Medical Supplies
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 & Updates |
|---|---|---|---|---|---|
| blade lancet, safety | MICROTAINER LANCETS | EACH | Y | ||
| blade lancet, safety | MEDLANCE PLUS SPECIAL BLADE | EACH | Y | ||
| blade lancet, safety | ASSURE HAEMOLANCE PLUS | EACH | Y | ||
| inhaler, assist devices | AEROCHAMBER | EACH | Y | ||
| inhaler, assist devices | WINDMILL TRAINER | SPACER | Y | ||
| inhaler, assist devices | PRIMEAIRE | SPACER | Y | ||
| inhaler, assist devices | VORTEX | SPACER | Y | ||
| inhaler, assist devices | SPACE CHAMBER | SPACER | Y | ||
| inhaler, assist devices | RITEFLO | SPACER | Y | ||
| inhaler, assist devices | PROCHAMBER | SPACER | Y | ||
| inhaler, assist devices | OPTICHAMBER DIAMOND | SPACER | Y | ||
| inhaler, assist devices | POCKET CHAMBER | SPACER | Y | ||
| inhaler, assist devices | AEROTRACH PLUS | SPACER | Y | ||
| inhaler, assist devices | INSPIRACHAMBER | SPACER | Y | ||
| inhaler, assist devices | LITEAIRE | SPACER | Y | ||
| inhaler, assist devices | MICROCHAMBER | SPACER | Y | ||
| inhaler, assist devices | FLEXICHAMBER | SPACER | Y | ||
| inhaler, assist devices | EASIVENT | SPACER | Y | ||
| inhaler, assist devices | COMPACT SPACE CHAMBER | SPACER | Y | ||
| inhaler, assist devices | BREATHRITE | SPACER | Y | ||
| inhaler, assist devices | BREATHERITE | SPACER | Y | ||
| inhaler, assist devices | AEROVENT II | SPACER | Y | ||
| inhaler, assist devices | AEROCHAMBER Z-STAT PLUS | SPACER | Y | ||
| inhaler, assist devices | AEROCHAMBER PLUS FLOW-VU | SPACER | Y | ||
| inhaler, assist devices | AEROCHAMBER MV | SPACER | Y | ||
| inhaler, assist devices | AEROCHAMBER MINI | SPACER | Y | ||
| inhaler, assist devices | AEROCHAMBER MECHANICAL VENT | SPACER | Y | ||
| inhaler, assist devices | ACE AEROSOL CLOUD ENHANCER | SPACER | Y | ||
| inhaler, assist devices | MICROSPACER | SPACER | Y | ||
| inhaler, assist devices | AEROVENT PLUS | SPACER | Y | ||
| lancets | ULTRA THIN PLUS LANCETS | EACH | Y | ||
| lancets | TRUEPLUS LANCET | EACH | Y | ||
| lancets | UNILET LANCET | EACH | Y | ||
| lancets | UNILET GP LANCET | EACH | Y | ||
| lancets | UNILET EXCELITE II | EACH | Y | ||
| lancets | UNILET EXCELITE | EACH | Y | ||
| lancets | UNILET COMFORTOUCH | EACH | Y | ||
| lancets | ULTRATLC LANCETS | EACH | Y | ||
| lancets | ULTRATLC | EACH | Y | ||
| lancets | ULTRA-THIN II | EACH | Y | ||
| lancets | UNISTIK 2 COMFORT | EACH | Y | ||
| lancets | ULTRA-CARE LANCETS | EACH | Y | ||
| lancets | UNISTIK 2 EXTRA | EACH | Y | ||
| lancets | ULTRA THIN LANCETS | EACH | Y | ||
| lancets | ULTRA THIN LANCET | EACH | Y | ||
| lancets | ULTRA FINE LANCETS | EACH | Y | ||
| lancets | ULTILET SAFETY | EACH | Y | ||
| lancets | ULTILET LANCETS | EACH | Y | ||
| lancets | ULTILET CLASSIC | EACH | Y | ||
| lancets | ULTILET BASIC | EACH | Y | ||
| lancets | TWIST TOP LANCET | EACH | Y | ||
| lancets | TWIST LANCETS | EACH | Y | ||
| lancets | ULTRALANCE | EACH | Y | ||
| lancets | UNISTIK PRO | EACH | Y | ||
| lancets | VIVAGUARD SAFETY LANCET | EACH | Y | ||
| lancets | VIVAGUARD LANCET | EACH | Y | ||
| lancets | VITALET PRO PLUS | EACH | Y | ||
| lancets | VITALET PRO | EACH | Y | ||
| lancets | VITALET | EACH | Y | ||
| lancets | VERIFINE UNIVERSAL LANCET | EACH | Y | ||
| lancets | VERIFINE SAFETY LANCET MINI | EACH | Y | ||
| lancets | UNIVERSAL 1 | EACH | Y | ||
| lancets | UNILET LANCETS | EACH | Y | ||
| lancets | UNISTIK SAFETY | EACH | Y | ||
| lancets | TRUE COMFORT SAFETY LANCET | EACH | Y | ||
| lancets | UNISTIK NORMAL | EACH | Y | ||
| lancets | UNISTIK EXTRA | EACH | Y | ||
| lancets | UNISTIK CZT | EACH | Y | ||
| lancets | UNISTIK COMFORT | EACH | Y | ||
| lancets | UNISTIK 3 NORMAL | EACH | Y | ||
| lancets | UNISTIK 3 EXTRA | EACH | Y | ||
| lancets | UNISTIK 3 DUAL | EACH | Y | ||
| lancets | UNISTIK 3 COMFORT | EACH | Y | ||
| lancets | UNISTIK 3 | EACH | Y | ||
| lancets | UNISTIK 2 NORMAL | EACH | Y | ||
| lancets | UNISTIK TOUCH | EACH | Y | ||
| lancets | 1ST TIER UNILET COMFORTOUCH | EACH | Y | ||
| lancets | TRUEPLUS LANCETS | EACH | Y | ||
| lancets | RELIAMED SAFETY SEAL LANCETS | EACH | Y | ||
| lancets | RELIAMED | EACH | Y | ||
| lancets | READYLANCE SAFETY LANCETS | EACH | Y | ||
| lancets | ACTI-LANCE | EACH | Y | ||
| lancets | ACCU-CHEK SOFTCLIX | EACH | Y | ||
| lancets | ACCU-CHEK SAFE-T-PRO PLUS | EACH | Y | ||
| lancets | ACCU-CHEK SAFE-T-PRO | EACH | Y | ||
| lancets | ACCU-CHEK FASTCLIX LANCET DRUM | EACH | Y | ||
| lancets | RIGHTEST GL300 LANCETS | EACH | Y | ||
| lancets | 2-IN-1 LANCET DEVICE | EACH | Y | ||
| lancets | SAFETY LANCETS | EACH | Y | ||
| lancets | ACCU-CHEK | EACH | Y | ||
| lancets | STERILANCE TL | EACH | Y | ||
| lancets | TRUE COMFORT LANCET | EACH | Y | ||
| lancets | TOPCARE UNIVERSAL1 THIN LANCET | EACH | Y | ||
| lancets | TOPCARE UNIVERSAL1 LANCET | EACH | Y | ||
| lancets | THIN LANCETS | EACH | Y | ||
| lancets | THIN LANCET | EACH | Y | ||
| lancets | TELCARE | EACH | Y | ||
| lancets | TECHLITE LANCETS | EACH | Y | ||
| lancets | SURE-LANCE | EACH | Y | ||
| lancets | SUPER THIN LANCETS | EACH | Y | ||
| lancets | RELION | EACH | Y | ||
| lancets | STERILE LANCETS | EACH | Y | ||
| lancets | SURE-TOUCH | EACH | Y | ||
| lancets | SOLUS V2 LANCETS | EACH | Y | ||
| lancets | SOLUS V2 | EACH | Y | ||
| lancets | SOFTCLIX | EACH | Y | ||
| lancets | SOFT TOUCH | EACH | Y | ||
| lancets | SMARTEST LANCET | EACH | Y | ||
| lancets | SMART SENSE LANCETS | EACH | Y | ||
| lancets | SMART SENSE | EACH | Y | ||
| lancets | SINGLE-LET | EACH | Y | ||
| lancets | SAFETY-LET | EACH | Y | ||
| lancets | SAFETY SEAL LANCETS | EACH | Y | ||
| lancets | SUPER THIN LANCET | EACH | Y | ||
| lancets | SURE COMFORT LANCETS | EACH | Y | ||
| lancets | GLUCOCOM LANCETS | EACH | Y | ||
| lancets | MICRODOT SAFETY LANCET | EACH | Y | ||
| lancets | EMBRACE SAFETY LANCET | EACH | Y | ||
| lancets | E-Z JECT LANCETS | EACH | Y | ||
| lancets | EZ SMART LANCETS | EACH | Y | ||
| lancets | E-ZJECT LANCETS | EACH | Y | ||
| lancets | EZ-LETS | EACH | Y | ||
| lancets | EZ-LETS II | EACH | Y | ||
| lancets | FIFTY50 SAFETY SEAL LANCETS | EACH | Y | ||
| lancets | FINGERSTIX | EACH | Y | ||
| lancets | FORA LANCETS | EACH | Y | ||
| lancets | FORACARE LANCETS | EACH | Y | ||
| lancets | FREESTYLE LANCETS | EACH | Y | ||
| lancets | EASY TWIST & CAP LANCETS | EACH | Y | ||
| lancets | GLUCOCOM | EACH | Y | ||
| lancets | EASY TOUCH | EACH | Y | ||
| lancets | GOJJI LANCETS | EACH | Y | ||
| lancets | HEALTHY ACCENTS UNILET LANCET | EACH | Y | ||
| lancets | INCONTROL SUPER THIN LANCETS | EACH | Y | ||
| lancets | INCONTROL ULTRA THIN LANCETS | EACH | Y | ||
| lancets | INJECT EASE LANCETS | EACH | Y | ||
| lancets | INVACARE LANCETS | EACH | Y | ||
| lancets | LANCETS | EACH | Y | ||
| lancets | LITE TOUCH | EACH | Y | ||
| lancets | MEDISENSE THIN LANCETS | EACH | Y | ||
| lancets | MEDLANCE PLUS | EACH | Y | ||
| lancets | MICRO THIN LANCET | EACH | Y | ||
| lancets | MICRO THIN LANCETS | EACH | Y | ||
| lancets | FREESTYLE UNISTIK 2 | EACH | Y | ||
| lancets | CARETOUCH SAFETY LANCETS | EACH | Y | ||
| lancets | ADVANCED TRAVEL LANCETS | EACH | Y | ||
| lancets | ADVOCATE LANCET | EACH | Y | ||
| lancets | ADVOCATE LANCETS | EACH | Y | ||
| lancets | ADVOCATE SAFETY LANCET | EACH | Y | ||
| lancets | ALTERNATE SITE LANCETS | EACH | Y | ||
| lancets | ASSURE HAEMOLANCE PLUS | EACH | Y | ||
| lancets | ASSURE LANCE | EACH | Y | ||
| lancets | AT-LAST LANCETS | EACH | Y | ||
| lancets | BLOOD LANCETS | EACH | Y | ||
| lancets | BULLSEYE MINI SAFETY LANCETS | EACH | Y | ||
| lancets | BUTTERFLY TOUCH LANCET | EACH | Y | ||
| lancets | CAREONE | EACH | Y | ||
| lancets | EMBRACE | EACH | Y | ||
| lancets | CARESENS LANCET | EACH | Y | ||
| lancets | BD MICROTAINER LANCETS | EACH | Y | ||
| lancets | CARETOUCH TWIST LANCET | EACH | Y | ||
| lancets | CHOSEN LANCET | EACH | Y | ||
| lancets | CHOSEN SAFETY LANCET | EACH | Y | ||
| lancets | CLEVER CHEK LANCETS | EACH | Y | ||
| lancets | COAGUCHEK | EACH | Y | ||
| lancets | COLOR LANCETS | EACH | Y | ||
| lancets | COMFORT EZ | EACH | Y | ||
| lancets | COMFORT LANCETS | EACH | Y | ||
| lancets | COMFORT TOUCH PLUS SAFETY LANC | EACH | Y | ||
| lancets | COMFORT TOUCH ULT THIN LANCET | EACH | Y | ||
| lancets | DROPLET LANCETS | EACH | Y | ||
| lancets | EASY COMFORT LANCETS | EACH | Y | ||
| lancets | CARESENS | EACH | Y | ||
| lancets | PRODIGY TWIST TOP LANCET | EACH | Y | ||
| lancets | MICROLET | EACH | Y | ||
| lancets | ASSURE LANCE PLUS | EACH | Y | ||
| lancets | PUSH BUTTON SAFETY LANCETS | EACH | Y | ||
| lancets | PUSH BUTTON SAFETY LANCET | EACH | Y | ||
| lancets | PURE COMFORT LANCETS | EACH | Y | ||
| lancets | PRODIGY LANCETS | EACH | Y | ||
| lancets | PRO COMFORT SAFETY LANCET | EACH | Y | ||
| lancets | PRO COMFORT LANCETS | EACH | Y | ||
| lancets | PRO COMFORT LANCET | EACH | Y | ||
| lancets | PRESSURE ACTIVATED LANCETS | EACH | Y | ||
| lancets | PIP LANCET | EACH | Y | ||
| lancets | PERFECT POINT SAFETY LANCETS | EACH | Y | ||
| lancets | ON-THE-GO | EACH | Y | ||
| lancets | ONETOUCH ULTRASOFT 2 LANCET | EACH | Y | ||
| lancets | MONOLET THIN LANCETS | EACH | Y | ||
| lancets | PURE COMFORT SAFETY LANCETS | EACH | Y | ||
| lancets | ONETOUCH SURESOFT | EACH | Y | ||
| lancets | MINILET | EACH | Y | ||
| lancets | MOBILE LANCETS | EACH | Y | ||
| lancets | MONOLET LANCETS | EACH | Y | ||
| lancets | MYGLUCOHEALTH LANCETS | EACH | Y | ||
| lancets | NOVA SAFETY LANCETS | EACH | Y | ||
| lancets | ONETOUCH DELICA PLUS LANCET | EACH | Y | ||
| lancets | ONETOUCH LANCETS | EACH | Y | ||
| lancets | ONETOUCH DELICA SAFETY LANCET | EACH | Y | ||
| lancets | NOVA SUREFLEX | EACH | Y | ||
| lancets | ONETOUCH DELICA | EACH | Y | ||
| lancets | ON CALL PLUS LANCET | EACH | Y | ||
| lancets | ON CALL LANCET | EACH | Y | ||
| needles, insulin disposable | NOVOFINE 31 | DIS NEEDLE | Y | ||
| pen needle, diabetic | 1ST TIER UNIFINE PENTIPS | DIS NEEDLE | Y | ||
| pen needle, diabetic | PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | UNIFINE PENTIPS | DIS NEEDLE | Y | ||
| pen needle, diabetic | ULTRA THIN | DIS NEEDLE | Y | ||
| pen needle, diabetic | VERIFINE PLUS PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | VERIFINE PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | UNIFINE ULTRA PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | UNIFINE PENTIPS PLUS | DIS NEEDLE | Y | ||
| pen needle, diabetic | UNIFINE PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | ULTRA-THIN II | DIS NEEDLE | Y | ||
| pen needle, diabetic | ULTRA-FINE SHORT PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | 1ST TIER UNIFINE PENTIPS PLUS | DIS NEEDLE | Y | ||
| pen needle, diabetic | ULTRA-FINE ORIGINAL PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | ULTRA-FINE MINI PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | ULTRA-FINE MICRO PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | ULTRACARE PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | UNIFINE SAFECONTROL PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | ULTRA-FINE NANO PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | EASY COMFORT PEN NEEDLES | DIS NEEDLE | Y | ||
| pen needle, diabetic | MICRODOT INSULIN PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | MAXICOMFORT II PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | ULTRA FLO PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | INSUPEN PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | ULTRA-FINE PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | INCONTROL PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | HEALTHY ACCENTS UNIFINE PENTIP | DIS NEEDLE | Y | ||
| pen needle, diabetic | HEALTHWISE PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | EMBRACE PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | MINI PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | EASY GLIDE PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | LITE TOUCH | DIS NEEDLE | Y | ||
| pen needle, diabetic | EASY COMFORT PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | DROPLET PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | COMFORT TOUCH PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | COMFORT EZ PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | CLICKFINE | DIS NEEDLE | Y | ||
| pen needle, diabetic | CARETOUCH PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | CAREFINE PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | AQINJECT PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | ADVOCATE PEN NEEDLES | DIS NEEDLE | Y | ||
| pen needle, diabetic | ADVOCATE PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | EASY TOUCH PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | TECHLITE PLUS PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | ULTILET PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | ULTICARE PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | TRUEPLUS PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | TRUE COMFORT PRO PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | INSULIN PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | TOPCARE CLICKFINE | DIS NEEDLE | Y | ||
| pen needle, diabetic | MINI ULTRA-THIN II | DIS NEEDLE | Y | ||
| pen needle, diabetic | TECHLITE PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | SURE-FINE PEN NEEDLES | DIS NEEDLE | Y | ||
| pen needle, diabetic | SURE COMFORT PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | SURE COMFORT | DIS NEEDLE | Y | ||
| pen needle, diabetic | NOVOFINE PLUS | DIS NEEDLE | Y | ||
| pen needle, diabetic | TRUE COMFORT PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | NANO 2ND GEN PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | PURE COMFORT PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | NOVOFINE 32 | DIS NEEDLE | Y | ||
| pen needle, diabetic | NANO PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | NOVOTWIST | DIS NEEDLE | Y | ||
| pen needle, diabetic | PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | PEN NEEDLES | DIS NEEDLE | Y | ||
| pen needle, diabetic | PENTIPS PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | PIP PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic | PRO COMFORT PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic, safety | PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic, safety | NOVOFINE AUTOCOVER | DIS NEEDLE | Y | ||
| pen needle, diabetic, safety | MAXICOMFORT SAFETY PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic, safety | HEALTHY ACCENTS UNIFINE PENTIP | DIS NEEDLE | Y | ||
| pen needle, diabetic, safety | EASY TOUCH SAFETY PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle, diabetic,disp unit | ULTIGUARD SAFEPACK-PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle,dual safety,diabetc | ASSURE ID DUO-SHIELD | DIS NEEDLE | Y | ||
| pen needle,dual safety,diabetc | AUTOSHIELD DUO PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle,dual safety,diabetc | UNIFINE SAFECONTROL PEN NEEDLE | DIS NEEDLE | Y | ||
| pen needle,dual safety,diabetc | UNIFINE PROTECT | DIS NEEDLE | Y |