GnRH Antagonists
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 00074003801 | ORILISSA | elagolix sodium | TABLET | 150 mg | N | Y | PA Document |
| 00074003807 | ORILISSA | elagolix sodium | TABLET | 150 mg | N | Y | PA Document |
| 00074003828 | ORILISSA | elagolix sodium | TABLET | 150 mg | N | Y | PA Document |
| 00074003901 | ORILISSA | elagolix sodium | TABLET | 200 mg | N | Y | PA Document |
| 00074003914 | ORILISSA | elagolix sodium | TABLET | 200 mg | N | Y | PA Document |
| 00074003956 | ORILISSA | elagolix sodium | TABLET | 200 mg | N | Y | PA Document |
| 00074101756 | ORIAHNN | elagolix/estradiol/norethindrn | CAP SEQ | 300 mg-1 mg-0.5 mg (AM)/300 mg (PM) | N | Y | PA Document |
| 72974041501 | MYFEMBREE | relugolix/estradiol/norethindr | TABLET | 40 mg-1 mg-0.5 mg | N | Y | PA Document |