Division of Medicaid & Medical Assistance – DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP)
PREFERRED DRUG LIST (PDL)
THERAPEUTIC
DRUG CLASS
ACE INHIBITORS
Preferred Status Implementation 1/27/06
Non-Preferred Agent will require Prior
Authorization
ACE INHIBITOR/CALCIUM CHANNEL
BLOCKER COMBINATIONS
Preferred Status Implementation 7/1/05
Non-Preferred Agent will require Prior
Authorization
ANALGESICS, NARCOTIC – Long Acting
Preferred Status Implementation 10/7/05
Non-Preferred Agent will require Prior
Authorization
ANALGESICS, NARCOTIC – Short Acting
Preferred Status Implementation 10/7/05
Non-Preferred Agent will require Prior
Authorization
PREFERRED AGENTS
Updated: December 1, 2005
PA
CRITERIA
NON-PREFERRED AGENTS
PA Is Required
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Dose optimization when applicable
captopril/HCTZ
enalapril/HCTZ
lisinopril/HCTZ
Altace
Mavik
Univasc/Uniretic
Lexxel
Lotrel
Tarka
benazepril/HCTZ
fosinopril/HCTZ
quinapril/HCTZ
Aceon
fentanyl (transdermal)
Kadian
morphine ER
oxycodone ER
Avinza
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Clinical criteria will still apply
Quantity limits are still in place
butalbital compound with codeine
codeine
codeine/APAP
codeine/ASA
hydrocodone/APAP
hydrocodone/ibuprofen
hydromorphone
levorphanol
meperidine
methadone
morphine IR
oxycodone IR
oxycodone/APAP
oxycodone/ASA
pentazocine/APAP
pentazocine/naloxone
propoxyphene
propoxyphene compound
propoxyphene/APAP
tramadol
tramadol/APAP
Actiq
Combunox
Darvon-N
Panlor DC/SS
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Clinical criteria will still apply
Quantity limits are still in place
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Dose optimization when applicable
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
1
Division of Medicaid & Medical Assistance – DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP)
PREFERRED DRUG LIST (PDL)
THERAPEUTIC
DRUG CLASS
ANGIOTENSIN II RECEPTOR BLOCKERS
Preferred Status Implementation 4/25/05
Non-Preferred Agent will require Prior
Authorization
ANTIEMETICS
PREFERRED AGENTS
Updated: December 1, 2005
PA
CRITERIA
NON-PREFERRED AGENTS
PA Is Required
Avapro/Avalide
Benicar/HCT
Cozaar/Hyzaar
Diovan/HCT
Atacand/HCT
Micardis/HCT
Teveten/HCT
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Dose optimization when applicable
Emend
Zofran/ODT
Anzemet
Kytril
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Clinical criteria will still apply
Quantity limits are still in place
clotrimazole
fluconazole
griseofulvin suspension
ketoconazole
nystatin
Gris-Peg
Mycostatin
clotrimazole/betamethasone
econazole
ketoconazole cream/shampoo
nystatin
nystatin/triamcinolone
Loprox gel
itraconazole
Ancobon
Grifulvin V
Lamisil
Vfend
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
ciclopirox cream/suspension
Ertaczo
Exelderm
Loprox shampoo
Mentax
Naftin
Oxistat
Penlac
Allegra/Allegra-D *
Clarinex/Clarinex-D *
Zyrtec/Zyrtec-D *
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Axert
Frova
Imitrex (injectable)
Relpax *
Zomig (nasal, oral), ZMT
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Quantity limits are still in place.
Preferred Status Implementation 1/20/06
Non-Preferred Agent will require Prior
Authorization
ANTIFUNGALS, ORAL
Preferred Status Implementation 10/7/05
Non-Preferred Agent will require Prior
Authorization
ANTIFUNGALS, TOPICAL
Preferred Status Implementation 10/7/05
Non-Preferred Agent will require Prior
Authorization
ANTIHISTAMINES, MINIMALLY SEDATING
Preferred Status Implementation 7/1/05
Non-Preferred Agent will require Prior
Authorization
ANTIMIGRAINE AGENTS, TRIPTANS
Preferred Status Implementation 4/18/05
Non-Preferred Agent will require Prior
Authorization
loratadine/loratadine-D
loratadine syrup
Clarinex syrup * (preferred for patients under 2 years
old)
Zyrtec syrup *(preferred for patients under 2 years
old)
Amerge
Imitrex (nasal, oral)
Maxalt, MLT
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
2
Division of Medicaid & Medical Assistance – DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP)
PREFERRED DRUG LIST (PDL)
THERAPEUTIC
DRUG CLASS
ANTIPARKINSON’S AGENTS
Preferred Status Implementation 1/27/06
Non-Preferred Agent will require Prior
Authorization
ANTIVIRALS
Preferred Status Implementation 10/7/05
Non-Preferred Agent will require Prior
Authorization
ATOPIC DERMATITIS
Preferred Status Implementation 10/7/05
Non-Preferred Agent will require Prior
Authorization
BETA BLOCKERS
Preferred Status Implementation 7/15/05
Non-Preferred Agent will require Prior
Authorization
BLADDER RELAXANT PREPARATIONS
Preferred Status Implementation 7/15/05
Non-Preferred Agent will require Prior
Authorization
PREFERRED AGENTS
Updated: December 1, 2005
PA
CRITERIA
NON-PREFERRED AGENTS
PA Is Required
benztropine
carbidopa/levodopa
selegiline
trihexyphenidyl
Comtan
Kemadrin
Mirapex
Requip
Stalevo
acyclovir
amantadine
rimantadine
Tamiflu
Valcyte
Valtrex
Elidel
Protopic
pergolide
Parcopa
Tasmar
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
ganciclovir
Famvir
Relenza
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Quantity limits are still in place.
atenolol
acebutolol
betaxolol
bisoprolol
labetalol
metoprolol tartrate
nadolol
pindolol
propranolol
sotalol
timolol
Coreg
Toprol XL
oxybutynin
Detrol/Detrol LA
Enablex
Oxytrol
Sanctura
Inderal LA ( systematic prior authorization will be generated
with submission of ICD9 code for migraine on claim )
Innopran XL
Levatol
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Ditropan XL
Vesicare
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
3
Division of Medicaid & Medical Assistance – DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP)
PREFERRED DRUG LIST (PDL)
THERAPEUTIC
DRUG CLASS
BONE RESORPTION SUPPRESSION AND
RELATED AGENTS
Preferred Status Implementation 10/14/05
Non-Preferred Agent will require Prior
Authorization
BPH TREATMENTS
Preferred Status Implementation 7/15/05
Non-Preferred Agent will require Prior
Authorization
BRONCHODILATORS, ANTICHOLINERGIC
PREFERRED AGENTS
PA Is Required
Actonel
Fosamax/Fosamax Plus D
Miacalcin
Boniva
Didronel
Evista
Forteo
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Clinical criteria will still apply
doxazosin
terazosin
Avodart
Flomax
Uroxatral
ipratropium nebulizer
Combivent
Proscar
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Atrovent/HFA
Duoneb
Spiriva
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Clinical criteria will still apply
albuterol (oral, inhaler, nebulizer)
metaproteranol (oral, inhalation)
terbutaline
Maxair
Serevent
amoxicillin/clavulanate suspension
cefaclor
cefadroxil
cefuroxime
cephalexin
Augmentin XR
Cefzil
Omnicef
Spectracef
Suprax
Enbrel
Humira
Kineret
Accuneb
Alupent
Foradil
Vospire ER
Xopenex
amoxicillin/clavulanate tablets
cefpodoxime
Cedax
Lorabid
Panixine
Raniclor
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Clinical criteria will still apply
Aranesp
Procrit
Epogen
Preferred Status Implementation 10/21/05
Non-Preferred Agent will require Prior
Authorization
BRONCHODILATORS, BETA AGONIST
Preferred Status Implementation 10/21/05
Non-Preferred Agent will require Prior
Authorization
CEPHALOSPORINS AND RELATED
ANTIBIOTICS
Preferred Status Implementation 10/7/05
Non-Preferred Agent will require Prior
Authorization
CYTOKINE AND CAM ANTAGONISTS
Preferred Status Implementation 7/1/05
Non-Preferred Agent will require Prior
Authorization
ERYTHROPOIESIS STIMULATING
PROTEINS
Updated: December 1, 2005
PA
CRITERIA
NON-PREFERRED AGENTS
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Clinical criteria will still apply
Preferred Status Implementation 10/7/05
Non-Preferred Agent will require Prior
Authorization
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
4
Division of Medicaid & Medical Assistance – DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP)
PREFERRED DRUG LIST (PDL)
THERAPEUTIC
DRUG CLASS
FLUOROQUINOLONES
Preferred Status Implementation 10/7/05
Non-Preferred Agent will require Prior
Authorization
GLUCOCORTICOIDS, INHALED
Preferred Status Implementation 4/11/05
Non-Preferred Agent will require Prior
Authorization
HEPATITIS C AGENTS
Preferred Status Implementation 7/15/05
Non-Preferred Agent will require Prior
Authorization
HYPOGLYCEMICS, INSULINS AND
RELATED
Preferred Status Implementation 2/17/06
Non-Preferred Agent will require Prior
Authorization
HYPOGLYCEMICS, METFORMINS
Preferred Status Implementation 1/13/06
Non-Preferred Agent will require Prior
Authorization
HYPOGLYCEMICS, METGLITINIDES
Preferred Status Implementation 10/14/05
Non-Preferred Agent will require Prior
Authorization
HYPOGLYCEMICS, TZDs
PREFERRED AGENTS
Updated: December 1, 2005
PA
CRITERIA
NON-PREFERRED AGENTS
PA Is Required
ciprofloxacin
Avelox
ofloxacin
Cipro suspension
Cipro XR
Factive
Levaquin (systematic prior authorization will be generated
with submission of ICD9 code for pneumonia or sinusitis on
the claim )
Maxaquin
Noroxin
Tequin
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Advair
Aerobid, M
Azmacort
Flovent
Pulmicort (respules)
Qvar
Copegus
Peg-Intron/Peg-Intron Redipen
Pegasys
Rebetol
Pulmicort (turbuhaler)
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
ribavirin
Infergen
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Lantus
Novolin
Novolog
Novolog Mix 70/30
Byetta
Humulin
Humalog
Humalog 75/25
Symlin
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Clinical criteria will still apply
metformin IR
metformin ER
Avandamet
Fortamet
glyburide/metformin
Metaglip
Riomet
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Starlix
Prandin*
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Actos
Avandia
Preferred Status Implementation 4/11/05
Non-Preferred Agent will require Prior
Authorization
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
5
Division of Medicaid & Medical Assistance – DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP)
PREFERRED DRUG LIST (PDL)
THERAPEUTIC
DRUG CLASS
INTRANASAL RHINITIS AGENTS
Preferred Status Implementation 4/18/05
Non-Preferred Agent will require Prior
Authorization
LEUKOTRIENE RECEPTOR ANTAGONISTS
Preferred Status Implementation 4/11/05
Non-Preferred Agent will require Prior
Authorization
LIPOTROPICS, OTHER
Preferred Status Implementation 4/25/05
Non-Preferred Agent will require Prior
Authorization
LIPOTROPICS, STATINS
Preferred Status Implementation 4/11/05
Non-Preferred Agent will require Prior
Authorization
MACROLIDES/KETOLIDES
Preferred Status Implementation 10/7/05
Non-Preferred Agent will require Prior
Authorization
NSAIDs
Preferred Status Implementation 4/25/05
Non-Preferred Agent will require Prior
Authorization
PREFERRED AGENTS
Updated: December 1, 2005
PA
CRITERIA
NON-PREFERRED AGENTS
PA Is Required
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
ipratropium
Astelin
Flonase
Nasarel
Nasonex
Accolate
Singulair
flunisolide
Beconase AQ
Nasacort AQ
Rhinocort Aqua
gemfibrozil
Antara
Colestid
Niaspan
Tricor
Zetia
Advicor
Altoprev
Lescol, XL
Lipitor
Pravachol
Vytorin
Zocor
clarithromycin
erythromycin
Biaxin XL
Ketek
Zithromax
diclofenac
fenoprofen
ibuprofen
indomethacin
ketorolac
naproxen
cholestyramine
Lofibra
Welchol
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
lovastatin
Crestor *
Pravigard PAC
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Once daily dosing required
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
etodolac
flurbiprofen
ketoprofen
meclofenamate
nabumetone
oxaprozin
piroxicam
sulindac
tolmetin
Arthrotec
Mobic
Ponstel
Prevacid NapraPAC
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
6
Division of Medicaid & Medical Assistance – DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP)
PREFERRED DRUG LIST (PDL)
THERAPEUTIC
DRUG CLASS
OPHTHALMICS, ALLERGIC
CONJUNCTIVITIS
PREFERRED AGENTS
PA Is Required
cromolyn
Alrex
Elestat
Patanol
Preferred Status Implementation 1/20/06
Non-Preferred Agent will require Prior
Authorization
OPHTHALMICS, ANTIBIOTICS
Preferred Status Implementation 1/20/06
Non-Preferred Agent will require Prior
Authorization
OPHTHALMICS, GLAUCOMA AGENTS
Preferred Status Implementation 7/1/05
Non-Preferred Agent will require Prior
Authorization
OTIC ANTIBIOTIC PREPARATIONS
Preferred Status Implementation 7/1/05
Non-Preferred Agent will require Prior
Authorization
Updated: December 1, 2005
PA
CRITERIA
NON-PREFERRED AGENTS
bacitracin
bacitracin/polymyxin
erythromycin
gentamicin
polymyxin/trimethoprim
sulfacetamide
tobramycin
triple antibiotic
Vigamox
Zymar
betaxolol
brimonidine
carteolol
dipivefrin
levobunolol
metipranolol
pilocarpine
timolol
Alphagan P
Azopt
Betimol
Betoptic S
Cosopt
Lumigan
Travatan
Trusopt
Xalatan
neomycin/polymyxin B/hydrocortisone
Ciprodex
Coly-Mycin S
Floxin
Acular
Alamast
Alocril
Alomide
Emadine
Optivar
Zaditor
ciprofloxacin
ofloxacin
Ciloxan
Quixin
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Quantity limits are still in place
Istalol
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Cipro HC
Cortisporin-TC
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
7
Division of Medicaid & Medical Assistance – DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP)
PREFERRED DRUG LIST (PDL)
THERAPEUTIC
DRUG CLASS
PHOSPHATE BINDERS
Preferred Status Implementation 7/1/05
Non-Preferred Agent will require Prior
Authorization
PLATELET AGGREGATION INHIBITORS
Preferred Status Implementation 1/13/06
Non-Preferred Agent will require Prior
Authorization
PROTON PUMP INHIBITORS
PREFERRED AGENTS
PA Is Required
Magnebind Rx 400
PhosLo
RenaGel
Fosrenol
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Clinical criteria will still apply
dipyridamole
Aggrenox
Plavix
ticlopidine
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Prevacid
omeprazole
Aciphex
Nexium
Prilosec OTC
Protonix
Zegerid
Asacol
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Clinical criteria will still apply
Preferred Status Implementation 4/11/05
Non-Preferred Agent will require Prior
Authorization
ULCERATIVE COLITIS AGENTS
Preferred Status Implementation 7/15/05
Non-Preferred Agent will require Prior
Authorization
Updated: December 1, 2005
PA
CRITERIA
NON-PREFERRED AGENTS
mesalamine enema
sulfasalazine
Canasa
Colazal
Dipentum
Pentasa
 Treatment failure with preferred
product.
 Contraindication to preferred product.
 Allergic reaction to preferred product.
Prospective DUR alerts still must be addressed by pharmacist prior to dispensing regardless of preferred status or clinical requirements.
*(grandfathered) clients currently receiving medication at implementation date may continue without prior authorization.
Future updates will be posted to the DMAP website (www.dmap.state.de.us/ /information/pharmacy.html).
Unless otherwise specified, the listing of a particular brand or generic name includes all dosage forms of that drug.
8