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Medicaid Medication Policies


*Statewide Preferred Drug List (PDL) Effective January 1, 2020*

As of January 1, 2020, all managed care organizations (MCOs) that provide outpatient drug services to Medicaid beneficiaries in Pennsylvania and the State Fee-for-Service (FFS) program will use the same Preferred Drug List (PDL). Any drugs designated as non-preferred will require prior authorization. In addition, the PA Medicaid MCOs and the FFS program will apply the same clinical prior authorization criteria to determine medical necessity for medications included on the PDL.  You may access the complete statewide PDL now through the Department of Human Services website. Beginning January 1, the searchable PDL and prior authorization guidelines will also be located on the Gateway Health, Medicaid website.



Name
Type
State
Adcetris Medical & Pharmacy PA Medicaid
Alimta Medical & Pharmacy PA Medicaid
Aloxi Medical & Pharmacy PA Medicaid
Antipsychotics for Children Less than 18 Pharmacy PA Medicaid
Avastin & Bevacizumab Biosimilars Medical & Pharmacy PA Medicaid
Avonex Pharmacy PA Medicaid
Benlysta Medical & Pharmacy PA Medicaid
Botox Medical & Pharmacy PA Medicaid
Brineura Medical & Pharmacy PA Medicaid
Cerdelga Pharmacy PA Medicaid
Cerezyme Medical & Pharmacy PA Medicaid
Cidofovir Medical & Pharmacy PA Medicaid
Chantix Pharmacy PA Medicaid
Cimzia Medical & Pharmacy PA Medicaid
Copaxone Pharmacy PA Medicaid
Cough and Cold Medications for Children less than 4 Pharmacy PA Medicaid
Crysvita Medical & Pharmacy PA Medicaid
Cystic Fibrosis Biologic Response Modifiers Pharmacy PA Medicaid
Daraprim Pharmacy PA Medicaid
Depen Pharmacy PA Medicaid
Duzallo Pharmacy PA Medicaid
Emflaza Pharmacy PA Medicaid
Strensiq Pharmacy PA Medicaid
Enbrel & Etanercept Biosimilars Pharmacy PA Medicaid
Erbitux Medical & Pharmacy PA Medicaid
Erythropoiesis Stimulating Agents Medical & Pharmacy PA Medicaid
Esbriet Pharmacy PA Medicaid
Eucrisa Pharmacy PA Medicaid
Exondys-51 Medical & Pharmacy PA Medicaid
Eylea Medical & Pharmacy PA Medicaid
Ezetimibe Pharmacy PA Medicaid
Faslodex Medical & Pharmacy PA Medicaid
Feraheme Medical & Pharmacy PA Medicaid
Freestyle Libre Pharmacy PA Medicaid
Gilenya Pharmacy PA Medicaid
Granulocyte Colony Stimulating Factors (GCS-Fs) Medical & Pharmacy PA Medicaid
Growth Hormone Pharmacy PA Medicaid
H.P. Acthar Gel Pharmacy PA Medicaid
Hemophila & Blood Factor Products Medical & Pharmacy PA Medicaid
Hepatitis B Pharmacy PA Medicaid
Hepatitis C Medications Pharmacy PA Medicaid
Herceptin & Trastuzumab Biosimilars Medical & Pharmacy PA Medicaid
Hereditary Angioedema (HAE) Medications Pharmacy PA Medicaid
Humira & Adalimumab Biosimilars Pharmacy PA Medicaid
Idiopathic Pulmonary Fibrosis(IPF) Medications Pharmacy PA Medicaid
Injectafer Medical & Pharmacy PA Medicaid
Interleukin-5 Inhibitors Medical & Pharmacy PA Medicaid
Intravenous and Subcutaneous Immune Globulin (IVIG & SCIG) Medical & Pharmacy PA Medicaid
Intravenous (IV) Iron Medical & Pharmacy PA Medicaid
Keytruda Medical & Pharmacy PA Medicaid
Kyprolis Medical & Pharmacy PA Medicaid
Krystexxa Medical & Pharmacy PA Medicaid
Latuda Pharmacy PA Medicaid
Lidocaine Patch Pharmacy PA Medicaid
Lucentis Medical & Pharmacy PA Medicaid
Lumizyme Medical & Pharmacy PA Medicaid
Lupron Medical & Pharmacy PA Medicaid
Luxturna Medical & Pharmacy PA Medicaid
Lyrica Pharmacy PA Medicaid
Makena Medical & Pharmacy PA Medicaid
Modafinil Pharmacy PA Medicaid
Mozobil Medical & Pharmacy PA Medicaid
Multiple Sclerosis (MS) Medications Medical & Pharmacy PA Medicaid
Non-TNF Biologics Pharmacy PA Medicaid
Nplate Medical & Pharmacy PA Medicaid
Ocrevus Medical & Pharmacy PA Medicaid
Oncology Medications Medical & Pharmacy PA Medicaid
Opdivo Medical & Pharmacy PA Medicaid
Opioid Analgesics Pharmacy PA Medicaid
Ozempic Pharmacy PA Medicaid
PCSK9 Inhibitors Pharmacy PA Medicaid
Perjeta Medical & Pharmacy PA Medicaid
Photofrin Medical & Pharmacy PA Medicaid
Portrazza Medical & Pharmacy PA Medicaid
Prialt Medical & Pharmacy PA Medicaid
Pulmonary Arterial Hypertension(PAH) Agents Pharmacy PA Medicaid
Pulmozyme Pharmacy PA Medicaid
Radicava Medical & Pharmacy PA Medicaid
Remicade & Infliximab Biosimilars Medical & Pharmacy PA Medicaid
Rituxan & Rituximab Biosimilars Medical & Pharmacy PA Medicaid
Simponi/Simponi Aria Medical & Pharmacy PA Medicaid
Somatuline Depot Medical & Pharmacy PA Medicaid
Spinraza Medical & Pharmacy PA Medicaid
Sublingual Immunotherapy Medications Pharmacy PA Medicaid
Supprelin LA Medical & Pharmacy PA Medicaid
Synagis Medical & Pharmacy PA Medicaid
Synvisc & Synvisc-One Medical & Pharmacy PA Medicaid
Tacrolimus Ointment Pharmacy PA Medicaid
Tecfidera Pharmacy PA Medicaid
Thrombopoietin (TPO) Receptor Agonists Medical & Pharmacy PA Medicaid
Topical Retinoid Pharmacy PA Medicaid
Trogarzo Medical & Pharmacy PA Medicaid
Tysabri Medical & Pharmacy PA Medicaid
Velcade Medical & Pharmacy PA Medicaid
Victoza Pharmacy PA Medicaid
Vimizim Medical & Pharmacy PA Medicaid
Xeljanz and Xeljanz XR Medical & Pharmacy PA Medicaid
Xgeva and Prolia Pharmacy PA Medicaid
Xifaxan Pharmacy PA Medicaid
Xolair Medical & Pharmacy PA Medicaid
Yervoy Medical & Pharmacy PA Medicaid
Zyvox Pharmacy PA Medicaid
Buprenorphine SL Pharmacy PA Medicaid
DPP-4 & SGLT2 Inhibitors Pharmacy PA Medicaid
Sandostatin LAR Depot Kit Medical & Pharmacy PA Medicaid
Quantity Limits Pharmacy PA Medicaid
Non-Formulary Medication/Medical Necessity Medical & Pharmacy PA Medicaid
Stimulant Medications (ADHD & Narcolepsy) Pharmacy PA Medicaid
Macugen Medical & Pharmacy PA Medicaid
Remodulin Medical & Pharmacy PA Medicaid
Vantas Medical & Pharmacy PA Medicaid
Zulresso Medical & Pharmacy PA Medicaid
Blincyto Medical & Pharmacy PA Medicaid
Folotyn Medical & Pharmacy PA Medicaid
Takhzyro Medical & Pharmacy PA Medicaid
Gamifant Medical & Pharmacy PA Medicaid
Spravato Pharmacy PA Medicaid
Visudyne Medical & Pharmacy PA Medicaid
Actimmune Medical & Pharmacy PA Medicaid
Ocular Rho Kinase Inhibitors (Rhopressa & Rocklatan) Pharmacy PA Medicaid
Imfinzi Medical & Pharmacy PA Medicaid
Myalept Medical & Pharmacy PA Medicaid
Austedo & Ingrezza PharmacyPA Medicaid
Calcitonin Gene-Related Peptide (CGRP) Inhibitors PharmacyPA Medicaid
Diacomit PharmacyPA Medicaid
Epidiolex PharmacyPA Medicaid
Fabry Disease Medications (Fabrazyme & Galafold) Medical & PharmacyPA Medicaid
Qbrexzas PharmacyPA Medicaid
Xyrem Medical & PharmacyPA Medicaid
Tavalisse PharmacyPA Medicaid
Phenylketonuria Medications (Kuvan & Palynziq)PA Medicaid Pharmacy
C5b Complement Inhibitors (Soliris & Ultomiris) Medical & PharmacyPA Medicaid
Chimeric Antigen Receptor T-cell (CAR-T) Immunotherapy (Kymriah & Yescarta) Medical & PharmacyPA Medicaid
Dupixent PharmacyPA Medicaid
Firdapse PharmacyPA Medicaid
Lucemyra PharmacyPA Medicaid
Nuedexta PharmacyPA Medicaid
Xiaflex Medical & PharmacyPA Medicaid
Hyperkalemia Agents (Lokelma & Veltassa) PharmacyPA Medicaid
Xiidra Pharmacy PA Medicaid
Sucraid PharmacyPA Medicaid
Alpha1-Proteinase Inhibitors Pharmacy PA Medicaid
Gattex Pharmacy PA Medicaid
Vyndaqel & Vyndamax Pharmacy PA Medicaid
Onpattro & Tegsedi Medical & Pharmacy PA Medicaid
Zolgensma Medical & Pharmacy PA Medicaid
Docetaxel Medical & Pharmacy PA Medicaid
Erwinaze Medical & Pharmacy PA Medicaid
Halaven Medical & Pharmacy PA Medicaid
Libtayo Medical & Pharmacy PA Medicaid
Lumoxiti Medical & Pharmacy PA Medicaid
Oncasper Medical & Pharmacy PA Medicaid
Rituxan Hycela Medical & Pharmacy PA Medicaid
Tecentriq Medical & Pharmacy PA Medicaid
Xofigo Medical & Pharmacy PA Medicaid
Zevalin Medical & Pharmacy PA Medicaid