Pancreatic Enzymes
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 73562011001 | ZENPEP | lipase/protease/amylase (pork) | CAPSULE DR | 10,000 unit-32,000 unit-42,000 unit | Y | Y | N | |
| 53489032101 | PANCRELIPASE 10000 | lipase/protease/amylase (pork) | CAPSULE DR | 10,000 unit-37,500 unit-33,200 unit | N | Y | N | |
| 00032004770 | CREON | lipase/protease/amylase (pork) | CAPSULE DR | 12,000 unit-38,000 unit-60,000 unit | Y | Y | N | |
| 00032121201 | CREON | lipase/protease/amylase (pork) | CAPSULE DR | 12,000 unit-38,000 unit-60,000 unit | Y | Y | N | |
| 73562011101 | ZENPEP | lipase/protease/amylase (pork) | CAPSULE DR | 15,000 unit-47,000 unit-63,000 unit | Y | Y | N | |
| 59767001601 | PERTZYE | lipase/protease/amylase (pork) | CAPSULE DR | 16,000 unit-57,500 unit-60,500 unit | N | Y | N | |
| 59767001602 | PERTZYE | lipase/protease/amylase (pork) | CAPSULE DR | 16,000 unit-57,500 unit-60,500 unit | N | Y | N | |
| 59767001699 | PERTZYE | lipase/protease/amylase (pork) | CAPSULE DR | 16,000 unit-57,500 unit-60,500 unit | N | Y | N | |
| 73562011201 | ZENPEP | lipase/protease/amylase (pork) | CAPSULE DR | 20,000 unit-63,000 unit-84,000 unit | Y | Y | N | |
| 00032122401 | CREON | lipase/protease/amylase (pork) | CAPSULE DR | 24,000 unit-76,000 unit-120,000 unit | Y | Y | N | |
| 00032263601 | CREON | lipase/protease/amylase (pork) | CAPSULE DR | 24,000 unit-76,000 unit-120,000 unit | Y | Y | N | |
| 59767002401 | PERTZYE | lipase/protease/amylase (pork) | CAPSULE DR | 24,000 unit-86,250 unit-90,750 unit | N | Y | N | |
| 59767002402 | PERTZYE | lipase/protease/amylase (pork) | CAPSULE DR | 24,000 unit-86,250 unit-90,750 unit | N | Y | N | |
| 73562011601 | ZENPEP | lipase/protease/amylase (pork) | CAPSULE DR | 25,000 unit-79,000 unit-105,000 unit | Y | Y | N | |
| 73562011301 | ZENPEP | lipase/protease/amylase (pork) | CAPSULE DR | 3,000 unit-10,000 unit-14,000 unit | Y | Y | N | |
| 00032004570 | CREON | lipase/protease/amylase (pork) | CAPSULE DR | 3,000 unit-9,500 unit-15,000 unit | Y | Y | N | |
| 00032120370 | CREON | lipase/protease/amylase (pork) | CAPSULE DR | 3,000 unit-9,500 unit-15,000 unit | Y | Y | N | |
| 00032263701 | CREON | lipase/protease/amylase (pork) | CAPSULE DR | 36,000 unit-114,000 unit-180,000 unit | Y | Y | N | |
| 00032301613 | CREON | lipase/protease/amylase (pork) | CAPSULE DR | 36,000 unit-114,000 unit-180,000 unit | Y | Y | N | |
| 59767000401 | PERTZYE | lipase/protease/amylase (pork) | CAPSULE DR | 4,000 unit-14,375 unit-15,125 unit | N | Y | N | |
| 59767000499 | PERTZYE | lipase/protease/amylase (pork) | CAPSULE DR | 4,000 unit-14,375 unit-15,125 unit | N | Y | N | |
| 73562011401 | ZENPEP | lipase/protease/amylase (pork) | CAPSULE DR | 40,000 unit-126,000 unit-168,000 unit | Y | Y | N | |
| 73562011501 | ZENPEP | lipase/protease/amylase (pork) | CAPSULE DR | 5,000 unit-17,000 unit-24,000 unit | Y | Y | N | |
| 00032004670 | CREON | lipase/protease/amylase (pork) | CAPSULE DR | 6,000 unit-19,000 unit-30,000 unit | Y | Y | N | |
| 00032120601 | CREON | lipase/protease/amylase (pork) | CAPSULE DR | 6,000 unit-19,000 unit-30,000 unit | Y | Y | N | |
| 58914000110 | ULTRASE MT 6 | lipase/protease/amylase (pork) | CAPSULE DR | 6,000 unit-20,000 unit-20,000 unit | N | Y | N | |
| 73562011701 | ZENPEP | lipase/protease/amylase (pork) | CAPSULE DR | 60,000 unit-189,600 unit-252,600 unit | Y | Y | N | |
| 59767000801 | PERTZYE | lipase/protease/amylase (pork) | CAPSULE DR | 8,000 unit-28,750 unit-30,250 unit | N | Y | N | |
| 59767000802 | PERTZYE | lipase/protease/amylase (pork) | CAPSULE DR | 8,000 unit-28,750 unit-30,250 unit | N | Y | N | |
| 73562010410 | VIOKACE | lipase/protease/amylase (pork) | TABLET | 10,440 unit-39,150 unit-39,150 unit | N | Y | N | |
| 73562020810 | VIOKACE | lipase/protease/amylase (pork) | TABLET | 20,880 unit-78,300 unit-78,300 unit | N | Y | N | |
| 00115702901 | PANCRELIPASE | lipase/protease/amylase (pork) | TABLET | 8,000 unit-30,000 unit-30,000 unit | N | Y | N |