Other Rheumatologic Agents

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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
AURANOFIN RIDAURA CAPSULE    
IBUPROFEN CALDOLOR VIAL    
INDOMETHACIN INDOCIN SUPP.RECT    
LEFLUNOMIDE LEFLUNOMIDE TABLET    
LEFLUNOMIDE ARAVA TABLET    
METHOTREXATE/PF OTREXUP AUTO INJCT    
METHOTREXATE/PF RASUVO AUTO INJCT    
PENICILLAMINE CUPRIMINE CAPSULE    
PENICILLAMINE DEPEN TABLET