Glucocorticoids, Other

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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
betamethasone acetate,sod phos CELESTONE VIAL    
betamethasone acetate,sod phos BETAMETHASONE ACETATE-SOD PHOS VIAL    
dexamethasone sod phosphate DEXAMETHASONE SODIUM PHOSPHATE SYRINGE    
dexamethasone sod phosphate DEXAMETHASONE SODIUM PHOSPHATE VIAL    
dexamethasone sodium phosp/PF DEXAMETHASONE SODIUM PHOSPHATE VIAL    
hydrocortisone COLOCORT ENEMA    
hydrocortisone CORTENEMA ENEMA    
hydrocortisone HYDROCORTISONE ENEMA    
hydrocortisone acetate CORTIFOAM FOAM/APPL    
hydrocortisone sod succinate SOLU-CORTEF VIAL    
hydrocortisone sodium succ/PF SOLU-CORTEF VIAL    
methylprednisolone acetate METHYLPREDNISOLONE ACETATE VIAL    
methylprednisolone acetate DEPO-MEDROL VIAL    
methylprednisolone sod succ SOLU-MEDROL VIAL    
methylprednisolone sod succ METHYLPREDNISOLONE SODIUM SUCC VIAL    
methylprednisolone sod succ/PF SOLU-MEDROL VIAL    
triamcinolone acetonide ZILRETTA SUSER VIAL    
triamcinolone acetonide TRIAMCINOLONE ACETONIDE VIAL    
triamcinolone acetonide KENALOG-10 VIAL    
triamcinolone acetonide KENALOG-40 VIAL