Antiemetics, Newer

← Back to Class List

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
ONDANSETRON ONDANSETRON ODT TAB RAPDIS Y    
ONDANSETRON ZOFRAN ODT TAB RAPDIS Y    
ONDANSETRON HCL ONDANSETRON HCL SOLUTION Y    
ONDANSETRON HCL ZOFRAN SOLUTION Y    
ONDANSETRON HCL ONDANSETRON HCL TABLET Y    
ONDANSETRON HCL ZOFRAN TABLET Y    
APREPITANT APREPITANT CAP DS PK N PA Document  
APREPITANT EMEND CAP DS PK N PA Document  
APREPITANT EMEND CAPSULE N PA Document  
APREPITANT APREPITANT CAPSULE N PA Document  
APREPITANT EMEND SUSP RECON N PA Document  
DOLASETRON MESYLATE ANZEMET TABLET N PA Document  
DOXYLAMINE SUCCINATE/VIT B6 DICLEGIS TABLET DR N PA Document  
GRANISETRON SUSTOL LIQ ER SYR N PA Document  
GRANISETRON SANCUSO PATCH TDWK N PA Document  
GRANISETRON HCL GRANISETRON HCL TABLET N PA Document  
NETUPITANT/PALONOSETRON HCL AKYNZEO CAPSULE N PA Document  
ONDANSETRON ZUPLENZ FILM N PA Document  
ROLAPITANT HCL VARUBI TABLET N PA Document  
FOSAPREPITANT DIMEGLUMINE EMEND VIAL    
GRANISETRON HCL GRANISETRON HCL VIAL    
GRANISETRON HCL/PF GRANISETRON HCL VIAL    
ONDANSETRON HCL ONDANSETRON HCL VIAL    
ONDANSETRON HCL ZOFRAN VIAL    
ONDANSETRON HCL/PF ONDANSETRON HCL SYRINGE    
ONDANSETRON HCL/PF ONDANSETRON HCL VIAL    
PALONOSETRON HCL ALOXI VIAL