Transcription of District of Columbia
1 District of Columbia Department of Health Care Finance Pharmacy Preferred Drug List (PDL) Effective September 21st, 2020 Non-preferred medications require prior authorization Page 1 of 21 ANALGESICS Drug Class Preferred Requires Prior Authorization Long-Acting Narcotics* * Clinical criteria apply to this entire therapeutic class Embeda fentanyl 12, 25, 50, 75, 100 mcg/hr (transdermal) morphine ER tablet (gen MSContin/Oramorph SR Arymo ER Belbuca buprenorphine patch Butrans ConZip Duragesic Exalgo fentanyl , , mcg/hr (transdermal) hydromorphone ER Hysingla ER Kadian Morphabond ER morphine ER cap (gen for Kadian & Avinza) MS Contin oxycodone ER OxyContin oxymorphone ER Xtampza ER Zohydro ER NSAIDS.)
2 Oral and Topical diclofenac sodium DR tabs diclofenac (topical) ibuprofen (tab & susp) indomethacin IR cap meloxicam tab naproxen tab sulindac Voltaren Anaprox Ansaid Arthrotec Capxib Cataflam tab Celebrex celecoxib Daypro Dermacinrx Lexitral diclofenac/capsicum diclofenac epolamine patch diclofenac potassium cap, tab, & soln diclofenac SR diclofenac/misoprostol diclofenac solution (topical) Diclofex DC diflunisal Duexis etodolac IR and SR Feldene fenoprofen Flector patch flurbiprofen Indocin indomethacin ER cap Inflamma-K ketoprofen ketoprofen ER ketorolac Lidoxib meclofenamate mefenamic acid meloxicam susp Mobic nabumetone Nalfon Naprelan Naprosyn naproxen DR naproxen-esomeprazole naproxen sodium naproxen susp oxaprozin Pennsaid piroxicam Ponstel Qmiiz ODT Sprix Tivorbex tolmetin Vimovo Vivlodex Voltaren XR Vopac MDS Xrylix Zipsor Zorvolex Opiate Dependence Treatment Agents.
3 Oral and Injectable Bunavail buprenorphine buprenorphine/naloxone film & tab Evzio Lucemyra naloxone syringe & vial naltrexone Narcan nasal spray Probuphine Sublocade Suboxone Film Vivitrol Zubsolv District of Columbia Department of Health Care Finance Pharmacy Preferred Drug List (PDL) Effective September 21st, 2020 Non-preferred medications require prior authorization Page 2 of 21 ANALGESICS Drug Class Preferred Requires Prior Authorization Tramadol and Tramadol Like Agents tramadol HCl tramadol HCl-acetaminophen ConZip Nucynta Nucynta ER tramadol ER Ultracet Ultram ANTI-INFECTIVES Drug Class Preferred Requires Prior Authorization Antibiotics: Fluoroquinolones ciprofloxacin tablet Cipro susp levofloxacin tablets Baxdela ciprofloxacin suspension Cipro levofloxacin soln moxifloxacin ofloxacin Antibiotics.
4 GI Firvanq metronidazole tabs Dificid Flagyl metronidazole caps neomycin paromomycin Solosec tinidazole Vancocin vancomycin Xifaxan Antibiotics: Macrolides & Ketolides azithromycin clarithromycin IR and ER tab erythromycin base DR cap clarithromycin susp 200 Susp 400 Tab Eryped susp Ery-tab Erythrocin erythromycin base tab erythromycin ethylsuccinate susp Zithromax Antibiotics: Vaginal Cleocin Ovules Clindesse metronidazole vaginal gel Nuvessa Vandazole Cleocin crm clindamycin vaginal crm Metrogel-Vaginal Antifungals fluconazole griseofulvin susp nystatin susp terbinafine Ancobon clotrimazole Cresemba Diflucan fluconazole susp flucytosine griseofulvin tabs griseofulvin ultra-microsize tabs itraconazole ketoconazole Noxafil nystatin tabs Onmel Oravig posaconazole Sporanox Tolsura Vfend voriconazole District of Columbia Department of Health Care Finance Pharmacy Preferred Drug List (PDL)
5 Effective September 21st, 2020 Non-preferred medications require prior authorization Page 3 of 21 ANTI-INFECTIVES Drug Class Preferred Requires Prior Authorization Antifungals, Topical ciclopirox (cream & soln) clotrimazole crm (OTC & RX) clotrimazole soln (OTC) clotrimazole-betamethasone crm econazole topical ketoconazole shampoo miconazole OTC (crm, powder) nystatin (crm, oint, powder) terbinafine OTC cream tolnaftate OTC (crm & powder) Alevazol OTC Bensal HP Ciclodan Kit ciclopirox (gel, kit, susp, shampoo) clotrimazole soln (RX) clotrimazole-betamethasone lotion Dermacinrx Therazole PAK Desenex Aero powder OTC Econasil Kit Ertaczo (topical) Exelderm Extina Fungoid OTC Jublia Kerydin ketoconazole (crm, foam) ketoconazole (crm, foam) Loprox Lotrimin AF OTC Lotrinin Ultra OTC luliconazole Luzu Mentax miconazole/zinc oxide/petrolatum naftifine crm & gel Naftin nystatin-triamcinolone topical oxiconazole cream Oxistat tolnaftate OTC (soln, Aero pwdr & spray) Vusion Zeasorb Antivirals: Herpes acyclovir cap, tab & susp famciclovir valacyclovir Sitavig Valtrex Zovirax Hepatitis B.
6 Oral Agents Baraclude solution entecavir Epivir HBV soln Hepsera lamivudine (HBV) tab Viread adefovir Baraclude tablet Epivir HBV tab Vemlidy Hepatitis C Agents* * Clinical criteria, genotype consideration and review apply to this entire therapeutic class Mavyret Pegasys Proclick Pegasys syringe / vial Ribapak ribavirvin tabs & caps Vosevi Epclusa Harvoni Ledipasvir-sofosbuvir Pegasys PEG-Intron Ribasphere ribavirin dose pack sofosbuvir-velpatasvir Sovaldi VieKira Pak Zepatier District of Columbia Department of Health Care Finance Pharmacy Preferred Drug List (PDL) Effective September 21st.
7 2020 Non-preferred medications require prior authorization Page 4 of 21 ANTI-INFECTIVES Drug Class Preferred Requires Prior Authorization HIV / AIDS abacavir tab abacavir/lamivudine abacavir/lamivudine/ zidovudine Aptivus atazanavir Atripla Biktarvy Cimduo Complera Crixivan Delstrigo Descovy didanosine DR cap Dovato Edurant emtricitabine Emtriva Epivir solution Evotaz Fuzeon Genvoya Intelence Invirase Isentress Isentress HD Juluca Kalentra lamivudine lamivudine / zidovudine Lexiva nevirapine tab nevirapine ER Norvir Odefsky Pifeltro Prezcobix Prezista Rescriptor Reyataz powder pak Rukobia Selzentry stavudine Stribild Sustiva cap Symfi Symfi Lo Symtuza Temixys tenofovir Tivicay Triumeq Truvada Tybost Videx solution Viracept Viramune susp Viread powder Zerit Ziagen zidovudine abacavir solution Combivir efavirenz Epivir tab Epzicom fosamprenavir lamivudine solution lopinavir/ritonavir solution nevirapine oral susp Retrovir syrup Reyataz cap ritonavir tab Sustiva tab Trizivir Videx EC DR Cap Viramune tab IR & XR Viread Ziagen tab Influenza Agents oseltamivir Relenza rimantadine Flumadine Tamiflu Xofluza
8 Topical Antibiotics bacitracin OTC gentamicin cream & ointment mupirocin ointment neomycin / polymyxin / pramoxine topical OTC triple antibiotic oint OTC Altabax bacitracin packet OTC bacitracin/polymyxin OTC Bactroban Centany Centany AT double antibiotic oint OTC mupirocin cream Neosporin Polysporin triple antibiotic oint PLUS Topical Antivirals Zovirax cream acyclovir cream & ointment Denavir Xerese Zovirax ointment District of Columbia Department of Health Care Finance Pharmacy Preferred Drug List (PDL) Effective September 21st, 2020 Non-preferred medications require prior authorization Page 5 of 21 CARDIOVASCULAR Drug Class Preferred Requires Prior Authorization ACE Inhibitors benazepril enalapril lisinopril ramipril Accupril Altace captopril Epaned fosinopril Lotensin moexipril perindopril Prinivil Qbrelis quinapril trandolapril Vasotec Zestril ACE Inhibitor/Diuretic Combinations enalapril w/HCTZ lisinopril w/HCTZ Accuretic benazepril w/HCTZ captopril w/HCTZ fosinopril w/HCTZ Lotensin HCT moexipril w/HCTZ quinapril w/HCTZ Vaseretic Zestoretic Angiotensin Receptor Blockers losartan irbesartan
9 Micardis olmesartan valsartan Atacand Avapro Benicar candesartan Cozaar Diovan Edarbi Entresto eprosartan telmisartan Angiotensin Receptor Blockers/Diuretic losartan/HCTZ irbesartan/HCTZ Micardis HCT olmesartan/HCTZ valsartan/HCTZ Atacand HCT Avalide Benicar HCT candesartan/HCTZ Diovan HCT Edarbyclor Hyzaar telmisartan/HCTZ Angiotensin Receptor Modulators Combinations amlodipine / benazepril amlodipine / valsartan Exforge HCT amlodipine/olmesartan amlodipine/olmesartan/ HCTZ amlodipine / valsartan / HCTZ Azor Exforge Lotrel Tarka telmisartan / amlodipine trandolapril / verapamil Tribenzor Twynsta Antihypertensives.
10 Sympatholytics Catapres-TTS patches clonidine guanfacine methyldopa Catapres clonidine patches methyldopa HCTZ Beta Blockers atenolol bisoprolol Bystolic carvedilol metoprolol succinate ER metoprolol tartrate propranolol ER / SA propranolol tabs / soln sotalol acebutolol betaxolol carvedilol ER Coreg Coreg CR Corgard Hemangeol Inderal LA Inderal XL Innopran XL Kapspargo Sprinkle labetalol Lopressor nadolol pindolol Sotylize Tenormin timolol Toprol XL Beta Blockers/Diuretic Combinations atenolol / chlorthalidone bisoprolol / HCTZ Corzide Dutoprol Lopressor HCT metoprolol / HCTZ nadolol / bendroflumethiazide propranolol / HCTZ Tenoretic Ziac Bidil Bidil N/A District of Columbia Department of Health Care Finance Pharmacy Preferred Drug List (PDL) Effective September 21st, 2020 No
