← Back to Class List

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 but eligible patients will encounter a co-pay at the pharmacy.
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
Current Drug Use Criteria New Drug Evaluation
allopurinol ZYLOPRIM TABLET Y    
allopurinol ALLOPURINOL TABLET Y    
probenecid/colchicine PROBENECID-COLCHICINE TABLET Y    
colchicine MITIGARE CAPSULE N PA Document  
colchicine COLCHICINE CAPSULE N PA Document  
colchicine COLCRYS TABLET N PA Document  
colchicine COLCHICINE TABLET N PA Document  
febuxostat ULORIC TABLET N PA Document  
lesinurad ZURAMPIC TABLET N PA Document Jul 28, 2016
probenecid PROBENECID TABLET N PA Document  
allopurinol sodium ALOPRIM VIAL    
allopurinol sodium ALLOPURINOL SODIUM VIAL    
pegloticase KRYSTEXXA VIAL    
rasburicase ELITEK VIAL