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.

Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria New Drug Evaluation
vit C/E/zinc/lutein/zeaxanthin OCUVITE EYE HEALTH TAB CHEW Y    
etranacogene dezaparvovec-drlb HEMGENIX KIT N PA Document Oct 05, 2023
etranacogene dezaparvovec-drlb HEMGENIX VIAL N PA Document Oct 05, 2023
fezolinetant VEOZAH TABLET N    
finasteride/tadalafil ENTADFI CAPSULE N    
omaveloxolone SKYCLARYS CAPSULE N PA Document Jun 01, 2023
paroxetine mesylate PAROXETINE MESYLATE CAPSULE N    
teprotumumab-trbw TEPEZZA VIAL N PA Document Dec 03, 2020
trofinetide DAYBUE SOLUTION N PA Document Aug 03, 2023
valoctocogene roxaparvovc-rvox ROCTAVIAN VIAL N PA Document Oct 05, 2023
AA/prot/arginine/C/zinc/copper PROTEINEX WC LIQUID PA Document  
acetic acid ACETIC ACID IRRIG SOLN    
acetohydroxamic acid LITHOSTAT TABLET    
acetylcysteine ACETYLCYSTEINE VIAL    
ADAMTS13, recombinant-krhn ADZYNMA KIT    
albumin human FLEXBUMIN IV SOLN    
albumin human BUMINATE IV SOLN    
albumin human ALBUTEIN IV SOLN    
albumin human ALBUMINAR-5 IV SOLN    
albumin human ALBUMIN (HUMAN) IV SOLN    
albumin human ALBURX VIAL    
albumin human ALBUKED-5 VIAL    
albumin human ALBUKED-25 VIAL    
albumin human ALBUTEIN VIAL    
albumin human-kjda ALBUMINEX VIAL    
albumin human/sodium chloride ALBUMIN-SALINE VIAL    
aloe vera ALOE VERA CAPSULE    
alosetron HCl LOTRONEX TABLET    
alosetron HCl ALOSETRON HCL TABLET    
alpha-1-proteinase inhibitor GLASSIA VIAL    
alpha-1-proteinase inhibitor PROLASTIN C VIAL    
alpha-1-proteinase inhibitor ARALAST NP VIAL    
alpha-1-proteinase inhibitor ZEMAIRA VIAL    
alprostadil CAVERJECT AMPUL    
alprostadil EDEX KIT    
alprostadil CAVERJECT KIT    
alprostadil MUSE SUPP.URETH    
alprostadil CAVERJECT SYRINGE    
alprostadil CAVERJECT VIAL    
amino acids/protein hydrolys PROTEINEX-18 LIQUID PA Document  
anagrelide HCl AGRYLIN CAPSULE    
anagrelide HCl ANAGRELIDE HCL CAPSULE    
anise oil ANISE OIL OIL    
anti-thymocyte globulin,rabbit THYMOGLOBULIN VIAL    
antithrombin III (plasma der) THROMBATE III VIAL    
asfotase alfa STRENSIQ VIAL    
azathioprine sodium AZATHIOPRINE SODIUM VIAL    
B3/azel/quer/tur/FA/B6/zn/copp NIACIN-AZE AC-TURMER-FA-B6-ZN TABLET PA Document  
B3/B6/C/FA/coppr/Mg/Zn/alip ac NICADAN TABLET PA Document  
B3/B6/folic/zinc/copper/co-Q10 NICADAN ZX TABLET PA Document  
bacteriostatic sodium chloride SODIUM CHLORIDE VIAL    
balsam peru/castor oil BPCO OINT. (G)    
balsam peru/castor oil BALSAM PERU-CASTOR OIL OINT. (G)    
basiliximab SIMULECT VIAL    
bean pod extract STARCH BLOCKER TABLET    
belatacept NULOJIX VIAL    
beractant SURVANTA VIAL    
beremagene geperpavec-svdt VYJUVEK GEL (ML) PA Document  
betaine CYSTADANE POWDER    
betaine BETAINE ANHYDROUS POWDER    
birch bark extract FILSUVEZ GEL (GRAM) PA Document  
bremelanotide acetate VYLEESI AUTO INJCT   Feb 06, 2020
C/rut/hes/bioflav,cit/Butch br TROMBONEX CAPSULE PA Document  
caplacizumab-yhdp CABLIVI KIT    
caplacizumab-yhdp CABLIVI VIAL    
carglumic acid CARGLUMIC ACID TAB DISPER    
carglumic acid CARBAGLU TAB DISPER    
cascara sagrada CASCARA SAGRADA CAPSULE PA Document  
chlorhexidine gluconate CHLORHEXIDINE GLUCONATE MOUTHWASH    
cinacalcet HCl SENSIPAR TABLET    
cinacalcet HCl CINACALCET HCL TABLET    
citric acid/sodium citrate ORAL CITRATE SOLUTION    
citric acid/sodium citrate SODIUM CITRATE-CITRIC ACID SOLUTION    
citric acid/sodium citrate ORACIT SOLUTION    
coagulation factor X COAGADEX VIAL    
cranberry fruit extract CRANBERRY FRUIT CAPSULE    
cromolyn sodium GASTROCROM ORAL CONC    
cromolyn sodium CROMOLYN SODIUM ORAL CONC    
cyclosporine SANDIMMUNE AMPUL    
cyclosporine CYCLOSPORINE AMPUL    
deoxycholic acid KYBELLA VIAL    
dextran 40 in 0.9 % NaCl LMD 10% WITH 0.9% SOD CHLORIDE IV SOLN    
dextran 40 in 0.9 % NaCl GENTRAN 40 IN NORMAL SALINE IV SOLN    
dextran 40 in dextrose 5 % GENTRAN 40 IN DEXTROSE 5% IV SOLN    
dextran 40 in dextrose 5 % LMD 10% WITH 5% DEXTROSE IV SOLN    
dextran 75 in 0.9 % NaCl GENTRAN 75 IN NORMAL SALINE IV SOLN    
dextran 75 in 0.9 % NaCl DEXTRAN 75 IN NORMAL SALINE IV SOLN    
dextran 75/inverted sugar 10 % GENTRAN 75 IN TRAVERT 10% IV SOLN    
dextromethorphan Hbr/quinidine NUEDEXTA CAPSULE PA Document  
dichlorphenamide KEVEYIS TABLET PA Document Mar 22, 2018
dichlorphenamide DICHLORPHENAMIDE TABLET PA Document Mar 22, 2018
diluent 1,live virus vac(swfi) DILUENT-MERCK LIVE VIRUS VACC SYRINGE    
diluent 1,live virus vac(swfi) DILUENT-MERCK LIVE VIRUS VACC VIAL    
diluent for artesunate DILUENT FOR ARTESUNATE VIAL    
diluent for coag factor Vlla DILUENT FOR NOVOSEVEN RT SYRINGE    
diluent for decitabine DILUENT FOR DECITABINE VIAL    
diluent for epoprostenol(glyc) PH 12 DILUENT FOR FLOLAN VIAL    
diluent for ixabepilone DILUENT FOR IXEMPRA VIAL    
diluent for leuprolide DILUENT FOR ELIGARD SYRINGE    
diluent for melphalan DILUENT FOR MELPHALAN VIAL    
diluent for mitomycin STERILE HYDROGEL FOR JELMYTO VIAL    
diluent for rasburicase (pol) DILUENT FOR ELITEK AMPUL    
diluent for treprostinil (gly) DILUENT FOR TREPROSTINIL VIAL    
diluent for treprostinil (gly) DILUENT FOR REMODULIN VIAL    
diluent, cabazitaxel (ethanol) DILUENT FOR JEVTANA VIAL    
diluent, carmustine (ethanol) DILUENT FOR CARMUSTINE VIAL    
diluent, carmustine (ethanol) DILUENT FOR BICNU VIAL    
diluent, dexrazoxane (sod lac) DEXRAZOXANE DILUENT-SODIUM LAC VIAL    
diluent, insulin aspart no.1 DILUTING MEDIUM FOR NOVOLOG VIAL    
diluent, romidepsin (prop gly) DILUENT FOR ROMIDEPSIN VIAL    
diluent, romidepsin (prop gly) DILUENT FOR ISTODAX VIAL    
diluent,caplacizumab-yhdp STERILE WATER DILUENT-CABLIVI SYRINGE    
diluent,insulin lispro,regular STERILE DILUENT FOR HUMALOG VIAL    
diluent,naltrexone microsphere DILUENT FOR VIVITROL VIAL    
diluent,temsirolimus (ethanol) DILUENT FOR TEMSIROLIMUS VIAL    
diluent,voretigene neparvovec DILUENT-VORETIGENE NEPARVOVEC VIAL    
dimethyl sulfoxide CRYOSERV VIAL    
dong quai DONG QUAI CAPSULE    
Echinacea root/goldenseal root ECHINACEA-GOLDENSEAL TABLET    
emicizumab-kxwh HEMLIBRA VIAL    
etelcalcetide hydrochloride PARSABIV VIAL    
evening primrose oil EVENING PRIMROSE CAPSULE    
factor IX ALPHANINE SD VIAL    
factor IX cplx(pcc)no4,3factor KONYNE 80 VIAL    
factor IX cplx(pcc)no4,3factor PROFILNINE VIAL    
factor IX human rec,pegylated REBINYN VIAL    
factor IX human recomb,Thr 148 IXINITY VIAL    
factor IX human recombinant RIXUBIS VIAL    
factor IX human recombinant BENEFIX VIAL    
factor IX rec, Fc fusion protn ALPROLIX VIAL    
factor IX recom,albumin fusion IDELVION VIAL    
factor XIII CORIFACT VIAL    
factor XIII A-subunit,recomb TRETTEN VIAL    
fat emul/soy/mct/oliv/fish oil SMOFLIPID EMULSION    
fat emulsion/olive/soy/phospho CLINOLIPID EMULSION    
fat emulsions TRAVAMULSION EMULSION    
fat emulsions NUTRILIPID EMULSION    
fat emulsions LIPOSYN III EMULSION    
fat emulsions LIPOSYN II EMULSION    
fat emulsions INTRALIPID EMULSION    
fatty acid6/fish oil/gly/p-lip OMEGAVEN EMULSION    
finasteride PROPECIA TABLET    
finasteride FINASTERIDE TABLET    
flaxseed oil FLAXSEED OIL CAPSULE    
flumazenil FLUMAZENIL VIAL    
fluoride (sodium) SODIUM FLUORIDE CREAM (G)    
fluoride (sodium) DENTA 5000 PLUS CREAM (G)    
fluoride (sodium) SODIUM FLUORIDE 5000 PLUS CREAM (G)    
fluoride (sodium) SODIUM FLUORIDE DROPS    
fluoride (sodium) SODIUM FLUORIDE GEL (GRAM)    
fluoride (sodium) DENTAGEL GEL (GRAM)    
fluoride (sodium) SODIUM FLUORIDE PASTE (ML)    
fluoride (sodium) SODIUM FLUORIDE 5000 DRY MOUTH PASTE (ML)    
fluoride (sodium) SODIUM FLUORIDE SOLUTION    
fluoride (sodium) FLUORIDE TAB CHEW    
fluoride (sodium) SODIUM FLUORIDE TAB CHEW    
folic acid/inositol PREGNITUDE POWD PACK PA Document  
garlic GARLIC CAPSULE    
garlic GARLIC ONE-A-DAY TABLET    
garlic GARLIN TABLET    
garlic GARLIC TABLET    
ginger root GINGER ROOT CAPSULE    
ginseng GINSENG CAPSULE    
glycerol phenylbutyrate RAVICTI LIQUID    
goldenseal root GOLDEN SEAL CAPSULE    
grape seed extract GRAPE SEED EXTRACT CAPSULE    
hemin PANHEMATIN VIAL    
hetastarch in 0.9 % NaCl HETASTARCH-0.9% NACL PLAST. BAG    
hetastarch in 0.9 % NaCl HESPAN PLAST. BAG    
hetastarch/electrolyt,lactated HEXTEND LACTATED ELECTROLYTE PLAST. BAG    
hum prothrombin cplx(PCC)-lans BALFAXAR VIAL    
hum prothrombin cplx(PCC)4fact KCENTRA VIAL    
hydrocortisone acetate HYDROCORTISONE ACETATE SUPP.RECT    
hydrocortisone acetate ANUDIL HC SUPP.RECT    
isopropyl alcohol ISOPROPYL ALCOHOL SOLUTION    
isopropyl alcohol ISOPROPYL RUBBING ALCOHOL SOLUTION    
kava KAVA KAVA CAPSULE    
L. acidophilus/Bifid. animalis MICROFLOR 33 CAPSULE    
L. acidophilus/Bifid. animalis DERMACINRX PROMEROL CAPSULE    
L. acidophilus/Bifid. animalis DERMACINRX PROBITROL CAPSULE    
L. acidophilus/Bifid. animalis DERMACINRX PROBITRAN CAPSULE    
L. acidophilus/Bifid. animalis DERMACINRX PROBISOL CAPSULE    
L. acidophilus/Bifid. animalis DERMACINRX PROBINATE CAPSULE    
L. acidophilus/Bifid. animalis DERMACINRX LACTEROL CAPSULE    
L. acidophilus/Bifid. animalis DIALYVITE CHEWABLE PROBIOTIC TAB CHEW    
L. acidophilus/L.bulgaricus FLORANEX GRAN PACK    
L. acidophilus/L.bulgaricus LACTOBACILLUS GRAN PACK    
L. acidophilus/L.bulgaricus LACTOBACILLUS TABLET    
L. acidophilus/L.bulgaricus FLORANEX TABLET    
L.acid,casei/B.animal/S.thermo RISAQUAD-2 CAPSULE    
L.acid,para/B.bifidum/S.therm RISAQUAD CAPSULE    
L.acid,para/B.bifidum/S.therm QUAD-PROBIOTIC CAPSULE    
L.acidoph,paracasei, B.lactis ENVIVE CAPSULE    
L.acidoph/L.bulg/B.bif/S.therm RISA-BID TABLET    
Lacto no.76/Bifido/FOS/larch WOMEN'S PROBIOTIC CAPSULE    
Lactobacil 2/Bifido 1/S.thermo VSL#3 DS PACKET    
Lactobacil 2/Bifido 11/S.therm HIGH POTENCY PROBIOTIC CAPSULE    
Lactobacillus acidophilus ACIDOPHILUS LACTOBACILLI CAPSULE    
Lactobacillus acidophilus/pect ACIDOPHILUS-PECTIN CAPSULE    
Lactobacillus combo no.5 PROVELLA TABLET DR    
Lactobacillus reuteri PEDIA-LAX PROBIOTIC YUMS TAB CHEW    
levocarnitine LEVOCARNITINE SF SOLUTION    
levocarnitine LEVOCARNITINE SOLUTION PA Document  
levocarnitine CARNITOR SF SOLUTION    
levocarnitine LEVOCARNITINE TABLET PA Document  
levocarnitine CARNITOR TABLET    
levocarnitine LEVOCARNITINE VIAL    
levocarnitine CARNITOR VIAL    
levocarnitine (with sugar) LEVOCARNITINE SOLUTION    
levocarnitine (with sugar) CARNITOR SOLUTION    
licorice root LICORICE ROOT CAPSULE    
lipase/protease/amylase TRI-PASE 8 TABLET PA Document  
lipase/protease/amylase TRI-PASE 16 TABLET PA Document  
Lu-177 vipivotide tetraxetan PLUVICTO VIAL    
lutein LUTEIN TABLET    
lutein/zeaxanthin OCUVITE LUTEIN 25 CAPSULE    
lutein/zeaxanthin OCUVITE BLUE LIGHT CAPSULE    
lymphocyte IG,antithymocyt,equ ATGAM AMPUL    
mannitol/sorbitol solution SORBITOL-MANNITOL IRRIG SOLN    
megestrol acetate MEGESTROL ACETATE ORAL SUSP    
mifepristone MIFEPRISTONE TABLET    
mifepristone MIFEPREX TABLET    
milnacipran HCl SAVELLA TAB DS PK PA Document  
milnacipran HCl SAVELLA TABLET PA Document  
mv-min/vit C/glut/lysine/hb124 GERM DEFENSE TABLET EFF PA Document  
mv-mins/folic acid/guarana/caf ONE DAILY TABLET PA Document  
mycophenolate mofetil HCl MYCOPHENOLATE MOFETIL VIAL    
mycophenolate mofetil HCl CELLCEPT VIAL    
neomycin sulf/polymyxin B sulf NEOMYCIN-POLYMYXIN B AMPUL    
neomycin sulf/polymyxin B sulf NEOMYCIN-POLYMYXIN B VIAL    
niacin1/folic/B12/iron/zinc/Cr DERMANIC TAB IR DR PA Document  
nitisinone ORFADIN CAPSULE    
nitisinone NITISINONE CAPSULE    
nitisinone ORFADIN ORAL SUSP    
nitisinone NITYR TABLET    
nitroglycerin RECTIV OINT. (G)    
nitroglycerin NITROGLYCERIN OINT. (G)    
omega-3/dha/epa/fish oil FISH OIL CAPSULE PA Document  
omega-3/dha/epa/vit E SYSTANE VITAMIN CAPSULE PA Document  
ospemifene OSPHENA TABLET PA Document  
Panax ginseng root KOREAN GINSENG CAPSULE    
pegvisomant SOMAVERT VIAL    
pentastarch/0.9 % sod chloride PENTASPAN INFUS. BTL    
pine bark ext (pycnogenols) PYCNOGENOL TABLET PA Document  
plasma human, blood group A OCTAPLAS PLAST. BAG    
plasma human, blood group AB OCTAPLAS PLAST. BAG    
plasma human, blood group B OCTAPLAS PLAST. BAG    
plasma human, blood group O OCTAPLAS PLAST. BAG    
poractant alfa CUROSURF VIAL    
potassium citrate UROCIT-K TABLET ER    
potassium citrate POTASSIUM CITRATE ER TABLET ER    
potassium citrate/citric acid POTASSIUM CITRATE-CITRIC ACID SOLUTION    
protein C, human CEPROTIN VIAL    
radium-223 dichloride XOFIGO VIAL    
rilonacept ARCALYST VIAL    
Ringer's solution RINGERS IRRIGATION IRRIG SOLN    
Ringer's solution TIS-U-SOL IRRIG SOLN    
Ringer's solution,lactated LACTATED RINGERS IRRIG SOLN    
saccharin DILUENT ORAL SUSP    
Saccharomyces boulardii SACCHAROMYCES BOULARDII CAPSULE    
Saccharomyces boulardii/FOS FLORANEX ONE CAPSULE    
shark cartilage SHARK FIN CARTILAGE CAPSULE PA Document  
shark cartilage SHARK CARTILAGE CAPSULE PA Document  
Siberian ginseng root SIBERIAN GINSENG CAPSULE    
simethicone GAS RELIEF CAPSULE    
simethicone SIMETHICONE CAPSULE    
simethicone PHAZYME CAPSULE    
simethicone ANTI-GAS CAPSULE    
simethicone INFANTS' SIMETHICONE DROPS SUSP    
simethicone INFANTS' GAS RELIEF DROPS SUSP    
simethicone COLIC DROPS SUSP    
simethicone INFANT GAS RELIEF DROPS SUSP    
simethicone SIMETHICONE TAB CHEW    
simethicone GAS RELIEF TAB CHEW    
sod,pot chlor/mag/sod,pot phos TIS-U-SOL PENTALYTE IRRIG SOLN    
sod/pot/K cit/sod cit/cit acid POTASS CIT-SOD CIT-CITRIC ACID SOLUTION    
sod/pot/K cit/sod cit/cit acid TRICITRATES SOLUTION    
sodium benzoate/sod phenylacet AMMONUL VIAL    
sodium benzoate/sod phenylacet SODIUM PHENYLACET-SOD BENZOATE VIAL    
sodium fluoride/potassium nit SODIUM FLUORIDE SENSITIVE PASTE (ML)    
sodium fluoride/potassium nit SODIUM FLUORIDE ENAMEL PROTECT PASTE (ML)    
sodium fluoride/potassium nit DENTA 5000 PLUS SENSITIVE PASTE (ML)    
sodium fluoride/vitamin D3 FLORIVA DROPS    
sodium phenylbutyrate PHEBURANE GRANULES    
sodium phenylbutyrate OLPRUVA PELET PACK    
sodium phenylbutyrate SODIUM PHENYLBUTYRATE POWDER    
sodium phenylbutyrate BUPHENYL POWDER    
sodium phenylbutyrate SODIUM PHENYLBUTYRATE TABLET    
sodium phenylbutyrate BUPHENYL TABLET    
sorbitol solution SORBITOL IRRIG SOLN    
strontium-89 chloride STRONTIUM-89 CHLORIDE VIAL    
sugammadex sodium BRIDION VIAL    
tacrolimus PROGRAF AMPUL    
teduglutide GATTEX KIT    
tiopronin TIOPRONIN TABLET    
tiopronin THIOLA TABLET    
tiopronin TIOPRONIN TABLET DR    
tiopronin THIOLA EC TABLET DR    
triamcinolone acetonide ORALONE PASTE (G)    
triamcinolone acetonide TRIAMCINOLONE ACETONIDE PASTE (G)    
ubidecarenone COENZYME Q-10 CAPSULE PA Document  
ubidecarenone COENZYME Q10 CAPSULE PA Document  
ubidecarenone CO Q-10 CAPSULE PA Document  
ubidecarenone CO Q10 CAPSULE PA Document  
valerian root VALERIAN ROOT CAPSULE    
vardenafil HCl VARDENAFIL HCL TAB RAPDIS    
vardenafil HCl VARDENAFIL HCL TABLET    
varenicline tartrate TYRVAYA SPRAY METR Age Restriction  
venom-wasp VENOMIL MAINTENANCE VIAL    
venom-wasp ALBAY VIAL    
venom-wasp protein VENOMIL INDIVIDUAL DIAGNOSTIC VIAL    
vit C/dios/rut/bioflav/butc br TROMBONEX-D CAPSULE PA Document  
vit C/E/Zn/coppr/lutein/zeaxan OCUVITE LUTEIN-ZEAXANTHIN CAPSULE    
vit C/E/Zn/coppr/lutein/zeaxan EYE MULTIVITAMIN CAPSULE    
vit C/E/Zn/coppr/lutein/zeaxan PRESERVISION AREDS 2 CAPSULE    
vit C/E/Zn/coppr/lutein/zeaxan PRESERVISION AREDS 2 TAB CHEW    
vits A,C,E/mins/herbal no.147 GERM DEFENSE PM TABLET EFF PA Document  
von Willebrand factor VONVENDI VIAL    
vosoritide VOXZOGO VIAL PA Document Apr 07, 2022
water for inj.,bacteriostatic WATER VIAL    
water for inj.,bacteriostatic BACTERIOSTATIC WATER-TRAZIMERA VIAL    
water for inj.,bacteriostatic BACTERIOSTATIC WATER-OGIVRI VIAL    
water for inj.,bacteriostatic BACTERIOSTATIC WATER-KANJINTI VIAL    
water for injection,sterile WATER IV SOLN    
water for injection,sterile WATER SYRINGE    
water for injection,sterile STERILE WATER FOR BERINERT VIAL    
water for injection,sterile WATER VIAL    
water for injection,sterile STERILE WATER FOR ZEMAIRA VIAL    
water for injection,sterile STERILE WATER FOR TNKASE VIAL    
water for injection,sterile STERILE WATER FOR PROLASTIN-C VIAL    
water for injection,sterile STERILE WATER FOR KCENTRA VIAL    
water for injection,sterile STERILE WATER FOR GAMMAGARD VIAL    
water for injection,sterile STERILE WATER FOR ACTIVASE VIAL    
water for injection,sterile STERILE WATER (GRIFOLS FACTOR) VIAL    
water for injection,sterile STERILE WATER FOR HUMATE-P VIAL    
yohimbe bark YOHIMBE TABLET    
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