Diabetes, Sulfonylureas

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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 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
GLIMEPIRIDE GLIMEPIRIDE TABLET Y    
GLIMEPIRIDE AMARYL TABLET Y    
GLIPIZIDE GLUCOTROL TABLET Y    
GLIPIZIDE GLIPIZIDE TABLET Y    
GLYBURIDE GLYBURIDE TABLET Y    
CHLORPROPAMIDE CHLORPROPAMIDE TABLET N    
GLIPIZIDE GLUCOTROL XL TAB ER 24 N    
GLIPIZIDE GLIPIZIDE XL TAB ER 24 N    
GLIPIZIDE GLIPIZIDE ER TAB ER 24 N    
GLYBURIDE,MICRONIZED GLYNASE TABLET N    
GLYBURIDE,MICRONIZED GLYBURIDE MICRONIZED TABLET N    
TOLAZAMIDE TOLAZAMIDE TABLET N    
TOLBUTAMIDE TOLBUTAMIDE TABLET N