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 FOSAMAX TABLET Y    
ALENDRONATE SODIUM ALENDRONATE SODIUM TABLET Y    
IBANDRONATE SODIUM BONIVA TABLET Y    
IBANDRONATE SODIUM IBANDRONATE SODIUM TABLET Y    
RISEDRONATE SODIUM ACTONEL TABLET Y    
RISEDRONATE SODIUM RISEDRONATE SODIUM TABLET Y    
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 BONIVA SYRINGE N PA Document  
IBANDRONATE SODIUM IBANDRONATE SODIUM SYRINGE N PA Document  
RALOXIFENE HCL RALOXIFENE HCL TABLET N PA Document  
RALOXIFENE HCL EVISTA TABLET N PA Document  
RISEDRONATE SODIUM ATELVIA TABLET DR N PA Document  
RISEDRONATE SODIUM RISEDRONATE SODIUM DR 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 RECLAST PGGYBK BTL    
ZOLEDRONIC ACID/MANNITOL-WATER ZOLEDRONIC ACID PGGYBK BTL    
ZOLEDRONIC ACID/MANNITOL-WATER ZOMETA PGGYBK BTL    
ZOLEDRONIC ACID/MANNITOL-WATER ZOLEDRONIC ACID PIGGYBACK