Gout
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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 |
---|---|---|---|---|---|
allopurinol | ALLOPURINOL | TABLET | Y | ||
colchicine | COLCRYS | TABLET | Y | Quantity Limit | |
colchicine | COLCHICINE | TABLET | Y | Quantity Limit | |
probenecid/colchicine | PROBENECID-COLCHICINE | TABLET | Y | ||
allopurinol | ALLOPURINOL | TABLET | N | PA Document | |
colchicine | MITIGARE | CAPSULE | N | PA Document | |
colchicine | COLCHICINE | CAPSULE | N | PA Document | |
colchicine | GLOPERBA | SOLUTION | N | PA Document | |
febuxostat | ULORIC | TABLET | N | PA Document | |
febuxostat | FEBUXOSTAT | TABLET | N | PA Document | |
probenecid | PROBENECID | TABLET | N | PA Document | |
allopurinol sodium | ALOPRIM | VIAL | |||
allopurinol sodium | ALLOPURINOL SODIUM | VIAL | |||
pegloticase | KRYSTEXXA | VIAL | |||
rasburicase | ELITEK | VIAL |