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 but eligible patients will encounter a co-pay at the pharmacy.
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
adenosine ADENOSINE VIAL    
barium sulfate EPI-STAT-61 ORAL SUSP    
barium sulfate EPI-STAT-57 ORAL SUSP    
barium sulfate BAROSPERSE POWDER    
barium sulfate BAROSPERSE-110 POWDER    
dipyridamole DIPYRIDAMOLE AMPUL    
dipyridamole PERSANTINE I.V. AMPUL    
dipyridamole DIPYRIDAMOLE VIAL    
ferumoxides FERIDEX I.V. VIAL    
florbetapir F-18 AMYVID VIAL    
fluciclovine F 18 AXUMIN VIAL    
fluorescein sodium FLUORESCEIN SODIUM DROPS    
fluorescein sodium D.E.T. DRY EYE TEST STRIP    
fluorescein sodium FLUOR-I-STRIP AT STRIP    
fluorescein sodium GLOSTRIPS STRIP    
fluorescein sodium FUL-GLO STRIP    
fluorescein sodium AK-FLUOR VIAL    
fluorescein sodium FLUORESCITE VIAL    
gadobutrol GADAVIST SYRINGE    
gadobutrol GADAVIST VIAL    
gadodiamide OMNISCAN SYRINGE    
gadodiamide OMNISCAN VIAL    
gadodiamide in 0.9 % NaCl OMNISCAN PREFILL PLUS SYRINGE    
gadopentetate dimeglumine MAGNEVIST SYRINGE    
gadopentetate dimeglumine MAGNEVIST VIAL    
gadoxetate disodium EOVIST VIAL    
glucagon HCl GLUCAGON HCL VIAL    
glucagon,human recombinant GLUCAGEN VIAL    
hexaminolevulinate HCl CYSVIEW VIAL    
indigotindisulfonate sodium INDIGO CARMINE AMPUL    
indocyanine green IC GREEN VIAL    
iodixanol VISIPAQUE INFUS. BTL    
iohexol OMNIPAQUE INFUS. BTL    
iohexol OMNIPAQUE PLAST. BAG    
iohexol OMNIPAQUE SOLUTION    
iohexol OMNIPAQUE VIAL    
iopamidol IOPAMIDOL INFUS. BTL    
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 VIAL    
kit for Tc-99m/bicisate di-HCl NEUROLITE VIAL    
kit In-111/capromab pendetide PROSTASCINT VIAL    
lidocaine HCl/glycerin PRO DNA MEDICATED COLLECTION KIT    
ovulation test kit OVULATION PREDICTOR KIT    
ovulation test kit REVEAL OVULATION PREDICTOR KIT    
perflutren lipid microspheres DEFINITY VIAL    
perflutren protein-A microsphr OPTISON VIAL    
pregnancy test kit ONE STEP PREGNANCY TEST KIT    
pregnancy test kit PREGNANCY TEST KIT    
pregnancy test kit REVEAL PREGNANCY TEST KIT    
regadenoson LEXISCAN SYRINGE    
thallous chloride Tl-201 THALLOUS CHLORIDE TL-201 VIAL    
urinary tract infection test REVEAL UTI TEST STRIP STICK (EA)    
urine phenaphthazine-pH test NITRATEST PAPER EACH