Thyroid Hormone, Oral
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 & Updates |
|---|---|---|---|---|---|
| levothyroxine sodium | UNITHROID | TABLET | Y | ||
| levothyroxine sodium | SYNTHROID | TABLET | Y | ||
| levothyroxine sodium | LEVOXYL | TABLET | Y | ||
| levothyroxine sodium | LEVOTHYROXINE SODIUM | TABLET | Y | ||
| levothyroxine sodium | LEVO-T | TABLET | Y | ||
| levothyroxine sodium | EUTHYROX | TABLET | Y | ||
| levothyroxine sodium | LEVOTHYROXINE SODIUM | CAPSULE | N | ||
| levothyroxine sodium | ERMEZA | SOLUTION | N | ||
| levothyroxine sodium | THYQUIDITY | SOLUTION | N | ||
| liothyronine sodium | CYTOMEL | TABLET | N | ||
| liothyronine sodium | LIOTHYRONINE SODIUM | TABLET | N | ||
| thyroid,pork | THYROID | TABLET | N | ||
| thyroid,pork | NP THYROID | TABLET | N | ||
| thyroid,pork | NIVA THYROID | TABLET | N | ||
| thyroid,pork | ARMOUR THYROID | TABLET | N | ||
| thyroid,pork | ADTHYZA | TABLET | N |