Non-Steroidal Anti-Inflammatory Drugs

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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.

Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria New Drug Evaluation
celecoxib CELECOXIB CAPSULE Y    
celecoxib CELEBREX CAPSULE Y    
diclofenac potassium DICLOFENAC POTASSIUM TABLET Y    
diclofenac sodium DICLOFENAC SODIUM TABLET DR Y    
etodolac ETODOLAC TABLET Y    
ibuprofen IBUPROFEN CAPSULE Y    
ibuprofen IBUPROFEN CAPSULE Y    
ibuprofen WAL-PROFEN CAPSULE Y    
ibuprofen MOTRIN IB CAPSULE Y    
ibuprofen ADVIL MIGRAINE CAPSULE Y    
ibuprofen ADVIL CAPSULE Y    
ibuprofen INFANTS' IBUPROFEN DROPS SUSP Y    
ibuprofen INFANT'S IBUPROFEN DROPS SUSP Y    
ibuprofen INFANT'S IBUPROFEN DROPS SUSP Y    
ibuprofen INFANTS IBUPROFEN DROPS SUSP Y    
ibuprofen INFANTS' ADVIL DROPS SUSP Y    
ibuprofen INFANTS' MOTRIN DROPS SUSP Y    
ibuprofen CHILDREN'S MOTRIN DROPS SUSP Y    
ibuprofen INFANTS' IBUPROFEN DROPS SUSP Y    
ibuprofen INFANT'S MOTRIN DROPS SUSP Y    
ibuprofen INFANTS PROFENIB DROPS SUSP Y    
ibuprofen IBUPROFEN ORAL SUSP Y    
ibuprofen CHILDREN'S IBUPROFEN ORAL SUSP Y    
ibuprofen IBUPROFEN ORAL SUSP Y    
ibuprofen CHILDREN'S IBUPROFEN ORAL SUSP Y    
ibuprofen CHILDREN'S PROFENIB ORAL SUSP Y    
ibuprofen CHILDREN'S PROFEN IB ORAL SUSP Y    
ibuprofen CHILDREN'S MOTRIN ORAL SUSP Y    
ibuprofen CHILDREN'S MEDI-PROFEN ORAL SUSP Y    
ibuprofen CHILDREN'S ADVIL ORAL SUSP Y    
ibuprofen MOTRIN ORAL SUSP Y    
ibuprofen IBUPROFEN IB TAB CHEW Y    
ibuprofen IBUPROFEN TAB CHEW Y    
ibuprofen IBUPROFEN IB TAB CHEW Y    
ibuprofen IBUPROFEN TAB CHEW Y    
ibuprofen CHILDREN'S MOTRIN TAB CHEW Y    
ibuprofen ADVIL JUNIOR STRENGTH TAB CHEW Y    
ibuprofen MOTRIN IB TABLET Y    
ibuprofen IBUPROFEN IB TABLET Y    
ibuprofen IBUPROFEN TABLET Y    
ibuprofen IBU-200 TABLET Y    
ibuprofen IBU TABLET Y    
ibuprofen IBUPROHM TABLET Y    
ibuprofen IBUPROFEN IB TABLET Y    
ibuprofen IBUPROFEN TABLET Y    
ibuprofen WAL-PROFEN TABLET Y    
ibuprofen TAB-PROFEN TABLET Y    
ibuprofen MOTRIN IB TABLET Y    
ibuprofen MIDOL CRAMP TABLET Y    
ibuprofen I-PRIN TABLET Y    
ibuprofen MEDI-PROFEN TABLET Y    
ibuprofen CAP-PROFEN TABLET Y    
ibuprofen ADVIL TABLET Y    
ibuprofen ADDAPRIN TABLET Y    
indomethacin INDOMETHACIN CAPSULE Y    
ketoprofen KIPROFEN CAPSULE Y    
ketoprofen KETOPROFEN CAPSULE Y    
meloxicam MELOXICAM TABLET Y    
meloxicam MOBIC TABLET Y    
nabumetone NABUMETONE TABLET Y    
naproxen NAPROXEN TABLET Y    
naproxen EC-NAPROXEN TABLET DR Y    
naproxen NAPROXEN TABLET DR Y    
naproxen sodium NAPROXEN SODIUM TABLET Y    
naproxen sodium ALL DAY RELIEF TABLET Y    
naproxen sodium ALL DAY PAIN RELIEF TABLET Y    
naproxen sodium WAL-PROXEN TABLET Y    
naproxen sodium NAPROXEN SODIUM TABLET Y    
naproxen sodium MEDIPROXEN TABLET Y    
naproxen sodium FLANAX TABLET Y    
naproxen sodium ALL DAY RELIEF TABLET Y    
naproxen sodium ALL DAY PAIN RELIEF TABLET Y    
naproxen sodium ALEVE TABLET Y    
oxaprozin DAYPRO TABLET Y    
oxaprozin OXAPROZIN TABLET Y    
salsalate SALSALATE TABLET Y    
sulindac SULINDAC TABLET Y    
diclofenac potassium DICLOFENAC POTASSIUM CAPSULE N PA Document  
diclofenac potassium DICLOFENAC POTASSIUM POWD PACK N PA Document  
diclofenac potassium LOFENA TABLET N PA Document  
diclofenac potassium DICLOFENAC POTASSIUM TABLET N PA Document  
diclofenac sodium DICLOFENAC SODIUM ER TAB ER 24H N PA Document  
diclofenac sodium/misoprostol DICLOFENAC SODIUM-MISOPROSTOL TAB IR DR N PA Document  
diclofenac sodium/misoprostol ARTHROTEC 50 TAB IR DR N PA Document  
diclofenac sodium/misoprostol ARTHROTEC 75 TAB IR DR N PA Document  
diflunisal DIFLUNISAL TABLET N PA Document  
etodolac ETODOLAC CAPSULE N PA Document  
etodolac ETODOLAC ER TAB ER 24H N PA Document  
fenoprofen calcium FENOPROFEN CALCIUM CAPSULE N PA Document  
fenoprofen calcium NALFON CAPSULE N PA Document  
fenoprofen calcium FENOPROFEN CALCIUM TABLET N PA Document  
fenoprofen calcium NALFON TABLET N PA Document  
flurbiprofen FLURBIPROFEN TABLET N PA Document  
flurbiprofen ANSAID TABLET N PA Document  
ibuprofen/famotidine IBUPROFEN-FAMOTIDINE TABLET N PA Document  
ibuprofen/famotidine DUEXIS TABLET N PA Document  
indomethacin INDOMETHACIN ER CAPSULE ER N PA Document  
indomethacin INDOMETHACIN ORAL SUSP N PA Document  
ketoprofen KETOPROFEN CAP24H PEL N PA Document  
ketorolac tromethamine KETOROLAC TROMETHAMINE SPRAY N Quantity Limit  
ketorolac tromethamine KETOROLAC TROMETHAMINE TABLET N Quantity Limit  
meclofenamate sodium MECLOFENAMATE SODIUM CAPSULE N PA Document  
mefenamic acid MEFENAMIC ACID CAPSULE N PA Document  
meloxicam, submicronized MELOXICAM CAPSULE N PA Document  
nabumetone RELAFEN DS TABLET N PA Document  
naproxen NAPROXEN ORAL SUSP N PA Document  
naproxen sodium NAPROXEN SODIUM CAPSULE N PA Document  
naproxen sodium NAPROXEN SODIUM ER TBMP 24HR N PA Document  
naproxen sodium NAPROXEN SODIUM CR TBMP 24HR N PA Document  
naproxen sodium NAPRELAN TBMP 24HR N PA Document  
naproxen/esomeprazole mag VIMOVO TAB IR DR N PA Document  
naproxen/esomeprazole mag NAPROXEN-ESOMEPRAZOLE MAG TAB IR DR N PA Document  
piroxicam PIROXICAM CAPSULE N PA Document  
piroxicam FELDENE CAPSULE N PA Document  
tolmetin sodium TOLMETIN SODIUM CAPSULE N PA Document  
tolmetin sodium TOLMETIN SODIUM TABLET N PA Document  
ibuprofen CHILDREN'S IBUPROFEN ORAL SUSP    
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