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