Other Hormones
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 |
|---|---|---|---|---|---|
| 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 | PREGNYL | VIAL | |||
| chorionic gonadotropin, human | NOVAREL | VIAL | |||
| clomiphene citrate | CLOMID | TABLET | |||
| clomiphene citrate | CLOMIPHENE CITRATE | TABLET | |||
| danazol | DANAZOL | CAPSULE | |||
| 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 | DESMOPRESSIN ACETATE | TABLET | |||
| desmopressin acetate | DDAVP | TABLET | |||
| desmopressin acetate | DESMOPRESSIN ACETATE | VIAL | |||
| desmopressin acetate | DDAVP | VIAL | |||
| follitropin alfa, recombinant | GONAL-F RFF REDI-JECT | PEN INJCTR | |||
| follitropin alfa, recombinant | GONAL-F | VIAL | |||
| follitropin alfa, recombinant | GONAL-F RFF | VIAL | |||
| follitropin beta,recomb | FOLLISTIM AQ | CARTRIDGE | |||
| follitropin beta/ganirelix | FOLLISTIM/ANTAGON | KIT | |||
| ganirelix acetate | GANIRELIX ACETATE | SYRINGE | |||
| ganirelix acetate | FYREMADEL | SYRINGE | |||
| gonadorelin acetate | LUTREPULSE | KIT | |||
| gonadorelin acetate | LUTREPULSE | VIAL | |||
| lanreotide acetate | LANREOTIDE ACETATE | SYRINGE | |||
| lanreotide acetate | SOMATULINE DEPOT | SYRINGE | |||
| levoketoconazole | RECORLEV | TABLET | |||
| macimorelin acetate | MACRILEN | SOLN RECON | |||
| mecasermin | INCRELEX | VIAL | |||
| menotropins | MENOPUR | VIAL | |||
| metreleptin | MYALEPT | VIAL | PA Document | ||
| metyrapone | METOPIRONE | CAPSULE | |||
| octreotide acetate | SANDOSTATIN | AMPUL | |||
| octreotide acetate | OCTREOTIDE ACETATE | AMPUL | |||
| octreotide acetate | MYCAPSSA | CAPSULE DR | |||
| octreotide acetate | BYNFEZIA | PEN INJCTR | |||
| 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 | VASOSTRICT | VIAL | |||
| vasopressin | VASOPRESSIN | VIAL | |||
| vasopressin in 0.9 % NaCl | VASOPRESSIN-0.9% NACL | PLAST. BAG |