Other Rheumatologic Agents

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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
ibuprofen/acetaminophen ACETAMINOPHEN-IBUPROFEN TABLET N    
ibuprofen/acetaminophen DUAL ACTION PAIN RELIEVER TABLET N    
auranofin RIDAURA CAPSULE    
glucosa su 2KCl/chondroitin su GLUCOSAMINE-CHONDROITIN TABLET    
glucosam/chon-msm1/C/mang/bosw GLUCOSAMINE-CHONDROITIN TABLET    
glucosam/chond-msm1/C/mang/bor GLUCOSAMINE-CHONDROITIN-MSM TABLET    
glucosam/msm/chond/hrb149/hyal GLUCOSAMINE-CHONDROITIN-MSM TABLET    
glucosamine HCl and sulfate GLUCOSAMINE COMPLEX TABLET    
glucosamine sulfate GLUCOSAMINE SULFATE CAPSULE    
glucosamine/chondroitin/C/Mang GLUCOSAMINE-CHONDROITIN CAPSULE    
ibuprofen CALDOLOR PIGGYBACK    
ibuprofen CALDOLOR VIAL    
ibuprofen sodium/acetaminophen COMBOGESIC IV VIAL    
ibuprofen/acetaminophen DUAL ACTION PAIN RELIEF TABLET    
indomethacin INDOMETHACIN SUPP.RECT    
leflunomide LEFLUNOMIDE TABLET    
leflunomide ARAVA TABLET    
methotrexate sodium METHOTREXATE TAB DS PK    
methotrexate/PF OTREXUP AUTO INJCT    
methotrexate/PF RASUVO AUTO INJCT    
naproxen/capsicum oleoresin NAPROTIN KIT    
penicillamine PENICILLAMINE CAPSULE    
penicillamine CUPRIMINE CAPSULE    
penicillamine DEPEN TABLET    
penicillamine PENICILLAMINE TABLET