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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
Current Drug Use Criteria New Drug Evaluation
acetylcysteine ACETYLCYSTEINE VIAL    
acetylcysteine ACETADOTE VIAL    
activated charcoal ACTIDOSE-AQUA ORAL SUSP    
activated charcoal INSTA-CHAR ORAL SUSP    
activated charcoal EZ CHAR SUSP RECON    
antivenin,Latrodectus mactans ANTIVENIN LATRODECTUS MACTANS VIAL    
antivenin,Micrurus fulvius ANTIVENIN MICRURUS FULVIUS VIAL    
charcoal/sorbitol solution ACTIDOSE ORAL SUSP    
charcoal/sorbitol solution INSTA-CHAR ORAL SUSP    
dexrazoxane HCl DEXRAZOXANE VIAL    
edetate calcium disodium EDETATE CALCIUM DISODIUM VIAL    
fomepizole FOMEPIZOLE VIAL    
leucovorin calcium LEUCOVORIN CALCIUM TABLET    
leucovorin calcium LEUCOVORIN CALCIUM VIAL    
levoleucovorin KHAPZORY VIAL    
levoleucovorin calcium LEVOLEUCOVORIN CALCIUM VIAL    
mesna MESNA VIAL    
mesna MESNEX VIAL    
methylene blue PROVAYBLUE AMPUL    
methylene blue METHYLENE BLUE VIAL    
methylene blue PROVAYBLUE VIAL    
pralidoxime chloride PROTOPAM CHLORIDE VIAL    
succimer CHEMET CAPSULE    
trientine tetrahydrochloride CUVRIOR TABLET    
trilaciclib dihydrochloride COSELA VIAL    
zinc acetate WILZIN CAPSULE    
zinc acetate GALZIN CAPSULE