Lipotropics

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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
Status
Current Drug Use Criteria New Drug Evaluation
chondroitin sulfate A CHONDROITIN SULFATE CAPSULE    
fsh/flx/prim/cur/bor/om3,6,9 5 OMEGA 3-6-9 FATTY ACIDS CAPSULE    
krill oil/omega-3/dha/epa OMEGA-3 KRILL OIL CAPSULE    
krill/omega-3/dha/epa/lipids KRILL OIL CAPSULE    
lecithin LECITHIN CAPSULE    
lecithin, soy LECITHIN CAPSULE    
omega-3 fatty acids FISH OIL CONCENTRATE CAPSULE    
omega-3 fatty acids FISH OIL CAPSULE    
omega-3 fatty acids/fish oil SEA-OMEGA 30 CAPSULE    
omega-3 fatty acids/fish oil FISH OIL OMEGA-3 CAPSULE    
omega-3 fatty acids/fish oil FISH OIL CAPSULE    
omega-3 fatty acids/fish oil FISH OIL CAPSULE DR    
omega-3/dha/epa/fish oil FISH OIL CAPSULE    
omega-3/dha/epa/fish oil OMEGA-3 FISH OIL CAPSULE    
omega-3/dha/epa/fish oil FISH OIL CAPSULE DR