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 | |||
| 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-110 | POWDER | ||||
| barium sulfate | BAROSPERSE | POWDER | ||||
| copper Cu-64 dotatate | DETECTNET | VIAL | ||||
| diatrizoate meglumine, sodium | DIATRIZOATE MEGLUMINE-SODIUM | SOLUTION | ||||
| dipyridamole | PERSANTINE I.V. | AMPUL | ||||
| dipyridamole | DIPYRIDAMOLE | AMPUL | ||||
| dipyridamole | DIPYRIDAMOLE | VIAL | ||||
| ferumoxides | FERIDEX I.V. | VIAL | ||||
| ferumoxytol | FERABRIGHT | VIAL | ||||
| florbetaben F-18 | NEURACEQ | VIAL | ||||
| florbetapir F-18 | AMYVID | VIAL | ||||
| floretyrosine F-18 | PIXCLARA | 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 | GLOSTRIPS | STRIP | ||||
| fluorescein sodium | FLUOR-I-STRIP AT | STRIP | ||||
| fluorescein sodium | FLUORESCITE | VIAL | ||||
| fluorescein sodium | FLUORESCEIN SODIUM | VIAL | ||||
| fluorescein sodium | AK-FLUOR | VIAL | ||||
| fluoroestradiol F-18 | CERIANNA | VIAL | ||||
| flurpiridaz F-18 | FLYRCADO | VIAL | ||||
| flutemetamol F-18 | VIZAMYL | VIAL | ||||
| gadobutrol | GADAVIST | SYRINGE | ||||
| gadobutrol | PIXXOSCAN | VIAL | ||||
| gadobutrol | GADOBUTROL | VIAL | ||||
| gadobutrol | GADAVIST | VIAL | ||||
| gadodiamide | OMNISCAN | VIAL | ||||
| gadoquatrane | AMBELVIST | SYRINGE | ||||
| gadoquatrane | AMBELVIST | VIAL | ||||
| gadoterate meglumine | CLARISCAN | SYRINGE | ||||
| gadoterate meglumine | GADOTERATE MEGLUMINE | VIAL | ||||
| gadoterate meglumine | CLARISCAN | VIAL | ||||
| gadoteridol | GADOTERIDOL | VIAL | ||||
| gadoxetate disodium | EOVIST | VIAL | ||||
| gallium-67 citrate | GALLIUM CITRATE GA-67 | VIAL | ||||
| glucagon | GVOKE VIALDX | VIAL | ||||
| indigotindisulfonate sodium | BLUDIGO | AMPUL | ||||
| indium In-111 oxyquinoline | INDIUM IN-111 OXYQUINOLINE | VIAL | ||||
| indium-111 chlor/pentetreotide | OCTREOSCAN | KIT | ||||
| indium-111 chlor/pentetreotide | INDIUM IN-111 CL-PENTETREOTIDE | KIT | ||||
| indium-111 chloride | INDIUM IN-111 CHLORIDE | VIAL | ||||
| indocyanine green | ZYOGREEN | AMPUL | ||||
| indocyanine green | INDOCYANINE GREEN | VIAL | ||||
| iobenguane sulfate I-123 | ADREVIEW | VIAL | ||||
| iodixanol | IODIXANOL | INFUS. BTL | ||||
| iodixanol | VISIPAQUE | INFUS. BTL | ||||
| ioflupane I 123 | IOFLUPANE I-123 | VIAL | ||||
| ioflupane I 123 | DATSCAN | VIAL | ||||
| iohexol | OMNIPAQUE | INFUS. BTL | ||||
| iohexol | IOHEXOL | 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 | SYRINGE | ||||
| isosulfan blue | ISOSULFAN BLUE | VIAL | ||||
| kit for prep of Ga 68/dotatate | NETSPOT | VIAL | ||||
| kit for prep of Tc-99m/albumin | PULMOTECH MAA | VIAL | ||||
| kit for prep Tc-99m/mebrofenin | TC99M MEBROFENIN PREP | VIAL | ||||
| kit for prep Tc-99m/tetrofosmn | MYOVIEW | VIAL | ||||
| kit for Tc 99m/sestamibi no.1 | CARDIOLITE | SYRINGE | ||||
| kit for Tc 99m/sestamibi no.1 | TC99M SESTAMIBI PREP | VIAL | ||||
| kit for Tc 99m/sestamibi no.1 | CARDIOLITE | VIAL | ||||
| kit for Tc 99m/sod thiosulfate | TC 99M SULFUR COLLOID PREP | VIAL | ||||
| kit for Tc-99m-labeled RBCs | ULTRATAG RBC | VIAL | ||||
| kit for Tc-99m/bicisate di-HCl | NEUROLITE | VIAL | ||||
| kit for Tc-99m/medronate sod | TC99M MEDRONATE PREP | VIAL | ||||
| kit for Tc-99m/sod oxidronate | TECHNESCAN HDP | VIAL | ||||
| kit for Tc-99m/sod pyrophospht | TECHNESCAN PYP | VIAL | ||||
| kit for Tc-99m/sod pyrophospht | TC99M PYROPHOSPHATE PREP | VIAL | ||||
| kit prep of Ga-68/gozetotide | LOCAMETZ | VIAL | ||||
| kit prep of Ga-68/gozetotide | ILLUCCIX | VIAL | ||||
| kit prep of Ga-68/gozetotide | GOZELLIX | VIAL | ||||
| kit prep Tc 99m/pentetic acid | TC99M PENTETATE PREP | VIAL | ||||
| kit prep Tc-99m/exametazime | CERETEC | VIAL | ||||
| kit Tc-99m/mertiatide (betiat) | TECHNESCAN MAG3 | VIAL | ||||
| kit Tc-99m/mertiatide (betiat) | TC99M MERTIATIDE PREP | VIAL | ||||
| mannitol | ARIDOL | CAP W/DEV | ||||
| methacholine chloride | PROVOCHOLINE | VIAL-NEB | ||||
| pegulicianine acetate | LUMISIGHT | VIAL | ||||
| pentetate indium disod. In-111 | INDIUM IN-111 DTPA | VIAL | ||||
| perflutren lipid microspheres | DEFINITY | VIAL | ||||
| perflutren protein-A microsphr | OPTISON | VIAL | ||||
| piflufolastat F 18 | PYLARIFY | SYRINGE | ||||
| piflufolastat F 18 | PYLARIFY | VIAL | ||||
| regadenoson | REGADENOSON | SYRINGE | ||||
| regadenoson | LEXISCAN | SYRINGE | ||||
| regadenoson | REGADENOSON | VIAL | ||||
| sodium iodide-123 | SODIUM IODIDE I-123 | CAPSULE | ||||
| sodium pertechnetate Tc-99m | ULTRA-TECHNEKOW V4 | VIAL | ||||
| sodium pertechnetate Tc-99m | TECHNELITE TC-99M GENERATOR | VIAL | ||||
| thallous chloride Tl-201 | THALLOUS CHLORIDE TL-201 | VIAL | ||||
| urinary tract infection test | REVEAL UTI TEST STRIP | STICK (EA) | ||||
| xenon 133 in air | XENON XE-133 | GAS (EA) | ||||
| xenon 133 in carbon dioxide | XENON XE-133 | GAS (EA) |