Other Rheumatologic Agents

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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 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
Status
Current Drug Use Criteria New Drug Evaluation
lesinurad/allopurinol DUZALLO TABLET N    
auranofin RIDAURA CAPSULE    
diclofenac sodium DYLOJECT VIAL    
ibuprofen CALDOLOR VIAL    
indomethacin INDOCIN SUPP.RECT    
leflunomide ARAVA TABLET    
leflunomide LEFLUNOMIDE TABLET    
methotrexate/PF RASUVO AUTO INJCT    
methotrexate/PF OTREXUP AUTO INJCT    
penicillamine CUPRIMINE CAPSULE    
penicillamine DEPEN TABLET