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Preferred Drug List Effective Date: 7/1/2021 Office of Pharmacy Services Medicaid Pharmacy Program Preferred Drug List Effective Date: 7/1/2021 Only drugs that are part of the listed therapeutic categories are affected by the Medicaid Preferred Drug List (PDL). Therapeutic categories not listed here are not part of the PDL and will continue to be covered as they always have for Maryland Medicaid participants. Note: Brand names listed in parentheses are only listed as a reference. For most multi-source products, the generic products are usually preferred and the branded innovator product is non- preferred. If a generic product is non-preferred, the corresponding brand product is also non-preferred except where specifically noted as “(generic only)”. PDL products that are new to market require prior authorization until they are reviewed. ANALGESICS Drug Class Preferred Requires Prior Authorization Analgesics, Narcotics (Long fentanyl patches (All strengths except buprenorphine patch (Butrans)ql Acting) 37.5mcg, 62.5mcg, 87.5mcg)cc,ql fentanyl 37.5mcg, 62.5mcg, 87.5mcg morphine sulfate SR (MS Contin)ql patchescc,ql Xtampza ER hydrocodone ER (Hysingla ER, Zohydro ER)cc,ql hydromorphone ER (Exalgo)ql methadone (Dolophine)ql morphine sulfate ER (Avinza)ql morphine sulfate ER (Kadian)ql oxycodone ER (Oxycontin)ql oxymorphone ER (Opana ER)ql tramadol ER (Conzip, Ryzolt, Ultram ER)ql Belbucaql Morphabond ER Nucynta ERql cc-Clinical criteria can be found at the link here ql- Quantity limits can be found at the link here All lowercase letters = generic product. Leading capital letter = brand name product. Page 1 of 30 ANALGESICS Drug Class Preferred Requires Prior Authorization Analgesics, Narcotics acetaminophen/codeine (Tylenol w/ benzhydrocodone/acetaminophen (Short Acting) codeine)ql (Apadaz) butalbital/acetaminophen/codeine/caffeineql butalbital/aspirin/codeine/caffeineql codeine tablets butorphanol nasal spray hydrocodone/acetaminophen tablets (Lorcet, carisoprodol/codeine/aspirin Norco, Vicodin)ql dihydrocodeine/acetaminophen/caffeine hydromorphone tablets (Dilaudid) fentanyl buccal (Actiq)cc,ql morphine sulfate tablets, solution hydrocodone/acetaminophen solution oxycodone capsules, tablets, solution (Lortab)ql oxycodone/acetaminophen (Percocet)ql hydrocodone/ibuprofen (Vicoprofen) tramadol 50mg (Ultram)ql hydromorphone solution, suppositories tramadol/acetaminophen (Ultracet)ql levorphanol meperidine (Demerol) morphine suppositories oxycodone syringe oxycodone/acetaminophen (Prolate)ql oxycodone concentrated solution oxycodone/aspirin (Percodan) oxymorphone (Opana) pentazocine/naloxone (Talwin NX) tramadol 100mg (Ultram)ql Abstralcc,ql Fentoracc,ql Nucynta Oxaydo Anti-Migraine Agents, Ajovy (Step Therapy)cc,ql Aimovig (Step Therapy)cc,ql Other Emgality 120mg/mL (Step Therapy)cc,ql Emgality 100mg/mL (Step Therapy)cc,ql *Appears in 2 places within Nurtec ODTcc,ql PDL document. Reyvowcc,ql Ubrelvycc,ql Vyepticc,ql cc-Clinical criteria can be found at the link here ql- Quantity limits can be found at the link here All lowercase letters = generic product. Leading capital letter = brand name product. Page 2 of 30 ANALGESICS Drug Class Preferred Requires Prior Authorization Anti-Migraine Agents, rizatriptan, rizatriptan ODT (Maxalt, Maxalt almotriptan (Axert)ql Triptans MLT)ql eletriptan (Relpax)ql sumatriptan nasal, syringe, tablets, vial frovatriptan (Frova)ql (Imitrex)ql naratriptan (Amerge)ql sumatriptan kit (Imitrex)ql sumatriptan/naproxen (Treximet)ql zolmitriptan, zolmitriptan ODT (Zomig, Zomig ZMT)ql Onzetra Xsail Tosymra Zembrace Symtouch Zomig nasalql Neuropathic Pain capsaicin OTC duloxetine 40mg (Irenka)ql duloxetine (Cymbalta)cc,ql gabapentin solution (Neurontin) gabapentin capsules, tablets (Neurontin) pregabalin XR (Lyrica CR) lidocaine patch (Lidoderm)ql pregabalin solution pregabalin capsulesql Drizalma Sprinklecc Gralise Horizant Qutenza Kit Savella ZTlido cc-Clinical criteria can be found at the link here ql- Quantity limits can be found at the link here All lowercase letters = generic product. Leading capital letter = brand name product. Page 3 of 30 ANALGESICS Drug Class Preferred Requires Prior Authorization Nonsteroidal Anti- diclofenac (Cataflam) celecoxib (Celebrex) cc,ql Inflammatories (NSAIDS) diclofenac gel (Voltaren Gel) diclofenac epolamine patch (Flector) ibuprofen Rx, OTC (Motrin) diclofenac potassium (Zipsor) indomethacin (Indocin) diclofenac topical solution (Pennsaid) meloxicam tablets (Mobic) diclofenac/capsicum oleoresin kit nabumetone (Relafen) diclofenac/misoprostol (Arthrotec) naproxen Rx, OTC (Aleve, Naprosyn) diclofenac SR (Voltaren XL) sulindac (Clinoril) diflunisal (Dolobid) etodolac, etodolac XL (Lodine, Lodine XL) fenoprofen flurbiprofen (Ansaid) ibuprofen chewable tabs OTC indomethacin ER (Indocin SR) ketoprofen, ketoprofen ER (Orudis, Oruvail) ketorolac (Toradol) ketorolac nasal spray (Sprix) meclofenamate (Meclomen) mefenamic acid (Ponstel) meloxicam (Vivlodex) meloxicam suspension naproxen/esomeprazole (Vimovo) naproxen EC naproxen sodium RX naproxen CR, Suspension oxaprozin (Daypro) piroxicam (Feldene) tolmetin, tolmetin DS (Tolectin, Tolectin DS) Duexis Ibupak Kit Indocin suppositories, suspension Licart Patchcc,ql Pennsaid Pump Qmiiz ODTcc,ql Relafen DS Tivorbex Venngel One Kit Zorvolex cc-Clinical criteria can be found at the link here ql- Quantity limits can be found at the link here All lowercase letters = generic product. Leading capital letter = brand name product. Page 4 of 30 ANALGESICS Drug Class Preferred Requires Prior Authorization Opioid Use Disorder buprenorphine (Subutex)cc,ql buprenorphine/naloxone film (Suboxone) Treatments naloxone (Narcan) (generic only)ql naltrexone (Revia)cc buprenorphine/naloxone tablets Bunavailql (Suboxone)ql Narcan nasal spray Lucemyraql Sublocadecc,ql Suboxone film (Brand only)ql Vivitrolcc Zubsolvql Skeletal Muscle Relaxants baclofen (Lioresal) carisoprodol (Soma) chlorzoxazone (Parafon) carisoprodol compound (Soma Compound) cyclobenzaprine (Flexeril)ql cyclobenzaprine ER (Amrix)ql methocarbamol (Robaxin) dantrolene (Dantrium) orphenadrine ER (Norflex) metaxalone (Skelaxin) tizanidine tablets (Zanaflex) tizanidine capsules (Zanaflex) Lorzone Norgesic Forte ANTI-INFECTIVES Drug Class Preferred Requires Prior Authorization Antibiotics, GI metronidazole tablets (Flagyl) metronidazole capsules (Flagyl capsules) neomycin nitazoxanide tablets (Alinia) tinidazole (Tindamax) paromomycin vancomycin capsules (Vancocin) vancomycin solution Firvanq Dificidcc,ql Solosec Xifaxancc,ql Antibiotics, Inhaled Bethkis (Brand only)cc,ql tobramycin inhalation solution (Tobi)cc,ql Kitabis Pak (Brand only)cc ql tobramycin pak (Kitabis) (generic only)cc,ql Tobi Podhaler cc,ql tobramycin solution (Bethkis) (generic only)cc,ql Arikaycecc,ql Caystoncc,ql Antibiotics, Topical bacitracin OTC mupirocin cream (Bactroban Cream) gentamicin Centany mupirocin ointment (Bactroban Ointment) neomycin/polymyxin/pramoxine OTC triple antibiotic OTC cc-Clinical criteria can be found at the link here ql- Quantity limits can be found at the link here All lowercase letters = generic product. Leading capital letter = brand name product. Page 5 of 30 ANTI-INFECTIVES Drug Class Preferred Requires Prior Authorization Antibiotics, Vaginal clindamycin (Cleocin) Vandazole metronidazole vaginal (Metrogel) Cleocin ovules Clindesse Nuvessa Antifungals, Oral clotrimazole troches (Mycelex) flucytosine (Ancobon) fluconazole (Diflucan) griseofulvin tablets (Gris Peg, GriFulvin V) griseofulvin suspension (GriFulvin V) itraconazole (Sporanox) ketoconazole (Nizoral) posaconazole (Noxafil) nystatin suspension, tablets voriconazole (Vfend) terbinafine (Lamisil) Cresemba Oravig Tolsura Antifungals, Topical clotrimazole cream Rx, OTC ciclopirox (Loprox, Loprox Kit, Loprox clotrimazole solution OTC Shampoo, Penlac) clotrimazole/betamethasone cream clotrimazole solution Rx (Lotrisone) clotrimazole/betamethasone lotion ketoconazole cream, shampoo (Nizoral) (Lotrisone) miconazole cream OTC econazole (Spectazole) nystatin ketoconazole foam (Ketodan) nystatin/triamcinolone (Mycolog) luliconazole (Luzu)cc,ql terbinafine OTC miconazole ointment, powder, spray OTC tolnaftate OTC miconazole nitrate/zinc oxide/petrolatum (Vusion) naftifine (Naftin) oxiconazole cream (Oxistat) Alevazol OTC Bensal HP Desenex spray powder Ertaczo Exelderm Fungoid OTC Jublia Kerydin Lamisil OTC Lotrimin AF, Ultra OTC Mentax Oxistat lotion Trilociclo Kit cc-Clinical criteria can be found at the link here ql- Quantity limits can be found at the link here All lowercase letters = generic product. Leading capital letter = brand name product. Page 6 of 30 ANTI-INFECTIVES Drug Class Preferred Requires Prior Authorization Antiparasitics, Topical permethrin Rx, OTC (Elimite, Acticin) ivermectin (Sklice)cc,ql piperonyl/pyrethrins OTC lindane shampoocc malathion (Ovide)cc,ql spinosad (Natroba)cc,ql Eurax Antivirals, Oral acyclovir (Zovirax) famciclovir (Famvir) oseltamivir (Tamiflu)ql rimantadine (Flumadine) valacyclovir (Valtrex) Relenza Sitavig Xofluza Antivirals, Topical acyclovir cream (Zovirax) acyclovir ointment (Zovirax ointment) docosanol 10% cream (Abreva OTC) Denavir Xerese Cephalosporins and amoxicillin/clavulanate tablets, suspension amoxicillin/clavulanate chewable tablets Related Antibiotics (Augmentin, Augmentin ES) (Augmentin) cefaclor capsules (Ceclor) amoxicillin/clavulanate ER (Augmentin XR) cefadroxil capsules (Duricef) cefaclor suspension, ER tablets (Ceclor, cefdinir (Omnicef) Ceclor CD) cefprozil (Cefzil) cefadroxil suspension, tablets (Duricef) cefuroxime tablets
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