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 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
Current Drug Use Criteria New Drug Evaluation
diclofenac/capsicum oleoresin INFLAMMACIN KIT N    
auranofin RIDAURA CAPSULE    
gluc su/chondro su A/vit C/Mn GLUCOSAMINE-CHONDROITIN CAPSULE    
glucosa su 2KCl/chondroitin su GLUCOSAMINE CHONDROITIN TABLET    
glucosam-chondro-herb 149-hyal GLUCOSAMINE-CHONDROITIN TABLET    
glucosam/chon-msm1/C/mang/bosw GLUCOSAMINE-CHONDROITIN TABLET    
glucosam/chon-msm1/C/mang/bosw GLUCOSAMINE-CHONDROITIN-MSM TABLET    
glucosam/chond-msm1/C/mang/bor GLUCOSAMINE-CHONDROITIN-MSM TABLET    
glucosam/msm/C/man/willow/ging MSM GLUCOSAMINE COMPLEX TABLET    
glucosam/msm/chond/hrb149/hyal GLUCOSAMINE-CHONDROITIN-MSM TABLET    
glucosam/msm/vit C/mang/herb21 GLUCOSAMINE-MSM COMPLEX TABLET    
glucosamin,chondroit-mvit-min3 GLUCOTEN TABLET    
glucosamine HCl and sulfate GLUCOSAMINE COMPLEX TABLET    
glucosamine HCl/chondroitin su GLUCOSAMINE-CHONDROITIN CAPSULE    
glucosamine sulfate GLUCOSAMINE SULFATE CAPSULE    
glucosamine sulfate GLUCOSAMINE SULFATE TABLET    
glucosamine sulfate GLUCOSAMINE TABLET    
glucosamine sulfate dipot chlr GLUCOSAMINE SULFATE TABLET    
glucosamine/chondr su A sod GLUCOSAMINE-CHONDROITIN TABLET    
glucosamine/chondro su A GLUCOSAMINE-CHONDROITIN TABLET    
glucosamine/chondroitin A/msm GLUCOSAMINE-CHONDROITIN-MSM CAPSULE    
glucosamine/methylsulfonylmeth GLUCOSAMINE-MSM CAPSULE    
glucosamine/methylsulfonylmeth GLUCOSAMINE TABLET    
glucosamine/msm/chondroitin A GLUCOSAMINE-CHONDROITIN-MSM TABLET    
hyaluronate sodium ORTHOVISC SYRINGE    
hyaluronate sodium EUFLEXXA SYRINGE    
hyaluronate sodium, stabilized MONOVISC SYRINGE    
hylan G-F 20 SYNVISC SYRINGE    
ibuprofen CALDOLOR VIAL    
indomethacin INDOCIN SUPP.RECT    
leflunomide ARAVA TABLET    
leflunomide LEFLUNOMIDE TABLET    
methotrexate sodium METHOTREXATE TAB DS PK    
methotrexate/PF OTREXUP AUTO INJCT    
methotrexate/PF RASUVO AUTO INJCT    
penicillamine CUPRIMINE CAPSULE    
penicillamine DEPEN TABLET    
penicillamine D-PENAMINE TABLET