Adrenergics

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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
DOPAMINE HCL DOPAMINE HCL VIAL    
DOPAMINE HCL IN DEXTROSE 5 % DOPAMINE HCL IN 5% DEXTROSE PLAST. BAG    
DROXIDOPA NORTHERA CAPSULE PA Document Jan 29, 2015
EPHEDRINE SULFATE EPHEDRINE SULFATE AMPUL    
EPHEDRINE SULFATE EPHEDRINE SULFATE VIAL    
EPINEPHRINE EPINEPHRINE AMPUL    
EPINEPHRINE EPINEPHRINE SYRINGE    
EPINEPHRINE ADRENALIN VIAL    
EPINEPHRINE EPINEPHRINE VIAL    
ISOPROTERENOL HCL ISUPREL AMPUL    
MIDODRINE HCL MIDODRINE HCL TABLET    
NOREPINEPHRINE BITARTRATE LEVOPHED BITARTRATE AMPUL    
NOREPINEPHRINE BITARTRATE LEVOPHED BITARTRATE VIAL    
NOREPINEPHRINE BITARTRATE NOREPINEPHRINE BITARTRATE VIAL    
PHENYLEPHRINE HCL PHENYLEPHRINE HCL VIAL