Antithyroid 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 | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 00832607311 | METHIMAZOLE | methimazole | TABLET | 10 mg | Y | N | ||
| 23155007101 | METHIMAZOLE | methimazole | TABLET | 10 mg | Y | N | ||
| 33342033611 | METHIMAZOLE | methimazole | TABLET | 10 mg | Y | N | ||
| 60687068001 | METHIMAZOLE | methimazole | TABLET | 10 mg | Y | N | ||
| 60687068011 | METHIMAZOLE | methimazole | TABLET | 10 mg | Y | N | ||
| 62135020618 | METHIMAZOLE | methimazole | TABLET | 10 mg | Y | N | ||
| 62135020690 | METHIMAZOLE | methimazole | TABLET | 10 mg | Y | N | ||
| 64380021301 | METHIMAZOLE | methimazole | TABLET | 10 mg | Y | N | ||
| 64980026501 | METHIMAZOLE | methimazole | TABLET | 10 mg | Y | N | ||
| 69452032920 | METHIMAZOLE | methimazole | TABLET | 10 mg | Y | N | ||
| 72603031601 | METHIMAZOLE | methimazole | TABLET | 10 mg | Y | N | ||
| 00832607211 | METHIMAZOLE | methimazole | TABLET | 5 mg | Y | N | ||
| 23155007001 | METHIMAZOLE | methimazole | TABLET | 5 mg | Y | N | ||
| 33342033511 | METHIMAZOLE | methimazole | TABLET | 5 mg | Y | N | ||
| 62135020518 | METHIMAZOLE | methimazole | TABLET | 5 mg | Y | N | ||
| 62135020590 | METHIMAZOLE | methimazole | TABLET | 5 mg | Y | N | ||
| 64380021201 | METHIMAZOLE | methimazole | TABLET | 5 mg | Y | N | ||
| 64380021202 | METHIMAZOLE | methimazole | TABLET | 5 mg | Y | N | ||
| 64980026401 | METHIMAZOLE | methimazole | TABLET | 5 mg | Y | N | ||
| 69452032820 | METHIMAZOLE | methimazole | TABLET | 5 mg | Y | N | ||
| 72603031501 | METHIMAZOLE | methimazole | TABLET | 5 mg | Y | N | ||
| 00228234810 | PROPYLTHIOURACIL | propylthiouracil | TABLET | 50 mg | Y | N | ||
| 00480924201 | PROPYLTHIOURACIL | propylthiouracil | TABLET | 50 mg | Y | N | ||
| 33342031411 | PROPYLTHIOURACIL | propylthiouracil | TABLET | 50 mg | Y | N | ||
| 62135060690 | PROPYLTHIOURACIL | propylthiouracil | TABLET | 50 mg | Y | N | ||
| 67253065110 | PROPYLTHIOURACIL | propylthiouracil | TABLET | 50 mg | Y | N | ||
| 67253065111 | PROPYLTHIOURACIL | propylthiouracil | TABLET | 50 mg | Y | N | ||
| 68084096425 | PROPYLTHIOURACIL | propylthiouracil | TABLET | 50 mg | Y | N | ||
| 68084096495 | PROPYLTHIOURACIL | propylthiouracil | TABLET | 50 mg | Y | N | ||
| 70752017110 | PROPYLTHIOURACIL | propylthiouracil | TABLET | 50 mg | Y | N |