Bone Metabolism Drugs

← Back to Class List

PDL Reference Documents

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.

< Return to summary view

NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
70539000101 TYMLOS abaloparatide PEN INJCTR 80 mcg/dose (3,120 mcg/1.56 mL) N Y N Pharmacy PA
70539000102 TYMLOS abaloparatide PEN INJCTR 80 mcg/dose (3,120 mcg/1.56 mL) N Y N Pharmacy PA
70539000198 TYMLOS abaloparatide PEN INJCTR 80 mcg/dose (3,120 mcg/1.56 mL) N Y N Pharmacy PA
70539000199 TYMLOS abaloparatide PEN INJCTR 80 mcg/dose (3,120 mcg/1.56 mL) N Y N Pharmacy PA
00054028259 ALENDRONATE SODIUM alendronate sodium SOLUTION 70 mg/75 mL N Y N Pharmacy PA
70954026410 ALENDRONATE SODIUM alendronate sodium SOLUTION 70 mg/75 mL N Y N Pharmacy PA
16714063101 ALENDRONATE SODIUM alendronate sodium TABLET 10 mg Y Y N  
16714063102 ALENDRONATE SODIUM alendronate sodium TABLET 10 mg Y Y N  
64980034001 ALENDRONATE SODIUM alendronate sodium TABLET 10 mg Y Y N  
64980034003 ALENDRONATE SODIUM alendronate sodium TABLET 10 mg Y Y N  
16714063201 ALENDRONATE SODIUM alendronate sodium TABLET 35 mg Y Y N  
16714063202 ALENDRONATE SODIUM alendronate sodium TABLET 35 mg Y Y N  
47335063760 ALENDRONATE SODIUM alendronate sodium TABLET 35 mg Y Y N  
64980034114 ALENDRONATE SODIUM alendronate sodium TABLET 35 mg Y Y N  
65862032804 ALENDRONATE SODIUM alendronate sodium TABLET 35 mg Y Y N  
69097022316 ALENDRONATE SODIUM alendronate sodium TABLET 35 mg Y Y N  
69097022376 ALENDRONATE SODIUM alendronate sodium TABLET 35 mg Y Y N  
76282068145 ALENDRONATE SODIUM alendronate sodium TABLET 35 mg Y Y N  
16714063301 ALENDRONATE SODIUM alendronate sodium TABLET 70 mg Y Y N  
16714063302 ALENDRONATE SODIUM alendronate sodium TABLET 70 mg Y Y N  
64980034201 ALENDRONATE SODIUM alendronate sodium TABLET 70 mg Y Y N  
64980034214 ALENDRONATE SODIUM alendronate sodium TABLET 70 mg Y Y N  
65862032904 ALENDRONATE SODIUM alendronate sodium TABLET 70 mg Y Y N  
69097022416 ALENDRONATE SODIUM alendronate sodium TABLET 70 mg Y Y N  
69097022476 ALENDRONATE SODIUM alendronate sodium TABLET 70 mg Y Y N  
76282068245 ALENDRONATE SODIUM alendronate sodium TABLET 70 mg Y Y N  
78206013501 FOSAMAX alendronate sodium TABLET 70 mg Y Y N  
70539040000 BINOSTO alendronate sodium TABLET EFF 70 mg N Y N Pharmacy PA
70539040004 BINOSTO alendronate sodium TABLET EFF 70 mg N Y N Pharmacy PA
78206013701 FOSAMAX PLUS D alendronate sodium/vitamin D3 TABLET 70 mg-2,800 unit N Y N Pharmacy PA
78206013601 FOSAMAX PLUS D alendronate sodium/vitamin D3 TABLET 70 mg-5,600 unit N Y N Pharmacy PA
49884016111 CALCITONIN-SALMON calcitonin,salmon,synthetic SPRAY/PUMP 200 unit/spray N Y N Pharmacy PA
60505082306 CALCITONIN-SALMON calcitonin,salmon,synthetic SPRAY/PUMP 200 unit/spray N Y N Pharmacy PA
24201040002 CALCITONIN-SALMON calcitonin,salmon,synthetic VIAL 200 unit/mL N Y N Pharmacy PA
25021047302 CALCITONIN-SALMON calcitonin,salmon,synthetic VIAL 200 unit/mL N Y N Pharmacy PA
42023020501 CALCITONIN-SALMON calcitonin,salmon,synthetic VIAL 200 unit/mL N Y N Pharmacy PA
43598005111 CALCITONIN-SALMON calcitonin,salmon,synthetic VIAL 200 unit/mL N Y N Pharmacy PA
63323086502 CALCITONIN-SALMON calcitonin,salmon,synthetic VIAL 200 unit/mL N Y N Pharmacy PA
69097077032 CALCITONIN-SALMON calcitonin,salmon,synthetic VIAL 200 unit/mL N Y N Pharmacy PA
67457067502 MIACALCIN calcitonin,salmon,synthetic VIAL 200 unit/mL N Y N Pharmacy PA
72078003802 MIACALCIN calcitonin,salmon,synthetic VIAL 200 unit/mL N Y N Pharmacy PA
72078003902 MIACALCIN calcitonin,salmon,synthetic VIAL 200 unit/mL N Y N Pharmacy PA
55513071001 PROLIA denosumab SYRINGE 60 mg/mL N Y N Pharmacy PA
55513071021 PROLIA denosumab SYRINGE 60 mg/mL N Y N Pharmacy PA
55513073001 XGEVA denosumab VIAL 120 mg/1.7 mL (70 mg/mL) Y N  
55513073021 XGEVA denosumab VIAL 120 mg/1.7 mL (70 mg/mL) Y N  
61314024063 JUBBONTI denosumab-bbdz SYRINGE 60 mg/mL N Y N Pharmacy PA
61314022894 WYOST denosumab-bbdz VIAL 120 mg/1.7 mL (70 mg/mL) Y N  
72606003701 STOBOCLO denosumab-bmwo SYRINGE 60 mg/mL N Y N Pharmacy PA
72606003801 OSENVELT denosumab-bmwo VIAL 120 mg/1.7 mL (70 mg/mL) Y N  
65219067201 BOMYNTRA denosumab-bnht SYRINGE 120 mg/1.7 mL (70 mg/mL) Y N  
65219066801 CONEXXENCE denosumab-bnht SYRINGE 60 mg/mL N Y N Pharmacy PA
65219067001 BOMYNTRA denosumab-bnht VIAL 120 mg/1.7 mL (70 mg/mL) Y N  
78206019301 BILDYOS denosumab-nxxp SYRINGE 60 mg/mL N Y N Pharmacy PA
78206019501 BILPREVDA denosumab-nxxp VIAL 120 mg/1.7 mL (70 mg/mL) Y N  
55150019183 IBANDRONATE SODIUM ibandronate sodium SYRINGE 3 mg/3 mL N Y N Pharmacy PA
60505609700 IBANDRONATE SODIUM ibandronate sodium SYRINGE 3 mg/3 mL N Y N Pharmacy PA
67457052433 IBANDRONATE SODIUM ibandronate sodium SYRINGE 3 mg/3 mL N Y N Pharmacy PA
33342015001 IBANDRONATE SODIUM ibandronate sodium TABLET 150 mg Y Y N  
33342015052 IBANDRONATE SODIUM ibandronate sodium TABLET 150 mg Y Y N  
33342015053 IBANDRONATE SODIUM ibandronate sodium TABLET 150 mg Y Y N  
55111057511 IBANDRONATE SODIUM ibandronate sodium TABLET 150 mg Y Y N  
55111057543 IBANDRONATE SODIUM ibandronate sodium TABLET 150 mg Y Y N  
60505279500 IBANDRONATE SODIUM ibandronate sodium TABLET 150 mg Y Y N  
65862023703 IBANDRONATE SODIUM ibandronate sodium TABLET 150 mg Y Y N  
69452037874 IBANDRONATE SODIUM ibandronate sodium TABLET 150 mg Y Y N  
61703032418 PAMIDRONATE DISODIUM pamidronate disodium VIAL 30 mg/10 mL (3 mg/mL) Y N  
67457043010 PAMIDRONATE DISODIUM pamidronate disodium VIAL 30 mg/10 mL (3 mg/mL) Y N  
61703032518 PAMIDRONATE DISODIUM pamidronate disodium VIAL 60 mg/10 mL (6 mg/mL) Y N  
61703032618 PAMIDRONATE DISODIUM pamidronate disodium VIAL 90 mg/10 mL (9 mg/mL) Y N  
67457044610 PAMIDRONATE DISODIUM pamidronate disodium VIAL 90 mg/10 mL (9 mg/mL) Y N  
00002418430 EVISTA raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
00093729001 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
00093729056 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
00904690204 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
16714021301 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
16714021302 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
16714021303 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
43598050501 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
43598050510 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
43598050530 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
50268069411 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
50268069415 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
60687026611 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
60687026621 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
65162005703 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
65162005710 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
65862070901 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
65862070930 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
69097082502 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
69097082507 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
69097082515 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
72241001005 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
72241001011 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
72241001022 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
76282025605 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
76282025630 RALOXIFENE HCL raloxifene HCl TABLET 60 mg N Y N Pharmacy PA
00430047801 ACTONEL risedronate sodium TABLET 150 mg Y Y N  
00430047802 ACTONEL risedronate sodium TABLET 150 mg Y Y N  
00093777113 RISEDRONATE SODIUM risedronate sodium TABLET 150 mg Y Y N  
00093777119 RISEDRONATE SODIUM risedronate sodium TABLET 150 mg Y Y N  
00093777179 RISEDRONATE SODIUM risedronate sodium TABLET 150 mg Y Y N  
47335092860 RISEDRONATE SODIUM risedronate sodium TABLET 150 mg Y Y N  
47335092867 RISEDRONATE SODIUM risedronate sodium TABLET 150 mg Y Y N  
59762040601 RISEDRONATE SODIUM risedronate sodium TABLET 150 mg Y Y N  
60505309702 RISEDRONATE SODIUM risedronate sodium TABLET 150 mg Y Y N  
60505309704 RISEDRONATE SODIUM risedronate sodium TABLET 150 mg Y Y N  
65862087003 RISEDRONATE SODIUM risedronate sodium TABLET 150 mg Y Y N  
65862087011 RISEDRONATE SODIUM risedronate sodium TABLET 150 mg Y Y N  
00093310056 RISEDRONATE SODIUM risedronate sodium TABLET 30 mg Y Y N  
00430047203 ACTONEL risedronate sodium TABLET 35 mg Y Y N  
00430047207 ACTONEL risedronate sodium TABLET 35 mg Y Y N  
00093309819 RISEDRONATE SODIUM risedronate sodium TABLET 35 mg Y Y N  
00093309829 RISEDRONATE SODIUM risedronate sodium TABLET 35 mg Y Y N  
00093309844 RISEDRONATE SODIUM risedronate sodium TABLET 35 mg Y Y N  
33342010937 RISEDRONATE SODIUM risedronate sodium TABLET 35 mg Y Y N  
33342010950 RISEDRONATE SODIUM risedronate sodium TABLET 35 mg Y Y N  
47335066862 RISEDRONATE SODIUM risedronate sodium TABLET 35 mg Y Y N  
47335066868 RISEDRONATE SODIUM risedronate sodium TABLET 35 mg Y Y N  
59762040504 RISEDRONATE SODIUM risedronate sodium TABLET 35 mg Y Y N  
60505316500 RISEDRONATE SODIUM risedronate sodium TABLET 35 mg Y Y N  
00093309956 RISEDRONATE SODIUM risedronate sodium TABLET 5 mg Y Y N  
33342010707 RISEDRONATE SODIUM risedronate sodium TABLET 5 mg Y Y N  
00430097903 ATELVIA risedronate sodium TABLET DR 35 mg N Y N Pharmacy PA
59762040704 RISEDRONATE SODIUM DR risedronate sodium TABLET DR 35 mg N Y N Pharmacy PA
63304044009 RISEDRONATE SODIUM DR risedronate sodium TABLET DR 35 mg N Y N Pharmacy PA
63304044011 RISEDRONATE SODIUM DR risedronate sodium TABLET DR 35 mg N Y N Pharmacy PA
55513088001 EVENITY romosozumab-aqqg SYRINGE 105 mg/1.17 mL N Y N Pharmacy PA
55513099801 EVENITY romosozumab-aqqg SYRINGE 105 mg/1.17 mL N Y N Pharmacy PA
55513088002 EVENITY (2 SYRINGES) romosozumab-aqqg SYRINGE 210 mg/2.34 mL (105 mg/1.17 mL x 2) N Y N Pharmacy PA
55513099802 EVENITY (2 SYRINGES) romosozumab-aqqg SYRINGE 210 mg/2.34 mL (105 mg/1.17 mL x 2) N Y N Pharmacy PA
47781085289 BONSITY teriparatide PEN INJCTR 20 mcg/dose (560 mcg/2.24 mL) N Y N Pharmacy PA
00002840001 FORTEO teriparatide PEN INJCTR 20 mcg/dose (560 mcg/2.24 mL) N Y N Pharmacy PA
00002967801 FORTEO teriparatide PEN INJCTR 20 mcg/dose (560 mcg/2.24 mL) N Y N Pharmacy PA
00093110616 TERIPARATIDE teriparatide PEN INJCTR 20 mcg/dose (560 mcg/2.24 mL) N Y N Pharmacy PA
47781065289 TERIPARATIDE teriparatide PEN INJCTR 20 mcg/dose (560 mcg/2.24 mL) N Y N Pharmacy PA
60505618800 TERIPARATIDE teriparatide PEN INJCTR 20 mcg/dose (560 mcg/2.24 mL) N Y N Pharmacy PA
66993049528 TERIPARATIDE teriparatide PEN INJCTR 20 mcg/dose (560 mcg/2.24 mL) N Y N Pharmacy PA
66993098928 TERIPARATIDE teriparatide PEN INJCTR 20 mcg/dose (560 mcg/2.24 mL) N Y N Pharmacy PA
25021082667 ZOLEDRONIC ACID zoledronic ac/mannitol/0.9NaCl PIGGYBACK 4 mg/100 mL Y N  
25021082682 ZOLEDRONIC ACID zoledronic ac/mannitol/0.9NaCl PIGGYBACK 4 mg/100 mL Y N  
25021082687 ZOLEDRONIC ACID zoledronic ac/mannitol/0.9NaCl PIGGYBACK 4 mg/100 mL Y N  
47335096241 ZOLEDRONIC ACID zoledronic acid VIAL 4 mg Y N  
16729024231 ZOLEDRONIC ACID zoledronic acid VIAL 4 mg/5 mL Y N  
23155017031 ZOLEDRONIC ACID zoledronic acid VIAL 4 mg/5 mL Y N  
43598023311 ZOLEDRONIC ACID zoledronic acid VIAL 4 mg/5 mL Y N  
43598033011 ZOLEDRONIC ACID zoledronic acid VIAL 4 mg/5 mL Y N  
55111068507 ZOLEDRONIC ACID zoledronic acid VIAL 4 mg/5 mL Y N  
63323096198 ZOLEDRONIC ACID zoledronic acid VIAL 4 mg/5 mL Y N  
67457039054 ZOLEDRONIC ACID zoledronic acid VIAL 4 mg/5 mL Y N  
68001043725 ZOLEDRONIC ACID zoledronic acid VIAL 4 mg/5 mL Y N  
68001061025 ZOLEDRONIC ACID zoledronic acid VIAL 4 mg/5 mL Y N  
69367019050 ZOLEDRONIC ACID zoledronic acid VIAL 4 mg/5 mL Y N  
72603019801 ZOLEDRONIC ACID zoledronic acid VIAL 4 mg/5 mL Y N  
83634080105 ZOLEDRONIC ACID zoledronic acid VIAL 4 mg/5 mL Y N  
66758015546 RECLAST zoledronic acid/mannitol-water PGGYBK BTL 5 mg/100 mL Y N  
55111068852 ZOLEDRONIC ACID zoledronic acid/mannitol-water PGGYBK BTL 5 mg/100 mL Y N  
63323096600 ZOLEDRONIC ACID zoledronic acid/mannitol-water PGGYBK BTL 5 mg/100 mL Y N  
67457061910 ZOLEDRONIC ACID zoledronic acid/mannitol-water PGGYBK BTL 5 mg/100 mL Y N  
71288080651 ZOLEDRONIC ACID zoledronic acid/mannitol-water PGGYBK BTL 5 mg/100 mL Y N  
25021083082 ZOLEDRONIC ACID zoledronic acid/mannitol-water PIGGYBACK 5 mg/100 mL Y N  
25021083087 ZOLEDRONIC ACID zoledronic acid/mannitol-water PIGGYBACK 5 mg/100 mL Y N  
67457079410 ZOLEDRONIC ACID zoledronic acid/mannitol-water PIGGYBACK 5 mg/100 mL Y N  
68001061133 ZOLEDRONIC ACID zoledronic acid/mannitol-water PIGGYBACK 5 mg/100 mL Y N  
72266015201 ZOLEDRONIC ACID zoledronic acid/mannitol-water PIGGYBACK 5 mg/100 mL Y N  
Back to Top ↑