Diagnostics
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 |
|---|---|---|---|---|---|---|
| blood sugar diagnostic | ONE TOUCH/ONE TOUCH II | KIT | Y | N | ||
| blood sugar diagnostic | TRUETEST TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | UNISTRIP1 | STRIP | Y | N | ||
| blood sugar diagnostic | ULTIMA | STRIP | Y | N | ||
| blood sugar diagnostic | ULTRATRAK | STRIP | Y | N | ||
| blood sugar diagnostic | CLEVER CHOICE MICRO TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | ULTRATRAK ULTIMATE | STRIP | Y | N | ||
| blood sugar diagnostic | TRUETRACK TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | VIVAGUARD INO TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | HEALTHPRO GLUCOSE TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | IGLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | PRODIGY NO CODING | STRIP | Y | N | ||
| blood sugar diagnostic | TRUE METRIX PRO TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | HARMONY GLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | QUINTET | STRIP | Y | N | ||
| blood sugar diagnostic | PRECISION Q-I-D | STRIP | Y | N | ||
| blood sugar diagnostic | PRECISION POINT OF CARE | STRIP | Y | N | ||
| blood sugar diagnostic | PRECISION PCX PLUS | STRIP | Y | N | ||
| blood sugar diagnostic | PRECISION PCX | STRIP | Y | N | ||
| blood sugar diagnostic | PLATINUM TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | PIP BLOOD GLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | PHARMACIST CHOICE | STRIP | Y | N | ||
| blood sugar diagnostic | OPTUMRX | STRIP | Y | N | ||
| blood sugar diagnostic | OPTIUM EZ | STRIP | Y | N | ||
| blood sugar diagnostic | OPTIUM | STRIP | Y | N | ||
| blood sugar diagnostic | PREMIER TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | ONETOUCH ULTRA TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | PREMIUM BLOOD GLUCOSE TEST | STRIP | Y | N | ||
| blood sugar diagnostic | ON CALL VIVID TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | ON CALL PLUS TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | ON CALL EXPRESS TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | NOVA MAX GLUCOSE TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | NEUTEK 2TEK TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | MYGLUCOHEALTH | STRIP | Y | N | ||
| blood sugar diagnostic | MICRODOT XTRA | STRIP | Y | N | ||
| blood sugar diagnostic | MICRODOT | STRIP | Y | N | ||
| blood sugar diagnostic | MICRO | STRIP | Y | N | ||
| blood sugar diagnostic | INFINITY VOICE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | INFINITY TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | IHEALTH GLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | ONETOUCH VERIO TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | RIGHTEST GS300 TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | TRACER BG | STRIP | Y | N | ||
| blood sugar diagnostic | TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | TEST N'GO | STRIP | Y | N | ||
| blood sugar diagnostic | TELCARE | STRIP | Y | N | ||
| blood sugar diagnostic | TD GOLD TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | SURE-TEST EASYPLUS MINI | STRIP | Y | N | ||
| blood sugar diagnostic | SOLUS V2 TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | SMARTEST TEST | STRIP | Y | N | ||
| blood sugar diagnostic | SMART SENSE TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | RIGHTEST MAX TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | RIGHTEST GT333 TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | PRECISION XTRA | STRIP | Y | N | ||
| blood sugar diagnostic | RIGHTEST GS550 TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | TRUE METRIX GLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | RIGHTEST GS260 TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | RIGHTEST GS250S TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | RIGHTEST GS100 TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | REVEAL TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | RELION PRIME TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | RELION CONFIRM-MICRO | STRIP | Y | N | ||
| blood sugar diagnostic | REFUAH PLUS | STRIP | Y | N | ||
| blood sugar diagnostic | REAGENT STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | QUINTET AC | STRIP | Y | N | ||
| blood sugar diagnostic | PTS PANELS EGLU TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | PRO VOICE V8-V9 TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | PREMIUM V10 | STRIP | Y | N | ||
| blood sugar diagnostic | RIGHTEST GS700 TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | EZ SMART PLUS | STRIP | Y | N | ||
| blood sugar diagnostic | EMBRACE EVO | STRIP | Y | N | ||
| blood sugar diagnostic | FORA TN'G ADVAN PRO TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | FORA TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | FORA GTEL GLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | FORA GD50 TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | FORA G30-PREMIUM V10 TEST STRP | STRIP | Y | N | ||
| blood sugar diagnostic | FORA G20 | STRIP | Y | N | ||
| blood sugar diagnostic | FORA D40-G31 TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | FORA D20 | STRIP | Y | N | ||
| blood sugar diagnostic | FORA D15G | STRIP | Y | N | ||
| blood sugar diagnostic | FORA 6CONN-GTEL-TN'G ADV STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | FORA V10 | STRIP | Y | N | ||
| blood sugar diagnostic | FIFTY50 TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | FORA V10-V12-D10-D20 | STRIP | Y | N | ||
| blood sugar diagnostic | EZ SMART | STRIP | Y | N | ||
| blood sugar diagnostic | EXACTECH | STRIP | Y | N | ||
| blood sugar diagnostic | EVOLUTION TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | EVENCARE PROVIEW TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | EVENCARE MINI GLUCOSE TEST STR | STRIP | Y | N | ||
| blood sugar diagnostic | EVENCARE G3 | STRIP | Y | N | ||
| blood sugar diagnostic | EVENCARE G2 | STRIP | Y | N | ||
| blood sugar diagnostic | EVENCARE | STRIP | Y | N | ||
| blood sugar diagnostic | EMBRACE WAVE GLUCOSE TEST STRP | STRIP | Y | N | ||
| blood sugar diagnostic | EMBRACE TALK TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | GLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | FORA 6 CONNECT GLUCOSE STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | FREESTYLE PRECISION NEO | STRIP | Y | N | ||
| blood sugar diagnostic | GLUCOFILM | STRIP | Y | N | ||
| blood sugar diagnostic | GLUCOCOM GLUCOSE | STRIP | Y | N | ||
| blood sugar diagnostic | GLUCOCARD VITAL SENSOR | STRIP | Y | N | ||
| blood sugar diagnostic | GLUCOCARD VITAL | STRIP | Y | N | ||
| blood sugar diagnostic | GOODLIFE AC-302 TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | GLUCOCARD EXPRESSION | STRIP | Y | N | ||
| blood sugar diagnostic | CLEVER CHOICE TALK | STRIP | Y | N | ||
| blood sugar diagnostic | GLUCO NAVII | STRIP | Y | N | ||
| blood sugar diagnostic | GENULTIMATE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | GENSTRIP | STRIP | Y | N | ||
| blood sugar diagnostic | GE333 BLOOD GLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | FORA TN'G VOICE TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | FREESTYLE TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | EMBRACE | STRIP | Y | N | ||
| blood sugar diagnostic | FREESTYLE LITE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | FREESTYLE LITE STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | FREESTYLE INSULINX TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | FREESTYLE INSULINX | STRIP | Y | N | ||
| blood sugar diagnostic | FORTISCARE GLUCOSE TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | FORTISCARE G1 TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | FORACARE GD40 | STRIP | Y | N | ||
| blood sugar diagnostic | FORACARE GD20 | STRIP | Y | N | ||
| blood sugar diagnostic | FORA V30A | STRIP | Y | N | ||
| blood sugar diagnostic | FORA V20 | STRIP | Y | N | ||
| blood sugar diagnostic | FORA V12 | STRIP | Y | N | ||
| blood sugar diagnostic | GE100 BLOOD GLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | ADVOCATE REDI-CODE+ | STRIP | Y | N | ||
| blood sugar diagnostic | EMBRACE PRO TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | CARESENS N | STRIP | Y | N | ||
| blood sugar diagnostic | BLULINK GLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | BLOOD GLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | AT-LAST TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | ASSURE PRISM MULTI | STRIP | Y | N | ||
| blood sugar diagnostic | ASSURE PLATINUM TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | ASSURE PLATINUM | STRIP | Y | N | ||
| blood sugar diagnostic | ASSURE 4 | STRIP | Y | N | ||
| blood sugar diagnostic | AGAMATRIX PRESTO | STRIP | Y | N | ||
| blood sugar diagnostic | AGAMATRIX JAZZ TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | CARETOUCH TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | ADVOCATE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | CHEMSTRIP BG | STRIP | Y | N | ||
| blood sugar diagnostic | ADVOCATE REDI-CODE | STRIP | Y | N | ||
| blood sugar diagnostic | ADVANCED GLUCOSE TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | ADVANCED GLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | ADVANCE TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | ACCUTREND GLUCOSE | STRIP | Y | N | ||
| blood sugar diagnostic | ACCU-CHEK SMARTVIEW | STRIP | Y | N | ||
| blood sugar diagnostic | ACCU-CHEK SIMPLICITY | STRIP | Y | N | ||
| blood sugar diagnostic | ACCU-CHEK GUIDE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | ACCU-CHEK AVIVA PLUS | STRIP | Y | N | ||
| blood sugar diagnostic | ACCU-CHEK ADVANTAGE | STRIP | Y | N | ||
| blood sugar diagnostic | ACCU-CHEK | STRIP | Y | N | ||
| blood sugar diagnostic | AGAMATRIX AMP | STRIP | Y | N | ||
| blood sugar diagnostic | EASY CHECK TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | ELEMENT TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | ELEMENT COMPACT | STRIP | Y | N | ||
| blood sugar diagnostic | EASYMAX 15 | STRIP | Y | N | ||
| blood sugar diagnostic | EASYMAX | STRIP | Y | N | ||
| blood sugar diagnostic | EASYGLUCO TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | EASY TRAK II TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | EASY TRAK | STRIP | Y | N | ||
| blood sugar diagnostic | EASY TOUCH TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | EASY TOUCH BLULINK TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | EASY TALK PLUS II | STRIP | Y | N | ||
| blood sugar diagnostic | EASY TALK | STRIP | Y | N | ||
| blood sugar diagnostic | CARESENS S TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | EASY PLUS II | STRIP | Y | N | ||
| blood sugar diagnostic | GLUCOCARD SHINE | STRIP | Y | N | ||
| blood sugar diagnostic | DIATRUE PLUS | STRIP | Y | N | ||
| blood sugar diagnostic | DEXTROSTIX REAGENT | STRIP | Y | N | ||
| blood sugar diagnostic | DARIO BLOOD GLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | COOL GLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | CONTOUR TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | CONTOUR PLUS TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | CONTOUR NEXT TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | CLEVER CHOICE VOICE+ TST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | CLEVER CHOICE TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | CLEVER CHOICE PRO | STRIP | Y | N | ||
| blood sugar diagnostic | CHOICEDM CLARUS TEST STRIPS | STRIP | Y | N | ||
| blood sugar diagnostic | EASY STEP | STRIP | Y | N | ||
| blood sugar diagnostic | GOJJI BLOOD GLUCOSE TEST STRIP | STRIP | Y | N | ||
| blood sugar diagnostic | GLUCOSTIX REAGENT | STRIP | Y | N | ||
| blood sugar diagnostic | GLUCOCARD 01 SENSOR PLUS | STRIP | Y | N | ||
| blood sugar diagnostic, disc | BREEZE 2 | STRIP | Y | N | ||
| adenosine | ADENOSINE | VIAL | N | |||
| aminolevulinic acid HCl | GLEOLAN | SOLN RECON | N | |||
| barium sulfate | EPI-STAT-61 | ORAL SUSP | N | |||
| barium sulfate | EPI-STAT-57 | ORAL SUSP | N | |||
| barium sulfate | BAROSPERSE | POWDER | N | |||
| barium sulfate | BAROSPERSE-110 | POWDER | N | |||
| copper Cu-64 dotatate | DETECTNET | VIAL | N | |||
| diatrizoate meglumine, sodium | DIATRIZOATE MEGLUMINE-SODIUM | SOLUTION | N | |||
| dipyridamole | PERSANTINE I.V. | AMPUL | N | |||
| dipyridamole | DIPYRIDAMOLE | AMPUL | N | |||
| dipyridamole | DIPYRIDAMOLE | VIAL | N | |||
| ferumoxides | FERIDEX I.V. | VIAL | N | |||
| florbetapir F-18 | AMYVID | VIAL | N | |||
| flortaucipir F-18 | TAUVID PATIENT READY DOSE | VIAL | N | |||
| flortaucipir F-18 | TAUVID | VIAL | N | |||
| flotufolastat F 18 gallium | POSLUMA | VIAL | N | |||
| fluciclovine F-18 | AXUMIN | VIAL | N | |||
| fluorescein sodium | FLUORESCEIN SODIUM | DROPS | N | |||
| fluorescein sodium | FLUOR-I-STRIP AT | STRIP | N | |||
| fluorescein sodium | GLOSTRIPS | STRIP | N | |||
| fluorescein sodium | FLUORESCITE | VIAL | N | |||
| fluorescein sodium | FLUORESCEIN SODIUM | VIAL | N | |||
| fluorescein sodium | AK-FLUOR | VIAL | N | |||
| flurpiridaz F-18 | FLYRCADO | VIAL | N | |||
| gadobutrol | GADAVIST | SYRINGE | N | |||
| gadobutrol | GADAVIST | VIAL | N | |||
| gadobutrol | GADOBUTROL | VIAL | N | |||
| gadodiamide | OMNISCAN | SYRINGE | N | |||
| gadodiamide | OMNISCAN | VIAL | N | |||
| gadoterate meglumine | CLARISCAN | SYRINGE | N | |||
| gadoterate meglumine | CLARISCAN | VIAL | N | |||
| gadoterate meglumine | GADOTERATE MEGLUMINE | VIAL | N | |||
| gadoteridol | GADOTERIDOL | VIAL | N | |||
| gadoxetate disodium | EOVIST | VIAL | N | |||
| gallium-67 citrate | GALLIUM CITRATE GA-67 | VIAL | N | |||
| glucagon | GVOKE VIALDX | VIAL | N | |||
| indigotindisulfonate sodium | BLUDIGO | AMPUL | N | |||
| indium-111 chlor/pentetreotide | OCTREOSCAN | KIT | N | |||
| indium-111 chloride | INDIUM IN-111 CHLORIDE | VIAL | N | |||
| iodixanol | VISIPAQUE | INFUS. BTL | N | |||
| iodixanol | IODIXANOL | INFUS. BTL | N | |||
| ioflupane I 123 | IOFLUPANE I-123 | VIAL | N | |||
| iohexol | OMNIPAQUE | INFUS. BTL | N | |||
| iohexol | OMNIPAQUE | PLAST. BAG | N | |||
| iohexol | OMNIPAQUE | SOLUTION | N | |||
| iohexol | OMNIPAQUE | VIAL | N | |||
| iopamidol | IOPAMIDOL | INFUS. BTL | N | |||
| iopamidol | IOPAMIDOL | VIAL | N | |||
| iopromide | ULTRAVIST | VIAL | N | |||
| isosulfan blue | ISOSULFAN BLUE | VIAL | N | |||
| kit for prep of Ga 68/dotatate | NETSPOT | VIAL | N | |||
| kit for prep of Tc-99m/albumin | PULMOTECH MAA | VIAL | N | |||
| kit for Tc 99m/sestamibi no.1 | CARDIOLITE | SYRINGE | N | |||
| kit for Tc 99m/sestamibi no.1 | CARDIOLITE | VIAL | N | |||
| kit for Tc 99m/sestamibi no.1 | TC99M SESTAMIBI PREP | VIAL | N | |||
| kit for Tc-99m-labeled RBCs | ULTRATAG RBC | VIAL | N | |||
| kit for Tc-99m/bicisate di-HCl | NEUROLITE | VIAL | N | |||
| kit for Tc-99m/sod oxidronate | TECHNESCAN HDP | VIAL | N | |||
| kit for Tc-99m/sod pyrophospht | TECHNESCAN PYP | VIAL | N | |||
| kit prep of Ga-68/gozetotide | LOCAMETZ | VIAL | N | |||
| kit prep of Ga-68/gozetotide | ILLUCCIX | VIAL | N | |||
| kit prep Tc 99m/pentetic acid | TC99M PENTETATE PREP | VIAL | N | |||
| kit Tc-99m/mertiatide (betiat) | TECHNESCAN MAG3 | VIAL | N | |||
| pegulicianine acetate | LUMISIGHT | VIAL | N | |||
| perflutren lipid microspheres | DEFINITY | VIAL | N | |||
| perflutren protein-A microsphr | OPTISON | VIAL | N | |||
| piflufolastat F 18 | PYLARIFY | SYRINGE | N | |||
| piflufolastat F 18 | PYLARIFY | VIAL | N | |||
| regadenoson | LEXISCAN | SYRINGE | N | |||
| regadenoson | REGADENOSON | SYRINGE | N | |||
| regadenoson | REGADENOSON | VIAL | N | |||
| sodium iodide-123 | SODIUM IODIDE I-123 | CAPSULE | N | |||
| sodium pertechnetate Tc-99m | ULTRA-TECHNEKOW V4 | VIAL | N | |||
| sodium pertechnetate Tc-99m | TECHNELITE TC-99M GENERATOR | VIAL | N | |||
| thallous chloride Tl-201 | THALLOUS CHLORIDE TL-201 | VIAL | N | |||
| urinary tract infection test | REVEAL UTI TEST STRIP | STICK (EA) | N | |||
| xenon 133 in air | XENON XE-133 | GAS (EA) | N | |||
| xenon 133 in carbon dioxide | XENON XE-133 | GAS (EA) | N |