PA Medicaid Online Formulary

Download Printable Formulary (PDF) Request Drug Exception Form View Recent Updates View Year to Date Updates
*NOTES
GC - Generic Covered PA - Prior Authorization
ST - Step Therapy QL - Quantity Limited
GA - Generic Available SPN - Specialty Pharmacy

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Therapeutic CategoryTherapeutic ClassGeneric NameBrand NameNotes
PAIN/INFLAMMATIONMISCBuprenorphine/NaloxoneSuboxone QL
ANTI-INFECTIVEANTIFUNGAL AGENTSClotrimazole TrocheMycelex Troche
ANTI-INFECTIVEANTIFUNGAL AGENTSFluconazoleDiflucan QL
ANTI-INFECTIVEANTIFUNGAL AGENTSKetoconazoleNizoral
ANTI-INFECTIVEANTIFUNGAL AGENTSNystatinMycostatin
ANTI-INFECTIVEANTIFUNGAL AGENTSFlucytosineAncobon
ANTI-INFECTIVEANTIFUNGAL AGENTSGriseofulvin UltramicrosizeGris PEG
ANTI-INFECTIVEANTIFUNGAL AGENTSGriseofulvin,MicrosizeGrifulvin V
ANTI-INFECTIVEANTIFUNGAL AGENTSTerbinafine HClLamisil QL
ANTI-INFECTIVEANTIFUNGAL AGENTSAmphotericin B InjFungizone IV SPN
ANTI-INFECTIVEANTI-INFECTIVE, MISCClindamycin HClCleocin HCl
ANTI-INFECTIVEANTI-INFECTIVE, MISCClindamycin Phosphate InjCleocin Phosphate SPN
ANTI-INFECTIVEANTI-INFECTIVE, MISCClindamycin PalmitateCleocin Palmitate
ANTI-INFECTIVEANTI-INFECTIVE, MISCMebendazoleVermox
ANTI-INFECTIVEANTI-INFECTIVE, MISCParomomycin SulfateHumatin
ANTI-INFECTIVEANTI-INFECTIVE, MISCVancomycin HClVancocin HCl
ANTI-INFECTIVEANTI-INFECTIVE, MISCDapsoneDapsone
ANTI-INFECTIVEANTI-INFECTIVE, MISCIodoquinolYodoxin
ANTI-INFECTIVEANTI-INFECTIVE, MISCPraziquantelBiltricide
ANTI-INFECTIVEANTI-INFECTIVE, MISCVancomycin HCl InjVancocin HCl SPN
ANTI-INFECTIVEANTI-INFECTIVE, MISCImipenem/Cilastatin sodium InjPrimaxin SPN
ANTI-INFECTIVEANTI-INFECTIVE, MISCMeropenemMerrem SPN
ANTI-INFECTIVEANTI-INFECTIVE, MISCPalivizumabSynagis SPN PA QL
ANTI-INFECTIVEANTIMALARIAL DRUGSChloroquine PhosphateAralen Phosphate
ANTI-INFECTIVEANTIMALARIAL DRUGSHydroxychloroquine SulfatePlaquenil
ANTI-INFECTIVEANTIMALARIAL DRUGSAtovaquone/Proguanil HClMalarone
ANTI-INFECTIVEANTIMALARIAL DRUGSMefloquine HClLariam
ANTI-INFECTIVEANTIMALARIAL DRUGSPrimaquine PhosphatePrimaquine
ANTI-INFECTIVEANTIMALARIAL DRUGSPyrimethamineDaraprim
ANTI-INFECTIVEANTIMALARIAL DRUGSPyrimethamine/SulfadoxineFansidar
ANTI-INFECTIVEANTI-MYCOBACTERIUM AGENTSEthambutol HClMyambutol
ANTI-INFECTIVEANTI-MYCOBACTERIUM AGENTSIsoniazidIsoniazid
ANTI-INFECTIVEANTI-MYCOBACTERIUM AGENTSPyrazinamidePyrazinamide
ANTI-INFECTIVEANTI-MYCOBACTERIUM AGENTSRifabutinMycobutin
ANTI-INFECTIVEANTIPROTOZOALMetronidazoleFlagyl
ANTI-INFECTIVEANTIPROTOZOALAtovaquoneMepron
ANTI-INFECTIVEANTIPROTOZOALPentamidine IsethionateNebupent
ANTI-INFECTIVEANTIVIRALS, GENERALAcyclovirZovirax
ANTI-INFECTIVEANTIVIRALS, GENERALAmantadine HClSymmetrel
ANTI-INFECTIVEANTIVIRALS, GENERALGanciclovir SodiumCytovene
ANTI-INFECTIVEANTIVIRALS, GENERALValacyclovir HClValtrex
ANTI-INFECTIVEANTIVIRALS, GENERALValganciclovir HydrochlorideValcyte
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSDelavirdine MesylateRescriptor
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSEfavirenzSustiva
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSNevirapineViramune
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSZidovudine/LamivudineCombivir
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSZidovudine/Lamivudine/AbacavirTrizivir
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSAbacavir Sulfate/LamivudineEpzicom
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSAbacavir SulfateZiagen
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSDidan/Calcium Carb/MagnesiumVidex
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSDidanosineVidex EC
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSDidanosine/Sodium CitrateVidex
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSLamivudineEpivir
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSStavudineZerit
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSZalcitabineHivid
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSZidovudineRetrovir
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSTenofovir Disoproxil FumarateViread
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSEfavirenz/Emtricitabine/TenofovirAtripla
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSEmtricitabine/TenofovirTruvada
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSRitonavir/LopinavirKaletra
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSAtazanavir SulfateReyataz
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSIndinavir SulfateCrixivan
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSNelfinavir MesylateViracept
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSRitonavirNorvir
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSSaquinavirFortovase
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSSaquinavir MesylateInvirase
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSFosamprenavir CalciumLexiva
ANTI-INFECTIVEANTIVIRALS, HIV/AIDSDarunavir ethanolatePrezista
ANTI-INFECTIVECEPHALOSPORINSCefadroxil HydrateDuricef
ANTI-INFECTIVECEPHALOSPORINSCephalexin MonohydrateKeflex
ANTI-INFECTIVECEPHALOSPORINSCefazolin Sodium InjAncef SPN
ANTI-INFECTIVECEPHALOSPORINSCefaclorCeclor
ANTI-INFECTIVECEPHALOSPORINSCefuroxime AxetilCeftin
ANTI-INFECTIVECEPHALOSPORINSCefotetan Disodium InjCefotan SPN
ANTI-INFECTIVECEPHALOSPORINSCefoxitin Sodium InjMefoxin SPN
ANTI-INFECTIVECEPHALOSPORINSCefuroxime Sodium InjZinacef SPN
ANTI-INFECTIVECEPHALOSPORINSCefdinirOmnicef
ANTI-INFECTIVECEPHALOSPORINSCeftazidime Pentahydrate InjFortaz SPN
ANTI-INFECTIVECEPHALOSPORINSCeftazidime Pentahydrate InjTazicef SPN
ANTI-INFECTIVECEPHALOSPORINSCeftriaxone Sodium InjRocephin SPN
ANTI-INFECTIVECEPHALOSPORINSCefepime HCl InjMaxipime SPN
ANTI-INFECTIVEHEPATITIS B&CRibavirinRebetol
ANTI-INFECTIVEHEPATITIS B&CLamivudineEpivir HBV
ANTI-INFECTIVEHEPATITIS B&CInterferon Alfacon-1Infergen SPN PA
ANTI-INFECTIVEHEPATITIS B&CPeginterferon Alfa-2BPEG-Intron SPN PA
ANTI-INFECTIVEHEPATITIS B&CRibavirinRibaPak
ANTI-INFECTIVEMACROLIDES/KETOLIDESEry E-Succ/SulfisoxazolePediazole
ANTI-INFECTIVEMACROLIDES/KETOLIDESErythromycin BaseE-Mycin
ANTI-INFECTIVEMACROLIDES/KETOLIDESErythromycin BaseEry-Tab
ANTI-INFECTIVEMACROLIDES/KETOLIDESErythromycin BaseEryc
ANTI-INFECTIVEMACROLIDES/KETOLIDESErythromycin EstolateErythromycin Estolate
ANTI-INFECTIVEMACROLIDES/KETOLIDESErythromycin EthylsuccinateE.E.S.
ANTI-INFECTIVEMACROLIDES/KETOLIDESErythromycin EthylsuccinateEryped
ANTI-INFECTIVEMACROLIDES/KETOLIDESErythromycin StearateErythrocin Stearate
ANTI-INFECTIVEMACROLIDES/KETOLIDESAzithromycinZithromax QL
ANTI-INFECTIVEMACROLIDES/KETOLIDESClarithromycinBiaxin QL
ANTI-INFECTIVEMACROLIDES/KETOLIDESClarithromycinBiaxin XL QL
ANTI-INFECTIVEPENICILLINSAmox Tr/Potassium ClavulanateAugmentin
ANTI-INFECTIVEPENICILLINSAmox Tr/Potassium ClavulanateAugmentin ES
ANTI-INFECTIVEPENICILLINSAmoxicillin TrihydrateAmoxil
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