Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

*The Statewide PDL is not an all-inclusive list of drugs covered by Medical Assistance. Drugs in Statewide PDL classes that are new to market will be non-preferred until reviewed by the DHS Pharmacy and Therapeutics Committee.

Fee-for-Service‡ (FFS) Pharmacy General Prior Authorization Requirements: https://dhs.pa.gov/providers/Pharmacy-Services/Pages/Pharmacy-Prior-Authorization-General-Requirements.aspx

FFS† Pharmacy Prior Authorization Clinical Guidelines: https://www.dhs.pa.gov/providers/Pharmacy-Services/Pages/Clinical-Guidelines.aspx

FFS‡ Pharmacy Prior Authorization Fax Forms: https://www.dhs.pa.gov/providers/Pharmacy-Services/Pages/Pharmacy-Services-Fax-Forms.aspx

FFS‡ Pharmacy Quantity Limits/Daily Dose Limits: https://dhs.pa.gov/providers/Pharmacy-Services/Pages/Quantity-Limits-and-Daily-Dose-Limits.aspx

‡This information is specific to FFS. Please refer to each managed care organization’s (MCO) website for MCO prior authorization procedures, prior authorization fax request forms, and quantity limits.

†Prior authorization guidelines for drugs and products included in the Statewide PDL apply to FFS and the Pennsylvania Medical Assistance MCOs. Prior authorization guidelines for drugs and products not included in the Statewide PDL are specific to FFS. Please refer to each MCO’s website for MCO-specific prior authorization requirements for drugs and products not included in the Statewide PDL.

ACNE AGENTS, ORAL Preferred Agents Non-Preferred Agents Amnesteem CapsulePA Absorica Capsule Myorisan CapsulePA Absorica LD Capsule Zenatane CapsulePA Claravis Capsule Isotretinoin Capsule

ACNE AGENTS, TOPICAL Preferred Agents Non-Preferred Agents Adapalene 0.3% Gel TubeAR Acanya Gel Pump Adapalene-Benzoyl Peroxide 0.1%-2.5% Gel Pump (generic Aczone 5% Gel EpiDuo)AR Aczone 7.5% Gel Pump Avita CreamAR Adapalene 0.1% CreamAR Benzoyl Peroxide Cleanser 6% (OTC) Adapalene 0.1% GelAR Benzoyl Peroxide Gel 2.5% (OTC) Adapalene 0.3% Gel PumpAR Benzoyl Peroxide Gel 5% (OTC) Aklief CreamAR Benzoyl Peroxide Gel 10% (OTC) Altreno LotionAR Benzoyl Peroxide Lotion 5% (OTC) Amzeeq Foam Benzoyl Peroxide Lotion 10% (OTC) Arazlo LotionAR Benzoyl Peroxide Wash 5% (OTC) Atralin GelAR Benzoyl Peroxide Wash 10% (OTC) Avita GelAR Clindamycin 1% Gel Benzaclin Gel Clindamycin 1% Lotion Benzaclin Gel Pump Clindamycin 1% Pledget Benzamycin Gel Clindamycin 1% Solution BP 10-1 Wash Clindamycin-Benzoyl Peroxide 1.2%-5% Gel (generic Duac, BP Cleansing Wash Neuac) BPO Foaming Cloths Differin 0.1% CreamAR Cleocin T Gel Differin 0.1% GelAR Cleocin T Lotion Ery Pads Clindacin ETZ Kit Erythromycin 2% Solution Clindacin ETZ Pledget Retin-A CreamAR Clindacin P Pledget

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 1 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Retin-A GelAR Clindacin Pac Kit Sodium Sulfacetamide-Sulfur 8%-4% Suspension Clindagel Sodium Sulfacetamide-Sulfur 9%-4.5% Wash Clindamycin 1% Daily Gel (generic Clindagel) SSS 10%-5% Cream Clindamycin Foam Clindamycin-Benzoyl Peroxide 1%-5% Gel (generic Benzaclin) Clindamycin-Benzoyl Peroxide 1%-5% Gel Pump (generic Benzaclin Gel Pump) Clindamycin-Benzoyl Peroxide 1.2%-2.5% Gel Pump (generic Acanya) Clindamycin-Tretinoin GelAR Dapsone 5% Gel Dapsone 7.5% Gel Pump Differin 0.1% LotionAR Differin 0.3% Gel PumpAR Epiduo Gel PumpAR Epiduo Forte Gel PumpAR Erygel Erythromycin Gel Erythromycin-Benzoyl Peroxide Gel Evoclin Foam Fabior FoamAR Klaron Lotion Neuac Gel Neuac Kit Onexton Gel Pump Retin-A Micro GelAR Retin-A Micro Gel PumpAR Sodium Sulfacetamide Lotion 10% Sodium Sulfacetamide-Sulfur Cleanser 9.8%-4.8% Sodium Sulfacetamide-Sulfur Cleanser 10%-2% Sodium Sulfacetamide-Sulfur Cleanser 10%-5% Sodium Sulfacetamide-Sulfur Cream 10%-2% Sodium Sulfacetamide-Sulfur Cream 10%-5% Sodium Sulfacetamide-Sulfur Medicated Pad 10%-4% Sodium Sulfacetamide-Sulfur Wash 9%-4% Sodium Sulfacetamide-Sulfur-Urea Cleanser 10%-5%-10% SSS 10%-5% Foam Sulfacetamide Sodium Suspension 10% Sumadan KitQL Sumadan Wash Sumadan XLT Kit Sumaxin Cleansing Pad Sumaxin CP KitQL Sumaxin Wash Tazarotene CreamAR Tretinoin CreamAR Tretinoin GelAR Tretinoin Micro GelAR Tretinoin Micro Gel PumpAR Ziana GelAR

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 2 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

ALZHEIMER’S AGENTS Preferred Agents Non-Preferred Agents Donepezil 5 mg, 10 mg TabletPA, QL Aricept TabletQL Galantamine TabletPA, QL Donepezil 23 mg TabletQL Memantine TabletPA, QL Donepezil ODTQL Rivastigmine CapsulePA, QL Exelon PatchQL Galantamine ER CapsuleQL Galantamine SolutionQL Memantine SolutionQL Memantine ER CapsuleQL Namenda TabletQL Namenda XR CapsuleQL Namzaric CapsuleQL Razadyne TabletQL Razadyne ER CapsuleQL Rivastigmine PatchQL

ANALGESICS, NON-OPIOID BARBITURATE COMBINATIONS Preferred Agents Non-Preferred Agents Butalbital-Acetaminophen-Caffeine 50-325-40 mg Tablet PA, QL Bupap 50-300 mg TabletQL Butalbital-Aspirin-Caffeine 50-325-40 mg Capsule PA, QL Butalbital-Acetaminophen 50-300 mg CapsuleQL Butalbital-Aspirin-Caffeine 50-325-40 mg Tablet PA, QL Butalbital-Acetaminophen 50-300 mg TabletQL Butalbital-Acetaminophen 50-325 mg TabletQL Butalbital-Acetaminophen-Caffeine 50-300-40 mg CapsuleQL Butalbital-Acetaminophen-Caffeine 50-325-40 mg CapsuleQL Esgic CapsuleQL Esgic TabletQL Fioricet 50-300-40 mg CapsuleQL Fiorinal 50-325-40 mg CapsuleQL Vanatol LQ SolutionQL Vanatol S SolutionQL Vtol LQ SolutionQL Zebutal 50-325-40 mg CapsuleQL

ANALGESICS, OPIOID LONG-ACTING Preferred Agents Non-Preferred Agents Butrans PatchPA, QL Arymo ER TabletQL Fentanyl Patch 12, 25, 50, 75, 100 mcg/hrPA, QL Belbuca FilmQL Morphine ER Capsule (generic Kadian)PA, QL Buprenorphine PatchQL Morphine ER Tablet (generic MS Contin)PA, QL DolophineQL Xtampza ER CapsulePA, QL Fentanyl Patch 37.5, 62.5, 87.5 mcg/hrQL Hydrocodone ER CapsuleQL Hydromorphone ER TabletQL Hysingla ER TabletQL Kadian ER CapsuleQL MethadoneQL Morphine ER Capsule (generic Avinza)QL MS Contin TabletQL Nucynta ER TabletQL Oxycodone ER TabletQL Oxycontin TabletQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 3 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Oxymorphone ER TabletQL Tramadol ER Capsule (generic Conzip)AR, QL Tramadol ER Tablet (generic Ryzolt)AR, QL Tramadol ER Tablet (generic Ultram ER)AR, QL Zohydro ER CapsuleQL

ANALGESICS, OPIOID SHORT-ACTING Preferred Agents Non-Preferred Agents Acetaminophen-Codeine SolutionAR, QL Acetaminophen-Caffeine-Dihydrocodeine CapsuleQL Acetaminophen-Codeine TabletAR, QL Actiq LozengeQL Benzyhydrocodone-Acetaminophen TabletQL Apadaz TabletQL Endocet TabletQL Ascomp With Codeine CapsuleAR, QL Hydrocodone-Acetaminophen TabletQL Butalbital-Caffeine-Acetaminophen-Codeine CapsuleAR, QL Lorcet HD TabletQL Butalbital Compound with Codeine CapsuleAR, QL Morphine Sulfate Concentrate SolutionQL Butorphanol Tartrate NasalQL Morphine Sulfate SolutionQL Carisoprodol-Aspirin-CodeineAR, QL Morphine Sulfate TabletQL Codeine TabletAR, QL Oxycodone 5 mg/5 ml SolutionQL Dilaudid Oral LiquidQL Oxycodone TabletQL Dilaudid TabletQL Oxycodone-Acetaminophen Tablet (generic Percocet)QL Dsuvia SL TabletQL Tramadol TabletAR, QL Fentanyl Citrate BuccalQL Tramadol-Acetaminophen TabletAR, QL Fentora Buccal TabletQL Fiorinal with Codeine CapsuleAR, QL Hydrocodone-Acetaminophen SolutionQL Hydrocodone-Ibuprofen TabletQL Hydromorphone Rectal SuppositoryQL Hydromorphone SolutionQL Hydromorphone TabletQL Levorphanol TabletQL Lorcet TabletQL Lorcet Plus TabletQL Lortab SolutionQL Meperidine SolutionQL Meperidine TabletQL Morphine Sulfate Rectal SuppositoryQL Norco TabletQL Nucynta IR TabletQL Oxaydo TabletQL Oxycodone CapsuleQL Oxycodone Concentrate SolutionQL Oxycodone-Aspirin TabletQL Oxycodone-Ibuprofen TabletQL Oxymorphone TabletQL Pentazocine-Naloxone TabletQL Percocet TabletQL Roxicodone TabletQL Tylenol with Codeine TabletAR, QL Ultracet TabletAR, QL Xylon TabletQL

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ANDROGENIC AGENTS Preferred Agents Non-Preferred Agents Depo-Testosterone VialPA, QL Anadrol-50 TabletQL Testopel Implant PelletPA, QL Androderm PatchQL Testosterone 1.62% (20.25 mg/1.25 gm) Gel Pump (generic Androgel 1% Gel Packet QL Androgel 1.62%)PA, QL Androgel 1.62% (20.25 mg/1.25 gm) Gel PacketQL Testosterone Cypionate VialPA, QL Androgel 1.62% (20.25 mg/1.25 gm) Gel PumpQL Aveed VialQL Fortesta 10 mg (2%) Gel PumpQL Jatenzo CapsuleQL Methitest TabletQL Methyltestosterone CapsuleQL Oxandrolone TabletQL Testim 1% GelQL Testosterone 1% Gel Packet (generic Androgel 1% Packet)QL Testosterone 1% Gel Pump (generic Androgel 1% Pump)QL Testosterone 1% Gel Tube (generic Testim 1%)QL Testosterone 1.62% Gel Packet (generic Androgel 1.62%)QL Testosterone 10 mg (2%) Gel Pump (generic Fortesta)QL Testosterone 30 mg/1.5 mL Solution Pump (generic Axiron)QL Testosterone Enanthate InjectionQL Vogelxo 1% Gel PacketQL Vogelxo 1% Gel PumpQL Vogelxo 1% Gel TubeQL Xyosted Auto-InjectorQL

ANGIOTENSIN MODULATOR COMBINATIONS Preferred Agents Non-Preferred Agents Amlodipine-Benazepril CapsuleQL Amlodipine-Olmesartan TabletQL Amlodipine-Valsartan TabletQL Azor TabletQL Amlodipine-Valsartan HCTZ TabletQL Exforge TabletQL Exforge HCTQL Lotrel CapsuleQL Olmesartan-Amlodipine-HCTZ TabletQL Tarka ER TabletQL Telmisartan-Amlodipine TabletQL Trandolapril-Verapamil ER TabletQL Tribenzor TabletQL

ANGIOTENSIN MODULATORS Preferred Agents Non-Preferred Agents Benazepril TabletQL Accupril TabletQL Hyzaar TabletQL Benazepril-Hydrochlorothiazide TabletQL Accuretic TabletQL Lotensin TabletQL Captopril TabletQL Aliskiren TabletQL Lotensin HCT TabletQL Enalapril TabletQL Altace CapsuleQL Micardis TabletQL Enalapril-Hydrochlorothiazide TabletQL Atacand TabletQL Micardis HCT TabletQL Entresto TabletQL Atacand HCT TabletQL Moexipril TabletQL Fosinopril TabletQL Avalide TabletQL Perindopril TabletQL Fosinopril-Hydrochlorothiazide TabletQL Avapro TabletQL Prinivil TabletQL Irbesartan TabletQL Benicar TabletQL Qbrelis SolutionAE<9, QL Irbesartan-Hydrochlorothiazide TabletQL Benicar HCT TabletQL Tekturna TabletQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 5 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Lisinopril TabletQL Candesartan TabletQL Tekturna HCT TabletQL Lisinopril-Hydrochlorothiazide TabletQL Candesartan-HydrochlorothiazideQL Telmisartan TabletQL Losartan TabletQL Captopril-HydrochlorothiazideQL Telmisartan-Hydrochlorothiazide Losartan-Hydrochlorothiazide TabletQL Cozaar TabletQL TabletQL Olmesartan TabletQL Diovan TabletQL L Vaseretic TabletQL Olmesartan-Hydrochlorothiazide TabletQL Diovan HCT TabletQL Vasotec TabletQL Quinapril TabletQL Edarbi TabletQL Zestoretic TabletQL Quinapril-Hydrochlorothiazide TabletQL Edarbyclor TabletQL Zestril TabletQL Ramipril CapsuleQL Epaned SolutionAE<9, QL Trandolapril TabletQL Valsartan TabletQL Valsartan-HydrochlorothiazideTabletQL

ANTIANGINAL AGENTS Preferred Agents Non-Preferred Agents Isosorbide Mononitrate Tablet BiDil Tablet Isosorbide Mononitrate ER Tablet Dilatrate-SR Capsule Nitro-BID Ointment Gonitro Powder Pack Nitroglycerin Patch Isordil Tablet Nitroglycerin SL Tablet Isordil Titradose Tablet Ranolazine ER TabletPA, QL Isosorbide Dinitrate Tablet Minitran Patch Nitro-DUR Patch Nitroglycerin Spray Nitrolingual Spray NitroMist Spray Nitrostat SL Tablet Ranexa TabletQL

ANTIBIOTICS, GI AND RELATED AGENTS Preferred Agents Non-Preferred Agents Firvanq Solution Dificid TabletQL Metronidazole Tablet Flagyl Capsule Neomycin Sulfate Tablet Flagyl Tablet Vancomycin Capsule Metronidazole Capsule Paromomycin Capsule Solosec Granule Packet Tinidazole TabletQL Vancocin Capsule Vancomycin Solution Xifaxan TabletQL Zinplava VialQL

ANTIBIOTICS, INHALED Preferred Agents Non-Preferred Agents Kitabis PakQL Arikayce VialQL Tobramycin 300 mg/5 mL Ampule (generic Tobi)QL Bethkis AmpuleQL Cayston Inhalation SolutionQL TOBI Podhaler Inhalation CapsuleQL TOBI SolutionQL Tobramycin Pak (generic Kitabis)QL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 6 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

ANTIBIOTICS, TOPICAL Preferred Agents Non-Preferred Agents Bacitracin Ointment Antibiotic Plus Cream Bacitracin Packet Centany Ointment Bacitracin Zinc Ointment Centany AT Ointment Kit Double Antibiotic Ointment (Bacitracin-Polymyxin) Cortisporin Cream Gentamicin Cream Cortisporin Ointment Gentamicin Ointment Mupirocin Cream Mupirocin Ointment Neomycin-Polymyxin B-Pramoxine Cream Poly Bacitracin Ointment (Bacitracin-Polymyxin) Neo-Synalar Cream Triple Antibiotic Ointment (Neomycin-Bacitracin-Polymyxin) Neo-Synalar Cream Kit Triple Antibiotic Ointment Packet (Neomycin-Bacitracin-Polymyxin) Xepi Cream Triple Antibiotic Plus Ointment (Neomycin-Bacitracin-Polymyxin- Pramoxine)

ANTICOAGULANTS Preferred Agents Non-Preferred Agents Eliquis TabletQL Arixtra SyringeQL Enoxaparin SyringeQL Coumadin Tablet Enoxaparin VialQL Fondaparinux SyringeQL Pradaxa CapsuleQL Fragmin SyringeQL Warfarin Tablet Fragmin VialQL Xarelto TabletQL Lovenox SyringeQL Lovenox VialQL Savaysa TabletQL

ANTICONVULSANTS Preferred Agents Non-Preferred Agents Carbamazepine Chewable TabletQL Aptiom TabletQL Lamotrigine ODT Carbamazepine SuspensionQL Banzel SuspensionQL Lamotrigine Starter Kit Carbamazepine TabletQL Banzel TabletQL Lamotrigine ER Tablet Carbamazepine ER CapsuleQL Briviact SolutionQL Lyrica CapsuleQL Carbamazepine ER TabletQL Briviact TabletQL Lyrica SolutionQL Clobazam SuspensionQL Carbatrol ER CapsuleQL Mysoline TabletQL Clobazam TabletQL Celontin CapsuleQL Neurontin CapsuleQL Clonazepam TabletAR, QL Clonazepam ODTAR, QL Neurontin SolutionQL Diazepam Rectal Kit Depakote DR Sprinkle Capsule Neurontin TabletQL Dilantin CapsuleQL Depakote DR Tablet Onfi SuspensionQL Divalproex Sodium DR Sprinkle Capsule Depakote ER Tablet Onfi TabletQL Divalproex Sodium DR Tablet Diacomit Capsule Oxtellar XR TabletQL Divalproex Sodium ER Tablet Diacomit Powder Packet Peganone TabletQL Epitol TabletQL Diastat Rectal Kit Phenytek CapsuleQL Equetro CapsuleQL Diastat Acudial Rectal Kit Qudexy XR CapsuleQL Ethosuximide CapsuleQL Dilantin Infatab Chewable TabletQL Sabril Powder PacketQL Ethosuximide SolutionQL Dilantin SuspensionQL Sabril TabletQL Gabapentin CapsuleQL Epidiolex SolutionQL Spritam Tablet for SuspensionQL Gabapentin SolutionQL Felbamate Suspension Sympazan FilmQL Gabapentin TabletQL Felbamate Tablet Tegretol SuspensionQL Lamotrigine Tablet Felbatol Suspension Tegretol TabletQL Levetiracetam SolutionQL Felbatol Tablet Tegretol XR TabletQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 7 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Levetiracetam TabletQL Fintepla SolutionQL Tiagabine Tablet Levetiracetam ER TabletQL Fycompa SuspensionQL Topamax Sprinkle CapsuleQL Nayzilam Spray Fycompa TabletQL Topamax TabletQL Oxcarbazepine SuspensionQL Gabitril Tablet Trileptal SuspensionQL Oxcarbazepine TabletQL Keppra SolutionQL Trileptal TabletQL Phenobarbital Elixir/Solution Keppra TabletQL Trokendi XR CapsuleQL Phenobarbital Tablet Keppra XR TabletQL Vigabatrin Powder PacketQL Phenytoin Chewable TabletQL Klonopin TabletAR, QL Vigabatrin TabletQL Phenytoin SuspensionQL Lamictal Chewable/Dispersible Vigadrone Powder PacketQL Phenytoin ER CapsuleQL Tablet Vimpat SolutionQL Pregabalin CapsuleQL Lamictal Tablet Vimpat TabletQL Pregabalin SolutionQL Lamictal ODT Xcopri TabletQL Primidone TabletQL Lamictal XR Tablet Zarontin CapsuleQL Topiramate Sprinkle CapsuleQL Lamotrigine Chewable/Dispersible Zarontin Solution/SyrupQL Topiramate TabletQL Tablet Topiramate ER Sprinkle CapsuleQL Valproic Acid CapsuleQL Valproic Acid SolutionQL Valtoco Spray Zonisamide CapsuleQL

ANTIDEPRESSANTS, OTHER Preferred Agents Non-Preferred Agents Amitriptyline Tablet Anafranil Capsle Nefazodone Tablet Amoxapine Tablet Aplenzin ER TabletQL Norpramin Tablet Bupropion TabletQL Clomipramine Capsule Nortriptyline Solution Bupropion SR TabletQL Cymbalta CapsuleQL Pamelor Capsule Bupropion XL TabletQL Desipramine Tablet Pristiq ER TabletQL Desvelafaxine Succinate ER Tablet (generic Pristiq)QL Desvenlafaxine ER TabletQL Protriptyline Tablet Doxepin Capsule Drizalma Sprinkle CapsuleQL Remeron SoltabQL Doxepin Concentrate Solution Duloxetine 40 mg Capsule (generic Remeron TabletQL Duloxetine 20 mg, 30 mg, 60 mg Capsule (generic Irenka)QL Spravato Nasal SprayQL Cymbalta)QL Effexor XR CapsuleQL Tranylcypromine Tablet Imipramine HCl Tablet Emsam PatchQL Trimipramine Capsule Mirtazapine TabletQL Fetzima CapsuleQL Trintellix TabletQL Nortriptyline Capsule Forfivo XL TabletQL Venlafaxine ER TabletQL Phenelzine Tablet Imipramine Pamoate Capsule Viibryd TabletQL Trazodone Tablet Maprotiline TabletQL Wellbutrin SR TabletQL Venlafaxine TabletQL Marplan Tablet Wellbutrin XL TabletQL Venlafaxine ER CapsuleQL Mirtazapine ODTQL Nardil Tablet

ANTIDEPRESSANTS, SSRIS Preferred Agents Non-Preferred Agents Citalopram SolutionQL Brisdelle CapsuleQL Citalopram TabletQL Celexa TabletQL Escitalopram TabletQL Escitalopram SolutionQL Fluoxetine CapsuleQL Fluoxetine DR CapsuleQL Fluoxetine SolutionQL Fluoxetine TabletQL Fluvoxamine TabletQL Fluvoxamine ER CapsuleQL Paroxetine TabletQL Lexapro TabletQL Sertraline Concentrate SolutionQL Paroxetine CR/ER TabletQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 8 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Sertraline TabletQL Paroxetine Mesylate CapsuleQL Paxil SuspensionQL Paxil TabletQL Paxil CR TabletQL Pexeva TabletQL Prozac CapsuleQL Sarafem TabletQL Zoloft Concentrate SolutionQL Zoloft TabletQL

ANTIEMETICS-ANTIVERTIGO AGENTS Preferred Agents Non-Preferred Agents Aloxi Vial Akynzeo CapsuleQL Bonjesta TabletQL Akynzeo VialQL Cinvanti VialQL Anzemet TabletQL Compro Rectal Suppository Aprepitant CapsuleQL Dimenhydrinate Tablet (OTC) Aprepitant Dose PackQL Emend Capsule, TripackQL Diclegis TabletQL Granisetron Vial Dimenhydrinate Vial Meclizine Chewable Tablet Doxyalmine Succinate-Pyridoxine DR Tablet Meclizine Tablet Dronabinol CapsuleQL Metoclopramide Solution Emend Powder PacketQL Metoclopramide Syringe Emend VialQL Metoclopramide Tablet Fosaprepitant VialQL Metoclopramide Vial Granisetron TabletQL Ondansetron ODTQL Marinol CapsuleQL Ondansetron SolutionQL Metoclopramide ODT Ondansetron TabletQL Phenergan AmpuleAR Ondansetron Syringe Phenergan VialAR Ondansetron VialQL Reglan Tablet Palonosetron Syringe Sancuso PatchQL Palonosetron Vial Scopolamine PatchQL Phosphorated Carbohydrate Oral Solution Sustol SyringeQL Prochlorperazine Rectal Suppository Tigan CapsuleQL Prochlorperazine Tablet Tigan VialQL Prochlorperazine Vial Varubi TabletQL Promethazine AmpuleAR Zofran TabletQL Promethazine Rectal SuppositoryAR, QL Zuplenz FilmQL Promethazine Solution/SyrupAR Promethazine TabletAR, QL Promethazine VialAR Transderm-Scop PatchQL Trimethobenzamide CapsuleQL

ANTIFUNGALS, ORAL Preferred Agents Non-Preferred Agents Clotrimazole TrocheQL Ancobon Capsule Fluconazole SuspensionQL Cresemba CapsuleQL Fluconazole TabletQL Diflucan SuspensionQL Griseofulvin Suspension Diflucan TabletQL Nystatin Suspension Flucytosine Capsule Nystatin Tablet Griseofulvin Microsize Tablet

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 9 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Terbinafine TabletQL Griseofulvin Ultramicrosize Tablet Itraconazole CapsuleQL Itraconazole SolutionQL Ketoconazole TabletQL Noxafil SuspensionQL Noxafil DR TabletQL Oravig Buccal TabletQL Posaconazole DR TabletQL Sporanox CapsuleQL Sporanox SolutionQL Tolsura CapsuleQL Vfend Suspension Vfend Tablet Voriconazole Suspension Voriconazole Tablet

ANTIFUNGALS, TOPICAL Preferred Agents Non-Preferred Agents Alevazol (clotrimazole) Ointment (OTC) Bensal HP (benzoic acid/salicylic acid) Loprox (ciclopirox) Shampoo Butenafine Cream Ointment Loprox (ciclopirox) Suspension Ciclopirox Cream Ciclodan 8% Solution Loprox (ciclopirox) Suspension Kit Ciclopirox 8% Solution Ciclopirox Gel Luliconazole Cream Clotrimazole Cream (OTC) Ciclopirox Shampoo Luzu (luliconazole) Cream Clotrimazole-Betamethasone Cream Ciclopirox Suspension Mentax (butenafine) Cream Ketoconazole Shampoo Ciclopirox 8% Treatment Kit Micnonazole-Zinc-Petrolatum Ointment Miconazole Aerosol Powder Clotrimazole Solution (generic Vusion) Miconazole Cream Clotrimazole Cream (Rx) Naftifine Cream Miconazole Powder Clotrimazole-Betamethasone Lotion Naftifine Gel Nyamyc Powder Econazole Cream Naftin (naftifine) Cream Nystatin Cream Ertaczo (sertaconazole) Cream Naftin (naftifine) Gel Nystatin Ointment Extina (ketoconazole) Foam Nystatin-Triamcinolone Cream Nystatin Powder Fungoid (miconazole) Tincture Nystatin-Triamcinolone Ointment Nystop Powder Jublia (efinaconazole) Solution Oxiconazole Cream Terbinafine Cream Kerydin (tavaborole) Solution Oxistat (oxiconazole) Cream Tolnaftate Aerosol Powder Ketoconazole Cream Oxistat (oxiconazole) Lotion Tolnaftate Cream Ketoconazole Foam Vusion (miconazole nitrate 0.25%-zinc Tolnaftate Powder Lamisil AT (terbinafine) Cream oxide 15% in white petrolatum) Tolnaftate Spray Loprox (ciclopirox) Cream Ointment Loprox (ciclopirox) Cream Kit

ANTIHEMOPHILIA AGENTS – BYPASSING AGENTS Non-Preferred Agents Feiba NF Novoseven RT

ANTIHEMOPHILIA AGENTS – FACTOR VIII Preferred Agents Non-Preferred Agents AdvatePA Jivi AdynovatePA Kovaltry AfstylaPA Obizur EloctatePA

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 10 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

EsperoctPA Hemofil MPA KoatePA Kogenate FSPA NovoeightPA NuwiqPA RecombinatePA XynthaPA Xyntha SolofusePA

ANTIHEMOPHILIA AGENTS – FACTOR VIII/VWF Preferred Agents Non-Preferred Agents AlphanatePA Vonvendi Humate-PPA WilatePA

ANTIHEMOPHILIA AGENTS – FACTOR IX Preferred Agents Non-Preferred Agents Alphanine SDPA Idelvion AlprolixPA Rebinyn BenefixPA IxinityPA MononinePA ProfilninePA RixubisPA

ANTIHEMOPHILIA AGENTS – MISCELLANEOUS Preferred Agents Non-Preferred Agents HemlibraPA

ANTIHISTAMINES, MINIMALLY SEDATING Preferred Agents Non-Preferred Agents Cetirizine SolutionQL Cetirizine Capsule Cetirizine TabletQL Cetirizine Chewable TabletQL Fexofenadine TabletQL Cetirizine-D TabletQL Levocetirizine TabletQL Clarinex TabletQL Loratadine ODTQL Clarinex-D TabletQL Loratadine SolutionQL Desloratadine ODTQL Loratadine TabletQL Desloratadine TabletQL Loratadine-D 24HR TabletQL Fexofenadine-D TabletQL Levocetirizine SolutionQL Loratadine Chewable TabletQL Loratadine-D 12HR TabletQL Semprex D CapsuleQL

ANTIHYPERTENSIVES, SYMPATHOLYTIC Preferred Agents Non-Preferred Agents Clonidine PatchQL Catapres Tablet Clonidine Tablet Catapres-TTS PatchQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 11 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Guanfacine TabletQL Methyldopa-HCTZ Tablet Methyldopa Tablet Minipress Capsule Prazosin Capsule

ANTIHYPERURICEMICS Preferred Agents Non-Preferred Agents Allopurinol Tablet Colcrys TabletQL Colchicine CapsulePA, QL Febuxostat TabletQL Colchicine TabletPA, QL Gloperba SolutionQL Probenecid Tablet Krystexxa VialQL Probenecid-Colchicine Tablet Mitigare CapsuleQL Uloric TabletQL Zyloprim Tablet

ANTIMALARIALS Preferred Agents Non-Preferred Agents Atovaquone-Proguanil TabletQL Malarone TabletQL Chloroquine Tablet Qualaquin Capsule Coartem Tablet Quinine Capsule Hydroxychloroquine Tablet Krintafel Tablet Mefloquine Tablet Primaquine Tablet

ANTIPARASITICS, TOPICAL Preferred Agents Non-Preferred Agents Natroba Topical Suspension Crotan Lotion Permethrin 1% Creme Rinse (OTC) (Lice Treatment 1% Creme Elimite Cream Rinse) Lindane Shampoo Permethrin 5% Cream Malathion Lotion Piperonyl Butoxide/Pyrethrins Kit (OTC) Ovide Lotion Piperonyl Butoxide/Pyrethrins Liquid (OTC) Sklice Lotion Piperonyl Butoxide/Pyrethrins Shampoo (OTC) (Lice Killing Spinosad Topical Suspension Shampoo) Vanalice Gel Piperonyl Butoxide/Pyrethrins/Permethrin Kit (OTC) (Lice Solutions Kit)

ANTIPARKINSON’S AGENTS Preferred Agents Non-Preferred Agents Amantadine Capsule Azilect TabletQL Amantadine Solution Carbidopa TabletQL Amantadine Tablet Carbidopa-Levodopa ODTQL Benztropine TabletQL Carbidopa-Levodopa-Entacapone TabletQL Bromocriptine CapsuleQL Comtan TabletQL Bromocriptine TabletQL Duopa Enteral SuspensionQL Carbidopa-Levodopa TabletQL Gocovri ER CapsuleQL Carbidopa-Levodopa ER TabletQL Inbrija Inhalation CapsuleQL Entacapone TabletQL Lodosyn TabletQL Parlodel CapsuleQL Mirapex ER TabletQL Parlodel TabletQL Neupro PatchQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 12 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Pramipexole TabletQL Nourianz TabletQL Ropinirole TabletQL Osmolex ER TabletQL Selegilene CapsuleQL Pramipexole ER TabletQL Selegilene TabletQL Rasagiline TabletQL Trihexyphenidyl ElixirQL Ropinirole ER TabletQL Trihexyphenidyl TabletQL Rytary ER CapsuleQL Sinemet TabletQL Sinemet CR TabletQL Stalevo TabletQL Tasmar TabletQL Tolcapone TabletQL Xadago TabletQL Zelapar ODTQL

ANTIPSORIATICS, ORAL Preferred Agents Non-Preferred Agents Soriatane CapsuleQL Acitretin CapsuleQL

ANTIPSORIATICS, TOPICAL Preferred Agents Non-Preferred Agents Calcipotriene Cream Calcipotriene-Betamethasone Ointment Calcipotriene Ointment Calcipotriene-Betamethasone Suspension Calcipotriene Solution Calcitriol Ointment Taclonex Ointment Dovonex Cream Taclonex Suspension Duobrii Lotion Enstilar Foam Sorilux Foam Tazarotene CreamAR Vectical Ointment

ANTIPSYCHOTICS Preferred Agents Non-Preferred Agents Abilify MaintenaAR, QL Abilify TabletAR, QL Aripiprazole TabletAR, QL Abilify MyciteAR Aristada ERAR, QL Adasuve Inhalation PowderAR, QL Aristada InitioAR, QL Aripiprazole ODTAR, QL Clozapine TabletAR, QL Aripiprazole SolutionAR, QL Fluphenazine ElixirAR Caplyta CapsuleAR, QL Fluphenazine Oral Concentrate SolutionAR Chlorpromazine AmpuleAR Fluphenazine TabletAR Chlorpromazine TabletAR Fluphenazine Decanoate VialAR Clozapine ODTAR, QL Haldol (Lactate) AmpuleAR Clozaril TabletAR, QL Haloperidol TabletAR Fanapt TabletAR, QL Haloperidol Decanoate AmpuleAR Fluphenazine HCl VialAR Haloperidol Decanoate VialAR Geodon CapsuleAR, QL Haloperidol Lactate AmpuleAR Geodon VialAR, QL Haloperidol Lactate SyringeAR Haldol Decanoate AmpuleAR Haloperidol Lactate VialAR Invega ER TabletAR, QL Haloperidol Lactate Concentrate SolutionAR Latuda TabletAR, QL Invega SustennaAR, QL Molindone TabletAR, QL Invega TrinzaAR, QL Nuplazid CapsuleAR, QL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 13 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Loxapine CapsuleAR Nuplazid TabletAR, QL Olanzapine TabletAR, QL Olanzapine ODTAR, QL Perphenazine TabletAR Olanzapine VialAR, QL Perseris ERAR, QL Olanzapine-Fluoxetine CapsuleAR, QL Quetiapine TabletAR, QL Paliperidone ER TabletAR, QL Quetiapine ER TabletAR, QL Perphenazine-Amitriptyline TabletAR Risperdal ConstaAR, QL Pimozide TabletAR Risperidone SolutionAR, QL Rexulti TabletAR, QL Risperidone TabletAR, QL Risperdal SolutionAR, QL Trifluoperazine TabletAR Risperdal TabletAR, QL Ziprasidone CapsuleAR, QL Risperidone ODTAR, QL Zyprexa RelprevvAR, QL Saphris SL TabletAR, QL Secuado PatchAR, QL Seroquel TabletAR, QL Seroquel XR TabletAR, QL Thioridazine TabletAR Thiothixene CapsuleAR Versacloz SuspensionAR Vraylar CapsuleAR, QL Ziprasidone VialAR, QL Zyprexa TabletAR, QL Zyprexa VialAR, QL Zyprexa ZydisAR, QL

ANTIVIRALS, CMV Preferred Agents Non-Preferred Agents Prevymis TabletPA, QL Valcyte Tablet Valcyte Solution Valganciclovir Solution Valganciclovir Tablet

ANTIVIRALS, HERPES Preferred Agents Non-Preferred Agents Acyclovir CapsuleQL Acyclovir CreamQL Acyclovir Suspension QL Acyclovir OintmentQL Acyclovir TabletQL Denavir CreamQL Docosanol CreamQL Sitavig Buccal TabletQL Famciclovir TabletQL Valtrex TabletQL Valacyclovir TabletQL Xerese CreamQL Zovirax CreamQL Zovirax OintmentQL Zovirax SuspensionQL

ANTIVIRALS, INFLUENZA Preferred Agents Non-Preferred Agents Oseltamivir CapsuleQL Rapivab Vial Oseltamivir SuspensionQL Rimantadine Tablet Relenza InhalationQL Tamiflu CapsuleQL Tamiflu SuspensionQL Xofluza TabletQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 14 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

ANXIOLYTICS Preferred Agents Non-Preferred Agents Alprazolam TabletAR, QL Alprazolam ER/XR TabletAR, QL Buspirone TabletQL Alprazolam Intensol/Oral Concentrate SolutionAR, QL Chlordiazepoxide CapsuleAR, QL Alprazolam ODTAR, QL Clonazepam TabletAR, QL Ativan TabletAR, QL Diazepam SolutionAR, QL Ativan VialAR Diazepam TabletAR, QL Clonazepam ODTAR, QL Diazepam VialAR Clorazepate TabletAR, QL Hydroxyzine HCl Solution Diazepam CartridgeAR Hydroxyzine HCl Tablet Diazepam Concentrate SolutionAR, QL Hydroxyzine Pamoate Capsule Diazepam SyringeAR Lorazepam CartridgeAR Klonopin TabletAR, QL Lorazepam TabletAR, QL Lorazepam Intensol/Concentrate SolutionAR, QL Lorazepam VialAR Meprobamate TabletQL Oxazepam CapsuleAR, QL Tranxene T-TabAR, QL Vistaril Capsule Xanax TabletAR, QL Xanax XR TabletAR, QL

BENIGN PROSTATIC HYPERPLASIA (BPH) TREATMENTS Preferred Agents Non-Preferred Agents Alfuzosin ER TabletQL Avodart CapsuleQL Doxazosin TabletQL Cardura TabletQL Dutasteride CapsuleQL Cardura XL TabletQL Finasteride TabletQL Cialis TabletQL Tamsulosin CapsuleQL Dutasteride-Tamsulosin CapsuleQL Terazosin CapsuleQL Flomax CapsuleQL Jalyn CapsuleQL Proscar TabletQL Rapaflo CapsuleQL Silodosin CapsuleQL Tadalafil Tablet (generic Cialis)QL

BETA BLOCKERS Preferred Agents Non-Preferred Agents Acebutolol Capsule Betapace Tablet Atenolol Tablet Betapace AF Tablet Atenolol-Chlorthalidone Tablet Bystolic TabletQL Betaxolol Tablet Carvedilol ER CapsuleQL Bisoprolol Tablet Coreg TabletQL Bisoprolol-Hydrochlorothiazide Tablet Coreg CR CapsuleQL Carvedilol TabletQL Corgard Tablet Hemangeol SolutionPA Inderal LA Capsule Labetalol Tablet Inderal XL CapsuleQL Metoprolol Succinate ER Tablet Innopran XL CapsuleQL Metoprolol Tartrate Tablet Kapspargo Sprinkle CapsuleQL Nadolol Tablet Lopressor Tablet Pindolol Tablet Metoprolol-Hydrolchlorothiazide Tablet Propranolol Solution Sotylize Solution

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 15 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Propranolol Tablet Tenoretic Tablet Propranolol ER Capsule Tenormin Tablet Propranolol-Hydrochlorothiazide Tablet Timolol Tablet Sotalol Tablet Toprol XL Tablet Sotalol AF Tablet Ziac Tablet

BILE SALTS Preferred Agents Non-Preferred Agents Cholbam CapsulePA Actigall CapsuleQL Ursodiol CapsuleQL Chenodal TabletQL Ursodiol TabletQL Ocaliva TabletQL Urso TabletQL Urso Forte TabletQL

BLADDER RELAXANT PREPARATIONS Preferred Agents Non-Preferred Agents Oxybutynin SyrupQL Darifenacin ER TabletQL Oxybutynin TabletQL Detrol TabletQL Oxybutynin ER TabletQL Detrol LA CapsuleQL Oxytrol for Women Patch (OTC)QL Ditropan XL TabletQL Solifenacin TabletQL Enablex TabletQL Tolterodine TabletQL Flavoxate Tablet Tolterodine ER CapsuleQL Gelnique Gel PacketQL Trospium TabletQL Myrbetriq ER TabletQL Oxytrol PatchQL Toviaz ER TabletQL Trospium ER CapsuleQL Vesicare TabletQL

BLOOD GLUCOSE METERS AND TEST STRIPS Preferred Products Non-Preferred Manufacturers Ascensia Glucometers All Other Blood Glucose Meters and Test StripsQL • ContourQL • Contour NextQL • Contour Next EZQL • Contour Next OneQL

Ascensia Test Strips • Contour (50-count and 100-count)QL • Contour Next (50-count and 100-count)QL

Lifescan Glucometers • OneTouch Ultra2QL • OneTouch UltraMini (standard color)QL • OneTouch VerioQL • OneTouch Verio FlexQL • OneTouch Verio IQQL • OneTouch Verio ReflectQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 16 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Lifescan Test Strips • OneTouch Ultra BlueQL • OneTouch VerioQL

BONE DENSITY REGULATORS Preferred Agents Non-Preferred Agents Alendronate TabletQL Actonel TabletQL Ibandronate TabletQL Alendronate SolutionQL Pamidronate Vial Atelvia DR TabletQL Zoledronic AcidQL Boniva SyringeQL Boniva TabletQL Calcitonin Salmon Nasal Spray/PumpQL Evenity SyringeQL Evista TabletQL Forteo PenQL Fosamax TabletQL Fosamax Plus D TabletQL Ibandronate SyringeQL Ibandronate VialQL Miacalcin VialQL Prolia SyringeQL Raloxifene TabletQL ReclastQL Risedronate TabletQL Risedronate DR TabletQL Teriparatide PenQL Tymlos PenQL Xgeva VialQL

BOTULINUM TOXINS Preferred Agents Non-Preferred Agents BotoxPA, QL MyoblocQL DysportPA, QL XeominQL

BRONCHODILATORS, BETA AGONISTS Preferred Agents Non-Preferred Agents Albuterol HFAQL Albuterol Tablet Albuterol Nebulizer Concentrate Solution Albuterol ER Tablet Albuterol Nebulizer Vial Brovana Nebulizer VialQL Albuterol Syrup Levalbuterol Nebulizer Concentrate SolutionQL Levalbuterol HFAQL Levalbuterol Nebulizer VialQL Proair HFAQL Metaproterenol Syrup Proair RespiclickQL Perforomist Nebulizer VialQL Proventil HFAQL Proair DigihalerQL Serevent DiskusPA, QL Striverdi RespimatQL Ventolin HFAQL Terbutaline Tablet Xopenex HFAQL Xopenex Nebulizer Concentrate SolutionQL Xopenex Nebulizer VialQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 17 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

CALCIUM CHANNEL BLOCKERS Preferred Agents Non-Preferred Agents Amlodipine TabletQL Calan SR TabletQL Cartia XT CapsuleQL Cardizem TabletQL Diltiazem TabletQL Cardizem CD CapsuleQL Diltiazem 24HR ER (CD) Capsule (generic Cardizem CD Cardizem LA TabletQL Capsule)QL Diltiazem 12HR ER Capsule (generic Cardizem SR Capsule)QL Diltiazem 24HR ER Capsule (generic Tiazac ER Capsule)QL Diltiazem 24HR ER (LA) Tablet (generic Cardizem LA Tablet)QL Ditliazem 24HR ER (XR) Capsule (generic Dilacor XR Capsule)QL Isradipine CapsuleQL Dilt-XR CapsuleQL Katerzia SuspensionQL Felodipine ER TabletQL Matzim LA TabletQL Nifedipine CapsuleQL Nicardipine CapsuleQL Nifedipine ER TabletQL Nisoldipine ER TabletQL Nimodipine Capsule Norvasc TabletQL Taztia XT CapsuleQL Nymalize Oral Syringe Tiadylt ER CapsuleQL Nymalize Solution Verapamil Tablet Procardia Capsule Verapamil ER/SR Capsule (generic Verelan Capsule)QL Procardia XL TabletQL Verapamil ER PM Capsule (generic Verelan PM Capsule)QL Sular ER TabletQL Verapamil ER Tablet (generic Calan SR/Isoptin SR Tablet)QL Tiazac ER CapsuleQL Verelan CapsuleQL Verelan PM CapsuleQL

CEPHALOSPORINS Preferred Agents Non-Preferred Agents Cefadroxil Capsule Cefaclor Capsule Cefdinir Capsule Cefaclor Suspension Cefdinir Suspension Cefaclor ER Tablet Cefpodoxime Tablet Cefadroxil Suspension Cefprozil Suspension Cefadroxil Tablet Cefprozil Tablet Cefixime Capsule Cefuroxime Tablet Cefixime Suspension Cephalexin 250 mg, 500 mg Capsule Cefpodoxime Suspension Cephalexin Suspension Cephalexin 750 mg Capsule Cephalexin Tablet Keflex Capsule Suprax Capsule Suprax Chewable Tablet Suprax Suspension

COLONY STIMULATING FACTORS Preferred Agents Non-Preferred Agents FulphilaPA, QL Leukine GranixPA Neulasta OnproQL NeupogenPA Neulasta SyringeQL NivestymPA UdenycaQL Zarxio ZiextenzoQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 18 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

CONTRACEPTIVES, ORAL - MONOPHASIC Preferred Agents Non-Preferred Agents Afirmelle Levonorgestrel-Ethinyl Estradiol-28 0.15 Balcoltra Altavera mg-30 mcg (generic Nordette, Levlen) Drospirenone-Ethinyl Estradiol-Levomefolate 3- Alyacen-28 1-35 Levora 0.03-0.451 mg (generic Safyral) Apri Lillow Loestrin-21 Aubra Low-Ogestrel Loestrin Fe-28 Aubra EQ Lutera Norethindrone-Ethinyl Estradiol Fe 0.4-0.035 (21)- Aurovela Marlissa 75 (generic Wymzya Fe Chewable) Aurovela FE Microgestin-21 Safyral Aviane Microgestin Fe-28 Tydemy Ayuna Mili Wymzya Fe Chewable Balziva Mono-Linyah Yasmin Blisovi Fe-28 Necon-28 0.5-35 Briellyn Necon-28 1-35 Chateal Necon-28 1-50 Chateal EQ Norethindrone-Ethinyl Estradiol-21 Cryselle (generic Loestrin-21) Cyclafem-28 1-35 Norethindrone-Ethinyl Estradiol Fe-28 Cyred (generic Loestrin Fe-28) Cyred EQ Norgestimate-Ethinyl Estradiol-28 Dasetta-28 1-35 (generic Ortho-Cyclen) Desogestrel-Ethinyl Estradiol-28 0.15-30 Nortrel-28 0.5-35 (generic Desogen) Nortrel-21 1-35 Drospirenone-Ethinyl Estradiol Nortrel-28 1-35 Elinest Nymyo Emoquette Ocella Enskyce Orsythia Estarylla Philith Ethynodiol-Ethinyl Estradiol Pirmella-28 1-35 Falmina Portia Femynor Previfem Hailey Reclipsen Isibloom Sprintec Juleber Sronyx Junel-21 Syeda Junel Fe-28 Tarina Fe Kalliga Tarina Fe EQ Kelnor-28 1-35 Vienva Kelnor-28 1-50 Vyfemla Kurvelo Vylibra Larin-21 Wera Larin Fe-28 Zarah Larissia Zovia 1-35 Lessina Zumandimine Levonorgestrel-Ethinyl Estradiol-28 0.1 mg-20 mg (generic Alesse, Levlite)

CONTRACEPTIVES, ORAL – BIPHASIC Preferred Agents Non-Preferred Agents Azurette Mircette Bekyree

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 19 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Desogestrel-Ethinyl Estradiol 21-2-5 (generic Mircette) Kariva Pimtrea Simliya Viorele Volnea

CONTRACEPTIVES, ORAL – TRIPHASIC Preferred Agents Non-Preferred Agents Alyacen-28 7-7-7 Estrostep Fe Aranelle Tilia Fe Caziant Tri-Legest Fe Cyclafem-28 7-7-7 Dasetta-28 7-7-7 Enpresse Leena Levonest Levonorgestrel-Ethinyl Estradiol (generic TriPhasil, Tri-Levlen) Norgestimate-Ethinyl Estradiol Lo-28 (generic Ortho Tri-Cyclen Lo) Norgestimate-Ethinyl Estradiol-28 (generic Ortho Tri-Cyclen) Nortrel-28 7-7-7 Nylia-28 7-7-7 Pirmella-28 7-7-7 Tri-Estarylla Tri-Femynor Tri-Linyah Tri-Lo-Estarylla Tri-Lo-Marzia Tri-Lo-Mili Tri-Lo-Sprintec Tri-Mili Tri-Nymyo Tri-Previfem Tri-Sprintec Trivora Tri-Vylibra Tri-Vylibra Lo Velivet

CONTRACEPTIVES, ORAL – FOUR-PHASIC Preferred Agents Non-Preferred Agents Natazia

CONTRACEPTIVES, ORAL – 28-DAY EXTENDED CYCLE Preferred Agents Non-Preferred Agents Drospirenone-Ethinyl Estradiol 3-0.02 mg Aurovela 24 Fe Gianvi Beyaz Jasmiel Blisovi 24 Fe Loryna Drospirenone-Ethinyl Estradiol-Levomefolate 3-0.02-0.451 mg Lo-Zumandimine (generic Beyaz) Nikki Generess Fe Chewable

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 20 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Hailey 24 Fe Junel 24 Fe Kaitlib Fe Chewable Larin 24 Fe Layolis Fe Chewable Lo Loestrin Fe Melodetta 24 Fe Chewable Mibelas 24 Fe Chewable Microgestin 24 Fe 1-20 Minastrin 24 Fe Chewable Noethindrone-Ethinyl Estradiol-Fe 0.8-0.025(24) Chewable (generic Generess Fe Chewable) Noethindrone-Ethinyl Estradiol-Fe 1-0.02(24) (generic Loestrin 24 Fe) Noethindrone-Ethinyl Estradiol-Fe 1-0.02(24)-75 (generic Minastrin 24 Fe) Tarina 24 Fe Taytulla Yaz

CONTRACEPTIVES, ORAL – 28-DAY CONTINUOUS CYCLE Preferred Agents Non-Preferred Agents Amethyst Dolishale Levonorgestrel-Ethinyl Estradiol-28 0.09-0.02 mg

CONTRACEPTIVES, ORAL – 3-MONTH EXTENDED CYCLE Preferred Agents Non-Preferred Agents Camrese (3-month) Amethia (3-month) Camrese Lo (3-month) Amethia Lo (3-month) Iclevia (3-month) Ashlyna (3-month) Introvale (3-month) Daysee (3-month) Jolessa (3-month) Fayosim (3-month) Levonorgestrel-Ethinyl Estradiol 0.15-0.03 mg (3-month) (generic Jaimiess (3-month) Seasonale-91) Levonorgestrel-Ethinyl Estradiol + EE 0.10-0.02 mg + 0.01 mg (3- Setlakin (3-month) month) (generic LoSeasonique-91) Levonorgestrel-Ethinyl Estradiol + EE 0.15-0.03 mg + 0.01 mg (3- month) (generic Seasonique-91) Levonorgestrel 0.15 mg-Ethinyl Estradiol 20-25-30 (3-month) (generic Quartette-91) Lojaimiess (3-month) Loseasonique (3-month) Quartette (3-month) Rivelsa (3-month) Seasonique (3-month) Simpesse (3-month)

CONTRACEPTIVES, ORAL – PROGESTIN-ONLY Preferred Agents Non-Preferred Agents Camila Slynd Deblitane

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 21 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Errin Heather Incassia Jencycla Lyleq Lyza Nora-Be Norethindrone-28 0.35 Norlyda Sharobel Tulana

CONTRACEPTIVES, OTHER Preferred Agents Non-Preferred Agents Depo-Provera 150 mg/ml VialQL AnnoveraQL Depo-SubQ Provera 104 InjectionQL Depo-Provera 150 mg/ml SyringeQL EluryngQL Etonogestrel-Ethinyl Estradiol Vaginal RingQL KyleenaQL LilettaQL Medroxyprogesterone Acetate SyringeQL Medroxyprogesterone Acetate VialQL MirenaQL NexplanonQL Paragard T 380-AQL SkylaQL Xulane PatchQL Zafemy PatchQL

COPD AGENTS Preferred Agents Non-Preferred Agents Anoro ElliptaQL Daliresp TabletQL Atrovent HFAQL Duaklir PressairQL Bevespi AerosphereQL Incruse ElliptaQL Combivent RespimatQL Lonhala Magnair RefillQL Ipratropium Nebulizer Vial Lonhala Magnair StarterQL Ipratropium-Albuterol Nebulizer VialQL Stiolto RespimatQL Spiriva HandihalerQL Trelegy ElliptaQL QL Spiriva RespimatQL Tudorza Pressair Yupelri Nebulizer VialQL

CYTOKINE AND CAM ANTAGONISTS Preferred Agents Non-Preferred Agents Enbrel PA, QL ActemraQL OtezlaQL HumiraPA, QL ArcalystQL Remicade TaltzPA, QL Avsola Renflexis CimziaQL RinvoqQL CosentyxQL SiliqQL EntyvioQL SimponiQL IlarisQL Simponi Aria

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 22 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

IlumyaQL SkyriziQL Inflectra StelaraQL KevzaraQL TremfyaQL Kineret XeljanzQL OlumiantQL Xeljanz XRQL OrenciaQL

ENZYME REPLACEMENTS, GAUCHER DISEASE Preferred Agents Non-Preferred Agents ElelysoPA CerdelgaQL ZavescaPA, QL Cerezyme MiglustatQL Vpriv

EPINEPHRINE, SELF-INJECTED Preferred Agents Non-Preferred Agents Epinephrine Auto-Injector (Mylan [49502] labeler only) Epinephrine Auto-Injector (all labelers except Mylan [49502]) EpiPen Auto-Injector EpiPen Jr. Auto-Injector

ERYTHROPOIESIS STIMULATING PROTEINS Preferred Agents Non-Preferred Agents EpogenPA Aranesp RetacritPA Mircera Procrit

ESTROGENS Preferred Agents Non-Preferred Agents Alora PatchQL Activella TabletQL Angeliq TabletQL Amabelz TabletQL Climara Pro PatchQL Bijuva CapsuleQL CombipatchQL Climara PatchQL Delestrogen Vial Divigel Packet Depo-Estradiol Vial Dotti Patch Elestrin Gel Duavee TabletQL Estradiol Patch (Once-Weekly)QL Estrace Tablet Estradiol Patch (Twice-Weekly)QL Estrace Vaginal Cream Estradiol Tablet Estradiol-Norethindrone Tablet (generic Activella Tablet)QL Estradiol Vaginal Cream Estrogen-Methyltestosterone Tablet Estradiol Vaginal Tablet Evamist Spray Estradiol Valerate Vial Femhrt TabletQL Estring Vaginal Ring Lopreeza TabletQL Femring Vaginal Ring Menest Tablet Fyavolv TabletQL Menostar PatchQL Jinteli TabletQL Mimvey TabletQL Premarin Cream Minivelle PatchQL Premarin Tablet Norethindrone-Ethinyl Estradiol Tablet (generic Femhrt Tablet)QL Premphase TabletQL Prefest TabletQL Prempro TabletQL Premarin Vial Vagifem Vaginal Tablet Vivelle-Dot PatchQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 23 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Yuvafem Vaginal Insert

FLUOROQUINOLONES, ORAL Preferred Agents Non-Preferred Agents Cipro Suspension Baxdela Tablet Ciprofloxacin Tablet Cipro Tablet Levofloxacin Tablet Levaquin Tablet Levofloxacin Solution Moxifloxacin Tablet Ofloxacin Tablet

GI MOTILITY, CHRONIC AGENTS Preferred Agents Non-Preferred Agents Amitiza CapsulePA, QL Alosetron TabletQL Linzess 145 mcg, 290 mcg CapsulePA, QL Linzess 72 mcg CapsuleQL Lotronex TabletQL Motegrity TabletQL Movantik TabletQL Relistor SyringeQL Relistor TabletQL Relistor VialQL Symproic TabletQL Trulance TabletQL Viberzi TabletQL

GLUCOCORTICOIDS, INHALED Preferred Agents Non-Preferred Agents

Single-Ingredient Glucocorticoids Single-Ingredient Glucocorticoids Asmanex TwisthalerQL AlvescoQL Budesonide 0.25 mg/2 ml, 0.5 mg/2 ml RespuleQL Arnuity ElliptaQL Flovent DiskusQL Asmanex HFAQL Flovent HFAQL Budesonide 1 mg/ml RespuleQL Pulmicort FlexhalerQL Pulmicort RespuleQL Qvar RedihalerQL

Glucocorticoid + LABA Combinations Glucocorticoid + LABA Combinations Advair HFAQL Advair DiskusQL DuleraQL Airduo RespiclickQL Fluticasone-Salmeterol Aerosol Powder (generic Airduo Breo ElliptaQL Respiclick)QL Budesonide-Formoterol Fumarate HFAQL Fluticasone-Salmeterol Blister w/ Device (generic Advair Diskus)QL Wixela InhubQL SymbicortQL

Glucocorticoid + LABA + LAMA Combinations Glucocorticoid + LABA + LAMA Combinations Trelegy ElliptaQL

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GLUCOCORTICOIDS, ORAL Preferred Agents Non-Preferred Agents Budesonide EC CapsuleQL Cortef Tablet Budesonide ER TabletQL Cortisone Acetate Tablet Dexamethasone Elixir Decadron Tablet Dexamethasone Intensol Drops Dexamethasone Dose Pack Dexamethasone Solution DexPak Dose Pack Dexamethasone Tablet Dxevo Dose Pack Fludrocortisone Tablet Emflaza SuspensionQL Hydrocortisone Tablet Emflaza TabletQL Methylprednisolone Dose Pack Entocort EC CapsuleQL Methylprednisolone Tablet Medrol Dose Pack Prednisolone Solution Medrol Tablet Prednisolone Sodium Phosphate Solution Millipred Tablet Prednisone Dose Pack Millipred DP Dose Pack Prednisone Solution Prednisolone Sodium Phosphate ODT Prednisone Tablet Prednisone Intensol Rayos DR Tablet Taperdex Dose Pack Uceris ER TabletQL

GROWTH HORMONES Preferred Agents Non-Preferred Agents NorditropinPA Genotropin OmnitropePA Humatrope Nutropin AQ Saizen SerostimQL Zomacton Zorbtive

H. PYLORI TREATMENTS Preferred Agents Non-Preferred Agents Lansoprazole-Amoxicillin-Clarthromycin Combo PackQL Omeclamox-Pak Combo Pack Pylera Capsule Talicia DR Capsule

HEMATOPOIETIC MIXTURES (PREVIOUSLY IRON, ORAL) Preferred Agents Non-Preferred Agents Ferrex 150 Forte Active Fe Hematogen Forte Folivane-F Auryxia TabletQL Hemocyte-F Iferex 150 Forte Centratex Hemocyte Plus Tandem Dual Action Chromagen Integra F Citranatal Bloom Integra Plus Corvita 150 Irospan Corvite 150 Nephron FA Corvite FE Niferex Feriva 21-7 Nufera Feriva FA Purevit Dualfe Plus

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 25 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Ferralet 90 SE-Tan Plus Ferraplus 90 Taron Forte Fusion Plus TL-HEM 150 Fusion Sprinkles Tricon Hematogen Trigels-F Forte Hematogen FA Virt-Fefa Plus

HEPATITIS B AGENTS Preferred Agents Non-Preferred Agents Adefovir Dipivoxil TabletQL Baraclude TabletQL Baraclude SolutionQL Epivir HBV TabletQL Entecavir TabletQL Vemlidy TabletQL Epivir HBV SolutionQL Viread 300 mg TabletQL Hepsera TabletQL Lamivudine HBV TabletQL Tenofovir Disoproxil Fumarate 300 mg TabletQL Viread PowderQL Viread Tablet (all strengths except 300 mg)QL

HEPATITIS C AGENTS Preferred Agents Non-Preferred Agents Mavyret TabletPA, QL Epclusa TabletQL Ribavirin CapsuleQL Harvoni Pellet PackQL Sofosbuvir-Velpatasvir TabletPA, QL Harvoni TabletQL Zepatier TabletPA, QL Ledipasvir-Sofosbuvir Tablet QL Pegasys SyringeQL Pegasys VialQL Pegintron Kit Ribavirin Tablet Sovaldi Pellet PackQL Sovaldi TabletQL Viekira PakQL Vosevi TabletQL

HEREDITARY ANGIOEDEMA (HAE) AGENTS Preferred Agents Non-Preferred Agents BerinertPA FirazyrQL Cinryze PA, QL HaegardaPA, QL IcatibantPA, QL Kalbitor PA, QL Ruconest PA, QL TakhzyroPA, QL

HISTAMINE 2 RECEPTOR BLOCKERS Preferred Agents Non-Preferred Agents Cimetidine Solution Acid Reducer Complete Tablet Chew (Famotidine-Calcium Cimetidine Tablet Carbonate-Magnesium Hydroxide Chewable) Famotidine Piggyback Pepcid TabletQL Famotidine Suspension

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 26 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Famotidine TabletQL Famotidine Vial Nizatidine Capsule Nizatidine Solution

HIV/AIDS ANTIRETROVIRALS – INSTIs Preferred Agents Non-Preferred Agents Isentress Chewable TabletQL Isentress HD TabletQL Isentress Powder PackQL Isentress TabletQL Tivicay TabletQL Tivicay PD Tablet for SuspensionQL

HIV/AIDS ANTIRETROVIRALS – MISCELLANEOUS Preferred Agents Non-Preferred Agents Fuzeon VialQL Rukobia ER TabletQL Selzentry SolutionQL Selzentry TabletQL Trogarzo VialQL Tybost TabletQL

HIV/AIDS ANTIRETROVIRALS – NRTIs Preferred Agents Non-Preferred Agents Abacavir SolutionQL Abacavir-Lamivudine-Zidovudine TabletQL Abacavir TabletQL Combivir TabletQL Abacavir-Lamivudine TabletQL Didanosine DR CapsuleQL Cimduo TabletQL Epivir SolutionQL Descovy TabletQL Epivir TabletQL Emtricitabine-Tenofovir Disoproxil Fumarate TabletQL Epzicom TabletQL Emtriva CapsuleQL Retrovir CapsuleQL Emtriva SolutionQL Retrovir SyrupQL Lamivudine SolutionQL Stavudine CapsuleQL Lamivudine TabletQL Temixys TabletQL Lamivudine-Zidovudine TabletQL Trizivir TabletQL Tenofovir Disoproxil Fumarate 300 mg TabletQL Truvada TabletQL Viread PowderQL Viread 300 mg TabletQL Viread Tablet (all strengths except 300 mg)QL Ziagen SolutionQL Zidovudine CapsuleQL Ziagen TabletQL Zidovudine SyrupQL Zidovudine TabletQL

HIV/AIDS ANTIRETROVIRALS – NNRTIs Preferred Agents Non-Preferred Agents Edurant TabletQL Intelence TabletQL Efavirenz CapsuleQL Nevirapine SuspensionQL Efavirenz TabletQL Nevirapine ER TabletQL Nevirapine TabletQL Pifeltro TabletQL Sustiva CapsuleQL Sustiva TabletQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 27 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Viramune SuspensionQL Viramune TabletQL Viramune XR TabletQL

HIV/AIDS – PIs Preferred Agents Non-Preferred Agents Atazanavir CapsuleQL Aptivus CapsuleQL Evotaz TabletQL Aptivus SolutionQL Kaletra SolutionQL Fosamprenavir TabletQL Kaletra TabletQL Invirase TabletQL Norvir Powder PacketQL Lexiva SuspensionQL Norvir SolutionQL Lexiva TabletQL Prezcobix TabletQL Lopinavir-Ritonavir SolutionQL Prezista SuspensionQL Norvir TabletQL Prezista TabletQL Reyataz CapsuleQL Reyataz Powder PacketQL Viracept TabletQL Ritonavir TabletQL

HIV/AIDS – SINGLE TABLET REGIMENS Preferred Agents Non-Preferred Agents Biktarvy TabletQL Atripla TabletQL Complera TabletQL Stribild TabletQL Delstrigo TabletQL Symtuza TabletQL Dovato TabletQL Efavirenz-Emtricitabine-Tenofovir Disoproxil Fumarate TabletQL Genvoya TabletQL Juluca TabletQL Odefsey TabletQL Symfi TabletQL Symfi Lo TabletQL Triumeq TabletQL

HYPOGLYCEMIA TREATMENTS Preferred Agents Non-Preferred Agents Baqsimi Spray Gvoke Hypopen Glucagen Vial Gvoke PFS Syringe Glucagon Emergency Kit

HYPOGLYCEMICS, ALPHA-GLUCOSIDASE INHIBITORS Preferred Agents Non-Preferred Agents Acarbose TabletQL Glyset TabletQL Miglitol TabletQL Precose TabletQL

HYPOGLYCEMICS, INCRETIN MIMETICS/ENHANCERS Preferred Agents Non-Preferred Agents

Incretin Enhancers (DPP-4 Inhibitors) Incretin Enhancers (DPP-4 Inhibitors) Janumet TabletPA, QL Alogliptin TabletQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 28 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Janumet XR TabletPA, QL Alogliptin-Metformin TabletQL Januvia TabletPA, QL Alogliptin-Pioglitazone TabletQL Jentadueto TabletPA, QL Glyxambi TabletQL Tradjenta TabletPA, QL Jentadueto XR TabletQL Kazano TabletQL Kombiglyze XR TabletQL Nesina TabletQL Onglyza TabletQL Oseni TabletQL Qtern TabletQL Steglujan TabletQL Trijardy XR TabletQL

Incretin Mimetics – GLP-1 Receptor Agonists Incretin Mimetics – GLP-1 Receptor Agonists OzempicPA, QL AdlyxinQL TrulicityPA, QL Bydureon BCiseQL VictozaPA, QL Bydureon PenQL ByettaQL RybelsusQL

Incretin Mimetics – Amylin Analogs Incretin Mimetics – Amylin Analogs Symlin PenQL

HYPOGLYCEMICS, INSULIN AND RELATED AGENTS Preferred Agents Non-Preferred Agents

Rapid-Acting Rapid-Acting Apidra (insulin glulisine) Solostar Admelog (insulin lispro) Solostar Apidra (insulin glulisine) Vial Admelog (insulin lispro) Vial Insulin Aspart Penfill Cartridge (generic Novolog Cartridge) Fiasp (insulin aspart) Flextouch Insulin Aspart Pen (generic Novolog Flexpen) Fiasp (insulin aspart) Penfill Cartridge Insulin Aspart Vial (generic Novolog Vial) Fiasp (insulin aspart) Vial Insulin Lispro Jr. Kwikpen (generic Humalog Junior Kwikpen) Humalog (insulin lispro) Cartridge Insulin Lispro Kwikpen U-100 (generic Humalog Kwikpen U-100) Humalog (insulin lispro) Kwikpen U-100 Insulin Lispro Vial (generic Humalog Vial) Humalog (insulin lispro) Kwikpen U-200 Novolog (insulin aspart) Cartridge Humalog (insulin lispro) Vial Novolog (insulin aspart) Flexpen Humalog Junior (insulin lispro) Kwikpen Novolog (insulin aspart) Vial Lyumjev (insulin lispro) Kwikpen U-100 Lyumjev (insulin lispro) Kwikpen U-200 Lyumjev (insulin lispro) Vial

Short-Acting Short-Acting Humulin R U-500 Kwikpen Novolin R Flexpen Humulin R Vial (U-100) Humulin R U-500 Vial Novolin R Vial Intermediate-Acting Intermediate-Acting Humulin N Vial Humulin N Kwikpen Novolin N Vial Novolin N Flexpen

Long-Acting (basal) Long-Acting (basal)

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Lantus (insulin glargine) Solostar Basaglar (insulin glargine) Kwikpen U-100 Lantus (insulin glargine) Vial Toujeo (insulin glargine) Solostar Pen Levemir (insulin detemir) Flextouch Toujeo Max (insulin glargine) Solostar Levemir (insulin detemir) Vial Tresiba (insulin degludec) Flextouch U-100 Tresiba (insulin degludec) Flextouch U-200 Tresiba (insulin degludec) Vial Insulin Mixes Insulin Mixes Humalog Mix (insulin lispro protamine-insulin lispro) 50-50 Novolin 70-30 Flexpen Kwikpen Novolin 70-30 Vial Humalog Mix (insulin lispro protamine-insulin lispro) 50-50 Vial Humalog Mix (insulin lispro protamine-insulin lispro) 75-25 Kwikpen Humalog Mix (insulin lispro protamine-insulin lispro) 75-25 Vial Humulin 70-30 Kwikpen Humulin 70-30 Vial Insulin Aspart Protamine-Insulin Aspart 70-30 Pen (generic NovoLog Mix 70-30 Flexpen) Insulin Aspart Protamine-Insulin Aspart 70-30 Vial (generic NovoLog Mix 70-30 Vial) Insulin Lispro Protamine Mix 75-25 Pen (generic Humalog Mix 75- 25 Kwikpen) NovoLog Mix (insulin aspart protamine-insulin aspart) 70-30 Flexpen NovoLog Mix (insulin aspart protamine-insulin aspart) 70-30 Vial Alternate Formulations Alternate Formulations Afrezza Powder Soliqua (insulin glargine/lixisenatide) PenQL Xultophy (insulin degludec/liraglutide) PenQL

HYPOGLYCEMICS, MEGLITINIDES Preferred Agents Non-Preferred Agents Nateglinide TabletQL Starlix TabletQL Repaglinide TabletQL

HYPOGLYCEMICS, METFORMINS Preferred Agents Non-Preferred Agents Glipizide-Metformin TabletQL Fortamet ER TabletQL Glyburide-Metformin TabletQL Glumetza ER TabletQL Metformin TabletQL Metformin SolutionQL Metformin ER 500 mg, 750 mg Tablet (generic Glucophage XR Metformin ER (Osmotic) Tablet (generic Fortamet ER)QL Tablet)QL Metformin ER (Gastric) Tablet (generic Glumetza ER)QL Riomet SolutionQL Riomet ER SuspensionQL

HYPOGLYCEMICS, SGLT2 INHIBITORS Preferred Agents Non-Preferred Agents Farxiga TabletPA, QL Invokamet XR TabletQL Invokamet TabletPA, QL Segluromet TabletQL Invokana TabletPA, QL Steglatro TabletQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 30 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Jardiance TabletPA, QL Synjardy XR TabletQL Synjardy TabletPA, QL Xigduo XR TabletQL

HYPOGLYCEMICS, SULFONYLUREAS Preferred Agents Non-Preferred Agents Glimepiride TabletQL Amaryl TabletQL Glipizide TabletQL Glucotrol TabletQL Glipizide ER/XL TabletQL Glucotrol XL TabletQL Glyburide TabletQL Glynase PrestabQL Glyburide Micronized TabletQL Tolbutamide TabletQL

HYPOGLYCEMICS, TZDS Preferred Agents Non-Preferred Agents Pioglitazone TabletPA, QL Actoplus Met TabletQL Actos TabletQL Avandia TabletQL Duetact TabletQL Pioglitazone-Glimepiride TabletQL Pioglitazone-Metformin TabletQL

IDIOPATHIC PULMONARY FIBROSIS (IPF) AGENTS Preferred Agents Non-Preferred Agents Esbriet CapsulePA, QL Esbriet TabletPA, QL Ofev CapsulePA, QL

IMMUNOMODULATORS, ATOPIC DERMATITIS Preferred Agents Non-Preferred Agents Elidel Cream DupixentQL Eucrisa OintmentPA Pimecrolimus Cream (all labelers except Oceanside [68682]) Pimecrolimus Cream (Oceanside [68682] labeler only) Tacrolimus Ointment Protopic Ointment

IMMUNOMODULATORS, TOPICAL Preferred Agents Non-Preferred Agents Imiquimod Cream 5% Packet Aldara Cream Packet Imiquimod Cream 3.75% Pump Zyclara Cream Packet Zyclara Cream Pump

IMMUNOSUPPRESSIVES, ORAL Preferred Agents Non-Preferred Agents Azathioprine Tablet Astagraf XL (tacrolimus extended-release) Capsule Cellcept (mycophenolate mofetil) Suspension Azasan (azathioprine) Tablet Cyclosporine Capsule Cellcept (mycophenolate mofetil) Capsule Cyclosporine (Modified) Capsule/Softgel Cellcept (mycophenolate mofetil) Tablet Cyclosporine (Modified) Solution Envarsus XR (tacrolimus extended-release) Tablet Mycophenolate Mofetil Capsule Everolimus Tablet Mycophenolate Mofetil Tablet Gengraf (cyclosporine, modified) Capsule

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 31 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Mycophenolic Acid DR Tablet Gengraf (cyclosporine, modified) Solution Rapamune (sirolimus) Solution Imuran (azathioprine) Tablet Rapamune (sirolimus) Tablet Mycophenolate Mofetil Suspension Sandimmune (cyclosporine) Solution Myfortic DR (mycophenolic acid delayed-release) Tablet Sirolimus Tablet Neoral (cyclosporine, modified) Capsule Tacrolimus Capsule Neoral (cyclosporine, modified) Solution Prograf (tacrolimus) Capsule Prograf (tacrolimus) Granule Packet Sandimmune (cyclosporine) Capsule Sirolimus Solution Zortress (everolimus) Tablet

INTRA-ARTICULAR HYALURONATES Preferred Agents Non-Preferred Agents DurolanePA, QL Gel-OneQL EuflexxaPA, QL Genvisc 850QL Gelsyn-3PA, QL HymovisQL HyalganPA, QL MonoviscQL Sodium HyaluronatePA, QL OrthoviscQL TriviscPA, QL Supartz FXQL Visco-3PA, QL SynviscQL Synvisc-OneQL TriluronQL

INTRANASAL RHINITIS AGENTS Preferred Agents Non-Preferred Agents Azelastine 0.1% (137 mcg) (generic Astelin)QL Azelastine 0.15% (205.5 mcg) (generic Astepro)QL Cromolyn Sodium Nasal (OTC) Azelastine-FluticasoneQL Fluticasone Propionate Nasal (Rx)QL Beconase AQQL Ipratropium NasalQL Budesonide Nasal (OTC)QL DymistaQL Flonase Allergy Relief (OTC)QL Flonase Sensimist (OTC)QL Flunisolide NasalQL Fluticasone Propionate Nasal (OTC)QL Mometasone Furoate NasalQL NasonexQL Olopatadine NasalQL OmnarisQL PatanaseQL QnaslQL Qnasl ChildrenQL Sinuva Implant Triamcinolone Acetonide NasalAE<4, QL XhanceQL ZetonnaQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 32 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

IRON CHELATING AGENTS Preferred Agents Non-Preferred Agents Deferasirox TabletPA Exjade Tablet for Oral Suspension Deferasirox Tablet for Oral SuspensionPA Ferriprox Solution Ferriprox Tablet Jadenu Sprinkle Granule Packet Jadenu Tablet

IRON, PARENTERAL Preferred Agents Non-Preferred Agents Ferrlecit FerahemeQL Infed Injectafer Sodium Ferric Gluconate Complex in Sucrose VenoferQL

LEUKOTRIENE MODIFIERS Preferred Agents Non-Preferred Agents Montelukast Chewable TabletQL Accolate TabletQL Montelukast TabletQL Montelukast Granule PacketAE<2, QL Singulair Chewable TabletQL Singulair Granule PacketQL Singulair TabletQL Zafirlukast TabletQL Zileuton ER TabletQL Zyflo TabletQL

LIPOTROPICS, OTHER Preferred Agents Non-Preferred Agents Cholestyramine Powder Antara CapsuleQL Cholestyramine Powder Packet Colesevelam Powder PacketQL Cholestyramine Light Powder Colesevelam TabletQL Cholestyramine Light Powder Packet Colestid Granule Colestipol TabletQL Colestid Granule Packet Ezetimibe TabletQL Colestid TabletQL Fenofibrate 54 mg, 160 mg Tablet (generic Lofibra Tablet)QL Colestipol Granule Fenofibrate Micronized 43 mg, 130 mg Capsule (generic Antara)QL Colestipol Granule Packet Fenofibrate Micronized 67 mg, 134 mg, 200 mg Capsule (generic Fenofibrate 50 mg, 150 mg Capsule (generic Lipofen)QL Lofibra Capsule)QL Fenofibrate 40 mg, 120 mg Tablet (generic Fenoglide)QL Fenofibrate Nanocrystalized 48 mg, 145 mg Tablet (generic Fenoglide TabletQL Tricor)QL Juxtapid CapsuleQL Fenofibric Acid (Choline) DR 45 mg, 135 mg Capsule (generic Lipofen CapsuleQL Trilipix)QL Lopid TabletQL Gemfibrozil TabletQL Lovaza CapsuleQL Omega-3 Ethyl Esters CapsuleQL Nexletol TabletQL Prevalite Powder Nexlizet TabletQL Prevalite Powder Packet Niacin ER Tablet (generic Niaspan) Niaspan ER Tablet PraluentQL Questran Powder Questran Powder Packet

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 33 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Questran Light Powder RepathaQL Tricor TabletQL Triglide TabletQL Trilipix DR CapsuleQL Vascepa CapsuleQL Welchol Powder PacketQL Welchol TabletQL Zetia TabletQL

LIPOTROPICS, STATINS Preferred Agents Non-Preferred Agents Atorvastatin TabletQL Altoprev ER TabletQL Lovastatin TabletQL Amlodipine-Atorvastatin TabletQL Pravastatin TabletQL Caduet TabletQL Rosuvastatin TabletQL Crestor TabletQL Simvastatin TabletQL Ezallor Sprinkle CapsuleQL Ezetimibe-Simvastatin TabletQL Fluvastatin CapsuleQL Fluvastatin ER TabletQL Lescol XL TabletQL Lipitor TabletQL Livalo TabletQL Pravachol TabletQL Vytorin TabletQL Zocor TabletQL Zypitamag TabletQL

LOCAL ANESTHETICS, TOPICAL Preferred Agents Non-Preferred Agents Glydo Jelly Syringe Lidocaine 4% Kit Lidocaine Cream Lidocaine-Prilocaine Kit Lidocaine Jelly Lidoderm PatchQL Lidocaine Ointment Lidozion Lotion Lidocaine 4% Patch (OTC) Pliaglis Cream Lidocaine 5% Patch (generic Lidoderm Patch)QL Synera Patch Lidocaine Solution Ztlido PatchQL Lidocaine Viscous SolutionAR Lidocaine-Prilocaine Cream

MACROLIDES Preferred Agents Non-Preferred Agents Azithromycin Packet Clarithromycin ER Tablet Azithromycin Suspension E.E.S. 400 Filmtab Azithromycin Tablet Ery-Tab DR Tablet Clarithromycin Suspension Erythrocin (Stearate) Filmtab Clarithromycin Tablet Erythromycin Base DR Capsule E.E.S. 200 Suspension Erythromycin Base DR Tablet EryPed Suspension Erythromycin Base Filmtab Erythromycin Ethylsuccinate Suspension Erythromycin Ethylsuccinate Tablet

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 34 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Zithromax Packet Zithromax Suspension Zithromax Tablet Zithromax Tri-Pak

MACULAR DEGENERATION AGENTS Preferred Agents Non-Preferred Agents EyleaPA, QL BeovuQL LucentisPA, QL MacugenPA, QL VisudynePA

METHOTREXATE Preferred Agents Non-Preferred Agents Methotrexate Tablet OtrexupQL Methotrexate Vial RasuvoQL Methotrexate Preservative-Free Vial Trexall Tablet Xatmep Solution

MIGRAINE ACUTE TREATMENT AGENTS (PREVIOUSLY ANTIMIGRAINE AGENTS, TRIPTANS) Preferred Agents Non-Preferred Agents Naratriptan TabletQL Almotriptan TabletQL Nurtec ODTPA, QL Amerge Tablet QL Rizatriptan TabletQL D.H.E.45 Ampule Rizatriptan ODTQL Dihydroergotamine Mesylate Ampule Sumatriptan CartridgeQL Dihydroergotamine Mesylate Nasal SprayQL Sumatriptan Nasal SprayQL Eletriptan Tablet QL Sumatriptan Pen InjectorQL Ergomar SL Tablet QL Sumatriptan SyringeQL Frova Tablet QL Sumatriptan TabletQL Frovatriptan Tablet QL Sumatriptan VialQL Imitrex CartridgeQL Zolmitriptan TabletQL Imitrex Nasal SprayQL Zolmitriptan ODTQL Imitrex Pen InjectorQL Zomig Nasal SprayQL Imitrex TabletQL Imitrex VialQL Maxalt Tablet QL Maxalt MLTQL Migranal Nasal SprayQL Onzetra XsailQL Relpax Tablet QL Reyvow Tablet QL Sumatriptan-Naproxen TabletQL Tosymra Nasal SprayQL Treximet Tablet QL Ubrelvy Tablet QL Zembrace SymtouchQL Zomig TabletQL Zomig ZMTQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 35 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

MIGRAINE PREVENTION AGENTS (PREVIOUSLY ANTIMIGRAINE AGENTS, OTHER) Preferred Agents Non-Preferred Agents AimovigPA, QL AjovyQL EmgalityPA, QL VyeptiQL Nurtec ODTPA, QL

MONOCLONAL ANTIBODIES (MABs) – ANTI-IL, ANTI-IGE Preferred Agents Non-Preferred Agents FasenraPA, QL Cinqair NucalaPA, QL DupixentQL Xolair Vial PA, QL Xolair SyringeQL

MULTIPLE SCLEROSIS AGENTS Preferred Agents Non-Preferred Agents Aubagio TabletPA, QL Ampyra ER TabletQL AvonexQL CopaxoneQL BetaseronQL ExtaviaQL Dalfampridine ER TabletPA, QL LemtradaQL Dimethyl Fumarate DR CapsulePA, QL Mavenclad TabletQL Gilenya CapsulePA, QL Mayzent TabletQL GlatiramerQL OcrevusQL GlatopaQL PlegridyQL RebifQL Tecfidera DR CapsuleQL Rebif RebidoseQL Vumerity DR CapsuleQL TysabriPA, QL Zeposia TabletQL

NEUROPATHIC PAIN AGENTS Preferred Agents Non-Preferred Agents Capsaicin Topical Cymbalta CapsuleQL Duloxetine DR 20 mg, 30 mg, 60 mg Capsule (generic Cymbalta)QL Drizalma Sprinkle CapsuleQL Gabapentin CapsuleQL Duloxetine DR 40 mg Capsule (generic Irenka)QL Gabapentin SolutionQL Gralise ER TabletQL Gabapentin TabletQL Horizant ER TabletQL Lidocaine 4% Patch (OTC) Lidoderm PatchQL Lidocaine 5% Patch (generic Lidoderm Patch)QL Lipritin Kit Pregabalin CapsuleQL Lyrica CapsuleQL Pregabalin SolutionQL Lyrica SolutionQL Lyrica CR TabletQL Neurontin CapsuleQL Neurontin SolutionQL Neurontin TabletQL Qutenza PatchQL Savella TabletQL Ztlido PatchQL

NSAIDs Preferred Agents Non-Preferred Agents Celecoxib CapsuleQL Arthrotec TabletQL Diclofenac GelQL Cambia PowderQL Diclofenac 1.5% Topical SolutionQL Celebrex CapsuleQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 36 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Diclofenac Sodium DR/EC 25 mg, 50 mg, 75 mg Tablet (generic Daypro TabletQL Voltaren EC Tablet)QL Diclofenac Epolamine PatchQL Flurbiprofen TabletQL Diclofenac Potassium TabletQL Ibuprofen CapsuleQL Diclofenac Sodium ER 24HR 100 mg Tablet (generic Voltaren- Ibuprofen Chewable TabletQL XR Tablet)QL Ibuprofen SuspensionQL Diclofenac-Misoprostol TabletQL Ibuprofen Suspension DropsQL Diclofex DC Pack Ibuprofen TabletQL Diflunisal TabletQL Indomethacin Capsule (generic Indocin)QL Duexis TabletQL Indomethacin ER CapsuleQL EC-Naproxen 375 mg, 500 mg TabletQL Ketorolac TabletQL Etodolac CapsuleQL Meloxicam TabletQL Etodolac TabletQL Nabumetone TabletQL Etodolac ER TabletQL Naproxen 250 mg, 375 mg, 500 mg Tablet (Rx) (generic Naprosyn Feldene CapsuleQL Tablet)QL Fenoprofen CapsuleQL Naproxen SuspensionQL Fenoprofen TabletQL Naproxen DR 375 mg, 500 mg Tablet (generic Naprosyn EC Flector PatchQL Tablet)QL Indocin Rectal SuppositoryQL Naproxen Sodium 220 mg Capsule (OTC) (generic Aleve Liquid Gel Indocin SuspensionQL Cap)QL Ketoprofen CapsuleQL Naproxen Sodium 220 mg Tablet (OTC) (generic Aleve Ketoprofen ER CapsuleQL Caplet/Tablet)QL Licart PatchQL Naproxen Sodium 275 mg Tablet (generic Anaprox Tablet)QL Meclofenamate CapsuleQL Naproxen Sodium DS 550 mg Tablet (generic Anaprox DS Tablet)QL Mefenamic Acid CapsuleQL Piroxicam CapsuleQL Mobic TabletQL Sulindac TabletQL Nalfon CapsuleQL Nalfon TabletQL Naprelan CR TabletQL Naproxen-Esomeprazole DR TabletQL Naproxen Sodium CR/ER Tablet (generic Naprelan CR Tablet)QL Oxaprozin TabletQL Pennsaid PumpQL Qmiiz ODTQL Relafen DS TabletQL Sprix Nasal SprayQL Tolmetin CapsuleQL Tolmetin TabletQL Vimovo DR TabletQL Vivlodex CapsuleQL Voltaren GelQL Zipsor CapsuleQL Zorvolex CapsuleQL

ONCOLOGY AGENTS, BREAST CANCER Preferred Agents Non-Preferred Agents Anastrozole TabletQL Arimidex TabletQL Exemestane TabletQL Aromasin TabletQL Letrozole TabletPA, QL Fareston TabletQL Tamoxifen TabletQL Femara TabletQL Soltamox SolutionQL Toremifene TabletQL

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ONCOLOGY AGENTS, ORAL Preferred Agents Non-Preferred Agents Abiraterone Acetate Tablet PA, QL MekinistPA, QL CasodexQL AfinitorPA, QL MektoviPA, QL EverolimusQL Afinitor DisperzPA NerlynxPA, QL GleevecQL AlecensaPA, QL NexavarPA, QL TarcevaQL AlunbrigPA, QL NinlaroPA, QL Xeloda AyvakitPA, QL NubeqaPA, QL YonsaQL BalversaPA, QL OdomzoPA, QL ZytigaQL BicalutamidePA, QL PemazyrePA, QL BosulifPA, QL PiqrayPA, QL BraftoviPA, QL RetevmoPA, QL BrukinsaPA, QL RozlytrekPA, QL CabometyxPA, QL RubracaPA, QL CalquencePA, QL RydaptPA, QL CapecitabinePA SprycelPA, QL CaprelsaPA, QL StivargaPA, QL CometriqPA, QL SutentPA, QL CopiktraPA, QL TabrectaPA, QL CotellicPA, QL TafinlarPA, QL DaurismoPA, QL TagrissoPA, QL ErivedgePA, QL TalzennaPA, QL ErleadaPA, QL TasignaPA, QL ErlotinibPA, QL TazverikPA, QL FarydakPA, QL TemozolomidePA GavretoPA, QL TibsovoPA, QL GilotrifPA, QL TukysaPA, QL IbrancePA, QL TuralioPA, QL IclusigPA, QL TykerbPA, QL IdhifaPA, QL VenclextaPA, QL ImatinibPA, QL VerzenioPA, QL ImbruvicaPA, QL VitrakviPA, QL InlytaPA, QL VizimproPA, QL InrebicPA, QL VotrientPA, QL IressaPA, QL XalkoriPA, QL JakafiPA, QL Xospata PA, QL KisqaliPA, QL XpovioPA, QL Kisqali FemaraPA, QL XtandiPA, QL KoselugoPA, QL ZejulaPA, QL LenvimaPA, QL ZelborafPA, QL LonsurfPA, QL ZolinzaPA, QL LorbrenaPA, QL ZydeligPA, QL LynparzaPA, QL ZykadiaPA, QL

OPHTHALMICS, ALLERGIC CONJUNCTIVITIS Preferred Agents Non-Preferred Agents Alaway Drops Alocril Drops Azelastine Drops Alomide Drops Cromolyn Sodium Drops Alrex Drops Ketotifen Drops (OTC) Bepreve Drops Naphcon-A Drops (OTC) Epinastine Drops Olopatadine Drops Lastacaft Drops

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Zaditor Drops (OTC) Pataday Eye Drops (OTC) Zerviate Droperette

OPHTHALMICS, ANTIBIOTICS Preferred Agents Non-Preferred Agents AK-Poly-Bac Ointment Azasite Drops Bacitracin-Polymyxin Ointment Bacitracin Ointment Ciprofloxacin Drops Besivance Drops Erythromycin Ointment Bleph-10 Drops Gatifloxacin Drops Ciloxan Drops Gentak Ointment Ciloxan Ointment Gentamicin Drops Levofloxacin Drops Ofloxacin Drops Moxeza Drops Polycin Ointment Moxifloxacin Drops Polymyxin B-Trimethoprim Drops Neomycin-Bacitracin-Polymyxin Ointment Tobramycin Drops Neomycin-Polymyxin-Gramicidin Drops Neo-Polycin Ointment Ocuflox Drops Polytrim Drops Sulfacetamide Sodium Drops Sulfacetamide Sodium Ointment Tobrex Drops Tobrex Ointment Vigamox Drops Zymaxid Drops

OPHTHALMICS, ANTIBIOTIC-STEROID COMBINATIONS Preferred Agents Non-Preferred Agents Neomycin-Bacitracin-Polymyxin-HC Ointment Blephamide Drops Neomycin-Polymyxin-Dexamethasone Drops Blephamide S.O.P. Ointment Neomycin-Polymyxin-Dexamethasone Ointment Maxitrol Drops Neo-Polycin HC Ointment Maxitrol Ointment Pred-G Drops Neomycin-Polymyxin-HC Drops Pred-G Ointment Tobradex ST Drops Sulfacetamide-Prednisolone Drops Tobramycin-Dexamethasone Drops Tobradex Drops Tobradex Ointment Zylet Drops

OPHTHALMICS, ANTI-INFLAMMATORIES Preferred Agents Non-Preferred Agents Dexamethasone Sodium Phosphate Drops Acular Drops Durezol Drops Acular LS Drops Flarex Drops Acuvail Droperette Fluorometholone Drops Alrex Drops Flurbiprofen Drops Bromfenac Drops FML Forte Drops Bromsite Drops FML S.O.P. Ointment Dextenza Insert Ilevro Drops Dexycu Vial Ketorolac (0.5%) Drops Diclofenac Drops

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 39 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Ketorolac LS (0.4%) Drops FML Liquifilm Drops Lotemax Ointment Iluvien Implant Maxidex Drops Inveltys Drops Nevanac Drops Lotemax Drops Pred Mild Drops Lotemax Gel Prednisolone Acetate Drops Lotemax SM Gel Prednisolone Sodium Phosphate Drops Loteprednol Drops Ozurdex Implant Pred Forte Drops Prolensa Drops Retisert Implant Triesence VialQL Yutiq Implant

OPHTHALMICS, GLAUCOMA Preferred Agents Non-Preferred Agents Alphagan P 0.1% Drops Apraclonidine Drops Phospholine Iodide Drops Alphagan P 0.15% Drops Azopt Drops Pilocarpine Drops Brimonidine 0.2% Drops Betaxolol Drops Rhopressa Drops Carteolol Drops Betoptic S 0.25% Drops Rocklatan Drops Combigan Drops Bimatoprost 0.03% Drops Timolol (Daily) Drops (generic Istalol) Dorzolamide Drops Brimonidine 0.15% Drops Timolol Gel-Solution Dorzolamide-Timolol Drops (generic Cosopt) Cosopt Drops Timoptic Drops Latanoprost 0.005% Drops Cosopt PF Droperette Timoptic Ocudose Droperette Levobunolol Drops Dorzolamide-Timolol Droperette Timoptic-XE GFS Simbrinza Drops (generic Cosopt PF) Travatan Z Drops Timolol Drops (generic Timoptic) Durysta Implant Travoprost Drops Iopidine Drops Trusopt Drops Isopto Carpine Drops Vyzulta Drops Istalol (Daily) Drops Xalatan Drops Lumigan 0.01% Drops Xelpros Drops Zioptan Droperette

OPHTHALMICS, IMMUNOMODULATORS Preferred Agents Non-Preferred Agents Restasis DroperetteQL Cequa DroperetteQL Restasis Multidose DropsQL Xiidra DroperetteQL

OPIOID DEPENDENCE TREATMENTS Preferred Agents Non-Preferred Agents Buprenorphine SL TabletPA, QL Bunavail FilmQL Buprenorphine-Naloxone SL FilmQL Catapres Tablet Buprenorphine-Naloxone SL TabletQL Lucemyra TabletQL Clonidine Tablet Probuphine ImplantQL Naltrexone Tablet Suboxone SL FilmQL SublocadeQL Zubsolv SL TabletQL VivitrolQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 40 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

OPIOID OVERDOSE AGENTS Preferred Agents Non-Preferred Agents Naloxone Cartridge Naloxone Syringe Naloxone Vial Narcan Nasal Spray

OTIC ANTIBIOTIC PREPARATIONS Preferred Agents Non-Preferred Agents Cipro HC Otic Suspension Ciprofloxacin-Fluocinolone Vial Ciprodex Otic Suspension Cortisporin-TC Ear Suspension Neomycin-Polymyxin-Hydrocortisone Ear Solution Otiprio Vial Neomycin-Polymyxin-Hydrocortisone Ear Suspension Otovel Ear Drops Ofloxacin Ear Drops

PANCREATIC ENZYMES Preferred Agents Non-Preferred Agents Creon DR Capsule Pancreaze DR Capsule Zenpep DR Capsule Pertzye DR Capsule Viokace Tablet

PENICILLINS Preferred Agents Non-Preferred Agents Amoxicillin Capsule Amoxicillin-Clavulanate Chewable Tablet Amoxicillin Chewable Tablet Amoxicillin-Clavulanate 250-62.5 mg/5 ml Suspension Amoxicillin Suspension Amoxicillin-Clavulanate ER Tablet Amoxicillin Tablet Augmentin Suspension Amoxicillin-Clavulanate 200-28.5 mg/5 ml Suspension Amoxicillin-Clavulanate 400-57 mg/5 ml Suspension Amoxicillin-Clavulanate 600-42.9 mg/5 ml Suspension Amoxicillin-Clavulanate Tablet Ampicillin Capsule Dicloxacillin Capsule Penicillin Solution Penicillin Tablet

PHOSPHATE BINDERS Preferred Agents Non-Preferred Agents Calcium Acetate CapsuleQL Auryxia TabletQL Calcium Acetate TabletQL Fosrenol Chewable TabletQL Calphron TabletQL Fosrenol Powder PacketQL Phoslyra SolutionQL Lanthanum Carbonate Chewable TabletQL Sevelamer Carbonate TabletQL Renagel TabletQL Renvela Powder PacketQL Renvela TabletQL Sevelamer Carbonate Powder PacketQL Sevelamer HCl TabletQL Velphoro Chewable TabletQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 41 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

PITUITARY SUPPRESSIVE AGENTS, LHRH Preferred Agents Non-Preferred Agents EligardPA, QL FensolviQL Leuprolide AcetatePA Supprelin LAQL Lupaneta PackPA, QL TrelstarQL Lupron DepotPA, QL Lupron Depot-PedPA, QL Oriahnn CapsulePA, QL Orilissa TabletPA, QL SynarelPA, QL TriptodurPA, QL Vantas KitPA, QL ZoladexPA, QL

PLATELET AGGREGATION INHIBITORS Preferred Agents Non-Preferred Agents Aspirin-Dipyridamole ER CapsuleQL Effient TabletQL Brilinta TabletQL Plavix TabletQL Clopidogrel TabletQL Zontivity TabletQL Dipyridamole TabletQL Prasugrel TabletQL

POTASSIUM REMOVING AGENTS Preferred Agents Non-Preferred Agents LokelmaPA, QL VeltassaPA, QL

PRENATAL VITAMINS Preferred Agents Non-Preferred Agents Complete Natal DHA Combo Pack Citranatal 90 DHA Combo Pack M-Natal Plus Tablet Citranatal Assure Combo Pack Niva-Plus Tablet Citranatal B-Calm Tablet PNV 29-1 Tablet Citranatal DHA Combo Pack Prenatal Vitamin Plus Low Iron Tablet Citranatal Harmony Capsule Preplus Tablet Citranatal Rx Tablet Pretab Tablet C-Nate DHA Trinatal RX 1 Tablet Completenate Chewable Tablet Triveen-Duo DHA Combo Pack Concept DHA Capsule Westab Plus Tablet Concept OB Capsule Elite-OB Tablet Enbrace HR Capsule Folivane-OB Capsule Nestabs Tablet Nestabs DHA Combo Pack Nestabs One Capsule OB Complete Tablet OB Complete One Capsule OB Complete Petite Capsule OB Complete Premier Tablet OB Complete with DHA Capsule

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 42 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

PNV-DHA Capsule PNV-DHA + Docusate Capsule PNV-Omega Capsule PNV-Select Tablet Prenaissance Capsule Prenaissance Plus Capsule Prenatal 19 Chewable Tablet Prenate AM Tablet Prenate Chewable Tablet Prenate DHA Capsule Prenate Elite Tablet Prenate Enhance Capsule Prenate Essential Capsule Prenate Mini Capsule Prenate Pixie Capsule Prenate Restore Capsule Primacare Capsule Provida OB Capsule Select-OB Chewable Tablet Select-OB + DHA Comba Pack Se-Natal 19 Chewable Tablet Se-Natal 19 Tablet Taron-C DHA Capsule Taron-Prex Prenatal Capsule Thrivite Rx Tablet Tricare Tablet Tristart DHA Capsule Vinate DHA RF Capsule Virt-C DHA Capsule Virt-Nate DHA Capsule Virt-PN DHA Capsule Virt-PN Plus Capsule Vitafol Fe Plus Capsule Vitafol Gummies Vitafol Nano Tablet Vitafol Ultra Capsule Vitafol-OB Tablet Vitafol-OB+DHA Combo Pack Vitafol-One Capsule VP-PNV-DHA Capsule Zatean-PN DHA Capsule Zatean-PN Plus Capsule

PROGESTATIONAL AGENTS Preferred Agents Non-Preferred Agents Depo-Provera 400 mg/ml VialQL Aygestin TabletQL Hydroxyprogesterone Caproate VialPA, QL Crinone Gel Makena Auto-InjectorPA, QL Makena VialQL Medroxyprogesterone TabletQL Prometrium CapsuleQL Norethindrone TabletQL Provera TabletQL Progesterone CapsuleQL Progesterone Vial

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PROTON PUMP INHIBITORS Preferred Agents Non-Preferred Agents Esomeprazole Magnesium DR Capsule (OTC)AR, QL Aciphex DR Sprinkle CapsuleAR, QL Esomeprazole Magnesium DR Capsule (Rx)AR, QL Aciphex DR TabletAR, QL Lansoprazole DR Capsule (OTC)AR, QL Dexilant DR CapsuleAR, QL Lansoprazole DR Capsule (Rx)AR, QL Esomeprazole Suspension PacketAR, QL Nexium DR Suspension PacketAR, QL Lansoprazole ODTAR, QL Omeprazole DR Capsule (Rx)AR, QL Nexium DR CapsuleAR, QL Pantoprazole DR TabletAR, QL Omeprazole DR Tablet (OTC)AR, QL Rabeprazole DR TabletAR, QL Omeprazole DR ODT (OTC)AR, QL Omeprazole Magnesium DR Capsule (OTC)AR, QL Omeprazole Magnesium DR Tablet (OTC)AR, QL Omeprazole-Sodium Bicarbonate CapsuleAR, QL Omeprazole-Sodium Bicarbonate PacketAR, QL Prevacid 24HR DR Capsule (OTC)AR, QL Prevacid DR CapsuleAR, QL Prevacid SolutabAR, QL Prilosec DR Suspension PacketAR, QL Protonix DR TabletAR, QL Protonix Suspension PacketAR, QL Zegerid CapsuleAR, QL Zegerid PacketAR, QL

PULMONARY ARTERIAL HYPERTENSION (PAH) AGENTS, ORAL AND INHALED Preferred Agents Non-Preferred Agents Ambrisentan TabletPA, QL Adcirca TabletQL Revatio SuspensionPA, QL Adempas TabletQL Sildenafil Tablet (generic Revatio)PA, QL Alyq TabletQL Tadalafil Tablet (generic Adcirca)PA, QL Bosentan TabletQL Tracleer TabletPA, QL Letairis TabletQL TyvasoPA, QL Opsumit TabletQL VentavisPA, QL Orenitram ER Tablet Revatio TabletQL Sildenafil Suspension (generic Revatio Suspension)QL Tracleer Tablet for SuspensionQL Uptravi TabletQL

SEDATIVE HYPNOTICS Preferred Agents Non-Preferred Agents Eszopiclone TabletQL Ambien TabletQL Temazepam 15mg, 30mg CapsuleAR, QL Ambien CR TabletQL Zaleplon CapsuleQL Belsomra TabletQL Zolpidem TabletQL Dayvigo TabletQL Doxepin TabletQL Edluar SL TabletQL Estazolam TabletAR, QL Flurazepam CapsuleAR, QL Halcion TabletAR, QL Hetlioz CapsuleQL Intermezzo SL TabletQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 44 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Lunesta TabletQL Midazolam SyrupAR Ramelteon TabletQL Restoril CapsuleAR, QL Rozerem TabletQL Seconal Sodium CapsuleQL Silenor TabletQL Temazepam 7.5mg, 22.5mg CapsuleAR, QL Triazolam TabletAR, QL Zolpidem ER TabletQL Zolpidem SL TabletQL Zolpimist SprayQL

SICKLE CELL ANEMIA AGENTS Preferred Agents Non-Preferred Agents Droxia Capsule Adakveo Vial Hydroxyurea Capsule Endari Powder PacketQL Hydrea Capsule Oxbryta TabletQL Siklos Tablet

SKELETAL MUSCLE RELAXANTS Preferred Agents Non-Preferred Agents Baclofen TabletQL Amrix ER CapsuleQL Cyclobenzaprine TabletQL Carisoprodol TabletQL Dantrolene CapsuleQL Chlorzoxazone TabletQL Methocarbamol TabletQL Cyclobenzaprine ER CapsuleQL Tizanidine TabletQL Dantrium CapsuleQL Fexmid TabletQL Lorzone TabletQL Metaxalone TabletQL Norgesic Forte TabletQL Orphenadrine ER TabletQL Robaxin TabletQL Skelaxin TabletQL Soma TabletQL Tizanidine CapsuleQL Zanaflex CapsuleQL Zanaflex TabletQL

SMOKING CESSATION Preferred Agents Non-Preferred Agents Bupropion SR TabletQL Nicoderm CQ PatchQL ChantixQL Nicorette GumQL Nicotine GumQL Nicorette LozengeQL Nicotine LozengeQL Nicorette Mini LozengeQL Nicotine Mini LozengeQL Nicotine Transdermal System (Steps 1, 2, 3)QL Nicotine PatchQL Nicotrol Cartridge InhalerQL Nicotrol NS SprayQL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 45 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

STEROIDS, TOPICAL – LOW POTENCY Preferred Agents Non-Preferred Agents Hydrocortisone Cream Alclometasone Cream Hydrocortisone Lotion Alclometasone Ointment Hydrocortisone Ointment Capex (fluocinolone) Shampoo Hydrocortisone-Aloe Cream Derma-Smoothe-FS (fluocinolone) Oil Hydrocortisone Plus Cream Desonate (desonide) Gel Scalpicin (hydrocortisone) Liquid Desonide Cream Desonide Lotion Desonide Ointment Fluocinolone Oil Texacort (hydrocortisone) Solution

STEROIDS, TOPICAL – MEDIUM POTENCY Preferred Agents Non-Preferred Agents Fluticasone Cream Beser (fluticasone) Kit Fluticasone Ointment Beser (fluticasone) Lotion Mometasone Cream Betamethasone Valerate Foam Mometasone Ointment Clocortolone Cream Mometasone Solution Clocortolone Cream Pump Cloderm (clocortolone) Cream Cloderm (clocortolone) Cream Pump Cutivate (fluticasone) Cream Fluocinolone Cream Fluocinolone Ointment Fluocinolone Solution Flurandrenolide Cream Flurandrenolide Lotion Flurandrenolide Ointment Fluticasone Lotion Hydrocortisone Butyrate Cream Hydrocortisone Butyrate Lotion Hydrocortisone Butyrate Ointment Hydrocortisone Butyrate Solution Hydrocortisone Valerate Cream Hydrocortisone Valerate Ointment Locoid (hydrocortisone butyrate) Cream Locoid (hydrocortisone butyrate) Lotion Locoid (hydrocortisone butyrate) Solution Locoid (hydrocortisone butyrate/emollient) Lipocream Luxiq (betamethasone valerate) Foam Pandel (hydrocortisone probutate) Cream Prednicarbate Cream Prednicarbate Ointment Synalar (fluocinolone) Cream Synalar (fluocinolone/emollient) Cream Kit Synalar (fluocinolone) Ointment Synalar (fluocinolone/emollient) Ointment Kit Synalar (fluocinolone) Solution Synalar (fluocinolone/cleanser) TS Kit

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 46 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

STEROIDS, TOPICAL – HIGH POTENCY Preferred Agents Non-Preferred Agents Betamethasone Dipropionate Cream Amcinonide Cream Betamethasone Dipropionate Lotion Amcinonide Lotion Betamethasone Dipropionate Augmented Cream Betamethasone Dipropionate Ointment Betamethasone Valerate Cream Betamethasone Dipropionate Augmented Gel Betamethasone Valerate Lotion Betamethasone Dipropionate Augmented Lotion Betamethasone Valerate Ointment Betamethasone Dipropionate Augmented Ointment Triamcinolone Acetonide Cream Desoximetasone Cream Triamcinolone Acetonide Lotion Desoximetasone Gel Triamcinolone Acetonide Ointment Desoximetasone Ointment Desoximetasone Spray Diflorasone Cream Diflorasone Ointment Diprolene (betamethasone dipropionate augmented) Ointment Fluocinonide Cream Fluocinonide Gel Fluocinonide Ointment Fluocinonide Solution Fluocinonide-E Cream Kenalog (triamcinolone) Spray Psorcon (diflorasone) Cream Sernivo (betamethasone dipropionate) Spray Topicort (desoximetasone) Cream Topicort (desoximetasone) Gel Topicort (desoximetasone) Ointment Topicort (desoximetasone) Spray Triamcinolone Spray Trianex (triamcinolone) Ointment Vanos (fluocinonide) Cream

STEROIDS, TOPICAL – VERY HIGH POTENCY Preferred Agents Non-Preferred Agents Clobetasol Cream Apexicon E (diflorasone/emollient) Cream Clobetasol Ointment Bryhali (halobetasol) Lotion Clobetasol Solution Clobetasol Foam Clodan (clobetasol) Shampoo Clobetasol Gel Clobetasol Lotion Clobetasol Shampoo Clobetasol Spray Clobetasol Emollient Cream Clobetasol Emollient Foam Clobetasol Emulsion Foam Clobex (clobetasol) Lotion Clobex (clobetasol) Shampoo Clobex (clobetasol) Spray Clodan (clobetasol/cleanser) Kit Halcinonide Cream Halobetasol Cream Halobetasol Foam Halobetasol Ointment Halog (halcinonide) Cream

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 47 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Halog (halcinonide) Ointment Halog (halcinonide) Solution Lexette (halobetasol) Foam Olux (clobetasol) Foam Olux-E (clobetasol/emollient) Foam Temovate (clobetasol) Cream Temovate (clobetasol) Ointment Tovet (clobetasol/emollient) Emollient Foam Tovet (clobetasol/emollient) Foam Kit Ultravate (halobetasol) Lotion

STIMULANTS AND RELATED AGENTS Preferred Agents Non-Preferred Agents Armodafinil TabletPA, QL Adderall TabletAR, QL Atomoxetine CapsuleAR, QL Adderall XR CapsuleAR, QL Dexmethylphenidate TabletAR, QL Adhansia XR CapsuleAR, QL Dexmethyphenidate ER CapsuleAR, QL Adzenys ER SuspensionAR, QL Dextroamphetamine TabletAR, QL Adzenys XR-ODTAR, QL Dextroamphetamine ER CapsuleAR, QL Amphetamine ER Suspension (generic Adzenys ER)AR, QL Dextroamphetamine-Amphetamine Tablet (generic Adderall)AR, QL Amphetamine TabletAR, QL Dextroamphetamine-Amphetamine ER Capsule (generic Adderall Aptensio XR CapsuleAR, QL XR)AR, QL Clonidine ER TabletAR, QL Guanfacine ER TabletAR, QL Concerta TabletAR, QL Methylphenidate SolutionAR, QL Cotempla XR-ODTAR, QL Methylphenidate TabletAR, QL Daytrana PatchAR, QL Methylphenidate ER (CD) Capsule (generic Metadate CD)AR, QL Desoxyn TabletAR, QL Methylphenidate ER Tablet (generic Ritalin SR)AR, QL Dexedrine ER CapsuleAR, QL Methylphenidate ER 24HR Tablet (generic Concerta)AR, QL Dextroamphetamine SolutionAR, QL Methylphenidate ER (LA) 24HR Capsule (generic Ritalin LA)AR, QL Dyanavel XR SuspensionAR, QL Modafinil TabletPA, QL Evekeo TabletAR, QL Quillichew ER Chewable TabletAR, QL Evekeo ODTAR, QL Quillivant XR SuspensionAR, QL Focalin TabletAR, QL Focalin XR CapsuleAR, QL Intuniv ER TabletAR, QL Jornay PM CapsuleAR, QL Methamphetamine TabletAR, QL Methylin SolutionAR, QL Methylphenidate Chewable TabletAR, QL Methylphenidate ER Capsule (generic Aptensio XR)AR, QL Methylphenidate ER 24HR 72 mg Tablet (generic Relexxii ER Tablet)AR, QL Mydayis ER CapsuleAR, QL Nuvigil TabletQL Procentra SolutionAR, QL Provigil TabletQL Relexxii ER 24HR TabletAR, QL Ritalin TabletAR, QL Ritalin LA CapsuleAR, QL Strattera CapsuleAR, QL Sunosi TabletQL Vyvanse CapsuleAR, QL Vyvanse Chewable TabletAR, QL

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 48 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Wakix TabletQL Zenzedi TabletAR, QL

TETRACYCLINES Preferred Agents Non-Preferred Agents Doxycycline Hyclate 50 mg, 100 mg Capsule (generic Vibramycin Demeclocycline Tablet Capsule) Doryx DR TabletQL Doxycycline Hyclate 20 mg Tablet (generic Periostat Tablet) Doryx MPC DR TabletQL Doxycycline Hyclate 100 mg Tablet (generic Vibra-Tabs Tablet) Doxycycline Hyclate 75 mg, 150 mg Tablet (generic Acticlate Doxycycline Monohydrate 50 mg, 100mg Capsule (generic Tablet) Monodox Capsule) Doxycycline Hyclate DR Tablet (generic Doryx DR Tablet)QL Doxycycline Monohydrate Suspension (generic Vibramycin Doxycycline IR-DR 40 mg Capsule (generic Oracea Capsule)QL Suspension) Doxycycline Monohydrate 75 mg Capsule (generic Monodox Doxycycline Monohydrate 50 mg, 75 mg, 100 mg Tablet (generic Capsule) Adoxa Tablet) Doxycycline Monohydrate 150 mg Capsule (generic Adoxa Minocycline Capsule Capsule) Doxycycline Monohydrate 150 mg Tablet (generic Adoxa Pak Tablet) Minocin Capsule Minocycline Tablet (generic Dynacin Tablet) Minocycline ER Tablet (generic Solodyn ER Tablet)QL Minolira ER Tablet Morgidox Capsule Morgidox Kit Nuzyra TabletQL Oracea CapsuleQL Solodyn ER TabletQL Tetracycline Capsule Vibramycin Capsule Vibramycin Suspension Vibramycin Syrup Ximino ER CapsuleQL

THALIDOMIDE AND DERIVATIVES Preferred Agents Non-Preferred Agents Revlimid CapsulePA, QL Pomalyst CapsuleQL Thalomid CapsulePA, QL

THROMBOPOIETICS Preferred Agents Non-Preferred Agents Nplate VialPA Doptelet TabletQL Promacta Powder PacketPA, QL Mulpleta TabletQL Promacta TabletPA, QL Tavalisse TabletQL

THYROID HORMONES Preferred Agents Non-Preferred Agents Armour Thyroid Tablet Levothyroxine Vial Cytomel TabletQL Liothyronine Vial Levo-T Tablet Synthroid Tablet

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 49 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Levothyroxine Tablet Tirosint Capsule Levoxyl Tablet Tirosint-Sol Solution Liothyronine TabletQL Triostat Vial NP Thyroid Tablet Unithroid Tablet Thyroid Tablet

ULCERATIVE COLITIS AGENTS Preferred Agents Non-Preferred Agents Apriso ER CapsuleQL Asacol HD DR TabletQL Balsalazide CapsuleQL Azulfidine TabletQL Delzicol DR CapsuleQL Azulfidine EN-TabQL Mesalamine DR 400 mg Capsule (generic Delzicol)QL Colazal CapsuleQL Mesalamine DR 1.2 g Tablet (generic Lialda)QL Dipentum CapsuleQL Mesalamine EnemaQL Lialda DR TabletQL Mesalamine Enema Kit Mesalamine DR 800 mg Tablet (generic Asacol HD)QL Mesalamine Rectal SuppositoryQL Mesalamine ER 0.375 g Capsule (generic Apriso ER)QL Pentasa CapsuleQL Rowasa Enema Kit Sulfasalazine TabletQL sfRowasa EnemaQL Sulfasalazine DR TabletQL Uceris Rectal FoamQL Zeposia TabletQL

UREA CYCLE DISORDER AGENTS Preferred Agents Non-Preferred Agents Buphenyl Powder Ravicti LiquidQL Buphenyl Tablet Sodium Phenylbutyrate Powder Sodium Phenylbutyrate Tablet

URINARY ANTI-INFECTIVES Preferred Agents Non-Preferred Agents Methenamine Hippurate TabletQL Hiprex TabletQL Nitrofurantoin Capsule (generic Macrodantin Capsule)QL Hyophen TabletQL Nitrofurantoin Monohydrate-Macro Capsule (generic Macrobid Macrobid CapsuleQL Capsule)QL Macrodantin CapsuleQL ME-NaPhos-MB-Hyo 1 Tablet Methenamine Mandelate Tablet Monurol SachetQL Nitrofurantoin SuspensionAE<9, QL Phosphasal Tablet Urelle TabletQL Urimar-T TabletQL Urin D.S. TabletQL Uro-458 Tablet Urogesic-Blue TabletQL Ustell CapsuleQL

VAGINAL ANTI-INFECTIVES Preferred Agents Non-Preferred Agents Cleocin Ovules Cleocin Vaginal Cream Clindamycin Vaginal Cream Flagyl Tablet

AR = age restriction, clinical prior authorization required PA = clinical prior authorization required AE = age exemption for specified ages (years) QL = quantity limit applies to FFS claims Non-preferred agents require prior authorization January 5, 2021 Page 50 of 51 Pennsylvania Department of Human Services Statewide Preferred Drug List (PDL)*

Clindesse Cream Gynazole 1 Cream Clotrimazole 3 (2%) Vaginal Cream Miconazole 3 (200 mg) Vaginal Suppository Clotrimazole 7 (1%) Vaginal Cream Nuvessa Gel Metronidazole Tablet Solosec Granule Packet Metronidazole Vaginal Gel Terconazole Vaginal Cream Miconazole 1 (1200 mg-2%) Combination Pack Terconazole Vaginal Suppository Miconazole 3 (200 mg-2%) Combination Pack Tinidazole Tablet Miconazole 3 (4%) Vaginal Cream Vandazole Gel Miconazole 7 (2%) Vaginal Cream Miconazole 7 (100 mg) Vaginal Suppository Tioconazole-1 (6.5%) Vaginal Ointment

VITAMIN D ANALOGS Preferred Agents Non-Preferred Agents Calcitriol Ampule Calcitriol Solution Calcitriol Capsule Doxercalciferol Capsule Doxercalciferol Vial Paricalcitol Capsule Hectorol Vial Rayaldee ER CapsuleQL Paricalcitol Vial Rocaltrol Capsule Rocaltrol Solution Zemplar Capsule Zemplar Vial

VMAT2 INHIBITORS Preferred Agents Non-Preferred Agents Austedo TabletPA, QL Xenazine TabletQL Ingrezza CapsulePA, QL Tetrabenazine TabletPA, QL