Diabetes, Glucagon

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PDL Reference 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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
00169191201 ZEGALOGUE AUTOINJECTOR dasiglucagon HCl AUTO INJCT 0.6 mg/0.6 mL N Y  
00169191202 ZEGALOGUE AUTOINJECTOR dasiglucagon HCl AUTO INJCT 0.6 mg/0.6 mL N Y  
00169191301 ZEGALOGUE SYRINGE dasiglucagon HCl SYRINGE 0.6 mg/0.6 mL N Y  
00169191302 ZEGALOGUE SYRINGE dasiglucagon HCl SYRINGE 0.6 mg/0.6 mL N Y  
72065012011 GVOKE HYPOPEN 1-PACK glucagon AUTO INJCT 0.5 mg/0.1 mL N Y  
72065012012 GVOKE HYPOPEN 2-PACK glucagon AUTO INJCT 0.5 mg/0.1 mL N Y  
72065012111 GVOKE HYPOPEN 1-PACK glucagon AUTO INJCT 1 mg/0.2 mL N Y  
72065012112 GVOKE HYPOPEN 2-PACK glucagon AUTO INJCT 1 mg/0.2 mL N Y  
00548835101 BAQSIMI glucagon SPRAY 3 mg/actuation Y Y  
00548835112 BAQSIMI glucagon SPRAY 3 mg/actuation Y Y  
00548835202 BAQSIMI glucagon SPRAY 3 mg/actuation Y Y  
72065013111 GVOKE PFS 1-PACK SYRINGE glucagon SYRINGE 1 mg/0.2 mL N Y  
72065013112 GVOKE PFS 2-PACK SYRINGE glucagon SYRINGE 1 mg/0.2 mL N Y  
00002752901 GLUCAGON EMERGENCY KIT glucagon VIAL 1 mg Y Y  
00378806532 GLUCAGON EMERGENCY KIT glucagon VIAL 1 mg Y Y  
00378806790 GLUCAGON EMERGENCY KIT glucagon VIAL 1 mg Y Y  
00548585000 GLUCAGON EMERGENCY KIT glucagon VIAL 1 mg Y Y  
70748030901 GLUCAGON EMERGENCY KIT glucagon VIAL 1 mg Y Y  
70748031101 GLUCAGON EMERGENCY KIT glucagon VIAL 1 mg Y Y  
72065014011 GVOKE glucagon VIAL 1 mg/0.2 mL N Y  
72065014111 GVOKE glucagon VIAL 1 mg/0.2 mL N Y  
63323058282 GLUCAGON EMERGENCY KIT glucagon HCl VIAL 1 mg Y  
63323058313 GLUCAGON HCL glucagon HCl VIAL 1 mg Y  
63323059303 GLUCAGON HCL glucagon HCl VIAL 1 mg/mL Y  
63323059403 GLUCAGON HCL glucagon HCl VIAL 1 mg/mL Y  
63323059603 GLUCAGON HCL glucagon HCl VIAL 1 mg/mL Y  
63323059606 GLUCAGON HCL glucagon HCl VIAL 1 mg/mL Y  
63323059608 GLUCAGON HCL glucagon HCl VIAL 1 mg/mL Y  
63323059611 GLUCAGON HCL glucagon HCl VIAL 1 mg/mL Y  
63323059613 GLUCAGON HCL glucagon HCl VIAL 1 mg/mL Y  
63323059616 GLUCAGON HCL glucagon HCl VIAL 1 mg/mL Y  
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