Other Hormones

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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
parathyroid hormone NATPARA CARTRIDGE N    
arginine HCl R-GENE 10 IV SOLN    
cabergoline CABERGOLINE TABLET    
choriogonadotropin alfa OVIDREL SYRINGE    
chorionic gonadotropin, human NOVAREL VIAL    
chorionic gonadotropin, human CHORIONIC GONADOTROPIN VIAL    
chorionic gonadotropin, human PREGNYL VIAL    
clomiphene citrate CLOMIPHENE CITRATE TABLET    
danazol DANAZOL CAPSULE    
desmopressin (nonrefrigerated) DDAVP SPRAY/PUMP    
desmopressin (nonrefrigerated) DESMOPRESSIN ACETATE SPRAY/PUMP    
desmopressin acetate DDAVP AMPUL    
desmopressin acetate DESMOPRESSIN ACETATE AMPUL    
desmopressin acetate DDAVP SOLUTION    
desmopressin acetate STIMATE SPRAY/PUMP    
desmopressin acetate NOCTIVA SPRAY/PUMP    
desmopressin acetate DESMOPRESSIN ACETATE SPRAY/PUMP    
desmopressin acetate NOCDURNA TAB RAPDIS    
desmopressin acetate DESMOPRESSIN ACETATE TABLET    
desmopressin acetate DDAVP TABLET    
desmopressin acetate DESMOPRESSIN ACETATE VIAL    
desmopressin acetate DDAVP VIAL    
follitropin alfa, recombinant GONAL-F RFF REDI-JECT PEN INJCTR    
follitropin alfa, recombinant GONAL-F RFF VIAL    
follitropin alfa, recombinant GONAL-F VIAL    
follitropin beta,recomb FOLLISTIM AQ CARTRIDGE    
follitropin beta/ganirelix FOLLISTIM/ANTAGON KIT    
gonadorelin acetate LUTREPULSE KIT    
gonadorelin acetate LUTREPULSE VIAL    
lanreotide acetate SOMATULINE DEPOT SYRINGE    
macimorelin acetate MACRILEN SOLN RECON    
mecasermin INCRELEX VIAL    
melatonin MELATONIN TABLET    
menotropins MENOPUR VIAL    
metreleptin MYALEPT VIAL PA Document  
metyrapone METOPIRONE CAPSULE    
octreotide acetate OCTREOTIDE ACETATE AMPUL    
octreotide acetate SANDOSTATIN AMPUL    
octreotide acetate OCTREOTIDE ACETATE SYRINGE    
octreotide acetate OCTREOTIDE ACETATE VIAL    
octreotide acetate SANDOSTATIN VIAL    
octreotide acetate,mi-spheres SANDOSTATIN LAR DEPOT VIAL    
pasireotide diaspartate SIGNIFOR AMPUL    
pasireotide pamoate SIGNIFOR LAR VIAL    
urofollitropin BRAVELLE VIAL    
vasopressin VASOSTRICT VIAL    
vasopressin VASOPRESSIN VIAL