Bone Metabolism Drugs

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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.

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Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria Carveout
‐ Bill FFS
New Drug Evaluation & Updates
alendronate sodium ALENDRONATE SODIUM TABLET Y   N  
alendronate sodium FOSAMAX TABLET Y   N  
ibandronate sodium IBANDRONATE SODIUM TABLET Y   N  
risedronate sodium RISEDRONATE SODIUM TABLET Y   N  
risedronate sodium ACTONEL TABLET Y   N  
abaloparatide TYMLOS PEN INJCTR N Pharmacy PA N  
alendronate sodium ALENDRONATE SODIUM SOLUTION N Pharmacy PA N  
alendronate sodium BINOSTO TABLET EFF N Pharmacy PA N  
alendronate sodium/vitamin D3 FOSAMAX PLUS D TABLET N Pharmacy PA N  
calcitonin,salmon,synthetic CALCITONIN-SALMON SPRAY/PUMP N Pharmacy PA N  
calcitonin,salmon,synthetic CALCITONIN-SALMON VIAL N Pharmacy PA N  
calcitonin,salmon,synthetic MIACALCIN VIAL N Pharmacy PA N  
denosumab PROLIA SYRINGE N Pharmacy PA N  
denosumab-bbdz JUBBONTI SYRINGE N Pharmacy PA N  
denosumab-bmwo STOBOCLO SYRINGE N Pharmacy PA N  
denosumab-bnht CONEXXENCE SYRINGE N Pharmacy PA N  
denosumab-nxxp BILDYOS SYRINGE N Pharmacy PA N  
ibandronate sodium IBANDRONATE SODIUM SYRINGE N Pharmacy PA N  
raloxifene HCl EVISTA TABLET N Pharmacy PA N  
raloxifene HCl RALOXIFENE HCL TABLET N Pharmacy PA N  
risedronate sodium ATELVIA TABLET DR N Pharmacy PA N  
risedronate sodium RISEDRONATE SODIUM DR TABLET DR N Pharmacy PA N  
romosozumab-aqqg EVENITY SYRINGE N Pharmacy PA N  
romosozumab-aqqg EVENITY (2 SYRINGES) SYRINGE N Pharmacy PA N  
teriparatide BONSITY PEN INJCTR N Pharmacy PA N  
teriparatide FORTEO PEN INJCTR N Pharmacy PA N  
teriparatide TERIPARATIDE PEN INJCTR N Pharmacy PA N  
denosumab XGEVA VIAL   N  
denosumab-bbdz WYOST VIAL   N  
denosumab-bmwo OSENVELT VIAL   N  
denosumab-bnht BOMYNTRA SYRINGE   N  
denosumab-bnht BOMYNTRA VIAL   N  
denosumab-nxxp BILPREVDA VIAL   N  
pamidronate disodium PAMIDRONATE DISODIUM VIAL   N  
zoledronic ac/mannitol/0.9NaCl ZOLEDRONIC ACID PIGGYBACK   N  
zoledronic acid ZOLEDRONIC ACID VIAL   N  
zoledronic acid/mannitol-water RECLAST PGGYBK BTL   N  
zoledronic acid/mannitol-water ZOLEDRONIC ACID PGGYBK BTL   N  
zoledronic acid/mannitol-water ZOLEDRONIC ACID PIGGYBACK   N