Opioids, Long-Acting
PDL Reference Documents
Drug Use Review Documents
Newsletters
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 |
|---|---|---|---|---|---|---|
| fentanyl | FENTANYL | PATCH TD72 | Y | Pharmacy PA | N | |
| morphine sulfate | MORPHINE SULFATE ER | TABLET ER | Y | Pharmacy PA | N | |
| buprenorphine | BUTRANS | PATCH TDWK | N | Pharmacy PA | N | |
| buprenorphine | BUPRENORPHINE | PATCH TDWK | N | Pharmacy PA | N | |
| buprenorphine HCl | BELBUCA | FILM | N | Pharmacy PA | N | |
| hydrocodone bitartrate | HYDROCODONE BITARTRATE ER | CAP ER 12H | N | Pharmacy PA | N | |
| hydrocodone bitartrate | HYSINGLA ER | TAB ER 24H | N | Pharmacy PA | N | |
| methadone HCl | METHADONE HCL | ORAL CONC | N | Pharmacy PA | N | |
| methadone HCl | METHADONE HCL | TABLET | N | Pharmacy PA | N | |
| methadone HCl | METHADOSE | TABLET SOL | N | Pharmacy PA | N | |
| morphine sulfate | MORPHINE SULFATE ER | CAP ER PEL | N | Pharmacy PA | N | |
| oxycodone HCl | OXYCODONE HCL ER | TAB ER 12H | N | Pharmacy PA | N | |
| oxymorphone HCl | OXYMORPHONE HCL ER | TAB ER 12H | N | Pharmacy PA | N | |
| tramadol HCl | TRAMADOL HCL ER | CPBP 25-75 | N | Pharmacy PA | N | |
| tramadol HCl | TRAMADOL HCL ER | TBMP 24HR | N | Pharmacy PA | N |