Diabetes, Glucagon
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 |
|---|---|---|---|---|---|
| glucagon | BAQSIMI | SPRAY | Y | ||
| glucagon | GLUCAGON EMERGENCY KIT | VIAL | Y | ||
| glucagon | GLUCAGEN | VIAL | Y | ||
| dasiglucagon HCl | ZEGALOGUE AUTOINJECTOR | AUTO INJCT | N | ||
| dasiglucagon HCl | ZEGALOGUE SYRINGE | SYRINGE | N | ||
| glucagon | GVOKE HYPOPEN 2-PACK | AUTO INJCT | N | ||
| glucagon | GVOKE HYPOPEN 1-PACK | AUTO INJCT | N | ||
| glucagon | GVOKE PFS 2-PACK SYRINGE | SYRINGE | N | ||
| glucagon | GVOKE PFS 1-PACK SYRINGE | SYRINGE | N | ||
| glucagon | GVOKE | VIAL | N | ||
| glucagon HCl | GLUCAGON HCL | VIAL | |||
| glucagon HCl | GLUCAGON EMERGENCY KIT | VIAL |