Statins & Combos
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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 |
|---|---|---|---|---|---|
| atorvastatin calcium | ATORVASTATIN CALCIUM | TABLET | Y | ||
| atorvastatin calcium | LIPITOR | TABLET | Y | ||
| lovastatin | LOVASTATIN | TABLET | Y | ||
| pravastatin sodium | PRAVASTATIN SODIUM | TABLET | Y | ||
| rosuvastatin calcium | ROSUVASTATIN CALCIUM | TABLET | Y | ||
| rosuvastatin calcium | CRESTOR | TABLET | Y | ||
| simvastatin | SIMVASTATIN | TABLET | Y | ||
| simvastatin | ZOCOR | TABLET | Y | ||
| atorvastatin calcium | ATORVALIQ | ORAL SUSP | N | ||
| ezetimibe/simvastatin | EZETIMIBE-SIMVASTATIN | TABLET | N | ||
| ezetimibe/simvastatin | VYTORIN | TABLET | N | ||
| fluvastatin sodium | FLUVASTATIN SODIUM | CAPSULE | N | ||
| fluvastatin sodium | LESCOL XL | TAB ER 24H | N | ||
| fluvastatin sodium | FLUVASTATIN ER | TAB ER 24H | N | ||
| lovastatin | ALTOPREV | TAB ER 24H | N | ||
| pitavastatin calcium | LIVALO | TABLET | N | ||
| pitavastatin calcium | PITAVASTATIN CALCIUM | TABLET | N | ||
| pitavastatin magnesium | ZYPITAMAG | TABLET | N | ||
| rosuvastatin calcium | EZALLOR SPRINKLE | CAP SPRINK | N |