Diagnostics

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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
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)