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.

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