPHETAMINE 5 MG TAB

DIABETES HEALTH PACK

DIABETES HEALTH FORMULA CAPLET

CVS DIABETES HEALTH SUPPORT

DIABETIC VITAMIN CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

DIACOMIT 250 MG CAPSULE

DIACOMIT 250 MG POWDER PACKET

DIACOMIT 500 MG CAPSULE

DIACOMIT 500 MG POWDER PACKET

DIALYVITE TABLET

DIALYVITE 3,000 TABLET

DIALYVITE 800 TABLET

DIALYVITE 800 WITH IRON TAB

DIALYVITE WITH ZINC TABLET

DIAMODE 2 MG TABLET

DIAMOX SEQUELS ER 500 MG CAP

DIASTIX REAGENT STRIPS

DIATRUE LEVEL 3 CONTROL SOLN

DIATRUE LEVEL 1 CONTROL SOLN

DIATRUE LEVEL 2 CONTROL SOLN

DIATRUE PLUS TEST STRIP

DIATRUE PLUS BLOOD GLUCOSE SYS

DICLOFENAC POT 50 MG TABLET

DICLOFENAC SOD DR 25 MG TAB

DICLOFENAC SOD DR 50 MG TAB

DICLOFENAC SOD DR 75 MG TAB

DICLOFENAC SOD EC 25 MG TAB

DICLOFENAC SOD EC 50 MG TAB

DICLOFENAC SOD EC 75 MG TAB

DICLOFENAC SOD ER 100 MG TAB

DICLOFENAC-MISOPROST 50-0.2 TB

DICLOFENAC-MISOPROST 50-200 TB

DICLOFENAC-MISOPROST 75-0.2 TB

DICLOFENAC-MISOPROST 75-200 TB

DICYCLOMINE 10 MG CAPSULE

DICYCLOMINE 10 MG/5 ML SOLN

DICYCLOMINE 20 MG TABLET

DIDANOSINE DR 125 MG CAPSULE

DIDANOSINE DR 200 MG CAPSULE

DIDANOSINE DR 250 MG CAPSULE

DIDANOSINE DR 400 MG CAPSULE

DIFLUNISAL 500 MG TABLET

DIGITEK 125 MCG TABLET

DIGITEK 250 MCG TABLET

DIGOX 125 MCG TABLET

DIGOX 250 MCG TABLET

DIGOXIN 0.05 MG/ML SOLUTION

DIGOXIN 0.125 MG TABLET

DIGOXIN 0.125 MG/2.5 ML SOLN

DIGOXIN 0.25 MG TABLET

DIGOXIN 0.25 MG/5 ML SOLUTION

DIGOXIN 125 MCG TABLET

DIGOXIN 250 MCG TABLET

DILANTIN 50 MG INFATAB

DILANTIN 100 MG CAPSULE

DILANTIN 100 MG KAPSEAL

DILANTIN 30 MG CAPSULE

DILANTIN 30 MG KAPSEAL

DILANTIN 125 MG/5 ML SUSP

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

DILATRATE-SR 40 MG CAPSULE

DILTIAZEM 12HR ER 120 MG CAP

DILTIAZEM 12HR ER 60 MG CAP

DILTIAZEM 12HR ER 90 MG CAP

DILTIAZEM 24HR ER 120 MG CAP

DILTIAZEM 24HR ER 180 MG CAP

DILTIAZEM 24HR ER 240 MG CAP

DILTIAZEM 24HR ER 300 MG CAP

DILTIAZEM 24HR ER 360 MG CAP

DILTIAZEM 24HR ER 420 MG CAP

DILTIAZEM 24H ER(CD) 120 MG CP

DILTIAZEM 24H ER(CD) 180 MG CP

DILTIAZEM 24H ER(CD) 240 MG CP

DILTIAZEM 24H ER(CD) 300 MG CP

DILTIAZEM 24H ER(CD) 360 MG CP

DILTIAZEM 24H ER(LA) 180 MG TB

DILTIAZEM 24H ER(LA) 240 MG TB

DILTIAZEM 24H ER(LA) 300 MG TB

DILTIAZEM 24H ER(LA) 360 MG TB

DILTIAZEM 24H ER(LA) 420 MG TB

DILTIAZEM 24H ER(XR) 120 MG CP

DILTIAZEM 24H ER(XR) 180 MG CP

DILTIAZEM 24H ER(XR) 240 MG CP

DILTIAZEM 120 MG TABLET

DILTIAZEM 30 MG TABLET

DILTIAZEM 60 MG TABLET

DILTIAZEM 90 MG TABLET

DILT XR 120 MG CAPSULE

DILT XR 180 MG CAPSULE

DILT XR 240 MG CAPSULE

DILUENT FOR EPOPROSTENOL VIAL

DILUENT FOR FLOLAN VIAL

DILUENT FOR REMODULIN VIAL

STERILE DILUENT-TREPROSTINIL

DINO-LIFE IRON-ZINC TAB CHEW

DINO-LIFE EXTRA C CHEW TABLET

DINO-LIFE CHEWABLE TABLET

DIOVAN 160 MG TABLET

DIOVAN 320 MG TABLET

DIOVAN 40 MG TABLET

DIOVAN 80 MG TABLET

DIOVAN HCT 160-12.5 MG TAB

DIOVAN HCT 160-25 MG TABLET

DIOVAN HCT 320-12.5 MG TAB

DIOVAN HCT 320-25 MG TABLET

DIOVAN HCT 80-12.5 MG TABLET

DIPENTUM 250 MG CAPSULE

DIPYRIDAMOLE 25 MG TABLET

DIPYRIDAMOLE 50 MG TABLET

DIPYRIDAMOLE 75 MG TABLET

DISALCID 500 MG TABLET

DISALCID 750 MG TABLET

DISOPYRAMIDE 100 MG CAPSULE

DISOPYRAMIDE 150 MG CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

DISULFIRAM 250 MG TABLET

DISULFIRAM 500 MG TABLET

DITROPAN XL 10 MG TABLET

DITROPAN XL 15 MG TABLET

DITROPAN XL 5 MG TABLET

DIURIL 250 MG/5 ML ORAL SUSP

DIVALPROEX DR 125 MG CAP SPRNK

DIVALPROEX SOD DR 125 MG TAB

DIVALPROEX SOD DR 250 MG TAB

DIVALPROEX SOD DR 500 MG TAB

DIVALPROEX SOD ER 250 MG TAB

DIVALPROEX SOD ER 500 MG TAB

DIVIGEL 0.25 MG GEL PACKET

DIVIGEL 0.5 MG GEL PACKET

DIVIGEL 0.75 MG GEL PACKET

DIVIGEL 1 MG GEL PACKET

DIVIGEL 1.25 MG GEL PACKET

DOFETILIDE 125 MCG CAPSULE

DOFETILIDE 250 MCG CAPSULE

DOFETILIDE 500 MCG CAPSULE

DOG EPITHELIUM 1:10 (W/V) VIAL

DOG EPITHELIUM 1:20 (W/V) VIAL

DOG FENNEL 1:20 (W/V) VIAL

DONEPEZIL HCL 10 MG TABLET

DONEPEZIL HCL 23 MG TABLET

DONEPEZIL HCL 5 MG TABLET

DONEPEZIL HCL ODT 10 MG TABLET

DONEPEZIL HCL ODT 5 MG TABLET

DONNATAL ELIXIR

DONNATAL TABLET

DORZOLAMIDE 2% EYE DROP

DORZOLAMIDE HCL 2% EYE DROPS

DORZOLAMIDE-TIMOLOL EYE DROPS

DORZOLAMIDE-TIMOLOL 2%-0.5%

DOTHELLE DHA SOFTGEL

DOTTI 0.025 MG PATCH

DOTTI 0.0375 MG PATCH

DOTTI 0.05 MG PATCH

DOTTI 0.075 MG PATCH

DOTTI 0.1 MG PATCH

DOVATO 50-300 MG TABLET

DOXAZOSIN MESYLATE 1 MG TAB

DOXAZOSIN MESYLATE 2 MG TAB

DOXAZOSIN MESYLATE 4 MG TAB

DOXAZOSIN MESYLATE 8 MG TAB

DOXEPIN 10 MG CAPSULE

DOXEPIN 10 MG/ML ORAL CONC

DOXEPIN 100 MG CAPSULE

DOXEPIN 150 MG CAPSULE

DOXEPIN 25 MG CAPSULE

DOXEPIN 50 MG CAPSULE

DOXEPIN 75 MG CAPSULE

DOXERCALCIFEROL 0.5 MCG CAP

DOXERCALCIFEROL 1 MCG CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

DOXERCALCIFEROL 2.5 MCG CAP

DOXERCALCIFEROL 4 MCG/2 ML AMP

DOXERCALCIFEROL 4 MCG/2 ML VL

D-PENAMINE 125 MG TABLET

DRECHSLERA 10,000 PNU/ML

DRECHSLERA 20,000 PNU/ML

DRISDOL 1.25 MG (50,000 UNIT)

DRIZALMA SPRINKLE DR 20 MG CAP

DRIZALMA SPRINKLE DR 30 MG CAP

DRIZALMA SPRINKLE DR 40 MG CAP

DRIZALMA SPRINKLE DR 60 MG CAP

DROPLET 0.5 ML 29GX12.5MM(1/2)

DROPLET 0.5 ML 30GX12.5MM(1/2)

DROPLET 0.5ML 30GX12.5MM(1/2)

DROPLET INS 0.5ML 30GX6MM(1/2)

DROPLET INS 0.5ML 30GX8MM(1/2)

DROPLET INS 0.5ML 31GX6MM(1/2)

DROPLET INS 0.5ML 31GX8MM(1/2)

DROPLET INS SYR 1 ML 30GX6MM

DROPLET INS SYR 1 ML 30GX8MM

DROPLET INS SYR 1 ML 31GX6MM

DROPLET INS SYR 1 ML 31GX8MM

DROPLET INS SYR 1ML 29GX12.5MM

DROPLET INS SYR 1ML 30GX12.5MM

DROPLET INS 0.3 ML 29GX12.5MM

DROPLET INS 0.3ML 30GX12.5MM

DROPLET INS SYR 0.3 ML 30GX6MM

DROPLET INS SYR 0.3 ML 30GX8MM

DROPLET INS SYR 0.3 ML 31GX6MM

DROPLET INS SYR 0.3 ML 31GX8MM

DROPLET 30G LANCETS

DROPLET PEN NEEDLE 29GX1/2"

DROPLET PEN NEEDLE 29GX3/8"

DROPLET PEN NEEDLE 31GX1/4"

DROPLET PEN NEEDLE 31GX3/16"

DROPLET PEN NEEDLE 31GX5/16"

DROPLET PEN NEEDLE 32GX1/4"

DROPLET PEN NEEDLE 32GX3/16"

DROPLET PEN NEEDLE 32GX5/16"

DROPLET PEN NEEDLE 32GX5/32"

DROPSAFE PEN NEEDLE 31GX1/4"

DROPSAFE PEN NEEDLE 31GX5/16"

DROSP-EE-LEVOMEF 3-0.02-0.451

DROSP-EE-LEVOMEF 3-0.03-0.451

DROSPIRENONE-EE 3-0.02 MG TAB

DROSPIRENONE-EE 3-0.03 MG TAB

DROXIA 200 MG CAPSULE

DROXIA 300 MG CAPSULE

DROXIA 400 MG CAPSULE

DUAKLIR PRESSAIR 400-12MCG INH

DUAVEE 0.45-20 MG TABLET

DUET DHA 400 COMBO PACK

DUET DHA BALANCED (25 MG IRON)

DUETACT 30-2 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

DUETACT 30-4 MG TABLET

DUEXIS 800-26.6 MG TABLET

DULERA 100 MCG-5 MCG INHALER

DULERA 200 MCG-5 MCG INHALER

DULERA 50 MCG-5 MCG INHALER

DULOXETINE HCL DR 20 MG CAP

DULOXETINE HCL DR 30 MG CAP

DULOXETINE HCL DR 40 MG CAP

DULOXETINE HCL DR 60 MG CAP

DUONEB 0.5 MG-3 MG/3 ML SOLN

DUOPA 4.63 MG-20 MG/ML SUSPENS

DUPIXENT 200 MG/1.14 ML SYRING

DUPIXENT 300 MG/2 ML SYRINGE

DURLAZA ER 162.5 MG CAPSULE

DUTASTERIDE 0.5 MG CAPSULE

DUTASTERIDE-TAMSULOSIN 0.5-0.4

DUTOPROL 100-12.5 MG TABLET

DUTOPROL 25-12.5 MG TABLET

DUTOPROL 50-12.5 MG TABLET

DUZALLO 200-200 MG TABLET

DUZALLO 200-300 MG TABLET

DYANAVEL XR 2.5 MG/ML SUSP

DYAZIDE 37.5-25 CAPSULE

DYRENIUM 100 MG CAPSULE

DYRENIUM 50 MG CAPSULE

EASTERN COTTONWOOD 1:20 (W/V)

EASY COMFORT 30G LANCETS

EASY COMFORT 1 ML 31GX5/16"

EASY COMFORT 1 ML 32GX5/16"

EASY COMFORT INSULIN 1 ML SYR

EASY COMFORT SYR 1 ML 30GX1/2"

EASY COMFORT 0.5 ML 30GX1/2"

EASY COMFORT 0.5 ML 31GX5/16"

EASY COMFORT 0.5 ML 32GX5/16"

EASY COMFORT 0.5 ML SYRINGE

EASY COMFORT 0.3 ML SYRINGE

EASY COMFORT PEN NDL 31GX3/16"

EASY COMFORT PEN NDL 31GX5/16"

EASY COMFORT PEN NDL 33G 4MM

EASY COMFORT PEN NDL 33G 5MM

EASY COMFORT PEN NDL 33G 6MM

EASY COMFORT PEN NDL 31GX1/4"

EASY COMFORT PEN NDL 32GX5/32"

EASY GLIDE INS 1 ML 31GX6MM

EASY GLIDE INS 0.5 ML 31GX6MM

EASY GLIDE INS 0.3 ML 31GX6MM

EASY GLIDE PEN NEEDLE 4MM 33G

EASY PLUS II TEST STRIP

EASY PLUS II CONTROL SOLN HIGH

EASY PLUS II CONTROL SOLN LOW

EASY PLUS II BLOOD GLUCOSE SYS

EASY STEP GLUCOSE TEST STRIPS

EASY STEP BLOOD GLUCOSE METER

EASY STEP GLUCOSE SYSTEM KIT

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

EASY STEP CONTRL SOLN-HIGH

EASY STEP CONTROL SOLN-LOW

EASY STEP CONTROL SOLN-NORMAL

EASY TALK GLUCOSE TEST STRIP

EASY TALK HIGH CONTROL SOLN

EASY TALK CONTROL SOLN LOW

EASY TALK BLOOD GLUCOSE METER

EASY TALK GLUCOSE SYSTEM KIT

EASY TOUCH BUTTON 30G LANCETS

EASY TOUCH PRESSURE 30G LANCET

EASY TOUCH PULL-TOP 26G LANCET

EASY TOUCH PULL-TOP 28G LANCET

EASY TOUCH PULL-TOP 30G LANCET

EASY TOUCH PULL-TOP 32G LANCET

EASY TOUCH SAFETY 21G LANCETS

EASY TOUCH SAFETY 23G LANCETS

EASY TOUCH SAFETY 26G LANCETS

EASY TOUCH SAFETY 28G LANCETS

EASY TOUCH SAFETY 32G LANCETS

EASY TOUCH TWIST 26G LANCETS

EASY TOUCH TWIST 28G LANCETS

EASY TOUCH TWIST 30G LANCETS

EASY TOUCH TWIST 32G LANCETS

EASY TOUCH TWIST 33G LANCETS

EASY TOUCH INSULIN SYR 1 ML

EASY TOUCH INSULIN SYR 0.5 ML

EASY TOUCH INSULIN SYR 0.3 ML

EASY TOUCH HIGH-LOW CTRL SOLN

GNP EASY TOUCH HIGH-LOW SOLN

EASY TOUCH INSULN 1ML 29GX1/2"

EASY TOUCH INSULN 1ML 30GX1/2"

EASY TOUCH INSULN 1ML 30GX5/16

EASY TOUCH INSULN 1ML 31GX5/16

EASY TOUCH GLUCOSE MONITOR SYS

GNP EASY TOUCH GLUCOSE MONITOR

EASY TOUCH 1 ML SYR 29GX1/2"

EASY TOUCH 1 ML SYR 30GX1/2"

EASY TOUCH 0.5 ML SYR 29GX1/2"

EASY TOUCH 0.5 ML SYR 30GX5/16

EASY TOUCH 1 ML SYR 27GX1/2"

EASY TOUCH 1 ML SYR 30GX1/2"

EASY TOUCH 0.5 ML SYR 27GX1/2"

EASY TOUCH 0.5 ML SYR 30GX1/2"

EASY TOUCH 0.3 ML SYR 30GX1/2"

EASY TOUCH 28G LANCETS

EASY TOUCH LUER LOK INSUL 1 ML

EASY TOUCH PEN NEEDLE 29GX1/2"

EASY TOUCH PEN NEEDLE 30GX5/16

EASY TOUCH PEN NEEDLE 31GX1/4"

EASY TOUCH PEN NEEDLE 31GX3/16

EASY TOUCH PEN NEEDLE 31GX5/16

EASY TOUCH PEN NEEDLE 32GX1/4"

EASY TOUCH PEN NEEDLE 32GX3/16

EASY TOUCH PEN NEEDLE 32GX5/32

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

EASY TOUCH SAF PEN NDL 30G 5MM

EASY TOUCH INSULIN 1ML 29GX1/2

EASY TOUCH INSULIN 1ML 30GX1/2

EASY TOUCH INSULN 1ML 30GX5/16

EASY TOUCH INSULN 1ML 31GX5/16

EASY TOUCH GLUCOSE TEST STRIP

GNP EASY TOUCH GLUC TEST STRIP

EASY TOUCH UNI-SLIP SYR 1 ML

EASY TRAK GLUCOSE TEST STRIP

EASY TRAK CONTROL SOLN HIGH

EASY TRAK CONTROL SOLN LOW

EASY TRAK BLOOD GLUCOSE METER

EASY TRAK GLUCOSE SYSTEM KIT

EASY TWIST & CAP 28G LANCETS

EASYGLUCO METER

EASYGLUCO METER STARTER KIT

EASYGLUCO PLUS TEST STRIPS

EASYGLUCO PLUS METER KIT

EASYGLUCO PLUS STARTER KIT

EASYGLUCO PLUS CTRL SOL NORMAL

EASYGLUCO TEST STRIPS

EASYMAX GLUCOSE TEST STRIPS

EASYMAX LOW CONTROL SOLN

EASYMAX NORMAL CONTROL SOLN

EASYMAX 15 GLUCOSE TEST STRIP

EASYMAX 15 LEVEL 1 SOLUTION

EASYMAX 15 LEVEL 2 SOLUTION

EASYMAX L BLOOD GLUCOSE SYSTEM

EASYMAX NG BLOOD GLUCOSE SYS

EASYMAX NG GLUCOSE SYSTEM KIT

EASYMAX V SPEAKING GLUCOSE SYS

EASYMAX V2 BLOOD GLUCOSE SYS

EASY-TOUCH BLOOD GLUCOSE METER

EASY-TOUCH INS 1 ML 31GX5/16"

BD ECLIPSE 30GX1/2" SYRINGE

EC-NAPROSYN EC 375 MG TABLET

EC-NAPROSYN EC 500 MG TABLET

NAPROSYN EC 500 MG TABLET

EC-NAPROXEN DR 375 MG TABLET

EC-NAPROXEN DR 500 MG TABLET

ECOTRIN EC 325 MG TABLET

ECOTRIN EC 81 MG TABLET

ECPIRIN EC 325 MG TABLET

EDARBI 40 MG TABLET

EDARBI 80 MG TABLET

EDARBYCLOR 40-12.5 MG TABLET

EDARBYCLOR 40-25 MG TABLET

EDECRIN 25 MG TABLET

EDEX 10 MCG CARTRIDGE 2-PK KIT

EDEX 10 MCG CARTRIDGE 6-PK KIT

EDEX 20 MCG CARTRIDGE 2-PK KIT

EDEX 20 MCG CARTRIDGE 6-PK KIT

EDEX 40 MCG CARTRIDGE 2-PK KIT

EDEX 40 MCG CARTRIDGE 6-PK KIT

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ED-SPAZ 0.125 MG ODT

EDURANT 25 MG TABLET

EEMT DS 1.25-2.5 MG TABLET

EEMT HS 0.625-1.25 MG TABLET

EFAVIRENZ 200 MG CAPSULE

EFAVIRENZ 50 MG CAPSULE

EFAVIRENZ 600 MG TABLET

EFFER-K 10 MEQ TABLET EFF

EFFER-K 20 MEQ TABLET EFF

EFFER-K 25 MEQ TABLET EFF

EFFEXOR XR 150 MG CAPSULE

EFFEXOR XR 37.5 MG CAPSULE

EFFEXOR XR 75 MG CAPSULE

EFFIENT 10 MG TABLET

EFFIENT 5 MG TABLET

EGRIFTA 1 MG VIAL

EGRIFTA 2 MG VIAL

EGRIFTA SV 2 MG VIAL

ELAPRASE 6 MG/3 ML VIAL

ELDERCAPS CAPSULE

ELDERTONIC ELIXIR

ELELYSO 200 UNITS VIAL

ELEMENT COMPACT TEST STRIPS

ELEMENT COMPACT GLUCOSE METER

ELEMENT COMPACT SOLN HIGH

ELEMENT COMPACT SOLN NORMAL

ELEMENT COMPACT V GLUCOSE MTR

ELEMENT CONTROL SOLUTION HIGH

ELEMENT CONTROL SOLUTION LOW

ELEMENT CONTROL SOLN NORMAL

ELEMENT PLUS BLOOD GLUCOSE KIT

ELEMENT TEST STRIPS

ELESTRIN 0.06% GEL

ELIGARD 22.5 MG SYRINGE KIT

ELIGARD 30 MG SYRINGE KIT

ELIGARD 45 MG SYRINGE KIT

ELIGARD 7.5 MG SYRINGE KIT

ELINEST-28 TABLET

ELIPHOS 667 MG TABLET

ELIQUIS 2.5 MG TABLET

ELIQUIS 5 MG TABLET

ELITE-OB CAPLET

ELIXOPHYLLIN 80 MG/15 ML ELIX

ELLIS TONIC

ELOCTATE 1,000 UNIT NOMINAL

ELOCTATE 1,500 UNIT NOMINAL

ELOCTATE 2,000 UNIT NOMINAL

ELOCTATE 250 UNIT NOMINAL

ELOCTATE 3,000 UNIT NOMINAL

ELOCTATE 4,000 UNIT NOMINAL

ELOCTATE 5,000 UNIT NOMINAL

ELOCTATE 500 UNIT NOMINAL

ELOCTATE 6,000 UNIT NOMINAL

ELOCTATE 750 UNIT NOMINAL

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ELON MATRIX 5000 COMPLETE TAB

ELON MATRIX COMPLETE TABLET

ELURYNG VAGINAL RING

EMBRACE GLUCOSE TEST STRIPS

EMBRACE TEST STRIPS

EMBRACE GLUC CONTROL SOLN HIGH

EMBRACE BLOOD GLUCOSE KIT

EMBRACE BLOOD GLUCOSE SYSTEM

EMBRACE 30G LANCETS

EMBRACE EVO TEST STRIPS

EMBRACE EVO LEVEL 1 CTRL SOLN

EMBRACE EVO LEVEL 2 CTRL SOLN

EMBRACE EVO BLOOD GLUCOSE KIT

EMBRACE GLUC CONTROL SOLN LOW

EMBRACE PRO CONTROL SOLUTION

EMBRACE PRO BLOOD GLUCOSE MTR

EMBRACE PRO TEST STRIP

EMBRACE TALK BLOOD GLUCOSE MTR

EMBRACE TALK BLOOD GLUCOSE SYS

EMBRACE TALK CTRL SOL-HIGH(L2)

EMBRACE TALK CTRL SOLN-LOW(L1)

EMBRACE TALK TEST STRIP

EMERGEN-C KIDZ 250 MG PACKET

EMFLAZA 18 MG TABLET

EMFLAZA 22.75 MG/ML ORAL SUSP

EMFLAZA 30 MG TABLET

EMFLAZA 36 MG TABLET

EMFLAZA 6 MG TABLET

EMGALITY 120 MG/ML PEN

EMGALITY 120 MG/ML SYRINGE

EMOQUETTE 28 DAY TABLET

EMSAM 12 MG/24 HOURS PATCH

EMSAM 6 MG/24 HOURS PATCH

EMSAM 9 MG/24 HOURS PATCH

EMTRIVA 10 MG/ML SOLUTION

EMTRIVA 200 MG CAPSULE

ENABLEX 15 MG TABLET

ENABLEX 7.5 MG TABLET

ENALAPRIL MALEATE 10 MG TAB

ENALAPRIL MALEATE 2.5 MG TAB

ENALAPRIL MALEATE 20 MG TAB

ENALAPRIL MALEATE 5 MG TABLET

ENALAPRIL-HCTZ 10-25 MG TABLET

ENALAPRIL-HCTZ 5-12.5 MG TAB

ENBRACE HR SOFTGEL

ENBREL 25 MG KIT

ENBREL 25 MG/0.5 ML SYRINGE

ENBREL 50 MG/ML SYRINGE

ENBREL 50 MG/ML MINI CARTRIDGE

ENBREL 50 MG/ML SURECLICK

ENDARI 5 GRAM POWDER PACKET

ENDUR-VM IRON-FREE SR TABLET

ENDUR-VM WITH IRON SR TABLET

ENGLISH PLANTAIN 1:20 (W/V) VL

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ENLITE SYSTEM KIT

ENLITE GLUCOSE SENSOR

ENPRESSE-28 TABLET

ENSKYCE 28 TABLET

ENTACAPONE 200 MG TABLET

ENTECAVIR 0.5 MG TABLET

ENTECAVIR 1 MG TABLET

ENTRESTO 24 MG-26 MG TABLET

ENTRESTO 49 MG-51 MG TABLET

ENTRESTO 97 MG-103 MG TABLET

ENTYVIO 300 MG VIAL

ENULOSE 10 GM/15 ML SOLUTION

ENVARSUS XR 0.75 MG TABLET

ENVARSUS XR 1 MG TABLET

ENVARSUS XR 4 MG TABLET

ENZADYNE CAPSULE

EPANED 1 MG/ML ORAL SOLUTION

EPANED 1 MG/ML SOLUTION

EPICOCCUM 10,000 PNU/ML VIAL

EPICOCCUM 20,000 PNU/ML VIAL

EPIDIOLEX 100 MG/ML SOLUTION

EPITOL 200 MG TABLET

EPIVIR 10 MG/ML ORAL SOLN

EPIVIR 150 MG TABLET

EPIVIR 300 MG TABLET

EPIVIR HBV 100 MG TABLET

EPIVIR HBV 25 MG/5 ML SOLN

EPLERENONE 25 MG TABLET

EPLERENONE 50 MG TABLET

EPOGEN 10,000 UNITS/ML VIAL

EPOGEN 2,000 UNITS/ML VIAL

EPOGEN 20,000 UNITS/2 ML VIAL

EPOGEN 20,000 UNITS/ML VIAL

EPOGEN 3,000 UNITS/ML VIAL

EPOGEN 4,000 UNITS/ML VIAL

EPOPROSTENOL SODIUM 0.5 MG VL

EPOPROSTENOL SODIUM 1.5 MG VL

EPROSARTAN MESYLATE 600 MG TAB

EPZICOM TABLET

EQUETRO 100 MG CAPSULE

EQUETRO 200 MG CAPSULE

EQUETRO 300 MG CAPSULE

ERGOLOID MESYLATES 1 MG TAB

ERIVEDGE 150 MG CAPSULE

ERLEADA 60 MG TABLET

ERLOTINIB HCL 100 MG TABLET

ERLOTINIB HCL 150 MG TABLET

ERLOTINIB HCL 25 MG TABLET

ERRIN 0.35 MG TABLET

ESBRIET 267 MG CAPSULE

ESBRIET 267 MG TABLET

ESBRIET 801 MG TABLET

ESCAVITE TABLET CHEWABLE

ESCAVITE D TABLET CHEWABLE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ESCAVITE LQ DROPS

ESCITALOPRAM 10 MG TABLET

ESCITALOPRAM 20 MG TABLET

ESCITALOPRAM 5 MG TABLET

ESCITALOPRAM OXALATE 10MG/10ML

ESCITALOPRAM OXALATE 5 MG/5 ML

ESOMEP-EZS KIT

CVS ESOMEPRAZOLE MAG 20 MG CAP

ESOMEPRAZOLE MAG DR 20 MG CAP

ESOMEPRAZOLE MAG DR 40 MG CAP

GS ESOMEPRAZOLE MAG DR 20 MG

HM ESOMEPRAZOLE MAG DR 20 MG

RA ESOMEPRAZOLE MAG DR 20 MG

SM ESOMEPRAZOLE MAG DR 20 MG

ESOMEPRAZOLE DR 24.65 MG CAP

ESOMEPRAZOLE DR 49.3 MG CAP

ESPEROCT 1,000 UNIT VIAL

ESPEROCT 1,500 UNIT VIAL

ESPEROCT 2,000 UNIT VIAL

ESPEROCT 3,000 UNIT VIAL

ESPEROCT 500 UNIT VIAL

ESSENTIA TABLET

ESSENTIAL BALANCE TABLET

ESSENTIAL DAILY TABLET

ESSENTIAL MAN TABLET

ESSENTIAL MAN 50+ TABLET

ESSENTIAL WOMAN 50+ TABLET

ESTARYLLA 0.25-0.035 MG TABLET

ESTRACE 0.01% CREAM

ESTRACE 0.5 MG TABLET

ESTRACE 1 MG TABLET

ESTRACE 2 MG TABLET

ESTRADIOL 0.01% CREAM

ESTRADIOL 0.025 MG PATCH

ESTRADIOL 0.0375 MG PATCH

ESTRADIOL 0.0375 MG/DAY PATCH

ESTRADIOL 0.05 MG PATCH

ESTRADIOL 0.06 MG/DAY PATCH

ESTRADIOL 0.075 MG PATCH

ESTRADIOL 0.075 MG/DAY PATCH

ESTRADIOL 0.1 MG PATCH

ESTRADIOL 0.5 MG TABLET

ESTRADIOL 1 MG TABLET

ESTRADIOL 10 MCG VAGINAL INSRT

ESTRADIOL 2 MG TABLET

ESTRADIOL TDS 0.025 MG/DAY

ESTRADIOL TDS 0.0375 MG/DAY

ESTRADIOL TDS 0.05 MG/DAY

ESTRADIOL TDS 0.06 MG/DAY

ESTRADIOL TDS 0.075 MG/DAY

ESTRADIOL TDS 0.1 MG/DAY

ESTRADIOL 0.05 MG/DAY PATCH

ESTRADIOL 0.1 MG/DAY PATCH

ESTRADIOL VALERATE 20 MG/ML VL

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ESTRADIOL VALERATE 40 MG/ML VL

ESTRADIOL-NORETH 0.5-0.1 MG TB

ESTRADIOL-NORETH 1-0.5 MG TAB

ESTRING 2 MG VAGINAL RING

ESTROGEL 0.06% GEL

ESTROGEN-METHYLTESTOS F.S. TAB

ESTROGEN-METHYLTESTOS H.S. TAB

ESTROPIPATE 0.625(0.75 MG) TAB

ESTROPIPATE 1.25(1.5 MG) TAB

ESTROPIPATE 2.5(3 MG) TAB

ESTROSTEP FE-28 TABLET

ETHACRYNIC ACID 25 MG TABLET

ETHOSUXIMIDE 250 MG CAPSULE

ETHOSUXIMIDE 250 MG/5 ML SOLN

ETHYNODIOL-ETH ESTRA 1MG-35MCG

ETHYNODIOL-ETH ESTRA 1MG-50MCG

ETIDRONATE DISODIUM 200 MG TAB

ETIDRONATE DISODIUM 400 MG TAB

ETODOLAC 200 MG CAPSULE

ETODOLAC 300 MG CAPSULE

ETODOLAC 400 MG TABLET

ETODOLAC 500 MG TABLET

ETODOLAC ER 400 MG TABLET

ETODOLAC ER 500 MG TABLET

ETODOLAC ER 600 MG TABLET

ETONOGESTREL-EE VAGINAL RING

EUTHYROX 100 MCG TABLET

EUTHYROX 112 MCG TABLET

EUTHYROX 125 MCG TABLET

EUTHYROX 137 MCG TABLET

EUTHYROX 150 MCG TABLET

EUTHYROX 175 MCG TABLET

EUTHYROX 200 MCG TABLET

EUTHYROX 25 MCG TABLET

EUTHYROX 50 MCG TABLET

EUTHYROX 75 MCG TABLET

EUTHYROX 88 MCG TABLET

EVAMIST 1.53 MG/SPRAY

EVEKEO 10 MG TABLET

EVEKEO 5 MG TABLET

EVEKEO ODT 10 MG

EVEKEO ODT 15 MG

EVEKEO ODT 20 MG

EVEKEO ODT 5 MG

EVENCARE G2 CONTROL SOLUTION

EVENCARE G2 TEST STRIP

EVENCARE G2 BLOOD GLUCOSE SYS

EVENCARE G3 CONTROL SOLUTION

EVENCARE G3 TEST STRIP

EVENCARE G3 BLOOD GLUCOSE SYS

EVENCARE MINI GLUCOSE TEST STR

EVENCARE MINI MONITOR SYSTEM

EVENCARE PROVIEW TEST STRIP

EVEROLIMUS 0.25 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

EVEROLIMUS 0.5 MG TABLET

EVEROLIMUS 0.75 MG TABLET

EVEROLIMUS 2.5 MG TABLET

EVEROLIMUS 5 MG TABLET

EVEROLIMUS 7.5 MG TABLET

EVERSENSE SMART TRANSMITTER

EVISTA 60 MG TABLET

EVOLUTION BLOOD GLUCOSE METER

EVOLUTION CONTROL SOLN NORMAL

EVOLUTION TEST STRIPS

EVOTAZ 300 MG-150 MG TABLET

EVOXAC 30 MG CAPSULE

EXELON 13.3 MG/24HR PATCH

EXELON 4.6 MG/24HR PATCH

EXELON 9.5 MG/24HR PATCH

EXEMESTANE 25 MG TABLET

EXFORGE 10-160 MG TABLET

EXFORGE 10-320 MG TABLET

EXFORGE 5-160 MG TABLET

EXFORGE 5-320 MG TABLET

EXFORGE HCT 10-160-12.5 MG TAB

EXFORGE HCT 10-160-25 MG TAB

EXFORGE HCT 10-320-25 MG TAB

EXFORGE HCT 5-160-12.5 MG TAB

EXFORGE HCT 5-160-25 MG TAB

EXJADE 125 MG TABLET

EXJADE 250 MG TABLET

EXJADE 500 MG TABLET

EXONDYS-51 100 MG/2 ML VIAL

EXONDYS-51 500 MG/10 ML VIAL

EXPECTA PRENATAL COMBO PACK

EXTAVIA 0.3 MG KIT

EXTAVIA 0.3 MG VIAL

CVS EYE HEALTH AND LUTEIN TAB

EQL EYE HEALTH PLUS LUTEIN TAB

EYE VITAMIN-MINERALS TABLET

EYEPROTECT TABLET

EYLEA 2 MG/0.05 ML SYRINGE

EYLEA 2 MG/0.05 ML VIAL

E-Z JECT COLORED LANCETS

E-Z JECT LANCETS

EZ SMART TEST STRIPS

EZ SMART SYSTEM KIT

EZ SMART 28G LANCETS

EZ SMART PLUS TEST STRIPS

EZ SMART PLUS SYSTEM KIT

EZALLOR SPRINKLE 10 MG CAPSULE

EZALLOR SPRINKLE 20 MG CAPSULE

EZALLOR SPRINKLE 40 MG CAPSULE

EZALLOR SPRINKLE 5 MG CAPSULE

EZETIMIBE 10 MG TABLET

EZETIMIBE-SIMVASTATIN 10-10 MG

EZETIMIBE-SIMVASTATIN 10-20 MG

EZETIMIBE-SIMVASTATIN 10-40 MG

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

EZETIMIBE-SIMVASTATIN 10-80 MG

E-ZJECT COLOR 32G LANCETS

E-ZJECT COLOR 33G LANCETS

E-ZJECT SUPER THIN 30G LANCETS

RA E-ZJECT 26G LANCETS

RA E-ZJECT 28G LANCETS

RA E-ZJECT 30G LANCETS

RA E-ZJECT COLOR 33G LANCETS

EZ-LETS 26G LANCETS

FA-8 CAPSULES

FABB TABLET

FABRAZYME 35 MG VIAL

FABRAZYME 5 MG VIAL

FALMINA-28 TABLET

FAMCICLOVIR 125 MG TABLET

FAMCICLOVIR 250 MG TABLET

FAMCICLOVIR 500 MG TABLET

EQ FAMOTIDINE 10 MG TABLET

FAMOTIDINE 10 MG TABLET

FAMOTIDINE 20 MG TABLET

FAMOTIDINE 40 MG TABLET

FAMOTIDINE 40 MG/5 ML SUSP

HM FAMOTIDINE 10 MG TABLET

HM FAMOTIDINE 20 MG TABLET

PUB FAMOTIDINE 20 MG TABLET

FAMVIR 125 MG TABLET

FAMVIR 250 MG TABLET

FAMVIR 500 MG TABLET

FANAPT 1 MG TABLET

FANAPT 10 MG TABLET

FANAPT 12 MG TABLET

FANAPT 2 MG TABLET

FANAPT 4 MG TABLET

FANAPT 6 MG TABLET

FANAPT 8 MG TABLET

FARESTON 60 MG TABLET

FARXIGA 10 MG TABLET

FARXIGA 5 MG TABLET

FASENRA 30 MG/ML SYRINGE

FASENRA PEN 30 MG/ML

FASLODEX 250 MG/5 ML SYRINGE

V-R FATIGUE REL COMPLEX CPL

FAYOSIM TABLET

FAZACLO 100 MG ODT

FAZACLO 12.5 MG ODT

FAZACLO 150 MG ODT

FAZACLO 200 MG ODT

FAZACLO 25 MG ODT

FEBUXOSTAT 40 MG TABLET

FEBUXOSTAT 80 MG TABLET

FEIBA NF 1,000 UNIT (NOMINAL)

FEIBA NF 2,500 UNIT (NOMINAL)

FEIBA NF 500 UNIT (NOMINAL)

FELBAMATE 400 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

FELBAMATE 600 MG TABLET

FELBAMATE 600 MG/5 ML SUSP

FELBATOL 400 MG TABLET

FELBATOL 600 MG TABLET

FELBATOL 600 MG/5 ML SUSP

FELDENE 10 MG CAPSULE

FELDENE 20 MG CAPSULE

FELODIPINE ER 10 MG TABLET

FELODIPINE ER 2.5 MG TABLET

FELODIPINE ER 5 MG TABLET

FEMARA 2.5 MG TABLET

FEMCON FE CHEWABLE TABLET

FEMHRT 0.5 MG-2.5 MCG TABLET

FEMRING 0.05 MG/DAY VAG RING

FEMRING 0.10 MG/DAY VAG RING

FEMYNOR 28 TABLET

FENOFIBRATE 120 MG TABLET

FENOFIBRATE 150 MG CAPSULE

FENOFIBRATE 160 MG TABLET

FENOFIBRATE 40 MG TABLET

FENOFIBRATE 50 MG CAPSULE

FENOFIBRATE 54 MG TABLET

FENOFIBRATE 145 MG TABLET

FENOFIBRATE 160 MG TABLET

FENOFIBRATE 48 MG TABLET

FENOFIBRATE 130 MG CAPSULE

FENOFIBRATE 134 MG CAPSULE

FENOFIBRATE 200 MG CAPSULE

FENOFIBRATE 43 MG CAPSULE

FENOFIBRATE 67 MG CAPSULE

FENOFIBRIC ACID 105 MG TABLET

FENOFIBRIC ACID 35 MG TABLET

FENOFIBRIC ACID DR 135 MG CAP

FENOFIBRIC ACID DR 45 MG CAP

FENOGLIDE 120 MG TABLET

FENOGLIDE 40 MG TABLET

FENOPROFEN 200 MG CAPSULE

FENOPROFEN 400 MG CAPSULE

FENOPROFEN 600 MG TABLET

FENORTHO 200 MG CAPSULE

FENORTHO 400 MG CAPSULE

FERRIPROX 1,000 MG TABLET

FERRIPROX 500 MG TABLET

FETZIMA ER 120 MG CAPSULE

FETZIMA ER 20 MG CAPSULE

FETZIMA ER 40 MG CAPSULE

FETZIMA ER 80 MG CAPSULE

FIASP 100 UNIT/ML VIAL

FIASP 100 UNIT/ML FLEXTOUCH

FIASP PENFILL 100 UNIT/ML CART

FIBRICOR 105 MG TABLET

FIBRICOR 35 MG TABLET

FIFTY50 SAFETY SEAL 30G LANCET

FIFTY50 SAFETY SEAL 32G LANCET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

FIFTY50 GLUCOSE TEST STRIP

FINASTERIDE 1 MG TABLET

FINASTERIDE 5 MG TABLET

FINE 30 UNIVERSAL 30G LANCETS

FINGERSTIX LANCETS

FIRDAPSE 10 MG TABLET

FIRE ANT 1:10 (W/V) VIAL

FIRE ANT 1:20 (W/V) VIAL

FIRMAGON 80 MG KIT

FIRST-LANSOPRAZOLE 3 MG/ML

FIRST-OMEPRAZOLE 2 MG/ML SUSP

FIRST 2% TESTOSTERONE OINT

FIRST-TESTOSTERONE MC 2% CR

FLANAX 220 MG TABLET

FLAVOXATE HCL 100 MG TABLET

FLEBOGAMMA DIF 10% VIAL

FLEBOGAMMA DIF 5% VIAL

FLECAINIDE ACETATE 100 MG TAB

FLECAINIDE ACETATE 150 MG TAB

FLECAINIDE ACETATE 50 MG TAB

FLINTSTONES TABLET CHEWABLE

FLINTSTONES MULTIVIT CHEW TAB

FLINTSTONES TAB CHEW

FLINTSTONES GUMMIES CHEW TAB

FLINTSTONES SOUR-GUM CHEW TAB

FLINTSTONES COMPLETE TABLET

FLINTSTONES COMPLETE CHEW TAB

FLINTSTONES COMPLETE GUMMIES

FLINTSTONES GUMMIES CHEW TAB

FLINTSTONES MULTI-VIT GUMMIES

FLINTSTONES MULTI-VIT GUMMIES

FLINTSTONES + CALCIUM TAB

FLINTSTONES EXTRA C TAB CHEW

FLINTSTONES EXTRA C GUMMIES

FLINTSTONES WITH IRON TAB CHEW

FLOLAN 0.5 MG VIAL

FLOLAN 1.5 MG VIAL

FLOLIPID 20 MG/5 ML ORAL SUSP

FLOLIPID 40 MG/5 ML ORAL SUSP

FLOMAX 0.4 MG CAPSULE

FLORIVA 0.25 MG CHEW TABLET

FLORIVA 0.5 MG CHEWABLE TABLET

FLORIVA 1 MG CHEWABLE TABLET

FLORIVA PLUS 0.25 MG/ML DROPS

FLORIVA PLUS 0.25 MG/ML DROP

FLOVENT 100 MCG DISKUS

FLOVENT 250 MCG DISKUS

FLOVENT 50 MCG DISKUS

FLOVENT HFA 110 MCG INHALER

FLOVENT HFA 220 MCG INHALER

FLOVENT HFA 44 MCG INHALER

FLUDROCORTISONE 0.1 MG TABLET

FLUNISOLIDE 0.025% SPRAY

FLUORABON 0.25 MG/0.6 ML DROPS

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

FLUORIDE 0.25 MG TABLET CHEW

FLUORIDE 0.5 MG TABLET CHEW

FLUORIDE 1 MG TABLET CHEWABLE

FLUORIDEX DAILY DEFENSE

FLUORIDEX DEFENSE 1.1% GEL

FLUORIDEX SENSITIV RLF PASTE

FLUORIDEX SENSITIVITY RLF GEL

FLUORITAB 0.5 MG TABLET CHEW

FLUORITAB 1 MG TABLET CHEW

FLUOXETINE DR 90 MG CAPSULE

FLUOXETINE 20 MG/5 ML SOLUTION

FLUOXETINE HCL 10 MG CAPSULE

FLUOXETINE HCL 10 MG TABLET

FLUOXETINE HCL 20 MG CAPSULE

FLUOXETINE HCL 20 MG TABLET

FLUOXETINE HCL 40 MG CAPSULE

FLUOXETINE HCL 60 MG TABLET

FLUPHENAZINE DEC 125 MG/5 ML

FLUPHENAZINE 1 MG TABLET

FLUPHENAZINE 10 MG TABLET

FLUPHENAZINE 2.5 MG TABLET

FLUPHENAZINE 2.5 MG/5 ML ELIX

FLUPHENAZINE 5 MG TABLET

FLUPHENAZINE 5 MG/ML CONC

FLURA-DROPS 0.25 MG/DROP

FLURBIPROFEN 100 MG TABLET

FLURBIPROFEN 50 MG TABLET

FLUTAMIDE 125 MG CAPSULE

FLUTICASONE PROP 50 MCG SPRAY

FLUTICASONE-SALMETEROL 100-50

FLUTICASONE-SALMETEROL 113-14

FLUTICASONE-SALMETEROL 232-14

FLUTICASONE-SALMETEROL 250-50

FLUTICASONE-SALMETEROL 500-50

FLUTICASONE-SALMETEROL 55-14

FLUVASTATIN ER 80 MG TABLET

FLUVASTATIN SODIUM 20 MG CAP

FLUVASTATIN SODIUM 40 MG CAP

FLUVOXAMINE MALEATE 100 MG TAB

FLUVOXAMINE MALEATE 25 MG TAB

FLUVOXAMINE MALEATE 50 MG TAB

FLUVOXAMINE ER 100 MG CAPSULE

FLUVOXAMINE ER 150 MG CAPSULE

FOCALGIN 90 DHA COMBO PACK

FOCALGIN CA COMBO PACK

FOCALIN 10 MG TABLET

FOCALIN 2.5 MG TABLET

FOCALIN 5 MG TABLET

FOCALIN XR 10 MG CAPSULE

FOCALIN XR 15 MG CAPSULE

FOCALIN XR 20 MG CAPSULE

FOCALIN XR 25 MG CAPSULE

FOCALIN XR 30 MG CAPSULE

FOCALIN XR 35 MG CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

FOCALIN XR 40 MG CAPSULE

FOCALIN XR 5 MG CAPSULE

FOLBEE TABLET

FOLBEE PLUS TABLET

FOLBEE PLUS CZ TABLET

FOLBIC TABLET

FOLET ONE SOFTGEL

FOLGARD RX TABLET

CVS FOLIC ACID 800 MCG TABLET

FOLIC ACID 0.4 MG TABLET

FOLIC ACID 0.8 MG TABLET

FOLIC ACID 1 MG TABLET

FOLIC ACID 1,000 MCG TABLET

FOLIC ACID 20 MG CAPSULE

FOLIC ACID 400 MCG TABLET

FOLIC ACID 5 MG CAPSULE

FOLIC ACID 800 MCG CAPSULE

FOLIC ACID 800 MCG TABLET

GNP FOLIC ACID 400 MCG TABLET

HM FOLIC ACID 400 MCG TABLET

RA FOLIC ACID 0.4 MG TABLET

RA FOLIC ACID 800 MCG TABLET

SM FOLIC ACID 0.4 MG TABLET

SM FOLIC ACID 400 MCG TABLET

SV FOLIC ACID 800 MCG TABLET

FA-CYANCOBA-PYRIDOXINE TAB

FOLIC ACID-VIT B6-VIT B12 TAB

FOLIC ACID-VIT B6-VIT B12 TAB

FOLIVANE-OB CAPSULE

FOLPLEX 2.2 TABLET

FOLTABS 800 TABLET

FORA NORMAL CONTROL SOLUTION

FORA D10 BLOOD GLUCOSE SYSTEM

FORA D15 GLUCOSE-BP MONITOR

FORA D15G GLUCOSE TEST STRIPS

FORA D20 GLUCOSE TEST STRIPS

FORA D20 BLOOD GLUCOSE SYSTEM

FORA D40D GLUCOSE-BP MONITOR

FORA D40G GLUCOSE-BP MONITOR

FORA D40-G31 TEST STRIPS

FORA G20 GLUCOSE TEST STRIPS

FORA G20 BLOOD GLUCOSE SYSTEM

FORA G30A BLOOD GLUCOSE SYSTEM

FORA G30-PREMIUM V10 TEST STRP

FORA GD50 BLOOD GLUCOSE SYSTEM

FORA GD50 TEST STRIPS

FORA GTEL GLUCOSE TEST STRIP

FORA GTEL KETONE TEST STRIP

FORA GTEL MULTIFUNCTN MONITOR

FORA 30G LANCETS

FORA PREMIUM V10 GLUCOSE METER

FORA TEST N'GO VOICE SYSTEM

FORA BLOOD GLUCOSE TEST STRIP

FORA TN'G VOICE GLUCOSE METER

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

FORA TN'G VOICE TEST STRIPS

FORA V10 GLUCOSE TEST STRIP

FORA V10 BLOOD GLUCOSE SYSTEM

FORA V10-V12-D10-D20 STRIPS

FORA V10-V12-D10-D20 STRP-LNCT

FORA V12 GLUCOSE TEST STRIP

FORA V12 BLOOD GLUCOSE SYSTEM

FORA V20 GLUCOSE TEST STRIPS

FORA V20 BLOOD GLUCOSE SYSTEM

FORA V30A GLUCOSE TEST STRIP

FORA V30A BLOOD GLUCOSE SYSTEM

FORACARE GD20 TEST STRIPS

FORACARE GD20 GLUCOSE SYSTEM

FORACARE GD40 GLUCOSE STRIPS

FORACARE GD40A GLUCOSE SYSTEM

FORACARE GD40B GLUCOSE SYSTEM

FORACARE GDH HIGH CONTROL SOLN

FORACARE GDH LOW CONTROL SOLN

FORACARE GDH NORM CONTROL SOLN

FORACARE 30G LANCETS

FORADIL AEROLIZER 12 MCG CAP

FORFIVO XL 450 MG TABLET

FORTAMET ER 1,000 MG TABLET

FORTAMET ER 500 MG TABLET

FORTAVIT SOFTGEL

FORTEO 600 MCG/2.4 ML PEN INJ

FORTESTA 10 MG GEL PUMP

FORTISCARE CONTROL SOLN HIGH

FORTISCARE CONTROL SOLN LOW

FORTISCARE CONTROL SOLN NORMAL

FORTISCARE BLOOD GLUCOSE SYST

FORTISCARE GLUCOSE TEST STRIPS

FOSAMAX 70 MG TABLET

FOSAMAX PLUS D 70 MG-2,800 IU

FOSAMAX PLUS D 70 MG-5,600 IU

FOSAMPRENAVIR 700 MG TABLET

FOSINOPRIL SODIUM 10 MG TAB

FOSINOPRIL SODIUM 20 MG TAB

FOSINOPRIL SODIUM 40 MG TAB

FOSINOPRIL-HCTZ 10-12.5 MG TAB

FOSINOPRIL-HCTZ 20-12.5 MG TAB

FOSRENOL 1,000 MG POWDER PACK

FOSRENOL 1,000 MG TABLET CHEW

FOSRENOL 500 MG TABLET CHEW

FOSRENOL 750 MG POWDER PACKET

FOSRENOL 750 MG TABLET CHEW

FREEDAVITE TABLET

FREESTYLE CONTROL SOLUTION

FREESTYLE CONTROL SOLUTION

FREESTYLE FLASH SYSTEM KIT

FREESTYLE FREEDOM KIT

FREESTYLE FREEDOM LITE METER

FREESTYLE FREEDOM LITE NFRS

FREESTYLE INSULINX STRIP NFRS

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

FREESTYLE INSULINX TEST STRIP

FREESTYLE INSULINX GLUCOSE SYS

FREESTYLE INSULINX TEST STRIPS

FREESTYLE 28G LANCETS

FREESTYLE LIBRE 10 DAY READER

FREESTYLE LIBRE 10 DAY SENSOR

FREESTYLE LIBRE 14 DAY READER

FREESTYLE LIBRE 14 DAY SENSOR

FREESTYLE LITE METER

FREESTYLE LITE METER NFRS

FREESTYLE LITE TEST STRIP

FREESTYLE LITE TEST STRIP NFRS

FREESTYLE NAVIGATOR SENSOR KIT

FREESTYLE PREC 1 ML 30GX5/16"

FREESTYLE PREC 1 ML 31GX5/16"

FREESTYLE PREC 0.5 ML 30GX5/16

FREESTYLE PREC 0.5 ML 31GX5/16

FREESTYLE PREC NEO TEST STRIPS

FREESTYLE PRECISION NEO METER

FREESTYLE SIDEKICK II VALPK

FREESTYLE SYSTEM KIT

FREESTYLE TEST STRIPS

FREESTYLE TEST STRIPS NFRS

FREESTYLE UNISTIK 2 LANCETS

FRUITY VITAMINS TABLET CHEW

FULL SPECTRUM B WITH VIT C TAB

FULVESTRANT 250 MG/5 ML SYRING

FUROSEMIDE 10 MG/ML SOLUTION

FUROSEMIDE 20 MG TABLET

FUROSEMIDE 40 MG TABLET

FUROSEMIDE 40 MG/4 ML ORAL SOL

FUROSEMIDE 40 MG/5 ML SOLN

FUROSEMIDE 80 MG TABLET

FUSARIUM 10,000 PNU/ML

FUSARIUM 20,000 PNU/ML

FUZEON 90 MG VIAL

FYAVOLV 0.5 MG-2.5 MCG TABLET

FYAVOLV 1 MG-5 MCG TABLET

FYCOMPA 0.5 MG/ML ORAL SUSP

FYCOMPA 10 MG TABLET

FYCOMPA 12 MG TABLET

FYCOMPA 2 MG TABLET

FYCOMPA 4 MG TABLET

FYCOMPA 6 MG TABLET

FYCOMPA 8 MG TABLET

GABAPENTIN 100 MG CAPSULE

GABAPENTIN 250 MG/5 ML SOLN

GABAPENTIN 300 MG CAPSULE

GABAPENTIN 300 MG/6 ML SOLN

GABAPENTIN 400 MG CAPSULE

GABAPENTIN 600 MG TABLET

GABAPENTIN 800 MG TABLET

GABITRIL 12 MG TABLET

GABITRIL 16 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

GABITRIL 2 MG TABLET

GABITRIL 4 MG TABLET

GABLOFEN 10,000 MCG/20 ML SYRG

GABLOFEN 10,000 MCG/20 ML VIAL

GABLOFEN 20,000 MCG/20 ML SYRG

GABLOFEN 20,000 MCG/20 ML VIAL

GABLOFEN 40,000 MCG/20 ML SYRG

GABLOFEN 40,000 MCG/20 ML VIAL

GABLOFEN 50 MCG/ML SYRINGE

GALAFOLD 123 MG CAPSULE

GALANTAMINE ER 16 MG CAPSULE

GALANTAMINE ER 24 MG CAPSULE

GALANTAMINE ER 8 MG CAPSULE

GALANTAMINE HBR 12 MG TABLET

GALANTAMINE HBR 4 MG TABLET

GALANTAMINE HBR 8 MG TABLET

GALANTAMINE 4 MG/ML ORAL SOLN

GAMIFANT 10 MG/2 ML VIAL

GAMIFANT 50 MG/10 ML VIAL

GAMMAGARD LIQUID 10% VIAL

GAMMAGARD S-D 10 G (IGA<1) SOL

GAMMAGARD S-D 5 G (IGA<1) SOLN

GAMMAKED 1 GRAM/10 ML VIAL

GAMMAKED 10 GRAM/100 ML VIAL

GAMMAKED 2.5 GRAM/25 ML VIAL

GAMMAKED 20 GRAM/200 ML VIAL

GAMMAKED 5 GRAM/50 ML VIAL

GAMMAPLEX 10 GRAM/100 ML VIAL

GAMMAPLEX 20 GRAM/200 ML VIAL

GAMMAPLEX 5 GRAM/50 ML VIAL

GAMMAPLEX 10 GRAM/200 ML VIAL

GAMMAPLEX 20 GRAM/400 ML VIAL

GAMMAPLEX 5 GRAM/100 ML VIAL

GAMUNEX-C 1 GRAM/10 ML VIAL

GAMUNEX-C 10 GRAM/100 ML VIAL

GAMUNEX-C 2.5 GRAM/25 ML VIAL

GAMUNEX-C 20 GRAM/200 ML VIAL

GAMUNEX-C 40 GRAM/400 ML VIAL

GAMUNEX-C 5 GRAM/50 ML VIAL

GASTROCROM 100 MG/5 ML CONC

GATTEX 5 MG 30-VIAL KIT

GATTEX 5 MG ONE-VIAL KIT

GE100 BLOOD GLUCOSE SYSTEM

GE100 BLOOD GLUCOSE TEST STRIP

GE100 CONTROL SOLUTION NORMAL

GEL-KAM 0.4% DENTAL GEL

GELNIQUE 10% GEL PUMP

GELNIQUE 10% GEL SACHET

GELNIQUE 10% GEL SACHETS

GEMFIBROZIL 600 MG TABLET

GENERESS FE CHEWABLE TABLET

GENERLAC 10 GM/15 ML SOLUTION

GENGRAF 100 MG CAPSULE

GENGRAF 100 MG/ML SOLUTION

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

GENGRAF 25 MG CAPSULE

GENGRAF 50 MG CAPSULE

GENOTROPIN 12 MG CARTRIDGE

GENOTROPIN 5 MG CARTRIDGE

GENOTROPIN MINIQUICK 0.2 MG

GENOTROPIN MINIQUICK 0.4 MG

GENOTROPIN MINIQUICK 0.6 MG

GENOTROPIN MINIQUICK 0.8 MG

GENOTROPIN MINIQUICK 1 MG

GENOTROPIN MINIQUICK 1.2 MG

GENOTROPIN MINIQUICK 1.4 MG

GENOTROPIN MINIQUICK 1.6 MG

GENOTROPIN MINIQUICK 1.8 MG

GENOTROPIN MINIQUICK 2 MG

GENSTRIP GLUCOSE TEST STRIP

GENTEEL VACUUM LANCING DEVICE

GENVOYA TABLET

GEODON 20 MG CAPSULE

GEODON 40 MG CAPSULE

GEODON 60 MG CAPSULE

GEODON 80 MG CAPSULE

GERITOL COMPLETE TABLET

GERITOL TONIC

GERMAN COCKROACH 1:20 (W/V) VL

GIANVI 3 MG-0.02 MG TABLET

GILDAGIA 0.4 MG-0.035 MG TAB

GILENYA 0.5 MG CAPSULE

GILOTRIF 20 MG TABLET

GILOTRIF 30 MG TABLET

GILOTRIF 40 MG TABLET

GIVLAARI 189 MG/ML VIAL

GLASSIA 1 GM/50 ML VIAL

GLATIRAMER 20 MG/ML SYRINGE

GLATIRAMER 40 MG/ML SYRINGE

GLATOPA 20 MG/ML SYRINGE

GLATOPA 40 MG/ML SYRINGE

GLEEVEC 100 MG TABLET

GLEEVEC 400 MG TABLET

GLIMEPIRIDE 1 MG TABLET

GLIMEPIRIDE 2 MG TABLET

GLIMEPIRIDE 4 MG TABLET

GLIPIZIDE 10 MG TABLET

GLIPIZIDE 5 MG TABLET

GLIPIZIDE ER 10 MG TABLET

GLIPIZIDE ER 2.5 MG TABLET

GLIPIZIDE ER 5 MG TABLET

GLIPIZIDE XL 10 MG TABLET

GLIPIZIDE XL 2.5 MG TABLET

GLIPIZIDE XL 5 MG TABLET

GLIPIZIDE-METFORMIN 2.5-250 MG

GLIPIZIDE-METFORMIN 2.5-500 MG

GLIPIZIDE-METFORMIN 5-500 MG

GLOPERBA 0.6 MG/5 ML SOLUTION

GLUCO NAVII GLUCOSE TEST STRIP

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

GLUCO NAVII GLUCOSE MONITOR KT

GLUCOCARD 01 METER KIT

GLUCOCARD 01 CONTROL SOLUTION

GLUCOCARD 01 CONTROL SOLUTION

GLUCOCARD 01 SENSOR PLUS STRIP

GLUCOCARD EXPRESSION TEST STRP

GLUCOCARD EXPRESSION CNTRL SLN

GLUCOCARD EXPRESSION METER

GLUCOCARD EXPRESSION METER KIT

GLUCOCARD SHINE TEST STRIPS

GLUCOCARD SHINE CONTROL SOLN

GLUCOCARD SHINE METER

GLUCOCARD SHINE METER KIT

GLUCOCARD SHINE CONNEX METER

GLUCOCARD SHINE EXPRESS METER

GLUCOCARD SHINE XL METER

GLUCOCARD VITAL TEST STRIPS

GLUCOCARD VITAL METER KIT

GLUCOCARD VITAL SENSOR STRIP

GLUCOCOM 33G LANCETS

GLUCOCOM BLOOD GLUCOSE KIT

GLUCOCOM VALUE KIT

GLUCOCOM CONTROL SOLUTION

GLUCOCOM CONTROL SOLUTION

GLUCOCOM GLUCOSE TEST STRIP

GLUCOCOM 28G LANCETS

GLUCOCOM 30G LANCETS

GLUCOPHAGE 1,000 MG TABLET

GLUCOPHAGE 500 MG TABLET

GLUCOPHAGE 850 MG TABLET

GLUCOPHAGE XR 500 MG TAB

GLUCOPHAGE XR 750 MG TAB

GLUCOSE CONTROL SOLN NORMAL

GLUCOSE CONTROL SOLN-NORMAL

FIFTY50 GLUCOSE CONTROL SOLN

GLUCOSE CONTROL SOLUTION

BLOOD GLUCOSE TEST STRIPS

V-R GLUCOSE TEST STRIP

GLUCOTROL 10 MG TABLET

GLUCOTROL 5 MG TABLET

GLUCOTROL XL 10 MG TABLET

GLUCOTROL XL 2.5 MG TABLET

GLUCOTROL XL 5 MG TABLET

GLUCOVANCE 2.5-500 MG TABLET

GLUCOVANCE 5-500 MG TABLET

GLUMETZA ER 1,000 MG TABLET

GLUMETZA ER 500 MG TABLET

GLYBURIDE 1.25 MG TABLET

GLYBURIDE 2.5 MG TABLET

GLYBURIDE 5 MG TABLET

GLYBURIDE MICRO 1.5 MG TAB

GLYBURIDE MICRO 3 MG TABLET

GLYBURIDE MICRO 6 MG TABLET

GLYBURIDE-METFORMIN 2.5-500 MG

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

GLYBURIDE-METFORMIN 5-500 MG

GLYBURID-METFORMIN 1.25-250 MG

GLYCATE 1.5 MG TABLET

GLYCOPYRROLATE 1 MG TABLET

GLYCOPYRROLATE 1.5 MG TABLET

GLYCOPYRROLATE 2 MG TABLET

GLYNASE 1.5 MG PRESTAB

GLYNASE 3 MG PRESTAB

GLYNASE 6 MG PRESTAB

GLYSET 100 MG TABLET

GLYSET 25 MG TABLET

GLYSET 50 MG TABLET

GLYXAMBI 10 MG-5 MG TABLET

GLYXAMBI 25 MG-5 MG TABLET

GMATE 30G LANCETS

GMATE CONTROL SOLUTION

GMATE SMART METER KIT

GMATE SMART STARTER KIT

GMATE TEST STRIPS

GMATE VOICE METER MONITOR SYST

GOCOVRI ER 137 MG CAPSULE

GOCOVRI ER 68.5 MG CAPSULE

GOLDENROD 1:20 W/V VIAL

GONITRO 0.4 MG SUBLINGUAL PWD

GRASTEK 2,800 BAU SL TABLET

GUANFACINE 1 MG TABLET

GUANFACINE 2 MG TABLET

GUANFACINE HCL ER 1 MG TABLET

GUANFACINE HCL ER 2 MG TABLET

GUANFACINE HCL ER 3 MG TABLET

GUANFACINE HCL ER 4 MG TABLET

GUARDIAN CONNECT TRANSMITTER

GUARDIAN LINK 3 TRANSMITTER

GUARDIAN REAL-TIME GLU MONITOR

GUARDIAN SENSOR 3

GUMMI BEAR MULTIVIT TAB CHEW

GUMMIES CHILDREN MULTIVITAMIN

CVS KIDS' MULTIVITAMIN GUMMY

CVS GUMMY DINOS VITAMIN

CVS CHILD GUMMY DINOS GUMMIES

CVS GUMMY DINOS GUMMIES

HACKBERRY 1:20 (W/V) VIAL

HAEGARDA 2,000 UNIT VIAL

HAEGARDA 3,000 UNIT VIAL

HAILEY 21 1.5 MG-30 MCG TAB

HAILEY 24 FE 1 MG-20 MCG TAB

HAIR FORMULA TABLET

HAIR VITAMINS

CVS HAIR, SKIN AND NAILS CPLT

SM HAIR, SKIN AND NAILS CAPLET

HAIR, SKIN AND NAILS TABLET

HAIR, SKIN AND NAILS CAPLET

HM HAIR, SKIN AND NAILS TABLET

HAIR, SKIN AND NAILS CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

SV HAIR, SKIN AND NAILS CAPLET

HAIR, SKIN AND NAILS SOFTGEL

HALDOL DECANOATE 100 AMPUL

HALDOL DECANOATE 50 AMPUL

HALOPERIDOL 0.5 MG TABLET

HALOPERIDOL 1 MG TABLET

HALOPERIDOL 10 MG TABLET

HALOPERIDOL 2 MG TABLET

HALOPERIDOL 20 MG TABLET

HALOPERIDOL 5 MG TABLET

HALOPERIDOL DEC 100 MG/ML AMP

HALOPERIDOL DEC 100 MG/ML VIAL

HALOPERIDOL DEC 250 MG/5 ML VL

HALOPERIDOL DEC 50 MG/ML VIAL

HALOPERIDOL DEC 500 MG/5 ML VL

HALOPERIDOL DECAN 50 MG/ML AMP

HALOPERIDOL DEC 100 MG/ML AMP

HALOPERIDOL LAC 2 MG/ML CONC

HARD NAILS 2.5 MG CAPSULE

HARMONY GLUCOSE TEST STRIP

HEALTHPRO CONTROL SOLN-L1, L3

HEALTHPRO GLUCOSE MONITOR SYST

HEALTHPRO GLUCOSE TEST STRIPS

HEALTHWISE INS 1 ML 30GX5/16"

HEALTHWISE INS 1 ML 31GX5/16"

HEALTHWISE INS 0.5ML 30GX5/16"

HEALTHWISE INS 0.5ML 31GX5/16"

HEALTHWISE INS 0.3ML 30GX5/16"

HEALTHWISE INS 0.3ML 31GX5/16"

HEALTHWISE PEN NEEDLE 31G 5MM

HEALTHWISE PEN NEEDLE 31G 8MM

HEALTHWISE PEN NEEDLE 32G 4MM

HEALTHY ACCENTS PENTIP 4MM 32G

HEALTHY ACCENTS PENTIP 5MM 31G

HEALTHY ACCENTS PENTIP 6MM 31G

HEALTHY ACCENTS PENTIP 8MM 31G

HEALTHY ACCENTS PENTP 12MM 29G

HEALTHY ACCENTS UNILET 30G

GNP HEALTHY EYES TABLET

HEALTHY EYES TABLET

GNP HEALTHY EYES SUPERVISION

HEALTHY EYES SUPERVISION SFTGL

HEARTBURN & ACID REFLUX TABS

EQL HEARTBURN PREVEN 20 MG TAB

EQL HEARTBURN PREVENTION TAB

HEARTBURN RELIEF 200 MG TABLET

SM HEARTBURN RELIEF 200 MG TAB

HEARTBURN RELIEF 10 MG TABLET

HEARTBURN RELIEF 20 MG TABLET

EQL HEARTBURN RELIEF 75 MG TAB

HEARTBURN RELIEF 150 MG TAB

HEARTBURN RELIEF 150 MG TABLET

HEARTBURN TREATMENT 20 MG CAP

HEARTBURN TREATMNT 24 HR 15 MG

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

HEATHER 0.35 MG TABLET

HECTOROL 0.5 MCG CAPSULE

HECTOROL 1 MCG CAPSULE

HECTOROL 2 MCG/ML VIAL

HECTOROL 2.5 MCG CAPSULE

HECTOROL 4 MCG/2 ML VIAL

HELIXATE FS 1,000 UNIT VIAL

HELIXATE FS 2,000 UNIT VIAL

HELIXATE FS 250 UNIT VIAL

HELIXATE FS 3,000 UNITS VIAL

HELIXATE FS 500 UNIT VIAL

HEMENATAL OB TABLET

HEMENATAL OB + DHA COMBO PACK

HEMLIBRA 105 MG/0.7 ML VIAL

HEMLIBRA 150 MG/ML VIAL

HEMLIBRA 30 MG/ML VIAL

HEMLIBRA 60 MG/0.4 ML VIAL

HEMOFIL M 1,000 UNIT NOMINAL

HEMOFIL M 1,700 UNIT NOMINAL

HEMOFIL M 250 UNIT NOMINAL

HEMOFIL M 500 UNIT NOMINAL

HERCEPTIN 150 MG VIAL

HERCEPTIN 440 MG VIAL

HERCEPTIN HYLECTA 600MG-10,000

HERZUMA 150 MG VIAL

HERZUMA 420 MG VIAL

HETLIOZ 20 MG CAPSULE

HIZENTRA 1 GRAM/5 ML VIAL

HIZENTRA 10 GRAM/50 ML VIAL

HIZENTRA 2 GRAM/10 ML VIAL

HIZENTRA 4 GRAM/20 ML VIAL

HOMAPIN 10 TABLET

HOMATROPAIRE 5% EYE DROPS

HOMATROPINE 5% EYE DROPS

HOMOCYSTEINE FORMULA TABLET

HONEY BEARS-IRON-ZINC TAB CHEW

HONEY BEARS CHEWABLE TABLET

HONEY BEE VENOM 100 MCG/ML VL

HORIZANT ER 300 MG TABLET

HORIZANT ER 600 MG TABLET

HORSE EPITHELIUM 1:10 (W/V) VL

HORSE EPITHELIUM 1:20 (W/V) VL

HUMALOG 100 UNIT/ML VIAL

HUMALOG 100 UNITS/ML CARTRIDGE

HUMALOG JR 100 UNIT/ML KWIKPEN

HUMALOG 100 UNITS/ML KWIKPEN

HUMALOG 200 UNITS/ML KWIKPEN

HUMALOG MIX 50-50 VIAL

HUMALOG MIX 50-50 KWIKPEN

HUMALOG MIX 75-25 VIAL

HUMALOG MIX 75-25 KWIKPEN

HUMAPEN LUXURA HD

HUMATE-P 1,200 UNIT VWF:RCO

HUMATE-P 2,400 UNIT VWF:RCO

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

HUMATE-P 600 UNIT VWF:RCO

HUMATROPE 12 MG CARTRIDGE

HUMATROPE 24 MG CARTRIDGE

HUMATROPE 5 MG VIAL

HUMATROPE 6 MG CARTRIDGE

HUMIRA 10 MG/0.2 ML SYRINGE

HUMIRA 20 MG/0.4 ML SYRINGE

HUMIRA 40 MG/0.8 ML SYRINGE

HUMIRA PEN 40 MG/0.8 ML

HUMIRA(CF) 10 MG/0.1 ML SYRING

HUMIRA(CF) 20 MG/0.2 ML SYRING

HUMIRA(CF) 40 MG/0.4 ML SYRING

HUMIRA(CF) PEDI CROHN 80MG/0.8

HUMIRA(CF) PEN 40 MG/0.4 ML

HUMULIN 70/30 KWIKPEN

HUMULIN 70-30 VIAL

HUMULIN N 100 UNIT/ML VIAL

HUMULIN N 100 UNITS/ML VIAL

HUMULIN N 100 UNITS/ML KWIKPEN

HUMULIN R 100 UNIT/ML VIAL

HUMULIN R 100 UNITS/ML VIAL

HUMULIN R 500 UNITS/ML VIAL

HUMULIN R 500 UNITS/ML KWIKPEN

HYDRALAZINE 10 MG TABLET

HYDRALAZINE 100 MG TABLET

HYDRALAZINE 25 MG TABLET

HYDRALAZINE 50 MG TABLET

HYDREA 500 MG CAPSULE

HYDROCHLOROTHIAZIDE 12.5 MG CP

HYDROCHLOROTHIAZIDE 12.5 MG TB

HYDROCHLOROTHIAZIDE 25 MG TAB

HYDROCHLOROTHIAZIDE 50 MG TAB

HYDROCORTISONE 10 MG TABLET

HYDROCORTISONE 20 MG TABLET

HYDROCORTISONE 5 MG TABLET

HYDROXYCHLOROQUINE 200 MG TAB

HYDROXYUREA 500 MG CAPSULE

HYLAVITE TABLET

HYOSCYAMINE 0.125 MG ODT

HYOSCYAMINE 0.125 MG TAB SL

HYOSCYAMINE 0.125 MG/5 ML ELIX

HYOSCYAMINE 0.125 MG/ML DROP

HYOSCYAMINE SULF 0.125 MG TAB

HYOSCYAMINE ER 0.375 MG TAB

HYOSCYAMINE SR 0.375 MG TAB

HYOSYNE 0.125 MG/ML DROP

HYOSYNE 125 MCG/5 ML ELIXIR

HYPOLANCE AST LANCING KIT

HYQVIA 10 GM-800 UNIT PACK

HYQVIA 2.5 GM-200 UNIT PACK

HYQVIA 20 GM-1,600 UNIT PACK

HYQVIA 30 GM-2,400 UNIT PACK

HYQVIA 5 GM-400 UNIT PACK

HYZAAR 100-12.5 TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

HYZAAR 100-25 TABLET

HYZAAR 50-12.5 TABLET

IBANDRONATE 3 MG/3 ML SYRINGE

IBANDRONATE 3 MG/3 ML VIAL

IBANDRONATE SODIUM 150 MG TAB

IBRANCE 100 MG CAPSULE

IBRANCE 125 MG CAPSULE

IBRANCE 75 MG CAPSULE

IBU 400 MG TABLET

IBU 600 MG TABLET

IBU 800 MG TABLET

IBU-200 200 MG TABLET

IBU-DROPS 40 MG/ML SUSP DRPS

CVS IBUPROFEN 200 MG CAPLET

CVS IBUPROFEN 200 MG CAPSULE

CVS IBUPROFEN 200 MG SOFTGEL

CVS IBUPROFEN 200 MG TABLET

CVS IBUPROFEN IB 200 MG TABLET

CVS IBUPROFEN JR STR 100 MG TB

EQ IBUPROFEN 200 MG CAPLET

EQ IBUPROFEN 200 MG SOFTGEL

EQ IBUPROFEN 200 MG TABLET

EQ IBUPROFEN JR STR 100 MG TAB

EQL IBUPROFEN 200 MG CAPLET

EQL IBUPROFEN 200 MG SOFTGEL

EQL IBUPROFEN 200 MG TABLET

EQL IBUPROFEN JR 100 MG TB CHW

GNP IBUPROFEN 200 MG CAPLET

GNP IBUPROFEN 200 MG SOFTGEL

GNP IBUPROFEN 200 MG TABLET

GNP IBUPROFEN JR STR 100 MG TB

GS IBUPROFEN 200 MG CAPLET

GS IBUPROFEN 200 MG SOFTGEL

GS IBUPROFEN 200 MG TABLET

HM IBUPROFEN 200 MG CAPLET

HM IBUPROFEN 200 MG CAPSULE

HM IBUPROFEN 200 MG TABLET

HM IBUPROFEN JR STR 100 MG CHW

IBUPROFEN 100 MG/5 ML SUSP

IBUPROFEN 200 MG CAPLET

IBUPROFEN 200 MG CAPSULE

IBUPROFEN 200 MG SOFTGEL

IBUPROFEN 200 MG TABLET

IBUPROFEN 200 MG/10 ML SUSP

IBUPROFEN 400 MG TABLET

IBUPROFEN 50 MG/1.25 ML SUSP

IBUPROFEN 600 MG TABLET

IBUPROFEN 800 MG TABLET

IBUPROFEN JR STR 100 MG CHEW

IBUPROFEN JR STR 100 MG TB CHW

KRO IBUPROFEN 200 MG CAPLET

KRO IBUPROFEN 200 MG TABLET

KRO IBUPROFEN JR STR 100 MG TB

PUB IBUPROFEN 200 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

PUB IBUPROFEN JR 100 MG CHEW

QC IBUPROFEN 200 MG CAPLET

QC IBUPROFEN 200 MG SOFTGEL

RA IBUPROFEN 100 MG/5 ML SUSP

RA IBUPROFEN 200 MG CAPLET

RA IBUPROFEN 200 MG LIQUID GEL

RA IBUPROFEN 200 MG SOFTGEL

RA IBUPROFEN 200 MG TABLET

RA IBUPROFEN JR STR 100 MG CHW

SB IBUPROFEN 200 MG CAPLET

SB IBUPROFEN 200 MG TABLET

SM IBUPROFEN 100 MG/5 ML SUSP

SM IBUPROFEN 200 MG CAPLET

SM IBUPROFEN 200 MG SOFTGEL

SM IBUPROFEN 200 MG TABLET

SM IBUPROFEN IB 100 MG TABLET

SM IBUPROFEN IB 200 MG CAPLET

CVS IBUPROFEN IB 200 MG CPLT

CVS IBUPROFEN IB 200 MG TAB

HM IBUPROFEN IB 100 MG CHEW TB

HM IBUPROFEN IB 200 MG CAPLET

HM IBUPROFEN IB 200 MG TABLET

QC IBUPROFEN IB 200 MG CAPLET

QC IBUPROFEN IB 200 MG TABLET

SM IBUPROFEN IB 100 MG CHEW TB

SM IBUPROFEN IB 200 MG CAPLET

SM IBUPROFEN IB 200 MG TABLET

ICAPS TABLET

ICAPS AREDS FORMULA DR TABLET

I-CAPS WITH LUTEIN-OMEGA 3 SFG

ICAPS AREDS SOFTGEL

ICAPS AREDS2 SOFTGEL

ICAPS AREDS2 CHEWABLE TABLET

ICAPS AREDS2 TABLET

ICAPS MV TABLET

ICLUSIG 15 MG TABLET

ICLUSIG 45 MG TABLET

IDELVION 1,000 UNIT RANGE VIAL

IDELVION 2,000 UNIT RANGE VIAL

IDELVION 250 UNIT RANGE VIAL

IDELVION 3,500 UNIT RANGE VIAL

IDELVION 500 UNIT RANGE VIAL

IDHIFA 100 MG TABLET

IDHIFA 50 MG TABLET

IGLUCOSE BLOOD GLUCOSE MONITOR

IGLUCOSE TEST STRIP

ILARIS 150 MG/ML VIAL

ILUMYA 100 MG/ML SYRINGE

ILUVIEN 0.19 MG IMPLANT

IMATINIB MESYLATE 100 MG TAB

IMATINIB MESYLATE 400 MG TAB

IMBRUVICA 140 MG CAPSULE

IMBRUVICA 140 MG TABLET

IMBRUVICA 280 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

IMBRUVICA 420 MG TABLET

IMBRUVICA 560 MG TABLET

IMBRUVICA 70 MG CAPSULE

IMFINZI 120 MG/2.4 ML VIAL

IMFINZI 500 MG/10 ML VIAL

IMIPRAMINE HCL 10 MG TABLET

IMIPRAMINE HCL 25 MG TABLET

IMIPRAMINE HCL 50 MG TABLET

IMIPRAMINE PAMOATE 100 MG CAP

IMIPRAMINE PAMOATE 125 MG CAP

IMIPRAMINE PAMOATE 150 MG CAP

IMIPRAMINE PAMOATE 75 MG CAP

IMLYGIC 100 MILLION PFU/ML VL

IMODIUM A-D 1 MG/7.5 ML LIQUID

IMODIUM A-D 2 MG CAPLET

IMODIUM MULTI-SYMPTOM REL CPLT

IMURAN 50 MG TABLET

IMVEXXY 10 MCG MAINTENANCE PAK

IMVEXXY 4 MCG MAINTENANCE PACK

INBRIJA 42 MG INHALATION CAP

INCASSIA 0.35 MG TABLET

INCONTROL PEN NEEDLE 12MM 29G

INCONTROL PEN NEEDLE 4MM 32G

INCONTROL PEN NEEDLE 5MM 31G

INCONTROL PEN NEEDLE 6MM 31G

INCONTROL PEN NEEDLE 8MM 31G

INCONTROL SUPER THIN 30G LANCT

INCONTROL ULTRA THIN 28G LANCT

INCRELEX 40 MG/4 ML VIAL

INCRUSE ELLIPTA 62.5 MCG INH

INDAPAMIDE 1.25 MG TABLET

INDAPAMIDE 2.5 MG TABLET

INDERAL LA 120 MG CAPSULE

INDERAL LA 160 MG CAPSULE

INDERAL LA 60 MG CAPSULE

INDERAL LA 80 MG CAPSULE

INDERAL XL 120 MG CAPSULE

INDERAL XL 80 MG CAPSULE

INDOCIN 25 MG/5 ML SUSPENSION

INDOMETHACIN 25 MG CAPSULE

INDOMETHACIN 50 MG CAPSULE

INDOMETHACIN ER 75 MG CAPSULE

INFANTS' ADVIL 50 MG/1.25 ML

INFANTS IBU-DROPS SUSPENSION

EQL INF IBUPROFEN 50 MG/1.25ML

INFANT IBUPROFEN 50 MG/1.25 ML

CVS INF IBUPROFEN 50 MG/1.25ML

EQ INF IBUPROFEN 50 MG/1.25 ML

HM INF IBUPROFEN 50 MG/1.25 ML

INFANT IBUPROFEN 50 MG/1.25 ML

QC INF IBUPROFEN 50 MG/1.25 ML

SB INF IBUPROFEN 50 MG/1.25 ML

CVS INFANT IBUPROFEN SUSP DROP

GNP INFANT IBUPROFEN SUSP DROP

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

INFANT IBUPROFEN 50 MG/1.25 ML

RA INFANT IBUPROFEN SUSP DROP

SM INFANT IBUPROFEN SUSP DROP

INFANTS' MOTRIN 50 MG/1.25 ML

INFANT'S MOTRIN 50 MG/1.25 ML

PUB INFANTS PROFENIB DROPS

INFANT-TODDLER MULTIVIT DROP

INFANT-TODDLER MULTIVIT-IRON

INFANT-TODDLER TRI-VIT DROP

INFINITY METER KIT

INFINITY STARTER KIT

INFINITY CONTROL SOLN HIGH

INFINITY CONTROL SOLN LOW

INFINITY CONTROL SOLN NORMAL

INFINITY TEST STRIPS

INFINITY VOICE CTRL SOLN-LVL 2

INFINITY VOICE GLUCOSE MONITOR

INFINITY VOICE TEST STRIP

INFLECTRA 100 MG VIAL

INFUSION SET 23"

INFUSION SET 23" 6MM

INFUSION SET 23" 9MM

INFUSION SET 43"

INFUSION SET 43" 6MM

INFUSION SET 43" 9MM

INGREZZA 40 MG CAPSULE

INGREZZA 80 MG CAPSULE

INJECT EASE 28G LANCETS

INJECT EASE 30G LANCETS

INLYTA 1 MG TABLET

INLYTA 5 MG TABLET

INNOPRAN XL 120 MG CAPSULE

INNOPRAN XL 80 MG CAPSULE

INPEN (FOR HUMALOG) BLUE

INPEN (FOR HUMALOG) GREY

INPEN (FOR HUMALOG) PINK

INPEN (NOVOLOG OR FIASP) BLUE

INPEN (NOVOLOG OR FIASP) GREY

INPEN (NOVOLOG OR FIASP) PINK

INREBIC 100 MG CAPSULE

INSET 30 INFUSION SET 23"

INSET INFUSION SET 23" 6MM

INSET INFUSION SET 23" 9MM

INSPRA 25 MG TABLET

INSPRA 50 MG TABLET

INSULIN ASPART 100 UNIT/ML VL

INSULIN ASPART 100 UNIT/ML PEN

INSULIN ASPART 100 UNIT/ML CRT

INSULIN ASPART PROT-INSULN ASP

INSULIN CARTRIDGE 3 ML

INSULIN LISPRO 100 UNIT/ML VL

INSULIN LISPRO 100 UNIT/ML PEN

COMFORT POINT PEN NDL 29GX1/2"

COMFORT POINT PEN NDL 31GX1/3"

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

COMFORT POINT PEN NDL 31GX1/4"

COMFORT POINT PEN NDL 31GX1/6"

BD INS SYR 0.3 ML 8MMX31G(1/2)

BD SYR 0.3 ML 6MMX31G (1/2)

INSULIN SYR 0.3ML 31GX1/4(1/2)

BD INS SYRN UF 1 ML 12.7MMX30G

BD INSULIN SYR 1 ML 12.7MMX30G

BD INSULIN SYR 1 ML 25GX1"

BD INSULIN SYR 1 ML 25GX5/8"

BD INSULIN SYR 1 ML 26GX1/2"

BD INSULIN SYR 1 ML 27GX12.7MM

BD INSULIN SYR 1 ML 27GX5/8"

BD INSULIN SYR 1 ML 28GX1/2"

BD INSULIN SYR 1 ML 29GX1/2"

BD INSULIN SYR 1 ML 29GX12.7MM

BD INSULIN SYR 1 ML 30GX1/2"

BD INSULIN SYR 1 ML 31GX15/64"

BD INSULIN SYR 1 ML 31GX5/16"

BD INSULIN SYR 1 ML 8MMX31G

BD INSULIN SYR UF 1 ML 8MMX31G

BD UF INS SYR 1 ML 30GX1/2"

CA INSULIN SYR 1 ML 29GX1/2"

CA INSULIN SYR 1 ML 30GX5/16"

CA INSULIN SYR 1 ML 31GX5/16"

CAREONE SYR 1 ML 30GX1/2"

CAREONE SYR 1 ML 31GX5/16"

EQL INS SYR 1 ML 29GX1/2"

EQL INSULIN 1 ML SYRINGE

EQL INSULIN SYR 1 ML 31GX5/16"

EXEL INS SYR U100 1 ML 28GX1/2

EXEL U100 1 ML 30GX5/16"

EXEL U100 INS SYR 1 ML 29GX1/2

FIFTY50 INS SYR 1 ML 31GX5/16"

GNP INSULIN SYR 1 ML 31GX5/16"

INSULIN 1 ML SYRINGE

INSULIN SYRIN 1 ML 29GX1/2"

INSULIN SYRINGE 1 ML

INSULIN SYRINGE 1 ML 27GX1/2"

INSULIN SYRINGE 1 ML 28GX1/2"

INSULIN SYRINGE 1 ML 29GX1/2"

INSULIN SYRINGE 1 ML 30GX1/2"

INSULIN SYRINGE 1 ML 30GX5/16"

INSULIN SYRINGE 1 ML 31GX1/4"

INSULIN SYRINGE 1 ML 31GX5/16"

INSULIN SYRINGE U100 1 ML

KINRAY INS SYR 1 ML 31GX5/16"

KMART VALU PLUS SYRINGE 1 ML

KRO INSULIN SYR 1 ML 30GX5/16"

KROGER INS SYR 1 ML 29GX1/2"

KROGER INS SYR 1 ML 31GX5/16"

LEADER INS SYR 1 ML 28GX1/2"

LEADER INS SYR 1 ML 29GX1/2"

LEADER INS SYR 1 ML 30GX5/16"

LEADER INS SYR 1 ML 31GX5/16"

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

MS INS SYR 1 ML 29GX1/2"

MS INS SYRINGE 1 ML 30GX1/2"

MS INSULIN SYR 1 ML 31GX5/16"

PREF PLUS SYRING 1 ML 29GX1/2"

PREFERRED PLUS SYRINGE 1 ML

PREFPLS INS SYR 1 ML 30GX5/16"

PUB INS SYRINGE 1 ML 30GX1/2"

PUB INSULIN SYR 1 ML 31GX5/16"

RA INS SYR 1 ML 29GX1/2"

RA INS SYRINGE 1 ML 30GX5/16"

RELION INS SYR 1 ML 29GX1/2"

RELION INS SYR 1 ML 30GX5/16"

RELION INS SYR 1 ML 31GX15/64"

RELION INS SYR 1 ML 31GX5/16"

RELI-ON INSULIN 1 ML SYR

SM INS SYR 1 ML 29GX1/2"

SM INS SYRINGE 1 ML 28GX1/2"

SM INS SYRINGE 1 ML 30GX5/16"

SM INSULIN SYR 1 ML 31GX5/16"

ULTCARE INS SYR 1 ML 31GX5/16"

ULTICARE INS SAFETY 1ML 29X1/2

ULTICARE INS SYR 1 ML 28GX1/2"

ULTICARE INS SYR 1 ML 29GX1/2"

ULTICARE SYR 1 ML 30GX5/16"

BD INSULIN SYRINGE 1 ML

BD INS SYR UF 0.5ML 12.7MMX30G

BD INS SYRNG 0.5 ML 29GX12.7MM

BD INS SYRNG UF 0.5 ML 8MMX31G

BD INSUL SYR 0.5 ML 31GX15/64"

BD INSULIN SYR 0.5 ML 28GX1/2"

BD INSULIN SYR 0.5 ML 29GX1/2"

BD INSULIN SYR 0.5 ML 30GX1/2"

BD INSULIN SYR 0.5 ML 8MMX31G

BD INSULIN SYR 0.5ML 31GX5/16"

BD SYRINGE 0.5 ML 12.7MMX30G

CA INS SYR 0.5 ML 30GX5/16"

CA INS SYR 0.5 ML 31GX5/16"

CA INSULIN SYR 0.5 ML 29GX1/2"

CAREONE SYR 0.5 ML 30GX1/2"

CAREONE SYR 0.5 ML 31GX5/16"

EQL INSUL SYR 0.5 ML 31GX5/16"

EQL INSULIN 0.5 ML SYRINGE

EXEL U100 0.5 ML 28GX1/2"

EXEL U100 0.5 ML 29GX1/2"

EXEL U100 0.5 ML 30GX5/16"

FIFTY50 INS 0.5 ML 31GX5/16"

GNP INSUL SYR 0.5 ML 31GX5/16"

INSULIN 1/2 ML SYRINGE

INSULIN SYRIN 0.5 ML 28GX1/2"

INSULIN SYRIN 0.5 ML 29GX1/2"

INSULIN SYRIN 0.5 ML 30GX1/2"

INSULIN SYRIN 0.5 ML 30GX5/16"

INSULIN SYRIN 0.5 ML 31GX5/16"

INSULIN SYRING 0.5 ML 27GX1/2"

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

INSULIN SYRING 0.5 ML 29GX1/2"

INSULIN SYRINGE 0.5 ML 31GX1/4

KINRAY SYRING 0.5 ML 31GX5/16"

KMART VALU PLUS SYR 1/2 ML

KRO INS SYRIN 0.5 ML 31GX5/16"

KROGER INS SYR 0.5 ML 29GX1/2"

KROGER SYR 0.5 ML 30GX5/16"

LEADER INS SYR 0.5 ML 28GX1/2"

LEADER INS SYR 0.5 ML 29GX1/2"

LEADER INS SYR 0.5 ML 30GX1/2"

LEADER SYRING 0.5 ML 31GX5/16"

MS INS SYR 0.5 ML 29GX1/2"

MS INSUL SYR 0.5 ML 30GX1/2"

MS INSUL SYR 0.5 ML 31GX5/16"

PREF PLUS SYR 0.5 ML 30GX5/16"

PREFERRED PLUS 0.5 ML 29GX1/2"

PREFERRED PLUS SYRINGE 0.5 ML

PUB INSUL SYR 0.5 ML 30GX1/2"

PUB INSUL SYR 0.5 ML 31GX5/16"

RA INS SYR 0.5 ML 29GX1/2"

RA INS SYR 0.5 ML 30GX5/16"

RELION INS SYR 0.5 ML 29GX1/2"

RELION INS SYR 0.5 ML 31GX6MM

RELI-ON INSULIN 0.5 ML SYR

RELION INSULIN SYR 0.5 ML

RELION SYR 0.5 ML 30GX5/16"

RELION SYRING 0.5 ML 31GX5/16"

SCHNUCKS SYR 0.5 ML 29GX1/2"

SCHNUCKS SYR 0.5 ML 30GX5/16"

SM INS SYR 0.5 ML 29GX1/2"

SM INS SYR 0.5 ML 30GX5/16"

SM INSUL SYR 0.5 ML 31GX5/16"

SM INSULIN SYR 0.5 ML 28GX1/2"

SURE-JECT INS 0.5 ML 31GX5/16"

ULTICARE SAFETY 0.5 ML 29GX1/2

ULTICARE SYR 0.5 ML 29GX1/2"

ULTICARE SYR 0.5 ML 30GX5/16"

ULTICARE SYR 0.5 ML 31GX5/16"

ULTICARE SYRIN 0.5 ML 28GX1/2"

BD INS SYR UF 0.3ML 12.7MMX30G

BD INS SYRNG 0.3 ML 29GX12.7MM

BD INS SYRNG UF 0.3 ML 8MMX31G

BD INSUL SYR 0.3 ML 31GX15/64"

BD INSULIN SYR 0.3 ML 28GX1/2"

BD INSULIN SYR 0.3 ML 29GX1/2"

BD INSULIN SYR 0.3 ML 31GX5/16

BD INSULIN SYR 0.3 ML 8MMX31G

BD INSULIN U100-3/10 ML SYR

BD SYRINGE 0.3 ML 12.7MMX30G

BROOKS INSULIN 0.3ML SYRN

CA INS SYR 0.3 ML 30GX5/16"

CA INS SYR 0.3 ML 31GX5/16"

CA INSULIN SYR 0.3 ML 29GX1/2"

CAREONE SYR 0.3 ML 30GX1/2"

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

CAREONE SYR 0.3 ML 31GX5/16"

EQL INSUL SYR 0.3 ML 31GX5/16"

EQL INSULIN 0.3 ML SYRINGE

EXEL U100 0.3 ML 29GX1/2"

EXEL U100 0.3 ML 30GX5/16"

FIFTY50 INS 0.3 ML 31GX5/16"

GNP INS SYR 0.3 ML 29GX1/2"

GNP INSUL SYR 0.3 ML 31GX5/16"

INSULIN 3/10 ML SYRINGE

INSULIN SYR 0.3 ML 30GX5/16"

INSULIN SYRIN 0.3 ML 29GX1/2"

INSULIN SYRIN 0.3 ML 30GX1/2"

INSULIN SYRIN 0.3 ML 30GX5/16"

INSULIN SYRIN 0.3 ML 31GX5/16"

INSULIN SYRINGE 0.3 ML

INSULIN SYRINGE 0.3 ML 31GX1/4

KINRAY SYRING 0.3 ML 31GX5/16"

KRO INS SYR 0.3 ML 29GX1/2"

KROGER INS SYR 0.3 ML 30GX5/16

KROGER SYRING 0.3 ML 31GX5/16"

LEADER INS SYR 0.3 ML 29GX1/2"

LEADER INSULIN SYRINGE 0.3 ML

LEADER SYRING 0.3 ML 31GX5/16"

MS INSUL SYR 0.3 ML 31GX5/16"

MS INSULIN SYR 0.3 ML 29GX1/2"

MS INSULIN SYRINGE 0.3 ML

PREF PLUS INS 0.3 ML 29GX1/2"

PREFERRED PLUS 0.3 ML 30GX5/16

PUB INS SYRIN 0.3 ML 30GX1/2"

PUB INSUL SYR 0.3 ML 31GX5/16"

RELION INS SYR 0.3 ML 29GX1/2"

RELION INS SYR 0.3 ML 30GX5/16

RELION INS SYR 0.3 ML 31GX6MM

RELI-ON INSULIN 0.3 ML SYR

RELION SYRING 0.3 ML 31GX5/16"

SM INS SYRING 0.3 ML 30GX5/16"

SM INSUL SYR 0.3 ML 31GX5/16"

SM INSULIN SYR 0.3 ML 29GX1/2"

SURE-JECT INS 0.3 ML 31GX5/16"

TERUMO INS SYR 0.3 ML 29GX1/2"

ULTICARE SYR 0.3 ML 30GX5/16"

ULTICARE SYR 0.3 ML 31GX5/16"

ULTICARE SYRIN 0.3 ML 29GX1/2"

INSUPEN 30G ULTRAFIN NEEDLE

INSUPEN 31G ULTRAFIN NEEDLE

INSUPEN 32G 6MM PEN NEEDLE

INSUPEN 32G 8MM PEN NEEDLE

INSUPEN PEN NEEDLE 29GX1/2"

INSUPEN PEN NEEDLE 29GX12MM

INSUPEN PEN NEEDLE 30GX8MM

INSUPEN PEN NEEDLE 31GX3/16"

INSUPEN PEN NEEDLE 31GX5/16"

INSUPEN PEN NEEDLE 31GX6MM

INSUPEN PEN NEEDLE 31GX8MM

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

INSUPEN PEN NEEDLE 32GX4MM

INSUPEN PEN NEEDLE 32GX5/32"

INSUPEN PEN NEEDLE 32GX6MM

INSUPEN PEN NEEDLE 32GX8MM

INSUPEN PEN NEEDLE 33GX4MM

BD INTEGRA SYR 1 ML 29GX1/2"

INTELENCE 100 MG TABLET

INTELENCE 200 MG TABLET

INTELENCE 25 MG TABLET

INTRON A 10 MILLION UNITS VIAL

INTRON A 18 MILLION UNIT/3 ML

INTRON A 18 MILLION UNITS VIAL

INTRON A 25 MILLION UNIT/2.5ML

INTRON A 50 MILLION UNITS VIAL

INTROVALE 0.15-0.03 MG TABLET

INTUNIV ER 1 MG TABLET

INTUNIV ER 2 MG TABLET

INTUNIV ER 3 MG TABLET

INTUNIV ER 4 MG TABLET

INVACARE 30G LANCETS

INVEGA ER 1.5 MG TABLET

INVEGA ER 3 MG TABLET

INVEGA ER 6 MG TABLET

INVEGA ER 9 MG TABLET

INVEGA SUSTENNA 117 MG/0.75 ML

INVEGA SUSTENNA 156 MG/ML SYRG

INVEGA SUSTENNA 234 MG/1.5 ML

INVEGA SUSTENNA 39 MG/0.25 ML

INVEGA SUSTENNA 78 MG/0.5 ML

INVEGA TRINZA 273 MG/0.875 ML

INVEGA TRINZA 410 MG/1.315 ML

INVEGA TRINZA 546 MG/1.75 ML

INVEGA TRINZA 819 MG/2.625 ML

INVIRASE 200 MG CAPSULE

INVIRASE 500 MG TABLET

INVOKAMET 150-1,000 MG TABLET

INVOKAMET 150-500 MG TABLET

INVOKAMET 50-1,000 MG TABLET

INVOKAMET 50-500 MG TABLET

INVOKAMET XR 150-1,000 MG TAB

INVOKAMET XR 150-500 MG TABLET

INVOKAMET XR 50-1,000 MG TAB

INVOKAMET XR 50-500 MG TABLET

INVOKANA 100 MG TABLET

INVOKANA 300 MG TABLET

IPRATROPIUM 0.03% SPRAY

IPRATROPIUM BR 0.02% SOLN

IPRAT-ALBUT 0.5-3(2.5) MG/3 ML

I-PRIN 200 MG TABLET

IRBESARTAN 150 MG TABLET

IRBESARTAN 300 MG TABLET

IRBESARTAN 75 MG TABLET

IRBESARTAN-HCTZ 150-12.5 MG TB

IRBESARTAN-HCTZ 300-12.5 MG TB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

IRENKA DR 40 MG CAPSULE

IRESSA 250 MG TABLET

ISENTRESS 100 MG POWDER PACKET

ISENTRESS 100 MG TABLET CHEW

ISENTRESS 25 MG TABLET CHEW

ISENTRESS 400 MG TABLET

ISENTRESS HD 600 MG TABLET

ISIBLOOM 28 DAY TABLET

ISOCHRON 40 MG TABLET SA

ISOPTO ATROPINE 1% EYE DROP

ISOPTO ATROPINE 1% EYE DROPS

ISOPTO CARPINE 1% EYE DROPS

ISOPTO CARPINE 2% EYE DROPS

ISOPTO CARPINE 4% EYE DROPS

ISORDIL 40 MG TABLET

ISORDIL TITRADOSE 5 MG TAB

ISOSORBIDE DINITRATE 10 MG TAB

ISOSORBIDE DINITRATE 20 MG TAB

ISOSORBIDE DINITRATE 30 MG TAB

ISOSORBIDE DINITRATE 40 MG TAB

ISOSORBIDE DINITRATE 5 MG TAB

ISOSORBIDE DINITR ER 40 MG TAB

ISOSORBIDE MONONIT 10 MG TAB

ISOSORBIDE MONONIT 20 MG TAB

ISOSORBIDE MONONIT ER 120 MG

ISOSORBIDE MONONIT ER 30 MG TB

ISOSORBIDE MONONIT ER 60 MG TB

ISOXSUPRINE 10 MG TABLET

ISOXSUPRINE 20 MG TABLET

ISRADIPINE 2.5 MG CAPSULE

ISRADIPINE 5 MG CAPSULE

ISTALOL 0.5% EYE DROPS

I-VITE PROTECT TABLET

I-VITE TABLET

IXINITY 1,000 UNIT RANGE

IXINITY 1,000 UNIT RANGE-2 VLS

IXINITY 1,000 UNIT VIAL

IXINITY 1,000 UNIT VIAL -2 VLS

IXINITY 1,500 UNIT RANGE

IXINITY 1,500 UNIT RANGE-2 VLS

IXINITY 1,500 UNIT VIAL

IXINITY 1,500 UNIT VIAL -2 VLS

IXINITY 2,000 UNIT RANGE

IXINITY 250 UNIT RANGE

IXINITY 3,000 UNIT RANGE

IXINITY 500 UNIT RANGE

IXINITY 500 UNIT VIAL

JADENU 180 MG TABLET

JADENU 360 MG TABLET

JADENU 90 MG TABLET

JADENU SPRINKLE 180 MG GRANULE

JADENU SPRINKLE 360 MG GRANULE

JADENU SPRINKLE 90 MG GRANULE

JAIMIESS 0.15-0.03-0.01 MG TAB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

JAKAFI 10 MG TABLET

JAKAFI 15 MG TABLET

JAKAFI 20 MG TABLET

JAKAFI 25 MG TABLET

JAKAFI 5 MG TABLET

JALYN 0.5-0.4 MG CAPSULE

JANTOVEN 1 MG TABLET

JANTOVEN 10 MG TABLET

JANTOVEN 2 MG TABLET

JANTOVEN 2.5 MG TABLET

JANTOVEN 3 MG TABLET

JANTOVEN 4 MG TABLET

JANTOVEN 5 MG TABLET

JANTOVEN 6 MG TABLET

JANTOVEN 7.5 MG TABLET

JANUMET 50-1,000 MG TABLET

JANUMET 50-500 MG TABLET

JANUMET XR 100-1,000 MG TABLET

JANUMET XR 50-1,000 MG TABLET

JANUMET XR 50-500 MG TABLET

JANUVIA 100 MG TABLET

JANUVIA 25 MG TABLET

JANUVIA 50 MG TABLET

JARDIANCE 10 MG TABLET

JARDIANCE 25 MG TABLET

JASMIEL 3 MG-0.02 MG TABLET

JATENZO 158 MG CAPSULE

JATENZO 198 MG CAPSULE

JATENZO 237 MG CAPSULE

JAZZ WIRELESS 2 METER KIT

JENCYCLA 0.35 MG TABLET

JENTADUETO 2.5 MG-1000 MG TAB

JENTADUETO 2.5 MG-500 MG TAB

JENTADUETO 2.5 MG-850 MG TAB

JENTADUETO XR 2.5 MG-1,000 MG

JENTADUETO XR 5 MG-1,000 MG TB

JEVANTIQUE LO 0.5 MG-2.5 MCG

JINTELI 1 MG-5 MCG TABLET

JIVI 1,000 UNIT VIAL

JIVI 2,000 UNIT VIAL

JIVI 3,000 UNIT VIAL

JIVI 500 UNIT VIAL

JOHNSON GRASS 1:20 (W/V)

JOLESSA 0.15 MG-0.03 MG TABLET

JOLIVETTE TABLET

JORNAY PM 100 MG CAPSULE

JORNAY PM 20 MG CAPSULE

JORNAY PM 40 MG CAPSULE

JORNAY PM 60 MG CAPSULE

JORNAY PM 80 MG CAPSULE

JULEBER 28 DAY TABLET

JULUCA 50-25 MG TABLET

JUNEL 1 MG-20 MCG TABLET

JUNEL 1.5 MG-30 MCG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

JUNEL FE 1 MG-20 MCG TABLET

JUNEL FE 1.5 MG-30 MCG TABLET

JUNEL FE 24 TABLET

JUXTAPID 10 MG CAPSULE

JUXTAPID 20 MG CAPSULE

JUXTAPID 30 MG CAPSULE

JUXTAPID 40 MG CAPSULE

JUXTAPID 5 MG CAPSULE

JUXTAPID 60 MG CAPSULE

JYNARQUE 15 MG TABLET

JYNARQUE 30 MG TABLET

JYNARQUE 45 MG-15 MG TABLET

JYNARQUE 60 MG-30 MG TABLET

JYNARQUE 90 MG-30 MG TABLET

K EFFERVESCENT 25 MEQ TABLET

KAITLIB FE CHEWABLE TABLET

KALETRA 100-25 MG TABLET

KALETRA 200-50 MG TABLET

KALETRA 80 MG-20 MG/ML SOLN

KALLIGA 28 DAY TABLET

KALYDECO 150 MG TABLET

KALYDECO 25 MG GRANULES PACKET

KALYDECO 50 MG GRANULES PACKET

KALYDECO 75 MG GRANULES PACKET

KANJINTI 150 MG VIAL

KANJINTI 420 MG VIAL

KANUMA 20 MG/10 ML VIAL

KAPOK 1:20 W/V VIAL

KAPSPARGO SPRINKLE 100 MG CAP

KAPSPARGO SPRINKLE 200 MG CAP

KAPSPARGO SPRINKLE 25 MG CAP

KAPSPARGO SPRINKLE 50 MG CAP

KAPVAY ER 0.1 MG TABLET

KARIVA 28 DAY TABLET

KATERZIA 1 MG/ML SUSPENSION

KAZANO 12.5-1,000 MG TABLET

KAZANO 12.5-500 MG TABLET

KELNOR 1-35 28 TABLET

KELNOR 1-50 TABLET

KELP-LECITHIN-VIT B-6 CAPSULE

KELP-LECITHIN-VIT B-6 TABLET

KENWOOD THERAPEUTIC LIQUID

KEPPRA 1,000 MG TABLET

KEPPRA 100 MG/ML ORAL SOLN

KEPPRA 250 MG TABLET

KEPPRA 500 MG TABLET

KEPPRA 750 MG TABLET

KEPPRA XR 500 MG TABLET

KEPPRA XR 750 MG TABLET

KETO-DIASTIX REAGENT STRIPS

CVS KETONE CARE TEST STRIP

KETONE TEST STRIP

RELION KETONE TEST STRIP

KETOPROFEN 50 MG CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

KETOPROFEN 75 MG CAPSULE

KETOPROFEN ER 200 MG CAPSULE

KETOSTIX REAGENT STRIP

KEVEYIS 50 MG TABLET

KEVZARA 150 MG/1.14 ML PEN INJ

KEVZARA 150 MG/1.14 ML SYRINGE

KEVZARA 200 MG/1.14 ML PEN INJ

KEVZARA 200 MG/1.14 ML SYRINGE

KEYTRUDA 100 MG/4 ML VIAL

KHEDEZLA ER 100 MG TABLET

KHEDEZLA ER 50 MG TABLET

KIDS COD LIVER OIL +D TAB CHEW

KIDS MULTIVIT-MINERALS GUMMIES

KIMIDESS 28 DAY TABLET

KINERET 100 MG/0.67 ML SYRINGE

KISQALI 200 MG DAILY DOSE

KISQALI 400 MG DAILY DOSE

KISQALI 600 MG DAILY DOSE

KISQALI FEMARA 200 MG CO-PACK

KISQALI FEMARA 400 MG CO-PACK

KISQALI FEMARA 600 MG CO-PACK

KITABIS PAK 300 MG/5 ML

KLONOPIN 0.5 MG TABLET

KLONOPIN 1 MG TABLET

KLONOPIN 2 MG TABLET

KLOR-CON 20 MEQ PACKET

KLOR-CON 25 MEQ PACKET

KLOR-CON 10 MEQ TABLET

KLOR-CON 8 MEQ TABLET

KLOR-CON M10 TABLET

KLOR-CON M15 TABLET

KLOR-CON M20 TABLET

KLOR-CON SPRINKLE ER 10 MEQ CP

KLOR-CON SPRINKLE ER 8 MEQ CAP

KLOR-CON-EF 25 MEQ TAB EFF

KOATE 1,000 UNIT VIAL

KOATE 250 UNIT VIAL

KOATE 500 UNIT VIAL

KOATE-DVI 1,000 UNIT VIAL

KOATE-DVI 250 UNIT VIAL

KOATE-DVI 500 UNIT VIAL

KOBEE TABLET

KOCHIA 1:20 (W/V) VIAL

KOGENATE FS 1,000 UNITS VIAL

KOGENATE FS 2,000 UNIT VIAL

KOGENATE FS 250 UNIT VIAL

KOGENATE FS 3,000 UNITS VIAL

KOGENATE FS 500 UNIT VIAL

KOMBIGLYZE XR 2.5-1,000 MG TAB

KOMBIGLYZE XR 5-1,000 MG TAB

KOMBIGLYZE XR 5-500 MG TABLET

KORLYM 300 MG TABLET

KOSHER PRENATAL PLUS IRON TAB

KOVALTRY 1,000 UNIT KIT

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

KOVALTRY 1,000 UNIT VIAL

KOVALTRY 2,000 UNIT KIT

KOVALTRY 2,000 UNIT VIAL

KOVALTRY 250 UNIT KIT

KOVALTRY 250 UNIT VIAL

KOVALTRY 3,000 UNIT KIT

KOVALTRY 3,000 UNIT VIAL

KOVALTRY 500 UNIT KIT

KOVALTRY 500 UNIT VIAL

K-PAX IMMUNE SUPPORT TABLET

KPN PRENATAL TABLET

KPN TABLET

KRISTALOSE 10 GM PACKET

KRISTALOSE 20 GM PACKET

KRYSTEXXA 8 MG/ML VIAL

K-SOL 10% (20 MEQ/15 ML) LIQ

K-SOL 20% (40 MEQ/15 ML) LIQ

K-TAB ER 10 MEQ TABLET

K-TAB ER 20 MEQ TABLET

K-TAB ER 8 MEQ TABLET

KURVELO TABLET

KUVAN 100 MG POWDER PACKET

KUVAN 100 MG TABLET

KUVAN 500 MG POWDER PACKET

KYLEENA 19.5 MG SYSTEM

KYNAMRO 200 MG/ML SYRINGE

KYPROLIS 10 MG VIAL

KYPROLIS 30 MG VIAL

KYPROLIS 60 MG VIAL

LABETALOL HCL 100 MG TABLET

LABETALOL HCL 200 MG TABLET

LABETALOL HCL 300 MG TABLET

LACTULOSE 10 GM PACKET

LACTULOSE 10 GM/15 ML SOLUTION

LACTULOSE 20 GM/30 ML SOLUTION

LAMB'S QUARTERS 1:20 (W/V) VL

LAMICTAL 100 MG TABLET

LAMICTAL 150 MG TABLET

LAMICTAL 200 MG TABLET

LAMICTAL 25 MG DISPER TABLET

LAMICTAL 25 MG TABLET

LAMICTAL 5 MG DISPER TABLET

LAMICTAL ODT 100 MG TABLET

LAMICTAL ODT 200 MG TABLET

LAMICTAL ODT 25 MG TABLET

LAMICTAL ODT 50 MG TABLET

LAMICTAL XR 100 MG TABLET

LAMICTAL XR 200 MG TABLET

LAMICTAL XR 25 MG TABLET

LAMICTAL XR 250 MG TABLET

LAMICTAL XR 300 MG TABLET

LAMICTAL XR 50 MG TABLET

LAMIVUDINE 10 MG/ML ORAL SOLN

LAMIVUDINE 100 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

LAMIVUDINE 150 MG TABLET

LAMIVUDINE 300 MG TABLET

LAMIVUDINE HBV 100 MG TABLET

LAMIVUDINE-ZIDOVUDINE TABLET

LAMOTRIGINE 100 MG TABLET

LAMOTRIGINE 150 MG TABLET

LAMOTRIGINE 200 MG TABLET

LAMOTRIGINE 25 MG DISPER TAB

LAMOTRIGINE 25 MG TABLET

LAMOTRIGINE 5 MG DISPER TABLET

LAMOTRIGINE ER 100 MG TABLET

LAMOTRIGINE ER 200 MG TABLET

LAMOTRIGINE ER 25 MG TABLET

LAMOTRIGINE ER 250 MG TABLET

LAMOTRIGINE ER 300 MG TABLET

LAMOTRIGINE ER 50 MG TABLET

LAMOTRIGINE ODT 100 MG TABLET

LAMOTRIGINE ODT 200 MG TABLET

LAMOTRIGINE ODT 25 MG TABLET

LAMOTRIGINE ODT 50 MG TABLET

LANCET 30G-GLUCOSE TEST STRIP

ASSURE COMFORT 28G LANCETS

ASSURE COMFORT 30G LANCETS

BD LANCETS 33G

CVS THIN 26G LANCETS

E-ZJECT THIN LANCETS

KROGER LANCETS

LANCETS

LANCETS 26G X 1.8MM

LANCETS 28G LANCETS

LANCETS 30G

LANCETS 33G

LANCETS ULTRA FINE 28G

MEDISENSE THIN LANCETS

MEIJER LANCETS

PHARMACIST CHOICE 30G LANCETS

PHARMACIST CHOICE 33G LANCETS

PREFERRED PLUS LANCETS

PREFERRED PLUS THIN LANCETS

PUB 28G LANCETS

RELION THIN 26G LANCETS

SAPS CARE 30G LANCETS

SAPS TWIST TOP 30G LANCET

SAPS TWIST TOP 30G LANCETS

SM LANCETS 21G

TWIST LANCETS

LANCETS THIN 23G

LANCETS ULTRA THIN 26G

CVS LANCING DEVICE

GS LANCING DEVICE AND LANCETS

KRO LANCING DEVICE

LANCING DEVICE

LIVE BETTER ADVANCED LANCING

RA HEALTH CARE LANCING DEVICE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

RELION LANCING DEVICE

LANOXIN 125 MCG TABLET

LANOXIN 187.5 MCG TABLET

LANOXIN 250 MCG TABLET

LANOXIN 62.5 MCG TABLET

CVS LANSOPRAZOLE DR 15 MG CAP

EQ LANSOPRAZOLE DR 15 MG CAP

EQL LANSOPRAZOLE DR 15 MG CAP

GS LANSOPRAZOLE DR 15 MG CAP

HM LANSOPRAZOLE DR 15 MG CAP

LANSOPRAZOLE DR 15 MG CAPSULE

LANSOPRAZOLE DR 30 MG CAPSULE

LANSOPRAZOLE ODT 15 MG TABLET

LANSOPRAZOLE ODT 30 MG TABLET

RA LANSOPRAZOLE DR 15 MG CAP

SM LANSOPRAZOLE DR 15 MG CAP

LANTHANUM CARB 1,000 MG TB CHW

LANTHANUM CARB 500 MG TAB CHEW

LANTHANUM CARB 750 MG TAB CHEW

LANTUS 100 UNIT/ML VIAL

LANTUS SOLOSTAR 100 UNIT/ML

LANZO LANCING DEVICE

LARIN 1.5 MG-30 MCG TABLET

LARIN 21 1-20 TABLET

LARIN 24 FE 1 MG-20 MCG TABLET

LARIN FE 1.5-30 TABLET

LARIN FE 1-20 TABLET

LARISSIA-28 TABLET

LARTRUVO 190 MG/19 ML VIAL

LARTRUVO 500 MG/50 ML VIAL

LASIX 20 MG TABLET

LASIX 40 MG TABLET

LASIX 80 MG TABLET

LATANOPROST 0.005% EYE DROPS

LATANOPROST 0.005% EYE DROP

LATUDA 120 MG TABLET

LATUDA 20 MG TABLET

LATUDA 40 MG TABLET

LATUDA 60 MG TABLET

LATUDA 80 MG TABLET

LAYOLIS FE CHEWABLE TABLET

LEENA 28 TABLET

LEFLUNOMIDE 10 MG TABLET

LEFLUNOMIDE 20 MG TABLET

LEMTRADA 12 MG/1.2 ML VIAL

LENVIMA 10 MG DAILY DOSE

LENVIMA 12 MG DAILY DOSE

LENVIMA 14 MG DAILY DOSE

LENVIMA 18 MG DAILY DOSE

LENVIMA 20 MG DAILY DOSE

LENVIMA 24 MG DAILY DOSE

LENVIMA 4 MG CAPSULE

LENVIMA 8 MG DAILY DOSE

LESCOL 20 MG CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

LESCOL 40 MG CAPSULE

LESCOL XL 80 MG TABLET

LESSINA-28 TABLET

LETAIRIS 10 MG TABLET

LETAIRIS 5 MG TABLET

LETROZOLE 2.5 MG TABLET

LEUPROLIDE 2WK 1 MG/0.2 ML KIT

LEUPROLIDE 2WK 14 MG/2.8 ML KT

LEVALBUTEROL CONC 1.25 MG/0.5

LEVALBUTEROL 0.31 MG/3 ML SOL

LEVALBUTEROL 0.63 MG/3 ML SOL

LEVALBUTEROL 1.25 MG/3 ML SOL

LEVALBUTEROL TAR HFA 45MCG INH

LEVBID ER 0.375 MG TABLET

LEVEMIR 100 UNIT/ML VIAL

LEVEMIR FLEXTOUCH 100 UNIT/ML

LEVETIRACETAM 1,000 MG TABLET

LEVETIRACETAM 100 MG/ML SOLN

LEVETIRACETAM 250 MG TABLET

LEVETIRACETAM 500 MG TABLET

LEVETIRACETAM 500 MG/5 ML SOLN

LEVETIRACETAM 750 MG TABLET

LEVETIRACETAM ER 500 MG TABLET

LEVETIRACETAM ER 750 MG TABLET

LEVITRA 10 MG TABLET

LEVITRA 2.5 MG TABLET

LEVITRA 20 MG TABLET

LEVITRA 5 MG TABLET

LEVOBUNOLOL 0.5% EYE DROPS

LEVOCARNITINE 330 MG TABLET

LEVOCARNITINE 1 G/10 ML SOLN

LEVOCARNITINE SF 1 G/10 ML SOL

LEVOCETIRIZINE 2.5 MG/5 ML SOL

LEVOCETIRIZINE 5 MG TABLET

LEVOMEFOLATE DHA CAPSULE

LEVONEST-28 TABLET

LEVONOR-ETH ESTRA 0.09-0.02 MG

LEVONOR-ETH ESTRAD 0.1-0.02 MG

LEVONOR-ETH ESTRAD 0.15-0.03

LEVONOR-ETH ESTRAD TRIPHASIC

LEVONO-E ESTRAD 0.15-0.03-0.01

LEVONOR-E ESTRAD 0.1-0.02-0.01

LEVONORG 0.15MG-EE 20-25-30MCG

LEVORA-28 TABLET

LEVO-T 100 MCG TABLET

LEVO-T 112 MCG TABLET

LEVO-T 125 MCG TABLET

LEVO-T 137 MCG TABLET

LEVO-T 150 MCG TABLET

LEVO-T 175 MCG TABLET

LEVO-T 200 MCG TABLET

LEVO-T 25 MCG TABLET

LEVO-T 300 MCG TABLET

LEVO-T 50 MCG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

LEVO-T 75 MCG TABLET

LEVO-T 88 MCG TABLET

LEVOTHYROXINE 0.025 MG TABLET

LEVOTHYROXINE 0.05 MG TABLET

LEVOTHYROXINE 0.075 MG TABLET

LEVOTHYROXINE 0.088 MG TABLET

LEVOTHYROXINE 0.1 MG TABLET

LEVOTHYROXINE 0.112 MG TABLET

LEVOTHYROXINE 0.125 MG TABLET

LEVOTHYROXINE 0.137 MG TABLET

LEVOTHYROXINE 0.15 MG TABLET

LEVOTHYROXINE 0.175 MG TABLET

LEVOTHYROXINE 100 MCG TABLET

LEVOTHYROXINE 112 MCG TABLET

LEVOTHYROXINE 125 MCG TABLET

LEVOTHYROXINE 137 MCG TABLET

LEVOTHYROXINE 150 MCG TABLET

LEVOTHYROXINE 175 MCG TABLET

LEVOTHYROXINE 200 MCG TABLET

LEVOTHYROXINE 25 MCG TABLET

LEVOTHYROXINE 300 MCG TABLET

LEVOTHYROXINE 50 MCG TABLET

LEVOTHYROXINE 75 MCG TABLET

LEVOTHYROXINE 88 MCG TABLET

LEVOXYL 100 MCG TABLET

LEVOXYL 112 MCG TABLET

LEVOXYL 125 MCG TABLET

LEVOXYL 137 MCG TABLET

LEVOXYL 150 MCG TABLET

LEVOXYL 175 MCG TABLET

LEVOXYL 200 MCG TABLET

LEVOXYL 25 MCG TABLET

LEVOXYL 50 MCG TABLET

LEVOXYL 75 MCG TABLET

LEVOXYL 88 MCG TABLET

LEVSIN 0.125 MG TABLET

LEVSIN-SL 0.125 MG TABLET SL

LEXAPRO 10 MG TABLET

LEXAPRO 20 MG TABLET

LEXAPRO 5 MG TABLET

LEXAPRO 5 MG/5 ML SOLUTION

LEXIVA 50 MG/ML SUSPENSION

LEXIVA 700 MG TABLET

LIALDA DR 1.2 GM TABLET

LIBERTY LEV 1 GLUCOSE CTRL SOL

LIBERTY LEV 2 GLUCOSE CTRL SOL

LIBERTY BLOOD GLUCOSE MONITOR

LIBERTY TEST STRIPS

LIBRAX CAPSULE

LIBTAYO 350 MG/7 ML VIAL

LIFE-PACK MEN'S

LIFE-PACK WOMEN'S

LILETTA 52 MG SYSTEM

LILLOW-28 TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

LINZESS 145 MCG CAPSULE

LINZESS 290 MCG CAPSULE

LINZESS 72 MCG CAPSULE

LIORESAL IT 0.05 MG/1 ML AMP

LIORESAL IT 10 MG/20 ML AMPULE

LIORESAL IT 10 MG/20 ML KIT

LIORESAL IT 10 MG/5 ML AMPULE

LIORESAL IT 10 MG/5 ML KIT

LIORESAL IT 40 MG/20 ML AMPULE

LIORESAL IT 40 MG/20 ML KIT

LIOTHYRONINE SOD 25 MCG TAB

LIOTHYRONINE SOD 5 MCG TAB

LIOTHYRONINE SOD 50 MCG TAB

LIPITOR 10 MG TABLET

LIPITOR 20 MG TABLET

LIPITOR 40 MG TABLET

LIPITOR 80 MG TABLET

LIPOFEN 150 MG CAPSULE

LIPOFEN 50 MG CAPSULE

LIPOTRIAD CAPLET

LIPOTRIAD VISIONARY SOFTGEL

LIQUID CALCIUM 600-VIT D3 SFGL

LISINOPRIL 10 MG TABLET

LISINOPRIL 2.5 MG TABLET

LISINOPRIL 20 MG TABLET

LISINOPRIL 30 MG TABLET

LISINOPRIL 40 MG TABLET

LISINOPRIL 5 MG TABLET

LISINOPRIL-HCTZ 10-12.5 MG TAB

LISINOPRIL-HCTZ 20-12.5 MG TAB

LISINOPRIL-HCTZ 20-25 MG TAB

GNP LITE COAT ASA 325 MG TAB

LITE COAT ASPIRIN 325 MG TAB

LITE TOUCH 28G LANCETS

LITE TOUCH 30G LANCETS

LITE TOUCH 33G LANCETS

LITE TOUCH 31GX1/4" PEN NEEDLE

LITE TOUCH PEN NEEDLE 29G

LITE TOUCH PEN NEEDLE 31G

LITE TOUCH INSULIN 1 ML SYR

LITE TOUCH INSULIN SYR 1 ML

LITE TOUCH INSULIN 0.5 ML SYR

LITE TOUCH INSULIN SYR 0.5 ML

LITE TOUCH INSULIN SYR 0.3 ML

LITETOUCH SYRIN 1 ML 28GX1/2"

LITETOUCH SYRIN 1 ML 29GX1/2"

LITETOUCH SYRIN 1 ML 30GX5/16"

LITETOUCH INS 0.5 ML 31GX5/16"

LITETOUCH SYR 0.5 ML 28GX1/2"

LITETOUCH SYR 0.5 ML 29GX1/2"

LITETOUCH SYR 0.5 ML 30GX5/16"

LITETOUCH INS 0.3 ML 29GX1/2"

LITETOUCH INS 0.3 ML 30GX5/16"

LITETOUCH INS 0.3 ML 31GX5/16"

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

LITHIUM 8 MEQ/5 ML SOLUTION

LITHIUM CARBONATE 150 MG CAP

LITHIUM CARBONATE 300 MG CAP

LITHIUM CARBONATE 300 MG TAB

LITHIUM CARBONATE 600 MG CAP

LITHIUM CARBONATE ER 300 MG TB

LITHIUM CARBONATE ER 450 MG TB

LITHOBID ER 300 MG TABLET

LITTLE ANIMALS-IRON TAB CHEW

LITTLE ANIMALS-IRON TAB CHEW

LIVALO 1 MG TABLET

LIVALO 2 MG TABLET

LIVALO 4 MG TABLET

L-METHYL-MC TABLET

L-METHYL-MC NAC TABLET

LO LOESTRIN FE 1-10 TABLET

LODINE 400 MG TABLET

LODOSYN 25 MG TABLET

LOESTRIN 21 1.5-30 TABLET

LOESTRIN 21 1-20 TABLET

LOESTRIN FE 1.5-30 TABLET

LOESTRIN FE 1-20 TABLET

LOFIBRA 160 MG TABLET

LOFIBRA 54 MG TABLET

LOFIBRA 134 MG CAPSULE

LOFIBRA 200 MG CAPSULE

LOFIBRA 67 MG CAPSULE

LOJAIMIESS 0.1-0.02-0.01 TAB

LOKELMA 10 GRAM POWDER PACKET

LOKELMA 5 GRAM POWDER PACKET

LOMEDIA 24 FE 1 MG-20 MCG TAB

LONHALA MAGNAIR 25 MCG REFILL

CVS LOPERAMIDE 1 MG/7.5 ML LIQ

CVS LOPERAMIDE 1 MG/7.5 ML SUS

EQ LOPERAMIDE 1 MG/7.5 ML SUSP

EQL LOPERAMIDE 1 MG/7.5 ML SUS

HM LOPERAMIDE 1 MG/7.5 ML LIQ

HM LOPERAMIDE 2 MG SOFTGEL

LOPERAMIDE 1 MG/5 ML LIQUID

LOPERAMIDE 1 MG/5 ML SOLUTION

LOPERAMIDE 1 MG/7.5 ML LIQUID

LOPERAMIDE 1 MG/7.5 ML SOLN

LOPERAMIDE 1 MG/7.5 ML SUSP

LOPERAMIDE 2 MG CAPLET

LOPERAMIDE 2 MG CAPSULE

LOPERAMIDE 2 MG TABLET

LOPERAMIDE 2 MG/15 ML SUSP

RA LOPERAMIDE 1 MG/7.5 ML SUSP

SM LOPERAMIDE 1 MG/7.5 ML LIQ

LOPID 600 MG TABLET

LOPINAVIR-RITONAVIR 80-20MG/ML

LOPREEZA 0.5 MG-0.1 MG TABLET

LOPREEZA 1 MG-0.5 MG TABLET

LOPRESSOR 100 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

LOPRESSOR 50 MG TABLET

LOPRESSOR HCT 50-25 TABLET

LORBRENA 100 MG TABLET

LORBRENA 25 MG TABLET

LORYNA 3 MG-0.02 MG TABLET

LOSARTAN POTASSIUM 100 MG TAB

LOSARTAN POTASSIUM 25 MG TAB

LOSARTAN POTASSIUM 50 MG TAB

LOSARTAN-HCTZ 100-12.5 MG TAB

LOSARTAN-HCTZ 100-25 MG TAB

LOSARTAN-HCTZ 50-12.5 MG TAB

LOSEASONIQUE TABLET

LOTENSIN 10 MG TABLET

LOTENSIN 20 MG TABLET

LOTENSIN 40 MG TABLET

LOTENSIN HCT 10-12.5 MG TABLET

LOTENSIN HCT 20-12.5 MG TABLET

LOTENSIN HCT 20-25 MG TABLET

LOTREL 10-20 MG CAPSULE

LOTREL 10-40 MG CAPSULE

LOTREL 5-10 MG CAPSULE

LOTREL 5-20 MG CAPSULE

LOTREL 5-40 MG CAPSULE

LOVASTATIN 10 MG TABLET

LOVASTATIN 20 MG TABLET

LOVASTATIN 40 MG TABLET

LOVAZA 1 GM CAPSULE

LOW DOSE ASPIRIN EC 81 MG TAB

LOW-OGESTREL-28 TABLET

LOXAPINE 10 MG CAPSULE

LOXAPINE 25 MG CAPSULE

LOXAPINE 5 MG CAPSULE

LOXAPINE 50 MG CAPSULE

LO-ZUMANDIMINE 3 MG-0.02 MG TB

LUCENTIS 0.3 MG VIAL

LUCENTIS 0.3 MG/0.05 ML SYRING

LUCENTIS 0.3 MG/0.05 ML VIAL

LUCENTIS 0.5 MG VIAL

LUCENTIS 0.5 MG/0.05 ML SYRING

LUCENTIS 0.5 MG/0.05 ML VIAL

LUDENT FLUORIDE 0.25 MG TB CHW

LUDENT FLUORIDE 0.5 MG TB CHEW

LUDENT FLUORIDE 1 MG TAB CHEW

BD LUER-LOK SYRINGE 1 ML

LUMIGAN 0.01% EYE DROPS

LUMIZYME 50 MG VIAL

LUPRON DEPOT 22.5 MG 3MO KIT

LUPRON DEPOT 45 MG 6MO KIT

LUPRON DEPOT 7.5 MG KIT

LUPRON DEPOT-4 MONTH KIT

LUPRON DEPOT-PED 11.25 MG 3MO

LUPRON DEPOT-PED 11.25 MG KIT

LUPRON DEPOT-PED 15 MG KIT

LUPRON DEPOT-PED 30 MG 3MO KIT

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

LUPRON DEPOT-PED 7.5 MG KIT

LUTERA-28 TABLET

LYNPARZA 100 MG TABLET

LYNPARZA 150 MG TABLET

LYNPARZA 50 MG CAPSULE

LYRICA 100 MG CAPSULE

LYRICA 150 MG CAPSULE

LYRICA 20 MG/ML ORAL SOLUTION

LYRICA 200 MG CAPSULE

LYRICA 225 MG CAPSULE

LYRICA 25 MG CAPSULE

LYRICA 300 MG CAPSULE

LYRICA 50 MG CAPSULE

LYRICA 75 MG CAPSULE

LYRICA CR 165 MG TABLET

LYRICA CR 330 MG TABLET

LYRICA CR 82.5 MG TABLET

LYSIPLEX PLUS LIQUID

LYSODREN 500 MG TABLET

LYSTEDA 650 MG TABLET

LYZA 0.35 MG TABLET

MACNATAL CN DHA SOFTGEL

MACUGEN 0.3 MG/90 MICROLITERS

MACULAR BENEFITS COMBO PACK

MACULAR HEALTH FORMULA CAPSULE

MACUVEX CAPSULE

MACUVITE EYE CARE TABLET

MACUZIN CAPSULE

MAGELLAN INSULIN SYRINGE 1 ML

MAGELLAN INSULIN SYR 0.5 ML

MAGELLAN INSULIN SYR 0.3 ML

MAGELLAN INSUL SYRINGE 0.5 ML

MAGELLAN INSUL SYRINGE 0.3 ML

MAPROTILINE 25 MG TABLET

MAPROTILINE 50 MG TABLET

MAPROTILINE 75 MG TABLET

MARLISSA-28 TABLET

MARNATAL-F CAPSULE

MARPLAN 10 MG TABLET

MATZIM LA 180 MG TABLET

MATZIM LA 240 MG TABLET

MATZIM LA 300 MG TABLET

MATZIM LA 360 MG TABLET

MATZIM LA 420 MG TABLET

MAVENCLAD 10 MG X 10 TABLET PK

MAVENCLAD 10 MG X 4 TABLET PK

MAVENCLAD 10 MG X 5 TABLET PK

MAVENCLAD 10 MG X 6 TABLET PK

MAVENCLAD 10 MG X 7 TABLET PK

MAVENCLAD 10 MG X 8 TABLET PK

MAVENCLAD 10 MG X 9 TABLET PK

MAVIK 1 MG TABLET

MAVIK 2 MG TABLET

MAXI-COMFORT INS 1 ML 28GX1/2"

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

MAXI-COMFORT INS 0.5 ML 28G

MAXICOMFORT II PEN NDL 31GX6MM

MAXICOMFORT INS 1 ML 27GX1/2"

MAXICOMFORT INS 0.5ML 27GX1/2"

MAXICOMFORT PEN NDL 29G X 5MM

MAXICOMFORT PEN NDL 29G X 8MM

MAXIMIN PACK

QC MAXIMUM DAILY MULTIVIT TAB

MAXINATE TABLET

MAXZIDE 75 MG-50 MG TABLET

MAXZIDE 37.5 MG-25 MG TABLET

MAYZENT 0.25 MG TABLET

MAYZENT 2 MG TABLET

MEBOLIC TABLET

MECLOFENAMATE 100 MG CAPSULE

MECLOFENAMATE 50 MG CAPSULE

MEDIPROXEN TABLET

MEDISENSE H-L CONTROL SOLUTION

MEDISENSE H-M-L CONTROL SOLN

MEDISENSE MID CONTROL SOLUTION

MEDISENSE GLUC-KET CONT SOL

MEDISENSE GLUC-KET CONT SOL

MEDISENSE THIN 28G LANCETS

MEDLANCE PLUS 21G LANCETS

MEDLANCE PLUS 30G LANCETS

MEDLANCE PLUS EXTRA 21G LANCET

MEDLANCE PLUS LITE 25G LANCETS

MEDLANCE PLUS SPECIAL BLADE

MEDROXYPROGESTERONE 10 MG TAB

MEDROXYPROGESTERONE 150 MG/ML

MEDROXYPROGESTERONE 2.5 MG TAB

MEDROXYPROGESTERONE 5 MG TAB

MEDTYCHOLL-B COMP-LIVER CAP

MEGA BIOTIN 10,000 MCG SOFTGEL

GNP MEGA MULTI FOR WOMEN TAB

MEGA MULTI FOR WOMEN TAB

GNP MEGA MULTI FOR MEN TABLET

MEGA MULTI FOR MEN TABLET

MEGA MULTIVIT-CHELATED MIN TAB

MEGACE 40 MG/ML ORAL SUSP

MEGACE ES 625 MG/5 ML SUSP

MEGESTROL 625 MG/5 ML SUSP

MEGESTROL 800 MG/20 ML SUSP

MEGESTROL ACET 40 MG/ML SUSP

MEGESTROL ACET 400 MG/10 ML

MEGESTROL ACET 800 MG/20 ML

MEKINIST 0.5 MG TABLET

MEKINIST 2 MG TABLET

MEKTOVI 15 MG TABLET

MELALEUCA 1:20 (W/V) VIAL

MELODETTA 24 FE CHEWABLE TAB

MELOXICAM 15 MG TABLET

MELOXICAM 7.5 MG TABLET

MEMANTINE HCL 10 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

MEMANTINE HCL 10 MG/5 ML SOLN

MEMANTINE HCL 2 MG/ML SOLUTION

MEMANTINE HCL 5 MG TABLET

MEMANTINE HCL ER 14 MG CAPSULE

MEMANTINE HCL ER 21 MG CAPSULE

MEMANTINE HCL ER 28 MG CAPSULE

MEMANTINE HCL ER 7 MG CAPSULE

CVS MENS 50 PLUS ADVANCED TAB

HM MENS 50 PLUS ADV ONE DAILY

MEN 50 PLUS MULTIVITAMIN TAB

MENEST 0.3 MG TABLET

MENEST 0.625 MG TABLET

MENEST 1.25 MG TABLET

MENEST 2.5 MG TABLET

MENOSTAR 14 MCG/DAY PATCH

MEN'S 50 PLUS DAILY FORMULA TB

MEN'S DAILY FORMULA TABLET

MEN'S DAILY FORMULA CAPSULE

CVS MEN'S DAILY GUMMIES

QC MEN'S DAILY MULTIVIT-MIN TB

MEN'S DAILY PACK

MEN'S MULTIVITAMIN CAPLET

MEN'S MULTIVITAMIN GUMMIES

CVS MEN'S MULTI-VIT TABLET

MENS MULTIVIT HIGH POTENCY TAB

EQL ONE DAILY MEN'S TABLET

HM MEN'S ONE DAILY TABLET

RA MEN'S ONE DAILY TABLET

SM MEN'S ONE DAILY TABLET

MEN'S PACK

MEPSEVII 10 MG/5 ML VIAL

MERCAPTOPURINE 50 MG TABLET

MERIBIN 5 MG CAPSULE

MESALAMINE 1,000 MG SUPP

MESALAMINE 4 GM/60 ML ENEMA

MESALAMINE 800 MG DR TABLET

MESALAMINE DR 1.2 GM TABLET

MESALAMINE 4 GM/60 ML KIT

MESALAMINE DR 400 MG CAPSULE

MESALAMINE ER 0.375 GRAM CAP

MESQUITE 1:20 (W/V) VIAL

MESTINON 180 MG TIMESPAN

MESTINON 60 MG TABLET

MESTINON 60 MG/5 ML SYRUP

METADATE CD 10 MG CAPSULE

METADATE CD 20 MG CAPSULE

METADATE CD 30 MG CAPSULE

METADATE CD 40 MG CAPSULE

METADATE CD 50 MG CAPSULE

METADATE CD 60 MG CAPSULE

METADATE ER 20 MG TABLET

METAFOLBIC TABLET

METAFOLBIC PLUS CAPLET

METAPROTERENOL 10 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

METAPROTERENOL 10 MG/5 ML SYR

METAPROTERENOL 20 MG TABLET

METFORMIN ER 1,000 MG GASTR-TB

METFORMIN ER 500 MG GASTRC-TB

METFORMIN ER 1,000 MG OSM-TAB

METFORMIN ER 500 MG OSMOTIC TB

METFORMIN HCL 1,000 MG TABLET

METFORMIN HCL 500 MG TABLET

METFORMIN HCL 500 MG/5 ML SOLN

METFORMIN HCL 850 MG TABLET

METFORMIN HCL ER 500 MG TABLET

METFORMIN HCL ER 750 MG TABLET

METHAMPHETAMINE 5 MG TABLET

METHAZOLAMIDE 25 MG TABLET

METHAZOLAMIDE 50 MG TABLET

METHIMAZOLE 10 MG TABLET

METHIMAZOLE 5 MG TABLET

METHITEST 10 MG TABLET

METHOTREXATE 2.5 MG TABLET

METHOXSALEN 10 MG CAPSULE

METHOXSALEN 10 MG SOFTGEL

METHSCOPOLAMINE BROM 5 MG TAB

METHYCLOTHIAZIDE 5 MG TABLET

METHYLDOPA 250 MG TABLET

METHYLDOPA 500 MG TABLET

METHYLDOPA-HCTZ 250-15 MG TAB

METHYLDOPA-HCTZ 250-25 MG TAB

METHYLIN 10 MG/5 ML SOLUTION

METHYLIN 5 MG/5 ML SOLUTION

METHYLPHENIDATE ER 10 MG TAB

METHYLPHENIDATE ER 18 MG TAB

METHYLPHENIDATE ER 20 MG TAB

METHYLPHENIDATE ER 27 MG TAB

METHYLPHENIDATE ER 36 MG TAB

METHYLPHENIDATE ER 54 MG TAB

METHYLPHENIDATE ER 72 MG TAB

METHYLPHENIDATE ER(LA) 10MG CP

METHYLPHENIDATE ER(LA) 20MG CP

METHYLPHENIDATE ER(LA) 30MG CP

METHYLPHENIDATE ER(LA) 40MG CP

METHYLPHENIDATE 10 MG CHEW TAB

METHYLPHENIDATE 10 MG TABLET

METHYLPHENIDATE 10 MG/5 ML SOL

METHYLPHENIDATE 2.5 MG CHEW TB

METHYLPHENIDATE 20 MG TABLET

METHYLPHENIDATE 5 MG CHEW TAB

METHYLPHENIDATE 5 MG TABLET

METHYLPHENIDATE 5 MG/5 ML SOLN

METHYLPHENIDATE CD 10 MG CAP

METHYLPHENIDATE CD 20 MG CAP

METHYLPHENIDATE CD 30 MG CAP

METHYLPHENIDATE CD 40 MG CAP

METHYLPHENIDATE CD 50 MG CAP

METHYLPHENIDATE CD 60 MG CAP

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

METHYLPHENIDATE ER(CD) 10MG CP

METHYLPHENIDATE ER(CD) 20MG CP

METHYLPHENIDATE ER(CD) 30MG CP

METHYLPHENIDATE ER(CD) 40MG CP

METHYLPHENIDATE ER(CD) 50MG CP

METHYLPHENIDATE ER(CD) 60MG CP

METHYLPHENIDATE LA 10 MG CAP

METHYLPHENIDATE LA 20 MG CAP

METHYLPHENIDATE LA 30 MG CAP

METHYLPHENIDATE LA 40 MG CAP

METHYLPHENIDATE LA 60 MG CAP

METHYLTESTOSTERONE 10 MG CAP

METIPRANOLOL 0.3% EYE DROPS

METOLAZONE 10 MG TABLET

METOLAZONE 2.5 MG TABLET

METOLAZONE 5 MG TABLET

METOPROLOL SUCC ER 100 MG TAB

METOPROLOL SUCC ER 200 MG TAB

METOPROLOL SUCC ER 25 MG TAB

METOPROLOL SUCC ER 50 MG TAB

METOPROLOL ER-HCTZ 100-12.5 MG

METOPROLOL ER-HCTZ 25-12.5 MG

METOPROLOL ER-HCTZ 50-12.5 MG

METOPROLOL TARTRATE 100 MG TAB

METOPROLOL TARTRATE 25 MG TAB

METOPROLOL TARTRATE 37.5 MG TB

METOPROLOL TARTRATE 50 MG TAB

METOPROLOL TARTRATE 75 MG TAB

METOPROLOL-HCTZ 100-25 MG TAB

METOPROLOL-HCTZ 100-50 MG TAB

METOPROLOL-HCTZ 50-25 MG TAB

MEXILETINE 150 MG CAPSULE

MEXILETINE 200 MG CAPSULE

MEXILETINE 250 MG CAPSULE

MIACALCIN 200 UNIT NASAL SPRAY

MIBELAS 24 FE CHEWABLE TABLET

MICARDIS 20 MG TABLET

MICARDIS 40 MG TABLET

MICARDIS 80 MG TABLET

MICARDIS HCT 40-12.5 MG TABLET

MICARDIS HCT 80-12.5 MG TABLET

MICARDIS HCT 80-25 MG TABLET

RELION MICRO TEST STRIPS

RELION MICRO THIN 33G LANCET

CVS MICRO THIN 33G LANCETS

EQL MICRO THIN 33G LANCETS

GNP MICRO THIN 33G LANCETS

HEB MICRO THIN 33G LANCETS

MICRO THIN 33G LANCETS

SM MICRO THIN 33G LANCETS

MICRODOT HIGH-LOW CONTROL SOL

MICRODOT TEST STRIPS

MICRODOT NORMAL CONTROL SOLUT

MICRODOT BLOOD GLUCOSE SYSTEM

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

MICRODOT PEN NEEDLE 31GX6MM

MICRODOT PEN NEEDLE 32GX4MM

MICRODOT PEN NEEDLE 33GX4MM

MICRODOT XTRA TEST STRIPS

MICROGESTIN 21 1.5-30 TAB

MICROGESTIN 21 1-20 TABLET

MICROGESTIN 24 FE 1 MG-20 MCG

MICROGESTIN FE 1.5-30 TAB

MICROGESTIN FE 1-20 TABLET

MICROLET LANCETS

MICROLET 2 LANCING DEVICE

MICROLET NEXT LANCING DEVICE

BD MICROTAINER LANCETS

MICROZIDE 12.5 MG CAPSULE

MIDOL 220 MG CAPLET

MIGLITOL 100 MG TABLET

MIGLITOL 25 MG TABLET

MIGLITOL 50 MG TABLET

MIGLUSTAT 100 MG CAPSULE

MILI 0.25-0.035 MG TABLET

MILLTRIUM SENIOR MULTIVIT TAB

MIMVEY 1-0.5 MG TABLET

MIMVEY LO 0.5-0.1 MG TABLET

MINASTRIN 24 FE CHEWABLE TAB

MINI PRENATAL TABLET

MINI ULTRA-THIN II PEN NDL 31G

MINILINK REAL-TIME TRANSMITTER

MINIMED INFUSION SET

MINIMED 630G GUARDIAN START KT

MINIMED RESERVOIR 1.8 ML

MINIMED RESERVOIR 3 ML

MINIPRESS 1 MG CAPSULE

MINIPRESS 2 MG CAPSULE

MINIPRESS 5 MG CAPSULE

MINITRAN 0.1 MG/HR PATCH

MINITRAN 0.2 MG/HR PATCH

MINITRAN 0.4 MG/HR PATCH

MINITRAN 0.6 MG/HR PATCH

MINIVELLE 0.025 MG PATCH

MINIVELLE 0.0375 MG PATCH

MINIVELLE 0.05 MG PATCH

MINIVELLE 0.075 MG PATCH

MINIVELLE 0.1 MG PATCH

MINOXIDIL 10 MG TABLET

MINOXIDIL 2.5 MG TABLET

MIO INFUSION SET 18"

MIO INFUSION SET 23"

MIO INFUSION SET 32"

MIRAPEX 0.125 MG TABLET

MIRAPEX 0.25 MG TABLET

MIRAPEX 0.5 MG TABLET

MIRAPEX 0.75 MG TABLET

MIRAPEX 1 MG TABLET

MIRAPEX 1.5 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

MIRAPEX ER 0.375 MG TABLET

MIRAPEX ER 0.75 MG TABLET

MIRAPEX ER 1.5 MG TABLET

MIRAPEX ER 2.25 MG TABLET

MIRAPEX ER 3 MG TABLET

MIRAPEX ER 3.75 MG TABLET

MIRAPEX ER 4.5 MG TABLET

MIRCERA 100 MCG/0.3 ML SYRINGE

MIRCERA 150 MCG/0.3 ML SYRINGE

MIRCERA 200 MCG/0.3 ML SYRINGE

MIRCERA 30 MCG/0.3 ML SYRINGE

MIRCERA 50 MCG/0.3 ML SYRINGE

MIRCERA 75 MCG/0.3 ML SYRINGE

MIRCETTE 28 DAY TABLET

MIRENA 52 MG SYSTEM

MIRTAZAPINE 15 MG ODT

MIRTAZAPINE 15 MG TABLET

MIRTAZAPINE 30 MG ODT

MIRTAZAPINE 30 MG TABLET

MIRTAZAPINE 45 MG ODT

MIRTAZAPINE 45 MG TABLET

MIRTAZAPINE 7.5 MG TABLET

MISOPROSTOL 100 MCG TABLET

MISOPROSTOL 200 MCG TABLET

MITIGARE 0.6 MG CAPSULE

MITOXANTRONE 20 MG/10 ML VIAL

MITOXANTRONE 25 MG/12.5 ML VL

MITOXANTRONE 30 MG/15 ML VIAL

MIXED ASPERGILLUS 20000 PNU/ML

MIXED FEATHERS 1:20 (W/V) VL

MIXED RAGWEED 1:20 (W/V)

MIXED VESPID VENOM 1,650 MCG

MIXED VESPID VENOM 300 MCG/ML

M-NATAL PLUS TABLET

MOBIC 15 MG TABLET

MOBIC 7.5 MG TABLET

MODAFINIL 100 MG TABLET

MODAFINIL 200 MG TABLET

MOEXIPRIL HCL 15 MG TABLET

MOEXIPRIL HCL 7.5 MG TABLET

MOEXIPRIL-HCTZ 15-12.5 MG TAB

MOEXIPRIL-HCTZ 15-25 MG TABLET

MOEXIPRIL-HCTZ 7.5-12.5 MG TAB

MOLINDONE HCL 10 MG TABLET

MOLINDONE HCL 25 MG TABLET

MOLINDONE HCL 5 MG TABLET

MOMETASONE FUROATE 50 MCG SPRY

MONOCAPS TABLET

MONOCLATE-P 1,000 UNIT KIT

MONOCLATE-P 1,500 UNIT KIT

MONOJECT 0.5 ML SYRN 28GX1/2"

MONOJECT INSULIN SYR U-100

MONOJECT 1 ML SYRN 27X1/2"

MONOJECT 1 ML SYRN 28GX1/2"

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

MONOJECT INSUL SYR U100 1 ML

MONOJECT INSULIN SYR 1 ML

MONOJECT SYRINGE 1 ML

MONOJECT INSUL SYR U100

MONOJECT INSUL SYR U100 0.5 ML

MONOJECT INSULIN SYR 0.5 ML

MONOJECT INSULIN SYR U-100

MONOJECT SYRINGE 0.5 ML

MONOJECT INSUL SYR U100

MONOJECT INSULIN SYR 0.3 ML

MONOJECT INSULIN SYRN 3/10 ML

MONOJECT SYRINGE 0.3 ML

MONOLET 21G LANCETS

MONOLET THIN 28G LANCETS

MONO-LINYAH 28 TABLET

MONONESSA 28 TABLET

MONONINE 1,000 UNIT VIAL

MONTELUKAST SOD 10 MG TABLET

MONTELUKAST SOD 4 MG GRANULES

MONTELUKAST SOD 4 MG TAB CHEW

MONTELUKAST SOD 5 MG TAB CHEW

MOSQUITO 1:100 (W/V) VIAL

MOTEGRITY 1 MG TABLET

MOTEGRITY 2 MG TABLET

MOTRIN IB 200 MG CAPLET

MOTRIN IB 200 MG LIQUID GEL

MOUNTAIN CEDAR 1:20 (W/V) VIAL

MOUSE EPITHELIUM 1:20 (W/V)

MTERYTI COMBO PACK

MTERYTI FOLIC 5 COMBO PACK

MUCOR 10,000 PNU/ML VIAL

MUCOR 20,000 PNU/ML VIAL

MUGWORT 1:20 (W/V) VIAL

MULTAQ 400 MG TABLET

MULTI COMPLETE-IRON TABLET

MULTI FOR HER SOFTGEL

MULTI FOR HER TABLET

MULTI FOR HER 50 PLUS SOFTGEL

MULTI-BETIC TABLET

MULTI-DAY PLUS IRON TABLET

MULTI-DAY PLUS MINERALS TABLET

MULTI-DELYN WITH IRON LIQUID

MULTIFUNCTION (GLUC-KETONE) KT

MULTI-LANCET DEVICE 2 KIT

MULTILEX TABLET

MULTILEX T-M TABLET

MULTIPLE VITAMIN W-MINERALS TB

MULTIPLE VITAMIN PLAIN TAB

MULTIPLE VITAMIN TABLET

MULTIPLE VITAMINS TABLET

MULTIVITAMIN TABLET

MULTIVITAMIN LIQUID

MULTI-VITAMIN GUMMIES

PUB MULTIVITAMIN 50 PLUS TAB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

MULTI-VITAMIN DAILY TABLET

MULTIVIT-FLUOR-IRON 0.25 MG/ML

MULTIVIT-FLUOR 0.25 MG/ML DROP

MULTIVIT-FLUOR 0.5 MG/ML DROP

MULTIVIT-FLUOR 0.25 MG TAB CHW

MULTIVIT-FLUOR 0.5 MG TAB CHEW

MULTIVIT-FLUORIDE 1 MG TAB CHW

MULTIVIT-FLUOR 0.25 MG TAB CHW

MULTIVIT-FLUOR 0.5 MG TAB CHEW

MULTIVIT-FLUORIDE 1 MG TAB CHW

MULTIVIT-FLUOR 0.25 MG/ML DROP

MULTIVIT-FLUOR 0.5 MG/ML DROP

MULTI-VITAMIN-MINERALS TABLET

MULTIVITAMIN WOMEN 50 PLUS TAB

MULTIVIT-IRON-FLUOR 0.25 MG/ML

MULTIVITAMINS CAPSULE

MULTIVITAMINS TABLET

SM MULTIVITAMINS TABLET

CVS DAILY VIT-IRON-CAL TAB

MULTIVIT-IRON-FL 0.25 MG/ML

MULTIVIT-FLUOR 0.25 MG/ML DROP

MULTIVIT-FLUOR 0.5 MG/ML DROP

MULTIVIT WITH IRON TAB CHEW

DAILY MULTI VITAMIN-IRON TAB

MULTIPLE VITAMIN WITH IRON TAB

MULTIVITAMINS-IRON TABLET

SM MULTIVITAMIN W-IRON TAB

DAILY MULTIVIT-MINERALS TAB

MULTIVIT-MINERALS TABLET

MULTIVITAMIN-MINERAL LIQUID

MULTIVIT-MINERAL HP CAP

MULTI-VITE LIQUID

MURO-128 5% EYE DROPS

MURO-128 5% EYE OINTMENT

MUSE 1,000 MCG URETHRAL SUPP

MUSE 125 MCG URETHRAL SUPPOS

MUSE 250 MCG URETHRAL SUPPOS

MUSE 500 MCG URETHRAL SUPPOS

MVC-FLUORIDE 0.25 MG TAB CHEW

MVC-FLUORIDE 0.5 MG TAB CHEW

MVC-FLUORIDE 1 MG TAB CHEW

MVW COMPLETE FORMUL PEDIA DRPS

MVW COMPLETE FORMUL D3000 CHEW

MVW COMPLETE FORMUL D3000 SFGL

MVW COMPLETE FORMUL D5000 CHEW

MVW COMPLETE FORMUL D5000 SFGL

MVW COMPLETE FORM MULTIVIT CHW

MVW COMPLETE FORM MULTIVI SFGL

MVW COMPLETE FORM MULTIVI SFGL

MYALEPT 11.3 MG (5 MG/ML) VIAL

MYCOPHENOLATE 200 MG/ML SUSP

MYCOPHENOLATE 250 MG CAPSULE

MYCOPHENOLATE 500 MG TABLET

MYCOPHENOLIC ACID DR 180 MG TB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

MYCOPHENOLIC ACID DR 360 MG TB

MYDAYIS ER 12.5 MG CAPSULE

MYDAYIS ER 25 MG CAPSULE

MYDAYIS ER 37.5 MG CAPSULE

MYDAYIS ER 50 MG CAPSULE

MYFORTIC 180 MG TABLET

MYFORTIC 360 MG TABLET

MYGLUCOHEALTH TEST STRIPS

MYGLUCOHEALTH MONITORING KIT

MYGLUCOHEALTH CONTROL SOLN PAK

MYGLUCOHEALTH 30G LANCETS

MYNATAL ULTRACAPLET

MYNATAL CAPSULE

MYNATAL ADVANCE TABLET

MYNATAL PLUS CAPTAB

MYNATAL-Z CAPTAB

MYNATE 90 PLUS CAPLET SA

MYNEPHROCAPS SOFTGEL

MYNEPHRON CAPSULE

MYRBETRIQ ER 25 MG TABLET

MYRBETRIQ ER 50 MG TABLET

MYSOLINE 250 MG TABLET

MYSOLINE 50 MG TABLET

MYVITALIFE SOFT-GEL CAPSULE

MYZILRA-28 TABLET

NABUMETONE 500 MG TABLET

NABUMETONE 750 MG TABLET

NADOLOL 20 MG TABLET

NADOLOL 40 MG TABLET

NADOLOL 80 MG TABLET

NADOLOL-BENDROFLU 40-5 MG TAB

NADOLOL-BENDROFLU 80-5 MG TAB

NAGLAZYME 5 MG/5 ML VIAL

NALFON 400 MG CAPSULE

NALFON 600 MG TABLET

NAMENDA 10 MG TABLET

NAMENDA 2 MG/ML SOLUTION

NAMENDA 5 MG TABLET

NAMENDA XR 14 MG CAPSULE

NAMENDA XR 21 MG CAPSULE

NAMENDA XR 28 MG CAPSULE

NAMENDA XR 7 MG CAPSULE

NAMZARIC 14 MG-10 MG CAPSULE

NAMZARIC 21 MG-10 MG CAPSULE

NAMZARIC 28 MG-10 MG CAPSULE

NAMZARIC 7 MG-10 MG CAPSULE

BD NANO 2 GEN PEN NDL 32GX4MM

NANO VM 1-3 POWDER

NANO VM 4-8 POWDER

NANOVM 9-18 POWDER

NANOVM T/F POWDER

NAPRELAN CR 375 MG TABLET

NAPRELAN CR 500 MG TABLET

NAPRELAN CR 750 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

NAPROSYN 125 MG/5 ML SUSPEN

NAPROSYN 500 MG TABLET

NAPROXEN 125 MG/5 ML SUSPEN

NAPROXEN 250 MG TABLET

NAPROXEN 375 MG TABLET

NAPROXEN 500 MG KIT

NAPROXEN 500 MG TABLET

NAPROXEN DR 375 MG TABLET

NAPROXEN DR 500 MG TABLET

NAPROXEN EC 375 MG TABLET

NAPROXEN EC 500 MG TABLET

CVS NAPROXEN SOD 220 MG CAPLET

CVS NAPROXEN SOD 220 MG TABLET

CVS NAPROXEN SODIUM 220 MG CAP

EQ NAPROXEN SOD 220 MG CAPLET

EQ NAPROXEN SOD 220 MG TABLET

EQ NAPROXEN SODIUM 220 MG CAP

EQL NAPROXEN SOD 220 MG CAPLET

EQL NAPROXEN SOD 220 MG TABLET

EQL NAPROXEN SODIUM 220 MG CAP

GNP NAPROXEN SOD 220 MG CAPLET

GNP NAPROXEN SOD 220 MG TABLET

GS NAPROXEN SOD 220 MG CAPLET

GS NAPROXEN SOD 220 MG TABLET

HM NAPROXEN SOD 220 MG CAPLET

HM NAPROXEN SODIUM 220 MG CAP

NAPROXEN SODIUM 220 MG CAPLET

NAPROXEN SODIUM 220 MG CAPSULE

NAPROXEN SODIUM 220 MG TABLET

NAPROXEN SODIUM 275 MG TAB

NAPROXEN SODIUM 550 MG TAB

PUB NAPROXEN SOD 220 MG TABLET

QC NAPROXEN SOD 220 MG TABLET

RA NAPROXEN SOD 220 MG TABLET

RA NAPROXEN SODIUM 220 MG CAP

SB NAPROXEN SOD 220 MG CAPLET

SM NAPROXEN SOD 220 MG CAPLET

SM NAPROXEN SOD 220 MG TABLET

SM NAPROXEN SODIUM 220 MG CAP

NAPROXEN SOD CR 375 MG TABLET

NAPROXEN SOD CR 500 MG TABLET

NAPROXEN SODIUM DS 550 MG TAB

NAPROXEN SOD ER 375 MG TABLET

NAPROXEN SOD ER 500 MG TABLET

NAPROXEN-ESOMEPRAZ DR 375-20MG

NAPROXEN-ESOMEPRAZ DR 500-20MG

NARDIL 15 MG TABLET

NASCOBAL 500 MCG NASAL SPRAY

NASONEX 50 MCG NASAL SPRAY

NATACHEW TABLET

NATAZIA 28 TABLET

NATEGLINIDE 120 MG TABLET

NATEGLINIDE 60 MG TABLET

NATELLE ONE CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

NATESTO NASAL 5.5 MG/0.122 GM

NATPARA 100 MCG DOSE CARTRIDGE

NATPARA 25 MCG DOSE CARTRIDGE

NATPARA 50 MCG DOSE CARTRIDGE

NATPARA 75 MCG DOSE CARTRIDGE

NATURE-THROID 113.75 MG TABLET

NATURE-THROID 130 MG TABLET

NATURE-THROID 146.25 MG TABLET

NATURE-THROID 16.25 MG TABLET

NATURE-THROID 162.5 MG TABLET

NATURE-THROID 195 MG TABLET

NATURE-THROID 260 MG TABLET

NATURE-THROID 32.5 MG TABLET

NATURE-THROID 325 MG TABLET

NATURE-THROID 48.75 MG TABLET

NATURE-THROID 65 MG TABLET

NATURE-THROID 81.25 MG TABLET

NATURE-THROID 97.5 MG TABLET

NEBUPENT 300 MG INHAL POWDER

NECON 0.5-35-28 TABLET

NECON 10-11-28 TABLET

NECON 1-35-28 TABLET

NECON 7-7-7-28 TABLET

NECON 1-50-28 TABLET

RELI ON 31G X 1/4" NEEDLES

NEEVODHA CAPSULE

NEFAZODONE HCL 100 MG TABLET

NEFAZODONE HCL 150 MG TABLET

NEFAZODONE HCL 200 MG TABLET

NEFAZODONE HCL 250 MG TABLET

NEFAZODONE HCL 50 MG TABLET

NEORAL 100 MG GELATIN CAPSULE

NEORAL 100 MG/ML SOLUTION

NEORAL 25 MG GELATIN CAPSULE

NEOVITE TABLET

NEPHPLEX RX TABLET

NEPHROCAPS SOFTGEL

NEPHRONEX LIQUID

NEPHRO-VITE TABLET

NEPHRO-VITE RX TABLET

NEPTAZANE 25 MG TABLET

NEPTAZANE 50 MG TABLET

NESINA 12.5 MG TABLET

NESINA 25 MG TABLET

NESINA 6.25 MG TABLET

NESTABS TABLET

NESTABS ABC PRENATAL COMBO PK

NESTABS DHA COMBO PACK

NESTABS ONE SOFTGEL

NEUPRO 1 MG/24 HR PATCH

NEUPRO 2 MG/24 HR PATCH

NEUPRO 3 MG/24 HR PATCH

NEUPRO 4 MG/24 HR PATCH

NEUPRO 6 MG/24 HR PATCH

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

NEUPRO 8 MG/24 HR PATCH

NEURONTIN 100 MG CAPSULE

NEURONTIN 250 MG/5 ML SOLN

NEURONTIN 250 MG/5 ML SOLUTION

NEURONTIN 300 MG CAPSULE

NEURONTIN 400 MG CAPSULE

NEURONTIN 600 MG TABLET

NEURONTIN 800 MG TABLET

NEUTEK 2TEK TEST STRIPS

NEVIRAPINE 200 MG TABLET

NEVIRAPINE 50 MG/5 ML SUSP

NEVIRAPINE ER 100 MG TABLET

NEVIRAPINE ER 400 MG TABLET

NEWGEN TABLET

RELION NEWTEK METER KIT

NEXA PLUS SOFTGEL

NEXAVAR 200 MG TABLET

NEXIUM DR 10 MG PACKET

NEXIUM DR 2.5 MG PACKET

NEXIUM DR 20 MG CAPSULE

NEXIUM DR 20 MG PACKET

NEXIUM DR 40 MG CAPSULE

NEXIUM DR 40 MG PACKET

NEXIUM DR 5 MG PACKET

NEXIUM 24HR 20 MG CAPSULE

NEXIUM 24HR 20 MG TABLET

NEXLETOL 180 MG TABLET

NIACIN 500 MG CAPSULE SA

NIACIN 500 MG TABLET

NIACIN ER 250 MG CAPSULE

NIACIN ER 500 MG CAPSULE

NIACIN SA 250 MG CAPSULE

NIACIN TR 250 MG CAPSULE

NIACIN TR 500 MG CAPSULE

GNP NIACIN 400 MG CAPSULE

NIACIN ER 1,000 MG TABLET

NIACIN ER 500 MG TABLET

NIACIN ER 750 MG TABLET

CVS NIACIN FLUSH FREE 500 MG

NIACIN FLUSH FREE 500 MG CAP

SV NIACIN FLUSH FREE 500 MG

NIACIN FLUSH-FREE 500 MG CAP

NIACIN INOSITOL 500 MG CAPSULE

NIACOR 500 MG TABLET

NIASPAN ER 1,000 MG TABLET

NIASPAN ER 500 MG TABLET

NIASPAN ER 750 MG TABLET

NICARDIPINE 20 MG CAPSULE

NICARDIPINE 30 MG CAPSULE

NICOMIDE TABLET

NICOMIDE TABLET

NIFEDIPINE 10 MG CAPSULE

NIFEDIPINE 20 MG CAPSULE

NIFEDIPINE ER 30 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

NIFEDIPINE ER 60 MG TABLET

NIFEDIPINE ER 90 MG TABLET

NIKKI 3 MG-0.02 MG TABLET

NILANDRON 150 MG TABLET

NILUTAMIDE 150 MG TABLET

NINLARO 2.3 MG CAPSULE

NINLARO 3 MG CAPSULE

NINLARO 4 MG CAPSULE

NISOLDIPINE ER 17 MG TABLET

NISOLDIPINE ER 20 MG TABLET

NISOLDIPINE ER 25.5 MG TABLET

NISOLDIPINE ER 30 MG TABLET

NISOLDIPINE ER 34 MG TABLET

NISOLDIPINE ER 40 MG TABLET

NISOLDIPINE ER 8.5 MG TABLET

NITISINONE 10 MG CAPSULE

NITISINONE 2 MG CAPSULE

NITISINONE 5 MG CAPSULE

NITRO-BID 2% OINTMENT

NITRO-DUR 0.1 MG/HR PATCH

NITRO-DUR 0.2 MG/HR PATCH

NITRO-DUR 0.3 MG/HR PATCH

NITRO-DUR 0.4 MG/HR PATCH

NITRO-DUR 0.6 MG/HR PATCH

NITRO-DUR 0.8 MG/HR PATCH

NITROGLYCERIN 0.3 MG TABLET SL

NITROGLYCERIN 0.4 MG TABLET SL

NITROGLYCERIN 0.6 MG TABLET SL

NITROGLYCERIN 400 MCG SPRAY

NITROGLYCERIN ER 2.5 MG CAP

NITROGLYCERIN ER 6.5 MG CAP

NITROGLYCERIN ER 9 MG CAPSULE

NITROGLYCERIN LINGUAL 0.4 MG

NITROGLYCERIN 0.1 MG/HR PATCH

NITROGLYCERIN 0.2 MG/HR PATCH

NITROGLYCERIN 0.4 MG/HR PATCH

NITROGLYCERIN 0.6 MG/HR PATCH

NITROLINGUAL 0.4 MG SPRAY

NITROMIST 400 MCG SPRAY

NITROSTAT 0.3 MG TABLET SL

NITROSTAT 0.4 MG TABLET SL

NITROSTAT 0.6 MG TABLET SL

NITRO-TIME ER 2.5 MG CAPSULE

NITRO-TIME ER 6.5 MG CAPSULE

NITRO-TIME ER 9 MG CAPSULE

NITYR 10 MG TABLET

NITYR 2 MG TABLET

NITYR 5 MG TABLET

NIVA-FOL TABLET

NIVA-PLUS TABLET

NIZATIDINE 15 MG/ML SOLUTION

NIZATIDINE 150 MG CAPSULE

NIZATIDINE 300 MG CAPSULE

NO FLUSH NIACIN 400 MG CAP

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

NOCDURNA 27.7 MCG TABLET SL

NOCDURNA 55.3 MCG TABLET SL

NOCTIVA 0.83 MCG/0.1 ML SPRAY

NOCTIVA 1.66 MCG/0.1 ML SPRAY

NORA-BE TABLET

NORDITROPIN FLEXPRO 10 MG/1.5

NORDITROPIN FLEXPRO 15 MG/1.5

NORDITROPIN FLEXPRO 30 MG/3 ML

NORDITROPIN FLEXPRO 5 MG/1.5

NORETHINDRONE 0.35 MG TABLET

NORETHINDRONE 5 MG TABLET

NORETH-EE-FE 1.5-0.03MG(21)-75

NORETHIND-ETH ESTRAD 0.5-2.5

NORETHIND-ETH ESTRAD 1-0.02 MG

NORETHIN-EE 1.5-0.03 MG(21) TB

NORETHIN-ETH ESTRAD 1 MG-5 MCG

NORET-ESTR-FE 0.4-0.035(21)-75

NORETHIN-ESTRA-FE 0.8-0.025 MG

NORETH-ESTRAD-FE 1-0.02(21)-75

NORETH-ESTRAD-FE 1-0.02(24)-75

NORG-EE 0.18-0.215-0.25/0.025

NORG-EE 0.18-0.215-0.25/0.035

NORG-ETHIN ESTRA 0.25-0.035 MG

NORG-ETHIN ESTR 0.5-0.05 MG TB

NORINYL 1-35 28 TABLET

NORLYDA 0.35 MG TABLET

NORLYROC 0.35 MG TABLET

NORPACE 100 MG CAPSULE

NORPACE 150 MG CAPSULE

NORPACE CR 100 MG CAPSULE

NORPACE CR 150 MG CAPSULE

NORPRAMIN 10 MG TABLET

NORPRAMIN 25 MG TABLET

NORTHERA 100 MG CAPSULE

NORTHERA 200 MG CAPSULE

NORTHERA 300 MG CAPSULE

NORTREL 0.5-35-28 TABLET

NORTREL 1-35 21 TABLET

NORTREL 1-35 28 TABLET

NORTREL 7-7-7-28 TABLET

NORTRIPTYLINE 10 MG/5 ML SOLN

NORTRIPTYLINE 20 MG/10 ML SOLN

NORTRIPTYLINE HCL 10 MG CAP

NORTRIPTYLINE HCL 25 MG CAP

NORTRIPTYLINE HCL 50 MG CAP

NORTRIPTYLINE HCL 75 MG CAP

NORVASC 10 MG TABLET

NORVASC 2.5 MG TABLET

NORVASC 5 MG TABLET

NORVIR 100 MG POWDER PACKET

NORVIR 100 MG TABLET

NORVIR 80 MG/ML SOLUTION

NOURIANZ 20 MG TABLET

NOURIANZ 40 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

NOVA MAX BLOOD GLUCOSE METER

NOVA MAX GLUCOSE CONTROL SOLN

NOVA MAX GLUCOSE TEST STRIP

NOVA SAFETY 23G LANCETS

NOVA SAFETY 28G LANCETS

NOVA SUREFLEX THIN LANCETS

NOVAFERRUM PED MULTIVIT-IRON

NOVAMAX PLUS KETONE TEST STRIP

NOVAMAX PLUS GLU-KET CTRL SOLN

NOVAMV MULTIVITAMIN DROP

NOVOEIGHT 1,000 UNIT VIAL

NOVOEIGHT 1,500 UNIT VIAL

NOVOEIGHT 2,000 UNIT VIAL

NOVOEIGHT 250 UNIT VIAL

NOVOEIGHT 3,000 UNIT VIAL

NOVOEIGHT 500 UNIT VIAL

NOVOFINE 30G X 1/3" NEEDLES

NOVOFINE 32G NEEDLES

NOVOFINE AUTOCOVER 30G NEEDLE

NOVOFINE PLUS PEN NDL 32GX1/6"

NOVOLIN 70-30 100 UNIT/ML VIAL

RELION NOVOLIN 70-30 VIAL

NOVOLIN 70-30 FLEXPEN

RELION NOVOLIN 70-30 FLEXPEN

NOVOLIN N 100 UNIT/ML VIAL

RELION NOVOLIN N 100 UNIT/ML

NOVOLIN N 100 UNIT/ML FLEXPEN

RELION NOVOLIN N U-100 FLEXPEN

NOVOLIN R 100 UNIT/ML VIAL

RELION NOVOLIN R 100 UNIT/ML

NOVOLIN R 100 UNIT/ML FLEXPEN

RELION NOVOLIN R U-100 FLEXPEN

NOVOLOG 100 UNIT/ML CARTRIDGE

NOVOLOG 100 UNIT/ML VIAL

NOVOLOG 100 UNIT/ML FLEXPEN

NOVOLOG 100 UNITS/ML FLEXPEN

NOVOLOG MIX 70-30 VIAL

NOVOLOG MIX 70-30 FLEXPEN

NOVOPEN 3 INSULIN DEVICE

NOVOPEN ECHO INSULIN DEVICE

NOVOTWIST NEEDLE 32G 5MM

NP THYROID 120 MG TABLET

NP THYROID 15 MG TABLET

NP THYROID 30 MG TABLET

NP THYROID 60 MG TABLET

NP THYROID 90 MG TABLET

NPLATE 125 MCG VIAL

NPLATE 250 MCG VIAL

NPLATE 500 MCG VIAL

NUBEQA 300 MG TABLET

NUCALA 100 MG VIAL

NUCALA 100 MG/ML AUTO-INJECTOR

NUCALA 100 MG/ML SYRINGE

NULEV 0.125 MG CHEWABLE MELT

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

NULL

NULOJIX 250 MG VIAL

NUPLAZID 10 MG TABLET

NUPLAZID 17 MG TABLET

NUPLAZID 34 MG CAPSULE

NUTRICAP CAPLET

NUTRIVIT LIQUID

NUTROPIN AQ PEN CARTRIDGE

NUTROPIN AQ NUSPIN 10 INJECTOR

NUTROPIN AQ NUSPIN 20 INJECTOR

NUTROPIN AQ NUSPIN 5 INJECTOR

NUVARING VAGINAL RING

NUVIGIL 150 MG TABLET

NUVIGIL 200 MG TABLET

NUVIGIL 250 MG TABLET

NUVIGIL 50 MG TABLET

NUWIQ 1,000 UNIT VIAL

NUWIQ 1,000 UNIT VIAL PACK

NUWIQ 2,000 UNIT VIAL

NUWIQ 2,000 UNIT VIAL PACK

NUWIQ 2,500 UNIT VIAL

NUWIQ 2,500 UNIT VIAL PACK

NUWIQ 250 UNIT VIAL

NUWIQ 250 UNIT VIAL PACK

NUWIQ 3,000 UNIT VIAL

NUWIQ 3,000 UNIT VIAL PACK

NUWIQ 4,000 UNIT VIAL

NUWIQ 4,000 UNIT VIAL PACK

NUWIQ 500 UNIT VIAL

NUWIQ 500 UNIT VIAL PACK

OB COMPLETE CAPLET

OB COMPLETE GOLD SOFTGEL

OB COMPLETE ONE SOFTGEL

OB COMPLETE PETITE SOFTGEL

OB COMPLETE PREMIER TABLET

OB COMPLETE WITH DHA SOFTGEL

OBSTETRIX DHA COMBO PAK

OBSTETRIX EC CAPLET

OBSTETRIX ONE SOFTGEL

OBTREX DHA PRENATAL VITAMIN

O-CAL FA TABLET

O-CAL PRENATAL TABLET

OCALIVA 10 MG TABLET

OCALIVA 5 MG TABLET

OCELLA 3 MG-0.03 MG TABLET

OCREVUS 300 MG/10 ML VIAL

OCTAGAM 10% VIAL

OCTAGAM 5% VIAL

OCTREOTIDE 1,000 MCG/5 ML VIAL

OCTREOTIDE 1,000 MCG/ML VIAL

OCTREOTIDE 5,000 MCG/5 ML VIAL

OCTREOTIDE ACET 0.05 MG/ML VL

OCTREOTIDE ACET 100 MCG/ML AMP

OCTREOTIDE ACET 100 MCG/ML SYR

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

OCTREOTIDE ACET 100 MCG/ML VL

OCTREOTIDE ACET 200 MCG/ML VL

OCTREOTIDE ACET 50 MCG/ML AMP

OCTREOTIDE ACET 50 MCG/ML SYR

OCTREOTIDE ACET 50 MCG/ML VIAL

OCTREOTIDE ACET 500 MCG/ML AMP

OCTREOTIDE ACET 500 MCG/ML SYR

OCTREOTIDE ACET 500 MCG/ML VL

OCULAR VITAMINS TABLET

OCUTABS TABLET

OCUVEL CAPSULE

OCUVITE ADULT 50 PLUS SOFTGEL

OCUVITE ADULT 50 PLUS SOFTGEL

OCUVITE EYE PLUS MULTI TABLET

OCUVITE WITH LUTEIN TABLET

ODACTRA 12 SQ-HDM SL TABLET

ODEFSEY TABLET

ODOMZO 200 MG CAPSULE

OFEV 100 MG CAPSULE

OFEV 150 MG CAPSULE

OGESTREL TABLET

OGIVRI 150 MG VIAL

OGIVRI 420 MG VIAL

OLANZAPINE 10 MG TABLET

OLANZAPINE 15 MG TABLET

OLANZAPINE 2.5 MG TABLET

OLANZAPINE 20 MG TABLET

OLANZAPINE 5 MG TABLET

OLANZAPINE 7.5 MG TABLET

OLANZAPINE ODT 10 MG TABLET

OLANZAPINE ODT 15 MG TABLET

OLANZAPINE ODT 20 MG TABLET

OLANZAPINE ODT 5 MG TABLET

OLANZAPINE-FLUOXETINE 12-25 MG

OLANZAPINE-FLUOXETINE 12-50 MG

OLANZAPINE-FLUOXETINE 3-25 MG

OLANZAPINE-FLUOXETINE 6-25 MG

OLANZAPINE-FLUOXETINE 6-50 MG

OLIVE TREE 1:20 (W/V) VIAL

OLMESARTAN MEDOXOMIL 20 MG TAB

OLMESARTAN MEDOXOMIL 40 MG TAB

OLMESARTAN MEDOXOMIL 5 MG TAB

OLMSRTN-AMLDPN-HCTZ 20-5-12.5

OLMSRTN-AMLDPN-HCTZ 40-10-12.5

OLMSRTN-AMLDPN-HCTZ 40-10-25MG

OLMSRTN-AMLDPN-HCTZ 40-5-12.5

OLMSRTN-AMLDPN-HCTZ 40-5-25 MG

OLMESARTAN-HCTZ 20-12.5 MG TAB

OLMESARTAN-HCTZ 40-12.5 MG TAB

OLMESARTAN-HCTZ 40-25 MG TAB

OLUMIANT 1 MG TABLET

OLUMIANT 2 MG TABLET

OMEGA-3 ETHYL ESTERS 1 GM CAP

OMEPPI 20 MG-1,100 MG CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

OMEPPI 40 MG-1,100 MG CAPSULE

CVS OMEPRAZOLE DR 20 MG TABLET

EQ OMEPRAZOLE DR 20 MG TABLET

EQL OMEPRAZOLE DR 20 MG TABLET

GNP OMEPRAZOLE DR 20 MG TABLET

GS OMEPRAZOLE DR 20 MG TABLET

HM OMEPRAZOLE DR 20 MG TABLET

OMEPRAZOLE DR 10 MG CAPSULE

OMEPRAZOLE DR 20 MG CAPSULE

OMEPRAZOLE DR 20 MG TABLET

OMEPRAZOLE DR 40 MG CAPSULE

PUB OMEPRAZOLE DR 20 MG TABLET

RA OMEPRAZOLE DR 20 MG TABLET

SB OMEPRAZOLE DR 20 MG TABLET

SM OMEPRAZOLE DR 20 MG TABLET

SW OMEPRAZOLE DR 20 MG TABLET

CVS OMEPRAZOLE MAG DR 20.6 MG

EQ OMEPRAZOLE MAG DR 20.6 MG

OMEPRAZOLE MAG DR 20 MG CAP

OMEPRAZOLE MAG DR 20.6 MG CAP

QC OMEPRAZOLE MAG DR 20.6 MG

CVS OMEPRAZOLE-BICARB 20-1,100

OMEPRAZOLE-BICARB 20-1,100 CAP

OMEPRAZOLE-BICARB 20-1,680 PKT

OMEPRAZOLE-BICARB 40-1,100 CAP

OMEPRAZOLE-BICARB 40-1,680 PKT

OMNARIS 50 MCG NASAL SPRAY

OMNICAP TABLET

OMNIPOD 10 PACK

OMNIPOD 5 PACK POD

OMNIPOD DASH 5 PACK POD

OMNITROPE 10 MG/1.5 ML CRTG

OMNITROPE 5 MG/1.5 ML CRTG

OMNITROPE 5.8 MG VIAL

OMNIVEX TABLET

ON CALL EXPRESS CTRL SOLN PAK

ON CALL EXPRESS METER

ON CALL EXPRESS METER SYSTEM

ON CALL EXPRESS TEST STRIP

ON CALL 30G LANCET

ON CALL PLUS CONTROL SOLUTION

ON CALL PLUS 30G LANCET

ON CALL PLUS METER

ON CALL PLUS TEST STRIP

ON CALL VIVID CONTROL SOLUTION

ON CALL VIVID METER

ON CALL VIVID PAL METER

ON CALL VIVID TEST STRIP

ONCE DAILY TABLET

ONCOVITE TABLET

ONE A DAY PRENATAL DHA PACK

GNP ONE DAILY TABLET

ONE DAILY TABLET

ONE DAILY WOMEN 50 PLUS TAB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ONE DAILY COMPLETE TABLET

ONE DAILY COMPLETE TABLET

RA ONE DAILY ENERGY TABLET

ONE DAILY ESSENTIAL TABLET

CVS ONE DAILY ESSENTIAL TABLET

ONE DAILY ESSENTIAL TABLET

RA ONE DAILY ESSENTIAL TABLET

ONE DAILY FOR MEN TABLET

ONE DAILY FOR MEN 50+ ADV TAB

ONE DAILY FOR WOMEN TABLET

ONE DAILY FOR WOMEN 50+ ADV TB

ONE DAILY GUMMY VITES GUMMIE

ONE DAILY HEALTHY WEIGHT TAB

ONE DAILY MAXIMUM TABLET

RA ONE DAILY MAXIMUM TABLET

EQ ONE DAILY MEN'S TABLET

EQ ONE DAILY MEN'S 50 PLUS TAB

EQL ONE DAILY MENS 50 PLUS ADV

ONE DAILY MEN'S 50 PLUS D3 TAB

RA ONE DAILY MEN'S 50 PLUS D3

ONE DAILY MEN'S 50+ TABLET

CVS ONE DAILY MEN'S HEALTH TAB

ONE DAILY MEN'S HEALTH TABLET

ONE DAILY MULTIVITAMIN TAB

ONE DAILY MULTIVITAMIN TABLET

SM ONE DAILY MULTIVITAMIN TAB

ONE DAILY MULTIVITAMIN-IRON TB

ONE DAILY MULTIVIT-MINERAL TAB

ONE DAILY PLUS IRON TABLET

ONE DAILY WITH MINERALS TABLET

HM ONE DAILY PRENATAL COMBO PK

RA ONE DAILY PRENATAL DHA PACK

SM ONE DAILY PRENATAL COMBO PK

ONE DAILY WITH IRON-CALCIUM TB

ONCE DAILY WITH IRON TABLET

ONE DAILY WOMEN'S TABLET

EQ ONE DAILY WOMEN'S TABLET

RA ONE DAILY WOMEN'S TABLET

ONE DAILY WOMENS 50 PLUS TAB

CVS ONE DAILY WOMEN'S 50 PLUS

EQL ONE DAILY WOMEN'S 50 PLUS

HM ONE DAILY WOMEN'S 50 PLUS

ONE DAILY WOMEN'S 50+ TABLET

CVS ONE DAILY WOMEN'S FORMULA

EQ ONE DAILY WOMEN'S HEALTH TB

ONE DAILY WOMEN'S HEALTH TAB

ONE DAILY WOMEN'S MULTIVITAMIN

ONE-A-DAY CHOLESTEROL PLUS TAB

ONE-A-DAY ENERGY TABLET

ONE-A-DAY ESSENTIAL TABLET

ONE-A-DAY KID'S GUMMIES

ONE-A-DAY MAX FORMULA TAB

ONE-A-DAY MEN VITACRAVES GUMMY

ONE-A-DAY MENOPAUSE FORMULA TB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ONE-A-DAY MEN'S TABLET

ONE-A-DAY MEN'S 50 PLUS TABLET

ONE-A-DAY MEN'S 50 PLUS TABLET

ONE-A-DAY PROACTIVE 65 PLUS TB

ONE-A-DAY TEEN ADVANTAGE TAB

ONE-A-DAY TEEN ADVANTAGE TAB

ONE-A-DAY TEEN HER VITACRAVES

ONE-A-DAY TEEN HIM VITACRAVES

ONE-A-DAY VITACRAVES GUMMIES

ONE-A-DAY VITACRAVES IMMUNITY

ONE-A-DAY VITACRAVES OMEGA-3

ONE-A-DAY VITACRAVES SOUR GMMY

ONE-A-DAY WEIGHTSMART TABLET

ONE-A-DAY WOMEN VITACRAVES

ONE-A-DAY WOMEN'S TABLET

ONE-A-DAY WOMEN'S TABLET

ONE-A-DAY WOMEN'S TABLET

ONE-A-DAY WOMEN'S 50 PLUS TAB

ONE-A-DAY WOMEN'S HEALTHY SKIN

ONE-A-DAY WOMEN'S PETITES TAB

ONE-A-DAY PRENATAL 1 DHA SFGL

ONE-DAILY MULTI-VIT POWDER PKT

ONE-DAILY MULTI-VITAMIN TAB

ONE-DAILY MULTI-VIT-IRON TAB

ONE-DAILY MULTIVIT-MINERAL PWD

ONE-TABLET-DAILY

ONETOUCH DELICA 30G LANCETS

ONETOUCH DELICA 33G LANCETS

ONETOUCH DELICA LANCING DEV

ONETOUCH DELICA PLUS LANC DEV

ONETOUCH DELICA PLUS 30G LANCT

ONETOUCH DELICA PLUS 33G LANCT

ONETOUCH ULTRASOFT LANCETS

ONETOUCH SURESOFT 18G LANC DEV

ONETOUCH SURESOFT 21G LANC DEV

ONETOUCH SURESOFT 28G LANC DEV

ONETOUCH ULTRA BLUE TEST STRP

ONETOUCH ULTRA CONTROL SOLN

ONETOUCH ULTRA2 GLUCOSE SYST

ONETOUCH ULTRAMINI METER

ONETOUCH VERIO TEST STRIP

ONETOUCH VERIO HIGH CNTRL SOL

ONETOUCH VERIO MID CNTRL SOLN

ONETOUCH VERIO METER SYSTEM

ONETOUCH VERIO FLEX SYSTEM KIT

ONETOUCH VERIO IQ METER

ONETOUCH VERIO SYNC SYST KIT

ONEVITE TABLET

ONFI 10 MG TABLET

ONFI 2.5 MG/ML SUSPENSION

ONFI 20 MG TABLET

ONGLYZA 2.5 MG TABLET

ONGLYZA 5 MG TABLET

ONPATTRO 10 MG/5 ML VIAL

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ON-THE-GO 30G LANCETS

SHOPKO ON-THE-GO 30G LANCETS

OPDIVO 100 MG/10 ML VIAL

OPDIVO 240 MG/24 ML VIAL

OPDIVO 40 MG/4 ML VIAL

OPSUMIT 10 MG TABLET

OPTISOURCE TABLET CHEWABLE

OPTIUM TEST STRIP

OPTIUM EZ TEST STRIP

SM OPTI-VITAMIN TABLET

OPTIVITE P.M.T. TABLET

OPTUMRX GLUCOSE CONTROL SOLN

OPTUMRX TEST STRIP

OPTUMRX BLOOD GLUCOSE METER

OPTUMRX BLOOD GLUCOSE SYSTEM

OPURITY MULTIVITAMIN TAB CHEW

ORALAIR 300 IR SUBLINGUAL TAB

ORAP 1 MG TABLET

ORAP 2 MG TABLET

ORENCIA 125 MG/ML SYRINGE

ORENCIA 50 MG/0.4 ML SYRINGE

ORENCIA 87.5 MG/0.7 ML SYRINGE

ORENCIA 250 MG VIAL

ORENCIA CLICKJECT 125 MG/ML

ORENITRAM ER 0.125 MG TABLET

ORENITRAM ER 0.25 MG TABLET

ORENITRAM ER 1 MG TABLET

ORENITRAM ER 2.5 MG TABLET

ORENITRAM ER 5 MG TABLET

ORFADIN 10 MG CAPSULE

ORFADIN 2 MG CAPSULE

ORFADIN 20 MG CAPSULE

ORFADIN 4 MG/ML SUSPENSION

ORFADIN 5 MG CAPSULE

ORILISSA 150 MG TABLET

ORKAMBI 100 MG-125 MG TABLET

ORKAMBI 100-125 MG GRANULE PKT

ORKAMBI 150-188 MG GRANULE PKT

ORKAMBI 200 MG-125 MG TABLET

ORSYTHIA-28 TABLET

ORTHO MICRONOR 0.35 MG TABLET

ORTHO TRI-CYCLEN 28 TABLET

ORTHO TRI-CYCLEN LO TABLET

ORTHO-CYCLEN 28 TABLET

ORTHO-NOVUM 1-35-28 TABLET

ORTHO-NOVUM 7-7-7-28 TABLET

OSCIMIN 0.125 MG ODT

OSCIMIN 0.125 MG TABLET

OSCIMIN SL 0.125 MG TABLET

OSCIMIN SR 0.375 MG TABLET

OSENI 12.5-15 MG TABLET

OSENI 12.5-30 MG TABLET

OSENI 12.5-45 MG TABLET

OSENI 25-15 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

OSENI 25-30 MG TABLET

OSENI 25-45 MG TABLET

OSMOLEX ER 129 MG TABLET

OSMOLEX ER 193 MG TABLET

OSMOLEX ER 258 MG TABLET

OSPHENA 60 MG TABLET

OTEZLA 30 MG TABLET

OTREXUP 10 MG/0.4 ML AUTO-INJ

OTREXUP 12.5 MG/0.4 ML AUTOINJ

OTREXUP 15 MG/0.4 ML AUTO-INJ

OTREXUP 17.5 MG/0.4 ML AUTOINJ

OTREXUP 20 MG/0.4 ML AUTO-INJ

OTREXUP 22.5 MG/0.4 ML AUTOINJ

OTREXUP 25 MG/0.4 ML AUTO-INJ

OTREXUP 7.5 MG/0.4 ML AUTO-INJ

OVCON-35 28 TABLET

OXANDRIN 10 MG TABLET

OXANDRIN 2.5 MG TABLET

OXANDROLONE 10 MG TABLET

OXANDROLONE 2.5 MG TABLET

OXAPROZIN 600 MG CAPLET

OXAPROZIN 600 MG TABLET

OXBRYTA 500 MG TABLET

OXCARBAZEPINE 150 MG TABLET

OXCARBAZEPINE 300 MG TABLET

OXCARBAZEPINE 300 MG/5 ML SUSP

OXCARBAZEPINE 600 MG TABLET

OXSORALEN-ULTRA 10 MG CAP

OXTELLAR XR 150 MG TABLET

OXTELLAR XR 300 MG TABLET

OXTELLAR XR 600 MG TABLET

OXYBUTYNIN 5 MG TABLET

OXYBUTYNIN 5 MG/5 ML SYRUP

OXYBUTYNIN CL ER 10 MG TABLET

OXYBUTYNIN CL ER 15 MG TABLET

OXYBUTYNIN CL ER 5 MG TABLET

OXYTROL 3.9 MG/24HR PATCH

OXYTROL FOR WOMEN 3.9 MG/24HR

OZEMPIC 0.25-0.5 MG DOSE PEN

OZEMPIC 1 MG DOSE PEN

OZOBAX 5 MG/5 ML SOLUTION

PACERONE 100 MG TABLET

PACERONE 200 MG TABLET

PACERONE 400 MG TABLET

PADCEV 20 MG VIAL

PADCEV 30 MG VIAL

PALFORZIA 12 MG (LEVEL 3)

PALFORZIA 120 MG (LEVEL 7)

PALFORZIA 160 MG (LEVEL 8)

PALFORZIA 20 MG (LEVEL 4)

PALFORZIA 200 MG (LEVEL 9)

PALFORZIA 240 MG (LEVEL 10)

PALFORZIA 3 MG (LEVEL 1)

PALFORZIA 300 MG (LEVEL 11)

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

PALFORZIA 300 MG (MAINTENANCE)

PALFORZIA 40 MG (LEVEL 5)

PALFORZIA 6 MG (LEVEL 2)

PALFORZIA 80 MG (LEVEL 6)

PALIPERIDONE ER 1.5 MG TABLET

PALIPERIDONE ER 3 MG TABLET

PALIPERIDONE ER 6 MG TABLET

PALIPERIDONE ER 9 MG TABLET

PALYNZIQ 10 MG/0.5 ML SYRINGE

PALYNZIQ 20 MG/ML SYRINGE

PAMELOR 10 MG CAPSULE

PAMELOR 25 MG CAPSULE

PAMELOR 50 MG CAPSULE

PAMELOR 75 MG CAPSULE

PANCREAZE DR 10,500 UNIT CAP

PANCREAZE DR 16,800 UNIT CAP

PANCREAZE DR 2,600 UNIT CAP

PANCREAZE DR 21,000 UNIT CAP

PANCREAZE DR 4,200 UNIT CAP

PANTOPRAZOLE SOD DR 20 MG TAB

PANTOPRAZOLE SOD DR 40 MG TAB

PANZYGA 10% (1 G/10 ML) VIAL

PANZYGA 10% (10 G/100 ML) VIAL

PANZYGA 10% (2.5 G/25 ML) VIAL

PANZYGA 10% (20 G/200 ML) VIAL

PANZYGA 10% (30 G/300 ML) VIAL

PANZYGA 10% (5 G/50 ML) VIAL

PARADIGM RESERVOIR 1.8 ML

PARADIGM RESERVOIR 3 ML

PARADIGM REAL-TIME SYSTEM

PARAGARD T 380-A IUD

PARICALCITOL 1 MCG CAPSULE

PARICALCITOL 10 MCG/2 ML VIAL

PARICALCITOL 2 MCG CAPSULE

PARICALCITOL 2 MCG/ML VIAL

PARICALCITOL 4 MCG CAPSULE

PARICALCITOL 5 MCG/ML VIAL

PARLODEL 2.5 MG TABLET

PARLODEL 5 MG CAPSULE

PARNATE 10 MG TABLET

PAROXETINE CR 12.5 MG TABLET

PAROXETINE CR 25 MG TABLET

PAROXETINE CR 37.5 MG TABLET

PAROXETINE ER 12.5 MG TABLET

PAROXETINE ER 25 MG TABLET

PAROXETINE ER 37.5 MG TABLET

PAROXETINE HCL 10 MG TABLET

PAROXETINE HCL 20 MG TABLET

PAROXETINE HCL 30 MG TABLET

PAROXETINE HCL 40 MG TABLET

PAROXETINE MESYLATE 7.5 MG CAP

PARSABIV 10 MG/2 ML VIAL

PARSABIV 2.5 MG/0.5 ML VIAL

PARSABIV 5 MG/ML VIAL

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

PAXIL 10 MG TABLET

PAXIL 10 MG/5 ML SUSPENSION

PAXIL 20 MG TABLET

PAXIL 30 MG TABLET

PAXIL 40 MG TABLET

PAXIL CR 12.5 MG TABLET

PAXIL CR 25 MG TABLET

PAXIL CR 37.5 MG TABLET

PECAN POLLEN 1:20 (W/V) VIAL

PEDIA POLY-VITE DROPS

PEDIA POLY-VITE WITH IRON DROP

PEDIA TRI-VITE DROP

PEGANONE 250 MG TABLET

EQL PEN 8MM 31G X 5/16" NEEDLE

FIFTY50 PEN 31G X 3/16" NEEDLE

FIFTY50 PEN 31G X 5/16" NEEDLE

FIFTY50 PEN NEEDLE 32G X 1/4"

FIFTY50 PEN NEEDLE 32G X 5/32"

GNP CLICKFINE PEN NDL 31GX1/4"

GNP CLICKFINE PEN NDL 31GX5/16

GS PEN NEEDLE 31G X 5/16"

GS PEN NEEDLE 31G X 5MM

GS PEN NEEDLE 31G X 6MM

GS PEN NEEDLE 31G X 8MM

GS PEN NEEDLE 32G X 4MM

GS PEN NEEDLE 32G X 6MM

KRO PEN NEEDLE 4MM X 32G

KRO PEN NEEDLE 4MM X 33G

KRO PEN NEEDLE 5MM X 31G

KRO PEN NEEDLE 6MM X 31G

KRO PEN NEEDLE 8MM X 31G

KROGER PEN NEEDLES 31G X 5/16"

LIVE BETTER PEN NEEDLES 8MM

MS PEN NEEDLE 6MM 31G

PEN NEEDLE 29G 12MM

PEN NEEDLE 30G X 5/16"

PEN NEEDLE 31G 5MM

PEN NEEDLE 31G 6MM

PEN NEEDLE 31G 8MM

PEN NEEDLE 31G X 1/4"

PEN NEEDLE 31G X 3/16"

PEN NEEDLE 31G X 5/16"

PEN NEEDLE 31G X 8MM

PEN NEEDLE 32G 4MM

PEN NEEDLE 32G X 1/4"

PEN NEEDLE 32G X 3/16"

PEN NEEDLE 32G X 5/32"

PEN NEEDLE 6MM 31G

PEN NEEDLES 12MM 29G

PEN NEEDLES 8MM 31G

PUB PEN 12MM 29G NEEDLES

PUB PEN 8MM 31G NEEDLES

PUB PEN NEEDLE 6MM 31G

RA PEN NEEDLE 31GX3/16"

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

RA PEN NEEDLE 31GX5/16"

RELION MINI PEN 31G X 1/4" NDL

RELION PEN 29G NEEDLE

RELION PEN 31G NEEDLE

RELION PEN NEEDLE 29GX1/2"

RELION PEN NEEDLE 31GX1/4"

RELION PEN NEEDLE 31GX5/16"

RELION PEN NEEDLE 32GX5/32"

TODAY'S HLTH PN NEEDLE 6MM 31G

LEADER PEN NEEDLES 12MM 29G

PEN NEEDLES 12MM 29G

PEN NEEDLES 4MM 32G

PEN NEEDLES 5MM 31G

PEN NEEDLES 6MM 31G

PEN NEEDLES 8MM 31G

PENICILLAMINE 250 MG CAPSULE

PENICILLAMINE 250 MG TABLET

PENICILLIUM NOTATUM 10,000/ML

PENICILLIUM NOTATUM 20,000/ML

PENTAMIDINE 300 MG INHAL POWDR

PENTASA 250 MG CAPSULE

PENTASA 500 MG CAPSULE

PENTIPS PEN NEEDLE 29GX1/2"

PENTIPS PEN NEEDLE 31GX1/4"

PENTIPS PEN NEEDLE 31GX3/16"

PENTIPS PEN NEEDLE 31GX5/16"

PENTIPS PEN NEEDLE 32GX5/32"

PENTIPS PEN NEEDLE 6MM 31G

PENTOXIFYLLINE ER 400 MG TAB

PEPCID 20 MG TABLET

PEPCID 40 MG TABLET

PEPCID 40 MG/5 ML ORAL SUSP

PEPCID AC 10 MG TABLET

PEPCID AC 20 MG TABLET

PERFOROMIST 20 MCG/2 ML SOLN

PERINDOPRIL ERBUMINE 2 MG TAB

PERINDOPRIL ERBUMINE 4 MG TAB

PERINDOPRIL ERBUMINE 8 MG TAB

PERIOMED 0.63% DENTAL RINSE

PERPHENAZINE 16 MG TABLET

PERPHENAZINE 2 MG TABLET

PERPHENAZINE 4 MG TABLET

PERPHENAZINE 8 MG TABLET

PERPHEN-AMITRIP 2 MG-10 MG TAB

PERPHEN-AMITRIP 2 MG-25 MG TAB

PERPHEN-AMITRIP 4 MG-10 MG TAB

PERPHEN-AMITRIP 4 MG-25 MG TAB

PERPHEN-AMITRIP 4 MG-50 MG TAB

PERRY PRENATAL CAPSULE

PERSERIS ER 120 MG SYRINGE KIT

PERSERIS ER 90 MG SYRINGE KIT

PERTZYE DR 16,000 UNIT CAPSULE

PERTZYE DR 24,000 UNIT CAPSULE

PERTZYE DR 4,000 UNIT CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

PERTZYE DR 8,000 UNIT CAPSULE

PEXEVA 10 MG TABLET

PEXEVA 20 MG TABLET

PEXEVA 30 MG TABLET

PEXEVA 40 MG TABLET

PH 12 DILUENT FOR FLOLAN

PHARMACIST CHOICE TEST STRIPS

PHARMACIST CHOICE GLUCOSE SYS

PHARMACIST CHOICE MINI GLU SYS

PHENELZINE SULFATE 15 MG TAB

PHENOBARBITAL 100 MG TABLET

PHENOBARBITAL 15 MG TABLET

PHENOBARBITAL 16.2 MG TABLET

PHENOBARBITAL 20 MG/5 ML ELIX

PHENOBARBITAL 20 MG/5 ML SOLN

PHENOBARBITAL 30 MG TABLET

PHENOBARBITAL 32.4 MG TABLET

PHENOBARBITAL 60 MG TABLET

PHENOBARBITAL 64.8 MG TABLET

PHENOBARBITAL 97.2 MG TABLET

PHENOBARBITAL-BELLADONNA ELIXR

PHENOHYTRO ELIXIR

PHENOHYTRO TABLET

PHENYTEK 200 MG CAPSULE

PHENYTEK 300 MG CAPSULE

PHENYTOIN 100 MG/4 ML SUSP

PHENYTOIN 125 MG/5 ML SUSP

PHENYTOIN 50 MG INFATAB

PHENYTOIN 50 MG TABLET CHEW

PHENYTOIN 50 MG/ML AMPUL

PHENYTOIN SOD EXT 100 MG CAP

PHENYTOIN SOD EXT 200 MG CAP

PHENYTOIN SOD EXT 300 MG CAP

PHILITH 0.4-0.035 MG TABLET

PHOMA 20,000 PNU/ML VIAL

PHOS-FLUR ORAL RINSE

PHOSLYRA 667 MG/5 ML SOLUTION

PHOSPHOLINE IODIDE 0.125%

PIFELTRO 100 MG TABLET

PILOCARPINE 1% EYE DROPS

PILOCARPINE 2% EYE DROPS

PILOCARPINE 4% EYE DROPS

PILOCARPINE HCL 5 MG TABLET

PILOCARPINE HCL 7.5 MG TABLET

PIMOZIDE 1 MG TABLET

PIMOZIDE 2 MG TABLET

PIMTREA 28 DAY TABLET

PINDOLOL 10 MG TABLET

PINDOLOL 5 MG TABLET

PIOGLITAZONE HCL 15 MG TABLET

PIOGLITAZONE HCL 30 MG TABLET

PIOGLITAZONE HCL 45 MG TABLET

PIOGLITAZONE-GLIMEPIRIDE 30-2

PIOGLITAZONE-GLIMEPIRIDE 30-4

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

PIOGLITAZONE-METFORMIN 15-500

PIOGLITAZONE-METFORMIN 15-850

PIP 28G LANCET

PIP 30G LANCET

PIQRAY 200 MG DAILY DOSE

PIQRAY 250 MG DAILY DOSE

PIQRAY 300 MG DAILY DOSE

PIRMELLA 1-35 28 TABLET

PIRMELLA 1-35-28 TABLET

PIRMELLA 7-7-7-28 TABLET

PIROXICAM 10 MG CAPSULE

PIROXICAM 20 MG CAPSULE

PLAQUENIL 200 MG TABLET

PLAVIX 75 MG TABLET

PLEGRIDY 125 MCG/0.5 ML SYRING

PLEGRIDY 125 MCG/0.5 ML PEN

PNV 29-1 TABLET

PNV OB+DHA COMBO PACK

PNV-DHA SOFTGEL

PNV-DHA + DOCUSATE SOFTGEL

PNV-OMEGA SOFTGEL

PNV-SELECT TABLET

PNV-VP-U CAPSULE

POLY VITAMIN-IRON CHEWABLE TAB

POLY-VI-FLOR 0.25 MG TAB CHEW

POLY-VI-FLOR 0.5 MG TAB CHEW

POLY-VI-FLOR 1 MG TAB CHEW

POLY-VI-FLOR 0.25 MG DROPS

POLY-VI-FLOR WITH IRON 0.5 MG

POLY-VI-FLOR WITH IRON 0.25 MG

POLY-VI-SOL DROPS

POLY-VI-SOL WITH IRON DROPS

POLY-VITA DROPS

POLY-VITA WITH IRON DROPS

POLY-VITAMIN TAB CHEW

POLY-VITAMIN DROPS

POLYVITAMIN WITH IRON TAB CHEW

POLYVITAMIN W-IRON DROPS

POMALYST 1 MG CAPSULE

POMALYST 2 MG CAPSULE

POMALYST 3 MG CAPSULE

POMALYST 4 MG CAPSULE

PORTIA-28 TABLET

POTABA 500 MG CAPSULE

POTASSIUM 99 MG CAPLET

GNP POTASSIUM 99 MG TABLET

HM POTASSIUM 99 MG TABLET

POTASSIUM 99 MG TABLET

SM POTASSIUM 99 MG CAPLET

SM POTASSIUM 99 MG TABLET

POTASSIUM 25 MEQ TABLET EFF

POTASSIUM CL 25 MEQ TAB EFF

POTASSIUM CL 10% (20 MEQ/15ML)

POTASSIUM CL 10% (40 MEQ/30ML)

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

POTASSIUM CL 20 MEQ PACKET

POTASSIUM CL 20% (40 MEQ/15ML)

POTASSIUM CL ER 10 MEQ CAPSULE

POTASSIUM CL ER 10 MEQ TABLET

POTASSIUM CL ER 20 MEQ TABLET

POTASSIUM CL ER 8 MEQ CAPSULE

POTASSIUM CL ER 8 MEQ TABLET

POTASSIUM CITRATE ER 10 MEQ TB

POTASSIUM CITRATE ER 15 MEQ TB

POTASSIUM CITRATE ER 5 MEQ TAB

CVS POTASSIUM GLUC 595 MG CPLT

POTASSIUM 99 MG TABLET

POTASSIUM GLU 99(595) MG CAPLT

POTASSIUM GLUC 500 MG TABLET

POTASSIUM GLUC 550 MG TABLET

POTASSIUM GLUC 595 MG CAPLET

POTASSIUM GLUC 595 MG TABLET

POTASSIUM GLUC ER 595 MG TAB

POTASSIUM GLUCONATE 595 CAPLET

POTASSIUM GLUCONATE 595 MG TAB

RA POTASSIUM GLUC 2.5 MEQ TB

RA POTASSIUM GLUC 595 MG TAB

SV POTASSIUM GLUC 595 MG CPLT

POTELIGEO 20 MG/5 ML VIAL

POTIGA 200 MG TABLET

POTIGA 300 MG TABLET

POTIGA 400 MG TABLET

POTIGA 50 MG TABLET

PR NATAL 400 COMBO PACK

PR NATAL 400 EC COMBO PACK

PR NATAL 430 COMBO PACK

PR NATAL 430 EC COMBO PACK

PRADAXA 110 MG CAPSULE

PRADAXA 150 MG CAPSULE

PRADAXA 75 MG CAPSULE

PRALUENT 150 MG/ML PEN

PRALUENT 75 MG/ML PEN

PRALUENT 75 MG/ML SYRINGE

PRAMIPEXOLE 0.125 MG TABLET

PRAMIPEXOLE 0.25 MG TABLET

PRAMIPEXOLE 0.5 MG TABLET

PRAMIPEXOLE 0.75 MG TABLET

PRAMIPEXOLE 1 MG TABLET

PRAMIPEXOLE 1.5 MG TABLET

PRAMIPEXOLE ER 0.375 MG TABLET

PRAMIPEXOLE ER 0.75 MG TABLET

PRAMIPEXOLE ER 1.5 MG TABLET

PRAMIPEXOLE ER 2.25 MG TABLET

PRAMIPEXOLE ER 3 MG TABLET

PRAMIPEXOLE ER 3.75 MG TABLET

PRAMIPEXOLE ER 4.5 MG TABLET

PRANDIN 0.5 MG TABLET

PRANDIN 1 MG TABLET

PRANDIN 2 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

PRASUGREL 10 MG TABLET

PRASUGREL 5 MG TABLET

PRAVACHOL 20 MG TABLET

PRAVACHOL 40 MG TABLET

PRAVACHOL 80 MG TABLET

PRAVASTATIN SODIUM 10 MG TAB

PRAVASTATIN SODIUM 20 MG TAB

PRAVASTATIN SODIUM 40 MG TAB

PRAVASTATIN SODIUM 80 MG TAB

PRAZOSIN 1 MG CAPSULE

PRAZOSIN 2 MG CAPSULE

PRAZOSIN 5 MG CAPSULE

PRECISION PCX TEST STRIPS

PRECISION PCX PLUS TEST STR

PRECISION POINT OF CARE STR

PRECISION Q-I-D TEST STRIPS

PRECISION XTR B-KETONE STRIP

PRECISION XTRA TEST STRIPS

PRECISION XTRA MONITOR

PRECISION XTRA MONITOR NFRS

PRECISION XTRA KETONE-GLUC KIT

PRECOSE 100 MG TABLET

PRECOSE 25 MG TABLET

PRECOSE 50 MG TABLET

PREFERA OB TABLET

PREFERA-OB ONE SOFTGEL

PREFERA-OB PLUS DHA COMBO PACK

PREFEST TABLET

PREGABALIN 100 MG CAPSULE

PREGABALIN 150 MG CAPSULE

PREGABALIN 20 MG/ML SOLUTION

PREGABALIN 200 MG CAPSULE

PREGABALIN 225 MG CAPSULE

PREGABALIN 25 MG CAPSULE

PREGABALIN 300 MG CAPSULE

PREGABALIN 50 MG CAPSULE

PREGABALIN 75 MG CAPSULE

PREGENNA TABLET

PREMARIN 0.3 MG TABLET

PREMARIN 0.45 MG TABLET

PREMARIN 0.625 MG TABLET

PREMARIN 0.9 MG TABLET

PREMARIN 1.25 MG TABLET

PREMARIN VAGINAL CREAM-APPL

RELION PREMIER BLU GLUCOSE MTR

RELION PREMIER COMPACT METER

RELION PREMIER TEST STRIP

RELION PREMIER VOICE GLUCO MTR

KRO PREMIUM BLOOD GLUCOSE SYST

PREMIUM BLOOD GLUCOSE SYSTEM

KRO PREMIUM BLOOD GLUCOSE TEST

PREMIUM BLOOD GLUCOSE TEST STR

PREMIUM BLOOD GLUCOSE TST STRP

PREMIUM V10 GLUCOSE TEST STRIP

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

PREMIUM V10 BLOOD GLUCOSE MTR

PREMPHASE 0.625-5 MG TABLET

PREMPRO 0.3 MG-1.5 MG TABLET

PREMPRO 0.45-1.5 MG TABLET

PREMPRO 0.625-2.5 MG TABLET

PREMPRO 0.625-5 MG TABLET

PRENA1 CHEW TABLET

PRENA1 PEARL SOFTGEL

PRENA1 TRUE COMBO PACK

PRENAISSANCE CAPSULE

PRENAISSANCE PLUS SOFTGEL

PRENATA CHEWABLE TABLET

PRENATABS FA TABLET

PRENATABS RX TABLET

PRENATAL GUMMIES

HM PRENATAL TABLET

PRENATAL CAPLET

PRENATAL TABLET

QC PRENATAL TABLET

SM PRENATAL TABLET

SV PRENATAL TABLET

CVS PRENATAL GUMMIES

PRENATAL TABLET

PRENATAL TABLET

CVS PRENATAL GUMMY VITAMINS

PRENATAL TABLET

PRENATAL + DHA COMBO PACK

PRENATAL 19 CHEWABLE TABLET

PRENATAL 19 TABLET

PRENATAL 19 TABLET

PRENATAL 19 CHEWABLE TABLET

PRENATAL COMPLETE CAPLET

PRENATAL FORMULA TABLET

PRENATAL FORMULA TABLET

PRENATAL FORMULA-DHA SOFTGEL

CVS PRENATAL GUMMIES

PRENATAL LOW IRON TABLET

PRENATAL MULTI TABLET

PRENATAL MULTI-DHA SOFTGEL

CVS PRENATAL MULTI-DHA SOFTGEL

PRENATAL MULTI-DHA SOFTGEL

PRENATAL MULTIVITAMIN TABLET

PRENATAL MULTIVITAMIN TABLET

PRENATAL MULTIVITAMIN-DHA SFGL

PRENATAL ONE DAILY TABLET

PRENATAL PLUS IRON TABLET

PNV PRENATAL PLUS MULTIVIT TAB

PRENATAL PLUS TABLET

PRENATAL PLUS-DHA COMBO PACK

PRENATAL PLUS-DHA COMBO PACK

PRENATAL PLUS-DHA COMBO PACK

PRENATAL VITAMIN TABLET

PRENATAL VITAMIN TABLET

PRENATAL VITAMIN TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

PRENATAL + DHA COMBO PACK

PRENATAL VITAMIN PLUS LOW IRON

GS PRENATAL VITAMINS TABLET

SV PRENATAL VITAMINS TABLET

GNP PRENATAL VITAMINS TABLET

PRENATAL TABLET

PRENATAL VITAMINS TABLET

SM PRENATAL VITAMINS TABLET

CVS PRENATAL VITAMINS TABLET

CVS PRENATAL VITAMIN TABLET

PRENATAL TABLET

PRENATAL TABLET

RA PRENATAL TABLET

PRENATAL-U CAPSULE

PRENATE AM TABLET

PRENATE CHEWABLE TABLET

PRENATE DHA SOFTGEL

PRENATE DHA SOFTGEL

PRENATE ELITE TABLET

PRENATE ELITE TABLET

PRENATE ENHANCE SOFTGEL

PRENATE ESSENTIAL SOFTGEL

PRENATE ESSENTIAL SOFTGEL

PRENATE MINI SOFTGEL

PRENATE PIXIE SOFTGEL

PRENATE RESTORE SOFTGEL

PRENATE STAR TABLET

PREPLUS CA-FE 27 MG-FA 1 MG TB

PREQUE 10 TABLET

PRESERVISION AREDS SOFTGEL

PRESERVISION AREDS TABLET

PRESERVISION LUTEIN SOFTGEL

PRESSURE ACTIVATED 21G LANCETS

PRESSURE ACTIVATED 28G LANCETS

PRESTALIA 14 MG-10 MG TABLET

PRESTALIA 3.5 MG-2.5 MG TABLET

PRESTALIA 7 MG-5 MG TABLET

PRESTO PRO BLOOD GLUCOSE METER

PRETAB 29 MG-1 MG TABLET

PREVACID 15 MG SOLUTAB

PREVACID 30 MG SOLUTAB

PREVACID DR 15 MG CAPSULE

PREVACID DR 30 MG CAPSULE

PREVACID 24HR DR 15 MG CAPSULE

PREVALITE PACKET

PREVALITE POWDER

PREVIDENT 0.2% RINSE

PREVIDENT 1.1% GEL

PREVIDENT 5000 BOOSTER PLUS

PREVIDENT DENTAL RINSE

PREVIDENT 5000 1.1% DRY MOUTH

PREVIDENT 5000 ENAMEL PROTECT

PREVIDENT 5000 PLUS CREAM

PREVIDENT 5000 SENSITIVE PASTE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

PREVIFEM TABLET

PREZCOBIX 800 MG-150 MG TABLET

PREZISTA 100 MG/ML SUSPENSION

PREZISTA 150 MG TABLET

PREZISTA 600 MG TABLET

PREZISTA 75 MG TABLET

PREZISTA 800 MG TABLET

PRILOSEC DR 10 MG SUSPENSION

PRILOSEC DR 2.5 MG SUSPENSION

PRILOSEC OTC 20 MG TABLET

PRILOSEC OTC 20.6 MG TABLET

PRIMACARE SOFTGEL

PRIMIDONE 250 MG TABLET

PRIMIDONE 50 MG TABLET

PRINIVIL 10 MG TABLET

PRINIVIL 20 MG TABLET

PRINIVIL 5 MG TABLET

PRISTIQ ER 100 MG TABLET

PRISTIQ ER 25 MG TABLET

PRISTIQ ER 50 MG TABLET

PRIVET 1:20 (W/V) VIAL

PRIVIGEN 10% VIAL

PRO COMFORT 1 ML 30GX1/2"

PRO COMFORT 1 ML 30GX5/16"

PRO COMFORT 1 ML 31GX5/16"

PRO COMFORT 0.5 ML 30GX1/2"

PRO COMFORT 0.5 ML 30GX5/16"

PRO COMFORT 0.5 ML 31GX5/16"

PRO COMFORT 31G LANCET

PRO COMFORT 30G LANCETS

PRO COMFORT PEN NDL 31GX5/16"

PRO COMFORT PEN NDL 32G X 1/4"

PRO COMFORT PEN NDL 4MM 32G

PRO COMFORT PEN NDL 5MM 32G

PRO VOICE V8 GLUCOSE MONITOR

PRO VOICE V8-V9 TEST STRIP

PRO VOICE V9 GLUCOSE MONITOR

PROAIR DIGIHALER 90 MCG INHALR

PROAIR HFA 90 MCG INHALER

PROAIR RESPICLICK 90 MCG INHLR

PROBENECID 500 MG TABLET

PROBENECID-COLCHICINE TABLET

PROCARDIA 10 MG CAPSULE

PROCARDIA XL 30 MG TABLET

PROCARDIA XL 60 MG TABLET

PROCARDIA XL 90 MG TABLET

PROCENTRA 5 MG/5 ML SOLUTION

PROCERV HP TABLET

PROCRIT 10,000 UNITS/ML VIAL

PROCRIT 2,000 UNITS/ML VIAL

PROCRIT 20,000 UNITS/ML VIAL

PROCRIT 3,000 UNITS/ML VIAL

PROCRIT 4,000 UNITS/ML VIAL

PROCRIT 40,000 UNITS/ML VIAL

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

PROCYSBI DR 25 MG CAPSULE

PROCYSBI DR 300 MG GRANULE PKT

PROCYSBI DR 75 MG CAPSULE

PROCYSBI DR 75 MG GRANULE PKT

PRODIGY AUTOCODE METER KIT

PRODIGY AUTOCODE MONITOR SYST

PRODIGY CONTROL SOLUTION LOW

PRODIGY INS SYR 1ML 28GX1/2"

PRODIGY SYRNG 0.5 ML 31GX5/16"

PRODIGY SYRNGE 0.3ML 31GX5/16"

PRODIGY PRESSURE ACTIVATED 28G

PRODIGY SAFETY 26G LANCETS

PRODIGY NO CODING TEST STRIPS

PRODIGY POCKET METER KIT

PRODIGY TWIST TOP 28G LANCET

PRODIGY VOICE METER KIT

PROFENO 600 MG TABLET

PROFILNINE 1,000 UNIT VIAL

PROFILNINE 1,500 UNIT VIAL

PROFILNINE 500 UNIT VIAL

PROGESTERONE 100 MG CAPSULE

PROGESTERONE 200 MG CAPSULE

PROGLYCEM 50 MG/ML ORAL SUSP

PROGRAF 0.2 MG GRANULE PACKET

PROGRAF 0.5 MG CAPSULE

PROGRAF 1 MG CAPSULE

PROGRAF 1 MG GRANULE PACKET

PROGRAF 5 MG CAPSULE

PROLASTIN C 1,000 MG VIAL

PROLASTIN C 1,000 MG/20 ML VL

PROLIA 60 MG/ML SYRINGE

PROMACTA 12.5 MG SUSPEN PACKET

PROMACTA 12.5 MG TABLET

PROMACTA 25 MG TABLET

PROMACTA 50 MG TABLET

PROMACTA 75 MG TABLET

PROMETRIUM 100 MG CAPSULE

PROMETRIUM 200 MG CAPSULE

PROPAFENONE HCL 150 MG TABLET

PROPAFENONE HCL 225 MG TAB

PROPAFENONE HCL 300 MG TAB

PROPAFENONE HCL ER 225 MG CAP

PROPAFENONE HCL ER 325 MG CAP

PROPAFENONE HCL ER 425 MG CAP

PROPANTHELINE 15 MG TABLET

PROPECIA 1 MG TABLET

PROPRANOLOL 10 MG TABLET

PROPRANOLOL 20 MG TABLET

PROPRANOLOL 20 MG/5 ML SOLN

PROPRANOLOL 40 MG TABLET

PROPRANOLOL 40 MG/5 ML SOLN

PROPRANOLOL 60 MG TABLET

PROPRANOLOL 80 MG TABLET

PROPRANOLOL ER 120 MG CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

PROPRANOLOL ER 160 MG CAPSULE

PROPRANOLOL ER 60 MG CAPSULE

PROPRANOLOL ER 80 MG CAPSULE

PROPRANOLOL-HCTZ 40-25 MG TAB

PROPRANOLOL-HCTZ 80-25 MG TAB

PROPYLTHIOURACIL 50 MG TABLET

PRORENAL QD SOFTGEL

PROSCAR 5 MG TABLET

PROSIGHT TABLET

PROTECT CARDIO AF SOFTGEL

PROTECT IRON TABLET

PROTECT PLUS NF LIQUID

PROTECT PLUS SO SOFTGEL

PROTONIX 40 MG SUSPENSION

PROTONIX DR 20 MG TABLET

PROTONIX DR 40 MG TABLET

PROTRIPTYLINE HCL 10 MG TABLET

PROTRIPTYLINE HCL 5 MG TABLET

PROVENT NASAL DEVICE

PROVENT STARTER KIT

PROVENTIL HFA 90 MCG INHALER

PROVERA 10 MG TABLET

PROVERA 2.5 MG TABLET

PROVERA 5 MG TABLET

PROVIDA DHA CAPSULE

PROVIDA OB CAPSULE

PROVIGIL 100 MG TABLET

PROVIGIL 200 MG TABLET

PROVIL 200 MG TABLET

PROZAC 10 MG PULVULE

PROZAC 20 MG PULVULE

PROZAC 40 MG PULVULE

PROZAC WEEKLY 90 MG CAPSULE

PULMICORT 0.25 MG/2 ML RESPUL

PULMICORT 0.5 MG/2 ML RESPULE

PULMICORT 1 MG/2 ML RESPULE

PULMICORT 180 MCG FLEXHALER

PULMICORT 90 MCG FLEXHALER

PULMOZYME 1 MG/ML AMPUL

PURE COMFORT 30G TWIST LANCET

PURE COMFORT PEN NDL 32G 4MM

PURE COMFORT PEN NDL 32G 5MM

PURE COMFORT PEN NDL 32G 6MM

PURE COMFORT PEN NDL 32G 8MM

PURE COMFORT 30G SAFETY LANCET

PUREFE OB PLUS CAPSULE

PUREFE PLUS CAPSULE

PURIXAN 20 MG/ML ORAL SUSP

PUSH BUTTON SAFETY 28G LANCET

PYRIDOSTIGMINE 60 MG/5 ML SOLN

PYRIDOSTIGMINE BR 30 MG TABLET

PYRIDOSTIGMINE BR 60 MG TABLET

PYRIDOSTIGMINE ER 180 MG TAB

QBRELIS 1MG/ML SOLUTION

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

QMIIZ ODT 15 MG TABLET

QMIIZ ODT 7.5 MG TABLET

QNASL 80 MCG NASAL SPRAY

QNASL CHILDREN'S 40 MCG SPRAY

QSYMIA 11.25 MG-69 MG CAPSULE

QSYMIA 15 MG-92 MG CAPSULE

QSYMIA 3.75 MG-23 MG CAPSULE

QSYMIA 7.5 MG-46 MG CAPSULE

QTERN 10 MG-5 MG TABLET

QTERN 5 MG-5 MG TABLET

QUARTETTE TABLET

QUASENSE 0.15-0.03 MG TABLET

QUDEXY XR 100 MG CAPSULE

QUDEXY XR 150 MG CAPSULE

QUDEXY XR 200 MG CAPSULE

QUDEXY XR 25 MG CAPSULE

QUDEXY XR 50 MG CAPSULE

QUEEN PALM 1:20 (W/V) VIAL

QUESTRAN PACKET

QUESTRAN POWDER

QUESTRAN LIGHT POWDER

QUETIAPINE FUMARATE 100 MG TAB

QUETIAPINE FUMARATE 200 MG TAB

QUETIAPINE FUMARATE 25 MG TAB

QUETIAPINE FUMARATE 300 MG TAB

QUETIAPINE FUMARATE 400 MG TAB

QUETIAPINE FUMARATE 50 MG TAB

QUETIAPINE ER 150 MG TABLET

QUETIAPINE ER 200 MG TABLET

QUETIAPINE ER 300 MG TABLET

QUETIAPINE ER 400 MG TABLET

QUETIAPINE ER 50 MG TABLET

QUFLORA PED 0.5 MG/ML DROP

QUFLORA 0.125 MG GUMMIES

QUFLORA PED 0.25 MG CHEW TAB

QUFLORA PED 0.5 MG CHEW TAB

QUFLORA PED 1 MG CHEW TAB

QUFLORA PED 0.25 MG/ML DROP

QUFLORA FE 0.25 MG CHEW TABLET

QUFLORA FE PED 0.25 MG/ML DROP

QUICK RELEASE TEFLN CANNULA

QUICK-SET PARADIGM SET 18"

QUICK-SET PARADIGM SET 32"

QUILLICHEW ER 20 MG CHEW TAB

QUILLICHEW ER 30 MG CHEW TAB

QUILLICHEW ER 40 MG CHEW TAB

QUILLIVANT XR 25 MG/5 ML SUSP

QUINAPRIL 10 MG TABLET

QUINAPRIL 20 MG TABLET

QUINAPRIL 40 MG TABLET

QUINAPRIL 5 MG TABLET

QUINAPRIL-HCTZ 10-12.5 MG TAB

QUINAPRIL-HCTZ 20-12.5 MG TAB

QUINAPRIL-HCTZ 20-25 MG TAB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

QUINIDINE GLUC ER 324 MG TAB

QUINIDINE SULFATE 200 MG TAB

QUINIDINE SULFATE 300 MG TAB

QUINTABS TABLET

QUINTABS-M TABLET

QUINTABS-M IRON FREE TABLET

QUINTET BLOOD GLUCOSE SYSTEM

QUINTET AC GLUCOSE TEST STRIPS

QUINTET AC BLOOD GLUCOSE METER

QVAR 40 MCG ORAL INHALER

QVAR 80 MCG ORAL INHALER

QVAR REDIHALER 40 MCG

QVAR REDIHALER 80 MCG

RABBIT EPITHELIUM 1:10 (W/V)

RABBIT EPITHELIUM 1:20 (W/V)

RABEPRAZOLE DR 10 MG SPRNKL CP

RABEPRAZOLE SOD DR 20 MG TAB

RADICAVA 30 MG/100 ML BAG

RAGWITEK SUBLINGUAL TABLET

RAJANI 28 TABLET

RALOXIFENE HCL 60 MG TABLET

RAMIPRIL 1.25 MG CAPSULE

RAMIPRIL 10 MG CAPSULE

RAMIPRIL 2.5 MG CAPSULE

RAMIPRIL 5 MG CAPSULE

RANEXA ER 1,000 MG TABLET

RANEXA ER 500 MG TABLET

CVS RANITIDINE 75 MG TABLET

EQ RANITIDINE 150 MG TABLET

EQ RANITIDINE 75 MG TABLET

PUB RANITIDINE 150 MG TABLET

RANITIDINE 15 MG/ML SYRUP

RANITIDINE 150 MG CAPSULE

RANITIDINE 150 MG TABLET

RANITIDINE 150 MG/10 ML SYRUP

RANITIDINE 300 MG CAPSULE

RANITIDINE 300 MG TABLET

RANITIDINE 75 MG TABLET

RANOLAZINE ER 1,000 MG TABLET

RANOLAZINE ER 500 MG TABLET

RAPAFLO 4 MG CAPSULE

RAPAFLO 8 MG CAPSULE

RAPAMUNE 0.5 MG TABLET

RAPAMUNE 1 MG TABLET

RAPAMUNE 1 MG/ML ORAL SOLN

RAPAMUNE 2 MG TABLET

RASAGILINE MESYLATE 0.5 MG TAB

RASAGILINE MESYLATE 1 MG TAB

RASUVO 10 MG/0.2 ML AUTOINJ

RASUVO 12.5 MG/0.25 ML AUTOINJ

RASUVO 15 MG/0.3 ML AUTOINJ

RASUVO 17.5 MG/0.35 ML AUTOINJ

RASUVO 20 MG/0.4 ML AUTOINJ

RASUVO 22.5 MG/0.45 ML AUTOINJ

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

RASUVO 25 MG/0.5 ML AUTOINJ

RASUVO 27.5 MG/0.55 ML AUTOINJ

RASUVO 30 MG/0.6 ML AUTOINJ

RASUVO 7.5 MG/0.15 ML AUTOINJ

RAVICTI 1.1 GRAM/ML LIQUID

RAYALDEE ER 30 MCG CAPSULE

RAZADYNE 12 MG TABLET

RAZADYNE 4 MG TABLET

RAZADYNE 8 MG TABLET

RAZADYNE ER 16 MG CAPSULE

RAZADYNE ER 24 MG CAPSULE

RAZADYNE ER 8 MG CAPSULE

READYLANCE 21G SAFETY LANCETS

READYLANCE 23G SAFETY LANCETS

READYLANCE 26G SAFETY LANCETS

READYLANCE 28G SAFETY LANCETS

READYLANCE 30G SAFETY LANCETS

REBIF 22 MCG/0.5 ML SYRINGE

REBIF 44 MCG/0.5 ML SYRINGE

REBIF REBIDOSE 22 MCG/0.5 ML

REBIF REBIDOSE 44 MCG/0.5 ML

REBLOZYL 25 MG VIAL

REBLOZYL 75 MG VIAL

RECLIPSEN 28 DAY TABLET

RECOMBINATE 1,241-1,800 UNIT V

RECOMBINATE 1,801-2,400 UNIT V

RECOMBINATE 220-400 UNIT VIAL

RECOMBINATE 401-800 UNIT VIAL

RECOMBINATE 801-1,240 UNIT VL

RED BIRCH 1:20 (W/V) VIAL

RED CEDAR 1:20 (W/V) VIAL

RED MAPLE 1:20 (W/V) VIAL

RED MULBERRY 1:20 (W/V) VIAL

REFUAH PLUS TEST STRIPS

REFUAH PLUS MONITORING SYSTEM

REFUAH PLUS CONTROL SOLUTION

RELEXXII ER 72 MG TABLET

RELIAMED 28G LANCETS

RELIAMED 30G LANCETS

RELIAMED SAFETY SEAL 28G LANCT

RELIAMED SAFETY SEAL 30G LANCT

RELION ALL-IN-ONE METER KIT

RELION CONFIRM SYSTEM KIT

RELION CONFIRM-MICRO TEST STRP

RELION MICRO SYSTEM KIT

RELION PEN NEEDLES 32GX5/32"

RELION PRIME BLOOD GLUCOSE MTR

RELION PRIME TEST STRIPS

RELION THIN 26G LANCETS

REMEDIENT CAPSULE

REMERON 15 MG SOLTAB

REMERON 15 MG TABLET

REMERON 30 MG SOLTAB

REMERON 30 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

REMERON 45 MG SOLTAB

REMERON 45 MG TABLET

REMICADE 100 MG VIAL

REMODULIN 1 MG/ML VIAL

REMODULIN 10 MG/ML VIAL

REMODULIN 2.5 MG/ML VIAL

REMODULIN 5 MG/ML VIAL

RENAGEL 400 MG TABLET

RENAGEL 800 MG TABLET

RENAL CAPS SOFTGEL

RENAL VITAMIN TABLET

RENAL-VITE TABLET

RENA-VITE TABLET

RENA-VITE RX TABLET

RENFLEXIS 100 MG VIAL

RENO CAPS SOFTGEL

RENVELA 0.8 GM POWDER PACKET

RENVELA 2.4 GM POWDER PACKET

RENVELA 800 MG TABLET

REPAGLINIDE 0.5 MG TABLET

REPAGLINIDE 1 MG TABLET

REPAGLINIDE 2 MG TABLET

REPAGLINIDE-METFORMIN 1-500 MG

REPAGLINIDE-METFORMIN 2-500 MG

REPATHA 420 MG/3.5ML PUSHTRONX

REPATHA 140 MG/ML SURECLICK

REPATHA 140 MG/ML SYRINGE

REQ49+ TABLET

REQUIP 0.25 MG TABLET

REQUIP 0.5 MG TABLET

REQUIP 1 MG TABLET

REQUIP 2 MG TABLET

REQUIP 3 MG TABLET

REQUIP 4 MG TABLET

REQUIP 5 MG TABLET

REQUIP XL 12 MG TABLET

REQUIP XL 2 MG TABLET

REQUIP XL 4 MG TABLET

REQUIP XL 6 MG TABLET

REQUIP XL 8 MG TABLET

RESCRIPTOR 100 MG TABLET

RESCRIPTOR 200 MG TABLET

RESTASIS 0.05% EYE EMULSION

RESTASIS MULTIDOSE 0.05% EYE

RETACRIT 10,000 UNIT/ML VIAL

RETACRIT 2,000 UNIT/ML VIAL

RETACRIT 3,000 UNIT/ML VIAL

RETACRIT 4,000 UNIT/ML VIAL

RETACRIT 40,000 UNIT/ML VIAL

RETISERT IMPLANT

RETROVIR 10 MG/ML SYRUP

RETROVIR 100 MG CAPSULE

REVATIO 10 MG/ML ORAL SUSP

REVATIO 20 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

REVCOVI 2.4 MG/1.5 ML VIAL

REVEAL BLOOD GLUCOSE METER

REVEAL TEST STRIP

REVLIMID 10 MG CAPSULE

REVLIMID 15 MG CAPSULE

REVLIMID 2.5 MG CAPSULE

REVLIMID 20 MG CAPSULE

REVLIMID 25 MG CAPSULE

REVLIMID 5 MG CAPSULE

REXULTI 0.25 MG TABLET

REXULTI 0.5 MG TABLET

REXULTI 1 MG TABLET

REXULTI 2 MG TABLET

REXULTI 3 MG TABLET

REXULTI 4 MG TABLET

REYATAZ 150 MG CAPSULE

REYATAZ 200 MG CAPSULE

REYATAZ 300 MG CAPSULE

REYATAZ 50 MG POWDER PACKET

RHIZOPUS 20,000 PNU/ML VIAL

RHOPRESSA 0.02% OPHTH SOLUTION

RIDAURA 3 MG CAPSULE

RIGHT STEP PRENATAL VIT TAB

RIGHTEST CONTROL SOLUTION HIGH

RIGHTEST CONTROL SOLN NORMAL

RIGHTEST GL300 30G LANCETS

RIGHTEST GM100 SYSTEM KIT

RIGHTEST GM300 SYSTEM KIT

RIGHTEST GM550 SYSTEM KIT

RIGHTEST GS100 TEST STRIPS

RIGHTEST GS300 TEST STRIPS

RIGHTEST GS550 TEST STRIPS

RILUTEK 50 MG TABLET

RILUZOLE 50 MG TABLET

RINVOQ ER 15 MG TABLET

RIOMET 500 MG/5 ML SOLUTION

RIOMET ER 500 MG/5 ML SUSP

RISEDRONATE SODIUM 150 MG TAB

RISEDRONATE SODIUM 35 MG TAB

RISEDRONATE SODIUM 5 MG TABLET

RISEDRONATE SOD DR 35 MG TAB

RISPERDAL 0.25 MG TABLET

RISPERDAL 0.5 MG TABLET

RISPERDAL 1 MG TABLET

RISPERDAL 1 MG/ML SOLUTION

RISPERDAL 2 MG TABLET

RISPERDAL 3 MG TABLET

RISPERDAL 4 MG TABLET

RISPERDAL CONSTA 12.5 MG VIAL

RISPERDAL CONSTA 25 MG VIAL

RISPERDAL CONSTA 37.5 MG VIAL

RISPERDAL CONSTA 50 MG VIAL

RISPERDAL M-TAB 0.5 MG ODT

RISPERDAL M-TAB 1 MG ODT

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

RISPERDAL M-TAB 2 MG ODT

RISPERDAL M-TAB 3 MG ODT

RISPERDAL M-TAB 4 MG ODT

RISPERIDONE 0.25 MG TABLET

RISPERIDONE 0.5 MG TABLET

RISPERIDONE 1 MG TABLET

RISPERIDONE 1 MG/1 ML ORAL SYR

RISPERIDONE 1 MG/ML SOLUTION

RISPERIDONE 2 MG TABLET

RISPERIDONE 2 MG/2 ML ORAL SYR

RISPERIDONE 3 MG TABLET

RISPERIDONE 3 MG/3 ML ORAL SYR

RISPERIDONE 4 MG TABLET

RISPERIDONE 0.25 MG ODT

RISPERIDONE 0.5 MG ODT

RISPERIDONE 1 MG ODT

RISPERIDONE 2 MG ODT

RISPERIDONE 3 MG ODT

RISPERIDONE 4 MG ODT

RITALIN 10 MG TABLET

RITALIN 20 MG TABLET

RITALIN 5 MG TABLET

RITALIN LA 10 MG CAPSULE

RITALIN LA 20 MG CAPSULE

RITALIN LA 30 MG CAPSULE

RITALIN LA 40 MG CAPSULE

RITONAVIR 100 MG TABLET

RITUXAN 100 MG/10 ML VIAL

RITUXAN 500 MG/50 ML VIAL

RITUXAN HYCELA 1,400 MG-23,400

RITUXAN HYCELA 1,600 MG-26,800

RIVASTIGMINE 13.3 MG/24HR PTCH

RIVASTIGMINE 4.6 MG/24HR PATCH

RIVASTIGMINE 9.5 MG/24HR PATCH

RIVASTIGMINE 1.5 MG CAPSULE

RIVASTIGMINE 3 MG CAPSULE

RIVASTIGMINE 4.5 MG CAPSULE

RIVASTIGMINE 6 MG CAPSULE

RIVELSA TABLET

RIXUBIS 1,000 UNIT NOMINAL

RIXUBIS 2,000 UNIT NOMINAL

RIXUBIS 250 UNIT NOMINAL

RIXUBIS 3,000 UNIT NOMINAL

RIXUBIS 500 UNIT NOMINAL

R-NATAL OB SOFTGEL

ROBINUL 1 MG TABLET

ROBINUL FORTE 2 MG TABLET

ROCALTROL 0.25 MCG CAPSULE

ROCALTROL 0.5 MCG CAPSULE

ROCALTROL 1 MCG/ML ORAL SOLN

ROCKLATAN 0.02%-0.005% EYE DRP

ROPINIROLE HCL ER 12 MG TABLET

ROPINIROLE HCL ER 2 MG TABLET

ROPINIROLE HCL ER 4 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ROPINIROLE HCL ER 6 MG TABLET

ROPINIROLE HCL ER 8 MG TABLET

ROPINIROLE HCL 0.25 MG TABLET

ROPINIROLE HCL 0.5 MG TABLET

ROPINIROLE HCL 1 MG TABLET

ROPINIROLE HCL 2 MG TABLET

ROPINIROLE HCL 3 MG TABLET

ROPINIROLE HCL 4 MG TABLET

ROPINIROLE HCL 5 MG TABLET

ROSUVASTATIN CALCIUM 10 MG TAB

ROSUVASTATIN CALCIUM 20 MG TAB

ROSUVASTATIN CALCIUM 40 MG TAB

ROSUVASTATIN CALCIUM 5 MG TAB

ROUGH MARSH ELDER 1:20 (W/V)

ROUGH PIGWEED 1:20 (W/V) VIAL

ROWASA 4 GM/60 ML ENEMA KIT

ROWEEPRA 1,000 MG TABLET

ROWEEPRA 500 MG TABLET

ROWEEPRA 750 MG TABLET

ROWEEPRA XR 500 MG TABLET

ROWEEPRA XR 750 MG TABLET

ROZLYTREK 100 MG CAPSULE

ROZLYTREK 200 MG CAPSULE

RUBRACA 200 MG TABLET

RUBRACA 250 MG TABLET

RUBRACA 300 MG TABLET

RULAVITE DHA SOFTGEL

RUSSIAN THISTLE 1:20 (W/V) VL

RUZURGI 10 MG TABLET

RYBELSUS 14 MG TABLET

RYBELSUS 3 MG TABLET

RYBELSUS 7 MG TABLET

RYDAPT 25 MG CAPSULE

RYTARY ER 23.75 MG-95 MG CAP

RYTARY ER 36.25 MG-145 MG CAP

RYTARY ER 48.75 MG-195 MG CAP

RYTARY ER 61.25 MG-245 MG CAP

RYTHMOL SR 225 MG CAPSULE

RYTHMOL SR 325 MG CAPSULE

RYTHMOL SR 425 MG CAPSULE

SABRIL 500 MG POWDER PACKET

SABRIL 500 MG TABLET

S. CEREVISIAE 20,000 PNU/ML

BD SAFE-CLIP BY MAIL SYSTEM

BD SAFE-CLIP NEEDL STORAGE DEV

SAFESNAP INSUL SYRINGE 0.3 ML

SAFESNAP INSULIN SYRINGE 1 ML

SAFESNAP INSUL SYRINGE 0.5 ML

SAFETY 21G LANCETS

SAFETY 28G LANCETS

SAFETY LANCETS 26G

SAFETY PEN NEEDLE 5MM X 31G

SAFETY SEAL 28G LANCETS

SAFETY SEAL 30G LANCETS

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

BD SAFETYGLD INS 1 ML 13MMX29G

BD SAFETYGLID INS 1 ML 6MMX31G

BD SAFTYGLD INS 0.5 ML 6MMX31G

BD SAFTYGLD INS 0.3 ML 6MMX31G

BD SAFETGLD INS 0.5 ML 8MMX30G

BD SAFETGLD INS 0.5ML 13MMX29G

BD SAFETGLD INS 0.3 ML 8MMX31G

BD SAFETGLD INS 0.3ML 13MMX29G

BD SAFETYGLIDE SYRINGE 27GX5/8

SAFETY-LET 30G LANCETS

SAFYRAL TABLET

SAGEBRUSH 1:20 (W/V) VIAL

SAIZEN 5 MG VIAL

SAIZEN 8.8 MG CLICK.EASY CARTG

SAIZEN 8.8 MG VIAL

SAIZEN 8.8 MG SAIZENPREP CART

SALAGEN 5 MG TABLET

SALAGEN 7.5 MG TABLET

SALSALATE 500 MG TABLET

SALSALATE 750 MG TABLET

SAMSCA 15 MG TABLET

SAMSCA 30 MG TABLET

SANDIMMUNE 100 MG CAPSULE

SANDIMMUNE 100 MG/ML SOLN

SANDIMMUNE 25 MG CAPSULE

SANDOSTATIN 0.05 MG/ML AMPUL

SANDOSTATIN 0.1 MG/ML AMPUL

SANDOSTATIN 0.2 MG/ML VIAL

SANDOSTATIN 0.5 MG/ML AMPUL

SANDOSTATIN 1 MG/ML VIAL

SANDOSTATIN LAR DEPOT 10 MG KT

SANDOSTATIN LAR DEPOT 10 MG VL

SANDOSTATIN LAR DEPOT 20 MG KT

SANDOSTATIN LAR DEPOT 30 MG KT

SAPHRIS 10 MG TAB SUBLINGUAL

SAPHRIS 2.5 MG TAB SUBLINGUAL

SAPHRIS 5 MG TAB SUBLINGUAL

SARAFEM 10 MG TABLET

SARAFEM 20 MG TABLET

SARCLISA 100 MG/5 ML VIAL

SARCLISA 500 MG/25 ML VIAL

SAVAYSA 15 MG TABLET

SAVAYSA 30 MG TABLET

SAVAYSA 60 MG TABLET

SAVELLA 100 MG TABLET

SAVELLA 12.5 MG TABLET

SAVELLA 25 MG TABLET

SAVELLA 50 MG TABLET

SAXENDA 18 MG/3 ML PEN

SCENESSE 16 MG IMPLANT

SCOOBY-DOO ONE A DAY TABLET

SCOOBY-DOO ONE A DAY GUMMIES

SEASONIQUE 0.15-0.03-0.01 TAB

SECTRAL 200 MG CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

SECTRAL 400 MG CAPSULE

SECUADO 3.8 MG/24 HR PATCH

SECUADO 5.7 MG/24 HR PATCH

SECUADO 7.6 MG/24 HR PATCH

SEEBRI NEOHALER 15.6 MCG INHAL

SEGLUROMET 2.5-1,000 MG TABLET

SEGLUROMET 2.5-500 MG TABLET

SEGLUROMET 7.5-1,000 MG TABLET

SEGLUROMET 7.5-500 MG TABLET

SELECT-OB CHEWABLE CAPLET

SELECT-OB CHEWABLE CAPLET

SELECT-OB + DHA PACK

SELEGILINE HCL 5 MG CAPSULE

SELEGILINE HCL 5 MG TABLET

SELZENTRY 150 MG TABLET

SELZENTRY 20 MG/ML ORAL SOLN

SELZENTRY 25 MG TABLET

SELZENTRY 300 MG TABLET

SELZENTRY 75 MG TABLET

SE-NATAL 19 CHEWABLE TABLET

SE-NATAL-19 TABLET

SENIOR TABS

SENSIPAR 30 MG TABLET

SENSIPAR 60 MG TABLET

SENSIPAR 90 MG TABLET

SENTRY TABLET

SENTRY SENIOR MULTIVITAMIN TAB

SENTRY SENIOR TABLET

SEREVENT DISKUS 50 MCG

SEROQUEL 100 MG TABLET

SEROQUEL 200 MG TABLET

SEROQUEL 25 MG TABLET

SEROQUEL 300 MG TABLET

SEROQUEL 400 MG TABLET

SEROQUEL 50 MG TABLET

SEROQUEL XR 150 MG TABLET

SEROQUEL XR 200 MG TABLET

SEROQUEL XR 300 MG TABLET

SEROQUEL XR 400 MG TABLET

SEROQUEL XR 50 MG TABLET

SEROSTIM 4 MG VIAL

SEROSTIM 5 MG VIAL

SEROSTIM 6 MG VIAL

SERTRALINE 20 MG/ML ORAL CONC

SERTRALINE HCL 100 MG TABLET

SERTRALINE HCL 25 MG TABLET

SERTRALINE HCL 50 MG TABLET

SETLAKIN 0.15 MG-0.03 MG TAB

SEVELAMER 0.8 GM POWDER PACKET

SEVELAMER 2.4 GM POWDER PACKET

SEVELAMER CARBONATE 800 MG TAB

SEVELAMER HCL 400 MG TABLET

SEVELAMER HCL 800 MG TABLET

SF 1.1% GEL

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

SF 5000 PLUS CREAM

SFROWASA 4 GM/60 ML ENEMA

SHAGBARK HICKORY 1:20 (W/V) VL

SHAROBEL 0.35 MG TABLET

SHEEP SORREL 1:20 (W/V) VIAL

SORREL-DOCK MIX 1:20 (W/V)

SHORT RAGWEED 1:20 (W/V) VIAL

SIDEKICK BLOOD GLUCOSE SYSTEM

SIGNIFOR 0.3 MG/ML AMPULE

SIGNIFOR 0.6 MG/ML AMPULE

SIGNIFOR 0.9 MG/ML AMPULE

SIGNIFOR LAR 10 MG KIT

SIGNIFOR LAR 20 MG KIT

SIGNIFOR LAR 20 MG VIAL

SIGNIFOR LAR 30 MG KIT

SIGNIFOR LAR 40 MG KIT

SIGNIFOR LAR 40 MG VIAL

SIGNIFOR LAR 60 MG KIT

SIGNIFOR LAR 60 MG VIAL

SIKLOS 1,000 MG TABLET

SIKLOS 100 MG TABLET

SILDENAFIL 10 MG/ML ORAL SUSP

SILDENAFIL 100 MG TABLET

SILDENAFIL 20 MG TABLET

SILDENAFIL 25 MG TABLET

SILDENAFIL 50 MG TABLET

SILHOUETTE INFUSION SET 23"

SILHOUETTE INFUSION SET 43"

SILIQ 210 MG/1.5 ML SYRINGE

SILODOSIN 4 MG CAPSULE

SILODOSIN 8 MG CAPSULE

SIMBRINZA 1%-0.2% EYE DROPS

SIMILAC PRENATAL COMBO PACK

SIMLIYA 28 DAY TABLET

SIMPESSE 0.15-0.03-0.01 MG TAB

SIMPONI 100 MG/ML PEN INJECTOR

SIMPONI 100 MG/ML SYRINGE

SIMPONI 50 MG/0.5 ML PEN INJEC

SIMPONI 50 MG/0.5 ML SYRINGE

SIMPONI ARIA 50 MG/4 ML VIAL

SIMVASTATIN 10 MG TABLET

SIMVASTATIN 20 MG TABLET

SIMVASTATIN 20 MG/5 ML SUSP

SIMVASTATIN 40 MG TABLET

SIMVASTATIN 5 MG TABLET

SIMVASTATIN 80 MG TABLET

SINEMET 10-100 MG TABLET

SINEMET 25-100 MG TABLET

SINEMET 25-250 MG TABLET

SINEMET CR 25-100 TABLET

SINEMET CR 50-200 TABLET

SINGLE-LET LANCETS

SINGULAIR 10 MG TABLET

SINGULAIR 4 MG GRANULES

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

SINGULAIR 4 MG TABLET CHEW

SINGULAIR 5 MG TABLET CHEW

SIROLIMUS 0.5 MG TABLET

SIROLIMUS 1 MG TABLET

SIROLIMUS 1 MG/ML SOLUTION

SIROLIMUS 2 MG TABLET

SKYLA 13.5 MG SYSTEM

SKYRIZI 150 MG DOSE KIT-2 SYRN

SLYND 4 MG TABLET

SMART SENSE COLOR 33G LANCETS

SMART SENSE STANDARD 21G

SMART SENSE THIN 26G LANCETS

SMART SENSE MONITORING SYSTEM

SMART SENSE TEST STRIPS

SMARTEST CONTROL SOLUTION

SMARTEST EJECT METER

SMARTEST LANCET

SMARTEST PERSONA STARTER KIT

SMARTEST PRONTO STARTER KIT

SMARTEST PROTEGE METER

SMARTEST TEST STRIPS

SOCHLOR 5% EYE DROPS

SOCHLOR 5% EYE OINTMENT

CVS SODIUM CHLORIDE 5% EYE DRP

CVS SODIUM CHLORIDE 5% OINT

RA SODIUM CHLORIDE 5% EYE DROP

SODIUM CHLORIDE 5% EYE DROP

SODIUM CHLORIDE 5% EYE OINT

SODIUM CHLORIDE 5% OPHT SOLN

SODIUM FLUORIDE 0.25 (0.55) MG

SODIUM FLUORIDE 0.5 MG(1.1 MG)

SODIUM FLUORIDE 0.5 MG/ML DROP

SODIUM FLUORIDE 1 MG (2.2 MG)

SODIUM FLUORIDE 1.1% CREAM

SODIUM FLUORIDE 1.1% GEL

SODIUM FLUORIDE 5000 PLUS CRM

SODIUM PHENYLBUTYRATE 500MG TB

SODIUM PHENYLBUTYRATE POWDER

SOF-SENSOR

SOF-SET ULTIMATE QR SET

SOF-SET MICRO INFUSION SET

SOFT TOUCH LANCETS

SOLIFENACIN 10 MG TABLET

SOLIFENACIN 5 MG TABLET

SOLIQUA 100 UNIT-33 MCG/ML PEN

SOLIRIS 300 MG/30 ML VIAL

SOLO TABLET

SOLTAMOX 10 MG/5 ML SOLN

SOLTAMOX 20 MG/10 ML SOLN

SOLUS V2 AUDIBLE METER

SOLUS V2 AUDIBLE METER SYS KIT

SOLUS V2 28G LANCETS

SOLUS V2 CONTROL SOLUTION HIGH

SOLUS V2 CONTROL SOLUTION LOW

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

SOLUS V2 30G TWIST LANCETS

SOLUS V2 LANCING DEVICE

SOLUS V2 AUDIBLE TEST STRIPS

SOMATULINE DEPOT 120 MG/0.5 ML

SOMATULINE DEPOT 60 MG/0.2 ML

SOMATULINE DEPOT 90 MG/0.3 ML

SOMAVERT 10 MG VIAL

SOMAVERT 15 MG VIAL

SOMAVERT 20 MG VIAL

SOMAVERT 25 MG VIAL

SOMAVERT 30 MG VIAL

SORIATANE 10 MG CAPSULE

SORIATANE 17.5 MG CAPSULE

SORIATANE 25 MG CAPSULE

SORINE 120 MG TABLET

SORINE 160 MG TABLET

SORINE 240 MG TABLET

SORINE 80 MG TABLET

SOTALOL 120 MG TABLET

SOTALOL 160 MG TABLET

SOTALOL 240 MG TABLET

SOTALOL 80 MG TABLET

SOTALOL AF 120 MG TABLET

SOTALOL AF 160 MG TABLET

SOTALOL AF 80 MG TABLET

SOTYLIZE 5 MG/ML ORAL SOLUTION

CVS SPECTRAVITE ADULT GUMMY

CVS SPECTRAVITE ADULT 50 PLUS

CVS SPECTRAVITE ADULT TAB CHEW

CVS SPECTRAVITE ADULT 50+ TABS

CVS SPECTRAVITE ADVANCED TAB

CVS SPECTRAVITE MEN'S TABLET

CVS SPECTRAVITE SENIOR TAB

CVS SPECTRAVITE SENIOR TABLET

CVS SPECTRAVITE ULTRA MEN TAB

CVS SPECTRAVITE ULTRA MEN'S TB

CVS SPECTRAVITE ULTRA WOMEN TB

CVS SPECTRAVITE WOMEN'S TABLET

SPINRAZA 12 MG/5 ML VIAL

SPINY PIGWEED 1:20 W/V VIAL

SPIRIVA 18 MCG CP-HANDIHALER

SPIRIVA RESPIMAT 1.25 MCG INH

SPIRIVA RESPIMAT 2.5 MCG INH

SPIRONOLACTONE 100 MG TABLET

SPIRONOLACTONE 25 MG TABLET

SPIRONOLACTONE 50 MG TABLET

SPIRONOLACTONE-HCTZ 25-25 TAB

SPRAVATO 56 MG DOSE PACK

SPRAVATO 84 MG DOSE PACK

SPRINTEC 28 DAY TABLET

SPRITAM 1,000 MG TABLET

SPRITAM 250 MG TABLET

SPRITAM 500 MG TABLET

SPRITAM 750 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

SPRYCEL 100 MG TABLET

SPRYCEL 140 MG TABLET

SPRYCEL 20 MG TABLET

SPRYCEL 50 MG TABLET

SPRYCEL 70 MG TABLET

SPRYCEL 80 MG TABLET

SRONYX 0.10-0.02 MG TABLET

ST. JOSEPH ASPIRIN 81 MG CHEW

ST. JOSEPH ASPIRIN EC 81 MG TB

STALEVO 100 TABLET

STALEVO 125 TABLET

STALEVO 150 TABLET

STALEVO 200 TABLET

STALEVO 50 TABLET

STALEVO 75 TABLET

STD BERMUDA GRASS 10,000/ML

STD MIX MITE 5,000-5,000 UNIT

STD RYE GRASS 100,000 BAU/ML

STD SWEET VERNAL 100,000/ML

STD CAT HAIR 10,000 BAU/ML

STD JUNE GRASS 100,000 BAU/ML

STD MEADOW FESCUE 100,000/ML

STD ORCHARD GRASS 100,000/ML

STD RED TOP GRASS 100,000/ML

STD TIMOTHY GRASS 10,000/ML

STD TIMOTHY GRASS 100,000/ML

STARLIX 120 MG TABLET

STARLIX 60 MG TABLET

STAVUDINE 15 MG CAPSULE

STAVUDINE 20 MG CAPSULE

STAVUDINE 30 MG CAPSULE

STAVUDINE 40 MG CAPSULE

STAXYN 10 MG ODT

STEGLATRO 15 MG TABLET

STEGLATRO 5 MG TABLET

STEGLUJAN 15-100 MG TABLET

STEGLUJAN 5-100 MG TABLET

STELARA 45 MG/0.5 ML SYRINGE

STELARA 45 MG/0.5 ML VIAL

STELARA 90 MG/ML SYRINGE

STENDRA 100 MG TABLET

STENDRA 200 MG TABLET

STENDRA 50 MG TABLET

STERILANCE TL TWIST 30G LANCET

STERILANCE TL TWIST 32G LANCET

STIMATE 1.5 MG/ML NASAL SPRAY

STIOLTO RESPIMAT INHAL SPRAY

STRATTERA 10 MG CAPSULE

STRATTERA 100 MG CAPSULE

STRATTERA 18 MG CAPSULE

STRATTERA 25 MG CAPSULE

STRATTERA 40 MG CAPSULE

STRATTERA 60 MG CAPSULE

STRATTERA 80 MG CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

STRENSIQ 18 MG/0.45 ML VIAL

STRENSIQ 28 MG/0.7 ML VIAL

STRENSIQ 40 MG/ML VIAL

STRENSIQ 80 MG/0.8 ML VIAL

STRESS B WITH ZINC TABLET

EQL STRESS B-COMPLEX TABLET

STRESS B-COMPLEX TABLET

STRESS FORMULA TABLET

SM STRESS FORMULA+ZINC TABLET

CVS STRESS FORMULA-ZINC TAB

STRESS FORMULA WITH ZINC TAB

STRESS-C WITH ZINC TABLET

STRESS-C TABLET

STRESSTABS W/ZINC TABLET

STRIANT 30 MG MUCOADHESIVE

STRIBILD TABLET

STRIVERDI RESPIMAT INHAL SPRAY

STROVITE FORTE CAPLET

STROVITE ONE CAPLET

STUART ONE CAPSULE

SUBLOCADE 100 MG/0.5 ML SYRING

SUBLOCADE 300 MG/1.5 ML SYRING

SUBOXONE 12 MG-3 MG SL FILM

SUBOXONE 2 MG-0.5 MG SL FILM

SUBOXONE 4 MG-1 MG SL FILM

SUBOXONE 8 MG-2 MG SL FILM

SUBVENITE 100 MG TABLET

SUBVENITE 150 MG TABLET

SUBVENITE 200 MG TABLET

SUBVENITE 25 MG TABLET

SUCRAID 8,500 UNITS/ML SOLN

SUCRALFATE 1 GM TABLET

SUCRALFATE 1 GM/10 ML SUSP

SULAR ER 17 MG TABLET

SULAR ER 34 MG TABLET

SULAR ER 8.5 MG TABLET

SULFASALAZINE 500 MG TABLET

SULFASALAZINE DR 500 MG TAB

SULINDAC 150 MG TABLET

SULINDAC 200 MG TABLET

SUNOSI 150 MG TABLET

SUNOSI 75 MG TABLET

SUNVITE TABLET

CVS SUPER B COMPLEX CAPLET

CVS SUPER B COMPLEX-VIT C CPLT

SM SUPER B COMPLEX-C CAPLET

SUPER B MAXI COMPLEX CAPLET

SUPER B WITH VIT C CAPSULE

SUPER B-50 COMPLEX CAPSULE

SUPER GINSENG MULTIVIT CAP

SUPER MULTIPLE VIT-MINERAL TAB

SUPER MULTIPLE CAPSULE

SUPER MULTIPLE-LOW IRON TABLET

SUPER MULTIVITAMIN TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

SUPER QUINTS B-50 TABLETS

SUPER QUINTS B-50 TABLET

SUPER THERA VITE M TABLET

KROGER SUPER THIN LANCETS

PC SUPER THIN 30G LANCETS

SM SUPER THIN 30G LANCETS

SMART SENSE SUPER THIN 30G

SUPER THIN 28G LANCETS

SUPER THIN 30G LANCETS

SUPERPLEX-T TABLET

SUPERVITE LIQUID

SUPPORT LIQUID

SUPPORT-500 SOFTGEL

SUPPRELIN LA 50 MG KIT

SURE COMFORT 30G PEN NEEDLE

SURE COMFORT 31G PEN NEEDLE

SURE COMFORT PEN NDL 29GX1/2"

SURE COMFORT PEN NDL 31GX3/16"

SURE COMFORT PEN NDL 32GX1/4"

SURE COMFORT PEN NDL 32GX5/32"

SURE COMFORT 1 ML SYRINGE

SURE COMFORT 0.5 ML SYRINGE

SURE COMFORT 0.3 ML SYRINGE

SURE COMFORT 3/10 ML SYRINGE

SURE COMFORT INS 1 ML 31GX1/4"

SURE COMFORT INS 0.5ML 31GX1/4

SURE COMFORT INS 0.3ML 31GX1/4

SURE COMFORT 18G LANCETS

SURE COMFORT 21G LANCETS

SURE COMFORT 23G LANCETS

SURE COMFORT 28G LANCETS

SURE COMFORT 30G LANCETS

SURE-FINE PEN NEEDLES 12.7MM

SURE-FINE PEN NEEDLES 5MM

SURE-FINE PEN NEEDLES 8MM

NOVA SUREFLEX LANCING DEVICE

SURE-JECT INSU SYR U100 1 ML

SURE-JECT INSUL SYR U100 1 ML

SURE-JECT INSULIN SYRINGE 1 ML

SURE-JECT INSU SYR U100 0.5 ML

SURE-JECT INSU SYR U100 0.3 ML

SURE-LANCE 26G LANCETS

SURE-LANCE FLAT LANCETS

SURE-LANCE THIN 28G LANCETS

SURE-LANCE ULTRA THIN 30G

SURE-T PARADIGM 18" SET

SURE-T PARADIGM 23" SET

SURE-T PARADIGM 32" SET

SURE-TEST EASYPLUS MINI STRIP

SURE-TEST EASYPLUS MINI SOLN

SURE-TEST EASYPLUS MINI METER

SURE-TOUCH LANCET

SURMONTIL 100 MG CAPSULE

SURMONTIL 25 MG CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

SURMONTIL 50 MG CAPSULE

SUSTIVA 200 MG CAPSULE

SUSTIVA 50 MG CAPSULE

SUSTIVA 600 MG TABLET

SUTENT 12.5 MG CAPSULE

SUTENT 25 MG CAPSULE

SUTENT 37.5 MG CAPSULE

SUTENT 50 MG CAPSULE

SWEETGUM 1:20 (W/V) VIAL

SYEDA 28 TABLET

SYLATRON 200 MCG KIT

SYLATRON 300 MCG KIT

SYLATRON 600 MCG KIT

SYLVANT 100 MG VIAL

SYLVANT 400 MG VIAL

SYMAX FASTABS 0.125 MG TABLET

SYMAX DUOTAB

SYMAX-SL 0.125 MG TABLET SL

SYMAX-SR 0.375 MG TABLET

SYMBICORT 160-4.5 MCG INHALER

SYMBICORT 80-4.5 MCG INHALER

SYMBYAX 12-25 MG CAPSULE

SYMBYAX 12-50 MG CAPSULE

SYMBYAX 3-25 MG CAPSULE

SYMBYAX 6-25 MG CAPSULE

SYMBYAX 6-50 MG CAPSULE

SYMDEKO 100/150 MG-150 MG TABS

SYMDEKO 50/75 MG-75 MG TABLETS

SYMFI 600-300-300 MG TABLET

SYMFI LO 400-300-300 MG TABLET

SYMLINPEN 120 PEN INJECTOR

SYMLINPEN 60 PEN INJECTOR

SYMPAZAN 10 MG FILM

SYMPAZAN 20 MG FILM

SYMPAZAN 5 MG FILM

SYMTUZA 800-150-200-10 MG TAB

SYNJARDY 12.5-1,000 MG TABLET

SYNJARDY 12.5-500 MG TABLET

SYNJARDY 5-1,000 MG TABLET

SYNJARDY 5-500 MG TABLET

SYNJARDY XR 10-1,000 MG TABLET

SYNJARDY XR 12.5-1,000 MG TAB

SYNJARDY XR 25-1,000 MG TABLET

SYNJARDY XR 5-1,000 MG TABLET

SYNRIBO 3.5 MG/ML VIAL

SYNTHROID 0.137 MG TABLET

SYNTHROID 100 MCG TABLET

SYNTHROID 112 MCG TABLET

SYNTHROID 125 MCG TABLET

SYNTHROID 137 MCG TABLET

SYNTHROID 150 MCG TABLET

SYNTHROID 175 MCG TABLET

SYNTHROID 200 MCG TABLET

SYNTHROID 25 MCG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

SYNTHROID 300 MCG TABLET

SYNTHROID 50 MCG TABLET

SYNTHROID 75 MCG TABLET

SYNTHROID 88 MCG TABLET

T:30 INFUSION SET 23" 13MM

T:30 INFUSION SET 43" 13MM

T:90 INFUSION SET 23" 6MM

T:90 INFUSION SET 23" 9MM

T:90 INFUSION SET 43" 9MM

T:FLEX 4.8 ML CARTRIDGE

T:SLIM 3 ML CARTRIDGE

T:SLIM G4 3 ML CARTRIDGE

TAB-A-VITE TABLET

TAB-A-VITE MULTIVIT WITH IRON

TAB-A-VITE WITH IRON TABLET

TAB-A-VITE-MINERALS TABLET

TACROLIMUS 0.5 MG CAPSULE

TACROLIMUS 1 MG CAPSULE

TACROLIMUS 5 MG CAPSULE

TADALAFIL 10 MG TABLET

TADALAFIL 2.5 MG TABLET

TADALAFIL 20 MG TABLET

TADALAFIL 5 MG TABLET

TAFINLAR 50 MG CAPSULE

TAFINLAR 75 MG CAPSULE

TAGAMET HB 200 MG TABLET

TAKHZYRO 300 MG/2 ML VIAL

TALL RAGWEED 1:20 W/V VIAL

TALTZ 80 MG/ML AUTOINJECTOR

TALTZ 80 MG/ML AUTOINJ (2-PK)

TALTZ 80 MG/ML AUTOINJ (3-PK)

TALTZ 80 MG/ML SYRINGE

TALTZ 80 MG/ML SYRINGE (2-PK)

TALTZ 80 MG/ML SYRINGE (3-PK)

TAMOXIFEN 10 MG TABLET

TAMOXIFEN 20 MG TABLET

TAMSULOSIN HCL 0.4 MG CAPSULE

TANZEUM 30 MG PEN INJECT

TANZEUM 50 MG PEN INJECT

TAPAZOLE 10 MG TABLET

TAPAZOLE 5 MG TABLET

TARCEVA 100 MG TABLET

TARCEVA 150 MG TABLET

TARCEVA 25 MG TABLET

TARGRETIN 75 MG CAPSULE

TARINA 24 FE 1 MG-20 MCG TAB

TARINA FE 1-20 TABLET

TARINA FE 1-20 EQ TABLET

TARKA ER 1-240 MG TABLET

TARKA ER 2-180 MG TABLET

TARKA ER 2-240 MG TABLET

TARKA ER 4-240 MG TABLET

TARON-C DHA CAPSULE

TARON-PREX PRENATAL DHA CAP

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

TASIGNA 150 MG CAPSULE

TASIGNA 200 MG CAPSULE

TASIGNA 50 MG CAPSULE

TASMAR 100 MG TABLET

TAYTULLA 1 MG-20 MCG CAPSULE

TAZTIA XT 120 MG CAPSULE

TAZTIA XT 180 MG CAPSULE

TAZTIA XT 240 MG CAPSULE

TAZTIA XT 300 MG CAPSULE

TAZTIA XT 360 MG CAPSULE

TAZVERIK 200 MG TABLET

TECENTRIQ 1,200 MG/20 ML VIAL

TECENTRIQ 840 MG/14 ML VIAL

TECFIDERA DR 120 MG CAPSULE

TECFIDERA DR 240 MG CAPSULE

TECHLITE 0.3 ML 29GX12MM (1/2)

TECHLITE 0.3 ML 30GX12MM (1/2)

TECHLITE 0.3 ML 30GX8MM (1/2)

TECHLITE 0.3 ML 31GX6MM (1/2)

TECHLITE 0.3 ML 31GX8MM (1/2)

TECHLITE 0.5 ML 29GX12MM (1/2)

TECHLITE 0.5 ML 30GX12MM (1/2)

TECHLITE 0.5 ML 30GX8MM (1/2)

TECHLITE 0.5 ML 31GX6MM (1/2)

TECHLITE 0.5 ML 31GX8MM (1/2)

TECHLITE INS SYR 1 ML 29GX12MM

TECHLITE INS SYR 1 ML 30GX12MM

TECHLITE INS SYR 1 ML 30GX8MM

TECHLITE INS SYR 1 ML 31GX6MM

TECHLITE INS SYR 1 ML 31GX8MM

TECHLITE 25G LANCETS

TECHLITE 28G LANCETS

TECHLITE 30G LANCETS

TECHLITE PEN NEEDLE 29GX1/2"

TECHLITE PEN NEEDLE 29GX3/8"

TECHLITE PEN NEEDLE 31GX1/4"

TECHLITE PEN NEEDLE 31GX3/16"

TECHLITE PEN NEEDLE 31GX5/16"

TECHLITE PEN NEEDLE 32GX1/4"

TECHLITE PEN NEEDLE 32GX5/16"

TECHLITE PEN NEEDLE 32GX5/32"

TEGRETOL 100 MG/5 ML SUSP

TEGRETOL 200 MG TABLET

TEGRETOL XR 100 MG TABLET

TEGRETOL XR 200 MG TABLET

TEGRETOL XR 400 MG TABLET

TEGSEDI 284 MG/1.5 ML SYRINGE

TEKTURNA 150 MG TABLET

TEKTURNA 300 MG TABLET

TEKTURNA HCT 150-12.5 MG TAB

TEKTURNA HCT 150-25 MG TABLET

TEKTURNA HCT 300-12.5 MG TAB

TEKTURNA HCT 300-25 MG TABLET

TELCARE TEST STRIPS

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

TELCARE BLOOD GLUCOSE MONITOR

TELCARE ULTRA THIN 30G LANCETS

TELCARE BGM BLOOD GLUCOSE KIT

TELCARE CONTROL SOLUTION

TELMISARTAN 20 MG TABLET

TELMISARTAN 40 MG TABLET

TELMISARTAN 80 MG TABLET

TELMISARTAN-AMLODIPINE 40-10

TELMISARTAN-AMLODIPINE 40-5 MG

TELMISARTAN-AMLODIPINE 80-10

TELMISARTAN-AMLODIPINE 80-5 MG

TELMISARTAN-HCTZ 40-12.5 MG TB

TELMISARTAN-HCTZ 80-12.5 MG TB

TELMISARTAN-HCTZ 80-25 MG TAB

TEMIXYS 300-300 MG TABLET

TENEX 1 MG TABLET

TENEX 2 MG TABLET

TENOFOVIR DISOP FUM 300 MG TB

TENORETIC 100 TABLET

TENORETIC 50 TABLET

TENORMIN 100 MG TABLET

TENORMIN 25 MG TABLET

TENORMIN 50 MG TABLET

TERAZOSIN 1 MG CAPSULE

TERAZOSIN 10 MG CAPSULE

TERAZOSIN 2 MG CAPSULE

TERAZOSIN 5 MG CAPSULE

TERBUTALINE SULFATE 2.5 MG TAB

TERBUTALINE SULFATE 5 MG TAB

TERUMO INS SYRINGE U100-1 ML

TERUMO INS SYRINGE U100-1/2 ML

TERUMO INS SYRNG U100-1/2 ML

TERUMO INS SYRINGE U100-1/3 ML

TEST N'GO GLUCOSE TEST STRIP

TEST N'GO BLOOD GLUCOSE SYSTEM

PHARMACIST CHOICE TEST STRIPS

TESTIM 1% (50MG) GEL

TESTONE CIK KIT

TESTOPEL 75 MG PELLETS

TESTOSTERONE 1.62% (2.5 G) PKT

TESTOSTERONE 1.62% GEL PUMP

TESTOSTERONE 1.62%(1.25 G) PKT

TESTOSTERONE 10 MG GEL PUMP

TESTOSTERONE 12.5 MG/1.25 GRAM

TESTOSTERONE 200 MG PELLET

TESTOSTERONE 25 MG/2.5 GM PKT

TESTOSTERONE 30 MG/1.5 ML PUMP

TESTOSTERONE 50 MG/5 GRAM GEL

TESTOSTERONE 50 MG/5 GRAM PKT

TESTOSTERON CYP 1,000 MG/10 ML

TESTOSTERON CYP 2,000 MG/10 ML

TESTOSTERONE CYP 1,000 MG/5 ML

TESTOSTERONE CYP 100 MG/ML

TESTOSTERONE CYP 200 MG/ML

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

TESTOSTERONE CYP 250 MG/5 ML

TESTOSTERONE CYP 500 MG/2.5 ML

TESTOSTERONE CYP 500 MG/5 ML

TESTOSTERONE CYP 6,000 MG/30ML

TESTOSTERON ENAN 1,000 MG/5 ML

TESTOSTERONE ENAN 200 MG/ML

TESTOSTERONE PROP 1,000MG/10ML

TESTRED 10 MG CAPSULE

TETRABENAZINE 12.5 MG TABLET

TETRABENAZINE 25 MG TABLET

TEXAVITE LQ DROPS

THALOMID 100 MG CAPSULE

THALOMID 150 MG CAPSULE

THALOMID 200 MG CAPSULE

THALOMID 50 MG CAPSULE

THEO-24 ER 100 MG CAPSULE

THEO-24 ER 200 MG CAPSULE

THEO-24 ER 300 MG CAPSULE

THEO-24 ER 400 MG CAPSULE

THEOCHRON ER 100 MG TABLET

THEOCHRON ER 200 MG TABLET

THEOPHYLLINE 80 MG/15 ML SOLN

THEOPHYLLINE ER 400 MG TABLET

THEOPHYLLINE ER 600 MG TABLET

THEOPHYLLINE ER 100 MG TABLET

THEOPHYLLINE ER 200 MG TABLET

THEOPHYLLINE ER 300 MG TAB

THEOPHYLLINE ER 450 MG TAB

THERA TABLET

THERA CAPLET

THERA M PLUS TABLET

THERAGRAN-M PREMIER 50+ CAPLET

THERA-M CAPLET

THERA-M TABLET

THERA-M CAPLET

THERA-M CAPLET

THERAMILL FORTE CAPSULE

THERANATAL CORE NUTRITION TAB

THERANATAL COMPLETE COMBO

THERANATAL LACTATION COMBO PCK

THERANATAL ONE SOFTGEL

THERANATAL OVAVITE COMBO PACK

THERANATAL PLUS COMBO PACK

SM THERAPEUTIC M TABLET

GNP THERAPEUTIC-M CAPLET

THERAPEUTIC-M CAPLET

THERAPEUTIC-M TABLET

THERA-TABS CAPLET

THERA-TABS M CAPLET

THERATRUM COMPLETE TABLET

THERATRUM COMPLETE 50 PLUS TAB

THERATRUM COMPLETE 50 PLUS TAB

THEREMS TABLET

THEREMS-H TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

THEREMS-M TABLET

LONGS THIN LANCETS 26G

LONGS THIN LANCETS 30G

RELION THIN 26G LANCETS

SM THIN LANCETS 26G

THIN 26G LANCETS

THIN LANCETS 28G

WALGREENS THIN LANCETS

THINPRO INS SYRIN U100-1 ML

THINPRO INS SYRIN U100-0.5 ML

THINPRO INS SYRIN U100-0.3 ML

THIOLA 100 MG TABLET

THIOLA EC 100 MG TABLET

THIOLA EC 300 MG TABLET

THIORIDAZINE 10 MG TABLET

THIORIDAZINE 100 MG TABLET

THIORIDAZINE 25 MG TABLET

THIORIDAZINE 50 MG TABLET

THIOTHIXENE 1 MG CAPSULE

THIOTHIXENE 10 MG CAPSULE

THIOTHIXENE 2 MG CAPSULE

THIOTHIXENE 5 MG CAPSULE

THRIVITE 19 TABLET

THRIVITE RX TABLET

THYROID 120 MG TABLET

THYROID 15 MG TABLET

THYROID 30 MG TABLET

THYROID 60 MG TABLET

THYROID 90 MG TABLET

THYROLAR-1 STRENGTH TABLET

THYROLAR-1/2 STRENGTH TAB

THYROLAR-1/4 STRENGTH TAB

THYROLAR-2 STRENGTH TABLET

THYROLAR-3 STRENGTH TABLET

TIADYLT ER 120 MG CAPSULE

TIADYLT ER 180 MG CAPSULE

TIADYLT ER 240 MG CAPSULE

TIADYLT ER 300 MG CAPSULE

TIADYLT ER 360 MG CAPSULE

TIADYLT ER 420 MG CAPSULE

TIAGABINE HCL 12 MG TABLET

TIAGABINE HCL 16 MG TABLET

TIAGABINE HCL 2 MG TABLET

TIAGABINE HCL 4 MG TABLET

TIAZAC ER 120 MG CAPSULE

TIAZAC ER 180 MG CAPSULE

TIAZAC ER 240 MG CAPSULE

TIAZAC ER 300 MG CAPSULE

TIAZAC ER 360 MG CAPSULE

TIAZAC ER 420 MG CAPSULE

TIBSOVO 250 MG TABLET

TICANASE KIT

TICASPRAY KIT

TICLOPIDINE 250 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

TIGLUTIK 50 MG/10 ML SUSP

TIKOSYN 125 MCG CAPSULE

TIKOSYN 250 MCG CAPSULE

TIKOSYN 500 MCG CAPSULE

TILIA FE 28 TABLET

TIMOLOL 0.25% GEL-SOLUTION

TIMOLOL 0.25% GFS GEL-SOLUTION

TIMOLOL 0.5% EYE DROP

TIMOLOL 0.5% GEL-SOLUTION

TIMOLOL 0.5% GFS GEL-SOLUTION

TIMOLOL MALEATE 0.25% EYE DROP

TIMOLOL MALEATE 0.5% EYE DROPS

TIMOLOL MALEATE 10 MG TABLET

TIMOLOL MALEATE 20 MG TABLET

TIMOLOL MALEATE 5 MG TABLET

TIMOL 0.5%-BRIM 0.15%-DORZO 2%

TIMOLOL-BRIMONI-DORZOL-LATANOP

TIMOLOL 0.5%-DORZOLAMIDE 2%

TIMO 0.5%-DORZ 2%-LATAN 0.005%

TIMOLOL 0.5%-LATANOPROS 0.005%

TIMOPTIC 0.25% EYE DROP

TIMOPTIC 0.25% EYE DROPS

TIMOPTIC 0.5% EYE DROP

TIMOPTIC 0.5% EYE DROPS

TIMOPTIC 0.25% OCUDOSE DROP

TIMOPTIC 0.5% OCUDOSE DROP

TIMOPTIC-XE 0.25% EYE GEL-SOLN

TIMOPTIC-XE 0.25% EYE SOLN

TIMOPTIC-XE 0.5% EYE SOLN

TIMOPTIC-XE 0.5% GEL-SOLUTION

TIROSINT 100 MCG CAPSULE

TIROSINT 112 MCG CAPSULE

TIROSINT 125 MCG CAPSULE

TIROSINT 13 MCG CAPSULE

TIROSINT 137 MCG CAPSULE

TIROSINT 150 MCG CAPSULE

TIROSINT 175 MCG CAPSULE

TIROSINT 200 MCG CAPSULE

TIROSINT 25 MCG CAPSULE

TIROSINT 50 MCG CAPSULE

TIROSINT 75 MCG CAPSULE

TIROSINT 88 MCG CAPSULE

TIROSINT-SOL 100 MCG/ML SOLN

TIROSINT-SOL 112 MCG/ML SOLN

TIROSINT-SOL 125 MCG/ML SOLN

TIROSINT-SOL 13 MCG/ML SOLN

TIROSINT-SOL 137 MCG/ML SOLN

TIROSINT-SOL 150 MCG/ML SOLN

TIROSINT-SOL 175 MCG/ML SOLN

TIROSINT-SOL 200 MCG/ML SOLN

TIROSINT-SOL 25 MCG/ML SOLN

TIROSINT-SOL 50 MCG/ML SOLN

TIROSINT-SOL 75 MCG/ML SOLN

TIROSINT-SOL 88 MCG/ML SOLN

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

TIVICAY 10 MG TABLET

TIVICAY 25 MG TABLET

TIVICAY 50 MG TABLET

TIZANIDINE HCL 2 MG CAPSULE

TIZANIDINE HCL 2 MG TABLET

TIZANIDINE HCL 4 MG CAPSULE

TIZANIDINE HCL 4 MG TABLET

TIZANIDINE HCL 6 MG CAPSULE

TL GARD RX TABLET

TOBAKIENT CAPSULE

TOBI 300 MG/5 ML SOLUTION

TOBI PODHALER 28 MG INHALE CAP

TOBRAMYCIN 300 MG/5 ML AMPULE

TOBRAMYCIN PAK 300 MG/5 ML

TOFRANIL 10 MG TABLET

TOFRANIL 25 MG TABLET

TOFRANIL 50 MG TABLET

TOLAZAMIDE 250 MG TABLET

TOLAZAMIDE 500 MG TABLET

TOLBUTAMIDE 500 MG TABLET

TOLCAPONE 100 MG TABLET

TOLMETIN SODIUM 200 MG TAB

TOLMETIN SODIUM 400 MG CAP

TOLMETIN SODIUM 600 MG TAB

TOLTERODINE TARTRATE 1 MG TAB

TOLTERODINE TARTRATE 2 MG TAB

TOLTERODINE TART ER 2 MG CAP

TOLTERODINE TART ER 4 MG CAP

TOPAMAX 100 MG TABLET

TOPAMAX 15 MG SPRINKLE CAP

TOPAMAX 200 MG TABLET

TOPAMAX 25 MG SPRINKLE CAP

TOPAMAX 25 MG TABLET

TOPAMAX 50 MG TABLET

TOPCARE CLICKFINE 31G X 1/4"

TOPCARE CLICKFINE 31G X 5/16"

TOPCARE ULTRA COMFORT SYRINGE

TOPCARE ULTRA COMFORT SYRINGE

TOPCARE ULTRA COMFORT SYRINGE

TOPCARE UNIVERSAL1 33G LANCETS

TOPCARE UNIVERSAL1 THIN LANCET

TOPIRAMATE 100 MG TABLET

TOPIRAMATE 15 MG SPRINKLE CAP

TOPIRAMATE 200 MG TABLET

TOPIRAMATE 25 MG SPRINKLE CAP

TOPIRAMATE 25 MG TABLET

TOPIRAMATE 50 MG TABLET

TOPIRAMATE ER 100 MG CAPSULE

TOPIRAMATE ER 150 MG CAPSULE

TOPIRAMATE ER 200 MG CAPSULE

TOPIRAMATE ER 25 MG CAPSULE

TOPIRAMATE ER 50 MG CAPSULE

TOPROL XL 100 MG TABLET

TOPROL XL 200 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

TOPROL XL 25 MG TABLET

TOPROL XL 50 MG TABLET

TOREMIFENE CITRATE 60 MG TAB

TORSEMIDE 10 MG TABLET

TORSEMIDE 100 MG TABLET

TORSEMIDE 20 MG TABLET

TORSEMIDE 5 MG TABLET

TOTAL B WITH VIT C CAPLET

TOTALDAY MULTIPLE TABLET SA

TOUJEO MAX SOLOSTR 300 UNIT/ML

TOUJEO SOLOSTAR 300 UNIT/ML

TOVIAZ ER 4 MG TABLET

TOVIAZ ER 8 MG TABLET

TRACLEER 125 MG TABLET

TRACLEER 32 MG TABLET FOR SUSP

TRACLEER 62.5 MG TABLET

TRADJENTA 5 MG TABLET

TRANDOLAPRIL 1 MG TABLET

TRANDOLAPRIL 2 MG TABLET

TRANDOLAPRIL 4 MG TABLET

TRANDOLAPR-VERAPAM ER 1-240 MG

TRANDOLAPR-VERAPAM ER 2-180 MG

TRANDOLAPR-VERAPAM ER 2-240 MG

TRANDOLAPR-VERAPAM ER 4-240 MG

TRANEXAMIC ACID 650 MG TABLET

TRANYLCYPROMINE SULF 10 MG TAB

TRAVATAN Z 0.004% EYE DROP

TRAVOPROST 0.004% EYE DROP

TRAVOPROST 0.004% EYE DROP

TRAZIMERA 420 MG VIAL

TRAZODONE 100 MG TABLET

TRAZODONE 150 MG TABLET

TRAZODONE 300 MG TABLET

TRAZODONE 50 MG TABLET

TRELEGY ELLIPTA 100-62.5-25

TRELSTAR 11.25 MG VIAL

TRELSTAR 22.5 MG VIAL

TRELSTAR 3.75 MG VIAL

TREMFYA 100 MG/ML INJECTOR

TREMFYA 100 MG/ML SYRINGE

TREPROSTINIL 100 MG/20 ML VIAL

TREPROSTINIL 20 MG/20 ML VIAL

TREPROSTINIL 200 MG/20 ML VIAL

TREPROSTINIL 50 MG/20 ML VIAL

TRESIBA 100 UNIT/ML VIAL

TRESIBA FLEXTOUCH 100 UNIT/ML

TRESIBA FLEXTOUCH 200 UNIT/ML

TRETTEN 2,500 UNIT VIAL

TREXALL 10 MG TABLET

TREXALL 15 MG TABLET

TREXALL 5 MG TABLET

TREXALL 7.5 MG TABLET

TRI FEMYNOR 28 TABLET

TRIAMTERENE 100 MG CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

TRIAMTERENE 50 MG CAPSULE

TRIAMTERENE-HCTZ 37.5-25 MG CP

TRIAMTERENE-HCTZ 37.5-25 MG CP

TRIAMTERENE-HCTZ 37.5-25 MG TB

TRIAMTERENE-HCTZ 50-25 MG CAP

TRIAMTERENE-HCTZ 75-50 MG TAB

TRIBENZOR 20-5-12.5 MG TABLET

TRIBENZOR 40-10-12.5 MG TABLET

TRIBENZOR 40-10-25 MG TABLET

TRIBENZOR 40-5-12.5 MG TABLET

TRIBENZOR 40-5-25 MG TABLET

TRI-BUFFERED ASPIRIN 325 MG

TRI-BUFFERED ASPIRIN 325 MG TB

TRICARE PRENATAL TABLET

TRICARE PRENATAL CHEWABLE TAB

TRICARE PRENATAL DHA ONE SFTGL

TRICARE PRENATAL DHA ONE SFTGL

TRICARE PRENATAL WITH DHA PACK

TRICHOPHYTON 20,000 PNU/ML VL

TRICOR 145 MG TABLET

TRICOR 48 MG TABLET

TRI-ESTARYLLA TABLET

TRIFERIC 27.2 MG/5 ML AMPULE

TRIFERIC 272 MG POWDER PACKET

TRIFERIC 272 MG/50 ML AMPULE

TRIFLUOPERAZINE 1 MG TABLET

TRIFLUOPERAZINE 10 MG TABLET

TRIFLUOPERAZINE 2 MG TABLET

TRIFLUOPERAZINE 5 MG TABLET

TRIGLIDE 160 MG TABLET

TRIHEXYPHENIDYL 2 MG TABLET

TRIHEXYPHENIDYL 2 MG/5 ML ELX

TRIHEXYPHENIDYL 5 MG TABLET

TRIJARDY XR 10-5-1,000 MG TAB

TRIJARDY XR 12.5-2.5-1,000 MG

TRIJARDY XR 25-5-1,000 MG TAB

TRIJARDY XR 5-2.5-1,000 MG TAB

TRIKAFTA 100/50/75 MG-150 MG

TRIKLO 1 GM CAPSULE

TRI-LEGEST FE-28 DAY TABLET

TRILEPTAL 150 MG TABLET

TRILEPTAL 300 MG TABLET

TRILEPTAL 300 MG/5 ML SUSP

TRILEPTAL 600 MG TABLET

TRI-LINYAH TABLET

TRILIPIX DR 135 MG CAPSULE

TRILIPIX DR 45 MG CAPSULE

TRI-LO-ESTARYLLA TABLET

TRI-LO-MARZIA TABLET

TRI-LO-MILI TABLET

TRI-LO-SPRINTEC TABLET

TRI-MILI 28 TABLET

TRIMIPRAMINE MALEATE 100 MG CP

TRIMIPRAMINE MALEATE 25 MG CAP

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

TRIMIPRAMINE MALEATE 50 MG CAP

TRINATAL RX 1 TABLET

TRINATE TABLET

TRINAZ TABLET

TRINESSA TABLET

TRINESSA LO TABLET

TRI-NORINYL 28 TABLET

TRINTELLIX 10 MG TABLET

TRINTELLIX 20 MG TABLET

TRINTELLIX 5 MG TABLET

TRIPHROCAPS SOFTGEL

TRI-PREVIFEM TABLET

TRIPTODUR 22.5 MG KIT

TRI-SPRINTEC TABLET

TRISTART DHA SOFTGEL

TRIUMEQ 600-50-300 MG TABLET

TRIVEEN-DUO DHA COMBO PACK

TRI-VI-FLOR 0.25 MG DROPS

TRI-VI-FLOR 0.5 MG DROPS

TRI-VI-SOL DROPS

TRI-VIT-FLUOR-IRON 0.25 MG/ML

TRI-VITA DROPS

TRI-VITAMIN DROPS

TRI-VIT-FLUOR 0.25 MG/ML DROP

TRI-VIT-FLUOR 0.5 MG/ML DROP

TRI-VITE-FLUORIDE 0.25 MG/ML

TRI-VITE-FLUORIDE 0.5 MG/ML

TRIVORA-28 TABLET

TRI-VYLIBRA 28 TABLET

TRI-VYLIBRA LO TABLET

TRIZIVIR TABLET

TROGARZO 200 MG/1.33 ML VIAL

TROKENDI XR 100 MG CAPSULE

TROKENDI XR 200 MG CAPSULE

TROKENDI XR 25 MG CAPSULE

TROKENDI XR 50 MG CAPSULE

TROPICAL LIQUID NUTRITION

TROSPIUM CHLORIDE 20 MG TABLET

TROSPIUM CHLORIDE ER 60 MG CAP

TRUE COMFORT 1 ML 31GX5/16"

TRUE COMFORT 0.5 ML 31GX5/16"

TRUE COMFORT 30G LANCET

TRUE COMFORT PEN NDL 31GX5MM

TRUE COMFORT PEN NDL 31GX6MM

TRUE COMFORT PEN NDL 32GX4MM

TRUE METRIX LEVEL 3 CTRL SOLN

TRUE METRIX LEVEL 1 CTRL SOLN

TRUE METRIX LEVEL 2 CTRL SOLN

HUMANA TRUE METRIX AIR GLU MTR

HUMANA TRUE METRIX AIR METER

TRUE METRIX AIR GLUCOSE METER

TRUE METRIX BLOOD GLUCOSE MTR

HUMANA TRUE METRIX TEST STRIP

TRUE METRIX GLUCOSE TEST STRIP

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

TRUE METRIX GO GLUCOSE METER

TRUE2GO BLOOD GLUCOSE SYSTEM

TRUECONTROL GLUCOSE SOLUTION

TRUECONTROL GLUCOSE SOLUTION

TRUEPLUS SYR 1ML 28GX1/2"

TRUEPLUS SYR 1ML 29GX1/2"

TRUEPLUS SYR 1ML 30GX5/16"

TRUEPLUS SYR 1ML 31GX5/16"

TRUEPLUS SYR 0.5ML 28GX1/2"

TRUEPLUS SYR 0.5ML 29GX1/2"

TRUEPLUS SYR 0.5ML 30GX5/16"

TRUEPLUS SYR 0.5ML 31GX5/16"

TRUEPLUS SYR 0.3ML 29GX1/2"

TRUEPLUS SYR 0.3ML 30GX5/16"

TRUEPLUS SYR 0.3ML 31GX5/16"

TRUEPLUS KETONE TEST STRIP

TRUEPLUS SAFETY 28G LANCET

TRUEPLUS 26G LANCETS

TRUEPLUS 30G LANCETS

TRUEPLUS 33G LANCETS

TRUEPLUS SAFETY 28G LANCET

TRUEPLUS SAFETY 28G LANCETS

TRUEPLUS SUPER THIN 28G LANCET

TRUEPLUS ULTRA THIN 30G LANCET

TRUEPLUS DIABETIC MULTIVITAMIN

TRUEPLUS PEN NEEDLE 29GX1/2"

TRUEPLUS PEN NEEDLE 31G X 1/4"

TRUEPLUS PEN NEEDLE 31GX3/16"

TRUEPLUS PEN NEEDLE 31GX5/16"

TRUEPLUS PEN NEEDLE 32GX5/32"

HUMANA TRUERESULT GLUCOSE MTR

TRUERESULT BLOOD GLUCOSE SYSTM

TRUETEST CONTROL SOLN HIGH

TRUETEST CONTROL SOLUTION LOW

TRUETEST CONTROL SOLN NORMAL

HUMANA TRUETEST TEST STRIPS

TRUETEST GLUCOSE TEST STRIP

TRUETEST GLUCOSE TEST STRIPS

TRUETRACK BLOOD GLUCOSE SYSTEM

TRUETRACK SMART SYSTEM

TRUETRACK GLUCOSE TEST STRIPS

TRULANCE 3 MG TABLET

TRULICITY 0.75 MG/0.5 ML PEN

TRULICITY 1.5 MG/0.5 ML PEN

TRUSOPT 2% EYE DROPS

TRUST NATAL DHA

TRUSTEEL INFUSION SET 23" 6MM

TRUSTEEL INFUSION SET 23" 8MM

TRUSTEEL INFUSION SET 32" 6MM

TRUSTEEL INFUSION SET 32" 8MM

TRUVADA 100 MG-150 MG TABLET

TRUVADA 133 MG-200 MG TABLET

TRUVADA 167 MG-250 MG TABLET

TRUVADA 200 MG-300 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

TUDORZA PRESSAIR 400 MCG INHAL

TULANA 0.35 MG TABLET

TURALIO 200 MG CAPSULE

TWIST LANCETS 30G

TWIST LANCETS 32G

TWYNSTA 40-10 MG TABLET

TWYNSTA 40-5 MG TABLET

TWYNSTA 80-10 MG TABLET

TWYNSTA 80-5 MG TABLET

TYBOST 150 MG TABLET

TYDEMY TABLET

TYKERB 250 MG TABLET

TYMLOS 80 MCG DOSE PEN INJECTR

TYR COOLER LIQUID

TYSABRI 300 MG/15 ML VIAL

TYVASO 1.74 MG/2.9 ML SOLUTION

TYVASO INHALATION REFILL KIT

UDAMIN SP CAPLET

ULORIC 40 MG TABLET

ULORIC 80 MG TABLET

ULTICARE SYR 1 ML 30GX5/16"

ULTICARE SYRINGE 1 ML 29GX1/2"

ULTICARE INS SYR 1 ML 30GX1/2"

ULTICARE SYR 1 ML 31GX5/16"

ULTICARE SYRINGE 1 ML 30GX1/2"

ULTICARE INS 0.5 ML 30GX1/2"

ULTICARE SYR 0.5 ML 30GX1/2"

ULTICARE SYR 0.5 ML 31GX5/16"

ULTICARE INS 0.3 ML 30GX1/2"

ULTICARE SYR 0.3 ML 30GX1/2"

ULTICARE SYR 0.3 ML 31GX5/16"

ULTICARE SYR 0.3 ML 29GX1/2"

ULTICARE SYR 0.3 ML 30GX5/16"

ULTICARE SYR 0.5 ML 29GX1/2"

ULTICARE SYR 0.5 ML 30GX5/16"

ULTICAR INS 0.3ML 31GX1/4(1/2)

ULTICARE INS 1 ML 31GX1/4"

ULTICARE INS 0.5 ML 31GX1/4"

ULTICARE INS 0.3 ML 31GX1/4"

HM ULTICARE PEN NEEDLE 4MM 32G

HM ULTICARE PEN NEEDLE 6MM 31G

HM ULTICARE PEN NEEDLE 8MM 31G

ULTICARE PEN NDL 12.7 MM 29G

ULTICARE PEN NEEDLE 31GX3/16"

ULTICARE PEN NEEDLE 4MM 32G

ULTICARE PEN NEEDLE 6MM 31G

ULTICARE PEN NEEDLE 8 MM 31G

ULTICARE PEN NEEDLE 8MM 31G

ULTICARE PEN NEEDLES 12MM 29G

ULTICARE PEN NEEDLES 4MM 32G

ULTICARE PEN NEEDLES 6MM 31G

ULTICARE PEN NEEDLES 6MM 32G

ULTICARE PEN NEEDLES 8MM 31G

YOURX ULTICARE PEN NDL 4MM 32G

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

YOURX ULTICARE PEN NDL 6MM 31G

YOURX ULTICARE PEN NDL 8MM 31G

ULTIGUARD SAFE PACK 31GX1/4"

ULTIGUARD SAFE PACK 31GX3/16"

ULTIGUARD SAFE PACK 31GX5/16"

ULTIGUARD SAFE PACK 32GX1/4"

ULTIGUARD SAFE PACK 32GX5/32"

ULTI-LANCE AUTO-AD DEVICE

ULTILET BASIC 30G LANCETS

ULTILET CLASSIC 26G LANCETS

ULTILET CLASSIC 28G LANCETS

ULTILET CLASSIC 30G LANCETS

ULTILET CLASSIC 33G LANCETS

INSULIN SYRINGE 1 ML

ULTILET INSULIN SYRINGE 1 ML

INSULIN SYRINGE 0.5 ML

ULTILET INSULIN SYRINGE 0.5 ML

INSULIN SYRINGE 0.3 ML

ULTILET INSULIN SYRINGE 0.3 ML

ULTILET 28G LANCETS

ULTILET 30G LANCETS

ULTILET 33G LANCETS

ULTILET PEN NEEDLE

ULTILET PEN NEEDLE 4MM 32G

ULTILET SAFETY 23G LANCETS

RELION ULTIMA TEST STRIPS

ULTIMA TEST STRIPS

RELION ULTIMA GLUCOSE METER

SM ULTIMATE MEN'S COMPLETE TAB

HM ULTIMATE WOMEN'S 50+ TABLET

SM ULTIMATE WOMEN'S 50+ TABLET

ULTIMATECARE ONE CAPSULE

ULTIMATECARE ONE NF CAPSULE

ULTOMIRIS 300 MG/30 ML VIAL

ULTRA B-100 COMPLEX TABLET

GNP ULT C 0.3ML 29GX1/2" (1/2)

SM ULT CFT 0.3ML 31GX5/16(1/2)

ULT CFT 0.3 ML 29GX1/2" (1/2)

ULT CFT 0.3 ML 30GX5/16" (1/2)

ULT CFT 0.3 ML 31GX5/16" (1/2)

DRUG MART ULTRA COMFORT SYR

GNP ULTR COMFORT 1 ML 29GX1/2"

GNP ULTRA COMFORT 1 ML SYRINGE

GNP ULTRA COMFRT 1 ML 28GX1/2"

ULTRA COMFORT 1 ML 28GX1/2"

ULTRA COMFORT 1 ML 29GX1/2"

ULTRA COMFORT 1 ML 30GX5/16"

ULTRA COMFORT 1 ML 31GX5/16"

ULTRA COMFORT 1 ML SYRINGE

DRUG MART ULTRA COMFORT SYR

GNP ULT CMFRT 0.5 ML 29GX1/2"

GNP ULTR CMFRT 0.5 ML 28GX1/2"

GNP ULTR CMFRT 0.5 ML 30GX5/16

GNP ULTRA COMFORT 0.5 ML SYR

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ULTRA COMFORT 0.5 ML 28GX1/2"

ULTRA COMFORT 0.5 ML 29GX1/2"

ULTRA COMFORT 0.5 ML 30GX5/16"

ULTRA COMFORT 0.5 ML 31GX5/16"

ULTRA COMFORT 0.5 ML SYRINGE

DRUG MART ULTRA COMFORT SYR

GNP ULTRA COMFORT 3/10 ML SYR

ULTRA COMFORT 0.3 ML 29GX1/2"

ULTRA COMFORT 0.3 ML SYRINGE

ULTRA FREEDA TABLET

ULTRA FREEDA WITH IRON TABLET

ULTRA THIN PEN NDL 32G X 4MM

ULTRA THIN 31G LANCET

CVS ULTRA THIN 30G LANCETS

LIVE BETTER ULTRA THIN LANCET

PHARMACIST CHOICE 28G LANCETS

RELION ULTRA THIN 30G LANCETS

ULTRA THIN 28G LANCETS

ULTRA THIN 30G LANCETS

ULTRA THIN 31G LANCETS

ULTRA THIN 33G LANCETS

WALGREENS ULTRA THIN LANCETS

RELION ULTRA THIN PLUS LANCETS

RELION ULTRA THIN PLUS 33G

ULTRACARE INS 1 ML 30G X 5/16"

ULTRACARE INS 1 ML 30GX1/2"

ULTRACARE INS 1 ML 31G X 5/16"

ULTRACARE INS 0.5 ML 30GX1/2"

ULTRACARE INS 0.5 ML 30GX5/16"

ULTRACARE INS 0.5 ML 31GX5/16"

ULTRACARE INS 0.3 ML 30GX5/16"

ULTRACARE INS 0.3 ML 31GX5/16"

ULTRA-CARE 30G LANCETS

ULTRACARE PEN NEEDLE 31GX1/4"

ULTRACARE PEN NEEDLE 31GX3/16"

ULTRACARE PEN NEEDLE 31GX5/16"

ULTRACARE PEN NEEDLE 32GX1/4"

ULTRACARE PEN NEEDLE 32GX3/16"

ULTRACARE PEN NEEDLE 32GX5/32"

ULTRACARE PEN NEEDLE 33GX5/32"

BD UF MICRO PEN NEEDLE 6MMX32G

BD UF MINI PEN NEEDLE 5MMX31G

BD UF NANO PEN NEEDLE 4MMX32G

BD UF ORIG PEN NDL 12.7MMX29G

BD UF SHORT PEN NEEDLE 8MMX31G

ULTRALANCE 26G LANCETS

ULTRALANCE 28G LANCETS

ULTRA-THIN II 26G LANCET

ULTRA-THIN II 28G LANCETS

ULTRA-THIN II 30G LANCETS

ULTRA-THIN II PEN NDL 29GX1/2"

ULTRA-THIN II PEN NDL 31GX5/16

ULTRA-THIN II 1 ML 31GX5/16"

ULTRA-THIN II INS SYR 1 ML 29G

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ULTRA-THIN II INS SYR 1 ML 30G

ULTRA-THIN II INS 0.5 ML 29G

ULTRA-THIN II INS 0.5 ML 30G

ULTRA-THIN II INS 0.5 ML 31G

ULTRA-THIN II INS 0.3 ML 29G

ULTRA-THIN II INS 0.3 ML 30G

ULTRA-THIN II INS 0.3 ML 31G

ULTRATLC LANCETS

ULTRATRAK CONTROL SOLUTION

ULTRATRAK TEST STRIP

ULTRATRAK CONTROL SOL NORMAL

ULTRATRAK BLOOD GLUCOSE METER

ULTRATRAK PRO GLUCOSE MTR SYS

ULTRATRAK PRO METER KIT

ULTRATRAK ULTIMATE CNTRL SOLN

ULTRATRAK ULTIMATE TEST STRIPS

ULTRATRAK ULTIMATE GLUCOSE MTR

UNICOMPLEX-M TABLET

CAREONE UNIFINE PENTIP 4MM 32G

CAREONE UNIFINE PENTIP 5MM 31G

CAREONE UNIFINE PENTIP 6MM 31G

CAREONE UNIFINE PENTIP 8MM 31G

CAREONE UNIFINE PNTP 12MM 29G

PC UNIFINE PENTIPS 12MM NEEDLE

PC UNIFINE PENTIPS 6MM NEEDLE

PC UNIFINE PENTIPS 8MM NEEDLE

QC UNIFINE PENTIPS 32GX5/32"

SHOPKO UNIFINE PENTIPS 4MM 32G

SHOPKO UNIFINE PENTIPS 5MM 31G

SHOPKO UNIFINE PENTIPS 8MM 31G

SHOPKO UNIFINE PNTIPS 12MM 29G

UNIFINE PENTIPS 12MM 29G

UNIFINE PENTIPS 31GX3/16"

UNIFINE PENTIPS 32GX1/4"

UNIFINE PENTIPS 32GX5/32"

UNIFINE PENTIPS 33GX5/32"

UNIFINE PENTIPS 6MM 31G

UNIFINE PENTIPS 6MM NEEDLE

UNIFINE PENTIPS 8MM 31G

UNIFINE PENTIPS 8MM NEEDLE

UNIFINE PENTIPS NEEDLES 29G

CAREONE UNIFINE PENTP 29GX1/2"

CAREONE UNIFINE PENTP 31GX1/4"

CAREONE UNIFINE PNTP 31GX3/16"

CAREONE UNIFINE PNTP 31GX5/16"

CAREONE UNIFINE PNTP 32GX5/32"

HEB UNIFINE PNTP PLUS 31GX3/16

PUB UNIFINE PNTP PLUS 31GX3/16

SHOPKO UNIFINE PENTIPS 4MM 32G

SHOPKO UNIFINE PENTIPS 5MM 31G

SHOPKO UNIFINE PENTIPS 8MM 31G

SHOPKO UNIFINE PNTIPS 12MM 29G

UNIFINE PENTIPS PLUS 29GX1/2"

UNIFINE PENTIPS PLUS 31GX1/4"

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

UNIFINE PENTIPS PLUS 31GX3/16"

UNIFINE PENTIPS PLUS 31GX5/16"

UNIFINE PENTIPS PLUS 32GX5/32"

UNIFINE PENTIPS PLUS 33GX5/32"

WM UNIFINE PENTIP PLUS 4MM 32G

WM UNIFINE PENTIP PLUS 5MM 31G

WM UNIFINE PENTIP PLUS 6MM 31G

WM UNIFINE PENTIP PLUS 8MM 31G

UNIFINE SAFECONTROL 30GX3/16"

UNILET COMFORTOUCH 26G LANCETS

UNILET COMFORTOUCH LANCET

UNILET EXCELITE LANCET

UNILET EXCELITE II LANCET

UNILET GP LANCET

UNILET GP LANCET SUPERLITE

UNILET MICRO THIN 33G LANCET

FIFTY50 UNILET 33G LANCETS

QC UNILET SUPER THIN 30G LANCT

QC UNILET ULTRA THIN 28G LANCT

SHOPKO UNILET SUPER THIN 30G

SHOPKO UNILET ULTRA THIN 28G

UNILET MICRO THIN 33G LANCETS

UNILET SUPER THIN 30G LANCETS

UNILET ULTRA THIN 28G LANCETS

UNISTIK 2 1.8 MM LANCING DEVIC

UNISTIK 2 2.4 MM DEVICE

UNISTIK 2 COMFORT 1.8 MM DEVIC

UNISTIK-2 3 MM DEVICE

UNISTIK 2 NORMAL 0.81MM DEVICE

UNISTIK 3 COMFORT LANCET

UNISTIK 3 GENTLE 30G LANCETS

UNISTIK 3 GENTLE ON-THE-GO 30G

UNISTIK 3 NORMAL 23G LANCETS

UNISTIK 3 SAFETY 21G LANCETS

UNISTIK 3 1.8 MM LANCING DEVIC

UNISTIK 3 COMFORT 1.8 ML DEVIC

UNISTIK 3 EXTRA 21G LANCETS

UNISTIK 3 NEONATAL 1.8 ML DEV

UNISTIK CZT COMFORT 28G LANCET

UNISTIK CZT NORMAL 23G LANCETS

UNISTIK PRO 21G LANCET

UNISTIK PRO 25G LANCET

UNISTIK PRO 28G LANCET

UNISTIK SAFETY 28G LANCET

UNISTIK SAFETY 30G LANCETS

UNISTIK TOUCH 21G LANCETS

UNISTIK TOUCH 23G LANCETS

UNISTIK TOUCH 28G LANCETS

UNISTIK TOUCH 30G LANCETS

UNISTRIP CONTROL SOLUTION HIGH

UNISTRIP CONTROL SOLUTION LOW

UNISTRIP1 GLUCOSE TEST STRIP

UNITHROID 100 MCG TABLET

UNITHROID 112 MCG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

UNITHROID 125 MCG TABLET

UNITHROID 137 MCG TABLET

UNITHROID 150 MCG TABLET

UNITHROID 175 MCG TABLET

UNITHROID 200 MCG TABLET

UNITHROID 25 MCG TABLET

UNITHROID 300 MCG TABLET

UNITHROID 50 MCG TABLET

UNITHROID 75 MCG TABLET

UNITHROID 88 MCG TABLET

GNP UNIVERSAL 1 STANDARD 21G

GNP UNIVERSAL 1 SUPER THIN 30G

GNP UNIVERSAL 1 THIN 26G LANCT

GS UNIVERSAL 1 MICRO THIN 33G

GS UNIVERSAL 1 THIN 26G LANCET

GS UNIVERSAL 1 ULTRA THIN 30G

KRO UNIVERSAL 1 THIN 26G LANCT

MEIJER UNIVERSAL 1 26G LANCETS

REXALL UNIVERSAL 1 30G LANCETS

UNIVERSAL 1 33G LANCETS

UPTRAVI 1,000 MCG TABLET

UPTRAVI 1,200 MCG TABLET

UPTRAVI 1,400 MCG TABLET

UPTRAVI 1,600 MCG TABLET

UPTRAVI 200 MCG TABLET

UPTRAVI 400 MCG TABLET

UPTRAVI 600 MCG TABLET

UPTRAVI 800 MCG TABLET

URECHOLINE 10 MG TABLET

URECHOLINE 25 MG TABLET

URECHOLINE 5 MG TABLET

URECHOLINE 50 MG TABLET

UROCIT-K ER 15 MEQ TABLET

UROCIT-K SR 10 MEQ TABLET

UROCIT-K SR 5 MEQ TABLET

UROSEX TABLET

UROXATRAL 10 MG TABLET

URSO 250 MG TABLET

URSO FORTE 500 MG TABLET

URSODIOL 250 MG TABLET

URSODIOL 300 MG CAPSULE

URSODIOL 500 MG TABLET

UTIBRON NEOHALER 27.5-15.6 MCG

VAGIFEM 10 MCG VAGINAL TAB

VALACYCLOVIR HCL 1 GRAM TABLET

VALACYCLOVIR HCL 500 MG TABLET

VALCHLOR 0.016% GEL

VALCYTE 450 MG TABLET

VALCYTE 50 MG/ML SOLUTION

VALGANCICLOVIR 450 MG TABLET

VALGANCICLOVIR HCL 50 MG/ML

VALPROIC ACID 250 MG CAPSULE

VALPROIC ACID 250 MG/5 ML ORAL

VALPROIC ACID 250 MG/5 ML SOLN

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

VALPROIC ACID 500 MG/10 ML SOL

VALSARTAN 160 MG TABLET

VALSARTAN 320 MG TABLET

VALSARTAN 40 MG TABLET

VALSARTAN 80 MG TABLET

VALSARTAN-HCTZ 160-12.5 MG TAB

VALSARTAN-HCTZ 160-25 MG TAB

VALSARTAN-HCTZ 320-12.5 MG TAB

VALSARTAN-HCTZ 320-25 MG TAB

VALSARTAN-HCTZ 80-12.5 MG TAB

VALTREX 1 GM CAPLET

VALTREX 500 MG CAPLET

VANISHPOINT U-100 29X1/2 SYR

VANISHPOINT 0.5 ML 30GX1/2" SY

VANISHPOINT INS 1 ML 30GX3/16"

VANTAS 50 MG KIT

VARDENAFIL HCL 10 MG ODT

VARDENAFIL HCL 10 MG TABLET

VARDENAFIL HCL 2.5 MG TABLET

VARDENAFIL HCL 20 MG TABLET

VARDENAFIL HCL 5 MG TABLET

VARISOFT INFUSION SET 23" 13MM

VARISOFT INFUSION SET 23" 17MM

VARISOFT INFUSION SET 32" 13MM

VARISOFT INFUSION SET 32" 17MM

VARISOFT INFUSION SET 43" 13MM

VARISOFT INFUSION SET 43" 17MM

VASCEPA 0.5 GM CAPSULE

VASCEPA 1 GM CAPSULE

VASERETIC 10-25 MG TABLET

VASOTEC 10 MG TABLET

VASOTEC 2.5 MG TABLET

VASOTEC 20 MG TABLET

VASOTEC 5 MG TABLET

VB7 MAX POWDER

V-C FORTE CAPSULE

VECAMYL 2.5 MG TABLET

VELETRI 0.5 MG VIAL

VELETRI 1.5 MG VIAL

VELIVET 28 DAY TABLET

VELPHORO 500 MG CHEWABLE TAB

VELTASSA 16.8 GM POWDER PACKET

VELTASSA 25.2 GM POWDER PACKET

VELTASSA 8.4 GM POWDER PACKET

VEMAVITE-PRX 2 CAPSULE

VEMLIDY 25 MG TABLET

VENCLEXTA 10 MG TABLET

VENCLEXTA 100 MG TABLET

VENCLEXTA 50 MG TABLET

VENLAFAXINE HCL 100 MG TABLET

VENLAFAXINE HCL 25 MG TABLET

VENLAFAXINE HCL 37.5 MG TABLET

VENLAFAXINE HCL 50 MG TABLET

VENLAFAXINE HCL 75 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

VENLAFAXINE HCL ER 150 MG CAP

VENLAFAXINE HCL ER 150 MG TAB

VENLAFAXINE HCL ER 225 MG TAB

VENLAFAXINE HCL ER 37.5 MG CAP

VENLAFAXINE HCL ER 37.5 MG TAB

VENLAFAXINE HCL ER 75 MG CAP

VENLAFAXINE HCL ER 75 MG TAB

VENTAVIS 10 MCG/1 ML SOLUTION

VENTAVIS 20 MCG/1 ML SOLUTION

VENTOLIN HFA 90 MCG INHALER

BD VEO INS 0.3ML 6MMX31G (1/2)

BD VEO INS SYRING 1 ML 6MMX31G

BD VEO INS SYRN 0.5 ML 6MMX31G

BD VEO INS SYRN 0.3 ML 6MMX31G

VERAMYST 27.5 MCG NASAL SPRAY

VERAPAMIL ER 120 MG CAPSULE

VERAPAMIL ER 120 MG TABLET

VERAPAMIL ER 180 MG CAPSULE

VERAPAMIL ER 180 MG TABLET

VERAPAMIL ER 240 MG CAPSULE

VERAPAMIL ER 240 MG TABLET

VERAPAMIL ER PM 100 MG CAPSULE

VERAPAMIL ER PM 200 MG CAPSULE

VERAPAMIL ER PM 300 MG CAPSULE

VERAPAMIL 120 MG TABLET

VERAPAMIL 360 MG CAP PELLET

VERAPAMIL 40 MG TABLET

VERAPAMIL 80 MG TABLET

VERAPAMIL SR 120 MG CAPSULE

VERAPAMIL SR 180 MG CAPSULE

VERAPAMIL SR 240 MG CAPSULE

VERASENS BLOOD GLUCOSE METER

VERASENS CONTROL SOLN-LEVEL 1

VERASENS METER STARTER KIT

VERASENS TEST STRIP

VERELAN 120 MG CAP PELLET

VERELAN 180 MG CAP PELLET

VERELAN 240 MG CAP PELLET

VERELAN 360 MG CAP PELLET

VERELAN PM 100 MG CAP PELLET

VERELAN PM 200 MG CAP PELLET

VERELAN PM 300 MG CAP PELLET

VERSACLOZ 50 MG/ML SUSPENSION

VERZENIO 100 MG TABLET

VERZENIO 150 MG TABLET

VERZENIO 200 MG TABLET

VERZENIO 50 MG TABLET

VESICARE 10 MG TABLET

VESICARE 5 MG TABLET

VESTURA 3 MG-0.02 MG TABLET

V-GO 20 DISPOSABLE DEVICE

V-GO 30 DISPOSABLE DEVICE

V-GO 40 DISPOSABLE DEVICE

VIAGRA 100 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

VIAGRA 25 MG TABLET

VIAGRA 50 MG TABLET

VIBERZI 100 MG TABLET

VIBERZI 75 MG TABLET

VIC-FORTE CAPSULE

VICTOZA 2-PAK 18 MG/3 ML PEN

VICTOZA 3-PAK 18 MG/3 ML PEN

VIDEX 2 GM PEDIATRIC SOLN

VIDEX 4 GM PEDIATRIC SOLN

VIDEX EC 125 MG CAPSULE

VIDEX EC 200 MG CAPSULE

VIDEX EC 250 MG CAPSULE

VIDEX EC 400 MG CAPSULE

VIENVA-28 TABLET

VIGABATRIN 500 MG POWDER PACKT

VIGABATRIN 500 MG TABLET

VIGADRONE 500 MG POWDER PACKET

VIIBRYD 10 MG TABLET

VIIBRYD 20 MG TABLET

VIIBRYD 40 MG TABLET

VIMIZIM 5 MG/5 ML VIAL

VIMOVO DR 375-20 MG TABLET

VIMOVO DR 500-20 MG TABLET

VIMPAT 10 MG/ML SOLUTION

VIMPAT 100 MG TABLET

VIMPAT 150 MG TABLET

VIMPAT 200 MG TABLET

VIMPAT 50 MG TABLET

VINACAL B PRENATAL COMBO PACK

VINATE CARE CHEWABLE TABLET

VINATE DHA RF GELCAP

VINATE ONE TABLET

VINATE-M TABLET

VIOKACE 10,440-39,150 UNITS TB

VIOKACE 20,880-78,300 UNITS TB

VIORELE 28 DAY TABLET

VIRACEPT 250 MG TABLET

VIRACEPT 625 MG TABLET

VIRAMUNE 200 MG TABLET

VIRAMUNE 50 MG/5 ML SUSP

VIRAMUNE XR 100 MG TABLET

VIRAMUNE XR 400 MG TABLET

VIREAD 150 MG TABLET

VIREAD 200 MG TABLET

VIREAD 250 MG TABLET

VIREAD 300 MG TABLET

VIREAD POWDER

VIRGINIA LIVE OAK 1:20 (W/V)

VIRT-ADVANCE TABLET

VIRT-C DHA SOFTGEL

VIRT-CAPS SOFTGEL

VIRT-GARD TABLET

VIRT-NATE TABLET

VIRT-NATE DHA SOFTGEL

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

VIRT-PN TABLET

VIRT-PN DHA SOFTGEL

VIRT-PN PLUS SOFTGEL

VIRTPREX CAPSULE

VIRT-SELECT CAPSULE

VIRT-VITE TABLET

VIRT-VITE FORTE TABLET

VIRT-VITE GT TABLET

VISION FORMULA TABLET

VISION FORMULA SOFTGEL

CVS VISION FORMULA TABLET

EQ VISION FORMULA TABLET

VISION FORMULA WITH LUTEIN TAB

VISION PLUS LUTEIN VITAMIN TAB

VISION VITAMINS TABLET

BP VIT 3 CAPSULE

VITA-BEE WITH C TABLET

VITABEX PLUS CAPSULE

VITACEL TABLET

VITAFOL FE PLUS SOFTGEL

VITAFOL FE+ DOCUSATE COMBO PCK

VITAFOL GUMMIES

VITAFOL NANO TABLET

VITAFOL ULTRA SOFTGEL

VITAFOL-OB CAPLET

VITAFOL-OB+DHA COMBO PACK

VITAFOL-ONE CAPSULE

VITALEE TABLET

VITALETS TABLET CHEWABLE

VITALETS TABLET CHEWABLE

VITAMEDMD ONE RX SOFTGEL

VITAMEDMD REDICHEW RX TAB CHEW

VITAMIN A & D CAPSULE

VITAMIN AND MINERALS TABLET

B COMPLEX CAPSULE

B COMPLEX TABLET

B-COMPLEX WITH B12 TABLET

EQL B COMPLEX 50 TABLET

RA B-COMPLEX-VITAMIN B-12 TAB

VITAMIN B COMPLEX CAPSULE

VITAMIN B COMPLEX SOFTGEL

VITAMIN B COMPLEX TABLET

SM VITAMIN B COMPLEX TABLET

VITAMIN B COMPLEX TABLET

SM VITAMIN B-100 COMPLEX TAB

VITAMIN B-100 COMPLEX TABLET

VITAMIN B-50 COMPLEX TABLET

RA B-COMPLEX WITH VIT C TAB SA

B-COMPLEX W-VITAMIN C CAPLET

CVS B-COMPLEX-VIT C CAPLET

VITAMIN B COMPLEX-VIT C CAP

VITAMIN B COMPLEX-VIT C CAPLET

VITAMIN D2 1.25MG(50,000 UNIT)

VITAMIN D3-ALOE 1,000 UNIT TAB

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

VITAMIN-MINERAL LIQUID

VIT A,C,D-FLUORIDE 0.25 MG/ML

VIT A,C,D-FLUORIDE 0.5 MG/ML

VIT A,D,C-FLUORIDE 0.25 MG/ML

VITAMINS A-D-E TABLET

VITAMINS FOR HAIR TABLET

VITAPEARL SOFTGEL

VITATRUE COMBO PACK

VITATRUM TABLET

VITEKTA 150 MG TABLET

VITEKTA 85 MG TABLET

VITRAKVI 100 MG CAPSULE

VITRAKVI 20 MG/ML SOLUTION

VITRAKVI 25 MG CAPSULE

VITRUM 50 PLUS SENIOR TABLET

VITRUM SENIOR TABLET

VIVAGUARD INO CONTROL SOLUTION

VIVAGUARD INO GLUCOSE METER

VIVAGUARD INO TEST STRIP

VIVAGUARD LANCET

VIVELLE-DOT 0.025 MG PATCH

VIVELLE-DOT 0.0375 MG PATCH

VIVELLE-DOT 0.05 MG PATCH

VIVELLE-DOT 0.075 MG PATCH

VIVELLE-DOT 0.1 MG PATCH

VIVITROL 380 MG VIAL + DILUENT

VIVLODEX 10 MG CAPSULE

VIVLODEX 5 MG CAPSULE

VIZIMPRO 15 MG TABLET

VIZIMPRO 30 MG TABLET

VIZIMPRO 45 MG TABLET

VOCALPOINT GLUCOSE CONTROL SOL

VOGELXO 12.5 MG/1.25 GRAM PUMP

VOGELXO 50 MG/5 GRAM GEL

VOGELXO 50 MG/5 GRAM GEL PACKT

VOL-CARE RX TABLET

VOL-NATE TABLET

VOLNEA 0.15-0.02-0.01 MG TAB

VOL-PLUS TABLET

VOL-TAB RX TABLET

VOLTAREN-XR 100 MG TABLET

VOTRIENT 200 MG TABLET

VP-CH-PNV PRENATAL SOFTGEL

VP-GGR-B6 TABLET

VP-HEME OB TABLET

VP-HEME ONE SOFTGEL

VP-PNV-DHA SOFTGEL

VPRIV 400 UNITS VIAL

VP-VITE RX TABLET

VRAYLAR 1.5 MG CAPSULE

VRAYLAR 3 MG CAPSULE

VRAYLAR 4.5 MG CAPSULE

VRAYLAR 6 MG CAPSULE

VUMERITY DR 231 MG CAPSULE

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

VYEPTI 100 MG/ML VIAL

VYFEMLA 28 TABLET

VYLIBRA 28 TABLET

VYNDAMAX 61 MG CAPSULE

VYNDAQEL 20 MG CAPSULE

VYONDYS-53 100 MG/2 ML VIAL

VYTORIN 10-10 MG TABLET

VYTORIN 10-20 MG TABLET

VYTORIN 10-40 MG TABLET

VYTORIN 10-80 MG TABLET

VYVANSE 10 MG CAPSULE

VYVANSE 10 MG CHEWABLE TABLET

VYVANSE 20 MG CAPSULE

VYVANSE 20 MG CHEWABLE TABLET

VYVANSE 30 MG CAPSULE

VYVANSE 30 MG CHEWABLE TABLET

VYVANSE 40 MG CAPSULE

VYVANSE 40 MG CHEWABLE TABLET

VYVANSE 50 MG CAPSULE

VYVANSE 50 MG CHEWABLE TABLET

VYVANSE 60 MG CAPSULE

VYVANSE 60 MG CHEWABLE TABLET

VYVANSE 70 MG CAPSULE

VYZULTA 0.024% OPHTH SOLUTION

WAKIX 17.8 MG TABLET

WAKIX 4.45 MG TABLET

WAL-PROFEN 200 MG CAPLET

WAL-PROFEN 200 MG CAPSULE

WAL-PROFEN 200 MG SOFTGEL

WAL-PROFEN 200 MG TABLET

WAL-PROXEN 220 MG CAPLET

WAL-PROXEN 220 MG TABLET

WAL-ZAN 150 MG TABLET

WAL-ZAN 75 MG TABLET

WARFARIN SODIUM 1 MG TABLET

WARFARIN SODIUM 10 MG TABLET

WARFARIN SODIUM 2 MG TABLET

WARFARIN SODIUM 2.5 MG TABLET

WARFARIN SODIUM 3 MG TABLET

WARFARIN SODIUM 4 MG TABLET

WARFARIN SODIUM 5 MG TABLET

WARFARIN SODIUM 6 MG TABLET

WARFARIN SODIUM 7.5 MG TABLET

WASP VENOM PROTEIN 100 MCG/ML

WASP VENOM PROTEIN 550 MCG VL

WAVESENSE AMP SYSTEM KIT

WAVESENSE CONTROL SOLN NORMAL

WAVESENSE JAZZ TEST STRIPS

WAVESENSE PRESTO TEST STRIPS

WAVESENSE PRESTO SYSTEM KIT

WELCHOL 3.75G PACKET

WELCHOL 625 MG TABLET

WELLBUTRIN SR 100 MG TABLET

WELLBUTRIN SR 150 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

WELLBUTRIN SR 200 MG TABLET

WELLBUTRIN XL 150 MG TABLET

WELLBUTRIN XL 300 MG TABLET

WELLESSE MULT VITAMIN PLUS LIQ

WERA 0.5/0.035 MG 28 TABLET

WESTAB MAX TABLET

WESTAB ONE TABLET

WESTERN JUNIPER 1:20 (W/V)

WESTHROID 130 MG TABLET

WESTHROID 195 MG TABLET

WESTHROID 32.5 MG TABLET

WESTHROID 65 MG TABLET

WESTHROID 97.5 MG TABLET

WEST-VITE WITH FOLIC ACID TAB

WHITE ASH 1:20 (W/V) VIAL

WHITE BIRCH 1:20 (W/V) VIAL

WHITE FACED HORNET 100 MCG/ML

WHITE MULBERRY 1:20 W/V VIAL

WHITE OAK 1:20 (W/V) VIAL

WHITE PINE 1:20 (W/V) VIAL

WHITE-FACED HORNET 550 MCG VL

WILATE 450-450 UNIT VIAL

WILATE 900-900 UNIT VIAL

WIXELA 100-50 INHUB

WIXELA 250-50 INHUB

WIXELA 500-50 INHUB

WOMEN'S 50 PLUS DAILY FORMULA

CVS WOMEN'S ACTIVE TABLET

BAYER WOMEN'S ASPIRIN TABLET

V-R WOMEN'S COMPLEX CAPLET

WOMEN'S DAILY CAPLET

WOMEN'S DAILY FORMULA CAPLET

WOMEN'S DAILY FORMULA CAPLET

WOMEN'S DAILY FORMULA TABLET

CVS WOMEN'S DAILY GUMMIES

WOMEN'S DAILY PACK

WOMEN'S MULTIVITAMIN GUMMIES

WOMEN'S MULTIVITAMIN TABLET

WOMENS MULTIVIT HI POTENCY TAB

WOMEN MULTIVIT W-BIOTIN GUMMY

HM WOMEN'S ONE DAILY TABLET

SM WOMEN'S ONE DAILY TABLET

CVS WOMEN'S PRENATAL PLUS DHA

WP THYROID 113.75 MG TABLET

WP THYROID 130 MG TABLET

WP THYROID 16.25 MG TABLET

WP THYROID 32.5 MG TABLET

WP THYROID 48.75 MG TABLET

WP THYROID 65 MG TABLET

WP THYROID 81.25 MG TABLET

WP THYROID 97.5 MG TABLET

WYMZYA FE CHEWABLE TABLET

XADAGO 100 MG TABLET

XADAGO 50 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

XALATAN 0.005% EYE DROPS

XALKORI 200 MG CAPSULE

XALKORI 250 MG CAPSULE

XARELTO 10 MG TABLET

XARELTO 15 MG TABLET

XARELTO 2.5 MG TABLET

XARELTO 20 MG TABLET

XATMEP 2.5 MG/ML ORAL SOLUTION

XELJANZ 10 MG TABLET

XELJANZ 5 MG TABLET

XELJANZ XR 11 MG TABLET

XELJANZ XR 22 MG TABLET

XELPROS 0.005% EYE DROP

XEMBIFY 20% (1 G/5 ML) VIAL

XEMBIFY 20% (10 G/50 ML) VIAL

XEMBIFY 20% (2 G/10 ML) VIAL

XEMBIFY 20% (4 G/20 ML) VIAL

XENAZINE 12.5 MG TABLET

XENAZINE 25 MG TABLET

XENICAL 120 MG CAPSULE

XHANCE 93 MCG NASAL SPRAY

XIFAXAN 550 MG TABLET

XIGDUO XR 10 MG-1,000 MG TAB

XIGDUO XR 10 MG-500 MG TABLET

XIGDUO XR 2.5 MG-1,000 MG TAB

XIGDUO XR 5 MG-1,000 MG TABLET

XIGDUO XR 5 MG-500 MG TABLET

XIIDRA 5% EYE DROPS

XOLAIR 150 MG VIAL

XOLAIR 150 MG/ML SYRINGE

XOLAIR 75 MG/0.5 ML SYRINGE

XOPENEX 0.31 MG/3 ML SOLUTION

XOPENEX 0.63 MG/3 ML SOLUTION

XOPENEX 1.25 MG/3 ML SOLUTION

XOPENEX CONC 1.25 MG/0.5 ML

XOPENEX HFA 45 MCG INHALER

XOSPATA 40 MG TABLET

XPOVIO 100 MG ONCE WEEKLY DOSE

XPOVIO 60 MG ONCE WEEKLY DOSE

XPOVIO 80 MG ONCE WEEKLY DOSE

XPOVIO 80 MG TWICE WEEKLY DOSE

XTANDI 40 MG CAPSULE

XULANE PATCH

XULTOPHY 100 UNIT-3.6MG/ML PEN

XURIDEN GRANULE PACKET

XYNTHA 1,000 UNIT KIT

XYNTHA 2,000 UNIT KIT

XYNTHA 250 UNIT KIT

XYNTHA 500 UNIT KIT

XYNTHA SOLOFUSE 1,000 UNIT KIT

XYNTHA SOLOFUSE 2,000 UNIT KIT

XYNTHA SOLOFUSE 250 UNIT KIT

XYNTHA SOLOFUSE 3,000 UNIT KIT

XYNTHA SOLOFUSE 500 UNIT KIT

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

XYOSTED 100 MG/0.5 ML AUTO-INJ

XYOSTED 50 MG/0.5 ML AUTO-INJ

XYOSTED 75 MG/0.5 ML AUTO-INJ

XYZAL 2.5 MG/5 ML SOLUTION

XYZAL 5 MG TABLET

XYZBAC TABLET

YASMIN 28 TABLET

YAZ 28 TABLET

YELETS TABLET

YELLOW DOCK 1:20 (W/V) VIAL

YELLOW HORNET VENOM 100 MCG/ML

YELLOW HORNET VENOM 550 MCG VL

YELLOW JACKET VENOM 100 MCG/ML

YELLOW JACKET VENOM 550 MCG VL

YONDELIS 1 MG VIAL

YONSA 125 MG TABLET

YOSPRALA DR 325-40 MG TABLET

YOSPRALA DR 81-40 MG TABLET

YUPELRI 175 MCG/3 ML SOLUTION

YUTIQ 0.18 MG IMPLANT

YUVAFEM 10 MCG VAGINAL INSERT

YUVAFEM 10 MCG VAGINAL TABLET

ZAFIRLUKAST 10 MG TABLET

ZAFIRLUKAST 20 MG TABLET

ZALTRAP 100 MG/4 ML VIAL

ZALTRAP 200 MG/8 ML VIAL

ZALVIT TABLET

ZANAFLEX 2 MG CAPSULE

ZANAFLEX 4 MG CAPSULE

ZANAFLEX 4 MG TABLET

ZANAFLEX 6 MG CAPSULE

ZANTAC 150 MG TABLET

ZANTAC 300 MG TABLET

ZANTAC 75 MG TABLET

ZARAH TABLET

ZARONTIN 250 MG CAPSULE

ZARONTIN 250 MG/5 ML SOLUTION

ZATEAN-CH CAPSULE

ZATEAN-PN DHA CAPSULE

ZATEAN-PN PLUS SOFTGEL

ZAVESCA 100 MG CAPSULE

ZEBETA 10 MG TABLET

ZEBETA 5 MG TABLET

ZEGERID 20 MG CAPSULE

ZEGERID 20 MG PACKET

ZEGERID 40 MG CAPSULE

ZEGERID 40 MG PACKET

ZEGERID OTC 20-1,100 MG CAP

ZEJULA 100 MG CAPSULE

ZELAPAR 1.25 MG ODT TABLET

ZELBORAF 240 MG TABLET

ZEMAIRA 1,000 MG VIAL

ZEMPLAR 1 MCG CAPSULE

ZEMPLAR 10 MCG/2 ML VIAL

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ZEMPLAR 2 MCG CAPSULE

ZEMPLAR 2 MCG/ML VIAL

ZEMPLAR 5 MCG/ML VIAL

ZENCHENT 0.4 MG-35 MCG TABLET

ZENCHENT FE TABLET CHEWABLE

ZENPEP DR 10,000 UNIT CAPSULE

ZENPEP DR 15,000 UNIT CAPSULE

ZENPEP DR 20,000 UNIT CAPSULE

ZENPEP DR 25,000 UNIT CAPSULE

ZENPEP DR 3,000 UNIT CAPSULE

ZENPEP DR 40,000 UNIT CAPSULE

ZENPEP DR 5,000 UNIT CAPSULE

ZENZEDI 10 MG TABLET

ZENZEDI 15 MG TABLET

ZENZEDI 2.5 MG TABLET

ZENZEDI 20 MG TABLET

ZENZEDI 30 MG TABLET

ZENZEDI 5 MG TABLET

ZENZEDI 7.5 MG TABLET

ZERIT 1 MG/ML SOLUTION

ZERIT 15 MG CAPSULE

ZERIT 20 MG CAPSULE

ZERIT 30 MG CAPSULE

ZERIT 40 MG CAPSULE

ZESTORETIC 10-12.5 MG TABLET

ZESTORETIC 20-12.5 MG TABLET

ZESTORETIC 20-25 MG TABLET

ZESTRIL 10 MG TABLET

ZESTRIL 2.5 MG TABLET

ZESTRIL 20 MG TABLET

ZESTRIL 30 MG TABLET

ZESTRIL 40 MG TABLET

ZESTRIL 5 MG TABLET

ZETIA 10 MG TABLET

ZETONNA 37 MCG NASAL SPRAY

ZIAC 10-6.25 MG TABLET

ZIAC 2.5-6.25 MG TABLET

ZIAC 5-6.25 MG TABLET

ZIAGEN 20 MG/ML SOLUTION

ZIAGEN 300 MG TABLET

ZIDOVUDINE 100 MG CAPSULE

ZIDOVUDINE 300 MG TABLET

ZIDOVUDINE 50 MG/5 ML SYRUP

ZILEUTON ER 600 MG TABLET

ZINBRYTA 150 MG/ML SYRINGE

ZINGIBER TABLET

ZIOPTAN 0.0015% EYE DROPS

ZIPRASIDONE HCL 20 MG CAPSULE

ZIPRASIDONE HCL 40 MG CAPSULE

ZIPRASIDONE HCL 60 MG CAPSULE

ZIPRASIDONE HCL 80 MG CAPSULE

ZOCOR 10 MG TABLET

ZOCOR 20 MG TABLET

ZOCOR 40 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ZOCOR 5 MG TABLET

ZOCOR 80 MG TABLET

ZOLADEX 10.8 MG IMPLANT SYRN

ZOLADEX 3.6 MG IMPLANT SYRN

ZOLEDRONIC ACID 4 MG/100 ML

ZOLEDRONIC ACID 4 MG VIAL

ZOLEDRONIC ACID 4 MG/5 ML VIAL

ZOLOFT 100 MG TABLET

ZOLOFT 20 MG/ML ORAL CONC

ZOLOFT 25 MG TABLET

ZOLOFT 50 MG TABLET

ZOMACTON 10 MG VIAL

ZOMACTON 5 MG VIAL

ZOMETA 4 MG/5 ML VIAL

ZONEGRAN 100 MG CAPSULE

ZONEGRAN 25 MG CAPSULE

ZONISAMIDE 100 MG CAPSULE

ZONISAMIDE 25 MG CAPSULE

ZONISAMIDE 50 MG CAPSULE

ZONTIVITY 2.08 MG TABLET

ZOO FRIENDS TABLET CHEWABLE

ZOO FRIENDS COMPLETE TAB CHEW

ZOO FRIENDS GUMMIES

ZORTRESS 0.25 MG TABLET

ZORTRESS 0.5 MG TABLET

ZORTRESS 0.75 MG TABLET

ZORTRESS 1 MG TABLET

ZORVOLEX 18 MG CAPSULE

ZORVOLEX 35 MG CAPSULE

ZOVIA 1-35E TABLET

ZOVIA 1-50E TABLET

ZOVIRAX 200 MG CAPSULE

ZOVIRAX 200 MG/5 ML SUSP

ZOVIRAX 400 MG TABLET

ZOVIRAX 800 MG TABLET

ZUBSOLV 0.7-0.18 MG TABLET SL

ZUBSOLV 1.4-0.36 MG TABLET SL

ZUBSOLV 11.4-2.9 MG TABLET SL

ZUBSOLV 2.9-0.71 MG TABLET SL

ZUBSOLV 5.7-1.4 MG TABLET SL

ZUBSOLV 8.6-2.1 MG TABLET SL

ZUMANDIMINE 3 MG-0.03 MG TAB

ZURAMPIC 200 MG TABLET

ZYDELIG 100 MG TABLET

ZYDELIG 150 MG TABLET

ZYFLO 600 MG FILMTAB

ZYFLO CR 600 MG TABLET

ZYKADIA 150 MG CAPSULE

ZYKADIA 150 MG TABLET

ZYLOPRIM 100 MG TABLET

ZYLOPRIM 300 MG TABLET

ZYPITAMAG 1 MG TABLET

ZYPITAMAG 2 MG TABLET

ZYPITAMAG 4 MG TABLET

OHIO MEDICAID Effective April 1, 2020

The maintenance drug list is subject to change Last Updated: 4/1/2020 OH-MED-P-54803

ZYPREXA 10 MG TABLET

ZYPREXA 15 MG TABLET

ZYPREXA 2.5 MG TABLET

ZYPREXA 20 MG TABLET

ZYPREXA 5 MG TABLET

ZYPREXA 7.5 MG TABLET

ZYPREXA RELPREVV 210 MG VIAL

ZYPREXA RELPREVV 210 MG VL KIT

ZYPREXA RELPREVV 300 MG VIAL

ZYPREXA RELPREVV 300 MG VL KIT

ZYPREXA RELPREVV 405 MG VIAL

ZYPREXA RELPREVV 405 MG VL KIT

ZYPREXA ZYDIS 10 MG TABLET

ZYPREXA ZYDIS 15 MG TABLET

ZYPREXA ZYDIS 20 MG TABLET

ZYPREXA ZYDIS 5 MG TABLET

ZYTIGA 250 MG TABLET

ZYTIGA 500 MG TABLET

ZYVIT TABLET