GnRH Agonists

← Back to Class List

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
histrelin acetate VANTAS KIT N PA Document  
histrelin acetate SUPPRELIN LA KIT N PA Document  
histrelin acetate SUPPRELIN KIT N PA Document  
leuprolide acetate LEUPROLIDE ACETATE KIT N PA Document  
leuprolide acetate LUPRON DEPOT-PED KIT N PA Document  
leuprolide acetate FENSOLVI SYRINGE N PA Document  
leuprolide acetate ELIGARD SYRINGE N PA Document  
leuprolide acetate LUPRON DEPOT (LUPANETA) SYRINGEKIT N PA Document  
leuprolide acetate LUPRON DEPOT SYRINGEKIT N PA Document  
leuprolide acetate LUPRON DEPOT-PED SYRINGEKIT N PA Document  
leuprolide acetate LEUPROLIDE ACETATE VIAL N PA Document  
leuprolide mesylate CAMCEVI SYRINGE N PA Document  
leuprolide/norethindrone acet LUPANETA PACK KT SYR TAB N PA Document  
nafarelin acetate SYNAREL SPRAY N PA Document  
triptorelin pamoate TRELSTAR VIAL N PA Document  
triptorelin pamoate TRIPTODUR VIAL N PA Document