Botulinum Toxins
PDL Reference Documents
Drug Use Review 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 | New Drug Evaluation |
|---|---|---|---|---|---|
| incobotulinumtoxinA | XEOMIN | VIAL | N | PA Document | |
| abobotulinumtoxinA | DYSPORT | VIAL | PA Document | ||
| incobotulinumtoxinA | XEOMIN | VIAL | PA Document | ||
| onabotulinumtoxinA | BOTOX COSMETIC | VIAL | PA Document | ||
| onabotulinumtoxinA | BOTOX | VIAL | PA Document | ||
| rimabotulinumtoxinB | MYOBLOC | VIAL | PA Document |