Progestational Agents
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 |
|---|---|---|---|---|---|
| hydroxyprogesterone caproat/PF | MAKENA | AUTO INJCT | Y | ||
| medroxyprogesterone acetate | PROVERA | TABLET | Y | ||
| medroxyprogesterone acetate | MEDROXYPROGESTERONE ACETATE | TABLET | Y | ||
| norethindrone acetate | NORETHINDRONE ACETATE | TABLET | Y | ||
| norethindrone acetate | NORETHINDRONE AC (LUPANETA) | TABLET | Y | ||
| norethindrone acetate | AYGESTIN | TABLET | Y | ||
| progesterone, micronized | PROMETRIUM | CAPSULE | Y | ||
| progesterone, micronized | PROGESTERONE | CAPSULE | Y | ||
| hydroxyprogesterone caproat/PF | HYDROXYPROGESTERONE CAPROATE | VIAL | N | ||
| hydroxyprogesterone caproate | HYDROXYPROGESTERONE CAPROATE | VIAL | N | ||
| progesterone | PROGESTERONE | VIAL | N | ||
| progesterone, micronized | CRINONE | GEL/PF APP | N | ||
| progesterone, micronized | ENDOMETRIN | INSERT | N |