Contraceptives
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 |
|---|---|---|---|---|---|
| copper | PARAGARD T 380-A | IUD | |||
| desog-e.estradiol/e.estradiol | AZURETTE | TABLET | |||
| desog-e.estradiol/e.estradiol | DESOGESTR-ETH ESTRAD ETH ESTRA | TABLET | |||
| desog-e.estradiol/e.estradiol | KARIVA | TABLET | |||
| desog-e.estradiol/e.estradiol | MIRCETTE | TABLET | |||
| desog-e.estradiol/e.estradiol | PIMTREA | TABLET | |||
| desog-e.estradiol/e.estradiol | SIMLIYA | TABLET | |||
| desog-e.estradiol/e.estradiol | VIORELE | TABLET | |||
| desog-e.estradiol/e.estradiol | VOLNEA | TABLET | |||
| desogestrel-ethinyl estradiol | DESOGESTREL-ETHINYL ESTRADIOL | TABLET | |||
| desogestrel-ethinyl estradiol | CYRED EQ | TABLET | |||
| desogestrel-ethinyl estradiol | ENSKYCE | TABLET | |||
| desogestrel-ethinyl estradiol | ISIBLOOM | TABLET | |||
| desogestrel-ethinyl estradiol | JULEBER | TABLET | |||
| desogestrel-ethinyl estradiol | KALLIGA | TABLET | |||
| desogestrel-ethinyl estradiol | RECLIPSEN | TABLET | |||
| desogestrel-ethinyl estradiol | APRI | TABLET | |||
| desogestrel-ethinyl estradiol | VELIVET | TABLET | |||
| drospir/eth estra/levomefol Ca | BEYAZ | TABLET | |||
| drospir/eth estra/levomefol Ca | SAFYRAL | TABLET | |||
| drospir/eth estra/levomefol Ca | TYDEMY | TABLET | |||
| drospir/eth estra/levomefol Ca | DROSPIRENONE-ETH ESTRA-LEVOMEF | TABLET | |||
| drospirenone | SLYND | TABLET | |||
| drospirenone/estetrol | NEXTSTELLIS | TABLET | |||
| estradiol valerate/dienogest | NATAZIA | TABLET | |||
| ethinyl estradiol/drospirenone | JASMIEL | TABLET | |||
| ethinyl estradiol/drospirenone | LORYNA | TABLET | |||
| ethinyl estradiol/drospirenone | LO-ZUMANDIMINE | TABLET | |||
| ethinyl estradiol/drospirenone | NIKKI | TABLET | |||
| ethinyl estradiol/drospirenone | OCELLA | TABLET | |||
| ethinyl estradiol/drospirenone | SYEDA | TABLET | |||
| ethinyl estradiol/drospirenone | VESTURA | TABLET | |||
| ethinyl estradiol/drospirenone | YASMIN 28 | TABLET | |||
| ethinyl estradiol/drospirenone | YAZ | TABLET | |||
| ethinyl estradiol/drospirenone | ZUMANDIMINE | TABLET | |||
| ethinyl estradiol/drospirenone | DROSPIRENONE-ETHINYL ESTRADIOL | TABLET | |||
| ethynodiol d-ethinyl estradiol | KELNOR 1-35 | TABLET | |||
| ethynodiol d-ethinyl estradiol | ETHYNODIOL-ETHINYL ESTRADIOL | TABLET | |||
| ethynodiol d-ethinyl estradiol | KELNOR 1-50 | TABLET | |||
| ethynodiol d-ethinyl estradiol | ZOVIA 1-35 | TABLET | |||
| ethynodiol d-ethinyl estradiol | DEMULEN 1-50-21 | TABLET | |||
| etonogestrel | NEXPLANON | IMPLANT | |||
| etonogestrel/ethinyl estradiol | NUVARING | VAG RING | |||
| etonogestrel/ethinyl estradiol | ELURYNG | VAG RING | |||
| etonogestrel/ethinyl estradiol | ENILLORING | VAG RING | |||
| etonogestrel/ethinyl estradiol | ETONOGESTREL-ETHINYL ESTRADIOL | VAG RING | |||
| etonogestrel/ethinyl estradiol | HALOETTE | VAG RING | |||
| L-norgest/e.estradiol-e.estrad | SIMPESSE | TBDSPK 3MO | |||
| L-norgest/e.estradiol-e.estrad | SEASONIQUE | TBDSPK 3MO | |||
| L-norgest/e.estradiol-e.estrad | RIVELSA | TBDSPK 3MO | |||
| L-norgest/e.estradiol-e.estrad | AMETHIA | TBDSPK 3MO | |||
| L-norgest/e.estradiol-e.estrad | QUARTETTE | TBDSPK 3MO | |||
| L-norgest/e.estradiol-e.estrad | ASHLYNA | TBDSPK 3MO | |||
| L-norgest/e.estradiol-e.estrad | CAMRESE | TBDSPK 3MO | |||
| L-norgest/e.estradiol-e.estrad | CAMRESE LO | TBDSPK 3MO | |||
| L-norgest/e.estradiol-e.estrad | DAYSEE | TBDSPK 3MO | |||
| L-norgest/e.estradiol-e.estrad | JAIMIESS | TBDSPK 3MO | |||
| L-norgest/e.estradiol-e.estrad | LEVONORG-ETH ESTRAD ETH ESTRAD | TBDSPK 3MO | |||
| L-norgest/e.estradiol-e.estrad | LOJAIMIESS | TBDSPK 3MO | |||
| L-norgest/e.estradiol-e.estrad | LOSEASONIQUE | TBDSPK 3MO | |||
| lactic acid/citric/potassium | PHEXXI | GEL/PF APP | |||
| levonorgest/eth.estradiol/iron | JOYEAUX | TABLET | |||
| levonorgest/eth.estradiol/iron | LEVONORG-ETH ESTRAD-FE BISGLYC | TABLET | |||
| levonorgest/eth.estradiol/iron | BALCOLTRA | TABLET | |||
| levonorgestrel | KYLEENA | IUD | |||
| levonorgestrel | LILETTA | IUD | |||
| levonorgestrel | MIRENA | IUD | |||
| levonorgestrel | SKYLA | IUD | |||
| levonorgestrel | NORPLANT | KIT | |||
| levonorgestrel | CURAE | TABLET | |||
| levonorgestrel | ECONTRA ONE-STEP | TABLET | |||
| levonorgestrel | NEW DAY | TABLET | |||
| levonorgestrel | HER STYLE | TABLET | |||
| levonorgestrel | LEVONORGESTREL | TABLET | |||
| levonorgestrel | MY WAY | TABLET | |||
| levonorgestrel | OPTION 2 | TABLET | |||
| levonorgestrel | MY CHOICE | TABLET | |||
| levonorgestrel/ethin.estradiol | TWIRLA | PATCH TDWK | |||
| levonorgestrel/ethin.estradiol | TYBLUME | TAB CHEW | |||
| levonorgestrel/ethin.estradiol | LEVONEST | TABLET | |||
| levonorgestrel/ethin.estradiol | LEVONORGESTREL-ETH ESTRADIOL | TABLET | |||
| levonorgestrel/ethin.estradiol | LUTERA | TABLET | |||
| levonorgestrel/ethin.estradiol | PORTIA | TABLET | |||
| levonorgestrel/ethin.estradiol | SRONYX | TABLET | |||
| levonorgestrel/ethin.estradiol | TRIVORA-28 | TABLET | |||
| levonorgestrel/ethin.estradiol | LEVLEN 28 | TABLET | |||
| levonorgestrel/ethin.estradiol | VIENVA | TABLET | |||
| levonorgestrel/ethin.estradiol | LEVORA-28 | TABLET | |||
| levonorgestrel/ethin.estradiol | MARLISSA | TABLET | |||
| levonorgestrel/ethin.estradiol | LESSINA | TABLET | |||
| levonorgestrel/ethin.estradiol | AFIRMELLE | TABLET | |||
| levonorgestrel/ethin.estradiol | ALTAVERA | TABLET | |||
| levonorgestrel/ethin.estradiol | ENPRESSE | TABLET | |||
| levonorgestrel/ethin.estradiol | KURVELO | TABLET | |||
| levonorgestrel/ethin.estradiol | AMETHYST | TABLET | |||
| levonorgestrel/ethin.estradiol | FALMINA | TABLET | |||
| levonorgestrel/ethin.estradiol | DOLISHALE | TABLET | |||
| levonorgestrel/ethin.estradiol | CHATEAL EQ | TABLET | |||
| levonorgestrel/ethin.estradiol | AYUNA | TABLET | |||
| levonorgestrel/ethin.estradiol | AVIANE | TABLET | |||
| levonorgestrel/ethin.estradiol | AUBRA EQ | TABLET | |||
| levonorgestrel/ethin.estradiol | LEVONORGESTREL-ETH ESTRADIOL | TBDSPK 3MO | |||
| levonorgestrel/ethin.estradiol | SETLAKIN | TBDSPK 3MO | |||
| levonorgestrel/ethin.estradiol | JOLESSA | TBDSPK 3MO | |||
| levonorgestrel/ethin.estradiol | ICLEVIA | TBDSPK 3MO | |||
| medroxyprogesterone acetate | DEPO-PROVERA | SYRINGE | |||
| medroxyprogesterone acetate | DEPO-SUBQ PROVERA 104 | SYRINGE | |||
| medroxyprogesterone acetate | MEDROXYPROGESTERONE ACETATE | SYRINGE | |||
| medroxyprogesterone acetate | DEPO-PROVERA | VIAL | |||
| medroxyprogesterone acetate | MEDROXYPROGESTERONE ACETATE | VIAL | |||
| norelgestromin/ethin.estradiol | NORELGESTROMIN-ETH ESTRADIOL | PATCH TDWK | |||
| norelgestromin/ethin.estradiol | XULANE | PATCH TDWK | |||
| norelgestromin/ethin.estradiol | ZAFEMY | PATCH TDWK | |||
| noreth-ethinyl estradiol/iron | KAITLIB FE | TAB CHEW | |||
| noreth-ethinyl estradiol/iron | LAYOLIS FE | TAB CHEW | |||
| noreth-ethinyl estradiol/iron | WYMZYA FE | TAB CHEW | |||
| noreth-ethinyl estradiol/iron | NORETHIN-ETH ESTRA-FERROUS FUM | TAB CHEW | |||
| norethindrone | NORA-BE | TABLET | |||
| norethindrone | CAMILA | TABLET | |||
| norethindrone | NORLYDA | TABLET | |||
| norethindrone | DEBLITANE | TABLET | |||
| norethindrone | EMZAHH | TABLET | |||
| norethindrone | ERRIN | TABLET | |||
| norethindrone | HEATHER | TABLET | |||
| norethindrone | INCASSIA | TABLET | |||
| norethindrone | JENCYCLA | TABLET | |||
| norethindrone | LYLEQ | TABLET | |||
| norethindrone | NORETHINDRONE | TABLET | |||
| norethindrone | SHAROBEL | TABLET | |||
| norethindrone ac-eth estradiol | NORETHINDRON-ETHINYL ESTRADIOL | TABLET | |||
| norethindrone ac-eth estradiol | MICROGESTIN | TABLET | |||
| norethindrone ac-eth estradiol | LARIN | TABLET | |||
| norethindrone ac-eth estradiol | JUNEL | TABLET | |||
| norethindrone ac-eth estradiol | LOESTRIN | TABLET | |||
| norethindrone ac-eth estradiol | HAILEY | TABLET | |||
| norethindrone ac-eth estradiol | AUROVELA | TABLET | |||
| norethindrone-e.estradiol-iron | GEMMILY | CAPSULE | |||
| norethindrone-e.estradiol-iron | MERZEE | CAPSULE | |||
| norethindrone-e.estradiol-iron | NORETHINDRONE-E.ESTRADIOL-IRON | CAPSULE | |||
| norethindrone-e.estradiol-iron | TAYSOFY | CAPSULE | |||
| norethindrone-e.estradiol-iron | TAYTULLA | CAPSULE | |||
| norethindrone-e.estradiol-iron | CHARLOTTE 24 FE | TAB CHEW | |||
| norethindrone-e.estradiol-iron | FINZALA | TAB CHEW | |||
| norethindrone-e.estradiol-iron | MIBELAS 24 FE | TAB CHEW | |||
| norethindrone-e.estradiol-iron | MINASTRIN 24 FE | TAB CHEW | |||
| norethindrone-e.estradiol-iron | NORETHINDRONE-E.ESTRADIOL-IRON | TAB CHEW | |||
| norethindrone-e.estradiol-iron | BLISOVI FE | TABLET | |||
| norethindrone-e.estradiol-iron | BLISOVI 24 FE | TABLET | |||
| norethindrone-e.estradiol-iron | AUROVELA FE | TABLET | |||
| norethindrone-e.estradiol-iron | AUROVELA 24 FE | TABLET | |||
| norethindrone-e.estradiol-iron | LARIN 24 FE | TABLET | |||
| norethindrone-e.estradiol-iron | HAILEY 24 FE | TABLET | |||
| norethindrone-e.estradiol-iron | HAILEY FE | TABLET | |||
| norethindrone-e.estradiol-iron | JUNEL FE 24 | TABLET | |||
| norethindrone-e.estradiol-iron | LARIN FE | TABLET | |||
| norethindrone-e.estradiol-iron | LO LOESTRIN FE | TABLET | |||
| norethindrone-e.estradiol-iron | LOESTRIN FE | TABLET | |||
| norethindrone-e.estradiol-iron | JUNEL FE | TABLET | |||
| norethindrone-e.estradiol-iron | MICROGESTIN 24 FE | TABLET | |||
| norethindrone-e.estradiol-iron | NORETHINDRONE-E.ESTRADIOL-IRON | TABLET | |||
| norethindrone-e.estradiol-iron | TARINA 24 FE | TABLET | |||
| norethindrone-e.estradiol-iron | TARINA FE 1-20 EQ | TABLET | |||
| norethindrone-e.estradiol-iron | TILIA FE | TABLET | |||
| norethindrone-e.estradiol-iron | TRI-LEGEST FE | TABLET | |||
| norethindrone-e.estradiol-iron | MICROGESTIN FE | TABLET | |||
| norethindrone-ethin. estradiol | BALZIVA | TABLET | |||
| norethindrone-ethin. estradiol | ARANELLE | TABLET | |||
| norethindrone-ethin. estradiol | BRIELLYN | TABLET | |||
| norethindrone-ethin. estradiol | DASETTA | TABLET | |||
| norethindrone-ethin. estradiol | LEENA | TABLET | |||
| norethindrone-ethin. estradiol | NECON | TABLET | |||
| norethindrone-ethin. estradiol | NORTREL | TABLET | |||
| norethindrone-ethin. estradiol | NYLIA | TABLET | |||
| norethindrone-ethin. estradiol | PHILITH | TABLET | |||
| norethindrone-ethin. estradiol | PIRMELLA | TABLET | |||
| norethindrone-ethin. estradiol | VYFEMLA | TABLET | |||
| norethindrone-ethin. estradiol | WERA | TABLET | |||
| norethindrone-ethin. estradiol | ALYACEN | TABLET | |||
| norgestimate-ethinyl estradiol | TRI-SPRINTEC | TABLET | |||
| norgestimate-ethinyl estradiol | NORGESTIMATE-ETHINYL ESTRADIOL | TABLET | |||
| norgestimate-ethinyl estradiol | NYMYO | TABLET | |||
| norgestimate-ethinyl estradiol | SPRINTEC | TABLET | |||
| norgestimate-ethinyl estradiol | TRI FEMYNOR | TABLET | |||
| norgestimate-ethinyl estradiol | TRI-ESTARYLLA | TABLET | |||
| norgestimate-ethinyl estradiol | TRI-LINYAH | TABLET | |||
| norgestimate-ethinyl estradiol | TRI-LO-ESTARYLLA | TABLET | |||
| norgestimate-ethinyl estradiol | TRI-LO-MARZIA | TABLET | |||
| norgestimate-ethinyl estradiol | TRI-LO-MILI | TABLET | |||
| norgestimate-ethinyl estradiol | TRI-LO-SPRINTEC | TABLET | |||
| norgestimate-ethinyl estradiol | TRI-NYMYO | TABLET | |||
| norgestimate-ethinyl estradiol | ESTARYLLA | TABLET | |||
| norgestimate-ethinyl estradiol | TRI-VYLIBRA | TABLET | |||
| norgestimate-ethinyl estradiol | TRI-VYLIBRA LO | TABLET | |||
| norgestimate-ethinyl estradiol | VYLIBRA | TABLET | |||
| norgestimate-ethinyl estradiol | TRI-MILI | TABLET | |||
| norgestimate-ethinyl estradiol | MONO-LINYAH | TABLET | |||
| norgestimate-ethinyl estradiol | MILI | TABLET | |||
| norgestrel | OPILL | TABLET | |||
| norgestrel-ethinyl estradiol | CRYSELLE | TABLET | |||
| norgestrel-ethinyl estradiol | ELINEST | TABLET | |||
| norgestrel-ethinyl estradiol | LOW-OGESTREL | TABLET | |||
| norgestrel-ethinyl estradiol | TURQOZ | TABLET | |||
| segesterone ac/ethin estradiol | ANNOVERA | VAG RING | Quantity Limit | Oct 06, 2022 | |
| ulipristal acetate | ELLA | TABLET |