Inflammatory Bowel Disease

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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
BALSALAZIDE DISODIUM BALSALAZIDE DISODIUM CAPSULE Y    
BALSALAZIDE DISODIUM COLAZAL CAPSULE Y    
MESALAMINE APRISO CAP ER 24H Y    
MESALAMINE CANASA SUPP.RECT Y    
MESALAMINE LIALDA TABLET DR Y    
OLSALAZINE SODIUM DIPENTUM CAPSULE Y    
SULFASALAZINE SULFASALAZINE TABLET Y    
SULFASALAZINE AZULFIDINE TABLET Y    
SULFASALAZINE SULFASALAZINE DR TABLET DR Y    
SULFASALAZINE AZULFIDINE TABLET DR Y    
BALSALAZIDE DISODIUM GIAZO TABLET N    
BUDESONIDE UCERIS FOAM/APPL N    
MESALAMINE DELZICOL CAP(DRTAB) N    
MESALAMINE PENTASA CAPSULE ER N    
MESALAMINE SFROWASA ENEMA N    
MESALAMINE MESALAMINE ENEMA N    
MESALAMINE ASACOL HD TABLET DR N    
MESALAMINE MESALAMINE TABLET DR N    
MESALAMINE W/CLEANSING WIPES MESALAMINE ENEMA KIT N    
MESALAMINE W/CLEANSING WIPES ROWASA ENEMA KIT N