Stimulants, Misc
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 24385007392 | AMMONIA AROMATIC | ammonia | SPIRIT | Y | |||
| 24385007391 | AMMONIA SPIRITS | ammonia | SPIRIT | Y | |||
| 00641601801 | DOPRAM | doxapram HCl | VIAL | 20 mg/mL | Y | ||
| 00254492928 | PEMOLINE | pemoline | TABLET | 18.75 mg | Y | ||
| 00254493028 | PEMOLINE | pemoline | TABLET | 37.5 mg | Y | ||
| 00254493128 | PEMOLINE | pemoline | TABLET | 75 mg | Y |