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 SYMAX TAB RAPDIS Y    
HYOSCYAMINE SULFATE OSCIMIN TAB RAPDIS Y    
HYOSCYAMINE SULFATE NULEV TAB RAPDIS Y    
HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE TAB RAPDIS Y    
HYOSCYAMINE SULFATE ED-SPAZ TAB RAPDIS Y    
HYOSCYAMINE SULFATE ANASPAZ TAB RAPDIS Y    
OXYBUTYNIN OXYTROL PATCH TDSW Y    
OXYBUTYNIN CHLORIDE GELNIQUE GEL MD PMP Y    
OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE SYRUP Y    
OXYBUTYNIN CHLORIDE DITROPAN XL TAB ER 24 Y    
OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE ER TAB ER 24 Y    
OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE TABLET Y    
DARIFENACIN HYDROBROMIDE ENABLEX TAB ER 24H N    
DARIFENACIN HYDROBROMIDE DARIFENACIN ER TAB ER 24H N    
FLAVOXATE HCL FLAVOXATE HCL TABLET N    
HYOSCYAMINE SULFATE HYOSYNE DROPS N    
HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE DROPS N    
HYOSCYAMINE SULFATE OSCIMIN SR TAB ER 12H N    
HYOSCYAMINE SULFATE OSCIMIN TABLET N    
HYOSCYAMINE SULFATE LEVSIN TABLET N    
HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE TABLET N    
MIRABEGRON MYRBETRIQ TAB ER 24H N    
OXYBUTYNIN OXYTROL FOR WOMEN PATCH TD 4 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