Opioids, Parenteral

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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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
buprenorphine HCl BUPRENORPHINE HCL CARTRIDGE   N  
codeine phosphate CODEINE PHOSPHATE SYRINGE   N  
fentanyl citrate/PF FENTANYL CITRATE SYRINGE   N  
hydromorphone HCl HYDROMORPHONE HCL CARTRIDGE   N  
hydromorphone HCl HYDROMORPHONE HCL VIAL   N  
hydromorphone HCl/PF HYDROMORPHONE HCL SYRINGE   N  
meperidine HCl DEMEROL AMPUL   N  
meperidine HCl DEMEROL VIAL   N  
meperidine HCl/PF DEMEROL CARTRIDGE   N  
morphine sulfate MORPHINE SULFATE CARTRIDGE   N  
morphine sulfate/PF DURAMORPH AMPUL   N  
morphine sulfate/PF INFUMORPH AMPUL   N  
morphine sulfate/PF MORPHINE SULFATE PCA VIAL   N  
morphine sulfate/PF MITIGO VIAL   N  
nalbuphine HCl NALBUPHINE HCL AMPUL   N  
nalbuphine HCl NALBUPHINE HCL VIAL   N  
remifentanil HCl REMIFENTANIL HCL VIAL   N  
remifentanil HCl ULTIVA VIAL   N  
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