Pennsylvania Department of Human Services …

1 Pennsylvania Department of Human Services Preferred Drug List (PDL) Effective January 20, 2016 AR = Age Restriction, Clinical Prior Authorization Required PA = Clinical Prior Authorization Required QL = Quantity Limit Applies Non-preferred medications require prior authorization Page 1 of 33 January 20, 2016 ACNE AGENTS, ORAL (TETRACYCLINES) Preferred Agents Non-Preferred Agents Prior Authorization Doxycycline Monohydrate 50 & 100mg Capsules Doxycycline Monohydrate Tablets Minocycline Capsules Tetracycline Adoxa Demeclocycline Doryx, Doryx DR Doxycycline Hyclate Doxycycline Hyclate DR Doxycycline Monohydrate75 & 150mg Capsules Minocycline ER Minocycline Tablets Morgidox Oracea Solodyn ER Vibramycin Capsules, Suspension, Syrup Link to PA Guidelines ACNE AGENTS, TOPICAL Preferred Agents Non-Preferred Agents Prior Authorization AzelexAR BenzaClin Gel Benzoyl Peroxide 5% & 10% wash OTC Benzoyl Peroxide gel (OTC) & lotion (OTC)

2 Clindamycin gel, lotion, solution Differin cream, lotion, gel, pumpAR Duac EpiduoAR Erythromycin Solution Erythromycin/Benzoyl Peroxide Klaron Panoxyl-4 wash OTC Panoxyl 10 OTC Retin-A GelAR Tretinoin cream, gelAR Acanya Aczone Adapalene Atralin Avita cream & gel BenzaClin Gel Pump BenzamycinBenzePro Foam Benzoyl Peroxide 6% cleanser OTC, foam, gel (RX), kit, towelette BP 10-1 Cleocin T gel, lotion, solution, swabs Clindacin Clindamycin-Benzoyl Peroxide Clindamycin foam & medicated swabs Erythromycin Gel Erythromycin Swabs Evoclin Fabior Neuac Onexton Rosanil Kit Retin-A CreamAR Retin-A-MicroAR Retin-A Micro PumpAR Sulfacetamide Sulfacetamide/Sulfur Sumadan Sumaxin TazoracAR Tretinoin microspheresAR Veltin ZianaAR Link to PA Guidelines ALZHEIMER S AGENTS Preferred Agents Non-Preferred Agents Prior Authorization DonepezilAR, QL Exelon TransdermalAR, QL Memantine TabletsAR, QL Aricept, Aricept ODTAR, QL Aricept 23 mgAR, QL Donepezil ODTAR, QL Donepezil 23 mg AR, QL Exelon CapsulesAR, QL Galantamine AR, QL Galantamine ERAR, QL Namenda SolutionAR,QL Namenda XR AR, QL Namzaric AR, QL Razadyne ERAR,QL RivastigmineAR.

3 QL Link to PA Guidelines Link to Quantity Limits List Link to PA Fax Form Pennsylvania Department of Human Services Preferred Drug List (PDL) Effective January 20, 2016 AR = Age Restriction, Clinical Prior Authorization Required PA = Clinical Prior Authorization Required QL = Quantity Limit Applies Non-preferred medications require prior authorization Page 2 of 33 January 20, 2016 ANALGESICS, NARCOTIC LONG ACTING Preferred Agents Non-Preferred Agents Prior Authorization Fentanyl (transdermal) 12, 25, 50,75, 100mcg/hrQL, AR KadianQL, AR Morphine ER tabletsQL, AR AvinzaQL, AR Butrans (transdermal)QL, AR Dolophine QL, AR DuragesicQL, AR Embeda QL, AR ExalgoQL, AR Fentanyl (transdermal) , , , AR Hydromorphone ER QL, AR Hysingla ER QL, AR MethadoneQL, AR MS ContinQL, AR Morphine ER capsulesQL, AR Nucynta ERQL, AR Opana ERQL, AR Oxycodone ERQL, AR OxycontinQL, AR Oxymorphone ERQL, AR Tramadol ERQL, AR Ultram ER QL, AR Zohydro ER QL, AR Link to PA Guidelines Link to Quantity Limits List Link to PA Fax Form - Narcotics, Long Acting in Recipients >21 Years Link to PA Fax Form - Narcotics, Long Acting in Recipients < 21 Years Link to PA Fax Form - Multiple Narcotic Prescriptions ANALGESICS, NARCOTIC SHORT ACTING Preferred Agents Non-Preferred Agents Prior Authorization APAP/CodeineQL, AR Hydrocodone/APAP TabletsQL, AR Hydromorphone TabletsPA, QL, AR IbudoneQL, AR Morphine IRQL, AR Oxycodone IR TabletsQL, AR Oxycodone/APAP tabletsQL, AR TramadolQL, AR Abstral QL, AR ActiqQL.

4 AR Butalbital/Caffeine/APAP w/CodeineQL, AR Butalbital Compound w/Codeine QL, AR Butorphanol Tartrate (nasal)QL, AR Capital w/ CodeineQL, AR Carisoprodol Compound/CodeineQL, AR Codeine QL, AR DemerolQL, AR Dihydrocodeine/ASA/ CaffeineQL, AR Dilaudid QL, AR Fentanyl (buccal)QL, AR FentoraQL, AR Fioricet/CodeineQL, AR Fiorinal/CodeineQL AR HycetQL, AR Hydrocodone/APAP SolutionQL, AR Hydrocodone/IbuprofenQL, AR Hydromorphone Liquid & SuppositoriesQL, AR LevorphanolQL, AR MeperidineQL, AR Morphine suppositories QL,AR Norco QL, AR NucyntaQL, AR Opana IRQL, AR Oxecta QL, AR Oxycodone IR Capsules, Concentrate, SolutionQL, AR Oxycodone/ASAQL, AR Oxycodone/IbuprofenQL, AR OxymorphoneQL, AR Pentazocine/NaloxoneQL, AR PercocetQL, AR PrimlevQL, AR Roxicet SolutionQL, AR RoxicodoneQL, AR SubsysQL, AR Tramadol/APAPQL, AR Tylenol with CodeineQL, AR UltracetQL, AR UltramQL, AR VicoprofenQL, AR Xartemis XR QL, AR Link to PA Guidelines Link to Quantity Limits List Link to PA Fax Form - Narcotics, Short Acting in Recipients 21 Years Link to PA Fax Form - Narcotics.

5 Short Acting in Recipients < 21 Years Link to PA Fax Form - Multiple Narcotic Prescriptions Pennsylvania Department of Human Services Preferred Drug List (PDL) Effective January 20, 2016 AR = Age Restriction, Clinical Prior Authorization Required PA = Clinical Prior Authorization Required QL = Quantity Limit Applies Non-preferred medications require prior authorization Page 3 of 33 January 20, 2016 ANDROGENIC AGENTS Preferred Agents Non-Preferred Agents Prior Authorization Androgel PA Oxandrolone PA Testosterone CypionatePA Anadrol-50 Androderm Android Aveed Axiron Depo-Testosterone Fortesta Methitest Striant Testim Testosterone Gel Testosterone Enanthate Testred Vogelxo Link to PA Guidelines Link to PA Fax Form Link to Quantity Limits List ANGIOTENSIN MODULATORS Preferred Agents Non-Preferred Agents Prior Authorization BenazeprilQL Benicar, Benicar HCTQL Enalapril, Enalapril HCTZQL FosinoprilQL Irbesartan, Irbesartan HCTZQL Lisinopril, Lisinopril HCTZQL Losartan.

6 Losartan HCTZQL QuinaprilQL RamiprilQL ValsartanQL Valsartan/HCTZQL AccuprilQL AltaceQL Atacand, Atacand HCTQL Avapro, AvalideQL Benazepril HCTZQL Candesartan, Candesartan HCTZ QL Captopril, Captopril HCTZQL Cozaar, HyzaarQL DiovanQL Diovan HCTQL Edarbi, EdarbyclorQL EpanedQL EprosartanQL Fosinopril HCTZQL LotensinQL Lotensin HCTQL MavikQL Micardis, Micardis HCTQL Moexipril, Moexepril HCTZQL PerindoprilQL PrinivilQL Quinapril,Quinapril HCTZQL Tekturna, Tekturna HCTQL Telmisartan, Telmisartan HCTZ QL Teveten, Teveten HCTQL TrandolaprilQL UnivascQL Vasotec, VasereticQL ZestrilQL Link to PA Guidelines Link to Quantity Limits List Link to PA Fax Form Link to Entresto PA Fax Form ANGIOTENSIN MODULATOR COMBINATIONS Preferred Agents Non-Preferred Agents Prior Authorization Amlodipine/BenazeprilQL AzorQL Exforge, Exforge HCTQL Amlodipine/Valsartan, Amlodipine/Valsartan HCTZQL AmturnideQL LotrelQL TarkaQL Tekamlo QL Telmisartan/AmlodipineQL Trandolapril/VerapamilQL TribenzorQL TwynstaQL Link to PA Guidelines Link to Quantity Limits List ANTI-ALLERGENS Preferred Agents Non-Preferred Agents Prior Authorization/Class Criteria GRASTEK (Timothy grass pollen allergen extract) PA ORALAIR (Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass mixed pollens allergen extract) PA RAGWITEK (Short Ragweed pollen allergen extract) PA Link to PA Guidelines Pennsylvania Department of Human Services Preferred Drug List (PDL)

7 Effective January 20, 2016 AR = Age Restriction, Clinical Prior Authorization Required PA = Clinical Prior Authorization Required QL = Quantity Limit Applies Non-preferred medications require prior authorization Page 4 of 33 January 20, 2016 ANTIBIOTICS, GI Preferred Agents Non-Preferred Agents Prior Authorization Alinia SuspensionQL Metronidazole Tablet Neomycin Vancomycin HCl Dificid Flagyl Flagyl ERQL Metronidazole Capsule Paromomycin Tindamax Tinidazole Vancocin XifaxanQL Link to PA Guidelines Link to Quantity Limits List Link to Xifaxan PA Fax Form ANTIBIOTICS, INHALED Preferred Agents Non-Preferred Agents Prior Authorization Bethkis QL Kitabis PakQL Cayston QL Tobi Podhaler QL Tobramycin Solution QL Link to PA Guidelines Link to Quantity Limits List ANTIBIOTICS, TOPICAL Preferred Agents Non-Preferred Agents Prior Authorization Bacitracin Bacitracin/Polymyxin Bactroban Cream Mupirocin Ointment Neomycin/Polymyxin/ Pramoxine Triple Antibiotic Ointment OTC Triple Antibiotic Packet OTC Altabax Bactroban Ointment Centany Double Antibiotic Ointment OTC Gentamicin Sulfate Mupirocin Cream Triple Antibiotic Plus Ointment Link to PA Guidelines ANTIBIOTICS, VAGINAL Preferred Agents Non-Preferred Agents Prior Authorization Cleocin Ovules Metronidazole Vaginal Vandazole Cleocin Cream Clindamycin Vaginal Clindesse MetroGel-Vaginal Nuvessa Link to PA Guidelines ANTICOAGULANTS Preferred Agents Non-Preferred Agents Prior Authorization Coumadin Enoxaparin Syringe QL Enoxaparin Vial QL Fragmin Syringe & Vial QL Pradaxa QL, PA Warfarin Xarelto QL.

8 PA Arixtra QL Eliquis QL Fondaparinux QL Lovenox Syringe QL Lovenox Vial QL Savaysa QL Xarelto Dose Pack QL Link to PA Guidelines Link to Quantity Limits List Link to Eliquis PA Fax Form Link to Pradaxa PA Fax Form Link to Xarelto PA Fax Form Link to Injectable Anticoagulants PA Fax Form Pennsylvania Department of Human Services Preferred Drug List (PDL) Effective January 20, 2016 AR = Age Restriction, Clinical Prior Authorization Required PA = Clinical Prior Authorization Required QL = Quantity Limit Applies Non-preferred medications require prior authorization Page 5 of 33 January 20, 2016 ANTICONVULSANTS Preferred Agents Non-Preferred Agents Prior Authorization Banzel TabletsQL Carbamazepine Chewable Tablet QL Carbamazepine ER CelontinQL Clonazepam TabletsQL Diastat (rectal) Dilantin 30 mg CapsulesQL Divalproex ERQL Divalproex Tablets Ethosuximide SyrupQL Gabapentin CapsulesQL Gabitril Lamotrigine Tablet Levetiracetam Solution, TabletsQL LyricaPA, QL Onfi TabletsQL Oxcarbazepine Suspension, TabletQL Peganone Phenobarbital PhenytoinQL Phenytoin Chewable TabletQL PrimidoneQL Tegretol Suspension, TabletQL Tegretol XRQL Topamax SprinkleQL Topiramate Tablet and SprinkleQL Trileptal SuspensionQL Valproic AcidQL VimpatQL Zarontin CapsuleQL ZonisamideQL AptiomQL Banzel SuspensionQL Carbamazepine Suspension, Tablet QL Carbamazepine XRQL CarbatrolQL Clonazepam ODTQL Depakene Depakote Depakote ER Depakote Sprinkle Diazepam (rectal)

9 Dilantin 100 mg capsulesQL Dilantin InfatabsQL Dilantin suspensionQL Divalproex Sprinkle EquetroQL Ethosuximide CapsuleQL Felbamate Felbatol FycompaQL Gabapentin Solution, TabletsQL KeppraQL Keppra XRQL KlonopinQL Lamictal Lamictal ODT Lamictal XR Lamotrigine XR Lamotrigine ODT Levetiracetam ERQL MysolineQL Neurontin QL Onfi suspension Oxtellar XR PhenytekQL PotigaQL Qudexy XRQL SabrilQL Tiagabine Topamax TabletQL Trileptal TabletsQL Trokendi XR Zarontin SyrupQL ZonegranQL Link to PA Guidelines Link to Quantity Limits List Link to PA Fax Form ANTIDEPRESSANTS, OTHER Preferred Agents Non-Preferred Agents Prior Authorization BupropionQL Bupropion SRQL Bupropion XLQL Duloxetine (Cymbalta) PA, QL Mirtazapine TabletsQL Trazodone Venlafaxine ER CapsulesQL Aplenzin BrintellixQL Cymbalta QL Desvenlafaxine ERQL Desvelafaxine fumarate ERQL Duloxetine (Irenka) Effexor XRQL Emsam TransdermalQL FetzimaQL Forfivo XL Irenka KhedezlaQL Marplan Mirtazapine ODTQL Nardil Nefazodone Oleptro ER Parnate Phenelzine PristiqQL RemeronQL Tranylcypromine Sulfate VenlafaxineQL Venlafaxine ER TabletsQL Venlafaxine ER Tablets (Generic) QL ViibrydQL Wellbutrin, SR, XLQL Link to PA Guidelines Link to PA Fax Form Link to Quantity Limits List Pennsylvania Department of Human Services Preferred Drug List (PDL)

10 Effective January 20, 2016 AR = Age Restriction, Clinical Prior Authorization Required PA = Clinical Prior Authorization Required QL = Quantity Limit Applies Non-preferred medications require prior authorization Page 6 of 33 January 20, 2016 ANTIDEPRESSANTS, SSRIS Preferred Agents Non-Preferred Agents Prior Authorization Citaloprom SolutionQL Citalopram TabletQL Escitalopram TabletQL Fluoxetine IR Capsule, SolutionQL Fluoxetine 10 mg, 20 mg, 60 mg TabletQL FluvoxamineQL Paroxetine TabletQL Sertraline TabletQL Brisdelle CelexaQL Escitalopram solutionQL Fluoxetine Capsule DRQL Fluvoxamine ERQL LexaproQL Paroxetine CRQL Paxil Tablet, Paxil CR,Paxil SuspensionQL PexevaQL ProzacQL SarafemQL Sertraline ConcentrateQL ZoloftQL Link to PA Guidelines Link to Quantity Limits List Link to PA Fax Form ANTIEMETICS/ANTIVERTIGO AGENTS Preferred Agents Non-Preferred Agents Prior Authorization Aloxi (Intravenous)QL Dimenhydrinate OTC EmendQL Emend (Intravenous)QL DronabinolQL Granisetron (Intravenous) Meclizine OTC & Rx Metoclopramide, Oral Metoclopramide, Syringe & Vial Ondansetron, Syringe & Vial Ondansetron, Tab, ODT & Solution Prochlorperazine Oral & Rectal Promethazine (Injection)AR Promethazine OralAR, QL Promethazine (Rectal except 50mg)AR, QL