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PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
1Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Demeclocycline XDoxycycline Hyclate XDoxycycline Hyclate DR XDoxycycline Monohydrate XMinocycline HCl XMinocycline ER XMinocycline Tablets XTetracycline X
Adoxa, Adoxa Pak XDoryx, Doryx DR XDynacin XMorgidox XOracea XSolodyn ER XVibramycin Suspension, Syrup X
Adapalene XBenzoyl Peroxide OTC X XBenzoyl Peroxide Rx XClindamycin XClindamycin-Benzoyl Peroxide XErythromycin Gel, Solution XErythromycin-Benzoyl Peroxide Gel X
Salicylic Acid Gel, Lotion X XSulfacetamide Sodium XSulfacetamide Sodium/Sulfur XTretinoin X X
Acanya XAczone XAkne-mycin XAtralin XAzelex X XBenzac AC, Benzac W XBenzaclin XBenzamycin XBenzefoam XBenziq XBP XBrevoxyl XClarifoam EF XCleocin T XClinac BPO XClindacin Pac XClindagel XDelos XDesquam-X XDifferin X XEpiduo X XEvoclin XInova XKlaron XLavoclen XNeobenz Micro XNuox XPacnex XPanoxyl X XPlexion XPrascion X
Acne Agents, Oral (Tetracyclines)
Acne Agents, Topical
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
2Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Retin-A X XRetin-A-Micro X XRosanil XSastid X XSulfoam X XSulpho-Lac X XSumadan XSumaxin XTazorac X XTriaz XVeltin XZencia XZiana X X
Donepezil X XGalantamine X XGalantamine ER X XRievastigmine X X
Aricept X XExelon Transdermal X X XExelon Capsules X XRazadyne X XRazadyne ER XExelon Solution X XNamenda X X
Capsaicin OTC X XFlector X XLidoderm X XLMX-4 X XPennsaid X XQutenza X XVoltaren X X
Fentanyl transdermal X XMethadone X XMorphine ER X XOxymorphone ER X XTramadol ER X X
Avinza X XButrans X XDolophine X XDuragesic X XExalgo X XKadian X XMethadose Oral Concentrate X XMS Contin X XOpana ER X XOramorph SR X XOxycontin X XRyzolt X XUltram ER X X
APAP/Codeine X XButalbital/Caffeine/APAP/Codeine X XButalbital/Caffeine/ASA/Codeine X XButorphanol nasal spray X X XCodeine X XDihydrocodeine/APAP/ Caffeine X XFentanyl (buccal) X XHydrocodone/APAP X XHydrocodone/Ibuprofen X XHydromorphone X X X
Analgesics, Narcotic - Short Acting
Analgesics, Narcotic - Long Acting
Alzheimer’s Agents
Analgesics/ Anesthetics, Topical
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
3Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Levorphanol X XMeperidine X XMorphine X XOxycodone X XOxycodone/APAP X XOxycodone/ASA X XOxycodone/Ibuprofen X XPentazocine/APAP X XPentazocine/Naloxone X XTramadol X XTramadol/APAP X XTrezix X X
Abstral X XActiq X XCapital w/Codeine X XCocet Plus X XDemerol X XDilaudid X XEndocet X XEndodan X XFentora X XFioricet/Codeine X XFiorinal/Codeine X XHycet X XIbudone X XLorcet Plus X XMagnacet X XMaxidone X XNorco X XNucynta X XOnsolis X XOpana X XPercocet X XPercodan X XPrimlev X XReprexain X XRoxanol X XRoxicet X XRoxicodone X XRybix ODT X XSynalgos-DC X XTrezix X XTylenol with Codeine X XTylox X XUltracet X XUltram X XVicodin X XUltracet X XUltram X XVicoprofen X XXodol X XXolox X XZamicet X XZolvit X XZydone X XAndroderm XAndrogel XAxiron XFortesta X
Androgenic Agents
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
4Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Testim XBenazepril, Benazepril HCTZ XCaptopril, Captopril HCTZ XEnalapril, Enalapril HCTZ X XFosinopril, Fosinopril HCTZ XLisinopril, Lisinopril HCTZ X XLosartan, Losartan HCTZ X XMoexipril, Moexepril HCTZ X XPerindopril X XQuinapril, Quinapril HCTZ XRamipril X XTrandolapril X
Accupril, Accuretic XAceon XAltace X XAtacand, Atacand HCT X XAvapro, Avalide X XBenicar, Benicar HCT X XCozaar, Hyzaar X XDiovan, Diovan HCT X XEdarbi X XLotensin, Lotensin HCT XMavik XMicardis, Micardis HCT X XPrinivil, Prinzide X XTekturna, Tekturna HCT X XTeveten, Teveten HCT X XUnivasc, Uniretic X XVasotec, Vaseretic X XZestril, Zestoretic X X
Amlodipine/Benazepril X XTrandolapril/Verapamil X X
Amturnide X XAzor X XExforge, Exforge HCT X XLotrel X XTarka X XTekamlo X XTribenzor X XTwynsta X XValturna X X
Metronidazole XNeomycin XTinidazole X
Alinia XFlagyl XFlagyl ER X XMycifradin XTindamax XVancocin XXifaxan XCayston XTobi X
Bacitracin Ointment X XBacitracin/Polymyxin Ointment X XGentamicin Cream, Ointment XMupirocin Ointment XNeomycin/Polymyxin/Pramoxine Cream X X
Angiotensin Modulators
Angiotensin Modulator Combinations
Antibiotics, Topical
Antibiotics, Inhaled
Antibiotics, GI
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
5Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Triple Antibiotic Ointment X XTriple Antibiotic Plus Ointment X X
Altabax Ointment XBactroban Cream XBactroban Ointment XCentany Ointment X
Clindamycin XMetronidazole X
Cleocin Cream XCleocin Ovules XClindesse XMetrogel-Vaginal XVandazole X
Enoxaparin XFondaparinux XWarfarin X
Arixtra XCoumadin XFragmin XInnohep XLovenox XPradaxa X X XXarelto X
Carbamazepine X XClonazepam X XDivalproex XDivalproex ER X XDivalproex Sprinkle XEthosuximide X XGabapentin X XLamotrigine XLevetiracetam X XMephobarbital XOxcarbazepine X XPhenobarbital XPhenytoin X XPrimidone X XTopiramate X XTopiramate Sprinkles X XValproic Acid X XZonisamide X X
Banzel X XCarbatrol X XCelontin X XDepakene XDepakote XDepakote ER X XDepakote Sprinkle XDiastat (rectal) XDilantin 30 mg capsules X XDilantin 100 mg capsules X XDilantin Infatabs X XDilantin suspension X XEpitol X XEquetro X XFelbatol XGabitril XKeppra Solution, Tablets X XKeppra XR X X
Anticonvulsants
Antibiotics, Vaginal
Anticoagulants
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
6Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Klonopin X XLamictal XLamictal ODT XLamictal XR XLuminal XLyrica X X XMebaral XMysoline X XNeurontin X XPeganone XPhenytek X XSabril X XStavzor X XTegretol X XTegretol XR X XTopamax X XTrileptal X XVimpat X XZonegran X X
Bupropion XBupropion SR X XBupropion XL X XMirtazapine XNefazodone XTranylcypromine Sulfate XTrazodone XVenlafaxine X XVenlafaxine ER Capsules X XVenlafaxine ER Tablets (Generic) X X
Aplenzin XCymbalta X X XEffexor XR X XEmsam Transdermal X XMarplan XNardil XParnate XPristiq X XVenlafaxine ER Tablets X X
Citalopram X XFluoxetine X XFluoxetine Weekly X XFluvoxamine X XParoxetine X XParoxetine CR X XSertraline X X
Lexapro X XLuvox CR X XPexeva X X
Dimenhydrinate injection XDimenhydrinate tablets X XDronabinol X XGranisetron injection XGranisetron solution, tablets X XMeclizine OTC X XMeclizine Rx XMetoclopramide XOndansetron XProchlorperazine XPromethazine suppositories X X
Antidepressants, SSRIs
Antidepressants, Other
Antiemetics/ Antivertigo Agents
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
7Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Trimethobenzamide XAloxi XAntivert XAnzemet injection XAnzemet tablets X XCesamet X XEmend capsules X XEmend injection XKytril XMarinol X XMetozolv ODT XReglan XSancuso X XScopace XTigan XTransderm-Scop XZofran XZuplenz X
Clotrimazole troche XFluconazole XGriseofulvin XItraconazole XKetoconazole XNystatin XTerbinafine XVoriconazole X
Ancobon XDiflucan XGrifulvin V XGris-Peg XLamisil XNoxafil XOravig XSporanox XTerbinex XVfend X
Ciclopirox XClotrimazole OTC X XClotrimazole RX XClotrimazole-Betamethasone XEconazole XKetoconazole cream XKetoconazole Shampoo XMiconazole X XNystatin XNystatin-Triamcinolone XTerbinafine X XTolnaftate X X
Bensal HP XCiclodan XCNL 8 XDesenex XErtaczo XExelderm XExtina XFungoid XKetocon XLamisil AF, AT XLamisil solution X
Antifungals, Oral
Antifungals, Topical
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
8Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Loprox XLotrimin AF X XLotrisone XMentax XNaftin XNizoral XOxistat XPediaderm AF XPenlac XTinactin X XVusion XXolegel X
Cetirizine OTC X X XCetirizine Rx XCetirizine-D X X X XFexofenadine OTC X X XFexofenadine Rx X XFexofenadine-D XLevocetirizine XLoratadine X X XLoratadine-D X X X X
Allegra X XAllegra-D X X XClarinex X XClarinex-D X X XClaritin X X XClaritin-D X X X XSemprex D X X XXyzal X X
Allopurinol XColchicine XProbenecid XProbenecid-Colchicine X
Colcrys XKrystexxa XUloric X
Sumatriptan nasal, injection X XNaratriptan X XSumatriptan tablets X X
Amerge X XAxert X XCambia XFrova X XImitrex injection, nasal X XImitrex tablets X XMaxalt, Maxalt MLT X XRelpax X XSumavel X XTreximet X XZomig, Zomig ZMT X X
Malathion XPermethrin XPermethrin OTC X XPiperonyl Butoxide/Pyrethrins X X
Eurax XLindane XNatroba XOvide XUlesfia X
Antimigraine Agents, Triptans
Antiparasitics, Topical
Antihistamines, Minimally Sedating
Antihyperuricemics
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
9Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Benztropine X XBromocriptine X XCarbidopa / Levodopa X XCarbidopa / Levodopa ODT X XPramipexole X XRopinirole X XSelegiline X XTrihexyphenidyl X X
Azilect X XComtan X XMirapex X XMirapex ER X XRequip XL X XStalevo X XTasmar X XZelapar X X
Amitriptyline / Perphenazine X XChlorpromazine X XClozapine X X XFluphenazine X X
Fluphenazine Decanoate (Injection) X X
Haloperidol X X
Haloperidol Decanoate (Intramusc) X X
Loxapine X XPerphenazine X XRisperidone X X XThioridazine X X
Antipsychotics
Antiparkinson’s Agents
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
10Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Thiothixene X XTrifluoperazine X X
Abilify X X XFanapt X X XFazaclo X X XGeodon (Intramusc) X XGeodon X X XInvega X X XInvega Sustenna (Intramusc) X XOrap X XRisperdal Consta (Intramusc) X XSaphris X X XSeroquel X X XSeroquel XR X X XSymbyax X X XZyprexa (Intramusc) X XZyprexa X X XZyprexa Relprevv (Intramusc) X X
Acyclovir XAmantadine XFamciclovir XRimantadine XValacyclovir X
Famvir XRelenza XTamiflu XValtrex XZovirax XAbreva X XDenavir XXerese XZovirax Cream XZovirax Ointment XElidel XProtopic X
Acebutolol XAtenolol, Atenolol/Chlorthalidone XBetaxolol XBisoprolol, Bisoprolol/HCTZ XCarvedilol X XLabetalol XMetoprolol, Metoprolol/HCTZ XNadolol, Nadolol/Bendroflumethiazide X
Pindolol XPropranolol, Propranolol HCTZ XSotalol XTimolol X
Betapace XBystolic XCoreg X XCoreg CR X XCorgard, Corzide XInderal, Inderal LA XInnopran XL XKerlone XLevatol XLopressor, Lopressor HCT XSectral X
Atopic Dermatitis
Antivirals, Oral
Antivirals, Topical
Beta-Blockers
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
11Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Tenormin, Tenoretic XToprol XL XTrandate XZebeta X
Ursodiol X XActigall X XChenodal X XUrso X XUrso Forte X X
Oxybutynin X XOxybutynin ER X XTrospium X
Detrol X XDetrol LA X XDitropan XL X XEnablex X XGelnique XOxytrol X XSanctura, Sanctura XR X XToviaz XVesicare X X
Alendronate Tablets X XCalcitonin nasal X XEtidronate XPamidronate injection X
Actonel X XActionel w/ Calcium X XAtelvia X XBoniva tablets X XBoniva injection X XDidronel XEvista X XForteo X XFortical X XFosamax Plus D X XFosamax X XMiacalcin injection X XMiacalcin nasal X XProlia XReclast XXgeva XZometa X
Doxazosin X XAlfuzosin X XFinasteride X XTamsulosin X XTerazosin X X
Avodart X XCardura, Cardura XL X XFlomax X XHytrin X XJalyn X XProscar X XRapaflo X XUroxatral X X
Ipratropium / Albuterol XIpratropium Nebulizer X
Atrovent HFA XCombivent X
Bile Salts
Bronchodilators, Anticholinergic
Bladder Relaxant Preparations
Bone Resorption Suppression and Related Agents
BPH Treatment
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
12Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Spiriva XAlbuterol (Oral) XAlbuterol Nebulizer XAlbuterol Nebulizer Low-Dose XLevalbuterol X XMetaproterenol (Oral) XTerbutaline (Oral) X
Brovana X XForadil X XMaxair XPerforomist X XProair HFA XProventil HFA XSerevent X XVentolin HFA XXopenex XXopenex HFA X X
Amlodipine X XDiltiazem, Diltiazem ER X XDiltiazem LA X XFelodipine ER X XIsradipine X XNicardipine X XNifedipine, Nifedipine ER X XNimodipine XNisoldipine X XVerapamil, Verapamil ER X XVerapamil ER PM X X
Adalat CC X XCalan, Calan SR X XCardene SR X XCardizem, Cardizem CD, Cardizem LA X X
Covera-HS X XDynacirc CR X XNimotop XNorvasc X XProcardia XProcardia XL X XSular X XTiazac X XVerelan X XVerelan PM X X
Amoxicillin / Clav Suspension XAmoxicillin / Clav Tablet XAmoxicillin / Clav XR XCefaclor XCefadroxil XCefdinir XCefditoren XCefpodoxime XCefprozil XCefuroxime XCephalexin X
Augmentin 125 Suspension XAugmentin 250 Suspension XAugmentin XR XCedax XCeftin Suspension X
Bronchodilators, Beta Agonist
Cephalosporins
Calcium Channel Blockers
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
13Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Suprax XLeukine XNeulasta X XNeupogen X
Apri XAmethia XAmethyst XAranelle XAviane XAzurette XBalziva XCamila XCaziant XCryselle XCyclafem XEnpresse XErrin XGeneress Fe XGianvi XGildess FE XHeather XIntrovale XJunel XJunel FE XKariva XKelnor 1-35 XLessina XLevora-28 XLoestrin XLevonorgestrel xLoestrin FE XLow-Ogestrel XLutera XMicrogestin XMicrogestin FE XNorethindrone XNorgestimate-Ethinyl Estradiol XNortrel XOgestrel XOvcon-35 XPortia XPrevifem XQuasense XReclipsen XSprintec XSronyx XTilia FE XTri-Legest FE XTrinessa XTri-Previfem XTri-Sprintec XVelivet XZarah XZenchent XZovia X
Beyaz XBrevicon XCesia XCyclessa X
Colony Stimulating Factors
Contraceptives, Oral
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
14Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Desogen XEstrostep FE XFemcon FE XJolessa XJolivette XLeena XLevlen-28 XLo-Ovral-28 XLo Loestrin Fe XLoestrin XLoseasonique XLybel XMicronor XMircette XModicon XMononessa XNatazia XNecon XNora-Be XNordette-28 XNorgestrel-Ethinyl Estradiol XNorinyl XNor-Q-D XOcella XOrtho Cyclen XOrtho Tri-Cyclen XOrtho Tri-Cyclen Lo XOrtho-Cept XOrtho-Novum XOvcon-50 XSafyral XSeasonale XSeasonique XSolia XTrinessa XTri-Norinyl XYaz XYasmin 28 XActemra XAmevive XCimzia X XEnbrel X XHumira X XKineret XOrencia XRemicade XSimponio XStelara XAbbott X XAgamatrix XArkray XBayer X XBecton Dickinson XCCS XEnvision XHMD XHome Diagnostics X XLifescan X XRoche X X
Cytokine and CAM Antagonists
Diabetic Meters
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
15Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Therasense X XTruetrack XUS Diagnostics XVertex XAbbott XAgamatrix XArkray XBayer XBecton Dickinson XCCS Medical XDiabetic Supply XDispense Express XHome Diagnostics XLifescan XMedisense XRoche XSolartek XUS Diagnostics XTherasense XAranesp X XEpogen X Procrit X XCymbalta X XLyrica X XSavella X
Ciprofloxacin ER XCiprofloxacin XLevofloxacin XOfloxacin X
Avelox XCipro XFactive XLevaquin suspension XLevaquin tablets XNoroxin XProquin XR X
Budesonide Respules X XAdvair / Advair HFA X XAerobid / Aerobid-M XAlvesco X XAsmanex X XFlovent / Flovent HFA XPulmicort Flexhaler XPulmicort Respules X XQvar XSymbicort X XGenotropin XHumatrope XNorditropin XNutropin XNutropin AQ X XOmnitrope XSaizen X XSerostim X XTev-tropin XZorbtive XAdvate XHelixate-FS XKogenate FS X
Diabetic Strips
Erythropoiesis Stimulating Proteins
Fibromyalgia
Glucocorticoids, Inhaled
Fluoroquinolones, Oral
Growth Hormones
Hemophilia Agents, Recombinant Factor VIII
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
16Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Recombinate XRefacto XAlphanate XHemofil-M XHumate-P XKoate-DVI XMonarc-M XMonoclate-P XAlphanine SD XBebulin VH Immuno XBenefix XMononine X
Hemophilia Agents, Anti-inhibitor Coagulant ComplexFeiba VH Immuno X
Hemophilia Agents, Factor VIIa Novoseven XEpivir HBV X XBaraclude X XHepsera X XTyzeka X X
Ribavirin XCopegus XIncivek XInfergen XPegasys X X XPeg-Intron XRebetol XRibasphere 400 mg, 600 mg XRibapak XVictrelis X
Didanosine XStavudine XZidovudine X
Aptivus XAtripla XCombivir XCrixivan XEmtriva XEpivir XEpzicom XFuzeon (Injection) XIntelence XInvirase XIsentress XKaletra XLexiva XNorvir XPrezista XRescriptor XRetrovir XReyataz XSelzentry XSustiva XTrizivir XTruvada XVidex XVidex EC XViracept XViramune XViramune XR X
Hemophilia Agents, Plasma-Derived Factor VIII
Hemophilia Agents, Factor IX
Hepatitis B Agents
Hepatitis C Agents
HIV/AIDS
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
17Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Viread XZerit XZiagan XByetta Pens (Subcutaneous) X X XJanumet X X XJanuvia X X XKombiglyze XR XOnglyza X X XSymlin (Subcutaneous) X X XTradjenta X X XVictoza (Subcutaneous) X X XApidra XApidra Pens XHumalog vials XHumalog Mix vials XHumalog Mix Pens XHumalog Pens XHumulin vials XHumulin Pens XLantus XLantus Pens XLevemir XLevemir Pens XNovolin vials XNovolin pens XNovolog XNovolog Mix 70/30 XNovolog Mix 70/30 Pens XNovolog Pens XNateglinide X XPrandimet X XPrandin X XStarlix X XActoplus Met X XActoplus Met XR X XActos X XAvandamet X XAvandia X XAvandryl X XDuetact X X
Azathrioprine XCyclosporine XCyclosporine, Modified XMycophenolate Mofetil XTacrolimus X
Azasan XCellcept XGengraf XImuran XMyfortic XNeoral XPrograf XZortress XRapamune XSandimmune X
Beconase AQ XFlunisolide XFluticasone XIpratropium X
Intranasal Rhinitis Agents
Hypoglycemics, Incretin Mimetics/ Enhancers
Hypoglycemics, Insulin
Hypoglycemics, Meglitinides
Hypoglycemics, TZDs
Immunosuppressive, Oral
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
18Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Astelin XAstepro XNasacort AQ XNasonex XOmnaris XPatanase XRhinocort Aqua XVeremyst XAccolate X XSingulair X XZyflo CR X X
Cholestyramine XColestipol XFenofibrate X XFenofibric Acid X XGemfibrozil XNiacin X X
Antara X XColestid XFenoglide X XFibricor XLofibra X XLipofen X XLopid XLovaza X XNiacor XNiaspan XQuestran XTricor X XTriglide X XTrilipix XWelchol XZetia X X
Lovastatin X XPravastatin X XSimvastatin X X
Advicor X XAltoprev X XCaduet X XCrestor X XLescol, Lescol XL X XLipitor X XLivalo X XMevacor X XPravachol X XSimcor X XVytorin X XZocor X X
Azithromycin XClarithromycin XClarithromycin ER XErythromycin X
Biaxin, Biaxin XL XPCE XKetek XZithromax, Zmax XAvonex XAmpyra X X XBetaseron X
Macrolides/ Ketolides
Multiple Sclerosis Agents
Lipotropics, Other
Lipotropics, Statins
Leukotriene Modifiers
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
19Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Copaxone X XGilenya X X XExtavia XRebif X
Diclofenac X XEtodolac X XFenoprofen X XFlurbiprofen X XIbuprofen OTC X X XIbuprofen RX X XIndomethacin (Oral/Rectal) X XKetoprofen X XKetorolac X X XMeclofenamate X XMefenamic Acid X XMeloxicam X XNabumetone X XNaproxen X XNaproxen OTC X X XOxaprozin X XPiroxicam X XSulindac X X
Arthrotec X XCelebrex X XIndocin (Rectal) X XIndocin Suspension X XTolmetin X XVimovo X XZipsor X X
Azelastine XCromolyn Sodium XKetorolac XKetotifen OTC X X
Acular XAlamast XAlocril XAlomide XAlrex XBepreve XElestat XEmadine XOptivar XPataday XPatanol X
Bacitracin XBacitracin / Polymyxin XCiprofloxacin Solution XErythromycin XGentamicin XNeomycin-Polymyxin-Gramicidin XOfloxacin XPolymyxin / Trimethoprim XSulfacetamide XTobramycin XTriple Antibiotic X
Azasite XBesivance XCiloxan Ointment XIquix X
Ophthalmics for Allergic Conjunctivitis
Ophthalmic Antibiotics
NSAIDs
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
20Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Natacyn XQuixin XTobrex Ointment XVigamox XZymar X
Betaxolol XBrimonidine XBrimonidine P XCarteolol XDorzolamide XDorzolamide / Timolol XLevobunolol XMetipranolol XPilocarpine XTimolol X
Alphagan P XAzopt XBetimol XBetoptic S XCombigan XCosopt XIstalol XLumigan XPropine XTravatan Z XTrusopt XXalatan X
Dexamethasone XDiclofenac XFluorometholone XFlurbiprofen XKetorolac LS XPrednisolone X
Acuvail XDurezol XFlarex XFML Forte XFML S.O.P. XLotemax XMaxidex XNevanac XOzurdex XPred Mild XRestasis X XRetisert XTriesence XVexol XXibrom X
Buprenorphine HCL X X XSuboxone Film X X XSuboxone Tablets X X XSubutex X X XVivitrol X
Neomycin/Polymyxin/HC XOfloxacin X
Cetraxal XCiprodex XCipro HC XColy-Mycin S X
Opiate Dependence Treatments
Otic Antibiotic Preparations
Ophthalmic Antiinflammatories
Ophthalmics, Glaucoma Agents
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
21Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Cortisporin, Cortisporin-TC XPediotic XAdcirca X XLetairis X XRevatio X X XTracleer X XTyvaso XVentavis X
Pancrelipase XCreon XPancreaze XZenpep X
Calcium acetate XEliphos XFosrenol XPhosLo XRenagel XRenvela X
Dipyridamole X XTiclopidine X X
Aggrenox X XEffient X X XPersantine X XPlavix X X
Advanced Care Plus XCavan One Omega XCavan-Alpha Kit XCavan-EC Sod DHA XCavan-Heme Omega XCombi RX XCo-Natal FA XDaily Prenatal Combo XDocosavit XDualvit OB XEdge OB XElite-OB 400 XFE C XFolbecal XFolinatal Plus B XFolivane-EC Calcium DHA NF XFolivane-OB XFolivane-PRX DHA NF XFoltabs XFoltabs Prenatal Plus DHA XIcar-C Plus XInatal Advance XInatal Ultra XMaternity XMultinatal Plus XNeevo XNeevo DHA XNutrispire XOB + DHA XOB-Natal One XPNV-DHA XPNV-DHA + Docusate XPNV-Select XPNV-Total XPR Natal 430 X
PAH Agents, Oral
Platelet Aggregation Inhibitors
Phosphate Binders
Prenatal Vitamins
Pancreatic Enzymes
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
22Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
PR Natal 430 EC XPR Natal 440 EC XPrenaplus XPrenatabs RX XPrenatal XPrenatal 19 XPrenatal AD XPrenatal Low Iron XPrenatal MR 90 FE XPrenatal Multivitamin w/ Iron XPrenatal Plus XPrenatal Plus Iron XPrenatal S OTC X XPrenatal Vitamins OTC X XPrenate Plus XPrenexa XPrevite RX XPruet DHA XPruet DHA EC XRE-Nata 29 XRE-Nata 29 OB XSE-Care XSE-Care Conceive XSE-Care Gesture XSelect-OB XSE-Natal 19 XSE-Natal 90 XSE-Natal One XSE-Plete DHA XSE-Tan DHA XSetonet XSetonet-EC XTaron-C DHA XTaron-EC Cal XTri RX XTriadvance XTricare XTrimesis RX XTriveen-PRX RNF XUltimatecare One XUltimatecare One NF XVemavite-PRX 2 XVenatal-FA XVinacal XVinate C XVinate Care XVinate IC XVinate One XVinate PN Care XVinate Ultra XVinate-M XVitanatal OB + DHA XVitaphil XVitaphil + DHA XVitaspire XVol-Nate XVol-Plus XVol-Tab Rx XZatean-CH X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
23Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Zatean-PN XZatean-PN DHA XZatean-PN Plus X
Citranatal 90 DHA XCitranatal Assure XCitranatal B-Calm XCitranatal DHA XCitranatal Harmony XCitranatal RX XComplete Natal DHA XCompletenate XComplete-RF Prenatal XConcept DHA XConcept OB XCorenate-DHA XDuet DHA XDuet DHA Balanced XDuet DHA Complete XDuet DHA EC XDuet DHA with Ferrazone XDuet Stuartnatal XED Cyte F XElite OB DHA XElite-OB XFemecal OB XFolcal DHA XFolcaps Care One XFolcaps Omega-3 XGesticare XGesticare DHA XIcar-C Plus SR XInatal GT XInfanate DHA XLactocal-F XMarnatal-F XMaxinate XMission Prenatal FA OTC X XMission Prenatal HP OTC X XMission Prenatal OTC X XMulti-Nate 30 DHA XMulti-Nate DHA Extra XM-Vit XNatachew XNatafort XNatalvit XNatelle One XNatelle-EZ XNavatab + DHA XNexa Select XOB 90 + DHA XOB Complete XOB Complete 400 XOB Complete Chewable XOB Complete DHA XOB Complete One XOB Complete Premier XO-Cal FA XO-Cal Prenatal XPaire OB Plus DHA X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
24Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
PNV-DHA Plus XPNV-Iron XPNV-Omega XPoly Iron PN XPoly Iron PN Forte XPR Natal 400 XPR Natal 400 EC XPrefera OB XPrefera-OB One XPrefera-OB Plus DHA XPrenafirst XPrenatabs FA XPrenatal-U XPrenate DHA XPrenate Elite XPrenate Essential XPrenavite OTC X XPrenexa Premier XPreque 10 XRenate DHA XRovin-NV XRovin-NV DHA XSelect-OB + DHA XTandem OB XTaron EC Calcium XTaron-BC XTaron-Duo EC XTaron-Prex Prenatal XTricare DHA XTrinatal RX 1 XTrinate XTriveen-Duo DHA XTriveen-One XTriveen-Ten XTriveen-U XTrust Natal DHA XUltimatecare Advantage XUltimatecare Combo XVinate AZ XVinate AZ Extra XVinate Calcium XVinate GT XVinate II XVitafol-OB XVitafol-OB+DHA XVitafol-PN XViva DHA X
Lansoprazole X XOmeprazole OTC X X XOmeprazole Rx X XOmeprazole-Sodium Bicarbonate X XPantoprazole X X
Aciphex X XDexilant X XNexium X XNexium Suspension X XPrevacid X XPrilosec Capsules X XPrilosec OTC X X X
Proton Pump Inhibitors
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
25Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Prilosec Suspension X XZegerid OTC X X XProtonix X XProtonix Suspension X X
Chloral Hydrate X XEstazolam X X XFlurazepam X X XTemazepam 15mg/30mg X X XTemazepam 7.5mg/22.5mg X X XTriazolam X X XZaleplon X XZolpidem X X
Ambien, Ambien CR X XDalmane X X XDoral X X XEdluar X XHalcion X X XLunesta X XProsom X X XRestoril 7.5mg X X XRozerem X XSonata X X
Baclofen X XCarisoprodol, Carisoprodol/ASA X XChlorzoxazone X XCyclobenzaprine X XCyclobenzaprine ER X XDantrolene Sodium X XMetaxalone X XMethocarbamol X XOrphenadrine, Orphenadrine Compound X X
Tizanidine X XAmrix X XDantrium X XFexmid X XParafon Forte DSC X XRobaxin X XSkelaxin X XSoma, XZanaflex X X
Alclometasone Dipropionate XDesonide XHydrocortisone XHydrocortisone OTC X X
Capex XDerma-Smoothe-FS XDesonate XPediaderm HC XVerdeso X
Fluocinolone Acetonide XFluticasone Propionate XHydrocortisone Butyrate XHydrocortisone Valerate XMometasone Furoate XPrednicarbate X
Cloderm XCordran Tape XCutivate Lotion X
Steroids, Topical – Medium Potency
Steroids, Topical – Low Potency
Skeletal Muscle Relaxants
Sedative Hypnotics
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
26Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Locoid Lipocream XLuxiq XMomexin XPandel X
Amcinonide XBetamethasone Dipropionate XBetamethasone Valerate XDesoximetasone XDiflorasone Diacetate XFluocinonide XFluocinonide Emollient XFluocinonide-E XTriamcinolone Acetonide X
Halog XKenalog Aerosol XVanos X
Clobetasol XClobetasol Emollient XClobetasol Propionate XHalobetasol Propionate X
Clobex XHalonate XHalonate PAC XOlux-E XOlux-Olux-E X
Amphetamine Salt Combo X X XAmphetamine Salt Combo ER X X XDexmethylphenidate X X XDextroamphetamine X X XMethamphetamine X X XMethylphenidate X X XMethylphenidate ER X X X
Adderall XR X X XConcerta X X XDaytrana X X XDesoxyn X X XFocalin X X XFocalin XR X X XIntuniv X X XMetadate CD X X XMethylin Chewable and Solution X X X
Nuvigil X X XProcentra X XRitalin LA X X XStrattera X X XVyvanse X X X
Tetracyclines - see Acne Agents, OralBalsalazide XMesalamine (rectal) XSulfasalazine X
Apriso XAsacol XAsacol HD XAzulfidine XCanasa XColazal XDipentum XLialda X
Ulcerative Colitis Agents
Steroids, Topical – High Potency
Steroids, Topical – Very High Potency
Stimulants and Related Agents
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
27Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Pentasa XRowasa, sfRowasa X