Miscellaneous

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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
atrasentan hydrochloride VANRAFIA TABLET N Pharmacy PA N  
colchicine LODOCO TABLET N Quantity Limit N  
diazoxide choline VYKAT XR TAB ER 24H N Pharmacy PA N Aug 07, 2025
dutasteride/tamsulosin HCl DUTASTERIDE-TAMSULOSIN CPMP 24HR N   N  
etranacogene dezaparvovec-drlb HEMGENIX VIAL N Pharmacy PA N Oct 05, 2023
paroxetine mesylate PAROXETINE MESYLATE CAPSULE N   N  
valoctocogene roxaparvovc-rvox ROCTAVIAN VIAL N Pharmacy PA N Oct 05, 2023
AA/prot/arginine/C/zinc/copper PROTEINEX WC LIQUID Pharmacy PA N  
acetic acid ACETIC ACID IRRIG SOLN   N  
acetylcysteine ACETYLCYSTEINE VIAL   N  
albumin human ALBUMINAR-5 IV SOLN   N  
albumin human ALBUKED-5 VIAL   N  
albumin human/sodium chloride ALBUMIN-SALINE VIAL   N  
aloe vera ALOE VERA CAPSULE   N  
alpha-1-proteinase inhibitor ZEMAIRA VIAL   N  
alpha-1-proteinase inhibitor GLASSIA VIAL   N  
alprostadil EDEX KIT   N  
alprostadil CAVERJECT SYRINGE   N  
anagrelide HCl AGRYLIN CAPSULE   N  
anise oil ANISE OIL OIL   N  
anti-thymocyte globulin,rabbit THYMOGLOBULIN VIAL   N  
asfotase alfa STRENSIQ VIAL   N  
azathioprine sodium AZATHIOPRINE SODIUM VIAL   N  
B3/B6/C/FA/coppr/Mg/Zn/alip ac NICADAN TABLET Pharmacy PA N  
B3/lmfol/turm/blk pep/garl/hrb INFLAMEX CAPSULE Pharmacy PA N  
balsam peru/castor oil BALSAM PERU-CASTOR OIL OINT PACK   N  
belatacept NULOJIX VIAL   N  
beractant SURVANTA VIAL   N  
betaine CYSTADANE POWDER   N  
C/rut/hes/bioflav,cit/Butch br TROMBONEX CAPSULE Pharmacy PA N  
calc/D3/magnes/L-mefol/B6/rhub MENATROL CAPSULE Pharmacy PA N  
caplacizumab-yhdp CABLIVI KIT   N  
caplacizumab-yhdp CABLIVI VIAL   N  
chlorhexidine gluconate CHLORHEXIDINE GLUCONATE MOUTHWASH   N  
cinacalcet HCl CINACALCET HCL TABLET   N  
citric acid/sodium citrate SODIUM CITRATE-CITRIC ACID SOLUTION   N  
citric acid/sodium citrate ORACIT SOLUTION   N  
concizumab-mtci ALHEMO PEN PEN INJCTR   N  
cranberry fruit extract CRANBERRY FRUIT CAPSULE   N  
cromolyn sodium GASTROCROM ORAL CONC   N  
deoxycholic acid KYBELLA VIAL   N  
dextran 40 in 0.9 % NaCl GENTRAN 40 IN NORMAL SALINE IV SOLN   N  
dextran 40 in dextrose 5 % GENTRAN 40 IN DEXTROSE 5% IV SOLN   N  
dextran 75/inverted sugar 10 % GENTRAN 75 IN TRAVERT 10% IV SOLN   N  
dichlorphenamide KEVEYIS TABLET Pharmacy PA N Mar 22, 2018
diluent 1,live virus vac(swfi) DILUENT-MERCK LIVE VIRUS VACC SYRINGE   N  
diluent for artesunate DILUENT FOR ARTESUNATE VIAL   N  
diluent for decitabine DILUENT FOR DECITABINE VIAL   N  
diluent for epoprostenol(glyc) PH 12 DILUENT FOR FLOLAN VIAL   N  
diluent for ixabepilone DILUENT FOR IXEMPRA VIAL   N  
diluent for melphalan DILUENT FOR MELPHALAN VIAL   N  
diluent for mitomycin STERILE HYDROGEL FOR ZUSDURI VIAL   N  
diluent for treprostinil (gly) DILUENT FOR REMODULIN VIAL   N  
diluent, carmustine (ethanol) DILUENT FOR CARMUSTINE VIAL   N  
diluent, insulin aspart no.1 DILUTING MEDIUM FOR NOVOLOG VIAL   N  
diluent, romidepsin (prop gly) DILUENT FOR ROMIDEPSIN VIAL   N  
diluent,insulin lispro,regular STERILE DILUENT FOR HUMALOG VIAL   N  
diluent,temsirolimus (ethanol) DILUENT FOR TEMSIROLIMUS VIAL   N  
diluent,voretigene neparvovec DILUENT-VORETIGENE NEPARVOVEC VIAL   N  
dimethyl sulfoxide CRYOSERV VIAL   N  
etelcalcetide hydrochloride PARSABIV VIAL   N  
factor IX ALPHANINE SD VIAL   N  
factor IX human recomb,Thr 148 IXINITY VIAL   N  
factor IX human recombinant RIXUBIS VIAL   N  
factor IX recom,albumin fusion IDELVION VIAL   N  
factor XIII A-subunit,recomb TRETTEN VIAL   N  
fat emulsions INTRALIPID EMULSION   N  
fat emulsions NUTRILIPID EMULSION   N  
fat emulsions LIPOSYN II EMULSION   N  
fatty acid6/fish oil/glycerin OMEGAVEN EMULSION   N  
fidanacogene elaparvovec-dzkt BEQVEZ VIAL   N  
finasteride PROPECIA TABLET   N  
fitusiran sodium QFITLIA PEN PEN INJCTR   N  
flumazenil FLUMAZENIL VIAL   N  
fluoride (sodium) SODIUM FLUORIDE CREAM (G)   N  
fluoride (sodium) DENTA 5000 PLUS CREAM (G)   N  
fluoride (sodium) SODIUM FLUORIDE 5000 PLUS CREAM (G)   N  
fluoride (sodium) SODIUM FLUORIDE GEL (GRAM)   N  
fluoride (sodium) DENTAGEL GEL (GRAM)   N  
fluoride (sodium) SODIUM FLUORIDE 5000 DRY MOUTH PASTE (ML)   N  
fluoride (sodium) SODIUM FLUORIDE SOLUTION   N  
fluoride (sodium) FLUORIDE TAB CHEW   N  
folic acid/inositol PREGNITUDE POWD PACK Pharmacy PA N  
garlic GARLIC CAPSULE   N  
garlic GARLIC ONE-A-DAY TABLET   N  
ginger root GINGER ROOT CAPSULE   N  
hemin PANHEMATIN VIAL   N  
hetastarch/electrolyt,lactated HEXTEND LACTATED ELECTROLYTE PLAST. BAG   N  
human prothrombin complex-lans BALFAXAR VIAL   N  
hydrocortisone acetate HYDROCORTISONE ACETATE SUPP.RECT   N  
isopropyl alcohol ISOPROPYL ALCOHOL SOLUTION   N  
L. acidophilus/B. coagulans ACIDOPHILUS-BACILLUS COAGULANS TABLET   N  
L. acidophilus/Bifid. animalis DERMACINRX PROBITROL CAPSULE   N  
L. acidophilus/Bifid. animalis DERMACINRX PROBISOL CAPSULE   N  
L. acidophilus/Bifid. animalis DERMACINRX LACTEROL CAPSULE   N  
L. acidophilus/L.bulgaricus FLORANEX TABLET   N  
L. acidophilus/pectin, citrus ACIDOPHILUS-PECTIN TABLET   N  
L.acid,para/B.bifidum/S.therm RISAQUAD CAPSULE   N  
L.acidoph/L.bulg/B.bif/S.therm RISA-BID TABLET   N  
Lactobacillus acidophilus ACIDOPHILUS LACTOBACILLI CAPSULE   N  
Lactobacillus acidophilus/pect ACIDOPHILUS-PECTIN CAPSULE   N  
Lactobacillus combo no.5 PROVELLA TABLET DR   N  
Lactobacillus plantarum PAXOTIN CAPSULE   N  
levocarnitine CARNITOR SF SOLUTION   N  
levocarnitine LEVOCARNITINE SOLUTION Pharmacy PA N  
levocarnitine LEVOCARNITINE VIAL   N  
levocarnitine CARNITOR VIAL   N  
levocarnitine (with sugar) CARNITOR SOLUTION   N  
licorice root LICORICE ROOT CAPSULE   N  
lipase/protease/amylase (pork) TRI-PASE 8 TABLET Pharmacy PA N  
lymphocyte IG,antithymocyt,equ ATGAM AMPUL   N  
mannitol/sorbitol solution SORBITOL-MANNITOL IRRIG SOLN   N  
megestrol acetate MEGESTROL ACETATE ORAL SUSP   N  
mifepristone MIFEPRISTONE TABLET   N  
milnacipran HCl SAVELLA TABLET Pharmacy PA N  
mv-mins/folic acid/guarana/caf ONE DAILY TABLET Pharmacy PA N  
mycophenolate mofetil HCl CELLCEPT VIAL   N  
mycophenolate mofetil HCl MYCOPHENOLATE MOFETIL VIAL   N  
neomycin sulf/polymyxin B sulf NEOMYCIN-POLYMYXIN B AMPUL   N  
niacin1/folic/B12/iron/zinc/Cr DERMANIC TAB IR DR Pharmacy PA N  
nitisinone ORFADIN CAPSULE   N  
nitisinone NITISINONE CAPSULE   N  
nitroglycerin NITROGLYCERIN OINT. (G)   N  
nitroglycerin RECTIV OINT. (G)   N Jun 28, 2012
ospemifene OSPHENA TABLET Pharmacy PA N  
pentastarch/0.9 % sod chloride PENTASPAN INFUS. BTL   N  
plasma human, blood group A OCTAPLAS PLAST. BAG   N  
poractant alfa CUROSURF VIAL   N  
potassium citrate UROCIT-K TABLET ER   N  
prademagene zamikeracel ZEVASKYN SHEET   N  
radium-223 dichloride XOFIGO VIAL   N  
Ringer's solution TIS-U-SOL IRRIG SOLN   N  
Ringer's solution,lactated LACTATED RINGERS IRRIG SOLN   N  
saccharin DILUENT ORAL SUSP   N  
shark cartilage SHARK CARTILAGE CAPSULE Pharmacy PA N  
Siberian ginseng root SIBERIAN GINSENG CAPSULE   N  
simethicone PHAZYME CAPSULE   N  
simethicone INFANTS' GAS RELIEF DROPS SUSP   N  
simethicone INFANT GAS RELIEF DROPS SUSP   N  
simethicone SIMETHICONE TAB CHEW   N  
sod/pot/K cit/sod cit/cit acid TRICITRATES SOLUTION   N  
sodium fluoride/hydroxyapatite FRAICHE 5000 KIDS PLUS GEL (GRAM)   N  
sodium fluoride/potassium nit SODIUM FLUORIDE SENSITIVE PASTE (ML)   N  
sodium fluoride/potassium nit DENTA 5000 PLUS SENSITIVE PASTE (ML)   N  
sorbitol solution SORBITOL IRRIG SOLN   N  
strontium-89 chloride STRONTIUM-89 CHLORIDE VIAL   N  
sugammadex sodium BRIDION VIAL   N  
taurolidine in heparin sodium DEFENCATH VIAL   N  
tiopronin TIOPRONIN TABLET   N  
tiopronin THIOLA TABLET   N  
tiopronin VENXXIVA TABLET DR   N  
tryptophan/tyrosine/blueberry BLUES AWAY POSTPARTUM SUPPORT LIQUID SEQ Pharmacy PA N  
ubidecarenone COENZYME Q-10 CAPSULE Pharmacy PA N  
ubidecarenone CO Q-10 CAPSULE Pharmacy PA N  
vardenafil HCl VARDENAFIL HCL TABLET Pharmacy PA N  
venom-wasp ALBAY VIAL   N  
venom-wasp VENOMIL MAINTENANCE VIAL   N  
venom-wasp protein VENOMIL INDIVIDUAL DIAGNOSTIC VIAL   N  
vit C/dios/rut/bioflav/butc br TROMBONEX-D CAPSULE Pharmacy PA N  
vit C/E/Zn/coppr/lutein/zeaxan PRESERVISION AREDS 2 CAPSULE   N  
vit C/E/Zn/coppr/lutein/zeaxan EYE MULTIVITAMIN CAPSULE   N  
vit D3/lutein/zeaxant/turmeric BLINK NUTRITEARS CAPSULE Pharmacy PA N  
vosoritide VOXZOGO VIAL Pharmacy PA N Apr 07, 2022
water for inj.,bacteriostatic BACTERIOSTATIC WATER-HERZUMA VIAL   N  
water for inj.,bacteriostatic WATER VIAL   N  
water for inj.,bacteriostatic BACTERIOSTATIC WATER-OGIVRI VIAL   N  
water for injection,sterile WATER SYRINGE   N  
water for injection,sterile STERILE WATER DILUENT-ABRYSVO SYRINGE   N  
water for injection,sterile STERILE WATER FOR ZEMAIRA VIAL   N  
water for injection,sterile STERILE WATER FOR TNKASE VIAL   N  
water for injection,sterile STERILE WATER FOR ACTIVASE VIAL   N  
water for injection,sterile STERILE WATER FOR KCENTRA VIAL   N  
yohimbe bark YOHIMBE TABLET   N  
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