Diabetes, Thiazolidinediones

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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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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
64764015104 ACTOS pioglitazone HCl TABLET 15 mg Y Y N  
00093727105 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
00093727156 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
00093727198 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
00904709061 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
16714064501 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
16714064502 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
16714064503 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
16729002015 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
16729002016 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
33342005407 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
33342005410 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
33342005415 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
57237021905 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
57237021930 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
57237021990 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
60687039101 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
60687039111 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
62135080430 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
65862051205 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
65862051230 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
65862051290 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
82009010305 PIOGLITAZONE HCL pioglitazone HCl TABLET 15 mg Y Y N  
64764030114 ACTOS pioglitazone HCl TABLET 30 mg Y Y N  
00093727205 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
00093727256 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
00093727298 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
00904709661 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
16714064601 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
16714064602 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
16714064603 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
16729002115 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
16729002116 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
33342005507 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
33342005510 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
33342005515 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
57237022005 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
57237022030 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
57237022090 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
62135080530 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
65862051305 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
65862051330 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
82009010405 PIOGLITAZONE HCL pioglitazone HCl TABLET 30 mg Y Y N  
64764045124 ACTOS pioglitazone HCl TABLET 45 mg Y Y N  
00093727305 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
00093727356 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
00093727398 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
16714064701 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
16714064702 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
16714064703 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
16729002215 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
16729002216 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
33342005607 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
33342005610 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
33342005615 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
57237022105 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
57237022130 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
57237022190 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
62135080630 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
65862051405 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
65862051430 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
65862051490 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
82009010505 PIOGLITAZONE HCL pioglitazone HCl TABLET 45 mg Y Y N  
64764030230 DUETACT pioglitazone HCl/glimepiride TABLET 30 mg-2 mg N Y N  
66993082130 PIOGLITAZONE-GLIMEPIRIDE pioglitazone HCl/glimepiride TABLET 30 mg-2 mg N Y N  
64764030430 DUETACT pioglitazone HCl/glimepiride TABLET 30 mg-4 mg N Y N  
66993082230 PIOGLITAZONE-GLIMEPIRIDE pioglitazone HCl/glimepiride TABLET 30 mg-4 mg N Y N  
33342017609 PIOGLITAZONE-METFORMIN pioglitazone HCl/metformin HCl TABLET 15 mg-500 mg N Y N  
33342017657 PIOGLITAZONE-METFORMIN pioglitazone HCl/metformin HCl TABLET 15 mg-500 mg N Y N  
57237021760 PIOGLITAZONE-METFORMIN pioglitazone HCl/metformin HCl TABLET 15 mg-500 mg N Y N  
65862052518 PIOGLITAZONE-METFORMIN pioglitazone HCl/metformin HCl TABLET 15 mg-500 mg N Y N  
65862052560 PIOGLITAZONE-METFORMIN pioglitazone HCl/metformin HCl TABLET 15 mg-500 mg N Y N  
64764015860 ACTOPLUS MET pioglitazone HCl/metformin HCl TABLET 15 mg-850 mg N Y N  
33342017709 PIOGLITAZONE-METFORMIN pioglitazone HCl/metformin HCl TABLET 15 mg-850 mg N Y N  
33342017757 PIOGLITAZONE-METFORMIN pioglitazone HCl/metformin HCl TABLET 15 mg-850 mg N Y N  
57237021860 PIOGLITAZONE-METFORMIN pioglitazone HCl/metformin HCl TABLET 15 mg-850 mg N Y N  
65862052618 PIOGLITAZONE-METFORMIN pioglitazone HCl/metformin HCl TABLET 15 mg-850 mg N Y N  
65862052660 PIOGLITAZONE-METFORMIN pioglitazone HCl/metformin HCl TABLET 15 mg-850 mg N Y N  
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