Diabetes, Emergency Therapy
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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 Status |
Current Drug Use Criteria | New Drug Evaluation |
|---|---|---|---|---|---|
| bromocriptine mesylate | CYCLOSET | TABLET | |||
| dextrose | GLUCOSE | TAB CHEW | |||
| dextrose/dextrin/maltose | INSTA-GLUCOSE | GEL (GRAM) | |||
| diazoxide | DIAZOXIDE | ORAL SUSP | |||
| diazoxide | PROGLYCEM | ORAL SUSP | |||
| mifepristone | MIFEPRISTONE | TABLET | |||
| mifepristone | KORLYM | TABLET |