Bone Metabolism Drugs

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
alendronate sodium ALENDRONATE SODIUM TABLET Y    
alendronate sodium FOSAMAX TABLET Y    
ibandronate sodium BONIVA TABLET Y    
ibandronate sodium IBANDRONATE SODIUM TABLET Y    
risedronate sodium ACTONEL TABLET Y    
risedronate sodium RISEDRONATE SODIUM TABLET Y    
abaloparatide TYMLOS PEN INJCTR N PA Document  
alendronate sodium ALENDRONATE SODIUM SOLUTION N PA Document  
alendronate sodium BINOSTO TABLET EFF N PA Document  
alendronate sodium/vitamin D3 FOSAMAX PLUS D TABLET N PA Document  
calcitonin,salmon,synthetic CALCITONIN-SALMON SPRAY/PUMP N PA Document  
calcitonin,salmon,synthetic MIACALCIN VIAL N PA Document  
denosumab PROLIA SYRINGE N PA Document  
etidronate disodium ETIDRONATE DISODIUM TABLET N PA Document  
ibandronate sodium IBANDRONATE SODIUM SYRINGE N PA Document  
ibandronate sodium BONIVA SYRINGE N PA Document  
raloxifene HCl RALOXIFENE HCL TABLET N PA Document  
raloxifene HCl EVISTA TABLET N PA Document  
risedronate sodium RISEDRONATE SODIUM DR TABLET DR N PA Document  
risedronate sodium ATELVIA TABLET DR N PA Document  
teriparatide FORTEO PEN INJCTR N PA Document  
denosumab XGEVA VIAL    
ibandronate sodium IBANDRONATE SODIUM VIAL    
pamidronate disodium PAMIDRONATE DISODIUM VIAL    
zoledronic ac/mannitol/0.9NaCl ZOLEDRONIC ACID PIGGYBACK    
zoledronic acid ZOMETA VIAL    
zoledronic acid ZOLEDRONIC ACID VIAL    
zoledronic acid/mannitol-water ZOLEDRONIC ACID PGGYBK BTL    
zoledronic acid/mannitol-water RECLAST PGGYBK BTL    
zoledronic acid/mannitol-water ZOMETA PGGYBK BTL    
zoledronic acid/mannitol-water ZOLEDRONIC ACID PIGGYBACK