Contraceptives, Oral

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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
DESOG-E.ESTRADIOL/E.ESTRADIOL AZURETTE TABLET    
DESOG-E.ESTRADIOL/E.ESTRADIOL BEKYREE TABLET    
DESOG-E.ESTRADIOL/E.ESTRADIOL DESOGESTR-ETH ESTRAD ETH ESTRA TABLET    
DESOG-E.ESTRADIOL/E.ESTRADIOL KARIVA TABLET    
DESOG-E.ESTRADIOL/E.ESTRADIOL KIMIDESS TABLET    
DESOG-E.ESTRADIOL/E.ESTRADIOL MIRCETTE TABLET    
DESOG-E.ESTRADIOL/E.ESTRADIOL PIMTREA TABLET    
DESOG-E.ESTRADIOL/E.ESTRADIOL VIORELE TABLET    
DESOGESTREL-ETHINYL ESTRADIOL CYRED TABLET    
DESOGESTREL-ETHINYL ESTRADIOL APRI TABLET    
DESOGESTREL-ETHINYL ESTRADIOL CYCLESSA TABLET    
DESOGESTREL-ETHINYL ESTRADIOL DESOGESTREL-ETHINYL ESTRADIOL TABLET    
DESOGESTREL-ETHINYL ESTRADIOL EMOQUETTE TABLET    
DESOGESTREL-ETHINYL ESTRADIOL ENSKYCE TABLET    
DESOGESTREL-ETHINYL ESTRADIOL JULEBER TABLET    
DESOGESTREL-ETHINYL ESTRADIOL RECLIPSEN TABLET    
DESOGESTREL-ETHINYL ESTRADIOL VELIVET TABLET    
DESOGESTREL-ETHINYL ESTRADIOL CAZIANT TABLET    
DROSPIR/ETH ESTRA/LEVOMEFOL CA SAFYRAL TABLET    
DROSPIR/ETH ESTRA/LEVOMEFOL CA BEYAZ TABLET    
DROSPIR/ETH ESTRA/LEVOMEFOL CA DROSPIRENONE-ETH ESTRA-LEVOMEF TABLET    
DROSPIR/ETH ESTRA/LEVOMEFOL CA RAJANI TABLET    
ESTRADIOL VALERATE/DIENOGEST NATAZIA TABLET    
ETHINYL ESTRADIOL/DROSPIRENONE GIANVI TABLET    
ETHINYL ESTRADIOL/DROSPIRENONE LORYNA TABLET    
ETHINYL ESTRADIOL/DROSPIRENONE NIKKI TABLET    
ETHINYL ESTRADIOL/DROSPIRENONE OCELLA TABLET    
ETHINYL ESTRADIOL/DROSPIRENONE SYEDA TABLET    
ETHINYL ESTRADIOL/DROSPIRENONE VESTURA TABLET    
ETHINYL ESTRADIOL/DROSPIRENONE YASMIN 28 TABLET    
ETHINYL ESTRADIOL/DROSPIRENONE ZARAH TABLET    
ETHINYL ESTRADIOL/DROSPIRENONE YAZ TABLET    
ETHINYL ESTRADIOL/DROSPIRENONE DROSPIRENONE-ETHINYL ESTRADIOL TABLET    
ETHYNODIOL D-ETHINYL ESTRADIOL ETHYNODIOL-ETHINYL ESTRADIOL TABLET    
ETHYNODIOL D-ETHINYL ESTRADIOL ZOVIA 1-35E TABLET    
ETHYNODIOL D-ETHINYL ESTRADIOL ZOVIA 1-50E TABLET    
ETHYNODIOL D-ETHINYL ESTRADIOL KELNOR 1-35 TABLET    
ETONOGESTREL NEXPLANON IMPLANT    
ETONOGESTREL/ETHINYL ESTRADIOL NUVARING VAG RING    
L-NORGEST/E.ESTRADIOL-E.ESTRAD DAYSEE TBDSPK 3MO    
L-NORGEST/E.ESTRADIOL-E.ESTRAD AMETHIA TBDSPK 3MO    
L-NORGEST/E.ESTRADIOL-E.ESTRAD AMETHIA LO TBDSPK 3MO    
L-NORGEST/E.ESTRADIOL-E.ESTRAD ASHLYNA TBDSPK 3MO    
L-NORGEST/E.ESTRADIOL-E.ESTRAD FAYOSIM TBDSPK 3MO    
L-NORGEST/E.ESTRADIOL-E.ESTRAD LEVONORG-ETH ESTRAD ETH ESTRAD TBDSPK 3MO    
L-NORGEST/E.ESTRADIOL-E.ESTRAD LOSEASONIQUE TBDSPK 3MO    
L-NORGEST/E.ESTRADIOL-E.ESTRAD QUARTETTE TBDSPK 3MO    
L-NORGEST/E.ESTRADIOL-E.ESTRAD RIVELSA TBDSPK 3MO    
L-NORGEST/E.ESTRADIOL-E.ESTRAD SEASONIQUE TBDSPK 3MO    
L-NORGEST/E.ESTRADIOL-E.ESTRAD CAMRESE TBDSPK 3MO    
L-NORGEST/E.ESTRADIOL-E.ESTRAD CAMRESE LO TBDSPK 3MO    
LEVONORGESTREL OPTION 2 TABLET    
LEVONORGESTREL AFTERA TABLET    
LEVONORGESTREL ECONTRA EZ TABLET    
LEVONORGESTREL MY WAY TABLET    
LEVONORGESTREL OPCICON ONE-STEP TABLET    
LEVONORGESTREL PLAN B ONE-STEP TABLET    
LEVONORGESTREL TAKE ACTION TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL SRONYX TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL TRIVORA-28 TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL VIENVA TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL PORTIA TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL AMETHYST TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL ALTAVERA TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL ORSYTHIA TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL AUBRA TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL AVIANE TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL CHATEAL TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL ENPRESSE TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL FALMINA TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL LUTERA TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL KURVELO TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL MARLISSA TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL LEVORA-28 TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL LEVONORGESTREL-ETH ESTRADIOL TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL LEVONEST TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL LESSINA TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL LARISSIA TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL MYZILRA TABLET    
LEVONORGESTREL-ETHIN ESTRADIOL QUASENSE TBDSPK 3MO    
LEVONORGESTREL-ETHIN ESTRADIOL SETLAKIN TBDSPK 3MO    
LEVONORGESTREL-ETHIN ESTRADIOL INTROVALE TBDSPK 3MO    
LEVONORGESTREL-ETHIN ESTRADIOL JOLESSA TBDSPK 3MO    
LEVONORGESTREL-ETHIN ESTRADIOL LEVONORGESTREL-ETH ESTRADIOL TBDSPK 3MO    
MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE SYRINGE    
MEDROXYPROGESTERONE ACETATE DEPO-SUBQ PROVERA 104 SYRINGE    
MEDROXYPROGESTERONE ACETATE DEPO-PROVERA SYRINGE    
MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACETATE VIAL    
MEDROXYPROGESTERONE ACETATE DEPO-PROVERA VIAL    
NORELGESTROMIN/ETHIN.ESTRADIOL XULANE PATCH TDWK    
NORETH-ETHINYL ESTRADIOL/IRON GENERESS FE TAB CHEW    
NORETH-ETHINYL ESTRADIOL/IRON KAITLIB FE TAB CHEW    
NORETH-ETHINYL ESTRADIOL/IRON LAYOLIS FE TAB CHEW    
NORETH-ETHINYL ESTRADIOL/IRON NORETHIN-ETH ESTRA-FERROUS FUM TAB CHEW    
NORETH-ETHINYL ESTRADIOL/IRON WYMZYA FE TAB CHEW    
NORETHINDRONE JOLIVETTE TABLET    
NORETHINDRONE CAMILA TABLET    
NORETHINDRONE JENCYCLA TABLET    
NORETHINDRONE LYZA TABLET    
NORETHINDRONE NORA-BE TABLET    
NORETHINDRONE NORETHINDRONE TABLET    
NORETHINDRONE NORLYDA TABLET    
NORETHINDRONE ORTHO MICRONOR TABLET    
NORETHINDRONE SHAROBEL TABLET    
NORETHINDRONE ERRIN TABLET    
NORETHINDRONE DEBLITANE TABLET    
NORETHINDRONE HEATHER TABLET    
NORETHINDRONE AC-ETH ESTRADIOL LOESTRIN TABLET    
NORETHINDRONE AC-ETH ESTRADIOL NORETHINDRON-ETHINYL ESTRADIOL TABLET    
NORETHINDRONE AC-ETH ESTRADIOL MICROGESTIN TABLET    
NORETHINDRONE AC-ETH ESTRADIOL JUNEL TABLET    
NORETHINDRONE AC-ETH ESTRADIOL LARIN TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON TAYTULLA CAPSULE    
NORETHINDRONE-E.ESTRADIOL-IRON MIBELAS 24 FE TAB CHEW    
NORETHINDRONE-E.ESTRADIOL-IRON MINASTRIN 24 FE TAB CHEW    
NORETHINDRONE-E.ESTRADIOL-IRON NORETHIN-ETH ESTRA-FERROUS FUM TAB CHEW    
NORETHINDRONE-E.ESTRADIOL-IRON BLISOVI 24 FE TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON BLISOVI FE TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON ESTROSTEP FE TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON JUNEL FE TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON JUNEL FE 24 TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON LARIN 24 FE TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON LARIN FE TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON LO LOESTRIN FE TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON LOMEDIA 24 FE TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON MICROGESTIN FE TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON NORETHIN-ETH ESTRA-FERROUS FUM TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON TARINA FE TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON TILIA FE TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON TRI-LEGEST FE TABLET    
NORETHINDRONE-E.ESTRADIOL-IRON LOESTRIN FE TABLET    
NORETHINDRONE-ETHINYL ESTRAD BALZIVA TABLET    
NORETHINDRONE-ETHINYL ESTRAD ALYACEN TABLET    
NORETHINDRONE-ETHINYL ESTRAD PHILITH TABLET    
NORETHINDRONE-ETHINYL ESTRAD BREVICON TABLET    
NORETHINDRONE-ETHINYL ESTRAD BRIELLYN TABLET    
NORETHINDRONE-ETHINYL ESTRAD CYCLAFEM TABLET    
NORETHINDRONE-ETHINYL ESTRAD DASETTA TABLET    
NORETHINDRONE-ETHINYL ESTRAD GILDAGIA TABLET    
NORETHINDRONE-ETHINYL ESTRAD LEENA TABLET    
NORETHINDRONE-ETHINYL ESTRAD NECON TABLET    
NORETHINDRONE-ETHINYL ESTRAD ORTHO-NOVUM TABLET    
NORETHINDRONE-ETHINYL ESTRAD ARANELLE TABLET    
NORETHINDRONE-ETHINYL ESTRAD PIRMELLA TABLET    
NORETHINDRONE-ETHINYL ESTRAD TRI-NORINYL TABLET    
NORETHINDRONE-ETHINYL ESTRAD VYFEMLA TABLET    
NORETHINDRONE-ETHINYL ESTRAD WERA TABLET    
NORETHINDRONE-ETHINYL ESTRAD ZENCHENT TABLET    
NORETHINDRONE-ETHINYL ESTRAD NORTREL TABLET    
NORETHINDRONE-MESTRANOL NECON TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL TRI-ESTARYLLA TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL TRI-LO-SPRINTEC TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN LO TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL ORTHO-CYCLEN TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL PREVIFEM TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL SPRINTEC TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL TRI FEMYNOR TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL TRI-LINYAH TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL NORGESTIMATE-ETHINYL ESTRADIOL TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL TRI-LO-MARZIA TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL MONONESSA TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL TRINESSA TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL TRINESSA LO TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL TRI-PREVIFEM TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL TRI-SPRINTEC TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL TRI-LO-ESTARYLLA TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL ORTHO TRI-CYCLEN TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL ESTARYLLA TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL FEMYNOR TABLET    
NORGESTIMATE-ETHINYL ESTRADIOL MONO-LINYAH TABLET    
NORGESTREL-ETHINYL ESTRADIOL CRYSELLE TABLET    
NORGESTREL-ETHINYL ESTRADIOL ELINEST TABLET    
NORGESTREL-ETHINYL ESTRADIOL LOW-OGESTREL TABLET    
NORGESTREL-ETHINYL ESTRADIOL OGESTREL TABLET    
ULIPRISTAL ACETATE ELLA TABLET