Contraceptives, Oral

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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
desog-e.estradiol/e.estradiol AZURETTE TABLET    
desog-e.estradiol/e.estradiol BEKYREE TABLET    
desog-e.estradiol/e.estradiol KARIVA TABLET    
desog-e.estradiol/e.estradiol MIRCETTE TABLET    
desog-e.estradiol/e.estradiol PIMTREA TABLET    
desog-e.estradiol/e.estradiol VIORELE TABLET    
desog-e.estradiol/e.estradiol KIMIDESS TABLET    
desog-e.estradiol/e.estradiol DESOGESTR-ETH ESTRAD ETH ESTRA TABLET    
desogestrel-ethinyl estradiol CYRED EQ TABLET    
desogestrel-ethinyl estradiol APRI TABLET    
desogestrel-ethinyl estradiol CAZIANT TABLET    
desogestrel-ethinyl estradiol CYRED TABLET    
desogestrel-ethinyl estradiol DESOGESTREL-ETHINYL ESTRADIOL TABLET    
desogestrel-ethinyl estradiol EMOQUETTE TABLET    
desogestrel-ethinyl estradiol ENSKYCE TABLET    
desogestrel-ethinyl estradiol ISIBLOOM TABLET    
desogestrel-ethinyl estradiol JULEBER TABLET    
desogestrel-ethinyl estradiol RECLIPSEN TABLET    
desogestrel-ethinyl estradiol VELIVET TABLET    
desogestrel-ethinyl estradiol CYCLESSA TABLET    
drospir/eth estra/levomefol Ca TYDEMY TABLET    
drospir/eth estra/levomefol Ca BEYAZ TABLET    
drospir/eth estra/levomefol Ca DROSPIRENONE-ETH ESTRA-LEVOMEF TABLET    
drospir/eth estra/levomefol Ca RAJANI TABLET    
drospir/eth estra/levomefol Ca SAFYRAL TABLET    
estradiol valerate/dienogest NATAZIA TABLET    
ethinyl estradiol/drospirenone GIANVI TABLET    
ethinyl estradiol/drospirenone LORYNA TABLET    
ethinyl estradiol/drospirenone NIKKI TABLET    
ethinyl estradiol/drospirenone OCELLA TABLET    
ethinyl estradiol/drospirenone SYEDA TABLET    
ethinyl estradiol/drospirenone VESTURA TABLET    
ethinyl estradiol/drospirenone YASMIN 28 TABLET    
ethinyl estradiol/drospirenone YAZ TABLET    
ethinyl estradiol/drospirenone ZARAH TABLET    
ethinyl estradiol/drospirenone DROSPIRENONE-ETHINYL ESTRADIOL TABLET    
ethynodiol d-ethinyl estradiol KELNOR 1-35 TABLET    
ethynodiol d-ethinyl estradiol ETHYNODIOL-ETHINYL ESTRADIOL TABLET    
ethynodiol d-ethinyl estradiol KELNOR 1-50 TABLET    
ethynodiol d-ethinyl estradiol ZOVIA 1-35E TABLET    
ethynodiol d-ethinyl estradiol ZOVIA 1-50E TABLET    
ethynodiol d-ethinyl estradiol DEMULEN 1-50-21 TABLET    
etonogestrel NEXPLANON IMPLANT    
etonogestrel/ethinyl estradiol NUVARING VAG RING    
L-norgest/e.estradiol-e.estrad ASHLYNA TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad AMETHIA LO TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad CAMRESE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad CAMRESE LO TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad DAYSEE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad FAYOSIM TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad LEVONORG-ETH ESTRAD ETH ESTRAD TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad LOSEASONIQUE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad QUARTETTE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad RIVELSA TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad SEASONIQUE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad AMETHIA TBDSPK 3MO    
levonorgest/eth.estradiol/iron BALCOLTRA TABLET    
levonorgestrel NORPLANT KIT    
levonorgestrel MY CHOICE TABLET    
levonorgestrel AFTERA TABLET    
levonorgestrel ECONTRA EZ TABLET    
levonorgestrel ECONTRA ONE-STEP TABLET    
levonorgestrel FALLBACK SOLO TABLET    
levonorgestrel LEVONORGESTREL TABLET    
levonorgestrel MY WAY TABLET    
levonorgestrel OPCICON ONE-STEP TABLET    
levonorgestrel NEW DAY TABLET    
levonorgestrel OPTION 2 TABLET    
levonorgestrel PLAN B ONE-STEP TABLET    
levonorgestrel TAKE ACTION TABLET    
levonorgestrel-ethin estradiol LILLOW TABLET    
levonorgestrel-ethin estradiol LUTERA TABLET    
levonorgestrel-ethin estradiol MARLISSA TABLET    
levonorgestrel-ethin estradiol MYZILRA TABLET    
levonorgestrel-ethin estradiol ORSYTHIA TABLET    
levonorgestrel-ethin estradiol PORTIA TABLET    
levonorgestrel-ethin estradiol SRONYX TABLET    
levonorgestrel-ethin estradiol VIENVA TABLET    
levonorgestrel-ethin estradiol LEVORA-28 TABLET    
levonorgestrel-ethin estradiol TRIVORA-28 TABLET    
levonorgestrel-ethin estradiol ALTAVERA TABLET    
levonorgestrel-ethin estradiol AMETHYST TABLET    
levonorgestrel-ethin estradiol AUBRA TABLET    
levonorgestrel-ethin estradiol AUBRA EQ TABLET    
levonorgestrel-ethin estradiol AVIANE TABLET    
levonorgestrel-ethin estradiol CHATEAL TABLET    
levonorgestrel-ethin estradiol LEVONORGESTREL-ETH ESTRADIOL TABLET    
levonorgestrel-ethin estradiol CHATEAL EQ TABLET    
levonorgestrel-ethin estradiol LEVONEST TABLET    
levonorgestrel-ethin estradiol LEVLEN 28 TABLET    
levonorgestrel-ethin estradiol LESSINA TABLET    
levonorgestrel-ethin estradiol LARISSIA TABLET    
levonorgestrel-ethin estradiol FALMINA TABLET    
levonorgestrel-ethin estradiol KURVELO TABLET    
levonorgestrel-ethin estradiol ENPRESSE TABLET    
levonorgestrel-ethin estradiol QUASENSE TBDSPK 3MO    
levonorgestrel-ethin estradiol SETLAKIN TBDSPK 3MO    
levonorgestrel-ethin estradiol LEVONORGESTREL-ETH ESTRADIOL TBDSPK 3MO    
levonorgestrel-ethin estradiol JOLESSA TBDSPK 3MO    
levonorgestrel-ethin estradiol INTROVALE TBDSPK 3MO    
medroxyprogesterone acetate MEDROXYPROGESTERONE ACETATE SYRINGE    
medroxyprogesterone acetate DEPO-SUBQ PROVERA 104 SYRINGE    
medroxyprogesterone acetate DEPO-PROVERA SYRINGE    
medroxyprogesterone acetate MEDROXYPROGESTERONE ACETATE VIAL    
medroxyprogesterone acetate DEPO-PROVERA VIAL    
norelgestromin/ethin.estradiol XULANE PATCH TDWK    
noreth-ethinyl estradiol/iron NORETHIN-ETH ESTRA-FERROUS FUM TAB CHEW    
noreth-ethinyl estradiol/iron GENERESS FE TAB CHEW    
noreth-ethinyl estradiol/iron KAITLIB FE TAB CHEW    
noreth-ethinyl estradiol/iron LAYOLIS FE TAB CHEW    
noreth-ethinyl estradiol/iron WYMZYA FE TAB CHEW    
noreth-ethinyl estradiol/iron ZEOSA TAB CHEW    
norethindrone HEATHER TABLET    
norethindrone CAMILA TABLET    
norethindrone ERRIN TABLET    
norethindrone INCASSIA TABLET    
norethindrone JENCYCLA TABLET    
norethindrone JOLIVETTE TABLET    
norethindrone LYZA TABLET    
norethindrone NORA-BE TABLET    
norethindrone NORETHINDRONE TABLET    
norethindrone NORLYDA TABLET    
norethindrone ORTHO MICRONOR TABLET    
norethindrone SHAROBEL TABLET    
norethindrone TULANA TABLET    
norethindrone DEBLITANE TABLET    
norethindrone ac-eth estradiol NORETHINDRON-ETHINYL ESTRADIOL TABLET    
norethindrone ac-eth estradiol LOESTRIN TABLET    
norethindrone ac-eth estradiol LARIN TABLET    
norethindrone ac-eth estradiol JUNEL TABLET    
norethindrone ac-eth estradiol GILDESS TABLET    
norethindrone ac-eth estradiol MICROGESTIN TABLET    
norethindrone-e.estradiol-iron TAYTULLA CAPSULE    
norethindrone-e.estradiol-iron MELODETTA 24 FE TAB CHEW    
norethindrone-e.estradiol-iron MIBELAS 24 FE TAB CHEW    
norethindrone-e.estradiol-iron MINASTRIN 24 FE TAB CHEW    
norethindrone-e.estradiol-iron NORETHIN-ETH ESTRA-FERROUS FUM TAB CHEW    
norethindrone-e.estradiol-iron TARINA FE TABLET    
norethindrone-e.estradiol-iron JUNEL FE 24 TABLET    
norethindrone-e.estradiol-iron JUNEL FE TABLET    
norethindrone-e.estradiol-iron HAILEY 24 FE TABLET    
norethindrone-e.estradiol-iron GILDESS FE TABLET    
norethindrone-e.estradiol-iron GILDESS 24 FE TABLET    
norethindrone-e.estradiol-iron LARIN 24 FE TABLET    
norethindrone-e.estradiol-iron BLISOVI FE TABLET    
norethindrone-e.estradiol-iron ESTROSTEP FE TABLET    
norethindrone-e.estradiol-iron LARIN FE TABLET    
norethindrone-e.estradiol-iron LO LOESTRIN FE TABLET    
norethindrone-e.estradiol-iron LOMEDIA 24 FE TABLET    
norethindrone-e.estradiol-iron MICROGESTIN 24 FE TABLET    
norethindrone-e.estradiol-iron MICROGESTIN FE TABLET    
norethindrone-e.estradiol-iron NORETHIN-ETH ESTRA-FERROUS FUM TABLET    
norethindrone-e.estradiol-iron LOESTRIN FE TABLET    
norethindrone-e.estradiol-iron TARINA FE 1-20 EQ TABLET    
norethindrone-e.estradiol-iron TILIA FE TABLET    
norethindrone-e.estradiol-iron TRI-LEGEST FE TABLET    
norethindrone-e.estradiol-iron BLISOVI 24 FE TABLET    
norethindrone-ethinyl estrad VYFEMLA TABLET    
norethindrone-ethinyl estrad PIRMELLA TABLET    
norethindrone-ethinyl estrad NORTREL TABLET    
norethindrone-ethinyl estrad ALYACEN TABLET    
norethindrone-ethinyl estrad ARANELLE TABLET    
norethindrone-ethinyl estrad BALZIVA TABLET    
norethindrone-ethinyl estrad BRIELLYN TABLET    
norethindrone-ethinyl estrad CYCLAFEM TABLET    
norethindrone-ethinyl estrad DASETTA TABLET    
norethindrone-ethinyl estrad GILDAGIA TABLET    
norethindrone-ethinyl estrad LEENA TABLET    
norethindrone-ethinyl estrad NORINYL 1-35 TABLET    
norethindrone-ethinyl estrad ORTHO-NOVUM TABLET    
norethindrone-ethinyl estrad PHILITH TABLET    
norethindrone-ethinyl estrad TRI-NORINYL TABLET    
norethindrone-ethinyl estrad WERA TABLET    
norethindrone-ethinyl estrad ZENCHENT TABLET    
norethindrone-ethinyl estrad NECON TABLET    
norethindrone-mestranol NECON TABLET    
norgestimate-ethinyl estradiol TRI-MILI TABLET    
norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN TABLET    
norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO TABLET    
norgestimate-ethinyl estradiol ORTHO-CYCLEN TABLET    
norgestimate-ethinyl estradiol PREVIFEM TABLET    
norgestimate-ethinyl estradiol SPRINTEC TABLET    
norgestimate-ethinyl estradiol TRI FEMYNOR TABLET    
norgestimate-ethinyl estradiol TRI-ESTARYLLA TABLET    
norgestimate-ethinyl estradiol TRI-LINYAH TABLET    
norgestimate-ethinyl estradiol TRI-LO-ESTARYLLA TABLET    
norgestimate-ethinyl estradiol MONONESSA TABLET    
norgestimate-ethinyl estradiol TRI-LO-SPRINTEC TABLET    
norgestimate-ethinyl estradiol MONO-LINYAH TABLET    
norgestimate-ethinyl estradiol TRINESSA TABLET    
norgestimate-ethinyl estradiol TRINESSA LO TABLET    
norgestimate-ethinyl estradiol TRI-PREVIFEM TABLET    
norgestimate-ethinyl estradiol TRI-SPRINTEC TABLET    
norgestimate-ethinyl estradiol TRI-VYLIBRA TABLET    
norgestimate-ethinyl estradiol VYLIBRA TABLET    
norgestimate-ethinyl estradiol TRI-LO-MARZIA TABLET    
norgestimate-ethinyl estradiol NORGESTIMATE-ETHINYL ESTRADIOL TABLET    
norgestimate-ethinyl estradiol ESTARYLLA TABLET    
norgestimate-ethinyl estradiol FEMYNOR TABLET    
norgestimate-ethinyl estradiol MILI TABLET    
norgestrel-ethinyl estradiol CRYSELLE TABLET    
norgestrel-ethinyl estradiol ELINEST TABLET    
norgestrel-ethinyl estradiol LOW-OGESTREL TABLET    
norgestrel-ethinyl estradiol OGESTREL TABLET    
ulipristal acetate ELLA TABLET