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 ADVIL LIQUI-GELS CAPSULE Y    
ibuprofen ADVIL CAPSULE Y    
ibuprofen ADVIL MIGRAINE CAPSULE Y    
ibuprofen IBUPROFEN CAPSULE Y    
ibuprofen NUPRIN CAPSULE Y    
ibuprofen WAL-PROFEN CAPSULE Y    
ibuprofen INFANTS' IBUPROFEN DROPS SUSP Y    
ibuprofen INFANT'S IBUPROFEN DROPS SUSP Y    
ibuprofen INFANTS IBUPROFEN DROPS SUSP Y    
ibuprofen INFANTS IBU-DROPS DROPS SUSP Y    
ibuprofen IBU-DROPS DROPS SUSP Y    
ibuprofen CHILDREN'S ADVIL DROPS SUSP Y    
ibuprofen IBUPROFEN DROPS SUSP Y    
ibuprofen CHILDREN'S MOTRIN DROPS SUSP Y    
ibuprofen CHILDREN'S 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 INFANTS' IBUPROFEN DROPS SUSP Y    
ibuprofen INFANTS MEDI-PROFEN DROPS SUSP Y    
ibuprofen INFANT'S MOTRIN DROPS SUSP Y    
ibuprofen INFANTS PROFENIB DROPS SUSP Y    
ibuprofen INFANTS' MOTRIN DROPS SUSP Y    
ibuprofen IBUPROFEN CHILD ORAL SUSP Y    
ibuprofen CHILDREN'S IBUPROFEN ORAL SUSP Y    
ibuprofen IBUPROFEN ORAL SUSP Y    
ibuprofen CHILDREN'S ADVIL ORAL SUSP Y    
ibuprofen CHILDREN'S PROFENIB ORAL SUSP Y    
ibuprofen IBUPROFEN ORAL SUSP Y    
ibuprofen CHILDREN'S PROFEN IB ORAL SUSP Y    
ibuprofen CHILDREN'S MOTRIN ORAL SUSP Y    
ibuprofen CHILDREN'S MEDI-PROFEN ORAL SUSP Y    
ibuprofen CHILDREN'S IBUPROFEN ORAL SUSP Y    
ibuprofen CHILD IBUPROFEN ORAL SUSP Y    
ibuprofen MOTRIN ORAL SUSP Y    
ibuprofen IBUPROFEN TAB CHEW Y    
ibuprofen IBUPROFEN IB TAB CHEW Y    
ibuprofen ADVIL TAB CHEW Y    
ibuprofen IBUPROFEN IB TAB CHEW Y    
ibuprofen IBUPROFEN JR TAB CHEW Y    
ibuprofen IBUPROFEN TAB CHEW Y    
ibuprofen CHILDREN'S ADVIL TAB CHEW Y    
ibuprofen MOTRIN TAB CHEW Y    
ibuprofen PROVIL TABLET Y    
ibuprofen IBUPROFEN TABLET Y    
ibuprofen IBUPROFEN IB TABLET Y    
ibuprofen IBU TABLET Y    
ibuprofen ADVIL TABLET Y    
ibuprofen IBUPROFEN PMR TABLET Y    
ibuprofen CAP-PROFEN TABLET Y    
ibuprofen BAYER SELECT TABLET Y    
ibuprofen BACKACHE TABLET Y    
ibuprofen A-G PROFEN TABLET Y    
ibuprofen ADVANCED PAIN RELIEF TABLET Y    
ibuprofen IBUPROFEN IB TABLET Y    
ibuprofen IBUPROFEN M TABLET Y    
ibuprofen IBU-PROFEN TABLET Y    
ibuprofen IBUPROFEN TABLET Y    
ibuprofen IBUPAIN-200 TABLET Y    
ibuprofen BUPRANOL FP TABLET Y    
ibuprofen IBUPRIN TABLET Y    
ibuprofen SALETO-200 TABLET Y    
ibuprofen MOTRIN TABLET Y    
ibuprofen MOTRIN IB TABLET Y    
ibuprofen MOTRIN MIGRAINE TABLET Y    
ibuprofen Q-PROFEN TABLET Y    
ibuprofen NUPRIN TABLET Y    
ibuprofen TAB-PROFEN TABLET Y    
ibuprofen WAL-PROFEN TABLET Y    
ibuprofen YAPROFEN TABLET Y    
ibuprofen IBUTAB TABLET Y    
ibuprofen NUPRIN MENSTRUAL RELIEF TABLET Y    
ibuprofen PROFEN IB TABLET Y    
ibuprofen IBU-TAB TABLET Y    
ibuprofen MIDOL IB TABLET Y    
ibuprofen MIDOL CRAMP TABLET Y    
ibuprofen MENADOL TABLET Y    
ibuprofen MEDI-PROFEN TABLET Y    
ibuprofen I-PRIN 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 NAPROXEN TABLET DR Y    
naproxen EC-NAPROSYN TABLET DR Y    
naproxen sodium MEDIPROXEN TABLET Y    
naproxen sodium MIDOL TABLET Y    
naproxen sodium NAPROXEN SODIUM TABLET Y    
naproxen sodium WAL-PROXEN TABLET Y    
naproxen sodium ALL DAY PAIN RELIEF TABLET Y    
naproxen sodium ALL DAY RELIEF TABLET Y    
naproxen sodium NAPROXEN SODIUM TABLET Y    
naproxen sodium FLANAX 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    
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  
meloxicam, submicronized VIVLODEX CAPSULE N PA Document  
naproxen NAPROXEN ORAL SUSP N PA Document  
naproxen sodium NAPROXEN SODIUM CAPSULE N PA Document  
naproxen sodium NAPROXEN SODIUM ER TBMP 24HR N PA Document  
naproxen sodium NAPROXEN SODIUM CR TBMP 24HR N PA Document  
naproxen sodium NAPRELAN TBMP 24HR N PA Document  
naproxen/esomeprazole mag VIMOVO TAB IR DR N PA Document  
piroxicam FELDENE CAPSULE N PA Document  
piroxicam PIROXICAM CAPSULE N PA Document  
tolmetin sodium TOLMETIN SODIUM CAPSULE N PA Document  
tolmetin sodium TOLMETIN SODIUM TABLET N PA Document