Thyroid Hormone, Oral

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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
Current Drug Use Criteria New Drug Evaluation
levothyroxine sodium LEVOXYL TABLET Y    
levothyroxine sodium UNITHROID TABLET Y    
levothyroxine sodium SYNTHROID TABLET Y    
levothyroxine sodium LEVOTHYROXINE SODIUM TABLET Y    
levothyroxine sodium LEVO-T TABLET Y    
levothyroxine sodium EUTHYROX TABLET Y    
levothyroxine sodium TIROSINT CAPSULE N    
levothyroxine sodium LEVOTHYROXINE SODIUM CAPSULE N    
levothyroxine sodium TIROSINT-SOL SOLUTION N    
levothyroxine sodium THYQUIDITY SOLUTION N    
liothyronine sodium CYTOMEL TABLET N    
liothyronine sodium LIOTHYRONINE SODIUM TABLET N    
thyroid,pork ARMOUR THYROID TABLET N    
thyroid,pork ADTHYZA TABLET N    
thyroid,pork NIVA THYROID TABLET N    
thyroid,pork NP THYROID TABLET N    
levothyroxine sodium ERMEZA SOLUTION