Antiemetics, Newer

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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.

Alternate detailed view >

Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
ondansetron ONDANSETRON ODT TAB RAPDIS Y   N  
ondansetron HCl ONDANSETRON HCL SOLUTION Y   N  
ondansetron HCl ONDANSETRON HCL TABLET Y   N  
aprepitant EMEND CAP DS PK N Pharmacy PA N  
aprepitant APREPITANT CAP DS PK N Pharmacy PA N  
aprepitant EMEND CAPSULE N Pharmacy PA N  
aprepitant APREPITANT CAPSULE N Pharmacy PA N  
aprepitant EMEND SUSP RECON N Pharmacy PA N  
dolasetron mesylate ANZEMET TABLET N Pharmacy PA N  
doxylamine succinate/vit B6 BONJESTA TAB IR DR N Pharmacy PA N  
doxylamine succinate/vit B6 DOXYLAMINE SUCC-PYRIDOXINE HCL TABLET DR N Pharmacy PA N  
doxylamine succinate/vit B6 DICLEGIS TABLET DR N Pharmacy PA N  
granisetron SUSTOL LIQ ER SYR N Pharmacy PA N  
granisetron SANCUSO PATCH TDWK N Pharmacy PA N  
granisetron HCl GRANISETRON HCL TABLET N Pharmacy PA N  
netupitant/palonosetron HCl AKYNZEO CAPSULE N Pharmacy PA N  
ondansetron ONDANSETRON ODT TAB RAPDIS N Pharmacy PA N  
amisulpride BARHEMSYS VIAL   N  
aprepitant CINVANTI VIAL   N  
aprepitant APONVIE VIAL   N  
fosaprepitant dimeglumine FOCINVEZ VIAL   N  
fosaprepitant dimeglumine EMEND VIAL   N  
fosaprepitant dimeglumine FOSAPREPITANT DIMEGLUMINE VIAL   N  
fosnetupitant/palonosetron AKYNZEO VIAL   N  
granisetron HCl GRANISETRON HCL VIAL   N  
granisetron HCl/PF GRANISETRON HCL VIAL   N  
ondansetron HCl ONDANSETRON HCL VIAL   N  
ondansetron HCl/PF ONDANSETRON HCL SYRINGE   N  
ondansetron HCl/PF ONDANSETRON HCL VIAL   N  
palonosetron HCl PALONOSETRON HCL SYRINGE   N  
palonosetron HCl POSFREA VIAL   N  
palonosetron HCl PALONOSETRON HCL VIAL   N  
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