Michigan Preferred Drug List (PDL)/Single PDL - Magellan Rx Management
嚜燐ichigan Preferred Drug List (PDL)/Single PDL
Effective 08/01/2024
Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page
ANALGESICS
Drug Class
Preferred Agents
Opioids 每 Long Acting
morphine sulfate ER tablets
tramadol ER tablets10
Opioids 每 Short and Intermediate Acting
codeine10,2
codeine/acetaminophen10
hydrocodone/acetaminophen
hydromorphone oral tablets2
morphine sulfate tablets, solution2
morphine sulfate supp
oxycodone tabs (5mg,10mg,15mg)2
oxycodone oral solution2
oxycodone /acetaminophen
tramadol10
tramadol/acetaminophen10
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.
2 Quantity limits apply 每 Refer to document at
3 Prior Authorization Required if Beneficiary is Over the Age of 65
4 PA required if a benzodiazepine is found in beneficiary drug history
5 Providers should consult yearly CDC guidelines for Influenza
6 Prior Authorization Required for Beneficiaries Under 15 years of age
7 Prior Authorization Required for Beneficiaries Under 18 years of age
8 Components of product must be in drug history
9 Electronic Step edit:2 or more NSAIDs on MPPL in history
10 Prior Authorization Required for Beneficiaries Under Age of 12
Non-Preferred Agents
Belbuca??2
Conzip ER?10
Diskets?
hydrocodone ER (generic Hysingla?, Zohydro ER)
hydromorphone ER?
Hysingla ER?
methadone
morphine sulfate ER caps (generic Avinza?)
morphine sulfate ER caps (generic Kadian?)
MS Contin?
Nucynta ER?
Oxycontin?2
oxycodone ER2
oxymorphone ER
tramadol ER capsules10
Xtampza ER??2
butorphanol2
codeine / acetaminophen/caffeine /butalbital 10
codeine / aspirin /caffeine /butalbital 10
dihydrocodeine/acetaminophen/caffeine
Dilaudid? all forms2
fentanyl citrate buccal2
Fentora??2
Fioricet w/ Codeine?10
hydrocodone/ ibuprofen
hydromorphone suppository
levorphanol
meperidine tablets, solution2
Nalocet?
Nucynta?
oxycodone caps 2
oxycodone tabs (20mg, 30mg)2
oxycodone oral conc soln2
oxycodone oral syr2
11 Prior Authorization Required for Beneficiaries over 5 years of age
12 Prior Authorization Required for Beneficiaries over 14 years of age
13 Prior Authorization Required if Beneficiary is Over the Age of 75
14 Prior Authorization Required for Beneficiaries Under 2 years of age
15 Prior Authorization Required for Beneficiaries Under 16 years of age
16 Prior Authorization Required for Beneficiaries Under 6 years of age
17 Prior Authorization Required for Beneficiaries Under 60 years of age
APAP = Acetaminophen ASA = Aspirin
CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide
? Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at
?Only products that can be self-administered will be included in the PDL class as other products are typically
billed as a medical benefit
Version 08012024v1
Page 1 of 43
Michigan Preferred Drug List (PDL)/Single PDL
Effective 08/01/2024
Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page
ANALGESICS
Drug Class
Opioids 每 Transdermal
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Preferred Agents
Non-Preferred Agents
oxymorphone2
pentazocine/naloxone
Percocet?
Prolate?
Qdolo?10
Roxybond?2
Roxicodone?2
Seglentis?10,2
tramadol oral solution (generic for Qdolo?)10
2
Butrans?
buprenorphine patches2
fentanyl patches (generic only) 2
fentanyl patches 37.5mg, 62.5mg and 87.5mg only
diclofenac
Arthrotec?
diclofenac topical gel 1% (generic for Voltaren) Daypro?
diclofenac topical gel 1% OTC
diclofenac ER
diclofenac topical solution 1.5%
diclofenac epolamine 1.3% patch
ibuprofen
diclofenac-misoprostol
indomethacin capsules
diclofenac potassium
ketorolac tablets
diclofenac 2% pump (generic for Pennsaid)
meloxicam tablets
diflunisal
nabumetone
Dual Action Pain (ibuprofen/acetaminophen)
naproxen OTC
Duexis?
naproxen (generic for Naprosyn?)
EC-naproxen
sulindac
etodolac / etodolac ER
Feldene?
fenoprofen
Flector Patch?2
flurbiprofen
indomethacin ext release capsules
indomethacin oral suspension
ketoprofen ext release
ketoprofen immediate release
ketorolac nasal spray?
Licart?2
Lofena?
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.
2 Quantity limits apply 每 Refer to document at
3 Prior Authorization Required if Beneficiary is Over the Age of 65
4 PA required if a benzodiazepine is found in beneficiary drug history
5 Providers should consult yearly CDC guidelines for Influenza
6 Prior Authorization Required for Beneficiaries Under 15 years of age
7 Prior Authorization Required for Beneficiaries Under 18 years of age
8 Components of product must be in drug history
9 Electronic Step edit:2 or more NSAIDs on MPPL in history
10 Prior Authorization Required for Beneficiaries Under Age of 12
11 Prior Authorization Required for Beneficiaries over 5 years of age
12 Prior Authorization Required for Beneficiaries over 14 years of age
13 Prior Authorization Required if Beneficiary is Over the Age of 75
14 Prior Authorization Required for Beneficiaries Under 2 years of age
15 Prior Authorization Required for Beneficiaries Under 16 years of age
16 Prior Authorization Required for Beneficiaries Under 6 years of age
17 Prior Authorization Required for Beneficiaries Under 60 years of age
APAP = Acetaminophen ASA = Aspirin
CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide
? Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at
?Only products that can be self-administered will be included in the PDL class as other products are typically
billed as a medical benefit
Version 08012024v1
Page 2 of 43
Michigan Preferred Drug List (PDL)/Single PDL
Effective 08/01/2024
Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page
ANALGESICS
Drug Class
Non-Steroidal Anti-Inflammatory 每
Cox II Inhibitors
Opioid Use Disorder Treatments
Opioid Withdrawal Symptom Management
Preferred Agents
celecoxib2
Brixadi?
buprenorphine SL tabs2
buprenorphine/naloxone SL tabs2
naltrexone tablets
Sublocade? SC injection
Suboxone? SL films2
Vivitrol? IM injection
Zubsolv? SL tabs 2
clonidine tabs
guanfacine/guanfacine ER
Lucemyra?
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.
2 Quantity limits apply 每 Refer to document at
3 Prior Authorization Required if Beneficiary is Over the Age of 65
4 PA required if a benzodiazepine is found in beneficiary drug history
5 Providers should consult yearly CDC guidelines for Influenza
6 Prior Authorization Required for Beneficiaries Under 15 years of age
7 Prior Authorization Required for Beneficiaries Under 18 years of age
8 Components of product must be in drug history
9 Electronic Step edit:2 or more NSAIDs on MPPL in history
10 Prior Authorization Required for Beneficiaries Under Age of 12
Non-Preferred Agents
meclofenamate sodium
mefenamic acid
meloxicam capsules
Nalfon?
Naprelan CR?
Naprosyn? suspension
naproxen (generic for Anaprox)
naproxen delayed release
naproxen/esomeprazole (generic for Vimovo)
naproxen suspension
oxaprozin
Pennsaid?
piroxicam
Relafen DS?
Tolectin?
tolmetin sodium
Vimovo??
Celebrex?2
buprenorphine/naloxone SL film (generic Suboxone films)2
11 Prior Authorization Required for Beneficiaries over 5 years of age
12 Prior Authorization Required for Beneficiaries over 14 years of age
13 Prior Authorization Required if Beneficiary is Over the Age of 75
14 Prior Authorization Required for Beneficiaries Under 2 years of age
15 Prior Authorization Required for Beneficiaries Under 16 years of age
16 Prior Authorization Required for Beneficiaries Under 6 years of age
17 Prior Authorization Required for Beneficiaries Under 60 years of age
APAP = Acetaminophen ASA = Aspirin
CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide
? Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at
?Only products that can be self-administered will be included in the PDL class as other products are typically
billed as a medical benefit
Version 08012024v1
Page 3 of 43
Michigan Preferred Drug List (PDL)/Single PDL
Effective 08/01/2024
Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page
ANTIBIOTICS / ANTI-INFECTIVES
Drug Class
Antibiotics 每 Inhaled
Antifungals 每 Oral
Antifungals 每 Topical
Preferred Agents
Bethkis?
Cayston ?
Kitabis?
Tobi-Podhaler?
tobramycin inhalation solution (generic for Tobi)
clotrimazole troches
fluconazole2
griseofulvin oral suspension
ketoconazole tablets
nystatin oral susp, tablets
terbinafine2
ciclopirox cream (generic for Loprox, Ciclodan)
ciclopirox 8% solution (generic for Ciclodan)
clotrimazole OTC cream, solution
clotrimazole Rx cream
clotrimazole/betamethasone cream
ketoconazole
miconazole nitrate
nystatin
nystatin/triamcinolone cream, ointment
tolnaftate cream, powder
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.
2 Quantity limits apply 每 Refer to document at
3 Prior Authorization Required if Beneficiary is Over the Age of 65
4 PA required if a benzodiazepine is found in beneficiary drug history
5 Providers should consult yearly CDC guidelines for Influenza
6 Prior Authorization Required for Beneficiaries Under 15 years of age
7 Prior Authorization Required for Beneficiaries Under 18 years of age
8 Components of product must be in drug history
9 Electronic Step edit:2 or more NSAIDs on MPPL in history
10 Prior Authorization Required for Beneficiaries Under Age of 12
Non-Preferred Agents
TOBI? inhalation
tobramycin inhalation solution (generic for Bethkis)
tobramycin inhalation solution (generic for Katabis)
Ancobon
Brexafemme2?
Cresemba??
Diflucan?2
flucytosine
griseofulvin tablets
griseofulvin microsize tablets
griseofulvin ultramicrosize
itraconazole2?
Noxafil?, Noxafil DR?
posaconazole
Sporanox? 2?
Tolsura?
Vfend??
Vivjoa2?
voriconazole?
butenafine
Ciclodan?
ciclopirox shampoo
ciclopirox suspension (generic for Loprox?)
clotrimazole / betamethasone lotion
clotrimazole Rx solution
econazole nitrate
Ertaczo?
Extina?
Jublia??
Kerydin??
ketoconazole foam
Ketodan?
11 Prior Authorization Required for Beneficiaries over 5 years of age
12 Prior Authorization Required for Beneficiaries over 14 years of age
13 Prior Authorization Required if Beneficiary is Over the Age of 75
14 Prior Authorization Required for Beneficiaries Under 2 years of age
15 Prior Authorization Required for Beneficiaries Under 16 years of age
16 Prior Authorization Required for Beneficiaries Under 6 years of age
17 Prior Authorization Required for Beneficiaries Under 60 years of age
APAP = Acetaminophen ASA = Aspirin
CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide
? Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at
?Only products that can be self-administered will be included in the PDL class as other products are typically
billed as a medical benefit
Version 08012024v1
Page 4 of 43
Michigan Preferred Drug List (PDL)/Single PDL
Effective 08/01/2024
Preferred Agents do not require prior authorization, except as noted in the chart at the bottom of the page
ANTIBIOTICS / ANTI-INFECTIVES
Drug Class
Antivirals 每 Herpes
Antivirals 每 Influenza
5
Antivirals 每 Topical
Preferred Agents
acyclovir tablets, capsules, suspension
famciclovir
valacyclovir
oseltamivir2
Relenza?2
rimantadine
Xofluza?
acyclovir cream, ointment
Denavir?
Cephalosporins - 1st Generation
cefadroxil capsules2
cefadroxil suspension
cephalexin
Cephalosporins - 2nd Generation
cefuroxime2
cefprozil tablets2
cefprozil suspension
cefdinir capsules, suspension2
cefixime capsules
Cephalosporins - 3rd Generation
1 Prior Authorization Not Required for Beneficiaries Under the Age of 12.
2 Quantity limits apply 每 Refer to document at
3 Prior Authorization Required if Beneficiary is Over the Age of 65
4 PA required if a benzodiazepine is found in beneficiary drug history
5 Providers should consult yearly CDC guidelines for Influenza
6 Prior Authorization Required for Beneficiaries Under 15 years of age
7 Prior Authorization Required for Beneficiaries Under 18 years of age
8 Components of product must be in drug history
9 Electronic Step edit:2 or more NSAIDs on MPPL in history
10 Prior Authorization Required for Beneficiaries Under Age of 12
Non-Preferred Agents
Loprox?
Lotrimin AF?
luliconazole
Luzu?
Mentax?
miconazole/zinc oxide/petrolatum
Micotrin AC?
Mycozyl AC?
Naftin?
naftifine
oxiconazole
Oxistat?
tavaborole
Vusion?
Valtrex?
Zovirax?
Flumadine?
Tamiflu?2
penciclovir
Xerese?
Zovirax? cream
Zovirax? ointment
cefadroxil tablets2
cefaclor2
cefaclor ER2
cefixime suspension
cefpodoxime tablets2
11 Prior Authorization Required for Beneficiaries over 5 years of age
12 Prior Authorization Required for Beneficiaries over 14 years of age
13 Prior Authorization Required if Beneficiary is Over the Age of 75
14 Prior Authorization Required for Beneficiaries Under 2 years of age
15 Prior Authorization Required for Beneficiaries Under 16 years of age
16 Prior Authorization Required for Beneficiaries Under 6 years of age
17 Prior Authorization Required for Beneficiaries Under 60 years of age
APAP = Acetaminophen ASA = Aspirin
CR, ER, SR, XL, XR, SA, LA = Extended Release, HCT = Hydrochlorothiazide
? Clinical PA required; refer to MI Clinical and PDL PA Criteria and PDL Criteria at
?Only products that can be self-administered will be included in the PDL class as other products are typically
billed as a medical benefit
Version 08012024v1
Page 5 of 43
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