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 New Drug Evaluation & Updates
alfentanil HCl ALFENTANIL HYDROCHLORIDE AMPUL    
buprenorphine HCl BUPRENORPHINE HCL CARTRIDGE    
buprenorphine HCl BUPRENORPHINE HCL VIAL    
butorphanol tartrate BUTORPHANOL TARTRATE VIAL    
codeine phosphate CODEINE PHOSPHATE SYRINGE    
fentanyl citrate/PF FENTANYL CITRATE AMPUL    
fentanyl citrate/PF FENTANYL CITRATE SYRINGE    
fentanyl citrate/PF FENTANYL CITRATE VIAL    
hydromorphone HCl HYDROMORPHONE HCL CARTRIDGE    
hydromorphone HCl HYDROMORPHONE HCL SYRINGE    
hydromorphone HCl HYDROMORPHONE HCL VIAL    
hydromorphone HCl/PF HYDROMORPHONE HCL SYRINGE    
hydromorphone HCl/PF DILAUDID SYRINGE    
hydromorphone HCl/PF HYDROMORPHONE HCL VIAL    
meperidine HCl DEMEROL AMPUL    
meperidine HCl DEMEROL VIAL    
meperidine HCl/PF DEMEROL AMPUL    
meperidine HCl/PF DEMEROL CARTRIDGE    
meperidine HCl/PF DEMEROL SYRINGE    
meperidine HCl/PF MEPERIDINE HCL VIAL    
methadone HCl METHADONE HCL VIAL    
morphine sulfate MORPHINE SULFATE CARTRIDGE    
morphine sulfate MORPHINE SULFATE SYRINGE    
morphine sulfate MORPHINE SULFATE VIAL    
morphine sulfate/PF INFUMORPH AMPUL    
morphine sulfate/PF DURAMORPH AMPUL    
morphine sulfate/PF MORPHINE SULFATE PCA VIAL    
morphine sulfate/PF MORPHINE SULFATE VIAL    
morphine sulfate/PF MITIGO VIAL    
nalbuphine HCl NALBUPHINE HCL AMPUL    
nalbuphine HCl NALBUPHINE HCL VIAL    
pentazocine lactate TALWIN AMPUL    
remifentanil HCl ULTIVA VIAL    
remifentanil HCl REMIFENTANIL HCL VIAL    
sufentanil citrate SUFENTANIL CITRATE VIAL