Contraceptives

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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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
copper PARAGARD T 380A (SINGLE HAND) IUD   N  
desog-e.estradiol/e.estradiol DESOGESTR-ETH ESTRAD ETH ESTRA TABLET   N  
desog-e.estradiol/e.estradiol PIMTREA TABLET   N  
desog-e.estradiol/e.estradiol VIORELE TABLET   N  
desogestrel-ethinyl estradiol APRI TABLET   N  
desogestrel-ethinyl estradiol CYRED EQ TABLET   N  
desogestrel-ethinyl estradiol ISIBLOOM TABLET   N  
desogestrel-ethinyl estradiol KALLIGA TABLET   N  
desogestrel-ethinyl estradiol VELIVET TABLET   N  
desogestrel/e.estradiol/iron AVERI TABLET   N  
drospir/eth estra/levomefol Ca DROSPIRENONE-ETH ESTRA-LEVOMEF TABLET   N  
drospirenone SLYND TABLET   N  
ethinyl estradiol/drospirenone DROSPIRENONE-ETHINYL ESTRADIOL TABLET   N  
ethinyl estradiol/drospirenone LORYNA TABLET   N  
ethinyl estradiol/drospirenone NIKKI TABLET   N  
ethinyl estradiol/drospirenone SYEDA TABLET   N  
ethinyl estradiol/drospirenone YAZ TABLET   N  
ethinyl estradiol/drospirenone ZUMANDIMINE TABLET   N  
ethinyl estradiol/drospirenone YASMIN 28 TABLET   N  
ethynodiol d-ethinyl estradiol ZOVIA 1-35 TABLET   N  
etonogestrel/ethinyl estradiol ELURYNG VAG RING   N  
etonogestrel/ethinyl estradiol ETONOGESTREL-ETHINYL ESTRADIOL VAG RING   N  
etonogestrel/ethinyl estradiol NUVARING VAG RING   N  
L-norgest/e.estradiol-e.estrad DAYSEE TBDSPK 3MO   N  
L-norgest/e.estradiol-e.estrad LEVONORG-ETH ESTRAD ETH ESTRAD TBDSPK 3MO   N  
L-norgest/e.estradiol-e.estrad RIVELSA TBDSPK 3MO   N  
L-norgest/e.estradiol-e.estrad SIMPESSE TBDSPK 3MO   N  
levonorgest/eth.estradiol/iron JOYEAUX TABLET   N  
levonorgest/eth.estradiol/iron BALCOLTRA TABLET   N  
levonorgest/eth.estradiol/iron LEVONORG-ETH ESTRAD-FE BISGLYC TABLET   N  
levonorgestrel SKYLA IUD   N  
levonorgestrel LILETTA IUD   N  
levonorgestrel NORPLANT KIT   N  
levonorgestrel MY CHOICE TABLET   N  
levonorgestrel ECONTRA ONE-STEP TABLET   N  
levonorgestrel LEVONORGESTREL TABLET   N  
levonorgestrel MY WAY TABLET   N  
levonorgestrel/ethin.estradiol TYBLUME TAB CHEW   N  
levonorgestrel/ethin.estradiol VIENVA TABLET   N  
levonorgestrel/ethin.estradiol LEVLEN 28 TABLET   N  
levonorgestrel/ethin.estradiol LEVONORGESTREL-ETH ESTRADIOL TABLET   N  
levonorgestrel/ethin.estradiol LUTERA TABLET   N  
levonorgestrel/ethin.estradiol PORTIA TABLET   N  
levonorgestrel/ethin.estradiol SRONYX TABLET   N  
levonorgestrel/ethin.estradiol FALMINA TABLET   N  
levonorgestrel/ethin.estradiol ENPRESSE TABLET   N  
levonorgestrel/ethin.estradiol AVIANE TABLET   N  
levonorgestrel/ethin.estradiol AMETHYST TABLET   N  
levonorgestrel/ethin.estradiol JOLESSA TBDSPK 3MO   N  
levonorgestrel/ethin.estradiol ICLEVIA TBDSPK 3MO   N  
medroxyprogesterone acetate DEPO-SUBQ PROVERA 104 SYRINGE   N  
medroxyprogesterone acetate MEDROXYPROGESTERONE ACETATE VIAL   N  
medroxyprogesterone acetate DEPO-PROVERA VIAL   N  
norelgestromin/ethin.estradiol XULANE PATCH TDWK   N  
noreth-ethinyl estradiol/iron XELRIA FE TAB CHEW   N  
noreth-ethinyl estradiol/iron GALBRIELA TAB CHEW   N  
noreth-ethinyl estradiol/iron LAYOLIS FE TAB CHEW   N  
noreth-ethinyl estradiol/iron WYMZYA FE TAB CHEW   N  
noreth-ethinyl estradiol/iron NORETHIN-ETH ESTRA-FERROUS FUM TAB CHEW   N  
norethindrone CAMILA TABLET   N  
norethindrone EMZAHH TABLET   N  
norethindrone HEATHER TABLET   N  
norethindrone JENCYCLA TABLET   N  
norethindrone NORETHINDRONE TABLET   N  
norethindrone ac/eth estradiol FEMLYV TAB RAPDIS   N  
norethindrone ac/eth estradiol NORETHINDRON-ETHINYL ESTRADIOL TABLET   N  
norethindrone ac/eth estradiol JUNEL TABLET   N  
norethindrone-e.estradiol-iron TAYTULLA CAPSULE   N  
norethindrone-e.estradiol-iron FINZALA TAB CHEW   N  
norethindrone-e.estradiol-iron MIBELAS 24 FE TAB CHEW   N  
norethindrone-e.estradiol-iron MINASTRIN 24 FE TAB CHEW   N  
norethindrone-e.estradiol-iron NORETHINDRONE-E.ESTRADIOL-IRON TAB CHEW   N  
norethindrone-e.estradiol-iron AUROVELA FE TABLET   N  
norethindrone-e.estradiol-iron BLISOVI 24 FE TABLET   N  
norethindrone-e.estradiol-iron BLISOVI FE TABLET   N  
norethindrone-e.estradiol-iron FEIRZA TABLET   N  
norethindrone-e.estradiol-iron HAILEY FE TABLET   N  
norethindrone-e.estradiol-iron JUNEL FE 24 TABLET   N  
norethindrone-e.estradiol-iron LARIN FE TABLET   N  
norethindrone-e.estradiol-iron XARAH FE TABLET   N  
norethindrone-e.estradiol-iron NORETHINDRONE-E.ESTRADIOL-IRON TABLET   N  
norethindrone-e.estradiol-iron TRI-LEGEST FE TABLET   N  
norethindrone-e.estradiol-iron TILIA FE TABLET   N  
norethindrone-e.estradiol-iron TARINA FE 1-20 EQ TABLET   N  
norethindrone-ethin. estradiol VYFEMLA TABLET   N  
norethindrone-ethin. estradiol PIRMELLA TABLET   N  
norethindrone-ethin. estradiol ALYACEN TABLET   N  
norethindrone-ethin. estradiol BALZIVA TABLET   N  
norethindrone-ethin. estradiol DASETTA TABLET   N  
norethindrone-ethin. estradiol NECON TABLET   N  
norethindrone-ethin. estradiol NYLIA TABLET   N  
norgestimate-ethinyl estradiol TRI-VYLIBRA LO TABLET   N  
norgestimate-ethinyl estradiol TRI-SPRINTEC TABLET   N  
norgestimate-ethinyl estradiol MILI TABLET   N  
norgestimate-ethinyl estradiol NORGESTIMATE-ETHINYL ESTRADIOL TABLET   N  
norgestimate-ethinyl estradiol TRI-ESTARYLLA TABLET   N  
norgestimate-ethinyl estradiol TRI-LO-ESTARYLLA TABLET   N  
norgestimate-ethinyl estradiol VYLIBRA TABLET   N  
norgestrel-ethinyl estradiol CRYSELLE TABLET   N  
norgestrel-ethinyl estradiol LOW-OGESTREL TABLET   N  
segesterone ac/ethin estradiol ANNOVERA VAG RING Quantity Limit N Oct 06, 2022
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