Opioids, Parenteral

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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
ALFENTANIL HCL ALFENTANIL HCL AMPUL    
BUPRENORPHINE HCL BUPRENEX AMPUL    
BUPRENORPHINE HCL BUPRENORPHINE HCL SYRINGE    
BUPRENORPHINE HCL BUPRENORPHINE HCL VIAL    
BUTORPHANOL TARTRATE BUTORPHANOL TARTRATE VIAL    
FENTANYL CITRATE/PF FENTANYL CITRATE AMPUL    
FENTANYL CITRATE/PF FENTANYL CITRATE SYRINGE    
FENTANYL CITRATE/PF FENTANYL CITRATE VIAL    
FENTANYL HCL IONSYS SYSTEMPCA    
HYDROMORPHONE HCL HYDROMORPHONE HCL AMPUL    
HYDROMORPHONE HCL HYDROMORPHONE HCL SYRINGE    
HYDROMORPHONE HCL DILAUDID SYRINGE    
HYDROMORPHONE HCL HYDROMORPHONE HCL VIAL    
HYDROMORPHONE HCL/PF HYDROMORPHONE HCL AMPUL    
HYDROMORPHONE HCL/PF HYDROMORPHONE HCL VIAL    
MEPERIDINE HCL MEPERIDINE HCL CARTRIDGE    
MEPERIDINE HCL DEMEROL VIAL    
MEPERIDINE HCL/PF DEMEROL AMPUL    
MEPERIDINE HCL/PF DEMEROL SYRINGE    
MEPERIDINE HCL/PF MEPERIDINE HCL VIAL    
METHADONE HCL METHADONE HCL VIAL    
MORPHINE SULFATE MORPHINE SULFATE CARTRIDGE    
MORPHINE SULFATE MORPHINE SULFATE PCA SYRING    
MORPHINE SULFATE MORPHINE SULFATE SYRINGE    
MORPHINE SULFATE MORPHINE SULFATE VIAL    
MORPHINE SULFATE/PF ASTRAMORPH-PF AMPUL    
MORPHINE SULFATE/PF DURAMORPH AMPUL    
MORPHINE SULFATE/PF INFUMORPH AMPUL    
MORPHINE SULFATE/PF MORPHINE SULFATE PCA VIAL    
MORPHINE SULFATE/PF ASTRAMORPH-PF VIAL    
MORPHINE SULFATE/PF MORPHINE SULFATE VIAL    
NALBUPHINE HCL NALBUPHINE HCL AMPUL    
NALBUPHINE HCL NALBUPHINE HCL VIAL    
OXYMORPHONE HCL OPANA AMPUL    
PENTAZOCINE LACTATE TALWIN AMPUL    
REMIFENTANIL HCL ULTIVA VIAL    
SUFENTANIL CITRATE SUFENTANIL CITRATE AMPUL    
SUFENTANIL CITRATE SUFENTANIL CITRATE VIAL