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 | New Drug Evaluation |
---|---|---|---|---|---|
glucagon | GLUCAGEN | VIAL | Y | ||
adenosine | ADENOSINE | VIAL | |||
aminolevulinic acid HCl | GLEOLAN | SOLN RECON | |||
barium sulfate | EPI-STAT-61 | ORAL SUSP | |||
barium sulfate | EPI-STAT-57 | ORAL SUSP | |||
barium sulfate | BAROSPERSE | POWDER | |||
barium sulfate | BAROSPERSE-110 | POWDER | |||
diatrizoate meglumine, sodium | DIATRIZOATE MEGLUMINE-SODIUM | SOLUTION | |||
dipyridamole | DIPYRIDAMOLE | AMPUL | |||
dipyridamole | PERSANTINE I.V. | AMPUL | |||
dipyridamole | DIPYRIDAMOLE | VIAL | |||
ferumoxides | FERIDEX I.V. | VIAL | |||
florbetapir F-18 | AMYVID | VIAL | |||
flortaucipir F-18 | TAUVID | VIAL | |||
flortaucipir F-18 | TAUVID PATIENT READY DOSE | VIAL | |||
flotufolastat F 18 gallium | POSLUMA | VIAL | |||
fluciclovine F 18 | AXUMIN | VIAL | |||
fluorescein sodium | FLUORESCEIN SODIUM | DROPS | |||
fluorescein sodium | FLUOR-I-STRIP AT | STRIP | |||
fluorescein sodium | GLOSTRIPS | STRIP | |||
fluorescein sodium | AK-FLUOR | VIAL | |||
fluorescein sodium | FLUORESCITE | VIAL | |||
fluorescein sodium | FLUORESCEIN SODIUM | VIAL | |||
gadobutrol | GADAVIST | SYRINGE | |||
gadobutrol | GADOBUTROL | VIAL | |||
gadobutrol | GADAVIST | VIAL | |||
gadodiamide | OMNISCAN | SYRINGE | |||
gadodiamide | OMNISCAN | VIAL | |||
gadoterate meglumine | CLARISCAN | SYRINGE | |||
gadoterate meglumine | GADOTERATE MEGLUMINE | VIAL | |||
gadoterate meglumine | CLARISCAN | VIAL | |||
gadoxetate disodium | EOVIST | VIAL | |||
indigotindisulfonate sodium | BLUDIGO | AMPUL | |||
iodixanol | VISIPAQUE | INFUS. BTL | |||
iodixanol | IODIXANOL | INFUS. BTL | |||
iohexol | OMNIPAQUE | INFUS. BTL | |||
iohexol | OMNIPAQUE | PLAST. BAG | |||
iohexol | OMNIPAQUE | SOLUTION | |||
iohexol | OMNIPAQUE | VIAL | |||
iopamidol | IOPAMIDOL | INFUS. BTL | |||
iopamidol | IOPAMIDOL | VIAL | |||
iopromide | ULTRAVIST | VIAL | |||
isosulfan blue | ISOSULFAN BLUE | VIAL | |||
kit for prep of Ga 68/dotatate | NETSPOT | VIAL | |||
kit for Tc 99m/sestamibi no.1 | CARDIOLITE | SYRINGE | |||
kit for Tc 99m/sestamibi no.1 | CARDIOLITE | VIAL | |||
kit for Tc 99m/sestamibi no.1 | TC99M SESTAMIBI PREP | VIAL | |||
kit for Tc-99m/bicisate di-HCl | NEUROLITE | VIAL | |||
kit prep of Ga-68/gozetotide | ILLUCCIX | VIAL | |||
kit prep of Ga-68/gozetotide | LOCAMETZ | VIAL | |||
perflutren lipid microspheres | DEFINITY | VIAL | |||
perflutren lipid microspheres | DEFINITY RT | VIAL | |||
perflutren protein-A microsphr | OPTISON | VIAL | |||
piflufolastat F 18 | PYLARIFY | SYRINGE | |||
piflufolastat F 18 | PYLARIFY | VIAL | |||
regadenoson | LEXISCAN | SYRINGE | |||
regadenoson | REGADENOSON | SYRINGE | |||
regadenoson | REGADENOSON | VIAL | |||
sodium pertechnetate Tc-99m | TECHNELITE TC-99M GENERATOR | VIAL | |||
urinary tract infection test | REVEAL UTI TEST STRIP | STICK (EA) | |||
xenon 133 in carbon dioxide | XENON XE-133 | GAS (EA) |