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 BETAMETHASONE ACETATE-SOD PHOS VIAL    
BETAMETHASONE ACETATE,SOD PHOS CELESTONE VIAL    
DEXAMETHASONE SOD PHOSPHATE DEXAMETHASONE SODIUM PHOSPHATE SYRINGE    
DEXAMETHASONE SOD PHOSPHATE DEXAMETHASONE SODIUM PHOSPHATE VIAL    
DEXAMETHASONE SODIUM PHOSP/PF DEXAMETHASONE SODIUM PHOSPHATE VIAL    
HYDROCORTISONE HYDROCORTISONE ENEMA    
HYDROCORTISONE CORTENEMA ENEMA    
HYDROCORTISONE COLOCORT ENEMA    
HYDROCORTISONE ACETATE CORTIFOAM FOAM/APPL    
HYDROCORTISONE SOD SUCCINATE SOLU-CORTEF VIAL    
HYDROCORTISONE SODIUM SUCC/PF SOLU-CORTEF VIAL    
METHYLPREDNISOLONE ACETATE DEPO-MEDROL VIAL    
METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE ACETATE VIAL    
METHYLPREDNISOLONE SOD SUCC SOLU-MEDROL VIAL    
METHYLPREDNISOLONE SOD SUCC METHYLPREDNISOLONE SODIUM SUCC VIAL    
METHYLPREDNISOLONE SOD SUCC/PF SOLU-MEDROL VIAL    
TRIAMCINOLONE ACETONIDE KENALOG-40 VIAL    
TRIAMCINOLONE ACETONIDE KENALOG-10 VIAL