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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.
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| cholestyramine | CHOLESTYRAMINE LIGHT | POWD PACK | Y | N | ||
| cholestyramine | PREVALITE | POWD PACK | Y | N | ||
| cholestyramine | QUESTRAN LIGHT | POWDER | Y | N | ||
| cholestyramine | PREVALITE | POWDER | Y | N | ||
| cholestyramine | CHOLESTYRAMINE LIGHT | POWDER | Y | N | ||
| cholestyramine (with sugar) | QUESTRAN | POWD PACK | Y | N | ||
| cholestyramine (with sugar) | CHOLESTYRAMINE | POWD PACK | Y | N | ||
| cholestyramine (with sugar) | QUESTRAN | POWDER | Y | N | ||
| cholestyramine (with sugar) | CHOLESTYRAMINE | POWDER | Y | N | ||
| cholestyramine/aspartame | CHOLESTYRAMINE LIGHT | POWDER | Y | N | ||
| evolocumab | REPATHA SURECLICK | PEN INJCTR | Y | Pharmacy PA | N | |
| evolocumab | REPATHA SYRINGE | SYRINGE | Y | Pharmacy PA | N | |
| evolocumab | REPATHA PUSHTRONEX | WEAR INJCT | Y | Pharmacy PA | N | |
| ezetimibe | EZETIMIBE | TABLET | Y | N | ||
| ezetimibe | ZETIA | TABLET | Y | N | ||
| fenofibrate | FENOFIBRATE | TABLET | Y | N | ||
| fenofibrate nanocrystallized | FENOFIBRATE | TABLET | Y | N | ||
| fenofibrate nanocrystallized | TRICOR | TABLET | Y | N | ||
| fenofibrate,micronized | FENOFIBRATE | CAPSULE | Y | N | ||
| fenofibric acid (choline) | FENOFIBRIC ACID | CAPSULE DR | Y | N | ||
| omega-3 acid ethyl esters | OMEGA-3 ACID ETHYL ESTERS | CAPSULE | Y | Pharmacy PA | N | |
| alirocumab | PRALUENT PEN | PEN INJCTR | N | Pharmacy PA | N | |
| bempedoic acid | NEXLETOL | TABLET | N | Pharmacy PA | N | |
| bempedoic acid/ezetimibe | NEXLIZET | TABLET | N | Pharmacy PA | N | |
| choline | CHOLINE | TABLET | N | N | ||
| colesevelam HCl | COLESEVELAM HCL | POWD PACK | N | N | ||
| colesevelam HCl | WELCHOL | POWD PACK | N | N | ||
| colesevelam HCl | WELCHOL | TABLET | N | N | ||
| colesevelam HCl | COLESEVELAM HCL | TABLET | N | N | ||
| colestipol HCl | COLESTID | GRANULES | N | N | ||
| colestipol HCl | COLESTIPOL HCL | GRANULES | N | N | ||
| colestipol HCl | COLESTIPOL HCL | PACKET | N | N | ||
| colestipol HCl | COLESTID | TABLET | N | N | ||
| colestipol HCl | COLESTIPOL HCL | TABLET | N | N | ||
| evinacumab-dgnb | EVKEEZA | VIAL | N | Pharmacy PA | N | |
| fenofibrate | LIPOFEN | CAPSULE | N | N | ||
| fenofibrate | FENOFIBRATE | CAPSULE | N | N | ||
| fenofibrate | FENOFIBRATE | TABLET | N | N | ||
| gemfibrozil | LOPID | TABLET | N | N | ||
| gemfibrozil | GEMFIBROZIL | TABLET | N | N | ||
| icosapent ethyl | ICOSAPENT ETHYL | CAPSULE | N | Pharmacy PA | N | |
| inclisiran sodium | LEQVIO | SYRINGE | N | Pharmacy PA | N | |
| inositol | INOSITOL | TABLET | N | Pharmacy PA | N | |
| lomitapide mesylate | JUXTAPID | CAPSULE | N | N | Jul 25, 2013 May 26, 2016 |
|
| niacin | NIACIN | CAPSULE ER | N | N | ||
| niacin | NIACIN ER | TAB ER 24H | N | N | ||
| niacin | NIACIN | TABLET | N | N | ||
| niacin | SLO-NIACIN | TABLET ER | N | N | ||
| niacin | NIADELAY | TABLET ER | N | N | ||
| niacin | NIACIN | TABLET ER | N | N | ||
| niacinamide | NIACINAMIDE | TABLET | N | N | ||
| niacinamide | VITAMIN B3 | TABLET | N | N | ||
| niacinamide | VITAMIN B3 | TABLET | N | |||
| olezarsen sodium | TRYNGOLZA | AUTO INJCT | Pharmacy PA | N |