Maryland Medicaid Preferred Drug List

PDL Effective July 1, 2016

Note: For most multi-source products, the generic product(s) are usually preferred and branded innovator product(s) are non-preferred. PDL products that are new to the market require prior authorization until they are reviewed. Key

Drugs listed in lower case letters -- generically available. The brand name is listed in parentheses for informational purposes only.

Drugs listed with a leading capital letter -- brand name drugs on the PDL.

Unless otherwise specified all dosage forms are covered.

ANALGESICS

Analgesics, Narcotics (Long-Acting)

fentanyl patches (Duragesic) (All strengths except 37.5 mg, 62.5 mg, and 87.5 mg)

morphine sulfate SR (MS Contin) Kadian (Brand only)

Embeda

ANALGESICS

Analgesics, Narcotics (Short-Acting)

acetaminophen w/codeine (Tylenol w/Codeine)

butalbital/apap/codeine/caffeine

butalbital/aspirin/codeine/caffeine

codeine tablets

hydrocodone/apap tablets (Vicodin)

hydrocodone/ibuprofen (Vicoprofen)

hydromorphone tablets (Dilaudid)

morphine sulfate tablets, solution

oxycodone capsules, tablets, solution

oxycodone/apap (Percocet)

tramadol (Ultram)

tramadol/acetaminophen (Ultracet)

ANALGESICS

Anti-Migraine Agents

rizatriptan, rizatriptan ODT (Maxalt, Maxalt MLT)

sumatriptan (Imitrex)

Relpax

ANALGESICS

Neuropathic Pain

capsaicin OTC

duloxetine (Cymbalta)

gabapentin capsules (Neurontin)

lidocaine patch

Lyrica capsules

ANALGESICS

Nonsteroidal Anti-Inflammatories (NSAIDs)

diclofenac, diclofenac XL (Cataflam, Voltaren XR)

diflunisal (Dolobid)

etodolac, etodolac XL (Lodine, Lodine XL)

fenoprofen

flurbiprofen (Ansaid)

ibuprofen Rx and OTC (Motrin)

indomethacin, indomethacin SR (Indocin, Indocin SR)

ketoprofen, ketoprofen ER (Orudis, Oruvail)

ketorolac (Toradol)

meclofenamate (Meclomen)

meloxicam (Mobic)

nabumetone (Relafen)

naproxen Rx and OTC (Aleve, Naprosyn)

oxaprozin (Daypro)

piroxicam (Feldene)

sulindac (Clinoril)

Voltaren gel

ANALGESICS

Opiate Dependence Treatments

buprenorphine (Subutex)

naloxone (Narcan)

naltrexone (Revia)

Narcan nasal spray

Zubsolv

ANALGESICS

Skeletal Muscle Relaxants

baclofen (Lioresal)

chlorzoxazone (Parafon)

cyclobenzaprine (Flexeril)

dantrolene (Dantrium)

methocarbamol (Robaxin)

orphenadrine (Norflex)

tizanidine tablets (Zanaflex)

ANTI-INFECTIVES

Antibiotics, GI

metronidazole tablets (Flagyl)

neomycin

vancomycin capsules (Vancocin)

Alinia

ANTI-INFECTIVES

Antibiotics, Inhaled

Bethkis Kitabis Pak (Brand only)

Tobi Podhaler (StepTherapy)

ANTI-INFECTIVES

Antibiotics, Topical

bacitracin OTC

bacitracin/polymyxin OTC

gentamicin

mupirocin ointment (Bactroban ointment)

triple antibiotic OTC

ANTI-INFECTIVES

Antibiotics, Vaginal

clindamycin (Cleocin, Clindesse)

metronidazole vaginal (MetroGel)

Cleocin ovule

ANTI-INFECTIVES

Antifungals, Oral

clotrimazole troches (Mycelex)

fluconazole (Diflucan)

griseofulvin suspension (GriFulvin V)

ketoconazole (Nizoral)

nystatin suspension and tablets

terbinafine (Lamisil)

ANTI-INFECTIVES

Antifungals, Topical

clotrimazole Rx and OTC

clotrimazole/betamethasone (Lotrisone)

ketoconazole cream and shampoo (Nizoral)

miconazole OTC

nystatin

nystatin/triamcinolone (Mycolog)

terbinafine OTC

tolnaftate OTC

ANTI-INFECTIVES

Antiparasitics, Topical

permethrin Rx and OTC (Elimite, Acticin)

piperonyl/pyrethrins OTC

piperonyl/pyrethrins/permethrin OTC

Ulesfia

ANTI-INFECTIVES

Antivirals, Oral

acyclovir (Zovirax)

rimantadine (Flumadine)

valacyclovir (Valtrex)

ANTI-INFECTIVES

Antivirals, Topical

Abreva OTC

Denavir

Zovirax cream

ANTI-INFECTIVES

Cephalosporin and Related Agents

amoxicillin/clavulanate (Augmentin, Augmentin ES)

cefaclor, cefaclor ER (Ceclor, Ceclor CD)

cefadroxil capsules (Duricef)

cefdinir (Omnicef)

cefixime suspension (Suprax)

cefprozil (Cefzil)

cefuroxime tablets (Ceftin)

cephalexin (Keflex)

Suprax capsules

ANTI-INFECTIVES

Fluoroquinolones

ciprofloxacin tablets (Cipro)

levofloxacin tablets (Levaquin)

ANTI-INFECTIVES

Hepatitis B Agents

Baraclude (Brand Only)

Epivir HBV (Brand Only)

Hepsera (Brand Only)

ANTI-INFECTIVES

Hepatitis C Agents

ribavirin (Copegus, Rebetol)

Daklinza

Harvoni

Pegasys

PegIntron

Sovaldi

Technivie

Viekira Pak

Zepatier

ANTI-INFECTIVES

Macrolides/Ketolides

azithromycin (Zithromax)

clarithromycin tablets (Biaxin)

erythromycin base capsule DR

E.E.S.

EryPed

Ery-Tab

Erythrocin

ANTI-INFECTIVES

Tetracyclines

doxycycline hyclate (Vibramycin)

doxycycline monohydrate 50mg, 100mg (Monodox)

minocycline capsules (Minocin)

tetracycline (Sumycin)

BLOOD MODIFIERS

Anti-Hyperuricemics

allopurinol (Zyloprim)

probenecid

probenecid/colchicine

BLOOD MODIFIERS

Colony Stimulating Factors

Granix

Neupogen

BLOOD MODIFIERS

Erythropoietins

Aranesp

Procrit

BLOOD MODIFIERS

Phosphate Binders and Related Agents

calcium acetate (PhosLo)

calphron OTC

CARDIOVASCULAR

Angiotensin Modulator Combinations

amlodipine/benazepril (Lotrel)

amlodipine/valsartan, amlodipine/valsartan/HCTZ (Exforge, Exforge HCT)

CARDIOVASCULAR

Angiotensin Modulators

benazepril, benazepril/HCTZ (Lotensin, Lotensin HCT)

captopril/HCTZ (Capozide)

enalapril, enalapril/HCTZ (Vasotec, Vaseretic)

irbesartan, irbesartan/HCTZ (Avapro, Avalide)

lisinopril, lisinopril/HCTZ (Prinivil, Zestril, Prinzide, Zestoretic)

losartan, losartan/HCTZ (Cozaar, Hyzaar)

quinapril, quinapril/HCTZ (Accupril, Accuretic)

ramipril (Altace)

valsartan, valsartan/HCTZ (Diovan, Diovan HCT)

Entresto

CARDIOVASCULAR

Anticoagulants

enoxaparin (Lovenox)

warfarin (Coumadin)

Fragmin

CARDIOVASCULAR

Antihypertensives, Sympatholytics

clonidine oral (Catapres)

guanfacine (Tenex)

methyldopa (Aldomet)

methyldopa/HCTZ (Aldoril) Catapres TTS (Brand only)

CARDIOVASCULAR

Beta Blockers

atenolol, atenolol/chlorthalidone (Tenormin, Tenoretic)

bisoprolol/HCTZ (Ziac)

carvedilol (Coreg)

labetalol (Normodyne, Trandate)

metoprolol tartrate (Lopressor)

metoprolol succinate XL (Toprol XL)

pindolol (Visken)

propranolol, propranolol/HCTZ (Inderal, Inderide)

propranolol LA (Inderal LA)

sotalol, sotalol AF (Betapace, Betapace AF)

CARDIOVASCULAR

Calcium Channel Blockers

amlodipine (Norvasc)

diltiazem(Cardizem)

diltiazem ER capsules (Cardizem CD, Tiazac)

nicardipine (Cardene)

nifedipine ER (Adalat CC, Procardia XL)

verapamil (Calan)

verapamil ER tablets (Calan SR, Verelan)

CARDIOVASCULAR

Lipotropics, Other

colestipol (Colestid)

cholestyramine (Questran)

fenofibrate nanocrystals (Tricor)

fenofibric acid (Trilipix)

gemfibrozil (Lopid)

niacin ER (Niaspan ER)

Niacor

CARDIOVASCULAR

Lipotropics, Statins

atorvastatin (Lipitor)

lovastatin (Mevacor)

pravastatin (Pravachol)

simvastatin (Zocor)

CARDIOVASCULAR

Platelet Aggregation Inhibitors

clopidogrel (Plavix)

dipyridamole (Persantine)

ticlopidine (Ticlid)

CARDIOVASCULAR

Pulmonary Arterial Hypertension, Oral Agents

sildenafil (Revatio)

Letairis

Tracleer

Ventavis

CENTRAL NERVOUS SYSTEM

The Mental Health Carve Out link is located at:

https://mmcp.dhmh.maryland.gov/pap/docs/MMPP_MHF.pdf

Anticonvulsants

carbamazepine tablets (Tegretol)

carbamazepine ER (Carbatrol ER)

clonazepam (Klonopin)

divalproex, divalproex ER (Depakote, Depakote ER)

lamotrigine (Lamictal)

levetiracetam (Keppra)

oxcarbazepine tablets (Trileptal) oxcarbazepine suspension (Trileptal) (Brand and generic)

phenobarbital

phenytoin, phenytoin ER (Dilantin, Dilantin Infatabs)

primidone (Mysoline)

topiramate (Topamax)

valproic acid (Depakene)

zonisamide (Zonegran)

Celontin Depakote sprinkles (Brand only)

Diastat (Brand only)

Gabitril (Brand only)

Peganone Tegretol suspension (Brand only)

CENTRAL NERVOUS SYSTEM

Antidepressants, Other

bupropion, bupropion SR, buproprion XL (Wellbutrin, Wellbutrin SR, Wellbutrin XL)

mirtazapine, mirtazapine ODT (Remeron, Remeron Soltab)

phenelzine (Nardil)

trazodone (Desyrel)

venlafaxine (Effexor)

venlafaxine ER capsules (Effexor XR)

Marplan Parnate (Brand only)

Pristiq

CENTRAL NERVOUS SYSTEM

Antidepressants, Selective Serotonin Reuptake Inhibitors (SSRIs)

citalopram (Celexa)

escitalopram tablets (Lexapro)

fluoxetine (all strengths except 60mg) (Prozac, Sarafem)

fluvoxamine (Luvox)

paroxetine (Paxil)

sertraline (Zoloft)

CENTRAL NERVOUS SYSTEM

Antipsychotics

1st Tier aripiprazole (Abilify) (generic only) (Age 17 and younger)

aripiprazole ODT (Abilify Discmelt) (generic only) (Age 17 and younger)

chlorpromazine (Thorazine)

clozapine (Clozaril)

fluphenazine (Prolixin)

fluphenazine decanoate inj (Prolixin Inj.)

haloperidol (Haldol)

haloperidol decanoate inj (Haldol IM)

loxapine capsules (Loxitane)

perphenazine (Trilafon)

perphenazine/amitriptyline (Triavil)

quetiapine (Seroquel)

risperidone, risperidone ODT (Risperdal)

thioridazine (Mellaril)

thiothixene (Navane)

trifluoperazine (Stelazine)

ziprasidone (Geodon)

Abilify Maintena

Aristada

Geodon IM

Invega Sustenna

Invega Trinza

Orap

Risperdal Consta 2nd Tier

aripiprazole (Abilify) (generic only) (Age 18 or older)

aripiprazole ODT (Abilify Discmelt) (generic only) (Age 18 or older)

olanzapine IM (Zyprexa IM)

olanzapine ODT (Zyprexa Zydis)

olanzapine tablets (Zyprexa)

Latuda

CENTRAL NERVOUS SYSTEM

Sedative Hypnotics

flurazepam (Dalmane)

temazepam 15mg, 30mg (Restoril)

triazolam (Halcion)

zaleplon (Sonata)

zolpidem (Ambien)

CENTRAL NERVOUS SYSTEM

Stimulants and Related Agents

1st Tier

amphetamine salt combo (Adderall)

dextroamphetamine capsules (Dexedrine ER)

dextroamphetamine tablets

guanfacine ER (Intuniv)

methylphenidate tablets (Ritalin)

methylphenidate ER tablets (Ritalin SR)

methylphenidate CR tablets (Concerta) Adderall XR (Brand only)

Daytrana

Focalin (Brand only)

Focalin XR (Brand only)

Metadate CD (Brand only)

Methylin oral solution (Brand only)

Quillivant XR Ritalin LA (Brand only)

Vyvanse 2nd Tier

Strattera

ENDOCRINE

Androgenic Agents

testosterone gel (Androgel)

testosterone gel (Testim)

ENDOCRINE

Bone Suppression and Related Agents

alendronate (Fosamax)

calcitonin salmon nasal (Miacalcin)

Fortical

ENDOCRINE

Growth Hormones

Genotropin

Norditropin

Nutropin, Nutropin AQ

ENDOCRINE

Hypoglycemics, Incretin Mimetics and Enhancers

Bydureon

Byetta

Janumet, Janumet XR

Januvia

Jentadueto

Symlin

Tradjenta

ENDOCRINE

Hypoglycemics, Insulins

Humalog

Humalog Mix

Humulin vial

Lantus

Levemir

NovoLog

NovoLog Mix

ENDOCRINE

Hypoglycemics, Meglitinides

nateglinide (Starlix)

repaglinide (Prandin)

ENDOCRINE

Hypoglycemics, SGLT2 Inhibitors

Invokana (Step Therapy)

Invokamet (Step Therapy)

ENDOCRINE

Hypoglycemics, TZDs

pioglitazone (Actos)

GASTROINTESTINAL

Antiemetics/Antivertigo Agents

dimenhydrinate Rx and OTC

meclizine Rx and OTC (Bonine, Antivert)

metoclopramide (Reglan)

ondansetron, ondansetron ODT (Zofran, Zofran ODT)

prochlorperazine (Compazine, Compro)

promethazine (Phenergan)

Emend capsules

TransDerm-Scop

GASTROINTESTINAL

Bile Salts

ursodiol capsules (Actigall)

ursodiol tablets (URSO Forte)

GASTROINTESTINAL

Gastrointestinal Motility, Chronic

Amitiza

Linzess

GASTROINTESTINAL

Pancreatic Enzymes

pancrelipase

Creon

Zenpep

GASTROINTESTINAL

Proton Pump Inhibitors

lansoprazole capsules (Prevacid)

omeprazole capsules (Prilosec)

pantoprazole (Protonix)

Nexium packet for suspension

Prevacid Solutab

Protonix suspension

GASTROINTESTINAL

Ulcerative Colitis Agents

balsalazide (Colazal)

sulfasalazine, sulfasalazine DR (Azulfidine, Azulfidine DR)

Apriso

Canasa

IMMUNOLOGICS

Cytokine and CAM Antagonists

Enbrel

Humira

IMMUNOLOGICS

Immunosuppressives, Oral

azathioprine (Imuran)

cyclosporine (Sandimmune)

cyclosporine modified (Gengraf, Neoral)

mycophenolate mofetil capsules, tablets (Cellcept)

sirolimus (Rapamune)

tacrolimus (Prograf)

Rapamune solution

Sandimmune solution

NEUROLOGICS

Alzheimer’s Agents

donepezil, donepezil ODT (all strengths except 23mg) (Aricept, Aricept ODT)

rivastigmine capsules (Exelon)

Exelon patch

memantine (Namenda)

NEUROLOGICS

Anti-Parkinson’s Agents

amantadine (Symmetrel)

benztropine (Cogentin)

levodopa/carbidopa IR, levodopa/carbidopa ER (Sinemet, Sinemet CR)

levodopa/carbidopa/entacapone (Stalevo)

pramipexole (Mirapex)

ropinirole (Requip)

selegiline tablets (Eldepryl)

trihexyphenidyl (Artane)

NEUROLOGICS

Multiple Sclerosis Agents

Avonex

Betaseron

Copaxone 20mg (Brand only)

Rebif

OPHTHALMIC

Ophthalmics, Allergic Conjunctivitis

cromolyn (Crolom)

ketotifen OTC (Zaditor OTC)

Alrex

Pataday

Pazeo

OPHTHALMIC Ophthalmics, Antibiotics

bacitracin/polymixin

ciprofloxacin solution (Ciloxan)

erythromycin

gentamicin (Garamycin)

neomycin/polymixin/gramicidin (Neosporin)

ofloxacin (Ocuflox)

polymyxin/trimethoprim (Polytrim)

sulfacetamide solution (Bleph-10)

tobramycin (Tobrex Drops)

triple antibiotic

Ciloxan ointment

Moxeza

Tobrex ointment

Vigamox

OPHTHALMIC

Ophthalmics, Antibiotic/Steroid Combinations

neomycin/polymyxin/dexamethasone (Maxitrol)

sulfacetamide/prednisolone

tobramycin/dexamethasone drops (Tobradex)

Tobradex ointment

OPHTHALMIC

Ophthalmics, Glaucoma Agents

brimonidine (Alphagan P 0.1%)

carteolol (Ocupress)

dorzolamide (Trusopt)

dorzolamide/timolol (Cosopt)

latanoprost (Xalatan)

levobunolol (Betagan)

metipranolol (OptiPranolol)

pilocarpine (Pilocar)

timolol (Timoptic, Timoptic XE) Alphagan P 0.15% (Brand only)

Azopt

Betimol

Combigan

Simbrinza

Travatan Z

OPHTHALMIC

Ophthalmics, Anti-Inflammatories

dexamethasone (Decadron)

diclofenac (Voltaren)

fluorometholone (FML)

flurbiprofen (Ocufen)

ketorolac (Acular)

ketorolac LS (Acular LS)

prednisolone acetate (Omnipred)

Durezol

Flarex

FML SOP

Lotemax Drops

Maxidex

Pred Mild

OTIC

Otics, Antibiotics

neomycin/polymyxin/HC solution (Cortisporin)

ofloxacin otic (Floxin Otic)

Ciprodex

RESPIRATORY

Antihistamines, Minimally Sedating

cetirizine, cetirizine D Rx and OTC (Zyrtec , Zyrtec D)

fexofenadine OTC (Allegra)

levocetirizine tablets (Xyzal)

loratadine, loratadine D Rx and OTC (Claritin, Claritin D)

RESPIRATORY

Bronchodilators, Beta Agonists

albuterol neb 0.083% and 5mg/ml

albuterol syrup and tablets (Proventil, Ventolin)

terbutaline (Brethine)

Foradil

ProAir HFA

Proventil HFA

Serevent

RESPIRATORY

COPD Agents

ipratropium neb (Atrovent)

ipratopium/albuterol neb (DuoNeb)

Atrovent HFA

Combivent Respimat

Spiriva

RESPIRATORY

Glucocorticoids, Inhaled

Advair Diskus, Advair HFA

Aerospan

Asmanex

Dulera Pulmicort Respules 0.25mg and 0.5mg (Brand only)

Qvar

Symbicort

RESPIRATORY

Intranasal Rhinitis Agents

azelastine nasal (Astelin)

fluticasone nasal (Flonase)

ipratropium (Atrovent Nasal) Nasonex (Brand only)

RESPIRATORY

Leukotriene Modifiers

montelukast chewables and tablets (Singulair)

zafirlukast (Accolate)

TOPICAL DERMATOLOGICS

Acne Agents

benzoyl peroxide OTC

clindamycin (all forms except the foam)

erythromycin

erythromycin/benzoyl peroxide

tretinoin

Azelex

Differin cream (Brand only)

Differin lotion

TOPICAL DERMATOLOGICS

Atopic Dermatitis

Elidel

UROLOGIC

Benign Prostatic Hyperplasia

alfuzosin (Uroxatral)

doxazosin (Cardura)

finasteride (Proscar)

tamsulosin (Flomax)

terazosin (Hytrin)

UROLOGIC Bladder Relaxant Preparations

oxybutynin, oxybutynin ER (Ditropan, Ditropan XL)

Toviaz