Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caDC-14-07054/USCOURTS-caDC-14-07054-1/pdf.json

Nature of Suit Code: 444
Nature of Suit: Civil Rights Welfare
Cause of Action: 

---

The attached material is cited in NB, et al. v. D.C., No. 

14-7054, slip op. at 4 (D.C. Cir. July 17, 2015); (citing 

the D.C. Pharmacy Preferred Drug List, available on 

7/17/15 at https://dc.fhsc.com/downloads/providers/ 

DCRx_PDL_listing.pdf).

Archived by the Circuit Library on 7/17/15

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 1 of 15
District of Columbia

Department of Health Care Finance

Pharmacy Preferred Drug List (PDL)

Effective June 17, 2015

Non-preferred medications require prior authorization Page 1 of 14

ANALGESICS

Drug Class Preferred Requires Prior Authorization

Long-Acting Narcotics*

* Clinical criteria apply to this entire 

therapeutic class

fentanyl 12, 25, 50, 75, 

100 mcg/hr 

(transdermal)

morphine ER (gen 

MSContin/Oramorph SR)

Kadian ® Avinza ®

Butrans ®

Duragesic®

Embeda ®

Exalgo ®

fentanyl 37.5, 62.5, 87.5 

mcg/hr (transdermal)

hydromorphone ER

Hysingla ®ER

morphine ER (gen for 

Avinza)

morphine ER (gen for 

Kadian)

MS Contin ®

Opana ER ®

OxyContin ®

oxymorphone ER

Zohydro® ER

NSAIDS: Oral and Topical diclofenac sodium

ibuprofen (tab & susp)

indomethacin IR cap

ketoprofen IR

ketorolac

meloxicam tab

naproxen tab

piroxicam

sulindac

Voltaren ® gel

Anaprox ®

Ansaid

Arthrotec

Cataflam® tab

Celebrex®

celecoxib

Daypro®

diclofenac potassium

diclofenac SR

diclofenac (topical)

diclofenac/misoprostol

diflunisal

Duexis®

etodolac IR and SR

feldene

fenoprofen

Flector ® patch

flurbiprofen

Indocin®

indomethacin ER cap

ketoprofen ERcap

meclofenamate

mefenamic acid

meloxicam susp

Mobic®

nabumetone

Nalfon®

Naprelan®

Naprosyn®

naproxen EC

naproxen susp

Pennsaid ®

Ponstel®

oxaprozin

Sprix®

Tivorbex®

tolmetin

Vimovo®

Voltaren® XR

Zipsor®

Zorvolex®

Opiate Dependance Treatment 

Agents

Naltrexone Suboxone ® Fim Bunavail®

Buprenorphine

buprenorphine/naloxone

Zubsolv ®

Tramadol and Tramadol Like Agents tramadol HCl tramadol HClacetaminophenConzip ®

Nucynta ER ®

Nucynta ®

Rybix ODT ®

Ryzolt ER ®

tramadol ER

Ultracet ®

Ultram ®

Ultram ER ®

ANTI-INFECTIVES

Drug Class Preferred Requires Prior Authorization

Antibiotics: Fluoroquinolones ciprofloxacin tablet

levofloxacin tablets

Cipro ® susp Avelox ®

Avelox ABC Pack ®

ciprofloxacin ER

moxifloxacin

ofloxacin

Cipro ®

Cipro XR ®

Factive ®

Levaquin ®

levofloxacin soln

Noroxin ®

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 2 of 15
District of Columbia

Department of Health Care Finance

Pharmacy Preferred Drug List (PDL)

Effective June 17, 2015

Non-preferred medications require prior authorization Page 2 of 14

ANTI-INFECTIVES

Drug Class Preferred Requires Prior Authorization

Antibiotics: GI metronidazole tabs vancomycin Alinia ®

Dificid ®

Flagyl ER ®

Flagyl ®

metronidazole caps

neomycin

paromomycin

Tindamax ®

tinidazole

Vancocin®

Xifaxan ®

Antibiotics: Vaginal Cleocin ® Ovules metronidazole vaginal gel Cleocin ® crm

clindamycin vaginal crm

Clindesse ®

Metrogel-Vaginal ®

Nuvessa®

Vandazole ®

Antifungals fluconazole

griseofulvin susp

Grifulvin V ® tabs

Gris-Peg ®

nystatin susp

terbinafine

Ancobon®

clotrimazole

Cresemba®

Diflucan®

fluconazole susp

flucytosine

griseofulvin microsize tabs

griseofulvin ultramicrosize tabs

itraconazole

ketoconazole

Lamisil ®

Noxafil®

nystatin tabs and powder

Onmel®

Oravig®

Sporanox capsule ®

Sporanox solution ®

Terbinex ®

Vfend®

voriconazole

Antivirals: Herpes acyclovir

famciclovir

Valtrex ® Famvir ®

Valacyclovir

Sitavig®

Zovirax ®

Hepatitis B: Oral Agents Baraclude ® tablet

Baraclude ® solution

Viread ® adefovir

entecavir

Epivir ® HBV tablet

Epivir ® HBV solution

Hepsera ®

lamivudine (HBV)

Tyzeka ®

Hepatitis C Agents*

* Clinical criteria and review apply to 

this entire therapeutic class

Incivek ®

Pegasys ® vial/ syringe

Pegasys Proclick ®

Ribapak®

ribavirvin tabs & caps

VieKira® Pak

Copegus®

Harvoni®

Olysio®

Pegasys Conv Pack/ Kit ®

PEG-Intron ®

PEG-Intron Redipen ®

Rebatol®

Ribasphere®

Sovaldi®

Victrelis®

Influenza Agents amantadine tabs

Relenza ®

rimantadine

Tamiflu ®

amantadine caps Flumadine ®

Topical Antibiotics Gentamicin

mupirocin ointment

neomycin / polymyxin / 

pramoxine topical

Altabax ®

Bactroban ®

Centany ®

Centany AT ®

mupirocin cream

Topical Antivirals Denavir®

Zovirax® cream

Zovirax® ointment acyclovir ointment Xerese ®

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 3 of 15
District of Columbia

Department of Health Care Finance

Pharmacy Preferred Drug List (PDL)

Effective June 17, 2015

Non-preferred medications require prior authorization Page 3 of 14

CARDIOVASCULAR

Drug Class Preferred Requires Prior Authorization

ACE Inhibitors benazepril

captopril

enalapril

lisinopril

Accupril ®

Altace ®

Epaned®

fosinopril

Lotensin ®

Mavik ®

moexipril

perindopril

Prinivil ®

quinapril

ramipril

trandolapril

Vasotec ®

Zestril ®

ACE Inhibitor/Diuretic

Combinations

benazepril w/HCTZ

captopril w/HCTZ

lisinopril w/HCTZ Accuretic ®

enalapril w/HCTZ

fosinopril w/HCTZ

Lotensin HCT ®

moexipril w/HCTZ

quinapril w/HCTZ

quinaretic

Uniretic ®

Vaseretic ®

Zestoretic ®

Angiotensin Receptor Blockers Diovan ® losartan

Micardis ®

Atacand ®

Avapro ®

Benicar ®

candesartan

Cozaar ®

Edarbi ®

eprosartan

irbesartan

telmisartan

Teveten ®

valsartan

Angiotensin Receptor 

Blockers/Diuretic

Diovan HCT ® losartan w/HCTZ

Micardis HCT ®

Atacand HCT ®

Avalide ®

Benicar HCT

Edarbyclor ®

Hyzaar ®

Irbesartan /HCTZ

telmisartan/hctz

Teveten HCT ®

valsartan-HCTZ

Angiotensin Receptor Modulators 

Combinations

amlodipine/benazepril Exforge®

Exforge ®HCT

amlodipine/valsartan

amlodipine/valsartan/ 

hctz

Amturnide ®

Azor ®

Lotrel ®

Tarka ®

Tekamlo ®

telmisartan / amlodipine

Tribenzor ®

Twynsta ®

Antihypertensives, Sympatholytics Catapres-TTS® patches

clonidine

guanfacine

methyldopa

Catapres®

clonidine patches

Clorpres®

methyldopa HTZ

reserpine

Tenex®

Beta Blockers atenolol

bisoprolol

Bystolic ®

carvedilol

metoprolol succinate ER

metoprolol tartrate

propranolol tabs/soln

acebutolol

Betapace ®

Betapace AF ®

betaxolol

Coreg ®

Coreg CR ®

Corgard ®

Inderal LA ®

Innopran XL ®

Hemangeol®

labetalol

levatol ®

Lopressor ®

Nadolol

pindolol

propranolol ER/SA

Sectral ®

Sorine ®

Sotalol

Sotylize®

Tenormin ®

Toprol XL ®

timolol

Trandate ®

Zebeta ®

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 4 of 15
District of Columbia

Department of Health Care Finance

Pharmacy Preferred Drug List (PDL)

Effective June 17, 2015

Non-preferred medications require prior authorization Page 4 of 14

CARDIOVASCULAR

Drug Class Preferred Requires Prior Authorization

Beta Blockers/Diuretic 

Combinations

atenolol /chlorthalidone bisoprolol w/HCTZ

Corzide ®

Dutoprol ®

Lopressor HCT ®

metoprolol w/HCTZ

nadolol w/ 

bendroflumethiazide

propranolol w/HCTZ

Tenoretic ®

Ziac ®

Bidil – Optional Bidil ® N/A

Calcium Channel Blockers (DHP) Afeditab CR ®

amlodipine

nicardipine HCl

nifediac CC

nifedical XL

nifedipine IR

nifedipine ER/SA/XL

Adalat CC ®

Cardene SR ®

felodipine ER

isradipine

nisoldipine

Norvasc ®

Nymalize®

Procardia ®

Procardia XL ®

Sular ® (reformulated)

Direct Renin Inhibitors Tekturna ® Tekturna HCT ® N/A

Lipotropics: Bile Acid Sequestrants cholestyramine

cholestyramine light

packet

cholestyramine light

powder

colestipol tablet

Prevalite ® powder

Prevalite ® packet

Colestid ® granules

Colestid ® packets

Colestid ® tablet

colestipol granules

Questran ® packet

Questran ® powder

Questran Light ® packet

Questran Light ® powder

Welchol®

Lipotropics: Cholesterol Absorption 

Inhibitors and Others

Zetia ® Juxtapid® Kynamro®

Lipotropics: HMG-CoA Reductase 

Inhibitors (Statins)

atorvastatin

lovastatin

pravastatin

simvastatin

Advicor ®

amlodipine/atorvastatin

Altoprev ®

Caduet ®

Crestor ®

Fluvastatin

Lescol ®

Lescol XL ®

Lipitor ®

Liptruzet®

Livalo ®

Mevacor ®

Pravachol ®

Simcor®

Vytorin ®

Zocor ®

Lipotropics: Niacin Derivatives niacin ER Niaspan ® Niacor ®

Lipotropics: Triglyceride Lowering 

Agents 

fenofibric acid

gemfibrozil

Antara ®

fenofibrate

Fibricor ®

Lipofen ®

Lofibra ®

Lopid ®

Lovaza ®

omega-3 acid ethyl esters 

(Rx)

Tricor ®

Triglide ®

Trilipix ®

Vascepa®

Platelet Aggregation Inhibitors Aggrenox ®

clopidogrel

dipyridamole

ticlopidine

Brilinta ®

Effient ®

Persantine ®

Plavix ®

Zontivity®

Ranexa like Agents 

Anti-Angina/Anti-Ischemic

Ranexa ® Corlanor®

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 5 of 15
District of Columbia

Department of Health Care Finance

Pharmacy Preferred Drug List (PDL)

Effective June 17, 2015

Non-preferred medications require prior authorization Page 5 of 14

CENTRAL NERVOUS SYSTEM

Drug Class Preferred Requires Prior Authorization

Alzheimer's Agents: Cholinesterase 

Inhibitors

donepezil tabs Exelon ® patch

rivastigmine

Aricept ®

Aricept ODT ®

donepezil 23 mg

donepezil ODT

Exelon ® caps/solution

galantamine IR/ER/soln

Razadyne ® ER

Razadyne ® tabs and soln

Alzheimer's Agents: NMDA 

Receptor Antagonist

Namenda ® tablet Namenda ® solution Namenda XR ®

Anti-Convulsants: Carbamazepine 

Derivatives

carbamazepine tablets

carbamazepine ER tabs

carbamazepine chew tabs

Carbatrol ®

Epitol ®

oxcarbazepine tablets

Tegretol ® susp

Tegretol ® XR

Trileptal ® oral susp

Aptiom®

carbamazepine ER cap 

(gen Carbatrol®)

carbamazepine oral susp

Equetro ®

oxcarbazepine susp

Oxtellar®

Tegretol ® chew tabs

Tegretol ® tablets

Trileptal ® tablets

anti-convulsants: second generation 

and others

lamotrigine tab

lamotrigine tab DS PK

levetiracetam solution

levetiracetam tablet

Topamax ® sprinkle cap

topiramate tablet

zonisamide 

Banzel ®

Fycompa®

Gabarone ®

Gabitril ®

Keppra ® / Keppra® XR

Lamictal ® /Chew/XR / 

ODT

lamotrigine ER/ ODT

levetiracetam ER

Onfi ®

Potiga ®

Qudexy XR®

Sabril ®

tiagabine

Topamax ® tablet

topiramate ER (generic for 

Qudexy XR) 

topiramate sprinkle cap

Trokendi XR®

Vimpat®

Zonegran ®

Anti-Convulsants: First Generation clonazepam tablets

Diastat ®

Dilantin ® chew tab

divalproex sodium

divalproex sodium 

sprinkle

ethosuximide capsule

ethosuximide susp

Felbatol ® oral susp

Felbatol ® tablet

phenobarbital elixir

phenobarbital tablets

Phenytek ®

phenytoin chewtab

phenytoin oral susp

phenytoin sodium 

extended

primidone

valproic acid capsule

valproic acid syrup

Celontin ®

clonazepam ODT

Depakene ® capsule

Depakene ® syrup

Depakote ®

Depakote ® ER

Depakote ® sprinkle

diazepam rectal

Dilantin ® capsule

Dilantin-125 ® oral susp

divalproex ER

felbamate

Klonopin®

Mysoline ® tablet

Peganone ®

Stavzor ®

Zarontin ® capsule

Zarontin ® syrup

Anti-Depressants: SSRIs citalopram solution

citalopram tablet

escitalopram tabs

fluoxetine 60 mg

fluoxetine IR

fluoxetine solution

paroxetine

sertraline tablet

sertraline solution

Brisdelle ®

Celexa ® tablet

escitalopram soln

fluoxetine DR/weekly

fluvoxamine

Lexapro ®

Luvox CR ®

paroxetine CR

Paxil ®

Paxil CR ®

Pexeva ®

Prozac ®

Prozac ® weekly

Sarafem ®

Zoloft ® solution

Zoloft ® tablet

Anti-Depressants: Others bupropion IR/SR/XL

mirtazipine IR/ODT

nefazadone

trazodone

venlafaxine IR

venlafaxine ER caps

(OSM 24)

Aplenzin

Brintellix®

desvenlafaxine ER

Effexor ®

Effexor XR ®

Fetzima®

Forfivo XL®

Khedezla®

Oleptro ER ®

Pristiq ®

Remeron®

venlafaxine ER tabs

Viibryd ®

Wellbutrin ® IR/SR/XL

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 6 of 15
District of Columbia

Department of Health Care Finance

Pharmacy Preferred Drug List (PDL)

Effective June 17, 2015

Non-preferred medications require prior authorization Page 6 of 14

CENTRAL NERVOUS SYSTEM

Drug Class Preferred Requires Prior Authorization

Anti-Hyperkinesis Agents*

* Clinical criteria apply to this entire 

therapeutic class

Adderall XR ®

amphetamine salt

combo IR

dexmethylphenidate

dextroamphetamine IR 

tab 

dextroamphetamine soln 

Focalin XR ®u

Metadate CD ®

Metadate ER ®

methylphenidate

methylphenidate ER 18, 

27, 36, 54 mg

methylphenidate 

ER/SR/SA 10 & 20mg

Ritalin LA ®

Strattera ®

Vyvanse ®

Adderall ®

amphetamine salt

combo XR

Aptensio ®XR

clonidine ER

Concerta ®

Daytrana ®

Desoxyn ®

Dexedrine ® Spansule

dexmethylphenidate XR

dextroamphetamine ER

dextroamphetamine soln

(generic for Procentra)

Evekeo®

Focalin ®

Intuniv ®

Kapvay ®

Methamphetamine

Methylin ®

methylphenidate CD

methylphenidate ER cap 

(gen Ritalin LA)

methylphenidate Liquid

modafinil

Nuvigil ®

Procentra ®

Provigil ®

Qullivant®

Ritalin ® IR and SR

Zenzedi®

Anti-Migraine: 5-HT1 Receptor 

Agonists

rizatriptan tablet

sumatriptan injection

sumatriptan nasal

sumatriptan tablet

Alsuma ®

Amerge ®

Axert ®

Cambia ®

Frova ®

Imitrex ®

Maxalt ® / Maxalt MLT ®

Naratriptan

Relpax ®

rizatriptan ODT

Sumavel

Treximet ®

zolmitriptan

Zomig ®

Atypical Antipsychotics Abilify discmelt ®

Abilify ® solution

Abilify ® tablet

clozapine

Fanapt ®

Fanapt® titration pack

Latuda ®

Olanzapine

quetiapine

risperidone ODT

risperidone solution

risperidone tablet

Saphris ®

Seroquel XR ®

ziprasidone

aripiprazole 

clozapine ODT

Clozaril ®

Fazaclo ®

Geodon ®

Invega ®

olanzapine / fluoxetine

Risperdal ®

Seroquel ®

Symbyax ®

Versacloz®

Zyprexa ®

Multiple Sclerosis Agents Avonex ®

Avonex® pen

Betaseron ®

Copaxone ® 20mg Kit

Rebif ®

Rebif® Rebidose

Ampyra ®

Aubagio®

Copaxone® 40mg syringe

Extavia ®

Gilenya ®

Tecfidera®

Neuropathic Pain duloxetine

gabapentin caps & soln

Lyrica ® capsules

Savella ®

Cymbalta 

gabapentin tabs

Gralise ®

Horizant ®

Irenka®

lidocaine patch

Lidoderm ®

Lyrica® solution

Neurontin ®

Qutenza ®

Parkinson's Agents: Non-Ergot 

Dopamine Receptor Agonists

pramipexole ropinirole Mirapex ®

Mirapex ER ®

Neupro®

Pramipexole ER

Requip ®

Requip XL ®

ropinirole ER

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 7 of 15
District of Columbia

Department of Health Care Finance

Pharmacy Preferred Drug List (PDL)

Effective June 17, 2015

Non-preferred medications require prior authorization Page 7 of 14

CENTRAL NERVOUS SYSTEM

Drug Class Preferred Requires Prior Authorization

Sedative Hypnotic Agents flurazepam

temazepam 15 & 30 mg

triazolam

zolpidem tartrate IR

Ambien ® / Ambien CR ®

Belsomra®

Doral ®

Edluar ®

eszopiclone

estazolam

Halcion ®

Hetlioz®

Intermezzo ®

Lunesta ®

Lunesta ®

Restoril ®

Rozerem ®

Silenor ®

Sonata ®

temazepam 7.5 & 22.5mg

zaleplon

zolpidem ER

Zolpimist ®

Skeletal Muscle Relaxants baclofen

chlorzoxazone

cyclobenzaprine HCl

methocarbamol

tizanidine HCl tablet

Amrix ®

carisoprodol

carisoprodol compound

Dantrium ®

dantrolene sodium

Fexmid ®

Lorzone ®

metaxolone

Parafon Forte DSC ®

orphenadrine

orphenadrine compound

Robaxin ®

Soma ®

Skelaxin ®

tizanidine HCl capsule

Zanaflex ®

ENDOCRINE AND METABOLIC AGENTS

Drug Class Preferred Requires Prior Authorization

Agents for Gout allopurinol

colchicines tabs

probenecid

probenecid-colchicine

colchicines caps

Colcrys ®

Uloric ®

Zyloprim®

Androgenic Agents Androgel® Androderm®

Axiron ®

Fortesta ®

Natesto® (nasal)

Testim®

testosterone (topical)

Vogelxo®

Bone: Bisphosphonates alendronate tablet Actonel ®

alendronate soln

Atelvia ®

Binosto®

Boniva ®

Fosamax ®

Fosamax ® Plus D

Ibandronate

risedronate

Bone: Nasal Calcitonins Fortical ® calcitonin, salmon Miacalcin ®

Bone: Others Evista ® Forteo ®

Prolia ®

raloxifene

Diabetes: Amylin Analogs N/A Symlin ® Symlin ® Pens

Diabetes: DPP-IV Inhibitors Janumet ®

Janumet ® XR

Januvia ®

Jentadueto ®

Tradjenta ® Glyxambi®

Juvisync ®

Kazano®

Kombiglyze XR ®

Nesina®

Onglyza ®

Oseni®

Trulicity®

Diabetes: GLP-1 Receptor Agonists Byetta ® Victoza ® Bydureon ® Tanzeum®

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 8 of 15
District of Columbia

Department of Health Care Finance

Pharmacy Preferred Drug List (PDL)

Effective June 17, 2015

Non-preferred medications require prior authorization Page 8 of 14

ENDOCRINE AND METABOLIC AGENTS

Drug Class Preferred Requires Prior Authorization

Diabetes: Insulin 70/30 Humulin ® 70/30 vial Humulin ® 70/30 pen

Novolin ® 70/30 vial

Relion Novolin 70/30 vial

Diabetes: Insulin Mix NovoLog® Mix 70/30 vial

NovoLog® Mix 70/30 

flexpen syr

Humalog ® Mix 50/50 vial

Humalog® Mix 75/25 vial

Humalog ® Mix 50/50 

kwikpen

Humalog ® Mix 50/50 pen

Humalog ® Mix 75/25 

kwikpen

Humalog ® Mix 75/25 pen

Diabetes: Insulin N Humulin ® N 100 u/ml vial Humulin ® N 100 u/ml pen

Novolin ® N

Relion Novolin N 100 u/ml

Diabetes: Insulin R Humulin ® R 100 u/ml vial Humulin ® R 500 u/ml vial Afrezza® (Inhalation)

Novolin ® R

Relion Novolin R 100 u/ml

Diabetes: Long Acting Insulins Levemir ® FlexPens Levemir ® vial Lantus ® cartridges

Lantus Solostar ®

Lantus ® vial

Toujeo® Solostar

Diabetes: Meglitinides nateglinide Prandin ® repaglinide Starlix ®

Diabetes: Meglitinide Combinations N/A PrandiMet ®

Diabetes: Metformins and 

Metformin-Sulfonylurea 

Combinations

metformin

metformin-glyburide

metformin ER (generic for 

Glucophage XR)

Fortamet ®

Glucophage ®

Glucophage XR ®

Glucovance ®

Glumetza ®

metformin ER (generic for

Fortamet)

metformin-glipizide

Riomet ®

Diabetes: Rapid Acting Insulins NovoLog ® cartridge

Novolog ® flexpen syr

Novolog ® vial

Humalog ® 100 u/ml vial

Apidra ®

Apidra Solostar ®

Humalog® 100 u/ml 

cartridge

Humalog ® 100 u/ml 

kwikpen

Humalog ® 100 u/ml pen

Diabetes: SGLT2 Inhibitors Ivokana® Farxiga®

Invokamet®

Jardiance®

Xigduo XR®

Diabetes: Thiazolidinediones pioglitazone Acotplus Met ®

ActoPlus Met XR ®

Actos ®

Avandamet ®

Avandaryl ®

Avandia ®

DuetAct ®

pioglitazone-glimepiride

pioglitazone-metformin

Growth Hormones*

* Clinical criteria apply to this entire 

therapeutic class

Genotropin ® cartridge

Genotropin ® syringe

Nutropin®

Nutropin AQ Cartridge ®

Nutropin AQ Vial ®

Nutropin NuSpin ®

Humatrope ® Cartridge

Humatrope ® Vial

Norditropin ® Flexpro

Norditropin ® Nordiflex

Omnitrope®

Saizen ® Cartridge

Saizen ® Vial

Serostim ®

Tev-Tropin ®

Zorbtive ®

Progestins Used for Cachexia megestrol acetate oral 

susp

Megace ® oral susp Megace ® ES oral susp

Vaginal Estrogen Preparations

(Intravaginal and Topical)

Premarin ® Estrace®

Estring®

Femring®

Vagifem®

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 9 of 15
District of Columbia

Department of Health Care Finance

Pharmacy Preferred Drug List (PDL)

Effective June 17, 2015

Non-preferred medications require prior authorization Page 9 of 14

GASTROINTESTINAL

Drug Class Preferred Requires Prior Authorization

Antiemetics – Oral metoclopramide

ondansetron ODT

ondansetron tablet Anzemet ®

Diclegis®Emend®

granisetron

Metozolv ODT ®

ondansetron solution

Reglan ®

Sancuso ®

Zofran ODT ®

Zofran Solution ®

Zofran Tablet ®

Zuplenz ®

Histamine-2-Receptor Antagonists Axid® solution

cimetidine HCl tablet

famotidine tabs

ranitidine tabs/syrup

cimetidine HCl liquid

famotidine susp

nizatidine

Pepcid ® tablets

Pepcid ® oral susp

ranitidine caps

Zantac ® tablets

Zantac ® syrup

H. Pylori Combinations Helidac ® Pylera ® Lansoprazole / amoxicillin

/ clarithromycin (pack)

Omeclamox-pak ®

Prevpac ®

Irritable Bowel Syndrome Amitiza ® Linzess ® alosetron Lotronex ®

Pancreatic Enzymes Creon ®

pancrelipase

Zenpep ® Pancreaze ®

Pertzye ®

Ultresa®

Viokace ®

Proton Pump Inhibitors Nexium ® capsules

pantoprazole

Prilosec ® OTC Aciphex ®

Aciphex Sprinkle®

Dexilant (Kapidex) ®

esomeprazole (generic for 

Nexium)

esomeprazole strontium

lansoprazole (all)

Nexium ® OTC

Nexium ® susp packets

omeprazole OTC

omeprazole (Rx)

omeprazole / sodium 

bicarbonate (all)

Prevacid ® capsules

Prevacid ® 15mg OTC

Prevacid SoluTab ®

Prilosec ® (Rx)

Prilosec ® susp (Rx)

Protonix ®

Protonix susp ®

rabeprazole

Zegerid OTC ®

Ulcerative Colitis – Oral Apriso ®

Delzicol®

sulfasalazine DR

sulfasalazine IR

Asacol-HD ®

Azulfidine ®

Azulfidine EN-tabs ®

balsalazide

Colazal ®

Dipentum ®

Giazo®

Lialda ®

Pentasa ®

Uceris®

Ulcerative Colitis – Rectal Canasa ® rectal 

suppositories

mesalamine enema mesalamine kit

Rowasa ® enema kit

Rowasa ® enema

sfRowasa ® enema

GENITOURINARY AND RENAL

Drug Class Preferred Requires Prior Authorization

Alpha Blockers for BPH alfuzosin tamsulosin Flomax ® Rapaflo ®

Uroxatral ®

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 10 of 15
District of Columbia

Department of Health Care Finance

Pharmacy Preferred Drug List (PDL)

Effective June 17, 2015

Non-preferred medications require prior authorization Page 10 of 14

GENITOURINARY AND RENAL

Drug Class Preferred Requires Prior Authorization

Androgen Hormone Inhibitors finasteride Avodart ® Jalyn ®

Proscar ®

Electrolyte Depleters calcium acetate caps and 

tabs

Eliphos ®

Fosrenol ®

Renagel ®

Renvela ® tablets

Fosrenol Powder Pack®

Phoslyra ®

PhosLo ®

Renvela ® packets

sevelamer carbonate

Velphoro®

Urinary Tract Antispasmodics oxybutynin immediatereleaseoxybutynin syrup

Toviaz ®

Vesicare ®

Detrol®

Detrol LA ®

Ditropan XL®

Enablex ®

flavoxate

Gelnique ®

Myrbetriq ER®

oxybutynin extendedrelease

Oxytrol ®

Sanctura ®

Sanctura XR ®

tolterodine

trospium IR and ER

HEMATOLOGICAL AGENTS

Drug Class Preferred Requires Prior Authorization

Anticoagulants Fragmin ®

Lovenox ®

Pradaxa ®

warfarin

Xarelto ®

Arixtra ®

Coumadin ®

Eliquis®

Enoxaparin

Fondaparinux

Savaysa®

Hematopoietic Agents Aranesp ® Procrit ® Epogen ®

IMMUNOLOGIC AGENTS

Drug Class Preferred Requires Prior Authorization

Immunomodulators Enbrel ® Humira ® Cimzia ®

CimziaKit ®

Kineret ®

Orencia ® SQ

Otezla®

Simponi ®

Stelara ®

Xeljanz®

Immunosuppressants azathioprine

Cellcept ® susp

cyclosporine

cyclosporine, modified

Gengraf ®

Hecoria ®

mycophenolate mofetil

Myfortic ®

Prograf ®

sirolimus

Astagraf XL®

Azasan ®

Cellcept ®

Imuran ®

mycophenolic acid

Neoral ®

Rapamune ®

Sandimmune ®

tacrolimus

Zortress ®

Topical Immunomodulators Atopic 

Dermatitis

Elidel ® Protopic ® tacrolimus oint.

Immunomodulators, Topical Aldara® imiquimod Zyclara®

OPHTHALMICS

Drug Class Preferred Requires Prior Authorization

Allergic Conjunctivitis Agents:

Antihistamines

ketotifen OTC Pataday ® Alrex ®

azelastine ophth drops

Bepreve ®

Elestat ®

Emadine ®

epinastine

Lastacaft ®

Optivar ®

Patanol ®

Pazeo®

Zaditor® OTC

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 11 of 15
District of Columbia

Department of Health Care Finance

Pharmacy Preferred Drug List (PDL)

Effective June 17, 2015

Non-preferred medications require prior authorization Page 11 of 14

OPHTHALMICS

Drug Class Preferred Requires Prior Authorization

Allergic Conjunctivitis Agents:

Mast Cell Stabilizers

cromolyn Alocril ® Alomide ®

Glaucoma Agents:

Alpha2 Adrenergic Agents

Alphagan P 0.1% ®

Alphagan P 0.15% ®

brimonidine 0.2% apraclonidine

brimonidine P 0.15%

Iopidine ®

Glaucoma Agents:

Beta Blockers

Betimol ®

carteolol

Combigan ®

levobunolol

metipranolol

timolol maleate

timolol maleate gelforming soln

Betagan ®

betaxolol

Betoptic S ®

Istalol ®

Timoptic ®

Timoptic-XE ®

Glaucoma Agents:

Carbonic Anhydrase Inhibitors

Azopt ®

dorzolamide

dorzolamide/timolol

Simbrinza ®

Cosopt ®

Cosopt ® PF

Trusopt ®

Glaucoma Agents:

Prostaglandin Agonists

latanoprost Travatan Z ® bimatoprost 

Lumigan ®

Rescula ®

travoprost

Xalatan ®

Zioptan ®

Ophthalmic Antiinflammatories: 

NSAIDs

diclofenac sodium

flurbiprofen

ketorolac ophth 0.4 (LS)

ketorolac ophth 0.5

Acular ®

Acular LS ®

Acuvail ®

Bromday ®

Bromfenac ® 

Ilevro ®

Nevanac ®

Ocufen ®

Prolensa ®

Ophthalmic Antiinflammatories: 

Corticosteroids

dexamethasone

Durezol ®

Lotemax drops ®

prednisolone acetate

Flarex ®

FML ®

FML Forte ®

FML S.O.P. ®

fluorometholone

Lotemax gel ®

Lotemax oint ®

Maxidex ®

Omnipred ®

Pred Forte ®

Pred Mild ®

prednisolone sodium 

phosphate

Ophthalmic Antibiotics: Macrolides erythromycin Azasite ® Ilotycin ®

Ophthalmic Antibiotics: Quinolones ciprofloxacin drops

Moxeza ®

ofloxacin drops

Vigamox ®

Zymar ®

Besivance ®

Ciloxan Drops ®

Ciloxan ointment ®

gatifloxacin

levofloxacin ophth

Ocuflox ®

Zymaxid ®

Ophthalmic Antibiotic-Steroid 

Combinations

neomycin/polymyxin/ 

dexamethasone

Tobradex ® oint

Tobradex ® susp

Blephamide ®

Blephamide ® S.O.P.

Maxitrol ® drops

Maxitrol ® oint

neomycin/bacitracin/ 

polymyxin/HC

neomycin/polymyxin/HC

Preg-G ® drops

Pred-G ® oint

sulfacetamide/ 

prednisolone

Tobradex ® ST

tobramycin/ 

dexamethasone susp

Zylet ®

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 12 of 15
District of Columbia

Department of Health Care Finance

Pharmacy Preferred Drug List (PDL)

Effective June 17, 2015

Non-preferred medications require prior authorization Page 12 of 14

OTICS

Drug Class Preferred Requires Prior Authorization

Otic Antibiotics Ciprodex ®

neomycin/polymyxin/HC 

soln and susp

ofloxacin drops ciprofloxacin otic

Cipro HC ®

Coly-Mycin S ®

Cortisporin ® soln

Cortisporin-TC ®

PAH AGENTS

Drug Class Preferred Requires Prior Authorization

Endothelin Receptor Antagonists

and Other PAH agents

Tracleer ® Letairis ® Adempas® Opsumit®

Orenitram® ER

PAH, Inhalation Tyvaso ® Ventavis ® N/A

PDE Inhibitors for PPH/PAH

* Clinical criteria apply to this entire 

therapeutic class

sildenafil Adcirca ® Revatio ®

RESPIRATORY

Drug Class Preferred Requires Prior Authorization

Inhaled Antibiotics Bethkis® Cayston ®

Tobi ®

tobi podhaler®

tobramycin inhaled soln

COPD Agents Atrovent HFA ®

Combivent ®

Combivent Respimat®

Ipratropium / albuterol 

nebs

ipratropium bromide

Spiriva ®

Anoro Ellipta®

Daliresp ®

DuoNeb ®

Spiriva Respimat®

Stiolto Respimat®

Tudorza Pressair®

Antihistamines, Non-Sedating cetirizine solution

cetirizine solution (OTC)

cetirizine tablets (OTC)

loratadine / 

pseudoephedrine (OTC)

loratadine solution (OTC)

loratadine tablet

Allegra ®

Allegra ® ODT

Allegra-D ®

cetirizine 5 mg/5 ml OTC 

solution

cetirizine chewable (OTC)

cetirizine-D (Rx and OTC)

Clarinex ®

Clarinex-D ®

Claritin ®

Claritin-D ®

desloratadine

fexofenadine

fexofenadine-D

levocetirizine

loratidine ODT (OTC)

Semprex-D ®

Xyzal ®

Zyrtec ®

Beta Agonists: Oral Agents albuterol syrup

albuterol tablet

metaproterenol syrup

terbutaline

albuterol ER

metaproterenol tablet

Vospire ER ®

Beta Agonists: Short-Acting MDI ProAir ® HFA Proventil HFA ® Maxair Autohaler ®

Ventolin HFA ®

Xopenex HFA ®

Beta Agonists: Long-Acting MDI*

*COPD only

Foradil ® Arcapta ®

Serevent Diskus ®

Striverdi Respimat®

Beta Agonists: Nebulizer albuterol sulfate albuterol (gen AccuNeb ®) AccuNeb ®

Brovana ®

levalbuterol inh soln

Perforomist ®

Xopenex ®

Beta Agonists: Combination 

Products

Advair Diskus ®

Advair HFA®

Dulera ®

Symbicort ®

Breo Ellipta ®

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 13 of 15
District of Columbia

Department of Health Care Finance

Pharmacy Preferred Drug List (PDL)

Effective June 17, 2015

Non-preferred medications require prior authorization Page 13 of 14

RESPIRATORY

Drug Class Preferred Requires Prior Authorization

Corticosteroids Inhaled Asmanex ®

Flovent Diskus ®

Flovent HFA ®

QVAR ®

Pulmicort ® 0.25, 0.5 mg 

respules

Aerospan®

Alvesco ®

Asmanex HFA ®

Breo Ellipta®

budesonide 0.25, 0.5 mg 

respules

Pulmicort Flexhaler ®

Pulmicort ® 1 mg respules

Intranasal Corticosteroids fluticasone propionate Nasonex ® Beconase AQ ®

budesonide Nasal Spray

Dymista ®

Flonase ®

flunisolide

Nasacort AQ ®

Omnaris ®

Qnasl ®

Rhinocort Aqua ®

triamcinolone Nasal Spray

Veramyst ®

Zetonna ®

Intranasal Rhinitis Agents Astepro ®

ipratropium

Patanase ® Astelin ®

Atrovent ®

azelastine

Leukotriene Receptor Antagonists montelukast zafirlukast Accolate ®

Singulair ®

Zyflo ® CR

Self-Injectable Epinephrine EpiPen ® EpiPen ® Jr. Auvi-Q®

Adrenaclick®

epinephrine

TOPICAL AGENTS FOR ACNE

Drug Class Preferred Requires Prior Authorization

Aczone N/A Aczone ®

Benzoyl Peroxide/Antibiotic 

Combination Products

Benzaclin ® with pump

Benzamycin® topical

Acanya Gel and pump ®

Benzaclin® topical

benzoyl peroxide / 

clindamycin

Duac ® CS

erythromycin-benzoyl 

peroxide topical

Neuac®

Onexton®

Topical Retinoids Epiduo ®

Retin-A ® cream and gel

Tazorac ® Cream adapalene

Atralin ®

Avita ®

Differin ®

Fabior®

Retin-A ® micro

Retin-A ® micro pump

Tazorac gel ®

tretinoin

tretinoin micro

Tretin-X ®

Veltin ®

Ziana ®

TOPICAL AGENTS FOR PSORIASIS

Drug Class Preferred Requires Prior Authorization

Topical Agents for Psoriasis calcipotriene crm

calcipotriene oint

calcipotriene scalp soln

calcipotriene/ 

betamethasone

calcitrene

calcitriol oint

Dovonex ® cream

Sorilux ®

Taclonex ®

Vectical ®

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 14 of 15
District of Columbia

Department of Health Care Finance

Pharmacy Preferred Drug List (PDL)

Effective June 17, 2015

Non-preferred medications require prior authorization Page 14 of 14

TOPICAL STEROIDS

Drug Class Preferred Requires Prior Authorization

Low Potency Topical Steroids desonide (crm & oint) hydrocortisone (crm, gel 

& oint)

alclometasone 

dipropionate (crm, oint)

Aqua Glycolic HC ®

Capex Shampoo ®

DERMA-SMOOTHE-FS ®

Desonate gel ®

desonide lotion

Desowen ®

fluocinolone 0.01% oil

hydrocortisone lotion

hydrocortisone / min oil / 

pet oint

hydrocortisone acetate / 

urea

hydrocortisone / aloe gel

Pediaderm HC ®

Pediaderm TA ®

Texacort ®

U-Cort®

Verdeso ®

Medium Potency Topical Steroids hydrocortisone butyrate

soln

hydrocortisone valerate 

(crm & oint)

mometasone furoate 

(crm, oint & soln)

Cloderm ®

Cordran ® Lotion

Cordran ® SP oint

Cordran Tape ®

Cutivate ® (crm & lot)

Dermatop ® (crm & oint)

Elocon ®(crm, oint & soln)

fluocinolone acetonide 

(crm, oint & soln)

fluticasone propionate 

(crm, lot &oint)

hydrocortisone butyrate 

(crm, emol & oint)

Luxiq ®

Momexin®

Pandel ®

Prednicarbate (crm & 

oint)

Synalar® kit (crm & oint)

Synalar® soln

Synalar® TS kit

High Potency Topical Steroids betamethasone 

dipropionate (crm & lot)

betamethasone valerate 

crm

fluocinonide (crm, 

emollient, gel, oint &

soln)

triamcinolone acetonide 

(crm & oint)

amcinonide (crm, lot, oint)

betamethasone

dipropionate / prop gly 

(crm, lot & oint)

betamethasone 

dipropionate (gel & oint)

betamethasone valerate 

(crm, lot, & oint)

desoximetasone (crm, gel

& oint)

diflorasone diacetate (crm 

& oint)

Diprolene ® (lot & oint)

Diprolene AF ® cream

Halog ® (crm & oint)

Kenalog Aerosol ®

Topicort LP ®

triamcinolone acetonide 

lotion

Trianex ®

Vanos®

Very High Potency Topical Steroids clobetasol emollient

cream

clobetasol propionate 

(crm, gel, oint & soln)

halobetasol propionate 

(crm & oint)

Apexicon E ®

clobetasol lotion & 

shampoo

clobetasol propionate 

foam

Clobex ® (lotion, shampoo

& spray)

Clodan®

Halonate ®

Olux ®

Olux-E ®

Temovate ®

Ultravate ® (crm & oint)

USCA Case #14-7054 Document #1592578 Filed: 07/17/2015 Page 15 of 15