Overactive Bladder 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.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
fesoterodine fumarate FESOTERODINE FUMARATE ER TAB ER 24H Y    
fesoterodine fumarate TOVIAZ TAB ER 24H Y    
oxybutynin OXYTROL PATCH TDSW Y    
oxybutynin chloride OXYBUTYNIN CHLORIDE SYRUP Y    
oxybutynin chloride OXYBUTYNIN CHLORIDE ER TAB ER 24 Y    
oxybutynin chloride DITROPAN XL TAB ER 24 Y    
oxybutynin chloride OXYBUTYNIN CHLORIDE TABLET Y    
solifenacin succinate SOLIFENACIN SUCCINATE TABLET Y    
solifenacin succinate VESICARE TABLET Y    
darifenacin hydrobromide DARIFENACIN ER TAB ER 24H N    
flavoxate HCl FLAVOXATE HCL TABLET N    
mirabegron MYRBETRIQ SUS ER REC N    
mirabegron MYRBETRIQ TAB ER 24H N    
oxybutynin OXYTROL FOR WOMEN PATCH TD 4 N    
oxybutynin chloride GELNIQUE GEL PACKET N    
solifenacin succinate VESICARE LS ORAL SUSP N    
tolterodine tartrate DETROL LA CAP ER 24H N    
tolterodine tartrate TOLTERODINE TARTRATE ER CAP ER 24H N    
tolterodine tartrate DETROL TABLET N    
tolterodine tartrate TOLTERODINE TARTRATE TABLET N    
trospium chloride TROSPIUM CHLORIDE ER CAP ER 24H N    
trospium chloride TROSPIUM CHLORIDE TABLET N    
vibegron GEMTESA TABLET N    
oxybutynin chloride OXYBUTYNIN CHLORIDE TABLET