Diagnostics

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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
BLOOD SUGAR DIAGNOSTIC ONE TOUCH/ONE TOUCH II KIT Y    
BLOOD SUGAR DIAGNOSTIC EASY STEP STRIP Y    
BLOOD SUGAR DIAGNOSTIC ACCUTREND GLUCOSE STRIP Y    
BLOOD SUGAR DIAGNOSTIC ASSURE PRISM MULTI STRIP Y    
BLOOD SUGAR DIAGNOSTIC ASSURE PLATINUM STRIP Y    
BLOOD SUGAR DIAGNOSTIC ASSURE 4 STRIP Y    
BLOOD SUGAR DIAGNOSTIC AGAMATRIX AMP STRIP Y    
BLOOD SUGAR DIAGNOSTIC ADVOCATE TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC ADVOCATE REDI-CODE+ STRIP Y    
BLOOD SUGAR DIAGNOSTIC ADVOCATE REDI-CODE STRIP Y    
BLOOD SUGAR DIAGNOSTIC EASY TOUCH TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC ADVANCE TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC BLOOD GLUCOSE TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC ACCU-CHEK SMARTVIEW STRIP Y    
BLOOD SUGAR DIAGNOSTIC ACCU-CHEK SIMPLICITY STRIP Y    
BLOOD SUGAR DIAGNOSTIC ACCU-CHEK GUIDE TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC ACCU-CHEK AVIVA PLUS STRIP Y    
BLOOD SUGAR DIAGNOSTIC ACCU-CHEK ADVANTAGE STRIP Y    
BLOOD SUGAR DIAGNOSTIC ACCU-CHEK STRIP Y    
BLOOD SUGAR DIAGNOSTIC RELION PRIME TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC ADVANCED GLUCOSE TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC CLEVER CHOICE VOICE+ TST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC EASY TALK STRIP Y    
BLOOD SUGAR DIAGNOSTIC EASY PLUS II STRIP Y    
BLOOD SUGAR DIAGNOSTIC EASY GLUCO G2 STRIP Y    
BLOOD SUGAR DIAGNOSTIC EASY CHECK TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC DIATRUE PLUS STRIP Y    
BLOOD SUGAR DIAGNOSTIC DEXTROSTIX REAGENT STRIP Y    
BLOOD SUGAR DIAGNOSTIC COOL GLUCOSE TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC AT-LAST TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC CONTOUR STRIP Y    
BLOOD SUGAR DIAGNOSTIC BLOOD GLUCOSE TEST STRIP Y    
BLOOD SUGAR DIAGNOSTIC CLEVER CHOICE TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC CLEVER CHOICE TALK STRIP Y    
BLOOD SUGAR DIAGNOSTIC CLEVER CHOICE PRO STRIP Y    
BLOOD SUGAR DIAGNOSTIC CLEVER CHOICE MICRO TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC CHOICEDM CLARUS TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC CHEMSTRIP BG STRIP Y    
BLOOD SUGAR DIAGNOSTIC CARESENS N STRIP Y    
BLOOD SUGAR DIAGNOSTIC EASY TRAK STRIP Y    
BLOOD SUGAR DIAGNOSTIC CONTOUR NEXT STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORACARE GD40 STRIP Y    
BLOOD SUGAR DIAGNOSTIC RELION CONFIRM-MICRO STRIP Y    
BLOOD SUGAR DIAGNOSTIC EMBRACE EVO STRIP Y    
BLOOD SUGAR DIAGNOSTIC EMBRACE STRIP Y    
BLOOD SUGAR DIAGNOSTIC ELEMENT TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC ELEMENT COMPACT STRIP Y    
BLOOD SUGAR DIAGNOSTIC EASYMAX 15 STRIP Y    
BLOOD SUGAR DIAGNOSTIC EASYMAX STRIP Y    
BLOOD SUGAR DIAGNOSTIC EASYGLUCO TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC EVENCARE STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORACARE GD20 STRIP Y    
BLOOD SUGAR DIAGNOSTIC EVENCARE G2 STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORTISCARE GLUCOSE TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC FREESTYLE INSULINX STRIP Y    
BLOOD SUGAR DIAGNOSTIC ULTRATRAK STRIP Y    
BLOOD SUGAR DIAGNOSTIC FREESTYLE INSULINX TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC FREESTYLE LITE STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC FREESTYLE LITE TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC FREESTYLE PRECISION NEO STRIP Y    
BLOOD SUGAR DIAGNOSTIC FREESTYLE TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC EASYGLUCO PLUS STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORA D20 STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORA V20 STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORA V12 STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORA V10-V12-D10-D20 STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORA V10 STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORA TN'G VOICE TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORA TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORA GD50 TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORA G30A STRIP Y    
BLOOD SUGAR DIAGNOSTIC EMBRACE PRO STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORA D40-G31 TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC GENULTIMATE TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORA D15G STRIP Y    
BLOOD SUGAR DIAGNOSTIC FIFTY50 TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC EZ SMART PLUS STRIP Y    
BLOOD SUGAR DIAGNOSTIC EZ SMART STRIP Y    
BLOOD SUGAR DIAGNOSTIC EXACTECH STRIP Y    
BLOOD SUGAR DIAGNOSTIC EVOLUTION TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC EVENCARE MINI GLUCOSE TEST STR STRIP Y    
BLOOD SUGAR DIAGNOSTIC EVENCARE G3 STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORA G20 STRIP Y    
BLOOD SUGAR DIAGNOSTIC PRECISION Q-I-D STRIP Y    
BLOOD SUGAR DIAGNOSTIC ONETOUCH ULTRA TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC ONETOUCH VERIO STRIP Y    
BLOOD SUGAR DIAGNOSTIC OPTIUM STRIP Y    
BLOOD SUGAR DIAGNOSTIC OPTIUM EZ STRIP Y    
BLOOD SUGAR DIAGNOSTIC OPTUMRX STRIP Y    
BLOOD SUGAR DIAGNOSTIC PHARMACIST CHOICE STRIP Y    
BLOOD SUGAR DIAGNOSTIC PRECISION PCX STRIP Y    
BLOOD SUGAR DIAGNOSTIC GE100 BLOOD GLUCOSE TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC PRECISION POINT OF CARE STRIP Y    
BLOOD SUGAR DIAGNOSTIC ON CALL EXPRESS TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC PRECISION XTRA STRIP Y    
BLOOD SUGAR DIAGNOSTIC PREMIUM BLOOD GLUCOSE TEST STRIP Y    
BLOOD SUGAR DIAGNOSTIC PREMIUM V10 STRIP Y    
BLOOD SUGAR DIAGNOSTIC PRODIGY NO CODING STRIP Y    
BLOOD SUGAR DIAGNOSTIC QUINTET STRIP Y    
BLOOD SUGAR DIAGNOSTIC QUINTET AC STRIP Y    
BLOOD SUGAR DIAGNOSTIC REAGENT STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC FORA V30A STRIP Y    
BLOOD SUGAR DIAGNOSTIC PRECISION PCX PLUS STRIP Y    
BLOOD SUGAR DIAGNOSTIC GLUCOSTIX REAGENT STRIP Y    
BLOOD SUGAR DIAGNOSTIC REFUAH PLUS STRIP Y    
BLOOD SUGAR DIAGNOSTIC GLUCO NAVII STRIP Y    
BLOOD SUGAR DIAGNOSTIC GLUCOCARD 01 SENSOR PLUS STRIP Y    
BLOOD SUGAR DIAGNOSTIC GLUCOCARD EXPRESSION STRIP Y    
BLOOD SUGAR DIAGNOSTIC GLUCOCARD SHINE STRIP Y    
BLOOD SUGAR DIAGNOSTIC GLUCOCARD VITAL STRIP Y    
BLOOD SUGAR DIAGNOSTIC GLUCOCARD VITAL SENSOR STRIP Y    
BLOOD SUGAR DIAGNOSTIC GLUCOCOM GLUCOSE STRIP Y    
BLOOD SUGAR DIAGNOSTIC ON CALL VIVID TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC GLUCOSE TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC ON CALL PLUS TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC HEALTHPRO TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC INFINITY TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC MICRO STRIP Y    
BLOOD SUGAR DIAGNOSTIC MICRODOT STRIP Y    
BLOOD SUGAR DIAGNOSTIC MICRODOT XTRA STRIP Y    
BLOOD SUGAR DIAGNOSTIC MYGLUCOHEALTH STRIP Y    
BLOOD SUGAR DIAGNOSTIC NEUTEK 2TEK TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC NOVA MAX GLUCOSE TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC GENSTRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC GLUCOFILM STRIP Y    
BLOOD SUGAR DIAGNOSTIC TELCARE STRIP Y    
BLOOD SUGAR DIAGNOSTIC REVEAL TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC RIGHTEST GS100 TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC RIGHTEST GS250S TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC RIGHTEST GS260 TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC RIGHTEST GS300 TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC RIGHTEST GS550 TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC SMART SENSE TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC SMARTEST TEST STRIP Y    
BLOOD SUGAR DIAGNOSTIC SOLUS V2 TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC TD GOLD TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC TEST N'GO STRIP Y    
BLOOD SUGAR DIAGNOSTIC TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC TRACER BG STRIP Y    
BLOOD SUGAR DIAGNOSTIC TRUE METRIX GLUCOSE TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC TRUETEST TEST STRIPS STRIP Y    
BLOOD SUGAR DIAGNOSTIC TRUETRACK TEST STRIP STRIP Y    
BLOOD SUGAR DIAGNOSTIC ULTIMA STRIP Y    
BLOOD SUGAR DIAGNOSTIC ULTRATRAK ULTIMATE STRIP Y    
BLOOD SUGAR DIAGNOSTIC WAVESENSE JAZZ STRIP Y    
BLOOD SUGAR DIAGNOSTIC UNISTRIP1 STRIP Y    
BLOOD SUGAR DIAGNOSTIC SURE-TEST EASYPLUS MINI STRIP Y    
BLOOD SUGAR DIAGNOSTIC WAVESENSE PRESTO STRIP Y    
BLOOD SUGAR DIAGNOSTIC, DISC BREEZE 2 STRIP Y    
BLOOD SUGAR DIAGNOSTIC, DRUM ACCU-CHEK COMPACT PLUS STRIPS STRIP Y    
ADENOSINE ADENOSINE VIAL    
DIPYRIDAMOLE DIPYRIDAMOLE VIAL    
FLORBETAPIR F-18 AMYVID VIAL    
FLUORESCEIN SODIUM AK-FLUOR VIAL    
FLUORESCEIN SODIUM FLUORESCITE VIAL    
GADOBUTROL GADAVIST SYRINGE    
GADOBUTROL GADAVIST VIAL    
GADODIAMIDE OMNISCAN SYRINGE    
GADODIAMIDE OMNISCAN VIAL    
GADODIAMIDE IN 0.9 % NACL OMNISCAN PREFILL PLUS SYRINGE    
GADOPENTETATE DIMEGLUMINE MAGNEVIST SYRINGE    
GADOPENTETATE DIMEGLUMINE MAGNEVIST VIAL    
GADOXETATE DISODIUM EOVIST VIAL    
GLUCAGON HCL GLUCAGON HCL VIAL    
GLUCAGON,HUMAN RECOMBINANT GLUCAGEN VIAL    
HEXAMINOLEVULINATE HCL CYSVIEW VIAL    
IODIXANOL VISIPAQUE INFUS. BTL    
IOHEXOL OMNIPAQUE INFUS. BTL    
IOHEXOL OMNIPAQUE VIAL    
IOPROMIDE ULTRAVIST VIAL    
ISOSULFAN BLUE ISOSULFAN BLUE VIAL    
KIT FOR TC 99M/SESTAMIBI NO.1 CARDIOLITE VIAL    
PERFLUTREN LIPID MICROSPHERES DEFINITY VIAL    
PERFLUTREN PROTEIN-A MICROSPHR OPTISON VIAL    
REGADENOSON LEXISCAN SYRINGE