Glucocorticoids, Other

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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
triamcinolone/lidocaine/priloc DERMACINRX CINLONE-I CPI KIT SS-CRM N    
betamethasone acetate,sod phos CELESTONE VIAL    
betamethasone acetate,sod phos BETAMETHASONE SOD PHOS-ACETATE VIAL    
dexamethasone sodium phosp/PF DEXAMETHASONE SODIUM PHOSPHATE VIAL    
dexamethasone sodium phosphate DEXAMETHASONE SODIUM PHOSPHATE SYRINGE    
dexamethasone sodium phosphate DEXAMETHASONE SODIUM PHOSPHATE VIAL    
hydrocortisone CORTENEMA ENEMA    
hydrocortisone HYDROCORTISONE ENEMA    
hydrocortisone COLOCORT ENEMA    
hydrocortisone acetate CORTIFOAM FOAM/APPL    
hydrocortisone sod succinate A-HYDROCORT VIAL    
hydrocortisone sod succinate SOLU-CORTEF VIAL    
hydrocortisone sodium succ/PF SOLU-CORTEF VIAL    
methylprednisolone acetate DEPO-MEDROL VIAL    
methylprednisolone acetate METHYLPREDNISOLONE ACETATE VIAL    
methylprednisolone sod succ METHYLPREDNISOLONE SODIUM SUCC VIAL    
methylprednisolone sod succ SOLU-MEDROL VIAL    
methylprednisolone sod succ/PF SOLU-MEDROL VIAL    
triamcinolone acetonide ZILRETTA SUSER VIAL    
triamcinolone acetonide KENALOG-10 VIAL    
triamcinolone acetonide TRIAMCINOLONE ACETONIDE VIAL    
triamcinolone acetonide KENALOG-40 VIAL