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MassHealth Drug List A - Z


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This is a listing of all of the drugs covered by MassHealth. Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for.



MassHealth Drug List table
Drug - Brand Name (Generic Name) PA Status Class Drug Notes
Dymista (azelastine / fluticasone propionate)drugId:2580 NASAL PREPARATIONS BP
double antibiotic ointment (bacitracin / polymyxin B topical ointment)drugId:6260 ANTIBIOTICS *
DiprolenedrugId:5022 (betamethasone dipropionate, augmented ointment)drugId:5022 GLUCOCORTICOIDS #
DiurildrugId:221 (chlorothiazide)drugId:221 CARDIOVASCULAR #
DuraclondrugId:2750 (clonidine injection)drugId:2750 ANALGESICS #
dabigatran etexilate mesylatedrugId:5286 ANTICOAGULANTS BP
dacarbazinedrugId:319 CHEMOTHERAPY
dactinomycindrugId:2674 CHEMOTHERAPY #
dalteparindrugId:321 ANTICOAGULANTS
danazol HORMONE AGENTS
dantrolene capsuledrugId:323 MUSCLE RELAXANT #
DantriumdrugId:323 (dantrolene capsule)drugId:323 MUSCLE RELAXANT #
dantrolene injection solutiondrugId:4645 MUSCLE RELAXANT ^
Dantrium (dantrolene injection solution)drugId:4645 MUSCLE RELAXANT ^
dantrolene injection suspensiondrugId:4634 MUSCLE RELAXANT ^
dapagliflozindrugId:2923 DIABETIC AGENTS
dapagliflozin / metformin extended-releasedrugId:4841 DIABETIC AGENTS
dapsone tabletdrugId:324 ANTIBIOTICS
daptomycindrugId:326 ANTIBIOTICS #
darunavirdrugId:330 ANTIVIRALS BP PD
darunavir / cobicistatdrugId:4792 ANTIVIRALS PD
darunavir / cobicistat / emtricitabine / tenofovir alafenamidedrugId:6822 ANTIVIRALS PD
dasatinibdrugId:331 CHEMOTHERAPY
daunorubicin, conventionaldrugId:2676 CHEMOTHERAPY
decitabinedrugId:332 CHEMOTHERAPY #
DacogendrugId:332 (decitabine)drugId:332 CHEMOTHERAPY #
decitabine / cedazuridinedrugId:7597 CHEMOTHERAPY
deferasirox 125 mg, 250 mg, 500 mgdrugId:333 ANTIDOTES BP
deferasirox 90 mg, 180 mg, 360 mgdrugId:4942 ANTIDOTES #
deferoxaminedrugId:334 CHELATING AGENT #
DesferaldrugId:334 (deferoxamine)drugId:334 CHELATING AGENT #
demeclocyclinedrugId:337 ANTIBIOTICS
desloratadine syrup, tabletdrugId:339 ANTIHISTAMINES #
desmopressin-DDAVPdrugId:476 HORMONE AGENTS #
DDAVPdrugId:476 (desmopressin-DDAVP)drugId:476 HORMONE AGENTS #
desonide creamdrugId:484 GLUCOCORTICOIDS #
DesowendrugId:484 (desonide cream)drugId:484 GLUCOCORTICOIDS #
desonide ointmentdrugId:7960 GLUCOCORTICOIDS
desoximetasone 0.25% creamdrugId:7961 GLUCOCORTICOIDS
dexamethasone injectiondrugId:5131 GLUCOCORTICOIDS
dexamethasone intravitreal implantdrugId:494 OPHTHALMIC PREPARATIONS ^
dexamethasone ophthalmic insertdrugId:7181 OPHTHALMIC PREPARATIONS ^
Dextenza (dexamethasone ophthalmic insert)drugId:7181 OPHTHALMIC PREPARATIONS ^
dexamethasone ophthalmic suspensiondrugId:493 OPHTHALMIC PREPARATIONS
dexamethasone sodium phosphate ophthalmic solutiondrugId:4919 OPHTHALMIC PREPARATIONS
dexamethasone solution, tabletdrugId:2491 GLUCOCORTICOIDS #
DecadrondrugId:2491 (dexamethasone solution, tablet)drugId:2491 GLUCOCORTICOIDS #
dexrazoxane ANTIDOTES
dextrindrugId:6205 GASTROINTESTINAL AGENT *
dextrose ELECTROLYTES AND NUTRIENTS
diazepam injectiondrugId:7663 BENZODIAZEPINES
diazoxide DIABETIC AGENTS BP
diclofenac 1% geldrugId:512 NONSTEROIDAL ANTI-INFLAMMATORY #
diclofenac 3% geldrugId:508 CHEMOTHERAPY #
diclofenac extended-releasedrugId:513 NONSTEROIDAL ANTI-INFLAMMATORY #
diclofenac ophthalmic solutiondrugId:2269 OPHTHALMIC PREPARATIONS
diclofenac tabletdrugId:2117 NONSTEROIDAL ANTI-INFLAMMATORY
diclofenac topical solutiondrugId:1944 NONSTEROIDAL ANTI-INFLAMMATORY
dicloxacillindrugId:515 ANTIBIOTICS
dicyclominedrugId:516 ANTISPASMODICS,ANTICHOLINERGIC #
didanosinedrugId:517 ANTIVIRALS
dienestrol HORMONE REPLACEMENT THERAPY
diflunisaldrugId:521 NONSTEROIDAL ANTI-INFLAMMATORY
difluprednatedrugId:522 OPHTHALMIC PREPARATIONS BP
Durezol (difluprednate)drugId:522 OPHTHALMIC PREPARATIONS BP
digoxin CARDIOVASCULAR #
diltiazem 120 mg, 180 mg, 240 mg, 300 mg-Cardizem CDdrugId:531 CARDIOVASCULAR #
diltiazem extended-release tabletdrugId:529 CARDIOVASCULAR #
diltiazem-CardizemdrugId:528 CARDIOVASCULAR #
diltiazem-Tiazac ERdrugId:533 CARDIOVASCULAR #
dimenhydrinate injectiondrugId:2677 ANTIHISTAMINES
dimercaprol ANTIDOTES ^
dimethyl sulfoxide solutiondrugId:2694 ANALGESICS
diphenhydraminedrugId:541 ANTIHISTAMINES * #
diphenoxylate / atropinedrugId:542 ANTIDIARRHEALS #
diphtheria / tetanus / acellular pertussis / poliovirus inactivated / haemophilus B conjugate / hepatitis B vaccinedrugId:7571 BIOLOGICAL
diphtheria / tetanus / acellular pertussis / poliovirus inactivated / haemophilus B conjugate vaccinedrugId:581 BIOLOGICAL 1
diphtheria / tetanus toxoids / acellular pertussis / hepatitis B, recombinant / poliovirus, inactivated vaccinedrugId:700 BIOLOGICAL 1
diphtheria / tetanus toxoids / acellular pertussis / poliovirus, inactivated vaccinedrugId:535 BIOLOGICAL 1
diphtheria / tetanus toxoids / acellular pertussis vaccinedrugId:536 BIOLOGICAL 1
Daptacel (diphtheria / tetanus toxoids / acellular pertussis vaccine)drugId:536 BIOLOGICAL 1
diphtheria / tetanus toxoids vaccinedrugId:7777 BIOLOGICALS 1
dipyridamoledrugId:545 ANTIPLATELET AGENT
disopyramide controlled-releasedrugId:548 CARDIOVASCULAR
disopyramide immediate-releasedrugId:546 CARDIOVASCULAR #
disulfiramdrugId:549 ALCOHOL AND DRUG CESSATION AGENT #
docetaxeldrugId:2985 CHEMOTHERAPY
Docefrez (docetaxel)drugId:2985 CHEMOTHERAPY
docusate enemadrugId:555 CONSTIPATION AGENTS
docusate sodiumdrugId:554 CONSTIPATION AGENTS *
dofetilide CARDIOVASCULAR #
dolutegravir / lamivudinedrugId:7240 ANTIVIRALS PD
Dovato (dolutegravir / lamivudine)drugId:7240 ANTIVIRALS PD
dolutegravir / rilpivirinedrugId:6781 ANTIVIRALS PD
dolutegravir tablet for oral suspensiondrugId:7459 ANTIVIRALS
doravirinedrugId:6986 ANTIVIRALS PD
doravirine / lamivudine / tenofovir disoproxil fumaratedrugId:6981 ANTIVIRALS PD
Delstrigo (doravirine / lamivudine / tenofovir disoproxil fumarate)drugId:6981 ANTIVIRALS PD
dornase alfadrugId:562 ENZYMES
dorzolamidedrugId:563 OPHTHALMIC PREPARATIONS #
dorzolamide / timololdrugId:564 OPHTHALMIC PREPARATIONS #
doxazosin immediate-release; See Table 18drugId:565; See Table 19drugId:5163 CARDIOVASCULAR #
doxercalciferol injectiondrugId:5780 ELECTROLYTES AND NUTRIENTS ^
doxorubicindrugId:571 CHEMOTHERAPY #
doxorubicin liposomal injectiondrugId:2689 CHEMOTHERAPY #
DoxildrugId:2689 (doxorubicin liposomal injection)drugId:2689 CHEMOTHERAPY #
doxycycline calcium syrupdrugId:2903 ANTIBIOTICS
doxycycline hyclate 100 mg capsuledrugId:575 ANTIBIOTICS #
doxycycline hyclate 20 mg, 100 mg tabletdrugId:2902 ANTIBIOTICS
doxycycline hyclate 50 mg capsuledrugId:2901 ANTIBIOTICS
doxycycline hyclate injectiondrugId:2301 ANTIBIOTICS
doxycycline monohydrate 50 mg, 100 mg capsuledrugId:2899 ANTIBIOTICS
doxycycline monohydrate 50 mg, 75 mg, 100 mg tabletdrugId:2300 ANTIBIOTICS
doxycycline monohydrate suspensiondrugId:2904 ANTIBIOTICS #
doxylamine SEDATIVE, NON-BARBITURATE *
dronedarone CARDIOVASCULAR
droperidol ANTIPSYCHOTIC
drospirenone CONTRACEPTIVES
dulaglutidedrugId:4814 DIABETIC AGENTS PD
Descovy (emtricitabine / tenofovir alafenamide)drugId:5381 ANTIVIRALS PD
Delestrogen (estradiol-Delestrogen) HORMONE REPLACEMENT THERAPY #
Depo-estradiol (estradiol-Depo-estradiol) HORMONE REPLACEMENT THERAPY
Divigel (estradiol-Divigel) HORMONE REPLACEMENT THERAPY
Duavee (estrogens, conjugated/bazedoxifene) ESTROGENS
DiflucandrugId:860 (fluconazole)drugId:860 FUNGICIDES #
Derma-Smoothe-FSdrugId:867 (fluocinolone body oil, scalp oil)drugId:867 GLUCOCORTICOIDS #
DermoticdrugId:870 (fluocinolone oil, otic drops)drugId:870 OTIC PREPARATIONS #
DyazidedrugId:1755 (hydrochlorothiazide / triamterene)drugId:1755 CARDIOVASCULAR #
Droxia (hydroxyurea)drugId:760 HEMATOLOGIC
Dilatrate-SR (isosorbide dinitrate extended-release capsule)drugId:977 CARDIOVASCULAR
Depo-Provera (medroxyprogesterone injection) CONTRACEPTIVES #
Depo-SubQ Provera 104 (medroxyprogesterone injection) CONTRACEPTIVES
Delzicol DRdrugId:2720 (mesalamine capsule)drugId:2720 GI ANTI-INFLAMMATORY #
Depo-MedroldrugId:966 (methylprednisolone acetate)drugId:966 GLUCOCORTICOIDS #
Demser (metyrosine) CARDIOVASCULAR BP
Dulera (mometasone / formoterol)drugId:1958 BRONCHODILATORS BP
Dipentum (olsalazine)drugId:1286 GI ANTI-INFLAMMATORY
DayprodrugId:1309 (oxaprozin)drugId:1309 NONSTEROIDAL ANTI-INFLAMMATORY #
Ditropan XLdrugId:1314 (oxybutynin extended-release tablet)drugId:1314 URINARY ANTISPASMODICS #
Depen (penicillamine tablet) CHELATING AGENT #
Dilantin Infatab (phenytoin chewable tablet); See Table 20drugId:1523; See Table 71drugId:4520 ANTICONVULSANTS #
Dilantin (phenytoin extended 30 mg and 100 mg capsule); See Table 20drugId:1525; See Table 71drugId:4523 ANTICONVULSANTS #
Dilantin-125 (phenytoin suspension); See Table 20drugId:2938; See Table 71drugId:4522 ANTICONVULSANTS #
Detrol LAdrugId:1725 (tolterodine extended-release)drugId:1725 URINARY ANTISPASMODICS #
DetroldrugId:1726 (tolterodine immediate-release)drugId:1726 URINARY ANTISPASMODICS #
DemadexdrugId:1732 (torsemide)drugId:1732 CARDIOVASCULAR #
DepacondrugId:1780 (valproate)drugId:1780 ANTICONVULSANTS #
DiovandrugId:1785 (valsartan)drugId:1785 CARDIOVASCULAR #
Diovan HCTdrugId:1786 (valsartan / hydrochlorothiazide)drugId:1786 CARDIOVASCULAR #
Diacomit (stiripentol); See Table 20drugId:7132; See Table 71drugId:7133 PA ANTICONVULSANTS
dihydrocodeine / acetaminophen / caffeinedrugId:5142 PA OPIOID ANALGESICS
dihydrocodeine / aspirin / caffeinedrugId:525 PA OPIOID ANALGESICS
Duragesic (fentanyl 75, 100 mcg/hr transdermal system)drugId:4800 PA OPIOID ANALGESICS
Demerol (meperidine)drugId:1144 PA OPIOID ANALGESICS
Dolophine (methadone oral-Dolophine)drugId:1163 PA OPIOID ANALGESICS
Duramorph (morphine, injection-Duramorph)drugId:1392 PA > 120 mg/day OPIOID ANALGESICS
DilaudiddrugId:754 (hydromorphone)drugId:754 PA > 32 mg/day OPIOID ANALGESICS #
DuragesicdrugId:845 (fentanyl 12, 25, 50 mcg/hr transdermal system)drugId:845 PA > 50 mcg/hr and PA > 10 patches/month OPIOID ANALGESICS #
diclofenac 18 mg, 35 mg capsuledrugId:2894 PA NONSTEROIDAL ANTI-INFLAMMATORY
diclofenac 25 mg capsuledrugId:511 PA NONSTEROIDAL ANTI-INFLAMMATORY
diclofenac powder for solutiondrugId:1953 PA NONSTEROIDAL ANTI-INFLAMMATORY
diclofenac topical patch-FlectordrugId:509 PA NONSTEROIDAL ANTI-INFLAMMATORY
diclofenac topical patch-LicartdrugId:7454 PA NONSTEROIDAL ANTI-INFLAMMATORY
diclofenac / misoprostoldrugId:514 PA < 60 years NONSTEROIDAL ANTI-INFLAMMATORY #
DuexisdrugId:2363 (ibuprofen / famotidine)drugId:2363 PA < 60 years NONSTEROIDAL ANTI-INFLAMMATORY #
doxylamine / pyridoxine delayed-releasedrugId:2778 PA ANTIEMETICS BP
Diclegis (doxylamine / pyridoxine delayed-release)drugId:2778 PA ANTIEMETICS BP
doxylamine / pyridoxine extended-releasedrugId:6680 PA ANTIEMETICS
dupilumabdrugId:6101 PA BIOLOGICAL
Dupixent (dupilumab)drugId:6101 PA BIOLOGICAL
delafloxacin tabletdrugId:6481 PA ANTIBIOTICS
doxycycline hyclate 75 mg, 150 mg tabletdrugId:6141 PA ANTIBIOTICS
doxycycline hyclate delayed-release 50 mg, 80 mg, 120 mg, 200 mg tabletdrugId:2900 PA ANTIBIOTICS
Doryx (doxycycline hyclate delayed-release 50 mg, 80 mg, 120 mg, 200 mg tablet)drugId:2900 PA ANTIBIOTICS
doxycycline hyclate delayed-release 75 mg, 100 mg, 150 mg tabletdrugId:574 PA ANTIBIOTICS
doxycycline monohydrate 150 mg capsuledrugId:576 PA ANTIBIOTICS
doxycycline monohydrate 150 mg tabletdrugId:2905 PA ANTIBIOTICS
doxycycline monohydrate 40 mg capsuledrugId:579 PA ANTIBIOTICS
doxycycline monohydrate 75 mg capsuledrugId:2906 PA ANTIBIOTICS
Dificid (fidaxomicin)drugId:2283 PA ANTIBIOTICS
Daraprim (pyrimethamine)drugId:1614 PA ANTIMALARIALS BP
dexlansoprazoledrugId:496 PA > 1 unit/day PROTON PUMP INHIBITORS BP
Dexilant (dexlansoprazole)drugId:496 PA > 1 unit/day PROTON PUMP INHIBITORS BP
Dyanavel XR (amphetamine extended-release 2.5 mg/mL oral suspension); See Table 31drugId:5383; See Table 71drugId:5384 PA CEREBRAL STIMULANTS
dextroamphetamine 2.5 mg, 7.5 mg, 15 mg, 20 mg, 30 mg tablet; See Table 31drugId:2819; See Table 71drugId:3121 PA CEREBRAL STIMULANTS
Daytrana (methylphenidate transdermal); See Table 31drugId:955; See Table 71drugId:3060 PA < 3 years and PA > 1 unit/day CEREBRAL STIMULANTS
dexmethylphenidate extended-release; See Table 31drugId:498; See Table 71drugId:3020 PA < 3 years and PA > 2 units/day CEREBRAL STIMULANTS BP PD
dexmethylphenidate; See Table 31drugId:497; See Table 71drugId:3101 PA < 3 years and PA > 3 units/day CEREBRAL STIMULANTS #
dextroamphetamine 5 mg, 10 mg tablet; See Table 31drugId:2968; See Table 71drugId:3120 PA < 3 years and PA > 3 units/day CEREBRAL STIMULANTS
dextroamphetamine 5 mg, 10 mg, 15 mg capsule; See Table 31drugId:500; See Table 71drugId:3140 PA < 3 years and PA > 3 units/day CEREBRAL STIMULANTS #
Dexedrine Spansule (dextroamphetamine 5 mg, 10 mg, 15 mg capsule); See Table 31drugId:500; See Table 71drugId:3140 PA < 3 years and PA > 3 units/day CEREBRAL STIMULANTS #
dextroamphetamine solution; See Table 31drugId:501; See Table 71drugId:3141 PA < 3 years and PA > 40 mL/day CEREBRAL STIMULANTS
doxazosin extended-releasedrugId:566 PA BENIGN PROSTATIC HYPERPLASIA AGENTS
dutasteridedrugId:586 PA BENIGN PROSTATIC HYPERPLASIA AGENTS
dutasteride / tamsulosindrugId:1960 PA BENIGN PROSTATIC HYPERPLASIA AGENTS
dolutegravir tabletdrugId:2852 PA > 1 unit/day ANTIVIRALS
Durolane (hyaluronate-Durolane)drugId:6381 - Non-Drug Product PA NON-DRUG PRODUCT
Denavir (penciclovir)drugId:1495 PA ANTIVIRALS
dihydroergotamine injectiondrugId:526 PA ANALGESICS
D.H.E. 45 (dihydroergotamine injection)drugId:526 PA ANALGESICS
dihydroergotamine nasal spraydrugId:527 PA ANALGESICS
Depo-Testosterone (testosterone cypionate)drugId:1680 PA HORMONE REPLACEMENT THERAPY BP
desipramine; See Table 17drugId:2620; See Table 71drugId:4020 PA ANTIDEPRESSANTS
desvenlafaxine extended-release; See Table 17drugId:2777; See Table 71drugId:3920 PA ANTIDEPRESSANTS
desvenlafaxine extended-release-Khedezla; See Table 17drugId:2907; See Table 71drugId:3922 PA ANTIDEPRESSANTS
duloxetine 40 mg capsule; See Table 17drugId:4910; See Table 71drugId:4911 PA PSYCHOSTIMULANTS-ANTIDEPRESSAN
duloxetine sprinkle capsule; See Table 17drugId:7346; See Table 71drugId:7347 PA CEREBRAL STIMULANTS
Drizalma (duloxetine sprinkle capsule); See Table 17drugId:7346; See Table 71drugId:7347 PA CEREBRAL STIMULANTS
duloxetine 20 mg, 30 mg, 60 mg capsule; See Table 17drugId:585; See Table 71drugId:3960 PA < 6 years ANTIDEPRESSANTS #
desvenlafaxine succinate extended-release; See Table 17drugId:490; See Table 71drugId:3940 PA < 6 years and PA > 1 unit/day ANTIDEPRESSANTS #
difenoxin / atropinedrugId:6111 PA ANTIDIARRHEALS
dalfampridinedrugId:320 PA MULTIPLE SCLEROSIS AGENTS
dimethyl fumaratedrugId:2793 PA MULTIPLE SCLEROSIS AGENTS BP PD
diroximel fumaratedrugId:7572 PA MULTIPLE SCLEROSIS AGENTS
Dysport (abobotulinumtoxinA)drugId:141 PA BIOLOGICAL
Differin (adapalene 0.1%, 0.3% gel tube)drugId:7678 PA DERMATOLOGICAL
Differin (adapalene cream, 0.3% gel pump, lotion)drugId:159 PA DERMATOLOGICAL BP
Duopa (carbidopa / levodopa enteral suspension)drugId:5104 PA ANTIPARKINSON
Duac (clindamycin / benzoyl peroxide-Duac)drugId:264 PA DERMATOLOGICAL
dapsone geldrugId:325 PA DERMATOLOGICAL
darifenacindrugId:328 PA URINARY ANTISPASMODICS
deferipronedrugId:2483 PA ANTIDOTES
deflazacortdrugId:6720 PA GLUCOCORTICOIDS
denosumab-XgevadrugId:2180 PA BIOLOGICAL
desmopressin-NocdurnadrugId:6984 PA HORMONE AGENTS
dexamethasone tablet packdrugId:492 PA GLUCOCORTICOIDS
dextromethorphan / quinidinedrugId:2177 PA MULTIPLE SCLEROSIS AGENTS
dichlorphenamidedrugId:5260 PA UNCLASSIFIED DRUG PRODUCTS
diltiazem 360 mg-Cardizem CDdrugId:2299 PA CARDIOVASCULAR
dimethyl sulfoxide liquiddrugId:7161 PA ANALGESICS
dorzolamide / timolol, preservative freedrugId:2517 PA OPHTHALMIC PREPARATIONS
doxepin cream-PrudoxindrugId:568 PA DERMATOLOGICAL
doxepin cream-ZonalondrugId:569 PA DERMATOLOGICAL
doxercalciferol capsuledrugId:570 PA ELECTROLYTES AND NUTRIENTS
dronabinol capsuledrugId:582 PA ANTIEMETICS
droxidopadrugId:4630 PA ADRENERGICS
Dekas Essential (multivitamin-Dekas Essential)drugId:5623 PA HEMATINIC AGENT
Dekas Plus (multivitamins / minerals / coenzyme Q10-Dekas Plus)drugId:5621 PA HEMATINIC AGENT
Dekas Bariatric (multivitamins / minerals / folic acid / coenzyme Q10-Dekas Bariatric)drugId:6605 PA ELECTROLYTES AND NUTRIENTS
Dekas Plus (multivitamins / minerals / folic acid / coenzyme Q10-Dekas Plus)drugId:5622 PA HEMATINIC AGENT
Dojolvi (triheptanoin)drugId:7488 PA ELECTROLYTES AND NUTRIENTS
Desoxyn (methamphetamine); See Table 31drugId:1165; See Table 71drugId:3142 PA CEREBRAL STIMULANTS
donepezil 5 mg, 23 mg tablet; See Table 56drugId:559; See Table 71drugId:7401 PA < 6 years and PA > 1 unit/day ALZHEIMER'S THERAPY #
donepezil orally disintegrating tablet; See Table 56drugId:560; See Table 71drugId:7402 PA < 6 years and PA > 1 unit/day ALZHEIMER'S THERAPY
donepezil 10 mg tablet; See Table 56drugId:2422; See Table 71drugId:7399 PA < 6 years and PA > 2 units/day ALZHEIMER'S THERAPY #
diazepam powder; See Table 69drugId:506; See Table 71drugId:4382 PA BENZODIAZEPINES
dapagliflozin / saxagliptindrugId:6406 PA DIABETIC AGENTS
Duetact (glimepiride / pioglitazone)drugId:1535 PA DIABETIC AGENTS BP
DovonexdrugId:420 (calcipotriene cream)drugId:420 PA > 60 grams/month DERMATOLOGICAL #
Durysta (bimatoprost implant)drugId:7489 PA OPHTHALMIC PREPARATIONS
divalproex extended-release; See Table 20drugId:550; See Table 71drugId:3340 PA < 6 years ANTICONVULSANTS #
Depakote ER (divalproex extended-release); See Table 20drugId:550; See Table 71drugId:3340 PA < 6 years ANTICONVULSANTS #
divalproex immediate-release; See Table 20drugId:552; See Table 71drugId:3320 PA < 6 years ANTICONVULSANTS #
Depakote (divalproex immediate-release); See Table 20drugId:552; See Table 71drugId:3320 PA < 6 years ANTICONVULSANTS #
divalproex sprinkle capsule; See Table 20drugId:2315; See Table 71drugId:3360 PA < 6 years ANTICONVULSANTS BP
Depakote (divalproex sprinkle capsule); See Table 20drugId:2315; See Table 71drugId:3360 PA < 6 years ANTICONVULSANTS BP
doxepin capsule, oral concentrate; See Table 17drugId:2040; See Table 71drugId:4040 PA < 6 years ANTIDEPRESSANTS
Depakene (valproic acid); See Table 20drugId:1782; See Table 71drugId:4506 PA < 6 years ANTICONVULSANTS #
diazepam solution, tablet; See Table 69drugId:504; See Table 71drugId:4381 PA < 6 years BENZODIAZEPINES
desonide geldrugId:485 PA GLUCOCORTICOIDS
Desonate (desonide gel)drugId:485 PA GLUCOCORTICOIDS
desonide lotiondrugId:2528 PA GLUCOCORTICOIDS
desoximetasone 0.05% cream, ointmentdrugId:5021 PA GLUCOCORTICOIDS
desoximetasone 0.25% ointment, spray, 0.05% geldrugId:488 PA GLUCOCORTICOIDS
diflorasone creamdrugId:4918 PA GLUCOCORTICOIDS
diflorasone cream / emollientdrugId:520 PA GLUCOCORTICOIDS
diflorasone ointmentdrugId:2207 PA GLUCOCORTICOIDS
Duobrii (halobetasol / tazarotene lotion)drugId:7134 PA GLUCOCORTICOIDS
diazepam nasal spraydrugId:7384 PA > 10 units/month BENZODIAZEPINES
diazepam rectal geldrugId:503 PA > 5 kits (10 syringes) /month BENZODIAZEPINES BP
Diastat (diazepam rectal gel)drugId:503 PA > 5 kits (10 syringes) /month BENZODIAZEPINES BP
deutetrabenazinedrugId:6121 PA NEUROLOGIC AGENT
darbepoetin alfadrugId:327 PA HEMATINIC AGENT
Doptelet (avatrombopag)drugId:6990 PA HEMATOLOGIC
dabrafenibdrugId:2823 PA CHEMOTHERAPY
dacomitinibdrugId:7048 PA CHEMOTHERAPY
daratumumabdrugId:5244 PA CHEMOTHERAPY
Darzalex (daratumumab)drugId:5244 PA CHEMOTHERAPY
daratumumab / hyaluronidase-fihjdrugId:7387 PA CHEMOTHERAPY
Darzalex Faspro (daratumumab / hyaluronidase-fihj)drugId:7387 PA CHEMOTHERAPY
daunorubicin / cytarabinedrugId:6412 PA CHEMOTHERAPY
dostarlimab-gxlydrugId:7921 PA ANTINEOPLASTICS
durvalumabdrugId:6122 PA CHEMOTHERAPY
duvelisibdrugId:7002 PA CHEMOTHERAPY
Daurismo (glasdegib)drugId:7100 PA CHEMOTHERAPY
Danyelza (naxitamab-gqgk)drugId:7725 PA CHEMOTHERAPY
dasiglucagondrugId:7888 PA DIABETIC AGENTS
denosumab-ProliadrugId:1967 PA BIOLOGICAL
doxepin tablet-Silenor; See Table 15drugId:2082; See Table 71drugId:4346 PA SEDATIVES
Dayvigo (lemborexant); See Table 15drugId:7388; See Table 71drugId:7389 PA SEDATIVE NON-BARBITURATE
degarelixdrugId:335 PA CHEMOTHERAPY
dalbavancindrugId:4623 PA ANTIBIOTICS
Dalvance (dalbavancin)drugId:4623 PA ANTIBIOTICS
dalfopristin / quinupristindrugId:2037 PA ANTIBIOTICS
delafloxacin injectiondrugId:6480 PA ANTIBIOTICS
Duaklir (aclidinium / formoterol)drugId:7330 PA BRONCHODILATORS
desloratadine / pseudoephedrinedrugId:474 PA ANTIHISTAMINES
desloratadine orally disintegrating tabletdrugId:2749 PA ANTIHISTAMINES
dexchlorpheniramine solutiondrugId:7220 PA ANTIHISTAMINES
Daliresp (roflumilast)drugId:2282 PA IMMUNOMODULATOR BP
darolutamidedrugId:7289 PA CHEMOTHERAPY

Note: Any drug that does not appear on the List requires prior authorization.


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Last updated 11/19/21

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