Other Rheumatologic Agents

← Back to Class List

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
ibuprofen/acetaminophen DUAL ACTION PAIN RELIEVER TABLET N    
ibuprofen/acetaminophen DUAL ACTION PAIN RELIEF TABLET N    
ibuprofen/acetaminophen ACETAMINOPHEN-IBUPROFEN TABLET N    
auranofin AURANOFIN CAPSULE    
auranofin RIDAURA CAPSULE    
glucosa su 2KCl/chondroitin su GLUCOSAMINE-CHONDROITIN TABLET    
glucosam/chon-msm1/C/mang/bosw GLUCOSAMINE-CHONDROITIN TABLET    
glucosamine HCl and sulfate GLUCOSAMINE COMPLEX TABLET    
glucosamine sulfate GLUCOSAMINE SULFATE CAPSULE    
glucosamine sulfate CIDATRINE TABLET    
glucosamine/chondr su A sod CIDAFLEX TABLET    
glucosamine/chondroitin/C/Mang GLUCOSAMINE-CHONDROITIN CAPSULE    
hyaluronate sodium EUFLEXXA SYRINGE    
ibuprofen CALDOLOR PIGGYBACK    
ibuprofen CALDOLOR VIAL    
ibuprofen sodium/acetaminophen COMBOGESIC IV VIAL    
indomethacin INDOMETHACIN SUPP.RECT    
leflunomide ARAVA TABLET    
leflunomide LEFLUNOMIDE TABLET    
methotrexate sodium METHOTREXATE TAB DS PK    
methotrexate/PF OTREXUP AUTO INJCT    
methotrexate/PF RASUVO AUTO INJCT    
naproxen/capsicum oleoresin NAPROTIN KIT    
penicillamine CUPRIMINE CAPSULE    
penicillamine PENICILLAMINE CAPSULE    
penicillamine PENICILLAMINE TABLET    
penicillamine DEPEN TABLET    
Back to Top ↑