Substance Use Disorders, Opioid & Alcohol
PDL Reference Documents
- Substance Use Disorders, Opioid & Alcohol - Oct 05, 2023
- Substance Use Disorder - Feb 02, 2023
- Substance Use Disorder - Dec 03, 2020
- Substance Use Disorder - Nov 21, 2019
- Substance Use Disorder - Jan 24, 2019
- Drugs for Substance Abuse Disorders - Sep 29, 2016
- Opioid Use Disorder Class Update - Jan 29, 2015
- Alcohol Use Disorder Abbreviated Class Review - Jul 31, 2014
Drug Use Review Documents
- Buprenorphine Quantity Limits - Aug 03, 2023
- Buprenorphine Polypharmacy Drug Use Evaluation - Jun 02, 2022
- Buprenorphine Indication Drug Use Evaluation - Jun 02, 2022
- Buprenorphine Duration Drug Use Evaluation - Jun 02, 2022
- Substance Use Disorder - Nov 21, 2019
- Substance Use Disorder - Jan 24, 2019
Newsletters
- May 2023 - Buprenorphine: Place in Therapy for Chronic Pain
- May 2019 - Update on Medications Used to Manage Opioid Use Disorder and Opioid Withdrawal
- April 2017 - Management of Opioid Use Disorder
- December 2016 - Guideline and Policy Updates for Use of Opioids for Non-Cancer Pain and Opioid Use Disorder
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 |
|---|---|---|---|---|---|
| acamprosate calcium | ACAMPROSATE CALCIUM | TABLET DR | Y | ||
| buprenorphine | SUBLOCADE | SOLER SYR | Y | ||
| buprenorphine | BRIXADI | SOLER SYR | Y | ||
| buprenorphine HCl/naloxone HCl | BUPRENORPHINE-NALOXONE | FILM | Y | Quantity Limit | |
| buprenorphine HCl/naloxone HCl | SUBOXONE | FILM | Y | Quantity Limit | |
| buprenorphine HCl/naloxone HCl | ZUBSOLV | TAB SUBL | Y | Quantity Limit | |
| buprenorphine HCl/naloxone HCl | BUPRENORPHINE-NALOXONE | TAB SUBL | Y | Quantity Limit | |
| naltrexone HCl | REVIA | TABLET | Y | ||
| naltrexone HCl | NALTREXONE HCL | TABLET | Y | ||
| naltrexone HCl | DEPADE | TABLET | Y | ||
| naltrexone microspheres | VIVITROL | SUS ER REC | Y | Nov 21, 2013 | |
| buprenorphine HCl | BUPRENORPHINE HCL | TAB SUBL | V | Quantity Limit | |
| disulfiram | DISULFIRAM | TABLET | V | ||
| lofexidine HCl | LOFEXIDINE HCL | TABLET | N | ||
| lofexidine HCl | LUCEMYRA | TABLET | N |