Diabetes, Glucagon

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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 New Drug Evaluation
glucagon BAQSIMI SPRAY Y    
glucagon GLUCAGON EMERGENCY KIT VIAL Y    
glucagon GLUCAGEN VIAL Y    
dasiglucagon HCl ZEGALOGUE AUTOINJECTOR AUTO INJCT N    
dasiglucagon HCl ZEGALOGUE SYRINGE SYRINGE N    
glucagon GVOKE HYPOPEN 2-PACK AUTO INJCT N    
glucagon GVOKE HYPOPEN 1-PACK AUTO INJCT N    
glucagon GVOKE PFS 2-PACK SYRINGE SYRINGE N    
glucagon GVOKE PFS 1-PACK SYRINGE SYRINGE N    
glucagon GVOKE VIAL N    
glucagon HCl GLUCAGON HCL VIAL    
glucagon HCl GLUCAGON EMERGENCY KIT VIAL