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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: 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))

2 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, 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: 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.

3 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) 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.

4 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, 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

5 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 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 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

6 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, 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)

7 Effective September 21st, 2020 Non-preferred medications require prior authorization Page 6 of 21 CARDIOVASCULAR Drug Class Preferred Requires Prior Authorization Calcium Channel Blockers (DHP) amlodipine nifedipine IR nifedipine ER/SA/XL Adalat CC felodipine ER isradipine Katerzia susp nicardipine HCl nisoldipine Norvasc Nymalize Procardia Procardia XL Sular Calcium Channel Blockers (NonDHP) diltiazem ER cap diltiazem tab verapamil tab verapamil ER tab Calan SR Cardizem CD Cardizem LA diltiazem LA Matzim LA Tiazac Tiazac 420 mg verapamil 360 mg cap verapamil ER cap verapamil ER PM Verelan Verelan PM Direct Renin Inhibitors N/A aliskiren Tekturna Tekturna HCT Lipotropics: Bile Acid Sequestrants cholestyramine cholestyramine light packet cholestyramine light powder colestipol tablet Prevalite colesevelam Colestid colestipol granules Questran Questran Light Welchol Lipotropics: Cholesterol Absorption Inhibitors and Others Zetia ezetimibe Juxtapid Nexlizet Praluent Repatha Lipotropics: HMG-CoA Reductase Inhibitors (Statins) atorvastatin lovastatin pravastatin rosuvastatin simvastatin Altoprev amlodipine/atorvastatin Caduet Crestor Ezallor Sprinkle fluvastatin SR and ER Lescol XL Lipitor Livalo Pravachol simvastatin/ezetimibe Vytorin Zocor Zypitamag Lipotropics: Niacin Derivatives Niaspan niacin ER Niacor Lipotropics.

8 Triglyceride Lowering Agents fenofibrate (generic for Tricor ) gemfibrozil fenofibric acid (generic for Trilipix ) Antara fenofibrate (Atara, Fenoglide, Fibricor, Lofibra, Lipofen, Triglide) Fenoglide Fibricor Lipofen Lopid Lovaza omega-3 acid ethyl esters (Rx) Tricor Triglide Trilipix Vascepa Platelet Aggregation Inhibitors Aggrenox Brilinta clopidogrel dipyridamole aspirin / dipyridamole Durlaza Effient Persantine Plavix prasugrel ticlopidine Yosprala Zontivity Ranexa-like Agents Anti-Angina/Anti-Ischemic ranolazine ER Ranexa District of Columbia Department of Health Care Finance Pharmacy Preferred Drug List (PDL) Effective September 21st, 2020 Non-preferred medications require prior authorization Page 7 of 21 CENTRAL NERVOUS SYSTEM Drug Class Preferred Requires Prior Authorization Alzheimer s Agents: Cholinesterase Inhibitors donepezil ODT donepezil tabs Exelon patch rivastigmine caps Aricept Aricept 23 mg donepezil 23 mg galantamine IR/ER/soln rivastigmine patch Alzheimer s Agents: NMDA Receptor Antagonist and combinations memantine tablets memantine dose pack memantine ER memantine solution Namenda Namenda XR Namzaric Anti-Convulsants: Carbamazepine Derivatives carbamazepine chew tabs carbamazepine ER caps (generic for Carbatrol ) oxcarbazepine susp oxcarbazepine tabs Tegretol susp Tegretol tablets Tegretol XR Aptiom carbamazepine oral susp carbamazepine tablets carbamazepine XR tablets Carbatrol Equetro Oxtellar XR Trileptal oral susp Trileptal tablets Anti-Convulsants.

9 First Generation clonazepam tablets diazepam rectal diazepam rectal device divalproex sodium DR divalproex sodium ER divalproex sodium sprinkle ethosuximide syrup phenobarbital elixir phenobarbital tablets phenytoin chewtab phenytoin oral susp phenytoin sodium extended cap phenytoin sodium extended cap (generic for Phenytek) primidone valproic acid capsule valproic acid syrup Valtoco Celontin clobazam clonazepam ODT Depakote Depakote ER Depakote sprinkle Diastat Diastat Acudial Dilantin capsule Dilantin-125 oral susp Dilantin chew tab ethosuximide capsule felbamate Felbatol Klonopin Mysoline tablet Nayzilam Onfi Peganone Phenytek Sympazan Vigabatrin Zarontin capsule Zarontin syrup Anti-Convulsants: Second Generation and Others lamotrigine chewable-dispersible tablet lamotrigine tab levetiracetam solution levetiracetam tablet topiramate sprinkle cap topiramate tablet zonisamide Banzel Briviact Diacomit Epidiolex Fintepla Fycompa Gabitril Keppra soln & tabs Keppra XR Lamictal / CD / XR / ODT lamotrigine ER / ODT lamotrigine tab levetiracetam ER Qudexy XR Sabril Spritam tiagabine Topamax sprinkle cap Topamax tablet topiramate ER (generic for Qudexy XR) Trokendi XR Vimpat Xcopri Anti-Depressants: SSRIs citalopram solution citalopram tablet escitalopram tabs fluoxetine caps, soln, tabs paroxetine sertraline tablet Brisdelle Celexa tablet escitalopram soln fluoxetine DR / weekly fluoxetine 60 mg fluvoxamine fluvoxamine ER Lexapro paroxetine (gen.)

10 For Brisdelle ) paroxetine CR Paxil susp / tab Paxil CR Pexeva Prozac sertraline solution Zoloft District of Columbia Department of Health Care Finance Pharmacy Preferred Drug List (PDL) Effective September 21st, 2020 Non-preferred medications require prior authorization Page 8 of 21 CENTRAL NERVOUS SYSTEM Drug Class Preferred Requires Prior Authorization Anti-Depressants: Others bupropion IR/SR/XL 150, 300 mirtazapine IR trazodone Venlafaxine IR venlafaxine ER caps (OSM 24) Aplenzin bupropion XL 450 (gen. for Forfivo XL) desvenlafaxine ER Effexor XR Fetzima Forfivo XL mirtazapine ODT nefazadone Pristiq Remeron Trintellix venlafaxine ER tabs Viibryd Wellbutrin SR / XL Anti-Hyperkinesis Agents* * Clinical criteria apply to this entire therapeutic class amphetamine salt combo IR amphetamine salt combo XR Aptensio XR atomoxetine dexmethylphenidate IR dextroamphetamine IR Dyanavel X