Other Rheumatologic Agents

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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
54766009306 RIDAURA auranofin CAPSULE 3 mg Y  
50268037711 GLUCOSAMINE-CHONDROITIN glucosa su 2KCl/chondroitin su TABLET 500 mg-400 mg Y  
50268037713 GLUCOSAMINE-CHONDROITIN glucosa su 2KCl/chondroitin su TABLET 500 mg-400 mg Y  
24385071825 GLUCOSAMINE-CHONDROITIN glucosam/chon-msm1/C/mang/bosw TABLET 500 mg-416.6 mg-20 mg-0.6 mg-33.3 mg-1 mg Y  
24385071871 GLUCOSAMINE-CHONDROITIN glucosam/chon-msm1/C/mang/bosw TABLET 500 mg-416.6 mg-20 mg-0.6 mg-33.3 mg-1 mg Y  
24385072441 GLUCOSAMINE-CHONDROITIN glucosam/chon-msm1/C/mang/bosw TABLET 750 mg-625 mg-30 mg-1 mg-50 mg-1.5 mg Y  
37205009872 GLUCOSAMINE COMPLEX glucosamine HCl and sulfate TABLET 200 mg-300 mg Y  
50268037511 GLUCOSAMINE SULFATE glucosamine sulfate CAPSULE 500 mg Y  
50268037515 GLUCOSAMINE SULFATE glucosamine sulfate CAPSULE 500 mg Y  
45861000001 CIDATRINE glucosamine sulfate TABLET 500 mg Y  
45861000000 CIDAFLEX glucosamine/chondr su A sod TABLET 500 mg-400 mg Y  
50268037611 GLUCOSAMINE-CHONDROITIN glucosamine/chondroitin/C/Mang CAPSULE 500 mg-400 mg Y  
50268037615 GLUCOSAMINE-CHONDROITIN glucosamine/chondroitin/C/Mang CAPSULE 500 mg-400 mg Y  
55566410003 EUFLEXXA hyaluronate sodium SYRINGE 20 mg/2 mL (10 mg/mL) (mw 2.4-3.6 million daltons) Y  
55566410004 EUFLEXXA hyaluronate sodium SYRINGE 20 mg/2 mL (10 mg/mL) (mw 2.4-3.6 million daltons) Y  
66220028411 CALDOLOR ibuprofen PIGGYBACK 800 mg/200 mL (4 mg/mL) Y  
66220028422 CALDOLOR ibuprofen PIGGYBACK 800 mg/200 mL (4 mg/mL) Y  
66220028708 CALDOLOR ibuprofen VIAL 800 mg/8 mL (100 mg/mL) Y  
00143915001 COMBOGESIC IV ibuprofen sodium/acetaminophen VIAL 300 mg-1,000 mg/100 mL Y  
00143915010 COMBOGESIC IV ibuprofen sodium/acetaminophen VIAL 300 mg-1,000 mg/100 mL Y  
00536137636 ACETAMINOPHEN-IBUPROFEN ibuprofen/acetaminophen TABLET 125 mg-250 mg N Y  
46122074268 ACETAMINOPHEN-IBUPROFEN ibuprofen/acetaminophen TABLET 125 mg-250 mg N Y  
70000062201 DUAL ACTION PAIN RELIEF ibuprofen/acetaminophen TABLET 125 mg-250 mg N Y  
00113530016 DUAL ACTION PAIN RELIEVER ibuprofen/acetaminophen TABLET 125 mg-250 mg N Y  
00113530068 DUAL ACTION PAIN RELIEVER ibuprofen/acetaminophen TABLET 125 mg-250 mg N Y  
46122081861 DUAL ACTION PAIN RELIEVER ibuprofen/acetaminophen TABLET 125 mg-250 mg N Y  
70677127401 DUAL ACTION PAIN RELIEVER ibuprofen/acetaminophen TABLET 125 mg-250 mg N Y  
83324014936 DUAL ACTION PAIN RELIEVER ibuprofen/acetaminophen TABLET 125 mg-250 mg N Y  
00054195030 INDOMETHACIN indomethacin SUPP.RECT 50 mg Y  
69238208603 INDOMETHACIN indomethacin SUPP.RECT 50 mg Y  
70710185206 INDOMETHACIN indomethacin SUPP.RECT 50 mg Y  
70710185207 INDOMETHACIN indomethacin SUPP.RECT 50 mg Y  
70710195807 INDOMETHACIN indomethacin SUPP.RECT 50 mg Y  
00088216030 ARAVA leflunomide TABLET 10 mg Y  
23155004303 LEFLUNOMIDE leflunomide TABLET 10 mg Y  
35573044730 LEFLUNOMIDE leflunomide TABLET 10 mg Y  
50268047711 LEFLUNOMIDE leflunomide TABLET 10 mg Y  
50268047715 LEFLUNOMIDE leflunomide TABLET 10 mg Y  
59651034830 LEFLUNOMIDE leflunomide TABLET 10 mg Y  
60505250201 LEFLUNOMIDE leflunomide TABLET 10 mg Y  
62135079330 LEFLUNOMIDE leflunomide TABLET 10 mg Y  
62332006130 LEFLUNOMIDE leflunomide TABLET 10 mg Y  
70710115703 LEFLUNOMIDE leflunomide TABLET 10 mg Y  
70748012906 LEFLUNOMIDE leflunomide TABLET 10 mg Y  
00088216130 ARAVA leflunomide TABLET 20 mg Y  
23155004403 LEFLUNOMIDE leflunomide TABLET 20 mg Y  
35573044830 LEFLUNOMIDE leflunomide TABLET 20 mg Y  
50268047811 LEFLUNOMIDE leflunomide TABLET 20 mg Y  
50268047815 LEFLUNOMIDE leflunomide TABLET 20 mg Y  
59651034930 LEFLUNOMIDE leflunomide TABLET 20 mg Y  
60505250301 LEFLUNOMIDE leflunomide TABLET 20 mg Y  
62135079430 LEFLUNOMIDE leflunomide TABLET 20 mg Y  
62332006230 LEFLUNOMIDE leflunomide TABLET 20 mg Y  
70710115803 LEFLUNOMIDE leflunomide TABLET 20 mg Y  
70748013006 LEFLUNOMIDE leflunomide TABLET 20 mg Y  
24338015301 XIFYRM meloxicam VIAL 30 mg/mL Y  
24338015302 XIFYRM meloxicam VIAL 30 mg/mL Y  
00555057245 METHOTREXATE methotrexate sodium TAB DS PK 2.5 mg Y  
00555057246 METHOTREXATE methotrexate sodium TAB DS PK 2.5 mg Y  
00555057247 METHOTREXATE methotrexate sodium TAB DS PK 2.5 mg Y  
00555057248 METHOTREXATE methotrexate sodium TAB DS PK 2.5 mg Y  
00555057249 METHOTREXATE methotrexate sodium TAB DS PK 2.5 mg Y  
59137051000 RASUVO methotrexate/PF AUTO INJCT 10 mg/0.2 mL Y  
59137051004 RASUVO methotrexate/PF AUTO INJCT 10 mg/0.2 mL Y  
54436001002 OTREXUP methotrexate/PF AUTO INJCT 10 mg/0.4 mL Y  
54436001004 OTREXUP methotrexate/PF AUTO INJCT 10 mg/0.4 mL Y  
59137051500 RASUVO methotrexate/PF AUTO INJCT 12.5 mg/0.25 mL Y  
59137051504 RASUVO methotrexate/PF AUTO INJCT 12.5 mg/0.25 mL Y  
54436001202 OTREXUP methotrexate/PF AUTO INJCT 12.5 mg/0.4 mL Y  
54436001204 OTREXUP methotrexate/PF AUTO INJCT 12.5 mg/0.4 mL Y  
59137052000 RASUVO methotrexate/PF AUTO INJCT 15 mg/0.3 mL Y  
59137052004 RASUVO methotrexate/PF AUTO INJCT 15 mg/0.3 mL Y  
54436001502 OTREXUP methotrexate/PF AUTO INJCT 15 mg/0.4 mL Y  
54436001504 OTREXUP methotrexate/PF AUTO INJCT 15 mg/0.4 mL Y  
59137052500 RASUVO methotrexate/PF AUTO INJCT 17.5 mg/0.35 mL Y  
59137052504 RASUVO methotrexate/PF AUTO INJCT 17.5 mg/0.35 mL Y  
54436001702 OTREXUP methotrexate/PF AUTO INJCT 17.5 mg/0.4 mL Y  
54436001704 OTREXUP methotrexate/PF AUTO INJCT 17.5 mg/0.4 mL Y  
54436002002 OTREXUP methotrexate/PF AUTO INJCT 20 mg/0.4 mL Y  
54436002004 OTREXUP methotrexate/PF AUTO INJCT 20 mg/0.4 mL Y  
59137053000 RASUVO methotrexate/PF AUTO INJCT 20 mg/0.4 mL Y  
59137053001 RASUVO methotrexate/PF AUTO INJCT 20 mg/0.4 mL Y  
59137053004 RASUVO methotrexate/PF AUTO INJCT 20 mg/0.4 mL Y  
54436002202 OTREXUP methotrexate/PF AUTO INJCT 22.5 mg/0.4 mL Y  
54436002204 OTREXUP methotrexate/PF AUTO INJCT 22.5 mg/0.4 mL Y  
59137053500 RASUVO methotrexate/PF AUTO INJCT 22.5 mg/0.45 mL Y  
59137053504 RASUVO methotrexate/PF AUTO INJCT 22.5 mg/0.45 mL Y  
54436002502 OTREXUP methotrexate/PF AUTO INJCT 25 mg/0.4 mL Y  
54436002504 OTREXUP methotrexate/PF AUTO INJCT 25 mg/0.4 mL Y  
59137054000 RASUVO methotrexate/PF AUTO INJCT 25 mg/0.5 mL Y  
59137054004 RASUVO methotrexate/PF AUTO INJCT 25 mg/0.5 mL Y  
59137055000 RASUVO methotrexate/PF AUTO INJCT 30 mg/0.6 mL Y  
59137055004 RASUVO methotrexate/PF AUTO INJCT 30 mg/0.6 mL Y  
59137050500 RASUVO methotrexate/PF AUTO INJCT 7.5 mg/0.15 mL Y  
59137050504 RASUVO methotrexate/PF AUTO INJCT 7.5 mg/0.15 mL Y  
59088063000 NAPROTIN naproxen/capsicum oleoresin KIT 500 mg-0.025 % Y  
25010070515 CUPRIMINE penicillamine CAPSULE 250 mg Y  
00591417101 PENICILLAMINE penicillamine CAPSULE 250 mg Y  
43598063401 PENICILLAMINE penicillamine CAPSULE 250 mg Y  
49884014601 PENICILLAMINE penicillamine CAPSULE 250 mg Y  
51991097401 PENICILLAMINE penicillamine CAPSULE 250 mg Y  
62559097001 PENICILLAMINE penicillamine CAPSULE 250 mg Y  
70010090701 PENICILLAMINE penicillamine CAPSULE 250 mg Y  
00037440101 DEPEN penicillamine TABLET 250 mg Y  
00254200001 PENICILLAMINE penicillamine TABLET 250 mg Y  
70748015301 PENICILLAMINE penicillamine TABLET 250 mg Y  
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