Thyroid Preps

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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
Current Drug Use Criteria New Drug Evaluation
levothyroxine sodium TIROSINT CAPSULE    
levothyroxine sodium TIROSINT-SOL SOLUTION    
levothyroxine sodium LEVO-T TABLET    
levothyroxine sodium SYNTHROID TABLET    
levothyroxine sodium UNITHROID TABLET    
levothyroxine sodium LEVOXYL TABLET    
levothyroxine sodium LEVOTHYROXINE SODIUM TABLET    
levothyroxine sodium LEVOTHYROXINE SODIUM VIAL    
liothyronine sodium LIOTHYRONINE SODIUM TABLET    
liothyronine sodium CYTOMEL TABLET    
liothyronine sodium LIOTHYRONINE SODIUM VIAL    
liothyronine sodium TRIOSTAT VIAL    
liotrix THYROLAR-1 TABLET    
liotrix THYROLAR-1/2 TABLET    
liotrix THYROLAR-1/4 TABLET    
liotrix THYROLAR-2 TABLET    
liotrix THYROLAR-3 TABLET    
thyroid,pork NP THYROID TABLET    
thyroid,pork THYROID TABLET    
thyroid,pork ARMOUR THYROID TABLET    
thyrotropin alfa THYROGEN VIAL