Parkinson's Disease Drugs, Oral & Topical

← Back to Class List

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
amantadine HCl AMANTADINE TABLET Y   N  
carbidopa/levodopa SINEMET TABLET Y   N  
carbidopa/levodopa/entacapone STALEVO 75 TABLET Y   N  
carbidopa/levodopa/entacapone STALEVO 100 TABLET Y   N  
pramipexole di-HCl PRAMIPEXOLE DIHYDROCHLORIDE TABLET Y   N  
selegiline HCl SELEGILINE HCL CAPSULE Y   N  
trihexyphenidyl HCl TRIHEXYPHENIDYL HCL TABLET Y   N  
apomorphine HCl KYNMOBI FILM N Pharmacy PA N  
bromocriptine mesylate BROMOCRIPTINE MESYLATE CAPSULE N Pharmacy PA N  
carbidopa/levodopa CREXONT CAP IR ER N Pharmacy PA N  
carbidopa/levodopa DUOPA INT PMP SP N Pharmacy PA N  
carbidopa/levodopa CARBIDOPA-LEVODOPA TAB RAPDIS N Pharmacy PA N  
foscarbidopa/foslevodopa VYALEV VIAL N Pharmacy PA N  
levodopa INBRIJA CAP W/DEV N Pharmacy PA N  
levodopa LARODOPA TABLET N Pharmacy PA N  
rasagiline mesylate AZILECT TABLET N Pharmacy PA N  
ropinirole HCl ROPINIROLE ER TAB ER 24H N Pharmacy PA N  
rotigotine NEUPRO PATCH TD24 N Pharmacy PA N  
tolcapone TOLCAPONE TABLET N Pharmacy PA N  
apomorphine HCl ONAPGO CARTRIDGE   N  
carbidopa/levodopa CARBIDOPA-LEVODOPA ER CAPSULE ER   N  
Back to Top ↑