Adrenergics
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| dopamine HCl | DOPAMINE HCL | VIAL | N | |||
| dopamine HCl in dextrose 5 % | DOPAMINE HCL IN D5W | INFUS. BTL | N | |||
| dopamine HCl in dextrose 5 % | DOPAMINE HCL IN 5% DEXTROSE | PLAST. BAG | N | |||
| droxidopa | DROXIDOPA | CAPSULE | Pharmacy PA | N | ||
| ephedrine sulfate | EPHEDRINE SULFATE | SYRINGE | N | |||
| ephedrine sulfate | EMERPHED | SYRINGE | N | |||
| ephedrine sulfate | AKOVAZ | SYRINGE | N | |||
| epineph bitart in 0.9% sod chl | EPINEPHRINE-0.9% NACL | PLAST. BAG | N | |||
| epinephrine | EPINEPHRINE | SYRINGE | N | |||
| epinephrine HCl/PF | EPINEPHRINE | AMPUL | N | |||
| isoproterenol HCl | ISOPROTERENOL HCL | VIAL | N | |||
| metaraminol bitartrate | ARAMINE | VIAL | N | |||
| norepinephrine bit/0.9 % NaCl | NOREPINEPHRINE BITAR-0.9% NACL | PLAST. BAG | N | |||
| norepinephrine bitartrate | NOREPINEPHRINE BITARTRATE | VIAL | N | |||
| phenylephrine HCl | VAZCULEP | VIAL | N |