Substance Use Disorders, Opioid & Alcohol

← Back to Class List

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.

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