Inflammatory Bowel Disease
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 |
|---|---|---|---|---|---|---|
| budesonide | BUDESONIDE EC | CAPDR - ER | Y | N | ||
| mesalamine | MESALAMINE ER | CAP ER 24H | Y | N | ||
| mesalamine | CANASA | SUPP.RECT | Y | N | ||
| mesalamine | MESALAMINE | TABLET DR | Y | N | ||
| sulfasalazine | AZULFIDINE | TABLET | Y | N | ||
| sulfasalazine | SULFASALAZINE | TABLET DR | Y | N | ||
| budesonide | BUDESONIDE | FOAM/APPL | N | N | ||
| mesalamine | MESALAMINE DR | CAP(DRTAB) | N | N | ||
| mesalamine | PENTASA | CAPSULE ER | N | N | ||
| mesalamine | SFROWASA | ENEMA | N | N | ||
| mesalamine | MESALAMINE | ENEMA | N | N | ||
| mesalamine w/cleansing wipes | ROWASA | ENEMA KIT | N | N |