Overactive Bladder Drugs
PDL Reference Documents
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.
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 | ||
| fesoterodine fumarate | FESOTERODINE FUMARATE ER | TAB ER 24H | Y | ||
| oxybutynin | OXYTROL | PATCH TDSW | Y | ||
| oxybutynin chloride | OXYBUTYNIN CHLORIDE | SYRUP | Y | ||
| oxybutynin chloride | OXYBUTYNIN CHLORIDE ER | TAB ER 24 | Y | ||
| oxybutynin chloride | OXYBUTYNIN CHLORIDE | TABLET | Y | ||
| solifenacin succinate | SOLIFENACIN SUCCINATE | TABLET | Y | ||
| solifenacin succinate | VESICARE | TABLET | Y | ||
| darifenacin hydrobromide | DARIFENACIN ER | TAB ER 24H | N | ||
| flavoxate HCl | FLAVOXATE HCL | TABLET | N | ||
| mirabegron | MYRBETRIQ | SUS ER REC | N | ||
| mirabegron | MYRBETRIQ | TAB ER 24H | N | ||
| oxybutynin | OXYTROL FOR WOMEN | PATCH TD 4 | N | ||
| oxybutynin chloride | GELNIQUE | GEL PACKET | N | ||
| oxybutynin chloride | OXYBUTYNIN CHLORIDE | TABLET | N | ||
| solifenacin succinate | VESICARE LS | ORAL SUSP | N | ||
| tolterodine tartrate | DETROL LA | CAP ER 24H | N | ||
| tolterodine tartrate | TOLTERODINE TARTRATE ER | CAP ER 24H | N | ||
| tolterodine tartrate | DETROL | TABLET | N | ||
| tolterodine tartrate | TOLTERODINE TARTRATE | TABLET | N | ||
| trospium chloride | TROSPIUM CHLORIDE ER | CAP ER 24H | N | ||
| trospium chloride | TROSPIUM CHLORIDE | TABLET | N | ||
| vibegron | GEMTESA | TABLET | N |