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 COLAZAL CAPSULE Y    
balsalazide disodium BALSALAZIDE DISODIUM CAPSULE Y    
budesonide ENTOCORT EC CAPDR - ER Y    
budesonide BUDESONIDE EC CAPDR - ER Y    
mesalamine APRISO CAP ER 24H Y    
mesalamine CANASA SUPP.RECT Y    
mesalamine MESALAMINE TABLET DR Y 800 mg Require PA  
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    
budesonide UCERIS TABDR - ER N    
mesalamine DELZICOL CAP(DRTAB) N    
mesalamine DELZICOL CAPSULE DR N    
mesalamine PENTASA CAPSULE ER N    
mesalamine SFROWASA ENEMA N    
mesalamine MESALAMINE ENEMA N    
mesalamine ASACOL HD TABLET DR N    
mesalamine w/cleansing wipes ROWASA ENEMA KIT N    
mesalamine w/cleansing wipes MESALAMINE ENEMA KIT N