Other Hormones

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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
arginine HCl R-GENE 10 IV SOLN    
cabergoline CABERGOLINE TABLET    
cetrorelix acetate CETRORELIX ACETATE KIT    
cetrorelix acetate CETROTIDE KIT    
choriogonadotropin alfa OVIDREL SYRINGE    
chorionic gonadotropin, human CHORIONIC GONADOTROPIN VIAL    
chorionic gonadotropin, human NOVAREL VIAL    
chorionic gonadotropin, human PREGNYL VIAL    
clomiphene citrate CLOMID TABLET PA Document  
clomiphene citrate CLOMIPHENE CITRATE TABLET PA Document  
desmopressin (nonrefrigerated) DESMOPRESSIN ACETATE SPRAY/PUMP    
desmopressin acetate DESMOPRESSIN ACETATE AMPUL    
desmopressin acetate DDAVP AMPUL    
desmopressin acetate DESMOPRESSIN ACETATE SPRAY/PUMP    
desmopressin acetate NOCDURNA TAB RAPDIS    
desmopressin acetate DDAVP TABLET    
desmopressin acetate DESMOPRESSIN ACETATE TABLET    
desmopressin acetate DDAVP VIAL    
desmopressin acetate DESMOPRESSIN ACETATE VIAL    
follitropin alfa, recombinant GONAL-F RFF REDI-JECT PEN INJCTR    
follitropin alfa, recombinant GONAL-F RFF VIAL    
follitropin alfa, recombinant GONAL-F VIAL    
follitropin beta,recomb FOLLISTIM AQ CARTRIDGE    
follitropin beta/ganirelix FOLLISTIM/ANTAGON KIT    
ganirelix acetate FYREMADEL SYRINGE    
ganirelix acetate GANIRELIX ACETATE SYRINGE    
gonadorelin acetate LUTREPULSE KIT    
gonadorelin acetate LUTREPULSE VIAL    
lanreotide acetate SOMATULINE DEPOT SYRINGE    
lanreotide acetate LANREOTIDE ACETATE SYRINGE    
levoketoconazole RECORLEV TABLET    
macimorelin acetate MACRILEN SOLN RECON    
mecasermin INCRELEX VIAL    
menotropins MENOPUR VIAL    
metreleptin MYALEPT VIAL PA Document  
octreotide acetate SANDOSTATIN AMPUL    
octreotide acetate OCTREOTIDE ACETATE AMPUL    
octreotide acetate MYCAPSSA CAPSULE DR    
octreotide acetate OCTREOTIDE ACETATE SYRINGE    
octreotide acetate OCTREOTIDE ACETATE VIAL    
octreotide acetate,mi-spheres SANDOSTATIN LAR DEPOT VIAL    
osilodrostat phosphate ISTURISA TABLET PA Document  
pasireotide diaspartate SIGNIFOR AMPUL    
pasireotide pamoate SIGNIFOR LAR VIAL    
vasopressin VASOSTRICT INFUS. BTL    
vasopressin VASOPRESSIN VIAL    
vasopressin VASOSTRICT VIAL    
vasopressin in 0.9 % NaCl VASOPRESSIN-0.9% NACL PLAST. BAG