GnRH Analogues

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Drug Use Review 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
GOSERELIN ACETATE ZOLADEX IMPLANT Age Restriction  
HISTRELIN ACETATE VANTAS KIT Age Restriction  
HISTRELIN ACETATE SUPPRELIN LA KIT Age Restriction  
LEUPROLIDE ACETATE LUPRON DEPOT-PED KIT Age Restriction  
LEUPROLIDE ACETATE LEUPROLIDE ACETATE KIT Age Restriction  
LEUPROLIDE ACETATE ELIGARD SYRINGE Age Restriction  
LEUPROLIDE ACETATE LUPRON DEPOT-PED SYRINGEKIT Age Restriction  
LEUPROLIDE ACETATE LUPRON DEPOT SYRINGEKIT Age Restriction  
LEUPROLIDE/NORETHINDRONE ACET LUPANETA PACK KT SYR TAB Age Restriction  
NAFARELIN ACETATE SYNAREL SPRAY Age Restriction  
TRIPTORELIN PAMOATE TRELSTAR SYRINGE Age Restriction  
TRIPTORELIN PAMOATE TRELSTAR VIAL Age Restriction