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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
Current Drug Use Criteria New Drug Evaluation
copper PARAGARD T 380-A IUD    
desog-e.estradiol/e.estradiol AZURETTE TABLET    
desog-e.estradiol/e.estradiol BEKYREE TABLET    
desog-e.estradiol/e.estradiol DESOGESTR-ETH ESTRAD ETH ESTRA TABLET    
desog-e.estradiol/e.estradiol KARIVA TABLET    
desog-e.estradiol/e.estradiol MIRCETTE TABLET    
desog-e.estradiol/e.estradiol PIMTREA TABLET    
desog-e.estradiol/e.estradiol SIMLIYA TABLET    
desog-e.estradiol/e.estradiol VIORELE TABLET    
desog-e.estradiol/e.estradiol VOLNEA TABLET    
desogestrel-ethinyl estradiol CYRED TABLET    
desogestrel-ethinyl estradiol APRI TABLET    
desogestrel-ethinyl estradiol CYRED EQ TABLET    
desogestrel-ethinyl estradiol DESOGESTREL-ETHINYL ESTRADIOL TABLET    
desogestrel-ethinyl estradiol ENSKYCE TABLET    
desogestrel-ethinyl estradiol ISIBLOOM TABLET    
desogestrel-ethinyl estradiol JULEBER TABLET    
desogestrel-ethinyl estradiol KALLIGA TABLET    
desogestrel-ethinyl estradiol RECLIPSEN TABLET    
desogestrel-ethinyl estradiol VELIVET TABLET    
drospir/eth estra/levomefol Ca SAFYRAL TABLET    
drospir/eth estra/levomefol Ca TYDEMY TABLET    
drospir/eth estra/levomefol Ca BEYAZ TABLET    
drospir/eth estra/levomefol Ca DROSPIRENONE-ETH ESTRA-LEVOMEF TABLET    
drospirenone SLYND TABLET    
drospirenone/estetrol NEXTSTELLIS TABLET    
estradiol valerate/dienogest NATAZIA TABLET    
ethinyl estradiol/drospirenone YAZ TABLET    
ethinyl estradiol/drospirenone DROSPIRENONE-ETHINYL ESTRADIOL TABLET    
ethinyl estradiol/drospirenone GIANVI TABLET    
ethinyl estradiol/drospirenone JASMIEL TABLET    
ethinyl estradiol/drospirenone LORYNA TABLET    
ethinyl estradiol/drospirenone LO-ZUMANDIMINE TABLET    
ethinyl estradiol/drospirenone NIKKI TABLET    
ethinyl estradiol/drospirenone OCELLA TABLET    
ethinyl estradiol/drospirenone SYEDA TABLET    
ethinyl estradiol/drospirenone YASMIN 28 TABLET    
ethinyl estradiol/drospirenone ZUMANDIMINE TABLET    
ethinyl estradiol/drospirenone VESTURA TABLET    
ethynodiol d-ethinyl estradiol DEMULEN 1-50-21 TABLET    
ethynodiol d-ethinyl estradiol ETHYNODIOL-ETHINYL ESTRADIOL TABLET    
ethynodiol d-ethinyl estradiol KELNOR 1-35 TABLET    
ethynodiol d-ethinyl estradiol KELNOR 1-50 TABLET    
ethynodiol d-ethinyl estradiol ZOVIA 1-35 TABLET    
etonogestrel NEXPLANON IMPLANT    
etonogestrel/ethinyl estradiol ELURYNG VAG RING    
etonogestrel/ethinyl estradiol ETONOGESTREL-ETHINYL ESTRADIOL VAG RING    
etonogestrel/ethinyl estradiol NUVARING VAG RING    
etonogestrel/ethinyl estradiol HALOETTE VAG RING    
etonogestrel/ethinyl estradiol ENILLORING VAG RING    
L-norgest/e.estradiol-e.estrad RIVELSA TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad QUARTETTE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad SEASONIQUE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad SIMPESSE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad LOSEASONIQUE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad LOJAIMIESS TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad AMETHIA TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad ASHLYNA TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad CAMRESE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad CAMRESE LO TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad DAYSEE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad JAIMIESS TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad LEVONORG-ETH ESTRAD ETH ESTRAD TBDSPK 3MO    
lactic acid/citric/potassium PHEXXI GEL/PF APP    
levonorgest/eth.estradiol/iron BALCOLTRA TABLET    
levonorgest/eth.estradiol/iron JOYEAUX TABLET    
levonorgest/eth.estradiol/iron LEVONORG-ETH ESTRAD-FE BISGLYC TABLET    
levonorgestrel MIRENA IUD    
levonorgestrel KYLEENA IUD    
levonorgestrel LILETTA IUD    
levonorgestrel SKYLA IUD    
levonorgestrel NORPLANT KIT    
levonorgestrel MY WAY TABLET    
levonorgestrel MY CHOICE TABLET    
levonorgestrel CURAE TABLET    
levonorgestrel ECONTRA EZ TABLET    
levonorgestrel ECONTRA ONE-STEP TABLET    
levonorgestrel HER STYLE TABLET    
levonorgestrel NEW DAY TABLET    
levonorgestrel OPCICON ONE-STEP TABLET    
levonorgestrel LEVONORGESTREL TABLET    
levonorgestrel OPTION 2 TABLET    
levonorgestrel/ethin.estradiol TWIRLA PATCH TDWK    
levonorgestrel/ethin.estradiol TYBLUME TAB CHEW    
levonorgestrel/ethin.estradiol SRONYX TABLET    
levonorgestrel/ethin.estradiol LESSINA TABLET    
levonorgestrel/ethin.estradiol LEVLEN 28 TABLET    
levonorgestrel/ethin.estradiol LEVONEST TABLET    
levonorgestrel/ethin.estradiol LEVONORGESTREL-ETH ESTRADIOL TABLET    
levonorgestrel/ethin.estradiol LEVORA-28 TABLET    
levonorgestrel/ethin.estradiol LUTERA TABLET    
levonorgestrel/ethin.estradiol MARLISSA TABLET    
levonorgestrel/ethin.estradiol FALMINA TABLET    
levonorgestrel/ethin.estradiol TRIVORA-28 TABLET    
levonorgestrel/ethin.estradiol VIENVA TABLET    
levonorgestrel/ethin.estradiol PORTIA TABLET    
levonorgestrel/ethin.estradiol KURVELO TABLET    
levonorgestrel/ethin.estradiol ENPRESSE TABLET    
levonorgestrel/ethin.estradiol AVIANE TABLET    
levonorgestrel/ethin.estradiol DOLISHALE TABLET    
levonorgestrel/ethin.estradiol CHATEAL EQ TABLET    
levonorgestrel/ethin.estradiol AYUNA TABLET    
levonorgestrel/ethin.estradiol CHATEAL TABLET    
levonorgestrel/ethin.estradiol AUBRA EQ TABLET    
levonorgestrel/ethin.estradiol AUBRA TABLET    
levonorgestrel/ethin.estradiol AMETHYST TABLET    
levonorgestrel/ethin.estradiol ALTAVERA TABLET    
levonorgestrel/ethin.estradiol AFIRMELLE TABLET    
levonorgestrel/ethin.estradiol JOLESSA TBDSPK 3MO    
levonorgestrel/ethin.estradiol LEVONORGESTREL-ETH ESTRADIOL TBDSPK 3MO    
levonorgestrel/ethin.estradiol SETLAKIN TBDSPK 3MO    
levonorgestrel/ethin.estradiol ICLEVIA TBDSPK 3MO    
medroxyprogesterone acetate DEPO-PROVERA SYRINGE    
medroxyprogesterone acetate DEPO-SUBQ PROVERA 104 SYRINGE    
medroxyprogesterone acetate MEDROXYPROGESTERONE ACETATE SYRINGE    
medroxyprogesterone acetate DEPO-PROVERA VIAL    
medroxyprogesterone acetate MEDROXYPROGESTERONE ACETATE VIAL    
norelgestromin/ethin.estradiol XULANE PATCH TDWK    
norelgestromin/ethin.estradiol ZAFEMY PATCH TDWK    
noreth-ethinyl estradiol/iron NORETHIN-ETH ESTRA-FERROUS FUM TAB CHEW    
noreth-ethinyl estradiol/iron LAYOLIS FE TAB CHEW    
noreth-ethinyl estradiol/iron KAITLIB FE TAB CHEW    
noreth-ethinyl estradiol/iron WYMZYA FE TAB CHEW    
norethindrone TULANA TABLET    
norethindrone CAMILA TABLET    
norethindrone SHAROBEL TABLET    
norethindrone DEBLITANE TABLET    
norethindrone ERRIN TABLET    
norethindrone HEATHER TABLET    
norethindrone INCASSIA TABLET    
norethindrone JENCYCLA TABLET    
norethindrone LYLEQ TABLET    
norethindrone LYZA TABLET    
norethindrone NORA-BE TABLET    
norethindrone NORETHINDRONE TABLET    
norethindrone NORLYDA TABLET    
norethindrone ac-eth estradiol LARIN TABLET    
norethindrone ac-eth estradiol AUROVELA TABLET    
norethindrone ac-eth estradiol NORETHINDRON-ETHINYL ESTRADIOL TABLET    
norethindrone ac-eth estradiol HAILEY TABLET    
norethindrone ac-eth estradiol LOESTRIN TABLET    
norethindrone ac-eth estradiol JUNEL TABLET    
norethindrone ac-eth estradiol MICROGESTIN TABLET    
norethindrone-e.estradiol-iron GEMMILY CAPSULE    
norethindrone-e.estradiol-iron NORETHINDRONE-E.ESTRADIOL-IRON CAPSULE    
norethindrone-e.estradiol-iron TAYSOFY CAPSULE    
norethindrone-e.estradiol-iron MERZEE CAPSULE    
norethindrone-e.estradiol-iron TAYTULLA CAPSULE    
norethindrone-e.estradiol-iron CHARLOTTE 24 FE TAB CHEW    
norethindrone-e.estradiol-iron FINZALA TAB CHEW    
norethindrone-e.estradiol-iron MELODETTA 24 FE TAB CHEW    
norethindrone-e.estradiol-iron MIBELAS 24 FE TAB CHEW    
norethindrone-e.estradiol-iron MINASTRIN 24 FE TAB CHEW    
norethindrone-e.estradiol-iron NORETHINDRONE-E.ESTRADIOL-IRON TAB CHEW    
norethindrone-e.estradiol-iron BLISOVI FE TABLET    
norethindrone-e.estradiol-iron BLISOVI 24 FE TABLET    
norethindrone-e.estradiol-iron AUROVELA FE TABLET    
norethindrone-e.estradiol-iron AUROVELA 24 FE TABLET    
norethindrone-e.estradiol-iron HAILEY 24 FE TABLET    
norethindrone-e.estradiol-iron HAILEY FE TABLET    
norethindrone-e.estradiol-iron JUNEL FE TABLET    
norethindrone-e.estradiol-iron JUNEL FE 24 TABLET    
norethindrone-e.estradiol-iron LARIN FE TABLET    
norethindrone-e.estradiol-iron LO LOESTRIN FE TABLET    
norethindrone-e.estradiol-iron LOESTRIN FE TABLET    
norethindrone-e.estradiol-iron LARIN 24 FE TABLET    
norethindrone-e.estradiol-iron TRI-LEGEST FE TABLET    
norethindrone-e.estradiol-iron MICROGESTIN 24 FE TABLET    
norethindrone-e.estradiol-iron MICROGESTIN FE TABLET    
norethindrone-e.estradiol-iron NORETHINDRONE-E.ESTRADIOL-IRON TABLET    
norethindrone-e.estradiol-iron TARINA 24 FE TABLET    
norethindrone-e.estradiol-iron TARINA FE TABLET    
norethindrone-e.estradiol-iron TARINA FE 1-20 EQ TABLET    
norethindrone-e.estradiol-iron TILIA FE TABLET    
norethindrone-ethin. estradiol WERA TABLET    
norethindrone-ethin. estradiol VYFEMLA TABLET    
norethindrone-ethin. estradiol ALYACEN TABLET    
norethindrone-ethin. estradiol ARANELLE TABLET    
norethindrone-ethin. estradiol BALZIVA TABLET    
norethindrone-ethin. estradiol BRIELLYN TABLET    
norethindrone-ethin. estradiol DASETTA TABLET    
norethindrone-ethin. estradiol LEENA TABLET    
norethindrone-ethin. estradiol NECON TABLET    
norethindrone-ethin. estradiol NORTREL TABLET    
norethindrone-ethin. estradiol NYLIA TABLET    
norethindrone-ethin. estradiol PHILITH TABLET    
norethindrone-ethin. estradiol PIRMELLA TABLET    
norgestimate-ethinyl estradiol TRI-MILI TABLET    
norgestimate-ethinyl estradiol MILI TABLET    
norgestimate-ethinyl estradiol MONO-LINYAH TABLET    
norgestimate-ethinyl estradiol NORGESTIMATE-ETHINYL ESTRADIOL TABLET    
norgestimate-ethinyl estradiol NYMYO TABLET    
norgestimate-ethinyl estradiol SPRINTEC TABLET    
norgestimate-ethinyl estradiol TRI FEMYNOR TABLET    
norgestimate-ethinyl estradiol TRI-ESTARYLLA TABLET    
norgestimate-ethinyl estradiol TRI-LINYAH TABLET    
norgestimate-ethinyl estradiol TRI-LO-ESTARYLLA TABLET    
norgestimate-ethinyl estradiol TRI-LO-MARZIA TABLET    
norgestimate-ethinyl estradiol TRI-LO-SPRINTEC TABLET    
norgestimate-ethinyl estradiol TRI-NYMYO TABLET    
norgestimate-ethinyl estradiol TRI-SPRINTEC TABLET    
norgestimate-ethinyl estradiol TRI-VYLIBRA TABLET    
norgestimate-ethinyl estradiol TRI-VYLIBRA LO TABLET    
norgestimate-ethinyl estradiol VYLIBRA TABLET    
norgestimate-ethinyl estradiol TRI-LO-MILI TABLET    
norgestimate-ethinyl estradiol ESTARYLLA TABLET    
norgestrel-ethinyl estradiol TURQOZ TABLET    
norgestrel-ethinyl estradiol ELINEST TABLET    
norgestrel-ethinyl estradiol CRYSELLE TABLET    
norgestrel-ethinyl estradiol LOW-OGESTREL TABLET    
segesterone ac/ethin estradiol ANNOVERA VAG RING Quantity Limit Oct 06, 2022
ulipristal acetate ELLA TABLET