PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL) 1 Effective August 8, 2011 v20110805 Therapeutic Drug Class Brand Names Generics OTC Preferred Status Non- Preferred Status Qty Limits Apply Clinical Prior Auth Required Age Limits Demeclocycline X Doxycycline Hyclate X Doxycycline Hyclate DR X Doxycycline Monohydrate X Minocycline HCl X Minocycline ER X Minocycline Tablets X Tetracycline X Adoxa, Adoxa Pak X Doryx, Doryx DR X Dynacin X Morgidox X Oracea X Solodyn ER X Vibramycin Suspension, Syrup X Adapalene X Benzoyl Peroxide OTC X X Benzoyl Peroxide Rx X Clindamycin X Clindamycin-Benzoyl Peroxide X Erythromycin Gel, Solution X Erythromycin-Benzoyl Peroxide Gel X Salicylic Acid Gel, Lotion X X Sulfacetamide Sodium X Sulfacetamide Sodium/Sulfur X Tretinoin X X Acanya X Aczone X Akne-mycin X Atralin X Azelex X X Benzac AC, Benzac W X Benzaclin X Benzamycin X Benzefoam X Benziq X BP X Brevoxyl X Clarifoam EF X Cleocin T X Clinac BPO X Clindacin Pac X Clindagel X Delos X Desquam-X X Differin X X Epiduo X X Evoclin X Inova X Klaron X Lavoclen X Neobenz Micro X Nuox X Pacnex X Panoxyl X X Plexion X Prascion X Acne Agents, Oral (Tetracyclines) Acne Agents, Topical
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PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
1Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Demeclocycline XDoxycycline Hyclate XDoxycycline Hyclate DR XDoxycycline Monohydrate XMinocycline HCl XMinocycline ER XMinocycline Tablets XTetracycline X
Adoxa, Adoxa Pak XDoryx, Doryx DR XDynacin XMorgidox XOracea XSolodyn ER XVibramycin Suspension, Syrup X
Adapalene XBenzoyl Peroxide OTC X XBenzoyl Peroxide Rx XClindamycin XClindamycin-Benzoyl Peroxide XErythromycin Gel, Solution XErythromycin-Benzoyl Peroxide Gel X
Salicylic Acid Gel, Lotion X XSulfacetamide Sodium XSulfacetamide Sodium/Sulfur XTretinoin X X
Acanya XAczone XAkne-mycin XAtralin XAzelex X XBenzac AC, Benzac W XBenzaclin XBenzamycin XBenzefoam XBenziq XBP XBrevoxyl XClarifoam EF XCleocin T XClinac BPO XClindacin Pac XClindagel XDelos XDesquam-X XDifferin X XEpiduo X XEvoclin XInova XKlaron XLavoclen XNeobenz Micro XNuox XPacnex XPanoxyl X XPlexion XPrascion X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
2Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Retin-A X XRetin-A-Micro X XRosanil XSastid X XSulfoam X XSulpho-Lac X XSumadan XSumaxin XTazorac X XTriaz XVeltin XZencia XZiana X X
Donepezil X XGalantamine X XGalantamine ER X XRievastigmine X X
Aricept X XExelon Transdermal X X XExelon Capsules X XRazadyne X XRazadyne ER XExelon Solution X XNamenda X X
Capsaicin OTC X XFlector X XLidoderm X XLMX-4 X XPennsaid X XQutenza X XVoltaren X X
Fentanyl transdermal X XMethadone X XMorphine ER X XOxymorphone ER X XTramadol ER X X
Avinza X XButrans X XDolophine X XDuragesic X XExalgo X XKadian X XMethadose Oral Concentrate X XMS Contin X XOpana ER X XOramorph SR X XOxycontin X XRyzolt X XUltram ER X X
APAP/Codeine X XButalbital/Caffeine/APAP/Codeine X XButalbital/Caffeine/ASA/Codeine X XButorphanol nasal spray X X XCodeine X XDihydrocodeine/APAP/ Caffeine X XFentanyl (buccal) X XHydrocodone/APAP X XHydrocodone/Ibuprofen X XHydromorphone X X X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
3Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Levorphanol X XMeperidine X XMorphine X XOxycodone X XOxycodone/APAP X XOxycodone/ASA X XOxycodone/Ibuprofen X XPentazocine/APAP X XPentazocine/Naloxone X XTramadol X XTramadol/APAP X XTrezix X X
Abstral X XActiq X XCapital w/Codeine X XCocet Plus X XDemerol X XDilaudid X XEndocet X XEndodan X XFentora X XFioricet/Codeine X XFiorinal/Codeine X XHycet X XIbudone X XLorcet Plus X XMagnacet X XMaxidone X XNorco X XNucynta X XOnsolis X XOpana X XPercocet X XPercodan X XPrimlev X XReprexain X XRoxanol X XRoxicet X XRoxicodone X XRybix ODT X XSynalgos-DC X XTrezix X XTylenol with Codeine X XTylox X XUltracet X XUltram X XVicodin X XUltracet X XUltram X XVicoprofen X XXodol X XXolox X XZamicet X XZolvit X XZydone X XAndroderm XAndrogel XAxiron XFortesta X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
4Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Testim XBenazepril, Benazepril HCTZ XCaptopril, Captopril HCTZ XEnalapril, Enalapril HCTZ X XFosinopril, Fosinopril HCTZ XLisinopril, Lisinopril HCTZ X XLosartan, Losartan HCTZ X XMoexipril, Moexepril HCTZ X XPerindopril X XQuinapril, Quinapril HCTZ XRamipril X XTrandolapril X
Accupril, Accuretic XAceon XAltace X XAtacand, Atacand HCT X XAvapro, Avalide X XBenicar, Benicar HCT X XCozaar, Hyzaar X XDiovan, Diovan HCT X XEdarbi X XLotensin, Lotensin HCT XMavik XMicardis, Micardis HCT X XPrinivil, Prinzide X XTekturna, Tekturna HCT X XTeveten, Teveten HCT X XUnivasc, Uniretic X XVasotec, Vaseretic X XZestril, Zestoretic X X
Amlodipine/Benazepril X XTrandolapril/Verapamil X X
Amturnide X XAzor X XExforge, Exforge HCT X XLotrel X XTarka X XTekamlo X XTribenzor X XTwynsta X XValturna X X
Metronidazole XNeomycin XTinidazole X
Alinia XFlagyl XFlagyl ER X XMycifradin XTindamax XVancocin XXifaxan XCayston XTobi X
Bacitracin Ointment X XBacitracin/Polymyxin Ointment X XGentamicin Cream, Ointment XMupirocin Ointment XNeomycin/Polymyxin/Pramoxine Cream X X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
5Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Triple Antibiotic Ointment X XTriple Antibiotic Plus Ointment X X
Altabax Ointment XBactroban Cream XBactroban Ointment XCentany Ointment X
Clindamycin XMetronidazole X
Cleocin Cream XCleocin Ovules XClindesse XMetrogel-Vaginal XVandazole X
Enoxaparin XFondaparinux XWarfarin X
Arixtra XCoumadin XFragmin XInnohep XLovenox XPradaxa X X XXarelto X
Carbamazepine X XClonazepam X XDivalproex XDivalproex ER X XDivalproex Sprinkle XEthosuximide X XGabapentin X XLamotrigine XLevetiracetam X XMephobarbital XOxcarbazepine X XPhenobarbital XPhenytoin X XPrimidone X XTopiramate X XTopiramate Sprinkles X XValproic Acid X XZonisamide X X
Banzel X XCarbatrol X XCelontin X XDepakene XDepakote XDepakote ER X XDepakote Sprinkle XDiastat (rectal) XDilantin 30 mg capsules X XDilantin 100 mg capsules X XDilantin Infatabs X XDilantin suspension X XEpitol X XEquetro X XFelbatol XGabitril XKeppra Solution, Tablets X XKeppra XR X X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
6Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Klonopin X XLamictal XLamictal ODT XLamictal XR XLuminal XLyrica X X XMebaral XMysoline X XNeurontin X XPeganone XPhenytek X XSabril X XStavzor X XTegretol X XTegretol XR X XTopamax X XTrileptal X XVimpat X XZonegran X X
Bupropion XBupropion SR X XBupropion XL X XMirtazapine XNefazodone XTranylcypromine Sulfate XTrazodone XVenlafaxine X XVenlafaxine ER Capsules X XVenlafaxine ER Tablets (Generic) X X
Aplenzin XCymbalta X X XEffexor XR X XEmsam Transdermal X XMarplan XNardil XParnate XPristiq X XVenlafaxine ER Tablets X X
Citalopram X XFluoxetine X XFluoxetine Weekly X XFluvoxamine X XParoxetine X XParoxetine CR X XSertraline X X
Lexapro X XLuvox CR X XPexeva X X
Dimenhydrinate injection XDimenhydrinate tablets X XDronabinol X XGranisetron injection XGranisetron solution, tablets X XMeclizine OTC X XMeclizine Rx XMetoclopramide XOndansetron XProchlorperazine XPromethazine suppositories X X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
7Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Trimethobenzamide XAloxi XAntivert XAnzemet injection XAnzemet tablets X XCesamet X XEmend capsules X XEmend injection XKytril XMarinol X XMetozolv ODT XReglan XSancuso X XScopace XTigan XTransderm-Scop XZofran XZuplenz X
Clotrimazole troche XFluconazole XGriseofulvin XItraconazole XKetoconazole XNystatin XTerbinafine XVoriconazole X
Ancobon XDiflucan XGrifulvin V XGris-Peg XLamisil XNoxafil XOravig XSporanox XTerbinex XVfend X
Ciclopirox XClotrimazole OTC X XClotrimazole RX XClotrimazole-Betamethasone XEconazole XKetoconazole cream XKetoconazole Shampoo XMiconazole X XNystatin XNystatin-Triamcinolone XTerbinafine X XTolnaftate X X
Bensal HP XCiclodan XCNL 8 XDesenex XErtaczo XExelderm XExtina XFungoid XKetocon XLamisil AF, AT XLamisil solution X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
8Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Loprox XLotrimin AF X XLotrisone XMentax XNaftin XNizoral XOxistat XPediaderm AF XPenlac XTinactin X XVusion XXolegel X
Cetirizine OTC X X XCetirizine Rx XCetirizine-D X X X XFexofenadine OTC X X XFexofenadine Rx X XFexofenadine-D XLevocetirizine XLoratadine X X XLoratadine-D X X X X
Allegra X XAllegra-D X X XClarinex X XClarinex-D X X XClaritin X X XClaritin-D X X X XSemprex D X X XXyzal X X
Allopurinol XColchicine XProbenecid XProbenecid-Colchicine X
Colcrys XKrystexxa XUloric X
Sumatriptan nasal, injection X XNaratriptan X XSumatriptan tablets X X
Amerge X XAxert X XCambia XFrova X XImitrex injection, nasal X XImitrex tablets X XMaxalt, Maxalt MLT X XRelpax X XSumavel X XTreximet X XZomig, Zomig ZMT X X
Malathion XPermethrin XPermethrin OTC X XPiperonyl Butoxide/Pyrethrins X X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
10Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Thiothixene X XTrifluoperazine X X
Abilify X X XFanapt X X XFazaclo X X XGeodon (Intramusc) X XGeodon X X XInvega X X XInvega Sustenna (Intramusc) X XOrap X XRisperdal Consta (Intramusc) X XSaphris X X XSeroquel X X XSeroquel XR X X XSymbyax X X XZyprexa (Intramusc) X XZyprexa X X XZyprexa Relprevv (Intramusc) X X
Acyclovir XAmantadine XFamciclovir XRimantadine XValacyclovir X
Famvir XRelenza XTamiflu XValtrex XZovirax XAbreva X XDenavir XXerese XZovirax Cream XZovirax Ointment XElidel XProtopic X
Acebutolol XAtenolol, Atenolol/Chlorthalidone XBetaxolol XBisoprolol, Bisoprolol/HCTZ XCarvedilol X XLabetalol XMetoprolol, Metoprolol/HCTZ XNadolol, Nadolol/Bendroflumethiazide X
Pindolol XPropranolol, Propranolol HCTZ XSotalol XTimolol X
Betapace XBystolic XCoreg X XCoreg CR X XCorgard, Corzide XInderal, Inderal LA XInnopran XL XKerlone XLevatol XLopressor, Lopressor HCT XSectral X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
11Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Tenormin, Tenoretic XToprol XL XTrandate XZebeta X
Ursodiol X XActigall X XChenodal X XUrso X XUrso Forte X X
Oxybutynin X XOxybutynin ER X XTrospium X
Detrol X XDetrol LA X XDitropan XL X XEnablex X XGelnique XOxytrol X XSanctura, Sanctura XR X XToviaz XVesicare X X
Alendronate Tablets X XCalcitonin nasal X XEtidronate XPamidronate injection X
Actonel X XActionel w/ Calcium X XAtelvia X XBoniva tablets X XBoniva injection X XDidronel XEvista X XForteo X XFortical X XFosamax Plus D X XFosamax X XMiacalcin injection X XMiacalcin nasal X XProlia XReclast XXgeva XZometa X
Doxazosin X XAlfuzosin X XFinasteride X XTamsulosin X XTerazosin X X
Avodart X XCardura, Cardura XL X XFlomax X XHytrin X XJalyn X XProscar X XRapaflo X XUroxatral X X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
12Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Spiriva XAlbuterol (Oral) XAlbuterol Nebulizer XAlbuterol Nebulizer Low-Dose XLevalbuterol X XMetaproterenol (Oral) XTerbutaline (Oral) X
Brovana X XForadil X XMaxair XPerforomist X XProair HFA XProventil HFA XSerevent X XVentolin HFA XXopenex XXopenex HFA X X
Amlodipine X XDiltiazem, Diltiazem ER X XDiltiazem LA X XFelodipine ER X XIsradipine X XNicardipine X XNifedipine, Nifedipine ER X XNimodipine XNisoldipine X XVerapamil, Verapamil ER X XVerapamil ER PM X X
Adalat CC X XCalan, Calan SR X XCardene SR X XCardizem, Cardizem CD, Cardizem LA X X
Covera-HS X XDynacirc CR X XNimotop XNorvasc X XProcardia XProcardia XL X XSular X XTiazac X XVerelan X XVerelan PM X X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
15Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Therasense X XTruetrack XUS Diagnostics XVertex XAbbott XAgamatrix XArkray XBayer XBecton Dickinson XCCS Medical XDiabetic Supply XDispense Express XHome Diagnostics XLifescan XMedisense XRoche XSolartek XUS Diagnostics XTherasense XAranesp X XEpogen X Procrit X XCymbalta X XLyrica X XSavella X
Ciprofloxacin ER XCiprofloxacin XLevofloxacin XOfloxacin X
Budesonide Respules X XAdvair / Advair HFA X XAerobid / Aerobid-M XAlvesco X XAsmanex X XFlovent / Flovent HFA XPulmicort Flexhaler XPulmicort Respules X XQvar XSymbicort X XGenotropin XHumatrope XNorditropin XNutropin XNutropin AQ X XOmnitrope XSaizen X XSerostim X XTev-tropin XZorbtive XAdvate XHelixate-FS XKogenate FS X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
17Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Viread XZerit XZiagan XByetta Pens (Subcutaneous) X X XJanumet X X XJanuvia X X XKombiglyze XR XOnglyza X X XSymlin (Subcutaneous) X X XTradjenta X X XVictoza (Subcutaneous) X X XApidra XApidra Pens XHumalog vials XHumalog Mix vials XHumalog Mix Pens XHumalog Pens XHumulin vials XHumulin Pens XLantus XLantus Pens XLevemir XLevemir Pens XNovolin vials XNovolin pens XNovolog XNovolog Mix 70/30 XNovolog Mix 70/30 Pens XNovolog Pens XNateglinide X XPrandimet X XPrandin X XStarlix X XActoplus Met X XActoplus Met XR X XActos X XAvandamet X XAvandia X XAvandryl X XDuetact X X
Azathrioprine XCyclosporine XCyclosporine, Modified XMycophenolate Mofetil XTacrolimus X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
18Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Astelin XAstepro XNasacort AQ XNasonex XOmnaris XPatanase XRhinocort Aqua XVeremyst XAccolate X XSingulair X XZyflo CR X X
Cholestyramine XColestipol XFenofibrate X XFenofibric Acid X XGemfibrozil XNiacin X X
Antara X XColestid XFenoglide X XFibricor XLofibra X XLipofen X XLopid XLovaza X XNiacor XNiaspan XQuestran XTricor X XTriglide X XTrilipix XWelchol XZetia X X
Lovastatin X XPravastatin X XSimvastatin X X
Advicor X XAltoprev X XCaduet X XCrestor X XLescol, Lescol XL X XLipitor X XLivalo X XMevacor X XPravachol X XSimcor X XVytorin X XZocor X X
Azithromycin XClarithromycin XClarithromycin ER XErythromycin X
Biaxin, Biaxin XL XPCE XKetek XZithromax, Zmax XAvonex XAmpyra X X XBetaseron X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
19Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Copaxone X XGilenya X X XExtavia XRebif X
Diclofenac X XEtodolac X XFenoprofen X XFlurbiprofen X XIbuprofen OTC X X XIbuprofen RX X XIndomethacin (Oral/Rectal) X XKetoprofen X XKetorolac X X XMeclofenamate X XMefenamic Acid X XMeloxicam X XNabumetone X XNaproxen X XNaproxen OTC X X XOxaprozin X XPiroxicam X XSulindac X X
Arthrotec X XCelebrex X XIndocin (Rectal) X XIndocin Suspension X XTolmetin X XVimovo X XZipsor X X
Azelastine XCromolyn Sodium XKetorolac XKetotifen OTC X X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
21Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Cortisporin, Cortisporin-TC XPediotic XAdcirca X XLetairis X XRevatio X X XTracleer X XTyvaso XVentavis X
Pancrelipase XCreon XPancreaze XZenpep X
Calcium acetate XEliphos XFosrenol XPhosLo XRenagel XRenvela X
Dipyridamole X XTiclopidine X X
Aggrenox X XEffient X X XPersantine X XPlavix X X
Advanced Care Plus XCavan One Omega XCavan-Alpha Kit XCavan-EC Sod DHA XCavan-Heme Omega XCombi RX XCo-Natal FA XDaily Prenatal Combo XDocosavit XDualvit OB XEdge OB XElite-OB 400 XFE C XFolbecal XFolinatal Plus B XFolivane-EC Calcium DHA NF XFolivane-OB XFolivane-PRX DHA NF XFoltabs XFoltabs Prenatal Plus DHA XIcar-C Plus XInatal Advance XInatal Ultra XMaternity XMultinatal Plus XNeevo XNeevo DHA XNutrispire XOB + DHA XOB-Natal One XPNV-DHA XPNV-DHA + Docusate XPNV-Select XPNV-Total XPR Natal 430 X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
22Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
PR Natal 430 EC XPR Natal 440 EC XPrenaplus XPrenatabs RX XPrenatal XPrenatal 19 XPrenatal AD XPrenatal Low Iron XPrenatal MR 90 FE XPrenatal Multivitamin w/ Iron XPrenatal Plus XPrenatal Plus Iron XPrenatal S OTC X XPrenatal Vitamins OTC X XPrenate Plus XPrenexa XPrevite RX XPruet DHA XPruet DHA EC XRE-Nata 29 XRE-Nata 29 OB XSE-Care XSE-Care Conceive XSE-Care Gesture XSelect-OB XSE-Natal 19 XSE-Natal 90 XSE-Natal One XSE-Plete DHA XSE-Tan DHA XSetonet XSetonet-EC XTaron-C DHA XTaron-EC Cal XTri RX XTriadvance XTricare XTrimesis RX XTriveen-PRX RNF XUltimatecare One XUltimatecare One NF XVemavite-PRX 2 XVenatal-FA XVinacal XVinate C XVinate Care XVinate IC XVinate One XVinate PN Care XVinate Ultra XVinate-M XVitanatal OB + DHA XVitaphil XVitaphil + DHA XVitaspire XVol-Nate XVol-Plus XVol-Tab Rx XZatean-CH X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
23Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Zatean-PN XZatean-PN DHA XZatean-PN Plus X
Citranatal 90 DHA XCitranatal Assure XCitranatal B-Calm XCitranatal DHA XCitranatal Harmony XCitranatal RX XComplete Natal DHA XCompletenate XComplete-RF Prenatal XConcept DHA XConcept OB XCorenate-DHA XDuet DHA XDuet DHA Balanced XDuet DHA Complete XDuet DHA EC XDuet DHA with Ferrazone XDuet Stuartnatal XED Cyte F XElite OB DHA XElite-OB XFemecal OB XFolcal DHA XFolcaps Care One XFolcaps Omega-3 XGesticare XGesticare DHA XIcar-C Plus SR XInatal GT XInfanate DHA XLactocal-F XMarnatal-F XMaxinate XMission Prenatal FA OTC X XMission Prenatal HP OTC X XMission Prenatal OTC X XMulti-Nate 30 DHA XMulti-Nate DHA Extra XM-Vit XNatachew XNatafort XNatalvit XNatelle One XNatelle-EZ XNavatab + DHA XNexa Select XOB 90 + DHA XOB Complete XOB Complete 400 XOB Complete Chewable XOB Complete DHA XOB Complete One XOB Complete Premier XO-Cal FA XO-Cal Prenatal XPaire OB Plus DHA X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
24Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
PNV-DHA Plus XPNV-Iron XPNV-Omega XPoly Iron PN XPoly Iron PN Forte XPR Natal 400 XPR Natal 400 EC XPrefera OB XPrefera-OB One XPrefera-OB Plus DHA XPrenafirst XPrenatabs FA XPrenatal-U XPrenate DHA XPrenate Elite XPrenate Essential XPrenavite OTC X XPrenexa Premier XPreque 10 XRenate DHA XRovin-NV XRovin-NV DHA XSelect-OB + DHA XTandem OB XTaron EC Calcium XTaron-BC XTaron-Duo EC XTaron-Prex Prenatal XTricare DHA XTrinatal RX 1 XTrinate XTriveen-Duo DHA XTriveen-One XTriveen-Ten XTriveen-U XTrust Natal DHA XUltimatecare Advantage XUltimatecare Combo XVinate AZ XVinate AZ Extra XVinate Calcium XVinate GT XVinate II XVitafol-OB XVitafol-OB+DHA XVitafol-PN XViva DHA X
Lansoprazole X XOmeprazole OTC X X XOmeprazole Rx X XOmeprazole-Sodium Bicarbonate X XPantoprazole X X
Aciphex X XDexilant X XNexium X XNexium Suspension X XPrevacid X XPrilosec Capsules X XPrilosec OTC X X X
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE MEDICAL ASSISTANCE PREFERRED DRUG LIST (PDL)
25Effective August 8, 2011
v20110805
Therapeutic Drug Class Brand Names Generics OTC Preferred Status
Non-Preferred
Status
Qty Limits Apply
Clinical Prior Auth Required
Age Limits
Prilosec Suspension X XZegerid OTC X X XProtonix X XProtonix Suspension X X
Chloral Hydrate X XEstazolam X X XFlurazepam X X XTemazepam 15mg/30mg X X XTemazepam 7.5mg/22.5mg X X XTriazolam X X XZaleplon X XZolpidem X X
Ambien, Ambien CR X XDalmane X X XDoral X X XEdluar X XHalcion X X XLunesta X XProsom X X XRestoril 7.5mg X X XRozerem X XSonata X X
Baclofen X XCarisoprodol, Carisoprodol/ASA X XChlorzoxazone X XCyclobenzaprine X XCyclobenzaprine ER X XDantrolene Sodium X XMetaxalone X XMethocarbamol X XOrphenadrine, Orphenadrine Compound X X
Tizanidine X XAmrix X XDantrium X XFexmid X XParafon Forte DSC X XRobaxin X XSkelaxin X XSoma, XZanaflex X X
Alclometasone Dipropionate XDesonide XHydrocortisone XHydrocortisone OTC X X
Capex XDerma-Smoothe-FS XDesonate XPediaderm HC XVerdeso X
Clobetasol XClobetasol Emollient XClobetasol Propionate XHalobetasol Propionate X
Clobex XHalonate XHalonate PAC XOlux-E XOlux-Olux-E X
Amphetamine Salt Combo X X XAmphetamine Salt Combo ER X X XDexmethylphenidate X X XDextroamphetamine X X XMethamphetamine X X XMethylphenidate X X XMethylphenidate ER X X X
Adderall XR X X XConcerta X X XDaytrana X X XDesoxyn X X XFocalin X X XFocalin XR X X XIntuniv X X XMetadate CD X X XMethylin Chewable and Solution X X X
Nuvigil X X XProcentra X XRitalin LA X X XStrattera X X XVyvanse X X X
Tetracyclines - see Acne Agents, OralBalsalazide XMesalamine (rectal) XSulfasalazine X
Apriso XAsacol XAsacol HD XAzulfidine XCanasa XColazal XDipentum XLialda X