Vitamin D Analogs

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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
CALCITRIOL CALCITRIOL AMPUL Y    
CALCITRIOL ROCALTROL CAPSULE Y    
CALCITRIOL CALCITRIOL CAPSULE Y    
CALCITRIOL ROCALTROL SOLUTION Y    
CALCITRIOL CALCITRIOL SOLUTION Y    
DOXERCALCIFEROL DOXERCALCIFEROL AMPUL N    
DOXERCALCIFEROL HECTOROL CAPSULE N    
DOXERCALCIFEROL DOXERCALCIFEROL CAPSULE N    
DOXERCALCIFEROL HECTOROL VIAL N    
DOXERCALCIFEROL DOXERCALCIFEROL VIAL N    
PARICALCITOL ZEMPLAR CAPSULE N    
PARICALCITOL PARICALCITOL CAPSULE N    
PARICALCITOL ZEMPLAR VIAL N    
PARICALCITOL PARICALCITOL VIAL N