Antiemetics, Newer
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 |
|---|---|---|---|---|---|---|
| ondansetron | ONDANSETRON ODT | TAB RAPDIS | Y | |||
| ondansetron HCl | ONDANSETRON HCL | SOLUTION | Y | |||
| ondansetron HCl | ONDANSETRON HCL | TABLET | Y | |||
| aprepitant | APREPITANT | CAP DS PK | N | Pharmacy PA | ||
| aprepitant | EMEND | CAP DS PK | N | Pharmacy PA | ||
| aprepitant | EMEND | CAPSULE | N | Pharmacy PA | ||
| aprepitant | APREPITANT | CAPSULE | N | Pharmacy PA | ||
| aprepitant | EMEND | SUSP RECON | N | Pharmacy PA | ||
| dolasetron mesylate | ANZEMET | TABLET | N | Pharmacy PA | ||
| doxylamine succinate/vit B6 | BONJESTA | TAB IR DR | N | Pharmacy PA | ||
| doxylamine succinate/vit B6 | DICLEGIS | TABLET DR | N | Pharmacy PA | ||
| doxylamine succinate/vit B6 | DOXYLAMINE SUCC-PYRIDOXINE HCL | TABLET DR | N | Pharmacy PA | ||
| granisetron | SUSTOL | LIQ ER SYR | N | Pharmacy PA | ||
| granisetron | SANCUSO | PATCH TDWK | N | Pharmacy PA | ||
| granisetron HCl | GRANISOL | SOLUTION | N | Pharmacy PA | ||
| granisetron HCl | GRANISETRON HCL | TABLET | N | Pharmacy PA | ||
| netupitant/palonosetron HCl | AKYNZEO | CAPSULE | N | Pharmacy PA | ||
| ondansetron | ONDANSETRON ODT | TAB RAPDIS | N | Pharmacy PA | ||
| tradipitant | NEREUS | CAPSULE | N | Pharmacy PA | ||
| amisulpride | BARHEMSYS | VIAL | ||||
| aprepitant | APONVIE | VIAL | ||||
| aprepitant | CINVANTI | VIAL | ||||
| fosaprepitant dimeglumine | EMEND | VIAL | ||||
| fosaprepitant dimeglumine | FOCINVEZ | VIAL | ||||
| fosaprepitant dimeglumine | FOSAPREPITANT DIMEGLUMINE | VIAL | ||||
| fosnetupitant/palonosetron | AKYNZEO | VIAL | ||||
| granisetron HCl | GRANISETRON HCL | VIAL | ||||
| granisetron HCl/PF | GRANISETRON HCL | VIAL | ||||
| ondansetron HCl | ONDANSETRON HCL | VIAL | ||||
| ondansetron HCl/PF | ONDANSETRON HCL | SYRINGE | ||||
| ondansetron HCl/PF | ONDANSETRON HCL | VIAL | ||||
| palonosetron HCl | PALONOSETRON HCL | SYRINGE | ||||
| palonosetron HCl | POSFREA | VIAL | ||||
| palonosetron HCl | PALONOSETRON HCL | VIAL |