Non-Steroidal Anti-Inflammatory 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
DICLOFENAC POTASSIUM DICLOFENAC POTASSIUM TABLET Y    
DICLOFENAC SODIUM DICLOFENAC SODIUM TABLET DR Y    
ETODOLAC LODINE TABLET Y    
ETODOLAC ETODOLAC TABLET Y    
FLURBIPROFEN FLURBIPROFEN TABLET Y    
IBUPROFEN IBUPROFEN CAPSULE Y    
IBUPROFEN IBUPROFEN CAPSULE Y    
IBUPROFEN WAL-PROFEN CAPSULE Y    
IBUPROFEN ADVIL LIQUI-GELS CAPSULE Y    
IBUPROFEN ADVIL MIGRAINE CAPSULE Y    
IBUPROFEN ADVIL CAPSULE Y    
IBUPROFEN INFANT'S IBUPROFEN DROPS SUSP Y    
IBUPROFEN IBU-DROPS DROPS SUSP Y    
IBUPROFEN INFANTS IBUPROFEN DROPS SUSP Y    
IBUPROFEN INFANTS' IBUPROFEN DROPS SUSP Y    
IBUPROFEN INFANTS IBU-DROPS DROPS SUSP Y    
IBUPROFEN INFANTS' IBUPROFEN DROPS SUSP Y    
IBUPROFEN INFANTS PROFENIB DROPS SUSP Y    
IBUPROFEN INFANTS' MOTRIN DROPS SUSP Y    
IBUPROFEN INFANT'S MOTRIN DROPS SUSP Y    
IBUPROFEN CHILDREN'S MOTRIN DROPS SUSP Y    
IBUPROFEN IBUPROFEN DROPS SUSP Y    
IBUPROFEN INFANTS' ADVIL DROPS SUSP Y    
IBUPROFEN INFANTS IBU-DROPS DROPS SUSP Y    
IBUPROFEN INFANTS IBUPROFEN DROPS SUSP Y    
IBUPROFEN INFANT'S IBUPROFEN DROPS SUSP Y    
IBUPROFEN CHILDREN'S IBUPROFEN ORAL SUSP Y    
IBUPROFEN IBUPROFEN ORAL SUSP Y    
IBUPROFEN CHILDREN'S PROFEN IB ORAL SUSP Y    
IBUPROFEN CHILDREN'S IBUPROFEN ORAL SUSP Y    
IBUPROFEN CHILDREN'S MEDI-PROFEN ORAL SUSP Y    
IBUPROFEN MOTRIN ORAL SUSP Y    
IBUPROFEN CHILDREN'S PROFENIB ORAL SUSP Y    
IBUPROFEN IBUPROFEN ORAL SUSP Y    
IBUPROFEN CHILDREN'S MOTRIN ORAL SUSP Y    
IBUPROFEN CHILDREN'S ADVIL ORAL SUSP Y    
IBUPROFEN IBUPROFEN TAB CHEW Y    
IBUPROFEN IBUPROFEN IB TAB CHEW Y    
IBUPROFEN IBUPROFEN TAB CHEW Y    
IBUPROFEN IBUPROFEN IB TAB CHEW Y    
IBUPROFEN ADVIL TAB CHEW Y    
IBUPROFEN IBUPROFEN TABLET Y    
IBUPROFEN IBUPROFEN IB TABLET Y    
IBUPROFEN PROVIL TABLET Y    
IBUPROFEN MEDI-PROFEN TABLET Y    
IBUPROFEN I-PRIN TABLET Y    
IBUPROFEN TAB-PROFEN TABLET Y    
IBUPROFEN WAL-PROFEN TABLET Y    
IBUPROFEN MOTRIN IB TABLET Y    
IBUPROFEN IBUPROFEN TABLET Y    
IBUPROFEN IBUPROFEN IB TABLET Y    
IBUPROFEN ADVIL TABLET Y    
IBUPROFEN MIDOL CRAMP TABLET Y    
IBUPROFEN CAP-PROFEN TABLET Y    
INDOMETHACIN INDOMETHACIN CAPSULE Y    
KETOPROFEN KETOPROFEN CAPSULE Y    
KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE TABLET Y Quantity Limit  
MELOXICAM MOBIC TABLET Y    
MELOXICAM MELOXICAM TABLET Y    
NABUMETONE NABUMETONE TABLET Y    
NAPROXEN NAPROXEN TABLET Y    
NAPROXEN NAPROSYN TABLET Y    
NAPROXEN NAPROXEN TABLET DR Y    
NAPROXEN EC-NAPROSYN TABLET DR Y    
NAPROXEN SODIUM ANAPROX DS TABLET Y    
NAPROXEN SODIUM ALL DAY RELIEF TABLET Y    
NAPROXEN SODIUM ALL DAY PAIN RELIEF TABLET Y    
NAPROXEN SODIUM NAPROXEN SODIUM TABLET Y    
NAPROXEN SODIUM NAPROXEN SODIUM DS TABLET Y    
NAPROXEN SODIUM ALEVE TABLET Y    
NAPROXEN SODIUM ALL DAY PAIN RELIEF TABLET Y    
NAPROXEN SODIUM ALL DAY RELIEF TABLET Y    
NAPROXEN SODIUM FLANAX TABLET Y    
NAPROXEN SODIUM MEDIPROXEN TABLET Y    
NAPROXEN SODIUM MIDOL TABLET Y    
NAPROXEN SODIUM NAPROXEN SODIUM TABLET Y    
NAPROXEN SODIUM WAL-PROXEN TABLET Y    
OXAPROZIN DAYPRO TABLET Y    
OXAPROZIN OXAPROZIN TABLET Y    
SALSALATE SALSALATE TABLET Y    
SULINDAC SULINDAC TABLET Y    
CELECOXIB CELECOXIB CAPSULE N PA Document  
CELECOXIB CELEBREX CAPSULE N PA Document  
DICLOFENAC POTASSIUM ZIPSOR CAPSULE N PA Document  
DICLOFENAC POTASSIUM CAMBIA POWD PACK N PA Document  
DICLOFENAC SODIUM DICLOFENAC SODIUM ER TAB ER 24H N PA Document  
DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 75 TAB IR DR N PA Document  
DICLOFENAC SODIUM/MISOPROSTOL ARTHROTEC 50 TAB IR DR N PA Document  
DICLOFENAC SODIUM/MISOPROSTOL DICLOFENAC SODIUM-MISOPROSTOL TAB IR DR N PA Document  
DICLOFENAC SUBMICRONIZED ZORVOLEX CAPSULE N PA Document  
DIFLUNISAL DIFLUNISAL TABLET N PA Document  
ETODOLAC ETODOLAC CAPSULE N PA Document  
ETODOLAC ETODOLAC ER TAB ER 24H N PA Document  
FENOPROFEN CALCIUM FENOPROFEN CALCIUM CAPSULE N PA Document  
FENOPROFEN CALCIUM FENOPROFEN CALCIUM TABLET N PA Document  
IBUPROFEN/FAMOTIDINE DUEXIS TABLET N PA Document  
INDOMETHACIN INDOMETHACIN ER CAPSULE ER N PA Document  
INDOMETHACIN INDOCIN ORAL SUSP N PA Document  
INDOMETHACIN, SUBMICRONIZED TIVORBEX CAPSULE N PA Document  
KETOPROFEN KETOPROFEN CAP24H PEL N PA Document  
KETOROLAC TROMETHAMINE SPRIX SPRAY N Quantity Limit  
MECLOFENAMATE SODIUM MECLOFENAMATE SODIUM CAPSULE N PA Document  
MEFENAMIC ACID MEFENAMIC ACID CAPSULE N PA Document  
MEFENAMIC ACID PONSTEL CAPSULE N PA Document  
MELOXICAM, SUBMICRONIZED VIVLODEX CAPSULE N PA Document  
NAPROXEN NAPROXEN ORAL SUSP N PA Document  
NAPROXEN SODIUM NAPROXEN SODIUM CAPSULE N PA Document  
NAPROXEN SODIUM NAPRELAN TBMP 24HR N PA Document  
NAPROXEN SODIUM NAPROXEN SODIUM CR TBMP 24HR N PA Document  
NAPROXEN SODIUM NAPROXEN SODIUM ER TBMP 24HR N PA Document  
NAPROXEN/ESOMEPRAZOLE MAG VIMOVO TAB IR DR N PA Document  
PIROXICAM PIROXICAM CAPSULE N PA Document  
PIROXICAM FELDENE CAPSULE N PA Document  
TOLMETIN SODIUM TOLMETIN SODIUM CAPSULE N PA Document  
TOLMETIN SODIUM TOLMETIN SODIUM TABLET N PA Document