Diabetes, Emergency Therapy
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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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 73515012330 | CYCLOSET | bromocriptine mesylate | TABLET | 0.8 mg | Y | ||
| 62011004201 | GLUCOSE | dextrose | TAB CHEW | 4 gram | Y | ||
| 62011004202 | GLUCOSE | dextrose | TAB CHEW | 4 gram | Y | ||
| 62011004301 | GLUCOSE | dextrose | TAB CHEW | 4 gram | Y | ||
| 62011004302 | GLUCOSE | dextrose | TAB CHEW | 4 gram | Y | ||
| 24208002401 | INSTA-GLUCOSE | dextrose/dextrin/maltose | GEL (GRAM) | 24 gram/31 gram | Y | ||
| 24208002402 | INSTA-GLUCOSE | dextrose/dextrin/maltose | GEL (GRAM) | 24 gram/31 gram | Y | ||
| 24208002403 | INSTA-GLUCOSE | dextrose/dextrin/maltose | GEL (GRAM) | 24 gram/31 gram | Y | ||
| 00254101019 | DIAZOXIDE | diazoxide | ORAL SUSP | 50 mg/mL | Y | ||
| 13517010030 | DIAZOXIDE | diazoxide | ORAL SUSP | 50 mg/mL | Y | ||
| 00575620030 | PROGLYCEM | diazoxide | ORAL SUSP | 50 mg/mL | Y | ||
| 43393000101 | MIFEPRISTONE | mifepristone | TABLET | 200 mg | Y | ||
| 43393000106 | MIFEPRISTONE | mifepristone | TABLET | 200 mg | Y | ||
| 76346007301 | KORLYM | mifepristone | TABLET | 300 mg | Y | ||
| 76346007302 | KORLYM | mifepristone | TABLET | 300 mg | Y | ||
| 00591439096 | MIFEPRISTONE | mifepristone | TABLET | 300 mg | Y | ||
| 76346065403 | MIFEPRISTONE | mifepristone | TABLET | 300 mg | Y |