Bone Metabolism Drugs
PDL Reference Documents
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 |
|---|---|---|---|---|---|---|
| alendronate sodium | ALENDRONATE SODIUM | TABLET | Y | |||
| alendronate sodium | FOSAMAX | TABLET | Y | |||
| ibandronate sodium | IBANDRONATE SODIUM | TABLET | Y | |||
| risedronate sodium | ACTONEL | TABLET | Y | |||
| risedronate sodium | RISEDRONATE SODIUM | TABLET | Y | |||
| abaloparatide | TYMLOS | PEN INJCTR | N | Pharmacy PA | ||
| alendronate sodium | ALENDRONATE SODIUM | SOLUTION | N | Pharmacy PA | ||
| alendronate sodium | BINOSTO | TABLET EFF | N | Pharmacy PA | ||
| alendronate sodium/vitamin D3 | FOSAMAX PLUS D | TABLET | N | Pharmacy PA | ||
| calcitonin,salmon,synthetic | CALCITONIN-SALMON | SPRAY/PUMP | N | Pharmacy PA | ||
| calcitonin,salmon,synthetic | CALCITONIN-SALMON | VIAL | N | Pharmacy PA | ||
| calcitonin,salmon,synthetic | MIACALCIN | VIAL | N | Pharmacy PA | ||
| denosumab | PROLIA | SYRINGE | N | Pharmacy PA | ||
| denosumab-bbdz | JUBBONTI | SYRINGE | N | Pharmacy PA | ||
| denosumab-bmwo | STOBOCLO | SYRINGE | N | Pharmacy PA | ||
| denosumab-bnht | CONEXXENCE | SYRINGE | N | Pharmacy PA | ||
| denosumab-kyqq | BOSAYA | SYRINGE | N | Pharmacy PA | ||
| denosumab-nxxp | BILDYOS | SYRINGE | N | Pharmacy PA | ||
| denosumab-qbde | ENOBY | SYRINGE | N | Pharmacy PA | ||
| ibandronate sodium | IBANDRONATE SODIUM | SYRINGE | N | Pharmacy PA | ||
| raloxifene HCl | RALOXIFENE HCL | TABLET | N | Pharmacy PA | ||
| raloxifene HCl | EVISTA | TABLET | N | Pharmacy PA | ||
| risedronate sodium | ATELVIA | TABLET DR | N | Pharmacy PA | ||
| risedronate sodium | RISEDRONATE SODIUM DR | TABLET DR | N | Pharmacy PA | ||
| romosozumab-aqqg | EVENITY | SYRINGE | N | Pharmacy PA | ||
| romosozumab-aqqg | EVENITY (2 SYRINGES) | SYRINGE | N | Pharmacy PA | ||
| teriparatide | BONSITY | PEN INJCTR | N | Pharmacy PA | ||
| teriparatide | FORTEO | PEN INJCTR | N | Pharmacy PA | ||
| teriparatide | TERIPARATIDE | PEN INJCTR | N | Pharmacy PA | ||
| denosumab | XGEVA | VIAL | ||||
| denosumab-bbdz | WYOST | VIAL | ||||
| denosumab-bmwo | OSENVELT | VIAL | ||||
| denosumab-bnht | BOMYNTRA | SYRINGE | ||||
| denosumab-bnht | BOMYNTRA | VIAL | ||||
| denosumab-kyqq | AUKELSO | VIAL | ||||
| denosumab-nxxp | BILPREVDA | VIAL | ||||
| denosumab-qbde | XTRENBO | VIAL | ||||
| pamidronate disodium | PAMIDRONATE DISODIUM | VIAL | ||||
| zoledronic ac/mannitol/0.9NaCl | ZOLEDRONIC ACID | PIGGYBACK | ||||
| zoledronic acid | ZOLEDRONIC ACID | VIAL | ||||
| zoledronic acid/mannitol-water | RECLAST | PGGYBK BTL | ||||
| zoledronic acid/mannitol-water | ZOLEDRONIC ACID | PGGYBK BTL | ||||
| zoledronic acid/mannitol-water | ZOLEDRONIC ACID | PIGGYBACK |