Progestational Agents

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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
hydroxyprogesterone caproat/PF MAKENA VIAL Y PA Document  
hydroxyprogesterone caproate MAKENA VIAL Y PA Document May 30, 2013
medroxyprogesterone acetate MEDROXYPROGESTERONE ACETATE TABLET Y    
medroxyprogesterone acetate PROVERA TABLET Y    
medroxyprogesterone acetate DEPO-PROVERA VIAL Y    
norethindrone acetate NORETHINDRONE ACETATE TABLET Y    
norethindrone acetate AYGESTIN TABLET Y    
progesterone, micronized PROMETRIUM CAPSULE Y    
progesterone, micronized PROGESTERONE CAPSULE Y    
hydroxyprogesterone caproate HYDROXYPROGESTERONE CAPROATE VIAL N PA Document  
progesterone PROGESTERONE IN OIL VIAL N    
progesterone PROGESTERONE VIAL N    
progesterone, micronized CRINONE GEL/PF APP N    
progesterone, micronized ENDOMETRIN INSERT N