Contraceptives, Systemic

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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
desog-e.estradiol/e.estradiol VIORELE TABLET    
desog-e.estradiol/e.estradiol SIMLIYA TABLET    
desog-e.estradiol/e.estradiol PIMTREA TABLET    
desog-e.estradiol/e.estradiol MIRCETTE TABLET    
desog-e.estradiol/e.estradiol KARIVA TABLET    
desog-e.estradiol/e.estradiol DESOGESTR-ETH ESTRAD ETH ESTRA TABLET    
desog-e.estradiol/e.estradiol BEKYREE TABLET    
desog-e.estradiol/e.estradiol AZURETTE TABLET    
desogestrel-ethinyl estradiol ISIBLOOM TABLET    
desogestrel-ethinyl estradiol ENSKYCE TABLET    
desogestrel-ethinyl estradiol EMOQUETTE TABLET    
desogestrel-ethinyl estradiol DESOGESTREL-ETHINYL ESTRADIOL TABLET    
desogestrel-ethinyl estradiol CYRED EQ TABLET    
desogestrel-ethinyl estradiol CYRED TABLET    
desogestrel-ethinyl estradiol CYCLESSA TABLET    
desogestrel-ethinyl estradiol APRI TABLET    
desogestrel-ethinyl estradiol VELIVET TABLET    
desogestrel-ethinyl estradiol CAZIANT TABLET    
desogestrel-ethinyl estradiol JULEBER TABLET    
desogestrel-ethinyl estradiol RECLIPSEN TABLET    
drospir/eth estra/levomefol Ca TYDEMY TABLET    
drospir/eth estra/levomefol Ca SAFYRAL TABLET    
drospir/eth estra/levomefol Ca RAJANI TABLET    
drospir/eth estra/levomefol Ca DROSPIRENONE-ETH ESTRA-LEVOMEF TABLET    
drospir/eth estra/levomefol Ca BEYAZ TABLET    
estradiol valerate/dienogest NATAZIA TABLET    
ethinyl estradiol/drospirenone GIANVI TABLET    
ethinyl estradiol/drospirenone ZARAH TABLET    
ethinyl estradiol/drospirenone YAZ TABLET    
ethinyl estradiol/drospirenone YASMIN 28 TABLET    
ethinyl estradiol/drospirenone OCELLA TABLET    
ethinyl estradiol/drospirenone LO-ZUMANDIMINE TABLET    
ethinyl estradiol/drospirenone JASMIEL TABLET    
ethinyl estradiol/drospirenone DROSPIRENONE-ETHINYL ESTRADIOL TABLET    
ethinyl estradiol/drospirenone SYEDA TABLET    
ethinyl estradiol/drospirenone LORYNA TABLET    
ethinyl estradiol/drospirenone NIKKI TABLET    
ethynodiol d-ethinyl estradiol ETHYNODIOL-ETHINYL ESTRADIOL TABLET    
ethynodiol d-ethinyl estradiol ZOVIA 1-35E TABLET    
ethynodiol d-ethinyl estradiol KELNOR 1-50 TABLET    
ethynodiol d-ethinyl estradiol DEMULEN 1-50-21 TABLET    
ethynodiol d-ethinyl estradiol KELNOR 1-35 TABLET    
etonogestrel NEXPLANON IMPLANT    
etonogestrel/ethinyl estradiol NUVARING VAG RING    
L-norgest/e.estradiol-e.estrad LOSEASONIQUE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad SEASONIQUE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad QUARTETTE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad LEVONORG-ETH ESTRAD ETH ESTRAD TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad FAYOSIM TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad DAYSEE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad CAMRESE LO TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad RIVELSA TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad CAMRESE TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad AMETHIA TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad AMETHIA LO TBDSPK 3MO    
L-norgest/e.estradiol-e.estrad ASHLYNA TBDSPK 3MO    
levonorgest/eth.estradiol/iron BALCOLTRA TABLET    
levonorgestrel NORPLANT KIT    
levonorgestrel ECONTRA EZ TABLET    
levonorgestrel OPTION 2 TABLET    
levonorgestrel OPCICON ONE-STEP TABLET    
levonorgestrel NEW DAY TABLET    
levonorgestrel MY WAY TABLET    
levonorgestrel MY CHOICE TABLET    
levonorgestrel LEVONORGESTREL TABLET    
levonorgestrel ECONTRA ONE-STEP TABLET    
levonorgestrel AFTERA TABLET    
levonorgestrel FALLBACK SOLO TABLET    
levonorgestrel PLAN B ONE-STEP TABLET    
levonorgestrel TAKE ACTION TABLET    
levonorgestrel-ethin estradiol MYZILRA TABLET    
levonorgestrel-ethin estradiol ALTAVERA TABLET    
levonorgestrel-ethin estradiol LEVORA-28 TABLET    
levonorgestrel-ethin estradiol FALMINA TABLET    
levonorgestrel-ethin estradiol LEVONORGESTREL-ETH ESTRADIOL TABLET    
levonorgestrel-ethin estradiol LEVONEST TABLET    
levonorgestrel-ethin estradiol LEVLEN 28 TABLET    
levonorgestrel-ethin estradiol LESSINA TABLET    
levonorgestrel-ethin estradiol LARISSIA TABLET    
levonorgestrel-ethin estradiol KURVELO TABLET    
levonorgestrel-ethin estradiol ENPRESSE TABLET    
levonorgestrel-ethin estradiol CHATEAL EQ TABLET    
levonorgestrel-ethin estradiol CHATEAL TABLET    
levonorgestrel-ethin estradiol AVIANE TABLET    
levonorgestrel-ethin estradiol AUBRA EQ TABLET    
levonorgestrel-ethin estradiol AUBRA TABLET    
levonorgestrel-ethin estradiol AMETHYST TABLET    
levonorgestrel-ethin estradiol PORTIA TABLET    
levonorgestrel-ethin estradiol LILLOW TABLET    
levonorgestrel-ethin estradiol LUTERA TABLET    
levonorgestrel-ethin estradiol MARLISSA TABLET    
levonorgestrel-ethin estradiol SRONYX TABLET    
levonorgestrel-ethin estradiol TRIVORA-28 TABLET    
levonorgestrel-ethin estradiol VIENVA TABLET    
levonorgestrel-ethin estradiol ORSYTHIA TABLET    
levonorgestrel-ethin estradiol LEVONORGESTREL-ETH ESTRADIOL TBDSPK 3MO    
levonorgestrel-ethin estradiol INTROVALE TBDSPK 3MO    
levonorgestrel-ethin estradiol JOLESSA TBDSPK 3MO    
levonorgestrel-ethin estradiol SETLAKIN TBDSPK 3MO    
levonorgestrel-ethin estradiol QUASENSE TBDSPK 3MO    
medroxyprogesterone acetate MEDROXYPROGESTERONE ACETATE SYRINGE    
medroxyprogesterone acetate DEPO-SUBQ PROVERA 104 SYRINGE    
medroxyprogesterone acetate DEPO-PROVERA SYRINGE    
medroxyprogesterone acetate MEDROXYPROGESTERONE ACETATE VIAL    
medroxyprogesterone acetate DEPO-PROVERA VIAL    
norelgestromin/ethin.estradiol XULANE PATCH TDWK    
noreth-ethinyl estradiol/iron KAITLIB FE TAB CHEW    
noreth-ethinyl estradiol/iron LAYOLIS FE TAB CHEW    
noreth-ethinyl estradiol/iron NORETHIN-ETH ESTRA-FERROUS FUM TAB CHEW    
noreth-ethinyl estradiol/iron WYMZYA FE TAB CHEW    
noreth-ethinyl estradiol/iron GENERESS FE TAB CHEW    
norethindrone TULANA TABLET    
norethindrone LYZA TABLET    
norethindrone CAMILA TABLET    
norethindrone DEBLITANE TABLET    
norethindrone ERRIN TABLET    
norethindrone HEATHER TABLET    
norethindrone INCASSIA TABLET    
norethindrone JOLIVETTE TABLET    
norethindrone NORA-BE TABLET    
norethindrone NORETHINDRONE TABLET    
norethindrone NORLYDA TABLET    
norethindrone ORTHO MICRONOR TABLET    
norethindrone SHAROBEL TABLET    
norethindrone JENCYCLA TABLET    
norethindrone ac-eth estradiol MICROGESTIN TABLET    
norethindrone ac-eth estradiol LOESTRIN TABLET    
norethindrone ac-eth estradiol NORETHINDRON-ETHINYL ESTRADIOL TABLET    
norethindrone ac-eth estradiol LARIN TABLET    
norethindrone ac-eth estradiol AUROVELA TABLET    
norethindrone ac-eth estradiol JUNEL TABLET    
norethindrone ac-eth estradiol GILDESS TABLET    
norethindrone-e.estradiol-iron TAYTULLA CAPSULE    
norethindrone-e.estradiol-iron MELODETTA 24 FE TAB CHEW    
norethindrone-e.estradiol-iron MIBELAS 24 FE TAB CHEW    
norethindrone-e.estradiol-iron MINASTRIN 24 FE TAB CHEW    
norethindrone-e.estradiol-iron NORETHIN-ETH ESTRA-FERROUS FUM TAB CHEW    
norethindrone-e.estradiol-iron GILDESS FE TABLET    
norethindrone-e.estradiol-iron GILDESS 24 FE TABLET    
norethindrone-e.estradiol-iron ESTROSTEP FE TABLET    
norethindrone-e.estradiol-iron BLISOVI FE TABLET    
norethindrone-e.estradiol-iron BLISOVI 24 FE TABLET    
norethindrone-e.estradiol-iron AUROVELA FE TABLET    
norethindrone-e.estradiol-iron AUROVELA 24 FE TABLET    
norethindrone-e.estradiol-iron HAILEY 24 FE TABLET    
norethindrone-e.estradiol-iron LO LOESTRIN FE TABLET    
norethindrone-e.estradiol-iron JUNEL FE TABLET    
norethindrone-e.estradiol-iron JUNEL FE 24 TABLET    
norethindrone-e.estradiol-iron LARIN FE TABLET    
norethindrone-e.estradiol-iron LOESTRIN FE TABLET    
norethindrone-e.estradiol-iron LOMEDIA 24 FE TABLET    
norethindrone-e.estradiol-iron MICROGESTIN FE TABLET    
norethindrone-e.estradiol-iron NORETHIN-ETH ESTRA-FERROUS FUM TABLET    
norethindrone-e.estradiol-iron LARIN 24 FE TABLET    
norethindrone-e.estradiol-iron TARINA 24 FE TABLET    
norethindrone-e.estradiol-iron TARINA FE 1-20 EQ TABLET    
norethindrone-e.estradiol-iron TILIA FE TABLET    
norethindrone-e.estradiol-iron TRI-LEGEST FE TABLET    
norethindrone-e.estradiol-iron TARINA FE TABLET    
norethindrone-ethinyl estrad NECON TABLET    
norethindrone-ethinyl estrad ALYACEN TABLET    
norethindrone-ethinyl estrad ARANELLE TABLET    
norethindrone-ethinyl estrad BALZIVA TABLET    
norethindrone-ethinyl estrad BRIELLYN TABLET    
norethindrone-ethinyl estrad CYCLAFEM TABLET    
norethindrone-ethinyl estrad DASETTA TABLET    
norethindrone-ethinyl estrad LEENA TABLET    
norethindrone-ethinyl estrad NORINYL 1-35 TABLET    
norethindrone-ethinyl estrad NORTREL TABLET    
norethindrone-ethinyl estrad ORTHO-NOVUM TABLET    
norethindrone-ethinyl estrad PHILITH TABLET    
norethindrone-ethinyl estrad PIRMELLA TABLET    
norethindrone-ethinyl estrad VYFEMLA TABLET    
norethindrone-ethinyl estrad WERA TABLET    
norethindrone-ethinyl estrad ZENCHENT TABLET    
norethindrone-ethinyl estrad GILDAGIA TABLET    
norgestimate-ethinyl estradiol TRI FEMYNOR TABLET    
norgestimate-ethinyl estradiol TRINESSA TABLET    
norgestimate-ethinyl estradiol PREVIFEM TABLET    
norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN TABLET    
norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO TABLET    
norgestimate-ethinyl estradiol ORTHO-CYCLEN TABLET    
norgestimate-ethinyl estradiol SPRINTEC TABLET    
norgestimate-ethinyl estradiol TRI-ESTARYLLA TABLET    
norgestimate-ethinyl estradiol TRI-LINYAH TABLET    
norgestimate-ethinyl estradiol TRI-LO-ESTARYLLA TABLET    
norgestimate-ethinyl estradiol TRI-LO-MARZIA TABLET    
norgestimate-ethinyl estradiol TRI-LO-MILI TABLET    
norgestimate-ethinyl estradiol MONONESSA TABLET    
norgestimate-ethinyl estradiol TRI-MILI TABLET    
norgestimate-ethinyl estradiol MONO-LINYAH TABLET    
norgestimate-ethinyl estradiol TRINESSA LO TABLET    
norgestimate-ethinyl estradiol TRI-PREVIFEM TABLET    
norgestimate-ethinyl estradiol TRI-SPRINTEC TABLET    
norgestimate-ethinyl estradiol TRI-VYLIBRA TABLET    
norgestimate-ethinyl estradiol TRI-VYLIBRA LO TABLET    
norgestimate-ethinyl estradiol VYLIBRA TABLET    
norgestimate-ethinyl estradiol TRI-LO-SPRINTEC TABLET    
norgestimate-ethinyl estradiol NORGESTIMATE-ETHINYL ESTRADIOL TABLET    
norgestimate-ethinyl estradiol ESTARYLLA TABLET    
norgestimate-ethinyl estradiol FEMYNOR TABLET    
norgestimate-ethinyl estradiol MILI TABLET    
norgestrel-ethinyl estradiol CRYSELLE TABLET    
norgestrel-ethinyl estradiol ELINEST TABLET    
norgestrel-ethinyl estradiol LOW-OGESTREL TABLET    
norgestrel-ethinyl estradiol OGESTREL TABLET    
ulipristal acetate ELLA TABLET