Bile Therapy
PDL Reference 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 |
|---|---|---|---|---|---|
| ursodiol | URSODIOL | CAPSULE | Y | ||
| ursodiol | URSODIOL | TABLET | Y | ||
| ursodiol | URSO | TABLET | Y | ||
| ursodiol | URSO FORTE | TABLET | Y | ||
| cholic acid | CHOLBAM | CAPSULE | N | PA Document | Nov 21, 2019 |
| obeticholic acid | OCALIVA | TABLET | N | PA Document | Jan 26, 2017 |
| ursodiol | RELTONE | CAPSULE | N | ||
| chenodiol | CHENODAL | TABLET | |||
| dehydrocholic acid | DECHOLIN | TABLET |