Glucocorticoids, Other
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| betamethasone acetate,sod phos | CELESTONE | VIAL | N | |||
| betamethasone acetate,sod phos | BETAMETHASONE SOD PHOS-ACETATE | VIAL | N | |||
| dexamethasone sodium phosp/PF | DEXAMETHASONE SODIUM PHOSPHATE | SYRINGE | N | |||
| dexamethasone sodium phosphate | DEXAMETHASONE SODIUM PHOSPHATE | SYRINGE | N | |||
| hydrocortisone | HYDROCORTISONE | ENEMA | N | |||
| hydrocortisone | CORTENEMA | ENEMA | N | |||
| hydrocortisone sod succinate | SOLU-CORTEF | VIAL | N | |||
| hydrocortisone sod succinate | HYDROCORTISONE SOD SUCCINATE | VIAL | N | |||
| methylprednisolone sod succ | METHYLPREDNISOLONE SODIUM SUCC | VIAL | N | |||
| methylprednisolone sod succ/PF | SOLU-MEDROL | VIAL | N | |||
| triamcinolone acetonide | TRIAMCINOLONE ACETONIDE | VIAL | N | |||
| triamcinolone acetonide | KENALOG-40 | VIAL | N | |||
| triamcinolone hexacetonide | HEXATRIONE | AMPUL | N |