Thyroid Preps
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 |
|---|---|---|---|---|---|---|---|
| 25021046810 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 100 mcg | Y | ||
| 42023020101 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 100 mcg | Y | ||
| 63323064907 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 100 mcg | Y | ||
| 63323064916 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 100 mcg | Y | ||
| 63323064994 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 100 mcg | Y | ||
| 70710183301 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 100 mcg | Y | ||
| 63323088510 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 100 mcg/5 mL (20 mcg/mL) | Y | ||
| 63323088512 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 100 mcg/5 mL (20 mcg/mL) | Y | ||
| 63323088514 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 100 mcg/5 mL (20 mcg/mL) | Y | ||
| 24201000201 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 100 mcg/mL | Y | ||
| 25021046910 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 200 mcg | Y | ||
| 42023020201 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 200 mcg | Y | ||
| 63323064710 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 200 mcg | Y | ||
| 70710183401 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 200 mcg | Y | ||
| 63323089010 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 200 mcg/5 mL (40 mcg/mL) | Y | ||
| 25021047010 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 500 mcg | Y | ||
| 42023020301 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 500 mcg | Y | ||
| 63323064810 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 500 mcg | Y | ||
| 70710183501 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 500 mcg | Y | ||
| 63323089510 | LEVOTHYROXINE SODIUM | levothyroxine sodium | VIAL | 500 mcg/5 mL (100 mcg/mL) | Y | ||
| 39822015101 | LIOTHYRONINE SODIUM | liothyronine sodium | VIAL | 10 mcg/mL | Y | ||
| 58468003001 | THYROGEN | thyrotropin alfa | VIAL | 0.9 mg | Y | ||
| 58468003002 | THYROGEN | thyrotropin alfa | VIAL | 0.9 mg | Y |