Non-Steroidal Anti-Inflammatory 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
celecoxib CELEBREX CAPSULE Y   N  
etodolac ETODOLAC TABLET Y   N  
ibuprofen ADVIL CAPSULE Y   N  
ibuprofen INFANTS' MOTRIN DROPS SUSP Y   N  
ibuprofen INFANTS PROFENIB DROPS SUSP Y   N  
ibuprofen INFANT'S IBUPROFEN DROPS SUSP Y   N  
ibuprofen INFANTS IBUPROFEN DROPS SUSP Y   N  
ibuprofen INFANTS' ADVIL DROPS SUSP Y   N  
ibuprofen IBUPROFEN ORAL SUSP Y   N  
ibuprofen CHILDREN'S ADVIL ORAL SUSP Y   N  
ibuprofen CHILDREN'S MEDI-PROFEN ORAL SUSP Y   N  
ibuprofen IBUPROFEN ORAL SUSP Y   N  
ibuprofen CHILDREN'S PROFENIB ORAL SUSP Y   N  
ibuprofen CHILDREN'S MOTRIN TAB CHEW Y   N  
ibuprofen IBU TABLET Y   N  
ibuprofen IBUPROFEN IB TABLET Y   N  
ibuprofen IBU-200 TABLET Y   N  
ibuprofen IBUPROFEN TABLET Y   N  
ibuprofen MIDOL CRAMP TABLET Y   N  
ibuprofen I-PRIN TABLET Y   N  
ibuprofen TAB-PROFEN TABLET Y   N  
ibuprofen WAL-PROFEN TABLET Y   N  
ibuprofen ADVIL TABLET Y   N  
ibuprofen IBUPROFEN IB TABLET Y   N  
ibuprofen IBUPROFEN TABLET Y   N  
ketoprofen KIPROFEN CAPSULE Y   N  
nabumetone NABUMETONE TABLET Y   N  
nabumetone RELAFEN TABLET Y   N  
naproxen NAPROXEN TABLET DR Y   N  
naproxen sodium NAPROXEN SODIUM TABLET Y   N  
naproxen sodium ALL DAY RELIEF TABLET Y   N  
naproxen sodium FLANAX TABLET Y   N  
naproxen sodium ALL DAY RELIEF TABLET Y   N  
naproxen sodium ALL DAY PAIN RELIEF TABLET Y   N  
oxaprozin OXAPROZIN TABLET Y   N  
oxaprozin DAYPRO TABLET Y   N  
salsalate SALSALATE TABLET Y   N  
diclofenac potassium DICLOFENAC POTASSIUM CAPSULE N Pharmacy PA N  
diclofenac potassium LOFENA TABLET N Pharmacy PA N  
diclofenac potassium DICLOFENAC POTASSIUM TABLET N Pharmacy PA N  
diclofenac sodium DICLOFENAC SODIUM ER TAB ER 24H N Pharmacy PA N  
diclofenac sodium/misoprostol ARTHROTEC 50 TAB IR DR N Pharmacy PA N  
diflunisal DOLOBID TABLET N Pharmacy PA N  
diflunisal DIFLUNISAL TABLET N Pharmacy PA N  
etodolac ETODOLAC ER TAB ER 24H N Pharmacy PA N  
fenoprofen calcium FENOPROFEN CALCIUM CAPSULE N Pharmacy PA N  
fenoprofen calcium NALFON TABLET N Pharmacy PA N  
flurbiprofen LURBIRO TABLET N Pharmacy PA N  
ibuprofen/famotidine IBUPROFEN-FAMOTIDINE TABLET N Pharmacy PA N  
indomethacin INDOMETHACIN ORAL SUSP N Pharmacy PA N  
ketoprofen KETOPROFEN CAP24H PEL N Pharmacy PA N  
ketorolac tromethamine KETOROLAC TROMETHAMINE TABLET N Quantity Limit N  
mefenamic acid MEFENAMIC ACID CAPSULE N Pharmacy PA N  
naproxen NAPROXEN ORAL SUSP N Pharmacy PA N  
naproxen sodium NAPROXEN SODIUM CR TBMP 24HR N Pharmacy PA N  
naproxen/esomeprazole mag NAPROXEN-ESOMEPRAZOLE MAG TAB IR DR N Pharmacy PA N  
tolmetin sodium TOLMETIN SODIUM TABLET N Pharmacy PA N  
tolmetin sodium TOLECTIN 600 TABLET N Pharmacy PA N  
celecoxib VYSCOXA ORAL SUSP   N  
fenoprofen calcium FENOPRON CAPSULE   N  
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