Substance Use Disorders, Opioid & Alcohol
PDL Reference Documents
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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.
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| buprenorphine | BRIXADI | SOLER SYR | Y | N | ||
| buprenorphine HCl/naloxone HCl | SUBOXONE | FILM | Y | Quantity Limit | N | |
| buprenorphine HCl/naloxone HCl | BUPRENORPHINE-NALOXONE | TAB SUBL | Y | Quantity Limit | N | |
| naltrexone HCl | NALTREXONE HCL | TABLET | Y | N | ||
| naltrexone microspheres | VIVITROL | SUS ER REC | Y | N | Nov 21, 2013 | |
| buprenorphine HCl | BUPRENORPHINE HCL | TAB SUBL | V | Quantity Limit | N | |
| lofexidine HCl | LUCEMYRA | TABLET | N | N |