GnRH Agonists

← Back to Class List

PDL Reference Documents

Drug Use Review Documents

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.

< Return to summary view

NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
67979000201 SUPPRELIN LA histrelin acetate KIT 50 mg (65 mcg/day) N Y PA Document
54092063875 SUPPRELIN histrelin acetate KIT 500 mcg/mL N Y PA Document
00121210602 LEUPROLIDE ACETATE leuprolide acetate KIT 1 mg/0.2 mL N Y PA Document
00781400332 LEUPROLIDE ACETATE leuprolide acetate KIT 1 mg/0.2 mL N Y PA Document
47335093640 LEUPROLIDE ACETATE leuprolide acetate KIT 1 mg/0.2 mL N Y PA Document
55150047801 LEUPROLIDE ACETATE leuprolide acetate KIT 1 mg/0.2 mL N Y PA Document
70121253706 LEUPROLIDE ACETATE leuprolide acetate KIT 1 mg/0.2 mL N Y PA Document
71288056990 LEUPROLIDE ACETATE leuprolide acetate KIT 1 mg/0.2 mL N Y PA Document
72603034401 LEUPROLIDE ACETATE leuprolide acetate KIT 1 mg/0.2 mL N Y PA Document
72664061128 LEUPROLIDE ACETATE leuprolide acetate KIT 1 mg/0.2 mL N Y PA Document
83634045461 LEUPROLIDE ACETATE leuprolide acetate KIT 1 mg/0.2 mL N Y PA Document
00074228203 LUPRON DEPOT-PED leuprolide acetate KIT 11.25 mg Y Y PA Document
00074244003 LUPRON DEPOT-PED leuprolide acetate KIT 15 mg Y Y PA Document
00074210803 LUPRON DEPOT-PED leuprolide acetate KIT 7.5 mg (pediatric 1 month) Y Y PA Document
62935022004 ELIGARD leuprolide acetate SYRINGE 22.5 mg (3 month) N Y PA Document
62935022104 ELIGARD leuprolide acetate SYRINGE 22.5 mg (3 month) N Y PA Document
62935022305 ELIGARD leuprolide acetate SYRINGE 22.5 mg (3 month) N Y PA Document
62935022710 ELIGARD leuprolide acetate SYRINGE 22.5 mg (3 month) N Y PA Document
62935030330 ELIGARD leuprolide acetate SYRINGE 30 mg (4 month) N Y PA Document
62935030529 ELIGARD leuprolide acetate SYRINGE 30 mg (4 month) N Y PA Document
62935030640 ELIGARD leuprolide acetate SYRINGE 30 mg (4 month) N Y PA Document
62935045345 ELIGARD leuprolide acetate SYRINGE 45 mg (6 month) N Y PA Document
62935045444 ELIGARD leuprolide acetate SYRINGE 45 mg (6 month) N Y PA Document
62935046150 ELIGARD leuprolide acetate SYRINGE 45 mg (6 month) N Y PA Document
62935015350 FENSOLVI leuprolide acetate SYRINGE 45 mg (pediatric 6 month) N Y PA Document
62935015450 FENSOLVI leuprolide acetate SYRINGE 45 mg (pediatric 6 month) N Y PA Document
62935016360 FENSOLVI leuprolide acetate SYRINGE 45 mg (pediatric 6 month) N Y PA Document
62935075375 ELIGARD leuprolide acetate SYRINGE 7.5 mg (1 month) N Y PA Document
62935075474 ELIGARD leuprolide acetate SYRINGE 7.5 mg (1 month) N Y PA Document
62935075680 ELIGARD leuprolide acetate SYRINGE 7.5 mg (1 month) N Y PA Document
00074366303 LUPRON DEPOT leuprolide acetate SYRINGEKIT 11.25 mg N Y PA Document
00074377903 LUPRON DEPOT-PED leuprolide acetate SYRINGEKIT 11.25 mg N Y PA Document
00074334603 LUPRON DEPOT leuprolide acetate SYRINGEKIT 22.5 mg (3 month) N Y PA Document
00074364103 LUPRON DEPOT leuprolide acetate SYRINGEKIT 3.75 mg N Y PA Document
00074364171 LUPRON DEPOT leuprolide acetate SYRINGEKIT 3.75 mg N Y PA Document
00074368303 LUPRON DEPOT leuprolide acetate SYRINGEKIT 30 mg (4 month) N Y PA Document
00074969403 LUPRON DEPOT-PED leuprolide acetate SYRINGEKIT 30 mg (pediatric 3 month) N Y PA Document
00074347303 LUPRON DEPOT leuprolide acetate SYRINGEKIT 45 mg (6 month) N Y PA Document
00074357501 LUPRON DEPOT-PED leuprolide acetate SYRINGEKIT 45 mg (pediatric 6 month) N Y PA Document
00074364203 LUPRON DEPOT leuprolide acetate SYRINGEKIT 7.5 mg (1 month) N Y PA Document
00121105355 LEUPROLIDE ACETATE leuprolide acetate VIAL 1 mg/0.2 mL N Y PA Document
00781300642 LEUPROLIDE ACETATE leuprolide acetate VIAL 1 mg/0.2 mL N Y PA Document
55150033801 LEUPROLIDE ACETATE leuprolide acetate VIAL 1 mg/0.2 mL N Y PA Document
70121169502 LEUPROLIDE ACETATE leuprolide acetate VIAL 1 mg/0.2 mL N Y PA Document
71288056503 LEUPROLIDE ACETATE leuprolide acetate VIAL 1 mg/0.2 mL N Y PA Document
72603020101 LEUPROLIDE ACETATE leuprolide acetate VIAL 1 mg/0.2 mL N Y PA Document
83634045203 LEUPROLIDE ACETATE leuprolide acetate VIAL 1 mg/0.2 mL N Y PA Document
69097090950 LEUPROLIDE DEPOT leuprolide acetate VIAL 22.5 mg (3 month) N Y PA Document
69097095032 LEUPROLIDE DEPOT leuprolide acetate VIAL 22.5 mg (3 month) N Y PA Document
83831013401 LUTRATE DEPOT leuprolide acetate VIAL 22.5 mg (3 month) N Y PA Document
83831015022 LUTRATE DEPOT leuprolide acetate VIAL 22.5 mg (3 month) N Y PA Document
69448001463 CAMCEVI leuprolide mesylate SYRINGE 42 mg (6 month) N Y PA Document
69448002363 CAMCEVI leuprolide mesylate SYRINGE 42 mg (6 month) N Y PA Document
00025016608 SYNAREL nafarelin acetate SPRAY 2 mg/mL N Y PA Document
74676590400 TRELSTAR triptorelin pamoate VIAL 11.25 mg N Y PA Document
74676590401 TRELSTAR triptorelin pamoate VIAL 11.25 mg N Y PA Document
74676590600 TRELSTAR triptorelin pamoate VIAL 22.5 mg N Y PA Document
74676590601 TRELSTAR triptorelin pamoate VIAL 22.5 mg N Y PA Document
24338015001 TRIPTODUR triptorelin pamoate VIAL 22.5 mg N Y PA Document
24338015020 TRIPTODUR triptorelin pamoate VIAL 22.5 mg N Y PA Document
74676590200 TRELSTAR triptorelin pamoate VIAL 3.75 mg N Y PA Document
74676590201 TRELSTAR triptorelin pamoate VIAL 3.75 mg N Y PA Document
Back to Top ↑