Miscellaneous

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Drug Use Review Documents

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
CALC/MAG/POT/BORON/LYS/THR/SIL CALCOR TABLET Y    
VIT C/E/ZINC/LUTEIN/ZEAXANTHIN OCUVITE EYE HEALTH TAB CHEW Y    
CALCIFEDIOL RAYALDEE CAP SA 24H N    
ELUXADOLINE VIBERZI TABLET N   Mar 31, 2016
SAPROPTERIN DIHYDROCHLORIDE KUVAN TABLET SOL N PA Document Jul 25, 2013
ACETIC ACID ACETIC ACID IRRIG SOLN    
ACETOHYDROXAMIC ACID LITHOSTAT TABLET    
ACETYLCYSTEINE ACETYLCYSTEINE VIAL    
AGALSIDASE BETA FABRAZYME VIAL    
ALBUMIN HUMAN ALBUMIN (HUMAN) IV SOLN    
ALBUMIN HUMAN BUMINATE IV SOLN    
ALBUMIN HUMAN FLEXBUMIN IV SOLN    
ALBUMIN HUMAN ALBUMINAR-5 IV SOLN    
ALBUMIN HUMAN ALBUTEIN VIAL    
ALBUMIN HUMAN ALBUKED-25 VIAL    
ALBUMIN HUMAN ALBUKED-5 VIAL    
ALBUMIN HUMAN ALBUMINAR-25 VIAL    
ALBUMIN HUMAN ALBURX VIAL    
ALBUMIN HUMAN KEDBUMIN VIAL    
ALBUMIN HUMAN PLASBUMIN-25 VIAL    
ALBUMIN HUMAN PLASBUMIN-5 VIAL    
ALGLUCOSIDASE ALFA LUMIZYME VIAL    
ALOSETRON HCL ALOSETRON HCL TABLET    
ALOSETRON HCL LOTRONEX TABLET    
ALPHA-1-PROTEINASE INHIBITOR PROLASTIN C VIAL    
ALPHA-1-PROTEINASE INHIBITOR ZEMAIRA VIAL    
ALPHA-1-PROTEINASE INHIBITOR ARALAST NP VIAL    
ALPHA-1-PROTEINASE INHIBITOR GLASSIA VIAL    
ALPROSTADIL EDEX KIT    
ALPROSTADIL CAVERJECT KIT    
ALPROSTADIL MUSE SUPP.URETH    
ALPROSTADIL CAVERJECT VIAL    
ANAGRELIDE HCL AGRYLIN CAPSULE    
ANAGRELIDE HCL ANAGRELIDE HCL CAPSULE    
ANTITHROMBIN III (PLASMA DER) THROMBATE III VIAL    
ASFOTASE ALFA STRENSIQ VIAL    
AVANAFIL STENDRA TABLET    
AZATHIOPRINE SODIUM AZATHIOPRINE SODIUM VIAL    
B3/AZEL AC/ZINC/B6/COPPER/FA VP-ZEL TABLET    
BACTERIOSTATIC SODIUM CHLORIDE SODIUM CHLORIDE VIAL    
BASILIXIMAB SIMULECT VIAL    
BELATACEPT NULOJIX VIAL    
BERACTANT SURVANTA VIAL    
BETAINE CYSTADANE POWDER    
C1 ESTERASE INHIBITOR BERINERT KIT    
C1 ESTERASE INHIBITOR CINRYZE VIAL    
C1 ESTERASE INHIBITOR, RECOMB RUCONEST VIAL    
CARGLUMIC ACID CARBAGLU TAB DISPER    
CERLIPONASE ALFA BRINEURA KIT    
CHLORHEXIDINE GLUCONATE CHLORHEXIDINE GLUCONATE MOUTHWASH    
CINACALCET HCL SENSIPAR TABLET    
CITRIC AC/GLUCONOLACT/MAG CARB RENACIDIN IRRIG SOLN    
CITRIC ACID/SODIUM CITRATE ORACIT SOLUTION    
CITRIC ACID/SODIUM CITRATE CYTRA-2 SOLUTION    
CITRIC ACID/SODIUM CITRATE SODIUM CITRATE-CITRIC ACID SOLUTION    
COAGULATION FACTOR X COAGADEX VIAL    
CROMOLYN SODIUM CROMOLYN SODIUM ORAL CONC    
CROMOLYN SODIUM GASTROCROM ORAL CONC    
CYCLOSPORINE CYCLOSPORINE AMPUL    
CYCLOSPORINE SANDIMMUNE AMPUL    
DEXTRAN 40 IN 0.9 % NACL LMD 10% WITH 0.9% SOD CHLORIDE IV SOLN    
DEXTRAN 40 IN DEXTROSE 5 % LMD 10% WITH 5% DEXTROSE IV SOLN    
DEXTROMETHORPHAN HBR/QUINIDINE NUEDEXTA CAPSULE PA Document  
DILUENT FOR EPOPROSTENOL(GLYC) DILUENT FOR EPOPROSTENOL VIAL    
DILUENT FOR EPOPROSTENOL(GLYC) DILUENT FOR FLOLAN VIAL    
ECALLANTIDE KALBITOR VIAL    
ECULIZUMAB SOLIRIS VIAL    
ELIGLUSTAT TARTRATE CERDELGA CAPSULE    
ELOSULFASE ALFA VIMIZIM VIAL    
FACTOR IX MONONINE VIAL    
FACTOR IX ALPHANINE SD VIAL    
FACTOR IX CPLX(PCC)NO4,3FACTOR PROFILNINE VIAL    
FACTOR IX CPLX(PCC)NO6,3FACTOR BEBULIN VIAL    
FACTOR IX HUMAN RECOMB,THR 148 IXINITY VIAL    
FACTOR IX HUMAN RECOMBINANT RIXUBIS VIAL    
FACTOR IX HUMAN RECOMBINANT BENEFIX VIAL    
FACTOR IX REC, FC FUSION PROTN ALPROLIX VIAL    
FACTOR IX RECOM,ALBUMIN FUSION IDELVION VIAL    
FACTOR XIII CORIFACT VIAL    
FACTOR XIII A-SUBUNIT,RECOMB TRETTEN VIAL    
FAT EMUL/SOY/MCT/OLIV/FISH OIL SMOFLIPID EMULSION    
FAT EMULSIONS INTRALIPID EMULSION    
FAT EMULSIONS NUTRILIPID EMULSION    
FINASTERIDE FINASTERIDE TABLET PA Document  
FINASTERIDE PROPECIA TABLET PA Document  
FLAXSEED/EVENING PRIM/BILBERRY VP-PRECIP CAPSULE    
FLIBANSERIN ADDYI TABLET   Mar 31, 2016
FLUMAZENIL FLUMAZENIL VIAL    
FLUORIDE (SODIUM) DENTA 5000 PLUS CREAM (G)    
FLUORIDE (SODIUM) SF 5000 PLUS CREAM (G)    
FLUORIDE (SODIUM) FLUOR-A-DAY DROPS    
FLUORIDE (SODIUM) SODIUM FLUORIDE DROPS    
FLUORIDE (SODIUM) SF GEL (GRAM)    
FLUORIDE (SODIUM) DENTAGEL GEL (GRAM)    
FLUORIDE (SODIUM) SODIUM FLUORIDE SOLUTION    
FLUORIDE (SODIUM) FLUORIDE TAB CHEW    
FLUORIDE (SODIUM) LUDENT FLUORIDE TAB CHEW    
GALSULFASE NAGLAZYME VIAL    
GLYCEROL PHENYLBUTYRATE RAVICTI LIQUID    
HESTARCH 130/0.4 IN 0.9 % NACL VOLUVEN PLAST. BAG    
HETASTARCH IN 0.9 % NACL HESPAN PLAST. BAG    
HETASTARCH IN 0.9 % NACL HETASTARCH-0.9% NACL PLAST. BAG    
HETASTARCH/E-LYTS,LACTATED HEXTEND LACTATED ELECTROLYTE PLAST. BAG    
HUM PROTHROMBIN CPLX(PCC)4FACT KCENTRA VIAL    
HYDROCORTISONE ACETATE ANUSOL-HC SUPP.RECT    
HYDROCORTISONE ACETATE HEMMOREX-HC SUPP.RECT    
HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE SUPP.RECT    
HYDROCORTISONE ACETATE PROCTOCORT SUPP.RECT    
HYDROCORTISONE ACETATE ANUCORT-HC SUPP.RECT    
HYDROXYUREA DROXIA CAPSULE    
ICATIBANT ACETATE FIRAZYR SYRINGE    
IDURSULFASE ELAPRASE VIAL    
IMIGLUCERASE CEREZYME VIAL    
ISOPROPYL ALCOHOL ISOPROPYL ALCOHOL SOLUTION    
ISOPROPYL ALCOHOL ISOPROPYL RUBBING ALCOHOL SOLUTION    
LACTOBACILLUS CASEI/FOLIC ACID RESTORA RX CAPSULE    
LARONIDASE ALDURAZYME VIAL    
LEVOCARNITINE CARNITOR SF SOLUTION    
LEVOCARNITINE CARNITOR TABLET    
LEVOCARNITINE LEVOCARNITINE TABLET    
LEVOCARNITINE CARNITOR VIAL    
LEVOCARNITINE (WITH SUGAR) CARNITOR SOLUTION    
LEVOCARNITINE (WITH SUGAR) LEVOCARNITINE SOLUTION    
MAGNESIUM SULFATE EPSOM SALT CRYSTALS    
MANNITOL/SORBITOL SOLUTION SORBITOL-MANNITOL IRRIG SOLN    
MEGESTROL ACETATE MEGESTROL ACETATE ORAL SUSP    
MEGESTROL ACETATE MEGACE ES ORAL SUSP    
MIGLUSTAT ZAVESCA CAPSULE    
MILNACIPRAN HCL SAVELLA TAB DS PK PA Document  
MILNACIPRAN HCL SAVELLA TABLET PA Document  
MINERAL OIL MINERAL OIL OIL    
MV-MINS NO.22/LUT/OM3/DHA/EPA TOZAL CAPSULE    
MYCOPHENOLATE MOFETIL HCL CELLCEPT VIAL    
MYCOPHENOLATE MOFETIL HCL MYCOPHENOLATE MOFETIL VIAL    
NEOMYCIN SULF/POLYMYXIN B SULF NEOSPORIN G.U. IRRIGANT AMPUL    
NEOMYCIN SULF/POLYMYXIN B SULF NEOMYCIN-POLYMYXIN B AMPUL    
NEOMYCIN SULF/POLYMYXIN B SULF NEOSPORIN G.U. IRRIGANT VIAL    
NEOMYCIN SULF/POLYMYXIN B SULF NEOMYCIN-POLYMYXIN B VIAL    
NITISINONE ORFADIN CAPSULE    
NITISINONE ORFADIN ORAL SUSP    
NITROGLYCERIN RECTIV OINT. (G) PA Document Jun 28, 2012
OSPEMIFENE OSPHENA TABLET PA Document  
PEGADEMASE BOVINE ADAGEN VIAL    
PEGVISOMANT SOMAVERT VIAL    
PLASMA PROTEIN FRACTION PLASMANATE VIAL    
PORACTANT ALFA CUROSURF VIAL    
POTASSIUM CITRATE POTASSIUM CITRATE ER TABLET ER    
POTASSIUM CITRATE UROCIT-K TABLET ER    
POTASSIUM CITRATE/CITRIC ACID CYTRA-K PACKET    
POTASSIUM CITRATE/CITRIC ACID CYTRA-K SOLUTION    
POTASSIUM CITRATE/CITRIC ACID POTASSIUM CITRATE-CITRIC ACID SOLUTION    
PROTEIN C, HUMAN CEPROTIN VIAL    
RADIUM-223 DICHLORIDE XOFIGO VIAL    
RILONACEPT ARCALYST VIAL    
RILUZOLE RILUZOLE TABLET    
RILUZOLE RILUTEK TABLET    
RINGER'S SOLUTION RINGERS IRRIGATION IRRIG SOLN    
RINGER'S SOLUTION,LACTATED LACTATED RINGERS IRRIG SOLN    
SAMARIUM SM 153 LEXIDRONAM QUADRAMET VIAL    
SAPROPTERIN DIHYDROCHLORIDE KUVAN POWD PACK PA Document  
SEBELIPASE ALFA KANUMA VIAL    
SIMETHICONE GAS RELIEF CAPSULE    
SIMETHICONE GAS-X CAPSULE    
SIMETHICONE GAS-X ULTRA STRENGTH CAPSULE    
SIMETHICONE SIMETHICONE CAPSULE    
SIMETHICONE INFANT GAS RELIEF DROPS SUSP    
SIMETHICONE GAS RELIEF DROPS SUSP    
SIMETHICONE INFANTS' GAS RELIEF DROPS SUSP    
SIMETHICONE SIMETHICONE DROPS SUSP    
SIMETHICONE GAS RELIEF TAB CHEW    
SIMETHICONE GAS RELIEF 80 TAB CHEW    
SIMETHICONE MI-ACID TAB CHEW    
SIMETHICONE MYTAB GAS TAB CHEW    
SIMETHICONE MYTAB GAS MAXIMUM STRENGTH TAB CHEW    
SIMETHICONE SIMETHICONE TAB CHEW    
SIMETHICONE GAS-X TAB CHEW    
SOD,POT CHLOR/MAG/SOD,POT PHOS TIS-U-SOL PENTALYTE IRRIG SOLN    
SOD/POT/K CIT/SOD CIT/CIT ACID TRICITRATES SOLUTION    
SOD/POT/K CIT/SOD CIT/CIT ACID CYTRA-3 SOLUTION    
SOD/POT/K CIT/SOD CIT/CIT ACID POTASS CIT-SOD CIT-CITRIC ACID SOLUTION    
SODIUM BENZOATE/SOD PHENYLACET AMMONUL VIAL    
SODIUM BENZOATE/SOD PHENYLACET SODIUM PHENYLACET-SOD BENZOATE VIAL    
SODIUM FLUORIDE/VITAMIN D3 FLORIVA DROPS    
SODIUM PHENYLBUTYRATE BUPHENYL POWDER    
SODIUM PHENYLBUTYRATE SODIUM PHENYLBUTYRATE POWDER    
SODIUM PHENYLBUTYRATE BUPHENYL TABLET    
SORBITOL SOLUTION SORBITOL IRRIG SOLN    
SUGAMMADEX SODIUM BRIDION VIAL    
TACROLIMUS PROGRAF AMPUL    
TALIGLUCERASE ALFA ELELYSO VIAL    
TEDUGLUTIDE GATTEX KIT    
TIOPRONIN THIOLA TABLET    
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE PASTE (G)    
TRIAMCINOLONE ACETONIDE ORALONE PASTE (G)    
VARDENAFIL HCL STAXYN TAB RAPDIS    
VARDENAFIL HCL LEVITRA TABLET    
VELAGLUCERASE ALFA VPRIV VIAL    
VON WILLEBRAND FACTOR VONVENDI VIAL    
WATER FOR INJ.,BACTERIOSTATIC WATER VIAL    
WATER FOR INJECTION,STERILE WATER IV SOLN    
WATER FOR INJECTION,STERILE WATER VIAL    
WATER/ME-PARABEN/PROPYLPARABEN WATER VIAL