Adrenergics

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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
dopamine HCl DOPAMINE HCL ADDITIVE SYRINGE SYRINGE    
dopamine HCl DOPAMINE HCL SYRINGE    
dopamine HCl DOPAMINE HCL VIAL    
dopamine HCl in dextrose 5 % DOPAMINE IN 5% DEXTROSE INFUS. BTL    
dopamine HCl in dextrose 5 % DOPAMINE HCL IN D5W INFUS. BTL    
dopamine HCl in dextrose 5 % DOPAMINE HCL IN 5% DEXTROSE INFUS. BTL    
dopamine HCl in dextrose 5 % DOPAMINE HCL IN 5% DEXTROSE PLAST. BAG    
droxidopa NORTHERA CAPSULE PA Document Jan 29, 2015
droxidopa DROXIDOPA CAPSULE PA Document  
ephedrine HCl REZIPRES AMPUL    
ephedrine sulfate EPHEDRINE SULFATE AMPUL    
ephedrine sulfate AKOVAZ SYRINGE    
ephedrine sulfate AKOVAZ VIAL    
ephedrine sulfate EPHEDRINE SULFATE VIAL    
ephedrine sulfate EMERPHED VIAL    
epinephrine EPINEPHRINE SYRINGE    
epinephrine EPINEPHRINE VIAL    
epinephrine ADRENALIN VIAL    
isoproterenol HCl ISOPROTERENOL HCL AMPUL    
isoproterenol HCl ISOPROTERENOL HCL VIAL    
metaraminol bitartrate ARAMINE VIAL    
midodrine HCl MIDODRINE HCL TABLET    
norepinephrine bitartrate LEVOPHED BITARTRATE AMPUL    
norepinephrine bitartrate NOREPINEPHRINE BITARTRATE AMPUL    
norepinephrine bitartrate NOREPINEPHRINE BITARTRATE VIAL    
norepinephrine bitartrate LEVOPHED VIAL    
norepinephrine bitartrate/D5W NOREPINEPHRINE BITARTRATE-D5W PLAST. BAG    
phenylephrine HCl PHENYLEPHRINE HCL VIAL    
phenylephrine HCl VAZCULEP VIAL