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