Serotonin Agonists, Oral
PDL Reference Documents
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.
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 |
|---|---|---|---|---|---|---|
| eletriptan hydrobromide | RELPAX | TABLET | Y | Quantity Limit | N | |
| naratriptan HCl | NARATRIPTAN HCL | TABLET | Y | Quantity Limit | N | |
| rizatriptan benzoate | RIZATRIPTAN | TAB RAPDIS | Y | Quantity Limit | N | |
| rizatriptan benzoate | MAXALT | TABLET | Y | Quantity Limit | N | |
| rizatriptan benzoate | RIZATRIPTAN | TABLET | Y | Quantity Limit | N | |
| sumatriptan succinate | SUMATRIPTAN SUCCINATE | TABLET | Y | Quantity Limit | N | |
| almotriptan malate | ALMOTRIPTAN MALATE | TABLET | N | Quantity Limit | N | |
| celecoxib | ELYXYB | SOLUTION | N | Quantity Limit | N | |
| frovatriptan succinate | FROVATRIPTAN SUCCINATE | TABLET | N | Quantity Limit | N | |
| sumatriptan succ/naproxen sod | SUMATRIPTAN SUCC-NAPROXEN SOD | TABLET | N | Quantity Limit | N |