Substance Use Disorders, Opioid & Alcohol

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Drug Use Review Documents

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 but eligible patients will encounter a co-pay at the pharmacy.
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.

Generic Name Brand Name Form PDL
Current Drug Use Criteria New Drug Evaluation
acamprosate calcium ACAMPROSATE CALCIUM TABLET DR Y    
buprenorphine HCl/naloxone HCl BUPRENORPHINE-NALOXONE FILM Y Quantity Limit  
buprenorphine HCl/naloxone HCl SUBOXONE FILM Y Quantity Limit  
buprenorphine HCl/naloxone HCl ZUBSOLV TAB SUBL Y Quantity Limit  
buprenorphine HCl/naloxone HCl BUPRENORPHINE-NALOXONE TAB SUBL Y Quantity Limit  
naltrexone HCl REVIA TABLET Y    
naltrexone HCl DEPADE TABLET Y    
naltrexone microspheres VIVITROL SUS ER REC Y   Nov 21, 2013
buprenorphine SUBLOCADE SOLER SYR N PA Document  
buprenorphine HCl BUPRENORPHINE HCL TAB SUBL N PA Document  
buprenorphine HCl/naloxone HCl BUNAVAIL FILM N PA Document  
disulfiram DISULFIRAM TABLET N    
disulfiram ANTABUSE TABLET N    
buprenorphine HCl PROBUPHINE IMPLANT PA Document  
lofexidine HCl LUCEMYRA TABLET PA Document