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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
carboprost tromethamine HEMABATE AMPUL    
carboprost tromethamine CARBOPROST TROMETHAMINE AMPUL    
carboprost tromethamine CARBOPROST TROMETHAMINE VIAL    
dinoprostone PREPIDIL GEL/PF APP    
dinoprostone CERVIDIL INSERT ER    
methylergonovine maleate METHYLERGONOVINE MALEATE AMPUL    
methylergonovine maleate METHYLERGONOVINE MALEATE TABLET    
methylergonovine maleate METHERGINE TABLET    
methylergonovine maleate METHYLERGONOVINE MALEATE VIAL    
oxytocin OXYTOCIN AMPUL    
oxytocin PITOCIN VIAL