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MARYLAND PREFERRED DRUG LIST - Provider …

MARYLAND Medicaid PREFERRED drug List EFFECTIVE DATE: 1/1/18. Only drugs that are part of the listed therapeutic categories are affected by the MARYLAND Medicaid PREFERRED drug List (PDL). Therapeutic categories not listed here are not part of the PDL and will continue to be covered as they always have for MARYLAND Medicaid participants. Note: Brand names listed in parentheses are only listed as a reference. For most multi-source products, the generic products are usually PREFERRED and the branded innovator product is non- PREFERRED . If a generic product is non- PREFERRED , the corresponding brand product is also non- PREFERRED except where specifically noted as (generic only).

Key: cc-Clinical criteria can be found at the link here ql- Quantity limits can be found at the link here All lowercase letters = generic product.

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Transcription of MARYLAND PREFERRED DRUG LIST - Provider …

1 MARYLAND Medicaid PREFERRED drug List EFFECTIVE DATE: 1/1/18. Only drugs that are part of the listed therapeutic categories are affected by the MARYLAND Medicaid PREFERRED drug List (PDL). Therapeutic categories not listed here are not part of the PDL and will continue to be covered as they always have for MARYLAND Medicaid participants. Note: Brand names listed in parentheses are only listed as a reference. For most multi-source products, the generic products are usually PREFERRED and the branded innovator product is non- PREFERRED . If a generic product is non- PREFERRED , the corresponding brand product is also non- PREFERRED except where specifically noted as (generic only).

2 PDL products that are new to market require prior authorization until they are reviewed. ANALGESICS. drug Class PREFERRED Requires Prior Authorization Analgesics, Narcotics (Long Acting) fentanyl patches (Duragesic) (All strengths except fentanyl mcg, mcg, and mcg mcg, mcg, and mcg)cc,ql patchescc,ql morphine sulfate SR (MS Contin)ql hydromorphone ER (Exalgo)ql Embeda methadone (Dolophine)ql morphine sulfate ER (Avinza)ql morphine sulfate ER (Kadian)ql oxymorphone ER (Opana ER)ql tramadol ER (Conzip, Ryzolt, Ultram ER)ql Arymo ER. Belbucaql Butransql Hysingla ERcc,ql Morphabond ER. Nucynta ERql Oxycontinql Xtampza ER.

3 Zohydro ERcc,ql Key: cc-Clinical criteria can be found at the link here ql- quantity limits can be found at the link here All lowercase letters = generic product. Leading capital letter = brand name product. Page 1 of 18. ANALGESICS. drug Class PREFERRED Requires Prior Authorization Analgesics, Narcotics (Short Acting) apap w/codeine (Tylenol w/codeine)ql butorphanol nasal spray butalbital/apap/codeine/caffeineql carisoprodol/codeine/asa butalbital/aspirin/codeine/caffeineql dihydrocodeine/aspirin/caffeine (Synalgos DC). codeine tablets fentanyl buccal (Actiq)cc,ql hydrocodone/apap tablets (Lortab, Norco, Vicodin)ql hydrocodone/apap solutionql hydrocodone/ibuprofen (Vicoprofen) hydromorphone suppositories and solution hydromorphone tablets (Dilaudid) levorphanol morphine sulfate tablets, solution meperidine (Demerol).

4 Oxycodone capsules, tablets, solution morphine suppositories oxycodone/apap (Percocet)ql oxycodone/acetaminophen (Primlev)ql tramadol (Ultram)ql oxycodone concentrated solution tramadol/apap (Ultracet)ql oxycodone/aspirin (Percodan). oxycodone/ibuprofen (Combunox). oxymorphone (Opana). pentazocine/naloxone (Talwin NX). Abstralcc,ql Fentoracc,ql Lazandacc,ql Nucynta Oxaydo Subsyscc,ql Xartemis XRcc,ql Anti-Migraine Agents eletriptan (Relpax)ql almotriptan (Axert)ql rizatriptan, rizatriptan ODT (Maxalt, Maxalt MLT)ql naratriptan (Amerge)ql sumatriptan nasal, syringe, tablets (Imitrex)ql sumatriptan kit, vial (Imitrex)ql zolmitriptan, zolmitriptan ODT (Zomig, Zomig ZMT)ql Frovaql Migranow Kit Onzetra Xsail Sumavel Treximetql Zecuityql Zembrace Symtouch Zomig nasalql Neuropathic Pain capsaicin OTC duloxetine 40mg (Irenka)ql duloxetine (Cymbalta)cc,ql gabapentin solution (Neurontin).

5 Gabapentin capsules (Neurontin) DermacinRx PHN Pak gabapentin tablets (Neurontin) Gralise lidocaine patch (Lidoderm)ql Horizant Lyrica capsulesql Lyrica solution Qutenza Kit Savella Key: cc-Clinical criteria can be found at the link here ql- quantity limits can be found at the link here All lowercase letters = generic product. Leading capital letter = brand name product. Page 2 of 18. ANALGESICS. drug Class PREFERRED Requires Prior Authorization Nonsteroidal Anti-Inflammatories diclofenac, diclofenac XL (Cataflam, Voltaren XR) celecoxib (Celebrex). (NSAIDS) diclofenac gel (Voltaren Gel) diclofenac potassium (Zipsor).

6 Flurbiprofen (Ansaid) diclofenac topical solution (Pennsaid). ibuprofen Rx and OTC (Motrin) diclofenac/capsicum oleoresin kit indomethacin (Indocin) diclofenac/misoprostol (Arthrotec). ketorolac (Toradol) diflunisal (Dolobid). meloxicam tablets (Mobic) etodolac, etodolac XL (Lodine, Lodine XL). nabumetone (Relafen) fenoprofen naproxen Rx and OTC (Aleve, Naprosyn) ibuprofen chewable tabs OTC. sulindac (Clinoril) indomethacin ER (Indocin SR). ketoprofen, ketoprofen ER (Orudis, Oruvail). meclofenamate (Meclomen). mefenamic acid (Ponstel). meloxicam suspension naproxen sodium RX. naproxen CR, Suspension oxaprozin (Daypro).

7 Piroxicam (Feldene). tolmetin, tolmetin DS (Tolectin, Tolectin DS). Advil OTC. Dermacinrx Lexitral Duexis Flectorcc,ql Indocin suppositories and suspension Pennsaid Pump Sprix Tivorbex Vimovo Vivlodex Vopac MDS. Xrylix Kit Zorvolex Opioid Use Disorder Treatments buprenorphine (Subutex)cc,ql buprenorphine/naloxone tablets (Suboxone)ql naloxone (Narcan). naltrexone (Revia)cc Bunavailql Narcan nasal spray Suboxone filmql Vivitrolcc,ql Zubsolvql Skeletal Muscle Relaxants baclofen (Lioresal) carisoprodol 250mg (Soma). chlorzoxazone (Parafon) carisoprodol 350mg (Soma). cyclobenzaprine (Flexeril)ql carisoprodol compound (Soma Compound).

8 Methocarbamol (Robaxin) dantrolene (Dantrium). orphenadrine (Norflex) metaxalone (Skelaxin). tizanidine tablets (Zanaflex) tizanidine capsules (Zanaflex). Amrix Lorzone Key: cc-Clinical criteria can be found at the link here ql- quantity limits can be found at the link here All lowercase letters = generic product. Leading capital letter = brand name product. Page 3 of 18. ANTI-INFECTIVES. drug Class PREFERRED Requires Prior Authorization Antibiotics, GI metronidazole tablets (Flagyl) metronidazole capsules (Flagyl capsules). neomycin paromomycin vancomycin capsules (Vancocin) tinidazole (Tindamax).

9 Alinia suspension Alinia tablet Dificidcc,ql Flagyl ER. Xifaxancc,ql Antibiotics, Inhaled Bethkiscc,ql tobramycin inhalation solution (Tobi)cc,ql Kitabis Pak(Brand only)cc ql tobramycin pak (Kitabis) (generic only)cc,ql Tobi Podhaler (Step therapy)cc,ql Caystoncc,ql Antibiotics, Topical bacitracin OTC mupirocin cream (Bactroban Cream). bacitracin/polymyxin OTC Altabax gentamicin Centany mupirocin ointment (Bactroban Ointment). triple antibiotic OTC. Antibiotics, Vaginal clindamycin (Cleocin) Nuvessa metronidazole vaginal (Metrogel) Vandazole Clindesse Cleocin ovule Antifungals, Oral clotrimazole troches (Mycelex) flucytosine (Ancobon).

10 Fluconazole (Diflucan) griseofulvin tablets (Gris Peg, GriFulvin V). griseofulvin suspension (GriFulvin V) itraconazole (Sporanox). ketoconazole (Nizoral) voriconazole (Vfend). nystatin suspension and tablets Cresemba terbinafine (Lamisil) Lamisil granules Noxafil Onmel Oravig Terbinex Antifungals, Topical clotrimazole Rx and OTC ciclopirox (Loprox,Loprox Kit,Loprox Shampoo,Penlac). clotrimazole/betamethasone cream (Lotrisone) clotrimazole/betamethasone lotion (Lotrisone). ketoconazole cream and shampoo (Nizoral) econazole (Spectazole). miconazole cream OTC ketoconazole foam (Ketodan). nystatin miconazole ointment, powder, spray OTC.