Opioids, Parenteral
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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 & Updates |
---|---|---|---|---|---|
alfentanil HCl | ALFENTANIL HYDROCHLORIDE | AMPUL | |||
buprenorphine HCl | BUPRENORPHINE HCL | CARTRIDGE | |||
buprenorphine HCl | BUPRENORPHINE HCL | VIAL | |||
butorphanol tartrate | BUTORPHANOL TARTRATE | VIAL | |||
codeine phosphate | CODEINE PHOSPHATE | SYRINGE | |||
fentanyl citrate/PF | FENTANYL CITRATE | AMPUL | |||
fentanyl citrate/PF | FENTANYL CITRATE | SYRINGE | |||
fentanyl citrate/PF | FENTANYL CITRATE | VIAL | |||
hydromorphone HCl | HYDROMORPHONE HCL | AMPUL | |||
hydromorphone HCl | HYDROMORPHONE HCL | CARTRIDGE | |||
hydromorphone HCl | HYDROMORPHONE HCL | SYRINGE | |||
hydromorphone HCl | HYDROMORPHONE HCL | VIAL | |||
hydromorphone HCl/PF | DILAUDID | SYRINGE | |||
hydromorphone HCl/PF | HYDROMORPHONE HCL | SYRINGE | |||
hydromorphone HCl/PF | HYDROMORPHONE HCL | VIAL | |||
meperidine HCl | DEMEROL | AMPUL | |||
meperidine HCl | DEMEROL | VIAL | |||
meperidine HCl/PF | DEMEROL | AMPUL | |||
meperidine HCl/PF | DEMEROL | CARTRIDGE | |||
meperidine HCl/PF | DEMEROL | SYRINGE | |||
meperidine HCl/PF | MEPERIDINE HCL | VIAL | |||
methadone HCl | METHADONE HCL | VIAL | |||
morphine sulfate | MORPHINE SULFATE | CARTRIDGE | |||
morphine sulfate | MORPHINE SULFATE | SYRINGE | |||
morphine sulfate | MORPHINE SULFATE | VIAL | |||
morphine sulfate/PF | DURAMORPH | AMPUL | |||
morphine sulfate/PF | INFUMORPH | AMPUL | |||
morphine sulfate/PF | MORPHINE SULFATE | PCA VIAL | |||
morphine sulfate/PF | MITIGO | VIAL | |||
morphine sulfate/PF | MORPHINE SULFATE | VIAL | |||
nalbuphine HCl | NALBUPHINE HCL | AMPUL | |||
nalbuphine HCl | NALBUPHINE HCL | VIAL | |||
oliceridine fumarate | OLINVYK | PCA VIAL | |||
oliceridine fumarate | OLINVYK | VIAL | |||
pentazocine lactate | TALWIN | AMPUL | |||
remifentanil HCl | REMIFENTANIL HCL | VIAL | |||
remifentanil HCl | ULTIVA | VIAL | |||
sufentanil citrate | SUFENTANIL CITRATE | VIAL |