Other Rheumatologic Agents
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 |
|---|---|---|---|---|---|---|
| ibuprofen/acetaminophen | DUAL ACTION PAIN RELIEF | TABLET | N | N | ||
| glucosa su 2KCl/chondroitin su | GLUCOSAMINE-CHONDROITIN | TABLET | N | |||
| glucosam/chon-msm1/C/mang/bosw | GLUCOSAMINE-CHONDROITIN | TABLET | N | |||
| glucosamine sulfate | GLUCOSAMINE SULFATE | CAPSULE | N | |||
| glucosamine/chondroitin/C/Mang | GLUCOSAMINE-CHONDROITIN | CAPSULE | N | |||
| ibuprofen | CALDOLOR | PIGGYBACK | N | |||
| ibuprofen sodium/acetaminophen | COMBOGESIC IV | VIAL | N | |||
| indomethacin | INDOMETHACIN | SUPP.RECT | N | |||
| leflunomide | LEFLUNOMIDE | TABLET | N | |||
| meloxicam | XIFYRM | VIAL | N | |||
| methotrexate/PF | OTREXUP | AUTO INJCT | N | |||
| penicillamine | PENICILLAMINE | CAPSULE | N | |||
| penicillamine | DEPEN | TABLET | N |