GnRH Agonists
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 |
---|---|---|---|---|---|
leuprolide acetate | LUPRON DEPOT-PED | KIT | Y | PA Document | |
histrelin acetate | SUPPRELIN | KIT | N | PA Document | |
histrelin acetate | SUPPRELIN LA | KIT | N | PA Document | |
leuprolide acetate | LEUPROLIDE ACETATE | KIT | N | PA Document | |
leuprolide acetate | ELIGARD | SYRINGE | N | PA Document | |
leuprolide acetate | FENSOLVI | SYRINGE | N | PA Document | |
leuprolide acetate | LUPRON DEPOT-PED | SYRINGEKIT | N | PA Document | |
leuprolide acetate | LUPRON DEPOT | SYRINGEKIT | N | PA Document | |
leuprolide acetate | LEUPROLIDE DEPOT | VIAL | N | PA Document | |
leuprolide acetate | LEUPROLIDE ACETATE | VIAL | N | PA Document | |
leuprolide mesylate | CAMCEVI | SYRINGE | N | PA Document | |
nafarelin acetate | SYNAREL | SPRAY | N | PA Document | |
triptorelin pamoate | TRIPTODUR | VIAL | N | PA Document | |
triptorelin pamoate | TRELSTAR | VIAL | N | PA Document |