Overactive Bladder 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
fesoterodine fumarate TOVIAZ TAB ER 24H Y    
hyoscyamine sulfate HYOSYNE ELIXIR Y    
hyoscyamine sulfate HYOSCYAMINE SULFATE ELIXIR Y    
hyoscyamine sulfate HYOSCYAMINE SULFATE TAB RAPDIS Y    
hyoscyamine sulfate OSCIMIN TAB RAPDIS Y    
hyoscyamine sulfate NULEV TAB RAPDIS Y    
hyoscyamine sulfate SYMAX TAB RAPDIS Y    
hyoscyamine sulfate ED-SPAZ TAB RAPDIS Y    
hyoscyamine sulfate ANASPAZ TAB RAPDIS Y    
oxybutynin OXYTROL PATCH TDSW Y    
oxybutynin chloride OXYBUTYNIN CHLORIDE SYRUP Y    
oxybutynin chloride OXYBUTYNIN CHLORIDE ER TAB ER 24 Y    
oxybutynin chloride DITROPAN XL TAB ER 24 Y    
oxybutynin chloride OXYBUTYNIN CHLORIDE TABLET Y    
darifenacin hydrobromide DARIFENACIN ER TAB ER 24H N    
darifenacin hydrobromide ENABLEX TAB ER 24H N    
flavoxate HCl FLAVOXATE HCL TABLET N    
hyoscyamine sulfate HYOSCYAMINE SULFATE DROPS N    
hyoscyamine sulfate HYOSYNE DROPS N    
hyoscyamine sulfate OSCIMIN SR TAB ER 12H N    
hyoscyamine sulfate LEVSIN TABLET N    
hyoscyamine sulfate HYOSCYAMINE SULFATE TABLET N    
hyoscyamine sulfate OSCIMIN TABLET N    
mirabegron MYRBETRIQ TAB ER 24H N    
oxybutynin OXYTROL FOR WOMEN PATCH TD 4 N    
oxybutynin chloride GELNIQUE GEL MD PMP N    
oxybutynin chloride GELNIQUE GEL PACKET N    
solifenacin succinate VESICARE TABLET N    
tolterodine tartrate TOLTERODINE TARTRATE ER CAP ER 24H N    
tolterodine tartrate DETROL LA CAP ER 24H N    
tolterodine tartrate TOLTERODINE TARTRATE TABLET N    
tolterodine tartrate DETROL TABLET N    
trospium chloride TROSPIUM CHLORIDE ER CAP ER 24H N    
trospium chloride TROSPIUM CHLORIDE TABLET N