Tobacco Smoking Cessation
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 |
|---|---|---|---|---|---|---|
| nicotine | NICOTINE PATCH | PATCH DYSQ | Y | N | ||
| nicotine | NICOTINE PATCH | PATCH TD24 | Y | N | ||
| nicotine | NICODERM CQ | PATCH TD24 | Y | N | ||
| nicotine polacrilex | NICOTINE LOZENGE | LOZENGE | Y | N | ||
| nicotine polacrilex | QUIT 4 | LOZENGE | Y | N | ||
| nicotine polacrilex | QUIT 2 | LOZENGE | Y | N | ||
| nicotine polacrilex | NICOTINE LOZENGE | LOZENGE | Y | N | ||
| nicotine polacrilex | NICORETTE | LOZENGE | Y | N | ||
| nicotine polacrilex | COMMIT | LOZENGE | Y | N | ||
| nicotine polacrilex | NICOTINE LOZENGE | LOZNG MINI | Y | N | ||
| nicotine polacrilex | NICORETTE | LOZNG MINI | Y | N | ||
| varenicline tartrate | CHANTIX | TABLET | Y | Age Restriction | N | |
| nicotine | NICOTROL NS | SPRAY | N | Pharmacy PA | N | |
| nicotine | NICOTINE PATCH | PATCH TD24 | N | |||
| varenicline tartrate | VARENICLINE TARTRATE | TABLET | Age Restriction | N |