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.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
arginine HCl R-GENE 10 IV SOLN   N  
cabergoline CABERGOLINE TABLET   N  
cetrorelix acetate CETRORELIX ACETATE KIT   N  
cetrorelix acetate CETROTIDE KIT   N  
choriogonadotropin alfa OVIDREL SYRINGE   N  
chorionic gonadotropin, human CHORIONIC GONADOTROPIN VIAL   N  
chorionic gonadotropin, human PREGNYL VIAL   N  
chorionic gonadotropin, human NOVAREL VIAL   N  
clomiphene citrate CLOMID TABLET Pharmacy PA N  
clomiphene citrate MILOPHENE TABLET Pharmacy PA N  
clomiphene citrate CLOMIPHENE CITRATE TABLET Pharmacy PA N  
danazol DANAZOL CAPSULE   N  
desmopressin (nonrefrigerated) DESMOPRESSIN ACETATE SPRAY/PUMP   N  
desmopressin acetate DESMOPRESSIN ACETATE AMPUL   N  
desmopressin acetate DDAVP AMPUL   N  
desmopressin acetate DESMOPRESSIN ACETATE SPRAY/PUMP   N  
desmopressin acetate NOCDURNA TAB RAPDIS   N  
desmopressin acetate DESMOPRESSIN ACETATE TABLET   N  
desmopressin acetate DDAVP TABLET   N  
desmopressin acetate DDAVP VIAL   N  
desmopressin acetate DESMOPRESSIN ACETATE VIAL   N  
follitropin alfa, recombinant GONAL-F RFF REDI-JECT PEN INJCTR   N  
follitropin alfa, recombinant GONAL-F VIAL   N  
follitropin beta,recomb FOLLISTIM AQ CARTRIDGE   N  
follitropin beta/ganirelix FOLLISTIM/ANTAGON KIT   N  
ganirelix acetate FYREMADEL SYRINGE   N  
ganirelix acetate GANIRELIX ACETATE SYRINGE   N  
gonadorelin acetate LUTREPULSE KIT   N  
gonadorelin acetate LUTREPULSE VIAL   N  
lanreotide acetate LANREOTIDE ACETATE SYRINGE   N  
lanreotide acetate SOMATULINE DEPOT SYRINGE   N  
mecasermin INCRELEX VIAL   N  
menotropins MENOPUR VIAL   N  
metreleptin MYALEPT VIAL Pharmacy PA N  
metyrapone METOPIRONE CAPSULE   N  
octreotide acetate SANDOSTATIN AMPUL   N  
octreotide acetate MYCAPSSA CAPSULE DR   N  
octreotide acetate OCTREOTIDE ACETATE SYRINGE   N  
octreotide acetate OCTREOTIDE ACETATE VIAL   N  
octreotide acetate,mi-spheres SANDOSTATIN LAR DEPOT VIAL   N  
octreotide acetate,mi-spheres OCTREOTIDE ACETATE ER VIAL   N  
osilodrostat phosphate ISTURISA TABLET Pharmacy PA N  
pasireotide diaspartate SIGNIFOR AMPUL   N  
pasireotide pamoate SIGNIFOR LAR VIAL   N  
secretin acetate (human) CHIRHOSTIM VIAL   N  
vasopressin VASOSTRICT INFUS. BTL   N  
vasopressin VASOSTRICT VIAL   N  
vasopressin VASOPRESSIN VIAL   N  
vasopressin in 0.9 % NaCl VASOPRESSIN-0.9% NACL INFUS. BTL   N  
vasopressin in 0.9 % NaCl VASOPRESSIN-0.9% NACL PLAST. BAG   N  
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